Assessment of the newborn is essential to ensure a

successful transition

1. Immediately after birth

2. Within the 1st 4 hours after birth

3. Prior to discharge

A ctivity/ Muscle Tone

P ulse/ Heart Rate

G rimace/ Reflex Irritability/ Responsiveness

A ppearance/ Skin Color

RR espiration/ Breathing

INDICATORS 2 1 0

Appearance Completely pink

Acrocyanosis (Body pink, Extremities

blue)

Pale or blue all over

Pulse More than 100 bpm

Less than 100 bpm

Absent

Grimace Pulls away when stimulated sneezes, coughs, good, strong cry

Facial grimace, feeble cry when stimulated

No response with stimulation

Activity Active movement, well-flexed extremities

Some flexionof extremities

No movement(flaccid, limp)

Respiration Good, strong cry

Slow, irregularWeak cry

Absent

Score Interpretation Nursing Interventions

7 to 10 Good Adjustment Rarely needs resuscitation

4 to 6 Moderately Depressed Infant

Airway clearance:

Suction

Dry immediately

Ventilate until stable

Careful observation

0 to 3 Severely Depressed Infant

Intensive resuscitation:

CPR

Intubation

Ventilate with 100% O2

Maintain body temperature

Parental support

General Guidelines•Keep warm during examination•From general to specific•Least disturbing first•Document ALL abnormal findings & provide nursing care

GENERAL APPEARANCEGENERAL APPEARANCE

•Symmetric• Flexion of head and extremities•Hands tightly fisted with thumb covered by the fingers

• Asymmetric • Fractured clavicle or humerus• Nerve injuries (Erb-Duchenne’s Paralysis)

• Breech Presentation• Extended leg, thighs fully rotated and

abducted, flattened occiput and extended neck

VITAL SIGNS

• Site: Axillary NOT Rectal• Duration: 3 mins• Normal Range: 36.5 – 37 °C (97.9 °F-

98°F)

• Convection – the flow of heat from the body surface to cooler surrounding air-Eliminating drafts such as windows or air con, reduces convection• Conduction – the transfer of body heat to a cooler solid object in contact with the baby-Covering surfaces with a warmed blanket or towel helps minimize conduction heat loss

• Radiation – the transfer of heat to a cooler object not in contact with the baby

-Cold window surface or air con; moving as far from the cold surface, reduces heat loss

• Evaporation – loss of heat through conversion of a liquid to a vapor– From amniotic fluid; NB should be

dried immediately

• Keep dry and well-wrapped• Keep away from cold objects or outside walls• Perform procedures in warm, padded surface• Keep room temperature warm

Nursing Considerations

PULSE

• Site: Apical (considered the most accurate)

• Duration: 1 full minute, not crying

• Awake: 120-140 bpm

• Asleep: 90-110 bpm

• Crying: 180 bpm

Nursing Considerations

• Keep warm

• Take heart rate for 1 full minute

• Listen for murmurs

• Palpate peripheral pulses

• Assess for cyanosis

• Observe for cardiopulmonary distress

Respiration

• Characteristics:

Nose breathers, gentle, quiet, rapid BUT shallow; may have short periods of apnea (<15 secs)

• Rate: 30-60 cpm

• Duration: 1 full minute

• No sound should be audible on inspiration or expiration.

Nursing Considerations

• Position on side

• Suction as needed

• Observe for respiratory distress

• Administer oxygen as prescribed

• NOT routinely measured UNLESS

in distress or CHD is suspected

• Oscillometric: 65/41 mmHg in arm and calf

Blood Pressure

• A drop in systolic BP of about 15 mm Hg the first hour after birth is common. • BP may be taken with a Doppler blood pressure device (greatly improves accuracy).

ANTHROPOMETRIC MESUREMENTS

• Weight:

– 5.5 to 9.5 lbs (2,500-4,300 gms)

• Caucasian: 7 lbs

• Filipinos: 6.5 lbs

– 70-75% of total body weight is water

– Low birth weight = below 2500 gms; regardless of Age of gestation

• Length:

– 45 to 55 cm (18-22 inches)

– Average: 50 cm

– Techniques: using tape measure

• Supine with legs extended

–Crown to rump

–Head to heel

• Head Circumference (HC):

– 33 to 35 cm (13-14 inches) about 2-3 cm larger than chest circumference

– Technique: using tape measure

• From the most prominent part of the Occiput to just above the Eyebrows

– 1/3 the size of an adult’s head

– Disproportionately LARGE for its body

• Chest Circumference (CC):

– 30 to 33 cm (12-13 inches)

– Technique: using tape measure

• From the lower edge of the scapulas to directly over the nipple line anteriorly

– Should be = or < 2 cm than Head circumference

SKIN

Nursing Considerations

• Under natural light• Assess for:

– Color– Hair distribution– Turgor/Texture– Pigmentation/Birthmarks– Other skin marks

• At birth: bright red, puffy, smooth

• 2nd – 3rd day: pink, flaky, dry

• Ruddy complexion due to increased RBC concentration and decreased subcutaneous fat.

Skin Color

Acrocyanosis • Bluish discoloration of palms of hands &

soles of feet

• Due to immature peripheral circulation

• Exacerbated by cold temperatures

• Normal within 1st 24 hrs

Skin Color

Jaundice• yellow discoloration that may be seen

in the infant's skin or in the sclera of the eye.

• caused by excessive amounts of free bilirubin in the blood and tissue.

