To establish, maintain and support respirations.

To provide warmth and prevent hypothermia.

To ensure safety, prevent injury and infection.

To identify actual or potential problems that may require immediate attention.

Establish respiration and maintain clear airway - The most important need for the newborn immediately after birth is a clear airway to enable the newborn to breathe effectively

To establish and maintain respirations

1.Wipe mouth and nose of secretions after delivery of the head2. Suction secretions from mouth and nose3. A crying infant is a breathing infant. Stimulate the baby to cry if baby does not cry spontaneously, or if the cry is weak.

4. Oral mucous may cause the newborn, to choke, cough or gag during the first 12 to 18 hours of life. Place the infant in a position that would promote drainage of secretions

5. Keep the nares patent. Remove mucus and other particles that may be cause obstruction

Care of the EyesNeisseria gonorrhea- the causative agent for gonorrhea conjunctivitis or opthalmia neonatorum, may be passed on the fetus from the vaginal canal during delivery.

Drug of choice:Erythromycin or tetracycline Opthalmic Ointment

This procedure is required by law in all states as prophylaxis against gonorrhea. The medications used are as follows:

a.Erythromycin Ophthalmic Ointment. This has become the drug of choice and is received in a sterile syringe from the pharmacy. It is injected into each eye from the inner to outer canthus immediately after birth (see figure 8-10). It does not appear to cause much eye irritation.

b.1% Silver Nitrate Solution. Two drops are applied in each eye in the conjunctival sac, not the cornea. The infant eyes may or may not be irrigated after instillation, depending on local policy. The infant may get profuse discharge and chemical conjunctivitis for a few days with no residual damage.One percent silver nitrate solution is no longer recommended for use.

Care of the cord

Report any unusual signs and symptoms which indicates infection.

- Foul odor in the cord- Presence of discharges- Redness around the cord- The cord remains wet and does not fall off within 7 to 10 days- Newborn fever

CORD CARE FOR THE NEWBORN INFANTa. Inspect the cord frequently for signs of bleeding immediately after it has been cut.b. Apply triple dye (refer to local policy) to the cord after the infant has had his bath and has been determined to be stable. The dye prevents infection and helps the cord to dry.c. Swab the cord with alcohol at least three times per day (refer to local policy). The alcohol aids in drying.d. Observe for cord detachment. The cord detaches in ten to fourteen days. The cord dries faster when left uncovered. Have the parents roll the infant's diaper down some in front initially so the cord is not covered.e. Observe for signs of infection and report findings immediately. The signs of infection are purulent drainage, redness, and possible swelling (more than usual).

Bactericidal substance

Antibiotic substance

3. Alcohol (70%)

4. Cleansed with mild soap solution

5. Air dry

APGAR SCORING SYSTEM

-it was developed by Dr. Virginia Apgar -it is a quick method of assessing the newborn's adjustment to extrauterine life and general condition.

- HR 160 signifies distress. - should take 1-5 minutes after birth Factors that affect the APGAR score are: 1. Degree of physiologic maturity 2. Fetal cardiorespiratory and neurologic conditions 3. maternal perinatal therapy such as use of analgesia during labor

a.Purpose. The APGAR scoring chart is used to evaluate the conditions of the baby at birth, determine the need for resuscitation, evaluate the effectiveness of resuscitative efforts, and to identify neonates at risk for morbidity and mortality.

b.Objective Signs Used for Evaluation.(1) Heart rate.(2) Respiratory effort.(3) Muscle tone.(4) Reflex irritability.(5) Color.

c.Scoring

Evaluations at each of the five categories are initially done at one minute after birth.Each item has a maximum score of two and a minimum score of zero.The final APGAR score is the sum total of the five items, with a maximum score of ten. The higher the final APGAR score, the better condition of the infant.Evaluations at one minute quickly indicate the neonate's initial adaptation to extrauterine life and whether or not resuscitation is necessary.The five-minute score gives a more accurate picture of the neonate's overall status, including obvious neurologic impairment or impending death.

SCORE INTERPRETATION NORMAL: 7-10 Good adjustment; vigorous; No intervention required IMMEDIATE: 4-6 Moderately depressed infant; newborns condition is guarded and may need airway clearance and supplementary oxygen LOW- 0-3 Severely depressed infant; newborn is in serious danger and id need of resuscitation.

ASSESSING THE AVERAGE NEWBORN

Head Circumference 34 35 cm Temperature36.5 C 37.5 CChest Circumference32 33 cmHeart Rate120 140 bpmRespirations30 60 bpmWeight2.5 to 3.4 kgLength46 to 54 cm

Place the infant in an open warmer for the remainder of the admission procedures to maintain adequate temperature.

