The document discusses the examination of newborns. It outlines the objectives of the initial examination, 24-hour examination, daily examinations, and discharge examination. The initial exam focuses on ensuring the baby's safe transition to the external environment using measures like the APGAR score. The 24-hour exam is a full, unhurried examination of all body systems. Follow-up exams monitor for emerging issues like jaundice or infection. The discharge exam re-assesses the baby's health and prepares the mother for caring for the newborn at home.

1. EXAMINATION OF THE
NEWBORN
Dr. Taher Yunus Kagalwala, M.D., D.C.H.,
Specialist Paediatrician,
Al Muwayh Province General Hospital, Al Muwayh,
Makkah Mukarramah Region,
Kingdom of Saudi Arabia

2. Impact of Pregnancy on the Newborn
 Before any discussion on the newborn, it is vital to remember that hundreds of antenatal factors can
affect the eventual outcome. Briefly, they include –
1. Age and health of the mother
2. Presence of maternal abnormalities such as a uterine malformation, fibroids, abnormal implantation,
placenta previa, etc.
3. Maternal diseases such as pre-eclampsia, hypertension, gestational or prenatal diabetes mellitus, etc.
4. Maternal use/abuse of tobacco, drugs, alcohol
5. Maternal infections – both prenatal and intranatal, systemic and local – e.g. tuberculosis, TORCH,
group B strep, genital herpes, HIV
6. Maternal diet – esp. Folic acid deficiency
7. Maternal level of antenatal care
8. Previous obstetric history
9. Foetal abnormalities such as twinning, abnormal presentations, intra-uterine growth retardation,
prematurity, congenital malformations

3. Objectives of the Newborn Examination
The initial examination
The 24-hour examination
The day-to-day examination
The on-discharge examination
Objectives of the examination of a newborn are different
on all the above occasions. While the general rule is to
ensure that the baby is alive and thriving, many specifics
apply.

4. The initial examination
The objective of the intial examination is making sure
that the baby transits safely and without any problems
from the intra-uterine environment into the external
environment that is the delivery room or the OR,
whichever is applicable.
For the objective in question, we most commonly use
the APGAR SCORE and also do a few important tests
to rule out immediate, life-threatening abnormalities
in the baby as soon after birth as possible, beginning
at 1 minute for the APGAR score.

5. The APGAR score
Scored out of a maximum of 10, the time-tested APGAR score is a test of
viability at 1 minute and a possible test of intermediate and subsequent
neurological outcome at 5, 10, 15 and 20 minutes.
It is a score comprising of the following FIVE attributes in a newborn baby
and must be assessed at 1 minute (60 seconds) after birth:
Heart rate and regularity
Respiration – rate and regularity
Colour – central and peripheries
Spontaneous activity and movement
Crying on stimulation
Each item is scored from 0 to 2, making up for a total score of between 0 and
10.

6. APGAR Score (continued)
Attribute 0 1 2
Heart Rate and
Rhythm
Absent or
< 60/min,,
Irregular
Weak, 60-100/min,
regular
Strong, > 100/min,
regular
Respiration Absent or gasping Irregular Regular or
periodic
Colour Blue or Pale Pink centrally, but
blue peripherally
Pink all over
Spontaneous
movements
Absent, limp or
with extended
limbs
Slight movement,
moderate flexor
tone
Good movements,
flexor tone
Crying on
stimulation
Absent Slight grimacing Vigorous crying

7. What do we check after stabilisation of the
newborn?
The next step after drying, stimulation and suctioning of a well
newborn is an unhurried examination to rule out life-
threatening congenital abnormalities and trauma during the
parturition and delivery process.
This is a vital exam that must be done under proper light and
with a calm mind.
The objective is to examine the baby from head to toe to
uncover the most important life-threatening abnormalities.
While this is a task for the neonatal specialist, it is good for
nurses to know what to look for, as most normal deliveries are
conducted by delivery room nurses.

