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Maternal and Child Health Nursing

Care of the Newborn

PRINCIPLES IN IMMEDIATE NEW BORN CARE

MATERNAL and CHILD HEALTH NURSING


CARE OF THE NEWBORN
Lecturer: Mark Fredderick R. Abejo RN, MAN

______________________________________
Objectives:

Describe the normal characteristics of a term


newborn.
Assess a newborn for normal growth and
development.
Formulate nursing diagnoses related to a newborn or
the family of a newborn.
Identify expected outcomes for a newborn and family
during the first 4 weeks of life.
Plan nursing care to augment normal development of
a newborn, such as ways to aid parent-child bonding
Implement nursing care of a normal newborn, such as
administering a first bath or instructing parents on
how to care for their newborn.
Evaluate expected outcomes to determine
effectiveness of nursing care and outcomes
achievement.
Use critical thinking to analyze ways that the care of
a term newborn can be more family centered.
Integrate knowledge of newborn growth &
development and immediate care needs with the
nursing process to achieve quality maternal and child
health nursing care.

Goals
To establish, maintain and support respirations.
To provide warmth and prevent hypothermia.
To ensure safety, prevent injury and infection.
To identify actual or potential problems that may
require immediate attention.

THE NEONATE
From birth through the first 28 days of life
Also called the newborn period
2/3 of all deaths that occur during the 1st year of
life occur during this period; more than half
occur in the 1st 24 hours after birth---an
indication of how hazardous this time is for an
infant
How well a NB makes major adjustments
depends on his or her:
Genetic composition
The competency of the recent intrauterine
environment
The care received during the neonatal
period
Care of the Newborn

1st day of life


1. Initiation and maintenance of respiration (used
bulb syringe)
2. Establishment of extra uterine circulation
3. Control of body temp
4. Intake of adequate nourishment
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant parent relationship
8. Care that balances rest and stimulation or mental
Development
Immediate care of the newborn.
A-airway (most neonatal deaths with in 24 h caused by
inability to initiate airway, lung function begins after
birth only)
B-body temperature
C-check/asses the newborn
D-determined identification

I. Establish and maintain a patent airway


A. Never stimulate a baby to cry unless secretions
have been drained out.
A crying infant is a breathing infant. Effective
cry means effective breathing
Do not slap the buttocks but rub the
soles of the feet
The normal infant cry is loud & lusty.
Observe for the ff. abnormal cry:
High-pitched cry : hypoglycemia, increased ICP
Weak cry: prematurity
Hoarse cry: laryngeal stridor
B. The position should be one that promotes
drainage of secretions (head lower than the rest
of the body) EXCEPT when there are signs of
increased intracranial pressure
Vomiting
Bulging
Tense fontanelles
abnormally large head
Increased B
Decreased PR and RR
Widening pulse pressure
Shrill, high-pitched cry

Oral mucus may cause the NB to choke, cough or


gag during the first 12 to 18 hours of life. Place the
neonate in a position that would promote drainage
of secretions
Trendelenburg (contraindicated to
Increased ICP)
Side lying position If trendelenburg
position is contraindicated, place infant
in side lying position to permit drainage
of mucus from the mouth. Place a small
pillow or rolled towel at the back to
prevent newborn from rolling back to
supine position.

C. Suction the newborn properly:


1. Turn the babys head to one side
2. Compress the suction bulb and insert in
one corner.

Abejo

Maternal and Child Health Nursing


Care of the Newborn

3.

Suction gently and quickly prolonged


and deep suctioning of the nasopharynx
during the first 5-10 minutes of life will
stimulate the vagus nerve (located in the
esophagus) and cause bradycardia.

Effects of cold stress


Cold stress
metabolic acidosis
CNS
depression
Coma
Death
Metabolic Acidosis one of the airways by
which heat is produced in the newborn is by
increasing metabolism. When this occurs,
fatty acids accumulate because of the
breakdown of brown fat (seen only in
newborns)
High risk for kernicterus- bilirubin in brain
leading to cerebral palsy
Additional fatigue to allergy stressful heart
Hypoglycemia due to the use of glucose
stored as glycogen
o

o
4.

5.

