Physical and physiological characteristics of term baby

Introduction-The nurse is in a unique position to aid the newborn infant in the stressful transition from a warm, dark,
fluid-filled environment to an outside world filled with light, sound, and novel tactile stimuli. During this period of the
newborn adjusting from intrauterine to extra uterine life, the nurse must be knowledgeable about a newborn's normal
bio-psychosocial adaptations to recognize any deviations. To begin life as an independent being, the baby must
immediately establish pulmonary ventilation in conjunction with marked circulatory changes. These radical and rapid
changes are crucial to the maintenance of life. The nurse performs an initial assessment to evaluate the neonate, its
immediate post birth adaptations, and the need for further support.
Definition of term baby- Babies with a gestational age between 37 – 41 weeks are called as term babies (259-293
days).
Normal characteristics of term baby

Vital signs-
Temperature-is measured in the apex of the baby’s axilla holding the thermometer for atleast 5 minutes. Normal
range of temperature is 36.5°-37.4°C.

Heart rate-The normal range is 120-140 beats /min. The rate may rise to 160 beats /min when the infant is crying or
drop to 100 beats /min when the infant is sleeping. The apical pulse is considered the most accurate.

Respiration-Neonates have a normal respiratory rate 40-60 breaths/minute. The respirations of a newborn infant are
irregular in depth, rate, and rhythm. Respirations are affected by the infant's activity (that is, crying). Normally,
respirations are gentle, quiet, rapid, and shallow. They are most easily observed by watching abdominal movement
because the infant's respirations are accomplished mainly by the diaphragm and abdominal muscles. No sound should
be audible on inspiration or expiration.

Blood pressure- Blood pressure 65/41 mm of Hg in arm and calf. Crying and activity increases B.P. Placing cuff on
thigh agitates infant. Thigh BP remains higher than arm or calf BP by 4-8 mm of Hg

General appearance-In the full term newborn the posture is one of flexion, a result of in utero position. Most infants
born in a vertex presentation and keep the head flexed, with the chin resting on the upper chest. The arms are flexed at
the elbows and rest, folded, on the chest with hands clenched or fisted. The legs are flexed at the knees, the hops are
flexed with thighs resting on the abdomen, and the feet are dorsiflexed against the anterior aspect of the legs. The
vertebral column is also flexed.

Characteristics of newborn infants skin-

The infant has delicate skin at birth that appears dark red because it is thin and layers of subcutaneous fat have not yet
covered the capillary beds. This redness can be seen through heavily pigmented skin and becomes even more flushed
when the baby cries. Edema around eyes, face, legs, dorsa of hands, feet and scrotum or labia is usual finding.

Vernix Caseosa- This is a soft, grayish white, cheesy substance on the infant's skin at birth, a mixture of sebum and
desquamating cells. It is caused by the secretions of the sebaceous glands of the skin. It offers protection from the
watery environment of the uterus, is absorbed in the skin after birth, and serves as a natural moisturizer.
Lanugo- A fine downy hair called lanugo may be present on the skin, especially on the forehead, cheeks, shoulders
and back.
Acrocyanosis- Cyanosis of hands and feet. Acrocyanosis is normal for a newborn during the first few hours,
disappearing over the next day.
Cutis marmorata- Transient mottling when infant is exposed to decreased temperature.
Common variations are—
Milia- Distended sebaceous glands that appear as tiny white papules on cheeks, chin and nose.

Harlequin color change-Clearly outlined color change as the infant lies on side. Lower half of the body becomes pink
and the upper half is pale.
Erythema toxicum- A pink papular rash on which vesicles may be superimposed. This is self limiting condition,
appearing 1 to 2 days after birth and disappearing several days later.
By 2 weeks of age newborn should have the typical rosy, soft, dewy skin that is associated with babies. The sweat
glands become active by the end of second week.

Mongolian spots- Irregular areas of deep blue pigmentation usually in sacral and gluteal regions.

