CHHS17/267

Canberra Hospital and Health ServicesClinical GuidelineAssessment of the NewbornContents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – The physical examination.......................................................................................3

Section 2 – Referral and Documentation..................................................................................9

Implementation...................................................................................................................... 10

Related Policies, Procedures, Guidelines and Legislation.......................................................10

References.............................................................................................................................. 10

Definition of Terms................................................................................................................. 11

Search Terms.......................................................................................................................... 12

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Guideline Statement

All 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 treatment Review any concerns that family have about the newborn and attempt to address them Review any problems arising or suspected from antenatal screening, family history or

labour Review weight and head circumference measurements Check the newborn has passed urine and meconium Recognise common neonatal problems and provide advice about management Diagnose congenital malformations and arrange appropriate management Discuss matters such as: care of the newborn, feeding, immunisations, safe sleeping,

purple crying, jaundice and any other matters relevant to the newborn Convey information about relevant support services and how to access them to parents

This 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.

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Scope

This document applies to Registered Nurses, Registered Midwives and Medical staff including neonatal, obstetric and paediatric clinicians working within their scope of practice

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Section 1 – The physical examination

Provision of family centred care Seek parental consent before examining the newborn Listen to parent views and choices regarding planning and delivery of care Respect family values, beliefs and culture (consider an interpreter if necessary –refer to

Language Services Interpreters Procedure) Communicate with and involve the parents as appropriate Ask 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 making Wherever possible perform the examination with at least one parent present

Equipment Stethoscope –paediatric Ophthalmoscope Documentation- Newborn Assessment form, BOS, Personal Health Record (blue book)

Procedure Review Maternal History including: Pregnancy and ultrasounds Medical concerns Medication/substance use Previous pregnancies and outcomes Labour (inc GBS, ROM)

Review Newborn History including: Type of Birth Apgars Gestational age Observations and measurements Feeding and output Resuscitation measures at birth

Physical examination Perform 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.

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OBSERVE GENERAL APPEARANCE ABNORMALSkin colour, warmth, perfusionState of alertness, responsivenessActivityRange of spontaneous movementPostureMuscle toneCrying sounds

Central cyanosisDysmorphic featuresLethargyJitteriness/irritabilityPalsyAbnormal toneWeak, high-pitched, irritable or hoarse cryNo cry (after stimulation)

SKIN NORMAL ABNORMALColour Pink, transient acrocyanosis,

mild jaundice – after 24 hoursCentral cyanosis, pallor, jaundice before 24 hours, plethoric, petechiae, traumatic cyanosis

Lacerations/ Trauma Broken skin, bruising, swellingSuperficial Skin Peeling Occurs on hands and feet in the

first week of life. Common in post term babies on the body.

Vernix Caseosa White, greasy protective substance.Milia White pin head spots around nose.Erythema Toxicum Irregular red blotchy or pustules

over the body.Harlequin Change Transient skin flushing creating a

clear demarcation down the midline.

Birthmarks Mongolian 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 spots

HEAD NORMAL ABNORMALShape Moulded, caput succedaneum Cephalohaematoma

Subgaleal HaemorrhageHydrocephalusMicrocephalyPlagiocephalyScaphocephaly

Fontanels Soft, flat diamond shaped anterior fontanelPosterior fontanel- triangle shaped

Bulging (caused by increased intracranial pressure).SunkenSmall - Craniosynostosis or microcephaly

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Large - HypothyroidismThird - Down Syndrome (occasionally)

FACE NORMAL ABNORMALHair Fine down- Lanugo

ColourWhite- albinoSwirl- tuft of hair

Eyes and eyelids Slight oedema2 x eyeballsRed eye reflexDoll’s eye movementsSticky eyes (non-purulent)

Bruising, oedemaSubconjunctival haemorrhagesPurulent dischargeSquintGlaucomaHypertelorismAbnormal pupil (grey or white)CataractPink iris- albinoEpicanthial folds

