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CHAPTER 5 Immediate Newborn Care After Birth
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99
Program (NRP),
200
and Centers for Disease Control
and Prevention (CDC)45 recommend skin-to-skin
contact for the term newborn after birth. The AAP
and ABM recommend that full-term neonates be
placed in immediate skin-to-skin contact after
birth and remain there until after the first breastfeeding.
2,8
The CDC45 recommends that the fullterm newborn remain skin-to-skin throughout
the postpartum period as a strategy to facilitate
breastfeeding.
The triad of nearly continuous skin-to-skin
care, exclusive breastfeeding, and close follow-up
after discharge comprises kangaroo mother care
(KMC) or kangaroo care (KC). Promoting uni-
versal KC, the International Network on Kangaroo
Mother Care recommends KC as soon after birth as
possible for as long as appropriate.
141
Even in the LBW
infant, continuous KC that is initiated early results in
a significantly higher proportion of exclusive breastfeeding at 6 months.
135
Using skin-to-skin care after
birth should be standard practice that is vigorously
promoted by all maternal-neonatal health care
providers.
93,197
Skin-to-skin contact in the first hour
of life is estimated to occur in only 1 of 4 newborn
infants.76 Globally breastfeeding within the first hour
of life occurs in only 2 of 5 newborns.
187
Initiation of
breastfeeding later than the first hour of life increases
the risk of neonatal mortality by 33%, while initiation
after 24 hours of life increases neonatal mortality by
187
50%.
Challenges to the implementation of early
and prolonged skin-to-skin care and strategies to
address these barriers are listed in Table 5.2.
Following a period of 60 to 90 minutes after
birth, with close monitoring during skin-to-skin
care and initiation of breastfeeding, routine care
includes a complete physical examination and
preventive interventions. Routine care can be provided at the mother’s bedside. Elements include eye
prophylaxis, administration of vitamin K1, as well as
glucose screening when indicated (see Table 5.3) .
By 60 to 90 minutes of age, every newborn,
regardless of where the baby is being cared
for, must be examined by a nurse with neonatal-perinatal competencies. During the first 6
hours after birth, heart rate, respirations, blood
pressure, degree of alertness, and color of skin
and mucous membranes should be assessed
frequently and the findings recorded. This peri-
od is when clinical signs of the most threatening
infections, cardiopulmonary diseases, and major
congenital abnormalities appear. Table 5.4 presents
a useful scoring system for assessing the pattern
of respirations for signs of respiratory distress;
findings should be documented. The range of
blood pressure in term infants during the first
few hours of life is 65 to 95 mm Hg systolic
and 30 to 60 mm Hg diastolic, with an average
mean blood pressure of 50 to 55 mm Hg. The
blood pressure value will steadily increase from birth
over the transitional period.
91
Abnormal Transition
Regardless of GA or route of delivery, the sequence
of clinical behavior just described is common to all
well newborns. Preterm infants may exhibit variations in the duration of the transitional phases—
shorter phase 1 or longer phase 2—but the patterns
are similar. Knowledge of the normal changes
occurring during transition enables early recognition of a newborn who is not making a
normal extrauterine adaptation.
91
Failure to make a normal transition to extrauterine life may result from obstetric anesthesia or
analgesia, neonatal illness, or stress of intrapartum
hypoxic-ischemic events. If the infant’s pulse, res-
pirations, color, and activity have not stabilized
within the normal ranges after 1 hour of life, a
problem should be suspected and investigated.
Observation for risk factors for abnormal transition is essential. A variety of conditions may result
in significant deviation from the normal sequence
of events during transition. Table 5.5 lists factors
that may alter the sequence or pattern of changes
expected to occur after birth and that result in either
a healthy newborn or a newborn with significant
illness. The health care provider’s challenge is
to discriminate between signs of diseases that
produce an ill newborn and the dynamic, rapidly
changing features that accompany the physiologic adjustments of normal or altered transition but
that still result in a healthy neonate.91 Box 5.2 lists
clinical manifestations of abnormal transition.
PHYSICAL ASSESSMENT OF THE
NEWBORN
Data Collection
HISTORY
Good perinatal care requires the identification of
social, demographic, and medical-obstetric risk
factors that correlate with fetal outcome. This must
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TABLE
5.2
CHALLENGES TO THE IMPLEMENTATION OF EARLY AND PROLONGED SKIN-TO-SKIN CARE AFTER
BIRTH
CHALLENGE/BARRIER STRATEGY FOR CHANGE
Professional (level of education, years of
experience, and primary practice settings)
197
and
parental beliefs, attitudes, and knowledge about
skin-to-skin care.