Telangiectatic nevi (“stork bites”)- Flat deep pink localized areas usually seen on back of neck, usually disappears by
2 years of age.
Anthropometry-
Length-- the length measured at birth is about 47- 50 cm.
Weight – The average weight of Indian baby is between 2.8 to 3.2 kg with a variation of 2.5 to 3.9 kg or more.
Head circumference-Normal head circumference is about 33-35 cm.
Chest circumference- at the nipples is about 3 cm less than head circumference. If the difference is more than 3 cm it
may be the indicator of intrauterine growth retardation.

Head and fontaneles-

 General observation of the head’s contour is important because molding occurs in almost all vaginal deliveries. In
a vertex delivery the head is usually flattened at the forehead, with the apex rising and forming a point at the end of
the parietal bones and the posterior skull and occiput dropping abruptly. The usual more oval head is apparent by 1
or 2 days after birth. The change on shape occurs because the bones of the cranium are not fused, allowing for
overlapping of the edges of these bones to accommodate to the size of the birth canal during delivery. Such
molding doesn’t happen in caesarean section unless there has been prolonged labor or the head has been engaged
in pelvis.

 The anterior fontanel is diamond shaped and measures 4 to 5 cm at its widest point (from bone to bone rather than
from suture to suture).

 The posterior fontanel is triangular, measuring between 0.5-1 cm at its widest part. The posterior fontanel may not
be palpable afterbirth because of edema (caput) or other cranial molding.

 The fontanel should feel flat, firm, and well demarcated against the bony edges of the skull. Frequently pulsations
are visible at the anterior fontanel. Coughing, crying or lying down may temporarily cause the fontanels to bulge
and become more taut.

 Some neonates have delayed ossification and resorption of bones making the skull feel soft like a ping pong ball.
This condition termed craniotabes, is a benign condition in neonates that resolve spontaneously.
 Caput succedaneum—A vaguely outlined area of edematous tissue situated over the portion of the scalp that
presents in a vertex delivery. The swelling consists of serum and or blood that has accumulated in the tissues
above the bone. Typically the swelling extends beyond the bone margins (or sutures) and may be associated with
overlying petechiae or ecchymosis. It is present at or shortly after birth. No specific treatment is needed, and the
swelling subsides within a few days.

 Cephalhematoma—A cephalhematoma is formed when blood vessels rupture during labour or delivery to
produce bleeding into the area between the bone and periosteum. The injury occurs most often with primiparous
women and is often associated with forceps delivery and vacuum extraction. Unlike caput succedaneum, the
boundaries of the cephalhematoma are sharply demarcated and do not extend beyond the limits of the bone. The
cephalhematoma may involve one or both parietal bones. The occipital bones are less commonly affected and the
frontal bones are rarely affected. The swelling is usually minimum or absent at birth and increases in size on the
second or third day. Blood loss is usually not significant. No treatment is indicated for uncomplicated
cephalhematoma. Most lesions are absorbed within 2 weeks to 3 months. Hyperbilirubinemia may result during
resolution of the hematoma. A local infection can develop and suspected when a sudden increase in swelling
occurs.
Neck, face, eyes and ears

Neck- Newborns universally have short necks, covered with folds of tissues.

Eyes-
 Edema of the lids are normally present for first 2 days after delivery.

 The two eyes and the space in between the eyes are in 1-1-1 relation.

 Tears may be present at birth, but purulent discharge from the eyes shortly after birth is abnormal. The
nasolacrimal duct is not fully patent in most neonates, but epiphora is observed in most newborns.

 Subconjunctival haemorrhages are common after vaginal delivery and resolve spontaneously. The sclera should be
white and clear.

 The corneal reflex is present at birth but is generally not elicited unless cerebral or eye damage is suspected.

 The pupils should be equal in size, symmetrical, usually responds to light by constricting.

 A searching nystagmus is common after birth. Strabismus is a normal finding because of the lack of the
binocularity.
 Color of iris--Most light skinned newborns have slate gray or dark blue eyes, whereas dark skinned infants have
brown eyes. Absence of color is characteristics of albinism.

