OB 2

Dr. Ursua
05/06-07/15

Care of the Newborn

THE 1 ST 24 HOURS OF LIFE

The 1st 24 hours of life is a very significant and a highly vulnerable time due to
critical transition from intrauterine to extrauterine life

AIRWAY AND BREATHING

Suction gently and quickly using bulb syringe or suction catheter

Starts in the mouth then, the nose to prevent aspiration
Stimulate crying by rubbing
Position properly: side lying and modified t-berg
o
To avoid aspiration
Provide oxygen when necessary

TEMPERATURE

Dry immediately
o
Using a towel or the sheets
Place in infant warmer or use drop light
o
Bacinette(?) Or crib is prepared
Wrap warmly

APGAR SCORING

Standardized evaluation of the newborn

Perform 1 minute and 5 minutes after birth

INVOLVES 5 INDICATOR S:
1.
2.
3.
4.
5.

Activity
Pulse
Grimace
Appearance
Respirations

CARE OF THE NEWBORN IN THE NURSERY (AMERICAN)

COMPONENTS :

Anthropometric measurements
Bathing: Oil bath/warm water bath
Cord Care
Dressing/ Wrapping: mummified
Eye prophylaxis: Credes
o
Before: silver nitrate is used

Presume that all babies delivered vaginally are infected

with N. gonorrhea to avoid opthalmia neonatorum
o
Unang Yakap: Erythromycin is used
Foot printing/Identification
Get APGAR score: 1 and 5 minutes
HR, RR, Temperature, BP
Injection of vitamin K: to prevent hemorrhage

DACM MED2016

COMPONENTS

Proper identification: tag/bracelet

Oil bath/warm w ater bath
Cord care/dressing
Measurements
o
Weight
o
Anthropometric measurements
Credes Prophylaxis
Vitamin K administration
Foot printing/ marking
Vital signs
Dressing/ wrapping

PROPER I DENTIFICATION

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 dirtiest part
Do not remove vernix caseosa vigorously

CORD CARE

Umbilical stump
Rubbing alcohol

OTHERS

Weight and anthropometric measurements

Credes prophylaxis
Vitamin K administration
Foot printing
Vital signs

DRESSING AND WRAPPIN G

Mummy
Wrap in warm blanket
Cover head with stockinette cap

DAILY CARE

Nutrition and Feeding

Elimination
Weight
Bathing and hygiene/grooming
Obtain vital signs
Rooming-in
Note for any abnormalities
o
Pediatrician will check after delivery

NEW BORN ASSESSMENT

GENERAL APPEARANCE

Assessment of the new born is essential to ensure a successful transition

3 MAJOR TIME FRAMES IN ASSESSING THE NEW BORN

1Immediately

after birth
o
Determine which baby needs CPR
2Within the 1st 24 hours after birth
3Prior to discharge

Essential newborn care is only

applied to NORMAL babies

Activity/ Muscle tone

Pulse/ Heart Rate
Grimace/ Reflex Irritability/ Responsiveness
Appearance/ Skin color
Respiration/ Breathing

VITAL SIGNS

APGAR SCORING SYSTEM

INDICATORS
Activity
Pulse
Grimace
Appearance
Respiration

2
Active,
spontaneous
>100bpm
Pulls away, sneezes,
coughs
Completely pink

1
Some flexion of
extremities
<100bpm
Facial grimace only

Good vigorous cry

Slow irregular weak

cry

Acrocyanosis

0
No movement
(flaccid or limp)
Absent
No response with
stimulation
Bluish gray or pale
all over
Absent

SCORE INTERPRETATION
SCORE
7 to 10
4 to 6

INTERPRETATION
Well baby
At risk
Infant needs intensive care

0 to 3

Sick baby
Prognosis for new born is
grave

NURSING INTERVENTIONS
Rarely needs resuscitation
Requires resuscitation
Suction
Dry immediately
Ventilate until stable
Careful observation
Intensive resuscitation
ET/ Ambu bag
Ventilate with 100% oxygen
CPR
Maintain body temperature
Parental support

GENERAL GUIDELINES

Keep warm during examination

From general to specific
Least disturbing first
Document ALL abnormal findings and provide nursing care

DACM MED2016

Full term:

Symmetric

Face turned to side

Flexed extremities

Hands tightly fisted with thumb covered by fingers

SPECIAL CONCERNS:

Asymmetric (brought about by long delivery)

o
Fractured clavicle or humerus
o
Nerve injuries (Erb-Duchennes Paralysis)

Breech presentation
o
Knees and legs straightened or in FROG position
o
All breech presentation should be delivered via CS!

