ASSESSMENT OF

NEWBORN

Ms.Shivani Mehta
1st year M.Sc.nursing.
 INTRODUCTION:-

A detailed and systemic whole body examination of a stabilized

newborn during a early hours of life. Each newborn baby is
carefully checked at birth for signs of problem or complications.
The healthcare provider will do a complete physical examination
that includes every body system. They are watching for signs of
problem or illness. The numerous biologic changes the neonate
makes during the transition of extrauterine life. The assessment
are in the following ways:
 ASSESSMENT:-

The newborn requires thorough, skilled observation to ensure a

satisfactory adjustment to extrauterine life. Physical assessment
following delivery can be divided into 4phases:
1. The initial assessment, which include the Apgar scoring system.
2. Transitional assessment during the period of reactivity.
3. Assessment of gestational age.
4. Systemic physical examination.
HISTORY OF APGAR SCORE:-
 History OF APGAR SCORE:-
Virginia Apgar (June 7, 1909 August 7, 1974) was an American
obstetrical anesthesiologist. She was a leader in the fields of
anesthesiology and teratology, and introduced obstetrical
considerations to the established field of neonatology. To the public,
however, she is best known as the inventor of the Apgar score, a way to
quickly assess the health of newborn children immediately after birth.
Work and research-
In 1949, Apgar became the first woman to become a full professor at
CUCPS, where she remained until 1959. During this time, she also did
clinical and research work at the affiliated Sloane Hospital for Women
. In 1953, she introduced the first test, called the Apgar score, to assess
the health of newborn babies. The Apgar score is calculated based on
an infant's condition at one minute and five minutes after birth. If the
five-minute Apgar score is low, additional scores may be assigned every
five minutes.
 INITIAL ASSESSMENT APGAR SCORING:-

The most frequently used method to assess the newborns immediate
adjustment to extrauterine life is the Apgar scoring system.
The score is based on observation of heartrate, respiratory effort,
muscle tone, reflex irritability, and color.
Each item a given score of 0,1,or 2. Evaluation of all five categories are
made at 1 and 5 minutes after birth and repeated until the infant
condition stabilizes.
Total score of 0-3 represent severe distress, 4-6 signify moderate
difficulty, 7-10 indicates absence of difficulty in adjusting to etrauterine
life.
The Apgar score is affected by the degree of physiologic immaturity,
Infection, congenital malformations, maternal sedation, analgesia, and
neuromuscular disorder.
APGAR SCORE:-
 CLINICAL ASSESSMENT OF GESTATIONAL AGE:-

Assessment of gestational age is an important criterion because

perinatal morbidity and mortality are related to gestational age and
birth weight.
A frequently used method to determining gestational age is the New
Ballard Scale(NBS) it assess 6 external and 6 neuromuscular signs. Each
sign has a number score, and the cumulative score correlates with a
maturity rating of 20-44 weeks of gestation.
Weight related to gestational age:-
The weight of the infant at birth also correlates with the incidence of
perinatal morbidity and mortality.
However birthweight alone is the poor indicator of gestational age and
fetal maturity.
Maturity implies the functional capacity-the degree to which the
neonate organ systems are able to adapt to the requirements of
extrauterine life.
Therefore gestational age is more closely related to fetal maturity than
is birth weight. Because hereditary influence a newborns size,nothing
the size of other family members is a part of the assessment process.
 General Measurement:-
Several important measurements of newborn have significance when
compared with each other and when recorded over a time of graph.
For the fullterm infant, average Head circumference is between 33-
35.5cm.Head circumference may be somewhat less immediately after
birth because of the moulding process that occur during a vagina
delivery. Usually by 2nd or 3rd day the skull is normal in size and contour.
 Chest circumference is 30.5-33cm.Head circumference is usually about
2-3cm greater than chest circumference . Because of moulding of head
during delivery.

Abdominal circumference is not be routinely measured in the

newborn,but should be done in the event of abdominal distension to
determine changes in girth over time.
 Vital signs-Axillary tempreture are
taken because insertion of
thermometer into the rectum can
potentially cause perforation of
the mucosa if performed
incorrectly. Core body temperature
varies according to the periods of
reactivity but is usually 97.7 to
99.7 F. Skin tempreture is slightly
lower than core body tempreture.
Therefore axillary tempreture may
be less then rectal temperature
Pulse and respiration also vary
according to the periods of reactivity
and the infants behaviour but are
usually in the range of 120-140
beats/min and 30-60
breadths/min,respectively. Both are
counted for a full 60sec. to detect
irregularity in rate or rhythm.
Bloodpressure provides baseline data
and may indicate cardiovascular
problems. When the newborn is in a
quite or sleep state,using an appropriate
cuff width-to-arm ratio of 0.45 to 0.70.
The average systolic/diastolic pressure is
65/41 mm Hg at 1 to 3 days of age.

