NEWBORN CARE

A. Essential Concepts:1. In the postpartal period, the newborn experiences complex bio-

physiologic and behavior change related to the transition to extrauterine life.

2. Nursing care of the newborn is based on knowledge of these changes and of the newborn’s impact on the family unit.

3. The first few hours after birth represent a critical period of adjustment for the newborn. In most setting, the nurse provides direct care to the newborn immediately after birth.

4. After the transition period, the nurse continues to evaluate the newborn at periodic intervals and to alter nursing plans according to ongoing findings.

5. The nurse must be skillful in balancing the family’s need for privacy and time to interact without interruptions with the need to closely monitor the newborn’s transition to extrauterine life.

B. GOALS OF NEWBORN CARE

1. For the initial postpartal perioda. Establish and maintain an airway and support

respirations.b. Maintain warmth and prevent hypothermia.c. Ensure safety to prevent injury or infection.d. Identify actual or potential problems that might require

immediate attention.

2. For continuing carea. Continue to protect from injury or infection and

identify actual or potential problems that could require attention.

b. Facilitate development of a close parent-infant relationship.

c. Provide parents with information about newborn care.

d. Assist parents in developing healthy attitudes about childrearing practices.

C. FACTORS AFFECTING NEWBORN ADAPTATION

1. Antepartal experiences of mother and newborn (e.g., exposure to toxic substances, parental attitude toward childbearing and childrearing)

2. Intrapartal experiences of mother and newborn (e.g., length of labor, type of intrapartal analgesia or anesthesia)

3. Newborn’s physiologic capacity to make the transition to extrauterine life.

4. Ability of health care providers to assess and respond appropriately in the event of potential problems.

D. NURSING RESPONSIBILITIES

1. Support the neonate’s physiologic adaptation to extrauterine life

2. Prevent or minimize potential complications3. Facilitate parent-infant interaction

IMMEDIATE NEWBORN CARE

• After the birth of the infant, every effort should be exerted to support him in his first minutes, hours and days of life. The quality of the immediate care afforded the newborn will spell his later state of health or well-being.

1. Establishment and maintenance of patent airway

• Right after the extension of the newborn’s head before the chest is delivered the mouth and nose should right away be cleared. This measure is the best prevention to meconium aspiration which results to lung infection:

ASPIRATION PNEUMONIA

a. Suction the newborn observing the following considerations:

Start with the mouth, then the nose – stimulation of the nerve receptors in the nose can cause reflex inhalation of oropharyngeal secretions into the trachea and bronchus and aspirate the secretions.

Press or deflate the rubber ball of the bulb syringe before inserting its tip into the mouth and nostrils of the newborn

Suction shallowly by using bulb syringe – deep suctioning can cause vagal stimulation leading to bradycardia and laryngospasm.

Suction briefly – to avoid suctioning needed oxygen.

Preterm: less than 5 seconds per suction timeFull-term: 5 to 10 seconds per suction time

Give oxygenation judiciously when necessary- giving more than 40% oxygen concentration can result to damage to the retina causing neonatal blindness called RETROLENTAL FIBROPLASIA

Position in SLIGHT TRENDELENBERG position (10 to 15 degrees angle) – to drain secretions from the oro-naso-pharynx.

• Test patency of the airway by occluding one nostril at a time – newborns are nasal breathers

• Position in slight Trendelenberg (10-15 degrees angles) – promote drainage of oro-naso-pharyngeal secretions.

Avoid the acute Trendelenberg position – can cause abdominal contents to exert pressure unto the diaphragm leading to difficult breathing

Head-down position is contraindicated in the presence of signs of increased intracranial pressure: vomiting; bulging/tensed fontanels; abnormally enlarged head; increased BP; decreased PR and RR; widening pulse pressure; shrill, high-pitched cry – place baby in Semi-Fowler’s position.

RESUSCITATION MEASUREAirway – make sure that the mouth and

nasopharynx are free of secretions; remove secretions by suction, small finger, or gentle milking of trachea

Breathing – if neonate does not make effort to breathe, start your mouth-to-mouth resuscitation. Pinch the nose and cover the baby’s mouth entirely with your mouth, and breath into him and notice the chest move

Circulation – if there are no heart sounds, apply index and middle fingers/thumb on the infant’s mid-sternum and apply 1 inch downward pressure. Do 5 chest compressions followed by mouth-to-mouth resuscitation.

LOOK, LISTEN, AND FEEL.

* Oxygen deprivation of more than 5 minutes can result to the death of the baby or permanent damage of sensitive brain cells

*Continue resuscitation until breathing is established or the heart stops beating and the baby is pronounced dead

*Stop resuscitation when pupils have remained dilated for 30 minutes

2. Maintenance of appropriate body temperature

• The newborn temperature at birth is 37.3oC & drops quickly to 35.5oC owing to the mechanisms of heat loss.

• Dry the newborn immediately after birth to prevent heat loss by evaporation.

• Wrap the body and promote flexion and apply cap to head to minimize the body surfaces exposed to cool air or cool surfaces; never place newborn on cold and unlined surfaces. – to prevent heat loss by conduction and radiation. Most of newborn’s heat is lost by RADIATION.

• Use a thermoregulator, such as a radiant warmer, or a temperature-controlled incubator to control environmental temperature until the neonate’s temperature stabilizes

Radiant warmer – maintains the neonate’s temp. by radiation.

