The EngagED Midwife
The EngagED Midwife
What If The Dates Are Wrong And The Baby Tells The Truth
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A newborn arrives fast, the dates are fuzzy, and everyone in the room is sure they know how far along the pregnancy was. Then the baby tells a different story. That’s where a solid gestational age assessment and real bedside pattern recognition can change the entire plan in minutes.
We talk through the Ballard assessment in a way that’s built for busy midwives, midwifery students, and anyone responsible for newborn care. We explain what the Ballard score is designed to do, when it matters most (limited prenatal care, language barriers, uncertain dating, misleading third-trimester growth ultrasound), and why the exam usually isn’t asking you to memorize a chart. The goal is safer clinical reasoning: term vs preterm vs post-term, and what that means for newborn transition, thermoregulation, blood sugar monitoring, and when to consult pediatrics.
You’ll hear our highest-yield neuromuscular maturity checks (posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear) and the physical maturity signs you can spot head-to-toe (skin texture, lanugo, plantar creases, breast buds, ear cartilage, and genital findings). We also work through real clinical scenarios: a “term” baby who acts like a 34-weeker, a baby with post-maturity features, and a small-for-gestational-age newborn who is physiologically mature, pointing you toward growth restriction rather than prematurity.
If newborn assessment has ever felt intimidating, this is your reminder that “normal” is the foundation and your best safety net. Subscribe for more midwifery exam prep and clinical refreshers, share this with a classmate who wants more newborn confidence, and leave a review. What’s the first sign you check to decide if a baby is truly term?
#Newborn #BabyBabyAreYouOkay #GestationalAge #Transition #Term #Preterm #Postterm #NewBallardScore #Maturity
Beachside Wrap And Student Mentoring
SPEAKER_00Welcome to the Engage Midwife podcast. This is Missy. And this is Kara. And we're coming to you live from the beach. Navarre, Florida. We just rapped the craziest week of our year. It's been fun. Really fun, actually. It was really fun, but I am really tired.
SPEAKER_01Yeah. 16 new midwives prepped and ready.
SPEAKER_00Yeah, and 16 doesn't sound like a big number until you realize that we've like literally lived with them for the whole week.
SPEAKER_01It's been really fun. Students from all over the country, West Coast, Midwest, East Coast, all over. Literally, we've covered the whole US.
SPEAKER_00Yeah, it's kind of amazing. We look forward to this week because the ability to just like have our hands on students like for the whole like exam prep. Yeah.
SPEAKER_01We, I mean, we have hugged them, but yeah, hands-on.
SPEAKER_00Well, it's different too to like be in a classroom. Yes. Like teaching for eight hours and then coming back to a classroom and teaching for another eight hours than like being at the beach where like during your downtime, you're like taking a walk or getting in the pool or like taking a nap.
SPEAKER_01Yeah, I think the side conversations and the mentoring that we're able to do in the downtimes is probably some of my favorite part. And even having students from my own program come here, it was so special to be able to spend time with them because we don't get to just be ourselves and be down and relaxed like we can here, which is really nice.
SPEAKER_00Yeah. It's um it's always just a change in like environment, which is nice
Annual Meeting Exam Prep Plans
SPEAKER_00for us. Yeah. But our next actually planned group exam prep will be at annual meeting. Yeah, we're back at the annual meeting this year, which is fun.
SPEAKER_01It's been a couple of years for us.
SPEAKER_00It's been a couple of years. We are only teaching our cases. Um, but we will run a special for people who come to that prep if they want the whole um caboodle. If they want the cases and the content. Yes. They'll get the cases from us live, but we'll run a special. So if you're gonna be at annual meeting and you're graduating in December, it's a great time to prep um with us. And we'd be we can't wait to see you. So I'm sure at the end of um this season, we'll be talking more about annual meeting and what to expect and those kinds of things too.
SPEAKER_01Yeah, it's exciting. It's gonna be in Kansas City. So in Kara's home turf. Yes. It's exciting. Yeah.
