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Lesson 1: History Taking of

Newborn
Neonatal History Overview

The neonatal history should include:

Maternal history

Maternal demographic and social data (age)

Previous maternal reproductive problems

Fertility problems

Cervical or uterine problems

Gestational history

Events occurring in the present pregnancy

Perinatal and birth history

Description of labor and events around time of delivery

Maternal History

Maternal Demographics and Social Factors

Maternal Factors

Teen pregnancies and 40 yo Particularly rimiparous have

increased risk for?

Intrauterine growth restriction IUGR

Fetal distress

Pre-eclampsia

Stillbirth

Advanced maternal age increases risk for?

both chromosomal and non-chromosomal fetal malformations

Other risk factors include

Maternal illness/infections

Heart problems

Virus

HIV

Hepa B

Lesson 1 History Taking of Newborn 1

 Multiple pregnancies - end up small for gestational age or
premature

Use of assisted reproductive technology

Ovulation induction

In vitro fertilization

Intracytoplasmic sperm injection

Increased risk for prematurity

Information for Maternal History

Mother's age

Parity G_P_)

What is G?

Gravida: no. of pregnancies

What is P?

Para: no. of live births

Marital status

Blood type and Rh - Rh incompatibility, ABO incompatibility

State of health

Smoker, alcohol drinker

Occupation

Exposure to hazards may cause dev't delay (e.g. lead products)

History of sexually transmitted disease/chronic illnesses

HIV, chronic hypertension, syphilis

May affect the baby

Previous Pregnancies: Problems and Outcomes

Infertility

Abortion and Fetal Demise

Perinatal Deaths

Prematurity

Congenital malformations

Jaundice

Did the baby go through phototherapy?

Common in third day of life

Inherited diseases (metabolic diseases)

Positive screening test

Lesson 1 History Taking of Newborn 2

 Phenylketonuria & Maple Syrup Disease

Gestational History

Gestational Age Dating

Last menstrual period → To measure expected due date and

gestational age of the baby

does not work when the mother's cycle is irregular

Formula

Gestational Age = 280 - EDD - Reference Date)) / 7

Estimated due date

First, determine the first day of your last menstrual period.

Next, count back 3 calendar months from that date.

Lastly, add 1 year and 7 days to that date.

Early ultrasound can be used to measure biparietal diameter and long

bones to estimate AOG

Expected date of delivery

Prenatal Care

Where was the prenatal care done?

Local Barangay Health Units, Hospitals, or OBGYNE Clinics

With whom?

May be in care of the nurses, mid-wives, and OBGYNE

physician

When did it start?

Usually done as early as 1st trimester

1st or last trimester

Adequacy?

Regular prenatal check-up: 46 visits

At least 2 times every trimester

At least 4 times in the whole pregnancy

When to have more frequent checkups?

third trimester,
especially with high-risk pregnancies

Results of any fetal testing

Amniocentesis

Lesson 1 History Taking of Newborn 3

 Congenital anomaly scan

Fetal monitoring: to monitor any deliveries and pregnancies that

are high risk

usually done when signs are seen

Drug Intake and Supplements

Table of Categorical Classification of Drugs

Table 1. Categorical classification of drugs

Description
Category

A No risk on the basis of evidence from controlled human studies

Either no risk has been shown in animal studies but no adequate
studies have been done in humans OR Some risk has been shown
B
in animal studies but these results are not confirmed by human
studies

Definite risk has been shown in animal studies but no adequate

C human studies have been performed OR; No data available for
both human and animal studies
With some risk but with benefit that may exceed the risk for the
D
treated life-threatening conditions

Contraindicated in pregnancy on the basis of human and animal

X
evidence & for which the risk exceeds the benefits

Multivitamins

Folic acid (to prevent neural tube defects)

Iron (to prevent anemia during pregnancy)

Maintenance drugs

In the case of expectant mothers with morbidities

cardiac problem, UTI, pregnancy

Needs to be classified for?

compatibility with breastfeeding

Chemotherapeutic agents are contraindicated because mother

cannot breastfeed

Illnesses and Infection

Include viral exanthem exposure (measules, rubella)

Joint pain, rashes, measles, and fever in the 1st trimester as it may
point to Rubella

Congenital Rubella Syndrome

Cataracts, patent ductus arteriosus PDA, etc.

