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Friday
Jul282006

Newborn Exam (and more!)

I know several other midwife bloggers chronicalled how they did their newborn exams, but I was recently asked about the HBAC birth and the baby's ears... what does having little cartilage have to do with dating a baby? So, because I didn't blog how I do newborn exams, I thought I would do a little here. It really is supposed to be a standardized method, though, so I will also share links with how the exams were meant to be accomplished.

(While I tend to be somewhat loose with the exams, as I wrote this, I think I am going to tighten up my standards. Especially since I'm teaching an apprentice!)

Observationally, I look at the baby's skin. Is it covered with lanugo (the hair that covers babies in the womb)? Is there lanugo just on the baby's back, shoulders and ears (the most common places for it to be if it isn't everywhere)? Or is most or all of the lanugo gone. The amount of lanugo can speak for where in the pregnancy the baby is - much is early, little to none is mature.

However, a group of us are doing our informal survey of LGA babies and find lanugo and vernix extremely common even in post-mature/post-dates babies. If we went by lanugo and vernix alone, the babies would look like 34 weekers! I have yet to find any information in any literature about this, though. I can't possibly be the only one to notice it, can I? I believe there is some disconnect in the maturing of the baby because of insulin issues... either insulin resistance or an insulin overload or not enough because of mom eating so very much. I would sure like to see someone else write about this. I'm going to start taking pictures of the phenomenon, though. Just to share.

Did you know that meconium is made up largely of lanugo? The baby sheds it into the amniotic fluid and then swallows it during its practice sessions for the outside world. Could be why meconium is blackish, eh? And while we're on lanugo in utero, I haven't seen blonde lanugo... any of you NICU nurses seen that? Is it always black? What would that mean? Is black hair more protective than blonde?

Is the skin translucent? Can I see blue veins throughout the baby's body? Of course, it makes a difference whether the baby is Anglo, Hispanic, Asian or of African descent. With Anglo babies with pale parents, it is much easier to see their veins even if they aren't early. Darker skinned babies aren't as likely to show their veins, even if they are some early. They definitely are lighter skinned than they will be later, but it can be deceptive, looking for those veins.

Does the baby have vernix? Or is the baby dry and peeling. The more vernix (typically), the earlier the baby. Dry and peeling babies tend to be pretty darned late in the womb. There might not be lots of extra amniotic fluid and if the vernix disappeared awhile ago, the baby hasn't been covered from the effects of the saltiness of the amniotic fluid.

Does the baby have a layer of fat on him/her? Or does the baby look like s/he is wearing a coat of loose and not-fitting skin. Is the baby really fluffy fat? Or normal-fatted.

Checking out a baby's fat stores is important for temperature regulation. Babies with an ample store of fat can withstand more cold stress than a baby without. Not that we want to stress the baby at all!

Do you know the difference between brown fat and white (adipose) fat? Brown fat is stored around the base of the neck and shoulders of the newborn and is burned off quickly simply by helping the baby remain warm. Brown fat is a heater (so to speak) for the baby, but once the brown fat is burned, the baby best be ready to regulate his or her own temperature or respiratory distress can set in because of cold stress. Some babies are born without a good supply (those babies with moms with metabolic disorders? Older babies and babies whose moms might not have been well-nourished are included.) and are much more susceptible to cold stress that dashes right to respiratory distress.

Why would cold stress lead to respiratory distress in the first place?

(In a very simplistic explanation...) For babies, heating their bodies takes precedence over any other function. They will divert energy from every other part of their bodies to accomplish their task. Breathing quickens as the internal organs are more deprived of oxygen - the baby is working harder with breathing faster, thereby increasing the amount of calories the brown fat is burning - or should be burning. Respiratory efforts quickly become labored... retractions (the chest caving in during inspirations), nasal flaring (the nostrils widening during inspirations) and grunting (a sound I cringe hearing - can be anything from squeaks to loud snores - and many shades inbetween). Each of the above activities requires a great deal of energy to do and the baby, once out of stores of calories (energy), eventually quits trying altogether and stops breathing.

So, please keep your babies warm! It's why we dry babies with warm towels/blankets and then change the towels out right away for new ones. The baby's head is dried and a warm hat put on. So much of their heat leaves through the head (as anyone living in the northern climes will tell you); it is crucial to keep a hat on them during the transition to the outside world.