• Physiologic Jaundice- after the 1st 24 hours

• Pathologic Jaundice- within 24 hours of life

Skin Color

Lanugo• fine downy hair that covers the newborn's shoulders, back, and upper arms • Immature newborns have more lanugo than mature infant• may disappear within 2 weeks

Vernix Caseosa• white cream-cheese like that serves as a

skin lubricant

• It offers protection from the watery environment of the uterus and serves as a natural moisturizer

• Nursing Considerations:

- Use baby oil

- DO NOT attempt to remove vigorously

• Multiple, tiny white

papules approx. 1 mm wide

• Due to enlarged or clogged sebaceous gland

• Usually found on the nose, chin, cheeks, eyebrows and forehead

MiliaMilia

BIRTHMARKS

Mongolian Spots

• Irregular areas blue-black colorations on the infant's lower back, buttocks, and anterior trunk. • The spots are not bruises nor are they associated with mental retardation. • They disappear in early childhood.

Stork Bites• Telangiectatic nevi• Flat deep pink

localized area on back of the neck

• Disappears at 2 years of age.

Strawberry marks• Nevus Vasculosus or Capillary Hemangioma• Elevated areas formed by immature capillaries and endothelial cells.• Head, neck trunk & extremities• Disappears after 7 to 9 years of age

Port wine stain• Nevus Flammeus• Large red purple lesion • Generally appear on the face or neck• Does not blanch with pressure• Not raised above the skin and does not spontaneously disappear

Mottling• Cutis marmorata• Transient mottling of skin when exposed to decrease temperature

                                      

                                      

Erythema toxicum• Newborn rash• Small pink papular rash • Thorax, back, buttocks and abdomen• Appears in 24 to 48 hours and subsides after several days

Petechiae• Pinpoint hemorrhages on skin• Due to increased vascular pressure, infection or thrombocytopenia• Within 48 hrs

                                      

Ecchymoses • Bruises• As a result of rupture of blood vessels• May appear at the presenting part as a result of trauma during delivery• May also indicate infection or bleeding problems

Harlequin Sign • Outlined color change as infant lies on side, dependent side turns red and the other turns pale • Due to gravity and vasomotor instability or immature circulation

Café-au-lait spots • Tan or light brown macules or patches• No pathologic significance, if < 3 cm in length and < 6 in number • If > 3 cm or 6 in number it may indicate Cutaneous

Neurofibromatosis

HEAD

• The infant’s head represents ¼ of

total body length.• Head circumference: 33 to 35 cm (13-

14 inches) about 2-3 cm larger than chest circumference.

• The head is shaped or molded as it is forced through the birth canal.

Fontanelles • The space where more than two bones

come together• Should be flat, soft and firm• Anterior Fontanel: diamond shape (2.5- 4

cm); closes at 12 to 18 months• Posterior Fontanel: triangular shape (0.5- 1

cm); closes at 2 months• Bulging fontanel due to crying & coughing

Caput Succedaneum • Edema of the soft scalp tissue at the

presenting part of the head.• Due to pressure on the presenting

part of the fetal head.

• Crosses the suture lines• 2- 3 days after birth

• Is a collection of blood between the periosteum of the skull bone and the bone

• Caused by pressure of the fetal head against the maternal pelvis during a prolonged or difficult labor

• Does not cross suture lines.• Within several weeks

• Localized softening of the cranial bones• Caused by pressure of the fetal skull

against the mother’s pelvic bone in utero• Can be indented by pressure of fingers

Craniosynostosis • Premature closure of the fontanelles.

Color: White sclera Slate gray, dark blue or brown Final eye color: 3- 6 months or may take

a year Pupils equal, round, reactive to light (+) Blink reflex

Lids usually edematous Able to move and fixate

momentarily May cross (strabismus) or twitch

(nystagmus) Absence of tears until one to three

months of age

Small and narrow Flattened, midline Nasal breathers (+) Periodic sneezing (+) Nasal flaring= respiratory distress (+) Low nasal bridge= Down’s syndrome

Folded and creased Pinna in line with outer canthus of the eye,

flexible and cartilage present Startle reflex is elicited by loud, sudden

noise (+) Low set ears= chromosomal defect &

kidney anomaly

Pink, moist Intact soft and hard palate• Epstein’s pearls- small, white epithelial

cysts (midline of hard palate) Uvula in midline Tongue smooth and symmetrical, moves

freely with short frenulum

Sucking reflex (strong and coordinated) Other reflexes: Rooting, Gag and Extrusion Small mouth or large, protruding tongue=

chromosomal problems (+) White patches on tongue or side of the

cheek= Candidiasis (oral thrush)

Short, creased with skin folds Head rotate freely but cannot support

the full weight of head Trachea midline Thyroid gland not palpable Intact clavicle

Chest circumference- should be = or < 2 cm than Head circumference

Antero-posterior & lateral diameters equal

Symmetrical Cylindrical thorax and flexible ribs (+) Breast engorgement subsides

after 2 wks.

(+) Witch’s milk Respirations appear diaphragmatic Bilateral equal bronchial breath sounds Cough reflex: absent at birth; present

by 1- 2 days Periodic apnea- common in preterm

infants

Heart rate: 120- 140 bpm (apical) Apex: 4TH to 5th ICS, lateral to left

sternal border S2 slightly sharper and higher pitch

than S1 Transient cyanosis when crying

Potential signs of distress:• Dextrocardia- heart on right side• Displacement of apex• Murmurs and thrills

- ASD, VSD, PDA• Persistent cyanosis

Umbilical Cord:- 2 arteries and 1 vein- Bluish white at birth- Begins to dry between 1-2 hrs. following

birth- Gradually falls off by 7 days Daily Cord Care:- Keep cord dry and clean & clamp secured

- Cleanse cord with 70% isopropyl alcohol with each diaper change and at least 2- 3 times a day

