Week 5 - C - Healthy Term Infant/Normal Newborn Care - APGAR, Vaccination, Guthrie Test, Neonatal Examination

Question 1

When is a baby said to be term?

Answer 1

A baby is said to be term from 37+0 weeks until 40+6weeks of gestation This is the NHS guidelines on what a term pregnancy is, if any other of the flashcards state differently, then this is the correct one

Question 2

What is the normal weight for a newborn baby? (in both kilograms and in pounds/ounces) WHat is foetal macrosomia?

Answer 2

Normal weight - 2.5kg (5 pounds 8 ounces) to 4kg (8 pounds 13 ounces) Greater than 4kg is foetal macrsomia Less than 2.5kg weight is a low birth weight .A baby diagnosed with fetal macrosomia has a birth weight of more than 8 pounds, 13 ounces (4,000 grams), regardless of his or her gestational age.

Question 3

What is large and small for gestational age?

Answer 3

Large for gestational age - when the baby weighs greater than the 90th centile for their gestational age Small for gestational age - when the baby weighs less than the 10th centile for their gestational age

Question 4

What is the approximate fat gain per day in the last 4 weeks of pregnancy leading to the baby being term?

What are the two different types of fat that accumulate in the baby?

Answer 4

Approximately 7grams of fat are gained per day in the 4 weeks leading up to a term pregnancy

• White fat - this mainly has calories for the baby
• Brown fat - accumulates between scapulae and internal organs - mitcohondria packed and burns energy to produce heat for the neonate

Pre-term has a lot less fat

Question 5

In the labour environment, the uterine contractions cause the baby to become slightly hypoxic with each contraction How does the foetus attempt to overcome this?

Answer 5

Foetal haemoglobin releases oxygen much more readily than adult and therefore this is used to try and combat the hypoxia with each uterine contraction

Question 6

When the foetus is born there are some perinatal adaptions in the foetus What do these include?

Answer 6

Due to the first breath/cry, there is alveolar expansion in the lungs with a decreased pulmonary vascular resistance to allow more blood to go to the lungs The decrease in the resistance causes the pressure in the right atrium to become less than that of the left atrium and therefore the foreman ovale closes Circulating prostoglandins decrease and ductus arteriosus closes also There is an increased partial pressure of oxygen in the blood after birth also

Question 7

What is the scoring system used as an objective measure of perinatal adaption at birth?

Answer 7

This is the APGAR scoring system

Question 8

What does APGAR stand for and how is it correctly scored? ie what does each letter in Apgar stand for (colour, heartbeat, reflex irritability, muscle tone, respiratory effort)

Answer 8

The total score is out of 10 with 0,1 or 2 given for each of the 5 componenents

• A - appearance (colour)
• P - pulse (heartbeat)
• G - grimace (reflex irritability)
• A - activity (muscle tone)
• R - respiration (respiratory effort)

Question 9

What is a normal apgar score in a newborn baby?

Answer 9

A normal apgar score is a score of >/= 8

Question 10

Describe 0,1 and 2 scoring for all the different regions of the Apgar scoring system Appearance (colour) Pulse (heartrate) Grimace (reflex irritability) Activity (muscle tone) Respiration (respiratory effort) What is acrocyanosis?

Answer 10

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Question 11

When is the apgar score carried out? Score of 0 means the thing you are assessing is absent score of 1 means it is kind of present State the max score of 2 for each section?

Answer 11

The apgar score is carried out at one minute, 5 minutes and 10 minutes after birth Appearance - no blue discolouration - baby is pink all over Pulse - pulse greater than 100bpm Grimace - baby has a strong cry/coughs well when stimulated Activty - full muscle action/flexion Respiration - strong cry, good breathing

Question 12

What is the apgar score usually in infants who are non-responsive, limp and pale and in need of immediate life saving efforts?

Answer 12

The apgar score in these infants is usually 0-3

Question 13

What is advised to keep the baby warm? When is feeding advised to start? What is the milk that the baby feeds on known as in the first 3/4 days?

Answer 13

Skin to skin contact is important to ensure the baby does not become hypothermic It is also advised to attempt feeding straight away with the baby - normal term infant will be able to use its own glucose and ketones for fuel as blood sugar The colostrum - rich in antiboides and proteins for the baby

Question 14

What is the difference between foremilk and hindmilk? This is the normal breastmilk that the mother produces after a few days post-natal

Answer 14

Foremilk - high in sugar, water and proteins Hindmilk - high in fat and calories - important for the baby to fully drain milk from one breast before moving on to the other in order to access the full range of milk

Question 15

Attahcment is crucial for the babies emotional development and therefore should be given skin to skin contact with the mother instantly What are the reasons for babies being relatively vitamin K deficient? What are the vast majorites of babies given at birth to combat this?