When I lift a baby onto mom's belly (or as she is lifting the baby), I check the spine, feet and hands quickly and silently. If there is an anomaly, I want to know sooner than later. Especially if it is a meningocele (spina bifida), transporting immediately and protecting the site is incredibly important.

If the baby is doing great on his/her own, I stay out of the space and let everyone catch their breaths. If the baby needs help, one of the things one of us does is listen to the heart to see if anything obvious is happening there. Clicks and whooshes can be hard to detect sometimes, but obvious heart problems can usually be heard quickly and the baby transported. Babies with heart difficulties also tend to stay bluish, mostly around the noses and mouths (central cyanosis)... I have also seen it around the heart, too, but I don't know if that has any clinical significance (I haven't seen any information about that) or not.

While we're on the subject, there are some babies that turn dusky (blue-grayish) when lying down, but who pink up when sitting. I've asked several professionals (pediatricians and neonatologists) and they explained that some babies' valves don't completely close with the first breath as they are supposed to do. They said sometimes it can take a couple three days for everything to seal the way it is supposed to and to just keep the baby upright until they are able to maintain their pink color lying down. We even have mom nurse with the baby more upright than lying down. This is not a baby in respiratory distress, simply a case of the baby turning darker when reclining. There is a difference.

Just looking at the few things mentioned above can give us a pretty good idea of what is going on with the baby. They happen in mere seconds, but can move us to either sit on our haunches or to move into action to help the baby out.

Babies breathe very erratically, but brand newborns should be making some breathing attempts that are productive. A baby crying, telling you his/her story or even some mild grutzing (different than grunting) is fine. A baby that is stunned, turning lighter, and then darker instead of pinker (even dark-skinned babies are pretty light at birth) is not a good thing.

Listen to the lungs. Are they "wet"? Wet lungs sound crackly, kind of like cellophane being crinkled. Lungs that are really crackly, like Easter basket cellophane, are wetter than Saran Wrap crackly.

Newborns aren't supposed to wheeze. If I heard wheezing, I'd be seriously considering a transport if I didn't find the cause (positioning?) quickly.

Many schools of thought exist regarding what to do for wet lungs. The most popular for midwives seems to be 1) nurse the baby 2) give blow-by oxygen. This can also assist a baby with transient tachypnea (Transient Tachypnea of the Newborn or TTN), which many believe is the result of those wet lungs previously mentioned.

If the baby moves deeper into respiratory distress with grunting or retractions, however, it is vital to take the steps necessary, including transport, to keep the baby healthy and stable. It is often grunting that is heard before retractions are seen since babies are covered on mom's belly. I know it seems intrusive sometimes, but that is why someone would move the blankets for a moment to get a glimpse of what the baby's chest is doing. Retractions, in my experience, come before grunting. Nasal flaring can be such a subtle sign, too many midwives/students/apprentices can miss it. Be alert to what your baby is doing! And help quickly if you see the magnification of symptoms of respiratory distress.

(Have I strayed from the topic? I don't think so!)

So, everything is fabulous and mom and baby are transitioning well. Periodic glances and listens to the baby (usually by the assistant in my experience) allow you to relax and do other things like deliver the placenta, clean up or take a breather in the next room. Birth rooms can be awfully warm (for the baby... our comfort is not important... didn't we just discuss that?), so stretching your legs and getting some cool air can be great for the attendants.

A couple of hours after the birth, or whenever the family is ready, we will do the newborn exam. The official one that is written down on the chart.

I tend to weigh large babies pretty quickly (within 30 minutes) so I have a gauge for whether they need extra nudging towards nursing to try and avoid any issues with hypoglycemia. I've been know to "borrow" another mom's milk if the baby starts to get sleepy and needs to nurse NOW.

The most common measurement of a baby's gestational age and well-being (the Apgar would be the most common measurement of immediate well-being) is the New Ballard Scale and this reference (click the link in this sentence) is a really good one since it explains many of the nuances the graphics might miss. The graphics chart at the bottom of the .pdf file is the one that is in many, if not most, charts for newborns around the United States. The test used to be called the Dubowitz, but it was updated and now the Ballard has replaced it. Many providers, especially older ones, still refer to it as "the Dubowitz".

