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INDEX

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CONTENT

PAGE
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2

DEFINITION OF NORMAL NEWBORN

CHARACTERSTICS OF NORMAL NEWBORN

PHYSICAL ADAPTATION OF NORMAL NEWBORN

10 -13

BEHAVIORAL ADAPTATION OF NORMAL NEWBORN

13 - 14

PHYSICAL ASSESSMENT OF NEWBORN

14 - 18

BEHAVIORAL ASSESSMENT OF NEWBORN

18 -19

GESTATIONAL AGE ASSESSMENT

19 - 20

ESSENTIAL NEWBORN CARE

21 - 22

IDENTIFICATION OF HIGH RISK NEWBORN AND REFFERAL

23 - 24

10

PARENTING PROCESS

24 - 27

11

RESEARCH ABSTRACT

27

12

CONCLUSION

27

13

BIBLIOGRAPHY

28

2-9

INTRODUCTION
A newborn is an infant who is only hours, days or up to a few weeks old.
The term newborn or neonates are derived from Latin word neonatus. A
new born baby brings many joy as well as many questions. Along with the
happiness parents feels with the birth of their child they often have
concern about his / her health and how to properly care their child. Today
babies have more opportunities than ever before to grow into healthy
children, adolescent and adults. Advances in medical research, the advent
of new vaccines, medications and the development of new technologies
have helped to improve the healthcare of both well and sick newborn
babies.
DEFINITION
A healthy newborn are those who are born at term (between 38-42
weeks), should have an average birth weight for the country (usually
exceed 2500 gm), cries immediately following birth, establishes,
independent rhythmic respiration and quickly adapt to the changed
environment.
D.C DUTTA
Neonatal Period
The interval from birth to 28 days of the life age, It represents the time of
the greatest risk to the infants. Approximately, 65% of all death that
occur in the first year of life happens during this 4 week period.
Early Neonatal period: - Refers to the period of 7 days of age.
Late Neonatal period: - Refers to the period from completion of 7 days up
to 28 days of life.
CHARACTERISTICS OF NORMAL NEWBORN
Physical characteristics
Weight
The weights vary from country to country, usually exceeds 2500 gm. In
India the weight varies between 2.7 to 3.1 Kg with a mean of 2.9 Kg.
There is 10 % loss of birth weight by 4th 5th day and is regained by 7th
10thday.
Length
The length is 50-52 cm. The length is more reliable criterion of gestational
age than the weight.
Head Circumference
The babys head may appear two large for its body. The head is 1/4 th of
the babys total size. Normal head circumference is 33 to 35 cm and it
should be 2 to 3 cm larger than the chest.
2

Chest Circumference
According to the Indian journal of pediatrics, a child between the age of
20 & 21 month should have a larger chest circumference than the head
circumference. This milestone indicates the healthy growth. While at birth
it should be 2 cm less than the head circumference. Normal chest
circumference ranges between 31-33 cm.
Abdominal Circumference
Normal abdominal circumference range between 31-33 cm.
Vital Signs
Temperature
The newborns body temperature drops immediately after birth in
response to the extrauterine environment. The internal organs are poorly
insulated and his skin is very thin and does not contain much
subcutaneous fat. The heat regulating mechanism has not fully
developed. The temperature rapidly reflects that of the environment. The
flexed position that the infant assumes is a safe guard against heat loss
as it substantially diminishes the amount of body surface exposed.
Pulse
The normal pulse rate for an infant is 120 to 140 beats per minute. The
rate may rise to 160 bpm when the infant is crying or drop to 100 bpm
when the infant is sleeping. The apical pulse is considered the most
accurate.
Blood Pressure
The average blood pressure of new born is 72/42. A drop in systolic BP of
about 15 mm Hg during the first hour after birth is common. The new
born BP may be taken with a Doppler blood pressure device. This greatly
improves accuracy.
Respirations
The respirations of a newborn infant are irregular in depth, rate and
rhythm and vary from 30 to 60 beats per minutes. Respiration is affected
by the infants activity i.e. crying. Normally respirators are gentle, quiet,
rapid and shallow. They are most easily observed by watching abdominal
movement because the infants reparations are accomplished mainly by
diaphragm and abdominal muscle. No sound should be audible on
inspiration or expiration.

Head
The head is shaped or molded as it is forced through the birth canal in
vertex presentation.
Fontanel
These soft spot are areas where the skull bones do not join. It allows the
babys head to grow. It usually pulsates with each beat of the heart. The
anterior fontanel is located at the intersection of the suture of the two
partial and frontal bones. It is diamond shaped and it strongly pulsates. It
closes by 18 months. The posterior fontanel is located at the junction of
the suture of the two partial and one occipital bone. Its small, triangular
shaped and less pulsatile. It normally closes by 6 weeks of age.
Moulding of the head
During the delivery, for the large head to pass through the small birth
canal, the skull bones may actually overlap in process referred to as
moulding. Such moulding reduces the diameter of the skull temporarily.
This elongated look usually disappears a few hours after birth as the
bones assume their normal relationships.
Cephalohematoma
This is the collection of blood between a cranial bone and its overlying
periosteum. Bleeding is limited to the surface of the particular bone. It is
caused by pressure of the fetal head against the material pelvis during a
prolonged or difficult labour. This pressure loosens the periosteum from
the underlying bone, therefore rupturing capillaries and causes bleeding.
It may be apparent at birth but sometimes are not seen until 24 to 48
hours of life because subperitoneal bleeding is slow. It varies in size. Most
of the Cephalohematoma are absorbed within several weeks. No
treatment is required in the absence of unexplained neurological
abnormalities.
Caput succedaneum
This is abnormal collection of blood under the scalp on the top of the skull
that may or may not cross the suture lines, depending on size. Pressure
on the presenting part of the fetal head against the cervix during labor
4

