How to examine newborn babies

D A Curnock

This is the first of two articles on the essentials of neonatology

The birth of a baby is usually a joyful experience, and the care of mother and baby in the first few weeks is usually straightforward. However, medical students often feel quite worried about even picking up newborn babies, let alone examining them or trying to answer mothers' questions. In this article I describe how to help at the delivery, how to examine a newborn baby, and how to talk to parents. With some basic knowledge and skills, caring for newborn babies can be an enjoyable part of medical practice. A small number of babies (less than 6%) will need to have neonatal intensive care, which I will not discuss as it is best learnt as a senior house officer or registrar.

Before the birth - be prepared

It is important to anticipate babies who are likely to have difficulties at birth, so that paediatricians can be called before the delivery and all the equipment checked. The box shows these high risk deliveries. Read the mother's notes, paying particular attention to

Gestational age - from the mother's date of her last period, the fundal height at booking, and the ultra sound scan measurements of the baby's head size (biparietal diameter)
Maternal health, including whether the mother has diabetes or other endocrine disorder, infection, or problems that may have developed during the pregnancy such as pre-eclampsia
Maternal blood group and whether raised antibody concentrations have been present
Any drugs given to the mother, especially during labour
When the membranes ruptured or were ruptured.

Resuscitation platforms are available for babies who need help at birth. These combine an overhead heater with a manometered oxygen supply, suction apparatus, and a timer. You should learn how the oxygen and air supplies and the suction are connected and switched on.

Babies may need help in establishing breathing by using a mask system (see picture) or by incubation. It is important to look at a mask and a laryngoscope to see how they work. The skill of intubation is best learnt initially on a special model. Check all the equipment before the delivery.

High Risk Deliveries

Prematurity
Fetal distress
Forceps (except simple outlet forceps) delivery
Ventouse delivery
Caesarean section
Breech presentation
Multiple birth
Antepartum haemorrhage
Intrauterine growth retardation
Severe toxaemia
Maternal diabetes
Rhesus isoimmunisation
Prolonged rupture of the membranes
Suspected major congenital abnormality

At birth-assessment of the baby

Wash your hands before helping at the delivery. Helping babies at birth is team work.

The midwife will help you by gently aspirating the baby's mouth and then the nostrils. At the moment of delivery start the timer. When breathing starts with a good cry, the baby should be given to the mother and soon wrapped in a warm towel.

If breathing is not established, lift the baby on to the resuscitation platform, wrap him or her in a warm towel, and switch the overhead heater on. Keeping the baby warm is of the greatest importance.

Efforts to establish breathing may fail if the baby becomes cold.

At one minute of age the baby's condition is assessed by the Apgar score. Dr Virginia Apgar, an American anaesthetist, designed a scoring system that is now in use throughout the world. When used properly it provides a universally understood evaluation of the baby's status at birth, and if necessary the response to resuscitation, when the baby's condition is rescored at 3, 5, and 10 minutes.

The Apgar score measures five variables, and each can score 0, 1, or 2.

Apgar Score
	Score 0	Score 1	Score 2
Heart rate	0	<100	>100
Respiration	Absent	Gasping	Regular
Response to suction	None	Facial grimace	Gasp or cry
Colour of trunk	White	Blue	Pink
Muscle tone	Flaccid	Some flexion	Normal with movements

Resuscitation

If the baby does not start to breathe, you should direct a stream of oxygen on to his or her face and continue gently applying suction to the airways. The baby's response and the Apgar score will then determine what to do next (fig 3).

Aspiration of meconium, the sticky black material sometimes passed through the anus by babies during labour, is an important problem. It can cause serious respiratory distress, complicated by pneumothorax and infection. If there has been meconium staining during labour then try to prevent aspiration occurring.

The baby's mouth and pharynx should be sucked out as soon as the head is delivered, and then the baby should be lifted to the resuscitation platform. The baby's glottis and vocal cords must be seen directly with a laryngoscope, even if the baby is well at birth. If there is any meconium in the pharynx or around the cords, the baby should be intubated or a suction catheter passed directly through the cords and suction applied. The tube or catheter should then be withdrawn with the suction still on, and the sticky meconium will come out stuck to the end of the tube. The whole process should then be repeated until there is no more meconium or until 1-2 minutes have passed. The baby must then be given intermittent positive pressure ventilation with oxygen. The use of this technique greatly reduces the serious morbidity and mortality of meconium aspiration. Talking to parents
When resuscitation has been successful talk to the parents about the help that their baby needed and reassure them that the prognosis is good.