Measure the infant

(a) Length (from top of head to the heel with the leg fully extended).(b) Head circumference - repeat after molding and caput succedaneum are resolved.(c) Chest circumference (at the nipple line).(d) Abdominal circumference.

(2) Record measurements in inches and centimeters.

(3) Document the information in the appropriate areas on, the delivery room record, and the instant data card.

(4) Take infant's vital signs and document on the delivery room record.(a) Temperature-only the first one is done rectally, the remainder are axillary.(b) Heart rate and respirations-count a full minute because of the irregularities in rhythm.

Crowning ready for suction

2. Expulsion of head wipe face and nose

Expulsion of newborn provide warmth, take note of time and sex of baby

Heat Loss Mechanisms

The ability of controlled dissipation and production of heat is a fundamental requirement for an organism to be homeothermic.

Heat loss is a two-step process that ultimately results in heat loss via: 1. radiation 39 % 2. convection 34 % 3. evaporation 24 % 4. conduction 3 %

Convection Convective heat loss is the transfer of heat from a body to moving molecules such as air or liquid

Evaporation Evaporative heat loss is the vaporization of water from the body or a mucosal surface, which uses the latent heat of vaporization of water as its source

Conduction Conduction refers to heat transfer between two surfaces that are in direct contact

Radiation Radiant heat loss refers to transfer of heat between two objects of different temperatures that are not in contact with each other (e.g., radiation is the mechanism by which the sun warms the earth)

The first step in the heat dissipation process is internal redistribution of heat, which refers to the transfer of heat from the body core (central compartment) to the periphery and the skin surface.

The second step in the process is the transfer of heat from the skin surface to the environment.

Measures to Prevent Heat Loss 1.Dry the newborns head and body immediately after heat loss from evaporation. 2. Wrap with dry and warm blanket before giving to the mother to hold. 3. Place newborn in a preheated environment such as radiant warmer or next to mother for about two hours after birth. 4. Perform any extensive examination or procedure under radiant heat to prevent heat loss. 5. Keep newborn away from air conditioning vents or fans that can promote heat loss 6. Maintain ambiant temperature of the delivery and nursery room. 7. Delay initial bath for atleast 2 hours or until temperature stabilized. 8. Warm all objects that will be used to examine or cover newborn by placing them first under radiant warmer.

WEIGHT

Varies depending on:

RaceNutritional statusIntrauterine factorGenetic factor

1st few days after birth

Diuresis

Voiding and passage of stool

4. Breastfed newborns

Remove blood, amniotic fluid, and excessive vernix caseosa as soon after birth as the temperature is stable

It decreases exposure to maternal blood and possible blood borne organism on the infants skin

e.g. Hep.B and HIV

Site: Vastus LateralisClassification: - fat soluble vitamin - anti-hemorrhagic agentAction: -promotes the formation of factors II,VII,IX,X by the liver for clotting factor, thus prevent bleeding- Provides Vit.K which is not synthesized in the intestine for the first 5 to 8 days after birth because the newborn lacks intestinal flora necessary for Vit.K production

Proper identification of the newborn and footprints must be taken and kept in the chart.Attach ID bracelet with a number that corresponds to the mothers hospital number, mothers full name, sex, date and time of birth.Inspect for the presence of 2 arteries and 1 vein.

AIRWAY

Respiratory rate assess respirations at least once every 30 mins. until stable for 2 hours after birth.

Observe for:Periodic breathingApnea

2. Breath sounds auscultate anterior and posterior lung fields for equal sounds which should be present equally throughout

Sounds of moisture in the lungs during the 1st hour or two after birth is NOT UNUSUAL because fetal lung fluid has not been completely absorbed.

SIGNS OF RESPIRATORY DISTRESS

1.Tachypnea respiratory rate above 60 bpm

2.Retractions due to infants weak chest wall muscles that are used to help draw air into the lungs

3. Flaring of Nares a reflexive widening of nostrils

4.Central cyanosis a purplish blue discoloration due to insufficient oxygen supply ( lips,tongue,mucous membrane and trunks )

Peripheral cyanosis (acrocyanosis) due to poor perfusion of blood to the periphery of the bodyBruising of face due to tight nuchal cord or pressure during birth and may look like central cyanosis

How to check for Cyanosis?

