The baby as an individual

Woman-centred care has been an important development in providing choice, continuity and control to women and their families. However, it is likely that the time and attention paid to the assessment and care of the baby, even on a day-to-day basis, has been a fraction of that paid to the woman. It is crucial that babies are viewed as individuals in their own right and that midwives allocate the same attention to their assessment and care. This requires in-depth knowledge of neonatal psychological and physiological development, and complex communication and educational skills.

The baby is recognized as a person (Children Act 1989) with individual needs that require the midwife to act as an advocate and act with duty of care for those needs. Rather than relying on verbal responses, the midwife communicates with the baby via sight, touch and hearing. This must be a focused activity in order to absorb all of the information provided by the baby’s responses and behaviour. Upon completion of the examination, the findings must be discussed with the parents so that the baby’s management and care can be planned as a partnership. Prior to the examination, the midwife must gain consent from the legal guardian. If an unmarried woman is unable to give consent, then it has to be gained from the woman’s next of kin. This should be discussed with the woman when she first attends for care, so that she can provide this information, which may be required in an emergency.

If consent is withheld, then further information, support of a peer, or medical advice may be sought. Consent needs to be obtained by the person providing the care – i.e. if the baby deviates from normal, the decision of how to proceed must be made in partnership with a senior neonatologist.

If the woman wishes the baby to be given oral (or no) vitamin K preparation, the midwife has a duty, under statute (NMC 2004), to ask the paediatrician to see the mother and ensure that the decision-making outcome is recorded in the baby’s notes. If invasive treatment is required, then consent needs to be obtained by the person implementing the invasive procedure, so that the parents can be given the information they need. If the parents feel that they have not been given adequate information, then consent may not be deemed valid (DH 2001).

If the parents refuse life-saving care for the baby, the midwife needs to work with the appropriate professionals (GP or senior neonatologist) to enable the parents to understand the severity of the situation. It is crucial to record what information has been given, and any discussions that take place.

The midwife should clearly document the decisions and justification of actions and omissions, providing a clear picture of the transitional events that occurred at birth and during the first 28 days of postnatal life.

Assessment of the newborn

This assessment is not a ‘one-off’ assessment but a complex, dynamic and continuous activity throughout the antenatal period, labour, at birth and in the neonatal period. Quick recognition and appropriate referral of the fetus/neonate with deviations from normal, results in an enhanced quality of life for that baby and family.

In order to achieve this, a formalized communication system between the baby and midwife is vital.

For a period of 9 months, the fetus has been in a safe, untouched and warm environment in which every need is catered for, free movement is allowed and psychological attachment to the mother is developed.

The long-term effects of the birth experience, and transition from this safe environment, are unknown, and it is imperative that birth attendants consider the baby and the environment he has recently left with equal empathy and care as that offered to the mother.

Respiratory system

In this section, the embryological development of lungs, role of lung fluid, fetal breathing movements, and development and function of surfactant will be explored. The respiratory system consists of:

The transitional events that take place, in order for the baby to take the initial breath, change the lungs from passive organs filled with fluid to structures which play a vital role in aerobic metabolism.

In uterine life, the fetus obtains oxygen and excretes carbon dioxide via the placenta. Although the lungs are not used for gaseous exchange, the healthy fetus makes breathing movements 80% of the time in utero to exercise the muscles of respiration.

Cardiovascular system (CVS) in the embryo and fetus

The first functioning system in the embryo, the CVS, is composed of the heart and blood vessels and is a closed system that continuously circulates a given blood volume. Blood can be seen circulating in the body by the end of 3 weeks.

Temperature control

Following birth, the baby must adjust to a lower and labile environmental temperature. The heat-regulating mechanism in the newborn is inefficient and the body temperature may drop unless great care is taken to avoid chilling. Heat is lost by radiation, convection, evaporation and conduction. These factors can be rectified if the baby is born into a warm environment of 26°C, dried carefully and wrapped warmly or provided with skin-to-skin contact with the mother (see Ch. 42).

Skin

The full-term newborn’s skin is well developed, opaque with few veins visible, has limited pigmentation and wrinkles around joints.