APGAR SCORE

POSTURE

TEMPERATURE

Site: Axillary NOT rectal

Duration: 3 minutes
Normal range: 36.5 -37.6 degree Celsius
Stabilizes within 8-12 hours
Monitor every 30 minutes until stable for 2 hours then every 8 hours

HEAT LOSS MECHANISMS

Convection
o
The flow of heat from the body surface to cooler surrounding air
o
Eliminating drafts such as windows or aircon, reduces convection

Conduction
o
The transfer of body heat to a cooler solid object in contact with the
baby
o
Covering surfaces with a warmed blanket or towel helps minimize
conduction heat loss

Radiation
o
The transfer of heat to a cooler object not in contact with the baby
o
Cold window surface or air con; moving as far from the cold surface,
reduces heat loss

Evaporation
o
Loss of heat through conversion of a liquid to a vapour
o
From amniotic fluid, new born 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

BODY MEASUREMENT
Awake: 120-160 bpm to 120-140 bpm
Asleep: 90-110bpm
Crying: 180 bpm
Rhythm: Irregular immaturity of cardiac regulatory center in the medulla
Duration: 1 full minute, not crying
Site: apical

SPECIAL CONCERNS

(+) Prominent radial pulse: CHD

(-) Femoral pulse: Coarctation of the Aorta

NURSING CONSIDERATIONS

Keep warm

Take HR for 1 full minute

Listen for murmurs

Palpate peripheral pulses

Assess for cyanosis

Observe for cardiopulmonary distress

RESPIRATIONS

Characteristics:
o
Nasal breathers, gentle, quiet, rapid BUT shallow
o
May have short periods of apnea (<15 secs) and irregular without
cyanosis periodic respirations
Rate: 30- 60 cpm
Duration: Full 1 minute

NURSING CONSIDERATIONS

Position on side

Suction as needed

Observe for respiratory distress

Administer oxygen via hood PRN and as prescribed

WEIGHT

5.5 to 9.5 lbs (2,500-4,300 grams)

o
Caucasian: 7 lbs
o
Filipinos: 6.5 lbs
70-75% TBW is water
LBW: below 2,500 grams; regardless of AOG

LENGTH

45 to 55 cms (18-22 inches)

Average: 50 cms
Techniques: using a tape measure
o
Supine with legs extended

Crown to rump

Head to heel

HEAD CIRCUMFERENCE

33 to 35.5 cm (13-14 inches)

Technique: using a tape measure
o
From the most prominent part of the occiput to just below the
eyebrows
1/3 the size of an adults head
Disproportionately large for his body
HC should be = or 2 cm > CC

CHEST CIRCUMFERENCE

30 to 33 cms (12-13 inches)

Technique: using a tape measure
o
From the lower edge of the scapula to directly over the nipple line
anteriorly
CC should be 2 cm than HC

SILVERMAN-ANDERSON INDEX

Perform to observe for signs of respiratory distress:

o
Chest lag
o
Retractions
o
Nasal flaring
o
Expiratory grunting

NURSING CONSIDERATIONS

Under natural light

Assess for:
o
Color
o
Hair distribution
o
Turgor/ texture
o
Pigmentation/ birthmarks
o
Other skin marks

BLOOD PRESSURE

SKIN COLOR

Not routinely measured unless in distress or CHD is suspected

At birth: 80/46 mmmHg
After birth: 65/41 mmHg
Using Doppler UTZ

Very smooth and puffy especially at the legs, dorsal aspects of the hands and
feet and in the scrotum and labia
Pinkish red (light skinned) to pinkish brown to yellow (dark skinned)
Ruddy or reddish due to increased RBC concentration and decreased
subcutaneous tissues
Examples: cyanosis/acrocyanosis, pallor, jaundice and meconium staining
3

DACM MED2016

ACROCYANOSIS

Bluish discoloration of the palms of hands and soles of the feet

o
Due to immature peripheral circulation
Exacerbated by cold temperatures
Normal within 1st 24 hours

