British Columbia Newborn Record Part 1 British Columbia Newborn Record Part 2 1

MM# 20313213 DRC 9355 1B 1A

British Columbia Newborn Record Part 1 British Columbia Newborn Record Part 2 1. Mother's Name Age Mother's Hospital ID # Hospital Name Date 9. dd/mm/yyyy Hearing Screening (completed by BC Early Hearing Program) Hospital Name Date Yes Passed Passed with Risk Factors for Delayed Onset Surname of Newborn Partner's Name Age Surname Given Name Surname Given Name No Declined N/A Comment: Address Needs Follow-up: (by BC Early Hearing Program) Address EDD G T P A L dd/mm/yyyy by LMP US Additional Screening Diagnostic Assessment Other

Blood Group: Rh: Antibodies: Phone Number Phone Number PRINT NAME SIGNATURE Risk Factors for Infant (Refer to Antenatal Record, Part 2 ) dd/mm/yyyy Exposure to Substances: Tobacco Alcohol Medication 10. Metabolic Screening Personal Health Number Physician / Midwife Name Other Personal Health Number Physician / Midwife Name Blood Dot Card Collected: Age (h) Yes No Comment: Bilirubin Screening: Age (h): Yes No Comment: Other Risks: (nomogram on reverse)

11. dd/mm/yyyy Prophylaxis 2. Apgar Score 3. Transition to One Hour of Age HBsAg Prophylaxis Indicated: Yes No HBIG Given Hepatitis B Vaccine Given 0 121 Min. 5 Min. 10 Min. Positioned: Skin-to-Skin Radiant Warmer Other: HIV Prophylaxis Indicated: Yes No HIV Prophylaxis Initiated Heart < > Amniotic Fluid: Clear Meconium Bloody Group B Strep Intrapartum Prophylaxis: Yes No Comment: Absent Rate 100 100 Suction: Oropharyngeal Trachea Mec. Below Cords Stomach Aspirated 12. dd/mm/yyyy Newborn Nutrition Weak Cry Oxygen: None Free Flow Start min. Stop min. Breastfeeding Initiated: <1 h >1-2 h >2-24 h > 24 h N/A Comment: Resp. Hypo- Good Absent Effort ventila- Crying IPPV per mask Start min. Stop min. Exclusive Breastmilk Partial Breastmilk Breastmilk Substitute Supplementation Indication: tion See Expanded Resuscitation Form 13. dd/mm/yyyy Problem List Date Resolved Muscle Some Active dd/mm/yyyy Limp Tone Flexion Motion Cord Gases: Done (see lab results) Not Done ACoRN Sequences Initiated: Yes No See Narrative Notes Resp. Active o Temperature: C Pulse Oximetry: Yes No to None Grimace With- Stim drawal Heart Rate: Time to HR >100 min. sec. Blue Acro- Colour All Pink Respirations: Time to Spontaneous Breathing min. sec. Pale cyanosis SIGNATURE SIGNATURE SIGNATURE

Apgar Total Score RM/RN RM/RN MD 14. dd/mm/yyyy Progress Notes 4. Delivery 8. Physical Examination at Birth (Including Stillbirths) Male Female

Birthdate dd mm yyyy Time Gestational Age from Gestational Age Undifferentiated Antenatal History wks. by Exam (see reverse Part 2) wks. Delivery Type Newborn Hospital # Normal Abnormal Comments Identified at Birth by: 1. General SIGNATURE: RN/RM Appearance Identified at Transfer by: (if applicable) SIGNATURE: RN/RM 2. Skin Pallor Mec. Staining Voided Passed Meconium Bruising Peeling Yes No Yes No Petechiae Jaundice

Breastfeeding Planned Yes No 3. Head 5. Routine Procedures 15. Discharge Examination 4. EENT Cleft Lip/Palate Suspected Choanal atresia 16. Status at Discharge Cord Blood Rh Other Newborn Age: <12h 13-24 h 25-48 h 49 - 72 h >72 h Micrognathia Eye Prophylaxis Erythromycin Other: 5. Respiratory Grunting Shallow B reathing Head Circumference cm Weight: g Weight loss: % Time Informed Refusal Nasal Flaring Tachypnea Normal Abnormal Comment SIGNATURE RN/RM Retracting Exclusive Breastmilk Partial Breastmilk Breastmilk Substitute Vitamin K 1. General 6. CVS Murmur Abn./ Delayed Femoral Pulses Comment: PO IM Dosage Site Informed Refusal Time Central Cyanosis Abnormal Rate/Rhythm 2. Skin Problems Requiring Follow-up: 7. Abdomen Scaphoid Splenomegaly 3. Head

SIGNATURE RN/RM Distended Abnormal Mass 4. EENT 6. Evaluation of Development Hepatomegaly (growth chart and curve on reverse) Mec. Stained Thin 5. Respiratory Birthweight g % 8. Umbilical Cord 2 Vessels 6. CVS Length cm % 17. Discharged

