INDEX

SI NO CONTENT PAGE NO

1 DEFINITION OF NORMAL NEWBORN 2

2 CHARACTERSTICS OF NORMAL NEWBORN 2 - 9

3 PHYSICAL ADAPTATION OF NORMAL NEWBORN 10 -13

4 BEHAVIORAL ADAPTATION OF NORMAL NEWBORN 13 - 14

5 PHYSICAL ASSESSMENT OF NEWBORN 14 - 18

6 BEHAVIORAL ASSESSMENT OF NEWBORN 18 -19

7 GESTATIONAL AGE ASSESSMENT 19 - 20

8 ESSENTIAL NEWBORN CARE 21 - 22

9 IDENTIFICATION OF HIGH RISK NEWBORN AND REFFERAL 23 - 24

10 PARENTING PROCESS 24 - 27

11 RESEARCH ABSTRACT 27

12 CONCLUSION 27

13 BIBLIOGRAPHY 28

1

INTRODUCTIONA newborn is an infant who is only hours, days or up to a few weeks old. The term newborn or neonates are derived from Latin word neonatus. A new born baby brings many joy as well as many questions. Along with the happiness parents feels with the birth of their child they often have concern about his / her health and how to properly care their child. Today babies have more opportunities than ever before to grow into healthy children, adolescent and adults. Advances in medical research, the advent of new vaccines, medications and the development of new technologies have helped to improve the healthcare of both well and sick newborn babies.

DEFINITIONA healthy newborn are those who are born at term (between 38-42 weeks), should have an average birth weight for the country (usually exceed 2500 gm), cries immediately following birth, establishes, independent rhythmic respiration and quickly adapt to the changed environment. D.C DUTTA

Neonatal PeriodThe interval from birth to 28 days of the life age, It represents the time of the greatest risk to the infants. Approximately, 65% of all death that occur in the first year of life happens during this 4 week period. Early Neonatal period: - Refers to the period of 7 days of age.Late Neonatal period: - Refers to the period from completion of 7 days up to 28 days of life.

CHARACTERISTICS OF NORMAL NEWBORNPhysical characteristicsWeightThe weights vary from country to country, usually exceeds 2500 gm. In India the weight varies between 2.7 to 3.1 Kg with a mean of 2.9 Kg. There is 10 % loss of birth weight by 4th – 5th day and is regained by 7th – 10thday.

LengthThe length is 50-52 cm. The length is more reliable criterion of gestational age than the weight.

Head CircumferenceThe baby’s head may appear two large for it’s body. The head is 1/4th of the baby’s total size. Normal head circumference is 33 to 35 cm and it should be 2 to 3 cm larger than the chest.

Chest CircumferenceAccording to the Indian journal of pediatrics, a child between the age of 20 & 21 month should have a larger chest circumference than the head circumference. This milestone

2

indicates the healthy growth. While at birth it should be 2 cm less than the head circumference. Normal chest circumference ranges between 31-33 cm.

Abdominal CircumferenceNormal abdominal circumference range between 31-33 cm.

Vital SignsTemperatureThe newborns body temperature drops immediately after birth in response to the extrauterine environment. The internal organs are poorly insulated and his skin is very thin and does not contain much subcutaneous fat. The heat regulating mechanism has not fully developed. The temperature rapidly reflects that of the environment. The flexed position that the infant assumes is a safe guard against heat loss as it substantially diminishes the amount of body surface exposed.

PulseThe normal pulse rate for an infant is 120 to 140 beats per minute. The rate may rise to 160 bpm when the infant is crying or drop to 100 bpm when the infant is sleeping. The apical pulse is considered the most accurate.

Blood PressureThe average blood pressure of new born is 72/42. A drop in systolic BP of about 15 mm Hg during the first hour after birth is common. The new born BP may be taken with a Doppler blood pressure device. This greatly improves accuracy.

RespirationsThe respirations of a newborn infant are irregular in depth, rate and rhythm and vary from 30 to 60 beats per minutes. Respiration is affected by the infant’s activity i.e. crying. Normally respirators are gentle, quiet, rapid and shallow. They are most easily observed by watching abdominal movement because the infant’s reparations are accomplished mainly by diaphragm and abdominal muscle. No sound should be audible on inspiration or expiration.

HeadThe head is shaped or molded as it is forced through the birth canal in vertex presentation.

3

Fontanel These “soft spot” are areas where the skull bones do not join. It allows the babys head to grow. It usually pulsates with each beat of the heart. The anterior fontanel is located at the intersection of the suture of the two partial and frontal bones. It is diamond shaped and it strongly pulsates. It closes by 18 months. The posterior fontanel is located at the junction of the suture of the two partial and one occipital bone. It’s small, triangular shaped and less pulsatile. It normally closes by 6 weeks of age.

Moulding of the headDuring the delivery, for the large head to pass through the small birth canal, the skull bones may actually overlap in process referred to as moulding. Such moulding reduces the diameter of the skull temporarily. This elongated look usually disappears a few hours after birth as the bones assume their normal relationships.

