Care of the newborn

							CARE OF THE NEWBORN

Prepared by: Prof. Jeremiah eco rn

st 1

24 hours
of Life

The

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

Immediate Care of the Newborn

• Airway • Breathing • Temperature

Airway & Breathing
• Suction gently & quickly using bulb syringe or suction catheter • Starts in the mouth then, the nose to prevent aspiration

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Airway & Breathing
• Stimulate crying by rubbing • Position properly- side lying / modified t-berg • Provide oxygen when necessary

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

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APGAR Scoring
• • • Standardized evaluation of the newborn Perform 1 minute and 5 minutes after birth Involves (5) indicators:
1. 2. 3. 4. 5.
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Activity Pulse Grimace Appearance Respirations
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Care of the Newborn in the Nursery

Components
• • • • • • • • • Anthropometric Measurements Bathing – Oil bath/ warm water bath Cord Care Dressing/ Wrapping - mummified Eye prophylaxis – Crede’s Foot printing / Identification Get APGAR score – 1 & 5 mins HR, RR, Temp, BP Injection of Vitamin K
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Components
1. 2. 3. 4. Proper identification –tag/bracelet Oil bath/ Warm water bath Cord Care/ Dressing Measurements 1. Weight 2. Anthropometric measurements
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6. Crede’s Prophylaxis 7. Vitamin K Administration 8. Foot printing/ marking 9. Vital signs 10.Dressing/ wrapping

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Proper Identification
• After delivery, gender should be determined • Pertinent records should be completed including the ID bracelet • Before transferring to nursery, ID tag should be applied.
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Bathing
• Oil bath or complete warm water bath • From cleanest to dirties part • DO NOT remove vernix caseosa vigorously

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Cord Care

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Weight/ Anthropometric Measurements

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Crede’s Prophylaxis

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Vitamin K Administration

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Foot Printing

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Vital Signs

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Dressing/ Wrapping
• “Mummy” • Wrap in warm blanket • Cover head with stockinette cap

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Daily Care
Nutrition/ Feeding Elimination Weight Bathing & Hygiene/ Grooming 5. Obtain vital signs 6. Rooming-in 7. Note for any abnormalities
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1. 2. 3. 4.

NEWBORN ASSESSMENT
Assessment of the newborn is essential to ensure a successful transition

Major Time Frames
1. Immediately after birth 2. Within the 1st 4 hours after birth 3. Prior to discharge

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APGAR Scoring System
A P G A R ctivity/ Muscle Tone ulse/ Heart Rate rimace/ Reflex Irritability/ Responsiveness ppearance/ Skin Color espiration/ Breathing
2 3
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5

INDICATORS
Activity

2
Active, spontaneous >100 bpm

1
Some flexion of extremities < 100 bpm

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

Pulse
Grimace Appearance Respiration
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Pulls away, Facial grimace sneezes, coughs only Completely pink Good vigorous cry Acrocyanosis Slow, irregular Weak cry

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Score 7 to 10 4 to 6

Interpretation
Well baby At risk

Nursing Interventions
Rarely needs resuscitation

Requires resuscitation Suction Dry immediately Ventilate until stable Careful observation
Intensive resuscitation ET/ Ambu bag Ventilate with 100% O2 CPR Maintain body temperature Parental support
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0 to 3

Sick baby

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

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GENERAL APPEARANCE

Posture
• Full term: – Symmetric – Face turned to side – Flexed extremities – Hands tightly fisted with thumb covered by the fingers
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Special Concerns
• Asymmetric – Fractured clavicle or humerus – Nerve injuries (Erb-Duchenne’s Paralysis) • Breech Presentation – Knees and legs straightened or in FROG position
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VITAL SIGNS

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

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Pulse
• • • • • • Awake: 120 – 160 bpm Asleep: 100 bpm Crying: 180 bpm Rhythm: irregular Duration: 1 full minute, not crying Site: Apical
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Nursing Considerations
• • • • • • Keep warm Take HR for 1 full minute Listen for murmurs Palpate peripheral pulses Assess for cyanosis Observe for CP distress
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Special Concerns
• (+) Prominent radial pulse = CHD • (-) Femoral pulse = Coarctation of aorta

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Respiration
• Characteristics: Nasal breathers, gentle, quiet, rapid BUT shallow; may have short periods of apnea (<15 secs) • Rate: 30-60 cpm • Duration: 1 full minute

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

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Silverman-Anderson Index
• Perform to observe for signs of respiratory distress – Chest lag – Retractions – Nasal flaring – Expiratory grunting
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Silverman Scoring System
0

1

2
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Score Interpretation
Score
0-3 4-6 7-10

Interpretation
No RDS

Moderate RDS
Severe RDS

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Blood Pressure
• NOT routinely measured UNLESS in distress or CHD is suspected • At birth: 80/46 mmHg* • After birth: 65/41 mmHg* • Using Doppler UTZ

