This document provides guidelines for assessing the health of a newborn infant. It describes evaluating the infant's history including prenatal and delivery factors. Physical appearance is assessed including skin, tone, head size and overall appearance. Vital signs like temperature, heart rate, respiratory rate and status are examined. Laboratory tests including arterial and capillary blood samples are outlined. Gestational age assessment tools like the Dubowitz Scale and Ballard Scale are presented. Proper technique for obtaining capillary blood samples is also covered.

1. Assessment of the
Neonate
220a

2. History – Prenatal
• Gestational age
• History of previous pregnancies

3. History – Prenatal
• Problems during pregnancy
– Eclampsia
– History of drug abuse
– Maternal history of diabetes
– History of infections

4. History – Labor
• Length of labor
• Difficulties during labor
• Monitoring results
during labor

5. History – Delivery
• APGAR scores
• Presentation
• Interventions in
the delivery room

6. Physical Examination – Assessment of
Gestational Age
• Two primary evaluation tools used to
determine gestational age
– Dubowitz Scale
– Ballard Scale

7. Dubowitz Scale – External Superficial
Criteria
EXTERNAL
SIGN
SCORE RECORD
SCORE
0 1 2 3 4 HERE
EDEMA
Obvious
edema of
hands &
feet; pitting
over tibia
No obvious
edema of
hands &
feet; pitting
over tibia
No edema
SKIN TEXTURE
Very thin,
gelatinous
Thin &
smooth
Smooth,
medium
thickness.
Rash or
superficial
peeling
Slight
thickening.
Superficial
cracking and
peeling, esp.
hands, feet
Thick and
parchment
like;
superficial or
deep cracking
SKIN COLOR
(Infant not crying)
Dark red
Uniformly
pink
Pale pink,
variable over
body
Pale. Only
pink over
ears, lips
palms, or
soles
SKIN CAPACITY
(Trunk)
Numerous
veins and
venules
clearly seen,
esp. over
abdomen
Veins and
tributaries
seen
A few large
vessels
clearly seen
over
abdomen
A few large
vessels seen
indistinctly
over
abdomen
No blood
vessels seen

8. Dubowitz Scale – External Superficial
Criteria – Cont
EXTERNAL
SIGN
SCORE RECORD
SCORE
0 1 2 3 4 HERE
LANUGO
(Over back)
No lanugo
Abundant;
long thick
over whole
back
Hair
thinning,
esp. over
lower back
Small
amount of
lanugo and
bald areas
At lest half of
back devoid
of lanugo
PLANTAR
CREASES
No skin
creases
Faint red
marks over
anterior half
of sole
Definite red
marks over
more than
anterior half;
indentations
over less
than anterior
third
Indentations
over more
than anterior
third
Definite deep
indentations
over more
than anterior
third
NIPPLE
FORMATION
Nipple
barely
visible; nor
areola
Nipple well-defined;
areola
smooth and
flat; diameter
< 0.75 cm
Areola
stippled,
edge not
raised;
diameter
< 0.75 cm
BREAST SIZE
No breast
tissue
palpable
Breast tissue
on one or
both side
<0.5 cm
diameter
Breast tissue
both sides,
one or both
0.5-1.0 cm

9. Dubowitz Scale – External Superficial
Criteria – Cont
EXTERNAL
SIGN
SCORE RECORD
SCORE
0 1 2 3 4 HERE
EAR FORM
Pinna flat
and
shapeless,
or no
incurving of
edge
Incurving of
part of edge
of pinna
Partial
incurving of
whole of
upper pinna
EAR FIRMNESS
Pinna soft,
easily
folded, no
recoil
Pinna, soft,
easily
folded, slow
recoil
Cartilage to
edge of
pinna, but
soft in
places,
ready recoil
Pinna firm,
cartilage to
edge, instant
recoil
GENITALIA
MALE/FEMALE (With
hips half abducted)
Neither testi
in scrotum
Labia majora
widely
separated,
labia minora
protruding
At lest one
testis high in
scrotum
Labia majora
almost cover
labia minora
At least one
testis fully
descended.
Labia majora
complete
cover labia
minora

