ASSESSMENT OF THE

NEWBORN

Aslina Mohamed yasin

Department of nursing,
Faculty of nursing, ukm.
FOUR PHASES OF ASSESSMENT:

1. Initial assessment
– Apgar scoring system
1. Transitional assessment
2. Gestational age
3. Physical examination
1. APGAR SCORING SYSTEM
WHAT IS APGAR SCORE?

 Standardized method of evaluating

newborn’s condition immediately
after delivery
 Itwas meant to identify only the
condition and need for neonatal
resuscitation measures
WHAT IS APGAR SCORE? (CONT..)

 Evaluating five factors:

1) Heart rate
osculate with a stethoscope

observing and counting the pulsations of the

cord at the abdomen (if the cord is still uncut)
2) Respiratory effort
cries spontaneously at about 30 seconds after
birth.
maintaining regular respirations by 1 minute
 WHAT IS APGAR SCORE? (CONT..)

3) Muscle tone
o mature newborns - hold the extremities tightly
flexed
o resist any effort to extend their extremities

4) Reflex irritability
response to suction or gentle stimulation on
the soles of the feet.
infant with heavily sedated mother will
probably demonstrate a low score in this
category
WHAT IS APGAR SCORE? (CONT..)

5) Skin color
Appear cyanotic at the moment of
birth
Pink with or shortly after the first
breath.
 WHAT IS APGAR SCORE? (CONT..)

 All the 5 factors are rated 0, 1 or 2; all

five scores are then added.
A score of 8 to 10
requires no action other than continued
observation and support of the infant’s
adaptation.
WHAT IS APGAR SCORE? (CONT..)

A score from 4 to 7
needs gentle stimulation such as
rubbing the back.
may need clearing of the airway and
supplementary oxygen
possibility of respiratory depression
should also be considered
Scores of 3 or lower
needs active resuscitation
APGAR SCORING SYSTEM

SIGN 0 1 2
Heart rate Absent Below 100b/min 100b/min or
higher
Resp No spont. resp Slow/ weak cry Spontaneous/
strong cry
Muscle tone Limp Min. flexion Active/ flexed
body posture
Reflex irritability No response Grimace Strong cry/ active

Color Cyanosed or pale Acrocynosis Completely pink

** The score is obtained at 1 and 5 minutes after birth. May

extend up to 10 and 20 minutes after birth.
 2. TRANSITIONAL ASSESSMENT: PERIODS OF REACTIVITY
 1st period of reactivity (6 – 8 hrs after birth)
 1st initial stage - first 30 minutes
 alert, cries vigorously
 appears interested in the environment
 Open eyes
 Opportune time to begin breast feeding
 Resp. rate can reach 80breath/min, heart rate can reach 180beats/min
 Bowel sounds active
 Mucus secretions – increased
 Temperature – slightly decrease

 2nd stage
 Deep sleep & calm
 Stimulation – elicits a minimal response
 Heart & resp. rates - decreased
 Temp. – decreased (avoid undressing & bathing)
 Mucus production - decreased
 Urine & stool - nil
2. TRANSITIONAL ASSESSMENT: PERIODS OF REACTIVITY (CONT…)

 2nd period of reactivity

Wakes from deep sleep

Alert & responsive

Heart & resp. rates increase

Gag reflex active

Gastric & resp. secretions increase

Passage of meconium usually

occurs
3. GESTATIONAL AGE

Purpose
1. Neonatal classification
 term vs preterm
 birth weight – growth chart
2. Mortality risk
3. Potential morbidity
3. GESTATIONAL AGE (CONT..)

Obstetric method
 LMP

 Pregnancy test

 Ultrasonographic

 Fetal heart tones – first detected 17 – 20 weeks’

gestation
 Amniotic fluid study
3. GESTATIONAL AGE (CONT..)

Ballard score

 A simplified scoring system

 Six neurologic & six physical criteria

 Highest reliability – performed within 48 hrs

 Accurate within 2 weeks of gestation

FORM - BALLARD SCORE
 3. GESTATIONAL AGE (CONT..)

Ballard score (cont..)

1. Assessment of neurologic signs

i) Posture
- Evaluated for increasing flexor & hip adduction with
increasing gestational age
- Hypotonic – early gestation
- Slight flexion of feet & knees – 30/52
- Thighs & hips flexed, arm remain extended – 34/52
- Thighs, hips, & arm begin to flexed – 35/52
- Total flexion – 36 – 38/52
3. GESTATIONAL AGE (CONT..)
i) Ballard score - assessment of neurologic signs - posture (cont..)
3. GESTATIONAL AGE (CONT..)

