Neonatal care

Definition

Neonatal care refers to that care given to the newborn infant from the time of delivery through about the first month of life. The term "neonate" is used for the newborn infant during this 28-30 day period.

Purpose

The purpose of neonatal care in the delivery room and newborn nursery is to:

• Assess and evaluate the newborn as s/he transitions from intrauterine life to extrauterine life.
• Evaluate and monitor the newborn system-by-system for normal versus abnormal functioning, providing maintenance of normal and potential treatment of abnormal findings.
• Foster bonding between infant and parent/s.
• Provide a safe environment at all times.

Description

Neonatal care begins as soon as the baby is born. In fact, suctioning of the nose and mouth may take place as the baby is in the process of being delivered—with the head out, and while the mother is taking a pause before the next push. In utero the infant is swimming in amniotic fluid. As he or she comes down the birth canal, the contractions exert pressure on the body and push some of the amniotic fluid out of the lungs . It is this fluid that is suctioned out during those first few moments. Shortly after delivery, the umbilical cord is clamped and then cut. Shortly after clamping, the cord will be checked for the presence of two arteries and one vein. Once the cord is clamped, the baby must breathe and function independently from the mother. The first few breaths cause several internal changes to occur. These will be discussed in the Results section below.

Because of the internal environment, the baby is very wet when born. Drying the baby off right away is critical, as the baby can lose considerable body heat through evaporation, convection, radiation, and conduction. This is especially true of the head, which has a large surface area in relation to the rest of the body. Also, head hair retains considerable moisture if not well dried. A cap placed on the head once it has been dried helps to maintain body temperature. The nurse may place the newborn on the mother's skin while drying the skin, both to begin the bonding process as well as to allow the mother's body heat to warm the infant. The rubbing that takes place to dry the infant provides tactile and sensory stimulation. The neonate may cry, bringing more oxygen into the lungs. A certain amount of pressure is needed in the heart and lungs in order to convert from fetal circulation to neonatal circulation. A color change is noticeable as the infant's skin changes from a bluish hue to pink. In some circumstances, oxygen from a mask may be placed near the mouth while the infant is being dried off to increase the initial intake of oxygen. Once dry, the infant is wrapped in several warm receiving blankets and may be placed at the mother's breast for an initial breastfeeding. If the mother will not be breastfeeding, she may choose to hold the newborn at this point.

The first breastfeeding helps to trigger the involution process of the uterus, as it stimulates the production of natural oxytocin, which helps the uterus contract. Also, in the first hour or so after birth, the neonate is usually quite alert, unless the mother was given pain medications late in labor.

While the infant is being dried off, the mother is delivering the placenta. The amniotic fluid is clear, perhaps tinged with blood . If it appears murky in any way, the baby most likely had a bowel movement during the stressful labor and delivery process. This first bowel movement is called meconium. If present in the amniotic fluid, it is possible that the infant inhaled some into its lungs. This is called meconium aspiration. The neonate with meconium in the amniotic fluid may be intubated to avoid aspiration. Meconium aspiration can lead to tachypnea (rapid respirations) and also pneumonia , and may require the neonate to spend some time under observation in the neonatal intensive care unit (NICU), instead of being kept with its mother. As the infant is being suctioned, assessed and dried, it may be placed in a slight Trendelenburg position, depending on the hospital. This downward slant of about 10 degrees allows gravity to assist in draining mucous.

At one and five minutes after birth the neonate is assessed for Apgar scores. The infant's heart rate, respiratory effort, muscle tone, reflex, irritability, and color are each given a score of 0, 1, or 2. Each score is then added together for a highest possible score of 10. The normal range is 7-10. It is rare to receive a 10, as some cyanosis in the hands and feet (called acrocyanosis) is quite normal.

In the birthing room a rapid physical examination is performed to assess any gross abnormalities as well as any heart-related problems, and to determine the need for any immediate intervention. The spine will be assessed, and should be free of any openings or dimpling. It will be flat, as the lumbar and sacral curves develop later when the child learns to sit and walk. A more detailed examination will take place about 24 hours later. The umbilical cord and placenta will also be examined for any abnormalities. Any medications given to the mother during labor and delivery are recorded in the neonate's chart, as the medication could affect the infant's respirations and its own ability for tissue oxygenation. The physician or nurse-midwife will also make sure the entire placenta has been expelled to avoid the risk of infection for the mother due to any retained tissue.

