Characteristic of NewbornThe end of your journey has come after 40 weeks. The fruit of your labour (literally) will soon be in your hands.There are a few things you might want to know about your new arrival. Typically, a newborn baby has the followingcharacteristic appearance:

Weight: Average 2.8 kg for Indian babies (range 2.5 – 3.2 kg). Babies below 2.5 kg at birth are considered to be low birth weight and need special evaluation.

Length: Approximately 50 cm. Remember, small women have small babies and many genetic factors also play a role in determining the length of the baby.

Head: Your baby’s head appears large for the body and may have an elongated shape or appear to havesome ‘bumps’. This is due to changes called molding, which occurs in labour and delivery. Small bumps called ‘caput’ usually disappear in 1 – 2 days. Soon the head gets rounder. The head circumference is 33 – 35 cm.

Soft spots or Fontanelles: There are 2 areas on the head where bone formation is incomplete at birth. The larger one, in front of the head closes by 6 – 18 months. The smaller one at the back usually closes by 6 weeks.

Hair: As all people vary, so does their hair. Your baby may have lots of hair or none at all! It depends on familial and racial factors.

Heart beats: Usually the heart rate is 120 – 140 beats per minute. Respiratory rate (breathing): It is faster than adults, usually 30 – 40 breaths / minute. Breathing may be

noisy or stop for many seconds. This is not uncommon. Colour: Depending on the parents, the skin colour of newborn varies. In general, newborn babies look

flushed and pink all over. However, the palms and soles of the feet may look dusky or little bluish soon after birth.

Axillary temperature measurement. The thermometer should remain in place for 3 minutes. The nurse presses the newborn’s arm tightly but gently against the thermometer and the newborn’s side, as illustrated

Proper Identification of the Newborn Proper Id is made in the delivery room before mother and baby are separated.

o Identification Bando Footprintso Others – fingerprints, crib card, bead bracelet

Birth certificate final identification check of the mother and infant must be performed before the infant can be allowed to

leave the hospital upon discharge to ensure that the hospital is discharging the right infant.Preventing Infection

Ophthalmia neonatorum Any conjunctivitis with discharge occuring during the first two weeks of life. It typically appears 2-5 days

after birth, although it may appear as early as the first day or as late as the 13th.

silver nitrate (used before) – 2 drops lower conjunctiva (not used now)Administering Erythromycin or Tetracycline Ophthalmic Ointment

These ointments are the ones commonly used nowadays for eye prophylaxis because they do not cause eye irritation and are more effective against Chlamydial conjunctivitis.

Apply over lower lids of both eyes, then, manipulate eyelids to spread medication over the eyes. Wipe excess ointment after one minute Č sterile cotton ball moistened Č sterile water.

Credes Prophylaxis – Dr. Crede prevent opthalmia neonatorum or gonorrhoeal conjunctivitis how transmitted – mom with gonorrhea

drug: erythromycin ophthalmic ointment- inner to outer

It is part of the routine care of the NB to give prophylactic eyetreatment against gonorrheal conjunctivitis or ophthalmianeonatorum within the first hour after delivery.

Neisseria gonorrhea, the causative agent,maybe passed on to thefetus when infected vaginal and cervical secretions enter the eyes as the baby passes the vaginal canal during delivery. This practice was introduced by Crede, German gynecologist in 1884. Silver Nitrate

Handwashing Before entering the nursery or caring for a

baby In between newborn handling or after the care

of each baby Before treating the cord After changing soiled diaper Before preparing milk formula.

Principles of cleanliness at birth: Clean hands Clean perineum Nothing unclean to be introduced into the

vagina Clean delivery surface Cleanliness in cutting the umbilical cord Cleanliness for cord care of the newborn baby

Preventing Hemorrhage As a preventive measure, 0.5mg (preterm) to 1 mg (full term) Vit. K or Aquamephyton is injected IM in

the NB’s vastus lateralis (lateral anterior thigh)muscle Vit-K – to prevent hemorrhage R/T physiologic hypoprothrombinemia Aquamephyton, phytomenadione or konakion .1 ml term IM, vastus lateral or lateral ant thigh .05 ml preterm baby Vit K – synthesized by normal flora of intestine Vit K – meds is synthetic due intestine is sterile

When the NB, is brought to the nursery, another clamp is applied . to 1 in from the abdomen and thecord is cut a second time.

