2. Aim : At the end of session , the group will be able to
implement knowledge of physical assessment of neonate
while caring for neonate.
Specific Objective :
At the end of the session , the students will be able to :
♣ explain classification of newborn
♣ identify apgar score
♣ calculate growth measurements
♣ monitor vital signs
♣ estimate the gestational age
♣ check the different body systems
♣ describe normal findings in the newborn examination
♣ recognize common newborn problems
3. Assessment
Gathering accurate, detailed data that
includes four components
Review history
Review results of physical exam
Review available data
Formulating an impression and plan
4. Comprehensive History
Prerequisite for adequate
assessment
Alerts examiner to potential
problems and may indicate the
need for more frequent exam
Gives clues to potential pathology
5. HISTORY
Demographics
Past Maternal illness & surgeries
Maternal conditions
Family History of congenital
conditions
Reproductive History
Antepartum History
Intrapartum History
Social History
7. Principles of Physical Assessment
Assess infant for clues for potential
pathology
Auscultate in a quiet environment
Keep the infant WARM & calm
during the exam
Handle gently!
Record & report abnormalities
10. Percussion
The body’s structures differ in
density.
To discern the location, size and
density of a structure.
Tympany
Resonance
Hyperresonance
Dullness
11. MiniMuM prerequisites
o Mother & baby together
o Warm room
o fresh clean sheet/clothes
o Thermometer
o Weighing scale
o Watch with seconds
o Stethoscope
17. APGAR 0 1 2 1
min
5
min
Activity (Muscle
tone)
Floppy Some
flexion
Well
Flexed
Pulse (HR) 0 <100 >100
Grimace (reflex
irritability)
No
respons
e
Grimace Cough
or
sneeze
Appearance
(Color)
Blue or
pale
Pink AC Pink all
over
Respirations Absent Slow,
irregular,
weak cry
Good,
strong
cry
1958
APGAR SCORE
18. Apgar score may be influenced by
Preterm birth
Administration of maternal drugs
Congenital anomalies
19. Examination of newborn physical
examination include the following:
1. Vital signs
2. Physical exam
3. Neurological exam
4. Estimation of gestational age
20. 1. vital signs
♣ temperature
♣ heart rate
♣ respiratory rate
♣ blood pressure
♣ capillary refill time
21. Temperature
♣ temperature should be taken axillary
♣ the normal temperature for infant is
36.5 C - 37.5 C.ᵒ ᵒ
♣ axillary temp.is 0.5 C - 1 C lowerᵒ ᵒ
than rectal temp
22. Heart rate
♣ it should be obtained by auscultation
and counted for a full minute
♣ normal heart rate is 120-160 bpm.
♣ if the neonate is tachycardic (heart
rate >170 bpm), make sure the baby
is not crying or moving vigorously.
23. Respiratory rate
♣ normal respiratory rate is
40 –60/minute
♣ respiratory rate should be obtained
by observation for one full minute
♣ newborns have periodic rather than
regular breathing
24. Blood pressure
♣ it is not measured routinely
♣ normal blood pressure varies with
gestational and postnatal ages
25. Capillary refill time
♣ normally < 3 seconds over the
trunk
♣ may be as long as 4 seconds on
extremities
♣ delayed capillary refill time
indicates poor perfusion
26. Physical examination
Measurements
There are three components for
growth measurements in neonates
♣ weight
♣ length
♣ head circumference
♣ All should be plotted on standardized
growth curves for the infant’s
gestational age
27. Weighing the baby
Prepare the scale: cover the pan with
a clean cloth/autoclaved paper;
ensure the scale reads zero
Preparing and weighing the baby
Remove all clothing
Wait till the baby stops moving
Weigh naked
Read and record
Return the baby to the mother
Scale maintenance
Calibrate daily
Clean the scale pan between
each weighing
EN-Teaching Aids: ENC 27
28. weight
• weight of full term baby at birth is 2.6– 3.8kg.
• babies less than 2.5 kg are considered low birth
weight.
• babies loose 5% – 10% of their birth weight in the
first few days after birth and regain their birth
weight by 7 – 10 days.
• weight gain varies between 15-20 gm/day.