may cause edema of the scalp. This diffuse swelling is temporary and will
be absorbed within 2 or 3 days.
EYES
Color
The babyseye color depends on skin tone. Initially it may be blue grey in
fair skinned or brown if dark skinned. A gradual deposition of pigment
produces the final eye color of the baby at the age of three to six months.
Pupils
The pupils do retract to light and the infant can focus on objects about
eight inches away. The infant s blinking is a natural protection reflex. May
notice cross eyed look due to weak eye muscles. Eye muscle strength will
improve and will get better focus.
Lacrimal apparatus
The lacrimal apparatus is small and nonfunctioning at birth and tears are
not usually produced with crying until one to three month of age.
Swollen eye lid
Babys eye may be puffed because of the pressure on the face during
delivery. They may be puffed and red if silver nitrate eye drops have been
used. This irritation should clear in about three days.
Hemorrhage on the eyes
Some babies have a flame shaped hemorrhage on the white of the eyes.
It is caused by breaking of blood vessel on the surface of the eye during
labor and is harmless.This blood is reabsorbed in two or three weeks.
EARS
External auditory canal is short and straight. Eardrum is thick. Eustachian
tube is short and broad.
Folded ears
The ears of newborn are commonly soft and floppy. Sometimes the edge
of one is folded over. The ear will resume its normal shape as the
cartilage became firmer over the first few weeks of life.
Structure
The newborns ear tents to be folded and creased. A line drawn through
the inner and outer canti of the eye should come to the top notch of the
ear where it joins the scalp.
Hearing
5

Babies can hear loud and soft noise at birth. Loud noise may cause babies
to startle while soft noise may help to calm your babies. Babies quickly
learn the difference in voice sounds. Babies will turn head to a familiar
sound especially mother and father.
Taste and smell
The newborn can taste and smell at birth. The baby will be able to taste
formula or breast milk. Avoid heavy perfume and do not smoke around
the babies.
Skin
The newborn has dedicate skin at birth that appear dark red because it is
thin and layers of subcutaneous fat have not yet covered the capillary
bed. This redness can be seen through heavily pigmented skin and even
become more flushed when babies cry.
Vernixcaseosa
This is a soft white cheesy yellowish cream on the newborns skin at birth.
It is caused by the secretion of sebaceous gland of the skin. It offers
protection from the watery environment of the uterus and is absorbed in
the skin after birth and serve as a natural moisturizer. If there is a large
amount of Vernixcaseosa present it should be meticulously removed as it
is thought to be a good culture medium for bacteria.
Lanugo
This is long soft growth of fine hair on the newborns shoulder, back and
forehead. It appears early in postnatal life.
Mongolian spot
These are blue black coloration on the infants lower back, buttocks and
anterior trunk. They are often seen in babies of black IndianMongolian or
Mediterranean ancestry. These spot occur less frequently in Caucasian
babies. The spot are not bruises nor they are associated with mental
retardation. They disappear in early childhood.
Jaundice
This is the yellowish discoloration that may be seen in babys skin or in
sclera of the eyes. Jaundice is caused by excessive amount of free
bilirubin in the blood and the tissues.
Petechiae
These are small blue red dot on the infants body caused by breakage of
tiny capillaries. They may be seen on the face as a result of pressure
exerted on the head during birth. True Petechiae does not blanch on
pressure.
6

Milia
These are tiny sebaceous retention cyst. They appear as small white or
yellow dots and are common on nose forehead and cheeks of baby. They
are pin head sized and opalescent. Milia are due to blocked sweat and oil
glands that have not begun to function properly. They disappear
spontaneously within few weeks.
Birthmark
These are small reddened area sometimes present on infants eyelid, mid
forehead and nape of the neck. They may be the result of local dilation of
the skin capillaries and abnormal thinness of the skin.They are sometimes
called stroke bites or telangiectasis. This mark usually fades and
disappears altogether. They may be noticeable when infant blushes, is
extremely warm or become excited.
Hemangioma or strawberry mark is a type of birthmark that is
characterized by a dark or bright red raised rough surface. They may
regress spontaneously or even increase in size .surgical removal is not
recommended there ia a wait and see attitude advocated before surgical
removal.
Respiratory system
Until the newborn first breath of air is taken, the alveoli in the lungs are in
almost complete state of collapse. The lungs should be in this stage
because the lung must not fill the amniotic fluid or other liquid. However
the fluid/liquid that flows in the lungs during normal delivery is squeezed
or drained from the newborns lung. The major portion of the fluid is
absorbed after delivery by alveolar membrane into the blood capillaries.
The most frequent cause of respiratory difficulty in the first few hours of
birth has been due to the too liberal use of sedatives, tranquilizer,
analgesics that affect not only the mother, but pass over the placenta to
the baby. These drugs make the baby sleepy and disinclined to take the
first breath.
Circulatory system
Blood flow
As umbilical blood stop flowing at birth, sudden pressure difference
occurs within the circulatory system. This difference causes the blood
flowing to the lungs and liver to increase and the blood flowing through
the bypass channel to decrease. Peripheral circulation refers to the
residual cyanosis in hands and feet. This may be apparent for one to
three hours after birth and is due to sluggish circulation. Blood is shunted
to vital organs immediately after birth.
Blood Coagulation
7

