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Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

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Too much amniotic fluid (polyhydramnios)

BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls.  https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70.  https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

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Fetal Presentation: Baby’s First Pose

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Occiput Anterior

Occiput posterior, transverse position, complete breech, frank breech, changing fetal presentation, baby positions.

The position in which your baby develops is called the “fetal presentation.” During most of your pregnancy, the baby will be curled up in a ball – that’s why we call it the “fetal position.” The baby might flip around over the course of development, which is why you can sometimes feel a foot poking into your side or an elbow prodding your bellybutton. As you get closer to delivery, the baby will change positions and move lower in your uterus in preparation. Over the last part of your pregnancy, your doctor or medical care provider will monitor the baby’s position to keep an eye out for any potential problems.

In the occiput anterior position, the baby is pointed headfirst toward the birth canal and is facing down – toward your back. This is the easiest possible position for delivery because it allows the crown of the baby’s head to pass through first, followed by the shoulders and the rest of the body. The crown of the head is the narrowest part, so it can lead the way for the rest of the head.

The baby’s head will move slowly downward as you get closer to delivery until it “engages” with your pelvis. At that point, the baby’s head will fit snugly and won’t be able to wobble around. That’s exactly where you want to be just before labor. The occiput anterior position causes the least stress on your little one and the easiest labor for you.

In the occiput posterior position, the baby is pointed headfirst toward the birth canal but is facing upward, toward your stomach. This can trap the baby’s head under your pubic bone, making it harder to get out through the birth canal. In most cases, a baby in the occiput posterior position will either turn around naturally during the course of labor or your doctor or midwife may help it along manually or with forceps.

In a transverse position, the baby is sideways across the birth canal rather than head- or feet-first. It’s rare for a baby to stay in this position all the way up to delivery, but your doctor may attempt to gently push on your abdomen until the baby is in a more favorable fetal presentation. If you go into labor while the baby is in a transverse position, your medical care provider will likely recommend a c-section to avoid stressing or injuring the baby.

Breech Presentation

If the baby’s legs or buttocks are leading the way instead of the head, it’s called a breech presentation. It’s much harder to deliver in this position – the baby’s limbs are unlikely to line up all in the right direction and the birth canal likely won’t be stretched enough to allow the head to pass. Breech presentation used to be extremely dangerous for mothers and children both, and it’s still not easy, but medical intervention can help.

Sometimes, the baby will turn around and you’ll be able to deliver vaginally. Most healthcare providers, however, recommend a cesarean section for all breech babies because of the risks of serious injury to both mother and child in a breech vaginal delivery.

A complete breech position refers to the baby being upside down for delivery – feet first and head up. The baby’s legs are folded up and the feet are near the buttocks.

In a frank breech position, the baby’s legs are extended and the baby’s buttocks are closest to the birth canal. This is the most common breech presentation .

By late in your pregnancy, your baby can already move around – you’re probably feeling those kicks! Unfortunately, your little one doesn’t necessarily know how to aim for the birth canal. If the baby isn’t in the occiput anterior position by about 32 weeks, your doctor or midwife will typically recommend trying adjust the fetal presentation. They’ll use monitors to keep an eye on the baby and watch for signs of stress as they push and lift on your belly to coax your little one into the right spot. Your doctor may also advise you to try certain exercises at home to encourage the baby to move into the proper position. For example, getting on your hands and knees for a few minutes every day can help bring the baby around. You can also put cushions on your chairs to make sure your hips are always elevated, which can help move things into the right place. It’s important to start working on the proper fetal position early, as it becomes much harder to adjust after about 37 weeks when there’s less room to move around.

In many cases, the baby will eventually line up properly before delivery. Sometimes, however, the baby is still in the wrong spot by the time you go into labor. Your doctor or midwife may be able to move the baby during labor using forceps or ventouse . If that’s not possible, it’s generally safer for you and the baby if you deliver by c-section.

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for transverse presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Presentation and position of baby through pregnancy and at birth

9-minute read

If you are concerned about your baby’s movements, contact your doctor or midwife for advice immediately.

• If you baby is in a breech presentation, your doctor may recommend trying a technique called an external cephalic version to try and move your baby while they are still in the uterus for an easier birth.

What does presentation and position mean?

Presentation refers to the part of your baby’s body that is facing downwards in the direction of the birth canal.

Position refers to where your baby’s occiput (the bottom part of the back of their head) is in relation to your body.

If your baby is in a breech presentation , then position refers to where your baby’s sacrum (lower back) is in relation to your body.

People — including medical professionals — sometimes use these terms incorrectly. Sometimes when speaking about babies in breech presentation, the word ‘position’ will be used to refer to their presentation. For example, you may read information or hear people say ‘breech position’ instead of ‘breech presentation’.

What are the different types of presentation my baby could be in during pregnancy and birth?

Most babies present headfirst, also known as cephalic presentation. Most babies that are headfirst will be vertex presentation. This means that the crown of their head sits at the opening of your birth canal.

In rare cases, your baby can be headfirst but in face or brow presentation, which may not be suitable for vaginal birth.

If your baby is in a breech presentation, their feet or bottom will be closest to your birth canal. The 3 most common types of breech presentation are:

• frank or extended breech — where your baby’s legs are straight up in front of their body, with their feet up near their face
• complete or flexed breech — where your baby is in a sitting position with their legs crossed in front of their body and their feet near their bottom
• footling breech — where one or both of your baby’s feet are hanging below their bottom, so the foot or feet are coming first

Read more on breech presentation .

What are the different positions my baby could be in during pregnancy and birth?

If your baby is headfirst, the 3 main types of presentation are:

• anterior – when the back of your baby’s head is at the front of your belly
• lateral – when the back of your baby’s head is facing your side
• posterior – when the back of your baby’s head is towards your back

How will I know what presentation and position my baby is in?

Your doctor or midwife can usually work out your baby’s presentation by feeling your abdomen. They may also double check it with a portable ultrasound. Your baby’s presentation is usually checked around 36 weeks .

Your doctor or midwife will also confirm your baby’s head position in labour by examining your belly and using an ultrasound , and they may also do a vaginal examination . During the vaginal examination they are feeling for certain ridges on your baby’s head called sutures and fontanelles that help them work out which way your baby is positioned.

What is the ideal presentation and position for baby to be in for a vaginal birth?

For a vaginal birth, your baby will ideally be headfirst with the back of their head at the front of your belly, also known as being in the anterior position. This position is best for labour and birth since it means that the smallest part of your baby’s head goes down the birth canal first.

When does a baby usually get in the ideal presentation and position for birth?

Your baby will usually be in a headfirst position by 37 weeks of pregnancy. Around 3 in every 100 babies will be in breech presentation after 37 weeks.

