SL 2 NEWBORN CARE

OBJECTIVES
After participating in varied activities designed for this concept, the second year
students will be able to:

1. Be aware of the Philippines’ experiences in integrating newborn care practices and BFHI in
the context of quality improvement for maternal and newborn health services
2. Familiarize self to the different procedures related to newborn care.
3. Display skills in doing newborn care procedures such as taking rectal temperature,
anthropometric measurements,crede’s prophylaxis and infant bath.
4. Justify the reasons for every steps/actions in the procedure.
5. Gradually develop the positive attitude expected from a pediatric nurse.
6. Realize the importance of providing safe environment and quality care to newborn.

INTRODUCTION
Nurses should be knowledgeable in terms of the basic on baby care. First time mothers
usually ask help from a nurse to show to them how to do different newborn care like bathing,
dressing, changing the diaper, taking the temperature, cleaning the umbilical cord, the eyes and
feeding and burping the baby! Mothers while in the hospital should practice doing all of these
newborn care. Remember, practice makes perfect. So, before discharge, nurses make sure that
mothers already learned how to take care of their babies.
Inadequate knowledge of nurses and mothers on proper care of newborn could contribute to
the increase in the number of neonatal deaths. This idea is supported in an article in Philippines
Inquirer published on June 7, 2008 entitled “ Tragedy of Newborn Deaths” where a large Metro
Manila hospital partially closed for cleanup as 25 babies reportedly died due to Infection with a
total of 32 babies died in the outbreak. Possible the cause is due to non – observance of aseptic
technique in doing different procedures and failure to maintain the cleanliness of the newborn’s
surrounding. Investigations were done and there were actions taken so as to solve this problem.
• This was considered and handled as a hospital infection control problem
• Environmental cultures were positive
• Government inquiry done, with World Health Organization
• How much colostrum did the cases receive? This is considered in the investigation.
• Development of policies to help reduce the number of neonatal deaths and to improve the
condition of both the newborn and postpartum mothers.
The newborn infant’s need to survive not only depend on breastmilk from the mother but
from the effort of the members of the health team, strict compliance on the newborn care protocol
and that of the maintenance of a safe environment.
 KEEP IN MIND
ESSENTIAL INTRAPARTAL AND NEWBORN CARE - ADPCN – UNICEF Project
Here in the Philippines the causes of neonatal deaths are the following, thus to reduce child
mortality is one of the goals of the government, considered as Millennium Development Goal 4
(MDG 4)
• Pneumonia 6%
• Preterm complications 31%
• Intrapartum-related 24%
• Sepsis 13%
• Tetanus0%
• Congenital Anomalies 17%
• Diarrhea 1%
• Others 8%
*Estimates generated by the UN Inter-agency Group for Child Mortality Estimation

The Millennium Development Goals

Policy Developments
• Administrative Order 2008-0029 (Sept. 9, 2008) – Implementing Health Reforms for Rapid
Reduction of Maternal and Neonatal Mortality

• Administrative Order 2009-0025 (Dec. 01, 2009)– Adopting New Policies and Protocol on
Essential Newborn Care

• Administrative Order no. 2012 -0009 (June 27, 2012) – National Strategy towards Reducing
Unmet Need for Modern Family Planning as a Means to Achieving MDGs for Maternal
Health
ESSENTIAL INTRAPARTUM AND NEWBORN CARE
• are set of practices that upon recommendations of the DOH, PhilHealth, and the WHO.
• because of its evidence-based standards that reduce maternal and newborn mortality rate.
• These practices are totally different from the traditional newborn care some of its objectives
are to provide evidence-based practices to ensure survival of the newborn from birth up to
the first 28 days of life.

• practice of cord clamping in Phil. hospitals is 12 seconds with 99% under 1 min
WHO standards require 1 – 2 mins or until pulsations stop.

• 97% do drying after 1 min

WHO standards - done immediately.

• Immediate skin-to-skin contact - not being observed, with only 9.6% doing it after 5 mins
WHO- should be done over 90% of the time.

• “Bad habits” or harmful practices:

– putting babies on a cold surface
– not drying the baby
– not drying the head
– washing or giving the baby a bath (done within 8 mins)
WHO - it could be delayed until after 6 hours.

Other new newborn care guidelines

• transferring babies to nursery is no longer necessary ---should be roomed in with their
mothers immediately.
• separating the baby from the mother, weighing, and examining the newborn - done at least
after more than an hour, not in just after 10 minutes.
• immediate breastfeeding (within one hour after birth or as soon as baby shows signs).
STANDARD ESSENTIAL NEWBORN CARE PRACTICES
ESSENTIAL NEWBORN CARE (ENC) PROTOCOL
 series of time bound, chronologically - ordered, standard procedures that a baby receives
at birth.
 Includes preventive measures which are needed to ensure the baby’s survival.