10. Dubowitz Scale – Neurological Criteria
Neurological
Sign
Score Record
Score
Here
0 1 2 3 4 5
Posture
Square
Window
Ankle
Dorsiflexion
Arm Recoil
Leg Recoil
Popliteal Angel
Heel to Ear
Scarf Sign
Head lag
Ventral
Suspension

11. Dubowitz Scale – Neurological Criteria –
Cont
Total
Score
Gestational
Age
(weeks)
Total
Score
Gestational
Age
(weeks)
Total
Score
Gestational
Age
(weeks)
10
12
14
16
18
20
22
24
26
28
27.2
27.8
28.3
28.8
29.4
29.9
30.4
30.9
31.5
32.0
30
32
34
36
38
40
42
44
446
48
32.5
33.0
33.6
34.1
34.6
35.2
35.7
36.2
36.7
37.3
50
52
54
56
58
60
62
64
66
68
37.8
38.3
38.9
39.4
39.9
40.4
41.0
41.5
42.0
42.6

12. Ballard Scale

13. Ballard Scale - Cont

14. Physical Examination – Assessment of
Gestational Age
• Necessary to determine course of
infant and anticipate problems that
may occur

15. Physical Examination – Physical
Appearance
• Skin
– Generally pink
– During first 24 hours of life, may have
acrocyanosis, bluish tinge of the hands and feet

16. Physical Examination – Physical
Appearance
• Skin
– Yellowish tinge
• Indicates the presence of hyperbilirubinemia
with bilirubin level > 4 mg/dL

17. Physical Examination – Physical
Appearance
• Skin
– Yellowish Tinge
• Physiologic jaundice
– Present in many infants first few days after birth
– Caused by break down of fetal red blood cells
and inability of neonatal liver to conjugate the
bilirubin

18. Physical Examination – Physical
Appearance
• Skin
– Yellowish tinge
• Physiologic jaundice
– Normally does not require treatment or may
require exposure to phototherapy lights or
sunlight to aid in lowering the level of bilirubin

19. Physical Examination – Physical
Appearance
• Skin
– Yellowish Tinge
• Pathologic jaundice
– Appears within first 24 hours of life
– Indirect bilirubin levels > 13 mg/dL in term infants or >
15 mg/dL in premature infants
– Direct bilirubin levels > 1.5 mg/Dl
– Indirect levels rise greater than 5 mg/dL in 24 hour
period

20. Physical Examination – Physical
Appearance
• Skin
• Pathologic Jaundice
– Causes Kernicterus
» Bilirubin encephalopathy
Kernicterus
» May result in neurological deficits, including
locomotor dysfunction, cerebral palsy, and
hearing impairment
» In extreme cases, may be treated by exchange
transfusion

21. Physical Examination – Physical
Appearance
• Skin
– Meconium staining
• Indicative of intrauterine asphyxia

22. Physical Examination – Physical
Appearance
• Skin
– Pale
• Indicates severe anemia
• May result from Rh incompatibility
• May result from placental abruption

23. Physical Examination – Physical
Appearance
• Skin
– Vernix
• White, cream cheese-like
material covering
the fetus
• Indicative of prematurity
• Decreases at week 36 and disappears by week 41

24. Physical Examination – Physical
Appearance
• Lanugo
– Fine, downy hair covering the fetus
– Thins around week 28 and disappears by week
32

25. Physical Examination – Physical
Appearance
• General overall tone
– Asymmetry in movement
• Birth injury
• Paralysis
• Neurological impairment

26. Physical Examination – Physical
Appearance
• General overall tone
– Usually in fetal position
• Legs drawn to abdomen, arms flexed, tight to body