The layers of the skin include the epidermis, dermis, and subcutaneous layer. The epidermis is a thin, effective barrier preventing penetration and absorption of potential toxins and microorganisms and retaining water, heat, and other substances (see website).

The skin of full-term newborns is covered with a varying amount of vernix caseosa, a thick white, creamy substance. This forms between 17 and 20 weeks’ gestation and by 40 weeks is found primarily in creases such as the axilla, neck and groins, acting as protection during uterine life (Moore & Persaud 2007). Vernix is a perfectly balanced moisturizer and any surplus should be massaged gently into the baby’s skin after the birth.

Gastrointestinal system (see website)

Normal function of the gastrointestinal (GI) system should be established prior to artificially feeding the newborn baby. This can be achieved through reviewing the woman’s history and antenatal profile. Polyhydramnios, for example, may indicate disruption of the GI tract.

The midwife needs to understand glucose metabolism of the fetus and newborn in order to support the woman in her chosen method of infant feeding (de Rooy & Hawdon 2002) (see Ch. 43).

After birth, the maturation of the GI tract is stimulated by specific peptides: enteroglucagon stimulates intestinal mucosa to develop and motilin encourages gut motor activity.

Nutritive/non-nutritive sucking is the baby’s main pleasure and may be satisfied by breast- or bottle-feeding alone. Babies will find solace in sucking their fingers or thumbs or suckling at the breast. Mothers need to understand why the baby is frequently feeding, so that they are reassured and not concerned that they have insufficient milk to satisfy their baby.

The knee-to-abdomen position increases abdominal pressure and may cause vomiting of newly ingested food, therefore napkin changing should be avoided soon after a feed. The supporting gastric and intestinal musculature of the newborn is relatively deficient, shown by the reduced peristaltic movement and the tendency towards distension. The use of pethidine or morphine during labour may decrease peristalsis and in some cases increase regurgitation for several days following birth.

Meconium, a soft, greenish black viscid substance which has gradually accumulated in the intestine from about the 16th week of intrauterine life, consists of mucus, epithelial cells, swallowed amniotic fluid, fatty acids and bile pigments.

• 5th day onwards – the stools become yellow:

The breastfed baby passes:

– soft, bright-yellow inoffensive stools

– may pass stools five or more times a day as lactation is establishing

– after 3 or 4 weeks (when lactation fully established) may only pass one soft yellow stool every 2 or 3 days as there are few waste products from breast milk.

The artificially fed baby passes:

– paler, more formed stools with a slightly offensive odour

– more regular stools when feeding is established, though constipation is more likely.

Renal system

The fetus passes urine into the amniotic fluid during pregnancy and oligohydramnios may indicate renal abnormalities. At term, the kidneys are relatively immature, especially the renal cortex. Glomerular filtration rate and ability to concentrate urine are limited. Relatively large amounts of fluid are required to excrete solids.

The baby should pass urine, which has a low specific gravity, within 24 hours of birth. Initially, urinary output is about 20–30 mL per day, rising to 100–200 mL daily by the end of the first week as fluid intake increases.

If the baby becomes dehydrated, excretion of solids such as urea and sodium chloride is impaired. Dehydration can be recognized by a sunken fontanelle, dry mouth and skin inelasticity, and, most importantly, more than 10% loss of birth weight. It is important to note that a baby who is dehydrated will continue to pass the normal amount of urine, thus a wet nappy does not validate normality.

Glucose metabolism

See website for fetal metabolism.

In utero, the fetus relies on the intravenous transfer of glucose and other nutrients via the umbilical vein for growth and development. Fetal metabolism is directed to anabolism under the influence of insulin, utilizing glycogen, fat and protein.

Musculoskeletal system

The musculoskeletal system provides stability and mobility for all physical activity and includes the bones, joints, and supporting and connecting tissue. This provides a means of protection for vital organs (brain, spinal cord), mineral storage (calcium, phosphorus) and production of red blood cells. In comparison with an adult or child’s skeleton, the newborn’s skeleton is flexible, the bones mainly consisting of cartilage, and joints are elastic, facilitating the passage through the birth canal.

