ASSESMENT OF THE

NEWBORN

Perinatology Division, Dept of Child Health,

Reproduction System
Medical Faculty of Hasanuddin University
 Framework for the clinical
diagnosis & plan of care

n Comprehensive Newborn History

n Physical assesment
n Comprehensive Newborn History

n Identifying data
n Chief complaint

n History of presenting problem

n Antepartum history

n Obstetric history

n Intrapartum history

n Family medical, Maternal medical, and

social history
 n Physical
assessment
Assessment → a continuous process of
evaluation throughout the course of
routine care of the neonate
n Initial examination at
birth
n Evaluation of extrauterine transition

n Determination of gestational age

n Comprehensive examination in 24 hour

n Discharge examination
Examination of the newborn baby

Minimum prerequisites
o Mother & baby together
o The baby should be naked under radiant warmer, Warm
room, fresh clean sheet/clothes
o Thermometer
o Weighing scale
o Watch with seconds
o Stethoscope

Always wash hands & clean stethoscope before each

examination
5
 Examination at birth

Aim
o To describe and carry out an examination of a
baby soon after birth
Objectives
o To screen for malformations , birth injuries
o To observe smooth transition to extra uterine life
o An asses overall of baby’s condition
Assess:
Inspection Look for:
Look for abnormal swelling
Abnormality of limbs & spine
Eyes, ears, umbilicus
Observe
Breathing rate /
pattern
Color
Heart rate
Activity/ movements
Color of the baby

n Normal vs. Abnormal

8
Caput succedaneum vs.
cephalohematoma

9
Quick screening for malformations
Screen from top to bottom, midline, and
back examination
Orifice examination
Anal opening
Single umbilical artery

10
Simian crease
Dysmorphic features
Excessive drooling of saliva
Auscultation

Grunting, Cry, Heart sounds

 Palpation
n Any abnormal swelling:
Caput, cephalhematoma
n Palpable femoral pulses
n Dislocation of hip
n Capillary refill time ( CRT)
n Confirm the findings of
inspection
n Palpate the abdomen
n Feel for testes in male baby
Weighing the baby
n Prepare the scale: cover the pan with a
clean cloth/autoclaved paper; ensure the
scale reads zero
n Preparing and weighing the baby
§ Remove all clothing
§ Wait till the baby stops
§
moving
§
Weigh
Read andnaked
record
§ Return the baby to the
mother
n Scale maintenance
§ Calibrate daily
§ Clean the scale pan between each
weighing
 Temperature recording
n Hands and feet should be checked for
warmth with the back of the hand to see
if
the baby is in cold stress
n Temperature measurement
§ Use clean thermometer
§ Hold vertically in the axilla for 3
§
minute
§
Read and
Normal record
36.5ºC-37.5ºC
 Evaluation of
transition
Physiologic & biochemical
changes/adaptation
affect physical finding

Color, respiration, heart rate, behavioral

state,
gastrointestinal function → normal during
transition but may be abnormal if they
appear at
other times,
n Acrocyanosis

In
th
n

e
n
Generalized hyperemia
15 min of life:

1
n HR: 160-180 beats/min, murmurs
n RR: 60-100 breath/min
st
Determination of Gestational
Age,
NEW BALLARD SCORE

Ø Preterm  < 37 weeks

Ø Aterm  37-42 weeks
Ø Post-term  >42 weeks
New Ballard score

19
20
 Posture
n The normal resting posture of a term newborn
baby:
n loosely clenched fists
n flexed arms, hips, and knees
n Small babies (less than 2.5 kg at birth or born
before 37 weeks gestation)
n the limbs may be
n Babiesextended
born in the breech position may have
fully
flexed hips and knees; the feet the mouth; and
legs may even reach near the mouth.
The normal resting posture of a
baby born breech
ABNORMAL position of arm
and hand

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Normal resting
posture
Physical Maturity
Assesment of Size & Growth
 Classify, based on:
n Gestational age-Birth weight (Battaglia &
Lubchenco curve):
n Appropriate for Gestational Age (AGA)
n Small for Gestational Age (SGA)
n Large for Gestational Age (LGA)
n Birth weght:
n Low birth weight (LBW)
 Low Birth Weight

 Birth weight < 2500 g, gestational age is

not taken into
account.

LLBW could be :
Term
Preterm
Postterm
Classification of LBW
n Based on BW:
Low
n birth weight (LBW) : BW 1500 - < 2500 g
Very Low Birth Weight (VLBW): BW 1000 g -
n
<1500 g
n Extremely LBW (ELBW) : BW < 1000 g

§ Based on GA:
Preterm baby , AGA
Small for gestational age (SGA):
Preterm
Aterm
Post-term
 Head circumference and length.

These measurements are usually done last

in
the examination.
ü The head circumference of a term is

usually 33-38 cm (13-15 in.).

ü Crown-foot length is 48 to 53 cm (19-21
in.).
Examination within 24 hours
Objective
To describe and carry out comprehensive newborn
examination within 24 hours of birth( the 1 st 12
to
18 hr of life)→ after transition has been completed
successfully.
Aim
To ensure that malformations are detected
To ensure establishment of breast feeding ;
maintenance of temperature ;classify baby as
normal or abnormal
Cont...

