ASSIGNMNT ON PHYSIOLOGY

& CHARACHTERISTICS OF NEWBORN,

physical & behavioral assessments
of newborn, needs of newborn

SUBMITTED TO,
Prof.DR.Manju Bala dash
HOD dept. of OBG
MTPG & RIHS

SUBMITTED BY,
Arya.V
MSc nursing 1ST year
MTPG & RIHS
 PHYSIOLOGY OF NEWBORN

Introduction

The physiology of newborns is fundamentally different than the physiology of older children
and adults. Perhaps the reason it is so different is that it constantly changes, with the biggest
change from intrauterine to extra uterine life. While some aspects, such as cardiovascular
alterations, change the moment the newborn takes its first breath, other aspects, such as
modifications in hemoglobin, change within a few months. The purpose here is to discuss the
physiology of newborns, particularly how it differs from than that of adults. Major organ systems
that will be discussed include cardiovascular, pulmonary, blood, and lymph, with special
considerations in energy metabolism and thermoregulation.

Issues of Concern

As mentioned, the physiology of newborns is constantly evolving and adapting to extra

uterine life. It is important to note these changes and ensure proper development at the
appropriate times. For instance, it is important for the infant, while taking its first breath, to shut
down and rewire the intrauterine cardiovascular shunts present in the infant's body. Failure to do
so can cause physiological imbalances, such as not getting enough oxygen to the brain.
Oxygenated blood, as opposed to deoxygenated blood, keeps getting oxygenated. Additionally, it
is important to understand what the infant lacks in the newborn period that requires
supplementation. For instance, a newborn infant is deficient in vitamin K, putting it at risk for a
hemorrhagic disease. To prevent this, all infants born should be given vitamin K prophylaxis.

Organ Systems Involved

Cardiovascular System To understand the changes occurring in the cardiovascular physiology

of the newborn, one must understand intrauterine fetal circulation. In the fetus, oxygenated blood
comes from the mother’s umbilical cord. Oxygenated blood enters the fetus through the
umbilical vein and then through the ductus venosus, the first of the three shunts to be discussed.
This ductus venosus conducts the well-oxygenated blood from the umbilical vein to the inferior
vena cava and right atrium. The reason it is considered a shunt is that it bypasses the hepatic
circulation. In the fetus, oxygenated blood is essential for life and is preferentially delivered to
the brain and heart myocardium.From the right atrium, the oxygenated blood travels through
the foramen ovale – the second shunt – and to the left atrium, as opposed to the right ventricle in
children and adults. Oxygenated blood is then subsequently delivered to the left ventricle, to the
brain, and to the rest of the body via the aorta, similar to adult circulation.Deoxygenated blood
from the liver, superior vena cava, and coronary sinus is preferentially directed from the right
atrium to right ventricle to the pulmonary arteries. From there, instead of going to the lungs, the
deoxygenated blood bypasses the pulmonary system via the ductus arteriosus, our third and final
shunt. The ductus arteriosus shunts blood away from the lungs, due to high fetal pulmonary
arterial resistance, and to the descending aorta. The primary mechanisms contributing to the high
pulmonary vascular resistance is the low oxygen tension and lack of pulmonary arterial flow.
These mechanisms allow the synthesis and release of prostaglandins from the endothelium
located in the pulmonary vessels. It is due to these prostaglandins that the ductus arteriosus
remains patent. It also is important to note that the placenta produces prostaglandins,
contributing to the patency of the ductus arteriosus.

