Maternal Week 7-9 PDF

**WEEK 7: INTRAPARTAL CARE (ASSESSMENT OF THE LABORING MOTHER)** **Theories of Labor Onset** - Labor normally begins when a fetus is sufficiently mature to cope with extrauterine life yet not too large to cause mechanical difficulty with birth. - Several theories including a combinati...

**WEEK 7: INTRAPARTAL CARE (ASSESSMENT OF THE LABORING MOTHER)** **Theories of Labor Onset** - Labor normally begins when a fetus is sufficiently mature to cope with extrauterine life yet not too large to cause mechanical difficulty with birth. - Several theories including a combination of factors originating from both the woman and fetus have been proposed to explain why progesterone withdrawal begins: - **Uterine muscle stretching**, which results in release of prostaglandins. - **Pressure on the cervix**, which stimulates the release of oxytocin from the posterior pituitary. - **Oxytocin stimulation**, which works togethers with prostaglandins to initiate contractions. - **Change in the ratio of estrogen to progesterone (**increasing estrogen in relation to progesterone, which is interpreted as progesterone withdrawal) - **Placental age,** which triggers contraction at a set point - **Rising fetal cortisol levels,** which reduces progesterone formation and increases prostaglandin formation. - **Fetal membrane production of prostaglandin,** which stimulates contraction. **Signs of Labor** - **Preliminary Signs of Labor** - Before a labor, a woman often experiences subtle signs that labor imminent. - It is important to review these with women during the last trimester of pregnancy co they can more easily recognize beginning signs. - **Lightening** - In primiparas, **lightening,** or descent of the fetal presenting part into the pelvis, occurs approximately 10-14 days before labor begins. - This fetal descent changes a woman abdominal contour, because it positions the uterus lower and more anterior in the abdomen. - Lightening gives a woman relief from the diaphragmatic pressure and shortness of breath that she has been experiencing and lightens her load. - **Increase in Level of Activity** - This increase in activity is related to an increase in epinephrine release initiated by a decrease in progesterone produced by the placenta. - This additional epinephrine prepares a woman's body for the work of labor ahead. - **Slight loss of weight** - As progesterone level falls, body fluid is more easily excreted from the body. - This increase in urine production can lead to weight loss between 1 to 3 pounds. - **Braxton Hicks Contraction** - Woman usually notices extremely strong Braxton Hicks contractions. - **Ripening of the cervix** - At term, the cervix becomes still softer (described as "**butter-soft"**), and it tips forward. - Cervical ripening this way is an internal announcement that labor is very close at hand. - **Signs of True Labor** - It involve uterine and cervical changes. - **Uterine Contraction** - The surest sign that labor has begun is productive uterine contractions. - Because contractions are involuntary and come without warning, their intensity can be frightening in early labor. - Helping a woman appreciate that she can predict when her next one will occur and therefore can control the degree of discomfort she feels by using breathing exercises offers her a sense of well-being. - **Show** - As the cervix softens and ripens, the **mucus plug** that filled the cervical canal during pregnancy (operculum) is expelled. - The exposed cervical capillaries seep blood as a result of pressure exerted by the fetus. - This blood, mixed with mucus takes on pink tinge and is referred to as "**show**" or "**bloody show**". - Women need to be aware of this event so that they do not think they are bleeding abnormally. - **Rupture of Membranes** - Labor may begin with rupture of the membranes, experienced either a **sudden gush** or as **scanty**, slow seeping of clear fluid from the vagina. - Early rupture of the membranes can be advantageous as it can cause the fetal head to settle snugly into the pelvis, shortens labor. - **2 risks associated with ruptured membranes** are, **intrauterine infection** and **prolapse of the umbilical cord,** which could cut off the oxygen supply of the fetus. - In most instances, if labor has not spontaneously occurred by 24 hours after membrane ruptured and the pregnancy is at term, labor will be induced to help reduce these risks. **Components of Labor** - A successful labor depends on four integrated concepts: 1. A woman's pelvis (**the passage**) is of adequate size and contour. 2. The passenger (**the fetus**) is of appropriate size and in an advantageous position and presentation. 3. The powers of labor (**uterine factors**) are adequate. (the powers of labor are strongly influenced by the woman's position during labor) 4. A woman's psychological outlook is preserved, so that afterward labor can be viewed as positive experience. 1. **Passage** - The passage refers to the route a fetus must travel from the uterus through the cervix and vagina to the external perineum. - Two pelvic measurements are important to determine the adequacy of the pelvic size: **the diagonal conjugate (**the anteroposterior diameter of the inlet**)** and the **transverse diameter of the outlet.** - At the pelvic inlet, the **anteroposterior diameter** is the narrowest diameter**;** at the outlet, the **transverse diameter** is the narrowest. 2. **Passenger** - The passenger is the **fetus** - The body part of the fetus that has the widest diameter is the head, so this is the part least likely to be able to pass through the pelvic ring. - Whether a fetal skull can pass depends on both its structure (bones, fontanelles, and suture lines) and its alignment with the pelvis. - **Molding** is change in the shape of the fetal skull produced by the force uterine contractions pressing the vertex of the head against the not-yet dilated cervix. - **Engagement** refers to the settling of the presenting part of the fetus far enough into the pelvis to be at the level of the ischial spines, a midpoint of the pelvis. - **Station** - It refers to the relationship of the presenting part of a fetus to the level of ischial spines. - When the presenting fetal part is at the level of ischial spines, it is at a 0 station (synonymous with engagement). - If the presenting part is above the spines, the distance is measure and described as **minus stations**, which range from 1 to 4 cm. - If the presenting part is below the ischial spines, the distance is stated as **plus stations,** (+1 to +4) - At a +3 or +4 station, the presenting part is at the **perineum** and can be seen if the vulva is separated (ex. Crowning) - **Fetal Attitude** - **Attitude** describes the degree of flexion a fetus assumes during labor or the relation of the fetal parts to each other. - A fetus in **good attitude** is in complete flexion - The spinal column is bowed forward - The head is flexed forward so much that the chin touches the sternum - The arms are flexed and folded on the chest, the thighs are flexed onto the abdomen - And the calves are pressed against the posterior aspect of the thighs. - This normal "fetal position" is advantageous for birth because it helps a fetus present the smallest anteroposterior diameter of the skull to the pelvis and also because it puts the whole body into an ovoid shape, occupying the smallest space possible. - A fetus is in moderate flexion if the chin is not touching the chest but is in an **alert or "military position"** - A fetus in **partial extension** present the "brow" of the head to the birth