Head 9. Genito- Hypospadias Undescended Teste(s) 7. Abdomen Home Adoption Foster Home Other Hospital rectal specify Circumference cm % Imperforate Anus Other 8. Umbilical Cord Preterm Term Postterm 10. Musculo- Spine Extremity Abnormality Neonatal Death skeletal SGA AGA LGA Hip Abnormality 9. Genitorectal Autopsy Consented 18 . Follow-up by dd/mm/yyyy 11. Neuro- 7. Stillbirth No Yes Hypotonia Jittery 10. Musculoskeletal logical Family Physician Macerated Cry Reflexes IUGR 11. Neurological Midwife Retroplacental Clot 12. Other Pediatrician Evidence of Anemia 12. Other Autopsy Consented Other Consultant Obvious Anomaly (describe below): DATE TIME SIGNATURE Date SIGNATURE Public Health Nurse

Apgar Total Score RM/RN RM/RN MD 14. dd/mm/yyyy Progress Notes 4. Delivery 8. Physical Examination at Birth (Including Stillbirths) Male Female

umbilical cord length cm Ministry for MD/RM dd/mm/yyyy MD/RM Children & Family Development PSBC 1583A – March 2008 © Perinatal Services BC White - Infant's Chart Yellow - Public Health Nurse Pink - Physician / Midwife BAR CODE AREA - DO NOT USE PSBC 1583A – March 2008 © Perinatal Services BC White - Infant's Chart Yellow - Public Health Nurse Pink - Physician / Midwife BAR CODE AREA: DO NOT USE MM# 20313213 DRC 9355 B1A Physical Maturity Age of Gestational Ballard Assessment Source: Ballard JL, Khoury JC, et.al: New Ballard Neuromuscular Maturity include extremely premature (female) (male) to ear Heel sign Scarf angle Skin Popliteall recoil Arm (wrist) window Square Posture Score Genitals Genitals EyeEar Lanugo Plantar Breast surface 55 50 45 40 35 30 25 20 15 42 40-50 mm: -1 oeSparse None Imperceptible Heel-toe transparent friable, Sticky, prominent, Clitoris Clitoris Lids fused labia flat smooth Scrotum flat, <40 mm: -2 tightly: -2 loosely:-1 40 -1 >90º 180º Gelatinous, red, translucent stays folded Clitoris Clitoris faint rugae no crease pinna flat Lids open Scrotum labia minora empty, small small prominent, perceptible Barely >50 mm, 0 160º 180º 90º infants. 32 34 36 38 visible veins Smooth pink, Smooth pink, red marks slow recoil curved pinna; bnatThinning Abundant Slightly Testes in Faint no bud soft; Flat areola upper canal, minora rare rugae enlarging Clitoris Clitoris prominent,

97 % 97 3 % 3 % 3

90 % 90 50 % 50

10 % 10 rd 10 % 10 th rd th th 90 % 90 50 % 50 97 % 97 th th th th th 1 J Pediatrics 140º-180º 140º 60º Gestational Age (weeks)

Head (cm)

Superficial and/or rash; peeling crease only transverse 1-2 mm bud Anterior few veins Testes Stippled descending, Well curved areola pinna; soft but Majora and ready recoil few rugae prominent equally minora 110º-140º 24 26 28 Score, expanded to 1991;119:417-423. Length (cm) 2 120º 45º 22

55 50 45 40 35 30 25 20 15 Centimetres minora small Majora large, adaes Bald areas Testes down, recoil instant firm, Formed and anterior rare veins Cracking, areola Raised 3-4 mm bud Creases pale areas, good rugae 90º-110º 3 0 500 4500 4000 3500 3000 2500 2000 1500 1000 5000 100º 2 30º 42 /3 (both sexes)

Most Full areola Full no vessels deep cracking, Parchment, 5-10 mm bud Creases over clitoris and 40 entire sole cartilage, Majora cover minora Testes Thick deep rugae pendulous, ear stiff ly bald 4 <90º Intrauterine Growth Chart 90º 0º Leathery, wrinkled cracked, Sc -10 20 -10 044 50 34 32 25 20 542 40 45 38 40 36 35 30 530 28 15 10 M ore 522 -5

26 5

24 0 Rating

th 50 % 50 97 % 97 90 % 90

10 % 10 aturity % 3 th th th 5 rd 32 34 36 38 We <90º eks 30

Gestational Age (weeks) 24 26 28 3. Refer to the table below for action to be taken 2. Plot the total serum bilirubin on this figure Source:Society, FN 2007-02. Canadian Paediatric 1. Use for term and later preterm newborns (> Evaluation of screening total bilirubin Based on data from Kitchen WH et al, 1983 Aust. Paed. J.19:157, modified by Whitfield MF, with additional data <27 weeks Aust. Paed. J.19:157, modified by Whitfield MF, Based on data from Kitchen WH et al, 1983 Zone Low diate Low-interm High-intermediate High guideline, treatment with phototherapy may also be indicated. DAT Direct antiglobulin test. *Arrangements must be made for a timely (eg.within 24 h) re-evaluation of bilirubin by serum testing. Depending on the level in dicated Figure 2 CPS Weight (gm) Weight Response to results of bilirubin screening 22

