Paed referral in L/Room Normal __genitalia )B/L testes descended) Term low birth weight < 2kg

Inform MO if any tachypneic baby Anus: patent 1. Admit 6c

Spine: normal 2. For incubator care
For baby already born Hips: stable 3. Start feeding
Received referral from L/room for baby with tachypneic ______by O&G team No CTEV 4. W/o feeding intolerance and respiratory distress
Attended stat by me. Upon arrival ___am/pm, the baby was (condition of the baby with Moro complete, grasp reflex, suckling reflex 5. CBS at 4HOL and 4hourly
vital sign T, HR, SpO2 under RA/NPO2)
Plan: Term low birth weight 2-2.5kg
For standby (attend since birth) TTN: 1. Discharge to mother
Baby wa born vigorous with good cry, good respiratory effort and good muscle one with 1. Admit 6c 2. Start feeding
Apgar score of ___(1)___(5) 2. Put on NPO2 2l/Min 3. CBS at 4 HOL and 4 hourly for 24 hours
Put under radian warmer__(detailed) 3. Keep SpO2 >95 % % 4. If discharge, biweekly weighing at KK until BW>2.5kg, then weekly until BW>3kg
(condition of the baby, any respiratory distress) 4. Watch out for respiratory distress
??nasal flaring, ?grunting, ?tachypneic with RR of __ 5. If unable to wean off O2 by 6 HOL, for CXR Macrosomic baby 4-4.5kg
Recession, SpO2 under RA__, HR__, RR__ 6. Keep KBM with IVD D10% 1. Discharge to mother
The baby was put on neopuff: PEEP: 5 7. FBC and Blood C+S (if risk of sepsis)
Macrosomic baby >4.5kg
Maternal history Resolved TTN 1. Admit to 6C
Age: 1. Discharge to mother 2. CBS at 4 HOL and 4 hourly
Para: 2. Paed to review at 6 HOL and cm 3. Inform if CBS < 2.6 or symptomatic of hypoglycemia
MBG: 3. Encourage breast feeding
HIV/VDRL: 4. Watch out for respiratory distress Prematurity (<35 week or <2kg)
ANC: 1. Plot growth chart
1) Presenting complaint Risk of MAS if stable 2. Admit 6c for observation
2) Sure of date? LMP? EOD? 1. Discharge to mother 3. Keep NBM with IVD 10%
3) Significant antenatal scan 2. Paed to review at 6 HOL and cm 4. CBS at 4HOL and 4 hourly
4) Dexa scan 3. W/o s/sx of respiratory distress and sepsis 5. W/out for feeding intolerance
5) MgS04 (neuroprotection) 4. Encourage breast feeding
6) Past medical and surgical history 5. No need CBS monitoring Caput/ cephalohematoma
7) Significant pass obstetric history- early neonatal death/ Poor spacing/ History of 6. KIV discharge if well>24 hours 1. Allow disharge paed
miscarriages/ preterm deliveries 2. Breasfeeding
8) AFI & Droppler Risk of sepsis (PROM) if stable 3. Top up feeding
1. Discharge to mother 4. COH monitoring 4 hourly
Peripartum history: 2. Paed to review at 6 HOL and cm 5. Inform stat if caput increasing in size, jaundice and tender
1. ROM, duration of rupture, duration of second stage of labour 3. W/out s/sx of sepsis (fever/ tachycardia/tachypnea)
2. Medication in labour (e.g pethidine) 4. No need CBS monitoring SAH:
3. Maternal pyrexia? FBC? HVS C+S 5. Encourage breast feeding 1. Admit 6C
4. If PROM- covered? Doses? Last dose and time? Liquor colour 6. Trace mother’s HVS C+S 2. Start feeding
5. CTG abnormalities 3. Coagulation profile, KIV FFP
6. Cord round neck/ Placenta abruption Presumed sepsis 2nd to PROM/PPROM >18H (inadequately covered/ 4. COH monitoring hourly
7. Fetal distress (Cord blood gasses- Umbilical arterial and venous) chorioamnionitis) 5. Inform if COH increasing in size or hemodynamically unstable (tachycardia poor pulse
8. Placental Weight 1. Admit 6C volume, hypotension)
2. FBC and blood C+S
Baby history: 3. Start IV C penicillin and gentamycin Post resus care (PPV/ AS <6 at 5 min)
DOB: TOB: 4. Start IVD D10% for transportation 1. Admit 6c for observation
Gender: 5. Start feeding at ward 2. Start feeding
Mode of delivery/ gestation 6. W/out of sepsis (fever/ tachycardia/tachypnea) 3. W/O respiratory distress
Birth weight/ Length/ COH 7. Trace mother’s HVS C+S and placenta swab if taken 4. W/O feeding intolerance
Apgar score
GDM on d/c or s/c insulin
O/E: 1. Discharge to mother
Active on handling 2. Encourage breast feeding. To calculate how much feeding
Good tone, good PV, CRT <2sec 3. CBS at 4 HOL and 4 hourly
AFNT, no scalp swelling 4. Inform if CBS <2.6 or symptomatic of hypoglycemia
No ear/ eye abnormalities/ discharge 5. Paeds to review CM
No cleft palate/ lip palate
No dysmorphism
CVS: DRNM
Lungs: clear
Abdo:soft and non tender, hepatosplenomegaly
B/L femoral pulses felt