By the end of this lecture, the student will be will be able to provide to provide safe nursing care to the

normal newborn care according to the essential knowledge, skills and attitudes needed

 The

student will be able to: Identify the characteristics of normal newborn. Describe the assessment of normal newborn. Identify the assessment criteria for estimation of gestational age for normal newborn. Recognize the different reflexes of normal newborn and its disappearance times. Recognize the nursing management of normal newborn.

Neonatal Period: The first four weeks of life. Full Term: Born at 37-42 weeks of pregnancy.

Fetal circulation depends on patency of the

the right and left atria) ,and Ductus arteriosus (an opening that allows blood to flow from the pulmonary artery into the aorta).

Foramen ovale (an opening between

 These two openings allow most blood volume to bypass the dormant lungs and instead to move through the fetal side of the placenta,
At birth, once the cord is clamped, these two communicating openings must close for proper circulation.

providing oxygen and eliminating carbon dioxide and wastes.

Thermo-regulation the newborn:

of

Maintain the neonates warmth immediately after birth

Babies are born with a substance in the upper back called brown fat, which is a stored energy that they can use to generate heat. Term infants have more brown fat than preterm babies -a finite amount, however, and once they use it, they produce no more. Therefore, keeping newborns warm and avoiding cold stressing them are essential.

Heat is lost in several ways, which are: I. Conduction. II. Convection. III.Radiation and IV. Evaporation.

Heat loss

Reason

Counter measures

Evaporation

Baby wet

Dry with towel (preferably warmed)

Radiation

Many cold surfaces (e.g. windows)

Wrap in warm dry towel or blanket Close doors and windows

Convection

Draughts

Conduction

Cold surface of trolley. Cot or Bed

Pre-warm with overhead heater

Physical assessment following delivery can be divided into four phases:

The initial assessment using the Apgar scoring system. Transitional assessment during the periods of reactivity. Assessment of gestational age, and Systematic physical examination.

Clear airway

Maintain body temperature

Establish respiration Protect from hemorrhage

Identification

It is indicated because airway is filled with amniotic fluid, meconium particles, blood, etc. and inhalation of these particles may plug, irritate or contaminate the respiratory tract.

Methods of clearing airway

Wiping off the neonates face

Gentle suctioning with a soft catheter

How can you prevent heat loss at the time of birth? (steps 2, 3, 4)

Preventing heat loss at the time of birth: drying - wrapping - skin-to-skin - breast-feeding

Suction must be done from mouth first then the nose. Make sure that there is nothing for the neonate to aspirate if he gasps when the nose is suctioned.

Be careful how vigorously the suction is and how deep the suction catheter or bulb syringe is inserted. Stimulation of the posterior pharynx during the first few minutes after birth can produce a vagal response causing severe bradycardia and / or apnea.

When using a mechanical suction apparatus, the suction pressure should be set so that when the suction tubing is occluded, the negative pressure doesnt exceed 100 mm Hg or 4 inches Hg. Following suction hold the neonates head down to drain secretions immediately while gently compressing the throat toward the mouth to milk out secretions.

If respiration doesnt occur spontaneously after clearance of airway the neonate should be stimulated to breathe by: Slapping the heel. Flicking the sole.

Rubbing the back gently. If breathing is still not initiated, the newborn will need resuscitation (refer to resuscitation protocol). Oxygen may be given according to the result of Apgar score evaluation

The Initial Assessment Using the Apgar Scoring System

The most frequently used method to assess the newborn's immediate adjustment to extra-uterine life is Apgar scoring system. The score is based on observation of heart rate, respiratory effort, muscle tone, reflex response and color. Each item is given a score of 0, 1, or 2. Evaluations of these five criteria are made at 1 and 5 minutes after Birth and repeated until the newborn's condition stabilized.

Total scores of 0 to 3 represent severe distress, and require vigorous resuscitation. Scores of 4 to 6 signify moderate difficulty, and require some resuscitative intervention. While scores of 7 to 10 indicate that the newborn adjusting well to extrauterine life, and require only observation.