With the birth of the infant and removal of the low-resistance placenta, there are major
cardiovascular responses related to pressures, blood flow, and pulmonary circulation. As the
infant takes its first breath, this causes a marked decrease in pulmonary vasculature resistance.
This causes an increase in left atrial pressure (due to blood flow from pulmonary vasculature),
and this pressure is higher than the pressure in the right atrium, prompting the foramen ovale to
close.Now that the newborn is breathing, functional closure of ductus arteriosus begins and can
last several days. Due to the decrease in pulmonary arterial resistance and increase in oxygen,
there is a decrease in prostaglandins, subsequently closing the ductus arteriosus. With the
placenta now separated, there is also a decrease in prostaglandin synthesis, contributing to the
closure of the ductus arteriosus.Lastly, and perhaps the longest to close (3 to 7 days), is the
ductus venosus. The umbilical vessels now constrict in response to two things: (1) increased
systemic vascular resistance due to clamping of the placenta and (2) increased oxygen content
from the infant’s respirations. Now that blood flow through the ductus venous is reduced, it starts
to constrict and close, reducing blood to the inferior vena cava. Pulmonary System During
intrauterine life, the fetal lungs are filled with amniotic fluid, so lung development requires the
clearance of the lung amniotic fluid, consistent and automatic breathing, as well as secretion of
surfactant. Infants that are born via vaginal deliveries are squeezed as they pass through the
vaginal canal, allowing compression of the fluid in the lungs. Once the baby is out of the uterus,
several external environmental factors, such as light, change in temperature, and noise, activate
the nervous system and prompt the infant to take the first breath. Additionally, internal factors,
such as central chemoreceptors, also play a role in driving respiration due to hypoxia. In the
newborn, the work of breathing is usually labored (i.e., using accessory muscles, costal
retractions, grunting) to overcome the high surface tension. As the fluid leaves the alveoli in the
lungs, the effort of breathing is reduced. This is also one of the reasons why newborns have an
increased respiratory rate (30 to 60 breaths per minute). Other reasons include compensation for
high metabolic rate and perfusion-ventilation differences. More importantly, the presence of
circulatory shunts forces the infant to increase the work of breathing .Due to immature central
drive responses, newborns may have periods of apnea lasting less than 5 seconds. While this is
considered abnormal in adults, it is normal for newborns to have apneic episodes.
Hematological System There are two things to consider when studying the hematology of a
newborn: blood and clotting. Blood is made up of two different major components: plasma and
cells (red blood cells, white blood cells, and platelets). In utero, blood is produced by the liver
and then picked up by the bone marrow after birth. Red blood cells carry hemoglobin which
transports oxygen and iron from the lungs to other tissues and organs of the body. There are
many different types of hemoglobin, but those pertinent to this discussion are Hb F and Hb A.Hb
F is the primary hemoglobin produced by the fetus. Its role is to transport oxygen adequately in
low oxygen environments. It has a high affinity for oxygen, making it suitable for oxygen
extraction from maternal hemoglobin across the placenta. Not only is Hb F important for
intrauterine development, it is important in the newborn period due to impairment of oxygen
delivery to the tissues. Around six months of age, Hb F is replaced with Hb A, also known as
adult hemoglobin. It is the most common hemoglobin, encompassing 98% of the total red blood
cell hemoglobin.Infants lack vitamin K due to immature hepatocyte function and lack of enteric
bacteria that produce vitamin K. Vitamin K is used in the synthesis of clotting factors II, VII, IX,
X and proteins C and S. Therefore, those who lack vitamin K have an increased risk of any form
of hemorrhage, from any cause. As a result, due to the deficiency of vitamin K, a prophylactic
shot of vitamin K is given to every newborn to protect against hemorrhagic disease.Metabolism
and ThermoregulationIntrauterine temperature is that of the normal maternal temperature. Fetal
body temperature is 0.5 C above the maternal temperature. At birth, the newborn loses its heat
due to the dramatic drop in environmental temperature. The newborn’s heat is mostly lost via
radiation, which can be reduced by raising the room temperature.For the newborn to be able to
thermo-regulate, the newborn’s sympathetic system activates in response to the cold stimulus.
The main mediators that aid the newborn’s transition to extrauterine life are cortisol and
catecholamine. The sympathetic release activates thermogenesis via brown adipose tissue.
Brown adipose tissue is present around the kidneys and muscles of the back. Brown adipose
tissue generates heat via uncoupling oxidative phosphorylation in the mitochondria. The
newborn also can produce heat by shivering thermogenesis, which is basically an increase in
skeletal muscle activity and limb movements.

The high heart rate (120 to 160 beats per minute) seen in newborn infants can be attributed to the
high metabolic rate of activity to main breathing, feeding, and thermogenesis.

Clinical Significance

Understanding the physiology of a newborn allows healthcare professionals to foster better care
for all newborns. Across the United States, hospitals are mandated by law to undergo newborn
screens for all babies born. Millions of babies are routinely screened for genetic, endocrine, or
metabolic disease. Additionally, they are screened for critical congenital heart defects.

Cardiovascular System

As mentioned earlier, cardiovascular shunts take time to close. If they fail to close, they can
cause complications for the infant. There are two different types of shunts: left-to-right and right-
to-left.

Left-to-right shunts

These are usually benign and present later in a child's life. They are used for the following:

 Atrial Septal Defect

 Ventricular Septal Defect

 Patent Ductus Arteriosus

Right-to-left shunts

These are usually present earlier in infancy and can be associated with other cardiac
abnormalities such as:

 Persistent Truncus Arteriosus

 Transposition of the Great Vessels

 Tricuspid Atresia

 Tetralogy of Fallot

 Total Anomalous Pulmonary Venous Return

Hematological System

Around six months of age, Hb F is replaced with Hb A. However, Hb F disappears much quicker
than HbA is produced. This leads to a physiological anemia of infancy at 7 to 11 weeks of life.