SPEAKER_00Okay.
Why Gestational Age Assessment Matters
SPEAKER_00So what are we gonna talk about today? Well, it's one it's a topic that I teach all the time, but that you don't necessarily love. I I mean, I teach newborn.
SPEAKER_01Um, I like newborns. I don't love newborn care per se. But yeah, I mean, this is something that as a nurse, we did gestational age assessment on every single baby. We just had a conversation last night, though, about maybe that's kind of fallen out of favor because everybody has dating ultrasounds, but um, it's a skill that I feel really comfortable with because I did it all the time as a nurse.
SPEAKER_00Yeah, I think we all did it all the time as a nurse. And um, yeah, and I still, when I deliver babies and like giving them the once over, like thinking about like, are they term, what what are their physical characteristics look like, what like all of those things.
SPEAKER_01Yeah, some of us just eyeballing them and then others like touching them and getting them bendy, right?
SPEAKER_00Yeah, or even just I was telling students yesterday that sometimes you just have to look at a few physical characteristics to really know if they're term. So we'll talk about that as we go through this. So yeah. Um, but we get like questions a lot from students and like, am I gonna be responsible for this? It kind of depends on where you work. Yes. If you're gonna be in a birth center, where in the birth center, like they're doing a lot of that work.
SPEAKER_01A lot, yeah. So there are a lot of hospital-based midwives that may not be doing much newborn care um and maybe turning babies over as soon as they're born to pediatricians or family medicine or that sort of thing. But if you're an out-of-hospital birth, you are the newborn provider oftentimes for at least that first week or two. Um, but certainly reminding everyone that as midwives, we are primary care providers for newborns up to 28 days of life. That's right. And we are the guardians of normal.
SPEAKER_00Ha. I wish I could get every student to like tattoo that on their forehead. Normal, like normal. Just remember if you're a student and you listen to us, that your midwifery certification exam is 60% based on normal. I just feel like it's the it's the first thing that should be out of my mouth every time I talk to a student about a test.
SPEAKER_01Yeah, and I tell people all the time that we are experts and normal. And that doesn't mean we can't take care of deviations or that, but we and we definitely should be able to recognize them. But really, really expert care and normal and really understanding how transitions happen. That's so much of what we do.
SPEAKER_00Yeah, it is. So I think that not necessarily, it's not that newborn, I think, is a difficult topic. It's more that like a lot of students aren't doing it.
SPEAKER_01Yeah.
SPEAKER_00Um, more because they're the midwives that they're precepting with don't do it, or they don't feel like they have opportunities. I just want to be really clear. Like, if you're a student and you haven't gotten a lot of exposure to newborn, there are nursery nurses and NICU nurses who would be happy to walk you through newborn assessment.
SPEAKER_01Yeah.
SPEAKER_00And even if you say to your preceptor, hey, while we're not doing something, do you care if I slip into the nursery and like assess a few newborns or have the nurses like walk me through assessment? Like it's a great way to learn. That's how in integration, when I was labor sitting, I would definitely always go to the nursery and be like, I'm gonna like watch the nurses, I'm gonna have them show me things. Like I had a lot of experience, like you doing it in my workplace. Right. But I really wanted to have the expertise and feel good about it. And we tease now because I got all the newborn questions on my certification test right. And I like give all that credit to the nursery nurses at Northside that like taught me all the things when I was a midwifery student. Yeah.
SPEAKER_01And then as a program director, I'm really encouraging my students all the time of if you catch a baby, assess it before you leave the room. You can assess that baby on mom's chest, you can assess that baby in mom's arms. You, if you go in and do postpartum rounds the next day, do an assessment on that baby. Show mom all of the different reflexes. Um, they think you're just amazing and they think their kid is so smart, not really understanding what reflexes are, but that's sterical. But yeah, assess babies if they're in for postpartum visits in the office, go ahead and assess their baby. Even if your midwife doesn't do newborn care, you can do that assessment and recognize normal.
