Baby's Name________________________________________Sex_______________________
Date of Birth____________________________Time of Birth____________________________
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_________________________________________________

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NEWBORN EXAM INFORMATION

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Examiner's Name(s)___________________________Date/Time of Exam__________________

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Axillary Temperature:	(date/time)_____________ (temp)__________degrees F / C
After the Birth:	(date/time)_____________ (temp)__________degrees F / C (date/time)_____________ (temp)__________degrees F / C (date/time)_____________ (temp)__________degrees F / C

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APGAR Scores
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

APGAR TOTAL

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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

Total Score of 0 indicates no respiratory distress. Total Score of 4-6 indicates moderated distress. Total Score of 7-10 indicates severe distress. Total Silverman Score

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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) _________
Alignment __________________________ Posture ___________________________________
Body Symmetry _____________________ Comments _________________________________


Excretory Function:
Passed Urine           (before)     (during)    (after)     the birth in first 24 hours.
Passed Meconium (before)     (during)     (after)     the 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 ______________________________
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 ___________________________
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________________________________________________________________________


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_______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________


REFLEXES

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 them self 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.

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Final Examination Comments:______________________________________________________
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