NEWBORN

Lecture 12

Care of Newborn in Delivery Room:

Adequate breathing pattern established Mouth suctioned 1st Nurse wraps infant in warm blanket & places under

radiant warmer Drying motion usually stimulates 1st cry. Drying

helps prevent heat loss Note time of 1st cry & success at breathing

attempts. May need resuscitative attempts. infant kept unwrapped on clean/dry radiant warmer

to promote thermoregulation

Apgar Score

Apgar score - assessment scale since 1958 to assess newborn well-being at 1 & 5 min.

Newborn observed & rated on 5 components .

Heart rate Respiratory effort Muscle tone Reflex irritability Color

Apgar score

Score of 0, 1, or 2 - each component Five scores added & final number @ 1 & 5 min 9/9 common - 2 on HR, Resp, reflexes, muscle

tone & 1 on color d/t acrocyanosis. Heavy sedation of mother may lower respiratory effort

or reflex irritability score. Score of 4 or less indication that infant most likely

needs resuscitative efforts Score of 4-6 may indicate suctioning and oxygen

therapy.

Umbilical Cord

Umbilical Cord: After delivery, 2 clamps placed

Cord clamped again 1- 2 inches from umbilicus Vessels counted [2 arteries; 1 vein - AVA].

Bleeding may occur if clamp not tight

umbilical stump; falls off by 7th - 10th day

Teach: do not bathe infant until site completely healed Sponge bath

Identification of Newborn

Done immediately > delivery by same nurse assisting mother

Prevent giving wrong infant to wrong mom. Identification is 1 band on mom, one on significant other & 2 on baby.

Footprints of infant & mother’s thumb print on footprint sheet.

Nurse’s Responsibilities in Delivery Room

Eye Care: erythromycin ointment > delivery Eliminates gonorrhea/chlamydia. Vitamin K Injection: produced in intestinal tract and

used by body for coagulation. Newborn @ risk for bleeding disorders during 1st wk

of life. injection given IM within 1st hour [Dose = 0.5 mg. to 1.0 mg.] Site: vastus lateralis

In DR, infant given to mom to begin bonding process & breast feeding started.

Nurse’s Responsibilities in Newborn Nursery

Admission to Nursery Infant transferred to Newborn Nursery. Report given by L&D nurse to NBN nurse. Routine newborn care. Infant under radiant warmer, VS, measurements,

head to toe assessment, bath [98.0 R]. To mom in 4 hrs. if WNL. [98.0] Universal security system on maternity units -

ensure safety of all newborns on unit. Alarm placed on infant ankle or umbilical cord

stump. All doors in unit are alarmed & locked.

Newborn Adaptation

Newborn’s ability to adapt successfully depends upon conditions in utero, care it receives during intrapartum period, & newborn period aka neonatal period = 1st 28 days of life.

2/3rds of all deaths that occur in 1st year of life occur during neonatal period [1st 28 days of life].

Head to Toe Assessment of Newborn

Head: General appearance NOTE: Size: ¼ of body size [33-35 cm., 13-14 in. circumference]

Molding: Asymmetry of skull Cephalohematoma: collection of blood bet. skull bone &

periosteum Caput succedaneum: swelling over presenting part

Fontanels: “soft spot” Anterior fontanel – diamond shaped, measures 2-3 cm. wide & 3-

4 cm. long. Closes @ 12-18 months. @ juncture of frontal & parietal bones. Overriding sutures w. NSVD. Level C/S

Posterior fontanel - triangular shaped; small [~0.5 cm.] hard to feel; juncture of occipital & parietal bones. Closes 2 mos.

*Depression indicates dehydration *Bulging > hydrocephalus Hair gestational marker; preterm sparse

Eyes

Eyes: usually blue or gray Permanent color develops 3 - 12 mos of age. Iris does not

develop color til 3-6 mos. Lacrimal [tear] glands- not fully mature Subconjunctival hemorrhage: from stress of vaginal delivery First 6 wks; transient strabismus; not able to focus. Constant strabismus < 6 weeks, further assessment needed.

Strabismus > 6 weeks, referral needed. Scant purulent discharge > erythromycin ointment Pupils round & equal; should constrict - normal response to light “PERL” =pupils equal & reactive to light

Nose

Nose: Infants obligatory “nose breathers”.

Note size & shape, & presence of nasal discharge or stuffiness.

Clean nose with bulb syringe; saline drops.

Observe for nasal flaring

Mouth Mouth: Examine palate with index finger Cleft lip and/or cleft palate

Epstein’s pearls [small, round, white cysts] Note size & shape of tongue and length of frenulum membrane

Supranumery teeth aka natal teeth

Sucking reflex- evaluate

Rooting reflex

Ears/Neck

Ears: Note position of ears in relation to eyes Pinna should be fully formed and firm. Term infant: pinna recoils easily Preterm infant, < 36 wks - relatively shapeless and flat; little

cartilage. Slow recoil. Skin tag – harmless; may be associated w. kidney disease.

