NEWBORN ASSESSMENT

Introduction
 Definition
Head to toe physical examination of a newborn to look
for any abnormalities or pathology.

Includes biochemical screening & certain special

screening.
 Purposes:
• To understand the physical and mental well being
of the child.

• To detect disease in early stage.

• To determine the cause and effect of the disease.

• To teach child and parent.

• To measure the health in future.

• To determine the nature of treatment or care

needed for the child.
Types of Health assessment of
newborn:
•Initial •Transitional •Assessment
assessment assessment of
gestational
age

•Behavioral •Systemic
assessment physical
examination
Initial Assessment
 Initial Assessment
Assessment immediately after birth. It includes:

First cry,

Heart rate, respiratory rate, temperature,

gross congenital anomalies,

consciousness,

birth injury, meconium staining &

APGAR assessment.
Newborn first exam : Apgar Score
Each item is given a score 0, 1, or 2
• 0-3 severe distress
• 4-6 moderate difficulty
• 7-10 no difficulty adjusting to life

Evaluation of all five categories are made on 1 & 5

min after birth.
 Transitional Assessment
First period of reactivity:

Begins at birth & lasts for first 30 minutes after birth.

Assessment includes:

• Temperature

• Pulse

• Respiratory rate

• Heart rate
 Second period of reactivity:
Begins when the newborn awake from the
deep sleep, it lasts about 2-8 hours.
The newborn is alert and responsive, heart
and respiratory rate are increased, gastric
and respiratory secretions are increased,
and passage of meconium commonly
occurs.
 Gestational Age Assessment:

An accurate assessment of age is important

for 2 reasons
• Age and growth patterns appropriate to that
age aid in identifying neonatal risks
• Help in developing management plans

Gestational age can measure by weight for

gestational age chart.
Gestational Age:
• SGA- small for gestational age-weight below 10th
percentile
• AGA-weight between 10 and 90th percentiles
• LGA-weight above 90th percentile
 Less than 36 More than 39
Character 37-38 weeks
weeks weeks
Skin texture & Shiny, oily plethoric, Less shiny, Pink, scanty lanugo
opacity plenty of lanugo, peripheral cyanosis, & only large veins
edema with visible less lanugo & veins are seen. Good
veins & venules on are only found on elasticity or turgor.
abdomen abdomen
Scalp hair Fine, Wooly, Fuzzy Fine, Wooly, Fuzzy Coarse, silky

Breast nodule 2 mm 4 mm 7 mm

Ear lobe No cartilage Moderate amount Stiff ear lobe, thick

of cartilage cartilage
 Less than 36 More than 39
Character 37-38 weeks
weeks weeks

Sole creases 1-2 transverse Multiple creases Entire sole covered

creases on anterior on anterior 2/3 of with creases
1/3 of sole sole

Male genitalia Testes partially - Testes fully

descended, descended,
scrotum small & scrotum normal
few rugae size, prominent
rugae

Female genitalia Labia majora Labia majora Labia majora

widely separated partially cover the completely cover
with prominent labia minora the labia minora &
labia minora & clitoris
clitoris
Behavioural Assessment
While babies may not speak their first
word for a year, they are born ready to
communicate with a rich vocabulary of
body movements, cries and visual
responses.
 The Neonatal Behavioral
Assessment Scale
(NBAS) was developed in 1973 by Dr. T. Berry
Brazelton and his colleagues. The scale represents
a guide that helps parents, health care providers
and researchers understand the newborn's
language. " The scale is designed to reveal an
infant’s strengths and preferences, so that parents
may have a better understanding of their
newborn’s capabilities.”
It is based on 3 assumptions:
1. Newborn baby control their
movements.
2. They communicate in different means.
3. They are social organisms.
The scale contains 28 behavioral and 18 reflex items
for parents and doctors to assess. It also reviews a
baby’s capabilities in several different
developmental areas: autonomic, motor, state
regulation, and social-interactive systems. The
result is not a score, but instead an understanding
of how infants integrate these areas as they adapt
to their new environment.

It includes habituation, orientation, motor maturity,

variation, self quieting ability & social behaviour.
Major components of growth &
development

Social &
Autonomic Motor
behavior activity
State interactive
activity
 Physical examination
• Complete physical examination within 24 hours of
birth.

• It is best to examine when the infant is quiet.

• Ensure infant is naked : he/she can be in diapers,

but you have to open it.

