Describe the physiological adaptations the newborn must make during the period of transition from

intrauterine to extrauterine environment.

- Newborn period: birth - day 28

Immediate Care After Birth

1) Assess: crying, breathing, good muscle tone
2) Place prone on parent’s chest
a) ↑ oxytocin, prolactin
b) ↑ suckling activity
3) Patent airway
4) Dry newborn with rubbing
a) Removes moisture
b) Encourages breathing
5) Cover parent + newborn with warm
blanket
6) Auscultate HR
7) Pink trunk + lips → may have
acrocyanosis
- Wear gloves if unbathed to prevent
possible viral transmission

Initial Physical Assessment

1) General Appearance
a) Colour: pink, acrocyanosis
b) Alert
c) Active
2) Neurological System
a) Moves all four extremities; flexion, muscle tone appropriate
b) Symmetrical features, movement
c) Moro, suck, rooting, and grasp reflexes present
d) Anterior fontanel soft and flat
3) Cardiovascular System
a) Heart auscultation, regular in rate and rhythm
b) No murmurs heard
c) Pulses strong, equal bilaterally
4) Respiratory System
a) Lungs auscultated, clear bilaterally with minimal fine crackles shortly after birth
b) RR less than 60 breaths/min
i) Count for full min
ii) Irregular + shallow
c) Respiratory effort nonlaboured
 d) Abdominal respirations
e) Chest expansion symmetrical
f) Absence of nasal flaring, grunting, retraction
5) Skin
a) Skin lesions or abrasions documented
b) Birthmarks documented
c) Caput/moulding
6) Eyes, Ears, Nose, and Throat
a) Eyes clear
b) Palates intact
c) Nares patent
d) Ears in place; correct alignment
7) Genitourinary System
a) Male: Urethral opening at tip of penis, testes descended bilaterally
b) Female: Labia minora and majora intact, hymenal tag may be visible
8) Gastrointestinal System
a) Abdomen soft, no visible distension
b) Cord attached and clamped
c) Anus patent

Prophylactic and Screening

- Universal newborn screening
- Done between 24-48 h
- 0.5% Erythromycin eye ointment within 1-2 hr of birth
- Ophthalmia neonatorum = inflammation of eyes from gonorrhea/chlamydia infection
when passing through birth canal
- Not done universally – only if family has identified infection
- Vitamin K IM injection within 1 hr. birth
- Prevents hemorrhagic disease in the newborn (HDNB)
- Don’t make vitamin K at birth → starts day 7
- Comes from food consumption
- Needed for clotting
- Hep. B vaccine at birth (against all known Hep B subtypes)
- HBIG 12 hrs after birth If maternal hep. B surface antigen is positive or unknown
- Blood glucose monitoring
- Baseline at 2 hr. post-birth if gestational diabetes, LGA, or SGA
- ½-1 hr. post birth if symptoms of hypoglycemia occur earlier
- Heel prick for:
- Bilirubin levels
- Phenylketonuria (PKU)
- Treated with diet
 - Hypothyroidism (mental retardation if untreated)
- Treated with hormone
- Sickle cell
- Heel used bc rich capillary bed
- Do not milk heel to obtain blood
- Prick on outer aspect of heel, no deeper than 2.4 mm
(shaded areas)
- Screening for critical congenital heart disease (CCHD):
- Most common congenital malformation
- Done at 24-36 h
- Includes:
- Prenatal ultrasounds
- Physical exam
- Pulse ox screening → detects hypoxemia
- 1st sign of CCHD
- Pre-ductal (right hand) and post-ductal (any foot) oxygen saturation obtained
- Normal: spO2 95% or more with less than 3% difference in hand + foot readings
- Borderline: repeat screen if >3% difference between 2 readings OR if O2 sat is
less than 94% on either extremity
- Abnormal: less than 90% spO2 in either extremity
- Hearing loss test – screening tests only
1) Evoked otoacoustic emissions test (EOAO)
a) Rubber that makes clicking noise is placed in outer ear
b) Normal: click is echoed back to microphone
2) Auditory brainstem response (ABR)
a) Sensors attached to forehead + behind each ear
b) Measures responses of newborns acoustic nerve + stored in computer
3) Abnormal = not passing screening – need follow up

Gestational Age Assessment

- 26 weeks or less: assess at 12 h or earlier
- 26 weeks or more: up to 96 hours after birth
- Recommended time within 48 h
- ↓ GA, ↓ birth weight = ↑ mortality rate
- Preterm/premature: born before completion
of 37 weeks of gestation, regardless of birth
weight
- Late preterm: born between 34 and 36 + 6
weeks
- Early term: born between 37 and 38 + 6 weeks
gestation
- Full term: born between the beginning of week 39 and the end of week 40 + 6 of gestation
- Late term: born in the forty-first week of gestation
- Post-term (postdate): born after completion of week 42 of gestation
- Postmature: born after completion of week 42 of gestation and showing the effects of
progressive placental insufficiency
- Fetal distress, macrosomia, meconium aspiration

1) Posture
a) Quiet and supine position newborn
b) Observe degree of flexion in arms and legs
c) Muscle tone and degree of flexion increase with maturity
d) Abnormal: hypotonia, hypertonia, limited ROM
e) Full flexion of arms + legs = score 4
2) Square Window
a) With thumb supporting back of arm below the wrist, apply gentle pressure with index
and third fingers on dorsum of hand without rotating newborn’s wrist.
b) Measure angle between base of thumb and
forearm
c) Full flexion (hand lies flat on ventral surface of
forearm) = score 4
3) Arm Recoil
a) Newborn supine, fully flex both forearms on
upper arms and hold for 5 seconds
b) Pull down on hands to fully extend and rapidly
release arm
c) Observe rapidity and intensity of recoil to a
state of flexion
d) A brisk return to full flexion = score 4
4) Popliteal Angle
a) Newborn supine + pelvis flat on a firm surface
b) Flex lower leg on thigh and then flex thigh on abdomen
c) While holding knee with thumb and index finger, extend lower leg with index finger of
the other hand
d) Measure degree of angle behind knee (popliteal angle)
e) An angle of less than 90 degrees = score 5.
5) Scarf Sign
a) Newborn supine, support head in midline with one hand
b) Use the other hand to pull newborn’s arm across the shoulder so that newborn’s hand
touches shoulder.
c) Determine location of elbow in relation to midline.
d) Elbow does not reach midline = score 4.
6) Heel to Ear
 a) With newborn supine and pelvis flat on a firm surface, pull foot as far as possible up
toward ear on same side
b) Measure distance of foot from ear and degree of knee flexion (same as popliteal angle)
c) Knees flexed with a popliteal angle of less than 10 degrees = score 4

Physical Adjustments to Extrauterine Life

Establishing + Maintaining Respirations
● Most immediate + critical adjustment
● Harder for preterm infants r/t lung immaturity and gestational age
● In utero: placenta is respiration organ for fetus
a) No blood flow to lungs until birth
● Clamping cord → ↑ BP —> ↑ circulation → ↑ lung perfusion
● Abdominal breathers → breathe through diaphragm
● Newborns with difficulty clearing airway secretions:
a) Side lying position until secretions clear, then supine
b) If choking:
i) Start CPR
ii) Suction secretions away from mouth centre
● 4 conditions for adequate O2 supply
1) Clear airway
2) Effective respirations
3) Adequate circulation, perfusion + cardiac function
4) Adequate thermoregulation
1) Chemical factors:
a) Hypoxia during contractions → low blood flow to uterus → impaired gas exchange →
chemoreceptors activated → respiratory centre in medulla stimulated
i) ↓PO2, ↑PCO2 = ↓ pH
b) ↓ in PGs by cord clamping = ↓ respirations
2) Mechanical factors:
a) Vaginal birth → newborn chest compresses →
positive intrathoracic pressure
b) After delivery → negative intrathoracic pressure →
air drawn into lungs → crying → positive pressure
→ air distributed into lungs → expands alveoli open
3) Thermal factors:
a) Temp is lower outside the womb
 b) Change in temp = skin receptors stimulated = respiratory centre stimulated = ↑ breathing
c) Cold stress:
i) May be important for initializing breathing, but avoid prolonged exposure
ii) By uncorrected hypothermia
iii) S+S: ↑ RR, resp distress symptoms, RDS
iv) ↑ O2 consumption – diverted away from brain + heart
v) Pulmonary + peripheral vasoconstriction = ↓ O2 uptake by lungs + tissues
(1) Maintains or reopens R-L shunt across ductus arteriosis
vi) Causes anaerobic glycolysis = ↓ PO2 and ↓ pH = metabolic acidosis
(1) Causes hypoglycemia r/t ↑ use of glucose stores
4) Sensory factors
a) Handling, drying newborn
b) ↑ breathing by lights, sounds, smells, pain
c) 20 mL of fluid/kg in term newborn lungs → replaced by air
i) Few days before labour = ↓ in fetal lung fluid production = ↓ alveolar fluid
volume
ii) ↑ catecholamines right before labour = fluid clearance
iii) Active transport moves fluid from air spaces into interstitium for drainage

