RECORD KEEPING OF A NEW BORN FROM AN

HIV/AIDS POSITIVE MOTHER

A new born record is a card or book that records important details /information about a baby. This
may include vaccinations, growth, nutrition status and any health related issues.

Before recording the newborn on the care card, it is import

ant to first take history/story of the newborn, carry out observations and investigators , make an
assessment then plan the management and care of the newborn which is recorded on the child’s
record as it is essential for reference on subsequent postnatal and under five care services.

History/story of the newborn;

Take history of the mothers’ previous pregnancies and its outcome. We also take note of the HIV
status of the siblings alive.

Secondly, take history of the current pregnancy, delivery process, duration of labour and any
important event that may have occurred within the first 6 hours of delivery.

Thirdly, note factors from the mother that may pose a threat on both the mother and baby such as
her occupation, un married and teen mother.

Observations and investigators

Physical examination is carried out to note the birth weight, birth defects anything that may
require special attention.

An investigation such as polymerase chain reaction (PCR) test is conducted to detect the HIV
RNA and DNA.

Assessment;

Assess if the neonate is born at term, premature, low birth weight, APGAR score, hypoglycemia,
jaundice and hypothermia.
Plan;

When coming up with an action plan, consider identified treats from the history, observations and
assessment in order to draw-out good midwifery care and parent management once discharged.

COMPONENTS
The infants’ record card is divided in parts;

1. Child particulars

We record the health facility in which the infant was born, child’s under 5 number, names,
sex, mothers’ name and national registration card number, fathers name and national
registration card number, date of birth, birth weight, place of birth and where the family lives:
address

2. REASONS FOR SPECIAL CARE:

This includes:

 Birth weight less than 2.5kg

 Brother or sisters undernourished
 Birth defect
 Mother dead
 Other handicaps or illness
 Father dead
 Fifth child or more
 3 or more children in family dead
 Birth less than 2yrs after last birth
 Multiple birth child
 Severe jaundice and Birth asphyxia
3. Nutrition records

Record special information given on Growth, Nutrition, Immunization and Illness such as:
exclusive breastfeeding, HIV/AIDS, malaria, feeding during and after illness and treatment of
diarrhea.
4. Immunization record

Immunization protects your child against serious diseases. All vaccines are recorded as
vaccinated on the exact date of vaccination,

 Bacillus Calmate Guerin against Tuberculosis

 oral Polio vaccine against poliomyelitis
 DPT+Heb+Hib vaccine against Diphtheria/Tetanus/Whooping Cough /Hepatitis
B/Haemophilus Influenza type B
 Measles and rubella against Measles and rubella
 Rota vaccine against diarrhea
 pneumococcal conjugate vaccine against pneumonia
5. Weight record of up to 5 years
 Watch the line showing the child’s growth: The growth curve should continue to go up
every time you have your child weighed. Hence important to note that:

 A child is severely over-weight for his or her age when the growth line crosses the
upper-most curve (“a”) or the weight lies above the upper-most curve (“b”)
 A child is severely under-weight when the growth curve crosses the lower-most
curve (“c”) or the weight lies below the lower-most curve (“d”)
6. Prevention of mother to child
 Firstly, determine the mother’s HIV status
Ask the mother:
 If she knows her HIV status
 If she is HIV positive, what treatment she has received and
When it commenced
 If she is HIV positive and not on HAART
 Determine her CD4 count and WHO stage
 Since the mother is HIV positive, indicate that the child is exposed (C.E)
 If mothers status is negative, indicate that child not exposed (C.N.E)
 If the mothers status is unknown, indicate mothers status unknown (M.S.U)
 Indicate when the first polymerase chain reaction (P.C.R) test is conducted
 Indicate the day the HIV/AIDS prophylaxis is first given
 REFERENCES

1. Zambian newborn health care framework 2013.

2. IMCI strategic plan 2013-2016, Zambia.
3. Zambia PMTCT Guidelines 2010.
4. World Health Organization. Newborns: reducing mortality [fact sheet]. Geneva: WHO;
2012.
5. Progress towards millennium development goals 4 and 5, building a future for women and
children, The 2012 Report, p. 17.