Score Item Color (Appearance)

Pink (light skinned) Or absence of cyanosis (dark skinned) >100 heartbeats per/min. Responds promptly to suction or a gentle slap to the sole with cry or active movement Flexed body posture, spontaneous and vigorous movement spontaneous respirations with Strong ,lusty cry

blue hands and feet

Pallor or cyanosis

Heart Rate (Pulse) Reflex response (Grimace)

<100 heartbeats/ min. Minimal response (grimace) to suction or gentle slap on soles

Absent No response to suction or gentile slap on soles Limp

Muscle tone (Activity)

Minimal flexion of extremities, sluggish movement Slow respirations or weak cry

Respiratory effort (Respiration)

No spontaneous respirations

In warning the newborn the nurse must consider the following

Re-warm the neonate gradually if he becomes chilled. Re-evaluate the neonates body temperature to stop or modify the warming devices. Record and report the neonates body temperature to the physician

Control the neonates bleeding through

Administration of single intramuscular dose of 0.5 1 mg vitamin K. Correct ligation of umbilical cord: Perform correct legation or clamping of cord. Do not cut too close to the umbilicus because the neonate may need catheterization.

The cord is tied approximately 2.5- 5 cm from the starting base of the umbilical cord, this prevent obstruction of any intestinal loop that may be possibly present in the umbilical cord. The cord must be observed closely from bleeding, when this occurs, an additional clamp or forceps must be placed.

Proper identification of the newborn is absolutely essential. The nurse must verify that two identifying bands are securely fastened, usually on the wrist and ankle. The information needed is the newborn's name, sex, the date and time of birth and mothers admission number. Foot printing or finger printing is recommended for neonatal identification

Classification of newborn based on maturity and intrauterine growth chart:

Gestational age can be estimated , independently from the obstetric history, by using a combination of external physical and neuromuscular criteria ( Ballard Score ). for infants >30 weeks gestation, the accuracy of this system is within 2 weeks.

 Preterm (pre mature) neonate: The neonate is born before completion of 37 weeks of gestation, regardless of birth weight. Term: The neonate is born between the beginning of the 38weeks and the completion of the 42 weeks of gestation regardless of birth weight. Post term (post mature) neonate: The neonate is born after 42 weeks of gestation.

Plot the weight, length and head circumference versus the estimated gestational age may be classified as: Low- birth-weight (LBW) infant: An infant whose birth weight is less than 2500 gm regardless of gestational age. Very-Low-Birth weight (VLBW): An infant whose birth weight is less than 1500 gm. Extremely low Birth weight (ELBW): An infant whose birth weight is less than 1000 gm.

 Moderately-Low Birth Weight (MLBW): An infant whose birth weight is 1500- 2500 kg. Appropriate for Gestational Age (AGA) infant: An infant whose weight falls between the 10th 90th percentiles on intrauterine growth curve. Small- for-Date (SFD) or Small for- Gestational Age (SGA) Infant: An infant whose rate of intrauterine growth was slowed and whose birth weight falls below the 10th percentile on intra-uterine growth curves.

 Intrauterine Growth Restriction (IUGR): Found in infants whose intrauterine growth is retarded (sometimes used as a more descriptive term for the SGA infant). Large for Gestational Age (LGA) infant: An infant whose birth weight falls above the 90th percentile on intrauterine growth charts.

It assesses six external physical and six neuromuscular signs. Physical signs as, skin, lanugo, planter surface, breast, eye/ear and genitals (male), genitals (female).

Neuromuscular

signs as posture, square window (wrist), arm recoil, popliteal angle, scarf sign and heal to ear sign. Each sign has a number score, and the cumulative score correlates with a maturity rating for 26-44 The new Ballard and Scale, a revision of the original scale, can be used with newborns as young as 20 weeks of gestation.

The tool has the same physical and neuromuscular sections but includes 1 and 2 scores that reflect signs of extremely premature infants such as fused eye lids, imperceptible breast tissue, sticky friable transparent skin, no Lanugo and square window (flexion of wrist) angle of greater than 90 degrees. The total numerical, score for both external physical and neuromuscular criteria is plotted on maturity rating graph and the estimated gestational age obtained.

Neuromuscular Maturity

Neuromuscular Criteria
Posture Handle the infant and observe the position of the arms and legs. More mature infants (with a higher gestational age) have better flexion (tone) of their limbs.

Neuromuscular Criteria
Square Window
Gently press on the back of the infant's hand to push the palm towards the forearm. Observe the degree of flexion. More mature infants have greater wrist flexion.