1. apply pressure to the area

2. use of pulse oximeter

3. Color of mucous membrane

5. Grunting a noise made on expiration when air crosses partially closed vocal cords

6. Seesaw respirations when the chest falls the abdomen rises and vice versa

7. Asymmetry decreased on one side of the lung may indicate a collapse of the lung ( atelectasis )

Blockage of one or both nasal passages by a narrowed bone or membrane that protrudes into the area

How to asses ?By closing the infants mouth and occluding one nostrils at a time and observe for breathing while each nostril is occludedPlacing a cold metal object under the nostrils and observe for foggingPassing a catheter (fr.5 or 8) thru each nostril to check for patency

Color Pallor indicates slight hypoxia or anemiaRuddy color ( plethora) an excessive number of RBC ( >65%)

Heart soundsAuscultate for rate, rhythm and presence of murmurs or abnormal sounds

Rhythm should be regular , the 1st and 2nd sounds should be heard clearly, abnormalities should be noted.

Murmurs abnormal sounds caused by abnormal blood flow through the heart and may indicate openings in the septum of the heart

- results from an incomplete transition from fetal to neonatal circulation

- is common until the ductus arteriosus functionally closed

Brachial and Femoral PulsesShould be present equally and bilaterally

Blood pressureTaken on all extremities if the infant has unequal pulses or other signs of cardiac complications

Method:Doppler UTZ

Average BP:Systolic 65 95 mmHgDiastolic 30 60 mmHg

Capillary Refill

Temperature should be assessed at least once every 30 minutes until the infant has been stable for 2 hours after birth

Method:Axillary Rectal

Types of Thermometer

Mercurial Digital Disposable Plastic StripsTympanic

A. HEAD & NECK

Head makes up one fourth of the length of the body and is much larger in proportion to the rest of the body - should be palpated to assess the shape and identify abnormalities

1.Molding caused by overriding of the cranial bones at the suture and is common especially a long second stage of labor - parietal bones often override the occipital and frontal bones and a ridge can be felt at the areas

Craniosynostosis - a hard ridged area that is not a result of molding due to premature closure of the cranial sutures before or shortly after birth which may impair brain growth and shape

a. Single Suture Synostosis Sagittal (SAJ-ut-ul)/ Scaphocephaly

- The sagittal suture is located on the midline, on top of the head and extends from the soft spot towards the back of the head. When the head is palpated, a ridge can be felt along the suture.

Preoperations at age 5 months7 months Post operation

2. Coronal(co-RO-nul)Suture Synostosis / Plagiocephaly- The coronal suture is located on the side of the head and extends from the soft spot to an area just in front of the ear. It allows the forehead and the frontal lobe to grow and expand forward.

3. Metopic (mih-TOP-ick) SutureSynostosis/ Trigonocephaly- This midline suture is located in the middle of the forehead and extends from the soft spot to the root of the nose. It allows both frontal lobes to expand forward and sideways as well as the eye socket to move to either side.

4. Lambdoidal (lam-DOID-ul) Suture Synostosis - Closure leads to posterior plagiocephalus (PLAY-gee-o-SEF-a-lee) with flattening of the back of the head on the affected side, protrusion of the mastoid bone and lowering of the affected ear. It may also cause the skull to tilt sideways.

2. Fontanels are areas of the head where sutures between the bones meet

2.1 Anterior - is a diamond shape area where the frontal and parietal bones met - Measures 2 to 4 cm - Closes between 12 to 18 months of age

2.2 PosteriorIs a triangular area where the occipital and parietal bones meet Measures 0.5 to 1cmCloses by the time the infant is 2 to 3 months

3. Caput succedaneumDue to the pressure against the mothers cervix and it interferes the blood flow in the area causing localized edema which crosses suture lines

4. CephalhematomaBleeding between the periosteum and the skull

Face assessed for:

- Symmetry - Positioning of facial features - Movement - Expression

Mouth assessed for:

cleft lip/palatePrecocious teethEpsteins pearl

Neck assess visually and note the ease with which the head turns from side to sidee.g. Turners syndrome

Turner syndromeorUllrich-Turner syndrome(also known as "Gonadal dysgenesis") encompasses several conditions, of whichmonosomyX (absence of an entire sex chromosome, theBarr body) is most common. It is achromosomal abnormalityin which all or part of one of thesex chromosomesis absent (unaffected humans have 46 chromosomes, of which two are sex chromosomes). Typical females have two X chromosomes, but in Turner syndrome, one of those sex chromosomes is missing or has other abnormalities. In some cases, the chromosome is missing in some cells but not others, a condition referred to asmosaicism[2]or 'Turner mosaicism'.

The syndrome manifests itself in a number of ways. Characteristic :physical abnormalities - short stature, swelling, - broad chest - low hairline - low set ears - webbed necks.[5]Girls with Turner syndrome typically experience gonadal dysfunction (non-workingovaries), which results inamenorrhea(absence of menstrual cycle) andsterility.

Concurrent health concerns are also frequently present, - congenital heart - hypothyroidism(reducedhormone secretion by thethyroid) - diabetes - visionproblems - hearingconcerns

Turner's syndrome is named afterHenry H. Turner.

