Newborn Exam

GENERAL APPEARANCE AND SKIN

It is good to examine a newborn, in front of the parents, (this is another benefit of a home birth) where they can see every check take place and have the information explained to them. The equipment that is needed for a newborn exam is a stethoscope, a tape measure, a scale and a chart.

A newborn exam should be done in a warm room and it is usually done about an hour after birth. This procedure is not to be confused with the APGAR scoring done immediately after birth to assess the baby’s breathing, heart rate and transition into life outside the womb.

COLOR & SKIN

This is the number one thing that a midwife looks at. If the baby’s color is off, it is cause for concern.

The newborn should be pink all over, although it is normal for the first day or two of transition into life outside the uterus, to have slight bluing or acrocyanosis in the hands and feet. Some infants exhibit a condition called petechiae; minor red spots that can be associated with pressure at birth and this is usually normal.

Also, mottling can be seen on an infant, due to cold exposure outside of womb. The newborn is checked for birthmarks and other skin appearances such as port-wine stain (a dark pink/red spot); Mongolian spot - a dark bluish/brown mark found on baby’s lower back, that is commonly seen in dark skinned, Native American and Asian babies; stork bites - red bumps on the upper eyelids, forehead, and nape of neck; and milia - white tiny pustules on the nose and
cheeks. These skin conditions are all normal.

What is abnormal and cause for concern is jaundice (yellow skin) within 24 hrs of birth; pallor which could mean anemia; or a baby who is purple, blue or dusky (central cyanosis). If jaundice, cyanosis or pallor is noticed then the baby will be referred to a lab, pediatrician or hospital for further evaluation and tests. These conditions could be due to a heart malfunction, infection, prematurity, or blood group incompatibility.

LANUGO AND VERNIX

Sometimes, usually depending on the gestational age of the newborn, lanugo is seen. Lanugo is a thin, downy like hair that can cover either the entire body or just local places such as face, shoulders, back. Premature babies tend to have more lanugo, but this is normal for newborns.

The amount of vernix – a protective white/smooth/creamy substance on the skin - is observed. The gestational age of the newborn, determines how much vernix is present. If the newborn is preterm usually there is more vernix; an older baby will have less. If the baby is post-dates, vernix may only be found in armpits, and other creases on the baby. Any peeling is also noted.

Muscle tone, amount of activity, a high pitched cry (a sign of possible neurological damage), ability to nurse well, whether the baby is active, jittery or lethargic are also noticed.

MEASUREMENTS

Head & Chest Circumference

The baby’s head is measured by taking a cloth tape measure and putting it around frontal forehead and occiput. The average range is usually 36-38 cm or 13-14 inches. Another measurement is taken of the chest.

Weight

The midwife will weigh the baby one of two ways:

The baby is placed on a fish hook type cloth scale and weighed above the bed; or placed on a digital scale on top of a soft blanket or paper pad. The baby can be weighed in kilograms or pounds. Digital scales have a tarring mechanism so the blanket is placed on the scale first, weighed and then zeroed out. Then the baby is put on the scale. The average baby weighs about 7-9 pounds. But some baby’s are as small as 6 and a few as large as 10 pounds.

Height

The baby is placed on a firm, sturdy surface. It usually takes two people to do the length measurement. One person can hold the baby in place and the other person puts the tape measure from the top of the newborn’s head down to the heel of the baby’s foot, straightening out the leg. Baby’s can measure anywhere between 18-24 inches in height; the average being about 20-21 inches.

NEWBORN VITALS

Temperature

The midwife may lay the baby on the bed to begin with and place a thermometer under the newborn’s armpit to assess the newborn’s temperature. (not all midwives opt to take the baby’s temperature) If the room for some reason is cold the baby should be wrapped to preserve any heat loss in order for the baby to not become stressed and to maintain a normal temperature.

