FORMAT CHILD BIRTH REPORT

DATE OF ADMISSION:                              05/12/2005 at 1245 hours NICU.

DATE OF BIRTH:                                        05/12/2005 at 1233 hours.

PLACE OF BIRTH:                                     Florida.

ATTENDING OBSTETRICIAN:                 Gilbert, MD

HISTORY:  The patient is the 1794 gm product of a 31-week gestation, born on 05/12/2010 at 1233 hours to a 34-year-old gravida 2,
F-1, P-0, A-0, L-1 mother, who did receive prenatal care.  Estimated date of confinement is 07/09/2010.  Gestational age by date is 31 weeks and 5 days and by ultrasound 31 weeks and 5 days.  Mother is serology negative, hepatitis B negative, HIV negative, rubella immune, blood type A negative, with negative antibody screen.  This is mother's second admission for preterm labour.  Mother was admitted in April 2010 for preterm labour, at which time she received steroid therapy.  Mother was sent home on Terbutaline for tocolysis, and remained at home up until last night when contractions started began.  Mother is admitted and with suspicion of incompetent cervix, and was started on magnesium sulphate for tocolysis.  With continued changes in cervix and as well as twin B being in the breech presentation a caesarean section was performed today.  Mother's internal complications are none.  There was preterm labour in April 2010.  There is no history of SIDS in the family.  Antepartum and intrapartum findings include incompetent cervix and breech position of twin B.  Mother is A negative, and has received RhoGAM therapy.  Mother's GBS status is positive and mother did receive clindamycin intrapartally.  Rupture of membranes were at delivery.  There was no fetal distress.  There was no meconium-stained amniotic fluid.  This infant was born in the vertex position via caesarean section and required only stimulation and suctioning in the delivery room.  Infant was pink and vigorous.  At delivery Apgars were 8 at 1 minute and 9 at 5 minute.  After showing infant to father, the infant's were transported to NICU for further evaluation and treatments.

PHYSICAL EXAMINATION:

GENERAL:                             Significant for 32-week AGA, white male white infant, admitted in room air but has presented with retraction and mild grunting and infant has been placed on bubble CPAP plus 5 on room air.

VITAL SIGNS:                       On admission, temperature is 97.4 degrees, pulse 168, respiratory rate 56, blood pressure 52/24 mmHg with a mean of 35.  Initial Chemstrip is 61.  Infant's weight of 1794 gm equals greater than 75th percentile.  Head circumference of 30.0 cm, equals 70th percentile and length of 42.5 cm, equals greater than 50th percentile.

HEENT:                                   Head:  Normal size and shape.  Anterior fontanelle open and flat.  No septal hematoma, no caput, no petechiae or bruising are seen.  Eyes showed red reflex bilaterally.  Pupils are equal, reactive to light and accommodation.  Ears are of normal shape and position and are appropriate for gestational age and showed no periauricular skin tags or pits.  Nares are patent bilaterally.  Face reveals no facial clefting.  Palate is intact.  Mouth and lips are moist and pink.

NECK:                                     Supple.  Carotids pulses were intact.

CHEST:                                   Symmetrical.  There were mild retraction.  There is no flaring, there is mild audible grunting.  Infant remains in bubble CPAP plus 5 on room air.  Air excursion is good bilaterally in the bubble CPAP.

HEART:                                   Pulses are palpable x 4.  Infant is well perfused with some residual acrocyanosis.  Heart tones are loudest in the left.  There is no audible murmur.

ABDOMEN:                           Soft and rounded.  There is a three-vessel cord stump with cord clamp in place.  Liver is palpable at the right costal margin.  Spleen is not palpable.  There are no palpable masses in the abdomen and bowel sounds are hypoactive.

GENITOURINARY:              Normal phenotypic male compatible with gestational age.  Male with descending testes bilaterally and immature rugae on the scrotum.  Anus is appears patent.  Hips are stable without clicks or clunk.

NEUROLOGICAL:                Infant responds to stimulation, has lusty cry, shows symmetrical Moro.  Normal reflex and tone for gestational age.  Infant has no seizure activity.

SKIN:                                       Pink, warm and dry.  No petechiae, ecchymosis, no vesicles or lacerations were seen.

MUSCULOSKELETAL:       Spine is closed and straight with no skin tuft or dimple at the base.  No evidence of overt syndrome or anomalies evidence on this initial exam.

HOSPITAL COURSE:  Infant was brought to the NICU from the OR suite and placed on an open warmer table.  Since infant is in bubble CPAP in room air, no arterial blood gas has been sent and no umbilical lines have been placed.  Infant has not received surfactant therapy.  Blood cultures were obtained and CBC with differentials was sent which results as follows WBC of 12.5, hemoglobin 17.  CBC results are pending.  Infant was started on methicillin and gentamicin.  The infant is placed on 80 cc/kg/day of D10W with 20 mg calcium gluconate 200 mL via peripheral IV site.  Initial Chemstrip is 61.  Mother's blood type is A negative with antibody screen.  The infant's blood type and Coombs' are pending.

IMPRESSION:

MATERNAL INTRAPARTUM FACTORS:

1.  Gestational age by date is 31 weeks and 5 days.

2.  Cesarean section secondary to preterm labour and incompetent cervix despite attempted tocolysis with   terbutaline at home and on magnesium sulphate in hospital.

3.  Twin gestation with twin B in breech presentation

4.  Ruptured membranes at delivery.

5.  Antepartal clindamycin for positive GBS status, as the mother allergic to penicillin.

NEONATAL FACTORS:

1.  Gestational age by exam is 31 weeks appropriate for gestational age.

2.  Respiratory distress.  Rule out hyaline membrane disease.  Rule transient tachypnea as a new born.  Rule out sepsis in new born status post caesarean section at 31 weeks gestation.

3.  Rule out sepsis secondary to preterm labor, GBS status is positive but there is low risk of sepsis from this.

PLAN:

Problem #1:  Respiratory status/cardiovascular status:

Should infant's respiratory efforts worsen we will consider intubation and surfactant therapy.  We will also at that time consider placement of central lines for atrial blood gas access.

Problem #2:  Infectious disease:

We will continue evaluation of infection with blood cultures are pending.  Repeat CBC in the morning.

Problem #3:  Fluids, electrolytes, and nutritions:

We will continue IV fluids 80 cc/kg/day.  Monitor electrolyte and renal parameters in the morning.

Problem #4:  Hematologic/bilirubin:

Observe for the development of jaundice.  Awaiting for type and Coombs' and begin phototherapy as indicated.

Problem #5:  Neurologic:

We will evaluate neurologic status.  Infant is a candidate for cranial ultrasound on day #7 of life.  We will offer pain management for invasive procedures.

I spoke with parents at the bedside today, as well as Dr. Gentle and gave them the infant's current status and plan of care.  Dr. Gentle is aware of the infant's current status and plan of care and is in agreement.