29. Length
♣ crown to heel length
should be obtained on
admission and weekly
♣ acceptable newborn
length ranges from 48-
52 cm at birth
30. Head circumference
♣ head circumference should
be measured on admission
and weekly
♣ using the measuring paper
tape around the most
prominent part of the occipital
bone and the frontal bone
♣ acceptable head
circumference at birth in term
newborn is 33-38 cm
32. General examination
1-colour
pallor: associated with low hemoglobin or shock
cyanosis: associated with hypoxemia
plethora: associated with polycythemia
jaundice: elevated bilirubin
Cyanosis, Acrocyanosis
33. skin
• purpura,echymosis
• mottling
• vernix caseosa- a lubricant found on the skin or skin
fold ,disappears as the fetus ages, almost absent in
post- term
Edema, Mongolian spots - dark blue bruise-like
macular spots usually over sacrum ♣ in 90% of
blacks and asians ♣ disappear by 4 yrs
Collodion baby
Rashes: Milia, Erythema toxicum, bullous impetigo,
diaper rash, nevi
42. Anterior and posterior fontanelle
• large anterior fontanelle is seen in hypothyroidism,
osteogenesis imperfecta, hydrocephalus
• small ant.fontanelle in microcephaly and craniostenosis
•Bulging ant. Fontanelle in
meningitis and hydrocephalus
intracranial hemorrhage
• depressed ant.fontanelle in
dehydration
• large post.fontanelle
suspicious of hypothyroidism
46. Ear examination
-assess for asymmetry or irregular shape
- note presence of auricular or pre-auricular pits,
fleshy appendages, lipomas, or skin tags.
- low set ears
- • below lateral canthus of eye
- • associated with genitourinary anomalies, because
these areas develop at similar times.
-malformed ears
• can be associated with downs or turners syndromes
48. Nose
♣patency of each nostril: exclude choanal atresia
♣flaring of nostrils
Dislocated nasal septum
49. Mouth
♣natal teeth
♣tongue size: Normal tongue
Ankyloglossia(tongue tie), Macroglossia
♣cleft lip and palate
-Unilateral cleft lip and cleft palate
-Bilateral cleft lip and cleft palate
♣Epstein pearls & cheeks • small white cysts which
contain keratin • frequently found on either side of
the median raphe of the palate. • resolves in 1-2
month
♣ranulas – small bluish-white swellings of variable
size on the floor of the mouth representing benign
mucous gland retention cysts♣Oral thrush
51. Neck
♣cysts: thyroglossal
cyst, cystic hygroma
masses:
sternomastoid tumor,
thyroid
Webbing
hematoma in the
middle third of the
sternomastoid muscle
torticolis, limitation of
lateral rotation of the
neck
53. Musculoskeletal
♣ Syndactyly
• simple – involves
soft tissue
attachment only • complex
– involves fusion of bone or nail
• partial - web extends from base
partially
• complete - web from base to tip of
finger
• radiographs needed to determine
degree of fusion should refer to
orthopedics.
Erb’s palsy
54. Back
inspect back for
spine curvature
examine for spina bifida
pilonidal dimple
meningeocele, Meningiomyelocele
55. Normal breathing
30 to 60 breaths per minute
No chest in-drawing, no grunting on breathing out
When assessing breathing:
Count number of breaths for a full minute
Babies may breathe irregularly for short periods of time
Small babies (<2.5 kg or born before 37 wks gestation) may:
Have some mild chest in-drawing
Periodically stop breathing for a few seconds
EN-Teaching Aids: ENC 55
56. Chest/lung examination
• inspection:
– supernumerary breast or nipple is common (10%)
– breast enlargement secondary to maternal
hormones
– unilateral absence or hypoplasia of pectoralis
major,
- poland's syndrome (poland's sequence)
- widely spaced nipples( turner's syndrome)
- noonan syndrome
61. Heart and vascular system
♣ Check for :♣ tachypnea,tachycardia
♣ increased pericordial activity
♣ cyanosis: hyperoxia test
♣ palpate femoral pulsation: absent in coarctation of the aorta
♣ bounding pulses often indicated PDA
♣ murmurs or irregular heart rhythm
♣ URSB for aortic valve
♣ ULSB for pulmonary valve
♣ LLSB for the tricuspid area for
ventricular septal defects
♣ the apex for mitral valve
62. Abdomen
♣ cylindrical in shape
♣Normal umbilical cord
• bluish white at birth with 2 arteries & one vein.