Heart Rate

The midwife will often listen with a stethoscope to the baby’s heart rate (normal: 120-160). She may be able to assess the heart sounds for arrhythmia’s (irregular heart beats.)

Respiratory Rate & Lung Sounds

It is important that the baby’s lungs are inflated and clear, so the midwife will most likely check his respiratory rate along with lung sounds. A normal newborn’s respirations are 30-40 breaths per minute. A respiratory rate of 80 for example could be cause for alarm. Some infants need a couple of hours to regulate their respiratory rate; however, in others high respirations could indicate a problem.

The practitioner when listening to the respiratory rate of a baby will also listen for any lung sounds. She will listen with a stethoscope applied to the back and front of the baby’s chest. Normal lungs are clear with only breath sounds; no rales, wheezing, squeaking, fluid, gurgling or a crackly noise.

Blood Pressure

A newborn’s blood pressure is optional and usually only taken if there is a concern regarding cardiac problems.

HEAD, FACE, NECK AND CHEST

Head

The midwife will check the newborn’s scalp for molding (over-riding of cranial bones), caput (swelling, fluid that crosses suture lines), and hematomas (blood filled swelling that does not cross suture line). She will make sure that the baby’s fontanelles - the anterior or large fontanelles in front and the posterior or smaller fontanelle toward the back of the skull - are both open and soft. She will also notice if the large fontanelle is sunken, indicating dehydration.

Face

The midwife checks the baby’s eyes to see that they are clear, not yellow, red or infected. She will notice if the eyes are level or not with the tops of the ears (not level is a sign of Downs Syndrome). She observes if the face is symmetrical when the baby is resting or crying and whether the ears are flat or folded.

Nostrils

The examiner observes the nostrils for patency, by holding one nostril closed and then the other to make sure both sides are equally working. Any nasal flaring – a sign of respiratory distress is noticed.

Mouth

A gloved finger is gently placed into the baby’s mouth to feel for a closed palate and to feel if the newborn has teeth or Epstein’s Pearls (a harmless condition common in a newborn; the pearls are protein-filled cysts). While checking the palate, the midwife will also check for a sucking reflex and see what type of suck the baby has, as well as a rooting reflex.

Neck and Clavicle

To assure that the baby’s neck is mobile, the midwife will gently rotate it from side to side. Then she will move down to examine the baby’s clavicles and shoulders, making sure (especially if it was a difficult birth involving shoulder dystocia, that there is no nerve damage or broken clavicle.

By sliding her fingers across the baby’s clavicles she can assess that there are no breaks, noticing if the baby screams in pain when touching them.

Chest

The chest is observed to make sure that the newborn has no chest retractions or see-saw breathing. This would most likely be noticed at birth, since it is a sign of a baby struggling to breathe. The midwife also notices if the baby’s breast buds are small, indicating a premature baby.

TRUNK AND EXTREMITIES

Abdomen

The midwife may or may not listen to all four quadrants of the abdomen for the presence or absence of bowel sounds (normal: 10 to 30 sounds per min). These sounds should be present 1-2 hours after birth. She may gently feel with her fingers to find any masses of any kind in the abdomen and notice if the abdomen is symmetrical on both sides. She may or may not palpate the liver lying 2 cm below costal margin and the kidneys.

Back and Spine

It is important though that the baby’s back and spine be observed for a condition called spina bifida - an opening in the spine and for dimples, which often occur. A slight shallow sacral dimple is normal.

Anus

Often the baby will pass meconium upon delivery, a clue that the baby’s anus is open. But the midwife can check that the baby’s anus is patent and that there is an anal reflex “wink.”

Genitals

The midwife may also observe the baby’s genitals – if the newborn is a girl, the labia minor and clitoris should be prominent. If he’s a boy, the examiner may check that both testes have descended.

Note: a midwife or any practitioner is not to pull back an infant male’s foreskin! The baby’s foreskin is normally and naturally adhered to the penis for the first 5 years or so of life. Pulling back the foreskin can abrade the glans of the penis and eventually cause adhesions and infection.

