Chapter 5
Examination and Assessment of
the Neonate
Gestational Age and Size
• GA assessment should be done within 12
hours of life for best reliability for infants
less than 26 weeks
• Evaluation of the infant is based on three
basic elements:
• Gestational age
– Maternal menstrual cycle
– Prenatal ultrasound
– Postnatal assessment (Ballard Score)
Estimating the Delivery Date
Nagele’s Rule
• a. Three months are subtracted from the first
day of the last menstrual period, then seven
days are added to the result
• b. For example, if the first day of the last
menstrual period is May 15, subtracting 3
months would arrive at February 15. Adding 7
days gives an EDC as February 22
• c. Requires a regular cycle of 28 days, use of
oral contraceptives or irregular cycle reduces
the accuracy
Estimating the Delivery Date
Fundal Height
• a. Fundus is the portion of the uterus
opposite the cervix
• b. The distance from the symphysis pubis and
the top of the fundus is measured
• c. The distance in centimeters is equal to the
gestational age (20cm = 20 weeks)
• d. Correlates during the first two trimesters
Estimating the Delivery Date
Quickening
• a. Sensation of fetal movement
• b. Usually occurs at 16-22 weeks
• c. Very rough estimate of gestational age
Determination of Fetal Heartbeat
• a. The fetal heartbeat is heard between 1620 weeks gestation
• b. As early as 8 weeks with a Doppler device
• c. Rough estimate of gestation age
Prenatal Assessments
Biophysical Tests of Well Being
Contraction stress test (CST)
• a. CST assesses fetal response to contractions
• b. Determines the presence of uteroplacental
insufficiency
• c. Fetus is stressed during contractions
• d. Positive CST: 50% of contractions have Type II
FHR decelerations
• e. Negative CST: no deceleration in FHR
• f. Most tests fall somewhere in between
• g. Can fetus tolerate normal labor and delivery or is
Cesarian section needed?
Biophysical Tests of Well Being
Contraction stress test (CST)
• Variation of CST: Oxytocin Contraction Test
(OST)
• IV is used to start contractions
• Positive CST indicates induction for delivery
Biophysical Tests of Well Being
The Non-Stress Test (NST)
• a. The response of FHR to movement is observed
• b. FHR increases 15 bpm > baseline for at lest 15
seconds
• c. Positive NST: at least 2 accelerations over a 20
minute period
• d. Negative NST: no accelerations over a 20 minute
period
• e. Fetal monitor is placed on mom’s abdomen; Mom
presses a button when the baby moves
• f. Simple to perform, less time consuming, little
risk
Biophysical Tests of Well Being
Interpretation of CST and NST
Positive CST and Negative NST
• 1. Fetus with hypoxia
Negative CST and Negative NST
• 1. Fetal sleep
• 2. CNS depression
Biophysical Tests of Well Being
Acoustic Stimulation
• a. Buzzer against mom’s abdomen
• b. FHR monitored for accelerations
• c. Failure to accelerate indicates that the
fetus is compromised and further testing is
required
The Biophysical Profile
a. Fetal breathing
b. Fetal movement
c. Fetal limb tone
d. NST
e. Amniotic fluid volume
f. Normal score is 8-10
g. May be best overall method of fetal risk
determination
Chorionic villus sampling
• Form of prenatal diagnosis to determine
chromosomal or genetic disorders in the fetus.
• It entails sampling of the chorionic villus
(placental tissue) and testing it for
chromosomal abnormalities, usually with FISH
(fluorescence in situ hybridization) or
polymerase chain reaction (PCR)
• CVS usually takes place at 10–12 weeks'
gestation, earlier than amniocentesis or
percutaneous umbilical cord blood sampling.
It is the preferred technique before 15 weeks
Possible reasons for having a CVS can include:
• Abnormal first trimester screen results
• Increased nuchal translucency or other abnormal ultrasound
findings
• Family history of a chromosomal abnormality or other genetic
disorder
• Parents are known carriers for a genetic disorder
• Advanced maternal age (maternal age above 35). AMA is
associated with increase risk of Down's syndrome and at age
35, risk is 1:400.
• Screening test are usually carried out first before deciding if
CVS should be done.
Amniocentesis
• used in prenatal diagnosis of chromosomal
abnormalities and fetal infections
• a small amount of amniotic fluid, which
contains fetal tissues, is sampled from the
amnion or amniotic sac surrounding a
developing fetus, and the fetal DNA is
examined for genetic abnormalities.
Amniocentesis tests
• L/S Ratio and presence of PG
• Alpha-Fetoprotein (AFP): increased in neural tube
defects, decreased in Down’s Syndrome and in fetal
death
• Bilirubin: hemolytic disease such as Rh
incompatibility
• Creatinine Levels: determine fetal kidney maturity
• Meconium Staining: green fluid (normally clear)
• Cytology: cells from skin, amnion, TB tree, detect
genetic and chromosomal disorders; cultured and
grown; takes two weeks for results
Amniocentesis
• Amniocentesis can also be used to detect
problems such as:
• Infection, in which amniocentesis can detect a
decreased glucose level, a Gram stain showing
bacteria or an abnormal differential count of
white blood cells
• Rh incompatibility
• Decompression of polyhydramnios
Genetic diagnosis
• Early in pregnancy, amniocentesis used for
diagnosis of chromosomal and other fetal
problems such as:
• Down syndrome (trisomy 21)
• Trisomy 13
• Trisomy 18
• Fragile X
• Rare, inherited metabolic disorders
• Neural tube defects (anencephaly and spina
bifida) by alpha-fetoprotein levels.
