IMMEDIATE CARE OF THE NEWBORN GOALS
To establish, maintain and support respirations. To provide warmth and prevent hypothermia To ensure safety, prevent injury and infection. To identify actual or potential problems that may require immediate attention. To promote maternal and child bonding
ESTABLISHING, ESTABLISHING, MAINTAINING, MAINTAINING, and SUPPORTING RESPIRATIONS RESPIRATIONS
The most important need for the newborn immediately after birth is a clear airway to enable the newborn to breathe effectively since the placenta has ceased to function as an organ of gas exchange.
It is in the maintenance of adequate oxygen supply through effective respiration that the survival of the newborn greatly depends.
To establish and maintain respirations:
Wipe mouth and nose of secretions after delivery of the head. Suction secretions from mouth and nose. Compress bulb syringe before inserting it. Suction mouth first, then, the nose. Insert bulb syringe in one side of the mouth. A crying infant is a breathing breathing infant. infant. Stimulate the baby to cry if baby does not cry spontaneously, or if the cry is weak. Do not slap the buttocks, rather rub the soles of the feet. Stimulate to cry after secretions are removed. The normal normal infant infant cry is loud loud and lusty . Obse Observe rve for the follow following ing abnormal cry: cry – indicates hypoglycemia, increased intracranial pressure. High-pitched cry – cry – prematurity Weak cry – cry – laryngeal stridor Hoarse cry –
Oral mucous may cause the newborn, to choke, cough or gag during the first 12 to 18 hours of life. Place the infant in a position that would promote drainage of secretions.
Trendelenburg position – position – head lower than the body
Side lying position – If trendelenburg position is contraindicated, place infant in side lying position to permit drainage of mucus from the mouth. Place a small pillow or rolled towel at the back to prevent newborn from rolling back to supine position.
Keep the nares patent. Remove mucus and other particles that may be cause obstruction. Newborns are obligatory nose breathers until they are about 3 weeks old.
Give Give oxyg oxygen en as neces necessa sary ry.. Ox Oxyg ygen en shoul should d be given given when when the the infant infant rema remains ins cyanotic after initial suctioning and stimulation.
If the heart rate is below 60 BPM, cardiac massage may need to be carried out.
PROVIDE WARMTH AND PREVENT HYPOTHERMIA
Immediately after delivery, the baby should be dried. Newborn hypothermia can occur quickly and depress breathing .
It is very important to keep the newborn warm. This can be accomplished by covering the baby with clothing as soon as it is dried.
Pay particular attention to keeping the head covered (but the airway open) as heat loss from the newborn head can be substantial.
Typically, the baby is wrapped in warm, soft blankets and a head covering put in place. Ideally, the newborn should be placed under a droplight if his temperature is below 36.5ºC.
In sub-optimal circumstances, nearly any cloth material can be used keep the baby warm.
If the mother is available, dry the baby, place the baby on the mother's chest, and cover both of them with blankets or clothing . The mother's body heat will help keep the baby warm.
Check the baby's temperature several times during the first few hours of life. The normal range of newborn axillary temperature is about 36.5-37.4ºC (97.7-99.3F). Average newborn temperature is around 37.2ºC.
Newborns loss about 2 to 3 Degrees Celsius of heat because the external environment is much cooler than the temperature inside the mother’s womb.
Such heat loss occurs primarily by way of the neonate’s wet head and the cold temperature in the delivery room.
Newborns also tend to take on the temperature of their environment; this means that the newborn can become hypothermic or hyperthermic easily depending on the temperature of their environment.
Delay the initial bath of the baby until 6 hours after delivery to avoid hypothermia. Maintain ambient temperature in the nursery at 24ºC.
Exposure to cold environment can cause cold stress (hypothermia) which can further lead to metabolic acidosis, a potentially lethal complication even to normal newborns.
Hypothermia occurs when the body temperature falls below 36ºC. The newborn is most sensitive to hypothermia during the first 6-12 hours of his life.
INITIAL ASSESSMENT AND APGAR SCORING
The APGAR Scoring System was developed by Dr. Virginia Apgar as a method of assessing the newborn’s adjustment to extrauterine life.
It is taken at one minute and five minutes after birth. With depressed infants, repeat the scoring every five minutes as needed.
The one minute score indicates the necessity for resuscitation. The five minute score is more reliable in predicting mortality and neurologic deficits.
The most important is the heart rate, and then the respiratory rate, the muscle tone, reflex irritability and color follows in decreasing order.
