Skip to 0 minutes and 7 secondsSo in terms of the breathing, it should be effortless for the baby. So just observing the baby, remembering that observation is the least invasive type of assessment. So on observation, you shouldn't be able to hear the baby breathing. Should be very quiet, and it should be effortless. But there are some important differences between observing a baby breathing and a child or an adult. And that is because the newborn is an abdominal breather. So when you are counting the respirations on a newborn, you're actually counting the rise and the fall of the abdomen, not the chest. Other things that you will notice is that the baby will breathe preferentially through the nose. So they are obligatory nose breathers.

Skip to 0 minutes and 56 secondsIt's very rare for a baby to breathe through the mouth. So if you observe that at rest the baby is breathing through their mouth, that is an area for concern that you need to report. But otherwise, the baby should be breathing preferentially through their nose. And as I've said, they are also abdominal breathers. We will talk more about the signs of respiratory distress later on. But just on observation, you might notice in a smaller baby that is less than 2.5 kilos that there may be some periods of intermittent breathing, where they will breathe regularly, take a bit of a rest, breathe again, take a bit of a rest. This is normal in a small baby.

Skip to 1 minute and 37 secondsAnd in a term baby, they may also be periodic breathers at times. But what we don't want to see is periods of time where they stop breathing for 15 seconds or more, OK? That is something that we would be concerned about. The xiphoid process, which is that little nub of bone on the bottom of the sternum, is visible in most babies. This is nothing to be concerned about if you can see that xiphoid process there at the bottom of the chest. When we are counting the baby's respirations, a rate of between 40 and 60 breaths per minute is considered normal.

Skip to 2 minutes and 14 secondsIf the baby at rest is breathing more than 60 breaths a minute, we call this tachypnea, and that is a finding that is associated with respiratory distress. You do need to count for a full minute, because as I've explained, many babies quite normally tend to be periodic breathers and will breathe quickly, take a couple of seconds pause, and keep breathing, which is quite a normal finding. So do count for a full minute. We usually would only go on to listen to the baby's chest in a normal baby who is breathing normally with a stethoscope if they're tachypneic or if they are having respiratory distress.

Skip to 2 minutes and 56 secondsSo if you do need to listen, you would place the stethoscope-- I've got a neonatal stethoscope here-- over the left side of the chest and over the right side of the chest. And here, I'm listening to the left upper lobe of the lung, the right upper lobe of the lung. The right lobe also has a middle lobe. But in a newborn baby, it's so small, it's really not discernible to the other lobes of the lung. If I want to listen to the two lower lobes of the lung, I actually need to turn the baby onto their side and listen to the back in order to hear those lower lobes of the lung.

Skip to 3 minutes and 39 secondsWhat I'm listening for are the muscles that are involved with inspiration and expiration. Those are the sounds that I'm going to hear. I shouldn't hear fluid. I shouldn't hear grunting. I shouldn't hear a wheezing or a stridor, which is a high-pitched sound. So it just should sound like normal breathing amplified, because I'm using a stethoscope. And that is all considered normal.

Assessing respiration

We next assess the baby’s chest, to listen to breathing and visually check structure.

To observe the chest, begin by simply observing the baby at rest. Note the shape of the chest - it should be cylindrical and symmetrical. Symmetry between the two sides of the chest is important, as asymmetry may indicate pneumothorax (an air leak).

Observe and gently palpate the nipples – there should be 2 nipples, however an extranumerary (3rd) nipple is not uncommon. The nipples should be symmetrical and in the midclavicular line. This is an imaginary line parallel to the chest bone, passing through the midpoint of the clavicle (collar bone). There should be an equal space between the nipples, and the areola should be visible in the term newborn. There may also be small secretions (sometimes referred to as ‘witch’s milk’) which is a normal finding in both female and male newborns (Kain & Mannix, 2018).

Use the stethoscope to listen to the lungs (auscultation). This will allow you to ensure the lung sounds are clear, bilateral and equal. It is not unusual for there to be some rales (slight bubbling or rattling sounds) heard for a few hours after birth.

The normal respiratory rate of the newborn should be less than 60 breaths per minute, but more than 40. Breathing may be periodic (irregular) in the neonatal period. You would be concerned about signs of respiratory distress and apnoeic episodes, where the baby stops breathing for more than 20 seconds at a time (Queensland Clinical Guideline, 2014).

Your task

If you have questions or comments about any aspect of assessing the newborn’s chest, please post them in the comments section below. We’ll be learning how to assess the newborn’s heart rate in the next step.

References

Kain. V & Mannix, T (2018). Neonatal Nursing in Australia and New Zealand, 1st Edition. Australia: Elsevier

Queensland Clinical Guideline (2014). Routine newborn assessment.

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This video is from the free online course:

Assessment of the Newborn

Griffith University