During the first few days of life, the prothrombin level decreases and
clotting time in all infants is prolonged. This process is most acute
between the second and fifth postnatal days. It can be prevented to a
large extent by giving vitamin K to the infant after birth. With the
ingestion of food, establishment of digestion, and maturation of liver,
vitamin K is produced by the baby and clotting time stabilize within a
week to 10 days.
Gastro intestinal system
Mouth
Sucking callus or blister occur in the centre of upper lip due constant
friction of this point during bottle or breast feeding. It will disappear when
the baby begins cup feeding.
Tongue tie is the short, tight band on the underside that connects it to the
floor of the mouth. These bands usually stretch with time, movement and
growth.
Epithelial pearl may be little cysts containing clear fluid or shallow, white
ulcer along the gum line or on the mouth. They result from blockage of
normal mucous gland; disappear along one or two months.
Stomach
The capacity of newborns stomach is one to two ounces (30 to 60 l), but
increases almost rapidly. Milk passes through infants stomach almost
immediately. The infant is capable of digesting simple carbohydrate and
proteins, but has a limited ability to digest fat.
Intestine
Irregular peristaltic mobility slows stomach emptying. Peristaltic
increases in lower ileum which results in one to six stools a day. The first
stool after birth, and for three to four days afterwards are called
meconium. Meconium is stringy, tenacious, and black and has tarry
texture. With the ingestion of colostrums or formula, a gradual transition
occurs.
At birth (meconium) stringy, tenacious, black,
tarry texture

Ingestion of colostrums or
formula
Gradual transition
Few greenish stools to gradual

Early infancy, stool of


breast feed babies
Yellow- orange color,
curdy

Early infancy stool of bottle fed


babies
Lemon yellow color soft more

Endocrine system
The endocrine glands are considered better organized than 6ther syste0s.
Disturbances are most often related to maternally provided hormones
(estrogen, luteal are prolactin)
Enlargement of mammary gland may occur in both sexes. This is
particularly noticeable about the third day of life. Breast secretion may
also occur. Swelling usually subsides in two or three weeks. The breast
should not be squeezed; it increases the chance of infection and injuries
to the tender tissues. In term baby the normal diameter of breast nodules
is 5 10 mm whereas it is less than 5 mm in preterm babies.
Vaginal discharge or bleeding occurs in female babies. This discharge
is white mucoid in color. Bleeding may occur as a result of withdrawal
from maternal hormones at the time of birth. There are usually only few
blood spot seen on diapers. This disappears in one or two days.
Neuromuscular system
Arms and legs
Arms and legs look bend and are held close to the body. Hands are in
tight fist. Legs may appear bowed. The arms and leg may also appear too
short for the body because of their bend appearance. By three to four
months the arms and leg stretch out. The hands will unfold and baby will
begin to reach for objects. The leg will also grow longer and stronger and
baby will sit crawl and stand
Reflexes
The reflexes are important and help the health care provider to determine
if the baby has a healthy nervous system.
Survival reflex
Sucking
Swallowing
Rooting
Safety reflex
Gag reflex
Cough
Tonic neck reflex
Grasp reflex
Genito urinary system
Female genitals
9

The labia minora may be quite swollen because of maternal hormones


and may have smooth half inch projections of pink tissue called tags.
These are harmless. They occour in 10% of newborn girls and slowly
shrink over two to four weeks.
Male genitals
The scortum of newborn boys maybe filled with clear fluids and that has
been squeezed into the scortum during birth. This common painless
collection of fluid is called a hydrocele and it may take six to 12 weeks to
clear completely. Regular check up should be there and consult doctor if
the swelling changes size frequently.
About 4% of full term newborn boys have undescented testis i.e. testis is
not in scrotum. They gradually descent in normal position. Most
uncircumcised baby boys have a tight foreskin. This is normal and the
foreskin should not be retracted. the foreskin separates from the head of
penis naturally by 5 to 10 years of age.
PHYSIOLOGICAL ADAPTATION OF NEWBORN
ESSENTIAL CONCEPTS
The neonatal period includes the time from birth through 28 days of life.
During this time the neonates must make many physiological and
behavioural adaptations to extra uterine life. The physiological adaptation
task are those that involves
a) Establishing and maintaining respiration
b) Adjusting to circulatory changes
c) Regulating temperature
d) Ingestion, retaining and digesting nutrients
e) Eliminating waste
f) Regulating weight
Respiratory adaptation
Initial respiration is triggered by physical, chemical and sensory factors
Physical factors include the effort required to expand the lung and fill the
collapsed alveoli. Adequate levels of surfactants (Lecithin and
spingomyelin) ensure mature lung function; prevent alveolar collapse and
respiratory distress syndrome
Chemical factors include change in blood such as decreased oxygen level,
increased carbon dioxide level, and decreased ph as a result of the
transitory asphyxia during delivery.
Sensory factors include temperature, noise, light, sound and drop in
temperature.

