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NEONATAL NURSING

I. INTRODUCTION
The birth of the baby is one of life’s happiest moments. The birth of the
baby is usually occasioned by a well term baby and a healthy mother. The
period of first 28 days of life of a baby is called neonatal period. They truly
constitute the foundation of human life. Just as children are not mini adult,
neonates are not mini children. The unique health issues and problems due to
structural and functional immaturity of various body organs depending up to
their gestational age and birth weight. Newborn period is the most vulnerable
phase of life and deaths during first 28 days of life account for over 60% of all
infant deaths and 40% of all deaths of under five children. Essential newborn
care is required by all neonates whether they are born healthy or unhealthy.
Baby may be borne by vaginal delivery or cesarean delivery. In the first
hour or two hours after birth, most babies are in an alert, wide awake phase. A
newborn is considered as healthy when the infant is born at term, cries almost
immediately at birth, is having the adequate birth weight according to the
country [around 2.7 kg in India] and establishes satisfactory rhythmic
pulmonary respiration. The first hour after birth has a major influence on the
survival, future health, and wellbeing of a newly born infant. The health worker
has an important role at this time. The care they provide during this period is
critical in helping to prevent complications and ensuring survival.
II. A. MEANING AND DEFINITION OF NEWBORN
a. In medical contexts, newborn or neonate (from Latin, neonatus, newborn)
refers to an infant in the first 28 days after birth; the term applies to
premature, full term, and post mature infants; before birth, the term
“fetus” is used.
b. The Cambridge Dictionary meaning of newborn is a child that has
recently born.
B. DEFINITION OF NEWBORN
1. The Newborn or neonate as a child that’s fewer than 28 days old.
-World Health Organization (WHO)

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III.GOALS OF NEONATAL NURSING
1. Reduction of morbidity and mortality rate for newborn.
In a major boost to mortality and mortality rate in India, the child
deaths have come down and stand same as global average, according to a
report by UNICEF, WHO, UN population Division and World Bank
Group.
2. Promotion of the physical and physiological development of the child
within the family.
Newborn in the first week of life have no control over their
movement and all their physical activity is involuntary or reflex. Even
from birth babies can communicate with their near ones. A newborn
doesn’t realize they are a separate person. Proper care by family members
only may help the newborn to adjust with new world.
3. To provide evidence based practices to ensure survival of newborn from
birth up to the first 28 days of life.
Two thirds of all newborn deaths occur in the first 3 days of life
primarily due to complications of low birth weight, prematurity, birth
asphyxia and newborn infections. International evidences suggest that
there are several opportune moments during which prevention of newborn
death is possible through provision of high quality routine care during
labour, delivery and the immediate postpartum period.
4. To deliver time-bound core intervention in the immediate period after the
delivery of the newborn.
Protocols of four time bound interventions are;
 Immediate and thorough drying.
 Early skin to skin contact followed by,
 Properly timed clamping and cutting of the code after 1 to 3minutes,
and
 Non separation of the newborn from the mother for early
breastfeeding initiation and rooming in
5. To provide appropriate and timely emergency newborn care to newborns in
need of resuscitation
Recent global discussions have centered on expansion of immediate
emergency care of newborn to avert death and disability.

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IV. PRINCIPLES OF NEONATAL NURSING
1. PREPARATIONS FOR DELIVERY: all delivery equipment & supplies
including newborn resuscitation equipment should be ready (E.g.: The bag &
mask of resuscitation. A baby needing help to breathe could easily die or
suffer brain damage if a bag and mask is not working properly. so make sure
all equipment is checked daily well before using it). Warm & clean delivery
room should be needed and room temperature must be 250c. Warm baby
cloths, cap & socks (The temperature inside the mother’s womb is 38 C, once
the baby is born it is in a much colder environment and immediately starts to
lose heat) must arrange. Resuscitation equipment should always be close to
where the baby is being born and health workers must know how to use it
quickly and correctly. Equipment must be checked daily and well before a
delivery takes place.
2. DRY & ASSESS: Immediately dry the newborn with a dry towel. Then
assess heart rate, breathing while drying.(to identify who need resuscitation)
(Not all babies cry after delivery, but it doesn’t mean that they have got
asphyxia: if baby breathes regularly with frequency of 30-60 per minute but
does not cry, it means the baby is not asphyxic. This baby stays on mother’s
belly while provided regular care)
3. SKIN TO SKIN CONTACT: Contamination by mother’s microflora & to
prevent hypothermia skin to skin contact is necessary. Keep the baby with
mother immediately to feel security for the baby and start of early breast
feeding is important.
4. CORD CLAMPING: Most optimal time for cord clamping is the end of 1st
minute from delivery. If the newborn is in mothers abdomen, the cord
clamping should be postponed until the pulsation stops. The early cord
clamping is permitted only in urgent cases (if resuscitation is needed).
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Delayed cord clamping results in a shift of blood from the placenta to the
infant. Placental transfusion was about 80% at 1 minute and was practically
completed at 3 minutes. Placental transfusion associated with delayed cord
clamping provides additional iron to the infant's reserves and may reduce the
frequency of iron deficiency anemia later in infancy. Delaying cord clamping
also favors early contact between mother and baby. In addition, it also
reduces splashing of blood, which helps protect the birth attendant in areas
where HIV infection is common. Delaying cord clamping by 30 to 120
seconds, rather than early clamping, seems to be associated with less need for
transfusion and less intraventricular haemorrhage.
5. START OF EARLY BREAST FEEDING: Skin to skin contact starts when
the baby’s attatchment to breast when he is ready (council mother how to
attach her baby to the breast when he is ready). Check the correctness of
attatchment & feeding and give the newborn the oppurtunity to suck from
both breasts long as they need. It is important to provide rooming in mother
& newborn as long as possible and postpone weighing, washing etc. upto first
feeding. Put the baby next to the breast with its mouth opposite the nipple
and areola. Let the baby attach to the breast by itself when it is ready. Do not
let a health worker attach the baby. When the baby is attached, check that the
attachment and positioning are correct, and help the mother to correct
anything which is not quite right and to help support her baby if needed. Help
the mother and baby into a comfortable position and tell the mother, when
her baby begins to show signs of wanting to feed, to help it into a position
where it can easily reach her breast. This can take up to 1 hour after delivery.
The baby will open its mouth and start to move its head from side to side, it
may also begin to dribble. The baby should have no other foods or drinks
apart from colostrum, as these reduce the amounts of protective and growth
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factors the baby receives from this important first milk. Colostrum is
produced in small amounts. It contains protective factors in a concentrated
form which the newborn baby needs to keep him healthy. It is a natural form
of immunization. Let the baby feed for as long as it wants, with no
interruption. When it finishes feeding on one breast let it feed from the other
breast. Keep the mother and baby together for as long as it is possible after
delivery. Unless there is a good medical reason delay the initial routine birth
procedures, such as weighing until after the first feed. This first time together
is very important in helping the mother and baby to get to know each other
and to form a close loving relationship. Maternal procedures can be done
with a baby in skin-to-skin contact unless she needs treatment requiring
sedation.
6. PROPHYLACTIC ACTIVITIES: If the baby had conjunctivitis 1% silver
nitrate / 0.5% erythromycin oinment / 1% tetracycline is used. Prevention of
newborn ophthalmia- 1% tetracycline or 1% tetracycline is effective against
neisseria gonorrhea & chlamydia trachomatis & have no side effects. For
effective prevention, the ointment must be applied with in 1 hour after
delivery. Use of vitamin-k helps to prevent bleeding & hemorrhagic disease.
A single dose (1.0 mg) of intramuscular vitamin k after birth is effective in
the prevention of classic HDN. Either intramuscular or oral (1.0 mg) vitamin
k prophylaxis improves biochemical indices of coagulation status at 1-7
days). Thermal regulations required to comfort the new born. A newborn
cannot regulate his temperature and need protection from hypothermia so
protect the baby from draught by setting the room temperature >25.
Immediate drying, skin-skin contact, early start of breast feeding, appropriate
clothing, rooming-in, warm transportation, resuscitation in warm conditions
are necessary in newborn care.
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7. INITIAL ASSESSMENT BASED ON APGAR (ACTIVITY PULSE
GRIMACE APPEARANCE RESPIRATION) SCORE: At the end of 1 and 5
minutes the baby’s score is less than 6, the baby needs to be re-assessed at 15
and 20 minutes until get 7 points and more. The APGAR SCORE is not the
indication for resuscitation, as resuscitation is to be started immediately after
the birth of the baby.
Breathing Check whether the baby is breathing. If so, evaluate the rate,
depth and symmetry of breathing together with any evidence of an abnormal
breathing pattern such as gasping or grunting. Heart rate is best assessed by
listening to the apex beat with a stethoscope. Feeling the pulse in the base of
the umbilical cord is often effective but can be misleading, cord pulsation is
only reliable if found to be more than 100 beats per minute (bpm). For
babies requiring resuscitation and/or continued respiratory support, a modern
pulse oximeter can give an accurate heart rate. Colour is a poor means of
judging oxygenation, which is better assessed using pulse oximetry if
possible. A healthy baby is born blue but starts to become pink within 30 s
of the onset of effective breathing. Peripheral cyanosis is common and does
not, by itself, indicate hypoxemia. Persistent pallor despite ventilation may
indicate significant acidosis or rarely hypovolaemia. Although colour is a
poor method of judging oxygenation, it should not be ignored: if a baby
appears blue check oxygenation with a pulse oximeter. Tone A very floppy
baby is likely to be unconscious and will need ventilatory support. Tactile
stimulation Drying the baby usually produces enough stimulation to induce
effective breathing. Avoid more vigorous methods of stimulation. If the
baby fails to establish spontaneous and effective breaths following a brief
period of stimulation, further support will be required.

