Course : I year M.

Sc (N)

SUBJECT : OBSTETRIC&GYNECOLOGICAL NURSING

Unit : UNIT 6
Topic : NORMAL NEWBORN
Name of the student : Mrs. Reshma S S
Name of the HOD : Mrs. Shakila K
Name of the evaluator : Mrs. Shakila K
Hours allocated : 3 hours
Submitted to : Prof. V. MARY ELIZABETH
Date of submission : 13/03/2019

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 NORMAL NEWBORN
INTEX

SL NO CONTENT PAGE
NO
I. INTRODUCTION 3

II. DEFINITIONS/MEANING OF NORMAL NEWBORN 3

III. OBJECTIVES OF NEWBORN CARE 4

IV. CHARACTERISTICS OF NORMAL NEWBORN 6

V. EXTRAUTERINE OR PHYSIOLOGICAL ADAPTATION OF 7

NEWBORN
VI. ASSESSMENT OF NEWBORN 14

a. INITIAL ASSESSMENT 11
b. ROUTINE ASSESSMENT 14
c. BEHAVIOURAL ASSESSMENT 18
VII. CARE OF NEWBORN 20
VIII. IDENTIFICATION OF HIGH RISK NEWBORN AND 29
REFERRALS
IX. PARENTING 33

X. MINOR DIRDER OF NEWBORN AND ITS MANAGEMENT 35

XI. NURSING MANAGEMENT 38

XII. NURSING DIAGNOSIS 41
XIII. SUMMARY 45
XIV. ABSTRACT 46
XV. CONCLUSION 47
XVI. BIBLIOGRAPHY 48

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 NORMAL NEWBORN

I. INTRODUCTION

The birth of the baby is one of life’s happiest moments. The birth of the baby is
usually occasioned by a well term baby and a healthy mother. The period of first 28
days of life of a baby is called neonatal period. They truly constitute the foundation of
human life. Just as children are not mini adult, neonates are not mini children. The
unique health issues and problems due to structural and functional immaturity of
various body organs depending up to their gestational age and birth weight. Newborn
period is the most vulnerable phase of life and deaths during first 28 days of life
account for over 60% of all infant deaths and 40% of all deaths of under five children.
Essential newborn care is required by all neonates whether they are born healthy or
unhealthy.
Baby may be borne by vaginal delivery or cesarean delivery. In the first
hour or two hours after birth, most babies are in an alert, wide awake phase. A
newborn is considered as healthy when the infant is born at term, cries almost
immediately at birth, is having the adequate birth weight according to the country
[around 2.7 kg in India] and establishes satisfactory rhythmic pulmonary respiration.
The first hour after birth has a major influence on the survival, future health, and
wellbeing of a newly born infant. The health worker has an important role at this time.
The care they provide during this period is critical in helping to prevent complications
and ensuring survival.

II. DEFINITION/ MEANING OF NEWBORN

In medical contexts, newborn or neonate (from Latin, neonatus, newborn)

refers to an infant in the first 28 days after birth; the term applies to premature, full
term, and post mature infants; before birth, the term “fetus” is used.

The Cambridge Dictionary meaning of newborn is a child that has recently born.

The Newborn or neonate as a child that’s fewer than 28 days old.

World Health Organization (WHO)

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III. OBJECTIVES OF NEWBORN CARE

1. Reduction of morbidity and mortality rate for newborn.

In a major boost to mortality and mortality rate in India, the child deaths
have come down and stand same as global average, according to a report by
UNICEF, WHO, UN population Division and World Bank Group.
2. Promotion of the physical and physiological development of the child within
the family.
Newborn in the first week of life have no control over their movement and
all their physical activity is involuntary or reflex. Even from birth babies can
communicate with their near ones. A newborn doesn’t realize they are a
separate person. Proper care by family members only may help the newborn to
adjust with new world.
3. To provide evidence based practices to ensure survival of newborn from birth
up to the first 28 days of life.
Two thirds of all newborn deaths occur in the first 3 days of life primarily
due to complications of low birth weight, prematurity, birth asphyxia and
newborn infections. International evidences suggest that there are several
opportune moments during which prevention of newborn death is possible
through provision of high quality routine care during lobour, delivery and the
immediate postpartum period.
4. To deliver time-bound core intervention in the immediate period after the
delivery of the newborn.
Protocols of four time bound interventions are;
 Immediate and thorough drying.
 Early skin to skin contact followed by,
 Properly timed clamping and cutting of the code after 1 to 3minutes, and
 Non separation of the newborn from the mother for early breastfeeding
initiation and rooming in
5. To provide appropriate and timely emergency newborn care to newborns in need
of resuscitation
Recent global discussions have centered on expansion of immediate
emergency care of newborn to avert death and disability.

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IV. CHARACTRISTICS OF NORMAL NEWBORN

Physical Characteristics of Healthy Neonates

A healthy newborn usually has the following physical characteristics:

a) Vital signs: Temperature should be recoded to detect cold stress or hypothermia.

Skin temperature is measured usually by axillary method. Respiration, heart rate and
blood pressure should also be recorded (when the baby is quiet) to detect the
physiological status.
Normal vital signs
 Temperature 35.5°C to 37.5°C
 Pulse 100 to 140 beats/minute
 Respiration 30 to 50 beats/minute
b) Anthropometric measurement: The results of five anthropometric parameters are
birth weight, crown heel length, head circumference, chest circumference and
ponderal index provides references for the care of newborns. Anthropometric
measurements are of both epidemiological and clinical use.
 Weight: The average weight of a normal full term newborn infant is about 2.9 kg
with variation of 2.5 to 3.9 kg or more. The weight is very variable from country
to country and in different socioeconomical status.
 Length: At birth the average crown heel length of the term infant is 50 cm with
the range of 48-53cm. The length is a more reliable criterion of gestational age
than the weight.
 Head circumference: The head circumference is usually varies from 33 to 37
cm, with the average of 35 cm.
 Chest circumference: The chest circumference is about 3 cm less than head
circumference. The chest is rounded rather than flattened anteroposteriorly.
 Ponderal index: Is an index of weight in relation to height. a ponderal index 2.5
is considered as normal in neonate.
c) Head to toe

General appearance: The upper segment to lower segment ratio is 1.8: 1. The midpoint
of the length/ stature of the neonate lie approximately at the level of the umbilicus,
instead of the symphysis pubis as in grown up child and adults. The trunk is relatively
larger and the extremities are short. Abdomen is prominent with short neck and large
head.

Posture: The neonate lies in a posture of partial flexion attitude as in utero.

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 Skin: The skin is pinkish but bluish hands and feet (acrocyanosis) may present for a
short time after birth, even in normal infant. Skin may be covered with vernixcaseosa
and lanugo hair, especially at back. Only large veins are seen prominently, skin shows
good elasticity or turgor.

Head: The head may show moulding and caput succedaneum. Hair is silky, black coarse
and individual strands distribution on scalp.

Face : The maxillary and ethmoid sinuses are small. The frontal and sphenoidal sinuses
are poorly developed

Ear: The ear cartilage is firm and fully curved, showing good elastic recoil. Pinna is
firm with definite cartilage and instant recoil in ears. The external auditory canal is
relatively short and straight. The eardrum is thick. The eustachian tube is short and
broad

Eyes :The eyes are largely covered with eye lids.

Trunk :The breast nodule is palpable, measuring over 5 mm in diameter. breast tissue
and nipple raised above skin level

Foot: The entire sole of foot shows prominent deep creases.

Abdomen: Kidney, liver and spleen may be palpable.

Male genitalia: The scrotum shows adequate rugae with deep pigmentation and palpable
testes (at least one).

Female genitalia: In female baby the labia majora completely covers the labia minora
and clitoris.

V. EXTRAUTERINE OR PHYSIOLOGICAL ADAPTATION OF NEWBORN

Newborn undergo phases of instability during the first 6 to 8 hours after birth.
These phases are collectively called the transition period between intrauterine and
extra uterine existence. The first period of transition period lasts up to 30 minute after
birth is called the first period of reactivity. After the first period of reactivity the
newborn either sleeps or has a marked decrease in motor activity. This period of
unresponsiveness, often accompanied by sleep, lasts from 60 to 100 minutes and is
followed by a second period of reactivity.

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 1. RESPIRATORY ADAPTATION
With cutting of the umbilical cord the infant undergoes rapid and complex
physiologic changes. The most critical and immediate adjustment of a newborn marks
at birth is establishment of respirations. With a vaginal birth some lung fluid is
squeezed from the newborn’s trachea and lungs; in infants who are born by cesarean
birth, some lung fluid may be retained within the alveoli. With the first breath of air
the newborn begins a sequence of cardiopulmonary changes.
Initial breathing is probably the result of a reflexes triggered by pressure
changes, exposure to cool air temperature, noise, light, and other sensations related to
birth process. In addition, the chemoreceptor in the aorta and carotid bodies initiate
neurologic reflexes when arterial oxygen pressure (Po2) falls, arterial carbon dioxide
pressure (PCo2) rises, and arterial pH falls. In most cases an exaggerated respiratory
reaction follows within 1 minute of birth, and the infant takes a first gasping breath
and cries

Method of cry
“Cry it out” method, also called extinction sleep training, refers to sleep training
method that allow your baby to shed a few tears and fuss for a set period of time, often
gradually increasing intervals, before you rush in to feed or console.

