Newborn Notes

Inform by SN in LDS to assess baby of GDM mother on diet control
Baby of Lisa Syuhada Binti Abd Hadi

Baby boy Born on 31/05/2020 @2322H
Born via SVD at 39w + 6d
BW: 3.19 kg Mother
Blood group B +ve
G6pd and cTSH Taken
Infective screening NR
Mother, 27 years old, G2P1 at 39 weeks 6 days
ANC :
1. 1 previous EMLSCS in 2015 for poor progress
- intraop/post op uneventful
- BW : 3.7kg
- no trial of scar
- VBAC signed
2. Maternal obesity
- booking BMI : 42
- seen by anaest on 19/5/2020
- plan : for intrapartum epidural
3. GDM on d/c
- MGTT x1 at 32w: 6.0/7.8
- HBA1C : 5.2%
- latest BSP 12/5/2020 : 5.2/5.0/5.2/6.1
- s/b dietician 22/4/2020
4. H/o miscarriage in 2019
- D&C not done
Birth history: (Given by staff nurse attended)

Baby born vigorous, pink, good breathing effort, good muscle tone Indirect suction: clear
Initial steps done Apgar Score : 9 in 5 minutes, 10 in 10minutes
No further resuscitation required
Attended the baby at 10min OL

Baby pink, crying , good breathing effort , good muscle tone no nasal flaring, no recession,
no grunting, no stridor SPO2 detecting HR 130 bpm
Attended the baby at 20 min OL
Baby pink, crying , good breathing effort , good muscle tone no nasal flaring, no recession,
no grunting, no stridor HR 140 bpm
O/E: active, crying, pink, AFNT, no scalp swelling, eyes and ears normal, no cleft lips and
palate, not tachypneic, no nasal flaring, no grunting, no stridor
Not dysmorphic, no neck swelling / No palpable mass, no chest deformities
Lungs : clear, equal air entry
CVS : DRNM
Abdomen : soft, not distended, no organomegaly
Bilateral femoral pulses palpable
Umbilicus: 2 UA, 1 UV
Normal male genitalia, both testes descended
Anus opening seen
No spine deformities
Hips stable
Moro complete
Suckling and grasp reflex present
No CTEV NPU
IMP: 1. Infant of GDM mother on diet control

2. Term baby of 39 w + 6d with BW 3.19kg
Plan: allow discharge to mother under paeds

allow breastfeeding within 1H OL
allow topup feeding 24cc/3 hourly (TF 60cc/kg/day) DXT at 2H OL (postfeeding), DXT
3hourly (prefeeding) x2, if stable 6 hourly off DXT after 12H OL if stable
inform if DXT <2.6 mmol/L
inform if there is s/sx of hypoglycemia (jitteriness,irritability,apnea,poor feeding,high pitch
cry,seizure,lethargy)
PRESUMED SEPSIS
informed by lds sn to assess baby
Baby of Sajidah binti Habir Ahmad

baby girl
Born 26/5/2020 at 0817H
Born via SVD at EDD + 6/7
BW: 2.755kg
AS 9/10
Mother Blood group O +ve
G6pd and cTSH Taken
mother 36 years old, para 6 at EDD + 6d

REDD 20/5/2020 (given at 28 weeks)
ANC:
1. PROM <24H
- leaking since 1130H (25/5/2020), history not suggestive, clinically not demonstrable
- minimal leaking of liquor, clear, not foul-smelling
- no signs and symptoms of chorioamnionitis
- good fetal movement, CTG @0330H 26/5/2020 normal
- on IV ampicillin 1g (given 2 doses,at 11pm 25/5/2020 and 6am 26/5/2020)
2. Late booker at 28w
3. Grandmultipara
- LCB 2016
4. Advanced maternal age
5. Anemia in pregnancy
- on T. Zincofer
6. H/o referred to SPG clinic TRO asymetrical IUGR

- scan done, growth chart AC growing, above 5th centile
- SGA, planned not to allow post date
p/w: Spontaneous active phase of labor
Birth history:
Baby born vigorous, good breathing effort, good muscle tone, HR 130bpm
Indirect suction: clear liquor
Initial steps done
At 1 min OL
Baby acryocyanosis, crying , good breathing effort , good muscle tone
no nasal flaring, no recession, no grunting, no stridor
SPO2 detecting
HR 150 bpm
AS at 1 min OL: 9
At 5 mins OL
Baby pink, crying , good breathing effort, good muscle tone
no nasal flaring, no recession, no grunting
SPO2 : 98 % under room air
HR: 160 bpm
AS at 5 mins OL: 10
At 10 mins OL
no intermittent, no nasal flaring, no recession, no grunting,
HR: 150 bpm
O/E:
active, crying, pink, AFNT, no scalp swelling, eyes and ears normal, no cleft lips and palate,
not tachypneic, no nasal flaring, no grunting, no stridor
Not dysmorphic, no neck swelling / No palpable mass,no chest deformities

CVS : DRNM

Normal female genitalia
Anus opening seen
Moro complete
haven't PU
just BO
imp:
1. presumed sepsis (mother PROM <24H, adequately covered, given IV ampicillin >4
hours;2 doses:1st dose at 11pm 25/5/2020,2nd dose at 6am 26/5/2020)
2. term baby EDD +6/7 with BW = 2.755 kg
plan:
1. allow baby to mother under paeds
2. observe for 48 hours
3. DXT monitoring 6 hourly
4. watchout for s/sx of sepsis (respiratory distress,poor
feeding,vomiting,seizure,hypoglycemia,seizure)
5. monitor temp, RR and HR 4 hourly
6. allow topup feeding 21cc/3hourly (TF 60cc/kg/day)
inform by Sn to assess PROM < 12 H
Baby of hanbenah
baby girl
Born 28/5/2020 at 0250H
Born via SVD at 39w2d
BW:3.23kg
Blood group O+ve
G6pd and cTSH Taken
21 years old, G2 at 39 weeks 2 days
blood group : O +ve
infective screening : NR
Issue :
PROM < 12 H at 27/5/20 2300H
given IV ampicillin x2 doses
ANC :
1. 1 previous scar in 2017 for fetal distress
- intraoperation uneventful
- post op plan : allow trial of scar

