Newborn history taking Format

Newborn history taking format tailored for clinical and teaching use. It emphasizes maternal, perinatal, and neonatal factors that influence the newborn’s health:

I. Newborn’s profile

• Name: B/O (mother’s name).
• Date of birth: (if the baby is <72-hour old, then time of birth should be asked).
• Gender: Male/female.
• Gestational age: To calculate the gestational age, last menstrual period (LMP) and (expected date of delivery (EDD) of mother can be asked.
• Weight of newborn.
• Type: Identify whether the baby’s weight is small for gestational age (SGA), appropriate for gestational age (AGA), or large for gestational age (LGA).
• Place and type of delivery: Institutional/home; normal vaginal/instrumental/cesarean
• Address of the client.
• Maternal age, gravida, para, and number of live births and abortions if any.
• Informant: Mother/father/significant others.
• Reliability: Determine whether the information provided by the person is reliable or not.

II. Antenatal history taking Format

Ask about the age of mother at marriage as well as conception. Details of medications taken and immunization, total number of antenatal visits, and history of any infection, such as fever, rash, and urinary tract infection should be noted. In the case of high-risk newborn, detailed history of antenatal events can be collected.

• First trimester: History of vomiting (hyperemesis gravidarum), fever with rash (e.g., rubella), intake of teratogenic drugs, and exposure to X-rays or radiation.
• Second trimester: Inquire about gestational week at which mother felt first fetal movement (quickening), TT injection, and intake of iron and folic acid supplements.
• Third trimester: History of decreased fetal movements, premature rupture of membranes and color of liquor, fever, and foul smelling vaginal discharge.

Details regarding onset and duration of labor, maternal medications and induction and history of maternal complications, such as hemorrhage, obstructed labor, rupture of uterus, and sepsis are noted.

III. Natal history taking Format

Date and time and mode of delivery of baby: Ask the informant whether the baby is delivered in hospital or at home. Inquire about mode of delivery, i.e., normal vaginal delivery or cesarean section. In the case of cesarean, reason should be known.

• Birth weight on newborn.
• Time of cry, Apgar score (if known), and any history of birth asphyxia.
• Any complications associated with umbilical cord like cord around the neck.

IV. Neonatal history taking format

Collect information regarding the following:

• Time of voiding urine and meconium: Normally newborns will pass urine within 48 hours and meconium within 24 hours.
• History of seizures: Ask regarding signs and symptoms of neonatal seizure, such as abnormal cyclic movement of limbs and uprolling of eyes.
• Umbilical cord fall: Usually umbilical cord will fall off after 7-10 days. Ask the informant about any discharge, color changes, and pustules around the umbilical cord of newborn.
• History of shock, infection, temperature instability (hypothermia/hyperthermia), and congenital anomalies.
• Details of admission to NICU.
• Feeding: Time of first feed, any prelacteal feed (such as sugar water and honey) given to the baby, frequency of feeding, and any difficulties in feeding should be gathered from the mother.
• Immunization: History of vaccinations at birth (BCG, polio).

V. Maternal health:

Neonatal health and

• Welfare is associated with the health condition of mothers. Hence, it is mandatory to collect information about mother’s health status. The information elicited should include the following:
• Systematic disorders (renal, cardiac, diabetes mellitus, etc.).
• Maternal drug abuse (alcohol, tobacco, cocaine, heroin, marijuana, etc.).
• Obstetrical complications in previous pregnancies.
• Nutritional status (anemia, malnutrition).

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Naveen Bajaj, Rajesh Kumar, Manual of Newborn Nursing, 2nd Edition, 2023, Jaypee Publishers, ISBN:978-9354659294
6. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

Stories are the threads that bind us; through them, we understand each other, grow, and heal.

JOHN NOORD

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