SPEAKER_00Yeah, now you can't do a full ballard assessment why the baby's on mom's chest. No, but you can do it in the when they're in the, you know, at the warmer, you can do it while they're in the bassinet in the mom's room. Yeah. Um, if they're having any kind of procedures done, a ballard assessment should not take long. No, and it's really more um accurate the sooner you do it. Yeah. So why the ballard? So ballard is named after a physician and she decided that we needed a way to be able to decide whether or not babies were term or preterm. Yes. And that was also like you were saying, before we had this idea of everybody having a dating ultrasound. But I will say, as a little caveat to that, we do have enough patients that either have limited or no prenatal care, that this definitely is a skill that's important. Because a growth ultrasound in third trimester is plus or minus three weeks. Yes. Agreed. And so you have a patient who comes in for with no prenatal care and they look term and you do a growth scan and they're like, oh, they look big enough. Your measurements are only good, plus or minus three weeks.
SPEAKER_01Well, and let's say someone's coming in and there's language differences and they precip, you don't have a lot of time to get a history or information. A ballard can be really, really helpful. Um, you know, is a baby small and term or are they actually preterm and small?
SPEAKER_00Right. No, it's so many things. Yeah. So the the part about Ballard is it's a standard approach for us to really assess the gestational age of a baby.
SPEAKER_01Yeah. So in the Ballard, it looks at two different, and you've kind of hinted at this, it looks at two different components, the physical maturity or like what the baby looks like, their skin, um, the soles of their feet, that kind of idea. And then the neuromuscular, which is when I said let's get them Bendy, is checking a lot of different things to see how neuromuscular maturity is. And you add those points together, it can range all the way from a negative 10 up to 50. And then that score translates into a gestational age.
SPEAKER_00Right. Which that is my only complaint about Ballard is that when you add it up, it doesn't give you a number of weeks, it gives you a score, and then you have to use a separate little chart to say the score is this, then what's the gestational age? The more intuitive way would have been that when you add it up, it gives you a gestational age. That would be nice and not like a thing that I have to go to another chart for. Yeah. So the piece here for students is they should not ask you to add up a score and then decide how many weeks a baby is. No. They, because you're not gonna see the chart probably on the exam. Right. You're gonna see a description of a baby and they're either gonna ask you what the intervention is, right? So knowing that the baby is either preterm or term, or you're gonna need to know that there's no intervention because the baby's term and it can just do normal transition things. And so I wouldn't get super caught up as we start to talk about neuromuscular and physical maturity. I wouldn't get super like caught up in the idea that like you have to memorize the whole chart because that's not it.
SPEAKER_01No.
SPEAKER_00You have to be able to identify whether a baby is term or preterm. And I know that there's a couple of questions that are in test banks that are out there that say very specific things. And one of the questions that comes to mind is like, your baby has abundant Lanooga, what's its approximate gestational age? And that is literally like one box out of 40 on the ballard. Right. And I don't think you necessarily need to memorize what's in every box.
SPEAKER_01But it could give you a description of like two or three things that are very clearly like post-term. Correct. And you know, oh, that is a fully cooked, oh extreme baby.
SPEAKER_00Or the descriptions were like a most of them are term and a couple of them are a little preterm, but that they would average out to being a term baby. I don't think you need to know that at 28 weeks a baby has abundant lamooga. Agree. I think that is a silly like call out when you see a question like that, because that's, I don't think the board that does not make you safe.
SPEAKER_01Yeah, it's also not, in my opinion, gonna ask you is it 36, 37, or 38 weeks? It's gonna want to know, is it 35, is it 38, or is it 42?
SPEAKER_00It's more so like what is even more specifically, is it term? Is it early third trimester? Is it late second trimester? Like it's gonna want you to be able to identify whether or not your baby is term.