The cord and the area around it are cleansed w/ antiseptic solution. The manner of cord care depends on hospital protocol or the discretion of the birth attendant in home

delivery, what is impt. Is that principles are followed. Cord clamp is removed after 48 hours when the cord has dried. The cord stump usually dries and falls

off within 7-10 days leaving a granulating area that heals on the next 7-10 days. Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and

seperates more rapidly if it is exposed to air. Report any unusual signs & symptoms that indicate infection:

Foul odor in the cord Presence of discharge Redness around the cord The cord remains wet and does not fall off within 7-10 days Newborn fever

“Tetanus microorganism thrives in anaerobic environment so you actually prevent infection if cord is exposed to air”.3 cleans in community

clean hand clean cord clean surface

betadine or povidone iodine – to clean cordcheck AVA, then draw 3 vessel cord

If 2 vessel cord- suspect kidney malformation leave about 1” of cord

if BT or IV infusion – leave 8” of cord best access - no nerve check cord every 15 min for 1st 6 hrs – bleeding .> 30 cc of blood bleeding of cord – Omphalagia –

suspect hemophiliaCord turns black on 3rd day & fall 7 – 10 days

Faiture to fall after 2 weeks- Umbilical granulationMgt: silver nitrate or catheterization

clean with normal saline solution not alcohol don’t use bigkis – air persistent moisture-urine, suspect patent uracus – fistula bet bladder and normal umbilicus

dx: nitrazine paper test – yellow – urinemgt: surgery

Bathing oil bath – initial to cleanse baby & spread vernix caseosa

Fx of vernix caseosa1. insulator2. bacterio- static

Babies of HIV + mom – immediately give full bath to lessen transmission of HIV 13 – 39% possibly of transmission of HIV

Procedure for vitamin K injection. Cleanse area thoroughly with alcohol swab and allow skin to dry. Bunch the tissue of the upper outer thigh (vastus lateralis muscle) and quickly insert a 25-gauge 5/8-inch needle at a 90-degree angle to the thigh. Aspirate, then slowly inject the solution to distribute the medication evenly and minimize the baby’s discomfort. Remove the needle and gently massage the site with an alcohol swab.

Care of the Cord The cord is clamped and cut approx. within 30 sec after birth. In

the DR, the cord is clamped twice about 8 inches from the abdomen and cut in between.

Immediate Care of the NewbornA irwayB ody temperatureC heck/ assess the newbornD etermine identification

Stimulate & dry infant Assess ABCs Encourage skin-to-skin contact Assign APGAR scores Give eye prophylaxis & Vit. K Keep newborn, mother, & partner together

wheneverNewborn Assessment and Nursing Care

Physical Assessment Temperature - range 36.5 to 37 axillary Common variations Crying may elevate temperature

o Stabilizes in 8 to 10 hours after delivery

o Temperature is not reliable indicator of infection a temperature less than 36.5

Temp: rectal- newborn to rule out imperforate anus take it once only , 1 inch insertion

Imperforate anus1. atretic – no anal opening2. agenetialism – no genital3. stenos – has opening4. membranous – has opening

Earliest sign:1. no mecomium2. abd destention3. foul odor breath4. vomitous of fecal matter5. can aspirate – resp problem

Mgt: Surgery with temporary colostomy

Heart Rate range 120 to 160 beats per minute Common variations Heart rate range to 100 when sleeping to 180

when crying Color pink with acrocyanosis Heart rate may be irregular with crying Although murmurs may be due to transitional

circulation-all murmurs should be followed-up and referred for medical evaluation Deviation from range Faint sound

Cardiac rate: 120 – 160 bpm newbornApical pulse – left lower nippleRadial pulse – normally absent. If present PDAFemoral pulse – normal present. If absent- COA - coartation of aorta

Respiration

range 30 to 60 breaths per minute Common variations

o Bilateral bronchial breath sounds Moist breath sounds may be present shortly

after birth

Signs of potential distress or deviations from expected findings

o Asymmetrical chest movementso Apnea >15 secondso Diminished breath soundso Seesaw respirationso Gruntingo Nasal flaringo Retractionso Deep sighingo Tachypnea - respirations > 60o Persistent irregular breathingo Excessive mucuso Persistant fine crackleso Stridor