Normal variations in shape, size, contour, or movement may be due to position in utero or genetic factors and should be distinguished from congenital anomalies and birth trauma. Early diagnosis of disorders and early intervention often prevent long-term deformity and the need for surgery.

Central nervous system

The development of the neurological system commences 18 days post conception (see website). After birth, the brain continues to grow rapidly within the first year of life, follows a more gradual growth rate until the age of 10, and then there is minimal growth to adolescence. Physiological and psychological wellbeing are vital to the development of full neurological potential.

Babies born at term can be active participants in their environment and are capable of social interaction. It has been shown that they are able to mimic the expression of their carers and are able to some extent to self-regulate themselves.

At birth, the baby’s autonomic system maintains homeostasis of all major organs, regulating temperature and cardiorespiratory function. The well newborn will have mature autonomic and motor systems which can be assessed by the ability to maintain stable cardiorespiratory function. If the baby is unwell or premature, handling will stress the autonomic system and the baby can become cyanosed and bradycardic (Roberton & Rennie 2001).

State of consciousness in the newborn is influenced by the reaction to stimuli, and understanding the baby’s level of consciousness ensures sensitive care and management in assisting in the adaptation to the environment and advance through stages of consciousness. Providing this information to the mother assists her in caring for her baby, may assist feeding, and utilizes the baby’s energy and available resources effectively (see Box 41.1).

Babies are able to ‘tune out’ noxious stimuli and this occurs through the process of habituation. The baby stores the memory of the stimulus and with repeated episodes learns not to respond to it. Overstimulation of babies who are on system overload will cause them to suffer further stress, requiring appropriate care such as minimal handling and an environment with minimal noise and lights in order to support recovery.

The newborn baby has very poor motor development compared with other mammals but highly developed senses (sight, hearing, taste, smell); hence the importance of picking babies up, talking to them and stroking them to stimulate and evoke response. Maternal–infant interaction is facilitated by eye-to-eye contact with the mother. A 12-day-old baby is able to imitate the facial and manual gestures of adults and this may operate as a positive feedback mechanism to caregivers.

Protection against infection

In utero, the fetus is protected from infection by the intact amniotic sac and the barrier mechanism of the placenta, although certain microorganisms do cross the placenta and may infect the fetus (see Ch. 47). During the last trimester of pregnancy, there is a transplacental transfer of IgG from the mother to the fetus, providing protection against the infectious diseases to which the mother has antibodies. These antibodies provide baby passive immunity for about 6 months (Remington & Klein 2000).

The newborn baby has no immunity to the common organisms, and when exposed to them at birth for the first time, is highly susceptible to infection. Soon after birth, the baby becomes colonized by the mother’s set of microorganisms, facilitated by early and frequent contact. Clinical infection occurs when the number and virulence of the organisms overwhelm the poorly developed defence mechanisms of the baby. Breastfeeding encourages specific bacteria to multiply in the bowel and the acid conditions that result from this may help to prevent the overgrowth of potential pathogens, providing some protection from infection.

Preparation

The midwife is obliged to support the birth of any baby showing signs of life at any gestation – in all environments, including outside hospital. It is crucial that midwives are knowledgeable about the physiology of the baby born at different gestations, and how this changes their care and management needs.

Preparations should be made prior to the baby’s birth and these include identifying women whose babies are at increased risk or who will require specialist care following delivery. The midwife must be prepared to provide care for ‘high-risk’ and ‘low-risk’ women (see Box 41.2), though research indicates that the classification of risk factors remains a debatable area.

The development of complications during labour and birth is a major contributor to increased neonatal mortality and morbidity (MCHRC 2001). The midwife can identify that all is normal, detect any deviations and make appropriate referral or alter management of care accordingly.

This action plan begins antenatally to ensure that the woman is prepared and informed to self-manage her body and pregnancy so that she becomes confident and seeks appropriate support should deviations occur.

At birth, the transition to independent life involves a significant physiological shift. The midwife needs to have a good insight into changes of fetal physiology, in order to evaluate the care each individual newborn baby requires.

