The first examination

Every newborn infant should be examined at least twice during the first few days of life. An additional examination after discharge but within the first week is recommended, particularly if the mother and infant are discharged from the hospital prior to 48 hours postnatally. If possible, perform the first assessment in the hospital’s delivery area to (1) identify any obvious major and minor congenital malformations, (2) assess gestational age, nutritional status, and vigor, and (3) determine how well the baby handles the transition from intrauterine to extrauterine life.

Most babies make the major physiologic adaptations of this transition smoothly. The few who do not adapt normally—particularly those born prematurely or after perinatal stress or asphyxia—will need help to adapt successfully.

The method used almost universally in delivery rooms to evaluate the central nervous system (CNS) status and general adaptation of the neonate to extrauterine life is the Apgar score. This scoring system, summarized in Table 4–2, evaluates the baby in five different respects: heart rate, respiration, color, muscle tone, and reflex irritability (response to stimulation). These signs are usually evaluated at 1 minute and 5 minutes after birth. The Apgar score is the total of the baby’s scores for each of the five signs. To be consistent, have the Apgar score recorded by an experienced clinical observer whose principal responsibility is caring for and evaluating the baby. Because inter-observer variation in scoring may be considerable, experience is essential. Evaluate the signs at exactly 1 minute and 5 minutes to establish the score, especially in relation to muscle tone and reflex irritability. The latter is usually elicited by firmly stroking the sole of the foot; the appropriate response to this stimulation is a vigorous cry.

Recording the Apgar score serves two purposes. First, it ensures a careful evaluation of the baby during the immediate newborn period. Second, it helps to determine the presence and level of CNS depression and whether there is a need to continue resuscitation. In babies who need resuscitation, serial scores measured at 1, 2, 5, and even 10 minutes furnish a semi-quantitative method of recording recovery. The relationship between low Apgar scores and neurologic abnormality later in infancy is not reliable.

The Apgar scoring system produces more than just a number. The presence or absence of individual signs should tell you not just that an infant had an “Apgar 6” but that this score was assigned because certain functions were absent or suboptimal. For example, a baby with congenital neuromuscular disease may score well for heart rate, respiratory effort, and color but poorly for muscle tone and reflex irritability. A preterm infant scores lower than a full-term baby because an immature baby’s muscle tone is always less than that of a normal-term infant.

The accurate diagnosis of perinatal asphyxia is not easy and requires not only evaluation of the clinical condition at birth but also evaluation of umbilical cord arterial blood gases and subsequent clinical neurologic sequelae in the newborn period (hypoxic-ischemic encephalopathy). Low Apgar scores may be caused by many conditions affecting the baby, such as sepsis, neuromuscular disorders, and perinatal asphyxia.

The second examination

The best place to carry out the second physical examination is in the mother’s room, preferably with both parents present. Having the parents there makes it possible to obtain further history details, complete the initial physical examination, answer questions on the spot, demonstrate and discuss normal variations or abnormalities discovered during the physical examination, and offer some valuable anticipatory guidance. This second, more thorough examination should be conducted within the first 12 hours of life. It is designed to identify congenital malformations, ascertain that adaptation to extrauterine life is proceeding normally, and detect any prenatally or perinatally acquired illnesses. The sooner it is performed, the happier the parents will be.

The third examination

The main purposes of the third examination are to discover postnatally acquired problems, such as infection and excessive jaundice, and to detect any malformations that were not apparent at the first or second examination, such as some forms of congenital heart disease whose murmurs are not audible on the first day of life. In past years, the third examination often was performed at 3 or 4 days of age. The current trend toward early discharge of mothers and infants from the hospital means that discharge may occur as early as 24 hours after birth, and discharge is common by 48 hours after a normal vaginal delivery. Thus the third examination often takes place after the mother has been discharged from the hospital. Early hospital discharge guidelines now recommend assessment of a newborn by a health care provider within 72 hours of discharge. However, it is important that this third examination and assessment of the baby’s condition be carried out within the first week of life. The third examination may be performed by a physician or by an experienced nurse or midwife and may take place in the hospital, in the home, or at a clinic or office.

Initially, many of us learned how to perform a physical examination with cooperative adult patients, in whom it was easy to start at the top of the head and work downward in a systematic cephalocaudal manner. Because infants are not always cooperative, you must be prepared to examine a newborn infant thoroughly but to keep the sequence of procedures flexible. For example, if the baby is resting quietly, first listen to the heart and chest, then palpate the abdomen. Carry out other parts of the examinations when the baby is active, moving, or even crying, but be sure to examine all systems and record the findings systematically.

Asymmetric tonic neck response

Assess for the asymmetric tonic neck response by turning the baby’s head from midline to one side and noting the arm’s gradual extension on the side to which the head is turned, along with flexion of the other arm. The position resembles the classic fencing or boxing posture. Because of this reflex, it is important to ensure that the baby’s head is midline before you elicit any of the other responses.

Moro reflex

Newborns often demonstrate the Moro, startle, or embrace reflex spontaneously when they are suddenly moved, exposed to a sudden loud noise, given the feeling of falling, or feel unstable on a flat surface. You can most reliably elicit this reflex by allowing the infant’s head to drop (while supporting it gently) below the level of the rest of the body while the baby is in a reclining position. The baby extends the arms suddenly and rapidly with the hands open, then brings them back together more slowly in a movement that looks like an embrace. The initial rapid movement may be accompanied by a grimace or cry (Fig. 4–3). Symmetry of movement is important. Weakness of one arm (e.g., in an infant with brachial plexus injury) results in an asymmetric Moro reflex.

FIGURE 4–3 Induce the Moro or “embrace” reflex by giving the infant the feeling of falling. The response begins with a sudden extension of the arms and legs (A), which is followed by a slower embracing movement in which the arms are brought together (B). The Moro reflex is sometimes accompanied by a cry.

Palmar grasp

Find the palmar grasp by placing your index fingers in each of the baby’s open hands; the baby’s fingers should close around your fingers with strength enough to lift the baby’s body part of the way off the bed or table (Fig. 4–4).

FIGURE 4–4 In the newborn, the prehensile grasp of the fingers is often strong enough to support the baby’s weight.

Plantar grasp

A strong plantar grasp usually can be demonstrated if you place your thumb on the sole of the baby’s foot in the space under the toes (Fig. 4–5).

FIGURE 4–5 The plantar grasp typically is strongest in the newborn period.

Placing and propulsive (stepping and walking) reflexes

Holding the baby upright, touch the dorsum of the feet to the bed or a table, and it will seem as if the baby is trying to walk. Parents are invariably fascinated and delighted by the demonstration that their newborn baby can “walk.”

If there is any doubt about the integrity of the baby’s CNS, either because of the history (difficult labor, delivery, traumatic procedures, or birth asphyxia) or because of associated physical findings, such as an abnormal cry, major deformities, or malformations, a more complete neurologic examination should be conducted (see Chapter 13).