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CHAPTER 5 Immediate Newborn Care After Birth
109
FIGURE 5.9 Male genitalia and gestational age. A, Age 28 to 35 weeks of gestation. B, Term. C, Age 42 or more weeks of gestation.
A B
FIGURE 5.10 Female genitalia and gestational age. A, Age 30 to 36
weeks of gestation. B, Term.
determine neonatal mortality risk, generate a problem list of potential morbidities, and quickly initiate
appropriate supportive care as well as screening procedures and/or interventions for recognized morbidities.
NEWBORN CLASSIFICATION
The neonatal population can be classified by the use
of BW, GA, fetal growth pattern, and a combination
of all of them into the following categories:
By Birth Weight.
• Normal birth weight (NBW): 2501 to 3999 g
• Excessive birth weight (EBW): 4000 g and above
• Low birth weight (LBW): 2500 g or less, with
the following subcategories: moderate low birth
weight (MLBW): 1501 to 2499 g, very low birth
weight (VLBW): 1500 g or less, and extremely
low birth weight (ELBW): 1000 g or less
By Gestational Age.
• Full-term (FT): 37 to 41
6/7
weeks (259 to 293
days)
• Postterm (PoT): 42 or more weeks (294 or more
days)
• Preterm (PT)44: Less than 37 weeks (36
6/7
weeks
or less than 259 days), with the following subcategories: late preterm (LPT): 34
0/7
to 36
6/7
weeks
(238 to 259 days), moderate-severe preterm
(MSPT): 28 to 33
and extreme preterm (EPT): 27
6/7
weeks (196 to 237 days),
6/7
or less weeks
(less than 196 days)
By Fetal Growth Pattern. Using the intrauterine
growth chart for the 10th and 90th percentiles,
newborns can be classified as follows: those below
the 10th percentile, SGA infants; those between
the 10th and 90th percentiles, AGA infants; and
those above the 90th percentile, LGA infants.
19
UNIT TWO Support of the Neonate110
Numbers in boxes represent actual percent mortality
Birth weight (g)
6000
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5500
5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
100
0–0.2%
0.2%–1%
1%–3%
3%–10%
10%–20%
20%–50%
50%–85%
85%–100%
100
100
100100
100
0
0
0
0
0
0
100
100
0
100
50
0
33
11
0
6
13
0
50
9
21
9
55
55
36
31
18
23
22
100
100
100
43
42
73
14
67
50
100
100
Risk regions derived using logistic regression of actual data
0
Corrected gestational age (weeks)
0
0
0
0
25
0
3
0
0
0
1
0
3
2
2
0
0
13
1
3
2
5
8
3
9
14
6
5
6
6
5
9
14
0
14
20
25
100
0
50
100
0
0
0
0
0
0
0
0
0
0
.8
0
1
.4
0
.7
.3
0
.9
.5
0
.4
.9
2
0
0
2
5
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3
0
0
0
1
0
0
.2
.1
.2
.4
.2
.2
.1
0
.1
.2
.2
.3
2
1
0
0
1
3
0
4
6
3
29
0
0
8
0
25
0
0
100
0
0
FIGURE 5.11 Neonatal mortality risk by birth weight and gestational age. (From Johnson JL, Merenstein G, Coll J, et al. Colorado
intrauterine growth curve, 1980–1992: the new Lubchenco growth curve. Pediatr Res. 1994;35:274A.)
14
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
.3
0
0
.3
0
0
.5
.7
0
0
0
2
0
0
0
0
0
1
0
0
0
0
0
0
0
0
By combining GA in weeks, BW in grams,
and intrauterine growth pattern, nine categories
of newborns were thus defined (see Fig. 5.4). This
type of classification allows clinicians to anticipate
likely problems in the immediate neonatal period
and potential morbidities in the long term.
NEONATAL MORTALITY RISK
Significant advances in obstetrics and perinatal-neonatal care during the past six decades have resulted
in a remarkable decline in the rate of neonatal mortality (see Chapter 2). Although BW is considered
to be the best predictor of neonatal survival, with
exponential improvement evident with the achievement of optimum BW, it is apparent that neonatal
mortality risk could be predicted more accurately for any individual infant based on the relation
of two factors: BW and GA.