FOUR CORE STEPS OF ESSENTIAL NEWBORN CARE

1. Immediate and thorough drying
2. Early skin-to-skin contact
3. Properly timed cord clamping
4. Non-separation of the newborn and mother for early initiation of breastfeeding

RATIONALE of the FOUR CORE STEPS

1. Immediate drying
• prevents hypothermia - important to survival

2. Skin-to-skin contact with the mother- on mother’s chest / abdomen

• to provide warmth (prevents hypothermia),
• increase the duration of breastfeeding
• allow the “good bacteria” from the mother’s skin to colonize the newborn.

3. Delaying cord clamping two to three minutes after birth or until the umbilical cord has
stopped pulsating
• increases the baby’s iron reserves
• reduces the risk of iron-deficiency anemia
• improves blood circulation and prevents brain hemorrhage.

4. Breastfeeding within the first hour of life

• prevents an estimated 19.1% of all neonatal deaths.
• Delaying breastfeeding - 2.6 X more prone to infection.

ENC GUIDELINES ARE CATEGORIZED INTO THE TIME BOUND, NON-TIME

BOUND AND UNNECESSARY PROCEDURES.
1. TIME BOUND PROCEDURES/ IMMEDIATE INTERVENTIONS
- should be routinely performed first
- refer to the four core steps of ENC

2. NON-TIME BOUND /NON-IMMEDIATE INTERVENTIONS

- Immunizations
- eye care
- Vitamin K administration,
- weighing
- Washing
3. UNNECESSARY PROCEDURES
- routine suctioning
- routine separation of newborn for observation
- Foot printing
- application of alcohol, medicine and other substances on the cord stump
- bandaging the cord stump or abdomen,
- administration of prelacteals - glucose water or formula

ESSENTIAL NEWBORN CARE PROTOCOL

I. TIME-BOUND INTERVENTIONS
IMMEDIATE NEWBORN CARE (THE FIRST 90 MINUTES)

TIME BAND: At perineal bulging, with presenting part visible (2nd stage of labor)
INTERVENTION: Prepare for the delivery
ACTION:
• Check temperature of the delivery room. SHOULD BE 25 - 28 *C; Free of air drafts
• Notify appropriate staff
• Arrange needed supplies in linear fashion.
• Check resuscitation equipment.
• Wash hands with clean water and soap.
• Double glove just before delivery.

1. IMMEDIATE THOROUGH DRYING

TIME BAND: Within the 1st 30 secs
OBJECTIVE: Dry, provide warmth; prevent hypothermia
INTERVENTION: Dry and provide warmth.
ACTION:
• Call out the time of birth
• Use clean, dry cloth to thoroughly dry the baby, wiping eyes, face, head, front and back,
arms/legs.
• Remove the wet cloth.
• Do a quick check of baby’s breathing while drying.

During the first 30 seconds:

• Do not ventilate unless baby is floppy/limp and not breathing.
• Do not suction unless mouth/nose are blocked with secretions.
• Do not separate from mother, if no severe chest in-drawing, gasping / apnea and mother
does
• not need urgent medical stabilization (e.g. hysterectomy.)
• Do not put on a cold/wet surface.
DONT’S
– Do not wipe off vernix
– Do not do foot printing
– No slapping
– No hanging upside -down
– No squeezing of chest
- No bathing the newborn earlier than 6 hours of life

TIME BAND: If after 30 sec of thorough drying, newborn is not breathing or is gasping
INTERVENTION: Re-position, suction, ventilate
ACTION:
• Clamp and cut the cord immediately.
• Call for help.
• Transfer to a warm, firm surface.
• Inform mother that newborn has difficulty breathing and will help the baby to breathe.
• Start resuscitation protocol.

2. EARLY SKIN-TO-SKIN CONTACT

Newborn is breathing or crying
OBJECTIVE: Facilitate bonding between mother and newborn; reduce likelihood of infection /
hypoglycemia
INTERVENTION: Do skin-to-skin contact
ACTION:
• Crying breathing normally - avoid any manipulation
– (suctioning - trauma ; introduce infection)
• Place on prone /on mother’s abdomen/chest and do skin-to-skin.
• Cover back with blanket and head with a bonnet. ( sanitex net )
• Place identification band on ankle (not wrist).
NOTE: Skin to skin contact is advisable even for cesarean section newborns.
If there is a 2nd baby, manage as multi-fetal pregnancy

3. PRACTICE PROPERLY - TIMED CORD CLAMPING

TIME BAND: 1 - 3 minutes
OBJECTIVE: Reduce incidence of anemia in full term ;
intraventricular hemorrhage in preterm
INTERVENTION: Do delayed/properly timed cord clamping
ACTION:
• Remove the first set of gloves immediately prior to cord clamping.
• After the umbilical pulsations have stopped (1 - 3 mins), clamp the cord using a sterile
plastic clamp/tie at 2 cm from umbilical base.
• Clamp again at 5 cm from the base
• Cut the cord close to the plastic clamp with sterile instrument.
• Observe for oozing blood.
Note:
– Do not milk the cord towards the newborn.
– After the 1st clamp, you may “strip” the cord of blood before applying the 2nd clamp.
– Cut the cord close to the plastic clamp - no need for a 2nd “trim.”
– Do not apply any substance onto the cord.