- Keep the newborn’s diaper below the cord- Note for any signs of infection (redness,

drainage, swelling, odor)- Avoid using creams, lotions or oils near

the cord

Newborn’s abdomen is shaped like a dome and cylindrical

Liver- palpable 2- 3 cm below right costal margin

Kidneys- about 1-2 cm above umbilicus

Spleen- tip palpable at end of first week of age

GITGIT- Capacity: 90 ml, with rapid intestinal

peristalsis ( 2 ½ to 3 hrs)- Bowels sounds; (+) within 1-2 hrs after

birth- (+) Scaphoid = diaphragmatic hernia- (+) Distended = LGIT obstruction/ mass- (+) Visible peristalsis= Hirschprung’s

disease

AnusAnus- Check patency

- First stool (Meconium) – usually passed within 12-24 hrs. after birth

• Sticky, tarlike, blackish-green, odorless

Meconium Transitional Stool

Milk Stool

(Breastfed)

Milk Stool (Bottlefe

d)

Within 48 hours after birth

From 2- 3 days

4- 5 days onwards

4- 5 days onwards

Thick, sticky, black – tarry

Yellow brown to greenish brown stools

Golden yellow and pasty, sour smelling

Pale yellow to light brown, more formed with foul odor

Female:Female:- Edematous labia and clitoris- Urethral meatus behind clitoris- First voiding should occur within 24 hours- Pseudomenstruation- blood- tinged

mucus from the vagina at 1st week after birth

- Hymental tag may be present but disappear in a few weeks.

Male:Male:- Prepuce covers glans penis• Small opening in the foreskin = Phimosis- Scrotum: edematous• Excessive amount of fluid= Hydrocele- Meatus: central• (+) ventral/ dorsal = Hypo/epispadias- Testes: descended• (+) undescended = Cryptorchidism

- First voiding should occur within 24 hrs

Spine:- Intact, straight and flat- No openings, masses or prominent

curves- Trunk incurvation reflex- disappears by 4

weeks- (+) Small tuft of hair or dimpling at the

base= Spina Bifida

Symmetrical and full range of motion Even gluteal folds Complete fingers and toes- Polydactyly- extra digits on either fingers or

toes- Syndactyly- fusion of 2 or more digits Legs- equal in length w/ symmetric skin

fold

Check for hip fractures or dysplasia- (+) Ortolani’s click & uneven gluteal folds =

Hip dysplasia Creases on soles of feet, usually flat- (-) crease= prematurity- Simian crease- single palmar crease

(Down’s syndrome) (+) inward turning of the foot = club foot

or talipes equinovarus

Polydactyly

Club foot

Syndactyly

Blinking or Corneal

Pupillary Doll’s Eye

Infant blinks with sudden appearance of bright light or approach of an object towards the cornea. Persists throughout life.

Pupils constrict when bright light shines toward it. Persists throughout life.

As the head is moved slowly (right or left), the eyes lag behind & do not adjust to new position of the head. Disappears as fixation develops.If it persists it may indicate neurologic damage. Sneeze Glabellar

Spontaneous response of nasal passages to irritation or obstruction Persists throughout life.

Tapping briskly on the bridge of the nose (glabella) Eyes close tightly

Sucking Gag Rooting Strong sucking movements of the circumoral area (response to stimulation). Persists throughout infancy (even without stimulation.

Stimulation of posterior pharynx causes the infant to gag. Persists throughout life.

Touching or stroking the cheek along the side of the infant’s mouth causes the head to turn towards that side. Should disappear at about 3-4 months. Persists up to 12 months.

Extrusion Yawn Cough Tongue is touched or depressed and the infant responds by forcing it outward. Disappears by age 4 months.

Spontaneous response to decreased oxygenation by increasing the amount of inspired air. Persists throughout life.

Irritation of the mucus membrane of the larynx or tracheobronchial tree causes coughing. Persists throughout life (usually present after the 1st day of birth).

CARE OF THE CARE OF THE NEWBORNNEWBORN

ESSENTIAL NEWBORN CARE ESSENTIAL NEWBORN CARE PROTOCOLPROTOCOL

On December 7, 2009 the Department of Health, in cooperation with WHO launched the Unang Yakap Camapaign which aims to cut down infant mortality in the Philippines by at least half.

The campaign employs Essential Newborn Care (ENC) Protocol a series of time bound, chronologically-ordered, standard procedures that a baby receives at birth.

ESSENTIAL NEWBORN CARE ESSENTIAL NEWBORN CARE PROTOCOLPROTOCOL

Provides an evidence-based, low cost, low technology package of interventions that will save thousands of lives.

Also supports the Philippine Government commitment to the United Nations Millenium Development Goals (MDG) 4 and 5 by year 2015.

Time- Bound Procedures Time- Bound Procedures

Should be routinely performed first Immediate drying, skin-to-skin contact Clamping of the cord after one to three

minutes or until pulsations have stopped Non-separation of the newborn from the

month Breastfeeding initiation.

Should only be done after the first full breastfeed.

Immunizations Eye care Vitamin K administration and weighing. Washing must be postponed by at

least 6 hours as this will hinder the crawling reflex.

Routine suctioning Routine separation of newborns for

observations Administration of pre lacteals like

glucose, water formula Footprinting.

I. Immediate Newborn CareI. Immediate Newborn Care(The First 90 Minutes)Time Band: Within the 1st 30 secs -Call out the time of birthIntervention: Dry and provide warmth.Action: - Use a clean, dry cloth to thoroughly

dry the baby by wiping the eyes, face, head, front and back, arms and legs.

 

Action: Action: - Remove the wet cloth.- Do a quick check of newborn’s

breathing while drying. Notes:- During the first 30 seconds:– Do not ventilate unless the baby

is floppy/limp and not breathing.– Do not suction unless the

mouth/nose are blocked with secretions or other material.

Time Band: After 30 secs of thorough drying

Intervention: Do skin-to-skin contactAction:- If a baby is crying and breathing

normally, avoid any manipulation, such as routine suctioning, that may cause trauma or introduce infection.

 - Place the newborn prone on the mother’s abdomen or chest skin-to-skin.

