THE NORMAL NEW BORN

The nurse is in a unique position to aid the newborn infant in the stressful transition from
a warm, dark, fluid-filled environment to an outside world filled with light, sound, and
novel tactile stimuli. During this period of the newborn adjusting from intrauterine to
extra uterine life, the nurse must be knowledgeable about a newborn's normal
biopsychosocial adaptations to recognize any deviations. To begin life as an independent
being, the baby must immediately establish pulmonary ventilation in conjunction with
marked circulatory changes. These radical and rapid changes are crucial to the
maintenance of life. All other neonatal body systems change their functions or establish
themselves over a longer period of time. The nurse performs an initial assessment to
evaluate the neonate, its immediate post birth adaptations, and the need for further
support.

PHYSICAL ADAPTATION OF A NEW BORN

The Successful transition from fetal to neonatal life requires a complex interaction
between the Immunologic ,Respiratory ,Cardiovascular and Thermoregulatory systems

The newborn must adapt from being completely dependent on another for life sustaining
oxygen and nutrients to an independent being, a task accomplished over a period of hours
to days.

Establishing respirations is critical to the newborn’s transition, as lungs become the organ
of gas exchange after separation from maternal uteroplacental circulation.
CIRCURATORY ADAPTATION
Fetal circulation

In utero, oxygenated blood flows to the fetus from the placenta through the umbilical
vein. Although a small amount of oxygenated blood is delivered to the liver, most blood
diverts the hepatic system through the ductus venosus, which forms a connection between
the umbilical vein and the inferior vena cava. Oxygenated blood from the inferior vena
cava enters the right atrium and most of it is directed through the foramen ovale to the left
atrium, then to the left ventricle, and onto the ascending aorta, where it is primarily
directed to the fetal heart and brain
Deoxygenated blood from the head and upper extremities comes back to the right atrium
by the superior vena cava, where it blends with oxygenated blood from the placenta. This
blood enters the right ventricle and pulmonary artery, where 90% of it is shunted across
the ductus arteriosus and into the descending aorta, providing oxygen to the lower half of
the fetal body and eventually draining back to the placenta through the two umbilical
arteries. The remaining 10% of the blood coming from the right ventricle perfuses lung
tissue to meet metabolic needs .

Neonatal Circulation

With the infant’s first breath and exposure to increased oxygen levels, there is an
increased blood flow to the lungs causing the closure of the foramen ovale. Constriction
of the ductus arteriosus is a gradual process that results from a reduction of pulmonary
vascular resistance (PVR), increasing systemic vascular resistance (SVR) and sensitivity
to a rise in arterial PaO2 levels. The removal of the placenta decreases prostaglandin
levels (which helped to maintain ductal patency) further influencing closure

At birth, the clamping of the umbilical cord eliminates the placenta as a reservoir for
blood, triggering an increase in systemic vascular resistance (SVR), an increase in blood
pressure, and increased pressures in the left side of the heart. The removal of the placenta
also eliminates the need for blood flow through the ductus venosus, causing functional
elimination of this fetal shunt. Systemic venous blood flow is then directed through the
portal system for hepatic circulation. Umbilical vessels constrict, with functional closure
occurring immediately. Fibrous infiltration leads to anatomic closure in the first week of
life

Successful transition and closure of fetal shunts creates a neonatal circulation where
deoxygenated blood returns to the heart through the inferior and superior vena cava.
Blood then enters the right atrium to the right ventricle and travels through the pulmonary
artery to the pulmonary vascular bed. Oxygenated blood returns through pulmonary veins
to the left atrium, the left ventricle, and through the aorta to systemic circulation.
Hypoxia, acidosis and congenital heart defects are conditions that lead to a sustained high
PVR and may interfere with the normal sequence of events

The graphics on the next page illustrate fetal and neonatal circulation.

Page 2 of 22
th
RESPIRATORY ADAPTATION

The initiation of breathing is a complex process that involves the interaction of biochemical,
neural and mechanical factors. Pulmonary blood flow, surfactant production, and respiratory
musculature also influence respiratory adaptation to extrauterine life.

•
Umbilical cord clamping decreases oxygen concentration, increases carbon dioxide
concentration, and decreases the blood pH. This stimulates the fetal aortic and carotid
chemoreceptors, activating the respiratory centre in the medulla to initiate respiration.