Neonatal mortality risk (NMR), the chance of
dying in the neonatal period, can be determined
19,109
from mortality graphs based on BW and GA,
such as that shown in Fig. 5.11. This figure
was constructed based on the Lubchenco Perinatal
Database, University of Colorado Hospital, 1980 to
1992. Mortality was calculated for each 100 g/1 week
BW/GA block. On the chart, the area of least risk
is the FT-AGA infant. Deviations from this area of
least risk in relation to either weight or GA increase
the newborn’s mortality risk. Further examination
of NMR in Fig. 5.11 reveals that two infants
with the same BW but with different GAs may
have very different risks for death. For example,
infant A may have a BW of 2000 g and a GA of 33
weeks, and shows an NMR of 2%. Infant B, on the
other hand, may also weigh 2000 g but have a GA
of 39 weeks, and shows an NMR of 0.2%. Infant A
thus has a mortality risk 10 times greater than that of
infant B, even though they have the same BW.
Mortality risk has changed over time because
an increasingly physiologic basis of care has been
CHAPTER 5 Immediate Newborn Care After Birth
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111
used, coupled with sophisticated professional care,
improved technology, new treatment modalities, transport systems, and aggressive management to handle increasingly at-risk populations.
Consequently, these neonatal mortality risks need
to be reviewed periodically.
Within the NICHD Neonatal Research Network,
mortality rates for newborns weighing 501 to 1500
g decreased from 23% (1987 to 1988) to 17% (1993
to 1994) to 14% (1999 to 2000) to 12.4% (2000 to
2009). However, within each BW category, survival
free of major morbidity (e.g., chronic lung disease/
bronchopulmonary dysplasia, necrotizing enterocolitis, grade 3 or 4 intraventricular hemorrhage) did
not change significantly. Because mortality (and
morbidity) rates are highest in infants of the
lowest BW and GA, VLBW and ELBW infants
would have more favorable outcomes when
they are born in a facility that can provide the
appropriate subspecialty care.
113,176,208
These
research findings have prompted recommendations that high-risk mothers/infants (e.g., less
than 32 weeks of GA) be delivered/born in
a facility capable of providing the anticipated
appropriate level of perinatal/neonatal care.
NEONATAL MORBIDITY RISK
8,9
Neonatal morbidity risk (Fig. 5.12) is determined
by deviations of intrauterine growth and newborn
classification. Classification of the newborn assists
in identification, observation, screening, and
treatment of the most commonly occurring
problems. For every newborn, formulate a
problem list based on the morbidities common
to the newborn classification. Observe, screen,
intervene, and refer as necessary to prevent
complications.
SGA/IUGR infants are at increased risk
for morbidities such as perinatal depression,
hypothermia, hypoglycemia, polycythemia, and
infection immediately after birth. Full-term
SGA infants have higher morbidities, mortality (including stillbirth), and hospital charges
when compared to other term infants.
72,127
LGA
infants are at an increased risk for more morbidities, including hypoglycemia, polycythemia,
and birth trauma.
126
There is also an associa-
tion between size at birth, altered physiologic
development, and long-term developmental and
health problems (especially heart disease and
stroke).
53
LATE-PRETERM INFANT
In the United States, as a result of shifting distribution of GA among spontaneous live, singleton
births, 39 weeks was found to be the most common
length of gestation.62 Preterm infants are infants
born before 37 completed weeks of gestation
0/7
(37
weeks or day 259). Late-preterm infants refer
to infants born between 34 completed (34
0/7
weeks or day 239) and less than 37 completed
weeks.
6/7
weeks or day 259).69 Early term
171
In 2011, the prematurity rate in the
0/7
weeks and
weeks (36
infants are infants born between 37
6/7
38
United States was 11.7%,81 and two-thirds (8.1%)
of these were due to “late-preterm” births. From
2006 to 2014, birth rates for late preterm and early
term births declined as a direct result of fewer clinician-initiated obstetric interventions.
152
However,
in 2018 the CDC reported that the preterm birth
rate in the United States increased from 9.57% to
9.85% from 2014 to 2016, mainly as a result of
an increase in LPI, especially those at 36 weeks
of gestation.
121
Because late preterm and early
term infants are at increased risk for health and
developmental problems,
147
elective delivery
before 39 weeks is considered a major public
health concern.