2. CIRCULATORY CHANGES

PRENATAL STATUS POST BIRTH STATUS ASSOCIATED

FACTORS
Primary changes
Pulmonary circulation: Low pulmonary vascular Expansion of collapsed
high Pulmonary vascular resistance;decreased pressure fetal lung with air
resistance, increased in right atrium, ventricle, and
pressure in right ventricle pulmonary arteries
and pulmonary arteries

Systemic circulation: low High systemic vascular Loss of placental blood

pressure in left atrium, resistance; increased flow
ventricle, an aorta pressure in left atrium,
ventricle, and aorta

Secondary changes
Umbilical arteries: patent, Functionally closed at birth; Closure proceeding that of
carrying of blood from obliteration by fibrous umbilical vein, probably
hypo gastric arteries to proliferation possibly taking accomplished by smooth
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placenta 2-months, distal portions muscle contraction in
becoming lateral response to thermal and
vesicoumbilical ligaments, mechanical stimuli and
proximal portions remaining alteration in oxygen
open as superior vesicle tension, mechanically
arteries severed with cord at birth

Umbilical vein: patent, Closed, becoming Closure shortly after

carrying of blood from ligamentum teres hepatis umbilical arteries, hence
placenta to ductus venous after obliteration nlood from placenta
and liver possibly entering neonate
for short period after
birth, mechanically
severed with cord at birth

Ductus venosus: patent, Closed, becoming Loss of blood flow from

connection of umbilical ligamentum venosum after umbilical vein
vein to inferior vene cava obliteration

Ductus arteriosus; patent, Functionally closed almost Increased oxygen content

shunding of blood from immediately after birth, of blood in ductus
pulmonary artery to anatomic obliteration of arteriosus creating
descending aorta lumen by fibrous vasospasam of its
proliferation requiring 1-3 muscular wall.
months, becoming High systemic resistance
ligamentum arteriosum increasing aortic pressure;
low pulmonary resistance
reducing pulmonary
arterial pressure

Foramen ovale: formation Functionally closed at birth, Increased pressure in left

of a valve opening that constant apposition
allows blood to flow gradually leading to fusion
directly to left atrium and permanent closure
(shunting of blood from within a few months or years
right to left atrium) in majority of persons
atrium and decreased
pressure in right atrium
causing closure of valve
over foramen

The heart rate of the baby is around 120-160 beats per minute. Peripheral
circulation is sluggish. Blood pressure ranges from 80-85/50-55 mm Hg during first
few days. The hemoglobin levels are high i.e., 18-20 gm/ dl. In the first week of life,
jaundice may appear in the baby because of the breakdown of the excess red blood
cells in the liver and spleen. With the clamping of the umbilical cord and first breath

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 by the baby, fetal circulation alters to the mature circulation. There is closure of
ductus arteriosus, converting into ligamentum arteriosum and closure of foramen
ovale. The umbilical vein becomes obliterated and is known as the ligamentum teres.
There is decreased pulmonary vascular resistance and increased aortic blood pressure.

3. GASTROINTESTINAL SYSTEM
The term newborn is capable of swallowing, digesting, metabolizing, and
absorbing protein and simple carbohydrates and emulsifying fats. The capacity of
the stomach varies from 30 to 90 ml depending on the size of the infant. Cardiac
sphincter and nervous control of the stomach are immature, thus some regurgitation
may occur, by burping the infant and by positioning the infant with the head slightly
elevated.
The mucus membrane of the term baby is moist and pink, and the sucking
pads give the full appearance of the cheek of the baby. After around one hour of the
birth, bowel sounds are present. The meconium containing bile, mucus, fatty acids
and epithelial cells, is passed for 2-3 days. The stool of the breast fed baby is loose,
bright yellow and inoffensive. On the other hand, stool of the bottle fed baby is semi
formed and have sharp smell. During the first few days, cardiac sphincter of the
baby is weak which may lead to regurgitation. Physiological jaundice generally
appears in the newborns due to low production of glucuronyl transferase enzyme
along with the red cell breakdown.
The infant liver plays an important role in iron storage, carbohydrate
metabolism, conjugation of bilirubin, and coagulation. In the newborn, the liver can
be palpated approximately 1 cm below the right costal margin because it is enlarged
and occupies approximately 40% of abdomen.
4. THERMAL REGULATORY SYSTEM
As there is immaturity of hypothalamus at birth, the neonate is
inefficient to maintain the optimum temperature and is at risk of hypothermia. The
baby will try to maintain thermoregulation by adopting flexed posture and by
peripheral vasoconstriction. The neonate has to be dressed properly and the
environment should not be cold, so that the baby can maintain temperature of 36-37
degree Celsius. The neonate is capable of producing heat through both general and
brown fat metabolism.
When the skin of the baby become cold, afferents convey the message
to the heat regulating system located in the pre-optic anterior hypothalamic area
near the wall of the third ventricle. Neurologic efferent, on reaching the brown fat
trigger the local release of noradrenalin so that the triglycerides are oxidized to
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 glycerol and fatty acids. The blood level of glycerol rises but the fatty acids are
locally consumed for the generation of heat. About 30 % of non-esterified fatty acid
are oxidized to generate heat, 60% are re-estrified and 10% are released in the
circulation. The area of brown fat become warm and heat is distributed to various
parts of the body through blood stream. It is obvious that the baby would need
oxygen and glucose for this metabolic effort in order to keep itself warm. Effective
metabolic thermogenesis demands integrity of central nervous system pathway,
adequacy of brown fat and availability of glucose and oxygen.

5. MUSCULOSKELTAL SYSTEM
The bones are not completely ossified, though the muscles are complete at
birth. The skull bones are also not ossified completely which is mainly for the growth
of the brain and for helping in the moulding during labour. The neonates is having
two fontanelles which can be palpated at birth; namely, anterior fontanelle or
bregma is a diamond-shaped membrane filled space. The junction where the two
frontal and two parietal bones meet. The anerior frontanalle remains soft until about
18 months to 2 years of age. Posterior frontanelle (lamdoid frontanelle or occipital
frontanalle) this is the junction of two parietal bones and the occipital bone. The
posterior frontanelle usually closes first [fuses at around 6-8 weeks].

6. RENAL SYSTEM
Kidneys of the neonate are not adequately mature. GFR is low along
with restricted tubular resorption capabilities. The bladder can be palpated
abdominally as the urine of the baby is straw colored, dilute and odorless, and is
passed for the first time at birth or within 24 hours of birth. The newborn bladder has
predicted capacity of approximately 20 to 30 ml. Some newborn urinate up to 20
times in 24 hours.

7. IMMUNOLOGICAL SYSTEM
There are mainly three main immunoglobulin; IgG, IgA, and IgM.
IgG can cross the placental barrier and gives immunity to certain viral infections in
the neonates; where as IgA and IgM do not cross the placental barrier. IgA is found
in the breast milk and is important because it coats and seals your baby’s respiratory
and intestinal tract to prevent germs from entering baby’s body and his bloodstream.
IgM is produced by newborn itself. Newborn is prone to infections because of
immature immune system. Passive immunity is provided by breast milk, especially
colostrums.

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 8. REPRODUCTIVE SYSTEM
After the birth there is withdrawal of the maternal hormones which can result in
breast engorgement and secretion of milk in both males and females. Pseudo
menstruation, there may be small amount of bleeding from the vagina may occur in
girls. By the third day after birth, breast swelling may also be seen in newborn boys
and girls. It should go away by the second week after birth due to withdrawal of
maternal hormone estrogen. DO NOT squeeze or massage the newborn’s breast
because this can cause an infection under the skin (abscess). Hormone from the mother
also causes some fluid to leak from the infant’s nipples. This is called witch’s milk. In
both the ovaries of the female, primordial follicles are present. In males, there is no
spermatogenesis till the puberty.
As a baby boy grows inside his mother’s womb, his testicles from
inside his abdomen and move down (descent) into the scrotum shortly before birth.
Undescended testicles move down on their own in about half of these babies by the
time, they are 6 months old. If they don’t, it’s important to get treatment.

9. NEUROLOGICAL SYSTEM
Like other system, nervous system is also not fully mature at birth. The brain
grows rapidly after birth. If the brain is not developed properly and remains immature,
there occur temperature instability and uncoordinated muscle movements in the baby.
Examine the muscle tone, mead control and reflexes. Reflexes are mainly two types
protective reflexes includes blinking, coughing, sneezing, and gagging and primitive
reflexes includes rooting, sucking, moro, startle, tonic neck etc. Normal newborn
shows almost reflexes.

VI. ASSESSMENT OF NEWBORN

Assessment of newborn, as soon as possible after birth and subsequent

assessment in the postnatal period are vital responsibility of the nurse working in the
hospital or in the community. The assessment postnatal period should be done at least
for three times,

a. Initial assessment
After the birth of the baby, a complete assessment of the baby should be done so as to
find out any early abnormalities and treat them properly. The systematic examination of
the baby is done from head to toe as mentioned below:

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Anthropometric measurements

Head circumference - 33 to 35 cm

Chest measurement -31 to 33 cm

Crown heel length - 45 to 55 cm

Weight of the baby -

Vital signs

Respiration is regular and shallow. Respiratory rate is between 40-60 breaths per
minute. The heart rate varies from 120-140 beats per minute. Blood pressure ranges
from 60-80 mm Hg systolic and diastolic pressure below 50 mm Hg. The normal
temperature of the baby is about 97.5°F (36.4°C) but this can be varying slightly.

Skin

The skin is pink, soft and covered with vernix caseosa. There can be presence of
Mongolian spots (bluish pigmentation, especially over sacral area), stork’s bite,
portwine stain or strawberry marks (dark red spots on the body). Bluish colour of the
extremities may sustain for several hours after the birth.

Head

There is one anterior fontanelle and one posterior fontanelle. Observe for bulging or
depressed fontanelles, which indicate intracranial pressure or dehydration. Caput
succedaneum may be seen which should be differentiated from cephalhematoma. There
can also be the overlapping of the cranial bones during delivery.

Moulding occur when the engaging (usually vertex molds to fit cervix)
during labour which appears asymmetric after birth. After few days head restores its
shapes.

Eyes

Eyes are shut most of the times. Pupils react to the light. Newborns cry tearlessly due to
immature lacrymal ducts.

