Newborn Circumcision: Procedure and Care

Newborn Circumcision

• Circumcision is a procedure with specific policies and recommendations
• The decision to perform a circumcision is made by the parents
• Procedure Types:
  • Yellen (Gomco) or Mogen clamp
  • Plasti-Bell device
    • If the Plasti-Bell device remains in place after 8 days, the provider must be notified
    • Following bleeding, use a loose diaper
    • Dark red coloration may be present
    • Yellow exudate indicates healing
    • Monitor for signs of infection
    • Sponge baths can be given
• Methods for Procedural Pain Management:
  • Skin-to-skin contact
  • Breastfeeding
  • Cuddling
  • Rocking
• Monitor the newly circumcised infant for bleeding or infection (Infection is uncommon in the hospital)
• Parents should understand the difference between expected and unexpected findings such as yellow exudate
• Post-Circumcision Care:
  • Apply vaseline and gauze to prevent sticking to diaper and reduce trauma
    • Continue for 4-10 days (avoid use with plasti bell)
    • Avoid wrapping the meatus
  • Cleanse gently with water for the first 3-4 days
    • Dab with water and avoid rubbing to prevent bleeding
  • Apply pressure to prevent bleeding in the first hour
  • Loosen the diaper when bleeding stops
  • Then use loose diapers

Newborn Voids

• 2-6 voids per 24 hours is expected for the first 1-2 days after birth
• 6-8 voids per 24 hours is expected 3-4 days after birth

Newborn Vital Signs

• Vital signs and assessments are done every 12 hours
• Heart Rate (HR):
  • Initially 160-180 bpm for the first 30 minutes
  • Then 120-160 bpm
• Respiratory Rate (RR): Irregular and shallow, 30-60 breaths per minute
• Blood pressure is usually not taken

Jaundice

• Jaundice is yellowing of the skin
• Severe jaundice can lead to kernicterus
• Kernicterus is a type of brain damage caused by high bilirubin that can leads to athetoid cerebral palsy, hearing loss, and seizures
• Risk factors for jaundice include ABO incompatibility, Rh incompatibility, and ethnicity
• Assessment for Jaundice:
  • Watch for dangerous signs like fussiness, difficulty eating, or irritability in infants
  • Monitor dark-colored urine or stools, fever, loss of weight, and appetite
  • Consider gestational age, ethnicity
  • Check sclera of the eye and mucous membranes
• Care Management:
  • Bilirubin binds to protein from consumed food and is excreted via GI
• Physiological jaundice is normal, appears after 24 hours and resolves in about a week
• Pathologic jaundice is seen in the first 24 hours after birth
• Early Onset/Late Onset:
  • Breastfeeding does not directly cause jaundice
  • It can occur due to ineffective breastfeeding which contributes to hyperbilirubinemia
    • Early onset appears 2-5 days of life
    • Late onset (breast milk jaundice) appears around 10 days

HIV Exposure

• Routine prenatal antibody testing is done during the first visit and in the third trimester
• PEP (Post-Exposure Prophylaxis) is also a consideration
• Provide baseline and prophylactic treatment post delivery

Newborn Infection

• Neonates have immature immune systems
• IgG (Immunoglobulin G):
  • Only immunoglobulin, transfers passive immunity from mother to fetus
  • Nadir (lowest point) occurs at 3–4 months
  • Endogenous production begins around 10–12 months (can start as early as 6 months)
• IgA:
  • Present in colostrum (breast milk)
  • Provides mucosal protection after birth
  • Does not cross the placenta
• IgM:
  • Does not cross the placenta
  • Suggests possible in utero infection if present in newborn
• Congenital Infections:
  • Route of infection:
    • Prenatal (in utero): placental transfer or amniotic fluid
    • Intrapartum: occurs during delivery
    • Postnatal: exposure after birth
  • Placental transfer of infection involves pathogens such as HSV, CMV, and Rubella
    • Placenta transfers infections directly to fetal circulation
• Common Sites of Infection:
  • Localized infections affect conjunctiva and oral cavity
  • Generalized/Systemic Infections affect the upper airway and gastrointestinal (GI) tract
• Varicella in pregnancy:
  • Most women are immune
  • Transmission rate to fetus is 25% if mother is infected
  • Early in utero transmission results in fetal death
  • Most serious when mother develops varicella 5 days before to 2 days after delivery
    • May have insufficient time for maternal antibody transfer leading to high neonatal death rate
• Prevention:
  • Varicella-Zoster Immune Globulin (VZIG) is given to exposed newborns or susceptible pregnant women

