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NEWBORN CARE
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A. Essential Concepts:1. In the postpartal period, the newborn experiences complex bio-
physiologic and behavior change related to the transition to
extrauterine life.2. Nursing care of the newborn is based on knowledge of these
changes and of the newborns impact on the family unit.
3. The first few hours after birth represent a critical period ofadjustment for the newborn. In most setting, the nurse providesdirect care to the newborn immediately after birth.
4. After the transition period, the nurse continues to evaluate the
newborn at periodic intervals and to alter nursing plansaccording to ongoing findings.
5. The nurse must be skillful in balancing the familys need forprivacy and time to interact without interruptions with the need to
closely monitor the newborns transition to extrauterine life.
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B. GOALS OF NEWBORN CARE
1. For the initial postpartal period
a. Establish and maintain an airway and support
respirations.
b. Maintain warmth and prevent hypothermia.
c. Ensure safety to prevent injury or infection.
d. Identify actual or potential problems that might require
immediate attention.
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2. For continuing care
a. Continue to protect from injury or infection and
identify actual or potential problems that couldrequire attention.
b. Facilitate development of a close parent-infant
relationship.
c. Provide parents with information about newborn
care.
d. Assist parents in developing healthy attitudes
about childrearing practices.
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C. FACTORS AFFECTING NEWBORN
ADAPTATION
1. Antepartal experiences of mother and newborn (e.g.,exposure to toxic substances, parental attitude toward
childbearing and childrearing)
2. Intrapartal experiences of mother and newborn (e.g.,length of labor, type of intrapartal analgesia or
anesthesia)
3. Newborns physiologic capacity to make the transition toextrauterine life.
4. Ability of health care providers to assess and respond
appropriately in the event of potential problems.
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D. NURSING RESPONSIBILITIES
1. Support the neonates physiologic adaptation to
extrauterine life
2. Prevent or minimize potential complications
3. Facilitate parent-infant interaction
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IMMEDIATE
NEWBORN CARE
After the birth of the infant, every effortshould be exerted to support him in his
first minutes, hours and days of life. The
quality of the immediate care afforded the
newborn will spell his later state of health
or well-being.
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1. Establishment and maintenance of
patent airway
Right after the extension of the newborns head
before the chest is delivered the mouth and
nose should right away be cleared. This
measure is the best prevention to meconium
aspiration which results to lung infection:
ASPIRATION PNEUMONIA
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Suction briefly to avoid suctioning needed
oxygen.
Preterm: less than 5 seconds per suction time
Full-term: 5 to 10 seconds per suction time
Give oxygenation judiciously when necessary-giving more than 40% oxygen concentration
can result to damage to the retina causing
neonatal blindness called
RETROLENTAL FIBROPLASIA
Position in SLIGHT TRENDELENBERG
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Test patency of the airway by occluding one
nostril at a timenewborns are nasal breathers
Position in slight Trendelenberg (10-15 degrees
angles)promote drainage of oro-naso-
pharyngeal secretions.
Avoid the acute Trendelenberg position can
cause abdominal contents to exert pressure
unto the diaphragm leading to difficult breathing
Head-down position is contraindicated in the
presence of signs of increased intracranialpressure: vomiting; bulging/tensed fontanels;
abnormally enlarged head; increased BP;
decreased PR and RR; widening pulse
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RESUSCITATION MEASURE
Airway make sure that the mouth and
nasopharynx are free of secretions; removesecretions by suction, small finger, or gentlemilking of trachea
Breathing if neonate does not make effort tobreathe, start your mouth-to-mouthresuscitation. Pinch the nose and cover thebabys mouth entirely with your mouth, and
breath into him and notice the chest moveCirculation if there are no heart sounds, apply
index and middle fingers/thumb on the infants
mid-sternum and apply 1 inch downwardressure. Do 5 chest com ressions followed b
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* Oxygen deprivation of more than 5 minutes
can result to the death of the baby or
permanent damage of sensitive brain cells
*Continue resuscitation until breathing is
established or the heart stops beating and
the baby is pronounced dead
*Stop resuscitation when pupils have
remained dilated for 30 minutes
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2. Maintenance of appropriate bodytemperature
The newborn temperature at birth is 37.3oC &
drops quickly to 35.5oC owing to the
mechanisms of heat loss.
Dry the newborn immediately after birth to
prevent heat loss by evaporation.
Wrap the body and promote flexion and apply
cap to head to minimize the body surfaces
exposed to cool air or cool surfaces; never
place newborn on cold and unlined surfaces.
to prevent heat loss by conduction and
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Use a thermoregulator, such as a radiant warmer,
or a temperature-controlled incubator to control
environmental temperature until the neonates
temperature stabilizesRadiant warmermaintains the neonates temp.
by radiation.
Incubatormaintains the neonates temp. byconduction and convection.