Trisomy 13 (Patau Syndrome)
• Some or all of the cells of the body contain extra genetic
material from chromosome 13.
• Full trisomy 13 is caused by nondisjunction of chromosomes
during meiosis (the mosaic form is caused by nondisjunction
during mitosis)
• Disrupts the normal course of development, causing severe
heart and kidney defects
• risk of this syndrome in the offspring increases with maternal
age at pregnancy, with about 31 years being the average.[
• Patau syndrome affects somewhere between 1 in 10,000 and
1 in 21,700 live births
Trisomy 18 (Edwards Syndrome)
• Presence of all or part of an extra 18th chromosome. This
genetic condition almost always results from nondisjunction
during meiosis.
• It is the second most common autosomal trisomy, after
Down's syndrome, that carries to term.
• Edwards syndrome occurs in around one in 6,000 live births
and around 80 percent of those affected are female.
• The majority of fetuses with the syndrome die before birth.
• The incidence increases as the mother's age increases. The
syndrome has a very low rate of survival, resulting from heart
abnormalities, kidney malformations, and other internal
organ disorders.
Fragile X syndrome (FXS), Martin–Bell syndrome, or Escalante's
syndrome
• genetic syndrome that is the most widespread
single-gene cause of autism and inherited
cause of mental retardation among boys.
• It results in a spectrum of intellectual
disabilities ranging from mild to severe as well
as physical characteristics such as an
elongated face, large or protruding ears, and
large testes (macroorchidism), and behavioral
characteristics such as stereotypic movements
(e.g. hand-flapping), and social anxiety.
Amniocentesis and lung maturity
• fetal lung maturity, which is inversely correlated to the risk of
infant respiratory distress syndrome.
• In pregnancies of greater than 30 weeks, the fetal lung
maturity may be tested by sampling the amount of surfactant
in the amniotic fluid.
• lecithin-sphingomyelin ratio ("L/S ratio"), the presence of
phosphatidylglycerol (PG), and more recently, the
surfactant/albumin (S/A) ratio. For the L/S ratio, if the result is
less than 2:1, the fetal lungs may be surfactant deficient. The
presence of PG usually indicates fetal lung maturity. For the
S/A ratio, the result is given as mg of surfactant per gm of
protein. An S/A ratio <35 indicates immature lungs, between
35-55 is indeterminate, and >55 indicates mature surfactant
production(correlates with an L/S ratio of 2.2 or greater).
Prenatal Ultrasound
• There are several types of fetal ultrasound,
each with specific advantages in certain
situations. A Doppler ultrasound, for example,
helps to study the movement of blood
through the umbilical cord between the fetus
and placenta. Three-dimensional ultrasound
provides a life-like image of an unborn baby.
Clinical applications
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Identification of pregnancy
Identification of multiple fetuses
Determination of fetal age, growth and maturity
Observation of polyhydramnios and oligohydramnios
Detection of fetal anomalies
Determination of placenta previa
Identification of placental abnormalities
Location of the placenta and fetus for amniocentesis
Determination of fetal position
Determination of fetal death
Examination of fetal heart rate and respiratory effort
Detection of incomplete miscarriages and ectopic pregnancies
Prenatal Ultrasound
• Ultrasound uses an electronic device called a
transducer to send and receive sound waves. When the
transducer is moved over the abdomen, the ultrasonic
sound waves then move through the skin, muscle,
bone, and fluids at different speeds. The sound waves
bounce off the fetus like an echo, returning to the
transducer. The transducer picks up the reflected
waves and converts them into an electronic picture.
• A clear gel is placed between the transducer and the
skin to allow for the best sound conduction and
smooth movement of the transducer.
Prenatal Ultrasound
• Certain fetal structures are checked during routine ultrasonography.
• Head and brain. The chambers within the brain (ventricles), distance
between parietal bones of the fetal head (biparietal diameter), and skin
thickness at the back of head (nuchal area) are evaluated for defects.
• Heart. The chambers and valves of the heart are evaluated and defects
may be identified.
• Abdomen and stomach. The size, location, and arrangement of stomach
and diaphragm are checked.
• Urinary bladder. The size and presence of the bladder is evaluated.
• Spine. Defects may be identified if present.
• Umbilical cord. Three blood vessels should be attached at the front of the
abdomen.
• Kidneys. Two kidneys should be present on either side of the mid-spine.
• Other fetal structures. Limbs and other parts may also be scanned and
evaluated.
