WELL BABY

(ASPECTS OF
NEONATAL CARE)
PGI Melinna Giann Racelis
October – Novemeber 2022
OBJECTIVES:

▸ TO PRESENT A CASE OF A NEWBORN PATIENT BORN AT

ARMMC
▸ TO BE ABLE TO DISCUSS THE SPECIFIC ASPECTS OF
HISTORY TAKING
▸ TO DISCUSS IMMEDIATE ASSESSMENT AND PHYSICAL
EXAMINATION OF THE NEWBORN
▸ TO ENUMERATE COMPONENTS OF ESSENTIAL
INTRAPARTUM AND NEWBORN CARE
▸ TO DISCUSS SIGNIFICANT ASPECTS OF NEONATAL CARE
▸ TO PROVIDE STUDIES FROM JOURNAL ARTICLE REGARDING
NEWBORN CARE DURING THE PANDEMIC

2
SPECIFIC ASPECTS OF HISTORY
3
TAKING
 GENERAL DATA
• Baby Boy BB
• Male
• 11/05/2022 12:58 PM
• Filipino
• Roman Catholic
• LB Upper Homes Armscor Avenue Fortune, Marikina
City Informant: Mother
% Reliability: 90%
 MATERNAL HISTORY
▸ Demographic and Social
Data (Age, Socioeconomic
details, Race) parity and
“ ▸ JB
▸ 29 Year-old
▸ Employee at a
gravidity of the mother at
Supermarket
the time of birth
▸ Filipino
▸ G4P4 (4004)

Source: Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
5
 MATERNAL HISTORY
▸ Prenatal care
▸ Regularity of Check-Up
▸ Work Up done ( CBC,
“ ▸ Total of 4 Prenatal
check-up:
▸ 2X at ARMMC
Urinalysis, Group B
streptococci (GBS) ▸ 2X at a nearby
Screening, HBsAg, test Lying In
for syphilis, ultrasound, ▸ Work-up done:
oral glucose test) Unrecalled

Source: Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
6
PRENATAL EXAMINATIONS
▸ Traditionally: scheduled at intervals of 4 weeks until
28 weeks,: then every 2-weeks until 36 weeks and
weekly thereafter

▸ For high risk group; the visits: are more often,

depending on the risk factor present

▸ WHO Technical Working Group: At least four visits

and more, if they have any problems

7
OBSTETRICS AND GYNECOLOGY, 3rd Edition by Charles Beckman et.al. p.72
 PRENATAL EXAMINATIONS
▸ WHO Technical Working Group: At least four visits and more, if they have any
problems:
▸ 1st visit:
▸ by the end of the 1st trimester (12 weeks) to screen and treat anemia, screen
and treat syphilis that can be best be addressed in early pregnancy
▸ 2nd visit in the 6th or 7th month (24-28 weeks)
▸ 3rd visit
▸ eight month (32 weeks), to screen for pre-eclampsia, multiple gestation and
anemia
▸ 4th visit on the 9th month (36 weeks) to identify fetal lie/presentation and to update
the individuals birthplace

8
OBSTETRICS AND GYNECOLOGY, 3rd Edition by Charles Beckman et.al. p.72
 MATERNAL HISTORY

“
TEST DISCUSSION

1.CBC To determine hematologic status; to rule out anemia

2.Urinalysis and urine To evaluate for UTI and renal function

culture and sensitivity

3 Blood group To determine blood type, Rh status, and risk of isoimmunization

4. Serologic Test for To detect previous/current infection; if positive, specific treponemal test required
syphilis (FTA-ABS or MHA-TP)

5. Hepatitis B surface To detect carrier status or active disease, if positive, further testing indicated
antigen
6. Rubella Titer Approximately 85% of mothers have evidence of prior. infection; if patient is
seronegative, special precautions are needed to avoid infection, which can" severely
effect the fetus, vaccination is then required postpartum
7. Cervical Cytology To screen for cervical dysplasia/cancer
9
 MATERNAL HISTORY

“
TEST DISCUSSION

8. Cervical culture for To screen for infection; both Neisseria gonorrhoea cause neonatal and chlamydia
Neisserira gonorrhoeae trachomatis conjunctivitis; association with premature labor and postpartum
endometriosis
9. Hemoglobin To detect sickle-cell trait electrophoresis
Electrophoresis (HbSA), associated with higher risk for UTl, and sickle-cell disease (HbSS),
thalassemias at risk for multiple fetal and maternal complications
10. HIV Titer by ELISA: Should be offered to ell patients Western blot if HIV +
Western Blot if HIV + by at risk (multiple sexual by ELISA partners, drug use, or sexual contact with drug
ELISA users)
11. Glucose Screening To screen for glucose intolerance in high-risk patients: usually at 28 weeks in low
risk patients

12. MSAFP at 15 and 18 Elevated levels seen with neural tube defects,
weeks (usually with HCG, gastroschisis, and omphalocele; low levels associated with Down syndrome
estriol)

