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SAMONTE, JBMM Page 1 of
2.1A NEWBORN CARE
Dra. Grace
January 07,
Emilio Aguinaldo College – School of
OBJECTIVES
1. To introduce normal newborn findings and behavior pattern.
Recognize the context of a normal pregnancy outcome.
Describe the process of transition from intrauterine to extra
uterine existence.
Perform a complete physical examination of the newborn
infant. Perform a concise neurodevelopment assessment of the
newborn infant.
2. To be aware of what constitute a comprehensive newborn
care.
Formulate a risk assessment list
Perform basic steps in neonatal resuscitation
Provide immediate care for the newborn
Continuing care
Discharge procedure with adequate instruction
PERINATAL HISTORY
1. Demographic and social date socioeconomic status, age, race
2. Past medical illnesses in the family – cardiopulmonary disease,
infection, genetic disorder3. Prior maternal reproductive problems – still births, prematurity
4. Events occurring in the present pregnancy – vaginal bleeding,
medications, acute illness, duration of pregnancy
5. Description of labor – duration, fetal presentation, fetal distress,
presence of fever
6. Delivery – normal, c-section, anesthesia of sedation, forceps
PREGNANCY RISK CLASSIFICATION
CLASS A
Low risk mother with low risk newborn – normal uncomplicated
pregnancies and normal labor pattern.
CLASS B
High risk mother with low-risk newborn – mothers who are sick
but in stable condition and therefore presents a minimal risk tothe baby.
Example: Gravidocardiac, primagravida >35 years or < 16
years, malignant disease not receiving therapy, pulmonary
disorder, hematologic disorder
CLASS C
Low risk mother with high risk newborn
Example: History of habitual abortion and stillbirth, abnormal
ultrasonographic findings, abnormal biophysical profile,
prolonged or early gestation, evidence if IUGR, multiple
gestation, rupture of membranes, abnormal fetal heart rate or
pattern, meconium staining of amniotic fluid, etc.
CLASS D High risk mother with high risk newborn – fetus and newborns
are compromised because of maternal illness.
Example: Chronic hypertension, pre-eclampsia/eclampsia,
diabetes mellitus (uncontrolled), renal/cardiac failure, viral or
bacterial infections, choroiamnionitis, 2nd
or 3rd trimester
bleeding, etc.
FETAL PHYSIOLOGY
CIRCULATORY SYSTEM
Normally complete by 40th week of gestation
Fetal circulation with 3 shunts:
o Ductus venosus
o Foramen ovale
o Ductus arteriosus
Fig1. Fetal Circulation
FETAL CIRCULATION
Placenta umbilical vein Ductus venosus Inferior vena
cava Right atrium Foramen ovale Left atrium Left
ventricle Ascending aorta Head and upper part of the
body
Superior vena cava Right atrium Right ventricle
Pulmonary artery Ductus arteriosus Descending aorta
Lower half of the body
Blood flows in parallel rather than in series.
Mainly affected by high pulmonary resistance brought about bnon-expansion of the lungs.
RESPIRATORY SYSTEM
Formation starts from the airways proceeding to alveolation. Alveolar epithelium excretes lung fluid that fills the alveoli.
Surfactant produced by type II alveolar cells by 20th week of
gestation.
Adequate surfactant lowers surface tension of the alveolarepithelium preventing alveolar collapse.
Respiratory movements occur as early as 18th week of
gestation but ceases as fetus approaches term.
At term, fetus breathes ONLY if a hypoxic stimulus is applied.
THE TRANSITION
Passage of the fetus through the birth canal Chest wall iscompressed lung fluid is expelled Elastic chest wall recoilsback High negative intra-thoracic pressure.
Infant’s first cry replaces lung fluid with air.
Fluid in the alveoli is absorbed into the lung tissue and
replaced by air. The oxygen in the air is able to diffuse into theblood vessels that surround the alveoli.
Alteration of the lungs eliminate the hypoxic state causingvasodilation of lung vessels.
Decrease in pulmonary vascular resistance and pressure More blood enter the lungs and return to the heart Left atriapressure increases causing physiologic closure of the foramenovale.
Increase in oxygen content causes the muscular constrictionand functional closure of the patent ductus arteriosus.
APGAR SCORE
Practical method of systematically assessing newborn infantsimmediately after birth to help identify those requiringresuscitation and to predict survival in the neonatal period.
