Immediate Newborn Care. Blanks

8/6/2019 Immediate Newborn Care. Blanks

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SAN ISIDRO COLLEGESCHOOL OF MIDWIFERY

UPDATES IN IMMEDIATE NEWBORN CARE

UNANG YAKAPA. IMMEDIATE NEWBORN CARE

1. Within the first 30 seconds

OBJECTIVE: Dry and provide warmth to the newborn and prevent hypothermia

1.1 Put on double gloves just before delivery

1.2 Use a clean, dry cloth to thoroughly dry the newborn by wiping the eyes, face, head, front and

back, arms and legs

1.3 Remove the wet cloth

1.4Do a quick check of newborns breathing while drying (see page 3 on Newborn Resuscitation)

1.5 Do not put the newborn on a cold or wet surface1.6 Do not bathe the newborn earlier than 6 hours of life

1.7 If the newborn must be separated from his/her mother, put him/her on a warm surface

1. After thorough drying

OBJECTIVE: Facilitate bonding between the mother and her newborn through skin to skin contact to

reduce likelihood of infection and hypoglycemia.

2.1Place the newborn prone on the mothers abdomen or chest, skin to skin.

2.2 Cover the newborns back with a blank blanket and head with a bonnet

2.3 Place the identification band on the ankle

2.4Do not separate the newborn from the mother, as long as the newborn does not exhibit severechest indrawing, gasping or apnea and the mother does not need urgent medical/surgical

stabilization eg. Emergency hysterectomy.

1. While on skin to skin contact (up to 3 minutes post-delivery)

OBJECTIVE: Reduce the incidence of anemia in term newborns and intraventricular hemorrhage in pre-

term newborns by delaying or non-immediate cord clamping.

1.1 Remove the first set of gloves immediately prior to cord clamping.

1.2 Clamp and cut the cord after cold pulsations have stopped (typically 1 to 3 minutes. Do not milk

the cord towards the newborn.

a. Put ties lightly around the cord at 2 cm and 5 cm from the newborns abdomen.b. Cut between ties with sterile instrument

c. Observe for oozing of blood.

1.1After Cord clamping, ensure 10 IU oxytocin IM is given to the number. Follow other protocols perPCPNC.

2. Within 90 minutes of Age

A. OBJECTIVE: Facilitate the newborns early initiation of breastfeeding and transfer of colostrums

through support and initiation of breastfeeding.

2.1 Leave the newborn on the mothers chest in skin to skin contact. Health workers should not

tough the newborn unless there is a medical indication.

2.2Observe the newborn. Advice the mother to start feeding the newborn once the newborn showsfeeding cues. (eg. Opening the mouth, tonguing, licking, rooting). Make verbal suggestion to the

mother to encourage her newborn move toward the breast, eg. Nudging

2.3Counsel on positioning and attachment. When the newborn is ready, advise the mother toposition and attach her newborn.

2.4 Advise the mother not to throw away the colostrums.

2.5 If the attachment or suckling is not good, try again and reassess.

Prepared by: Ms. May Princes T. Abucejo Page 1


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2.6 A small amount of breast milk may be expressed before starting breastfeeding to soften the

nipple area, so that it is easier for the newborn to attach

A. OBJECTIVE: to prevent from ophthalmia neonatorum through proper eye care.

1.1Administer erythromycin or tetracycline ointment or 2.5% povidone iodine drops to both eyes afterthe newborn has located the breast Do not wash away the eye antimicrobial.

B. NON IMMEDIATE INTERVENTIONS

1. Vitamin K administration

Vitamin K facilitates production of the clotting factor thus preventing bleeding

Vitamin K is synthesized in the presence of normal bacterial flora

Newborns intestines are still sterile thus Vitamin K would not be synthesized

Site of Injection

Anterior Vastus Lateralis IM

Gauge 26 or 27 Tuberculin

Ideal

Dosage: 2.5 below - 0.05 cc2.5 above - 0.10 cc

Actual/Unang Yakap Practice

Inject a single dose of Vitamin K 1 mg IM (if parents decline intramuscular injections)

offer oral Vitamin K as a 2nd line.

2. Inject Hepatitis B and BCG Vaccinations

Inject Hepatits B (IM) and BCG (ID)

3. Examine the newborn. Check for birth injuries, malformation and defects

Weigh the newborn and record.

Look for possible birth injury or malformation

Refer for special treatment and or evaluation if available.

If the newborn has feeding difficulties because of the injury or malformation, help the

mother to breastfeed. If not successful, teach her alternative feeding methods.

4. Cord Care

Wash Hands

Fold diaper below the stump.

Keep cord stump loosely covered with clean clothes

If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean cloth.

