NEONATAL EXAMINATION

Introduction
The whole key to the management of
the newborn infant lies in a proper
assessment of the baby at birth.
This necessitates obtaining certain
basic information in relation to two
different individuals, the mother and
the baby, by the history and the
physical examination.
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History
Certain detailed and accurate
information is essential in order to
evaluate the results of the physical
examination of the baby.
This is required both for the mother
and the infant

The mother:
The information obtained from the
mother will determine whether the baby
is at risk in terms of the mother having
a 'high risk' pregnancy or labour.

The maternal history include:

Social and family history,

Personal and reproductive medical
histories and especially knowledge of the
current pregnancy, labour and delivery
The parent's blood groups,
Date of last menstrual period,
Estimated date of delivery,
Duration of labour,
State of fetal heart during labour,
Length of second stage,
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 Duration of rupture of membranes,

Presentation of fetus
Whether or not there was an operative
delivery
Drugs and anaesthetics given with their
dosage and time of administration
Characteristics and quantity of amniotic
fluid, and
Abnormalities of the placenta.
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The baby:
History required for the baby include:
Condition at birth,
Apgar scores at 1 and 5 minutes after
birth, and
Details of any resuscitative measures
used.
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Examination
Importance
1. Earliest possible detection of
deviations both from usual and from
normal. This includes detection of
serious correctable congenital
malformations, such as:
a)Oesophageal atresia,
b)Imperforate anus, and
c)Diaphragmatic hernia

Early diagnosis of these malformations

enables treatment which may make the
difference between life and death

For some of the other malformations, the

earlier the diagnosis and initiation of
treatment the less the incidence of
permanent and severe disability.
These include:
a) Congenital dislocation of the hips
and
b) Club feet
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2. Establishes a baseline for

subsequent examinations.
3. Enables the doctor to give parents
a true account of the baby's
physical state, and where present to
explain and reassure them about
minor deviations from usual which if
not explained are likely to cause
concern. Best pointed out by doctor
rather than discovered by mother.
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Timing of neonatal examination

1. Immediately after birth
2. Before discharge from maternity unit
3. Whenever there is any concern about the
infant's progress
4. At six weeks of age or second RCH clinic
visit (8 weeks)
These examinations should, where
possible, be carried out in the presence
of the mother or both parents.
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Examination
The examination includes:
General
Head
Overall Inspection
Chest
Auscultation of the Heart
Abdomen
Femoral Pulses
Genitalia
Imperforate Anus
Feet

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 Nervous System
Myelocoele and
Meningomyelocoele
Congenital Dislocation of the Hips
Oesophageal Atresia

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General
Requires a knowledge of limits of both the usual and the normal.
The range of normal is wide. Therefore regard with suspicion
any findings outside the range of usual.
Take and record exact measurements:
Weight,
Crown-heel length,
Occipito-frontal circumference and plotted them on appropriate
centile chart
.

Record the dimensions of any visible or palpable structural

abnormality
Record respiratory rate and heart rate with infant quiet.
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Overall
Inspection

Does the baby look ill or well?

Is he normally active?
Is the cry normal?
Are there any obvious malformations?
(In particular, is the baby funny-looking
(dysmorphic, e.g. with Down
Syndrome?)

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What of his colour

Pallor? If pallor of skin is present, what
of mucus membranes and nail beds?
Pallid cyanosis of shock?
Cyanosis? If present, is it generalized or
localized? Does the upper surface of
the tongue look blue? What is the
response of the cyanosis to oxygen and
on crying?
Plethora?
Jaundice?
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 Is the cord yellow?

What of respiration? Chest
movements? Is there a grunt? Is there
dyspnoea? The apex beat is
frequently visible on inspection.
What of the shape of the head? Do
the bones move freely against each
other along the suture lines?

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Features of fetal malnutrition

Unusually skinny (wasting)
Dry scaly skin on abdomen and
extremities and/or abdominal skin
creases and lack of normal
subcutaneous fat.
These babies need:
a)To be watched for hypoglycaemia
and fed early
b)Check of weight for length
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Head and neck

Palpate the anterior fontanelle, sagittal,
coronal and lambdoid sutures and posterior
fontanelle.
Exclude presence of a third fontanelle,
craniotabes and premature synostosis of
skull bones.
The eyes are most easily examined if
opened by the baby itself. This often occurs
spontaneously if the eyes are shaded from
light with hands

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Head and neck

Shine a light from the side to detect
cataracts.
Note presence of flattened bridge of
nose or epicanthic folds.
Is there a coloboma (defect of iris)?
Are there any Brushfield's spots in the
iris?
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Head and neck

Choanal atresia checked for by:
Seeing if the infant can breathe with mouth
closed and then
With left and right nostril occluded alternately.
If in any doubt check nasal airways with a
catheter, and if this is too large, try a feeding
tube, and finally if necessary a probe. The
nasal airway is the vital one in the neonate. 22

Head and neck

Sternomastoid muscles should be
palpated and the range of rotation of
head to each side checked.