Your baby’s position can change with your contractions during labour as they move down the birth canal, so their exact position can change during labour.

What are my options if baby isn't in the ideal presentation or position for a vaginal birth?

If your baby is in a breech presentation, your doctor may recommend a technique called an external cephalic version (ECV) to try and move your baby while they are still in the uterus . An ECV involves your doctor using their hands to apply pressure on your belly and help turn your baby to a headfirst position. It has a 1 in 2 chance of success and is a safe option in most pregnancies.

There is no evidence to show that alternative therapies, such as exercises, acupuncture or chiropractic treatments, help your baby change from a breech presentation to headfirst.

If your baby remains breech, your doctor may discuss having a breech vaginal birth. Not all doctors and hospitals offer this option. They may also suggest you birth your baby with a planned caesarean section .

If your baby’s presentation is headfirst but the position of your baby’s head is not ideal for labour, it can lead to a longer labour, and potential complications . The position of your baby’s head will often change as your labour progresses. If it doesn’t, sometimes you can still give birth without assistance, or you may need your doctor to help turn your baby’s head or help your birth with a vacuum or forceps .

Any procedure or decision for a type of birth will only go ahead with your consent . You will be able to discuss all the options with your doctor, and based on your preferences for yourself and your baby’s safety, make a decision together .

Resources and support

The Royal Australian and New Zealand College of Obstetrics and Gynaecology has a factsheet about the options available to you if your baby is in a breech presentation at the end of your pregnancy .

Mercy Perinatal has information on external cephalic version (ECV) safety and benefits if your baby is in a breech presentation at the end of your pregnancy.

The Women’s Hospital has information about the different presentations and positions your baby could be in, and how it can affect your birthing experience.

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Last reviewed: October 2023

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External cephalic version (ecv), malpresentation, breech pregnancy, search our site for.

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Breech presentation and turning the baby

In preparation for a safe birth, your health team will need to turn your baby if it is in a bottom first ‘breech’ position.

Read more on WA Health website

Breech Presentation at the End of your Pregnancy

Breech presentation occurs when your baby is lying bottom first or feet first in the uterus (womb) rather than the usual head first position. In early pregnancy, a breech position is very common.

Read more on RANZCOG - Royal Australian and New Zealand College of Obstetricians and Gynaecologists website

External Cephalic Version for Breech Presentation - Pregnancy and the first five years

This information brochure provides information about an External Cephalic Version (ECV) for breech presentation

Read more on NSW Health website

When a baby is positioned bottom-down late in pregnancy, this is called the breech position. Find out about 3 main types and safe birthing options.

Read more on Pregnancy, Birth & Baby website

Malpresentation is when your baby is in an unusual position as the birth approaches. Sometimes it’s possible to move the baby, but a caesarean maybe safer.

Labour complications

Even if you’re healthy and well prepared for childbirth, there’s always a chance of unexpected problems. Learn more about labour complications.

ECV is a procedure to try to move your baby from a breech position to a head-down position. This is performed by a trained doctor.

Having a baby

The articles in this section relate to having a baby – what to consider before becoming pregnant, pregnancy and birth, and after your baby is born.

Anatomy of pregnancy and birth - pelvis

Your pelvis helps to carry your growing baby and is tailored for vaginal births. Learn more about the structure and function of the female pelvis.

Planned or elective caesarean

There are important things to consider if you are having a planned or elective caesarean such as what happens during and after the procedure.

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INTRODUCTION

PATHOGENESIS AND RISK FACTORS

● The fetus does not fully occupy the pelvis, thus allowing a fetal extremity room to prolapse. Predisposing factors include early gestational age, multiple gestation, polyhydramnios, or a large maternal pelvis relative to fetal size [ 2,3 ].

● Membrane rupture occurs when the presenting part is still high, which allows flow of amniotic fluid to carry a fetal extremity, umbilical cord, or both toward the birth canal.

MARY L. LEWIS, MD

Am Fam Physician. 2014;90(5):289-296

This is part I of a two-part article on the newborn examination. Part II, “ Skin, Trunk, Extremities, Neurologic ,” appears in this issue of AFP .

Author disclosure: No relevant financial affiliations.

A comprehensive newborn examination involves a systematic inspection. A Ballard score uses physical and neurologic characteristics to assess gestational age. Craniosynostosis is caused by premature fusion of the sutures, and 20% of children with this condition have a genetic mutation or syndrome. The red reflex assessment is normal if there is symmetry in both eyes, without opacities, white spots, or dark spots. If the red reflex findings are abnormal or the patient has a family history of pertinent eye disorders, consultation with an ophthalmologist is warranted. Newborns with low-set ears should be evaluated for a genetic condition. Renal ultrasonography should be performed only in patients with isolated ear anomalies, such as preauricular pits or cup ears, if they are accompanied by other malformations or significant family history. If ankyloglossia is detected, a frenotomy may be considered if it impacts breastfeeding. The neck should be examined for full range of motion because uncorrected torticollis can lead to plagiocephaly and ear misalignment. Proper auscultation is crucial for evaluation of the broncho-pulmonary circulation with close observation for signs of respiratory distress, including tachypnea, nasal flaring, grunting, retractions, and cyanosis. Benign murmurs are often present in the first hours of life. Pulse oximetry should be performed in a systematic fashion before discharge.

Part I of this two-part article discusses the assessment of general health, head and neck, heart, and lungs. Part II focuses on assessing extremities, and neurologic function. 1

General Assessment

A detailed newborn examination should begin with general observation for normal and dysmorphic features. A term newborn should have pink skin, rest symmetrically with the arms and legs in flexion, cry vigorously when stimulated, and move all extremities equally. Table 1 shows the normal ranges for newborn vital signs at 40 weeks' gestation. 2 – 4 The new Ballard score ( http://www.ballardscore.com ) was designed to assess a newborn's gestational age through a scoring system that combines physical characteristics with neuromuscular development. 5 A video depicting this examination is available at http://www.ballardscore.com/Pages/videos.aspx . Once the child's gestational age is established, weight, length, and head circumference should be plotted on a nomogram to determine percentiles. Using this information, the newborn can be classified as average, large, or small for gestational age.

A newborn is considered small for gestational age if birth weight is below the 10th percentile. Intrauterine growth restriction occurs when the baby's growth during pregnancy is poor compared with norms. Measurements that are symmetrically decreased suggest that the newborn has a chronic exposure (e.g., maternal smoking or drug use) that impacted growth, or a congenital infection such as a TORCH infection (toxoplasmosis, other agents, rubella, cytomegalovirus, herpes simplex), a metabolic disorder, or a chromosomal abnormality (e.g., Turner syndrome, trisomies). Newborns with these conditions often display dysmorphic features or are simply constitutionally small. If the causative factor occurred later in pregnancy (e.g., uteroplacental insufficiency), the head circumference will be preserved relative to other measurements. 6 A newborn with a birth weight above the 90th percentile is considered large for gestational age. The most common cause is maternal diabetes mellitus, although other causes include a metabolic or genetic syndrome such as Beckwith-Wiedemann syndrome.