Incubator – maintains the neonate’s temp. by conduction and convection.

Make sure the warmer is set to the desired temperatureWarm blankets, washcloths, or towels under a heat

sourceKeep the neonate under the radiant warmer until his

temperature remains stableWhen an incubator is used, keep it away from cold walls

or objects, and perform all required procedures quickly, closing the portholes in the hood after completion

• The warm abdomen of the of the mother ca be a good place to keep the newborn warm immediately after birth.

• The initial temperature of the newborn is taken per RECTUM – to detect for IMPERFORATE ANUS.

• After the initial temperature taking, all other temperature taking should be per AXILLA – to minimize potential risk to traumatizing the mucus membrane of the rectum; every 15-30 min. until it stabilizes and then every 4 hours to ensure stability

• Avoid exposing infant to drafts, wetness, and direct or indirect contact with cold surface.

• Maintain normal body temperature (97.7 to 98.6 oF) (36.5 to 37oC)

• Temperature is stabilized within 8 to 12 hours at 36.8oC (98.2oF).

• During the entire immediate care procedures, place newborn under the floorlamp – to keep him warm.

• Subjecting the newborn to COLD STRESS can cause:

1.Increased brown fat metabolism causing an increased in fatty acids in the circulation thus METABOLIC ACIDOSIS.

2.Increased activity/metabolic rate causing more utilization of glucose and oxygen thus HYPOGLYCEMIA and RESPIRATORY DISTRESS.

3. Do immediate Assessment of the Newborn

• APGAR SCORING- Is the standardized evaluation of the

newborn’s condition at birth done at:• 1 min. after birth – to determine the general

condition; &• 5 min. after – to determine how well the

newborn is adjusting to extrauterine life.- The scoring system is named after DR.

VIRGINIA APGAR, an anesthesiologist, who studied the observations in the newborn.

- The normal infant should have an APGAR of 7 or more; the higher the APGAR score, the better is the prognosis.

APGAR SCORE CHARTSIGN 0 1 2

COLOR

(Appearance)

Generalized pallor or bluish

Body pink, extremities blue(Acrocyanosis)

Pink all over

HEART RATE

(Pulse)Absent < 100/min 100/min or

more

REFLEX IRRITABILITY

(Grimace)

None; No response

Grimace, weak cry

Cry; sneezing

MUSCLE TONE

(Activity)

Limp, flaccid

Some tone in limbs; some flexion of ext.

Active flexion of limbs; well flexed extremities

BREATHING

(RespiratoryEffort)

None slow, irregular

Regular, with cry

O – 3 = severely depressed with HR slow, inaudible and reflex response are depressed or absent. The baby is in serious danger and needs immediate resuscitation.

4 – 6 = mildly to moderately depressed infants; demonstrates depressed respiration, flaccidity, and pale to blue color. HR and reflex irritability are good. Condition is guarded and may need more extensive clearing of the airway.

7 – 10 = excellent condition and require no aid other than simply nasopharyngeal suctioning.

• COLOR. Many babies may be blue when they are delivered, but they usually regain color and become pink soon. If the newborn remains bluish, the baby may not be breathing well, or may be cold, or may have infection, or a congenital heart problem – refer the newborn immediately to the doctor .

• HEART RATE. The heart rate of a newborn is between 120 to 160 beats every minute – count the HR in 1 full minute; if outside the normal rate, refer immediately.

• MUSCLE TONE. A newborn with his arms and legs bent has good muscle tone. A limp baby with his arms and legs loose has poor muscle tone. A baby with poor/weak muscle tone may have trouble breathing. – try rubbing his back so the baby will wake up; or refer immediately.

• BREATHING. Babies who cry after birth are usually breathing well. However, some newborns may have breathing problems. The following are bad signs:

• The nostrils are flaring when the baby breathes

• The skin between the ribs retracts on breathing

• Very rapid breathing – mote than 60 per min.• Very slow breathing – less than 30 per min.• The baby grunts when he breathes- A baby who is not breathing or is gasping

needs immediate help.

• If the baby has lots of secretions, use the bulb syringe to clear the airway.

• Turn the baby on his side for few minutes. Rub your hand firmly on his back.

• Never hit the baby nor hold him upside down to make him cry.

• Give oxygen inhalation if there is one available.

Refer immediately.

Silverman-Anderson Scoring -An index of respiratory distress or is a useful tool in

the evaluation of status of the newborn’s respiration to determine degree of

respiratory distress syndrome (RDS).signs 0

No difficulty

1Moderate difficulty

2Maximum difficulty

Upper chest movement

Synchronized breathing

Chest lag See-saw breathing

Lower chest movement

No retractions

minimal Marked

signs 0No difficulty

1Moderate difficulty

2Maximum difficulty

Xiphoid process retractions

No retractions

minimal Marked

Nasal flaring

No flaring

Just visible Marked

Expiratory grunting

Quiet breathing

Expiratory grunts on auscultation

Grunting on bare ears

Initial assessment and action to be taken:

Initial assessment Action

PinkHR > 120 bpmBreathing regularly

Dry and wrap babyBaby stays with mother

Blue HR >100 bpmBreathing inadequate

Dry and wrapClear the airway

Blue or paleHR <100 bpmNot breathing

Dry and wrapClear the airwayAsk for helpRefer to the doctor

Assessment of gestational age• NAGELE’S RULE – calculation of EDC using the

mother’s LMP; count back 3 mos. from the first day of LMP and add 7 days.

