Newborn History

Aka: Newborn History, Neonatal History

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II. History: Maternal History

  1. Maternal Age
  2. Blood Type and history of Blood Group sensitization
  3. Transfusions
  4. Bleeding Disorders
  5. Chronic Maternal Illness
  6. Diabetes Mellitus
  7. Hypertension
  8. Renal or Cardiac Disease
  9. Sexually Transmitted Disease (e.g. Genital Herpes)
  10. Infertility
  11. Recent Infections or Exposures

III. History: Family History

  1. Metabolic Disorders
  2. Hemophilia
  3. Cystic Fibrosis
  4. Polycystic Kidneys
  5. History Perinatal Deaths

IV. History: Previous Pregnancies and Outcomes

  1. Abortions
  2. Fetal demise
  3. Neonatal deaths
  4. Preterm delivery or postterm delivery
  5. Malformations
  6. Respiratory Distress Syndrome
  7. Jaundice
  8. Apnea

V. History: Maternal Drug History

  1. Medications
    1. Lithium
    2. Magnesium
    3. Beta Blocker
  2. Substance Abuse
  3. Alcohol Abuse
  4. Tobacco Abuse

VI. History: Current Pregnancy

  1. Probable Gestational age at delivery
    1. Last Menstrual Period
    2. Quickening (16-18 wks)
    3. Fetal Heart Tones heard with doppler fetal monitor (10-12 wks)
    4. Ultrasound results
      1. Confirms dates (how early was the Ultrasound)?
      2. Amniocentesis
      3. Polyhydramnios or Oligohydramnios
    5. Lung maturity labs
      1. L/S ratio
    6. Preterm Labor
      1. Labor suppressants
      2. Glucocorticoids
  2. Infection (including Prenatal Lab results)
    1. Rubella Immunity
    2. Syphilis Screening (e.g. RPR)
    3. HIV Test
    4. Hepatitis B Screening
    5. GBS Culture
    6. Maternal Antibiotics (including GBS Prophylaxis)
  3. Other maternal complications
    1. Pregnancy Induced Hypertension (Preeclampsia)
    2. Second or Third Trimester Bleeding
    3. Trauma
    4. Surgery

VII. History: Labor and Delivery

  1. Presentation
    1. Breech or other abnormal presentation
  2. Onset of Labor
  3. Rupture of Membranes
    1. Premature Rupture of Membranes
    2. Prolonged Rupture of Membranes >18 hours
  4. Duration of Labor
    1. Prolonged labor: >24 hours
    2. Prolonged Second Stage of Labor: >24 hours
  5. Maternal Fever
  6. Fetal Monitoring
    1. Fetal Bradycardia
    2. Non-reassuring Fetal Heart Rate tracing
  7. Amniotic Fluid
    1. Blood or Meconium in fluid
    2. Amniotic Fluid Volume
  8. Analgesic (e.g. Narcotics within 4 hours of delivery)
  9. Anesthesia (e.g. general Anesthesia)
  10. Maternal Oxygenation and Perfusion
  11. Method of Delivery
    1. Vaginal Delivery
    2. Instrumentation
      1. Vacuum Assisted Delivery (number of times applied to scalp)
      2. Forceps Assisted Delivery
    3. Cesarean Section (indications?)
  12. Initial Delivery Room Assessment
    1. Shock
    2. Asphyxia or respiratory distress
    3. Trauma
    4. Anomalies
    5. Fever, Hypothermia or other signs of Infection
    6. Hypoglycemia
    7. APGAR Scores
    8. Resuscitation
    9. Placental Exam
  13. Other complications
    1. Prolapsed Cord
    2. Abruptio Placentae
    3. Placenta Previa
  14. Immediate postnatal hospital stay
    1. Feeding problems
    2. Jaundice

VIII. History: Since hospital discharge (if indicated)

  1. Infant general, nutrition and hydration
    1. Alertness and sleep habits
    2. Feeding type (Breast Feeding or Bottle Feeding)
    3. Urination and stooling
  2. Maternal health
    1. Medications that may cross into Breast Milk
    2. Maternal Fever or illness since discharge
  3. Home environment
    1. Sick contacts
    2. Exposures (pets, passive smoke)

IX. References

  1. Joseph and Webb (2015) Crit Dec Emerg Med 29(1): 10-8

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