2.1a newborn care

8/10/2019 2.1a Newborn Care

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SAMONTE, JBMM of

2.1A NEWBORN CARE

Dra. Grace

January 07,

Emilio Aguinaldo College – School of

OBJECTIVES

1. To introduce normal newborn findings and behavior pattern.

Recognize the context of a normal pregnancy outcome.

Describe the process of transition from intrauterine to extra

uterine existence.

Perform a complete physical examination of the newborn

infant. Perform a concise neurodevelopment assessment of the

newborn infant.

2. To be aware of what constitute a comprehensive newborn

care.

Formulate a risk assessment list

Perform basic steps in neonatal resuscitation

Provide immediate care for the newborn

Continuing care

Discharge procedure with adequate instruction

PERINATAL HISTORY

1. Demographic and social date socioeconomic status, age, race

2. Past medical illnesses in the family – cardiopulmonary disease,

infection, genetic disorder3. Prior maternal reproductive problems – still births, prematurity

4. Events occurring in the present pregnancy – vaginal bleeding,

medications, acute illness, duration of pregnancy

5. Description of labor – duration, fetal presentation, fetal distress,

presence of fever

6. Delivery – normal, c-section, anesthesia of sedation, forceps

PREGNANCY RISK CLASSIFICATION

CLASS A

Low risk mother with low risk newborn – normal uncomplicated

pregnancies and normal labor pattern.

CLASS B

High risk mother with low-risk newborn – mothers who are sick

but in stable condition and therefore presents a minimal risk tothe baby.

Example: Gravidocardiac, primagravida >35 years or < 16

years, malignant disease not receiving therapy, pulmonary

disorder, hematologic disorder

CLASS C

Low risk mother with high risk newborn

Example: History of habitual abortion and stillbirth, abnormal

ultrasonographic findings, abnormal biophysical profile,

prolonged or early gestation, evidence if IUGR, multiple

gestation, rupture of membranes, abnormal fetal heart rate or

pattern, meconium staining of amniotic fluid, etc.

CLASS D High risk mother with high risk newborn – fetus and newborns

are compromised because of maternal illness.

Example: Chronic hypertension, pre-eclampsia/eclampsia,

diabetes mellitus (uncontrolled), renal/cardiac failure, viral or

bacterial infections, choroiamnionitis, 2nd

or 3rd trimester

bleeding, etc.

FETAL PHYSIOLOGY

CIRCULATORY SYSTEM

Normally complete by 40th week of gestation

Fetal circulation with 3 shunts:

o Ductus venosus

o Foramen ovale

o Ductus arteriosus

Fig1. Fetal Circulation

FETAL CIRCULATION

Placenta umbilical vein Ductus venosus Inferior vena

cava Right atrium Foramen ovale Left atrium Left

ventricle Ascending aorta Head and upper part of the

body

Superior vena cava Right atrium Right ventricle

Pulmonary artery Ductus arteriosus Descending aorta

Lower half of the body

Blood flows in parallel rather than in series.

Mainly affected by high pulmonary resistance brought about bnon-expansion of the lungs.

RESPIRATORY SYSTEM

Formation starts from the airways proceeding to alveolation. Alveolar epithelium excretes lung fluid that fills the alveoli.

Surfactant produced by type II alveolar cells by 20th week of

gestation.

Adequate surfactant lowers surface tension of the alveolarepithelium preventing alveolar collapse.

Respiratory movements occur as early as 18th week of

gestation but ceases as fetus approaches term.

At term, fetus breathes ONLY if a hypoxic stimulus is applied.

THE TRANSITION

Passage of the fetus through the birth canal Chest wall iscompressed lung fluid is expelled Elastic chest wall recoilsback High negative intra-thoracic pressure.

Infant’s first cry replaces lung fluid with air.

Fluid in the alveoli is absorbed into the lung tissue and

replaced by air. The oxygen in the air is able to diffuse into theblood vessels that surround the alveoli.

Alteration of the lungs eliminate the hypoxic state causingvasodilation of lung vessels.

Decrease in pulmonary vascular resistance and pressure More blood enter the lungs and return to the heart Left atriapressure increases causing physiologic closure of the foramenovale.

Increase in oxygen content causes the muscular constrictionand functional closure of the patent ductus arteriosus.

APGAR SCORE

Practical method of systematically assessing newborn infantsimmediately after birth to help identify those requiringresuscitation and to predict survival in the neonatal period.