Action: Action: - Cover newborn’s back with a

blanket and head with a bonnet.- Place identification band on ankle.Notes:- Do not separate the newborn from

mother, as long as the newborn does not exhibit severe chest in-drawing, gasping or apnea.

Notes:Notes:- Do not wipe off vernix if present.- Do not bathe the newborn earlier

than 6 hours of life.- Do not do footprinting.- If the newborn must be separated

from his/her mother, put him/her on a warm surface, in a safe place close to the mother.

Time Band: 1 - 3 minutesIntervention: Do delayed or non-

immediate cord clampingAction:- Remove the first set of gloves

immediately prior to cord clamping.- Clamp and cut the cord after cord

pulsations have stopped (typically at 1 to 3 minutes)

Action:Action:- Put ties tightly around the cord at 2 cm

and 5 cm from the newborn’s abdomen.– Cut between ties with sterile

instrument.– Observe for oozing blood. Notes: - Do not milk the cord towards the

newborn.- After cord clamping, ensure Oxytocin 10

IU IM is given to the mother.

Time Band: Within 90 min of ageIntervention: Provide support for

initiation of breastfeeding.Action: - Remove the first set of gloves

immediately prior to cord clamping.- Leave the newborn on mother’s chest

in skin-to-skin contact. - Observe the newborn. When the

newborn shows feeding cues (e.g. opening of mouth, rooting), make verbal suggestions to the mother to encourage her newborn to move toward the breast e.g. nudging.

Action: Action: - Counsel on positioning and attachment. When

the baby is ready, advise the mother to: • Make sure the newborn’s neck is not flexed or

twisted.• Make sure the newborn is facing the breast,

with the newborn’s nose opposite her nipple and chin touching the breast.

• Hold the newborn’s body close to her body.- Support the newborn’s whole body, not just

the neck and shoulders. – Wait until her newborn’s mouth is opened

wide.– Move her newborn onto her breast, aiming

the infant’s lower lip well below the nipple 

- Look for signs of good attachment and suckling:

• Mouth wide open• Lower lip turned outwards• Baby’s chin touching breast• Suckling is slow, deep with some pauses.- Do not give sugar water, formula or other

prelacteals.– Do not give bottles or pacifiers.– Do not throw away colostrum. Adapted fro: Newborn Care until the First Week Of Life: Clinical

Practice Pocket Guide, World Health Organization, 2009.

Cord careCord care Nursing Responsibilities: - Put nothing on the stump. – Fold diaper below 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 pus.

Cord careCord care Notes:– Do not bandage the stump or abdomen.– Do not apply any substances or medicine on the stump.– Avoid touching the stump unnecessarily.

NEWBORN SCREENING NEWBORN SCREENING • R.A. 9288• Disorder Screened:-Congenital Hypothyroidism (CH)- Congenital Adrenal Hyperplasia (CAH)- Galactosemia - Phenylketonuria- G6PD Deficiency • Done 48th to 72nd hour of life or 24 hours from birth.• Uses the heel prick method.

Breastfeeding Breastfeeding The traditional and ideal form of

infant feeding, meeting an infant’s nutritional needs for his first 4-6 mos. of life.

Is one of the most effective ways to ensure child health and survival.

The WHO actively promotes breastfeeding as the best source of nourishment for infants and young children.

Exclusive Exclusive BreastfeedingBreastfeeding

Giving the infant only breastmilk with no additional foods or liquids, not even water.

Recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond.

The Rooming- in and Breastfeeding Act of 1992 (R.A 7600)

Milk Code (E.O. 51) Rooming- inRooming- in- the practice of placing

the newborn in the same room as the mother right after delivery up to discharge to facilitate mother-infant bonding and to initiate breastfeeding.

Advantages of Advantages of BreastfeedingBreastfeeding

1. Breastmilk is the best natural food for babies. It contains the right amount of proteins, fats, sugars, vitamins & minerals needed by a growing baby.

2. Breastmilk is easily digested. Protein is in the form of lactalbumin which is superior to casein and is readily digested by the infant’s enzymes because it forms small amounts of curds.

4. Colostrum, the first yellowish milk secretion has immune bodies that gives the baby immunity against some gastro-intestinal infections and common illness during the first six months of life.

5. Breastfeeding is beneficial to the health of the mother. It hastens the return of her uterus to normal size. Because she does not menstruate she conserves her iron stores.

6. Breastfeeding is economical and convenient because it is available 24 hours and needs no special preparation.

7. It offers an excellent opportunity for the mother to develop a stable and close bond with her child.

8. Breastfeeding promote birth spacing through LAM method (Lactational amenorrhea method).

9. Human milk contains Bifidus Factor that promotes growth of desirable bacteria in the GUT.

Protection against infectionProtection against infection> Breastmilk contains white blood cells,

and a number of anti- infective factors, which help protect a baby against many infections.

> Protects babies against diarrheal and respiratory illness and also ear infections, meningitis and urinary tract infections.

> A baby should not be separated from his mother when she has an infection, because breast milk protects him against the infection.

Variations in Composition of Variations in Composition of Breast MilkBreast Milk

ColostrumColostrum The breast milk that women

produce in the first few days after delivery. It is thick and yellowish or clear in color.

Recommended by WHO as the perfect food for the newborn, and feeding should be initiated within the first hour after birth.

Colostrum Colostrum PropertyProperty- Antibody rich

- Many white cells

- Purgative

- Growth factors- Rich in Vitamin

A

ImportanceImportance- Protects against allergy &

infection- Protects against infection- Clears meconium- Helps to prevent jaundice- Prevents allergy,

intolerance- Reduces severity of

infection

Mature MilkMature Milk The breast milk that is produced

after few days. The quantity becomes larger, and the breasts feel full, hard and heavy. Some people call this the breast milk ‘coming in’.

