Assessment of the Newborn



Canberra Hospital and Health ServicesClinical GuidelineAssessment of the NewbornContents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc496780386 \h 1Guideline Statement PAGEREF _Toc496780387 \h 2Scope PAGEREF _Toc496780388 \h 2Section 1 – The physical examination PAGEREF _Toc496780389 \h 3Section 2 – Referral and Documentation PAGEREF _Toc496780390 \h 9Implementation PAGEREF _Toc496780391 \h 10Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc496780392 \h 10References PAGEREF _Toc496780393 \h 10Definition of Terms PAGEREF _Toc496780394 \h 11Search Terms PAGEREF _Toc496780395 \h 12Guideline StatementAll term newborn babies will receive appropriate and timely assessments and examination with appropriate referral to neonatal medical care when indicated.The assessment of the newborn provides an opportunity to:Identify the newborn who is acutely unwell and requires urgent treatmentReview any concerns that family have about the newborn and attempt to address themReview any problems arising or suspected from antenatal screening, family history or labourReview weight and head circumference measurementsCheck the newborn has passed urine and meconiumRecognise common neonatal problems and provide advice about managementDiagnose congenital malformations and arrange appropriate managementDiscuss matters such as: care of the newborn, feeding, immunisations, safe sleeping, purple crying, jaundice and any other matters relevant to the newbornConvey information about relevant support services and how to access them to parentsThis Clinical Guideline applies to well newborns born >36 weeks gestation and/or > 2.0 kg who remain under the care of maternity services. An initial assessment of the newborn is performed soon after birth to detect significant abnormalities, birth injuries and cardio respiratory disorders that may compromise a successful adaptation to extra uterine life. A single more detailed clinical examination is accepted good practice and is done with the mother/ parent present, prior to discharge from The Centenary Hospital for Women and Children and preferably after the first 24 hours following birth. Staff training prerequisites:All staff who will be performing Newborn assessments will have completed all the requirements of ACT Health Newborn Assessment training. Key ObjectivesNewborn Assessment is performed to confirm normal features and a well newborn, to reassure parents and to identify and act upon any abnormalities that may be detected.Back to Table of ContentsScopeThis document applies to Registered Nurses, Registered Midwives and Medical staff including neonatal, obstetric and paediatric clinicians working within their scope of practice Back to Table of ContentsSection 1 – The physical examinationProvision of family centred careSeek parental consent before examining the newbornListen to parent views and choices regarding planning and delivery of careRespect family values, beliefs and culture (consider an interpreter if necessary –refer to Language Services Interpreters Procedure)Communicate with and involve the parents as appropriateAsk the parents about any concerns that they may have about the newborn Ensure information is shared in a complete, unbiased and timely manner to ensure parents effectively participate in care and decision makingWherever possible perform the examination with at least one parent presentEquipment Stethoscope –paediatricOphthalmoscopeDocumentation- Newborn Assessment form, BOS, Personal Health Record (blue book)Procedure Review Maternal History including:Pregnancy and ultrasoundsMedical concernsMedication/substance usePrevious pregnancies and outcomesLabour (inc GBS, ROM)Review Newborn History including:Type of BirthApgarsGestational ageObservations and measurementsFeeding and outputResuscitation measures at birthPhysical examinationPerform a full set of observations including Oxygen saturations and document on the Neonatal Early Warning System (NEWS) chart, the Newborn Assessment form and the Personal Health Record book (blue book)Ensure hand hygiene is performed prior to performing the physical exam.Ensure environment is warm with adequate lighting and newborn is undressed.OBSERVE GENERAL APPEARANCEABNORMALSkin colour, warmth, perfusionState of alertness, responsivenessActivityRange