•
http://www.baby2see.com/medical/charts.html#Measurement_Standards_Chart
• Gestational age is usually determined by the date of the
woman's last menstrual period, and assuming ovulation
occurred on day fourteen of the menstrual cycle.
• Sometimes a woman may be uncertain of the date of her last
menstrual period
• Ultrasound scans offer an alternative method of estimating
gestational age. The most accurate measurement for dating is
the crown-rump length of the fetus, which can be done
between 7 and 13 weeks of gestation. After 13 weeks of
gestation, the fetal age may be estimated using the biparietal
diameter (the transverse diameter of the head), the head
circumference, the length of the femur, the crown-heel length
(head to heel), and other fetal parameters.[
• Dating is more accurate when done earlier in the pregnancy; if
a later scan gives a different estimate of gestational age, the
estimated age is not normally changed but rather it is
assumed the fetus is not growing at the expected rate
Alpha-Fetal Protein
• a protein that in humans is encoded by the
AFP gene
• The AFP gene is located on the q arm of
chromosome 4
• AFP is a major plasma protein produced by
the yolk sac and the liver during fetal
development that is thought to be the fetal
form of serum albumin.
Alpha-Fetal Protein
• In pregnant women, fetal AFP levels can be
monitored in urine. AFP is cleared strongly
from the kidneys allowing AFP to tend to
mirror fetal serum levels.
• In contrast, maternal serum AFP levels are
much lower but continue to rise until about
week 32. This is thought to be because the
mother is not utilizing the AFP, and therefore
clears it from her system without issue.
Alpha-Fetal Protein
• AFP in amniotic fluid has one or two sources. The fetus
normally excretes AFP into its urine, hence into the amniotic
fluid. A fetus with one of three broad categories of defects
also releases AFP by other means. These categories are open
neural tube defect, open abdominal wall defect, and skin
disease or other failure of the interior or exterior body
surface.
• Abnormally elevated AFP in amniotic fluid can have one or
more of many different causes:
• normal elevation. 75% of AF AFP test results in the range 2.0
to 4.9 MoM are false positives: the baby is normal.
• open neural tube defect
• open abdominal wall defect
• congenital nephrosis
Neural tube defects
• one of the most common birth defects,
occurring in approximately one in 1,000 live
births in the United States.
• A NTD is an opening in the spinal cord or brain
that occurs very early in human development.
In the 3rd week of pregnancy called
gastrulation, specialized cells on the dorsal
side of the fetus begin to fuse and form the
neural tube. When the neural tube does not
close completely, an NTD develops
Neural tube defects
• Anencephaly (without brain) is a neural tube defect that occurs when the
head end of the neural tube fails to close, usually during the 23rd and 26th
days of pregnancy, resulting in an absence of a major portion of the brain
and skull. Infants born with this condition are born without the main part
of the forebrain-the largest part of the cerebrum. Infants born with this
condition are usually blind, deaf and unconscious. The lack of a
functioning cerebrum will ensure that the infant will never gain
consciousness. Infants are either stillborn or usually die within a few hours
or days after birth.
• Encephaloceles are characterized by protrusions of the brain through the
skull that are sac-like and covered with membrane. They can be a groove
down the middle of the upper part of the skull, between the forehead and
nose, or the back of the skull. Encephaloceles are often obvious and
diagnosed immediately. Sometimes small encephaloceles in the nasal and
forehead are undetected.
• Hydranencephaly is a condition in which the cerebral hemispheres are
missing and instead filled with sacs of cerebrospinal fluid.
Cordocentesis
• a. In utero sampling of fetal umbilical cord
blood
• b. Under ultrasound, the umbilical cord is
punctured with a 22 gauge needle and blood
samples are drawn into tuberculin syringes
• c. Samples checked for sickle-cell,
hemophilia, fetal infection, metabolic disease,
congenital defects, PO2 and acid-base status
• d. Fetal and maternal risk is < 1%
Maternal Estriol
• Secreted in high quantities by the placenta in the
latter half of pregnancy
• Normal levels depend on properly functioning fetal
liver and adrenal glands
• Levels are decreased in growth retardation, fetal
distress, and placental insufficiency
• Maternal blood and /or urine is collected several
times a week
• Fetal distress is indicated by a 50-60% drop from
previous tests or ongoing drop
• Inconvenient, high number of false negatives
Human Placental Lactogen (HPL)
• Produced by the placenta, excreted in
maternal blood
• Prepares breasts for milk production
• Levels increase until 37 weeks then remains
same or decreases slightly
• Serum levels are evaluated weekly
• Normal range (term) 5.4-7.0 ug/mL
• HPL< 4 ug/mL after 30 weeks gestation may
indicate fetal compromise
• Less popular in recent years, inconvenient
MRI in assessing fetal status
• Used to assess the status of soft tissue
structure and function
• Indicated when ultrasound is insufficient
• Used to detect placental and fetal
abnormalities
• Assess development of the fetal lungs and
brain
• No risk of damage to the fetus
Meconium Staining
• Assessed during amniocentesis or through
fluid discharge before delivery
• Treat with Amnioinfusion, a method of
thinning thick meconium that has passed into
the amniotic fluid through pumping of sterile
fluid into the amniotic fluid, has not shown a
benefit in treating MAS
Assessing Fetal Heart Rate
• Purpose correlates with fetal well-being
• Three ways to monitor FHR
i. Doppler transducer on mom’s abdomen
ii. ECG monitor on mom’s abdomen
iii. Small electrode on fetal scalp; membranes
are ruptured so there is a risk of infection
Assessing Fetal Heart Rate
• Normal range is 120 to 160 bpm
• An increase or decrease of 20 to 30 bpm may be
abnormal even if in normal range
• Variability: Fetus has a constantly changing heart
rate (5-10 bpm)
• Decreased variability is caused by:
a. CNS depression secondary to hypoxia
b. fetal sleep
c. immaturity
d. maternal narcotic use
Bradycardia
• Heart rate < 100 bpm or a drop of 20 bpm
from baseline
Causes
a. Fetal asphyxia
i. most dangerous cause
ii. treat by giving mom O2
b. congenital heart defects
c. hypothermia
Tachycardia
Heart rate > 180 consistently
• Causes
a. maternal fever
b. most common cause
c. infection
d. dehydration
e. anxiety, asphyxia
f. sympathomimetics
g. parasympatholytics
Decels
• Decelerations
• 1. Fetal heart rate < 120 bpm for < 2 minutes
• 2. May be threatening or harmless, depending on the type of
deceleration.