Hemolytic Disease of Newborn

• Alloimmunity occurs when fetal erythrocyte (RBC) antigens stimulate a maternal immune response
  • The maternal immune system recognizes fetal RBC antigens as foreign and produces IgG antibodies that cross the placenta
• Immune Response Mechanism involves maternal IgG antibodies specific to fetal RBCs
  • Antibodies cross the placenta and bind to fetal RBCs causing agglutination (clumping) and erythrocyte lysis (destruction)
• Fetal RBC destruction causes anemia (due to volume decrease), hemolysis, and hyperbilirubinemia
• Consequences of Hemolysis:
  • Increased RBC destruction leads to elevated bilirubin levels (jaundice) and hemolytic anemia
• Fetal response is characterized by increased production of immature RBCs (reticulocytes)
  • This condition is known as erythroblastosis fetalis and involves severe anemia, cardiac decompensation, cardiomegaly (enlarged heart), hepatosplenomegaly (enlarged liver and spleen), and hypoxia
• Causes of Alloimmunization:
  • ABO incompatibility is more common and typically less severe
  • Rh incompatibility is less common and more severe
    • Can cause maternal sensitization (formation of antibodies against fetal Rh antigen)
    • Sensitization may occur during first pregnancy and worsen in subsequent ones
• Treatment options are based on elevated serum bilirubin levels, low hematocrit (indicator of anemia), and high reticulocyte count (bone marrow response)
• Rh immune globulin prevents maternal sensitization in Rh-negative mothers
• O-negative blood transfusion given via umbilical vein in severe cases (intrauterine transfusion).
• Postnatal interventions may include:
  • Phototherapy for hyperbilirubinemia
  • Exchange transfusion if bilirubin or anemia is severe

Heroin Exposure

• Placental Transfer involves opioids that cross the placenta and affect fetal development and health
• Maternal complications associated with opioid dependence during pregnancy include miscarriage, preterm labor/birth, placental abruption, chorioamnionitis, intrauterine growth restriction (IUGR), and fetal distress
• Neonatal drug withdrawal, also known as Neonatal Abstinence Syndrome (NAS) or Neonatal Opioid Withdrawal Syndrome (NOWS)
  • Symptoms may be delayed up to 72 hours post-birth
  • Severity increases when heroin is used closer to delivery
• S/S:
  • Acute Symptoms (may persist for weeks):
    • CNS Hyperirritability, restlessness, tremors, high-pitched cry, increased muscle tone, exaggerated Moro reflex and seizures (seen in 1–2% of heroin-exposed neonates; ~7% in methadone-exposed)
  • GI: feeding problems or diarrhea
  • Respiratory: distress
  • Autonomic instability includes sweating and nasal stuffiness
  • Subacute symptoms (may persist 4-6 months) as irritability, disturbed sleep patterns, hyperactivity, feeding difficulties, and hypertonia
• Treatment for NAS:
  • Determined by Finnegan score and clinical symptoms
    • Medications given: morphine or phenobarbital
    • Provide with feeding assistance, continuous monitoring and comfort measures (swaddling, soothing)

Opioids Exposure/NAS Scoring

• The Finnegan Neonatal Abstinence Scoring System is an assessment tool that evaluates 21 withdrawal symptoms, including tremors and irritability
• Score interpretation: 0–8 Mild withdrawal, 9–12 Moderate withdrawal, 13+ Severe withdrawal

Newborn Temperature

• Promote Skin to skin-maternal bonding (prone abdomen/chest)
• Perform routine assessments while infant has a cap and wet/warm blankets to help maintain heat
• Blood glucose will be higher in the first 2 hours compared to non skin to skin
• Consider breastfeeding duration and cardiac stability because of their effect on the body temperature

Cephalhematoma/Caput/Subgaleal

• Cephalohematoma (blood): caused by collection of blood between a skull bone and its periosteum; does not cross cranial suture
  • Is firmer and better defined compared to caput succedaneum and resolves in 2-8 weeks
  • Hematoma resolution can lead to hemolysis which causes hyperbilirubinemia
  • Observe and monitor
  • Treatment depends on bilirubin level (usually none)
• Caput (edema) crosses suture line
• Subgaleal hemorrhage occurs because of accumulation of blood between skull and scalp and crosses suture line
• Obtain baselines to monitor progression

