A Life After Born

A Well-Baby Case

LOUIJE P. MOMBAEL
POST GRADUATE INTERN – ARMMC
OBJECTIVES:
To discuss the history and physical
examination of Newborn
To discuss Essential Intrapartum &
Neonatal Care
GENERAL DATA:
 AB
 Newborn
 Female
 Filipino
 Born on March 1, 2020 in Marikina City
CHIEF COMPLAINT
 NEWBORN (WELL BABY)
BRIEF HISTORY
 Born live term
 Baby girl
 Via Normal Spontaneous Delivery
 21 y/o, G1P1(1001) Mother
 6x Prenatal Consult (Local Health Center)
 Regular intake of Multivitamins / Ferrous Sulfate
 No history Maternal Illness
 At birth, Good cry and Pinkish in color
 Appropriate for Gestational Age
PRENATAL HISTORY

 Prenatal Check-ups: 6x at Local Health Center

 Maternal Illness: None
 Exposure to Radiation/Teratogens: None
BIRTH HISTORY

Mother: 21 year old, G1P1 (1001)

Date of birth: March 1, 2020
Place of birth: Marikina City
Mode of delivery: Normal spontaneous delivery
Gestational age: 38 5/7 weeks
Maturity: Full term
Weight: 3kg (3000 grams)
Complications: None
IMMUNIZATION HISTORY
 BCG
 HEPA-B

FEEDING HISTORY
 Breast Feeding
FAMILY HISTORY

 Paternal Age – 22 y/o, no known illnesses, apparently

healthy
 Maternal Age – 21 y/o, no known illnesses, apparently
healthy

 Hereditary/Familial diseases:
(-) Epilepsy (-) Tuberculosis
(-) Allergy (-) Malignancy
(-) Diabetes Mellitus (-) Hypertension
(-) Bronchial Asthma (-) Cardiac diseases
SOCIOECONOMIC HISTORY
 Father: Educational Attainment: College Undergraduate

Occupation: Electrician
 Mother: Educational Attainment: College Level

Occupation: Student
PHYSICAL EXAMINATION
 General survey
[+] Awake [+] Alert [-] Cardiorespiratory distress

 Vital signs
HR: 136bpm RR: 56cpm Temperature: 37C O2 saturation: 98%

 Anthropometric measurements
BW: 3000g BL: 45cm HC: 34cm CC: 33cm AC: 31cm

 Skin
[+]Pink [+] Smooth [-] Lesions [-] Jaundice
PHYSICAL EXAMINATION
 HEENT
 Normocephalic, anicteric sclerae, pink palpebral
conjunctivae; patent ears, no skin tags, not low set, no
discharge; patent nose, septum midline; pink, moist
oral/buccal mucosa, no cleft lip/palate

 Chest and Lungs

 Symmetrical chest expansion, no intercostal/subcostal
retraction, clear and equal breath sounds
PHYSICAL EXAMINATION
 Heart  Extremities
 Adynamic  Pulses full and
precordium, apex equal, CRT <2 secs,
beat at 4th LICS MCL, no deformities
no murmurs, lifts,
thrills
 Genitals/Anus
 Grossly female, Anus
 Abdomen Patent
 Soft, not distended,
umbilicus: 2
arteries, 1 vein
PHYSICAL EXAMINATION
 Neuro  Motor: Spontaneous movement with
 Awake, Alert good muscle tone
 Cranial Nerves:
 CN I – not assessed  Reflex:
 CN II – blinks with presence of bright light, pupil
size 1-2mm
[+] Babinski [+] grasping [+] rooting
 CN III, IV, VI – spontaneous eye movement, [-] [+] Moro [+] sucking [+] blinking
ptosis
 CN V – not assessed
 Sensory: Not assessed.
 CN VII – [-] facial asymmetry
 CN VIII – not assessed
 CN IX, X – not assessed  Meningeal Signs: [-]
 CN XI – turns head side to side
 CN XII – tongue midline
IMPRESSION
Newborn live term baby girl via
Normal Spontaneous Delivery, Birth
weight: 3000g; Birth length: 45cm;
APGAR: 8,9; Ballard’s score: 40weeks,
Appropriate for Gestational Age
ESSENTIAL
INTRAPARTUM &
NEONATAL CARE
4 CORE STEPS OF EINC

Immediate
drying
Immediate & Thorough Drying of the
Newborn
4 CORE STEPS OF EINC

Immediate Skin-to-skin
drying contact
Skin-to-Skin Contact Between Mother
& Newborn
4 CORE STEPS OF EINC

Immediate Skin-to-skin
drying contact

Proper cord
clumping &
cutting
Properly-Timed Cord Clamping &
Cutting
4 CORE STEPS OF EINC

Immediate Skin-to-skin
drying contact

Proper cord Non-separation

clumping & of Newborn &
cutting Mother
Non-Separation of Baby from Mother
for Early Breastfeeding Initiation &
Rooming-in
Thank you .