Physical Examination and
Assessment
Of The Newborn
APGAR SCORING SYSTEM
❂ Developed in 1950s ❂ A = Appearance (skin
❂ Cardiopulmonary color)
status ❂ P = Pulse (heart rate)
❂ Dr. Virginia Apgar ❂ G = Grimace (reflex
❂ 1 minute after birth irritability)
❂ 5 minutes after birth ❂ A = Activity (muscle
❂ 5 parameters tone)
❂ R= Respiration
• (respiratory effort)
Criteria for Apgar Scoring
Category 0 Points 1 Point 2 Points
Heart Rate Absent Under 100 Over 100
Respiratory Absent Irregular, Weak Crying,
Effort Vigorous
Muscle Tone Flaccid, Limp Some flexion Active flexion,
good motion
Reflex Unresponsive Frown/Grimace Active motion-
Irritability w/ stimulation cry, cf. sneeze
Skin Color Cyanosis Acrocyanosis Completely
Pink
APGAR SCORING SYSTEM
❂ One Minute Score
• Identifies need for immediate intervention
• Score 2 0r less = immediate resuscitation
• Score 3 to 6 = some assistance, usually
stimulation, suctioning, oxygen
• Score 7 or more = routine care and observation
APGAR SCORING SYSTEM
❂ Five Minute Score
• Assess infant’s recovery from depression
• Also assess effectiveness of intervention
• Score 7 to 10 = Few, if any, supportive measures
• Score 4 to 6 = Mild to moderate asphyxia;
suctioning, oxygenation, mech ventilation
• Score 0 to 3 = Full cardiopulmonary
resuscitation
SILVERMAN SCORE
❂ Looks at level of respiratory distress
❂ Scoring in 5 areas, range from 0 to 2
• Upper chest movement
– Synchronized = 0
– Lag of chest on inspiration = 1
– Seesaw movement upper chest = 2
• Lower chest movement
SILVERMAN SCORE- continued
❂ Lower chest movement (continued)
• No retractions = 0
• Retractions - just visible = 1
• Marked retractions = 2
❂ Xiphoid retractions
• No retractions = 0
• Retractions - just visible = 1
• Marked retractions = 2
SILVERMAN SCORE- continued
❂ Dilation of nares
• None = 0
• Minimal dilation = 1
• Marked dilation = 2
❂ Expiratory Grunt
• None = 0
• Heard only w/ stethoscope = 1
• Heard w/ naked ear = 2
SILVERMAN SCORE- continued
❂ Scoring Scale
• 0 to 3 = no respiratory distress to mild distress
• 4 to 6 = moderate respiratory distress
• 7 to 10 = severe respiratory distress
ESTIMATION OF GESTATIONAL AGE
❂ Dubowitz Score
• Dr. Dubowitz and co-workers (Early 1970s)
• 10 external characteristics
• 11 Neuromuscular signs
❂ New Ballard Score (NBS)
• Increase accuracy in very low birthweight
• 7 physical & 6 neurologic criteria
– No lifting patient ; intubated & monitored
ESTIMATION OF GESTATIONAL AGE
NBS - continued
❂ Each category scored from -1 to +4 or +5
❂ Physical Maturity
• Skin - transparent to leathery, cracked
• Lanugo - none to mostly bald, upper back only
• Plantar Surface - little or no creases to creases
over entire sole
• Breast - imperceptible to full areola
ESTIMATION OF GESTATIONAL AGE
NBS - continued
• Eye/Ear - lids fused, pinna flat to well curved
pinna, thick cartilage ear stiff
• Genitals male -scrotum flat, smooth to testes
pendulous
• Genitals female - clitoris prominent, labia flat
to majora cover clitoris and minora
ESTIMATION OF GESTATIONAL AGE
NBS - continued
❂ Neuromuscular Maturity
• Posture & extremities / muscle tone:
• Posture - hypotonic w/ arms & legs extended
to arms & legs flexed w/ recoil
• Square Window (wrist) - greater than 90* to 0*
• Arm Recoil - none to full recoil w/ angle < 90*
• Knee Joint Angle (popliteal) - from 180* to less
than 90*
ESTIMATION OF GESTATIONAL AGE
NBS - continued
❂ Scarf Sign - no resistance to full resistance
❂ Heel to Ear - no resistance w/ little or no
knee flexion to significant resistance with
flexed knee
ESTIMATION OF GESTATIONAL AGE
NBS - continued SCORING SYSTEM
-10 20 wks 25 34 wks
-5 22 wks 30 36 wks
0 24 wks 35 38 wks
5 26 wks 40 40 wks
10 28 wks 45 42 wks
15 30 wks 50 44 wks
20 32 wks
ESTIMATION OF GESTATIONAL AGE
- continued: External Criteria
❂ Vernix • Preterm covered
• grayish white • Term has very little,
cheeselike substance only in body creases
• composed of • Post-term has none
– sebaceous gland ❂ Nails
secretions
• present and cover nail
– lanugo
bed all ages
– shed epithelial cells
• amount is age related • may be especially long
in post-term
Growth Assessment
Colorado intrauterine growth curve
❂ Plot gestational age against:
• Birth weight
• Length
• Head circumference
• Data from Colorado infants 1948 to 1961
Colorado intrauterine growth curve
❂ Score between 10th and 90th percentiles
= AGA
❂ Score below the 10th percentile = SGA
❂ Score above the 90th percentile = LGA
VITAL SIGNS
❂ RESPIRATORY RATE ❂ BLOOD PRESSURE
❂ HEART RATE ❂ TEMPERATURE
RESPIRATORY RATE
❂ Normal = 30 to 60, variable
❂ Periodic Breathing = respiration
interrupted by short periods of apnea, up to
10 seconds, not associated w/ other
abnormalities
• Common in preterm infants
❂ Very little chest wall movement
❂ Count for full minute
HEART RATE
❂ Normal newborn = 110 to 160
❂ Determined by auscultation
❂ Transient increases w/ agitation
❂ Persistent tachy associated w/ congenital
heart defects
❂ Brady associated w/ significant apnea
❂ Apical impulse - normal vs. abnormal location
BLOOD PRESSURE
❂ Normal Ranges:
• Low birth weight = 50/35 mmHg.