Clavicle fracture are more likely to occur in large infantse.g. shoulder dystocia Shoulder dystociais a specific case ofdystociawhereby after the delivery of the head, the anteriorshoulderof theinfantcannot pass below thepubic symphysis, or requires significant manipulation to pass below thepubic symphysis. It is diagnosed when the shoulders fail to deliver shortly after the fetal head. In shoulder dystocia, it is the chin that presses against the walls of theperineum. Shoulder dystocia is an obstetrical emergency, and fetal demise can occur if the infant is not delivered, due to compression of theumbilical cordwithin the birth canal.

Fracture a lump or tenderness over the area

Method of Detecting:Moro Reflex a difference in the movement of the arm

Treatment :Immobilization of the affected part for a short time

C. Cord should contain three (3) vessels arteries (2) - are small and may stand up at the end cut vein - (1) - is larger than the arteries and resembles a slit

Thin cord the infant may have been poorly nourished in uteroYellow Brown or Green tinge cord - indicates that meconium was released sometime before birthPatent urachus abnormal connection between the umbilucus and bladderUmbilical cord hernia - "Paraumbilical Hernias" develop in and around the area of the umbilicus (belly button or navel). - A congenital weakness (meaning present since birth) exists in the naval area in the region where vessels of the fetal and infant umbilical cord exited through the muscle of the abdominal wall. After birth, although the umbilical cord disappears (leaving just the dimpled belly-button scar), the weakness or gap in the muscle may persist.

D. Extremities - normally a term infant should remain sharply flexed & resist extension during examination

Poor muscle tone results in a limp or floppy infant

Continued poor muscle tone may result from prematurity or neurologic changes

All extremities are examines for signs of fracture:

1.Crepitus2.Redness3. Lumps or swelling4. Lack of use /immobility

Erb-Duchenne paralysis- paralysis of the arm resulting from injury to the brachial plexus (usually during childbirth) - Instead of the usual flexed position, the affected arm is extended at the infants side with the forearm prone

Treatment: - exercise - splinting or both

Are examined for extra digits which are often small and may not have bones

Nails : - in term infants it should extend to the end of the fingers or slightly beyond

Creases :- normally, two long transverse creases extend most of the way across the palm

Polydactyly - is a condition in which a person has more than five fingers per hand or five toes per foot.

Syndactyly - is a condition where two or more digits are fused together. It occurs normally in somemammals, such as thesiamangand kangaroo, but is an unusual condition in humans.Syndactyly can be complete or incomplete.In complete syndactyly, the skin is joined all the way to the tip of the fingerIn incomplete syndactyly, the skin is only joined part of the distance to the fingertip.Syndactyly can be simple or complex.In simple syndactyly, adjacent fingers or toes are joined by soft tissue.In complex syndactyly, the bones of adjacent digits are fused. Thekangarooexhibits complex syndactyly.

Feet are assessed for club foot

Talipes equinovarus:The common ("classic") form of clubfoot. Talipes is made up of the Latin talus (ankle) + pes (foot). Equino- indicates the heel is elevated (like a horse's) and -varus indicates it is turned inward. With this type of clubfoot, the foot is turned in sharply and the person seems to be walking on their ankle.

Aclub foot, orcongenital talipes equinovarus(CTEV)is a congenital deformity involving one foot or both.The affected foot appears rotated internally at the ankle.

TEV is classified into 2 groups: 1. Postural TEV 2. Structural TEV

Are examined for signs of developmental dysplasia which occurs more often on breech presentation

Normally both legs should abduct equally in normal infants with click sound while in dysplasia is a clunk sound

Dysplasia instability of the hip joint which occurs at the head of the femur which can be moved in and out of the acetabulum

Methods of Assessing:

1. TheBarlow maneuveris a physical examination performed oninfantsto screen fordevelopmental dysplasia of the hip. - It is named for T.G. Barlow, 1962 at Hope Hospital Salford, Manchester

- The maneuver is easily performed byadductingthe hip (bringing the thigh towards the midline) while applying light pressure on the knee, directing the force posteriorly. If the hip is dislocatable - that is, if the hip can be popped out of socket with this maneuver - the test is considered positive. TheOrtolani maneuveris then used, to confirm the positive finding (i.e., that the hip actually dislocated).

2. TheOrtolani testorOrtolani maneuveris aphysical examinationfordevelopmental dysplasia of the hip.

It is performed by an examiner firstflexingthe hips and knees of a supine infant to 90 degrees, then with the examiner's index fingers placinganteriorpressure on thegreater trochanters, gently and smoothlyabductingthe infant's legs using the examiner's thumbs.