Because of an increased risk of hypoglycemia, the American Academy of Pediatrics recommends scheduled glucose screening for newborns who are large or small for gestational age, newborns of mothers with diabetes, and late preterm newborns (34 to 36 6/7 weeks gestational age), and provides protocols for their management. 7

At 40 weeks' gestation, the average head circumference is 14 in (35 cm); range, 13 to 15 in (33 to 37 cm, 10th to 90th percentile). 2 Microcephaly (isolated asymmetrically small head, less than the second percentile or two standard deviations below the mean for age and sex) may indicate central nervous system malformation (e.g., holoprosencephaly, neural tube defect), an infection (e.g., toxoplasmosis, cytomegalovirus infection), or a genetic syndrome (e.g., trisomy 13 and 18 syndrome, fetal alcohol syndrome). Macrocephaly (isolated head enlargement, greater than the 98th percentile or greater than two standard deviations above the mean) may be hereditary or the result of a central nervous system disorder (e.g., hydrocephalus, brain tumor), and imaging may be needed. 3 , 4

After evaluating the overall size and shape of the head for asymmetry or gross structural abnormalities, the fontanelles and sutures should be palpated with the newborn in the upright position. Figure 1 illustrates a normal newborn skull and common deformities. The anterior fontanelle is generally 3 to 6 cm in diameter, whereas the posterior fontanelle is no larger than 1 to 1.5 cm in diameter. A large anterior fontanelle may indicate increased intracranial pressure, Down syndrome, hypophosphatemia, trisomy, or congenital hypothyroidism. Fontanelles are often small in newborns with microcephaly. A prematurely fused suture indicates craniosynostosis and occurs in one out of 1,000 newborns. 8 , 9 Craniosynostosis limits growth of the skull in a direction perpendicular to the suture, while growth may continue in other directions. More than 20% of cases are caused by specific single-gene mutations or chromosomal abnormalities and may be associated with conditions such as Crouzon, Apert, and Pfeiffer syndromes. 10 A misshapen head may be caused by prenatal compressions rather than true synostosis. If this is the case, the misshapen head should resolve spontaneously within the first few months of life. 11

The scalp examination may reveal caput succedaneum, cephalohematoma, and other lesions ( Figure 2 ) . A caput succedaneum is scalp edema that is not limited by suture lines, is often pitting, and decreases over time. Most caputs resolve within 48 hours. A cephalohematoma is caused by injury of a blood vessel in the subperiosteal layer of the calvaria. It is limited by suture lines and occurs more commonly in deliveries in which forceps or a vacuum extractor was used. Cephalohematoma is a risk factor for jaundice and sepsis and may worsen over 48 hours, potentially taking up to three to four months to fully reabsorb. Skull fractures are rarely present. If a fracture is depressed or accompanied by neurologic symptoms, computed tomography should be performed to rule out intracranial pathology. 12

Forceps use or a difficult delivery may also lead to a facial nerve palsy resulting in the inability to close the eye, loss of the nasolabial fold, drooping at the corner of mouth, or the inability to contract the ipsilateral lower facial muscles. This usually resolves within the first few weeks of life, but further evaluation is warranted if symptoms persist. 13

The newborn evaluation should include noting eye color; pupil size; appearance of the conjunctiva, sclera, and eyelid; eye movement; and spacing between the eyes. Genetic syndromes often cause unusual eye shape, such as epicanthal folds (excess skin over the medial aspect of the eye) and upslanting of palpebral fissures associated with Down syndrome. Colobomas (a gap or defect in the structure of the eye, primarily the iris) may occur with many syndromes, including CHARGE (coloboma of the eye, heart defects, choanal atresia, retraction of growth and/or development, genital and/or urinary abnormalities, and ear abnormalities and deafness). Infants with colobomas need a formal ophthalmology evaluation. Hypertelorism (increased space between the eyes) and hypotelorism (decreased space between the eyes) are often associated with a genetic disorder. 14 The visual acuity of newborns is approximately 20/400, and a dysconjugate gaze is normal in the first two to three months of life. Subconjunctival hemorrhages from blood vessel rupture are also a common benign finding that may take weeks to resolve.

The red reflex test is performed by using an ophthalmoscope, with the lens power set at 0 and the examiner standing approximately 18 inches away. Light should project onto both eyes simultaneously. A red reflex result is normal if there is symmetry in both eyes without opacities, white spots, or dark spots ( Figure 3 15 ) . The color of the reflex may be different among ethnic groups because of varying amounts of pigmentation in the ocular fundus; however, the reflex should not be white. 14 , 16 Table 2 gives a differential diagnosis of leukokoria. 14 , 16 An abnormal red reflex result warrants urgent referral to an ophthalmologist. Regardless of red reflex findings, all newborns with a family history of retinoblastoma, cataracts, glaucoma, or retinal abnormalities should be referred to an ophthalmologist experienced in the examination of children because of the high risk of serious eye abnormalities. 17

Dacryostenosis should be differentiated from ophthalmia neonatorum, which is conjunctivitis within the first four weeks of life ( Table 3 ) . 18 With dacryostenosis, a blocked tear duct causes secretions to accumulate with a yellow sticky appearance while the rest of the eye appears normal. 19 With conjunctivitis, however, there is often edema and conjunctival injection. 18

Hearing should be evaluated in all newborns before one month of age, but preferably before discharge, using the auditory brainstem response or the otoacoustic emissions test. 20 Assessing the size, shape, and position of the ears may reveal congenital abnormalities. Ears are considered low-set when the helix of the ear meets the cranium at a level below that of a horizontal plane through both inner canthi ( Figure 4 ) . Low-set ears are often a sign of a genetic condition (e.g., Down, Turner, or trisomy 18 syndrome). Microtia (small and underdeveloped pinnae) is commonly associated with another defect, such as CHARGE syndrome. 21 Because preauricular skin tags and ear pits are associated with permanent hearing impairment in newborns, screening and close monitoring are warranted. 22 There is a known association between ear and renal abnormalities, and a variety of syndromes demonstrate both ear and renal defects. 23 – 25

In the past, there was uncertainty about which ear malformations warranted screening renal ultrasonography. Recent data indicate that ultrasonography should be performed in patients with isolated ear anomalies, such as preauricular pits or cup ears, only when they are associated with one or more of the following characteristics: other malformations or dysmorphic features, teratogenic exposures, a family history of deafness, or a maternal history of gestational diabetes. 26 – 28 Ear canals should be observed for patency.

