INFANT BIRTH RECORD & NEWBORN EXAM
Baby's Name_____________________________________________Sex ________________
Date of Birth______________________________Time of Birth_________________________
Estimated Gestational Age___________weeks. EDD_________________ (SGA) (AGA) (LGA)
Mother's Name________________________ Father's Name___________________________
Mother's condition after birth & her reaction?_______________________________________
Gravida________ Para________ Single or Multiple Birth________ Birth Order____________
Length of Labor - First Stage__________________Second Stage______________________
Type of Birth - Vaginal_____ Cesarean_____Type of Feeding (Breast) (Bottle)___________
Was any analgesic or anesthesia used?_____ If so, what type?________________________
Mother's Blood Type & Rh____________ Infant's Blood Type & Rh_____________________
Complications in labor or delivery ________________________________________________
NEWBORN EXAM INFORMATION
Examiner's Name(s)_________________________Date/Time of Exam___________________
Axillary Temperature:(date/time)_____________________ (temp)____________degrees F / C
After the Birth:
(date/time) ______________________________ (temp)____________ degrees F / C
(date/time) ______________________________ (temp)____________ degrees F / C
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APGAR Scores:
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| APGAR |
Score 0 |
Score 1 |
Score 2 |
1 MINUTE |
5 MINUTES |
| Heart Rate |
Absent |
Under 100 |
Over 100 |
|
|
| Respirations |
Absent |
Slow (Irregular) |
Good (Cry) |
|
|
| Muscle Tone |
Limp |
Some Flexion |
Active |
|
|
| Color |
Blue/White |
Blue Hands or Feet |
Pink Totally |
|
|
| Reflex Response |
None |
Grimaces |
Sneezes or coughs |
|
|
| Total Apgar Score |
|
|
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Silverman Retraction Scores (Evaluation of Respiratory Status): |
| Feature Observed |
Score 0 |
Score 1 |
Score 2 |
Score |
| Chest Movement |
Synchronized Respiration |
Lag on Respirations |
Seesaw Respirations |
|
| Intercostal Retractions |
None |
Just Visible |
Marked |
|
| Xiphoid Retractions |
None |
Just Visible |
Marked |
|
| Nares Dilation |
None |
Minimal |
Marked |
|
| Expiratory Grunt |
None |
Audible- Stethoscope |
Audible- Unaided Ear |
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| Total Silverman Score |
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Total Score of 0 indicates no respiratory distress.
Total Score of 4-6 indicates moderated distress.
Total Score of 7-10 indicates severe distress.
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Infant Measurements:
Length______________inches Chest______________inches Head________________inches
Abdomen ________ inches Weight __________ lbs. ___________ oz. (or) __________grams
Comments _____________________________________________________________________
General Appearance:
Muscle Tone_________________________ Position of Extremities_______________________
Activity_____________________________ Cry (loud) (strong) (weak) (high-pitched)_________
Body Alignment______________________ Posture____________________________________
Body Symmetry______________________ Comments_________________________________
Excretory Function:
Passed Urine: (before) (during) (after) the birth in first 24 hours.
Passed Meconium: (before) (during) (after ) the birth in first 48 hours.
Comments______________________________________________________________________
Skin:
Texture _______________________________ Color____________________________________
Opacity _______________________________ Turgor __________________________________
Bruises _______________________________ Location ________________________________
Birth Marks ____________________________ Location ________________________________
Edema ________________________________ Location ________________________________
Lanugo _______________________________ Location ________________________________
Peeling _______________________________ Location _________________________________
Vernix ________________________________ Location _________________________________
Comments _____________________________________________________________________
Feet:
Prints ______________________________ Toenails ___________________________________
Color of Nailbeds ___________________ Number of Toes ______________________________
Comments______________________________________________________________________
Legs:
Ankles_______________________________ Leg Formation_____________________________
Range of Motion ______________________ Hip Rotation _______________________________
Leg Creases __________________________ Femoral Pulse (L) ___________ (R) ___________
Buttocks Creases _____________________ Flexion___________________________________
Comments_____________________________________________________________________
Hands:
Prints _______________________________ Fingernails ________________________________
Color of Nailbeds _____________________ Number of Fingers __________________________
Comments______________________________________________________________________
Arms:
Wrists_______________________________ Arm Formation _____________________________
Range of Motion ______________________ Arm Rotation ______________________________
Arm Creases _________________________ Radial Pulse (L) ____________ (R) ____________
Comments_____________________________________________________________________
Genitalia:
Female:
Inguinal Area_______________________
Labia Majora_______________________
Labia Minora_______________________
Clitoris____________________________
Urethral Orifice_____________________
Vaginal Orifice_____ Discharge________
Anus, Patent_______________________
Male:
Inguinal Area________________________
Rugae_____________________________
Scrotum____________________________
Meateal Slit__________________________
Foreskin____________________________
Testes Descended (L) ______ (R) ______
Anus, Patent________________________
Comments____________________________________________________________________
Abdomen:
Umbilicus: Color_________Odor _______ Condition ________ Arteries _______ Veins_______
Umbilical Abnormalities___________________________________________________________
Superficial Palpation: Masses__________________ Tenderness_________________________
Deep Palpation: Masses_______________________ Tenderness_________________________
Hernias__________________________________ Percussion Resonance__________________
Peristalic Sounds____________ Abdominal Appearance (soft) (hard) (distended)___________
Comments______________________________________________________________________
Breasts:
Nipple Appearance (L)___________________________ (R)______________________________
Areola Size__________ Fullness __________ Engorgement __________Discharge _________
Comments______________________________________________________________________
Chest:
Symmetry_______________________________ Breast Cartilage _________________________
Clavicals (L)_____________________________ (R) ____________________________________