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SAMONTE, JBMM Page 2 of
2.1 NEWBORN CAREPediatrics I
Not designed to predict neurological outcome
SIGN 0 1 2
Heart rate Absent < 100 100
Respiratoryeffort
Absent Slow irregular Good crying
Muscle tone Limp Some flexionof ext. Active motion
Response tocatheter in
nostril
(-) Response Grimace Cough sneeze
Color Blue, pale Body pink, ext.blue
Pink all over
1 minute score – signal the need for immediate resuscitation. 5 minute score – probability of successfully resuscitating an
infant. May be extended to 10, 15, 20 minutes until score of 7 is
reached.
NEONATAL RESUSCITATION
Drying, warming, positioning, suction,
Tactile stimulation
Oxygen
Bag-mask ventilation
Endotracheal intubation
Chest compressions
Medications
Inverted pyramid reflecting the appropriate relative frequencies
of neonatal resuscitative efforts.
ESSENTIAL NEWBORN CARE
Protocol promulgates by the WHO and endorsed by DOH to
decrease neonatal mortality.
Evidence based intervention. Emphasizes on core sequence of actions performed step by
step.
Four core steps:
1. Immediate and thorough drying.
2. Early skin to skin contact.
3. Properly timed cord clamp.
4. Non-separation of the newborn and mother for early
initiation of breastfeeding.
TIME-BOUND INTERVENTIONSWithin 30seconds
objective: Tostimulatebreathing,
providewarmth.
After thoroughdrying
objective: Toprovide
warmth,bonding,prevent
infection &hypoglycemia.
Up to 3 minutespost-deliveryobjective: To
reduce anemia
in term &preterm; IVH and
transfusions inpreterm.
Within 30minutes of ageobjective: To
facilitate initiation
of breastfeedingthrough
sustainedcontact.
-Put on doublegloves-Dry thoroughly-Remove wetcloth-Quick check ofNB’s breathing
-Suction only ifneeded
-Put prone onchest/abdomenskin to skin-Cover withblanket, bonnet-Placeidentification onankle-Do not removevernix
-Remove 1s set of
gloves-Clamp and cutcord after cordpulsations stop. (1-3 mins)
-Do not milk cord.-Give oxytocin 10mg IM to mother.
-Uninterrupted skinto skin contact.-Observe NB forfeeding cues.Counsel onpositioning &attachment.-Do eye care,injections, etc after1
st breastfeeding.
EXPANDED BALLARD SCORE
Assessment of gestational age by determining state of
maturity.
Use of physical features and neurological responses.
Extremely prematures assessed as early as 12 hours, term
infants may be assessed even up to 72 hours.
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SAMONTE, JBMM Page 3 of
2.1 NEWBORN CAREPediatrics I
PHYSICAL MATURITY NEUROMUSCULAR MATURITY
SkinLanugo
Plantar surfaceBreast
Eyes/earsGenitalia
PostureSquare window
Arm recoilPopliteal angle
Scarf signHeel to ear
PHYSICAL EXAMINATION OF THE NEWBORN
Initial examination performed as soon as possible after delivery
o To detect abnormalities and
o To establish a baseline for subsequent examinations
2nd
examination: within 24 hours after birth
3rd examination: within 24 hours of discharge
Tailored to fit both the gestational and postnatal age of an
infant.
Requires patience and procedural flexibility to return to do part
of the examination in order to stay within the limits of an infant’s
tolerance.
Requires gentleness.
Anthropometric measurements: weight, length, head
circumference, chest circumference and abdominal
circumference.
Vital signs:
o Pulse rate: 120-160 beats/min.
o Respiratory rate: 30-60 breaths/in.
o Temperature, color, activity: Monitored every 30 mins
after birth for 2 hours or until stabilized.
GENERAL APPEARANCE
Physical activity: absent, deceased, vigorous crying
Muscle tone: Active or passive
Take note of unusual posture
Coarse tremulous movements vs. convulsive twitchings
Edema: Generalized or localized
SKIN
Vasomotor instability and peripheral circulatory sluggishness –
deep redness or purple lividity during crying.
Acrocyanosis of the hands and feet
Mottling – associated with
severe illness or related to
transient fluctuation of skin
temperature.
Fig2. Mottling
Harlequin color change –
extraordinary division of the
body from the forehead to thepubis into red and pale halves;
transient and harmless
condition.
Fig3. Harlequin color change
Pallor – represents asphyxia, anemia, shock or edema.
Vernix caseosa - also known
as vernix, is the waxy or
cheese-like white substance
found coating the skin of
newborn human babies.
Vernix starts developing on the
baby in the womb around 18
weeks into pregnancy. Fig4. Vernix caseosa
Plethora – Polycythemia
Lanugo – fine, soft immature
hair on scalp, brow and face;
especially among prematures.