- VBAC signed
2. Resolved anemia in pregnancy
- booking Hb : 11
- latest Hb 12/5/2020 : 11
- on T Zincofer 1/1 OD
3. Maternal overweight
- booking BMI : 29
inform by SN baby born crying ,born vigorous ,good breathing effort
initial steps done
suction clear
spo2 : 975
HR 150
apgar 9’10’
O/E: active, pink no tachypnea AFNT CRT < 2 s good pulse volume
normal tone
No dysmorphism
no cleft lip or cleft palate
CVS S1S2 no murmur
lungs clear
PA not distended, soft
Umbilical cord – 2 UA, 1UV
female genitalia
femoral pulse palpable
spine normal
Hip stable
Moro’s complete
suckling and grasping present
no CTEV
anus opening seen
Impression:
Infant with risk of sepsis
(leaking liquor <12 H , covered adequately )
Plan:
Admit PNW under peads
watch out ssx sepsis
DXT at 2H OL , if stable 3 hourly x2 if stable 6 hourly x2 ,inform if DXT < 2.6 mmol/l
encourage BFOD
Imform by SN to standby in LDS for prem twin babies
Baby of Aslinawati Binti Mohd Lazim (1/2)

baby girl
27/05/2020, 1751H
Born via SVD at 35w 2d
BW: 2.34kg
AS 9/10
Mother Blood group: A +ve
G6pd and cTSH Taken
infective screening NR
41 y/o, G6P2+3 at 36w2d
ANC:
1. Cholelithiasis and choledocholithiasis causing biliary obstruction

- ERCP x 2 done during this pregnancy
-ANA NR
CMV Ig G: detected, Ig M: NR
EBV Ig G: Pos, Ig M Neg
Hep B, Hep C: NR
Toxo Ig G: pos
2. GBS bacteriuria
- urine C&S (8/1/20) strep agalactiae
- treated with cephalexin for 1/52
3. Hepatitis A Carrier
--noted screening taken during admission in nov
--Hep A: IgG positive (27/11/2020)
Birth history:
passover from O&G Team
baby born vigorous, crying, pink with blue extremeties
not tachypneic, no grunting
initial steps done
suction light stained
SPO2 detected
AS at birth: 9
at 1 min OL
MO Dr Chow arrived to attend the twins
was told that the baby was well and saturating well, thus Dr Chow went ahead to attend the
second twin to be delivered
active, not tachypneic, no nasal flaring
SPO2 was 88%
at 5 min OL
active, pink, not tachypneic, no nasal flaring
SPO2 was >90%
at 7 min OL
staff nurse called for Paeds MO to assess the baby due to baby suddenly became
desaturated under room air
Dr Chow attended stat
breathing was irregular, RR 58, SPO2 54%, HR 134
however, no nasal flaring, no chest recession
given CPAP with FiO2 70%

SPO2 picked up to 100%
HR 145
gradually reducing the FiO2 to 30%

then changed to NPO2 1L/min
no chest recession, no nasal flaring, not tachypneic
SPO2 100%
HR 150
O/E:

CVS : DRNM

Anus opening seen
Moro complete
haven't PU/BO
IMP:
1. Presumed sepsis (mother was GBS positive)
Plan (given by Dr Chow):

Admit NICU
Cont NPO2
Start IV Gentamicin 10mg 24 hourly
Start IV C-Penicillin 230,000 units 12 hourly
To take blood C&S and FBC
If worsening repiratory distress, to get CXR and blood gas
KIV start oral feeding if not tachypneic (TF 60cc/kg/day)
HO Danial 78916
baby of Baljit Kaur A/P Amerik Singh

baby boy
Born 27/5/2020 at 1117H
Born via SVD at 39 weeks 6 days
BW: 3.45kg
AS 9/10
Mother Blood group AB +ve
G6pd and cTSH Taken
30 y/o P2 at 39weeks + 6days
ANC:
1. Alpha Thalassemia trait
- no blood transfusion
- husband screening before, no alpha thalassemia
- Latest Hb: 12/5/2020: 9.1
- on Zincofer 1/1 OD
2. Maternal obesity
BMI booking 37
MGTT X2 Normal
3.Poor spacing
- LCB May 2019
informed by lds to assess baby of maternal Alpha Thalassemia trait

attended by Ho Danial at 1220H
O/E:
active, crying, pink, AFNT, eyes and ears normal, no cleft lips and palate, not tachypneic, no
nasal flaring, no grunting, no stridor
Not dysmorphic, no neck swelling / No palpable mass, no chest deformities

CVS : DRNM

Anus opening seen
Moro complete
BO in pampers
haven't PU
imp:
1. Infant of Alpha Thalassemia trait mother
plan:
1. allow to mother under paeds
2. encourage BF
3. allow topup feeding 60cc/kg/day
4. TCA nearest KKIA at 1 years of age for Thalassemia screening
HO Danial 78916
Baby of Desi Purnama

