ASSESSMENT PREMATURE BABY

PREPARED BY: SITI ZAHARAH MAT ADAM PART TIME STUDENT

Learning Objective

Define Premature, term and post term babies . Discuss the classification of preterm. Discuss the timing and types of newborn assessment. Differentiate the physical maturity Discuss the normal and abnormal physical findings of newborns.

PREMATURE BABY
A baby born before 37 weeks of gestation have passed. Historically, the definition of prematurity was 2500 grams (about 5 1/2 pounds) or less at birth. The current World Health Organization definition of prematurity is a baby born before 37 weeks of gestation, counting from the first day of the Last Menstrual Period (the LMP).

Term Baby

birth between 37 and 42 weeks Typically, baby measures 19.5 inches (50 cm) from the head to the heel. Baby weighs up to 7 pounds or 3 kilograms. The head diameter is over 3.5 inches (9cm). The water could break at any time.

Post Term Baby

Post maturity is when a baby has not yet been born after 42 weeks of gestation, two weeks beyond the normal 4

Classification Of Preterm And Low Birth Weight Babies

The lower the birth weight and gestational age of the newborn, the higher the risk of complications and death and the more special care he or she needs. The special care they will need should take into account the classification of early and tiny babies

Classification On Birth Weight

In relation to birth weight, most preterm babies are low birth weight or very low birth weight

Classification On Birth Weight

Low birth weight: born with birth weight between 1,500-2,499 gm usually be managed safely at home with some extra care and support. Very low birth weight: born with birth weight less than 1,500 gm A life-threatening problem in such tiny babies is that suckling, swallowing and breathing are not well coordinated, so they require special attention in order to feed them adequately and safely difficulty in maintaining their body temperature, so they are at increased risk of hypothermia

Classification on gestational age

premature baby Preterm baby Very preterm baby

baby born before 37 completed weeks of pregnancy

Babies born between the gestational ages of 32-36 weeks of gestation calculated from the mothers last normal menstrual period (LNMP date). can usually be managed safely at home with some extra care and support

born between the gestational ages of 28-31 weeks as calculated from the LNMP date Like very low birth weight babies have problems in feeding and maintaining their body temperature

premature baby

Preterm baby

Very preterm baby

Term baby

Classification of newborn babies according to birth weight and gestational age.

Birth weight and gestational age
Weight less than 1,500 gm Gestational age less than 32 weeks Classification Action Refer URGENTLY to a hospital, making sure to keep the baby warm on the journey Keep the newborn baby warm and refer it soon. If there is no other problem:counsel on optimal breast feeding, prevention of infection and keeping the baby warm As above for low birth weight babies As above for low birth weight and preterm

Very low birth weight

Very preterm

Weight 1,500 to 2,500 gm

Low birth weight

Gestational age 32-36 weeks Weight equal to or above 2,500 gm; gestational age

Preterm Normal weight and full term

BALLARD SCORE
Use this score sheet to assess the gestational maturity of your baby. At the end of the examination the total score determines the gestational maturity in weeks.
NEUROMUSCULAR MATURITY
SCORE SIGN Posture Square Window -1 0 1 2 3 4 5 SIGN SCORE

Arm Recoil

Popliteal Angle Scarf Sign Heel To Ear TOTAL NEUROMUSCULAR SCORE

PHYSICAL MATURITY

SIGN

SCORE -1

Skin

gelatinous, Sticky, friable, red, transparent translucent

none sparse

2 superficial smooth pink, peeling &/or visible veins rash, few veins abundant thinning anterior transverse crease only stippled areola 1-2 mm bud well-curved pinna; soft but ready recoil

4 parchment, cracking, pale deep areas, rare cracking, no veins vessels bald areas mostly bald

SIGN SCORE

leathery, cracked, wrinkled

Lanugo

Plantar Surface

heel-toe >50 mm 40-50mm: -1 no crease <40mm: -2 imperceptabl barely e perceptable lids fused loosely: -1 tightly: -2 scrotum flat, smooth clitoris prominent & labia flat lids open pinna flat stays folded scrotum empty, faint rugae prominent clitoris & small labia minora

faint red marks flat areola no bud sl. curved pinna; soft; slow recoil

creases ant. 2/3

creases over entire sole

Breast

raised areola full areola 3-4 mm bud 5-10 mm bud formed & firm thick cartilage instant recoil ear stiff testes testes down, pendulous, good rugae deep rugae majora cover majora large, clitoris & minora small minora TOTAL PHYSICAL MATURITY SCORE

