Clinical Assessment of a Neonate

The newborn requires thorough, skilled observation to ensure a satisfactory adjustment to extra-uterine life. Assessment following delivery can be divided into three phases: the initial assessment using the Apgar scoring system, transitional assessment during the periods of reactivity and periodic assessment through systemic physical examination. Awareness of the expected normal findings during each assessment process helps the doctor recognize any deviation that may prevent the infant from progressing uneventfully through the early postnatal period.

Initial assessment: Apgar scoring
During the first seconds of the newborn's life, complex extensive physiologic changes are occurring. It is imperative that the doctor makes astute observations during this time. One of the methods used to assess the newborn's immediate adjustment to extra-uterine life is the Apgar scoring system, developed by Virginia Apgar in 1952.

The score is based on observation of heart rate, respiratory effort, muscle tone, reflex irritability and color. Each item is given a score of 0, 1 or 2. Evaluations of al five categories are made at 1 and 5 minutes after birth and may be repeated until the infant's condition stabilizes. Total scores of 0 to 3 represent severe distress, scores of 4 to 6 signify moderate difficulty, and scores of 7 to 10 indicate absence of difficulty in adjusting to life. Studies have shown tat a 5 minute score of 0 or 1 correlates with a 50% neonatal mortality rate. In terms of morbidity, children with Apgar scores of 0 to 3 exhibits three times as many neurologic abnormalities at 1 year of age as do children with a 5 minute score of 7 or higher.

The heart rate is the most evaluative of the five items. A heart rate less than 100 beats/minute is indicative of severe asphyxia and usually means that some form of resuscitation is necessary. Tachycardia, or heart rate greater than 160 beats/minute, indicates moderate, but recent, asphyxia and may be poor prognostic sign. For accuracy, the heart rate should be counted for 1 minute and correlated with the infant's activity, Detection of the apical pulse should be done with a stethoscope, although palpation of the umbilical cord at its junction with the abdomen is reliable, and visible pulsations of the cord may be counted.

Respiratory effort is evaluated as an index of adequate ventilation. If the respirations are slow, shallow, irregular, or gasping, they are indicative of respiratory distress.

Muscle tone refers to the degree of flexion and resistance offered by the neonate when the doctor attempts to extend his extremities. The normal infant's position is one of flexion- the extremities are flexed and close to the body and the fist in tightly clenched. At the other extreme, an asphyxiated infant is limp and offers no resistance.

Reflex irritability is judged by the neonate's response to passing a catheter through the nose after suctioning. It an also be evacuated by slapping the sole of the foot with the palm of the hand. Flicking the sole of the foot with the finger or slapping the buttocks should be avoided when attempting to elicit a response. The usual response from a healthy newborn is a loud, angry cry. A moderately depressed infant demonstrates his annoyance by facial grimace, but a severely depressed neonate has no behavioral response.

Color is indicative or peripheral tissue oxygenation. Few newborns are completely pink at 1 minute after birth; most continue to have same blueness of the extremities, whereas the rest of the body is pink. Pallor and cyanosis all over the body are indicative of a severely asphyxiated neonate. In evaluating color of nonwhite newborns, it is important to inspect the color of the mucous membranes of mouth and conjunctiva as well as the color of the lips, palms of the hands, and soles of the feet.

Infant evaluation at birth-Apgar scoring system
The '0' Score
This score is given when there is absence of heart rate and respiratory effort. Limp muscle tone, nor response to reflex irritability and color is blue or pale.

The '1' score
When Heart rate is slow (less than 100 beats/minute) and respiratory effort is also slow or irregular. Also the score is given when there is some flexion of extremities, grimace reflex irritability and color pf body is pink, extremities are blue.

The '2' score
When heart rate is greater than 100 beats/minute. The child cries loudly and good, there is active motion of the child, cough or sneezing is experienced by the chil
The newborn requires thorough, skilled observation to ensure a satisfactory adjustment to extra-uterine life. Assessment following delivery can be divided into three phases: the initial assessment using the Apgar scoring system, transitional assessment during the periods of reactivity and periodic assessment through systemic physical examination. Awareness of the expected normal findings during each assessment process helps the doctor recognize any deviation that may prevent the infant from progressing uneventfully through the early postnatal period.

Initial assessment: Apgar scoring
During the first seconds of the newborn's life, complex extensive physiologic changes are occurring. It is imperative that the doctor makes astute observations during this time. One of the methods used to assess the newborn's immediate adjustment to extra-uterine life is the Apgar scoring system, developed by Virginia Apgar in 1952.

The score is based on observation of heart rate, respiratory effort, muscle tone, reflex irritability and color. Each item is given a score of 0, 1 or 2. Evaluations of al five categories are made at 1 and 5 minutes after birth and may be repeated until the infant's condition stabilizes. Total scores of 0 to 3 represent severe distress, scores of 4 to 6 signify moderate difficulty, and scores of 7 to 10 indicate absence of difficulty in adjusting to life. Studies have shown tat a 5 minute score of 0 or 1 correlates with a 50% neonatal mortality rate. In terms of morbidity, children with Apgar scores of 0 to 3 exhibits three times as many neurologic abnormalities at 1 year of age as do children with a 5 minute score of 7 or higher.

The heart rate is the most evaluative of the five items. A heart rate less than 100 beats/minute is indicative of severe asphyxia and usually means that some form of resuscitation is necessary. Tachycardia, or heart rate greater than 160 beats/minute, indicates moderate, but recent, asphyxia and may be poor prognostic sign. For accuracy, the heart rate should be counted for 1 minute and correlated with the infant's activity, Detection of the apical pulse should be done with a stethoscope, although palpation of the umbilical cord at its junction with the abdomen is reliable, and visible pulsations of the cord may be counted.

Respiratory effort is evaluated as an index of adequate ventilation. If the respirations are slow, shallow, irregular, or gasping, they are indicative of respiratory distress.

Muscle tone refers to the degree of flexion and resistance offered by the neonate when the doctor attempts to extend his extremities. The normal infant's position is one of flexion- the extremities are flexed and close to the body and the fist in tightly clenched. At the other extreme, an asphyxiated infant is limp and offers no resistance.

Reflex irritability is judged by the neonate's response to passing a catheter through the nose after suctioning. It an also be evacuated by slapping the sole of the foot with the palm of the hand. Flicking the sole of the foot with the finger or slapping the buttocks should be avoided when attempting to elicit a response. The usual response from a healthy newborn is a loud, angry cry. A moderately depressed infant demonstrates his annoyance by facial grimace, but a severely depressed neonate has no behavioral response.

Color is indicative or peripheral tissue oxygenation. Few newborns are completely pink at 1 minute after birth; most continue to have same blueness of the extremities, whereas the rest of the body is pink. Pallor and cyanosis all over the body are indicative of a severely asphyxiated neonate. In evaluating color of nonwhite newborns, it is important to inspect the color of the mucous membranes of mouth and conjunctiva as well as the color of the lips, palms of the hands, and soles of the feet.

Infant evaluation at birth-Apgar scoring system
The '0' Score
This score is given when there is absence of heart rate and respiratory effort. Limp muscle tone, nor response to reflex irritability and color is blue or pale.

The '1' score
When Heart rate is slow (less than 100 beats/minute) and respiratory effort is also slow or irregular. Also the score is given when there is some flexion of extremities, grimace reflex irritability and color pf body is pink, extremities are blue.

The '2' score
When heart rate is greater than 100 beats/minute. The child cries loudly and good, there is active motion of the child, cough or sneezing is experienced by the chil