Ballard score - assessment of neurologic signs (cont..)

ii) Square window (wrist)
- Angle decreases with increasing gestational age
3. GESTATIONAL AGE (CONT..)

Ballard score - assessment of neurologic signs (cont..)

iii) Arm recoil

 After the arms are flexed for 5 seconds, the arms are fully
extended by pulling the hands downward & releasing them
 The degree of arm flexion & the strength of recoil are
scored
 Slow response – low score
 Vigorous & fully flexed – high score
3. GESTATIONAL AGE (CONT..)

iii) Ballard score - assessment of neurologic signs – arm recoil (cont..)

3. GESTATIONAL AGE (CONT..)

Ballard score - assessment of neurologic signs (cont..)

iv) Popliteal angle

 Measuring the angle between lower leg &
thigh – posterior to the knee
 Angle decreases – gestational age
increase
 3. GESTATIONAL AGE (CONT..)

iv) Ballard score - assessment of neurologic signs – popliteal angle (cont..)

3. GESTATIONAL AGE (CONT..)

Ballard score - assessment of neurologic signs (cont..)

v.Scarf sign
 The arm is pulled across the chest & around the
neck
 The score is determined by the position of the
elbow to the midline of the body
 Resistant – increased gestational age
 3. GESTATIONAL AGE (CONT..)
v) Ballard score - assessment of neurologic signs – scarf sign (cont..)
3. GESTATIONAL AGE (CONT..)

Ballard score (cont..)

1.Assessment of neurologic signs (cont..)

vi) Heel to ear

 With the hips kept flat on the bed, the foot is drawn toward
the head
 Measure distance between foot & head, and the degree of
knee extension
 Resistance – increased gestational age
 3. GESTATIONAL AGE (CONT..)
Ballard score (cont..)
vi) Assessment of neurologic signs – heel to ear (cont..)
BALLARD SCORE - ASSESSMENT OF PHYSICAL SIGNS
3. GESTATIONAL AGE (CONT..)

Ballard score (cont..)

2. Assessment of physical signs

i) Skin
- Less transparent – increased gestational age
- Lost its transparency & underlying vessels no longer
visible – 36-37/52
- Subcutaneous tissue decreased, causing wrinkling &
desquamation – beyond 38/52
3. GESTATIONAL AGE (CONT..)

i) Ballard score – assessment of physical signs – skin (cont..)

3. GESTATIONAL AGE (CONT..)
Ballard score - Assessment of physical signs (cont..)
ii) Lanugo
 fine, downy hair covers from 20 – 28/52

 Begins to disappear – 28/52

 Few patches over shoulder - term

3. GESTATIONAL AGE (CONT..)
Ballard score - Assessment of physical signs (cont..)
iii) Plantar creases
 First appear on the anterior portion of the foot – 28-30/52, extend
toward the heel as gestation progresses
 IUGR – may have more plantar creases than expected
 Not a valid indicator after 12 hrs – skin begins to dry
3. GESTATIONAL AGE (CONT…)
Ballard score - assessment of physical signs (cont..)

iv) Breast development

- Examine – nipple size & amt. of breast tissue

- A 1-2mm nodule of breast tissue is palpable – 36/52

- Grows approximately 10mm – 40/52

 3. GESTATIONAL AGE (CONT..)

Ballard score - assessment of physical signs (cont..)

v. Eyes & ears
- Evaluated for fusion of the eyelids
- Fused eyelids open – 26 -30/52
- Ears – formation & amt. of cartilage in the pinna
- Inward curving of upper pinna – 34/52, extend to
lobe by 40/52
- <34/52 – pinna has little cartilage & stay folded
- 36/52 – some cartilage, pinna will spring back from
being folded
3. GESTATIONAL AGE (CONT…)

Ballard score - assessment of physical signs (cont..)

v) Eyes & ears (cont…)
GESTATIONAL AGE (CONT..)

Ballard score - assessment of physical signs (cont..)

v) Eyes & ears (cont…)
3. GESTATIONAL AGE (CONT..)

Ballard score - assessment of physical signs (cont..)

vi) Genitalia- female
 Evaluate - development of labia minora & majora and prominance of
clitoris
 Early gestation – prominent clitoris, small & widely separated labia
 40/52 – completely covered
3. GESTATIONAL AGE (CONT..)