The heart rate and respirations should be counted for one full minute because of the irregularities of the rhythms.
A heart rate below 100 signifies an asphyxiated baby and a heart rate above 160 signifies distress. ASSESS
0
SCORE 1
2
HEART RATE (Pulse) RESPIRATION
Absent
Below 100
Above 100
Absent
Slow
Good crying
MUCLE TONE (Activity) REFLEX IRRITABILITY (Grimace) COLOR (Appearance)
Flaccid
Some flexion
Active motion
No response
Grimace
Vigorous cry
Blue all over
Body pink, Extremities blue (acrocyanosis)
Pink all over
Score:
7 – 10 : Good adjustment, vigorous 4 – 6 : Moderately depressed infant, needs airway clearance 0 – 3 : Severely depressed infant, in need of resuscitation.
Acrocyanosis is normal for a newborn during the first few hours , disappearing over the next day. It is due to relatively sluggish circulation of blood through the peripheral structures, related to immaturity or inexperience of the newborn blood flow regulatory systems.
Central cyanosis is not normal and indicates the need for treatment . It is due to the accumulation of desaturated (oxygen-depleted) hemoglobin.
PREVENTION OF INFECTION
Care of the Eyes: Crede’s Prophylaxis It is part of the routine care of the newborn to give prophylactic eye treatment against gonorrheal conjunctivitis or opthalmia neonatorum . Neisseria gonorrhea, the causative agent, may be passed on the fetus from the vaginal canal during delivery. This practice was introduced by Dr. Crede, a German gynecologist in1884. Silver nitrate, erythromycin and tetracycline ophthalmic ointments are the drugs used for this purpose.
Erythromycin or Tetracycline Ophthalmic Ointment These ointments are the ones commonly used nowadays for eye prophylaxis because they do not cause eye irritation and are more effective against Chlamydial conjunctivitis .
Apply over lower lids of both eyes, then, manipulate eyelids to spread medication over the eyes starting from the inner and going into the outer canthus.
Ophthalmia neonatorum is defined as any conjunctivitis with discharge occurring during the first two weeks of life.
It typically appears 2-5 days after birth, although it may appear as early as the first day or as late as the thirteenth.
Most often both eyelids become swollen and red with purulent discharge.
Principles of cleanliness at birth are: Clean hands Clean perineum Nothing unclean to be introduced into the vagina Clean delivery surface Cleanliness in cutting the umbilical cord Cleanliness for cord care of the newborn
Hand washing The single most effective way of preventing infection among newborns is proper hand washing technique. Hand washing should be done: Before entering the nursery or before caring for the baby In between handling or after caring for each baby Before cleaning the umbilical cord After changing soiled diaper Before preparing milk formula
Each newborn should have his/her own individual supplies to prevent cross infection
Newborns should be handled with gloves until after the first initial bath.
Persons with infectious diseases should not be allowed to care for newborns and excluded from contact with newborns.
PREVENTION OF BLEEDING
The newborn has a sterile intestine at birth; hence, the newborn does not possess the intestinal bacteria that manufacture vitamin K which is necessary for the formation of clotting factors. This makes the newborn prone to bleeding.
As a preventive measure, 0.5 mg (preterm) and 1 mg (full term) Vitamin K or aquamephyton is injected IM in the newborn’s vastus lateralis (lateral anterior thigh) muscle.
Vitamin K prevents a now rare, but often fatal, bleeding disorder called hemorrhagic disease of the newborn (HDN).
This is a self-limiting hemorrhagic disorder of the first days of life, caused by a deficiency of the vitamin K-dependent blood clotting factors II, VII, and X .
HDN can cause bleeding into the brain, which may result in brain damage.
The warning signs of HDN include the following: Spontaneous bruising or excessive bruising after minor injury Nose bleeds (epistaxis) Oozing or bleeding from the umbilicus Dark colored vomitus Dark stools (melena) Excessive bleeding from skin lesions CARE OF THE CORD
Traditionally, the cord is clamped and cut approximately within 30 seconds after birth. But new standards advocated by DOH stated that the umbilical cord must be cut only once the pulsation on it stopped .
In the delivery room, the cord is clamped twice about 8 inches from the abdomen and cut in between.
When the newborn is brought to the nursery, another clamp is applied ½ to 1 inch from the abdomen and the cord is cut at second time.
The cord and the area around it are cleansed with antiseptic solution.
The manner of cord care depends on hospital protocol.
What is important is that the principles are followed.
Cord clamp maybe removed after 48 hours when the cord has dried.