Ask
o Breastfeeding
o Activity of the baby
o Any other problems*

Check
o Weigh the baby
o Temperature

Record
•Passage of meconium up to 24 hrs and urine up
to 48 hrs of life is usually normal
A. Cardiorespiratory System
n 1. Color:
nImportant index of cardiorespiratory
function
→ in white infant: reddish pink, possibly
acrocyanosis
→ dark-skinned : the mucous membranes are
more reliable indicators than skin
→ infant of DM mother & preterm are pinker
than average
→ postmature infants are paller
2. Respiration

- Respiratory rate: N : 40-60

breath/min
- Periodic rather than regular breathing,
esp in preterm → breathe at a fairly
regular rate for a minute and then have
a short period of no breathing (usually 5-
10 sec)
- No expiratory grunting, little or no
flaring
of the nostril.
§ When crying : mild chest retraction,
if
unaccompanied by grunting, may be
considered normal
§ Small babies (<2.5 kg or born before 37
wks gestation) may:
n Have some mild chest in-drawing

n Periodically stop breathing for a few

seconds
R
E
T
R
A
C
T
I
O
N
S
37
 Evaluation of Respiratory Distress of the
Newborn with Downe’s Score

0 1 2
Respiration < 60x/min 60-80x/min > 80x/min
Rate
Retraction No Retraction Mild Retraction Severe Retraction

Cyanosis No Cyanosis Cyanosis relieved Persistent

by O2 Cyanotic (with O
)
2

Air entry Good bilateral Decrease in air No air entry

air entry entry

Grunting No Grunting Audible by Audible without

stethoscope stethoscope

38
Evaluation of Respiratory Distress of the
Newborn with Downe’s Score

Score < 4 Mild Respiratory distress

Score 4 -7 Severe Respiratory distress

Score > 7 Impending respiratoty failure

(Blood gas analysis)

39
 3. Heart :
§ Precordial activity, rate, rhythm, the quality
of the heart sounds, and murmurs.
§ On the right side or left side→ auscultation and
palpation.
§ HR : 120 to 160 beats/minute.
§ It varies with changes in the infant's

§
activity :
An occasional term or post mature infant
may, at rest, have a heart rate well
below
100. In a normal infant, the heart rate
will
increase if the baby is stimulated
Ø If there is any doubt after auscultation
and observation that the heart
Øis:abnormally placed, abnormally large, or
overactive
→ a chest x-ray is the best means of further
assessment.
Ø Distant heart sounds, especially if
accompanied by respiratory symptoms, are
often secondary to pneumothorax or
pneumomediastinum.
Ø The femoral pulses should be felt (often
they are weak in the first day or
Øtwo)
If there is doubt about the femoral pulses by
time of discharge, the blood pressure in the
upper and lower extremities should be
checked. In infants with coarctation, pulses
and pressures may be normal in the first few
days of life while the ductus is still open
 B. Abdomen
Ø The anterior abdominal organs (e.g., liver,
spleen, bowel) can often be seen through
the abdominal wall, especially in thin or
premature infants.
Ø The edge of the liver is occasionally seen
Ø Intestinal pattern is easily visible.
Ø Asymmetry due to congenital anomalies
or
masses is often first appreciated by
observation.
Ø When palpating the abdomen:
§ start with gentle pressure or
§ stroking
moving from lower to upper quadrants
to
reveal
§Try the edgesmushiness
to appreciate of the liverwhen
or spleen.
palpating
over the intestine compared with the firmer
feel over the liver or other organs or masses.
The
§ normal newborn liver extends 2 to 2.5 cm
below the costal margin.
§ The spleen is usually not palpable.

§ Remember there may be situs inversus.

C. Genitalia and rectum
1. Male
Ø Phimosis.
Ø The scrotum is often quite large,
because it is an embryonic analog of
the female labia and has therefore
responded to maternal hormones.
Ø Hydroceles are not uncommon, but
unless they are of communicating type,
they will disappear in time without
being
the forerunner of an inguinal hernia.
2. Female
Ø Female genitalia at term are most
noticeable for their enlarge labia
majora.
Ø Occasionally, a mucosal tag from the
wall of the vagina is
noted.
 ØA discharge from the vagina, usually
creamy white in color, is commonly
found and, on occasion, replaced after
the second day by pseudo menses.
Ø The labia should always be spread, and
cysts of the vaginal wall, imperforate
hymen, or other less common
anomalies should be sought.
 D. Skin
ØThe epidermis of a newborn (especially a
premature infant) is thin; therefore,
the
oxygenated capillary blood makes it very
pink.
Ø Common abnormalities:
§milia (plugged sweat glands) on the nose
§ Mongolian spots. Mongolian spots are
bluish, often large areas most commonly seen
on the back, buttocks, or thighs that fade
slightly
over the first year of life.
 Erythema
§ toxicum may be noted occasionally
at birth, although it is more common in the next
day or two. These popular lesions with an
erythematous base are found more on the trunk
than on the extremities and fade without
treatment by 1 week of age.
§ Look for jaundice : Kramer 1,2,3,4,5.
E. Lymph nodes
Ø Palpable in approximately one-third of
normal neonates.
§ Usually under 12 mm in diameter
§ Often found in the inguinal, cervical, and
occasionally the axillary area.
F. Extremities, spine, and joints