• McDONALD’S METHOD – determines age of gestation by measuring the fundic height (fundus to symphysis) in cm. , then divide by 4 = AOG in months.

• BARTHILOMEW’S RULE – estimates AOG by the relative position of the uterus in the abdominal cavity.

3rd lunar month – fundus is slightly above the symphysis pubis.

5th lunar month – fundus is at the level of the umbilicus.

9th lunar month – fundus is below the xiphoid process.

• Time quickening is first felt.• Ultrasound• Assessment of the newborn at birth

Rapid estimation of the gestational age of the newborn

sign 36 weeks or less

37 -38 weeks

39 weeks or more

Sole creases

Anterior transverse

occasional

Sole covered with crease

Scalp hair

Fine and fuzzy

Fine and fuzzy

Coarse and silky

sign 36 weeks or less

37 -38 weeks

39 weeks or more

Breast nodule diameter

2mm 4 mm 7 mm

Earlobe flexible With some cartilage

With cartilage

Testes and scrotum

Testes in lower canal; scrotum small with few rugae

intermediate

Testes pendulous; scrotum full with extensive rugae

Ballard Scoring System

• Uses physical and neurologic findings to estimate gestational age

• This system enables estimates of gestational age to within 1 week, even in extremely preterm neonates

• This evaluation can be done anytime between birth and 42 hours of age, but the greatest reliability is at 30 and 42 hours

- Cephalometry – measurement of the diameters of the skull.

4. Identify the newborn properly.

- Done as soon as possible after birth before the newborn is separated from the mother.

- The best way to identify the newborn is by means of taking his footprints.

- Proper identification is a legal and moral responsibility of the midwife/nurse.

- May use bracelets or foot tags.

5. Provide skin care.• Immediate soap and water bath is given to the

normal fullterm newborns – to primarily cleanse the skin and prevent infection; is given once vital signs have stabilized

• Wear gloves when giving the first bath• Oil bath is given to pre-terms and other high-

risk newborns.• Never give the newborn marine bath (- bath that

someone gives as he holds the newborn directly under cold, running water of the faucet and briskly bathes him) – subjects newborn to cold stress.

• Do not wash vernix routinely. Vernix can be antibacterial. Besides, it is absorbed by the skin in a day or day.

• Wash, rinse, and dry each portion of the body separately to minimize heat loss

- Begin the bath with the eyes and face first, proceeding from the cleanest to the least cleanest area last

- Clean the diaper area last• Give sponge bath until the umbilical cord

falls off, usually within 10 to 14 days• Use a mild, hexachlorophene-free soap• Don’t use soap on infant’s face• Bathe before feedings instead of afterward

to prevent vomiting• Apply alcohol, if ordered, to the base of the

umbilical cord with each diaper change

6. Give Crede’s Prophylaxis• Given to all newborns as a prevention against

OPHTHALMIA NEONATORUM/GONORRHEAL CONJUNCTIVITIS caused by Neisseria gonorrhea – causes blindness as baby may acquire it as he passes through the birth canal of an infected/untreated mother.

• Can be delayed for 1 to 2 hours – not to interfere with the bonding process.

• NOW: Apply tetracycline ophthalmic ointment to each eye, from the inner canthus to the outer canthus.

• 1 -2 cm ribbon of 0.5% ERYTHROMYCIN ointment – drug of choice.

• BEFORE: 2 gtts of 1% Silver Nitrate to each eye.

7. Perform Cord Dressing• Is performed under strict aseptic technique to

prevent TETANUS NEONATORUM caused by Clostridium tetani.

• Examine the cord for the presence of 3 blood vessels: 1 umbilical vein and 2 umbilical arteries – incomplete number of vessels warrants immediate reporting for thorough assessment for congenital defects.

• The vessels are covered with Wharton’s jelly – protects vessels from being twisted or compressed.

• Leave about 1 inch of the cord from the base – longer cord stump causes longer drying and dropping off time that can lead to OMPHALITIS (-infection of the cord).

• signs: smelly discharge on the surface of the umbilical stump; the umbilical stump remains wet and soft; there is redness around the base of the umbilicus

• Apply 70% isopropyl alcohol to the umbilical cord stump 3 – 4 times daily – will keep it dry & clean, & help in making it fall off early.

• Umbilical cord stumps usually fall off in 7 – 10 days.

• In the first 24 hours, inspect cord for OMPHALANGIA (- bleeding of the cord).

• Place diaper below the umbilicus to prevent contamination

8. Inject Vitamin K intramuscularly.

• 0.5 – 1 mg of Vitamin K is injected to prevent bleeding or hemorrhagic disease in the newborn by improving blood coagulation.

• Lack of vit. K can cause a bleeding condition known as “Hemorrhagic Disease of the Newborn” that can lead to permanent brain damage or even death.

• Newborn’s GIT is initially sterile – no E. coli to synthesize the vitamin.

• The liver needs vit. K to make other clotting factors, but because of its immaturity at birth, it has no stores of vit. K.

• The best site for IM injections is the THIGH MUSCLE, specifically the mid-antero-lateral aspect called VASTUS LATERALIS.