The Apgar score

The Apgar score, devised by Virginia Apgar in 1953 (Levene & Tudehope 1993), is a universally and commonly used quantitative measure of the neonate’s wellbeing at and around birth, though criticized for its simplicity. Five indicators are used to measure this: heart rate, respiratory effort, colour, muscle tone and response to stimuli (Table 41.1).

Table 41.1 The Apgar score

Recording the numerical score alone provides insufficient information concerning the neonatal condition. The important factor is that the neonate’s physiological condition and progress is recorded verbally and in writing until the neonate is in a good condition.

It is also advisable, if more than one practitioner is present at a delivery where resuscitation is undertaken, that the baby’s Apgar score is agreed between practitioners prior to the formal record being made. Disagreements can be discussed with the supervisor of midwives and senior neonatologist. It is important for the future management of the newborn’s wellbeing that an accurate assessment is given (UK Resuscitation Council 2006).

The heart and respiratory rate, the most important measures within this scoring system, will indicate the nature and timing of active resuscitation. An Apgar score of 8–9 indicates that the neonate is in good condition. The midwife should expect that most mature babies would obtain a score of about 9 as those above 38 weeks’ gestation will have a mature neurological system restricting blood flow to the extremities in order to supply the brain and other major organs with extra oxygenated blood. Therefore the baby will have acrocyanosis and this continues until after 24 hours because of poor peripheral circulation (see website).

Maternal–infant relationship

The relationship between mother and baby begins at birth. The experience of the pregnancy may act as a positive or negative foundation for this relationship. The mother’s reaction to her baby will vary greatly according to her culture, experience, expectations and environment and will be affected by her physical and emotional state. In some cultures, the mother will wish to have immediate and close contact with her baby from the moment of birth. Others will want the baby cleansed before holding. So that individual needs can be appropriately met, the midwife needs to discuss the mother’s wishes, expectations and fears prior to the labour.

‘Bonding’ is a term to be used with caution as it may imply an immediate and strong relationship at the moment of first sight. This may be very threatening and inhibiting for some mothers who will build up their relationship with their new baby in a slower and less obvious way, though the end result is as enduring and strong (see website).

Research illustrates mothers’ reactions to newborn infants. The mother’s first response is to touch her baby (easier if the baby is naked) with fingertips, progressing to a protective caressing movement. The mother will often then move the baby to a position to facilitate face-to-face eye contact. Throughout this time, she talks to the baby in a higher-pitched voice than usual (Klaus & Kennell 1976). Early research suggested the existence of a ‘sensitive time’ around the birth, at which the mother and baby should be encouraged to be together, and that women missing this time were at risk of neglecting or abusing their infants. However, Brazelton postulated that even should parent and child have to be separated, if the attendants ensure that the mother has photographs of her baby and is involved in the baby’s management and care, cuddling or even just touching her child, the relationship can be effectively preserved and nurtured (Brazelton 1983).

Warmth

The baby, accustomed to a constant intrauterine temperature of 37.8°C, is born into a much cooler atmosphere, ideally 26°C. At birth, the baby should be dried immediately to prevent evaporation and handed to the mother to keep warm, avoiding unnecessary exposure. Warm covers are placed over the baby, if necessary for skin-to-skin contact, and later the baby should be dressed, covered appropriately and placed in a preheated cot. Within an hour of birth, the baby’s axillary temperature is taken using a low-reading thermometer (see Ch. 42).

Identification

Two identification labels record name, date of birth and sex, using an indelible pen with clear and legible writing. These should be shown to the mother or partner and applied to the baby’s ankles or wrists in the mother’s presence. Should a label become detached, a replacement should be completed and placed on the baby using the same procedure. Ideally, the labels should not be removed until the baby is in his own home. During daily examination, these labels are checked by the midwife for cleanliness, comfort – neither too tight nor too loose for the baby’s wrist or ankle – and number (i.e. two).

Several maternity units have developed systems to ensure that babies are properly identified and secure, including recording footprints and handprints, and these should include the names of the mother and baby.

Ideally, a resuscitaire should be situated in the delivery room, because, should the baby need resuscitation, to remove him from his parents can add significantly to their distress. If the baby has to be separated from the mother, a relative must accompany the baby to enable feedback to be given to the mother as to what events took place and to validate that the baby returned to the mother is indeed her own baby.

