Your newborn baby’s first check

Assessing your baby’s health and well-being starts from the moment they are born; this very first assessment is referred to as the Apgar score. It is undertaken by the midwife or paediatrician (baby doctor) present at the birth and is designed to evaluate your baby’s physical health and well-being immediately after they have been born. Your baby’s condition is assessed at one minute, five minutes and, if there are any concerns, at 10 minutes after their birth. The Apgar score helps identify those babies requiring immediate assistance with their breathing and/or extra care; however, it cannot predict a baby’s longer-term health and well-being.

The term ‘Apgar’ is commonly referred to as an acronym for:

A – Activity (baby’s movements, muscle tone)

P – Pulse (heart rate)

G – Grimace (reflex response)

A – Appearance (skin colour – a good colour, or pale?)

R – Respirations (breathing)

A score between 0-2 is given for each of these factors and then added together at each time interval (1, 5 and 10 minutes) to calculate your baby’s Apgar score — scores obtainable range from the maximum of 10 to 0. If your midwife/paediatrician is concerned about your baby’s Apgar score, they will explain why and let you know what care is being given, and how your baby is responding to that care.

Shortly after your baby has been born, and if the baby appears to be in good health, the midwife caring for you will perform an initial check of the baby. This is often performed after you’ve enjoyed your first cuddle with your newborn and tends to be undertaken on a flat surface, such as the bed, a cot, or if in the hospital Delivery Suite, the resuscitaire (ie the apparatus often used to warm up the baby’s blankets before their birth). This enables the midwife/paediatrician to be able to get a good view of your baby’s general appearance and responses.

It includes checking the baby’s head and facial features — their eyes, ears and nose — as well as inside the baby’s mouth and their skin surface and their skin folds (eg under the arms, around the neck). The midwife will also count the number of fingers and toes that are present, to see whether there are any extra digits (ie fingers or thumbs) or small skin tags. Your baby will then have its back and spine checked and will be measured; this measurement is taken around the circumference of your baby’s head. Midwives also used to measure the length of the baby (as measured from the top of their head (crown) to the heel of their foot), but this no longer happens because the measurements were found to be too inaccurate.

This is a very basic early check by the midwife that is designed to pick up any immediate concerns with your baby’s condition; however, you will then be offered a more thorough top-to-toe physical examination of your baby, which is usually performed within six to 48 hours of their birth. This examination is a lot more detailed and will involve examination of your baby’s skin, their head and face, nervous system, heart and lungs, abdomen and genitals. It is usually completed by a health care professional in the maternity unit and tends to be a paediatrician, or a midwife who has completed additional specialist training in order to undertake this role. Where you have given birth at home, your GP or community midwife will probably perform this examination.

The examination is best undertaken when your baby is settled and calm. This provides a more accurate assessment of their health and well-being, rather than trying to examine an agitated, crying baby, where it can be more difficult to detect concerns or conditions that may need to be monitored or followed-up. Your baby’s examination will include the following checks:

Your baby’s skin – some swelling and bruising on your baby’s scalp is normal, particularly where the head has been resting against the cervix (neck of the womb) during labour, or where your baby has been born using forceps or the ventouse (vacuum extraction). During labour the bones of your baby’s skull overlap to help ease baby’s passage down the birth canal; this is called ‘moulding’ and can persist for a few days. The fontanelles (soft spots) on your baby’s head will also be checked to make sure they are where they should be, and are soft and not tense or bulging.

Where your baby is born bottom first (breech), then their buttocks (bottom) and genitals can be very bruised and swollen at birth, but this too will resolve within a few days.

Your baby’s heart – the midwife/paediatrician will look at your baby to check that their skin is a good colour, which indicates a healthy blood circulation (ie oxygen is reaching all their tissues). Babies with darker skins will often have the paler areas of skin observed to check that they have a healthy circulation. Sometimes babies can be a more ‘reddish’ colour and their hands and feet can look a more ‘blue’ colour and be cold to the touch. This can persist for up to 48 hours until your baby’s circulatory system has properly adjusted from their being inside the uterus (womb) to independent circulation. If you are concerned that your baby is cold, the best way to check their temperature is to feel their chest or back.

The midwife/paediatrician will listen to your baby’s heartbeat and lungs using a stethoscope and will feel the pulses in each of your baby’s groins to ensure that the blood circulation is effective to their lower limbs (legs and feet). They will also listen to baby’s heart to check for any possible heart murmurs or irregular heartbeats. Where a heart murmur is picked up, this will be re-checked within 24 hours as they often resolve spontaneously before this. However, if this isn’t found to be the case, your baby will be followed-up at four weeks of age, by which time 90per cent of heart murmurs will have resolved.

The health professional will also listen to your baby’s breathing and by listening to their lungs can check that there is good air entry and that your baby is not experiencing any difficulties. They will also ask you how your baby is feeding; this is because some babies that are born with a serious heart condition don’t always feed as well, because they tire easily. However, if you are asked this question, please don’t automatically think that your baby must have a problem with their heart. Your midwife/paediatrician will always ask about feeding with every baby in their care.

Should any potential concerns be picked up, these will be explained to you, as would any further tests or investigations that might be considered appropriate.