Fig5. Lanugo
Mongolian spots – slate blue, well-
demarcated areas of pigmentation
seen over the buttocks, back – tend to disappear within the 1st
year of life.
Fig6. Mongolian spots
Erythema toxicum – small white
occasionally vesiculopustular
papules on an erythematous base
seen on the face, trunk and
extremities – appears 1-3 days
after birth and persists for as long
as 1 week.
Fig7. Erythema toxicum
Milia – small whitish papules made
up of distended sebaceous glands,
usually covering the nose.
Fig8. Milia
Salmon patch - (also called stork
bites) appear on 30%-50% of
newborn babies. These marks
are small blood vessels
(capillaries) that are visible
through the skin. They are most
common on the forehead,
eyelids, upper lip, between the
eyebrows, and the back of the neck. Fig9. Salmon patch
Often, these marks fade as the
infant grows.
Hemangiomas - benign(noncancerous) vascular tumorscomposed of cells that normallyline the blood vessels (endothelialcells).
Fig10. Hemangiomas
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2.1 NEWBORN CAREPediatrics I
HEAD
Molding: Usually among first born, parietal bones tend tooverride the occipital and frontal bones.
Suture lines: Check for premature fusion = craniosyntosis
Anterior and posterior fontanels: check for abnormal size
Craniotabes: soft area in the parietal bones at the vertex nearsagittal suture.
Caput succedaneum – edematousswelling of the soft tissue of thescalp.
Fig12. Caput succedaneum
Cephalhematoma – subperiostealhemorrhage
Fig13. Cephalhematoma
FACE
Dysmorphic features – epicanthal folds, widely spaced eyes,microphthalmia, low set ears.
Asymmetry: Abnormal fetal posture, 7th nerve palsy
Facial nerve paralysis – Theforehead on the affected side issmooth, eye cannot be closed,nasolabial fold is absent, corner ofmouth drops.
Fig14. Facial nerve paralysis
EYES
Conjunctival and retinal hemorrhages usually benign.
Check for bilateral red reflex.
Leukocoria: White pupillary reflex = cataracts, tumors,chorioretinitis, ROP
EARS
Deformitis of the pinnae
Preauricular skin tags
NOSE
Patency and symmetry of the nares
Assymetry: Dislocation of nasal cartilage from the vomeriangroove.
Choanal atresia – may lead to respiratory distress
MOUTH
Precocious dentition:o Natal – present at birtho Neonatal – eruption after birth
Soft and hard palate: Check for complete or submucosal cleftcheck for contour
Epstein pearls: Retention epithelial cells cysts seen on the hapalate and gums.
Tongue: Short frenulum
NECK
Relatively short
Abnormalities not common: Goiter, cystic hygroma, brachialcleft vestiges, sternocleidomastoid hematomas
Redundant skin or webbing: Turner syndrome
Clavicular fracture
CHEST
Breast hypertrophy common
Supernumerary nipples occasionally seen
Milk may be present (witch’s milk)
Retractions (intercostal/subcostal): Respiratory distress
LUNGS
Variation in rate and rhythm of breathing according to infant’sphysical activity.
RR > 60/min: Respiratory, cardiac or metabolic disease
Breathing is diaphragmatic – “paradoxical movement”
Prematures: Cheyne-stokes rhythm = periodic breathing
Breath sounds – bronchovesicular
Expiratory grunting : Respiratory distress
HEART
Determine location: Dextrocardia
Fig15. Dextrocardia
Transitory benign murmur are common
Congenital heart disease may not initially produce the murmuthat will appear later.
Palpation of pulses in the upper and lower extremities:Coarctation of the aorta.
Fig16. Coarctation of the aorta
ABDOMEN
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2.1 NEWBORN CAREPediatrics I
Prominent, globular but not distended
Liver usually palpable 2 cm below the rib margin.
Tip of the spleen may be felt less commonly
Abnormal masses: Renal pathology most common.
Scaphoid abdomen: Diaphragmatic hernia.
Abdominal wall defects: Omphalocoele vs gastroschisis
Fig17. Omphalocoele
Fig18. Gastrochitis
Fig19. Gastroschisis VS Ompalocoele
Air in the GIT vary, present in the rectum by radiograph by 24hours of age.
Umbilicus: 2 arteries and 1 vein
GENITALIA
Maternal hormones – enlargement and secretion of breasts,prominent female genitalia with non-purulent discharge.
Testes may not be fully descended but are palpable in thecanals.
