1. Congenital malformations
2. Short gestation/ low birthweigth
3. SIDS
4. Maternal complications
5. Unintentional injuries

• Bed and blankets pre-warmed
• Emergency equipment present and tested (to ensure it works):
• Oxygen
• Suction
• Ambu bag

APGAR Scores

(see full chart slide 8 on ppt)

• Performed at 1 and 5 minutes, each category scored 0-2 (total 10 possible points)
• Categories:
• Appearance
• Pulse
• Griamce
• Activity
• Respirations

• Appropriate for gestational age (AGA)
• 10th - 90th percentile
• Small for gestational age (SGA)
• 0 - 9th percentile
• Large for gestation age (LGA)
• 91st - 100th percentile

• Weight: 2500-4000 grams (5 lbs 8 oz - 8 lbs 13 oz)
• Length: 19-21" (48-53 cm)
• Head circumference: 13-14" (33-35 cm)
• Measure right above eyebrows
• Chest circumference: 12-13" (30.5-33 cm)
• Measure at nipple line

• HR: 100-160 bpm
• Respirations: 30-60 bpm
• BP: 80/46 at birth, 100/50 as fetal circulation shuts down (not taken unless indicated)
• Temperature: 
• Axillary 36.5-37.5 C (97.7-99.5 F)
• Rectal 36.5-37.6 C (97.7-99.7 F)

• Blood glucose: >40 mg/dl
• Bilirubin leve: <12 (peaks on 3rd day of life)
• Newborn screening test (NBS): state required test
• Genetic testing required by law, don't need consent from parents
• Detects severe health issues that can be deadly if not treated early

• Thin skin and blood vessels close to surface
• Little SQ fat to block heat loss
• 3x higher surface to body mass ratio as adults
• Very susceptible to heat loss ! (even more so if preterm)

• Evaporation (wet surfaces exposed to air)
• Conduction (direct contact with objects cooler than skin)
  Convection (heat is transferred to air)
• Radiation (indirect contact that transfers heat to objects cooler than the skin)

• Increased need for O2
• Respiratory distress
• Decreased surfactant production
• Hypoglycemia
• Metabolic acidosis
• Jaundice

• Increased metabolic rate
• Increased O2 requirement

• Helps prevent heat loss in newborns
• Maintains stable temp without increasing O2 or metabolic rate
• In healthy unclothed NB's--> 89.6-92.3 F

1. First alert period
2. Resting period
3. Second alert period

• First 15-30 minutes after birth
• Baby is alert
• Respirations irregular
• Responds vigorously to stimulation

• 30-120 minutes after birth
• Color and vitals stabilize
• Baby sleeps
• Difficult to arouse

• 4-8 hours after birth
• Awakening
• Becoming responsive to stimuli again
• May have a lot of mucous to clear

Deep sleep

No eye movement

Resp. quiet and slower

Rapid eye movements

May move extremities or stretch

Transitional period

Yawns

Eyes glazed

Infant able to focus on objects or people

Tuned into environment

Restless

Starting to fuss

Faster respirations

More aware of discomfort

1. Chemical factors
2. Thermal factors
3. Mechanical factors

• Cold receptors
• Low PO2
• Increased PCO2

• Nasal flaring
• Intercostal/ subcostal retractions
• Stridor
• Gasping

Shunts blood in fetus from right ventricle into aorta (bypasses lungs)

Closes immediately after birth in response to increased O2 and decreased resistance in lungs

Opening in septum of fetus between left and right atria

Closes immediately after birth due to increased pressure in left atrium 

Connects left umbilical vein to with the inferior vena cava of the fetus 

Constricts when umbilical cord is clamped

• Anemia
• Hypovolemia
• Hyperthermia
• Sepsis

• Congenital heart block
• Hypoxemia

Should be equal to the weeks of gestation

Ex: infants born at 40 weeks should have MAP of 40

• RBC's: higher than adults (4.6-5.2 million/mm³)
• H&H: higher than adults (14-24 gl/dl & 51-56%, decrease to 12-20 gl/dl & 3-59% by 8 weeks)
• WBCs: elevation is normal
• No Vitamin K (given in injection at birth, especially important for babies being circumcised)

Can be stretched to hold up to 90 mL

Limited ability to digest fat and starch in first few weeks (few pancreatic enzymes)