Answer 15

Reasons for baby being relatively vitamin K deficient - vitK crosses the placenta poorly, levels of vitK in the breast milk are poor and the gut flora has not been fully produced yet - intestinal flora usually produces vitamin K Therefore vast majority of babies are given 1mg vitK IM at birth

Question 16

What are the vaccinations given to the mother during pregnancy?

Answer 16

Maternal pertussis vaccine and the influenza vaccine (whooping cough and flu vaccine)

Question 17

What is the vaccination schedule for children? (4, 2, 3, 4, 2) Which vaccine is given to girls at age 12-13 years?

Answer 17

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Question 18

What is the newborn screening test carried out at 5 days known as? What is the mnemonic i have to remember the tests?

Answer 18

This is Guthrie’s test Sometimes Chris Cares Poorly, Meanwhile Mhairi Is Greatly Happy

Question 19

State what are the 9 things tested for in Guthrie’s test?

Answer 19

• Sickle cell disease - autosomal recessive
• Cystic Fibrosis - autosomal recessive
• Congenital hypothyroidism
• Phenylketonuria (PKU)
• Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
• Maple syrup urine disease (MSUD)
• Isovaleric acidaemia (IVA)
• Glutaric aciduria type 1 (GA1)
• Homocystinuria (pyridoxine unresponsive) (HCU)

Question 20

Top to toe examination is carried out by midwifery staff immediately following delivery Formal neonatal examination is a required part of health care When does the top to toe examination of the newborn generally take place?\

Answer 20

Generally takes place within 72 hours of birth of the newborn but usually by 24 hours

Question 21

The neonatal examination is a systematic head to toe examination What are 4 main important parts in the head to toe examination of the newborn?

Answer 21

Red reflex of the newborn - congenital cataracts Examine the mouth carefully Examine the femoral pulse - coarctation of the aorta Hip - looking for developmental dysplasia of the hip

Question 22

What is examined on the head of the head to examination?

Answer 22

Feel the fontanelles - anterior and posterior - identify whteher sunken or bulging Assess facial features -symmetry and eye positions The measure the occipital head circumference Check for any ventous/foreceps marks

Question 23

When looking at the head, the head can present with different bulges if there is a build up of blood in different layers of the What are the layers of the scalp before discussing which layers two common swelling arise between? Which layer of the scalp is very vascular?

Answer 23

Skin Connective tissue Aponeurosis - epicranial aponeurosis Loose areolar connective tissue Periosteum The connective tissue layer of the scalp is very vascualr

Question 24

What does the epicranial apnoeruosis exist between?

Answer 24

The epicranial aponeurosis is the aponoeurosis between the fronatalis and the occipitalis

Question 25

What is another name for the epicranial aponeurosis? What is the pooling of blood between the skull and perisoteum known as? What is the oedamtous swelling between the skin and aponeurosis known as? often caused by pressure against the cervix and lower segment during labour

Answer 25

Epicranial aponeurosis - galeal aponeurosis

Pooling of blood between the skull and periosteum is known as a cephalohaematoma

Oedematous swelling between skin and the aponeuroiss of the scalp is known as caput succedaneum - pressure against the cervix

Question 26

How is it possible to tell whether it is a cephalohaematoma or a caput succadeneum? The caput succadaneum can also be cause caused by pressure due to forceps or ventouse delivery

Answer 26

Caput succadenaeum is superficial to the cranial perisoteum and therefore is not limited and can spread around the scalp The cephalohaematoma is limited to the bone over which the haemtoma arises due to the perisoteum

Question 27

How long does caput succadenaeum generally take to disappear? What can cephalohaemtoma cause?

Answer 27

Caput succadeneum usually resolves within a few days after birth Cephalohaematoma can cause jaundice due to the large pool of blood and may take weeks to spontaneously resolve - cephalohaematoma is more serious than caput succadenaeum

Question 28

What do the pictures on the left show? What do the pictures on the right show?

Answer 28

Pictures on the left show cephalohaematoma - the swelling does not spread Pictures on the right show caput succedaneum - the swelling of the scalp is not limited and can extend

Question 29

After examining the head and assessing facial symmetry, the eyes and ears are assessed What is looked for in both? What is a coloboma?

Answer 29

Eyes - assess for symmetry of eyes Assess for red reflex

Coloboma - when there is a hole in the eye ie iris or uvea or rarely choroid

Ears - note size and shape of ears, normal or low set,

Any evidence of tags or pits front or back of ears

Question 30

Describe the abnormality seen in each ear?

Answer 30

Top left - can see a pre-auricular pit Middle - could be Treacher-Collins syndrome Bottom - can see a pre-auricular tag

Question 31

Low set ears can be normal or due to a variety of conditions Name at least 3?

Answer 31

Can be due to Down’s syndrome Turner syndrome - 46X Edwards syndrome - trisomy 18

Question 32

What is choanal atresia? How is the suckling reflex of the baby examined in the newborn examination?

