Assessment and Care of the Term Newborn Transitioning to Extrauterine Life

Assessment and Care of the Term Newborn Transitioning to Extrauterine Life

Lucinda Steen Stewart

Erin Rodgers


The birth of a baby is a life-changing event for a family, a life event that may have been anticipated for months or even years or may have been completely unplanned. Families transition to their new roles of mother, father, grandparent, or sibling in many different ways depending on cultural conventions, family traditions, personal decisions, and life circumstances. During this transition period, the nurse provides care to the newborn and family unit to optimize adaptations to extrauterine life. Not only does the nurse provide essential physical newborn care but also incorporates sensitive social, emotional, cultural, and spiritual care to the mother and family unit. This chapter contains information to guide the nurse in safe, client-centered care of the term newborn and family.

As early as 1991, the World Health Organization (WHO) and United Nations Children’s Emergency Fund (UNICEF) began to promote the global “Baby-Friendly Hospital Initiative.” The main purpose of this initiative is to promote practices that support breastfeeding in hopes of mothers exclusively breastfeeding and breastfeeding for a longer duration. Since that time, many hospitals have changed long-standing philosophies, policies, and practices of newborns being whisked off to the nursery for the first several hours of life, to having the newborn stay with the mother continuously throughout the hospital stay. In addition, extensive literature supports the importance of early contact between the newborn and the mother. Through such measures as early skin-to-skin contact and breastfeeding, maternal–infant bonding is enhanced.

These changes in practice oftentimes left the labor and delivery nurse to simultaneously care for the immediate postpartum woman as well as the transitioning newborn. In response to promoting patient care safety during this highly crucial transitioning time for mother and newborn, AWHONN’s Guidelines for Professional Registered Nurse Staffing for Perinatal Units (2010) recommends that one RN provide care for the immediate postpartum woman and a second RN be assigned to care for the newborn.3 Many institutions use either an additional labor and delivery nurse or a newborn nursery nurse to provide care for the transitioning newborn. Which nurse provides care for the newly born infant will depend upon philosophy of the facility, physical layout of the unit and staffing patterns. Each facility needs clearly outlined guidelines to define who is responsible for providing this care for each patient.

NOTE: Regardless of the nurse’s role, the criteria for care of the transitional newborn care remains the same.

Transition to Extrauterine Life

As the newborn takes its first breaths and the umbilical cord is clamped, a separate human life is begun.4,5,6 The newborn is expected to breathe spontaneously, cry, maintain a heart rate range of 100 to 180 bpm, demonstrate flexion of the extremities and have reflexes present, all within the first few minutes of life. With adequate respirations and circulation, color gradually changes from dusky blue/pink immediately after birth to the overall color normal for the newborn’s ethnicity. Lips and tongue should be pink for all ethnicities with transitional acrocyanosis expected.

Multiple physiological adaptations occur simultaneously due to mechanical, chemical, thermal, and sensorial stimuli. As the fetus is delivered vaginally or by cesarean birth, pressure
on the newborn thorax is released and passive recoil of the chest allows intake of air. The very low fetal pO2, high pCO2, stimulate chemoreceptors in the respiratory center of the brain to also initiate inspiration at birth (in the absence of acidosis). Continued respirations provide positive pressure to sustain alveolar inflation.

At the same time as these respiratory changes are occurring, fetal circulation also begins adapting to newborn circulation patterns. With cord clamping the umbilical artery, vein and ductus venosus close and will become ligaments over the next several weeks. Initial inspiration decreases intrathoracic pressure allowing decreased pulmonary resistance and increased pulmonary capillary filling. These adaptations lead to decreased right-sided heart pressures, thus permitting functional closure of the foramen ovale. When the newborn pO2 increases to approximately 50 mm Hg, the ductus arteriosus closes which allows for increased pulmonary circulation and increased circulation of oxygenated blood systemically, thus resulting in the newborn becoming pink in the first few minutes of life.

