gestational age assessment handout color 6 per pg

The S.T.A.B.L.E. Program: GA Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for educational purposes. 1 © K. Karlsen 2006 Kristine A. Karlsen MSN, RNC, NNP Author National Program Director, Founder The S.T.A.B.L.E. Program Park City, Utah stable@stableprogram.org Kristine A. Karlsen Kristine A. Karlsen MSN, RNC, NNP MSN, RNC, NNP Author Author National Program Director, Founder National Program Director, Founder The S.T.A.B.L.E. Program The S.T.A.B.L.E. Program Park City, Utah Park City, Utah stable@stableprogram.org stable@stableprogram.org PowerPoint ® Design Mary Puchalski MS, RNC, APN/CNS Lombard, Illinois mary@stableprogram.org Medical Illustrations John Gibb MA PowerPoint PowerPoint ® ® Design Design Mary Puchalski Mary Puchalski MS, RNC, APN/CNS MS, RNC, APN/CNS Lombard, Illinois Lombard, Illinois mary@stableprogram.org mary@stableprogram.org Medical Illustrations Medical Illustrations John Gibb MA John Gibb MA Gestational Age Assessment of the Newborn Gestational Age Gestational Age Assessment of the Newborn Assessment of the Newborn © K. Karlsen 2006 Ballard Gestational Age Assessment Ballard Gestational Age Assessment Adapted from: Adapted from: Ballard et al. (1991) Ballard et al. (1991) J J Pediatr Pediatr ., ., 119(3): 417 119(3): 417 - - 423. 423. Physical Maturity Physical Maturity Female Female Genitals Genitals Male Male Genitals Genitals Eyes / ears Eyes / ears Breast Breast Plantar Plantar surface surface Lanugo Lanugo Skin Skin Thick cartilage Ear stiff Formed and firm Instant recoil Well-curved pinna Soft but ready recoil Slightly curved pinna Soft slow recoil Lids open Pinna flat Stays folded Lids fused: Loosely: -1 Tightly: -2 Testes pendulous Deep rugae Testes down Good rugae Testes descending Few rugae Testes in upper canal Rare rugae Scrotum empty Faint rugae Scrotum flat, smooth Majora cover clitoris and minora Majora large Minora small Majora and minora equally prominent Prominent clitoris Enlarging minora Prominent clitoris Small labia minora Clitoris prominent Labia flat Full areola 5-10 mm bud Raised areola 3-4 mm bud Stippled areola 1-2 mm bud Flat areola no bud Barely perceptible Imperceptible Creases over entire sole Creases anterior 2/3 Anterior transverse crease only Faint red marks Heel- toe > 50 mm No crease Heel- toe 40-50 mm < 40 = -2 Mostly baldBald Areas Thinning Lanugo Abundant lanugo Sparse lanugoNo lanugo Parchment Deep cracking No vessels 4 4 Cracking Pale areas Rare veins 3 3 Leathery Cracked Wrinkled 5 5 Superficial peeling and/or rash Few veins Smooth pink Visible veins Gelatinous Red Translucent Sticky Friable Transparent 2 2 1 1 0 0 - - 1 1 Neuromuscular Maturity Neuromuscular Maturity Heel to ear Heel to ear Scarf sign Scarf sign Popliteal Popliteal angle angle Arm recoil Arm recoil Square Square window window (wrist) (wrist) Posture Posture © K. Karlsen 2006 Ballard Gestational Age Assessment Ballard Gestational Age Assessment Neuromuscular illustrations were adapted Neuromuscular illustrations were adapted with permission of Dr. Ballard with permission of Dr. Ballard A detailed monograph and explanation about how to perform the Ballard exam (written by Dr. Ballard), may be found at www.BallardScore.com A detailed monograph and A detailed monograph and explanation about how to explanation about how to perform the Ballard exam perform the Ballard exam (written by Dr. Ballard), (written by Dr. Ballard), may be found at may be found at www.BallardScore.com www.BallardScore.com Adapted from: Adapted from: Ballard et al. (1991) Ballard et al. (1991) J J Pediatr Pediatr ., ., 119(3): 417 119(3): 417 - - 423. 