Infants lack vitamin K due to immature hepatocyte function and lack of enteric bacteria that
produce Vitamin K. Infants that do not receive the vitamin K shot are at increased risk of
bleeding disorders, the most common disorder being a Hemorrhagic disease of the newborn, also
known as, Vitamin K deficiency bleeding.

Metabolism and Thermoregulation

Preterm infants are at a particular disadvantage when it comes to thermoregulation because the
brown adipose tissue has not fully developed and does not provide adequate heat response. The
following can aid the preterm infant with thermoregulation:

 Drying the infant several times with different warm cloths directly after delivery

 Using baby bed warmers to warm the air and bed via convection

 Increasing the humidity and reducing external air flow with a plastic bag or cover
Newborn Characteristics

Skin

Peeling or cracking skin around the wrists or ankles is common, especially in babies who have
gone past their due date. As new skin cells grow, this condition will clear up without treatment.
Newborns often have a lot of downy fuzz on their backs, arms and ears. This will soon rub off
and disappear. Newborns also have a white, waxy coating that protects their skin. This is
usually removed during the baby's first bath. It will be absorbed through the baby's skin within
24 hours after birth, if not removed during the first bath.

Stork bites

Many new babies have red areas around their foreheads, eyelids, and noses or on the backs of
their necks. They are called "stork bites." They will be more visible when the baby cries and
disappear by itself during the first year.

Milia

These look like "white heads" or pimples. They usually appear on the nose or chin. They
usually disappear by themselves in the first weeks of life. Do not squeeze or put cream or lotion
on them.

Rashes

Newborns often have rashes (reddened areas with an pinhead sized yellow or white raised center)
that usually come and go during the first 10 days of life. These are normal and will soon
disappear without treatment.

A raised pimple-like rash around the cord or genital area may occur. Usually this rash will clear
up with normal bathing, sunbathing, or exposure to air. If the rash does not go away or
increases, see your healthcare provider. A more severe blister-like rash that ruptures, leaves a
scab, and continues to spread should be checked by your healthcare provider.
Skin rashes can also result from overdressing or harsh laundry soaps. As the baby becomes
warm and sweats, skin irritation develops in skin folds. Keep the areas clean and dry, and avoid
overdressing. You can also try a milder laundry soap, dissolve the soap before adding clothes
and rinse twice. It is not recommended to put lotions or creams on a newborn's skin.

Acrocyanosis

Your baby's hands and feet may look blue for the first few days. This is normal. If you notice
other parts of the baby turning blue, call your baby's healthcare provider immediately.

Sneezing

Babies clear their noses by sneezing. A stuffy nose, which is most noticeable when the baby is
nursing, is common during the first days of life. It is caused by the swelling of the mucus
membranes in response to the hormones from the mother. Breathing may be noisy and irregular
at first. Soon you will get accustomed to your baby's habits.

Eyes

Your newborn may have swelling around the eyes. This will disappear a few days after birth.
Some babies also have a red area in the white part of the eye. This is a small hemorrhage from
the pressure during birth. No treatment is necessary, as it will disappear within several weeks.

A newborn can only see well for 8 to 12 inches. When an object is moved beyond this range,
your baby's eyes wander and may appear crossed. As the eye muscles mature, your baby will be
able to focus both eyes on the same object at the same time.

Head

Your infant will have a very large head in relation to the rest of the body. At birth, your infant's
head takes on a melon-shaped appearance to help it fit through the birth canal. It will return to
its normal shape a few days after birth.
Your baby will have soft spots (fontanelles) on the top of the head where bones are still growing
together. A thick membrane covers these spots to protect the head and brain. You may gently
touch these spots. Soft spots close completely by 2 years of age.

Crying

Right from the beginning, you should realize that babies cry and have fussy periods. Crying is
their way of communicating (and relieving tension or boredom). Babies may cry for food, when
uncomfortable, bored or in pain, or if they just want to be held close. Your baby may cry for
several hours at the same time every day for no apparent reason. Sometimes babies cry from too
much stimulation. If you suspect this is the case, take your baby to a quiet, darkened room so he
or she can calm him or herself.

At times you will be able to comfort your baby very easily, and at other times nothing will work.
Stay calm! Otherwise the baby will pick up on your discomfort. You may need to hand the baby
to a different pair of arms and walk away for a few minutes. Never shake a baby. If the cries
continue for long periods of time, call your healthcare provider.

Hormones

The effects of hormones may cause your newborn to have some swelling in the breasts or
scrotum or a little bloody fluid/mucus coming from the vagina. These will go away and do not
require treatment of any kind. Leftover hormones from Mother may cause both boys and girls to
have swollen nipples. This swelling will go away a few days after birth.