SPEAKER_01And you mentioned the accuracy of ultrasound being in the third trimester about three weeks, plus or minus three weeks. It's terrible for the ballard, it is more accurate and that it is plus or minus two weeks.
SPEAKER_00Well, and you know, we could go on and on about ultrasound because there are some things about ultrasound and fetal monitoring that help us decide if a baby has got good well-being, right? Like a late, like a third trimester ultrasound looking for fluid. If they don't have any fluid, we have a problem. Yeah. Right. But the ultrasounds that we do that are really helpful in third trimester really have to do with fetal well-being and not with growth. Yeah. Yeah. The reason that we would be doing like high-level growth ultrasounds for babies have more to do with like growth restriction than with like, is this like what's the approximate gestation like?
SPEAKER_01Yeah. And and with this, we're not trying to use the ballard to like confirm the dates. It's more so finding those things where there are deviations. Um, so you know, like if you had a baby that looks 40 weeks, but they're acting like a 34-weeker, then that's the red flag. That's when we see a deviation. And it can help us know do we need to refer this baby to a pediatric provider or a specialist, or is this really what we expect?
SPEAKER_00For those of you who know, since we're at the beach, we are recording live sitting next to each other at the beach. Yeah, windows open. Windows open. I was gonna say breeze coming in and all the noise that comes with uh being in a place where beach houses are getting ready for the summer. Yeah, the birds and the seagulls and all the things. So the background noise is all of that. So let's dive in.
Neuromuscular Ballard Checks Explained
SPEAKER_00Let me talk about neuromuscular maturity and then you can talk more about physical maturity. Sounds good. So neuromuscular maturity is really looking at postures and um the flexibility of a baby. And I'm just gonna start by saying preterm babies are much more flexible than term babies. When the baby is term, their joints and their muscles and all of the things are when they're more mature, they tend to be much more well flexed or brought in and not as stretchy. Kind of that classic fetal position, tucked in tight. Tucked in tight. And so as we talk about these, there's only one in which a term baby is more flexible than a preterm baby. And I will give you that clue when we get there. So the first thing is that I feel like students should know, or midwife should know, everything that makes a baby a term baby. Yep. And so that's the way I teach this, and this is what I think you should know. That way, if it's not that, you would be like, oh, maybe suspecting that a baby wasn't term. And so the first thing is that their posture should be kind of frog-like. So their elbows should be in, their knees should be up, everything should be like sort of all kind of in, not like a ball, but kind of like a frog. Yeah. Like frog-like posture. Um, the second thing is the square window. So this is the one where the term baby is more likely to be more flexible than a preterm baby. A term baby can take its hand all the way to its arm at the wrist. So there's zero degrees of angle between the hand and the bones of the arm. Whereas a preterm baby, their wrist is not very flexible. They can sometimes not even get to 90, a very preterm baby. Yeah. Um, the next thing is arm recoil. And so this is where we grab both of the baby's hands and we sort of pull out to extend the baby's arms and we let go. Where do the arms recoil to? And in a term baby, the arm should recoil quickly with the elbows coming down in back into the sides, really quickly into like its original position. And so it's like a less than 90 degree angle at the elbow when the um when the arms recoil. Now, if you pull a pre-turn baby's arms out, they may leave them there. They may stay there, or they might only go to like 180 degrees, or they might go to a hundred degrees or 110 degrees. Yeah. But a term baby should go back to that frog-like posture where they have like, you know, bent elbows, right? And they come back into their bodies. Um, the next three, one is the poplate heal angle, and this is the angle behind the knee. So when we hold the hip down to the bed and we try to bend at the hip, so flex at the hip and extend at the knee, it's the angle behind the knee. And so in a term baby, that's going to be less than 90 degrees. They can't, like they don't have any hamstring flexibility. So that's what that is. Pop lateal angle has to do with hamstring flexibility. Whereas, like a preterm baby, they don't have any of that mobility issue. So they can get a like 150 degrees of poplateal angle. So angle behind the knee.
