Immediate Care of Newborns

• Fontanelles:

  • Anterior fontanelle = junction of the two parietal bones (diamond)
  • Posterior fontanelle = junction of the parietal and occipital bones (triangular)
  • Should neither be sunken nor bulging and tense
• ADVANTAGES OF BREASTFEEDING FOR INFANTS:

  • Breast milk contains secretory immunoglobulin (IgA) that binds foreign proteins
  • Lactoferrin interferes with the growth of pathogenic bacteria
  • Lysozyme actively destroys bacteria in breast milk
  • Leukocytes provide protection against respiratory infections
  • Macrophages produce interferon to interfere with virus growth
  • Bifidus factor promotes beneficial bacteria growth and reduces diarrhea incidence
• Goals of the immediate care of the newborn:

  • Establish, maintain, and support respiration
  • Provide warmth and prevent hypothermia
  • Ensure safety and prevent injury and infection
  • Identify actual or potential problems that may require immediate attention
• • A score between 4-6 indicates moderate distress
  • A score between 7-10 indicates severe distress
• Initial assessment for well-being:

  A. APGAR Scoring:

  • Stands for: Appearance, Pulse, Grimace, Activity, Respiration
  • Newborns are observed and rated at 1 minute and 5 minutes after birth
  • A score of 0-3 indicates a severely depressed infant in need of resuscitation
  • A score of 4-6 indicates a moderately depressed infant needing airway clearance
  • A score of 7-10 indicates good adjustment and vigor

  B. Silverman and Andersen Scoring:

  • Used to estimate degrees of respiratory distress in newborns
  • CIXNE: Chest Movement, Intercostal Retraction, Xiohoid Retraction, Nasal Dilatation, Expiratory Grunt
• Profile of a newborn:

  A. Vital Statistics:

  • Weight: Lower limit of normal is 2.5 kg (5.5 lb)
  • Length: Lower limit of normal length is 46 cm (18 in)
  • Head circumference: Usually 34 to 35 cm (13.5 to 14 in)
  • Chest circumference: About 2 cm (0.75 to 1 in) less than head circumference

  B. Vital Signs:

  • Temperature: Falls to below normal immediately after birth due to heat loss
  • Pulse: Heart rate averages 120 to 160 bpm in utero, stabilizes to 120 to 140 bpm after birth
  • Respiration: Rate settles to 30 to 60 bpm at rest, irregular depth, rate, and rhythm
• • Blood pressure: Approximately 80/46 mmHg at birth, rises to about 100/50 mmHg by the 10th day
• • Blood coagulation: Newborns have lower-than-normal level of vitamin K, prolonged coagulation time
• Physiologic function:

  A. Cardiovascular System:

  • Lungs oxygenate blood formerly oxygenated by the placenta
  • Closure of ductus arteriosus promoted by pressure decrease in pulmonary artery
  • Foramen ovale closes due to pressure against the lip of the structure
  • Blood volume: 80 to 110 mL per kilogram of body weight
  • Hemoglobin level: 17 to 18 g/100 mL of blood
  • Hematocrit: 45% to 50%
  • Bilirubin: Indirect bilirubin level at birth is 1 to 4 mg/100 mL
  • White blood cells: 15,000 to 30,000 cells/mm3 (leukocytosis)
• Respiratory System:

  • First breath requires a tremendous amount of pressure
  • All newborns have fluid in their lungs from intrauterine life
  • Breathing becomes easier after alveoli inflation with first breath
  • Newborns may have difficulty establishing effective respirations if alveoli do not open well
  • GI tract is usually sterile at birth, but bacteria may be cultured within hours after birth
  • First stool usually passed within 24 hours after birth, consists of meconium
• Newborn stool changes:

  • Within 24 hours after birth, consists of meconium
  • Meconium is a sticky, tarlike, blackish-green, odorless material formed from mucus, vernix, lanugo, hormones, and carbohydrates accumulated during intrauterine life
  • If a newborn does not pass meconium stool by 24 to 48 hours after birth, suspect factors like meconium ileus, imperforate anus, or volvulus
  • Transitional stool appears on the second or third day of life, green and loose
  • Breastfed babies by the fourth day pass three or four light yellow, sweet-smelling stools per day
• • Formula-fed newborns pass two or three bright yellow stools per day, with a slightly more noticeable odor compared to breastfed babies
  • Newborns under phototherapy lights for jaundice have bright green stools due to increased bilirubin excretion
  • Newborns with bile duct obstruction have clay-colored (gray) stools due to bile pigments not entering the intestinal tract
  • Blood-flecked stools indicate an anal fissure
  • Swallowed maternal blood during birth may lead to vomiting fresh blood immediately after birth or passing a black tarry stool after 2 or more days
• • First voiding may be pink or dusky due to uric acid crystals formed in the bladder in utero
  • Small amount of protein may be present in voidings for the first few days until kidney glomeruli are more fully mature
• Urinary system in newborns:

  • Average newborn voids within 24 hours after birth
  • Newborns who do not void within this time should be examined for urethral stenosis, absent kidneys, or ureters
  • Force of urinary stream can indicate obstruction
  • Breast milk high in lactic acid reduces putrefactive organisms in stool
  • Newborn urine is usually light-colored and odorless due to kidneys not concentrating urine well
  • Daily urinary output for the first 1 or 2 days is about 30 to 60 mL total
  • By week 1, total daily volume rises to about 300 mL
• Autoimmune system in newborns:

  • Difficulty forming antibodies against invading antigens until about 2 months of age
  • Newborns have passive antibodies (IgG) from their mother against diseases like poliomyelitis, measles, diphtheria, pertussis, chickenpox, rubella, and tetanus
  • Hepatitis B vaccine is routinely administered during the first 12 hours after birth
  • Little natural immunity is transmitted against herpes simplex
  • Health care personnel with herpes simplex eruptions should not care for newborns until lesions have crusted
• Neuromuscular system in newborns:

  • Mature newborns demonstrate neuromuscular function by moving extremities, attempting to control head movement, exhibiting a strong cry, and demonstrating reflexes
  • Limpness or absence of a muscular response suggests narcosis, shock, or cerebral injury
  • Reflexes include blink, rooting, sucking, swallowing, extrusion, palmar grasp, step-walk-in-place, placing, plantar grasp, tonic neck, Moro, Babinski, magnet, crossed extension, trunk incurvation, and Landau reflexes
• Senses in newborns:

  • Hearing: A fetus can hear in utero, and hearing becomes acute within hours after birth
  • Vision: Newborns see at birth and possibly have been "seeing" light and dark in utero
  • Touch: Well-developed at birth, demonstrated by quieting at a soothing touch and reacting to painful stimuli
  • Taste: Newborns can discriminate taste, turning away from bitter tastes and accepting sweet tastes
  • Smell: Present as soon as the nose is clear of lung and amniotic fluid, used to document alertness
• Physiologic adjustment to extrauterine life:

  • Newborns move through periods of irregular adjustment in the first 6 hours of life before body systems stabilize
  • Periods of reactivity described by Desmond in 1963
  • First phase lasts about half an hour with exploring, searching activity and rapid heartbeat and respiratory rate
  • Quiet resting period follows with slowed rates and sleep for about 90 minutes
  • Second period of reactivity occurs between 2 and 6 hours of life, with the baby waking again, often gagging and choking on accumulated mucus
• Appearance of the newborn:

  • Skin color: Most term newborns have a ruddy complexion due to increased RBC concentration in blood vessels and decreased subcutaneous fat
  • Infants with poor CNS control may appear pale
• Infants with poor CNS control may appear pale and cyanotic
• Gray color in newborns generally indicates infection
• Cyanosis: generalized mottling of the skin is common
• A newborn’s lips, hands, and feet are likely to appear blue from immature peripheral circulation
• Acrocyanosis: blueness of extremities

  • Prominent in some newborns
  • Appears as if some stricture were cutting off circulation, with usual skin color on one side and blue on the other
  • Normal phenomenon in the first 24 to 48 hours after birth
• Central cyanosis: cyanosis of the trunk

  • Indicates decreased oxygenation, result from a temporary respiratory obstruction or an underlying disease state
• Always suction the mouth of a newborn before the nose to prevent reflex gasp and possible aspiration
• Hyperbilirubinemia leads to jaundice

  • Occurs on the second or third day of life in about 50% of all newborns, due to breakdown of fetal RBCs (physiologic jaundice)
  • High RBC count built up in utero is destroyed, releasing heme and globin
  • Heme is further broken down into iron and protoporphyrin
  • Protoporphyrin is further broken down into indirect bilirubin
  • Indirect bilirubin is fat soluble and cannot be excreted by the kidneys
  • Converted by the liver enzyme glucuronyl transferase into direct bilirubin for excretion
• Many newborns have immature liver function that prevents conversion of indirect bilirubin to direct form

  • Buildup of indirect bilirubin in the circulatory system causes jaundice
• Observe infants prone to extensive bruising carefully for jaundice
• Cephalhematoma: collection of blood under the periosteum of the skull

  • Bruising in these locations can release additional indirect bilirubin, causing jaundice
• Early feeding of newborns promotes intestinal movement and excretion of meconium, preventing indirect bilirubin buildup
• Phototherapy: exposure of the infant to light to initiate maturation of liver enzymes
• Compared with formula-fed babies, a small proportion of breastfed babies may have difficulty converting indirect bilirubin to direct bilirubin
• Pallor: result of anemia, caused by various factors including excessive blood loss at birth, inadequate blood flow, low iron stores, and blood incompatibility
• Harlequin Sign: newborn lying on the side appears red on the dependent side and pale on the upper side
• Hemangiomas: vascular tumors of the skin

  • Nevus flammeus: macular purple or dark-red lesion present at birth
  • Strawberry hemangioma: elevated areas formed by immature capillaries and endothelial cells
  • Cavernous hemangioma: dilated vascular spaces that do not disappear and may require surgical removal
• Mongolian Spots: collections of melanocytes that appear as slate-gray patches across the sacrum or buttocks
• Vernix Caseosa: white, cream cheese-like substance that serves as a skin lubricant in utero
• Lanugo: fine, downy hair covering a newborn's shoulders, back, upper arms, forehead, and ears
• Desquamation: peeling of dry skin within 24 hours after birth, especially on the palms and soles