423. © K. Karlsen 2006 Principles of Exam Principles of Exam Timing Timing Most reliable if performed by 12 hours of life Most reliable if performed by 12 hours of life Keep infant warm Keep infant warm © K. Karlsen 2006 Ballard Exam  Physical Maturity Ballard Exam  Physical Maturity Female Female Genitals Genitals Male Male Genitals Genitals Eyes / Eyes / ears ears Breast Breast Plantar Plantar surface surface Lanugo Lanugo Skin Skin Thick cartilage Ear stiff Formed and firm Instant recoil Well-curved pinna Soft but ready recoil Slightly curved pinna Soft slow recoil Lids open Pinna flat Stays folded Lids fused: Loosely: -1 Tightly: -2 Testes pendulous Deep rugae Testes down Good rugae Testes descending Few rugae Testes in upper canal Rare rugae Scrotum empty Faint rugae Scrotum flat, smooth Majora cover clitoris and minora Majora large Minora small Majora and minora equally prominent Prominent clitoris Enlarging minora Prominent clitoris Small labia minora Clitoris prominent Labia flat Full areola 5-10 mm bud Raised areola 3-4 mm bud Stippled areola 1-2 mm bud Flat areola no bud Barely perceptible Im- perceptible Creases over entire sole Creases anterior 2/3 Anterior transverse crease only Faint red marks Heel- toe > 50 mm No crease Heel- toe 40-50 mm <40 = 2 Mostly baldBald areas Thinning Lanugo Abundant lanugo Sparse lanugo No lanugo Parchment Deep cracking No vessels 4 4 Cracking Pale areas Rare veins 3 3 Leathery Cracked Wrinkled 5 5 Superficial peeling and/or rash Few veins Smooth pink Visible veins Gelatinous Red Translucent Sticky Friable Transparent 2 2 1 1 0 0 - - 1 1 © K. Karlsen 2006 Skin Skin 0 1 - - 1 1 Parchment Deep cracking No vessels 4 4 Cracking Pale areas Rare veins 3 3 Leathery Cracked Wrinkled 5 5 Superficial peeling and/or rash Few veins Smooth pink Visible veins Gelatinous Red Translucent Sticky Friable Transparent 2 2 1 1 0 0 - - 1 1 The S.T.A.B.L.E. Program: GA Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for educational purposes. 2 © K. Karlsen 2006 Skin Skin 2 2 3 3 Parchment Deep cracking No vessels 4 4 Cracking Pale areas Rare veins 3 3 Leathery Cracked Wrinkled 5 5 Superficial peeling and/or rash Few veins Smooth pink Visible veins Gelatinous Red Translucent Sticky Friable Transparent 2 2 1 1 0 0 - - 1 1 © K. Karlsen 2006 Skin Skin 3 3 5 5 4 4 Parchment Deep cracking No vessels 4 4 Cracking Pale areas Rare veins 3 3 Leathery Cracked Wrinkled 5 5 Superficial peeling and/or rash Few veins Smooth pink Visible veins Gelatinous Red Translucent Sticky Friable Transparent 2 2 1 1 0 0 - - 1 1 © K. Karlsen 2006 Lanugo Lanugo Mostly baldBald areasThinningAbundantSparseNo lanugo 4 4 3 3 2 2 1 1 0 0 - - 1 1 Begins to appear 24 Begins to appear 24 – – 25 weeks 25 weeks Abundant across shoulders and upper back by 28 weeks Abundant across shoulders and upper back by 28 weeks With increasing gestation With increasing gestation Lower back area thins first Lower back area thins first Bald areas appear over Bald areas appear over lumbo lumbo - - sacral area sacral area Mostly bald by term Mostly bald by term Amount and location may vary with nutritional status, Amount and location may vary with nutritional status, ethnicity, hormonal and metabolic factors ethnicity, hormonal and metabolic factors © K. Karlsen 2006 Lanugo Lanugo -1 0 Mostly baldBald areasThinningAbundantSparseNo lanugo 4 4 3 3 2 2 1 1 0 0 - - 1 1 © K. Karlsen 2006 Lanugo Lanugo Mostly baldBald areasThinningAbundantSparseNo lanugo 4 4 3 3 2 2 1 1 0 0 - - 1 1 1 © K. Karlsen 2006 Lanugo Lanugo 1 Mostly baldBald areasThinningAbundantSparseNo lanugo 4 4 3 3 2 2 1 1 0 0 - - 1 1 The S.T.A.B.L.E. Program: GA Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for educational purposes. 