Explain to the mother that she should seek care if the umbilicus is red or draining with pus

Teach the mother to treat local umbilical infection three times a day.

C. NURSERY CARE

A. Check identification band

B. Take ANTROPOMETRIC MEASUREMENTS

1. Length 45.7 cm to 53.75 cm (Ave: 50cm)

2. Head Circumference 33cm to 35cm

3. Chest Circumference 31 cm to 33 cm

4. Abdominal Circumference 31 cm to 33 cm

A. Take Temperature

At birth the temperature is around 37.2 Celsius but will stabilize in 8 hours

Must be maintained at 35.5 to 36.5 CelsiusRectal route is preferred to check patency of Anus

B. Specific Nursing Actions

1. Give initial bathe to cleanse the baby

2. Dress the umbilical cord; check for AVA

3. Weight Taking

Average BW: 6.5 7.5 lbs

3 3.4 kilograms



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PulseGrimaceActivityRespiration

SIGN 0 1 2

Heart Rate (Pulse) Absent Less than 100 Over 100

Respiratory Effort

(Respiration)

Absent Weak cry Good strong cry

Muscle Tone (Activity) Flaccid Some flexion of

extremities

Well-flexed

extremities

Reflex-Irritability

(grimace)

No response Weak cry; grimace Good strong cry;

sneeze

Color Pale;Blue Body Pink

Extremities - Blue

Pink all Over

Interpretation of Score

___________- the baby is in best possible health

___________- moderately depressed; condition is guarded and may need more extensive

clearing of the airway

___________- serious danger; needs immediate resuscitation

Heart Rate most important vital sign of the newborn

__________ beats per minute

Increases when infant is crying; decreases when infant is asleep

HR of less than requires ________________

Respiratory Effort - cries ________________,no problems with breathing

Greater than _________ per minute

Signs of respiratory distress:

1. ______________ 2. _______________3. ___________________

Muscle Tone - good muscle tone is manifested when newborn keep his extremities flexed and

resists efforts of the midwife to extend them.

Color immediately after birth, it is normal for the newborn to appear _________ known as

____________ but body must become pink in ______________.

ASSESSMENT OF GESTATIONAL AGE

SIGN TILL 36 WEEKS 37-38 WEEKS 39 WEEKS

1. SOLE

CREASES

Anterior transverse

crease only

Occasional

creases; anterior

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Sole covered with

creases

2. Breast Nodule

Diameter

2mm 4mm 7mm

3. Scalp/Hair Fine and Fuzzy Fine and Fuzzy Coarse and Silky



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4. Earlobe Pliable; no cartilage Some cartilage Stiffened by thick

cartilage

5. Testes and

Scrotum

Testes in lower

scrotal sac

Intermediate Testes pendulous; testes

full and extensive rugae

CONCEPTS ON LABOR AND DELIVERY

__________________ a series of physiologic and mechanical processes by which the

products of conception (baby, placenta and fetal membranes) are expelled from the birth Canal

__________________ part of the process of labor, actual expulsion of the fetus

I. THEORIES OF LABOR ONSET

1. _________________________

Any hollow body organ when stretched to capacity will necessarily contract and

empty

1. _________________________

Labor, being considered a stressful event, stimulates the hypophysis to produce

oxytocin from the posterior pituitary gland. Oxytocin causes contraction of the

smooth muscle of the body. Ex. Uterine Muscles

1. ________________________

Progesterone, being the hormone designed for pregnancy, is believed to inhibit uterinemotility. Thus, if its amount decreases, labor pains can occur.

2. _________________________

Initiation of labor is said to result from the release of arachidonic acid produced by

steroid action on lipid precursors. Arachidonic Acid is said to increase prostaglandin

synthesis, which in turn causes uterine contractions.

1. ________________________

Because of the decreasing blood supply, the uterus contracts.

*PROGESTERONE maintains pregnancy; Inhibits LH secretion

* PROSTAGLANDIN secreted by a lot of body organs including uterine endometrium and

affect body functions including menstruation, pregnancy and parturition.

II. PRELIMINARY/PRODROMAL SIGNS OF LABOR

1. Lightening

The settling of the fetal head into the pelvic brim

In primis, it occurs two weeks before EDC; in multis on or before labor onset

Lightening should not be confused with engagement, which occurs when thepresenting part has descended into the pelvic inlet.

Results of Lightening:

a. Increase in Urinary Frequency from pressure in the bladder

b. Relief of abdominal tightness and diaphragmatic pressures ad shortness of breath

c. Shooting pains down the legs because of the pressure on the ______________



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kinking. Instead, cover any exposed portion with __________________to prevent

drying.