A positive sign is a distinctive 'clunk' which can be heard and felt as thefemoral headrelocates anteriorlyinto theacetabulum:

This is part of the standard infant exam performed preferably in early infancy; it usually becomes negative after 2 months of age.

It is named forMarino Ortolani, who developed it in 1937.[3

- palpate the entire length of the newborns vertebral column to discover any defects in the vertebrae.

Check for:

Spina bifida - (Latin: "split spine") is a developmentalcongenital disordercaused by the incomplete closing of theembryonicneural tube. Somevertebraeoverlying the spinal cord are not fully formed and remain unfused and open. If the opening is large enough, this allows a portion of the spinal cord to protrude through the opening in the bones. There may or may not be a fluid-filled sac surrounding the spinal cord.

Other neural tube defects:

1.anencephaly, a condition in which the portion of the neural tube which will become thecerebrumdoes not close,2.encephalocele, which results when other parts of the brain remain unfused.

Classification:

Spina bifida occulta

OccultaisLatinfor "hidden". This is the mildest forms of spina bifida.

In occulta, the outer part of some of the vertebrae are not completely closed.The split in the vertebrae is so small that the spinal cord does not protrude. The skin at the site of thelesionmay be normal, or it may have some hair growing from it; there may be a dimple in the skin, or a birthmark.

2. Spina bifida cystica In spina bifida cystica, a cyst protrudes through the defect in the vertebral arch. These conditions can be diagnosed in utero on the basis of elevated levels of alpha-fetoprotein, after amniocentesis, and by ultrasound imaging. Spina bifida cystica may result in hydrocephalus and neurological deficits.

3. MeningoceleThe least common form of spina bifida is a posteriormeningocele(ormeningeal cyst).

In aposterior meningocele, the vertebrae develop normally, however the meninges are forced into the gaps between the vertebrae. As the nervous system remains undamaged, individuals with meningocele are unlikely to suffer long-term health problems

A meningocele may also form through dehiscences in the base of skull. These may be classified by their localisation to occipital, frontoethmoidal, or nasal. Endonasal meningoceles lie at the roof of thenasal cavityand may be mistaken for anasal polyp. They are treated surgically.

Encephalomeningoceles are classified in the same way and also contain brain tissue.

4. MyelomeningoceleIn this, a serious and commonform, the unfused portion of the spinal column allows the spinal cord to protrude through an opening. The meningeal membranes that cover the spinal cord form a sac enclosing the spinal elements.

1.The protruding tissue should be covered with moist sterile saline dressing immediately after birth

2. Intravenous antibiotics are started to prevent meningitis.

3. An adhesive plastic surgical field drape taped over the buttocks deflects feces away from the back--"mud flap.

4. The most important words to say at the baby's birth are: "Congratulations on the birth of your child!" These words extend joy, optimism, reverence, respect, acceptance, and nonabandonment. This simple step facilitates parental interest, learning, and care provision.

Neurologic system

Reflexes - assessment of the presence and strength of the reflexes is important to determine the health of the newborns central nervous system

Moro reflex is the most dramatic reflex - startle reflex or infantile reflex - It may be observed in incomplete form inpremature birthafter the 28th week ofgestation, and is usually present in complete form by week 34 (3rd trimester) - It is normally present in all infants/newborns up to 4 or 5 months of age, and its absence indicates a profound disorder of the motor system

An absent or inadequate Moro response on one side is found in infants with :

hemiplegia,brachial plexus palsyfractured clavicle.

Persistence of the Moro response beyond 4 or 5 months of age is noted only in infants with severe neurological defects.

* It was discovered and first described by AustrianpediatricianErnst Moro(1874-1951).

The primary significance of thisreflexis evaluating integration of thecentral nervous system(CNS), and it involves 3 distinct components:

spreading out thearms(abduction) - the reflex is initiated by pulling the infant up from the floor and then releasing him; unspreading the arms (adduction) - spreads arms and pulls arms incrying(usually)

Palmar Grasp reflex - a flexion of the fingers caused by stimulation of the palm of the hand. The reflex is present at birth and usually disappears by 6 months of age.

Plantar Grasp reflex - a reflex characterized by the flexion of the toes when the sole of the foot is stroked gently. It is present in babies at birth but should disappear after 6 weeks.

Babinski reflex - is obtained by stimulating the external portion (the outside) of the sole. The examiner begins the stimulation back at the heel and goes forward to the base of the toes. - Most newborn babies are not neurologically mature and therefore show a Babinski response - A Babinski response in an older child or adult is abnormal. It is a sign of a problem in the(CNS), most likely in a part called the pyramidal tract.

Rooting reflex - A reflex in infants in which rubbing or scratching about the mouth causes the infant to turn its head toward the stimulus.

