POSTNATAL BABY REVIEW

<Paeds Review>

B/o Jane Doe
DOB 11/4/19 at 1206H
Born via SVD at 38 weeks POA
BW 3.3Kg
12 Hour of life

ANC (Antenatal Care)
Mother 31 year-old, G2P1 at 38 weeks

1. 1 Previous Scar in 2016
2. GDM on diet control
3. H/o UTI at 31 weeks, completed T Cefuroxime 1/52
4. Etc

Currently,
Stable under room air
Establish breastfeed
PU normal
BO x 1

O/E: Active on handling, good perfusion, not jaundice/ jaundice till abdomen

PR 140
RR 38
T 37
Spo2 100%

Lung equal breath sound
CVS DRNM
P/A soft, not distended

Physical Examination

No dysmorphism
No cleft lip or palate
No spina bifida, normal spine

Bilateral femoral pulse palpable
Bilateral hip stable/ no DDH
No cynosis
No murmur

Normal male genitalia
(Bilateral testes palpable)

Normal Female Genitalia

Moro complete
Good Cry
Good ms tone
No CTEV

PLAN

1. Allow discharge to mother

2. Trace cTSH and G6PD

3. Watchout for jaundice

4. Encourage breastfeed

EXTRA

1. If septic workout taken at labor room, result finally come out Total White Cell high (> 25)

Atau HCT High (some doctor ambil value more than 60, some >65)

➢ High TWC : Presumed sepsis secondary to mother UTI/URTI/PROM >24 Hour, CAP, etc

➢ High HCT : Polycythemia for observation

2. Jika baby nampak jaundice, put baby under phototherapy, then take jaundice workout (depend case to case). Jaundice workout:

➢ Serum Bilirubin

➢ ABO (blood group)/ DCT (direct coombs test)

➢ G6PD (trace)

➢ FBC/ Reticulocyte

3. Jika SB (serum bilirubin) above photo level (ada jadualnya, photo level berbeza mengikut umur baby (day ? of life) dan samada mature or prem baby ketika delivery), admit baby to ward. 

➢ PLAN :

1. Start Phototherapy

2. Repeat SB cm/ or 

3. Repeat SB 4Hour post photo (if patient on intensive phototherapy)