Newborn Assessment Flashcards
Neonatal History: from mom and dad
Genetic History: from mom and dad
PMHx. from mom and dad
- chronic conditions
- vaccination status
- medications
- child abuse risk
- occupational hazards?
Obstetric History
- age, gravidity, bllod type, screening tests BPPs
- pregnancy induce HTN, GDM, bleeding, UTI, pre-term labor?
- previous pregnancy and complications?
High Risk Infants
what maternal/obstertic/natal hisotyr would indicate high risk infant
preterm baby
premature rupture of membrane
choriamnionitis (infection)
SGA, IUGR, LGA
TORCH infections (viral ones in pregnancy)
low APGAR score
meconium: stooling in uterus
abruption
IVF
multiple gestations
how is age calculated in the newborn
terminlogy for the baby at different ages
neonate
preterm
later preterm
early term
term
late term
post-term
Age
- determines as actual age-time since birht (3 weeks, etc.) since birth
- corrected gestational age = age based on gestation
- so if your baby was born premature: at 28 weeks: and is 4 weeks out of womb = baby is 32 weeks (not a 4 week old)
Neonate
- first 28 days of life
Preterm
- baby born < 34 weeks
Late preterm
- baby born 34-36 weeks + 6 days
early term
- baby born 37-38 weeks 6 days
Term
- 39 weeks - 40 weeks 6days ( called 40 + 6 weeks)
Late Term
- 41- 41+ 6 weeks
Post Term
- 42+ weeks
Gestational Weight
normal
low
very low
extremely low
Appropriate for gestational age (AGA) : birth weight betwee the 10th-90th percentile
Normal = 2500-4000 g
LBW = < 2500 g
VLBW = < 1500 g
ELBW = < 1000 g
Intrauterine Growth Restriction (IUGR)
what is it
how will they look
IUGR
- restricted growth in utero
can be due to
- drinking, smoking
- twin-twin transfustion
- torch infections
baby will appear as
- malnourished
- small head circum.
- dry and loose skin
- small abd.
- thin umbilical cord
SGA: small for Gestational Age
SGA
- born at term with no complications just physically small for gestational age
- they will follow normal growth curve
- defined as any weight below the 10th percentile
these babies will stay small: follow a normal curve but stay small
Breifly Define Fetal Circulation
Fetal Circulation
placenta through umbilical vein:oxygen rich blood to the liver through the ductus venosus
from liver through IVC to the right side of the heart
from here; two pathways arise: through the patent foramen ovale (PFO) which connects the RA and LA together
this allows oxygenated blood to get to the LA and out the aorta to the brain and other organs wihtin the fetus
once the blood returns from the body it enters the RA again, and this time the blood is sent to the RV and then to the pulmonary artery
instead of going into the lungs; the deoxy. blood goes through the dutuc arterious down to the lower limbs
then it exists via the umbilical arteries (through umbilicus back to placenta
at first breathe: these opening being to shut, the PFO, ductus venousus and dusctus arteriosus
- PFO closes
- ductucus venosus = becomes medial umbilical lig.
- ductus arteriosus = become ligamentum arteriosus which is behind the aorta
What happen immediately after birth in terms of pulmonary involvement: First Breath
lung expansion and increased blood flow: icnreases the spO2
Rise in O2 and fall in Co2: results in vasodilation
PVR drop: results in an increase in pulmonary blood flow
APGAR Scoring at Birth
What does it include
when is it done
APGAR
- activity
- pulse
- grimace
- appearance (skin color)
- respirations
done at 1 minute and 5 minutes
Activity (muscle tone)
- absent, flexed or active movement(normal)
Pulse (felt at umbilicus)
- absent, below 100, over 100(normal)
Grimace (reflex irratibility)
- flaccid, some flexion, active motion/sneeze,cough,etc. (norm.)
Appearance (skin color): cyanosis in hands and feet is norm
- blue/pale, body pink, extremities blue, all pink
Respirations
- absent, slow/irregular, vigourous cry (normal) want a spontaneous cry, can flick feet, etc. to initiate
severely depressed: 0-3
moderate: 4-6
good condition: 7-10
Transition to Extra-uterine life: what would be the main reason for lack of breathing
PPV v CPAP for labored breathing/apnea
think pulmonary issues with neonates: first!!!
