1. Providence Clinical Academy
Perinatal Curriculum
LAST REVIEWED: May 2016

2. Newborn Assessment Atlas
*all pictures, unless otherwise noted, from Stanford University Photo Gallery (newborns.stanford.edu/PhotoGallery/)

3. Skin Findings Mongolian spot Erythema toxicum Café au lait
Mongolian spots-gray or blue-green macule or patch commonly seen on the buttocks, flanks or shoulders of African-American, Asian and Hispanic infants ; benign
Erythema Toxicum (Newborn Rash)-present in 50% of newborn; yellowish papule surrounded by a halo of erythema; benign; occurs within 5 days of birth (several weeks for PT babies)
Café au lait spots-increased melanin; *6 or more may indicate neurofibromatosis
Café au lait

4. Skin Findings Nevus simplex “Stork bites” Milia
Nevus simplex (“Stork bite”)-dilated capillaries, blanches with pressure, more prominent with crying; common-70% of newborns; may last 1-2 years or into adulthood
Milia-epidermal cysts, accumulation of sebaceous gland secretions; common- 40% of newborns; will resolve in first week of life

5. Skin Findings Forceps mark Hemangioma Nevus Forceps mark
Nevus(pigmented) – dark brown macule, 10% undergo malignant changes
Hemangioma (strawberry) – raised, lobular tumor caused by dilated capillaries, gradually increase in size for 6 months then spontaneously regress over years (1-3% occurrence)
Nevus
Hemagioma photo from: lugaluda.com

6. Skin Findings Circumoral cyanosis Acrocyanosis Mottling
Acrocyanosis – bluish color of palms of hands and soles of feet, benign in the first 48 hours after delivery; exacerbated by cold
Circumoral cyanosis – bluish color around the mouth (lips/tongue pink), benign in first hours after birth
Mottling – marbling of skin caused by dilation of capillaries, usually seen in response to chilling and disappears when warmed
Mottling

7. Large for Gestational Age (LGA) Small for Gestational Age (SGA)
Nutritional Status
Large for Gestational Age (LGA)
Small for Gestational Age (SGA)

8. Sutures, Fontanels & Bones of Neonatal Skull
Why does molding happen?
Fontanels:
Anterior
Posterior
Molding is an adaptive mechanism to facilitate passage through the birth canal
Sutures may be overlapping at birth
Fontanels should be flat when infant is quiet
AF is larger than PF
AF normally closes by 18 months
PF normally closes by 2 months
From: Green-Hernandez, C. Et al.

9. Breech presentation molding Overlapping coronal sutures
Head Molding
Breech presentation molding
Overlapping coronal sutures

10. Caput Succedaneum vs. Cephalohematoma
Soft tissue edema
Edema extends across suture lines
Present at birth
Poorly defined borders
May include ecchymosis
Disappears within 48 hrs
Collection of blood between the periostium and the skull
Swelling does not cross suture lines
Not usually present at birth
Usually due to traumatic birth
Increases in size over 1st day of life
Takes months to resolve

11. Caput vs. Cephalohematoma

12. Eye Assessment
Iris is normally dark blue until 3-6 months of age then may change
Sclera should be white
Pupils should be equal, round and react to light
Distance between inner and outer canthus of one eye should approximate the inner canthal distance; abnormal spacing is associated with various syndromes

13. Subconjunctival hemorrhage
Eye Findings
Dysconjugate eye movements
Subconjunctival hemorrhage
Eyelid edema after birth is common; resolves over first few days
Dysconjugate eye movements-eyes may cross of diverge intermittently; normal finding in the first few months of life
Subconjunctival hemorrhage – results from breakage of small blood vessels during pressure of delivery; resolves in several days
Eyelid edema

14. Ear Assessment Position Pinna External auditory canal
Normal position: 30% of pinna lies above imaginary line drawn between inner and outer canthus of eye
Pg. 605 in Perinatal book
Low-set ears may be associated with various syndromes and chromosomal anomalies
Pinna should be completely formed; firm by wks gestation
External auditory canal should be visible
Position
Pinna
External auditory canal