• Do not forget to wash hands prior to examination.

 Anthropometric Measurement

• Weight: 2.5-3 kg

• Length: 50-52 cm

• Head circumference:

32cm-37cm

• Chest circumference:

30-32 cm

• Mid arm circumference: 9-13

 Vital signs
a) Temperature : Normal 36.5 0c to 37.50c.

b) Respirations : Normal rate is 40-60bpm

c) Blood pressure :Normal 45-60/25-40mmhg.

Correlates with gestational age, post natal age,

birth weight.

a) Pulse rate : Awake 120-160bpm, Asleep 70-

80bpm

b) Heart rate: 140-160 bpm

 FONTANELLES
• Bulge – IICP

• Depressed –
dehydration
 Molding
• Overriding sutures.

• Resolve quickly
 Caput Succedaneum
• Soft tissue edema
from birth trauma.

• Crosses suture lines.

 Cephalohematoma
Bleeding between
the cranial bone and
the periosteum in
periosteal space.
Does not cross
suture lines
What will happen
when it starts to
resolve?
 SKIN
• Reddish in color,
smooth, puffy.

• Edema

• Turgor

• Cord

• Nails
Acrocyanosis

Mottling

Jaundice
PHYSIOLOGIC JAUNDICE
 Hyperbilirubinemia not
associated with
hemolytic disease or
other pathology in the
newborn. Jaundice that
appears in full term
newborns 24 hours
after birth and peaks at
72 hours. Bilirubin may
reach 6 to 10 mg/dl and
resolve in 5 to 7 days.
Vernix

Milia
 Rashes/Marks
- Erythema Toxicum (Newborn Rash)

- Forcep marks

- Mongolian spots

- Birthmarks:

 Port wine stain

 Stork bite/Nevi

 Strawberry mark

 Café au lait

- Petechiae
 Erythema Toxicum

Mongolian spot

Forcep mark
 Port wine stain

Stork bite/ Nevi

Strawberry hemangioma
 Head
o Anterior and posterior fontanell
o Moulding
o Caput succedaneum
o Cephalohematoma
o Craniosynostosis
o Craniotabes
 Face

• Eyes :eyes are examined for congenital

cataract, sub conjunctival hemorrhage,
conjunctivitis & Down’s syndrome.

• Ears : Unusual shape, low set ears,

periauricular skin tags (papillomas),
hairy ears.
 Face & neck
• Nose : Verify patency (Flat nasal bridge , Deviated septum ,
Choanal atresia-back of the anal passage is blocked )

• Mouth : Hard & soft palate for evidence of cleft palate

Neonatal tooth (predeciduos,true deciduos (milk teeth),
Macroglossia (unusually large tongue) & Oral thrush.

• Neck : Note shape, range of motion, and any webbing;

palpate for masses
– Brachial palsy –weakness/loss of motion
– Erb’s palsy –condition which turns muscles towards the
body (delivery)
– Fractured clavicle
 Chest
• Observation : respiratory rate, chest symmetrical,
sternal/intercostal /subcostal recession, nasal
flaring, grunting, stridor

• Breath sounds : Equality bilaterally, presence of

any additional sound.

• Breast in newborn.
 Heart
• Observation : heart rate, rhythm, quality of heart
sounds, active precordium

• Position of heart : may be determined by

auscultation

• Presence of murmur

• Palpate the pulses (femoral) & define whether its

normal, weak or absent.

• Signs of congestive heart failure : gallop,

tachycardia & abnormal pulses
 Abdomen
• Observation : scaphoid abdomen, omphalocele,
gastroschisis

• Palpation : Check for distension, tenderness or

masses. Palpate liver, spleen, kidneys and groin
and note any masses

• Auscultation : Listen for bowel sound

 Umbilicus
• Should have 2 arteries 1 vein.

• Inspect for discharge, redness or edema

around base of the cord.
Normal Umbilical Cord Umbilical Hernia
 Genitalia
Male Female

• Palpate bilateral testicles • Inspect for size and

location of the labia,
• Examine for inguinal hernia clitoris, meatus, and
vaginal opening
• Look for hypospadias, epispadias,
Phimosisforeskin is too tight • Pseudomenses
to be pulled back over the
head of the penis (glans)

• Observe colour of scrotum

• Cryptotorchidism-a condition in
which one or both of the testes
fail to descend from the
abdomen into the scrotum
Female Genitalia Abnormal
Normal Configuration
 Male Genitalia
Normal Undescended Testes
Ambiguous Genitalia
Anus & rectum
 Extremities
• Syndactyly-he condition
of having some or all of
the fingers or toes wholly
or partly united

• Polydactyly-condition
where someone is born
with one or more extra
fingers or toes.

