APPRAISAL OF NEWBORN

BY:
Benita David
 Objectives:
• To detect congenital anomalies which are not identified at

birth. (e.g. congenital heart disease, DDH etc)

• To determine any wide range of acute neonatal problems

• To check for problems arising due to maternal diseases,

familial disorders or problems present during pregnancy

 Give opportunity to the parents to discuss regarding their

neonate.

 To initiate health promotion of the newborn.

 Introduction:
• Conducting a thorough neonatal assessment is necessary
to ensure that the new born transitions appropriately to
extra-uterine life. Skilled observation should begin at the
time of birth and continue frequently during the first 24
hours. Nurses should be aware of the normal features of
the transition period in order to detect disorders in
adaptation soon after birth. The new born assessment
provides much needed information concerning the state of
health of the transitioning new born as well as a basis with
which to formulate further care.
 Time for examination
 Immediately after birth

 Within 24hrs of birth

 Daily during hospital stay

 At discharge

 On follow up

 During episodes of illness

 Minimum pre-requisites
Mother and baby together
Warm room, fresh clean sheets/ clothes
Thermometer
Infantometer
Watch with seconds
Stethescope
Measuring tape
Chart for documentation
 Point to be considered

Examine the baby in the presence of parents if possible.

Ensure adequate warmth and lighting.

Prevent cross infection by implementing standard

precaution.
 Significant history for neonatal
assessment
 The mother’s medical and obstetrical history

 Risk factors:

• Intrapartum temp ≥ 100°F

• Membrane rupture ≥18hrs

• Delivery ˂ 37 weeks of gestation

• Chorioamnitis

• Sustained fetal tachycardia

Events around delivery:
 Duration of labor

 Mode of delivery

 Newborn’s condition at delivery

 Need of resuscitation
 Assessment of newborn
I. Apgar scoring

II. Anthropometric measurement

III. Vital signs

IV. Assessment of gestational age

V. Head to toe examination

VI. Neonatal reflexes

APGAR SCORE
 Anthropometric Measurements:

Head circumference:
• 33-35cms
Chest Circumference:
• 2 cm less than head
circumference
 Weight :
• Average weight- 2.5 kg
• Second born children weight more than the first
born
• Exceeding 4.7 kg is unusual
• 5-10% weight loss in the first few days
• 75-90% weight is due to fluid
• 2lb/month during 1st 6 months
 Length:

• Average birth length of a mature female neonate is 53cm

and that of male neonate is 54cm.

• The lower limit of normal length is 46cm.

VITAL SIGNS
• Normal Vital signs-
• Temp 97.7-99.5 F Axillary( 37.2 C)
Temperature falls immediately with heat loss and immature temperature regulating
system
• Apical Pulse 120-140 beats/min- may raise to 160 bpm as infant struggles to
initiate respiration.( apical-1 full min).
• Respirations 30-60 breaths/min.( Initially 80 breaths/min), (short periods of
apnoea and irregularities in rate rhythm and depth when the child is at rest are
normal)
convection

Radiation

Evaporation

Conduction
 Blood pressure:

• The blood pressure of a new born is approx.

80/46 mm/Hg at birth. By the 10th day, it rises
to about 100/50mm/Hg.
• Blood pressure is not routinely measured
unless a cardiac anomaly is suspected.
Head to toe examination
Posture: Extremities Flexed And Fists Clutched
 Skin:
• Velvety smooth and
puffy esp. at the
legs, dorsal aspects
of hands & feet and in
the scrotum or labia
• Pinkish red (light
skinned) to pinkish
brown to yellow (dark
skinned)
• “Ruddy” or reddish
due to increased RBC
concentration and
decreased subQ
tissues
 Skin Color
• Cyanosis/ Acrocyanosis
• Pallor
• Jaundice
• Meconium Staining

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Acrocynosis- Bluish Purple
Discolouration of hands and
feet (Normal in first 24-48
hours after birth)
 Acrocyanosis

• Bluish discoloration of palms of hands

& soles of feet
• Due to immature peripheral circulation
• Exacerbated by cold temperatures
• Normal within 1st 24 hrs
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 Central Cyanosis:
Temporary Respiratory
Obstruction
 Hyperbilirubinemia-
Physiological Jaundice, occurs on the
2nd or 3rd day of life in about 50% of all
newborn
 Jaundice
• Under natural light
• Blanch skin over the chest or tip of
the nose

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 • Physiologic
– FT: after the 1st 24 hrs (2-7 days)
– PT:after the 1st 48 hrs
– Peaks at 5-7 days & disappears by the 2nd
week
– Due to immaturity of liver
– Usually found over the face, upper body
and conjunctiva of eyes