Suction the mouth first before the nose


when suctioning the nose, the
stimulation of the nasal mucosa will
cause reflex inhalation of pharyngeal
material into the trachea and bronchi,
causing aspiration.
To test for patency of the airway,
occlude one nostril at a time
(REMEMBER: Newborns are nasal
breathers). If the newborn struggles
when a nostril has been occluded,
additional suctioning is indicated

D. Keep the nares patent. Remove mucus and other


particles w/c can cause obstruction as newborns
are obligatory nasal breathers until they are
about 2-3 weeks old.
E. Give O2 as needed. Oxygen should be given for
20-30 minutes when the neonate remains
cyanotic or tachycardic after initial suctioning
and stimulation.
* asphyxiation hypoxia hypercapnia
( CO2) acidosis coma death
Observe precaution in giving oxygen
Do not give more than 40% O2 as
this may lead to retrolental
fibroplasia (blood vessels of the eyes
become spastic leading to blindness)
Use pulse oximeter and monitor O2
concentration every hour
F.

Every NB is born slightly acidotic. Any new


build-up of acid may lead to life-threatening
metabolic acidosis, which can be lethal even
to normal newborn infants.
The average NB temp.@ birth is around
37.2C.
NB lose heat easily because:
They have immature temp.-regulating
system
Of very little amount of subcutaneous
fat to provide heat
They have a larger body surface area
that results in more heat loss
They have little ability to conserve heat
by changing posture and no ability to
adjust its own clothing

Methods of Heat Loss in Newborn


Convection the flow of heat from the NBs
body surface to cooler surrounding air; ex:
windows, air conditioners
Conduction- the transfer of a body heat to a
cooler solid object in contact with a baby; ex:
baby placed on a cold counter
Radiation the transfer of body heat to a cooler
solid obj. not in contact with a baby; ex: cold
window or air con
Evaporation loss of heat through conversion
of a liquid to a vapor; ex: after delivery,
newborns are wet, with amniotic fluid on their
skin, tsb

If the heart rate falls below 60 bpm, cardiac


massage may need to be carried out.

II. Maintain appropriate body temperature.


Chilling will increase the bodys need for
oxygen. The newborn suffers large losses of heat (cold
stress) because he is wet at birth, the delivery room is
cold, he does not have enough adipose tissues and does
not know how to shiver.
Temp Regulation
Goal in temp regulation is to maintain it not less
than 97.7% F (36.5 C)
Maintenance of temp is crucial on preterm and
SGA (small for gestational age) - babies prone to
hypothermia or cold stress
o Neonates have physiologic resilience
wherein they tend to adopt or take
temperature of their own environment.
(poikilothermic)
cold stress (hypothermia) is more
dangerous than hyperthermia
Care of the Newborn

Abejo

Maternal and Child Health Nursing


Care of the Newborn

To Prevent Hypothermia
1. Dry and wrap baby
2. Mechanical pressure radiant warmer pre-heated
first isolette (or square acrylic sided incubator)
3. Prevent is necessary exposure cover baby
4. Cover baby with tin foil or plastic
5. Embrace the baby- kangaroo care
6. Delay initial bath until temp. has stabilized for at
least 2 hours.
7. Maintain ambient temp. of nursery at 24C or
75F.
8. Perform any extensive examination or procedure
under radiant heat to prevent heat loss and
expose only the part of the body to be examined.
9. Note the presence of any cyanosis:
2 types of cyanosis:
a.) central cyanosis
b.) peripheral cyanosis hands & feet
are cyanotic, due to cold
environment and poor circulation

The Silverman & Anderson Scoring System


o Devised in 1956 and is a test used to
evaluate or estimate the degrees of
respiratory distress in newborns or the
respiratory status of premature infants.
o A NB is observed and then scored on
each of five criteria ---0,1 or 2. The
scores are then added. (the scores of this
system are interpreted as opposite of the
Apgar)
The Silverman & Anderson Scoring System
0
1
Synchronized
Lag
on
Chest
Movement respirations inspiration

Axillary temperature measurement. The thermometer


should remain in place for 3 minutes. The nurse presses
the newborns arm tightly but gently against the
thermometer and the newborns side, as illustrated