Face: Face is looked for hypertelorism ( eyes widely separated ) or low set ears (trisomy 9,18) or
facial nerve injury.

Neck: It is checked for movement, goiter, thyroglossal cysts, sternomastoid hematoma or short
neck (Turner’s syndrome) webbed neck .

Eyes: Are examined for congenital cataract, brushfield’s spots in the iris (Down syndrome) or
subconjunctival hemorrhage (traumatic delivery)

Nose : cartilage of nose , flaring of nostrils.

 Ears : cartilage of ears, hearing ability.

Mouth : the gums are smooth, tongue is red.

Mouth is checked for clefts (palate, lips), deciduous teeth, linguinal frenulum (tongue-tie),
and oral thrush, Epstein pearl, pulling Cleft lip Cleft palate pulling of saliva, circumoral
cyanosis, and facial nerve paralysis

Chest: Is examined for any asymmetry(tension pneumothorax), tachypnea, grunting, intercostal

retractions(respiratory distress), pectus exacavatum and the breath sounds. The newborn’s
breasts may “witch’s milk”.

Heart: Is examined for rate (normal 120-160 bpm), rhythm, the quality of heart sound and
presence of any murmur. Significance of murmur in the new born is less. In case of doubt a chest
X-ray is helpful for further.

Abdomen: Is examined for any defects or e.g. omphalocele, hepatomegaly(sepsis) splenomegaly

(CMV, rubella infection) or any other mass.

Umbilicus: Is examined for omphalocel, any discharge, redness or infection. A greenish –

yellow coloured cord suggests Meconium staining (fetal distress). Single umbilical artery (more
in twin births) indicates genetic (trisomy 18)and congenital anomalies, and IUGR.

Genitalia: Should be examined carefully before gender assignment.

Male is examined for penis (normal>2cm),testes within the scrotum, any hydrocele and
hypospadias, epispediasis. Foreskin covers the glans penis.

Female is examined for any clitorial enlargement (maternal drug),fused labia with clitorial
enlargement (adrenal hyperplasia). Blood stained vaginal discharge may be due to maternal
estrogen withdrawal. Normally labia majora cover the labia minora and clitoris.

Back: normal newborns back is smooth and firm seen for spine congenital anomalies, spina
bifida, pilonidal dimple, tufts of hairs may indicate fistula.

Anus and Rectum: Is checked to rule out imperforation and their position. Meconium should
pass within 48 hours of birth.
Extremities : are examined for syndactyly (fusion of digits),polydactyl, simian crease (down
syndrome), hip dislocation(ortolani and barlow maneuvers), symmetry of both extremities.

Nervous system is examined for any irritability, abnormal muscle tone , reflexes, cranial and
peripheral nerves. Neurological development is dependent on gestational age.

Hematological findings – Blood volume soon after birth is about 80ml/kg body weight, it
immediate cord clamping is carried out. RBC- 6-8 million /cumm, Hb% -18-20gm%, WBC-
10,000-17,000/cumm, Platelets – 3, 50,000/cumm, nucleated red cells 500/cumm, sedimentation
rate – markedly elevated. Clotting power may be poor because of deficient vitamin K which is
necessary for production of prothrombin from the liver.

Physical and behavioral assessment of newborn

 The American academy of pediatrics recommended since 1967 the all newborn are
classified by birth weight and gestational age and it scored by the Ballard scoring tool.
 A baby whose lies in between 10th and 90th percentile this is described as appropriate
gestational age(AGA). If the baby weight is greater than 90 percentile this described as
large for gestational age (LGA) baby who weights bellow 10 percentile is described as
small gestational age (SGA)

Assessment of neuromuscular maturity

 Posture
 Square window
 Arm recoil
 Popliteal angle
 Scarf sign
 Heal to ear

Posture : posture is the natural position that the newborn assumes on its back. It observed with
the infant quiet and in spine position.
Square window: wrist flexibility and/or resistance to extensor stretching are responsible for the
for the resulting angle of flexion at wrist.

Arm recoil: this maneuver focuses on positive flexor tone of biceps muscles by measuring the
angle of recoil following very brief extension of upper arm

Popliteal angle: this is the maneuver assess maturation of positive flexor tone about knee joint
by testing for resistance to extension of the lower extremities

Scarf sign: in the supine position hold the baby's elbow and move the arm across the midline of
the chest towards the opposite side.

Heel to ear: this maneuver assesses hip flexibility in infants.

Assessment of physical maturity

 Skin
 Lanugo
 Palmar surface
 Breast
 Eyes and ears
 Genital

Skin – scoring in this category is based on the palpation and visual inspection skin texture,
transparency, relative thickness, flacking and peeling of epidermis is noted.
Lanugo – Lanugo is the fine hairs seen mostly on the back and arms of premature infants. It is
eventually things out in the lumbar region and disappears.