27. Physical Examination – Physical
Appearance
• Overall appearance
– Head in proportion to body
• Large head may indicate hydrocephaly
• Small head may indicate microcephaly or
anencephaly

28. Hydrocephaly

29. Microcephaly

30. Anencephaly

31. Physical Examination – Physical
Appearance
• Overall appearance
– Abdomen
• Should move up as chest moves up
• Lag on inspiration indicates mild distress
• Opposing movement (see-saw movement) in
relation to chest indicates severe distress

32. Physical Examination – Physical
Appearance
• Overall appearance
– Scaphoid abdomen
• Concave abdomen
• May indicate diaphragmatic hernia or
agenesis of abdominal organs
– No obvious defects or abnormalities

33. Physical Examination – Vital Signs
• Temperature
– Normal value – 37⁰ C
– Axillary temperature
most common site

34. Physical Examination – Vital Signs
• Temperature
– Neutral thermal environment
• Environmental temperature at which infant’s metabolic
demands and oxygen consumption is minimized
– Chilling the infant causes increasing metabolic rate
and oxygen consumption; infants incapable of
shivering to respond to cold
– Overheating infant increases metabolism as infant
tries to cool; may cause apnea

35. Physical Examination – Vital Signs
• Temperature
– Neutral thermal environment
• Based upon weight and gestational age
• Ratio of body surface area to body mass is
greater in newborn, so heat loss is increased in
comparison to adult; in 1 kg infant, heat loss is
6 times greater

36. Physical Examination – Vital Signs
• Heart rate
– Normal Value – 120 to 160 beats per minute
– Measured either apically or at the brachial artery

37. Physical Examination – Vital Signs
• Respiratory rate
– May be observed, but most accurate if counted
via auscultation
– Normal value – 30 to 60 breaths per minute

38. Physical Examination – Vital Signs
• Respiratory rate
– Periodic breathing
• Periods of apnea lasting less than 20 seconds
• Common in pre-term infants
• No change in heart rate observed

39. Physical Examination – Vital Signs
• Respiratory rate
– True apnea
• Lasts at least 20 seconds
• Accompanied by bradycardia

40. Physical Examination – Vital Signs
• Respiratory rate
– True apnea
• Primary apnea
– Initial apnea after attempt at breathing
– Responds to stimulation

41. Physical Examination – Vital Signs
• Respiratory rate
– True apnea
• Secondary apnea
– Occurs after continuing oxygen deprivation
and attempts to gasp
– Does not respond to stimulation; assisted
ventilation required

42. Physical Examination – Vital Signs
• Respiratory status
– Retractions
• Inward movement of the skin of the chest during
inspiration

43. Physical Examination – Vital Signs
• Respiratory status
– Retractions
• Location of retractions
– Intercostal
– Subcostal
– Substernal
– Supraclavicular

44. Physical Examination – Vital Signs
• Respiratory status
– Retractions
• Indicates respiratory distress, increased
inspiratory effort
• Intercostal retractions – occur between the ribs
• Xyphoid retractions – occur as the xyphoid is
drawn inward

45. Physical Examination – Vital Signs
• Respiratory status
– Nasal flaring
• Widening of the nares during inspiration and
returning to normal during expiration
• Attempt by the infant to get more volume into the
lungs
• Uses principle of Poiseuille’s Law

46. Physical Examination – Vital Signs
• Respiratory status
– Expiratory grunt
• Sound produced as infant exhales against a
partially closed glottis
• Analogous to pursed lip breathing in COPD
patients
• Used instinctively to generate positive pressure in
the airway to maintain integrity of the alveoli

47. Physical Examination – Vital Signs
• Respiratory status
– Silverman-Anderson Index
• Used to evaluate respiratory status

