INITIAL ASSESSMENT OF THE NEWBORN

Presented By Barbara D. Mlewah

OBJECTIVES
1. To outline the techniques used in
examination of the newborn. 2. To outline the principles of newborn examination. 3. To describe the procedure of initial assessment of the newborn. 4. To describe the characteristics of a normal newborn.

TECHNIQUES USED
Observation/inspection (very important
technique) Auscultation Palpation Percussion

PRINCIPLES OF NEWBORN EXAMINATION

Necessary tools should be ready at hand;
stethoscope, ophthalmoscope, tape measure, thermometer and watch Create a conducive environment; clean, safe, flat surface, warm and out of draughts, well lit Review records: -antenatally; medical history that can be passed on to the baby, weight gain, obstetric complications during pregnancy any STIs

PRINCIPLES OF NEWBORN EXAMINATION

-labor; duration of first & second stages of labor, time of rapture of membranes, number of vaginal examination, medications received in labor, any obstetric complications, mode of delivery, fetal condition during labor, Apgar score Wash hands before touching the baby

PRINCIPLES OF NEWBORN EXAMINATION

Calm the baby before beginning the
examination Keep baby warm during the examination Handle the neonate gently Examination should be systematic Complete the examination

PROCEDURE FOR INITIAL EXAMINATION

When examining the newborn start with
inspection of the general condition, if satisfactory continue with specific examination as follows: -check V/S starting with temperature -temperature should be within the normal range 36 to 37.2 degrees Celsius, if not stop the whole examination- keep baby warm

PROCEDURE
Area examined Expected characteristic of a term neonate Posture: Head turned to 1 inspection side, arms & legs flexed (supine or prone) Appearance Abnormal findings

Extended limbs or flog positionpreterm, sick, nerve injury, fracture No apparent An apparent injury/abnormalit injury or y abnormality

Well being: inspection color: inspection

Active, alert, normal muscle tone Face, chest, tongue & lips are pink. Hand and feet may be bluish

Lethargic & sick, twitches, fits & coma Cyanosis, pallor, jaundice, dark red, grey, meconeum staining

Temperature (axilla) Respirations : inspection & auscultation

Less than 36 or more than 37.2 30-60 b/min (not crying) More than 60b/min, regular & quite, no chest gasping, apnea with in-drawings, no nasal low heart rate or flaring, chest and abdomen cyanosis, grunting, move with each breath stridor, wheezes Heart rate: 100-160b/min, short More than 160/less auscultation periods of change in heart than 100 rate are normal (crying) (persistent)

36 to 37.2 degrees Celsius

Skin & scalp: Inspect & palpate

Color: as above State: soft & smooth, white bumps on the face (milia), Vernix caseosa and lanugo on the face, slight bruises, birth marks, Mongolian spots

Color as above State: dry, peeling, very red, very thick or thin. Little or excessive vernix or lanugo, swelling

Measurement Head circumference: 33-37cm occipital s

Weight: after 1 hour of birth

Less than 33cmmicrocephally, SGA, frontal preterm. Length: crown heel 48- More than 37cm 54cm, average 51cm LGA, hydrocephaly 2500 to 3800gm. Less than 2500-SGA, Newborns loose 5-10% preterm more than of bwt, but should 3800gm- LGA
th

Head: shape Inspect and palpate

Elongated or uneven due to caput and moulding

Abnormal shape in anencephaly or hydrocephaly Excessive caput & moulding, cephalohematoma due to vacuum extraction

Head: skull bones, sutures and fontanels Inspect and palpate

Bones: slightly movable at sutures Sutures: slightly open or just overriding Fontanelles: open, soft and flat

Bones: very soft or hard & immobile sutures: very wide, excessive overriding, fused Fontanelles: very wide or not palpable

Head: scalp & hair inspect

Scalp: intact, slight swelling (caput) Hair: good scalp growth

Scalp: bruising and swellings, abrasions and cuts Hair: fine, downy for preterm, low black hair line (turner syndrome)

Face: inspection

Normal appearance

Eyes: inspection, examine with light or ophthalmoscope

Normal size and shape, correct placement, symmetrical. No discharges & not sticky 1.5cm- 2.5cm

Slight or gross anomalies, bruising, facial palsy Agenesis (one or both), asymmetrical, eyelid edema, bruising, tears, discharge, ptosis

Eyeballs: cornea correct size, clear, bright and shiny. No lesions or marks Sclera: white

Eyeballs: cornea small (rubella), large (glaucoma), sub-conjunctiva bleeding Sclera: blue (brittle bones) yellow Pupils: react evenly to Pupils: irregular, light cataracts, abnormal eye movements Conjunctival Conjunctival sacs: sacs: pale pink

Nose: inspection

Midline, flattish, broad, low bridge, wide & patent nostrils. Air from nostrils heard & felt during breathing Pink, normal size and shape Both soft and hard Pink, symmetrical, horse shoe shape, small retention cysts