canal. - **Descent** - Widest part of the fetus (the biparietal diameter in a **cephalic presentation**; the intertrochanteric diameter in a **breech presentation)** has passed through the pelvis inlet or the pelvic inlet has been proved adequate for birth. - **Fetal Lie** - **Lie --** relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis of a woman's body - Whether the fetus is lying in a horizontal (transverse) or a vertical (longitudinal) position. **Types of Fetal Presentation** - Fetal presentation denotes the body part that will first contact the cervix or be born first. - This is determined by a combination of fetal lie and the degree of fetal flexion (attitude) 1. **Cephalic Presentation** - It is the most frequent type of presentation, occurring as often 95% of the time. - With this type of presentation, the fetal head is the body part that will first contact the cervix. - The 4 types of cephalic presentation: **vertex, brow, face, and mentum** 2. **Breech Presentation** - It means that either the buttocks or the feet are the first body parts that will contact the cervix. - It occurs in approximately 3% of births and are affected by fetal attitude - A **good attitude** brings the fetal knees up against the fetal abdomen - A **poor attitude** means that the knees are extended. - Breech presentations can be difficult births, with the presenting point influencing the degree of difficulty. - Three types of breech presentation: **complete, frank, and footing** 3. **Shoulder Presentation** - In a transverse lie, a fetus lies horizontally in the pelvis so that the longest fetal axis is perpendicular to that of the mother. - The presenting part is usually one of the shoulder (acromion process), an iliac crest, a hand, or an elbow. - **Fetal position** - Position is the relationship of the presenting part to a specific quadrant of a woman's pelvis. - The maternal pelvis is divided into four quadrants according to the mother's right and left: **right anterior, left anterior, right anterior, and left posterior**. **Mechanisms of Labor (Cardinal Movements)** - Passage of a fetus through the birth canal involves several different position changes to keep the smallest diameter of the fetal head (in cephalic presentations) always presenting to the smallest diameter of pelvis. - These position changes are termed the cardinal movements of labor: **descent, flexion, internal rotation, extension, external rotation, and expulsion.** 1. **Descent** - Downward movement of the biparietal diameter of the fetal head to within the pelvic inlet. - **Full descent** occurs when the fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor. - Descent occurs because of pressure on the fetus by the uterine fundus. - The pressure of the fetal head on the sacral nerves at the pelvic floor cause the mother to experience a pushing sensation. - **Full descent** may be aided by abdominal muscle contraction as the woman pushes. 2. **Flexion** - As descent occurs and the fetal head reaches the pelvic floor, the head bens forward onto the chest, making the smallest anteroposterior diameter (the suboccipitobregmatic diameter) present to the birth canal. - Flexion is also aided by abdominal muscle contraction during pushing. 3. **Internal rotation** - During descent, the head enter the pelvis with the fetal anteroposterior head diameter (suboccipitobregmatic, occipitomental, or occipitofrontal, and depending on the amount of flexion) in a diagonal transverse position. - The head flexes as it touches the pelvic floor, and the occiput rotates to bring the head into the best relationship to the outlet of the pelvis (the anteroposterior diameter is now in the anteroposterior plane of the pelvis) - This movement brings the shoulders, coming next, into the optimal position to enter the inlet, putting the widest diameter of the shoulders (a transverse one) in the line with the wide transverse diameter of the inlet. 4. **Extension** - As the occiput is born, the back o the neck stops beneath the pubic arch and acts as the pivot for the rest of the head. - The head extends. And the foremost parts of the head, the face and chin, are born. 5. **External Rotation** - In external rotation, almost immediately after the head of the infant is born, the head rotates (from the anteroposterior position it assumed to enter the outlet) back to the diagonal or transverse position of the early part of labor. - This brings the aftercoming shoulders into an anteroposterior position, which is best for entering the outlet. - The anterior shoulder is born first, assisted perhaps by downward flexion of the infant's head. **-** Once the shoulders are born, the rest of the baby is born easily and smoothly because it's smaller size. **-** This movement, called expulsion, is the end of the pelvic division of labor. 3. **Powers of Labor** - The second important requirements for a successful labor are effective powers of labor. - This is the force supplied by the fundus of the uterus, implemented by uterine contractions, a natural process that causes cervical dilation and then expulsion of the fetus from the uterus. - After full dilation of the cervix, the primary power is supplemented by use of the abdominal muscle. - It is important for women to understand they should not bear down with their abdominal muscles until the cervix is fully dilated. - Doing so impedes the primary force and could cause fetal and cervical damage. - **Uterine Contraction** - The mark of effective uterine contractions is rhythmicity and progressive lengthening and intensity. - **Phase** - A contraction consist of three phases: 1. **the increment,** when the intensity of the contraction increases 2. **the acme,** when the contraction is at its strongest 3. **the decrement,** when the intensity decreases. - **Cervical Changes** - Even more marked than the changes in the body of the uterus are two changes that occur in the cervix: **effacement** and **dilatation** 1. **Effacement** - It is shortening and thinning of cervical canal. - Normally, the canal is approximately, 1 to 2 cm long - With effacement, the canal virtually disappears. 2. **Dilatation** - It refers to the enlargement or widening of the cervical canal from an opening a few millimeters wide to one large enough (approximately 10cm) to permit passage of fetus. 4. **Psyche** - The fourth "P", or a woman's psychological outlook, refers to the psychological state or feelings that a woman brings into labor. - For many women, this is a feeling of apprehension or fright. - For almost everyone, it includes a sense of excitement or awe. **WEEK 8: STAGES OF LABOR AND PARTOGRAPH** **Stages of Labor** **1^st^ Stage -- Stage of Dilatation** - **Latent Phase** - **Duration:** 6 hours (nullipara); 4.5 hours (multipara) - **Duration of contractions:** 20-40 sec - **Interval of contractions:** 5-10 minutes - **Cervical dilatation:** 0-3cm - **Psyche:** excited, still can communicate - **Active Phase** - **Duration:** 3 hours (nullipara); 2 hours (multipara) - **Duration of contractions:** 40-60 sec - **Interval of contractions:** 3-5 minutes - **Cervical dilatation:** 4-6 cm - **Psyche:** frightened, anxious, irritable, but still can comprehend - **Transition Phase** - **Duration:** - **Duration of contractions:** 60-90 sec - **Interval of contractions:** 2-3 minutes - **Cervical dilatation:** 8-10 cm - **Psyche:** loss of control - **Nursing Care during the 1^st^ Stage of Labor** - **Latent and Active Phase** - **Assessment and Monitoring** - Physical exam - Internal exam - Uterine contractions - Vital signs - FHR - **Health Teachings** - Bath - Ambulation - NPO - Breathing - Emptying the bladder - Sim's position - Discourage pushing - **Preparation for birth** - Perineal prep - Perineal shave - Administer analgesics as ordered - Assist in the administration of anesthesia - Assist in the transport to delivery room - **Transition Phase** - Comfort measures - Proper bearing down techniques **2^nd^ Stage -- Stage of Expulsion** - This is the period from full dilatation and cervical effacement to birth of the infant; with uncomplicated birth, this stage takes about 1 hour. - A woman feels contractions change from the characteristics crescendo-decrescendo pattern to an overwhelming, uncontrollable urge to push or bear down with each contraction as if to move her bowels. - **Nursing Care during the 2^nd^ Stage of Labor** - Put legs at the same time when positioning in lithotomy - As soon as the head crowns, instruct not to push but to pant - Assist in episiotomy - Apply the Modified Ritgen's Maneuver **3^rd^ Stage -- Placental Stage** - It begins with the birth of the infant and ends with the delivery of the placenta. - Two separate phases of the placenta that are involved: **Placental Separation and Placental Expulsion** - **Schultze Presentation --** shiny and glistening - **Duncan Presentation --** raw, red, and irregular, with the ridges or cotyledons that separate blood collection. -- dirty - **Nursing Care during the 3^rd^ Stage of Labor** - Do not hurry the expulsion of the placenta - Note for the signs of placental separation - Follow the Brandt-Andrews Maneuver - Take note of the time of placental delivery - Inspect for the completeness of cotyledons - Palpate the uterus to determine the degree of contraction - Inject oxytocin/Methergine after placental delivery - Inspect perineum for lacerations - Perineal care - Provide additional blankets - Allow to sleep to regain lost energy **4^th^ Stage -- Recovery Stage** - **Assessments** - Fundus - Vital Signs - Lochia - Perineum - **Health Interventions and Teachings** - Rooming-in concept - Early ambulation - Dangling of legs **Partograph** - A graphical presentation of the progress of labor, and of fetal and maternal condition during labor. - It is the best tool to help you detect whether labor is progressing normally or abnormally, and to warn you as soon as possible if there are signs of fetal distress or if the mother's vital signs deviate from normal range. - Research studies have shown that maternal and fetal complication due to prolonged labor were less common when the progress of labor was monitored by the birth attendant using a partograph. - It was developed and extensively tested by the **World Health Organization (WHO)** **Overview** - The partograph can be used by health workers with adequate training in midwifery who are able to: - Observe and conduct normal labor and delivery. -- Perform vaginal examination in labour and assess cervical dilation accurately -- Plot cervical dilation accurately on a graph against time - There is no place for partograph in deliveries at home conducted by attendants other than those trained in midwifery - Whether used in health centers or in hospitals, the partograph must be accompanied by a program of training in its use and by appropriate supervision and follow up **Objectives** - early detection of abnormal progress of a labor - prevention of prolonged labour - assist in early decision on transfer, augmentation, or termination or labor - increase the quality and regularity of all observations of mother and fetus - early recognition of maternal or fetal problems - the partograph can be highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (death, anoxia, infections, etc.) - The partograph is actually your record chart for the laboring mother. - It has an identification section at the top where you write the name and age of the mother, her 'gravida' and 'para' status, her Health Post or hospital registration number, the date and time when you first attended her for the delivery, and the time the fetal membranes ruptured (her 'waters broke'). **Purpose of Partograph** - Prevent and manage prolonged or obstructed labor - Prevent serious complications such as ruptured uterus, still birth - Monitor the vital signs of the client **Using the Partograph** - Start the using the partograph only when the client is having regular contractions and the client is in active phase of labor - Make sure that you endorsed to assigned person next shift the partograph for the continuation of care - Observation should be systematic and made at the right frequency - The nurse should know how to plot, read the graph and how to make decision **Components of the partograph** I. **Progress of Labor** - **Cervical dilatation** - **Vaginal examinations** are carried out approximately every 4 hours from this point until baby is born - The active phase of the first stage of labor starts when the cervix is 4cm dilated and it is completed at full dilatation. - Progress in cervical dilatation during the active phase is at least 1 cm per hour (often quicker in multigravida mothers) - The dilatation of the cervix is estimated by vaginal examination and recorded on the partograph with an X mark every 4 hours. - Cervical dilatation in multipara women may need to be checked more frequently than every 4 hours in advanced labor, because their progress is likely to be faster than that of women who are giving birth for the first time. - **Contraction Pattern** - Good uterine contractions are necessary for good progress of labor. - Contractions are recorded every 30 minutes on the partograph in their own section. II. **Maternal well-being** - **Pulse, temperature, blood pressure** - Blood pressure is measured every four hours - Pulse is recorded every 30 minutes - Temperature is recorded every 2 hours - **Urine voided** - Urine output is recorded every time urine is passed III. **Fetal well being** - **Fetal heart rate and pattern** - The normal fetal heart rate at term (37 weeks and more) is in the range of **120-160 beats/minute.** - If the fetal heart rate counted at any time in labor is either below 120 beats/minute or above 160 beats/minute, it is a warning for you to count it more frequently until it has established within the normal range. - **Color of amniotic fluid** - Another indicator of fetal distress which has already been mentioned is meconium-stained amniotic fluid (greenish or blackish liquor). - Lightly stained amniotic fluid may not necessarily indicate fetal distress, unless it is accompanied by persistent fetal heart rate deviations outside the normal range. - The following observations are made at each vaginal examination and recorded on the partograph: - If the fetal membranes are intact, write the letter **"I"** (for "intact") - If the membranes are ruptured write: - "C: if clear - "M' if meconium stained - "A" if absent - "B" if bloody - **Conditions that do not need the use of partograph** - Antepartum hemorrhage - Severe pre-eclampsia and eclampsia - Fetal distress - Previous cesarean section - Multiple pregnancy - Malpresentation - Very premature baby - Obvious obstructed labor **The Parts of the Partograph** - **Progress of labor** - The **upper colored portion** is where you plot the progress of labor - The **lower portion** is where you are supposed to write you other observations particularly the findings of your monitoring of the maternal and fetal well-being. - Maternal and fetal well-being - **Dilatation** - **Alert line** - Each **horizontal gridline** corresponds to the cervical dilatation in centimeter from 4 cm to 10 cm. - While the **vertical gridlines** indicate the time, in hours, the patient