Examination of The Newborn                                        

Elaine Foye, Sarah Rodriguez- Martin and Anne Moylan

1. History of Newborn Examinations

It can become a little confusing when we talk about examining a newborn and who has what
responsibility and when it is all carried out. Even the examination itself comes under various
names like "baby check", "paediatric check" "discharge check" depending on what area you
are working in.

Traditionally, the midwife in attendance at a birth conducts the initial inspection of the
newborn baby. This involves a top to toe systematic examination of the newborn in the
presence of the parents.  Should she find anything irregular, the baby will be referred to the
Neonatal Advanced Nurse Practitioner (ANNP) or Paediatrician. Following this, almost
everyday the midwife carries out a similar "top to  check" while  simultaneously caring for
the mother, discussing feeding and enquiring about overall  general well being of the mother
and baby.

However, there is a more detailed examination of every baby that must take place by staff
qualified in either the Examination of the Newborn or Newborn Infant Physical Examination
(NIPE).  While of course there will be overlap in what we do during all of  these
examinations, this more detailed examination  is referred to as a screening tool. It takes place
within the first 72 hours of life. It is then repeated again between 6-8 weeks of age, this time
usually by the General Practitioner or possibly the Health Visitor if she is qualified to do so.
This more detailed examination has been purposely developed in an effort to screen for and 
exclude specific anomalies. Should an abnormality or irregularity be detected, then this
examination is the first point of referral to specialists. The examination should screen for
congenital abnormalities of the eyes, heart, hips and testes, reassure parents and allow referral
for further test where appropriate. Originally this detailed exam was only undertaken by
paediatricians, but things have changed over this past few years.

The Best Practice Statement Routine Examination of the Newborn was originally developed
in 2004 by a project midwife seconded to the Practice Development Unit of NHS
Quality Improvement Scotland (QIS) together with a multiprofessional working group. The
aim of the statement was to offer guidelines for all registered maternity care professionals
undertaking the routine examination of newborn and an  audit tool was also developed, This
led to the development of a multidisciplinary course of education on detailed new born
examination, particularly for Midwives. This type of detailed examination of the newborn is
now embedded in many midwifery courses of education.

  Clinical connection

What have you seen in practice so far? can you identify the different professionals who carry
out both of these examinations.

During any examination problems can be identified, and if appropriate referred for
investigation, specialist assessment and treatment, as well as being fully discussed with the
parents. However midwives hav been found to be significantly more likely to discuss
healthcare issues such as feeding, sleeping and skin care, and provide continuity of care.

Advanced Neonatal Nurse Practitioners (ANNPs), who have undertaken specific training
which includes examination of the newborn, take responsibility, in some NHS boards, for the
routine examination of babies. This can be done in the labour ward, post natal area or they
may run a special clinic where babies born in the community or babies who have had early
discharge can return to.

Confused??

If you have not seen an examination being carried out on a newborn you may find all these
roles and who does what a little confusing.........it can be! 

To keep it simple and  for the purpose of this online lesson we are going to talk about the
examination of the newborn in 3 different  sections

1. The examination at birth by the Midwife in attendance.

2. The detailed examination screening tool, places greater emphasis on examining the eyes,
heart hips and genitalia particularly the testes and scrotum. This examination is carried out by
staff who have undergone extra training in this procedure and can be medical staff, ANNPs or
midwifes 

3. The daily baby check that you as midwives  carry out routinely, usually on a daily basis

I hope that makes this lesson a bit clearer for you.

It goes without saying if a baby need assistance at birth then our assessment or examination
of that baby is within a different context. I have included a little information that you may
have previously covered on this topic. 

2. The Role of The Midwife

To provide a seamless service, especially in remote areas, it is expected that midwives should
be able to complete the first and discharge examination of the baby. To complete the
examination, the professional must be able to understand the relevance of the examination,
examine, assess and identify normality and abnormality and be able to refer appropriately.

