As soon as a child has been born, its condition is assessed using the Apgar score, as described earlier. If the child has a good Apgar score, a systematic physical examination is performed. This examination usually takes place within two hours of the birth.
Conditions
The child must be completely undressed and be examined in a warm room or under a heat lamp. If the examination takes place in too cold an environment the child will cry and the muscle tone will increase. Before the examination the examiner should wash their hands. The structured examination comprises several general checks (inspection, weighing, measurement and taking the temperature). After that the neonate is examined caudally to cranially. The least pleasant examination for the baby should preferably take place last. Continually note your findings.
General inspection
Carry out an overall inspection of the child. Note the following:
- proportions
- motor function
- muscle tone
- evident congenital abnormalities
- colour (reddish-pink, cyanosis, jaundice, anaemia)
- oedema
- haematomas
- petechiae
- erythema toxicum (urticaria neonatorum)
- Mongolian spot
- vernix caseosa
- lanugo hair.
Weighing
Determine the weight of the naked baby.
Measurement
- Determine the length using a measuring tape.
- Place the measuring tape with the zero against the wall.
- Place the child with its back on the measuring tape and the crown against the wall.
- Make sure that the head remains lying against the wall (helper).
- Carefully stretch both legs as far as possible at the hips and the knees.
- Make sure that the feet are perpendicular to the lower legs.
- Place the heels on the tape and read off the length.
Measuring the temperature
- Measure the temperature rectally (preferably with a digital thermometer).
- Wait until the temperature indication no longer rises.
- Read off the correct temperature.
Examination of the head
Measuring the size of the head
- Measure the circumference of the skull.
- Place the measuring tape over the occipital protuberance.
- Place both sides around the skull above the eyebrows (frontal-occipital circumference).
- Read off the measurement.
Inspection and palpation of the head
Note the following:
- shape (enlarged, asymmetric)
- head
- cephalic haematoma
- cranial sutures (yielding, overriding, moulding, mobility of the scalp bones with respect to each other)
- large and small fontanel (dimensions, sunken, level, bulging, tense).
Inspection and palpation of the face
Note the following:
- asymmetry
- colour (pinkish-red, pale, perioral cyanosis, jaundice)
- milia
- naevus unna (stork bite mark), naevus flammeus (port wine stain), cavernous haemangioma.
Inspect in turn:
- eyes: shape, position (strabismus), epicanthal fold
- ears: shape, position, auricular appendages, implantation position, external auditory canal
- nose: shape, nasal flaring
- mouth: shape, lips (colour), symmetry, disFigurement (harelip)
- tongue: size, colour, frenulum of the tongue. With the little finger palpate whether the palate is whole (cleft palate) and note any submucous defects. At the same time assess the sucking reflex.
The examination of the neck
Note the following:
- asymmetry
- position of the head with respect to the trunk (torticollis)
- swellings (goitre)
- palpate towards both sternocleidomastoid muscles.
Examination of the thorax
Inspection
Note the following:
- shape (pectus excavatum or carinatum)
- skin, colour
- mammary gland swelling
- clavicles (position, discontinuity)
- breathing movements: frequency, regularity, grunting, stridor, accessory muscles of respiration (nasal flaring), retractions
- pulsations (ictus).
Palpation
Note the following:
- bony structures of the thorax (clavicles, ribs, sternum)
- tenderness and swellings
- apex beat – note the following:
- position (on the midclavicular line at the height of the 4th intercostal space)
- frequency (90-160)
- surface
- duration
- character.
Auscultation
Auscultation of the newborn’s heart and lungs provides a lot of information and is, therefore, vitally important. The examination should preferably be performed on a sleeping baby using a stethoscope with a small cup. Warm up the stethoscope to body temperature. A cold stethoscope might frighten the baby causing it to cry. Listen to the heart at the following locations:
- left 4th intercostal space at the height of the midclavicular space
- left 4th intercostal space at the height of the parasternal line
- left and right 2nd intercostal space parasternally
Initially murmurs can still be heard as Botalli’s duct only closes after several days.
Auscultation of the lungs, anterior and posterior.
Note the following:
- frequency (40-60)
- rhythm (regularity)
- depth
- quality (puerile: sharpened breath sound)
- rhonchi (pathological)
- crepitations (this is physiological immediately after birth)
Auscultate the heart.
Note the following:
- rate (90-160)
- rhythm (regularity)
- heart sounds (first and second sound)
- murmurs
- position in the heart cycle (systolic or diastolic)
- point of maximum intensity
- volume
- character.
After this examination the pulsations of the femoral arteries in both groins should be palpated.
It is not necessary to take the newborn’s blood pressure.
Percussion
Percussion plays a minor role in the examination of the newborn’s thorax. Both comparative and topographic percussion can be performed, but both approaches only provide global information about the lungs and the lung-liver boundary.
The heart size cannot be reliably determined by means of percussion.
