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NEWBORN CARE

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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 newborns impact on the family unit.

3. The first few hours after birth represent a critical period ofadjustment for the newborn. In most setting, the nurse providesdirect 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 plansaccording to ongoing findings.

5. The nurse must be skillful in balancing the familys need forprivacy and time to interact without interruptions with the need to

closely monitor the newborns transition to extrauterine life.

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B. GOALS OF NEWBORN CARE

1. For the initial postpartal period

a. 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.

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2. For continuing care

a. Continue to protect from injury or infection and

identify actual or potential problems that couldrequire 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.

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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. Newborns physiologic capacity to make the transition toextrauterine life.

4. Ability of health care providers to assess and respond

appropriately in the event of potential problems.

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D. NURSING RESPONSIBILITIES

1. Support the neonates physiologic adaptation to

extrauterine life

2. Prevent or minimize potential complications

3. Facilitate parent-infant interaction

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IMMEDIATE

NEWBORN CARE

After the birth of the infant, every effortshould 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.

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1. Establishment and maintenance of

patent airway

Right after the extension of the newborns 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

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Suction briefly to avoid suctioning needed

oxygen.

Preterm: less than 5 seconds per suction time

Full-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

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Test patency of the airway by occluding one

nostril at a timenewborns 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 intracranialpressure: vomiting; bulging/tensed fontanels;

abnormally enlarged head; increased BP;

decreased PR and RR; widening pulse

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RESUSCITATION MEASURE

Airway make sure that the mouth and

nasopharynx are free of secretions; removesecretions by suction, small finger, or gentlemilking of trachea

Breathing if neonate does not make effort tobreathe, start your mouth-to-mouthresuscitation. Pinch the nose and cover thebabys mouth entirely with your mouth, and

breath into him and notice the chest moveCirculation if there are no heart sounds, apply

index and middle fingers/thumb on the infants

mid-sternum and apply 1 inch downwardressure. Do 5 chest com ressions followed b

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* 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

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2. Maintenance of appropriate bodytemperature

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

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Use a thermoregulator, such as a radiant warmer,

or a temperature-controlled incubator to control

environmental temperature until the neonates

temperature stabilizesRadiant warmermaintains the neonates temp.

by radiation.

Incubatormaintains the neonates temp. byconduction and convection.

Make sure the warmer is set to the desired

temperatureWarm blankets, washcloths, or towels under a heat

source

Keep the neonate under the radiant warmer until

his tem erature remains stable

Th bd f th f th th b

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The warm abdomen of the of the mother ca bea good place to keep the newborn warmimmediately after birth.

The initial temperature of the newborn is takenper RECTUM to detect for IMPERFORATE

ANUS.

After the initial temperature taking, all othertemperature taking should be per AXILLA tominimize potential risk to traumatizing themucus membrane of the rectum; every 15-30

min. until it stabilizes and then every 4 hours toensure stability

Avoid exposing infant to drafts, wetness, and

direct or indirect contact with cold surface.

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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

D d f h

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3. Do immediate Assessment of theNewborn

APGAR SCORING- Is the standardized evaluation of the newborns

condition at birth done at:

1 min. after birth to determine the generalcondition; &

5 min. after to determine how well thenewborn is adjusting to extrauterine life.

- The scoring system is named after DR.VIRGINIA APGAR, an anesthesiologist, whostudied the observations in the newborn.

- The normal infant should have an APGAR of 7

APGAR SCORE CHART

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APGAR SCORE CHARTSIGN 0 1 2

COLOR

(Appearance)

Generalize

d pallor orbluish

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 inlimbs; some

flexion of ext.

Active flexion oflimbs; well flexed

extremities

BREATHING

(RespiratoryEffort)

None slow, irregular Regular, with cry

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O 3 = severely depressed with HR slow,

inaudible and reflex response are

depressed or absent. The baby is inserious danger and needs immediate

resuscitation.

4 6 = mildly to moderately depressedinfants; 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 sim l naso har n eal

COLOR M b bi b bl h th

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COLOR. Many babies may be blue when theyare delivered, but they usually regain color andbecome pink soon. If the newborn remains

bluish, the baby may not be breathing well, ormay be cold, or may have infection, or acongenital heart problem refer the newbornimmediately to the doctor .

HEART RATE. The heart rate of a newborn isbetween 120 to 160 beats every minute countthe 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 babywith his arms and legs loose has poor muscletone. A baby with poor/weak muscle tone may

BREATHING B bi h ft bi th

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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.

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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 upsidedown to make him cry.

Give oxygen inhalation if there is one

available.

Refer immediately.

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- -respiratory distress or is a useful tool in the

evaluation of status of the newborns

respiration to determine degree of respiratorydistress syndrome (RDS).

signs 0No difficulty

1

Moderate

difficulty

2

Maximum

difficulty

Upper

chest

movement

Synchron

ized

breathing

Chest lag See-saw

breathing

Lower

chest

movement

No

retraction

s

minimal Marked

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signs 0No difficulty

1Moderate difficulty

2Maximum difficulty

Xiphoid

process

retractions

No

retractions

minimal Marked

Nasal

flaring

No flaring Just visible Marked

Expiratorygrunting

Quietbreathing

Expiratorygrunts on

auscultation

Grunting onbare ears

n a assessmen an ac on o e

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n a assessmen an ac on o etaken:

Initial assessment Action

PinkHR > 120 bpm

Breathing regularly

Dry and wrap babyBaby stays with mother

Blue

HR >100 bpm

Breathing inadequate

Dry and wrap

Clear the airway

Blue or pale

HR

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Assessment of gestational age NAGELES RULE calculation of EDC using

the mothers LMP; count back 3 mos. from thefirst day of LMP and add 7 days.

