“Is my baby healthy?”
This is usually the first and most important question parents ask after delivery. Answering that question accurately requires careful observation, thorough examination and, if needed, onwards referral for further assessment.
The aim of both the initial examination at birth and the full neonatal examination within the first 72 hours of life is to confirm normality, identify any congenital abnormalities and exclude medical concerns. It also gives the Midwife a precious opportunity for further health education and parental reassurance (RCM 2012).
Initial Post-Delivery Assessment and Examination and APGAR Score
Monitoring successful transition to extra-uterine life begins from the moment of birth with an assessment of the APGAR score. This is measured at one, five and if needed ten minutes after birth, and is followed by an initial examination soon after birth.
|Score of 0||Score of 1||Score of 2|
|Appearance||Skin color||Blue or pale all over||Blue at extremities
Body and extremities pink
|Pulse||Pulse rate||Absent||< 100 beats per minute||> 100 beats per minute|
|Grimace||Reflex irritability grimace||No response to stimulation||Grimace on suction or aggressive stimulation||Cry on stimulation|
|Activity||Activity||None||Some flexion||Flexed arms and legs that resist extension|
|Respiration||Respiratory effort||Absent||Weak, irregular, gasping||Strong, robust cry|
The initial post-delivery assessment aims to exclude obvious abnormalities and includes:
- Assessment of colour to exclude pallor or cyanosis
- Muscle tone, posture and responsiveness
- Heart and respiratory rate
- Normality of facial features including eyes and mouth
- Normal alignment spine and exclusion of spina bifida
- Genitalia to exclude ambiguity
- Trunk and limbs to exclude obvious abnormality
- Check anus for patency
- Evidence of birth trauma such as bruises or scalpel marks
Birthweight, head circumference, temperature and the number of cord vessels are also recorded at this stage, and any concerns or abnormalities are reported to the paediatrician.
The Newborn and Infant Physical Examination (NIPE)
Recent standards for newborn and infant physical examination (NIPE) set a timeline of 72 hours after birth for full newborn examination (RCM 2012).
The aim of this more thorough examination is to:
- Screen for abnormalities
- Make referrals for further tests or treatment if needed
- Provide reassurance to the parents.
(Nottingham Neonatal Service, 2017)
This examination is more thorough than the initial assessment at birth and includes the key components of the NIPE screening test. These are the examination of the heart, eyes, hips, and in male infants, examination of the testes (Royal Cornwall Hospitals NHS Trust 2017).
Gathering relevant information prior to examination
- Anticipated problems based on the maternal and family history
- Factors affecting wellbeing during pregnancy and birth such as poor foetal growth
- Date, time, type of delivery and birth weight
- Whether the baby has passed urine and meconium
Prior to examination, maternal consent should be obtained, the procedure explained and where possible the examination should take place at the bedside with the mother present. Including the mother, or if possible both parents, gives the midwife a valuable opportunity to observe the parent’s interaction with their baby and to address any general concerns they may have.
Who should conduct the examination?
Examination of the newborn is usually performed by a Midwife who is qualified in the Newborn and Infant Physical Examination Screening Programme (NIPE). However, regional variations may occur depending on the availability and qualifications of the staff available.
Examination prior to discharge may also be performed by a Paediatrician or General Practitioner.
Wolke (2002) notes that mothers were more likely to be satisfied when the newborn examination was conducted by a midwife rather than a doctor. This was because midwives were more likely to discuss healthcare issues during the examination and were able to provide continuity of care.
Exclusion criteria for midwife examinations
- Prematurity, under 36+6 weeks gestation
- Admission to intensive care, or paediatric referral
- Family history of significant genetic, or congenital abnormalities
- Suspected, or confirmed abnormality at antenatal screening
- Birth trauma, for example, shoulder dystocia or nerve palsy
The Newborn Examination:
- Observe the baby’s general condition, including colour, breathing, behaviour, activity, posture and cry.
- Head and skull. Note facial symmetry, the size of the fontanelles and the presence of any remaining caput, cephalhaematoma or trauma. Note the position and placement of the ears.
- Examine the baby’s eyes for size, position, absence of discharge and red reflexes. Note any appearance of squint, conjunctivitis, discharge, or haemorrhage. The prime purpose of screening at this stage is to identify congenital cataracts as approximately 2 or 3 in 10,000 newborn babies have problems with their eyes that require treatment (Public Health England 2016).
- Mouth and palate. The palate should be inspected for craniofacial abnormalities such as a cleft lip or palate. These are among the most common of all birth defects, affecting over 1,000 babies in the UK each year (Nursing Times 2012).
- Palpate the neck and clavicles. Check limbs, hands, feet and digits, assessing proportions and symmetry. Examine feet to exclude any postural abnormalities such as talipes.
