NEWBORN ASSESSMENT

MIHAI CRAIU MD PhD

INITIAL EVALUATION
Physical assessment in neonates serves to describe anatomic NORMALITY. The improved techniques for fetal diagnosis help in predicting major malformations, but the neonatal examination carries a primary purpose of identifying more subtle anomalies.

Neonatal examination
First examination immediately at birth Recurrent evaluations at 5 minutes interval The evaluation tool is Apgar score

APGAR SCORE 1
The mnemonic was introduced in 1963 by the pediatrician Dr. Joseph Butterfield. Same acronym is used in German (Atmung, Puls, Grundtonus, Aussehen, Reflexe), Spanish (Apariencia, Pulso, Gesticulacin, Actividad, Respiracin) French (Apparence, Pouls, Grimace, Activit et Respiration) although the letters have different meanings.

APGAR SCORE*
Score of 0 Score of 1 Score of 2 Component of acronym
Appearance

Skin color

blue all over

blue at extremities body pink (acrocyanosis)

no cyanosis body and extremities pink >100

Pulse rate
Reflex irritability Muscle tone Breathing

absent

<100

Pulse Grimace

no response to stimulation

grimace/feeble cry when stimulated

sneeze/cough/pulls away when stimulated active movement

none

some flexion

Activity

absent

weak or irregular

strong

Respiration

* Apgar Virginia. A proposal for a new method of evaluation of the newborn infant. Curr. Res. Anesth. Analg.

1953. 32 (4): 260267

APGAR SCORE

APGAR SCORE 2
The test is generally done at one and five minutes after birth, and may be repeated later if the score is and remains low. Scores 3 and below are generally regarded as critically low, 4 to 6 fairly low, and 7 to 10 generally normal.

APGAR SCORE 3
A low score on the one-minute test may show that the neonate requires medical attention, but is not necessarily an indication that there will be long-term problems, particularly if there is an improvement by the stage of the fiveminute test.

APGAR SCORE 4
Apgar score remains below 3 at later times such as 10, 15, or 30 minutes, there is a risk that the child will suffer longer-term neurological damage. There is also a small but significant increase of the risk of cerebral palsy.

APGAR SCORE 5
The purpose of the Apgar test is to determine quickly whether a newborn needs immediate medical care It was not designed to make long-term predictions on a child's health.

APGAR SCORE 6
Apgar score is no longer used to decide if a neonate requires resuscitation. That decision is based on emergency assessment of airway, breathing, and circulation ("ABC").

APGAR SCORE 7
The test has also been reformulated with a different mnemonic, How Ready Is This Child - HRITC The criteria are essentially the same:
Heart rate, Respiratory effort, Irritabililty, Tone, Color.

COMPLETE EXAMINATION
Is complete after the 24 h after birth If any part of an assessment is abnormal at that time, discharge will de delayed > 48 h Reevaluation should focus on :
Eyes Cardiovascular system Hepatobiliary system

FIRST SECOND

10 SECONDS

100 SECONDS

1000 SECONDS

IN THE DELIVERY ROOM

Delivery room resuscitation should be available in all maternities, regardless of level and staff size and knowledge.

 Ensure that all medical and nursing staff are familial with neonatal resuscitation. Ensure that a roster of trained staff immediately available for resuscitation is posted in a visible space of the ER Ensure that delivery room staff are able to mobilize timely qualified people for any anticipated problem. Ensure that the resuscitation equipment is available and working.

RESPONSABILITIES OF THE NEONATAL MEDICAL TEAM

IN THE DELIVERY ROOM

Transitional pathophysiology 1 Acute severe peripartum hypoxia results in primary apnoea (in-utero) This is compensated by Redistribution of blood flow occurs
Fetal bradycardia Rise in fetal BP

Increase in blood flow in brain & heart Decrease in skin & kidneys

IN THE DELIVERY ROOM

Transitional pathophysiology More severe and prolonged hypoxia results in secondary apnoea (in-utero) This is difficult to differentiate primary and secondary apnoea. It has practical consequences
Secondary apnoea does not respond to stimulat. Primary apnoea responds to tactile stimulation

IN THE DELIVERY ROOM

Anticipation It is possible to anticipate many babies that may require resuscitation 20% of children in poor condition at birth can not be predicted This is why all attending staff in delivery room should master basic resuscitation procedures.

IN THE DELIVERY ROOM

Min 0 Min 0 1 Min 2 3 Min 3 4 General care (Thermal care) - Airway and breathing - Circulation - Consider

Fluid Inotrope infusion Sodium bicarbonate