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An Introduction to the
Nursery
Newborn Nursery Faculty:Division of General
Pediatrics
Photgraph: Anne Geddes
Created by: Maria Kelly MD
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Objectives Recognize what aspects of the
maternal history are important for a complete newborn assessment
Understand the basics of a newborn physical exam and familiarize yourself with normal variations and/or abnormalities
Learn the basics of a Ballard gestational age assessment
Understand the importance of gestational age in the complete newborn assessment
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Your daily newborn responsibilities…
Please see the document “Newborn Orientation for Family Medicine Residents”. This document explains the day to day activities, goals, objectives and responsibilities.
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Newborn Record
(Page 1 - Admission)
Maternal History and Delivery Record
Infant record Initial Exam Assessment and
Plan**Medical students should NOT write in the red area. They may document in the green area as long as enough room is left for you to document a full note. **
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Newborn Record (Page 2 -
Discharge) Discharge Exam Information to
be included in Discharge Summary
Hospital Course Summary**Medical students should NOT
write in the red area. They may document in the green area as long as enough room is left for you to document a full note. **
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Pertinent Maternal History
Everyone involved in the care of the infant should have knowledge of the relevant maternal history Pre-partum Antenatal Perinatal
This information can routinely be found on the maternal fact sheet in newborn’s chart (yellow form) or in the mother’s chart.
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Maternal Fact
Sheet Maternal
History Infant
Record Delivery
Record**Although the
maternal serologies are listed on this sheet we do NOT believe them. All
serologies must be confirmed by lab
report!**
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Maternal History
Family History Inherited diseases (cystic fibrosis, sickle
cell disease, metabolic disease, polycystic kidneys, hemophilia, and history of perinatal death)
Maternal History Age, blood type, chronic diseases,
diabetes, hypertension, renal disease, cardiac disease, bleeding disorders, infertility, recent infections/exposures, rubella status, GBS status, and STD’s
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Maternal History Sexually transmitted diseases (STD’s)
HIV Syphilis (RPR or VDRL) Hepatitis B (HepBsAg) Gonorrhea (GC DNA) Chlamydia (Cz DNA)
Group B Streptococcus “GBS” (streptococcus agalactiae) Rectal/vaginal swab results at 35-37 weeks
gestation
**all maternal results must be verified/confirmed by visualizing a lab report**
Group B Strep
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Maternal History
Previous pregnancies Abortions, fetal demise, neonatal death,
premature births, postdate births, malformations, respiratory distress syndrome, jaundice, apnea
Drug history Medications, drugs of abuse, ETOH,
tobacco usage during pregnancy
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Maternal History
Current Pregnancy Gestational age, results of fetal testing,
pre-eclampsia, bleeding, trauma, infection, surgery, polyhydramnios, oligohydramnios, glucocorticoids, labor suppressants, antibiotics
Important factors during labor……
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Labor and Delivery:
Important Factors
Onset of labor: spontaneous vs.
inducedRupture of
membranes
Analgesia
Anesthesia
Apgar scores
Duration of labor
Placental exam
Resuscitation
Presentation
Maternal fever
Fetal monitoring
Method of delivery
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Medical Student Progress Note
Include brief maternal and child history relevant to pregnancy and birth
S: Include subjective components O: Include objective components
Include growth parameters, vital signs (highlow), I/O’s Include COMPLETE exam
A: Includes overall assessment of infant P: Include plan
Identify risk factors and/or concerns for sepsis, jaundice, feeding, murmurs, social, etc.
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Newborn Examination A child’s first exam should be one of the
most thorough the child ever receives. The newborn assessment is different from
an adult exam!!! If you start at the head and plan to go to toes,
a quiet child may no longer be quiet!
Look, listen, feel Listen to heart, lungs, and abdomen while the
infant is quiet, then attempt to work “head to toe”.
May have to continuously adjust your exam and examine what becomes available
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Cardiopulmonary Exam Look at the chest
Color, symmetry, work of breathing, and respiratory rate
Observe for retractions, nasal flaring, malformations, abnormal pulsations, and parasternal heave.
Heart examination Rate, rhythm, murmurs, gallops, clicks,
loudest on right side or left side, location and strength of PMI (point of maximal impulse)
PDA murmur sound link: http://www.merck.com/mrkshared/mmanual/audio/197au23.jsp
Check femoral pulses and compare with brachial pulses
Listen to the lungs Bilateral breath sounds, crackles, wheezes, or
rhonchi
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Abdominal Exam
Inspect first Listen for bowel sounds
Present or absent Feel the tummy!
