Maternity - Newborn, part 1: APGAR Scoring, Vital Signs, New Ballard Scale, Thermoregulation, Height/Weight
by Meris Shuwarger BSN, RN, CEN, TCRN November 23, 2021 Updated: December 07, 2022 10 min read
Hi. I'm Meris with Level Up RN. And in this video, I'm going to be starting the newborn assessment section of our deck. I'm going to be following along with our maternity flashcards, which are available on our website LevelUpRN.com if you want to grab a set for yourself. If you have a set of your own, I would invite you to follow along with me as we go through a lot of these really important concepts for newborn assessment. All right. So let's go ahead and get started.
So first up, we're going to be talking about Apgar scoring, and Apgar scoring was created by Dr. Virginia Apgar, who wanted to use her last name to be part of this score, which I totally get because I would do the same thing. Shuwarger does not really lend itself to a catchy mnemonic though. So the thing about Apgar scoring you'll see is that there is the category that she came up with based on her name. And then there's kind of the category that you will hear it referred to more frequently. That kind of makes a little bit more sense rather than having to fit in with the letters of her name.
So Apgar scoring is done one and five minutes after the birth of an infant.
And the point of it is to see how they are adapting to extra-uterine life, meaning outside of the uterus. Now that they are in the world, how are we doing?
So the score can go from 0 to 10, and 10 being the best and 0 being the worst. And all along that number line there, we have different variables for what it means.
So 0 to 3 means that the infant is in severe distress; 4 to 6 means moderate distress; and 7 to 10 means minimal difficulty adapting to extra-uterine life. So that's what we want. We want something 7 or higher.
So the categories here are activity or muscle tone is what you'll hear it called most often, pulse, grimace or reflex irritability, appearance or color, and respiration.
So you can get 0, 1, or 2 points for activity. If the baby is flaccid, no tone at all, they get 0 points. 1 point for some flexion. And 2 points for well-flexed active motion.
For pulse, if it's absent, 0 points. If it is less than 100 beats a minute, 1 point. Remember, infants have higher pulse rates than adults. And if it is above 100 beats a minute, 2 full points.
Grimace or reflex irritability, if there is no grimace, then we're going to say 0 points. If they are grimacing, but not crying, then they get 1 point. And if they are crying, then they get 2 points.
For appearance or color, if their whole body is blue or pale, 0 points. If they have acrocyanosis, meaning that their trunk is pink, but their extremities are blue, then they get1 point. And if their whole body is pink, then they get both points, 2 points.
And then for respirations. If the baby is not breathing, 0 points. If they have a slow or a weak cry, 1 point. And if they had a good cry, they get the full 2 points.
Okay. So now moving on to newborn vital signs, we talked slightly in this previous card about them. But these are the expected ranges for newborn vital signs.
Temperature 97.4 to 99.6 degrees Fahrenheit.
Pulse 100 to 160 beats per minute. That is, I think it's kind of easy to remember because it's kind of the opposite of the adults. Adults are 60 to 100; newborns are 100 to 160.
Respirations 30 to 60 breaths a minute. That is so rapid when compared to adults, but that is absolutely the case so we need it to be above that 30 mark.
And then blood pressure, although this is not something that is necessarily routinely measured on an infant, systolic blood pressure would be 65 to 90 and diastolic would be 45 to 65.
So basically, everything, heart rate and respirations are going to be increased. Blood pressure is the one that is the opposite; it is decreased for adults. Remember that infants have to adapt to being on the outside and breathing air, so it is normal for them to have brief periods of apnea, like less than 15 seconds. That is okay and normal.
All right. Moving on, we're going to talk about the New Ballard scale. And I just want to point these out because I think that this is a really good set of cards that shows you really what we're talking about here.
So New Ballard scale is a type of scale that helps us to determine if a baby is premature or fully mature. The reason that this matters is sometimes we could have an infant where there was no prenatal care done, or perhaps the mom had no idea that they were pregnant, right? That happens as well. There could be something like if there were a trauma and the baby were born, and mom is not conscious to be able to tell us about how far along they were, that sort of a thing.