Institutional culture that does not value skin-toskin care as a standard of practice for all parents
and newborns.
Professional education about parental and neonatal benefits, recommendations for use of skin-to-skin
care and implementation strategies.
Parental education about the benefits of skin-to-skin care: (a) beginning in childbirth education
classes and during clinic visits and (b) reinforced postpartally by all members of the health care
93,94,108,210
team.
A written policy that establishes skin-to-skin care as the standard practice for the maternal-newborn
department, as well as all departments providing services to mothers and their babies.
policy defines expectations for use of skin-to-skin care, who is responsible, who is eligible, and how
safe skin-to-skin care is to be provided.
Using an implementation algorithm to analyze the implementation of skin-to-skin care in the first hour
33,41
after birth
Establishing universal use of skin-to-skin care as a quality improvement activity
Dedicating quality improvement champions to educate, promote, and advise colleagues on changing
practice to improve the use of skin-to-skin care at birth and throughout inpatient care.
Institutional expectation that the entire maternal-neonatal health care team collaborate on educating,
advocating for, and facilitating the use of skin-to-skin care with parents and other professionals such
as anesthesia, laboratory, respiratory therapy, operating room, and recovery room staff.
Professional concerns about care of the newborn:
(a) safety, (b) assessment, (c) maintenance of
physiologic stability, and (d) loss of professional
control.
A qualified neonatal /perinatal professional is responsible and controls newborn care after birth
through (a) assessment of neonatal condition, (b) performance of routine care, and (c) provision
of a supportive/stress-free environment that nurtures neonatal transition with skin-to-skin care.73
Interruptions of early skin-to-skin contact interfere with early breastfeeding.
Parental presence during care does not remove control from the health care provider; rather it
provides an opportunity for professionals to teach new parents about their newborn, how to read
and interpret cues, and how to respond in a developmentally appropriate way. It is an opportunity to
engage parents as partners in care of their neonate by modeling, role-modeling, and teaching them to
care for and advocate for their baby.
Professional concerns about lack of time or
inadequate staffing.
175
If mothers and their newborns are recovered together after birth, the nurse caring for them must be
able to provide the standard of neonatal as well as maternal care.
Provision of neonatal care while the mother or father holds the newborn skin-to-skin is no different
than caring for the newborn in a crib, except that the baby is more comfortable.
Routine care during transition (see Table 5.3) does not differ whether the baby is being held skinto-skin or is in a crib or radiant warmer. Parental proximity provides a more efficient opportunity for
teaching and mentoring new parents, thus enabling them to begin providing care to their newborn
with professional supervision.
Professional perceptions/misperceptions about
willingness of parents to provide skin-to-skin care
because of culture, ethnicity, or religion.
77
Partner with parents to provide care. Individualize the experience of skin-to-skin care93 by including
parents in the decision of how it is to be done—after drying the baby; after clothing the baby; with
baby wrapped in a blanket—any way the parents prefer to skin-to-skin with their baby is the “right
way” to do it.
Interruptions of new mothers/families by visitors,
large groups of visitors, and those who stay at
the bedside of the new family for more than 1
80
hour.
Initiation of a family bonding time (i.e., mothers/newborns resting together in their rooms, limiting
interruptions to medically necessary procedures or upon the request of the mother) as a quality
improvement project that significantly increased exclusive breastfeeding rates.
*
63,73,93,108
15,62,175
The
30,129
37,93,177
153
80
*References 73, 93, 108, 175, 185, 197, 210.
CHAPTER 5 Immediate Newborn Care After Birth
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TABLE
5.3
ROUTINE CARE DURING TRANSITION
ROUTINE CARE TIME DRUG/DOSE COMMENTS
Glucose screening (see
At 30–60 minutes of age By POC glucometer device Abnormal screen: glucose <40 mg/dL
Chapter 15)
Eye prophylaxis Within 1 hour of age Erythromycin (0.5%) or tetracycline
(1%) eye ointment: apply ribbon in
each conjunctival sac
Vitamin K
1
Within 1 hour of age 0.5–1 mg IM as a single dose for
infants <1.5 kg or >1.5 kg
Eye prophylaxis for ophthalmia neonatorum
Bactericidal effect depends on tissue concentration of drug and microorganisms.