95
A 2005 National Institutes of Health (NIH)
meeting
136
adopted the description late-preterm
rather than near-term to reflect the increased
morbidity (and mortality) rates of this group of
biologically and physiologically immature neonates.68 These infants are larger than the usual pre-
mature infants, and they may be treated as mature
infants, but they often manifest signs of physiologic
immaturity in the neonatal period.
Morbidity and Mortality Outcomes
in Late-Preterm Infants
Numerous studies have documented the high
incidence of neonatal complications leading to
neonatal intensive care unit (NICU) admission
(30% to 59%) of LPIs.
found that 10% of LPIs admitted to mother-baby
units required transfer to a higher level of care.
Table 5.7 shows a list of the most frequently encoun-
tered morbidities in LPIs. When spontaneous and
medically indicated late preterm birth are compared,
LPIs born because of a medical indication have a
higher incidence of respiratory complications,
64,69
A multicenter study
124
UNIT TWO Support of the Neonate112
Grams
5000
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4750
4500
4250
4000
3750
3500
3250
3000
2750
2500
2250
2000
1750
1500
1250
1000
750
Increased
mortality
Cause undetermined
Congenital
anomalies
Immaturity of
all systems
Hypotension
Sepsis
Apnea
RDS
Inadequate
calories
Gavage feeding
Jaundice
Bleeding
Hypoglycemia
Congenital
anomalies
IDM
hypoglycemia
RDS
Slow
feeding
Increased
jaundice
Hypothermia
Infection
Hypoglycemia
Congenital
anomalies
Discordant
twin
Small
placenta
Birth trauma
Increased cesarean
rate
IDM
Transposition
of
aorta
Morbidity
caused by
intrapartum
accidents and
congenital
anomalies
Fetal
distress
Hypoglycemia Hypoglycemia
Congenital
anomalies
Congenital
infection
Polycythemia
Increased
cesarean rate
Birth trauma
Postmaturity
syndrome
Fetal distress
Aspiration of
meconium
Congenital
anomalies
(trisomy 16-18,
Seckel’s)
500
24 25
FIGURE 5.12 Specific neonatal morbidity by birth weight and gestational age based on statistics from Newborn and Premature Center
at the University of Colorado Medical Center. IDM, Infant of diabetic mother; RDS, respiratory distress syndrome. (From Lubchenco LO. The
High-Risk Infant. Philadelphia, PA: Saunders; 1976.)
such us transient tachypnea of the newborn, respiratory distress syndrome, persistent pulmonary hypertension of the newborn, respiratory failure, and
respiratory depression requiring resuscitation at
27,64,104,178
birth.
The incidence of these morbidities
increases with decreasing GA. A single-center study
showed that neonates born at 34 weeks of gestation
had the highest risk for morbidities during neonatal
transition to extrauterine life, including need for
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
Weeks of gestation
Preterm Term
Postterm
resuscitation at birth, hypothermia, hypoglycemia,
and NICU admission.64 This confirms the results of
a previous study that also found 34-week GA LPIs
with the highest morbidities.
196
Each additional
week of gestation decreases neonatal morbidity,
mortality, and length of stay.
64,119
With every
additional week of gestation past 35 weeks, there is a
decrease in specific and overall developmental delay
in the first 2 years of life.
67
CHAPTER 5 Immediate Newborn Care After Birth
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TABLE
5.7
MORBIDITY LATE PRETERM FULL TERM LATE PRETERM FULL TERM LATE PRETERM FULL TERM
Temperature
instability
Hypoglycemia 15.6% 5.3% 14.3% 0.6% 46% 1%
Respiratory
distress
Apnea/brady-
cardia
Jaundice/hyper-
bilirubinemia
Sepsis evalu-
ation
Poor feeding 76% 28.6% 39% 1.4%
Intravenous
infusions
MORBIDITIES IN LATE-PRETERM VERSUS TERM INFANTS
WANG ET AL. (2004) LEONE ET AL. (2011) VISRUTHAN ET AL. (2015)
FREQUENCY FREQUENCY FREQUENCY
10% 0% 2.5 % 0.6% 6.7% 0.2%
28.9% 5.3% 34.7% 4.6% 5%*
4.4% 0%
54.4% 37.9% 47.7% 3.4% 87%
36.7% 12.6%
26.7% 5.3% 70% 3%
31%
†
‡
0.1%*
†
3%
†
8%
113
*Respiratory distress syndrome.