baby Girl
Born 20/5/2020 at 1455H
Born via SVD
BW:3.17
Blood group O+ve
G6pd and cTSH Taken
p/w
1. Contraction pain since 0000H
Regular, increasing in intensity and frequency
+show
No leaking liquor
Good fetal movement
Mother history
30 ys old, G2 P2
ANC
1) 1 st pregnancy 2nd union
2) subfertility 4 ys
3) LCB 17 ys ago
4) hypothyroidsm not on medication ( TFT 1st trimester, TSH 1.89 , FT4 14.1 )
Attended as received call from labour room for baby born flat
attended at 2 min of life
Passover by O&G team
term baby
no maternal risk of sepsis
delivered via SVD
Born non-vigorous
attended by O&G team
initial step done – clear liquor
Apgar score at first min of life was given 6 (HR 100, irregular breathing effort, some flexion
and grimace, pink centrally)
Initiated CPAP by O&G MO Dr Zarif
No PPV given
Attended baby at 2 min of life
good cry, good breathing effort, HR 150bpm, active, pink, Spo2 detecting
not tachypnoeic, no chest recession
no grunting or nasal flaring
Apgar score at 5 min of life was 10
SpO2: 98% under room air, HR 160bpm
O/E: active, pink
not tachypnpoeic
AFNT, no scalp swelling
No dysmorphism
CVS S1S2 no murmur
lungs clear
normal female genitalia
spine normal
Hip stable
Moro’s complete
Impression: Delayed transition of newborn
Plan:
discharge to mother
Chow
55216
b/o linda arfayiani
inform by Sn to assess at 2 min OL for preterm 34w
attended stat by Ho Lim and Dr chow
Baby of
baby girl
Born 28/5/2020 at 0424H
Born via SVD at 34w
BW:1.88kg
Blood group B +ve
G6pd and cTSH Taken
32yo G1 P0 at 33w 6d POA
ABO B+ve
Issue:
-PPROM day 2(history suggestive , clinically demonstrable) with preterm labour
- p/w clear liq dribbling down her thigh while ambulating @ 1430H 25/5/20
-PSE in ward today:minimal liquor seen, litmus positive /os tip of finger / cx tubular middle
-on tab EES 400mg BD
-IM dexa Completedx2
- urine c&s, HVS c&s: pending
- ventilator available
ANC
1. Primary subfertility for 6 years
- investigated, was told to be normal for husband and wife
- current pregnancy spontaneous conception
2. persistent proteinuria since 19 weeks
- 24H urine protein at 0.02g/day, volume is 750ml
- creatinine baseline is 38
3. H/o UTI at 17w POA
- treated with T Cephalexin
- RP normal
- no urine C&S not taken
- HVS C&S Candida (not albicans)
MGTTx2 at 25w : 4.4 / 5.3
initial steps done
suction clear
spo2 : detecting
HR 150
apgar at 1 min OL 9
attended by ho lim and Dr chow
At 2min OL
no recession , no nasal flaring ,no grunting
HR 155
Spo2 : 90 %
At 5 min OL
HR 160
Spo2 : 95 %
At 10min OL
HR 158
Spo2 : 96 %
At 15min OL
HR 160
Spo2 : 98 % RA
O/E: active, pink no tachypnpoeic AFNT CRT < 2 s good pulse volume
No dysmorphism
CVS S1S2 no murmur
lungs clear
female genitalia
spine normal
Hip stable
Moro’s complete
no CTEV
anus opening seen
IMP :
1) Preterm at 34week with LBW 1.88kg
2) Presumed sepsis
PLAN : d/w Dr chow
admit NICU
keep NBM with IVD D 10 % 4.7cc/h
FBC, blood c + S , DXT
Start IV c penicillin / gentamicin
Watch out ssx sepsis
DXT 4 hourly
ballad score
trace mother HVS C+ S

suction clear
spo2 : 97 % RA
HR 155
apgar 9' 10 attended at 20 min OL Baby of Nik Intan Ika Syaierah
baby male
Born 27/5/2020 at 2320H
Born via SVD at 36w
BW:2.63kg
Blood group AB+ve
G6pd and cTSH Taken
21 years old, para 3 at 36w

blood group : AB +ve
infective screening : NR
ANC :
1. PPROM>24H
- T Prostin 3mg inserted at 0630H 27/5/2020, Os 1cm Cx 2cm
- leaking since 12 noon 24/05/2020
- On IV ampicillin
2. GBS positive
HVS C&S (24/5) : Strepto agalactiae, Candida albicans
- sensitive to Erythromycin, Penicillin
3. Poor spacing (LCB <2 years)

O/E: active, pink not tachypnpoeic AFNT no recession CRT < 2 s good pulse
volume normal tone
No dysmorphism
CVS S1S2 no murmur
lungs clear
PA not distended, soft Umbilical cord – 2 UA, 1UV
normal male genitalia , bilateral tested descended
spine normal
Hip stable
Moro’s complete
no CTEV
anus patent Impression: 1) late preterm at 36w with Bw 2.63kg
2) infant with risk of sepsis ,mother GBS +
- ( leaking clear liquor >24 H , covered adequetly )
Plan:
admit to PNW under peads monitor tempareture , RR and HR 4 hourly DXT 3 hourly
x1 if stable 6 hourly x2
inform if DXT < 2.6 mmol/l watch out for ssx hypogylcaemia watch out ssx of sepsis for
48 H
encourage BFOD allow top up 20cc 3 hourly ( TF 60cc/kg /h )
Baby of Syafawati binti Zamri

baby boy
Born 26/5/2020 at 1113H
Born via SVD at 31 weeks 6 days
BW: 1.735 kg
AS 9/10
Mother Blood group A +ve
G6pd and cTSH Taken
mother 25yo para 1 at 31w 6d POA
** Allergic to seafood - crab**

develop itchiness and perioral oedema
- NKDA
ANC:
1. PPROM since 22/5/2020 (>24H)
- IM Dexa 1x given at 1445H (22/5/2020)
- IM Dexa 2x completed at 1445H (23/5/2020)
- HVS C&S (22/5/2020) : NG after 48H
- gram stain genital (22/5/2020) :
Scanty pus cells seen
Scanty Epithelial cells seen
Scanty Gram Positive Rods seen
Scanty Gram Negative Rods seen
- WBC (26/5/2020) : 17.3 --> 17.7
- given T EES 400mg BD x10/7 since 22/5/2020
2. GDM on diet control

- Latest BSP 20/5/2020 : 4.7 / 6.1 / 5.3 / 4.6
- HbA1C pending
- MGTT X1 : 4.4/3.6
- MGTT X2 : 4.4/8.5
3. h/o thyroid surgery at 14 yo in 2008

- done in Hosp Sg Petani
- ? thyroglossal cyst
p/w:
Leaking liquor since 0800H 22/5/2020 (PPROM >24H)
- dribbling of warm fluid
- used 1 pad
- clear color, no foul smelling
- no more leaking on 23/5/2020
Otherwise
no show
no contraction pain
good fetal movement
no fever
no UTI/URTI symptoms
Birth history:
Baby born weak, poor breathing effort, good muscle tone, HR 130bpm
Initial steps done
At 1 min OL
Baby acyocyanosis, poor breathing effort , good muscle tone
no nasal flaring, mild recession, no grunting, no stridor
SPO2 detecting
HR : 130 bpm
RR : 35
AS at 1 min OL: 9
At 5 mins OL
no nasal flaring, no recession, no grunting
SPO2 : 95 % under NCPAP
HR : 160 bpm
RR : 50
AS at 5 mins OL: 10
At 10 mins OL
Baby pink, crying , good breathing effort, good muscle tone, no nasal flaring, mild recession,
no grunting
HR: 160 bpm
RR : 60
At 15 mins OL
baby pink, crying, good breathing effort, good muscle tone, no nasal flaring, no recession, no
grunting
HR : 160 bpm
O/E:

CVS : DRNM

Anus opening seen
Moro complete
just PU
haven't BO yet
imp:
1. premature baby 31 weeks 6 days with BW = 1.735 kg
2. infant of GDM mother on diet control
3. infant with LBW of 1.735kg
plan:
1. admit to NICU
2. DXT at 1H OL, 2H OL subsequently every 4hourly, inform if DXT <2.6 mmol/L
3. inform if s/sx of hypoglycemia (jitteriness, poor feeding, lethargy, high pitch cry, apnoea,
seizure)
4. allow feeding 13cc/3hourly (TF 60cc/kg/day)
Baby of Makiah Binti Sahefudin

baby boy
Born 25/5/2020 at 1541H
Born via VAD for fetal distress
BW: 3.08kg
Mother Blood group O -ve
G6pd and cTSH Taken
22YO, G2P1 @ 39w POG

REDD : 01/06/2020 (given based on scan at 8w subsequent scan corresponded)
Blood group : O NEG
VDRL / HIV : NR
ANC:
Unbooked unscreened at KK
p/w
Birth history:
Initial steps done
At 1 min OL
Baby crying , good breathing effort , good muscle tone
mild nasal flaring, mild recession, no grunting, no stridor
SPO2 detecting
HR 150 bpm
AS at 1 min OL: 9
At 5 mins OL
mild nasal flaring, mild recession, no grunting
HR: 160 bpm
AS at 5 mins OL: 10
Put on headbpx 10L/min
At 10 mins OL
mild intermittent nasal flaring, mild recession, no grunting,
HR: 150 bpm
Lodge in SCN under NPO2 1L/min
O/E:active, crying, pink

Anterior fontanelle normotensive, chignon over the right occipital region,
Not tachypneic, mild intermittent nasal flaring, mild recession, no grunting, no stridor
Not dysmorphic, no low set ears
No neck swelling / No palpable mass
Opening bilateral eyes
No cleft lip and palate

No chest deformities
Lungs clear, equal air entry

CVS S1S2 no murmur
Abdomen soft, not distended, no organomegaly
Anus opening seen
Moro complete
No other neurocutaneous stigmata
IMP:
TTN
Post VAD
Infant of Rhesus negative mother
Plan:
Lodge in SCN under NPo2 1L/min
Keep Spo2>95%
Send Cord blood for FBC + Reti + TSB + ABO and rhesus + Coombs test
Trace the Ix and inform MO urgently
Baby of Makiah Binti Sahefudin

baby boy
Born 25/5/2020 at 1541H
Born via VAD for fetal distress
BW: 3.08kg
Mother Blood group O -ve
G6pd and cTSH Taken
22YO, G2P1 @ 39w POG

REDD : 01/06/2020 (given based on scan at 8w subsequent scan corresponded)
Blood group : O NEG
VDRL / HIV : NR
ANC:
Unbooked unscreened at KK
p/w Spontaneous labour
Birth history:
Initial steps done
At 1 min OL
Baby crying , good breathing effort , good muscle tone
mild nasal flaring, mild recession, no grunting, no stridor
SPO2 detecting
HR 150 bpm
AS at 1 min OL: 9
At 5 mins OL
mild nasal flaring, mild recession, no grunting
HR: 160 bpm
AS at 5 mins OL: 10
Put on headbpx 10L/min
At 10 mins OL
mild intermittent nasal flaring, mild recession, no grunting,
HR: 150 bpm
Lodge in SCN under NPO2 1L/min
O/E:active, crying, pink

Anterior fontanelle normotensive, chignon over the right occipital region,
Not tachypneic, mild intermittent nasal flaring, mild recession, no grunting, no stridor
Not dysmorphic, no low set ears
No neck swelling / No palpable mass
Opening bilateral eyes
No cleft lip and palate

No chest deformities
Lungs clear, equal air entry

CVS S1S2 no murmur
Abdomen soft, not distended, no organomegaly

Anus opening seen
Moro complete
No other neurocutaneous stigmata
IMP:
TTN
Post VAD
Infant of Rhesus negative mother
Plan:
Lodge in SCN under NPo2 1L/min
Keep Spo2>95%
Send Cord blood for FBC + Reti + TSB + ABO and rhesus + Coombs test
Trace the Ix and inform MO urgently
Informed by from O&G team for prem delivery. Attend stat with Dr Ng. Baby of Noreleen
Izwani Binti Khairul Anuar
Baby girl
Born at 01/06/2020 at 0147H
Born SVD at 32 weeks
BW : 1.82kg
AS : 8/10
G6PD and cTSH taken 27 y/o, G1P0 at 32 weeks 6 days POG
REDD : 20/7/2020 (given at 26 weeks)
blood group: pending
hiv rapid test: non reactive
vdrl/ rpr: not taken.
ANC:
1) newly dx PIH - not on treatment.
BP at PAC 153/91 urine albumin : 1+
PE profile normal
UFEME: alb: nil
2) PPROM >24H
-leaking liquor since 0300H 29/5/2020
-os 3 cm
- AFI 3.2, EFW 1864g
-UFEME: no UTI
-WBC 15
-dexa completed on 30/5/2020
- MgSo4 given for neuroprotection- 10 hours.
- IV C Pen given adequately, 1 dose 4 hours before delivery

3) Bronchial asthma
- diagnosed at 17 years old
- not on any medications and follow up
- no h/o admission/intubation
- last attack : last week - went to hospital and was given nebulizer and MDI Ventolin PRN
- PEFR 14/4/2020 : 290,290,300
-triggering factors : pesticide, eating cabbage
4) Late booker at 27 weeks,
-defaulted KK follow up to repeat scan and TCA
5) Maternal obesity (booking BMI 37)
6) Single parent
- partner : patient's fiancé (engagement in April 2019), an officer in Publika
- plan to get married post delivery Social History:
Mother working as receptionist at spa
Partner, 29y/o, working as a rider
Engaged last year, planning to get married after delivery
Partner is Bugis from Sabahan
Mother planned to take care of child after delivery
Partner’s mother will take care of child after delivery when she’s working
Mother went back to Perlis with partner on 05/05/2020 to Perlis to attend her mom’s funeral in
Taman Utama Jaya, Kangar (green zone).
Mother and partner were screened for COVID on 18/05/2020 in Perlis.
Mother was unsure about the COVID screening test result, but was given surat pelepasan from KK.
Mother came back to KL for follow up and was informed by KK Segambut she has GDM. Birth
history: No cord around neck
Noted foul smelling liquor upon delivery.
No meconium stain
Baby born vigorous, crying.
Apgar score 8,10 in 1 min OL (resp 1, colour 1)
SpO2 detecting HR 120
Noted irregular breathing.
PPV x2 cycle given.
Subsequently Apgar Score 9,10 in 5minutes
HR 160bpm
SpO2 100% under RA OE: active on handling, crying, pink, AFNT
no scalp swelling
not dysmorphic
eyes and ears normal
mouth normal
no neck abnormalities
no cleft lips/palate lungs: clear
CVS : DRNM
pa: soft, not distended
umbilicus : 2UA, 1UV