3 © K. Karlsen 2006 Lanugo Lanugo 4 2 Mostly baldBald areasThinningAbundantSparseNo lanugo 4 4 3 3 2 2 1 1 0 0 - - 1 1 3 © K. Karlsen 2006 -1 1 Creases over entire sole 4 4 Creases anterior 2/3 3 3 Anterior transverse crease only Faint red marks > 50 mm No crease Heel–toe 40 – 50 mm < 40 = – 2 2 2 1 1 0 0 - - 1 1 0 Plantar Surface Plantar Surface © K. Karlsen 2006 Plantar Surface Plantar Surface 2 4 Creases over entire sole 4 4 Creases anterior 2/3 3 3 Anterior transverse crease only Faint red marks > 50 mm No crease Heel–toe 40 – 50 mm < 40 = – 2 2 2 1 1 0 0 - - 1 1 3 © K. Karlsen 2006 Breast Breast -1 Full areola 5–10 mm bud 4 4 Raised areola 3–4 mm bud 3 3 Stippled areola 1–2 mm bud Flat areola no bud Barely perceptible Im- perceptible 2 2 1 1 0 0 - - 1 1 0 1 © K. Karlsen 2006 Breast Breast 4 Full areola 5–10 mm bud 4 4 Raised areola 3–4 mm bud 3 3 Stippled areola 1–2 mm bud Flat areola no bud Barely perceptible Im- perceptible 2 2 1 1 0 0 - - 1 1 32 © K. Karlsen 2006 Eye and Ear Eye and Ear -2 Thick cartilage Ear stiff 4 4 Formed and firm Instant recoil 3 3 Well-curved pinna Soft but ready recoil Slightly curved pinna Soft slow recoil Lids open Pinna flat Stays folded Lids fused: Loosely: -1 Tightly: -2 2 2 1 1 0 0 - - 1 1 0 The S.T.A.B.L.E. Program: GA Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for educational purposes. 4 © K. Karlsen 2006 Eye and Ear Eye and Ear 3 4 2 1 Thick cartilage Ear stiff 4 4 Formed and firm Instant recoil 3 3 Well-curved pinna Soft but ready recoil Slightly curved pinna Soft slow recoil Lids open Pinna flat Stays folded Lids fused: Loosely: -1 Tightly: -2 2 2 1 1 0 0 - - 1 1 © K. Karlsen 2006 Genitalia  Male Genitalia  Male 0 1 Testes pendulous Deep rugae 4 4 Testes down Good rugae 3 3 Testes descending Few rugae Testes in upper canal Rare rugae Scrotum empty Faint rugae Scrotum flat, smooth 2 2 1 1 0 0 - - 1 1 3 42 © K. Karlsen 2006 Genitalia Genitalia 0 3 4 Majora cover clitoris and minora Majora large Minora small Majora and minora equally prominent Prominent clitoris Enlarging minora Prominent clitoris Small labia minora Clitoris prominent Labia flat 4 4 3 3 2 2 1 1 0 0 - - 1 1  Female  Female © K. Karlsen 2006 Heel to Heel to ear ear Scarf Scarf sign sign Popliteal Popliteal angle angle Arm Arm recoil recoil Square Square window window (wrist) (wrist) Posture Posture 4 4 3 3 5 5 2 2 1 1 0 0 - - 1 1 Ballard Exam  Neuromuscular Maturity Ballard Exam  Neuromuscular Maturity © K. Karlsen 2006 Principles of Neuromuscular Exam Principles of Neuromuscular Exam Positioning Positioning Head midline Head midline Hips flat Hips flat Reliability of Reliability of exam altered by: exam altered by: Sedation Sedation Anesthesia Anesthesia Paralysis Paralysis Critically ill state Critically ill state Breech position Breech position ! ! Neuromuscular assessment may be too stressful for premature and sick infants  should be performed by skilled neonatal ICU personnel once infant stabilized and able to tolerate the exam ! ! Neuromuscular assessment may be too Neuromuscular assessment may be too stressful for premature and sick infants stressful for premature and sick infants   s s hould be performed by skilled hould be performed by skilled neonatal ICU personnel once infant neonatal ICU personnel once infant stabilized and able to tolerate the exam stabilized and able to tolerate the exam © K. Karlsen 2006 Posture Posture 4 4 3 3 2 2 1 1 0 0 - - 1 1 1 2 The S.T.A.B.L.E. Program: GA Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for educational purposes. 5 © K. Karlsen 2006 Posture Posture 4 4 3 3 2 2 1 1 0 0 - - 1 1 3 4 © K. Karlsen 2006 Square Window Square Window Assesses wrist flexibility and/or resistance to extensor Assesses wrist flexibility and/or resistance to extensor stretching at the wrist stretching at the wrist Press gently on knuckles to straighten fingers Press gently on knuckles to straighten fingers Apply gentle pressure on back of hand close to Apply gentle pressure on back of hand close to fingers fingers   avoid wrist rotation avoid wrist rotation Stop pressing when resistance felt Stop pressing when resistance felt Angle Angle decreases decreases as gestational age as gestational age increases increases 4 4 3 3 2 2 1 1 0 0 - - 1 1 90 90   60 60   45 45   30 30   0 0   >90 >90   © K. Karlsen 2006 Square Window Square Window 4 4 3 3 2 2 1 1 0 0 - - 1 1 0 1 90 90   60 60   45 45   30 30   0 0   >90 >90   © K. Karlsen 2006 4 4 3 3 2 2 1 1 0 