newborn care

Immediate care of the newborn and newborn assessment.

IMMEDIATE CARE OF THE NEWBORN

I. Care of the Newborn at the DELIVERY ROOM

>Establish and Maintain AIRWAY (Respiration)

A. Suctioning >Turn the baby’s head to one side.

>Suction gently and quickly (5 to 10 seconds). =bradycardia.

> Suction the MOUTH first before the nose. ASPIRATION.

>REMEMBER: newborns are NASAL BREATHERS.

C. TEMPERATURE REGULATION (THERMOREGULATION)

Maintain appropriate Body Temperature. Chilling will increase the body’s need for O2.

Wrap the newborn immediately

Wrap him warmly

Put him under a droplight

HEAT LOSS IN NEWBORN CONVECTION – flow of heat from body surface

to cooler surroundings RADIATION – transfer of body heat to a cooler

solid object not in contact with the body EVAPORATION – loss of heat through

conversion of a liquid to a vapor CONDUCTION – transfer of body heat to a

cooler solid object in contact with the body

D. APGAR Scoring System – standard tool to evaluate the condition of the neonate

Done twice: 1st minute: to determine general condition

(NEURO/RESPI/CIRCULATORY CHECK) 5th minute: to determine if neonate can

adjust to extracellular life Appearance (color) – least important criteria Pulse rate (most important criteria) Grimace (reflex activity)- irritability Activity (muscle tone) Respiration

*Lowest individual score is 0. *Highest individual score is 2.

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APPEARANCEAPPEARANCE BLUE/ PALEBLUE/ PALE BODY PINK, BODY PINK, EXTREMITIES EXTREMITIES BLUE, BLUE, (ACROCYANOSIS S- (ACROCYANOSIS S- NORMAL) 1NORMAL) 1STST 48 480 0

DUE TO DUE TO IMMATURITY OF IMMATURITY OF CIRCULATIONCIRCULATION

Completely Completely PINKPINKRUDDY SKINRUDDY SKIN

PULSEPULSE ABSENTABSENT < 100 BEATS / < 100 BEATS / MINMIN

> 100 BEATS / > 100 BEATS / MINMIN

GRIMACEGRIMACE NONENONE > WEAK CRY> WEAK CRY > SNEEZE, / > SNEEZE, / COUGH,LUSTY COUGH,LUSTY CRY (GOOD, CRY (GOOD, STRONG, STRONG, VIGOROUS)VIGOROUS)

ACTIVITYACTIVITY FLACID / LIMPFLACID / LIMP > SOME EXT. > SOME EXT. FLEXFLEX

WITHDRAWAL WITHDRAWAL OF FEETOF FEET EXT. FLEX EXT. FLEX WELLWELL

RESPIRATIONRESPIRATION ABSENTABSENT < 30< 30 > 60> 60

SCORE: 9 HIGHEST SCORE

10 PERFECT SCORE

ADD ALL SCORES AND INTERPRET:

0 – 3 = POOR, SERIOUS, SEVERELY DEPRESSED, NEEDS CPR

4 – 6 = FAIR, GUARDED, MODERATELY DEPRESSED

7 – 10 = GOOD, HEALTHY

I. Physical Assessment1. Vital Signs

Temperature – axillary: 36.5º – 37ºC (97.91-98ºF)/ rectal

Crying may increase body temperature slightly.Radiant warmer will falsely increase axillary temperature.

RESPIRATION – normally RAPID, QUIET, GENTLE, SHALLOW, IRREGULAR with

physiologic APNEA of less than 5 seconds

Largely diaphragmatic and abdominal•60-80 breaths/min at birth•30-60 breaths/min (stable)

BLOOD PRESSURE

not routinely obtained except for suspicion of Coarctation of the Aorta.

BP at birth: 70/50 At 10 days:

100/50

E. PROPER IDENTIFICATION IS DONE IN THE DR BEFORE BEING BROUGHT TO THE NURSERY.

BEST METHOD OF IDENTIFICATION:

** FOOTPRINTING – MOST RELIABLE

** ID BANDS – ( ANKLE & WRIST) ACCURATE & RACTICAL

** BIRTHMARKS – LESS RELIABLE

II. Care of the Newborn at the NURSERY

A. Check the ID bands of mother and baby B. THERMOREGULATIONC. BATH – done if infant’s skin temperature

stabilizes at 36.5ºC (98.6ºF); temperature stabilizes 6-8 hours after

birth*VERNIX CASEOSA *USE NON-ALKALINIC SOAP*USE OF ANTISEPTIC SOLUTIONS *WARM WATER

Maintain at 35.5ºC-36.5ºC **Rectal route is preferred **Passage of meconium should be

within 24 to 36 hrs afterbirth. No meconium imperforate anus

D. Initial Cord DressingCORD: 2 A + 1 V*Practice aseptic technique* Use 70% Isoprophyl alcohol to prevent Tetanus Neonatorum and Omphalitis infection of the cord (streptococcal and staphylococcal)

Signs of Omphalitis:*Reddening of the area*Fever*Discharge and foul smell

Application of sterile cord clamp ** The cord will fall off after – 7-10 days

E. CREDE’S PROPHYLAXIS to prevent Opthalmia

Neonatorum or Gonorrheal Conjunctivitis (Neisseria gonorrhea) which causes blindness if not treated.