is in active labor. - The **upper portion** is also divided into 3 colors - **green, yellow, and red** - The boundary between the green and yellow parts from a diagonal line - this is designated as the **alert line** which starts at 4 cm to 10 cm. - **Action Line** - Parallel and 4 hours to the right of alert line - Parallel and 4 hours to the right of the alert line is another line formed by the boundary between the yellow and red part -- this is the **action line** - Note that it too starts at 4 cm and ends in 10 cm **Plotting the progress of labor** - Plot only the **cervical dilatation** using the symbol "**X**", start when woman is in **active labor (4 cm or more)** and is contracting adequately (3-4 contractions in 10 minutes) - **If plotting passes the alert line** - Reassess woman and consider referral if facilities are not available to deal with obstetric emergencies, unless delivery is imminent - Alert transport services - Monitor intensively - Encourage woman to empty bladder - Encourage upright position and walking if woman wishes - If referral takes a long time, refer immediately. DO NOT WAIT TO CORSS ACTION LINE **How to fill in the Partograph** - Should contain all the information needed - The key of partograph reading are the cervical dilation, descent of the head, and hours of labor - Dilatation of the cervix is marked by X - Descent of the head is marked by O - Alert line begins at 4 cm cervical dilation to the expected full dilation at the rate of 1cm/hour read the graph and how to make decision **WEEK 9: The Newborn Assessment and Care** **The Newborn Physical Exam -- Vital Signs and Growth Parameters** - **Heart rate** is usually 90-160 beats per minute - **Respiratory rate** is usually 30-60 breaths per minute - **Blood pressure** is not usually measured unless infant is critically ill - **Pulse oximeter** increases rapidly in first 10 minutes (**60% to 90%**) **Newborn Physical Exam -- Vital Signs** **Vital Sign** **Immediately at Birth** **After Birth** ---------------- -------------------------- ----------------------------- Temperature 36.5 to 37.2 Celsius Pulse 180 beats/minute 120-140 beats/minute ave. Respiration 80 breaths/minute 30-50 breaths/minute Blood Pressure 80/46 mmHg 100/50 mmHg (by 10^th^ day) **Adjustment to Extrauterine Life** - Color on the first 15 to 30 minutes of life is still **acrocyanotic,** and after 2 to 6 hours, there are quick color changes that may occur with movement or crying. - Temperature within the first 15 to 30 minutes after birth falls from the intrauterine temperature of 100.6ᴼF or 38.1ᴼC then stabilizes at 37.6ᴼ after 2 to 6 hours - Rapid heart rate of as much as 180 BPM on the first 15 to 30 minutes of life will have wide swings in rate with activity as it slows to 120-140 BPM - Respirations are irregular in the first few minutes of life, then slows to 30-60 breaths per minute after 30 minutes and will become irregular again only during activity - Alert in the first 15 to 30 minutes of life, and later on, will alternate between the sleeping and awakening phases - Few minutes after birth, newborn would respond to stimulation vigorously but would be difficult to arouse while it is still on a resting period until it becomes responsive again 2 to 6 hours after birth - **Bowel sounds** -- heard after the first 15 minutes of life and becomes present afterward. **Temperature** - Routinely taken via **armpit (axillary)** - A newborn loses heat easily because of difficulty conserving heat under any circumstances - **Insulation --** it is not effective in newborn (little subcutaneous fat) - **Shivering --** a means of increasing metabolism and thereby providing heat in adults (rarely in newborns) - Newborns can conserve heat by constricting blood vessels and moving blood away from the skin. - **Brown fat --** a tissue found in mature newborns, helps to conserve or produce body heat by increasing metabolism (intrascapular region, thorax, and perineal area) - Newborns exposed to cool air tend to kick and cry to increase their metabolic rate and produce more heat - Drying and wrapping newborn and placing them in warmed cribs, or under a radiant heat source, are excellent mechanical measures to help conserve heat **Pulse** - **Heart rate --** remains slightly irregular because of immaturity of the cardiac regulatory center in the medulla. - **Transient murmurs --** may result from the incomplete closure of fetal circulation shunts - During crying, the rate may rise again to 180 bpm - Heart rate can decrease during sleep, ranging from 90 to 110 bpm - Able to palpate brachial and femoral pulses in a newborn - Heart rate is always determined by listening for an apical heartbeat (4^th^ intercostal space (ICS), lateral to midclavicular line) for a full minute, rather than assessing in extremity. **Respirations** - **Normal respiratory rate:** 30-60 breaths per minute - Assess for any signs of distress: nasal flaring, chest retractions, skin color, \60 breaths per minute - Count for one full minute: at this age the rate is irregular so you need to count for 1 full minute - Infants have what is called **periodic breathing** (the infant breathes and stops for a few seconds and then breathes again) - **Tip:** infants are abdominal breathers so watch this area or lightly place a hand on the area while counting. **Blood Pressure** - Approximately 80/40 mmHg at birth - By the 10^th^ day, it rises to about 100/50 mmHg - It is not routinely measured unless a cardiac anomaly is suspected - Blood pressure tends to increase with crying - **Doppler method** may be used to take blood pressure **Cardiovascular System** - The lungs must oxygenate the blood - When the cord is clamped, a neonate is forced to take in oxygen through the lungs - As the lungs inflate for the first time, pressure decrease in the pulmonary artery (the artery leading from the heart to the lungs) - This decrease in pressure plays a role in **promoting closure of the ductus arteriosus**, a fetal shunt - As pressure increases in the left side of the heart from increased blood volume, the foramen ovale between the two atria closes because of the pressure against the lip of the structure (permanent closure does not occur for weeks) - With the remaining fetal circulatory structure (umbilical vein, two umbilical arteries, and ductus venosus) no longer receiving blood, the blood within them clots, and the vessels atrophy over the next few weeks. - The **hematocrit** is between 45% and 50%. - A newborn also has an elevated red blood cell count, about 6 million cells per cubic millimeter - Once proper lung oxygenation has been established, the need for the high red cell count diminishes - Within a matter of days, a newborn's red cells begin to deteriorate - **Bilirubin** is a by product of the breakdown of red blood cells - An indirect bilirubin level at birth is 1 to 4 mg/100 mL - Excessive red blood cells breakdown = increase release of bilirubin - **High white blood cell count** at birth, about 15,000 to 30,000 cells/cubic millimeter - Values as high as 40,000 cells/cubic millimeter may be seen if the birth was stressful **Respiratory System** - All newborns have some fluid in their lungs from intrauterine life that will ease the surface tension on alveolar walls and allows alveoli to inflate more easily than if the lung walls were dry. - About a third of this fluid is forced out of the lungs by the **pressure of vaginal birth** - Additional fluid is quickly absorbed by lung blood vessels and lymphatics after the first breath - A newborn who has difficulty establishing respirations at birth should examined closely in