Lecturer:

MARIA FE L. TABUJARA, RN.,MAN

1. APGAR SCORING –
newborn is assess at 1
min and at 5 min to
determine neurologic
deficit.
HEART RATE RESPIRATORY MUSCLE REFLEX COLOR
EFFORT TONE IRRITABILITY
 ▪ Heart Rate – auscultate the heart with
a stethoscope, or by observing and
counting the pulsations of the cord.
▪ Respiratory Effort – mature newborn
usually cries and aerates the lungs.
5 PARAMETERS > depressed respiratory effort may be
anticipated to newborn whose mother
received large amounts of analgesia
or general anesthetic.
▪ Muscle Tone – mature newborn hold their
extremities tightly flexed, simulating their
intrauterine position.
> tested by observing their resistance to any
effort to extend their extremities.
> poor if no flexion on arms and legs
▪ Reflex Irritability
2 cues to evaluate reflex irritability
> response to a suction catheter in the nostrils
> response to having of the soles of the feet
slapped.
A good response if with vigorous crying or
strong facial grimace
▪ Color – all infants appear cyanotic at birth.
> acrocyanosis is common in newborn that a
score of 1 on this category is normal.
▪ Perfect Score – 10
▪ A score of less than 4 – in serious danger of
respiratory or cardiovascular failure and needs
resuscitation.
▪ 4-6 – condition is guarded and need clearing of
the airway and oxygen supplementation
2. RespiratoryEvaluation:
SILVERMAN AND ANDERSEN
INDEX – used to estimate
degrees of respiratory distress in
NB
▪ Features observed ASSESSMENT OF
> Chest movement WELL BEING
> Intercostals retractions
> Xiphoid Retractions
> Nares dilatation
> Expiratory grunt
▪ Each item is given a value of 0, 1 or 2. the values
are then added.
▪ A total score of 0 indicates no respiratory
distress
▪ 4-6 moderate distress
▪ 7-10 severe distress
1. DUBOWITZ Maturity scale – revised by BALLARD,
now known as BALLARD GESTATIONAL AGE
CRITERIA
a. Physical Maturation (skin, lanugo, plantar creases,
breast, ear and genital)
b. Neuromuscular (posture, square window, arm recoil,
popliteal angle, scarf sign, heel to ear
▪ Resting Posture: relaxed posture (extension)
seen in the premature; flexion increases with
maturity.
▪ Square Window angle:
flex hand to underside
of forearm. Identify
angle at which you feel
resistance. Angle
decreases with
increasing gestational
age
▪ Arm Recoil: flex’s infant’s arms. Extend for 5
seconds, then release. Note angle formed as
arms recoil. Decreases with increasing
gestational age.
▪ Scarf sign: draw one arm
across chest until resistance is
felt: note relation of elbow to
midline of chest. Resistance
increases with advancing
gestational age
▪ Heel to Ear: attempt
to raise foot to ear,
noting point at which
foot slips from your
grasp. In premature
infant very little
resistance; full term
there will be marked
resistance.
 A score of 5 – 26
weeks gestational age

BALLARD 10 – 28 weeks
GESTATIONAL gestational age

40 – 40 weeks
gestational age