SAMONTE, JBMM of

2.1 NEWBORN CAREPediatrics I

Not designed to predict neurological outcome

SIGN 0 1 2

Heart rate Absent < 100 100

Respiratoryeffort

Absent Slow irregular Good crying

Muscle tone Limp Some flexionof ext. Active motion

Response tocatheter in

nostril

(-) Response Grimace Cough sneeze

Color Blue, pale Body pink, ext.blue

Pink all over

1 minute score – signal the need for immediate resuscitation. 5 minute score – probability of successfully resuscitating an

infant. May be extended to 10, 15, 20 minutes until score of 7 is

reached.

NEONATAL RESUSCITATION

Drying, warming, positioning, suction,

Tactile stimulation

Oxygen

Bag-mask ventilation

Endotracheal intubation

Chest compressions

Medications

Inverted pyramid reflecting the appropriate relative frequencies

of neonatal resuscitative efforts.

ESSENTIAL NEWBORN CARE

Protocol promulgates by the WHO and endorsed by DOH to

decrease neonatal mortality.

Evidence based intervention. Emphasizes on core sequence of actions performed step by

step.

Four core steps:

1. Immediate and thorough drying.

2. Early skin to skin contact.

3. Properly timed cord clamp.

4. Non-separation of the newborn and mother for early

initiation of breastfeeding.

TIME-BOUND INTERVENTIONSWithin 30seconds

objective: Tostimulatebreathing,

providewarmth.

After thoroughdrying

objective: Toprovide

warmth,bonding,prevent

infection &hypoglycemia.

Up to 3 minutespost-deliveryobjective: To

reduce anemia

in term &preterm; IVH and

transfusions inpreterm.

Within 30minutes of ageobjective: To

facilitate initiation

of breastfeedingthrough

sustainedcontact.

-Put on doublegloves-Dry thoroughly-Remove wetcloth-Quick check ofNB’s breathing

-Suction only ifneeded

-Put prone onchest/abdomenskin to skin-Cover withblanket, bonnet-Placeidentification onankle-Do not removevernix

-Remove 1s set of

gloves-Clamp and cutcord after cordpulsations stop. (1-3 mins)

-Do not milk cord.-Give oxytocin 10mg IM to mother.

-Uninterrupted skinto skin contact.-Observe NB forfeeding cues.Counsel onpositioning &attachment.-Do eye care,injections, etc after1

st breastfeeding.

EXPANDED BALLARD SCORE

Assessment of gestational age by determining state of

maturity.

Use of physical features and neurological responses.

Extremely prematures assessed as early as 12 hours, term

infants may be assessed even up to 72 hours.



SAMONTE, JBMM of


PHYSICAL MATURITY NEUROMUSCULAR MATURITY

SkinLanugo

Plantar surfaceBreast

Eyes/earsGenitalia

PostureSquare window

Arm recoilPopliteal angle

Scarf signHeel to ear

PHYSICAL EXAMINATION OF THE NEWBORN

Initial examination performed as soon as possible after delivery

o To detect abnormalities and

o To establish a baseline for subsequent examinations

2nd

examination: within 24 hours after birth

3rd examination: within 24 hours of discharge

Tailored to fit both the gestational and postnatal age of an

infant.

Requires patience and procedural flexibility to return to do part

of the examination in order to stay within the limits of an infant’s

tolerance.

Requires gentleness.

Anthropometric measurements: weight, length, head

circumference, chest circumference and abdominal

circumference.

Vital signs:

o Pulse rate: 120-160 beats/min.

o Respiratory rate: 30-60 breaths/in.

o Temperature, color, activity: Monitored every 30 mins

after birth for 2 hours or until stabilized.

GENERAL APPEARANCE

Physical activity: absent, deceased, vigorous crying

Muscle tone: Active or passive

Take note of unusual posture

Coarse tremulous movements vs. convulsive twitchings

Edema: Generalized or localized

SKIN

Vasomotor instability and peripheral circulatory sluggishness –

deep redness or purple lividity during crying.

Acrocyanosis of the hands and feet

Mottling – associated with

severe illness or related to

transient fluctuation of skin

temperature.

Fig2. Mottling

Harlequin color change –

extraordinary division of the

body from the forehead to thepubis into red and pale halves;

transient and harmless

condition.

Fig3. Harlequin color change

Pallor – represents asphyxia, anemia, shock or edema.

Vernix caseosa - also known

as vernix, is the waxy or

cheese-like white substance

found coating the skin of

newborn human babies.

Vernix starts developing on the

baby in the womb around 18

weeks into pregnancy. Fig4. Vernix caseosa

Plethora – Polycythemia

Lanugo – fine, soft immature

hair on scalp, brow and face;

especially among prematures.