10
 MATERNAL HISTORY
▸ Maternal Illness
▸ Drug
pregnancy
Intake during “ ▸ Mother denies of any
maternal illness and drug
intake during pregnancy
▸ Exposure to ionizing ▸ Mother also had irregular
intake of Multivitamins and
radiation (e.g. radiographs,
Ferrous Sulfate during the
CT scan) or injurious pregnancy and;
chemicals (e.g. alcohol, ▸ Also denies of smoking,
smoking illicit dug use) alcohol beverage drinking
emotional stress during and illicit drug use.
Source: Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
pregnancy 11
 RECOMMENDATIONS
▸ IRON: 27 mg of elemental
iron should be supplemented
daily
“ ▸ Mother denies of any
maternal illness and drug
intake during pregnancy
▸ FOLIC ACID: 400 ug orally ▸ Mother also had irregular
intake of Multivitamins and
before conception and
Ferrous Sulfate during the
through the first trimester pregnancy and;
▸ CALCIUM: 1.5 – 2.0 g ▸ Also denies of smoking,
Ca/day from 20 weeks of alcohol beverage drinking
gestation up to end of and illicit drug use.
Source: WHO Guideline
pregnancy 12
IMMUNIZATION

“ ▸ Mother had one

ultrasonography done
during the first
trimester
▸ Mother denies of any
reproductive problems
from prior pregnancies

13
OBSTETRICS AND GYNECOLOGY, 3rd Edition by Charles Beckman et.al.
PERIPARTUM HISTORY
▸Age of gestation upon delivery
▸Mode of delivery (spontaneous vaginal,CS,

▸
forceps, vacuum assisted, anesthesia or
sedation)
Total duration of labor and delivery
“ ▸ AOG: 38 WEEKS
▸ Via Normal Spontaneous
Delivery

▸Oligohydramnios / polyhydramnios ▸ At ARMMC-DR, attended by

▸Premature rupture of membranes (PROM) OB service
▸ With no noted complications
▸Place of delivery and attendant during the
delivery (OB, midwife, traditional birth
attendant)

▸Presence of complications 14
Source: Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
FAMILY HISTORY

▸ No history of heredofamilial
diseases “
NUTRITIONAL AND FEEDING HISTORY
▸ For exclusive breastfeeding until 2
years of age and may start
complementary feeding at 6 months

Source: https://www.who.int/health-topics/complementary-feeding
15
PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY

“
▸ Patient would be residing with five other family members at a two-storey owned
house with regular supply of water and electricity
▸ Patient’s mother is a 29 year-old employee at a supermarket who is apparently
well while patient’s father is a 32-year old factory worker, who is also apparently
well
▸ No family members are known smokers
▸ No pets and other sources of possible exposure to smoke, noise and pollution
nearby

16
PHYSICAL EXAMINATION OF
17
THE NEWBORN
INITIAL EXAMINATION
▸Done as soon as soon as possible after
Delivery
▸Condition of the baby at birth:
▸Spontaneous breathing
▸APGAR score
“
▸Cord coil
▸Meconium staining
▸Vital signs
▸Ballard score/maturity scoring
▸Anthropometric measurements (ideally plotted
against nomograms)
▸Quick and general physical examination
18 Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
Source: Kliegman R, et al.
INITIAL EXAMINATION

“
Maintenance of Body Heat
Causes of Heat loss/ Hypothermia

a. Relative body weight: The body surface area

of newborn infant is approximately 3x that of the
adult
b. Faster rate of heat loss: Estimated rate of
heat loss in newborn approximately 4x c.
c. Decrease in body temperature: Under the
usual delivery condition (20- 25°C,) an infant skin
temperature falls approximately 0.3 °C per minute
After delivery: there is a decrease in temperature
by 0.1 °C per minute
19 Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
Source: Kliegman R, et al.
INITIAL EXAMINATION

“
Four Mechanism of Heat Loss

a. Convection of heat energy to the cooler

surrounding
b. Conduction of heat to the colder material
touching the infant (bassinette, blanket, care
giver)
c. Heat radiation from the infant to other
nearby
cooler surrounding (aircon, lights, etc)
d. Evaporation from skin and lungs

20
INITIAL EXAMINATION

“
To prevent Heat Loss:

a. Infants are dried and either wrapped in

blankets or placed under radiant warmer (dry
the head first because it occupies a large body
surface area then dry the body)

b. Skin to skin contact with the mother is

optimal method of maintaining temperature
in stable newborn

c. Radiant heat source

21
SECOND EXAMINATION
▸Done within 24 hours

“
▸More detailed and comprehensive physical examination

DISCHARGE EXAMINATION
▸If neonate stays >48 hours
▸Note changes in the physical examination
▸Normal anatomic variations should be explained to the parents

22
INITIAL EXAMINATION 23
INITIAL EXAMINATION

▸ Respiratory Rate: 30-60 counts per minute

▸ Heart Rate: 120-160 beats per minute
▸ Core Temperature: 36.5 – 37.5 Degrees Celsius
▸ Blood Pressure: Not routinely taken in newborns
unless there are signs and predisposing factors
associated to circulatory problem
BABY BOY BB