Breathing ( ventilating the lungs)o check for breathlessnesso if breathless, give 2 breaths- ambu bago 1 yr old- mouth to mouth, pinch noseo < 1 yr – mouth to noseo force – different between baby & childo infant – puff

Circulationo Check for pulslessness :carotid- adult

¨ Brachial – infants CPR – breathless/pulseless Compression – inf – 1 finger breath below

nipple line or 2 finger breaths or thumb CPR inf 1:5 Adults 2:30 Blood Pressure

o not done routinely Factors to considero Varies with change in activity levelo Appropriate cuff size important for accurate

readingo 65/41 mmHg

General Measurementso Head circumference - 33 to 35 cmo Expected findingso Head should be 2 to 3 cms larger than the chesto Abdominal circumference – 31-33 cmo Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8

lbs. 13 oz.)o Length range - 46 to 54 cms (19 - 21 inches)

Anthropometic measurementnormal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cmhead circumference 33- 35 cm or 13 – 14 “Hydrocephalus - >14”Chest 31 – 33 cm or 12 – 13”Abd 31 – 33 cm or 12 – 13”

Signs of increased ICP1.) abnormally large head2.) bulging and tense fontanel3.) increase BP and widening pulse pressure #3 & #4 are Cushings triad of4.) Decreased RR, decreased PR ICP85.) projective vomiting- sure sign of cerebral irritation6.) high deviation – diplopia – sign of ICP older child

4-6 months- normal eye deviation>6 months- lazy eyes

7.) High pitch shrill cry-late sign of ICp

Skin o Jaundice is first detectable on the face (where

o Skin reddish in color, smooth and puffy at birtho At 24 - 36 hours of age, skin flaky, dry and

pink in coloro Edema around eyes, feet, and genitalso Venix Caseosa -whitish, cheese-like substance,

covers the fetus while in utero and lubricates the skin of the NB. The skin of the term or postterm nb has less vernix and is frequently dry; peeling is common, esp. on the hands & feet

o Lanugo -moderate in full term; more in preterm; absent in postterm; shed after 2 weeks in time of desquammation

o Turgor good with quick recoilo Hair silky and soft with individual strandso Nipples present and in expected locationso Cord with one vein and two arterieso Cord clamp tight and cord dryingo Nails to end of fingers and often extend slightly

beyond

Skin colorWhite – edema Blue – cyanosis or hypoxia Grey – infection Yellow – jaundice , carotene

Acrocyanosiso Bluish discoloration of the hands and feet maybe

present in the first 2 to 6 hours after birtho This condition is caused by poor peripheral

circulation, w/c results in vasomotor instability & capillary stasis, esp. when the baby is exposed to cold.

Mongolian Spots

Mottling

Physiologic Jaundiceo Hyperbilirubinemia not associated with

hemolytic disease or other pathology in the newborn. Jaundice that appears in full term newborns 24 hours after birth and peaks at 72 hours. Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days.

o If jaundice occurs within 2 days – pathologic jaundice

o If jaundice occurs at 3rd-7th days of life – physiologic jaundice

skin overlies cartilage) and the mucus membranes of the mouth and has a head-to-toe progression.

o Evaluate it by blanching the tip of the nose, the forehead, the sternum, or the gum line. This procedure must be done with appropriate lighting. Another are to assess is the sclera.

o Jaundice maybe related to breastfeeding, hematomas, immature liver function, bruises from forceps, blood incompatibility, oxytocin induction or severe hemolysis process.

Nsg Resp:1. cover eyes – prevent retinal damage2. cover genitals – prevent priapism – painful continuous erection3. change position regularly – even exposed to light4. increase fld intake – due prone to dehydration5. monitor I&O – weigh baby6. monitor V/S – avoid use of oil or lotion due- heat at phototherapy = bronze baby syndrometransient S/E of phototherapy

Care of Newborn in JaundicePhototherapy

o Is the exposure of the NB to high intensity light.

o Maybe used alone or in conjunction w/ exchange transfusion to reduce serum bilirubin levels.

o Decreases serum bilirubin levels by changing bilirubin from the non-water soluble form to water-soluble by products that can be excreted.

