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Newborn Care: Skills workshop Gestational age and weight.

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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents

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Newborn Care: Skills workshop Gestational age and weight.

  1. 1. Skills workshop: Gestational age and weight Objectives Nipple clearly seen Palpable breast bud Yes Yes No No Descended testes Yes No When you have completed this skills Covered labia minora Yes No workshop you should be able to: • Assess an infant’s gestational age using Postterm infants can usually be recognised by their long finger nails. With experience, the Ballard scoring method. most preterm infants can be identified by their • Accurately measure weight and head general appearance and behaviour on clinical circumference. inspection. • Plot weight and head circumference for gestational age. 2-b Scoring gestational age To obtain a more accurate idea of the gestational age, the Ballard scoring methodASSESSING THE can be used. The accuracy of the method depends on the experience of the examiner.GESTATIONAL AGE With practice and careful attention to detail, the infant’s correct gestational age can be estimated with an accuracy of about 2 weeks.2-a Assessing gestational age by simple If the scored age is within 2 weeks of theinspection gestational age suggested by the mother’sThere are a number of easily observable dates, then accept her dates as correct.clinical signs that can help you decide whether However, if the scored age is more than 2an infant is term or preterm: weeks higher or lower than the mother’s dates, then her dates are probably incorrect and Term Preterm the scored age should be used. The scoredSucks well Yes No gestational age can also be used to decideFlexes arms and legs Yes No whether the gestational age, determined byVeins seen under skin No Yes obstetric assessment, is correct or not.
  2. 2. 54 NEWBORN CAREOther scoring methods such as the Finnstrom • Score 1 if the wrist can be flexed to 60°.method and the Dubowitz method can also • Score 2 if the wrist can be flexed halfway tobe used. the forearm. • Score 3 if the wrist can be flexed to 30°.2-c Use of the Ballard method • Score 4 if the palm of the hand can be pressed against the arm.The Ballard scoring method uses bothneurological features and external features. The Arm recoil: Fully bend the arm at the elbow sodescriptions given below describe how to assess that the infant’s hand reaches the shoulder, andthe features illustrated in Figure 2.A. Each keep it flexed for 5 seconds. Then fully extendfeature is given a score and these individual the arm by pulling on the fingers. Release thescores are added up to give a final total score. hand as soon as the arm is fully extended andThis final total score can then be converted to observe the degree of flexion at the elbowan estimated gestational age by consulting the (recoil). Arm recoil is better in more maturetable in Figure 2.A. Where possible, examine infants. Note that a score of 1 is not given.both the left and right sides of the body when • Score 0 if there is no arm recoil at all.doing the Ballard score and give the average • Score 2 if there is some arm recoil.score observed on either side. Half scores can • Score 3 if the arm recoil is good and thebe used. Note that some features have negative arm is flexed halfway back to the shoulder.scores for very preterm infants. • Score 4 if there is a brisk arm recoil and the infant pulls the arm back almost to the2-d Neurological features shoulder.All 6 neurological features are assessed with Popliteal angle: With your one hand hold thethe infant lying supine (the infant’s back on the infant’s knee against the abdomen. With thebed). The infant should be awake but not crying. index finger of the other hand gently pushPosture: Handle the infant and observe the behind the infant’s ankle to bring the footposition of the arms and legs. More mature towards the face. Observe the angle formedinfants (with a higher gestational age) have behind the knee by the upper and lower legsbetter flexion (tone) of their limbs. (the popliteal angle). More mature infants have a smaller popliteal angle with less extension of• Score 0 if both arms and legs are fully the knee. extended.