Palmar surface - creases on the soles of both feet's are scored according to the extent to which
the creases cover the surface of sole.

Breast – breast tissue is approximated by gently measuring the tissues present on the infants
using the measuring tape in millimeters.

Eyes and ears – eye lids should be open easily in mature infants ears are inspect for curving the
pinna and palpate for any determination of thickness of cartilage.

Genitalia:

 Male – the testes are descended in to the scrotum deep creases are gradually develops on
the scrotum as the infant more mature.
 Female – assessed for covering of the clitoris and size of labia majora and minora , the
distance between edge of labia majora and minor.

Formula for calculating age = (2 * score + 120)/5

BEHAVIORAL ASSESS MENT OF NEWBORN

Behavior: It may be defined as the way in which one acts or conducts oneself, especially towards
others. It is the way in which an animal or person behaves in response to a particular situation or
stimulus. And in case of a newborn behavior may be defined the way it functions and attains
different stages of growth and development.
Importance of Newborn Behavioral Assessment:

Newborn, or neonatal, deaths account for 45% of all deaths among children under 5. The
majority of all neonatal deaths (75%) occur during the first week of life, and between 25% to
45% occur within the first 24 hours.The main causes of newborn deaths are prematurity and low-
birth-weight, infections, asphyxia (lack of oxygen at birth) and birth trauma. These causes
account for nearly 80% of deaths in this age group.Up to two thirds of newborn deaths could be
prevented if skilled health workers perform effective health measures at birth and during the first
week of life.

Thus assessment of the newborn is very vital. While babies may not speak their first word for a
year, they are born ready to communicate with a rich vocabulary of body movements, cries and
visual responses: all part of the complex language of infant behaviour.All newborn babies are
routinely examined by a pediatrician within the first 24 hours of life and again prior to discharge
to home. A general appraisal of the baby's color, overall appearance, muscular activity and
response to handling are made throughout the examination. A professional examination will
certainly include sensing the sensing capacities of the newborn. Thus, special senses and
behavioral patterns are assessed and evaluated in order to establish normality of the baby. If there
are variances from the normal patterns, it’s assessed accordingly a response is devised and
designed to address it.

What and how newborn Behavior is assessed:

A professional assessment scheme must reveal the individuality of then newborn. By the end of
the assessment, the examiner must have a behavioural "portrait" of the infant, describing the
baby's strengths, adaptive responses and possible vulnerabilities. The examiner shares this
portrait with parents (and other stake holders) to develop appropriate caregiving strategies aimed
at enhancing the earliest relationship between babies and parents and other stakeholders. Though
newborns seem vulnerable, yet they are highly capable when they are born. "A newborn already
has nine months of experience when she is born," Dr. T. Berry Brazelton, the developer of the
Neonatal Behavioural Assessment Scale (NBAS) proclaims. The newborn is capable of
controlling his/her behaviour in order to respond to her new environment. Babies "communicate"
through their behaviour, which, although it may not always seem like it, is a rational language.
Not only do infants respond to cues around them, like their parents' faces, but they also take steps
to control their environment, such as crying to get a response from their caregivers. Newborns
are social organisms, individuals with their own unique qualities, ready to shape as well as be
shaped by the caregiving environment.

Thus professionals have developed standard procedures (e.g., scales) to assess the newborns:
they need to be assessed physically and neurologically to portrait a picture of the potentialities
(or the absence of them) of the baby. The examiners are trained to get the best performance from
the child by doing everything possible to support the infant in "succeeding." For example, one
part of the exam looks at an infant's ability to self-console when she is upset. Some infants
console themselves easily, while others have a more difficult time. If the infant cannot console
herself, the examiner takes measured steps to help her. Not only do we learn how much support
the infant may need at home, but also how far along the child is at completing her developmental
agenda.

By the end of the exam, the examiner has developed a vibrant portrait of the newborn, which
can be used to tailor care giving to the baby's specific physical needs and behavioural style. Does
the baby like to be handled? Is the baby receptive to social interaction? Does the baby easily
calm herself? These standard scales must give a peep into the possible and, may be, a designer
future of the newborn. A professional may study and assess the baby through

 Special Senses and,

 Reflexes

Special Senses and Behavior Patterns

Vision

The structures necessary for vision are present and functional at birth although immature. The
baby is sensitive to bright lights, which cause him/her to frown or blink. The body demonstrates
a preference for black and white patterns and the shape of human face. The newborn’s focusing
distance is about 15-20 cm which, allows him/her to see the mother's face when being nursed.
He/She can track a moving object briefly within the first five days.

