Neonatal History Taking : Format

Neonatal Period extends from birth to 28 days of life. History taking in newborn and neonates is different from those in elder children because, most of the things are related to when bay was in the maternal womb. So maternal history becomes an integral part of Neonatal history. MBBS and PG students need to know the proper format and components of Neonatal history. Here, is a commonly followed format.

Components of Neonatal History includes

Particulars of the baby

Maternal history

Antenatal history

Birth History

Neonatal history

Chief complains and elaboration of presenting illness

 

Particulars of the patient : is needed for identification of the patient. Baby’s name, Day of Life, Sex , IP number are usually noted although the things may get repeated later on.

Maternal History:

Name,  Address

Ask all factors that affect the child, specifically

• Age of the mother:  Less than 20 yrs and more than 35 both leads to complications in delivery. Trisomies are common in elderly mothers.
• Para and Gravida of the mother,  Along with sibling age and status. History of abortions ( Spontaneous or MTP )
• Blood group and Rh
• Chronic maternal illnesses- Chronic hypertension, Diabetes Mellitus, Hemolytic anemias, Renal cardiac disease, STDs, Bleeding disorders , Endocrine disorders.
• Addiction: Tobacco, Alcohol, Substance abuse
• Use of any Drugs: like Anticonvulsants, Anti-coagulants
• Previous complications of pregnancy
• Type of contraception used, if any

Paternal History: Age, Blood group, Consanguinity, Infections and illness, genetic disorders in family members.

 

Antenatal History:

Last Menstrual period

Expected date of delivery

Antenatal USG findings

1st Trimester

2nd trimester:

3rd trimester: events and complications

 

Birth History:

Presentation
Breech or other abnormal presentation
Onset of Labor
Rupture of Membranes
Premature Rupture of Membranes
Prolonged Rupture of Membranes  ( PROM)
Duration of Labor

Other risk factors
Maternal Fever
Fetal Distress
Blood or Meconium in fluid
Amniotic Fluid Volume
Analgesic (e.g. Narcotics within 4 hours of delivery)
Anesthesia (e.g. general anesthesia)

Method of Delivery- Vaginal Delivery/ CS if CS indications/Instrumentation/Vacuum Assisted Delivery /Forceps Assisted Delivery

Time of delivery                 Sex of baby            Cry at birth

Complications:
Asphyxia or respiratory distress
Trauma, Meconium aspiration
Prolapsed Cord

Post-natal events and feeding history. 

Feeding

Passage of urine and stool

Other issues

 

Chief complains:

Current presenting complains

1

2

3

HOPI- Eloboration, Negative history, Progress and complications, Related history.

 

Proceed to examinations

In the End, Summarize.

Provisional diagnosis would be in format

Single/ Term ( 38 wks)/ LBW/2.1 kg ( SGA)/LSCS with Apgar score 8/10.9/10/ Meconium aspiration syndrome/ Neonatal Hyperbilirubinemia / Staph. aureus Sepsis.

Complied by

Dr Sujit Shrestha

Neonatology ( GRIPMER )

MD Pediatrics ( IOM, TUTH)