Infection can be acquired during vaginal delivery from mother with untreated gonorrhea

Ophthalmic drops – BEFORE: Silver Nitrate or

AgNO3 1% 1-2 drops1-2 gtts into the lower

conjunctival sac PRESENT:

Ointment – inner to outer canthusErythromycin – drug of choice of Chlamydial Trachomatis

F. Vitamin K InjectionVitamin K facilitates production of the clotting factor; thus, prevents bleeding,

1 mg. Aquamephyton (generic: phytonadione)Route: IM into the lateral anterior thigh (Vastus lateralis). In children below 12 months of age who have not yet learned how to walk.

G.Take Anthropometric Measurements (Vital Statistics)

BL: 47–54 cm

HC: 33 – 35 cmCC: 31 – 33 cmAC: 31 – 33 cmBW: 5.5-7.5 lbs

>Physiologic weight loss (reduction of 5-10% of BW) during the 1st 10 days of life is normal.

PHYSIOLOGIC WEIGHT LOSS (first 10 days of life)

Causes:-Infant is no longer under the influence of maternal hormones.-Voids and passes out stools.-Has relatively low nutritional intake- Difficulty sucking

H. Initial Feeding – given 1-6 hours after birth.1 oz of sterile water then glucose water

Purposes of breastfeeding:*Primarily to promote bonding*Facilitates uterine contraction *Facilitates release of colostrums (contains antibodies-IgA).

2. Skin

Dark red = prematurityAcrocyanosis = body pink, extremities blue – normal during the 1st 24-48 hours of lifeGeneralized mottling (cutis marmorata)RUDDY – normal (stable)Grayish – infectionJaundice Pallor due to anemia because of:

*Excessive blood loss when cord is cut*Untimely cutting of the cord* Inadequate iron stores-poor maternal

nutrition.*Blood incompatibility

Breastfed babies have longer physiologic jaundice because human milk has PREGNANEDIOL

Types:1. Physiologic Jaundice – Icterus NeonatorumCauses:

*Begins from 2nd day – 7th day = TERM 2nd day – 10th day =

PRE- TERM

2. Pathologic JaundiceCauses:

Infection Hemolytic disorders Inability of the newborn to conjugate bilirubin

Most accurate method of assessing the presence of jaundice: Use natural light and blanch skin on the chest or tip of the nose.

Accumulation of bilirubin in the brain tissues

SEIZURES MENTAL RETARDATION EXCHANGE TRANSFUSION

Goal of treatment: to decrease the bilirubin levels

Management: Bililight(Phototherapy)Nursing Care:

Cover eyes with an opaque mask Distance of about 18-20 inches from source of light.Monitor V/S especially temp.Cover the genitalia to prevent (PRIAPISM)Turning the baby q2hours.Hydration.

bluish gray or dark nonelevated pigmentation area over the lower back and buttocks present at birth, primarily nonwhite, disappear at SCHOOL AGE

Nevus vasculosus/Strawberry nevus

Nevus flammeus/PORTWINE STAIN

Is the fine downy, hair that covers a newborn’s shoulder, back and upper arms

Found also in the forehead and ears. Post-mature infants have rarely have

lanugo Disappears by 2 weeks of age.

Within 24 hrs. of birth, the skin of most newborns has become extremely dry

The dryness is particularly evident on the palms of the hands and soles of the feet.

this is normal and needs no treatment.

Normal mature infants’ newborn rash. Appears in the 1st to 4th day of life, may

appear up to 2 wks of age Also called Flea bite rash One of the chief characteristic of the

rash is the lack of pattern.

There may be a circular or linear contusion matching the rim of the blade of the forcep on the infants cheek.

The mark disappears in 1-2 days along with the edema that accompanies it.

HARLEQUIN SIGN

- BECAUSE OF IMMATURITY OF CIRCULATION, AN INFANT WHO HAS BEEN LYING ON HIS SIDE WILL APPEAR RED ON THE DEPENDENT SIDE & PALE ON THE UPPER SIDE.

CUTIS MARMORATA

- TRANSITORY MOTTLING ON NB’S SKIN WHEN IT IS EXPOSED TO COLD.

Newborn sebaceous gland is immature.