Your baby’s reflexes and nervous system – the midwife/paediatrician will check your baby’s nervous system and will do this by examining your baby’s reflexes. There are three reflexes that should be present in the first few weeks after birth:

• Moro  – when newborns are startled they will fling out their arms and legs
• Rooting – if either side of the mouth/cheek are touched, the baby will instinctively turn their head in that direction
• Sucking – when the soft pad of a finger tip is introduced into the baby’s mouth, they will immediately start sucking on it.

Your baby’s abdomen – this is checked for its size and shape and to see whether there is any obvious bruising, distension (swellings) or small lumps that could suggest a hernia. These can be present around the area of the umbilical cord (ie an umbilical hernia). The umbilical cord will also be checked to make sure that it is clean and dry, there are three blood vessels present (ie two arteries and one vein) and there is no bruising and/or bleeding from the cord itself or the surrounding area.

Your baby’s hips – the midwife/paediatrician will want to check your baby’s hip joints and their range of movements to ensure that their hips have developed properly. Babies who are in the breech position (bottom down) while inside your uterus (womb) are more likely to have unstable hip joints. If this isn’t treated appropriately, it could lead to your child walking with a limp or having joint problems (‘clicky’/dislocatable hips). Each hip will be carefully examined and while the examination may look painful for your baby, it shouldn’t actually hurt them. In fact, a number of babies sleep through the entire process! If your baby does find it a little uncomfortable, you will be able to hold their hand during the examination to help soothe them. If a problem with your baby’s hips is detected, your baby may need to have an ultrasound scan of its hip(s). Out of every 1000 babies born each year, one or two will be found to have a hip problem which requires further treatment. This problem tends to be hereditary and a baby is more likely to have ‘clicky’ or dislocated hips where its parent(s) or sibling(s) have had this problem at birth. You will therefore be asked during the examination whether there is a family history of ‘clicky’ or dislocated hips that have required treatment.

Your baby’s eyes – your baby will have its eyes checked using an ophthalmoscope; this is a special torch-like instrument that enables the health care professional to look into the baby’s eyes. By doing this they are able to check the back of the eye (the retina), which can help to detect any potential conditions, such as cataracts, which might need to be followed up or treated. Out of every 10,000 babies born each year, two or three will be found to have eye problems that require further treatment.

Your baby’s genitals (nappy area) – the health professional will need to check that the anus (back passage) and urethra (the opening for urine) are open and in the correct location. With little boys, the urethral opening can sometimes be located on the upper or lower surfaces of the baby’s penis, rather than being at the very tip. You will also be asked whether your baby has passed urine, which demonstrates that their bladder and kidneys are working well. Their anus will also be checked to ensure it is present and you will be asked whether your baby has passed meconium (baby’s first ‘poo’) which shows that the baby’s anus and bowel are functioning as they should be.

In baby girls, the genitals (labia) can be very prominent because of the baby’s exposure to its mothers (female) hormones while in the uterus. This can result in a ‘white’ mucous discharge, or sometimes a very small amount of vaginal blood loss. This is normal and will resolve in a few days when the hormone levels in the baby decrease.

If you have given birth to a baby boy, the health care professional will need to examine their scrotum to check that both testes have developed properly and are in the right place (ie the testes have descended into the scrotum). Sometimes when the baby is examined, it is found that one of the testes has not descended. This needn’t be an immediate cause for concern as it can take a number of months for them to descend. However, where after around 12 months, descent of the testes still hasn’t occurred, an operation may be advised to bring the testes down into the scrotum and secure them into the correct position; this is normally performed when your baby is 1-2 years of age. Out of every 100 baby boys that are born each year, approximately one will go on to require an operation.

Your baby’s back and spine – the baby’s spine is checked and the midwife/paediatrician will look for the presence of a sacral dimple. The baby’s hands are checked too, for the number of digits (fingers and thumbs), and the palms of baby’s hands checked to see that there are two ‘palmar creases’ (natural skin creases that should be present) on each hand.

Your baby’s skin – this is checked all over for any blemishes, rashes and birth marks. The baby’s collar bones (clavicles) are also checked, particularly where your baby is of an above average birth weight, to ensure they have not been damaged during their birth.

The baby’s nipples are also checked, as they can sometimes be red and swollen (even in boys) due to the effects of the mother’s hormones. Sometimes baby’s nipples can leak (excrete) a small amount of milk. This is normal and will settle in a few days when the hormone is out of your baby’s system.

Your baby’s mouth – the baby’s mouth will be checked and the area at the roof and back of the mouth (called the hard and soft palate) looked at with a torch to ensure they are intact and there is no sign of a cleft palate Your baby’s mouth will also be checked to see whether there are any teeth or fluid filled swellings (cysts) present, and to check for tongue-tie, which can stop the baby extending (poking out) its tongue and may interfere with breastfeeding.

This first check is to identify any obvious problems or concerns with your baby’s development; however, the midwife/paediatrician will also tell you that some conditions, such as heart or kidney problems, do not become apparent for days or even weeks following the baby’s birth. Therefore, if you have any concerns whatsoever, it is important that you always let your midwife, health visitor or GP know about these. They will be able to advise, support and reassure you. In addition to all of the above, your GP will also perform a similar check when your baby is around 6-8 weeks old; this further check helps to ensure that your baby is healthy and well and there are no developing problems.