RR: 50 cpm
HR: 120 bpm
Temperature: 36.5

24
INITIAL EXAMINATION
▸ APGAR: based on the neurological
awareness of the baby

▸ The Apgar Score is an assessment of

the newborn immediately after birth

▸ It has 5 components that classify

the newborn’s neurologic recovery
from the stress of birth and
immediate adaptation to
extrauterine life

25
INITIAL EXAMINATION
▸Taken at 1 and 5 minutes after birth
▸May be repeated at 5-minute
intervals for infants with 5 minute
scores <7
▸ It is used as method of reporting the
status of the newborn and the
response to resuscitation

INTERPRETATION OF APGAR SCORE:

7-10 points: Good cardiopulmonary adaptation, newborn will do well
4-6 points: Need for resuscitation, especially ventilatory support and
medical intervention
0-3 points: need for immediate resuscitation and may need NICU care

26
INITIAL EXAMINATION
o BABY BOY BB APGAR SCORE 8,9

2 2

2 2

1 1

2 2

1 2
8 9
INITIAL EXAMINATION

28
INITIAL EXAMINATION
ANTHROPOMETRIC MEASUREMENT
BIRTH WEIGHT and LENGTH:
▸ Measure infants directly with an
Low Birth Weight <2500 grams
infant scale. Infants should be
Very Low Birth Weight <1500 grams
weighed naked or be clothed only in
Extremely Low Birth <1000 grams
diaper, measure the length with tape Weight
measure with hips and knees
extended.
▸ Plotted against gestational age on
standard growth curves (Lubchenco
Chart)
29
INITIAL EXAMINATION
ANTHROPOMETRIC MEASUREMENT

▸Classification based on Birth Weight Low Birth Weight <2500 grams

versus Gestational Age (Using
Very Low Birth Weight <1500 grams
Lubchenco Chart)
▸ Small For Gestational Age Birth Extremely Low Birth
Weight
<1000 grams

Weight below 10th percentile

▸ Appropriate for Gestational Age:
Birth Weight between 10th to 90th
percentile
▸ Large for Gestational Age: 90th
percentile 30
INITIAL EXAMINATION
ANTHROPOMETRIC MEASUREMENT

▸Classification based on Birth Length

versus Gestational Age (Using
Lubchenco Chart)
▸ Small For Gestational Age Birth
Length below 10th percentile
▸ Appropriate for Gestational Age:
Birth Length between 10th to 90th
percentile
▸ Large for Gestational Age: 90th
percentile 31
INITIAL EXAMINATION
ANTHROPOMETRIC MEASUREMENT

HEAD CIRCUMFERENCE: Measuring

tape is placed over the mid-
forehead/supraorbital ridge and
extended circumferentially to include
the most prominent portion of the
occiput.

32
INITIAL EXAMINATION
ANTHROPOMETRIC MEASUREMENT

▸Classification based on Birth HC

versus Gestational Age (Using
Lubchenco Chart)
▸ Small For Gestational Age: Birth HC
below 10th percentile
▸ Appropriate for Gestational Age:
Birth HC between 10th to 90th
percentile
▸ Large for Gestational Age: 90th
percentile 33
INITIAL EXAMINATION
BABY BOY BB
WEIGHT: 3000 grams HEAD CIRCUMFERENCE: 31 cm
LENGTH: 50 cm APPROPRIATE FOR GESTATIONAL AGE

34
INITIAL EXAMINATION
ANTHROPOMETRIC MEASUREMENT

▸CHEST CIRCUMFERENCE:
measured along the level of nipple

▸ABDOMINAL CIRCUMFERENCE;
measured along the level of
umbilicus

35
INITIAL EXAMINATION
BALLARD SCORING SYSTEM
(MATURITY RATING)
*Used for maturational assessment of
gestational age
*Accuracy is +/- 2 weeks the actual
gestational age
*Two components:
-Neuromuscular maturity
-Physical Maturity

36
INITIAL EXAMINATION
BALLARD SCORING SYSTEM Neuromuscular maturity
PARAMETER INSTRUCTIONS ILLUSTRATION

POSTURE Wait until the infant is settled into relax position

May do gentle manipulation to allow the infant

baseline position

SQUARE Straighten the infant’s fingers and apply gentle

WINDOW pressure on the dorsum of the hand, close the
fingers

ARM RECOIL With the infant lying supine, the examiner

places one hand beneath the elbow for
support, elbow is then placed into flexion then
momentarily extends the arm before releasing
the hand, the angle to which the forearm
springs back to flexion is noted 37
INITIAL EXAMINATION
BALLARD SCORING SYSTEM Neuromuscular maturity
PARAMETERS INSTRUCTIONS ILLUSTRATION

POPLITEAL Infant is placed on supine position, thigh is gently

ANGLE placed on the abdomen with the knees flexed, after
the infant has relaxed, examiner holds the foot at
sides with one hand supporting the side of the
thigh. Leg is extended until a definite resistance

SCARF SIGN With the infant lying supine and head in the
midline, examiner supports the infant’s hand across
the upper chest with one hand, elbow is nudged
across the chest until resistance is felt