48. Silverman-Anderson Index
Upper Chest
Lower
Chest
Xyphoid
Retractions
Nasal
Flaring
Expiratory
Grunt
0 Synchronized
No
Retractions
None None None
1
Lag on
Inspiration
Just Visible Just Visible Minimal
Audible on
Auscultation
Only
2 See-Saw Marked Marked Marked
Audible With
Naked Ear
• Significance of Silverman-Anderson Score – the Greater the
Number, the More Distress the Infant is in

49. Laboratory Data – Arterial Samples
• Umbilical artery
– Preferred site
– May not produce valid results in presence of
patent ductus arteriosus
– May cause infection or thromboembolism

50. Laboratory Data – Arterial Samples
• Radial artery
– More difficult to obtain
– May be inaccurate secondary to crying induced
by pain of
stick

51. Laboratory Data – Arterial Samples
• Radial artery
– Used to determine presence of patent ductus
arteriosus – compare samples from right radial
artery and umbilical artery (more common
method is echocardiogram)

52. Laboratory Data – Arterial Samples
• Normal values for neonatal arterial samples
– PaO2 – 50 to 70 mmHg
– PaCO2 – 35 to 45 mmHg
– pH – 7.35 to 7.45
– HCO3
- − 22 to 26 mEq/L

53. Laboratory Data – Capillary Samples
• Less hazardous and more easily obtained
than arterial sticks
• Useful in assessing pH and PCO2
– PCO2 and pH will approximate arterial values
– PO2 less than arterial value, but degree of
variation is unreliable for management

54. Laboratory Data – Capillary Samples
• Indications
– Arterial blood gas analysis is indicated but not
available
– Non-invasive monitor readings are abnormal
– Assessment of initiation, administration, or
change in therapeutic modalities is indicated

55. Laboratory Data – Capillary Samples
• Indications
– Change in patient status is detected by history
or physical assessment
– Monitoring of the severity and progression of a
documented disease process is desirable

56. Laboratory Data – Capillary Samples
• Contraindications
– Unsuitable sites are only sites available
• Posterior curvature of heel
• Finger of neonate
• Previous puncture site
• Inflamed, swollen, or edematous tissue

57. Laboratory Data – Capillary Samples
• Contraindications
– Unsuitable sites are only sites available
• Cyanotic or poorly perfused tissue
• Localized areas of infection
• Peripheral arteries

58. Laboratory Data – Capillary Samples
• Contraindications
– Patients less than 24 hours old
– Need for direct analysis of oxygenation
– Peripheral vasoconstriction
– Polycythemia
– Hypotension

59. Laboratory Data – Capillary Samples
• Hazards and complications
– Infection
– Burns
– Hematomas
– Bone calcification

60. Laboratory Data – Capillary Samples
• Hazards and complications
– Nerve damage
– Bruising
– Scarring

61. Laboratory Data – Capillary Samples
• Hazards and complications
– Laceration of tibial artery
– Pain
– Hemorrhage

62. Technique for Obtaining a Capillary
Sample
• Verify physician’s order and need for
procedure
• Ensure that the conditions of the patient have
not changed, e.g., no
change in FIO2
• Assemble the required
supplies

63. Technique for Obtaining a Capillary
Sample
• Wash hands and don gloves
• Warm the heel to approximately 42⁰ C
using a heat pack or other method
• Clean the area
with an antiseptic
solution

64. Technique for Obtaining a Capillary
Sample
• Puncture the skin with the lancet
• Wipe away the first
drop of blood and
observe flow
• Do not squeeze

65. Technique for Obtaining a Capillary
Sample
• Fill the sample tube
from the middle of the
drop of blood
• Place the metal flea in
the capillary tube and
seal both ends

66. Technique for Obtaining a Capillary
Sample
• Cover the site of the puncture with a
band-aid or sterile cotton
• Mix the sample by moving the flea back
and forth using the magnet

67. Technique for Obtaining a Capillary
Sample
• Place the sample in an icy slush for
transport
• Dispose of contaminated
materials properly
• Document the procedure