Eye / Ear

Genitals (Male)

testes in testes upper canal, descending, rare rugae few rugae prominent clitoris & enlarging minora majora & minora equally prominent

Genitals (Female)

MATURITY RATING

TOTAL SCORE (NEUROMUSCULAR + PHYSICAL) -10 -5 0 5 10 15 20 25 30 35

WEEKS 20 22 24 26 28 30 32 34 36 38

40
45 50

40
42

Characteristics of premature babies

Premature babies have a number of characteristics depending on their gestational age: Skin: may be reddened. The skin may be thin so blood vessels are easily seen. Lanugo: there is a lot of fine hair all over the babys body. Limbs: the limbs are thin and may be poorly flexed or floppy due to poor muscle tone. Head size: appears large in proportion to the body. The fontanelles (open spaces where skull bones join) are smooth and flat. Chest: no breast tissue before 34 weeks of pregnancy. Sucking ability: weak or absent. Genitals: in boys the testes may not be descended and the scrotum may be small; in girls the clitoris and labia minora may be large. Soles of feet: creases are located only in the anterior (front) of the sole, not all over, as in the term baby

Characteristic of Newborn
Weight : Average 2.8 kg for Indian babies (range 2.5 3.2 kg). Babies below 2.5 kg at birth are consideredto be low birth weight and need special evaluation. Length : Approximately 50 cm. Remember, small women have small babies and many genetic factors also play a role in determining the length of the baby. Head

: Your babys head appears large for the body and may have an elongated shape or appear to havesome bumps. This is due to changes called molding, which occurs in labour and delivery. Small bumpscalled caput usually disappear in 1 2 days. Soon the head gets rounder. The head circumference is 33 35 cm.

Soft spots or Fontanelles : There are 2 areas on the head where bone formation is incomplete at birth. Thelarger one, in front of the head closes by 6 18 months. The smaller one at the back usually closes by 6weeks. Hair : As all people vary, so does their hair. Your baby may have lots of hair or none at all! It depends onfamilial and racial factors. Heart beats : Usually the heart rate is 120 140 beats per minute. Respiratory rate (breathing) : It is faster than adults, usually 30 40 breaths / minute. Breathing may benoisy or stop for many seconds. This is not uncommon. Colour : Depending on the parents, the skin colour of newborn varies. In general, newborn babies look flushed and pink all over. However, the palms and soles of the feet may look dusky or little bluish soonafter birth.

newborn baby will go through a number of assessments when he is first born, to make sure that he is in good health. His first assessments, called the Apgar score, occur when he is just one minute and five minutes old.

Newborn first exam: Apgar score

Factor Score 0 Score 1 Score 2

Heart rate
Muscle tone Reflexes

No heart rate

Below 100 beats/min

Slow and irregular Some flexing of arms and legs

Above 100 beats/min

Good Actively moving

Breathing No breathing Limp and loose No reflex responses

Grimaces or frowns Vigorously cries when when reflexes are reflexes are stimulated stimulated Body is pink but hands and feet are blue Entire body is pink

Colour

Blue and pale

Physical Examination
Vital SignsTake the temperature at birth 37.2c, must be maintain 35.5-36.5c. Rectal route is preferred In order to check the patency of the anus. Respiratory Rate: For all spontaneously breathing infants, term and premature, respiratory rates fall to within a range of 40-60 by one hour of age. Watch for: respiratory distress (grunting, flaring, cyanosis), tachypnea, bradypnea, apnea (>10s) Heart Rate: 120-180 Watch for: bradycardia, tachycardia

General Observations Nude, warm and settled if possible. Watch for: sick or well?, cyanosis, pallor, jaundice, symmetry, weak or high pitched cry, hoarseness, aphonia,

Skin White vernix is most abundant in premature infants and is less prominent : closer to term. Post term newborns have little or no vernix and the skin is dry, cracked and wrinkled. Scan for hemangiomas, urticaria, pustules, vesicular, nodular or gangrenous rashes. Check for dermal sinuses in the midline of the back, from occiput to coccyx and in the pilonidal region. Look carefully along the midline for dimples, sinuses, hirsute areas, or cystic swellings that suggest the presence of congenital cranial dermal sinuses or defects in the underlying vertebral column. Note ecchymoses, petechiae, milia, erythema toxicum, stork
bite (flame hemangiomas). Watch for: jaundice (always abnormal if noted on first day of life). Anticipatory Guidance: Mongolian spots usually resolve by age 4, stork bites on the neck tend to persist whereas facial flame hemangiomas usually fade within months. Facial petechiae are normal, milia, and e. toxicum are transient.

pustules

hemangiomas,

urticaria

Vesicular Rash

dermal sinus with intraspinal

hirsute

HEAD
Most common abnormalities are caput succedaneum (crosses sutures) and cephalohematoma (subperiosteal and does not cross sutures). Absent suture separations or excessive spreading of the lines are significant. Run a fingertip from occiput to nasion along the sagittal and metopic sutures and

over the occiptoparietal junctures to define the lambdoidal sutures. Large fontanels and split sutures most often are a normal variant, but they can be associated with increased intracranial pressure or conditions that impair bone growth (eg. Hypothyroidism).