Fig5. Lanugo

Mongolian spots – slate blue, well-

demarcated areas of pigmentation

seen over the buttocks, back – tend to disappear within the 1st

year of life.

Fig6. Mongolian spots

Erythema toxicum – small white

occasionally vesiculopustular

papules on an erythematous base

seen on the face, trunk and

extremities – appears 1-3 days

after birth and persists for as long

as 1 week.

Fig7. Erythema toxicum

Milia – small whitish papules made

up of distended sebaceous glands,

usually covering the nose.

Fig8. Milia

Salmon patch - (also called stork

bites) appear on 30%-50% of

newborn babies. These marks

are small blood vessels

(capillaries) that are visible

through the skin. They are most

common on the forehead,

eyelids, upper lip, between the

eyebrows, and the back of the neck. Fig9. Salmon patch

Often, these marks fade as the

infant grows.

Hemangiomas - benign(noncancerous) vascular tumorscomposed of cells that normallyline the blood vessels (endothelialcells).

Fig10. Hemangiomas



SAMONTE, JBMM of


HEAD

Molding: Usually among first born, parietal bones tend tooverride the occipital and frontal bones.

Suture lines: Check for premature fusion = craniosyntosis

Anterior and posterior fontanels: check for abnormal size

Craniotabes: soft area in the parietal bones at the vertex nearsagittal suture.

Caput succedaneum – edematousswelling of the soft tissue of thescalp.

Fig12. Caput succedaneum

Cephalhematoma – subperiostealhemorrhage

Fig13. Cephalhematoma

FACE

Dysmorphic features – epicanthal folds, widely spaced eyes,microphthalmia, low set ears.

Asymmetry: Abnormal fetal posture, 7th nerve palsy

Facial nerve paralysis – Theforehead on the affected side issmooth, eye cannot be closed,nasolabial fold is absent, corner ofmouth drops.

Fig14. Facial nerve paralysis

EYES

Conjunctival and retinal hemorrhages usually benign.

Check for bilateral red reflex.

Leukocoria: White pupillary reflex = cataracts, tumors,chorioretinitis, ROP

EARS

Deformitis of the pinnae

Preauricular skin tags

NOSE

Patency and symmetry of the nares

Assymetry: Dislocation of nasal cartilage from the vomeriangroove.

Choanal atresia – may lead to respiratory distress

MOUTH

Precocious dentition:o Natal – present at birtho Neonatal – eruption after birth

Soft and hard palate: Check for complete or submucosal cleftcheck for contour

Epstein pearls: Retention epithelial cells cysts seen on the hapalate and gums.

Tongue: Short frenulum

NECK

Relatively short

Abnormalities not common: Goiter, cystic hygroma, brachialcleft vestiges, sternocleidomastoid hematomas

Redundant skin or webbing: Turner syndrome

Clavicular fracture

CHEST

Breast hypertrophy common

Supernumerary nipples occasionally seen

Milk may be present (witch’s milk)

Retractions (intercostal/subcostal): Respiratory distress

LUNGS

Variation in rate and rhythm of breathing according to infant’sphysical activity.

RR > 60/min: Respiratory, cardiac or metabolic disease

Breathing is diaphragmatic – “paradoxical movement”

Prematures: Cheyne-stokes rhythm = periodic breathing

Breath sounds – bronchovesicular

Expiratory grunting : Respiratory distress

HEART

Determine location: Dextrocardia

Fig15. Dextrocardia

Transitory benign murmur are common

Congenital heart disease may not initially produce the murmuthat will appear later.

Palpation of pulses in the upper and lower extremities:Coarctation of the aorta.

Fig16. Coarctation of the aorta

ABDOMEN



SAMONTE, JBMM of


Prominent, globular but not distended

Liver usually palpable 2 cm below the rib margin.

Tip of the spleen may be felt less commonly

Abnormal masses: Renal pathology most common.

Scaphoid abdomen: Diaphragmatic hernia.

Abdominal wall defects: Omphalocoele vs gastroschisis

Fig17. Omphalocoele

Fig18. Gastrochitis

Fig19. Gastroschisis VS Ompalocoele

Air in the GIT vary, present in the rectum by radiograph by 24hours of age.

Umbilicus: 2 arteries and 1 vein

GENITALIA

Maternal hormones – enlargement and secretion of breasts,prominent female genitalia with non-purulent discharge.

Testes may not be fully descended but are palpable in thecanals.

Prepuce normally tight and adherent.

