NEWBORN CARE

A. Essential Concepts:
1. In the postpartal period, the newborn experiences complex biophysiologic and behavior change related to the transition to extrauterine life. Nursing care of the newborn is based on knowledge of these changes and of the newborns impact on the family unit. The first few hours after birth represent a critical period of adjustment for the newborn. In most setting, the nurse provides direct care to the newborn immediately after birth. After the transition period, the nurse continues to evaluate the newborn at periodic intervals and to alter nursing plans according to ongoing findings. The nurse must be skillful in balancing the familys need for privacy and time to interact without interruptions with the need to closely monitor the newborns transition to extrauterine life.

2.
3. 4. 5.

B. GOALS OF NEWBORN CARE

1. For the initial postpartal period a. Establish and maintain an airway and support respirations. b. Maintain warmth and prevent hypothermia. c. Ensure safety to prevent injury or infection. d. Identify actual or potential problems that might require immediate attention.

2. For continuing care a. Continue to protect from injury or infection and identify actual or potential problems that could require attention. b. Facilitate development of a close parent-infant relationship. c. Provide parents with information about newborn care. d. Assist parents in developing healthy attitudes about childrearing practices.

C. FACTORS AFFECTING NEWBORN ADAPTATION

1. Antepartal experiences of mother and newborn (e.g., exposure to toxic substances, parental attitude toward childbearing and childrearing) 2. Intrapartal experiences of mother and newborn (e.g., length of labor, type of intrapartal analgesia or anesthesia) 3. Newborns physiologic capacity to make the transition to extrauterine life. 4. Ability of health care providers to assess and respond appropriately in the event of potential problems.

D. NURSING RESPONSIBILITIES
1. Support the neonates physiologic adaptation to extrauterine life 2. Prevent or minimize potential complications 3. Facilitate parent-infant interaction

IMMEDIATE NEWBORN CARE

After the birth of the infant, every effort should be exerted to support him in his first minutes, hours and days of life. The quality of the immediate care afforded the newborn will spell his later state of health or well-being.

1. Establishment and maintenance of patent airway

Right after the extension of the newborns head before the chest is delivered the mouth and nose should right away be cleared. This measure is the best prevention to meconium aspiration which results to lung infection: ASPIRATION PNEUMONIA

a. Suction the newborn observing the following considerations: Start with the mouth, then the nose stimulation of the nerve receptors in the nose can cause reflex inhalation of oropharyngeal secretions into the trachea and bronchus and aspirate the secretions. Press or deflate the rubber ball of the bulb syringe before inserting its tip into the mouth and nostrils of the newborn Suction shallowly by using bulb syringe deep suctioning can cause vagal stimulation leading to bradycardia and laryngospasm.

Suction briefly to avoid suctioning needed oxygen. Preterm: less than 5 seconds per suction time Full-term: 5 to 10 seconds per suction time Give oxygenation judiciously when necessarygiving more than 40% oxygen concentration can result to damage to the retina causing neonatal blindness called RETROLENTAL FIBROPLASIA Position in SLIGHT TRENDELENBERG

 Test patency of the airway by occluding one nostril at a time newborns are nasal breathers Position in slight Trendelenberg (10-15 degrees angles) promote drainage of oro-nasopharyngeal secretions. Avoid the acute Trendelenberg position can cause abdominal contents to exert pressure unto the diaphragm leading to difficult breathing Head-down position is contraindicated in the presence of signs of increased intracranial pressure: vomiting; bulging/tensed fontanels; abnormally enlarged head; increased BP; decreased PR and RR; widening pulse

RESUSCITATION MEASURE

Airway make sure that the mouth and

nasopharynx are free of secretions; remove secretions by suction, small finger, or gentle milking of trachea

Breathing if neonate does not make effort to

breathe, start your mouth-to-mouth resuscitation. Pinch the nose and cover the babys mouth entirely with your mouth, and breath into him and notice the chest move

Circulation if there are no heart sounds, apply

index and middle fingers/thumb on the infants mid-sternum and apply 1 inch downward pressure. Do 5 chest compressions followed by

* Oxygen deprivation of more than 5 minutes can result to the death of the baby or permanent damage of sensitive brain cells *Continue resuscitation until breathing is established or the heart stops beating and the baby is pronounced dead *Stop resuscitation when pupils have remained dilated for 30 minutes

2. Maintenance of appropriate body temperature

The newborn temperature at birth is 37.3oC & drops quickly to 35.5oC owing to the mechanisms of heat loss. Dry the newborn immediately after birth to prevent heat loss by evaporation. Wrap the body and promote flexion and apply cap to head to minimize the body surfaces exposed to cool air or cool surfaces; never place newborn on cold and unlined surfaces. to prevent heat loss by conduction and