III. Perform Initial Assessment


APGAR Scoring System
o Developed by Dr. Virginia Apgar in 1958
o It is a standardized method for evaluation of
the newborn and serves as a baseline for
future evaluations.
o It is taken twice: initially @ 1 minute, and
then @ 5 minutes after birth
Special Considerations:
1st 1 min determine general condition of baby
Next 5 min- determine babys capabilities to adjust extra
uterine
Next 15 min dependent on the 5 min
APGAR Scoring System
0
Appearance
(Color)
Pulse/ rate
Grimace/
Reflex
Irritability
A ctivity /
Muscle Tone
Respiratory
Effort

Pale or
Body pink,
Pink all over
blue all extremities blue
over
absent
Below 100
Above 100
No
response

grimace

Sneezes,gags,
coughs,vigorous
cry and foot
withdrawal
Limp, Some flexion of Active motion/
flaccid the extremities
well-flexed
absent Slow,irregular,
Good,
weak cry
strong,lusty cry

APGAR result
0 3 = severely depressed, need CPR, admission NICU
4 6 = moderately depressed, needs addl suctioning &
oxygen
7 - 10 = good/ healthy
Care of the Newborn

Intercostal
Retraction
Xiphoid
Retraction
Nares
Dilatation
Expiratory
Grunt

2
Seesaw
respirations

none

Just visible

Marked

none

Just visible

Marked

none

minimal

Marked

none

Audible by
stethoscope

Audible by
unaided ear

Silvermann and Anderson Scoring Interpretation


0 : no respiratory distress
4-6 : moderate respiratory distress
7-10 : severe respiratory distress
IV. Proper Identification of the Newborn
Proper Id is made in the delivery room before
mother and baby are seperated.
o Identification Band
o Footprints
o Others fingerprints, crib card, bead
bracelet
Birth certificate
A final identification check of the mother and
infant must be performed before the infant can
be allowed to leave the hospital upon discharge
to ensure that the hospital is discharging the right
infant.
V. Preventing Infection
Principles of cleanliness at birth:
Clean hands
Clean perineum
Nothing unclean to be introduced into the vagina
Clean delivery surface
Cleanliness in cutting the umbilical cord
Cleanliness for cord care of the newborn baby
Handwashing
Before entering the nursery or caring for a baby
In between newborn handling or after the care of
each baby
Before treating the cord
After changing soiled diaper
Before preparing milk formula.
Abejo

Maternal and Child Health Nursing


Care of the Newborn

Credes Prophylaxis Dr. Crede


-prevent opthalmia neonatorum or gonorrheal
conjunctivitis
- how transmitted mom with gonorrhea
drug: erythromycin ophthalmic ointment
(inner to outer)

Aspirate, then slowly inject the solution to


distribute the medication evenly and minimize
the babys discomfort.
Remove the needle and gently massage the site
with an alcohol swab.

*It is part of the routine care of the NB to give


prophylactic
eye
treatment
against
gonorrheal
conjunctivitis or ophthalmia neonatorum within the first
hour after delivery.
* Neisseria gonorrhea, the causative agent,maybe passed
on to the fetus when infected vaginal and cervical
secretions enter the eyes as the baby passes the vaginal
canal during delivery. This practice was introduced by
Crede, German gynecologist in 1884. Silver Nitrate,
erythromycin and tetracycline ophthalmic ointments are
the drugs used for this purpose.

VII. Care of Cord

Ophthalmia neonatorum
Any conjunctivitis with discharge occuring during
the first two weeks of life. It typically appears 2-5
days after birth, although it may appear as early as
the first day or as late as the 13th.

Administering
Erythromycin
or
Tetracycline
Ophthalmic Ointment
These ointments are the ones commonly used
nowadays for eye prophylaxis because they do not
cause eye irritation and are more effective against
Chlamydial conjunctivitis.
Apply over lower lids of both eyes, then,
manipulate eyelids to spread medication over the
eyes.
Wipe excess ointment after one minute sterile
cotton ball moistened sterile water.

VI. Preventing Hemorrhage


As a preventive measure, 0.5mg (preterm) to 1
mg (full term) Vit. K or Aquamephyton is
injected IM in the NBs vastus lateralis (lateral
anterior thigh)muscle
Vit-K to prevent hemorrhage R/T
physiologic hypoprothrombinemia
Aquamephyton,
phytomenadione or konakion
.1 ml term IM, vastus lateral or
lateral ant thigh
.05 ml preterm baby
Vit K synthesized by normal flora of
intestine
Vit K meds is synthetic due intestine is
sterile
Procedure for Vitamin K injection.
Cleanse area thoroughly with alcohol swab and
allow skin to dry.
Bunch the tissue of the upper outer thigh (vastus
lateralis muscle) and quickly insert a 25-gauge
5/8-inch needle at a 90-degree angle to the thigh.