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 • Pathologic
– Within 1st 24 hrs
– May indicate early hemolysis of RBC or
underlying disease process
– Duration:
• FT: 1 wk
• PT: 2 wks

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 Pallor:
• Gray colour:
Indicative of
infection
• CNS Damage
may cause
pallor as well
as cyanosis
 Pallor/ Cyanosis
• May indicate hypothermia, infection,
anemia, hypoglycemia, cardiac,
respiratory or neurological problems

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 Meconium Staining
• Over the skin, fingernails & umbilical cord
• Due to passage of meconium in utero r/t
fetal hypoxia

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Harlequin Sign: Due
Immature circulation
 Harlequin Sign
• When on side,
dependent side
turns red and upper
side/ half turns pale
• Due to gravity and
vasomotor instability
or immature
circulation
• Skin resembles a
CLOWN’S SUIT
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Vernix caseosa:
 Vernix caseosa:
• Protective cheesy-like, gray-white fatty
substance
• FT: skin folds under the arms and in the
groin under the scrotum or in the labia
• Nursing Considerations:
– Use baby oil
– DO NOT attempt to remove vigorously
 Lanugo:
• Fine downy hair over
shoulders, back and
upper arms.
• Post mature infants
rarely have lanugo
• Disappears by the age of
2 weeks
 Nursing Considerations:
• More mature, less lanugo
• May disappear within 2 weeks
• Preterm: woolly patches of lanugo on skin
and head
• Post term: parchment-like skin w/o lanugo

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 Desquamation:
• Peeling of the skin that occurs within 2-4
weeks of life because of pressure and
erosion of sheets.
 Milia:
• Pin point white
sebeceous papule
found on the cheek or
across the bridge of
the nose, disappears
by 2-4 weeks of age,
as the sebeceous
glands mature and
drain.
Birthmarks
 Mongolian Spots
• Blue-green or gray
pigmentation
• Lower back,
sacrum & buttocks
• Disappears by
4 years of age

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051104 Neonatal Care 47
 Salmon Patches
• Seen commonly in NB
• More on Caucasian
• Naevus simplex, "angel
kisses" (when on the
forehead or eyelids),
and "stork bites" (over
the nape of the neck)
• midline malformations
consisting of ectatic
capillaries in the upper
dermis with normal
overlying skin.

051104 Neonatal Care 48

 Mottling
• Cutis marmorata
• reticulated pattern of
constricted capillaries
and venules due to
vasomotor instability in
immature infants
• Bluish mottling or
marbling of skin in
response to chilling,
stress or
overstimulation

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 Petechiae
• Pinpoint hemorrhages
on skin
• Due to increased
vascular pressure,
infection or
thrombocytopenia
• Within 48 hrs

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 Ecchymosis
• Bruises
• As a result of rupture of
blood vessels
• May appear over the
presenting part as a result
of trauma during delivery
• May also indicate infection
or bleeding problems
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Erythema Toxicum:
It is a rash seen in normal
mature infants, usually
appears in 1-4th day of life
but may appear upto 2
weeks of age.
•HEAD
 What to assess
• For symmetry, shape, swelling,
movement
–Soft, pliable, moves easily
–With some molding round & well-
shaped Measure HC; HC = or >
CC

051104 Neonatal Care 55

 Head:
Anterior Fontanelle:
• Soft spot, is diamond-shaped and demarcated by the
coronal and sagittal sutures.
• Its anteroposterior measurement is approximately
4–5 cm, and it can be palpated midline, above the
forehead .The anterior fontanelle normally closes by
18 months of age.
 Posterior
Fontanelle:
• The posterior fontanelle can be palpated midline, toward the
back of the head, above the occiput.
• It is triangular in shape and demarcated by the sagittal and
lambdoidal sutures.
• Its posterolateral measurement is approximately 0.5–2 cm.
• The posterior fontanelle normally closes by 2 months of age;
it is possible for a newborn to be born with a posterior
fontanelle already closed.
 Sunken fontanelle:
• A sunken fontanelle presents as a
concave area that feels spongy but
depressed.
• Sunken fontanelles are associated
with dehydration and decreased ICP.
• Decreased peripheral perfusion,
poor skin turgor, and sunken eyes
may also be present.
 Sutures:

• Overriding sutures are a normal

finding resulting from birth trauma
and molding and usually resolve
spontaneously.
• There are four suture lines that
can be palpated: the frontal,
coronal, sagittal, and lambdoid
sutures.
 Caput
Succedaneum:
• Caput succedaneum is the
formation of edema of the scalp
at the presenting part of the
head.
• It has a generally symmetrical
appearance and crosses the
suture lines, will gradually be
absorbed and disappear about
3rd day of life. It needs no
treatment.
 Cephalohematoma:
• Cephalohematoma, a collection of blood beneath
the periosteum, may also occur as a result of
increased force to the newborn's head during
vaginal birth.
• It has a generally asymmetrical appearance and
does not cross suture lines.
• It may look like a large "goose egg." It is blue-
black because of the presence of coagulated
blood.
 Craniotabes:

• It is a localized softening
of then cranial bones
caused by pressure of fetal
skull against the mothers
pelvic bone in utero.
 Craniosynostosis

• Premature closure of the fontanelles

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 Forcep Marks
• U –shaped
bruising usually
on the cheeks
after forcep
delivery

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Face/Eyes/Ears/
Nose /Mouth
 What to Assess
• Facial movement & symmetry
• Symmetry, size, shape and spacing of
eyes, nose and ears

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 Eyes:
• Newborn’s usually cry tearlessly because the lacrimal ducts are not
fully mature until about 3 months of age.
• Infants eye assume their permanent colour between 3-12 months of
age. Gray in color
• Eyes should be clear without redness and purulent discharges.
• Edema is often present around the orbit or eyelids (2-3 days)
• Pupil: React to light
• A white pupil suggests of congenital cataract.
• Blinking reflex is present in response to touch
• Can not follow an object (Rudimentary fixation on objects).
Normal Eye:
Eyelid edema:
Dysconjugate Eye
Movements
Sub Conjunctival
Haemorrhage
Congenital
glaucoma:
Congenital Cataracts
 Ears:
• Position
Startle Reflex
Pinna flexible, cartilage present.
• Low set ears indicate chromosomal anomalies.
 Low set ears
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 Congenital preauricular sinus:
ends blindly
risk for infection

051104 Neonatal Care 77

Ear Tag
 Nose:

• A small amount of clear or white discharge

from the nose may be noted as a normal
finding in the newborn. However, copious
or discolored nasal discharge may be a
sign of congenital syphilis or respiratory
problems.
Dislocated/ Deviated
Nasal Septum
 Mouth:
• Intact, high arched palate.
- Sucking reflex – strong and coordinated
- Rooting reflex
- Gag reflex
- Minimal salivation
• Crying- Look for any Cranial nerve injury
• Epstein pearls- glistening well circumcised cysts present on the
palate as a result of temporary accumulation of epithelial cells.
• Mucus that seems to be blowing bubbles is suggestive of TEF
• Natal Teeth is unusual- Extraction has to be done if they are loose
Natal Teeth
Irregular Edges With
Natal Teeth
Cleft Palate:
Cleft Lip:
 Cheeks:
• Have a chubby appearance due to development
of fatty sucking pads that help to create
negative pressure inside the mouth which
facilitates sucking.
Epstein Pearls
Tongue Tie
Ankyloglossia -Short
Frenulum ("Tongue
Tie")
• Small mouth or large tongue =
chromosomal problems
• (+) white patches on tongue or side of the
cheek = Oral thrush
 Neck:
• Shorter and more flexible than that of an adult or child.
• Exhibit creasing and skinfolds on the neck.
• Generally not capable of supporting their heads at birth and
will experience head lag when they are moved to a sitting
position from a lying one.
• Assess lymph nodes and monitor for webbing and any
masses. Webbing of the neck, generally noticed from the
back of the neck, may be indicative of chromosomal
abnormalities
Neck
• Trachea midline
• Thyroid gland not palpable
• Intact clavicle
 Chest:

• Assessment of the infant's breasts should include size,

shape, and nipple formation, placement, and number.
• Breast bud size is an important indicator of gestational age.
Some infants are born with supernumerary nipples, usually
located vertically, below the normal nipple. These are very
rarely associated with any adverse effects or conditions.
• Gynecomastia is common in either gender and may be
noted as late as the second or third day of life. It is caused
by high levels of maternal estrogen that have passed
through the placenta and should resolve spontaneously.
Neonatal gynecomastia is often accompanied by
galactorrhea, also called pseudomenses milk or "witch's
milk". In infants with galactorrhea, the discharge is usually
bilateral.
 Chest Retractions