Contains proteins, vitamins and minerals, lactose (sugar), fatty acids, antibodies and enzymes that aid in digestion and absorption.

ForemilkForemilk The milk that is produced early in a feed. Looks bluer than Hindmilk Produced in larger amounts & it provides

plenty of protein, lactose & other nutrients.

Hindmilk Hindmilk Is the milk that is produced later in a

feed. Looks whiter than foremilk, because it

contains more fat which provides much of the energy of a breastfeed.

  Summary of Differences Summary of Differences Between MilkBetween Milk

Human Milk Animal Milk

Formula Milk

Protein

Correct amount, Easy

to digest

Too much,

difficult to digest

Partly corrected

Fat Enough essential

fatty acids, lipase to digest

Lacks essential

fatty acids, no

lipase

No lipase

Adapted from: Breastfeeding counselling: A training course. Geneva, World Health Organization, 1993

Human Milk

Animal Milk

Formula Milk

Water Enough Extra needed

May need extra

Anti- infective

properties

Present Absent Absent

Adapted from: Breastfeeding counselling: A training course. Geneva, World Health Organization, 1993

Nutrients in Human Milk Nutrients in Human Milk Human milk contains essential fatty

acids that are needed for a baby’s growing brain and eyes, and other healthy blood vessels.

Human milk contains more whey proteins that contain anti- infective proteins which help to protect a baby against infection.

Human milk is better absorbed. Totally breastfed infants triple their birth weight, maintain normal iron status without iron supplements.

Occurrence of Rickets in breastfed infants is minimal because of water soluble Vitamin D sulfate.

Human milk has softer, smaller and sweeter- smelling curd.

Human milk has 2 times more of readily absorbed Olein; a better source of Linoleic acid (supplies 4- 5 %); has dienoic fat, which is necessary to prevent growth failure & production of dry, thick and scaly skin.

ProlactinProlactin Secreted after a feed to produce

next feed. The pituitary gland at the base of

the brain secretes prolactin. Prolactin makes the milk secreting

cells produce milk. Most of the prolactin is in the

blood about 30 minutes after the feed so it makes the breast produce milk for the next feed.

OxytocinOxytocin Works before or during feed to make milk

flow. Is produced more quickly than prolactin. Makes a mother’s uterus contract after

delivery. Oxytocin reflex- easily affected by a

mother’s thoughts and feelings. Sensations such as touching or seeing her baby, or hearing him cry, can also help the reflex. But bad feelings, such as pain or worry or doubt that she has enough milk, can hinder the reflex and stop her milk from flowing.

ABC’s of BreastfeedingABC’s of Breastfeeding

AAwarenesswareness- Watch for the baby's signs of hunger, and breastfeed whenever your baby is hungry.

BBeing patient- eing patient- Breastfeed as long as the baby wants to nurse each time. Infants typically breastfeed for 10 to 20 minutes on each breast.

CComfortomfort- Get comfortable with pillows to support arms, head, and neck and a footrest to support feet and legs before beginning to breastfeed.

““Latching On”Latching On” Position the baby facing the mother. With one hand, cup breast and gently

stroke the baby's lower lip with the nipple. With the mother’s hand supporting the

baby's neck, bring the baby's mouth closer around the nipple, trying to center the nipple in the baby's mouth above the tongue.

The baby is "latched on" correctly when both lips are pursed outward around the mother’s nipple.

Complementary Feeding Complementary Feeding • Given to infants at age 6 months in order to

meet their evolving nutritional requirements.

• Appropriate complementary feeding means:a. Timely- introduced when the need for

energy & nutrients exceeds what can be provided through breastfeeding.

b. Adequate- provide sufficient energy, protein and micronutrients to meet a growing child’s nutritional needs.

c. Safe- hygienically stored and prepared, and fed with clean hands using clean utensils and not bottles and teats or artificial nipples.

d. Properly fed- given consistent with a child’s signals of appetite and satiety, and meal frequency and feeding method.

• Frequent feeding (4–5 times a day) with appropriate foods ensures that young children get sufficient energy and nutrients to grow normally and stay healthy.

• Good first complementary foods include soft meat, vegetables and fruits, mashed to a thin consistency.

• Foods should be prepared without added salt.

• New foods should be introduced to the child one at a time, allowing the child to get used to the food before another new food is introduced in their diet.

• By 5- 6 months, the infant is ready to eat scraped banana, papaya, rice gruel or commercial cereal food can e given.

• When teething begins, chewy foods such as crackers are given.

• Between 7th and 8th months, foods are chopped finely such as soft cooked rice with boiled fish and leafy vegetables.

• From 9th to the 12th month, depending on the child’s dental development, whole tender foods or food chopped coarsely are given.

Nutrition in LactationNutrition in Lactation• A mother who is breastfeeding needs to

eat 300 more calories to provide the extra energy the body needs.

• Choose foods with a lot of fiber- fruits, vegetables, dry beans, whole grain breads and cereals, and other whole grain products.

• Eat food containing vitamin B9 (folic acid).

• Consume 1,200 milligrams of calcium/day can be partly met by from dairy products and raw vegetables.

• Iron Supplementation in Lactating Women

- 60 mg elemental iron with 400 mcg Folic acid 1 tablet once a day.

• Avoid smoking and consumption of alcohol.

MOTHER BABY MOTHER BABY

FRIENDLY FRIENDLY HOSPITAL HOSPITAL INITIATIVE INITIATIVE

- BFHI was launched by WHO and UNICEF in 1991.

- The initiative is a global effort to implement practices that protect, promote and support breastfeeding.

- The goal is to encourage optimal breastfeeding practices through prolonged, exclusive and early initiated breastfeeding.

- The MBFHI, the name for the Filipino version of the initiative, was launched by the Department of Health in 1992 in line with the Rooming-in and Breastfeeding Act of 1992 (RA 7600).