Nursing Interventions:1. Exposing as much of the NB’s skin as possible however genitals are covered & the nurse monitors the genitals area forskin irritation2. Eyes are covered with patches or eye shields and are removed at least once per shift to inspect the eyes3. Monitor temp. closely & ↑ fluids to compensate water loss4. NB is repositioned q 2° and stimulation is provided.

o NB will have loose green stools and green colored urine.

Exchange Transfusiono Is the withdrawal and replacement of

newborn’s blood with donor blood.

If the central circulation is adequate, the blood supply should return quickly when the skin is blanched with a finger. Blue hands and nails are poor indicator of oxygenation in NB. The nurse should assess the face & mucus membranes for pinkness reflecting adequate oxygenation

Patch of purple-black or blue-blackcolor distributed over coccygeal andsacral regions of infants of African-American or Asian descent. Notmalignant. Resolves in time. Theygradually fade during the first orsecond year of life. They maybemistaken for bruises and should bedocumented in the NB’s chart.

lacy pattern of dilated blood vesselsunder the skinOccurs as a result of generalcirculation fluctuations. It may lastseveral hours to several weeks ormay come and go periodically.Mottling maybe related to chillingor prolonged apnea.

Milia which are exposed to sebaceous glands, appear as raised white spots on the face, esp. across the nose. No treatment is necessary, because they willclear within first month.Infants of African heritage have a similar condition called transient neonatal pustular melanosis.

Erythema toxicum

o It is often called “newborn rash” or “fleabite” dermatitis

o The rash may appear suddenly, usually overo the trunk and diaper area and is frequently

widespread.o The lesions do not appear on the palms of the

hands or soles of the feet.o The peak incidence is 24-48 hours of life.o Cause is unknown and no treatment

Harlequin Signo The color of the newborn's body appears to be

half red and half pale. This condition is transitory and usually occurs with lusty crying. Harlequin Coloring may be associated with to an immature vasomotor reflex system.

BIRTH MARKS

Telangiectatic nevi (stork bites)

Appear as pale pink or red spots and are frequently found on the eyelids, nose, lower occipital bone and nape of the neck

These lesions are common in NB w/ light complexions and are more noticeable during periods ofcrying.

3 types Hemangiomasa.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgicallyb.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermalarea. Enlarges, disappears at 10 yo.c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappearwith age.

Flammeus (port-wine stain) A capillary angioma directly below the

epidermis, is a non-elevated, sharply demarcated, red-to-purple area of dense capillaries.

Macular purple

The size & shape vary, but it commonly appears on the face. It does not grow in size, does not fade in time and does not blanch. The birthmark maybe concealed by using an opaque cosmetic cream.

If convulsions and other neurologic problem accompany the nevus flammeus,----5th cranial nerve involvement.

Nevus vasculosus (strawberry mark)

Such marks usually grow starting the second or third week of life and may not reach their fullest size for 1 to 3 months; disappears at the age of 1 yr. but as the baby grows it enlarges.

Birthmarks frequently worry parents. The mother maybe especially anxious, fearing that she is to blame (“Is my baby marked because of something I did?”) Guilt feelings are common when parents have misconceptions about the cause. Identify and explain them to the parents.

Providing appropriate information about the cause and course of birthmarks often relieves the fears and anxieties of the family. Note any bruises, abrasions,or birthmarks seen on admission to the nursery.

HEAD Head circumference should be 2 cm greater

than chest circumference Assess fontanelles and sutures - observe for

signs of hydrocephalus and evaluate neurologic status

Craniosynostosis Microcephaly Macrocephaly

o Is an eruption of lesions in the area surrounding a hair follicle that are firm, vary in size from 1-3 mm, and consist of a white or pale yellow papule or pustule w/ an erythematous base.

A capillary hemangioma, consists of newly formed and enlarged capillaries in the dermal and subdermal layers.

It is a raised,clearly delineated, dark-red, rough-surfaced birthmark commonly found in the head region.

Face, Mouth, Eyes, and Ears Assess and record symmetry Assess for signs of Down syndrome. Low set ears Assess history for risk factors of hearing loss Test for Moro reflex- elicited by a loud noise or

lifted slightly above the crib and then suddenly lowered. In response, the NB straightens arms and hands outward while the knees flexed. Slowly the arm returns to the chest as in embrace. The fingers spread, forming a C and the newborn may cry. This lasts up to 6 months of age.

