Physical Examination and Assessment Of The Newborn

APGAR SCORING SYSTEM

Developed in 1950s Cardiopulmonary status Dr. Virginia Apgar 1 minute after birth 5 minutes after birth 5 parameters

A = Appearance (skin color) P = Pulse (heart rate) G = Grimace (reflex irritability) A = Activity (muscle tone) R= Respiration

(respiratory effort)

Criteria for Apgar Scoring

Category
Heart Rate Respiratory Effort Muscle Tone Reflex Irritability Skin Color

0 Points
Absent Absent Flaccid, Limp Unresponsive Cyanosis

1 Point
Under 100 Irregular, Weak Some flexion

2 Points
Over 100 Crying, Vigorous Active flexion, good motion

Frown/Grimace Active motionw/ stimulation cry, cf. sneeze Acrocyanosis Completely Pink

APGAR SCORING SYSTEM

One Minute Score

Identifies need for immediate intervention Score 2 0r less = immediate resuscitation Score 3 to 6 = some assistance, usually stimulation, suctioning, oxygen Score 7 or more = routine care and observation

APGAR SCORING SYSTEM

Five Minute Score

Assess infants recovery from depression Also assess effectiveness of intervention Score 7 to 10 = Few, if any, supportive measures Score 4 to 6 = Mild to moderate asphyxia; suctioning, oxygenation, mech ventilation Score 0 to 3 = Full cardiopulmonary resuscitation

SILVERMAN SCORE
Looks at level of respiratory distress Scoring in 5 areas, range from 0 to 2

Upper chest movement

Synchronized = 0 Lag of chest on inspiration = 1 Seesaw movement upper chest = 2

Lower chest movement

SILVERMAN SCORE- continued

Lower chest movement

(continued)

No retractions = 0 Retractions - just visible = 1 Marked retractions = 2

Xiphoid retractions

No retractions = 0 Retractions - just visible = 1 Marked retractions = 2

SILVERMAN SCORE- continued

Dilation of nares

None = 0 Minimal dilation = 1 Marked dilation = 2

Expiratory Grunt

None = 0 Heard only w/ stethoscope = 1 Heard w/ naked ear = 2

SILVERMAN SCORE- continued

Scoring Scale

0 to 3 = no respiratory distress to mild distress 4 to 6 = moderate respiratory distress 7 to 10 = severe respiratory distress

ESTIMATION OF GESTATIONAL AGE

Dubowitz Score

Dr. Dubowitz and co-workers (Early 1970s) 10 external characteristics 11 Neuromuscular signs
New Ballard Score (NBS)

Increase accuracy in very low birthweight 7 physical & 6 neurologic criteria

No lifting patient ; intubated & monitored

ESTIMATION OF GESTATIONAL AGE

NBS - continued
Each category scored from -1 Physical Maturity

to +4 or +5

Skin - transparent to leathery, cracked Lanugo - none to mostly bald, upper back only Plantar Surface - little or no creases to creases over entire sole Breast - imperceptible to full areola

ESTIMATION OF GESTATIONAL AGE

NBS - continued
Eye/Ear - lids fused, pinna flat to well curved pinna, thick cartilage ear stiff Genitals male -scrotum flat, smooth to testes pendulous Genitals female - clitoris prominent, labia flat to majora cover clitoris and minora

ESTIMATION OF GESTATIONAL AGE

NBS - continued
Neuromuscular Maturity

Posture & extremities / muscle tone: Posture - hypotonic w/ arms & legs extended to arms & legs flexed w/ recoil Square Window (wrist) - greater than 90* to 0* Arm Recoil - none to full recoil w/ angle < 90* Knee Joint Angle (popliteal) - from 180* to less than 90*

ESTIMATION OF GESTATIONAL AGE

NBS - continued
Scarf Sign - no resistance to full resistance Heel to Ear - no resistance w/ little or no

knee flexion to significant resistance with flexed knee

ESTIMATION OF GESTATIONAL AGE

NBS - continued
-10 -5 0 5 10 15 20 20 wks 22 wks 24 wks 26 wks 28 wks 30 wks 32 wks

SCORING SYSTEM
25 30 35 40 45 50 34 wks 36 wks 38 wks 40 wks 42 wks 44 wks

ESTIMATION OF GESTATIONAL AGE

- continued: External Criteria

Vernix
grayish white cheeselike substance composed of
sebaceous gland secretions lanugo shed epithelial cells