Because the neonate has difficulty maintaining its temperature, any examination that is immediately needed usually takes place under a source of radiant heat. During the first 24 hours the neonate is adjusting to extrauterine life and some normal fluctuations are expected. It is for this reason that the more thorough examination will take place a bit later on, once the initial fluctuations stabilize. The expected findings of the head-to-toe neonatal assessment will be discussed in the Results section below.

Before leaving the delivery room the nurse will:

• Place an identification band on the neonate's hands and feet.
• Place an ID band with the same number as the baby's on the mother's (and in some hospitals) on the father's wrist.
• Take a foot print of the infant (in some hospitals).
• Give an intramuscular (IM) injection of vitamin K to the neonate.
• Administer an antibacterial eye ointment into both eyes.

To assist the neonate's blood's ability to clot in its early life, infants receive an IM injection of vitamin K in the delivery room. The injection is usually given in the thigh muscle, as this is the largest and safest muscle in which to give an infant an injection. The antibacterial eye ointment used prevents contracting an infection from one present in the birth canal, such as gonorrhea or chlamydia.

Hospitals differ in which identification system they use, but the premise is the same: before the infant leaves the delivery room, he or she should receive an ID band with a number on it. The same ID number is on a band for the mother, as well as possibly for the father. Before leaving the baby with the parents, the bands should be checked by the nurse or nursing student to avoid any mix-up. Some hospital ID bands contain a microchip in it that causes an alarm bell to ring if the infant is taken out of a certain area. Also, some hospitals require that if the mother is going to take a nap or a shower, the infant must be returned to the nursery so that the infant is not unattended in the mother's room. Some hospitals use a band on each of the baby's hands and feet, so that if one or two fall off, proper ID still remains on the neonate. In addition to the ID band, a print of the infant's foot is made along with the mother's fingerprint. Both are recorded on the same sheet of paper.

If the neonate appears physiologically unstable, she will be taken either to the nursery or to the NICU for further evaluation or treatment. Once the mother's condition is stable, she may be wheeled to the infant's location if she desires.

Weight and length are measured, either in the birthing room or in the newborn nursery, vital signs are closely monitored and skin color is assessed for signs of jaundice . Jaundice that appears in the first 24 hours is of a different nature than that which sets in after 24 hours. If undressed, the infant is kept under radiant heat to assist in maintaining proper body temperature. Temperature may be regulated for several hours with a monitor attached to the chest skin. A rectal temperature may be taken to check for a patent anus. After any examinations, the infant will be swaddled in several layers of receiving blankets, a cap will be placed on the head to further reduce loss of body heat, and the newborn is placed in a bassinette either on its side, with a rolled blanket behind the back to prevent tipping, or on its back. To prevent sudden infant death syndrome (SIDS), infants should not be placed on their stomach .

Most insurance plans allow hospital stays of only 48 hours after an uncomplicated vaginal delivery, so much takes place within that time. Twenty-four to seventy-two hours after the neonate's first intake of protein her blood is checked via a heel-stick for the presence of phenylketonuria (PKU), a protein metabolism disorder that requires strict nutritional guidelines for treatment to avoid central nervous system (CNS) damage. Neonates whose mothers had gestational diabetes will have their blood sugar monitored in the nursery. During the second day of life the infant will have a detailed physical assessment done cephalocaudal (head-to-toe). The normal ranges for this will be discussed in the Results section. Parents who wish to have their male infants circumcised in the hospital will make those arrangements. The nursery nurses will monitor the circumcised infant for any signs of infection or abnormal bleeding.

Hospitals may differ in terms of how much time the infant spends with the mother in her room. The aim is for a balance between the mother's need for rest to ensure more rapid healing, the need for the parents and baby to form a strong bond, and the safety of the infant if unattended. Most hospitals bring the breast-feeding infant to the mother on demand. Formula-fed babies may spend more time in the nursery with staff feeding the baby, if the mother needs more rest time after a difficult delivery.

In July 1999 the Centers for Disease Control (CDC) determined that hepatitis B immunizations, which had been routinely given to newborns, should no longer be administered to neonates until the preservative thimerosal is removed from vaccines. Since thimerosal is derived from ethylmercury, and even though there is no evidence that exposure to low levels of thimerosal is harmful, concerns about the exposure to mercury compounds led to the decision as a precautionary measure.

