Clinical Examination Demonstration

The clinical examination begins with measurements. Measurements should include a crown heel length, making sure that the leg is fully stretched, a weight and a head circumference.

The last is most easily accomplished using a string and then measuring the string on a fixed ruler. The baby is evaluated for the degree of maceration. This indicates how long the infant has been dead in utero. In this baby there are slight to mild external macerative changes, particularly evident on the lower back.

The remainder of the examination is basically a head to foot assessment with special attention being paid to those features frequently seen in babies who are stillborn because of the presence of birth defects.

The head is examined for the presence of anencephaly, apparent hydrocephalus, any abnormalities of shape or the presence of scalp defects or masses.

Examination of the face begins with assessment of the eyes including whether they are normally placed and slanted, whether the globes are normal (which of course require opening the eyelids) and so forth.

Note is made of the size and shape of the nose and whether the nostrils are patent. The mouth is examined including assessment of size, whether the upper lip is intact or cleft, and then is opened to determine whether or not the palate is normal; feeling the roof of the mouth with a finger often helps to insure that no cleft or other abnormality is present.

The ears are examined for abnormal external architecture and, if they seem unusual, a drawing or description should be included. They are also assessed for position and rotation -- that is, if the top of the ear is below the line from the two corners of the eye, then the ear is low set and if the orientation of the ear is more than about thirty degrees from vertical, then it is posteriorly rotated. The region in front of the ear is examined for tags or pits.

The neck may be abnormally short, show excess or redundant skin or may have associated with it a cystic mass which is most often a cystic hygroma; such hygromas are exceedingly common in stillbirths.

The chest is examined for symmetry, size and shape. Likewise the abdomen is examined for the presence of abdominal wall defect such as an omphalocele, gastrosschissis or umbilical hernia.

The baby should be turned over so that the back is examined for evidence of abnormal curvature and for any sign of spina bifida.

Both the upper and lower limbs need to be described with respect to length, form, symmetry and positions. Descriptions of the hands should include careful assessment of the fingers including number, form, position, abnormal webbing and so forth. A similar evaluation of the feet looks for the presence of clubbing, number or toes, abnormal spacing of the toes and so forth.

The genitalia are examined. In males that includes description of the penis, whether the urethral opening is normally placed and whether the scrotum is normal and the testes descended. In females it includes identifications of the urethral opening and vaginal introitus and description of the clitoris. In both sexes the anus should be examined for placement and patency.

The umbilical cord should also be evaluated as part of the clinical examination. Whether there are, the normal, three vessels or only two is most easily seen if a thin splice is removed from the umbilical stump and it is viewed in cross section.