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Course: Maternity Nursing

Topic: Newborn Care

The Nurses International Community

Contact info: info@nursesinternational.org

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Module Goals

The learner will be able to:

Identify immediate care of the newborn after delivery
Describe the assessment of newborn after the delivery
Describe the components of essential newborn care during initial hours of the birth
Identify client teaching for newborn care

Contact info: info@nursesinternational.org

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Newborn Needs after Birth

Transition from fetal respiration to external respiration

(Assure good quality respirations)

Maintain thermoregulation

(Keep the infant warm and dry, skin to skin contact with mother)

Contact info: info@nursesinternational.org

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Immediate Care After Birth

Put infant on the mother’s bare abdomen (skin to skin) right after delivery
Dry the infant thoroughly with a clean, warm, soft cloth

Do not wipe away vernix
Do wipe away blood or meconium

Keep the infant dry and warm

Skin-to-skin with mother
Cover infant’s head to feet with a dry, warm, soft cloth

Monitor the infant’s breathing

While the infant is skin-to skin with the mother
Act quickly to manage a baby who is not breathing

Contact info: info@nursesinternational.org

According to Hesperian Health Guides -‘The New Where There Is No Doctor: Chapter Newborn Babies and Breastfeeding’ -
The best place for a new baby is on her mother.
Mother’s own body heat will warm the baby.
Do not take away the baby from the mother to examine or bathe.
The baby does not need a bath right away and a bath may cause the baby to become dangerously cold.
There no need to separate the mother and baby- unless rescue breathing is needed

According to Bettercare/Newborn care/3. The routine care of normal infants:
Vernix protects the skin and kills bacteria
Vernix disappears spontaneously after a few days
The only indication for bathing newborn soon after birth is severe meconium staining or contamination with blood or maternal stool
Delay bathing until baby is few hours old if they must be bathed
A carbolic soap that kills bacteria is suitable

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Making sure Baby is Breathing

Baby is stable if he/she is breathing well or crying.
Respiration rate >30 breaths/min <60 breaths/min
If the baby is limp, blue, or not breathing:

Clear mucus from the baby’s mouth by gently wiping it with a finger wrapped in a clean piece of cloth, or using a soft bulb syringe
Bulb syringe or suction trap is used to get the mucus out of the mouth, then the nose
Rub firmly up and down the baby’s back, across the bottom of the baby’s feet to stimulate the infant to take a deep breath

If the infant is not breathing, provide rescue breathing

strong legs and arms

good color

Breathing well and crying

Limp, floppy arms and legs

Struggling to breathe or no signal of breathing or crying

Dark red or purple or turning blue, play, or gray

Contact info: info@nursesinternational.org

According to the Hesperian Health Guides -‘The New Where There Is No Doctor: Chapter Newborn Babies and Breastfeeding’ -

Rescue breathing

1. lay the baby on a firm surface:

Place a warm cloth on a firm surface, a table or the floor. Then lay the baby on top of it and partially cover the baby to keep warm.

1. Lift the baby’s chin just a little, so the chin is tilted slightly up, toward the ceiling. Putting a small rolled-up cloth under the baby’s shoulder can help do that. This keeps the baby’s throat open for breathing.

2. Open your mouth wide. Seal your lips over the baby’s mouth and nose. You can use a bag and mask, if available, instead of your mouth.

3. Puff air into the baby. Use only small breaths. Give one small quick puff of air every 1 or 2 seconds. Be careful not to blow too hard, or you can damage the baby’s tiny lungs.

4. After each puff, wait a moment for the baby to breathe out.

5. If the air does not seem to go in, stop. Lift the baby’s chin to be sure it is facing straight up and the throat is open. Then try again.

If the baby starts to cry or breathes at least 30 breaths each minute on her own, stop rescue breathing and continue to monitor breathing. Put her on mother's chest, skin-to-skin, to keep baby warm. Closely monitor the baby for the next few hours.

Is the baby a good color? is she breathing easily? if the baby becomes blue around the body or mouth or struggles to breathe, get expert help immediately.

· If the baby does not begin to breathe on her own after 20 minutes of rescue breathing, and there is no advanced medical assistance available, this is an indication that the infant will not be able to breathe on her own, and breathing will cease permanently. Treat the expired infant with gentle care and remain close to family in this time of grief. The family will need your attention and care.

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APGAR Score

Apgar score is used to measure a newborn’s general condition at birth
Apgar score is measured at 1 minute and 5 minutes after birth

Source: KidsHealth.org February 2018,, What is the Apgar Score?.