Late Preterm Newborn Assessment and Interventions

• Refer to chart contained in text for assessment for:
  • Respiratory Distress, Thermal Instability, Hypoglycemia, Jaundice, and Feeding Problems

Clinical Signs of Sepsis

• Respiratory: Apnea, tachypnea, grunting, nasal flaring, retractions, cyanosis, decreased O2, and metabolic acidosis
• Cardiovascular: Decreased CO, tachycardia or bradycardia, arrhythmias, hypotension, decreased perfusion, with poor peripheral pulses, delayed cap refill, cold clammy or mottled skin
• Neuro: Temp instability (hypothermia/fever), lethargy, hypotonia, jitteriness, irritability, seizures, bulging fontanels, and high pitched or abnormal cry.
• GI: Feeding intolerance (decreased suck strength and intake increasing residuals, vomiting, diarrhea, abdominal distention, and hypoactive bowel sounds

Asymmetric SGA-small for Gestational Age

• Characteristics include potential for normal growth, less than 10th percentile @ term, lack of expected growth pattern, and head/brain are expected size
• SGA & IUGR (Intrauterine growth restriction) are different
• SGA infants are healthy, but show slow growth rates
• IUGR is related to environmental and/or genetic factors that affect fetal growth, such as infections, teratogens or chromosomal abnormalities
  • May lead to risk of neonatal morbidity including respiratory distress, intraventricular hemorrhage, sepsis, and neonatal death

Eye Ointment-EES Erythromycin Ophthalmic Ointment

• Given to prevent ophthalmia neonatorum, eye infection in newborns
• Indication: Prevents neonatal conjunctivitis caused by Neisseria gonorrhoeae and Chlamydia trachomatis
• Action: Dependent on concentration, can be either Bacteriostatic or bactericidal
  • Inhibits protein synthesis in susceptible bacteria
  • Reduces risk of eye infections that can lead to blindness
• Dosage is 0.5% ophthalmic ointment
  • Apply 1 cm ribbon of ointment to each lower conjunctival sac (1-2hrs after birth)
• Adverse reactions may include mild eye irritation or redness, blurred vision temporarily, and rare hypersensitivity reactions
• Nursing considerations include applying within 1–2 hours of birth after application
  • Do not rinse eyes
  • Inform parents that blurring of vision could occur.
  • Monitor for allergic reaction
  • Required by law

First Period of Reactivity

• Lasts up to 30 minutes after birth
• HR increases to 160-180 bpm while respirations are irregular and shallow (60-80 bpm)
• Monitor for tachycardia and tachypnea for >1 hour
• Where you want the mom and baby to bond and baby to latch

Period of Decreased Responsiveness

• This period lasts from 60-100 minutes, when respirations shallowed but unlabored
• Occurs After the first period of reactivity and baby will begins to pink up
• Second period of reactivity is signified by bowel sounds becoming more pronounced

Physical Adaptations

• Occurs 2-8hrs after birth and lasts from 10 minutes to several hours
• S/S:
  • Tachycardia, tachypnea, increased muscle, and mucous production
  • Needs to be suctioned out and meconium typically passed
• Respiratory: Initiation of breathing/establishing respirations
  • Chemical Factors is caused by cord clamping when uterotansplacental oxygenation: fetus is receiving oxygen through mom via placenta and cord
• Mechanical compression has little effect, the longer baby is in utero, the better because surfactant begins around 28 weeks ( want at least 34-35 weeks)
• Crying will keep the alveoli open and decreases surface tension on the lungs
• Thermal Factors environment doesn't have to be to cold or to warm
• Sensory Factors: Suction initiates breathing
• Establishing "ADEQUATE" respirations is critical
• Chect wall contraction if fluid is in the lung but then it is mechanically removed C-section cause's/TTN a transient tachypnea as there is no compression with the c-section
• If a baby pauses in breathing it should be less then 20 seconds or it is is defined as apnea

Cardiovascular Problems

• Persistent tachycardia can indicate anemia, hypovolemia, sepsis, or hypothermia - GBS positive women should be on active surveillance for infection and given antibiotics
• Persistent bradycardia can indicate heart block or hypoxemia Skin color: pallor, cyanosis - Small opening through ductus may result in cyanosis

Renal

• An infant who has not voided by 24hrs needs assessment for fluid intake, amount of soiled diapers, bladder distention, restless/ crying
• Not uncommon to run renal scan
• Not uncommon for mom to receive rhogam as 23 weeks if need for invasive procedure at 28 weeks again

