objectives by the end of this presentation the learner should…. understand the prenatal...
TRANSCRIPT
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
Neonatal Gestational Age AssessmentPhysical Maturity
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
Neonatal Gestational Age AssessmentPhysical Maturity
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
Neonatal Gestational Age AssessmentPhysical Maturity
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
Neonatal Gestational Age AssessmentPhysical Maturity
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
Neonatal Gestational Age AssessmentNeuromuscular Maturity
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
Neonatal Gestational Age AssessmentNeuromuscular Maturity
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
Neonatal Gestational Age AssessmentNeuromuscular Maturity
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
Neonatal Gestational Age AssessmentNeuromuscular Maturity
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
Neonatal Gestational Age AssessmentNeuromuscular Maturity
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.