25 Apr 2019 ▪ Dr. Delfin B.

Santos

History Taking of the Newborn 01a

PEDI ATRI CS 01

Outline • Intrauterine growth

I. Introduction Error! Bookmark not defined. ○ Appropriate for gestational age (AGA)
II. General Data of the Infant 1 ○ Small for gestational age (SGA)
III. Obstetric and Maternal History 1 ▪ Complications include hypoglycemia, polycythemia,
IV. History of Present Pregnancy 2 hypothermia, dysmorphology
V. Course of Labor and Delivery 2
A. APGAR Score 2
○ Large for gestational age (LGA)
VI. Course in Transitional Nursery 3 ▪ Prone to hypoglycemia and problems with sugar control
VII. Family History 3 • Type of delivery
VIII. Stakeholders’ Analysis 3 ○ C-section is associated with greater mortality and morbidities, in
Review Questions 4 comparison with normal spontaneous delivery
References 4 ○ Breast milk production is sometimes delayed in those who
Appendix 5
underwent C-section
• Race
I. Goals of History Taking ○ Blacks have the highest mortality
• The history should Identify diseases the can be remedied with ○ Due to income class and prenatal care received
preventive action or treatment ○ Chinese have the lowest mortality
○ E.g. HIV ○ Sickle Cell Anemia is common in Africans
○ Maternal group B streptococcal infection: can cause septicemia ○ Cystic fibrosis is common in Jews
in the newborn, preventable by giving prophylaxis to the mom, ○ High risk of thalassemia and G6PD among Filipinos
or giving antibiotics to the baby ▪ Racial differences in mortality rates are based on health-
• Anticipate conditions that are of clinical importance seeking behavior and access to healthcare
○ E.g. Prematurity: major cause of morbidity and mortality in the • Sex, date, time of birth
newborn ○ Important to be able to chronologically time the progress of the
• Uncover possible causative factors that may explain certain baby during their course in the nursery
pathologic findings
○ Sometimes, we cannot get this from the history of the mom, but
can only be seen when the baby comes out
○ E.g. the baby could have congenital cataracts, rashes, or small
for gestational age, etc. We would then have to interview the
mother and ask for possible infections that may have occurred
during pregnancy like TORCH infections

Questions to Consider
• Where and when do we get the neonatal history?
○ On admission of the pregnant woman to the labor room
○ During labor in the labor room
▪ OB usually ask the what happened during the labor, when
was the bag of waters ruptured, was the amniotic fluid
meconium-stained or not
○ During delivery in the delivery room or the operating room
▪ Ask staff what happened during the delivery, what happened Figure 1. Neonatal mortality per 1,000 births based on birthweight.
to the child during cesarean section, possible reasons why
the APGAR was low
○ After birth in the mother’s room
▪ Again, ask about possible infections during pregnancy
○ In TMC, this is usually an easy step because the mothers have
an OB packet (lab tests during pregnancy, ultrasound, etc.) In
contrast to other hospitals wherein the patients may not have
had any prenatal check-ups at all
• Who are our informants?
○ Mother and Father Figure 2. Infant Mortality Rates by Selected Racial/Ethnic Populations.
○ OB resident and consultant
○ Nurses Sample Write-up for General Data (Santos, 2019)
○ Anesthesiologist • Baby Boy Vasquez, Filipino, born by NSD with a birth weight of
▪ Sometimes the baby may be depressed, thus you’d need to 3010 grams, AGA, 38 6/7 weeks AOG at 3:10AM on February
ask what anesthesia or pain reliver was given 14, 2019
• What are the questions we need to ask?
• Why are we asking these questions? III. Obstetric and Maternal History
• How are we going to write or present our history?
• Maternal factors affecting infant mortality
○ Age, race, marital status, gravida
II. General Data of the Infant ○ Blood type
• Birth weight ○ VDRL/RPR (date and results)
○ Single most important determinant of morbidity and ○ Expected date of confiment
mortality ○ Previous complications of pregnancy, labor, and delivery
○ Mortality rate increases as the birth weight decreases, especially ▪ E.g. Intrauterine fetal demise, neonatal death, prematurity,
for those that are less than 1,500 g. intrauterine growth restriction, congenital malformation,
▪ 500 gram baby: neonatal mortality rate is close to 90% (refer incompetent cervix, blood group sensitization, neonatal
to Figure 1) jaundice, neonatal thrombocytopenia, hydrops, inborn errors
○ Good predictor of baby’s survivability of metabolism
• Gestational age ○ Type of contraception used (if any)
○ Predicts if the baby is post-term or premature, both present with ○ If the present pregnancy was planned
their own special problems upon delivery ○ Any pre-existing medical condition, drug use, alcohol intake, and
cigarette smoking

