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Very Low Birth Weight Self-Monitoring Tool

As required in Regulation 61-16 Level I and II hospitals shall review all live births or fetal/neonatal deaths in which the neonate weighed at least 350 grams and less than 1500 grams, utilizing the Department’s Very Low Birthweight Self-monitoring Tool. Each completed self-monitoring DHEC form shall be retained by the facility and a copy made available to the Department as specified in the self-monitoring tool.

A state and national goal is that 90% of VLBW births occur in Level III or above hospitals, as this is shown to reduce neonatal mortality. There are times when the decision is made, in consultation with the Regional Perinatal Center, to deliver a VLBW infant in a Level I or II facility. Review of these high-risk deliveries allows for surveillance of the statewide system of communication and care for our state’s mothers and infants.

Entries on the Very Low Birthweight Self-Monitoring Tool reflect information obtained through review of perinatal records, hospital records, and electronic birth certificate data and are specific to a mother and her neonate. The form should be completed by a licensed Registered Nurse to assure quality and completeness of data. Sections I, II, III, and IV should be completed within a week of delivery and sections V and VI should be completed at time of infant’s discharge.

The tool and instructions on its use can be found here.

At the time of infant discharge, please submit this form to SC DHEC Bureau of Maternal and Child Health via e-mail at VLBWForm@DHEC.SC.GOV or by fax to (803) 898-2065, Attn: VLBW form.

Please do not include patient names. Please e-mail VLBWForm@DHEC.SC.GOV with any questions or comments you may have.