Immediate Care After Birth

The primary goal of care in the first moments after birth is to assist the newly born infant to transition to extrauterine life by establishing effective respirations. If the infant is at term, is crying or breathing, and has good muscle tone, routine care can begin (Kattwinkel, Perlman, Aziz, et al., 2010). The infant is placed prone on the mother’s abdomen or chest, and the nurse assesses the airway. Slight extension of the neck helps keep the airway patent. Drying the infant with vigorous rubbing removes moisture to prevent evaporative heat loss and provides tactile stimulation to stimulate respiratory effort. The mother and her newborn are covered with a warm blanket (Niermeyer and Clarke, 2011).

If the neonate is apneic or has gasping respirations, positive-pressure ventilation is needed. The heart rate is quickly assessed by grasping the base of the cord or by auscultating the left chest with a stethoscope. Count for 6 seconds and multiply by 10 to calculate the heart rate. It should be greater than 100 beats/min. The newborn’s trunk and lips should be pink; acrocyanosis is a normal finding (see Fig. 22-4) (Niermeyer and Clarke, 2011).

If the newborn requires respiratory or circulatory support, the nurse and other members of the health care team (e.g., neonatologist, respiratory therapist) follow the American Heart Association guidelines for neonatal resuscitation (Kattwinkel, Perlman, Aziz, et al., 2010). The neonatal resuscitation algorithm directs the care (Fig. 23-1).

As soon as possible after birth, the nurse places identically numbered bands on the infant’s wrist and ankle, on the mother, and on the father or significant other. An electronic infant security tag or abduction system alarm should be placed on all newborns to aid in protecting against infant abduction. The infant is footprinted with ink or a scanning device within 2 hours of birth (Vincent, 2009). (See later discussion of infant abduction.)

Apgar Scoring and Initial Assessment

The initial assessment of the neonate is performed immediately after birth using the Apgar score (Table 23-1) and a brief physical examination (Table 23-2). A gestational age assessment is completed within the first hours of birth in a stable newborn (Fig. 23-2). A more comprehensive physical assessment is completed within 24 hours of birth (Table 23-3).

TABLE 23-2

INITIAL PHYSICAL ASSESSMENT OF THE NEWBORN

General appearance	Color pink
	Acrocyanosis present
	Flexed posture
	Alert
	Active
Respiratory system	Airway patent
	No upper airway congestion
	No retractions or nasal flaring
	Respiratory rate, 30-60 breaths/min
	Lungs clear to auscultation bilaterally
	Chest expansion symmetric
Cardiovascular system	Heart rate strong and regular
	No murmurs heard
	Pulses strong and equal bilaterally
Neurologic system	Moves extremities
	Normotonic
	Symmetric features, movement
	Reflexes present:
	Sucking	Rooting
	Moro	Grasp
	Anterior fontanel soft and flat
Gastrointestinal system	Abdomen soft, no distention
	Cord attached and clamped
	Anus appears patent
Eyes, nose, mouth	Eyes clear
	Palates intact
	Nares patent
Skin	No signs of birth trauma
	No lesions or abrasions
Genitourinary system	Normal genitalia
Other	No obvious anomalies
Comments: ___________________________________________________ ___________________________________________________ ___________________________________________________

