CARE OF THE NEWBORN
Immediately after birth:
Maintain cardio respiratory function
Clear Airway (bulb or suction)
Assess breathing
Assess color
Assist if needed- warm and humidify oxygen before delivery
APGAR SCORE
Devised by Dr. Virginia Apgar
Grading scale that indicates stability of the infant
Assess at 1 and 5 minutes old
Reassess every 5 minutes until >7
Criteria:
Color- pale, pink, blue, cyanotic
(Blue 0, Partial blue-1 Pink-2)
Pulse- brachial, apical (can also listen to breath sounds)
(No pulse- 0 <100-1 >100-2)
Reflexes- response to stimuli
(No grimace-0 some grimace-1 grimace-3)
Activity- movement, tone
(No movement- 0 Some flexion-1 flailing- 3)
Respirations- crying, breathing on their own
(no resp-0 weak, slow-2, strong cry-3)
Best is 10 but needs to be >7
Acrocyanosis- blue hands and feet in newborn, poor perfusion in periphery, normal in newborn and
resolve in about a week
Central cyanosis- blue in the trunk or head, not normal
Calculate Apgar score for infant
1 minute old, HR 156 bpm, Res 48/min, Strong cry, blue hands and feet, good movement
9
SUPPORTING THERMOREGULATION
Newborns lose heat quickly by:
Conduction- surface touch the skin and heat exchange occurs- laying naked on cold scales
Evaporation- lose heat from wet skin to the air
Convection- air moving over the skin, drafts
Radiation- transfer from skin to surrounding environment- radiant warmers
Head is major site of heat loss- newborn caps
Temperature taken 1st rectally, then subsequent checks will be axillary and should be greater than 98.0
degrees. Also indicates that the rectum is patent and stimulates them to have their first BM.
Will check temp every four hours
Axillary less than 97.6 or greater than 99.0 then will want to retake as a rectal temp
If rectal temp is less than 97.0 then needs to go the radiant warmer
If rectal temp is 97.0-97.6, then wrap with 2 blankets and put hat on and reassess temp in an
hour.
If rectal temp greater than 99.0, decrease wrappings and reassess in an hour
HELP MAINTAIN TEMPERATURE
Infant should be dried after birth, especially hair
Place in radiant warmer or skin to skin
Hypothermia can lead to:
Hypoglycemia: jittery, sweaty, diaphoretic
Respiratory distress: grunting, nasal flaring, retractions
UMBILICAL CORD
“Lifeline” while in utero
Attached to the placenta at birth
Should have 3 vessels:
AVA: artery, vein, artery- Vein is the largest
2 vessel cord may indicate kidney problems
Observe for any bleeding and sign of infection from around the umbilical cord.
Stays clamped for at least 24 hours. If end feels dry after that, then can remove with the clamp
remover.
If cord clamp falls off, hold pressure on the umbilical cord and put another clamp on
Cord usually falls off in one to two weeks. Baby can’t take a tub bath until it falls off. Cord should not
be pulled off, it should just fall off.
Clean around the base of the cord with alcohol 2-3 times a day.
OBSERVE FOR URINARY FUNCTION
Document 1st voiding
Establishes patency of urinary tract
May not void for 24 hours and some not until 48, but want them to void around 8 hours
Refer to facility policy regarding notifying MD
URINARY FUNCTION
3-4 times per day for the first few days
6-10 times per day after hydrated
Good charting while in the hospital
IDENTIFICATION
Extremely important
ID bands on mother, baby, and significant other
Visually check ID number when returning and compare it to Mom’s.
Code “Pink” or Code “Adam” for missing baby
CARE UPON ADMISSION TO NURSERY
3 minute hand scrub before handling babies
Review labor and delivery record
(prenatal care, medication usage, time of rupture of membranes)
Provide warm, well lit environment for assessment
Gather assessment supplies
Clean gloves, stethoscope, thermometer, measuring tape, scales, …)
EVALUATION OF GESTATIONAL AGE
Ballard or Dubowitz Assessment form- measures neuromuscular and physical maturity
More accurate than relying on weight
Gestational age= actual time in uterus
Neuromuscular maturity (see book)
Posture- preterm will be stretched out. The more preterm the more extension, the
more term the more flexion
Square window- bend wrist down and see how far it will go. Term babies’ hands will
bend all the way down.
