Objectives

By the end of this presentation the learner should.

Understand the prenatal gestational age assessment tools
Classify the size differences between IUGR, SGA, AGA, &
LGA infant
Complete the physical maturity portion of the neonatal
gestational age assessment tool
Conduct the neuromuscular portion of the neonatal
gestational age assessment
Compile the maturity score on the neonatal gestational age
assessment tool
Identify those common differential findings found on
newborn exam

Calculation by the mother estimated date of

confinement
(EDC)
Collection of prenatal data
First fetal movement (16-20 weeks)
Fetal heart tones (20 weeks) (with doppler 9-12
weeks)
Fundal height (One cm = 1 week after 18-20
weeks)
20 weeks (fundus normally at umbilicus)
Term (fundus at xyphoid)
Amniotic fludi creatinine levels
Maternal serum and urine estriols

Prenatal Gestational Age

Assessment
Fetal US Measurements
Crown to rump length
Biparietal diameter
Femur length
Abdominal

Circumference
Head Circumference
Placental grade

Basics of Newborn Physical

Review the perinatal history for clues to potential
Exam

pathology
Begins with conception and includes events that
occurred throughout gestation
Genetic history
Labor & delivery history
Assess the infants color for clues for potential
pathology
Auscultate in a quiet environment
Keep infant warm during exam
Calm the infant before exam
Handle gently

Classification of Size

Classification of size for

gestational
age

Growth for dates can be determined by

weight, length, and head circumference
Plotted on a graph appropriate for gestation
Preterm before 37 weeks
Term 38-41 weeks
Post term after 42 weeks

Classification of size for

gestational age
Using the

gestational age
score the weight,
height and head
circumference can
be plotted on the
infants growth chart
This information is
how the infant is
diagnosed as SGA,
LGA, or AGA

Classification of size for

gestational
age

SGA- small for gestational age-weight below

10th percentile
AGA-weight between 10 and 90th percentiles
(between 5lb 12oz (2.5kg ) and 8lb 12 oz
(4kg).
LGA-weight above 90th percentile
IUGR-deviation in expected fetal growth
pattern, caused by multiple adverse
conditions, not all IUGR infants are SGA, may
or may not be head sparing

Neonatal Gestational AgeThe physicalExam

Ballard
maturity part of the examination

should be done in the first two hours of birth

The neuromuscular maturity examination should
be completed with 24 hours after delivery
Derived to look at various stages in an infants
gestational maturity and observe how physical
characteristics change with gestational age
Neonates who are more physically mature
normally have higher scores than premature
infants
Points are awarded in each area -2 for extreme
prematurity to 5 for postmature infants

Physical Maturity
Skin
Lanugo
Plantar surface
Breast
Eyes & Ears
Genital

Neonatal Gestational Age

Physical Maturity

Physical Maturity-Skin
Examine the texture, color and opacity
As the infant matures:

More subcutaneous tissue develops

Veins become less visible and the skin
becomes more opaque

Neonatal Gestational Age

Assessment
Physical Maturity
Skin

Before 28 weeksgelatinous red, friable

28-37 weeks-skin
over abdomen thin,
translucent, pink with
visible veins
37-39 weeks smooth,
pink, increased
thickness, rare veins
over abdominal wall

Neonatal Gestational Age

Assessment
Physical
Maturity
Skin

40 Weeksvessels have
now appeared,
skin may be
leathery with
deep cracking

Differential Skin Findings

Scalp Electrode

Differential Skin Findings

Forcep Marks

Differential Skin Findings

Vacuum Bruising

Differential Skin Findings

Milia-exposed

sebaceous glands
No treatment
necessary

Differential Skin Findings

Sebaceous

hyperplasia
More yellow than
milia
Result of maternal
androgen in utero
Resolves in time

Differential Skin Findings

Mongolian Blue-

Grey Spots
Most common in
Asian, Hispanic,
and African
descent
Gradual fade over
the first years

Differential Skin Findings

Skin Tags
Most common

on ears
Usually tied off
or clipped

Differential Skin Findings

Salmon patches or

nevus simplex
Angel kisses
Stork bites

Differential Skin Findings

Erythema

toxicum
White or
yellow papule
or pustule
With
erythematous
base
No treatment
necessary

Differential Skin Findings

Caf Au Lait spots
Increased amount of

melanin, may
increase in number in
age
Presence of 6 or
more- greater then
0.5 cm in size may be
indicative of
neurofibromatosis

Neonatal Gestational Age

Assessment
Physical Maturity
Lanugo
After 20 weeks-begins to
appear
28 weeks-abundant
After 28 weeks-thinning,
starts to disappear from
the face first
38 weeks-bald areas
slight amount may be
present on shoulders

Neonatal Gestational Age

Assessment
Vernix
Before 34 weeks-vernix

thick and covers entire

body
34-38 weeks-vernix is
absorbed gradually,
portions over shoulder and
neck is the last to be
absorbed
38-40 weeks-vernix only
present in folds of skin
After 40 weeks-no vernix
present

Neonatal Gestational Age

Assessment
Plantar Surface
Before 28 weeks-no creases
28-32 weeks-virtually no

sole creases, faint thin red

lines over anterior aspect of
foot
34-37 weeks-1-2 anterior
creases
37-39 weeks-creases now
over the anterior 2/3 of the
sole

