Skip to 0 minutes and 8 secondsSo now we're going to move on to assessment or examination of the neonatal pelvis. So we'll remove the nappy, but keep it there in case of any accidents. And we're going to be just doing an inspection of the genitalia, first off. So in the female term baby, you'd expect to see the labia majora covering the labia minora. And in a pre-term baby, the labia minora will be more prominent, as will the clitoris. So you'd note those two differences in either a pre-term and a term baby. And, often, the genitalia does appear quite reddened, and that's OK. And sometimes you may see a tiny amount of mucus or even slightly blood-stained discharge.

Skip to 0 minutes and 56 secondsAnd that is normal, and that's from exposure to maternal oestrogen. The other thing that you need to check is that there is a patent hymen as well in the baby. So that's usually just through inspection of that genitalia. For the male genitalia, you need to make sure that the penis is midline and that the urethral opening-- or urethral meatus-- is at the centre of the glans of the penis. Sometimes there are abnormalities known as hypospadias where there is actually the urethral opening below the head or the glans of the penis. So you need to ensure that is placed centrally. And also you need to check that the foreskin is intact and not retractable at this point.

Skip to 1 minute and 54 secondsAnd also the other part of the male genitalia is to inspect the testicles and to check that there is actually a testicle-- two testicles in the scrotal sac. When you are examining the testicles, a really good idea to have warm hands because just cold hands can actually cause the testicles to move back into the pelvic cavity. And, in order to-- so that helps avoid a reflex, known as the cremasteric reflex. And the other thing that you can do is actually place a finger at the top of the scrotal sac when you're examining the testicles, and that actually stops those testicles moving back into the pelvis. The next part of your examination of the pelvis is to check the baby's hips.

Skip to 2 minutes and 46 secondsIn some places, you need to actually complete an education programme to perform a hip assessment and be accredited in performing those manoeuvres. And, in those settings, sometimes this will only be done by paediatricians. So please don't attempt this unless you've received appropriate training. However, I will go through the process with you. So there are two main tests that we use to check the baby's hips. And what we're looking for is that there's no evidence of dislocation of those hips, which happens in a condition known as developmental hip dysplasia. So there are two manoeuvres, and they're both named after doctors who developed these manoeuvres.

Skip to 3 minutes and 32 secondsThe first one was Doctor Barlow and Barlow's manoeuvre, and the second one was Doctor Ortolani, so the Ortolani manoeuvre. So a good way to remember these manoeuvres is you perform the Barlow's manoeuvre first, and then, secondly, you perform the Ortolani manoeuvre. So if you're thinking about B before O. So when you've inspecting the baby and the baby is lying facing you, the first thing you look at is extending the baby's legs and just checking that the legs are symmetrical in terms of leg length. Because an abnormality in leg length on one side may indicate a problem with hips.

Skip to 4 minutes and 15 secondsThe next thing you need to do is holding your middle finger against the prominence of the greater trochanter, which is the femur in the baby's leg-- the large bone of the baby's leg-- and your thumb on the inside of the baby's thigh on both sides. What you then do-- and I can't do it terribly well on our model here, but in a normal baby, you will-- you flex the knees at a 90-degree angle. And then you apply a gentle pressure down in a posterior, or towards the baby's back. And you'll actually feel the head of the femur or the greater trochanter. You'll feel that slip out of the hip socket or the acetabulum, and that indicates dislocatable hip.

Skip to 5 minutes and 8 secondsAnd you may find that is on one side or both sides, and you need to make a note of that. The second manoeuvre is the Ortolani manoeuvre, and that's performed after the Barlow manoeuvre, as I've said. And so, in this case, once you flex the hips and knees, then you abduct or move apart the baby's legs. And, as I said, I can't do it terribly well on this model. And then you apply-- with those middle fingers, you apply a gentle pressure towards you, or anteriorly. And what you will hear, if this is a positive manoeuvre, is an audible clunk as the head of the femur clicks back into the hip socket, or the acetabulum.

Skip to 5 minutes and 54 secondsSo you'll definitely hear that, if there is a dislocatable hip. So both of those manoeuvres will give you an indication of whether the developmental hip dysplasia is present. [CHIMES]

Pelvis, hips and limbs

Our head to toe assessment concludes with an examination of the baby’s pelvis, arms and legs.