Hearing test done before newborn D/C home; If fails 2nd time, hearing eval.done as outpt.

Neck: Normal newborn neck short, chubby w.creased skin folds. Head support necessary. Inspect masses, limitation of movement & webbing.

Clavicles: straight, palpate each clavicle for intactness; “crepitus” Common in larger infants delivered vaginally

Chest

Chest: Inspect shape, symmetry, position, development of nipples; breast tissue.

Chest 12-13 in. [30 –33 cm.]. Breast engorgement – maternal hormones. Normal respirations 40 – 60 breaths/minute.

Retractions abnormal; indicates respiratory distress. RR can be in 30’s [sleep].

After 4 hr. transition period, RR 40’s.Grunting [hoarse sound - expiration] transient d/t mucous in lungs. Suction. If retractions/grunting not clear by 4-6 hrs, may

indicate respiratory distress TTN; transient tachypnea of NB. RR = 70-80’s for

several hrs. [transition period] if more > 4 hrs., NICU.

Abdomen/Kidneys

Abdomen: palpate for masses/organs Umbilical Cord: Inspect 3 vessels (“AVA”); falls off in

7 – 10 days. Let dry. If only 2 vessels present, artery and vein, observe

infant closely d/t association with heart or kidney anomalies.

Kidneys may be felt on right & left side of abdomen by deep palpation.

S/S infection

Genitalia - Male Genitalia: Male: Assess for gestational maturity &

sexual ambiguity. Scrotum in full term infant swollen; + rugae; both R & L

testes descended into scrotal sac. Testes may be in process of descending. If one or

both testes are undescended = “cryptorchidism”, Agenesis [no testes] or closed scrotal sac Normal length of newborn’s penis = ~ 2cm long.

Assess for urethral opening “aka” urinary meatus Abnormal placement on dorsal surface *epispadias*; ventral surface *hypospadias

Genitalia - Female

Female: Vulva typically swollen. Labia minora & clitoris large with labia majora covering both

Female infants have “pseudomenstruation”

“Hymenal tag” or small piece of pink tissue protrudes between labia

Extremities

Extremities: Assess for muscle tone Note length of arms/legs; should be

symmetrical Limp arm may have nerve damage [birth

injury] “aka” brachial plexus palsy. Observe palm: simean crease [single Assess: syndactyly: webbing of fingers/toes

& polydactyly: > than 10 fingers or toes. Assess sole creases; mature infant: 2/3rds or

full sole w.creases

Skin Reddish in color; smooth and puffy At 24 - 36 hours of age, skin flaky, dry and pink in color. Edema

around eyes, feet, genitals. Acrocyanosis: Bluish discoloration of hands and feet. Lasts for

24-48 hrs. Mucous obstruction may cause central cyanosis Milia: Pinpoint white papules; Disappear 2-4 wks Neck: Normal newborn neck short, chubby w. creased skin folds.

Support is necessary. Inspect for masses, limitation of movement & webbing

Clavicles: straight, palpate for intactness; feel for “crepitus” Commonly found in larger infants delivered vaginally.

Skin

Lanugo: fine hair covering newborn’s upper arms, shoulders, & back that decreases as gestational age increases

Vernix caseosa: white, cream cheese like substance; skin lubricant.

Erythema neonatorum [toxicum]: NB rash; red rash with flea-

biten appearance. Stork Bites - a.k.a. telangiectasia - pink spots found on nape of

neck, nose, upper eyelids, upper lip. Disappear in 1-2 yrs. Mottling: Generalized red and white discoloration of skin of

exposed infants with fair complexion. Mongolian Spots: Collections of pigment cells [melanocytes]

that appear as patches across infant’s sacral area and buttocks. Tend to occur in newborn’s of Asian, African, or Southern European descent

Skin

Capillary Hemangiomas: 3 types, all are vascular

Nevus flammeus: macular (flat), purple or dark red lesions, present @ birth. Aka “port wine stain

Strawberry hemangiomas: raised areas formed by immature capillaries & endothelial cells. Occurs typically in term infant.

Cavernous hemangiomas: Raised; resembles

strawberry hemangioma Can be surgically removed

Back/Anus/Rectum

Spine: Assess for intact spine without masses or

openings. Small indentation @ base of spine may suggest “pilonidal dimple”. May be pilonidal sinus [opening]; represents possible spina bifida occulta.

Tuft of hair present @ base of spine = Nevus pilosus.