9. Neonates to Rh(-)/Type O mothers, should have blood

specimen for:

• Blood type• Bilirubin level• Direct Coomb’s test. An abnormal result

indicates presence of maternal antibodies in the neonate’s blood, suggesting blood incompatibility

• Reticulocyte count. Increased count indicates the body’s response to RBC destruction

• Hematocrit. Decreased result suggests anemia

• Neonates weighing less than 2,500 g or more than 4,000 g should undergo blood glucose screening within 30 min. of birth to determine glucose stability

- glucose levels less than 40 mg/dl indicate hypoglycemia and require treatment

- the neonate should receive 10ml/kg of body weight of formula

- Blood glucose level is checked 1 hour after feeding

- If the glucose level is higher than 45 mg/dl, another glucose level is obtained before the next feeding

• The neonate is assessed for signs of hypoglycemia, including jitteriness, irritability, seizures, hypothermia, lethargy, poor feeding, apnea, cyanosis, pallor, and a high pitched cry

10. Take the weight and other Anthropometric Measurements• Size and weight measurements establish the

baseline for monitoring normal growth. When obtaining these measurements, place the neonate in a supine position in the crib or on the examination table and remove all clothing.

• WEIGHT. The normal weight of newborns ranges from 3000 to 3400 g with the lowest normal limit of 2500 g.

• Physiologic weight loss: 5% to 10% in the first 7 to 10 days of life. Lost weight is regained after the 10th day.

• Perinatal mortality and morbidity are related to gestational age and birth weight.

• HEIGHT. Normal height rangers from 18 to 21 inches (46-53 cm), or an average of 50 cm.; taken by heel-to-crown measurement; fully extend the neonate’s legs with the toes pointing up.

• HEAD CIRCUMFERENCE. Measures 33-35 cm (13-14 in)

* Slide a tape measure under the neonate’s head at the occiput and draw the tape around snugly, just above the eyebrows.

• CHEST/ABDOMINAL CIRCUMFERENCE. Measures 31-33 cm (13-14 in); 2-3 cm. less than HC

• Place a tape measure under the back and wrap it snugly around the chest at the nipple, keeping the back and front of the tape level; take the measurement after the neonate inspires and before he begins to exhale

• Place a tape under the back and wrap it snugly around the abdomen just above the umbilicus

11. Advise the mother to frequently observe the baby for danger signs. The following are the conditions of

the newborn needing urgent intervention:

• Change in color from pink to paleness, blue or deep yellow

• Poor suck or weak cry or limpness• Irritability or non-stop crying• Pre-term or very low birth weight• Gasping or not breathing (fast, slow

breathing, grunting0• CONVULSIONS

• Frequent loose stools or difficulty of defecating

• Fever or hypothermia • Pus in the umbilicus or redness around

the umbilicus extending to the skin• Bleeding• Pustules in the skin or swelling and

redness

12.Start immunization with hepatitis B vaccine and BCG as recommended

• Routine Hepatitis B immunization of all newborns within 12 hours of life provides the best chance of preventing perinatal transmission of the virus according to the WHO.

• Hepatitis B is injected IM into the outer part of the thigh at a dose of 0.5 ml. the vaccine is 05% efficient in preventing chronic infection and is 90% effective in preventing perinatal transmission of the if the 1st dose is given with 24 hours of birth followed by the 2nd and 3rd doses at 6 and 14 weeks in that order or at least 4 weeks apart from each dose.

• Bacillus Calmette-Guerin (BCG) is given single dose at 0.5 ml injected intradermally using a sterile tuberculin syringe and needle. The sites of injection are the upper arm just below the deltoid or in the upper outer buttock. BCG can be given practically to all newborns. If a baby is sick, or if the mother has active TB and has been receiving less than two months of treatment, defer BCG. If not given at birth, BCG may be given anytime after when the baby is well.

WHO recommends that four doses of OPV be given routinely before the age of 1 year:

• OPV0, at birth or within 14 days of birth• OPV1, at 6 weeks• OPV2, at 10 weeks• OPV3, at 14 weeks of age

If dose OPV0 has not been given within 14 days of birth, it should be skipped and immunization starts at 6 weeks old or at dose OPV1

About 2 gtts of OPV is given through the mouth. There are no contraindications but giving the vaccine may be deferred if the infant has diarrhea or you can give an extra dose after four weeks. Reactions are unusual.

Key elements of postpartum care

6 – 12 hours

Baby

•Breathing•Warmth•Feeding•Cord•immunization

Emergencies in the newborn and three delays

Many newborn deaths occur at home, often after childbirth. The most important causes of newborn deaths are infections, birth asphyxia, prematurity and congenital birth defects. Just like the mother, the newborn can also die because of three delays that prevent their timely access to emergency care.

• Delay in seeking care. The woman and the family do not know the danger signs in the newborn that need urgent referral to the hospital or doctor.