• 3. Types of Decelerations
Type I Decelerations(Early); Closely follow uterine contractions
in onset and duration. Heart rate decreases to 60-80 bpm during
the contraction, then rapidly returns to baseline after the
contraction. Caused by compression of the fetal head against the
cervix during the contraction (vagal response). Benign, it doesn’t
indicate hypoxia
Decels
Type II Decelerations (Late)
• Occur 10-30 after start of contraction with a
slow return to baseline
• Even a small decrease of 10-20 bpm indicates
a problem. Secondary to uteroplacental
insufficiency
• Caused by compression of the vessels of the
uterus and placenta during the contraction
• Leads to decreased transfer of O2 to the fetus
and fetal asphyxia
Decels
Type III Decelerations (Variable)
• Decelerations independent of contractions
• Random in onset, duration and severity
• Caused by compression of the umbilical cord
• Umbilical cord wrapped around the fetuses
neck or compressed between the pelvis and
body part
• Danger depends on frequency and severity
• Turn mom side to side or place in knees to
chest position to alleviate cord compression
Scalp pH
Purpose
• Used in conjunction with fetal heart monitoring
• Assesses fetal asphyxia
Indications
• Absence of baseline variability
• Late decelerations with decreasing variability
• Abnormal FHM tracings
Procedure
• Mother placed in lithotomy position
• Fetal head visualized through the cervix
• Scalp incision made
• Blood collected in heparinized capillary tube
lithotomy position
Scalp pH
• Poor gas exchange leads to increased PaCO2
and lactic acidosis (mixed acidosis)
• Interpretation of Fetal Scalp pH
pH
Interpretation
7.25
Normal
7.20-7.24
Slight asphyxia
< 7.20
Severe
Fetal Position
Breech
Tocolysis
• medications used to suppress premature labor
• They are given when delivery would result in
premature birth The therapy also buys time for the
administration of betamethasone, a glucocorticoid
drug which greatly accelerates fetal lung maturity,
but takes one to two days to work.
• The suppression of contractions is often only partial
and tocolytics can only be relied on to delay birth for
several days. Depending on the tocolytic used the
mother or fetus may require monitoring, as for
instance blood pressure monitoring when nifedipine
is used as it reduces blood pressure. In any case the
risk of preterm labor alone justifies hospitalization.
Cord Gas
• Umbilical cord blood gas samples are analyzed for
pH, PCO2 and PO2. Bicarbonate, base excess and
oxygen saturation are all calculated from the
measured parameters.
• Oxygen saturation is calculated as though the
hemoglobin were all hemoglobin rather than fetal
hemoglobin; consequently, the calculated oxygen
saturation in umbilical cord blood significantly
underestimates the true value.
• The bicarbonate and the base excess are generally
approximately the same in umbilical venous and
arterial blood, but if one is worse (a greater
metabolic acidosis), it is the arterial blood.
Cord Gas Values
Venous
• pH 7.35 (+/-) 0.05
• PCO2 38 (+/-) 5.6
• PO2 29 (+/-) 5.9
• BE -4 (+/-) 2
• HCO3 20 (+/-) 2.1
Arterial
• pH 7.28 (+/-) 0.05
• PCO2 49 (+/-) 8.4
• PO2 18 (+/-) 6.2
• BE -4 (+/-) 2
• HCO3 22 (+/-) 2.5
Note that the bicarbonate value is misleadingly elevated whenever the
PCO2 is exceptionally high, because the PCO2 is in equilibrium with
bicarbonate. As soon as the baby is well ventilated, the bicarbonate will
"disappear," however the base excess will not change until the true
metabolic acidosis improves.
