Care of The Newborn

st 1
24 hours
of Life
The
The first 24 hours of life is a very significant and a highly vulnerable time due to critical transition from intrauterine to extrauterine life
Immediate Care of the Newborn
Airway Breathing Temperature
Airway & Breathing

Suction gently & quickly using bulb syringe or suction catheter Starts in the mouth then, the nose to prevent aspiration
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Neonatal Care
Airway & Breathing

Stimulate crying by rubbing Position properly- side lying / modified t-berg Provide oxygen when necessary
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Neonatal Care
Temperature
Dry immediately Place in infant warmer or use droplight Wrap warmly
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Neonatal Care
APGAR Scoring
Standardized evaluation of the newborn Perform 1 minute and 5 minutes after birth Involves (5) indicators:
1. 2. 3. 4. 5.
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Activity Pulse Grimace Appearance Respirations

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Care of the Newborn in the Nursery
Components
Anthropometric Measurements Bathing Oil bath/ warm water bath Cord Care Dressing/ Wrapping - mummified Eye prophylaxis Credes Foot printing / Identification Get APGAR score 1 & 5 mins HR, RR, Temp, BP Injection of Vitamin K
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Components
1. 2. 3. 4. Proper identification tag/bracelet Oil bath/ Warm water bath Cord Care/ Dressing Measurements 1. Weight 2. Anthropometric measurements
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6. Credes Prophylaxis 7. Vitamin K Administration 8. Foot printing/ marking 9. Vital signs 10.Dressing/ wrapping
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Proper Identification
After delivery, gender should be determined Pertinent records should be completed including the ID bracelet Before transferring to nursery, ID tag should be applied.
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Bathing
Oil bath or complete warm water bath From cleanest to dirties part DO NOT remove vernix caseosa vigorously
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Cord Care
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Weight/ Anthropometric Measurements
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Credes Prophylaxis
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Vitamin K Administration
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Foot Printing
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Vital Signs
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Dressing/ Wrapping
Mummy Wrap in warm blanket Cover head with stockinette cap
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Daily Care
1. 2. 3. 4. Nutrition/ Feeding Elimination Weight Bathing & Hygiene/ Grooming 5. Obtain vital signs 6. Rooming-in 7. Note for any abnormalities
NEWBORN ASSESSMENT
Assessment of the newborn is essential to ensure a successful transition
Major Time Frames

1. Immediately after birth 2. Within the 1st 4 hours after birth 3. Prior to discharge
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APGAR Scoring System

A P G A R ctivity/ Muscle Tone ulse/ Heart Rate rimace/ Reflex Irritability/ Responsiveness ppearance/ Skin Color espiration/ Breathing
2 3
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INDICATORS
Activity
2
Active, spontaneous >100 bpm
1
Some flexion of extremities < 100 bpm
0
No movement (flaccid, limp) Absent No response with stimulation Bluish-gray or pale all over Absent
Pulse
Grimace Appearance Respiration
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Pulls away, Facial grimace sneezes, coughs only Completely pink Good vigorous cry Acrocyanosis Slow, irregular Weak cry
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Score 7 to 10 4 to 6
Interpretation
Well baby
Nursing Interventions
Rarely needs resuscitation
Requires resuscitation At risk Suction INFANT NEEDS Dry immediately INTENSIVE CARE Ventilate until stable Careful observation Intensive resuscitation ET/ Ambu bag Sick baby Ventilate with 100% O2 PROGNOSIS FOR CPR NB IS GRAVE Maintain body temperature Parental support
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0 to 3
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General Guidelines
Keep warm during examination From general to specific Least disturbing first Document ALL abnormal findings & provide nursing care
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GENERAL APPEARANCE
Posture
Full term: Symmetric Face turned to side Flexed extremities Hands tightly fisted with thumb covered by the fingers
Special Concerns
Asymmetric Fractured clavicle or humerus Nerve injuries (Erb-Duchennes Paralysis) Breech Presentation Knees and legs straightened or in FROG position
VITAL SIGNS
TEMPERATURE
Site: Axillary NOT Rectal Duration: 3 mins Normal Range: 36.5 37.6 C Stabilizes within 8-12 hrs Monitor q 30 mins until stable for 2 hrs then q 8 hrs
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Heat Loss Mechanisms