So, now we come to the part where the cartilage in the ear becomes the focus. The more pliability in the ear, the less cartilage there is; the younger the baby, the more pliable the ear.

Creases on the sole of the baby's foot also are taken into consideration (called the Plantar Creases). Babies who have creases covering more surface area of the foot are more mature.

I'll let you play around on the website because it really does go into great depth, much more than many teachers I had (but not textbooks).

All of this said, babies are not graded so they pass or fail. This is not an SAT. This is a guide to use as an indication for how (gestationally) old the baby is. When I mapped out the HBAC baby and found his gestational age to be about 38 weeks, then the information becomes relevant and good for mom to know she wasn't crazy when she knew her baby wasn't ready to be scheduled for his birth 4 weeks earlier.

Can babies be "advanced" in some areas and "premature" in others? Absolutely! It's why there are places to add the numbers up. Remember my observation that babies of moms with insulin issues come with loads of vernix and lanugo, but are mature in every other way? Their numbers would combine for a final score and variations are taken into account. It is part of why I like the test - because pieces of the puzzle can be separated from the whole and noted.

In the end, those of us who do homebirth tend to see those babies that fall right at mature... 37-42 weeks... and it isn't typically an issue. However, if we see a baby that might be much younger, signs of respiratory distress can take on a whole new meaning.

I know this was long, but I hope there were helpful parts. If you need anything clarified or explained, just let me know.

I need to reiterate that the information I mention is second nature to most of us now. By doing copious exams, we learn. It takes volumes of exams and newborns to be able to glance at an emerging baby to see if s/he is okay. Sure, they surprise you once in awhile (don't they all?), but generally, having this information at the ready can keep your baby safe and well.

You can practice by doing the Ballard on every newborn you see. Doing a 3 day home visit? Do another Ballard for practice. Visiting your sister's newborn in the hospital? Take the opportunity to learn. Learn everywhere and in every way you can.

You will never regret it.

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Reader Comments (15)

Wow! What a lot of knowledge you have.

My Grandma was a midwife ( retired in the early 1950s) and we have her log books. Fascinating but not to be read before breakfast.

July 28, 2006 | Unregistered CommenterCherrypie

Fabulous post!
I just wanted to comment that 4 of my 6 babies have had blonde lanugo. One had black and the other had none. The one that had black was born the earliest and the one that had none was born the latest. Not sure if there is any significance there, but something I think I'll start looking at.

July 28, 2006 | Unregistered CommenterBabylady

Cherrypie: *I* want to see your mom's logs!!! I could eat breakfast, lunch and dinner without skipping a beat. Do you live anywhere near Southern California? I would love, love, love to read what she wrote. They could be published, you know, right?

Babylady: thanks! BLONDE LANUGO! It *does* exist! How cool. I laughed after writing the post thinking, "gee, 80% of my clients have been Hispanic... wonder why I haven't seen blonde lanugo!"

I look forward to poking around both of your sites. Thanks for being here!

July 28, 2006 | Unregistered CommenterNavelgazing Midwife

Thanks for answering my question! My baby had blonde lanugo and a fairly thick covering of it. He looked just like a little monkey :)

He also had wet lungs and they did a stomach washout on him in the NICU. Not sure why - said he had swallowed blood in the delivery etc? Poor baby.

My third baby, by c-sect, didn't have wet lungs or anything wrong with him.

For a while I thought maybe it was me that couldn't give birth properly that made the first two ill.

PS. How on earth did I spell lanugo as laguno in my previous comment ?? Been a long time since I had to think about it I guess!

July 29, 2006 | Unregistered CommenterAsh

interesting!

I stopped putting hats on babies about a year ago. I don't think they really help unless they're wool. That said, I think there is something beneficial to the change in body temperature with babies. I just think it hasn't come to full knowledge yet.

I don't do blow-by oxygen on babies unless there is something obviously wrong and we need to transport. It's not evidence-based and I feel like skin to skin is nicer, but cold O2 in the face is not so nice. In fact, I don't use my O2 much at all anymore since learning alot about it from a fab midwife named Gail Hart.

I think I mostly just observe for that first hour baby is in mom's arms. We've gotten to a point where we may have the baby away for about 5 minutes total doing things. Everything else, in my opinion, can wait for the third day postpartum or so.