DIFFERENTIATION BETWEEN TRUE AND FALSE LABOR CONTRACTIONS

FALSE CONTRACTIONS TRUE CONTRACTIONS

Begin and remain irregular Begin irregularly but become regular and

predictable

Felt first abdominally and remain confined to

the abdomen and groin

Felt first in lower back and sweep around to

the abdomen in a wave

Often disappear with ambulation and sleep Continue no matter what the womans level of

activity

Do not increase in duration, frequency or

intensity

Increase in duration, frequency and intensity

Do not achieve cervical dilatation Achieve cervical dilatation

A SUCCESSFUL LABOR DEPENDS ON FOUR INTEGRATED CONCEPTS:

1. Passage the woman pelvis is of adequate size and contour

2. Passenger the fetus is of appropriate size and in advatageous position and and

presentation3. Powers the powers of labor (uterine factors) are adequate

4. Psyche a womans psyche is preserved, so that afterward labor can be viewed as

positive.

STAGES OF LABOR

A. FIRST STAGE OF LABOR

Divided into three phases

Begins with true labor and ends with complete dilatation of the cervix

Average 12-14 hours for Primigravida Clients and Average 7-8 hours for Multigravida

Clients

1. Latent Phase

begins at the onset of regularly perceived uterine contractions and

ends with rapid cervical dilatation begins.

A woman can and should continue to walk and make preparations of

birth

1. Active Phase

Show and spontaneous rapture of membranes may occur at the

phase

The mother fears of s losing control of herself.

1. Transition

Both cervical dilatation and effacement have occurred

LATENT ACTIVE TRANSITION

Cervical Dilatation 0-4cm 4-7 cm 8-10 cm

Contractions Interval occurs every

5 minutes

Interval occurs

every 2- 5 minutes

Interval occurs every

2 to 3 minutes



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Duration 20 to 40

seconds

Intensity Mild

Duration 30 to 50

seconds

Intensity moderate

Duration 50 to 60

seconds

Intensity Severe

Last 6 hours nullipara

4.5 hours - multipara

3 hours nullipara

2 hours - multipara

ASSESSMENT:

FETUS

1. Heart Rate (120-160 bpm) Should not be mistaken with uterine souffl (synchronizes with

maternal heart rate/pulse)

Should not be taken during uterine contractions, for it tends to

decrease

For any abnormality in FHR, initial nursing action is to change the

mothers position.

1. Lie if the fetus is lying in horizontal or vertical position

2. Position if the fetus is LOA, ROP, LOP, ROA etc.

3. Presentation Cephalic/Breech/Shoulder

4. Station refers to the relationship of the presenting part of the fetus to the level of the

ischial spines.

Station 0 presenting part is at the level of the ischial spine

Station -1 to -4 presenting part is above the ischial spine

Station +1 to +4 presenting part is below the ischial spine

At Station +3 to +4 presenting part is at the perineum

MOTHER

1. Baseline Vital Signs

2. Rupture of Membranes

3. Uterine Contractions

______________- from the beginning of one contraction to the end of the

same contraction

______________- from the end of oen contraction to the beginning of the

next contraction

______________- from the beginning of the one contraction to the beginning

of hte next contraction

______________- the strength of uterine contraction (mild, moderate, strong)

Measured by the consistency of the fundus at the same

of the contraction

1. Dilatation/Effacement

2. Bloody Show or any Vaginal Discharges

3. Fundus, just below the Xiphoid Process



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Health Teachings

1. _________________ - is advisable if contraction are tolerable or not to close to

one another. It will make the mother feel more comfortable

2. _________________ - during the latent phase of labor helps shorten the first

stage of labor. But definitely not allowed anymore if membranes have ruptured.

3. Encourage the mother to void every 2 to 3 hours by offering a bedpan since a fullbladder retards fetal descent; urinary stasis can lead to UTI; a full bladder can be

traumatized during delivery.

4. Encourage __________ position because

It favors anterior rotation of the fetal head

Promotes relaxation between contractions

It prevents continued pressure of the gravid uterus on the inferior vena

cava; pressure results in SUPINE HYPOTENSIVE SYNDROME OR

VENA CAVA SYNDROME. Hypotension is due to the reduced venous

return resulting in decreased cardiac output therefore a fall in BP.

A. SECOND STAGE OF LABOR

From full dilatation and cervical effacement to birth of infant

CARDINAL MOVEMENTS EDFIrEErE

E ngagement

D escent

F lexion

Ir nternal Rotation

E xtension

Er xternal Rotation

E xpulsion

NURSING CARE:

a. When positioning legs on lithotomy put them up at the same time to prevent injury to the

uterine ligaments

b. As soon as the fetal head crowns, instruct mother not to push but to pant instead (rapid

and shallow breathing) to prevent expulsion of the baby

c. Assist in episiotomy incision made in the perineum primarily to prevent lacerations.