- The cardiovascular system. Khalilian et. al. (2016) reports that auscultation is one of the most important procedures in routine examination of neonates for congenital heart disease (CHD). Yet, differentiating between innocent and pathologic murmurs during auscultation is very hard and usually unfeasible. According to Public Health England (2016), the overall incidence of congenital heart defects is 4-10 per 1000 live births ranging from non-significant to major and critical lesions. However, Niccolls (2009) suggests that the presence of a murmur does not always signify the presence of heart disease, nor does the absence of a murmur provide reassurance of normality.
- Lungs. Observe the rate and pattern of chest movement. Listen to the air entry to check for crackles and stridor. Note the presence of any respiratory problems such as tachypnoea at rest, retraction, grunting, or nasal flaring.
- Observe the baby’s abdomen. Gently palpate to identify any organomegaly, masses or a hernia. Confirm the presence of bowel sounds. The condition of the umbilical cord should also be noted.
- Observe the baby’s genitalia and anus, to check normal appearance, positioning and patency. Palpate femoral pulses.
- Palpate testes in male infants for presence or undescended position. Cryptorchidism (failure of one or both of the testes to descend into the scrotum) affects approximately 2-6% of male babies born at term and is associated with a significant increase in the risk of testicular cancer and reduced fertility. Bilateral undescended testes may also be associated with ambiguous genitalia or an underlying endocrine disorder. According to Public Health England (2016), early diagnosis and intervention improves fertility, reduces the risk of torsion and may aid earlier identification of testicular cancer.
- Examination of the back. Inspect the bony structures and skin of the baby’s spine, with the baby prone. Note the presence of dimples, hair tufts, naevus, or abnormal skin patches.
- Note the colour and texture of the skin as well as the presence of any birthmarks, rashes or abrasions.
- Reflexes and central nervous system. Observe tone, behaviour, movements and posture. The grasp, rooting and sucking reflexes are assessed. The Moro reflex may also be included, though many experts choose to exclude it on the basis that it is cruel to deliberately startle the baby (Ferrari et. al. 2012).
- Check hips, symmetry of the limbs and skin folds. Perform Barlow and Ortolani’s tests to exclude dislocation. According to statistics from Public Health England (2016), approximately 1 or 2 in 1,000 babies have hip problems that require treatment.
Six-week follow up
Finally following the newborn examination, the parents should be informed that the examination will be repeated at 6-8 weeks of age as some conditions can develop or become apparent later (Public Health England 2016).
- Ferrari, F, Lugli, L, Ori, L, Gallo, C, Bertoncelli, N 2012, ‘Neurological Examination of the Newborn Infant’, Neonatology, pp. 1100-12, viewed 5 February 2018, https://link.springer.com/chapter/10.1007/978-88-470-1405-3_130
- Khalilian, MR, Malekian, A, Aramesh, MR, Dehdashtian, M & Maryam, T 2016, ‘Innocent versus pathologic murmurs: A challenge of neonatal examination’, Journal of Clinical Neonatology, vol. 5, no. 3, pp. 174-8, viewed 5 February 2018, http://www.jcnonweb.com/article.asp?issn=2249-4847;year=2016;volume=5;issue=3;spage=174;epage=178;aulast=Khalilian
- Niccolls, C 2009, ‘Examination of the newborn: The innocent heart murmur’, Journal of Neonatal Nursing, vol. 15, no. 2, pp. 38-46
- Nottingham Neonatal Service 2017, Clinical Guidelines Guideline, No A11, viewed 5 February 2018, https://www.nuh.nhs.uk/handlers/downloads.ashx?id=62455
- The Press Association 2012, ‘Too many cleft palates ‘found late”, in The Nursing Times, 13 December, viewed 5 February 2018, https://www.nursingtimes.net/5052863.article
- Public Health England 2016, Newborn and Infant Physical Examination Screening Programme Handbook 2016/17, PHE, London, viewed 5 February 2018, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/572685/NIPE_programme_handbook_2016_to_2017_November_2016.pdf
- The Royal College of Midwives 2012, Evidence Based Guidelines for Midwifery-Led Care in Labour: Immediate Care of the Newborn, RCM, viewed 5 February 2018, https://www.rcm.org.uk/sites/default/files/Immediate%20Care%20%20of%20the%20Newborn.pdf
- Royal Cornwall Hospitals NHS Trust 2017, Newborn Infant Physical Examination (NIPE) Clinical Guideline, NHS Trust, viewed 5 February 2018, https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2014/06/nipe-ratified-guideline.pdf
- Wolke, D 2002, ‘Routine examination of the newborn and maternal satisfaction: a randomised controlled trial’, ADC Fetal & Neonatal Edition, vol. 86, no. 3, viewed 5 February 2018, http://fn.bmj.com/content/86/3/F155