One pin-point white papule (a plugged or unopened sebaceous gland)

Found in the cheek or across the bridge of the nose

Disappears by 2-4 wks of age Avoid scratching or squeezing the

papules

Head is the largest part of the infants’ body (1/4 of his total length); forehead is large and prominent; chin is receding when startled or

crying.

a. Symmetry of the Head

b. Fontanels1.Anterior – diamond shape; closes at 12-18 months

between the 2 parietal bones and 2 fused frontal bones.

Suture lines should never appear widely separated. It indicates Hydrocephalus

2.Posterior – triangular in shape; between parietal and occipital bones.

Closes by end of 2nd month.

CRANIOSTENOSIS/CRANIOSYNOSTOSISpremature closure of the sutures leading to mental retardation.

MOLDING

Cephalhematoma

collection of blood under the periosteum of the cranialbone.

Disappears in weeks to months

Caput succedaneum – localized soft swelling of the scalp often associated with a long and difficult birth; present at birth; overrides the suture line, fluid is reabsorbed within hours to days after delivery

Localized softening of the cranial bones It corrects itself without treatment after a

few months It is probably caused by the pressure of

the fetal skull against the mother’s pelvic bone in utero.

It is more common in 1st borne infants

EYES•Eyelids of equal size•Temporarily gray or brown in color •Cry tearlessly during first 3 months•Cornea should be round and adult sized•Pupils should be round•Eyes may appear cross-eyed (Strabismus)V.A. of 20/200 to 20/500

d. EARS•Top of ear should align with the inner and

outer canthus of the eye. •If set of ears lower

>kidney malformation or

>chromosomal defect •Sense of Hearing – highly developed in NB

e. NOSE•Note for marked flaring of alae nasi,•Causes of obstruction:

SecretionsAnatomical defect: septal deviation

Sense of smell – least developed

f. MOUTH•Should open evenly when crying. •Palate should be intact; no breaks on the lip •Epstein Pearls – small round glistening cysts seen on palate and gums.•If with tooth (NATAL TOOTH=not covered with gum membrane) should be extracted to prevent aspiration.•Oral thrush – white gray patches usually on the tongue and sides of cheeks due to Candida albicans.

Bell's (facial nerve) Palsy: The prognosis for facial nerve palsies is excellent, and recovery usually occurs in the first month. In the meantime, prevention of corneal drying is essential.

Bell's (facial nerve) Palsy: The prognosis for facial nerve palsies is excellent, and recovery usually occurs in the first month. In the meantime, prevention of corneal drying is essential.

g. NECK•Thyroid gland is not palpable.•Appears soft and palpable and creased with skin folds•Head should rotate freely on the neck and flex

forward and back.•Rigidity of the neck suspect CONGENITAL TORTICOLLIS •In NB with nuchial rigidity suggests meningitis.

h. CHEST•As large as or smaller than the head•Symmetrically expands •Breasts may be engorged (due to maternal

hormones) •Passage of WITCH’S MILK.

i. Abdomen•Normally dome shaped;• If saphead, suspect DIAPHRAGMATIC HERNIA

(bowel sounds heard in the chest).•Bowel sounds should be present within

1 hour after birth.

j. EXTREMITIES

•Symmetric and of equal length•Fingers and toes in equal count. •Supernumery = POLYDACTYLY; •Fused or webbed = SYNDACTYLY•Simean line – single palmar crease = DOWN’S

SYNDROM•Observe for clubfoot deformities

SYNDACTYLY

POLYDACTYLY

Congenital Hip Dislocation

k. SENSESSight – newborns can see at birth, cannot see

objects past the visual midline (not until 6-8 weeks). The visual field is 9 inches.

Hearing – as soon as amniotic fluid has been absorbed, the newborn can already hearTaste – as soon as secretions have been

suctioned, newborns can already tasteSmellSmell – as soon as the nose has been cleared of

mucus and fluid, newborns can smellTouch – the most developed of all the senses

Blood CoagulationMost newborn are born with a prolonged

coagulation or Prothrombin time. It takes 24 hrs. for flora to accumulate and

vitamin K to be synthesized

Increased pressure on the left side of the newborn’s heart results in:

>Closure of the foramen ovale>Change of the ductus arteriosus into a mere ligament (ligamentum arteriosum)>Ductus venosus becomes ligamentum venosum

>Atrophy of the umbilical vein and arteries

Within 10 minutes after birth, newborn has establish a good residual volume.

A baby born by CS have more lung fluid at birth as one born vaginally, so they may have more difficulty establishing effective respiration (because of excessive fluid blocks air exchange space)

3 types of stools passed by NB:1. Meconium – greenish-blackish viscous; formed during fetal life from amniotic fluid, intestinal secretions and cells shed from mucosa; should be within 24 hours2. Transitional – passed from 3rd to 10th day•Milk stool•Breast fed infant stool •Bottle fed infant stool

The average newborn voids within 24 hrs after birth

A single voiding in a newborn is only about 15 ml

The daily urinary output for the 1st 1-2 days is about 30-60 ml total.