CephalohematomaThis is the collection of blood between a cranial bone and its overlying periosteum. Bleeding is limited to the surface of the particular bone. It is caused by pressure of the fetal head against the material pelvis during a prolonged or difficult labour. This pressure loosens the periosteum from the underlying bone, therefore rupturing capillaries and causes bleeding. It may be apparent at birth but sometimes are not seen until 24 to 48 hours of life because subperitoneal bleeding is slow. It varies in size. Most of the Cephalohematoma are absorbed within several weeks. No treatment is required in the absence of unexplained neurological abnormalities.

Caput succedaneumThis is abnormal collection of blood under the scalp on the top of the skull that may or may not cross the suture lines, depending on size. Pressure on the presenting part of the fetal head against the cervix during labor may cause edema of the scalp. This diffuse swelling is temporary and will be absorbed within 2 or 3 days.

EYESColorThe baby’seye color depends on skin tone. Initially it may be blue grey in fair skinned or brown if dark skinned. A gradual deposition of pigment produces the final eye color of the baby at the age of three to six months.

PupilsThe pupils do retract to light and the infant can focus on objects about eight inches away. The infant s blinking is a natural protection reflex. May notice cross eyed look due to weak eye muscles. Eye muscle strength will improve and will get better focus.

Lacrimal apparatus

4

The lacrimal apparatus is small and nonfunctioning at birth and tears are not usually produced with crying until one to three month of age.

Swollen eye lidBaby’s eye may be puffed because of the pressure on the face during delivery. They may be puffed and red if silver nitrate eye drops have been used. This irritation should clear in about three days.

Hemorrhage on the eyesSome babies have a flame shaped hemorrhage on the white of the eyes. It is caused by breaking of blood vessel on the surface of the eye during labor and is harmless.This blood is reabsorbed in two or three weeks.

EARSExternal auditory canal is short and straight. Eardrum is thick. Eustachian tube is short and broad.

Folded earsThe ears of newborn are commonly soft and floppy. Sometimes the edge of one is folded over. The ear will resume its normal shape as the cartilage became firmer over the first few weeks of life.

StructureThe newborn’s ear tents to be folded and creased. A line drawn through the inner and outer canti of the eye should come to the top notch of the ear where it joins the scalp.

HearingBabies can hear loud and soft noise at birth. Loud noise may cause babies to startle while soft noise may help to calm your babies. Babies quickly learn the difference in voice sounds. Babies will turn head to a familiar sound especially mother and father.

Taste and smellThe newborn can taste and smell at birth. The baby will be able to taste formula or breast milk. Avoid heavy perfume and do not smoke around the babies.

SkinThe newborn has dedicate skin at birth that appear dark red because it is thin and layers of subcutaneous fat have not yet covered the capillary bed. This redness can be seen through heavily pigmented skin and even become more flushed when babies cry.

VernixcaseosaThis is a soft white cheesy yellowish cream on the newborns skin at birth. It is caused by the secretion of sebaceous gland of the skin. It offers protection from the watery environment

5

of the uterus and is absorbed in the skin after birth and serve as a natural moisturizer. If there is a large amount of Vernixcaseosa present it should be meticulously removed as it is thought to be a good culture medium for bacteria.

LanugoThis is long soft growth of fine hair on the newborns shoulder, back and forehead. It appears early in postnatal life.

Mongolian spotThese are blue black coloration on the infant’s lower back, buttocks and anterior trunk. They are often seen in babies of black IndianMongolian or Mediterranean ancestry. These spot occur less frequently in Caucasian babies. The spot are not bruises nor they are associated with mental retardation. They disappear in early childhood.

JaundiceThis is the yellowish discoloration that may be seen in baby’s skin or in sclera of the eyes. Jaundice is caused by excessive amount of free bilirubin in the blood and the tissues.

PetechiaeThese are small blue red dot on the infant’s body caused by breakage of tiny capillaries. They may be seen on the face as a result of pressure exerted on the head during birth. True Petechiae does not blanch on pressure.

MiliaThese are tiny sebaceous retention cyst. They appear as small white or yellow dots and are common on nose forehead and cheeks of baby. They are pin head sized and opalescent. Milia are due to blocked sweat and oil glands that have not begun to function properly. They disappear spontaneously within few weeks.

BirthmarkThese are small reddened area sometimes present on infant’s eyelid, mid forehead and nape of the neck. They may be the result of local dilation of the skin capillaries and abnormal thinness of the skin.They are sometimes called stroke bites or telangiectasis. This mark usually fades and disappears altogether. They may be noticeable when infant blushes, is extremely warm or become excited.Hemangioma or strawberry mark is a type of birthmark that is characterized by a dark or bright red raised rough surface. They may regress spontaneously or even increase in size .surgical removal is not recommended there ia a wait and see attitude advocated before surgical removal.