 Use a thermoregulator, such as a radiant warmer, or a temperature-controlled incubator to control environmental temperature until the neonates temperature stabilizes Radiant warmer maintains the neonates temp. by radiation. Incubator maintains the neonates temp. by conduction and convection. Make sure the warmer is set to the desired temperature Warm blankets, washcloths, or towels under a heat source Keep the neonate under the radiant warmer until his temperature remains stable

 The warm abdomen of the of the mother ca be a good place to keep the newborn warm immediately after birth. The initial temperature of the newborn is taken per RECTUM to detect for IMPERFORATE ANUS. After the initial temperature taking, all other temperature taking should be per AXILLA to minimize potential risk to traumatizing the mucus membrane of the rectum; every 15-30 min. until it stabilizes and then every 4 hours to ensure stability Avoid exposing infant to drafts, wetness, and direct or indirect contact with cold surface.

 Temperature is stabilized within 8 to 12 hours at 36.8oC (98.2oF). During the entire immediate care procedures, place newborn under the floorlamp to keep him warm. Subjecting the newborn to COLD STRESS can cause: 1.Increased brown fat metabolism causing an increased in fatty acids in the circulation thus METABOLIC ACIDOSIS. 2.Increased activity/metabolic rate causing more utilization of glucose and oxygen thus HYPOGLYCEMIA and RESPIRATORY

3. Do immediate Assessment of the Newborn

APGAR SCORING - Is the standardized evaluation of the newborns condition at birth done at: 1 min. after birth to determine the general condition; & 5 min. after to determine how well the newborn is adjusting to extrauterine life. - The scoring system is named after DR. VIRGINIA APGAR, an anesthesiologist, who studied the observations in the newborn. - The normal infant should have an APGAR of 7

APGAR SCORE CHART

SIGN COLOR 0 1 2 Pink all over

(Appearance)
HEART RATE

Generalize Body pink, d pallor or extremities blue bluish (Acrocyanosis) Absent None; No response < 100/min Grimace, weak cry

100/min or more Cry; sneezing

(Pulse)
REFLEX IRRITABILITY

(Grimace)
MUSCLE TONE

(Activity)
BREATHING

Limp, flaccid

Some tone in limbs; some flexion of ext. slow, irregular

Active flexion of limbs; well flexed extremities Regular, with cry

None

(RespiratoryEffort)

O 3 = severely depressed with HR slow, inaudible and reflex response are depressed or absent. The baby is in serious danger and needs immediate resuscitation. 4 6 = mildly to moderately depressed infants; demonstrates depressed respiration, flaccidity, and pale to blue color. HR and reflex irritability are good. Condition is guarded and may need more extensive clearing of the airway. 7 10 = excellent condition and require no aid other than simply nasopharyngeal

 COLOR. Many babies may be blue when they are delivered, but they usually regain color and become pink soon. If the newborn remains bluish, the baby may not be breathing well, or may be cold, or may have infection, or a congenital heart problem refer the newborn immediately to the doctor . HEART RATE. The heart rate of a newborn is between 120 to 160 beats every minute count the HR in 1 full minute; if outside the normal rate, refer immediately. MUSCLE TONE. A newborn with his arms and legs bent has good muscle tone. A limp baby with his arms and legs loose has poor muscle tone. A baby with poor/weak muscle tone may

 BREATHING. Babies who cry after birth are usually breathing well. However, some newborns may have breathing problems. The following are bad signs: The nostrils are flaring when the baby breathes The skin between the ribs retracts on breathing Very rapid breathing mote than 60 per min. Very slow breathing less than 30 per min. The baby grunts when he breathes - A baby who is not breathing or is gasping needs immediate help.

 If the baby has lots of secretions, use the bulb syringe to clear the airway. Turn the baby on his side for few minutes. Rub your hand firmly on his back. Never hit the baby nor hold him upside down to make him cry. Give oxygen inhalation if there is one available. Refer immediately.