Check for presence of gag, swallowing reflexes, coordinated with sucking reflex

Check for clefts in either hard or soft palates Check for excessive drooling Check tongue for deviation, white cheesy

coatingEyes

Assess for PERLA (pupils equal and reactive to light and accommodation)

Assess cornea and blink reflex Note true eye color does not occur before 6

months May have blocked tear duct

Heart and Lungs Assess and maintain airway Assess heart rate, rhythm - evaluate murmur:

location, timing, and durationo Examine appearance and size of chesto Note if there is funnel chest, barrel

chest, unequal chest expansion Assess breath sounds and respiratory efforts -

evaluate color for pallor or cyanosis Breasts are flat with symmetric nipples - note

lack of breast tissue or dischargeAbdomen

Abdomen appears large in relation to pelviso Note increase or decrease in peristalsiso Note protrusion of umbilicus

Measure umbilical hernia by palpating the opening and record

o Note any discharge or oozing from cord

o Note appearance and amount of vessels

Auscultate and percuss abdomeno Assess for signs of dehydrationo Assess femoral pulseso Note bulges in inguinal areao Percuss bladder 1 to 4 cm above

symphysiso Voids within 3 hours of birth or at

time of birthGenitals

Pseudomenstruation: the discharge w/c can become tinged w/ blood and is caused by withdrawal of

maternal hormones Smegma: a white cheeselike substance is often

present between labia. Removing it may traumatize tender

tissue Phimosis : tight foreskin or prepuce; w/c

sometimes lead to early circumcision Cryptoorchidism: undescended testes ;if the

testes did not go down Orchidopexy: repair of undescended testes

before 2 y/o Penis: urethra should be at the tip of the penis Hypospadias : if the opening is at the ventral

Epispadias: if the opening is at the dorsal surface

Hydrocele – swelling due to accumulation of serous fluid in the tunica vaginalis of the testis or in the spermatic cord

Anus Inspect anal area to verify that it is patent and

has no fissure Digital exam by physician or nurse practitioner

if needed Note passage of meconium

Extremities Tic dwarfism : very short arms Amelia : absence of arms Phocomelia : absence of long arm Polydactilism: more fingers; extra digits on

either hands or feet Syndactilism: webbing; fusion of fingers or

toes

Inspect the hands for normal palmar creases. A single palmar crease called SIMIAN line is frequently present in Down’s syndrome

Adactyl : no foot Down’s syndrome: inward rotation of little

fingers Clubfoot/ talipes deformity – inward rotation

of foot fingers. Erb-Duchenne paralysis (Erb’s palsy) :

resulting from injury to the 5th and 6th cervical roots of the brachial plexus; usually from a difficult birth; it occurs commonly when strong traction is exerted on the head of the NB in an attempt to free a shoulder lodged behind the symphysis pubis in the presence of shoulder dystocia

Clubfooto Nurse examines feet for evidence of talipes deformity (clubfoot)o Intrauterine positions can cause feet to appear to turn inward - "positional" clubfooto To determine presence of clubfoot, nurse moves foot to midline - if resists, it is true clubfoot

A. The asymmetry of gluteal and thigh fat folds see

B. Barlow's (dislocation) maneuver. Baby's thigh is grasped and adducted (placed together) with gentle downward

C, Dislocation is palpable as femoral head slips out of acetabulum.

D, Ortolani's maneuver puts downward pressure on the hip and then inward rotation. If the hip is dislocated, thismaneuver forces the femoral head over the acetabular rim

surfaceTALIPES – “clubfoot”a.) Equinos – plantar flexion –horsefootb.) Calcaneous – dorsiflexion –heal lower that foot anterior posterior of foot flexed towards anterior legc.) Varus- foot turns ind.) Valgus- foot turns outEquino varus- most common

Nursing Role Be knowledgeable about normal newborn

variations and responses that indicate further investigation

o Respiratory distresso Central cyanosiso Thermoregulation problemso Dehydrationo Teaching

During physical and behavioral assessment, identify family's need for teaching

o Involve family early in care of infanto Process establishes uniqueness and

allays concern Teaching

o Feeding cueso Alert stateo Cord careo Sleeping

Neurological Status Assessment begins with period of observation Observe behaviors - note:

o State of alertnesso Resting postureo Cryo Quality of muscle toneo Motor activity

