Immediate Care of the Newborn

Goals:
   

To establish, maintain and support respirations. To provide warmth and prevent hypothermia. To ensure safety, prevent injury and infection. To identify actual or potential problems that may require immediate attention.

Establish respiration and maintain clear airway The most important need for the newborn immediately after birth is a clear airway to enable the newborn to breathe effectively since the placenta has ceased to function as an organ of gas exchange. It is in the maintenance of adequate oxygen supply through effective respiration that the survival of the newborn greatly depends. Newborns are obligatory nose breathers. The reflex response to nasal obstruction, opening the mouth to maintain airway, is not present in most newborns until 3 weeks after birth. To establish and maintain respirations: 1. Wipe mouth and nose of secretions after delivery of the head. 2. Suction secretions from mouth and nose.
  

Compress bulb syringe before inserting Suction mouth first, then, the nose Insert bulb syringe in one side of the mouth

3. A crying infant is a breathing infant. Stimulate the baby to cry if baby does not cry spontaneously, or if the cry is weak.
 

Do not slap the buttocks rather rub the soles of the feet. Stimulate to cry after secretions are removed.

The normal infant cry is loud and husky. Observe for the following abnormal cry:
  

High, pitched cry indicates hypoglycemia, increased intracranial pressure. Weak cry prematurity Hoarse cry laryngeal stridor

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

Trendelenburg position head lower than the body Side lying position If trendelenburg position is contraindicated, place infant in side lying positionto permit drainage of mucus from the mouth. Place a small pillow or rolled towel at the back to prevent newborn from rolling back to supine position.

5. Keep the nares patent. Remove mucus and other particles that may be cause obstruction. Newborns are obligatory nose breathers until they are about 3 weeks old. Care of the Eyes It is part of the routine care of the newborn to give prophylactic eye treatment against gonorrhea conjunctivitis or opthalmia neonatorum. Neisseria gonorrhea, the causative agent, may be passed on the fetus from the vaginal canal during delivery. This practice was introduced by Crede, a German gynecologist in1884. Silver nitrate, erythromycin and tetracycline ophthalmic ointments are the drugs used for this purpose. Erythromycin or tetracycline Opthalmic Ointment:
1. These ointments are the ones commonly used now a days for eye prophylaxis because they do not cause eye irritation and are more effective against Chlamydial conjunctivitis. 2. Apply over lower lids of both eyes, then, manipulate eyelids to spread medication over the eyes.

Vitamin K or Aquamephyton The newborn has a sterile intestine at birth, hence, the newborn does not possess the intestinal bacteria that manufactures vitamin K which is necessary for the formation of clotting factors. This makes the newborn prone to bleeding. As a preventive measure, .5 (preterm) and 1 mg (full term) Vitamin K or aquamephyton is injected IM in the newborns vastus lateralis (lateral anterior thigh) muscle. Care of the cord The cord is clamped and cut approximately within 30 seconds after birth. In the delivery room, the cord is clamped twice about 8 inches from the abdomen and cut in between. When the newborn is brought to thenursery, another clamp is applied to 1 inch from the abdomen and the cord is cut at second time. The cord and the area around

it are cleansed with antisepticsolution. The manner of cord care depends on hospital protocol. What is important is that the principles are followed. Cord clamp maybe removed after 48 hours when the cord has dried. The cord stump usually dries and fall within 7 to 10 days leaving a granulating area that heals on the next 7 to 10 days. Instruction to the mother on cord care:
1. No tub bathing until cord falls off. Do not sponge bath to clean the baby. See to it that cord does not get wet by water or urine. 2. Do not apply anything on the cord such as baby powder or antibiotic, except the prescribedantiseptic solution which is 70% alcohol. 3. Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does not get wet when the diaper soaks with urine. 4. Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and separates more rapidly if it is exposed to air. 5. If you notice the cord to be bleeding, apply firm pressure and check cord clamp if loose and fasten. 6. Report any unusual signs and symptoms which indicates infection.
    

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

THE APGAR SCORING SYSTEM The APGAR Scoring System was developed by Dr.Virginia Apgar as a method of assessing the newborns

adjustment to extrauterine life. It is taken at one minute and five minutes after birth. With depressed infants, repeat the scoring every five minutes as needed. The one minute score indicates the necessity for resuscitation. The five minute score is more reliable in predicting mortality and neurologic deficits. The most important is the heart rate, then the respiratory rate, the muscle tone, reflex irritability and color follows in decreasing order. A heart rate below 100 signifies an asphyxiated baby and a heart rate above 160 signifies distress.