HEEL TO EAR Infant is placed in supine position and the flexed

lower extremity is brought to a point of significant
resistance

38
INITIAL EXAMINATION
BALLARD SCORING SYSTEM

*Full term infants are scored as early

as possible and may be reliably scored
within 72 hours of birth

*The physical and neurological scores

are added, the sum of which calculates
gestational age

39
INITIAL EXAMINATION
BABY BOY BB

18 + 19 = 37
MATURITY RATING 38 WEEKS
INITIAL EXAMINATION
BABY BOY BB
PERTINENT PHYSICAL EXAMINATION
FINDINGS:
(-) alar flaring, (-) bulging fontanelle,(-) cleft
lip/palate, (+) caput
Equal chest expansion, (-) retractions, clear
breath sounds
Adynamic precordium, normal rate, (- )
murmur
Soft non distended abdomen, (-) palpable
mass
Good pulses, CRT<2 secs, (-) gross deformities
41
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION

I. GENERAL APPEARANCE
• Physical activity maybe absent during normal sleep, or it may be decreased by the
effects of illness or drugs.

• Either be lying with extremities motionless, to conserve energy for the effort of difficult
breathing, or vigorously crying, with accompanying activity of the arms and legs.

• Both active and passive muscle tone & unusual postures should be noted.

Source: Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
42
Gleason C, et al. Avery's diseases of the newborn (10th ed.). Elsevier 2017
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL
EXAMINATION
II. SKIN
•ACROCYANOSIS

• Bluish or purple discoloration of the hands

and feet caused by vasomotor instability and
peripheral circulatory sluggishness in a
crying infant.

Source: Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
43
Gleason C, et al. Avery's diseases of the newborn (10th ed.). Elsevier 2017
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL
EXAMINATION
II. SKIN
•MOTTLING
• Another example of general circular
instability
▪ Related to transient fluctuation in skin
temperature.
▪ May be associated with serious illness..

Source: Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
44
Gleason C, et al. Avery's diseases of the newborn (10th ed.). Elsevier 2017
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL
EXAMINATION
II. SKIN
•HARLEQUIN COLOR CHANGE
• Extraordinary division of body from
forehead to pubis into red and pale halves
▪ Transient and harmless condition.

Source: Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
45
Gleason C, et al. Avery's diseases of the newborn (10th ed.). Elsevier 2017
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL •MONGOLIAN SPOTS
EXAMINATION • Slate-blue, well-demarcated areas of
II. SKIN pigmentation seen on buttocks, back, and
•PALLOR other parts of the body.
• May be caused by anemia, asphyxia, shock ▪ Benign patches
or edema. ▪ Tend to disappear within the 1st year
▪ May masked significant cyanosis.
▪ Without being anemic, post-mature infants
tend to have paler and thicker skin than term
or premature infants.

Source: Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
46
Gleason C, et al. Avery's diseases of the newborn (10th ed.). Elsevier 2017
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL
EXAMINATION
II. SKIN
•VERNIX
White cheesy substance that covers ad
protects the skin of the fetus and is still over
the skin of a baby at birth.
▪ May stained brownish yellow if the amniotic
fluid has been colored by the passage of
meconium during or before birth.
▪ Helps in thermoregulation

Source: Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
47
Gleason C, et al. Avery's diseases of the newborn (10th ed.). Elsevier 2017
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION

II. SKIN

TUFTS OF HAIR
Over lumbosacral spine suggests underlying
abnormality such as spina bifida, sinus tract or tumor
-Important clue of the possible problem at the lower
part of spinal cord

48
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION

II. SKIN

ERYTHEMA TOXICUM
▪ Small white papules on an erythematous base develop
1-3d after birth.
▪ Benign rash that persists for as long as 1 wk &
contains eosinophils. It will resolve.
▪ Distributed on face, trunk & extremities

49
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION

II. SKIN

PUSTULAR MELANOSIS
▪ Benign lesion seen in black neonates, contains
neutrophils
▪ Present at birth as vesiculopustular eruption around
chin, neck, back, extremities & palms and soles
▪ Lasts for 2-3 days. It will resolve.

50
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
III. SKULL
✓ Head circumference of all infants should be plotted on growth chart to
rule out Microcephalus & Megalencephaly.
✓ Skull may be molded, particularly if infant is the first-born and if the head
has been engaged in the pelvic canal.
✓ Head of infant born by CS or from breech presentation is characterized by
its roundness.
✓ Suture lines and the size of and fullness of the anterior and posterior
fontanels should be determined digitally by palpation.
✓ Normal range: 34-35 cm

51
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION

CAPUT SUCCEDANEUM MOLDING

Portion of fetal scalp immediately above Changes in bony fetal head shape as a result of
the cervical os which becomes edematous external compressive forces resulting to shortened
due to prolonged labor prior cervical suboccipitobregmatic diameter and lengthened
dilation mentocervical diameter

52
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
▸ CRANIAL SYNOSTOSIS
▸Premature fusion of sutures (sagittal and horizontal) is identified as hard
nonmovable ridge over the suture and abnormally shaped skull
▸ CRANIOTABES
▸Soft areas found in parietal bones at vertex near sagittal suture, more
common in preterm infants & infants exposed to uterine compression.
▸Can also be a manifestation of syphilis
▸MEGALENCEPHALY
▸Excessively large head suggests: hydrocephaly, storage diseases,
achondroplasia, cerebral gigantism, neurocutaneous syndromes or inborn
errors of metabolism or maybe familial.