8. The initial exam for life-threatening problems in the newborn - I
The following is a list of the most important problems, though
the list is not all-inclusive:
Severe respiratory problems – distress, frothing, apnoea,
breathlessness – examples: bilateral choanal atresia,
diaphragmatic hernia, tracheo-oesophageal fistula, lung
hypoplasia, pneumothorax
Severe heart problems – distress, irregular heart rate, absent
apical impulse, external heart, cyanosis not improving with
oxygenation – examples: congenital cyanotic heart disease,
primary pulmonary hypertension, ectopia cordis, dextrocardia
with murmur or cyanosis

9. The initial exam for life-threatening problems in the newborn - II
Gastro-intestinal abnormalities – absent anal orifice suggestive
of imperforate anus, boat-like abdomen with respiratory
distress suggestive of diaphragmatic hernia, bloated abdomen
with frothing at the mouth worsening with AMBU bagging
suggestive of T-O fistula
Neurological abnormalities – large/small head, wide open
anterior fontanelle, absent vertebral points on back
examination, lumps anywhere on the head or the spine, fitting
(c0nvulsions), limp child with no movements – examples:
hydrocephalus, severe microcephaly, haemorrhage due to
birth trauma, asphyxia, spina bifida, meningomyelocoele, etc.

10. The initial exam for life-threatening problems in the newborn - III
Uro-genital system – absent or abnormal genitalia
anatomy, abnormalities of other organs that point to
the possibility of internal urinary abnormalities such
as ear anomalies, accessory nipple, single umbilical
artery, or genital abnormalities – examples include
renal and urinary system anomalies and the unique
problem of ambiguous genitalia.
Trauma – carefully look for birth trauma that is life-
threatening such as intra-cranial or extra-cranial
haemorrhage, etc.

11. The unhurried neonatal examination:
Preparation
Read case notes and history – includes family history,
past medical history, past obstetric history, present
obstetric history, intra-partum and birth history
Listen to care-takers – baby’s appearance, feeding
history, behaviour and wakefulness; mother’s
behaviour and attitudes
Gather equipment – stethoscope, ophthalmoscope,
measuring tape, centile charts, spatula, thermometer
Wash and warm hands – correct technique

12. Steps of Neonatal Examination
Observation – also listen to the baby
Look for obvious problems on exposed areas first and auscultate the
heart before proceeding with completely undressing the baby
Naked examination from head to toe
Inspection -> Palpation -> Auscultation -> Percussion (if needed).
Clinical aids like use of torch, hammer, ophthalmoscope, spatula, etc.
as indicated.
Special tests to rule out congenital anomalies
Assessment of gestational age
Assessment of neonatal reflexes

13. Examination of exposed parts
Several areas can be examined without disturbing the quiet state of the
awake baby: these include -
Scalp
Head and fontanelles
Face
Eyes, ears, nose
Mouth, neck
Hands and feet
Upper and lower limbs
Heart rate/rhythm and breathing sounds from lungs
Genitalia (if baby is clean)

14. Final examination
 Usually, this examination is done at the age of 24 hours. The child should be quiet and alert
for this exam.
 The baby must be undressed completely, allowing for proper viewing of all parts of the
body.
 Attention must be paid to assessing normality of all body parts, external and internal, and
where there is doubt, a plan of further assessment needs to be made.
 The physical examination should not take more than 5-10 minutes. It should include all the
steps mentioned in the previous slide, such as inspection, palpation, etc., measurements of
weight, length, head circumference (with centile charting) and special tests for congenital
anomalies.
 Assessment of gestational age by physical and neurological criteria must follow. In relevant
cases, one must then test the neonatal reflexes.
 At the end of the exam, documentation must be done.
 Information to the care-takers and mother is the last step of the final examination.

15. Important aspects of neonatal examination
With immediate bearing on the well-being of the child: vital signs, jaundice,
cyanosis, pallor, health of the umbilical cord, fever, state of alertness, sucking,
major congenital anomalies like cleft lip or a heart murmur, large head, absence
of light reflex, not passed meconium or urine, swelling of the body, recognised
syndromic abnormalities, abnormal reflexes, paralysis of body parts, abnormal
breathing, major birth trauma, asphyxia, etc.
With long-term bearing on the well-being of the child: small baby, asymmetrical
limb length, extra digits and other minor congenital anomalies, heart murmur in
a well-baby, etc.
Feeding behaviour, excessive or abnormal crying, and examination of reflexes are
also important and may have a bearing on both immediate and later outcomes.

