newborn assessment and care 1

suctioning infant at delivery

used to remove secretions from mouth and nose

bulb suction

non-meconium

suction catheter

meconium

meconium suctioning

only done if infants are pale, limp, and have no respiratory effort and no muscle tone

stabilization at delivery

• dry and stimulate baby to cry (slap sole of foot, flick heel, rub back) which helps open up the airway and clear secretions

• warm (kangaroo care/warmer)

  • warm blankets/hat

identification

• moms fingerprints and baby’s fingerprints

• matching identification bracelets with mom

apgar scoring system

looks at how well baby is transitioning to extrauterine life

• done at 1 minute and 5 minute mark

• includes heart rate, respiratory effort, muscle tone, reflex irritability, and color

newborn pulse

• 110-160 bpm (during sleep as low as 80; vigorous crying up to 180)

• count apical pulse for 1 full minute

newborn temperature

97.7-99.5 axillary

newborn respirations

30-60 breaths/min (count for full minute)

initiation of respirations in newborn

• mechanical changes

• chemical changes

• thermal changes

• sensory changes

mechanical changes

during birth process, fetal chest is compressed and squeezes fluid out

• at time of delivery, 80-100 mL of fluid remains in lungs of full term infant

  • decreased production of lung fluid 2-4 days prior to delivery

chemical changes

• first breath is triggered by increased Pco2 and decreased pH and Po2

• trigger brains respiratory center

• natural result of normal vaginal birth

thermal changes

• decrease in environmental temp after birth

• newborn responds with increase in respirations

• avoid prolonged exposure to cold = cold stress/apnea

sensory changes

• light

• sounds

• gravity

• touch

respiratory rate

• normal respirations for first 2 hours - 60-70 breaths/min

• after first 2 hours - 30-60 breaths/min

periodic breathing

when baby can have pauses in respiration for up to 20 seconds

• considered normal

apneic breathing

baby’s that have greater than 20 second breaks in breathing

• considered abnormal

signs of respiratory distress

• nasal flaring

• intercostal or xiphoid retractions

• expiratory grunting or sighing

• seesaw respirations

• tachypnea

clearing newborn airway

• bulb suctioning

• chest percussion

  • help loosen up secretions to cry/suction out

transient tachypnea of the newborn

progressive respiratory distress noted by at least 6 hours of age until 72 hours in more severe cases

causes of transient tachypnea

• LGA

• late preterm infants

• maternal oversedation

• maternal bleeding

• prolapsed cord

• breech birth

• maternal diabetes

• C/S

treatment of transient tachypnea

• chest xray: hyperexpanded lungs, clear by 72 hours

• oxyhood - less than 40%, O2 cannula 2 L

• possible IV fluids or tube feedings

  • due to elevated respiratory rate to prevent aspiration

respiratory distress syndrome (RDS)

breathing problem that affects preterm babies caused by fewer number of alveoli at birth

• alveoli are last to form during development of lung and are critical to extrauterine life because of gas exchange

• younger the baby = fewer alveoli, more severe RDS is likely to be

stimulating surfactant development in alveoli

• give mother betamethasone

• rupture of membranes

treatment for RDS

• oxygen therapy via CPAP, mechanical ventilation, or high frequency ventilation

• surfactant administration

• thermoregulation via incubator

• ECMO (modified heart/lung machine that allows baby’s lungs to rest/heal)

newborn circulation

• increased systemic vascular resistance

• decreased pulmonary vascular resistance

  • enhances perfusion of body systems

• closure of foramen ovale (area between atriums) within 1-2 hours after birth

• closure of ductus arteriosus

• closure of ductus venosus

assessing newborn pulses

• brachial pulse

• femoral pulse

heat loss

• convection

• radiation

• evaporation

• conduction

convection

loss of heat from warm body surface to cooler air temp

radiation

heat is transferred from body surface to cooler surface nearby (not direct contact)

evaporation

loss of heat when water turns to vapor

conduction

heat is transferred from body surface through direct contact with cooler surface or object

causes of heat loss

• large surface area to body mass ratio

• decreased subcu fat

• increased body water content

• immature skin leading to increased evaporative water

• poorly developed metabolic mechanism for responding to thermal stress (shivering)

