2. A normal neonate for the purpose of this guideline has
been defined as:
Birth weight greater than or equal to 2500 g
Gestation greater than or equal to 37 wk
Birth weight between 10th to 90th percentiles
on a standard intrauterine growth chart
No need for assisted ventilation or beyond for
resuscitation at birth
Apgar score greater than or equal to 7 at 1
minute
No postnatal illness such as respiratory
distress, sepsis, hypoglycemia or polycythemia
or requiring admission in neonatal unit
3. What are issues of concern in
the first few hours of birth in
normal newborn?
4. • Cleaning of the baby: All infants should be
cleaned at birth with a clean, sterile cloth to
remove blood clots and/or meconium present
on the body. One should not attempt to remove
vernix from the body by any means, as it can
result in trauma to skin and increase chance of
infections
• Baby Identification marking: Each infant
must have an identity band containing name of
the mother,hospital registration number, gender
and birth weight of the infant.
• Recording of weight: All the infants should be
weighed at within one hour of birth on a scale
with at least 5 gm sensitivity.
5. • Administration of Vitamin K: Vitamin K in
dose of 1 mg to term and 0.5 mg to preterm
infants must be routinely administered
intramuscularly to all neonates to prevent
vitamin K deficiency bleeding.
• Stomach wash: There is no role of routine
stomach wash after birth to prevent any kind
of gastritis. If the infant is born through
meconium stained liquor, the stomach may be
aspirated to remove the content to prevent
vomiting in early neonatal period.
6. • Examination at birth: The infant should be
examined thoroughly for cardio-respiratory
stability,malformation or trauma and
determination of gestation at birth using a
predesigned proforma.
• There is no need for routine passage of
catheter in the stomach for detection of
esophageal atresia, in the nostrils for detection
of choanal atresia or into the rectum for
detection of anorectal malformation.
• Body temperature to the infant must be
recorded by axillary route using electronic
thermometer. If mercury thermometer is used,
temperature should be recorded for 3 minutes.
7. • Prevention of tetanus: If mother has not
received adequate tetanus immunization during
pregnancy, the infant should be given a
tetanus toxoid dose and concurrent tetanus
immunoglobulin 250 IU intramuscularly to
prevent tetanus neonatorum.
• Rooming in: There is no indication for
separating a normal infant from the mother for
routine observation in the nursery, irrespective
of the mode of delivery.
• During initial couple of hours after birth,
infants are awake and very active and this
opportunity should be utilized for bonding and
initiation of breastfeeding.
8. • Initiation of breastfeeding: The
breastfeeding must be initiated as early as
possible within one hour of birth.
• Communication with the family: The health
provider attending the birth of the infant must
communicate with the mother and other family
members regarding time, weight at birth,
gender and well being of the infant.
• The infant should be shown to the family with
particular attention given to the fact that family
members get to know the gender and about
the identity tag on the infant. This would avoid
any confusion with legal implications regarding
identity and gender of the infant.
10. • Cord care: The umbilical cord must be kept
open and dry. The nappy should be folded well
below the umbilical stump
• Eye care: Eyes of the infant must be cleaned
with a sterile swab soaked in normal saline or
sterile water.Clean from inner to outer canthus
and use a separate swab for each eye.
• Exclusive breastfeeding
• Oil massage: Oil massage is a low cost
traditional practice well ingrained in Indian
culture . However, a paucity of data still exists
as to what oil should be used for this purpose .
11. • Evaluation for jaundice: All the infants must
be examined for the development and severity
of jaundice twice a day for first few days of life.
Visual assessment in daylight is the preferred
method.
• Vaccination: All the infants must be offered
the immunization at birth, before discharge, as
per their state policy.
• Bathing: Routine bathing in the hospital
should be avoided in view of risks of cross
infection and hypothermia.The infant can be
sponged, as required. Infant can be bathed at
home once discharged from the hospital.
12. • Sleep Position: All healthy neonates who are
born at term and have no medical
complications should preferably be placed
down for sleep on their back
• Traditional practices: A variety of traditional
practices are common place in India. These can
be beneficial such as oil massage,
inconsequential such as putting black mark on
forehead. However there are a variety of
harmful traditional practices such as applying
kajal/surma in eyes , putting oil in ear,putting
boric acids in nostrils or applying substances
such as cow dung on cord must be actively
discouraged.
14. Ideally infant should be discharged after 72-96 h once all
the following criteria are fulfilled:
• Infant is free from any illness including significant
jaundice
• The infant has been immunized
• Adequacy of breastfeeding has been established.
• Mother is free from any significant illness and confident
to take care of her infant.
Early discharge (within first 24 to 48 h): This can be
considered for non-primigravida mothers with prior
breastfeeding experience and who fulfill the above
mentioned criteria before discharge. However
primigravida mothers should not be discharged before
72 hr in order to ensure adequate breastfeeding.
15. Adequacy of breastfeeding has been
established. This must be assessed in all
infants and the same would be indicated by
passage of urine at 6 to 8 times/24 hr,
onset of transitional stools,
baby sleeping well for 2-3 h after feeding.
If there is any concern about adequacy of
breastfeeding, the infant can be weighed on
the same weighing scale that was used to
weigh the infant at birth.Excessive weight loss
(normal 8-10% of birth weight by 3-4 days of
age) would indicate inadequate breastfeeding.
16. Art of newborn examination
Immediately after resuscitation
aimed at r/o congenital malformations
Examination of normal newborn
Gestational age assessment
Neurological examination of newborn
Problem oriented clinical approach
i.e. Resp distress, neonatal jaundice etc.,
17. History
THE FAMILY, MATERNAL, PATERNAL, PREGNANCY & PERINATAL
HISTORY SHOULD BE REVIEWED
FAMILY HISTORY:-
Inherited diseases (e.g.Metabolic disorders,
hemophilia, cystic fibrosis, H/o perinatal death)
Maternal history
Age/bld group
Maternal illness/PIH/RHD/diabetes
STD including HIV status
Recent infections/exposure
18. Mother’s & Infant’s Records
Items of particular relevance in the mother’s and infant’s
medical & nursing records are
Maternal age, occupation, and social background
Family history
History of maternal drug or alcohol abuse
Details of previous pregnancies & any medical problems
experienced by those children
History of maternal disease & drugs taken during
pregnancy
19. Mother’s & Infant’s Records (contd..)
Results of pregnancy screening tests (e.g., blood tests
including maternal syphilis & hepatitis B surface antigen,
prenatal ultrasound scans)
Results of special diagnostic procedures (e.g.,
amniocentesis, chorionic villous sampling)
Problems during labor & delivery
Infant’s condition at birth & if resuscitation was required
Any concerns about the infant from nursing staff or
parents
The infant’s birthweight
The gestational age & if there is any uncertainty about it
The Infant’s gender
20. Drug History
* Medications * Alcohol
* Drug Abuse * Tobacco
Current Pregnancy
Probable gest. age
Quickening (16-18 wks)
Results of fetal testing
Poly/oligohydramnios
Infection/surgery/PIH
Glucocorticoids/antibiotics/tocolytics
History (contd..)
24. Prevalence of Serious Congenital Anomalies
(per 1000 live births)
ANOMALY PREVALENCE
Congenital heart disease 6-8 (0.8 identified in the
first day of life)
Developmental dysplasia of the hip 0.8 (about 7/1000 have
an abnormal initial
examination)
Talipes equinovarus 1.5
Down syndrome 1.5
Cleft lip & palate 0.8
Urogenital (hypospadias, undescended
testes)
1.2
Spina bifida/anencephalopathy 0.5
25. Objectives of Routine Examination of the Newborn
Detect congenital abnormalities not already
identified at birth (e.g., congenital heart disease &
developmental dysplasia of the hip)
Determine if any of the wide range of non acute
neonatal problems are present & initiate their
management or reassure the parents
Check for potential problems arising from maternal
disease, familial disorders, or problems detected
during pregnancy
Provide an opportunity for the parents to discuss
any questions about their infant
Initiate health promotion for the newborn
27. First physical examination
First overall visual & auditory appraisal of naked
infant is most informative
Some part of clinical assessment is worthless
(Chest percussion)
Comprehensive examination visually takes 5-7 mts
28. First physical examination (contd…)
Initial Examination aimed at
Whether any congenital anomalies present.
Whether infant has made placental transition from “water
breathing” to “air breathing”.
To what extent gestation, labor, delivery, analgesics have
affected the newborn.
Whether he or she has any sign of infection or metabolic
disease which was unsuspected.
29. General examination
Examine Neonate unclothed
Explore ideal time for examination
Just before scheduled feed
Appreciate Transient Skin Lesions
Erythema toxicum
Milia
Neonatal pustular melanosis
Epstein pearls
Mongolian spots
Visualize opening at either end
Watch out for jaundice
38. Head, Neck & Mouth
OFC at term 33-36 cms.
