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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Obstetrics And Gynaecology

Document Title

: Neonatal Referral Letter

MOTHERS DETAILS

Name

Para

Blood Group

VDRL

HIV

Gestation At Delivery

Abortion

RH

Hepatitis B

Pre-Existing Maternal Conditions

Diabetes Mellitus

On Insulin

Hypertension

Anaemia (Hb<11gm %)

Antenatal Rhesus Disease

Others, specify

DELIVERY DETAILS

Type Of Labour

Please Update Method

Apgar Score

Please Update Method

Cord Blood Gas

Please Update Method

Purpose Of Referral

Fetal Distress

Prolonged 2nd Stage

Instrumental delivery

Baby of diabetic mother

Macrosomic baby

Preterm

IUGR

Poor Apgar Score

Suspected congenital anomalies

GBS / Infection

Presumed sepsis / suspected

No passing urine for 24 hours

No bowel opening for 24 hours

Jaundice

Others, specify

REFERRAL DETAILS

Referral Type

Referral Note

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