Jitteriness – feeling of extreme nervousness Differentiate causative factors Examine for symmetry and strength of

movements Note head lag of less than 45 degrees Assess ability to hold head erect briefly

Immature central nervous system (CNS) of newborn is characterized by variety of reflexes

o Some reflexes are protective, some aid in feeding, others stimulate interaction

o Assess for CNS integration Protective reflexes are blinking, yawning,

coughing, sneezing, drawing back from pain Rooting and sucking reflexes assist with

feeding“What reflexes should be present in a newborn? Reflexes are involuntary movements or actions. Some movements are spontaneous, occurring as part of the baby's usual activity. Others are responses to certain actions. Reflexes help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. The following are some of the normal reflexes seen in newborn babies”

Palmar & Plantar Grasp Reflex

Babinski reflex - When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about 2 years of age.

Tonic neck reflex - When a baby's head is turned to one side, the arm on that sidestretches out and the opposite arm bendsup at the elbow. This is often called the "fencing" position. The tonic neck reflex lasts about six to seven months.

Grasp reflex - Stroking the palm of a baby'shand causes the baby to close his/her fingers ina grasp. The grasp reflex lasts only a couple ofmonths and is stronger in premature babies.Palmar & Plantar

The Moro reflex is often called a startle reflex because it usually occurs when a baby is startled by a loud sound or movement. In response to the sound, the baby throws back his/her head,extends out the arms and legs, cries, then pulls the arms and legs back in. A baby's own cry can startle him/her and begin this reflex. This reflex lasts about five to six months.

Step reflex This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his/her feet touching a solidsurface.

ASSESSMENT OF PHYSICAL MATURITY CHARACTERISTICS OF NEWBORN

Observable characteristics of newborn should be evaluated while not disturbing baby

Gestational assessment tools examine the following physical characteristics

o Resting postureo Skino Lanugoo Sole (planar) creaseso Breast tissueo Ear form and cartilage distributiono Evaluation of genitals

Male genitals

A, Preterm newborn’s testes are not within the scrotum. The scrotal surface has few rugae. score 2.

B, Term newborn’s testes are generally fully descended. The entire surface of the scrotum is covered by rugae. Score 3.Female genitals

Neuromuscular Components

Square window sign

Signs of Preterm Babieso Born after 20 weeks, after 37 weekso frog leg or laxed positono hypotonic muscle tone- prone resp problemo scarf sign – elbow passes midline pos.o square window wrist – 90 degree angle of wristo heal to ear signabundant lanugo-

Signs of Post term babies:> 42 weeks

o classic sign – old man’s faceo desquamation – peeling of skino long brittle finger nailso wide & alert eyes

Babies with special needsSome babies may need some extra attention from you and the doctor after birth. These include:

o Low birth weight babies (less than 2.5kg).o Babies born too early (premature).o Babies with pathological jaundice.o Babies with infection.

Root reflex - This reflex begins when the corner of the baby's mouth is stroked or touched. The baby will turn his/her head and open his/her mouth to follow and"root" in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding.

Suck reflex Rooting helps the baby become ready tosuck. When the roof of the baby's mouth istouched, the baby will begin to suck. This reflex does not begin until about the 32ndweek of pregnancy and is not fully developed until about 36 weeks. Premature babies mayhave a weak or immature sucking ability because of this. Babies also have a hand-to mouth reflex that goes with rooting and sucking and may suck on fingers or hands.

B, The clitoris is still visible.The labia minora are now covered by the larger labia majora. Score 2. The gestational age is 36 to 40 weeks.

C, The term newborn has well-developed, large labia majora that cover both clitoris and labiaminora. Score 3.

A, This angle is 90 degrees and suggests an immaturenewborn of 28 to 32 weeks’ gestation. Score 0.

B, A 30- to 40-degree angle is commonly found from 39 to 40 weeks’ gestation. Score 2-3.

C, A 0-degree angle can occur from 40 to 42 weeks. Score 4. (C) Used with permission from V.Dubowitz, MD,Hammersmith Hospital,London, England.

o Those needing an operation soon after birth.o Those with low blood sugar.o Babies of diabetic mothers.

A, Newborn has a prominent clitoris. The labia majora are widely separated, and thelabia minora, viewed laterally, would protrude beyond the labia majora. Score 1. The gestational age is 30 to 35 weeks.