The newborn must also accomplish the essential adaptations of clearing the airway, regulating temperature, maintaining blood glucose control, and learning how to coordinate the suck and swallow reflex for successful breast- or bottle feeding. The nurse continuously assesses for the expected newborn adaptations and intervenes to promote optimal transitioning to extrauterine life.

Initial Assessment and Care of the Newborn4,6,7,8,9,10,11,12,13,14,15,16,17,18

During the initial newborn period, if an infant is transitioning well, the following sequence of events can be expected. Throughout this period, it is crucial that a nurse experienced in newborn care be vigilant in assisting this transition.

Initial drying and skin-to-skin contact: Newborns demonstrating an expected transition to extrauterine life are encouraged to remain with the woman for routine newborn care. Upon delivery, the infant is immediately placed prone, skin-to-skin, on woman’s bare abdomen. During this time the newborn is dried with blankets and a cap is placed on the newborn’s head. Removal of wet blankets and placing a warm dry blanket over the newborn and woman will help to prevent heat loss. The drying of the newborn also provides appropriate stimulation for spontaneous respirations. During this time, the nurse is continuously assessing the newborn. If the newborn is able to clear his/her own secretions without difficulty, then routine bulb suctioning is not warranted.

Cord clamping: There is much debate and controversy regarding the ideal time for cord clamping. When the umbilical cord is clamped too soon after birth, there is the potential for the newborn to not receive a sufficient amount of blood from the placental circulation and subsequently develop anemia and decreased iron stores. Other studies conclude that delaying the cord clamping allows too much blood to be delivered from the placenta to the newborn, resulting in polycythemia, and potential significant hyperbilirubinemia. The nurse caring for a newborn can expect either immediate cord clamping, within 15 to 20 seconds of birth, or delayed cord clamping, up to several minutes after birth depending on provider preferences and the newborn’s condition. (See Module 5 for additional information regarding delayed cord clamping.)

Initial assessment—Apgar scoring: At 1 minute of age, the initial Apgar score is assigned. The Apgar score is a quick assessment of five criteria, used to evaluate the newborn’s transition to extrauterine life. Introduced in 1952 by Dr. Virginia Apgar, the five criteria are outlined in Table 18.1: heart rate, respiratory rate, muscle tone, reflex irritability, and color, with each criteria scored from 0 to 2. The highest possible Apgar score is 10. The blanket covering the newborn is removed for this assessment. The Apgar score will be repeated at 5 minutes of age. If newborn condition warrants intervention, do not wait until 1-minute Apgar to begin resuscitation. The Apgar score is helpful in evaluating the newborn’s adjustment to extrauterine life. It is an indicator for neither implementation of neonatal resuscitation nor of future neurological outcome.18 As the Apgar score does require some subjective evaluation of the newborn’s physiological condition, the assessment should be done by a nurse experienced in newborn care or a neonatal team member.

  • Total score of 7 to 10: Adjusting well to extrauterine life

  • Total score of 4 to 6: Moderate difficulty adjusting to extrauterine life

  • Total score of 0 to 3: Severe distress


Heart rate Not detectable <100 >100
Respiratory rate Absent Slow, irregular Good, crying
Muscle tone Flaccid Some extremity flexion Active motion
Reflex irritability      
   Response to tap on sole of foot No response Grimace Grimace
   Response to catheter in nostril (after oropharynx is cleared) No response Cry Cough or sneeze
Color Blue, pale Body pink, blue extremities Completely pink
Reprinted with permission from Apgar, V. (1953). A proposal for a new method of evaluation of the newborn infant. Current Researches in Anesthesia and Analgesia, 32(4), 260–267.