ASSESS HEART RATE RESPIRATION MUCLE TONE REFLEX IRRITABILITY COLOR Score:
  

0 Absent Absent Flaccid No response Blue all over

1 Below 100 Slow Some flexion Grimace Body pink, Extremities blue

2 Above 100 Good crying Active motion Vigorous cry Pink all over

7 10 Good adjustment, vigorous Moderately depressed infant, needs airway clearance

Severely depressed infant, in need of resuscitation. ASSESSING THE AVERAGE NEWBORN

Head Circumference Temperature Chest Circumference Heart Rate Respirations Weight Length

34 35 cm 97.6 98.6 F axillary 32 33 cm 120 140 bpm 30 60 bpm 2.5 to 3.4 kg 46 to 54 cm

Newborns undergo profound physiologic changes at the moment of birth, as they are released from a warm, snug, dark liquid-filed environment that has met all of their basic needs, into a chilly, unbounded, brightly lit, gravity based outside world. Within minutes after being plunged into this strange environment, a newborn s body must initiate respirations and accommodate a circulatory system to extrauterine oxygenation.

How well the newborn makes these major adjustments depends on his or her genetic composition, the competency of the recent intrauterine environment, the care received during the labor and birth period, and the care received during the newborn or neonatal period from birth through the first 28 days of life. (Adele Pillitteri, 2007) Two thirds of all deaths that occur during the first year of life occur in the neonatal period. More than half occur in the first 24 hours after birth an indication of how hazardous this time is for an infant. Close observation of a newborn for this indication of distress is essential during this period (National Center for Health Statistics, 2005).

Establish and Maintain a Patent Airway

1. Never stimulate a baby to cry unless secretions have been drained out. 2. Mucus should be sustained from a newborn s mouth by a bulb syringe as soon as the head is delivered. 3. As soon as an infant is born, he/she should be held for a few seconds with the head lightly lowered for further drainage of secretion. 4. Suction the newborn properly: 1. Turn the baby s head to one side 2. Suction gently and quickly. 3. Suction the mouth first before the nose. 4. Occlude one nostril at a time when testing for airway patency. 5. Record the first cry. 6. Maintain appropriate body temperature as chilling will increase the body s need for oxygen. 7. Newborn suffers large losses of heat because he is wet at birth, the delivery room is cold he does not have enough adipose tissues and does not know how to shiver.

Keep Newborn Warm

Effects of Cold Stress
 

1. 2. 3. 4. 5. 6.

Metabolic acidosis Hypoglycemia Dry the newborn immediately Wrap him with a warm blanket but not too tight as not to compromise respiratory effort Lay infant on his side in a warmed bassinet or place under a droplight Place a head cap to conserve heat especially if they are in an open crib. All nursing care should be accomplished quickly as possible to minimize exposure of the infant. Apgar score standardized evaluation of the newborn s condition. Done at one minute after birth to determine the general condition and then at 5 minutes to determine how well the newborn is adjusting to extrauterine life. 1. Color all infants appear cyanotic at birth and grow pink with or shortly after the first breath 2. Heart Rate auscultation of the newborn s heart 3. Reflex irritability response to a suction catheter or having the soles of their feet slapped. 4. Muscle tone newborn hold the extremity tightly flex. They should resist any effort to extend their extremities

5. Respiratory effort a mature newborn usually cries spontaneously at about 30 seconds after birth. At one minute, the infant is maintaining regular although rapid respirations.

Immediate Assessment of the Newborn

Sign Appearance: Color 0 Pale, Blue all over 1 Pinky body, extremities Less than 100 2 blue Pink all over

Pulse: Pulse Rate Grimace: Reflex Irritability

Absent No response stimulation

More than 100 away good

to Grimace/feeble cry when Sneeze/Coughs/Pulls stimulated when stimulated; strong cry Some flexion extremities Weak or irregular of Well-flexed extremities

Activity: Muscle Tone

Limp, flaccid

Respiration: Breathing Scoring

Absent

Good, strong cry

  

0-3 points the baby is serious danger and need immediate resuscitation. 4-6 points the baby s condition is guarded and may need more extensive clearing of the airway and supplementaryoxygen. 7-10 points are considered good and in the best possible health.

Vital Statistics/Anthropometric Measurements

Vital Statistic Weight Length Head Circumference Chest Circumference Average 6.5 to 7.5 lbs 50cms (20in) 33 to 35 inches. 31-33cms or 2cms less than head circumference Low or Arbitrary Low less than 5.5 lbs. 46cms (18in)

Abdominal Circumference Vital Signs Vital Sign Temperature Pulse Respiration Blood Pressure

31 to 33 cms

Immediately At Birth 36.5 to 37.2 Celsius 180 beats/minute 80 breaths/minute 80/46 mmHg

After Birth

120-140 beats/minute ave. 30-50 breaths/minute 100/50 mmHg (by 10th day)

1. Proper Identification and Charting 1. Proper identification of the newborn and footprints must be taken and kept in the chart. 2. Attach ID bracelet with a number that corresponds to the mother s hospital number, mother s full name, sex, date and time of birth. 3. Inspect for the presence of 2 arteries and 1 vein. Suspect a congenital anomaly if blood vessels are not complete. 4. Apply triple dye or Betadine for faster healing effect. 5. This is to cleanse the baby of blood mucus and vernix, and then followed with sponge bath. Dry infant, wrap and keep him warm. 6. Crede s Prophylaxis prophylactic treatment of the newborns eyes against gonorrheal conjunctivitis akaopthalmia neonatarum, which the baby acquires as he passes through the birth canal of the mother who has untreated gonorrhea.