• Delay in reaching care. There is lack of money to pay for transportation and not knowing where quality newborn care is available. These are two reasons that may prevent timely access of the newborn with a life threatening health problem or complication to the hospital,

• Delay in receiving care. The hospital may lack trained personnel to attend to newborn having complications. There is also the common complaint of lack of supplies and equipments needed during emergencies. Some overworked hospital staff may not be courteous in dealing with the referring midwife or even with the family of the newborn. Sadly, many babies experience these realities especially in hospitals with limited resources

• Functional closure occurs with 15 minutes to 12 hours after birth; fibrosis within 3 weeks

• The ductus arteriosus eventually occludes and becomes a ligament

- Clamping and severing of the umbilical cord immediately closes the umbilical vein, arteries, and ductus venosus (fibrosis occurs within 3 to 7 day, and the structures eventually convert into ligaments.

Neonatal Physical

Examination

Vital signs• Respiration. Irregular in depth, rate and rhythm,

gentle, quiet, rapid but shallow; normally is 30 – 60 bpm; is largely diaphragmatic and abdominal.

• Pulse. Normally irregular and is 120 – 140 or 150 bpm.

• Apical pulse is recommended since the radial pulse is normally not palpable.

Monitor apical pulse & RR every 4 H & then once every shift

• Blood pressure. Characteristically low and not routinely measured unless Coarctation of the Aorta is suspected. The average BP at birth is 60 – 80/10 – 45 mmHg; after 10 days becomes 100/50 mmHg

head• The neonate’s head is about ¼ of body size,

appearing disproportionate to the rest of the neonate’s body

• The forehead is large and highly prominent• The chin appears somewhat receding• The neonate’s head may appear misshapen and

asymmetrical • Molding refers to asymmetry of the skull from

overriding of cranial sutures during labor and delivery

- This occurs as the presenting part of the fetal head, usually the vertex, adjusts to fit the shape of the birth canal

- Normal shape usually is restored in several days

• Cephalhematoma is the collection of blood between a flat skull bone and the periosteum that doesn’t cross the suture lines

- This usually occurs about 24 hours after birth

- Area appears egg-shaped- It may take 2-3 or several weeks to

resolve

• Caput succedaneum is localized swelling over the presenting part that can cross suture lines, usually resolves in about 3-5 days

for both caput succedaneum and cephalhematoma, the single nursing care is the provision of psychological support to the parents who are likely fearful; of brain injury. Reassure that these head injuries do not cause brain damage and mental retardation

FONTANELS• The diamond-shaped anterior fontanel is

located at the juncture of the frontal and parietal bones

- It measures 1 1/8” to 1 5/8” (3 to 4 cm) long and ¾” to 1 1/8” (2 to 3 cm) wide

- It closes in about 18 months- The largest fontanel and is also called the

bregma• The triangular-shaped posterior fontanel is

located at the juncture of the occipital and parietal bones

- It measures about 0.5 to 1 cm across- It closes in about 8 to 12 weeks

• The fontanels should be flat and feel soft to touch

- A depressed fontanel indicates dehydration

- A bulging fontanel requires immediate attention because it may indicate increased intracranial pressure

eyes• Lid a re puffy but disappears

spontaneously in 1 -2 weeks time• The neonate’s eyes are usually blue or

gray because of scleral thinness• Permanent eye color is established in 3 to

12 months• Lacrimal glands are immature at birth,

resulting in tearless crying for up to 2 months

• The neonate may demonstrate transient strabismus

• Doll’s eye phenomenon may persist for about 10 days

• Subconjuctival hemorrhages may appear from vascular tension change during birth

• The red reflex is present• The neonate may fix on objects and

follow to the midline

nose• Infants are nose breathers for the first

few months of life• Nasal passages must be kept clear to

ensure adequate respirations• Neonates instinctively sneeze to remove

obstruction• Appears large for the face; with no septal

defect

mouth

• Epstein’s pearls may be found on the gums or hard palate

• The neonate usually has scant saliva and pink lips

• Precocious teeth may appear• An intact palate with a midline uvula is normal• The neonate’s tongue appears large and is

prominent- The frenulum of the tongue in neonates

should appear normal

- In some neonates, the frenulum is attached hear the tip of the tongue – restricts tongue mobility called Ankyloglossia/tongue-tied

• Sucking, rooting, and gag reflexes are present

• Should open evenly when crying, if not, suspect cranial nerve injury

ears• The neonate’s ears are characterized by

incurving of the pinna and cartilage deposition- The pinna of the external ear bends easily due

to to incomplete formation- Recoil of the pinna after bending is

characteristic in term neonates• The top of the ear should be above or parallel

to an imaginary line from the inner to outer canthus of the eye

• Low-set ears are associated with several syndromes, including chromosomal abnormalities such as trisomy 18 and trisomy 13

• The neonate typically responds to loud noises with the startle reflex

• Examination of the tympanic membrane is avoided due to difficulty in visualizing the eardrum and landmarks from accumulated amniotic fluid and vernix

neck• The neonate’s neck is typically short and

weak- The neonate’s neck cant support his head- The head should be able to rotate freely- Some lifting of the head is possible when in

the prone position- When pulled to a sitting position, head lag is

noticeable• It has deep skin folds without any webbing• Stork beak marks or telangiectatic nevi may

be noted on the back of the neck• Neonates typically deminstrate tonic neck

reflex at about 1 week of age

chest• Cylindrical thorax and flexible ribs are

characteristic at birth• Measurement of diameter of front to back

is equal to hat for side to side• Breast engorgement may occur from

maternal hormones• May secrete a substance similar to

colostrum called “witch’s milk”• Extra nipples (supernumery) may be

located below and medially to the true nipples

• Bilateral clear breath sounds typically are present

• The apex of the heart or point of maximal impulse is located at the 3rd or 4th ICS

• Xiphoid process may appear prominent

abdomen• The abdomen is usually cylindrical with

some protrusion• A scaphoid appearance indicates

diaphragmatic hernia• Bowel sounds are present about 1 hour

after birth• The liver border is located 1 to 3 cm

below the right costal margin• Kidneys are palpable 1 to 2 cm above and

on both sides of the umbilicus

• Meconium – first stool which is sticky, tarlike, blackish- green, odorless material formed from mucus, vernix, lanugo, hormones & carbohydrates that were accumulated while in utero.