10

Oral mucous secretions may cause the newborn to cough and gang
especially during the first 12 to 18 hours. Newborns are obligatory nose
breathers the reflex response to nasal obstruction, opening the mouth to
maintain an airway is not present in most newborns until 3 weeks after
birth.
Cardiovascular adaptation
Fetal Circulation
Oxygenated blood from placenta via umbilical vein
66% shunted past liver by DUCTUS VENOSUS to IVC
50% of this blood shunted from right atrium to left atrium via
FORAMEN OVALE
This blood continues to left ventricle, ascending aorta, and arteries
feeding head and right arm
Venous blood from head (SVC) is directed via right atrium to right
ventricle into the pulmonary artery
90% of blood in PA is shunted away from lungs and into descending
aorta via the DUCTUS ARTERIOUS and returns to the placenta via the
umbilical arteries.
Various anatomic changes have take place after birth. Some are
immediate and the other occur with time.
STRUCTURE

BEFORE BIRTH

Umbilical vein

Brings arterial blood to the heart

Umbilical
arteries

Brings arteriovenous blood to the


placenta

Ductus
venousus
Ductus
arteriosus

Shunts arterial blood into inferior


venacava
Shunts arterial and some venous
blood from pulmonary artery to
the aorta
Connects right and left atria
Contains no air and very little
blood, filled with fluids
Brings little blood to lungs

Foramen ovale
lungs
Pulmonary
arteries
aorta
Inferior
venacava

Receives blood from both


ventricles
Brings venous blood from body
and arterial blood from placenta

AFTER BIRTH
Obliterates; become round
ligament of the liver
Obliterates; become vesicle
ligaments on anterior abdominal
wall
Obliterates; becomes ligamentum
venosum
Obliterates; become ligamentum
arteriosum
Obliterates
Filled with air and well supplied
with blood
Brings much blood to lungs
Receives blood only from left
ventricles
Brings blood only to right auricles

Peripheral circulation is sluggish, causing acrocynosis (cyanosis of hand


and feet and around the mouth). The feet may be cold to touch.
11

Hematopoetic system
The blood volume of the full term neonates is 80 to 110 ml/kg of body
weight, averaging about 300 ml. The amount of blood bound to
hemoglobin is less in a neonate than in a fetus. The partial pressure of
oxygen in the blood is less in a neonate than in a fetus. Neonates are
born with high erythrocyte counts secondary to the effect of fetal
circulation and need to ensure adequate oxygenation. Levels of vitamin K
in the neonates are lower than normal leading to an increase in bleeding
time. The normal newborn hematological values are
parameter
Hemoglobin
RBC
Hematocrit
White blood cell
Neutrophills
Eosinophils
Lymphocytes
Monocytes
Platelets
Reticulocytes
Blood volume

Normal range
14 20 g/dl
5 7.5 million/mm3
43% - 63%
10,000 30,000/mm3
40% - 80%
2% - 3%
20% - 40%
3% - 10%
150,000 350,000/mm3
3% - 7%
Total blood volume at term 80 85 ml/kg
Third day after early cord clamping 82.3
ml/kg
Third day after late cord clamp 92.6
ml/kg

Thermogenic system
Thermoregulation is the maintenance of the balance between heat loss
and heat production. Thermo genesis is accomplished primarily by
metabolism of brown fat which is located in superficial deposits in the
intrascapular region and axille, deeply deposited in the thorxic in the left,
along the vertebral colum and around kidney.
Rapid heat loss may occur in a suboptimal thermal environment by the
way of conduction, convection, radiation and evaporation
Conduction involves heat loss to cold surface with which the neonates is
in contact
Convection involves heat loss to the air that is cooler than the neonates
temperature
Radiation involves heat loss to solid objects that are near the neonates
but not contacting the neonates. Evaporation involves heat loss through
vaporization of liquid on the neonates skin.
Gastro intestinal adaptation
12