Extremities

The midwife will look at the baby’s arms and legs for symmetry, extension and flexion and rule out joint disorders and conditions such as Herb’s Palsy. Bowing of the baby’s legs is normal. She will notice if the hands have any abnormal creases and examine the baby’s foot prints in order to determine gestational age.

Hip Abduction

To rule out hip dysplasia, the midwife will most likely check the baby’s hips by placing the infant onto her back and into a frog leg position, then she will rotate both upper thighs backwards and up slowly, then back down creating a circular motion. She is listening for a click sound. Normal is no click sound, no “clunk”
when moving hips back down to original position.

Femoral pulses

During a newborn exam the midwife may also take the femoral pulses especially if a heart defect is suspected. These pulses are located on the baby’s inner thighs.

REFLEXES

All or some of these reflexes may be observed:

Grasp reflex

The examiner puts her finger into the baby’s hands. She notices if the baby has a strong or weak grasp. A Weak grasp could indicate problem such as Herb’s palsy and indicate problems with shoulders, arms neck.

Walking Reflex

The examiner holds the baby upright, with her hands on either side of baby’s chest. As the baby’s feet touch the ground, he makes a walking motion.

Babinski Reflex

The midwife slides a finger up the sole of the baby’s foot; the baby’s toes should fan.

Plantar Reflex

The examiner presses on the sole of the foot and the toes should curl and “grasp” around her finger.

Moro Reflex

This is also called the startle reflex. The baby lies flat on the bed then the examiner holds the infant by its arms a few inches above bed, then gently drops the infant back onto the bed to elicit a startle; the baby should throw her arms out in extension.

Doll’s Eyes

The examiner puts one finger into each hand of the baby, and then pulls the baby to sitting position. The baby’s eyes should open while sitting up.

Righting Reflex

Again, when the examiner pulls the baby up from the bed by the baby’s hands, the baby will strive to lift his head and instinctively try to get up.

Tonic Reflex

If the baby’s head is rotated leftward, the left arm (face up) stretched into extension and the right arm flexes up above head (fencer’s pose). The opposite
reaction should occur if the baby’s head is rotated to the right.

Crawling Reflex

When the examiner places the newborn on his abdomen, his legs should flex under him, and he should make a crawling motion.

Rooting Reflex

When the examiner touches the newborn on each side of the baby’s cheek, and the baby should turn to find the breast.

Sucking Reflex & Palate

One of the most important parts of the newborn exam and post partum care is noticing how the baby breastfeeds. A baby with a heart condition, infection or open palate cannot breastfeed well, if at all. A baby who is tongue tied will not suck properly, not get nourishment and bruise the breast.

The examiner puts a clean, gloved finger in the newborn’s mouth to check for a closed palate and to feel how the baby sucks. She checks for tongue tie, a congenital anomaly in which the frenulum is unusually short, not allowing for proper breast feeding.

A more comprehensive newborn exam would involve using the procedures outlined in the Dubowitz Scale.

PLACENTA AND UMBILICAL CORD EXAM

The midwife examines the placenta and the umbilical cord. There are several things to evaluate when examining the placenta, such as the size, shape, consistency and completeness of the placenta; the presence of accessory lobes, placental infarcts, hemorrhage, tumors and nodules; as well as placement of the
umbilical cord in the placenta.

The most important thing a midwife notes is whether the placenta is intact or not. All of the lobes should fit together with no missing pieces; any of which if retained in the uterus could cause infection or bleeding.

The umbilical cord is assessed for length, insertion, number of vessels, thromboses, knots and the presence of Wharton's jelly (connective tissue of the umbilical cord). There should be 3 vessels in the cord; if the cord has 2 vessels it could, but not always, point to a problem in the baby, such as a heart defect.

Tiara Duffy, Student Midwife