TABLE 23-3

PHYSICAL ASSESSMENT OF THE NEWBORN

AREA ASSESSED AND APPRAISAL PROCEDURE	NORMAL FINDINGS		DEVIATIONS FROM NORMAL RANGE: POSSIBLE PROBLEMS (ETIOLOGY)
	AVERAGE FINDINGS	NORMAL VARIATIONS
Posture
Inspect newborn before disturbing for assessment Refer to maternal chart for fetal presentation, position, and type of birth (vaginal, surgical), given that newborn readily assumes in utero position	Vertex: arms, legs in moderate flexion; fists clenched Resistance to having extremities extended for examination or measurement, crying possible when attempted Cessation of crying when allowed to resume curled-up fetal position (lateral) Normal spontaneous movement bilaterally asynchronous (legs moving in bicycle fashion) but equal extension in all extremities	Frank breech: legs straighter and stiff, newborn assuming intrauterine position in repose for a few days Prenatal pressure on limb or shoulder possibly causing temporary facial asymmetry or resistance to extension of extremities	Hypotonia, relaxed posture while awake (preterm or hypoxia in utero, maternal medications, neuromuscular disorder such as spinal muscular atrophy) Hypertonia (chemical dependence, central nervous system [CNS] disorder) Limitation of motion in any of extremities
Vital Signs
Check heart rate and pulses:
Thorax (chest)
Inspection	Visible pulsations in left midclavicular line, fifth intercostal space
Palpation	Apical pulse, fourth intercostal space 120-160 beats/min when awake	80-100 beats/min (sleeping) to 180 beats/min (crying); possibly irregular for brief periods, especially after crying	Tachycardia: persistent, ≥180 beats/min (respiratory distress syndrome [RDS]; pneumonia) Bradycardia: persistent, ≤80 beats/min (congenital heart block, maternal lupus)
Auscultation Apex: mitral valve Second interspace, left of sternum: pulmonic valve Second interspace, right of sternum: aortic valve Junction of xiphoid process and sternum: tricuspid valve	Quality: first sound (closure of mitral and tricuspid valves) and second sound (closure of aortic and pulmonic valves) sharp and clear	Murmur, especially over base or at left sternal border in interspace 3 or 4 (foramen ovale anatomically closing at approximately 1 yr)	Murmur (possibly functional) Dysrhythmias: irregular rate Sounds: Distant (pneumopericardium) Poor quality Extra Heart on right side of chest (dextrocardia, often accompanied by reversal of intestines)
Peripheral pulses: femoral, brachial, popliteal, posterior tibial	Peripheral pulses equal and strong		Weak or absent peripheral pulses (decreased cardiac output, thrombus, possible coarctation of aorta if weak on left and strong on right) Bounding
Obtain temperature:
Axillary: method of choice Temporal and intraauricular thermometers not effective in measuring newborn temperature	Axillary: 37° C (98.6° F) Temperature stabilized by 8-10 hr of age	36.5°-37.5° C (97.7°-100° F) Heat loss: from evaporation, conduction, convection, radiation	Subnormal (preterm birth, infection, low environmental temperature, inadequate clothing, dehydration) Increased (infection, high environmental temperature, excessive clothing, proximity to heating unit or in direct sunshine, chemical dependence, diarrhea and dehydration) Temperature not stabilized by 6-8 hr after birth (if mother received magnesium sulfate, newborn less able to conserve heat by vasoconstriction; maternal analgesics possibly reducing thermal stability in newborn)
Observe and monitor respiratory rate and effort:
Observe respirations when infant is at rest Observe respiratory effort Count respirations for full minute Auscultate breath sounds Listen for sounds audible without stethoscope	40/min Tendency to be shallow and irregular in rate, rhythm, and depth when infant is awake Crackles may be heard after birth No adventitious sounds audible on inspiration and expiration Breath sounds: bronchial; loud, clear	30-60/min Short periodic breathing episodes and no evidence of respiratory distress or apnea (>20 sec); periodic breathing First period (reactivity): 50-60/min Second period: 50-70/min Stabilization (1-2 days): 30-40/min Crackles (fine)	Apneic episodes: >20 sec (preterm infant: rapid warming or cooling of infant; CNS or blood glucose instability) Bradypnea: <25/min (maternal narcosis from analgesics or anesthetics, birth trauma) Tachypnea: >60/min (RDS, transient tachypnea of the newborn, congenital diaphragmatic hernia) Breath sounds: Crackles (coarse), rhonchi, wheezing Expiratory grunt (narrowing of bronchi) Distress evidenced by nasal flaring, grunting, retractions, labored breathing Stridor (upper airway occlusion)
Obtain blood pressure (BP) (usually not done in normal term infant)