•
Mechanical compression of the chest during the vaginal birth forces approximately 1/3
of the fluid out of the fetal lungs. As the chest is delivered, it re-expands, generating a
negative pressure and drawing air into the lungs. Passive inspiration of air replaces
fluid. As the infant cries, a positive intrathoracic pressure is established which keeps
the alveoli open, forcing the remaining fetal lung fluid into the lymphatic circulation.

•
In order for the respiratory system to function effectively, the infant must have:

- adequate pulmonary blood flow

- adequate amount of surfactant

- respiratory musculature strong enough to support respiration

CHARACTERISTICS OF A NEWBORN

 A normal newborn baby should have strong lusty cry

 the birth weight is of 2.5 -3.5kgs.
 The length is 45 – 55cm.
 Head circumference 33- 35cm and the head is larger than the face.
 The anterior fontanelle will be open and pulsation being observed on inspection (note
sometimes pulse rate is taken here).
 The sutures can be felt very easily.
 the limbs are shorter in comparison to the body.
 The abdomen is larger compared to the thorax.
 The skin is pink, firm and inelastic and underneath the subcutaneous fat is sparse.
 The skin is covered with vernix caseosa a white sticky substance (importance of vernix
caseosa; protects the skin from the fluid and from any friction against itself).
 Downy hair, lanugo, covers the skin and is plentiful over the shoulders, upper arms and
thighs.
 A mature baby has plentiful skin creases on the palms, his hands and soles of the feet.
 The babies’ nails are long and reach the finger tips, are soft and peel off easily.
 His hair is soft and silky.
 The cartilage of ears is well formed.
 Both boys and girls have a nodule of breast tissue around the nipple.
 In males, the testicles are descended into the scrotum which has plentiful rugae.
 The urethral meatus opens at the tip of the penis and the prepuce is adherent to the
glans. In female the labia majora cover the labia minora.
 No tears are present in the eyes of the newborn and they become infected easily.
 There is response to taste at birth, sensitive to pain and hunger, hearing is present at
birth. Respiration should be regular 40 – 60b/min and the heart rate should be regular
120- 160b/m.
CARE OF THE NEWBORN

 At birth, a healthy newborn should be immediately put skin-to-skin on his/her mother,

dried and covered by dry warm blankets.
 The newborn’s Apgar scoring and initial assessments should be done while remaining
skin-to-skin (unless resuscitation is required).
 Administration of medications, measurements and weight should be delayed until a
period of uninterrupted skin-to-skin contact on mother for at least one hour, or until
after the newborn’s first attempt to breastfeed.
 The infant’s respiratory rate, heart rate, colour and axillary temperature should be
measured and recorded

1. Apgar Score
The purpose of the Apgar score is to provide an estimate of how well the newborn is adapting
to life. The score is done at 1 and 5 minutes after birth, and may be repeated at 10 minutes if
the score is and remains low.
Score ≤ 3 - critically low
Score 4 to 6 - fairly low
Score 7 to 10 - generally
normal. A low score on the one-
minute test may show that the
newborn requires medical attention
but is not necessarily an indication
that there will be long-term
problems, particularly if there is an
improvement by the stage of the
five-minute test.

2. Vital Signs

a) RESPIRATIONS
•
Assess respirations while the infant is at rest.
•
Count respirations for one full minute while observing abdominal and thoracic
movement.
The normal rate for respirations is 40-60 breaths/minute.
 •
Ausculate the chest bilaterally and over all the lung fields to determine the quality of
air entry and breathe sounds.

b) HEART RATE
•
Place the warm stethoscope on the left side of the infant’s chest, near the edge of the
sternum and slightly lower than the nipple line. The heart sounds can be clearly heard
at the point of maximal intensity (PMI) which is located at the third to fourth
intercostal space just lateral to the mid-clavicular line.
•
Assess the heart rate and the rhythm for one full minute, noting heart sounds (i.e.:
murmurs).
•
The normal heart rate ranges from 100-160 beats/minute, but some term babies may
have a resting heart rate as low as 80 bpm (ACoRN, 2010).