Anus & Rectum: Assess rectal patency [NBN] with 1st temp; lubricated thermometer. If rectum not patent, called imperforate anus

Routine Exam of Newborn – Vital Signs

Vital Signs: admission NBN & q shift. Temperature (ax 97.7 – 98.6 º F) Initial rectal. Heart Rate: 110 –160 bpm. Femoral, radial, brachial pulses can be palpated;. Apical pulse

used for HR; auscultate 1 min Respiratory Rate: 40-60 min. Initial rate 80 /min. BP ~ 80/46 mmHg @ birth. By 10th day, 100/50. Daily: Weight: 2,500-4,000 gm (5 lb 8oz - 8 lb 13 oz); compare with

previous day. 5-10 % weight loss acceptable Assess feedings daily. # voids/stools in 24 hrs. Done once on admission to nursery: Length: 45-55 cm = 18-22 in Head: slightly larger than chest; 13-14 in.= 33-35 cm Chest: 12-13 in. = 31- 33 cm

SENSORY BEHAVIORS OF THE NEWBORN

Tactile

Olfactory

Vision (see black & white best)

Auditory

Taste

REFLEXES

Sucking – place finger in mouth; infant sucks right away. Moro – [“startle reflex”] elicit by loud noise; infant

extends arms & legs suddenly. Rooting – touch cheek; turns head in direction of touch. Babinski – stroke sole of foot from top to

bottom; toes fan out. Grasping – place finger in newborn’s hand;

grabs & hold. Stepping – hold infant upright w. feet on

surface; stepping movements

Behaviors – Sleep/Awake

Predictable Behaviors: 1st 4 hours > delivery: 1st period of reactivity: alert, active state; awake, crying,

sucking. Then Sleep phase 4-6 hrs. 2nd period of reactivity 2-3 hrs. Sleep/awake during day.Sleep States 1. Deep Sleep 2. Light Sleep

Awake States Drowsy; Quiet Alert – best time for breast feeding/bonding Active Alert; Crying

Behaviors

Brazelton Neonatal Behavioral Assessment Scale:

Scale developed in 1970’s to evaluate newborn’s behavior to stimuli

Assesses motor maturity & social behavior. Takes ~ 30 min to do

Ballard Assessment scale: developed 1970’s to assess gestational maturity; takes 2-3 minutes to do.

Assesses physical & neuromuscular maturity. Useful in differentiating between SGA infant & miscalculated due date

SGA infant is mature gestationally. Full term infant gets score of ~ 3.3 in each category. Compare

infants in NICU to those in NBN.

Nutrition in Newborn

Bonding process reinforced during feeding – w. breast & bottle. Approx. 64% of women breast feed in early post partum period 29 % still nursing @ 6 months; 16% still nursing @ 1 year. Growth & caloric requirements during neonatal period & early

infancy are faster than any other period of life. Newborns can lose up to 5-10% of birth weight while waiting for

breast milk to come in. Colostrum rich in antibodies but has less calories than breast milk. Breast milk has no allergies.

Education

Teach mom: ^ calories by 500/day ^ fluids by 8 glasses/day Well balanced diet; omit caffeine/alcohol. Breast feed q2-3 hrs./day; Bottle feed q 3-4 hrs./day Avoid fish containing mercury. Teach positions for breast feeding; football hold for C/S. Any position OK as long as baby has nipple & areola; infant can

breathe. Find comfortable position; Use pillows - free up hands.

Nutrition in NewbornDaily Requirements: Calories: body maintenance & growth.Birth to 2 months of age: require 110-120 calories/kg/24 hrs. Up to 6 months, require 108 cal/kg/24 hrs. 6 mos. to 1 yr. require 98 cal//kg/24 hrs. Protein: needed to form new cells; important for rapid growth. Up to 2 months, 2.2 g/kg/24hrs required. 6mos.-1yr. 1.6g/kg req. Fluid: 150-200 mL/kg/24 hrs 75% of NB body composed of water Fluids: Need 65 ml/kg [30 ml/lb] daily 1st 2 days of life then 100-

150 ml/kg [45-68 ml/lb/day] afterwards. Voids: 1st few days 2-6 voids/day; > 2-3 days: 6 or more voids.

Nutrition in Newborn

Fat: [Linoleic acid] found in both breast milk & formulas

Carbohydrates: Lactose most easily digested of carbohydrate group. Helps to reduce GI illness in newborns by producing stool with gram + bacteria instead of gram negative bacteria. Rare to have infant with lactose intolerance

Iron: Found in breast milk & added to commercial formulas

Flouride: Not found in breast milk or formula; need supplement starting @ 6 mos. if not found in drinking water

Calcium: needed for bone growth

Vitamins: Start supplement @ 6 months of age

ADVANTAGES OF BREAST FEEDING

Helps with uterine involution. May help prevent breast cancer. Empowering effect on mother; ↑ self esteem. Provides more

frequent close contact Inexpensive. Complete nutrition for baby. Provides extension of

immunity for up to 6 mos. Colostrum IgA [immunoglobulin] which binds to bacteria & viruses; proteins/enzymes destroy bacteria. Macrophages produce interferon - interfere with virus growth.

