NEWBORN ASSESSMENT

INTRODUCTION:
Newborn assessment is done as soon as after
birth as possible, the mother should be
allowed to spend some time with the baby
immediately after birth to initiate the bonding
process. Early assessment can assist the
nurse in ascertaining if the newborn is infant is
within the range of ‘normal’.
Definition:
• Health assessment is a thorough inspection or
a detailed study of the entire body or some
part of the body to determine the general
physical or mental conditions of the body.
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.
• General Points to be Remembered During Examination
of a Newborn:
– examine 1 hour after feeding
– examine in neutral thermal environment – examine the presence
of the mother.
– examine gently, methodically ( from top to bottom)
– examine those system which require a quiet child first and later do
examination that tend to disturb the child. Eg. Reflex testing, ear
examination.
Recommendations for general physical examination is to
examine patient in a supine position from the patient’s
right side. Right side is preferred because;
• Right jugular veins are more reliable for estimating
venous pressure.
• Palpating hand rests more comfortably on apical
impulse.
• A kidney is more frequently palpable.
Health assessment:
Assessment of the newborn as soon as possible after
birth and subsequent assessment in the neonatal
period are responsibility of the mucous working in the
hospital and in the community.
PHASES ASSESSMENT:
 Initial
Transitional
Assessment of gestational age
Systemic physical examinations
• INITIAL ASSESSMENT:
• The most frequently used method to assess the newborns
immediate assessment is done in newborn life including Apgar
Scoring System.
Apgar Scoring:
In 1953, virgenia Apgar introduced a simple systematic assessment
of intrapartum stress and neurologic depression at birth.
Causes of low Apgar Score:
• Asphyxia
• Maternal drugs
• Central nervous system disease
• Congenital muscular disease
• Prematurity
• Fetal sepsis
TRANSITIONAL ASSESSMENT:
1 stage: lasts for 6 hours, first 30 minutes awake, remaining hours
baby will be sleeping.
• 2 stage: 6 to 12 hours observation should be made until the vital
signs are stabilized.
ASSESSMENT OF GESTATIONAL AGE:
Dubowitz scale:It is an important criteria because perinatal morbidity
and mortality are related to gestational age and birth weight. A
frequently used method is by the use of determining gestational
age is by the ‘ Dubowitz scale’ a simplified version developed by
Ballard,Novack and Driver (1979).
Ballard scale: the new ballard scale is a revised scale of dubowitz
scale. It can be used with newborns as young as 20 weeks of
gestation. The tool has the same physical and neuromuscular
sections but includes -1 and -2 scores.
Neuromuscular maturity include: posture, square window, arm recoil,
popliteal angle, scarf sign, heel to ear.
Physical maturity: skin, lanugo, plantar surface, breast, eye/ear,
genital(male, female)
• GENERAL PHYSICAL EXAMINATIONS:
Vital signs:
Temperature: --neonates normally respond to infection with low
temperatures.
-- in neonates the temperature can be taken from the groin, axilla or
groin.
Normal temperature 36.5-37.5oC
Hypothermia < 36o C
Hyperthermia > 41oC
Respiration: -- count by observing the abdominal movements in
infants as the movement are primarily diaphgramatic.
-- count for one full minute for accuracy.
normal respiration 35 breath/ min
tachypnea >40 breath/min
bradycardia < 20 breath/min
• Pulse:
 apical pulse are more reliable for infants (between 4th and 5th
intercoastal).
Pulse is counted for one full minute in infants and young children.

Blood pressure: manual blood pressure monitoring is not routinely

done in neonatal nursery but in certain circumstances with
Oscillometry. The average systolic/ diastolic pressure is
65/44mmHg at 1 to 3 days of age.
• ANTHROPOMETRIC MEASUREMENTS:
Puposes:
1. To assess the body’s size against known standards for the
population.
2. To compare the size with estimated period of gestation
3. To provide a baseline against which susequent progress can be
measured.
Weight: it should be recorded within an hour of birth.
Average weight for term babies is about 2.5kg to 3.5kg.

• Length: the length can be taken more accurately in a measuring

table or a board with a fixes head piece on which the infant lies
supine with his legs fully extended. The average length of a
newborn is 48-50cm.
Head circumference: this measurement may slight change during the
first three days owing to moulding during labor, scalp edema or
bruising and cephalhematoma.
• Normally head circumference is 33-35cm in a term baby.
• Head circumference is 2-3 cm larger than chest circumference.

• Chest circumference: it is measured around nipple line

in mid expiration. Normal chest circumference 30-
33cm.
Abdominal circumference: it will be same as that of the
chest circumference.
 • GENERAL APPEARANCE:
Physical activity: the first 30 min , immediately after birth the
baby will be active. The newborn will be at sleep most of the time for the first 3
days.
Posture: normal posture is that of universal flexion. Extended posture of
newborn may be due to hypotonicity.
Head to foot examination:

Area Normal Abnormal

Skin Color: pink in color
Texture: soft
Turgidity : sensation of fullness
derived from the presence of
hydrated subcutaneous tissue.
Elasticity: when the skin is
grasped and released, the skin
promptly springs back.
Lanugo:
Vernix caseosa
Mongolian spot
Milia etc
Pallor: anemia, edema, shock, hypoxia, hypotension.
Cyanosis: central cyanosis, CHD, severe respiratory distress.
Jaundice: within first 24hrs- hemolytic disease, Rh
incompatibility, ABO incompatibility.
Within 24hrs- physiological jaundice. Petechiae:
infection, DIC
Edema: over hydration, renal failure, CHD, anemia. etc
area normal Abnormal

Cry Depressed: maternal

sedation, asphyxia
neonatorum etc. High
pitched cry: CNS
involvement.
Weak cry: respiratory
distress.

