1. EXAMINATION OF THE NEWBORN Dr. Taher Yunus Kagalwala, M.D., D.C.H., Specialist Paediatrician, Al Muwayh Province General Hospital, Al Muwayh, Makkah Mukarramah Region, Kingdom of Saudi Arabia

2. Impact of Pregnancy on the Newborn Before any discussion on the newborn, it is vital to remember that hundreds of antenatal factors can affect the eventual outcome. Briefly, they include 1. Age and health of the mother 2. Presence of maternal abnormalities such as a uterine malformation, fibroids, abnormal implantation, placenta previa, etc. 3. Maternal diseases such as pre-eclampsia, hypertension, gestational or prenatal diabetes mellitus, etc. 4. Maternal use/abuse of tobacco, drugs, alcohol 5. Maternal infections both prenatal and intranatal, systemic and local e.g. tuberculosis, TORCH, group B strep, genital herpes, HIV 6. Maternal diet esp. Folic acid deficiency 7. Maternal level of antenatal care 8. Previous obstetric history 9. Foetal abnormalities such as twinning, abnormal presentations, intra-uterine growth retardation, prematurity, congenital malformations 3. Objectives of the Newborn Examination The initial examination The 24-hour examination The day-to-day examination The on-discharge examination Objectives of the examination of a newborn are different on all the above occasions. While the general rule is to ensure that the baby is alive and thriving, many specifics apply. 4. The initial examination The objective of the intial examination is making sure that the baby transits safely and without any problems from the intra-uterine environment into the external environment that is the delivery room or the OR, whichever is applicable. For the objective in question, we most commonly use the APGAR SCORE and also do a few important tests to rule out immediate, life-threatening abnormalities in the baby as soon after birth as possible, beginning at 1 minute for the APGAR score. 5. The APGAR score Scored out of a maximum of 10, the time-tested APGAR score is a test of viability at 1 minute and a possible test of intermediate and subsequent neurological outcome at 5, 10, 15 and 20 minutes. It is a score comprising of the following FIVE attributes in a newborn baby and must be assessed at 1 minute (60 seconds) after birth: Heart rate and regularity Respiration rate and regularity Colour central and peripheries Spontaneous activity and movement Crying on stimulation Each item is scored from 0 to 2, making up for a total score of between 0 and 10. 6. APGAR Score (continued) Attribute 0 1 2 Heart Rate and Rhythm Absent or < 60/min,, Irregular Weak, 60-100/min, regular Strong, > 100/min, regular Respiration Absent or gasping Irregular Regular or periodic Colour Blue or Pale Pink centrally, but blue peripherally Pink all over Spontaneous movements Absent, limp or with extended limbs Slight movement, moderate flexor tone Good movements, flexor tone Crying on stimulation Absent Slight grimacing Vigorous crying 7. What do we check after stabilisation of the newborn? The next step after drying, stimulation and suctioning of a well newborn is an unhurried examination to rule out life- threatening congenital abnormalities and trauma during the parturition and delivery process. This is a vital exam that must be done under proper light and with a calm mind. The objective is to examine the baby from head to toe to uncover the most important life-threatening abnormalities. While this is a task for the neonatal specialist, it is good for nurses to know what to look for, as most normal deliveries are conducted by delivery room nurses. 8. The initial exam for life-threatening problems in the newborn - I The following is a list of the most important problems, though the list is not all-inclusive: Severe respiratory problems distress, frothing, apnoea, breathlessness examples: bilateral choanal atresia, diaphragmatic hernia, tracheo-oesophageal fistula, lung hypoplasia, pneumothorax Severe heart problems distress, irregular heart rate, absent apical impulse, external heart, cyanosis not improving with oxygenation examples: congenital cyanotic heart disease, primary pulmonary hypertension, ectopia cordis, dextrocardia with murmur or cyanosis 9. The initial exam for life-threatening problems in the newborn - II Gastro-intestinal abnormalities absent anal orifice suggestive of imperforate anus, boat-like abdomen with respiratory distress suggestive of diaphragmatic hernia, bloated abdomen with frothing at the mouth worsening with AMBU bagging suggestive of T-O fistula Neurological abnormalities large/small head, wide open anterior fontanelle, absent vertebral points on back examination, lumps anywhere on the head or the spine, fitting (c0nvulsions), limp child with no movements examples: hydrocephalus, severe microcephaly, haemorrhage due to birth trauma, asphyxia, spina bifida, meningomyelocoele, etc. 10. The initial exam for life-threatening problems in the newborn - III Uro-genital system absent or abnormal genitalia anatomy, abnormalities of other organs that point to the possibility of internal urinary abnormalities such as ear anomalies, accessory nipple, single umbilical artery, or genital abnormalities examples include renal and urinary system anomalies and the unique problem of ambiguous genitalia. Trauma carefully look for birth trauma that is life- threatening such as intra-cranial or extra-cranial haemorrhage, etc. 11. The unhurried neonatal examination: Preparation Read case notes and history includes family history, past medical history, past obstetric history, present obstetric history, intra-partum and birth history Listen to care-takers babys appearance, feeding history, behaviour and wakefulness; mothers behaviour and attitudes Gather equipment stethoscope, ophthalmoscope, measuring tape, centile charts, spatula, thermometer Wash and warm hands correct technique 12. Steps of Neonatal Examination Observation also listen to the baby Look for obvious problems on exposed areas first and auscultate the heart before proceeding with completely undressing the baby Naked examination from head to toe Inspection -> Palpation -> Auscultation -> Percussion (if needed). Clinical aids like use of torch, hammer, ophthalmoscope, spatula, etc. as indicated. Special tests