Apgar sign	2	1	0
Appearance (skin color)	Normal color all over (hands and feet are pink)	Normal color (but hands and feet are bluish)	Bluish-gray or pale all over
Pulse (heart rate)	Normal (>100 beats/min)	<100 beats/min	Absent (no pulse)
Grimace (reflex irritability)	Pulls away, sneezes, coughs, or cries with stimulation	Facial movement only (grimace with stimulation)	Absent (no response to stimulation)
Activity (muscle tone)	Active, spontaneous movement	Arms and legs flexed with little movement	No movement, floppy tone
Respiration (40 breaths/min, cry)	Normal rate and effort, good cry	Slow or irregular breathing, weak cry	Absent (no breathing)

Contact info: info@nursesinternational.org

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Monitor Newborn’s Condition

Monitor the baby’s condition every 15 minutes for the first two hours after birth and respond immediately if there are abnormal findings:

Check the baby’s breathing and colour

Assess the baby’s temperature

Check cord for bleeding and assess for three vessels

Assess breastfeeding

Contact info: info@nursesinternational.org

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Components of Essential Newborn Care:

Immediate care after birth
Skin-to-skin care and monitoring breathing
Umbilical cord care
Breastfeeding
Eyecare
Measure temperature, weight, height, and head circumference
Vitamin K injection
Newborn head to toe examination
Begin immunizations
During discharge, reassess and give parents guidance for home care
Assessment and management of danger signs

Contact info: info@nursesinternational.org

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Continue Skin-to-Skin Care (Kangaroo Care)

The best place for baby is skin-skin with the mother

Cover the baby’s head and body with a warm, clean, soft cloth
place a warm cap on the infant’s head

Only interrupt skin-to-skin contact for essential care
Prevent hypothermia in newborn when not in skin-to-skin contact with mother by swaddling infant and providing head covering
Change wet diapers, and replace with a dry, warm cloth or diaper

Contact info: info@nursesinternational.org

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Monitor Breathing

Leave normally breathing babies, 30-60 breaths/minute, with the mother
If breathing difficulty is noted, indrawing chest (retractions), respiration <30 breaths/minute

Call for help
Move the newborn to a flat surface to initiate resuscitation using positive pressure ventilation

If breathing > 60 breaths/min,

Look for signs of infection and treat accordingly

has the baby inhaled meconium (stool)?

Encourage the baby to breastfeed

Short cycles of apnea of 5-10 seconds is normal in infants

Contact info: info@nursesinternational.org

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Case study:

An infant is delivered to a primigravid mother by spontaneous vaginal delivery at term. Immediately after birth, the infant cries well and appears normal. The infant is dried, and the cord is clamped. The infant has a lot of vernix. The infant is placed in a cot and sent to the nursery for a bath.

Evaluate the nurse’s actions

When should the mother be encouraged to put the infant to her breast?

Should the vernix be washed off immediately after delivery?

Contact info: info@nursesinternational.org

What should the nurse have done?

The nurse should have put the baby skin-to-skin on the mother’s abdomen as soon as the baby was delivered, where she could have been dried and kept warm by covering head to toe with a clean, warm cloth.

The newborn should not be bathed for a couple of days after birth if no severe meconium staining or blood staining. ( This practice may vary with institutions and in varying locations)

When should the mother be encouraged to put the newborn to her breast?

The mother should be encouraged to put the newborn on her chest as soon after birth as she is able.

Should the vernix be washed off immediately after delivery?

Vernix should not be washed off after delivery. It may be massaged into the infant’s skin.

It protects the baby from infections so must be left as it is. It disappears on its own in a day or two.

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Umbilical Cord Care

Clamp and cut the umbilical cord 1 to 3 minutes after the birth of the baby, while initiating simultaneous essential newborn care
The umbilical cord should be clamped or tied 3 to 4 cm from the infants abdomen
Only clamp the cord early (within one minute) if the newborn needs to be moved immediately for resuscitation
Provide cord care:

Keep the cord clean and dry
Nothing should be applied to the cord unless recommended by the health authority (for example, chlorhexidine, betadine, gentian violet)

Monitor for signs of redness, swelling, discharge, or bleeding. Seek medical attention if present

Contact info: info@nursesinternational.org

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Umbilical Cord Care- Patient Teaching

Wash hands before touching the cord
If the cord becomes dirty or has a lot of dried blood on it:

clean it with soap and boiled (then cooled) (sterile)water, or
clean it with medical alcohol (strong drinking alcohol may be used in remote locations)
handle the cord gently

Keep it clean and dry
Do not put anything else on the cord
Cord stump will dry up and usually fall off 5 to 7 days after birth.