Slight substernal
retraction evident
during inspiration,
which needs to be
tackled.
 Xiphesternal
process evident:
 Contd….
• Respiration is chiefly abdominal-chest is ‘Bell-shaped’ at birth.
Cough reflex is absent at birth, present by 1-2 days postnatal.
Possible signs of RDS are:
- Cyanosis other than hands & feet.
- Flaring of nostrils.
-Intercostal retractions.
- Expiratory grunt-heard with or without stethoscope.
• A high crowing sound on inspiration suggests stridor or
immature tracheal development.
 Cardiovascular Examination:
• Heart murmurs are very common in newborns
as their cardiopulmonary systems adjust to
extrauterine life. These benign murmurs in
newborns are usually transient in nature and
caused by the foramen ovale not being closed
completely. Murmurs are usually benign and not
necessarily indicative of heart disease. They
generally resolve spontaneously.
•.
• CHD-Feeding difficulties are often a first sign, and they may
be evident as early as 6 to 12 hours prior to symptoms of
heart failure. Because feeding difficulty may be attributed
to many different causes, it should exceed 30 minutes and
be accompanied by tachypnea, sweating, and subcostal
retraction to be considered related to a CHD or heart
failure.
• Assess for capillary refill time
 Abdomen:
• Cylindrical shape and protruberant.
• The umbilical stump initially is white and gelatinous in
appearance and begins to dry within the first few hours.
• The umbilical stump should be inspected for the presence
of two umbilical arteries and one vein.
• They make the appearance of a "smiley face," as the
musculature in the arteries makes them appear round, like
the eyes of a face, and the vein tends to collapse due to lack
of musculature.
 Normal shape Normal Cord
.
Meconium stained
umbilical cord
 Abdomen contd…
• A scaphoid or sunken appearance may indicate missing
abdominal contents or diaphragmatic hernia.
• Inspect cord clamp to be certain it is secure. It begins to
dry in 1st hr, turns black by 2-3days. It falls by 6-10days.
• The base of the cord should appear dry.
• Bowel sound should be present within an hour after birth.
• Bruits heard on auscultation may reveal AV fistula, renal
artery stenosis.
 Abdomen…
• Palpate and percuss beginning below the umbilicus and
proceeding upward. The abdomen should feel soft.
• Infants may draw their legs up or cry if in pain during
palpation of the abdomen. The liver is palpable 1–3 cm
below the right costal margin.
• The kidneys are moderately firm and lobulated. The bladder
can be assessed for distension by palpating for a firm dome
shape midline, in the lower portion of the abdomen
 • GIT:
– Capacity: 90 ml, with rapid intestinal
peristalsis ( 2 ½ to 3 hrs)
– Bowels sounds; (+) within 1-2 hrs after
birth
– Presence of mass, distention depression
or protrusion
– (+) Scaphoid = diaphragmatic hernia
– (+) Distended = LGIT obstruction/ mass

051104 Neonatal Care 108

 GenitoUrinary System

• Observe for colour, odour, frequency, and amount of void.

• Failure to void with in the first 24 hours is considered a

warning sign and warrants further evaluation.

• The normal urine output for an infant is at least 1–2

cc/kg/hr. Output may be as high as 4 cc/kg/hr in the first
few days of life.
 Female Genitalia:
• Labia & Clitoris are usually
edematous.
• Vulva may be swollen.
• Blood tinged mucous
vaginal secretions.This is
due to the action of the
maternal hormones.
Pseudomenstruation
or Infantile
Menstruation
• Anus
– Check patency
– First stool (Meconium) – within 1st 24 hrs
• Sticky, tarlike, blackish-green, odorless material

051104 Neonatal Care 112

 Transitional Stool
• Within 2- 10 days after birth
• Breastfed:
– golden yellow, mushy, more frequent 3-4x
and sweet smelling
• Bottlefed:
– Pale yello, firm, less frequent 2-3x, with more
noticeable odor

051104 Neonatal Care 113

 Nursing Considerations
• Breastfeeding can usually begin
immediately after birth
• Bottlefeeding may be started with sterile
water to 4 hrs after birth prior to formula
feeding
• Burp during and after feeding
• Position properly during and after feeding

051104 Neonatal Care 114

 Male Genitalia:

• Urethral opening is at tip of glans pens.