Characteristics of Respiratory System Effect on Function

Immature alveoli; decreased size and number of Risk of respiratory insufficiency, inadequate
alveoli oxygenation and ventilation

Thicker alveolar wall; decreased alveolar surface Less efficient gas transport and exchange; poor
area alveolar compliance

Continued development of alveoli until childhood Possible opportunity to reduce effects of chronic
lung disease

Decreased lung elastic tissue and recoil Decreased lung compliance = higher pressures +
more work to expand
Increased risk of atelectasis

Reduced diaphragm movement and maximal Less effective respiratory movement; difficulty
force potential generating negative intrathoracic pressures; risk
of atelectasis

Tendency to nose breathe; altered position of Enhanced ability to synchronize swallowing and
larynx and epiglottis breathing; risk of airway obstruction; possibly
more difficult to intubate

Small compliant airway passages with higher Risk of airway obstruction and apnea
airway resistance; immature reflexes
 Increased pulmonary vascular resistance with Risk of ductal shunting + hypoxemia (hypoxia,
sensitive pulmonary arterioles acidosis, hypothermia, hypoglycemia, and
hypercarbia)

Increased oxygen consumption Increased respiratory rate + work of breathing;

risk of hypoxia; risk of retinopathy of prematurity

Increased intrapulmonary right–left shunting Increased risk of atelectasis with ineffective

ventilation; risk of persistent pulmonary
hypertension; lower Pco2

Immaturity of pulmonary surfactant system in Increased risk of atelectasis and respiratory

immature newborns distress syndrome; increased work of breathing

Immature respiratory control Irregular respirations with periodic breathing; risk

of apnea; inability to rapidly alter depth of
respirations

Signs of Respiratory Distress

1) Nasal flaring
2) Intercostal retractions
3) Grunting with respirations
4) Upper airway obstruction
a) Suprasternal/subclavicular retractions
b) Stridor
c) Gasping
5) Seesaw respirations → rising abdomen as chest falls
6) RR lower than 30 or over 50 at rest
7) spO2 less than 95%
8) Central cyanosis = abnormal, hypoxia
a) Bluish lips + mucous membranes
b) By poor O2 to alveoli, poor perfusion, cardiac dysfunction
c) Late sign of distress
d) Normal:
i) Acrocyanosis (normal in 7-10 days after birth, bluish discolouration of hands +
feet)
ii) Duskiness while crying immediately after birth
● Causes of tachypnea
○ Lung fluid not cleared
○ Newborn respiratory distress syndrome
○ Cardiac, metabolic, infectious illness
● Transient tachypnea of the newborn
○ Lasts 1-2 h after birth
○ Resolves in 24-48 h
 ○ By low catecholamines = fluid retention
■ ↑ risk in C section babies
○ Intermittent grunting, nasal flaring, mild retractions
○ Need supplemental O2 or noninvasive ventilator
● Serious respiratory distress
○ Lasts beyond 2 h after birth
○ RR over 120 breaths/min
○ Moderate-severe retractions
○ Grunting
○ Pallor
○ Central cyanosis
○ Hypotension
○ Temperature instability
○ Hypoglycemia
○ Acidosis
○ Cardiac concerns
○ Complications
■ RDS
■ Meconium aspiration
■ Pneumonia
■ Persistent pulmonary hypertension of the newborn (PPHN)
● Abnormal respiratory findings
○ Apneic episodes longer than 20 s
■ Rapid warming, cooling
■ Glucose instability
○ Bradypnea – less than 30 breaths/min
■ Maternal narcosis, birth trauma
○ Tachypnea – over 60 breaths/min
■ RDS, TTN, diaphragmatic hernia
○ Adventitious sounds
■ Coarse cracks, rhonchi, wheezing
○ Expiratory grunt
○ Distress signs

Adjusting to Circulatory Changes

- HR = 110 to 160 bpm
- Deviations should re-evaluated in 30 mins - 1h
- 180 bpm = crying
- 80-100 bpm = sleeping
- Precordial activity = PMI visible and palpable on 4th ICS, left midclavicular
- Apical pulse auscultate for full minute
- Irregular HR common
 - S1 louder than S2
- Murmurs not pathological unless:
- Poor feeding, apnea, cyanosis, pallor
- Disappear by 6 months
- Abnormal:
- Persistent tachycardia 160 bpm+
- RDS, pneumonia, fever
- Persistent bradycardia → less than 80 bpm
- Congenital heart block, maternal lupus
- Fetal Hb = high O2 affinity
- Promotes oxygenation while producing own Hb
- ↑ RBC and Hb than adults
- Hematocrit ↑ slightly as fluid goes from intravascular → interstitium
- Normal = 14-24 g/dL
- 6 - 12 months = risk for transient anemia
- Short RBC lifespan = ↓ Hb by 6-12 months
- Fetal WBC
- At birth: 9-30/L
- Day 1: 23-24/L
- Newborn period: 12/L
- ↑ by: crying, maternal HTN, hypoglycemia, hemolytic disease, meconium aspiration,
labour induction with oxytocin, surgery, difficult labor, high altitude, maternal fever
- Fetal Platelets
- Normal: 150-300/L
- Same as adults
- Vit-K dependent clotting factors ↑ slowly after
birth, reach adult levels by 6 months
- Blood volume = 300 mL
- Depends on how long it takes to clamp cord
- Delayed cord clamping (DCC) = ↑ volume by 100
mL, ↑ BP
- ↓ intraventricular hemorrhage +
enterocolitis
- Good for preterm or term newborns not
needing CPR
- Risk for polycythemia (Hct greater than
65%)
- Lung expansion = ↑ BP
- Normal: SBP 60-80/ DBP 40-50 mmHg
- ↑ by day 2
- Crying + movement ↑ BP = measure at rest
 - Not routinely measured unless CV symptoms
- Abnormal:
- Difference between upper + lower extremity pressures
- Hypotension
- Hypertension
- Signs of cardiovascular concern
- Persistent tachycardia (160 bpm+)
- Anemia, hypovolemia, hyperthermia, sepsis.
- Persistent bradycardia (-100 bpm) congenital heart block, hypoxemia, normal sinus
bradycardia, hypothermia
- Unequal or absent pulses, bounding pulses, and decreased or elevated blood pressure
can indicate cardiovascular concerns
- Pallor right after birth → anemia, intrapartum asphyxia, assisted birth, sepsis
- Central/prolonged cyanosis → immediate action; respiratory/cardiac concern
- Umbilical vein → oxygenated
- Umbilical arteries → deoxygenated
- Pulmonary circulation:
- Prenatal: ↑ resistance = ↑ pressure in RV + pulmonary arteries
- Post birth: ↓ resistance = ↓ pressure in RV, RA, pulmonary arteries = ↓ blood to ductus
arteriosus = ductus arteriosus closed
- Causes = breathing + alveolar capillary dilation = lung inflation = blood flow to lungs
- ↑ LV pressure = foramen ovale closes

- Systemic circulation:
- Prenatal: ↓ pressure in LA, LV, aorta
- Postbirth: ↑ systemic resistance = ↑ pressure in LV, LA, aorta
- Causes: loss of placental blood flow
- Umbilical arteries:
- Prenatal: patent; blood carried from hypogastric arteries → placenta
- Postbirth: functionally closed at birth
- Removed in 2-3 months
- Distal portions = lateral vesicoumbilcal ligaments
- Proximal portions = open; superior vesicle arteries
- Causes:
1) Smooth muscle contracts in response to thermal/mechanical stimuli → O2
alterations
2) Mechanically cut with cord at birth
- Umbilical vein
- Prenatal: patent; blood carried from placenta → ductus venosus and liver
- Postbirth: closed; ligamentum teres hepatis after obliteration
- Causes:
 1) Closes after umbilical arteries = placental blood stays in baby for short amount
of time after birth
2) Mechanically cut with cord at birth
- Ductus venosus
- Prenatal: patent; blood from umbilical vein →inferior vena cava
- Postbirth: closed
- Turns into ligamentum venosum
- Causes: loss of blood flow from umbilical vein
- Cord clamping = umbilical vein + arteries constrict 2 mins after birth = closes
ductus venosus
- Ductus arteriosus
- Prenatal: blood from pulmonary artery + aorta
- Postbirth: closes functionally at birth within 24-48 h by ↓ pulmonary pressures + ↓ blood
to ductus arteriosus
- Closes fully in 1-3 months
- Turns into ligamentum arteriosum
- Causes:
1) ↑ O2 in ductus arteriosus = vasospasm of muscular wall
2) ↑ systemic resistance by ↑ aortic pressure
3) Low pulmonary resistance = ↓ pulmonary arterial pressure
- Patent ductus arteriosus (reopens) by:
- Hypoxia
- Asphyxia
- Prematurity
- Heart murmur on auscultation
- Foramen ovale: shunt between LA and RA
- Prenatal: valve opening allows blood to flow directly from RA to LA
- Postbirth: closes functionally at birth
- Gradual fusion + permanent closure within few
months/years
- Causes:
- ↑ LA pressure + ↓ RA pressure = valve closes
- In utero:
- PO2: 20-30 mmHg
- After birth:
- CO doubles
- Blood flow ↑ to lungs, heart, kidneys, GI tract
- PO2: 50 mmHg

