INTRODUCTION The birth of an infant is one of the most awe-inspiring and emotional events that can occur in ones

life time. The individuality of each baby requires the nurse to be knowledgeable about the averages and the range of normality of newborn infants. Newborn period encompasses the first four weeks of extra uterine life. Assessment of the newborn, as soon as possible after birth and subsequent assessment in the post natal period are vital responsibility of the nurses as a new individual is being evaluated for the first time. DEFINITION OF NEW BORN A healthy infant born at term (between 38-42 weeks) should have an average birth weight for the country (usually exceeds 2500g), cries immediately following birth, establishes independent rhythmic respiration and quickly adapts to the changed environment. Most essential assessment is the first cry. Good cry helps in establishment of satisfactory breathing. Another significant assessment of the neonate is Apgar Scoring as described by Dr Virginia Apgar. Five objective criteria are evaluated in one minute and five minute. The criteria are respiration, heart rate/minute, muscle tone, reflex irritability and skin color. APGAR SCORING CRITERIA Respiration Heat rate Muscle tone Reflex response Skin color 0 Absent Absent Flaccid No response Blue, pale 1 Slow, irregular Slow(below 100) Some flexion of extremities Grimace Body pink, extremities blue 2 Good, crying More than 100 Active body movements cry Completely pink

Total score = 10 No depression : 7-10 Mild depression : 4-6 Severe depression :0-3

PHYSICAL FEATURES OF NEW BORN The newborn must be examined thoroughly within 24 hours of birth.

Posture: Arms flexed and fists clenched. Legs flexed at knees and hips. Infants behavior is carefully noted by asking certain questions to self such as Is the newborn awakened easily by a loud noise? Is the baby comforted by rocking, sucking or cuddling? Do there seem to be periods of deep and light sleep? When awake does the infant seem satisfied after a feeding? What stimuli elicit response from the infant? When disturbed how much does the infant protest?

Anthropometric Measurement Length: 48-53 cm (from top of head to heel). Because of the usual flexed position of the infant, it is important to extend the leg completely when measuring total body length. Weight: most newborn weigh 2700 -4000g, the average weight being about 3,400g. 10% loss of birth weight occurs by 4th to 5th day and is regained by 7th to 10th day. The loss is due to loss of water through skin, lungs, urine and bowel when very little food is taken. The bigger the baby, the more the weight loss. Weight gain is at the rate of 25-30g/day. Head circumference: For a full term infant average head circumference is between 33-35 cm. (occiputo-frontal). Head circumference may be somewhat less immediately after birth because of the molding process that occurs during vaginal delivery. Usually by the second or third day, the skull is normal in size and contour. Head circumference is also be compared with crown-to-rump length, or sitting height. Crown-to-rump measurements are usually 31-35 cm and are approximately equal to head circumference. Head circumference has been shown to be equal to or up to 1 cm more than crown-to-rump length in 62%n of the infants examined and determined to be normocephalic. Chest circumference: 31-33 cm (measure at nipple line). Abdominal circumference: same as chest circumference. Abdominal circumference is measured just above the level of the umbilicus, since the umbilical cord is still attached. Measuring the abdominal circumference below the umbilical region is unsuitable because bladder status may affect the reading. Vital signs: Temperature: 36.5-37.2 degree centigrade. Temperature is stabilized by 8-10 hours of age.

Pulse: Apical pulse: heart rate is taken apically with a stethoscope. Visible pulse in left mid clavicular line, fifth intercostals space. Pulse vary according to the periods of reactivity and the newborns behaviors, but are usually in the range of 120-140 beats per minute. Both are counted for a full 60 seconds to detect irregularities in rate or rhythm. Peripheral pulses and femoral pulses are equal and strong. Respiration: 30-60 breaths /minute. BP: Blood pressure is most easily and accurately assessed using oscillometry (Dinamap). The average oscillometric systolic/diastolic pressure is 65/41 at 1-3 days of age. Compare blood pressure in the upper and lower extremities, which should be equal. Skin: The skin has an important role in temperature regulation, protection from infection reflecting the well being of the baby, and in facilitating communication. The texture of the newborns skin is velvety smooth and puffy. Sebaceous glands are inactive. The infants poor melanin production renders him vulnerable to infection. At birth skin is covered with vernix caseosa and lanugo. Vernix Caseosa: Grayish white, cheesy, odorless substance which covers the newborns skin. It is the mixture of sebum and desquamating cells. It is more in creases and folds. Lanugo: It is a slight, downy distribution of fine hair over the body. It is most evident on the shoulders, back, extremities, and forehead. It begins to appear on the fetus by about 16th week of gestation and to disappear after the 32nd week. Skin colorSkin color depends on racial and familial background and varies greatly among newborns. Normally pink in color. Acrocyanosis may be normal immediately following birth. It may be due to cold stress. Cutis Marmorata: A transitory mottling of the skin, sometimes due to exposure of the skin to cold. Common variations or minor abnormalities of skin Neonatal jaundice after first 24 hours. Extensive bruising: May be due to difficult or traumatic delivery. Milia (milk spot): it is due to sebaceous glands. Seen on the nose, forehead and cheeks. When milia is in the deeper layer, it appears as red. So it is called milia rubra. Miliaria or sudamina: distended sweat glands that appear as minute vesicles, especially on face.
3