Care of the Newborn

The cord is clamped and cut approximately


within 30 seconds after birth.
In the delivery room, the cord is clamped twice
about 8 inches from the abdomen and cut in
between.
When the newborn is brought to the nursery,
another clamp is applied to 1 inch from the
abdomen and the cord is cut at second time.
The cord and the area around it are cleansed with
antiseptic solution.
The manner of cord care depends on hospital
protocol. What is important is that the principles
are followed. Cord clamp maybe removed after
48 hours when the cord has dried.
The cord stump usually dries and fall within 7 to
10 days leaving a granulating area that heals on
the next 7 to 10 days.
Instruction to the mother on cord care:
1. No tub bathing until cord falls off. Do not
sponge bath to clean the baby. See to it that cord
does not get wet by water or urine.
2. Do not apply anything on the cord such as baby
powder or antibiotic, except the prescribed
antiseptic solution which is 70% alcohol.
3. Avoid wetting the cord. Fold diaper below so
that it does not cover the cord and does not get
wet when the diaper soaks with urine.
4. Leave cord exposed to air. Do not apply dressing
or abdominal binder over it. The cord dries and
separates more rapidly if it is exposed to air.
5. If you notice the cord to be bleeding, apply firm
pressure and check cord clamp if loose and
fasten.
6. Report any unusual signs and symptoms which
indicates infection.
Foul odor in the cord
Presence of discharge
Redness around the cord
The cord remains wet and does not fall
off within 7 to 10 days
Newborn fever

Abejo

Maternal and Child Health Nursing


Care of the Newborn

NOTE: If 2 vessel cord- suspect kidney malformation


- leave about 1 of cord
- if BT or IV infusion leave 8 of cord best
access - no nerve
- check cord every 15 min for 1st 6 hrs
bleeding .> 30 cc of blood
bleeding of cord Omphalagia suspect
hemophilia
NOTE: Cord turns black on 3rd day & fall 7 10 days
Faiture to fall after 2 weeks- Umbilical
granulation
Mgt: silver nitrate or catheterization
- clean with normal saline solution not
alcohol
- dont use bigkis air
- persistent moisture-urine, suspect patent
uracus fistula bet bladder and normal
umbilicus
dx: nitrazine paper test yellow urine
mgt: surgery

VIII. Initial feeding


May breastfeed immediately after birth
Formula feeding- 2 to 4 hours of age
Demand schedule
Mother's milk is the best food a baby can have in the
first 6 months of life
ADVANTAGES OF BREAST FEEDING
Enhances the infants immune system (IgA
Lactoferrin, lysozyme, interferon, bifidus Factor)
It reduces the cost of feeding and preparation
time
An excellent opportunity to enhance symbiotic
bond
It is easy to digest.
It is clean and has the right temperature.
It contains the ideal electrolyte and mineral
composition for infant growth
Breastfeeding should start within 30 minutes after
birth
COLOSTRUM (first 2-3 days): good for babies and
helps protect them against infection
When the baby is 6 months old, start giving other
food in addition to breastmilk
Continue to breastfeed sick babies
Breastfeeding mothers should eat nutritious food to
become stronger

Care of the Newborn

IX. Immunization
BCG should be given as soon as possible after
birth in all population at high risk of
tuberculosis infection
OPV a single dose of OPV at birth or in the two
weeks after birth is recommended to increase
early protection.
Hepatitis B vaccine it is important to administer
the first dose as soon as possible or within 24
hours after birth

NOTE: Instruct the mother to be aware of the


following EARLY SIGNS OF SERIOUS DISEASE
and refer the baby immediately to a doctor
Not gaining weight
Excessive cry or not crying
Convulsion, Twitching, Eye blinking
Stiff neck, body and limbs
Pus discharge or swelling of cord
Eye drainage
Feverish or cold baby
Fast respiration, groaning and chest
retraction
Not accepting feed
Irritable or lethargic
Pale or Jaundice
Cyanotic
Vomiting and Abdominal distension
Not passed urine within 2 days and stool
within 1 day

Abejo