Few drops of blood of smooth mucus is normal when cord falls off

If bleeding purulent( pus), redness, swelling, are present seek medical assistance

Contact info: info@nursesinternational.org

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Breastfeeding

Encourage the mother to breastfeed :

Within an hour after birth
All newborns, including low birth weight babies can breastfeed
(Very low weight, or premature infants may need to be fed enterally by tube due to loss of calories from breastfeeding)
When babies are clinically stable and begin ‘rooting’ (seeking out the mother’s nipple)

Encourage the mother to breastfeed exclusively (no water) when the baby begins rooting

Do not force the baby to the breast
Baby should have both nipple and areola inside the mouth for latching

Contact info: info@nursesinternational.org

Please refer to slide decks ‘Breastfeeding’ and ‘HIV and pregnancy’ of this course package for more details in breastfeeding.

According to Hesperian Health Guides- ’The New Where There Is No Doctor’:-
Babies tend to fall asleep within about an hour of birth. The baby should be breastfed before falling asleep.
If the baby does not nurse right away, try squeezing a few drops of the mother’s first milk onto her lips to get her interested. Or, tickle the baby’s cheek with the mother’s nipple.

According to Bettercare/Newborn Care/ 3. The routine care of normal infants:
Studies have shown that sooner the infant is put to the breast, the greater is the chance that the mother will successfully breastfeed.
Nipple stimulation by sucking may speed up the third stage of labour by stimulating the release of maternal oxytocin which causes the uterus to contract.
It reassures the mother that her infant is healthy.
Some mothers want to hold the baby but not breastfeed. Their wishes should be respected.

According to Hesperian Health Guides ‘A Book for Midwives’- Chapter 15:
Breastfeed whenever the baby wants
Breastfeed as long as the baby wants- at least every 2 or 3 hours
Breastfeed for at least 20 minutes each time, until the breast is empty.

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Newborn Eye Care

Chlamydia or gonorrhea is common among women in various areas

Unless they have tested negative for these infections, the baby must get prophylactic antibiotic eye medication to prevent blindness

Provide antimicrobial drops (1% silver nitrate solution or 2.5% povidone-iodine solution) or ointment (1% tetracycline ointment) to both the baby’s eyes once, and according to national guidelines

Povidone-iodine should not be confused with tincture of iodine which, could cause blindness if used

Contact info: info@nursesinternational.org

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Assess Heart Rate, Muscle Tone, Reflexes, Colour

Normal heart rate: 120 and 160 beats/min

Normal muscle tone:Baby holds arms and legs tight and close to the body with elbows and knees bent (flexed) has strong muscle tone
Normal reflexes should show signs of grimace, Moro reflex, and sneezing

Normal color: Assess the baby’s color. Bluish color of hands and feet (Acrocyanosis or peripheral cyanosis) is normal first few hours after birth and may be normal intermittently for 7 - 10 days

Contact info: info@nursesinternational.org

Babies breathing, heartbeat, muscle tone, reflexes, and color can be checked while the baby is breastfeeding.

According to Hesperian Health Guides ‘A Book for Midwives’:

· Baby’s heartbeat should beat between 120 and 160 beats/min

o if slower than 100 beats/min or if no heartbeat at all, give rescue breathing

o if heartbeat faster than 180 beats/min, get medical help

· The baby who holds arms and legs tight and close to the body with elbows and knees bent has strong muscle tone which is normal

o A limp baby has weak muscle tone, will not breathe well, and may need oxygen

· Babies with normal reflexes should:

o Grimace: make a face if suction in mouth and nose

o Moro reflex: stiffly flings his arms wide and opens his hands when moved suddenly or hears a loud noise.

o Sneeze when there is water or mucus inside the nose

o A baby lacking these reflexes may need medical advice.

· Assess the baby’s color

o Most babies are blue or even purple when they are born, but quickly become a more normal color in 1 or 2 minutes

o Babies with darker skin do not look as blue as those with lighter skin

o Dark-skinned baby’s needs to be assessed through color in their hands and feet to see if they are bluish

o All babies look dusty or pale if they are not getting enough air in their lungs

o Babies can also be blue

§ when they are cold

§ when they have an infection

§ when they have heart problems

o If the baby is cold, wrap the baby in blankets or clothes and cover the baby’s head.

o If the baby is warm but pale, then the baby needs help breathing

o If the baby’s still blue or pale after giving oxygen, then medical help is needed.