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ANTHROPOMETRIC MESUREMENTS

Body Measurements
• Weight: – 5.5 to 9.5 lbs (2500-4300 gms) • Caucasian: 7 lbs • Filipinos: 6.5 lbs – 70-75% TBW is water – LBW = below 2500 gms; regardless of AOG
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• Length: – 45 to 55 cm (18-22 inches) – Average: 50 cm – Techniques: using tape measure • Supine with legs extended –Crown to rump –Head to heel
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• Head Circumference (HC): – 33 to 35.5 cm (13-14 inches) – Technique: using tape measure • From the most prominent part of the OCCIPUT to just above the EYEBROWS

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– 1/3 the size of an adult’s head – Disproportionately LARGE for its body – HC should be = or 2cm > CC

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• Chest Circumference (CC): – 30 to 33 cm (12-13 inches) – Technique: using tape measure • From the lower edge of the SCAPULAS to directly over the NIPPLE LINE anteriorly – CC should be = or < 2 cm than HC

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SKIN

Nursing Considerations
• Under natural light • Assess for: –Color –Hair distribution –Turgor/ Texture –Pigmentation/ Birthmarks –Other skin marks
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Skin Color
• Velvety smooth and puffy esp. at the legs, dorsal aspects of hands & feet and in the scrotum or labia • Pinkish red (light skinned) to pinkish brown to yellow (dark skinned) • “Ruddy” or reddish due to increased RBC concentration and decreased subQ tissues
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Skin Color
• • • • Cyanosis/ Acrocyanosis Pallor Jaundice Meconium Staining

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Acrocyanosis
• Bluish discoloration of palms of hands & soles of feet • Due to immature peripheral circulation • Exacerbated by cold temperatures • Normal within 1st 24 hrs
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Pallor/ Cyanosis
• May indicate hypothermia, infection, anemia, hypoglycemia, cardiac, respiratory or neurological problems

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

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• Physiologic – FT: after the 1st 24 hrs (2-7 days) – PT:after the 1st 48 hrs – Peaks at 5-7 days & disappears by the 2nd week – Due to immaturity of liver – Usually found over the face, upper body and conjunctiva of eyes
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• Pathologic – Within 1st 24 hrs – May indicate early hemolysis of RBC or underlying disease process – Duration: • FT: 1 wk • PT: 2 wks
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Management of Jaundice
• Monitoring serum bilirubin levels – Physiologic: not more than 5 mg/dl per day – Pathologic: more than 15-20 mg/dl (critical levels) • Maintain hydration • Place in bilirubin lights as needed • Provide emotional support to parents
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Meconium Staining
• Over the skin, fingernails & umbilical cord • Due to passage of meconium in utero r/t fetal hypoxia

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Lanugo
• Found after 20 weeks of gestation on the entire body except the palms & soles • Fine downy hair that covers the shoulders, back & upper arms

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Nursing Considerations:
• More mature, less lanugo • May disappear within 2 weeks • Preterm: woolly patches of lanugo on skin and head • Post term: parchment-like skin w/o lanugo

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Vernix Caseosa
• Protective cheesy-like, gray-white fatty substance • FT: skin folds under the arms and in the groin under the scrotum or in the labia • Nursing Considerations: – Use baby oil – DO NOT attempt to remove vigorously 051104 Neonatal Care

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

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Milia
• Multiple, yellow or pearly white papules approx. 1 mm wide • Due to enlarged or clogged sebaceous gland • Usually found on the nose, chin, cheeks, eyebrows and forehead
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Birthmarks

Mongolian Spots
• Blue-green or gray pigmentation • Lower back, sacrum & buttocks • Disappears by 4 years of age

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Stork bites
• Telangiectatic Nevi • Flat red or purple lesions • Back of neck, lower occiput, upper eyelid and bridge of the nose • After 2 years of age
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Strawberry marks
• Nevus Vasculosus or Capillary Hemangioma • Dark red, raised lobulated tumor • Head, neck trunk & extremities • After 7 to 9 years of age
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Port-wine stain
• Nevus Flammeus or Capillary Angioma • Flat Red to purple, sharply demarcated dense areas beneath the capillaries • Face • Does not fade with time
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Other Skin Marks

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

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Erythema toxicum
• Newborn rash • Small, white, yellow, or pink to red papular rash • Trunk, face & extremities • Within 48 hrs
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Petechiae
• Pinpoint hemorrhages on skin • Due to increased vascular pressure, infection or thrombocytopenia • Within 48 hrs
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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
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Harlequin Sign
• When on side, dependent side turns red and upper side/ half turns pale • Due to gravity and vasomotor instability or immature circulation • Skin resembles a CLOWN’S SUIT
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Café-au-lait spots
• Tan or light brown macules or patches • NO pathologic significance, if <3cm in length and <6 in number • If > 3 or 6 = Cutaneous neurofibromatosis

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HEAD

What to assess
• For symmetry, shape, swelling, movement –Soft, pliable, moves easily –With some molding (if VSD); round & well-shaped (if CS) • Measure HC; HC = or > CC
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• Fontanelles “soft spot” –BAD (12-18 mos) –LPT (2-3 mos or 8-12 wks) –Bulging or sunken • Sutures –Overriding or separated
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• Head lag – Common when pulling newborn to a sitting position – When prone, NB should be able to lift the head slightly and turn head from side to side