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V.ASSESSMENT OF NEWBORN
Assessment of newborn, as soon as possible after birth and subsequent
assessment in the postnatal period are vital responsibility of the nurse working in
the hospital or in the community. The assessment postnatal period should be done
at least for three times,

a. Initial assessment
After the birth of the baby, a complete assessment of the baby should be done so as
to find out any early abnormalities and treat them properly. The systematic
examination of the baby is done from head to toe as mentioned below:
Anthropometric measurements
Head circumference - 33 to 35 cm
Chest measurement -31 to 33 cm
Crown heel length - 45 to 55 cm
Weight of the baby -
Vital signs
Respiration is regular and shallow. Respiratory rate is between 40-60 breaths per
minute. The heart rate varies from 120-140 beats per minute. Blood pressure
ranges from 60-80 mm Hg systolic and diastolic pressure below 50 mm Hg. The
normal temperature of the baby is about 97.5°F (36.4°C) but this can be varying
slightly.
Skin
The skin is pink, soft and covered with vernix caseosa. There can be presence of
Mongolian spots (bluish pigmentation, especially over sacral area), stork’s bite,
portwine stain or strawberry marks (dark red spots on the body). Bluish color of
the extremities may sustain for several hours after the birth.
Head
There is one anterior fontanels and one posterior fontanel. Observe for bulging or
depressed fontanels, which indicate intracranial pressure or dehydration. Caput

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succedaneum may be seen which should be differentiated from cephalhematoma.
There can also be the overlapping of the cranial bones during delivery.
Moulding occur when the engaging (usually vertex molds to fit cervix)
during labour which appears asymmetric after birth. After few days head restores
its shapes.
Eyes
Eyes are shut most of the times. Pupils react to the light. Newborns cry tearlessly
due to immature lacrymal ducts.
Nose
The patency of the nasal airways is checked and mucus secretions should be
cleared. Neonates generally breathe through the nose. Check for milia. Nasal
flaring is a sign of respiratory distress.
Ears
The ears are checked for size, shape and any deformity. The ears of premature
infants lack cartilage. Pinna bends easily and should recoil after bending. The level
of top part of external ear should be on a line drawn from inner canthus to outer
canthus of eye. Low set ears are found in certain chromosomal abnormalities
(trisomy 13 & 18)
Mouth
It can be best examined when the neonate is yarning or crying. Mouth can be
assessed for cleft lip and palate. Observe the natal teeth (natal teeth present at birth
some times and erupt within one month of age). Assess for the epithelial pearls or
Epstein’s pearl which the tiny cysts are found on the hard palate. Tongue tie should
be checked, which is a small thickened band from the frenulum is extending to the
margin of the lower gum preventing protrusion and upward movement of the
tongue.
Neck
Neck should be checked for its free movability, tightness of muscles, brachial
palsy or fractured pelvis. Normal newborn have full range of motion

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Chest
Observe size and shape of chest. Normally, neonate chest is barrel shaped. Observe
the nipple and breast tissues; observe witch’s milk which is milky discharge due to
effect of maternal hormones. Check the rate and rhythm of respiration, neonates
abdomen rise and falls during each breathe. Chest should be two inches smaller to
head. Clavicles are straight. Breasts may be engorged which subside by one week.
Umbilical cord
The stump of the umbilical cord has three blood vessels, i.e., two arteries and one
vein.
Upper extremities
Arms are checked for their normal size. In the term baby, fingernails are well
developed. There can be abnormal fusion of the fingers. Presence of extra digits is
called as polydactylism. Syndactylism is birth defect in which there is partial or
total webbing connecting two or more fingers or toe.
Genitalia
In the normal term male baby, testes can be palpated in the scrotum. Concurrently,
the scrotal skin thickens and develops deeper and more numerous rugae present.
Inspect for urethral opening on tip of penis. Exclude opening on dorsal (epispadias)
or on ventral side (hypospadias). In female babies, labia minora is covered by labia
majora, baby girls may have prominent clitoris and there can be presence of some
vaginal discharge or pseudomenstruation due to withdrawal of the maternal
hormones.
Back
For checking the back, infant is held in prone position and the back is evaluated. If
tufts of hair are present, it indicates fistula. Assess for spina bifida, a birth defect in
which a developing baby’s spinal cord fails to develop properly, it may leads to
deformities from scoliosis to deformities of lower extrimities.
Anus
After the birth of the baby, anus is checked for perforation. A rubber catheter is
introduced into the rectum to check the passage of the stool.

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Lower extremities
Assess the size and symmetry of the legs. One can doubt hip dislocation if there is
asymmetry in abduction and there is presence of hip click.
In feet Polydactylism, syndactylism and webbing can be assessed in the toes.
Presence of some congenital abnormalities should be noted, such as, talipes
equinovarus, talipes calcaneovalgus and bow legs. The soles of the term neonate
should be wrinkled and in some cases acrocyanosis may be present immediately
after birth
Talipes equinovarus , a Club foot, a congenital abnormality in which one or both
feet are rotated internally.
Talipes calcaneovalgus, a congenital abnormality that is combination of talipes
calcaneus and talipes valgus, in which there is dorsiflexed, everted and abducted
foot.

b. Daily or routine assessment


After initial assessment, daily assessment is performed to identify the problems at
an early stage.
Vital signs - Temperature is checked axillary to look for thermal regulation.
Respiration should be regular and without any noise. Heart rate is auscultated
Weight - Weight is checked regularly. Initially, there is loss in the weight for few
days, but the baby regains the weight in 7-10 days.
Head - Anterior fontanelle is assessed any swelling on the head is also checked
such as cephalhematoma or caput succedaneum
Skin colour - Skin is assessed for any cyanosis. In some babies jaundice may
arises in 2nd to 3rd day and in certain abnormal cases jaundice can arise early.
Mouth - Mouth should be checked for any infection such as oral thrush ( adherent
white plaques).
Umbilical cord - Infection can arise, so umbilical cord should be assess daily until
it fall off.

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Feeding behaviour -Nurse should assess the feeding behavior of the baby. If there
are any problems in feeding, it should be brought to the notice and treated.
Urine and stool - Elimination pattern is to be assessed. Stool of the baby is
inspected for its normalcy. Constipation or loose stools should be treated. Mother
or nurse can note the frequency of passing urine and stool.

Reflexes
Following reflexes are found in the baby at birth;
Reflexes Eliciting the reflex Characteristic comments
responses
Sucking Touch infant’s lip, Infant turns head Disappears after
and rooting cheek, or coner of toward stimulus, 3 to 4 months but
mouth with nipple open mouth, takes may persist up to 1
hold, and suck year. If response is
weak or absent,
consider
prematurity or
neurologic defect
Swallowing Feed infant; Swallowing is Sucking and
swallowing usually usually coordinated swallowing are
follows sucking and with sucking and often
obtaining fluids usually occurs uncoordinated in
without occurs preterm infant
without gagging,
coughing, or
vomiting
Grasp; Place finger in palm of Infant’s fingers curl Response lessens
palmar hand around examiner’s by 8 months
fingers
Plantar Place finger at base of Toes curl
toes downward
Extrusion Touch or depress tip Newborn forces Response
of tongue tongue outward disappears about
fourth month of
life
Glabellar Tap over forehead, Newborn blinks for Continued
(Myerson bridge of nose, of first four or five blinking with
sign) newborn whose eyes taps repeated taps is
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are open consisted with
extra pyramidal
disorder
Tonic neck With infant falling With infant facing Responces in leg
or fencing asleep or sleeping, left side, arm and are more
turn head quickly to leg on that side consistant, after 6
one side extend; opposite weeks persisting
arm and leg flex response is sign of
(tern head to right, possible cerebral
and extrimities palsy.
assume opposite
postures)
Moro Hold infant in Symmetric Response is
reflex semisitting position, abdomen and present at birth,
allow head and trunk extension of arms complete response
to fall backward to an are seen; fingers fan may be seen in 8
angle of atleast 30 out and form a ‘c’ wk; body jerk is
degrees with thumb and seen only between
forefingers; slight 8 to 18 wks;
tremor may be response is absent
noted by 6 mo;
Preterm infant does Response is
not complete incomplete if
“embrace” instead infant is deeply
arms fall backward asleep
because of
weakness
Stepping or Hold infant vertically, Infant will Response is
walking allowing one foot to stimulate walking, normally present
touch table surface alternating flexion for 3 to 4 wk
and extension of
feet; term infant
walk with their sole
of feet, and preterm
infants walk on
their toes
Crawling Place newborn on Newborn makes Response should
abdomen crawling disappear about 6
movements with wk of age
arms and legs.
[12]
Deep Use fingers to elicit Reflex jerk is Responces can be
tendon patellar or knee jerk present; even with used to the
reflex; newborn must newborn relaxed, presents of a
be relaxed nonselective overall neuromuscular
reaction may occur disease.
Closed Infant should be Opposite leg flexes, This reflex should
extension supine; extend one adducts, and then be present during
leg, press knee extends newborn period
downward, stimulate
bottom of foot;
observe opposite leg
Startle Perform sharp and Arms abduct with Response should
clap; best elicited if flexion of elbows, disappear by 4
newborn is 24 to 36 hr hands stay clenched months of age.
old or older Response is
elicited more
readily in preterm
newborn
Babinski On sole of feet, All toes Absence requires
sign beginning at heel, hyperextend, with neurologic
stroke upward along dorsiflexion of big evaluation, should
lateral aspect of sole, toe; recorded as a disappear after 1
then move finger positive sign year of age
across ball of foot
Pull-to-sit Pull infant up by Head will hold until Response depends
(traction) wrists from supine infant is in upright on general muscle
position with head in position, then head tone and maturity
midline will be held in same and condition of
plane with chest infant
and shoulder
momentarily before
falling forward
infant will attempt
to right head
Trunk Place infant prone on Trunk is flexed, and Response
incurvation flat surface, run finger pelvis is swung disappears by
(galant) down back about 4 to toward stimulated fourth week.
5 cm lateral to spine, side Absence suggests
first on one side and general depression
then down other of nervous system
[13]
with transverse
lesion of cord, no
response below the
level of lesion is
present
Magnet Place infant in a Both lower limbs Absence suggests
supine position, should extend damage to spinal
partially flex both against examiner’s cord or
lower extremities, and pressure malformation.
apply pressure to soles Reflex may be
of feet weak or
exaggerated after
breech birth
Additional These responses are May be slightly Parental guidance:
newborn spontaneous behaviors depressed most of these
responses: temporarily because behaviors are
yawn, of maternal pleasurable to
stretch, analgesia or parents. Parents
burp, anesthesia, fetal need to be assured
hiccup, hypoxia, or that behaviors are
sneeze infection normal
Sneeze is usually
response to lint,
etc., in nose and
not an indicator of
a cord
No treatment is
needed for
hiccups; sucking
may help

c) Behavioral assessment

Another important area of assessment is observation of


behavior. Infants behavior helps to shape their environment, and their ability to
react to various stimuli affects how others relate to them. The principal areas of
behavior for newborns are sleep; wakefulness; and activity, such as crying.