Prophylaxis for hemorrhagic disease of the
newborn. Vitamin K concentrations are
physiologically low in breast milk so that
or
exclusively breastfed infants are at increased
risk for vitamin K deficiency, as are infants
with fat malabsorption (e.g., biliary atresia,
cystic fibrosis, α1-antitrypsin deficiency), and
prolonged treatment with antibiotics.
Use sucrose, breastfeeding, kangaroo care,
and topical analgesia for pain relief during
injections (see Chapter 12)
2 mg PO Repeated oral dosing (e.g., first feed, 1 week,
4 weeks, 8 weeks) is necessary; increased risk
for late-onset hemorrhagic disease when infant
receives only one dose.
Oral intake is contraindicated in preterm infants, sick infants with diarrhea or cholestasis,
or those receiving antibiotics.
101
188
*Routine care is required wherever the newly born infant is cared for after birth (e.g., labor-delivery-recovery; labor-delivery-recovery-postpartum; birth center; mother-baby unit; nursery).
IM, Intramuscular; PO, orally; POC, point-of-care.
Modified from Hernandez JA, Thilo E. Routine care of the full-term newborn. In Osborn LC, DeWitt TG, First LR, et al, eds: Pediatrics. St Louis, MO: Mosby; 2005.
TABLE
5.4
CLINICAL RESPIRATORY DISTRESS SCORING SYSTEM*
Respiratory rate (breaths/min) 60 60–80 >80 or apneic episode
Cyanosis None In room air In 40% Fio
Retractions None Mild Moderate to severe
Grunting None Audible with stethoscope Audible without stethoscope
†
Air entry
*The respiratory distress syndrome score is the sum of the individual scores for each of the five observations.
†
Air entry represents the quality of inspiratory breath sounds as heard in the midaxillary line.
Fio2, Fraction of inspired oxygen; RDS, respiratory distress syndrome.
From Downes JJ, Vidyasager DD, Boggs TR, et al. Respiratory distress syndrome in newborn infants: I. New clinical scoring system (RDS score) with acid-base and blood-gas correlates.
Clin Pediatr. 1970;9:325.
0 1 2
2
Clear Delayed or decreased Barely audible
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TABLE
5.5
Maternal Factors Chronic hypertension
Obstetric Factors Rh or other isoimmunization
Neonatal Factors
From Hernandez JA, Thilo E. Routine care of the full-term newborn. In Osborn LC, DeWitt
TG, First LR, et al, eds: Pediatrics. St Louis, MO: Mosby; 2005.
MATERNAL, OBSTETRIC, AND NEONATAL
CONDITIONS THAT INCREASE THE RISK
OF ABNORMAL TRANSITION
Preeclampsia
Diabetes mellitus
Renal disease
Infection
Abuse of tobacco, alcohol, or illicit
drugs
Collagen vascular diseases
Hemizygous hemoglobinopathies
Certain maternal medications
Fetal growth restriction
Decreased fetal movements
Multiple gestation
Oligohydramnios or polyhydramnios
Premature rupture of membranes
Third-trimester bleeding
Delivery by cesarean section
Prematurity (<37 weeks)
Postmaturity (>42 weeks)
Small for gestational age
Large for gestational age
Infection
Metabolic abnormalities
Birth trauma
Major malformations
Anemia
Apgar 0-4 at 1 minute or need for
resuscitation at delivery
BOX
5.2
• Persistent tachypnea, flaring, grunting, and retractions (respiratory
• Diffuse and persistent rales, retractions, flaring, and grunting (res-
• Persistent cyanosis (persistent oxygen saturation <90% in room air)
• Episodes of prolonged apnea (>20 seconds) and bradycardia (<80
• Marked pallor or ruddiness
• Temperature instability, persistently (after 2 to 3 hours of age) low
• Poor capillary filling (>3 seconds) and blood pressure instability
• Unusual neurologic behavior (lethargy, decreased activity with marked
• Excessive oral secretions, drooling, and choking/coughing spells,
Modified from Hernandez JA, Thilo E. Routine care of the full-term newborn. In: Osborn LC,
DeWitt TG, First LR, et al., eds. Pediatrics. St Louis, MO: Mosby; 2005.