53
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION

▸HYDROCEPHALY
▸Skull of the premature infant because of relatively larger brain growth in
comparison with growth of other organs.
▸ DEPRESSION OF SKULL
▸Indentation, fracture, ping pong ball deformity
▸Prenatal onset & result of prolonged focal pressure by bony part of the
skull.

54
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
IV. FACE
A. GENERAL APPEARANCE
✓ Note dysmorphic features often associated with congenital syndromes such
as:
o Epicanthal folds
o Widely or narrowly spaced eyes
o Microphthalmos
o Asymmetry
o Long philtrum – sign of Fetal Alcohol Syndrome
o Low-set ears – sign of chromosomal abnormalities, specifically Down
Syndrome
55
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
IV. FACE
A. GENERAL APPEARANCE
*ASSYMETRIC FACE
✓ 7th nerve palsy, hypoplasia of depressor muscle at
the angle of the mouth (if bilateral), or an abnormal
fetal posture
✓ when jaw has been held against a shoulder or an
extremity during intrauterine period, mandible may
deviate strikingly from the midline

56
INITIAL EXAMINATION
1. EYES
✓ open spontaneously if infant is held up ✓ Cornea: >1 cm in diameter in a term
& tipped gently forward & backward infant (with photophobia & tearing)
✓ This maneuver a result of labyrinthine suggests congenital glaucoma & requires
& neck reflexes, is more successful in prompt ophthalmologic consultation.
inspecting the eyes than forcing lids
apart.
✓ Pupillary reflexes: present after 28-30
weeks of gestation.
✓ Iris: inspect for colobomas &
heterochromia

57
INITIAL EXAMINATION 3. NOSE
2. EARS
GENERAL APPEARANCE
GENERAL APPEARANCE
✓ slightly obstructed by mucus
✓ deformities of pinnae are
accumulated in narrow nostrils
occasionally seen
✓ Nares should be symmetric &
✓ unilateral or bilateral preauricular
patent
skin tags occur frequently; if
✓ Dislocation of nasal cartilage from
pedunculated, they can be tightly
vomerian groove results in
ligated at the base → dry gangrene and
asymmetric nares
sloughing
✓ Anatomic obstruction secondary to
✓ tympanic membrane is easily seen
unilateral or bilateral choanal atresia
otoscopically through short & straight
results in respiratory distress.
external auditory canal, normally dull
gray
58
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL
EXAMINATION
4. MOUTH
✓ rarely have precocious dentition, with
natal (present at birth) or neonatal teeth
(eruption after birth)

✓ Soft and hard palate should be inspected

for a complete or submucosal cleft

59
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
V. NECK
✓ abnormalities include:

o goiter
o cystic hygroma (some NB have a big mass in the lateral side of the neck usually
unilateral which can be seen after birth; problems with the development
pharyngeal arches intrauterine)
o branchial cleft rests
o teratoma
o hemangioma

60
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
VI. CHEST
✓ Breast hypertrophy is common because of the hormonal changes in the mother
✓ Milk may be present (should not be expressed)

✓ Asymmetry
✓ Erythema
✓ Induration
✓ Tenderness: mastitis or breast abscess
✓ Supernumerary nipples, inverted nipples or widely spaced nipples
61
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION

VI. LUNGS – Breathing

✓ Note if there are suprasternal,, subcostal, intercostal retraction. Rising up and down of
the chest, looking for any clue if there is already a difficulty in respiration.
✓ Another clue as to whether there is a problem is the baby’s cry
✓ Normal Respiratory rate:30-60 breaths/min

62
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION

VI. LUNGS

✓ Breathing of NB infants at rest : diaphragmatic

✓ Baby is relaxed, quiet & with good color, this “paradoxic movement” (soft front
of thorax drawn inward while abdomen protrudes) does not necessarily signify
insufficient ventilation.
✓ Always look at the lips, extremities, and O2 saturation

63
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION

VII. HEART

✓ look for the PMI (point of maximal impulse), apex beat by auscultation.
✓ Location of heart be determined to detect dextrocardia. (If there are no heart
sounds in the left and the heart sounds are in the right)
✓ Transitory murmurs represent closing ductus arteriosus.
✓ Oxygen saturations are below 95% and is used to screen for congenital heart
disease

64
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION

VII. HEART

✓ Pulse Rate:
o Usually 120-160 beats/min at rest
o 90 beats/min, relaxed sleep
o 160 beats/min during activity
o Note for the pulses at the axillary, radial, dorsalis pedis left and
right.
o Discrepancy in the pulse in the upper and lower extremity suggest
coarctation of the aorta.
65
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
VIII. ABDOMEN

✓ Liver - Palpable, 2cm below rib margin

✓ Spleen - Tip may be felt less commonly.
✓ Kidney - Size and location determined on deep palpation
✓ Gas should be normally present in rectum on roentgenogram by
24hrs of age. If there is no passage of meconium in the first 24 hrs
then you can request your x-ray. You can note if there’s no gas in the
rectal area and then there’s some form of obstruction.