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Temperature, Height, Weight and Head Circumference

Measure temperature of the baby

Normal temperature: 37°C (98.6°F) (axillary)
If the temperature is 36.5°C (97.7°F), warm the baby quickly

Place infant between the mother’s breast skin-to-skin
Place warm compresses and warm blankets around infant

Measure and document height, weight, and head circumference on the growth chart

Normal height: 45 - 53 centimeters, Head circumference: 35 centimeters Normal weight: 2.5 kg- 4 kg

Initiate special care for babies weighing less than 2500 gm

Contact info: info@nursesinternational.org

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Administer Vitamin K

Administer Prophylaxis Medication if Needed

Inject Vitamin K to all infants in the vastus lateralis of anterolateral thigh muscle

Term babies: 1 mg/0.5 mL IM
Preterm babies: 0.4 mg/kg for a maximum dose of 1 mg IM

Based on the mother’s record, appropriate prophylaxis medication is given:

Those exposed to risk factors for infection (i.e preterm prelabour rupture of membrane, foul-smelling or purulent, amniotic fluid)
Those exposed to syphilis, tuberculosis, or HIV
Immunizations are given according to national guidelines

Contact info: info@nursesinternational.org

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Monitor Newborn’s Condition: Special Considerations

Assess for low blood glucose, i.e < 40 gm/dL, in:

Preterm newborn or low birth weight newborn (less than 2.5 kg)
Newborn of diabetic mothers
Newborn with signs of infections

Treatment:

IV infusion of 10% D/W or oral glucose for infants of diabetic mothers, extremely premature, having respiratory distress, or are sick
Other at risk infants that are not sick: Started on early frequent breastfeeding, or expressed breastmilk/formula feedings with spoon

Monitor newborn of mother diagnosed with Group B Strep for infection

Partial source: (Kevin C Dysart, Dec 2018)

Contact info: info@nursesinternational.org

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Newborn Head to Toe Exam

Assess heart, respiratory rate, and temperature
Measure height, weight, head circumference
Palpate head shape, suture lines, and fontanelles
Examine ears, eyes for abnormalities
Assess rooting and sucking reflex
Examine for tongue tie, cleft lip, and cleft palate.
Examine neck, chest, shoulders, arms, and hands for swelling fractures or abnormalities
Examine back, feet, hips, and legs.
Examine abdomen, genitalia and anus

Newborn exam link: https://www.youtube.com/watch?v=cracmPo3iYo

Fontanelles

sutures

Normal suture lines and fontanelles

Not normal. Could be hydrocephalus

Contact info: info@nursesinternational.org

According to Hesperian Health Guides ‘A Book for Midwives’- Chapter 14:

Head shape, sutures lines, and fontanelles:

· The newborn skull is made of 5 separate pieces, unlike children and adults which is solid

· Spaces between these 5 pieces are called sutures or sutures lines

· Babies skull has two larger soft areas between these sutures, called fontanelles.

· These spaces allow skull bones to squeeze during delivery for fetal head to pass through the mother’s vagina

· Moulding

o Sometimes skull bones overlap each other for the fetal head to be born, called moulding

o Moulding is normal

o Presents as pointed head and flattens (back to normal) in 1 to 3 days.

· Get medical help if :

· the sutures are unusually wide, if the front suture goes down to the middle of the forehead if the soft spots are tense or bulging the baby may have hydrocephalus (water in the brain).

· or there are no fontanelles.

· Caputs and hematoma:

o Swelling called caput can be felt in the area that was pressed against the cervix during labor and birth. It resolves in 1 or 2 days

o If the swelling does not cross a suture line, it may be a hematoma, indicating difficult birth for the baby.

o Hematoma can cause jaundice in the baby while healing. Monitor for jaundice in the baby while healing from hematoma, if possible get medical advice.

Examine ears:

· Look straight into the baby’s face.

· Imagine a line across the baby’s eyes.

· Some parts baby’s ear should be above this line.

· Low or uneven ears may indicate other problems in the baby’s body. Should get medical advice.

· Check baby’s hearing:

o Softly clap near the baby’s ears.

o Most babies will move when they hear a sound.

o if the baby does not hear, get medical advice.

Examine eyes

· Assess if both eyes move together, and seem normal.