0 - - 1 1 2 3 4 Square Window Square Window 90 90   60 60   45 45   30 30   0 0   >90 >90   © K. Karlsen 2006 Arm Recoil Arm Recoil Tests for passive flexor tone of biceps muscle Tests for passive flexor tone of biceps muscle Test one arm at a time in order to avoid the Moro Test one arm at a time in order to avoid the Moro reflex reflex Supine position Supine position Hold infant Hold infant ’ ’ s hand s hand Briefly flex arm Briefly flex arm   then momentarily extend arm and then momentarily extend arm and release hand release hand Scores based on angle of recoil when arms return Scores based on angle of recoil when arms return to flexion to flexion 4 4 3 3 2 2 1 1 0 0 - - 1 1 180 180   140 140 - - 180 180   110 110 - - 140 140   90 90 - - 110 110   <90 <90   © K. Karlsen 2006 Arm Recoil Arm Recoil 4 4 3 3 2 2 1 1 0 0 - - 1 1 1 3 4 180 180   140 140 - - 180 180   110 110 - - 140 140   90 90 - - 110 110   <90 <90   The S.T.A.B.L.E. Program: GA Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for educational purposes. 6 © K. Karlsen 2006 Assesses maturation of passive flexor tone about the Assesses maturation of passive flexor tone about the knee joint knee joint Refrain from touching hamstrings (the muscle group Refrain from touching hamstrings (the muscle group being tested) during maneuver being tested) during maneuver Thigh placed in knee Thigh placed in knee - - chest position with knee fully flexed chest position with knee fully flexed Allow infant to relax, then grasp foot at sides Allow infant to relax, then grasp foot at sides Extend leg until resistance is felt Extend leg until resistance is felt Estimate angle behind the knee Estimate angle behind the knee Measurement unreliable if frank breech in utero Measurement unreliable if frank breech in utero Popliteal Angle Popliteal Angle 4 4 5 5 3 3 2 2 1 1 0 0 - - 1 1 180 180   160 160   140 140   120 120   <90 <90   100 100   90 90   © K. Karlsen 2006 0 1 Popliteal Angle Popliteal Angle 4 4 5 5 3 3 2 2 1 1 0 0 - - 1 1 180 180   160 160   140 140   120 120   <90 <90   100 100   90 90   © K. Karlsen 2006 Popliteal Angle Popliteal Angle 2 4 3 4 4 5 5 3 3 2 2 1 1 0 0 - - 1 1 180 180   160 160   140 140   120 120   <90 <90   100 100   90 90   © K. Karlsen 2006 Scarf Sign Scarf Sign Tests passive tone of the posterior shoulder girdle Tests passive tone of the posterior shoulder girdle flexor muscles flexor muscles Supine position with head midline Supine position with head midline Hold infant Hold infant ’ ’ s hand across chest and use thumb of other s hand across chest and use thumb of other hand to gently push elbow across chest hand to gently push elbow across chest Or, gently pull arm across chest Or, gently pull arm across chest (shown in photos) (shown in photos) Stop when resistance is felt Stop when resistance is felt Scores based on position of elbow at landmarks Scores based on position of elbow at landmarks 4 4 3 3 2 2 1 1 0 0 - - 1 1 neck neck axillary line axillary line nipple line nipple line xyphoid xyphoid process process nipple line nipple line axillary line axillary line © K. Karlsen 2006 Scarf Sign Scarf Sign 4 4 3 3 2 2 1 1 0 0 - - 1 1 1 2 neck neck axillary line axillary line nipple line nipple line xyphoid xyphoid process process nipple line nipple line axillary line axillary line © K. Karlsen 2006 Scarf Sign Scarf Sign 4 4 3 3 2 2 1 1 0 0 - - 1 1 3 4 neck neck axillary line axillary line nipple line nipple line xyphoid xyphoid process process nipple line nipple line axillary line axillary line The S.T.A.B.L.E. Program: GA Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for educational purposes. 