Pediatric Delivery Template

DATE OF CONSULT: []

REASON FOR CONSULTATION: []

PRESENCE OF PEDIATRICIAN REQUESTED BY: [Pediatrician/Nurse/Midwife]

MATERNAL HISTORY AND DELIVERY:

Mom: [Age, GP Status]

Mom: PMHx

Maternal medications in pregnancy:

Maternal substance use during pregnancy (EtOH, cigarettes, cannabis)

NIPT

20-week antenatal ultrasound:

OGTT

Mom's blood type: []

Moms history/medications: [PNV, Others]

GBS: [Negative/Positive]

Serology: [Protective/List Problems], Rubella: [Immune/Not]

Membranes: [Spontaneous/Assisted] of rupture membranes at [time], Discharge was [clear/purulent/cloudy]. Δh. Resuscitation. Suction.

Intrapartum antibiotics: [Not given / Abx Name]

Type of delivery: [SVD/Assisted VD/C-Section]

Delivery aids: [None/Vaccum/Forceps etc]

Babys Gestational age: []

APGAR: [Out of 9 or 10]

PHYSICAL EXAM:

BW: [AGA/SGA/LGA], [] percentile, [] g, Length was []cm, percentile.

Calculate percentiles here; enter as [W D/7], just enter "growth metrics on analysis date”

General: []

CNS: [Normal, anterior fontanelle soft and flat, Moro reflex intact, good posture and tone. No Caput or Molding]

Eyes/face: [Red reflex not done, palate intact]

Neck: [Trachea midline, no clavicular deformities]

Resp: [Good air entry bilaterally, mucus suctioned]

CV: [S1-S2, no extra heart sounds, femoral pulses equal and bilateral]

Abdo: [Soft, nontender, nondistended, three-vessel cord]

GU: [Normal male/female, anus patent]

MSK: [Unremarkable, Ortolani and Barlow negative]

Spine: [Normal, no abnormal spinal dimpling or tufts of hair]

Skin: [Good capillary refill, normal skin]

IMPRESSION AND PLAN:

Baby born at [] weeks via [SVD/AVD/C-Section].

There were [no] risk factors for sepsis. GBS was [negative] and there were [no] maternal fevers.

Rupture of membranes was [spontaneous and clear] at [time] and [no] antibiotic prophylaxis was given.

Overall the baby is doing [], with [no active resuscitation required]. [Details here]

The baby was transferred back to her parents for skin to skin contact

Standard care under [OB/Midwife/etc.]

Thank you for involving us in the care of this patient.