Preterm covered Term has very little, only in body creases Post-term has none

Nails
present and cover nail bed all ages may be especially long in post-term

amount is age related

Growth Assessment
Colorado intrauterine growth curve

Plot gestational age against:

Birth weight Length Head circumference Data from Colorado infants 1948 to 1961

Colorado intrauterine growth curve

Score between 10th and 90th percentiles

= AGA
Score below the 10th percentile

= SGA

Score above the 90th percentile = LGA

VITAL SIGNS

RESPIRATORY RATE
HEART RATE

BLOOD PRESSURE
TEMPERATURE

RESPIRATORY RATE
Normal = 30 to 60, variable Periodic Breathing = respiration

interrupted by short periods of apnea, up to 10 seconds, not associated w/ other abnormalities

Common in preterm infants
Very little chest wall movement Count for full minute

HEART RATE
Normal newborn = 110 to 160 Determined by auscultation Transient increases w/ agitation Persistent tachy associated w/ congenital

heart defects Brady associated w/ significant apnea Apical impulse - normal vs. abnormal location

BLOOD PRESSURE
Normal Ranges:

Low birth weight = 50/35 mmHg. Mid b.w. above 2000 gm. = 60/35 mmHg. High b.w. above 3000 g. = 65/40 mmHg.
Assessed with doppler and cuff Peripheral pulses for indirect assessment

- brachial - radial - femoral

TEMPERATURE
Normal core = somewhat variable Rectum is best assessment of core Axilla, usually lower but may be falsely high

Skin Temp
Allow continual measurement Pt. Care not interfered Maintained about 36.5 degrees (C) Minimize O2 consumption

OTHER CLINICAL ASSESSMENTS

SIGNS OF RESPIRATORY DISTRESS
5 Common

Tachypnea Cyanosis Nasal Flaring - Silverman score Expiratory Grunting - Silverman score Retractions - Partially Silverman score

RESPIRATORY DISTRESS -continued

Tachypnea = RR > 60

Over 50 should increase suspicion Full minute assessment

Cyanosis = bluish discoloration

Local vs. General Central

Involves mucous membranes Indicates excessive unsaturated hemoglobin

RESPIRATORY DISTRESS -continued

Central Cyanosis - continued
In excess of 5 g / dl Presence usually indicative of PO2 < 40 mmHg Slight drop in PO2 yields dangerous sharp decline in hemoglobin saturation, O2 carrying capacity Anemic baby may have no cyanosis w/ extreme hypoxemia

Acrocyanosis - hands & feet

common in newborns

RESPIRATORY DISTRESS -continued

Retractions = inward movement of chest wall

Intercostal = between ribs Supraclavicular = above clavicles Subcostal = below rib margins Suprasternal = top margins of sternum Xiphoid = bottom margins at xiphoid process

RESPIRATORY DISTRESS -continued

Apnea

= periods of no respiration for at least 20 seconds Or periods of absence of respiration accompanied by bradycardia (HR < 100)

Chest Auscultation

Rales
crackles short, interupted sounds usually during inspiration associated with
HMD Pulmonary Edema Pneumonia

Rhonchi
changes in pitch narrowing of airways
secretions swelling foreign matter smooth muscle spasm

Course = low pitch Wheeze = high pitch

Head, Face, & Neck Exam

Assessment of Congenital Anomalies Head

Shape & Size

Compression during birth - self correcting

Occipital Frontal Circumference (OFC) Ears

Shape, Size, Position, Presnce of ear canals

Head, Face, & Neck Exam - cont.

Face

Eyes
Size -Shape -Position
-Patency of Nasal Pasages -Size of tongue & jawbone

Nose
Size -Shape

Mouth
Lips -Hard/Soft Palate

Head, Face, & Neck Exam - cont.

Neck Inspected for;

Range of motion Goiter Presence of cysts

ABDOMEN, SKIN, EXTREMETIES

Abdomen

Protrusion of abdominal contents Appearance & position of umbilicus

Skin

Pigmentation, Rashes, Bruising, Unusual Jaundice

ABDOMEN, SKIN, EXTREMETIES

Extremeties - fingers & toes

Position Size Number

Hands & Feet

Color
Pulses

Brachial & Femoral