Regulating Temperature
- Heat regulation = critical to newborn survival
- Hypothermia = excessive heat loss
- Subnormal → preterm birth, infection, low environmental temperature, inadequate clothing,
dehydration
- Anatomical and physiological characteristics of newborns place them at risk for heat
loss-hypothermia
- Larger body surface to body weight
- ↓ adipose tissue & fat in newborn
- Underdeveloped sweating and shivering mechanisms
- Blood vessels closer to skin surface – contribute to heat loss
- Environmental factors:
- Temperature and humidity of the air
- Flow and velocity of the air
- Temperature of surfaces in contact with and around the newborn.
- Goal of care = maintain a neutral thermal environment where heat balance is maintained
- Allows newborn to maintain a normal body temperature → minimize O2 and glucose
consumption
- Axillary temperature – between 36.4 – 37.2°
- Evaporation: loss of heat when H2O evaporates from the skin + respiratory tract
- Heat loss ↑ by failing to completely dry after bathing
- Dry baby quickly and remove wet towels/blankets
- Less maturity = severe evaporation
- Conduction: heat loss from the body surface to cooler surfaces in direct contact
- Prewarm incubator/radiant warmer to ensure warm mattress
- Cover x-ray plates and scales
- Prewarm hands, stethoscopes, blankets and other equipment
- Weighing the newborn should have a protective cover to minimize conductive heat loss
- Radiation: heat lost to surrounding colder solid objects (not in direct contact) but in close
proximity
- Keep incubator, warmer, examination table, crib cot away from outside walls and
windows
- Dress baby
- Avoid exposing the newborn to direct air drafts
- Convection: heat lost from the body surface to cooler ambient air
- Raise surrounding temp to 22° and 26°C
- Cover baby’s head
- Wrap and dress baby
- Warm O2
- Skin to skin contact: baby will gain heat if placed on warm surface
- Skin-to-skin keep newborns warmer than swaddled
- ↓ conductive + radiant heat loss
- ↑ temp control + bonding
- Thermogenesis: ↑ muscle activity in response to hypothermia = ↑ peripheral constriction
- Crying, restlessness, cool skin, acrocyanosis
 - Flexion posture
- ↑ O2 and glucose consumption
- Non-shivering thermogenesis by
1) Brown fat metabolism
a) Richer vascular + nerve supply than
normal fat
b) Metabolism warms baby
c) Rapidly depleted with cold stress
d) ↑ brown fat with ↑ gestational age
2) Metabolic activity in brain, heart, liver
- Hyperthermia: temp over 37.5C
- Rapid development than in adults
- R/t larger newborn surface area + poorly
functioning sweat glands
- Overheating = cerebral damage, stroke, death
- Causes:
- Sepsis
- ↓ heat loss
- Phototherapy
- Inappropriate use of external heat sources
- Sunlight
- ↑ environmental temp
- Excessive clothing + blankets
- S+S of ↓ heat loss
- Skin vessels dilate = flushed skin
- Hands + feet warm to touch
- Extension posture
- S+S of sepsis
- Constricted vessels = pale skin
- Hands and feet cool to touch
- Postpone bathing until temperature stabilizes

Body Measurement
- Weights
- Female: 3 400 g
- Male: 3 500 g
- Acceptable weight loss: 10% or less in first 3–5 days
- Regaining of birth weight within first 2 weeks
- Weight ≤ 2 500 g = preterm, small for gestational age, rubella syndrome
- Weight ≥ 4 000 g = large for gestational age, maternal
diabetes, heredity
 - Normal for these parents
- Weight loss 10–15% = growth failure, dehydration → assess breastfeeding
- Length
- 45–55 cm
- < 45 cm or > 55 cm may be r/t chromosomal abnormality or heredity—normal for these
parents
- ​Head circumference – distance around head
- 33–35 cm
- Circumference of head + chest approximately the same for first 1 - 2 days after birth
- < 32 –microcephaly
- R/t maternal rubella, toxoplasmosis, cytomegalovirus, Zika virus, fused cranial
sutures [craniosynostosis]
- Hydrocephaly:
- Sutures widely separated
- Circumference ≥ 4 cm more than chest circumference
- R/t infection, increased intracranial pressure (hemorrhage, space-occupying
lesion)
- Fontanelles:
- Anterior fontanel 5-cm diamond → increasing as moulding resolves
- Closes within 18 months
- Posterior fontanel triangle 0.5x1 cm → smaller than anterior
- Closes within 8-12 weeks after birth
- Sutures (allow for brain growth)
- Should be palpable and separated suture
- Possible overlap of sutures with moulding
- Widely spaced (hydrocephaly)
- Premature closure (fused) (craniosynostosis)
- Signs of fontanels concerns:
- Full, bulging (tumour, hemorrhage, infection)
- Large, flat, soft (malnutrition, hydrocephaly, delayed bone age, hypothyroidism)
- Depressed (dehydration)
- Caput succedaneum
- Localized edematous area of soft tissues of scalp
- Mostly occiuput
- Presenting part causes compression of local vessels = slow venous return
- ↑ tissue fluids within skin of the scalp
- Edematous swelling develops
- Extends across the suture lines of the skull
- Disappears spontaneously within 3 to 4 days.
- Cephalohematoma
- Collection of blood between skull bone + periosteum
- Caused by external:
 - Pressure during L & D
- Forceps delivery
- Largest on 2nd or 3rd day → bleeding stops
- Feels boggy, edematous to touch
- Does not cross suture lines
- Firmer + better defined
- Resolves in 3 to 6 weeks
- Risk of jaundice r/t RBC hemolysis when healing
- Not aspirated due to risk of infection
- Can occur at the same time as caput succedaneum
- Subgaleal hemorrhage
- Bleeding into subgaleal compartment
- Causes:
- Difficult operative vaginal birth
- Vacuum extraction
- Scalp pulled away from bony calvarium → tears vessels → blood pools
in subgaleal space
- S+S
- Boggy scalp
- Pallor
- Tachycardia
- ↑ head circumference
- Complications:
- Hypovolemic shock
- DIC
- Death
- Interventions
- Repeat head circumference measurements
- Inspect back of neck for ↑ edema + firm mass
- Replace blood + clotting factors
- Forward + lateral positioning of newborn ears → hematoma extends
posteriorly
- Spine
- 2 primary concave curvatures → thoracic + sacral
- 3 months → head control → 3rd curve at cervical region
- Abnormal: pilonidal dimple – cleft at base of sacrum
- Benign alone
- Watch for sinus + nevus pilosus – spina bifida
- Extremities
- Oligodactyly = missing fingers/toes
- Polydactyly = extra fingers/toes
- Syndactyly = fused fingers/toes
 - Bowleg appearance
- Developmental dysplasia of the hip (DDH)
- S+S
- Asymmetrical gluteal creases + thigh skinfolds
- Uneven knee levels
- Positive Ortolani test
- Positive Barlow test → clunk heard when dislocating hip
- Fractured clavicle: macrosomia, difficult birth
- Clubfoot : foot fixed in plantar-flexion → congenital condition
- Gradually resolves
- R/t fetal positioning in the womb

Eyes
- Size & shape should be symmetrical
- Space between eyes is ⅓ the distance from outer (left) to outer (right) canthus
- Iris is usually blue or gray for light skinned; brown for darker skinned newborns.
- Immature lacrimal ducts – tears only produced at around 2 months
- Blink reflex - elicited by bright lights, lightly touching eyelid
- Pupils equal, reactive to light
- Eyelids may be edematous for the first few days
- Colour vision after first 3 months
- Prefer black + white
- Acuity = clearest distance from infant at breast to mother’s face
- 17-20 cm
- Prefer faces
- Response to movement
- E.g. follow bright lights visually
- Epicanthal folds when present with other signs
- Chromosomal disorders such as Down, cri-du-chat syndromes
- Discharge: purulent (infection)
Ears
- Firm, well formed cartilage of pinna in term infant
- Small, large, floppy, soft and pliable
- Correct placement: line drawn through inner and outer canthi of eyes reaching to top notch of
ears (at junction with scalp)
- Hearing assessed by responsiveness to loud noise without vibration
- Watch for Moro/startle reflex
- Newborn sound preferences:
- High pitched intonation
- Rhythmic sounds → mother’s regular heartbeat in the womb
- Anomalies
- Agenesis
 - Lack of cartilage (preterm)
- Low placement (chromosomal disorder, cognitive impairment, kidney disorder)
- Preauricular tag or sinus
- May indicate renal disorder
Nose
- Midline
- Slight deformity (flat or deviated to 1 side) from passage through birth canal
- Nose breathers in 1st few months
- Narrow passageways, easily obstructed with mucous & amniotic fluid
- Some mucus but no drainage
- Sneezing as a reflex to clear passageways
- Response to overstimulation of autonomous nervous system
- Smell is present in newborns.
- Allows newborns to turn to milk
- Infants prefer mother’s milk to other mothers’ milk
- Infants react to noxious smells shortly after birth

