Immediate Newborn Care

❖ Mottling - The hue and color patterns of a

newborn's skin may be startling to some
❖ Apgar Scoring - method of parents. Mottling of the skin, a lacy pattern of
evaluating/monitoring cardiovascular small reddish and pale areas, is common
adaptation of the baby. The Apgar score is a because of the normal instability of the blood
test given to newborns soon after birth. This circulation at the skin's surface.
test checks a baby's heart rate, muscle tone,
and other signs to see if extra medical care or
emergency care is needed. The test is usually
given twice: once at 1 minute after birth, and
again at 5 minutes after birth.
❖ Acrocyanosis - bluish discoloration of body
and extremities.
❖ Harlequin’s Sign – dependence sign; reddish
on one side of the baby. Harlequin color
change appears transiently in approximately
10% of healthy newborns. This distinctive
phenomenon presents as a well-demarcated
❖ Lanugo – downy hair of newborn; anterior
color change, with one half of the body
shoulder, buttocks, scapular region, forehead.
displaying erythema and the other half pallor.

❖ Mongolian Spots
❖ Milia - pinpoint whitish structures on baby’s
nose, forehead and chin.
- Bluish discoloration in lumbar region and
buttocks. Mongolian blue spots, also
known as slate gray nevi, are a type of
pigmented birthmark. They’re formally
called congenital dermal melanocytosis.
- These marks are flat and blue-gray. They
typically appear on the buttocks or lower
back, but may also be found on the arms
or legs. They’re generally present at birth
or develop soon after.
- These birthmarks are noncancerous and
present no health danger. However, your
child’s pediatrician should examine the
marks to confirm the diagnosis. There’s
no recommended treatment for
Mongolian blue spots. They usually fade
before adolescence.

1
Compiled by: Chielo monceda
 Immediate Newborn Care
❖ Your assessment of these changes begins in
the delivery room and continues through the
infant’s hospital stay.
❖ During the birth process, fluid is squeezed
from the fetal lungs.
❖ As the chest emerges, most healthy newborns
will take their first breaths spontaneously.
❖ The onset of respiration stimulates a series of
cardiopulmonary changes as the infant
makes the transition from fetal to neonatal
circulation.

❖ Vernix Caseo - also known as vernix, is the

waxy or cheese like white substance found
coating the skin of newborn human babies. It
is produced by dedicated cells and is thought
to have some protective roles during fetal
development and for a few hours after birth.
❖ Newborns may look alike, but each has their
own physical attributes and personalities.
Some newborns are fat and short while
some are long and thin. There are newborns
who never give a fuss whenever they are
changed or cuddled, but some can cry in
high decibels whenever you lift them from
their cradles.
❖ The weight of newborns varies according to
their race, genetics, and nutritional factors.

❖ New Born Care - the care is performed

immediately after birth through the first 28
days of life, making the transition to extra
uterine life smoothly easy in promoting the
physical well-being of the newborn and
supporting the establishment of a well-
functioning family unit.

❖ The newborn’s transition from intrauterine to

extrauterine life is marked by a series of rapid
and complex physiologic changes.

2
Compiled by: Chielo monceda
 Immediate Newborn Care
❖ The infant is weighed nude at approximately
the same time each day. Newborn loses 5%
to 10% of birth weight days after birth due to:
- No longer under the influence of
salt-fluid retaining maternal
hormones
- Adjustment in breastfeeding
A. HEAD CIRCUMFERENCE
- Proceeds from cephalocaudal principle:
head longer than the rest of the body; head:
33-35 cm using a tape. Measurement
above head just above eyebrows and pina
ears, resting on occipital regions. If above
33-35 cm- suspect hydrocephalus.
- For accurate measurement the tape is
placed over the most prominent part of the
occiput and brought to just above the
eyebrows. The circumference of the
newborn’s head is approximately 2 cm
greater than the circumference of the
newborn’s chest at birth.
Compiled by: Chielo monceda
B. CHEST CIRCUMFERENCE
- Chest circumference should be taken with
the tape measure at the lower edge of the
scapula and brought around anteriorly
directly over the nipple line.
C. LENGTH
- The length of the newborn is difficult to
measure because the legs are flexed and
tensed. To measure length, start from the
crown of the newborn’s head following the
conjunction of the spine /back then the
buttocks, thigh down to the heel of the foot.
- Other way of measuring the length, the
nurse should place the newborn’s flat on
their backs with legs extended as much as
possible.
D. VITAL SIGNS
- Temperature
o 37.2ºC (99ºF) at birth
o It will fall immediately below normal
due to heat loss, temperature of
birthing room, immature
thermoregulating mechanism and less
subcutaneous fat.
o Newborn lose heat by 4 mechanisms:
1. Convection
• Flow of heat from Newborn’s
body to cooler surrounding
air.
• Prevention: Eliminate drafts
from windows/air
conditioners.
3
 Immediate Newborn Care
area in a newborn, can be
responsible for a great
amount of heat loss so cover
the hair with a cap after
drying.