PALLOR/CYANOSIS

May indicate hypothermia, infection, anemia, hypoglycaemia, cardiac,

respiratory or neurological problems

JAUNDICE

Under natural light

Blanch skin over the chest or tip of the nose yellowing

PHYSIOLOGIC JAUNDICE

FT: after the 1st 24 hours (2-7 days)

PT: after the 1st 48 hours

Peaks at 5-7 days and disappears by the 2nd week

Due to immaturity of the liver

Usually found over the face, upper body and conjunctiva of the eyes
PATHOLOGIC JAUNDICE

Within 24 hours

May indicate early hemolysis of RBC or underlying disease process

Duration:
o
Fullterm: 1 week
o
Preterm: 2 weeks
MANAGEMENT OF JAUNDICE

Monitoring serum bilirubin levels

o
Physiologic: not more than 5 mgl/dl per day
o
Pathologic: more than 15-20 mg/dl (critical levels)

Maintain hydration

Place bilirubin lights as needed

Provide emotional support to parents

MECONIUM STAINING

Over the skin, fingernails and umbilical cord

Due to passage of meconium in utero related to fetal hypoxia

LANUGO

Found after 20 weeks of gestation on the entire body except the palms and
soles
Fine downy hair that covers the shoulders, back and 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 without lanugo

DACM MED2016

VERNIX CASEOSA

Protective cheesy-like, gray-white fatty substance

Fullterm: 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 and desquamation signs of postmaturity

MILIA

Multiple, yellow or pearl white papules approximately 1 mm wide

Due to enlarged or clogged sebaceous gland
Usually found on the nose, chin, eyebrows, and forehead

MONGOLIAN SPOTS

Blue-green or gray pigmentation

Lower back, sacrum and buttocks
Disappears by 4 years of age

SALMON PATCHES

Seen commonly in the NB

More on Caucasian
AKA Naevus simplex, Angel kisses when on the forehead or eyelids and
stork bites over the nape or the neck
Midline malformations consisting of ectatic capillaries in the upper dermis with
overlying skin

STORK BITES

Telangiectatic Nevi
Flat red or purple lesions
Back of the neck, lower occiput, upper eyelid and bridge of the nose
Can be seen after 2 years of age

STRAWBERR Y MARKS

Nevus Vasculosus or Capillary Hemangioma

Dark red, raised lobulated tumor
Present in the head, neck, trunk and extremities
After 7 to 9 years of age

PORT WINE STAIN

Nevus Flammeus or Capillary Angioma

Capillary malformation
Flat red to purple, sharply demarcated dense areas beneath the capillaries
May be present on the face
Does not fade with time
May be 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).

MOTT LING

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
May be seen in trunk, face and extremities
Seen within 48 hours

PETECHIAE

Pinpoint hemorrhages on skin

o
Due to increased vascular pressure, infection or thrombocytopenia
Within 48 hours
Tourniquet test petechiae can be seen

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 one side, dependent side turns red and upper side/half turns pale
Due to gravity and vasomotor irritability or immature circulation
Skin resembles a Clowns suit

CAF-AU-LAIT SPOTS

Tan or light brown macules or patches

No pathologic significance if > 3cm length and <6 in number
o
If >3cm or 6: cutaneous neurofibromatosis

Dont attempt to excise!

DACM MED2016

WHAT TO ASSESS IN THE FETAL HEAD

FOR SYMMETRY, SHAPE AND SWELLING A ND MOVEMENT

Soft, pliable, moves easily

With some molding (if VSD)
Round and well-shaped (if CS)

MEASURE

Head circumference: if HC is CC

FONTANELLES, SOFT S POT

BAD: 12-18 months

LPT: 2-3 months or 8-12 weeks
Bulging or sunken

SUTURES

Overriding or separated

HEAD LAG

Common when pulling newborn to a sitting position

When prone, newborn should be able to lift the head slightly and turn head
from side to side

CAPUT SUCCEDANEUM

Swelling of soft tissues of the scalp

Due to pressure
Crosses the suture lines
Presenting part
May be present up to 3 days after birth
o
Assure the mother

CEPHALHEMATOMA

Subperiosteal hemorrhage with collection of blood

Due to rupture of capillaries as a result of trauma
Does not cross suture lines
May be present up to 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 forceps delivery