Respiratory systemUntil the newborn first breath of air is taken, the alveoli in the lungs are in almost complete state of collapse. The lungs should be in this stage because the lung must not fill the

6

amniotic fluid or other liquid. However the fluid/liquid that flows in the lungs during normal delivery is squeezed or drained from the newborns lung. The major portion of the fluid is absorbed after delivery by alveolar membrane into the blood capillaries.The most frequent cause of respiratory difficulty in the first few hours of birth has been due to the too liberal use of sedatives, tranquilizer, analgesics that affect not only the mother, but pass over the placenta to the baby. These drugs make the baby sleepy and disinclined to take the first breath.

Circulatory systemBlood flowAs umbilical blood stop flowing at birth, sudden pressure difference occurs within the circulatory system. This difference causes the blood flowing to the lungs and liver to increase and the blood flowing through the bypass channel to decrease. Peripheral circulation refers to the residual cyanosis in hands and feet. This may be apparent for one to three hours after birth and is due to sluggish circulation. Blood is shunted to vital organs immediately after birth.

Blood CoagulationDuring the first few days of life, the prothrombin level decreases and clotting time in all infants is prolonged. This process is most acute between the second and fifth postnatal days. It can be prevented to a large extent by giving vitamin K to the infant after birth. With the ingestion of food, establishment of digestion, and maturation of liver, vitamin K is produced by the baby and clotting time stabilize within a week to 10 days.

Gastro intestinal systemMouthSucking callus or blister occur in the centre of upper lip due constant friction of this point during bottle or breast feeding. It will disappear when the baby begins cup feeding.Tongue tie is the short, tight band on the underside that connects it to the floor of the mouth. These bands usually stretch with time, movement and growth.Epithelial pearl may be little cysts containing clear fluid or shallow, white ulcer along the gum line or on the mouth. They result from blockage of normal mucous gland; disappear along one or two months.

StomachThe capacity of newborns stomach is one to two ounces (30 to 60 l), but increases almost rapidly. Milk passes through infant’s stomach almost immediately. The infant is capable of digesting simple carbohydrate and proteins, but has a limited ability to digest fat.

Intestine Irregular peristaltic mobility slows stomach emptying. Peristaltic increases in lower ileum which results in one to six stools a day. The first stool after birth, and for three to four days

7

afterwards are called meconium. Meconium is stringy, tenacious, and black and has tarry texture. With the ingestion of colostrums or formula, a gradual transition occurs.

Endocrine systemThe endocrine glands are considered better organized than 6ther syste0s. Disturbances are most often related to maternally provided hormones (estrogen, luteal are prolactin)Enlargement of mammary gland may occur in both sexes. This is particularly noticeable about the third day of life. Breast secretion may also occur. Swelling usually subsides in two or three weeks. The breast should not be squeezed; it increases the chance of infection and injuries to the tender tissues. In term baby the normal diameter of breast nodules is 5 – 10 mm whereas it is less than 5 mm in preterm babies. Vaginal discharge or bleeding occurs in female babies. This discharge is white mucoid in color. Bleeding may occur as a result of withdrawal from maternal hormones at the time of birth. There are usually only few blood spot seen on diapers. This disappears in one or two days.

Neuromuscular systemArms and legsArms and legs look bend and are held close to the body. Hands are in tight fist. Legs may appear bowed. The arms and leg may also appear too short for the body because of their bend appearance. By three to four months the arms and leg stretch out. The hands will unfold and baby will begin to reach for objects. The leg will also grow longer and stronger and baby will sit crawl and stand

ReflexesThe reflexes are important and help the health care provider to determine if the baby has a healthy nervous system.

8

At birth (meconium) stringy, tenacious, black, tarry texture

Ingestion of colostrums or formulaGradual transitionFew greenish stools to gradual yellow color

Early infancy, stool of breast feed babiesYellow- orange color, curdy

Early infancy stool of bottle fed babiesLemon yellow color soft more frequent

Survival reflex Sucking Swallowing Rooting Safety reflex Gag reflex Cough Tonic neck reflex Grasp reflex

Genito urinary systemFemale genitalsThe labia minora may be quite swollen because of maternal hormones and may have smooth half inch projections of pink tissue called tags. These are harmless. They occour in 10% of newborn girls and slowly shrink over two to four weeks.

Male genitalsThe scortum of newborn boys maybe filled with clear fluids and that has been squeezed into the scortum during birth. This common painless collection of fluid is called a hydrocele and it may take six to 12 weeks to clear completely. Regular check up should be there and consult doctor if the swelling changes size frequently.About 4% of full term newborn boys have undescented testis i.e. testis is not in scrotum. They gradually descent in normal position. Most uncircumcised baby boys have a tight foreskin. This is normal and the foreskin should not be retracted. the foreskin separates from the head of penis naturally by 5 to 10 years of age.

PHYSIOLOGICAL ADAPTATION OF NEWBORN

ESSENTIAL CONCEPTSThe neonatal period includes the time from birth through 28 days of life. During this time the neonates must make many physiological and behavioural adaptations to extra uterine life. The physiological adaptation task are those that involves

a) Establishing and maintaining respirationb) Adjusting to circulatory changesc) Regulating temperatured) Ingestion, retaining and digesting nutrientse) Eliminating wastef) Regulating weight

Respiratory adaptationInitial respiration is triggered by physical, chemical and sensory factors

9

Physical factors include the effort required to expand the lung and fill the collapsed alveoli. Adequate levels of surfactants (Lecithin and spingomyelin) ensure mature lung function; prevent alveolar collapse and respiratory distress syndromeChemical factors include change in blood such as decreased oxygen level, increased carbon dioxide level, and decreased ph as a result of the transitory asphyxia during delivery. Sensory factors include temperature, noise, light, sound and drop in temperature.