Caput succedaneum V/s Cephalhematoma
Minor moulding of skull bones - normal.
Craniotabes common in post matured babies.
Normally two, occasionally six fontanelles felt.
Check neck for range of motion, goiter & cystic
swelling.
Check in the mouth-cleft lip/palate, natal tooth,
clefts, Epstein’s pearls.
40. Eye examination
Physiological photophobia limits eye
evaluation in the newborn
Mild lid edema, matting of eyelids common
Sub-conjunctival hemorrhages, corneal
haziness in preterm are of no concern
Nystagmus, squint doesn’t warrant
immediate evaluation
41. Cardiorespiratory system
Color is probably single most important index of the cardiac
status
RR is 40-60/min, & most infants are periodic rather than regular
breathers
Be familiar with sequential changes during cardiopulmonary
adaptation
Normal H.R.-120-160/min & always feel femoral along with upper
limb pulses
Presence of a split S2 may be reassuring
Murmurs mean less in the newborn than at any other time
42. Features of a Heart Murmur in a Neonate
Features of an Innocent Murmur
Soft (grade 1/6 or 2/6) murmur at left sternal edge
No audible clicks
Normal pulses
Otherwise normal clinical examination
Features Suggesting a Murmur is Significant
Pansystolic
Loud (≥ grade 3/6)
Harsh quality
Best heard in the upper left sternal edge
Abnormal second heart sound
Femoral pulses difficult to feel
Other abnormality on clinical examination
43. Abdominal examination
See through phenomenon because of poorly
developed abdominal musculature
Liver usually palpable
Upper pole of kidneys often palpable for first two
weeks
Small umbilical hernia-normal phenomenon
Any palpable abdominal lump is renal in origin
unless proved otherwise.
46. Genitalia and Rectum
MALE BABIES
Marked phimosis, hydrocele normal Phenomenon
Pendulous scrotum indicates euthermia
Length & width of penis should be noted
FEMALE BABIES
At term enlarged labia majora
occasionally mucosal tag
Pseudomenses & white discharge
ANUS & RECTUM should be checked for patency,
position & size
47. Extremities, Spine & Joints
Anomalies of the digits, club feet & hip
dislocation (CDH) are common
Mild tibial bowing- normal phenomenon
Check CDH by detecting clicks
Check spine for dimple, sinuses, tuft of
hair
48. Absolute Risk for a Positive Result on Routine
Examination of the Newborn Hip
NEWBORN
CHARACTERISTICS
ABSOLUTE RISK OF A
POSITIVE EXAMINATION
PER 1000 NEWBORNS
Over all
All newborns 11.5
Boys 4.1
Girls 19
Positive Family History
Boys 6.4
Girls 32
Breech Presentation
Boys 29
Girls 133
49. Developmental dysplasia of Hip-Algorithmic approach
Physical exam
Positive
Physical exam
inconclusive
Refer to orthopedist
Do not use triple diapers
Follow-up examination at 2
weeks
Physical exam
normal but risk
factors
Female or
Family history + male
Family history + female
or
Breech + male
Breech + female
Recheck at periodic intervals
Optional imaging:
*ultrasound<5 months old
*x-ray >4 months old
Imaging (see above)
51. Neurological examination
Undertake it in state III or IV - Pretchl scale of
wakefulness
Assess cranial nerves during crying
Differentiate normal v/s pathological cry
Elicit minimum reflexes(DTR) & plantars often
extensor
Bare minimum neonatal reflexes
Moro’s reflex
Plantar/Palmar grasp
Placing & stepping reflex
54. Discharge examination
At discharge, Newborn should be reexamined with
following points in mind
Heart - development of murmur, cyanosis or
failure
CNS - activity, sutures, fullness of fontanelle
Abdomen - any masses previously missed, stool &
urine output
Skin - jaundice, pyoderma
55. Cord - Infection
Infection - Any signs of sepsis
Feeding - spitting, vomiting, distension, Wt.gain
Maternal competence - to provide adequate care
PRACTISE IDEAL PERINATAL DISCHARGE POLICIES (D5)
Discharge examination (contd…)
56. Danger signs
Summary
Not cried for 5 mts
Respiratory distress Jaundice D1, palm
& sole stains
Convulsion
Bleeding Neonate
Temp <36° C
Wt. <1500gms
Gest age <32 wks
DO NO HARM
STRIVE FOR INTACT SURVIVAL
BABY
Vomiting/Diarrhoea
Abdominal distension