c) TEMPERATURE
•
Assess the temperature via the axillary route. This is the safest and most convenient
route to measure temperature in the neonate. The risk of trauma is increased with a
temperature taken rectally. The use of tympanic thermometers is not recommended as
readings may not be accurate in children under 2 years of age (ACoRN, 2010).
•
The normal axilla temperature ranges from 36.3 – 37.2°C (ACoRN, 2010).
NOTE: A cold stressed infant may exhibit normal to elevated axilla temperatures in
response to metabolism of brown fat.
•
If using an electronic thermometer, apply a clean probe cover to temperature probe
and ensure that it is firmly in place.
•
Place the probe gently against the axilla (in alignment with the length of the baby’s
body) and hold the infant’s arm pressed firmly against the side and hold the
thermometer in place until a reading is obtained.

3 Medication Administration

Newborns routinely receive two medications at birth: an intramuscular injection of Vitamin K

and an antibiotic agent for eye prophylaxis.
Parents may refuse Vitamin K; however, it is important to document the reason for refusal as
well as information given to parents about the risks of disregarding the recommended
treatments. Some institutions have specific forms for parents to sign should they refuse
standard procedures recommended/required for newborn care.
a) VITAMIN K

Intramuscular administration of Vitamin K (phytonadione) is the most effective method of

preventing hemorrhagic disease of the newborn. It is administered to the newborn in order to
facilitate normal clotting until the newborn’s intestinal tract produces the bacteria necessary to
synthesize Vitamin K. Vitamin K should be given as a single intramuscular dose to all
newborns within 6 hours of birth (Canadian Paediatric Society and College of Family
Physicians of Canada, 2004).
For infants weighing less than or equal to 1500 grams, the dose is 0.5 mg IM; for infants
weighing more than 1500 grams, the dose is 1.0 mg IM.
b. EYE PROPHYLAXIS
All newborns should receive a prophylactic agent against ophthalmia neonatorum, from
gonorrhea or chlamydia, except for very premature newborns whose lids are fused at the time
of birth. It is recommended that each eye be treated with a 1-cm ribbon of 0.5% erythromycin
ointment. The eyes should not be irrigated with sterile water or saline. The administration may
be delayed for up to two hours after birth to enable parent–infant contact and initial
stabilization of the baby (Health Canada, 2000).

4. Newborn Measurements

a) WEIGHT

• Place a paper or warm blanket on the scale basket and zero scale.

• Remove the infant’s clothing/blanket (no diaper).

• Place the infant on the scale, keeping one hand over the infant without touching.

• If this is the first weight following birth, encourage support person to take a picture of
the baby on the scale so the weight can be seen (useful if transcription error occurs).
• Read and note weight.

b) LENGTH

• Lay the infant on a flat surface in a recumbent position.

• Place a hand over the knees so that the infant’s legs are extended.
 • With the foot flexed, draw a line marking the bottom of the heel.

• Continue to immobilize the infant and draw a line at the infant’s head.

• Remove the infant and measure the distance between the two points.

c) HEAD CIRCUMFERENCE

• Wrap measuring tape around the largest area of the infant’s head, over the occipital,
parietal, and frontal prominences. Begin above the eyebrows and ears, and continue
around the back of the head. Take the largest of several measurements.
• NOTE: Cranial molding or scalp edema may affect the measurements.

• Measure head circumference (HC) daily or as ordered if abnormal results are obtained.

d) CHEST CIRCUMFERENCE

• Place the measuring tape under the infant’s back at a level corresponding to the xiphoid
process and bring each end toward front under the axilla at the nipple line.
• Secure the zero end over the sternum and then pull the other portion of the tape so it fits
snuggly around the chest.
• Read the measurement when the infant exhales.

e) ABDOMINAL GIRTH

• Place the tape under the infant’s back at a level corresponding to the position of the
umbilicus.
• Secure the zero mark above the umbilicus.
• Pull the other portion of the tape until it fits snuggly around the abdomen.
• Read measurement at the point where the zero mark meets the other portion of the tape
when the infant exhales.