66
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
VIII. ABDOMEN
▪ ABDOMINAL DISTENTION
▪ Birth or shortly afterwards suggests either obstruction or perforation of GIT as a
result of meconium ileus
later distention suggests lower bowel obstruction, sepsis or peritonitis
▪ Scaphoid abdomen: diaphragmatic

OMPHALITIS - acute local inflammation of

periumbilical tissue

67
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
IX. GENITALS
✓ Scrotum
o Normally large at term
o size may be increased by trauma of breech delivery or by a transitory
hydrocele (distinguished from a hernia by palpation and illumination)
Testes:
o Should be in scrotum or palpable in canals in term infants
o During term and delivery, both testes should be descended
✓ Prepuce of a newborn infant: normally tight and adherent
✓ Urine passed during or immediately after birth
✓ Most neonates void in the first 12hrs, and approximately 95% of preterm & term
infants void within 24hrs. If none, you must
68
investigate the renal pathology
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION

X. ANUS

✓ passage of meconium within 1st 12hrs after birth

✓ 99% term infants & 95 % of premature infants pass meconium
within 48hrs of birth. If beyond 2 days and there’s no passage of
meconium, investigate.
✓ Imperforate anus: is not always visible; radiographic study is
required.

69
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
XI. EXTREMITIES
✓ Effects of fetal posture should be noted
✓ Fracture or nerve injury associated with delivery can be detected more
commonly by observation in spontaneous or stimulated activity
✓ Hands & feet examined for polydactyly, syndactyly & abnormal
dermatoglyphic patterns such as a simian crease

MUSCULOSKELETAL
▸ Check and palpate back for spinal abnormalities
▸ Barlow and ortolani test if suspecting hip dislocation

70
INITIAL EXAMINATION

71
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
XII. NEUROLOGIC
✓Vision
▸A normal 37 week infant turns the head and eyes toward a soft light, and
a term infant is able to fix on and follow a target, such as the examiner’s
face

72
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
XII. NEUROLOGIC
✓ Tone
▸Muscle tone, which is generated by an unconscious, continuous, partial
contraction of muscle, creates resistance to passive movement of a joint
▸Tone varies greatly based on a patient’s age and state:
▸At 28 wk of gestation, all 4 extremities are extended and there is little
resistance to passive movement.
▸Flexor tone is visible in the lower extremities at 32 wk and is palpable in the
upper extremities at 36 wk; a normal-term infant’s posture is characterized by
flexion of all 4 extremities.

73
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
XII. NEUROLOGIC
There are 3 key tests for assessing postural tone in neonates:
▸ Traction response
▸ Vertical suspension
▸ Horizontal suspension
*Scarf sign
*Popliteal sign

74
INITIAL EXAMINATION
QUICK AND GENERAL PHYSICAL EXAMINATION
XII. NEUROLOGIC

✓ Primitive reflexes appear and disappear at specific times during development

and their absence or persistence beyond those times signifies CNS dysfunction.
✓ Although many primitive reflexes have been described, the Moro, grasp, tonic
neck, and parachute reflexes are the most clinically relevant.

75
ADMITTING IMPRESSION

NEWBORN LIVE TERM BABY BOY VIA NORMAL

SPONTANEOUS DELIVERY
BIRTH WEIGHT 3000 GM, BIRTH LENGTH 50 CM,
APGAR 8, 9 , BALLARD SCORE 38 WEEKS AOG,
APPROPRIATE FOR GESTATIONAL AGE

76
MANAGEMENT
• FEEDING: Exclusive Breastfeeding as •May bathe patient after 6th hour of life
per demand with SAP •Skin-to-skin contact with mother
• VITAL SIGNS: Q15minutes for the first •Daily Cord care
hour, Q1hr for the next 4 hours and •Suction secretions PRN
then Q4 thereafter if stable • I and 0 Q shift and record
•DIAGNOSTICS:’ • WEIGH patient daily and record
o Newborn screening >24 HOL • Keep patient thermoregulated (36.5 to
o Hearing screening prior to 37.5 degrees Celsius)
discharge
• THERAPEUTICS:
o BCG 0.05 ml intradermal
o Hep B vaccine 0.5ml IM
o Vitamin K 1 ml IM
o Erythromycin eye ointment 77
DISCUSSION 78
DOH PROTOCOLS OF ESSENTIAL INTRAPARTUM CARE

▸ Developed by Department of Health

▸ Adopts international evidence-based
standards set by World Health
Organization
▸ Directly addresses MDG 4 (reducing child
mortality)
STEPS:
▸ 1. Immediate and thorough drying
▸ 2. Early skin-to-skin contact
▸ 3. Properly timed cord clamping
▸ 4. Non-separation for early breastfeeding
*Carry out eyecare and immunization
procedures
*Rooming in
79
 1. Immediate and thorough drying
▸ Immediately dry the baby to stimulate breathing and
to avoid hypothermia for a full 30 seconds unless the
infant is both floppy /limp and apneic
▸ Sequence of drying is as follows (5 seconds each):
face, head, trunk, back, arms, legs
▸ Hypothermia can lead to infection, coagulation
defects, acidosis, delayed fetal to newborn circulatory
adjustment, hyaline membrane disease, or brain
hemorrhage
▸ Routine suctioning of nose and mouth has no proven
benefit unless meconium stained and the baby is limp
or apneic