Neonates born beyond 32 to 34 weeks gestation have adequate sucking


and swallowing coordination. Bacteria are not normally present in the
neonates gastro intestinal tract. Bowel sounds can be heard 1 hour after
birth. Uncoordinated peristaltic activity in the esophagus exists for first
few days of life. The neonates has a limited ability to digest fast because
amylase and lipase are absent at birth.
Immature cardiac sphincter may allow reflux of food, so neonates should
be burped after each feed. The lower intestine contains meconium at
birth; the first meconium usually passes within 24 hours and failure to
pass meconium in the first 24 48 hours suggests possible meconium
ileum, imperforate anus or bowel obstruction.
Kidney adaptation
Renal function is not fully mature until after the first year of life. The
neonates have a minimal range of chemical balance and safety. Low
ability to excrete drugs and excessive fluid loss can rapidly lead to
acidosis and fluid imbalances. Most newborns void in the first24 hours
after birth and two to six times per day for the first 1 to 2 days. Thereafter
they void 5 to 20 times in 24 hours. Urine may be cloudy from mucus and
urate.
Hepatic adaptation
The liver continues to play a role in blood formation. Jaundice is a major
concern in the neonatal hepatic system because of increased serum level
of unconjugated bilirubin from increased red blood cell lysis, altered
bilirubin conjugation, or increased bilirubin reabsorption from the GIT.
Physiological jaundice develops in about 50% of the full term neonates
and 80% of preterm neonates. The icteric color isnt apparent until the
bilirubin levels are between 4 and 6 mg/dl. Physiological jaundice appears
after the first 24 hours of extra uterine life.
Immune system adaptation
The newborn cannot limit an invading organism at the portal of entry. The
immaturity of a number of protective systems significantly increases the
risk of infection in the newborn period.
The neonates immune system depends largely on three
immunoglobulins IgG, IgM, IgA
IgG a placentally transferred immunoglobulin, provides the neonates with
antibodies to bacterial and viral agents. Can be detected in the fetus at
the third month of gestation. The infant first synthesis its own IgG during
the first 3 months of life, thus compensating for concurrent catabolism of
maternal antibodies.
IgM is synthesized in fetus by the 20th week of gestation. IgM does not
cross the placenta. High levels of IgM in the neonate indicate a non
specific intrauterine infection.
13

IgA is not detectable at birth, it does not cross the placenta. Secretion of
IgA is found in colostrums and breast milk. IgA limits bacterial growth in
the GIT.
The neonates have fragile defenses against infection.
Neurological adaptation
General neurological function is evident by the neonates movement.
These movements are uncoordinated and poorly controlled indicating the
immaturity of the neurological system. The neonate demonstrates
primitive reflexes, which disappear during the infancy period, being
replaced by purposeful activity.
The full term neonates neurological system should produce equal
strength and symmetry in response & reflexes. Diminished or absent
reflexes may indicate a serious neurological problem and asymmetrical
response may indicate trauma during birth, including nerve damage,
paralysis and fracture.
Reproductive system
Female
At birth the ovaries contain thousands of primitive germ cells. These
represent the full complement of potential ova. The ovary, cortex, which
is made up primarily of primordial follicles, occupies a larger portion of
ovary in female newborn than in female adults.
Male
The testis descend into the scrotum by birth in 90% of new born boys
BEHAVIOURAL ADAPTATION
First period of reactivity
This is a phase of instability during the first 6 to 8 hours of life
through which all newborn pass, regardless of gestational age or nature of
labor and delivery. The newborn undergoes an intense period of activity
and alertness that probably represents a sympathetic nervous system
response to the intense stimulation of the labor and delivery process.
During this period the infant enters a state of alertness, peering intently
at the surrounding people and the environment. This may allow the
newborn to achieve eye contact with the parents or the caregivers for
brief period of time. Immediately after birth respiration is rapid (may
reach 80 breaths per minute) and transient nostril flaring retractions and
grunting may occur. The heart rate may reach 180 beats per minute
during the first few minutes of life.
Period of decreased activity
Following the initial response the newborn becomes quite, relaxes
and falls asleep. This first sleep also known as sleep phase occur within 2
hours of birth and last from a few minutes to several hours
14

Second period of reactivity


The second period of reactivity begins when the baby awakens and
show an increased responsiveness to environmental stimuli. The period is
marked by hyper responsiveness to stimuli, skin color changes from pink
to slightly cyanotic and rapid heartbeat.
Other behavioral adaptation include
a) Establishing a regulated behavioral tempo independent of mother,
which include self regulation of arousal, self monitoring of changes
in state, and patterning of sleep.
b) Processing, storing and organizing multiple stimuli
c) Establishing a relationship with care givers and the environment
ASSESSMENT OF NEWBORN
The first 24 hours are critical because respiratory distress and circulatory
failure can occur rapidly and with little warning. So the assessment of
newborn is very important. The initial assessment of the newborn is done
at birth by using Apgar score and a brief physical examination. A
gestational age assessment is done within 2 hours of birth. A more
comprehensive physical assessment is completed within 24 hours of
birth.
PHYSICAL ASSESSMENT
Initial physical assessment
CNS
Moves extremities, muscle tone good, symmetrical features, movement,
sucking reflex, rooting reflex, Moro reflexes, grasp reflex, anterior fontanel
soft and flat.
CARDIOVASCULAR SYSTEM
Heart rate strong and irregular
No murmers
Pulse strong and equal bilaterally
RESPIRATION
Lungs clear to auscultation bilaterally
No retraction or nasal flaring
respiratory rate 30 60 breaths per minute
Chest expansion symmetrical
No upper airway congestion
GASTROINTESTINAL SYSYEM
Abdomen soft, no distension
Cord attached and clamped
Anus appear patent
15

ENT
Eyes clear
Palates intact
Nares present
GENITOURINARY SYSTEM
Male- urethral opening at the tip of penis, testes descent bilaterally
Female- vaginal opening apparent skin color
APGAR SCORE

Detailed physical examination


1. Baseline data
Name of the baby
Age
Sex
Date of birth
Birth weight
Delivery
- singleton/ twins/triplet
Diagnosis
- prematurity/ post maturity/ normal
Cord
- normal/ prolapsed
Condition at birth
- active/ asphyxiated
Any birth anomalities
- present/ absent
Treatment at birth
Apgar score
16