Wet lungs and TTN are so normal, I think in many babies. Homeopathic Antimonium Tart and nursing seem to help ALOT. I don't worry about it much unless there are other s/s present, but I give a little speech to parents about what to look for.

It's so interesting to read the differences! :)

July 29, 2006 | Unregistered CommenterSage Femme

Great post! And a printable chart for my clipboard to take to births too!

We do not use baby hats. Ever since taking a cord clamping workshop with Anne Frye (she says if the cord is left until all pulsing stops at the umbilicus -- usually 2-3 hours -- that babies have no trouble with temps) and NNR with Karen Strange (who says the tube cotton hats are "worthless") we have not been using hats. Gail Hart also suggests that hats are unecessary, and that they interfere with maternal-infant bonding as the mom doesn't touch, kiss and fondle the baby head when there is a hat on it. Gail says she is on a personal campaign against bulb syringes and baby hats. :-)

That said, we live in a hot climate and there are no cold rooms here. An Amish baby when the temp in the room is cold may benefit from a (wool) hat.

I'm thinking of buying some fine wool to crochet baby hats if we ever find them necessary.

July 29, 2006 | Unregistered CommenterOne Hot Mama

Hmmm... I don't want you to get the idea that the baby spends any time but a few moments out of mom's arms. We do the newborn exam typically when mom is in the shower, but always ask if she wants to watch or hold the baby while we do it. All can be done right in someone's arms except for a couple of turns and checking of relexes.

I also have not turned on my O2 in ages... once recently for a mom who felt like she was going to faint, but I do not resuscitate with O2 anymore either since the research has come out saying it isn't helpful and might actually be harmful.

I do not have as much of a problem with blow-by on low... and I cup my hand around it, maybe warming it a little?

You give me good things to think about.

I am *extremely* aware of keeping the baby warm and dry, including the hat (keeping it dry, too) probably because I have seen babies (plural)crash because of cold stress (not since I was in Texas years ago, but it was quite the education). I can't imagine ever removing the hat as a normal part of my newborn ritual.

But then again, I also never thought I wouldn't suction with meconium, either.

Good things to think about... thanks.

July 29, 2006 | Unregistered CommenterNavelgazing Midwife

Look! Again! Stuff to think about. Where did y'all get this information?! I feel out of the loop. :(

What if the baby has a wool allergy? How come when I remove a hat on a hot baby, the temperature goes down? What about covering mom and baby's head with a blanket? You have zero concern for the baby's temperature? Do you bring a heater as Michel Odent suggests and crank it when the baby is being born so they can sit in heat and be with each other?

Okay, you students... are you watching this? Learning, even for a pretty darned experienced midwife! The learning never stops!!

And while I have a bulb syringe in the birth bowl, I haven't used one in YEARS. I also have a DeLee there... just an odd ritual I can't seem to do away with even though I know I won't be using them. I don't know where that comes from.

Learning. Learning. Always learning.

July 29, 2006 | Unregistered CommenterNavelgazing Midwife

Barb, my preceptor has taught me to do things *exactly* the way you do/observe. It's great having the opportunty to read through again and fine tune our practices.

She (my preceptor) mentioned to me very recently (at our last birth?) how she'd heard about the new "campaign" to do away with hats. I'm assuming it's a rather new theory!

It seems blonde lanugo is all we ever see--with the majority of our clients being caucasian. ;)

Again, thanks so much for your writing and being such a great resource.

July 29, 2006 | Unregistered Commenterladyelms

Much of the discussion on baby hats took place on the Radical Midwives of America yahoogroup (http://groups.yahoo.com/group/rmamidwives/) last June. Also, Anne Frye discusses thermoregulation in several places in her Vol II of Holistic Midwifery, most notably from pp 284-290 and on p 493.

Hope that helps!!

July 29, 2006 | Unregistered CommenterOne Hot Mama

for me, the idea about the hat came from two places: Gail and a chiropractor. The DC explained that putting something tight and constrictive on their heads does not allow for a normal transition with skull plates retreating, etc.

I don't do temps on babies. It fluctuates so much and there's so much disagreement about what is "normal" - it's alot like blood sugars on babies. There hasn't been enough conclusive evidence to show what a "normal" value is vs an abnormal (aside from those really obvious high/low numbers).