Infant Assessment
Dubowitz/
Ballard
Score
http://www.medcalc.com/ballard.ht
ml
New Ballard Score Maturational
Assessment of Gestational Age
• The New Ballard Score is a set of procedures
developed by Dr. Jeanne L Ballard, MD to
determine Gestational Age through
neuromuscular and physical assessment of a
newborn infant.
• http://www.ballardscore.com/Pages/videos.as
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Performing the Assessment of
Neuromuscular Maturity
Posture
• Total body muscle tone is reflected in the infant's preferred
posture at rest and resistance to stretch of individual
muscle groups.
• As maturation progresses, the fetus gradually assumes
increasing passive flexor tone that proceeds in a centripetal
direction, with lower extremities slightly ahead of upper
extremities.
• For example, very early in gestation only the ankles are
flexed. Knees will flex as wrists just begin to flex. Hip
flexion, then abduction are just ahead of elbow, then
shoulder girdle flexion. The preterm infant primarily
exhibits unopposed passive extensor tone, while the infant
approaching term shows progressively less opposed passive
flexor tone.
•Ankle
flexion
Posture
• To elicit the posture item, the infant is placed
supine and the examiner waits until the infant
settles into a relaxed or preferred posture.
• If the infant is found supine, gentle manipulation
(flex if extended; extend if flexed) of the
extremities will allow the infant to seek the
baseline position of comfort. Hip flexion without
abduction results in the frog-leg position as
depicted in posture square #3. Hip adduction
accompanying flexion is depicted by the acute
angle at the hips in posture square #4. The figure
that most closely depicts the infant's preferred
posture is selected.
Square Window
• Wrist flexibility and/or resistance to extensor stretching
are responsible for the resulting angle of flexion at the
wrist.
• The examiner straightens the infant's fingers and
applies gentle pressure on the dorsum of the hand,
close to the fingers. From extremely pre-term to postterm, the resulting angle between the palm of the
infant's hand and forearm is estimated at;
• >90°, 90°, 60°, 45°, 30°, and 0°.
• The appropriate square on the score sheet is selected.
Arm Recoil
• This maneuver focuses on passive flexor tone of the biceps
muscle by measuring the angle of recoil following very brief
extension of the upper extremity.
• With the infant lying supine, the examiner places one hand
beneath the infant's elbow for support. Taking the infant's
hand, the examiner briefly sets the elbow in flexion, then
momentarily extends the arm before releasing the hand.
The angle of recoil to which the forearm springs back into
flexion is noted, and the appropriate square is selected on
the score sheet. The extremely pre-term infant will not
exhibit any arm recoil. Square #4 is selected only if there is
contact between the infant's fist and face. This is seen in
term and post term infants.
Popliteal Angle
• This maneuver assesses maturation of passive flexor
tone about the knee joint by testing for resistance to
extension of the lower extremity. With the infant lying
supine, and with diaper re-moved, the thigh is placed
gently on the infant's abdomen with the knee fully
flexed. After the infant has relaxed into this position,
the examiner gently grasps the foot at the sides with
one hand while supporting the side of the thigh with
the other. Care is taken not to exert pressure on the
hamstrings, as this may interfere with their function.
The leg is extended until a definite resistance to
extension is appreciated. In some infants, hamstring
contraction may be visualized during this maneuver. At
this point the angle formed at the knee by the upper
and lower leg is measured.
Scarf Sign
• This maneuver tests the passive tone of the flexors about
the shoulder girdle.
• With the infant lying supine, the examiner adjusts the
infant's head to the midline and supports the infant's hand
across the upper chest with one hand. the thumb of the
examiner's other hand is placed on the infant's elbow.
• The examiner nudges the elbow across the chest, felling for
passive flexion or resistance to extension of posterior
shoulder girdle flexor muscles.
• The point on the chest to which the elbow moves easily
prior to significant resistance is noted. Landmarks noted in
order of increasing maturity are: full scarf at the level of the
neck (-1); contralateral axillary line (0); contralateral nipple
line (1); xyphoid process (2); ipsilateral nipple line (3); and
ipsilateral axillary line (4).
Heel to Ear
• This maneuver measures passive flexor tone about the pelvic girdle
by testing for passive flexion or resistance to extension of posterior
hip flexor muscles.
• The infant is placed supine and the flexed lower extremity is
brought to rest on the mattress alongside the infant's trunk.
• The examiner supports the infant's thigh laterally alongside the
body with the palm of one hand. The other hand is used to grasp
the infant's foot at the sides and to pull it toward the ipsilateral ear.
• The examiner fells for resistance to extension of the posterior pelvic
girdle flexors and notes the location of the heel where significant
resistance is appreciated. Landmarks noted in order of increasing
maturity include resistance felt when the heel is at or near the: ear
(-1); nose (0); chin level (1); nipple line (2); umbilical area (3); and
femoral crease (4).
