NICU AUDIT August 2014

Patient Profile C.A. Live Preterm Baby Girl Delivered Via Stat Primary Cesarean Section for Non- Reassuring Fetal heart rate pattern to a 36 y/o G2P2 (1102) 28 4/7 weeks AOG MT 32, SGA APGAR score 9,9

Anthropometrics Birth weight: 950 grams Birth Length: 38 cm Head circumference: 26 cm Chest circumference: 21 ½ cm Abdominal Circumference: 20 cm

MATERNAL HISTORY: GDM since 20 weeks AOG on Diet modification; Gestational HTN at 15 weeks maintained on Methyldopa 250 mg TID PAST MEDICAL HISTORY: GERD; admitted 1 day prior due to chest pain. FAMILY HISTORY: DM OB HISTORY: G1- Live Full term female, NSD, no complications G2- Present pregnancy

Upon Delivery Good cry and activity HR Acrocyanotic Good cardiac tone Good air entry

At the NICU SubjectiveObjectiveAssessmentPlan Good cry and activity Spontaneous breathing HR 150’s Good cardiac tone Good air entry acrocyanotic Live Preterm Baby Girl Place inside a plastic bag for thermoregulation Hooked to 1 lpm via nasal Cannula Umbilical catheterization NPO Blood Culture CBC Blood Typing Hgt Chest Xray D10 W TFR 80 Ampicillin mkdose q12 Amikacin mkdose q36 hrs Vitamin K Tobramycin

At the NICU SubjectiveObjectiveAssessmentPlan Good cry and activity Spontaneous breathing HR 150’s Good cardiac tone Good air entry acrocyanotic Live Preterm Baby Girl D10 W TFR 80 Ampicillin mkdose q12 Amikacin mkdose q36 hrs Vitamin K Tobramycin

CBC6 th hr of life Hgb Hct WBC Band Neutro Lympho Mono Platelet nrbc/100 wbc Blood TypeO+ Blood Culture No growth for 7 days CRP0.25 Chest XrayGround glass opacities noted with some air bronchogram suggesting an element of surfactant deficiency; Pneumonia may not be excluded UVC at the level of 9 th vertebral body Hgt70

13 th Hour of life SubjectiveObjectiveAssessmentPlan NPO No cyanosis No vomiting HR 135 RR 53 O2 Sat 100% at 1 lpm Good air entry Subcostal retractions Live Preterm Baby Girl; Neonatal Pneumonia Discontinue Amikacin, Start Cefotaxime mkdose q12

Day 1 of life SubjectiveObjectiveAssessmentPlan NPO No cyanosis No vomiting Spontaneous breathing HR 128 RR 65 O2 Sat 98% at 0.25 lpm Good air entry Subcostal and intercostal retractions Live Preterm Baby Girl; Neonatal Pneumonia TFR increased to 100 IVF shifted to D10IMB Ampicillin Day 2 ½ Cefortaxime Day 2

Day 2 of life SubjectiveObjectiveAssessmentPlan 3 ml of D5W given via OGT every 3 hrs then supplemental feeding was started 3 ml every 3 hrs No cyanosis No vomiting Spontaneous breathing Occasional desaturations HR 163 RR 63 O2 Sat 99% at 0.25 lpm Light jaundice to abdomen Good air entry Subcostal and intercostal retractions Live Preterm Baby Girl; Neonatal Pneumonia; Hyperbilirubinemia, unspecified TFR increased to 120 Single Overhead Phtototherapy started OGT inserted Ampicillin Day 3 ½ Cefortaxime Day 3

Day 3 of life SubjectiveObjectiveAssessmentPlan Tolerates supplemental feeding was given 4 ml every 3 hrs No cyanosis No vomiting Spontaneous breathing HR 155 RR 61 O2 Sat 97% at 0.25 lpm Pink skin Good air entry Subcostal and intercostal retractions Live Preterm Baby Girl; Neonatal Pneumonia; Hyperbilirubinemia, unspecified TPN started Single Overhead Phtototherapy- discontinued OGT inserted Hgt 87 Ampicillin Day 4 ½ Cefortaxime Day 4

The patient remained stable and was transferred to another institution at the 7 th day of life.

FINAL DIAGNOSIS Live Preterm baby girl delivered via Stat Primary Cesarean Section for Non-reassuring Heart rate pattern to a 30 year old G2P2 (1102) at 28 4/7 weeks AOG, Apgar score 9,9, Maturity Testing 32 weeks, SGA Infant of mother with GDM and Gestational Hypertension Neonatal Pneumonia Hyperbilirubinemia, unspecified.