The first day examination

A definitive examination is best delayed until babies are about 24 hours old for several reasons.

Cardiac murmurs, from the ductus arteriosus or the foramen ovale which have not completely closed, are often present immediately after birth
Auscultation of the lung fields often reveals crackles due to lung fluid that has not yet been reabsorbed
Newborn babies are neurologically in a state of shock at first. Leboyer, a famous French obstetrician, likened a baby's passage down the birth canal to a journey through hell. The baby will feel more comfort able being handled 24 hours later
Newborn babies easily get cold when they are wet with amniotic fluid immediately after birth, and they should not be exposed to a lengthy examination
The hips are not easy to examine when babies are wet and slippery with amniotic fluid and vernix
Importantly, the parents are tired and want to cuddle their baby and rest, without undue disturbance. They will not be receptive to your detailed examination, whereas 24 hours later they will be more amenable to your discussing their baby's features, and more likely to ask you questions.

This examination when babies are about a day old is very important and is done by a general practitioner if the mother leaves hospital a few hours after having given birth.

Introduce yourself

When babies are about 24 hours old introduce yourself to the mother and find out their sex and their name. Referring to a baby by name is obviously preferable to saying "it." Ask the mother how she intends to feed her baby, and whether there are problems with feeding, as these are often a source of anxiety. Support the mother in whatever method of feeding she has chosen-breast or bottle. The room should be warm and well lit (preferably natural light, especially if you want to rule out jaundice). Always make sure that the mother is present for the newborn examination since an important part of the reason for the check is to answer her queries and give reassurance.

Take the mother with you

If you need to take a baby to the nursery for any reason take the mother with you. The mother's bed is the ideal place to examine the baby, but do use a changing mat because you will not be popular if the bed cover is not protected from urine and meconium. The baby's cot or bassinette is too small and deep sided to carry out all the procedures, especially the hip stability test. Also, the mother will not be able to see properly what you are doing.

The head to toe examination

The best way to examine a newborn baby thoroughly is from head to toe, rather than trying to do it system by system. Examining a system such as the cardiovascular system would entail going from conjunctivae to lips to peripheral pulses to precordium, and the parents would not be able to follow the logical sequence. In contrast they can see you being thorough as you move steadily from the top of the head down the body to the toes. In my experience, doctors are less likely to miss anything out by using this head to toe method.

Always wash your hands before examining the baby. Initially check that there are no abnormal facial features and that the baby looks normally propor tioned. Then start at the top of the head and work downwards: the things you need to examine are summarised in the box. Tell the parents what you are checking as you go along, and encourage them to ask questions and to participate when appropriate„for example, get parents with their first baby to feel the fontanelle and reassure them that it is normal and that the skull is not broken.

Ensure that the baby's weight and head circum ference are recorded, and check on a weight chart whether the baby is small for dates (90th centile). Hopefully, the mother should be satisfied by the thoroughness of the examination: ask her whether she has any questions. The written notes should always include statements about the baby's cardiac findings, femoral pulses, and hip examination.

Finally, if it is the mother's first baby, or if she is unwell, put a clean nappy on the baby and redress the baby: there is nothing more demoralising for the mother than being left with a naked baby needing a nappy change when she does not know what to do.

