History

History

1. In collecting the neonatal patient's medical history, it is important to include information about antenatal events. Fetal growth and development are affected by maternal disorders, including hypertension, diabetes, lupus, and drug, cigarette, and alcohol use. Poly- or oligohydramnios, abnormal α-fetoprotein, maternal infections, and premature labor are often associated with neonatal problems.
2. Perinatal history also includes gestational age, time of onset of labor and rupture of membranes, use of tocolytics and fetal monitors, signs of fetal distress, type of anesthesia used and mode of delivery (spontaneous, forceps or vacuum assisted, or cesarean), condition of the infant at delivery, and immediate resuscitation steps required (e.g., intubation for meconium, ventilatory assistance, surfactant administration, CPR, or medication administration). The Apgar score should be noted as it reflects the degree of intrapartum stress as well as the effectiveness of initial resuscitation (Table 30.1). Points are awarded for each of the five criteria, with the maximum score being 10. Although the Apgar score at 1 minute correlates with intrauterine conditions, the 5- and 10-minute Apgar scores correlate best with neonatal outcome. In addition, ensure that vitamin K and ocular antibiotic ointment were given after birth to prevent hemorrhagic disease of the newborn and ophthalmia neonatorum, respectively.