 General Appearance:-
Before each body system is assessed,it is important to describe the
general posture and behaviour of the newborn.
Skin- The texture of the newborns skin is velvety smooth and puffy,
especially about eyes, the legs, the dorsl aspects of the hands and the
feet, and the scrotum or labia. Skin color depends on racial and familial
background and varies greatly among newborns. In general,infant is
usually pink or red. At birth the skin may be partially covered with a
greyish white, cheeselike substance called vernix caseosa, a mixture of
sebum and desquamating cells. It will be absorbed by 24-28 hours. A
fine,drowny hair called lanugo may be present on the skin, asepcially
on the forehead, cheeks, shoulders,back.
 Head- General observation of the
counter of head is important, Since
moulding occurs in almost all vaginal
deliveries. 6 bones- Frontal, occipital,
2 parietal, 2 temporals- make-up the
cranium. Between the junction of
this bones are bands of connective
tissue called sutures.
At the junction of the sutures are
wider spaces of unossified
membraneous tissue called
fontanels.
The two most prominent fontanels in
infant are the anterior fontanel,
formed by the junction of sagittal,
coronal, and frontal sutures, and
posterior fontanel formed by the
junction of the sagittal and lambdoid
sutures.
 The anterior fontanel is a diamond shape and measured anywhere
from barely palpable to 4-5 cm at its widest point.
The posterior fontanel is easily located by following the sagittal suture
towards the occiput. It is triangular in shape, usually measuring
between 0.5 and 1 cm at its widest point.
The fontanels should be feel flat, firm and well demarcated against the
bony edges of the skull.
Eyes- Because newborn tend to have
their eyes tightly closed, it is the best
to begin the examination of eye by
observing the lid for edema, which is
normaly present after 2 days of
delivery. Tears may be present at
birth, but purulent discharge from
the eyes shortly after birth is
abnormal. The eyes will usually open,
similar to the mechanism of Dolls
eye. The sclera Should be white and
clear. The cornea is examined for the
presence of any opacities or
haziness. The corneal reflex is
normally present at birth but may
not be elicited unless neurologic or
eye damage is suspected.
Ears- The ear are examined for
position, structure and auditory
function. The top of the pinna
should lie in a horizontal plane
to the outer canthus of the eye.
An otoscopic examination
ordinarily may not be
performed because the canal
are filled with vernix caseosa
and amniotic fluid, making
visualization of the tympanic
membrane difficult.
 Nose- The nose is usually
flattened after birth, and bruises
are common.
Patency of the nasal canals can be
assessed by holding a hand over
the infants mouth and one canal
and noting the passage of air
through the unobstructed opening.
 Mouth and throat- An external defect of the mouth such as cleft lip is
readily apparent, however the internal structure requires careful
inspection.
The palate is normally highly arched and somewhat narrow. Rarely
teeth may be present. A common finding is Epstein pearls, small, white,
epithelial cysts along both sides of the midline of the hard palate. They
are significant and disappear at several weeks.
The Frenulum of the upper lip is the band of thick, pink tissue that lies
under the inner surface of the upper lip and extend to the maxillary
alveolar ridge. It is particularly evident when the infant yawns or
smiles. It disappear when the maxilla grows.
sucking reflex by placing a nipple
or nonlatex finger in the infants
mouth. The infant should exibit
strong vigorous suck.