4. NON-SEPARATION OF NEWBORN FROM MOTHER FOR EARLY BREASTFEEDING

TIME BAND: WITHIN 90 minutes of age
OBJECTIVE: Facilitate early initiation to breastfeeding and transfer of colostrum.
INTERVENTION: Provide support for initiation of BF
ACTION:
• Leave baby on mother’s chest - skin-to-skin.
• Observe the newborn. when newborn shows feeding cues (e.g. opening of mouth, tonguing,
licking, rooting)
• encourage mother to move baby toward the breast e.g. nudging.
• Counsel on positioning
– Newborn’s neck is not flexed nor twisted
– Newborn is facing the breast
– Newborn’s body is close to mother’s body
– Newborn’s whole body is supported
• Counsel on attachment and suckling
– Mouth wide open
– Lower lip turned outwards
– Baby’s chin touching breast
– Suckling is slow, deep with some pauses
Notes:
– Minimize handling by health workers
– Do not give sugar water, formula or other prelacteals
– Do not give bottles or pacifiers
– Do not throw away colostrum

B. NON-IMMEDIATE INTERVENTIONS
- within 6 hours after birth and should never be made to compete with the time-bound
interventions.
1. Give Vitamin K prophylaxis
2. Inject Hepatitis B and BCG vaccinations
3. Examine the newborn. Check for birth injuries, malformations or defects
4. Cord care
5. Weighing, bathing, eye care, examinations, injections (hepatitis B, BCG) - done after the first
full breastfeed is completed
6. Postpone washing until at least 6 hours
NON-IMMEDIATE INTERVENTIONS

*INTERVENTION: Do eye care

Objective: To prevent ophthalmia neonatorum
ACTION:
• Administer erythromycin or tetracycline ointment or 2.5% povidone-iodine drops to both
eyes after newborn has located breast.
• Do not wash away the eye antimicrobial.

Newborn Care from 90 minutes to 6 hours after birth

TIME BAND: From 90 Min - 6 Hrs
1. INTERVENTION: Give Vitamin K prophylaxis
ACTION:
• Wash hands.
• Inject a single dose of Vitamin K 1 mg IM. (.1ml)

2. INTERVENTION: Inject hepatitis B and BCG vaccinations at birth.

ACTION:
• Inject hepatitis B vaccine ( .5ml) intramuscularly and BCG intradermally.
• Record.

3. INTERVENTION: Examine the baby

ACTION:
• Thoroughly examine the baby.
• Weigh the baby and record.

4.INTERVENTION: Check for birth injuries, malformations or defects.

ACTION:
 Look for possible birth injury:
– Bumps on head, bruises, swelling on buttocks, abnormal position of legs (after breech
presentation) or asymmetrical arm movement, or arm that does not move.
If present:
– Gently handle the limb that is not moving.
– Do not force legs into a different position.
 Look for malformations:
– Cleft palate or lip
– Club foot
– Odd looking, unusual appearance
– Open tissue on head, abdomen or back
If present:
– Cover any open tissue with sterile gauze before referral and keep warm.
• Refer for special treatment and/or evaluation if available.
– Help mother to breastfeed. If not successful teach her alternative feeding methods
5. INTERVENTION: Cord care
ACTION:
- Wash hands.
– Put nothing on the stump.
– Fold diaper below stump. Keep cord stump loosely covered with clean clothes.
– If stump is soiled, wash it with clean water. Dry it thoroughly with clean cloth.
– Explain to the mother that she should seek care if the umbilicus is red or draining pus.
– Teach the mother to treat local umbilical infection three times a day.
– Wash hands with clean water and soap.
– Gently wash off pus and crusts with boiled and cooled water and soap.
– Dry the area with clean cloth.
– Paint with gentian violet.
– Wash hands.
– If pus or redness worsens or does not improve in 2 days, refer urgently.
Notes:
– Do not bandage the stump or abdomen.
– Do not apply any substances or medicine on the stump.
– Avoid touching the stump unnecessarily.

III. UNNECESSARY PROCEDURES

1. Routine suctioning
– No benefit if the amniotic fluid is clear and especially with newborns who cry or breathe
immediately after birth
– Moreover, a dirty bulb can become a source of infection
– Has been associated with cardiac arrhythmia
– Indicated only if the mouth/nose is blocked with secretions or other materials

2. Early bathing/washing
– Hypothermia which can lead to infection, coagulation defects, acidosis, delayed fetal to
newborn circulatory adjustment, hyaline membrane disease, brain hemorrhage
– Infection – the vernix is a protective barrier to bacteria such as E. coli and Group B
Strep; so is maternal bacterial colonization
– No crawling reflex

3. Foot printing
– an inadequate technique for newborn identification purposes
– Better identification techniques such as DNA genotyping and human leukocyte
antigen tests
4. Giving sugar water, formula or other prelacteals and the use of bottles or pacifiers
– Delayed initiation to breastfeeding- increases in the chances of newborn deaths due
to infection
– using a bottle, the newborn may develop a learned preference for the bottle leading
to nipple confusion and inefficient suckling which can further lead to failure in
breastfeeding
– A pacifier contributes to nipple confusion if these are used before the newborn is offered
the mother’s breast.