Ears-
 Top of pinna on horizontal line with outer canthus of the eye. Pinna flexible, cartilage present.

 The pinna is often flattened against the side from pressure in utero.

 One way to asses auditory ability is by making a sharp, loud noise close to the infants head and noting the
presence of the startle reflex or twitching of the eyelids. Full term newborns have the ability to habituate to
noxious stimuli such as noise and may not react every time.

Nose-
 Nasal canal should be patent. The shape of the nose is usually flattened after birth and bruises are common,
especially if forceps are used.
 Thin white mucus is common in the newborn, but a thick bloody nasal discharge should be evaluated. Sneezing is
common.
 The newborn infants are obligatory nose breathers because of the apposition of the relatively large tongue to the
palate.

Mouth and throat-

 The palate is normally high arched and somewhat narrow. It should not have any cleft. A common finding is
Epstein pearls--small, white, epithelial cysts along both sides of the midline of the hard palate. They are
insignificant and disappear in several weeks.

 The frenulum of the upper lip is a band of thick, pink tissue that lies under the inner surface of the upper lip and
extends to the maxillary alveolar ridge. It usually disappears as the maxilla grows. It is particularly evident if the
infant yawns or smiles.

 The lingual frenulum attaches the underside of the tongue midway between the ventral surface of the tongue and
the tip of the lower palate. It is estimated that 4% to 5% of newborns have a tight lingual frenulum, sometimes
referred to as tongue tie, which may restrict adequate sucking. The infant should exhibit strong vigorous suck.
 The uvula may be retracted upward and backward during crying. Tonsillar tissue is generally not seen in the
newborn.

 Natal teeth (teeth present at birth as opposed to neonatal teeth- teeth that erupt during the first month of life) are
seen infrequently and erupt chiefly at the position of the lower central incisors. Most natal teeth are loosely
attached.

Chest-
 The shape of the newborns chest is almost circular, with equal antero-posterior and lateral diameters.

 The ribs are flexible and slight intercostal retractions are normally seen on inspiration.

 The xiphoid process is commonly visible as a small protrusion at the end of the sternum. The sternum is raised and
slightly curved.

 Breast enlargement appears in many newborns of either gender by the second or third day and is caused by
maternal hormones. Occasionally a milky substance (sometimes called witch’s milk) is secreted by the infant’s
breasts.

Lungs-
 The newborn’s normal respirations are irregular and abdominal, and the rate is between 40-60 breaths per minute.
 Periods of apnea lasting more than 20 seconds are normal and may be accompanied by bradycardia. Occassional
irregularities occur in relation to crying, sleeping, and feeding. Periodic breathing is commonly seen in full-term
newborns and consists of rapid nonlabored respirations followed by pauses of less than 20 seconds; periodic
breathing may be more prominent during sleep and is not accompanied by status changes such as cyanosis or
bradycardia.
 Bronchial breath sounds should be equal bilaterally. Crackles soon after birth may indicate areas of atelectasis or
the presence of fluid, which represent the normal transition of the lungs to extra uterine life. However wheezes,
persistence of crackles and stridor should be reported.
 Cough reflex is absent at birth, present by 1 or 2 days.

Heart-
 Heart rate ranges from 100 to 180 beats /min shortly after birth and when the infant’s condition has stabilized,
from 120-140 beats/min. The point of maximum intensity is (PMI), which usually in the fourth and fifth
intercostals space, medial to the left mid clavicular line. Auscultation of the specific components of the heart
sounds is difficult because of the rapid rate and effective transmission of respiratory sounds. The first (S1) and
second (S2) sounds should be clear and well defined; the second sound is somewhat higher in pitch and sharper
than the first.

Abdomen-
 The normal contour of the abdomen is cylindrical and prominent with visible veins.

 Bowel sounds are heard within the first 15 to 20 minutes after birth. Visible peristaltic waves may be observed in
thin newborns but should not be seen in well nourished infants.