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An assessment of the neonate's behavioral responses should be a part of every
pediatric examination. A behavioral assessment reflects the capacity for integration
of the central and autonomic nervous systems and therefore is a window to the
wellbeing of the newborn. In order to fully understand and evaluate the
significance of the newborn's behavior, it is essential to put this examination into
context by a complete prenatal and perinatal history. Behavioral assessments of the
newborn are being increasingly utilized to evaluate effects of intrauterine
experiences, such as fetal malnutrition, exposure to alcohol and drugs, obstetric
procedures such as maternal anesthesia and analgesia, cesarean section, as well as
the effects of techniques in neonatal management, such as phototherapy and drugs.
Behavioural assessments can give us insights into individual differences among
neonates and cross-cultural differences among groups of newborns. Behavioural
assessments over time will give us insight into a baby's capacity to adapt to his
environment and to overcome the physiologic stresses of delivery. We can begin to
assess a baby's potential availability for processing information necessary to future
progress. It may predict to his capacity to capture the attachment energies of his
environment as well.

In its most limited use, neonatal behavior becomes a sensitive indicator of the
integrity of the central nervous system. In a more general sense, behavioral
responses can be tied to other responses to reflect the integrity of the whole
organism. And, eventually, the infant's capacity for total responses can become a
measure of prediction for the response of the environment to him. Thus, behavioral
assessment in the neonatal period can predict the risk in the infant himself and to
deficits in his environment as he becomes a participant in parent-infant interaction.
Evaluation of a baby's abilities to respond and style of response provides the
clinician with a powerful tool in his role of helping parents to foster a child's
physical and emotional wellbeing. The pattern of recovery of his potential for
behavior over the first week becomes the most important way of predicting not
only to his immediate coping capacity but to his future reactions to stress. Thus,
several assessments in the perinatal period become of significance.

It is important now to follow up our neonatal behavioral assessment with


behavioral assessments throughout the first year of life to begin to understand how
developmental processes include both the infant's capabilities and those of his
environment, as well as the relationship between them. This will give us a better

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handle on our goals to optimize emotional as well as physical development in our
work with parents and their infants.
Patterns of Sleep and Activity: Newborns begin life with a systematic schedule
of sleep and wakefulness that is initially evident during the periods of reactivity.
After this initial period, it is not unusual for the infant to sleep almost constantly
for the next 2 to 3 days to recover from the exhausting birth process.
Infants have six distinct sleep-wake states, which represent a particular form of
neural control. As maturity increases, each state becomes more precisely defined
according to the behaviors observed. State is defined as a “group of characteristics
that regularly occur together” (Blackburn, 2003) and includes body activity, eye
and facial movements, respiratory pattern, and response to internal and external
stimuli. The six sleep-wake states are quiet, (deep) sleep, active (light) sleep,
drowsy, quiet alert, active alert, and crying. Infants respond to internal and external
environmental factors by controlling sensory input and regulating the sleep-wake
states; the ability to make smooth transitions between states is called state
modulation. The ability to regulate sleep-wake states is essential in infants’
neurobehavioral development. The more immature the infant, the less able he or
she is able to cope with external and internal factors that affect the sleep-wake
patterns.
Newborns typically spend as much as 16 to 18 hours sleeping and do not
necessarily follow a pattern of light-dark diurnal rhythm. With increasing age,
sleep-wake states change, with increasing amounts of time spent in awake alert
states and decreasing amounts of sleep time. Approximately 50% of total sleep
time is spent in irregular or rapid eye movement sleep.
Cry. Newborns should begin extrauterine life with a strong, lusty cry. The sounds
produced by crying can be described as hunger, anger, pain, and “bid for attention”
cries. Discomfort (pain), sounds initially consist of gasps and cries in which the
consonant H is clearly distinguishable. The duration of crying is as variable in each
infant as the duration of sleep patterns. Newborn may cry as little as 5 minutes or
as much as 2 hours or more per day. Feeding usually terminates the state of crying
when hunger is the cause. Holding the infant skin to skin or waddling or wrapping
an infant snugly in a blanket promotes sleep and maintains body temperature.
Rocking the infant may reduce crying and induce quiet alertness or comfort.
Variations in the initial cry can indicate abnormalities. A weak, groaning cry or

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grunting during expiration usually indicates respiratory disturbance. Absent, weak,
or constant crying requires further investigation for possible management
VI. CHARACTERESTICS OF NEWBORN
Physical Characteristics of Healthy Neonates
A healthy newborn usually has the following physical characteristics:

a) Vital signs: Temperature should be recoded to detect cold stress or


hypothermia. Skin temperature is measured usually by axillary method.
Respiration, heart rate and blood pressure should also be recorded (when the
baby is quiet) to detect the physiological status.
Normal vital signs
 Temperature 35.5°C to 37.5°C
 Pulse 100 to 140 beats/minute
 Respiration 30 to 50 beats/minute
b) Anthropometric measurement: The results of five anthropometric parameters
are birth weight, crown heel length, head circumference, chest circumference
and ponderal index provides references for the care of newborns.
Anthropometric measurements are of both epidemiological and clinical use.
 Weight: The average weight of a normal full term newborn infant is about
2.9 kg with variation of 2.5 to 3.9 kg or more. The weight is very variable
from country to country and in different socioeconomical status.
 Length: At birth the average crown heel length of the term infant is 50 cm
with the range of 48-53cm. The length is a more reliable criterion of
gestational age than the weight.
 Head circumference: The head circumference is usually varies from 33 to
37 cm, with the average of 35 cm.
 Chest circumference: The chest circumference is about 3 cm less than head
circumference. The chest is rounded rather than flattened anteroposteriorly.
 Ponderal index: Is an index of weight in relation to height. a ponderal index
2.5 is considered as normal in neonate.
c) Head to toe

General appearance: The upper segment to lower segment ratio is 1.8: 1. The
midpoint of the length/ stature of the neonate lie approximately at the level of the

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umbilicus, instead of the symphysis pubis as in grown up child and adults. The
trunk is relatively larger and the extremities are short. Abdomen is prominent with
short neck and large head.
Posture: The neonate lies in a posture of partial flexion attitude as in utero.
Skin: The skin is pinkish but bluish hands and feet (acrocyanosis) may present for
a short time after birth, even in normal infant. Skin may be covered with
vernixcaseosa and lanugo hair, especially at back. Only large veins are seen
prominently, skin shows good elasticity or turgor.
Head: The head may show moulding and caput succedaneum. Hair is silky, black
coarse and individual strands distribution on scalp.
Face : The maxillary and ethmoid sinuses are small. The frontal and sphenoidal
sinuses are poorly developed
Ear: The ear cartilage is firm and fully curved, showing good elastic recoil. Pinna
is firm with definite cartilage and instant recoil in ears. The external auditory canal
is relatively short and straight. The eardrum is thick. The eustachian tube is short
and broad
Eyes :The eyes are largely covered with eye lids.
Trunk :The breast nodule is palpable, measuring over 5 mm in diameter. breast
tissue and nipple raised above skin level
Foot: The entire sole of foot shows prominent deep creases.
Abdomen: Kidney, liver and spleen may be palpable.
Male genitalia: The scrotum shows adequate rugae with deep pigmentation and
palpable testes (at least one).
Female genitalia: In female baby the labia majora completely covers the labia
minora and clitoris.
VII. NURSING CARE OF NEWBORN AT BIRTH
1) Introduction

Every year about 27 million babies (20%of global birth) are born in India and
almost 1.2 million die during newborn period accounting for 30% of global deaths.
In order to reduce neonatal mortality, essential or basic newborn care services

[18]
should be available at all the health care level because they are highly cost-
effective. The component of essential newborn care services include good quality
antenatal care (at least 3 antenatal visit), safe delivery and optional care at birth,
promotion of exclusive breast feeding, prevention and early treatment of
hypothermia and bacterial infections.
2) Definition

Essential newborn care is a comprehensive strategy to reduce the death of newborn


through cost effective interventions, during pregnancy, immediately after birth and
postnatal period.
3) Objectives of newborn care

1. To make sure baby is thriving


Poor nutrition during this period may have lasting harmful effects on
brain development. Most babies double their birth weight by 6 months and
triple it by age 1, but kids who fail to thrive usually don’t meet those
milestones.
2. Early detection of problems or danger signs.
The important danger signs are: lethargy, breathing problems,
temperature instability, and failure to pass meconium and/or urine, vomiting,
diarrhea, cyanosis, jaundice, abdominal distention, convulsions, bleeding
and excessive loss of weight.
3. Helping the mother to meet the baby’s basic needs- warmth, feeding,
infection prevention. Advising mother and family members about danger
sign and baby care.
4. Baby breast feed early as possible.
Breastfeeding within an hour after birth is critical for saving newborns
lives. Skin to skin contact along with suckling at the breast stimulate the
mother’s production of breast milk, including colostrums, also called the
baby’s ‘first vaccine’ which is extremely rich in nutrients and antibodies.
5. Advising and encouraging the mother to breast feed exclusively
Encouraging mother to give only breastfeeding frequently, day and
night, and advise the mother to allow the baby to feed as long as baby wants
more than eight times a day. It makes positive association between mother
and newborn.