· a little bit of blood under the surface of the sclera is normal, Resolves itself in a few days.

· Put antibiotics in the eyes to prevent blindness.

Check nose and mouth

· Check if the baby can breathe easily through the nose, if not try suctioning the baby.

· Gently stroke the baby’s cheek. Baby should turn head towards your finger, called rooting reflex.

· Put a very clean finger inside the baby’s mouth, the baby should suck on your finger.

· The absence of rooting or sucking may indicate the baby is weak or sick. Get medical help.

· Check for cleft lip (harelip) and cleft palate

o presence of opening or gap between baby’s upper lip, often connecting to the nose is called the cleft lip. It can be fixed by surgical operation at age of 4-6 months.

o A split in the roof of the baby’s mouth is cleft palate. Often repaired when the baby is about 1 ½ years old.

o Needs help with breastfeeding. In the case of cleft lip, the nipple should go deep into the baby’s mouth so the breast fills up the cleft. If there still space in the lip, the mother can put a finger over it.

o In the case of cleft palate, the nipple should be pointed to the side of the cleft and go as far back into the baby’s mouth as possible. Baby should drink with head up to prevent milk from going into his nose. If the baby cannot breastfeed, the mother can express the breastmilk and feed with a clean spoon.

Examine neck, chest, shoulder arms, and hands for swelling or lumps, or abnormality.

· Assess if the baby moves normally.

· Feel the bones to ensure they are not broken during delivery. If present, get medical help.

Assess belly

· Does it look normal? When the baby cries, if the insides of the belly push the skin out then it indicates belly muscles are not connected, called an umbilical hernia. Get medical help.

· Palpate belly for lumps, cysts, or other odd shapes under the skin.

Examine hips for dislocation:

· the upper leg partly covers part of the body

· There are not as many skin folds

· the leg may seem shorter or turned at an angle

· Hold both legs bent at knees, then open them wide. If a click is heard, get medical advice.

· To treat dislocated hips, parents will need to keep the baby’s knees high and open.

Examine genitals and anus

· examine if the anus is an opening or covered with skin. Baby having bowel movement indicates it is functioning well.

· For a boy, assess scrotum and penis

o feel for firm balls called testicles inside the scrotum. If you did not feel them, ask parents to feel for them in a month or so. If the testicles have not descended by then, advice to get medical help.

o if the hole of the penis is not in the right place or does not look normal, get medical help.

· For a baby girl, assess for the presence of outer and inner labia of her genitals.

o Ensure she has a small opening in her vagina. The absence of the vaginal opening needs surgical intervention.

o Tell parents it is normal for girls to have a small amount of blood from the vagina for 1 to 2 days after birth.

Examine feet

· if one foot turns inwards and cannot be straightened, the baby may have clubfoot. Can usually be fixed with a cast if the baby gets help in the first few days.

Examine back along the spine for holes, sores, cysts, growths, or tufts of hair. If any present, get medical advice.

Examine Neurological reflexes of the baby:

(Information extracted from- StatPearls Publishing, Jan 2020)

Assess for glabella sign:

With your finger tap in the baby’s head between the eyebrows. Normal response would be bilateral blinking of the baby’s eyes.

Assess doll’s eye reflex:

Briskly rotate baby’s head side-to-side and observe the baby’s eyes
Normal response would be that the baby move the eyes opposite of the rotation of the head, such that the eyes stay looking forward (like doll’s eye)

The asymmetric tonic neck reflex:

Rotate baby’s head to one side. The infant will extend its arm to the opposite side.

Assess Moro reflex:

Gather and pull up on both arms of the baby in supine position, then suddenly release both arms, or raise the head of the baby in supine position and let the head fall on your hand. The infant experiences the sensation of falling resulting in abduction at the shoulder and extension at the elbow with the spreading of the fingers, followed by immediate flexion of the upper extremities.

The grasping reflex:

Place your finger into the baby’s palm, this should result in flexion of the baby’s fingers forming a fist around your finger.

(Absent grasp

Assess babinski reflex:

Stimulate the lateral foot of the baby, this should result in dorsiflexion of the great toe and fanning of the other toes.

Assess plantar grasp:

places a finger to the plantar aspect of the baby’s foot. The normal response is curling inward of the toes.

Assess stepping:

holding the baby upright while both feet touch a surface. The normal response is that the baby raises the feet as if walking.