• Testes are palpable in each scrotum.
• Scrotum is usually pigmented, pendulous &
rugaeted
• Penis is about 2 cm long if less should be
referred to endocrinologist.
• Inspect for epispadiasis and hypospadiasis
 Extremities:
• The Arms And Hands Should Be
Evaluated For Symmetry, Webbing,(
Syndactly Or Polydactly), Signs Of
DDH, Range Of Motion, And The
Number Of Digits.
• Fingernails Are Generally Long And In
Need Of Trimming In The Term New
Born.
• The Palms Should Be Examined For
The Presence Of A Simian Crease,
Which Is A Single Palmar Crease That
Extends All The Way Across The Hand.
A Simian Line Is Associated With
Down Syndrome.
• (+) Creases on soles of feet
– (-) Creases = prematurity
• Check for hip fractures or dysplasia
– (+) Ortolani’s click & uneven gluteal folds =
Hip dysplasia

051104 Neonatal Care 117

051104 Neonatal Care 118
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• (+) inward turning of the foot = club foot or
talipes equinovarus

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 • (+) extra digits =
Polydactyly
• (+) web fingers =
Syndactyly

051104 Neonatal Care 121

 Legs:

• The new born's legs should be assessed for flexion,

symmetry, and length.
• In some cases, the uterine position can make an infant's foot
appear clubbed, such as in the case of metatarsus adductus.
• In cases of true club foot, both the foot and the ankle are
turned inward and offer resistance.
 Back and spine:
• The spine of a new born typically appears flat in the lumbar
and sacral areas.
• The curves appear only when the child is able to sit and
walk
• The base of the spine should be inspected carefully to sure
there is no pin point opening or dimpling on the skin, which
would suggest a spinabifida.
• Gluteal folds should also be symmetrical and may have
small dimples within the gluteal crease
Spinal bifida
 Mongolian spots:

• Greenish-Black coloration on the lower back, buttocks,

anterior trunk, & around the wrist or ankle.
• They are not bruise marks or a sign of mental retardation,
they usually disappear during preschool years without any
treatment.
• (+) Creases on soles of feet
– (-) Creases = prematurity
• Check for hip fractures or dysplasia
– (+) Ortolani’s click & uneven gluteal folds =
Hip dysplasia

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051104 Neonatal Care 127
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• (+) inward turning of the foot = club foot or
talipes equinovarus

051104 Neonatal Care 129

 • (+) extra digits =
Polydactyly
• (+) web fingers =
Syndactyly

051104 Neonatal Care 130

ASSESSMENT OF GESTATIONAL AGE
Neuromuscular maturity
Physical maturity
Maturity rating
Physical maturity

051104 Neonatal Care

19
145
Neuromuscular Maturity

051104 Neonatal Care

17
146
 Scoring

19+17=36

36 39

051104 Neonatal Care 147

Reflexes
Reflexes in newborn
 New Ballard Score, expanded to include extremely
premature infants.

• The Ballard Maturational Score was refined and expanded to achieve greater accuracy
and to include extremely premature neonates. To test validity, accuracy, interrater
reliability, and optimal postnatal age at examination, the resulting New Ballard Score
(NBS) was assessed for 578 newly born infants and the results were analyzed.
Gestational ages ranged from 20 to 44 weeks and postnatal ages at examination ranged
from birth to 96 hours. In 530 infants, gestational age by last menstrual period was
confirmed by agreement within 2 weeks with gestational age by prenatal
ultrasonography (C-GLMP). For these infants, correlation between gestational age by
NBS and C-GLMP was 0.97. Mean differences between gestational age by NBS and C-
GLMP were 0.32 +/- 1.58 weeks and 0.15 +/- 1.46 weeks among the extremely premature
infants (less than 26 weeks) and among the total population, respectively. Correlations
between the individual criteria and C-GLMP ranged from 0.72 to 0.82. Interrater
reliability of NBS, as determined by correlation between raters who rated the same
subgroup of infants, ws 0.95. For infants less than 26 weeks of gestational age, the
greatest validity (97% within 2 weeks of C-GLMP) was seen when the examination was
performed before 12 hours of postnatal age. For infants at least 26 weeks of gestational
age, percentages of agreement with C-GLMP remained constant, averaging 92% for all
postnatal age categories up to 96 hours. The NBS is a valid and accurate gestational
assessment tool for extremely premature infants and remains valid for the entire
newborn infant population.
1.A method of transmission
of heat by circulation of
warmed molecules of liquid
or a gas?
• Evaporation
• Conduction
• Convection
• Radiation
2.Head circumference of a
new born in cms
• 33-34
• 31-32
• 33-35
• 35-40
3.Which is the principle of
heat loss here?
4.Harlequin sign is due to
an infection
• True
• False
5. Retractions are inward
movement of the chest
• True
• False
6.Which the method of
thermoregulation?
7. Infantometer is used to
check
• Weight
• length
• Chest circumference
• Head circumference
8.Which is the principle of
thermoregulation ?
9. Witch’s Milk is due to
withdrawal of maternal
Estrogen
Progestron
Testosterone
Growth hormone
10.Which is the principle of
thermoregulation?
Congratulations……
 Conclusion:

“Eyes sees what mind

Knows”