Square Window -1 to 4
>90 degrees 90 degrees 60 degrees 45 degrees 30 degrees 0 degrees

Neuromuscular Criteria
Arm Recoil
Fully bend the arm at the elbow so that the infant's hand reaches the shoulder, and keep it flexed for 5 seconds. Then fully extend the arm by pulling on the fingers. Release the hand as soon as the arm is fully extended and observe the degree of flexion at the elbow (recoil). Arm recoil is better in more mature infants. Note that a score of 1 is not given. es

Arm Recoil 0 to 4
Extended 180 degrees or random movements

Neuromuscular Criteria
Popliteal Angle
With your one hand hold the infant's knee against the abdomen. With the index finger of the other hand gently push behind the infant's ankle to bring the foot towards the face. Observe the angle formed behind the knee by the upper and lower legs (the popliteal angle). More mature infants have less extension of the knee.

Popliteal Angle -1 to 5
Thigh held in knee chest position and leg is gently extended from behind the ankle. Measure the angle behind the knee. 180 degrees 160 degrees 140 degrees 120 degrees 100 degrees 90 degrees <90 degrees

Neuromuscular Criteria
Scarf sign
Place infant in supine position with head in mid-line position. Grasp the infants hand and pull the arm across the chest and around the neck. Look at the relationship of elbow to mid-line of body when arm pulls across the chest

Scarf Sign -1 to 1
Elbow reaches/nears level of opposite shoulder Elbow crosses opposite anterior axillary line Elbow reaches opposite anterior axillary line

Neuromuscular Criteria
Heel to ear
Place the infant supine with pelvis flat on table. Grasp one foot with thumb and index finger and draw foot as near to head as possible. Note the distance between the foot and head as well as degree of knee extension

Physical Criteria
Skin
less transparent and tougher with increasing gestational age 36-37 weeks loses transparency and underlying vessels are no longer visable Increasing gestational age the veins become less viable and increasing subcutaneous tissue

Skin

Physical Criteria
Lunago
Fine downy hair covering fetus from 20-28 weeks Disappears around face and anterior trunk ~28 weeks Term infants may have a few patches over shoulders

Lanugos

Physical Criteria
Sole creases
28-30 weeks appear and cover the anterior portion of of the plantar surface of the foot Extend toward the heel as increases gestational age After 12 hours sole creases are not valid indicator of gestational age due to drying of the skin

Plantar creases

Physical Criteria
Breast tissue and aerola
Aerola is raised by 34 weeks A 1-2 mm nodule of breast tissue is palpable by 36 weeks By 40 weeks the nodule is 10mm

Physical Criteria
Ears
Incurving of the upper pinna begins by 34 weeks gestation and extend entire lobe by 40 weeks Before 34 weeks, pinna has very little cartilage (Stays folded on itself) At 36 weeks, there is some cartilage and will spring back

Ear cartilage

Physical Criteria
Female Genitalia
Early gestation, clitoris prominent and widely separated labia By 40 weeks, fat deposits have increased in size in labia majora so labia minora are completely covered

Genitalia

Physical Criteria
Male genitalia
Testes begin to descend from abdomen around 28 weeks At 37 weeks, testes can be palpated high in scrotum At 40 weeks, testes are completely descended and covered with rugae As gestation progresses, scrotum becomes more pendulous

Physical Maturity
Breast (-1 to 4)
<34 weeks: not generally palpable at 36weeks: diameter does not usually exceed 3mm

Eye/Ear (-2 to 4)
appears mainly after 36 weeks

Genitals M/F (-1 to 4)

<36 weeks: few anterior, inferior scrotal rugae 40 weeks: rugae cover entire scrotum

4:Systematic physical examination

Physical growth
Weight

General Measurements: Birth weight: 2700-4000 g. the average weight is 3400g

Height

Average boys length is 50 cm and 49 cm for girls (normal range for both sexes 47.5 to 53.75 cm) They gain 3.0 cm by the end of the first month.

Head Circumference

It is 33 to 35 cm at birth.

Chest Circumference & Length

Chest Circumference: 30.5- 33 cm. Head to heel length: 48-53cm.

Temperature: Axillary: 36.5C- 37.6C. Heart Rate: Apical 120 -140 beats/ min. Respiratory: 30-60 breaths/ min. Blood Pressure: 65/41 mmHg.