the postpartal period for a cardiac murmur (patent fetal cardiac structures -- patent ductus arteriosus) **Gastrointestinal System** - Gastrointestinal tract is usually sterile at birth - Most of these bacteria enter the tract through the newborn's mouth from airborne sources - Others may come from vaginal secretions at birth, from hospital bedding, and from contact at the breast - Accumulation of bacteria in the gastrointestinal tract is necessary for digestion and for the synthesis of vitamin K - Second or third day of life, newborn stool changes in color and consistency, becoming green and loose - Termed as **Transitional Stool,** and it may resemble diarrhea to the untrained eye - Fourth day of life, breastfed babies passes three or four light yellow stools per day - Sweet-smelling (high in lactic acid, which reduces the amount of putrefactive organisms in the stool) - Newborn who receives formula usually passes two or three bright yellow stools a day - Slightly more noticeable odor **Urinary System** - Newborns voids within 24 hours after birth - Newborns who do not void = urethral stenosis or absent kidney or ureters - A single voiding in a newborn is only about 15 ml - Specific gravity ranges from **1.008 to 1.010** - Daily urinary output for the first 1 or 2 days is about 30 to 60 mL total - By week 1, total daily volume rises about 300 mL - The first voiding may be pink or dusky because of uric acid crystals that were formed in the bladder in utero **Immune System** - They have difficulty forming antibodies against invading antigens until about 2 months of age, newborns are prone to infection - This inability to form antibodies = most immunizations against childhood diseases are not given to infants younger than 2 months of age - Immunologic protection, with passive antibodies (immunoglobulin G) - Newborns are routinely administered hepatitis B vaccine during the first 12 hours after birth to protect against this disease. **Neuromuscular System** - Mature newborns demonstrate neuromuscular function by moving their extremities, attempting to control head movement, exhibiting a strong cry, and demonstrating newborn reflexes. - Limpness or total absence of a muscular response to manipulation is never normal and suggests narcosis, shock, or cerebral injury. **Newborn Reflexes can be tested with consistency by using Simple Maneuvers** **Blink Reflex** - A blink reflex in a newborn serves the same purpose as it does in an adult -- to protect the eye from any object coming near it by rapid eyelid closure. - It may be elicited by shining a strong light such as flashlight or an otoscope light on an eye - A sudden movement toward the eye sometimes can elicit the blink reflex **Rooting Reflex** - If the cheek is brushed or stroked near the corner of the mouth, a newborn infant will turn the head in that direction - To help a newborn find food **Sucking Reflex** - When a newborn's lips are touched, the baby makes a sucking motion - Helps newborn find food: when the newborn's lips touch the mother's breast or a bottle, the baby sucks - Diminish at about 6 months of age **Swallowing Reflex** - Reflex in a newborn is the same as in the adult - Food that reaches the posterior portion of the tongue is automatically swallowed - **Gag, cough, and sneeze reflexes** also are present, to maintain a clear airway; keep the pharynx free of obstructing mucus **Extrusion Reflex** - A newborn extrudes any substance that is placed on the anterior portion of the tongue - Protective reflex prevents the swallowing of inedible substances - Disappears 4 months of age **Palmar Grasp Reflex** - Grasp an object placed in their palm by closing their fingers on it - Reflex disappears at about 6 weeks to 3 months of age **Step (Walk) in Place Reflex** - Newborns who are held in a vertical position with their feet touching a hard surface will take a few quick, alternating steps - This reflex disappears by 3 months of age **Plantar Grasp Reflex** - When an object touches the sole of a newborn's foot at the base of the toes, the toes grasp in the same manner as do the fingers. - Disappears at about 8 to 9 months of age -- preparation for walking **Tonic Neck Reflex** - When newborns lie on their backs, their heads usually turn to one side or the other. - The arm and the leg on the side toward which the head turns extend, and the opposite arm and leg contract - Also called a **boxer or fencing reflex --** position stimulates someone preparing to box or fence - Disappears between the second and third months of life **Moro or Startle Reflex** - It can be initiated by starting a newborn with a loud noise or by jarring the bassinet - Hold newborns in a supine position and allow their heads to drop backward about 1 inch - Strong for the first 8 weeks of life and then fades by the end of the fourth or fifth month. **Babinski Reflex** - When the sole of the foot is stroke in an inverted "J" curve from the heel upward, a newborn fans the toes (positive Babinski sign) - Occur because nervous system development is immature - Positive (toes fan) until at least 3 months of age **Magnet Reflex** - If pressure is applied to the soles of the feet of newborn lying in a supine position, he or she pushes back against the pressure - This and the two following reflexes are test of spinal cord integrity **Crossed Extension Reflex** - If one leg of a newborn lying supine is extended and the sole of that foot is irritated by being rubbed with a sharp object, such as thumbnail, the infant raises the other leg and extends it, as if trying to push away the hand irritating the first leg **Trunk Incurvation or Galant Reflex** - When newborns lie in a prone position and are touched along the paravertebral area by a probing finger, they flex their trunk and swing their pelvis toward the touch. **Landau Reflex** - A newborn who is held in a prone position with a hand underneath, supporting the trunk, should demonstrate some muscle tone. - Babies may not be able to lift their head or arch their back in this position (as they will at 3 months of age), but neither should they sag into an inverted "U" position - The latter response indicates extremely poor muscle tone, the cause of which should be investigated. **Senses** **Vision** - See as soon as they are born and possibly have been seeing light and dark - Demonstrate sight at birth by blinking at a strong light (blink reflex) or by following a bright light or toy a short distance with their eyes. **Touch** - Well developed at birth - Demonstrate this by quieting at a soothing touch and by sucking and rooting reflexes - Also react to painful stimuli **Taste** - Has the ability to discriminate taste - Taste buds are developed and functioning even before birth - A newborn turns away from a bitter taste but readily accepts the sweet taste of milk or glucose water **Smell** - Present in newborns as soon as the nose is clear - Newborns turn toward their mothers' breast partly out of recognition of the smell of breast milk and partly as a manifestation of the rooting reflex. - Their ability to respond to odors can be used to document alertness **Appearance of a Newborn** **Skin** A. **Color** - **Ruddy Complexion** - Increased concentration of red blood cells in blood vessels and a decrease in the amount of subcutaneous fat (fades slightly over the first month) - **Pale and Cyanotic** - Infants with poor central nervous system control - **Gray color** - In newborns generally indicates infection - **Cyanosis** - Lips, hands, and feet are likely to appear blue from immature peripheral circulation - **Acrocyanosis** - (Blueness of hands and