80
 2. Early skin-to-skin contact
▸ Place the baby on mother's chest or abdomen to provide
warmth & allow the
▸ "good bacteria" from the mother's skin to infiltrate the
newborn
▸ Increases the duration of breastfeeding
▸ Technique (if breathing or crying):
▸ Position prone on the mother's abdomen or chest in
between the breasts
▸ Cover the newborn
▸ Dry linen for back
▸ Bonnet for head
▸ Temperature check: (room: 25-28 degrees, baby:36.5-
37.5 degrees) 81
 2. Early skin-to-skin contact

▸ Benefits include:
▸ B: Breastfeeding success
▸ L: Lymphoid tissue system stimulation
▸ E: Exposure to maternal skin flora
▸ S: Sugar (protection from hypoglycemia)
▸ T: Thermoregulation

82
 3. Properly timed cord clamping

▸ Delay cord clamping 2-3 minutes after birth or

until the cord has stopped pulsating, whichever
comes first
▸ Remove the first set of gloves (may use "double
gloving" method) before handling the umbilical
cord, so the sterile underlying pair should be used
to handle and cut the cord
▸ Clamp the cord without milking it 2 cm from the
base & put the second clamp 5 cm from the base
and cut the cord
83
 3. Properly timed cord clamping

▸ Benefits of properly timed cord clamping:

▸ Decreases anemia in term and preterm babies
▸ Decreases need for blood transfusions in
premature babies
▸ Decreases bleeding in the brain in premature
babies

84
 4. Non-separation for early breastfeeding
▸ Non-separation for 90 minutes after birth or after
the first full breastfeed
▸ Leave the newborn between the mother's breasts
in continuous skin-to-skin contact.
▸ Monitor mother and baby regularly in the first 1-2
hours and assess baby:
▸ Breathing: listen for grunting, look for chest in-
drawing and fast breathing

85
 Recommends against these traditional newborn care
practices

▸ Foot printing
▸ Use of bigkis or abdominal binder
▸ Early bathing and removal of vernix
▸ Artificial milk substitutes

86
NEWBORN CARE 87
 EYE PROPHYLAXIS

▸ For all infants, including those born by cesarean

section
▸ To protect against gonococcal ophthalmia
neonatorum
▸ Medications:
▸ Erythromycin ointment 0.5% or tetracycline
ointment 1%
▸ Alternative is Crede's prophylaxis: 1% silver nitrate
solution (can lead to a transient chemical
conjunctivitis in 10-20% of cases)
88
 Vitamin K

▸ Dose: 0.5-1.0 mg IM at anterolateral thigh

▸ To prevent hemorrhagic disease of the newborn

89
 Vaccinations

▸ Bacillus Calmette-Guerin (BCG): 0.05 mL

intradermally
▸ Hepatitis B vaccine (0.5 mL)
▸ HbIg IM (0.5 mL) if mother is HBsAg-positive or if
mother's HBsAg status is unknown and birth
weight is < 2 kg

90
 NEWBORN SCREENING (NBS)

▸ Mandated by RA #9288 "The Newborn Screening Act of 2004"

▸ Collection of blood is done by heel-prick method
TIMING OF NEWBORN SCREENING
▸ Should be done after 24 hours of life, but not later than 3
days of age (if blood was collected <24 hours old, must
repeat at 2 weeks old)
▸ For preterm infants: ideal time should be at 5-7 days old
▸ If newborn is placed in intensive care, test by 7 days old
▸ Can be done until 1 month old for really sick babies

91
 FACTORS THAT MIGHT AFFECT NBS RESULTS

▸ Blood transfusions
▸ Dialysis
▸ Parenteral use of antibiotics
▸ Prematurity
▸ Patient not fed since birth

92
 NEWBORN HEARING LOSS SCREENING

▸ Republic Act No. 9709: The Universal Newborn

Screening and Intervention Act of 200
▸ All infants shall undergo newborn hearing loss
screening on or after 24 hours after birth, before
discharge
▸ Infants who are not born in hospitals should be
screened within the first three months
▸ If hearing loss is detected, audiologic evaluation
should be made before 6 months

93
 RISK FACTORS FOR HEARING LOSS

▸ Family history of hearing loss

▸ TORCH infection
▸ Birth weight <1500 grams
▸ Bacterial meningitis
▸ Hyperbilirubinemia needing exchange transfusion
▸ Low APGAR (0-6 at 1 min/5min)
▸ Mechanical ventilation
▸ Neurodegenerative disorders
▸ Trauma

94
 DISCHARGE CRITERIA
Plan to discharge when:
1. Breastfeeding well
2. Body temperature between
36.5 and 37.50 C for 3
consecutive days.
3. Mother able and confident in
caring for the newborn.