Oral mucous secretions may cause the newborn to cough and gang especially during the first 12 to 18 hours. Newborns are obligatory nose breathers the reflex response to nasal obstruction, opening the mouth to maintain an airway is not present in most newborns until 3 weeks after birth.

Cardiovascular adaptationFetal Circulation

Oxygenated blood from placenta via umbilical vein 66% shunted past liver by DUCTUS VENOSUS to IVC 50% of this blood shunted from right atrium to left atrium via FORAMEN OVALE This blood continues to left ventricle, ascending aorta, and arteries feeding head and

right arm Venous blood from head (SVC) is directed via right atrium to right ventricle into the

pulmonary artery 90% of blood in PA is shunted away from lungs and into descending aorta via the

DUCTUS ARTERIOUS and returns to the placenta via the umbilical arteries.

Various anatomic changes have take place after birth. Some are immediate and the other occur with time.

STRUCTURE BEFORE BIRTH AFTER BIRTHUmbilical vein Brings arterial blood to the heart Obliterates; become round ligament of

the liverUmbilical arteries Brings arteriovenous blood to the placenta Obliterates; become vesicle ligaments on

anterior abdominal wallDuctus venousus Shunts arterial blood into inferior

venacavaObliterates; becomes ligamentum venosum

Ductus arteriosus Shunts arterial and some venous blood from pulmonary artery to the aorta

Obliterates; become ligamentum arteriosum

Foramen ovale Connects right and left atria Obliterateslungs Contains no air and very little blood, filled

with fluidsFilled with air and well supplied with blood

Pulmonary arteries Brings little blood to lungs Brings much blood to lungsaorta Receives blood from both ventricles Receives blood only from left ventriclesInferior venacava Brings venous blood from body and

arterial blood from placentaBrings blood only to right auricles

10

Peripheral circulation is sluggish, causing acrocynosis (cyanosis of hand and feet and around the mouth). The feet may be cold to touch.

Hematopoetic systemThe blood volume of the full term neonates is 80 to 110 ml/kg of body weight, averaging about 300 ml. The amount of blood bound to hemoglobin is less in a neonate than in a fetus. The partial pressure of oxygen in the blood is less in a neonate than in a fetus. Neonates are born with high erythrocyte counts secondary to the effect of fetal circulation and need to ensure adequate oxygenation. Levels of vitamin K in the neonates are lower than normal leading to an increase in bleeding time. The normal newborn hematological values are

parameter Normal rangeHemoglobin 14 – 20 g/dlRBC 5 – 7.5 million/mm3Hematocrit 43% - 63%White blood cell 10,000 – 30,000/mm3Neutrophills 40% - 80%Eosinophils 2% - 3%Lymphocytes 20% - 40%Monocytes 3% - 10%Platelets 150,000 – 350,000/mm3Reticulocytes 3% - 7%Blood volume Total blood volume at term – 80 – 85 ml/kg

Third day after early cord clamping – 82.3 ml/kgThird day after late cord clamp – 92.6 ml/kg

Thermogenic systemThermoregulation is the maintenance of the balance between heat loss and heat production. Thermo genesis is accomplished primarily by metabolism of brown fat which is located in superficial deposits in the intrascapular region and axille, deeply deposited in the thorxic in the left, along the vertebral colum and around kidney.Rapid heat loss may occur in a suboptimal thermal environment by the way of conduction, convection, radiation and evaporationConduction involves heat loss to cold surface with which the neonates is in contactConvection involves heat loss to the air that is cooler than the neonate’s temperatureRadiation involves heat loss to solid objects that are near the neonates but not contacting the neonates. Evaporation involves heat loss through vaporization of liquid on the neonate’s skin.

Gastro intestinal adaptationNeonates born beyond 32 to 34 weeks gestation have adequate sucking and swallowing coordination. Bacteria are not normally present in the neonate’s gastro intestinal tract.

11

Bowel sounds can be heard 1 hour after birth. Uncoordinated peristaltic activity in the esophagus exists for first few days of life. The neonates has a limited ability to digest fast because amylase and lipase are absent at birth. Immature cardiac sphincter may allow reflux of food, so neonates should be burped after each feed. The lower intestine contains meconium at birth; the first meconium usually passes within 24 hours and failure to pass meconium in the first 24 – 48 hours suggests possible meconium ileum, imperforate anus or bowel obstruction.

Kidney adaptationRenal function is not fully mature until after the first year of life. The neonates have a minimal range of chemical balance and safety. Low ability to excrete drugs and excessive fluid loss can rapidly lead to acidosis and fluid imbalances. Most newborns void in the first24 hours after birth and two to six times per day for the first 1 to 2 days. Thereafter they void 5 to 20 times in 24 hours. Urine may be cloudy from mucus and urate.