Prepuce normally tight and adherent.
Ambiguity in external genitalia requires further investigation.
Fig20. Ambiguous genitalia
ANUS
Check for patency
Passage of meconium by 48 hours of life
EXTREMITIES
Check of effect of fetal posture
Poly or syndactyly
Clubfoot
Abnormal dermatoglyphic pattern: Simian crease
Congenital hip dislocation: Ortolani’s maneuver
NEUROLOGICAL EXAMINATION
POSTURE
Resting, unrestrained posture
Flexion and adduction of the hips, flexion of the knees, armsadducted and flexed at the elbow, fists often clenched.
STATE OF WAKEFULNESS
1. Deep sleep – no movement, regular breathing2. Light sleep – with eye movements, hypotonic and irregular
breathing3. Quiet, awake – eyes closed or half-open, with slight activity4. Fully awake – eyes open, alter with some movements5. Fully awake, active – with plenty of movements6. Fully awake, crying
The neurodevelopmental exam is most reliably done in statesor 4
Rooting, licking, sucking reflexes reflect level ofresponsiveness.
Observe eye opening, yawning, facial expressions andstretching.
TONE
Observe for posture
Frog leg position suggests flaccidity
Passive tone: Observe by performing vertical suspension andhorizontal suspension.
Active tone: Pull to sit maneuver
Ankle clonus of >10 beats probably abnormal
Differentiate tremulousness from seizures
REFLEXES
Deep tendon: patellar reflex test (L2-L4)
Less easy to elicit: biceps, ankle, truncal innervation
Primitive: assessed for presence or absence, symmetry,completeness, persistence
Moro, palmar and plantar grasp, rooting, sucking, placingreflexes at birth
Tonic neck reflex at later days
Fig21. Moro reflex Fig22. Grasp reflex
Fig23. Rooting reflex Fig24. Asymmetric tonic refle
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2.1 NEWBORN CAREPediatrics I
Fig25. Placing reflex
HIGHER FUNCTION AND CRANIAL NERVES
Observe response to breast-feeding, human voice (particularlymother’s voice)
Capable of visual fixation and limited tracking during alertperiods.
Especially responsive to the human face
IMMEDIATE CARE FOR THE NEWBORNTHERMOREGULATION
Relative to body weight, body surface area of a newborn infantis approximately 3x that of an adult.
Estimated rate of heat loss in a newborn is approximately 4xthat of an adult.
Maintain 36.6-37.2 C
Skin to skin contact with the mother is the optimal method tomaintain temperature in the stable newborn.
SKIN AND CORD CARE
Once infant’s temperature has stabilized, entire skin and cordshould be cleaned with warm water and milk non-medicatedsoap.
Careful removal of blood and meconium, do not remove vernix.
Cord may be treated daily with bactericidal or anti-microbial;
agents such as triple dye or bacitracin. 2x daily alcohol soaking until cord falls off reduces colonization,
exudates and foul odor of the umbilicus.
Hand washing of nursery personnel is mandatory.
EYE CARE
Instillation of 1% silver nitrate drops or erythromycin 0.5% ortetracycline ophthalmic ointment.
To prevent gonococcal eye infections.
VITAMIN K ADMINISTRATION
Water-soluble vitamin K (phytonadione) given by intramuscularinjection.
0.5 mg for premature infants, 1.0 mg for term infants
To prevent hemorrhagic disease of the newborn.
IMMUNIZATION Hepatitis B and BCG
Babies of mothers with reactive HBsAg should receive bothHepatitis B immune globulin and vaccine.
CONTINUING CARE
ROOMING-IN
Within 2 hours after birth or as soon as possible.
Clear bassinet to allow easy monitoring and care.
Advise on thermoregulation and hand washing.
Mother directly responsible for the routine care of the infantduring rooming-in.
BREASTFEEDING
Latch-on within 30-45 mins after birth or as soon as the infantshows signs of readiness.
Proper technique in breastfeeding.
No pacifiers or other artificial forms of feeding.
On demand deeding preferred.
NEWBORN SCREENING Collection of blood samples form the sole of the feet of
newborn infants, placed on filter paper.
For detection of:o Congenital hypothyroidismo Congenital adrenal hyperplasiao Phenyketonuriao Galactosemiao Glucose 6 phosphate dehydrogenase deficiency
DISCHARGE PROCEDURE
Continue exclusive breastfeeding
Cord care
Bathing
Signs of illness, contact numbers, emergency room
Well baby visit schedule
END OF TRANS
Life isn’t about getting and having, it’s about giving and being.–Kevin Kruse