feet) with usual skin color on one side and blue on the other. - Normal: first 24 to 48 hours after birth - **Central cyanosis** - Indicates decreased oxygenation - Result of a temporary respiratory obstruction or an underlying disease state - **Hyperbilirubinemia** - Leads to jaundice o yellowing of the skin - Occurs on the second or third day of life in about 50% of all newborns, as a result of a breakdown of fetal red blood cells (physiologic jaundice) - Skin and the sclera of the eyes appear noticeably yellow - High red blood cell count built up in utero is destroyed, and heme and globin are released. - Above-normal indirect bilirubin levels are potentially dangerous because, if enough indirect bilirubin (about - 20mg/100mL) leaves the bloodstream. - **Kernicterus or bilirubin encephalopathy** - Bilirubin-induced neurological damage, which is most commonly seen in infant - If this occurs, permanent neurologic damage, including cognitive challenge, may result - If the level rises to more than 10 to 12mg/100mL, treatment is usually considered. - **Phototherapy --** (exposure of the infant to light to initiate maturation of liver enzymes) is a common therapy. - Compared with formula-fed babies, a small proportion of breastfed babies may have more difficulty converting indirect bilirubin to direct bilirubin, because breast milk contains pregnanediol (a metabolite of progesterone), which depresses the action of glucuronyl transferase - However, breastfeeding alone rarely causes enough jaundice to warrant therapy. - **Pallor** - **Causes:** - Excessive blood loss when the cord was cut - Inadequate flow of blood from the cord into the infant at birth - Fetal-maternal transfusion - Low iron stores caused by poor maternal nutrition during pregnancy - Blood incompatibility in which a large number of red blood cells were hemolyzed in utero - It also may be the result of internal bleeding. - A baby who appears pale should be watched closely for signs of blood in stool or vomitus. - **Harlequin Sign** - Occasionally, because of immature circulation, a newborn who has been lying on his or her side appears red on the dependent side of the body and pale on the upper side, as if a line had been drawn down the center of the body. - This is a transient phenomenon; although starting, it is of no clinical significance - The odd coloring fades immediately if the infant's positions is changed or the baby kicks or cries vigorously B. **Birthmarks** - **Hemangiomas --** vascular tumors of the skin - **Three types occur** 1. **Nevus Flammeus** - Macular purple or dark-red lesion (portwine stain) - Typically appear on the face, although they are often found on the thighs and above the bridge of the nose tend to fade - Nevus flammeus lesions also occur as lighter, pink patches at the nape of the neck, known as **stork's beak marks or telangiectasia** - These do not fade, but they are covered by the hairline (often in females than in males) 2. **Strawberry hemangioma** - Refers to elevated areas formed by immature capillaries and endothelial cells. - Most are present at birth in the term neonate, although they may appear up to 2 weeks after birth - Typically, they are not present in the preterm infant because of the immaturity of the epidermis - Formation is associated with the high estrogen levels of pregnancy - It may continue to enlarge from their original size up to 1 year of age. - After the first year, they tend to be absorbed and shrink in size - By the time the child is 7 years old, 50% to 75% of these lesions have disappeared - A child may be 10 years old before the absorption is complete - Application of hydrocortisone ointment may speed the disappearance of these lesions by interfering with the binding of estrogen to its receptor sites. 3. **Cavernous hemangiomas** - Dilated vascular spaces - They are usually raised and resemble a strawberry hemangioma in appearance - However, they do not disappear with time as do strawberry hemangiomas. - Such lesions can be removed surgically. - **Steroids, interferon-alfa-2a,** or **vincristine** can be used to reduce these lesions in size, although their use must be weighed in light of side effects - Children who have a skin lesion may have additional ones on internal organs - Blows to the abdomen, such as those from childhood games, can cause bleeding from an internal hemangioma. - For this reason, children with cavernous hemangiomas usually have their hematocrit levels assessed at health maintenance visits, to evaluate for possible internal blood loss. - **Mongolian Spots** - Collection of pigment cells (melanocytes) that appear as slate-gray patches across the sacrum or buttocks and possibly on the arms and legs. - They tend to occur in children of Asian, southern European, or African ethnicity - They disappear by school age without treatment. - Be sure to inform parents that these are not bruises; otherwise, they may worry their baby sustained a birth injury. - **Vernix Caseosa** - A white, cream cheese-like substance that serves as a skin lubricant in utero - It is noticeable on a term newborn's skin, at least in the skin folds, at birth - Document the color of vernix, because it takes on the color of the amniotic fluid. - **Yellow vernix --** implies that the amniotic fluid was yellow from bilirubin - **Green vernix --** indicates that meconium was present in the amniotic fluid - Until the first bath, when vernix is washed away, handle newborns with gloves to protect yourself from exposure to this body fluid - Never use harsh rubbing to wash away vernix - **Lanugo** - Fine, downy hair that covers a newborn's shoulder, back, and upper arms - It may be found also on the forehead and ears. - A baby born between 37 to 39 weeks of gestation has more lanugo than a newborn of 40 weeks' gestational age. - Postmature infants (more than 42 weeks of gestation) rarely have lanugo - Lanugo is rubbed away by the friction of bedding and clothes against the newborn's skin. - By 2 weeks of age, it has disappeared. - **Desquamation** - Within 24 hours after birth, the skin of most newborns has become extremely dry. - The dryness is particularly evident on the palms of the hands and soles of the feet - This results in areas of peeling similar to those caused by sunburn - This is normal, however, and needs no treatment - Parents may apply hand lotion to prevent excessive dryness if they wish - **Milia** - Small, white cysts on NB skin - All newborn sebaceous glands are immature - At least one pinpoint white papule (a plugged or unopened sebaceous gland) can be found on the cheek or across the bridge of the nose of almost every newborn - They disappear by 2 to 4 weeks of age, as the sebaceous glands mature and drain. - Teach parents to avoid scratching or squeezing the papules, to prevent secondary infections. - **Erythema Toxicum** - In most normal mature infants, a newborn rash - This usually appears in the first to fourth day of life but may appear up to 2 weeks of age - It begins with papule, increases in severity to become erythema by the second day, and then disappears by the third day. - Sometimes called **flea-bite rash** because the lesions are so minuscule - One of the chief characteristics of the rash is **its lack of pattern** - It occurs sporadically and unpredictably and may last hours rather than days. - It is caused by a newborn's eosinophils reacting to the environment as the immune systems matures - It requires no treatment - **Skin Turgor** - Skin's elasticity - Newborn skin should feel resilient if the underlying tissue is well hydrated - If a fold of the skin is grasped between the thumb and fingers, it should feel elastic - When it is released, it should fall back to form a smooth surface. - If severe dehydration is present, the skin will not smooth out again but will remain in an elevated ridge - **Poor turgor** is seen in newborn who suffered malnutrition in utero, who have difficulty sucking at birth, or who have certain metabolic disorders such as **adrenocortical insufficiency.