Hepatic adaptationThe liver continues to play a role in blood formation. Jaundice is a major concern in the neonatal hepatic system because of increased serum level of unconjugated bilirubin from increased red blood cell lysis, altered bilirubin conjugation, or increased bilirubin reabsorption from the GIT. Physiological jaundice develops in about 50% of the full term neonates and 80% of preterm neonates. The icteric color isn’t apparent until the bilirubin levels are between 4 and 6 mg/dl. Physiological jaundice appears after the first 24 hours of extra uterine life.

Immune system adaptationThe newborn cannot limit an invading organism at the portal of entry. The immaturity of a number of protective systems significantly increases the risk of infection in the newborn period.The neonate’s immune system depends largely on three immunoglobulin’s IgG, IgM, IgAIgG a placentally transferred immunoglobulin, provides the neonates with antibodies to bacterial and viral agents. Can be detected in the fetus at the third month of gestation. The infant first synthesis its own IgG during the first 3 months of life, thus compensating for concurrent catabolism of maternal antibodies.IgM is synthesized in fetus by the 20th week of gestation. IgM does not cross the placenta. High levels of IgM in the neonate indicate a non specific intrauterine infection. IgA is not detectable at birth, it does not cross the placenta. Secretion of IgA is found in colostrums and breast milk. IgA limits bacterial growth in the GIT.The neonates have fragile defenses against infection.

Neurological adaptationGeneral neurological function is evident by the neonate’s movement. These movements are uncoordinated and poorly controlled indicating the immaturity of the neurological

12

system. The neonate demonstrates primitive reflexes, which disappear during the infancy period, being replaced by purposeful activity.The full term neonate’s neurological system should produce equal strength and symmetry in response & reflexes. Diminished or absent reflexes may indicate a serious neurological problem and asymmetrical response may indicate trauma during birth, including nerve damage, paralysis and fracture.

Reproductive systemFemaleAt birth the ovaries contain thousands of primitive germ cells. These represent the full complement of potential ova. The ovary, cortex, which is made up primarily of primordial follicles, occupies a larger portion of ovary in female newborn than in female adults.MaleThe testis descend into the scrotum by birth in 90% of new born boys

BEHAVIOURAL ADAPTATION

First period of reactivity This is a phase of instability during the first 6 to 8 hours of life through which all newborn pass, regardless of gestational age or nature of labor and delivery. The newborn undergoes an intense period of activity and alertness that probably represents a sympathetic nervous system response to the intense stimulation of the labor and delivery process. During this period the infant enters a state of alertness, peering intently at the surrounding people and the environment. This may allow the newborn to achieve eye contact with the parents or the caregivers for brief period of time. Immediately after birth respiration is rapid (may reach 80 breaths per minute) and transient nostril flaring retractions and grunting may occur. The heart rate may reach 180 beats per minute during the first few minutes of life.Period of decreased activity Following the initial response the newborn becomes quite, relaxes and falls asleep. This first sleep also known as sleep phase occur within 2 hours of birth and last from a few minutes to several hoursSecond period of reactivity The second period of reactivity begins when the baby awakens and show an increased responsiveness to environmental stimuli. The period is marked by hyper responsiveness to stimuli, skin color changes from pink to slightly cyanotic and rapid heartbeat.Other behavioral adaptation include

a) Establishing a regulated behavioral tempo independent of mother, which include self regulation of arousal, self monitoring of changes in state, and patterning of sleep.

b) Processing, storing and organizing multiple stimulic) Establishing a relationship with care givers and the environment

13

ASSESSMENT OF NEWBORNThe first 24 hours are critical because respiratory distress and circulatory failure can occur rapidly and with little warning. So the assessment of newborn is very important. The initial assessment of the newborn is done at birth by using Apgar score and a brief physical examination. A gestational age assessment is done within 2 hours of birth. A more comprehensive physical assessment is completed within 24 hours of birth.PHYSICAL ASSESSMENTInitial physical assessmentCNSMoves extremities, muscle tone good, symmetrical features, movement, sucking reflex, rooting reflex, Moro reflexes, grasp reflex, anterior fontanel soft and flat.

CARDIOVASCULAR SYSTEMHeart rate strong and irregularNo murmersPulse strong and equal bilaterally

RESPIRATIONLungs clear to auscultation bilaterallyNo retraction or nasal flaringrespiratory rate 30 – 60 breaths per minuteChest expansion symmetricalNo upper airway congestion

GASTROINTESTINAL SYSYEMAbdomen soft, no distensionCord attached and clampedAnus appear patent

ENTEyes clearPalates intactNares present

GENITOURINARY SYSTEMMale- urethral opening at the tip of penis, testes descent bilaterallyFemale- vaginal opening apparent skin color

14

APGAR SCORE

Detailed physical examination1. Baseline data

Name of the baby -Age -Sex -Date of birth -Birth weight -Delivery - singleton/ twins/tripletDiagnosis - prematurity/ post maturity/ normalCord - normal/ prolapsedCondition at birth - active/ asphyxiatedAny birth anomalities - present/ absentTreatment at birth -Apgar score -