Convection the flow of heat from the body surface to cooler surrounding air
Eliminating drafts such as windows or air con, reduces convection
Conduction the transfer of body heat to a cooler solid object in contact with the baby
Covering surfaces with a warmed blanket or towel helps minimize conduction heat loss
Radiation the transfer of heat to a cooler object not in contact with the baby
Cold window surface or air con; moving as far from the cold surface, reduces heat loss
Evaporation loss of heat through conversion of a liquid to a vapor

From amniotic fluid; NB should be dried immediately
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Nursing Considerations
Keep dry and well-wrapped Keep away from cold objects or outside walls Perform procedures in warm, padded surface Keep room temperature warm
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Pulse
Awake: 120 160 bpm120 140 bpm Asleep: 90-110 bpm Crying: 180 bpm Rhythm: irregular, immaturity of cardiac
regulatory center in the medulla
Duration: 1 full minute, not crying Site: Apical

Keep warm Take HR for 1 full minute Listen for murmurs Palpate peripheral pulses Assess for cyanosis Observe for CP distress
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Special Concerns
(+) Prominent radial pulse = CHD (-) Femoral pulse = Coarctation of aorta
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Respiration
Characteristics: Nasal breathers, gentle, quiet, rapid BUT shallow; may have short periods of apnea (<15 secs) and irregular without cyanosisperiodic respirations Rate: 30-60 cpm Duration: 1 full minute
Position on side Suction PRN Observe for respiratory distress Administer oxygen via hood PRN and as prescribed
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Silverman-Anderson Index
Perform to observe for signs of respiratory distress Chest lag Retractions Nasal flaring Expiratory grunting
Silverman Scoring System

