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.

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