Newborn Immediate Care and APGAR Scoring

Immediate Care After Birth

• Initial assessment completed in delivery area
• Maintain a patent airway and respirations.
• Assign Apgar scores.
• Obtain and monitor vital signs.
• Maintain thermoregulation.
• Add ID bands to infant, parents, and security tag.
• Assess the 3 vessel umbilical cord.
• Take footprints.
• Take measurements and weight.
• Promote bonding.
• Documentation.

APGAR Score

• Two points are allotted in each category and assessed at 1 and 5 minutes after birth, repeated at 10 minutes
• A = Appearance (color)
• P = Pulse (heart rate)
• G = Grimace (reflex irritability)
• A = Activity (muscle tone)
• R = Respiratory (respiratory effort)

Respiratory System

• Respiratory system adjusts from a fluid-filled intrauterine environment to a gaseous extrauterine environment.
• Surfactant reduces surface tension to prevent alveolar collapse.
• Normal respirations are 30 to 60 breaths per minute; irregular, shallow, unlabored; short periods of apnea (<15 seconds); symmetrical chest movements.

Cardiovascular System

• Heart rate should be 110-160 beats per minute.
• Apical pulse should be assessed for one full minute.
• BP should be 60-80 mmHg systolic and 40-50 mmHg diastolic.
• Delayed umbilical cord clamping increases blood volume and blood pressure.

Newborn Temperature Regulation

• Thermoregulation maintains balance between heat loss and production.
• Newborns are predisposed to heat loss due to thin skin, blood vessels close to the surface, large body surface area, lack of subcutaneous fat, and lack of shivering ability.

Mechanisms of Heat Exchange

• Conduction is the transfer of heat when two objects are in direct contact.
• Convection is the flow of heat from body surface to cooler air.
• Evaporation is the loss of heat when liquid is converted to a vapor.
• Radiation is the loss of body heat to cooler, solid surfaces in close proximity, not in direct contact.

Transition to Extrauterine Life: Thermoregulation

• Goal is to promote a neutral thermal environment (NTE).
• Body temperature is maintained without increasing metabolic rate or oxygen consumption.
• Brown adipose tissue (brown fat) is important for thermogenesis.
• Cold stress is ineffective thermoregulation.
• Contributing factors include decreased subcutaneous fat, large body surface, and decreased brown fat in preterm infants.
• Cold stress signs include: low temperature, weak cry, decreased tone/lethargy, respiratory distress, cool/mottled skin, poor feeding, and hypoglycemia.

Renal System

• There is limited ability to concentrate urine and reduced glomerular filtration rate.
• Newborns are susceptible to dehydration and fluid overload.
• This affects ability to excrete drugs.
• Many newborns void right after birth when they are born.
• Typically void within 24 hours of birth.
• For the first 2 days void, 2-6 times/day, then increases to 6 to 8 times /day ***
• Pseudomenstruation occurs due to withdrawal of maternal hormones in female neonates.
• "Brick dust spots" are urates, and normal.

Gastrointestinal System

• GI system is still immature, but has ability to transport nutrients.
• Bowel sounds are audible a short time after birth.
• Newborns adapt to bacterial colonization of the gut.
• Nutrition is required for the production of Vitamin K
• Regurgitation of feeding is common due to immature cardiac sphincter and nervous control of stomach.
• Weight gain is typical 5-10% weight loss in the first week of life.

Characteristics of Newborn Stools

• Meconium is greenish black and viscous within 24 to 48 hours.
• Transitional stools are greenish brown to yellow brown on day 3 ,thin and less sticky than meconium.
• Milk stools occur by day 4.
• Breast-fed newborns have yellow/gold, mustard/cottage cheese, sour milk smell stools.
• Formula-fed newborns have pale yellow to light brown stool that is of firmer consistency with unpleasant odor.

Hepatic System

• Liver assumes function of placenta and is important for iron storage
• If maternal iron intake is adequate, the newborn should have enough iron stored in the liver to last the first 6 months.
• The newborn relies on Carbohydrate metabolism.
• Glucose is the essential fuel for brain metabolism that is the main source of energy for the first few hours after birth.
• Liver releases glucose from glycogen stores for the first 24 hours, initiate early feedings to help stabilize glucose levels.

Hypoglycemia

• Glucose regulation is an issue during transition.
• Impaired ability to generate glucose from glycogen stores
• Slower postnatal glucose increase
• Increased glucose utilization

Risk Factors for Hypoglycemia

• Maternal: diabetic, multiples, obesity
• Fetal/Neonatal: hypothermia, birth weight variations, stress, sepsis

Hypoglycemia Signs

• Irritability
• Tremors/jitteriness
• High-pitched cry
• Lethargy/floppiness/hypotonia
• Cyanosis
• Apnea/Tachypnea
• Hypothermia/temperature instability
• Poor feeding

Bilirubin Synthesis

• Imbalance in rate of bilirubin production and elimination; total serum bilirubin level >5 mg/dL.
• Physiologic jaundice occurs on the 3rd to 4th day of life and is considered benign.
• Pathologic jaundice occurs within the first 24 hours of life.
• Kernicterus presents when Total Bilirubin is > 20 mg/dl which is irreversible and crosses the blood-brain barrier, causing permanent impaired neurological function
• Rh isoimmunization and ABO incompatibility can also be causes

Nursing Assessment related to Bilirubin

• Monitor skin, sclera, early and frequent feedings, and possible phototherapy.
• Check and monitor bilirubin levels.