As follow on work from the 2004 edition of the best practice statement the Scottish
Multiprofessional Maternity Development Programme (SMMDP) has developed a training
programme for the preparation of all registered maternity care professionals who wish to
undertake this additional activity as part of their holistic care of women and their babies.
Midwives are now examining babies alongside other registered maternity care professionals
in 11 of the 14 NHS boards in Scotland. In an impact evaluation of the SMMDP and some of
its courses the Robert Gordon University stated that the “Scottish routine examination of the
newborn course is accessed by more midwives in a range of settings, including tertiary level
units throughout Scotland”. The structured approach and core competencies outlined in the
2004 best practice statement 1 are used as the baseline for this training course. This best
practice statement is applicable to the routine examination of babies who are thought to be
well, without significant problems, and being cared for in a postnatal ward or at home.
Routine examination is used to indicate the examination of a baby carried out between 6-72
hours after birth. In Scotland this is generally performed at around 24 hours of age. Normality
is defined as no unexpected or abnormal findings detected at the time of examination. This
does not guarantee absolute normality as signs of abnormality may only present later.

What do you think about midwives taking on this role? 

Some practitioners feel it is an excellent move towards extending the midwives role and

providing holistic practice. However not everyone agrees, with some seeing the role as a
medical responsibility.

2.1. Initial Assessment of The Baby

Initial assessment of a baby at birth

This is really more an initial  assessment of transition to extra uterine life as opposed to a
clinical examination but it is worth including here and I think highlights the many different
ways we are constantly assessing newborns.

 Assessment at birth. This is what you do immediately the baby is born. It may all not be in
exactly the same order as I have listed below but the process will be similar. If the baby is
vigorous and well at birth, then skin to skin contact  should be established, but if the baby
requires help with transition to extra uterine life, then you must follow the neonatal
resuscitation guidelines.

Note the time of birth

if all is well, then proceed to skin to skin contact. 

Dry and re wrap the baby, put a hat on if that's the routine practice in your area

Listen to heart rate, check tone as you note if baby is making respiratory effort ( of course if
you have any concerns at this point you would call for help and begin life support as
appropriate)

Note onset of regular respirations 

Determine the Apgar score at 1 minute and 5 minutes

Clamp the cord allowing  delayed cord clamping if appropriate. Take cord bloods if
necessary .

Check weight and occipito frontal circumference 

Ask for parental permission to undertake a top to toe examination- parents love to do this
with you.
Ensure you are in a suitably warm environment and undertake a top to toe examination to
determine any physical abnormality or irregularity  that may require referral.

Discuss with parents and if all is well continue skin to skin contact.

Record your findings on Badgernet or whatever system you use.

2.2. Assessment at Birth

Of course if a baby requires help to transition from intra uterine to extra uterine life at birth in
any way, then you must follow the newborn life support algorithm

Remember if you suspect a baby needs help at birth, call for  immediate assistance and follow
the resuscitation guidelines if required.
2.3. The Apgar Score

The Apgar score is a method for assessing a neonate immediately after birth and is also used
to record a neonates response to resuscitation or life support  measures if needed.  It is an
international  accepted method of assessment. 

There are five elements that are assessed at 1 minute, 5 minutes and 10 minutes of life
-although this  type of scoring may be continued throughout a resuscitation event. Each
element is awarded a point between 0-2 and the overall score, out of ten, is recorded
electronically on in Badgernet or the babies case notes.

The elements assessed at birth are:

A: Activity or muscle tone

 0 points: limp or floppy

 1 point: limbs flexed
 2 points: active movement

P: Pulse or rather, heart rate

 0 points: absent
 1 point: less than 100 beats per minute
 2 points: greater than 100 beats per minute

G: Grimace (in response to stimulation, such as handling or suctioning if required)

 0 points: absent
 1 point: facial movement or grimace 
 2 points: cough or sneeze, cry and withdrawal of limbs. 

A: Appearance  or colour

 0 points: blue, bluish-grey, or pale all over

 1 point: body pink but extremities blue
 2 points: pink all over

R: Respiration or breathing pattern

 0 points: absent
 1 point: irregular, weak crying
 2 points: good, strong cry.  