5. Application of alcohol, medicine and other substances on the cord stump and bandaging the
cord stump or abdomen.

INTERVENTION: Look for danger signs

ACTION:
• Look for signs of serious illness :
– Fast breathing (>60 breaths per min)
– Slow breathing (<30 breaths per min)
– Severe chest in-drawing
– Grunting
– Convulsions
– Floppy or stiff
– Fever (temperature >38 C)
– Temperature <35 C or not rising after re-warming
- Umbilicus draining pus
– More than 10 skin pustules or bullae, or swelling, or redness, or hardness of skin
(sclerema)
– Bleeding from stump or cut
– Pallor
If any of the above is present, consider possible serious illness.

DISCHARGE INSTRUCTIONS
1. Advise the mother to return or go to the hospital immediately if:
– Jaundice of the soles or any of the following are present*
– Difficulty of feeding
– Convulsions
– Movement only when stimulated
– Fast or slow or difficult breathing (e.g. severe chest in-drawing)
– Temperature >37.5 C or <35.5 C
2. to bring her newborn to the health facility for routine check-up schedule:
– Postnatal visit 1: at 48-72 hours of life
– Postnatal visit 2: at 7 days of life
– Immunization visit 1: at 6 weeks of life
3. Advise additional follow-up visits appropriate to problems in the following:
– Two days – if with breastfeeding difficulty, Low Birth Weight in the first week of
life, red umbilicus, skin infection, eye infection, thrush or other problems
– Seven days – if Low Birth Weight discharged more than a week of age and not
gaining weight adequately

4.Advise for Newborn Screening

LEARN MORE

IMMEDIATE ASSESSMENT OF NEWBORN THROUGH APGAR SCORING and

BALLARD SCORING

I. APGAR SCORING – by Virginia Apgar specialized in anesthesiology and childbirth . She

developed the Newborn Scoring System, later called the Apgar score, in 1949.

DEFINITION: A tool used to assess neonates in five areas as to: heart rate, respiratory rate, muscle
tone, reflex, and skin color.

PURPOSE: This score provides a uniform method of observation and evaluation of a newborn
infant's need for resuscitation immediately after delivery at one minute and
again at five minutes.

INDICATOR 0 1 2
HEART RATE -None apparent -Less than 100 bpm -Strong heartbeat
-No pulse -Sluggish/weak -more than 100 bpm
RESPIRATORY -No breaths taken -Hyperventilation -Good strong cry
RATE -No chest movement -Cry is weak Spirited cry
-Brisk movement
MUSCLE TONE -Limp arms and legs -Extremities show -Excellent flexion
-No movement some flexion and -Energetic movement
bending
REFLEX -No facial or verbal -Minimal motion -Hearty cry
IRRITABILITY response to aspiration -Signs of grimace -Cough, Sneeze

COLOR -Ashen or pale blue -Trunk pink but -Trunk and

extremities may extremities are pink
be blue
Take the APGAR 0 minute
1 minute
5 minutes

APGAR SCORING SYSTEM

1) Heart Rate
o heart rate of 100-140 is good, baby is vigorous = 2
o less100, baby is not very responsive = 1
o no heart beat seen, felt or heard = 0

2) Respiratory Effort
o breathed and cried lustily, good, strong cry = 2
o irregular, shallow ventilation, weak cry–may sound like whimpering or grunting = 1
o apneic at 60 seconds after birth = 0
- infant who had gasped once at thirty or forty-five seconds after birth, and who then became
apneic, received a zero score, since he was apneic at the time decided upon for evaluation.

3) Reflex Irritability
o Grimace and cough or sneeze during stimulation = 2
o Grimace during stimulation = 1
o No response to airways being stimulated = 0
- response to some form of stimulation.
- the usual testing method was suctioning the oropharynx and nares with a soft rubber catheter
which called forth a response of facial grimaces, sneezing or coughing.

4) Muscle Tone
o Active motion, good tone, spontaneously flexed arms / legs which resisted extension = 2
o Some flexing (bending) of arms and legs = 1
o completely flaccid infant, limp = 0

5) Color
o completely pink or good color = 2
o acrocyanosis, good color in body but with blue hands or feet = 1
o entire body is blue or pale = 0
- All infants are obviously cyanotic at birth because of their high capacity for carrying oxygen
and their relatively low oxygen content and saturation.

- The disappearance of cyanosis depends directly on two signs previously considered --

respiratory effort and heart rate. Comparatively few infants were given a full score of two
for this sign.
INTERPRETATION OF SCORE and the INTERVENTION
7 - 10 = indicate that the baby will need only routine post delivery care
4 - 6 = indicate that some assistance for breathing, to clear the airway, need for
SUCTIONING.
0 - 3 = can call for prompt, lifesaving measures, need to intubate.