Nose

The patency of the nasal airways is checked and mucus secretions should be cleared.
Neonates generally breathe through the nose. Check for milia. Nasal flaring is a sign of
respiratory distress.
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Ears

The ears are checked for size, shape and any deformity. The ears of premature infants
lack cartilage. Pinna bends easily and should recoil after bending. The level of top part
of external ear should be on a line drawn from inner canthus to outer canthus of eye.
Low set ears are found in certain chromosomal abnormalities (trisomy 13 & 18)

Mouth

It can be best examined when the neonate is yarning or crying. Mouth can be assessed
for cleft lip and palate. Observe the natal teeth (natal teeth present at birth some times
and erupt within one month of age). Assess for the epithelial pearls or Epstein’s pearl
which the tiny cysts are found on the hard palate. Tongue tie should be checked, which
is a small thickened band from the frenulum is extending to the margin of the lower
gum preventing protrusion and upward movement of the tongue.

Neck

Neck should be checked for its free movability, tightness of muscles, brachial palsy or
fractured pelvis. Normal newborn have full range of motion.

Chest

Observe size and shape of chest. Normally, neonate chest is barrel shaped. Observe the
nipple and breast tissues; observe witch’s milk which is milky discharge due to effect of
maternal hormones. Check the rate and rhythm of respiration, neonates abdomen rise
and falls during each breathe. Chest should be two inches smaller to head. Clavicles are
straight. Breasts may be engorged which subside by one week.

Umbilical cord

The stump of the umbilical cord has three blood vessels, i.e., two arteries and one vein.

Upper extremities

Arms are checked for their normal size. In the term baby, fingernails are well
developed. There can be abnormal fusion of the fingers. Presence of extra digits is
called as polydactylism. Syndactylism is birth defect in which there is partial or total
webbing connecting two or more fingers or toe.

Genitalia

In the normal term male baby, testes can be palpated in the scrotum. Concurrently, the
scrotal skin thickens and develops deeper and more numerous rugae present. Inspect
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for urethral opening on tip of penis. Exclude opening on dorsal (epispadias) or on
ventral side (hypospadias). In female babies, labia minora is covered by labia majora,
baby girls may have prominent clitoris and there can be presence of some vaginal
discharge or pseudomenstruation due to withdrawal of the maternal hormones.

Back

For checking the back, infant is held in prone position and the back is evaluated. If tufts
of hair are present, it indicates fistula. Assess for spina bifida, a birth defect in which a
developing baby’s spinal cord fails to develop properly, it may leads to deformities
from scoliosis to deformities of lower extrimities.

Anus

After the birth of the baby, anus is checked for perforation. A rubber catheter is
introduced into the rectum to check the passage of the stool.

Lower extremities

Assess the size and symmetry of the legs. One can doubt hip dislocation if there is
asymmetry in abduction and there is presence of hip click.

In feet Polydactylism, syndactylism and webbing can be assessed in the toes. Presence
of some congenital abnormalities should be noted, such as, talipes equinovarus, talipes
calcaneovalgus and bow legs. The soles of the term neonate should be wrinkled and in
some cases acrocyanosis may be present immediately after birth

Talipes equinovarus , a Club foot, a congenital abnormality in which one or both feet
are rotated internally.

Talipes calcaneovalgus, a congenital abnormality that is combination of talipes

calcaneus and talipes valgus, in which there is dorsiflexed, everted and abducted foot.

b. Daily or routine assessment

After initial assessment, daily assessment is performed to identify the problems at an
early stage.

Vital signs - Temperature is checked axillary to look for thermal regulation.

Respiration should be regular and without any noise. Heart rate is auscultated

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Weight - Weight is checked regularly. Initially, there is loss in the weight for few days,
but the baby regains the weight in 7-10 days.

Head - Anterior fontanelle is assessed any swelling on the head is also checked such as
cephalhematoma or caput succedaneum

Skin colour - Skin is assessed for any cyanosis. In some babies jaundice may arises in
2nd to 3rd day and in certain abnormal cases jaundice can arise early.

Mouth - Mouth should be checked for any infection such as oral thrush ( adherent
white plaques).

Umbilical cord - Infection can arise, so umbilical cord should be assess daily until it
fall off.

Feeding behaviour -Nurse should assess the feeding behavior of the baby. If there are
any problems in feeding, it should be brought to the notice and treated.

Urine and stool - Elimination pattern is to be assessed. Stool of the baby is inspected
for its normalcy. Constipation or loose stools should be treated. Mother or nurse can
note the frequency of passing urine and stool.

Reflexes
Following reflexes are found in the baby at birth;

Reflexes Eliciting the reflex Characteristic comments

responses
Sucking Touch infant’s lip, Infant turns head Disappears after 3
and rooting cheek, or coner of mouth toward stimulus, to 4 months but
with nipple open mouth, takes may persist up to 1
hold, and suck year. If response is
weak or absent,
consider
prematurity or
neurologic defect
Swallowing Feed infant; swallowing Swallowing is Sucking and
usually follows sucking usually coordinated swallowing are
and obtaining fluids with sucking and often uncoordinated
usually occurs in preterm infant
without occurs
without gagging,
coughing, or
vomiting
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Grasp; Place finger in palm of Infant’s fingers curl Response lessens
palmar hand around examiner’s by 8 months
fingers
Plantar Place finger at base of Toes curl downward
toes
Extrusion Touch or depress tip of Newborn forces Response
tongue tongue outward disappears about
fourth month of life
Glabellar Tap over forehead, Newborn blinks for Continued blinking
(Myerson bridge of nose, of first four or five taps with repeated taps
sign) newborn whose eyes are is consisted with
open extra pyramidal
disorder
Tonic neck With infant falling asleep With infant facing Responces in leg
or fencing or sleeping, turn head left side, arm and leg are more consistant,
quickly to one side on that side extend; after 6 weeks
opposite arm and leg persisting response
flex (tern head to is sign of possible
right, and extrimities cerebral palsy.
assume opposite
postures)
Moro Hold infant in Symmetric abdomen Response is present
reflex semisitting position, and extension of at birth, complete
allow head and trunk to arms are seen; response may be
fall backward to an angle fingers fan out and seen in 8 wk; body
of atleast 30 degrees form a ‘c’ with jerk is seen only
thumb and between 8 to 18
forefingers; slight wks; response is
tremor may be noted absent by 6 mo;
Preterm infant does Response is
not complete incomplete if infant
“embrace” instead is deeply asleep
arms fall backward
because of weakness
Stepping or Hold infant vertically, Infant will stimulate Response is
walking allowing one foot to walking, alternating normally present
touch table surface flexion and for 3 to 4 wk
extension of feet;
term infant walk
with their sole of
feet, and preterm
infants walk on their
toes
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Crawling Place newborn on
abdomen
Deep Use fingers to elicit
tendon patellar or knee jerk
reflex; newborn must be
relaxed
Closed Infant should be supine;
extension extend one leg, press
knee downward,
stimulate bottom of foot;
observe opposite leg
Startle Perform sharp and clap; Arms abduct with
best elicited if newborn flexion of elbows,
is 24 to 36 hr old or older hands stay clenched
Babinski On sole of feet,
sign beginning at heel, stroke
upward along lateral
aspect of sole, then move
finger across ball of foot
Pull-to-sit Pull infant up by wrists
(traction) from supine position
with head in midline
Trunk Place infant prone on flat
incurvation surface, run finger down
(galant) back about 4 to 5 cm
lateral to spine, first on
one side and then down
other
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Newborn makes Response should
crawling movements disappear about 6
with arms and legs. wk of age
Reflex jerk is Responces can be
present; even with used to the presents
newborn relaxed, of a neuromuscular
nonselective overall disease.
reaction may occur
Opposite leg flexes, This reflex should
adducts, and then be present during
extends newborn period
Response should
disappear by 4
months of age.
Response is elicited
more readily in
preterm newborn
All toes Absence requires
hyperextend, with neurologic
dorsiflexion of big evaluation, should
toe; recorded as a disappear after 1
positive sign year of age
Head will hold until Response depends
infant is in upright on general muscle
position, then head tone and maturity
will be held in same and condition of
plane with chest and infant
shoulder
momentarily before
falling forward
infant will attempt to
right head
Trunk is flexed, and Response
pelvis is swung disappears by
toward stimulated fourth week.
side Absence suggests
general depression
of nervous system
with transverse
lesion of cord, no
response below the
 level of lesion is
present
Magnet Place infant in a supine Both lower limbs Absence suggests
position, partially flex should extend damage to spinal
both lower extremities, against examiner’s cord or
and apply pressure to pressure malformation.
soles of feet Reflex may be
weak or
exaggerated after
breech birth
Additional These responses are May be slightly Parental guidance:
newborn spontaneous behaviors depressed most of these
responses: temporarily because behaviors are
yawn, of maternal analgesia pleasurable to
stretch, or anesthesia, fetal parents. Parents
burp, hypoxia, or infection need to be assured
hiccup, that behaviors are
sneeze normal
Sneeze is usually
response to lint,
etc., in nose and not
an indicator of a
cord
No treatment is
needed for hiccups;
sucking may help

c) Behavioral assessment

Another important area of assessment is observation of behavior.

Infants behavior helps to shape their environment, and their ability to react to various
stimuli affects how others relate to them. The principal areas of behavior for newborns
are sleep; wakefulness; and activity, such as crying.