      Clinical connection
It is not often in practice you see the scoring system with the APGAR headings, it more likely
in  a format similar to the one below. Of course nowadays there would be no handwriting to
complete these scores as we do it all electronically.
There are very few newborn babies who receive a score of ten, as newborns are generally not
uniformly pink and may have blue hands and feet for some time following birth -this is 
called acrocyanosis ( please do not confuse this with central cyanosis, a blueness around the 
lips and face which would indicate a lack of oxygen and is a very serious sign.) The Apgar
score, although it has limitations is generally accepted as a convenient method to report in a
shorthand format, the condition of a baby at birth and response to any resuscitation methods
required. However you must understand that you have to be aware immediately when a baby
requires intervention or assistance with transition at birth and not wait for one minute to
calculate an Apgar score and then act accordingly.

I would like you to take some time some time to watch this
Play Video

      Did you know ?

2.4. Cord Clamping

Cord Clamping

Again only included as a refresher for you. Please move onto the next chapter if you dont feel
you require an update on this topic.

Delayed Cord Clamping

Delayed or deferred cord clamping has now come to be " the norm" at the birth of a baby.

These WHO guidelines from 2014 explain why we do this and of course this will be a part of
your practice you will be very familiar with at the birth of a baby. 

  Clinical connection

I was interested to read this  blog from a midwife in England regarding the implementation
and updating of clinical guidelines on delayed cord clamping. What are the guidelines in
your delivery suite? Is this what is always practiced? Reflect on your own experiences?
What have you noted with regards to delayed cord clamping at term vaginal births 
 and  preterm births. Have you attended an emergency birth where the baby was distressed
and required immediate intervention? What happened ? was there delayed cord clamping
in that instance?

3. The Immediate Examination

This first part of the presentation will introduce you to the Initial examination of the
newborn. It will introduce the different steps we midwives, follow during this examination. It
is vital to get familiarised with this assessment as it is an important part of the care we
provide. The midwife must accurately assess the health and wellbeing of the newborn baby
and be competent in this 

Any deviations from normal must be recognised and appropriate referrals made.

In a well baby, this examination is usually undertaken within a hour of birth.

It is important that the examination is thorough and complete, the midwife should develop a
systematic approach to the examination.

Always review or have a working knowledge of the maternal history. Remember that any
maternal illness, pregnancy or intra partum complications can impact on the baby

 Explain procedure to the parents and gain consent

 Wash and dry hands
 Ensure adequate lighting
 Keep the baby warm
 Document findings. React appropriately if needed
 Discuss with parents

The Midwife needs to explain to parents that the assessment of baby’s wellbeing is a
continuous process and that each examination validates normality for that moment in time.

4. The Head, Face Neck & Clavicles

Start at the top and work down.

Examine the head

Due to moulding, the shape of the newborn’s head can be round (a), bullet-shaped (b) or
elongated oval (c). You may need to reassure parents that head will assume its normal shape. 

(a)
(b)

(c)

However any moulding needs to be noted, as well as the head circumference. The average
head circumference (OFC) in a full-term baby is 32-37cm.

The Eyes

Eyes 2, general shape and size

It is sometimes difficult to get a good look at the eyes. You

might need to return to this aspect of the exam when the
baby is in a quiet relaxed mode.

The Nose

Shape and size, note if any flaring of the nostrils and that 2 
nostrils are patent.The Mouth

Symmetrical. Palate visualised using a torch preferably as well as digital

examination of soft palate to exclude cleft palate. Exclude tongue-tie.

Make sure you get a good look!

Ears, 2, symmetrical and normal position, any skin tags should be noted.

 Neck
Check for  swelling, normal movement
of neck should be noted. 

Clavicles
Feel and palpate clavicles for size and contour.