2. Vital signs Temperature - Pulse - Respiration -

15

3. Anthropometric measurement Weight - Height - Head circumference - Chest circumference - Abdominal circumference

4. General appearance Posture - Activity - Active/ Dull Body build - Thin / Well built

5. Skin Color - Pale/ Pink/ Jaundiced/ Cyanosed Texture - Smooth/ Dry Turgor - Normal/ DryVernix caseosa - Present/ AbsentLanugo - Present/ AbsentEdema - Present/AbsentMilia - Present/ AbsentMongolian Spot - Present/ Absent

6. Head Size - Normal/ Macrocephaly/ Microcephaly Shape - Normal/ Abnormal Anterior fontanels - Palpable/ Depressed/ Bulging Posterior fontanels - Palpable/ Depressed/ Bulging Caput succedaneum - Present/ AbsentCephalohematoma - Present/ Absent

7. Eyes Eyelid - Normal/ Edematous Iris color - Sclera - White/ Blue/ Yellow Red reflex - Present/ Absent

8. Nose Patent nostrils - Present/ Absent Nasal discharge - Present/ Absent Nasal septal deviation - Present/ Absent Flaring of nostrils - Present/ Absent

9. Ear

16

Symmetry - Appearance -Pinna in line with eyes -

10.Mouth Secretions - Present/ Absent Intact lips and palate - Oral trush - Present/ Absent

11.Neck Size - normal Neck webbing - Present/ Absent

12.Chest Shape - Movement - Symmetry/ Asymmetry Breath sound - Heart sound -

13.Abdomen Shape - Umbilical cord - Wharton’s jelly - Present/ Absent Bowel sounds - Present/ Absent

14.Female Genitalia Labia Majora - Normal/ EdematousLabia Minora - Normal/ AbnormalVaginal Discharge - Present/ Absent

15.Male Genitalia Urethral opening - Present/ AbsentTestis - Descended/ UndescendedEpispadia - Present/ AbsentHypospadia - Present/ Absent

16.Spine Spine - Intact/ AbnormalSpina bifida - Present/ AbsentAbnormal curvature - Present/ Absent

17.Extremities Shape - Symmetric/ Asymmetric

17

Range of motion - Active/ InactiveNail Buds - Pink/ CynosisedMuscle tone - Normal/ AbnormalPolydactylity - Present/ AbsentSyndactylity - Present/ Absent

18.Neuromuscular Cry - Weak/ Loud/ High pitched Lethargic - Present/ AbsentActivity - Active and alert/ DrowsyReflexes -

o Moro Reflexo Sucking reflexo Rooting Reflexo Tonic neck reflexo Grasp reflexo Stepping or walking reflexo Babinski sign

BEHAVIORAL ASSESSMENTNewborn behavioral state are

Sleep stateo Deep or quite sleepo Active or REM sleep

Alert stateo Drowsyo Wide Awakeo Active Awakeo Crying

The newborn behavioral assessment is done through Brazelton neonatal behavioral assessment scale

BRAZELTON NEONATAL BEHAVIOURAL ASSESSMENT SCALEState 1 Deep sleep, without movements, breathing regularlyState 2 Light sleep, closed eyes, some corporal movementState 3 Sleepy, eyes opening and closingState 4 Awake, opening eyes, minimum corporal movementState 5 Completely awake, strong corporal movementState 6 Cry

18

GESTATIONAL AGE ASSESSMENTTwo methods are commonly used clinically for the assessment of gestational age. They are Parkin Score and New Ballard Method.Parkin ScoreThis depends on skin texture, skin color, breast size and ear firmnessSkin textureThis is tested by picking up the fold of abdominal skin between fingers and thumb and assessment is done through inspectionScore 0 – very thin and gelatinous feelScore 1 – thin smoothScore 2 – slight thickening and stiff feelingScore 3 – Thick and parchment like superficial or deep cracking

Skin colorScore 0 – Dark redScore 1 – Uniformly pinkScore 2 – Pale pinkScore 3 – Pale

Breast sizeMeasured by feeling the breast nodule by finger and thumbScore 0 – No breast tissue palpableScore 1 – Not more than 0.5 cm in diameterScore 2 – 0.5 to 1 cm in diameterScore 3 – more than 1 cm in diameter

Ear firmnessTested by palpation and folding of the upper Pinna and noticing the recoilingScore 0 – Pinna feels soft and easily folded in bizarre position without springling back into

Position simultaneously.Score 1 – Pinna feels softer along the edge and easily folded and return slowly to the

Correct position simultaneously.Score 2 – Cartilage can be felt up to the edge of the Pinna and it spring back immediately

after being folded.Score 3 – Pinna is firm with definite cartilage extended up to the periphery and spring back

immediately into the position after being folded

19

MATURITY RATINGParkin Score Age ( in weeks)

1 262 303 334 345 356 367 378 389 39

10 4011 4112 42

Ballard Score MethodUsed to assess neuromuscular maturity. Calculated by assessing the posture, angle of wrist, arm recoil, popliteal angle, scarf sign, and heel to ear maneuver.