of spontaneous movementPostureMuscle toneCrying soundsCentral cyanosisDysmorphic featuresLethargyJitteriness/irritabilityPalsyAbnormal toneWeak, high-pitched, irritable or hoarse cryNo cry (after stimulation)SKINNORMALABNORMALColourPink, transient acrocyanosis,mild jaundice – after 24 hoursCentral cyanosis, pallor, jaundice before 24 hours, plethoric, petechiae, traumatic cyanosisLacerations/ TraumaBroken skin, bruising, swellingSuperficial Skin PeelingOccurs on hands and feet in the first week of life. Common in post term babies on the body.Vernix CaseosaWhite, greasy protective substance.MiliaWhite pin head spots around nose.Erythema ToxicumIrregular red blotchy or pustules over the body.Harlequin ChangeTransient skin flushing creating a clear demarcation down the midline.BirthmarksMongolian Blue-spotStork marksStrawberry marksHaemangiomas Port wine stain Cafe-au-lait spot (one or two)Pigmented naevi- facial or multiple haemangiomas- can also be intracranial- multiple spotsHEADNORMALABNORMALShapeMoulded, caput succedaneumCephalohaematomaSubgaleal HaemorrhageHydrocephalusMicrocephalyPlagiocephalyScaphocephalyFontanelsSoft, flat diamond shaped anterior fontanelPosterior fontanel- triangle shapedBulging (caused by increased intracranial pressure).SunkenSmall - Craniosynostosis or microcephalyLarge - HypothyroidismThird - Down Syndrome (occasionally)FACENORMALABNORMALHairFine down- LanugoColourWhite- albinoSwirl- tuft of hairEyes and eyelidsSlight oedema2 x eyeballsRed eye reflexDoll’s eye movementsSticky eyes (non-purulent)Bruising, oedemaSubconjunctival haemorrhagesPurulent dischargeSquintGlaucomaHypertelorismAbnormal pupil (grey or white)CataractPink iris- albinoEpicanthial foldsEarsShapeSite- pinna level with eyes(familial variation)Pre-auricular skin tags or sinusLarge, small or malformed earUnusual dischargeNosePatent- bilaterallyVariations in width and depthChoanal atresia (bilateral or unilateral)Frequent regurgitationMouthLips- shape and position(familial variation)Cleft lipLong or flat philtrumDownturned mouthPalateEpstein’s pearls- small inclusion cyst in midline of hard palateCleft palateHigh arched palateBifid uvulaPalatal insufficiencyTongue and JawSize and shapeSymmetrical(familial variation)Large: cretinism, mongolismBeckwith’s syndromeSmall: Glossoptosis /micrognathiaPierre Robin syndromeTongue TieTeethNatal teethNECKNORMALABNORMALShapeShort Fully mobileCentral positionTorticollisWebbing Excessive tissue back of neckAsymmetryPalpable massesSternomastoid tumourUPPER EXTREMETIESNORMALABNORMALHandsShape and positionLimited joint movementAccessory digitsMissing DigitsPalmar creasesArmsSymmetrical lengthProportionateFull range of movement PositionFracturesAchondroplasiaDislocation of the elbowBrachial plexus injuryPalsyShoulder GirdleSymmetrical clavicle and scapulaFracturesLumpsGrinding of boneBruising/SwellingCHESTChestShape and size (familial variation)SymmetryDeeper from back to front (depth) and narrower widthAsymmetricPectus excavatum (funnel chest)Pectus carinatum (pigeon chest)Small chest- dwarfismRibsMinimal rib slopeSoft and easy in-drawing during respirationProminent xiphoid processPneumothoraxProminent sternumBreastsUp to 1 cm palpable breast tissueX 2 nipplesWitches milkMastitisSupernumerary nipplesLUNGSNORMALABNORMALRate <60Periodic breathing (cessation of breathing for <15 seconds) Symmetrical breath soundsAsymetric breath soundsCrepitations / RhonchiPneumothorax/ AtelectasisBowel sounds (diaphragmatic hernia)After one hour of age (can be normal in the first hour):Retractions- intercostals/ subcostal/substernal = respiratory distressSuprasternal= upper airway obstruction.Persisitent grunting/flaring of nasi/stridor (inspiratory stridor indicates upper airway obstruction).HEARTNORMALABNORMALThe apex beat is found in the mid-clavicular line in the fourth intercostals spaceHR 100-175bpm (can drop to 90bpm when asleep).Can have a grade I-II/VI systolic murmur in the first 24 hours of lifeFemoral and brachial pulses should be palpated when the newborn is quietShifted to the right, left or displaced downwardDextrocardia, pneumothorax, collapse, diaphragmatic hernia.Tachycardia- cardiac failure, infection, anaemia.Bradycardia- hypoxia, raised intracranial pressure, heart block.Murmur after 24 hrs of ageWeak or absent- coarctation, hypoplastic