Choanal atresia occurs when one or both sides of the nasal airway are narrowed or blocked. To assess patency of the nostrils, a small-caliber catheter can be passed through the nasal passages. If bilateral choanal atresia is present, the infant may have cyanosis that is relieved by crying. Asymmetry of the nasal septum is often due to in utero positioning. If it can be corrected by depression of the tip of the nose, it will usually resolve on its own. However, asymmetry that does not correct with depression of the nose tip indicates a dislocated septum, and the patient should be evaluated by an otolaryngologist. 29 , 30

The maxilla and mandible should fit together well and open at equal angles. Micrognathia (a small mandible) occurs with Pierre Robin syndrome. Table 4 details common oral cavity findings. 31 Ankyloglossia occurs when a short frenulum attaches the tongue to the floor of the mouth, limiting its mobility. This may interfere with breastfeeding or impair articulation, although frenotomy is controversial. 32 – 34 Palpating the palate can reveal submucosal and mucosal clefts. A bifid uvula is often associated with a submucosal cleft. Cleft lip and palate are the most common anomalies of the head and neck. Midline clefts warrant investigation for a midline defect in the brain or other abnormalities. 35

The neck should be inspected for full range of motion because congenital torticollis is a common musculoskeletal anomaly of newborns. Torticollis is primarily due to birth trauma to the sternocleidomastoid muscle that causes swelling or sometimes hematoma formation within the muscle. It can usually be corrected with physical therapy. 36 If not corrected, torticollis can lead to plagiocephaly and ear misalignment.

Other possible findings on the neck examination include webbing, which can occur with Turner syndrome, and branchial clefts, pits, and masses. A cystic hygroma is a congenital lymphatic malformation in the neck region. A midline neck lesion may represent a thyroglossal duct cyst and typically shifts with movement of the tongue. The clavicles should be palpated for fracture, which may manifest only as asymmetric Moro reflex if nondisplaced. A suspected fracture should be confirmed with a radiograph. Fractures can be a result of birth trauma and are typically treated with analgesics for pain. 37

When a newborn takes the first breath, subsequent decreases in resistance in the pulmonary vasculature and increases in oxygen concentration result in eventual closure of the shunts, which allow the newborn to transition to adult circulation. Congenital heart disease occurs in approximately six out of 1,000 live births. 38 Newborns with heart disease often exhibit tachypnea without retractions. Cyanosis is often present with severe disease. 38 This appearance should be differentiated from acrocyanosis (isolated cyanosis of the hands and feet), which is normal in newborns.

Upon auscultation of the heart in the standard four locations (right upper sternal border, left upper sternal border, left lower sternal border, and between the fifth and sixth intercostal space in the midclavicular line), the first heart sound should be single and the second heart sound split. Table 5 summarizes important cardiac examination findings. 38 , 39 Because of changes in vasculature immediately after birth, benign murmurs are common in the first hours of life. 38 , 39 Routine screening for congenital heart disease via pulse oximetry is recommended before discharge at 24 hours of life or later, or shortly before discharge if earlier than 24 hours. Diagnostic echocardiography should be performed if screening results are positive ( Table 6 ) . 40 , 41

The respiratory examination is important because the infant is transitioning from fetal to neonatal life. The alveoli are filling with air, the systemic vascular resistance is increasing, and the pulmonary vascular resistance is decreasing. The examiner should observe for signs of respiratory distress, including tachypnea, nasal flaring, grunting, retractions, and cyanosis. Breath sounds should be equal on auscultation. Unequal breath sounds may indicate a pneumothorax and should prompt imaging.

Transient tachypnea of the newborn occurs predominantly in those born via cesarean delivery or precipitous delivery. It is caused by retained fluid in the lungs, which can result in alveolar hypoventilation. 42 Treatment includes supportive respiratory care because the condition resolves within 48 hours. Respiratory distress syndrome arises from lack of surfactant, which leads to alveolar collapse. Although it is most common in preterm infants, it may occur in term infants, particularly if the mother has diabetes. A previous article in American Family Physician includes a detailed review of respiratory distress in the newborn. 43

Data Sources : A PubMed search was completed using the terms infant, newborn, developmental delay, developmental disturbance, and physical examination. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. We also searched POEMs (patient-oriented evidence that matters), Clinical Evidence, the Cochrane database, and Essential Evidence Plus. Search dates: January 1, 2012, and May 2, 2014.

The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.

Lewis ML. A comprehensive newborn examination: part II. Skin, trunk, extremities, neurologic. Am Fam Physician. 2014;90(5):297-302.

Lissauer T. Physical examination of the newborn. In: Martin RJ, Fanaroff AA, Walsh MC, eds. Fanaroff and Martin's Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant . 9th ed. Philadelphia, Pa.: Saunders/Elsevier; 2011:485.

Sniderman A. Abnormal head growth. Pediatr Rev. 2010;31(9):382-384.

Tschudy MM, Arcara KM; Johns Hopkins Hospital. The Harriet Lane Handbook . 19th ed. Philadelphia, Pa.: Mosby Elsevier; 2012.

Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard score, expanded to include extremely premature infants. J Pediatr. 1991;119(3):417-423.

Intrauterine growth restriction. Washington, DC: American College of Obstetricians and Gynecologists; May 2013. ACOG Practice Bulletin No. 134.

Adamkin DH Committee on Fetus and Newborn. Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics. 2011;127(3):575-579.

Marchac D, Renier D. Treatment of craniosynostosis in infancy. Clin Plast Surg. 1987;14(1):61-72.

Nagaraja S, Anslow P, Winter B. Craniosynostosis. Clinic Rad. 2013;68(3):284-292.

Johnson D, Wilkie AO. Craniosynostosis. Eur J Hum Genet. 2011;19(4):369-376.

Kabbani H, Raghuveer TS. Craniosynostosis. Am Fam Physician. 2004;69(12):2863-2870.

Uhing MR. Management of birth injuries. Pediatr Clin North Am. 2004;51(4):1169-1186.

Falco NA, Eriksson E. Facial nerve palsy in the newborn: incidence and outcome. Plast Reconstr Surg. 1990;85(1):1-4.

Guercio JR, Martyn LJ. Congenital malformations of the eye and orbit. Otolaryngol Clin North Am. 2007;40(1):113-140.

Bell AL, Rodes ME, Collier Kellar L. Childhood eye examination [published correction appears in Am Fam Physician . 2014;89(2):76]. Am Fam Physician. 2013;88(4):241-248.

Cheng KP, Hiles DA, Biglan AW. The differential diagnosis of leukokoria. Pediatr Ann. 1990;19(6):376-383.