The rooting reflex is elicited by

stroking the cheek and noting
the infants response of turning
towards a stimulated side and
sucking
 Neck- Because the newborn neck is short and covered with folds of
tissue, adequate assessment of neck requires allowing the head to fall
gently backward in hyperextension while the back is supported in a
slightly raised position. Observe for range of motion, shape, and any
abnormal masses, and palate each clavicle for possible fractures.
Chest- The shape of the newborn chest is almost circular because the
anterio-posterior and lateral diameters are equal. The ribs are flexible
and slight intercoastal retraction are normally seen on inspection.
Inspect the breast for size, shape,and nipple formation, location and
number.
Breast enlargement appears in many newborns of either gender by
second or third day and is caused by maternal hormones. Ocassionally
aa milky substance, sometimes called witchs milk, is secreted by the
infants breast by the end of the first week. Supernumerary nipples
may be found on the chest, on the abdomen, or in the axilla.
 Lungs- The normal respirations of the newborn are irregular and
abdominal, and the rate is between 30 and 60 breaths/min. Pauses in
respiration of less than 20 seconds
Duration are considered normal. After the initial forceful breaths
required to initiate respiration, subsequent breaths should be
nonlabored and fairly regular in rhythm
Occasional irregularities occur in realtion to crying, sleeping, stooling,
and feeding.
Crackles soon after birth indicate the presence of fluid, which
represents the normal transition of the lungs to extrauterine life.
However, wheezes, persistence of medium or coarse crackles after the
first few hours of life, and stridor should be reported for further
investigation.
 Heart- Heart rate is
ascultated and may range
from 100 to 180 beats/min
shortly after birth and, when
the infantss condition has
stabilized, from 120 to 140
beats/min.
Dextrocardia, an anomaly
wherein the heart is on the
right side of the body, is
reported, because the
abdominal organs may also
be reversed, with associated
circulatory abnormalities.
 Abdomen- The normal contour of the abdomen is cylindric and
usually prominent with few visible viens. Bowel sounds are heard
within the first 15 to 20 minutes aftr birth. Visible peristaltic waves
maybe observed in some newborn. Inspect the umbilical cord to
determine the presence of two arteries, which look like popular
structures, and one vein, which has a larger lumen than the arteries
and a thinner vessel wall. At birth the cord appears a dull, yellowish
brown. It progressively shrivels in size and turns greenish black.
The liver is normally palpable 1 to 3 cm (about 0.5 to 1 inch) below the
right costal margin. The tip of the spleen can sometimes be felt, but a
palpable spleen more than 1 cm below the left coastal margin suggests
enlargement and warrant further investigation. Although both kidneys
should palpated, this maneuver requires considerable practice. When
felt, the lower half of the right kidney are 1 to 2 cm above the
umbilicus.
 Female Genitalia- Normally, the labia minora, labia majora and
clitoris are edematous, especially after a breech delivery. However, the
labia and clitoris must be carefully inspected to identity any evidence
of ambiguous genitalia or other abnormalities. Normally, in a female,
the urethral opening is located behind and below the clitoris.
Vaginal discharge may be noted during the first week of life. This
pseudomenstruation is a manifestation of the abrupt decrease of
maternal hormones and usually disappers by 2 to 4 weeks. Fecal
discharge from the vaginal opening indicates a rectovaginal fistula and
is always reported. Vernix caseosa may be present in large amounts
between the labia.
 Male Genitalia- The penis is inspected for the urethral opening,
which is located at the tip. However the opening may be totally
covered by the prepuce, or foreskin, which covers the glans penis.
A tight prepuce is a common finding in the newborn. It should not be
forcefully retracted; locating the urinary meatus is usually possible
without retracting the foreskin.
Smegma, a white cheesy substance, is commonly found around the
glans penis, under the foreskin. Small, white, firm lesions called
epithelial pearls may be seen at the tip of the prepuce. An erection is
common in the newborn.
 Back and Rectum- Inspect the spine with the infant prone. The shape
of the spine is gently rounded, with none of the characteristic S-shaped
curves seen later in file. Any abnormal openings, masses, dimples, or
soft areas are noted. A protruding sac anywhere along the spine, but
most commonly in the sacral area, indicates some type of spina bifida.
The presence of an anal orifice and passage of meconium from the
anal orifice during the first 24 to 48 hours of life indicates anal patency.
If an imperforate anus is suspected report this to the primary
practitioner for further evaluation infants.
 Neurologic System- Assessing neurologic status is a critical part of
the physical examination of the newborn. Much of the neurologic
testing takes place during evaluation of body systems, such as eliciting
localized reflexes and observing posture, muscle tone, head control,
and movement However, several important mass reflexes also need to
be elicited. Test these at the end of the examination, since they may
disturb the infant and interfere with auscultation . These reflexes as
well as several local reflexes.
 Transitional Assessment: Periods of reactivity
The New born exhibits behavioural and physiological characteristics
that may at first appear to be signs of stress. However, during the initial
24 hours, changes in heart rate respiration, motor activity, colour,
mucus production and bowel activity occur in an orderly, predictable
sequence that is normal and indicates lack of stress.
 For 6 to 8 hours after birth, the new born is the first period of
reactivity. During the first 30 minutes the infant is very alert, cries
vigorously, my suck his or her fingers or fist, and appears very
interested in the environment. At this time the new borns eyes are
usually open, making this an excellent opportunity for mother, father,
and child to see each other. Because the new born has a vigorous suck,
this is also an opportunate time to begin breastfeeding. The infant will
usually grasps a nipple quickly , both mother and infant. This
particularly important to point out to parents, because after the
initially highly activate state the the infant may be sleepy and
unintrersted in the sucking. Phyiologically, the respiratory rate during
this period during the periods as high as 80breaths crackles may be
heared heat rate reaches 180 beats/min, and bowel sounds are active
mucus secretion are decreased.
Temperature may be decereases. Maintaning appropriate temperature
for the new born is the best accomplished by practicing skin to s=kin
care whereby only a diaper is wrong to allow majority of skin surface.
To be in a contact with mothers skin.
 The second period of reactivity begins when the infants awake from
this deep sleep:
It lasts about 2 to 5 hours and provides another excellent opportunity
for child and parents to intereact. The infant is again alert and
responsive, heart and respiratory rates increase, the gag reflex is active,
gastric and respiratory secretions are increased, and the passage of
meconium frequently occurs. This period is usually over when the
amount of respiratory mucus has decreased. After this stage as a
period of stabilization of physiologic systems and a vacillating pattern
of sleep and activity.