SPEAKER_01The one place this may be a little bit different is if you had a breech baby. Their positioning is going to be a little bit off, but otherwise, yes.
SPEAKER_00Um, the next one is the scarf sign. So this is when we hold the shoulder down on the bed and we try to reach across the arm across the body. A term baby usually can't get its elbow much past its axilla. Whereas in a preterm baby, the arm will go like all the way across and the elbow will almost be at the nipple line on the opposite side of the body. It's like you can wrap their arm around the mascarf. Like a boa. Yeah. Um, and then finally, in terms of neuromuscular maturity, we have heel to ear. So heel to ear and poplet's heel angle oftentimes look a lot alike. Yeah. But in this case, we're trying to figure out how close the heel of the baby's foot can get to their ear. It also has to do with hamstring and knee mobility. And a term baby will just have very little, like a less than 90 degree angle. They cannot get their heels very far back. Whereas a term baby can pretty much take a preterm baby can pretty much take its heel all the way back to its ear, with the exception of breech babies. You'll have that like crazy mobility.
SPEAKER_01Yeah, absolutely.
Physical Maturity Signs Head To Toe
SPEAKER_01So now let's talk about physical maturity. And there's a couple of different things that we look at here. Um, looking at the skin on a term baby, there may be some cracking of the skin, um, some peeling. You'll see some veins potentially, where on a really like fully, like even post-term baby, maybe it's leathery and cracked. And on a preterm baby, it can be almost kind of really smooth pink skin or gelatinous feeling or more sticky. When we look at lanugo, that's that fine baby hair. Um, you know, as Missy said, on our preterm babies, maybe they have abundant lanugo, where on a term baby we're starting to see more bald areas or mostly bald. Um, then looking at the foot, the plantar surface. So when we look at the bottom of the baby's foot, it will have the more wrinkles there are, um, the more creases there are on the foot, the more term they are, where a baby might have slick bottom feet if they are more preterm.
SPEAKER_00That was one that the nurses used to always say to me, like the old nurses used to be like, Oh, I just look at the bottoms of their feet.
SPEAKER_01Absolutely, absolutely. I always think about, you know, as a night shift nurse, we were always the ones doing the uh uh the footprints as well. So we got really used to what feet looked like. Yeah. Um, the next is breast buds. And so in a term baby, they'll have a full areola. Um, term, I'd say three to four millimeter breast bud, where in a post-term, maybe a little bit bigger, five to ten. Um, and it could be, you know, barely perceptible or a flat areola um on a preterm baby. Then we look at the ears and the ear cartilage. If this is one of those things, again, where if you fold the ear down, a term baby, their ear is going to pop right back into place. But a preterm baby, when you fold their ear down, it almost kind of sticks there. It's a little slower in popping back into place. Um, and then for the genitals, you know, obviously um boy babies and girl babies looking a little bit different. But with our boy babies and genitals and a term baby, the testes are gonna be descended. There's gonna be good rugae noted on the scrotum. Um, if it's a post-term baby, it may be really deep and almost more cracked looking rouge. If they're preterm, they may not have descended descended testes, um, and the scrotum is gonna look a little bit more smooth. And then in our girl babies, um, at term, we're gonna have more larger majora and smaller menorah. Um, in a post-term baby, the majora could cover the menorah completely and the clitoris, where in a preterm baby, everything's gonna be much more prominent on the menorah. The clitoris is gonna be larger and the majora are not gonna cover as much.
SPEAKER_00Yeah, it's not it's the not covering.
SPEAKER_01Yeah, yeah. And as a reminder, just remembering that baby's genital areas can be pretty swollen looking and um that sort of thing. But this is all all of these measurements are most accurate when done earlier. If we get past like 48 hours of age and stuff, the measurements aren't as accurate. Yep. But I agree. I think the feet, um, there's a couple of others of you know, really thinking about um what are the classic like golden things that we think about. The feet are one for me, and then the leathery skin in a post-term baby.