Group 9: Balmadrid, Eleccion, Pagalilauan, Villanueva 1/6

• High-Risk Infants V. Course of Labor and Delivery
• Demographic social factors
○ Maternal age <16 or >40 years Table 2. Pertinent information regarding the course of labor and delivery
○ Illicit drug, alcohol, cigarette use Category Description
○ Poverty Start of Labor • Spontaneous / Induced
○ Unmarried Complications • Take note of any complications present
○ Emotional or physical stress
• Previous pregnancy
○ Intrauterine fetal demise
Fetal Monitoring • Heart Rate
○ Neonatal death Fetal Distress • Decreased fetal movement
○ Prematurity • Abnormal fetal heart rate
○ Intrauterine growth restriction • Abnormal amniotic fluid level
○ Congenital malformation • Maternal vaginal bleeding
○ Incompetent cervix • Abnormal cramping
○ Blood group sensitization causing neonatal jaundice • Insufficient or excessive maternal weight gain
▪ Mother is type O,while fatheris A, B, or AB Rupture of • Artificial / Spontaneous
○ Neonatal thrombocytopenia membranes • Timing
○ Hydrops ○ # of hours before delivery
○ Inborn errors of metabolism • Character of fluid
○ clear, bloody, etc.
Sample Write-up for Obstetric and Maternal History (Santos, Medications • Take note of analgesics / anesthetics
○ Drug
2019)
○ Dose
• The mother is a 35yo Filipina G3P2 (2002), Blood type O+. EDC: ○ Route
July 2, 2009. She has no history of pre-existing diseases and ○ Timing
denied drug use, alcohol intake, and cigarette smoking Duration • Stage I
○ Cervical dilatation
Table 1. Write-up for each pregnancy
○ Lasts up to 20 hours
Pregnancy Year History
• Stage II
G1 2002 • Full term baby boy delivered by normal
○ Upon full cervical dilatation until delivery of
spontaneous delivery. Birth weight = 3020g.
the baby
Stayed in the nursery for 3 additional days for ○ Lasts ~ 2 hours
jaundice secondary to ABO incompatibility. No
• Stage III
other complications
○ Placental delivery
G2 2004 • Full-term baby boy delivered by normal ○ Lasts ~ 20 minutes
spontaneous delivery. Birth weight = 2750g. Type of Delivery • Vaginal
Uncomplicated stay in the nursery
• C-section
G3 2008 • Present pregnancy
Fetal presentation • Cephalic
and position • Breech
IV. History of Present Pregnancy • Shoulder
• Location of prenatal care and number of visits • Compound
• Complications of pregnancy Use of Forceps • Type of forceps
• Special tests (Hepatitis B , HIV) • Indication
• Ultrasound exams, stress tests APGAR score • Ex:
• Medications ○ 4 at 1 minute
○ 7 at 5 minutes
○ Drug, dose, route, length of therapy, indication, when used
during pregnancy Resuscitation (if • Bulb suction
performed) • Free flowing oxygen
• Any infection during pregnancy and medications taken
• Bag and mask
• Check for
• Intubation
○ Vaginal bleeding, familial or acquired hypercoagulable states
• Drugs used (dose and route)
○ STIs, Acute medical or surgical illness
○ Multiple gestation, short interpregnancy time • Check for
○ Preeclampsia, premature rupture of membranes ○ Premature labor (<37 weeks), postdates (>42 weeks)
○ Poly/oligohydramnios, abnormal fetal ultrasonography ○ Fetal distress
○ Inadequate prenatal care ○ Immature L:S ratio, absent phosphatidylglycerol
○ Treatment of infertility ○ Breech presentation
○ Meconium-stained fluid
Sample Write-up for History of Present Pregnancy (Santos, ○ Nuchal cord
2019) ○ Cesarian section, forceps delivery
• The mother has regular monthly prenatal check-up since 2 ○ Apgar score <4 at 1 min
months age of gestation and every two weeks from 37 weeks
age of gestation. Vaginal bleeding occurred during the second A. APGAR Score
month of pregnancy and the patient was given Isoxsuprine 10 • Test performed that measures the baby’s performance and status
mg tab every 8 hours for 5 days. There was no recurrence of the upon childbirth
vaginal bleeding. Serial ultrasounds done during the prenatal • Taken at two intervals
visits were all normal. The mother had urinary tract infection on ○ 1 minute – Indicates how the baby tolerated childbirth
the 4th month of pregnancy and she was given Cefuroxime 500 ○ 5 minutes – Indicates performance outside the womb
mg tab, one tablet twice a day for 7 days. Urinalysis on • Used as predictor for neonatal death
admission is normal • Relative Risk for APGAR Score
○ 0-3: 1,460 (835 – 2,555)
○ 4-6: 53 (20 – 140)
○ 7-10: 1