 Posture: Complete flexion as a result of in utero position. Most newborns are born in a vertex presentation with the head flexed and the chin resting on the upper chest, the arms flexed with the hands clenched, the legs flexed at the knees and hips and the feet dorsiflexed. The vertebral column is also flexed.

Skin: The texture of newborn skin is Bright red, smooth and puffy especially the eyes, the legs, the dorsal aspect of the hands and feet and the scrotum or labia. Skin color depends on race.

In observing the skin, you find:

Vernix Caseosa: It is white cheesy substance. It is formed of sebaceous gland mixed with old epithelial cells. It is present on the back, head, body crease and between the labia. The newborn have varying amounts of vernix, but preterm newborn usually have little amount.

Vernix
Cheesy-white Normal Antibacterial properties Protects the newborn skin

Mediterranean and Negro babies often manifest normal bluish areas of the skin. They are not bruise marks, or a sign of ill treatment and arent associated with mental retardation. They disappear during preschool years without treatment

Pealing of the skin occurs within 2-4 weeks of life. These are denoted areas where the delicate skin has been rubbed off the nose, knees and elbows, because of pressure and erosion of sheets. The skin of buttocks is particularly sensitive and should not be left wet and /or soiled

Appears 2-3 days after delivery; the skin begins to take on a yellow coloration. This jaundice is not pathological it is associated with excessive destruction of erythrocytes (R.B.C.) that are not needed after birth. It increases for a few days and usually disappears by the 7-10 days.

These are small pinpoint white papules are often present on the nose and chin due to blockage of the sebaceous glands. They can be felt with the fingers. They will disappear within a few weeks (one to two weeks). They should not be expressed.

The cranium is composed of six bones: The frontal, occipital, two parietals and two temporal. Between the junctions of these bones are bands of connective tissue called sutures. At the junction of the sutures are wider spaces of unossified membranous tissue called fontanels.

The anterior fontanel:

Is diamond in shape and located at the junction of two parietal and frontal bones or formed by the junction of the sagittal, coronal and frontal sutures. It is 2-3 cm in width and 3-4 cm in length. It closes between 12-18 months of age.

The posterior fontanel:

Is triangular and located between the occipital and parietal bones or formed by the junction of the sagittal and lambdoid sutures. It closes by the 2nd month of age. Fontanels should be flat, soft, and firm. It bulges when the baby cries or if there is increased intracranial pressure.

Two conditions may appear in the head:

1.Caput Succedaneum: Is edema of the scalp resulting from pressure during labor.

1. Cephalhematoma: Is a hemorrhage under the periosteum of one of the cranial bones (usually parietal) resulting from trauma of labor.

Comparison of Caput Succedaneum and Cephalhematoma

Characteristics Cause Caput Succedaneum Diffuse, edematous swelling involving the soft tissue of the scalp Cephalhematoma Blood between skull bone and periosteum (Subperiosteal hemorrhage)

Appears

At birth no increase in size

Several hours after birth increase in size for 2-3 Approximately 6 weeks after birth

Disappears

Several days after birth

Border Cross suture line

Vague, poorly defined Sometimes

Marked, well defined Never

Treatment

No specific treatment

No treatment is indicated for uncomplicated cephalhematoma

Complications

Rarely anemia

Jaundice, underlying skull fracture, intracranial bleeding, shock

 Lids: Usually edematous. Color: Gary, dark blue, brown. True eyes color is not determined until the age of 3-6 months. Pupil: React to light. Absence of tears. Blinking reflex in response to light or touch.

Ears
Position: Top of pinna on horizontal line with outer canthus of eye. Startle reflex elicited by a loud sudden noise. Pinna flexible, cartilage present.

Nasal potency. Nasal discharge thin white mucous. Sneezing reflex is present.

 Intact, high-arched palate. Sucking reflex- strong and coordination. Rooting reflex. Gag reflex. Minimal salivation. Vigorous cry.

 Short, thick, usually surrounded by skin folds. Tonic neck reflex present.

System Assessment of the neonates

 Mouth should be examined for abnormalities such as cleft lip, cleft palate and oral candidiasis. Epstein pearls are small, white, shine spots near the midline of the hard palate they mark the fusion of the 2 hollows of the palate. It will disappear in time. Gum: May appear with a quite irregular edge sometimes back of gums may be whitish deciduous teeth are semi-formed but not erupted.

