Department of Neonatal Medicine Protocol Book by TevitaVaikona

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									    From the: Perinatal Society of Australia and New Zealand Perinatal Mortality Audit Guideline; Section 2: Institutional Perinatal Mortality Audit; Appendix 1.4




Appendix A                                                                                                       Maternal Sticker
                                                                              If other, describe: ............................................                Enlarged                                    Other
Clinical examination of baby                                                                                                                                  If other, describe: ...........................................
                                                                                                                         (Inc Name, DOB, UR, Address, Telephone Number)
checklist                                                                                                                                                 Ambiguous sex                          .....................................
                                                                                                                                                              ........................................................................
Please tick appropriate box and complete details as required

Baby measurements
Crown – heel (stretched)                ............................ cms
Head circumference ........................................ cms
Weight............................................................. gms
                                                                            Singleton                     Multiple                     Baby number.......... (e.g. Twin 1)
Estimated date of IUFD: ......./......../........
Maceration degree                                                          NECK
Fresh; no skin peeling ...............................                       Normal                                 Preauricular tags
Slight; focal minimal skin slippage..............                             Lowset                                Preauricular pits
                                                                                                                                                          LIMBS
Mild; some skin sloughing, moderate                                           Other                       Posteriorly                                       Length
   skin slippage...........................................                rotated                                                                          Normal                   Short                       Long
Moderate; much skin sloughing but                                             If other, describe: ............................................              If Short, what segments seem short
   no secondary comprehensive                                                                                                                                ......................................................................
   changes or decomposition......................                          CHEST
                                                                                                                                                            Form
                                                                             Normal                                  Long & narrow
Marked, advanced ......................................                                                                                                     Normal             Asymmetric                Missing parts
                                                                              Short & broad                          Other                                  If other, describe: ...........................................
HEAD AND FACE                                                                                                                                                ........................................................................
                                                                           If Spina bifida, describe: .....................................
Head                                                                                                                                                      HANDS
  Relatively normal                          Collapsed                                                                                                      Length
  Anencephalic                                                             ABDOMEN
                                                                             Normal                                  Flattened                                Appearance: Normal                               Abnormal
Hydrocephalic
                                                                                                                                                              If abnormal, describe: ................................
   Abnormal shape                                                             Distended                              Hemia
                                                                                                                                                          Fingers
   If abnormally shaped, describe: .....................                      Omphalocele                            Gastroschisis
                                                                                                                                                              Number present: .........................................
Eyes                                                                       BACK                                                                               If not 4 + 4, describe ...................................
Normal              Prominent            Sunken                              Normal                                  Spina bifida                              ....................................................................
Straight            Far apart            Close together
                                                                              If Spina bifida, describe: .................................                    Unusual form of fingers
Upslanting                                Downslanting                                                                                                        Unusual position of fingers
   Globes normal                             Absent                                                                                                           Abnormal webbing or syndactyly
                                                                              Scoliosis                              Kyphosis
   Eyes very small                          Very large                                                                                                        If abnormal, describe...................................
                                                                              Other
   Lens opacity                        Corneal opacity                        If other, describe: ............................................            Thumbs
   Eyelids fused                             Other                             ........................................................................     Number present: .........................................
                                                                                                                                                            If not 1+ 1 describe .....................................
   If other, describe: ...........................................         GENITALIA                                                                         ....................................................................
Nose                                                                       Anus                                                                             Unusual position
                                                                             Normal          Imperforate                 Other
  Normal                               Abnormally                                                                                                           Looks like a finger
                                                                             If other, describe: ............................................
small                                                                                                                                                       If abnormal, describe...................................
  Asymmetric                           Abnormally large                    Gender                                                                         Finger nails
                                                                             Male                   Female                   Ambiguous                      All present
Nostrils
  Apparently patent                     Obstructed                         Male                                                                             If not describe..............................................
  Single nostril                        Other                                Penis
                                                                             Normal                                            Very
   If other, describe: ...........................................                                                                                        FEET
                                                                           small
                                                                                                                                                            Appearance Normal                                Abnormal
Mouth                                                                         Hypospadias                                      Chordee                      If abnormal, describe ..................................
 Normal size                   Large               Small                      Hypospadias, level of opening                                                  ....................................................................
Upper Lip                                                                      ........................................................................   Toes
  Intact                       Cleft                                          Scrotum                                                                       Number present: .........................................
  If cleft, location:                                                         Normal                                            Abnormal                    If not 5+ 5 describe .....................................
   Left                                            Right                      If abnormal, describe
   Bilateral                                       Midline                     ........................................................................      Spacing:             Normal                 Abnormal
Palate                                                                        Testes                                                                         If abnormal, describe ..................................
  Intact                                           Cleft                      Descended                         Undescended                               ........................................................................
Mandible                                                                      Other                                                                       Toe nails
 Normal                                            Large                      If other, describe: ............................................               All present
                                                                                                                                                             If not describe..............................................
   Small                                       Other                       Female
   If other, describe: ...........................................           Urethral opening                                                             Revised gestational age ................................
                                                                             Present                          Absent/unidentifiable                       Based on ........................................................
   Ears                                                                    Vaginal introitus
   Normal                            Preauricular tags                       Present                          Absent/unidentifiable                       Examined by: ................................(Print name)
   Lowset                            Preauricular pits                        Clitoris                                                                    Date: ...............................................................
   Other                           Posteriorly rotated                        Present                                     Unidentifiable                  Summary of key findings: ............................

								
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