Answer 32

Choanal atresia is when the back of nasal cavity is blocked causing a failure to communicate with the nasopharynx The suckling reflex is assessed by putting a finger in the babies mouth - feel along the length of the palate whilst doing this

Question 33

It is very important to assess the mouth during the neonatal examination How is it examined?

Answer 33

Use a wooden spatula to gently open the mouth The shine light in the mouth to examine for any evidence of a hard or soft cleft or choanal atresia

Question 34

WHat is the syndrome associated with patients who have coloboa, heart defects, atresia of the choana?? What are the other aspects of this syndrome?

Answer 34

CHARGE syndrome

• Coloboma
• Heart defects
• Atresia of the choana
• Retardation of growth and/or development
• Genital and/or urinary abnormalities – boys with CHARGE syndrome commonly have a small penis and/or undescended testicles. The inner lips of the vagina in girls with CHARGE syndrome may be very small.
• Ear abnormalities and deafness

Question 35

Where does the mutation occur in charge syndrome?

Answer 35

CHD7 gene - protein that makes chromatin

Question 36

What are the facial characteristics of foetal alcohol syndrome?

Answer 36

Wide and smooth philtrum Flat midface Prominent epicanthal folds Upturned nose

Question 37

Important to also assess the babies hands for any single palmar crease What is carried out when looking at respiratoy pattern?

Answer 37

Watch the respiratory pattern, rate and depth for a few seconds Look for evidence of intercostal recession, nasal flaring and grunting Listen for stridor which could indicate airway obstruction Crackles may indicate underlying infection Auscultate both lung fields for added sounds

Question 38

What 5 heart areas are auscultated and which pulses are assessed when examining the heart?

Answer 38

Aortic Pulmonary Tricuspid Mitral And midscapular Also radial, brachial and femoral pulses

Question 39

Where are the 5 heart areas auscultated? Why is the femoral pulse assessed? Why is the midscapular area assessed?

Answer 39

Aortic area - second intercostal space - right sternal border Pulmonary area - second intercostal space - left sternal border Tricuspid - lower left sternal border 4th intercostal space Mitral area - 5th intercostal space midclavicular line left side Midscapular area - posteriorly assessed Midscapular area and femoral pulse assessed for coarctation of the aorta

Question 40

Head, face, eyes and ears, lungs, heart and hands have all been examined Now move on to the abdomen What is examined for on the abdomen?

Answer 40

Check the babies umbilicus Carry out a superficial and deep palpation - looking for evidence of hepatomegaly and splenomegaly and ballot for kidneys Also assess for passage of meconium and look to make sure an anus is present

Question 41

What is looked for in the gentalia of a male child?

Answer 41

Normal genitalia Descended testicles and No evidence of hypospadius - want urethra to be at ip of foetus

Question 42

After examining the abdomen look at legs , count toes and observe spacing between toes What is a sign of downs syndrome here? What should be checked for in the feet? amniocentesis before 15 weeks can cause this

Answer 42

Sign of downs syndrome - wide spaced 1st metatarsal space Also check for talipes equinovarus (club foot in the feet)

Question 43

After checking the legs it is time to check the hips What is checked for in the hips?

Answer 43

Assess leg length before going on to examine each hip for developmental dysplasia of the hip

Question 44

What procedures are used for examining for DDH? Where should your fingers be for this examination?

Answer 44

Use Ortalani and Barlow test

• Ortalani - hip already out so abduct leg and push anteriorly
• Barlow - done first - adduct leg and push posteriorly

Middle finger should feel the greater trochanter and be rested there throughout the procedure

Question 45

Finally after examining the hip, inspect the babies back What is assessed for here? WHat is used to treat DDH?

Answer 45

On the back look for any sacral dimples, sign of spina bifidia, palpate spine from neck to coccyx Now is a good time to listen to the midscapular area DDH treated with pavlik harness

Question 46

Check the babies primitive reflexes as the final part of the examination What are the primitive reflexes?

Answer 46

The primitive reflexes are Suckling reflex Rooting reflex Moro reflex ATNR reflex Stepping reflex Grasp reflex

Question 47

Examining the skin of the baby is also important Describe each picture

Answer 47

• Top left - erythema toxicum - perfectly benign
• Top right - strawberry neavus - should disappear
• Bottom left - mongolian spot - benign & common in Asians
• Bottom right - port wine stain - This stain is a birthmark caused by an overabundance of capillaries near the surface of the skin.

Question 48

What can the port wine stain seen on childrens faces be due to?

Answer 48

invoves the ophthalmic division with the trigeminal nerve– Sturge-Weber syndrome (SWS) is a neurological disordermarked by a distinctive port-wine stain on the forehead, scalp, or around the eye.