objectives by the end of this presentation the learner should…. understand the prenatal...

ObjectivesObjectivesBy the end of this presentation the learner should….Understand the prenatal gestational age assessment

toolsClassify the size differences between IUGR, SGA, AGA,

& LGA infantComplete the physical maturity portion of the neonatal

gestational age assessment toolConduct the neuromuscular portion of the neonatal

gestational age assessmentCompile the maturity score on the neonatal gestational

age assessment toolIdentify those common differential findings found on

newborn exam

Calculation by the mother estimated date of confinement (EDC)Collection of prenatal data

First fetal movement (16-20 weeks)Fetal heart tones (20 weeks) (with doppler 9-12 weeks)Fundal height (One cm = 1 week after 18-20 weeks)20 weeks (fundus normally at umbilicus)Term (fundus at xyphoid)Amniotic fludi creatinine levelsMaternal serum and urine estriolsFetal US

Prenatal Gestational Age AssessmentFetal US Measurements

Crown to rump lengthBiparietal diameterFemur lengthAbdominal

CircumferenceHead CircumferencePlacental grade

Basics of Newborn Physical ExamReview the perinatal history for clues to

potential pathologyBegins with conception and includes events

that occurred throughout gestationGenetic historyLabor & delivery history

Assess the infant’s color for clues for potential pathology

Auscultate in a quiet environmentKeep infant warm during examCalm the infant before examHandle gently

Classification of Size

Classification of size forgestational ageGrowth for dates can be determined by

weight, length, and head circumferencePlotted on a graph appropriate for gestation

• Preterm before 37 weeks• Term 38-41 weeks• Post term after 42 weeks

Classification of size for gestational ageUsing the

gestational age score the weight, height and head circumference can be plotted on the infants growth chart

This information is how the infant is diagnosed as SGA, LGA, or AGA

Classification of size for gestational ageSGA- small for gestational age-weight below

10th percentile AGA-weight between 10 and 90th percentiles

(between 5lb 12oz (2.5kg ) and 8lb 12 oz (4kg).

LGA-weight above 90th percentileIUGR-deviation in expected fetal growth

pattern, caused by multiple adverse conditions, not all IUGR infants are SGA, may or may not be “head sparing”

Neonatal Gestational Age- Ballard ExamThe physical maturity part of the examination

should be done in the first two hours of birthThe neuromuscular maturity examination should

be completed with 24 hours after deliveryDerived to look at various stages in an infants

gestational maturity and observe how physical characteristics change with gestational age

Neonates who are more physically mature normally have higher scores than premature infants

Points are awarded in each area -2 for extreme prematurity to 5 for postmature infants

Physical MaturitySkinLanugoPlantar surfaceBreastEyes & EarsGenital

Neonatal Gestational AgePhysical Maturity

Physical Maturity-SkinExamine the texture, color and opacity As the infant matures:

More subcutaneous tissue develops Veins become less visible and the skin

becomes more opaque

Neonatal Gestational Age AssessmentPhysical Maturity

Skin Before 28 weeks-

gelatinous red, friable 28-37 weeks-skin over

abdomen thin, translucent, pink with visible veins

37-39 weeks smooth, pink, increased thickness, rare veins over abdominal wall

Neonatal Gestational Age AssessmentPhysical

MaturitySkin

40 Weeks-vessels have now appeared, skin may be leathery with deep cracking

Differential Skin FindingsScalp Electrode

Differential Skin FindingsForcep Marks

Differential Skin FindingsVacuum Bruising

Differential Skin FindingsMilia-exposed

sebaceous glandsNo treatment

necessary

Differential Skin FindingsSebaceous

hyperplasiaMore yellow than

miliaResult of maternal

androgen in uteroResolves in time

Differential Skin FindingsMongolian Blue-

Grey SpotsMost common in

Asian, Hispanic, and African descent

Gradual fade over the first years

Differential Skin FindingsSkin TagsMost common

on earsUsually tied off

or clipped

Differential Skin FindingsSalmon patches or

nevus simplexAngel kissesStork bites

Differential Skin FindingsErythema

toxicumWhite or

yellow papule or pustule

With erythematous base

No treatment necessary

Differential Skin FindingsCafé Au Lait spotsIncreased amount of

melanin, may increase in number in age

Presence of 6 or more- greater then 0.5 cm in size may be indicative of neurofibromatosis

Neonatal Gestational Age Assessment• Physical Maturity• Lanugo

• After 20 weeks-begins to appear

• 28 weeks-abundant• After 28 weeks-thinning,

starts to disappear from the face first

• 38 weeks-bald areas slight amount may be present on shoulders

Neonatal Gestational Age AssessmentVernix

Before 34 weeks-vernix thick and covers entire body

34-38 weeks-vernix is absorbed gradually, portions over shoulder and neck is the last to be absorbed

