Revision Classes in Pediatrics Pushpendra Magon
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Clinical Pediatrics

History Taking of a Newborn1

A good neonatal history should include details regarding baby's intrauterine stay along with the activities at the time of birth and subsequent establishment of feeding. Further, the various pathologies which may exist should also be elicited from the history.
The First Statement
The first statement in a neonatal history should include the gravida (number of pregnancies), parity (the number of live and stillbirths prior to the present pregnancy), age of the mother, gestation (based on clinical parameters and last menstrual period), the route of delivery and the indication for the same, e.g. LSCS conducted for CPD. It is equally important to note the place and the personnel conducting the delivery, as also the one receiving the newborn (obstetrician, trained Dai, physician, pediatrician or a relative).
Example: A two days old baby born to a 30 years old G4 P3 mother at full-term by normal vaginal delivery conducted by an obstetrician and received by a pediatrician.
Normal Vaginal Delivery
It is defined as the expulsion of the products of conception at term, with full maternal effort, without instrumentation, except episiotomy, in vertex presentation, through vaginal route.
Intrauterine Stay
Subsequently, history regarding the baby's stay in utero is asked, which includes history of radiation, drugs, rash or fever in the first trimester or an abnormally high blood pressure, presence of albuminuria, bleeding per vaginum, leaking per vaginum in the second trimester and the onset of labor pains, time of rupture of membranes, bleeding or leaking per vaginum, color of liqor (clear or meconeum stained) with special emphasis on history regarding background of sepsis any time during the pregnancy more so in the last trimester (like fever in the mother, unsterile or frequent per vaginal examinations, etc.). Knowing the duration of second stage of labor in home deliveries may be difficult but rough assessment can be made by asking the mother regarding the time as to when the Dai actively started interfering in the process of delivery till the baby was delivered.2
Investigations Done during Pregnancy
A special note has to be made of the results of investigation done during pregnancy like hemoglobin, urine examination, ultrasound with its indication (for fetal well-being or placenta previa or biophysical profile).
After Birth
Once the baby is delivered, questions like color, activity, and cry of baby would give a rough indication of baby's Apgar score. Care must be taken to ask regarding the time taken to initiate feeding in an otherwise healthy baby (Preferably within half an hour of birth, as rooting reflex is strongest at this time) with special emphasis on rooming in (keeping baby and mother on the same bed to develop bonding and lactation) and Kangaroo care (for warmth and growth of the baby by activating intestinal hormones for better digestion of feeds).
Feeding History
History regarding use of prelacteal feeds, which if given may be considered as one of the ‘background for sepsis’ as also overhandling of the neonate (we advise minimum handling and baby friendly activities like exclusive breastfeeding).
Indicators of Good Health
Every neonatal history should include the time of first passage of urine and meconeum (normally a baby should pass meconeum within 24 hours and urine within first 48 hours of life). If the baby is sleeping well and gaining weight, it indicates a healthy baby. Yawning and hiccups in a newborn also indicate well-being of the baby.
Indicators of Sickness
One may proceed with further history by asking and looking for specific complaints like jaundice, cough, etc (cough in a newborn is a pneumonia unless proved otherwise). History of baby having received IV fluids and/or NG feeds may point towards presence of some previous illness, low birth weight or prematurity which may be confirmed on examination.
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