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Case Study:

A mother delivers an active infant weighing 2400g at a private hospital. Vitamin K is not given because the nurse said that the infant ‘is too small’. The nurse did not have time to administer the eye prophylaxis. The mother is not given the infant to hold after delivery and only visits her infant for the first time the following day. The hospital does not allow rooming in because it wants the mother to have rest. The mother is worried because the infant has a “ blocked nose” at times.

Is this infant too small to be given vitamin K?

Should the mother and infant be separated after delivery to give her a chance to rest?

Do you think that private hospitals should practise rooming-in?

Contact info: info@nursesinternational.org

Is this infant too small to be given vitamin K?

No. All infants must be given vitamin K to prevent haemorrhagic disease. Vitamin K is best given by intramuscular injection into the side of the thigh.

Why is it important that ‘eye prophylaxis’ is not forgotten?

Eye prophylaxis should be placed in both eyes after birth to prevent severe conjunctivitis due to infections from the mother’s genital tract during delivery.

Should the mother and infant be separated after delivery to give her a chance to rest?

No. Every effort must be made to keep the mother and her infant together. Most mothers want their infants to stay with them.

Do you think that private hospitals should practice rooming-in?

Yes. Rooming-in promotes bonding and breastfeeding and helps the mother become confident in caring for her infant. Many progressive private hospitals practice rooming-in because it is the best way of providing good care.

What factors to you think contributed to the nurse’s actions? How can this be accessed?

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Newborn Head to Toe Exam

Ears below the eyes can be sign that something is wrong

Moulding

Not normal. Hematoma

Cleft lip

Cleft Palate

Club foot

Check back along the spine for abnormalities

Clicking sound when moving hips is sign of a problem

click

Contact info: info@nursesinternational.org

According to Bettercare/Newborn Care/3. The routine care of normal infants:
Check if the baby has a tongue-tie, web of mucous membrane under the tongue that continues to the tip preventing the infant from sticking tongue out.

It does not interfere with sucking and usually corrects itself with time.
Do not cut the membrane as this may cause severe bleeding.
Refer the child to a surgeon if the tongue does not appear normal by 2 years.
It is very rare to interfere with speech development.

A blue patch over the sacrum is very common and is called a ‘Mongolian spot’.

seen in normal infants due to delayed migration of pigment cells in the skin.
It is not a sign of Down syndrome (mongolism).
Sometimes similar patches are seen over the back, arms, and legs, and may look like bruises.
Need no treatment and disappear during the first few years of life.
Unlike bruises, these patches do not change colour after a few days.

Few small pink or brown marks on the skin are also normal.
Pink areas on the upper eyelid, the bridge of the nose, and back of the neck that become more obvious when the infant cries are also normal and disappear during the first few years.

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Newborn Elimination

Newborns should urinate and pass stool within the first day of birth
If the newborn does not urinate or pass stool within 24 hours of birth

Urethra, anus or intestines may be blocked
Refer to health care provider

Four or more wet nappies/diapers per day by 72 hours of age indicates adequate milk intake
The infant should have three to four stools per day by the fourth day of life

stools of breastfeeding infants change from meconium to mustard yellow by third day of life
Pale stools and jaundice are indicators of liver disease

Contact info: info@nursesinternational.org

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Newborn Immunization

All babies should get the first injection of the hepatitis B vaccine within the first 12 hours of birth
In places with tuberculosis (TB) cases, or if the mother has TB, the newborn may be given the BCG vaccine at birth
Babies who are HIV positive should not be given BCG vaccine
Parents should be provided information about required vaccines
Please visit this site for WHO recommendations - https://www.who.int/teams/immunization-vaccines-and-biologicals/policies/who-recommendations-for-routine-immunization---summary-tables

Note: Document all immunizations

Obtain consent from parent before administering vaccines

Contact info: info@nursesinternational.org

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Infant Growth

Normal for a baby to lose 10% off their body weight the first week of life
The baby should regain their birth weight by 2 weeks and continue to gain weight steadily
The weight of the baby should be assessed and documented in the growth chart at every postnatal visit
Reasons for continued weight loss or insufficient growth:

Insufficient nutrition (not getting enough milk)
Infection
Diarrhea or other health problems

Babies who do not maintain expected growth patterns need to be evaluated by a healthcare professional

Contact info: info@nursesinternational.org

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Neonatal Jaundice

Neonatal jaundice: Yellow discoloration of skin and mucous membranes
Physiologic Jaundice (non urgent concern. Continue to monitor)

Associated with hyperbilirubinemia due to immature liver
Normally, a new baby’s body breaks the bilirubin down in a few days