Ambiguity in external genitalia requires further investigation.

Fig20. Ambiguous genitalia

ANUS

Check for patency

Passage of meconium by 48 hours of life

EXTREMITIES

Check of effect of fetal posture

Poly or syndactyly

Clubfoot

Abnormal dermatoglyphic pattern: Simian crease

Congenital hip dislocation: Ortolani’s maneuver

NEUROLOGICAL EXAMINATION

POSTURE

Resting, unrestrained posture

Flexion and adduction of the hips, flexion of the knees, armsadducted and flexed at the elbow, fists often clenched.

STATE OF WAKEFULNESS

1. Deep sleep – no movement, regular breathing2. Light sleep – with eye movements, hypotonic and irregular

breathing3. Quiet, awake – eyes closed or half-open, with slight activity4. Fully awake – eyes open, alter with some movements5. Fully awake, active – with plenty of movements6. Fully awake, crying

The neurodevelopmental exam is most reliably done in statesor 4

Rooting, licking, sucking reflexes reflect level ofresponsiveness.

Observe eye opening, yawning, facial expressions andstretching.

TONE

Observe for posture

Frog leg position suggests flaccidity

Passive tone: Observe by performing vertical suspension andhorizontal suspension.

Active tone: Pull to sit maneuver

Ankle clonus of >10 beats probably abnormal

Differentiate tremulousness from seizures

REFLEXES

Deep tendon: patellar reflex test (L2-L4)

Less easy to elicit: biceps, ankle, truncal innervation

Primitive: assessed for presence or absence, symmetry,completeness, persistence

Moro, palmar and plantar grasp, rooting, sucking, placingreflexes at birth

Tonic neck reflex at later days

Fig21. Moro reflex Fig22. Grasp reflex

Fig23. Rooting reflex Fig24. Asymmetric tonic refle



SAMONTE, JBMM of


Fig25. Placing reflex

HIGHER FUNCTION AND CRANIAL NERVES

Observe response to breast-feeding, human voice (particularlymother’s voice)

Capable of visual fixation and limited tracking during alertperiods.

Especially responsive to the human face

IMMEDIATE CARE FOR THE NEWBORNTHERMOREGULATION

Relative to body weight, body surface area of a newborn infantis approximately 3x that of an adult.

Estimated rate of heat loss in a newborn is approximately 4xthat of an adult.

Maintain 36.6-37.2 C

Skin to skin contact with the mother is the optimal method tomaintain temperature in the stable newborn.

SKIN AND CORD CARE

Once infant’s temperature has stabilized, entire skin and cordshould be cleaned with warm water and milk non-medicatedsoap.

Careful removal of blood and meconium, do not remove vernix.

Cord may be treated daily with bactericidal or anti-microbial;

agents such as triple dye or bacitracin. 2x daily alcohol soaking until cord falls off reduces colonization,

exudates and foul odor of the umbilicus.

Hand washing of nursery personnel is mandatory.

EYE CARE

Instillation of 1% silver nitrate drops or erythromycin 0.5% ortetracycline ophthalmic ointment.

To prevent gonococcal eye infections.

VITAMIN K ADMINISTRATION

Water-soluble vitamin K (phytonadione) given by intramuscularinjection.

0.5 mg for premature infants, 1.0 mg for term infants

To prevent hemorrhagic disease of the newborn.

IMMUNIZATION Hepatitis B and BCG

Babies of mothers with reactive HBsAg should receive bothHepatitis B immune globulin and vaccine.

CONTINUING CARE

ROOMING-IN

Within 2 hours after birth or as soon as possible.

Clear bassinet to allow easy monitoring and care.

Advise on thermoregulation and hand washing.

Mother directly responsible for the routine care of the infantduring rooming-in.

BREASTFEEDING

Latch-on within 30-45 mins after birth or as soon as the infantshows signs of readiness.

Proper technique in breastfeeding.

No pacifiers or other artificial forms of feeding.

On demand deeding preferred.

NEWBORN SCREENING Collection of blood samples form the sole of the feet of

newborn infants, placed on filter paper.

For detection of:o Congenital hypothyroidismo Congenital adrenal hyperplasiao Phenyketonuriao Galactosemiao Glucose 6 phosphate dehydrogenase deficiency

DISCHARGE PROCEDURE

Continue exclusive breastfeeding

Cord care

Bathing

Signs of illness, contact numbers, emergency room

Well baby visit schedule

END OF TRANS

Life isn’t about getting and having, it’s about giving and being.–Kevin Kruse

2.1a newborn care

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