bilateral femoral pulses palpable
normal female genitalia
hip stable
spine normal
Moro's complete
sucking and grasp reflex present
no CTEV
Anus patent
PU already Imp:
1) Prem @32 weeks
2) Presumed sepsis infant
3) Infant of newly diagnosed GDM mother
4) Single mother
Plan:
1) Admit NICU
2) keep SpO2 >92%
3) watch out for worsening respiratory distress
4) Keep NBM
5) Start IV C Pen and Genta
6) IVD 4.6cc/hour x3
7) For FBC, blood gas and blood c+s
8) DXT monitoring 2hourly x2, if stable 6hourly
9) Trace formal report COVID screening from KK Kangar tomorrow
10) Refer JKSP tomorrow
HO NADIA 84834
Standby for ELLSCS for fetal compromise (CTG por variability with baseline HR 130).
Attended by Dr Koo Ho Wai (MO) and me (Ho Ainaa) and Ho Faiz. Baby of Siti Norita
Baby girl
Born via EMLSCS for fetal compromise at 38w1d
DOB 15/4/2020 at 2037H
BW 2.83kg
AS 8/10
cTSH and G6PD taken
Mother, 35 years old, Para 2 MBG: O +ve Infective screening: NR
Mother Issues:
1) IOL For late onset PIH, on T methyldopa 250 mg BD
- Foleys catheter inserted at 0915h (14/4/2020)- Os tip of finger, cx tubular, st -2, MI
- Foleys catheter removed at 0530H ( 15/04/20)
- 1st prostin 1.5mg inserted at posterior fornix at 1100H 15/4/2020
ANC 1. 1 Previous scar - 2015

-VBAC form signed.
2. Maternal obesity
- BMI 35.4
- MOGTT x2 normal
3. Bronchial asthma
- on MDI Salbutamol 2puff PRN
- last attack july 2019
- no h/o ICU admission/ intubation Electively admitted for IOL.
Birth history: Baby born vigorous, blue with good breathing effort and good muscle tone
Initial HR: 180
Indirect suction: clear
Initial steps done SPO2 detecting AS at 1 min OL: 8 Reassess at 5mins OL
Baby pink, good breathing effort, good muscle tone
No nasal flaring, not tachypnoeic, no recession, no grunting
SPO2 85%
HR 170bpm AS at 5 mins OL: 10
Reassess at 10mins OL Baby pink, good breathing effort, good muscle tone
No nasal flaring, not tachypnoeic, no chest recession SPO2 97%
HR 146bpm O/E: Active, AFNT
Caput succedaneum measuring 2cm x 1.5cm
Not dysmorphic
Not tachypnoeic
No recession
No cleft lip/palate
Lungs clear
CVS DRNM
Abdomen soft, not distended, 2UA, 1UV
Bilateral hips stable
Bilateral femoral pulses felt
Anus patent
No CTEV
Spine normal Moro complete
Impression:
- Term baby girl at 38weeks 1day with birth weight 2.83kg Plan:
- Allow baby to mother under paeds - Encourage BFOD - Allow top up feeding 21cc 3 hourly
(TF 60cc/kg/hr) if required - For newborn screening by MO cm - Monitor COH per shift for 1
day - DXT monitoring at 2H OL, then 3 hourly x 2, then 6 hourly - Inform if DXT < 2.6
--------------------------------------------------------
Standby for EMLSCS for poor progress (MCDA twins)

Attended by Dr Koo Ho Wai (MO) and me (Ho Ainaa)
Baby of Nor Syazana
Baby boy
Born via EMLSCS for poor progress at 37w4d
DOB 15/4/2020 at 1847H
BW 2.49kg
AS 9/10
cTSH and G6PD taken
Mother, 28 years old, Para 2

MBG: O +ve
Infective screening: NR
Initially electively admitted for IOL

- Post foley's catheter
-- Foley's catheter with 60cc sterile water removed at 1110H 14/4/2020
ANC
1) MCDA twin pregnancy
2) resolved anemia in pregnancy
- previously on T iberet 1/1 OD
-Latest HB(12/04/2020):12.4
Birth history:
Baby born vigorous, acrocynosis with good breathing effort and good muscle tone
Initial HR: 160
Initial steps done
SPO2 detecting
AS at 1 min OL: 9
Reassess at 5mins OL
SPO2 93%
HR 167bpm
AS at 5 mins OL: 10
Reassess at 10mins OL
No nasal flaring, not tachypnoeic, no chest recession
SPO2 100%
HR 146bpm
O/E:
Active, AFNT
Caput succedaneum measuring 2cm x 2cm
Not dysmorphic
Not tachypnoeic
No recession
No cleft lip/palate
Lungs clear
CVS DRNM
Anus patent
No CTEV
Spine normal
Moro complete
Impression:
- Late preterm baby boy at 37weeks 1day with birth weight 2.49kg
Plan:
- Allow baby to mother under paeds
- Encourage BFOD
- Allow top up feeding 20cc 3 hourly (TF 60cc/kg/hr) if required
- For newborn screening by MO cm
HO AINAA 79732
------------------------------------------------------------------
Mother Encounter ID: 10172945Mother Details

Gravida 3
Parity 0
Gestational Period 38Weeks 2Days
Delivery Type EM LSCS
Multiple Birth N
No of Births 1
Attending Practitioner Koo Ho Wai,DR
Attending Nurse Nur Idayu Razali,SN
Baby Details (Dygku. Noor Baizura Binti Awangku Ismail,Baby of / WCH0080278)

Demographical Details
Gender Female
Relationship Biologic. Child
Birth Date / Time 15/04/2020 22:05
Born Where In Facility
Clinical Details
Outcome Live
Length of Baby 46
Birth Weight 2.89
Head Circumference 33
Umbilical Cord Status Normal
Umbilical Cord Cut By Tay Chuu Suen,DR
Patency of Anus Yes
Apgar Score
Apgarscore in 1 mins 9
Apgarscore in 5 mins 10
Standby for EMLSCS for fetal compromise (CTG 172-196 bpm).