Pathological Jaundice: (urgent concern, requires immediate attention)

Jaundice is seen before 24 hours of birth: possible ABO incompatibility

Other concerns:

Physiologic jaundice lasts for more than two weeks
Extends to the baby’s hands or feet
Baby seems very sleepy or does not wake up to breastfeed
Baby unable to maintain normal temperature
High levels of bilirubin may cause kernicterus (brain damage)

Contact info: info@nursesinternational.org

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Neonatal Jaundice

Clinical assessment:

Visual assessment: Yellow coloration of sclera, gums, yellow blanching of skin on nose or forehead when pressed upon with a finger; pale stool or yellow/dark urine
blood test for total serum bilirubin

Mild jaundice can be managed as follows:

Put infant in sunlight (helps to metabolize bilirubin) for 5 minutes, once or twice a day, morning sunlight preferable for 20 minutes

Baby should be undressed in the light to expose as much as the skin to the light as possible
Protect baby’s eyes from direct sun rays with eye pads
Make sure environment is warm to prevent hypothermia

Breastfeed frequently to prevent dehydration and metabolize bilirubin

Contact info: info@nursesinternational.org

According to NHS UK website on ‘Newborn Jaundice’:(https://www.nhs.uk/conditions/jaundice-newborn/diagnosis/)

Diagnosis can be made through combined assessment of:

Visual assessment:

yellow coloration of eyes, gums
gently pressing fingers on the tip of baby’s nose or on their forehead to spot any yellowing
Check baby’s urine for yellow/dark coloration, and stool for pale color

Bilirubin test:

blood sample collected by pricking baby’s heel with a needle and tested for serum bilirubin

According to Queensland Health, Queensland Clinical Guidelines on ‘Neonatal Jaundice’:

Clinical Assessment:

Examine all babies for jaundice every 8 to 12 hours in the first 72 hours of life and prior to discharge.
Do not rely on visual examination alone to assess level of jaundice
Potential signs of bilirubin encephalopathy:

lethargy
poor feeding
vomiting
high pitched cry
hypotonia followed by hypertonia
Opisthotonus
Seizures

The percentage of weight loss on day three may be predictive of significant hyperbilirubinemia
Dark urine may be indicative of conjugated hyperbilirubinemia
Pale stools and jaundice are key indicators of liver disease
Initial investigations for jaundice:

Maternal history of antenatal screening of blood group, RhD type, red cell antibodies
Test total serum bilirubin

Total bilirubin:

Conjugated, bilirubin:

unconjugated bilirubin:

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Danger Signs

Fast breathing: more than 60 breaths per minute
Chest indrawing: spaces between, above, or below the ribs indent with each breath (retractions)
Nasal flaring: sign of respiratory distress
Temperature too low or high: Temperature < 35.5 ℃ or > 37.5 ℃
Not feeding: No suck, and/or swallow, or no interest in feeding.
No movement: no spontaneous movement or no movement when stimulated
Listlessness: a feeling of lack of interest or energy
Convulsions or tremors: rhythmic shaking movements of the limbs
Dehydration and severe jaundice

A baby with danger signs needs urgent medical care!

Contact info: info@nursesinternational.org

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Postnatal Visits for Infants

First contact: 24 hours of birth
Second contact: between 48 - 72 hours of birth
Third contact: between 7 - 14 days of birth
Final contact at six weeks
Additional follow up visits are scheduled as follows:

After two days if breastfeeding difficulty, low birth weight in the first week of life, red umbilicus, skin infection, eye infection, thrush, or other problems; or,
After seven days if low birth weight baby was discharged at more than a week of age and gaining weight adequately

(WHO, 2014)

Contact info: info@nursesinternational.org

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Patient Teaching Before Discharge

Proper breastfeeding technique, emphasize exclusive breastfeeding for six months
Keep baby warm and dry
Cord care
Proper infant bathing technique
Assessment and management of mild jaundice
Information about Immunizations
Identification of danger signs and when to seek immediate medical help
Recommended routine postnatal visits for infants

Schedule the next visit before discharge!

Contact info: info@nursesinternational.org

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Informational Resources

In United States of America, newborn are routinely tested for metabolic disorders beginning 24-48 hours, as part of public health service
For more information on Recommended Uniform Screening Panel: https://www.hrsa.gov/advisory-committees/heritable-disorders/rusp/index.html
Newborn exam link:

https://www.youtube.com/watch?v=cracmPo3iYo

Assessment of newborn reflexes link: https://www.youtube.com/watch?v=rHYk1sYsge0&authuser=0

Contact info: info@nursesinternational.org

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Case study:

A normal infant weighs 3000 g at birth. By day 2, the infant appears well, but the weight has dropped to 2900 g. During discharge, the mother expressed her concerns about the infant’s weight loss.