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Head and neck

A short neck is often significant and
webbing should be looked for.
Ears which are unusual in size or shape,
are floppy and lacking in normal
cartilage, and especially if low placed,
are of significance and may be
associated with urinary tract
abnormalities.

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Head and neck

The mouth should be fully inspected
with a good light and spatula and the
palate inspected right back to the
uvula to exclude minor degrees of
cleft palate.

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Chest
Asymmetry, thoracic cage defects
and spinal scoliosis should be noted.
Apex beat position should be
confirmed or determined if not visible
in order to help determine heart size
and possible presence of mediastinal
shift.
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Auscultation of the chest may help

give additional information, but apparent
presence of normal findings auscultation
does not exclude gross intra-thoracic
abnormality.
Chest X-ay is mandatory if there is the
slightest suspicion about the state of
heart and lungs, such as:

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 Definite displacement, or any doubt

as to the position of the apex beat,
even in the absence of other signs of
possible abnormality, such as
cyanosis, differences in the two sides
of the chest with regard to movement
on respiration, air entry, breath
sounds, and/or in percussion note.
Scaphoid abdomen which would
favour the diagnosis of gross
diaphragmatic hernia with abdominal
viscera largely in the thorax.

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Where the baby requires transfer and its

condition is so bad it is unlikely to survive
transport, certain immediate life saving
measures may be indicated. For example:
Infant with a large proven
pneumothorax, air should be aspirated
from the pleural cavity,
Baby with so large an intra-thoracic
space occupying lesion that it causes
severe cyanosis not relieved by oxygen
requires intra-tracheal intubation and
intermittent positive pressure oxygen.
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Auscultation of the heart

Presence of a significant murmur in itself in
the absence of associated evidence of
cardiac failure would only be an indication for
checking on femoral and peripheral pulses,
X-ray of heart, ECG, ECHO and watching
carefully.
If facilities for these special investigations
are not available, then immediate transfer to
a unit with such facilities is called for.
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 Evidence of significant systemic

cyanosis or of early heart failure, or
any deterioration in baby's
condition, e.g. not as energetic as
previously, or no longer taking feeds
as well, is an indication for
transferring to a specialised
cardiological unit.

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Abdomen
Scaphoid abdomen suggests the
presence of a gross diaphragmatic
hernia.
Distended abdomen calls for more
detailed examination and additional
investigations to determine cause, which
may vary from distension of stomach
and intestines as a result of
resuscitation, to gross pathology such as
that associated with intrauterine
peritonitis, or gross neoplastic disease.
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The liver and spleen should be felt for,

and where palpable, their size, shape
and consistency determined and
recorded.
Routine palpation of kidneys should be
carried out to determine whether they
are present and if so their position, size,
shape and consistency.
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Abdomen
Careful inspection of umbilicus for
adequacy of cord, tie, umbilical vessels
and clamp.
A yellow cord at birth suggests
intrauterine anoxia or haemolytic
disease.
If only two instead of the usual three
umbilical vessels are found, there is a
greater chance of the baby having other
more serious congenital abnormalities
not necessarily revealed on initial
clinical examination.
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 If exomphalos (omphalocele) is
present, this is an indication for
applying a protective sterile plastic
covering and transferring urgently to a
surgical unit experienced in neonatal
surgery. Prior to transfer give antibiotics
capable of coping with both gram
positive cocci and gram negative bacilli.

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Femoral Pulses
Routine palpation of femoral pulses should
be simultaneously with the brachial pulses
and may be the first indication of the
presence of coarctation or of interruption of
the thoracic aorta.
This would warrant careful examination of the
cardiovascular system including x-ray, ECG
and taking arm and leg blood pressures.
Absence of a higher blood pressure in the
legs than that of the arms would strongly
support the diagnosis and indicate the need
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for urgent cardiological assessment.