McDONALDS METHOD determines age ofgestation by measuring the fundic height

(fundus to symphysis) in cm. , then divide by 4= AOG in months.

BARTHILOMEWS RULE estimates AOG by

the relative position of the uterus in theabdominal cavity.

3rd lunar month fundus is slightly above thesymphysis pubis.

5th lunar month fundus is at the level of the

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Time quickening is first felt.

Ultrasound

Assessment of the newborn at birth

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Rapid estimation of the gestational age

of the newbornsign 36 weeks or

less

37 -38

weeks

39 weeks

or more

Solecreases

Anteriortransverse

occasional Solecovered

with crease

Scalp

hair

Fine and

fuzzy

Fine and

fuzzy

Coarse and

silky

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sign 36 weeks or

less

37 -38

weeks

39 weeks or

more

Breastnodule

diameter

2mm 4 mm 7 mm

Earlobe flexible With somecartilage

Withcartilage

Testes

andscrotum

Testes in lower

canal; scrotumsmall with few

rugae

intermediate Testes

pendulous;scrotum full

with

extensive

ru ae

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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 thegreatest reliability is at 30 and 42 hours

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- Cephalometry measurement of the diameters

of the skull.

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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.

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

normal fullterm newborns to primarily cleansethe skin and prevent infection; is given oncevital 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 newborndirectly under cold, running water of the faucetand briskly bathes him) subjects newborn tocold stress.

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Wash, rinse, and dry each portion of the bodyseparately to minimize heat loss

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

- Clean the diaper area last

Give sponge bath until the umbilical cord fallsoff, usually within 10 to 14 days

Use a mild, hexachlorophene-free soap

Dont use soap on infants face Bathe before feedings instead of afterward to

prevent vomiting

Apply alcohol, if ordered, to the base of the

6 Gi C d P h l i

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6. Give Credes Prophylaxis Given to all newborns as a prevention against

OPHTHALMIANEONATORUM/GONORRHEALCONJUNCTIVITIS caused by Neisseriagonorrhea causes blindness as baby may

acquire it as he passes through the birth canalof an infected/untreated mother.

Can be delayed for 1 to 2 hours not tointerfere with the bonding process.

NOW: Apply tetracycline ophthalmic ointment toeach eye, from the inner canthus to the outercanthus.

1 -2 cm ribbon of 0.5% ERYTHROMYCIN

7 Perform Cord Dressing

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

prevent TETANUS NEONATORUM caused byClostridium 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 Whartons jelly

protects vessels from being twisted or

compressed.

Leave about 1 inch of the cord from the base

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signs: smelly discharge on the surface ofthe umbilical stump; the umbilical stump

remains wet and soft; there is rednessaround the base of the umbilicus

Apply 70% isopropyl alcohol to theumbilical cord stump 3 4 times daily willkeep it dry & clean, & help in making it falloff early.

Umbilical cord stumps usually fall off in 710 days.

In the first 24 hours, inspect cord forOMPHALANGIA (- bleeding of the cord).

Place dia er below the umbilicus to revent

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8. Inject Vitamin Kintramuscularly.

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 braindamage or even death.

Newborns GIT is initially sterile no E. coli to

synthesize the vitamin.

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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 VASTUSLATERALIS.

9 N t t Rh( )/T O

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9. Neonates to Rh(-)/Type Omothers, should have blood specimen

for: Blood type

Bilirubin level

Direct Coombs test. An abnormal result

indicates presence of maternal antibodies in the

neonates blood, suggesting blood

incompatibility

Reticulocyte count. Increased count indicates

the bodys response to RBC destruction

Hematocrit. Decreased result su ests anemia

Neonates weighing less than 2 500 g or more

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Neonates weighing less than 2,500 g or morethan 4,000 g should undergo blood glucosescreening 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 bodyweight of formula

- Blood glucose level is checked 1 hour afterfeeding

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

The neonate is assessed for signs of

10 Take the weight and other

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10. Take the weight and otherAnthropometric Measurements

Size and weight measurements establish thebaseline for monitoring normal growth. Whenobtaining these measurements, place theneonate 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 afterthe 10th day.

Perinatal mortalit and morbidit are related to

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HEIGHT. Normal height rangers from 18

to 21 inches (46-53 cm), or an average of

50 cm.; taken by heel-to-crownmeasurement; fully extend the neonates

legs with the toes pointing up.

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

* Slide a tape measure under the neonates

head at the occiput and draw the tapearound snugly, just above the eyebrows.

CHEST/ABDOMINAL CIRCUMFERENCE

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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 neonateinspires 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

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11. Advise the mother to frequentlyobserve 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

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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

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12.Start immunization with hepatitis Bvaccine and BCG as recommended

Routine Hepatitis B immunization of allnewborns within 12 hours of life provides thebest chance of preventing perinataltransmission of the virus according to the WHO.

Hepatitis B is injected IM into the outer part ofthe thigh at a dose of 0.5 ml. the vaccine is 05%

efficient in preventing chronic infection and is90% effective in preventing perinataltransmission of the if the 1st dose is given with24 hours of birth followed by the 2nd and 3rddoses at 6 and 14 weeks in that order or at

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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 deltoidor in the upper outer buttock. BCG can

be given practically to all newborns. If a

baby is sick, or if the mother has activeTB and has been receiving less than two

months of treatment, defer BCG. If not

given at birth, BCG may be given

WHO recommends that four doses of OPV be

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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 daysof birth, it should be skipped and immunizationstarts at 6 weeks old or at dose OPV1

About 2 gtts of OPV is given through the mouth.There are no contraindications but giving thevaccine may be deferred if the infant hasdiarrhea or you can give an extra dose after