[19]
6. Treatment of key problems such as asphyxia and sepsis
Neonatal sepsis or septicemia is a clinical syndrome characterized by
systemic signs of circulatory compromise in the first month of life was
usually fatal. Parental antibiotic therapy is needed. Birth asphyxia is
medical condition resulting from deprivation of oxygen to a newborn infant
that lasts long enough during the birth process to cause physical harm,
usually to the brain.
7. Making plans for continuing care, immunizations and growth monitoring.
Plotting the information on a growth chart to make abnormal growth
visible. According to which make plan for further movements about
newborn care.
a) IMMEDIATE CARE OF NEWBORN AT BIRTH
The following care needs to be given to the new born at birth, in the labor room
1. Deliver the baby on a warm and clean towel.
2. Establish and maintain a patent airway.
3. Apgar score
4. Clamp and cut the cord.
5. Ensure warmth and feeding.
6. Care of eyes.
7. Care of skin.
8. Assessment and documentation of baby’s condition
9. . Identification of baby.
10.Administration of vitamin K.
11.Transfer of the baby according to level of care required.
1. Deliver the baby on a warm, clean and dry towel.
2. Establish and maintain a patent airway: The neonate cries spontaneously at
birth. During crying the secretions of mouth and nose are suctioned to clear the
airway of mucous and amniotic fluid. If the baby is not crying, gentle tactile
stimulation is provided. If the child does not cry even after stimulation, CPR
should be given. Suction of baby’s mouth and nose should be done using a bulb
syringe or mucous trap. Gentle suction should be done to prevent bradycardia,
laryngospasm and cardiac arrhythmias from vagal stimulation.
3. Apgar score: it is a scoring system doctors and nurses used to assess newborn
one minute and five minutes after they’re born. Dr. Virginia apgar created the

[20]
system in 1952, and used her name as a mnemonic for each of the five categories
that a person will score. The baby may score low at one minute, at the five minute
the baby has ideally improved. A score of 7 to 10 after 5 minutes is reassuring. A
score of 4 to 6 is moderately abnormal. A score of 0 to 3 is concerning, it indicate a
need for increased interventions usually is assistance for breathing.
SIGNS 0 1 2
Heart rate Absent Slow (<100) >100
Respiratory rate Absent Slow, weak cry Good cry
Muscle tone flacid Some flexion of Well flexed
extremities
Reflex irritability No responce Grimce Cry
Color Blue, pale Body pink, Completely
extrimities blue pink

4. Clamp and cut the cord: The umbilical cord is clamped when the cord pulsation
stops as this provides the infant with extra blood from the placenta. The cord is
clamped with two clamps and then cut between the clamps leaving about 1 or 5 cm
from abdomen of baby. The stump is left without any dressing and it is inspected
repeatedly for any bleeding for up to 24 hours. It is observed routinely for any
redness, inflammation and discharge till it falls off.
5. Ensure warmth: In neonates, the heat regulating mechanism is immature. The
neonate loses heat due to evaporation, radiation, conduction and convection. To
prevent heat loss from the baby following steps should be taken:
 The delivery room should be warm, with temperature of 25°-28°C.
 Dry the infant thoroughly soon after birth using a warm towel.
 Place the baby under radiant warmer or over the mother’s chest in skin to
skin contact with her.
6. Care of eyes: The eyes of the neonate are cleaned as soon as the head is
delivered using sterile cotton swabs dipped in sterile water. The eyes are cleaned
from inner canthus to outer canthus with separate swabs for each eye. Thereafter
medicated eye drops should be instilled to protect baby’s eyes from bacterial
infections that may be contracted during delivery.

[21]
7. Care of skin: The newborn’s skin is delicate so it should be gently wiped off
blood, mucous and secretions. No attempt should be made to rub off the protective
vernixcaseosa. The areas with folds Such as neck, axillae, groins and creases at
joints require special attention. The practice of giving bath to the baby at the time
of birth increases the risk of hypothermia so bathing should be postponed for 48-72
hours or more after birth depending on baby’s condition.
8. Assessment and documentation of infant’s condition: At 1 minute and 5
minute of birth Apgar scoring is done and while drying the baby head-to-toe
assessment is done to find out any abnormality in the new born. Administration of
vitamin K.
9. Identification of the baby: Before the baby is transferred from the labor room,
an identification band placed to baby’s wrist, specifying the name of mother,
registration number, date and time of birth and sex. Also foot impression of baby is
taken for baby’s identification. It is important to provide mother an opportunity to
see and touch the baby and note the sex before transferring the baby to the nursery.
10. Administration of vitamin K: For a few days after birth, the new born is unable
to synthesize vitamin K that is needed for blood clotting so there is a potential
problem of abnormal bleeding. Therefore 1mg Vitamin K is administered to the
baby intramuscularly.
11. Transfer: All the normal babies are transferred to the mother and nursed then
keep the baby comfortable with the mothers. This is called rooming in. Breast
feeding should be started within half an hour of birth. However Sick or at risk
neonates should be transferred to a Neonate Intensive Care Unit (NICU).
Level II Nursery: Preterm babies with i) Gestational age between 32 & 36 weeks
ii) Low birth Weight (1500-2000gm) iii) Major congenital malformation or iv)
Suspected of having aspirated meconium, should be transferred to special care
nursery.
Level III Nursery: The following categories of neonates should be admitted to
Intensive Care Nursery i) Birth weight less than 1.5kg ii) Gestational Period less
than 32 weeks iii) Neonates with respiratow distress iv) Infants with convulsions,
central cyanosis (Congenital heart disease), severe Neonate jaundice
(erythroblastosisfetalis) and those requiring major surgery.

[22]
b) DAILY AND ROUTINE CARE OF NEW BORN

Daily care of new born includes the care that baby needs after being transferred to
postnatal ward. It includes
i. Rooming In
ii. Initiating feeding
iii. Observation for early signs of diseases
iv. Prevention of infections
v. Care of bladder and bowel
vi. Maintenance of personal hygiene
vii. Parental teaching and follow-up

i. Rooming –In
After the baby is transferred to the post natal ward, he should be nursed in a
bassinet beside the mother’s bed. This is called rooming-in. It has the following
advantages. Promote early initiation of breast feeding. Provide opportunity for
mother-baby interaction and bonding. Relieves mother’s anxiety related to where
about of the baby.
ii. Initiating feeding
Breast feeding must be initiated as soon as possible to prevent neonatal
hypoglycemia. As soon as the mother has recovered from the fatigue of labor,
preferably within half an hour of birth, the baby should be put to breast. The baby
must receive 23olostrums secreted during first 2-3 days after birth. Colostrum is
rich in protective antibodies so provides passive immunity to the baby and it also
has high nutritive contents.
iii. Observation for early signs of disease (warning signs of complication)
A daily routine examination should be done till the mother and baby is discharged
from the hospital. The nurse should carefully watch for the following danger signs
and report immediately to the physician. These danger signs are
Failure to pass meconium within 24 hours of birth.
Failure to pass urine within 48 hours of birth.
Bleeding from any site.
Failure to take feed.

[23]
Excessive crying or undue lethargy.
Jaundice within 24 hours of birth (Pathological Jaundice)
Hypothermia (< 36 to 36.5°C) or hyperthermia (rectal temperature of 100.4°F
(38°C)
Seizure – nerve cell activity in the brain is disturbed causing seizures.
Persistent vomiting or diarrhea
Breathing difficulty, if it is noisy need to notice like whistling noise means
blockage in the nostrils.
Evidence of superficial infection like oral thrush, conjunctivitis, umbilical
cord infection, pustules on skin etc.
Apart from observing the baby for the above stated danger signs, the baby should
be weighed daily at same time. Also monitor vital signs regularly.
iv. Prevention of Infection
The neonate’s defenses against infection are not mature so they are susceptible to
infection. Following things must be kept in mind to prevent them from infection
 All personnel coming in contact with the baby should be free from infection.
Hand washing should be practiced strictly.
 Strict aseptic precautions should be taken while handling the baby.
 The personal hygiene of mother and baby should be maintained.
 Restrict the number of visitors attending the baby.

v. Care of bladder and bowel


If the neonate fails to pass urine and stool within 24 hours of birth, it should be
notified to the physician. The urine output is about 200-300 ml by the end of first
week of life so neonate voids about 15-20 times in a day. Diaper should be
changed as soon as wet. The neonate also passes stool frequently so diaper area
should be cleaned with mild soap and water. The baby should be kept clean and
dry.
vi. Maintenance of personal hygiene
The personal hygiene of both baby and mother should be maintained to prevent
infections. The baby should be given sponge bath daily in summers and every
alternate day in winters. Care should be taken to prevent chilling and draughts
while giving dip bath to the baby. Lukewarm water and mild baby soap should be

[24]
used for giving baby bath. Special attention should be paid to skin creases at axilla,
neck, groin and thighs. Vernixcaseosa should not be rubbed off during bath.
vii. Eye care and cord care

After giving bath, dry the baby thoroughly and put on soft clothes. The umbilical
stump should be cleaned Using Betadine solution. The cord dries and falls off
within 10-14 days. Eye care should also be done daily Using sterile swabs dipped
in sterile water. Eyes should be cleaned from inner canthus to outer canthus Using
separate swab for each eye.
viii. Parental teaching and follow -up

The period when mother is in post natal ward can be utilized for teaching the
mother about all aspects of baby care. Parents are taught to observe the child’s
daily behavior related to feeding, sleep, activity, cry. elimination etc. Parents need
to be told about holding the baby, baby bath, eye and cord care, feeding and
nutritional supplements, immunization, prevention from infection and followup.
The parents should be educated about the danger signs in the baby, which if
present require immediate hospitalization.
VIII. CARE OF NEWBORN AND FAMILY
 Clean childbirth- Child birth is performed in a clean, hygienic, sterile way,
unclean delivery room predisposes to the infections. Baby is handled gently
after birth and sex is noted.
 Cord care- Clamps are applied on the umbilical cord and cut in between in
separate the baby from the placenta. After cutting and clamping the cord, it is
checked for any redness, tenderness or oozing. 1n hospital deliveries, cord m
is performed daily in which the base, stump and cord is cleaned.
 Initiation of breathing and resuscitation- Breathing starts Spontaneously
the baby after the first cry, if not, resuscitative measures are to be followed
 Prevent new infection- Prevention of infection is an essential aspect. As the
immunity of the baby is not so well developed, so he is prone to infections.
 Thermal protection- Baby has to be kept warm. The baby is wiped and dried
so that heat loss is minimized. Baby can be kept under the radiant warmer or
the warm blankets. Skin to skin contact with the mother is helpful in
maintaining the temperature of the baby.