Mongolian spots: are bluish, often large, commonly seen on the back, buttocks or thighs. It occurs due to melanin containing spindle shaped melanocytes in dermis. They disappear by 4 years of age. Erythema Toxicum: Papular lesions with an erythematous base. Commonly seen after 48 hours of birth. This rash resolves spontaneously. Common in trunk and face, occur anywhere except in palms and soles. Harlequin Color Change: A rare discrepancy in color between the two longitudinal halves of the body when the neonate is placed on the side for several minutes. The dependent portion of the body becomes pink, while the upper halves remain pale. Salmon patches (stork bites/ nevus simplex/ telangiectatic nevi): flat, deep pink localized areas usually seen in back of neck, upper eyelid, forehead and root of the nose, which spontaneously disappear within one month. Major abnormalities Pallor- occurs due to anemia, birth asphyxia or shock. Central cyanosis: It is caused by low oxygen saturation. It may be due to congenital heart or lung disease. Peripheral cyanosis: may be due to drugs (nitrites or nitrates). Jaundice: Progressive jaundice, especially in first 24 hours. Bilirubin level more than 5 mg/dl. Plethora: commonly seen in infants with polycythemia. A term applied to the beefy red coloration of a newborn. The "boiled lobster" hue of the infant's skin is caused by an unusually high proportion of erythrocytes per volume of blood. The term formerly was used to describe any red-faced person. Hemorrhage, poor skin turgor, rashes, pustules or blisters. Nevus flammeus: port-wine stain. Head: Making up 1/4th of body length. General observation of the contour of the head is important, because molding occurs in almost all vaginal deliveries. The usual, more oval contour of the head is apparent by 1-2 days after birth. The change in shape occurs because the bones of the cranium are not fused, allowing for the overlapping of the edges of these bones to accommodate to the size of the birth canal during delivery. Head is covered with fine, silky hair. Cranium is large and face relatively small. Six bones- the frontal, occipital, two parietals and two temporal-makes up the cranium. Skull is formed of 8 bony plates, each one connected to another by bands of connective tissue called suture lines. At the junction of the sutures are wider spaces of unossified membranous tissue called fontanels. These are palpated to determine whether they
4

are open or closed. The 2 most prominent fontanels in infants are the anterior fontanel and the posterior fontanel. Sutures feel like cracks between the skull bones. Fused cranial sutures are called craniosynostosis. Craniotabes: softening of skull bones. That is pung-pong feel when pressure is exerted by a fingertip near suture lines. Fontanels feel like wider soft spots at the junction of the sutures. These are palpated by using the tip of the index finger and running it along the ends of the bones. The fontanels should feel flat, firm. Frequently pulsations are felt at the anterior fontanel. Anterior fontanel: It is formed by joining of the 4 sutures in the mid plane. The sutures are anteriorly frontal, posteriorly sagital and on either side, coronal. It is diamond shaped. It is 2-3cm in width and 3-4 cm in length. It becomes ossified 18 months after birth. Posterior fontanels: Formed by junction of 3 suture lines such as sagital suture anteriorly and lambdoid suture on either side. It is triangular in shape and measures between 0.5 and 1 cm. It normally closes by the end of the second month. Other fontanels include mastoid and sphenoid fontanels. Head lag is common in newborn. Frontal baldness is common in neonates. Caput succedaneum: Swelling or edema of the presenting portion of the scalp, and may be localized or fairly extensive. Usually disappears by the third day. Cephalhematoma: Accumulation of blood between the flat skull bone and the periosteum. Collection of blood does not cross a suture line. The mass is soft and fluctuating.