2. Vital signs
Temperature
Pulse
Respiration

3. Anthropometric measurement
Weight
Height
Head circumference
Chest circumference
Abdominal circumference
4. General appearance
Posture
Activity
Body build

- Active/ Dull
- Thin / Well built

5. Skin
Color
Texture
Turgor
Vernix caseosa
Lanugo
Edema
Milia
Mongolian Spot

- Pale/ Pink/ Jaundiced/ Cyanosed


- Smooth/ Dry
- Normal/ Dry
- Present/ Absent
- Present/ Absent
- Present/Absent
- Present/ Absent
- Present/ Absent

6. Head
Size
Shape
Anterior fontanels
Posterior fontanels
Caput succedaneum
Cephalohematoma
7. Eyes
Eyelid
Iris color
Sclera
Red reflex

- Normal/ Macrocephaly/ Microcephaly


- Normal/ Abnormal
- Palpable/ Depressed/ Bulging
- Palpable/ Depressed/ Bulging
- Present/ Absent
- Present/ Absent
- Normal/ Edematous
- White/ Blue/ Yellow
- Present/ Absent

8. Nose
17

Patent nostrils
- Present/ Absent
Nasal discharge
- Present/ Absent
Nasal septal deviation - Present/ Absent
Flaring of nostrils
- Present/ Absent
9. Ear
Symmetry
Appearance
Pinna in line with eyes 10.
Mouth
Secretions
Intact lips and palate
Oral trush

- Present/ Absent
- Present/ Absent

11.
Neck
Size
Neck webbing

- normal
- Present/ Absent

12.
Chest
Shape
Movement
Breath sound
Heart sound

- Symmetry/ Asymmetry
-

13.
Abdomen
Shape
Umbilical cord
Whartons jelly
Bowel sounds

- Present/ Absent
- Present/ Absent

14.
Female Genitalia
Labia Majora
- Normal/ Edematous
Labia Minora
- Normal/ Abnormal
Vaginal Discharge
- Present/ Absent
15.
Male Genitalia
Urethral opening
- Present/ Absent
Testis
- Descended/ Undescended
Epispadia
- Present/ Absent
Hypospadia
- Present/ Absent
16.
Spine
Spine
Spina bifida

- Intact/ Abnormal
- Present/ Absent
18

Abnormal curvature
17.
Extremities
Shape
Range of motion
Nail Buds
Muscle tone
Polydactylity
Syndactylity

- Present/ Absent
- Symmetric/ Asymmetric
- Active/ Inactive
- Pink/ Cynosised
- Normal/ Abnormal
- Present/ Absent
- Present/ Absent

18.
Neuromuscular
Cry
- Weak/ Loud/ High pitched
Lethargic
- Present/ Absent
Activity
- Active and alert/ Drowsy
Reflexes
o Moro Reflex
o Sucking reflex
o Rooting Reflex
o Tonic neck reflex
o Grasp reflex
o Stepping or walking reflex
o Babinski sign
BEHAVIORAL ASSESSMENT
Newborn behavioral state are
Sleep state
o Deep or quite sleep
o Active or REM sleep
Alert state
o Drowsy
o Wide Awake
o Active Awake
o Crying
The newborn behavioral assessment is done through Brazelton neonatal
behavioral assessment scale

State
State
State
State
State
State

1
2
3
4
5
6

BRAZELTON NEONATAL BEHAVIOURAL ASSESSMENT SCALE


Deep sleep, without movements, breathing regularly
Light sleep, closed eyes, some corporal movement
Sleepy, eyes opening and closing
Awake, opening eyes, minimum corporal movement
Completely awake, strong corporal movement
Cry
19

GESTATIONAL AGE ASSESSMENT


Two methods are commonly used clinically for the assessment of
gestational age. They are Parkin Score and New Ballard Method.
Parkin Score
This depends on skin texture, skin color, breast size and ear firmness
Skin texture
This is tested by picking up the fold of abdominal skin between fingers
and thumb and assessment is done through inspection
Score 0 very thin and gelatinous feel
Score 1 thin smooth
Score 2 slight thickening and stiff feeling
Score 3 Thick and parchment like superficial or deep cracking
Skin color
Score 0 Dark red
Score 1 Uniformly pink
Score 2 Pale pink
Score 3 Pale
Breast size
Measured by feeling the breast nodule by finger and thumb
Score 0 No breast tissue palpable
Score 1 Not more than 0.5 cm in diameter
Score 2 0.5 to 1 cm in diameter
Score 3 more than 1 cm in diameter
Ear firmness
Tested by palpation and folding of the upper Pinna and noticing the
recoiling
Score 0 Pinna feels soft and easily folded in bizarre position without
springling back into
Position simultaneously.
Score 1 Pinna feels softer along the edge and easily folded and return
slowly to the
Correct position simultaneously.
Score 2 Cartilage can be felt up to the edge of the Pinna and it spring
back immediately
after being folded.
Score 3 Pinna is firm with definite cartilage extended up to the periphery
and spring back
immediately into the position after being folded
20

MATURITY RATING
Parkin Score
Age ( in
weeks)
1
26
2
30
3
33
4
34
5
35
6
36
7
37
8
38
9
39
10
40
11
41
12
42

Ballard Score Method


Used to assess neuromuscular maturity. Calculated by assessing the
posture, angle of wrist, arm recoil, popliteal angle, scarf sign, and heel to
ear maneuver.