Arm recoil- bend elbows and hold arm down for 5 seconds and see how far it comes
back up. Preterm will stay flat and term baby will bend it back up.
Popliteal- degree of knee flexion. Flex the thigh to the abdomen and if it touches nose it
is preterm. Term baby will resist.
Scarf sign- arm across the neck- preterm will go past the midline, term baby will meet
resistance.
Heel to ear- foot to ear. Preterm will go to ear and term will meet resistance
Physical Maturity
Skin- Term will have normal skin, preterm will be thin and can see veins, post term will
have leathery quality
Lanugo- preterm comes out fuzzy, term baby not so furry
Plantar creases- preterm have creases on a third of their feet, term 2/3 of foot
wrinkled, post date completely wrinkled
Breast tissue- preterm little breast tissue, term infants will have swollen breast tissue
Ears- flick ears- preterm feels like wax paper b/c no cartilage, term babies firm
Genitals- male scrotum preterm small and no wrinkles, female labia major and minor
will be equal size, term the majora will be larger and cover up the minora
INTERUTERINE GROWTH AND DEVELOPMENT
LGA- birth weight >90% for their gestational age
Causes: genetics, maternal weight gain, maternal diabetes
Birth weight <10% for their gestational age
Causes: maternal high BP, anemia, malnutrition, substance abuse, smoking
TRANSITIONAL PERIODS OF REACTIVITY (SEE BOOK)
First Period of Reactivity- 1st 1-2 hours after baby born
Respirations: irregular; peak at 69-90 per minute; transient, mild nasal flaring may be seen
Heart Rate: Tachycardia; variability of heart rate may be see; mean peak of 180 bpm
Color: Brief initial cyanosis; Acrocyanosis
Body Temperature- Drops if preventative measures are not taken
Bowel Sounds: Absent initially; bowel inflates as newborn swallows air
Oral mucous: may be visible
Activity: alert; exploratory
Response to stimuli: Vigorous
Period of Relative Inactivity 2 hours to 1 day old
Respirations: Respiratory rate declines; shallow, synchronous breathing
Heart Rate: Heart rate declines to approximately 124-140 bpm
Color: Color improves; flushed when crying
Body temperature: Low; will drop slightly even under warmer
Bowel sounds: audible; abdomen should be rounded
Oral mucous: small amounts of watery mucus may be visible around lips
Activity: sleep or drowsy state; spontaneous jerks or twitches are common
Response to stimuli: Relatively unresponsive to external and internal stimuli
Second Period of Reactivity: More than 24 hours old
Respirations: Brief periods of rapid respirations related to stimuli and activity; periods of irregular
respirations with apnea periods
Heart Rate: Labile; wide swings related to activity and external stimuli
Color: abrupt color changes
Body Temperature: Begins to rise; 97.6 F is the desirable minimum
Bowel Sounds: Bowel often cleared of meconium
Oral Mucous: Prominent; may have gagging and choking
Activity: variable and more predictable
Response to stimuli: More responsive to exogenous stimuli
NEWBORN EXAM
Head shaping:
Molding: over-riding cranial bones
Normal finding after delivery
Resolves after 5 days
Change their position frequently
Caput Succedaneum:
Skin or soft tissue edema
Does cross suture lines
Reabsorbed 12 hours to 2 days
Long labor or vacuum extraction
Cephalhematoma:
Blood under scalp
Does not cross suture lines because deeper in the tissue and the sutures keep it from moving
Resolves in 2-3 weeks
Unilateral or bilateral
Fontanelles
Size, sunken=dehydration, bulging=septic
Anterior closes by 24 months- up from nose line and larger
Posterior closes by 2 months- back of head in line from anterior, very small and hard to feel
Measure Head Circumference
Measuring tape above ears
Normal 33-38 centimeters
Ear Assessment
Low set ears: below lateral canthus of eye and associated with genitourinary anomalies
Stimulated by high-pitched sounds and will have a very high pitched shrill cry
Nose
Nose breathers until 4 months old
Check patency by occluding one side
Choanal Atresia- nare obstruction
Mouth
Cleft lip
Cleft palate
Gag reflex
Epstein’s Pearls:
Small white cysts often seen in mouth of newborn
Fluid fill sacs
Resolve spontaneously
Eyes- Normal Findings
Normal finds
Retinal or subconjunctival hemorrhages
Lid edema and lid eversion
Color
Blue/gray, permanent color by 3-12 months
Acuity
Birth: 20/400 (can see from breast to mother’s face)
Can see and fixate on points of contrast (black/white good stimulation)
Eyes are not coordinated- muscles underdeveloped at birth
Nystagmus: involuntary movement of eyes- “jump, dance, or wiggle” and lasts <3
months
Transient strabismus: misaligned eyes; poor neuromuscular control of eyes and will
resolve in 3-4 months
Red reflex: used to detect cataracts in newborns; red orange flash of color observed
when an ophthalmoscope light reflects off the retina= normal and absence= possible
cataracts
Eye Medication
Erythromycin Ophthalmic Ointment
Prophylactic (state required)
Prevent ophthalmic neonatorum (caused by gonorrhea or Chlamydia)
Prevents blindness
Newborn Skin Exam
Vernix
Cheesy white covering
Protects skin in utero
Least in post term baby
Milia
Pinpoint whit papules on nose and cheeks
Blocked sebaceous glands
Desquamation
Shedding of outer layer of skin
Associated with post term infant
Erythema toxic
White papule with red base
Usually on trunk, may spread over body and disappear within days
Mongolian Spots
Large bluish pigment patches
Lumber areas, buttocks, extremities in dark races
Lanugo
Fine hair on shoulders, back and face
Often seen in preemies
Birthmarks
Stork Bite- hemiangioma
Strawberry mark- more raised texture and may fade or disappear by 18 months
Port wine stain- does not disappear, on face a lot. Laser surgery to correct
Abnormal Skin Findings
Pallor- anemia
Jaundice
Yellow of skin and whites of eyes
Bilirubin excess caused by breakdown of red blood cells in the blood
Bilirubin should be excreted by the liver but babies have immature livers and will need
some time to adjust to excrete the Bilirubin
Treat for excessively high levels only as it will attack the brain tissue and cause
permanent brain damage
Types of jaundice:
1. Physiological jaundice: seen in most newborns within the 1 st week of life (2-3
days old)
2. Pathological jaundice: seen with infection, mismatch in baby’s and mother’s
blood group, or defect in the liver- has to be treated
3. Jaundice of Prematurity: liver premature
4. Breast milk jaundice: substance in mother’s milk can lead to jaundice in few
babies. Formula 2 days, then resume breastfeeding. 1-5% of babies.
Treatment:
Sunlight 10 min. morning and evening near the window
Frequent feedings
Phototherapy (fluorescent and natural light convert Bilirubin to a water soluble
type that can be easily excreted (protect eyes and genitals)
CyanosisCentral cyanosis: bluish coloration of lips and face *should clear in minutes after birth*
if not, think cardiac. (transposition of the great arteries)
Peripheral Cyanosis: (Acrocyanosis) bluish distal extremities *clears within 1-2 days*
common, no reflective of inadequate oxygenation
Newborn Cardiopulmonary Exam
Normal HR: 120-160
Normal BP: 70/45 or preterm 60/40
Always listen apically on baby, count for one full minute
Murmurs are very common in newborns (PDA) 90% go away on their own
Respiratory Exam
Norm respiratory rate: 30-60 breath/minute. Tachypnea may aspirate
Count before disturbing baby
Normal to be irregular
Brief periods of apnea normal in transition (greater than 20 second apnea not normal)
Breathing with diaphragm
Keep bulb syringes on hand
Avoid using oxygen for long periods of time. Blow-by. Can cause retinopathy and blindness.