Regurgiate easily b/c of immature cardiac sphincter

First stool passed by newborn

Sticky, tar-like, black-green, odorless

Formed from mucous, vernix, lanugo, and amniotic fluid

Should pass within 24-48 hours of birth

• Imperforate anus
• Meconium ileus
• Bowel obstruction
• Cystic fibrosis

• Formula-fed:
• 2-3 bright stools/day
• May appear seedy and have strong odor
• Remain loose over time
• Breastfed:
• Several small light yellow stools/day (about one per feeding)
• Little or no odor
• Consistency of toothpaste over time

• Enlarged, occupies 40% of abdominal cavity
• Iron stored up to last 4-6 months
• Synthesizes clotting/ coagulation factors (vitamin K)
• Conjugates bilirubin (causes hyperbilirbuinemia)
• Metabolizes drugs

Yellowing of sclera and skin; noticeable in face first, then chest and body

Physiologic jaundice seen in 50% of NBs on 2nd/3rd day of life (due to breakdown of excess RBCs)

RBCs break into heme and globin

Heme is further broken down into iron and into bilirubin 

Bilirubin needs to be excreted and excess (hyperbilirubinemia) causes jaundice 

• Bilirubin-- byproduct of RBCs breakdown
• Fat-soluble; absorbed by SQ fat
• Released in unconjugated form
• Liver conjugates bilirubin
• Changes it into water-soluble form
• Excreted through the urine and stool

(see slide 39 for visual) 

After first 24 hours

Physical response to trauma of birth

Abotu 50% of all NBs develop in 2-3 days

Peaks at day 5

• Within first 24 hours
• May indicate infection, metabolic disorder, or bleeding disorder

• Maintain thermoregulation (decreases stress and acidosis)
• Monitor stools for frequency
• Encourage early breastfeeding and adequate hydration

• Bilirubin levels at or greater than 20 may cause permanent brain damage (kernicterus)
• Physiologic jaundice in a healthy, full term NB should resolve on its own with proper hydration and feeding

• Anything that causes increased hematocrit or hemolysis
• Excessive bruising, cephalohematoma, LGA infant, twin-to-twin transfusion, IDDM

• Prevention:
• Early feeding (colostrum has laxative effect)
• Treatment:
• Phototherapy (lights or blanket)
• Cover eyes to protect from lights !

• Should void w/in first 24 hours
• If not, examine for urethral stenosis, renal agenesis, or dehydration
• 15 mL at a time and only 3-4 over 1st 2 days is norm
• 1st void may be dark colored or pink d/t uric acid crystals formed in utero (normal)
• Urine normally pale iwth low specific gravity (d/t immature kidneys)

• Can't make antibodies of own until about 8 weeks old
• Passive immunity lasts less than 6 months
• Continue to receive passive until as long as breastfeeding !

Infant's head and arms are allowed to drop back from 30 degree angle

Arms and legs extend and abduct, figners extend, and forefingers and thumbs form a "C"

In response to a loud noise

Same as moro reflex except fingers are clenched

Tonic Neck Reflex

(aka Archer's Reflex)

1. Hearing-- well developed; recognize mom's voice
2. Vision-- see best at 9-12 inches in black and white 
3. Touch--well developed to postive and negative touch
4. Taste--well developed; prefers sweet
5. Smell--well developed; can pick out mom's breast milk

• Skin may look ruddy
• Acrocyanosis common (first 24 hours)
• Sudden gagging/ coughing is common (d/t mucous)
• Vernix caseosa
• Lanugo
• Erythema toxicum
• Milia
• Head molding (from birth canal)
• Forceps marks (bruising)

Cheesy substance

Lubricates skin in utero

Begins to fade at term

In first bath, gently wash it off

Find downy hair

Covers shoulders, back, upper arms, face

Less as babies get closer to term

Rubs off within first 2 weeks

Newborn rash

Usually appears on days 1-4, but can occur later

Begins with papule, area around gets red adn blotchy

Looks worst on 2nd day and disappears on 3rd

Papules d/t plugged sebaceous glands on nose, cheesk, chin

Usually disappears by 2 weeks

Instruct parents to leave it alone !