Meconium stained umbilical cord, bleeding,
granuloma, discharge, inflammation
♣organomegaly: liver may be palpable 1-2 cm below
the costal margin .spleen is at the costal margin
♣ masses, distension ,
scaphoid abdomen
64. Genitalia and rectum
♣ male genitalia
• in full term,scrotum is well developped,with deep
rugae. Both testes are in the scrotum
• in preterm,scrotum is small with few rugae.testes
are absent or high in the scrotum abnormalities.
undescended testis
hydrocele,
inguinal hernia
Hypospadius meatus
Epispadius meatus
65.
66. Genitalia and rectum
♣Female genitalia
• in full term,labia majora completely cover labia
minora
• in preterm,labia majora is
widely separated and
labia minora protruded
• a discharge from the vagina or withdrawal bleeding
may be observed in the first few days
• infant with ambiguous genitalia should not undergoe
gender assignment until endocrinal evaluation is
performed
Withdrawal bleeding
67. Imperforate anus
The anus is inspected for its
location and patency . An
imperforate anus is not always
immediately apparent.
Thus, patency often is checked by
careful insertion of a rectal
thermometer to measure the baby's
first temperature
• Meconium should pass in the first 48h after birth
• Delayed passage of meconium may indicate
imperforate anus or intestinal obstruction
• Urine should pass in the first 24h of life
69. Recaptualisation
Baby of Archana was born to a Primigravida mother
at term, baby is now 20 hours of age noticed to
have yellowness of face and trunk.
Q. - What is the problem?
Q. - What action you will take?
Baby of Radhika was born with weight of 1.5kg.
Baby weighs 1.3 kg today on day 2.
Q. - What are your concerns?
Q. - What action you will take?
71. Conclusion
All newborn babies must be
examined at
Birth
24 hrs
Before discharge and
Follow-up
A systematic approach consisting
of ‘Ask, Check, Look, Listen, Feel’
should be followed at each
assessment
Notes de l'éditeur
Bluish mottling or marbling of the skin. Seen in response to: chilling, stress, overstimulation. Caused by dilation of the capillaries and disappears when the infant is warmed.
So….. If you have a calm warm infant and see this it might alert you to: trisomy 21, 18, cornelia de lange syndrome.
Only seen in the newborn period. It occurs in both healthy and ill infants. It is the temporary imbalance of the autonomic regulatory mechanism of the cutaneous vessels. It can last anywhere from 1-30 minutes. It can change depending on which side of the body is the dependent half of the body (red color in the dependent part, white in the superior part).
Discolored flat spot less than 1 cm in diameter
Nevi-lower back and buttocks, with or without hair
Café au lait- can be normal but greater than 3-5 can be indicative of neurofibromatosis
Transient neonatal pustular melanosis. This is a benign neonatal dermatosis that is most common among African- American infants. The original lesion is a vesiculopustule, which may be present at birth. This small blister quickly ruptures and leaves a typical collarette of superficial scale processes, such as neonatal herpes simplex. Tzanck smear of a pustule of erythema toxicum neonatorum will reveal numerous eosinophils but no multinucleated giant cells or bacteria.
An affected baby may suddenly lose his or her active behavior and become lethargic. The baby may stop caring about things such as feeding, or may do just the opposite and become very irritable. This, of course, is a very common thing in normal babies as well, but an irritable baby should be assessed to make sure it is nothing more than &quot;just colic.&quot; Shaking, twitching, or fits - like epileptic fits - should be checked out by a physician without delay. Babies with herpes infection of the nervous system may have skin sores, but very often a baby with serious herpes infection shows no skin problem whatsoever.
A coloboma (from the Greek koloboma, meaning defect,[1]) is a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic disc. The hole is present from birth and can be caused when a gap called the choroid fissure, which is present during early stages of prenatal development, fails to close up completely before a child is born. The classical description in medical literature is of a key-hole shaped defect. A coloboma can occur in one eye (unilateral) or both eyes (bilateral). Most cases of coloboma affect only the iris. People with coloboma may have no vision problems or may be blind, depending on severity. It affects less than one in every 10,000 births.
These red spots are called subconjunctival hemorrhages. They are common in newborns and typically result from the normal trauma of birth. As newborns are squeezed through the birth canal blood vessels (on the eyes and elsewhere) can rupture. Subconjunctival hemorrhages are basically bruises of the eye. As with any bruising in newborns, they increase the risk of jaundice. Subconjunctival hemorrhages resolve over 2 to 4 weeks.
blue when you were born. Why? Melanin, the brown pigment molecule that colors your skin, hair, and eyes, hadn&apos;t been fully deposited in the irises of your eyes or darkened by exposure to ultraviolet light. The iris is the colored part of the eye that
controls the amount of light that is allowed to enter. Some other animals are born with blue eyes, too, such as kittens.