Ears ShapeSite- pinna level with eyes(familial variation)

Pre-auricular skin tags or sinusLarge, small or malformed earUnusual discharge

Nose Patent- bilaterallyVariations in width and depth

Choanal atresia (bilateral or unilateral)Frequent regurgitation

Mouth Lips- shape and position(familial variation)

Cleft lipLong or flat philtrumDownturned mouth

Palate Epstein’s pearls- small inclusion cyst in midline of hard palate

Cleft palateHigh arched palateBifid uvulaPalatal insufficiency

Tongue and Jaw Size and shapeSymmetrical(familial variation)

Large: cretinism, mongolismBeckwith’s syndromeSmall: Glossoptosis /micrognathiaPierre Robin syndromeTongue Tie

Teeth Natal teethNECK NORMAL ABNORMAL

ShapeShort Fully mobileCentral position

TorticollisWebbing Excessive tissue back of neckAsymmetryPalpable massesSternomastoid tumour

UPPER EXTREMETIES NORMAL ABNORMALHands Shape and position Limited joint movement

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Accessory digitsMissing DigitsPalmar creases

Arms Symmetrical lengthProportionateFull range of movement Position

FracturesAchondroplasiaDislocation of the elbowBrachial plexus injuryPalsy

Shoulder Girdle Symmetrical clavicle and scapula FracturesLumpsGrinding of boneBruising/Swelling

CHESTChest Shape and size (familial variation)

SymmetryDeeper from back to front (depth) and narrower width

AsymmetricPectus excavatum (funnel chest)Pectus carinatum (pigeon chest)Small chest- dwarfism

Ribs Minimal rib slopeSoft and easy in-drawing during respirationProminent xiphoid process

PneumothoraxProminent sternum

Breasts Up to 1 cm palpable breast tissueX 2 nipplesWitches milk

MastitisSupernumerary nipples

LUNGS NORMAL ABNORMALRate <60Periodic breathing (cessation of breathing for <15 seconds) Symmetrical breath sounds

Asymetric 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).

HEART NORMAL ABNORMALThe apex beat is found in the mid- Shifted to the right, left or displaced

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clavicular line in the fourth intercostals space

HR 100-175bpm (can drop to 90bpm when asleep).

Can have a grade I-II/VI systolic murmur in the first 24 hours of life

Femoral and brachial pulses should be palpated when the newborn is quiet

downwardDextrocardia, pneumothorax, collapse, diaphragmatic hernia.

Tachycardia- cardiac failure, infection, anaemia.Bradycardia- hypoxia, raised intracranial pressure, heart block.

Murmur after 24 hrs of age

Weak or absent- coarctation, hypoplastic left heart syndrome, shock. Bounding- patent ductus arteriosis

GI SYSTEM NORMAL ABNORMALAbdomen Often prominent

Rectus muscle often separated in the midline of the upper abdomen

Gaseous distension or visible bowelMasses

Liver Palpable 1cm below the right rib cage

>1cm = enlarged liver associated with congestive heart failure, macrosomia, infection.

Umbilicus Umbilical hernia is common and generally requires no treatment.

Redness of the skin surrounding the umbilicus may indicate infection

Groin HerniaAnus Patent

PositionImperforate anusFistulaFissure

GENITALIA NORMAL ABNORMALMale: Testes Descended to scrotum (may take

one month)None palpable after one monthHydrocele- fluid surrounding the testses

Penis and Urethra Uretheral opening at centre of glans. Foreskin not retractable

Hypospadias- uretheral opening on ventral surface of the penis.Epispadius- uretheral opening on dorsal surface of the penis.Chordee/ micropenis

Female: Hymen Hymenal tag Hydrometrocolpos behind a bulging imperforated hymen or labial adhesions.

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Clitoris Variable in size Large clitoris- adreno-genital syndrome, maternal progestogen, hermaphroditism.

Vagina and vulva Mucous vaginal discharge or bleeding caused by maternal hormone withdrawal.