Attended by Dr Koo Ho Wai (MO) and me (Ho Faiz)
Baby of Dygku. Noor Baizura Binti Awangku Ismail

Baby girl
Born via EMLSCS for fetal compromise at 38w 2d

DOB 15/4/2020 at 22:05H
BW 2.89kg
AS 9/10
cTSH and G6PD taken
Mother, 35 years old, Para 1+2

Delivered at 38Weeks + 2Days
ANC
1. IOL for chronic hypertension
- Post foley's, removed this morning
- poor progress
2. Chronic hypertension not on treatment
- BP well controlled
3. GDM on D/C
-MOGTT at 24wks :5.0/10.2
-HbA1C at 5.9% at 31wks
4. H/o first trimester miscarriage in 2018 x 2
- D&C done in first miscarriage
5. Resolved IDA in pregnancy
- FBP: IDA, freritin 14.1
- Given IM inferon x 6, last injection on 8/3/2020
- Latest Hb: 11
Birth history:
Baby born vigorous, acrocynosis with good breathing effort and good muscle tone
Initial HR: 180
Initial steps done
SPO2 detecting
AS at 1 min OL: 9
Reassess at 5 amins OL
SPO2 85%
HR 170 bpm
AS at 5 mins OL: 10
Reassess at 10 mins OL
SPO2 95%
HR 144 bpm
Reassess at 15 mins OL
SPO2 97%
HR 133 bpm
On examination
Active, AFNT, Caput succedaneum measuring 2cm x 1.5cm over the left parietal
Not dysmorphic
Not tachypnoeic
No recession
No cleft lip/palate
Lungs clear
CVS DRNM

Anus patent
No CTEV
Spine normal
Moro complete
tone normal
PU - clear
Impression:
- Term baby girl at 38 weeks 2 day with birth weight 2.89kg
- infant of GDM mother on diet control and chronic hypertension
Plan:
- Encourage BFOD
- Allow top up feeding
- Monitor COH per shift for 1 day
- DXT monitoring at 2H OL, then 3 hourly x 2, then 6 hourly
- Inform if DXT <2.6
- to plot growth chart
HO Faiz 77567
------------------------------------------------------------
Received call from LDS to assess baby of GDM on T.MTF mother
30 minutes of life
Baby boy of Samihah Binti Abdullah
born at 37 weeks 3 days via SVD
AG: 9/10
birth weight: 2.4kg
TSH and G6PD taken
Mother hx:
34y'o P2 delvered via SVD at 37w 3d - post IOL
mother blood group :B positive
Infective screening :NR
Mother issue:
1. IOL for Late onset PIH
- Prostin X 1 inserted 1.5mg at posterior fornix 0645H (15/4/2020)
- T labetolol 100mg stat given at 2008H
ANC:
1. GDM on T. Metformin 1gm BD
-MGTT at 8 week : 4.7 / 7.9
- BSP : 4.6 / 5.6 / 5.5 / 5.7 / 5.5 / 5.7 /5.4
2. H/o 1 prev LSCS in 2014 for breech in labour
- EMLSCS @ 36+6 for PIH in labour
4. maternal obesity
BMI 37
5. H/O of preeclampsia previous pregnancy
- on T Cardiprin 100 mg OD/ T CaCO3 500 mg BD
Birth hx - hx given by staffnurse attended

baby born vigorous, pink, , good breathing effort, good muscle tone,
suction: clear
Apgar score: 9 in 5 minutes, 10 in 10 minutes
no further resuscitation required
upon examination:
active on handling, pink, not tachypneic, no subcostal recession, no nasal flaring, AFNT, no
cleft lip or palate,
suckling reflex normal
Lungs: clear, equal air entry

CVS: dual ryhtm, no murmur
warm peripheries
moving all 4 limbs
Abdomen soft, no organomegaly, bowel sound present,

umbilicus 2 artery, 1 vein
normal male genitalia, bilateral testes descended, no hypospadias
anus patent

hips stable
no CTEV, babinski normal
spine normal, moro reflex complete, good muscle tone

HR: 133
Spo2: 100% pre ductal under room air
Impression:
1 - late preterm baby bot at 37 weeks 3 days with birth weight of 2.4kg
2 - infant og GDM mother on T.MTF and late PIH
plan:
- Encourage BFOD
- Allow top up feeding
- DXT monitoring at 2H OL, then 3 hourly x 2, then 6 hourly x2, then 12hourly, if 12hourly
normal to off
- Inform if DXT <2.6
- to plot growth chart
HO Faiz 77567
--------------------------------------------------------------------------------
Received call from LDS to assess baby of hyperthyroidism mother
30 minutes of life
Baby girl of Marlina Binti Abu Bakar
born at EDD + 1day via SVD on 18/04/2020 22:25H
AG: 9/10
birth weight: 2.78kg
TSH and G6PD taken
Mother hx:
30 yo para 2 at EDD+1D
mother Blood Group: B+
ANC:
1. PROM < 12H (since 1430H on 18/4/2020) in Spontaneous active phase of labor
- clear liquor
- not foul smelling
- HVS C+S taken
2. Hyperthyroidsm in pregnancy
- Noted RME anterior neck swelling, tremor and occasional palpitation
- TFT taken(24/9/2019):
>> TSH : <0.01
>> T4 : 34.70
- Was started on T Carbimazole 10mg OD since 18/12/2019, stopped on 6/2/2020
- Latest TFT 13/2/2020
>>T4 13.87
>>TSH 0.63
MGTT x 1 (3/1/2020): 3.9/6.0
Birth hx - hx given by staffnurse attended

baby born vigorous, pink, , good breathing effort, good muscle tone,
suction: clear
Apgar score: 9 in 5 minutes, 10 in 10 minutes
no further resuscitation required
upon examination:
active on handling, pink, not tachypneic, no subcostal recession, no nasal flaring, AFNT,
no cleft lip or palate,

no macroglossia
suckling reflex normal
no mass palpable over the neck
Lungs: clear, equal air entry