Newborn identification: In order to protect the safety of the newborn, early and accurate identification is imperative. This will include applying matching identification bracelets on the newborn, mother, and support person. This is done in the delivery area, prior to any separation from mother or transport to another unit. Often, the newborn has a bracelet applied to each ankle, or to an ankle and wrist, and should be secured tight enough to remain on the infant with anticipated weight loss but should not impair blood flow to the extremity. In addition, some hospitals have electronic infant security systems that require bands that remain in constant contact with the newborn’s skin to prevent alarming. It is important to be knowledgeable of hospital policies and provide consistent infant identification and security measures.

Early breastfeeding: Breastfeeding during the immediate postpartum period should be encouraged and supported by nurses. AWHONN supports breastfeeding as the optimal method of infant nutrition. If the women wishes to breastfeed and the newborn is transitioning well to extrauterine life, breastfeeding can begin within a few minutes of birth. Breastfeeding in the first hour of life can improve success rate and duration of breastfeeding.

Apgar at 5 minutes of age: As the nurse continues to closely monitor the newborn, a second Apgar score is assessed at 5 minutes of age. This score can be obtained as the newborn and mother continue skin-to-skin contact. If the 5-minute Apgar is less than 7, it is recommended by the American Academy of Pediatrics (AAP) to repeat the Apgar score every 5 minutes up to 20 minutes. In addition, other supportive measures per Neonatal Resuscitation Program (NRP) guidelines are continued to facilitate transition. Factors that may influence the Apgar score are outlined in Table 18.2.

First set of vital signs: Though protocol can vary for different institutions, it can be expected that the first set of vital signs will be obtained at 30 minutes of age. This will include heart rate, respiratory rate, and temperature. Axillary temperature is an accurate and safe method to measure body temperature in the newborn. Many institutions require initial temperature to be measured at 15 minutes of age. If the newborn continues to transition well, vital signs are obtained every

30 minutes until the newborn has remained stable for 2 hours. In addition to vital signs, the nurse will continue to assess skin color, respiratory effort, muscle tone, and level of activity every 30 minutes as well. Vital signs can be measured while the newborn remains skin-to-skin (Table 18.3).


Factors that can cause variations in Apgar scores
Several factors can cause variations in Apgar scores and may not indicate a need for resuscitation. An overall clinical evaluation is important in these situations when considering the care of the infant. Some of these factors include the following:
Gestational age The standard Apgar goal of 10 points might not be an appropriate gauge of fetal well-being for babies of less than 31–34 wks’ gestation. These infants often lack the tone of a term infant and the ability to respond appropriately when reflex irritability is tested.
Intubation and cord visualization Meconium-stained amniotic fluid may indicate the need for immediate intubation and suctioning of the hypopharynx and trachea. Intubation often produces stimulation of the vagus nerve and subsequent temporary lowering of the heart rate. Newborns usually recover from this intervention spontaneously, but this temporary slowing of the heart rate can affect Apgar scoring.
Congenital defects Newborns with congenital defects of the heart or neuromuscular or cerebral malformations may have Apgar scores that do not reflect a need for resuscitation. These infants need further evaluation.
Infection Infection in the newborn may affect tone, color, and reflexes.


Heart rate: count for a full minute Apical heart rate: 120–160 bpm, when awake Variations: Heart rate can increase to 180 bpm with crying and decrease to 100 bpm with sleeping.
Respiratory rate: count for a full minute 30–60 breaths/min Variations: Periodic breathing (irregular rate and rhythm) can occur. RR can increase with crying, and decrease with sleeping. Sometimes rate is elevated just after birth, but decreases to a normal range by 1–2 hrs old.
Triggers: Respiratory distress or apnea greater than 15 sec is not an expected variation.
Temperature: Axillary: 36.5–37.2°C or 97.7–99°F Triggers: Hypothermia, hyperthermia, or temperature instability can be related to infection or uncontrolled environmental temperature.
RR, respiratory rate.

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Jul 10, 2020 | Posted by in NURSING | Comments Off on Assessment and Care of the Term Newborn Transitioning to Extrauterine Life

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