Clinical/Communication

Question 1

What are important history questions to ask in a newborn examination?

Answer 1

• Maternal - PMHx, pregnancy issues, drugs, infection risks
• Infant - fetal growth, fetal anomaly, delivery, resuscitation

Question 2

What are the vital signs that need reviewed in a newborn examination and their relevant ranges?

Answer 2

• Heart rate 120-140/min
• RR 40-60/min
• Cap Refill 2-3 secs
• Work of breathing/respiratory effort
• SaO2 95%
• Others - jaundice, low tone (floppy), seizures, poor feeding, bilious vomit

Question 3

What is involved in general inspection in the examination of a newborn?

Answer 3

• inspect colour - pallor, cyanosis, jaundice
• Assess overall appearance
• Assess general condition, proportions and maturity
• Look for asymmetry, palsy, or abnormality of facial characteristics
• Listen to cry and note sound
• Note weight and gestation of baby and position on growth chart

Question 4

What should be examined on a baby’s head in a newborn examination?

Answer 4

• Shape of head, fontanelles, whether normal, sulken, or bulging
  
  • Overlapping sutures
  • Ventuouse/forceps marks
  • Moulding
  • Caput Succedaneum
  • Cephalhaematoma
• Measure and record head circumference on the growth chart, take 3 measurements for accuracy
• Assess facial appearance and eye position

Question 5

What is moulding in a newborn examination?

Answer 5

common after birth, resolves within a few days

Question 6

What is caput succedaneum?

Answer 6

• diffuse subcutaneous fluid collection with poorly defined margins (often crossing suture lines) caused by pressure on the presenting part of the head during delivery
  
  • Does not usually cause complications and resolves over the first few days

Question 7

What is cephalhaematoma?

Answer 7

• subperiosteal haemorrhage which occurs in 1-2% of infants and may increase in size after birth
  
  • The haemorrhage is bound by the periosteum, therefore, the swelling does not cross suture lines (in contrast to a caput succedaneum)
  • Cephalhaematoma is more common with instrumental delivery

Question 8

What should be noted on skin examination of the newborn?

Answer 8

• Note birthmarks, rashes, skin abnormalities
  
  • Erythema toxicum
  • Strawberry birthmarks
  • Port wine stain
  • Mongolian blue spots

Question 9

What should be noted on eye examination of the newborn?

Answer 9

• Are they normal in shape and appearance?
• Check for ‘red reflex’
• Look for cataracts, coloboma, or signs of ophthalmic infection

Question 10

What should be noted on ear examination of the newborn?

Answer 10

• Note size and shape of ears
• Normal or low set
• Check patency of external auditory meatus
• Check for family history of hearing defects

Question 11

What should be noted on mouth examination of the newborn?

Answer 11

• Use tongue depressor to check colour of mucous membrane, observe palate form and fusion
• Check suckling reflex by inserting CLEAN little finger inside baby’s mouth, can also palpate the palate at this stage
• Observe for cholonal atresia

Question 12

What should be noted on arms and hands examination of the newborn?

Answer 12

• Are hands moving normally, shape normal
• Look for evidence of traction birth injury (e.g. Erb’s palsy) by checking neck, shoulders, and clavicles
• Count fingers and observe shape and any deformities
• Check palmar creases

Question 13

What should be noted on peripheral pulses of the newborn?

Answer 13

• Check brachial, radial and femoral pulses for rate, rhythm and volume
• A hyperdynamic pulse may suggest a patent ductus arteriosus
• A weak pulse may suggest a congenital cardiac abnormality, impairing cardiac output

Question 14

What is checked on examination of the heart in the newborn?

Answer 14

• Check the cardiac position by palpation and feel for any thrill or heave
• Listen carefully to heart sounds and any added sounds and murmurs
• Suspected abnormalities require further examination and opinion
• Aortic: second right intercostal space
• Pulmonary: second left intercostal space at the left sternal border
• Tricuspid: left intercostal space at lower sternal border
• Mitral: left 5th intercostal space at midclavicular line (apex)
• Midscapular: posteriorly situated (coarction of aorta)

Question 15

What should be checked on examination of the lungs in the newborn?

Answer 15

• Watch respiratory pattern, rate and depth for a few seconds
• Look for evidence of intercostal recession, nasal flaring and grunting
• Listen for stridor which could indicate airway obstruction
• Crackles may indicate underlying infection
• Auscultate both lung fields for added sounds

Question 16

What should be checked in the abdomen on examination of the newborn?

Answer 16

• Observe abdominal girth and shape
• Carefully check the umbilical stump for signs of infection or hernia
• Palpate gently to feel for organs, masses, and herniae
• Note - it is normal to feel the liver and spleen in healthy babies
• Check external genitalia, look for hypospadias in boys
• Check labia, vaginal introitus, and warn to expect some spotting in girls
• Palpate for testes in boys
• Inspect anus and establish whether meconium has been passed

Question 17

What should be checked on examination of the back and hips in a newborn?

Answer 17

• Inspect skin over back, at at spinal curvature, not symmetry
• Observe any evidence of spina bifida occulta or sinus hidden by flesh creases or dimples, and any hair tufts
• Palpate spine from neck to coccyx
• Specifically check for congenital dislocation of the hip (congenital hip dysplasia) using a combination of Barlow and Ortolani manoeuvres
• Observe groin creases for symmetry and leg length

Question 18

What should be noted on examination of the legs of a newborn?

Answer 18

• Observe movements at each joint
• Check for evidence of talipes equinovarus
• Count toes and check for shape and normal gaps

Question 19

What should be noted on examination of the central nervous system in a newborn?

Answer 19

• Observe tone, behaviour, movements and posture
• Elicit newborn reflexes if safe and appropriate

Question 20

What are the further steps after a neonatal examination?

Answer 20

• Document findings of examination in postnatal care plan record and child health record
• Proforma of examination should be kept within the notes, to ensure nothing has been missed
• Routine neonatal screening is repeated at 6-8 weeks, this included visual fixation and social smiling
• Hearing screening is normally carried out by hearing screening technicians prior to discharge from hospital