Labial fusion in adreno-genital syndrome.

LOWER EXTREMETIES NORMAL ABNORMALLegs Symmetrical

Flexed fetal position for several days after birth and often cannot be completely extended at the knee.

FracturesShort BonesAchondroplasiaMissing Bones

Feet Movement, mild postural deformity may be normal

Overriding toes and syndactalyTalipies equinovarus, calcaneovalgus, metatarsus adductus.

Hips Perform Ortolani and Barlow manoeuvresFull abduction of flexed hip. Hips symmetrical,Equal leg length,

Congenital subluxation or dislocation of the hip.

SPINE NORMAL ABNORMALStraight/ symmetrical Mongolian spotSacral pit

Dimple at base of spineScoliosisKhyphosisTufts of hair on sacrumSpina Bifida

NEUROLOGIC Stimulus ResponseSucking Reflex Touching or stroking the lips Mouth opens and sucking

movements are initiatedRooting Reflex Stroke and corner of mouth Head turns towards stimulus and

mouth opensPalmer Reflex Using the index finger of both

hands apply slight pressure to the palmer surfaces of newborn’s hands

Newborn grasps fingers and can be held momentarily off the bed surface

Tonic Neck Reflex With newborn in supine position turn his/her head to one side

Newborn 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 reflex Holding newborn’s head several centimetres off the bed withdraw hand rapidly and let newborn fall onto bed or other waiting hand

Initial response should be to extend and abduct arms and hands will be open, then the arms flex and hands are closed into fists.

Startle reflex A loud noise or sudden movement There is flexion of the extremities

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should produce a ‘moro like reflex ‘response

and palmer grasping but not a complete ‘moro’ response

Stepping Reflex Holding the newborn upright ensuring the soles of the feet are touching a flat surface

Stepping movements are observed

Galant reflex Newborn 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 area

Flexion of the pelvis towards the side of stimulus

Babinski Reflex Stimulate 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.

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Section 2 – Referral and Documentation

Any 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 record

A 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)

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Implementation

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.

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Related Policies, Procedures, Guidelines and Legislation

Policies Healthcare Associated Infections Consent and Treatment

Procedures Care of the Well baby

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References

1. ACT Health- Staff Development Unit, Examination of the Newborn, Information and Record Book, 2013.

2. Government of Western Australia; Department of Health, Care of the Neonate: Neonatal Screening Clinical Guideline, 2015.

3. Queensland Department of Health, Queensland Clinical Guidelines: Translating Evidence into Best Clinical Practice: Routine Newborn Assessment, 2014.

4. Southern Health, Neonatal Assessment and Discharge Examination in the Term Newborn- Guideline for Midwives and Obstetric Staff, 2009.

5. Tappero. E, and Honeyfield.M, (2014) Physical assessment of the Newborn: A comprehensive Approach to the Art of Physical Examination. NICUINK California

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Definition of Terms

Achondroplasia: genetic disorder disturbing normal growth of cartilage, resulting in a form of dwarfism characterized by a usually normal torso and shortened limbs

Calcaneovalgus: a condition where the foot and ankle are excessively bent up, where the toes may be touching the shin

Cephalohematoma: 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 skull Dextrocardia: 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 reversed Epicanthial 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.

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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 brain

Hydrometrocolpos: an accumulation of watery fluid in the uterus and vagina Hypertelorism: excessive width between the eyes Kyphosis: exaggerated outward curvature of the thoracic region of the spine resulting in

a rounded upper back Metatarsus adductus: a condition of the foot that causes the front half of the foot, or

forefoot, to turn inward Micrognathia: 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 lip Plagiocephaly: 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 suture Scaphocephaly: a congenital deformity of the skull in which the vault is narrow,

elongated, and boat-shaped caused by premature ossification of the sagittal suture Subgaleal 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 sole

Torticollis: 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 sideways

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Search Terms

Newborn, Well baby, Assessment

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Disclaimer: 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 Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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