- All private & government hospitals offering maternity and newborn care may be accredited as Mother-Baby Friendly if they implement the 10 Steps to Successful Breastfeeding adopted from UNICEF/WHO criteria of BFI.

The revised BFHI package includes:• Section 1: Background and

Implementation• Section 2: Strengthening and sustaining

the Baby-friendly Hospital Initiative• Section 3: Breastfeeding Promotion and

Support in a Baby-Friendly Hospital• Section 4: Hospital Self-Appraisal and

Monitoring• Section 5: External Assessment and

Reassessment

The 10 Steps to Successful BreastfeedingThe 10 Steps to Successful Breastfeeding1. Baby-friendly hospitals have a written

breastfeeding policy that is routinely communicated to all health care staff.

2. Baby-friendly hospitals train all health care staff in skills necessary to implement this policy.

3. Baby-friendly hospitals inform all pregnant women about the benefits and management of breastfeeding.

4. Baby-friendly hospitals help mothers initiate breastfeeding within one half-hour of birth.

5. Baby-friendly hospitals show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants.

6. Baby-friendly hospitals give newborn infants no food or drink other than breastmilk, not even sips of water, unless medically indicated.

7. Baby-friendly hospitals practice rooming- in that is, allow mothers and infants to remain together 24 hours a day.

8. Baby-friendly hospitals encourage breastfeeding on demand.

9. Baby-friendly hospitals give no artificial teats or pacifiers to breastfeeding infants.

10. Baby-friendly hospitals foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Source: Baby-Friendly Hospital Initiative. World Health Organization. January 2009.

Accreditation Process of MBFHI Accreditation Process of MBFHI FacilitiesFacilities

Self- Assessment by the facility using the Global Criteria on MBFHI Self- Appraisal

Submission of self- assessment of the health facility for validation by the CHD

MBFHI Assessors/ Coordinators

Issuance of Certificate of Commitment by the CHD Director for validated compliance.

Accreditation Process of MBFHI FacilitiesAccreditation Process of MBFHI Facilities

Re- assessment of the CHD MBFHI Assessor/ Coordinator after 2 years of sustained implementation by the health facility

Issuance of Plaque of Accreditation by the Secretary of Health for sustained

implementation on MBFHI and integration of Mother Friendly indicators

Annual MBFHI Implementation Report (Using the Self-Assessment Tool) for submission by the

health facility to the CHD

Accreditation Process of MBFHI FacilitiesAccreditation Process of MBFHI Facilities

Re- Assessment every three (3) years by the CHD Team of Assessors for MBFHI sustainability

Best Practices/ Innovations for sustaining

MBFHI status

Hall of Fame Award based on guidelines set by the IYCF National Management Committee and upon

recommendation by the CHD’s

Hospital Self- Appraisal and Monitoring• Specific purposes of monitoring and

reassessment:- To support and motivate facility staff to

maintain baby-friendly practices.- To verify whether mothers experiences at

the facility are helping them to breastfeed.- To identify if the facility is doing poorly on

any of the Ten Steps and thus whether needs to do further work to make needed improvements.

 

Monitoring- Monitoring- a dynamic system for data collection & review that can provide information on implementation of the Ten Steps to assist with on-going management of the initiative.

Reassessment- Reassessment- “re-evaluation” of already designated baby-friendly hospitals to determine if they continue to adhere to the Ten Steps and other baby-friendly criteria.

PHOTOTHERAPY PHOTOTHERAPY

Most common treatment for reducing high bilirubin levels/ hyperbilirubinemia that cause jaundice in a newborn.

Goal: Decrease the serum unconjugated bilirubin level because a high level may lead to bilirubin encephalopathy (kernicterus).

Safe, effective, non- invasive and easy to use.

> Normal unconjugated bilirubin are 0.2 to 1.4 mg/dl. In newborns level must exceed 5 mg/dl before jaundice (icterus) is observable.

The ff: are the indicators of pathologic jaundice > Persistent jaundice over 2 weeks in a full- term

formula- fed infant > Total serum bilirubin level over 12.9 mg/dl

(term infant) or over 15 mg/dl (preterm infant); the upper limit for breastfed infant is 15 mg/dl.

> Increase in serum bilirubin by 5 mg/dl/day> Direct bilirubin exceeding 1.5 to 2mg/dl

Possible causes of hyperbilirubinemia in Possible causes of hyperbilirubinemia in newborns:newborns:

> Prematurity> Excess production of bilirubin (hemolytic

disease)> Disturbed capacity of the liver to secrete

conjugated bilirubin (e.g., enzyme deficiency, bile duct obstruction)

> Sepsis> Some disease states (e.g.,

hypothyroidism, galactosemia, infant of a diabetic mother)

Devices Used for PhototherapyDevices Used for Phototherapy Fluorescent tubes- Classified as: “daylight” (white), blue &

special blue- Narrow- spectrum blue lamps work best

while white fluorescent tubes are less efficient.

Halogen lamps- Most heat producing- Use a commercially available tungsten-

halogen light bulb and direct a strong beam of white/yellow light towards the infant

Devices Used for PhototherapyDevices Used for Phototherapy Fiberoptic systems- Deliver high energy levels but, but to a

limited surface area.- Low risk of overheating the infant. LED lights- Low power consumption- Low heat production- Longer life span of the light- emitting

unit

Factors Affecting the Dose of Factors Affecting the Dose of PhototherapyPhototherapy

1. Type of light used2. Light intensity3. Surface area of skin exposed to

light

The optimum distance of the light source from the baby is 30- 50 cm in conventional lights.

LED System

Halogen Lamp

Fiberoptic Fluorescent tube

Nursing Care and ProcedureNursing Care and Procedure Expose as much of the newborn’s skin as

possible. Cover the genital area, and monitor

genital area for skin irritation or breakdown.