20

ESSENTIAL NEWBORN CARE

The first hour after birth has a major influence on the survival, future health and wellbeing of the newly born child

1) Clean child birth and cord care Maintain the principle of child birth Clean hand Clean perineum Nothing unclean introduced vaginally Clean delivery surface Cleanliness in cord clamping and cutting Cord care Infection prevention Control measures at health care facilities

2) Clean airway Suction of the airway and initiate respiration

3) Thermal Protection Delivery in a warm room Dry newborn thoroughly and wrap in dry, warm cloth Keep out of draft and place on a warm surface Initiate skin to skin contact ( kangaroo care) Check warmth by touching the babies feet

4) Early and immediate breast feeding Promote breast feeding within one hour Educate about correct breast feeding techniques No prelacteal feed or other supplement Psycho social support to breast feeding mother

5) Care of eyes Prevent ophtalmo neonatorum (conjunctivitis with discharge during first 2 weeks of

life) 1% silver nitrate solution or 1% tetracyclineoinment

6) Nutrition The rate of growth of newborn during the first 6 month of life is greater and faster

than any other period of life. The weight is doubled by the age of 5 month and tripled by the end of one year. A term healthy infant need 100 – 110 kcal/kg of body weight per day

21

All babies regardless of the type of delivery should be given early and exclusive breast feeding up to 6 months

7) Immunization Age (completed weeks/ months/years)

Vaccines

Birth BCGOPV0HepB 1

6 weeks DPT/DTaP1OPV1Hib1HepB2

10 weeks DPT/ DTaP2OPV2Hib 2

14 weeks DTP/ DTaP3OPV3Hib 3

6 month Hepatitis B39 months Measles15 – 18 months MMR16 – 24 months DPT/D TaP4

OPV4Hib booster

4 – 5 years DPT/DTap4OPV5

10 Years Inj TT16 Years Inj TT

Optional vaccinesAge (completed weeks/ months/years) Vaccines2 Months PCV 7 I4 Months PCV 7 II6 Months PCV 7 III15 Months PCV & Booster6 Months – 6 Years Influenza vaccineLess than 1 year Varicella vaccineLess than 2 years Inj.HAV, Typhoid vaccineLess than 6 years MMR II

22

IDENTIFICATION OF HIGH RISK NEWBORN AND REFFERAL

Early identification of the high risk newborn is the first step in detecting and managing complication to reduce morbidity and mortalityDEFINITIONThe high risk neonates can be defined as a newborn, regardless to the gestational age or weight, who has greater than average chance of morbidity and mortality, because of conditions or circumstances superimposed on the normal course of event associated with birth and adjustment to extra uterine existence.

CLASSIFICATIONClassification according to the birth weight

Low birth weight – birth weight less than 2500 gm Very low birth weight – birth weight less than 1500 gm Extremely low birth weight – newborn whose birth weight is less than 1000 gm Appropriate for gestational age – babies whose birth weight falls between 10and 90

percentile on the intrauterine growth curve Small for date or small for gestational age – whose rate of intrauterine growth has

slowed and whose birth weight falls below the 10 percentile on intrauterine growth curve

Large for gestational age – whose birth weight falls above 90 percentile.

Classification according o gestational age Premature (preterm babies) – born before completion of 37 weeks of gestation Full term baby – born between the beginning of 38th week and completion of 42

week of gestation regardless of gestational weight Post maturity (post term) - Baby born after 42 week of gestation regardless to the

birth weight

Classification according to mortality Live birth -birth in which the neonates manifest heartbeat, breathing or display

voluntary movement regardless to gestational age Fetal death – death of the fetus after 20 weeks of gestation and before delivery with

the absence of any signs of life after birth Neonatal death – death of that occur in the first 28 days of life.

Early neonatal death -that occur within the first week of life. Late neonatal death - that occur at 7 to 27 days

Classification according to pathophysiologic problems Associated with state of maturity, chemical disturbance e.g. hypoglycemia,

hypocalcaemia Immature organ and system e.g. respiratory distress, hypothermia

23

PREVENTION Maternal nutrition Life style modification Early detection and management of maternal disease condition like gestational

diabetes mellitus, hypertension etc Regular antenatal check up

MANAGEMENT Temperature control Oxygen therapy Nutritional management

PARENTING PROCESSThe Process of Parenting describes the many ways parents and caregivers can translate their love for children into effective parenting behavior. Parenting is the process of raising and educating a child from birth until adulthood. This is usually done in a child’s family by the mother and the father (the biological parents )

MOTHER= IS THE NATURAL OR SOCIAL FEMALE PARENT OF AN OFFSPRING.FATHER= IS TRADITIONALLY THE MALE PARENT OF A CHILD.

DEFENITIONParenting process is promoting and supporting the physical, emotional, social, and intellectual development of a child from infancy to adulthood. it refers to the activity of raising a child rather than the biological relationship.