• Score 1 if there is slight flexion of the legs • Score –1 if the leg can be fully extended to only. form an angle of 180°.• Score 2 if there is moderate flexion of the • Score 0 if the knee can only be extended to legs. 160°.• Score 3 if the legs are flexed to 90° and the • Score 1 if the knee can only be extended to arms are partially flexed. 140°.• Score 4 if all limbs are fully flexed against • Score 2 if the knee can only be extended to the body. 120°. • Score 3 if the knee can only be extended toSquare window: Gently press on the back of 100°.the infant’s hand to push the palm towards the • Score 4 if the knee can be extended to 90°.forearm. Observe the degree of wrist flexion. • Score 5 if the knee cannot be extended toMore mature infants have greater wrist flexion. 90°.• Score –1 if the wrist cannot be flexed to 90°. Scarf sign: Take the infant’s hand and gently• Score 0 if the wrist can only be flexed to pull the arm across the front of the chest and 90° only, giving the appearance of a ‘square around the neck like a scarf. With your other window’. hand gently press on the infant’s elbow to help
  3. 3. SK ILLS WORKSHOP : GESTATIONAL AGE AND WEIGHT 55the arm around the neck. In more mature Skin: Examine the skin over the front of theinfants the arm cannot be easily pulled across chest and abdomen, and also look at the limbs.the chest. More mature infants have thicker skins.• Score –1 if the arm can be wrapped tightly • Score –1 if the skin is sticky and transparent. around the neck (like a scarf). • Score 0 if the skin appears very thin, red• Score 0 if the elbow can only be pulled and gelatinous (jelly-like). beyond the chest but not fully wrapped • Score 1 if the skin is thin and smooth with around the neck. many small blood vessels visible.• Score 1 if the elbow reaches the other side • Score 2 if the skin is thicker with only a of the chest but cannot be pulled beyond few blood vessels seen. Fine peeling of the the chest. skin is often noticed, especially around the• Score 2 if the elbow can reach the midline ankles. of the chest. • Score 3 if the skin is pale and slightly dry• Score 3 if the elbow cannot reach the with only a few bigger blood vessels seen. midline of the chest. • Score 4 if the skin is dry and cracked with• Score 4 if the elbow cannot be pulled as far no blood vessels visible. as the side of the chest. • Score 5 if the skin is very thick and looks like leather.Heel to ear: Hold the infant’s toes and gentlypull the foot towards the ear. Allow the knee Lanugo: This is the fine, fluffy hair that is seento slide down at the side of the abdomen. over the back of small infants. Except for veryUnlike the illustration, the infant’s pelvis may immature infants that have no lanugo, pretermbe allowed to lift off the bed. Observe how infants have a lot of lanugo and this decreasesclose the heel can be pulled towards the ear. with maturity.More mature infants have less flexion of the • Score –1 if no lanugo is seen in a veryhips and, therefore, you cannot bring the heel small infant.towards the ear. • Score 0 if there is only some lanugo in a• Score –1 if the heel can easily be pulled to very small infant. the ear. • Score 1 if the lanugo is thick and present• Score 0 1 if the heel can almost reach the over most of the back. ear. • Score 2 if the lanugo is thinning, especially• Score 1 if the heel gets close to the ear. over the lower back.• Score 2 if the heel can be pulled just • Score 3 if there are bald areas with no beyond halfway to the ear. lanugo.• Score 3 if the heel can be pulled halfway to • Score 4 if very little lanugo is seen. These the ear. are always bigger infants.• Score 4 if the heel cannot not be pulled Plantar creases: Use your thumbs to stretch halfway to the ear. the skin on the bottom of the infant’s foot. Only note definite creases and not very fine2-e External features wrinkles, that disappear when the skin isSix external features are examined. The infant stretched. More mature infants have morehas to be turned over to examine the amount creases. To measure the length of the foot inof lanugo on the back. If the infant is too sick very small infants place a ruler on the sole andto be turned over, then the amount of lanugo measure the distance in mm from the back ofis not scored. the heel to the tip of the big toe. • Score –2 if there are no creases at all (there may be fine wrinkles) and the heel-toe distance is less than 40 mm.