We assess the newborn’s hips in order to check for congenital hip dysplasia (dislocation of the hip). This occurs when the hip joint has not formed correctly and the head of the large bone of the thigh (femur) slips out of the hip socket (acetabulum). It should normally be firmly secured in the socket.

Who performs the hip assessment and how?

The Paediatrician, specialised midwife, paediatric or child health nurse or Paediatric Orthopaedic surgeon uses two clinical tests to determine the presence of hip dysplasia: The Barlow and the Ortolani Maneuvers. Both of these tests are performed while the newborn lies in the supine position (on their back) and where possible, at a time when the baby is relaxed and content. This is important, as muscle tightness caused by tension may lead to unreliable results (Aiello, 1989).

The Barlow manoeuvre involves flexing the newborn’s hips and knees at 90 degrees and applying gentle pressure downwards. The Barlow test is considered to be positive if the examiner feels the head of the femur slip out of the hip socket.

The Ortolani manoeuvre is performed after the Barlow manoeuvre. It confirms hip displacement and returns the displaced bone back into the hip socket. The Ortolani manoeuvre involves abducting (moving apart) the flexed legs while applying a gentle forward pressure with the middle finger against the head of the femur. An audible ‘clunk’ can be heard when the femoral head returns to the hip socket.

Assessing genitalia

Assessment of the pelvis also includes an assessment of the newborn genitalia.

For male babies first ensure your hands are warm and then check for the presence of two equal size testicles within the scrotal pouch. To do this, place the thumb and index finger (or two fingers) on the upper portion of the scrotal sac (along the inguinal canal). This will prevent retraction of the testes into the pelvic cavity, which may occur due to the cremasteric reflex (Forster & Marron, 2018). The cremasteric reflex causes the scrotal skin to shrink, pulling the testes high into the pelvic-abdominal cavity (Forster & Marron, 2018).

When inspecting the scrotal sac, feel for fluid and the appearance of swelling. This may indicate hydrocele (Kain & Mannix, 2018), which is an accumulation of fluid and fairly common in newborns. In addition, there may be swelling or bruising of the scrotal sac due to birth trauma - particularly if the baby is born breech (legs first) (Kain & Mannix, 2018). Next, the penis and urethra is examined. The tip or head of the penis (glans) should have a centrally placed urethral opening. The foreskin should be complete and non-retractile and the shaft of the penis should be straight (Kain & Mannix, 2018).

In some male newborns, the urethral opening may be on the underside of the penis, known as hypospadias or on the upper surface of the penis, known as epispadias (Kain & Mannix, 2018).

The assessment of newborn female genitalia includes observation of a patent (open) hymen along with the presence of the labia majora, which covers the labia minora in term neonates (Kain & Mannix, 2018). In premature neonates, the clitoris and labia minora will be more prominent (Kain & Mannix, 2018). When inspecting the vagina and vulva, there may be some white mucus-like substance or a small amount of blood discharge. This is due to exposure to the maternal hormone oestrogen and is a normal finding (Kain & Mannix, 2018).

Assessing the newborn’s limbs

It is important to observe the legs, feet and toes of the newborn to determine their range of motion (ROM), tone and strength. You are also looking to ensure all toes are present and correctly formed. It is important to assess the foot and its position, noting its ability to also move through a normal ROM.

Assessment of the newborn’s upper limbs focuses on assessing spontaneous movement, normal ROM, along with the tone of the shoulders, arms and hands. Check that there are 10 fingers and 10 fingernails.

This is an additional video, hosted on YouTube.

Going further

If you’re interested in learning more about assessing newborn muscle tone, investigate this excellent series of online instructional videos

This website also has easy to follow instructions and diagrams that will help you learn more about assessing ROM of the baby’s upper body.

Your task

Use the comments section below to ask questions or leave your observations on assessment of the pelvis and the limbs.

References

Aiello, D.H. (1989). Congenital dysplasia of the hip. Association of Perioperative Registered Nurses Journal, 49(6), 1566-1606.

Forster, E. & Marron, C. (2018). Paediatric assessment skills. In E.Forster & J. Fraser. (Eds.) Paediatric Nursing Skills for Australian Nurses (pp.37-58). Port Melbourne VIC: Cambridge.

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

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Assessment of the Newborn

Griffith University