SIGNS AND SYMPTOMS
NEONATAL CLINICAL MANIFESTATIONS
SIGNALING ABNORMAL TRANSITION
score >4; duration >first hour of life); fixed bradycardia
piratory score >4; duration >first hour of life)
and prolonged requirements for supplemental oxygen (after 2 to
3 hours of age)
beats/min)
temperature (<36.5°C)
and persistent hypotonia, irritability, excessive tremors and jitteriness)
cyanosis
Unlike the verbalizing adult patient, the nonverbal
neonate communicates needs primarily by behavior.
Through objective observations and evaluations, the neonatal care provider interprets this
behavior into information about the individual
infant’s condition. Initial newborn assessment
includes the following:
• Assessment of GA and fetal growth
• Newborn classification to estimate neonatal
mortality and morbidity risk
• Physical and neurologic examination
• Assessment of neurobiologic development
be an ongoing process, because high-risk patients
may be identified on the first prenatal visit, during
follow-up prenatal visits, or not until the intrapartum and postpartum periods. Review of the
perinatal history is important in determining
significant factors for neonatal health management. Identification of an at-risk maternal situation
is essential to plan and organize care for an at-risk
neonate. Review of the perinatal history includes
antepartum and intrapartum events (see Chapter 2)
and early neonatal events, both in the delivery room
and during transition.
ASSESSMENT OF GESTATIONAL AGE AND
FETAL GROWTH
Optimal management of the pregnant woman and
her fetus is entirely dependent on an accurate knowledge of the age of the fetus. An assessment of GA
should be done on all newborns to establish
maturity and pattern of fetal growth at birth.
Pattern of Fetal Growth. With the use of anthropo-
116
metric measurements, including weight, length, and
head circumference, together with GA, fetal growth
standards have been determined for different ref-
CHAPTER 5 Immediate Newborn Care After Birth
24
2400
2200
2000
1800
1600
1400
1200
1000
25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
Weeks of gestation
24
25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
Weeks of gestation
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103
cm
53
52
51
50
49
48
47
46
45
44
43
42
41
40
39
38
37
36
35
34
33
32
31
30
800
600
400
Intrauterine length chart
both sexes
Intrauterine weight chart
0
g
0
24 25 26 27 28 29 30 31 32 33 34
both sexes
90%
75%
50%
25%
10%
90%
75%
50%
25%
10%
35 36 37 38 39 40 41 42 43
g
4200
4000
3800
3600
3400
3200
3000
2800
2600
cm
3.50
3.40
3.30
3.20
3.10
3.00
2.90
2.80
2.70
2.60
2.50
2.40
2.30
2.20
2.10
2.00
1.90
1.80
1.70
1.60
37
36
35
34
33
32
31
30
29
28
27
26
25
24
23
22
ntrauterine head growth
circumference
both sexes
0
Intrauterine weight-length ratio
0
24 25 26 27 28 29 30 31 32 33 34
100 w g/L
both sexes
3
cm
90%
75%
50%
25%
10%
90%
75%
50%
25%
10%
35 36 37 38 39 40 41 42 43
FIGURE 5.3 Colorado intrauterine growth charts. (From Lubchenco LO, Hansman C, Boyd E, et al. Intrauterine growth in weight, length
and head circumference as estimated from live births at gestational ages from 26–43 weeks. Pediatrics. 1966;37:403.)
erence populations from various locations. From
these data, it is apparent that there are variations in
“normal” weight at any given GA from one locale
to another. This variation is related to a number of
factors, including sex, race, socioeconomic class, and
even altitude. The Colorado intrauterine growth
curves presented by Lubchenco and colleagues
in the 1960s (Fig. 5.3) are unique in that each
anthropometric measurement was related to GA.
The graphic display of this relationship provides
a useful and simple method for determining
the appropriateness of growth with respect to
GA. New fetal growth graphs include the Eunice
Kennedy Shriver National Institute of Child Health
and Human Development (NICHD) Fetal Growth
Studies,
38,39
the INTERGROWTH-21st project,
145
and the WHO Multicentre Growth Reference
105
Study.
Even though such curves differ in details,
all demonstrate nearly linear growth between 20
and 38 weeks of gestation, with slowing thereafter.
In 1967, Battaglia and Lubchenco used the GA/
BW relationship to categorize those infants
whose BWs were less than the 10th percentile
as small for gestational age (SGA), those weigh-
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Classification of newborns
Grams
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ing more than the 90th percentile as large for
gestational age (LGA), and the remaining 80% as
appropriate for gestational age (AGA) (Fig. 5.4).
