KUALA MUDA, 3.8.08, (DAY 5): SPECIFIC REPORT

After delivery, home visit are done from the 1st to 10th day and on the 20th day. This is visit is for both maternal and child.

During the post natal visit, the neonate is assessed as below:

weight
head circumference
length
general well being
-weak
-irritable
-anemic
-cyanosis
-jaundice
-alter bowel habit
-problems related to micturation
-feeding problem
-skin problem
5. Vital signs
-respiratory rate (normal 40-60/min)
-heart rate (normal 120-160/min)
-temperature




6. Examination of the head
-shape
-fontanelle
-swelling
-caput
7. Examination of neck
-swelling
8. Examination of eye
-abnormal e.g. congenital ptosis, squint
-cataract
-abnormal conjunctiva
-discharge
9. Examination of mouth
-cleft palate
-cleft lip
-oral thrush
10. Examination of ears
-abnormalities
-discharge
11. Respiratory system
-abnormalities in the nose
-sub/intercoastal recessation
-shape of chest wall
-breath sound
12. Cardiovascular system
-murmur
-femoral pulse
13. Gastrointestinal system
-distension
-umbilicus
-mass
-patency of anus
14. Genitalia
-male: testis, penis, scrotum
-female: imperforated hymen, discharge
15. Musculoskeletal system
-spine
-fingers and toes
-clubfoot / CTEV
-hip dislocation
16. Neurological system
-fits
-reflex ( moro / grasp / rooting)
-tone


The mother is assessed for:
a) general well being
b) temperature
c) blood pressure
d) pulse rate
e) breast examination
f) SFH
g) Perineum
h) Lokia
i) Urine albumin/sugar
j) BO/PU
k) Signs and symptoms of pulmonary thromboembolism



We were also briefed about the colour coding system which includes:
White 1: Deliver in hospital
a) primigravida
b) age <18>40
c) gravida 6 and above
d) height <145>145
f) age >18 or <40>37 and <41>2 kg and <3.5kg>3)
g) unsure of LMp
h) Past obstetric history e.g caesarean, DM, eclampsia, hypertension, prenatal death, perineum tear of grade 3, postpartum hemorrhage, instrumental delivery, baby weight <2.5kg>4.0kg
i) High blood pressure (140/90 mmHg) with urine albumin negative
j) Hb <>2kg in a week)
n) Weight >80kg
o) SFH more or less than 4 cm compared to POA
p) Malposition with no signs of delivery in >34 week
q) Head not engaged
Yellow: Refer to family health specialist or O&G specialist clinic
a) HIV +ve
b) Hepatitis B+ve
c) DM
d) Reduce fetal movement when >32 weeks
e) Gestation more than 7 days than given EDD
f) More than 1 fetus

Red: Immediate admission to hospital
a) eclampsia
b) pre eclampsia or BP >160/110mmHg
c) chest pain with symptoms such as palpitation, shortness of breath
d) Shortness of breath noted while performing simple task e.g. Sweeping, washing dishes
e) Uncontrolled DM
f) Abnormal fetal heart rate
g) Anemia
h) Premature contraction
i) Leaking liquor without contraction
j) Sudden exacerbation of asthma
k) Antepartum hemorrhage

Reported by Rathna