0
2
Example
0
2
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Score: 5
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Score Interpretation
Score
0-3 4-6 7-10
Interpretation
No RDS
Moderate RDS
Severe RDS
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Blood Pressure
NOT routinely measured UNLESS in distress or CHD is suspected At birth: 80/46 mmHg* After birth: 65/41 mmHg* Using Doppler UTZ
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ANTHROPOMETRIC MESUREMENTS
Body Measurements
Weight: 5.5 to 9.5 lbs (2500-4300 gms) Caucasian: 7 lbs Filipinos: 6.5 lbs 70-75% TBW is water LBW = below 2500 gms; regardless of AOG
Length: 45 to 55 cm (18-22 inches) Average: 50 cm Techniques: using tape measure Supine with legs extended Crown to rump Head to heel
Head Circumference (HC): 33 to 35.5 cm (13-14 inches) Technique: using tape measure From the most prominent part of the OCCIPUT to just above the EYEBROWS
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1/3 the size of an adults head Disproportionately LARGE for its body HC should be = or 2cm > CC
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Chest Circumference (CC): 30 to 33 cm (12-13 inches) Technique: using tape measure From the lower edge of the SCAPULAS to directly over the NIPPLE LINE anteriorly CC should be = or < 2 cm than HC
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SKIN
Under natural light Assess for: Color Hair distribution Turgor/ Texture Pigmentation/ Birthmarks Other skin marks
Skin Color
Velvety smooth and puffy esp. at the legs, dorsal aspects of hands & feet and in the scrotum or labia Pinkish red (light skinned) to pinkish brown to yellow (dark skinned) Ruddy or reddish due to increased RBC concentration and decreased subQ tissues
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Skin Color
Cyanosis/ Acrocyanosis Pallor Jaundice Meconium Staining
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Acrocyanosis
Bluish discoloration of palms of hands & soles of feet Due to immature peripheral circulation Exacerbated by cold temperatures Normal within 1st 24 hrs
Pallor/ Cyanosis
May indicate hypothermia, infection, anemia, hypoglycemia, cardiac, respiratory or neurological problems
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Jaundice
Under natural light Blanch skin over the chest or tip of the nose
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Physiologic FT: after the 1st 24 hrs (2-7 days) PT:after the 1st 48 hrs Peaks at 5-7 days & disappears by the 2nd week Due to immaturity of liver Usually found over the face, upper body and conjunctiva of eyes
Pathologic Within 1st 24 hrs May indicate early hemolysis of RBC or underlying disease process Duration: FT: 1 wk PT: 2 wks
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Management of Jaundice
Monitoring serum bilirubin levels Physiologic: not more than 5 mg/dl per day Pathologic: more than 15-20 mg/dl (critical levels) Maintain hydration Place in bilirubin lights as needed Provide emotional support to parents
Phototherapy units
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Nursing Responsibilities: -cover eyes and sex organ
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Meconium Staining
Over the skin, fingernails & umbilical cord Due to passage of meconium in utero r/t fetal hypoxia
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Lanugo
Found after 20 weeks of gestation on the entire body except the palms & soles Fine downy hair that covers the shoulders, back & upper arms
Nursing Considerations:
More mature, less lanugo May disappear within 2 weeks Preterm: woolly patches of lanugo on skin and head Post term: parchment-like skin w/o lanugo
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Vernix Caseosa
Protective cheesy-like, gray-white fatty substance FT: skin folds under the arms and in the groin under the scrotum or in the labia Nursing Considerations: Use baby oil DO NOT attempt to remove vigorously 051104 Neonatal Care
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Desquamation
Dryness/ peeling of the skin Usually occurs after 24-36 hours Marked scaliness & desquamation = signs of postmaturity
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Milia
Multiple, yellow or pearly white papules approx. 1 mm wide Due to enlarged or clogged sebaceous gland Usually found on the nose, chin, cheeks, eyebrows and forehead
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Birthmarks
Mongolian Spots
Blue-green or gray pigmentation Lower back, sacrum & buttocks Disappears by 4 years of age
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Salmon Patches
Seen commonly in NB More on Caucasian AKA: Naevus simplex, "angel kisses" (when on the forehead or eyelids), and "stork bites" (over the nape of the neck) midline malformations consisting of ectatic capillaries in the upper dermis with normal overlying skin.
