Ballard Exam Flashcards
Why is the estimation of GA important?
knowledge of the neonate’s age and growth patterns aid in the identification of neonatal risks and in the development of a management plan, especially if on the edge of viability
What are the three general methods of determining GA in the newborn?
1) calculation of dates based on LMP
2) evaluation of OB parameters obtained in pregnancy
3) physical exam of the neonate
What is the average gestation of the human?
280 days, 40 weeks from the onset of the LMP
Why can calculation based on reported LMP be potentially misleading?
if MOB menstrual cycles are irregular, h/o recent contraception use, patient with medically induced ovulations, limited prenatal care
What is the most accurate guide to GA?
the combination of menstrual dates and ultrasound measurements
What are the 2 methods used to determine GA based on physical assessment?
1) assessment of the anterior vascular capsule of the lens
2) assessment of neuromuscular and physical criteria by inspection and palpation
What is the basis for the anterior vascular capsule exam as a determinant of GA?
the hyaloid system and the tunica vasculosa lentis are transient embryologic vascular systems that invade the developing eye to nourish the eye during periods of active growth.
When can the anterior vascular capsule be appreciated?
appears at 27 wk GA and then atrophies progressively until it is gone after wk 34
When should the anterior vascular capsule be evaluated?
performed within the first 24 to 48h of life because the vascular system atrophies rapidly after that period
What maternal conditions are thought to influence the anterior vascular capsule?
chronic HTN accelerates atrophy of this system; chronic intrauterine stress may influence the maturation of this vascular structure
What can primitive reflexes and active muscle tone evaluation reveal?
indicator of illness or wellness
What is the definition of passive muscle tone?
the slight constant tension of healthy muscles which contributes a slight resistance of passive displacement of a limb
What is the progression of development?
caudo-cephalad direction
What is the difference between extensor and flexor tone?
flexor tone is the resistance to extensor tone, as seen by positioning the limb midlined and with small angle between limbs
How does flexor tone change over the course of development?
passive flexion overcomes passive extension as CNS maturation progresses
What are tests of passive flexor tone?
square window, angle of recoil, arm recoil, resistance to extension, scarf sign, popliteal angle, heel to ear
How do eyes begin to develop in utero?
wide open; develops from the outer canthus ~48d progressing to the inner canthus ~51d
When do eyes close in utero?
close from canthi to center (~57 d); fusion then persists until 7th mo (26-28wk GA)
How is the posture of a newborn evaluated?
remove restrictive clothing and nesting materials, place infant supine, observe preferred attitude at rest; assign score based on the degree of flexion of the arms, knees and hips
What is the square window an assessment of?
passive flexion at the wrist
How is the square window test completed?
Apply gentle pressure of dorsum of baby’s hand at metacarpal-phalangeal joint; measure the angle between the forearm and the palm
When conducting the square window test, how are the results affected by GA?
the angle decreases with advancing GA
What is the arm recoil an assessment of?
passive flexor tone of biceps muscle
How is the arm recoil test completed?
set arm in flexion, extend momentarily and release- too long and you will fatigue the muscle; note position of the arm at the end of recoil
When conducting the arm recoil test, how are the results affected by GA?
a sluggish response with little or no flexion receives a low score. a brisk, fully flexed response receives a high score
What is the popliteal angle an assessment of?
passive flexor tone of hamstring muscle group
How is the popliteal angle test completed?
flex leg with knee on abdomen, raise lower leg feeling for first sign of resistance, estimate angle between leg and thigh; don’t touch hamstring or plantar surface
When conducting the popliteal angle test, how are the results affected by GA?
the popliteal angle angle decreases with advancing GA
What is the scarf sign an assessment of?
passive flexor tone of shoulder girdle muscles
How is the scarf sign test completed?
support arm on chest, place thumb on infant’s elbow, sweep arm across chest; note position of elbow at the first sign of resistance
Why should an infant’s hand not be pulled when completing the scarf sign?
pulling elicits a reflex by the bicep and doesn’t isolate the shoulder muscle
When conducting the scarf sign test, how are the results affected by GA?
increasing resistance to this maneuver with advancing GA
What is the heel to ear an assessment of?
passive flexor tone of the gluteus muscles
How is the heel to ear test completed?
flex leg, set along side the body, move heel toward the ear on same side of the body, note the distance betwen the foot and the ear as well as the degree of knee extension at first sign of resistance
Where does the leg have to be in the heel to ear test to be considered in the chest area?
superior to the diaphragm
When conducting the heel to ear test, how are the results affected by GA?
demonstrates increasing resistance to this maneuver with advancing GA
What is the examiner assessing for as it r/t newborn skin?
texture, color and opacity: gelatinous, adherent quality progressing to smoother texture, appearance then loss of vernix, peeling over abd & lower back, cracking at ankles and wrists, progressing to parchment to leathery character of the post term infant
When does lanugo production begin?
toward the end of the 12th week, appearance at 24-25th week; devoid in extreme prematurity
When does lanugo peak in abundance?
28-30 weeks and then declines with advancing maturity, virtual absence by term, post term
Where is lanugo most abundant?
over the back (particularly between the scapulae), also the face, legs, and arms
Where does thinning of lanugo begin?
on the back
What population of infants have more lanugo later in GA?
IDM
How do major foot creases progress?
1) anterior wrinkle
2) deep anterior crease
3) multiple creases anterior to heel
4) creases on sole, including heel
5) measurement of heel to toe distance in extreme prematurity
What is the general mode of foot crease progression?
from ball to heel of foot, related to foot flexion
How should the heel to toe measurement be conducted in extremely preterm infants?
from the tip of the great toe to the back of the heel
What influences breast tissue and fat deposition in utero?
maternal estrogens and fetal nutrition
How should breast tissue be evaluated in the newborn?
1) appearance of areolar rim
2) stippling and raising of areola
3) palpable, measurable nodule beneath skin
How are ears evaluated for an indication of prematurity?
- note outer curvature of pinnae
- palpate thickness of cartilage
- fold toward face and release
What is assessed for in the examination of male genitalia as an indicator of prematurity?
1) presence of testes
2) degree of descent of the testes into the scrotum
3) development of rugaw
When does testicular descent begin?
left testicle then right in the upper canals at about 30th week; undescended in extreme prematurity
Where should the testes be palpated by the 32nd week?
both palpable in the upper scrotum (above the line of rugae)
Where should the testes be palpated by the 34th week?
below the line of rugation
How does the process of rugation occur?
scrotal rugation develops with testicular descent (caused by the same hormone)
How should the descent of testes be scored?
score by the one that has descended
What is unilateral cryptotorphism?
L up, right descended
How should the tested be palpated?
look, then feel; finger off scrotum!
What is assessed for in the examination of female genitalia as an indicator of prematurity?
1) prominence of clitoris
2) development of labia majora
3) development of labia minora
How should the examination of female genitalia be conducted?
abduct hips to 45˙
How should female genitalia be scored?
- prominent clitoris is extreme prematurity
- labia minora enlarging as clitoris recedes
- labia majora develop fatty tissue and cover over labia minora and clitoris