Cover the newborn’s eyes with eye shields or patches; make sure eyelids are closed when shields or patches are applied and should be properly sized & correctly positioned.

Remove the shields or patches at least once per shift.

Nursing Care and ProcedureNursing Care and Procedure Measure the quantity of light every 8 hours. Monitor skin temperature closely. Increase fluids to compensate for water

loss. Monitor the newborn’s skin color with the

fluorescent light turned off, every 4 to 8 hours.

Monitor the skin for the bronze baby syndrome, a grayish brown discoloration of the skin.

Reposition newborn every 2 hours.

Nursing Care and ProcedureNursing Care and Procedure During breastfeeding switch off the

phototherapy unit. Provide frequent breastfeeding.

Keep baby at a distance of 45 cm from the source.

Monitor temperature every 2 to 4 hours. Maintain baby in a flexed position with

rolled blankets along the sides of the body.

Weight is taken at least once a day.

Nursing Care and ProcedureNursing Care and Procedure Ensure that serum bilirubin levels are

obtained as prescribed. Discontinue phototherapy when serum

bilirubin returns to a safe value as per unit protocol.

Accurate documentationdocumentation is another important nursing responsibility:

• time that phototherapy is started & stopped

• proper shielding of the eyes & covering of the genitals

• type of fluorescent lamp (by manufacture)

• no. of lamps• distance between

lamps & infant (should not be less than 45 cms.)

• use of phototherapy in combination with an incubator or open bassinet

• occurrence of side effect.

• length of time the bulbs have been used

• record VS every 2 hrs.

• maintain feeding and weight chart regularly

• serum bilirubin is monitored every 12 hrs.

Side Effects of PhototherapySide Effects of Phototherapy• Bronze- baby syndrome• Loose, greenish stools• Transient skin rashes• Hyperthermia• Increased metabolic rate• Dehydration• Electrolyte disturbance

Umbilical Umbilical CannulationCannulation

Indications for Catheterization• For frequent measurement of arterial

blood gases / other blood tests• For continuous arterial blood pressure

monitoring.• For exchange transfusion.• For administration of IV fluids Contraindications• Gastroschisis Peritonitis• Omphalocele Necrotizing enterocolitis• Omphalitis

Before initiating the procedure, a radiant warmer should be obtained, and the patient should be connected to a cardiac monitor.

Make sure that the baby’s condition & vital signs are stable.

Babies with umbilical lines can be safely nursed prone, provided that the lines have been correctly secured.

Equipment :Equipment :• Personal protective equipment (i.e.,

sterile gown, gloves, mask)• Sterile drapes• #3.5 or #5 Fr. Single or double lumen

umbilical catheter• Iris forceps without teeth• Small clamps• Scalpel• Scissors

• Tape measure• Limb restraints• Needle holder• Silk suture (3-0) or umbilical tape• Intravenous tubing and 3-way stopcock• Infusion solution (dextrose 5% in water

or 0.9% sodium chloride NaCl with heparin 1 U/mL solution)

Procedure:Procedure:• Perform the shoulder to umbilicus

measurement.a. Measure in a straight line parallel to the

neonate’s body and record in cm’s the distance from the infant’s distal end of the clavicle to the umbilicus.

b. Take the SU measurement and multiply x 0.66 for UAC placement plus stump length.

c. Multiply x 0.5 for UVC placement plus stump length. This length is needed to place the tip of the catheter between the diaphragm and

the right atrium.

• Restrain infant’s arms and legs. Observe buttocks, legs and feet for baseline color/perfusion prior to and following catheterization.

• Assemble equipment for UAC/UVC placement.

• Hold the umbilical cord clamp upward while the provider cleans the cord and surrounding skin with betadine swabs. The provider will drape the patient and place the umbilical tie around the stump of the cord.

• Using the scalpel, the cord is cut horizontally, approximately 1.5-2 cm from the abdominal wall.

• Hemostasis is achieved through tightening the umbilical tape or suture. The arteries do not usually bleed secondary to vasospasm.

• Forceps are then used to clear any thrombi and dilate the vein.

• A 3.5F catheter is used for preterm newborns, and a 5F catheter is used for full-term newborns.

• The catheter should be flushed with pre-heparinized solution and attached to a closed stopcock.

• The catheter is then grasped 1 cm from its distal tip with the iris forceps and gently inserted, aiming the tip toward the right shoulder. Advance the catheter only 1-2 cm beyond the point at which good blood return is obtained.

• Do not force the advancement.

• Secure the catheter with a suture through the cord, marker tape, and a tape bridge.

• The position of the catheter must be confirmed radiographically.

• In an emergency resuscitation, the catheter is best advanced only 1-2 cm beyond the point at which good blood return is obtained.

• To ensure an air-free catheter, fill the lumen with infusion solution and close the stopcock until the catheter is in the vein/artery.

Removal of UAC/UVC Removal of UAC/UVC • Identify patient per nursery procedure.• Restrain extremities.• Assemble equipment at bedside.• Wash hands and don clean gloves.• Remove the UAC/UVC tape from the

catheter.• Using the knife blade or scissors cut and

remove the sutures securing the UAC/UVC. Always cut away from the catheter.

• Turn the stopcock off toward the patient. Discontinue infusion.

• Withdraw the catheter gradually with steady continuous pulling action until all but approx. 2 cm of the catheter has been removed. Retape the UAC/UVC to the abdomen to prevent accidental dislodgment or tighten umbilical tie.

• Open the stopcock to air & observe for pulsation’s or blood return in the catheter. If pulsation’s or blood return is noted, return the stopcock to the off position and wait an additional 5-10 minutes before opening the stopcock to air again.

• If no blood return or pulsations are noted, the catheter may be slowly withdrawn.