Mouth
- Lips should be symmetrical
- Pink, moist lips and mucosa
- Sucking blisters - from breastfeeding latch
- Sucking well developed by 36-38 weeks
- Small bursts of 3-4 sucks, or 8-10 at a time with pausing
- Saliva not excessive
- Intact hard and soft palate; freely moving tongue
- Tongue not protruding; freely movable; symmetrical in shape, movement
- Sucking pads inside cheeks
- Soft and hard palates intact
- Uvula in midline
- Epstein’s pearls: small, firm white cysts on gums.
- Resolve on own during 1st weeks
- Anatomical groove in palate to accommodate nipple, disappearance by 3–4 yr of age
- Common conditions:
- Thrush: white plaque – similar to milk curds, does not easily scrape off
- Precocious tooth: premature eruption of a tooth, often around lower incisors.
- Cleft lip/palate: cyanosis, circumoral pallor (respiratory distress, hypothermia)
- Asymmetry in movement of lips (7th cranial nerve paralysis)
- Teeth: predeciduous or deciduous (hereditary)
- Short lingual frenulum (ankyloglossia - tongue-tie)

Neck
- Short with skin folds
 - Freely mobile range of motion
- Head lag r/t prematurity

Renal System
- 40 mL may present in the bladder at term birth
- Void within 24 hours, may void during delivery
- No void by 24 h:
- Assess fluid intake adequacy
- Bladder distension
- Restlessness
- Pain symptoms
- 1st void characteristics
- Cloudy
- Concentrated
- Day 1: minimum of 1 void
- 60 to 80 mL/kg/day during the first 2 days of life
- 1 week: 6-8 voids per day
- Day 1 and 2 =-2-5 times
- After day 2 = 2-8 times per day
- Amount per void = 15 - 60 mL/kg/day → gradually increases over 1st month
- Pale straw-coloured urine = adequate fluid intake
- Daily fluid requirement for newborns weighing more than 1 500 g:
- 3 to 7 days: 100 to 150 mL/kg/day
- 8 to 30 days: 120 mL/kg/day to 180 mL/kg/day
- 5-10% loss of birth weight = normal over 3-5 days
- Causes: urine, feces, ↑ metabolic rate, limited fluid intake
- Must regain over 10-14 days with feeding

Reproductive System
Female Genitalia
- Labia – examined for size
- Labia majora develops close to term
- Assess to ensure that labia not fused
- Assess ambiguous genitalia
- Excessively prominent clitoris
- Vaginal opening not clearly patent
- Normally edematous labia → resolves in few days
- Vernix caseosa normally present
- Milky vaginal discharge- due to circulating maternal hormones
- Pseudomenses: blood tinged mucus r/t hormones of pregnancy
- Vaginal tag: (hymenal tag) usually disappears in first few weeks after birth
- No tags can be r/t vaginal agenesis
 - Swelling of the breast tissue in term newborns of both sexes → due to ↑ estrogen in utero
- Thin discharge may be seen
- Symmetrical nipples
- If urethral opening isn’t behind clitoris → adrenal hyperplasia
Male Genitalia
- Foreskin/prepuce completely covers glands
- Has small white firm cysts (epithelial pearls)
- Hypospadias: urinary meatus on ventral surface of penis (underside)
- Circumcision is contraindicated in hypospadias or epispadias
- Foreskin is used in repair of these anomalies
- Epispadias: Meatus on the dorsal surface
- Phimosis: foreskin cannot be fully retracted
- Hydrocele: collection of fluid around testes
- Transilluminated with light
- Usually decreases in size with treatment
- Discoloration of testes → assess for testicular torsion
- Can be r/t breech birth – should resolve in few days
- Crepitus in groin or scrotal sac = hernia
- Resolve with time
- More obvious when newborn cries
- Undescended testes = cryptorchidism
- Failure of testes to descend into scrotal sac in term infant
- Preterm, low birth weight related
- Scrotum is more pigmented than rest of skin r/t ↑ in estrogen

GI System
- Able to swallow, digest, absorb proteins + emulsify fats
- All enzymes present at birth, except pancreatic amylase + lipase
- Rounded, prominent, and dome-shaped
- Bowel sounds within 2 hrs. post birth
- Present within minutes after birth in healthy term newborn
- Patent anus → wink reflex in response to touch
- Meconium passed within first 24-48 h after birth
- Umbilical cord → whitish grey – 2 arteries & 1 vein
- Definite demarcation between cord and skin; no intestinal structures within cord
- Cord status
- Gastroesophageal reflux = relaxing of lower esophageal sphincter = backflow up esophagus =
spitting, regurgitation is common in first 3 months
- Stomach size + capacity ↑ depending on feedings time + amount
- Day 1 = 10 mL
- Day 3 = 30 mL
- Day 7 = 60 mL
- Digestion
- Amylase → needed to process colostrum
- Salivary: 3 months
- Pancreas: 6 months
- Unable to digest fats at birth → needs mammary lipase to help
- Lactase = ↑ in newborns
- Stools
- Newborn’s 1st stool
- Composed of amniotic fluid and its constituents, intestinal secretions, bilirubin, shed
mucosal cells
- Greenish black, viscous, contains occult blood.
- Passed within 12 to 24 hours, and almost all do by 48 hours
- Low birth weight = up to 7 days
- Transitional stools:
- Appear by 3rd day of feeding
- Greenish brown-yellowish brown
- Thin and less sticky
- Contain milk curds
- Milk stools
- Appears by 4th day of feeding
- Breastfed:
- Yellow-golden
- Pasty consistency
- Odour = sour milk
- Mixture of mustard + cottage cheese look
- Formula:
- Pale yellow to light brown
- Firmer consistency
- Odour = like adult stool
- Failure to pass meconium
- Bowel obstruction
- Small or large bowel atresia
- Inborn error of metabolism (e.g., cystic fibrosis)
- Congenital disorder (e.g., Hirschsprung disease or an imperforate anus)
- Most amount of stool = 3-6 days
- Anomalies:
- 1 artery (renal anomaly)
- Meconium stained → intrauterine distress
- Bleeding or oozing around cord → hemorrhagic disease
- Redness or drainage around cord → infection, possible persistence of urachus
- Hernia: herniation of abdominal contents through cord opening → omphalocele
- Defect covered with thin, friable membrane, possibly extensive
 - Scaphoid, with bowel sounds in chest and severe respiratory distress → congenital
diaphragmatic hernia
- Gastroschisis: herniation of abdominal contents to the side or above the cord
- Abdominal distension at birth
- Ruptured vicus, abdominal wall defects
- Abdominal distension postbirth
- Overfeeding, failing to pass stool
- Diarrhea: forceful stool ejection, water ring around stool
- R/t inability to digest formula
- Bilous emesis = critical action needed
- Iron storage
- Iron store at birth depends on total Hb content + length of gestation
- Lasts 4-6 months
- Glucose homeostasis
- Cord cut = hypoglycemic rxn r/t cut off from maternal glucose supply
- First few hours = 2.5 -3.0
- 3rd day = 4.0 - 6.0
- S+S
- Jitteriness
- Lethargy
- Apnea
- Feeding issues
- Seizures
- Also can be asymptomatic
- Stabilizing glucose levels
- Colostrum
- Initiation of feedings
- Only routinely assessed if:
- Small/large gestational age
- Preterm
- Diabetic mother