Ø Anomalies of the digits (too few, too many,

syndactyly, or abnormal placement), club feet,
and hip dislocation are the common problems.
Ø Because of fetal positioning:
§ Forefoot adduction
→ if correctable with stretching, will often correct
itself in weeks and is no cause for concern.
§ Tibial bowing or torsion
→Mild degrees of tibial bowing or torsion are also
normal. Decreased motion of an arm should make
one consider Erb palsy or a fracture of a clavicle or
other bone.
 Ø Because of fetal positioning:
§ Forefoot adduction
→ if correctable with stretching, will often correct
itself in weeks and is no cause for concern.
§ Tibial bowing or torsion
→Mild degrees of tibial bowing or torsion are also
normal. Decreased motion of an arm should make
one consider Erb palsy or a fracture of a clavicle or
other bone.
Ø Decreased motion of an arm → consider
Erb palsy or a fracture of a clavicle or
other bone
Neurologic examination
Primitive reflexes
a. Palmer grasp → Put your index
fingers in the infant's palms to obtain
the Palmer grasp.
b. To test the Moro reflex, pull your
fingers quickly from his or her grasp just
before the head touches the mattress,
allowing the infant to fall onto the back.
Usually the Moro reflex will result,
although a "complete" Moro is
demonstrable only in approximately 20%
of cases.
ü Touching the upper lip laterally will cause
most infants to turn toward the touch and
open their mouths; the hungrier and more
vigorous the infant, the more intense is
the rooting response.
ü Placing a nipple in the mouth will initiate
a sucking response.
ü Stepping (and placing) can be elicited by
holding the infant upright with the feet
on
the mattress and then making the baby
lean forward. This forward motion often
sets off a slow alternate stepping action.
However, frequently a normal infant will
not perform the reflex.
 Examination at discharge

Aim
To ensure that baby is normal on exclusive breast
feeds
Objective
To screen that heart is normal
To ensure baby has no significant jaundice or
danger signs
Tell about follow up and danger signs
57
At discharge, the infant should be reexamined with the
following points considered:
A. Heart. Development of murmur, cyanosis, failure,
femoral pulses.
B. CNS. Fullness of fontanelles, sutures, activity.
C. Abdomen. Any masses previously missed,
stools, urine output.
D. Skin. Jaundice, pyoderma.
E. Cord. Infection.
F. Infection. Signs of sepsis.
G. Feeding. Spitting, vomiting, distension, degree of
weight loss (or gain), dehydration.
H. Parental competence. To provide adequate
care.
I. Follow-up. Arrangements made with infant's
primary physician.
Danger signs

n Not feeding well n Floppy or stiff C

n Less active than before or
n Temperature >37.50
n Fast breathing (>60/ <35.50C
min) n Umbilicus draining pus
n Moderate or severe or umbilical redness
chest in-drawing extending to skin.
n Grunting n >10 skin pustules
n Convulsions n Bleeding from umbil.
Stump
 Examination on follow-up

Aim
To ensure that baby is growing well on exclusive breast
feeds & give immunization as per national policy

Objective
To record the anthropometry weight , head circumference
To ensure baby has no malformations like – cardiac
murmurs
Normal: feeding behaviour

n Positioning
o Head in line with body
o Well supported
o Abdomen touches the
mother abdomen
o Turned to the mother
n Attachment
o Mouth wide open
o Lower lip everted
o Little areola visible
o Chin touches mother breast
n Assessment of feeding
adequacy
 It is NORMAL for a baby

§ To pass urine six or more times a day after day 2

§ To pass six to eight watery stools (small volume)
in 24 hrs
§ Female baby may have some vaginal bleeding
for a
few days during the first week after birth. It is
not a
§ Loses weight and regains by 7-10 days
sign of a problem.
The umbilicus: Which one is
normal?

n Normal vs. Abnormal

63
Umbilicus
The NORMAL umbilicus is:
§Bluish-white in colour on day 1.
§It then begins to dry and shrink and

§If falls off after 7 to 10 days

§No discharge

LOCAL UMBILICAL INFECTION

§ RED umbilicus or
§ RED skin around the umbilicus

POSSIBLE SERIOUS INFECTION

§Umbilicus draining pus or

§Umbilical redness, swelling extending to skin

Skin
A baby may have PUSTULES
MORE than 10 are a DANGER SIGN
§ Refer this baby urgently

Less than 10 are a local skin

infection
§ Treat them immediately
Skin conditions: Which baby will
you treat?

Teaching Aids: ENC

n Normal vs. Abnormal EN- 66
Skin pustules

Locate ?