For most infants, the first physical exam occurs several hours after birth.  For complicated deliveries, the Pediatrician may be present at the delivery itself.  Upon delivery of the infant, the newborn is immediately dried and warmed.  The baby is monitored for normal breathing and vital signs.  Infants are evaluated by a nurse or other practicioner immediately after birth.  APGAR scores are often used to measure the baby's performance at 1 minute, 5 minutes, and 10 minutes after birth.  If there are no complications, the baby may be placed in the mother's arms and may breastfeed as soon as the infant and mother are ready.  Infants are taken to the newborn nursery for the first bath and for evaluation by a pediatrician.

When is a baby evaluated after an uncomplicated delivery?

For a routine delivery, C-section or vaginal, the infant is evaluated by a nurse, nurse practitioner, or other medical personnel immediately after birth.  If the transition goes well, the infant is delivered to the newborn nursery for a bath and warming.  The pediatrician is typically required to evaluate the infant within the first 24 hours of life.  If the newborn nursery staff is concerned about the baby's progress, a physician may be called at any time.

When is a baby evaluated after a difficult delivery?

In some cases, a pediatrician may be called to attend the delivery itself.  Most hospitals are equiped with an emergency response team to respond to newborn infants in distress.  Infants who show evidence of distress, difficulty breathing, or other problems may be sent to a neonatal intensive care unit for close monitoring.

What occurs during a newborn physical exam?

Vital signs

All infants have routine vital sign checks starting at birth (i.e., temperature, heart rate, breathing rate, blood pressure, blood sugar).  Infants are measured for length, weight, and head circumference.

Maternal and pregnancy history

The physician will review the chart for possible complications (i.e., maternal diabetes, maternal infections, maternal blood type and Rh factor mismatch - compared to umbilical cord blood)

General observations

Pediatricians are trained to form a quick opinion about the general status of a patient immediately upon entering the room.  Is the infant pink?  Is she moving?  Does she respond to touch?  Is the breathing rate appropriate?

Skin

Is the skin pink?

Pink is good.  Blue and pale may indicate poor blood supply, inadequate breathing, or poor heart function.  It is normal for newborns to have blue hands and feet (i.e., acrocyanosis).  It may also be normal for infants to have blotchy red or pink skin areas also.

Jaundice?

Yellow skin color (i.e., jaundice) is caused by excess bilirubin in the blood.  Bilirubin is a normal byproduct of red blood cell recycling.  The liver normally converts bilirubin into a form which can be eliminated in the bile (leading to the green, yellow or brown color of poop).  If liver function is slow or too many red blood cells are broken down quickly (i.e., hemolysis), the bile levels in the blood may become too high. This leads to jaundice.  Jaundice may also affect the white parts of the eyes, and this is called scleral icterus.

Rashes?

There are many rashes that affect newborn infants.  Most of these rashes are harmless.  Open sores or bruise-type rashes may represent a more serious problem.

Bruising?

Difficult deliveries may lead to bruising or petechiae (small pinpoint bruises).  Excess or unusual bruising may represent illness or a clotting disorder.  Did the infant receive the normal dose of vitamin K after birth?

Head

Head shape?

Infants, especially those born vaginaly, may have abnormally shaped heads.  Newborns are born with skulls that are made of plates of bone which can bend and even overlap to allow passage through the birth canal. 

Fontanels?

Infants have normal soft spots in the skull between the plates of bones.  These areas are caused by underdeveloped areas of skull that allow the skull to be reshaped during the birth process (i.e., called molding).  Without these soft areas and moveable plates of bone, many newborns would become stuck in the birth canal due to the mother's pelvis.  A bulging fontanel may be due to increased brain pressure.  A sunken fontanel may be due to dehydration.

Signs of trauma?

Is there a sore at the site of a scalp lead placed during labor or delivery?  Is there a soft, mushy mass on the top of the head due to excess fluid (i.e., caput succedaneum) or bleeding under the skin (i.e., cephalohematoma).

Eyes

Does the infant open her eyes and look around normaly?

While infants are born nearsighted, they should recognize light and dark and human faces.  Newborn infants do not track well (i.e., follow objects moved in front of the face).

Are the eyes symmetric?

The eyes should be lined up appropriately.  This is best determined by looking directly at the infants face and determining if the light reflections on the eyeball are in the same location on both sides.  The eyelids and lashes may normally be slightly asymmetric.

Are the eyelids swollen or red?

Eyelid swelling in newborns is normal.  Most infants should still be able to open the eyes however.  The eyes should be inspected for excess swelling, redness or discharge that may represent an eye infection or eye irritation.  Infants are given antibiotic eye drops (or a gel) after birth.  This medicine may cause irritation in some newborns.