Stork bites
Telangiectatic Nevi Flat red or purple lesions Back of neck, lower occiput, upper eyelid and bridge of the nose After 2 years of age
Strawberry marks
Nevus Vasculosus or Capillary Hemangioma Dark red, raised lobulated tumor Head, neck trunk & extremities After 7 to 9 years of age
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Large capillary hemangioma
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Cavernous Hemangioma
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Port-wine stain
Nevus Flammeus or Capillary Angioma capillary malformation Flat Red to purple, sharply demarcated dense areas beneath the capillaries Face Does not fade with time Associated with SturgeWeber syndrome 051104 Neonatal Care
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Sturge-Weber syndrome
PWS involving the forehead (V1 area of the trigeminal nerve), eye abnormalities (choroidal vascular abnormalities, glaucoma), and leptomeningeal and brain abnormalities (vascular malformations, calcification, or cerebral atrophy)
Other Skin Marks
Mottling
Cutis marmorata reticulated pattern of constricted capillaries and venules due to vasomotor instability in immature infants Bluish mottling or marbling of skin in response to chilling, stress or overstimulation
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Erythema toxicum
Newborn rash Small, white, yellow, or pink to red papular rash Trunk, face & extremities Within 48 hrs
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Petechiae
Pinpoint hemorrhages on skin Due to increased vascular pressure, infection or thrombocytopenia Within 48 hrs
Ecchymosis
Bruises As a result of rupture of blood vessels May appear over the presenting part as a result of trauma during delivery May also indicate infection or bleeding problems
Harlequin Sign
When on side, dependent side turns red and upper side/ half turns pale Due to gravity and vasomotor instability or immature circulation Skin resembles a CLOWNS SUIT
Caf-au-lait spots
Tan or light brown macules or patches NO pathologic significance, if <3cm in length and <6 in number If > 3 or 6 = Cutaneous neurofibromatosis
Neurofibromatosis
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HEAD
What to assess
For symmetry, shape, swelling, movement Soft, pliable, moves easily With some molding (if VSD); round & well-shaped (if CS) Measure HC; HC = or > CC
Fontanelles soft spot BAD (12-18 mos) LPT (2-3 mos or 8-12 wks) Bulging or sunken Sutures Overriding or separated
Head lag Common when pulling newborn to a sitting position When prone, NB should be able to lift the head slightly and turn head from side to side
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Caput Succeedaneum
Swelling of soft tissues of the scalp Due to pressure Crosses the suture lines Presenting part 3 days after birth
Cephalhematoma
Subperiosteal hemorrhage with collection blood Due to rupture of capillaries as a result of trauma Does not crossed suture lines Several weeks
Molding
Overlapping of skull bones Due to compression during labor and delivery Disappears in few days
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Forcep Marks
U shaped bruising usually on the cheeks after forcep delivery
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Craniotabes
Localized softening of the cranial bones Can be indented by pressure of fingers MOST common among 1st born babies, pathological in older childmetabolic disorder Caused by pressure of the fetal skull against the mothers pelvic bone in utero
Craniosynostosis
Premature closure of the fontanelles
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Face/Eyes/Ears/ Nose /Mouth
What to Assess
Facial movement & symmetry Symmetry, size, shape and spacing of eyes, nose and ears
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Eyes
Color: white sclera Slate gray, brown or dark blue Final eye color: after 6-12 months Symmetrical Pupils equal, round, reactive to light (+) Blink reflex
(+) transient strabismus due to weak EOM Able to move and fixate momentarily (+) Red reflex if (-), cataract (+) Edema on eyelids r/t pressure during delivery or effects of medication (-) Tear formation (begins @ 2-3 mos)
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Administer eye medication within 1 hr after birth to prevent Ophthalmia neonatorum DOC: Erythromycin 0.5% Tetracycline 1% Silver Nitrate 1% From inner to outer canthus of the eye (conjunctival sac)
Nose
Small & narrow Flattened, midline Nasal breathers (+) Periodic sneezing Reactive to strong odors (+) Flaring = respiratory distress (+) Low nasal bridge = Downs syndrome
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Ears
Soft and pliable; with firm cartilage Pinna should be at the level of outer canthus of the eye (+) Low set ears = renal or chromosomal abnormalities May be congested and hear well after few days
Low set ears