Make sure the warmer is set to the desired
temperatureWarm blankets, washcloths, or towels under a heat
source
Keep the neonate under the radiant warmer until
his tem erature remains stable
Th bd f th f th th b
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The warm abdomen of the of the mother ca bea good place to keep the newborn warmimmediately after birth.
The initial temperature of the newborn is takenper RECTUM to detect for IMPERFORATE
ANUS.
After the initial temperature taking, all othertemperature taking should be per AXILLA tominimize potential risk to traumatizing themucus membrane of the rectum; every 15-30
min. until it stabilizes and then every 4 hours toensure stability
Avoid exposing infant to drafts, wetness, and
direct or indirect contact with cold surface.
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Temperature is stabilized within 8 to 12 hours at
36.8oC (98.2oF).
During the entire immediate care procedures,
place newborn under the floorlamp to keep
him warm.
Subjecting the newborn to COLD STRESS can
cause:
1.Increased brown fat metabolism causing an
increased in fatty acids in the circulation thus
METABOLIC ACIDOSIS.
2.Increased activity/metabolic rate causing more
utilization of glucose and oxygen thus
HYPOGLYCEMIA and RESPIRATORY
D d f h
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3. Do immediate Assessment of theNewborn
APGAR SCORING- Is the standardized evaluation of the newborns
condition at birth done at:
1 min. after birth to determine the generalcondition; &
5 min. after to determine how well thenewborn is adjusting to extrauterine life.
- The scoring system is named after DR.VIRGINIA APGAR, an anesthesiologist, whostudied the observations in the newborn.
- The normal infant should have an APGAR of 7
APGAR SCORE CHART
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APGAR SCORE CHARTSIGN 0 1 2
COLOR
(Appearance)
Generalize
d pallor orbluish
Body pink,
extremities blue(Acrocyanosis)
Pink all over
HEART RATE
(Pulse)
Absent < 100/min 100/min or more
REFLEX
IRRITABILITY
(Grimace)
None; No
response
Grimace, weak
cry
Cry; sneezing
MUSCLE TONE(Activity)
Limp,flaccid Some tone inlimbs; some
flexion of ext.
Active flexion oflimbs; well flexed
extremities
BREATHING
(RespiratoryEffort)
None slow, irregular Regular, with cry
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O 3 = severely depressed with HR slow,
inaudible and reflex response are
depressed or absent. The baby is inserious danger and needs immediate
resuscitation.
4 6 = mildly to moderately depressedinfants; demonstrates depressed
respiration, flaccidity, and pale to blue
color. HR and reflex irritability are good.
Condition is guarded and may need more
extensive clearing of the airway.
7 10 = excellent condition and require no
aid other than sim l naso har n eal
COLOR M b bi b bl h th
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COLOR. Many babies may be blue when theyare delivered, but they usually regain color andbecome pink soon. If the newborn remains
bluish, the baby may not be breathing well, ormay be cold, or may have infection, or acongenital heart problem refer the newbornimmediately to the doctor .
HEART RATE. The heart rate of a newborn isbetween 120 to 160 beats every minute countthe HR in 1 full minute; if outside the normal
rate, refer immediately. MUSCLE TONE. A newborn with his arms and
legs bent has good muscle tone. A limp babywith his arms and legs loose has poor muscletone. A baby with poor/weak muscle tone may
BREATHING B bi h ft bi th
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BREATHING. Babies who cry after birth are
usually breathing well. However, some
newborns may have breathing problems. The
following are bad signs:
The nostrils are flaring when the baby breathes
The skin between the ribs retracts on breathing
Very rapid breathing mote than 60 per min.
Very slow breathing less than 30 per min.
The baby grunts when he breathes- A baby who is not breathing or is gasping
needs immediate help.
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If the baby has lots of secretions, use the
bulb syringe to clear the airway.
Turn the baby on his side for few minutes.
Rub your hand firmly on his back.
Never hit the baby nor hold him upsidedown to make him cry.
Give oxygen inhalation if there is one
available.
Refer immediately.
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- -respiratory distress or is a useful tool in the
evaluation of status of the newborns
respiration to determine degree of respiratorydistress syndrome (RDS).
signs 0No difficulty
1
Moderate
difficulty
2
Maximum
difficulty
Upper
chest
movement
Synchron
ized
breathing
Chest lag See-saw
breathing
Lower
chest
movement
No
retraction
s
minimal Marked
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signs 0No difficulty
1Moderate difficulty
2Maximum difficulty
Xiphoid
process
retractions
No
retractions
minimal Marked
Nasal
flaring
No flaring Just visible Marked
Expiratorygrunting
Quietbreathing
Expiratorygrunts on
auscultation
Grunting onbare ears
n a assessmen an ac on o e
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n a assessmen an ac on o etaken:
Initial assessment Action
PinkHR > 120 bpm
Breathing regularly
Dry and wrap babyBaby stays with mother
Blue
HR >100 bpm
Breathing inadequate
Dry and wrap
Clear the airway
Blue or pale
HR
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Assessment of gestational age NAGELES RULE calculation of EDC using
the mothers LMP; count back 3 mos. from thefirst day of LMP and add 7 days.