15. Ear Findings: Pits & Tags
Pits and tags may be familial or part of a syndrome; increased incidence of deafness and renal anomalies

16. Ear Findings External canal not visualized Low –set ears
Small, incompletely formed

17. Ear Findings “lop” ear “cup” ear
“lop” ear and “cup” ear may be isolated, cosmetic findings

18. Nose Assessment Size/shape/symmetry Patency Flaring?
Size and shape usually familial
Broad, flat bridge may be associated with Down Syndrome
Infants are obligate nose breathers – assess patency
Mild stuffiness right after birth is normal
Nasal flaring is abnormal
Asymmetry may be due to positional deformity

19. Mouth Assessment Size/shape/symmetry Palates Reflexes Epstein’s pearls
Color
Epstein’s pearls
Assess mouth for abnormal shape and size of mouth, lips, tongue, filtrum, frenulum and mandible
Hard and soft palates should be intact
Rooting and sucking reflexes are assessed
Epstein’s pearls – benign small white epidermal cysts common on palate and gums; disappear after a few weeks

20. Mouth Findings Cleft Palate Cleft Lip Tight frenulum “tongue tied”
Cleft lip: May be unilateral or bilateral, can vary from a notch in the lip to complete separation extending up to the floor of the nose
Tight frenulum: May make feeding difficult requiring frenulectomy
Tight frenulum
“tongue tied”

21. Mouth Findings Natal teeth Microganthia
Natal Teeth: If mobile, may need to be removed to reduce aspiration risk
Micrognathia: Small mandible with very recessed chin; associated with chromosomal conditions
Microganthia

22. Neck & Clavicles Assessment
Fractured
Clavicle
Cystic hygroma
Torticollus: injury to the sternocleidomastoid muscle; more common on the R side; congenital or during birth
Stretching and PT
Fractured clavicle: May see swelling, discoloration, asymmetric arm movements ; may feel crepitus on palpation
Neck: May see webbing or mass; webbing is associated with syndromes
Cystic hygroma is most common mass: can effect breathing and feeding; surgical intervention
Neck
webbing
Cystic hygroma photo from adhb.govt.nz

23. Chest/Lung Assessment
Normal Findings:
Respiratory Rate: , irregular ok
Breath sounds: Clear and equal bilaterally
No grunting, nasal flaring or retractions
Prominent xyphoid not uncommon
Transient breast enlargement due to maternal estrogen
Nipple spacing should be 25% of full chest circumference

24. Chest/Lung Assessment
Intercostal and subcostal retractions are signs of respiratory distress or increased work of breathing

25. Chest/Lung Assessment
Extra nipple
Extra nipple(s) are a non-pathological finding
Pectus excavatum: Chest appears to cave in; generally benign resulting in no functional impairment
Pectus excavatum

26. Cardiovascular Assessment
Observe
Color
Visible precordial activity is okay during 1st 6 hours of life
Auscultate
Heart rate & rhythm
PMI location
Murmurs
cyanosis, pallor, plethora, mottling
120–160, term infant may be 80–90 during sleep but should increase when awakens; S1 S2 without irregularity
PMI: normally lateral to left midclavicular line at 4th intercostal space
Murmurs: may be related to transition during 1st 48 hours as opposed to CHD; loudest murmurs are often associated with relatively benign defects

27. Cardiovascular Assessment
Palpate
Capillary Refill Time (CRT)
Pulses
BP (if ordered):
Cuff size should be 40-50% of arm circumference (or thigh circumference for lower extremity BP)
Systolic BP in thigh should be 5-10 mm Hg higher than in arm.
Capillary Refill Time (CRT):
Central vs. peripheral site, should be 3 seconds or less
Pulses:
Brachial and femoral strength and equality; bounding pulses associated with PDA
Absent femoral pulses associated with coarctation of aorta

28. Abdomen Assessment Size/shape/symmetry Auscultate Umbilical cord Anus
Normal Findings
Abdomen is slightly rounded, soft, smooth and intact
Bowel tones audible shortly after delivery
Umbilical cord has 3 blood vessels; single-umbilical artery is associated with renal anomalies
Umbilical core may be meconium-stained
Anus is patent