19
Gestational Age. GA can be assessed by obstetric meth-
ods and by pediatric methods. The most reliable
antenatal method combines early ultrasound evaluation with information about the mother’s last
menstrual period (LMP). Dating gestation based
on the mother’s LMP can be highly accurate if the
mother is sure of the dates of her last menstrual period and the cycles are regular (see Chapter 2). Early
antenatal ultrasonography appears to have 95% confidence intervals of less than 7 days.
199
Ultrasonography
is preferred because it confirms conception, assesses
gestation, and evaluates fetal growth.
5000
4750
4500
4250
4000
3750
3500
3250
3000
2750
2500
2250
2000
1750
1500
1250
1000
750
500
by birth weight and gestational age
Pediatric methods of determining GA are
based on physical characteristics and neurologic
examination. Within 2 hours after birth, every
newborn should have an assessment of GA by
physical characteristics.8 Physical criteria are used
because they progress in an orderly fashion with
increasing gestation. Neurologic criteria involve the
assessment of posture, passive and active tone, reflexes, and righting reaction. Numerous tables, charts,
and graphs are available for determining GA. Some
tables are more subjective and laborious than others,
and each has proponents and detractors. There is
no perfect system, and all require the examiner
to be familiar with and have experience in their
use. At least one form should be adopted and
consistently used by each nursery.
90th %
Large for gestational age
10th %
Appropriate for gestational age
Small for gestational age
FIGURE 5.4 Classification of newborns by birth weight and gestational age. Birth weight of liveborn singleton white infants at gestational age from 24
to 42 weeks. (From Battaglia F, Lubchenco LO: A practical classification of newborn infants by weight and gestational age. J Pediatr. 1967;7:159.)
24 4645444342414039383736
2625
Pre-term Term Post-term
353433323130292827
Weeks of gestation
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105
GA can be assessed most accurately by
combining the physical criteria and the neurologic assessment. The revised Ballard system9
displayed in Fig. 5.5 is a combined scoring sys-
tem that is widely used. The Ballard system
incorporates physical maturity (six characteristics) and neuromuscular maturity (six criteria)
on an equal basis and includes assessment for
extremely premature infants. The score for the
neuromuscular and physical maturity is added and
noted under the maturity rating column. Weeks of
gestation are assigned according to the maturity
rating score.
Neuromuscular maturity
10 1234 5
Posture
Square
window
(wrist)
Arm recoil
Popliteal
angle
Scarf sign
90° 90° 60° 45° 30° 0°
180° 140°–180° 110°–140° 90°–110° 90°
180° 160° 140° 120° 100° 90°
Assessment of Gestational Age in Very-Low-Birth-Weight
and Extremely Premature Infants. Accuracy in estima-
tion of GA is important because, for VLBW and
extremely premature infants, small differences in
GA result in large differences in outcome and may
influence treatment and decision making by parents
and professionals.65 Research has shown that estimation of GA in very immature preterm infants is
inaccurate. For preterm infants of 22 to 28 weeks
of gestation, estimates of GA (by the scoring system
shown in Fig. 5.5) exceeded the GA (by dates) by
1.3 to 3.3 weeks.65 These inaccuracies must be considered in decision making, and better scoring systems are needed, particularly in the delivery room.
90°
Heel to ear
Skin
Lanugo
Plantar
surface
Breast
Eye/ear
Genitals
male
Genitals
female
FIGURE 5.5 Clinical estimation of gestational age. (From Ballard JL, Khoury JC, Wedig K, et al. New Ballard score, expanded to include
extremely premature infants. J Pediatr. 1991;119:417.)
