How To Take History Of a Neonate in Hospital Admission

Neonates needs special care if they are ill. When neonates are being admitted in Hospital first the history is taken and written in a form. As I am an Intern Doctor of Rajshahi Medical College Hospital, I have received many neonatal cases. Certain points must be noted in the Admission form. Fort example, If the blood group of the baby or mother is negative, it should be highlighted. Usually Rh Negative Mother gives Birth to Rh +ve Baby. This baby needs after delivery special care.

[highlight]The format I am going to share is well practiced in Rajshahi Medical College Hospital. This format is Also applicable for any Hospital. A lot of things are excluded here. Maintaining everything is always not possible. But this will give you an Idea at least. And the vital things that must not forget.[/highlight]

Chief Complaints (Always with duration):

First note the chief complaints for which the baby is admitted. Note the date and time of birth with the procedure. Delayed crying after birth indicates perinatal asphyxia.

1. H\O NVD/LUCS on …….at ….. with\without delayed crying after birth.
2. Reluctant to feed and/or vomiting for …..Times.
3. H/O convulsion for ….times ……hour back
4. Abdominal distension or diarrhea for ….times.
5. Yellow discoloration of the body.

Maternal History:

Then ask for maternal history. Any disease condition of mother would affect the health of the baby. Also note the blood group of the mother.

• Age
• Para and Gravida of the mother:
• Use of any Drugs:
• Blood type:
• Previous complications of pregnancy:
• Type of contraception used, if any:

Any Risk Factors:

1. Diabetes Mellitus
2. Hypertension
3. Bronchial asthma
4. Smoking

Any history of following conditions should be noted:

1. Term/preterm baby
2. DM
3. Prolong or Obstructed labor
4. PROM
5. Fetal distress
6. Eclampsia/Preeclampsia

History and Examination of Neonate

The newborn neonate should be examined with extreme caution. Unnecessary handling should be avoided.

The weight of the neonate is very much vital and it is highlighted in the front page. Normal weight for an neonate is NO less than 2.5 Kg. See here everything about low birth weight baby.

Examination precaution: Hand should be washed with proper antiseptic. Thermal environment must be maintained during the examination. You should make your hand warm by gentle rubbing. Noise free quite environment is necessary. Total examination time should not exceed 5-10 minutes.

Cardiopulmonary stability:

Apgar score is examined immediately after birth and 5 min after birth. One minute Apgar score usually predicts immediate neonatal outcome. While the 5 minutes or later Apgar score is fairly predictive of future mental prognosis of such infant.

1. Appearance ( Color of the baby )
2. Pulse (Heart rate )
3. Grimace (reflex response)
4. Activities and muscle tone
5. Respiration

On General and Systemic Examination of Neonate:

1. Appearance: Well alert/Lethargic/Unconscious/Dyspnea
2. HR 100-160 normal
3. RR <60 normal
4. Sucking reflex
5. Moro reflex
6. Colour
7. Urine
8. Stool
9. Heart/Lung
10. Pupil

The neonate is througly examined for any congenital abnormalities.

Characteristics of New born Infant:

1. Length: 50cm
2. OFC: 35cm
3. Colour: Pinkish
4. RR: 30-60/min
5. HR: 100-160/min
6. Temp: 97.5-99 F
7. Chest: <3 cm of OFC
8. Urine: Usually pass within 24hours, but up to 72 hours is normal
9. Stool: usually pass within 24 hours but up to 48 hours is normal.

There may be transitory murmur. There are ½ chance that murmur heard at birth, will present as CHD. Breathing of infant is entirely Diaphragmatic. During inspiration soft front of thorax usually draws inwards, while abdomen protrudes. Paradoxical. Liver is usually palpable 2cm below rib margin.

See here more history and examination point NORMAL NEWBORN: HISTORY AND PHYSICAL EXAM OUTLINE

Download PDF: Complete Examination of a Newborn

Examination of the Newborn – A Practical Guide