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An Introduction to the Nursery Newborn Nursery Faculty: Division of General Pediatrics Photgraph: Anne Geddes Created by: Maria Kelly MD.

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Presentation on theme: "An Introduction to the Nursery Newborn Nursery Faculty: Division of General Pediatrics Photgraph: Anne Geddes Created by: Maria Kelly MD."— Presentation transcript:

1 An Introduction to the Nursery Newborn Nursery Faculty: Division of General Pediatrics Photgraph: Anne Geddes Created by: Maria Kelly MD

2 Objectives Recognize what aspects of the maternal history are important for a complete newborn assessment Recognize what aspects of the maternal history are important for a complete newborn assessment Understand the basics of a newborn physical exam and familiarize yourself with normal variations and/or abnormalities Understand the basics of a newborn physical exam and familiarize yourself with normal variations and/or abnormalities Learn the basics of a Ballard gestational age assessment Learn the basics of a Ballard gestational age assessment Understand the importance of gestational age in the complete newborn assessment Understand the importance of gestational age in the complete newborn assessment

3 Your daily newborn responsibilities… Please see the document “Newborn Orientation for Family Medicine Residents”. This document explains the day to day activities, goals, objectives and responsibilities. Please see the document “Newborn Orientation for Family Medicine Residents”. This document explains the day to day activities, goals, objectives and responsibilities.

4 Newborn Record (Page 1 - Admission) Maternal History and Delivery Record Maternal History and Delivery Record Infant record Infant record Initial Exam Initial Exam Assessment and Plan Assessment and Plan **Medical students should NOT write in the red area. They may document in the green area as long as enough room is left for you to document a full note. **

5 Newborn Record (Page 2 - Discharge) Discharge Exam Discharge Exam Information to be included in Discharge Summary Information to be included in Discharge Summary Hospital Course Summary Hospital Course Summary **Medical students should NOT write in the red area. They may document in the green area as long as enough room is left for you to document a full note. **

6 Pertinent Maternal History Everyone involved in the care of the infant should have knowledge of the relevant maternal history Everyone involved in the care of the infant should have knowledge of the relevant maternal history Pre-partum Pre-partum Antenatal Antenatal Perinatal Perinatal This information can routinely be found on the maternal fact sheet in newborn’s chart (yellow form) or in the mother’s chart. This information can routinely be found on the maternal fact sheet in newborn’s chart (yellow form) or in the mother’s chart.

7 Maternal Fact Sheet Maternal History Maternal History Infant Record Infant Record Delivery Record Delivery Record **Although the maternal serologies are listed on this sheet we do NOT believe them. All serologies must be confirmed by lab report!**

8 Maternal History Family History Family History Inherited diseases (cystic fibrosis, sickle cell disease, metabolic disease, polycystic kidneys, hemophilia, and history of perinatal death) Inherited diseases (cystic fibrosis, sickle cell disease, metabolic disease, polycystic kidneys, hemophilia, and history of perinatal death) Maternal History Maternal History Age, blood type, chronic diseases, diabetes, hypertension, renal disease, cardiac disease, bleeding disorders, infertility, recent infections/exposures, rubella status, GBS status, and STD’s Age, blood type, chronic diseases, diabetes, hypertension, renal disease, cardiac disease, bleeding disorders, infertility, recent infections/exposures, rubella status, GBS status, and STD’s

9 Maternal History Sexually transmitted diseases (STD’s) HIV Syphilis(RPR or VDRL) Hepatitis B(HepBsAg) Gonorrhea(GC DNA) Chlamydia(Cz DNA) Group B Streptococcus “GBS” (streptococcus agalactiae) Rectal/vaginal swab results at weeks gestation **all maternal results must be verified/confirmed by visualizing a lab report** Group B Strep

10 Maternal History Previous pregnancies Previous pregnancies Abortions, fetal demise, neonatal death, premature births, postdate births, malformations, respiratory distress syndrome, jaundice, apnea Abortions, fetal demise, neonatal death, premature births, postdate births, malformations, respiratory distress syndrome, jaundice, apnea Drug history Drug history Medications, drugs of abuse, ETOH, tobacco usage during pregnancy Medications, drugs of abuse, ETOH, tobacco usage during pregnancy

11 Maternal History Current Pregnancy Current Pregnancy Gestational age, results of fetal testing, pre- eclampsia, bleeding, trauma, infection, surgery, polyhydramnios, oligohydramnios, glucocorticoids, labor suppressants, antibiotics Gestational age, results of fetal testing, pre- eclampsia, bleeding, trauma, infection, surgery, polyhydramnios, oligohydramnios, glucocorticoids, labor suppressants, antibiotics Important factors during labor…… Important factors during labor……

12 Labor and Delivery: Important Factors Onset of labor: spontaneous vs. induced Rupture of membranes Analgesia Anesthesia Apgar scores Duration of labor Placental exam Resuscitation Presentation Maternal fever Fetal monitoring Method of delivery

13 Medical Student Progress Note Include brief maternal and child history relevant to pregnancy and birth Include brief maternal and child history relevant to pregnancy and birth S: Include subjective components S: Include subjective components O: Include objective components O: Include objective components Include growth parameters, vital signs (high  low), I/O’s Include COMPLETE exam Include growth parameters, vital signs (high  low), I/O’s Include COMPLETE exam A: Includes overall assessment of infant A: Includes overall assessment of infant P: Include plan P: Include plan Identify risk factors and/or concerns for sepsis, jaundice, feeding, murmurs, social, etc. Identify risk factors and/or concerns for sepsis, jaundice, feeding, murmurs, social, etc.