SPEAKER_00I think it's genitals because when I'm sitting at the foot of the bed, like delivering a baby, I usually have a pretty clear view of what their genitals look like. Yeah, yeah. That makes a good point. I can see if what the scrotum looks like. I can kind of see what's happening with labio. Like I know that for me, that's a good one. Um, their nails, actually, and two, like the appearance of their skin. Like, if can you see the vessels? Can you not see the vessels? Yeah, like that's a whole nother thing. Agree.
SPEAKER_01And we can't always go, we didn't say anything about vernix, right? But you always hear people talk about the vernix when a baby's born. Babies have all kinds of different varying amounts of vernix, and it can certainly be left in the creases and different things. We can't really look to that as a measurement. Um, but the Linugo and the skin, like you said, that's a good point.
SPEAKER_00Yeah. So I think that I wouldn't really memorize all of the squares inside of a ballard. It's really like being able to like in your brain, like work head to toe and think like, oh, these are the things I want to think about, right? And when we were saying like you can do an assessment when mom's on the when the baby's on the belly, like what's their posture? Right? What's their skin look like? What are their genitals look like? Do they have a lot of Linugo? Yeah. Um, you can maybe even get an idea about their breast buds, right? You're probably not doing that whole neuromuscular assessment, but certainly there's a lot of skin findings that you can be like these physical maturity things that you can see just like at a quick glance.
SPEAKER_01And it's nice to do newborn assessments in general and also the gestational age assessment by looking at things before you touch them or without making a lot of noise and stimulating them. Yeah. So, do you want to do a few clinical scenarios?
Clinical Scenarios That Change Management
SPEAKER_01That'd be good. Yeah. I think it's helpful to think about. Um, so let's say that we are at a birth and the labor progressed unexpectedly fast and the gestational age was uncertain. We didn't have ultrasound reports, the things were moving very fast, the baby's born, and the parents insist that they are full term, but the baby appears small and has a really weak cry. So, in that situation, an assessment, a ballard assessment can be really, really helpful. And in this scenario, we do a ballard assessment and the score is consistent with a 34-week gestation. So that's a pretty big difference. The parents swear their term, but their baby is looking and acting like a 34-weeker. This is gonna instantly change our management. We're gonna go from that routine newborn care of a term infant to the preterm transition and that late kind of late preterm, early term, thinking about we really have to prioritize thermoregulation and we have to watch their blood sugar really closely. And then we also want to decide a 34-weeker, I'm probably I am consulting pediatric uh at that point because we could have some respiratory distress or that sort of thing.
SPEAKER_00Yeah, they may. Um, also, like I mean, they will definitely look like RDS. They don't have a lot of, they don't have enough surfactant, they may have trouble overcoming the surface tension of their lungs during transition. There's all kinds of things.
SPEAKER_01Well, and if it was a fast delivery, they didn't get as long of a squeeze, they may not have gotten that fluid pushed out of their lungs as well either.
SPEAKER_00And they also may have like jaundice, more jaundice issues because they're preterm, like there's just all kinds of things with a 34-weeker. Yeah, absolutely. All right, what about a client who's potentially 42 weeks by dates, but the born baby is born with vernix and seems it that seems robust. Um and the ballard assessment shows that the baby physiologically is post-mature. So deep peeling skin, long nails, and deep creases. So now we're looking at things that may have to do with post-maturity syndrome, right? Um, so hypoglycemia, hypoxia, the I think hypoglycemia and hyper hypothermia are the big ones. They are like cousins that like to hang out together. Yeah. Um, you can get cold stress, and then that will drop your blood sugar too. Um, babies have really big surface areas of their bodies. So that like will tell us too that they will get hypothermic really easy. And so your baby may need a little bit more support just in terms of metabolic stability than like a baby who is potentially like 38 or 39 weeks.