Lips: inspection palate: inspection Gums: inspection

Squashed, no bridge (syphyillis) blocked, mucus ++ (choanal atresia) purulent or bloody secretions, cleft Blue, bruised Cleft lip Clefts, high arch, congenital defects Cyanosed, asymmetrical due to clefts, jaundice, teeth, sweeling, bleeding

Mucus membranes: inspection

Pink, moist and shiny Cyanosed, yellow, pale

Saliva: inspection
Ears: inspection

Normal: drooling
Upper ear in line with outer corner of the eye. Pinna vertical, ears well formed, symmetrical Short, thick with skin folds. Head in midline, no masses, some head control, side to side movement, extension and flexion

Excessive bubbles
Low set ears (downs syndrome) Poorly formed Webbing, extended, goiter, no head control, restricted movement, fractured clavicle, swelling

Neck: inspect & palpate

Chest: inspect Barrel, prominent end of ximphsternum, symmetrical movements with respirations Breast: Palpable breast nodules inspect and 0.5 1 cm diameter palpate Enlarged and lactating witches milk The abdomen: shape & movement Inspect & auscultate Rounded, bowel sound present 1hr after birth, moves with respirations

Funnel or bulging chest, rib recession in respiratory distress Mastitis, small nodules poorly developed nipples Mal-positioned nipples Distended or hollow, no bowel sounds or bowel sounds heard in the chest with problems

Umbilicus: inspect

2 arteries, 1vein, grayish white, drying around base, no bleeding

Abdominal organs: palpate

1 artery, 1 vein, redness, soggy, smelly, bleeding, hernia, meconeum staining Liver palpable 2cm Liver: enlarged, firm, below right costal tender margin, soft Spleen: enlarged, Spleen: tip firm palpable in thin Kidneys: enlarged, infants firm, malformation, kidneys: lower absent border palpable back flank in thin infants only

Female genitalia

Male genitalia

Clitoris & labia often edematous. Labia majora well developed, vagina orifice present, white discharge, mucoidal blood tinged discharge (up to 7 days) hymenal tags seen Scrotum well developed, testes palpable in a sac Penis: urethral opening at centre of glans

Clitoris enlarged, labia fusion, absence of vaginal orifice or imperforated hymen

Undescended testes, inguinal hernia Penis: micro-penis

Anus: inspection

Arms and hands: inspect and palpate

Correct position Imperforated anus and patent, or displaced meconeum passed anteriorly, no stools, blood in stools Arms: full range of Arms extended movement, with no movement brachial pulse (Erb-Duchenne palpable 80paralysis) 150b/min in 1st 24 Fractured clavicle hours, equal and strong Hands well formed, all digits present , palmer creases well developed

Lower extremities: inspection, palpation- Ortolan or Barlow test for dislocated hip

Back and spine: inspect

Hips & legs: semiflexed, full range of motion including abduction, long bones normal size, femoral pulses felt. Well developed planter creases Spine: straight, easily flexed

Legs extended (fractured), dislocated, abduction limited, reduced femoral pulses, extra abnormal digits, clubfoot or talipes

limited movement, neural tube defect, spina bifida

NEUROLOGICAL ASSESSMENT

A. MORO REFLEX 1. Grasp the baby's hands, extend the arms and release suddenly

2.

-gives a startled response. Arms fling out in embracing movement, fingers fan out symmetrically Lift the baby's -Legs may extend, head off the eyes wide open lying surface Slow return of in the palm of limbs to the flexed the hand, then position. Present allow head to up to 8 months fall back in the palm about 2cm

-asymmetrical body response (fractured clavicle, injury to brachial plexus)

-weak incomplete or absent- gross immaturity

B. GRASP REFLEX 1. Palmer: place Baby will firmly the tip of your grasp tip of the finger in the finger baby's hand

2. Plantar: place

finger at base of baby's toes

Toes curl downward Present from birth to 8 months

C. WALKING REFLEX Hold baby around upper thorax, under arms, in a standing position with the feet on a flat surface

-baby simulates walking by lifting and placing one foot in front of the other

-asymmetry of walking (neurological abnormality)

D. ROOTING AND SUCKLING REFLEX Touch baby's cheek, corner of mouth or lip with nipple or finger. Must be done before breast feeds

-baby turns head towards stimulus seeking nipple. Opens mouth, accepts nipple and sucks strongly -Both present from birth, rooting goes after 6 months

-preterm infants will not root -weak suckpreterm, sedation

E. SWALLOWING REFLEX Offer a breast

-suckling coordinated with swallowing without gaggling, coughing or vomiting

-weak suck at preterm, sedation, jaundice, infection, breathing problems, cerebral injury, mental retardation, cleft lip/palate

THE END