Eyes: Hold the infant upright and note: size of the eyeball, haziness of clouding of the cornea, lens or media. Note dermoids or small hemangiomas. Watch both eyes for normal excursion or the lids and note proptosis, squint or asymmetric closure (facial nerve palsy). Red reflex (abnormal in retinoblastoma, congenital cataract). Anticipatory Guidance: Discuss the antibiotic cream. Explain focal length, occasional dyscoordination of extraocular movements.

Ears: The ears can be grossly malformed, uncommonly large or small, angled abnormally or set lower on the head than normal. Very low placement plus unusual size, floppiness and perpendicularity to the skull suggest renal agenesis or chromosomal aberration. Malformations stemming from the first branchial arch often involve the ears, and one must look carefully for abnormal skin tags, dimples, and deep sinuses, especially in front and behind the tragus. The infant should respond to a loud noise or tone.

Mouth: Note clefts of lip and palate (examine entire palate), symmetric movement of lip corners, excessive mucoid secretions (suggesting esophageal atresia). Look for retention cysts along the alveolar ridge, and the plaques of thrush. Note the size of the tongue and depress the lower jaw or take advantage of a cry to see the posterior pharynx. Examine the frenulum and note its length

Nose: One can assess the patency of the posterior choanae by holding the mouth closed and listening with the stethoscope for the outrush of each naris. Inspection up the naris may reveal an encephalocoele.

Choanal atresia is a congenital disorder

Neck: Note length and mobility and inspect for congenital cysts, hygromas, thyroglossal duct cysts, and thyromegaly. Look for webbing and palpate the length of both clavicles to rule out fracture.

Chest: The chest deserves primary concern. Inspect for overinflation, symmetric movement, presence or absence of retractions and the use of accessory muscles. Auscultate for rales, rhonchi, and bowel sounds. Heart: Size and position of the heart, as well as the rate, rhythm and strength of its sounds are as important as the presence or absence of murmurs. Note extrathoracic signs such as cyanosis, size of the liver, dilatation of superficial veins, and palpability of the femoral and distal arterial pulses

Abdomen: Look for unusual flatness (diaphragmatic hernia) or excessive fullness (one must then determine if this is due to an excess of air within or outside the bowels, to excess fluid, to an enlarged viscous or viscera or to the presence of a cystic or solid tumor). Visible gastric or bowel patterns may be considered an almost certain sign of obstruction. The umbilicus should be inspected carefully for signs of infection, bleeding, polyp, granuloma or abnormal communication with intraabdominal viscera.

diaphragmatic hernia

Genitals: Male-size and formation of the penis, position of the meatus, size of the scrotum and the nature of its skin and descent of nondescent of the testes. Female-size of the clitoris, the nature of the skin of the labia majora, and if possible the position of the vaginal and urethral orifices. Note the fusion of the labia if present. One should palpate over the inguinal canals for presence of herniae or gonads and imperforate anus should be ruled out.
ambiguous genitalia.

Back and Hips: Compare leg lengths and perform Barlow's maneuver.

Barlow maneuver. A gentle downward force

Extremities:

Do all four move well and approximately symmetrically? Note unusual resistance to flexion or extension or its converse: excessive malleability or flaccidity. Note polydactylism or syndactylism, clubbing, cyanosis, or unusual creasing of the palms or soles.

Newborn tone - upper extremity

POLYDACTYLISM. 9. LAMREY DISE

syndactylism

Reflexes: Timing of Selected Primitive Reflexes: Reflex: Onset Fully Developed Duration Palmar grasp 28 wk 32 wk 2-3 months Palmar grasp reflex. Rooting 32 wk 36 wk Less prominent by 1 mo Moro 28-32 wk 37 wk 5-6 months Tonic neck 35 wk 1 mo 6-7 months Parachute 7-8 mo 10-11 mo Permanent

The Moro reflex

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