Sample WriteUp of a Newborns History

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This 2830-g female infant was born at 38 2/7 weeks to a 47-year-old G1 P0-0-0-0 mother by NSVD (normal spontaneous vaginal delivery) at 1:35 am on 1/16/2008. The pregnancy was complicated by chronic hypertension, for which the mother was treated with Aldomet (methyldopa). The mother is O+ and hepatitis B surface antigen, syphilis, HIV, and Chlamydia negative. Amniocentesis at 14 weeks revealed a 47,XX trisomy 21 karyotype. The mother continued the pregnancy, despite the amniocentesis results, explaining that she ''wanted to know what I would be facing beforehand.'' At 36 weeks, a vaginal culture for group B streptococcus was negative. Mother went into labor at 38+ weeks;she developed malignant hypertension unresponsive to magnesium sulfate, so a C-section (cesarean section) was performed under general anesthesia after 17 hours of labor. Rupture of membranes was at delivery. The baby's Apgar scores were 5 and 8, with points off for tone, reflex, respiratory effort, and color at 1 minute. Baby was transferred to the NICU (neonatal intensive care unit) for observation for Down's syndrome and hypermagnesemia.

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