5

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 mothers pelvic bone in utero

EARS

Soft and pliable, with firm cartilage

Pinna should be at the level of the outer canthus of the eye
(+)Low set ears: renal or chromosomal abnormalities
May be congested and hear well after few days

CRANIOSYNOSTOSIS

Premature closure of the fontanels

Emergency

WHAT TO ASSESS IN TH E FACE, EYES, EARS, NOSE AND MOUTH

Facial movement and symmetry

Symmetry, size, shape and spacing of eyes, nose and ears

Color
o
White sclera
o
Slate gray, brown or dark blue
o
Final eye color: seen after 6-12 months
Symmetrical
Pupils equally round and reactive to light
(+) Blink reflex
(+) transient strabismus due to weak EOM
Able to move and fixate momentarily
(+) Red reflex
o
If (-): cataract
(+) Edema on eyelids related to pressure during delivery or effects of
medication
(-) Tear formation
o
Begins at 2-3 months

NURSING CONSIDERATIONS

Administer eye medication within 1 hour after birth to prevent ophthalmia

neonatorum (due to N. gonorrhea)

DOC:
o
Erythromycin 0.5%
o
Tetracycline1%
o
Old: Silver Nitrate 1%

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

NOSE

Congenital preauricular sinus

Ends blindly; ask for infection

MOUTH

EYES

Accessory tragus
Remnant of the 1st branchial arch

Small and narrow

Flattened, midline
Nasal breathers
(+)periodic sneezing
Reactive to strong odors
(+) Flaring: respiratory distress
(+) Low nasal bridge: Down Syndrome

DACM MED2016

Pink , moist gums

Intact soft and hard palates
o
(+) Ebsteins pearls: NORMAL
Uvula midline
Tongue moves freely, symmetrical with short frenulum
(+)extrusion and gag reflexes
Small mouth or large tongue: chromosomal problems
(+) white patches on tongue or side of the cheek: oral thrush

NECK

Short, thick in midlines

Able to flew and extend but cannot support full weight of head
Creased with skin folds
Trachea midline
Thyroid gland not palpable
Intact clavicle
o
(+) shoulder dystocia clavicle is cut for the baby to pass through

CHEST, ABDOMEN, GENI TALS

CHEST

CC 2cm than HC
Cylindrical, equal AP:T diameters
Symmetrical
Abdominal breathers
(+) Bronchial sounds
(+) Breast engorgement: subsides after 2 weeks
(+)Prominent/edematous nipples
(+)Accessory nipples
(+) Witch Milk

ABDOMEN
UMBILICAL CORD

2 arteries, 1 vein

White and gelatinous immediately after birth

Begins to dry between 1-2 hours following birth

Blackened or shriveled between 2-3 days

Dried and gradually falls off by 7 days

DAILY CORD CARE

Keep cord dry and clean and 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

MALES

Prepuce: covers the glans penis

o
(+) adherent foreskin: Phimosis
Scrotum: edematous
o
(+) enlarged: Hernia
Meatus: central
o
(+) Ventral/dorsal: hypo/epispadias
Testes: descended
o
(+) Undescended: cryptorchidism

WHAT TO ASSES IN THE BACK, EXTREMITIES

SPINE

Straight, posture fixed

Supports head momentarily
Arms and legs fixed
Chin flexed on upper chest
Check for protrusion, excessive or poor muscle contractions: CNS Damage

EXTREMITIES

ANUS

Capacity: 90 ml with rapid intestinal peristalsis (2 to 3 hours)

Bowel sounds: (+) within 1-2 hours after birth
Presence of mass, distention, depression or protrusion
(+) Scaphoid: diaphragmatic hernia
(+) Distended: LGIT obstruction/ mass

Check patency
First stool: Meconium: within 1st 24 hours
o
Sticky, tarlike, blackish-green, odorless material
Transitional stool
o
Within 2-10 days after birth
o
Breastfeed

Golden yellow, mushy, more frequent 3-4x and sweet

smelling
o
Bottlefeed

Pale yellow, firm , less frequent 2-3x with more noticeable odor

NURSING CONSIDERATIONS

Breast feeding can usually begin immediately after birth

Bottle feeding may be started with sterile water to 4 hours after birth prior to
formula feeding