Vitamin K

Following birth, free circulating vitamin K is low, decreasing during the first few days of life and gradually rising after 3–4 days. This may result in excessive bleeding if trauma occurs, for example during instrumental delivery.

It has been advised that all babies should be given vitamin K (DH) and parents should be provided with information on whether or not to give vitamin K and the route of administration as advised in the Drugs and Therapeutics Bulletin (www.dtb.org.uk/dtb/index.html).

Vitamin K deficiency bleeding (VKDB) (formerly known as haemorrhagic disease of the newborn) is a bleeding tendency which results from a lack of ability in the newborn to utilize vitamin K (see Ch. 44).

Signs and symptoms include bleeding from:

Oral use of vitamin K

Absorption from the gastrointestinal tract is erratic in the newborn and there is the possibility of regurgitation, inhalation and loss of vitamin K. Additional evidence is required before firm recommendations can be made concerning the optimal dose and form of the vitamin K.

Initial post-birth examination

The midwife will undertake a thorough examination of the newborn soon after birth. This initial examination uses information elicited from intuitive knowledge gained from experience; the Apgar score; and physiological assessment using the senses: sound, vision and touch. It provides basic information, detects any obvious abnormalities or deviations from normal that require referral, and provides an opportunity for the midwife to support the parents in their role as carers for the new addition to their family.

Prior to this first examination, the baby should have at least 1 hour following birth to recover (NICE 2006). This allows mother and baby time to adapt to physiological changes and gives the baby time to adapt to the environment and, if breastfeeding, to feed successfully.

The holistic examination

This examination – including heart and lung sounds, full central nervous system examination, abdominal examination and examination of the neonate’s hips – is undertaken by an appropriately trained health professional. Some of these skills require postgraduate training at present. The main aim of the holistic examination is to validate normality and, where possible, detect abnormalities and communicate any action required to the parents.

Since 1994, increasingly midwives have undertaken this holistic examination rather than their medical colleagues, providing continuity of care as recommended by Changing childbirth (DH 1993), facilitating the midwife’s self-audit and with the potential for improving interprofessional partnerships (Hall 1999).

Midwives have a vital role to recognize and validate normality and refer when deviation from the norm is detected. Any possible problems should be ascertained at the outset, providing stabilization and minimizing any future harm prior to transfer in order to ensure future wellbeing.

The United Kingdom National Screening Committee (UKNSC) of the Newborn and Infant Physical Examination (NIPE) (UKNSC 2008) advocates the first holistic examination is undertaken within 72 hours of birth, allowing the postnatal transition of major organs, such as the heart, to take place prior to examination. This is done prior to discharge and transfer to the care of a health visitor and GP. It is expected that the midwife (NICE 2006) will care for the newborn from birth to 6 to 8 weeks. It is intended that the second holistic examination is combined into a single postnatal visit at 6 weeks to validate the woman’s wellbeing. In between those two examinations, the midwife will assess each baby, reviewing past and present individual history prior to deciding which criteria need assessment during physical examination and which can be validated through observation alone.

Examination of the newborn assessment tool

A clinical assessment tool (see website also) has been designed to assess the physiological and behavioural cues to assist the midwife to validate normality and recognize deviations (Michaelides 2010).

Using a tool enables the midwife to gather important information through assessment and analysis of the woman’s oral and recorded history. A systematic framework, beginning with examination of the heart while the baby is quiet, goes through to the most intrusive testing – the Moro reflex and measuring the head circumference – at the end. The latter is undertaken last as the baby will find it uncomfortable and will require comforting upon completion.

The tool consists of 26 criteria (Fig. 41.1 A–Z), the number of which that will be fully examined at each examination being dependent on the purpose of the examination, and the experience and training of the midwife.

Figure 41.1 The A–Z Examination of the Newborn tool, detailing the different systems.