Ears

assessed for :1. Placement 2. Appearance3. Maturity

Signs of potential distress or deviations from expected findings:Ear placement lowClefts presentMalformationsCartilage absentPreauricular sinus

Expected findings:Slate gray or blue eye colorNo tearsFixation at times - with ability to follow objects to midlineRed reflexBlink reflexDistinct eyebrowsCornea bright and shinyPupils equal and reactive to light

DischargesOpaque lensesAbsence of Red Reflex/Bruckner reflexEpicanthal foldsReflexes absent"Doll's Eyes" Reflex(beyond 10 days of age): When the head is moved slowly to the right or left, the eyes do not follow nor adjust immediately to the position of the head. This reflex should not be elicited once fixation is present. The persistence of the Doll's Eyes Reflex suggests neurologic damage.

StaphylococcusChlamydia gram (-) bacteriaNeisseria gonorrhoea

A. Newborns with hypoglycemia

low levels of blood sugar in the first days following birthSugar levels in newborns may drop for a number of reasons:elevated insulin levels, decreased glycogen levels, low glucose production or overuse of glucose stores.

Signs:Irritability high pitched cryLethargySeizure / jitterinessSweating Poor suckingRespiratory distress : TachypneaDyspneaApnea7. Discoloration / Cyanosis8. Poor appetite9. Excessive drowsiness

Causes of Hypoglycemia:Maternal diabetesPrematurityInfection / IllnessIntrauterine growth retardation (IUGR)

Blood Sugar Level in Newbornsshould remain above 40 milligrams per deciliter, or mg/dL. Levels below 35 mg/dL indicate severe hypoglycemia levels under 50 mg/dL warrant close observation. A level between 54 and 72 mg/dL indicates a more normal newborn blood glucoseAt-risk infants need blood glucose monitoring within the first two hours after birth.

TreatmentIf the baby can eat and the blood glucose level is not too low, giving formula, sugar water or breastmilkwill raise blood glucose levels in most cases. Babies who can't eat or those with very low blood glucose levels need intravenous infusion of dextrose, a type of sugar, to raise their blood sugar. Infants receiving glucose infusions may develop temporary hyperglycemia, or blood glucose levels over 125 mg/dL, which usually requires no treatment,

Prevention

At-risk infants require blood glucose screening via heel stick or from blood drawn from a central umbilical line. The baby may need frequent blood tests in the first 12 hours after birth to ensure that levels don't drop. Hypoglycemia most often develops within the first 24 hours after birth,

B. Newborn JaundiceJaundice is a yellow discoloration of the skin and the white part (thesclera) of the eyes. It results from having too much of a substance calledbilirubinin the blood.Bilirubin is formed when the body breaks down oldred blood cells. Theliverusually processes and removes the bilirubin from the blood.Jaundice in babies usually occurs because their immature livers are not efficient at removing bilirubin from the bloodstream.

Causes:

Jaundice in newborns most commonly occurs because their livers are not mature enough to remove bilirubin from the blood. Jaundice may also be caused by a number of other medical conditions.

Physiologic jaundice is the most common form of newborn jaundiceNeonatal jaundice will be seen in cases of maternal-fetal blood type incompatibilityhemolysis

4. Polycythemia

5. Cephalohematoma

6. Sometimes a baby swallows blood during birth

7. A mother who hasdiabetes

8. Crigler-Najjar syndrome

9. Lucey-Driscoll syndrome

Carotenemia - A condition that causes a yellowish discoloration of the skin and tends to be a darker orange than seen with jaundice.Eating a lot of yellow vegetables causes this condition.Children with carotenemia have normal bilirubin levels.Unlike jaundice, carotenemia does not cause a discoloration of the white part of the eyes.This condition causes no harm and requires no treatment.

Symptoms:As a baby's bilirubin levels rise: jaundice moves from the head to include the arms, trunk, and finally the legs. bilirubin levels are very high : a baby will appear jaundiced below the knees and on the palms of his or her hands.

How to Assess?- One easy way to check for jaundice is to press a finger against your baby's skin, temporarily pushing the blood out of it. Normal skin will turn white when you do this, but jaundiced skin will stay yellow.

Exams and Tests Before a baby can be treated, the exact cause of an infant's jaundice must be determined. In some cases, a careful examination by a pediatrician is all that is needed. In other cases, blood tests may be required.

Laboratory Tests:First, the total serum bilirubin level will be checked. Based on this test, the doctor may request that more tests be done.A Coombs test checks for antibodies that destroy an infant's red blood cells.Acomplete blood count may be done.Areticulocyte count checks to be sure your baby is making enough new red blood cells.Certainred blood celldiseases are found in people of Mediterranean descent. In such cases, it may be necessary to check blood samples for a condition known asG6PD deficiency.

