NEWBORN by Prof. Unn Hidle Updated Spring 2010

1. NEWBORNby Prof. Unn Hidle Updated Spring 2010

2. Suggested audio-visual: • Nursing Care of the Newborn: The first 12 hours of life (Video) • Newborn Bath (Prof. Dillon) – An old, but good video (we haven’t changed much in terms of giving a newborn bath!

3. Suggested website: • Breastfeeding issues: • http://www.lalecheleague.org

6. Biological adjustment in the neonatal period • Neonatal transition – first few hours of life when the newborn stabilizes respiratory and circulatory functions • Fetal breathing can be perceived as a continuation of an intrauterine process as the lungs convert from a fluid-filled to a gas-filled organ

7. Fetal breathing • Two radical changes takes place for the lungs to function. • Pulmonary ventilation must be established through lung expansion following birth (strong cry) • An increase in the pulmonary circulation must occur

8. Cardiopulmonary adaptation • The onset of respiration stimulates changes in the cardiovascular system that are necessary for successful transition to extrauterine life • For adequate oxygenation to occur, the heart must deliver sufficient blood to functional, open alveoli

9. Newborn Pulmonary Function • The normal newborn respiratory rate is 30-60 breaths/min. • Periodic breathing occurs when the breathing pattern is paused by 5-15 seconds – very common in newborns • Neonates = Obligatory nose breathers

10. Newborn Cardiovascular Adaptation • During fetal life, blood with a higher O2 content is diverted to the heart and brain • Changes that occurs during birth includes expansion of the lungs (first breath) which decreases the pulmonary vascular resistance and increases pulmonary blood flow.

11. Newborn Cardiovascular Adaptation (continued……) • Pressure in the L-atrium increases as blood returns to the pulmonary veins • Pressure in the right atrium drops, and systematic vascular resistance increases as umbilical venous blood flow is halted when the cord is clamped

12. Cardiac function • Heart rate: • Accelerates immediately to 175-180 BPM. • Levels off in the full-term newborn to 120-160 • BP: • Highest immediately after birth (this is the “normal BP”) and then descends to its lowest level about 3 hours of age. • By days 4-6, the BP levels off at the original high (“normal”) level after birth

13. Heart Murmurs • 90% of all murmurs in newborns are transient and not associated with anomalies. • Murmurs associated with VSD and PDA are usually not picked up until first well-baby visit due to early discharge

14. IMMEDIATE CARE OF THE NEWBORN

16. Place in Trendelenburg position for pulmonary & NP (naso-pharyngeal) drainage • Suction with bulb syringe prn (may need deep suctioning) • Maintain infant warm (skin-to-skin contact, blankets or warmer)

17. Bulb syringe Suction catheter

19. Umbilical cord: • Before placing the cord clamp, examine for presence of two arteries (smaller vessels) and one vein (larger vessel) • The Hollister clamp is removed in the newborn nursery approximately 24 hours after the cord has dried.

20. Hollister clamp

21. APGAR Scoring System • Used to evaluate the physiological condition of the newborn at birth • Ratings take place 1 and 5 minutes after birth and an Apgar score or total score ranging from 0-10 is given • The scoring categories include (from most important to least important) – REFER TO TEXTBOOK FOR SCORES: • heart rate • respiratory effort • muscle tone • reflex irritability • skin color • A score of 8-10 indicates a newborn in good condition who requires only NP suctioning and possibly “blow-by” O2 • A score <8 may need resuscitative measures

22. APGAR score

23. APGAR score (not in order of priority)

24. Attachment • In the first few hours post-delivery is extremely important as the newborn has gone through dramatic events. • Remember, the infant is most alert in the first 30 minutes post-delivery. (“Kangeroo” care) • Newborn identification: • The nurse places two bracelets on the newborn – one on the wrist and one on the ankle. The mother gets either 1 or 2 ID bands depending on the institution. • Now, also electronic alarm bracelets. • Nurseries are ALWAYS locked units

25. Newborn assessment summary • Respirations: For signs of respiratory distress such as retractions, rhonchi or crackles which may indicate aspiration of oral secretions. Suctioning may be needed. Normal RR: 30-60, irregular without retractions or grunting • Apical pulse: 120-160 AR, irregular • Temperature: >36.5C (97.8F) • Skin color: Body pink with bluish extremities (acrocyanosis) • Umbilical cord: 2 arteries and 1 vein • Gestational age: 38-40 weeks in order to remain with parents for extended time (variable)

26. Temperature: Thermoregulation • Normal skin temperature is 36-36.5C (96.8-97.7F). • If no heat conservation measures are started, the normal term newborn’s core body temperature falls0.1degree C (0.2F) per minute and skin temperature drops 0.3C (0.5F) per minute. • Skin temperature is measured most accurately by means of continuous skin probe, especially for small newborns or newborns in incubators/radiant warmers.