Silverman-Anderson Scoring -An index of respiratory distress or is a useful tool in the evaluation of status of the newborns respiration to determine degree of respiratory distress syndrome (RDS).
signs
0 No difficulty 1 Moderate difficulty 2 Maximum difficulty

Upper Synchron Chest lag chest ized movement breathing

See-saw breathing

Lower No minimal chest retraction movement s

Marked

signs

0 No difficulty

1 Moderate difficulty

2 Maximum difficulty

Xiphoid process retractions Nasal flaring Expiratory grunting

No minimal retractions

Marked

No flaring Just visible Quiet breathing Expiratory grunts on auscultation

Marked Grunting on bare ears

Initial assessment Pink HR > 120 bpm Breathing regularly Blue HR >100 bpm Breathing inadequate Blue or pale HR <100 bpm Not breathing

Initial assessment and action to be taken:

Action Dry and wrap baby Baby stays with mother Dry and wrap Clear the airway Dry and wrap Clear the airway Ask for help Refer to the doctor

Assessment of gestational age

NAGELES RULE calculation of EDC using the mothers LMP; count back 3 mos. from the first day of LMP and add 7 days. McDONALDS METHOD determines age of gestation by measuring the fundic height (fundus to symphysis) in cm. , then divide by 4 = AOG in months. BARTHILOMEWS RULE estimates AOG by the relative position of the uterus in the abdominal cavity. 3rd lunar month fundus is slightly above the symphysis pubis. 5th lunar month fundus is at the level of the

 Time quickening is first felt. Ultrasound Assessment of the newborn at birth

Rapid estimation of the gestational age of the newborn

sign 36 weeks or less 37 -38 weeks 39 weeks or more

Sole Anterior creases transverse

occasional Sole covered with crease Fine and fuzzy Coarse and silky

Scalp hair

Fine and fuzzy

sign Breast nodule diameter

36 weeks or less 2mm

37 -38 weeks 4 mm

39 weeks or more 7 mm

Earlobe

flexible

With some cartilage

With cartilage

Testes and scrotum

Testes in lower canal; scrotum small with few rugae

intermediate Testes pendulous; scrotum full with extensive rugae

Ballard Scoring System

Uses physical and neurologic findings to estimate gestational age This system enables estimates of gestational age to within 1 week, even in extremely preterm neonates This evaluation can be done anytime between birth and 42 hours of age, but the greatest reliability is at 30 and 42 hours

- Cephalometry measurement of the diameters of the skull.

4. Identify the newborn properly.

- Done as soon as possible after birth before the newborn is separated from the mother. - The best way to identify the newborn is by means of taking his footprints. - Proper identification is a legal and moral responsibility of the midwife/nurse. - May use bracelets or foot tags.

5. Provide skin care.

Immediate soap and water bath is given to the normal fullterm newborns to primarily cleanse the skin and prevent infection; is given once vital signs have stabilized Wear gloves when giving the first bath Oil bath is given to pre-terms and other highrisk newborns. Never give the newborn marine bath (- bath that someone gives as he holds the newborn directly under cold, running water of the faucet and briskly bathes him) subjects newborn to cold stress.

 Wash, rinse, and dry each portion of the body separately to minimize heat loss - Begin the bath with the eyes and face first, proceeding from the cleanest to the least cleanest area last - Clean the diaper area last Give sponge bath until the umbilical cord falls off, usually within 10 to 14 days Use a mild, hexachlorophene-free soap Dont use soap on infants face Bathe before feedings instead of afterward to prevent vomiting Apply alcohol, if ordered, to the base of the

 Given to all newborns as a prevention against OPHTHALMIA NEONATORUM/GONORRHEAL CONJUNCTIVITIS caused by Neisseria gonorrhea causes blindness as baby may acquire it as he passes through the birth canal of an infected/untreated mother. Can be delayed for 1 to 2 hours not to interfere with the bonding process. NOW: Apply tetracycline ophthalmic ointment to each eye, from the inner canthus to the outer canthus. 1 -2 cm ribbon of 0.5% ERYTHROMYCIN

6. Give Credes Prophylaxis

7. Perform Cord Dressing

Is performed under strict aseptic technique to prevent TETANUS NEONATORUM caused by Clostridium tetani. Examine the cord for the presence of 3 blood vessels: 1 umbilical vein and 2 umbilical arteries incomplete number of vessels warrants immediate reporting for thorough assessment for congenital defects. The vessels are covered with Whartons jelly protects vessels from being twisted or compressed. Leave about 1 inch of the cord from the base

 signs: smelly discharge on the surface of the umbilical stump; the umbilical stump remains wet and soft; there is redness around the base of the umbilicus Apply 70% isopropyl alcohol to the umbilical cord stump 3 4 times daily will keep it dry & clean, & help in making it fall off early. Umbilical cord stumps usually fall off in 7 10 days. In the first 24 hours, inspect cord for OMPHALANGIA (- bleeding of the cord). Place diaper below the umbilicus to prevent

8. Inject Vitamin K intramuscularly.

0.5 1 mg of Vitamin K is injected to prevent bleeding or hemorrhagic disease in the newborn by improving blood coagulation. Lack of vit. K can cause a bleeding condition known as Hemorrhagic Disease of the Newborn that can lead to permanent brain damage or even death. Newborns GIT is initially sterile no E. coli to synthesize the vitamin.