Is there a normal red reflex?

A physician should check your infant's eyes with an opthalmoscope (i.e., a device with a light and magnifying glass designed to look in the eyes).  The physician should check to see if the eyes have a normal red reflection from behind the pupil.  This is the same effect caused by the flash bulb of your camera when you take a picture of someone and the photograph shows bright red pupils.  If there is a mass in the eyeball (i.e., retinoblastoma) or abnormal cloudiness of the clear parts of the eye (i.e., cataracts), the red reflex may be absent or appear white.

Ears

Are the ears in normal position?

Abnormal development or position of the ears may represent an isolated finding or may be part of a genetic syndrome.  Newborn ears are often normally bent in funny positions for several days after birth due to compression in the uterus before birth.

Is the infant's hearing normal?

Infants undergo hearing tests in the newborn nursery.  A device is placed in the ears and sound waves are measured as they bounce back and forth from the ear drum.  Infants are born with near normal hearing and should startle when they hear a loud noise (i.e., if the physician claps her hands in front of the infant's face).

Nose

Does the nose have a normal appearance?

Many newborns have noses that are bent or compressed due to compression in the uterus prior to birth.  The appearance of the nose should return to normal after a day or two.

Are the nostrils patent (i.e., open)?

Newborn infants breathe through their noses, unless they are crying.  A physician can simply place a finger over each nostril to see if the infant can continue to breathe through the other nostril normally.  If there is uncertainty about whether a nostril is open, a catheter (a thin rubbery tube) can be passed through the nose to check.  Choanal atresia is a condition where one or both nostrils are blocked by tissue or bone.

Mouth

Is there a cleft lip or palate?

A cleft lip is usually visible from the outside.  To detect a cleft palate, your physician can put a gloved finger in your baby's mouth to feel the roof of the mouth for abnormalities.

Are there any teeth?

Newborns occasionally are born with teeth.  These teeth can fall out and drop into the lungs if they are not removed.

Heart

Is the heart rate and rhythm normal?

A newborn infant's heart rate should be around 120 - 160 beats per minute.  Fast and slow heart rates may indicate a medical problem.

Is there a heart murmur?

All infants are born with a hole in the heart wall called a foramen ovale and a connection between the big blood vessels called a ductus arteriosus.  These connections normally close shortly after birth.  As these connections are closing, they often create a sound that may be detected with a stethoscope as a heart murmur.  Most newborn murmurs resolve after 1-2 days.  If the heart murmur persists or the infant is not thriving, she may require a more thorough evaluation.

Are the pulses normal?

Baby pulses can be felt in the upper arms (i.e., brachial pulses), creases of the legs (i.e., femoral pulses), and other locations.  It is important for your physician to feel for the femoral pulses to make sure there is adequate blood pressure to the legs.  Weak pulses in this area may indicate a narrowing of a big blood vessel (i.e., aortic stenosis).

Abdomen

Is the belly soft?

A baby's belly should feel soft.  There is often a lot of air in the intestines from air swallowing after birth.  There should be no abnormal masses in the belly. 

Is the umbical cord stump normal?

There should be 3 visible vessels in the umbilical cord stump.  There should not be any abnormal bulging or redness around this area.

Genitalia/anus

Is the anus in normal position?

The anus should be in a normal position.  A rectal thermometer should pass easily through the anus.  There should not be any deep pits or abnormal holes in the skin.

Males - Does the penis appear normal?  Are the testicles in the scrotum?  Abnormal swelling?

Newborn infants normally have swollen genitalia.  The penis should be visible and longer than about 1cm.  The testicles should be felt within the scrotum.  Testicles that are not felt in the scrotum may have not developed normally (i.e., undescended testicles) and may require surgery in the future.

Females - Abnormally large clitorus? Abnormal swelling?

Newborn infants normally have swollen genitalia. The clitorus may appear large at birth but should not have a penis-like appearance.

Musculoskeletal

Are the legs and arms normal?

Leg and arm length should be the same on both sides.  Joints should bend freely. 

Is the back normal?

The back should be inspected for abnormal birthmarks or dimples that may represent an underlying spinal abnormality (i.e., spina bifida).

Are the feet and hands normal?

Extra fingers and toes may have to be removed.  Severe club feet may require bracing or surgery.

Are the hip joints normal?

The hip joints should be tested for dislocation.

Neurologic

Does the infant have normal reflexes?

The Moro reflex is a normal startle response that can be tested with noise or with a slight lift and release maneuver over a soft matress.

Does muscle movement appear normal?

The arms and legs should be tested for free movement and strength.

Bookmark with: