 OB Unit 4
 Care of the Newborn
 Rev. Oct. 2010
 Neonate
 Term used for a child in the first 4 weeks of life
 Initial Care & Assessment of the Newborn
 Immediately After
 Birth
 Assess:
Respirations
Heart Rate
Temp
APGAR
Warmth

Identification
 Done in delivery room
 2 ID bands (ankle & wrist) on newborn
 1 ID band on mother
 Footprinting & fingerprinting

Protection of Disease
 Eye prophylaxis w/ Erythromycin
 Vitamin K injection
 Spine & Extremities
 Straight without curves
 Dimples, tufts of hair and masses
 Syndactyly
 polydactyly
•
Single crease in palm of hand
•
Equal length of legs
 Simian Crease

Bonding
 Promotion of attachment between neonate & family
 Should begin immediately
 Characteristics of the Normal Newborn
 A. Weight & Length
 Weight ranges from 5.5-10 lbs.
 Loses 5-10% during the 1st few days after birth
 Length ranges from 18-22 inches
 B. Head & Body
 Lg. Head (13-14”)
 Short neck
 Chest smaller than head (12-13”)
 Large protruding abdomen
 Head irregularly shaped “molded”
 Caput succedaneum
 Cephalhematoma
 Both resolve on their own
 Reassure parents

C. Fontanels
 Soft spots
 Anteriorabove forehead, diamond shaped,closes bet. 18 mos.
 Posterior@ crown of head,
Triangular, closes at 2nd mo.
 D.
Eyes
•
Blue or gray @ birth
•
Appear cross-eyed, unable to focus
•
Eyelids red/edematous
•
No tears

E.
Ears

Positioned with outer canthus of the eye

High pitched sounds

Mothers voice
 F.
Skin
•
Rashes are common
•
By 3rd day, more natural tone
•
Acrocyanosis
•
Harlequin sign
 G.
Jaundice
•
Pathological  occurs w/i 24 hrs  Abnormal
•
Physiologic  May occur in 2-3 days  Normal
•
Immature liver
•
Elevated bilirubin
 Treatment
 Freq. Feeding q 2-3 hrs
 Sunlight
 Phototherapy
 Monitor temp
 Allow for bonding
 Influences of Maternal Hormones on Neonate
 gynecomastia
 Edematous labia in females
 Pseudomenstruation
 Large scrotum
 Common Skin Observations
 IN THE NEWBORN…..


Milia

Erythema toxicum

Stork bites

Mongolian spots

Port wine stain
 Epsteins pearls
 Various birthmarks
 Petechiae
 Lanugo
 Vernix caseosa
 Normal Activities and Reflexes
 Of the Neonate….
 Movement & Activities
 Sleeps ~ 17 hrs/day
 Awakens easily
 Cries when hungry or uncomfortable
 Arms & legs move freely & symmetrically
 Able to flex extremities
 Unable to support weight of head
 Reflexes
 Rooting Reflex
 Sucking Reflex
 Dance or Step
 Grasp
 Moro or Startle
 Tonic neck reflex
 Babinski reflex
 Newborn movements are jerky due to immature nervous system

Senses
•
Sight
•
Hearing
•
Touch
•
Smell & Taste
 Protection of the Newborn
 Each neonate is isolated from other babies
 Specific handwashing & scrub techniques
 Scrub suits & gowns
 People w/ infectious diseases not allowed access
 Each neonate has own equipment/supplies
 Nursery NEVER left unattended
 Preventing Infant Abduction
 Essential role of nurse
 Proper ID w/ badge
 Visitors required to check in
 Sensors, alarms, exits lock automatically
 Daily Newborn Care
 Nursing
 Assessment
 Every day, assess :
Vital Signs
Weight
Eyes, Nose & Ears
Elimination (Urine & Stools)
Umbilical Cord
Urination
 Usually 4-8 hrs fol. delivery
 Be sure baby voids & document
 Should have 6-8 wet diapers/day
Stools
 Meconium1st stool
 Dark green, sticky, tarry
 Transitional stoolgreenish yellow
 Breast fed stoolpale green to golden yellow, smooth, pasty or “seedy” w/ less odor
 Formula fed stoolbrighter yellow, more formed
 Always remember to maintain body temp by:
 Caps
 Clothing
 Blankets
 Warmer/isolette
 Incubator
 Cleansing the Newborn
 1st bath after Temp = 98.6
 Assess skin color; assess for blemishes, rash,abnormal jerking, twitching, bleeding, or
congenital abnormalities during bathing
 Wipe eyes from inner to outer corner

Fol. By face & ears
 Rinse & dry hair

Work from head down
 Use mild soap sparingly
 Special attention to skin folds
 Observe for bleeding at circumcision site first 12 hrs.
 DO NOT use lotion, petroleum jelly or powder
 DO NOT wet unhealed cord
 Treat cord as ordered
 Dress and wrap in blanket
 Care of the Penis
 Only retract foreskin if ordered
 Very small opening phimosis
 Smegma secretions that accum. Under foreskin
 Circumcision
 Part or all of foreskin is removed
 Ritual for all Jewish babies
 Must be kept clean
 Assess for bleeding, swelling, & voiding
 Normal Anatomy
 Gomco Clamp
 Plastibell
 Hollister Plastibell Technique
 Never place on stomach fol.
Circumcision
Assess q 15 min for 4 hours
 Sleep
 Newborns sleep most of the time
 Except when hungry or uncomfortable
 Place on side or back
 No pillows
 Holding the Newborn
 Wrap in blanket
 Support head, neck & buttocks
 Football hold gives you a free hand
 Baby’s Responses
 Cries & tightens muscles in response to sudden, loud noise
 Crying is only way to ask for help
 Hunger cries are healthy, demanding cries
 May put fingers in mouth as sign of hunger

Infant Feeding
 Suck & swallow reflexes are present at birth
 Feed on “demand”
 Every 3-4 hrs
 Breastfeeding
 Colostrum decreases allergies
 Superior nutrition
 Economical
 Readily available
 Promotes transfer of maternal antibodies
 Enhances bonding
 Speeds involution
 1st feeding is immed. p birth
 Best NOT to supplement with bottle
 Tickle mouth to trigger rooting reflex
 Entire areola in mouth not just nipple
 Place finger in mouth to break suction
 Offer both breast at each feeding
 Start with breast used last at previous feeding
 Treat engorgement w/ frequent feeding
 Diet when breastfeeding
 Inc. calories by 500/day
 Inc. Milk (1qt./day)
 Inc. fluids
 ETOH inhibits let-down reflex & found in breastmilk
 Caffeine is transferred
 Consult MD re: medications
 Bottlefeeding
 1-3 oz per feeding1st wk
 Total of 15 oz in 24 hrs
 Intake increases rapidly after 3 wk
 Always hold infant when feeding
 Do NOT prop bottle
 Wash hands before & after
 Right side-lying to prevent regurgitation

Burping
 During and after each feeding
 Done whether breast or bottle feeding
 Hold upright on knee or against shoulder
 DISORDERS OF THE NEONATE

Group B Strep ( GBS)
 Life threatening infection
 Caused by bacterium
 Common cause of sepsis and meningitis and pneumonia in newborns

Diagnosis & Treatment
 Vaginal swab at 35-37 wks
 Women with +GBS are given antibiotics at time of labor
 PCN is safe and effective  Mom
 PCN or Ampicillin  newborns

Gestational Age
•
Preterm
•
Term
•
Post term

Gestational Size
 A.G.A.
 S.G.A.
 L.G.A.
 L.B.W.
 Nursing Considerations
 With Preterm
 Neonates
 Conserve Energy
 Handle as little as possible
 Delay bathing
 Special care to keep warm
 Feeding
 No food for 36 hrs
 Very small amounts on a 2-3 hr
 Reflexes may be weak or absent
 Gavage (NG) or expressed milk using a nipple
 Elimination
 Kidneys not fully developed
 Weigh diaper before & after they urinate
 Color and Skin
 ruddy
 Cyanotic
 Very thin, translucent skin
 Respiratory Status
 Nasal flaring
 Retractions of sternum and incostal muscles
 Grunting
 Air hunger
 Infection Prevention
 Good handwashing
 Contacts with people other than parents is limited
 Special Care Nursery
 Respiratory Distress Syndrome (RDS)
 Leading cause of death
 Inadequate oxygenation
 Cause of RDS is unknown
 Deficiency in pulmonary surfactant
 Atelectasis is common
 http://www.wisegeek.com/what-is-retrolental-fibroplasia.htm
 What is Retrolental Fibroplasia?
 Symptoms
 Dyspnea
 Cyanosis
 tachypnea
 Flaring nares
 Chest retractions
 Treatment
 Oxygen & humidity
 Antibiotics
 Exogenous pulmonary surfactant
 Corticosteroids
 Minimal handling
 Retrolental Fibroplasia
 Often led to blindness in preterm newborns
 Occurs when oxygen concentration is > 40 % for long periods of time
 Monitor Oxygen bld levels
 Potential Complications

of High Risk
 Newborns
 Meconium/Amniotic Fluid Aspiration
 Anal sphincter relaxes meconium passes into amniotic fluid
 Can occur in utero or @birth
 If first breath is taken prior to suctioning  aspiration
 Asirated fluid Can lead to :
 Atelectasis
 Pneumonia
 Pulmonary problems
 Treatment
 Oxygen
 Encourage fluids
 Regulate temperature
 antibiotics
 Cyanosis
 Blue or dusky color
 Caused by:
 Prolapsed cord during delivery
 Congenital heart defect
 Medications (analgesics)
 Treatment
 Suction
 Oxygen
 Postural drainage
 Rub back
 GI Disturbances of High Risk Neonate
 Vomiting, Diarrhea
 Dehydration
 Vomiting
 Congenital defects
 Birth injury
 Infection
 Distinct difference between Vomiting & spitting up
 Diarrhea
 Most commonly caused by bacteria
 May be formula or an allergy
 Stool is formless, greenish-yellow & foul smelling
 Isolate baby
 Obtain stool cultures
 Dehydration can occur quickly
 Treat quickly w/ IV, and oxygen & antibiotics
 Necrotizing Enterocolitis
 Bowel wall necrose & die
 Common in preterm babies
 SX: lethargy, abd. Distention, hypothermia, apnea & irritability
 Treatment
 NG tube to suction
 IV fluids
 TPN
 Antibiotics
 Surgical resection PRN
 Hypoglycemia
 Blood sugar < 40mg/100ml
 S/S : tremors, irritability, jittery, apnea & tachycardia
 Tx  10-15% glucose water
 Hemolytic Conditions
 Result from Rh or ABO incompatibility
 Erythroblastosis Fetalis
 Occurs when Rh- mother has an Rh+ feturs
 Condition is uncommon today
 Preventable with RhoGAM
 Birth Injuries
 Fractures
 Fractured clavicle most common
 Sx: asymetrical Moro reflex and crying when affected arm is moved
 Fx will heal w/o difficulties
 Intracranial Hemorrhage
 Primarily problem of preterm newborns
 Other causes: dystocia, precipitate labor & delivery or prolonged labor
 Symptoms
 Seizures
 Respiratory distress
 Cyanosis
 Shrill cry
 Muscle weakness
 Treatment
 HOB slightly elevated
 Oxygen
 Vitamin K
 Antibiotics
 Anticonvulsive meds
 sedatives
 Brachial Plexus Injury
 Results from trauma during a difficult delivery
 SX: unable to elevate arm, hand or forearm
 TX: ROM, splinting
 Facial Paralysis
 Bell’s Palsy
 Result of forceps delivery
 One side of face affected
 Sucking reflex impaired
 Most cases are temporary
 Congenital Disorders
 Abnormality that exists
 at birth
 MUSCULOSKELETAL
 Congenital Disorders
 Talipes ( Clubfoot )
 One or both feet turn out of normal position
 Occurs more often in boys
 Excellent prognosis
 Tx: braces, casts, special shoes
 Congenital Dislocated Hip
 More frequently in girls
 Treat early to prevent permanent damage
 Limitation of abduction is 1st sign
 One leg shorter than other
 Skin folds are asymmetrical
 X-ray needed to confirm
 TX: stabilizing head of femur
 Polydactylism & Syndactylism
 PolyExtra finger or toe
 Suture used to tie off appendage
 Occ. Surgery is necessary
 SynFusing together of two or more digits
 Polydactyly
 Syndactyly
 Nervous System Disorders
 That would make an Infant “High Risk”
 Hydrocephalus
 Overabundance of CSF
 Enlarged head,bulging fontanels, irritability
 TX: VP shunts inserted into ventricles to drain
 Measure head circumference daily
 Spina Bifida
 Vertebral spaces fail to close
 Spinal contents herniate into a sac
 Meningocele
 Myelomeningocele
 Surgery to correct
 Prognosis depends on deformity’s extent
 Folate(Folic Acid) reduces the risk for neural tube defects
 Down Syndrome
 Trisomy 21
 Physical and mental manifestations range from mild to severe
 Mental retardation & heart defects also exist
 Trisotomy 21
 Anencephally
 Part or all of the brain is missing
 Skull is flat
 Newborn will live for only a short time
 Microcephaly
 Abnormally small head
 Brain does not develop normally
 Almost always mentally retarded
 Cardiovascular Disorders
 That would make an infant “High Risk”
 Patent Ductus Arteriosus
 Ductus Arteriosus remains open
 Oxygenated blood returns to the pulmonary circulation
 TX: Indocin
 ASD & VSD
 Abnormal openings exist between respective chambers
 TX: Teflon patch
 Tetrology of Fallot
 Four major heart defects occur simultaneously
1. Pulmonary stenosis
2. VSD
3. Overriding aorta
4. Hypertrophy of r. ventricle
 Coarctation of the Aorta
 Aorta narrows as it leaves the heart
 Surgery consists of excising the coarctation & suturing the two ends together or using a bl.
Vessel graft
 Respiratory Disorders
 That would make an infant
 “High Risk”
 Choanal Atresia
 Nostrils are closed at the throat entrance
 Quickly corrected w/ surgery
 G.I. Disturbances
 That would make an infant
 “High Risk”
 Esophageal Atresia
 Esophagus ends in a blind pouch
 Immediate surgery
 TPN in interim for nutrition
 Tracheoesophageal Fistula
 Opening between esophagus & trachea
 1st sign Choking with first feed
 Life threatening
 Emergency surgery
 Tracheoesophageal Fistula
 Pyloric Stenosis
 Pyloric opening constricts
 Food cannot pass through into intestines
 Projectile vomiting classic symptom
 Surgical correction is nec.
 Infant abdominal hernia (gastroschisis)
 Imperforate Anus
 Rectum ends in a blind pouch
 Suspect, if newborn does not pass a stool within 24 hours of delivery
 Surgery to correct
 Imperforate Anus
 PKU(Phenylketonuria)
 Baby cannot use the protein, phenylalanine
 Substance builds in blood
 Can cause brain damage & mental retardation
 No cure exists
 All newborns are tested prior to discharge and at 6 wk
 Testing is mandatory
 Galactosemia
 Cannot digest galactose
 Galactose builds up & damages brain, liver & eyes
 SX:vomiting,poor weight gain, yellow color to skin
 TX: lactose free diet
 Maternal Conditions Affecting the Neonate
 Sexually Transmitted Diseases
 Syphilis
 Law requires testing of pregnant women
 If + penicillin is used early in pregnancy
 Untreated syphilispremature labor
 Gonorrhea
 Law requires antibiotic ointment to eyes after birth to prevent ophthalmia neonatorum(cau.
By gonorrhea organism)
 Herpes Simplex Virus 2
 If virus is active prior to 20th wkspontaneous abortion will result
 Active virus later in pregnancypremature labor or local infection
 AIDS
 HIV can be transmitted through placenta or during delivery
 May be stillborn
 Nearly all infants will test HIV+
 Rubella
 German Measles
 Dangerous  fetus  congenital rubella syndrome
(catarracts, deafness, heart defects, cardiac disease, &
Mental retardation)
 Toxoplasmosis
 Parasite (found in cat feces & uncooked meat)
 Possible neonatal effects :
 Stillbirth
 Premature delivery
 Thrush
 Yeast infection
 Candida albicans
 Transmitted from mother to baby during delivery if mother has yeast infection
 Infected neonate is isolated
 Cytomegalovirus (CMV)
 Belongs to herpes virus group
 Effects on newborn:
 SGA
 Microgephaly & hydrocephaly
 Mental retardation
 Chemically Dependent Newborn
 Drugs reach fetus through placenta
 Newborn experiences withdrawal symptoms
 Newborn is likely to be preterm or LBW
 Fetal Alcohol Syndrome
 Effects include :
•
Growth deficiency
•
Microcephaly
•
Facial abnormalities
•
Cardiac anomalies
•
Mental retardation
 Cocaine & Crack
 Dependent newborns experience significant withdrawal syndrome
 Lasts 2-3 wks
 Marijuana
 Crosses the placenta
 May cause shortened gestation or precipitate labor
 Higher incidence of meconium aspiration
 Neonatal Abstinence Syndrome
 Generalized disorder
 Signs appear w/i 72 hours after birth
 Lasts from 8-16 wks or longer