Genitalia
Abnormality suggestive of hermaphroditism
should always be checked for. If present, the
infant should be referred early for specialist
assessment and possible biochemical,
hormonal, cytological and chromosomal study.
Causes of pseudohermaphroditism
(ambiguous sex) includes congenital adrenal
cortical hyperplasia (adreno-genital syndrome)
which presents with anorexia, vomiting,
diarrhoea, weight loss and extreme
dehydration. Restriction of fluid and salt intake
results in sudden collapse and death.
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Genitalia
In boys the presence of the 'hooded foreskin'
strongly suggests the presence of
hypospadias which strongly contra-indicates
carrying out circumcision.
Inguinal hernias should be looked for and
other things being equal, be excised as soon
as possible, preferably before the infant goes
home.
In girls an attempt should be made to
separate the vulva. In this way, presence of
vaginal cysts and vulval fusion will not be
missed.
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Imperforate Anus
This can be excluded by routine careful
examination of the anus.
It has to be remembered that passage of
normal meconium does not preclude the
need for careful examination, e.g.
imperforate anus with associated rectovaginal fistula.
Insertion of thermometer in taking
temperature is advocated instead of PR.
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Congenital Dislocation of Hips

Recognition in the early neonatal period is
essential for proper treatment. The chances
of early diagnosis by demonstration of
positive Ortolani's sign are greatest when
the examination is carried out immediately
after birth. The standard method is Barlow's
test.
This must be repeated at all subsequent
examinations until the infant is walking
normally.
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Feet
All feet should be examined at birth and
where club feet (talipes, equino varus or
talipes varus) or calcaneo valgus
deformities are present, referral to an
orthopaedic surgeon is indicated.
Inability to dorsiflex and externally rotate
foot so that the little toe can be brought
in contact with the exterior aspect of the
leg makes the diagnosis of 'club foot'.
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 Inability to plantar flex foot properly, i.e.

to at least 45 degrees beyond the right
angle, makes the diagnosis of
calcaneus deformity

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Nervous System
The presence of normal activity and
limb movements and normal limb tone
should be checked.
Attempts should be made to elicit
normal grasp and Moro 'startle' reflex.
Inability to do this strongly suggests
significant abnormality of central
nervous system.
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Myelocoele & Meningomyelocoele

This is to be regarded as an indication for
urgent referral to a neurosurgeon,
especially where the membrane is thin or
defective, as early closing of the defect
may be called for where this is possible.
The ultimate prognosis of many of these
infants has been radically altered now that
the associated hydrocephalus frequently
developing is amenable to shunt operation
in the early neonatal period.
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Oesophageal Atresia
Early diagnosis oesophageal atresia is
essential, preferably before the giving of the
first feed because of the dangers of
aspiration and pneumonia. Proper
management in the time elapsing between
diagnosis and surgical correction can be vital.
Thought of and looked for, most cases can
be diagnosed before the first feed is given.
The classical picture is of spluttering,
choking, coughing, sometimes going blue
and returning to food.
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Oesophageal Atresia
Every infant born to a mother with
hydramnios or has excessive secretions
after birth should have a large soft plastic
catheter (English size 6 or 8) passed
through the mouth into the stomach. Failure
to pass the catheter into the stomach, or
where there is any doubt as to whether the
catheter has entered the stomach should
lead to immediate radiological examination,
initially with a radio-opaque catheter in the
oesophagus.
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 The presence of the catheter in the

stomach can be suspected if it goes in far
enough to reach below the costal margin
and confirmed by viewing the end of the
catheter or by palpating it through the
abdominal wall.
The large soft rubber or plastic catheter is
less traumatic than the smaller one which
can be passed through the nose and unlike
it, is not able to bend back on itself, giving
a misleading impression that it has passed
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into the stomach.

Conclusion
Routine physical examination should be
carried out in all infants at the earliest
possible moment after birth, and again just
before discharge from the maternity
hospital.
Routine physical examination excludes
obvious abnormalities and helps make
possible an earlier diagnosis of many not
quite so obvious conditions.
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 Many of the serious correctable congenital

malformations can be detected at birth or
within a few days, provided they are thought
of and looked for.
Early diagnosis of certain of these
abnormalities, e.g. oesophageal atresia,
greatly increases the chances of successful
surgery and frequently makes the difference
between survival and death. In other cases
e.g. congenital dislocation of the hips, early
detection and commencement of treatment
prevents or greatly reduces permanent
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residual disability.

END

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