The cord stump usually dries and falls within 7 to 10 days leaving a granulating area that heals on the next 7 to 10 days.
Instruction to the mother on cord care:
In the first few hours after birth, if you notice the cord to be bleeding , apply firm pressure and check cord clamp if loose and fasten.
No tub bathing until cord falls off. Do sponge bath to clean the baby. See to it that cord does not get wet by water or urine.
Do not apply anything on the cord such as baby powder or antibiotic, except the prescribed antiseptic solution which is 70% alcohol.
Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does not get wet when the diaper soaks with urine.
Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and separates more rapidly if it is exposed to air.
Report any unusual signs and symptoms which indicate infection. Foul odor in the cord Presence of discharge Redness around the cord The cord remains wet and does not fall off within 7 to 10 days Newborn fever
Based on the new guidelines set by the DOH regarding newborn care, the cord must be left as is after it is cut. There is no more need to apply anything on the cord (even the 70% isopropyl alcohol). If unusual signs and symptoms are noticed, the mother or the immediate caregiver is advised to report it to a doctor.
NEWBORN IDENTIFICATION
Proper identification is made in the delivery room before mother and baby are separated.
Newborn identification is not performed in home delivery unless more than one infant is born.
A final identification check of the mother and the infant must be performed before the infant can be allowed to leave the hospital upon discharge.
This is to ensure that the hospital is discharging the right infant.
Several methods of identifying an infant are as follows: Identification band (ID tag): identification bands are placed around the infant’s wrist or ankle and around the mother’s wrist. Information contained in the ID band includes name of the mother, date, time and manner of delivery, hospital number, gender of the baby, and the name of the doctor who facilitated the delivery. Footprints: footprints are obtained and kept with other records of the infant and mother. Ridges of the foot are easier to obtain that the newborn’s fingerprints. The infant’s foot should be clean and dry and must be pressed firmly on the ink pad and then gently on the footprint form beginning from the heel to the toes.
INITIAL FEEDING
If an infant is to be breastfed, feeding can be started as soon as after the umbilical cord is clamped.
It is recommended that breastfeeding be started within the hour after the birth of the baby.
There is no need to give water first because colostrum (first milk of the mother) is non-irritating and is easily absorbed in the lungs if aspirated.
Early breastfeeding not only provides early protection to the newborn. It also stimulates the release of oxytocin from the mother’s body, which in turn stimulates uterine contractions that is necessary to prevent bleeding.
Early breastfeeding is also an ideal way of initiating bonding between mother and child.
Breastmilk has unique anti-infective properties.
By breastfeeding, the mother begins the immunization process at birth and protects her baby against a variety of viral and bacterial pathogens before the acquisition of active immunity through vaccination.
ASSESS FOR POTENTIAL PROBLEMS
Instruct the mother to be aware of the following UNUSUAL/ABNORMAL MANIFESTATIONS and to refer the baby immediately to the health care provider: Not gaining weight Excessive crying or not crying Convulsions, twitching Stiff neck, body, and limbs Pus discharge/swelling of the cord or the area around it Eye discharge/boils on body Feverish or cold baby Rapid respiration, groaning, and chest retraction Not accepting any feeding Irritable, lethargic Pale, jaundiced Blue nails, lips, or body Vomiting and abdominal distension Not passing urine and stool IF YOU NOTICE ANY OF THOSE MANIFESTATIONS, CONSULT YOUR DOCTOR AT ONCE !
IMMUNIZATION SCHEDULE
Basic newborn immunization in the Philippines is composed of the following vaccines: BCG (bacillus calmette guerrin) vaccine OPV (oral polio vaccine) Hepatitis B vaccine (HBV) Diphtheria Pertussis Tetanus (DPT) vaccine Measles vaccine Tetanus toxoid (TT) vaccine BCG should be given as soon as possible after birth to protect the newborn from possible infection from household members who may be carriers or have latent infections of tuberculosis. Generally, Hepatitis B vaccine is administered immediately after birth as well to protect the infant from Hepatitis B infection from health care providers who are possibly carriers of the virus.
NAME OF VACCINE BCG
DPT OPV Hepatitis B Measles
MINIMUM AGE
# OF
MINIMUM INTERVAL
ROUTE OF
AT 1ST DOSE At birth or any
DOSES 1
BETWEEN DOSES -
ADMINISTRATION Intradermal
time after birth 6 weeks 6 weeks 6 weeks 9 months
3 3 3 1
4 weeks 4 weeks 4 weeks -
Intramuscular Oral Intramuscular Subcutaneous
