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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

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Chapter 5

Examination and Assessment of the Neonate

gestational age and size
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
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 date1
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 date2
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 16-20 weeks gestation
  • b.   As early as 8 weeks with a Doppler device
  • c.    Rough estimate of gestation age
biophysical tests of well being
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 being1
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 being2
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 being3
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 being4
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
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
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
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
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
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
amniocentesis1
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
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
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
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
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
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
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
Clinical applications
  • 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 ultrasound1
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 ultrasound2
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
slide33

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
Alpha-Fetal Protein
  • a proteinthat 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 protein1
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 protein2
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
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 defects1
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
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
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
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
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
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
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 rate1
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
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
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
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

decels1
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
decels2
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
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
scalp ph1
Scalp pH
  • Poor gas exchange leads to increased PaCO2 and lactic acidosis (mixed acidosis)
  • Interpretation of Fetal Scalp pH
tocolysis
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
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
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.

new ballard score maturational assessment of gestational age
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.aspx
performing the assessment of neuromuscular maturity
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.
posture
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
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 post-term, 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
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
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
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
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
Physical Maturity - Skin
  • Maturation of fetal skin involves the development of its intrinsic structures concurrent with the gradual loss of its protective coating, the vernixcaseosa. 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 skin1
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
  • 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.
lanugo1
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
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
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
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 eye1
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
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
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
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
general appearance
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
general appearance1
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
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
  • 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
jaundice1
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 examination1
Physical Examination
  • Respiratory function
    • Rate
    • Rhythm
    • Silverman score
    • Auscultation
    • Chest radiography
    • ABGs/CBGs http://www.youtube.com/watch?v=q5J1cCyrASs
capillary blood gases
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 gases1
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
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
Variability in Cap Gases
  • Warming time
  • Amount of contact with air
  • Squeezing blood
pulse oximeters
Pulse Oximeters
  • Sites of attachment

(foot and hand)

  • Preductal placement in first twelve hours

(right hand)

pulse ox monitoring
Pulse Ox monitoring
  • Pre-ductal and post-ductal pulse O2 saturation (SpO2) monitors (to detect R → Lshunting at ductus arteriosus).
  • A difference of ≥10% suggests marked pulmonaryhypertension 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 oximeters1
Pulse Oximeters
  • Reads high
    • Methemoglobin
    • Caboxyhemoglobin
    • Jaundice
  • Reads low
    • Medical dyes
  • Other causes of inaccuracy
    • Motion
    • Hypothermia/vasoconstriction
    • Hypotension
    • Excessive ambient light on sensor probe
hemodynamic monitoring
Hemodynamic Monitoring
  • Umbilical Artery Catheter (UAC) preferred
uac insertion procedure
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
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
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
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 oxygen in clinical practice
http://www.perimed-instruments.com/transcutaneous-oxygen-in-clinical-practicehttp://www.perimed-instruments.com/transcutaneous-oxygen-in-clinical-practice
calibration of transcutaneous monitors
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
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
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
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 score1
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
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 assessment1
Respiratory Assessment
  • Retractions
  • Nasal flaring
  • Tachypnea
physical examination2
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)
physical examination cont
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
  • 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
Physical Assessment
  • Abdomen
    • Contour
    • Obvious abdominal wall anomalies
    • Auscultation and palpation
      • More than stomach
    • Cord
      • Anatomy
physical examination3
Physical Examination
  • Head and neck
    • Shape of head
      • Fontanelles
    • Scalp edema
    • Face
      • Dysmorphic
      • Edema
    • Ears
physical examination cont1
Physical Examination (cont.)
  • Head and neck
    • Nares
    • Mouth
      • Lips
      • Oral cavity
    • Neck
    • Clavicles
physical examination cont2
Physical Examination (cont.)
  • Musculoskeletal system, spine, and extremities
    • Dysmorphic
    • Number of digits
    • Abnormal positioning of joints
    • Spine
      • Dimple
physical examination4
Physical Examination
  • Cry
    • Strength
    • Sound
neurologic examination
Neurologic Examination
  • Response to environment
  • Movement
  • Neonatal reflexes
    • Grasp
    • Moro
  • Hearing
moro reflex
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 examination cont
Laboratory Examination (cont.)

Electrolytes

Renal function

Calcium

Glucose

Bilirubin

Screening

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