A : airway
B: breathing
C: Circulation
T: thermoregulation: warm them up in a swaddle: large surface area is wet
D: decreased pulmonary vascualr resistance: takes a second to get that spontantous circualtion
Protocol
- NRP: neonatal resusitation program
- first minute: establish HR > 100 and unlabored breathing > 60% pO2
Algorithm for neonatal assessment of respiration
- apna, gasping, HR < 100 = PPV (positive pressure vent)
- labored breathing or cyanosis = CPAP
if HR < 100 = consider ETT or laryngeal mask (intubation)
dont want baby at 100% oxygen; risk of increase VEGF and decreased vision
keep baby at like 60-65% in first minute, then at 10mins. 85-95%
Ballard Testing: Determinig Maturity of the baby (if you dont know age or gestational age of mom)
Ballard Testing
- Neruomuscular and physical testing to determine baby age
- > 26 weeks: before 96 hours of life
- < 26 weeks: before 12 hours of life
Surival of infants depending on when born
in general, after 23 weeks, every week of gestation increases survival odds by 10%
- at 23 weeks = 50% survival rate
What are some disease states that can worsen overall outcome of infant survival
what to do
when should we aim to have them “caught up”
Infection
- CLD: chornic lung disease
- IVH: interventricualr hemorrhage
- PDA: patent ductus arteriosus
- ROP: retionpathy of pre-mature
- NEC: necrotizing enterocolitis
what to do
- send to devleopment peds
- difficult to predict outcomes for these babies
- goal: catch up to “normal” by age 2
Vital Signs of the Newborn
apnea v periodic breathing
BP
- ensure calm infant & every newborn should have BP measures in all 4 extremities
- get MAP
Temp: under axilla
- (only rectal to confirm an abnormal axillary)
HR: will be faster than ours; 95-160
Respirations: will be faster
- apena: pauses > 20 seconds OR pauses causing cyanosis/bradycardia ABNORMAL
- Perioidic breathing: short pauses in breathing (5-10 seonds) = common in newborns and premies, normal
Pulse OX
- via beams of light which detect color and percentage of oxygen
Physical Exam of the Newborn
- general tips
- cardiac and lung specifics
General
- well lit room
- undressed baby to see all skin and areas
- listen to heart and lungs in the beginning of the exam: when baby is the most quiet
- go from head to feet
Lungs
- stethescope to listen for our normal lung sounds
- rales,wheezes,rhonci,stridor
Heart
- note rate, rhythm, PMI, quality of sound
- note for murmurs: PDA murmur!!
- PDA murmur: continuous washing machine murmur; can be normal in first few days of life
then compare pulses bilaterally uppr and lower = grade them (1+ or 2+)
- femoral pulses can be weak in the first few days but; if weak after this: consider coartation of aorta
Physical Exam of the Newborn
- Derm
- Eyes
- Ears
Dermatologic
- jaundice
- Cutus marmorta baby goosepumps: looks like mottled skin
- Mongolian blue spots
- Milia : white pustules which resolve
- Erythema Toxicum: looks like herpes but not a concern
Skull
- assess Fotanelles: open, large, small, bulging
- large = hypothyroid or OI
- small = IUGR
- assess shape: plagiocephaly or oxycephaly (premature closing)
Eyes
- red reflex
- naso-lacrimal duct obstruction: yellow crusty
- subconj. hemorrhage
Ears
- eat pitts and tags
- note position of ears in relation to eyes
Physical Exam of the Newborn
mouth
clavicles
Mouth
- cleft palate
- cleft lip
- anklyglossia: tongue tied
- Epstein pearls: bengin white/yellow pearls on the tongue
- Neonatal teeth
- nasal deformities
Clavicles
- creptius, pain, lack of arm movement or hard pump = fracture
- birth trauma
Physical Exam of the Newborn
Abd. exam
Abdomen
- listen first: bowel sounds
- palpation: masses, liver, hepatosplenomegaly
- observation: firmness and distention
Abnormal Findings
- pectus excavatum
- prune belly (urinary issues)
- distended abd.
- scaphoid abdomen: congenital diaphargm (abd. contents in the thoracic cavity)
GU Exam
- assess umbilical exam: 2 arteries 1 vein
- palpate femoral arteries
- male: testes decended, hypospadius, edema
- female: discharge, edema
- ambiguous
hypospadius = ureathra opening posterior penis
epispadius= urethra opening anterior penis
Hip Dysplasia
Risk Factors
Ortolani and Barlow Testing
Hip Dysplasia
- a physiologic laxity of the hip: due to immature acetabulum
- discovered in the first few weeks of life
Risk Factors
- Breech position (feet first)
- family hisotry
- female
Prevention
- exam hip dysplagia until 2 years: first 2 weeks are most important
Barlow
- graps thigh, adduct and posterior pressure
- if clunk = + test with suxlux. of hip
Ortolani
- start adducted and abduct pushing anteriorly
- if clunk again = + test
- means dislocated hip is reducable
Treatment
- Pavlik Harness: abduction splint
- if Pavlik Harness fails: can do closed or open reduction
- if older than 6 months at dx. = surgery