 Abdominal palpation is carried out using one or two fingers and counter pressure in the flank with other hand.
Normally 1-2 cm of liver, tip of the spleen overlying the stomach and the lower pole of the kidney are palpated.

 The umbilical cord consists of two arteries and one vein, which has a larger lumen than the arteries and a thinner
vessel wall. At birth the cord appears bluish white and moist. After clamping, it begins to dry and appears a dull
yellowish brown. It progressively shrivels and turns greenish black.
 Femoral pulses should be strong and equal bilaterally.

Genitalia-
Female-
 Normally the labia majora covers the labia minora. The labia and clitoris are edematous, especially after a breech
delivery.

 Normally in girls the urethral opening is located behind the clitoris.

 Vernix caseosa may be present in larga amounts between the labia. Vaginal discharge may be noted during the
first week of life. This pseudomenstruation is a manifestation of the abrupt decrease in maternal hormones and
usually disappears by 2 to 4 weeks of age.

Male-
 Urethral opening should be at the tip of the glans. The opening may be totally covered by the prepuce, or foreskin,
which covers the glans penis. A tight prepuce is common finding in newborns and doesn’t indicate phimosis. It
should not be forcefully retracted.

 Smegma, a white cheesy substance, is commonly found around the glans penis, under the foreskin. An erection is
common in the newborn.

 Small, white, firm lesions called epithelial pearls may be seen at the tip of the prepuce.

 The scrotum may be large, edematous, and pendulous in the full-term neonate, especially in the infant born in
breech position. It is more deeply pigmented in dark skinned infant. A non communicating hydrocele commonly
occurs unilaterally and disappears within a few months.

 Palpable lymph nodes are commonly found in the inguinal area.

Back and anus-

 The shape of the spine is gently rounded, with none of the characteristics of S- shaped curves seen later in life. It
should not have any abnormal openings or sinuses, masses, dimples or soft areas.

 Gluteal folds are symmetrical. The presence of an anal orifice and passage of meconium through the orifice during
the first 24 to 48 hours of life indicates anal patency.

Extremities-
 The arms and limbs are fully movable with no evidence of dislocation or asymmetry of movements.

 Each arm should have 5 fingers, and each leg should have 5 toes. A partial syndactyly between the second and
third toes is a common variation seen in otherwise normal infants. More extensive fusion is abnormal and reported.

 The newborn will demonstrate full range of motion in the elbow, hip, shoulder, and knee joints. Movements should
be symmetric, smooth, and unrestricted.

 The nail beds should be pink, although slight blueness is evident in acrocyanosis. Persistent cyanosis of the nail
beds may indicate intrauterine distress, postmaturity or haemolytic disease. Short or absent nails are seen in
premature infants, whereas long nails extending over the ends of the fingers, are characteristics of post mature
newborns.

 The palms of the hands should have the usual creases. A transverse palmar crease (simian crease) suggests Down
syndrome but may also be a normal finding. The full term newborn usually has creases covering the entire sole of
the foot. The soles are flat with prominent fat pads.
 Muscle tone should be equal bilaterally. Extension of any extremity is usually met with resistance, and when
released, the extremity returns to its previous flexed position.

Physiologic status

Thermoregulation- Although newborn’s capacity for heat production is adequate, several factors predispose the
newborn to excessive heat loss-
 First the newborn’s large surface area relative to weight facilitates heat loss to the environment. The newborn’s
large body surface is partially compensated by usual position of flexion, which decreases the amount of surface
area exposed to the environment.
 The second factor is the newborn’s thin layer of subcutaneous fat.

 Third factor is the mechanism for producing heat. The chilled neonate cannot shiver but produces heat through non
shivering, or chemical thermogenesis. NST is produced by stimulating cellular respiration, resulting in increased
oxygen and glucose. A thermogenic source in full term newborn is brown fat.

