care of the newborn

The 1st 24 hours

of Life

The first 24 hours of life is a very significant and a highly vulnerable time due to critical transition from

intrauterine to extrauterine life

Immediate Care of the Newborn

• Airway

• Breathing

• Temperature

051104 Neonatal Care 4

Airway & Breathing• Suction gently & quickly

using bulb syringe or suction catheter

• Starts in the mouth then, the nose to prevent aspiration

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Airway & Breathing• Stimulate crying by rubbing• Position properly- side lying /

modified t-berg• Provide oxygen when

necessary

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http://www.theblueplanet.org/picpages/images/1998/newborn.jpg

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Temperature• Dry immediately• Place in infant warmer or use droplight• Wrap warmly

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APGAR Scoring• Standardized evaluation of the newborn• Perform 1 minute and 5 minutes after

birth• Involves (5) indicators:

1. Activity2. Pulse3. Grimace4. Appearance5. Respirations

Care of the Newbornin the Nursery


Components• Anthropometric Measurements• Bathing – Oil bath/ warm water bath• Cord Care• Dressing/ Wrapping - mummified• Eye prophylaxis – Crede’s• Foot printing / Identification• Get APGAR score – 1 & 5 mins• HR, RR, Temp, BP• Injection of Vitamin K


Components

1. Proper identification –tag/bracelet2. Oil bath/ Warm water bath3. Cord Care/ Dressing4. Measurements

1. Weight2. Anthropometric measurements


6. Crede’s Prophylaxis7. Vitamin K Administration8. Foot printing/ marking9. Vital signs10.Dressing/ wrapping


Proper Identification• After delivery, gender

should be determined • Pertinent records should

be completed including the ID bracelet

• Before transferring to nursery, ID tag should be applied.


Bathing• Oil bath or complete

warm water bath• From cleanest to

dirties part• DO NOT remove

vernix caseosa vigorously


Cord Care


Weight/ Anthropometric Measurements


Crede’s Prophylaxis


Vitamin K Administration


Foot Printing


Vital Signs


Dressing/ Wrapping• “Mummy”• Wrap in warm

blanket• Cover head with

stockinette cap


Daily Care1. Nutrition/ Feeding2. Elimination3. Weight4. Bathing & Hygiene/

Grooming5. Obtain vital signs6. Rooming-in7. Note for any

abnormalities

NEWBORN ASSESSMENT

Assessment of the newborn is essential to ensure a successful

transition


Major Time Frames

1. Immediately after birth2. Within the 1st 4 hours after birth3. Prior to discharge


APGAR Scoring SystemA ctivity/ Muscle ToneP ulse/ Heart RateG rimace/ Reflex Irritability/ ResponsivenessA ppearance/ Skin ColorR R espiration/ Breathing

1 2 3 4 5


INDICATORS 2 1 0ActivityActivity Active,

spontaneous Some flexionof extremities

No movement(flaccid, limp)

PulsePulse >100 bpm < 100 bpm Absent

GrimaceGrimace Pulls away, sneezes, coughs

Facial grimace only

No response with stimulation

AppearanceAppearance Completely pink Acrocyanosis Bluish-gray or pale all over

RespirationRespiration Good vigorous cry

Slow, irregularWeak cry

Absent


Score Interpretation Nursing Interventions7 to 10 Well baby Rarely needs resuscitation

4 to 6 At riskINFANT NEEDS

INTENSIVE CARE

Requires resuscitationSuctionDry immediatelyVentilate until stableCareful observation

0 to 3 Sick babyPROGNOSIS FOR

NB IS GRAVE

Intensive resuscitationET/ Ambu bagVentilate with 100% O2

CPRMaintain body temperatureParental support


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

provide nursing care

GENERAL APPEARANCE


Posture• Full term:

– Symmetric– Face turned to side– Flexed extremities– Hands tightly fisted with thumb

covered by the fingers


Special Concerns • Asymmetric

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

• Breech Presentation– Knees and legs straightened or in FROG

position

VITAL SIGNS


TEMPERATURE• Site: Axillary NOT Rectal• Duration: 3 mins• Normal Range: 36.5 – 37.6 C• Stabilizes within 8-12 hrs• Monitor q 30 mins until stable for 2 hrs

then q 8 hrs

Heat Loss Mechanisms• Convection – the flow of

heat from the body surface to cooler surrounding air– Eliminating drafts such as

windows or air con, reduces convection

• Conduction – the transfer of body heat to a cooler solid object in contact with the baby– Covering surfaces with a

warmed blanket or towel helps minimize conduction heat loss


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

air con; moving as far from the cold surface, reduces heat loss

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

should be dried immediately



Nursing Considerations• Keep dry and well-wrapped• Keep away from cold objects or outside

walls• Perform procedures in warm, padded

surface• Keep room temperature warm


Pulse• Awake: 120 – 160 bpm—120 – 140

bpm• Asleep: 90-110 bpm• Crying: 180 bpm• Rhythm: irregular, immaturity of cardiac

regulatory center in the medulla

• Duration: 1 full minute, not crying• Site: Apical


Nursing Considerations• Keep warm• Take HR for 1 full minute• Listen for murmurs• Palpate peripheral pulses• Assess for cyanosis• Observe for CP distress


Special Concerns• (+) Prominent radial pulse = CHD• (-) Femoral pulse = Coarctation of aorta


Respiration• Characteristics:

Nasal breathers, gentle, quiet, rapid BUT shallow; may have short periods of apnea (<15 secs) and irregular without cyanosis—periodic respirations

• Rate: 30-60 cpm• Duration: 1 full minute


Nursing Considerations• Position on side• Suction PRN• Observe for respiratory distress• Administer oxygen via hood PRN and

as prescribed


Silverman-Anderson Index• Perform to observe for signs of

respiratory distress– Chest lag– Retractions– Nasal flaring– Expiratory grunting


Silverman Scoring System

0

1

2


Example

0

1

2Score: 5


Score Interpretation

Score Interpretation

0-3 No RDS

4-6Moderate RDS

7-10 Severe RDS


Blood Pressure• NOT routinely measured UNLESS

in distress or CHD is suspected• At birth: 80/46 mmHg*• After birth: 65/41 mmHg*• Using Doppler UTZ

ANTHROPOMETRIC MESUREMENTS


Body Measurements• Weight:

– 5.5 to 9.5 lbs (2500-4300 gms)• Caucasian: 7 lbs• Filipinos: 6.5 lbs

– 70-75% TBW is water– LBW = below 2500 gms; regardless

of AOG


• Length: – 45 to 55 cm (18-22 inches)– Average: 50 cm– Techniques: using tape measure

• Supine with legs extended–Crown to rump–Head to heel


• Head Circumference (HC): – 33 to 35.5 cm (13-14 inches)– Technique: using tape measure

• From the most prominent part of the OCCIPUT to just above the EYEBROWS


– 1/3 the size of an adult’s head– Disproportionately LARGE for its

body– HC should be = or 2cm > CC


• Chest Circumference (CC): – 30 to 33 cm (12-13 inches)– Technique: using tape measure

• From the lower edge of the SCAPULAS to directly over the NIPPLE LINE anteriorly

– CC should be = or < 2 cm than HC


Nursing Considerations• Under natural light• Assess for:

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


Skin Color• Velvety smooth and puffy esp. at the

legs, dorsal aspects of hands & feet and in the scrotum or labia

• Pinkish red (light skinned) to pinkish brown to yellow (dark skinned)

• “Ruddy” or reddish due to increased RBC concentration and decreased subQ tissues


Skin Color• Cyanosis/ Acrocyanosis• Pallor• Jaundice• Meconium Staining


Acrocyanosis

• Bluish discoloration of palms of hands & soles of feet

• Due to immature peripheral circulation• Exacerbated by cold temperatures• Normal within 1st 24 hrs