Burp during and after feeding

Position properly during and after feeding

GENITALS
FEMALES

Labia: edematous

Clitoris: Enlarged

(+) Smegma (even females have smegma)

Pseudomenstruation possible

Visible: Hymen tag

First vomiting within 24 hours

DACM MED2016

Flexed ROM, symmetrical

Clenched fists, flat soles
With 10 fingers and toes in each hand??? (baka toes in each foot haha)
Legs bowed
Even gluteal folds
(+) Creases on soles of feet
o
(-) Creases: prematurity
Check for hip fractures or dysplasia
o
(+) Ortolanis click and uneven gluteal folds: hip dysplasia
(+) Inward turning of the foot: club foot or talipes equinovarus
(+) Extra digits: polydactyly
(+) Web fingers: syndactyly

REFLEXES
SUCKING/ROOTING

Touch the tip, cheek or corner of the mouth

Turns head toward the nipple, opens mouth, takes hold of the nipple and sucks
Disappears after 3-4 months up to 1 year

EXTRUSION

Anything placed on the anterior portion of the tongue will be spit out
To prevent swallowing of inedible substances
Disappears after 4 months
o
Disappearance indicates readiness for semi-solid to solid foods

SWALLOWING

Occurs spontaneously after sucking and obtaining fluids

Never disappear
Newborn swallow in coordination with sucking without gagging, coughing or
7
vomiting

TONIC NECK/ FENCING

While the baby is falling asleep or is 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 months

BALLARDS SCORING

Completed in 3-4 mins

2 portions
o
Physical maturity
o
Neuromuscular maturity

PALMAR (GRASPING)/ P LANTAR

Place a finger in the palm of the babys hand, then place a finger at the base
of the toes
Fingers will curl or grasp the examiners finger and the toes will curl downward
Palmar: fades within 3-4 months
Plantar fades within 8 month

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 and forms a C
with the thumb and the forefinger, and adducts the arms to an embracing
position and returns to a relaxed state
Present at birth
Complete response at 8 weeks
Most significant reflex indicative of CNS problem ( >6 months)
Disappears after 4-5 months

STARTLE

Best elicited if baby is 24 hours old

Make a loud noise or claps hands
Babys arms adduct while elbow flex with fists clenched
Disappears within 4 months

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
Disappear: starts at 3 months to 1 year
o
Disappearance indicates maturity of CNS

STEP PING, WALKING, DANCIN G

Hold baby in a standing position allowing one foot to touch a surface

Simulates walking by alternatively flexing and extending feet
Disappears after 3-4 months

ASSESSMENT OF GESTAT IONAL AGE

DUBOWITZ MATURITY SC ALE

Gestational rating scale

NB are observed and tested according to the criteria
Help determine whether the NB needs immediate high risk nursery intervention

DACM MED2016

OTHER NURSING RESPON SIBILITIES

Identification band
Birth registration
Birth record and documentation
8

NEWBORN SCREENING

SHOULDER HOLD

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
Screens for:
o
Congenital hypothyroidism (CH)
o
Congenital Adrenal Hyperplasia (CAH)
o
Galactosemia (GAL)
o
Phenylketonuria (PKU)
o
Glucose-6-Phosphate-Dehydrogenase Deficiency (G6PD Deficiency)

?
CH
CAH
GAL
PKU
G6PD

?
Severe mental retardation
Death
Death or cataract
Severe mental retardation
Severe anemia, kernicterus

Purpose: used for burping

Procedure
o
Draw baby towards your chest with one forearm
o
Bracing his back and your hand cradling his head
o
Support your babys bottom and thighs with your other arm
o
Gently press his head against shoulder

?
Normal
Alive and normal
Alive and normal
Normal
Normal

INFANT CARE SKILLS

Holding the baby through

o
Football hold
o
Cradle hold
o
Shoulder hold

FOOTBALL HOLD

Purpose: to carry on one hand free

o
A holding technique in bathing a baby
o
Use for small babies
Procedure
o
Slide forearm under his back
o
Support neck and head with your hand
o
Press his arm firmly against your side
o
His head faces you
o
Infants feet tucked under your elbow

CRADLE HOLD

Purpose: used for feeding and cuddling a baby

Procedure
o
Support hear in the crook of your arm
o
Encircle the body with your arm
o
Press baby firmly against your side
o
Use other hand to support bottom and thigh

DACM MED2016