THE NEWBORN

Nelson Textbook of Pediatrics 21st Edition

January 18, 2021

I. HISTORY-TAKING
I. Perinatal History
II. Risk Assessment
A. Antepartum Risk Factors
1. Maternal DM
2. Pregnancy-induced HT
3. Chronic HT
4. Fetal anemia / isoimmunization
5. Previous fetal death
6. 2nd or 3rd trimester bleeding
7. Infection (maternal)
8. Cardiac, renal, pulmonary, thyroid, neurologic disease
9. Polyhydramnios
10. Oligohydramnios
11. Premature ruptured membrane
12. Fetal hydrops
13. Post-term gestation
14. Multiple gestation
15. Size-date discrepancy
16. Drug therapy (magnesium or adrenergic block)
17. Drug abuse
18. Fetal malformation / anomalies
19. Low fetal activity
20. No prenatal care
21. Age <16 or >35 year old
B. Intrapartum Risk Factors
1. Emergency CS
2. Forceps or vacuum-assisted delivery
3. Breech or abnormal presentation
4. Premature labor
5. Precipitous labor
6. Chorioamnionitis
7. Prolonged membrane rupture (>18 hours)
8. Prolonged labor (>24 hours)
9. Prolonged 2nd stage of labor (>2 hours)
10. Macrosomia
11. Fetal bradycardia
12. Non-reassuring fetal heart patterns
13. Use of general anesthesia
14. Uterine hyperstimulation
15. Narcotics given within 4 hours of delivery
 16. Meconium-stained amniotic fluid
17. Prolapsed cord
18. Abruptio placentae
19. Placenta previa
20. Significant intrapartum bleeding
III. Interval History
A. Breastfeeding
B. Stooling
C. Urination
D. Crying
E. Sleeping
IV. Review of Systems

II. IMMEDIATE CARE AFTER BIRTH

When: 1st hour of life
I. call out time of birth
 II. dry the baby thoroughly, remove wet cloth, and check breathing
III. quickly check:
A. breathing
1. regular and easy chest movement
2. crying
B. tone
1. flexion of extremities
2. extremities adducted to trunk
IV. skin-to-skin contact
V. cover baby’s back and head
VI. clamp and cut cord after pulsations stop (at least 30 seconds)
VII. allow uninterrupted skin-to-skin care & initiate breastfeeding (within 60 to 90 minutes)
VIII. perform:
A. weighing
B. complete Physical Examination
C. vitamin K
D. Hepatitis B vaccine
E. BCG vaccine
F. eye prophylaxis

III. PHYSICAL EXAMINATION

1st Physical Examination: during drying
I. Resuscitation Assessment – if satisfied, no need for resuscitation
 A. Term gestation?
B. Crying or breathing?
C. Good muscle tone?
II. Ongoing Assessment – if any are unsatisfactory, may require additional resuscitation
A. Breathing
B. Activity
C. Color
III. APGAR Score – 1st minute, 5th minute, every 5 minutes if score < 7 points
0 points 1 point 2 points
Appearance / Color [blue] pale [pink] body [pink] all over
[blue] extremities
Pulse / Heart rate - < 100 bpm > 100 bpm
Grimace / Reflex - grimace grimace
irritability cough or sneeze
Activity / Muscle limp bending of some active motion
tone limbs limbs well-flexed
Respiratory effort - weak cry good cry
irregular breaths regular breaths
IV. Vital Signs
A. Temperature = 36.5 to 37.4°C
B. Heart Rate = 120 to 160 bpm
C. Respiratory Rate = 40 to 60 breaths / minute
D. Blood Pressure

2nd Physical Examination: within 24 hours of birth; after transition and first breastfeeding Commented [JDT1]: Nelson Textbook of Pediatrics,
I. General Appearance p.3762
A. Physical Activity
B. Muscle Tone
1. Active
2. Passive
C. Posture
D. Edema
II. Skin
III. Skull
IV. Face
V. Eyes
VI. Ears
VII. Nose
VIII. Mouth
IX. Neck
X. Chest
XI. Lungs
XII. Heart
XIII. Abdomen
XIV. Genitals
XV. Anus
XVI. Extremities Commented [JDT2]: Nelson Textbook of Pediatrics,
Chapter 113.2
3rd Physical Examination: time of discharge
I. Positioning and attachment of breastfeeding
II. Adequacy of suck and milk transfer
III. Jaundice
IV. Development of murmurs
V. Patterns of voiding, stooling, etc.

IV. THE BALLARD EXAMINATION

When: extremely premature → within 12 hours; full term → up to 72 hours
I. Neuromuscular Maturity
 A. Posture
B. Square Window
C. Arm Recoil
D. Popliteal Angle
E. Scarf Sign
F. Heel-to-Ear
II. Physical Maturity
A. Skin
B. Lanugo
C. Plantar Surface
D. Breast
E. Eye and Ear
F. Genitalia
III. Maturity Rating
A. Pre-term: <37 weeks
B. Term: 37 - 42 weeks
C. Post-term: >42 weeks
 V. GROWTH CATEGORIZATION
I. Anthropometric Measurements
A. Weight
B. Length
C. Head Circumference
II. Gestational Age – derived from Ballard Examination
III. Plotting
IV. Categorization
A. by Gestational Age
B. Appropriate for Gestational Age
1. Small for Gestational Age
a. < 2 standard deviations
b. <10th percentile
2. Large for Gestational Age
a. >90th percentile
C. by Birth Weight
1. Low: < 2500 g
2. Very Low: < 1500 g
3. Extremely Low: < 1000 g
 VI. NEURODEVELOPMENTAL EXAMINATION
When: 2nd or 3rd day, 2 to 3 hours after feed
I. Posture
II. State of Wakefulness
A. Deep sleep
B. Light sleep
C. Quiet awake
D. Fully awake
E. Fully awake with plenty of movement
F. Fully awake, crying
III. Tone
A. Passive Tone
B. Active Tone
IV. Reflexes
A. Deep Tendon Reflexes
1. Patellar
2. Biceps
3. Ankle
4. Truncal incurvation
5. Anal wink
B. Primitive Reflexes
1. Grasp
2. Traction
3. Moro AKA Startle
4. Asymmetrical tonic neck AKA Fencing
C. Breastfeeding Reflexes
1. Feeding Reflexes
i. Rooting
ii. Sucking
iii. Swallowing
2. Protective Reflexes
i. Coughing / Gagging
ii. Vomiting
iii. Biting
3. Motor Reflexes
i. Righting
ii. Placing / Stepping
iii. Crawling
iv. Moro
v. Tonic Neck
vi. Grasp
V. Special Senses
A. Vision
B. Hearing
C. Smell and Taste
D. Touch