** **Head** - Newborn's head appears disproportionately large because it is about one fourth of the total body length - The forehead of a newborn is large and prominent - The chin appears to be receding, and it quivers easily if an infant is startled or cries - Well-nourished newborns have full-bodied hair; poorly nourished and preterm infants have thin, lifeless hair. - **Fontanelles** - Spaces or opening where the skull bones join - **Anterior fontanelle** is located at the junction of the two parietal bones and the two fused frontal bones. - It is diamond shaped and measures 2 to 3 cm (0.8to 1.2 in) in width and 3 to 4 cm (1.2 to 1.6 in) in length - Can be felt as a soft spot - Normally closes at 12 to 18 months of age - It should not appear **indented** (a sign of dehydration) or **bulging** (a sign of increased intracranial pressure) when the infant is held upright - **Posterior fontanelle** is located at the junction of the parietal bones and the occipital bone. - It is triangular and measures about 1 cm (0.4 in) in length - The posterior fontanelle closes by the end of the second month - **Sutures** - Separating lines of the skull - May override at birth because of the extreme pressure exerted on the head during passage through the birth canal. - If the sagittal suture between the parietal bones overrides, the fontanelles are less perceptible than usual - The overriding subsides in 24 to 48 hours - Suture lines should never appear widely separated in newborns - Wide separation suggests increased intracranial pressure because of abnormal brain formation, abnormal accumulation of cerebrospinal fluid in the cranium (hydrocephalus), or an accumulation of blood from a birth injury such as subdural hemorrhage - Fused suture lines also are abnormal, they require radiographic confirmation and further evaluation, because they will prevent the head from expanding with brain growth. - **Molding** - Part of the infant's head that engaged the cervix (usually the vertex) molds to fit the cervix contours during labor - After birth, this area appears prominent and asymmetric - Molding may be so extreme in the baby of primiparous woman that the baby's head appears as a dunce cap - The head will restore to its normal shape within a few days after birth - **Caput Succedaneum** - Edema of the scalp at the presenting part of the head - It may involve wide areas of the head, or it may resemble a large egg. - The edema, which crosses the suture lines, is gradually absorbed and disappears at about the third day of life - It needs no treatment - **Cephalhematoma** - A collection of blood between the periosteum of a skull bone and the bone itself, caused by rupture of a periosteal capillary because of the pressure of birth. - Swelling usually appears 24 hours after birth - Although the blood loss is negligible, the swelling is usually severe and is well outline as an egg shape - It may be discolored (black and blue) because of the presence of coagulated blood - A cephalhematoma is confined to an individual bone, so the associated swelling stops at the bone's suture line - It often takes weeks for a cephalhematoma to be absorbed. - It might be supposed that the blood could be aspirated to relieve the condition. - **Craniotabes** - A localized softening of the cranial bones that is probably caused by pressure of the fetal skulls against the mother's pelvic bone in utero. - It is more common in firstborn infants than in infants born later, because of the lower position of the fetal head in the pelvis during the last 2 weeks of pregnancy in primiparous women. - With craniotabes, the skull is so soft that the pressure of an examining finger can indent it. - The bone returns to its normal contour after the pressure is removed - The condition corrects itself without treatment after a few months, as the infant takes in calcium in milk **Eyes** - Newborns usually cry tearlessly, because their lacrimal ducts do not fully mature until about 3 months of age. - Almost without exception, the irises of the eyes of newborns are gray or blue, the sclera may be blue because of this thinness - Infant eyes assume their permanent color between 3 and 12 months of age - To inspect the eyes, lay the newborn in a supine position and lift the head - This maneuver causes the baby to open the eyes - A newborn's eyes should appear clear, without redness or purulent discharge **Ears** - A newborn's external ear is not as completely formed as it will be eventually, so the pinna tends to be bend easily - In the term newborn, however, the pinna should be strong enough to recoil after bending - The level of the top part of the external ear should be on a line drawn from the inner canthus to the outer canthus of the eye and back across the side of the head - Ears that are set lower than this are found in infants with certain chromosomal abnormalities, particularly **trisomy 18 and 13**, syndromes in which low-set ears and other physical defects are coupled with varying degrees of cognitive challenge/ - A good practice is to test a newborn's hearing by ringing a bell held about 6 inches from each ear. **Nose** - Tends to appear large for the face - As the infant grows, the rest of the face grows more than the nose does, and this discrepancy disappears - Test for **choanal atresia** (blockage at the rear of the nose) by closing the newborn's mouth and compressing one naris at a time with your fingers. - Note any discomfort or distress while breathing this way - Nasal flaring upon inspiration is another indication of respiratory distress and should be further evaluated. **Mouth** - A newborn's mouth should open evenly when he or she cries - If one side of the mouth moves more than the other, cranial nerve injury is suggested. - A newborn's tongue appears large and prominent in the mouth - Because the tongue is short, the frenulum membrane is attached close to the tip of the tongue, creating the impression that the infant is **tongue tied** - Inspect the palate of a newborn to be sure it is intact **Neck** - The neck of newborn is short and often chubby, with creased skin folds - The head should rotate freely on it. - If there is rigidity of the neck, **congenital torticollis,** caused by the injury to the sternocleidomastoid muscle during birth, might be present - In newborns whose membranes were ruptured more than 24 hours before birth, nuchal rigidity suggest meningitis - The neck of a newborn is not strong enough to support the total weight of the head but in a sitting position, a newborn should make a momentary effort at head control. - When lying prone, newborns can raise the head slightly, usually enough to lift the nose out of mucus or spit-up formula - If they are pulled into a sitting position from a supine position, the head will lag behind considerably. **Chest** - The chest in some newborns looks small because the head is large in proportion - It is actually approximately 2 inches smaller in circumference than and as wide in the anteroposterior diameter as it is across - Not until a child is 2 years of age does the chest measurement exceed that of the head. - The clavicles should be straight - A crepitus or actual separation on one or the other clavicle may indicate that