11.6 Genitourinary & Musculoskeletal Examination and Primitive Reflexes
Key Takeaways
- Hypospadias is an absolute contraindication to neonatal circumcision because the prepuce is required for later urethroplasty.
- Ortolani tests reduction of a dislocated hip by abduction with anterior lift, while Barlow tests dislocatability by adduction with posterior pressure.
- More than 99 percent of term infants pass meconium within 24 to 48 hours, and failure by 48 hours suggests imperforate anus, Hirschsprung disease, meconium ileus, or atresia.
- Pseudomenses and milky vaginal discharge in a female newborn reflect withdrawal of maternal estrogen and are benign.
- An asymmetric Moro reflex suggests clavicular fracture or brachial plexus injury rather than a central nervous system abnormality.
Last updated: September 2026
Systematic Organ System Examination: Genitourinary & Musculoskeletal
Genitourinary System
- Male Neonate:
- Inspect the urethral meatus at the tip of the glans. In hypospadias, the urethral orifice opens on the ventral surface of the glans, shaft, or perineum, often with ventral chordee and a hooded dorsal prepuce. In epispadias, the meatus opens on the dorsal aspect.
- CRITICAL MIDWIFERY RULE: Hypospadias is an absolute, strict contraindication to routine neonatal circumcision. The prepuce (foreskin) is surgically indispensable and must be preserved for future pediatric urological reconstruction (urethroplasty).
- Palpate the scrotum for bilateral testicular descent. Cryptorchidism (undescended testicle) warrants surveillance; hydroceles (fluid collections within the tunica vaginalis) transilluminate clearly and typically resolve spontaneously within 1 year.
- Female Neonate: The labia majora are prominent and normally cover the labia minora and clitoris in term infants. A milky, white mucoid discharge and pseudomenses (scant blood-tinged vaginal spotting) are common, benign phenomena caused by the abrupt withdrawal of transplacental maternal estrogens; parents should be reassured.
- Anus: Verify anal patency and location. Over 99% of normal term infants pass meconium within 24 to 48 hours of life. Failure to pass meconium by 48 hours suggests imperforate anus, Hirschsprung disease, meconium ileus (cystic fibrosis), or intestinal atresia.
Musculoskeletal System & Developmental Dysplasia of the Hip (DDH)
All newborns must be systematically screened for Developmental Dysplasia of the Hip (DDH). The exam is performed with the infant relaxed and supine on a firm surface, examining each hip independently:
DDH Screening Maneuvers
├── Ortolani Maneuver ──> Tests REDUCTION of a dislocated hip ──> Abduct hip + Lift trochanter anteriorly ──> Palpable "Clunk"
└── Barlow Maneuver ──> Tests DISLOCATABILITY of hip ──> Adduct hip + Apply posterior pressure ──> Femoral head slips out
- Ortolani Maneuver (Tests Reduction): Flex the hips and knees to 90°. The examiner places the index and middle fingers along the greater trochanter laterally and the thumb along the inner medial thigh. Gently abduct the hip while applying upward anterior traction on the greater trochanter. If the femoral head is dislocated, a positive Ortolani is confirmed by a palpable "clunk" as the femoral head slips over the acetabular rim and reduces back into the acetabular cup.
- Barlow Maneuver (Tests Dislocatability): From the flexed position, gently adduct the hip past the midline while applying gentle posterior pressure along the shaft of the femur. A positive Barlow is confirmed if the femoral head is felt to subluxate or slide posteriorly out of the acetabulum.
- Differentiating Joint Clicks: High-pitched adventitious "clicks" are common, benign sounds originating from ligamentous movement across the pelvic fascia; they must not be confused with the distinct, low-pitched, palpable "clunk" of true hip dislocation/reduction.
- Additional Signs: Asymmetry of thigh or gluteal skin folds and the Galeazzi sign (unequal knee heights when the infant's feet are flat on the table with hips and knees flexed to 90°) indicate unilateral hip displacement. A positive exam mandates pediatric orthopedic referral and hip ultrasonography at 4 to 6 weeks of age.
