In these videos, Dr Elizabeth Forster discusses what to take note of when assessing the newborn's face, with focus on the eyes, ears and nose.
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The first thing you’re looking at with the baby is symmetry. So if you imagine a vertical line down the centre of the baby’s face, you just want to see that there’s symmetry there, so that there’s matching from both sides, in terms of the position of the eyes, the nose, the lips. Sometimes, if babies have had a complicated delivery, they may have some nerve damage to the face. And so you may see some evidence of palsy or nerve damage. And that might show up in one eye being closed and a droop in one side of the baby’s face.
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In terms of the eyes, you want to make sure that– there’s a rule of thumb that we think about in terms of eye placement, and that is that it’s roughly a third, a third, a third with each eye and the nose. So you want to actually look at the distance between both of the eyes and make sure that is roughly equivalent to that one is to one is to one spacing, as some conditions might see a decreased distance between the eyes. For example, fetal alcohol syndrome and other syndromes might have a particularly increased space between the eyes.
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When you’re examining the eyes, you need to note the colour of the sclera, or the white of the eyes, and that should normally be white. However, during delivery, sometimes babies can experience a little bit of trauma and there may be some small little hemorrhages in the sclera of the eyes. And that’s normally OK and will resolve in the days after the birth. The other thing that you need to look at of course, is to use your pen torch and make sure that the baby’s pupils are equal in size and also, reactive to light. So when you use your pen torch, essentially, you’re going to shine it into one eye.
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And you’re going to check that there’s a consensual, or equal, reaction of pupil constriction in the other eye. And do the same in reverse. The other thing that you’ll be looking at– and sometimes you’ll use an ophthalmoscope to actually check this– but when you actually shine the light in the baby’s eye, you need to check for a red eye reflex. So you’ll see a redness appear which indicates the retina of the baby’s eyes. And that red eye reflex is very important. If it’s not shaped normally, not uniformly shaped, or if it’s absent or opaque, then that might indicate a complication, so that needs to be investigated further.
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The other thing that you’ll be looking at with the baby’s eyes are the eyelids. And sometimes, with oedema or trauma in the birth, they may actually have quite a lot of oedema, and that may be difficult to observe the eye properly. The other thing is that the actual eyelids might be fused in a very premature baby. And the other thing you’re looking for is sometimes, there are little folds of tissue of skin in the eyelids that we call epicanthal folds. And they are often present in certain types of syndromes for babies. The other thing that you’ll look at is, I guess, the presence of tears and any discharge that may be present in the eyes.
Checking for symmetry is a key focus when assessing the newborn’s eyes, ears and nose.
Start by imagining a straight line down the centre of the newborn’s face. Observe and determine whether each side is similar. Ideally, there will be symmetry in terms of the shape and placement of the baby’s facial structures.
To assess the positioning of the newborn’s eyes and nose, this time imagine a vertical plane of three sections across the baby’s face. The left and right eye, along with the nose should each occupy roughly one third of spacing on the face. An abnormally small distance between the eyes is called hypotelorism and may be a sign of fetal alcohol syndrome. A particularly wide distance between the eyes (hypertelorism) may also be indicative of a problem and should be reported (Kain & Mannix, 2018).
Next, inspect the sclerae (white of the eyes). Sometimes there are small hemorrhages (bleeding) in the sclerae, which can occur during birth. Also assess the eyelids. They may be swollen and in very premature neonates, may even be fused (Kain & Mannix, 2018). Make a note of any skin folds over the medial (middle) aspect of the eyes. These are known as epicanthal folds and are present in babies with some syndromes, such as Down syndrome (Kain & Mannix, 2018).
Use your pen torch or an ophthalmoscope to shine light into the eye. You will need to observe the size, shape and location of the pupil. Check the baby’s reaction to light. The pupil should constrict briskly in the eye you shine the light into and have a similar reaction in the other eye at the same time (Forster & Marron, 2018).
Also look for the red eye reflex. This is a uniform reflection of red that can been seen in both eyes. It indicates that the cornea and lens of the eye are normal. If the red eye reflex is absent or only apparent in one eye, report this finding immediately to paediatric medical staff (Forster & Marron, 2018). Look out for the additional resource at the end of this step, which will guide you on what to look for.
Assessing the ears and nose
This is an additional video, hosted on YouTube.
The newborn’s ears
Observe the ears and note their position and symmetry. Again, imagine a line extending from the outer corners of the eye to the top of the pinna (Kain & Mannix, 2018). The ears should each have an external ear meatus (opening). You may note some small skin tags, which are usually not of concern.
Observe the size of the ears and the folding of the helix (outer rim of the ear). If the helix is over-folded and the ear is small, this may indicate a genetic syndrome. Hearing can be tested by clapping to see the newborn’s response, however many maternity hospitals provide newborn hearing screening to all babies.
The nose
The newborn’s nose should be located in the middle third of the baby’s face. Both nares (nasal passages) should be patent (open). If not, it may indicate a condition known as choanal atresia, where one or both nasal passages are blocked. This interferes with breathing, as newborns are obligatory nasal breathers.
Sometimes, the newborn’s nose can be squashed during the birth process and this will usually resolve within a few days (Kain & Mannix, 2018). Also note whether the nose is thin or broad and whether the nasal bridge is depressed, as this may indicate a genetic condition (Kain & Mannix, 2018).
Your task
Once you have watched both the videos, post your questions and comments in the link below.
References
Forster, E. & Marron, C. (2018). Paediatric Assessment Skills. In E.Forster & J.Fraser. Paediatric Nursing Skills for Australian Nurses. Port Melbourne, Victoria: 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
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