CVS: dual ryhtm, no murmur
HR: 140-160 bpm
warm peripheries
moving all 4 limbs
Abdomen soft, no organomegaly, bowel sound present,

umbilicus 2 artery, 1 vein
normal female genitalia,
anus patent

hips stable
bilateral positional CTEV
babinski normal
spine normal, moro reflex complete, good muscle tone
Impression:
1 - Term baby girl at EDD + 1 day with birth weight of 2.78kg
2 - Infant of hyperthyroidism mother
3 - Bilateral positional CTEV
plan: (D/W Dr Ai)

- Allow baby to PNW under paeds
- KIV to take TFT at day 5 of life
- Encourage BFOD + top up feeding as tolerated
- trace mother HVS C+S taken on 18/4/2020
- to refer occupational theraphy for bilateral positional CTEV
HO Faiz 7
OT 06/06/2020
B/O Kasturi A/p Silvarajoo

Standby in OT for EMLSCS for breech in labour
Attended by MO lee WC and HO Nadia
Baby boy
Born on 6/6/2020 @ 0916H
Baby born via EMLSCS @35w3d
Birth weight: 3070g
Apgar score : 9 in 1 min, 10 in 5 mins OL
G6PD and cTSH Taken
Mother,37y/o, G2P1 at 35W3DAYS POA

EDD 7/7/2020
Issue : for BSP 7 point monitoring
ANC :
1. DM complicating pregnancy
- Newly diagnosed since early Oct at private GP
- currently on S/C Insulatard 16 iU ON, S/C Actarapid 5/6/8, T. Metformin 500mg BD
- bsp 7POINTS NORMAL RANGE
- HbA1C 22/4/2020 : 6.5
- Baseline creat 4/11/19: 53
- urine PCI 15/11/19: unable to calculate ratio
- under endocrine team:
s/c actrapid 5/6/8
s/c insulatard 16u ON
T.MTF 500mg BD
- Detailed scan by MFM : structurally normal fetus
2) H/o 1 previous caesarean section in 2014 for failed IOL.

- op done at Hosp ganesan medical centre : No Report available.
- Pt claims uneventful.
- keen for spontaneous vaginal delivery but if bishop score unfavourable and require IOL at 38
weeks, patient disagree with induction and opted for ERCS
3) Secondary subfertility
- LCB 2014
- was induced with clomid in Jan 19, one cycle
- current conception, spontaneous
Birth History:
At 1 min OL
Baby born vigorous, good breathing effort, active, acrocyanosis, crying
Indirect suction: Clear
Initial steps done
HR: 130
spo2: detecting
AS 9
At 5 mins OL,
baby pink, active, good breathing effort, no grunting, no recessions, no nasal flaring, good muscle
tone
SPO2: 95%
HR : 172
AS: 10
Temp optimized
At 10 min OL
Pink, active, good breathing effort, no recessions, no nasal flaring, good muscle tone
HR: 170/min
SPO2: 95%
At 30 min OL
Pink, active, good breathing effort, no recessions, noted nasal flaring, good muscle tone
HR: 167/min
SPO2: 97% under RA
Put under NPO2 1L/min
On Examination:
Active on handling, pink, AFNT, CRT<2s, no recessions, not tachypneic, not grunting
Not dysmorphic
No scalp swelling
Bilateral normal ears and eyes
No cleft lip/palate
No neck swelling
Lungs:Clear, equal air entry

CVS : DRNM
Abdomen: Soft, not distended
Umbilicus: 2UA, 1UV

Normal male genitalia, bilateral testes descended
Anus patent
No CTEV
Spine normal
Moro’s Reflex complete
Grasping & Suckling present
Ballards score 34-36w
Issue:
1) TTN
2) Infant of GDM mother on insulin
Plan:
1) Admit to SCN under NPO2 1L/min
2) Trial to wean off nasal prong in ward
3) DXT at 2 HOL, 3 Hourly prefeding for the first 6 HOL, then 6 hourly until 24 HOL
4) To inform if DXT <2.6mmol/L
5) Topup feeding 23cc 3 hourly TF 60cc/kg/day
HO NADIA 84834
B/O Nurul Zakirah Binti Zakaria
Standby in OT for EMLSCS due to suspected chorioamnitis
Attended by MO Lee WC and HO Nadia
Baby boy
Born on 6/6/2020 @ H
Baby born via EMLSCS @32w
Birth weight: 1480g
G6PD and cTSH Taken
ANC :
22 y/o, G2P1 @ 32w0d
LMP: USOD
EDD: 1/8/2020
Blood group: *not documented in pink book
ANC:
1. Chorioamnionitis
- On IV Cefuroxime, IV Flagyl - Day 1
- WCC: 10
- Having spiking temp at 0800H: 38.3C
- Tachycardic since 0400H
- Leaking since 1pm yesterday (05/06/2020), liquor clear
2. Epilepsy under NeuroHKL follow up

- on Lamotrigine 150mg ON and T. Epilim 400mg BD
- Not compliant to medication.
- 3 - 4x fitting episode in 2019 d/t missed medication
- last fitting in May (as per husband)
- Had an episode of seizure today (06/06/2020) in ward at 4am
- Further history noted patient has been having seizure 1x/ week since discharge from ward in
early May 2020
- Patient claimed non compliant to anti epileptic medications
3. History of admission of prolonged cough

-CXR 5/5/2020:Features suggestive of large right lower lobe lung mass with surrounding
consolidations
-@ 2018 ?month, took medication for 2/12 only, not compliant to medication defaulted f/up
- Sputum AFB x 1 (6/5/20): Negative
- Mantoux test reading (8/5/2020) - no induration - negative
4- GDM on d/c
- MGTT 6/5/2020 (27 weeks) : 3.9/ 8.0
- Never do BSP monitoring
Birth History:
Baby born vigorous, good breathing effort, flexion of limbs, acrocyanosis
Initial steps done, put in ziplock bag and cap applied
Indirect suction: Clear
HR: 140
AS 8
Early CPAP applied at 2min of life. PEEP 5, FiO2 0.3