An assessment of the neonate's behavioral responses should be a part of every pediatric

examination. A behavioral assessment reflects the capacity for integration of the central
and autonomic nervous systems and therefore is a window to the wellbeing of the
newborn. In order to fully understand and evaluate the significance of the newborn's
behavior, it is essential to put this examination into context by a complete prenatal and
perinatal history. Behavioral assessments of the newborn are being increasingly utilized
to evaluate effects of intrauterine experiences, such as fetal malnutrition, exposure to
alcohol and drugs, obstetric procedures such as maternal anesthesia and analgesia,
18
cesarean section, as well as the effects of techniques in neonatal management, such as
phototherapy and drugs. Behavioural assessments can give us insights into individual
differences among neonates and cross-cultural differences among groups of newborns.
Behavioural assessments over time will give us insight into a baby's capacity to adapt to
his environment and to overcome the physiologic stresses of delivery. We can begin to
assess a baby's potential availability for processing information necessary to future
progress. It may predict to his capacity to capture the attachment energies of his
environment as well.

In its most limited use, neonatal behavior becomes a sensitive indicator of the integrity
of the central nervous system. In a more general sense, behavioral responses can be tied
to other responses to reflect the integrity of the whole organism. And, eventually, the
infant's capacity for total responses can become a measure of prediction for the
response of the environment to him. Thus, behavioral assessment in the neonatal period
can predict the risk in the infant himself and to deficits in his environment as he
becomes a participant in parent-infant interaction. Evaluation of a baby's abilities to
respond and style of response provides the clinician with a powerful tool in his role of
helping parents to foster a child's physical and emotional wellbeing. The pattern of
recovery of his potential for behavior over the first week becomes the most important
way of predicting not only to his immediate coping capacity but to his future reactions
to stress. Thus, several assessments in the perinatal period become of significance.

It is important now to follow up our neonatal behavioral assessment with behavioral

assessments throughout the first year of life to begin to understand how developmental
processes include both the infant's capabilities and those of his environment, as well as
the relationship between them. This will give us a better handle on our goals to optimize
emotional as well as physical development in our work with parents and their infants.

Patterns of Sleep and Activity: Newborns begin life with a systematic schedule of
sleep and wakefulness that is initially evident during the periods of reactivity. After this
initial period, it is not unusual for the infant to sleep almost constantly for the next 2 to
3 days to recover from the exhausting birth process.

Infants have six distinct sleep-wake states, which represent a particular form of neural
control. As maturity increases, each state becomes more precisely defined according to
the behaviors observed. State is defined as a “group of characteristics that regularly
occur together” (Blackburn, 2003) and includes body activity, eye and facial
movements, respiratory pattern, and response to internal and external stimuli. The six
sleep-wake states are quiet, (deep) sleep, active (light) sleep, drowsy, quiet alert, active
alert, and crying. Infants respond to internal and external environmental factors by
19
 controlling sensory input and regulating the sleep-wake states; the ability to make
smooth transitions between states is called state modulation. The ability to regulate
sleep-wake states is essential in infants’ neurobehavioral development. The more
immature the infant, the less able he or she is able to cope with external and internal
factors that affect the sleep-wake patterns.

Newborns typically spend as much as 16 to 18 hours sleeping and do not necessarily

follow a pattern of light-dark diurnal rhythm. With increasing age, sleep-wake states
change, with increasing amounts of time spent in awake alert states and decreasing
amounts of sleep time. Approximately 50% of total sleep time is spent in irregular or
rapid eye movement sleep.

Cry. Newborns should begin extrauterine life with a strong, lusty cry. The sounds
produced by crying can be described as hunger, anger, pain, and “bid for attention”
cries. Discomfort (pain), sounds initially consist of gasps and cries in which the
consonant H is clearly distinguishable. The duration of crying is as variable in each
infant as the duration of sleep patterns. Newborn may cry as little as 5 minutes or as
much as 2 hours or more per day. Feeding usually terminates the state of crying when
hunger is the cause. Holding the infant skin to skin or waddling or wrapping an infant
snugly in a blanket promotes sleep and maintains body temperature. Rocking the infant
may reduce crying and induce quiet alertness or comfort. Variations in the initial cry
can indicate abnormalities. A weak, groaning cry or grunting during expiration usually
indicates respiratory disturbance. Absent, weak, or constant crying requires further
investigation for possible management

VII. CARE OF NEWBORN

1) Introduction

Every year about 27 million babies (20%of global birth) are born in India and almost
1.2 million die during newborn period accounting for 30% of global deaths. In order to
reduce neonatal mortality, essential or basic newborn care services should be available
at all the health care level because they are highly cost-effective. The component of
essential newborn care services include good quality antenatal care (at least 3 antenatal
visit), safe delivery and optional care at birth, promotion of exclusive breast feeding,
prevention and early treatment of hypothermia and bacterial infections.

2) Definition

20
Essential newborn care is a comprehensive strategy to reduce the death of newborn
through cost effective interventions, during pregnancy, immediately after birth and
postnatal period.

3) Objectives of newborn care

1. To make sure baby is thriving

Poor nutrition during this period may have lasting harmful effects on brain
development. Most babies double their birth weight by 6 months and triple it by
age 1, but kids who fail to thrive usually don’t meet those milestones.
2. Early detection of problems or danger signs.
The important danger signs are: lethargy, breathing problems, temperature
instability, and failure to pass meconium and/or urine, vomiting, diarrhea,
cyanosis, jaundice, abdominal distention, convulsions, bleeding and excessive
loss of weight.
3. Helping the mother to meet the baby’s basic needs- warmth, feeding, infection
prevention. Advising mother and family members about danger sign and baby
care.
4. Baby breast feed early as possible.
Breastfeeding within an hour after birth is critical for saving newborns lives.
Skin to skin contact along with suckling at the breast stimulate the mother’s
production of breast milk, including colostrums, also called the baby’s ‘first
vaccine’ which is extremely rich in nutrients and antibodies.
5. Advising and encouraging the mother to breast feed exclusively
Encouraging mother to give only breastfeeding frequently, day and night,
and advise the mother to allow the baby to feed as long as baby wants more than
eight times a day. It makes positive association between mother and newborn.
6. Treatment of key problems such as asphyxia and sepsis
Neonatal sepsis or septicemia is a clinical syndrome characterized by
systemic signs of circulatory compromise in the first month of life was usually
fatal. Parental antibiotic therapy is needed. Birth asphyxia is medical condition
resulting from deprivation of oxygen to a newborn infant that lasts long enough
during the birth process to cause physical harm, usually to the brain.
7. Making plans for continuing care, immunizations and growth monitoring.
Plotting the information on a growth chart to make abnormal growth visible.
According to which make plan for further movements about newborn care.

21
 a) IMMEDIATE CARE OF NEWBORN AT BIRTH

The following care needs to be given to the new born at birth, in the labor room

1. Deliver the baby on a warm and clean towel.

2. Establish and maintain a patent airway.
3. Apgar score
4. Clamp and cut the cord.
5. Ensure warmth and feeding.
6. Care of eyes.
7. Care of skin.
8. Assessment and documentation of baby’s condition
9. . Identification of baby.
10.Administration of vitamin K.
11.Transfer of the baby according to level of care required.

1. Deliver the baby on a warm, clean and dry towel.

2. Establish and maintain a patent airway: The neonate cries spontaneously at birth.
During crying the secretions of mouth and nose are suctioned to clear the airway of
mucous and amniotic fluid. If the baby is not crying, gentle tactile stimulation is
provided. If the child does not cry even after stimulation, CPR should be given. Suction
of baby’s mouth and nose should be done using a bulb syringe or mucous trap. Gentle
suction should be done to prevent bradycardia, laryngospasm and cardiac arrhythmias
from vagal stimulation.

3. Apgar score: it is a scoring system doctors and nurses used to assess newborn one
minute and five minutes after they’re born. Dr. Virginia apgar created the system in
1952, and used her name as a mnemonic for each of the five categories that a person
will score. The baby may score low at one minute, at the five minute the baby has
ideally improved. A score of 7 to 10 after 5 minutes is reassuring. A score of 4 to 6 is
moderately abnormal. A score of 0 to 3 is concerning, it indicate a need for increased
interventions usually is assistance for breathing.

SIGNS 0 1 2
Heart rate Absent Slow (<100) >100
Respiratory rate Absent Slow, weak cry Good cry
Muscle tone flacid Some flexion of Well flexed
extremities

22
 Reflex irritability No responce grimce Cry
Color Blue, pale Body pink, Completely
extrimities blue pink

4. Clamp and cut the cord: The umbilical cord is clamped when the cord pulsation
stops as this provides the infant with extra blood from the placenta. The cord is clamped
with two clamps and then cut between the clamps leaving about 1 or 5 cm from
abdomen of baby. The stump is left without any dressing and it is inspected repeatedly
for any bleeding for up to 24 hours. It is observed routinely for any redness,
inflammation and discharge till it falls off.

5. Ensure warmth: In neonates, the heat regulating mechanism is immature. The

neonate loses heat due to evaporation, radiation, conduction and convection. To prevent
heat loss from the baby following steps should be taken:

 The delivery room should be warm, with temperature of 25°-28°C.

 Dry the infant thoroughly soon after birth using a warm towel.
 Place the baby under radiant warmer or over the mother’s chest in skin to skin
contact with her.
6. Care of eyes: The eyes of the neonate are cleaned as soon as the head is delivered
using sterile cotton swabs dipped in sterile water. The eyes are cleaned from inner
canthus to outer canthus with separate swabs for each eye. Thereafter medicated eye
drops should be instilled to protect baby’s eyes from bacterial infections that may be
contracted during delivery.

7. Care of skin: The newborn’s skin is delicate so it should be gently wiped off blood,
mucous and secretions. No attempt should be made to rub off the protective
vernixcaseosa. The areas with folds Such as neck, axillae, groins and creases at joints
require special attention. The practice of giving bath to the baby at the time of birth
increases the risk of hypothermia so bathing should be postponed for 48-72 hours or
more after birth depending on baby’s condition.