So there's two parts. There's the neuromuscular assessment and then there's the physical maturity assessment.
So I have my daughter's doll here. Her name is Molly. Say, Hi, Molly. So she's going to help us do our New Ballard scale assessment here.
So with neuromuscular, one of the things is posture. So this has to do again with the tone of the infant. Molly has no tone. She's very flaccid. She is extended. This is not normal. This is what would be considered for a premature baby. A fully mature baby is going to be, well-flexed. They're going to have those arms in, and everything's going to be pulled in, and there's going to be resistance against you as well if you pull on them. So that would be a mature baby.
Now, square window has to do with the wrist. Now Molly can't do anything, so I'll show you on myself. Square window refers to, can I bend the wrist all the way down to the arm? I mean, I can't. But in a mature infant, you can. And we would call that a 0-degree square window, meaning that there is no space between the wrist and the arm versus a 90-degree square window like this would be indicative of a premature infant. They're not going to be able to get that wrist all the way down.
Now, arm recoil. So again, here's Molly. She's got her arms up here. She's well flexed. I pull on her arm and she brings it right back up. That's going to be a mature infant. Versus if it's a premature infant, if I pull on that arm, they may not recoil at all. They may not bring it up at all. Or if they do, it would be delayed.
Moving on to popliteal angle. That's going to have to do with extension of the baby's knee, so I can't bend hers very well. But if you were able to bend it and we had less than-- if we had 90 degree where we were able to get that up, that would be a mature infant. Versus if I'm able to get it all the way up to her head, that's going to be 180 degrees, premature infant.
Moving on to scarf sign. I always think of this as like throwing a scarf over; if you're throwing that tail of a scarf over. So scarf sign here. If I go to pull Molly's arm over her neck, she's resisting me pretty strongly, it's difficult to do, that would be indicative of a mature infant. If I take baby's arm and we're able to get it all the way over across their neck like a scarf with little to no resistance, that would be indicative of a premature infant.
And then heel to ear, again if I am able to bring Molly's heel all the way up to her ear, this is indicative of a premature infant. Think about how folded up they are when they're little like that in the womb versus if I have some resistance doing that, that would be more indicative of a mature infant.
Now, the second part of New Ballard is the physical maturity assessment here.
So this has to do with more like looking at them. So looking at Molly, I'm going to see does her skin look leathery and wrinkled? Or does it look sticky and transparent? Sticky and transparent is going to be indicative of a premature infant. But a leathery and a wrinkled, if it's to the extreme, it could actually be indicative of a post-mature infant. But think about the fact that as I age, I'm going to have more wrinkles. That's how I remember that the wrinkles are going to be for a mature baby.
Lanugo. Lanugo is that very fine hair that covers an infant's body. We have kind of three things here that we can talk about. A very premature infant is going to have no lanugo. They will not have developed that yet. A premature infant is going to have abundant lanugo that is keeping them warm; it's helping with thermo regulation. And a mature infant is going to have very little; they're going to be mostly bald by the time they are born.
Now plantar surface creases. If you look at the surface of the baby's foot, plantar surface, if it is smooth and there are no creases that seem to go across the sole, then this is a premature infant. Molly looks pretty premature to me here. But if I look at the plantar surface and I see wrinkles or creases that go all the way across the sole, that is a mature infant.
Then eyes and ears. Remember that the eyes don't really open until a certain point in the baby's development. So if the eyes are kind of fused shut, then that would be a premature infant. If the eyes open spontaneously, most likely mature.
The pinna. If I pulled the pinna of an infant's ear forward and it immediately pops back into place, that is a mature infant. Versus premature, it might sort of slowly unfold or get back to that point, but it's not going to kind of pop right back.