21

ESSENTIAL NEWBORN CARE


The first hour after birth has a major influence on the survival, future
health and wellbeing of the newly born child
1) Clean child birth and cord care
Maintain the principle of child birth
Clean hand
Clean perineum
Nothing unclean introduced vaginally
Clean delivery surface
Cleanliness in cord clamping and cutting
Cord care
Infection prevention
Control measures at health care facilities
2) Clean airway
Suction of the airway and initiate respiration
22

3) Thermal Protection
Delivery in a warm room
Dry newborn thoroughly and wrap in dry, warm cloth
Keep out of draft and place on a warm surface
Initiate skin to skin contact ( kangaroo care)
Check warmth by touching the babies feet
4) Early and immediate breast feeding
Promote breast feeding within one hour
Educate about correct breast feeding techniques
No prelacteal feed or other supplement
Psycho social support to breast feeding mother
5) Care of eyes
Prevent ophtalmo neonatorum (conjunctivitis with discharge during
first 2 weeks of life)
1% silver nitrate solution or 1% tetracyclineoinment
6) Nutrition
The rate of growth of newborn during the first 6 month of life is
greater and faster than any other period of life.
The weight is doubled by the age of 5 month and tripled by the end
of one year.
A term healthy infant need 100 110 kcal/kg of body weight per day
All babies regardless of the type of delivery should be given early
and exclusive breast feeding up to 6 months
7) Immunization
Age (completed
weeks/
months/years)
Birth

Vaccines

6 weeks

DPT/DTaP1
OPV1
Hib1
HepB2
DPT/ DTaP2
OPV2
Hib 2

10 weeks

14 weeks

BCG
OPV0
HepB 1

DTP/ DTaP3
OPV3
23

6 month
9 months
15 18 months
16 24 months
4 5 years
10 Years
16 Years

Hib 3
Hepatitis B3
Measles
MMR
DPT/D TaP4
OPV4
Hib booster
DPT/DTap4
OPV5
Inj TT
Inj TT

Optional vaccines
Age (completed weeks/ months/years)
2 Months
4 Months
6 Months
15 Months
6 Months 6 Years
Less than 1 year
Less than 2 years
Less than 6 years

Vaccines
PCV 7 I
PCV 7 II
PCV 7 III
PCV & Booster
Influenza vaccine
Varicella vaccine
Inj.HAV, Typhoid vaccine
MMR II

IDENTIFICATION OF HIGH RISK NEWBORN AND REFFERAL


Early identification of the high risk newborn is the first step in detecting
and managing complication to reduce morbidity and mortality
DEFINITION
The high risk neonates can be defined as a newborn, regardless to the
gestational age or weight, who has greater than average chance of
morbidity and mortality, because of conditions or circumstances
superimposed on the normal course of event associated with birth and
adjustment to extra uterine existence.
CLASSIFICATION
Classification according to the birth weight
Low birth weight birth weight less than 2500 gm
Very low birth weight birth weight less than 1500 gm
Extremely low birth weight newborn whose birth weight is less than
1000 gm
Appropriate for gestational age babies whose birth weight falls
between 10and 90 percentile on the intrauterine growth curve
24

Small for date or small for gestational age whose rate of


intrauterine growth has slowed and whose birth weight falls below
the 10 percentile on intrauterine growth curve
Large for gestational age whose birth weight falls above 90
percentile.

Classification according o gestational age


Premature (preterm babies) born before completion of 37 weeks of
gestation
Full term baby born between the beginning of 38 th week and
completion of 42 week of gestation regardless of gestational weight
Post maturity (post term) - Baby born after 42 week of gestation
regardless to the birth weight
Classification according to mortality
Live birth -birth in which the neonates manifest heartbeat,
breathing or display voluntary movement regardless to gestational
age
Fetal death death of the fetus after 20 weeks of gestation and
before delivery with the absence of any signs of life after birth
Neonatal death death of that occur in the first 28 days of life.
Early neonatal death -that occur within the first week of life.
Late neonatal death - that occur at 7 to 27 days
Classification according to pathophysiologic problems
Associated with state of maturity, chemical disturbance e.g.
hypoglycemia, hypocalcaemia
Immature organ and system e.g. respiratory distress, hypothermia
PREVENTION
Maternal nutrition
Life style modification
Early detection and management of maternal disease condition like
gestational diabetes mellitus, hypertension etc
Regular antenatal check up
MANAGEMENT
Temperature control
Oxygen therapy
Nutritional management
PARENTING PROCESS
The Process of Parenting describes the many ways parents and caregivers
can translate their love for children into effective parenting behavior.
25

