Physical Exam of the Newborn LOG 3 RET 203 Prematurity 37 - 40 Weeks gestation is considered Term 32 - 36 Prematurity Lower percentage of infants ventilated 28 - 32 Prematurity Half the infants in need of
mechanical ventilation 24 - 28 Severe prematurity Frequently in need of mechanical ventilation Gestational Age Assessment Evaluating gestational age requires consideration of several factors. The three main factors are as follows Gestational duration based on the last menstrual cycle
Prenatal ultrasound evaluation Postnatal findings based on physical and neurologic examinations Dubowitz Assessment Obtained during a routine physical exam Examines 11 physical signs and 10 neurological signs
Each area is assigned a point value Points added up for a score that reflects a gestational age Accurate to within 2 weeks and is used in the first 5 days of life Problem Takes a lot of time to do. Both Dubowitz and Ballard are reliable, but the Ballard system is quicker
Physical Examination to Determine Gestational Age EXTERNAL CRITERIA: Vernix
Grayish/white, cheese-like substance that covers fetus Composed of subaceous gland secretions, lanugo, and shed epithelial cells Appears around 20 - 24 weeks and remains thick on fetus until ~week 36 Usually disappears by weeks 41 - 42
Skin Maturity Appearance of skin is an excellent indicator of
gestational age Skin becomes thicker and less transparent with in age As fetus matures, vessels become less visible and skin becomes pink Preterm Thin, almost transparent with many visible blood vessels Term Adult-looking skin
Post-term Many cracks/wrinkles and no visible vessels Nails Always present Post-term Long fingernails Lanugo
Fine, downy hair that covers the fetal body Appears at ~ week 26 and covers the thorax, head, and extremities Slowly disappears as fetus matures Term Might have some lanugo on the shoulders and forehead, but usually gone by 40 weeks More common in neonates with dark skin
Ear recoil Examination of pinna (External portion of the ear) Cartilage in ear is not fully present until around 34 weeks At 25 - 26 weeks the pinna is basically flat and will remain folded if doubled over As the cartilage grows, the recoil will increase Recoils and looks similar to an adult at term Breast tissue/areola
25 - 26 weeks The breast is barely visible 27 weeks The areola is a bit visible but there is no palpable tissue As fetus matures, areola grows and breast tissue increases Sole creases Creases on the soles of the foot (Plantar creases)
Increase in wrinkles as gestation increases Prem Starts as faint red lines, by term the entire sole is covered with deep creases Suctioning Infant head is suctioned upon
delivery (first) Again after delivery, and as needed May use bulb syringe to clear mouth, then nose Apgar Scoring
Apgar A Appearance (Colour)
P Pulse G Grimace (Reflex irritability) A Activity (Muscle tone) R Respiratory rate Each of these categories is scored with 0, 1, or 2, depending on the observed condition of the newborn
Apgar Score Heart rate Heart rate is evaluated by stethoscope. This is the most important assessment If there is no heartbeat = scores 0
Less than 100 beats per minute = scores 1 Greater than 100 beats per minute = scores 2 Apgar Score Heart rate Assessed by 1. Palpating the base of the umbilical cord 2. Auscultating
3. Palpating the brachial/femoral artery Apgar Score Respiratory effort No respirations = scores 0 Respirations are slow or irregular = scores 1 Good crying = scores 2
Apgar Score Muscle tone Muscle tone is flaccid = scores 0 Some flexion of the extremities = scores 1 Active motion = scores 2 Apgar Score Reflex irritability
Reflex irritability is a term describing the level of newborn irritation in response to stimuli (Such as a mild pinch) No reaction = scores 0 Grimacing = scores 1 Grimacing and a cough, sneeze, or a vigorous cry = scores 2 Apgar Score
Colour Pale blue (Cyanotic) = scores 0 Body is pink and the extremities are blue (Acrocyanosis) = scores 1 Entire body is pink = scores 2 Apgar Score
The 1-minute APGAR score assesses how well the infant tolerated the birthing process The 5-minute APGAR score assesses how well the newborn is adapting to the environment The Apgar Score
Stabilizing the Neonate Post-delivery, there are several questions you should ask 1. What is the gestational age? 2. Was the amniotic fluid clear? 3. Is the baby breathing or crying? 4. Is there good muscle tone? If there is more time, you may ask other pertinent questions regarding the labour and delivery, moms health, and/or any
known complications in-utero Stabilizing the Neonate Once the baby is presented in front of you, you should 1. Dry/warm the infant 2. Position the infant 3. Suction Clear the airway
Stabilizing the Neonate Once the baby is presented in front of you, you should 1. Dry/warm the infant Reduce thermal stress Overhead (radiant) warmer Remove wet linen < 1500 g infant Place in a polyethylene bag
Stabilizing the Neonate Once the baby is presented in front of you, you should 1. Position the infant Stabilizing the Neonate 3. Suction Clear the airway Clearing the a/w should be performed when there are
ineffective respirations Suctioning is performed with a bulb suction Mouth first Nares second 90 - 100 mmHg vacuum pressure Physical Examination
Physical Examination General inspection Body position and symmetry Birth injury Skin
Colour Vernix caseosa Lanugo Physical Examination (cont.) Respiratory function
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