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Caput Succeedanum
• Swelling of soft tissues of the scalp • Due to pressure • Crosses the suture lines • Presenting part • 3 days after birth
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Cephalhematoma
• Subperiosteal hemorrhage with collection blood • Due to rupture of capillaries as a result of trauma • Does not crossed suture lines • Several weeks
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Molding
• Overlapping of skull bones • Due to compression during labor and delivery • Disappears in few days
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Forcep Marks
• U –shaped bruising usually on the cheeks after forcep delivery

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

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Craniosynostosis
• Premature closure of the fontanelles

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Face/Eyes/Ears/ Nose /Mouth

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

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Eyes
• Color: – white sclera – Slate gray, brown or dark blue – Final eye color: after 6-12 months • Symmetrical • Pupils equal, round, reactive to light • (+) Blink reflex
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• (+) transient strabismus due to weak EOM • Able to move and fixate momentarily • (+) Red reflex – if (-), cataract • (+) Edema on eyelids r/t pressure during delivery or effects of medication • (-) Tear formation (begins @ 2-3 mos)
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Nursing Considerations
• Administer eye medication within 1 hr after birth to prevent Opthalmia neonatorum • DOC: Erythromycin 0.5% Tetracycline 1% Silver Nitrate 1% • From inner to outer canthus of the eye (conjunctival sac)
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Nose
• • • • • • • Small & narrow Flattened, midline Nasal breathers (+) Periodic sneezing Reactive to strong odors (+) Flaring = respiratory distress (+) Low nasal bridge = Down’s syndrome
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Ears
• Soft and pliable; with firm cartilage Pinna should be at the level of outer canthus of the eye • (+) Low set ears = renal or chromosomal abnormalities • May be congested and hear well after few days
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Mouth
• Pink, moist gums • Intact soft & hard palates – (+) Eipstein’s pearls • Uvula midline • Tongue moves freely, symmetrical with short frenulum • (+) Extrusion & Gag reflexes
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• Small mouth or large tongue = chromosomal problems • (+) white patches on tongue or side of the cheek = Oral thrush

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Neck
• Short, thick, in midline • Able to flex and extend but cannot support the full weight of head • Creased with skin folds • Trachea midline • Thyroid gland not palpable • Intact clavicle
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Chest
• • • • CC = or < 2cm than HC Cylindrical; equal AP:T diameters Symmetrical Abdominal breathers

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• (+) Bronchial sounds • (+) Breast engorgement ; subsides after 2 wks • (+)Prominent/ edematous nipple • (+) Accessory nipples • (+) “Witch Milk”
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Abdomen
• Umbilical Cord – 2 arteries; 1 vein – White & gelatinous immediately after birth – Begins to DRY between 1-2 hrs following birth – Blackened or shriveled between 2-3 days – Dried & gradually falls off by 7 days
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Daily Cord Care
• Keep cord dry and clean & clamp secured • Apply 70% isopropyl alcohol to the cord with each diaper change and at least 2-3x a day. • DO NOT cover with diaper • Note for any signs of bleeding or drainage from the cord and other abnormalities • Sponge bath until cord falls off.
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• GIT: – Capacity: 90 ml, with rapid intestinal peristalsis ( 2 ½ to 3 hrs) – Bowels sounds; (+) within 1-2 hrs after birth – Presence of mass, distention depression or protrusion – (+) Scaphoid = diaphragmatic hernia – (+) Distended = LGIT obstruction/ mass
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• Anus – Check patency – First stool (Meconium) – within 1st 24 hrs • Sticky, tarlike, blackish-green, odorless material

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Transitional Stool
• Within 2- 10 days after birth • Breastfed: – golden yellow, mushy, more frequent 3-4x and sweet smelling • Bottlefed: – Pale yello, firm, less frequent 2-3x, with more noticeable odor
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Genitals
• Female: – Labia: edematous – Clitoris: enlarged – (+) Smegma – Pseudomenstruation possible – Visible “hymen tag” – First voiding within 24 hrs
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Nursing Considerations
• Breastfeeding can usually begin immediately after birth • Bottlefeeding may be started with sterile water to 4 hrs after birth prior to formula feeding • Burp during and after feeding • Position properly during and after feeding
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• Male: – Prepuce covers glans penis • (+) adherent foreskin = Phimosis – Scrotum: edematous • (+) enlarged = Hernia – Meatus: central • (+) ventral/ dorsal = Hypo/epispadias – Testes: descended • (+) undescended = Cryptorchidism
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•

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Back
• Spine – Straight, posture flexed – Supports head momentarily – Arms & legs flexed – Chin flexed on upper chest – Check for protrusion, excessive or poor muscle contractions = CNS damage
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Extremities
• Flexed, full ROM, symmetrical • Clenched fists; flat soles • With 10 fingers and toes in each hand • Legs bowed • Even gluteal folds
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• (+) Creases on soles of feet – (-) Creases = prematurity • Check for hip fractures or dysplasia – (+) Ortolani’s click & uneven gluteal folds = Hip dysplasia

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

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• (+) extra digits = Polydactyly • (+) web fingers = Syndactyly

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