Head Head circumference: 33- Microcephaly: H.C<2.5cm

35cm of standard deviation.
Sutures are normally Macrocephaly: H.C>2 cm
palpable as cracks. of standard deviation
Fontanelle: anterior Widely separated sutures:
fontanelle-closes by 9-18 preterm, hydrocephalus,
months. Its having cerebral edema, high ICP
diamond shape. .
Posterior fontanelle: Bulging fontanelle:
closes by 2-4 months. subdural hemorrhage,
hydrocephalus, TORCH,
dysmaturity( absence of
subcutaneous fat, skin
wrinkling ), CHF.
Area Normal Abnormal

Delayed closure: rickets, hypothyroidism,

down syndrome.
Caput succedaneum: diffuse swelling of
subcutaneous tissue, over presenting part at
birth, not restricted to suture line.
Cephalhematoma: well demarcated
subperiosteal hemorrhage over parietal
bone, restricted by suture line.

Hair Fine silky hair. Preterm- fuzzy hair

Low hair line- turner’s syndrome.

Eyes Eye movements are not Upper slant- down syndrome

coordinated.
Eyelids may be edematous
for 2 days.
Sclera may be pale colored.
Iris of the eyes should be
round.
Cataract- congenital rubella, CMV etc
Conjunctivits:
Nystagmus ( eyes condition that makes a
repetitive , uncontrolled movement ):
Corneal reflex should be ruled out.
Areas Normal Abnormal

Nose Neonates are obligatory nose breathers. oral breathing: obstruction by mucus
Nose is usually flattened after birth. Nasal plugs, choanal atresia.
patency should be assessed.

Ears Top of pinna should be in line with outer Low set ears- a feature of genetic
canthus of the eyes. syndrome.
Tympanic membrane will be grey in
newborn. Normal infants hear at birth and
startle or have a complete moro reflex with
a sudden noise.
Areas Normal
Mouth or throat Epstein pearls are normally found on
both sides of the hard palate.
Precocious teeth may be present which
fall off soon.(1 in 2000 births)
Neck Neonates neck is usually short. To
examine the neck, head should be
extended.
Thorax Shape- normally barrel shaped
Respiratory rate- 40-60 breath/min
Heart rate- 120-160 beats/min
Type of breathing –diaphragmatic
Witch’s milk- normal
Supernumerary nipples- harmless
Swollen breast- normal
Abnormal
Excessive salivation: hare lip ( cleft
lip ), cleft palate, deviation of angle
of mouth – 7th nerve palsy.
Webbing of neck- turner’s syndrome
( is a chromosomal condition that
affects development in females. The
most common feature of Turner
syndrome is short stature, which
becomes evident by about age 5.)
Swelling of neck- sternomastoid
tumor common in breech, forceps
delivery etc
Emphysematous chest-
pneumothorax.
Dextrocardia (is a rare heart
condition in which your heart points
toward the right side of your chest
instead of the left side. ) ( - suspect
diaphgramatic hernia
Abdomen Normally- protruberant
Inspection- round in shape
Palpation- liver can be felt 1inch
(23cm) below right coastal margin.
Tip of the spleen may be palpable
by about 1 week after in left upper
quadrant
Scaphoid- diaphramatic hernia
Distended-ascitis,hydronephrosis,
meconium ileus etc. Prominent
liver- hematoma, hepatoblastoma.
Gastric mass-bag & mask ventilation,
duodenal obstruction
Areas Normal Abnormal
Abdomen Percussion- help to identify any fluid or Kidney may be palpable in case of
gas collection hydronephrosis, renal vein thrombosis.
Auscultation- bowel sounds can be heard
soon after the initiation of feeding

Umbilical Color- blue to white at birth Green in meconium staining

cord Structure- 2 arteries and 1 vein are seen. Single artery may be associated with
cardiac anomalies, intestinal
malformations.

Genitalia Male: normally prepuce covers the entire Phimosis, hypospadias, epispadias.
glans penis. Sometimes prepuce cannot
be retracted back up to 4-6 months in
normal babies.
Scrotum: varies in size, rugated with
descended testis. Preterm female babies- labia majora
does not cover minora.
Female: normally labia majora covers
labia minora
Spine Normally the curvature of the spine is spina bifida, meningomyelocele.
“C” shaped.