  4. 4. 56 NEWBORN CARE• Score –1 if there are no creases at all and • Score 1 if the ear slowly unfolds, and the the heel-toe distance is 40 to 50 mm. upper margin of the ear (pinna) has started• Score 0 if shallow, red creases are present, to curl in. especially over the anterior sole, and the • Score 2 if the upper margin of the ear is heel to toe distance is more than 50 mm. well curled and the ear unfolds quickly.• Score 1 if shallow, red creases are present, Areas of cartilage still feel soft, especially especially over the anterior sole. towards the edge of the ear.• Score 2 if deeper creases are present on the • Score 3 if the cartilage feels firm anterior third of the sole only. throughout the ear, and the ear springs• Score 3 if deep creases are present over two back rapidly if folded. thirds of the sole. • Score 4 if the ear feels stiff and the whole• Score 4 if the whole sole is covered with ear margin is well curled in. deep creases. Genitalia: Male and female genitalia are scoredBreast: Both the appearance of the breast differently. With maturity the testes descend inand the size of the breast bud are considered. the male and the scrotum becomes wrinkled.Palpate for the breast bud by gently feeling In females the labia majora increase in size withunder the nipple with your index finger and maturity. Note that a score of 1 is not given.thumb. More mature infants have a bigger Males:areola and breast bud. • Score –1 if the scrotum is very small, flat• Score –1 if the areola (pink skin around the and smooth with no testes palpable. nipple) cannot be seen. • Score 0 if the scrotum has faint wrinkles• Score 0 if the areola is very small but can (rugae) with no testes palpable. be seen. • Score 1 if there are a few wrinkles on the• Score 1 if the areola is small and flat, and scrotum and the testes are felt high in the no breast bud can be felt. groin.• Score 2 if the breast bud can just be felt and • Score 2 if there are a few wrinkles and the the areola is stippled (has fine bumps). testes are felt high in the scrotum.• Score 3 if the areola is raised above the • Score 3 if the testes are in the scrotum and surrounding skin and the breast bud is the skin of the scrotum has a lot of wrinkles. easily felt (3–4 mm). • Score 4 if the scrotum hangs low with fully• Score 4 if the areola appears distended descended testes. and the breast bud is the size of a pea (5–10 mm). Females:Ears and eyes: Both the shape and thickness • Score –1 if the clitoris is prominent and theof the external ear are considered. With labia flat.increasing maturity the edge of the ear curls • Score 0 if the clitoris is prominent and thein. In addition, the cartilage in the ear thickens labia minora (inner labia) still small.with maturity so that the ear springs back into • Score 1 if the clitoris is prominent and thethe normal position after it is folded against labia minora are larger.the infant’s head. The eyelids separate with • Score 2 if the labia majora (outer labia) andincreasing maturity. labia minora are of equal size. • Score 3 if the labia majora are bigger than• Score –2 if the eyelids are tightly fused the labia minora. (stuck together). • Score 4 if the labia majora cover the clitoris• Score –1 if the eyelids are still partly fused. and labia minora.• Score 0 if the eyelids are open and the ear is soft and flat and stays folded. Each separate criteria is given a score after examining that sign on the infant. These
  5. 5. SK ILLS WORKSHOP : GESTATIONAL AGE AND WEIGHT 57separate scores are then added together to give PLOTTING WEIGHT ANDa total score. From the total score the estimatedgestational age can be read off the table. HEAD CIRCUMFERENCEMEASURING WEIGHT AND 2-h Plotting weight for gestational age On the chart in Figure 2.B an infant’s birthHEAD CIRCUMFERENCE weight of 3000 g and gestational age of 39 weeks have been recorded. Note that lines have been2-f Weighing an infant drawn from the given weight and gestational age. The weight for gestational age is recordedThe naked infant is weighed, to the nearest at the point where these 2 lines meet.10 g, on a scale. Usually a digital scale isused. If a spring scale is used, it should be Practise plotting weight for gestational agestandardised with a known weight every on the above chart by recording the followingmonth. If possible, the infant should always be infants’ weight and gestational