Screening at Birth

Without doubt, voluntarily allowing your wee bundle to be manhandled by someone else for medical examinations is a Big Ask for some mums … especially if Bubs is crying, which they typically seem to. “Whoa!” you can find yourself muttering inside your head, “What are they doing that for?!” as the midwife or doctor performs all their little precious ‘checks’ on your little precious baby. I mean, what the heck are they really checking for anyway, and are such tests really all that necessary?

Checks on neonates fall into three main categories: The Apgar scores which are recorded at and around birth; the full Physical Assessment of a neonate done at birth, one-week and 4-6 weeks; and the Guthrie heel-prick blood-test usually performed between days 2-5.

When babies are born, they have to dramatically transform from an aquatic fetus to an oxygen-reliant neonate, and the first few minutes of life are truly hazardous. Often within seconds of birth the LMC will give the baby a brief rub-down to stimulate it to take a first gasp of air to inflate its lungs, popping them open like little parachutes. Then, within 1-2 minutes, the expanded lungs set off an amazing chain reaction of miraculous and profound circulatory changes, including increasing blood-flow to the lungs and triggering the formation of the heart’s four chambers. Any dyspnoea (laboured difficult breathing) can potentially cause cyanosis (bluish skin from inadequate oxygen), and ultimately heart failure – though most newborns are a violet-blue colour until they have inhaled oxygen and ‘pinked-up’.

Smooth breathing is the initial focus, so the LMC will look for symmetrical chest expansion and diaphragm movement, and watch for signs of difficult effort, perhaps providing a few whiffs of oxygen, or resuscitation. [Note: If the opioid analgesic narcotic Pethidine was administered for labour pain-relief within a couple of hours before birth, then this can depress a newborn’s respiration, so the baby can need Naloxone (Narcan) antidote injections.]

Once respiration is well established, the next most important area of observation is the cardio-vascular system (heart and blood vessels), with the LMC looking for symmetrical skin colour, centrally (torso and head), peripherally (arms and legs), and that Bub’s mucous membranes (lips and gums) are pink.

The Apgar scoring system was devised by Virginia Apgar in 1953 as a quantitative measure of the neonate’s well-being based on measuring five indicators, with scores of ‘0’, ‘1’ or ‘2’:

  • Appearance (skin colour) – blue, mixture or pink
  • Pulse (heart rate) – absent, irregular or regular
  • Grimace (response to stimuli) – absent, grimace or crying
  • Activity (muscle-tone) – limp, lethargic or active
  • Respiration (breathing) – absent, difficult or good

A score of 7-10 indicates good overall condition. A score of 4-6 is considered okay but may need a little oxygen. A score of 3 or less requires more intensive care. It is usual that the first score (at 1 minute) is lower than the second score (at 5 minutes).

The mother, fetus and placenta were a biological trinity, all inter-dependent on each other’s independent normal development. So after the umbilical cord is cut, it is inspected to ascertain that three vessels are present (as two vessels can be an indication of fetal abnormalities). The placenta is also inspected for its normalcy and completeness including membranes.

As neonates are born with initially low levels of Vitamin-K (a co-factor required for effective blood-clotting), very commonly newborns receive a Vitamin-K intramuscular injection to protect them against spontaneous hemorrhaging (particularly brain bleeds which can cause irreversible brain damage). Vitamin-K can be given orally, but due to a newborn’s mucousy spillyness the injection is often preferred.

Within the first minutes or first hour of birth, a full Physical Assessment of the neonate will be done by the LMC of nine main areas, including:

  • Skull – symmetrical shape; circumference size; suture check (skull plate joins); size and tension of anterior (front) and posterior (back) fontanelles.
  • Eyes & Ears – shape and size; symmetrical alignment; complete red eye reflex; equal pupil reaction to light; open unblocked ear-canals.
  • Nose, Mouth, Chin & Neck – shape symmetry; open unblocked nostrils; complete arched palate with no cleft; tongue size, colour and movement with no tongue-tie; suckling and swallowing reflexes; chin and neck shape, size and movement.
  • Heart – characteristic symmetrical rhythm of the brachial (upper arm) and femoral (upper thigh) pulse rates; auscultation of heart sounds (listening with stethoscope for murmours).
  • Abdomen – check umbilical cord-clamp is secure; and palpation (feeling) for size of liver etc.
  • Spine & Hips – trunk spine curve; symmetrical buttock folds; check for jerks or clicks from congenital hip dislocation.
  • Genitalia & Anus – unblocked urethral opening; testes descended (in boys); open and unblocked anus.
  • Neurological and Musculo-skeletal – normal symmetrical body shape, proportions, movement and reflexes of arms, hands, legs, ankles and feet; reaction to stimuli evoking responses.
  • Weight, height and vitals (temperature, pulse, respiration, heart-rate).

Around 2-5 days after birth, it is normal for a newborn to have the Guthrie test, when the heel is pricked and blood squeezed out to fill four small circles onto a special card, which is then sent away for screening of a number of congenital (inborn) metabolic disorders (involving the body’s chemicals). This NMSP (newborn metabolic screening programme) confirms statistically rare but serious diseases that usually would not be diagnosed until after irreversible symptoms have appeared (such as brain damage). Even though the diseases can’t be ‘cured’ as such, the worst effects can be reasonably well managed by special diets or medicine treatments. The NMSP improves enormously the long-term lives of 30-35 NZ children annually.

Diseases screened for include:

  • PKU (Phenylketonuria) – missing liver enzyme causing severe mental retardation, treated by special diet.
  • Hypothyroidism – low thyroid gland hormone causing slowed growth disability and mental handicap, treated by thyroxine medication.
  • CF (Cystic Fibrosis) – abnormal secretions causing poor growth, chest infections and shortened life, treated by medicine and physiotherapy.

Be warned that around 1 in every 100 babies requires a second blood-test, which may not mean anything more than the first blood sample was not optimal. For a full list of disorders, you can visit www.moh.govt.nz/newbornscreening. If you haven’t heard anything from your LMC after a month or so, then no news is good news. If you would like your baby’s card returned to you after testing, a form is available from the National Testing Centre in Auckland contactable at 09-3074949 ext 6759 or email [email protected].

It is such a blessing that our children are born into this Western country within the ‘developed’ world, to enable them to be so vigilantly protected, not just from Day-One, but actually from Minute-One. Let us be ever graciously grateful!

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