[ DOH ADMINISTRATIVE ORDER NO. 2009-0025,

95 December 01, 2009 ]
Source: Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
 DISCHARGE INSTRUCTIONS

▸ Daily newborn care

▸ Daily cord care
▸ Exclusive breastfeeding
▸ Things to watch out for
▸ Follow up schedule

96
NEWBORN CARE 97
 DISCHARGE INSTRUCTIONS

1. Advise the mother to return or go to the hospital immediately if:

▸ - Jaundice
▸ - Difficulty of feeding
▸ - Convulsions
▸ - Movement only when stimulated
▸ - Fast or slow or difficult breathing (e.g. severe chest-in-drawing)
▸ - Temperature > 37.50C or < 35.50C

* From Lancet 2008, new IMCI algorithm for Young Infant II Study
98
 DISCHARGE INSTRUCTIONS

2. Advise the mother to bring her newborn to the health facility for
routine check- up at the following prescribed schedule:
▸ - Postnatal visit 1: at 48 -72 hours of life
▸ - Postnatal visit 2: at 7 days of life
▸ - Immunization visit 1: at 6 weeks of life

[ DOH ADMINISTRATIVE ORDER NO. 2009-0025, December 01, 2009 ]

99
 DISCHARGE INSTRUCTIONS

Advise additional follow-up visits appropriate to problems in the

following:
- Two days-if with breastfeeding difficulty, Low Birth Weight in the
first week of life, red umbilicus, skin infection, eye infection, thrush or
other problems.
- Seven days - If Low Birth Weight discharged more than a week of
age and not gaining weight adequately.

[ DOH ADMINISTRATIVE
100 ORDER NO. 2009-0025, December 01, 2009 ]
 DISCHARGE INSTRUCTIONS
3.Daily cord care
▸ cord should be cleansed with warm water or a mild nonmedicated
soap solution and rinsed with water to reduce the incidence of skin
and periumbilical colonization with pathogenic bacteria and
subsequent infectious complications
▸ to reduce colonization with Staphylococcus aureus and other
pathogenic bacteria, the umbilical cord may be treated daily with a
bactericidal or antimicrobial agents such as chlorhexidine, triple
dye, or bacitracin
▸ Cleaning with alcohol and bandaging delays healing and falling off of
the stump. The alcohol keeps the stump moist while bandaging
prevents aeration which facilitates the drying process.
101
[ DOH ADMINISTRATIVE ORDER NO. 2009-0025, December 01, 2009 ]
 DISCHARGE INSTRUCTIONS

4. General Principles of Bathing a Baby

▸ World Health Organization recommends delaying the first
bath until at least 24 hours after birth.
▸ Delaying the first bath has a positive effect on bonding,
breastfeeding and in the prevention of hypothermia and
hypoglycaemia. However the exact timing of the first bath
should be specific to the individual needs of each baby and
their parents/carers.
www.clinicalguidelines.scot.nhs.uk/nhsggc-guidelines/nhsggc-guidelines/neonatology/bathing-newborn-infants/

102
• SARS-CoV-2 has created a dilemma about care of mother-newborn dyads, particularly regarding KMC and
breastfeeding
• Evidence suggests that intrauterine mother-to-fetus transmission of SARS-CoV-2 infection is rare
• Compared the benefits of KMC on neonatal survival during the pandemic with the risk of SARS-CoV-2 acquired
through close contact with an infected mother or caregiver
• Analyses show that even in a scenario of universal coverage of KMC, including direct breastfeeding and
prolonged skin-to-skin contact, the survival benefits of KMC for neonates born in facilities weighing ≤2000 g
substantially outweigh the risk of death due to COVID-19
• Newborns of infected mothers in New York reported that none tested positive for SARS-CoV-2 through 14 days
when kept in a closed isolette in the mother's room and held for feeding suggesting that rooming-in and
breastfeeding are safe when accompanied by mask-wearing and hygiene precautions
103
•Mothers and newborn infants may room-in according to usual center
practice.
•During the birth hospitalization, the mother should maintain a
reasonable distance from the infant when possible and wear a face mask.
When a mother provides hands-on care to the infant, the mother should
wear a mask and perform hand hygiene.
•Infected mothers should perform hand hygiene before breastfeeding
and wear a mask during breastfeeding.
•If an infected mother chooses not to breastfeed her newborn infant, she
may express breast milk to be fed to the infant by other uninfected
caregivers.
104
 REFERENCES
OBSTETRICS AND GYNECOLOGY, 3rd Edition by Charles Beckman et.al.
Kliegman R, et al. Nelson Textbook of Pediatrics (21st ed.). Elsevier; 2020
Minckas, N. (2021, March 1). Preterm care during the COVID-19 pandemic: A comparative risk
analysis of neonatal deaths averted by kangaroo mother care versus mortality due to
SARS-CoV-2 infection.
eClinicalMedicine. https://www.thelancet.com/journals/eclinm/article/PIIS2 589-
5370(21)00013-4/fulltext

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