• Transitional stool – 2nd to 4th day stool; slimy green and loose

• Breastfed stool- golden yellow, mushy, more frequent & sweet-smelling because of LACTIC ACID content which reduces the amount of putrefactive microbes.

• Bottlefed stool – pale-yellow, firm, less frequent and with more noticeable odor; neutral to slightly alkaline

Umbilical cord

• The cord is white and gelatinous with 2 arteries and 1 vein

• It begins to dry within 1 to 2 hours after delivery

• Bleeding at the cord site should be absent

• Base of the cord appears dry

genitals

• In males, rugae on the scrotum- Testes are descended into the scrotum- Urinary meatus is located at the penile tip

(normal), on the dorsal surface (epispadias), or on the ventral surface (hypospadias)

- Foreskin is adhered to the glans- Penis is about 2 cm long- Cremasteric reflex is present

Circumcision Care:Observe a& record the first voidance after

circumcisionApply a thin layer of petroleum gauze to the site to

control bleeding & prevent the diaper from adhering the penis

Wash the penis gently with water and apply fresh petroleum gauze to the glans with each diaper change

Apply gentle pressure with a sterile 4” x 4” gauze pad if bleeding occurs; notify the physician if bleeding continues

Teach parents to keep the area clean and covered with petroleum gauze if appropriate for about 3 days and to report any redness or tenderness

• In females, labia majora cover the labia minora and clitoris

- Vulva may appear edematous (from maternal hormones)

- Muscuslike, possibly blood-tinged vaginal discharge may be noted; this is called pseudomenstruation/withdrawal bleeding; it results from maternal hormones

- Hymenal tag is present- Urinary meatus is located below the

clitoris

extremities• All neonates are bowlegged and have flat feet• Sole creases cover the anterior 2/3 of the foot• The neonate may have abnormal extremities- Polydactyl – more than five digits on an

extremity- Syndactyl – fusing together of two or more

digits• Extremities should move symmetrically with

full range of motion

• Peripheral pulses are present and equal

• Nail beds are pink with a capillary refill time of less than 3 seconds

• Acrocyanosis may be present during the first 12 to 24 hours after birth

• Hip abduction should be smooth without clicks, with legs abducting to the point that they are almost flat against the surface on which the neonate is lying

- Gluteal and thigh folds should be even- Ortholani’s and Barlow’s signs are negativePlace the neonate in supine position on a

bed or examination tableFlex the neonate’s knees to 90 degrees at

the hipApply pressure over the greater

trochanter area while abducting the hips; typically the hips should abduct to about 180 degrees, almost touching the surface of the bed or examination table

Listen for any sounds, normally this motion should produce no sound; evidence of a clicking sound denotes the femoral head hitting the acetabulum as it slips back into it; this sound is considered a positive Ortolani’s sign suggesting hip subluxation.

Then flex the neonate’s kneed and hips to 90 degrees

Apply pressure down and laterally while abducting the hips

Feel for any slipping of the femoral head out of the hip socket; evidence of slipping denotes positive Barlow’s sign suggesting hip instability and possible developmental dysplasia of the hip

back

• The spine should be straight and flat• Nevus pilosus at the base of the spine is

commonly associated with spina bifida• A pilonidal dimple may be present at the

base of the spine; if present, further evaluation is needed to determine the presence of a sinus and its dept

anus

• Normally patent• Absence of fissures

skin• The neonate may exhibit acrocyanosis resulting

from adjustments to extremities circulation- The neonate’s skin is pink for the first 24 to 48

hours- Jaundice or yellowing of the skin typically occurs at

48 to 72 hours in a full-term neonate• Milia are clogged sebaceous glands, usually on the

nose or chin • Lanugo is fine, downy hair found after 20 weeks’

gestation on the entire body except the palms and soles

• Vernix caseosa is a white cheesy protective coating composed of desquamated epithelial cells and sebum

• Erythema neonatorum toxicum is a transient, maculopapular rash

• Telengiectasia (flat, reddened vascular areas) may appear on the neck, upper eyelid, or upper lip

• Port-wine stain (nevus flamneus), a capillary angioma located below the dermis and commonly found on the face, is a flat, sharply demarcated purple-red birthmark

• Strawberry mark (nevus vasculosus), a capillary angioma located in the dermal and subdermal skin layers, is a rough, raised, red, sharply demarcated birthmark; continue to enlarge until 1 year, then shrinks in size or absorbed. Total absorption is at 10 years.

• Cavarnous hemangioma – resembles strawberry mark but does not disappear.