†
Transient tachypnea of the newborn.
‡
Requiring phototherapy.
Data from Wang M, Dorer D, Fleming M, et al. Clinical outcomes of near-term infants. Pediatrics 2004;114:372; Leone A, Ersfeld P, Adams M, et al. Neonatal mortality in singleton late
preterm infants compared with full-term infants. Acta Paediatr. 2011;101:e6; Visruthan NK, Agarwal P, Sriram B, Rajadural VS. Neonatal outcome of the late preterm infant (34 to 36
weeks): the Singapore story. Ann Acad Med Singapore 2015;44(7):235.
LPIs not only have more morbidities but
also have been shown to have increased mortal-
ity risk. A report from the Institute of Medicine
in 2005 points out that whereas the mortality
rates for full-term neonates were stable at 2.5
per 100,000 live births, the rate for moderately
preterm neonates (32 to 36 weeks of gestation)
rose from 8.9 to 9.2 per 100,000 live births from
2001 to 2002.
136
A more recent study compared
overall and cause-specific mortality rates between
singleton late-preterm and term infants.
184
This
study concluded that LPIs have higher mortality
rates throughout infancy compared with term
infants. LPI mortality rates were threefold
higher than those of term infants (7.9 vs. 2.4
deaths per 1000 live births).
184
In the first month
of life, when evaluating deaths in the early (1 to
6 days) and late (7 to 27 days) neonatal periods,
mortality rates were six and three times higher,
respectively, for the LPI. Postneonatal deaths were
twice as high as term infants. During infancy,
LPIs were approximately four times more
likely than term infants to die. In another study,
neonatal mortality rates were significantly higher
for LPIs (1.1, 1.5, and 0.5 per 1000 live births at 34,
35, and 36 weeks, respectively) compared with 0.2
per 1000 live births at 39 weeks.
123
A recent secondary analysis of the WHO multicountry survey
on maternal and newborn health found that elective cesarean section was associated with reduced
perinatal mortality and non-significantly associated
with late preterm birth. However, labor induction
was associated with increased late preterm birth
and in less developed countries with an increase
in perinatal mortality.
132
Although the rate of
mortality increases with decreasing GA,40 two
recent studies found the highest mortality
occurring at 37 weeks of gestation.
195,205
BOX
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5.3
UNIT TWO Support of the Neonate114
LONG-TERM OUTCOMES OF LATE PRETERM INFANTS: RESEARCH FROM 2015 TO 2018
Growth
Higher risk for less weight gain and height in first year of life.86 Faster head
growth from 20 to 56 months of age associated with better adult neurocognitive function but not consistently associated with mental health outcomes.
155
Higher Use of Health Care Resources
More hospital readmissions for jaundice, feeding difficulties, respiratory
problems/infections, asthma, diarrhea, fever, and neurologic, and/or mental health problems from infancy
86,89,98,99,156
to adulthood.98 More lower
respiratory tract infections in preschool years, and more asthma at school
age.60 Reduction in measures of airway function.
182
Developmental Delays
Being late preterm did not increase the risk of poorer neurocognitive functioning in adulthood. However being SGA and late preterm increases the risk
of poorer neurodevelopmental outcomes.90 No difference in IQ between LPI
and full term infants.
compared to early-term and full-term birth.
At 4 and 8 Months CA
• LPI at 4 months had lower fine motor scores
• LPI at 4 and 8 months had significantly lower communication and gross
motor scores
At 9 Months CA
• Less optimum developmental outcomes than full-term controls
• Delays not seen at 24 months CA
• Delays reemerged at preschool and kindergarten
and mathematics)
133
Increased risk of lower cognitive ability in LPI when
24
161
46
204
(delays in reading
At 1 Year of Life
• Early intellectual delay (lower scores in adaptability, gross motor skills,
and social competence) than full-term group
209
• LPI admitted to an NICU increased the risk of developmental delay (i.e.,
communication and gross motor skills)
At 18 Months CA
24
16
• No significant difference in fine motor skills, gross motor skills, or communication delays seen at 4 and 8 months CA
At 2 Years CA
• Worse cognitive, language, and motor delays of moderate and LPIs compared to full term controls
48,170
• Worse socioemotional competence of moderate and late preterm infants
compared to full term controls
48
At 3 Years CA
• Increased risk of emotional problems for girls born at late preterm and
173
early term
At 4 to 5 Years of Age
• Resolving communication problems and emerging motor problems that
are comparable to early-preterm–born children but at a lower rate
92
At 6 to 12 Years of Age
• Greater risk for emotional and behavioral problems and lower quality of
life compared to full-term peers
149
CA, Corrected age; IQ, intelligence quotient; LPI, late preterm infant; SGA, small for gestational age.