Parenting is the process of raising and educating a child from birth until
adulthood. This is usually done in a childs family by the mother and the
father (the biological parents )
MOTHER= IS THE NATURAL OR SOCIAL FEMALE PARENT OF AN
OFFSPRING.
FATHER= IS TRADITIONALLY THE MALE PARENT OF A CHILD.
DEFENITION
Parenting process is promoting and supporting the physical, emotional,
social, and intellectual development of a child from infancy to adulthood.
it refers to the activity of raising a child rather than the biological
relationship.
GOALS
Survival goal - To promote the physical survival health of their children,
thereby ensuring that the child live long enough to produce their children
Economic goal - To foster the skills and behavioral capacities that the
children will need for economic self maintenance as adult.
Self actualization goal - To foster behavioral capacities for maximizing
cultural values and beliefs.
TYPES OF PARENTING
Authoritative parenting
Authoritarian Parenting
Permissive Parenting
Neglectful Parenting
Authoritative parenting
Democratic or balance parenting.
It has a give and take nature.
It encourages children to be independent but still places limits and
controls on their actions.
Authoritative parents sets limits and demand maturity but when
punishing a child, the parent will explain his or her motive for their
punishment.
Parent are attentive to their children's needs and concerns and will
typically forgive and teach instead of punishing if a child falls short.
Result in children having a higher self esteem.
This is the most recommended style of parenting by child rearing
experts.
Authoritarian Parenting
Also called strict parenting.
Characterized by high expectations of conformity and compliance to
parental rules and directions.
26

It is a restrictive punitive style in which parents advise the child to


follow their directions and to respect their work and effort.
Authoritarian parents expect much of their child but generally do not
explain the reason for the rules and boundaries.
Authoritarian parents are less responsive to their childrens needs
and are more likely to spank a child rather than discuss the problem.
Permissive Parenting
Permissive parents want to and tend to give up most control of the
home and family life to their children.
Parents make very few rules and even when they do decide to make
a rule, the rules that they makes are usually not enforced all the
time or properly.
Parents want children to feel as if they can be free to do or say as
they wish.
Neglectful Parenting
This is also called uninvolved, detached, and dismissive or hands- off
parenting style.
The parents are low in warmth and control and are generally not
involved in the childs life.
Parents are emotionally unsupportive of their children but will still
provide their basic needs.
TRANSITION TO PARENTHOOD
The transition to parenthood is described as a time of disorder and
disequilibrium, asa well as satisfaction for the mother and their partners
Maternal adjustments
Three phases are evident as the mother adjusts to her parental role.
These phases are characterized by dependent behavior, dependentindependent behavior and interdependent behavior.
Dependent: taking in
First 24 hours or may rang 1 to 2 days
Focus is on self and meeting the basic needs
Reliance on other to meet needs for comfort, rest, closeness,
ndnourishment
Excited and talkative
Desire to review birth experience
Dependent independent: taking hold
Starts second or third day, and last 10 days to several weeks
Focus is on care of baby and competent mothering
Desire to take charge of the baby
Still has need for nurturing and acceptance by others
27

Eagerness to learn and practice optimal period of teaching by


nurses
Handling of physical discomfort and emotional changes
Interdependent: letting go
Focus is on forward movement of family as a unit with interacting
with members
Reassertation of relationship with partners
Resumption of sexual intimacy
Resolution of individual roles
Paternal adjustment
The paternal adjustment occur mainly in three stages
Stage 1 expectation
Father has preconceptions about what life will be like after baby
comes home
Stage 2 Reality
Father realizes that expectations are not always based on fact
Common feeling experienced are sadness, ambivalence, jealousy,
frustration
Overwhelming desire to be more involved
Some fathers are pleasantly surprised at the ease and fun of
parenting
Stage 3 :transition to mastery
Fathers make conscious decision to take control and become more
activelyinvolved with infant
Sibling adjustment
Demonstrate acquaintance behavior with the newborn and the
behavior depands upon the information that is given to the child
before the baby is born and on the childs cognitive developmental
level.
The initial behavior of sibling with the newborn includes looking at
the infant and touching the head.
There should be a unrealistic level of maturity for the child to accept
and love a rival for the parents affection
FACTORS INFLUENCING PARENTAL RESPONSES
Age adolescent mother
Adolescent father
Maternal age greater than 35 years
Paternal age greater than 35 years
28

Culture
Socioeconomic conditions
Personel aspirations
RESEARCH ABSTRACT
A cohort study was done among 250 consecutively born late preterm and
equal number of term newborn to assess the morbidity and mortality of
late preterm in comparison to full term neonates in a tertiary care
hospital at Delhi. The study revealed that the late preterm neonates have
significantly more mortality and morbidity mostly due to respiratory
distress, invasive ventilation seizures, jaundice and shock compared to
term neonates. The maternal hypertension and lower gestational age was
the strongest predictors of morbidity.
CONCLUSION
The above study reveals the importance of maintaining good maternal
health during course of pregnancy for having a healthy newborn. The
newborn adaptation and management is a complex process. The health of
the newborn largely depends on the maternal health.

BIBLIOGRAPHY
Textbook
I. Barbara R. Straight. Maternal newborn nursing. 4 th edition. Lippincot.
Page no 159
29

II.
III.

Brown miller. Pediatrics. 1st edition. Lippincot. Page no 33


Lynna Y Littileton. Maternity Nursing Care. 1st edition. Delmar
learning. Page no.741
IV. Deitra Leonard Lowdwermilk. Maternity Nursing. 7 th edition. Elsevier.
Page no 512
V. D.C.Dutta. Text book of obstetrics. 6th edition. New central book
publisher. Page no 213
VI. Kamini Rao. Text book of midwifery and obstetrics for nurses
Internet
VII. www.wikipedia.com
VIII. www.authorstream.com
IX. www.parentingprocess.org
X. www.googlebooks.com

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