27. THERMOREGULATION

28. Vitamin K1 Phytonadione • Generic name: Aquamethyton • Used in prophylaxis and treatment of hemorrhagic disease of the newborn • It promotes liver formation of the clotting factors II, VII, IX, and X • Given as a one-time-only prophylactic dose of 0.5-1mg IM in the birthing area or within 1 hour of birth • If the mother received anticoagulants during pregnancy, an additional dose may be ordered to be given 6-8 hours after the first injection • Most common side effect is pain and edema at the injection site

29. Vastus lateralis

30. Erythromycin Ophthalmic Ointment • Generic name: Ilotycin ophthalmic • Used as a prophylactic treatment of ophthalmia neonatorum which is caused by the bacteria Neisseria gonorrhoeae • Ophthalmic ointment is instilled as a narrow ribbon or strand along the lower conjunctival surface of each eye, starting at the inner canthus • Silver nitrate no longer used due to chemical conjunctivites

31. Circumcision care • Teaching regarding the normal circumcised penis. • Initially glands penis is dark and red and then becomes covered with whitish yellow exudate (granulation tissue) which is not to be removed as it is part of the healing process.

32. CIRCUMCISION

33. Circumcision

34. Cultural / Religious Practices

35. For Ethical Discussion……… Female Circumcision

36. Cleanse with warm water ONLY, squeezed gently over penis to remove urine and feces and pat dry. Some places they use Vaseline gauze, but usually only for the first 1-2 diaper changes or X 12-24 hours (see individual hospital policies). • No soap until circumcision is healed. • Watch for adhesions • If Plastibell was used, it may be in place for up to 8 days and then fall off or be manually removed by clinician. Rarely used!

37. MALE CIRCUMCISION

38. Plastibell for circumcision

39. NEWBORN MEASUREMENTS

40. WEIGHT • Average 3504 g (7Ib, 8oz) • Range: 2500-4000g (5Ib8oz-8Ib13oz.) or even more/less • Weight is influenced by racial origin and maternal age and size. • Approximately 70%-75% of the newborn’s body weight is water. • Physiologic weight loss: During the initial newborn period, there is a physiologic weight loss of 5-10% for full term newborns (15% for pre-term) because of fluid shifts.

41. Other factors contributing to initial weight loss include small fluid intake resulting from delayed breastfeeding or a slow adjustment to the formula, increased volume of meconium excretion, and urination. • Growth is 198 g or 17oz/week for the first 6 months. • Birth weight doubles in the first 6 months. • Birth weights triples in the first year

42. LENGTH • Average 50cm (20inches). • Range 48-52cm (18-22inches). • Growth 2.5cm (1inch) per month for the first 6 months. • The length of the newborn is difficult to measure because the legs are flexed and tensed

43. Head circumference: • 32-37 cm (12.5-14.5 inches) – bipariatal diameter. • Approximately 2 cm larger than chest circumference. The two measurements will remain in this proportion for the next few months. • At birth the newborn’s head is 1/3 the size of an adult head.

44. Chest circumference: • Average 32cm (12.5 inches) • Range 30-35cm (12-14 inches)

45. Gastrointestinal function • Meconium • Formed in utero from the amniotic fluid and its constituent, intestinal secretions, and shed mucosal cells which is passed within 8-24 hours of life. • It is thick, tarry black or dark-green. • If >24 hours without stool, consultation and work-up • Transitional • Thin brown to green stool consisting of part meconium and part fecal material are passed for the next day or two, and then the stools become entirely fecal.

46. Stool of breastfed newborns are usually pale yellow but may be pasty green, more liquid and more frequent than formula fed newborns whose stools are usually paler • Frequency of stools varies from one every 2-3 days to 10 daily! Teaching regarding constipation.

47. Stool variations

48. Urinary function • A newborn who has not voided by 48 hours (hospital policy is often 24 hours) should be assessed for adequacy of fluid intake, bladder distention, restlessness, and symptoms of pain • First 2 days, void 2-6 X/day with urine output 15ml/kg/day. Thereafter, 5-25 X/24 hours with a volume of 25 ml/kg/day • Often cloudy urine due to mucous content

49. Occasionally pink stains (“brick dust spots”) appearing on the diaper due to urates. • Blood may be observed in females, pseudomenstruation secondary to the withdrawal of female hormones. Males, spotting from circumcision • Early infancy, urine is straw colored and odorless.

50. Physiologic jaundice (also in lecture) • Yellowish discoloration of the skin and sclera (icteric) that develops from deposit of the yellow pigment bilirubin in lipid tissues • Fetal unconjugated (indirect) bilirubin is normally cleared by the placenta in utero, so total bilirubin at birth is usually less than 3 mg/dL unless an abnormal hemolytic process has been present