Chest circumference
Measure at nipple line
Chest circumference should be 2 cm less than head circumference
Newborn breast enlarged is normal hormonal change (male and female) and will decrease in
about a week
Newborn Reflexes
Moro: (Startle reflex) – throws arms out in extension and grimaces (most common)
Grasping reflex: clutch hands into fists, grasping whatever is inside
Rooting: touch on cheek, will turn head
Sucking: enables infant to take nourishment (good form of brain development in preemies)
Stepping/dancing: as feet touch ground, baby makes walking motion
Tonic neck: (Fencing) turn head leftward, the left arm stretches into extension, the right arm
flexes up above head. Opposite reaction if head turned rightward.
Protective reflexes: protects airway and eyes
If airway is obstructed, will arch neck and turn head from side to side and swipe face
with hands
Gag reflex:
Blink reflex
Cough and sneeze reflex
Babinski reflex: stroke foot- heels up toes out
Musculoskeletal System
Bones soft
Movements uncoordinated
Develop cephalocaudal
Should not feel “limp:
Measure length: stretch out as much as possible Average: 18-22 and grow about 1 inch per
month for the first 6 months
Digits
Supernumerary digit: skin tag like swelling without bone palpable, no voluntary motion
connected on hand beside pinky finger- usually inherited
Polydactyl: actual extra digit, with bone palpable, may have voluntary movement
Syndactyly: having 2 or more fingers or toes fused together (webbed)
Upper extremities
Palmar creases: simian crease are commonly seen in babies in Down syndrome (line
goes straight across with no lines going down.
Torticollis: neck muscles contract on one side. Baby will hold their head to one side and
can’t move it. Placement in utero
Clavicle fracture from birth trauma (crepitus, pain- safety pin sleeve to shirt- callus
forms 7-10 days, heals in 4-6 weeks)
Lower Extremities
Bowing of legs is normal
Clubfoot- foot is down and in
Hip dislocation: hip click
Spina Bifida- opening in spine- spinal cord may protrude outside- will go to surgery- may be fixed in utero
if caught during pregnancy. Can’t kick their feet.
Abdominal Exam
Assess for distention- do not want
Umbilicus- triple dye/alcohol to prevent infection
Keep clean and dry and watch for s/s of infection
No tub bath until falls off in 1-2 weeks
Rectum and Anus
Determine patency
Meconium (amniotic fluid + mucus + lanugo + bile + dead skin cells) thick, greenish-black and
sticky. *Usually passed within 1st 24 hours of life* transitional 1st week
Breast stool- mushy, yellow, seedy
Bottle stool- firm, pasty, yellow brown
Sacral dimple- (pilonidal dimple)- shallow is normal deep is not normal (where the tail fell off) may have
a tuft of hair coming out of the dimple area
Newborn genitalia Exam
Male
Term appearance- descended testicles, with deep rugae
Hydrocele- collection of watery fluid around the testicles (traumatic delivery) usually
resolves but intestines may prolapse- hold flashlight to testicles and if dark notify
doctor. Called testicle torsion and can cut off blood supply to the testicle
Chordee- downward curvature of the penis. Hypospadius- hole is underneath the peniswill not circumcise in the hospital
Foreskin- retractable double-layered fold of skin that covers the glans penis
Circumcision- surgical removal of the foreskin Purposes: religious, hygiene, or health
purposes- controversial
Consent
Properly ID the baby
Limit oral intake for 2-3 hours before
Placed on circumcision board
Lidocaine or topical anesthetic
Monitor for bleeding and chart 1st priority
Vaseline gauze and then Vaseline
Monitory urinary output 2nd priority and infection
No tub bath until circumcision is completely healed (about 2 weeks)
Gently pull foreskin away from tip of penis
Rinse tip of penis and inside part of foreskin with soap and water
Return foreskin back over tip of penis
Never force- bleeding/discomfort