3. Complete Physical Examination of the Newborn

SPECIFIC USUAL
AREA VARIATIONS ABNORMALITIES
S FINDINGS
HEAD Shape • Symmetrical • Asymmetry due to • Severe molding,
• Molded (with molding, especially if
vaginal birth) • Scalp lesions or accompanied by
abrasion abnormal transition
• Round (if
cesarean birth) • Cephalohematoma • Tension of the anterior
fontanel (To be
• Caput
determined when the
• Palpable anterior succedaneum infant is in a sitting
and posterior • Posterior fontanel position)
fontanels and may be difficult to
• Remarkable pulsation
sutures palpate if sutures
of fontanels
• Anterior fontanel are overriding
• Depressed fontanel
flush with
neighbouring (dehydration)
parts (can be • Full bulging fontanels
• Overriding of the
expected to be (intracranial pressure)
sutures (observe
slightly and notify MD) • Depressed skull
depressed when fracture (notify MD
child is in sitting immediately)
position) • Unusually large or
small head in relation
• Sutures are to body size
normally felt as • Unusual hair pattern or
ridges texture
immediately • Subgaleal hemorrhage
after birth or as
(notify MD
depressions
immediately)
within a day

EYES Symmetry • Correct • Centered or deviated

placement on to right or left
face in relation
to one another
Appearance • Marked edema or
• Edema inflammation
• Drooping
• Blink reflex
• Setting-sun sign
present

• Fused < 25
weeks approx.
Discharge • None • Purulent
 Sclera • Bluish-white
• Hemorrhage, jaundice
SPECIFIC USUAL
AREA VARIATIONS ABNORMALITIES
S FINDINGS
 EARS Shape • Well-formed • Preauricular • Malformations
papillomas
• Cartilage present (ear tags)
may be
present
• Upper part of ear • Low placement
• Amt. of
should be on same
cartilage
plane or above
varies (less
angle of eye
with
prematurity)
• May be
folded or
creased

NOSE Symmetry • Midline of face

• Deviated to the right or
left
Shape • Malformation or
• Appears flattened unusual flattening

Patency • Should breathe • Some • Flaring of nares,

easily through mucous • Stenosis of naris
nose when mouth present in (choanal atresia)
is closed nares may
interfere with
breathing
MOUTH Lips • Transient • Cleft
• Pink circumoral • Persistent cyanosis
cyanosis
• Rooting reflex
Tongue • Thrush
• Pink • Protrusion
• Frenulum linguae
• Positioned inside
(tongue tie)
mouth
(may interfere with
• Normal size sucking)
• Large and thick
Palate • Pink and well
formed • Epstein’s • Cleft
pearls
Gums • Pink • Rear gums
whitish

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• Can appear
jagged
• Teeth can be
present or
inclusion
cysts
(whitish
tooth-like
cysts)

NECK Appearance • Masses

• Short, straight • Distended veins or
edema
• Webbing

Motion • Unrestricted range

of motion • Congenital torticollis

• Opisthotonus
CHEST Shape • Almost circular • Depressed Barrel
sternum

Clavicles • Straight, smooth • Fractures (crepitations,

tenderness, palpable
mass)

Expansion • Symmetry of • Asymmetrical

movement with movements (e.g.
respirations diaphragmatic hernia,
pneumothorax)

CHEST (cont’d) Respiration • Rate 40-60/min • Laboured breathing

s • Grunting on
expiration
• Retractions with
respirations
• Tachypnea

AREA SPECIFICS USUAL FINDINGS VARIATIONS ABNORMALITIES

 Breast • Present in both • Excessive
Tissue sexes amount of
breast tissue
• Breast
engorgement

Nipples • Symmetrical • Presence of Asymmetrical

placement of supernumerary placement of nipples
nipples nipples

CIRCULATIO Heart Rate • Rate 100-160 • Heart sounds heard

N bpm on right side
• Rate increased (dextrocardia)
following • Tachycardia
physical or
emotional
stimulus
Capillary • < 3 seconds • > 3-4 seconds (poor
refill perfusion)
Murmur • Intermittent • Persistent
• Absent during first • Muffled heart sounds
few days of
• Extra sound
life

Pulses • Absent or weak

• Equal • Bounding (PDA)
bilaterally
• Upper > lower

ABDOMEN Shape • Contour • Asymmetry

cylindrical and • Distention
relatively
• Gastroschisis
prominent
• Bladder
• Soft
extrophy
• Localized
bulging (e.g. hernia)
• Scaphoid
abdomen (e.g.
diaphragmatic hernia)