2. RADIATION
• Transfer of body heat NOT IN
CONTACT with the baby such
as a cold window or air
conditioner.
• Prevention: Move the infant
as far from the cold surface o If the newborn’s temperature does not
as possible. stabilize shortly after birth, the cause
needs to be investigated to rule out
infection.
- PULSE
o Transient murmurs
▪ Result from incomplete closure
of fetal circulation shunt
o During crying
▪ May rise to 180 bp
o During sleep
▪ 90 – 110 bp
3. Conduction o Palpate for femoral pulses
• Transfer of body heat to a ▪ Absence suggests coarctation
cooler solid object in contact (narrowing) of the aorta.
with the baby. - RESPIRATION
o Coughing & sneezing present to clear
the airway.
o Maybe as high as 90breaths per
minute right after birth but will settle to
an average 0f 30- 60 breaths per
minute
o NBs are obligate nose- breathers
▪ Show signs of distress if nostrils
become obstructed.
- BLOOD PRESSURE
4. Evaporation o At birth:
• Loss of heat through ▪ 80/46 mmHg
conversion of a liquid to a o By 10th day:
vapor. ▪ 100/50 mmH
• Drying the infant’s face and
hair effectively reduces E. CREDE’S PROPHYLAXIS
evaporation because the - Crede’s prophylaxis and apply terramycin
head which is a large surface eye ointment on both eyes.
4
Compiled by: Chielo monceda
 Immediate Newborn Care
- Retract lower eyelid outward to instill inch
strand of ointment along the conjunctival
surface.
F. NEONATAL REFLEXES
- Also known as developmental, primary, or
primitive reflexes.
- They consist of autonomic behaviors that do
not require higher level brain functioning.
They can provide information about lower
motor neurons and muscle tone.
- They are often protective and disappear as
higher-level motor functions.
G. NEUROMUSCULAR SYSTEM
1. Blink reflex
- May be elicited by shining a strong light
on an eye.
- To protect eyes from any object coming
near it.
2. Rooting reflex
- Serves to help the NB find food.
- When cheek is stroked near the corner
of the mouth, a NB will turn the head in
that direction.
Compiled by: Chielo monceda
- Reflex disappears 6 wks. of life
▪ At this time, NB eyes can focus
steadily so food source can be
seen.
3. Sucking reflex
- This reflex helps the NB find food.
- When a NB’s lips are touched, the baby
makes a sucking motion.
- Begins to diminish at 6 months of age
4. Swallowing reflex
- Food that reaches the posterior portion
of the tongue is automatically
swallowed.
5. Extrusion reflex
- Prevents swallowing of inedible
substances.
- Disappears in 4 months
- Extrudes any substance placed on
anterior portion of the tongue
6. Palmar grasp
- Disappears: 6 wks. - 3 months
- Elicited by the examiner placing his
finger on the palmar surface of the
infant’s hand and the infant’s hand
grasps the finger.
- Attempts to remove the finger result in
the infant tightening the grasp.
- Grasps meaningfully at 3 months of age.
5
 Immediate Newborn Care
7. Step (Walk)-in-Place
- NBs who are held in a vertical position
with their feet touching a hard surface
will take a few quick, alternating steps.
- Disappears by 3 months of age
11. Moro Reflex
8. Placing reflex
- Similar to step-in-place reflex
- Elicited by touching the anterior surface
of the lower part of the NB’s leg against
a hard surface.
▪ Edge of table or bassinet
9. Plantar grasp
- When an object touches the sole of a
NB’s foot at the base of the toes, the toes
grasp in the same manner as do the
fingers.
- Disappears at 8 – 9 months of age in
preparation for walking.
10. Tonic neck (Fencing posture)
- Elicited by rotating the infants head
from midline to one side. The infant
should respond by extending the arm on
the side to which the head is turned and
flexing the opposite arm. The lower
12. BABINSKI REFLEX
extremities respond similarly.
- Disappears between 2 – 3 months of life
Compiled by: Chielo monceda
- The examiner holds the infant so that
one hand supports the head and the
other supports the buttocks. The reflex is
elicited by the sudden dropping of the
head in her hand. The response is a
series of movements: the infant’s hands
open and there is extension and
abduction of the upper extremities. This
is followed by anterior flexion of the
upper extremities and audible cry.
- Their fingers assume a typical “C”
position.
- Fades by end of 4-5 months.
- An absent or inadequate Moro response
on one side:
▪ Hemiplegia, brachial plexus
palsy, or a fractured clavicle
- Persistence beyond 5 months of age:
▪ Indicate severe neurological
defects.
- Elicited when the sole of the foot is
stroked in an inverted “J” curve from
the heel upward. The infant responds by
plantar flexion and either flexion or
extension of the toes (fans the toes).
- Remains positive until 3 months of age
6
 Immediate Newborn Care
16. LANDAU REFLEX
- A NB who is held in prone position with
a hand underneath supporting the
trunk, should demonstrate some muscle
tone.