Anus Anal patency should be checked

Meconium should be passed within 24hrs
of birth.
Hypospadias- is a birth defect (congenital condition) in which the opening of the urethra is on the
underside of the penis instead of at the tip.

epispadias is a rare type of malformation of the penis in which the urethra ends in an opening on the
upper aspect of the penis.[1] It can also develop in females when the urethra develops too far
anteriorly.
Spina bifida is a birth defect where there is incomplete closing of the backbone and membranes around
the spinal cord. There are three main types: spina bifida occulta, meningocele, and myelomeningocele.
• SYSTEMIC ASSESSMENT:
A careful general examination of a newborn baby provides
more information of the condition of the baby. The system
to be examined includes:
1. Cardiovascular system
2. Respiratory system
3. Central nervous system
Examination of CVS: history of drug and TORCH ( TORCH,
which includes Toxoplasmosis, Other (syphilis, varicella-zoster,
parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes
infections, are some of the most common infections associated with
congenital anomalies) exposure
Anomalies - cleft lip/ cleft palate, cataract, polydactyl ( with extra
fingers or toes )
Respiratory rate - normal/ increased or decreased/ type of breathing
Pulse - 120-160 beats/min apical pulse normally taken
Average BP - term baby: 70/45mmhg
preterm: 60/20mmhg
• Examination of respiratory system:
History of cough - pneumonia
Diabetes mellitus - RDS
Preterm - RDS
Polyhydromnios - asphyxia, respiratory distress
Character:
Dyspnea, tachypnea, apnea, grunting ( abnormal, short, deep, hoarse sounds in
exhalation that often accompany severe chest pain)

Examination of central nervous system:

- examination of neonatal
reflexes- Conventional
examinations:
> consciousness; immediate and delayed response to external stimuli,
response to comforting, excessive crying, excessive quiteness.
 > involuntary movements: jitterness (is an involuntary
movement that is particularly frequent in the newborn. Its hallmark is
tremor), convulsive movement, spasms of tetanus.

- neurological examination for the

assessment of gestational age
-

REFLEXES OF NORMAL
NEWBORN
Reflexes are involuntary movements or actions. Some movements are spontaneous, occurring
as part of the baby's usual activity. Others are responses to certain actions. Reflexes help
identify normal brain and nerve activity. Some reflexes occur only in specific periods of
development.
Babinski

Babinski reflex. When the sole of the foot is firmly stroked,

the big toe bends back toward the top of the foot and the
other toes fan out. This is a normal reflex up to about 2
years of age.
 Moro Reflex

Moro reflex. The Moro reflex is often called a startle reflex because it usually occurs when a baby is startled by a
loud sound or movement. In response to the sound, the baby throws back his or her head, extends out the arms
and legs, cries, then pulls the arms and legs back in. A baby's own cry can startle him or her and trigger this reflex.
This reflex lasts about 5 to 6 months.
Tonic neck reflex. When a baby's head is turned to one side, the arm on that side stretches out and
the opposite arm bends up at the elbow. This is often called the "fencing" position. The tonic neck
reflex lasts about 6 to 7 months.
Grasp reflex. Stroking the palm of a baby's hand causes the baby to close his or her fingers in a grasp.
The grasp reflex lasts until about 5 to 6 months of age.
Step reflex. This reflex is also called the walking or dance reflex because a baby appears to take steps
or dance when held upright with his or her feet touching a solid surface.
 Rooting

Root reflex. This reflex begins when the corner of the baby's mouth is
stroked or touched. The baby will turn his or her head and open his
or her mouth to follow and "root" in the direction of the stroking.
This helps the baby find the breast or bottle to begin feeding.
 Sucking

Suck reflex. Rooting helps the baby become ready to

suck. When the roof of the baby's mouth is touched, the
baby will begin to suck. This reflex does not begin until
about the 32nd week of pregnancy and is not fully
developed until about 36 weeks. Premature babies may
have a weak or immature sucking ability because of this.
Babies also have a hand-to-mouth reflex that goes with
rooting and sucking and may suck on fingers or hands.
Doll’s Eye
Palmar grasp

Grasp reflex. Stroking the palm of a

baby's hand causes the baby to close
his or her fingers in a grasp. The grasp
 reflex lasts until about 5 to 6 months
of age.

• Swallowing
Accompanies the sucking reflex.
Food reaching the posterior of the
mouth is swallowed.

• Extrusion
- Substance placed on the anterior
portion of tongue. Extrusion of
substance to prevent swallowing.

• Sneezing and coughing-

Foreign substance entering the
upper or lower airways.clearing of
the upper air passages by
sneezing.Clearing of the lower
passages by swallowing.
 - Exposure of eyes to bright light.

Sudden movement of object toward

eye.

- Startle reflex - (pulling arms and legs

in after hearing loud noise)
Examples of reflexes that last into
adulthood :

 Blinking reflex: blinking the eyes when

they are touched or when a sudden bright
light appears
 Cough reflex: coughing when the airway is
stimulated
 Gag reflex: gagging when the throat or
back of the mouth is stimulated
 Sneeze reflex: sneezing when the nasal
passages are irritated
 Yawn reflex: yawning when the body
needs more oxygen

- Infant reflexes can occur in adults

who have:
- Brain damage
- Stroke