Comments______________________________________________________________________
Lungs:
Respirations___________________ / minute Lung Sounds (L) ___________ (R) ____________
Comments_____________________________________________________________________
Heart:
Heart Rate____________________ / minute Heart Sounds______________________________
Comments_____________________________________________________________________
Neck:
Positions ___________________ Masses ________________ Trachea ____________________
Length__________ Mobility ____________ Presence of webbing and/or fat pad?___________
Comments_____________________________________________________________________
Mouth & Throat:
Lips ________________________________ Teeth _____________________________________
Mucus Membranes (pink) (white patches) (cyanotic) ___________________________________
Saliva _______________________________ Palate (intact) (abnormal) ____________________
Thyroid _____________________________ Masses or Abnormalities_____________________
Comments______________________________________________________________________
Nose:
Discharge/Drainage______________________ Patency________________________________
Flaring Nostrils__________________________ Shape__________________________________
Blockage_______________________________ Abnormalities____________________________
Comments______________________________________________________________________
Eyes:
Color (L) _____________ (R) _____________ Spacing (L) ______________ (R) ______________
Shape (L) ____________ (R) _____________ Sclearae (L) ______________ (R) ______________
Cornea (L) ___________ (R) _____________ Hemorrhages (L) __________ (R) ______________
Eye Movement ________________________ Pupils (L) ________________ (R) ______________
Condition (Clear) (Discharge) (Swelling) (Abnormalities) ________________________________
Comments______________________________________________________________________
Ears:
Shape (L)____________ (R)___________ Placement (L) __________ (R) ____________________
Cartilage (L)__________ (R)___________ Hearing (L) ____________ (R) ____________________
Canals (L)____________ (R)___________ Abnormalities or Masses ________________________
Comments_______________________________________________________________________
Head:
Molding _______________________________ Birth Presentation_________________________
Fontanelles- Anterior_____________________cms Posterior__________________________cms
Caput / Cephalohematoma________________ Circumference______________________inches
Hair Texture____________________________ Skull Firmness____________________________
Comments_______________________________________________________________________
Back & Spine:
Complete_____________________________ Closed ____________________________________
Tufts of Hair___________________________ Scapulas __________________________________
Pilonidal Dimple________________________ Dermal Sinuses ____________________________
Abnormalities____________________________________________________________________
Comments_______________________________________________________________________
State of Awareness:
Observation of General Awareness of Newborn During Immediate Postpartum Period:
Deep Sleep - REM Sleep - Light Sleep
Groggy - Crying - Transitional
Quiet Awake - Active Awake - Other _______________________________________
Comments_______________________________________________________________________
Feeding & Nourishment:
Observation of the Newborn's Breastfeeding Skills:
Hunger appears
(immediately upon birth) (within 30 minutes) (within 1 hour) (longer than 1 hour)
List any problems or concerns about the infant's ability to feed: __________________________
________________________________________________________________________________
Comments_______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Nervous System:
Moro (Startle) Reflex_________________ This is a startle reflex that can be initiated by holding the infant in a supine position and letting the head drop back an inch or two.
They abduct and extend their arms and legs. Their fingers assume a typical C position.They then bring their arms into an embrace position and pull up their legs against their abdomen (abduction). The reflex simulates the action of someone trying to ward off an attacker, then covering themselves up to protect themselves. The reflex is strong for the first 8 weeks of life. It fades by the end of the fourth or fifth month, when the infant can roll away from danger.
Palmar Grasping Reflex_______________ When an object is placed in a newborn's palm, the child will grasp it so strongly that they can actually be raised from a supine position and be suspended momentarily from an examiner's fingers. The reflex disappears at about 6 weeks to 3 months. A baby begins to grasp meaningfully at about 3 months of age.
Plantar Grasping Reflex_______________ When an object touches the sole of a newborn's foot at the base of the toes, the toes grasp in the same manner as the fingers do. The reflex disappears at about 8 to 9 months of age in preparation for walking, although it may be present in sleep for a longer period of time.
Sucking Reflex _______________________ When an infant's lips are touched, the baby makes a sucking motion. Thus, as the lips touch the mother's breast the baby sucks and so takes in food. The sucking reflex begins to diminish at about 6 months of age. It disappears immediately if it is never stimulated (thus a pacifier can be used to stimulate the sucking reflex in sick infants that are not receiving oral feedings).
Rooting Reflex________________________ If a newborn's cheek is brushed or stroked near the corner of the mouth, the child will turn the head in that direction. This reflex serves to help the baby find food. The reflex disappears at about 6 weeks of life. At about that time, the eyes focus steadily and a food source can be seen.
Trunk Incurvation Reflex ________________ When newborns lie in a prone position and are touched along the paravertebral area by a probing finger, they will flex toward the touch. This tests spinal cord integrity.
Magnet Reflex_________________________ If pressure is applied to the soles of the feet of an infant lying in a supine position, the child pushes back against the pressure. This tests spinal cord integrity.
Heel To Ear Maneuver___________________ Tests maturity of a newborn baby. This maneuver is impossible with a full term baby.
Scarf Maneuver _________________________ This is by trying to cross midline of a baby's chest with the elbow by grasping the hand and pulling it toward the opposite shoulder. This is not supposed to be possible to cross the midline in a full term infant.
Automatic Walking_______________________ The newborn is held in a vertical position and their feet touch a hard surface causing the baby to "walk" along the surface. This reflex disappears by 3 months of age.
Pupil Reactions (L)________ (R)_________ Both pupils should react normally to light.
Final Examination Comments:_________________________________________________________
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