Preparation

Preparation is vital to ensure a smooth and effective examination process. An area, to provide privacy and a controlled environment, needs to be set aside; an examining table with an overhead heater and light source can be utilized to examine babies at a height that will prevent practitioner back strain. It provides a safe environment for the baby (see Fig. 41.2) and a safe storage space for the required equipment (see Box 41.3). In the home environment, the midwife can use a changing mattress or table (or similar surface area) covered with a warm sheet/towel to examine the baby.

Figure 41.2 Apparatus for examining babies.

Box 41.3

Resources and equipment required to undertake the examination

• Firm surface

• Sheets and blankets

• A spare nappy

• Cleaning equipment (bowl and cotton wool)

• Ophthalmoscope (cleaned and pre-set to the practitioner’s eyesight)

• Stethoscope

• Small torch

• Tape measure

• Thermometer

• Mediswabs

• Gloves

• Cord clamp remover

• Bag for used nappy

• Non-stretchable tape measure

• Scales

• Supine stadiometer/roll measuring mat

Daily examination

As part of the postnatal examination, the midwife will examine the baby, including checking the eyes, skin, umbilicus and napkin area, feeding patterns, and (if in hospital) the presence of two identification labels. This examination provides an opportunity to teach the mother what to look for in monitoring her baby’s wellbeing, and to learn skills in baby care.

Formal assessment of the newborn

Physical examination of the newborn baby should be performed systematically, examining each physiological system to ensure entirety (see Fig. 41.1), using the skills of observation, palpation and, where relevant, auscultation. Each system should be critically evaluated, normality validated and deviations recognized. Where deviations occur, the midwife needs to ascertain the severity in order to plan appropriate management and transfer to the care of the neonatologist as appropriate.

The midwife needs to explain that the assessment of wellbeing is a continual process and that each examination only validates normality for that moment in time. With continual observation, care and professional support through education and physical assessment, there is a growing reassurance.

History

During the antenatal period, a full record is taken of the family, previous medical and obstetric histories of the woman and partner. The present pregnancy, labour and prenatal period should be reviewed to identify any risk factors which may affect the baby.

When obtaining a history from women, it is important that the communication process is open and interactive. Women should be given the reasons for certain questions and how this affects the care provided (see website).

Laboratory results need to be assessed by the midwife for their relevance to the assessment of the newborn. For example, a group O positive mother with a baby who is jaundiced may trigger consideration of the possibility of ABO incompatibility.

Kell antibodies can attack the bone marrow, reduce red cell production and may result in the baby being anaemic at the time of birth. Anaemia in the newborn will render the baby hypoxic, requiring resuscitation at the time of birth and administration of fresh blood.

Sexually transmitted diseases, if not treated in the antenatal period, may affect the baby postnatally and thus the baby will need to be observed for signs of infection (see Ch. 47).

Health education is important though it is not always possible to reduce at-risk behaviour of women, and a non-judgemental and supportive approach is required in obtaining true and accurate information to facilitate appropriate care (see website).

Information such as the date of the first day of the last menstrual period (LMP) and the estimated date of conception (EDC) is crucial in the calculation of gestational age, an important aspect of management of care.

When undertaken correctly, fetal surveillance (see Ch. 36) can assist the midwife to have the relevant practitioners present at birth. The type of birth may affect the management of the baby – after a protracted labour, the baby may be traumatized and may require an initial superficial examination to validate wellbeing, followed by a full examination when signs of recovery are apparent. Minimal handling may assist the shocked newborn to recover. The examination should last no longer than 15 minutes.

Maternal concerns are an important guide to the focus of the examination as the majority of women will spend time examining, feeling, stroking and counting their baby’s fingers and toes. In the majority of cases, they themselves will recognize if their baby deviates from normal.

General appearance

A baby’s age and gestation will influence his general appearance. Type of birth, postnatal age, and the timing of the last feed affects his behaviour. A hungry baby will be difficult to examine as many of the assessments require a quiet, calm baby, able to tolerate handling for 10–15 minutes in order to complete the physical examination.

A baby who has had a difficult birth may be very irritable or be in a deep sleep (State 1 – see Box 41.1), and the midwife uses the baby’s behaviour to guide the examination. The physical examination can be delayed until the baby is able to tolerate handling and an interim observational examination undertaken.

Observation

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