Managing Newborn Assessments

Required Documents

• Maternal prenatal record with lab results
• Labor and delivery summary including intrapartum fetal monitoring
• Delivery room resuscitation record (NRP documentation if applicable)
• Birth weight, length, and head circumference measurements
• Cord blood lab results (if obtained)

If any maternal lab results are unavailable, flag with [VERIFY] and escalate to attending before discharge planning proceeds.

Step 1 — APGAR Scoring (1 and 5 Minutes)

Score each of the five APGAR components at 1 minute and 5 minutes of life:

Scoring rules

• Record 1-minute score to assess transition status.
• Record 5-minute score to evaluate response to any intervention.
• If 5-minute score is < 7, continue scoring at 10, 15, and 20 minutes per NRP guidelines.
• APGAR does not guide resuscitation decisions — resuscitation follows NRP algorithm independently.
• Document who assigned the score and their role.

Step 2 — Gestational Age Assessment (New Ballard Score)

Perform the New Ballard Score within the first 12-24 hours of life:

Neuromuscular Maturity (6 criteria)

• Posture, square window (wrist), arm recoil, popliteal angle, scarf sign, heel to ear

Physical Maturity (7 criteria)

• Skin, lanugo, plantar surface, breast, eye/ear, genitalia (male or female)

Interpretation

• Total score range: -10 to 50, corresponding to 20-44 weeks gestation
• Compare Ballard-estimated GA to obstetric dating (LMP, early ultrasound)
• Discrepancy > 2 weeks between Ballard and obstetric dates warrants documentation and attending review
• Classify: SGA (< 10th percentile), AGA (10th-90th), LGA (> 90th) using Fenton or Olsen growth curves for preterm, WHO for term

Step 3 — Comprehensive Newborn Physical Examination

Perform the systematic head-to-toe exam within 24 hours of birth. Document each system:

Head/Fontanelles

• Anterior fontanelle size (normal: 1-4 cm diamond), posterior fontanelle (normal: < 1 cm, may be closed)
• Molding, caput succedaneum vs. cephalohematoma (crosses vs. does not cross suture lines)
• Subgaleal hemorrhage screen: boggy diffuse swelling crossing sutures — emergent if present

Eyes

• Red reflex bilaterally (absent = refer ophthalmology urgently for retinoblastoma, cataract rule-out)
• Conjunctival discharge, pupil symmetry

Cardiac

• Precordial activity, heart rate, rhythm
• Murmur present? If yes: timing, grade, location, radiation
• Pre- and post-ductal pulse oximetry per CCHD screening protocol (see Step 5)
• Four-extremity blood pressures if coarctation suspected

Hips

• Ortolani maneuver (reduction of a dislocated hip) and Barlow maneuver (provocation of dislocation)
• Document: stable, clicky (benign ligamentous), subluxable, dislocatable, or irreducible
• Risk factors for DDH: breech presentation, family history, female sex, oligohydramnios

Genitalia

• Male: testicular descent (bilateral? unilateral?), hypospadias, hydrocele
• Female: normal labia, vaginal patency, clitoral size
• Ambiguous genitalia: do NOT assign sex; emergent endocrine consult

Neurological

• Tone: resting posture, pull-to-sit head lag
• Primitive reflexes: Moro, palmar/plantar grasp, rooting, sucking, stepping
• Alertness and cry quality

Step 4 — Weight Classification and Growth Plotting

• Plot birth weight, length, and head circumference on appropriate growth chart:
  • WHO growth standards for term infants (≥ 37 weeks)
  • Fenton preterm growth chart for < 37 weeks
• Calculate weight-for-gestational-age percentile
• SGA < 10th percentile — screen for hypoglycemia per AAP protocol (glucose < 25 mg/dL in first 4 hours, < 35 mg/dL at 4-24 hours triggers intervention)
• LGA > 90th percentile — screen for hypoglycemia, assess for infant of diabetic mother (IDM) complications
• Macrosomia (> 4000g term): evaluate for birth trauma (clavicle fracture, brachial plexus injury)

Step 5 — Mandated Newborn Screening

Critical Congenital Heart Disease (CCHD) Screening

• Pulse oximetry on right hand (preductal) AND either foot (postductal) after 24 hours of age or before discharge
• Pass: both readings ≥ 95% AND difference ≤ 3%
• Fail: any reading < 90% — immediate echocardiogram
• Repeat: any reading 90-94% OR difference > 3% — rescreen in 1 hour, up to 3 attempts

Metabolic Newborn Screen (state-specific panel)

• Collect after 24 hours of age and adequate protein feeding
• Core conditions (ACMG-recommended): PKU, congenital hypothyroidism, galactosemia, sickle cell disease, CF, CAH, biotinidase deficiency, MCAD, and others per state mandate
• Document specimen collection time, feeding status, and any transfusions (which can affect results)

Hearing Screen

• OAE (otoacoustic emissions) or ABR (auditory brainstem response) before discharge
• Refer failures for diagnostic ABR by 3 months of age per JCIH guidelines
• Risk factors for hearing loss: NICU stay > 5 days, family history, ototoxic medications, hyperbilirubinemia requiring exchange transfusion, CMV

Step 6 — Risk Factor Documentation and Discharge Readiness

Document the following risk assessments before discharge:

• Hyperbilirubinemia risk: pre-discharge bilirubin level plotted on Bhutani nomogram; assign risk zone (low, low-intermediate, high-intermediate, high)
• Feeding adequacy: documented latch assessment (if breastfeeding), stool and urine output, percent weight loss from birth (> 7% by day 3 triggers lactation evaluation)
• Infection risk: GBS status, duration of rupture of membranes, maternal fever, and antibiotic administration per neonatal early-onset sepsis calculator
• Social risk: safe sleep environment confirmed, car seat available, follow-up appointment within 48 hours of discharge per AAP guidelines

Checkpoint B — Assessment Review

Before finalizing the newborn assessment record:

• APGAR scores recorded at 1 and 5 minutes (and extended intervals if < 7 at 5 minutes)
• Gestational age assessment completed with SGA/AGA/LGA classification
• Complete physical exam documented with all systems addressed
• Growth parameters plotted on appropriate charts
• CCHD pulse oximetry screening result documented with pass/fail/refer
• Metabolic newborn screen specimen collected with time and feeding status noted
• Hearing screening completed or scheduled with result documented
• Pre-discharge bilirubin plotted on Bhutani nomogram with risk zone assigned
• Feeding assessment documented with weight loss percentage calculated
• Follow-up appointment scheduled within 48 hours of discharge
• All [VERIFY] flags resolved or escalated to attending

Quality Audit

Guidelines

• Follow AAP "Guidelines for Perinatal Care" (8th edition) for examination timing and content
• Use NRP (Neonatal Resuscitation Program) 8th edition for delivery room assessment protocols
• Apply the New Ballard Score per Ballard et al. for gestational age assessment
• Follow AAP 2022 hyperbilirubinemia clinical practice guideline for bilirubin risk stratification
• Apply ACMG Recommended Uniform Screening Panel for metabolic newborn screen
• Follow JCIH (Joint Committee on Infant Hearing) 2019 position statement for hearing screening
• Never assign sex when genitalia are ambiguous — immediate endocrine and genetics consultation
• All findings should be documented using precise anatomical terminology, not shorthand
• Escalate to attending physician for any unexpected finding, abnormal screening, or maternal concern
• This skill produces documentation for clinical use; it does not replace clinical judgment