GOALSSurvival goal - To promote the physical survival health of their children, thereby ensuring that the child live long enough to produce their childrenEconomic goal - To foster the skills and behavioral capacities that the children will need for economic self maintenance as adult.Self actualization goal - To foster behavioral capacities for maximizing cultural values and beliefs.

TYPES OF PARENTINGAuthoritative parentingAuthoritarian ParentingPermissive ParentingNeglectful Parenting

Authoritative parenting Democratic or balance parenting. It has a give and take nature. It encourages children to be independent but still places limits and controls on their

actions.

24

Authoritative parents sets limits and demand maturity but when punishing a child, the parent will explain his or her motive for their punishment.

Parent are attentive to their children's needs and concerns and will typically forgive and teach instead of punishing if a child falls short.

Result in children having a higher self esteem. This is the most recommended style of parenting by child rearing experts.

Authoritarian Parenting Also called strict parenting. Characterized by high expectations of conformity and compliance to parental rules

and directions. It is a restrictive punitive style in which parents advise the child to follow their

directions and to respect their work and effort. Authoritarian parents expect much of their child but generally do not explain the

reason for the rules and boundaries. Authoritarian parents are less responsive to their children’s needs and are more

likely to spank a child rather than discuss the problem.

Permissive Parenting Permissive parents want to and tend to give up most control of the home and family

life to their children. Parents make very few rules and even when they do decide to make a rule, the rules

that they makes are usually not enforced all the time or properly. Parents want children to feel as if they can be free to do or say as they wish.

Neglectful Parenting This is also called uninvolved, detached, and dismissive or hands- off parenting style. The parents are low in warmth and control and are generally not involved in the

child’s life. Parents are emotionally unsupportive of their children but will still provide their basic

needs.TRANSITION TO PARENTHOODThe transition to parenthood is described as a time of disorder and disequilibrium, asa well as satisfaction for the mother and their partnersMaternal adjustmentsThree phases are evident as the mother adjusts to her parental role. These phases are characterized by dependent behavior, dependent-independent behavior and interdependent behavior.

Dependent: taking in First 24 hours or may rang 1 to 2 days Focus is on self and meeting the basic needs Reliance on other to meet needs for comfort, rest, closeness, ndnourishment

25

Excited and talkative Desire to review birth experience

Dependent – independent: taking hold Starts second or third day, and last 10 days to several weeks Focus is on care of baby and competent mothering Desire to take charge of the baby Still has need for nurturing and acceptance by others Eagerness to learn and practice – optimal period of teaching by nurses Handling of physical discomfort and emotional changes

Interdependent: letting go Focus is on forward movement of family as a unit with interacting with members Reassertation of relationship with partners Resumption of sexual intimacy Resolution of individual roles

Paternal adjustmentThe paternal adjustment occur mainly in three stagesStage 1 expectation

Father has preconceptions about what life will be like after baby comes home

Stage 2 Reality Father realizes that expectations are not always based on fact Common feeling experienced are sadness, ambivalence, jealousy, frustration Overwhelming desire to be more involved Some fathers are pleasantly surprised at the ease and fun of parenting

Stage 3 :transition to mastery Fathers make conscious decision to take control and become more activelyinvolved

with infant

Sibling adjustment Demonstrate acquaintance behavior with the newborn and the behavior depands

upon the information that is given to the child before the baby is born and on the childs cognitive developmental level.

The initial behavior of sibling with the newborn includes looking at the infant and touching the head.

There should be a unrealistic level of maturity for the child to accept and love a rival for the parents affection

FACTORS INFLUENCING PARENTAL RESPONSESAge – adolescent mother

26

Adolescent father Maternal age greater than 35 years Paternal age greater than 35 yearsCultureSocioeconomic conditionsPersonel aspirations

RESEARCH ABSTRACTA cohort study was done among 250 consecutively born late preterm and equal number of term newborn to assess the morbidity and mortality of late preterm in comparison to full term neonates in a tertiary care hospital at Delhi. The study revealed that the late preterm neonates have significantly more mortality and morbidity mostly due to respiratory distress, invasive ventilation seizures, jaundice and shock compared to term neonates. The maternal hypertension and lower gestational age was the strongest predictors of morbidity.

CONCLUSIONThe above study reveals the importance of maintaining good maternal health during course of pregnancy for having a healthy newborn. The newborn adaptation and management is a complex process. The health of the newborn largely depends on the maternal health.

BIBLIOGRAPHYTextbook

27

I. Barbara R. Straight. Maternal newborn nursing. 4th edition. Lippincot. Page no 159II. Brown miller. Pediatrics. 1st edition. Lippincot. Page no 33

III. Lynna Y Littileton. Maternity Nursing Care. 1st edition. Delmar learning. Page no.741IV. Deitra Leonard Lowdwermilk. Maternity Nursing. 7th edition. Elsevier. Page no 512V. D.C.Dutta. Text book of obstetrics. 6th edition. New central book publisher. Page no

213VI. Kamini Rao. Text book of midwifery and obstetrics for nursesInternetVII. www.wikipedia.com

VIII. www.authorstream.com IX. www.parentingprocess.org X. www.googlebooks.com

28