Physical Maturity - Skin
• Maturation of fetal skin involves the
development of its intrinsic structures
concurrent with the gradual loss of its
protective coating, the vernix caseosa. Hence,
it thickens, dries and becomes wrinkled
and/or peels, and may develop a rash as fetal
maturation progresses. These phenomena
may occur at varying paces in individual
fetuses depending in part upon the maternal
condition and the intrauterine environment.
Physical Maturity - Skin
• Before the development of the epidermis with its
stratum corneum, the skin is transparent and adheres
somewhat to the examiner's finger. Later it smoothes,
thickens and produces a lubricant, the vernix, that
dissipates toward the end of gestation.
• At term and post-term, the fetus may expel meconium
into the amniotic fluid. This may add an accelerating
effect to the drying process, causing peeling, cracking,
dehydration, and imparting a parchment, then
leathery, appearance to the skin. For scoring purposes,
the square which describes the infant's skin the most
closely should be selected.
Lanugo
• Lanugo is the fine hair covering the body of the fetus.
• In extreme immaturity, the skin lacks any lanugo. It
begins to appear at approximately the 24th to 25th
week and is usually abundant, especially across the
shoulders and upper back, by the 28th week of
gestation.
• Thinning occurs first over the lower back, wearing away
as the fetal body curves forward into its mature, flexed
position. Bald areas appear and become larger over the
lumbo-sacral area. At term, most of the fetal back is
devoid of lanugo, i.e., the back is mostly bald.
Lanugo
• Variability in amount and location of lanugo at a
given gestational age may be attributed in part to
familial or national traits and to certain
hormonal, metabolic, and nutritional influences.
For example, infants of diabetic mothers
characteristically have abundant lanugo on their
pinnae and upper back until close to or beyond
full-term gestation. When scoring for lanugo, the
examiner selects the square that most closely
describes the relative amounts of lanugo on the
upper and lower areas of the infant's back.
Plantar Surface
• This item pertains to the major foot creases on
the sole of the foot. The first appearance of a
crease appears on the anterior sole at the ball of
the foot. this may be related to foot flexion in
utero, but is contributed to by dehydration of the
skin.
• Very premature and extremely immature infants
have no detectable foot creases. To further help
define the gestational age of these infants,
measuring the foot length or heel-toe distance is
helpful.
Breast
• The breast bud consists of breast tissue that is stimulated
to grow by maternal estrogens and fatty tissue which is
dependent upon fetal nutritional status. the examiner
notes the size of the areola and the presence or absence of
stippling
• The examiner then palpates the breast tissue beneath the
skin by holding it between thumb and forefinger, estimating
its diameter in millimeters, and selects the appropriate
square on the score sheet.
• Under- and over-nutrition of the fetus may affect breast
size variation at a given gestation. Maternal estrogen effect
may produce neonatal gynecomastia on the second to
fourth day of extrauterine life.
Ear/Eye
• The pinna of the fetal ear changes it
configuration and increases in cartilage
content as maturation progresses. Assessment
includes palpation for cartilage thickness, then
folding the pinna forward toward the face and
releasing it. The examiner notes the rapidity
with which the folded pinna snaps back away
from the face when released, then selects the
square that most closely describes the degree
of cartilagenous development.
Ear/Eye
• In very premature infants, the pinnae may remain
folded when released. In such infants, the
examiner notes the state of eyelid development
as an additional indicator of fetal maturation.
• The examiner places thumb and forefinger on the
upper and lower lids, gently moving them apart
to separate them. The extremely immature infant
will have tightly fused eyelids, i.e., the examiner
will not be able to separate either palpebral
fissure with gentle traction.
Genitals-Male
• The fetal testicles begin their descent from the
peritoneal cavity into the scrotal sack at approximately
the 30th week of gestation. The left testicle precedes
the right and usually enters the scrotum during the
32nd week. Both testicles are usually palpable in the
upper to lower inguinal canals by the end of the 33rd
to 34th weeks of gestation. Concurrently, the scrotal
skin thickens and develops deeper and more numerous
rugae.
• Testicles found inside the rugated zone are considered
descended. In extreme prematurity the scrotum is flat,
smooth and appears sexually undifferentiated.
Genitals-Female
• To examine the infant female, the hips should be only
partially abducted, i.e., to approximately 45° from the
horizontal with the infant lying supine. Exaggerated
abduction may cause the clitoris and labia minora to
appear more prominent, whereas adduction may cause
the labia majora to cover over them.
• In extreme prematurity, the labia are flat and the
clitoris is very prominent and may resemble the male
phallus. As maturation progresses, the clitoris becomes
less prominent and labia minora become more
prominent. Nearing term, both clitoris and labia
minora recede and are eventually enveloped by the
enlarging labia majora.