II. BALLARD SCORING

DEFINITION:
- is a commonly used technique of gestational age assessment. It assigns a score to various criteria,
the sum of all of which is then extrapolated to the gestational age of the fetus. These criteria are
divided into Physical and Neurological criteria.

PURPOSE:
- to assess the gestational maturity of the newborn in weeks.

SPECIAL CONSIDERATIONS:
1) The physical maturity part of the examination should be done in the first two hours of birth
2) The neuromuscular maturity examination should be completed with 24 hours after delivery
3) Observe how physical characteristics change with gestational age. Neonates who are more
physically mature normally have higher scores than premature infants.
4) Points are awarded in each area -2 for extreme prematurity to 5 for postmature infants.

PROCEDURE
STEPS Rationale
1. Observe the following physical characteristics To assess the physical maturity of the
newborn
of newborn.
a. Skin
b. Lanugo
c. Plantar surface
d. Breast
e. Eyes & Ears
f. Genital
 2. Use the Ballard Scoring Sheet to assign a
score in each area.
3. Place the newborn on bed. Make sure baby is
quiet and observe his posture and tone.
 Square Window
 Arm Recoil
Neonates who are more physically mature
normally have higher scores than
premature infants.
Total body muscle tone is reflected in the
infants preferred posture at rest and
resistance to stretch of individual muscle
groups. The more mature an infant is the
greater their tone will be

 Popliteal Angle A more flexed position indicated greater

tone.
 Scarf Sign
 Heel to Ear

BALLARD SCORING / Neonatal Gestational Age

• The physical maturity part of the examination should be done in the first two hours of birth
• The neuromuscular maturity examination should be completed with 24 hours after delivery
• Derived to look at various stages in an infant’s gestational maturity and observe how
physical characteristics change with gestational age
• Neonates who are more physically mature normally have higher scores than premature
infants
• Points are awarded in each area -2 for extreme prematurity to 5 for postmature infants

I. Physical Maturity
• Skin
• Lanugo
• Plantar surface
• Breast
• Eyes & Ears
• Genital
 A. SKIN
• Examine the texture, color and opacity
• As the infant matures:
 More subcutaneous tissue develops
 Veins become less visible and the skin becomes more opaque
• Physical Maturity - Skin
 28 wks-gelatinous red pink, veins visible
 32 wks-smooth, pink, few veins visible abdomen thin,
 36 wks smooth pink
 37-39 weeks smooth
 40 wks cracking, pale skin


Differential Skin Findings

Skin Tags
• Most common on ears; Usually tied off or clipped
Telangiectatic Nevi-
• frequently found on eye lids, nose, lower occipital bone, and nape of neck. Common in light
complexioned infants, most noticeable when crying. No clinical significance, usually fade
by second birthday.
Café Au Lait spots
• Increased amount of melanin, may increase in number in age
• Presence of 6 or more- greater then 0.5 cm in size - a sign of Neurofibromatosis- a genetic
disorder that disturbs cell growth in nervous system, causing tumors to form on nerve tissue.
Erythema toxicum
• White or yellow papule or pustule; With erythematous base
• No treatment necessary

B. LANUGO
After 20 weeks-begins to appear
 28 wks-abundant
 32 wks-thinning,
 36 wks-on shoulder, upper back
 40wks bald areas, little on shoulder
• VERNIX CASEOSA - the pasty, cheese-like material. It is a mixture of sebum produced by
the infant's skin and cellular debris that has accumulated in utero
C. PLANTAR SURFACE
Before 28 weeks-no creases
 28wks - scant anterior creases
 32 wks, 1/3 anterior creases
 36 wks-1-2 anterior creases
 40 wks-creases over the entire sole.
Differential Findings: Bilateral Club Feet - feet are plantar-flexed and inverted, this is a bone
deformity.
D. BREAST
Before 28 wks-nipples imperceptible
 28 wks-flat areola, no bud
 32wks- scant bud, stripped areola
 36 wks – 3- 4 mm bud palpable
 40 wks - well defined nipple, 5-10mm bud, raised areola

E. EYES/ EARS
 Eyes are evaluated as either fused as seen in extremely premature infants or open
 Before 26 weeks eyes are fused
 most infants exhibit some degree of eyelid edema after birth. the puffiness may
make it seem that the infant has difficulty opening one or both eyes, but with a
gentle examination, the eye can be easily evaluated. edema resolves over the first
few days of life.
o Ears
 28 wks-pinna flat, cartilage not present, lies flat, remains folded
 32 wks pinna soft, remains folded.
 36 wks-pinna firm, soft recoils
 40wks pinna firm; instant recoil.
Differential Findings
• Ear Tags
• Ear Pits (Preauricular pits)
• superior attachment of the pinna to the face and may be unilateral or bilateral.
• Lop Ear
• Prominent Ear

