Overall daily assessment of the term neonate including vital signs and bladder and bowel function
For most term neonates adapting to extrauterine life is a normal physiological event. But in order to thrive and develop, they depends on others to provide their basic needs, and to be vigilant on their behalf for any changes to wellbeing.
The overall daily assessment of the term neonate, including vital signs, bladder and bowel function, acts as an important screening tool to ensure wellbeing is maintained. This assessment is a continuation in a modified format and not a replica of the examination of the newborn check. Box 38.1 outlines the aims of the assessment.
Effective communication is vital for the parents to understand the findings and know who to contact for support. An aid to this is the individualised postnatal care plan (IPCP), which should be reviewed and updated at each visit.
At every visit the midwife should ensure consent is obtained, including the rationale for the assessment. The examination should be undertaken in a warm, private well-lit room with one or both parents present and findings clearly explained in words that the parents can understand.
Before the assessment read the IPCP. The original birth examination should be used as a comparison in case any visible marks or bruising are found, to ensure that no physical abuse has occurred. Midwives have a duty to report concerns about the vulnerability or abuse of the baby.
Box 38.2 summarises best practice when completing the assessment. A systematic approach is required in order to complete the assessment satisfactorily and to prevent any omissions occurring (Box 38.3). Before checking the baby, it is important to ask the parents if they have any concerns.
The baby needs to be considered holistically, commencing with overall appearance: tone, movement, posture, sleepiness and rousability. The head can then be checked, particular attention is paid to the fontanelles, which if sunken is a sign of dehydration. The eyes of the baby should be clear, and checked for signs of infection. As most babies are obligatory or preferential nose-breathers the nostrils should be checked for signs of dry secretions that could interfere with the baby’s ability to breathe properly.
An ideal time to mention infant feeding is when checking the baby’s mouth, as it can be incorporated to queries about possible thrush or tongue-tie. Infant feeding is an integral part of the health promotion activity during the assessment (see Chapters 43 and 44).
The baby can then be undressed and the trunk, arms and hands exposed. If there are any concerns that the baby is unwell perform a set of observations:
- Respirations observing pattern, rate and depth
- Heart rate can then be listened to
- Axillary temperature reading is always performed last as the thermometer will need to be held in place, and might upset the baby and thus can impact on the normal reference ranges for these vital signs (Box 38.4).
Both sexes may present with transient breast engorgement due to a withdrawal of maternal oestrogens and the parents need to be reassured that this will resolve.
The baby’s abdomen should look and feel soft and rounded. The umbilical cord should be checked for signs of infection.
At this point the baby can have its upper body redressed whilst the bottom half is exposed.
The contents of the nappy can be a source for much discussion as checking bladder and bowel function is an indicator that the baby is feeding normally and that the body systems are functioning normally. Parents need to be reassured regarding the frequency and contents of wet and dirty nappies.
The assessment of bladder function can be challenging especially as the bladder capacity in the neonatal period is around 10 mL. Another contributory factor is that urine output can be difficult to monitor due to the absorbency of disposable nappies.
Parents can be reassured by getting them to put a piece of tissue paper inside the nappy. Parents also need to be informed that a build-up of urates can cause pink crystals to appear which may be mistaken for blood in both sexes. Moreover, female neonates may develop pseudomenstruation due to a withdrawal of maternal oestrogens (Figure 38.1b).
The stool pattern is dependent on the method of feeding. Parents can be reassured that their baby’s stool pattern is normal by discussing how the first stool, meconium, a greenish black colour, changes, and that within 2–3 days, breastfed babies stools turn yellow. If formula fed the stools may vary from yellow, brown or greenish in colour. From day 4 and in the first weeks, the baby will pass at least two stools a day which should be similar in size to a £2 coin. (Examples of contents are provided in Figure 38.2).
The check ends with an inspection of the buttocks, spine, legs and feet. A blue or blue/ grey discoloration of the skin over the buttocks, back and legs may be due to a pigmented birth mark known as Mongolian blue spots.
Local guidelines may apply and the baby undressed completely and weighed. However, it is recognised that healthy babies can lose weight in the first week of life. The baby can then be dressed.
It is important to thank the parents and explain the findings. If any abnormalities were found they must be acted upon and either monitored or a referral made to the appropriate healthcare professional.
Finally, remind the parents that if they have any concerns before the next visit who they can contact. All the findings should be documented in the neonate’s child health record book.