Vital Signs
• Heart Rate: 120-170 bpm; fluctuates
dramatically with sleep, pain/crying- especially
with term newborns
• Temperature: 97.6 +/- 1 axillary and -99.6 +/1 rectally; will vary depending on radiant
warmer temperature/room temp
• Respiratory Rate: Fluctuates 40-60
•
http://www.youtube.com/watch?v=Dphf24JNEv4
Physical Examination
General Appearance
• Ideally done while infant is not distressed in a
supine position, unclothed in a neutral
thermal environment
• Note symmetrical movement of extremities,
note birthing traumas
• Skin represents intravascular volume, and
perfusion status/oxygenation
• Capillary refill should be less than 3 seconds
Acrocyanosis is ok! Central is not
General Appearance
• Note mottling, extremely pale may represent
anemia/hypotension
• Note ruddy, reddish blue appearance, may
represent polycythemia/hyperviscosity
syndrome
• Note presence of Jaundice
• Note presence of vernix
Fetal hemoglobin
• main oxygen transport protein in the fetus during the last
seven months of development in the uterus and in the
newborn until roughly 6 months old. Functionally, fetal
hemoglobin differs most from adult hemoglobin in that it is
able to bind oxygen with greater affinity than the adult form,
giving the developing fetus better access to oxygen from the
mother's bloodstream.
• In newborns, fetal hemoglobin is nearly completely replaced
by adult hemoglobin by approximately 6 months postnatally.
In adults, fetal hemoglobin production can be reactivated
pharmacologically, which is useful in the treatment of
diseases such as sickle-cell disease.
• Newborn to six months: HbF may be up to 70 percent of total
hemoglobin.
Jaundice
• Jaundice is a yellow coloring of the skin and eyes caused by too
much bilirubin.
• Bilirubin is a yellow substance that is created when the body
replaces old red blood cells with new ones.
• occurs when a newborn's liver is unable to break down red blood
cells for excretion. Usually due to prematurity
• The resulting buildup of the byproduct bilirubin
• Left untreated, the condition can lead to cerebral palsy, brain
damage or hearing loss. Some amount of jaundice is expected in
newborns, since the infant's liver has to take over the job of
breaking down bilirubin for the first time -- the placenta and the
mother's liver do the work before birth. If the jaundice lasts too
long, is accompanied by other factors, or if the baby has risk factors
such as being born prematurely, then treatment is necessary
Jaundice
• A bili light is a phototherapy tool to treat
newborn jaundice (hyperbilirubinemia) which in
higher levels causes brain damage (kernicterus),
leading to cerebral palsy, auditory neuropathy,
gaze abnormalities and dental enamel
hypoplasia.
• The therapy uses a blue light (420-470 nm) that
converts bilirubin so that it can be excreted in the
urine and feces. Soft eye shields are placed on
the baby to protect their eyes from damage that
may lead to retinopathy due to the bili lights.
Physical Examination
• Respiratory function
– Rate
– Rhythm
– Silverman score
– Auscultation
– Chest radiography
– ABGs/CBGs http://www.youtube.com/watch?v=q5J1cCyrASs
CAPILLARY BLOOD GASES
• pH: Same as arterial or slightly lower
(Normal = 7.35-7.40)
• pCO2: Same as arterial or slightly higher
(Normal = 40-45)
• pO2: Lower than arterial (Normal = 45-60)
• O2 Saturation: >70% is acceptable.
• https://secure1.csmc.edu/nicu/cbg/
CAPILLARY BLOOD GASES
• Saturation is probably more useful than
the pO2 itself when interpreting a CBG.
• The heel is the most commonly used site
• The CBG is often used for pediatric patients
because it is easier to obtain than the ABG
• less traumatic (no risk of arterial
thrombosis, hemorrhage).
Capillary Gases
• Drawn from heel
• Procedure:
– heel warmed to ‘arterialize’ blood
– lancet puncture
– blood flows, trapped in capillary tube
•Preferred Sites
Variability in Cap Gases
• Warming time
• Amount of contact with air
• Squeezing blood
Pulse Oximeters
• Sites of attachment
(foot and hand)
• Preductal placement in first twelve hours
(right hand)
Pulse Ox monitoring
• Pre-ductal and post-ductal pulse O2 saturation
(SpO2) monitors (to detect R → L
shunting at ductus arteriosus).
• A difference of ≥10% suggests marked
pulmonary
hypertension or PDA dependent leison.
Pre-ductal and post-ductal pulse O2 saturation
(SpO2) can be used as screening for cyanotic
heart disease for NB befor discharge hom fro
postnatal ward.
Pulse Oximeters
• Reads high
– Methemoglobin
– Caboxyhemoglobin
– Jaundice
• Reads low
– Medical dyes
• Other causes of inaccuracy
– Motion
– Hypothermia/vasoconstric
tion
– Hypotension
– Excessive ambient light on
sensor probe
Hemodynamic Monitoring
• Umbilical Artery Catheter (UAC) preferred
http://vimeo.com/35337127
UAC Insertion Procedure
• Insertional position 1/3 length heel to crown
• Procedure
–
–
–
–
–
–
–
sterile field and drape
purse string suture around umbilicus
cut cord and snug
tease umbilical artery open
insert catheter
fix position
follow with CXR
Monitoring UAC Post
Insertion
• Position of catheter tip
(aortic arch is preductal
and not preferred)
Normal position above
diaphragm
(low position is L3-L4)
• Monitor leg color of infant
(blanching indicates
obstruction of flow)
Transcutaneous Gas Monitors
•
•
•
•
Useful as ‘trend’ monitor
Can detect hypoxemia, hyperoxemia
Can detect hypocarbia, hypercarbia
Also responds to changes in blood flow
Principle of Operation
Tc Monitors
•
•
•
•
Heated electrode placed on skin
Temperature 43 to 45 C
‘Arterializes’ sample
Gas diffuses through skin
http://www.perimed-instruments.com/transcutaneous-oxygenin-clinical-practice
Calibration of Transcutaneous
Monitors
• Requires high and low calibration
• TcPO2
– Can be done with chemical zero and room air
– Most commonly done with cylinders
•Calibration value = Concentration of gas in cylinder x Pb
•Using a cylinder that contains 10% O2, what would be the
calibration value of a TcPO2 device if the barometric pressure was
760?