F. GENITALIA-MALE
Before 28 weeks-scrotum empty and flat
 28wks-testicles undescended, scrotal surface smooth
 32 wks testes descending with a few scrotal rugae
 36wks-testes high in scrotum, more scrotal rugae
 40wks testes descended, scrotum pendulous, covered with rugae

GENITALIA-FEMALE
 Before 28 weeks-clitoris prominent labia flat
 28wks-prominent clitoris, small labia minora
 32wks-prominent clitoris enlarging labia minora
 36wks labia majora more prominent, labia minora small
 40wks clitoris and labia minora covered by labia majora.
II. NEUROMUSCULAR MATURITY
a. Posture & Tone
b. Square Window
c. Arm Recoil
d. Popliteal Angle
e. Scarf Sign
f. Heel to Ear

A. POSTURE/TONE
 Total body muscle tone is reflected in the infants preferred posture at rest & resistance to
 stretch of individual muscle groups
 Make sure infant is quiet. The more mature an infant is the greater their tone will be.
 A more flexed position indicated greater tone.

B. SQUARE WINDOW
 wrist flexibility and/or resistance to extensor stretching resulting in angle or flexion at wrist
 Flex hand down to wrist-measure the angle between the forearm & palm.

C. ARM RECOIL
 measures the angle of recoil following a brief extension of the upper extremity
 For 5 seconds flex the arms while infant is in supine position, pulling the hands fully extend
the arms to the side,then release-measure the degree of arm flexion & strength (recoil).
 Before 28 weeks-no recoil; After 40 weeks-rapid full recoil

D. POPLITEAL ANGLE
 assesses maturation of passive flexor tone of the knee joint by testing resistance to
extension of the leg
 The angle decreases with advancing gestational age
- Before 26 weeks-angle 180 degrees
- 32-36 weeks angle 120 degrees

E. SCARF SIGN
 tests the passive tone of the flexors about the shoulder girdle
 Increased resistance to this maneuver with advancing gestational age
 Before 28 weeks-elbow passes torso
 36-40 weeks-elbow to midline with some resistance
 After 40 weeks-doesn’t reach midline

F. Heel to Ear
 measures passive flexor tone about the pelvic girdle by testing passive flexion or
resistance to extension of the posterior hip flexor muscles
 Breech infants will score lower than normal
 Before 34 weeks-no resistance
 40 weeks-great resistance may be difficult to perform
 score

Total Physical Maturity Score _______

Total Neuromuscular Maturity Score _______
Ballard Score _______
Age of Gestation in Weeks _______
 YOUR TASK

1. Determine the APGAR Score of the newly delivered baby, Baby X, if she manifested the
following: weak cry, grimace with stimulation; with some flexion of extremities, cardiac
rate of 80/min; body pink blue extremities.
a. What is the score per area? the APGAR Score?
b. Interpretation of score and the needed interventions?

2. HR is 80/min, gasped once and became apneic for 60 secs after birth, completely flaccid,
is blue or pale in color and inactive.
Color
HR
RR
Reflex Irritability
Muscle Tone
AS=
Intervention:

3. BABY JOY

________ _________ _________ __________ _________ ___________

Neuromuscular Maturity Score _________

- W/ THINNING OF LANUGO = _____

- 3-4 MM BUD = _____
-SMOOTH, PINK SKIN = _____
- W/ ANTERIOR TRANSVERSE CREASES = _____
-WELL CURVED SOFT PINNA = _____
-PROMINENT LABIA MINORA AND MAJORA = _____
Physical maturity score _________

TOTAL SCORE _______________ AOG = ________

INTERPRETATION ___________________________________________________________________
 LEARN MORE
NEWBORN CARE
A. Taking Rectal Temperature
Definition: is the measurement of baby's body temperature through rectal route.
Purposes:
1. Taking temperature rectally gives the most accurate measurement of the baby’s body
temperature.
2. Rectal route is used to check the patency of the anus.

Materials:
- Digital thermometer
- Cotton balls with alcohol
- Oil / lubricant
- Nonsterile gloves

Procedure
Prepare the materials
Wash hands before the procedure and put on
nonsterile gloves.
Ensure the digital thermometer is in working
condition
Wipe the thermometer with a wet cotton ball
from tip (sensor) to stem (probe).
Apply lubricant (oil) on tip of the thermometer.
Position the baby. Hold infant’s ankle in your
hand. Lift slightly to expose the anus.
Insert gently the thermometer to the anus about
1 inch. Hold it in place till you hear a beep
sound. Note the temperature reading on the
display.
Rationale
Preparation promotes efficient time
management and provides an organized
approach to the task.
Hand hygiene deters the spread of
microorganisms. Gloves prevent contact with
body fluids.
Improperly functioning thermometer may not
give an accurate reading.
Cleaning the thermometer before using reduces
microorganism transmission.
Lubricant reduces friction and facilitates
insertion, minimizing the risk of irritation or
injury to the rectal mucous membrane.
This allows the nurse to visualize the anus.
Exposing only the buttocks keeps the baby
warm.
Age of patient must be considered in
determining the depth of thermometer insertion.
Movement of the thermometer in the rectum
could cause injury.The signal indicates the
measurement is completed. The electronic
thermometer provides a digital display of the
measured temperature.
 Remove the thermometer and wipe from stem
to tip using cotton ball with alcohol.
Discard used materials, remove the gloves and
wash hands.
Document the result.
Wiping the thermometer from least to more
contaminated area prevents the spread of
miscroorganism.
Proper waste disposal and hand hygiene
prevents the spread of microorganisms.
Recording of result/information can help
support the proper treatment plan.