Types of Episiotomy

1. Median from middle portion of lower vaginal border directed towards the anus

2. Mediolateral begun in the midline but directed laterally away from the anus.

*Natural Anesthesia is used in episiotomy; no anesthesia is injected because

pressure of fetal presenting part against the perineum is so intense that nerve

endings for pain are momentarily deadened.

a. Apply Modified Ritgens Maneuver

Cover the anus with sterile towel and exert upward forward pressure on

the fetal chin, while exerting gentle pressure with two fingers on the head

to control emerging head. This will not only support the perineum from lacerations but will also favor

flexion.

a. Insert 2 fingers into the vagina so as to feel for the presence of a cord looped around the

neck. If so, but loose, slip it down the shoulders or up over the head; but if tight, clamp

cord twice, an inch apart and then cut in between.



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b. As the head rotates, deliver the anterior shoulder by exerting a gentle pressure

downward and push then slowly give an upward lift to deliver the posterior shoulder.

c. While supporting the head and the neck, deliver the rest of the body. Take note of the

exact time of delivery.

d. Wrap the baby in a sterile diaper to keep him warm. REMEMBER: Chilling increases the

body needs for oxygen.e. Put the baby on the mothers abdomen. The weight of the baby will help contract the

uterus.

f. Cutting of the cord is postponed until the pulsations have stopped because it is believed

that 50 to 100 ml of blood is flowing from the placenta to the baby at this time. After cord

pulsations have stopped. Clamp it twice, an inch apart and then cut in between.

g. Show the baby to the mother; inform her of the sex and time of delivery.

A. THIRD STAGE (Placental Stage)

Begins with the birth of the infant abd ends with the delivery of the

placenta

2 separate phases includea. Placental separation

b. Placental expulsion

The following signs indicate that the placenta has loosened and is ready to be delivered.

a. Lengthening of the umbilical cord

b. Sudden gush of vaginal blood

c. Change in the shape of the uterus

d. Firm contraction of the uterus

The PLACENTA

a. Shultze shiny, fetal membrane surface

b. Duncan dirty, raw, red, irregular maternal surface

Bleeding occur as part of normal consequence of placental separation before the uterus

contracts sufficiently to seal maternal sinuses.

Normal blood loss 300 to 500 ml.

NURSING CARE

a. Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing

vigorous fundal push as this can cause UTERINE INVERSION. Just watch for the signs

of placental separation

b. Tract the cord slowly, winding it around the clamp, until placenta spontaneously comes

out, rotating it slowly so that no membranes are left inside the uterus, a method called

Brandt Andrews maneuver.

c. Take note of the time of placental delivery; it should be delivered within 20 minutes after

the delivery of the baby. Otherwise, refer immediately to the doctor as this can cause

severe bleeding.d. Inspect the completeness of the cotyledons; any placental fragment retained can also

cause severe bleeding and possible death.

e. Palpate the uterus to determine degree of contraction. If relaxed, boggy or non-

contracted. First nursing intervention is to massage gently and properly. An ice cap

over the abdomen will also help contract the uterus since cold can cause

vasoconstriction.



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f. Inject oxytocics (Methergin or Syntocinon) to maintain uterine contractions, prevent

hemorrhage. NOTE: OXYTOCICS are not given before placental delivery because

placental entrapment may occur.

g. Inspect the perineum for lacerations. Anytime the uterus is firm following placental

delivery, yet bright red vaginal bleeding is gushing forth from the vaginal opening

suspect lacerations.DEGREE OF LACERATIONS

1. First Degree involves the vaginal mucous, membranes and skin

2. Second Degree involves not only the vaginal mucous membranes ans skin but also

the muscle.

3. Third Degree involves not only the muscles, vaginal mucous membranes and skin

but also the external sphincter of the rectum.

4. Fourth Degree involves only not the external sphincter of the rectum, the muscles,

vaginal mucous membranes and skin but also the mucous membrane of the rectum.

a. Assist the doctor in doing episiotomy

b. Make mother comfortable by perineal care and applying clean sanitary napkin snugly to

prevent moving forward from the anus to the vagina. Soiled napkins should be removedfrom front to back.

c. Position the newly delivered mother flat on bed without pillows to prevent dizziness due

to increase in intra abdominal pressure.

d. The newly delivered mother may suddenly complain of chills due to the rapid decrease

of pressure, fatigue or cold temperature in the delivery room. Provide additional

blankets to keep her warm.

STUDY WELL


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Immediate Newborn Care. Blanks