7 © K. Karlsen 2006 Heel-to-Ear Heel-to-Ear Tests for passive flexion or resistance to extension Tests for passive flexion or resistance to extension of posterior hip flexor muscles of posterior hip flexor muscles Refrain from touching gluteus muscle (the muscle group Refrain from touching gluteus muscle (the muscle group being tested) during maneuver being tested) during maneuver Rest leg alongside the body Rest leg alongside the body Grasp foot along both sides Grasp foot along both sides Gently pull toward ear until resistance felt Gently pull toward ear until resistance felt Scores based on location of heel to landmarks Scores based on location of heel to landmarks Measurement unreliable if frank breech in utero Measurement unreliable if frank breech in utero 4 4 3 3 2 2 1 1 0 0 - - 1 1 ear ear nose nose chin chin nipple line nipple line umbilical area umbilical area femoral crease femoral crease © K. Karlsen 2006 Heel-to-Ear Heel-to-Ear 4 4 3 3 2 2 1 1 0 0 - - 1 1 ear ear nose nose chin chin nipple line nipple line umbilical area umbilical area femoral crease femoral crease 2 1 0 © K. Karlsen 2006 Heel-to-Ear Heel-to-Ear 4 4 3 3 2 2 1 1 0 0 - - 1 1 4 ear ear nose nose chin chin nipple line nipple line umbilical area umbilical area femoral crease femoral crease 3 © K. Karlsen 2006 Neuromuscular Maturity Neuromuscular Maturity Heel to ear Heel to ear Scarf sign Scarf sign Popliteal Popliteal angle angle Arm recoil Arm recoil Square Square window window (wrist) (wrist) Posture Posture Physical Maturity Physical Maturity Female Female Genitals Genitals Male Male Genitals Genitals Eyes / ears Eyes / ears Breast Breast Plantar Plantar surface surface Lanugo Lanugo Skin Skin Thick cartilage Ear stiff Formed and firm Instant recoil Well-curved pinna Soft but ready recoil Slightly curved pinna Soft slow recoil Lids open Pinna flat Stays folded Lids fused: Loosely: -1 Tightly: -2 Testes pendulous Deep rugae Testes down Good rugae Testes descending Few rugae Testes in upper canal Rare rugae Scrotum empty Faint rugae Scrotum flat, smooth Majora cover clitoris and minora Majora large Minora small Majora and minora equally prominent Prominent clitoris Enlarging minora Prominent clitoris Small labia minora Clitoris prominent Labia flat Full areola 5-10 mm bud Raised areola 3-4 mm bud Stippled areola 1-2 mm bud Flat areola no bud Barely perceptible Im-perceptible Creases over entire sole Creases anterior 2/3 Anterior transverse crease only Faint red marks > 50 mm No crease Heel- toe 40-50 mm < 40 = -2 Mostly baldBald Areas Thinning Lanugo Abundant lanugo Sparse lanugoNo lanugo Parchment Deep cracking No vessels 4 4 Cracking Pale areas Rare veins 3 3 Leathery Cracked Wrinkled 5 5 Superficial peeling and/or rash Few veins Smooth pink Visible veins Gelatinous Red Translucent Sticky Friable Transparent 2 2 1 1 0 0 - - 1 1 Gestational Age Evaluation Gestational Age Evaluation 10 + 15 = 25 10 + 15 = 25 15 15 15 10 10 10 Sum scores Sum scores © K. Karlsen 2006 Sum scores Sum scores Neuromuscular Neuromuscular Physical maturity Physical maturity Total score correlates to Total score correlates to weeks gestation weeks gestation 20 20 - - 10 10 22 22 - - 5 5 24 24 0 0 44 44 50 50 42 42 45 45 40 40 40 40 38 38 35 35 36 36 30 30 34 34 25 25 32 32 20 20 30 30 15 15 28 28 10 10 26 26 5 5 Wks Wks Score Score 10 + 15 = 25 10 + 15 = 25 Gestational Age Evaluation Gestational Age Evaluation A detailed monograph and explanation about how to perform the Ballard exam (written by Dr. Ballard), may be found at www.BallardScore.com . MA Gestational Age Assessment of the Newborn Gestational Age Gestational Age Assessment of the Newborn Assessment of the Newborn © K. Karlsen 20 06 Ballard Gestational Age Assessment Ballard Gestational Age Assessment Adapted. 20 06 Ballard Gestational Age Assessment Ballard Gestational Age Assessment Neuromuscular illustrations were adapted Neuromuscular illustrations were adapted with permission of Dr. Ballard with permission. gestation 20 20 - - 10 10 22 22 - - 5 5 24 24 0 0 44 44 50 50 42 42 45 45 40 40 40 40 38 38 35 35 36 36 30 30 34 34 25 25 32 32 20 20 30 30 15 15 28 28 10 10 26 26 5 5 Wks Wks Score Score 10 + 15 = 25 10 + 15 = 25 Gestational Age Evaluation Gestational Age Evaluation A detailed