Annexures Annexure 2.2: Newborn Case Record Sheet for the facil Newborn Case Record Sheet 01. Nameofbaby 02. Admission No. 03. Date of admission [dd/mm/yyyy] 04. Mother's Name 05. Father's Name 06. Address 07. Dateofbirth [dd/mm/yyyy] 08. Time of Birth hr min 09. Ageofbaby 10. Sex [M) fF ‘Maternal history — present pregnancy 11. Age Gravida Para Abortion 12. LMP) EDD 13. ANC Check up ™ INI a. Number of ANC visits 14, Tetanus Toxoid ni] INI 15. History of a. PIH ni] INI b. Diabetes Ma] INI c. APH M™ IN d, Maternal Fever rM] INI 16. Anyothersignificant history17. 18. 19. 20. 21 22. 23. 24, 25. 26. 27. 28. 29. 30. Intra-partum history Place of delivery [Home] [Other hospital] This Hospital] Deliveryattendedby [Doctor] [NurseorANM] [Dai] [Anyother] Mode of Delivery [Caesarean] [Normal Vaginal] IForceps/vacuum] a, Indication for Caesarean, ifapplicable J PROM > 24hr mM IN Amniotic Fluid [Clear] [Meconium] —[FoulSmelling] __[Don'tKnow] Apgar 1 min [Not Known} Smin [Not Known] Baby cried atbirth MIN) Resuscitation MIN] HfYes, details a. Bagand mask M oN b. Oxygen MN ©. Others (specify) [ Gestation at birth in completed weeks (best estimate) weeks Preterm Term/Postterm Weightatbirth grams Presenting complaints Presenting complaints FeedingHistory Breastfed [Y]_ IN] Fed8times/day [Y] {NJ Anyotherfluids [YI [NI Ifyes,how [bottle] [cup/spoon] Immunization BCG [Y] IN) OPV [Y]_ IN] HepB [Y] IN] 31 32. 33. 34. 35. 36. Apnea [Y] [N] _ Respiratory rate Jin Fastbreathing. [YI [N] Cyanosis [Y] [NJ Chestindrawing [Y] [NI Grunting [Y] [NI Temperature °c irculation: Extremities cool [Y] [N] CFT > 3secs [YI [N] HR beats/min General condition [Alert] _[Lethargic] [Comatose] Convulsions ™ IN] Skin pinch > 2 seconds ™ IN] SoANXIUUYAnnexures 37. Jaundice [¥] IN] 38. Bulginganteriorfontanelle [YJ [N] Ifyes, extent: [Face] [Chest] [Abdomen] [Legs] [Palms/soles] 39, Bleeding [YJ [N] Ifyes, specifysite [Skin] [Mouth] [Rectal] _[Umbilicus] 40, Umbilicus [Red] [Discharge] 41. Skinpustules [No] [<10] [>10] _ [Abscess] 42. Major congenital malformations [Y] [N]_ If Yes specify 43. Neonatal reflexes Anthropometry 44. Weight grams 45. Head Circumference cm 46. Gestation assessment weeks [Term] Feeding assessment 47. Sucking [Good] [Poor] 48. Attachment [Well attached] [Poorly attached] Systemic examination: [Preterm] [No sucking} [Notattached] Provisional diagnosis: Plan of investigations: Treatment:NOTESNOTES