McDONALDS METHOD determines age ofgestation by measuring the fundic height
(fundus to symphysis) in cm. , then divide by 4= AOG in months.
BARTHILOMEWS RULE estimates AOG by
the relative position of the uterus in theabdominal cavity.
3rd lunar month fundus is slightly above thesymphysis pubis.
5th lunar month fundus is at the level of the
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Time quickening is first felt.
Ultrasound
Assessment of the newborn at birth
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Rapid estimation of the gestational age
of the newbornsign 36 weeks or
less
37 -38
weeks
39 weeks
or more
Solecreases
Anteriortransverse
occasional Solecovered
with crease
Scalp
hair
Fine and
fuzzy
Fine and
fuzzy
Coarse and
silky
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sign 36 weeks or
less
37 -38
weeks
39 weeks or
more
Breastnodule
diameter
2mm 4 mm 7 mm
Earlobe flexible With somecartilage
Withcartilage
Testes
andscrotum
Testes in lower
canal; scrotumsmall with few
rugae
intermediate Testes
pendulous;scrotum full
with
extensive
ru ae
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Ballard Scoring System
Uses physical and neurologic findings to
estimate gestational age
This system enables estimates of
gestational age to within 1 week, even in
extremely preterm neonates
This evaluation can be done anytime
between birth and 42 hours of age, but thegreatest reliability is at 30 and 42 hours
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- Cephalometry measurement of the diameters
of the skull.
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4. Identify the newborn properly.
- Done as soon as possible after birth
before the newborn is separated from the
mother.
- The best way to identify the newborn is by
means of taking his footprints.
- Proper identification is a legal and moral
responsibility of the midwife/nurse.
- May use bracelets or foot tags.
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5. Provide skin care. Immediate soap and water bath is given to the
normal fullterm newborns to primarily cleansethe skin and prevent infection; is given oncevital signs have stabilized
Wear gloves when giving the first bath
Oil bath is given to pre-terms and other high-risk newborns.
Never give the newborn marine bath (- bath that
someone gives as he holds the newborndirectly under cold, running water of the faucetand briskly bathes him) subjects newborn tocold stress.
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Wash, rinse, and dry each portion of the bodyseparately to minimize heat loss
- Begin the bath with the eyes and face first,proceeding from the cleanest to the leastcleanest area last
- Clean the diaper area last
Give sponge bath until the umbilical cord fallsoff, usually within 10 to 14 days
Use a mild, hexachlorophene-free soap
Dont use soap on infants face Bathe before feedings instead of afterward to
prevent vomiting
Apply alcohol, if ordered, to the base of the
6 Gi C d P h l i
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6. Give Credes Prophylaxis Given to all newborns as a prevention against
OPHTHALMIANEONATORUM/GONORRHEALCONJUNCTIVITIS caused by Neisseriagonorrhea causes blindness as baby may
acquire it as he passes through the birth canalof an infected/untreated mother.
Can be delayed for 1 to 2 hours not tointerfere with the bonding process.
NOW: Apply tetracycline ophthalmic ointment toeach eye, from the inner canthus to the outercanthus.
1 -2 cm ribbon of 0.5% ERYTHROMYCIN
7 Perform Cord Dressing
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7. Perform Cord Dressing Is performed under strict aseptic technique to
prevent TETANUS NEONATORUM caused byClostridium tetani.
Examine the cord for the presence of 3 blood
vessels: 1 umbilical vein and 2 umbilical arteries incomplete number of vessels warrants
immediate reporting for thorough assessment for
congenital defects.
The vessels are covered with Whartons jelly
protects vessels from being twisted or
compressed.
Leave about 1 inch of the cord from the base
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signs: smelly discharge on the surface ofthe umbilical stump; the umbilical stump
remains wet and soft; there is rednessaround the base of the umbilicus
Apply 70% isopropyl alcohol to theumbilical cord stump 3 4 times daily willkeep it dry & clean, & help in making it falloff early.
Umbilical cord stumps usually fall off in 710 days.
In the first 24 hours, inspect cord forOMPHALANGIA (- bleeding of the cord).
Place dia er below the umbilicus to revent
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8. Inject Vitamin Kintramuscularly.
0.5 1 mg of Vitamin K is injected to prevent
bleeding or hemorrhagic disease in the
newborn by improving blood coagulation. Lack of vit. K can cause a bleeding condition
known as Hemorrhagic Disease of the
Newborn that can lead to permanent braindamage or even death.