left heart syndrome, shock. Bounding- patent ductus arteriosisGI SYSTEMNORMALABNORMALAbdomenOften prominentRectus muscle often separated in the midline of the upper abdomenGaseous distension or visible bowelMassesLiverPalpable 1cm below the right rib cage>1cm = enlarged liver associated with congestive heart failure, macrosomia, infection.UmbilicusUmbilical hernia is common and generally requires no treatment.Redness of the skin surrounding the umbilicus may indicate infectionGroinHerniaAnusPatentPositionImperforate anusFistulaFissureGENITALIANORMALABNORMALMale: TestesDescended to scrotum (may take one month)None palpable after one monthHydrocele- fluid surrounding the testsesPenis and UrethraUretheral opening at centre of glans. Foreskin not retractableHypospadias- uretheral opening on ventral surface of the penis.Epispadius- uretheral opening on dorsal surface of the penis.Chordee/ micropenisFemale: HymenHymenal tagHydrometrocolpos behind a bulging imperforated hymen or labial adhesions.ClitorisVariable in sizeLarge clitoris- adreno-genital syndrome, maternal progestogen, hermaphroditism.Vagina and vulvaMucous vaginal discharge or bleeding caused by maternal hormone withdrawal. Labial fusion in adreno-genital syndrome.LOWER EXTREMETIESNORMALABNORMALLegsSymmetricalFlexed fetal position for several days after birth and often cannot be completely extended at the knee.FracturesShort BonesAchondroplasiaMissing BonesFeetMovement, mild postural deformity may be normalOverriding toes and syndactalyTalipies equinovarus, calcaneovalgus, metatarsus adductus.HipsPerform Ortolani and Barlow manoeuvresFull abduction of flexed hip. Hips symmetrical,Equal leg length,Congenital subluxation or dislocation of the hip.SPINENORMALABNORMALStraight/ symmetrical Mongolian spotSacral pitDimple at base of spineScoliosisKhyphosisTufts of hair on sacrumSpina BifidaNEUROLOGICStimulusResponseSucking Reflex Touching or stroking the lipsMouth opens and sucking movements are initiatedRooting Reflex Stroke and corner of mouthHead turns towards stimulus and mouth opensPalmer ReflexUsing the index finger of both hands apply slight pressure to the palmer surfaces of newborn’s handsNewborn grasps fingers and can be held momentarily off the bed surfaceTonic Neck ReflexWith newborn in supine position turn his/her head to one sideNewborn should extend the upper extremity (arm) on the side toward which the head is turned and flex the lower extremity (leg) on the opposite side (fencing position)Moro reflexHolding newborn’s head several centimetres off the bed withdraw hand rapidly and let newborn fall onto bed or other waiting handInitial response should be to extend and abduct arms and hands will be open, then the arms flex and hands are closed into fists.Startle reflexA loud noise or sudden movement should produce a ‘moro like reflex ‘responseThere is flexion of the extremities and palmer grasping but not a complete ‘moro’ responseStepping ReflexHolding the newborn upright ensuring the soles of the feet are touching a flat surfaceStepping movements are observedGalant reflexNewborn held in a ventral suspension with anterior chest wall in the palm of the examiners hand. Using a thumb apply pressure parallel to the spine in the thoracic areaFlexion of the pelvis towards the side of stimulusBabinski ReflexStimulate the sole of the foot (both feet)Extension or flexion of the toes. Absence of this response is abnormal and may indicate central nervous system depression or abnormal spinal nerve innervations.Back to Table of ContentsSection 2 – Referral and DocumentationAny abnormal features are referred to the Neonatology Registrar for review before discharge, urgency of referral will be based on clinical presentation and severity of symptoms.Notable features (eg birth mark/ umbilical herniation) while not requiring referral, are documented in the clinical recordA plan of care or follow up will be discussed and developed with the referring midwife, continuity or midcall midwife, the neonatology team, the parents and other relevant/ referral points (eg physio/ tongue tie clinic). The plan of care will be documented in the clinical record and any other assessments competed by the referring midwife/doctor.All findings will be documented on the Newborn Assessment form, in the electronic Birthing Outcomes System (BOS) and the Personal Health Record book (blue book) HYPERLINK \l "Contents" Back to Table of ContentsImplementation This Clinical Guideline will be available via the ACT Health Intranet “Policy/Clinical Guidance” tab and will be accessible to all practitioners. Education on the implementation of the policy will be provided to medical officers and midwifery staff to inform practice.