Results

The clamping of the umbilical cord signals the neonate's abrupt transition from intrauterine to extrauterine life. In utero the fetus's blood was oxygenated through the placenta and the mother's circulation. Now the neonate's lungs must take over. With the first breath, the lungs expand and create a pressure difference in the chest, pulmonary artery and heart. This leads to the closing of the ductus arteriosus and the foramen ovale. The blood flow through the cord stops and any blood within the cord will clot, causing the vessels to dry out, allowing the cord to fall off within about 10 days. Assessment of the cord area can be done with each diaper change.

The cord site should remain dry, with no evidence of redness, bleeding or discharge.

Infants born by cesarian section do not have the force of the birth canal pushing amniotic fluid out of the lungs. Because of this, some infants may have some initial difficulty with respirations, due to the excess of fluid still remaining in their lungs.

During the first hour after birth, the neonate is very alert. He or she may be interested in nursing, or may spend time just gazing at the mother or parents. The initial breastfeeding establishes the neonate's ability to coordinate breathing, sucking and swallowing.

Variability is normal in the newborn, so pulse and respirations should be monitored for an entire minute. If abnormal values are noted, yet the infant does not appear in distress, wait a minute or two and then recheck. Normal values for the neonate include:

• Apical pulse (recorded over the heart) between 120 and 160. The sleeping newborn may have a pulse of 100, the crying infant may have a pulse of 180. Rates below 100 and above 180 should be investigated.
• Respirations range from 30 to 60 breaths per minute. Infants are nose-breathers, so a clear nasal passage is critical. Poor breastfeeding position can block the nose and requires repositioning. Respirations can be counted by watching the abdomen move up and down. While short periods of crying can be beneficial in bringing more oxygen into the lungs, long periods of crying exhausts the neonate's cardiovascular system and should be avoided.
• The average weight of a newborn is 7.5 pounds (3.4 kg), with a normal range of 5.5 to 8.5 (2.5-3.8 kg). A weight above 10 pounds (4.5 kg) may indicate that the mother had gestational diabetes. The average length of the newborn is 20-21 inches (50-53 cm) long.
• Initially, the newborn is very sensitive to temperature changes, as her ability to regulate her temperature is not yet well developed. A normal rectal temperature ranges from 97.8-99°F (36.5-37.2°C). A newborn experiencing heat loss will increase his or her respirations.
• Within the first 24 hours, the newborn should void and pass meconium, a sticky, tar-like first stool. The neonate does not take in a great deal within the first few days, but intake and output should increase after the first few days. Bowel sounds are present.

A head-to-toe assessment is usually done without the parents present, but can be very helpful if done in front of the first-time parent for reassurance. The head will appear large in relation to the body. Average head circumference is about 13.5–14 inches (34–35 cm) in diameter. A circumference of less than 33 cm or greater than 37 cm may indicate a neurological abnormality and warrants further evaluation. The head of a baby born vaginally may look misshapen at first. This is called molding. The baby's skull allows for movement so that it can pass through the birth canal. Within a few days it takes on its normal shape. Infants delivered with the help of forceps or vacuum aspiration may have bruising on the head, or even a cephalhematoma. Cephalhematoma is a collection of blood under the scalp, such as can result from blood vessels that have ruptured during birth. It does not cross the midline of the skull. Caput succedaneum is an area of edema under the scalp. It may cross the midline. These will resolve over time, although the increased amount of blood being processed from the cephalhematoma may result in jaundice. Infants born by cesarian delivery have normally shaped heads right at birth if it is a scheduled caesarian delivery. If the mother has been in prolonged labor and a caesarian delivery is deemed necessary, the newborn's head may still be molded. Newborns may have a full head of hair, although most often falls out during the first month. The two soft spots on top of the head are called fontanels. The anterior fontanel should close after 12 to 18 months; the smaller, posterior fontanel should close by the third month. A bulging fontanel in a quiet infant indicates increased intracranial pressure. A depressed fontanel indicates dehydration . It is normal to be able to feel the pulsing of each heart contraction at the anterior fontanel. The eyes and ears should be in good proportion. Low-set ears indicate a chromosomal abnormality, such as trisomy 13 or 18. The nose, which is large at this age for the face, may have little white dots called milia. These are blocked sebaceous glands, and will disappear in a few weeks. These should not be squeezed or scratched, to avoid creating a portal for infection. The mouth should have an intact palate. Small round dots may be present and are called Epstein pearls. They are a form of calcium deposit and will disappear. Parents may confuse them with white patches of thrush, which is a Candida infection.

