Transition and Normal Newborn
Care
Monica L. Scrudder, RNC-NIC, BSN, MSN
Franciscan Health System
Regional Nurse Educator, Nursery Services
Objectives
• Identify primary features of fetal circulation.
• Identify physiological changes that occur at birth in
the newborn’s transition to extrauterine homeostasis.
• Identify routine care for the newborn in the transition
period.
• Identify signs and symptoms of common problems in
the transition period.
• Identify nursing intervention that promote parental
bonding.
What Is Transition???
The Transition Period
• Birth to 6 hours of age
• Physiological change from placental support to
self-maintenance
• Fetus prepares for transition over the course
of gestation
• Transition depends on gestational age and
quality of placental support
The Cardiac Puzzle
Anatomy and Physiology
• Placental Fetal Circulation
• Blood follows the path of least resistance
• Low pulmonary blood flow (only 8-10% of
right ventricular output secondary to high
pulmonary vascular resistance
The Fetal Circulation
Ductus Venosus
Foramen Ovale
Ductus Arteriosis
Fetal Lungs
Fetal Metabolism and Hematology
• Glucose
– Fetal concentrations 70-80% of maternal glucose
concentrations
• Glycogen
– Large glycogen stores provide large energy
reserves to sustain newborn through transition
period
• Brown Fat
– Unique to newborn
– Metabolized for heat
Cardiopulmonary Adaptation at Birth
Cardiovascular Adaptations At Birth
• Umbilical cord is clamped.
• Three major shunts functionally close during
transition
– Ductus Arteriosis
– Foramen Ovale
– Ductus Venosus
Pulmonary Adaptation At Birth
• Stimuli for initiating respiration
– Mild hypercapnia, hypoxia and acidosis
– Light, noise, touch
– Thoracic squeeze during vaginal delivery
• Empties approximately 1/3 of fetal lung fluid
First Breath
• Air enters lungs at 2x normal pressure
– 40-80 cm H2O
• Pulmonary vessels vasodilate in response to
increased oxygen
– Pulmonary vascular resistance decreases
– Pulmonary blood flow increases
Continued Pulmonary Adaptations
• Pulmonary vascular resistance (PVR)
decreases to reach adult levels at 2-3 weeks
of age
• Lung compliance improves
Measurements
• Apgar score
– Done at 1 minute and 5 minutes of age
– If apgar less than 7 at 5 minutes of age, continue
every 5 minutes until greater than 7 for maximum
of 20 minutes
The Apgar Score
Sign
0
1
2
Heart rate
Absent
Slow (<100
bpm)
> 100 bpm
Respirations
Absent
Weak cry,
Hypo-ventilation
Good, strong cry
Muscle Tone
Limp
Some flexion
Active motion
Reflex
Irritability
No response
Grimace
Cough or sneeze
Color
Blue or pale
Body pink,
Extremities blue
Completely pink
Assessment Findings During Transition
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Head circumference, length, weight
Gestational age assessment
Skin
Head
Respiratory assessment
Cardiac assessment
Gastrointestinal assessment
Extremities
Medications in Transition
• Erythromycin Ointment
• Vitamin K (AquaMEPHYTON)
• Hepatitis B vaccine/Hepatitis B
Immunoglobulin
Glucose Needs
Feeding
Contraindications to Feeding
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Cyanosis
Shock or asphyxia
Increased work of breathing
Ongoing oxygen requirement
Routine Care Considerations
AAP/ACOG/AWHONN Guidelines
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Proper identification of newborn
Initial assessment within 2 hours of birth
Develop a plan of care
Document observations at least every 30 minutes until stable for 2
hours
Prophylactic eye care within 1 hour of birth
Primary health care provider
– Perform initial physical exam no later than 24 hours of birth
– Perform physical exam within 24 hours before discharge
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Document daily weight
Perform metabolic screening
Instruct parent in care of infant
Guidelines (Cont)
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Implement emergency measures, including resuscitation, when
necessary using such programs as the Neonatal Resuscitation Program
Observe parent-infant interactions
Identify with parent(s) the appropriate facility for follow-up
Inform parent(s) of importance of immunizations
Identify high-risk mothers
Evaluate home environment
Nursing Considerations
• Observations must be documented every 2
hours according to the State of Washington.
– Follow hospital policy regarding this guideline.
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Vital sign routine
Daily weight
Physician notification
Timing of metabolic screening
Specific teaching issues for population
Nursing Observations
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Cardiac and Respiratory Status
Feeding
Temperature
Color
Tone
Activity
Output
Parent-infant bonding
Parent-Infant Bonding
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Bonding
Attachment
“En face”
“Parentese”
Red Flags
Assess Parenting Styles and Abilities
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Parents’ level of knowledge
Family’s communication
Parental expectations
Infant’s responses to parenting activities
Parental feelings about self and infant
Parental support
Cultural beliefs
Potential need for referral
Routine Care and Documentation
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Documentation of birth
Measurements
Medications
Physical assessment
Abduction prevention
Bathing/Hygiene
Cord Care
Feeding assessment
Metabolic screening
Elimination
Discharge Criteria
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Feedings
Discharge weight
Metabolic screening
Birth certificate worksheet/paternity papers
Teaching documented
Hearing screening
Discharge Teaching
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Begins on admission
Assess Mother’s readiness to learn
Assess Father’s involvement
Involve Grandparents, siblings, and other
significant people
Teaching Documentation
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Thermoregulation
Holding and Positioning
Hygiene
Feeding
Bulb syringe
Choking
Elimination
Circumcision Care
Safety
When to Call the Physician
References
• Askin, DF. (2002) Complications in the Transition from Fetal to
Neonatal Life. JOGNN 31(3): 318-27
• Buschbach, D., Schaub-Bordeaux, M. (2002) Newborn
Physiological and Developmental Transitions: Integrating Key
Components of Perinatal and Neonatal Assessment. Association
of Women’s Health, Obstetric and Neonatal Nurses.
• Kenner, C., Wright-Lott, J. (2003) Comprehensive Neonatal
Nursing: A Physiological Perspective. Philadelphia:Saunders
• Sansoucie DA, Cavaliere, TA. (1997) Transition from Fetal to
Extrauterine Circulation. Neonatal Network, 16(2):5-12
• Verklan,TM, Walden, M., editors (2004) Core Curriculum for
Neonatal Intensive Care Nursing (3rd ed.) St. Louis:Elsevier
References (2)
• http://www.cayugacc.edu/people/web_pages/greer/biol204/heart
4/heart4.html
• http://dic.academic.ru/pictures/enwiki/80/Pate
nt_ductus_arteriosus.jpg
• http://www.007b.com/breastfeeding_pictures.
php
• http://pregnancy.about.com/od/newbornbabie
s/ig/Newborn-Photo-Gallery/index.01.htm