Hearing
The baby turns the eyes towards sound, comforted by low-pitched sounds. High-pitched sounds
make him uncomfortable. A sudden sound elicits a startle or blink reflex. He/She prefers the
sound of the human voice to other sounds. The baby can discriminate between voices and prefers
the mother's. This too, promotes mother-baby interaction (De Casper and Fifer, 1987).

Smell and Taste Babies prefer the smell of milk to that of other substances and show a
preference for human milk. Within a few days, the baby can differentiate the smell of his/her
mother's milk. The baby turns away from unpleasant smells. His/Her preference for sweet taste is
demonstrated by vigorous and strong sucking and a grimacing response to bitter, salty or sour
substances (Blackburn and Loper, 1992).

Touch

Infants are acutely sensitive to touch, enjoy skin-to-skin contact, immersion in water, stroking,
cuddling and rocking movements (Blackburn and Loper, 1992).

A puff of air on the baby's face induces an inspiration or gasp reflex. His curving response to
touch and the gasp reflexes enhance his/her relationship with the mother. The baby withdraws
from painful stimuli, bulges his brow and nasolabial furrow and may cry vigorously (Rushforth
and Levene, 1994)

Sleeping and Waking Following the initiation of respiration at birth, the baby remains alert and
reactive for a period of approximately 1 hour after which the baby relaxes and sleeps. The length
of this first sleep varies from a few minutes to several hours. Subsequent sleeping and waking
rhythms show marked variations and the baby takes some time to settle into his/her individual
pattern. Initially, waking periods are related to hunger, but within a few weeks, the waking
periods last longer and meet the need for social interaction.

Two sleep states are identifiable:

Deep sleep in which the baby's eyes are closed, respirations are regular, no eye movements are
present, response to stimuli is delayed and is quickly suppressed. Jerky movements may occur at
intervals.
Light sleep in which eye movements could be observed through the closed eyelids. Respirations
are irregular and sucking movements occur intermittently. Response to stimuli occurs more
readily and may result in alteration of sleep state. Random movements are noted.

Awakening states

A wider range of awakening states is observed, ranging from drowsiness to crying.

 Drowsy state: The baby's eyes may be open or closed with some fluttering of the eyelids.
Smiling may occur. Limb movements are generally smooth, but are interspersed by
startle responses.
 Quiet alert state: Motor activity is minimal; the baby is alert to visual and auditory
stimuli.
 Active alert state: The baby is generally active and reactive to the environment.
 Active crying state: The baby cries vigorously and may be difficult to console. Muscular
activity is considerable.

Remarks

The amount of time that the baby spends in which state varies and influences the way in which
he responds to stimuli, whether visual, auditory or tactile (Brazelton, 1984).

Crying

Crying is the way in which the baby communicates discomfort and summons assistance. With
experience, it is possible to differentiate the cry and identify the need, which may be hunger,
thirst, pain, general discomfort [for example, wanting a change of position or feeling too cold or
too warm), boredom, loneliness or a desire for physical or social contact. The mother needs to
learn how to comfort her baby. Rocking induces sleep, and swaddling and upright position
appear to be soothing (Downey and Bidder, 1990).

Growth and Development

Because of physical limitations, the baby is dependent on the mother (or other care Giver) for
his/her continued growth, development and survival. These will progress satisfactorily only if the
baby is in a safe environment, the nutritional needs are met and the psychological development is
promoted by appropriate stimulation and loving care. Abnormality of the baby's body systems

Inadequate nutrition or emotional deprivation will compromise the baby's ability to grow and
develop to his/her full potential.

His relatively immature organ functions and vulnerability to infections and hypothermia demand
that care must be designed to meet the needs and capabilities.

Reflexes:

The baby's reflex responses are elicited in order to establish normality of the nervous system.

Rooting Reflex: It is a primitive reflex. If the cheek is rubbed, the infant will turn his head into
that direction of the stimulus.

Sucking reflex — it develops at 32-36 weeks of gestation. If sucking reflex is poor it indicates
the baby is premature or there may be some difficulty in swallowing.

Moro's reflex/startle reflex — it can be assessed in two ways:

I. The baby should be held supine over the right hand and arm. The flexed head is
suddenly allowed to drop by about 30°. A Positive response consists of rapid
abduction and extension of upper limbs and opening of hands followed by slower
addiction and flexion or embrace equivalent (
II. Place newborn on a firm surface and make a loud sound by banging the
examination table. The limbs will extend and then flex.

This reflex is useful to evaluate the alertness, muscle tone and hearing of the baby. This reflex
should be assessed last, as the infant will start crying.

Stepping/dancing Reflex- Place the child in standing position near the table, the feet will touch
the table and flex alternately by both legs giving an appearance as if the baby is dancing. It
disappears by 1-2 months.