38-40 weeks-vernix only present in folds of skin

After 40 weeks-no vernix present

Neonatal Gestational Age AssessmentPlantar Surface

Before 28 weeks-no creases28-32 weeks-virtually no

sole creases, faint thin red lines over anterior aspect of foot

34-37 weeks-1-2 anterior creases

37-39 weeks-creases now over the anterior 2/3 of the sole

Differential FindingsBilateral Club Feet

Polysyndactyly

Syndactyly


Breast Before 28 weeks-nipples imperceptible 28-32 weeks-nipple barely visible, no areola 32-37 weeks-well defined nipple areola 38-40 weeks-well defined nipple raised areola


Eyes Eyes are evaluated as either fused as seen in

extremely premature infants or open Before 26 weeks eyes are fused

Differential FindingsCongenital CataractsEyelid EdemaSubconjunctival Hemorrhage


Ears Before 34 weeks-pinna

is very immature cartilage not present, lies flat, remains folded

34-37 weeks-pinna curved with soft recoil

37-40 weeks-formed, firm instant recoil

After 40 weeks-thick cartilage ear stiff

Differential FindingsEar TagsEar Pits (Preauricular pits)Lop EarProminent Ear


Genitalia-Male Before 28 weeks-scrotum

empty and flat 28-30 weeks-testes

undescended into scrotal sac

30-36 weeks testes descending with a few rugae over the scrotum

36-39 weeks-testes have descended into scrotum which is now pendulous and complete with rugae

Genitalia-Female• Before 28 weeks-clitoris

prominent labia flat• 28-32 weeks-prominent

clitoris, enlarging labia minora

• 33-36 weeks-labia majora widely spaced with equally prominent labia minora

• 33-39 weeks-labia extends over the labia minora but not over the clitoris

• 39 weeks-labia majora completely covers the labia minora and clitoris

Differential FindingsHydrocele

Hypospadias

Undescended testicles

Hymenal Tag

Neonatal Gestational Age Neuromuscular Assessment

Neonatal Gestational Age AssessmentNeuromuscular Maturity

Posture & ToneSquare WindowArm RecoilPopliteal AngleScarf SignHeel to Ear

Neonatal Gestational Age Assessment• Neuromuscular Maturity

• Posture/Tone-Total body muscle tone is reflected in the infants preferred posture at rest and resistance to stretch of individual muscle groups• Make sure infant is quiet• The more mature an infant is the greater their tone

will be• A more flexed position indicated greater tone

Neonatal Gestational Age Assessment• Neuromuscular

Maturity• Posture & Tone

• Before 30 weeks-hypotonic, little or no flexion seen

• 30-38 weeks-varying degrees of flexed extremities

• 38-42 weeks-may appear hypertonic


Square Window-wrist flexibility and/or resistance to extensor stretching resulting in angle or flexion at wrist Flex hand down to wrist-

measure the angle between the forearm & palm Before 26 weeks-wrist

can’t be flexed more than 90 degrees

Before 30 weeks-wrist can be flexed no more than 90 degrees

36-38 weeks-wrist can be flexed no more than


Arm Recoil-measures the angle of recoil following a brief extension of the upper extremity

For 5 seconds flex the arms while infant is in the supine position, pulling the hands fully extend the arms to the side, then release-measure the degree of arm flexion & strength (recoil) Before 28 weeks-no recoil 28-32 weeks-slight recoil 32-36 weeks-recoil does not pass 90 degrees 36-40 weeks-recoils to 90 degrees After 40 weeks-rapid full recoil


Popliteal Angle-assesses maturation of passive flexor tone about the knee joint by testing resistance to extension of the leg

The angle decreases with advancing gestational age Before 26 weeks-angle 180

degrees 26-28 weeks-angle 160 degrees 28-32 weeks-angle 140 degrees 32-36 weeks angle 120 degrees


Scarf Sign-tests the passive tone of the flexors about the shoulder girdle

Increased resistance to this maneuver with advancing gestational age Before 28 weeks-elbow passes

torso 28-34 weeks-elbow passes

opposite nipple line 34-36 weeks-elbow can be pulled

past midline, no resistance 36-40 weeks-elbow to midline

with some resistance After 40 weeks-doesn’t reach

midline


Heel to Ear-measures passive flexor tone about the pelvic girdle by testing passive flexion or resistance to extension of the posterior hip flexor muscles

Breech infants will score lower than normal

Before 34 weeks-no resistance

40 weeks-great resistance may be difficult to perform

ReferencesAby, J. (2008). Stanford School of Medicine. Newborn

Nursery at LPCH. Retrieved October 10th, 2009 from

http://newborns.stanford.edu/RNMDEducation.htmlBallard J. (1991). New Ballard Score, expanded to

include extremely premature infants. Journal of Pediatrics, 119, 417-423.

Tappero, E. & Honeyfield, M. (1996). Physical assessment of the newborn. Santa Rosa, CA: NICU Ink Publishers.

objectives by the end of this presentation the learner should…. understand the prenatal...

Documents

gestational ageweight

gestational age growth

gestational age neonates

infants gestational

gestational age sga

aga slide

classification of size

sparing slide