14 Newborn Examination A child’s first exam should be one of the most thorough the child ever receives. A child’s first exam should be one of the most thorough the child ever receives. The newborn assessment is different from an adult exam!!! The newborn assessment is different from an adult exam!!! If you start at the head and plan to go to toes, a quiet child may no longer be quiet! If you start at the head and plan to go to toes, a quiet child may no longer be quiet! Look, listen, feel Look, listen, feel Listen to heart, lungs, and abdomen while the infant is quiet, then attempt to work “head to toe”. Listen to heart, lungs, and abdomen while the infant is quiet, then attempt to work “head to toe”. May have to continuously adjust your exam and examine what becomes available May have to continuously adjust your exam and examine what becomes available

15 Cardiopulmonary Exam Look at the chest Look at the chest Color, symmetry, work of breathing, and respiratory rate Color, symmetry, work of breathing, and respiratory rate Observe for retractions, nasal flaring, malformations, abnormal pulsations, and parasternal heave. Observe for retractions, nasal flaring, malformations, abnormal pulsations, and parasternal heave. Heart examination Heart examination Rate, rhythm, murmurs, gallops, clicks, loudest on right side or left side, location and strength of PMI (point of maximal impulse) Rate, rhythm, murmurs, gallops, clicks, loudest on right side or left side, location and strength of PMI (point of maximal impulse) PDA murmur sound link: PDA murmur sound link: Check femoral pulses and compare with brachial pulses Check femoral pulses and compare with brachial pulses Listen to the lungs Listen to the lungs Bilateral breath sounds, crackles, wheezes, or rhonchi Bilateral breath sounds, crackles, wheezes, or rhonchi

16 Abdominal Exam Inspect first Inspect first Listen for bowel sounds Listen for bowel sounds Present or absent Present or absent Feel the tummy! Feel the tummy! Palpate for liver, spleen, kidneys, and presence of masses Palpate for liver, spleen, kidneys, and presence of masses

17 Genitourinary Exam: Male Penis: Phimosis is normal!!! Penis: Phimosis is normal!!! Do not attempt to retract the foreskin over the glans Do not attempt to retract the foreskin over the glans Look for epi- or hypospadias Look for epi- or hypospadias Testes: Feel both testes, look for hydroceles, hernias, or other abnormalities Testes: Feel both testes, look for hydroceles, hernias, or other abnormalities Ambiguous genitalia Ambiguous genitalia Anus: Check for patency and placement Anus: Check for patency and placement

18 Genitourinary Abnormalities: Male Normal neonatal phimosis Hypospadias

19 Genitourinary Abnormalities: Male Left hydrocele www1.medizin.uni-halle.de Left inguinal hernia

20 Genitourinary Exam: Female Labia: Labia: Large labia major is common due to maternal hormones Large labia major is common due to maternal hormones Examine for fusion and clitoral hypertrophy Examine for fusion and clitoral hypertrophy Vagina: Vagina: Vaginal discharge is common; white & mucoid to pseudomenses Vaginal discharge is common; white & mucoid to pseudomenses May have hymenal tags May have hymenal tags Ambiguous genitalia Ambiguous genitalia Anus: check for patency and placement Anus: check for patency and placement

21 Genitourinary Abnormalities Ambiguous genitalia Imperforate anus

22 Genitourinary Abnormalities Hymenal Tag

23 Extremities Digits: number and abnormalities Digits: number and abnormalities Examples: polydactyly, syndactyly, clinodactyly, simian creases Examples: polydactyly, syndactyly, clinodactyly, simian creases Arms/Legs: Arms/Legs: Examine range of motion, tone, asymmetry Examine range of motion, tone, asymmetry Clavicles Clavicles Feel for fractures!!! Feel for fractures!!! Hips: Hips: Barlow and Ortaloni exam Barlow and Ortaloni exam Clicks are common and benign due to estrogenic effect Clicks are common and benign due to estrogenic effect Clunks are indicative of hip dislocation/relocation and can represent developmental dysplasia of the hip Clunks are indicative of hip dislocation/relocation and can represent developmental dysplasia of the hip

24 Hip Exam

25 Extremity Abnormalities Single Palmar Crease Polydactyly

26 Spine Flip infant onto your forearm and look at entire spine Flip infant onto your forearm and look at entire spine Feel the vertebral column for bony defects Feel the vertebral column for bony defects Examine sacral area closely Examine sacral area closely Clefts, hairy tufts, change in pigmentation Clefts, hairy tufts, change in pigmentation Look for gross defects Look for gross defects Meningomyelocele, teratomas, sinus tracts Meningomyelocele, teratomas, sinus tracts