• Mid b.w. above 2000 gm. = 60/35 mmHg.
• High b.w. above 3000 g. = 65/40 mmHg.
❂ Assessed with doppler and cuff
❂ Peripheral pulses for indirect assessment
• - brachial - radial - femoral
TEMPERATURE
❂ Normal core = ❂ Skin Temp
somewhat variable • Allow continual
❂ Rectum is best measurement
assessment of core • Pt. Care not interfered
• Maintained about 36.5
❂ Axilla, usually lower
degrees (C)
but may be falsely
• Minimize O2
high consumption
OTHER CLINICAL ASSESSMENTS
SIGNS OF RESPIRATORY DISTRESS
❂ 5 Common
• Tachypnea
• Cyanosis
• Nasal Flaring - Silverman score
• Expiratory Grunting - Silverman score
• Retractions - Partially Silverman score
RESPIRATORY DISTRESS -continued
❂ Tachypnea = RR > 60
• Over 50 should increase suspicion
• Full minute assessment
❂ Cyanosis = bluish discoloration
• Local vs. General
• Central
– Involves mucous membranes
– Indicates excessive unsaturated hemoglobin
RESPIRATORY DISTRESS -continued
• Central Cyanosis - continued
– In excess of 5 g / dl
– Presence usually indicative of PO2 < 40 mmHg
– Slight drop in PO2 yields dangerous sharp decline
in hemoglobin saturation, O2 carrying capacity
– Anemic baby may have no cyanosis w/ extreme
hypoxemia
• Acrocyanosis - hands & feet
– common in newborns
RESPIRATORY DISTRESS -continued
❂ Retractions = inward movement of chest wall
• Intercostal = between ribs
• Supraclavicular = above clavicles
• Subcostal = below rib margins
• Suprasternal = top margins of sternum
• Xiphoid = bottom margins at xiphoid process
RESPIRATORY DISTRESS -continued
❂ Apnea
= periods of no respiration for at least 20
seconds
❂ Or periods of absence of respiration
accompanied by bradycardia (HR < 100)
Chest Auscultation
❂ Rales ❂ Rhonchi
• “crackles” • changes in pitch
• short, interupted • narrowing of airways
sounds – secretions
• usually during – swelling
inspiration – foreign matter
– smooth muscle spasm
• associated with
– HMD • “Course” = low pitch
– Pulmonary Edema • “Wheeze” = high pitch
– Pneumonia
Head, Face, & Neck Exam
❂ Assessment of Congenital Anomalies
❂ Head
• Shape & Size
– Compression during birth - self correcting
• Occipital Frontal Circumference (OFC)
• Ears
– Shape, Size, Position, Presnce of ear canals
Head, Face, & Neck Exam - cont.
❂ Face
• Eyes
– Size -Shape -Position
• Nose
– Size -Shape -Patency of Nasal Pasages
• Mouth
– Lips -Hard/Soft Palate -Size of tongue & jawbone
Head, Face, & Neck Exam - cont.
❂ Neck
❂ Inspected for;
• Range of motion
• Goiter
• Presence of cysts
ABDOMEN, SKIN, EXTREMETIES
❂ Abdomen
• Protrusion of abdominal contents
• Appearance & position of umbilicus
❂ Skin
• Pigmentation, Rashes, Bruising, Unusual
• Jaundice
ABDOMEN, SKIN, EXTREMETIES
❂ Extremeties - fingers & toes
• Position
• Size
• Number
❂ Hands & Feet
• Color
❂ Pulses
• Brachial & Femoral