• Oligodactyly- presence of
fewer than five fingers or
toes

• Congenital deformities of
foot
 Back & Spine
• Observe curvature and integrity

• Spina bifida – defect in closure of the neural tube that is

associated with malformations of the vertebrae & spinal
cord.

• Meningocele- (a sac protruding from the spinal column ) &

Meningomyelocele ( spinal canal and the backbone don't
close before the baby is born)
 Hips
• Congenital hip dislocation ( Ortolani & Barlow
Maneuvers)
• Assymetry of the skin folds on the dorsal surface
• Shortening of the affected leg
 Nervous System
• Neuromuscular system evaluation:

-Gestational maturity rating is measured after the baby is

born by the Ballard Scale, it consists of six evaluation
areas of Neuromuscular maturity and seven items of
physical maturity.

-A score is assigned to each area. The more neurologically

mature the baby, the higher the score.
Neuromuscular system evaluation, includes:

• Posture - how does the baby hold his/her arms and

legs
• Square window - how far the baby's hands can be
flexed toward the wrist
• Arm recoil - how far the baby's arms "spring back" to
a flexed position
• Popliteal angle - how far the baby's knees extend
• Scarf sign - how far the elbows can be moved across
the baby's chest
• Heel to ear - how close the baby's feet can be moved
to the ears.
 Posture
• Score 0 if all extremities are fully flexed
• 1 if there is slight flexion of the legs only.
• 2 if there is moderate flexion of the legs.
• 3 if the legs are flexed and the arms are partially flexed.
• 4 if all limbs are fully flexed against the body
 Square Window
Score 1 if the wrist can be flexed to 60 degrees
Score 2 if the wrist can be flexed half way to the forearm.
Score 3 if the wrist can be flexed to 30.
Score 4 if the palm of the hand can be pressed against the arm
 Arm Recoil
Score
• 0- there is no arm recoil at all
• 2 - there is some arm recoil.
• 3 -the arm recoil is good and the arm is flexed half way back to
the shoulder
• 4-a brisk arm recoil and the infant pulls the arm back almost to
the shoulder.
 Popliteal Angle
• 0 if the leg can be fully extended to form an angle of 180.
• 1 if there is some limitation to full extension of the leg.
• 2 if the knee can only be extended to 140.
• 3 if the knee can be extended just beyond 90.
• 4 if the knee can be extended to 90.
• 5 if the knee cannot be extended to 90
 Scarf Sign
0 if arm can be wrapped around neck like a scarf
1 if elbow can be pulled across chest, not fully around neck
2 if elbow reaches other side of chest, but not around neck
3 if elbow only reaches midline of chest
4 if elbow cannot be pulled as far as the midline
 Heel to ear
0 if heel can easily be pulled to ear
1 if heel doesn’t reach ear
2 if heel can be pulled most of the way
3 if heel can be pulled half way to ear
4 if heel cannot be pulled half way to ear
 Reflexes
• Glabellar reflex
• Blinking reflex
• Doll’s eye reflex
• Corneal reflex
• Sneezing & coughing
reflex
• Gagging reflex
•Plantar grasping
reflex
•Babinski reflex
•Traction reflex
•Ventral suspension
reflex
Subsequent assessment
•First day examination
•Daily examination
•Examination on discharge
 First day assessment
• Vital signs
• General behavior
• Anthropometric assessment
• Feeding behavior
• Pattern of elimination
• Head to toe assessment
 Daily assessment
• Feeding behaviour
• Vomiting
• Passage of urine & stool
• Sleep pattern
• Hypothermia
• Respiratory distress
•Jaundice
•Umbilical sepsis
•Oral thrush
•conjunctivitis
•Any other problems
On discharge assessment
Detailed head to toe assessment
 ADDITIONAL CARE
 Suctioning
 Positioning
 Wrapping
 Holding
 Circumcision Care
 Newborn Testing
 PKU, T4
 Hearing
 PARENT EDUCATION
 Axillary temp
 Bathing
 Care of nails
 Diapering
 Feeding
 Health care provider
visits
 When to call for
immediate attention.