Maternal History: Include age at delivery, prenatal care, GxPx, prenatal labs (Blood type, GBS, VRDL, Rubella, HBsAg, HIV status), results of any prenatal sonograms or other tests. Any infections, complications (eg, preterm labor), conditions (diabetic, anemic, etc.). Any medications during pregnancy? Any use of alcohol, tobacco, caffeine, or illicit drugs during pregnancy, if so quantify and date. Any problems with previous pregnancies?
Labor History: How were membranes ruptured? What was the time interval between ROM and delivery? What was the appearance of fluid after ROM (clear, turbid, maliferous, containing meconium?) Any antibiotics during labor? Any history of elevated maternal temperature during labor? Any drugs administered during labor such as MgSO4, terbutaline, anaesthetics, narcotics?
Birth History: Type of delivery (vaginal, c-section, VBAC). Was delivery assisted by mechanical means (vacuum, forceps). Was delivery complicated (by unusual presentation, nuchal cord, meconium); if complicated, how were the complications handled?. If meconium was present, was it thick or thin? Was there meconium beneath the cords? Was the patient intubated? Did the patient undergo tracheal suctioning (how many times)? Were resuscitative measures necessary such as BBO2, bag-mask ventilation, emergency meds? What were the Apgar scores? What was the final disposition of the baby -- sent to well baby nursery or special care nursery?
Physical:
The physical is the same as a regular new baby physical, although attention
should be paid to those areas that caused admission to the SCN (eg, respiration).
Make sure to do the opthalmic exam before the baby receives erythromycin
ointment which will obscure the red reflex. Premies should be evaluated
on the Dubowitz scale to estimate gestational age at birth. Growth charts
should be recorded.
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