Long-Term Outcomes
Two large systematic reviews
late-preterm infants (LPIs) with full-term infants
found that the children and adults born late
preterm fare worse than their full-term born peers
in cognitive function, school outcomes, behavior
problems, psychiatric disorders, and subtle intellectual and neuropsychological deficits. Box 5.3
lists long-term outcomes from more recent research
studies not included in the systematic reviews. These
retrospective reports in no way confirm causality.
Outcomes are not only the result of physiologic
immaturity, but also of the biologic determinants of preterm birth interacting with GA.36
Neurodevelopmental follow-up of LPIs has been,
18,134
comparing
until recently, a long neglected area of research. More
research, including longitudinal, prospective studies,
are needed to fully appreciate the impact of latepreterm birth, biologic determinants, and perinatal
events on developmental and health outcomes in this
population of at-risk infants.
36,151
Clearly, LPIs are not term infants and need
close observation, a high level of suspicion,
assessment, and timely intervention by all care
providers. Regardless of the setting of care for
the LPI, these immature infants require more
nursing time and care than do full-term infants.
If the level of care cannot be provided in the
birth setting, these infants should be transferred
to a higher level of care (either in the same or
a different facility) as soon as possible.
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115
Physical and Neurologic Examination
The purpose of the physical examination is (1) to
discover common variations of normal or obvious
congenital defects, (2) to quickly initiate intervention or referral for deviations from normal,
and (3) to establish a baseline for serial observations and comparisons. The best data are obtained
from the neonate when the physical examination
is organized to limit stress, maximize interaction
with the examiner, and not overwhelm the newborn. To maximize data and minimize stress,
the physical examination should proceed in
an orderly fashion from the least stressful to
the more stressful aspects of the examination
(Box 5.4).
When one appreciates how stressful it is to the
newborn to be undressed, it becomes obvious
that as much as possible should be done without
exposing the infant. Warm hands and instruments
are essential, and a warm environment helps. Before
touching the infant or removing any covers, observe
the face, head, and hands as they appear.
OBSERVATION
Observation of the neonate provides pertinent
data without touching him or her. General condition, anomalies, resting posture, and respirations should be observed.
GENERAL CONDITION
The general condition of the infant should be assessed
by noting the color, activity, and neonatal state.
Color. The color of the newborn is normally
pink. Acrocyanosis, or peripheral cyanosis of
the hands and feet, is commonly present in the
first 24 hours of life and may be the result of
immature circulation or cold stress. Ecchymotic
areas, especially on the presenting part, are common;
however, they may be confused with cyanosis. To
differentiate the two, apply pressure to the area. An
ecchymotic area remains blue with pressure, whereas a cyanotic area will blanch.
General cyanosis and central cyanosis of the
lips, mouth, and mucous membranes may indicate central nervous system (CNS), heart, or lung
disease. Jaundice appearing at birth or within the
first 24 hours of life is abnormal. Physiologic jaun-
dice appears after 24 hours, but jaundice may indicate
other abnormalities. Pallor at or directly after birth
BOX
5.4
CRITICAL FINDINGS
PHYSICAL EXAMINATION OF
THE NEWBORN
I. Observation Examination
A. General condition
1. Color
2. Activity and neonatal state
B. Crying
C. Anomalies
D. Resting posture
E. Respirations
II. Quiet Examination
A. Auscultation
1. Heart
2. Lungs
3. Abdomen
B. Palpation
1. Fontanels
2. Abdomen
C. Inspection
1. Eyes
2. Blood pressure
III. Head-to-Toe Examination
A. Skin
B. Head
1. Ears
2. Nose
3. Mouth
C. Thorax
1. Breast
2. Clavicles
D. Genitalia
E. Rectum
F. Back
G. Extremities
1. Upper
2. Lower
is a sign of circulatory failure, anoxia, edema, or
shock. Pallor of anoxia is associated with bradycardia
and the pallor of anemia with tachycardia. Plethora,
a beef-red color, may indicate polycythemia
and is confirmed by hemoglobin and hematocrit
determinations. However, lack of plethora does not
rule out polycythemia or hyperviscosity.