Disadvantages of Breast Feeding: Father feels left out. Sore nipples. Painful engorgement. More frequent feeding required so less time with other children.

Embarrassment R/T feeding in public. Mastitis. Infections: Hepatitis B & HIV can pass thru milk.

ADVANTAGES OF BOTTLE FEEDING

^^ freedom d/t less frequent feedings; infant sleeps longer periods.

No sore nipples. No worry over breast feeding in public or pumping at work. Father can feed infant frequently. Frees up mom with older children.

Disadvantages of Bottle Feeding More expensive; infant may not tolerate formula May have to try different formulas before finding right one More prep time; more shopping time. ^ waste: discard unused portion > 1 hr. [^bacteria]. No transfer of passive immunity.

General Care of Infant

Bathing q day; Teach parents: sponge bathe daily before cord falls off and tub bath > cord falls off & healed. Mild soap Positioning & holding – lay infant on back to sleep; Hold upright to feed formula & burp. Teach breast feeding positions: cradle hold, side lying, & football hold.Vaseline to buttocks w. diapering. Record stools/voids. VS q shift . Teach parents to take temp. if 100.0 R*call MD!Stools: Meconium: very dk. green/almost black, sticky. Transitional stool: yellow/green [> meconium] Breast fed stool: yellow seedy w. sweet odor. Formula fed stool: green/yellow.

Adaptation to Extrauterine Life

Adaptation to Extrauterine Life

Cardiovascular: NB must initiate respirations & sustain extrauterine oxygenation

When born, infant forced to take in oxygen thru lungs. Shunts close & vessels clot off & regress

Respiratory: First breath also in response to temperature & pressure changes, light & noise.

1st breath requires great amt.of pressure; 40-70 cm H2O. Small amt of fluid present in lungs.

1/3 rd of this fluid forced out by pressure of vaginal birth; rest absorbed by lung tissue. C/S infants may need more suctioning & oxygen therapy.

Adaptation to Extrauterine Life

Renal: Renal function does not fully mature until > 1st yr. 1st void occurs within 1st 24 hrs.

No urine for 36 hrs. needs further eval. for obstruction or absent kidneys.

1st voiding may be dk.pink/red d/t uric acid crystals. Disappears 1st few days as kidneys mature. Alarming to parents; harmless

finding. Gastrointestinal: GI tract sterile @ birth; bacteria enters GI tract

thru mouth within 24 hrs.of life. Bacteria needed for prod. Vit.K

Infant: limited ability to digest fats & starches Meconium passed 1st 24-48 hrs. of life By 2nd - 3rd day, transitional stool passed

Thermogenesis

Brown fat : helps conserve body heat; produces heat.

Found in upper chest, back of neck, around abdomen.

Is deposited in 2nd trimester; Helps regulate body temp>delivery.

Radiant warmer - helps regulates body temp. by conserving heat.Newborns can produce sufficient heat in optimal thermal Environment if warm enough. Rapid heat loss occurs in suboptimal environment [cooler]. Infants do not shiver; can go into cold stress quickly. Uses up extra glucose & oxygen to thermoregulate. Leads to: metabolic acidosis; respiratory distress Hypoglycemia; Jaundice; decreased surfactant production

Thermogenesis

Infants Lose heat in 4 ways: Convection Evaporation Conduction Radiation

IMMUNOLOGIC: Newborn still prone to infection, handwashing important! IgG: Infant born with passive immunity from mom. Fetus makes

own starting @ 20 wks IgM too large to cross; makes own after delivery. IgA do not cross placenta. Produced by infant > birth @ 6-12

wks. Found in breast milk.

Labs Hemoglobin: 15-20 g/dl.; Hct: 43-61% Blood volume: 80-110 ml/kg. or 300 ml. WBC: 10-30,000 mm Glucose 45-60 mg/dl - heel stick < 45 & feed with ½ oz formula.

Repeat within hour. Send serum blood glucose as per protocol.

JAUNDICE: Breast Fed Jaundice: 1 out of 3 breast feeding infants. Most

common cause: insufficient intake - 1st week of life. Bili can reach 12mg/dl. Theory: Enzymes in breast milk thought to interfere with conjugation process.

Feed @ least 8-10 feedings in 24 hrs. Teach moms: ^^ their own po fluids Kernicterus rare with breast fed jaundice