American Academy of Pediatrics; Section on Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology; American Association of Certified Orthoptists. Red reflex examination in neonates, infants, and children [published correction appears in Pediatrics . 2009;123(4):1254]. Pediatrics. 2008;122(6):1401-1404.

Prevention of neonatal ophthalmia. In: Pickering LK, ed. Red Book: 2009 Report of the Committee on Infectious Diseases . 29th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2012:880–882.

Robb RM. Congenital nasolacrimal duct obstruction. Ophthalmol Clin North Am. 2001;14(3):443-446.

American Academy of Pediatrics, Joint Committee on Infant Hearing. Year 2007 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007;120(4):898-921.

Harris J, Källén B, Robert E. The epidemiology of anotia and microtia. J Med Genet. 1996;33(10):809-813.

Roth DA, Hildesheimer M, Bardenstein S, et al. Preauricular skin tags and ear pits are associated with permanent hearing impairment in newborns. Pediatrics. 2008;122(4):e884-e890.

Leung AK, Robson WL. Association of preauricular sinuses and renal anomalies. Urology. 1992;40(3):259-261.

Hilson D. Malformations of ear as a sign of malformations of genitourinary tract. Br Med J. 1957;2(5048):785-789.

Wang RY, Earl DL, Ruder RO, Graham JM. Syndromic ear anomolies and renal ultrasounds. Pediatrics. 2001;108(2):e32.

Kugelman A, Tubi A, Bader D, Chemo M, Dabbah H. Pre-auricular tags and pits in the newborn: the role of renal ultrasonography. J Pediatr. 2002;141(3):388-391.

Wang RY, Earl DL, Ruder RO, Graham JM. Syndromic ear anomalies and renal ultrasounds. Pediatrics. 2001;108(2):E32.

Deshpande SA, Watson H. Renal ultrasonography not required in babies with isolated minor ear anomalies. Arch Dis Child Fetal Neonatal Ed. 2006;91(1):F29-F30.

Myer CM, Cotton RT. Nasal obstruction in the pediatric patient. Pediatrics. 1983;72(6):766-777.

Hengerer AS, Brickman TM, Jeyakumar A. Choanal atresia: embryologic analysis and evolution of treatment, a 30-year experience. Laryngoscope. 2008;118(5):862-866.

Mueller DT, Callanan VP. Congenital malformations of the oral cavity. Otolaryngol Clin North Am. 2007;40(1):141-160.

Forlenza GP, Paradise Black NM, McNamara EG, Sullivan SE. Ankyloglossia, exclusive breastfeeding, and failure to thrive. Pediatrics. 2010;125(6):e1500-e1504.

Messner AH, Lalakea ML. Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol. 2000;54(2–3):123-131.

Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110(5):e63.

Fisher DM, Sommerlad BC. Cleft lip, cleft palate, and velopharyngeal insufficiency. Plast Reconstr Surg. 2011;128(4):342e-360e.

Cheng JC, Wong MW, Tang SP, Chen TM, Shum SL, Wong EM. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases. J Bone Joint Surg Am. 2001;83-A(5):679-687.

Hsu TY, Hung FC, Lu YJ, et al. Neonatal clavicular fracture: clinical analysis of incidence, predisposing factors, diagnosis, and outcome. Am J Perinatol. 2002;19(1):17-21.

Wren C, Reinhardt Z, Khawaja K. Twenty-year trends in diagnosis of life-threatening neonatal cardiovascular malformations. Arch Dis Child Fetal Neonatal Ed. 2008;93(1):F33-F35.

Dolbec K, Mick NW. Congenital heart disease. Emerg Med Clin North Am. 2011;29(4):811-827.

Mahle WT, Martin GR, Beekman RH, Morrow WR Section on Cardiology and Cardiac Surgery Executive Committee. Endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease. Pediatrics. 2012;129(1):190-192.

Centers for Disease Control and Prevention. Screening for critical congenital heart defects. http://www.cdc.gov/ncbddd/pediatricgenetics/pulse.html . Accessed April 22, 2014.

Machado LU, Fiori HH, Baldisserotto M, Ramos Garcia PC, Vieira AC, Fiori RM. Surfactant deficiency in transient tachypnea of the newborn. J Pediatr. 2011;159(5):750-754.

Hermansen CL, Lorah KN. Respiratory distress in the newborn. Am Fam Physician. 2007;76(7):987-994.

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Excellent Care from the Moment of Birth

The Newborn Examination

Clinical rotations for students.

This introduction is not intended to be comprehensive, but is instead designed to cover the main components of the newborn examination. During your time in the nursery, we trust that you will become comfortable with the essential elements of the exam and be able to identify many of the common physical findings.

• General Appearance
• Neck and Clavicles
• Ears, Nose, Mouth, Throat
• Thorax and Breasts
• Lungs and Heart
• Abdomen and Umbilicus
• Trunk and Spine
• Extremities
• Neurological

Before even touching the infant, notice the following:  color ,  posture/tone ,  activity ,  size ,  maturity , and quality of cry .

This infant has a normal pink color, normal flexed posture and strength, good activity and resposiveness to the exam, relatively large size (over 9 pounds), physical findings consistent with term gestational age (skin, ears, etc), and a nice strong cry.

photo by Janelle Aby, MD

Inspect and palpate the head noting:  bruising ,  edema ,  molding/shape ,  sutures , and  fontanelles .

Bruising is visible on this infant's head. Scalp edema (caput succedaneum) is a very common finding. Cephalohematoma (sub-periosteal bleed) is occasionally noted. Gentle but firm palpation will help distinguish these two entities from each other and from molding. Suture frequently overlap each other ("over-riding") and fontanelle size varies. Within 24 hours, edema and molding will already show improvement.

Examine neck and clavicles for:  range of motion ,  asymmetry ,  masses , or  crepitus .

Infants have very short necks, but they should have full range of motion from side to side, and the neck should appear symmetric. To palpate clavicles, use a firm, steady pressure along the enitre length of the bone, from shoulder to sternum, to detect crepitus, edema, or step-offs that indicate clavicular fracture. The infant above has swelling over the left clavicle as a result of a fracture.

Assess the eyes for:  symmetry ,  set/shape ,  discharge ,  erythema , and  red light reflexes  .

Eyes should be symmetric and in a normal position. Eyelid edema is common after birth and resolves a a few days. Slight yellow discharge in a normal eye may be benign, but injection in the conjunctiva (seen above in the baby's right eye) is abnormal. Red light reflexes can be seen by looking at the pupils through an ophthalmoscope; they may appear orange-yellow in darker skinned infants.

Make note of:  ear   set/shape ,  preauricular pits/tags ,  nasal shape/patency ,  palate ,  gums ,  lips and tongue .