to rule out congenital anomalies Assessment of gestational age Assessment of neonatal reflexes 13. Examination of exposed parts Several areas can be examined without disturbing the quiet state of the awake baby: these include - Scalp Head and fontanelles Face Eyes, ears, nose Mouth, neck Hands and feet Upper and lower limbs Heart rate/rhythm and breathing sounds from lungs Genitalia (if baby is clean) 14. Final examination Usually, this examination is done at the age of 24 hours. The child should be quiet and alert for this exam. The baby must be undressed completely, allowing for proper viewing of all parts of the body. Attention must be paid to assessing normality of all body parts, external and internal, and where there is doubt, a plan of further assessment needs to be made. The physical examination should not take more than 5-10 minutes. It should include all the steps mentioned in the previous slide, such as inspection, palpation, etc., measurements of weight, length, head circumference (with centile charting) and special tests for congenital anomalies. Assessment of gestational age by physical and neurological criteria must follow. In relevant cases, one must then test the neonatal reflexes. At the end of the exam, documentation must be done. Information to the care-takers and mother is the last step of the final examination. 15. Important aspects of neonatal examination With immediate bearing on the well-being of the child: vital signs, jaundice, cyanosis, pallor, health of the umbilical cord, fever, state of alertness, sucking, major congenital anomalies like cleft lip or a heart murmur, large head, absence of light reflex, not passed meconium or urine, swelling of the body, recognised syndromic abnormalities, abnormal reflexes, paralysis of body parts, abnormal breathing, major birth trauma, asphyxia, etc. With long-term bearing on the well-being of the child: small baby, asymmetrical limb length, extra digits and other minor congenital anomalies, heart murmur in a well-baby, etc. Feeding behaviour, excessive or abnormal crying, and examination of reflexes are also important and may have a bearing on both immediate and later outcomes. 16. Jaundice 17. Cyanosis 18. Caput Succedaneum 19. Cephalhaematoma 20. Cleft lip and palate 21. Down Syndrome (Trisomy 21) 22. Erbs Palsy 23. Amniotic Bands 24. Congenital Cataracts 25. Gastroschisis 26. Thanatophoric Dysplasia 27. Achondroplasia 28. Supernumerary Nipples 29. Erythema toxicum 30. Disorders of external genitalia 31. Breastfeeding correct position 32. Congenital Hydrocephalus 33. Meningomyelocoele 34. Developmental Dysplasia of the Hip 35. Benign Vascular malformations Strawberry Nevus Stork Mark (Capillary Nevus) 36. Mongolian Spot 37. Polydactyly 38. Umbilical cord Infection 39. Measurements in the Newborn Head circumference Total body length by stadiometry 40. Assessment of Gestational Age There are two methods of assessing the gestational age of the baby apart from calculating it from the first date of the last menstrual period or calculating it by foetal ultrasonography. The first is the PHYSICAL CRITERIA method which bases the estimate on various physical findings such as the shape, feel and size of the ear cartilage, size of the breast nodule, texture of the skin, hair and blood vessels of the skin, creases on the soles of the feet, etc. The second method uses the NEUROLOGICAL CRITERIA to assess the gestational age. In this, we make use of the tone, posture and flexibility of the joints to arrive at a gestational age. 41. Examination of Neonatal Reflexes Intact neonatal reflexes such as the sucking reflex, the Moros response, placing and stepping reflexes, rooting reflex etc. are used to know whether the baby is neurologically normal or not, whether it is likely that he/she will have feeding difficulties, and whether some intranatal problems have likely caused some degree of brain damage. Neonatal reflexes are also helpful in assessing the gestational age of a preterm baby. Persistence of otherwise temporary neonatal reflexes may also point to brain damage, e.g. cerebral palsy or mental retardation cases. 42. Follow-up examination in the nursery During the stay of a baby in the post-natal ward or nursery, the following important examinations must be carried out: - establishment, success and adequacy of breastfeeding (daily weight check is very important) - checking the umbilical stump, mouth and genitalia for infection - daily check of the heart for emerging murmurs as the cardiac physiology changes from foetal to adult type of circulation - checking for development of jaundice, various skin rashes, and other benign problems - looking out for possible metabolic problems, should they occur, esp. hypoglycemia, hypocalcemia, and inborn errors of metabolism. 43. On-discharge Neonatal Examination The on-discharge examination should be a review of the maternal-baby unit as a whole, esp. with respect to breastfeeding. In addition, re-examine the baby for jaundice, infection, general well-being etc. Take the spO2 in the right hand and left leg to rule out co-arctation of the aorta, a serious vascular malformation that can cause hypertension, heart failure, etc. The result is significant if the difference between the two readings is more than 3% Re-check the babys weight and head circumference at discharge to confirm that there is no undue weight loss and no head-size problems. Train the mother on how to change the babys dress and diaper, look for hypothermia, and recognise sickness. 44. Final comments and conclusion The neonate is a special human being whose health depends on his familys and mothers well-being; hence, examination should be preceded by a review of the history of the family and the mother. The initial examination is designed to check viability, look for serious and life-threatening issues and guide initial care. The detailed examination is done at 24 hours and is a systematic, unhurried examination to look for all possible abnormalities and to establish breastfeeding. The follow-on examinations are meant to uncover emerging problems in an otherwise normal neonate. The on-discharge examination is more of a re-assurance before sending the mother and the baby home. 45. Thank you