The examination of the abdomen
Inspection
Note the following:
- skin
- abdominal respiration
- umbilical stump (insertion site, infection)
- shape (swollen, collapsed)
- breathing movements
- umbilical hernia
- peristalsis.
Auscultation
Not necessary.
Percussion
To be performed:
- global percussion. Note the following: varying tympany in all abdominal regions; dullness (bladder).
- percussion of the liver and spleen. These are relatively large compared to adults. The liver is located two fingers under the ribcage and the spleen just beyond the anterior axillary line.
Palpation
Note skin turgor. Do this by taking a fold of skin between the fingers; this effaces immediately in the case of a good state of hydration. With careful palpation, the edge of the liver can be felt just under the right costal arch.
Procedure
- Place the fingers of the palpating hand against the lateral edge of the rectus abdominis muscle, 2 cm below the point where the edge of the liver was palpated.
- Press the abdominal wall gently and move the fingers cranially.
- Palpate the edge of the liver and note the consistency.
The spleen is not palpable unless the abdominal wall is very frail.
The kidneys can be palpated quite easily during the first two weeks.
Procedure
- Place the non-palpating hand at the back of the flank.
- Place the palpating hand on the abdominal wall.
- Bring both hands carefully towards each other.
- Palpate the right and left kidney separately.
- Assess the size and the surface.
The examination of the external genitals
The external genitals are relatively large in newborns, particularly following a breech birth as this region was the presenting part during the delivery. As a result of congestion, the external genitals are sometimes so swollen after a breech birth that a thorough examination can best take place several days later once the swelling has subsided.
The male external genitals
Penis
The prepuce is often still attached to the glans. This is a physiological phenomenon (phimosis). Pushing back the prepuce is contraindicated.
Inspect the penis. Note the following:
- shape
- size
- prepuce
- epispadias, hypospadias.
If necessary, try to push the prepuce back slightly to the mouth of the urethra. Note the following:
- urethral opening (epispadias, hypospadias)
- glans penis.
Scrotum
In neonates the scrotum is relatively large. The testes are usually descended but are often retractile. Standard practice is to make a record of the findings after palpation of the testicles and to pass this information on to the GP.
Inspect the scrotum. Note the following:
- size
- symmetry
- skin
- swellings (hydrocele).
Palpate the scrotum. Note the following:
- testicles (descended)
- swellings (hydrocele).
If the testicles are not palpable, carry out the following examination.
Procedure
- With a finger stroke from the groin area in a downwards motion, bringing the retractile testicle into the scrotum.
- Palpate the testicle brought into the scrotum with the fingers of the other hand.
- Repeat this examination on the other side.
If a suspected hydrocele swelling is felt in the scrotum, it should be further examined by means of transillumination. A congenital hydrocele usually disappears spontaneously over the course of several weeks to months.
Procedure
- Darken the room.
- Stretch the swelling felt in the scrotum between the two fingers of one hand.
- Take a lit torch in the other hand.
- Hold the torch against the back of the scrotum at the height of the swelling.
- Note whether the swelling allows light to pass through and whether it lights up clearly.
The female external genitals
Inspect the external sex organs. Note the following:
- labia major (relatively large)
- labia minor (as above, sometimes stuck together slightly)
- discharge
- mucus
- blood
Spread the labia minor. Note the following:
- urethra opening
- clitoris
- vaginal orifice.
Perineum and anus
Examine the anus and premium of both male and female newborns. Note the following:
- swellings
- open anus (atresia); the anus will be open if the child’s temperature is measured rectally.
The examination of the back and extremities
The examination of the back
The baby should lie on its abdomen on a flat surface with the nose and mouth free or on the examiner’s left hand and forearm.
Inspection
Note the following:
- asymmetry
- shape of the spine
- skin:
- colour
- port wine stain
- pigmented naevus
- cavernous haemangioma
- Mongolian spot
- open spina bifida.
Palpation
Palpate the entire back, especially the median line and note defects (spina bifida occulta).
The examination of the upper extremities
Inspection
Note the following:
- position (flexion predominates over extension)
- paresis/paralysis
- mobility
- skin
- colour
- palm lines (Down’s syndrome)
- fingers (number, shape, syndactyly).
Palpation
Palpate both arms and hands and note swellings and defects.
The examination of the lower extremities
Inspection
Note the following:
- position (flexion predominates over extension)
- length with respect to each other (feet flat on the ground and knees at the same height)
- paresis/paralysis
- mobility
- skin
- colour
- skin folds
- gluteal cleft symmetry
- position of foot with respect to lower leg
- toes (number, shape, syndactyly).
Palpation
Examination for congenital hip dislocation.
Procedure
- Bend the neonate’s knees by 90°.
- Take hold of both upper legs.
- Place your thumbs on the inside of the upper legs.
- Place the tops of your index and middle finger on the neonate’s greater trochanter.
- Abduct both upper legs carefully. Note the following:
- movement trajectory
- symmetry.
The neurological examination
For this examination refer to the ‘The Neurological Examination – The examination of the newborn (0-4 weeks)’.