Ears should not appear low or posteriorly rotated. Although nasal congestion can be present in newborns, there should not be nostril flaring or respiratory distress. Palate should be intact visibly and by palpation (submucosal clefts occur). Tongue should be freely mobile. In the photo above, the lingual frenulum under the tongue is restricting tongue elevation when the baby cries.

Observe:  shape of thorax ,  position of nipples , and  work of breathing .

Chest should have a normal contour with nipples near the mid-clavicular line. Small breast buds are present in term infants. Breathing should appear easy. The infant in the photo above has unusually prominent ribs as a result of intercostal retractions, a sign of respiratory distress.

Listen for and assess:  breath sounds ,  heart murmurs , and  femoral pulses .

Lung sounds should be clear and equal. Normal respiratory rate is 40 - 60 bpm. Normal heart rate is 120 - 160 bpm. Quality and location of murmurs should be noted. Femoral pulses are best obtained when the infant is quiet. They should feel strong and equal.

Assess:  bowel sounds ,  liver ,  spleen ,  kidneys  and  umbilical cord  .

Bowel sounds should be present and the abdomen soft. A liver edge in nornally palpable 1 - 2 cm below the right costal margin. A spleen should not be detected on physical exam. Kidneys may be palpated by an experienced examiner, but are likely enlarged if easily felt. The cord should be clean and dry. If fresh, the umbilical vessels may be assesssed also. There should be two arteries and one vein.

Evaluate:  labia ,  hymen  (or  penis ,  testicles ) and  anus  .

For girls, both labia majora and minora should be seen. Normal hymenal tissue is light pink with a central orifice between the labia minora. White or mucoid disharge (as in the photo) is normal. For boys, the penile shaft should appear straight with an intact foreskin. Testicles should be palpable bilaterally as small (1 cm) symmetric masses. The anus should have a visible orifice within the sphincter. Stool in the diaper is  not evidence of patency.

Assess back and spine for:  symmetry ,  skin lesions , and  masses .

Back should appear symmetric and spine should be palpable all along its length. Unusual skin lesions, tags, or masses should be noted as these may indicate underlying spinal dysraphism.

Inspect extremities for:  mobility ,  deformity , and  stability .

Fingers and toes should be counted and evaluated for evidence of malformation. Arms and legs should appear symmetric bilaterally and have normal position and good tone.  Ortolani and Barlow maneuvers  are used to evaluate hips for subluxation or dislocation. This newborn has bilateral clubfeet.

Evaluate the following reflexes:  suck ,  grasp (hands and feet) , and  Moro .

There are several other reflexes present at birth, but unless there is concern about the neurologic state of the infant, a general screening with the items listed above should be sufficient.

For more detailed information on the examination of the newborn, click on the links below. These excellent articles were published in the American Family Physician in 2002. The video is from the University of British Columbia's "Learn Pediatrics" website.

The Newborn Examination: Part 1  

Emergencies and Common Abnormalities Involving the Skin, Head, Neck, Chest, and Respiratory and Cardiovascular Systems

The Newborn Examination: Part 2  

Emergencies and Common Abnormalities Involving the Abdomen, Pelvis, Extremities, Genitalia, and Spine

• Daily Schedule
• Roles and Responsibilities
• Newborn Exam
• Notes and Presentations

Appointments at Mayo Clinic

• Infant and toddler health
• What a newborn really looks like

Do you wonder what your newborn baby will look like? Some physical features of newborns can surprise people who've only seen these tiny babies in the movies or magazines.

Being born affects how a baby looks. Pregnancy and birth can cause a baby's skin, face, arms and legs, or genitals to look different than you might expect.

Your healthcare team will examine the newborn just after the baby is born as well as before you take your baby home. If you have any questions, make sure to ask a person on your healthcare team.

Every baby is different, but here's a peek at some real newborns so that you know what to expect.

Your newborn's eyes

As a baby goes through the birth canal, pressure on the face can cause the baby's eyelids to look puffy or swollen. This swelling should go down over a day or two after birth.

Sometimes right after birth, a baby's eyes seem cross-eyed, meaning they look more toward the baby's nose. As your baby's eye muscles strengthen over time, this cross-eyed condition usually gets better.

Also, a baby's eye color may not be set at birth. You might notice your baby's eye color changing over the first six months.

Your newborn's head

An infant's skull bones can shift and overlap. This allows a baby to move through the birth canal. In general, being in labor for a long time means a baby's head might be more cone shaped than a baby who experienced a shorter labor.

A baby's head also may look taller if tools such as a vacuum extractor were used in the birth. In the few days after birth, the cone shape usually becomes rounder. Babies born buttocks or feet first or by C-section are more likely to have round heads at birth.

A newborn's soft spots

There are two soft areas at the top of your baby's head where the skull bones haven't yet grown together. These spots, called fontanels, allow for the skull to reshape as needed to pass through the birth canal. Later, these areas provide the space needed by a baby's rapidly growing brain. These areas can look like bumps or dents in the baby's scalp. You might notice these spots pulsing when your baby cries or strains.

Fontanels are covered by a thick fibrous layer. The larger soft spot is a diamond shape about the size of a quarter coin. This is about an inch in diameter (about 2.5 centimeters). The smaller soft spot is at the back of the head. That area is about the size of a dime. This is just over half an inch (1.79 centimeters).

Fontanels are safe to touch and typically close when the skull bones fuse together by age 2 years old.

Your newborn's umbilical cord

The umbilical cord attaches the baby to the placenta during pregnancy. After the baby is born, a healthcare professional will clamp the cord close to the baby's body.

The stump of a newborn's umbilical cord is usually a yellow-green color at birth.

The clamped bit of umbilical cord will dry out over a few weeks after birth. It will change in color to brown and then to black. It typically falls off around 1 to 3 weeks after birth.

In the meantime, caregivers should keep the stump clean and dry. Fold your baby's diaper under the stump so that air can help dry out the base. Stick to sponge baths while the area is healing. There's no need to swab the stump with rubbing alcohol.

Your newborn's skin

After birth, babies can have all sorts of spots, rashes, bruises or blotches. Dry, peeling skin is typical in newborns, especially on hands and feet in the first few weeks. The top layer of skin is usually flaky in the first weeks after birth. Daily moisturizing can help keep your baby comfortable.

You might notice white bumps on your newborn's face that look like tiny pimples. These harmless spots, known as milia, typically disappear on their own. Don't try and pinch these bumps, scrub your baby's face, or use lotions or oils on milia. Mild soap and water once a day usually helps clear up milia over time, usually in a few weeks.

Your newborn's skin also might be covered by fine, downy hair at birth. This is known as lanugo. It can be found especially on the back and shoulders and is most common in premature babies. It typically wears off within several weeks.