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Activity and Neonatal State. Activity and the neo-
natal state at the beginning of the examination and appropriate changes throughout the
examination should be observed. If the infant is
asleep, is it quiet or rapid-eye-movement (REM)
sleep? Spontaneous, symmetric movements are
normal. Tremors and twitching movements of
short duration are normal in relation to states of
coldness or startling or REM sleep. Good muscle
tone is established with adequate oxygenation
soon after birth.
Flaccidity, floppiness, or poor muscle tone
should be noted. Spasticity, hyperactivity, opist-
hotonos, twitching, hypertonicity, tremors, or seizures may be indicative of CNS damage. A lack
of crying or evasive behavior in response to
the manipulations of a physical examination is
abnormal.
Crying. Attempts to calm and console a crying
infant during this part of the examination
assist in better data collection during the quiet
examination. Crying is beneficial in (1) ductal
closure and transition from fetal to neonatal cardiorespiratory status, (2) improving pulmonary
capacity, (3) maintaining homeostasis, (4) facilitating vocal tract development, and (5) cueing and
care-eliciting behavior. Negative effects include
(1) changes in cardiovascular (e.g., tachycardia,
hypoxia, changes in cerebral blood flow, increased
risk for brain injury and cardiac dysfunction)
and endocrine systems; (2) stress production and
energy drainage;
117
and (3) strong, sometimes
117
negative feelings in care providers.
Although uniquely individual, types of cries
that reflect the infant’s state and contextual basis
have been identified as birth, distress call, hunger, pain, spontaneous, and pleasure.52 At birth,
the term neonate has a loud, lusty cry (a signal of
robustness and wellness), whereas the preterm’s cry
may be weak or absent. Observe the infant’s ability to quiet himself or herself when crying. High
responsivity of the newborn to sustained handling,
undressing, and being put down is associated with
more infant crying.
A high-pitched cry suggests CNS irritation from
increased intracranial pressure, injury, infection, or
abnormality. Weak crying, no crying, or constant,
irritable crying may indicate brain injury, infection,
or abnormality. Hoarse cries or crowing inspirations
result from laryngeal inflammation, injury, vocal
cord dysfunction (e.g., paresis/paralysis), or anomalies. A weak, groaning cry or expiratory grunt is
indicative of respiratory disease or systemic illness.
ANOMALIES
Obvious bodily malformations such as abdominal wall defects (omphalocele or gastroschisis),
cleft lip and palate, imperforate anus, syndactyly, polydactyly, club foot (talipes equinovarus),
or myelomeningocele should be observed and
recorded as anomalies. Odd facies or body
appearances that are often associated with specific syndromes also should be noted.
RESTING POSTURE
Resting posture should be observed while the
infant is quiet and not disturbed. The infant’s
posture systematically develops according to GA:
(1) from extension to flexion of the lower extremities, and (2) to flexion of the upper extremities.
Asymmetry may result from intrauterine pressure
or birth trauma. The infant may take a position of
comfort assumed in utero.
RESPIRATIONS
Respirations should be evaluated while the
infant is at rest and before any manipulation.
The normal rate is 30 to 60 breaths/min. Count
the respiratory rate and rhythm, noticing the
infant’s use of accessory muscles. Respiration is
normally abdominal or diaphragmatic.
After the first hour of life, a respiratory rate of
more than 60 breaths/min indicates tachypnea.
Tachypnea is the earliest sign of many neonatal
respiratory, cardiac, metabolic, and infectious
illnesses. Tachypnea, apnea, dyspnea, or cyanosis
may indicate cardiorespiratory distress. Labored
respirations include retractions, flaring nares, and
expiratory grunt. Maternal epidural analgesia with
fentanyl has been shown to cause respiratory depression in neonates because fentanyl freely diffuses from
the epidural space to maternal blood, equilibrating
within 10 to 30 minutes and freely transporting
across the placenta with slightly higher concentrations in the fetal compartment.