Doll’s eye Reflex — Turn the head of the infant. The eyes move in the opposite direction. It
disappears once the Child is able to focus.
Tonic neck reflex — When infant’s; head is quickly turned to one side, the extremities on that
side extend and those on opposite side will flex.

Grasping reflex —put your finger near the child's palm; the child closes its finger around it. If
finger is placed near the toe, they curl around the finger.'

Babinski reflex —when a stimulus is given to the plantar surface. Stroke the sole of the foot
beginning at the heel. Stroke upward along lateral aspect of the sole then move finger across ball
of foot. There is dorsiflexion of the large with fanning of other, toes.

NEEDS AND CARE OF NEWBORN

Immediate Safety Measures for the Newborn

• Watch for excessive mucus: use bulb syringe to remove mucus.

• Have baby sleep on his or her back in crib or in someone’s arms.

Voiding and Stool Characteristics and Patterns

• Urine is straw to amber color without foul smell. Small amounts of uric acid crystals are

normal in first days of life (may be mistaken by parents as blood in diaper because of reddish

“brick dust” appearance).

• At least 6 to 10 wet diapers a day after the first few days of life.

• Normal progression of stool changes:

1. Meconium (thick, tarry, dark green);

2. Transitional stools (thin, brown to green)

3. Breastfed infant: yellow gold, soft or mushy stools

4. Formula-fed infant: pale yellow, formed and pasty stools.

• Only 1 to 2 stools a day for formula-fed baby.

• Six to 10 small, loose yellow stools per day or only one stool every few days after

breastfeeding is well established (after about 1 month).

Cord Care

o Wash hands with clean water and soap before and after care. Keep the cord dry and

exposed to air or loosely covered with clean clothes. (If cultural custom demands binding

of the abdomen, a sanitary method such as the use of a clean piece of gauze can be

recommended.)

o Clean cord and skin around base with a cotton swab or cotton ball. Clean 2 to 3times a day

or with each diaper change. Touching the cord, applying unclean substances to it, and

applying bandages should be avoided. Do not give tub baths until cord falls off in 7 to 14

days.

o Fold diapers below umbilical cord to air-dry the cord (contact with wet or soiled diapers

slows the drying process and increases the possibility of infection).

o Check cord each day for any odor, oozing of greenish yellow material, or reddened areas

around the cord. Expect tenderness around the cord and darkening and shriveling of cord.

Report to healthcare provider any signsof infection.

o Normal changes in cord: Cord should look dark and dry up before falling off.

o A small drop of blood may present when cord falls off.

o Never pull the cord or attempt to loosen it.

Care Required for Circumcision and Uncircumcised Infants

Circumcision Care

• Squeeze water over circumcision site once a day.

• Rinse area off with warm water and pat dry.

• Apply small amount of petroleum jelly ) with each diaper change.

• Fasten diaper over penis snugly enough so that it does not move and rub the tender glans.
• Because the glans is sensitive, avoid placing baby on his stomach for the first day after the

procedure.

• Check for any foul-smelling drainage or bleeding at least once a day.

• Let Plastibell fall off by itself (about 8 days after circumcision).

• Plastibell should not be pulled off.

• Light, sticky, yellow drainage (part of healing process) may form over head

of penis.

Uncircumcised Care

• Clean uncircumcised penis with water during diaper changes and with bath.

• Do not force foreskin back over the penis; foreskin will retract normally over time (may take 3

to 5 years).

Techniques for Waking and Quieting Newborns

Techniques for Waking Baby

o Loosen clothing, change diaper.

o Hand-express milk onto baby’s lips.

o Talk with baby while making eye contact.

o Hold baby in upright position (sitting or standing).

o Have baby do sit-ups (gently and rhythmically bend baby back and forth while grasping the

baby under his or her knees and supporting baby’s head and back with your other hand).

o Play patty-cake with baby.

o Stimulate rooting reflex (brush one cheek with hand or nipple).

o Increase skin contact (gently rub hands and feet).

 Techniques for Quieting Baby

o Check for soiled diaper.

o Swaddle or bundle baby (bring arms and legs into midline, which increases sense of

security).

o Hold swaddled baby upright against mid-chest, supporting bottom and back of head. Baby

can hear heartbeat, feel warmth, and hear your softly spoken words or calming sounds.

o Use slow, calming movements with baby.

o Softly talk, sing, or hum to baby.

RESEARCH ARTICLES

1] Behavior of the Newborn during Skin-to-Skin.

Dani C, Cecchi A, Commare A, Rapisardi G, Breschi R, Pratesi S.

Abstract
BACKGROUND:
Early skin-to-skin contact (SSC) significantly increases the breastfeeding rate in healthy term
infants.