SPEAKER_01Yeah. Yeah. So and then lastly, we could have a baby that's born really small and has a low birth weight. Um, and the parents are worried about is this a situation where there might be failure to thrive or growth issues? But you perform a ballard and this kiddo is a 39-week term infant. And so that is gonna look different. Maybe we have growth restriction versus a preterm baby, or just small for gestational age versus preterm. Yeah. Or, you know, we were talking a fair amount this week about constitutionally small. Some smaller people are gonna have smaller babies.
SPEAKER_00Oh, yeah. I was so small when I was born, but I was so long. Yes. And being so long, I just like look back at pictures now and I'm like, I look like I am just a bag of bones.
SPEAKER_01My parents joked all the time that my sister and I looked like uh monkeys because we were hairy and long, but skinny scrawny. Yeah, scrawny.
SPEAKER_00Like you you guys were only like four pounds. I think we were growth restricted. I was term and six pounds, but like 22 inches long. That's so crazy. My mom used to like tuck my legs up into my blanket to make me look tiny. Yeah. Because it was like all limbs. Yeah, nothing.
SPEAKER_01But understanding how a small for gestational age or a growth restricted baby looks compared to a premature baby that's small is really helpful in understanding what we should expect, like neuromuscular maturity, that kind of idea.
SPEAKER_00If you are a student or a new midwife and you do not have experience with preterm babies, go to the NICU. Yeah. Just go to the NICU and ask the nurses if you can walk around. Yeah. Tell them who you are and be like, hey, can you tell me a little, like, what's the gestational age of your baby? How long has it been here? Or what was it born at and what is it now? It you should just be, you don't even have to touch them, but just look at the physical characteristics. I always say if you look at a at a NICU baby laying in an isolate, like they sometimes just don't have any tone. Yeah. They're literally just like laying there with their arms outstretched and their legs outstretched because they just don't have any tone yet.
SPEAKER_01When you're there, also look for the ginormous baby in the NICU that is probably an infant of a diabetic mother and doesn't have the lung maturity, but oh, they are big and puffy. And just see what that looks like as well. It can be really, really helpful.
SPEAKER_00Yeah. Big babies, the fattest baby in the NICU, right?
SPEAKER_01Sometimes the sickest.
SPEAKER_00Yeah. Yeah. Right. Right. So really a ballard is something that's gonna like help you hone your own intuition, right? It if something doesn't feel right, the ballard might tell you why it's not right.
SPEAKER_01Yeah. Yeah. And then don't forget to trust your gut. Like I think we talk about this all the time with nurses. We talk about this as midwives, of like sometimes there's some intuition when something doesn't quite seem right. And your ballard can be really, really helpful for you in that situation.
SPEAKER_00Yep.
Practice Questions Plus Transition Red Flags
SPEAKER_00So, all right, we have a few practice questions. So we'll do these and then maybe wrap up the episode. Yeah, sounds great. Okay. So I'm gonna start. Um, a midwife is performing a gestational age assessment on a newborn who's born to a G1P0 mother at 39 weeks. When assessing the scarf sign, the midwife moves the neonate's arm across the chest. Which finding is most consistent with the expected physical maturity for this gestational age? So we're talking about the things that we said earlier in the podcast, which is what does a term baby scarf sign look like? And I said that the scarf sign should be the elbow will stay mostly near the side or near the axilla. The answer choices here are A, the elbow reaches the axillary line on the opposite side, the elbow crosses the midline of the chest, the elbow encounters resistance and does not reach the midline of the chest, or the elbow reaches the nipple line with no resistance. So the best answer here is C. It sounds like the one with the least amount of flexibility, which is the elbow encounters resistance and does not reach the midline of the chest.