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Umbilical • Bluish white • Umbilical • Abnormal redness

Stump • 3 vessels hernia may • Bleeding or
be present oozingOdour
• Dry within and is
several hours • Omphalocele
usually
after birth insignificant

Sounds • Transient in • Intermittent • Hypermobility

first 24 hrs
ANUS
Patency • Normal position • Imperforated anus
• Dimpled or
puckered
appearance

SPECIFIC USUAL
AREA VARIATIONS ABNORMALITIES
S FINDINGS
GENITALIA Appearance Female

• Labia minora • Smegma • Excessive vaginal

quite bleeding
prominent and • Vaginal
protrude over discharge -
labia majora mucoid or
blood tinged
Male • Malformations (e.g.
• Prepuce usually • Undescended epispadias,
adherent to the testicles on hypospadias,
glands either side phimosis) Hydrocele
• Testicles usually • Ambiguous (both
in scrotum male/female)
• Scrotum small
and firm or
fairly loose,
relaxed and
pendulous
 • Meatal opening
should appear
as a slit

Appearance • Generally • May retain in • Limitation of

flexed but can utero position movement in any
be passively put when sleeping joint (e.g. fractures,
through a full paralysis).
range of motion • Presence of defects
• Alignment of or missing parts of
parts and all extremities (club
presence of all feet, webbing,
limbs and palmar or plantar
extremities simian crease, extra
digits

EXTREMITIE Color • Acrocyanosis • Difference in colour

S may last for or temperature
This needs to several hours between the
be moved up to after birth extremities
face the second
Appearance Appearance • Pink
above here and This one • Varies with race • Hemangiomas • Pallor
Appearance should have and ethnic origin
and color a heading • Lanugo • Jaundice in 1st 24 hrs
• Remove bullet
should both go called: of life
under SKIN • Milia
extremities. • central cyanosis (e.g.
• Vernix cardiac, neurological
caseosa or respiratory
problem)
• Peeling
• Pustules
• Birthmarks
• Abrasions
• Mongolian
spots • Lacerations

• Petechiae •
(rapid
delivery)

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• Meconium
stained

• Erythemia

• Bruising

•
SPINE Appearance • Spine straight, • Pilonidal • Malformations (e.g.
closed and easily dimple over spina bifida)
flexed coccygeal • Abnormal curvature of
area spine
• Lanugo over • Pilonidal cyst or sinus
shoulders and
• Tufts of hair anywhere
back,
over the spine,
especially in
especially the sacrum
preterm
(e.g.
infants
spina bifida)

NEW BORN REFLEXES

Primitive neonatal reflexes are unique in the newborn period, a consequence of the continued
development of the CNS after birth. Any asymmetry, increase, or decrease in tone elicited by
passive movement may indicate a significant CNS abnormality and requires further evaluation.
Similarly a delay in the expected disappearance of the reflexes may warrant an evaluation of
the CNS. The most important reflexes to assess during the newborn period are as follows:

 The Moro reflex is elicited by allowing the infant's head gently to move back suddenly
(from a few inches off the crib mattress). This results in abduction and upward
movement of the arms followed by adduction and flexion. The Moro reflex disappears
by 4 to 6 months.
 The rooting reflex is elicited by touching the corner of the infant's mouth, resulting in
the lowering of the lower lip on the same side with tongue movement toward the
stimulus. The face may turn to the stimulus. The rooting reflex disappears at 4 to 6
months.
 The sucking reflex occurs with almost any object placed in the newborn's mouth. The
infant responds with vigorous sucking. The sucking reflex is replaced later by voluntary
sucking only.
 The grasp reflex occurs when placing an object, such as a finger, onto the infant's palm
(palmar grasp) or sole (plantar grasp). The infant responds by flexing fingers or curling
the toes. The palmar grasp usually disappears by 3 to 4 months and the plantar grasp by
6 to 8 months.
  The asymmetric tonic neck reflex is elicited by placing the infant supine and turning
the head to the side. This placement results in ipsilateral extension of the arm and the
leg into a "fencing" position. The contralateral side flexes as well. This reflex
disappears by 2 to 3 months of age.