Eyes: Eyes are blue or gray at birth, changing to the permanent color in 3-6 months. Eye movements are not co-ordinated. The eyelids may be edematous for about 2 days after birth, until the excess fluid is eliminated by the kidneys. Sclera should be clear and white. Corneal reflex is normally present at birth. The pupil will usually respond to light by constricting. The pupils are usually malaligned. A searching nystagmus is common. Strabismus is a normal finding because of the lack of binocularity. Sub conjunctival hemorrhage: Because of the pressure on the neonates head during vaginal delivery, the venous return of blood may be impaired and small capillaries may rupture in the sclera of the eye. This has no pathological significance and the red areas will disappear in 2-3 weeks.

Ophthalmia neonatorum: acquired mainly from maternal genital tract during delivery. Erythema and edema of palpebral conjunctiva, purulent discharge in eyelids are the main features. This is of mainly 4 types such as chemical conjunctivitis, bacterial conjunctivitis, chlamydial and viral conjunctivitis. To prevent this instillation of silver nitrate drops can be used.

Ears: Pinna: see for the correct placement. Low set ears may be an indication of mental retardation.
Nose: The nose is usually flattened after birth, and bruises are common. Most newborns are obligatory nose breathers. The narrow nostrils of the new born may be slightly obstructed from an

accumulation of mucus. An unusual amount of nasal discharge should be removed. Mouth and Throat: The palate is normally highly arched and somewhat narrow. Examine for the presence of cleft lip or cleft palate. Elicit sucking reflex by placing nipple or non-latex gloved finger in the infants mouth. The uvula can be inspected while the infant is crying and the chin is depressed. See for the presence of natal teeth. It appears yellow because of the deficiency of enamel. It is also seen in stotos syndrome, Ellis van creveld syndrome etc. Pernicious dentition or supernumerary teeth may be observed in the lower incisor area. Epstein Pearls (palatine cyst): Temporary accumulation of epithelial cells, on each side of the hard palate. Normally this disappears about a week after birth.

Neck: Neck appears short in comparison with the size of the baby. Check for movements, sternomastoid hematoma or short neck (Turners syndrome). Chest: It is almost circular because the anterio-posterior and lateral diameters are equal. The ribs are very flexible and slight intercostals retractions are normally seen on inspiration. The xiphoid process is commonly visible as a small protrusion at the end of the sternum. The sternum is generally raised and slightly curved. The circumference is same as that of the abdomen and about 1 inch less than the head circumference. Inspect the breast for size, shape and nipple formation, location and number. See for supernumerary nipples. See for witchs milk-i.e., pale milky fluid can be expressed from the infants breast. The condition disappears in 2-4 weeks without treatment.

Lungs The normal respiration of the newborn is irregular and abdominal, and the rate is between 30 and 60 breaths/minute. Pauses in respiration less than 20seconds is considered as normal. Occasional irregularities occur in relation to crying, sleeping and feeding. Heart Heart rate is auscultated and may range from 100-180 beats per minute shortly after birth and, when the infants condition has stabilized, from 120-140 beats/minute. The point of maximum intensity (PMI) may be palpated and is usually found in the 4th to 5th intercostals space, medial to the left midclavicular line. The PMI gives some indication of the location of the heart. See for dextrocardia, where the heart is on the right side of the body, the abdominal organs may also be reversed. Auscultate for heart sounds s1 and s2. The second sound is higher in pitch and sharper than the first. Hematologic System: the vascular system and heart are larger in the neonate in comparison with their size in adult life. The blood volume of the newborn infant is about 10-12 percent of body weight. The total circulating blood volume at birth is 80ml/kg body weight. This percentage is influenced by the amount of blood received from the placenta before clamping of the cord. RBC (4.0-6.6millions of cells/mm3) and hemoglobin level (14.5-22.5g/dl) are high at birth. Hematocrit: 48-69% Physiologic Anemia: During the first 2-3 months of life, RBC and hemoglobin level continue to fall and results in physiologic anemia. Leukocyte count at birth is 10,000/mm3. During the first 24 hours, it increases to 25,000 to 35,000/mm3. Vitamin K: Most new born babies have reduced levels of vitamin K in their blood, resulting in prolonged prothrombin time. This is because their intestinal tracts are sterile at birth. So vitamin K is given to the neonates after delivery. Intestinal flora begins to accumulate after their first feedings. Therefore, normal synthesis of vitamin K is possible. Esophagus, Stomach and Intestine: The cardiac sphincter is not as well developed as the pyloric sphincter. So, the infant should be bubbled several times while being fed so that air that has been swallowed may be eructed. Capacity of the Stomach:

At birth: 1-2 ounces. At 2 weeks: 3 ounces. At 5 month: 7 ounces. At 10 month: 10 ounces. Meconium It is the first fecal material passed from 8-24 hours after birth. It is a sticky and odorless material, greenish black to brownish green in color. The nature of the stool changes daily in the 1st week. These are called transitional stools. From the third to the fifth day, they are loose, contain mucus and are greenish yellow. After the 5th day, the nature and the frequency of the stool depend on feeding. The stools of breast fed infants are yellow and pasty; between 2 and 4 are passed a day. The stools of a formula fed infants are light yellow and hard and are passed once or twice daily. Abdomen: The normal contour of the abdomen is cylindric and usually prominent with few visible veins. Bowel sounds heard soon after birth, usually within the first 15-20 minutes. Visible peristaltic waves may be observed in some newborns. The umbilical cord is a bluish white, gelatinous structure at birth. Normally 2 arteries and 1 vein are present. After clamping, the cord begins to dry and appears dull, yellowish brown. It progressively shrivels in size and turns greenish black. It sloughs off by 6-10 days after birth.If the umbilical cord appears unusually large in diameter at the base, inspect for the presence of a hematoma or small omphalocele. Palpate after inspecting the abdomen. The liver is normally palpable 1-3 cm below the right costal margin. The tip of the spleen can sometimes be felt, but a palpable spleen more than 1 cm below the left costal margin suggest enlargement and warrants further investigation. The lower half of the right kidney and the tip of the left kidney are 1-2 cm above the umbilicus. Genitalia: Male babies: The scrotum appears edematous. The urethral opening at the tip of penis. Skin of the scrotum is deeply rugated and darker in color than the surrounding skin. Smegma, a white cheesy substance, is commonly found around the glans penis, under the fore-skin. An erection is
8

common in the newborn. A noncommunicating hydrocele commonly occurs unilaterally and disappears within a few months. Palpate the scrotum for the presence of testes. Female babies: Labia minora and clitoris appears large. Large amount of vernix caseosa may be evident. The vagina exudes a mucus discharge that occasionally may be blood- tinged called pseudo menstruation. This is caused by the hormone s transmitted from mother to newborn daughter and usually disappears by 2-4 weeks. Urine: The bladder contains urine at birth and may empty immediately or after several hours. Urine is dilute because of the immaturity of the kidneys. Pink stain may be found on the diaper, which is usually due to deposition of uric acid crystals. Skeletal Structure: Bones are soft, because they are composed mainly of cartilages. Back and anus Inspect the spine with the infant prone. The shape of the spine is gently rounded. Any abnormal opening, masses, dimples are noted. A protruding sac anywhere along the spine, but most commonly in the sacral area indicates some area of biostatistics. With the infant prone note symmetry of the gluteal folds. Test for developmental dysplasia of the hip are performed. The presence of an anal orifice and passage of meconium during the first 24 to 48 hours of life indicates anal patency. Anal patency can be checked by inserting a small catheter into the anal opening. Extremities Examine the extremities for symmetry, range of motion and reflexes. Count the fingers and toes, and note supernumerary digits (polydactyly), or fusion of digits (syndactyly). The nail beds should be pink, although slight blueness is evident in acrocyanosis. The palms of the hand should have the usual creases. The full term newborn usually has creases covering the entire sole of the foot. Observe the range of motion of the extremities. The absence of arm movement signals a potential birth injury paralysis such as klumpke or erbs palsy. Examine the lower extremities for limb length, symmetry and hip abduction and flexion. Assess muscle tone:
9

Hypotonia suggests some degree of hypoxia or neurologic disorder and is common in down syndrome. Asymmetry of muscle tone may indicate a degree of paralysis from brain damage or nerve damage. Failure to move the lower limbs suggest a spinal cord lesion or injury. Tremors, twitches and myoclonic jerks characterize neonatal seizure or may indicate neonatal narcotic withdrawal syndrome.

COMMON NEWBORN REFLEXES: Reflexes are involuntary movements or actions. Some movements are spontaneous, occurring as part of the baby's usual activity. Others are responses to certain actions. Reflexes help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. The following are some of the normal reflexes seen in newborn babies: LOCALIZED REFLEXES EYES: Blinking or corneal reflex

Exposure of eyes to bright light or sudden movement of object towards eye causes the closure of eyelid, persist throughout life. Dolls eye

When the infants head is turned slowly to the right or left side, normally eyes lag behind and do not immediately adjust to new position of head; disappears as fixation develops; if persists, indicates neurological damage. Pupillary reflex

Pupils constrict when a bright light shines towards it; persist throughout life. NOSE Sneeze

Spontaneous response of nasal passages to irritation or obstruction; persist throughout life.