[25]
 Early and exclusive breastfeeding -Breast feeding should be started as soon
as possible or within half an hour for normal delivery and one hour for LSCS
child birth. Breast feeding should be continued for 6 months exclusively, and
afterwards complementary feeding may be started along with the breast
feeding.
 Eye care - Eye care is performed by wiping the eyes from inner to outer
cantus with a sterile saline swab.
 Immunization - At birth: Bacilli Calmette-Guerin (BCG) vaccine, oral
poliovirus vaccine (OPV) and hepatitis B virus (HBV) vaccine.

I. Newborn care at home


 Exclusive breast feeding/artificial feeding and burping:
The WHO recommends that infants are exclusively breastfed for the first six
months. Whether feeding the newborn by breast or a bottle, may be stumped as to
how often to do so. Generally, it's recommended that babies be fed on
demand whenever they seem hungry. Your baby may cue you by crying, putting
fingers in his or her mouth, or making sucking noises.
A newborn baby needs to be fed every 2 to 3 hours.
Preferably if breastfeeding, give chance to the baby nurse about 10–15 minutes at
each breast. If formula-feeding, baby will most likely take about 2–3 ounces (60–
90 millilitres) at each feeding.

Try these burping tips:


 Hold the baby upright with his or her head on your shoulder. Support baby's head
and back while gently patting the back with your other hand.

 Sit your baby on your lap. Support your baby's chest and head with one hand by
cradling your baby's chin in the palm of your hand and resting the heel of your
hand on your baby's chest (be careful to grip your baby's chin — not throat). Use
the other hand to gently pat your baby's back.

 Lay your baby face-down on your lap. Support your baby's head, making sure it's
higher than his or her chest, and gently pat or rub his or her back.

[26]
 Baby bath

The baby must be cleaned off, no bath especially dip baths should be given till the
umbilical cord has fallen off. In summer months, the baby can be sponged using
unmedicated soap and clean lukewarm water and during winter months the baby
should have sponge bath rather than dip bath to avoid cold stress or hypothermia.
No vigorous attempt should be made to remove the vernix caseosa, as it provides
protection to the dedicate skin. The baby should dried swiftly and thoroughly from
head to toe and wrapped in a dry warm towel or clothing. Bathing should be
avoided in open place. Unnecessary exposure should be avoided. Use of olive oil
or coconut oil can be allowed after 3 to 4 weeks of age. Oil massage improves
circulation and muscle tone.

 Rooming in

Rooming in can be done in a variety of ways. A lot of women choose to have full
rooming in, where the baby stay with the mother entire time. Both mother and
baby gets benefits from this practice, that are

 Babies cry less are easier to calm

 Mother get more rest

 Ability to respond to baby’s feeding cues

 Make more breast milk, faster

 Ability to ensure the care mother want for baby ( e.g. no pacifier, bottles,
tests etc)

 No fear of baby switching

 Care of umbilical cord

The cord must be inspected afterwards is important. No dressing should be


applied and the cord should be kept open and dry. Normally it falls off after 5 to

[27]
10 days but may take longer especially when infected. Application of any
medication is not recommended

 Clothing

The baby should be dressed with loose, soft and cotton cloths. Dress should be
open on the front or back for easy wearing. Large buttons, synthetic frock and
plastic or nylon napkin should be avoided. A triangle of square piece of thick, soft
absorbent cloth should be used as napkin. The cloth should not be tight especially
around the neck or abdomen. Baby clothing always be cleaned with light detergent,
that will be washed properly and sun dried to prevent skin irritation

 Mummification

Swaddling is an age old practice of wrapping infant in blankets or similar cloths. It


is an art of snugly wrapping baby from a baby. It can keep the baby from being
disturbed by her own startle reflex, and so that movement of the limbs is tightly
restricted. Also it can help stay warm for the first few days of life until internal
thermostat kicks in. It may even help to calm baby

 Care of eye

Eyes should be cleaned at birth and once everyday using sterile cotton swabs
soaked in sterile water or normal saline. Each eye should be cleaned using a
separate swab. Application of kajal in the eyes must be avoided to prevent
infection or led poisoning. The cultural practice of instillation of human colostrums
in the eyes has been found to be useful to reduce the incidence of sticky eyes.

[28]
IX. HIGH RISK NEWBORN

Delivery

Normal infant High risk infant

Without
With complications
complications

Temporary observation unit


(recovery room for high risk
infants)

Regular nursery
Special care nursery with neonatal
intensive care unit

Home Special procedures

Fig:1 Flow chart for optimum newborn care


Identification of “at-risk” infants
The number of infants in a community, or attending a child health clinic, may be so
large that it may not be possible to give sufficient time and attention to all of them.
It is therefore necessary to identify particularly those “at-risk” and give them
special intensive care, because it is these “at-risk” babies that contribute so largely
to perinatal, neonatal and infant mortality. The basic criteria for identifying at-risk
babies include :
1. birth weight less than 2.5 kg
2. twins
3. birth order 5 and more
4. artificial feeding

[29]
5. weight below 70 per cent of the expected weight (i.e., II and III degrees of
malnutrition)
6. failure to gain weight during three successive months
7. children with PEM, diarrhea
8. Working mother/one parent.

a) LEVELS OF NEWBORN CARE

Because newborn infants may be born with depressed respiration or


circulatory impairment without warning, and unexpected deterioration of an
initially healthy newborn may be rapid and catastrophic, all health care facilities
providing care for newborn infants must be able to resuscitate and stabilize such
infants until transfer to another appropriate facility, including the initiation of
intravenous access and assisted respiration. Readiness to intervene for such infants
must take into account the geo~ graphical location and the duration of time before
assistance and transfer is likely. Some units providing lower levels of care must be
capable of supporting infants for several hours while awaiting assistance. A family
physician or pediatrician should be available on call at all medical conditions.
Level I Care (Well baby clinic)
Over 80 percent of newborn babies require minimal care which can be
provided by their mothers under the supervision of basic health care professionals.
Neonates weighing above 1800 g or having gestational maturity of 34 weeks or
more belong to this category. The care can be provided at home, subcenter and
primary health center level. Basic care at birth, provision of warmth, maintenance
of asepsis and promotion of breast feeding form the mainstay of level I care.
Traditional birth attendants and community health workers must be trained in the
art of esssential perinatal care. The unit should provide nursing care for both
mothers and their babies. Each nurse may provide care for up to four mothers and
their babies.
Level II Care (Special nursery)
Infants weighing between 1200-1800 g or having gestational maturity of
30-34 weeks need specialized neonatal care supervised by trained nurses and
pediatricians. First referral units, district hospitals, teaching institutions and
nursing homes should be equipped to provide intermediate neonatal care.
Equipment for resuscitation, maintenance of thermo neutral environment,

[30]
intravenous infusion and gavage feeding, phototherapy and exchange blood
transfusion should be available. There should be no compromise on the basic needs
of adequate space, nursing staff and maintenance of asepsis including provision for
disposable gamma-irradiated suction catheters, feeding tubes, end tracheal tubes,
small-vein infusion sets etc. Intermediate neonatal care is needed for about 10 to
15 percent of newborn population and should be available at all hospitals catering
to 1000 to 1500 deliveries per year. A pediatrician should be available on call at all
times. When mechanical ventilation is in progress, the pediatrician should be
available in-house or must make sure that skilled staff, capable of immediately
responding to potential emergency medical practioners, are continually present For
sick babies, a nurse may be required to care for fewer than four babies.
Level III Care (Intensive care)
Intensive neonatal care is required for babies weighing less than 1200
g or those born before 30 weeks of gestation. Apex institutions or regional
perinatal centers equipped with centralized oxygen and suction facilities, servo-
controlled incubators, vital sign and transcutaneous monitors, ventilators and
infusion pumps etc. are best suited to provide intensive neonatal care. Skilled
nurses and neonatologists especially trained in the art of neonatal intensive care are
required to organize this service. About 3 to 5 percent of newborn population
qualifies for intensive care. Establishment of intensive care neonatal center
demands a sound infrastructure and should be envisaged only when optimal
intermediate neonatal care facilities have already been in existence for some time.
The capital and recurring expenditure for level III care is exorbitant and it is not
cost effective unless service is regionalized.
b) TRANSPORTATION OF NEWBORN

An organized transport team trained in neonatal care, resuscitation and transport


care with appropriate equipment must be available for the transfer of patients in
each region. A system for managing transport requests around the clock must be
clearly defined and easily accessible by medical team’s at all regional units
requesting transfer.
The principles of safe transport of sick babies are expressed by a number of
mnemonics like STABLE. Where each alphabet stands for Sugar, Temperature,
Airway, Blood pressure, Lab work and Emotional support. SAFER: Sugar,

[31]
Arterial circulatory support, Family support. And TOPS: Temperature,
Oxygenation (airway and breathing), Perfusion and sugar.
i. Indications for neonatal transport

When a high risk mother identified, it is best time to transfer her to a center
having NICU facilities because uterus is an ideal transport incubator. It is desirable
that delivery should be take place in tertiary care center so that a sick or high risk
baby is not exposed to the risks of neonatal transport.
 Preterm infant with a birth weight < 1500 g or gestation <32 weeks.
 Respiratory distress requiring CPAP or assisted ventilation.
 Severe hypoxic-ischemic encephalopathy
 Life threatening sepsis
 Intractable sepsis
 Bleeding neonate
 Congenital anomalies or surgical neonate
 Inborn error of metabolism
 Severe hyperbilirubinemia
 Procedure or diagnostic facilities unavailable at the parent hospital
ii. Admission procedure to NICU

The transport team should remain in constant touch with the referral NICU during
the course of journey. Ideally the referral center should have a dedicated
communication facility with mobile help lines operating 24 hours a day for ease of
constant communication. The team should brief the NICU care givers regarding
the status of the baby and immediate clinical concerns. The clinical documents
including copies of charts, consent form, radiographs, investigation reports etc.
should be handed over to the receiving unit. The referring hospital and parents of
the baby (if not accompanying during transport) should be informed about the safe
arrival and latest condition of the baby. The inventory of transport equipment
should be checked, medications and essential supplies should be restocked for the
next transport service.
iii. Role of parents in care of newborn in NICU

There should be appropriate facilities for parents, who should be encouraged to


participate in the care of the infants. Facilities should include private breast pump
rooms, refrigeration and storage facilities for breast milk, and parent rooms for