Other skin marks that caregivers may see on a newborn are bruises on a baby's head from the mother's pelvis. If tools were used during birth, such as forceps, the baby may have a scrape or bruise. These marks generally should all go away within about two weeks.

Your newborn's birthmarks

Birthmarks are areas of skin that are present at birth or develop later. Some are permanent and some fade as a child grows.

They can range from blue-gray to brown to red in color. A common birthmark is called a salmon patch. This is a pink to red patch at the back of a newborn's neck, on the eyelids or forehead, or between the baby's eyes.

Salmon patch birthmarks are sometimes nicknamed stork bites or angel kisses. These marks tend to get brighter during crying.

Some marks disappear in a few months, while others fade over a few years or persist. Marks at the back of the neck usually last longer than marks on the face.

Babies of African or Asian ethnicity may be born with birthmarks that are flat, blue-green or blue-gray marks typically found on the lower back or buttocks. Sometimes these marks are mistaken for bruises. But, in general, this type of mark fades during early childhood.

Your newborn's breasts and genitals

As the pregnant body prepares for birth and breastfeeding, some hormones can cross the placenta. These hormones can affect a newborn.

Babies may have swollen breast tissue at birth, and this tissue may produce a fluid.

Vaginal tissue may be swollen, or newborns may have a harmless vaginal discharge for a few weeks after birth.

The loose skin that holds the testes, called the scrotum, may be swollen. The swelling may be caused by hormones or the pressure in the birth canal, especially if a baby is born feet first, called breech.

The swelling is due to fluid in the scrotum, a condition called hydrocele. Typically, this fluid will be reabsorbed over time.

Right after birth, a healthcare professional will examine your baby and talk with you about any concerns. If you have questions then or later, ask your baby's healthcare professional.

Your first look at your newborn

Every baby is different. But in general, newborns look wrinkly. And they may be damp or even a bit bloody.

At birth, a baby's legs and feet might look bowed or bent. This is because of the lack of space in the uterus. You can expect the baby's legs to straighten on their own as the baby grows and starts to move around.

Your healthcare professional will do a full examination of the baby and explain the findings. Be sure to ask any questions you may have.

No matter how the baby looks, your baby is born ready to be cared for and held. If everyone is healthy, your healthcare team may put your baby right on your chest for skin-to-skin contact. Some caregivers immediately feel a bond. Others are too exhausted or overwhelmed. Not everyone feels the same way. Caregivers can expect their feelings to grow over time.

• Cook WJ, et al., eds. Mayo Clinic Guide to Your Baby's First Years: Newborn to Age 3. Mayo Clinic Press; 2020.
• Kliegman RM, et al. The newborn infant. In: Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020. http://www.clinicalkey.com. Accessed Aug. 29, 2023.
• Coin specifications. United States Mint. https://www.usmint.gov/learn/coin-and-medal-programs/coin-specifications. Accessed Aug. 30, 2023.
• McKee-Garrett TM. Assessment of the newborn infant. https://www.uptodate.com/contents/search. Accessed Aug. 29, 2023.
• Palazzi DL, et al. Care of the umbilicus and management of umbilical disorders. https://www.uptodate.com/contents/search. Accessed Aug. 30, 2023.

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Jewish Newborn Ceremonies 101

An overview of ceremonies to welcome baby boys and girls.

By My Jewish Learning

History and Development

The practice of circumcising baby boys ( brit milah , or “the covenant of circumcision”) has its roots in Abraham’s circumcising the male members of his household, as recorded in the biblical Book of Genesis . It is a deep and persistent symbol of covenant and continuity for the Jewish people.

A parallel ceremony for girls (often called a simchat bat , “celebration of a daughter,” or brit banot, “daughters’ covenant”) is a contemporary development with historical and cultural predecessors, inspired by Jewish feminism , and practiced in most liberal and some traditional communities. Families and communities have also acknowledged and celebrated the arrival of babies in many other ways throughout Jewish history, and in different Jewish traditions throughout the world, with a variety of home and synagogue rituals of celebration and naming.

Liturgy, Ritual, and Custom

For boys, the ceremony for brit milah (also known as a “bris”) traditionally takes place on the eighth day of life, and includes words of blessing, the circumcision itself, and the giving of a name. Traditionally the responsibility of the baby’s father, the act of circumcision is usually performed (according to prescribed custom) by a mohel , an individual trained in the practice and its rituals. For many girls, the much newer simchat bat or brit banot (frequently referred to in English as a “baby naming”) can take place on a variety of days. It often follows a similar structure as the brit milah, with one of several covenantal or welcoming acts (e.g., candlelighting, footwashing, or being wrapped in a tallit [prayer shawl]) as the ritual centerpiece. Some families follow the simpler and longer-standing custom of having their new daughter receive her Hebrew or Yiddish name during a synagogue Torah-reading service, rather than holding a freestanding simchat bat.

Just as the longstanding tradition of brit milah for boys inspired the creation of parallel ceremonies for girls, the creative approach to tradition that has marked simchat bat ceremonies has in many cases shaped the way that brit milah is celebrated, for example, with fuller involvement of the mother, and an emphasis on themes equally applicable to girls and boys.

In Practice

A ceremony and celebration for a Jewish baby is often planned in a hurry after the baby is born. Fortunately, there are many resources available to parents and families to help with the planning a brit milah or a simchat bat . Those attending such an event have a special role to play as family and community members. Enjoying the festive meal (or seudah) is considered a sacred obligation. Families may mark the occasion with a tzedakah (charity) donation or other social action project, or continue the ancient custom of planting a tree in honor of each child.

Pidyon HaBen

Jewish tradition mandates a ceremony in which first-born Jewish males (those who are the first to “open the womb” of their mother) are “ redeemed ” from the service of the ancient priests. It is usually a small, private ceremony in which someone who is believed to be a descendant from the priestly class (a cohen) symbolically releases the child back to his parents. It is mainly practiced today by traditionally observant Jews.

The encounter between tradition and modernity, and between different Jewish customs, raises interesting questions about ceremonies of welcoming, naming, and covenant. What are the connections and differences between ceremonies for girls and those for boys? Is there a move toward standardization or diversity in ceremonies for girls? And what happens when Jewish tradition collides with contemporary debates about the morality and effects of circumcision ? Finally with a large percentage of Jews marrying non-Jews, some couples debate what faith tradition to raise their child, and if both, then how are newborn ceremonies reflecting those decisions?

For more Jewish parenting help, visit our partner site Kveller.

Pronounced: breet mee-LAH, Origin: Hebrew, literally “covenant of circumcision,” the Jewish circumcision ceremony for an 8-day-old boy, marking the covenant between God and the Jews. Also known as a bris.

simchat bat

Pronounced: SEEM-khat BAHT, Origin: Hebrew, ceremony welcoming a Jewish baby girl, also known as a brit bat.