TreatmentSelf-Care at Home

* Sunlight helps to break down bilirubin so that a baby's liver can process it more easily. Placing a child in a well-lit window for 10 minutes twice a day is often all that is needed to helpcure mild jaundice. Never place aninfantin direct sunlight.

If the bilirubin level is too high, the child may need to be placed under a special type of light.

This treatment is called phototherapy - These lights are able to penetrate a baby's skin and affect the bilirubin within the child. The light changes bilirubin into lumirubin, which is easily handled by the baby's body.

If an infant's bilirubin levels are very high or if the child appears ill, the baby will most likely be admitted to the hospital for treatment.

Types of Jaundice The most common types of jaundice are:Physiological (normal) jaundice:occurring in most newborns, this mild jaundice is due to the immaturity of the baby's liver, which leads to a slow processing of bilirubin. It generally appears at 2 to 4 days of age and disappears by 1 to 2 weeks of age.

Jaundice of prematurity:occurs frequently inpremature babiessince they are even less ready to excrete bilirubin effectively. Jaundice in premature babies needs to be treated at a lower bilirubin level than in full term babies in order to avoid complications.

Breastfeeding jaundice:jaundice can occur when a breastfeeding baby is not getting enough breast milk because of difficulty with breastfeeding or because the mother's milk isnt in yet. This is not caused by a problem with the breast milk itself, but by the baby not getting enough to drink.Breast milk jaundice:in 1% to 2% ofbreastfedbabies, jaundice may be caused by substances produced in their mother's breast milk that can cause the bilirubin level to rise. These can prevent the excretion of bilirubin through the intestines. It starts after the first 3 to 5 days and slowly improves over 3 to 12 weeks.

Blood group incompatibility (Rh or ABO problems):if a baby has a different blood type than the mother, the mother might produce antibodies that destroy the infant's red blood cells.

The endocrine glands are considered better organized than other systems. Disturbances are most often related to maternally provided hormones (estrogen, luteal, and prolactin) that may cause the following conditions:

Vaginal discharge and/or bleeding may occur in female infants. Enlargement of the mammary glands may occur in both sexes

Physical AssessmentGenitourinary System

Important to note that infant is voidingKeep record of number of voiding

A. Male infantsAssess for descended testicles.Care following circumcisionCare of the uncircumcised infant

B. Female infantsLabia may be swollen.May have blood-tinged discharge.Teach peri-care.

SKIN is fragile and shows marked easily especially for infants with fair color

Nsg. Responsibility:Must examine every inch of the skin surface carefully during the initial assessment and at the beginning of the shift.

ASSESS for:Harlequin coloration- a clear color division over the body from the head to the abdomen with one half deep pink or red and the other half pale or of normal color

- indicate shunting of blood with cardiac problems or sepsis. Redness may occur on the lower side when the infant lies on the side

2. Mottling (cutis marmorata)Is a lacy pattern from dilated blood vessels under the skin

May be a sign of:Cold stressOverstimulationSepsis

- if persistent, may indicate chromosomal abnormality

3. Vernix caseosaA thick ,white substance that resembles cream cheeseProvides a protective covering for the fetal skin in utero

4. Lanugo Fine hair that covers the fetus during intrauterine life

5. MiliaAre white cysts, 1-2 mm in size resulting from distention of sebaceous glands that are not yet functioning properly

6. Erythema toxicumA red, blotchy areas that may have white or yellow papules or vesicles in the center- Commonly called as fleabite or newborn rash

7. BirthmarksAssess the size and location and should be carefully documented

7.1 Mongolian spots are bluish-black marks that resembles bruises - Usually found in sacral area but may appear in arm andshoulder 7.2 Nevus simplex also called salmon patch, stork bite or telangiectatic nevus - a flat, pink or reddish discoloration from capillaries that occur over the eyelids, just above the bridge of the nose or at the nape of the neck.

7.3 Nevus flammeus (port-wine stain) - is a permanent, flat dark, reddish-purple mark and varies in size, location and blanches minimally or not at all with pressure. - located over the forehead and eyelid

7.4 Nevus Vasculosus (strawberry hemangioma) - consists of enlarged capillaries in the outer layer of the skin - is a dark red and raised with a rough surface giving a strawberry like appearance

7.5 Caf-au-lait spots - are permanent,light brown areas that may occur anywhere on the body. Although harmless, the number and size are important.