13. MAGNET REFLEX

- If pressure is applied to the sole of the
feet of the NB lying in supine position,
he/she pushes back against the press.

Muscle toned is determined by evaluating

the degree of flexion and resistance of the
extremities.
14. CROSSED EXTENSION REFLEX
- If one leg of the NB lying supine is 1) The square window sign is elicited by gently
extended, and the sole of that foot flexing the newborn’s hand towards the
irritated by being rubbed with a sharp ventral forearm until resistance is felt. The
object (thumbnail), the infant raises the angle formed at the wrist is measured.
other leg and extends it, as if trying to
push the hand away.

2) Arm Recoil is elicited when the newborn is in

supine position, the forearm is fully flexing for
5 seconds the fully extend by pulling the hands
15. TRUNK INCURVATION and release.
- When NB lie in prone and is touched
along the paravertebral area by a
probing finger, they flex their trunk and
swing their pelvis toward the touch.

3) The popliteal angle (degree of knee flexion) is

determined with the newborn flat on his or her
back. Flex the thigh on the abdomen and
7
Compiled by: Chielo monceda
 Immediate Newborn Care
chest, place the index finger of the other hand
behind the newborns ankle to extend the
lower leg until resistance is met, and measure
the angle form. Results vary from no
resistance in the very immature newborn to
an 80-degree angle in a term newborn.
7) Head Lag (neck flexor) is measured by pulling
4) The scarf sign is elicited by placing the
newborn supine and drawing an arm across
the chest toward the newborns opposite
shoulder until resistance is met. Note the
location of the elbow in relation to the midline
of the chest.
8) Ventral suspension (horizontal position) is
5) The heel – to – ear extension is performed by
placing the newborn in a supine position and
then gently drawing the foot toward the ear on
the same side until resistance is felt. Allow the
knee to bend during the test.
6) Ankle dorsiflexion is determined by flexing the
ankle on the shin. Use a thumb to push on the
sole of the newborns foot while the fingers
support the back of the leg. Then measure the
Compiled by: Chielo monceda
angle form by the foot and the interior leg.
Intrauterine position and congenital
deformities can influence the sign.
the newborn sitting position and noting the
degree of head lag. Total lag is common in
newborns up to 43 weeks gestation, whereas
post term newborn (42+weeks) holds their
heads in front of their body lines. Full – term
newborn can support their heads
momentarily.
evaluated by holding the newborn prone on
the hand and noting the position of the head
and the back and degree of flexion and the
arms and legs.
NEWBORN CARE COMPETENCIES
❖ Dry the baby for at least 30seconds, wipe
eyes, face, head, front, back, arms and legs
❖ Remove the wet cloth § Check breathing, do
not ventilate unless not breathing and do not
8
 Immediate Newborn Care
suction unless with secretions but first
suction the mouth first.
❖ Do APGAR scoring immediately then after 5
minutes.
❖ If the baby is breathing and crying, position
the baby prone on the mother’s abdomen
then cover with cloth, cover the head with
bonnet and place ID band on ankle.
❖ Remove the first set of gloves then when the
umbilical pulsation is gone, clamp the cord
using sterile clamp at 2cm from the umbilical
base then clamp again at 5cm from the base
then cut the cord close to the clamp.
❖ Check for presence of 2 arteries and one
vein.
❖ Then allow skin to skin contact with the
mother, observe feeding cues and
encourage the mother to feed the baby
through her breast.
❖ After the first full breastfeeding, proceed to
weighing, eye care, injection of Vitamin K
and examination. Check temperature per
rectum for patency.
EYE CARE/CREDE’S PROPHYLAXIS
❖ Eye Prophylaxis: Erythromycin; Ophthalmic
Ointment, 0.5%, and Tetracycline
Ophthalmic Ointment, 1%
❖ Action: These antibiotic ointments are
bacteriostatic and bactericidal. They provide
prophylaxis against Neisseria Gonorrhoeae
and Chlamydia Trachamatis.
❖ Indication: These medications are applied to
prevent ophthalmia neonatorum in
Compiled by: Chielo monceda
newborns of mothers who are infected of
gonorrhea and conjunctivitis in newborn of
mothers infected with chlamydia.