• altered skin bloodflow

preterm babies and thermoregulation

at even greater risk because they usually

• lack a flexed posture reserving heat

• very thin skin with capillaries close to surface

signs and symptoms of hypothermia

• acrocyanosis and cool, mottled, or pale skin

• hypoglycemia

• transient hyperglycemia

• bradycardia

• tachypnea, restlessness, shallow and irregular rr

• respiratory distress, apnea, hypoxemia, metabolic acidosis

• decreased activity, lethargy, hypotonia

• feeble cry, poor feeding

• decreased weight gain

causes of hyperthermia

• overheating from incubators, radiant warmers, or ambient environmental temp

• maternal fever

• maternal epidural anesthesia

• phototherapy lights, sunlight

• excessive bundling or swaddling

• infection

• CNS disorders

• dehydration

symptoms of hyperthermia

• tachycardia, tachypnea, apnea

• warm extremities, flushing, perspiration (term newborns)

• dehydration

• lethargic, hypotonia, poor feeding

• irritability

• weak cry

consequences of hyperthermia

• hypotension and dehydration (result of increased insensible water loss)

• seizures and apnea

• hypernatremia

• respiratory distress

managing hyperthermia

• adjust environmental conditions

• move away from source of hear and undressed partially or fully

• lower air temp in incubator

• breastfeed to replace lost fluids

brown fat

• starts to form around 26-28 weeks gestation and will continue until about 3-5 weeks after birth

• form of non-shivering thermogenesis to control body temp

kangaroo care

• good for bonding

• heat loss protection

• promote breastfeeding

• stimulates breasts

radiant warmers

• used for C/S babies, unstable babies, and for close assessments instead of kangaroo care

newborn weight

average weight of 2405 g at term (7lb 8oz)

• range of 5.8 lbs-8.13 lbs

• weight loss - term: 5-10% of birth weight

  preterm: 15% of birth weight

• infants maintaining their weight will typically double birth weight by 6 months and triple birth weight by 1 year

newborn length

average length of 50 cm (20 in)

• range - 18-22 inches

skin color assessment

• acrocyanosis

• central cyanosis

acrocyanosis

blue tinge of the hands and feet after birth (up to first 24 hours)

• centrally pink

• considered normal finding

central cyanosis

baby’s body is blue or pale

• signs that baby is not perfused and oxygenated well

baby’s position

flexed extremities: term

extended extremities: pre-term

premature skin (<28 weeks)

• thinner

• not many lines on soles of feet

full-term skin

• more creases in the sole

• skin will not appear transparent

post-term skin (>42 weeks)

• dryness and peeling

head

proportionally larger than body

• approx ¼ of body size

fontanelles

• anterior

• posterior

• should be soft and flat

• sunken = dehydration

• bulging = vigorous crying or increased intracranial pressure (brain, blood, or fluid)

molding of the head

cranial bones shift to fit through pelvis

• looks like conehead

• normal finding, should return to normal after 24 hours of delivery

cephalohematoma

collection of blood resulting from ruptured blood vessels between cranial bone and periosteum membrane

• does not cross sutures

• increased jaundice risk (increased bilirubin from breakdown of blood cells)