Check oscillometric monitor BP cuff: BP cuff width affects readings, use appropriate-size cuff and palpate brachial, popliteal, or posterior tibial pulse (depending on measurement site)	60-80/40-50 mm Hg (approximate ranges) At birth Systolic: 60-80 mm Hg Diastolic: 40-50 mm Hg At 2 weeks Systolic: 68-88 mm Hg Diastolic: 40-60 mm Hg	Variation with change in activity level: awake, crying, sleeping	Difference between upper and lower extremity pressures (coarctation of aorta) Hypotension (sepsis, hypovolemia) Hypertension (coarctation of aorta, renal involvement, thrombus)
Weight
Put cloth or paper protective liner in place and adjust scale to 0 g or pounds and ounces Weigh at same time each day Protect newborn from heat loss	Female: 3400 g (7.5 lb) Male: 3500 g (7.7 lb) Regaining of birth weight within first 2 weeks	2500-4000 g (5.5-8.8 lb) Acceptable weight loss: 10% or less in first 3-5 days Second baby weighing more than first (on average)	Weight ≤2500 g (preterm, small for gestational age, rubella syndrome) Weight ≥4000 g (large for gestational age, maternal diabetes, heredity—normal for these parents) Weight loss more than 10% to 15% (growth failure, dehydration); assess breastfeeding success
Length
Measure length from top of head to heel; measuring is difficult in term infant because of presence of molding, incomplete extension of knees	50 cm (19.7 in)	45-55 cm (17.7-21.7 in)	<45 cm (17.7 in) or >55 cm (21.7 in) (chromosomal abnormality, heredity—normal for these parents); some syndromes present shorter-than-average limb length (skeletal dysplasias, achondroplasia)
Head Circumference
Measure head at greatest diameter: occipitofrontal circumference May need to remeasure on second or third day after resolution of molding and caput succedaneum	33-35 cm (13-13.8 in) Circumference of head and chest approximately the same for first 1 or 2 days after birth; chest rarely measured on routine basis	32-36.8 cm (12.6-14.5 in)	Microcephaly, head ≤32 cm: (maternal rubella, toxoplasmosis, cytomegalovirus, fused cranial sutures [craniosynostosis]) Hydrocephaly: sutures widely separated, circumference ≥4 cm more than chest circumference (infection) Increased intracranial pressure (hemorrhage, space-occupying lesion)
Chest Circumference
Measure at nipple line	2-3 cm (0.8-1.2 in) less than head circumference; average 30-33 cm (11.8-13 in)	≤30 cm	Prematurity
Skin
Check color: Inspect and palpate Inspect semi-naked newborn in well-lighted, warm area without drafts; natural daylight best Inspect newborn when quiet and alert	Generally pink Varies with ethnic origin, skin pigmentation beginning to deepen right after birth in basal layer of epidermis Acrocyanosis common after birth	Mottling Harlequin sign Plethora Telangiectases (“stork bites” or capillary hemangiomas) (see Fig. 22-6, A) Erythema toxicum/neonatorum (“newborn rash”) (see Fig. 22-6, B) Milia Petechiae over presenting part Ecchymoses from forceps in vertex births or over buttocks, genitalia, and legs in breech births	Dark red (preterm, polycythemia) Gray (hypotension, poor perfusion) Pallor (cardiovascular problem, CNS damage, blood dyscrasia, blood loss, twin-to-twin transfusion, infection) Cyanosis (hypothermia, infection, hypoglycemia, cardiopulmonary diseases, neurologic or respiratory malformations) Generalized petechiae (clotting factor deficiency, infection) Generalized ecchymoses (hemorrhagic disease)
Observe for jaundice	None at birth	Physiologic jaundice in up to 60% of term infants in first week of life	Jaundice within first 24 hr (increased hemolysis, Rh isoimmunization, ABO incompatibility)
Observe for birthmarks or bruises: Inspect and palpate for location, size, distribution, characteristics, color, if obstructing airway or oral cavity		Mongolian spot (see Fig. 22-5) in infants of African-American, Asian, and Native-American origin	Hemangiomas Nevus flammeus: port-wine stain Nevus vasculosus: strawberry mark Cavernous hemangioma
Check skin condition: Inspect and palpate for intactness, smoothness, texture, edema, pressure points if ill or immobilized	Edema confined to eyelid (result of eye prophylaxis) Opacity: few large blood vessels visible indistinctly over abdomen	Possibly puffy Slightly thick; superficial cracking, peeling, especially of hands, feet No visible blood vessels, a few large vessels clearly visible over abdomen Some fingernail scratches	Edema on hands, feet; pitting over tibia; periorbital (overhydration; hydrops) Texture thin, smooth, or of medium thickness; rash or superficial peeling visible (preterm, postterm) Numerous vessels very visible over abdomen (preterm) Texture thick, parchment-like; cracking, peeling (postterm) Skin tags, webbing Papules, pustules, vesicles, ulcers, maceration (impetigo, candidiasis, herpes, diaper rash)
Weigh infant routinely	Dehydration: loss of weight best indicator	Normal weight loss after birth: up to 10% of birth weight