❖ Do Crede’s prophylaxis and apply
terramycin eye ointment on both eyes.
❖ Retract lower eyelid outward to instill ¼ inch
strand of ointment along the conjunctiva
surface.
❖ Record observation done and medications
given.
❖ Report for any abnormalities noted.
INJECTION OF VITAMIN
❖ Synthesize through the action of intestinal
flora and is responsible for the formation of
clotting factors.
❖ Newborn have less coagulation ability so
vitamin K is usually administered to prevent
from bleeding.
❖ Single dose of 0.5 mg (for premature) – 1.0
mg (for FT), IM 1st hr. of life
INJECTION OF VITAMIN K ON THE VASTUS
LATERALIS
❖ Cleanse the area thoroughly with alcohol
swab and allow skin to dry. Bunch the tissue of
the upper thigh (vastus lateralis muscle) and
quickly insert a 25G 5/8-inch needle at 90
degrees angle to the thigh. Aspirate and t h e
n slowly inject the solution to distribute the
medication evenly. Remove the needle and do
not massage the site.
HEPATITIS B VACCINE
❖ Vaccine must be given within 12 hrs. after
birth
9
 Immediate Newborn Care
❖ 2nd dose at 1 month ✓ Weighing scale and goose neck lamp
❖ 3rd dose at 6 months 2. Prepare the room temperature of the delivery
❖ Infants with mothers positive for Hep B room. Room temperature should be 25-28 C.
surface antigen (HBsAg) should also receive 3. Notify appropriate staff.
Hep B immunoglobulin (HBIG) 4. Arrange needed supplies in linear fashion.
5. Check resuscitation equipment.
6. Wear face mask and bonnet properly.
7. Wash hands with clean water and soap.
8. Don’t double glove just before delivery.
9. Within first 30 seconds:
- Dry the newborn thoroughly for at least
30 seconds.
- Do a quick check of breathing while
drying. (Do not suction unless the
mouth/nose are blocked with secretions
1. Prepare all equipment or other materials)
- Cebu Puericulture Center and Maternity - Wipe the eyes, face, head, front and back,
Inc. (CPCMHI) arms and legs. (DO NOT wipe off the
✓ Cord clamp vernix caseosa)
✓ Sterile OC (3-4 pcs) - Remove the wet cloth.
✓ Sterile cotton balls (2-3 pcs) 10. After 30 seconds, if newborn is breathing and
✓ Mayo Scissors crying,
✓ Bulb Syringe - Position the newborn prone on the
✓ Tape measure mother’s abdomen or chest.
✓ Vitamin K ampule - Cover the newborn’s back with a dry
✓ Terramycin eye ointment tube blanket.
✓ ICC Syringe - Cover the newborn’s head with a
✓ Baby diaper bonnet/cap
✓ ID band – Blue (male), Pink (female) 11. After 1-3 minutes, properly time cord
✓ Receiving blanket clamping.
✓ Digital Thermometer - Remove the first set of gloves.
✓ Baby’s cap - After the umbilical pulsations have
✓ Weighing scale stopped, lamp the cord using a sterile
✓ Goose neck lamp plastic clamp at 2cm from the base.
- Vicente Sotto Memorial Medical Center - Do not milk the cord towards the baby.
(VSMMC) - Clamp again at 5 cm using Kelly forceps
✓ Cord Clamp from the base.
✓ Sterile OS (3-4 pcs) - Cut the cord close to the plastic clamp.
✓ Sterile Cotton balls (2-3 pcs) 12. Place the identification band on ankle (not
✓ Cord cuter wrist) of corresponding gender.
✓ Tape measure - CPCMHI – left ankle
✓ Vitamin K ampule - VSMMC – both ankles
✓ Terramycin eye ointment tube - Leave the newborn in skin-to-skin
✓ ICC Syringe contact.
✓ Baby diaper - Observe for feeding cues, including
✓ ID band – Blue (male), Pink (female) tonguing, licking, rooting.
✓ Receiving blanket - Point these out to the mother and
✓ Digital Thermometer encourage her to nudge.
✓ Baby’s clothes § Baby’s blanket

10
Compiled by: Chielo monceda
 Immediate Newborn Care
13. . After 90 minutes, remove the newborn from
mother’s abdomen.
14. Transfer the newborn to the work table.
15. Weigh the newborn to the work table.
16. Perform physical assessment of the newborn
and do APGAR scoring.
- Perform Anthropometric measurement
- Head circumference
- Chest circumference
- Mid-arm
- Body length
17. Take the rectal temperature
18. Inject Vitamin K
- CPCMHI – left thigh
- VSMMC – right thigh
19. Apply eye prophylaxis.
20. Put on baby’s clothes.
21. Wrap the baby with baby’s blanket
22. Obtain heart rate and respiratory rate.
23. Show the baby to the mothers. Latch on the
baby to the mother’s breast.
24. Documentation immediately after cord care
and latch on.
25. Do after care.

11
Compiled by: Chielo monceda