10

Glabellar

Tapping briskly on glabella (bridge of nose) causes eyes to close tightly. MOUTH AND THROAT Rootingreflex This reflex begins when the corner of the baby's mouth is stroked or touched. The baby will turn his/her head and open his/her mouth to follow and "root" in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding. This reflex disappears by 3-4 months. Rooting reflex will be absent in developmental defects. Suckingreflex Rooting helps the baby become ready to suck. When the roof of the baby's mouth is touched, the baby will begin to suck. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability because of this. Babies also have a hand-tomouth reflex that goes with rooting and sucking and may suck on fingers or hands. Disappears by 6 month. Swallowing reflex This accompanies the sucking reflex. Food reaching the posterior of the mouth is swallowed. Abnormal response in neurological depression, hypotonia, bulbar palsy. Gagging reflex Stimulation of posterior pharynx by food, suction, or passage of a tube causes infant to gag; persist throughout life. Extrusion: When substance is placed on the anterior position of the tongue, baby pulls the tongue out. This disappears by 4 months. Yawn Spontaneous response to decreased oxygen by increasing amount of inspired air; persist throughout life. Cough
11

Irritation of mucous membrane of larynx or tracheobronchial tree causes coughing.

EXTREMITIES

PlantarGraspreflex Touching the sole of the foot at the base of the digits causes the toes grasp around the very small objects. It disappears by 8-9 months. Absent in spinal cord defects, asymmetrical in CNS defects.

Palmar grasp: When object is placed in the newborns arm, the baby grasps the object by closing fingers around it. Palmar grasp lessens after age 3 months. Abnormal response in case of cerebral injury.

Babinskireflex When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to 1 year of age. Ankle clonus Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements.

MASS REFLEX

Mororeflex sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers, with index finger and thumb forming a c shape, followed by flexion and adduction of extremities. Infant may cry. Disappear after 3-4 months. Incomplete moro reflex indicates prematurity (only abduction and extension) Startle reflex A sudden loud noise causes abduction of the arms with flexion of elbows; hands remain clenched, disappear by 4 months. Tonicneckreflex When a baby's head is turned to one side, the arm on that side stretches out and the
12

opposite arm bends up at the elbow. This is often called the "fencing" position. Disappears by 18 -20 weeks. Abnormal response occurs when brain damage in hemisphere opposite to extended limbs.

Stepreflex This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his/her feet touching a solid surface. Perez reflex While infant is prone on a firm surface, thumb is pressed along side from sacrum to neck; infant response by crying, flexing extremities, and elevating pelvis and head as well as defecation and urination may occur, disappear by 4-6 months.

Trunk incurvation reflex (gallant): stroking infants back alongside spine causes hip to move towards stimulated side; disappears by age 4 weeks. Crawl reflex When placed on abdomen, infants make crawling movement with arms and legs; disappears about age 6 weeks.

CONCLUSION The nurse is in a unique position to aid the newborn infant in the stressful transition from a warm, dark, fluid-filled environment to an outside world filled with light, sound, and novel tactile stimuli. During this period of the newborn adjusting from intrauterine to extra uterine life, the nurse must be knowledgeable about a newborn's normal biopsychosocial adaptations to recognize any deviations. To begin life as an independent being, the baby must immediately establish pulmonary ventilation in conjunction with marked circulatory changes. These radical and rapid changes are crucial to the maintenance of life. All other neonatal body systems change their functions or establish themselves over a longer period of time. The nurse performs an initial assessment to evaluate the neonate, its immediate post birth adaptations, and the need for further support. BIBLIOGRAPHY Marlow, D.R; Redding B.A. (2010). TEXT BOOK OF PEDIATRIC NURSING. (6TH ed). India: Elsevier Publishers. Assuma Beevi, T.M. (2010). Text Book of Pediatric Nursing. India: Elsevier Publishers. Bennet, V.R, Brown, L.K. (1999).Myles Text Book for Midwives. (13th ed). New York: Churchill Livingstone Publishers. Lowdermilk, D.L, Perry, S. Maternity Nursing. (7th ed).USA: Elsevier Publishers.
13

PEDIATRIC NURSING.

TOPIC: PROFILE AND CHARACTERISTICS OF NEW BORN

SUBMITTED TO:
MRS. SAJINA, ASSO. PROFESSOR, MIMS COLLEGE OF NURSING.

SUBMITTED BY:
ASHA JOSE, 1ST YEAR M.Sc. NSG, MIMS CON.

SUBMITTED ON: 22-05-2012.

14