Sticky,
friable,
transparent
Heel-toe
40–50 mm: 1
40 mm: 2
Imperceptible
Lids fused
loosely: 1
tightly: 2
Scrotum
smooth
Clitoris
prominent,
labia flat
Gelatinous
Smooth pink,
red,
50 mm
no
crease
Barely
pinna flat,
Scrotum
empty,
Prominent
clitoris,
small
visible veins
Faint
red marks
Flat areola,
no bud
Sl. curved
pinna; soft,
slow recoil
Testes in
upper canal,
rare rugae
Prominent
clitoris,
enlarging
minora
translucent
None Sparse Abundant Thinning
perceptible
Lids open;
stays folded
flat,
faint rugae
labia minora
Superficial
peeling
and/or rash,
few veins
Anterior
transverse
crease only
Stippled
areola
1–2 mm bud
Well-curved
pinna;
soft but
ready recoil
Testes
descending,
few rugae
Majora
and minora
equally
prominent
Cracking
pale areas,
rare veins
Bald
areas
Creases
ant. 2/3
Raised
areola,
3–4 mm bud
Formed
and firm,
instant
recoil
Testes
down,
good
rugae
Majora
large,
minora
small
Parchment
deep,
cracking,
no vessels
Mostly
bald
Creases
over
entire sole
Full areola,
5–10 mm
bud
Thick
cartilage,
ear stiff
Testes
pendulous,
deep rugae
Majora
cover
clitoris
and minora
Leathery,
cracked,
wrinkled
Maturity ratingPhysical maturity
Score Weeks
10 20
522
024
526
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
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One quick and effective way to estimate GA in
VLBW infants is by measuring foot length. Foot length
of AGA preterm infants has been correlated with
GA (Table 5.6). In short gestation (i.e., 24th to 34th
week), there is a predictable increase in the mean
foot length of 0.5 cm every 2 weeks. Measurement
of foot length from the posterior prominence of the
heel to the tip of the first (great) toe with a millimeter ruler is a rapid and simple method of assessing
maturation of all newborns, even the very ill, VLBW,
moderate intrauterine growth restricted (IUGR)
TABLE
5.6
GESTATIONAL AGE (WEEKS) NO. OF INFANTS MEAN MEDIAN SD RANGE
24 6 4.22 4.1 0.17 3.8–4.4
25 12 4.5 4.5 0.08 4.4–4.6
26 16 4.72 4.7 0.07 4.65–4.9
27 19 4.99 5.0 0.14 4.8–5.2
28 18 5.23 5.2 0.13 5.0–5.5
29 22 5.47 5.4 0.129 5.3–5.7
30 27 5.75 5.75 0.23 5.6–6.2
31 24 5.95 6.0 0.19 5.7–6.23
32 21 6.22 6.2 0.13 6.0–6.4
33 25 6.5 6.5 0.26 6.3–6.9
34 24 6.77 6.8 0.20 6.5–7.1
35 20 7.1 7.0 0.15 6.8–7.3
36 22 7.27 7.27 0.21 7.0–7.6
37 24 7.51 7.5 0.24 7.4–8.0
38 40 7.92 8.0 0.23 7.6–8.3
39 42 8.22 8.3 0.32 7.9–8.6
40 56 8.6 8.7 0.37 8.2–8.9
41 22 8.75 8.9 0.30 8.3–9.1
42 12 9.1 9.2 0.33 8.7–9.3
43 8 9.27 9.3 0.25 8.9–9.6
FOOT LENGTH BY GESTATIONAL AGE*
FOOT LENGTH (cm)
infant. With this method, as with other physical
measurements of GA, one must consider the standard deviation in interpreting results.
In areas where obstetric ultrasonography is not
readily available and birth attendants do not estimate
GA, research on other methods of determining
GA is ongoing. Methods being investigated include
DNA methylation in cord blood,
newborn fetal hemoglobin levels,
of newborn metabolic markers,
106
measurement of
202
measurement
154
and noninvasive
measurement of cell-free RNA transcripts.
137
*Applies to both male and female infants
SD, Standard deviation.
From Hernandez JA, Lazarte R, Pisano D, et al. Foot length and gestational age in the very-low-birth-weight infant. The Children’s Hospital Pediatric Update. September 1987; 4.
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107
SIGNS OF PHYSICAL MATURITY
To use these charts accurately, the examiner must
assess the following physical characteristics
Vernix. At 20 to 24 weeks, vernix is produced by
116,189
:
sebaceous glands. Vernix is high in fat content and
protects the skin from the aqueous amniotic fluid
and bacteria. At 36 weeks, the white, cheeselike
material begins to decrease and disappears by 41
weeks Note the amount and distribution of ver-
nix on the baby’s skin (best done in the delivery
room).
Skin. In early gestation, the skin of the fetus is
very transparent, and veins are easily seen. As
gestation progresses, the skin becomes tougher,
thicker, and less transparent. By 37 weeks, very
few vessels are visible. From 36 weeks to delivery,
fat deposits begin to form and grow. In a postterm
infant, desquamation will be prominent at the
ankles, wrists, and possibly palms and soles. As gestation progresses, the loss of vernix and subcutaneous
tissue causes wrinkling. Note skin turgor, color,
texture, and the prominence of vessels, especially on the abdomen.