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Neonatal respiratory depression secondary to fentanyl epidural
analgesia is more common when mothers receive
large amounts of fentanyl during labor; naloxone
administration reverses the respiratory depression.
If the infant is swaddled, the observation exam-
ination will not be as extensive as is possible when
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the infant is unclothed in an incubator or under a
radiant warmer. If the infant is swaddled, unwrap
gently so that observations of the thorax, abdomen,
genitalia, and extremities may also be done during
this phase of the examination.
Without touching the infant, one can rule out
a multitude of conditions. In fact, more than 80%
of the newborn examination is made through
observation.
QUIET EXAMINATION
Quiet examination is defined as any part of
the examination in which data are best collected from the quiet, cooperative newborn.
The heart, lungs, head and neck, scalp and
skull, abdomen, eyes, and blood pressure are
areas that should be checked during the quiet
examination. Using pacifiers, warming hands and
stethoscopes, and holding and gently manipulating
the infant are ways to avoid overwhelming the baby
and to prevent crying.
AUSCULTATION
Heart. Auscultation of the heart, lungs, and
abdomen is most effective when the infant is
quiet. When the infant is quiet and at rest,
auscultate the heart rate, rhythm, and regularity at the apex. The normal rate is 120 to
160 beats/min at a regular rhythm. Variations
in heart rate occur with respiratory cycles and
single premature beats are commonly heard
and generally normal. The point of maximal
intensity (PMI) of the neonatal heart is lateral
to the midclavicular line at the third to fourth
interspace. Note the PMI.
A rate of less than 80 beats/min is bradycardia. Full-term newborns in quiet sleep may have
heart rates as low as 80 beats/min. Newborns
with persistent bradycardia may have complete
heart block caused by maternal systemic lupus
erythematosus (see Chapter 2). A rate greater
than 160 beats/min is tachycardia, which may
be associated with respiratory problems, anemia,
or congestive heart failure when accompanied by
cardiomegaly, hepatomegaly, and generalized edema.
Murmurs are noted for loudness, quality,
location, and timing. They are best auscultated
at the base of the third or fourth interspace.
Heart murmurs in the newborn period are common, perhaps as frequent as 10% of the population (see Chapter 24). Note dextrocardia—heart
sounds audible on the right side of the chest.
Pneumothorax, pneumomediastinum, dextrocardia,
and diaphragmatic hernia result in muffled heart
sounds or a shift in PMI. To complete the cardiac
assessment, careful attention to the femoral pulses is necessary; diminished femoral pulses suggest
coarctation of the aorta (see Chapter 24). Often
newborns with serious congenital heart disease do
not present with clinical signs and symptoms of
their anomaly. Use of pulse oximetry to screen all
newborns at 24 hours of age and before discharge
for critical congenital heart disease is discussed in
Chapter 31.
Lungs. Normally, the lungs and chest are resonant
after birth, and fine rales may be present for the
first few hours. Auscultation reveals bronchial
breath sounds bilaterally. Air entry should be
good, particularly in the midaxilla. A normal
respiratory rate is 30 to 60 breaths/min.
Hyperresonance suggests pneumomediastinum,
pneumothorax, or diaphragmatic hernia. Decreased
resonance is a result of decreased aeration—atelectasis, pneumonia, or respiratory distress syndrome.
Expiratory grunt suggests difficulty in aeration and
oxygenation. Peristaltic sounds heard in the chest
may be caused by a diaphragmatic hernia.
Abdomen. Bowel sounds are normally heard shortly
after birth.
PALPATION
Palpation of the fontanels and abdomen is best
accomplished before the infant begins crying,
because guarded muscles and the normally tense
fontanels of the crying infant give little useful data.
Scalp and Skull. Temporary deformation of the
head is caused by pressures during labor and
delivery. The head circumference measurements
may be altered so that the occipitofrontal circumference on the first day of life may be smaller than
on the second or third. Caput succedaneum is an
edematous area over the presenting part of the scalp
that extends across suture lines and resolves in 24 to
48 hours. A cephalhematoma is a soft mass of blood in
the subperiosteal space on the surface of the skull
bone. The blood mass does not extend across suture
lines and resolves in 6 to 8 weeks.
Deviating from the normal, skull fractures may
be linear or depressed, palpable or nonpalpable.