[32]
overnight rooming in with the infant before discharge from hospital. A quiet room
should be available for consultations and for families who may need privacy to
deal with emergent circumstances. That includes:
iv. Clinical standards at NICU

Clinical protocols: Written protocols should be available for key procedures and
practices, including resuscitation and stabilization of babies, and should be
reviewed and updated regularly.
Quality assurance: Units should longitudinally monitor mortality, morbidity,
workload, resource use, practices and policies using a prospective database with
well-defined items. These should be regularly reviewed and benchmarked against
national standards. An audit program and critical incident reporting program
should be place.
Developmental follow-up assessment: Each unit should enroll high-risk infants in
a developmental follow-up program that can longitudinally assess infants after
discharge home.
Quality improvement: Each unit should have a multidisciplinary team trained to
motivate, initiate and support quality improvement initiatives. Ideally, this team
should work in coordination with similar teams in other hospitals.
Annual report: Each unit should produce an annual report summarizing their
activity and performance appraisal in standardized form. The report should also
benchmark individual unit activity and performance against other units nationally,
and against national criteria for service provision.
c) NURSING MANAGEMENT

1. THERMAL CONTROL
Thermoregulation is the balance between heat production and heat loss. The
prevention of cold stress which may lead to hypothermia (body temperature less
than 35°C) is a critical for the intact survival of the LBW baby. In hospital higher
ambient temperature are maintained, the baby should be dressed cotton gown and
covered by two cellular blankets. An additional blanket underneath the bottom
sheet will provide extra warmth for baby’s who are having difficulty in
maintaining a stable body temperature at home. Baby water should be warm
(36°C) and wet clothing should be changed as soon as possible, it is essential also

[33]
to avoid overheating. Parents should be advised to take account of the
environmental temperature when dressing the baby. Dressing should be loose for
the movement of arms and legs. Gestational age and weight of the baby influence
the type of the care given for baby’s under two kg. Incubator care is necessary
when the baby is not receiving skin to skin contact with mother. The warm
condition of the incubator should be maintained at 30-32°C; babies are clothed
with bedding in a room temperature at 26°C. Most preterm babies between 2 to 2.5
kg will be care for in a cot at room temperature of 24°C.
Prevention of hypothermia
 Deliver in a warm room - To prevent the hypothermia, the delivery room’s
temperature should be maintained. The windows and doors must be closed.
A warm delivery room is the first step to prevention of hypothermia
 Dry newborn thoroughly and wrap in dry, warm cloth –As soon as the
baby is born, he should be dried thoroughly with a clean cloth to wipe off
the secretions. After proper cleaning, baby is wrapped in clean, dry, warm
clothes.
 Keep out of draft and place on a warm surface- Baby should be protected
from cold, in the nursery, while transferring or at the home.
 Give to mother as soon as possible- Baby should be given to the mother
soon.
. Skin-to-skin contact first few hours after childbirth maintains the
temperature.
. Promotes bonding between the mother and the baby.
. Enables early breastfeeding.
 Bath when temperature is stable (after 24 hrs)- Generally babies are not
given bath in the hospital to prevent the chances of infection. In the home,
also baby should be given bath after 24 hours when the temperature
stabilizes.

2. PREVENTION OF HYPOGYCEMIA

Hypoglycemia should be prevented by early initiation of breastfeeding within first


hour of birth. The baby should be nursed in warm or thermo neutral environment
with careful observation of ’at-risk’ situations and prevention of hypoxia and

[34]
hypothermia. For a baby with risk factors, healthcare providers will need to watch
carefully for the signs and treat as soon as possible.
In symptomatic infant with convulsions, 25 percent dextrose 2 ml / kg
intravenously is given as a bolus. If there is no convulsion 10% dextrose 2ml/kg/IV
bolus is given followed by continuous infusion of 10 percent dextrose at a rate of
6-8 mg/ kg/ minute. Blood glucose level to be checked every 1/2 hourly. Infusion
rate to be reduced only if last two glucose estimation is more than 60 mg / dl. Oral
feeds are introduced gradually and glucose infusion is tapered off.
If blood glucose level is not corrected then bolus administration of dextrose can be
repeated and serum cortisol and insulin levels to be checked. Hydrocortisone
therapy is given 5 mg / kg / IV every 12 hours in intractable case. Glucagon and/ or
epinephrine, diazoxide may be given to the babies with maternal diabetes mellitus
or erythroblastosis. Asymptomatic cases with low blood sugar level should be
treated as symptomatic cases.
3. PREVENTION OF INFECTION
Provision of a safe environment newborn is of central importance, particularly in
hospital where babies are at risk of cross infection. Careful and frequent hand
washing with soap or spirit remains the single most important method of
preventing infection. In busy situation cleansing with an alcohol based hand rub
solution is most practical means of improving staff compliance and wearing gloves
further reduces the contamination. Other evidence based midwifery strategies that
help to reduce infection in all environmental include
 Encouraging and assisting women with breast feeding thus increasing the
baby immune protection
 Discouraging visitors who have infections or have been exposed to a
communicable disease.
 Avoid any irritation or trauma to the baby’s skin and mucus membrane.
 Early diagnosis and treatment of infection
 Always using individual equipment for each baby
 Isolating infected babies when absolutely essential.
Managements include:
Caring for the baby in warm thermo neutral environment and observing for
temperature instability.

[35]
o Prompt systemic antibiotic or other drug therapy and local treatment
of infection.
o Ongoing monitoring of the baby’s neurobehavioral status.
o Reducing separation of mother and baby, it requires admission to a
neonatal intensive care unit then the midwife should encourage
parents to be with their baby.
o Encouraging breast feeding or expression of milk.

4. IMMUNIZATION
Immunizations help prevent the spread of diseases and protect newborn against
dangerous complications. Immunization is the process of whereby a person is
made immune or resistant to an infectious disease. The Centers for Disease Control
and Prevention (CDC) provides a list of diseases that can be prevented with
vaccines, as well as the benefits and risk of vaccination.
5. BREAST FEEDING

Breast milk is natural food for the newborn and the process by which it is secreated
by mammary gland is known as lactation. During the first two or three days
secrets, watery and yellowish fluid that provides immunity for the baby. Enough
nutrients and needed amount of feed will get from breastfeed. So it is important to
give exclusive breast feeding for the baby at least 6 months.

X. PARENTING
Parenting or child rearing is the process of promoting and supporting the
physical, emotional, social, and intellectual development of a child from infancy to
adulthood. Parenting refers to the intricacies of raising a child and not exclusively
to the biological relationship.
The most common caretaker in parenting is the biological parent(s) of the child in
question, although others may be an older sibling, a grandparent, a legal guardian,
aunt, uncle or other family member, or a family friend. Governments and society
may also have a role in child-rearing. In many cases, orphaned or abandoned
children receive parental care from non-parent blood relations. Others may be
adopted, raised in foster care, or placed in an orphanage. Parenting skills vary, and
a parent with good parenting skills may be referred to as a good parent.

[36]
Preparation for parenthood
The basic goals of parenting are to promote the physical survival and health of
children, to foster the skills and abilities necessary to be a self-sustaining adult, and
to foster behavioral capabilities for optimizing cultural values and beliefs.
However, new parents often approach parenthood with limited experience and
knowledge. Parents learn by trial and error, committing the same mistakes
committed by countless time, but they manage to accomplish the task, becoming
more skilled with each additional child. Tradition, rather than rational planning,
furnishes the chief norms for childrearing. Experience in having been nurtured as a
child is an essential component of successful parenting. Their own parents are
probably the only persons whom parents observe intimately in the parental role.
These results in a generational continuity parents rear their own children in much
the same way as they themselves were reared. Other essential skills that parents
need to feel comfortable in the parenting role include a basic understanding of
childhood growth and development, bathing, feeding, uses of play, and
interpersonal communication skills.
Transition to parenthood
Although experts disagree as to whether the birth of the first child should be
labeled a crisis, the early weeks of 0 infant’s life call for parents to make drastic
adjustments. Even though the parents have anticipated and prepared for the child’s
arrival, the birth presents the challenge of providing total care 24 hours a day for a
new member of the family. A crisis may occur if the event is perceived as
disturbing old habits and relationships and eliciting new responses. The birth
requires role changes or significantly modifies former relationships. In addition to
the roles of husband and wife, the couple must assume the roles of father and
mother.
The advent of a new family member requires that the family cope with greater
financial responsibilities, at possible loss of income, changes in sleeping habits,
and less time for the parents to spend with each other (especially if it is a firstborn)
and with other children. If these events are perceived as aversive, it can disrupt the
couple’s bond and reduce the couple’s intimacy and affection.
Parenting styles vary by historical time period. Race/ethnicity, social class, and
other social features. Additionally, research has supported that parental history
both in terms of attachments of varying quality as well as parental

[37]
psychopathology particularly in the wake of adverse experiences, can strongly
influence parental sensitivity and child outcomes.
Parenting practices reflect the cultural understanding of children. Parents in
individualistic countries like Germany spend more time engaged in face-to-face
interaction with babies and more time talking to the baby about the baby. Parents
in more communal cultures, such as West African cultures, spend more time
talking to the baby about other people, and more time with the baby facing
outwards, so that the baby sees what the mother sees. Children develop skills at
different rates as a result of differences in these culturally driven parenting
practices. Children in individualistic cultures learn to act independently and to
recognize themselves in a mirror test at a younger age than children whose cultures
promote communal values. However, these independent children learn self-
regulation and cooperation later than children in communal cultures. In practice,
this means that a child in an independent culture will happily play by herself, but a
child in a communal culture is more likely to follow his parent’s instruction to pick
up his toys. Children that grow up in communities with a collaborative orientation
to social interaction, such as some Indigenous American communities, are also
able to self-regulate and become very self-confident, while remaining involved in
the community.

XI. POST MATURE INFANT

Definition

The fetus who remains in the uterus from 1 to 3 weeks or more after the
expected date of delivery (in other words. Beyond 42 weeks or 300 days gestation)
is called as postmature or post-term regardless of the weight at birth.

- Dorothy R. Marlow

About 4 to 9 per cent of infants are born after the expected date of delivery.
The cause for the delay in the onset of labor is not well under stood.