• Mongolian spots are bluish black marks resembling bruises that appear on the sacrum, buttocks, back, and other areas; disappears after the first few year of life

• Marks from labor and delivery may be noted- Bruises may possibly occur from the use of

vacuum extractor- Petechiae are small hemorrhagic spots that

may develop due to pressure during the birth process

- Small puncture mark may be seen due to use of internal fetal scalp electrode

- Forceps marks over the cheeks and ears may occur from the use of forceps

reflexes• Sucking – anything placed between the lips will be

sucked; present even before birth and disappears at 6 months; sucking motion begins when a nipple is placed in the neonate’s mouth;

• Swallowing – fluid is placed on the back of the tongue and the neonate swallows; it should be coordinated with the sucking reflex; permanent but modified by experience

• Moro’s reflex – when the neonate is lifted above the bassinet and then suddenly lowered, the arms and legs symmetrically extend, then abduct; thumb and forefinger spread, forming a C

• Rooting – stroking the cheek makes the neonate turn his head in the direction of the stroke

• Tonic neck (fencing position) – when the neonate is in a supine position and his head is turned to one side, extremities on the same side straighten, whereas those on the opposite side flex

• Babinski’s reflex – stroking the lateral sole on the side of the small toe toward and across the ball of the foot makes the toes fan upward

• Palmar grasp – placing a finger in each hand makes the neonate grasp the fingers tightly enough to be pulled to a sitting position

• Stepping – holding the neonate upright with the feet touching a flat surface elicits dancing or stepping movements

• Startle – aloud noise, such as a hand clap, elicits arm abduction and elbow flexion; the hands stay clenched

• Trunk incurvature – when a finger is run down the neonate’s back, laterally to the spine, the trunk flexes and the pelvis swings toward the stimulated side

• Plantar grasp – examiner’s finger touching an area below the toes causes the toes to curl over the examiner’s finger (similar to palmar grasp)

• Gagging reflex – at stimulation of the uvula, the esophagus opens and reverse peristalsis occurs; present at birth and the duration is lifelong

• Extrusion/spitting-up reflex – anything that touches the posterior tongue is extruded/spitted-out; protects infants from swallowing inedible substances; disappears by 4 months.

SENSORY ASSESSMEN

T

Tactile behaviors

• Sensations of pressure, pain, and touch are present at birth or soon after

• Lips are hypersensitive• Skin on thighs, forearms, and trunk is

hyposensitive• The neonate is especially sensitive to

being cuddled and touched

Olfactory behaviors

• The neonate can differentiate pleasant from unpleasant odors after mucus and amniotic fluid have been cleared from nasal passages

• The neonate can distinguish the mother’s wet breast pad from those of other mothers at age 1 week

Vision behaviors

• The neonate can see 7” to 12” (17.5 to 30.5 cm) at birth

• Eyes have immature muscle control and coordination

• Eyes are sensitive to light• The neonate prefers complex patterns

in black and white because retinal cones aren’t fully developed at birth

Auditory behaviors

• The neonate can detect sounds at birth

• The neonate will turn his head to familiar voices

Taste behaviors

• Taste buds develop before birth• The neonate prefers sweet tastes to

bitter or sour ones• Ability to distinguish between

different tastes is present by 3 days of age

BEHAVIORAL ASSESSMEN

T

Period of reactivity• It lasts about 30 minutes after birth• The neonate is awake and active• The neonate may demonstrate searching

activities and sucking reflex• Respiratory rate and heart rate increase• Excessive respiratory secretions may be

present• Acrocyanosis is present• The neonate vigorously responds to

stimulation• Its an ideal time to initiate parental-infant

bonding and breast-feeding

Resting period

• It lasts several minutes to 2 to 4 hours• Pulse rate and respiratory rate slow,

returning to baseline• Color appears to be stabilizing• The neonate may sleep for approximately

1 ½ hours and be difficult to arouse

Second period of reactivity

• It lasts 4 to 6 hours• Pulse rate and respiratory rate

increase again• Color changes occur quickly when

crying or moving around• Mouth typically filled with mucus,

causing gagging• Meconium stool may be passed

Adaptation to

Extrauterine Life

Cardiovascular System• The first breath expands the neonate’s lungs,

decreasing pulmonary vascular resistance• Clamping the cord increases systemic

vascular resistance and left atrial pressure• Major changes occur as the neonate adapts

to extrauterine life- Changing atrial pressures functionally close

the foramen ovale almost immediatelynafter birth (fibrosis may take from several weeks to a year)

- Increasing partial presure of oxygen (PO2) constricts the ductus arteriosus

– Functional closure occurs within 15 minutes to 12 hours after birth; fibrosis within 3 weeks

– The ductus arteriosus eventually occludes and becomes a ligament

• Clamping and severing of the umbilical cord immediately closes the umbilical vein, arteries, and ductus venosus (fibrosis occurs within 3 to 7 days, and the structures eventually convert into ligaments)

Respiratory System• The initial breath is a reflex triggered in response

to chilling, noise, light, or pressure changes• Air replaces the fluid that filled the lungs before

birth- Between 7 and 42 ml of amniotic fluid is

squeezed or drained from the lungs during vaginal delivery; other lung fluid crosses the alveolar membrane into the capillaries

- Fluid retention greatly impedes normal respiratory adjustment

• Surfactant maintains respiratory stability by lowering surface tension in the alveolus at the end of expiration, thus preventing collapse