Baby's skin becoems very dry in abouy 24 hours, particularly on palms and soles

Sooner in post-term infants

Normal; do not treat

Elevated areas that look like little strawberries

Usually there at birth can can appear up to 2 weeks after

Often fade by age 10 years

Raised dilated vessels

Do not fade with age 

Appear opposite of how name sounds !

Collection of melanocytes in grayish patches across sacrum or buttocks (can be elsewhere too)

Common in darker skinned babies

Normal

AKA storck bites

Light, pale pink birthmark

Nape of neck

Eventually covered by hair

Fade by 5 yo

AKA port wine stain

Basically a vascular tumor

Does not blanche with pressure or fade iwth age

Enlarged capillaries in outer layer of skin

Most often on head, scalp, or neck

Grow larger for 5-6 months

Disappear by 6-8 yo

May become visible with exercise, emotion, or heat

Permanent birthmark

Light brown irregular edge

Harmless

If 6 or more present and larger than 0.5 cm, consider neurofibromatosis (need to get genetic consult !!)

May be on presenting part due to forceps or from cord (where compressed; neck, shoulder, etc.)

Monitor and determine cause

May need to evaluate for bleeding disorder, low platelets, infection

Bruises on presenting part due to forceps use

May be edematous

Usually fade within a few days

NBs have very reliable skin turgor due to elasticity of skin

Poor turgor = dehydration

• Observe for:
• Pallor, plethora, bruises, petechia, central cyanosis, jaundice
• Bruising from face presentation or instrumentation can cause hyperbilirubinemia (jaundice)
• Report scattered petechiae to HCP

Edema of the scalp over the presenting part

Crosses the suture lines and will gradually be absorbed and disappear

Abnormal

• Collection of blood b/w periosteum of skull bone and bone itself
• D/t periosteum capillary rupture from pressure in birth
• Swelling not visible until about 24 hours PP
• Looks like an egg and is discolored
• Does not cross sutures
• May take weeks to be absorbed and cause jaundice

Localized softening of skull bones

Dents like a ping pong ball !

Improves with time

Abnormal

• Irises almost always grey of blue; pupils dark
• No tears
• Conjunctival hemorrhage
• Periorbital edema

• Soft cartilage
• External ear level 
• Low set ears may indicate anomaly (like Down syndrome)

Looks large !

Will grow into it

Test for choanal atresia by occluding one nostril at a time

Congenital disorder

Back of nasal passage is blocked by abnormal bony or soft tissue

Didn't develop properly in utero

Short and thick

Not strong enough to support weight of head

May look small b/c head is larger

Head circumference > chest until about 2 years old

Check for retractions and fractured clavicles

Slightly protuberant

Bowel sounds should be heard w/in 1 hour of birth

• Check base of umbilicus for hernia and tears
• Assess for presence of Wharton's Jelly
• Count cord vessels (1 vein, 2 arteries)
• Only 1 artery could indicate CHD
• Redness or exudate around cord = infection
• Yellow discoloration = hemolytic disease or meconium stained

• Leave clamp on cord for about 24 hours or until cord looks dry
• All about educating the parents !
• Leave cord stump exposed to air
• Keep clean and dry until it drops off
• Sponge baths only until cord falls off

• Check for patency
• Should have 1st stool w/in 24 hours--report to HCP if not
• Assess for:
• Symmetry of buttocks, patency, no tuft, no dimple, thigh and buttock creases symmetrical

• Scrotum
• May be edematous
• Rugae present in full term infants
• More deeply pigmented than rest of body
• Testes-- should be present in scrotal sac
• Penis-- check urinary meatus location
• Foreskin (prepuce)
• Don't try to force away from meatus is NB

• Inspect and palpate:
• Urinary meatus at tip of penis (should be center)
• Prepuce covering glans penis
• Testes within scrotal sac
• Rugae (folds) on scrotum

Hypospadias

Congenital condition

Urinary meatus is on underside (ventral side) of the penis

May require foreskin for surgical repair (don't circumcise)

Congenital condition

Urinary meatus is on upper aspect (dorsal side) of the penis

May require foreskin for surgical repair (don't circumcise)

Abduct the thighs and apply gentle pressure forward over the greater trochanter

Clicking sound indicates dislocation of femoral head (abnormal, report to HCP)