29. Normal drying and healing of cord

30. Abdominal Findings Umbilical Hernia Diastasis recti
Diastasis rectii – benign vertical bulge down middle of abdomen, relative weakness of fascia between rectus muscles
Umbilical hernia – most resolve spontaneously; surgery considered if still present at 2-3 years of age
Diastasis recti

31. Abdominal Findings Gastroschisis Omphalocele
Omphalocele: abdominal contents usually contained in membrane; cord inserts into sac; often associated with other anomalies
Gastroschisis: abdominal wall defect resulting in no sac covering abdominal contents; cord is discrete; low incidence of other anomalies
Omphalocele

32. Genitourinary Assessment - Female
Labia
Normal female findings:
Labia may be smooth, wrinkled or edematous
Urethra and vagina should be visible
Perineum is smooth and fingertip width
White or blood-tinged vaginal discharge is normal, may last for 2-4 weeks
Vaginal skin tags will spontaneously recede into the vagina
Vaginal Skin Tag
Vaginal Discharge

33. Genitourinary Assessment - Male
Penis
Meatus
Scrotum
Testes
Normal findings:
Penis is straight ,proportionate to body and glans covered by foreskin
Urinary meatus is midline at the glans tip
Scrotum is symmetrical
Testes are firm, smooth and equal size; palpable in the scrotal sac
Uric acid crystal (rust colored) may be seen in diaper

34. Genitourinary Assessment - Male
Hypospadias
Undescended testicles
Undescended testicles – bilateral rare in term baby, unilateral more common, often in canal
Hypospadius – the urethral meatus is positioned ventrally, incomplete foreskin development common; affects 1:250 boys

35. Genitourinary Assessment - Male
Inguinal hernia
Hydrocele
Inguinal hernia – fullness in the scrotum and inguinal area seen, more common in premature babies but term babies with hydroceles may develop hernias; a hernia that is not reducible may be incarcerated requiring immmediate attention
Hydrocele – unilateral or bilateral fluid collection in sac, can’t be “reduced”, transillumination may aid in diagnosis, resolves spontaneously

36. Genitourinary Assessment
Bladder Extrophy
Ambiguous Genitalia
Ambiguous genitalia – requires work-up to determine sex, very upsetting to parents
Bladder extrophy – requires surgical correction

37. Uric Acid Crystals High during infancy
Due to high protein content of breastmilk
Hydration is important!
Uric acid excretion is high during infancy
The high protein content of breast milk facilitates acid urine
Acid urine favors precipitation of uric acid crystals (Robson & Leung, 2006)
Good hydration is important

38. Musculoskeletal Assessment
Simian crease
Most newborns have two creases neither of which extends completely across their palms
A single transverse palmar crease or “Simian crease” is found in about 5% of newborns, frequently familial but may also be associated with Down Syndrome
Abnormalities may be deformations related to compression and position in utero rather than congenital defects
Assess for appropriate number of limbs and digits, size and symmetry of upper and lower extremities, movement, range of motion and trauma, spinal alignment and integrity and presence of lesions over spine
Normal creases

39. Musculoskeletal Assessment
Polydactyly and syndactyly are both often familial

40. Musculoskeletal Assessment
Club Foot
Club foot - may be unilateral or bilateral, feet are plantar-flexed and inverted, may be a boney deformity (rigid)or positional (moveable)
Brachial plexus injury - may occur as a result of shoulder dystocia. Affected arm is extended with hand turned medially , grasp may or may not be intact, other arm is flexed with crying, moro will be asymmetrical; if no improvement in first day, should be referred to OT/PT
Brachial Plexus Injury

41. Musculoskeletal Assessment
Breech Baby!
B before O
Barlow: Hip popped out with this manuever
Ortolani: Femoral head is reduced back into socket

42. Musculoskeletal Assessment
Myelomeningocele
Sacral dimple – most are benign, examine to make sure it is a simple pit
Myelomeningocele – neural tube defect resulting from incomplete closure of the spine, spinal cord and meninges may be external or may be covered with skin, requires surgical intervention
Sacral Dimple