B. TAKING THE ANTHROPOMETRIC MEASUREMENTS

Definition:
Anthropometric measurements are series of quantitative measurements of the muscle and
bone used to assess the composition of the body. The elements of anthropometry are weight,
height and body circumference.

Purposes:
a. Head, Chest and Abdominal Measurement
1. To provide an indicator of brain growth and physical growth.
2. To provide correlation to neurologic and developmental functions.

b. Weight Measurement
1. To provide an indicator of physical growth.
2. To calculate safe dosages of medications.
3. To identify early nutritional problems, eating disorders or medical conditions.
c. Height Measurement
1. To provide an indicator of physical growth.
2. To provide an indicator for certain diseases and deficiencies like heart or renal disease or
growth hormone deficiency.
Materials:
- tape measure
- nonsterile gloves
- handwashing kit
- receptacle

PROCEDURE RATIONALE
Wash hands before the procedure and put on Reduces transmission of microorganisms.
gloves.
Prepare a complete materials Preparation promotes efficient time management
and provides an organized approach to the task.
Place light drape on flat surface. Lay baby in Placing a light drape on surface prevents
supine position. transmission of microorganism through direct
contact. Supine is a safe position for the baby
while taking antropometric measurements.
A. Measuring the Head Circumference
Place tape measure around fullest part of
baby’s brow around occipital prominence
B. Measuring the Chest Circumference
Remove the clothing/cover of the body.
Measure around the chest at the nipple line,
keeping the measuring tape at the same level
in anterior and posterior.
C. Measuring the Abdominal Circumference
Measure around the abdomen at the level
of the umbilicus.
D. Measuring the Length
Hold child’s head at midline point and
extend legs fully
Stretch a tape measure from crown
of child’s head to heel of child’s foot, along
side baby’s body.
E.Measuring Weight
Place light drape on scale.
Calibrate scale to “0” position.
Quickly but carefully moves the counter
weights to balance the apparatus exactly.
Place the child gently on the scale.
Keep one hands over or near the child on
scale at all times.
Carefully remove baby from scale.
Record the anthropometric measurements
and report abnormal findings.
Do after care of the area.
Do handwashing after the procedure
This is known as the occipitofrontal circumference
(OFC), which is normally 33-35cm
Removal of clothes only when necessary prevent
exposure of the body which could result to chills.
Placing the tape measure at the same level in
anterior and posterior chest ensure correct
measurement.
Correct placement of tape measure gives accurate
measurement.
Proper placement of tape measure and correct
manner of measurement gives accurate reading.
To avoid direct contact to weighing scale to
prevent transmission of microorganism and heat
loss.
To assure that weighing scale is measuring
correctly and accurately.
To prevent injury or fall
Findings that are of concern should be
communicated directly to the doctor.
To prevent spread of microorganism
C. CREDE’S PROPHYLAXIS
Definition:
Application of eye ointment to prevent infection of the eyes of newborns.

Purposes:
To prevent ophthalmia neonatorum.

Materials:
- ophthalmic ointment
- wet cotton balls
- gloves
- gauze
-

PROCEDURE
Prepare the materials.
Wash hands before the procedure and wear
gloves.
Clean the eyelids carefully with a sterile
cotton ball moistened with sterile NSS
from the inner to outer canthus of the eye.
Use a new cotton ball for each eye.
Retract the lower eyelid using your thumb.
Apply adequate amount of prescribed
ophthalmic ointment to lower conjunctival
sac from inner to outer canthus of the eye.
Wipe off excess medication with sterile
gauze.
Do the same procedure with the other eye.
Do after care and handwashing.
Document the drug administered.
RATIONALE
Preparation promotes efficient ime management and
provides an organized approach to the task.
Reduces transmission of microorganisms.
A separate cotton ball is used in each eye to prevent
spread of infection. Wet cotton ball is used to clean
the lid margins to loosen secretions/ discharge.
To expose the conjunctival sac.
This allows even distribution of the eye ointment,
and prevents rapid clearance of medication caused
by blinking.
To prevent spread of microorganisms.
Recorded information can help support the proper
treatment and nursing care.
D. INFANT BATH
DEFINITION: Cleaning or washing the baby’s body.
PURPOSE:
1. To provide hygienic care for the infant.
2. To prevent “nappy” rash.
3. To provide umbilical cord care for newborn.
MATERIALS:
tub/basin small basin soft padded mattress / small sheet to place the infant
handwashing kit hypoallergenic soap/liquid soap clean lukewarm water for bathing
small bath towel Rubber mat/sheet cotton balls / cotton applicator
70% alcohol comb baby' clothes / bonnet
washcloth / Sanitex diaper baby wrap

PROCEDURE RATIONALE
Check the documents to ensure This will ensure that the baby is able to withstand the
the baby is ready for the procedure bath procedure and that he is not scheduled for other
procedures

Check when was the last time the baby was If the infant’s bath is carried out too soon after to the
fed. last feed, the infant may vomit.

