BASIC SCAN Fetal Number Fetal Presentation Placental Location Documentation of fetal life Assessment of amniotic fluid Assessment of gestational age (see diagrams) BPD HC AC FL Evaluation for Maternal Pelvic mass
Evaluation for fetal anatomy to inlcude: Cerebral Ventricles Four Chambers Heart and Thorax Spine Urinary bladder Abdominal wall (see diagram) Renal region Stomach
Documentation of Basic Scan Minimum of 8 photos on all patients BPD and OFD Spine - 3 views (tranverse,upper, and lower) Thorax and 4 chamber view AC with stomach Bladder Femur length Anything unusual - myoma, oligohydramnios, polyhydramnios Please state the reason if the scan is unsatisfactory. A scan may be unsatisfactory due to: OIigo, fetal position, engagement, compression of fetal parts, maternal factors.

MISCELLANEOUS INFORMATION

Grams to Pounds Conversion: 1 pound = 454 grams

1500 grams = 3lbs, 5oz
2000 grams = 4lb, 7oz
2500 grams = 5lbs, 8oz
3000 grams = 6lbs, 10oz
3500 grams = 7lbs, 11oz
4000 grams = 8lbs, 13oz
4500 grams = 9lbs, 15oz
5000 grams = 11lbs, 0oz

Normal AFI – between 5 and 15

Pre-eclampsia: 24 hour urine protein greater than 300 mg

NST – acceleration is defined as 15 bpm rise for 15 sec;
            need 2 accelerations in 20 minutes to be reactive

Asthma:  Give Albuterol with Atrovent unit dose with peak flow pre and post.
                  Abuterol 0.5/Atrovent 2.5 Nebs Q 4h x 24hrs

Heparin Sliding Scale:  Adjust by monitoring Q 6h.

Initial Dose:  80 u/kg then 18 u/kg/hr
PTT <35:  80 u/kg bolus then increase by 4 u/kg/hr
     35-69:  40 u/kg bolus then increase by 2 u/kg/hr
   70-100:  No change
100-130:  decrease by 2 u/kg/hr
      >130:  stop infusion x 1h, then decrease by 3u/kg/h

RISK OF RUPTURE after C/S:  (NEJM) 

Repeat C/S  0.16%
Spont Labor 0.52%
Pitocin Induction   0.77%
Prostaglandin Induction  2.45%

NEW BORN BABY PROG NOTES:

S: Baby doing fine lying comfortably in the crib, no concerns from nurse and mom

Apgar 1 min:  9
Apgar 5 min:  10

Ins:
Outs:
Net:
Stool:

BW:

CW:

O: Vital Signs:

PHYSICAL EXAM
Cry: Strong
Mucus: Some mucus
Skin: Clear, no lesions
Color: Pink
Activity: Strong flexor muscle tone, symmetrical posture and movement
Reflexes: Moro strong, grasp strong, sucking strong
Head: Molding, fontanels open
Eyes: Normal appearance, red reflex present bilaterally
Ears: Normal size and shape, same plane as eyes
Mouth: Normal size and shape, no deformities, palate intact, symmetrical movement
Nose: Normal size and shape, nares patent
Jaw: Normal size
Neck: Normal appearance
Chest and Lungs: Symmetric, good bilateral breath sounds
Cardiovascular: Regular heart sounds, capillary refill <=2sec, pulses equal and symmetric
Abdomen: Normal, bowel sounds present, no masses, no hernia
Genitalia: normal male anatomy, testes both descended, anus appears to be patent./ Normal female anatomy noted
Back: Straight, no dimple
Cord: 3 vessels, bluish-white color
Skeletal: Normal appearance, clavicles intact, full range of motion of all extremities, no hip click

Laboratory Data:

ASSESSMENT/PLAN
1 day old Baby boy , delivered via SVD/ LTCS (sec to arrested labor) by 28 G1, now P1 mention maternal history of  ANY DISEASES/INFECTION AND WHAT TREATMENT DID SHE GET AND WHEN WAS THE LAST DOSE TAKE, now doing well, HD stable, afebrile.

1. continue routine care
2. Breast and bottle feeding
3. Anticipate discharge to home possibly tomorrow with mother.

DISCHARGE ORDERS
Discharge baby home with mother
Dx: NB Baby Boy
Condition: Stable
Diet: Breast/ Bottle feeding
F/U in 2 weeks at Salinas/ FHC call for appt if going to FHC Tel# 358-9601
Instructions to Mom: Sleep baby on back, proper positioning for breast feeding, safety about car seats.
Return to ER or Clinic earliest if baby develops fever, jaundice, unable to feed or any other concerns.