Further Reading
Curnock DA. Newborn. In: Hull D, Johnston Dl, eds. Essential paediatrics. 3rd ed. Edinburgh: Churchill Living stone, 1993:44-74.
Roberton NRC. Resuscitation of the newborn. In: A manual of neonatal intensive care. 3rd ed. London: Arnold, 1993: 49-67 .
D A Curnock, consultant paediatrician Neonatal Unit, City Hospital, Nottingham NG5 lPB

Observations to be made and points to be noted
Scalp Moulding, caput, bruising, forceps marks, cephalhaematoma, or damage from scalp electrodes

Anterior fontanelle size Tension, cranial sutures Closely applied, widely separated, or normal

Head circumference Remeasure if the measurement in the labour suite is outside normal limits (normal range 32-38 cm)

Facial birthmarks Salmon patch, port wine stain

Eyes Position and size. Normal clear black pupils (no cataracts) with a normal red reflex from the retina when a bright torch is used. Subconjunctival haemorrhages are dramatic but harmless

Ears Normal pinna, no accessory auricle. Use an auriscope if you see any dysmorphic features externally and refer for a newborn hearing screening test

Nose Patency of nasal passages (pass feeding tube if in doubt)

Palate Clefts of hard or soft palate

Tongue and gums Cysts. Loose supernumerary teeth will need removing

Neck Abnormally short or webbed; cysts, sinuses, or swellings

Arms Equal in size and length. Fingers normal. Two palmar creases on each hand. Brachial pulses

Chest Size and shape. Clear lung fields

Heart Normal heart sounds and no murmurs

Abdomen No distension. Liver not more than 2 cm below the costal margin, spleen not palpable, kidneys felt only on deep bimanual palpation, bladder not palpable. Anus patent - meconium should be passed within 24 hours

Genitalia: Boys Both testes in scrotum, normal prepuce (excludes hypospadias). Normal urinary stream (urine should be passed by 24 hours)

Genitalia: Girls Normal labia (not fused) and clitoris normal in size. White vaginal discharge is normal and caused by maternal oestrogen's (may become pink on about fourth day)

Legs Equal in size and length. Femoral pulses

Ankle deformities Talipes. Check that the deformity can be fully corrected by gentle manipulation - refer if not

Tone: Passive tone Put each of the four limbs through a full range of passive movements

Active tone Traction to sitting position - look at neck and arm flexors. Ventral suspension - held up to horizontal briefly

Reflexes Grasping, sucking, rooting, stepping, placing, Moro's test

Hips Ortolani's test and Barlow's test to detect dislocated and unstable hips

Observations to be made and points to be noted
Scalp	Moulding, caput, bruising, forceps marks, cephalhaematoma, or damage from scalp electrodes
Anterior fontanelle size	Tension, cranial sutures Closely applied, widely separated, or normal
Head circumference	Remeasure if the measurement in the labour suite is outside normal limits (normal range 32-38 cm)
Facial birthmarks	Salmon patch, port wine stain
Eyes	Position and size. Normal clear black pupils (no cataracts) with a normal red reflex from the retina when a bright torch is used. Subconjunctival haemorrhages are dramatic but harmless
Ears	Normal pinna, no accessory auricle. Use an auriscope if you see any dysmorphic features externally and refer for a newborn hearing screening test
Nose	Patency of nasal passages (pass feeding tube if in doubt)
Palate	Clefts of hard or soft palate
Tongue and gums	Cysts. Loose supernumerary teeth will need removing
Neck	Abnormally short or webbed; cysts, sinuses, or swellings
Arms	Equal in size and length. Fingers normal. Two palmar creases on each hand. Brachial pulses
Chest	Size and shape. Clear lung fields
Heart	Normal heart sounds and no murmurs
Abdomen	No distension. Liver not more than 2 cm below the costal margin, spleen not palpable, kidneys felt only on deep bimanual palpation, bladder not palpable. Anus patent - meconium should be passed within 24 hours
Genitalia: Boys	Both testes in scrotum, normal prepuce (excludes hypospadias). Normal urinary stream (urine should be passed by 24 hours)
Genitalia: Girls	Normal labia (not fused) and clitoris normal in size. White vaginal discharge is normal and caused by maternal oestrogen's (may become pink on about fourth day)
Legs	Equal in size and length. Femoral pulses
Ankle deformities	Talipes. Check that the deformity can be fully corrected by gentle manipulation - refer if not
Tone:	Passive tone Put each of the four limbs through a full range of passive movements
Active tone	Traction to sitting position - look at neck and arm flexors. Ventral suspension - held up to horizontal briefly
Reflexes	Grasping, sucking, rooting, stepping, placing, Moro's test
Hips	Ortolani's test and Barlow's test to detect dislocated and unstable hips