Ballard score - assessment of physical signs (cont..)

vi) Genitalia- male
- Evaluate for presence of testes, degree of descent into the scrotum &
development of rugae
- 28/52 – testes begin to descend from abdomen
- 37/52 – testes can be palpated in scrotum
4. PHYSICAL EXAMINATION

1. General condition
 Purpose
 To rule out:
 Obvious congenital anomalies
 Birth injuries

 Cardiorespiratory distress

 Within 24hrs of birth

 Most cooperative 1-2hrs after feeding – alert or
sleepy state
 Head to toe - in sequence
4. PHYSICAL EXAMINATION (CONT…)

1. General condition (cont..)

Assess for:
i) Size, contour & general well-being
ii) Posture
 Healthy term – flexion of extremities
 Breech – extension of legs & head
iii) Activity
 Flexion & extension alternate between arms & legs
 Hypotonia – decreased flexion (preterm or CNS)
 Asymmetric movements – arms, legs or face – birth
injury e.g. brachial plexus palsy, bone #, congenital
anomaly
4. PHYSICAL EXAMINATION (CONT…)

1. General condition (cont..)

Assess for (cont…)

iv) Skin
 Dry, peeling, rashes, pustules, petechiae,
pigmentation
 Skin lesions
v) State
 Robust & vigorous cry – term
 Sleep states – deep sleep, light sleep, quiet, active
4. PHYSICAL EXAMINATION (CONT..)

1. General condition (cont..)

Assess for (cont…)

vi) Respirations (use silverman-Andersan index)

 Rate, rhythm, effort
 Nasal flaring – decrease airway resistance
 Expiratory grunting – increase intratoracic pressure to prevent
volume loss during expiration as a result of alveolar collapse
 Wheeze – high-pitched ronchi on exp.- louder than inspiration
due to restricted airway
 Stridor – partially obstructed airway
 Intercostal & substernal retractions – to maintain adequate
resp.
SILVERMAN-ANDERSEN INDEX – EVALUATING RESPIRATORY STATUS
 4. PHYSICAL EXAMINATION (CONT..)

1. General condition (cont..)

Assess for (cont…)

vii) Morphologic features

 Congenital defects
 Symmetry of body parts

 Propotional body parts

viii) Nutrition
 Well-nourishedappearance
 Thin & wasted – IUGR, postterm
4. PHYSICAL EXAMINATION (CONT..)

1. General condition (cont..)

Assess for (cont…)

ix) Color
 Mucous membrane
 central cyanosis – low O2
 Acrocyanosis – peripheral circulation, cold, shock
 Pallor – poor perfusion
 Pallor with bradycardia – anoxia, vasoconstriction in shock,
sepsis, RDS
 Pallor with tachycardia – anemia

 Plethora – red appearance – polycythemia

 Jaundice – apper first 24hrs - pathologic

4. PHYSICAL EXAMINATION (CONT…)
2. Auscultation & palpation
Assess for:
i) Heart
 Heart rate – count full 1 minute
 Normal – 110 – 160b/min, less 100b/min – brady, above
160b/min - tachy
 Rhythm & regularity
 Murmurs
 Shifted heart sounds – pneumothorax, diaphragmatic hernia
 Palpate pulses – note the rate, rhythm, volume, character
 Grading scale
 0 – not palpable - shock
 +1 – very difficult to palpate, weak & thready - shock
 +2 – difficult to palpate
 +3 – easy to palpate
 +4 – strong & bounding – PDA
 BP
4. PHYSICAL EXAMINATION (CONT..)

2. Auscultation & palpation (cont..)

Assess for (cont..):

ii) Chest & lungs

 Respirations – easy & unlabored
 Nose breather
 Round chest – anteroposterior diameter equal billaterally
 Breast & nipples – symmetry, size, number & discharge
 Respiratory rate & pattern
 Normal 40 – 60 breaths/min
 Air entry – audible bilaterally
4. PHYSICAL EXAMINATION (CONT..)

2. Auscultation & palpation (cont..)

Assess for (cont..):

iii) Abdomen & trunk

 Rounded, soft & symmetric
 Concave abdomen – dipghramatic hernia
 Prune-belly syndrome – no muscle in the abdominal wall

 Abdominal distension – obstruction, infection

 Observe for abdominal wall defect e.g. ompholocele,

gastrochisis, umbilical hernia
 Palpate for organs enlargement e.g. liver, spleen
 Umbilical cord – 2 arteries & 1 vein
4. PHYSICAL EXAMINATION (CONT..)