a fracture occurred during birth and calcium is now being deposited at that point - Overall, a newborn's chest should appear symmetric side to side - Respirations are normally rapid (30 to 60 breaths per minute) but not distressed. - A **supernumerary nipple** (usually found below and in line with the normal nipples) may be present, if so, it may be removed later for cosmetic purposes although this is not necessary. - In both female and male infants, the breast may be engorged - Occasionally, the breast of newborn babies secrete a thin, watery fluid popularly termed **witch's milk** - Engorgement develops in utero as a result of the influence of the mother's hormones. - As soon as the hormones are cleared from the infant's system (about 1 week), the engorgement and any fluid that is present subside - Retraction (drawing in of the chest wall with inspiration) should not be present. - An infant with retractions is using such strong force to pull air into the respiratory tract that he or she is pulling in the anterior chest muscle. - An abnormal sound, such as grunting, suggests respiratory distress syndrome - A high, crowing sound on inspiration suggests stridor or immature tracheal development **Abdomen** - The contour of a newborn abdomen looks slightly protuberant - A scaphoid or sunken appearance may indicate missing abdominal contents or a diaphragmatic hernia (bowel positioned in the chest instead of the abdomen) - Bowel sounds should be present within 1 hour after birth - The edge of the liver is usually palpable 1 to 2 cm below the right costal margin - The edge of the spleen may be palpable 1 to 2 cm below the left costal margin - Tenderness is difficult to determine in a newborn - If it is extreme, however, palpation will cause the infant to cry, thrash about, or tense the abdominal muscles to protect the abdomen - For the first hour after birth, the stump of the umbilical cord appears as a white, gelatinous structure marked with the blue and red streaks of the umbilical vein and arteries - When the cord is first cut, the vessels are counted to be certain that one vein and two arteries are present. - After the first hour of life, the cord begins to dry and shrink, and it turns brown like the dead end of a vine - By the second or third day, it has turned black - It breaks free by day 6 to 10, leaving a granulating area a few centimeters wide that heals during the following week - The base of the cord should appear dry. - A moist or odorous cord suggests infection - If present, infection should receive immediate treatment or it may enter a newborn's bloodstream and cause septicemia **Anogenital** A. **Anal Area** - Inspect the anus: present, patent, and not covered by a membrane (imperforate anus) - Test for anal patency: gently inserting the tip of your gloved and lubricated little finger - Notes for first passes meconium (first 24 hours) B. **Female Genitalia** - Vulva in female newborns may be swollen (effect of maternal hormones) - **Pseudomenstruation** - Some female newborns have mucus vaginal secretion, which is sometimes blood-tinged - Disappears as soon as the infant's system has cleared the hormones - Discharge should not be mistaken for an infection or indication of trauma C. **Male Genitalia** - Scrotum in most male; edematous and has rugae (folds in the skin) - Both testes should be present in the scrotum - **Cryptorchidism** - One or both testicles are not present; caused by agenesis (absence of an organ) - **Ectopic testes** - The testes cannot enter the scrotum - Opening to the scrotal sac is closed - **Undescended testes** - The vas deferens or artery is too short - Penis of newborns appears small, approximately 2 cm long - Inspect the urethral opening (tip of the glans) - **Epispadias --** dorsal surface - **Hypospadias --** ventral surface **Back** - **Spine** - It typically appears flat in the lumbar and sacral areas - **Curves** appear only after a child is able to sit and walk - Inspect the base of a newborn's spine: - For pinpoint opening, dimpling, or sinus tract in the skin, which would suggest a dermal sinus or spinal bifida occulta - Normally assumes the positions maintained in utero, with the back rounded and the arms and legs flexed on the abdomen and chest. - **Extremities** - The arms and legs of a newborn appear short - Hands are plump and clenched into fists - Newborn fingernails are soft and smooth, and usually long enough to extend over the fingertips - Test the upper extremities for muscle tone by unflexing the arms for approximately 5 seconds - If tone is good, an arm should return immediately to its flexed position after being released - Holds the arms down by the sides and note their length - The fingertips should reach the proximal thigh - Unusually short arms may signify **achondroplastic dwarfism** - Observe for unusual curvature of the little finger, and inspect the palm for a simian crease (a single palmar crease, in contrast to the three creases normally seen in a palm) - Although curved finger and simian creases can occur normally, they are commonly associated with **down syndrome** - Assess for **webbing (syndactyly),** extra toes or fingers **(polydactyly),** or unusual spacing of toes, particularly between the big toes and the others (this finding is present in certain chromosomal disorders, although it is also a normal finding in some families) - Normally, newborn legs are bowed as well as short - Sole of the foot appears flat because of an extra pad of fat in the longitudinal arch - The foot of a term newborn has many crisscrossed lines on the sole, covering approximately two thirds of the foot - If these creases cover less than two-thirds of the foot or are absent, suspect immaturity. - With a newborn in a supine position, both hips can be flexed and abducted to such an extent (180 degrees) that the knees touch or nearly touch the surface of the bed - If the hip joint seems to lock short of this distance (160 to 170 degrees), **hip subluxation** (a shallow and poorly formed acetabulum) - A further test for subluxation can be elicited by holding the infants leg with the fingers on the greater and lesser trochanter and then abducting the hip - If a subluxation is present, a **"clunk"** of the femur head striking the shallow acetabulum can be heard (Ortolani's sign) - If the hip can be felt to actually slip in the socket, this is **Barlow's sign.** - Subluxated hip may be bilateral but is usually unilateral. It is important that hip subluxation be discovered as early as possible. **Apgar Scoring** - Apgar scoring is done during the first 1 minute and 5 minutes of life - Heart rate, respiratory rate, muscle tone, reflex irritability, and color are evaluated in an infant - Apgar score is the baseline for all future observations. - Each parameter can have the highest score of two and the lowest is 0 - Scores of the five parameters are added to determine the status of the infant - **0-3 points:** the baby is serious danger and need immediate resuscitation - **4-6 points:** the baby's condition is guarded and may need more extensive clearing of the airway and supplementary oxygen - **7-10 points:** considered good and in the best possible health **Indicator** **0** **1** **2** ------- --------------- ------------ --------------------------------- -------------------------------- **A** Activity Absent Flexed arms and legs Active **P** Pulse Absent Below 100bpm Over 100 bpm **G** Grimace Floppy Minimal response to stimulation Prompt response to stimulation **A** Appearance Blue; Pale Pink body, blue extremities Pink **R** Respiration Absent Slow and irregular Vigorous cry