Pronounced: tzuh-DAH-kuh, Origin: Hebrew, from the Hebrew root for justice, charitable giving.

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Original Author(s): Dr Phil Jordan and Dr Umberto Piaggio Last updated: 16th February 2021 Revisions: 19

• 1 Introduction
• 2.1 Physiological jaundice
• 2.2 Pathological jaundice
• 3 Risk factors and history
• 4 Clinical Presentation
• 5.1 Bilirubin
• 5.2 Further investigations
• 5.3 As needed
• 6.1 Phototherapy
• 6.2 Fluid intake
• 6.3 Exchange Transfusion
• 6.4 IV Immunglobulin
• 7 Complications
• 8 Prognosis
• 9 References

Introduction

Jaundice is t he yellow colouring of skin and sclera caused by the accumulation of bilirubin in the skin and mucous membranes.

Neonatal jaundice  occurs in 60% of term infants and 80% of preterm infants [1] and is caused by hyperbilirubinaemia that is unconjugated (divided into physiological or pathological) or conjugated (always pathological).  High levels of unconjugated bilirubin have acute harmful effects as well as long term damage if left untreated, such as kernicterus .

10% of breast fed babies are jaundiced at 1 month.

Types of Jaundice

Physiological jaundice.

Jaundice in a healthy baby, born at term, is normal and may result from:

• Increased red blood cell breakdown: in utero the fetus has a high concentration of Hb (to maximise oxygen exchange and delivery to the fetus) that breaks down releasing bilirubin as high Hb is no longer needed
• Immature liver not able to process high bilirubin concentrations

Starts at day 2-3, peaks day 5 and usually resolved by day 10.   The baby remains well and does not require any intervention beyond routine neonatal care.

Physiological jaundice can progress to pathological jaundice if the baby is premature or there is increased red cell breakdown e.g. Extensive bruising or cephalohaematoma following instrumental delivery.

Pathological jaundice

Jaundice which requires treatment or further investigation.

• Onset less than 24 hours
• ?previous siblings treated for jaundice/family history/maternal rhesus status
• Maternal blood group (type O most likely to produce enough IgG antibodies to cause haemolysis)
• Requires investigation and treatment
• Onset after 24 hours
• likely dehydrated ?breast fed baby establishing feeding
• increased haemolysis due to bruising/cephalohaematoma
• Unwell neonate: jaundice as a sign of congenital or post-natal infection
• Metabolic: Hypothyroid/pituitarism, galactosaemia
• Breast milk jaundice: well baby, resolves between 1.5-4 months
• GI: biliary atresia, choledhocal cyst

Risk factors and history

Risk factors for pathological hyperbilirubinaemia: to be asked in history

• Prematurity, low birth weight, small for dates
• Previous sibling required phototherapy
• Exclusively breast fed
• Jaundice <24 hours
• Infant of diabetic mother

Clinical Presentation

• Colour: All babies should be checked for jaundice with the naked eye in bright, natural light (if possible). Examine the sclera, gums and blanche the skin. Do not rely on your visual inspection to estimate bilirubin levels, only to determine the presence or absence of jaundice.
• Drowsy: difficult to rouse, not waking for feeds, very short feeds
• Neurologically: altered muscle tone, seizures-needs immediate attention
• Other: signs of infection , poor urine output, abdominal mass/organomegaly, stool remains black/not changing colour

Investigations

• Transcutaneous bilirubinometer (TCB) can be used in >35/40 gestation and >24 hours old for first measurement. TCB can be used for all subsequent measurements, providing the level remains <250 µmol/L and the child has not required treatment
• Serum bilirubin to be measured if <35/40 gestation, <24 hours old or TCB >250 µmol/L
• Infants that are not jaundice to the naked eye do not need routine bilirubin checking.  
• Total and Conjugated Bilirubin is important if suspected; liver or biliary disorder, metabolic disorder, congenital infection or prolonged jaundice. Do not subtract conjugated from total to make management decisions for hyperbilirubinaemia.

Further investigations

• Serum bilirubin for all subsequent levels
• Blood group (Mother and Baby) and DCT
• FBC for haemoglobin and haematocrit
• U&Es if excessive weight loss/dehydrated
• Infection screen if unwell or <24 hours including Microbiological cultures if infection suspected: blood, urine, CSF. Consider TORCH screen.
• Glucose-6-phosphate dehydrogenase especially if Mediterranean or African origin
• LFTs if suspected hepatobiliary disorder

Phototherapy

Figure 1 – NICE treatment threshold graph [3]

• Above: If level is on or above the phototherapy line for their gestation and age (in days) phototherapy should be initiated and bilirubin monitored
• >50µmol/L below, clinically well with no risk factors for neonatal jaundice do not routinely repeat level
• <50µmol/L below, clinically well repeat level within 18 hours (risk factors present) to 24 hours (no risk factors present)
• Repeat bilirubin 4-6 hours post initiation to ensure not still rising, 6-12 hourly once level is stable or reducing.
• NB. Maximum skin coverage, eye protection for babies, breaks for breastfeeding/nappy changes/cuddles to be coordinated to maximise phototherapy
• Stop phototherapy once level >50µmol/L below treatment line on the threshold graphs
• Check for rebound of hyperbilirubinaemia 12-18 hours after stopping phototherapy

Fluid intake

Do not give additional fluids with phototherapy unless indicated and if possible expressed maternal milk is preferred. If phototherapy intensified or feeding poorly consider NGT feeding or IV fluids.

Give consideration to underlying cause i.e. infection, biliary obstruction

Exchange Transfusion

This is the simultaneous exchange of the baby’s blood (hyperbilirubinaemic) with donated blood or plasma (normal levels of bilirubin) to prevent further bilirubin increase and decrease circulating levels of bilirubin.

Performed via umbilical artery or vein and is indicated when there are clinical features and signs of acute bilirubin encephalopathy or the level/rate of rise (>8.5µmol/L/hour) of bilirubin indicates necessity based on threshold graphs. This will require admission to an intensive care bed.

IV Immunglobulin

IVIG can be used as adjunct to intensified phototherapy in rhesus haemolytic disease or ABO haemolytic disease.

Complications

Kernicterus , billirubin-induced brain dysfunction, can result from neonatal jaundice. Bilirubin is neurotoxic and at high levels can accumulate in the CNS gray matter causing irreversible neurological damage . Depending on level of exposure, effects can range from clinically undetectable damage to severe brain damage.

Depends on underlying cause but if correctly and promptly treated prognosis is excellent.

Always refer to local trust guidelines.

1st Author: Dr Phil Jordan

Senior Reviewer: Dr Umberto Piaggio

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