NEWBORN CLINICAL HISTORY Delivery

a. Mode (vaginal, abdominal) _________________________________________

Nam e: _________________________________________________ Age:______ Sex: ______ b. Assistance (forceps, vacuum extraction) _______________________________
Nam e of Gu ardian : __________________________________ Relatio nship: ______________ c. Positio n _________________________________________________________
Residence: __________________________________________________________________ d. Anesthesia or analgesia ____________________________________________
Date o f Admission : ____________________ Reliability: ( ) Go od ( ) Fair ( ) P oor e. Complications ____________________________________________________

General Data (i. e. 1,100g 30-week AGA male delivered by C aesarean section to a 22 year old Immed iate Neonatal P erio d
G1P0 mother for progressive eclampsia) a. Apgar score
____________________________________________________________________________
____________________________________________________________________________ SIGN 0 1 2
Appearance Blue, pale limb s Blue limbs, pink C ompletely pink
Maternal Obstetrical Hist ory (significant past histor y especially pregnancy losses, and trun k trunk
complications or infertility pro blem ) Pulse Absent Below 100 Above 100
____________________________________________________________________________ Grimace No response Grim ace Cries, coughs,
____________________________________________________________________________ sneezes
____________________________________________________________________________ Activity Limp Some flexion of Active moto r
____________________________________________________________________________ extremities
Respiration Absent Slow, irregular Good stron g cry
History o f Pregnancy
a. Last menstrual period _________________________________________ Total: _________
b. Estimated date of confinemen t __________________________________
c. Prenatal care ________________________________________________ b. Resuscitation provided (ventilation, drugs, etc) _________________________
d. Weight gain _________________________________________________ ________________________________________________________________
e. Medications/ drugs, including OTC preparations ____________________ ________________________________________________________________
___________________________________________________________
f. Illnesses/ infections ___________________________________________ c. Neonatal course (procedures, labs) ___________________________________
g. Alcohol/ tobacco use __________________________________________ ________________________________________________________________
h. Blood type/ antibody screen ____________________________________ ________________________________________________________________
i. Serology/ cultures ____________________________________________
j. Gestational age dating (quickening, ultrasound, fun dal height) _________ Fam ily Hist ory
____________________________________________________________ ____________________________________________________________________
k. Complications (bleeding or spotting, edema, abdom inal pain) ____________________________________________________________________________
____________________________________________________________ ____________________________________________________________________________
____________________________________________________________________________
Labor ____________________________________________________________________________
a. Onset of uterine activity (spontaneou s, indu ced) ________________________ ____________________________________________________________________________
b. Duration ________________________________________________________
c. Intensity of C ontractions ___________________________________________ Social History (marital status, planned pregnancy, socioeconomic status)
d. Memb rane status (intact, ruptured spon taneously or artificially) ___________ ____________________________________________________________________
________________________________________________________________ ____________________________________________________________________________
e. Amniotic fluid (volume, color, character) ______________________________ ____________________________________________________________________________
________________________________________________________________ ____________________________________________________________________________
f. Presentation (vertex, breech, transverse) ______________________________ ____________________________________________________________________________
g. Augmen tation (oxytocin) ___________________________________________ ____________________________________________________________________________
h. Monitori ng (auscultation, electronic) _________________________________
i. Analgesia ( type, rou te) ____________________________________________

P HYSICAL EXAMINATION
General Ap pearance
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Back
____________________________________________________________________________
____________________________________________________________________________
An us
____________________________________________________________________________
____________________________________________________________________________

Vital Signs T ____ P ____ R ____ BP ____ Ht. ______ Wt. ______ Neurolo gical Examination
HC ______ CC ______
1. Initial Presentatio n ( ) Symm etrical Position
HEENT ( ) Gross abnormalities of skeletal, vascular, skin dev’
t
____________________________________________________________________________
____________________________________________________________________________ 2. Mental Status ( ) spontaneous activity (alert)
____________________________________________________________________________ ( ) response to external stimulation
( ) drowsiness
Neck ( ) ease of consolabi lity
____________________________________________________________________________ ( ) orientation to visual and auditory stimuli
____________________________________________________________________________ ( ) habituation to various stimuli

Ch est an d Lungs 3. Posture o f Flexio n ( ) limbs semi-flexed, legs partially abducted at hips
____________________________________________________________________________ ( ) head is slightly flexed, positioned at midline or side
____________________________________________________________________________ ( ) spontaneous motor activity of flexion and
____________________________________________________________________________ extension alternation between arms and legs
( ) for earms supin ate with flexion at the elbow and
Heart pronate with extension
____________________________________________________________________________ ( ) fingers are flexed with tight fist
____________________________________________________________________________ ( ) low frequency and high frequency tremors of the
____________________________________________________________________________ arms, legs and bod y (vigorou s crying or at rest
dur ing the first 48 hours)
Abdomen
____________________________________________________________________________ ( ) negative flexion (hypoton ia)
____________________________________________________________________________ ( ) head and legs ar extended (breech presen tation)
____________________________________________________________________________ ( ) legs abducted and externally rotated (frank breech baby)
( ) tremo rs at rest (4 days after birth)
Umbilicus ( ) asymmetrical movem ent of arms and legs (central/ peripheral
____________________________________________________________________________ neur ologic deficits, birth inju ries, congenital anomalies)
____________________________________________________________________________
HEAD:
Genitalia
____________________________________________________________________________ 1. Inspection/ Palpation:
____________________________________________________________________________ a. Anter ior fon atanels (size) _______
____________________________________________________________________________ b. Tenderness _____
c. Contour:
Extremiti es ( ) Bleeding ( ) vascular lesion ( ) defect
____________________________________________________________________________ ( ) nodules ( ) irregularities of bone densities
____________________________________________________________________________ of frontal and parietal bone
____________________________________________________________________________
 2. Head Circumfer ence:____________________cm or in. REFLEXES
3. Auscultation: __________________________
4. Transillumination: ______________________cm 1. Primitive Reflexes (infantile au to matism)
( ) Mor o reflex ( ) Babinski
CRANIAL NERVES ( ) Tonic neck ( ) Stepp ing
( ) Palmar Grasp ( ) Plantar Grasp
1. CN I –not tested ( ) Placing ( ) Rooting
( ) Galant/ Truncal Incurvation
2. CN II
( ) fixed at an object placed 10-12 inches from eyes and 2. Deep Tend on Reflexes
Can follow it 60 degr ees ( ) Biceps ( ) Ankle
( ) pur suit is not smooth ( ) Triceps ( ) Knee Jerk

3. CN III, IV, VI SENSORY

( ) symmetr ical size of glob e
( ) doll’ s eye maneuver Response to pain: ( ) awake
( ) nystagmus ( ) w ithdraw
( ) ptosis ( ) change in facial expression

4. CN V Gestational Age Assessment

( ) sucking reflex ____________________________________________________________________
____________________________________________________________________________
5. CN VI I ____________________________________________________________________________
( ) symmetr ical face
( ) ineffective sucking and droolin g Impression __________________________________________________________________
____________________________________________________________________________
6. CN VI II
( ) Moro reflex

7. CN IX, X
( ) evaluate baby’
s cry ________
( ) swallow

8. CN XI
( ) good SCM

9. CN XII
( ) tongue symmetrical
( ) tongue atrophy

MOTOR
( ) spastic ( ) flaccid ( ) hypotonic