 The liver needs vit. K to make other clotting factors, but because of its immaturity at birth, it has no stores of vit. K. The best site for IM injections is the THIGH MUSCLE, specifically the midantero-lateral aspect called VASTUS LATERALIS.

9. Neonates to Rh(-)/Type O mothers, should have blood specimen for:

Blood type Bilirubin level Direct Coombs test. An abnormal result indicates presence of maternal antibodies in the neonates blood, suggesting blood incompatibility Reticulocyte count. Increased count indicates the bodys response to RBC destruction Hematocrit. Decreased result suggests anemia

 Neonates weighing less than 2,500 g or more than 4,000 g should undergo blood glucose screening within 30 min. of birth to determine glucose stability - glucose levels less than 40 mg/dl indicate hypoglycemia and require treatment - the neonate should receive 10ml/kg of body weight of formula - Blood glucose level is checked 1 hour after feeding - If the glucose level is higher than 45 mg/dl, another glucose level is obtained before the next feeding The neonate is assessed for signs of

10. Take the weight and other Anthropometric Measurements

Size and weight measurements establish the baseline for monitoring normal growth. When obtaining these measurements, place the neonate in a supine position in the crib or on the examination table and remove all clothing. WEIGHT. The normal weight of newborns ranges from 3000 to 3400 g with the lowest normal limit of 2500 g. Physiologic weight loss: 5% to 10% in the first 7 to 10 days of life. Lost weight is regained after the 10th day. Perinatal mortality and morbidity are related to

 HEIGHT. Normal height rangers from 18 to 21 inches (46-53 cm), or an average of 50 cm.; taken by heel-to-crown measurement; fully extend the neonates legs with the toes pointing up. HEAD CIRCUMFERENCE. Measures 3335 cm (13-14 in) * Slide a tape measure under the neonates head at the occiput and draw the tape around snugly, just above the eyebrows.

 CHEST/ABDOMINAL CIRCUMFERENCE. Measures 31-33 cm (13-14 in); 2-3 cm. less than HC Place a tape measure under the back and wrap it snugly around the chest at the nipple, keeping the back and front of the tape level; take the measurement after the neonate inspires and before he begins to exhale Place a tape under the back and wrap it snugly around the abdomen just above the umbilicus

11. Advise the mother to frequently observe the baby for danger signs. The following are the conditions of the newborn needing urgent intervention:
Change in color from pink to paleness, blue or deep yellow Poor suck or weak cry or limpness Irritability or non-stop crying Pre-term or very low birth weight Gasping or not breathing (fast, slow breathing, grunting0 CONVULSIONS

 Frequent loose stools or difficulty of defecating Fever or hypothermia Pus in the umbilicus or redness around the umbilicus extending to the skin Bleeding Pustules in the skin or swelling and redness

12.Start immunization with hepatitis B vaccine and BCG as recommended

Routine Hepatitis B immunization of all newborns within 12 hours of life provides the best chance of preventing perinatal transmission of the virus according to the WHO. Hepatitis B is injected IM into the outer part of the thigh at a dose of 0.5 ml. the vaccine is 05% efficient in preventing chronic infection and is 90% effective in preventing perinatal transmission of the if the 1st dose is given with 24 hours of birth followed by the 2nd and 3rd doses at 6 and 14 weeks in that order or at

 Bacillus Calmette-Guerin (BCG) is given single dose at 0.5 ml injected intradermally using a sterile tuberculin syringe and needle. The sites of injection are the upper arm just below the deltoid or in the upper outer buttock. BCG can be given practically to all newborns. If a baby is sick, or if the mother has active TB and has been receiving less than two months of treatment, defer BCG. If not given at birth, BCG may be given

WHO recommends that four doses of OPV be given routinely before the age of 1 year: OPV0, at birth or within 14 days of birth OPV1, at 6 weeks OPV2, at 10 weeks OPV3, at 14 weeks of age If dose OPV0 has not been given within 14 days of birth, it should be skipped and immunization starts at 6 weeks old or at dose OPV1 About 2 gtts of OPV is given through the mouth. There are no contraindications but giving the vaccine may be deferred if the infant has diarrhea or you can give an extra dose after four weeks. Reactions are unusual.