Pallor/ Cyanosis• May indicate hypothermia, infection,

anemia, hypoglycemia, cardiac, respiratory or neurological problems


Jaundice• Under natural light• Blanch skin over the chest or tip of

the nose


• Physiologic– FT: after the 1st 24 hrs (2-7 days) – PT:after the 1st 48 hrs– Peaks at 5-7 days & disappears by

the 2nd week– Due to immaturity of liver– Usually found over the face, upper

body and conjunctiva of eyes


• Pathologic– Within 1st 24 hrs– May indicate early hemolysis of RBC

or underlying disease process– Duration:

• FT: 1 wk• PT: 2 wks


Management of Jaundice• Monitoring serum bilirubin levels

– Physiologic: not more than 5 mg/dl per day

– Pathologic: more than 15-20 mg/dl (critical levels)

• Maintain hydration• Place in bilirubin lights as needed• Provide emotional support to parents

Phototherapy units



Nursing Responsibilities: -cover eyes and sex organ


Meconium Staining• Over the skin, fingernails & umbilical

cord• Due to passage of meconium in utero r/t

fetal hypoxia

Lanugo• Found after 20

weeks of gestation on the entire body except the palms & soles

• Fine downy hair that covers the shoulders, back & upper arms



Nursing Considerations:• More mature, less lanugo• May disappear within 2 weeks• Preterm: woolly patches of lanugo on

skin and head• Post term: parchment-like skin w/o

lanugo


Vernix Caseosa• Protective cheesy-like, gray-white fatty

substance• FT: skin folds under the arms and in

the groin under the scrotum or in the labia

• Nursing Considerations:– Use baby oil– DO NOT attempt to remove

vigorously


Desquamation• Dryness/ peeling of the skin• Usually occurs after 24-36 hours • Marked scaliness & desquamation =

signs of postmaturity


MiliaMilia• Multiple, yellow or pearly

white papules approx. 1 mm wide

• Due to enlarged or clogged sebaceous gland

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

Birthmarks


Mongolian Spots• Blue-green or gray

pigmentation• Lower back,

sacrum & buttocks• Disappears by

4 years of age

Salmon Patches• Seen commonly in NB• More on Caucasian• AKA: Naevus simplex,

"angel kisses" (when on the forehead or eyelids), and "stork bites" (over the nape of the neck)

• midline malformations consisting of ectatic capillaries in the upper dermis with normal overlying skin.



Stork bites• Telangiectatic Nevi• Flat red or purple

lesions• Back of neck, lower

occiput, upper eyelid and bridge of the nose

• After 2 years of age


Strawberry marks• Nevus Vasculosus or

Capillary Hemangioma• Dark red, raised

lobulated tumor• Head, neck trunk &

extremities• After 7 to 9 years of

age


Large capillary hemangioma


Cavernous Hemangioma


Port-wine stain• Nevus Flammeus or

Capillary Angioma• capillary malformation• Flat Red to purple, sharply

demarcated dense areas beneath the capillaries

• Face• Does not fade with time• Associated with Sturge-

Weber syndrome

Sturge-Weber syndrome• PWS involving the forehead (V1 area of

the trigeminal nerve), eye abnormalities (choroidal vascular abnormalities, glaucoma), and leptomeningeal and brain abnormalities (vascular malformations, calcification, or cerebral atrophy)


Other Skin Marks


Mottling• Cutis marmorata• reticulated pattern of

constricted capillaries and venules due to vasomotor instability in immature infants

• Bluish mottling or marbling of skin in response to chilling, stress or overstimulation