16. Jaundice

17. Cyanosis

18. Caput Succedaneum

19. Cephalhaematoma

20. Cleft lip and palate

21. Down Syndrome (Trisomy 21)

22. Erb’s Palsy

23. Amniotic Bands

24. Congenital Cataracts

25. Gastroschisis

26. Thanatophoric Dysplasia

27. Achondroplasia

28. Supernumerary Nipples

29. Erythema toxicum

30. Disorders of external genitalia

31. Breastfeeding – correct position

32. Congenital Hydrocephalus

33. Meningomyelocoele

34. Developmental Dysplasia of the Hip

35. Benign Vascular malformations
Strawberry Nevus Stork Mark
(Capillary Nevus)

36. Mongolian Spot

37. Polydactyly

38. Umbilical cord Infection

39. Measurements in the Newborn
Head circumference Total body length by
stadiometry

40. Assessment of Gestational Age
There are two methods of assessing the gestational age of the baby
apart from calculating it from the first date of the last menstrual
period or calculating it by foetal ultrasonography.
The first is the PHYSICAL CRITERIA method which bases the
estimate on various physical findings such as the shape, feel and size
of the ear cartilage, size of the breast nodule, texture of the skin, hair
and blood vessels of the skin, creases on the soles of the feet, etc.
The second method uses the NEUROLOGICAL CRITERIA to assess
the gestational age. In this, we make use of the tone, posture and
flexibility of the joints to arrive at a gestational age.

41. Examination of Neonatal Reflexes
Intact neonatal reflexes such as the sucking reflex, the Moro’s
response, placing and stepping reflexes, rooting reflex etc. are
used to know whether the baby is neurologically normal or not,
whether it is likely that he/she will have feeding difficulties, and
whether some intranatal problems have likely caused some
degree of brain damage.
Neonatal reflexes are also helpful in assessing the gestational age
of a preterm baby.
Persistence of otherwise temporary neonatal reflexes may also
point to brain damage, e.g. cerebral palsy or mental retardation
cases.

42. Follow-up examination in the nursery
During the stay of a baby in the post-natal ward or nursery, the
following important examinations must be carried out:
- establishment, success and adequacy of breastfeeding (daily
weight check is very important)
- checking the umbilical stump, mouth and genitalia for infection
- daily check of the heart for emerging murmurs as the cardiac
physiology changes from foetal to adult type of circulation
- checking for development of jaundice, various skin rashes, and
other benign problems
- looking out for possible metabolic problems, should they occur,
esp. hypoglycemia, hypocalcemia, and inborn errors of metabolism.

43. On-discharge Neonatal Examination
The on-discharge examination should be a review of the maternal-baby unit as a
whole, esp. with respect to breastfeeding.
In addition, re-examine the baby for jaundice, infection, general well-being etc.
Take the spO2 in the right hand and left leg to rule out co-arctation of the aorta, a
serious vascular malformation that can cause hypertension, heart failure, etc. The
result is significant if the difference between the two readings is more than 3%
Re-check the baby’s weight and head circumference at discharge to confirm that there
is no undue weight loss and no head-size problems.
Train the mother on how to change the baby’s dress and diaper, look for hypothermia,
and recognise sickness.

44. Final comments and conclusion
The neonate is a special human being whose health depends on his
family’s and mother’s well-being; hence, examination should be
preceded by a review of the history of the family and the mother.
The initial examination is designed to check viability, look for serious
and life-threatening issues and guide initial care.
The detailed examination is done at 24 hours and is a systematic,
unhurried examination to look for all possible abnormalities and to
establish breastfeeding.
The follow-on examinations are meant to uncover emerging problems
in an otherwise normal neonate.
The on-discharge examination is more of a re-assurance before
sending the mother and the baby home.

45. Thank you