HR: 178/min, SPO2: 97%
FiO2 reduced gradually to 0.21
At 5 mins OL,
baby pink, active, good breathing effort, no grunting, no recessions, no nasal flaring.
SPO2: 96-99 %
HR : 167/min
AS: 10
At 10 min OL
Pink, active, good breathing effort, no recessions, no nasal flaring, good muscle tone
HR: 158/min
SPO2: 97 % on CPAP PEEP 5, FiO2 0.21
On Examination:
No scalp swelling
No cleft lip/palate
No neck swelling

CVS : DRNM
Umbilicus: 2UA, 1UV

Male genitalia, testes descended
Anus patent
No CTEV
Spine normal
Issue:
1) Prematurity at 32weeks
2) Infant with risk of sepsis (maternal chorioamnionitis)

3) Infant of GDM mother on diet control
Plan:
1) Admit to SCN
2) For septic work up (FBC, Blood C&S, blood gas)
3) Start IV C Penicillin and IV Gentamicin
4) DXT at 2 HOL, 3 Hourly prefeeding for the first 6 HOL, then 6 hourly until 24 HOL
5) To inform if DXT <2.6mmol/L
6) KNBM with IVD D10% @ 3.7c/hour
7) Oral Caffeine 29mg stat (20mg/kg/dose)
8) Keep CPAP PEEP 5, FiO2 0.21
HO NADIA 84834
Standby in OT for EMLSCS due to IUGR with abnormal doppler (absent end diastolic flow)
Attended by MO Dakshna and HO Nadia
B/O Nur Hanani Binti Karim

Baby girl
Born on 6/6/2020 @ 1310H
Baby born via EMLSCS @32w5d
Birth weight: 1960g
G6PD and cTSH Taken
Mother, 38 years old G5P3+1 @32w 5d

Dates verified at 9w2d
EDD 27/7/2020
weight: 84.5 kg
******* H/O METHYLDOPA - INDUCE JAUNDICE*********
Issue : Hypertension complicating pregnancy with superimposed pre-eclampsia with abnormal

doppler (absent end diastolic flow)
ANC:
1) Hypertensive crisis with underlying chronic hypertension
Currently on T. Labetolol 400mg TDS
T. Nifedipine 10mg TDS
2) Grave's disease
- TFT:(5/03/2020)
- Ft4: 9.23
- TSH: 0.78
3) 2 previous LSCS scar
4) Adjustment disorder
- under psy HKL, next TCA on 24/6/2020
- on T. seroquel IR 250 mg ON
- on T. seroquel IR 50 mg OM
5) GDM on diet control
Birth History:
At 1 min OL
Baby born vigorous, good breathing effort, acrocyanosis, crying, good muscle tone
Delayed cord clamping at 45seconds
Brought to warmer, put on plastic cap
Indirect suction: Clear liqour
Initial steps done
HR: 120
spo2: detecting
AS 9
Subsequently, baby became apneic possibly due to indirect suction too deep.
Given PPV cycle x2.
Then continue with CPAP PEEP 5, FiO2 40%
Gradually wean down to match SPO2 level
Insert nasal ETT CPAP size 2.5, anchored at 4cm
At 5 mins OL,
baby pink, active, good breathing effort, no grunting, no recessions, no nasal flaring, good muscle
tone
SPO2: 80%
HR : 120-130bpm on CPAP FiO2 40%
AS: 10
At 10 min OL
Wean down to FiO2 30% PEEP 5
HR: 136min
SPO2: 90-92%
T : 35.8
On Examination:
Not dysmorphic
No scalp swelling
No cleft lip/palate
No neck swelling

CVS : DRNM
Umbilicus: 2UA, 1UV

Anus patent
No CTEV
Spine normal
Grasping & Suckling present
PU/BO already
Issue:
1) Preterm at 32 weeks
2) IUGR with abnormal doppler
3) Infant of GDM mother on diet control
Plan:
1) Admit to SCN
2) To take FBC, blood gas and CXR
3) Keep NBM with drip 4.9cc/hourly
4) Plot growth chart and Ballard score

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Inform by SN in LDS to assess baby of GDM mother on diet control

Baby of Lisa Syuhada Binti Abd Hadi

1. 1 previous EMLSCS in 2015 for poor progress

- seen by anaest on 19/5/2020

- plan : for intrapartum epidural

- MGTT x1 at 32w: 6.0/7.8

- latest BSP 12/5/2020 : 5.2/5.0/5.2/6.1

- s/b dietician 22/4/2020

4. H/o miscarriage in 2019

- D&C not done

Birth history: (Given by staff nurse attended)

Attended the baby at 10min OL

IMP: 1. Infant of GDM mother on diet control

Plan: allow discharge to mother under paeds

Baby of Sajidah binti Habir Ahmad

mother 36 years old, para 6 at EDD + 6d

2. Late booker at 28w

4. Advanced maternal age

6. H/o referred to SPG clinic TRO asymetrical IUGR

p/w: Spontaneous active phase of labor

Lungs : clear, equal air entry

Bilateral femoral pulses palpable

inform by Sn to assess PROM < 12 H

Born 28/5/2020 at 0250H

Born via SVD at 39w2d

Blood group O+ve

G6pd and cTSH Taken

21 years old, G2 at 39 weeks 2 days

blood group : O +ve

PROM < 12 H at 27/5/20 2300H

given IV ampicillin x2 doses

1. 1 previous scar in 2017 for fetal distress

- post op plan : allow trial of scar

2. Resolved anemia in pregnancy

inform by SN baby born crying ,born vigorous ,good breathing effort

initial steps done

no cleft lip or cleft palate

CVS S1S2 no murmur

PA not distended, soft

Umbilical cord – 2 UA, 1UV

femoral pulse palpable

suckling and grasping present

anus opening seen

Infant with risk of sepsis

(leaking liquor <12 H , covered adequately )

Admit PNW under peads

watch out ssx sepsis

Imform by SN to standby in LDS for prem twin babies

Baby of Aslinawati Binti Mohd Lazim (1/2)

41 y/o, G6P2+3 at 36w2d

1. Cholelithiasis and choledocholithiasis causing biliary obstruction

given CPAP with FiO2 70%

gradually reducing the FiO2 to 30%

Lungs : clear, equal air entry

Bilateral femoral pulses palpable

Plan (given by Dr Chow):

baby of Baljit Kaur A/P Amerik Singh

30 y/o P2 at 39weeks + 6days