OB exam 3

• Initial Assessment


  1. Airway, breathing, circulation

  2. Apgar scores- evaluate the impact of intrapartum events on the infant and the infant's adaptation to extrauterine life

  3. Tone, reflex irritability, color
• Newborn Stabilization

  1. Warm, dry and stimulate

  2. Remove wet blankets

  3. Assess baby (respirations, color, etc)

  4. If not breathing or inadequate breathing, provide positive pressure ventilation at 1:3 (breath.. 2..3.. breath..2..3)

  5. Continue PPV until baby is breathing or advanced airway is placed

  6. Assess pulse (umbilical cord or auscultation, count for 6 sec and x 10)

  7. If hr<60= start compressions, if hr>60 but <100= continue PPV
• Expected ranges for newborn vital signs

  • Temp: 97.4-99.6
  • Pulse: 120-160 BPM
  • RR: 30-60
  • BP: 65-90 Systolic/45-65 Diastolic
• Complete physical assessment


  Vital signs, general appearance, head, face, neck, chest, abdomen, back, genitalia, urinary system function, extremities, reflexes
• Weight loss

  Normal: 5-10% in first 3-4 days. More is a problem. Average weight: 7lb 8oz
• Head circumference


  Bigger than chest first few months
• Temperature measurement

  Axillary temp or skin probe. Some places use rectal - others, no way!
• Low temperature


  Indicates infection
• High temperature


  Indicates dehydration
• Molding


  • Asymmetry caused by overriding cranial bones during labour and delivery. Usually resolves in 2-3 days. "Cone heads" vs. Round headed C-S babies
• Fontanelles


  • Anterior - diamond shaped, posterior - triangular. Assess for abnormal bulging, sunken, overriding
• Cephalohematoma


  Collection of blood from ruptured capillaries - does not cross suture lines, takes longer to resolve
• Caput succedaneum


  Edema of tissues - crosses suture lines, frequently seen with vacuum delivery
• Normal skin findings

  • Acrocyanosis (blue hands and feet 2-6 hrs after birth)
  • Mottling (lacey pattern dilated blood vessels under skin)
  • Lanugo (normal to have a little bit of hair)
• Jaundice


  Assess color in good daylight. First noted on face - yellowing. Sclera. Will then spread down body. Prevent cold stress. Monitor I & O's, stooling. Teaching to parents re: phototherapy
• Jaundice within the first 24 hr


  Not normal
• Erythema toxicum


  Transient newborn rash - small, varied lesions, may have papule, pustule. Resolves spontaneously - usually by 24-48 hr old
• Milia


  Sebaceous glands - small white spots. Usually on face. Resolves spontaneously
• Turgor


  Assess at abdomen or thigh - should be very elastic
• Vernix caseosa


  Whitish - cheese like - good skin lubricant - don't scrub it all off!
• Forceps/vacuum marks

  Evaluate for other problems - paralysis, drooping
• Stork bites


  Pale pink or red spots - eyelids, nose, nape of neck. Fade by 2 yr
• Mongolian spots


  Bluish blackish, pigmentation, dorsal area, buttocks. Will fade within a couple of years
• Nevus flammeus


  "Port wine stain" capillary angioma under the skin. Frequently on face OR neck. Permanent, does not go away
• Nevus vasculosus


  "Strawberry mark" - capillary hemangioma. Raised. Can grow quickly. Usually resolve spontaneously
• Mouth


  • Teeth: May have neonatal teeth - needs eval
  • Palate: Stim to lip - sucking. Visualize and palpate palate
  • Epstein's pearls: insignificant, usually resolve=NORMAL
  • Thrush: white patches on mucus membranes that don't wipe off. Candida - yeast infection from mom's vagina at birth. Treat baby's mouth and mom's breasts and vagina - all together - or infection will travel around!
• Ears


  • Soft, pliable, good recoil. Pinna parallel to canthus of eye. Now, NB hearing eval. Check for skin tags, patent ear canal
• Ear tags

  Renal ultrasounds bc ear and kidney are being formed at same time in utero
• Ear stays down


  Preemie baby
• Neck


  • Masses, nodes, webbing, ROM. Clavicles - intact - no crepitus
• Chest

  • Symmetry, breast engorgement, super-numery nipples (nubbin?)
• Cry

  Strong, lusty, medium pitch. High-pitched, shrill - eval
• Breathing

  • Abnormal breathing- nasal flaring, retractions, grunting. Count by observing abdomen. Listen, look, rest hand to feel
• Heartbeat

  Listen carefully to hear beat when infant in quiet state. Rate 120-160. Any Slur or slush sound - eval by MD. Most murmurs resolve. Pulses - brachial, femoral, pedal
• Abdomen


  • Visualize - no distention, few if any vessels. Listen. Palpate - softness, nontender, no masses
• Umbilical cord


  3 vessels - 2 ARTERIES, 1 VEIN. Bleeding, discharge
• Genitals


  • Female - size, appropriate to gestational age
  • Male - position of urethral meatus. Movement of foreskin - if void - don't worry about it. Size and symmetry of scrotum. Testes descended bilaterally
• Extremities


  • Deformities? # digits? ROM?
  • Erb's palsy - damage to 5th and 6th cervical nerves - paralysis of upper arm - no movement, no moro on that side. Prognosis relates to how much trauma
  • Legs - equal length, symmetric skin folds
  • Ortolani maneuver to r/o congenital hip dysplasia (dislocated)
  • True club foot - foot won't move to midline. May have positional issues that will resolve
• Back


  • Spine intact, straight? No openings (spina bifida) or tufts of hair at base of spine
• Respiratory/circulatory transition in the newborn

  1. Fluid is moved out of lungs as fetus passes thru the birth canal—chest is compressed —>then when trunk is delivered recoil of chest—> negative lung pressure —>passive 1st inhalation and air starts replacing fluid in the lungs

  2. First exhalation— shift to positive pressure in the lungs, now more movement of air thru out the alveoli, more fluid absorbed into the capillaries surrounding the alveoli and into the lymphatic system

  3. Then downward movement of the diaphragm pulls in the 2nd inhalation

  4. While all of this is going on, the alveolar air volume increases—> increased pulmonary blood flow (less resistance to form fluid in alveoli)—> picks uo the absorbed fluids more and more