Lesson 1 History Taking of Newborn 4

 Alcohol and Tobacco Use

Possible effects on newborn

Intrauterine growth restriction

Alcoholic mother

May cause fetal alcohol syndrome

Use of Illicit Drugs

Illegal drugs

Marijuana may cause withdrawal symptoms

Like anti-convulsants and anti-coagulants

Radiation Exposure

Background fetal radiation exposure in pregnancy:

0.1 rad

x-ray: thyroid and other organ problems

Table 2. Dosage and effect of radiation exposure during pregnancy

Timing of Exposure Effects

Radiation
Before implantation 02 weeks
510 rad Miscarriage
post-conception)

Congenital anomalies, fetal

28 weeks gestation >/20 rad
growth restriction

>/25
Before 25 weeks gestation Severe intellectual disabilities
rad

Hepatitis B Screening

What do you do

Monitors the mother's HbsAg titer if it present or within the

suggested range

If not, the mother is encouraged for Hepa B vaccination

If the mother is positive for Hepatitis B

Introduce both passive and active immunization

DM Screening

Diabetic mothers during pregnancy are at risk for multiple

complications

Large baby

Heart problem

Screening INcludes:

Lesson 1 History Taking of Newborn 5

 HbA1c and OGTT

Pregnancy Related Risks and Complications

Preeclampsia

Hypertension during pregnancy

Mother's chronic hypertension

Bleeding

Trauma

Surgery

Appendicitis

Intrauterine Growth Restriction IUGR

Infection

Pregnant women are at risk of concomitant appendicitis

If mother had a case of gonorrhea or chlamydia infection

Sepsis

Polyhydramnios

GI anomaly

Fetus does not swallow amniotic fluid and it accumulates

Oligohydramnios

Renal system anomaly

Developed countries:

Group B Strep Screening

To prevent sepsis

The above conditions increase risk for:

Preterm labor

IUGR

COVID

RTPCR and X-ray tests are required before labor/delivery

Perinatal and Birth History

Description of Labor and Events around the Time of Delivery

Onset and duration of labor

Presentation (ie. What came out first?

Vertex Head)

Hand, Buttocks

Breach or other abnormal presentation

Lesson 1 History Taking of Newborn 6

 Can be accompanied by asphyxia

Augmentation

Jaundice

Membrane status: ruptured or intact

18 hours: Infection into the uterine space

Baby may have an infection

Maternal fever

Especially during the 1st trimester

Increased risk for congenital malformation

can also refer to fetal infection

Fetal heart rate monitoring

observation of any fetal distress

Normal heart rate

120160 bpm

If heart rate is 100bpm

Congenital heart problem

If greater than 160 bpm

Perinatal asphyxia

Intrauterine resuscitation

Administer oxygen to normalize oxygen level

Characteristics of amniotic fluid

color

If ruptured

Meconium stained

volume

If ruptured

polyhydramnios or oligohydramnios

character

Analgesic (e.g. Narcotics within 4 hr of delivery) and anesthesia (e.g.

General anesthesia)

Anesthetics given to the mother 4 hrs before delivery

increases the risk of respiratory problems in the newborn

Not breathing at birth but with a good heart rate

Lesson 1 History Taking of Newborn 7

 Perinatal History

Method of Delivery

Types include:

Forceps delivery

Vacuum extraction

Head is extracted

For mothers with cardiac problems

Caesarian

Normal spontaneous/vaginal spontaneous delivery

Time of delivery

Sex of baby

Cry at birth

Initial Delivery room assessment

Birth Injuries

Cut in the face or back

Clavicular fracture

Babies who are large for gestational age

Congenital anomalies

Can be grossly identified at delivery

Hydrocephalus

Cleft lip or cleft palate

Abnormalities of the extremities

Not evident at delivery

Congenital anomalies of the heart

Monitor baby more frequently

Complications

Asphyxia or respiratory distress, trauma,

meconium aspiration or prolapsed cord

APGAR scores

Ask the mom if the baby cried out loud at birth

"Mommy, si baby po ba umiyak nang malakas nung

lumabas?"

Resuscitation provided

Was oxygen given

Lesson 1 History Taking of Newborn 8

 Placental examination

To identify placental abnormalities

Bleeding on the placenta

Infarcts in the placenta

Example of a Newborn History

Baby Girl D.L.Cruz was born to a 24 year-old primigravid with
regular prenatal check up with an OB-gyne in a tertiary
hospital. The mother is a non-smoker and non-alcoholic
beverage drinker. She was not exposed to x-ray radiation. Her
blood type is O and she was screened for Hepatitis B and
DM. She had a urinary tract infection in the second trimester
and was treated with Amoxicillin 500 mg tid for 7 days with
good compliance. She took multivitamins and folic acid all
throughout the pregnancy.

The baby was delivered term via spontaneous vaginal delivery

by an OB Gyne in a tertiary hospital. The baby had a good cry
with an APGAR score of 8,9. Routine newborn care was
provided including BCG and Hepatitis B immunization at birth,
newborn and hearing screening.

The baby was discharged after 72 hours with the mother.

Lesson 1 History Taking of Newborn 9