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesHealthcare Associated InfectionsConsent and TreatmentProceduresCare of the Well babyBack to Table of ContentsReferencesACT Health- Staff Development Unit, Examination of the Newborn, Information and Record Book, ernment of Western Australia; Department of Health, Care of the Neonate: Neonatal Screening Clinical Guideline, 2015.Queensland Department of Health, Queensland Clinical Guidelines: Translating Evidence into Best Clinical Practice: Routine Newborn Assessment, 2014. Southern Health, Neonatal Assessment and Discharge Examination in the Term Newborn- Guideline for Midwives and Obstetric Staff, 2009.Tappero. E, and Honeyfield.M, (2014) Physical assessment of the Newborn: A comprehensive Approach to the Art of Physical Examination. NICUINK CaliforniaBack to Table of ContentsDefinition of TermsAchondroplasia: genetic disorder disturbing normal growth of cartilage, resulting in a form of dwarfism characterized by a usually normal torso and shortened limbsCalcaneovalgus: a condition where the foot? and ankle are excessively bent up, where the toes may be touching the shinCephalohematoma: a subperiosteal haematoma that occurs underneath the skin, in the periosteum of the newborn's skull bone Choanal atresia is a congenital disorder where the back of the nasal passage (choana) is blocked, usually by abnormal bony or soft tissue (membranous) due to failed recanalization of the nasal fossae during fetal development. Craniosynostosis: premature fusion of the sutures of the skullDextrocardia: a cardiac condition in which the heart is situated on the right side of the chest and the great blood vessels of the right and left sides are reversedEpicanthial fold: is skin of the upper eyelid that covers the inner corner of the eye. The fold runs from nose to the inner side of the eyebrow Glossopteris: a condition which involves the downward displacement or retraction of the tongue. Hydrocephalus: is an abnormal build-up of cerebrospinal fluid (CSF) in the ventricles of the brain. The fluid is often under increased pressure and can compress and damage the brainHydrometrocolpos: an accumulation of watery fluid in the uterus and vaginaHypertelorism: excessive width between the eyes Kyphosis: exaggerated outward curvature of the thoracic region of the spine resulting in a rounded upper backMetatarsus adductus: a condition of the foot? that causes the front half of the foot, or forefoot, to turn inwardMicrognathia: a condition in which the jaw is undersized. Micrognathia may interfere with a child's feeding and breathing. Philtrum: the vertical groove on the median line of the upper lipPlagiocephaly: a malformation of the head marked by an oblique slant to the main axis of the skull and usually caused by closure of half of the coronal sutureScaphocephaly: a congenital deformity of the skull in which the vault is narrow, elongated, and boat-shaped caused by premature ossification of the sagittal sutureSubgaleal haemorrhage: accumulation of blood between the epicranial aponeurosis of the scalp and the periosteum caused by rupture of the emissary veins, which are connections between the dural sinuses and the scalp veins. Syndactyly: a union of two or more digits and is marked by webbing of two or more fingers or toes Talipes equinovarus: a congenital condition of the foot in which both talipes equinus and talipes varus occur so that walking is done on the toes and outer side of the soleTorticollis: condition characterized by involuntary intermittent or sustained contraction of the muscles of the neck (such as the sternocleidomastoid or trapezius) that causes the head to tilt or turn sidewaysBack to Table of ContentsSearch Terms Newborn, Well baby, AssessmentBack to Table of ContentsDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC Chair ................
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