Abduct the hips and apply gentle pressure down and back with thumbs

If you feel femoral head move out of the acetabulum, it indicates hip dysplasia (abnormal, report to HCP)

10 fingers and 10 toes

Assess for syndactyly (webbing), polydactyly, clindactyly (permanat deviation/ turning aside of a finger), and clubbing

• Done about 24 hours after birth (8 days if Jewish)
• Gives time to ensure vitamin K is working 
• Contraindicated if there are any penile abnormalities 
• May need the foreskin for repairs !
• Pain relief, four methods:
• EMLA cream (1 hour to work) or lidocaine IM
• Oral sucrose ("sugar water")
• Ring block
• Dorsal penile nerve block (DPNB)

Protrusion of abdominal-cavity contents into inguinal canal

Common in males, especially if African American

• Vulva may look swollen (d/t mom's hormones)
• May have pseudomenstruation
• Mons pubis-- consistent skin color; amy be pigmented in darker skinned NBs
• Labia majora--cover labia minor; symmetrical and size appropriate for GA; larger if pre-term
• Clitoris--normally large; may be swollen and bruised if breeched; larger if pre-term

Mucous vaginal secretion, sometimes bloody

Common in NB girls due to maternal hormones

Fistula between rectum and vagina

Will see stool from the vagina

Abnormal, report to HCP

Spinal dimple

If sinus present as well, may indicate spinabifida

Abnormal, report to HCP

• Lots of handwashing !!
• Initial feeding:
• Breastfeeding-- first alert period
• Bottle-feeding-- second alert period
• Bathing--do when temp is stable; usually 1 hour PP
• Sleeping--back to sleep ! (educate parents too)

1 mg

IM (vastus lateralis)

Promotes clotting factor formation

Erythromycin ointment

Protects again gonorrheal and chlamydial infections possibly contracted in birth canal

Can cause blindness if ointment isn't given (state law, given to every mom)

• Check on babies who are:
• SGA, LGA, have low temperature, jittery, or had stressful delivery
• If < 40 mg/dl, start feeding protocol per hospital !

• Petroleum gauze or petroleum jelly covered with gauze used until healed (2-3 days)
• Prevent penis from sticking to diaper and pulling off fresh clots
• Teach parents care and S/S of infection (fever, odor, yellow discharge, etc.)

Surgical removal of the foreskin for circumcision

Metal bell covers glans, then clamp cuts off blood to foreskin, which is then cut off

Minimizes blood loss

Fast, takes about 5 minutes

Not completed while in hospital

Plastic bell is fitted over the glans, a suture is tied around the rim of the bell, and excess foreskin is cut away

Plastic rim stays in place and falls off after healing has taken place (about 5-7 days)

• Recommended exclusive breastfeeding (EBF) for 6 months !
• Continue for at least 12 months
• If weaned before 12 months--> use iron-fortified infant formula !

• Superior to any alternative
• Contains almost as many live cells as blood
• Nutrients more easily absorbed by infant
• May be contraindicated for some moms

• Maternal cancer therapy
• Active TB (not being treated)
• HIV
• Herpes simplex lesion on breast
• CMV
• Substance abuse

• 15-20 pores in each nipple that expel milk
• Prolactin released after birth
• Constantly produces milk as infant feeds (supply meets demand)
• Breasts never completely empty when lactating
• Oxytocin essential ! (nipple stimulation produces it)

• Cow's milk based
• Soy-based
• Casein or whey based
• Amino acid formulas

• How to recognize hunger cues
• Digestion problems
• Formula preparation
• Vitamin and mineral supplements
• Weaning
• No unmodified (whole) cow's milk for 1st year

Large compared to pelvis

Soft

Bowel sounds w/in first hour of life

Diastis recti and linea nigra common in African descent

Covered defect of the umbilical ring into which abdominal organs can herinate

Organs outside of body in sac !

Sac can rupture during or after birth

Associated with choromsomal abnormalities and CHDs

Herniation of the bowel throuhg a defect in the abdominal wall to the right of the umbilical cord

No membrane covers the contents

Intestinal atresia can occur with this

• Document amount and color of vomiting after feedings
• Color change, gaggin, and projectile vomiting --> pyloric stenosis
• Bilous emesis--> intestinal obstruction or malrotation