Melanin is a protein. Like other proteins, the amount and type you get is coded in your genes. Irises containing a large amount of melanin appear black or brown. Less melanin produces green, gray, or light brown eyes. If your eyes contain very small amounts of melanin, they will appear blue or light gray.
A coloboma (from the Greek koloboma, meaning defect,[1]) is a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic disc. The hole is present from birth and can be caused when a gap called the choroid fissure, which is present during early stages of prenatal development, fails to close up completely before a child is born. The classical description in medical literature is of a key-hole shaped defect. A coloboma can occur in one eye (unilateral) or both eyes (bilateral). Most cases of coloboma affect only the iris. People with coloboma may have no vision problems or may be blind, depending on severity. It affects less than one in every 10,000 births.
These red spots are called subconjunctival hemorrhages. They are common in newborns and typically result from the normal trauma of birth. As newborns are squeezed through the birth canal blood vessels (on the eyes and elsewhere) can rupture. Subconjunctival hemorrhages are basically bruises of the eye. As with any bruising in newborns, they increase the risk of jaundice. Subconjunctival hemorrhages resolve over 2 to 4 weeks.
blue when you were born. Why? Melanin, the brown pigment molecule that colors your skin, hair, and eyes, hadn&apos;t been fully deposited in the irises of your eyes or darkened by exposure to ultraviolet light. The iris is the colored part of the eye that
controls the amount of light that is allowed to enter. Some other animals are born with blue eyes, too, such as kittens.
Melanin is a protein. Like other proteins, the amount and type you get is coded in your genes. Irises containing a large amount of melanin appear black or brown. Less melanin produces green, gray, or light brown eyes. If your eyes contain very small amounts of melanin, they will appear blue or light gray.
Ear anomalies are usually non specific and are supportive rather than diagnostic
The small white papule seen in the midline of the palate of this infant is an Epstein pearl. It represents epithelial tissue that becomes trapped during the palatal fusion. It is a very common and benign finding.
Neonatal teeth erupt within the first 30 days of life. As many as 85 percent of these are a part of the normal primary dentition and are not supernumerary (extra teeth). Often, these teeth are hypermobile, and aspiration is a concern.
Cleft lip (cheiloschisis) and cleft palate (palatoschisis), which can also occur together as cleft lip and palate, are variations of a type of clefting congenital deformity caused by abnormal facial development during gestation. A cleft is a fissure or opening—a gap. It is the non-fusion of the body&apos;s natural structures that form before birth
Increased work of breathing:
Tachypnea: respiratory rate &gt;60/minute (increased respiratory rate to maintain ventilation in the face of decreased tidal volume)
Grunt: partial closure of glottis during expiration (attempt to maintain lung volume and allow for adequate gas exchange)
Nasal flaring: attempt to decrease airway resistance
Suprasternal retractions/ tracheal tug: suggests upper airway obstruction
Subcostal retractions: less specific sign, associated with either pulmonary or cardiac disease
Direct Auscultation: Grunting can be a sign of respiratory distress in a newborn. Grunting frequently occurs in combination with nasal flaring and intercostal or subcostal retractions as all three are associated with increased work of breathing. The distinctive sound of grunting is produced when the glottis is closed during expiration. This increases end-expiratory pressure in the lungs (similiar to increasing the PEEP setting on a ventilator) and helps to improve oxygenation to the patient. Although occasional grunt can at times be heard in healthy infants during normal crying.
Stridor is an occasionally encountered sound in an otherwise healthy newborn. It is a high-pitched whistling sound that occurs on inspiration and is typically audible without using a stethescope. In newborns, it is most commonly caused by laryngomalacia, however other congenital anomalies (vascular slings, double aortic arch, vocal cord paresis, etc) should be considered. Laryngoscopy can confirm the diagnosis of mild laryngomalacia.
Gastroschisis is an abdominal wall defect to the side of the umbilical cord (umbilicus). The infant is born with intestines protruding through the defect and no protective sac is present. Gastroschisis is rarely associated with other birth defects. Gastroschisis is a life-threatening event requiring immediate intervention.