8. Markings from Delivery

8.1 Petechiae pinpoint bruises that resembles a rash, may appear over areas such as the back, face and groin - due to increase intravascular pressure during the birth process such as in nuchal cord

8.2 Bruises may occur on any part of the body where pressure occurred during delivery especially when second-stage labor was difficult

8.3 Small puncture mark is present on the newborns head if a fetal monitor scalp electrode was attached

8.4 Forceps mark occurs over the checks and ears where the instrument applied - size and location are carefully documented, lack of movement or asymmetry of the face may indicate injury of the facial nerve

Breasts note the placement of the nipple and look for extra nipples which may appear on the chest or axilla

Hair and Nails hair should be silky and soft - nails come to the end of finger or beyond

ASSESSMENT OF GESTATIONAL AGEIs an examination of the newborns physical and neurological characteristics to determine the number of weeks from conception to birth

TOOLS: DUBOWITZ SCORING- is an in-depth, detailed assessment tool that includes examination of physical, neurological and behavioral; characteristics

NEW BALLARD SCORE- focuses on physical and neuromuscular characteristics, eliminating the behavioral

Neuromuscular CharacteristicsPosture posture and degree of flexion of the extremities are scoredSquare Window- is elicited by bending the hand at the wrist until the palm is as flat against the forearm as possible with gentle pressureArm recoil nurse hold the neonates arms fully flexed at the elbows for 5 seconds, then extends the am by pulling the hands straight down to the sides and released quickly and the degree of flexion is measuredPopliteal Angle newborns lower leg is folded against the thigh, with the thigh on the abdomen the lower leg is straightened just until resistance is met

e. Scarf Sign the nurse grasps the infants head and brings the arm across the body to the opposite side, keeping the shoulder flat on the bed and the head in the middle of the body

f. Heel to Ear the nurse grasps the infants foot and pulls it straight up alongside the body toward the ears while the hips remain flat on the bed surface

II. Physical CharacteristicsSkinAssessed for:ColorVisibility of veinsPeeling and cracking

b. Lanugo appears at 20 wks of gestation and increases in amount until 28 wks and begins to disappear until little is left

c. Plantar Surface- begins to appear at 32 wks of gestation although the creases are only red lines near to toes at first, they gradually spread down toward the heal and become deeper

d. Breasts Assess:NippleAreolaSize of breast bude. Eyes and EarsEyes- are fused until 26 to 28 weeks of gestationEars the incurvation and thickness of pinna rated

f. GenitalsAssess:(Female)Size of clitoris-labia majora and minoraMale: location of testes and rugae of scrotum

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Periodic breathing pauses in breathing lasting 5 10 seconds without other changes - this occurs in some full-term infants during the first few days but most often in preterm infants.

Apnea lasting longer than 20 seconds or accompanied by cyanosis, heart rate changes.**Epicanthal folds - common in down syndrome

Red reflex- This reflex is produced when the light from the doctors instrument, called an ophthalmoscope, travels through the pupil and is reflected back from the cells of theretinaat the back of the eye, can cause congenital cataract*Neonatal conjunctivitis presents during the first month of life. It may be aseptic or septic.Aseptic neonatalconjunctivitismost often is a chemicalconjunctivitisthat is induced by silver nitrate solution, which is used for prophylaxis of infectiousconjunctivitis. Chemical conjunctivitis is less common owing to the use of erythromycin ointment in place of silver nitrate solution for the prophylaxis of infectious conjunctivitis. (See Etiology and Treatment.)Bacterialandviralinfections are major causes of septic neonatalconjunctivitis, withChlamydiabeing the most common infectious agent. Infants may acquire these infective agents as they pass through the birth canal during the birth process. (The effects of gonococcal conjunctivitis are seen in the images below.) (See Etiology.)

*Severe purulent discharge and eyelid edema in a newborn with gonococcal conjunctivitis (confirmed with Gram stain and culture).*Cloudy cornea without ulcer in neonatal gonococcal conjunctivitis.*Subconjunctival hemorrhage is a bright red patch appearing in the white of the eye. This condition is one of several disorders called red eye

A subconjunctival hemorrhage is common in newborn infants. In this case, the condition is thought to be caused by the pressure changes across the infant's body during childbirth.*BACKGROUND and PATHOPHYSIOLOGY:Glucose is the major energy source for fetus and neonate. The newborn brain depends upon glucose almost exclusively.Up to 90% of total glucose used is consumed by the brain. Alternate fuels (e.g., ketones, lactate) are produced in very low quantities.The usual rate of glucose utilization is 4-8 mg/kg/min. Glucose regulatory mechanisms are sluggish at birth. Thus, the infant is susceptible to hypoglycemia when glucose demands are increased or when exogenous or endogenous glucose supply is limited. Severe or prolonged hypoglycemia may result in long term neurologic damage.

*DEFINITION: Hypoglycemia in the first few days after birth is defined as blood glucose