Integumentary System
- Normal findings:
- Pink varying with ethnic group, well perfused
- Perfusion assessed by capillary refill of 2 seconds or less
- Skin should spring back when pinched
- Dehydration fold of skin persisting after release of pinch
- Skin is soft, dry texture.
- Acrocyanosis: bluish discoloration of hands and feet in first 6 -8 h post birth
- Due to cardiovascular immaturity
- Seen intermittently in first 7-10 days
 - Mottling: temperature instability; overstimulation of autonomous nervous system
- Harlequin sign
- Telangiectatic nevus; nevus simplex
- Pale pink or reddish discolouration at nape of neck or lower occipital bone,
eyelids and above nasal bridge
- R/t capillary defect
- Easily blanched
- 80% of newborns
- More prominent in fair skinned, light haired infants
- More noticeable with crying
- No clinical significance
- Generally fades by age 2
- Erythema toxicum
- Shows up in first 24-72 h
- Lasts up to 3 weeks
- Inflammatory response, but not clinically significant
- Abnormal findings:
- Dark red → preterm, polycythemia
- Grey → hypotension, poor perfusion
- Pallor → cardio issue, CNS damage, blood dyscrasia, blood loss, infection
- Cyanosis → hypothermia, infection, hypoglycemia, cardiopulmonary disease, neuro,
respiratory malformations
- Generalized petechiae → clotting disorder, infection
- Generalized ecchymosis → hemorrhagic disease
- Yellow
- 1st week = common in term
- First 24 h – ↑ hemolysis, Rh isoimmunization, ABO incompatibility
- Hemangiomas
- Port-wine stain
- Nevus vasculosus
- Pitting edema on hands, feet, tibia
- Rash or superficial peeling
- Texture thin or thick
- Skin tags, webbing
- Papules, pustules, vesicles, ulcers, maceration
- Postmature infants: dry skin, cracking on feet and hands
- Loose, wrinkled skin → prematurity, postmaturity
- Congenital dermal melanocytosis: bluish-black areas
- Common in Latin American, Asian, African, Mediterranean ethnicities
- Tense, tight, shiny skin → edema, extreme cold, shock, infection
- Vernix caseosa: waxy, cheesy substance
- Shows up at 35 weeks
 - Protects skin from astringent effect of amniotic fluid
- Prevents fluid loss
- Disappear closer to term
- Leaving vernix intact benefits for skin + hydration
- Absent/minimal = postmature
- Abundant = preterm
- Green colour = intrauterine release of meconium or presence of bilirubin
- Odour = possible intrauterine infection
- Lanugo: fine downy hair on neonate’s body
- Most abundant – 28-32 weeks
- Decreases with fetal maturity
- Disappears from face 1st day, then extremities
- Abundant = preterm, especially if lanugo abundant, long, and thick over back
- Skin creases
- ↑ creases on soles of feet = ↑ maturity
- Sweat glands
- Milia: small white sebaceous glands on face
- Sweating starts day 3 on face + palms
- Birth injuries to skin
- Marked ecchymosis on face of newborn → r/t face presentation, assisted vaginal birth
- Forceps injury → linear mark on both sides of face
- Phototherapy required for treatment of jaundice resulting from breakdown of
accumulated blood
- Swelling of genitalia + bruising of the buttocks → r/t breech birth
- Nuchal cord, face presentation
- Bruises, petechiae on head, neck and face
- Bruises ↑ risk of hyperbilirubinemia
- Petechiae – low platelet count, infection if lasting more than 2-3 days
- Bruises + petechiae don’t blanch, rashes/discolouration do blanch
- Subconjuctival + retinal hemorrhages
- By capillary rupture by ↑ pressure during birth
- Clears within 5 days, usually harmless
- C section
- Accidental superficial lacs with scalpel
- Usually heal with strips

Newborn Reflexes
- Sucking → when anything is placed in mouth or touches lips
- Rooting → infant turns head when side of mouth/cheek are stimulated
- Present for 3-4 months
- Aids in latching
- Moro → startling infant
 - Response by symmetrically extending arms outward while knees flex
- Lasts up to 6 months
- Most sensitive assessment for neuro system
- Babinski → plantar reflex
- Hyperextension of toes when sole stroked from heel up to ball of foot
- Lasts up to age 1
- Galant/trunk → incurvation of trunk with stroking or tapping spine in prone position
- Pelvis turns to stimulated side
- Lasts up to 6 months
- Palmar grasp → fingers curl around finger placed in palm
- Decreases by 3-4 months
- Plantar grasp:
1) Toes curl downward when finger is placed at base
a) Disappears 3-4 months
2) Object placed in infants palm; grasp tightens with attempts to remove object
a) Disappear by 8 months
- Extrusion → forces tongue out when depress tip of tongue
- Lasts 4-5 months
- Glabellar → blinking in response to forehead, nose, maxilla
- Good extrapyramidal signs
- Crawling movements → with arms + legs when placed on abdomen
- Lasts 6 weeks
- Stepping → stimulate walking when held upright with feet touching solid surface
- Lasts for 2 months
- Tonic neck → head turned to one side, arm on that side stretches out + opposite arm bends up
at elbow
- Lasts up to 5-7 months

Physical Examination of Newborn

- Provide a normothermic and nonstimulating examination area.
- Check that equipment and supplies are working properly and are accessible.
- Undress only the body area to be examined → prevent heat loss
- Proceed in an orderly sequence (usually head to toe), with the following exceptions:
- Perform all procedures that require quiet first, such as observing position, skin colour,
tone, and condition.
- Next auscultate the lungs, heart, and abdomen.
- Perform more disturbing procedures, such as taking temperature and testing reflexes,
last.
- Measure head circumference and length as a baseline for further comparison as needed
- Proceed quickly to avoid stressing the newborn.
- Comfort the newborn during and after examination; involve parents in the following:
- Talking softly to the newborn
 - Holding the newborn’s hands against the chest
- Holding the newborn
- Placing the baby skin-to-skin

- Transition period = 3 stages of newborn adaptation

1) First period of reactivity – lasts 30 mins
a) HR increases to 160-180 bpm, then falls to baseline by 30 mins (100-160 bpm)
b) Irregular RR (60-80 bpm)
c) Resolves within 1 hour:
i) Nasal flaring
ii) Fine crackles on auscultation
iii) Audible grunting
iv) Chest retractions
d) Alert
e) Startled spontaneously
f) Tremors
g) Crying
h) Head movements side to side
i) Audible bowel sounds
j) Ribs are horizontal slope, not downward slope
2) Period of decreased responsiveness – lasts 60-100 mins
a) Pink colour
b) Rapid RR + shallow, but not laboured
i) 30-60 breaths/min
ii) Pauses lasting less than 20 seconds
c) Bowel sounds audible
d) Rounded abdomen + peristaltic waves
e) Decreased motor activity
3) Second period of reactivity – lasts 10 mins to several hours
a) Starts 2-8 hours after birth
b) Brief period of tachypnea + tachycardia
c) Increased muscle tone
d) Skin colour changes
e) Meconium commonly passed
f) Mucus production
Behavioural Adjustments to Extrauterine Life
1) Establishing regulated behavioural tempo independent of mother
a) Self-regulating arousal
b) Self-monitoring changes in state
c) Patterning sleep
2) Processing, storing and organizing multiple stimuli
3) Establishing relationship with caregivers and environment

Purpose and components of the Apgar score

- Immediate assessment of the newborn

- 1 and 5 minutes after birth
- 0 to 3: severe distress
- 4 to 6: moderate difficult
- 7 to 10: minimal or no difficulty adjusting to extrauterine life
- Reassessment at 10 and 20 minutes if the score is less than 7 at 5 minute
- Resuscitation may occur at any point when the newborn is compromised
- Should not wait until the initial 1-minute Apgar score

Management of meconium aspiration in newborn

 Risk factors associated with the birth and transition of an infant of a diabetic mother

Sensory and perceptual function of the newborn

Caring high risk newborns (preterm, diabetes, jaundice Characteristics and clinical issues of
preterm, late preterm, term, and post-term newborns, Jaundice and phototherapy)
- Infants born considerably before term and survive = susceptible to development of sequelae
related to preterm birth.
- High-risk infants classified according to:
- Birth weight
- Gestational age
- Common pathophysiological problems

Hyperbilirubinemia
- Bilirubin greater than 340 mcmol/L in first 28 days
1) Physiological jaundice
a) 60% of term infants
b) 80% of preterm infants
c) Self limiting
d) ↑ bilirubin
 e) Starts after 24 h resolves by day 5
f) No therapy needed → unless bilirubin rises higher/faster than normal
2) Pathological jaundice
a) Appears within first 24 hours
b) Phototherapy needed
c) ↑ serum unconjugated bilirubin > 100 mcmol/L in 24 h OR exceeds >256
mcmol/L at any time
d) Rises until day 5
- S+S
- Yellowing of sclera, mucous membranes, progress to extremities, abdomen, thorax
- Blanchable skin
- Causes
- ↑ bilirubin level r/t breakdown in RCS
- Short lifespan of RBC = RBC mass breakdown
- Immature liver can’t break down bilirubin for excretion
- Hepatic obstruction
- Unconjugated bilirubin highly toxic to neurons
- Risk factors
- 35-38 weeks
- Exclusive poor breastfeeding
- Weight loss
- Sibling who had hyperbilirubinemia
- Visible bruising
- Hypoglycemia
- Liver impairment
- Biliary atresia
- Maternal fetal Rh or ABO incompatibility
- Cephalohematoma
- Positive Coombs test
- Ethnic background
- Hypoxia
- Hypothermia
- Hemolytic disease
- Acidosis
- Albumin less than 30 g/L
- Temperature instability
- Sepsis
- Delayed meconium passage
- Lethargy
- Interventions
- Monitor total serum bilirubin (TSB) per hour – 35 weeks or more
- Adequate feeding
 - Colostrum = meconium passage = get rid of bilirubin
- Prevents dehydration with phototherapy
- Prevents losing weight
- Assess at-risk newborns for TSB within 24 hours
- Universal screening = 24-72 h
- ↓ serum unconjugated bilirubin
1) Phototherapy
a) Converts SUB to molecules
that can be excreted
b) Newborn placed supine
45-50 cm away from light
source
i) Eye mask to
prevent retinal
damage
ii) Removed
periodically +
during feeding
c) Levels ↓ within 4-6 h
i) Within 24 h = ↓ by 30-40%
d) Continued until bilirubin is downward trending to normal range
e) Monitor temp q2h → risk of hyperthermia
i) ↑ insensible water loss = dehydration
f) Monitor urine output
g) Monitor number and consistency of stools
i) Normal: loose
h) No creams, ointments, lotions
i) ↑↑ bilirubin = combine conventional lights + fibre-optic blankets
2) Exchange blood transfusion
a) When phototherapy doesn’t work or bilirubin is too high
b) Common in very preterm NBs with hyperbilirubinemia
- Complications
- Sensorineural hearing loss
- Mild cognitive delays
- Kernicterus – bilirubin goes to brain
- Long term consequences of bilirubin toxicity
- Irreversible
- Hypotonia
- Delayed motor skills
- Hearing loss
- Cerebral palsy
- Gaze abnormalities
 - Acute bilirubin encephalopathy
- Lethargy
- Hypotonia
- Poor sucking
- Irritability
- Seizures
- Coma
- Death
- Follow-up
- Educate parents about signs of jaundice + treatment
- Repeat serum tests for NBs treated for jaundice