8. Assessment and documentation of infant’s condition: At 1 minute and 5 minute of

birth Apgar scoring is done and while drying the baby head-to-toe assessment is done to
find out any abnormality in the new born. Administration of vitamin K.
9. Identification of the baby: Before the baby is transferred from the labor room, an
identification band placed to baby’s wrist, specifying the name of mother, registration
number, date and time of birth and sex. Also foot impression of baby is taken for baby’s

23
identification. It is important to provide mother an opportunity to see and touch the
baby and note the sex before transferring the baby to the nursery.

10. Administration of vitamin K: For a few days after birth, the new born is unable to
synthesize vitamin K that is needed for blood clotting so there is a potential problem of
abnormal bleeding. Therefore 1mg Vitamin K is administered to the baby
intramuscularly.

11. Transfer: All the normal babies are transferred to the mother and nursed then keep
the baby comfortable with the mothers. This is called rooming in. Breast feeding should
be started within half an hour of birth. However Sick or at risk neonates should be
transferred to a Neonate Intensive Care Unit (NICU).

Level II Nursery: Preterm babies with i) Gestational age between 32 & 36 weeks ii)
Low birth Weight (1500-2000gm) iii) Major congenital malformation or iv) Suspected
of having aspirated meconium, should be transferred to special care nursery.

Level III Nursery: The following categories of neonates should be admitted to Intensive
Care Nursery i) Birth weight less than 1.5kg ii) Gestational Period less than 32 weeks
iii) Neonates with respiratow distress iv) Infants with convulsions, central cyanosis
(Congenital heart disease), severe Neonate jaundice (erythroblastosisfetalis) and those
requiring major surgery.

b) DAILY AND ROUTINE CARE OF NEW BORN

Daily care of new born includes the care that baby needs after being transferred to
postnatal ward. It includes

i. Rooming In
ii. Initiating feeding
iii. Observation for early signs of diseases
iv. Prevention of infections
v. Care of bladder and bowel
vi. Maintenance of personal hygiene
vii. Parental teaching and follow-up

i. Rooming –In

After the baby is transferred to the post natal ward, he should be nursed in a bassinet
beside the mother’s bed. This is called rooming-in. It has the following advantages.

24
Promote early initiation of breast feeding. Provide opportunity for mother-baby
interaction and bonding. Relieves mother’s anxiety related to where about of the baby.

ii. Initiating feeding

Breast feeding must be initiated as soon as possible to prevent neonatal hypoglycemia.

As soon as the mother has recovered from the fatigue of labor, preferably within half an
hour of birth, the baby should be put to breast. The baby must receive 25olostrums
secreted during first 2-3 days after birth. Colostrum is rich in protective antibodies so
provides passive immunity to the baby and it also has high nutritive contents.

iii. Observation for early signs of disease (warning signs of complication)

A daily routine examination should be done till the mother and baby is discharged from
the hospital. The nurse should carefully watch for the following danger signs and report
immediately to the physician. These danger signs are

Failure to pass meconium within 24 hours of birth.

Failure to pass urine within 48 hours of birth.
Bleeding from any site.
Failure to take feed.
Excessive crying or undue lethargy.
Jaundice within 24 hours of birth (Pathological Jaundice)
Hypothermia (< 36 to 36.5°C) or hyperthermia (rectal temperature of 100.4°F
(38°C)
Seizure – nerve cell activity in the brain is disturbed causing seizures.
Persistent vomiting or diarrhea
Breathing difficulty, if it is noisy need to notice like whistling noise means
blockage in the nostrils.
Evidence of superficial infection like oral thrush, conjunctivitis, umbilical cord
infection, pustules on skin etc.
Apart from observing the baby for the above stated danger signs, the baby should be
weighed daily at same time. Also monitor vital signs regularly.

iv. Prevention of Infection

The neonate’s defenses against infection are not mature so they are susceptible to
infection. Following things must be kept in mind to prevent them from infection

 All personnel coming in contact with the baby should be free from infection.
Hand washing should be practiced strictly.
 Strict aseptic precautions should be taken while handling the baby.
25
  The personal hygiene of mother and baby should be maintained.
 Restrict the number of visitors attending the baby.

v. Care of bladder and bowel

If the neonate fails to pass urine and stool within 24 hours of birth, it should be
notified to the physician. The urine output is about 200-300 ml by the end of first
week of life so neonate voids about 15-20 times in a day. Diaper should be changed as
soon as wet. The neonate also passes stool frequently so diaper area should be cleaned
with mild soap and water. The baby should be kept clean and dry.

vi. Maintenance of personal hygiene

The personal hygiene of both baby and mother should be maintained to prevent
infections. The baby should be given sponge bath daily in summers and every alternate
day in winters. Care should be taken to prevent chilling and draughts while giving dip
bath to the baby. Lukewarm water and mild baby soap should be used for giving baby
bath. Special attention should be paid to skin creases at axilla, neck, groin and thighs.
Vernixcaseosa should not be rubbed off during bath.

vii. Eye care and cord care

After giving bath, dry the baby thoroughly and put on soft clothes. The umbilical stump
should be cleaned Using Betadine solution. The cord dries and falls off within 10-14
days. Eye care should also be done daily Using sterile swabs dipped in sterile water.
Eyes should be cleaned from inner canthus to outer canthus Using separate swab for
each eye.

viii. Parental teaching and follow -up

The period when mother is in post natal ward can be utilized for teaching the mother
about all aspects of baby care. Parents are taught to observe the child’s daily behavior
related to feeding, sleep, activity, cry. elimination etc. Parents need to be told about
holding the baby, baby bath, eye and cord care, feeding and nutritional supplements,
immunization, prevention from infection and followup. The parents should be educated
about the danger signs in the baby, which if present require immediate hospitalization.

I. Teach and counsel mother and family about the newborn care

26
  Clean childbirth- Child birth is performed in a clean, hygienic, sterile way,
Unclean delivery room predisposes to the infections. Baby is handled gently after
birth and sex is noted.
 Cord care- Clamps are applied on the umbilical cord and cut in between in
separate the baby from the placenta. After cutting and clamping the cord, it is
checked for any redness, tenderness or oozing. 1n hospital deliveries, cord m is
performed daily in which the base, stump and cord is cleaned.
 Initiation of breathing and resuscitation- Breathing starts Spontaneously the
baby after the first cry, if not, resuscitative measures are to be followed
 Prevent new infection- Prevention of infection is an essential aspect. As the
immunity of the baby is not so well developed, so he is prone to infections.
 Thermal protection- Baby has to be kept warm. The baby is wiped and dried so
that heat loss is minimized. Baby can be kept under the radiant warmer or the
warm blankets. Skin to skin contact with the mother is helpful in maintaining the
temperature of the baby.
 Early and exclusive breastfeeding -Breast feeding should be started as soon as
possible or within half an hour for normal delivery and one hour for LSCS child
birth. Breast feeding should be continued for 6 months exclusively, and afterwards
complementary feeding may be started along with the breast feeding.
 Eye care - Eye care is performed by wiping the eyes from inner to outer cantus
with a sterile saline swab.
 Immunization - At birth: Bacilli Calmette-Guerin (BCG) vaccine, oral poliovirus
vaccine (OPV) and hepatitis B virus (HBV) vaccine.

II. Newborn care at home

 Exclusive breast feeding/artificial feeding and burping:
The WHO recommends that infants are exclusively breastfed for the first six months.
Whether feeding the newborn by breast or a bottle, may be stumped as to how often to
do so. Generally, it's recommended that babies be fed on demand whenever they seem
hungry. Your baby may cue you by crying, putting fingers in his or her mouth, or
making sucking noises.
A newborn baby needs to be fed every 2 to 3 hours. Preferably
if breastfeeding, give chance to the baby nurse about 10–15 minutes at each breast. If
formula-feeding, baby will most likely take about 2–3 ounces (60–90 millilitres) at each
feeding.

Try these burping tips:

 Hold the baby upright with his or her head on your shoulder. Support baby's head and
back while gently patting the back with your other hand.

27
 Sit your baby on your lap. Support your baby's chest and head with one hand by
cradling your baby's chin in the palm of your hand and resting the heel of your hand on
your baby's chest (be careful to grip your baby's chin — not throat). Use the other hand
to gently pat your baby's back.

 Lay your baby face-down on your lap. Support your baby's head, making sure it's higher
than his or her chest, and gently pat or rub his or her back.

 Baby bath

The baby must be cleaned off, no bath especially dip baths should be given till the
umbilical cord has fallen off. In summer months, the baby can be sponged using
unmedicated soap and clean lukewarm water and during winter months the baby should
have sponge bath rather than dip bath to avoid cold stress or hypothermia. No vigorous
attempt should be made to remove the vernix caseosa, as it provides protection to the
dedicate skin. The baby should dried swiftly and thoroughly from head to toe and
wrapped in a dry warm towel or clothing. Bathing should be avoided in open place.
Unnecessary exposure should be avoided. Use of olive oil or coconut oil can be allowed
after 3 to 4 weeks of age. Oil massage improves circulation and muscle tone.

 Rooming in

Rooming in can be done in a variety of ways. A lot of women choose to have full
rooming in, where the baby stay with the mother entire time. Both mother and baby gets
benefits from this practice, that are

 Babies cry less are easier to calm

 Mother get more rest

 Ability to respond to baby’s feeding cues

 Make more breast milk, faster

 Ability to ensure the care mother want for baby ( e.g. no pacifier, bottles, tests
etc)

 No fear of baby switching

28
  Care of umbilical cord

The cord must be inspected afterwards is important. No dressing should be applied

and the cord should be kept open and dry. Normally it falls off after 5 to 10 days but
may take longer especially when infected. Application of any medication is not
recommended

 Clothing

The baby should be dressed with loose, soft and cotton cloths. Dress should be open on
the front or back for easy wearing. Large buttons, synthetic frock and plastic or nylon
napkin should be avoided. A triangle of square piece of thick, soft absorbent cloth
should be used as napkin. The cloth should not be tight especially around the neck or
abdomen. Baby clothing always be cleaned with light detergent, that will be washed
properly and sun dried to prevent skin irritation

 Mummification

Swaddling is an age old practice of wrapping infant in blankets or similar cloths. It is an

art of snugly wrapping baby from a baby. It can keep the baby from being disturbed by
her own startle reflex, and so that movement of the limbs is tightly restricted. Also it
can help stay warm for the first few days of life until internal thermostat kicks in. It may
even help to calm baby

 Care of eye

Eyes should be cleaned at birth and once everyday using sterile cotton swabs soaked in
sterile water or normal saline. Each eye should be cleaned using a separate swab.
Application of kajal in the eyes must be avoided to prevent infection or led poisoning.
The cultural practice of instillation of human colostrums in the eyes has been found to
be useful to reduce the incidence of sticky eyes.