EXAMINATION OF THE NEW BORN ( PRACTICAL)

It is a thorough systemic assessment carried out before the first bath of the baby.

This examination is performed on all newborn babies, ideally within 48 hours of birth.  It is
also rechecked by the baby’s general practitioner at the 6 week check.  It is basically a top-to-
toe examination of a baby.

Requirements

Tray containing the following;

 Gallipot with cotton swabs.

 Bottle of normal saline or boiled cooled water.
 Tape measure.
 Rectal thermometer.
 Stethoscope.
 2 receivers.
 Gloves.
 Vaseline or lubricant.
 Cord ligatures/ties
 Pair of cord scissors
 Light Pen

At the bed side

 Weighing scale.
 Adequate light.

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 Plastic apron.
 Baby`s clothes.
 Baby`s chart
 Firm flat surface

Procedure

1. Introduce yourself to mum and clarify her and baby’s identity.  Explain what you would
like to do i.e. full examination of her new baby(s) and gain her consent. Congratulate
her on the birth as this will put her at ease and help gain your trust. New mums are
protective of their babies so trust and rapport is essential.
2. Close nearby windows to provide warmth.
3. Request the mother to attend the procedure if not contraindicated to build confidence.
4. Undress the baby and expose only the part to be examined to avoid unnecessary
exposure of the baby and maintain warmth.
5. Position the baby in supine position to examine the baby systematically
6. Observe the colour, texture of the skin and presence of vernix caseosa to confirm
maturity and detect abnormalities.
7. Examine the head for shape, size and symmetry. Palpate the fontanelles and sutures ;
take the head circumference (33-35cm)
8. Observe the appearance the face to exclude possible paralysis
9. Examine the eyes, note any discharge, conjuctival haemorrhage, setting of the eyes,
colour and response to light to detect abnormalities and ensure timely management.
10. Examine the nose for presence of 2 nostrils, patency and nasal septum.
11. Examine the mouth for colour, presence of thrush and palpate the hard and soft palate;
examine the tongue for size and presence of tongue tie.
12. Ears; assess the firmness, presence of cartilage, placement and hearing.
13. Neck: turn the neck gently, palpate for masses and palpate the clavicles to rule out birth
fractures.
 14. Hands; note the size, length and symmetry of the hands, examine the axilla, elbows and
the flexion and rotation of the wrist and elbow joints; count the number and formation
of fingers, examine the palm creases.
15. Measure chest circumference using tape measure (30-33cm), count the respirations to
detect abnormal respirations and apex beat; note regularity. Breasts; note the size, extra
and location of nipples to exclude extra nipple, engorged breasts and discharge.
16. Abdomen; inspect the abdomen for shape and size, palpate the liver and spleen rule out
enlarged organs , auscultate for bowel sounds and examine the cord for bleeding or any
sign of infection.
17. External genitalia; determine the sex of the baby and examine the genitalia; for male
palpate the scrotum and penis, for female note the discharge.
18. Lower limbs; barrows test; flex the limbs and abduct the thighs to rule out dislocation
of the hip. Extend the limbs and examine the size.
19. Back; turn the baby gently and make the baby lie on its abdomen and pass the finger
along the vertebral column to rule out neuro-tubal defects.
20. Measure the baby’s length using a tape measure; place the tape measure at the occipital
prominence up to the heel and note the length.
21. Anus; place the baby in lateral position, lubricate rectal thermometer and pass insert it
gently into the rectum. Note if baby has meconium. To rule out imperforate anus.
22. Reflexes; rooting, sucking, Moro, grasping and step reflexes to determine maturity and
rule out endocrine disorders.

Rooting reflex; stroke or touch the infant’s cheek or mouth and note the baby’s
response.

Sucking reflex; place mothers nipple or finger in the baby’s mouth, the baby should
suck vigorously.

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Moro reflex; hold the infant in supine position, displace the baby downwards few
centimeters, note whether the baby extends and abducts the extremities with fingers
spread in asymmetrical fashion.

Grasping reflex; place the finger in the baby’s palms and note whether the baby
responds by grasping the finger.

Step reflex; hold the baby upright with feet touching flat.

23. Keep the baby warm, share findings with the mother to avoid chilling.

Wash hands and clear away and record the findings to prevent cross infection