Newborns GIT is initially sterile no E. coli to
synthesize the vitamin.
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The liver needs vit. K to make other
clotting factors, but because of its
immaturity at birth, it has no stores of vit.
K.
The best site for IM injections is the
THIGH MUSCLE, specifically the mid-
antero-lateral aspect called VASTUSLATERALIS.
9 N t t Rh( )/T O
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9. Neonates to Rh(-)/Type Omothers, should have blood specimen
for: Blood type
Bilirubin level
Direct Coombs test. An abnormal result
indicates presence of maternal antibodies in the
neonates blood, suggesting blood
incompatibility
Reticulocyte count. Increased count indicates
the bodys response to RBC destruction
Hematocrit. Decreased result su ests anemia
Neonates weighing less than 2 500 g or more
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Neonates weighing less than 2,500 g or morethan 4,000 g should undergo blood glucosescreening within 30 min. of birth to determine
glucose stability- glucose levels less than 40 mg/dl indicate
hypoglycemia and require treatment
- the neonate should receive 10ml/kg of bodyweight of formula
- Blood glucose level is checked 1 hour afterfeeding
- If the glucose level is higher than 45 mg/dl,another glucose level is obtained before thenext feeding
The neonate is assessed for signs of
10 Take the weight and other
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10. Take the weight and otherAnthropometric Measurements
Size and weight measurements establish thebaseline for monitoring normal growth. Whenobtaining these measurements, place theneonate in a supine position in the crib or on
the examination table and remove all clothing. WEIGHT. The normal weight of newborns
ranges from 3000 to 3400 g with the lowest
normal limit of 2500 g. Physiologic weight loss: 5% to 10% in the first 7
to 10 days of life. Lost weight is regained afterthe 10th day.
Perinatal mortalit and morbidit are related to
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HEIGHT. Normal height rangers from 18
to 21 inches (46-53 cm), or an average of
50 cm.; taken by heel-to-crownmeasurement; fully extend the neonates
legs with the toes pointing up.
HEAD CIRCUMFERENCE. Measures 33-35 cm (13-14 in)
* Slide a tape measure under the neonates
head at the occiput and draw the tapearound snugly, just above the eyebrows.
CHEST/ABDOMINAL CIRCUMFERENCE
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CHEST/ABDOMINAL CIRCUMFERENCE.
Measures 31-33 cm (13-14 in); 2-3 cm. less
than HC
Place a tape measure under the back and
wrap it snugly around the chest at the nipple,
keeping the back and front of the tape level;
take the measurement after the neonateinspires and before he begins to exhale
Place a tape under the back and wrap it snugly
around the abdomen just above the umbilicus
11 Advise the mother to frequently
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11. Advise the mother to frequentlyobserve the baby for danger signs. The
following are the conditions of the
newborn needing urgent intervention:
Change in color from pink to paleness, blue or
deep yellow Poor suck or weak cry or limpness
Irritability or non-stop crying
Pre-term or very low birth weight
Gasping or not breathing (fast, slow breathing,
grunting0
CONVULSIONS
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Frequent loose stools or difficulty of
defecating
Fever or hypothermia
Pus in the umbilicus or redness around the
umbilicus extending to the skin
Bleeding
Pustules in the skin or swelling and
redness
12 Start immunization with hepatitis B
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12.Start immunization with hepatitis Bvaccine and BCG as recommended
Routine Hepatitis B immunization of allnewborns within 12 hours of life provides thebest chance of preventing perinataltransmission of the virus according to the WHO.
Hepatitis B is injected IM into the outer part ofthe thigh at a dose of 0.5 ml. the vaccine is 05%
efficient in preventing chronic infection and is90% effective in preventing perinataltransmission of the if the 1st dose is given with24 hours of birth followed by the 2nd and 3rddoses at 6 and 14 weeks in that order or at
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Bacillus Calmette-Guerin (BCG) is given
single dose at 0.5 ml injected
intradermally using a sterile tuberculin
syringe and needle. The sites of injection
are the upper arm just below the deltoidor in the upper outer buttock. BCG can
be given practically to all newborns. If a
baby is sick, or if the mother has activeTB and has been receiving less than two
months of treatment, defer BCG. If not
given at birth, BCG may be given
WHO recommends that four doses of OPV be
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given routinely before the age of 1 year:
OPV0, at birth or within 14 days of birth
OPV1, at 6 weeks OPV2, at 10 weeks
OPV3, at 14 weeks of age
If dose OPV0 has not been given within 14 daysof birth, it should be skipped and immunizationstarts at 6 weeks old or at dose OPV1
About 2 gtts of OPV is given through the mouth.There are no contraindications but giving thevaccine may be deferred if the infant hasdiarrhea or you can give an extra dose after