VIII. IDENTIFICATION OF HIGH RISK NEWBORN &REFERALS

Delivery

Normal infant High risk infant

29
 Without
With complications
complications

Temporary observation unit

(recovery room for high risk
infants)

Regular nursery
Special care nursery with neonatal
intensive care unit

Home Special procedures

Fig:1 Flow chart for optimum newborn care

Identification of “at-risk” infants

The number of infants in a community, or attending a child health clinic, may be so

large that it may not be possible to give sufficient time and attention to all of them. It is
therefore necessary to identify particularly those “at-risk” and give them special
intensive care, because it is these “at-risk” babies that contribute so largely to perinatal,
neonatal and infant mortality. The basic criteria for identifying at-risk babies include :

1. birth weight less than 2.5 kg

2. twins
3. birth order 5 and more
4. artificial feeding
5. weight below 70 per cent of the expected weight (i.e., II and III degrees of
malnutrition)
6. failure to gain weight during three successive months
7. children with PEM, diarrhea
8. Working mother/one parent.

a) LEVELS OF NEWBORN CARE

Because newborn infants may be born with depressed respiration or circulatory

impairment without warning, and unexpected deterioration of an initially healthy
30
newborn may be rapid and catastrophic, all health care facilities providing care for
newborn infants must be able to resuscitate and stabilize such infants until transfer to
another appropriate facility, including the initiation of intravenous access and assisted
respiration. Readiness to intervene for such infants must take into account the geo~
graphical location and the duration of time before assistance and transfer is likely. Some
units providing lower levels of care must be capable of supporting infants for several
hours while awaiting assistance. A family physician or pediatrician should be available
on call at all medical conditions.

Level I Care (Well baby clinic)

Over 80 percent of newborn babies require minimal care which can be

provided by their mothers under the supervision of basic health care professionals.
Neonates weighing above 1800 g or having gestational maturity of 34 weeks or more
belong to this category. The care can be provided at home, subcenter and primary health
center level. Basic care at birth, provision of warmth, maintenance of asepsis and
promotion of breast feeding form the mainstay of level I care. Traditional birth
attendants and community health workers must be trained in the art of esssential
perinatal care. The unit should provide nursing care for both mothers and their babies.
Each nurse may provide care for up to four mothers and their babies.

Level II Care (Special nursery)

Infants weighing between 1200-1800 g or having gestational maturity of 30-

34 weeks need specialized neonatal care supervised by trained nurses and pediatricians.
First referral units, district hospitals, teaching institutions and nursing homes should be
equipped to provide intermediate neonatal care. Equipment for resuscitation,
maintenance of thermo neutral environment, intravenous infusion and gavage feeding,
phototherapy and exchange blood transfusion should be available. There should be no
compromise on the basic needs of adequate space, nursing staff and maintenance of
asepsis including provision for disposable gamma-irradiated suction catheters, feeding
tubes, end tracheal tubes, small-vein infusion sets etc. Intermediate neonatal care is
needed for about 10 to 15 percent of newborn population and should be available at all
hospitals catering to 1000 to 1500 deliveries per year. A pediatrician should be
available on call at all times. When mechanical ventilation is in progress, the
pediatrician should be available in-house or must make sure that skilled staff, capable of
immediately responding to potential emergency medical practioners, are continually
present For sick babies, a nurse may be required to care for fewer than four babies.

Level III Care (Intensive care)

31
 Intensive neonatal care is required for babies weighing less than 1200 g or
those born before 30 weeks of gestation. Apex institutions or regional perinatal centers
equipped with centralized oxygen and suction facilities, servo-controlled incubators,
vital sign and transcutaneous monitors, ventilators and infusion pumps etc. are best
suited to provide intensive neonatal care. Skilled nurses and neonatologists especially
trained in the art of neonatal intensive care are required to organize this service. About
3 to 5 percent of newborn population qualifies for intensive care. Establishment of
intensive care neonatal center demands a sound infrastructure and should be envisaged
only when optimal intermediate neonatal care facilities have already been in existence
for some time. The capital and recurring expenditure for level III care is exorbitant and
it is not cost effective unless service is regionalized.

b) TRANSPORTATION OF NEWBORN

An organized transport team trained in neonatal care, resuscitation and transport care
with appropriate equipment must be available for the transfer of patients in each region.
A system for managing transport requests around the clock must be clearly defined and
easily accessible by medical team’s at all regional units requesting transfer.

The principles of safe transport of sick babies are expressed by a number of

mnemonics like STABLE. Where each alphabet stands for Sugar, Temperature,
Airway, Blood pressure, Lab work and Emotional support. SAFER: Sugar, Arterial
circulatory support, Family support. And TOPS: Temperature, Oxygenation (airway
and breathing), Perfusion and sugar.

i. Indications for neonatal transport

When a high risk mother identified, it is best time to transfer her to a center having
NICU facilities because uterus is an ideal transport incubator. It is desirable that
delivery should be take place in tertiary care center so that a sick or high risk baby is
not exposed to the risks of neonatal transport.

 Preterm infant with a birth weight < 1500 g or gestation <32 weeks.
 Respiratory distress requiring CPAP or assisted ventilation.
 Severe hypoxic-ischemic encephalopathy
 Life threatening sepsis
 Intractable sepsis
 Bleeding neonate
 Congenital anomalies or surgical neonate
 Inborn error of metabolism
 Severe hyperbilirubinemia
32
  Procedure or diagnostic facilities unavailable at the parent hospital
ii. Admission procedure to NICU

The transport team should remain in constant touch with the referral NICU during the
course of journey. Ideally the referral center should have a dedicated communication
facility with mobile help lines operating 24 hours a day for ease of constant
communication. The team should brief the NICU care givers regarding the status of the
baby and immediate clinical concerns. The clinical documents including copies of
charts, consent form, radiographs, investigation reports etc. should be handed over to
the receiving unit. The referring hospital and parents of the baby (if not accompanying
during transport) should be informed about the safe arrival and latest condition of the
baby. The inventory of transport equipment should be checked, medications and
essential supplies should be restocked for the next transport service.

iii. Role of parents in care of newborn in NICU

There should be appropriate facilities for parents, who should be encouraged to

participate in the care of the infants. Facilities should include private breast pump
rooms, refrigeration and storage facilities for breast milk, and parent rooms for
overnight rooming in with the infant before discharge from hospital. A quiet room
should be available for consultations and for families who may need privacy to deal
with emergent circumstances. That includes:

iv. Clinical standards at NICU

Clinical protocols: Written protocols should be available for key procedures and
practices, including resuscitation and stabilization of babies, and should be reviewed
and updated regularly.

Quality assurance: Units should longitudinally monitor mortality, morbidity,

workload, resource use, practices and policies using a prospective database with well-
defined items. These should be regularly reviewed and benchmarked against national
standards. An audit program and critical incident reporting program should be place.

Developmental follow-up assessment: Each unit should enroll high-risk infants in a

developmental follow-up program that can longitudinally assess infants after discharge
home.

Quality improvement: Each unit should have a multidisciplinary team trained to

motivate, initiate and support quality improvement initiatives. Ideally, this team should
work in coordination with similar teams in other hospitals.

33
 Annual report: Each unit should produce an annual report summarizing their activity
and performance appraisal in standardized form. The report should also benchmark
individual unit activity and performance against other units nationally, and against
national criteria for service provision.

IX. PARENTING

Parenting or child rearing is the process of promoting and supporting the

physical, emotional, social, and intellectual development of a child from infancy to
adulthood. Parenting refers to the intricacies of raising a child and not exclusively to the
biological relationship.

The most common caretaker in parenting is the biological parent(s) of the child in
question, although others may be an older sibling, a grandparent, a legal guardian, aunt,
uncle or other family member, or a family friend. Governments and society may also
have a role in child-rearing. In many cases, orphaned or abandoned children receive
parental care from non-parent blood relations. Others may be adopted, raised in foster
care, or placed in an orphanage. Parenting skills vary, and a parent with good parenting
skills may be referred to as a good parent.

Preparation for parenthood

The basic goals of parenting are to promote the physical survival and health of
children, to foster the skills and abilities necessary to be a self-sustaining adult, and to
foster behavioral capabilities for optimizing cultural values and beliefs. However, new
parents often approach parenthood with limited experience and knowledge. Parents
learn by trial and error, committing the same mistakes committed by countless time, but
they manage to accomplish the task, becoming more skilled with each additional child.
Tradition, rather than rational planning, furnishes the chief norms for childrearing.
Experience in having been nurtured as a child is an essential component of successful
parenting. Their own parents are probably the only persons whom parents observe
intimately in the parental role. These results in a generational continuity parents rear
their own children in much the same way as they themselves were reared. Other
essential skills that parents need to feel comfortable in the parenting role include a basic
understanding of childhood growth and development, bathing, feeding, uses of play,
and interpersonal communication skills.

Transition to parenthood

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Although experts disagree as to whether the birth of the first child should be labeled a
crisis, the early weeks of 0 infant’s life call for parents to make drastic adjustments.
Even though the parents have anticipated and prepared for the child’s arrival, the birth
presents the challenge of providing total care 24 hours a day for a new member of the
family. A crisis may occur if the event is perceived as disturbing old habits and
relationships and eliciting new responses. The birth requires role changes or
significantly modifies former relationships. In addition to the roles of husband and wife,
the couple must assume the roles of father and mother.