Newborn skin may be somewhat mottled, and early acrocyanosis in the hands and feet is common. Central cyanosis in the trunk should be investigated, as it indicates decreased oxygenation. Jaundice that sets in after the first 24 hours is common, but the bilirubin level should be closely monitored if the jaundice travels below the nipple line. Birthmarks, or hemangiomas, are common. Some are flat and reddish-purple in color. They may fade or disappear over time, but some larger ones may remain. Laser treatment in later life is becoming more common to remove those marks that are large or prominent enough to interfere with an individual's self-esteem. Raised, cavernous hemangiomas may indicate similar lesions on internal organs which can rupture and bleed with a blow to the child's abdomen. Mongolian spots are gray-purple-blue patches seen on children of Asian, Mediterranean, or African descent. They can resemble bruises, and are usually found on the buttocks and sacrum.

Newborns may be covered in vernix caseosa, a waxy substance that acts as a skin lubricant. It is especially noticeable in skin folds. Babies born post-dates (over 40 weeks) have very dry skin and may have cracks in the skin folds. The color of the vernix is an indicator of intrauterine life. It may be green-tinged, indicating the presence of meconium in the amniotic fluid. Yellow vernix indicates bilirubin. Lanugo is a fine, downy hair that may cover the shoulders, back, and upper arms. Premature infants have more lanugo; post-dates infants usually have none at all. The neonate's skin is sensitive and may respond to washing products with a rash.

The hormones circulating in the mother are passed into the fetus. Newborns may have enlarged genitalia in response to the circulating maternal hormones. Female neonates may have some white or blood-tinged discharge

KEY TERMS

Acrocyanosis —The slight cyanosis of the hands and feet of the neonate is considered normal and is due to an immature circulatory system which is still in flux.

Ductus arteriosus —The ductus arteriosus is a vessel connecting the pulmonary artery to the aorta in the fetus. After birth, this begins to constrict and the neonate's blood now leaves the heart via the pulmonary artery, going into the lungs to be oxygenated. Once fully constricted, it becomes a ligament.

Foramen ovale —The foramen ovale is a fetal cardiac structure that allows the blood in both upper chambers (atria) of the heart to mix. After birth, the pressure rises in the left atrium pushing this opening closed, allowing the heart to function in a two-sided fashion: the right side carries the unoxygenated blood to the lungs, and the left side pumps the oxygenated blood out into the body.

Trendelenburg —In the Trendelenburg position the body is at a slant with the head below the heart. For suctioning purposes, the neonate is placed in a slight Trendelenburg position, of about 10 degrees. This allows the force of gravity to assist in expelling amniotic fluid and mucous.

from the vagina for a week or so after birth. There should be no evidence of trauma, however.

The neonate is able to move her arms and legs symmetrically. Lack of movement or limpness indicates an injury and needs careful evaluation. A broken clavicle may be the result of a difficult birth, but should heal to full movement. The examiner will check for extra digits, or fused/webbed digits. The legs are normally bowed at this time, and will straighten with growth. Feet may appear twisted, due to a long-held intrauterine position. If they can be easily brought into alignment, this will usually revert to normal with growth and weight bearing. A foot that does not come into alignment may indicate talipes, or clubfoot. Early treatment brings the best success. The hips are checked for symmetrical abduction. Clicking heard during examination may indicate subluxation, and treatment is usually begun right away.

Neonatal reflexes are checked to assess for any neuromuscular abnormalities. Intact reflexes provide a safety/survival mechanism for the newborn. These reflexes include:

• Rooting; present from birth until about six weeks of age. To elicit the reflex, stroke the corner of the mouth. The neonate should turn his head in that direction. This reflex assists the infant in finding the breast.
• Sucking; from birth until about six months of age. Touching the lips begins the sucking reflex. When the lips are touched by the breast or bottle nipple, the infant begins to suck, taking in nourishment.
• Swallowing; as food reaches the back of the tongue, the swallowing reflex is elicited and the food is swallowed.
• Palmar grasp; disappears by three months of age. Placing an object, such as a finger, into the neonate's palm elicits this reflex. The infant will grasp tightly onto whatever has been placed into her hand.
• Stepping; present from birth until about three months of age. Hold the infant upright with his feet just touching a flat surface. The infant will take small weight-bearing "steps." These are not true steps, and the infant must be fully supported.
• Babinski; present until about three months of age. To elicit the response, stroke the sole of the neonate's foot, starting at the heel. The newborn will curl and fan his toes upward and outward. Once the reflex disappears, the same motion should cause the toes to flex, as in the neurologically intact adult.
• Moro; strongest from birth through two months of age, then fades until it disappears around the fifth month. This is a startle reflex, so evaluation is done somewhat gently. One method is for the examiner to clap her hands near the newborn, but out of eyesight. Another method is to hold the infant above a padded mat, then either let the head fall backwards by an inch or so, or quickly lower the infant's body towards the mat. This gives the infant a sense of falling. The reflex action is for the neonate to first extend both arms and legs, then to pull his legs up towards his abdomen while making the shape of a "C" with his fingers. For some very sensitive infants, walking quickly down the stairs may elicit this response. Such infants may feel more comforted being swaddled.