27 Vertebral Abnormalities Sacral Sinus and Dimple Hair tuft

28 Skin Look at the skin during the entire exam Look at the skin during the entire exam Jaundice Jaundice Mongolian spots (Important to document!!!) Mongolian spots (Important to document!!!) Rashes Rashes - HSV lesions - Milia - Transient pustular melanosis- Cradle cap - Neonatal Acne- Stork bites - Erythema toxicum neonatorum

29 Skin Findings Mongolian Spot (Congenital dermal melanocytosis) dermis.multimedica.de

30 Skin Findings Erythema toxicum neonatorum Transient pustular melanosis ethnomed.org

31 Skin Findings Sebaceous Gland Hyperplasia Neonatal Acne

32 Skin Findings Stork bite (Nevus simplex) Cradle Cap (Seborrheic dermatitis) en.wikipedia.org

33 HEENT Head Head Head circumference (average 34-35cm) Head circumference (average 34-35cm) Look and feel scalp Look and feel scalp Caput succedaneum, cephalohematoma, abrasions, sutures, fontanelles (anterior and posterior) Caput succedaneum, cephalohematoma, abrasions, sutures, fontanelles (anterior and posterior) Ears Ears Formed, pits, tags, rotation, position, size Formed, pits, tags, rotation, position, size Nose Nose Nares patent bilaterally Nares patent bilaterally

34 Head Findings Caput succedaneum Cephalohematoma

35 HEENT Mouth Mouth Check for clefts (lip and palate), arched palate, neonatal teeth, Epstein pearls Check for clefts (lip and palate), arched palate, neonatal teeth, Epstein pearls Eyes Eyes Scleral hemorrhages, icterus, discharge, pupil size, extra-ocular movements, red reflex, clear cornea Scleral hemorrhages, icterus, discharge, pupil size, extra-ocular movements, red reflex, clear cornea Neck Neck Range of motion, goiter, cysts, clefts, Range of motion, goiter, cysts, clefts,

36 HEENT Findings Absent red reflex Epstein’s pearls Cleft lip and palate

37 Neurologic Exam Look carefully and evaluate neurologic status during exam of other systems Look carefully and evaluate neurologic status during exam of other systems Symmetry of motion, tone, bulk, response to stimulation, pitch of cry, repetitive motions, palsies Symmetry of motion, tone, bulk, response to stimulation, pitch of cry, repetitive motions, palsies Primitive Reflexes: Moro, suck, rooting, palmar/plantar grasp, stepping Primitive Reflexes: Moro, suck, rooting, palmar/plantar grasp, stepping

38 Newborn Reflexes Palmar and plantar grasp Rooting reflex

39 Newborn Reflexes Moro reflex Stepping reflex

40 Newborn Exam Pointers Listen first, a crying baby doesn’t promote a good listening environment Listen first, a crying baby doesn’t promote a good listening environment Take your time, develop a system, and use it every single time Take your time, develop a system, and use it every single time Look at every square inch of the baby! Look at every square inch of the baby! Follow-up any abnormalities Follow-up any abnormalities Don’t forget gestational age assessment Don’t forget gestational age assessment

41 So what’s the big deal with gestational age? Gestational age can predict problems, morbidity, mortality, and can help you keep alert for certain problems Gestational age can predict problems, morbidity, mortality, and can help you keep alert for certain problems Pre-term infants are at a higher risk for: Pre-term infants are at a higher risk for: Respiratory distress syndrome Respiratory distress syndrome Necrotizing enterocolitis Necrotizing enterocolitis Patent ductus arteriosis Patent ductus arteriosis Apnea Apnea Post-term infants are at a higher risk for: Post-term infants are at a higher risk for: Asphyxia Asphyxia Meconium aspiration Meconium aspiration Trisomies and other syndromes Trisomies and other syndromes

42 Gestational Age & Birth Weights Gestational Age: Gestational Age: Pre-term: < 37 weeks Pre-term: < 37 weeks Term: /7 weeks Term: /7 weeks Post-term: 42 or more weeks Post-term: 42 or more weeks Term Infant (weight classification) Term Infant (weight classification) LGA: >4000 g LGA: >4000 g AGA: g AGA: g SGA: <2500 g SGA: <2500 g

43 Gestational Age Classification Pre-term, term, and post term infants must all be plotted to determine if they are SGA, AGA, and LGA with regards to weight, length, and head circumference. Pre-term, term, and post term infants must all be plotted to determine if they are SGA, AGA, and LGA with regards to weight, length, and head circumference. LGA AGA SGA XXX

44 Summary Be thorough Be thorough Be complete Be complete Find a system and use it each and every time!!! Find a system and use it each and every time!!! The more infants you examine, the more comfortable you will become with normal variations. The more infants you examine, the more comfortable you will become with normal variations.

45 References Nelson’s Textbook of Pediatrics, 17 th ed Nelson’s Textbook of Pediatrics, 17 th ed Gomella’s Neonatology, 5 th ed Gomella’s Neonatology, 5 th ed


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