OBJECTIVE:
This study aimed to confirm previously described behavioral sequences during SSC.

METHODS:
We recorded live and videotaped infant behavioral sequences during SSC in a cohort of healthy
term infants, whose outcome was then evaluated.

RESULTS:
We studied 17 mother-infants dyads. While the majority of infants (59%) had behavioral phases
that have been previously reported, some of them had alternative sequences. We observed
the infant's massage of the mother's breast with its hand during SSC, which had not been
previously reported. We found no correlations between behavioral sequence during SSC,
breastfeeding, and neonatal outcome. Moreover, maternal pain stimuli did not affect the neonatal
SSC behavioral sequence.
CONCLUSION:
Our study confirms that immediate and undisturbed postpartum SSC is characterized by
specific behavioral phases whose sequence may vary without affecting the suckling rate at the
end of SSC, breastfeeding success, or the short-term neonatal outcome.

2] Newborn Physiological Immaturity A Concept Analysis

Maria-Eulàlia Juvé-Udina, PhD, BSN, RN, Núria Fabrellas-Padrés, PhD, BSN, RN, Pilar
Delgado-Hito, PhD, BSN, RN, Bárbara Hurtado-Pardos, BSN, RN, Montserrat Martí-Cavallé,
RN, Marta Gironès-Nogué, BSN, RN, Rosa-Maria García-Berman, PCNS, RN, and Sergio
Alonso-Fernandez, RN

Abstract

Background:
Most standardized nursing care plans for healthy neonates include multiple nursing diagnoses to
reflect nurses' judgments on the infant's status; however scientific literature concerning this issue
is scarce. Newborn physiological immaturity is a concept in the ATIC terminology (architecture,
terminology, interface, information, nursing [infermeria], and knowledge [coneixement]) to
represent the natural status of vulnerability of the healthy neonate.

Purpose:
To identify the essential attributes of the concept and provide its conceptual and operational
definition, using the Wilsonian approach.

Findings:
The concept under analysis embeds a natural cluster of vulnerabilities and environmental
interactions that enhance the evolving maturation process.

Implications for Practice:

The use of this diagnosis may simplify the process of charting the nursing care plans and reduce
time needed for documentation while maintaining the integrity of the information.

Implications for Research:

Consistent development and use of nursing concepts is essential for knowledge building. Studies
on the actual use of nursing diagnoses are needed to inform decision making.
[3] The needs of mothers to newborns hospitalised in intensive care units
Lucie Sikorova, Jana Kucova
Objective.
The aim of the survey was to identify the needs of mothers to infants hospitalized in intensive
care units (ICUs) and second, to assess the level of parental support provided by the health
personnel.

Methods
The sample consisted of 147 mothers to infants hospitalized in ICUs. The research was
conducted over six months in ICUs for newborns at two hospitals in Ostrava. The study used two
standardized questionnaires: The parental stressor questionnaire scale: Neonatal Intensive Care
Unit which measures the degree of stress in parents of hospitalized infants and the questionnaire
The Nurse Parent Support Tool which evaluates the level of parental support provided by nursing
staff.

Results:
The highest level of stress was identified in the parental role. Specifically, the inability to
help the child remain separate from the mother, a feeling of helplessness and inability to protect
the child from painful procedures and the inability to feed her baby. Mothers evaluated the
support of nursing staff in most of these areas as high. Top were rated the ability of the caring
staff to respond well to the questions of parents and the mother's willingness to engage in
childcare.

Conclusion:
Intensive care units for the newborn obviously need to be family-centered care and at the
same time they must be aware of all the factors that can be sources of stress for the parents.Only
in this way can stress be eliminated with positive impact on the relationship between mother and
child.

BIBILIOGRAPHY
1) Lowdermilk & Perry “Maternity Nursing”, 6th edition Published by Mosby
(Philadelphia), , page no: 293-307.
2) Krishna Kumari Gulani, “Community Health Nursing (Principles and Practices)”, 1 st
Edition, Chapter-11, Maternal and Child Health, published by Kumar Publishing House,
2005, page no.: 284 – 286.
3) K Park, “Park’s Textbook of Preventive and Social Medicine”, 19th Edition, Chapter – 9,
Preventive Medicine in Obstetrics, Pediatrics and Geriatrics, published by M/s Banarsidas
Bhanot, 2007, page no.: 176 – 180.
4) Dutta D.C Text book of Obstetrics –Including perinatology and Contraception,6th Edition
(2004), New central book Agency (Kolkata) Pg. No.95-113.
5) Basavanthappa B.T Essentials of Midwifery & Obstetrical, Jaypee Publications (New
Delhi) Pg.No.110-128.