 Cheeks: Have a chubby appearance due to development of fatty sucking pads that help to create negative pressure inside mouth and facilitate sucking. Stomach and intestine: The capacity of infants stomach varies after birth from 3060 cc and increase rapidly. Many infants swallow air during feeding so eructation is necessary

 Abdomen: Cylindrical in shape.

Liver: Palpable 1-3 cm below the right costal margin. Spleen: Tip of the spleen can sometimes be felt but a palpable spleen more than 1 cm below the left costal margin suggest s enlargement. Umbilical cord: Bluish white at birth with two arteries and one vein. It is formed of gelatinous connective tissue called Whartons jelly. The cord shrinks, dries and drops off its place of attachment heals in about 7-10 days.

2-Circulatory System:
Heart: Point of Maximum Intensity (PMI) may be palpated and is usually found in the fourth to fifth intercostals space, medial to the left midclavicular line. Heart sounds includes the first (S1) and second (S2) sounds should be clear and well defined. The second sound is somewhat higher in pitch and sharper than the first. In fetal life, the circulatory system severs as modified respiratory system since O2 isnt obtained through breathing but through umbilical cord.

3-Respiratory System:
Slight sternal retraction evident during inspiration. Xiphoid process evident. Antero-posterior diameter and lateral diameter are equal. Respiratory chiefly abdominal. Cough reflex absent at birth, present by 12 days.

4-Urinary System
Normally, the newborn has urine in his bladder and voids at birth or some hours later. Newborn pass urine within 24 hours after birth.

Female genitalia: Labia and clitoris usually edematous. Urethral meatus behind clitoris. Vernix Caseosa between labia. Male genitalia: Urethral opening is at tip of glans pens. Testes palpable in each scrotum. Scrotum usually large edematous, pendulous and covered with rugae and pigmented.

5-Endocrine system:
There are maternal hormones that have crossed through the placenta to the baby. After birth these are withdrawn and cause some normal phenomenal such as: Swollen breasts: This appears on 3rd day in both males and females. It lasts for 2-3 weeks and gradually disappears without treatment. The breasts should not be expressed as it may result in infection or injury to tissue. Sometimes there is also breast secretion called Witchs milk.

Pseudo menstruation: Maternal hormones in uterus cause the endometrial lining of female fetus to thicken. When it is withdrawn after birth, this thickening is no more maintained. Tiny menstrual flow is observed. This consists of few spots of blood for 1-2 days can be seen in the diaper.

6: The Nervous System:

Reflexes: Certain reflexes are absolutely essential to the infant life- as protective reflexes:
Blinking reflex- it is aroused when the infant is subjected to light. Coughing and sneezing- to clear the respiratory tract.

Gagging- to prevent choking

 Feeding reflexes:
The rooting reflex causes the infant to turn his head towards anything, which touched his check, and in his way to reach for food. Sucking reflex provide such movements when anything touches the lips.

Swallowing reflex: It follows sucking reflex. The gage reflex: Comes into play when he has taken more into his mouth than he can successfully swallow, can also cough if a little of the fluid is swallowed the wrong way and enters the trachea.

Other reflexes: The grasp reflex: an infant will grasp any object put into his hands, holds on briefly and then drop it. Moro reflex (startle reflex): This is aroused by a sudden loud noise or less of support. The reaction is aimless muscular activity. It demonstrates an awareness of equilibrium. In its absence the possibility of brain damage must be considered. The tonic neck reflex. It is a postural reflex in which the infant when lying on his back turns his head to one side and extends the leg on the side to which the head turned.

 Successful use of reflex mechanism is evidence of normal functioning of the nervous system. (Refer to the given table and picture).
Extremities usually maintain some degree of flexion. Extension of an extremity followed by pervious position of flexion. Head lag while sitting, but momentary ability to hold the head erect. Able to turn head in horizontal line with back when held prone.

7: Extremities:
Ten fingers and toes. Full range of motion. Nail beds pink, with transient cyanosis immediately after birth. Creases on anterior two thirds of sole. Symmetry of extremities. Equal bilateral brachial pulse.

Any question