Erythema toxicum• Newborn rash• Small, white,

yellow, or pink to red papular rash

• Trunk, face & extremities

• Within 48 hrs


Petechiae• Pinpoint hemorrhages

on skin• Due to increased

vascular pressure, infection or thrombocytopenia

• Within 48 hrs


Ecchymosis• Bruises• As a result of rupture of

blood vessels• May appear over the

presenting part as a result of trauma during delivery

• May also indicate infection or bleeding problems


Harlequin Sign• When on side,

dependent side turns red and upper side/ half turns pale

• Due to gravity and vasomotor instability or immature circulation

• Skin resembles a CLOWN’S SUIT

Café-au-lait spots• Tan or light brown

macules or patches• NO pathologic

significance, if <3cm in length and <6 in number

• If > 3 or 6 = Cutaneous neurofibromatosis


Neurofibromatosis



What to assess• For symmetry, shape, swelling,

movement–Soft, pliable, moves easily–With some molding (if VSD);

round & well-shaped (if CS)• Measure HC; HC = or > CC


• Fontanelles “soft spot”–BAD (12-18 mos)–LPT (2-3 mos or 8-12 wks)–Bulging or sunken

• Sutures–Overriding or separated


• Head lag– Common when pulling newborn to a

sitting position– When prone, NB should be able to lift

the head slightly and turn head from side to side


Caput Succeedaneum• Swelling of soft

tissues of the scalp

• Due to pressure• Crosses the

suture lines• Presenting part• 3 days after birth


Cephalhematoma• Subperiosteal

hemorrhage with collection blood

• Due to rupture of capillaries as a result of trauma

• Does not crossed suture lines

• Several weeks


Molding• Overlapping of skull

bones• Due to compression

during labor and delivery

• Disappears in few days


Forcep Marks• U –shaped

bruising usually on the cheeks after forcep delivery


Craniotabes• Localized softening of the cranial bones• Can be indented by pressure of fingers• MOST common among 1st born babies,

pathological in older child—metabolic disorder

• Caused by pressure of the fetal skull against the mother’s pelvic bone in utero


Craniosynostosis• Premature closure of the fontanelles

Face/Eyes/Ears/Nose /Mouth


What to Assess• Facial movement & symmetry• Symmetry, size, shape and spacing of

eyes, nose and ears


Eyes• Color:

– white sclera– Slate gray, brown or dark blue– Final eye color: after 6-12 months

• Symmetrical• Pupils equal, round, reactive to light• (+) Blink reflex


• (+) transient strabismus due to weak EOM

• Able to move and fixate momentarily• (+) Red reflex – if (-), cataract• (+) Edema on eyelids r/t pressure

during delivery or effects of medication• (-) Tear formation (begins @ 2-3 mos)


Nursing Considerations• Administer eye medication within 1 hr

after birth to prevent Ophthalmia neonatorum

• DOC: Erythromycin 0.5%Tetracycline 1%Silver Nitrate 1%

• From inner to outer canthus of the eye (conjunctival sac)


Nose• Small & narrow• Flattened, midline • Nasal breathers• (+) Periodic sneezing• Reactive to strong odors• (+) Flaring = respiratory distress• (+) Low nasal bridge = Down’s syndrome


Ears• Soft and pliable; with firm cartilage

Pinna should be at the level of outer canthus of the eye

• (+) Low set ears = renal or chromosomal abnormalities

• May be congested and hear well after few days


Low set ears


Accessory tragus: remnant of 1st branchial arch

Congenital preauricular sinus:ends blindlyrisk for infection


Mouth• Pink, moist gums• Intact soft & hard palates

– (+) Epstein’s pearls• Uvula midline• Tongue moves freely, symmetrical with

short frenulum• (+) Extrusion & Gag reflexes


• Small mouth or large tongue = chromosomal problems

• (+) white patches on tongue or side of the cheek = Oral thrush


Neck• Short, thick, in midline• Able to flex and extend but cannot

support the full weight of head• Creased with skin folds• Trachea midline• Thyroid gland not palpable• Intact clavicle