Differential Findings
Bilateral Club Feet

Polysyndactyl
y

Syndactyly

Neonatal Gestational Age

Assessment
Physical Maturity
Breast

Before 28 weeks-nipples imperceptible

28-32 weeks-nipple barely visible, no areola
32-37 weeks-well defined nipple areola
38-40 weeks-well defined nipple raised areola

Neonatal Gestational Age

Assessment
Physical Maturity
Eyes

Eyes are evaluated as either fused as seen in

extremely premature infants or open
Before 26 weeks eyes are fused

Differential Findings
Congenital Cataracts
Eyelid Edema
Subconjunctival Hemorrhage

Neonatal Gestational Age

Assessment
Physical Maturity
Ears

Before 34 weeks-pinna
is very immature
cartilage not present,
lies flat, remains folded
34-37 weeks-pinna
curved with soft recoil
37-40 weeks-formed,
firm instant recoil
After 40 weeks-thick
cartilage ear stiff

Differential Findings
Ear Tags
Ear Pits (Preauricular pits)
Lop Ear
Prominent Ear

Neonatal Gestational Age

Assessment
Physical Maturity
Genitalia-Female

Genitalia-Male

Before 28 weeks-scrotum
empty and flat
28-30 weeks-testes
undescended into scrotal
sac
30-36 weeks testes
descending with a few
rugae over the scrotum
36-39 weeks-testes have
descended into scrotum
which is now pendulous
and complete with rugae

Before 28 weeks-clitoris

prominent labia flat

28-32 weeks-prominent
clitoris, enlarging labia
minora
33-36 weeks-labia majora
widely spaced with equally
prominent labia minora
33-39 weeks-labia extends
over the labia minora but
not over the clitoris
39 weeks-labia majora
completely covers the labia
minora and clitoris

Differential Findings
Hydrocele

Hypospadias

Undescended testicles

Hymenal Tag

Neonatal Gestational Age

Neuromuscular Assessment

Neonatal Gestational Age

Assessment
Neuromuscular Maturity
Posture & Tone
Square Window
Arm Recoil
Popliteal Angle
Scarf Sign
Heel to Ear

Neonatal Gestational Age

Assessment
Neuromuscular Maturity
Posture/Tone-Total body muscle tone is reflected

in the infants preferred posture at rest and

resistance to stretch of individual muscle
groups

Make sure infant is quiet

The more mature an infant is the greater their tone
will be
A more flexed position indicated greater tone

Neonatal Gestational Age

Assessment
Neuromuscular Maturity
Posture & Tone
Before 30 weekshypotonic, little or no
flexion seen
30-38 weeks-varying
degrees of flexed
extremities
38-42 weeks-may
appear hypertonic

Neonatal Gestational Age

Assessment
Neuromuscular Maturity
Square Window-wrist

flexibility and/or resistance

to extensor stretching
resulting in angle or flexion
at wrist
Flex hand down to wristmeasure the angle
between the forearm &
palm
Before 26 weeks-wrist
cant be flexed more than
90 degrees
Before 30 weeks-wrist can
be flexed no more than 90
degrees
36-38 weeks-wrist can be
flexed no more than

Neonatal Gestational Age

Assessment
Neuromuscular Maturity
Arm Recoil-measures the angle of recoil following

a brief extension of the upper extremity

For 5 seconds flex the arms while infant is in the
supine position, pulling the hands fully extend
the arms to the side, then release-measure the
degree of arm flexion & strength (recoil)
Before 28 weeks-no recoil
28-32 weeks-slight recoil
32-36 weeks-recoil does not pass 90 degrees
36-40 weeks-recoils to 90 degrees
After 40 weeks-rapid full recoil

Neonatal Gestational Age

Assessment
Neuromuscular Maturity
Popliteal Angle-assesses

maturation of passive flexor

tone about the knee joint by
testing resistance to extension
of the leg
The angle decreases with
advancing gestational age
Before 26 weeks-angle 180
degrees
26-28 weeks-angle 160 degrees
28-32 weeks-angle 140 degrees
32-36 weeks angle 120 degrees

Neonatal Gestational Age

Assessment
Neuromuscular Maturity

Scarf Sign-tests the passive tone of

the flexors about the shoulder girdle

Increased resistance to this
maneuver with advancing
gestational age

Before 28 weeks-elbow passes

torso
28-34 weeks-elbow passes opposite
nipple line
34-36 weeks-elbow can be pulled
past midline, no resistance
36-40 weeks-elbow to midline with
some resistance
After 40 weeks-doesnt reach
midline

Neonatal Gestational Age

Assessment
Neuromuscular Maturity
Heel to Ear-measures

passive flexor tone about

the pelvic girdle by
testing passive flexion or
resistance to extension of
the posterior hip flexor
muscles
Breech infants will score
lower than normal
Before 34 weeks-no
resistance
40 weeks-great
resistance may be
difficult to perform

References
Aby, J. (2008). Stanford School of Medicine. Newborn
Nursery at LPCH. Retrieved October 10th, 2009 from
http://newborns.stanford.edu/RNMDEducation.html
Ballard J. (1991). New Ballard Score, expanded to
include extremely premature infants. Journal of
Pediatrics, 119, 417-423.
Tappero, E. & Honeyfield, M. (1996). Physical
assessment of the newborn. Santa Rosa, CA: NICU
Ink Publishers.