Palpate for liver, spleen, kidneys, and presence of masses
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Genitourinary Exam: Male
Penis: Phimosis is normal!!! Do not attempt to retract the foreskin
over the glans Look for epi- or hypospadias
Testes: Feel both testes, look for hydroceles, hernias, or other abnormalities
Ambiguous genitalia Anus: Check for patency and
placement
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Genitourinary Abnormalities: Male
Normal neonatal phimosiswww.vghtpe.gov.tw
Hypospadiaswww.meddean.luc.edu
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Genitourinary Abnormalities: Male
Left hydrocelewww1.medizin.uni-halle.de
Left inguinal herniawww.pediatriconcall.com
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Genitourinary Exam: Female
Labia: Large labia major is common due to maternal
hormones Examine for fusion and clitoral hypertrophy
Vagina: Vaginal discharge is common; white & mucoid
to pseudomenses May have hymenal tags
Ambiguous genitalia Anus: check for patency and placement
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Genitourinary Abnormalities
Ambiguous genitaliawww.thefetus.net
Imperforate anuswww.bms.brown.edu
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Genitourinary Abnormalities
Hymenal Taghttp://newborns.stanford.edu/PhotoGallery/HymenalTag2.html
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Extremities Digits: number and abnormalities
Examples: polydactyly, syndactyly, clinodactyly, simian creases
Arms/Legs: Examine range of motion, tone, asymmetry
Clavicles Feel for fractures!!!
Hips: Barlow and Ortaloni exam Clicks are common and benign due to
estrogenic effect Clunks are indicative of hip
dislocation/relocation and can represent developmental dysplasia of the hip
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Extremity Abnormalities
Single Palmar Creasewww.emedicine.com
Polydactylywww.mrcophth.com
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Spine
Flip infant onto your forearm and look at entire spine
Feel the vertebral column for bony defects
Examine sacral area closely Clefts, hairy tufts, change in
pigmentation Look for gross defects
Meningomyelocele, teratomas, sinus tracts
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Vertebral Abnormalities
Sacral Sinus and Dimplewww.adhb.govt.nz
Hair tuftwww.fammed.washington.edu
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Skin Look at the skin during the entire
exam Jaundice Mongolian spots (Important to
document!!!) Rashes
- HSV lesions - Milia- Transient pustular melanosis - Cradle
cap- Neonatal Acne - Stork bites- Erythema toxicum neonatorum
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Skin Findings
Mongolian Spot (Congenital dermal melanocytosis) www.koori-childrens-clinic.com dermis.multimedica.de
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Skin Findings
Erythema toxicum neonatorum
www.dermis.net www.nursing.duq.edu
Transient pustular melanosiswww.ahsl.co.nz ethnomed.org
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Skin Findings
Sebaceous Gland Hyperplasiawww.ahsl.co.nz
Neonatal Acnewww.derm101.com
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Skin Findings
Stork bite (Nevus simplex)www.ritari.org
Cradle Cap (Seborrheic dermatitis)en.wikipedia.org
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HEENT Head
Head circumference (average 34-35cm) Look and feel scalp
Caput succedaneum, cephalohematoma, abrasions, sutures, fontanelles (anterior and posterior)
Ears Formed, pits, tags, rotation, position,
size Nose
Nares patent bilaterally
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Head Findings
Caput succedaneumwww.fammed.washington.edu
Cephalohematomawww.emedicine.com
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HEENT
Mouth Check for clefts (lip and palate),
arched palate, neonatal teeth, Epstein pearls
Eyes Scleral hemorrhages, icterus,
discharge, pupil size, extra-ocular movements, red reflex, clear cornea
Neck Range of motion, goiter, cysts, clefts,
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HEENT Findings
Absent red reflexwww.stjude.org
Epstein’s pearlswww.dentistry.bham.ac.uk
Cleft lip and palatewww.thefetus.net
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Neurologic Exam
Look carefully and evaluate neurologic status during exam of other systems Symmetry of motion, tone, bulk,
response to stimulation, pitch of cry, repetitive motions, palsies
Primitive Reflexes: Moro, suck, rooting, palmar/plantar grasp, stepping
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Newborn Reflexes
Palmar and plantar graspwww.winfssi.com
Rooting reflexwww.winfssi.com
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Newborn Reflexes
Moro reflexwww.nlm.nih.gov
Stepping reflexwww.imi.org.uk
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Newborn Exam Pointers
Listen first, a crying baby doesn’t promote a good listening environment
Take your time, develop a system, and use it every single time
Look at every square inch of the baby!
Follow-up any abnormalities Don’t forget gestational age
assessment
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So what’s the big deal with gestational age?
Gestational age can predict problems, morbidity, mortality, and can help you keep alert for certain problems Pre-term infants are at a higher risk for:
Respiratory distress syndrome Necrotizing enterocolitis Patent ductus arteriosis Apnea
Post-term infants are at a higher risk for: Asphyxia Meconium aspiration Trisomies and other syndromes
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Gestational Age & Birth Weights
Gestational Age: Pre-term: < 37 weeks Term: 37-41 6/7 weeks Post-term: 42 or more weeks
Term Infant (weight classification) LGA: >4000 g AGA: 2500-3999 g SGA: <2500 g
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Gestational Age
Classification
Pre-term, term, and post term infants must all be plotted to determine if they are SGA, AGA, and LGA with regards to weight, length, and head circumference.
LGA
AGA
SGA
X X X
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Summary
Be thorough Be complete Find a system and use it each and
every time!!! The more infants you examine, the
more comfortable you will become with normal variations.
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References
Nelson’s Textbook of Pediatrics, 17th ed
Gomella’s Neonatology, 5th ed