A neonate's hearing and vision will be assessed. The fetus is able to hear inside the uterus, and after birth it will clearly respond to the voices of the mother and father but may ignore unfamiliar voices. The neonate focuses best on an object 9-12 inches (23-30 cm) away. This is approximately the distance between its face and the face of the mother when held in a breastfeeding position. There should be no redness or drainage from the eye on inspection. The blink reflex should be intact, elicited by briefly shining a bright light at the eye. Depending on the birthing position, there may be edema around the eye, although this fluid should reabsorb in a few days after birth.

Health care team roles

At birth, the physician or nurse-midwife is in attendance, along with the labor and delivery nurse. If the fetus has been in distress, a neonatalogist may also be present. After birth the newborn is handed to the nurse who begins the drying off of the newborn, and addresses the other issues mentioned above. Nurses perform the neonatal care tasks discussed above in the nursery. Blood drawn drom the neonate's heel is usually done by the nursery nurse, and then sent to the laboratory for processing by the laboratory technicians. In some hospitals nurses may care for both the newborn and the mother as a unit. Nurses provide all the necessary teaching provided to the new mother.

Neonatal care continues through about the fourth week after birth. During this time the infant and mother may receive a home nursing visit to ensure that breastfeeding is well established, that no jaundice is present in the neonate, and that the mother is healing well from the delivery. At the follow-up office visit, the nurse or medical assistant will weigh and measure the length of the infant.

Patient education

Parent education, especially for the first-time parent is extremely important. Nurses or nurse-midwives will provide breastfeeding and postpartum teaching for the mother, as well as explaining the care needed for the newborn. This may include cord care, normal number of daily feedings and diapers, how to determine the presence of jaundice, how and when to bathe the infant, as well as answer any questions the new parents may have. A follow-up appointment is usually established before the infant leaves the hospital. The nurse will often be the one to ensure that a car seat is present and properly installed in the car before allowing the mother and baby to leave the hospital, as mandated by state law. Nurses also provide information when parents call with questions to the doctor's office.

Resources

BOOKS

Curtis, Glade B. and Judith Schuler. Your Baby's First Year Week by Week. Tucson, AZ: Fisher Books, 2000.

Doenges, Marilynn E. and Mary Frances Moorhouse. Maternal/Newborn Plans of Care; Guidelines for Individualizing Care. Philadelphia: F. A. Davis Company, 1999.

Klaus, Marshall H. and Phyllis H. Klaus. Your Amazing Newborn. Reading, MA: Perseus Books, 1998.

The Parents' Answer Book from Birth Through Age Five. New York: St. Martin's Griffin, 1998.

Pasquariello, Patrick S. The Children's Hospital of Philadelphia: Book of Pregnancy and Child Care. New York: John Wiley & Sons, Inc., 1999.

Pillitteri, Adele. Maternal & Child Health Nursing 3rd Edition. Philadelphia: Lippincott, 1999.

Swanson, Jennifer, ed. Infant and Toddler Sourcebook 1st Edition. Detroit: Omnigraphics, 2000.

ORGANIZATIONS

The American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. (847) 434-4000. <http://www.aap.org>.

Medscape, Inc. 20500 NW Evergreen Parkway, Hillsboro, OR 97124. (503) 531-7000. <http://www.medscape.com>.

OTHER

The American Academy of Family Physicians, The American Academy of Pediatrics, The Advisory Committee on Immunization Practices, and The United States Public Health Service. "Joint Statement Concerning Removal of Thimerosal From Vaccines." Centers for Disease Control website. June 22, 2000. <http://www.cdc.gov/nip/vacsafe/concerns/thimerosal/joint_statement_00.htm>.

Esther Csapo Rastegari, R.N., B.S.N., Ed.M