Gently pinch skin between thumb and forefinger over abdomen and inner thigh to check for turgor	After pinch released, skin returns to original state immediately		Loose, wrinkled skin (prematurity, postmaturity, dehydration: fold of skin persisting after release of pinch) Tense, tight, shiny skin (edema, extreme cold, shock, infection)
Note presence of subcutaneous fat deposits (adipose pads) over cheeks, buttocks		Variation in amount of subcutaneous fat	Lack of subcutaneous fat, prominence of clavicle or ribs (preterm, malnutrition)
Check for vernix caseosa: Observe color, amount, and odor before bath or removing clothing	Whitish, cheesy, odorless	Usually more found in creases, folds	Absent or minimal (postmature infant) Abundant (preterm) Green color (possible in utero release of meconium or presence of bilirubin) Odor (possible intrauterine infection)
Assess lanugo: Inspect for this fine, downy hair, amount and distribution	Over shoulders, pinnas of ears, forehead	Variation in amount	Absent (postmature) Abundant (preterm, especially if lanugo abundant, long, and thick over back)
Head
Palpate skin	(See “Skin”)	Caput succedaneum, possibly showing some ecchymosis (see Fig. 22-10, A)	Cephalhematoma (see Fig. 22-10, B)
Inspect shape, size	Making up one fourth of body length Molding (see Fig. 22-9)	Slight asymmetry from intrauterine position Lack of molding (preterm, breech presentation, cesarean birth)	Severe molding (birth trauma) Indentation (fracture from trauma)
Palpate, inspect, and note size and status of fontanels (open vs. closed)	Anterior fontanel 5-cm diamond, increasing as molding resolves Posterior fontanel triangle, smaller than anterior	Variation in fontanel size with degree of molding Difficulty in feeling fontanels possible because of molding	Fontanels: Full, bulging (tumor, hemorrhage, infection) Large, flat, soft (malnutrition, hydrocephaly, delayed bone age, hypothyroidism) Depressed (dehydration)
Palpate sutures	Palpable and separated sutures	Possible overlap of sutures with molding	Sutures: Widely spaced (hydrocephaly) Premature closure (fused) (craniosynostosis)
Inspect pattern, distribution, amount of hair; feel texture	Silky, single strands lying flat; growth pattern toward face and neck	Variation in amount	Fine, wooly (preterm) Unusual swirls, patterns, or hairline; or coarse, brittle (endocrine or genetic disorders)
Eyes
Check placement on face	Eyes and space between eyes each one-third the distance from outer-to-outer canthus	Epicanthal folds: characteristic in some ethnicities	Epicanthal folds when present with other signs (chromosomal disorders such as Down, cri-du-chat syndromes)
Check for symmetry in size, shape	Symmetric in size, shape
Check eyelids for size, movement, blink	Blink reflex	Edema if eye prophylaxis drops or ointment instilled
Assess for discharge	None No tears	Some discharge if silver nitrate used Occasional presence of some tears	Discharge: purulent (infection) Chemical conjunctivitis from eye medication is common—requires no treatment
Evaluate eyeballs for presence, size, shape	Both present and of equal size, both round, firm	Subconjunctival hemorrhage	Agenesis or absence of one or both eyeballs Lens opacity or absence of red reflex (congenital cataracts, possibly from rubella, retinoblastoma [cat’s eye reflex]) Lesions: coloboma, absence of part of iris (congenital) Pink color of iris (albinism) Jaundiced sclera (hyperbilirubinemia)
Check pupils	Present, equal in size, reactive to light		Pupils: unequal, constricted, dilated, fixed (intracranial pressure, medications, tumor)
Evaluate eyeball movement	Random, jerky, uneven, focus possible briefly, following to midline	Transient strabismus or nystagmus until third or fourth month	Persistent strabismus Doll’s eyes (increased intracranial pressure) Sunset (increased intracranial pressure)
Assess eyebrows: amount of hair, pattern	Distinct (not connected in midline)		Connection in midline (Cornelia de Lange syndrome)
Nose
Observe shape, placement, patency, configuration	Midline Some mucus but no drainage Preferential nose breather Sneezing to clear nose	Slight deformity (flat or deviated to one side) from passage through birth canal	Copious drainage (rarely congenital syphilis); blockage membranous or bone with cyanosis at rest and return of pink color with crying (choanal atresia) Malformed (congenital syphilis, chromosomal disorder) Flaring of nares (respiratory distress)
Ears
Observe size, placement on head, amount of cartilage, open auditory canal	Correct placement line drawn through inner and outer canthi of eyes reaching to top notch of ears (at junction with scalp) Well-formed, firm cartilage	Size: small, large, floppy Darwin’s tubercle (nodule on posterior helix)	Agenesis Lack of cartilage (preterm) Low placement (chromosomal disorder, intellectual disability, kidney disorder) Preauricular tag or sinus Size: possibly overly prominent or protruding ears
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