5. Arms & Hands

Arms 
 Should be the same length
 Both should move freely, lack of movement may denote underlying trauma or palsy
Hands
 Note shape, size
and posture.
 Number of digits
should be
counted,
polydactyly or
syndactyly
should be noted
 Palm should be
straightened and
palmar creases examined. There should be 2 palmar creases.
 Look at the nails, red nail beds may be a sign of infection

6. The Chest

 Examine for symmetry

 Nipples and areola should be well
formed
 Breasts may appear enlarged, not a
concern if no signs of infection
 Heart rate should be assaulted over the
apex area
 Respiration rate
  Any sternal recession or indrawing of the intercostal muscles should be reported
immediately as this is a sign of respiratory distress
Could you identify respiratory distress respiratory?

It is important you know normal parameters for heart rate and respiratory rate. Again this
takes us back to always being able to identify the normal or we will never realise what is
abnormal.
 7. The Abdomen

 Shape of the abdomen should be rounded, soft symmetrical and move in synchrony
with the chest.
 Inspect and gently palpate for swelling
 Umbilical cord should be securely clamped with no signs of haemorrhage or infection
around the base of the cord 

At this first examination the cord will usually be a blue white colour and you may see vessels
running through it. The cord darkens and shrivels as it dries, and separates usually between
5th-7th day. 
You should discuss this with the mother.

8. Male Genitalia

Male Infant Genitalia

● Check the penis shape and length should
be observed. 
●Position of urethral meatus should be
noted. Observing the baby pass urine
is a good method of validating
normality.
●Palpate scrotum and feel for the presence
of 2 testes. They have the consistency
to that of a pea. 
It is important that you note the testes have
descended down the inguinal canal
into the scrotal sac on both sides.
Gestational age and congenital 
problems may influence testicular
descent.
9. Female Infant Genitalia & Examinaton of the Anus

 Examine for urethral and vaginal orifices.

 Labia majora should be parted and clitoris observed to be appropriate size.
 Mucoid discharge may be present.

Passage of  urine should be recorded

In both male and female infants, the  anus and rectum should be checked for patency and
position.

   Passage of meconium should be noted and recorded

10. Legs and Feet

Legs
 Examine for  normal appearance.
 Examine shape and movement, make sure each limb can move fully and joints are
functional.
 Straighten both legs to examine length. 

Feet
 Ankles should move freely. Notice and
refer any fixed or positional talipes. 

 Note shape of the feet, presence of nails,

count digits

11. Back & Spine

 Look for obvious signs of skin disruption, swelling, dimpling or patches of hair.
 Observe curvature of spine, examine from the base of the skull to the coccyx.
 Gently palpate the entire length of the newborn’s spine to ensure there is no sign of
pain.
 Gently part cleft of buttocks to look for any dimples, sinuses and to confirm the
presence of the anal sphincter

12. Skin

Newborn skin is thin and delicate.

 Postmature newborn’s skin is dry and sometimes peeling.

During the examination the general condition of the  skin

should be observed.
 Obvious swelling, spots, birthmarks  should be recorded.

 Port wine stain birth mark

Mongolian blue spot  may be present.

Slate-brown or blue-black macular lesions generally located over the lumbosacral areas,
buttocks, and occasionally the lower limbs, back, flanks, and shoulders of normal infants,
with a predilection for certain racial groups. They represent collections of spindle-shaped
melanocytes located deep in the dermis and usually fade in early childhood.

       

Why do you think that it is vitally important that this skin discolouration is discussed with
the parents and recorded in the notes?

13. Documentation

 In most areas documentation now is electronic within Badgernet

You must record:

 Weight- weigh  newborn naked. Record weight in kilograms.

 Length- record newborn’s length in cm
 OFC- record OFC in cm. 
 Temperature
 Heart rate
 Respiration rate

On completion of newborn examination
 Baby should be dressed and left comfortable.
 Document all your findings - (newborn notes, TRAK, BadgerNet systems
 Inform parents of the result of your assessment and react to your findings appropriately. 
If you have any referrals to make you must inform the parents of this and explain why.

Always remember:
 Accountability.
 Informed consent.
 Record keeping.