0 500 Grams 5000 4500 4000 3500 3000 2500 2000 1500 1000 e Bilirubin (μmol/L) 250 100 200 150 300 350 50 0 0 12 etto n A-eaiegestation or DAT-positive gestation and DAT-negative Greater than 37 weeks' Routine care Routine care Routine care Further testing or treatment required* 0 500 4500 4000 3500 3000 2500 2000 1500 1000 Grams 44

e 70th percentile e 40th percentile 95th percentile

g 24 g

term

90th% 10th% Post- A

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a a

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Paedr Child Health Vol 12 Suppl B May/June 2007 s

35 weeks’ gestation) gestation) weeks’ 35 e

Term G

o G

48 High intermediate zone i

r t

f t

Low intermediate zone s

e t

High zone e

60 r

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o 35 to 37 6/7 weeks' Routine care Routine care Follow-up within 24 h to 48 Further testing or treatment required*

Age (hours) g p

p a

L Low zone A 72 84 96 108 Gestational Age (weeks) Preterm Classification of Newborns gestation and DAT-positive 35 to 37 6/7 weeks' Routine care Further testing or treatment required* Further testing or treatment required* Phototherapy required 2 132 120 by Birthweight and Gestational Age by Birthweight and Gestational 144 22 24 26 28 30 32 34 36 38 40 42 0 500 4500 4000 3500 3000 2500 2000 1500 1000 Grams Based on data from Kitchen WH et al, 1983 Aust. Paed. J.19:157, modified by Whitfield MF, with additional data <27 weeks Aust. Paed. J.19:157, modified by Whitfield MF, Based on data from Kitchen WH et al, 1983 MM# 20313213 DRC 9355 B1A Physical Maturity Age of Gestational Ballard Assessment Source: Ballard JL, Khoury JC, et.al: New Ballard Neuromuscular Maturity include extremely premature (female) (male) to ear Heel sign Scarf angle Skin Popliteall recoil Arm (wrist) window Square Posture Score Genitals Genitals EyeEar Lanugo Plantar Breast surface 55 50 45 40 35 30 25 20 15 42 40-50 mm: -1 oeSparse None Imperceptible Heel-toe transparent friable, Sticky, prominent, Clitoris Clitoris Lids fused labia flat smooth Scrotum flat, <40 mm: -2 tightly: -2 loosely:-1 40 -1 >90º 180º Gelatinous, red, translucent stays folded Clitoris Clitoris faint rugae no crease pinna flat Lids open Scrotum labia minora empty, small small prominent, perceptible Barely >50 mm, 0 160º 180º 90º infants. 32 34 36 38 visible veins Smooth pink, Smooth pink, red marks slow recoil curved pinna; bnatThinning Abundant Slightly Testes in Faint no bud soft; Flat areola upper canal, minora rare rugae enlarging Clitoris Clitoris prominent,

97 % 97 3 % 3 % 3

90 % 90 50 % 50

10 % 10 rd 10 % 10 th rd th th 90 % 90 50 % 50 97 % 97 th th th th th 1 J Pediatrics 140º-180º 140º 60º Gestational Age (weeks)

Head (cm)

26 5

24 0 Rating

th 50 % 50 97 % 97 90 % 90

10 % 10 aturity % 3 th th th 5 rd 32 34 36 38 We <90º eks 30

Gestational Age (weeks) 24 26 28 Source:Society, FN 2007-02. Canadian Paediatric 3. Refer to the table below for action to be taken 2. Plot the total serum bilirubin on this figure 1. Use for term and later preterm newborns (> Evaluation of screening total bilirubin Based on data from Kitchen WH et al, 1983 Aust. Paed. J.19:157, modified by Whitfield MF, with additional data <27 weeks Aust. Paed. J.19:157, modified by Whitfield MF, Based on data from Kitchen WH et al, 1983 Zone Low diate Low-interm High-intermediate High guideline, treatment with phototherapy may also be indicated. DAT Direct antiglobulin test. *Arrangements must be made for a timely (eg.within 24 h) re-evaluation of bilirubin by serum testing. Depending on the level in dicated Figure 2 CPS Weight (gm) Weight Response to results of bilirubin screening 22

e 70th percentile e 40th percentile 95th percentile

g 24 g

term

90th% 10th% Post- A

l l

a a

n n

o 36 o i

t A

a a

a s

Paedr Child Health Vol 12 Suppl B May/June 2007 s

35 weeks’ gestation) gestation) weeks’ 35 e

Term G

o G

48 High intermediate zone i

r t

f t

Low intermediate zone s

e t

High zone e

60 r

p S

o 35 to 37 6/7 weeks' Routine care Routine care Follow-up within 24 h to 48 Further testing or treatment required*

Age (hours) g p

p a