Hypoglycemia
- BGL less than 1.7 mmol/L
- Not routinely assessed in healthy term newborns
- Breastfeeding early, skin-to-skin = maintains good BGL
- S+S
- Jitteriness
- Lethargy
- Poor feeding
- Abnormal cry
- Hypotonia
- Temperature instability – hypothermia
- Respiratory distress
- Apnea
- Seizures
- Can also present asymptomatically
- Risk Factors:
- Cord clamping → drops to 1.7
- Asphyxia
- Perinatal hypoxia
- Infection
- Hypothermia
- Polycythemia
- Late preterm newborns
- ↓ glycogen stores
- Lack liver enzymes for glucose production
- Immature insulin + hormonal secretion
- Hyperinsulinism
- SGA/LGA
- Maternal illness factors → diabetes, gestational HTN
- Preterm/SGA
 - Test for up to 36 h + keep above 2.6
- Complications
- Neurological, tissue, organ injury
- Interventions
- At risk newborns
- Test BGL after 1 effective feeding at 2 hours of age
- Abnormal: less than 2.8
- Persistent BGL less than 2.6 despite feedings = IV dextrose therapy
- Low risk newborns
- Resolved by feeding carbohydrates, dextrose gel, skin-to-skin

Infants of Diabetic Mothers

- Higher Risk of Hypoglycemia
- High maternal BLG during fetal life = fetal islet cells produce insulin
- Leads to hypertrophy and hyperplasia of the pancreatic islet cells
- Transient state of hyperinsulinism
- Sudden removal of newborn’s glucose supply after birth + continued production of insulin
- Depletes blood of circulating glucose
- State of hyperinsulinism and hypoglycemia within 0.5 to 4 hours
- Quick drops in blood glucose levels = neurological damage or death
- S+S
- Jitteriness or tremors,
- Cyanotic episodes,
- Seizures
- Intermittent apneic episodes
- Difficulties feeding
- Clinical Manifestations
- Macrosomia or LGA
- Very plump and full faced
- Abundant vernix caseosa
- Plethora (ruddy complexion)
- Listless and lethargic
- Possibly meconium stained at birth
- Hypotonia
- Complications
- Hypoglycemia, hypocalcemia, hypomagnesemia, polycythemia, hyperbilirubinemia,
cardiomyopathy
- Respiratory Distress Syndrome
- CNS anomalies
- Anencephaly, spina bifida, holoprosencephaly
 - Cardiac anomalies – ventricular septal defects and coarctation of the aorta
- Sacral agenesis and caudal regression
- Increased risk for birth injuries
- Management and nursing care
- Feedings with breast milk/formula initiated within the 1st hour after birth if
cardiorespiratory status stable
- Test glucose before feedings for at least first 12 h after birth
- Abnormal = below 2.6 mmol/L
- If enteral supplementation failed or infant unable to feed:
- Continuous IV infusion of 10% dextrose at 4 - 6 mg/min/kg
- BGL is below 1.8 mmol/L, a 1-time bolus infusion of 10% dextrose (200 mg/kg)
given over 2 to 4 minutes
- Followed by a continuous IV infusion of 10% dextrose
- Evaluation of serum glucose q30 minutes
- Pharmacological agents (glucagon and diazoxide) may be required
- Assess for congenital anomalies, signs of possible respiratory or cardiac issues
- Maintenance of adequate thermoregulation
- Introduction of carbohydrate feedings as appropriate
- Monitoring of serum blood glucose levels
- Monitored closely for hyperbilirubinemia

Hypocalcemia
- Term: less than 2 mmol/L
- Preterm: less than 1.75 mmol/L
- Early onset = first 24-48 h after birth
- Self limited, resolves in 1-3 days
- S+S
- Jitteriness
- Tremors
- Twitches
- High pitched cry
- Irritability
- Apnea
- Laryngospasm
- Can also present asymptomatically
- Risks
- Maternal factors → diabetes, anticonvulsant treatment
- Perinatal asphyxia
- Trauma
- Low birth weight
- Preterm
- Treatment
- Early feeding of calcium → fortified human milk, preterm formula
- IV calcium and phosphorus
- Unstable, extreme low birth weight

Preterm
- Born before completion of 37 weeks of gestation, regardless of birth weight
- Organ systems are immature
- Lack adequate physiological reserves to function in the extrauterine environment.
- Leading cause of newborn deaths globally
- Almost 40% in Canada
- Low birth weight (LBW):
- Weighing 2 500 g or less = risk for health issues
- Extremely low birth weight (ELBW)
- Weighing less than 1000 g (2 lb, 3 oz)
- Practical and ethical dimensions of resuscitation of extremely low-birth-weight infants (ELBW)
- Causes
- Poverty → contribute to suboptimal health care and prenatal nutrition
- Maternal infections
- Previous preterm birth
- Multiple pregnancies
- Pregnancy-induced hypertension
- Placental conditions that interrupt the normal course of gestation
- Smoking
- Advanced maternal age
- Fetal disorders
- Intrauterine growth restriction (IUGR) → associated with LBW
- Risks
- Respiratory distress
- Thermal instability
- Hypoglycemia
- Jaundice
- Feeding difficulties
- Neurodevelopmental issues → speech, behavioural, and cognitive
- Infection
- Complications
- Respiratory distress syndrome (RDS)
- Patent ductus arteriosus
- Periventricular-intraventricular hemorrhage
- Necrotizing enterocolitis
- Nursing care
1) Respiratory support
 a) Oxygen therapy
i) Nasal cannula
ii) Continuous distending pressure
iii) Mechanical ventilation
iv) Weaning from ventilatory support
2) Cardiovascular support
a) Assess:
i) Heart rate and rhythm, BP, spO2
ii) Skin colour
iii) Perfusion
iv) Peripheral pulses
3) Thermoregulation
a) Maintaining a neutral thermal environment (NTE)
4) Neurological
a) Monitor for:
i) Seizure activity
ii) Hyperirritability
iii) CNS depression
iv) Elevated intracranial pressure
v) Abnormal movements
5) Nutrition and Hydration
a) Breastfeed if sucking and swallowing reflexes are adequate and no other
contraindications.
b) Gavage feeding (nasogastric or orogastric tube)
c) Gastrostomy feeding (surgical placement of a tube through abdomen into the
stomach.
d) Supplemental parenteral fluids to supply additional calories, electrolytes, or
water
6) Renal support
a) Assess acid–base and electrolyte balance
b) Serum levels of medication for adequate therapeutic range for treatment and to
prevent toxicity
c) Hematological support → signs of bleeding, anemia
7) Nurturing environment
a) Avoid slamming doors (including isolette portholes), listening to radios, talking
loudly, and handling equipment (e.g., trash containers), jarring chairs
b) Monitoring sound levels in the nursery
c) Shielding newborns’ eyes from bright lights
d) Clustering of care and assessments to enable undisturbed sleep periods
8) Skin care
a) Avoid damage to the delicate structure
b) Use skin products with caution
 i) E.g., alcohol, chlorhexidine, povidone-iodine
c) Rinsed with water afterward to prevent severe irritation and chemical burns in
VLBW and ELBW infants.
d) Minimal use of adhesive tape, backing the tape with cotton, and delay removal
adhesive until adherence is reduced
9) Protection from infection
a) Strict hand hygiene is the single most important measure to prevent infections
- Developmental Care: comprehensive strategies + interventions designed to reduce the effects of
negative stress in newborn and optimize neurobehavioural development
- NICU produces multiple exposures to noxious stimuli that affects the preterm infant’s
brain
- Components:
- Protected sleep
- Activities of daily living
- Healing environment
- Management of pain
- Family centred care
- Tailored to each newborn on based on comprehensive assessment