18.01a History Taking of the Newborn 2/6

VERSION 01
Table 2. APGAR Scoring.
Sign 0 1 2 VII. Family History
Muscle tone (Activity) Limp Some flexion Active motion • Ask familial histories with impact on the neonate
of extremities ○ Do not just say, “No diabetes. No hypertension.”
Heart rate (Pulse) Absent Below 100 Over 100 ○ Better to say “No heredito/familial disease” 

Reflex irritability/ No Grimace Cough or • Relationship of neonate’s mother and father
Response to catheter in response Sneeze ○ Married, divorced, cohabiting, live apart, no contact maintained,
nostril (Grimace; tested etc. 

after the oropharynx is
• Mother
cleared)
○ Amount of education
Color (Appearance) Blue, Body pink, Completely
pale extremities pink ○ Employment outside of the home 

blue • Father
Respiration Absent Slow, irregular Good, crying ○ Age
• In the 90s, they considered the APGAR score to be predictive of ○ Amount of education
neurologic development/damage, especially if the score was low. ○ Occupation 

Latest literature suggests that this is no longer true and that the • Any illnesses (physical, mental, growth failure) in other members of
score is only predictive of neonatal deaths father's or mother’s family? If so, what? 

• Is there any disorder/s that mother worries her child mild develop? 

Table 2. Incidence of Neonatal Death in 132, 228 Singleton Infants Born at Term • High-risk infant
(37th week of gestation or later) in relation to APGAR Scores at 5 min. of age. ○ Economic
(Santos, 2019) ▪ Poverty
5-min No. of Live No. of Relative Risk ▪ Unemployment
APGAR Births Neonatal (95% CI) ▪ Uninsured, underinsured health insurance
score Deaths (Rate ▪ Poor access to prenatal care
per 1,000 ○ Cultural-Behavioral
births) ▪ Low educational status
0-3 86 21 (244) 1,460 (835 - ▪ Poor health care attitudes
2,555)
▪ No care or inadequate prenatal care
4-6 561 5 (9) 53 (20 - 140)
▪ Cigarette, alcohol, illicit drug use
7-10 131,581 22 (0.2) 1
▪ Age less than 20 or over 35 years
• For neonates with a 0-3 APGAR score, the relative risk of death is ▪ Unmarried
1,460 times more than babies who have a higher APGAR score. ▫ Lack of spousal support
▫ Lower rates of prenatal follow-up
Sample Write-up for Course of Labor and Delivery (Santos, ▫ Short inter-pregnancy interval
2019) ▫ Lack of support group (husband, family, religion)
• The mother had spontaneous labor 3 hours prior to ▫ Stress (physical, psychological)
admission. The course of the labor was unremarkable. ▫ Black race
Regular fetal monitoring showed no abnormal fetal heart
rate decelerations. The membranes were artificially Sample Write-up for Family History (Santos, 2019)
ruptured at 6 cm cervical dilatation showing normal amount The mother and father are presently not married,but living together
of non-foul-smelling whitish amniotic fluid without in a rented apartment. The mother is a high school graduate,
meconium staining. The duration of the stages of labor are working as a sales staff in SM, while the father is a college
within normal limits. The baby was delivered by normal graduate, working as a manager in a call center. There are no
spontaneous vaginal delivery on the 16th hour of admission heredito/familial diseases in both sides of the family. They reside in
under epidural anesthesia. Routine resuscitation was done a rented 2-bedroom apartment in Taguig, with potable water from
and the APGAR scores were: Manila Water. Two other children share 1 bedroom. The parents
○ 1 minute APGAR : 9 ( minus 1 for color) plan to put the baby in a crib next to them in the Master bedroom.
○ 5 minute APGAR : 10 Presently, their income can support their household expenses