2. Auscultation & palpation (cont..)

Assess for (cont..):

iii) Abdomen & trunk (cont..)

 Anus
 patency

 1st
stool within 24hrs
 Rectovaginal or rectourethral fistula

 Back & spine

 flat,
straight vertebral column
 Observe for neural tube defect
4. PHYSICAL EXAMINATION (CONT..)

2. Auscultation & palpation (cont..)

Assess for (cont..):

iv) Genitalia
 Male
 Covered with foreskin
 Urinary meatus at center
 Scrotum size, rugae, testes
 Ambiguous

 Female
 Covered by labia majora
 Vaginal discharge – normal for first 48 hrs
 Echymosis & edema of labia – breech deliveries
 Patency of vaginal opening
 Ambiguous
4. PHYSICAL EXAMINATION (CONT..)
2. Auscultation & palpation (cont..)
Body part examination
i) Head
 Size, shape, symmetry & general appearance
 2-3cm larger than chest
 Microcephaly – delayed brain growth
 Macrocephaly – accumulation CSF
 Caput succedaneum, cephalhematoma
 Fontanelles
 Location, number & size
 Bulging, full or tense – increased ICP, birth injury
 Depressed – late sign of dehydration
 Anterior – diamond shape, 4-6cm, closes @ 18mths
 Posterior – triangular shape, closes @ 2mths
 Scalp
 Observe for lacerations or abrasions
 Hair whorls – result of brain growth
 Absence or number >2 – abnormal brain growth
4. PHYSICAL EXAMINATION (CONT..)
2. Auscultation & palpation (cont..)
Body part examination (cont..)

ii) Eyes
 Subconjunctival hemorrhage – pressure on fetal head
during delivery
 Pupil response to light & symmetry eye movement
 Tears – produced until 2mths age

iii) Ears
 Maturity, symmetry & size
 Observe for unusual shape or position
 Low-set ears – chromosomal abnormalities
 Malformed or malpositioned – chromosomal or
congenital abnormalities
4. PHYSICAL EXAMINATION (CONT..)

2. Auscultation & palpation (cont..)

Body part examination (cont..)

iv) Nose
 Shape & size
 Patency of nostrils

v) Mouth
 Symmetric & positioned in the midline
 Cleft lip or palate
 Mucous membrane mouth & tongue – pink
 Natal teeth
 Oral thrush – contact with vaginal moniliasis during delivery
 Assess for
 Root & gag reflex
 Suck & swallow
 Size of jaw – small – Pierre Robin syndrome
4. PHYSICAL EXAMINATION (CONT..)

2. Auscultation & palpation (cont..)

Body part examination (cont..)

vi) Face
 Symmetry & location of the eyes, nose & mouth
 Obs. for symmetry when crying – facial falsy
 Facial characteristics e.g. wide-spaced eyes, flat & broad
nasal bridge, mouth size – congenital abnormalities

vii) Neck
 Thyroid enlargement
 Webbing or redundant skin – turner or down syndrome
 Palpable mass, crepitus, tenderness, limited arm
movement - # clavicle
4. PHYSICAL EXAMINATION (CONT..)

2. Auscultation & palpation (cont..)

Body part examination (cont..)

viii) Extremities (including hands & feet)

 Length, contour & symmetry
 Shape & length of digits & fingernails
 Full range of motion in each extremities
 Palmar crease – simian or single – trisomy 21
 Congenital hip dysplasia
 Talipes

ix) Skin
 Soft, smooth & opaque
 Warm to touch
 Capillary refill – normal 2-3 seconds
 Benign lesions e.g. mongolian spots, erythema toxicum, milia
4. PHYSICAL EXAMINATION (CONT..)

3. Nervous system
i) Hx & gestational age
 Hx of family, genetic, birth trauma, prolonged labor,
maternal medication/drugs/alcohol
 Gest. Age – preterm - underdeveloped nervous syst.

ii) External examination

 Signs of birth trauma, symmetric movement, skin
integrity
 Posture, movement, cry & muscle tone

iii) Developmental reflexes

 Sucking, rooting, palmar grasp, tonic neck, moro,
stepping, babinski
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