The 1st voiding may be pink or dusky because of uric acid crystals that were formed in the bladder in utero

Epispadias - urethral opening on the dorsal surface of the penis

Surgical correction

HYPOSPADIA Male urethral

opening on the ventral surface of penis, or female urethral opening in vagina

Surgical reconstruction

Female Genitalia – May have swollen labia and “PSEUDOMENSTRUATION”

Male Genitalia – Scrotum may be edematous

CRYPTORCHIDISM – undescended testis ORCHIOPEXY – repair for undescended testis.

HYDROCOELE INGUINAL HERNIA

Care of the penisUncircumcised – do not force

retraction of foreskin >(complete separation of foreskin

and glans penis takes 3-5 y)Circumcised (surgical removal of

prepuce/foreskin)Ensure signed permission before

procedure.Postprocedure monitor for bleeding

and voiding, Teach parents to clean area with warm water squeezed over penis and dry gently; a whitish yellow exudate.

PASSIVE NATURAL IMMUNITY – type of immunity transferred from mother to newborn (present in the infant for one year)

*Newborns have difficulty forming antibodies until 2 months of age (that is why immunizations are started at 2 months).

Reflexes Blink Reflex- to protect the eye

from any object coming near it by rapid eyelid closure

• Rooting Reflex– turns toward any object touching/stroking cheek/mouth, opens mouth, and sucks rhythmically when finger/nipple is inserted into mouth (usually disappears by 6 wks.)

• Sucking Reflex- when newborn’s lips are touched, the baby makes a sucking motion. Disapears at about 6 months

Swallowing Reflex- food that reaches the posterior portion of the tongue is automatically swallowed.

Extrusion Reflex- a newborn will extrude any substance that is placed in the anterior portion of the tongue.Protective reflex prevents the swallowing of

inedible substanceDisappears at 6 wks to 3 mos.

Palmar grasp – pressure on palm elicits grasp (fades by 3-4 mo)

• Moro or Startle Reflex – elicited by sudden disturbance in the infant’s immediate environment, body will stiffen, arms in tense extension followed by embrace gesture with thumb and index finger a “c” formation (disappears by 6 mo)

Stepping (walk)-in-place reflex – when held upright with one foot touching a flat surface, with alternating step (fades 4-5 mo)

Babinski’s sign – stroking the sole of the foot from heel upward like an inverter “J” across ball of foot will cause all toes to fan (reverts to usual adult response by 12 mo)

Landau reflex- a newborn who is held in a prone position with a hand underneath supporting the trunk should demonstrate some muscle tone

11. BACK•On prone appears flat, (curves start to form when child learns to sit or stand)•Note: for mass, hairy nodule and a dimple

along axis. This may be indicative of Spina Bifida.

Discharge InstructionsBathing – maybe given anytime as long as it is not within 30

minutes after a feeding.

>Sponge baths are done until the cord falls off (7th to the 10th day).Cord Care

Fold down diapers so that cord does not get wet during voidingDab rubbing alcohol (70%) once or twice a daySmall pink granulating area may be seen on the day the cord falls off. If it remains moist for a week, advise mother to bring baby to the doctor’s clinic.

REPUBLIC ACT NO. 9288

“…ensure that every baby born in the Philippines is offered the opportunity to undergo newborn screening and thus be spared from heritable conditions that can lead to mental retardation and death if undetected and untreated.”

Thyroid hypofunction or enzyme defect reduced T3, T4S/sx: excessive sleeping, enlarged

tongue, noisy respiration, poor suck, cold extremities, slow pulse and respiratory rate, lethargy and fatigue, short and thick neck, dull expression, open mouthed, slow DTR, obesity, brittle hair, delayed dentition, dry, scaly skin

Dx: low T3 T4, inc TSHTx: synthetic thyroid hormoneNsg Care: Assist parents administer drugs

- reduction in the levels of the enzyme G6PD in RBC leads to hemolysis of the cell upon exposure to oxidative stress

Dx: blood smear – heinz bodies rapid enzyme screening test, electrophoresis

Mx: avoid sulfonamides, antimalarials, fava beans

- Deficient or absent phenylalanine hydroxylase w/c converts phenylalanine to tyrosine

S/sx: mental retardation, musty odor of urine, blond hair, blue eyes

Dx: Guthrie blood test

Tx: decrease phenylalanine (Lofenalac) regulate diet

(-) enzyme that converts galactose to glucose

S/sx: wt loss, vomiting, hepatosplenomegaly, jaundice and cataract

Dx: Beutler test

Tx: decrease lactose – soy based formularegulate diet