• higher risk of anemia and hypotension

caput succedaneum

soft tissue swelling in localized soft area of scalp

• crosses suture lines

• feels soft and mushy

eye variations

• subconjunctival hemorrhage

• transient strabismus

• dolls eye

subconjunctival hemorrhage

• found in the sclera

• caused by changes in vascular attention or ocular pressure during birth

• will resolve itself

transient strabismus

baby can be cross eyed

• can happen as eyes finish development

• not usually treated right at birth

dolls eyes

if you turn the head of the baby, eyes will move in the opposite direction

• due to underdeveloped head-eye coordination

ears and mouth

• placement of ears

  • edge of eye should align with top of ear

  • low set might indicate down syndrome

• ear form and cartilage distribution

  • preterm - relatively shapeless and flat, no recoil

  • term - some cartilage and slight incurving of upper pinna, good recoil

• mouth assessment

  • assess sucking ability

  • cleft lip and palate

    • greatest immediate risk is aspiration of feedings

  • precocious teeth

  • epstien’s pearls

    • small, harmless cysts made of keratin that will eventually go away

back

assess spine

• sacral dimple (pilonidal dimple)

  • indentation or pit at base of spine (sometimes accompanied by tufts of hair)

  • if not closed, need ultrasound to rule out spina bifida occulta and tethered cord syndrome

spina bifida occulta

spine doesn’t close properaly around spinal cord

tethered cord syndrome

tissue attached to the cord limits movement

• causes weakness, numbness, and bladder and bowel problems

lanugo

fine, downy hair that covers body

• may notice more with prematurity or certain ethnicities

assessing breast bud

• nipple should be symmetrical and even

• preterm babies often do not have a very formed breast bud

• term - measured between 0.5-1 cm

umbilical hernia

usually spontaneously closes at age 2, so it is not something normally requires surgical intervention right after birth

• check if umbilical cord has three vessels (1 vein 2 arteries)

male genitalia

preterm - small scrotum, few rugae, testes palpable in inguinal canal

term - testes generally in lower scrotum, which is pendulous and covered with rugae

female genitalia

preterm - clitoris more prominent, labia majora small and widely separated

term - labia majora cover labia minora and clitoris

male genitalia variations

• hypospadias

  • urinary meatus is located on ventral surface of penis

• epispadias

  • urinary meatus located on dorsal surface of penis

• phimosis

  • opening of foreskin that is small and can’t be retracted

• hydrocele

  • collection of fluid around testes (in scrotum)

• cyptorchidism

  • failure of testes to descend

female genitalia variations

• pseudomenstruation

  • vaginal discharge tinted with blood caused by withdrawal of maternal hormones and will resolve

vernix caseosa

white, cheesy substance that covers baby in utero to lubricate newborn’s skin

• older the gestation, less vernix caseosa (possibly only in creases)

milia

exposed sebaceous glands that are white spots usually on face and nose

• clear spontaneously within about a month

telangiectatic nevi (stork bites)

pale pink or red spots found on eyelids, nose, lower occipital bone, and nape of neck

• usually fade by age 2

mongolian spots

birth marks often found in non-caucasian babies often on back or buttocks

nevus flammeus (port wine stain)

capillary angioedema below the epidermis

• usually non-elevated and looks red to purple

• usually on face and does not go away or face

strawberry mark

enlarged capillaries in dermal and subdermal layers

• usually raised, dark red, and have a rough surface

• type of birth mark

• usually grow rapidly but later may shrink and resolve spontaneously

fractured clavicle

• could be related to birth injury, shoulder dystocia, large baby, or difficult delivery

right erb’s palsy

• result from injury to 5th and 6th cervical root of brachial plexus

• portion of arms have nerve damage

• usually take a few months to return if its minimal trauma, but could be partial paralysis if there was moderate trauma

simian crease

single palmar crease on one or both palms that indicates conditions like trisomy 21

syndactyly

webbing inbetween toes or fingers

polydactyly

extra toes or fingers

club foot

foot will not turn to midline position or realign

• resistance to movement of foot to midline indicated true club foot

dysplasia of hip

lines of thigh and buttocks do not match bilaterally, more creases on one side

plantar creases

term - more sole creases

preterm- little to no sole creases

barlow (dislocation) maneuver

used to check for hip dysplasia

• add depth to newborns thigh and apply gentle downward pressure and feel for a hip click

ortolani maneuver

puts downward pressure on hip then inward rotation

• if hip is dislocated, this will force femoral head back into acetabular rim with noticeable clunk