1. Physical Assessment of the Newborn

2. Assessment Two fundamental types of exams Periodic comprehensive exam
Problem specific exam

3. Assessment
Gathering accurate, detailed data that includes four components
Review history
Review results of physical exam
Review available data
Formulating an impression and plan

4. Comprehensive History
Prerequisite for adequate assessment
Alerts examiner to potential problems and may indicate the need for more frequent exam
Gives clues to potential pathology

5. Medical History Demographics Past Maternal illness & surgeries
Maternal conditions
Family History of congenital conditions
Reproductive Hx
Antepartum Hx
Intrapartum Hx
Social Hx

6. Prenatal Factors Affecting the Newborn
Diabetes Mellitus
Hyperthyroid
PKU
Systemic Lupus Erythematosus
Hypertension
Smoking & substance abuse

7. Principles of Physical Assessment
Assess infant for clues for potential pathology
Auscultate in a quiet environment
Keep the infant WARM & calm during the exam
Handle gently!
Record & report abnormalities

8. Refresh your anatomy

11. Techniques of Physical Assessment
Observation / Inspection
Palpation
Percussion
Auscultation
Inspection
Auscultation
Palpation
Percussion

12. Inspection / Observation
Most important technique to master
Alerts examiner to areas needing more thorough assessment
General / Visual
Auditory
Olfactory

13. Palpation
Using the sense of touch
Superficial
Deep

14. Percussion The body’s structures differ in density.
To discern the location, size and density of a structure.
Tympany
Resonance
Hyperresonance
Dullness

15. Percussion techniques
Direct
Indirect
Blunt
Not use frequently in the neonate

16. Auscultation Listening to sounds produced by internal body structures
Indirect - using the appropriate stethoscope
Direct - audible

17. Order of Examination General observation Head and neck region Facies
Nose
Mouth
Ears

18. Order of Examination Trunk Cardiopulmonary systems Abdomen Back
Genitalia and rectum

19. Order of Examination
Extremities
Neurologic exam
Eye Exam

20. Equipment
Ophthalmoscope
Stethoscope
Otoscope
Transilluminater

22. 1958 1 2 1 min 5 min APGAR Activity (Muscle tone) Pulse (HR)1 2
1 min
5 min
Activity (Muscle tone)
Floppy
Some flexion
Well Flexed
Pulse (HR)
<100
>100
Grimace (reflex irritability)
No response
Grimace
Cough or sneeze
Appearance (Color)
Blue or pale
Pink AC
Pink all over
Respirations
Absent
Slow, irregular, weak cry
Good, strong cry
1958

23. Baby A Born SVD to a G2 P2 26yo, no complications
At 1 min: Comes out crying and vigorous but color is still blue. When you bulb syringe the baby he gets mad!
At 5 min: Crying off and on, pink with blue hands and feet, good flexion, HR 140’s.

24. Baby A 8 9 1 min 5 min Activity (Muscle tone) Flexed - 2 Flexed - 2
Pulse (HR)
HR>
HR >
Grimace (reflex irritability)
Coughed with bulb - 2
Cough with bulb - 2
Appearance (Color)
Blue – 0
Pink with AC - 1
Respirations
Crying – 2
Crying - 2
Total 8 9

25. Baby B
Mom 35, G1P1, PIH induction. Having “lates”, vacuum assisted delivery.
At 1 min: Infant is floppy, HR 120, when you bulb syringe baby turns away, color is blue and the breathing is slow & irregular.
At 5 min: There is now some flexion, HR 180, coughing, pink with AC, good breathing but not crying.

26. Baby B 4 8 1 min 5 min Activity (Muscle tone) Floppy - 0
Some flexion - 1
Pulse (HR)
Grimace (reflex irritability)
Turns away from bulb - 1
Coughs - 2
Appearance (Color)
Blue - 0
Blue with AC - 1
Respirations
Slow, irregular - 1
Good, not crying - 2
Total 4 8

27. Apgar score may be influenced by
Preterm birth
Administration of maternal drugs
Congenital anomalies

28. Before leaving the DR Inspect for birth injuries/anomalies
Evaluate pulmonary & cardiovascular stability
Inspect extremities
Inspect genitalia