If I had a baby that was having issues oxygenating itself and/or I was resuscitating, I would work on whole body warmth, but I don't think the head would be a huge factor.

I think what happens with newborn care is we put what we associate with our own comfort on the babies. I think this leads to a huge misunderstanding about what nature intended for the transition. We know that the mother's chest cools down and warms up based on her baby's needs when they're skin to skin. If nature intended for all babies to suddenly become ill or not survive because they weren't wearing a hat, wouldn't they come with it? And to some extent, they do - vernix is an excellent protectant against chills, as is lanugo and that subcutaneous brown fat.

I always go back to how we were designed when I question things. If there's a crisis, then fine, things change, but for a normal transition, I think babe in mom's arms without any other hands on or in the birth bubble is key.

My preceptor always had a rush of motion at the moment of birth. As the assist, I was to get the hat on the baby, get a blanket on the baby, listen to heart tones/respirations, etc. We had a high rate of hemorrhages.

Since keeping my hands off all babies for at least a half hour after the birth, I have noticed a HUGE decline in hemorrhage and such a beautiful picture of that incredible birth bubble that moms need to stay in.

I don't keep the rooms warm because coming out of a 99'-100' environment, even an 80' room is going to be cool. I honestly think there are some benefits to the baby re: temperature fluctuations and changes that are vital for the transition.

It's an interesting topic and one that has been discussed on the RMAMidwives list. But, I don't think many midwives are ready to give up any of these things. I know for me, in my practice, it feels right and I've noticed fewer complications.

I've also noticed so much more touching and kissing of the baby's head by mom and exploration of the whole body since leaving the hat and blanket off. Sometimes the mom asks for a blanket, but that's different. Most of my clients birth in water and that's a different environment, too.

:)

July 30, 2006 | Unregistered CommenterSage Femme

true wool alergic reactions are exceedingly rare....rather it's the modern processing methods, and the harsh chemical residue that 99% are reacting to...

So if wool reactions are a concern, I'd find a nice handspun wool, or a "in the grease" fisherman's wool

now if i could just find time to get back to my knitting, spinning, and weaving....hmmm...wonder if there would be enough of a market willing to pay for a nice handspun, handwoven shawl and matching baby hat?

July 30, 2006 | Unregistered CommenterOpening Pandora

Regarding babies who need to be kept upright b/c of the heart valve not closing completely, could you administer ibuprofen as it is a prostaglandin inhibitor?

July 31, 2006 | Unregistered CommenterLindsay

coming from all hospital based training, I always hated the rush when a baby was born. Poor little things first experience in the world in a hospital often involve rough rubbing and pinching/tapping of feet, a bulb syringe being shoved down your throat, and parents get the impression that we have to do a lot to get the baby going. I've worked hard to change this in my practice. I lift baby immediateley to mom's tummy, or have mom pull the baby up herself, and I don't touch the baby at all unless they are truly struggling. Turns out many babies are quiet at birth, and often blink and sputter, and take a few minutes to cry, if they cry at all. We don't use hats at all until after a baby is bathed usually, and usually cover baby with a blanket, remove it for a dry one in a few minutes, and then cover mom and baby with a warm blanket without doing a lot of rubbing or drying of the baby. I've not had a cold stressed baby this way yet (but I do see cold babies when the mom and family insist on passing the baby around in the first hour, no matter how we wrap them or put hats on.)
Like sage femme, I like to fade into the background once the baby is out, and just keep an eye out for bleeding, and watch that baby does pink up. I feel like I see a difference in how parents respond to their baby when they are the only ones to touch the baby in the first few minutes, vs when the nurses are all over doing Important Procedures and creating a sense of urgency.
Doesn't make sense to me that babies would be born with an urgent need for a hat, vs their mother's arms and warm skin, and breasts.

July 31, 2006 | Unregistered Commenterfpmama

I must say the body temp discussion interests me- I had a very quick easy vaginal delivery in a hospital and was able to hold my daughter right after delivery, but then she was taken from me to be put in a warmer because she was "too cold". I tried to argue because she was obviously okay to me, and she cried when they took her away, but they wouldn't listen. It really irritated me and it's one of the reasons why I'll be having a homebirth next time.

March 6, 2010 | Unregistered CommenterSara

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