Lanugo. At 20 weeks, fine, downy hair (lanugo)
appears over the entire body of the fetus. At 28
weeks, it begins to disappear around the face and
anterior trunk. At term, a few patches of lanugo may
still be present over the shoulders. Note the distri-
bution of lanugo, first on the face and anterior
trunk and then on the rest of the body.
Hair on the Head. Hair appears on the head at 20
weeks. At 20 to 23 weeks, the eyelashes and eyebrows develop. From 28 to 36 weeks, the hair is
fine and woolly and sticks together. It appears
disheveled and sticks out in bunches from the head.
At term, the hair lies flat on the head, it feels silky,
and single strands are identifiable. Note the quality
and distribution of the hair, and feel its texture. Scalp hair abnormalities (e.g., growth pattern,
hypopigmentation, quantity, distribution, texture)
may be external markers of genetic, metabolic, and
neurologic disorders.
Sole Creases. Sole creases develop from toe to heel,
progressing with GA. An infant with IUGR and
early loss of vernix may have more sole creases than
expected. By 12 hours after birth, the skin has
dried to a point that sole creases are no longer
a valid indicator of GA. Note the extent of sole
creases (Fig. 5.6).
Eyes. In the third month of fetal life, the eyelids fuse;
they reopen between 26 and 30 weeks. In neonates
of 27 to 34 weeks of gestation, examination of
A B C
FIGURE 5.6 Sole creases at different gestational ages. A, Age 31 to 33 weeks of gestation. B, Age 34 to 38 weeks of gestation. C, Term.
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the anterior vascular capsule of the lens is useful
in assessing GA. GA is determined by assessing
the level of remaining embryonic vessels on the
lens (Fig. 5.7). Before 27 weeks, the hazy cornea
prevents visualization of the vascular system. After
34 weeks, only remnants of the vascular system are
visible. Because rapid atrophy occurs in the vascular
system, an ophthalmoscopic examination should be
performed during the first physical examination or
within 24 to 48 hours after birth.
Ears. Before 34 weeks, the pinna of the ear is a slightly
formed, cartilage-free double thickness of skin. When
it is folded, it remains folded. As gestation progress-
es, the pinna develops more cartilage, resulting in
better form, so that it recoils when folded (Fig.
5.8). Check ear recoil by folding the ear in half or
into a three-corner-hat shape. Consistently folding it
the same way helps the care provider develop a baseline for judging maturity. Note the form and carti-
lage development of the ear. Examine both ears
to be sure they are the same and without defects.
Grade 4
27-28 weeks
Grade 3
29-30 weeks
Breast Development. Breast development is the
result of the growth of glandular tissue related to
high maternal estrogen levels and fat deposition.
The areola is raised in an infant at 34 weeks of
gestation. Note the size, shape, and placement
of both breasts. Palpate the breast nodule, and
determine its size. If the infant is growth restricted, breast size may be less than expected at term.
Genitalia
Male Genitalia. At 28 weeks, the testes begin to
descend from the abdomen. By 37 weeks, they are
high in the scrotum. By 40 weeks, the testes are
completely descended, and the scrotum is covered
with rugae. As gestation progresses, the scrotum
becomes more pendulous (Fig. 5.9). Note the pres-
ence of rugae on the scrotum and its size in relation to the position of the testes. When examin-
ing the baby for descended testes, put the fingers
of one hand over the inguinal canal to prevent the
testes from ascending into the abdominal cavity, and
palpate the scrotal sac with the other hand.
Female Genitalia. Early in the female’s gestation, the
clitoris is prominent with small and widely separated
labia. By 40 weeks, the fat deposits have increased
in size so that the labia majora completely cover the
labia minora (Fig. 5.10) . Note the labial develop-
ment in relation to the prominence of the clitoris.
Grade 2
31-32 weeks
FIGURE 5.7 Anterior vascular capsule and gestational age. (From Hittner
H, Hirsch NJ, Rudolph AJ. Assessment of gestational age by examination of the
anterior vascular capsule of the lens. J Pediatr. 1977;91:455.)
Grade 1
33-34 weeks
A B
FIGURE 5.8 Ear form and gestational age. A, Age 34 to 38 weeks of
gestation. B, Term.
NEWBORN CLASSIFICATION AND
NEONATAL MORTALITY AND
MORBIDITY RISKS
At birth, after establishing fetal maturity and pattern
of fetal growth, the next step is to ensure appropriate assignment of a clinical newborn classification,
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