Accessory tragus: remnant of 1st branchial arch
Congenital preauricular sinus: ends blindly risk for infection
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Mouth
Pink, moist gums Intact soft & hard palates (+) Epsteins pearls Uvula midline Tongue moves freely, symmetrical with short frenulum (+) Extrusion & Gag reflexes
Small mouth or large tongue = chromosomal problems (+) white patches on tongue or side of the cheek = Oral thrush
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Neck
Short, thick, in midline Able to flex and extend but cannot support the full weight of head Creased with skin folds Trachea midline Thyroid gland not palpable Intact clavicle
Chest
CC = or < 2cm than HC Cylindrical; equal AP:T diameters Symmetrical Abdominal breathers
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(+) Bronchial sounds (+) Breast engorgement ; subsides after 2 wks (+)Prominent/ edematous nipple (+) Accessory nipples (+) Witch Milk
Abdomen
Umbilical Cord 2 arteries; 1 vein White & gelatinous immediately after birth Begins to DRY between 1-2 hrs following birth Blackened or shriveled between 2-3 days Dried & gradually falls off by 7 days
Daily Cord Care

Keep cord dry and clean & clamp secured Apply 70% isopropyl alcohol to the cord with each diaper change and at least 2-3x a day. DO NOT cover with diaper Note for any signs of bleeding or drainage from the cord and other abnormalities Sponge bath until cord falls off.
GIT: Capacity: 90 ml, with rapid intestinal peristalsis ( 2 to 3 hrs) Bowels sounds; (+) within 1-2 hrs after birth Presence of mass, distention depression or protrusion (+) Scaphoid = diaphragmatic hernia (+) Distended = LGIT obstruction/ mass
Anus Check patency First stool (Meconium) within 1st 24 hrs Sticky, tarlike, blackish-green, odorless material
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Transitional Stool
Within 2- 10 days after birth Breastfed: golden yellow, mushy, more frequent 3-4x and sweet smelling Bottlefed: Pale yello, firm, less frequent 2-3x, with more noticeable odor
Breastfeeding can usually begin immediately after birth Bottlefeeding may be started with sterile water to 4 hrs after birth prior to formula feeding Burp during and after feeding Position properly during and after feeding
Genitals
Female: Labia: edematous Clitoris: enlarged (+) Smegma Pseudomenstruation possible Visible hymen tag First voiding within 24 hrs
Male: Prepuce covers glans penis (+) adherent foreskin = Phimosis Scrotum: edematous (+) enlarged = Hernia Meatus: central (+) ventral/ dorsal = Hypo/epispadias Testes: descended (+) undescended = Cryptorchidism
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Back
Spine Straight, posture flexed Supports head momentarily Arms & legs flexed Chin flexed on upper chest Check for protrusion, excessive or poor muscle contractions = CNS damage
Extremities
Flexed, full ROM, symmetrical Clenched fists; flat soles With 10 fingers and toes in each hand Legs bowed Even gluteal folds
(+) Creases on soles of feet (-) Creases = prematurity Check for hip fractures or dysplasia (+) Ortolanis click & uneven gluteal folds = Hip dysplasia
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(+) inward turning of the foot = club foot or talipes equinovarus
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(+) extra digits = Polydactyly (+) web fingers = Syndactyly
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Neurologic System
Reflexes
Sucking/ Rooting
Touch the lip, cheek or corner of the mouth Turns head toward the nipple, opens mouth, takes hold of the nipple and sucks Disappears after 3-4 mos up to 1 year
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Extrusion
Anything place on the anterior portion of the tongue will be spit out To prevent swallowing of inedible substances Disappears after 4 months Disappearance indicates readiness for semi-solid to solid foods
Swallowing
Occurs spontaneously after sucking and obtaining fluids NEVER disappear Newborn swallows in coordination with sucking without gagging, coughing or vomiting
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Tonic Neck/ Fencing

While the baby is falling asleep or sleeping, gently and quickly turn the head to one side As the baby faces the left side, the left arm and leg extend outward while the right arm or leg flex and vice-versa Disappears within 3-4 mos
Palmar(Grasping)/ Plantar
Place a finger in the palm of the babys hand, then place a finger at the base of the toes Fingers will curl or grasp the examiners finger and the toes will curl downward Palmar: fades within 3-4 mos Plantar: fades within 8 mos
Moro
Hold baby in a semi sitting position then allow the head and trunk to fall backward to at least a 30-degree angle Symmetrically abducts and extends the arms; fans the fingers out and forms a C with the thumb and the forefinger; and adducts the arms to an embracing position & returns to a relaxed state
Present at birth; complete response at 8 weeks MOST significant singular reflex indicative of CNS problem (>6 mos) Disappears after 4-5 mos.
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Startle
Best elicited if baby is 24 hrs old Make a loud noise or claps hands Baby s arms adduct while elbows flex with fists clenched Disappears within 4 mos
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Babinski
Gently stroke upward along the lateral aspect of the sole, starting at the heel of the foot to the ball of the foot Dorsiflexion of big toe and fanning of little toes Disappears starts a 3 mos to 1 year Disappearance indicates maturity of CNS
Stepping/ Walking/ Dancing

Hold baby in a standing position allowing one foot to touch a surface Simulates walking by alternately flexing and extending feet Disappears after 3-4 mos
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Assessment of Gestational Age

