The initial examination of the newborn by the midwife at birth is essential, as the transition from intrauterine life to extrauterine existence becomes a reality. It sets the parameter for care and provides a baseline to inform the subsequent detailed newborn and infant physical examination (NIPE) (Lomax 2015). It also provides an opportunity for health education for the parent(s).

The baby transitions from a warm, calm and fluid environment, one that is life sustaining, to one that is drier and harsher, where physiological adaptations must be made quickly in order to adjust satisfactorily to the demands of extrauterine life. Colour, tone, breathing and heart rate are vital signs when assessing well-being. A midwife’s understanding of this process of adjustment and change are factored into the systematic physical examination of the baby at birth.

Prior to the examination, informed consent from the parent(s) must be obtained, including rationale. The room should be at an ambient temperature, supporting a thermoneutral environment, to minimise heat loss throughout the assessment, as outlined in Table 36.1.

The initial assessment commences with inspection or observation using the Apgar score (Chapter 35). The midwife employs a systematic ‘top to toe’ approach when performing the examination.

Examination of the skin should be done at the moment of birth and forms a core part of the continuing assessment of the neonate. Apart from the skin colour (e.g. obvious perfusion, pallor or cyanosis), the midwife is also observing for signs of underlying infection (may be apparent if liquor was offensive in odour at birth), lesions, birthmarks, signs of bruising and presence/absence of vernix, lanugo or meconium staining.

The temperature of the baby should be checked in line with local policy and documented.

Head and neck (including face, eyes, ears and mouth): Starting from the head, the scalp is examined for any bruising or swelling (e.g. caput succedaneum). Any moulding, elongation of the head, asymmetry/abnormal shape, characteristic facies such as Down syndrome and size of sutures and fontanelles are noted and referred to a paediatrician as required. The head circumference is measured to establish a baseline parameter. The midwife then assesses the neck for any signs of swelling, asymmetry or extra skin folds.

Ears: Note position and any preauricular skin tags or malformation.

Eyes: Note any asymmetry, presence/absence of eye(s), any epicanthic skin folds and any obvious corneal opacities.

Nostrils: Observe breathing and note any nasal flaring or evidence of choanal atresia.

Mouth: Externally, the condition of the lips is assessed to exclude any congenital malformations such as cleft lip as well as the angle of the chin to note any chin recession. The midwife inspects the inside of the mouth noting any anomalies such as any abnormal tongue protrusion, ankyloglossia, any defects such as cleft palate or the presence of teeth at birth.

Chest/breathing: Respiratory rate is observed to detect any early signs of abnormality such as tachypnoea, sternal recession, grunting noise or high-pitched cry. Any obvious chest mass should be noted and communicated to the parent(s) and paediatrician.

Abdomen (including umbilical cord): check to ensure the umbilical cord is securely clamped. Detailed examination of the placenta at birth will reveal presence/absence of umbilical vessels. The midwife will also inspect for any signs of swelling of the abdomen or herniation.

Arms/hands/digits: Check movement and note muscle tone. The arms are also checked for any irregularity, absence or asymmetry. The digits of each hand are examined to confirm normality and exclude anomalies, for example extra or fewer digits.

Groins/genitalia and anus:  The groin area is inspected to exclude any unexpected masses. Inspection of the genitalia usually confirms gender. The position of the urethra is noted in male babies. Patency of the anus is checked. The passage of meconium or urine at birth should be noted and must be included as part of contemporaneous record keeping.

Legs/feet/digits: These are checked for any irregularity, absence or asymmetry and also extra or fewer digits.

Back/spine: The curvature of the spine is noted as well as any lesions, swelling, bruising and dimpling at the base of the spine.

Weight: The baby must be weighed, the birth weight checked by the parent(s) and recorded.

Figure 36.1 summarises this examination.

Identification of newborns

The National Patient Safety Agency (2008) uses the term ‘wristband’ to address both wristbands and any other form of identity band, for example anklets. Their guidance for identification of the newborn relates to the hospital setting only, as detailed in Box 36.1.

Documentation/communication