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Skull fractures are more common with forceps
delivery. Craniotabes, softening of the skull bones, is
caused by maternal vitamin D deficiency.
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The anterior fontanel, a diamond-shaped space
normally measuring from 1 to 4 cm, may be gently
palpated at the junction of the sagittal suture and
coronal suture and between the two parietal bones.
Normally the anterior fontanel softly pulsates with
the infant’s pulse, becomes slightly depressed when
the infant sits upright and is quiet, and may bulge
when the infant cries. Within 24 to 48 hours after
birth, the initial molding of the head and overlap of
the sutures resolve, resulting in a larger fontanel and
in suture lines that should be palpated as depressions.
The posterior fontanel, formed at the juncture
of the sagittal suture and the lambdoidal suture, is
palpated between the occipital and parietal bones.
Normally it is triangular shaped and barely admits
a fingertip.
A bulging, tense, or full fontanel may be associated
with increased intracranial pressure caused by
birth injury, bleeding, infection, or hydrocephalus. A depressed fontanel, a very late sign in the
newborn, may indicate dehydration. A third fontanel, located along the sagittal suture between the
anterior and posterior fontanels, may be a sign of
congenital infection or Down syndrome or may be
a normal variant.
Sutures are palpable ridges between skull
bones. The coronal suture is located between the
frontal and two parietal bones. The sagittal suture
intersects the two parietal bones, and the lambdoidal
suture lies between the occipital and the two parietal
bones. With increasing GA, the suture edges become
firmer and with gentle palpation are felt as hard
ridges. Sutures may be open to a varying degree or
may be overlapped because of molding. Lack of normal expansion may indicate microcephaly or craniosynostosis. Abnormally rapid expansion indicates
hydrocephalus or increased intracranial pressure.
Abdomen. The abdomen will appear slightly
scaphoid at birth but will become distended
as the bowel fills with air. The technique of
palpating the abdomen with one hand beneath
the back as the other hand defines organs and
masses is quite useful. Gentle palpation of the
abdomen for organs or masses reveals that the
spleen tip can be felt from the infant’s left side
and is sometimes 2 to 3 cm below the left costal
margin. The liver is palpable 1 to 2 cm below
the right costal margin. Superficial veins over
the abdominal wall may be prominent.
A markedly scaphoid abdomen coupled
with respiratory difficulty may indicate a diaphragmatic hernia. Abdominal distention and
lack of bowel sounds may occur because of intestinal obstruction, paralytic ileus, ascites, imperforate
anus, meconium plug, peritonitis, omphalocele,
Hirschsprung’s disease, or necrotizing enterocolitis.
The abdominal wall should be inspected for defects,
such as umbilical hernia, omphalocele (a herniation
into the base of the umbilical cord), and gastroschisis
(a defect of the abdominal wall).
The umbilical cord may also be observed and
inspected while the abdomen is being palpated.
The diameter of the cord varies, depending on the
amount of Wharton’s jelly present. Two arteries
and one vein are normally present in the umbilical cord. The umbilical cord begins to dry soon
after birth, becomes loose from the skin by 4 to 5
days, and falls off by 7 to 10 days. Redness/umbilical
erythema, foul odor, or wetness/oozing of the cord
may indicate omphalitis. Persistent drainage may
indicate a patent urachus, umbilical fistula, or cysts.
INSPECTION
Head and Neck. The head and neck of a newborn
make up 25% of the total body surface. The
head is usually 2 cm larger than a newborn’s chest.
Normal head circumference ranges between 32
and 38 cm for a FT-AGA infant. Note the size,
shape, symmetry, and general appearance.
Microcephaly is characterized by a small head
size in proportion to body size. Craniosynostosis is
a small head size caused by early closure of sutures.
Hydrocephalus is a condition in which an increase in
cerebrospinal fluid creates an abnormally large and
growing head.
Eyes. Inspection of an infant’s eyes is best
accomplished when the infant is found in the
quiet alert state or when the infant has been
aroused to wakefulness during the examination. The eyes cannot be observed while the baby
is crying. Tipping the baby backward and raising
him or her slowly or shading the infant’s eyes
from bright light often causes the eyes to open.
The newborn’s eyes open spontaneously,
look toward a light source, fix, focus, and follow. Uncoordinated eye movements are common. Subconjunctival or scleral hemorrhages are a
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