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

 Comprehensive Newborn History

 Physical assesment
 Comprehensive Newborn History

 Identifying data
 Chief complaint
 History of presenting problem
 Antepartum history
 Obstetric history
 Intrapartum history
 Family medical, Maternal medical, and
social history
  Physical assessment

Assessment → a continuous process of

evaluation throughout the course of routine
care of the neonate
 Initial examination at birth
 Evaluation of extrauterine transition
 Determination of gestational age
 Comprehensive examination in 24 hour
 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

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 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:
Look for
Look for abnormal swelling
Abnormality of limbs & spine
Eyes, ears, umbilicus
Observe
Breathing rate / pattern
Color
Heart rate
Activity- feeding , movements

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Color of the baby

 Normal vs. Abnormal

Teaching Aids: ENC EN- 8
Caput succedaneum vs.
cephalohematoma

 Normal vs. Abnormal

Teaching Aids: ENC EN- 9
Assess:
Look for

Quick screening for malformations

Screen from top to bottom, midline, and back
examination
Orifice examination
Anal opening

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Assess:
Look for

Single umbilical artery

Simian crease
Dysmorphic features
Excessive drooling of saliva
Assess:
Listen for

Grunting, Cry, Heart sounds

 Assess:
Feel for
 Any abnormal swelling:
Caput, cephalhematoma
 Palpable femoral pulses
 Dislocation of hip
 Capillary refill time ( CRT)
 Confirm the findings of inspection
 Palpate the abdomen
 Feel for testes in male baby
Weighing the baby
 Prepare the scale: cover the pan with a
clean cloth/autoclaved paper; ensure the
scale reads zero
 Preparing and weighing the baby
 Remove all clothing
 Wait till the baby stops moving
 Weigh naked
 Read and record
 Return the baby to the mother
 Scale maintenance
 Calibrate daily
 Clean the scale pan between each
weighing
Temperature recording
 Hands and feet should be checked for
warmth with the back of the hand to see if
the baby is in cold stress
 Temperature measurement
 Use clean thermometer
 Hold vertically in the axilla for 3 minute
 Read and record
 Normal 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,
 Acrocyanosis
 Generalized hyperemia
 In the 1st 15 min of life:
 HR: 160-180 beats/min, murmurs
 RR: 60-100 breath/min
Determination of Gestational Age,

NEW BALLARD SCORE

New Ballard score

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20
Posture
 The normal resting posture of a term newborn baby:
 loosely clenched fists
 flexed arms, hips, and knees
 Small babies (less than 2.5 kg at birth or born before
37 weeks gestation)
 the limbs may be extended
 Babies 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

Teaching Aids: ENC EN- 23

ABNORMAL position of arm
and hand

Teaching Aids: ENC EN- 24

Normal resting
posture
Physical Maturity
Assesment of Size & Growth
 Battaglia & Lubchenco Curve:
 Classify : AGA, SGA, LGA
J. Head circumference and
length.
These measurements are usually done last in
the examination.
 The head circumference of a term is

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

 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 1st 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
Examination at 24 hrs: Assess

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
 1. Color:
 Important 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. 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
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
 If there is any doubt after auscultation
and observation that the heart is:
 abnormally placed, abnormally large, or
overactive
→ a chest x-ray is the best means of further
assessment.
 Distant heart sounds, especially if
accompanied by respiratory symptoms, are
often secondary to pneumothorax or
pneumomediastinum.
 The femoral pulses should be felt (often
they are weak in the first day or two)
 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
C. Abdomen
 The anterior abdominal organs (e.g., liver,
spleen, bowel) can often be seen through
the abdominal wall, especially in thin or
premature infants.
 The edge of the liver is occasionally seen
 Intestinal pattern is easily visible.
 Asymmetry due to congenital anomalies or
masses is often first appreciated by
observation.
 When palpating the abdomen:
 start with gentle pressure or stroking
 moving from lower to upper quadrants to
reveal the edges of the liver or spleen.
 Try to appreciate mushiness when 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.
D. Genitalia and rectum
1. Male
 Phimosis.
 The scrotum is often quite large,
because it is an embryonic analog of
the female labia and has therefore
responded to maternal hormones.
 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
 Female genitalia at term are most
noticeable for their enlarge labia
majora.
 Occasionally, a mucosal tag from the
wall of the vagina is noted.
 A discharge from the vagina, usually
creamy white in color, is commonly
found and, on occasion, replaced after
the second day by pseudo menses.
 The labia should always be spread,
and cysts of the vaginal wall,
imperforate hymen, or other less
common anomalies should be sought.
E. Skin
 The epidermis of a newborn (especially a
premature infant) is thin; therefore, the
oxygenated capillary blood makes it very
pink.
 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.
F. Lymph nodes
 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.
G. Extremities, spine, and joints

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

syndactyly, or abnormal placement), club feet,
and hip dislocation are the common problems.
 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.
 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.
 Decreased motion of an arm → consider
Erb palsy or a fracture of a clavicle or
other bone
Neurologic examination

a. Palmer grasp → Put your index fingers in the

infant's palms to obtain the Palmer grasp.
b. Then hold the infant's fingers between your thumb
and forefinger and pull him or her to a sitting
position. Note the degrees of head lag and head
control; remember a crying infant often throws the
head back in anger. The infant should be held in a
sitting position and the trunk moved forward and
back enough to test head control again. Then let
the trunk and head slowly fall back.
 Neurologic examination

Hold the infant's fingers between

your thumb and forefinger and
pull him or her to a sitting
position. Note the degrees of
head lag and head control;
remember a crying infant often
throws the head back in anger.
The infant should be held in a
sitting position and the trunk
moved forward and back
enough to test head control
again. Then let the trunk and
head slowly fall back.
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.
 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.
 Placing a nipple in the mouth will initiate a
sucking response.
 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.
Record
Findings Normal Abnormal
Heart rate
Respiratory rate
Retractions
Color
Temperature
Feeding
Weight
 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
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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
 Not feeding well
 Less active than before
 Fast breathing (>60/
min)
 Moderate or severe
chest in-drawing
 Grunting
 Convulsions
 Floppy or stiff
 Temperature >37.50C
or <35.50C
 Umbilicus draining pus
or umbilical redness
extending to skin.
 >10 skin pustules
 Bleeding from umbil.
Stump
EN-
 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

Teaching Aids: ENC EN- 56

Normal: feeding behaviour

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

Teaching Aids: ENC EN- 57

 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 sign of a problem.
 Loses weight and regains by 7-10 days
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Normal breathing
 30 to 60 breaths per minute
 No chest in-drawing, no grunting on breathing out
 When assessing breathing:
 Count number of breaths for a full minute
 Babies may breathe irregularly for short periods of time
 Small babies (<2.5 kg or born before 37 wks gestation) may:
 Have some mild chest in-drawing
 Periodically stop breathing for a few seconds

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R
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The umbilicus: Which one is
normal?

 Normal vs. Abnormal

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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

Teaching Aids: ENC EN- 62

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
Teaching Aids: ENC EN- 63
Skin conditions: Which baby will
you treat?

Teaching Aids: ENC

 Normal vs. Abnormal EN- 64
 Skin pustules

Teaching Aids: ENC

Locate ? EN- 65