29. Evaluating Transition

30. Transition requires significant adjustments to tolerate the relatively stable fluid filled environment where nutrition and respiration are provided through the placenta and amniotic fluid to an environment where the newborn is physiologically independent in a few hours

32. Circulation changes from fetal to neonatal routes
Brief period when oxygen saturation of the blood going to the head, upper body, and right arm are significantly higher than the lower body
Line of demarcation across the chest

33. Evaluating Transition
Auscultate the chest - Is there sufficient air exchange?
Evaluate the cry - Describe the quality of the cry. Lusty or weak? Is there an obstruction or narrowing of the airway?
Is the infant vigorous? What is the perfusion, oxygenation and appropriateness of state?

34. Evaluating Transition
Term newborns generally complete transition in a few hours
Premature infant take a longer period of time to complete transition and may require external assistance to complete the process

35. Evaluating Transition
Monitor vital signs
Observe general alertness
Color
Signs of respiratory distress
Cardiac rhythm and rate
Ability to suck and swallow
Handling of secretions

36. Erythema neonatorum Blushed or bright red color Few hours after birth
Last several minutes to an hour
Signals the successful completion of fetal to neonatal transition of the cardiopulmonary system

37. Three particular observations are reassurances of a healthy baby
Normal variations in behavior state
Comfortable respiratory effort with intermittent vigorous cry
Transitional blush or erythema neonatorum

38. Periods of Reactivity Sympathetic activity Color Respiration
Heart Rate
Behavioral state
Gastrointestinal function
Temperature

39. Periods of Reactivity Initial Period of reactivity (birth to 30 min)
Period of relative inactivity (30 m -2 hours after)
Second period of reactivity (2-6 hours after)
Stability period (6-24 hours)
Actual times vary by baby, but there should always be a pattern of activity/sleep/activity.
The presence of periods of reactivity indicate a positive adjustment to extrauterine life

40. Stimulus for breathing
Sensory
Chemistry
Thermal
Mechanical
Stimulus for breathing

41. Cardiovascular Adaptations

42. Renal Intrauterine – kidney function not essential to life
Fetal urine helps to make up amniotic fluid
At birth
Vascular resistance of the renal vessels decreases
Increased blood flow through kidneys

43. Maintenance of Body Temperature
4/19/2017
Maintenance of Body Temperature
Thermogenesis
(brown fat metabolism)
Can find on the body in:
Intrascapular region
Thorax
Peri-renal area
Newborn’s ability to conserve heat is lacking due to not able to shiver.
Thermogenesis (heat production)
basal metabolic rate, muscular activity, and
chemical thermogenesis (nonshivering thermogenesis - infant uses stores of brown adipose tissue/brown fat (first appears at wks/increases until 2 to 5 wks after birth). Shivering rarely seen in newborn(if infant shivers, metabolic rate has already doubled)
Convection - is the loss of heat from the warm body surface to the cooler air currents (air conditioned rooms, oxygen by masks, removal from incubator
Radiation - losses occur when heat transfers from the heated body surface to cooler surgaces and objects not in direct contact with the body (walls of a room or of an incubator)
Evaporation - is the loss of heat incurred when water is converted to a vapor. Newborn particularly prone to this immediately after birth when wet with amniotic fluid, and during baths. Drying is critical
Conduction - is the loss of heat to a cooler surface by direct skin contact (chilled hands, cool scales, cold exam tables, and cold stethoscopes)

44. Body surface to air (drafts) Radiation
4/19/2017
Convection
Body surface to air (drafts)
Radiation
Body surface to cooler object not in contact (cold walls or window)
Evaporation
Conversion of a liquid to a vapor (dry infant)
Conduction
Body surface to cooler object in contact with baby ( warm surface)

45. Cold Stress Increased Metabolic Rate Increased need for O2
Increased respiratory rate
Anaerobic metabolism
Metabolic Acidosis, fatigue & CV collapse

46. Observe for signs of physical abnormalities

47. Newborn Vital Signs Heart rate: Apical pulse (120-160, irregular)
RR (30 to 60, no retractions, no grunting)
Temperature ( )
Blood pressure 70’s/40’s
Color: centrally pink with acrocyanosis