Phototherapy

• Reduces bilirubin by converting it to a water-soluble form.
• Nursing care consists of skin care and eye protection, providing hydration through frequent feedings, thermoregulation education.
• Interpret all bilirubin levels according to infant's age in hours.
• Side effects include increased insensible water loss, decreased maternal-newborn interaction, and lack of visual sensory input.

Immune System

• Newborn immune system is immature and doesn't readily respond to infections.
• Hypothermia may be a sign of infection in first days of life (<36.5-37.5℃/97.7-99.5°F).
• Passive acquired immunity happens through transfer of antibodies from mother to fetus.
• IgG antibodies cross the placenta and give the neonate protection against infection up to 2 months.
• Colostrum is high in IgA.
• Active Acquired immunity through immunizations, begin at 2 months of age.

Skeletal System - Head

• Molding
• Fontanels have fluid that crosses suture line
• Caput succedaneum has fluid that crosses suture line
• Cephalohematoma contains blood that does not cross the suture line

Skeletal System - Extremities

• Look for hip dysplasia and family history, breeched birth, females
• Barlow test
• Ortolani test

Neuromuscular System

• The nervous system is immature and develops during the first year.
• Development follows cephalocaudal (head to toe) and proximal-distal (center to outside) patterns.
• Reflexes assess neurologic development and function.

Neonatal Assessment- Reflexes

• Growth - cephalo-caudal / proximo-distal
• Sucking and rooting
• Palmer grasp
• Tonic neck (fencer position)
• Moro
• Stepping
• Babinski

Sensory Behaviors

• Acute senses of hearing, smell, and taste
• Able to distinguish mothers breast milk, sweet and sour by 72 hours.
• Touch-sensitive to pain.
• Responds to environmental stimuli
• Exhibits temperament, habituation
• Exhibits consolability and cuddliness
• Experiences irritability and crying

Medications

• Erythromycin ophthalmic ointment (0.5%) prevents STDs like Chlamydia and Gonorrhea, the antibiotic ointment is mandatory to prevent ophthalmia neonatorum,
• Apply 1-2 cm ribbon of ointment to lower conjunctival sac of each eye,
• Vitamin K (phytonadione) 0.5 to 1 mg IM within one hour after birth to prevent hemorrhagic disorders,
• Vitamin K is not produced by Gl tract of newborn until day 7, when it is produced by colon: bacteria form after formula or breast milk
• Hepatitis B protects against hepatitis B requires parent to sign an informed consent, dosage is at birth, one month, and 6 months, and it should not be administered into same site.

Newborn Vital Signs

• Temperature: 97.7- 99.5 F (36.5-37.5)
• Heart Rate: 120-160 bpm
• Respirations: 30-60 breaths/minute at rest
• Blood Pressure: 60-80 mm Hg systolic, 40-50 mmHg diastolic
• Pain assessment: Neonatal Infant Pain Scale (NIPS)

Immediate Care After Birth- Vitals

• Birth weight: 2500-4000 grams
• Length: 46-54 cm (19-21 inches)
• Head Circumference: 33-35 cm (13-14 inches)
• Chest Circumference: 30.5-33 cm (12-13 inches)
• Abdominal Circumference
• Neurologic Assessment

Physical Maturity Assessment

• With the Ballard scale, one can determines the newborn's gestational age by looking at physical and neuromuscular maturity
• This includes assessing skin texture, lanugo, plantar creases, breast tissue, eyes, ears, and genitals.

Care Management

• Need to complete Laboratory and diagnostic tests and universal newborn screening includes:
• PKU; done 24-48 hours after feeding
• Newborn hearing screening
• Critical congenital heart disease

Circumcision

• Is the "Removal of foreskin of penis"
• Contraindications include preterm neonates or those with genitourinary defects such as hypospadius
• Should not be done for bleeding disorders and compromised neonates: Respiratory distress syndrome
• Risks: hemorrhage, infection, pain, adhesions
• Has benefits: Reported decrease UTI,STI's-including HIV;penile cancer and cervical cancer in female partner

Circumcision Continued

• Procedure: AAP recommends anesthesia
• Types: Nerve block, topical, concentrated oral sucrose, pacifier
• Types of circumcisions:Use Mogen clamp- with wound covered sterile petroleum gauze to prevent bleeding and/or infection
• Or, Plastibell- falls off 5-7 days plastibell, no petroleum gauze used
• The nurse post procedure should: Assess bleeding every 15 to 30 minutes for the first hour then every hour for 4 to 6 hours
• Note first voiding, assess for signs of infection, may prescribe acetaminophen 10-15 mg/kg every 4 to 6 hours for 24 hours post procedure
• With the Caution of maximum dose 30-45 mg/kg/day

Discharge Planning

• Includes instructions on newborn care like bathing, cord care, feeding, temperature, and positioning.
• Swaddling
• SIDS
• Sleep /Activity
• Safety
  • Infant car seat
  • Rear facing, back seat in middle until age 2
  • Home safety
  • Infection prevention
• Bilirubin screen
• Newborn Screen- PKU-24 to 48 hours after protein feeding
• Hearing and congenital cardiac
• Follow up care with Pediatrician in 1-2 weeks post discharge
• When to call Pediatrician and recognize signs of illness