And then the genitals. If we have a baby with a penis, if we see a smooth scrotum and we don't really have wrinkles or anything like that in the scrotum, that's premature. Versus a mature infant with a scrotum is going to have what we call pendulous testicles, meaning they're hanging down and then they will have rugae, which are wrinkles. So we will have a wrinkled scrotum indicating maturity. If we have an infant that has a vulva, a premature will have a prominent clitoris and the labia will be flatter. So you'll be able to see the clitoris extending past the labia, perhaps. Whereas with a mature infant who has a vulva, the labia will be fully developed and the labia majora will cover the clitoris and labia minora. And so that would be the thing that you would see most prominently with that infant.
Up next, we're talking about thermo regulation, which is very important for newborns because they have a very hard time regulating their own temperature. You and I do a much better job at it, but these are newborns who come out of the uterus wet. First of all, they have a different sort of body makeup than an adult, and they don't have adipose tissue in the way that we do. They have something called brown fat. So we have a lot of risk factors for losing heat here, but it's important to understand the different ways in which we can lose heat. So we have a few types of heat loss.
Conduction, it's going to be heat loss from direct contact with a cooler surface, such as if I placed an infant on a metal scale without anything in between, they're going to lose heat through conduction by touching that cold metal surface.
Convection, heat loss from cooler air. So like a fan, circulating air past the newborn that would be convection heat loss.
Evaporation comes from heat loss when surface liquid is converted into a vapor. So, for instance, immediately after birth, they come out covered in fluid, right? They are at risk for losing heat through evaporation. Or if we were to give them a bath and now they are wet, then they are at risk for evaporative heat loss.
And then radiation. So this is heat loss from proximity to a closer surface. For instance, if I have a crib for my newborn that is right next to a cold window, they could lose some heat through radiation.
So important things would be make sure to dry the newborn thoroughly right after birth. Put a cap on their head, wrap them up tightly in a blanket, do skin-to-skin care with mom or another parent, and make sure that we are always protecting them from contact with cold or cooler surfaces because we need them to keep all of that heat inside.
And then lastly, in this video, we're talking about anthropometric measurements, which just means what is their body measurements like? So we have some important stuff here. We put it in a table for you. Bold, red text. We love to see it.
So weight is one of those things that I would know because weigh every baby, right? So we need to know what a normal range is. So 2,500 to 4,000 grams is the expected range, which is 5 pounds 8 ounces to 8 pounds 13 ounces. It's much easier to remember the metric measurements though here.
Length would be 48 to 53 centimeters or a 19 to 21 inches; more narrow of a window there.
Head circumference 13 to 15 inches.
And chest circumference 12 to 14 inches. But we do have a key point here that says at birth, the head circumference is 2 to 3 centimeters larger than the chest circumference. It's not until one year of age that the head and chest circumference approximate one another. So I always think that these are pumpkins on broomsticks, right? Babies and children have big heads compared to adults. So big head on a smaller body at birth.
I hope this review was helpful for you. I'm going to ask you some quiz questions to test your knowledge of key facts I provided you. So let me know how you do in the comments.
First up, I want you to name the five components of the Apgar score. So you can remember them either with Dr. Apgar's name, or you can try and remember the more commonly used ones as well. So the five components of the Apgar score.
Next, I'm going to tell you about an infant, and I want you to tell me what Apgar score you would give them. So we have a newborn with a strong cry. Their body is pink, but their extremities have a blue tint to them. Their pulse is 95, and they are actively moving all of their extremities. What Apgar score would you give to this infant?
Okay. Next, I want you to imagine that you are assessing a newborn of unknown gestational age. And you note that they have a zero-degree square window. They do show resistance to the scarf sign. They have creases covering the entire plantar sole, and they have very little lanugo. So you, as the nurse, do you interpret these findings to indicate a premature or a mature infant?
Okay. And lastly, what type of heat loss is experienced if the nurse were to place a newborn onto a cold metal scale? What is the type of heat loss that that infant would experience?
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