48. Signs of Distress Increased respiratory rate (tachypnea)
Difficult respirations (dyspnea)
Retractions
Excessive mucous
Cyanosis
Facial grimacing
Abdomen scaphoid or distended

49. Silverman-Anderson Observations of synchrony in the chest & abdomen
Retractions of the lower ribs
Retractions of the sternum
Nasal flaring
Presence & intensity of grunt on expiration
0 = no respiratory disease
10 = sever respiratory disease
>7 = impending respiratory failure

50. Morley
The need to relate signs & symptoms to grades of illness rather than to specific diagnoses d.t.:
S/S nonspecific
Diagnosis not always predictive of degree of illness
Parents & practitioners can inform parents of the severity of illness even in the absence of a diagnosis

51. Evaluating Transition
Tachypnea
C/S or preciptous delivery
Metabolic acidosis
Absence of tachypnea in the presence of cyanosis & poor air movement then it indicates inadequate respiratory drive
May suggest depression from maternal drugs, stress

52. Remember…
Delay determining sex of infant until accurate assessment of ambiguity is complete
Inspect the infant for major anomalies
Check the umbilical cord for the presence of 3 vessels (2 arteries, 1 vein)

53. Remember... Establish patency of upper airway
A term fetus swallows 450ml of amniotic fluid/day. Gastric emptying at 20 ml/hr.
Aspirated gastric contents >15 ml is increased
> 25ml is abnormal and suggests obstruction at the pylorus or duodenum

54. Remember...
May be green-brown in color(old swallowed meconium), or blood
Blood may be fetal or maternal APT test can distinguish
Don’t forget to look at the back
Check that the palate is intact
Look for the anus! Is there an opening?

55. Before leaving DR Inspect for birth injuries Congenital anomalies
Evaluation of pulmonary & cardiovascular stability
Extremities
Genitalia

56. Facilitate Infant’s Relationship with Parents

57. Newborn Care to Prevent Complications
Vitamin K, Eye prophylaxis, & glucose evaluation
Medves, Jennifer. (2002). Three infant care interventions: Reconsidering the evidence. JOGNN,31(5), pp

58. Assessing Growth Weight, Length, Head & Chest 4/19/2017
HC cm or 13 to 14 inches
Length 46 to 54 cm or inches
Weight 2.5 to 3.4 kg or about 7 1/2 pounds
chest 2cm or 1inch less than head
Newborns are 75 t 90% fluid and may lose up to % of birthweight, should regain by days of age
Weight, Length, Head & Chest

59. Assessing Growth
A normal growth pattern is an indicator of fetal and neonatal well-being.
Growth follows a predictable path
Influenced by genetic and environmental patterns
May be proportionate or disproportionate

60. Assessing Growth
Standard measurements are head circumference, height and weight
Compare the individual to himself over time by looking at the rate of growth or the expected pattern of an infant of similar characteristics
Validity & Reliability of measurements

61. Measurements Weight Length Head Circumference Chest Circumference
Abdominal Circumference

62. Gestational Age Assessment

63. Gestational Age Assessment: Estimating post-conceptual age of the neonate
An accurate assessment of age is important for 2 reasons
Age and growth patterns appropriate to that age aid in identifying neonatal risks
Help in developing management plans

64. Gestational Age Assessment
There are 3 general methods to determine gestational age
Calculation of dates based on LMP
Evaluation of obstetrical patterns
Physical exam of the neonate

65. Gestational Age Assessment
Physical Assessment
Assessment of anterior vascular lens capsule using opthalmoscope
Best done on the 2nd day of life
Assessment of neuromuscular and physical criteria by inspection and palpation

66. Assessment of the
Anterior vascular lens capsule

67. Grade 4, 27 – 28 wks

68. Grade 3, 29 – 30 wks

69. Grade 2, 31 – 32 wks

70. Grade 1, 33 – 34 wks

71. Modified Ballard

72. Plotting Weight, Length, HC

73. Pre-term: born before end of 37th week gestation

74. Term

75. AGA

76. SGA: < 10th %

77. LGA: >90th%

78. Post term: Born after the 42nd week of pregnancy

79. Low birth weight: g

80. Very Low Birth weight: 1000-1500g

81. Extremely very low birthweight: 500-1000g

82. Skin

83. Lanugo

84. Plantar creases

85. Ear cartilage

86. Genitalia

87. Neuromuscular Criteria
Posture
Observe in the supine position
Score is assigned based on the degree of flexion of arms, knees and hips
Increased flexion and hip adduction with increased gestational age