Always return foreskin back over tip
Female:
Labia minora and clitoris prominent
Vaginal skin tag- may be absorbed and go away
Mucoid discharge- clear or white or may have some pink tinge (withdrawal bleeding
from hormonal changes)
VITAMIN K ADMINISTRATION (AQUA-MEPHYTON)
Needed for blood clotting
Prophylactic treatment to prevent cranial bleeding from birth trauma
Gut bacteria produce it but babies have very little in body at birth
Does not cross the placenta
0.5-1.0 mg IM (anterior thigh)
Document leg, muscle, time) Usually immediately after delivery
HEPATITIS B IMMUNIZATION
3 shot series and need 1st dose Hepatitis B Immunization
Need consent
IM (anterior thigh) try to use opposite thigh from Vit. K
Start the immunization card ( have to have it to start Kindergarten in public schools)
Redness, pain at the site
If Mom is Hep B positive, the baby will get Hep B and HBIG vaccinations
PROMOTE BONDING AND ATTACHMENT
Assess for bonding
Provide appropriate time
Document
Feeding times good bonding time
NUTRITIONAL NEEDS OF THE NEWBORN
Bottle Feeding
Some types of formula:
Enfamil w/iron
Similac Advance w/iron Standard 20 calorie/fluid ounce)
Prosobee/Isomil (soy based and lactose free)
Nutramigen/Alimentum (hypoallergenic- for protein allergy)
Not recommend to change without consulting MD
Estimate 1-2 oz every 3-4 hours for the first week
Stomach capacity 90 mL
Ready to feed, powder, concentrate
Boil if not city water
Bottle good for only 1 hour
Burp every ½ ounce
Breastfeeding
Physiology of lactation
Milk secreted by mammary glands
Hormone oxytocin produced after birth
Lactation stimulates hormone Prolactin which is produced in response to the length of
time infant nurses
Advantages
Perfect nutrition balance
Right temperature
Convenient
Bonding
Cost effective
Disadvantages
Privacy
Time consuming for the mother
Must pump for others to feed the baby
May need stimulation/encouragement to feed initially
Participate in teaching of breastfeeding with RN
Positions (use variety)
Milk supply
Colostrum
Hygiene- don’t use soaps as it will dry out the nipples
Latching on
Removing baby from breast
Burping between breasts
Diet and rest- need extra 500 calories a day, needs to rest when the baby rests
Special considerations and weaning- wean slowly to gradually reduce milk supply and
prevent engorgement, breastfeed exclusively for 1st 2 weeks.
Problems associated with breastfeeding
Engorgement- breasts engorged with milk
Causes: bottle feeding, poor nurser, overproduction of milk
Treatment: decrease stimulation to breasts, pump, warm shower
Sore nipples: redness, cracking of skin, and possible bleeding from nipples
Causes: Improper latching, fair skin, frequent nurser
Treatment: improve latching technique, alternate breasts, lanolin, air dry
Breastfeeding support groups
La Leche League (most active resource)
Lactation centers
Community support groups
SCREENING TESTS
PKU- PhenylketonuriaMandatory in all states- - heel stick 24 hours after 1st feeding
If positive, change in formula can prevent severe mental retardation
NORMAL NEWBORN WEIGHT LOSS
5-10% birth weight is lost is normal
Fluid shifts and increased metabolism
Over 10% is excessive and needs to be monitored
SUDDEN INFANT DEATH SYNDROME
Sudden, unexpected death of infant 2 weeks- 1 year
About 6000 cases per year in US
Peak between 2-4 months old
2 constant features
1. Occurs during sleep
2. Infant does not cry or make sounds of distress
Thought to be caused by brainstem abnormality of cardio-respiratory control
Risk factors: maternal smoking or cocaine use, preterm birth, poor postnatal care
Face down sleeping position may cause rebreathing of expired air or airway occlusion
Home apnea monitors for high risk infants
BACK TO SLEEP
American Academy of Pediatrics- 1996- recommended all healthy infants sleep supine or side lying- firm
mattress- no pillows. All parents need to know CPR.