Post-Term
- Beyond 42 weeks, regardless of birth weight
- Associated with placental insufficiency
- Characteristics
- Thin, emaciated appearance at birth due to loss of subcutaneous fat and muscle mass
- Dry, loose, peeling skin
- Meconium staining of the fingernails;
- Hair and nails may be long
- Vernix may be absent..
- Meconium aspiration syndrome (MAS)
- Meconium in the amniotic fluid = careful supervision of labour and close monitoring of
fetal well-being.
- Infant breathing problems → may require neonatal resuscitation

Large for Gestational Age (LGA)

- Birth weight above the 90th percentile on growth charts
- Higher incidence of birth injuries
- Asphyxia
- Congenital anomalies such as heart defects
- Causes:
- Maternal diabetes in the mother (most common cause)
- Maternal obesity
 - Having had previous LGA babies
- Genetic abnormalities or syndromes
- Excessive weight gain during pregnancy

Small for Gestational Age (SGA)

- Weight less than 10th percentile for gestational age
- Risk Factors
- Intrauterine exposure to maternal substances
- Maternal diabetes
- Maternal pre-eclampsia
- Maternal chronic systems failure (renal, cardiac, etc.)
- Maternal anemia, thrombocytopenia
- Uteroplacental insufficiency
- Intrauterine viral infection
- Fetal chromosomal abnormalities
- Cord prolapse, cord thrombosis
- Other risk factors
- Geography
- Poor neighbourhood
- Rural area with limited access to prenatal and L&D care
- Multiple gestations (twins, triplets)
- Maternal age (teen or 35+)
- Parity (number of pregnancies)
- Previous preterm birth
- Maternal hypertension
- Substance abuse (smoking, drugs, alcohol)
- Clinical manifestations:
- Jittery, hypoglycemic
- Polycythemia (elevated Hct., ruddy colour)
- Temperature instability
- Meconium staining
- Perinatal asphyxia, hypoxia

Discharge Planning: High Risk

- Parents should be given the opportunity to room-in and spend a night or two providing care
- Home care needs of infant's parents are assessed.
- Referrals for appropriate resources
- Assistance with medical supplies
- Parent teaching include bathing and skin care, infection prevention
- Nutritional requirements for meeting nutritional needs
- Parent education and opportunity for return demonstrations care skills
- Age-appropriate car seat
- Health care provider contact
- Appropriate immunizations, metabolic screening, hematology assessment, and evaluation of
hearing and for retinopathy of prematurity (ROP) before discharge
- Transport to a regional centre

Circumcision and parent teaching regarding care of circumcised or uncircumcised penis

- Not covered by OHIP
- Cultural factors in circumcision decisions
- Done within 1st week, but can be later
- Parental choice
- Some health benefits
- Easier hygiene, decreased risk UTI, STI, penile cancer and some penile problems
- Routine circumcision is not recommended in developed countries
- Contraindications:
- Premature
- Known bleeding problem
- Genitourinary defect
- Hypospadias or epispadias as foreskin may be needed for repair
- Risks:
- Hemorrhage
- Difficulty urinating
- Infection
- Discomfort
- Separation of circumcision edges
- Pain management
- Anaesthetics
- Ring block
- Dorsal penile nerve block
- Topical anaesthetic
- Non-pharmacological
- Concentrated oral sucrose
- Non-nutritive sucking
- Swaddling
- Patient Teaching
- Check circumcision for bleeding
- 1st hour: q15-30 mins
- Hourly for next 4-6 h
- If uncontrollable bleeding, 1 nurse applies pressure with folded sterile gauze +
another notifies PCP and preps surgical field
- Observe for urinary output
- Note time + amount of first void after procedure
 - Check wet diaper after circumcision
- Provide comfort
- Withhold feedings 2-3 h before circumcision
- Prevents vomiting + aspiration
- Check for infection
- Redness, swelling, or discharge
- White exudate is normal within the first 3 days
- Keep area clean
- Change the diaper and inspect every 4 hours.
- Wash the penis gently with warm water to remove urine and feces
- Apply petrolatum to glans with each diaper change – clamp procedure only
- Use sponge bath only until circumcision heals
- Apply the diaper loosely over the penis to prevent pressure
- Do not use newborn wipes because they can contain alcohol.
- Do not wash the penis with soap until healed (5 to 6 days)
- If not circumcised:
- How to clean with soap + water
- Do not retract foreskin until it’s easily done – usually 3-4 years old

Pain assessment in the newborn

- Newborn responses to pain
- Vocalization, crying
- Facial expressions – grimacing, eye squeeze, brow contraction, deepened nasolabial
furrows, taut/quivering tongue, open mouth
- Flexion + adduction of upper body + lower limbs – withdraw from painful stimulus
- Preterm newborns + pain
- Lower pain threshold
- Higher pain perception + stress, but less obvious responses
- Hormone release:
- EPI, norepi
- Glucagon
- Corticosterone, cortisol
- Glucose, lactate, pyruvate
- Lab evidence:
- Hyperglycemia
- Low pH
- High corticosteroids
- Physical observations
- Increased muscle tone
- Dilated pupils
- Decreased vagal nerve tone
 - Increased intracranial pressure
- Assessment of pain in the newborn
- Minimum 30 s visual observation
- Goal of newborn pain management:
- Minimize the intensity, duration, and physiological cost of the pain
- Maximize the newborn’s ability to cope with and recover from the pain.

- Non pharmacological management

- Non-nutritive sucking on a pacifier promote comfort
- Oral sucrose in small amounts given with a syringe with or without a pacifier for sucking
reduces pain during single events
- Skin-to-skin contact (kangaroo) care help reduce pain during a painful procedure
- Breastfeeding or breast milk helps reduce pain during heel lancing and blood collection
- Swaddling or snugly wrapping with a blanket
- Self-regulation
- Reduces physiological and behavioural stress
- Safe swaddling = wrap baby in lightweight blanket, arms extended, legs flexed,
hips not rotated in a neutral position
- Touch, massage, rocking, holding, and environmental modification (e.g., low noise and
lighting)
- Distraction with visual, oral, auditory stimulation
- Pharmacological pain management
- Local anaesthesia → circumcision, chest tube insertion
- Topical anaesthesia → circumcision, lumbar puncture, venipuncture, heel sticks
- Nonopioid analgesia → mild/moderate pain
- Opioid analgesia (morphine, fentanyl) → continuous or bolus infusion
 Providing a safe environment for a newborn (safe sleep, car seats, preventing Shaken Baby
Syndrome, risk factors for SIDS