Chest

• CC = or < 2cm than HC• Cylindrical; equal AP:T diameters• Symmetrical• Abdominal breathers


• (+) Bronchial sounds• (+) Breast engorgement ;

subsides after 2 wks • (+)Prominent/ edematous nipple• (+) Accessory nipples• (+) “Witch Milk”


Abdomen• Umbilical Cord

– 2 arteries; 1 vein– White & gelatinous immediately after

birth– Begins to DRY between 1-2 hrs

following birth– Blackened or shriveled between 2-3

days– Dried & gradually falls off by 7 days


Daily Cord Care• Keep cord dry and clean & clamp secured• Apply 70% isopropyl alcohol to the cord

with each diaper change and at least 2-3x a day.

• DO NOT cover with diaper• Note for any signs of bleeding or drainage

from the cord and other abnormalities• Sponge bath until cord falls off.


• GIT:– Capacity: 90 ml, with rapid intestinal

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

after birth– Presence of mass, distention

depression or protrusion– (+) Scaphoid = diaphragmatic hernia– (+) Distended = LGIT obstruction/

mass


• Anus– Check patency– First stool (Meconium) – within 1st 24

hrs• Sticky, tarlike, blackish-green,

odorless material


Transitional Stool• Within 2- 10 days after birth• Breastfed:

– golden yellow, mushy, more frequent 3-4x and sweet smelling

• Bottlefed:– Pale yello, firm, less frequent 2-3x,

with more noticeable odor


Nursing Considerations• Breastfeeding can usually begin

immediately after birth• Bottlefeeding may be started with sterile

water to 4 hrs after birth prior to formula feeding

• Burp during and after feeding• Position properly during and after

feeding


Genitals• Female:

– Labia: edematous– Clitoris: enlarged– (+) Smegma– Pseudomenstruation possible– Visible “hymen tag”– First voiding within 24 hrs


• Male:– Prepuce covers glans penis

• (+) adherent foreskin = Phimosis– Scrotum: edematous

• (+) enlarged = Hernia– Meatus: central

• (+) ventral/ dorsal = Hypo/epispadias– Testes: descended

• (+) undescended = Cryptorchidism


•


Back• Spine

– Straight, posture flexed– Supports head momentarily– Arms & legs flexed– Chin flexed on upper chest– Check for protrusion, excessive or

poor muscle contractions = CNS damage


Extremities• Flexed, full ROM, symmetrical• Clenched fists; flat soles• With 10 fingers and toes in each

hand• Legs bowed• Even gluteal folds


• (+) Creases on soles of feet– (-) Creases = prematurity

• Check for hip fractures or dysplasia– (+) Ortolani’s click & uneven gluteal

folds = Hip dysplasia

click

!


• (+) inward turning of the foot = club foot or talipes equinovarus


• (+) extra digits = Polydactyly

• (+) web fingers = Syndactyly

Neurologic System

Reflexes


Sucking/ Rooting• Touch the lip, cheek or corner of the

mouth• Turns head toward the nipple, opens

mouth, takes hold of the nipple and sucks

• Disappears after 3-4 mos up to 1 year


Extrusion• Anything place on the anterior portion of

the tongue will be “spit out’• To prevent swallowing of inedible

substances• Disappears after 4 months• Disappearance indicates readiness for

semi-solid to solid foods


Swallowing• Occurs spontaneously after sucking and

obtaining fluids• NEVER disappear• Newborn swallows in coordination with

sucking without gagging, coughing or vomiting


Tonic Neck/ Fencing• While the baby is falling asleep or

sleeping, gently and quickly turn the head to one side

• As the baby faces the left side, the left arm and leg extend outward while the right arm or leg flex and vice-versa

• Disappears within 3-4 mos


Palmar(Grasping)/ Plantar• Place a finger in the palm of the baby’s

hand, then place a finger at the base of the toes

• Fingers will curl or grasp the examiner’s finger and the toes will curl downward

• Palmar: fades within 3-4 mos• Plantar: fades within 8 mos


Moro• Hold baby in a semi sitting position then

allow the head and trunk to fall backward to at least a 30-degree angle

• Symmetrically abducts and extends the arms; fans the fingers out and forms a C with the thumb and the forefinger; and adducts the arms to an embracing position & returns to a relaxed state


• Present at birth; complete response at 8 weeks

• MOST significant singular reflex indicative of CNS problem (>6 mos)

• Disappears after 4-5 mos.