• If bleeding occurs after removal of the catheter, tighten umbilical tie and apply continuous pressure with 4x4 sterile gauze for 3-5 minutes.

• Observe the umbilicus for bleeding after catheter removal.

• Document: Time UAC/UVC removed, amount of bleeding noted upon removal, patient’s tolerance of procedure

Nursing ManagementNursing Management• Ensure that the baby is comfortably

positioned, is normothermic and is stable before the procedure starts.

• Connections are checked at beginning of each shift to ensure they are secure and there are no kinks in the lines.

• The toes, feet and legs are checked frequently for changes in color and circulation. Cyanosis or pallor of toes/feet/buttock discoloration is reported to doctor immediately.

• Ensure there is no blood or bubbles present in the blood pressure line causing damping of the reading.

• Check umbilicus for oozing of blood regularly.

• UAC and UVC infusions are changed daily or as prescribed.

• Cleaning outer surface and umbilical stump with alcohol as needed.

• Positioning infant on back.• Securing connections and stabilizing

catheter with tape.

ComplicationsComplications• Infection• Hemorrhage• Vessel perforation• Air embolism• Catheter tip embolism• Portal venous thrombosis • Dysrhythmia and pericardial

tamponade or perforation (if the catheter is advanced to the heart).

PEDIATRIC/ PEDIATRIC/ NEONATAL NEONATAL

INTUBATIONINTUBATION

Indications• Ventilation – Apgar score 0-3,

ventilatory failure (or resuscitation), bag and mask unsuccessful or undesirable (diaphragmatic hernia, meconium aspiration)

• Obstruction - upper airway• Protection - from aspiration

Anatomic Considerations for Infant IntubationAnatomic Considerations for Infant Intubation• Larynx more anterior and cephalad• Tongue relatively large• Short neck• Epiglottis is longer, stiffer and protrudes at

45o angle• Trachea is short (easy for bronchial

intubation)• Elevation of hyoid bone may precipitate

apnea Cautions: Do not overextend neck in infants.• Never attempt procedure for more than 30

seconds at a time

Preparing for Intubation (Endotracheal)1. Recognize the need for intubation.2. Notify physician and respiratory therapist.

Ensure consent obtained if not emergency.3. Gather all necessary equipment:• Laryngoscope (with extra batteries and

bulbs)• Blades - Straight blade (infants and young children) - Curved blade (older children and adolescents)• Uncuffed tubes (infants to 8 years)• Cuffed tubes (8 years and older)

• Stylet• Suction device• Suction catheters (all sizes), Yankauer• ETCO2 detector (Pediatrics Only)• Magill forceps (if necessary)• Sterile water or lubricant• Fixation device (Neobar), scissors, tape,

etc.• Syringe• Sedation medications as ordered by the

physician.

Tube Sizes for Pediatric Tube Sizes for Pediatric Intubation Intubation

Age Endotracheal Tube(mm)

Suction Catheter

Premature 2.5 6F

Newborn 3.0 6F

6 month 3.5 8F

18 month 4.0 8F

3 years 4.5 8F

5 years 5.0 10F

6 years 5.5 10F

8 years 6.0 10F

12 years 6.5 10F

Blade Sizes For Pediatric Blade Sizes For Pediatric Intubation Intubation

Age Blade SizePremature No. 0 straight

MillerTerm newborn to 3- year old

No. 1 straight Miller

3- year old to adolescent

No. 2 straight Miller or curved Macintosh

Adolescent No. 3 curved Macintosh

Nursing ResponsibilitiesNursing Responsibilities• Obtain the necessary equipment and

ensure its working order. Explain to the child and the family the need for the procedure, as time permits.

• Don gloves, goggles and mask. • Select the correct size of the

laryngoscope blade and two Endotracheal tubes. Ensure that the distal end of the stylet is at least 2cm proximal from the tip of the endotracheal tube.

• Obtain and administer paralyzation and sedation medications.

• Place the child in the head-tilt position. • Hyperventilate the child a100 percent oxygen

using a bag-valve-mask device for several minutes prior to the intubation attempt.

• Place the laryngoscope in your left hand and open the child’s mouth with your right hand.

• Introduce the laryngoscope into the right side of the mouth, & sweep the tongue over to the left side; have suction readily available.

• If a curved blade is used, advance it gently until the tip is in the vallecula; if a straight blade is being used, tip should be placed just under the epiglottis.

• Once the vocal cords are visualized, the endotracheal tube is inserted until the black marker is at the level of the vocal cords. If the vocal cords are not easily visualized, slight external cricoid pressure may be helpful.

• Confirm correct tube placement:- Observe symmetrical chest wall movement. - Attach an end-tidal CO2 detector between

the bag-valve- mask device and endotracheal tube.

• Tape or tie the tube where the upper central incisors touch the endotracheal tube.

• Obtain a chest x- ray to confirm the tube’s placement. (when time permits.)

• Reevaluate the tube placement at frequent intervals and observe for complications.

• Explain to the family and the child why the tube is in place, how it works, why the child cannot speak and so forth.

DocumentationDocumentation• time of intubation• the size of the endotracheal tube• confirmation of the placement• medications administered • how the child tolerated the procedure• changes in the child’s condition.

Cardiopulmonary Cardiopulmonary ResuscitationResuscitation

(Hospital Setting)(Hospital Setting)

The 2010 AHA GuidelinesThe 2010 AHA Guidelines• Change in CPR Sequence (C-A-B

Rather Than A-B-C)• Continued emphasis on provision

of high-quality CPR.• AED Use in Children Now

Includes Infants• Removal of “look, listen, and feel

for breathing” from the sequence.

Prepared by: Julie Ann E. Cordovez, RNPrepared by: Julie Ann E. Cordovez, RNNursing Service- Ospital ng MakatiNursing Service- Ospital ng Makati