Chettinad Hospital

Neonatal History & Examination Record

Name:
age

occupation

Literacy

Mother H.No

Mother
Father

Past Obstetrics History

Year

GA

Married

Years

Consanguinity

A
ANC Place Delivery

Sex

Wt

Neo problems

Present condition

1
2
3
4
Other diseases
Present pregnancy

Booked/ Unbooked

LMP :
PIH +

EDD :
-

Max BP at

Antenatal care at
TT 1 2 3 B

Wks

DM +

Oedema + -

Fits +

APH + -

Drugs for Hypertension:

Other complications /Drugs during pregnancy

No of Antenatal Visits during present pregnancy

Investigations : Hb

ICT at

Date
1.
2.
3.
Urine C/S :

Rh

Thyroid

Weeks + -

HbsAg + Hypothyroid

Blood Group

VDRL + + -

HBsAg

Drugs :
Urine routine

HIV

+ -

Duration:
Urine Alb + -

HCV

+ Dose:

Diabetic :

Gestational

Pregestational

Drugs for DM:

RBS :

PPBS:

HbA1C

GCT

FBS :

PPBS:

HbA1C

GCT

Renal/ Hepatic Function

Any other significant history:

USG Findings
1.

2.

3.

4.

Placental flow
Admitted to Ward

Yes

No

Reason

History During Labour:

Antepartum Steroids

+ -

Date

Time

No.of Doses

Time between last dose and delivery:

Admitted to Labour Room

Date

Time

Onset of Labour

Date

Time

Spontaneous / Induced

- Indication

Oxytocin / Others
Vaginal Examinations:

No. of Times:

Done outside by

no.of times

Membranes ruptured

Hospital
Spontaneously

Home

Date

Artificially

Hrs before delivery

Time

Amniotic Fluid quality:

quantity:

Clear

Meconium stained

Normal

H/O Fever :

Excessive

Foul smelling
Decreased

Absent

Max Temp :

Uterine Tenderness:
Sedation in previous 6hrs

Nil

Drugs in Labour : Antibiotics

+ -

CTG

Fetal Distress

DELIVERY:

Normal

Anaesthesia

Nil

Magsulph
Others

Abnormal
Local

Others

Duration
Indica

Spinal

General

Drugs
Placenta

Healthy

Duration of Labour

Unhealthy(Specify)
1st stage

Retroplacental clot + 2nd Stage

Baby Details:
Baby

Born on

at

Sex

Age of first Examination

Apgar Score :

Examination
General condition
Colour
Skin
Head & Neck
Eyes
Ears , Nose, Mouth
Thorax, Breast,
Clavicles
Spine

Normal

Description of abnormal Findings

Hrs

Musculoskeletal
Patent Oesophagus
Lungs ,Respiration
Heart
Abdomen including
Umbilicus
Genitalia
Anus
Neurological

Cry

Moro

Suck

Risk Factors

Tone

AF

PF

Rooting

Maternal

Neonatal

1
2
3
Diagnosis :Single/
AGA /

SGA /

PreTerm/ Term

Baby Born NVD / SVD /

LGA

Problems:
Plan : Keep at Mothers Side / Shift to Neonatal ICU

Advice :
1. Blood grouping and Typing

2. Neonatal TSH on 3rd Day

3. Keep Baby Warm

4. Exclusive Breast Feeds

5. Burping after feeds

6. Inj. Vitamin K 1mg Im Stat Given

Doctor attended

Signature of Paediatrician