The advent of a new family member requires that the family cope with greater financial
responsibilities, at possible loss of income, changes in sleeping habits, and less time for
the parents to spend with each other (especially if it is a firstborn) and with other
children. If these events are perceived as aversive, it can disrupt the couple’s bond and
reduce the couple’s intimacy and affection.

Parenting styles vary by historical time period. Race/ethnicity, social class, and other
social features. Additionally, research has supported that parental history both in terms
of attachments of varying quality as well as parental psychopathology particularly in the
wake of adverse experiences, can strongly influence parental sensitivity and child
outcomes.

Parenting practices reflect the cultural understanding of children. Parents in

individualistic countries like Germany spend more time engaged in face-to-face
interaction with babies and more time talking to the baby about the baby. Parents in
more communal cultures, such as West African cultures, spend more time talking to the
baby about other people, and more time with the baby facing outwards, so that the baby
sees what the mother sees. Children develop skills at different rates as a result of
differences in these culturally driven parenting practices. Children in individualistic
cultures learn to act independently and to recognize themselves in a mirror test at a
younger age than children whose cultures promote communal values. However, these
independent children learn self-regulation and cooperation later than children in
communal cultures. In practice, this means that a child in an independent culture will
happily play by herself, but a child in a communal culture is more likely to follow his
parent’s instruction to pick up his toys. Children that grow up in communities with a
collaborative orientation to social interaction, such as some Indigenous American
communities, are also able to self-regulate and become very self-confident, while
remaining involved in the community.

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X. MINOR DISORDER OF NEWBORN & ITS MANAGEMENT

SYSTEM MINOR DISORDERS MANAGEMENTS

(PECULIARITIES)
Integumentory system  Erythema Toxicum (newborn
rash)
A rash consisting of small red, flat
or raised lesion commonly appears
on the chest, abdomen, back and
buttocks of the newborn
 Milia
It is the distended sebaceous gland
in the skin. Yellowish-pin point
size lesion located on the bridge of
nose, chin and cheeks.
No specific treatment,
it will disappear within
first two weeks,
reassure and explain
the mother.
The lesion will
disappear first few
weeks of the life. Do
not attempt to pick or
squeeze them

 Mangolian spot No specific treatment

Large aggregations of melanin rich most gradually
dark cells. Purple or bluish black disappear as child
area of discolouration mostly in grows
sacral or cocxygeal region.

 Harlequin color change It may last for few

May become blanched and pale on minutes. No specific
one half of the body while other treatment. Mother’s
half remains pink. It may be due to anxiety to be relieved
unexplained vasomotor by adequate
phenomenon explanation and
reassurance

 Sucking callosities
Button like cornified plaque at the It subsides
center of upper lip may found at spontaneously.
birth
Head and neck  Caput succedanum
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 Caused by head pressing on the It normally disappears
pelvic outlet on the last period of in 1-2 weeks
labour leading to edema of the
scalp.

 Cephalhematoma Although most infants

it is a traumatic subperiosteal will heal on their own.
hematoma that occur underneath No treatment is
the skin, in the periosteum of the necessary and
infant’s skull bone. It does not pose resolution takes place
any risk to the brain cells. in a matter of 3-4
weeks.
Eyes  Conjunctivitis (sticky eyes)
or Opthalmia neanatorum Clean eyelid with
It may be due to a chemical silver cotton balls soaked in
nitrte instilled after birth or warm saline solution.
bacterial conjunctivitis. It occur Use erythromycin
within first 24 hours and last about every 6 hours for 7-10
2-4 days days
Mouth  Oral thresh Local application of
It manifests as white patches with 0.5% aqueous solution
erythematous margins disturbed of violet or nystatin
over the tongue and buccal mucosa. suspension applied
each side of mouth
with a cotton tipped
swab 3-4 times a day is
effective

 Tongue-tie Surgical division of

A short and sometimes thicked frenulum in the second
frenulam attached more than or third month of life
usually anteriorly to the base of the
tongue
 Precocious teeth
Teeth found in the mouth of the
baby before birth

Chest  Neonatal breast No treatment needed

engorgement
The result of the sudden
withdrawal of maternal endocrine
secretions
Alimentary tract and  Vomiting Follows proper
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abdomen Posseting of a mouth ful milk soon
after feeding is a normal course.
 Physiological jaundice
About 60-70% newborn babies
develop jaundice on the second or
third day of life.
feeding techniques and
burping.
It does not need any
treatment, if jaundice
persists beyond 2 week
need investigation and
treatment.

 Constipation Correction of diet and

It is commonly seen in artificially extra water is usually
fed babies effective
Nose  Stuffy nose The nostrils may be
It may lead to mouth breathing and cleaned by cotton
excessive air swallowing which in soaked with normal
turn may lead to abdominal saline.
distention and vomiting.

XI. NURSING MANAGEMENT

1. THERMAL CONTROL
Thermoregulation is the balance between heat production and heat loss. The prevention
of cold stress which may lead to hypothermia (body temperature less than 35°C) is a
critical for the intact survival of the LBW baby. In hospital higher ambient temperature
are maintained, the baby should be dressed cotton gown and covered by two cellular
blankets. An additional blanket underneath the bottom sheet will provide extra warmth
for baby’s who are having difficulty in maintaining a stable body temperature at home.
Baby water should be warm (36°C) and wet clothing should be changed as soon as
possible, it is essential also to avoid overheating. Parents should be advised to take
account of the environmental temperature when dressing the baby. Dressing should be
loose for the movement of arms and legs. Gestational age and weight of the baby
influence the type of the care given for baby’s under two kg. Incubator care is necessary
when the baby is not receiving skin to skin contact with mother. The warm condition of
the incubator should be maintained at 30-32°C; babies are clothed with bedding in a
room temperature at 26°C. Most preterm babies between 2 to 2.5 kg will be care for in a
cot at room temperature of 24°C.

Prevention of hypothermia

38
  Deliver in a warm room - To prevent the hypothermia, the delivery room’s
temperature should be maintained. The windows and doors must be closed. A
warm delivery room is the first step to prevention of hypothermia
 Dry newborn thoroughly and wrap in dry, warm cloth –As soon as the baby
is born, he should be dried thoroughly with a clean cloth to wipe off the
secretions. After proper cleaning, baby is wrapped in clean, dry, warm clothes.
 Keep out of draft and place on a warm surface- Baby should be protected
from cold, in the nursery, while transferring or at the home.
 Give to mother as soon as possible- Baby should be given to the mother soon.
. Skin-to-skin contact first few hours after childbirth maintains the temperature.
. Promotes bonding between the mother and the baby.
. Enables early breastfeeding.
 Bath when temperature is stable (after 24 hrs)- Generally babies are not given
bath in the hospital to prevent the chances of infection. In the home, also baby
should be given bath after 24 hours when the temperature stabilizes.

2. PREVENTION OF HYPOGYCEMIA

Hypoglycemia should be prevented by early initiation of breastfeeding within first hour

of birth. The baby should be nursed in warm or thermo neutral environment with careful
observation of ’at-risk’ situations and prevention of hypoxia and hypothermia. For a
baby with risk factors, healthcare providers will need to watch carefully for the signs
and treat as soon as possible.

In symptomatic infant with convulsions, 25 percent dextrose 2 ml / kg intravenously is

given as a bolus. If there is no convulsion 10% dextrose 2ml/kg/IV bolus is given
followed by continuous infusion of 10 percent dextrose at a rate of 6-8 mg/ kg/ minute.
Blood glucose level to be checked every 1/2 hourly. Infusion rate to be reduced only if
last two glucose estimation is more than 60 mg / dl. Oral feeds are introduced gradually
and glucose infusion is tapered off.

If blood glucose level is not corrected then bolus administration of dextrose can be
repeated and serum cortisol and insulin levels to be checked. Hydrocortisone therapy is
given 5 mg / kg / IV every 12 hours in intractable case. Glucagon and/ or epinephrine,
diazoxide may be given to the babies with maternal diabetes mellitus or
erythroblastosis. Asymptomatic cases with low blood sugar level should be treated as
symptomatic cases.

3. PREVENTION OF INFECTION

39
Provision of a safe environment newborn is of central importance, particularly in
hospital where babies are at risk of cross infection. Careful and frequent hand washing
with soap or spirit remains the single most important method of preventing infection. In
busy situation cleansing with an alcohol based hand rub solution is most practical
means of improving staff compliance and wearing gloves further reduces the
contamination. Other evidence based midwifery strategies that help to reduce infection
in all environmental include

 Encouraging and assisting women with breast feeding thus increasing the baby
immune protection
 Discouraging visitors who have infections or have been exposed to a
communicable disease.
 Avoid any irritation or trauma to the baby’s skin and mucus membrane.
 Early diagnosis and treatment of infection
 Always using individual equipment for each baby
 Isolating infected babies when absolutely essential.
Managements include:

Caring for the baby in warm thermo neutral environment and observing for temperature
instability.

o Prompt systemic antibiotic or other drug therapy and local treatment of

infection.
o Ongoing monitoring of the baby’s neurobehavioral status.
o Reducing separation of mother and baby, it requires admission to a
neonatal intensive care unit then the midwife should encourage parents to
be with their baby.
o Encouraging breast feeding or expression of milk.

4. IMMUNIZATION
Immunizations help prevent the spread of diseases and protect newborn against
dangerous complications. Immunization is the process of whereby a person is made
immune or resistant to an infectious disease. The Centers for Disease Control and
Prevention (CDC) provides a list of diseases that can be prevented with vaccines, as
well as the benefits and risk of vaccination.