Dubowitz Maturity Scale Gestational rating scale NB are observed and tested according to the criteria Help determine whether the NB needs immediate high-risk nursery intervention
Ushers Criteria
FINDINGS 0-36 WKS 37-38 WKS 39 WKS AND OVER
Sole creases
Breast nodule diameter (mm) Scalp hair Ear lobe Testes and scrotum
Anterior transverse Occl creases in crease only ant 2/3

2 Fine and fuzzy Pliable; no cartilage Testes in lower canal; scrotum small; few rugae 4 Fine and fuzzy Some cartilage Intermediate
Sole covered with creases

7 Coarse and silky Stiffened by thick cartilage Testes pendulous, scrotum full; extensive rugae
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Ballards Scoring
Completed in 3-4 min 2 portions: physical maturity and neuromuscular maturity
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Physical maturity
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Neuromuscular Maturity
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Scoring
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Physical maturity
19
Neuromuscular Maturity
17
Scoring
19+17=36
36
39
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Other Nursing Responsibilities

Identification band Birth Registration Birth record and documentation
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Newborn Screening
The Newborn Screening Reference Center (NSRC) is an office under the National Institutes of Health (NIH), University of the Philippines Manila created under RA 9288 The Newborn Screening Act of 2004 Performed after 24 hours of life up to 3 days except for patient in intensive care, must be tested by 7 days
Congenital Hypothyroidism (CH) Congenital Adrenal Hyperplasia (CAH) Galactosemia (GAL) Phenylketonuria (PKU) Glucose-6-Phosphate-Dehydrogenase Deficiency (G6PD Def)
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Disorder Screened
Congenital Hypothyroidism Congenital Adrenal Hyperplasia Galactosemia
If not screened
Severe mental retardation Death
If screened
Normal
Alive and Normal
Death or Cataracts
Alive and normal
PKU
Severe mental retardation

Severe Anemia, Kernicterus
Normal
G6PD Deficiency
Normal
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Infant Care Skills

Holding the baby Football Hold Cradle Hold Shoulder Hold
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Football Hold
Purpose: to carry on one hand free A holding technique in bathing a baby Use for small babies Procedure: 1. slide forearm under his back 2. support neck and head with your hand 3. press his arm firmly against your side 4. his head faces you 5. infants feet tucked under your elbow
Cradle Hold
Purpose: use for feeding and cuddling a baby
Procedure: support head in the crook of your arm encircle the body with your arm press baby firmly against your side use other hand to support bottom and thigh
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Shoulder Hold
Purpose: use for burping
Procedure: draw baby towards your chest with one forearm bracing his back and your hand cradling his head support your babys bottom and thighs with your other arm gently press his head against shoulder
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Care of The Newborn

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st 1

Immediate Care of the Newborn

Airway Breathing Temperature

Airway & Breathing

Airway & Breathing

Activity Pulse Grimace Appearance Respirations

Care of the Newborn in the Nursery

Weight/ Anthropometric Measurements

Major Time Frames

APGAR Scoring System

Heat Loss Mechanisms

Evaporation loss of heat through conversion of a liquid to a vapor

Duration: 1 full minute, not crying Site: Apical

Silverman Scoring System

Nursing Responsibilities: -cover eyes and sex organ

Large capillary hemangioma

Other Skin Marks

Face/Eyes/Ears/ Nose /Mouth

Low set ears

Accessory tragus: remnant of 1st branchial arch

Congenital preauricular sinus: ends blindly risk for infection

Daily Cord Care

(+) inward turning of the foot = club foot or talipes equinovarus

(+) extra digits = Polydactyly (+) web fingers = Syndactyly

Tonic Neck/ Fencing

Stepping/ Walking/ Dancing

Assessment of Gestational Age

Anterior transverse Occl creases in crease only ant 2/3

Sole covered with creases

Other Nursing Responsibilities

Alive and Normal

Alive and normal

Severe mental retardation

Infant Care Skills

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