Many postmature infants are normal and healthy, similar to full-term neonates.
Others have the typical characteristics of postmature infants. They may appear
more mature and mentally alert than do normal neonates. The nails and scalp hair
are longer than those of a full-term infant, but there may be an absence of lanugo

[38]
or vernix caseosa on the skin. The skin may be cracked and pee ling and have the
consistency of parchment. The skin, cord, and nails may be stained yellow-green
from meconium. These infants are long and thin, appearing wasted without
subcutaneous fat. Hypoglycemia may occur due to decreased fat stores. The
incidence of intrauterine hypoxia and meconium aspiration is increased in post-
term infants. Some of these characteristics are due to placental dysfunction that
causes inadequate nutritional and oxygen exchange between mother and fetus.
Since they may also suffer from birth asphyxia, pos t mature infants have a higher
mortality rate than do term infants.

Since the mortality rates increase after 42 weeks gestation, elective induction of
labor or a caesarean section may be clone. Cesarean section may be especially
indicated for older mothers having their first infants, if the fetus shows signs of
distress. After the birth, oral feedings or intravenous glucose or both are given
early in order to prevent hypoglycemia, Blood glucose levels are monitored
carefully.

XII. BABY OF DIABETIC MOTHERS

A. Introduction

There has been continuing improvement in the care of mothers with diabetes
mellitus and their neonates, resulting in a decline in the morbidity and
mortality rates. In fact, perinatal mortality of infants of metabolically
controlled diabetic mothers, except for those having congenital anomalies, is
not much different from that of infants of non diabetic mothers.

B. Pathophysiology

Fetal blood glucose levels follow maternal levels. Since the lDM can release
insulin faster than a normal infant, this increased demand for insulin in the
fetus in response to maternal hyperglycemia results in hyperplasia of the
beta cells in the islets of Langerhans in the pancreas. Since insulin acts as the
primary anabolic hormone of fetal growth and development,
hyperinsulinemia in utero has an effect on various fetal organ systems. Its
presence in the fetus of the diabetic mother can result in macrosomia
(increased body size) and visceromegaly especially of the heart and liver.
Whe excess giucose is present, fat synthesis and deposition are increased
[39]
during the third trimester of pregnancy. These changes create predictable
problems in the care of these infants.

C. Assessment

The nurse needs to collect certain pertinent information includes the


classification of the mothers diabetes, since the degree of severity of maternal
disease and the adequacy of control have a relationship to the severity of
problems in the neonate; the Apgar score of the infant, which provides some
indication of status at birth; the neonate s gestational age, since this is more
positively correlated with level of development than is physical size; and the
laboratory tests that have been done, including haemoglobin, hematocrit,
glucose, calcium, and blood gases. Another test, C-peptide immunoreactivity
(CPR.), is done in order to measure the fetal beta-cell activity. The results of
these laboratory tests on cord blood are obtained so that baseline values can be
compared with later tests.

D. Physical examination

Approximately one third of infants of diabetic mothers are large for gestational
age, the classic neonatal gigantism. They are over the 90 th percentile for weight
and length. The puffy, plump, full-faced appearance of these infants is not
caused by edema, but by fat. Their weight loss after birth is about that of infants
of similar gestational age. IDMs generally have abundant scalp hair and are
plethoric. These infants lie in a hypotonic position with the legs flexed and
abducted and with the hands beside the head. The sucking reflex may be poor
owing, to immaturity and hypotonia.

E. Diagnostic evaluation

Hypoglycemia: Because of maternal hyperglycemia, the fetus also develops


hyperglycemia. As the fetal pancreas produces increasing amounts of insulin,
which cannot cross the placenta because of the large size of the insulin
molecule, fetal hyperinsulinism results. At birth, the neonate has moderate
hypoglycaemia, which, because of inadequate compensatory mechanisms,
becomes severe hypoglycaemia. When the blood glucose levels fall below 30
mg per dl in the full-term and below 20 mg per dl in the premature infant,

[40]
indicating hypoglycaemia, the result may be lethargy, sweating, jitteriness,
tremors, and seizures.

Hypocalcemia: If the serum calcium levels drop below 7 mg per dl during the
first 2 days of life, the neonate may show symptoms of tremors, jitteriness, and
hyperirritability similar to those of hypoglycaemic infants. The frequency and
severity of clinical symptoms are correlated with the maternal status.

F. Nursing management

Optimal care of the diabetic mother leading to control of the disease is essential
to the well-being of the fetus. Fetal monitoring during labor and a determination
of fetal scalp blood pH and glucose should be done as appropriate. After birth,
the cord is generally clamped immediately to prevent placental transfusion. It is
clamped away from the base in case an umbilical catheterization becomes
necessary.

The stomach contents may be aspirated and chest radiograph may be taken to
determine the presence of lung changes indicative of the respiratory distress
syndrome or of a cardiac defect. The infant is placed in an Isolette for
temperature regulation. A warmed environment is necessary for these large
infants, because their increased size and total body surface lead to an increase in
heat loss. These infants have an increased output of urine may lead to
dehydration. The nurse keep an intake and output flow sheet and administer
fluids as prescribed.

Frequent blood glucose levels are obtained on all infants of diabetic mothers
during the first 2 days of life to determine the degree of hypoglycaemia present.
Infants of diabetic mothers are generally fed early either orally or by gavage
with ,5 to lo per cent glucose and given formula when it can be tolerated.

Crystalline glucagon can be given subcutaneously, intramuscularly, or


intravenously in order to produce a rapid rise in blood sugar, especially if the
infant has good glycogen stores. Epinephrine may be given intramuscularly to
inhibit the re lease of insulin and to stimulate the release of glucose from
glycogen stores in the muscles and liver.

[41]
Asymptomatic infants with polycythemia may be treated with increased
hydration. Since polycythemia may cause cardiorespiratory failure when the
packed cell volume is over 70 per cent, a venesection may be done. The amount
of blood removed is replaced with plasma.

G. Outcome and Prevention

The only preventive measure that can be taken is to provide for each pregnant
diabetic sufficient education care to help her maintain good control of her
disease and to remain euglycemic throughout the period of gestation. The
prevention of congenital anomalies in these infants remains an unresolved
problem.

Infants of diabetic mothers should be monitored throughout childhood with a


glucose tolerance test done yearly. If they can maintain an ideal weight through
good nutrition, their risk of developing diabetes is reduced.

XIII. BABY OF SUBSTANCE USE MOTHERS

1.FETAL ALCOHOL SYNDROM (FAS)

Introduction

The increased incidence of alcoholism among adolescent and adult women has
resulted in an increased incidence of the fetal alcohol syndrome (FAS). This
syndrome is the third leading cause of birth defects and the third most commonly
diagnosed cause of mental retardation.

Pathophysiology

Alcohol passes across the placenta quickly. It interferes with protein synthesis and
with the absorption of many nutrients, and can damage the embryo and fetus
irreversibly. These effects may be due to the alcohol itself, to its breakdown
products, or to secondary deficiencies such as vitamin B1, or B6 deficiency.

When the pregnant woman drinks ethanol, it is rapidly diffused to all tissues and
10 percent of the total amount is excreted in the breath and urine. The liver, kidney

[42]
cortex, and lungs metabolize the remaining 90 percent to acetaldehyde and acetic
acid. The acetic acid is then converted to carbon dioxide by muscle tissue. The
acetaldehyde alone is cytotoxic and this intermediate metabolite of ethanol
contributes to the toxicity of alcohol. When the fetus receives alcohol across the
placenta, its lower liver and kidney function does not allow the ethanol in its blood
to be detoxified, and its cells may be damaged.

A moderate to high level of alcohol consumption during the first trimester of


pregnancy when organogenesis is occurring may result in abortion or may
seriously affect the structure of the fetus. If poor diet and heavy alcohol
consumption are continued into later pregnancy when there should be an increase
in fetal cell size, the neonate may be born with growth deficiency and low birth
weight.

Assessment

Neonates who have the fetal alcohol syndrome are shorter in length, lower in
weight, and have a smaller head circumference than do normal neonates. Facial
abnormalities may be observed. The newborn may be microcephalic. Congenital
heart disease, especially septal defects, may be found. The sleep of these neonates
may be disturbed. The growth after birth is slower than normal. The intelligence
level is lowered, so that a borderline to moderate degree of mental retardation may
be Present.

Nursing management

The nurse who sees the mother during pregnancy may be the first person to learn
of her alcoholism. A thorough nursing assessment should then be done in order to
plan for her care. The nurse can encourage the mother to abstain from alcohol and
to improve her nutritional intake during pregnancy. Her diet should be based on the
recommended daily food allowances during normal pregnancy.

Deviations from normal fetal growth can be detected as early as 16 weeks


gestation. After this time, fetal growth can continue to be monitored using serial
ultrasonography at 2-week intervals.

[43]
After birth, the infant may be lethargic or irritable, depending on the time of the
mother s last intake of alcohol. If there is involvement of the brain stem, the
sucking reflex may be poor. It may become necessary to give nasogastric feedings.

Outcome

Consumption of alcohol during pregnancy can cause spontaneous abortion or can


seriously harm the fetus both mentally and physically. Emotional and physical
problems such as hyperactivity may also occur years later. Ideally, the alcoholic
mother is helped to stop drinking before and during pregnancy. Counseling is also
provided to prevent a recurrence of this serious problem.

2. NARCOYIC ADDICTION

Introduction

As the incidence of addiction to narcotics such morphine and heroin and


dependence on methadone has increased among the adolescent and adult
populations, so has it increased among infants born to addicted mothers. Al though
maternal addiction is many times a symptom of a pervasive personality
maladjustment, if a pregnant addict is at least motivated to enter a methadone
maintenance program. She can receive prenatal care and be helped to learn a new
approach to living.

Pathophysiology

Infants born to actively addicted mothers have a physiologic addiction because


many of these drugs cross the placenta. In fact, these foetuses respond to their
mothers need for drugs with increased activity in utero. At birth, the neonates may
be premature, of low birth weight, or stillborn. There is a high incidence of
sexually transmitted disease in infants of addicted mothers.