Discharge Planning and Teaching

- Community follow up may occur, but not standard practice
- Feeding habits
- Weight changes
- Jaundice assessments
- Parental bonding
- Postpartum mood disorder
- Vaccination guidelines
- Resources + relevant community resources
- Temperature
- Elevation in body temperature
- Overwrapping
- Cold stress with resultant vasoconstriction
- Response to infection
- Ways to promote normal body temperature
- Dressing appropriately for the environmental air temperature
- Protecting from exposure to direct sunlight
- How to assess whether the newborn is hot or cold by feeling the back of the
neck
- Technique for taking the newborn’s axillary temperature, and normal values for axillary
temperature
- Signs to be reported to the primary health care provider:
- High or low temperatures with accompanying fussiness, lethargy, irritability,
poor feeding, and excessive crying
- Respirations
- Normal variations in the rate and rhythm
- Normal reflexes = sneezing to clear the airway
- Steps to take if the newborn appears to be choking
- Protect the newborn from the following:
- Exposure to people with upper respiratory tract infections and respiratory
syncytial virus
- Exposure to second-hand and third-hand tobacco smoke
- Suffocation from loose bedding, water beds, and beanbag chairs
 - Drowning in bath water
- Entrapment under excessive bedding or in soft bedding
- Anything tied around the newborn’s neck
- Blind cords near cribs
- Poorly constructed playpens, bassinets, or cribs
- Avoid the use of baby powder, which is a commonly aspirated substance.
- Whenever a powder is used, it should be placed in the caregiver’s hand and then
applied to the skin
- Kept away from the newborn’s face.
- Notify the health care provider if the newborn develops symptoms:
- Difficulty breathing or swallowing
- Nasal congestion
- Excess drainage of mucus
- Coughing, sneezing
- Decreased interest in feeding
- Fever
- What to do if newborn has respiratory illnesses like the common cold:
- Feed smaller amounts more often to prevent overtiring the newborn.
- Hold the baby in an upright position to feed.
- For sleeping, raise the baby’s head and chest by raising the mattress 30 degrees.
- Do not use a pillow
- Avoid drafts; do not overdress the baby.
- Use only medications prescribed by a pediatric health care provider.
- Do not use over-the-counter medications without HCP approval.
- Use nasal saline drops in each nostril and suction well with a bulb syringe to
decrease and relieve secretions.
- Feeding patterns
- Put to breast within 1st hour of birth
- Encourage cue-based feeding
- Breastfed babies feed more frequently → digested faster than formula
- 8-12 times/day
- Formula fed babies → q3-4 h
- Elimination
- Colour of normal urine and number of voidings to expect each day
- 1 wet diaper for each day of life until the 5th to 7th day
- Then frequent, clear, pale yellow voiding
- Changes to be expected in the colour of the stool
- Meconium → transitional → soft yellow/golden yellow
- Number of bowel movements, plus the odour of stools for breastfed or
formula-fed newborns
- Formula-fed newborns:
- 1 stool every other day after the first few weeks of life
 - Pasty to semiformed.
- Breastfed newborns:
- At least 5 stools q24 hours from 7 - 28 days of age
- Looser and resemble mustard mixed with cottage cheese.
- Sudden Infant Death Syndrome (SIDS) Prevention
- Death of infant under 1 year
- Sudden, unexpected, no clear cause
- Usually during sleep
- Environmental, genetic, metabolic factors
- Higher rates in low SES, Indigenous
- Prevention:
- Supine position for sleep
- Barrel chest + curveless spine makes it easier to roll to prone
position → risk for SIDS
- Smoke free environment
- Safe crib environment
- Room sharing for 6 months
- Avoiding overheating
- No sleep on sofas, waterbeds
- Breastfeeding, pacifier use
- Place on stomach to ↑ muscle tone for crawling several times a day WHILE
AWAKE and supervised
- Rashes
- Diaper rash – dermatitis, skin inflammation
- Redness, scaling, blisters, papules
- R/t infrequent diaper changes, diarrhea, plastic pants to cover diaper, diet
change
- Prevention:
- Check often + changed as soon as void/stools
- Clean with plain water + mild soap
- Use unscented wipes without alcohol
- Allow skin to dry before putting another diaper
- Management
- Zinc oxide creams
- Watch for Candida albicans growth
- Dermatitis in perianal, inguinal + lower abdomen area
- Oral thrush can turn into rashes
- Cheek rash: scratching face, rubbing against sheets
- Treat dry skin with emollient 1x or 2x daily
- Clothing
- Dress according to external temp
- Feel temp at back of neck → indication if too hot or too cold
 - Sleepwear: fitted 1 piece outfit
- Can safe swaddle for first 2-3 months
- Car safety
- Car seat should face at the back in the middle of the backseat
- Until they’re 9kg
- 9kg to 18 kg → age appropriate car seat
- Booster seat until 4 ft 9 in
- Never place carseat in the front → airbag injuries
- Dress thinner when in car seat + place blanket over buckles
- Non-nutritive sucking
- Strong need for newborns
- Benefits = increased weight gain, less crying
- Pacifier use can reduce risk of SIDS
- Safe pacifiers
- 1 piece, shield with 2 ventilation holes
- Bathing
- Purposes
- Cleansing baby
- Observing condition
- Promoting comfort
- Promoting parent-child interaction
- Use neutral pH cleanser without preservatives
- Bathing by immersion = less heat loss, crying
- Bathing by swaddling = 1 body part is unwrapped at a time
- Delay bath until thermal + cardiorespiratory stability achieved
- Do not bathe more frequently than every other day
- Do not bathe immediately after feeding
- Room temp = 26-27 C
- Water temp = 38-40C
- Do not hold baby under running water
- If washing hair, wrap baby
- If scalp desquamation, remove scales with fine-toothed comb or brush
- Umbilical cord care
- Prevent risk of hemorrhage and infection (omphalitis)
- Signs: foul odour, redness, swelling, purulent discharge, granuloma, bleeding
- Medium for bacteria growth
- Average cord separation time = 10-13 days, or up to 3 weeks
- Clean cord with water + cleanser if debris, during initial bath
- Use plain water for all baths after
- Cord dries, shrivels + blackens by day 2-3
- Follow up care
- 2-3 days – check for jaundice status, feeding, elimination
 - 1 week
- 2, 4, 6, 9, 12, 18 months
- Yearly from 2-5 years
- CPR for neonates
- Classes for parents with preterm babies or with cardiopulmonary issues
- Practical suggestions for first weeks at home
- Focus on helping parents cope
- Printed materials, community resources
- Prenatal, postpartum classes
- Topics: ADLs, visitors, activity, rest
- Interpretation of crying
- Hunger, discomfort, wet, ill, bored, or no reason
- Calming strategies
- Sensory stimulation
- Skin-to-skin, warmth, patting, back massage, swaddling
- Mild rhythmic movements – rocking, hold upright on shoulder
- White noise, heartbeat sounds
- Period of PURPLE Crying → teaches parents how to deal with crying
- Dangers of shaken baby syndrome → shaking baby with undeveloped brain
- Period – infers that crying has a beginning + end
- S+S
- LOC alterations
- Irritable crying + moaning
- Abnormal flexion, extension of extremities
- Repeated or persistent vomiting
- P - peak of crying
- May cry more each week
- Most at 2 months, less at 3-5 months
- U - unexpected → comes + goes for no reason
- R - resists soothing → nothing works
- P - pain-like face
- Look like they’re in pain even when they’re not
- L - long-lasting
- Lasts as much as 5 h/day or more
- E - evening
- May cry more in later afternoon/evening
- Bc they’re tired, hungry
- Prolactin works at night → supply higher in the morning, lower at night
- Signs of illness
- Fever: temperature above 38°C axillary
- Continual rise in temperature
 - Note: Tympanic [ear] thermometers are not recommended for babies younger
than 3 months
- Hypothermia: temperature below 36.5°C axillary
- Not able to ↑ temperature by putting an extra layer of clothing or skin-to-skin
- Poor feeding or little interest in food: refusal to eat for two feedings in a row
- Vomiting: more than 1 episode of forceful vomiting or frequent vomiting
- Over a 6-hour period
- Diarrhea: 2 consecutive green, watery stools
- Note: Stools of breastfed newborns are normally looser than stools of
formula-fed infants
- Diarrhea will leave a water ring around the stool, whereas breastfed stools will
not
- ↓ bowel movement:
- Breastfed newborn: fewer than 3 stools per day
- Formula-fed infant: fewer than 1 stool every other day
- Decreased urination:
- Fewer than 6 wet diapers per day after 6 days of age
- Breathing difficulties:
- Laboured breathing with flared nostrils
- Absence of breathing for more than 20 seconds
- Newborn’s breathing is normally irregular and between 30 and 60 breaths/min.
- Count the breaths for a full minute but only if concerned
- Cyanosis (bluish skin colour) whether accompanying a feeding or not
- Lethargy: sleepiness, difficulty waking, or periods of sleep longer than 6 hours
- Most newborns sleep for short periods, usually from 1 to 4 hours, and wake to
be fed
- Inconsolable crying: attempts to quiet not effective) or continuous high-pitched cry
- Bleeding or purulent (yellowish) drainage from umbilical cord or circumcision
- Foul odour or redness at the site
- Drainage from the eyes
-
- Infant safety
- Never leave baby alone on a bed, couch, or table → risk for falls
- Never put your baby on a cushion, pillow, beanbag, or waterbed to sleep → risk for
suffocation
- Do not keep pillows, large floppy toys, or loose plastic sheeting in the crib.
- Always lay the baby flat in bed on their back for sleep. Do not place your baby on the
abdomen or side for sleep.
- When using an infant carrier, place carrier on the floor in a place where you can see the
baby
- Never be on a high place, such as a table, couch, or store counter.
 - Infant carriers do not keep your baby safe in a car. Always place your baby in an
approved car safety seat when travelling in a motor vehicle (car, truck, bus, or van). Car
safety seats are recommended for travel on trains and airplanes as well. Use the car
safety seat for every ride.
- Should be in a rear-facing infant car safety seat from birth until at minimum 1
year or until exceeding the car seat’s limits for height and weight.
- The car safety seat should be in the back seat of the car
- When bathing your baby, never leave them alone → can drown in 2-5 cm of water
- Hot water heater set at 49°C (120°F) or less.
- Check bath-water temperature with your elbow before putting baby in
- Do not tie anything around your baby’s neck. Pacifiers, for example, tied around the neck
with a ribbon or string can strangle your baby.
- Check your baby’s crib for safety. Slats should be no more than 5.7 cm apart. The space
between the mattress and sides should be less than two fingerwidths. The bedposts
should have no decorative knobs.
- Keep the crib or playpen away from window blind and drapery cords → risk of strangling
- Keep the crib and playpen well away from radiators, heat vents, and portable heaters →
fire risk
- Install smoke detectors on every floor of your home. Check them once a month to be
sure they are working properly. Change batteries twice a year.
- Avoid exposing your baby to cigarette or cigar smoke in your home or other places.
Passive exposure to tobacco smoke greatly increases the likelihood that your baby will
have respiratory symptoms and illnesses.
- Do not pick your baby up or swing your baby by the arms or throw them up in the air.
Never shake the baby
- Hold baby with head support

Routine Immunization schedules and implications of vaccine hesitancy on vaccine rates and
communicable diseases

Hepatitis B
- Some provinces give at birth
- Newborns at high risk:
- Parent is Hep B positive
- Parent Hep B status is
unknown
- If mother is carrier/infected
- Give vaccine + Hep B immune globulin within 12 h of birth