Renal System• Because renal function doesn’t fully

mature until after the first year of life, the neonate has a minimal range of chemical balance and safety

• Low ability to excrete drugs and excessive fluid loss can rapidly lead to acidosis and fluid imbalances

Gastro-Intestinal System

• Neonates born beyond 32 to 34 weeks’ gestation have adequate sucking and swallowing coordination

• Bacteria aren’t normally present in the neonates’s GIT

• Bowel sounds can be heard 1 hour after birth

• Uncoordinated peristaltic activity in the esophagus exists for the first few days of life

• The neonate has a limited ability to digest fats because amylase and lipase are absent at birth

• The lower intestine contains meconium at birth; the first meconium (sterile, greenish black, & vicous) usually passes within 24 hours – failure to pass meconium in the first 24-48 hours suggests possible meconium ileus, imperforate anus, or bowel obstruction

Thermogenesis

• Temperature regulation is immature in a neonate because of a large body surface to the body mass and the inability to generate heat from shivering

- It is difficult for the neonate to conserve body heat because he has only a thin layer of subcutaneous fat

- Blood vessels are closer to the surface of the skin

- Vasomotor control is less developed- Sweat glands have little thermogenic function

until the fourth week or later of life

• The principal source of thermogenesis are the heart, liver, and brain. Additional source unique to neonates is the brown fat or brown adipose tissue which is metabolized leading to lipolysis & fatty acid oxidation causing heat production which is released to the perfusing blood

• Rapid heat loss may occur in a suboptimal thermal environment by way of conduction, convection, radiation, or evaporation

• Conduction involves heat loss to cold surface with which the neonate is in contact

• Convection involves heat loss to the air that’s cooler than the neonate’s temperature

• Radiation involves heat loss to solid objects that are near the neonate but not contacting the neonate

• Evaporation involves heat loss through vaporization of liquid on the neonate’s skin

Immune System

• The neonatal immune system depends largely on three immunoglobulins: IgG, IgM, and IgA.

• IgG a placentally transferred Ig, provides the neonate with antibodies to bacterial and viral agents

- Can be detected in the fetus at the third month of gestation

- The infant first synthesizes its own IgG during the first 3 months of life, thus compensating for concurrent catabolism of maternal antibodies

• The fetus synthesizes IgM by the 20th week gestation

- IgM doesn’t cross the placenta- High levels of IgM in the neonate indicate a

nonspecific intrauterine infection• IgA is not detectable at birth; it doesn’t cross the

placenta- Secretory IgA is found in colostrum and breast milk- IgA limits bacterial growth in the GIT• The neonate has fragile defenses against infection- The neonate’s skin is fragile, thin, and easily

broken allowing for easy entry of microorganisms- The neonate’s immune response is limited to

localized infections, thus spread of microorganisms is rapid

Hematopoietic System• The blood volume of the full-term neonate is 80

to 110 ml/kg of body weight, averaging about 300 ml

• The amount of blood bound to hemoglobin is less in a neonate than in a fetus

• The partial pressure of oxygen in the blood is less in a neonate than in a fetus

• Neonates are born with high erythrocyte counts secondary to the effects of fetal circulation and the need to ensure adequate oxygenation

• Levels of vitamin K in the neonate are lower than normal leading to an increase in coagulation time

Neurologic System• General neurologic function is evident by

the neonate’s movements• These movements are uncoordinated and

poorly controlled indicating the immaturity of the neurologic system

• The neonate demonstrate primitive reflexes, which disappear during the infancy period, being replaced by purposeful activity

• The full-term neonate’s neurologic system should produce equal strength and symmetry in responses & reflexes

• Diminished or absent reflexes may indicate a serious neurologic problem, and asymmetrical responses may indicate trauma during birth, including nerve damage, paralysis, and fracture

• Neurologic development follows a cephalocaudal, proximodistal pattern

Hepatic System

• The liver continues to play a role in blood formation

• Jaundice is a major concern in the neonatal hepatic system because of increased serum levels of unconjugated bilirubin from increased red blood cell lysis, altered bilirubin conjugation, or increased bilirubin reabsorption from the GIT

• Physiologic jaundice (icterus neonatorum) develops in about 50% of the full-term neonates and 80% of preterm neonates

- The icteric color (yellow) isn’t apparent until the bilirubin levels are between 4 and 6 mg/dl

- Unconjugated bilirubin levels seldom exceed 12 mg/dl; peak levels occur by 3 to 5 days after delivery (full-term) and 5 to 6 days (preterm)

• Physiologic jaundice appears after the first 24 hours of extrauterine life

• Pathologic jaundice is evident at birth or within the first 24 hours of extrauterine life

• Breast milk jaundice appears after the first week of extrauterine life when physiologic jaundice is declining

- Peak level is 15 to 25 mg/dl- Between 1% to 2% of breast-feeding

neonates are affected- The exact cause is unknown; current

theories revolve around increased intestinal absorption of bilirubin from beta-glucoronidase

• Breast-feeding-associated jaundice appears 2 to 3 days after birth in about 10% of breast-fed neonates

- Peak level is 9 to 19 mg/dl- Poor caloric intake leads to decreased

hepatic transport and bilirubin clearance• Management of jaundice includes

monitoring serum bilirubin levels, maintaining hydration, using bilirubin lights as needed, and providing emotional support to the parents