What is the recommended step‑by‑step approach for taking a neonatal history in English?

Neonatal History Taking: A Structured Approach

A comprehensive neonatal history should systematically cover maternal prenatal history, labor and delivery events, immediate postnatal course, and family history, with particular attention to gestational age, birth complications, and risk factors that impact neonatal morbidity and mortality.

Maternal Prenatal History

Pregnancy Dating and Gestational Age

• Establish accurate gestational age using multiple criteria: last menstrual period, early pelvic examination, earliest fetal heart tones auscultation with fetoscope, fundal height measurements between 20-30 weeks, and sonographic measurements 1
• Document any discrepancies between dating methods, as accurate pregnancy dating is particularly important in the periviable period 2
• For premature infants (<36 weeks gestation), note that measurements should be corrected for gestational age for at least the first 24 months of life 3

Maternal Medical History

• Pre-existing medical conditions: diabetes, hypertension, cardiac disease, renal disease, autoimmune disorders 2
• Previous pregnancy outcomes including birth weights and congenital malformations, which may indicate predisposition to vascular, hypertensive, or diabetic illness 4
• Medication use during pregnancy, particularly teratogens such as warfarin, phenytoin, and blood glucose control in diabetics 4

Antenatal Complications

• Pregnancy complications such as preeclampsia, gestational diabetes, placental abnormalities 5
• Infections during pregnancy, particularly recent exposure to upper respiratory illness, paroxysmal cough, or pertussis 2
• Premature rupture of membranes and duration 2

Antenatal Interventions

• Antenatal corticosteroid administration (timing and number of doses) 2
• Tocolysis use 2
• Magnesium sulfate for neuroprotection 2
• Antibiotics for latency prolongation 2

Labor and Delivery History

Delivery Characteristics

• Mode of delivery (vaginal vs. cesarean) and indication for cesarean if applicable 2
• Duration of labor and any complications 6
• Intrapartum antibiotics for Group B Streptococcus prophylaxis 2
• Presence of meconium-stained amniotic fluid 2

Immediate Delivery Events

• Resuscitation requirements: need for positive-pressure ventilation, chest compressions, medications 2
• Response to initial resuscitation efforts 2
• Apgar scores at 1,5, and 10 minutes 7
• Cord management: delayed cord clamping (≥30 seconds) vs. early clamping 8

Birth Trauma

• Any evidence of birth trauma requiring immediate coverage with cling film or nonadherent dressing 8
• Need for stimulation or suctioning at birth 2

Immediate Postnatal Course

Vital Signs and Anthropometrics

• Birth weight, length, and head circumference plotted on appropriate growth charts 3
• Initial vital signs: axillary temperature (36.5°C to 37.4°C), respiratory rate (<60 breaths/minute), heart rate (100-190 bpm when awake) 3

Initial Assessment

• Physical examination findings: skin color, tone, activity level, respiratory effort 2
• Presence of congenital anomalies or dysmorphic features 2
• Umbilical cord vessels (should be two arteries and one vein) 3

Early Feeding and Elimination

• First void documented 3
• Feeding method (breastfeeding vs. formula) and tolerance 9
• Weight loss pattern: up to 10% is normal in term newborns during first 2-5 days, but approaching this limit warrants evaluation 9

Screening and Prophylaxis

• Newborn metabolic screening completed (venous sample preferred on day 2-3) 8
• Vitamin K administration 2
• Hepatitis B vaccine if indicated 2
• Hearing screening 3

Past Medical History (for subsequent encounters)

Previous Episodes

• Any previous unexplained events or brief resolved unexplained events (BRUE) 2
• Previous hospitalizations or surgeries 2

Ongoing Issues

• Reflux symptoms and management 2
• Breathing problems, noisy breathing, or snoring 2
• Growth patterns and developmental milestones 2

Family History

Sudden Death and Cardiac History

• Sudden unexplained death in first- or second-degree family members before age 35, particularly as an infant 2
• Apparent life-threatening events in siblings 2
• Long QT syndrome or arrhythmias 2

Genetic and Metabolic Conditions

• Inborn errors of metabolism 2
• Genetic diseases or developmental delays in family members 2

Social and Environmental History

Home Environment

• Family structure and individuals living in home 2
• Housing conditions, water damage, or mold problems 2
• Exposure to tobacco smoke, toxic substances, or drugs 2

Psychosocial Factors

• Recent changes, stressors, or family strife 2
• Support systems and access to needed resources 2
• Current level of parental concern or anxiety 2
• Previous child protective services or law enforcement involvement 2
• Exposure to adults with mental illness or substance abuse history 2

Special Considerations for High-Risk Neonates

Periviable Birth (22-25 weeks)

• Factors affecting viability beyond gestational age: fetal sex, multiple gestation, suspected major malformations, birth weight 2
• Parental preferences regarding resuscitation and intensive care 2
• Multidisciplinary counseling provided by obstetricians and neonatologists 2

Prematurity Risk Factors

• Gestational age <32 weeks and postconceptional age <45 weeks confer higher risk 2
• Infants <2 months of age at higher risk for adverse outcomes 2
• Multiple events increase risk 2

Documentation Priorities

Key elements requiring precise documentation:

• Exact gestational age by best estimate using multiple criteria 1
• Any resuscitation interventions and infant's response 2
• Maternal complications during pregnancy, labor, and delivery 6
• Family history of sudden death or cardiac conditions 2
• Social risk factors including substance exposure and family stressors 2