VI. Course in Transitional Nursery VIII. Stakeholders’ Analysis

• Historically, Babies are separated from the mother after birth and • Stakeholders
placed in a nursery for ~24 hours for examination and observation ○ Persons other than the patient who have an impact or interest
• Presently, transitional nurseries are no longer used because of the on the needed changes to improve health
Unang Yakap program • Interest in Issue
○ The baby is now only separated momentarily: • Role
▪ To perform anthropometric measurements ○ Position about the required changes
▪ To administer initial vaccinations ○ Ally, resistor or bystander
▪ To perform formal Physical examination • Level of influence
▫ Complete PE done within 5 minutes ○ Grandparents usually have a high level of influence
▫ Decide if the baby is physically fit to latch onto the mom ▪ Even if vitamins have no approved therapeutic claim, we still
▫ Latch on to the mom for ~2 hours then take both to the buy it because it is already part of our culture
admitting section together ▪ Newborns with a kiss mark on the forehead, red- black-red
• Transitional Nurseries can still be used for babies that are: bracelets, amulets pinned on the clothing
○ Small for Gestational age ▪ If it does not cause harm, do not mention it anymore, but
○ Problematic Delivery inform them that it does not have an effect
○ Poor APGAR score • Pertinent Beliefs
• Things performed in the Transitional Nursery ○ Underlying belief systems that have an impact on how 
the
○ Vital signs
patient thinks, feels, and behaves about health
○ Hematocrit
▪ Jehovah's Witness and Blood Transfusion, or beliefs 
about
○ Dextrostix to screen for hypogylcemia
bodily integrity in death and possible limb amputation
• Take note of problems: cyanosis, respiratory distress, etc.
• Impact on Family
• Estimate gestational age by Dubowitz
○ Psychological, social or economic impact of patient’s disease on
○ Physical score
the family as a unity, and on its members
○ Neuromuscular score
• Consider the culture and the stakeholders
○ HC and length are the only metrics acquired
○ Try to respect this, if it is not harmful

18.01a History Taking of the Newborn 3/6

VERSION 01
• Community Factors
○ Facilitating
▪ Factors that would help the patient achieve, restore, and
maintain health
○ Hindering
○ Burden of illness
▪ Review data regarding the burden of the patient’s illness in
the community/ country, region, and world
• Pertinent Legislation/ Policies
○ Review pertinent legislation or policies that have an impact on
the care of patients with their condition
○ Current Events: Dengvaxia issue may have impacted current
vaccination rates

Review Questions
1. Lower birth weights are associated with lower survivability of the
infant. All infections in the newborn can only be treated once they
have been delivered.
A. Both statements are false
B. Both statements are true
C. Only the first statement is true
D. Only the second statement is true

2. Baby Thanos was brought to the ER by his mom Gamora and

presented with limp extremities, a heart rate of 70, grimace, blue
and pale appearance, with slow and irregular respiration. What is
his APGAR score?
A. 7
B. 3
C. 4
D. 6

3. What is baby Thanos’ relative risk of dying in relation to his

APGAR score?
A. 53
B. 1
C. 1460
D. 1450

Answer Key: 1c 2b 3c

References
(1) ASMPH 2020. (2018). History Taking of the Newborn [Trans].
(2) Santos. (2019). History Taking of the Newborn [Lecture slides].

18.01a History Taking of the Newborn 4/6

VERSION 01
 25 Apr 2019 ▪ Dr. Santos

History Taking of the Newborn 01a

PEDI ATRI CS 01

Appendix
For clinic use

Figure A1. Problems of IUGR (SGA) Infants

Figure A3. Drugs on pregnant woman and its adverse effect on the
newborn

Figure A2. Drugs and its effect on fetus

Figure A4. Maternal conditions affecting the fetus or neonate

Group 9: Balmadrid, Eleccion, Pagalilauan, Villanueva 5/6

 Figure A5. Maternal infections affecting the fetus or newborn

18.01a History Taking of the Newborn 6/6

VERSION 01