How should the nurse address this mother’s worries?

What danger signs should be discussed with the mother before discharge?

Contact info: info@nursesinternational.org

How should the nurse address mother’s worries?

The nurse should inform the mother that it is normal for the baby to lose some weight during the first few days after birth, as long as the baby recovers the birth weight by 2 weeks.

The nurse should encourage the mother to breastfeed exclusively on-demand or every 2 hours, for at least 20 minutes each time.

Before discharge, what danger signs should the nurse inform the mother?

The nurse should inform the mother of the following danger signs :

Fast breathing: more than 60 breaths per minute

Chest indrawing: ( retractions) spaces between, above, or below the ribs indent with each breath

Temperature too low or high: Temperature < 35.5 ℃ or > 37.5 ℃ ( Obtained unfer arm pit)

Not feeding: No suck, and/or swallow, or no interest in feeding

No movement: no spontaneous movement or no movement when stimulated

Convulsions: rhythmic movements of the limbs that do not stop withholding

Dehydration and severe jaundice (dry mucous membranes or yellow skin and yellow sclera)

A baby with danger signs needs urgent medical care!

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Cultural Considerations

Cultural practices that do not harm the baby should be allowed

Cultural practices like using oil or other home treatments to help the cord fall off faster need to be reassessed with the family member in a family friendly way

Contact info: info@nursesinternational.org

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Reference:

American Academy of Pediatrics. (2020). ‘Helping Babies Survive: Essential Care of Every Baby, Facilitator Flip Chart’. Retrieved from: https://internationalresources.aap.org/Resource/Home

Beltre G, Mendez MD. Child Development. [Updated 2020 Oct 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564386/

Bettercare (n.d.). Newborn Care/ 3. The routine care of normal infants. Retrieved from: https://bettercare.co.za/learn/newborn-care/text/03.html#3-the-routine-care-of-normal-infants

CDC (2020). Breastfeeding/Vitamin K. Retrieved from: https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet-and-micronutrients/vitamin-k.html

Contact info: info@nursesinternational.org

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Reference:

CDC (February, 2020). Vaccines for Your Children. Retrieved from: https://www.cdc.gov/vaccines/parents/by-age/birth.html

Dishion E, Tadi P. Doll's Eyes. [Updated 2020 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551716/

Dysart, K.C. (Dec 2018). Neonatal Hypoglycemia. MSD Manual Professional version. Retrieved from: https://www.msdmanuals.com/professional/pediatrics/metabolic-electrolyte-and-toxic-disorders-in-neonates/neonatal-hypoglycemi a

Hesperian Health Guides ‘A Book for Midwives’. Retrieved from: https://en.hesperian.org/hhg/A_Book_for_Midwives:What_to_do_for_the_baby:_The_first_few_hours_after_the_birth

Contact info: info@nursesinternational.org

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Reference:

Hesperian Health Guides-’New Where There Is No Doctor: Newborn Babies and Breastfeeding’. Retrieved from

https://en.hesperian.org/hhg/New_Where_There_Is_No_Doctor:Chapter_27:_Newborn_Babies_and_Breastfeeding

KidsHealth.org (February 2018). What is the Apgar Score?. Retrieved from: https://kidshealth.org/en/parents/apgar.html?ref=search

Kondamudi, N.P., Krata, L., Wilt, A.S. Infant Apnea. [Updated 2020 Sep 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441969/

Modrell AK, Tadi P. Primitive Reflexes. [Updated 2020 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554606/

Contact info: info@nursesinternational.org

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Reference:

Queensland Clinical Guideline- Neonatal Jaundice, Queensland Health, Licensed under Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 Australia. Retrieved from:

https://www.health.qld.gov.au/__data/assets/pdf_file/0018/142038/g-jaundice.pdf

WHO (2014). Early essential newborn care: clinical practice pocket guide. Retrieved from: https://apps.who.int/iris/handle/10665/208158

WHO (2017). Managing complications in pregnancy and childbirth: a guide for midwives and doctors( 2nd ed.). Licence: CC BY-NC-SA 3.0 IGO. Retrieved from: https://apps.who.int/iris/handle/10665/255760

Contact info: info@nursesinternational.org

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