GI

• Feeding behavior is related to gestational age, neuromuscular maturity, mothers medications during labor and birth, type of initial feeding, aspiration
• Brestfeeding is important in establishing that microbiome in NB
• Assess for digestion, signs of GI issues, Meconium and stools
• Fluid and electrolyte balance is 10% and may not be uncommon to loose 5% of weight with formula or 10% with breast but both will gain back
  • Signs of renal issues

Temp and Glucose

• Encourage Skinto skin, prone, routine assessment, and put cap, wet and dry towel
• BS: the NB does not need it if skinto skin
  • Breast during, cardiac issues

Nasal Blockage

• Nasal brathers but with blockage may breath with nose but mouthbreaht is not intact until 3 weeks and can advance to cyanosis
• Nasal distres, subcostal retraction can indicate nicu admission
• Assess HR which shd be done for a full Minute, there is some high hematacrit so volume will change

Thermoregulation

• Thermogenic system. Goal of care is to provide a neutral temp
  • Next to est resp and circulation heat regulation is vital to survival.
  • In the first 12 hrs the body tires to regulate
• Newborns have larger body surface to body weight ratio than adults
• Environment temp changes affect blood flow adn centers in hypothalamus
• Brown Fat can cause higher vascular flow and burn 100% capacity.
• Preterm at risk for hypothermia and may need isolate Convection is the body touching something cooler and can regulate temp form 22-26c
• Rad: touching somthing in Proximity which happens a lot at the window
• Evap: Heat is loss by liquid and sweat
• Conduction is heat by body being surface
• Term NB flexion helps guards against eat loss b/c body contracts blood vessels and conserves heat
• NB: adults preduce heta by shivering but in NBs not as much NB production by metabolism of " BROWN" Fat

Temperature Imbalances

• If not regulated may leat to cold stress and further death Hypothermia: blood constrictor occurs but with increased heat the RR increases as does the oxygen consumption for brain nad heart
• If they cannot maintain po2 they may have right to left shuit
• The basic rate will also increase during cold stress
• Excess acid may cause Hypoglycemai and be asymptomatic
• Infants wit hypo thermia ma have accrocynosis, tachycardia increase'd RR/ apnea and decreased compation

Hyperthermia

• Less frquent but must be corrected for by less blankets etc The infant is pale with small surface isssues

Skin/Rashes

• Bath needs to be done in warm water and room with lots of wraps Acrosynosis is normal in first 24 hours as protective measure
• Vernix is white cheese like with lots fluid and premies are more prone
• Erythema is a common rash

Assessment of Birthmarks in Newborns

• Stork bites are caused capillary vessels and fade with time
• Hemangionms have rapid growth
• The is common for Mongolian spots and peeling with term babies
• Nevi can fade

Sleep States

• Sleep is deep and wake
• Wake include drowsiness

PPH & Interventions

• Causes:*
• Tone: Uterine Atony (most common cause). Uterus fails to contract. Increased risks:
  • High parity
  • Hydramnios
  • Macrosomia
  • Obesity
  • Multifetal gestation
• Tissue: Retained Placenta or Abnormal Adherence
  • Retained Placental fragments.
  • Placenta Accreta – Slight myometrial penetration.
  • Placenta Increta – Deep myometrial penetration.
  • Placenta percreta – Through the wall: other organs involved.
• Trauma: Lacerations or Hematomas – to the cervix, vagina, or perineum.
• Thrombin: Coagulapathies. Pre-existing or acquired.

Interventions

• Use standardized protocols and regular emergency drills
• If there in vaginal pressure and blood
  • Fundal massage
  • Assesses skin
  • Call lab and team for help

Tone/Trauma/Thrombin/Tissue

• Causes issues with atony to lacerations to issues of hematomas such as the perineum.
• Meds: Oxytocin, meth
• Make sure that that is maintained and that they void If bleeding, assess/admin/ monitor/empty bladder/ provide support.

PostPartum and Elevated Readings

• Watch out for postpartum levels in relation with PPH as the PPH is is the the major cause
• Infections can occur if longer than 38c with discharge
• Trauma is very important for for 2nd/3rd/4th

Mastisis

• Can have from lots breast or little pumping so use heat and proper latch

Baby Care

• Follow parental cues and ensure for follow up's
• Use correct bulbsyringe and give a 20 minute break
• And to use cloth safely with cord in proper area

Other

• Magnesium and Oxytocin may cause issues
• Coag: continous bleeding Assess lung sounds and breath