age. Decideweighed on the same scale. The birth weight whether each infant is overweight, appropriatemust be recorded on the infant record card. weight, or underweight for gestational age. Remember that the centile lines mark theSee Figure 2.B for a weight for gestational age outer limit of the normal (or appropriate)chart. weight for gestational age. NOTE Measurements made on a spring scale are 1. Weight 1500 g and gestational age 30 weeks. called weight while measurements recorded 2. Weight 1500 g and gestational age with a balance scale are called mass. The result is 34.5 weeks. the same and both are read in grams (g). In this programme all measurements are called weight. 3. Weight 3950 g and gestational age 39 weeks. 4. Weight 4000 g and gestational age 42.2 weeks.2-g Measuring head circumference 5. Weight 3000 g and gestational age 43 weeks.The occipito-frontal head circumference ismeasured with a tape measure or a special 2-i Plotting head circumference forplastic head circumference tape to the nearest gestational age1 mm. The largest head circumference mustbe measured around the forehead and back of Practise plotting head circumference forthe occiput. Usually the head circumference gestational age by recording the followingis measured after delivery when the weight infants’ head circumference and gestationalis recorded. However, the measurement of age on the chart in Figure 2.C. Decide whetherhead circumference should be postponed each infant’s head is large, appropriate or smallfor 24 hours if marked moulding or severe for gestational age.caput are present at birth as they may result 1. Head circumference 27 cm and gestationalin an incorrect reading. If possible, the head age 29.5 weeks.circumference should be recorded on the 2. Head circumference 25.5 cm andinfant record card. gestational age 29 weeks.The crown-heel length is usually not 3. Head circumference 30 cm and gestationalmeasured routinely as this is very inaccurate age 32 weeks.unless a special measuring box is used. 4. Head circumference 30 cm and gestationalInfant length is measured only in special age 35.7 weeks.circumstances, e.g. when dwarfism is 5. Head circumference 36 cm and gestationalsuspected or for research on growth. age 38 weeks.
  6. 6. –1 0 1 2 3 4 5PostureSquarewindow(wrist) >90° 90° 60° 45° 30° 0°Arm recoil 180° 140–180° 110–140° 90–110° <90°Poplitealangle 180° 160° 140° 120° 100° 90° <90°Scarf signHeel toearPhysical maturity –1 0 1 2 3 4 5Skin Sticky, Gelatinous, Smooth, Superficial Cracking Parchment, Leathery, friable, trans- red, trans- pink, visible peeling pale areas, deep cracked, parent lucent veins and/or rash, rare veins cracking, no wrinkled few veins vesselsLanugo None Sparse Abundant Thinning Bald areas Mostly baldPlantar Heel–toe >50 mm Faint red Anterior Creases Creases oversurface 40–50 mm: No crease marks transverse anterior 2/3 entire sole –1 crease only <40 mm: –2Breast Imper- Barely per- Flat areola, Stippled Raised Full areola ceptible ceptible no bud areola areola 5–10 mm 1–2 mm bud 3–4 mm bud budEye/ear Lids fused Lids open; Slightly Well-curved Formed and Thick loosely: –1 pinna flat, curved pinna; soft firm, instant cartilage, ear tightly: –2 stays folded pinna, soft, but ready recoil stiff slow recoil recoilGenitals: Scrotum flat, Scrotum Testes in Testes Testes down, Testesmale smooth empty, faint upper canal, descending, good rugae pendulous, rugae rare rugae few rugae deep rugaeGenitals: Clitoris Prominent Prominent Majora and Majora Majorafemale prominent, clitoris, small clitoris, minora large, cover clitoris labia flat labia minora enlarging equally minora and minora minora prominent smallMaturity ratingScore –10 –5 0 5 10 15 20 25 30 35 40 45 50Weeks 20 22 24 26 28 30 32 34 36 38 40 42 44Figure 2.A: The Ballard scoring method
  7. 7. Birth weight (g)50004000300020001000 500 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 Gestational age (weeks)Figure 2.B: Weight for gestational age chartBirth weight (g) 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 Gestational age (weeks)Figure 2.C: Head circumference for gestational age chart
  8. 8. 60 NEWBORN CAREREFERENCESThe Ballard scoring method – J Pediatr 1991;119: 417–423.Weight for gestational age chart – ActaPaediatr Scand Suppl 1985; 31: 180.Head circumference for gestational age chart– Pediatr Res 1978; 12: 987.

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