Check the identity of the baby. To ensure that the right patient receives the care.
Assess the general condition Prevents hypothermia. Assessment of infant will
of the baby, especially the temperature. indicate whether it is safe to bathe him. To detect
Inspect the body. abnormality.

Prepare the materials needed Preparation promotes efficient time management

Prepare the bath tub by filling the bathtub
with about 8 cm of water; pour cold water
first, followed by warm water. Use your
elbow/ wrist to test the water; it should not
feel hot.
Switch off the fan/air-con.
and provides an organized approach to the task.
Ensures all items are within reach.
To ensure the safety of the baby. Prevents accidental
scalding.To avoid burns caused by hot water or
hypothermia by cold water. Prevent sudden shock
caused by the change in temperature.
Prevents hypothermia.
Wash hands.
Place rubber mat on table top next to basin
and a towel laid out in diamond fashion.
Remove all clothing except shirt and diaper.
Wipe the eyes using a cotton ball moistened
with water, starting from inner to outer
canthus. Use a new cotton ball for each eye.
Dip washcloth. Wash the face, ears and
neck. Dry all areas thoroughly.
Hold infant on one arm (Football Hold)
over the tub/basin and wet hair. Soap own
hands and lather to hair and scalp using
gentle, circular motion. Splash water against
head to rinse off.
Place infant on towel and dry the head using
the corners of the towel.
Undress the infant. Wet upper extremities,
front, back, buttocks and legs using wash
cloth. Apply soap and lather.
Pick up infant and slowly lowers him into
the bath tub to rinse off. Fold the ears using
your thumb and finger.
Support baby while lifting him from the
tub/basin, by placing your hand and arm
around the infant, cradling his head and
neck in your elbow. Grasp his thigh with the
other hand. Dry infants body gently but
thoroughly.
Hold the cord clamp and clean the base of
the cord in one direction.
A. For a female infant – separates labia and
with a cotton ball moistened with soap and
water, cleanse downward one on each side.
Uses a new piece of cotton ball on each
side.
B. For a male infant – retracts foreskin and
gently cleanse glans penis with a cotton ball
moistened with soap and water.
Re-dress infant. Put a clean diaper, Fold the
diaper down. Hold infant for a period of
time following the bath procedure.
Document the procedure.
Prevents transfer of microorganisms.
This provides a clean bath area for baby. Rubber mat
which serves as pad helps prevent injury to baby.
A separate cotton ball is used in each eye to prevent
spread of infection. Wet cotton ball is used to clean
the lid margins to loosen secretions/ discharge.
Immediate drying after washing prevents
chills/hypothermia.
Holding your baby alongside your ribcage with your
arm under provides full support to the body and
head of the baby. Soap helps in the removal of dirt
in the head and hair.
This prevents chills/hypothermia.
Removal of clothes only when necessary prevent
exposure of the body which could result to chills.
Folding the ears will prevent the water from entering
the ears which may cause infection.
In handling the newborn, always ensure the safety
of patient.
Immediate drying prevents hypothermia from heat
loss caused by evaporation.
To prevent infection of the cord.
Prevents transmission of infection to urinary orifice,
especially for female.
Folding the diaper down helps prevent infection of
the cord of newborn caused by diaper wet with
urine. Exposure of cord facilitates drying.
For continuity of care and proper management of the
infant.
 YOUR TASK

General Instruction:
Watch the video of newborn care which includes taking of rectal temperature, anthropometric
measurements, application of eye ointment/Crede’s prophylaxis and infant bath. Get ready for the
return demonstration of the said procedures.

CORDIAN VALUES

As a care giver, rendering care is a great work for which the purpose is to serve the sick and
helpless. It is similar to the demonstration of the mother of her unconditional love to her baby.
Of all the types of love, a mother's is the strongest. ... A mother's love is unconditional and eternal.
When we say that nature is wise, one of the things that we refer to is the bond between mothers and
their children. A mother's instinct to protect her offspring begins from the moment she knows she is
pregnant.
Just like everything else we do for a baby, baby's skincare requires that extra bit of
gentleness. The gentle touch of loved ones, care giver and the right kind of care is all that is needed
to keep baby happy, healthy and safe. The most important thing is to show genuine care to and to
serve with a happy heart.

EVALUATION

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