- Spinal Examination: Inspect and palpate the entire vertebral column from cervical to sacrococcygeal regions. A sacral dimple is considered benign if it is small (<0.5 cm diameter), situated within the gluteal cleft, located within 2.5 cm of the anus, and has a visible intact base. Conversely, dimples that are deep, large (>0.5 cm), situated high above the gluteal cleft (>2.5 cm from anus), or accompanied by cutaneous markers (tuft of hair, hemangioma, lipoma, or skin tag) warrant spinal ultrasonography to exclude occult spinal dysraphism (spina bifida occulta, tethered cord).
Primitive Neonatal Neuro-Reflexes
Primitive reflexes are involuntary, subcortically mediated motor responses present at birth that reflect central nervous system integrity. They disappear in a predictable sequence as the cerebral cortex matures and myelinates:
| Reflex | Elicitation Technique | Normal Motor Response | Clinical Significance & Timing |
|---|---|---|---|
| Moro Reflex | Allow the infant's head and trunk to drop gently backward 1–2 cm from a semi-sitting position, or produce a sudden loud noise | Phase 1: Sudden, symmetric abduction and extension of both upper extremities with fingers spreading into a 'C' shape.<br/>Phase 2: Inward adduction and flexion of arms ('embrace') accompanied by crying | Present at birth; disappears by 4 to 6 months.<br/>Asymmetric Moro: Strongly indicates clavicular fracture or brachial plexus palsy (Erb-Duchenne C5–C6 'waiter's tip' palsy or Klumpke C8–T1 palsy). Absent Moro indicates profound CNS depression. |
| Rooting Reflex | Stroke the perioral skin or lateral cheek of the infant | The infant turns the head toward the stimulus, opens the mouth, and attempts to latch | Present at birth; disappears by 3 to 4 months (transitions to voluntary head turning). Facilitates breastfeeding. |
| Sucking Reflex | Place a gloved finger or nipple into the infant's oral cavity, touching the hard palate | Rhythmic, coordinated, vigorous sucking contractions | Present at birth (matures by 34–36 weeks gestation); disappears by 12 months. Absence indicates neurologic depression or prematurity. |
| Palmar Grasp | Place examiner's finger into the infant's palm from the ulnar side | Immediate, strong flexion of all fingers curling around the examiner's finger | Present at birth; disappears by 3 to 4 months. Persistence beyond 6 months suggests cerebral palsy or cortical lesions. |
| Plantar Grasp | Press the examiner's thumb firmly against the plantar surface of the foot at the base of the toes | Immediate downward flexion (curling) of all toes around the thumb | Present at birth; disappears by 9 to 12 months (must extinguish before independent walking occurs). |
| Babinski Sign (Plantar Reflex) | Stroke the lateral plantar aspect of the sole upward from the heel across the metatarsal heads | Extensor response: Dorsiflexion of the great toe accompanied by fanning of the other toes | Completely normal in newborns and infants up to 12 to 24 months of age due to incomplete corticospinal tract myelination. An extensor response in adults is pathological. |
| Stepping Reflex | Hold the infant upright under the axillae with feet touching a flat, firm surface | The infant makes coordinated, reciprocal stepping motions | Present at birth; disappears by 2 months of age. |
Test Your Knowledge
During the newborn musculoskeletal and orthopedic examination of a 24-hour-old term female infant, the certified nurse-midwife evaluates for developmental dysplasia of the hip (DDH). The midwife flexes the infant's hips and knees to 90 degrees, places fingers over the greater trochanters, and gently abducts the hips while lifting the trochanters anteriorly. On the left side, the midwife feels a distinct, palpable 'clunk' as the femoral head slips into the acetabular cup. Which physical examination maneuver was performed, and what does this finding represent?
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B
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D
Test Your Knowledge
A certified nurse-midwife examines a 2-hour-old term male infant following an uncomplicated spontaneous vaginal birth. On genital inspection, the midwife observes that the urethral meatus is located on the ventral surface of the shaft of the penis near the coronal sulcus, accompanied by an incomplete dorsal hood foreskin. The infant's parents express desire for immediate routine religious circumcision prior to hospital discharge on day 2. What is the certified nurse-midwife's appropriate counseling and clinical management?
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B
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D