Care of the Umbilical Cord Give Initial Oil Bath

Administer Eye Care

Procedure
  

Wipe the face dry. Shade the eyes from light and open one eye at a time by exerting gentle pressure on the upper and lower lids. Apply Erythromycin/Terramycin Opthalmic ointment from the inner to outer canthus of the eye. The antibiotic will eliminate gonorrhea and Chlamydia as well.

Administration of Vitamin K
1. Vitamin K facilitates production of the clotting factor, thus preventing bleeding. Method: Aquamephyton 1mg (Phytonadione), a synthetic Vitamin K is injected IM into the lateral aspect of the anterior thigh (vastus lateralis).

Document Birth Record

1. Accomplish the form properly. Continue Physical Assessment

Characteristics of a Newborn
1. General Appearance position and activity 2. Skin 1. a. Color ruddy complexion due to increased RBC concentration and decreased subcutaneous fat which makes blood vessels more visible. 1. Acrocyanosis 2. Physiologic Jaundice 3. Texture slight desquamation for the first 2 to 4 weeks of life 4. Skin Turgor good elasticity 5. Vernix Caseosa white cream-cheese like that serves as a skin lubricant 6. Milia pinpoint size white spots seen on the nose and chin due to obstruction of the sebaceous glands.

7. Erythema Toxicum newborn rash. It begins with a papule and eventually to an erythematic appearance. 8. Lanugo is the fine downy hair that covers a newborn s shoulders, back and upper arms. Immature newborns have more lanugo than mature infant. 9. Birthmarks 1. Hemangiomas are vascular tumors of the skin. 1. Nevus flammeus muscular purple or dark red lesion. Generally appear on the face and thighs. 2. Strawberry hemangiomas elevated areas formed by immature capillaries and endothelial cells. 3. Cavernous hemangiomas these are dilated vascular spaces. 4. Mongolian spots slate gray patches across the sacrum or buttocks and consist of a collection of pigment cells. 5. Forceps marks these are circular or linease contusion matching the rim of the blade forceps on the infant s cheeks. 3. Head newborn s head is disproportionately large 1. Fontanelles spaces or opening where the skull bones join 2. Molding the part of the infant s head that engages the cervix. It is molded to fit the cervix contours. 3. Caput Succedaneum is edema of the scalp at the presenting part of the head. 4. Cephalhematoma is a collection of blood between the periosteum of the skull bone and the bone itself caused by rupture of the periosteum capillary due to the pressure of birth. 5. Craniotabes is a localized softening of the cranial bones. 4. Eyes vision is present as evidence of blinking reflex 5. Ears hearing is present as soon as amniotic fluid is drained or is absorbed from the middle ear. 6. Nose may appear large for the face. 7. Mouth should open evenly when the baby cries. 8. Neck is short and chubby, creased with skin folds and head rotate freely. 9. Chest appear small in proportion to infant s head. 1. Abdomen contour is slightly protuberant (sticking out from the surroundings)

2. Anogenital Area anus should not be covered by a membrane. Take note of the time meconium is first passed. 1. Back the spine appears flat in the lumbar and sacral areas 2. Extremities 1. Arms and legs appear short 2. Hands are plump and clinch into fists 3. Should move symmetrically 4. Fingernails are soft, smooth 5. Good muscle tone, arms always in flexed position 6. Palm of hands should have three creases. 7. Legs are bowed as well short 8. Soles of the feet appears to be flat 9. Presence of crisscrossed lines on the soles of the foot. 3. Feeding

Provide Discharge Instructions

1. Breast-fed babies are fed immediately after birth and can be fed on demand or at least every 2 hours for the first few days of life. Advice to alternate both breast at 10-15 minutes each. 2. Bottle-fed babies routinely received an initial feeding of about 1oz of sterile water at 4-6 hours of age to be certain the infant can swallow without gagging and aspirating. The newborn is then fed every four hours. 1. Sleep patterns newborns sleep 16-20 hours a day 2. Bathing may be given anytime convenient as long as it is not within 30 minutes after feeding as handling might cause regurgitation. Sponge baths are done until cord falls off. 3. Cord Care 1. Dab rubbing alcohol (70% sol n) two or three times a day for faster drying. 2. Fold down diapers so that cord does not get wet during voiding. 3. Small, pink granulating area may be seen on the day the cord falls off. If it remains moist or with foul discharge, advise mother to bring baby to the doctor s clinic. 4. Car Safety. Until a child reaches a weight of 20lbs, the best type of car seat is an infant only seat that faces the back of the car.