88. Neuromuscular Criteria
Square Window
Infants hand is flexed on the forearm between the thumb and index finger of the examiner
Apply enough pressure to get FULL flexion without rotating the wrist
Angle between the forearm and palm is measured

89. Neuromuscular Criteria
Arm Recoil
Flex the neonates arms for 5 seconds while in the supine position
Fully extend the arms by pulling on the hands and release
The degree of arm flexion and strength of recoil are scored

90. Neuromuscular Criteria
Popliteal Angle
Place infant in supine position with the pelvis on the mattress
Using the thumb and index finger of one hand, examiner holds the knee adjacent to the chest and abdomen. Gently extend the leg with the index finger
Look at the angle between the lower leg, thigh and posterior knee

91. Neuromuscular Criteria
Scarf sign
Place infant in supine position with head in mid-line position.
Grasp the infants hand and pull the arm across the chest and around the neck.
Look at the relationship of elbow to mid-line of body when arm pulls across the chest

92. Neuromuscular Criteria
Heel to ear
Place the infant supine with pelvis flat on table.
Grasp one foot with thumb and index finger and draw foot as near to head as possible.
Note the distance between the foot and head as well as degree of knee extension

93. Physical Criteria Skin
less transparent and tougher with increasing gestational age
36-37 weeks loses transparency and underlying vessels are no longer visable
Increasing gestational age the veins become less viable and increasing subcutaneous tissue

94. Physical Criteria Lunago
Fine downy hair covering fetus from weeks
Disappears around face and anterior trunk ~28 weeks
Term infants may have a few patches over shoulders

95. Physical Criteria Sole creases
28-30 weeks appear and cover the anterior portion of of the plantar surface of the foot
Extend toward the heel as increases gestational age
After 12 hours sole creases are not valid indicator of gestational age due to drying of the skin

96. Physical Criteria Breast tissue and aerola
Aerola is raised by 34 weeks
A 1-2 mm nodule of breast tissue is palpable by 36 weeks
By 40 weeks the nodule is 10mm

97. Physical Criteria Ears
Incurving of the upper pinna begins by 34 weeks gestation and extend entire lobe by 40 weeks
Before 34 weeks, pinna has very little cartilage (Stays folded on itself)
At 36 weeks, there is some cartilage and will spring back

98. Physical Criteria Female Genitalia
Early gestation, clitoris prominent and widely separated labia
By 40 weeks, fat deposits have increased in size in labia majora so labia minora are completely covered

99. Physical Criteria Male genitalia
Testes begin to descend from abdomen around 28 weeks
At 37 weeks, testes can be palpated high in scrotum
At 40 weeks, testes are completely descended and covered with rugae
As gestation progresses, scrotum becomes more pendulous

100. CANSCORE Nine signs for assessing nutritional status in term infants
4/19/2017
CANSCORE Nine signs for assessing nutritional status in term infants
Hair
Cheeks
Chin & neck
Arms
Back
Buttocks
Legs
Chest
Skin on Abdominal wall

101. 4/19/2017
CANSCORE, Fletcher, p34 Nine signs for assessing nutritional status in term infants
Hair
Cheeks
Chin & neck
Arms
Back
Buttocks
Legs
Chest
Skin on Abdominal wall

102. 4/19/2017
Cheeks from full buccal pads & rouind face to narrow, flat face
Neck & chin from double or triple chin fat folds, neck not evident to thin chin, no fat folds, neck with loose, wrinkled skin easily evident.

103. Assessing Growth Normal growth pattern Follows a predictable path
Influenced by genetic & environmental patterns
Compare individual to himself over time.

104. Quiet
Sleep

105. Active Sleep

106. Drowsy

107. Quiet Alert

108. Active
Alert

109. Crying

110. State Related Behaviors
Visual responses
Auditory responses
Motor behavior
Smile
Habituation
Consolability
Cuddliness
Readability