5. BREAST FEEDING

Breast milk is natural food for the newborn and the process by which it is secreated by
mammary gland is known as lactation. During the first two or three days secrets, watery

40
and yellowish fluid that provides immunity for the baby. Enough nutrients and needed
amount of feed will get from breastfeed. So it is important to give exclusive breast
feeding for the baby at least 6 months.

THE NEWBORN PROBLEMS AND NEEDS

Problems of newborn

Actual problems Potential problems

o Colic and crying o Risk for infection

o Abdominal distention o Risk for hypovolemia
o jaundice o Risk for hypothermia
o Diaper rash o Risk for hypoglycemia
o Vomiting
o Skin problems
o Oral thresh
o Flatus
o Hiccoughs
o Spooling
o Colic and crying

Needs of the newborn

General needs Specific needs

 Fluid management o Infection prevention
 Maintenance of body o Maintain normal body
temperature temperature
 Nurturing and o Maintain normal blood
bonding sugar
 Elimination needs o Maintain hydration
 Maintain hygiene o Maintain normal
 Sleeping respiration
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XI. NURSING DIAGNOSIS

1. NURSING DIAGNOSIS:
Impaired gas exchange related to inadequate surfactant level ;
as evidenced by grunting, flaring, substernal and intercostals retractions.
GOAL: Neonates maintains normal respiration by own effort
INTERVENTIONS:
 Administer warm and humidified oxygen at rate ordered
 Monitor and document hourly fiO2 level, and vital signs.
 Auscultate lung sound every hourly.
 Maintain gastric decompression per oral gastric tube open to air, perform
oral/ nasal suctioning.
 Maintain temperature in normal range, to minimize stress, conserve
energy, and reduce oxygen requirements
 Provide physiotherapy.

2. NURSING DIAGNOSIS
Risk for imbalanced body temperature related to less adipose tissue.
EXPECTED OUTCOME
Neonate temperature remains in range of 36.5 to 37.2 degree celsius
INTERVENTIONS
 Maintain a neutral thermal environment to identify any changes in
the neonate’s temperature that may be related to other causes.
 Monitor the neonate’s auxiliary temperature frequently to identify
any changes promptly and ensure early interventions.

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  Bathe the neonate efficiently when temperature is stable, using
warm water, drying carefully, and avoiding exposing neonate to
drafts to avoid heat losses from evaporation and convection.
 Report any alterations in temperature findings promptly to assess
and treat for possible infection.

3. NURSING DIAGNOSIS
Risk for infection related to immature immunological defences and
environmental exposure
EXPECTED OUTCOME
The neonate may free from sign of infection
NURSING INTERVENTIONS
 Review the maternal record for evidence of any risk factors to ascertain
whether the neonate may be predisposed to infection.
 Monitor vital signs to identify possible evidence of infection, especially
temperature instability.
 Have all care provider, including parents, practice good hand washing
techniques before handling the newborn to prevent the spread of infection.
 Provide the prescribed eye prophylaxis to prevent infection.
 Keep the genital area clean and dry using proper cleansing techniques to
prevent skin irritation, cross- contamination, and infection.
 Keep the umbilical stump clean and dry, and keep it exposed to the air to
allow to dry and minimize the chance of infection.
 If the infant is circumcised, keep the site clean, and apply the diaper
loosely to prevent trauma and infection.
 Teach the parents to keep the neonate away from crowds and
environmental irritants to reduce potential sources of infection.

4. NURSING DIAGNOSIS:
Risk for imbalanced nutritional status less than body
requirement related to poor sucking.
GOAL: Newborn baby maintains adequate nutritional status
INTERVENTIONS:
 Assess the feeding techniques
 Provide adequate education for mother about feeding technique.
 Assess the newborn for strong sucking, gag or swallowing
reflex.
43
  Maintain intake and output chart
 Assess the need for parenteral nutrition or formula feeding.
 Monitored glucose levels hourly until stable, then each four
hours, then each eight hourly.

5. NURSING DIAGNOSIS
Risk for aspiration related to poor breast feeding technique or parental
knowledge deficit
GOAL: infant and mother establish mutually enjoyable breast feeding by
hospital discharge.
INTERVENTIONS:
 Assess the mother’s knowledge level of breast feeding technique.
 Assist mother with breast feeding as needed
 Remind the mother that rapid respirations and crying make
sucking difficulties and chance of aspiration.
 Make the infant calm and maintain comfortable position both of
them before start feeding.
6. NURSING DIAGNOSIS
Risk for injury related to sole dependence on caregiver
EXPECTED OUTCOME
Neonate remains free of injury
NURSING INTERVENTIONS
 Monitor the environment for hazards such as sharp objects, long
fingernails of the caretaker and neonate, and jewelry of the caretaker that
may be sharp to prevent injury.
 Handle the neonate gently and support the head, ensure the use of a car
seat by parents, teach parents to avoid placing the neonate on a high
surface unsupervised and to supervise pet and sibling interactions to
prevent injury.
 Assess the neonate frequently for any evidence of jaundice to identify
rising bilirubin level, that promptly and prevent kernicterus.
7. NURSING DIAGNOSIS
Readiness for enhanced family coping related to anticipatory guidance
regarding responses to the neonate’s crying
EXPECTED OUTCOME

44
 Parents verbalize their understanding of the method of coping with the
neonate’s crying and describe increased success in interpreting the neonate’s
cries.
NURSING INTERVENTIONS
 Alert the parents to crying as the neonate’s form of communication and
that cries can be differentiated to indicate hunger, wetness, pain, and
loneliness to provide reassurance that crying is not indicative of the
neonate’s rejection of parents and that parents will learn to interpret the
different cries of their child.
 Differentiate self-consoling behaviors from fussing or crying to give
parents concrete examples of interventions.
 Discuss methods of consoling a neonate who has been crying, such as
checking and changing diapers, talking softly to the neonate, holding the
neonate’s arms close to the body, picking the neonate up, rocking using a
pacifier, feeding or burping to provide anticipatory guidance.

45
XII. SUMMARY
The birth of the newborn is important occasion in a family. As we discussed
about the normal newborn it comprises of detailed introduction about the normal
newborn, the students can define the newborn, the physiological characteristics
that shows by the normal newborn. How the newborn is going to adapt with extra
uterine or physiological life in the new world.
How the nurse is going to do the assessment of newborn includes physical
assessment it divided into initial and daily assessment and also as normally how
the newborn behavioral assessment is doing. In the essential newborn care the
nurse is giving care as priority of newborn needs. How we can identify the high
risk newborn and referrals services available to stabilize the condition. The
process that explains the adaptation of newborn and parents that means parenting
process. The minor disorders that can occur normally in newborn and its
management. Mainly nursing management includes nursing diagnosis, goal and
interventions of newborn.

46
47
XIII. CONCLUSION

At discharge, the newborn is examined and a postpartum visit is scheduled. The

newborn's progress is assessed in terms of feeding and body weight. Blood is
obtained (heel-stick) to assess abnormalities, including genetic and metabolic
disorders. The parents are updated with their child's progress and their concerns
are addressed. Usual questions pertain to feeding, follow-up visits,
immunizations, bathing, rashes, use of car seats, etc.
After the completion of newborn assessment, and if the assessment remains
uneventful, the newborn is discharged. However, in the event of other outcomes
that might emerge due to various reasons during the assessment, the newborn is
further assessed for restoration of complete health.
WHO has recommended important factors that are essential with respect to
newborn care which includes initiation of breastfeeding, vitamin K prophylaxis,
prevention of hypothermia, care for the cord, and immunization at birth.
Matters such as cleanliness, hygiene during delivery, thermal control, and infant
feeding practices must be followed scrupulously. Good and essential newborn
practices include safe cord care, which includes use of a sterile instrument to cut
the umbilical cord, clean thread to tie the cord, optimal thermal care which
includes wrapping the baby within 10 minutes of birth and bathing the baby after
6 hours of birth, and neonatal feeding practice, which includes initiating
breastfeeding within the first one hour after birth, are all essential elements.

48
 The postpartum care to the mother is as important as postnatal. Only a healthy
mother can bring up a healthy child. Factors including maternal age, educational
status, economic status, ethnicity, occupation, and accessibility to health services
are important factors that affect the upbringing of the newborn.

XIV. BIBLIOGRAPHY

BOOK REFERENCE
1. Dutta D C. (2004). Text book of Obstetrics. Sixth edition. Culcutta: New central
boob agency (p)ltd; 445-456
2. Lowdermilk, Perry & Cashion. (2010). Maternity nursing. 8th edition. North
Carolina. Elsevier; 438-528
3. Maharban Singh. (2010). Care of the Newborn. 7TH edition. New Delhi. Sagar
printers & publishers; 1-510
4. Parul Datta. (2009). Pediatric nursing. 2nd edition. India. JAYPEE; 66-136
5. Annamma Jacob (2005). A Comprehensives Text book of Midwifery. Third
edition. JAYPEE. 459-497
6. Neelam kumari, Shivani sharma & Dr. Preti gupta (2014). A Text book of
Midwifery and gynecological nursing. Third edition. Pee Vee . 261-284
7. Marilyn J. Hockenberry & David Wilson. Wong’s Essentials of Pediatric
nursing, First South Asia Edition. ELSEVIER New Delhi. 163-189.
8. Dorothy R. Marlow & Barbara A. Redding. Text book of Pediatric nursing.
Sixth Edition. ELSEVIER Florida. 345-466

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JOURNAL REFERENCE

1. Staebler, Suzanne; Meier (2016). The Future of Neonatal Advanced

Practice Regisered Nurse Practice: White paper. 8-14
2. Lund, Caroiyn(2016). Bathing and Beyond: Current Bathing controversies
for newborn infant. 33-38

INTERNET RESOURCES

1. https://medlineplus.gov> ency >article

2. https://www.slideshare.net >mobile>ppt

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