•Calibration value = .1 x 760 = 76 mm Hg
Advantages of Transcutaneous
Monitors
• Decreased number of ‘sticks’
– cost reduction
– lower infant risk (less invasive)
• Trend tool
– blood sample provides ‘view’ at one moment
– gases values wander (+ 7 torr)
– infant reaction to sample varies
Problems with Transcutaneous
Monitors
• Labor Intensive
–
–
–
–
Change site every 4 to 6 hours or more
Limited choices for attachment
(site must have perfusion)
Air leak around electrode
• Burns
– called ‘hookies’ after Huch
Interpretation of Tc Results
• Air leak under electrode
– TcPCO2 reading near zero
– TcPO2 reading near PbO2
• Decreased perfusion under electrode
– TcPCO2 will increase
– TcPO2 will decrease
Silverman Score
Silverman Score
• Silverman Respiratory Status Index
• Purpose - objectively score physical evidence
of increased work of breathing (WOB)
• Five observations, scored 0-2
• Higher score ==> greater WOB
• (maximum score = 10)
Respiratory Assessment
• Grunting: http://www.youtube.com/watch?v=aptwttJ6y_4
• Patient exhales against a half closed glottis in
order to create intrinsic peep in response to
low FRC. Treatment involves CPAP, PPV and
surfactant delivery; or depending on cause,
simple allowance to transition to extrauterine
life
Respiratory Assessment
• Retractions
• Nasal flaring
• Tachypnea
Physical Examination
• Chest and cardiovascular system
– Chest configuration
– Point of maximal cardiac impulse (PMI):
the place where the apical pulse is palpated
as strongest, often in the fifth intercostal
space of the thorax, just medial to the left
midclavicular line
– Transillumination (pneumothorax)
•Scaphoid abdomen from CDH
Physical Examination (cont.)
• Chest and cardiovascular system
– Heart rate
– Cardiac sounds
– http://www.youtube.com/watch?v=lp8gUJQvsSs
– Pulses
– Blood pressure
Blood Pressure
• Blood pressure increases with Gestation, birth weight,
postnatal age
• There is no significant difference between arm and calf blood
pressure in normal infants.
• It is difficult to define 'normal' BP values in ELBW infants.
• In clinical practice, the infant's blood pressure is generally
considered to be adequate as long as urine output (>
1ml/kg/hr) and capillary refill (< 3 seconds) are within normal
limits and there is no metabolic acidosis. However, these are
not reliable indicators of tissue perfusion.
• Arbitrary definitions of hypertension are as follows
• term infant: systolic > 90 mmHg, diastolic > 60 mmHg
• preterm infant: systolic > 80 mmHg, diastolic > 50 mmHg
Physical Assessment
• Abdomen
– Contour
– Obvious abdominal wall anomalies
– Auscultation and palpation
• More than stomach
– Cord
• Anatomy
Physical Examination
• Head and neck
– Shape of head
• Fontanelles
– Scalp edema
– Face
• Dysmorphic
• Edema
– Ears
Physical Examination (cont.)
• Head and neck
– Nares
– Mouth
• Lips
• Oral cavity
– Neck
– Clavicles
Physical Examination (cont.)
• Musculoskeletal system, spine, and
extremities
– Dysmorphic
– Number of digits
– Abnormal positioning of joints
– Spine
• Dimple
Spine
Physical Examination
• Cry
– Strength
– Sound
Neurologic Examination
• Response to environment
• Movement
• Neonatal reflexes
– Grasp
– Moro
• Hearing
Moro reflex
• The Moro reflex is an infantile reflex normally
present in all infants/newborns up to 4 or 5 months
of age as a response to a sudden loss of support,
when the infant feels as if it is falling. It involves 3
distinct components:
– spreading out the arms (abduction)
– unspreading the arms (adduction)
– crying (usually)
The primary significance of the Moro reflex is in evaluating
integration of the central nervous system. It is distinct from
the startle reflex and is believed to be the only unlearned
fear in human newborns
Laboratory Assessment
Laboratory Examination (cont.)
•
•
•
•
•
•
Electrolytes
Renal function
Calcium
Glucose
Bilirubin
Screening
Laboratory Red Flags