Assessment

The nurse determines from the antenatal record the type of drug the mother has
used, the extent of the addiction, and the time of injection prior to delivery. If
maternal addiction is denied, the mother s extremities may be examined for

[44]
scarring due to needle punctures, cellulitis, and thrombophlebitis. The clinical
manifestations of drug addiction in the neonate usually appear within 24 to 72
hours after birth. Bilateral coarse (flapping) or fine tremors and hyperirritability are
the most common symptoms of addiction in the neonate. Hyperactivity may result
in abrasion of the skin from friction of movement on crib linens. The extremities
may be rigid, resistant to flexion and extension, and hyperreflexic. The neonate
may have an elevation of temperature, rapid respirations, and a high-pitched cry.
Sucking of the fist and poor feeding may be evident, as may be sleeping
difficulties. When feedings are taken, regurgitation, vomiting, and diarrhea may
result. The Moro reflex is decreased, but the tendon reflexes are increased.

Laboratory determinations of blood glucose and calcium rule out hypoglycaemia


and hypocalcemia, and examination of the urine may reveal the presence of
opiates. This specimen should be collected soon after birth because the narcotic
metabolites disappear rapidly.

Nursing management

The addicted infant is kept warm, swaddled and placed on the abdomen or propped
on the side to prevent aspiration should vomiting occur. The pulse and respirations
are checked every 15 to 30 minutes until they are stable. Oxygen is administered as
ordered, if needed. External auditory, visual, and tactile stimulation is minimized
to prevent central nervous system stimulation. If a convulsion does occur, oxygen
is given, and suctioning and resuscitation are carried out as necessary. The crib
sides are padded and the infants hands may be covered with mitts to prevent self-
injury. A sheepskin pad may be placed under the infant to prevent skin abrasions
due to hyperactivity. Small, frequent feedings are given.

The drugs prescribed for the treatment of narcotic addiction include combinations
of sedatives, narcotics, and hypnotics. Phenobarbital or chlorpromazine
hydrochloride (Thorazine) is usually used. Neonates with severe autonomic
clinical manifestations may be given gradually diminishing doses of morphine,
paregoric, or chloral hydrate. Methadone and diazepam (Valium) may also be
used.

[45]
Outcome

If untreated, the severely addicted neonate may develop convulsions and die. If
narcotic addiction is diagnosed early and appropriate treatment given, the mortality
rate is about 3 to 4 per cent. These infants may continue to be irritable after
discharge and are more likely than other infants to be victims of the sudden infant
death syndrome. The ultimate outcome for infants who survive is questionable
because of the environment into which they may be taken after leaving the
hospital. For this reason, follow-up care is of the utmost importance.

Prevention of addiction in the neonate

Education concerning the effects of alcohol and narcotics taken during pregnancy
should be made available to adolescents and adults through programs in schools
and various organizations, in public education programs, and in the mass media. It
should be made clear that the use of any amount of these drugs at any point during
pregnancy may negatively affect the fetus. Such education and the early treatment
of’ addiction, when it does occur, could prevent the tragedy of addiction in the
neonate.

XIV. ROLE OF NURSE IN NEONATAL NURSING

The nurses’s role is unique because of developmental immaturity and


vulnerability in neonates. The goals of nursing care of newborn, based on
primary health care are:

[46]
primary care
giver
nurse health
researcher teacher

nurse
consultant
care nurse
counsellor

nurse
recreationist giver social
worker

co-ordinator
nurse &
manager
child care collaborator
advocate

Fig. 2 Role of nurse

1. Primary Caregiver: Pediatric nurses are providing basic care to children


Like hospitalized Child physical, Growth and developmental assessment,
Immunization, feeding. It should be focused on

1. Preventive aspect of care

2. Promotive aspect of care

3. Curative aspect of care

4. Rehabilitative aspect of care

2. Health Teacher: A child health teaching is very basic duty for nurses since
they are the ones responsible for monitoring the child as well as carry out the
Physician’s discharge orders. She must be anticipating parent’s doubts
regarding improvement of their children’s health status such as parenting

[47]
and disease process so as to prevent future hospital admission as such as
much as possible.
3. Nurse Counsellor : On Providing guidance to parents in health hazards of
children and health them for own decision making in different situations.
Nurse counsellor must be active listeners in order to establish a therapeutic
relationship between parents and child, making health care plans easier.
Nurse counsellor will be solving the parent’s problem towards their child
care. She help the parents to take the independent decision for betterment of
their child health care.
4. Social Worker : Pediatric nurse can participate in social services or refer
child family to Child welfare agencies for necessary support. In child health
care, sometimes, pediatric nurse act as a social worker, try to reduce the
social problems which is going to affect the child health. She should guide
the parents related to child welfare agencies for improvement of Child
health.
5. Coordinator and Collaborator: Pediatric nurses are sometimes or most of
the time works with other health care team members, where he or she is the
avenue of important information that other health team members need in
delivering competent care. 80 it is a must that pediatric nurses need to be a
good information giver and communicator among health team members to
promote a harmonious working environment.
There are many roles that a pediatric nurse could perform as health care
settings evolved from one stage to another. The challenge lies behind the
application of evidenced-based practice to provide competent care to
children. Last but not the least, having a heart for children matters a lot when
the work load at the area seems to be heavy children could make you smile
no matter how harsh the world could be.
[48]
6. Child Care Advocate : Pediatric nurses are expected to be sensible enough
in voicing out the needs of their child and folks in behalf of them when it is
impossible for them to readily address their needs. She can help the child
and parents to receive the best quality of care from the hospital.
7. Nurse Manager: A pediatric nurse managers should help the child and
parents by managing the nurses who care for them. While these nurses are
mainly responsible for recruitment and retention of the nursing staff and
overseeing them, they should be collaborate with doctors on child care, and
help to assist child and their families when needed.
8. Nurse Recreationist : The pediatric nurse plays supportive role for the child
to provide play facilities for recreation and diversion. It helps to decrease
crisis imposed by illness or hospitalization.
9. Nurse Consultant: The pediatric nurse can act as consultant to guide
parents and family members for maintenance and promotion of health. For
example, Guiding parents about feeding practices, accident prevention,
drowning and childhood poisoning.
10.Nurse Researcher: Pediatric nurse researchers are more important in
pediatric nursing field for improvement Of Child health status. A change is
constant in the health care setting, so it is must to practice evidenced-based
practice. This means that pediatric nurses should have the ability to improve
themselves in order to give updated care to children.

[49]
XV. SUMMARY

The birth of the newborn is important occasion in a family. As we


discussed about the normal newborn it comprises of detailed introduction
about the normal newborn, the students can define the newborn, the
physiological characteristics that shows by the normal newborn. How the
newborn is going to adapt with extra uterine or physiological life in the new
world.
How the nurse is going to do the assessment of newborn includes
physical assessment it divided into initial and daily assessment and also as
normally how the newborn behavioral assessment is doing. In the essential
newborn care the nurse is giving care as priority of newborn needs. How we
can identify the high risk newborn and referrals services available to
stabilize the condition. The process that explains the adaptation of newborn
and parents that means parenting process. The minor disorders that can
occur normally in newborn and its management. Mainly nursing
management includes nursing diagnosis, goal and interventions of newborn.

[50]
[51]
XVII. CONCLUSION

At discharge, the newborn is examined and a postpartum visit is scheduled.


The newborn's progress is assessed in terms of feeding and body weight.
Blood is obtained (heel-stick) to assess abnormalities, including genetic and
metabolic disorders. The parents are updated with their child's progress and
their concerns are addressed. Usual questions pertain to feeding, follow-up
visits, immunizations, bathing, rashes, use of car seats, etc.
After the completion of newborn assessment, and if the assessment remains
uneventful, the newborn is discharged. However, in the event of other
outcomes that might emerge due to various reasons during the assessment,
the newborn is further assessed for restoration of complete health.
WHO has recommended important factors that are essential with respect to
newborn care which includes initiation of breastfeeding, vitamin K
prophylaxis, prevention of hypothermia, care for the cord, and immunization
at birth.
Matters such as cleanliness, hygiene during delivery, thermal control, and
infant feeding practices must be followed scrupulously. Good and essential
newborn practices include safe cord care, which includes use of a sterile
instrument to cut the umbilical cord, clean thread to tie the cord, optimal
thermal care which includes wrapping the baby within 10 minutes of birth
and bathing the baby after 6 hours of birth, and neonatal feeding practice,
which includes initiating breastfeeding within the first one hour after birth,
are all essential elements.
The postpartum care to the mother is as important as postnatal. Only a
healthy mother can bring up a healthy child. Factors including maternal age,
educational status, economic status, ethnicity, occupation, and accessibility
to health services are important factors that affect the upbringing of the
newborn.

[52]
XVIII. BIBLIOGRAPHY

BOOK REFERENCE
1. Dutta D C. (2004). Text book of Obstetrics. Sixth edition. Culcutta: New
central boob agency (p)ltd; 445-456
2. Lowdermilk, Perry & Cashion. (2010). Maternity nursing. 8 th edition. North
Carolina. Elsevier; 438-528
3. Maharban Singh. (2010). Care of the Newborn. 7TH edition. New Delhi.
Sagar printers & publishers; 1-510
4. Parul Datta. (2009). Pediatric nursing. 2nd edition. India. JAYPEE; 66-136
5. Annamma Jacob (2005). A Comprehensives Text book of Midwifery. Third
edition. JAYPEE. 459-497
6. Neelam kumari, Shivani sharma & Dr. Preti gupta (2014). A Text book of
Midwifery and gynecological nursing. Third edition. Pee Vee . 261-284
7. Marilyn J. Hockenberry & David Wilson. Wong’s Essentials of Pediatric
nursing, First South Asia Edition. ELSEVIER New Delhi. 163-189.
8. Dorothy R. Marlow & Barbara A. Redding. Text book of Pediatric nursing.
Sixth Edition. ELSEVIER Florida. 345-466

JOURNAL REFERENCE
1. Staebler, Suzanne; Meier (2016). The Future of Neonatal Advanced
Practice Regisered Nurse Practice: White paper. 8-14
2. Lund, Caroiyn(2016). Bathing and Beyond: Current Bathing
controversies for newborn infant. 33-38

INTERNET RESOURCES
1. https://medlineplus.gov> ency >article
2. https://www.slideshare.net >mobile>ppt

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