SPEAKER_01Yeah, great. So, next question: we have a midwife performs a physical assessment on a neonate that's born via precipitous delivery with unknown prenatal care. The midwife notes the following findings deep plantar creases covering the entire sole, leathery and wrinkled skin, and sparse lanugo only on the upper back. So, based on these findings, which gestational age range is most accurate? A 28 to 30 weeks, B, 32 to 34 weeks, C 36 to 37 weeks, or D 38 to 40 plus weeks. And for this, the correct answer is D. As we mentioned, each of those different physical findings, the creases covering the entire sole, the leathery wrinkled skin, all of this makes us think of a term or a post-term infant, specifically thinking about the feet. And preterm infants would be more like the smooth skin, not having the creases covering the entire foot, that sort of thing. So this is a really helpful question. And I think one that could be something you would see on boards.
SPEAKER_00Yeah, it's almost exactly what I say that students should prepare for.
SPEAKER_01Yeah, exactly.
SPEAKER_00All right. Last one, and we're gonna talk about um clinical reasoning here. So a mother with severe gestational hypertension delivers an infant at 40 weeks gestation. The infant's noted to be small for gestational age. During the ballot assessment, the infant scores highly on both the neuromuscular and physical maturity section. How should the midwife interpret these results? A, the assessment is inaccurate because the infant's too small to be term. B, the ballard score confirms the infant's physiologically and physiologically mature, indicating the low birth weight is likely due to growth restriction rather than preterm birth. C, the high ballard score suggests the infant is actually post-term, despite the 40-week delivery date. Or D, the assessment should be repeated in 24 hours to account for the infant's compromise state. So the best answer here is B, the ballard score confirms that the infant is physiologically mature. And so this, like we've been saying, ballard is designed to assess the physiologic, like the physiologic maturation of a baby. Um, and that would be present even in the presence of growth restriction. And so um distinguishing, it'll help us distinguish between preterm, low birth weight, and term growth restricted babies. So this is a really great, I mean, I think, conversation, especially for students who don't understand this.
SPEAKER_01Yeah, I think it can seem simple. Um, and if it is simple for you, that's great. This is a great update, a great reminder of this um topic. But if newborn is challenging to you or it scares you, we hope this builds your confidence a little bit.
SPEAKER_00Yeah. And I think they you're you still are gonna have like even when you do a gestational age assessment or you're doing an apgar, you're doing all the things of the baby in transition, you're always gonna be still looking for your red flags that don't have anything to do with that, right? Right. Respiratory compromise, neurologic depletion, temperature dysregulation, color changes. Um, I would also challenge you to go back and look at the normal transition period in the first eight hours. So the first period of reactivity, the period of decreased responsiveness, the second period of reactivity. Because honestly, babies can do crazy things in eight hours. Their bodies are trying to adjust to being outside of the uterus. And it doesn't happen just as soon as we clamp the cord. Yeah. All of those shunts have to close, the lungs have to become an organ of gas exchange, the kidneys have to start like working to produce um urine, the gut has to be working on vitamin K and bilirubin. So if you're thinking about what a baby has to do when it comes out, transition can look sort of bizarre.
SPEAKER_01Can you imagine? Like you were in a nice warm bath that was, I mean, you know, mom's heart rate and gut sounds could be loud, but it's kind of a little muffled in there and it's really like relaxing. And then to come out into this world, I think I'd be a little overstimulated. It's cold.
SPEAKER_00It's cold, it's loud, it's bright. Oh, so bright. But also now that we know that I have this thing with low-level repetitive noise, I'm probably glad that I don't remember being in utero and having to listen to blood flow flow through the aorta every day for 40 weeks.
SPEAKER_01It's so funny. It makes me think back to that um happiest baby on the block by Harvey Carp. And um, I had the heartbeat sound in my baby's room all the time, but that may have set you off.
SPEAKER_00Yeah. Hate low level repetitive noise.
SPEAKER_01Ah, it's killing me. Well, we hope this was helpful for you all.
Final Takeaways And Closing
SPEAKER_01It was a good reminder for me. Um, I I love um I love normal.
SPEAKER_00Normal is so good. But it's also good to be confident when you things when you know things aren't normal. So absolutely. Well, thanks for joining us for the Engaged Midwife podcast. We can't wait to talk to you again. Take care.