Startle• Best elicited if baby is 24 hrs old• Make a loud noise or claps hands• Baby ‘s arms adduct while elbows flex

with fists clenched• Disappears within 4 mos


Babinski• Gently stroke upward along the lateral

aspect of the sole, starting at the heel of the foot to the ball of the foot

• Dorsiflexion of big toe and fanning of little toes

• Disappears starts a 3 mos to 1 year• Disappearance indicates maturity of

CNS


Stepping/ Walking/ Dancing• Hold baby in a standing position

allowing one foot to touch a surface• Simulates walking by alternately flexing

and extending feet• Disappears after 3-4 mos

Assessment of Gestational Age

• Dubowitz Maturity Scale– Gestational rating scale– NB are observed and tested

according to the criteria– Help determine whether the NB

needs immediate high-risk nursery intervention


Usher’s Criteria


FINDINGS 0-36 WKS 37-38 WKS 39 WKS AND OVER

Sole creases Anterior transverse crease only

Occl creases in ant 2/3

Sole covered with creases

Breast nodule diameter (mm)

2 4 7

Scalp hair Fine and fuzzy Fine and fuzzy Coarse and silky

Ear lobe Pliable; no cartilage

Some cartilage Stiffened by thick cartilage

Testes and scrotum

Testes in lower canal; scrotum small; few rugae

Intermediate Testes pendulous, scrotum full; extensive rugae

Ballard’s Scoring• Completed in 3-4 min• 2 portions: physical maturity and

neuromuscular maturity



Physical maturity


Neuromuscular Maturity


Scoring


Physical maturity

19


Neuromuscular Maturity

17


Scoring

19+17=36

36 39

Other Nursing Responsibilities

• Identification band• Birth Registration• Birth record and

documentation


Newborn Screening


• The Newborn Screening Reference Center (NSRC) is an office under the National Institutes of Health (NIH), University of the Philippines Manila created under RA 9288– The Newborn Screening Act of 2004

• Performed after 24 hours of life up to 3 days except for patient in intensive care, must be tested by 7 days

• Congenital Hypothyroidism (CH)• Congenital Adrenal Hyperplasia (CAH)• Galactosemia (GAL)• Phenylketonuria (PKU)• Glucose-6-Phosphate-Dehydrogenase

Deficiency (G6PD Def)


Disorder Screened If not screened If screened

Congenital Hypothyroidism

Severe mental retardation

Normal

Congenital Adrenal Hyperplasia

Death Alive and Normal

Galactosemia Death or Cataracts Alive and normal

PKU Severe mental retardation

Normal

G6PD Deficiency Severe Anemia, Kernicterus

Normal


Infant Care Skills• Holding the baby

– Football Hold– Cradle Hold– Shoulder Hold


Football HoldPurpose: to carry on one hand free

A holding technique in bathing a babyUse for small babies

Procedure:1. slide forearm under his back2. support neck and head with your hand3. press his arm firmly against your side4. his head faces you5. infant’s feet tucked under your elbow


Cradle HoldPurpose: use for feeding and cuddling a baby Procedure:• support head in the crook of your arm• encircle the body with your arm• press baby firmly against your side• use other hand to support bottom and thigh


Shoulder HoldPurpose: use for burping Procedure:• draw baby towards your chest with one forearm• bracing his back and your hand cradling his head• support your baby’s bottom and thighs with your

other arm• gently press his head against shoulder


The end


care of the newborn

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