Hemopoietic system-

 The blood volume of full-term infant is about 80-85 ml/kg of body weight. Immediately after birth the total blood
volume averages 300ml, but depending on how long the infant is attached to the placenta as much as 100 ml can
be added to the blood volume.

Fluid and electrolyte balance-

 The fetus has more extracellular fluid than intracellular fluid, but this shifts progressively throughout post natal
life, probably because of the growth of cells at the expense of extracellular fluid.

 The infant has a proportionately higher ratio of extracellular fluid than the adult and consequently has a higher
level of total body sodium and chloride and a lower level of potassium, magnesium and phosphate.

 The rate of fluid exchange is seven times greater in the infant than in the adult, and the infant’s rate of
metabolism is twice as great in relation to body weight. As a result, twice as much acid is formed, leading to
more development of acidosis. In addition, the immature kidneys cannot sufficiently concentrate urine to
conserve body water. These three factors make the infant more prone to problems of dehydration, acidosis and
over hydration.

Gastrointestinal system-

 The newborn’s ability to digest, absorb, and metabolize food is adequate but limited in certain functions. Enzymes
are available to catalyze proteins and simple carbohydrates but deficient production of pancreatic amylase impairs
utilization of complex carbohydrates. Human milk, despite its high fat content, is easily digested and absorbed
because it contains enzymes such as lipase, which assist in digestion. A deficiency of pancreatic lipase limits the
absorption of fats, especially cow’s milk (high saturated fatty acid content).

 The liver is the most immature of the gastrointestinal organs. The activity of the enzyme glucoronyl transferase is
reduced, affecting the conjugation of bilirubin with glucoronic acid, which contributes to physiologic jaundice of
the newborn.

 The liver is also deficient in forming plasma proteins, which plays a role in the edema usually seen at birth.

 Prothrombin and other coagulation factors are also low. The liver stores less glycogen at birth than later in life.
Consequently, the newborn is prone to hypoglycemia.
 The stomach capacity is limited to about 90 ml in an average sized full term infant. Thus infant requires frequent
small feedings.
 The infant’s intestine has a large number of secretory glands and a large surface area for absorption compared with the
adult intestine. Rapid peristaltic waves and simultaneous nonperistaltic waves occur along the entire intestines. These
waves, called the migrating motor complex (MNC), propel nutrients forward. The relative immaturity of the MNC,
combined with decreased lower esophageal sphincter (LEC) pressure, inappropriate relaxation of the LES, and delayed
gastric emptying, makes regurgitation a common occurrence. It generally does not require any treatment. Persistent
vomiting on the first day may be due to swallowed amniotic fluid or maternal blood. Stomach wash with normal saline
generally takes care of this problem.

 Some salivary glands are functioning at birth, but the majority do not begin to secrete saliva until about 2 to 3
months when drooling is common.

 Changes in stool patterns of newborns-

Meconium - Infant’s first stool, composed of amniotic fluid and its constituents, intestinal
secretions, shed mucosal cells, and possibly blood (ingested maternal blood or minor
bleeding of alimentary tract vessels).

Transitional stools-These usually appear by the third day after initiation of feeding; they are greenish brown to
yellowish brown, thin, and less sticky than meconium and may contain some milk curds.

Milk stools-
-These usually appears by fourth day.
-In breast fed infants stools are yellow to golden, pasty in consistency, and have an odor similar to that of sour
milk.
-In formula fed infants stools are pale yellow to light brown, are firmer in consistency, and have a more
offensive odor.

Renal system- Structural components are present but the kidney has functional deficiency to concentrate urine and to
cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load. Total volume of urinary
output per24 hours is about 200-300 ml by the end of the first week. The bladder involuntarily empties when stretched
by a volume of 15 ml, resulting in as many 20 voidings per day. The first voiding should occur within 24 hours. The
urine is colorless and odorless and has a specific gravity of approximately 1.020.

Integumentary system-
 The two layers of the skin, the epidermis and dermis, are loosely bound to each other and are very thin.
 Erythema toxicum is an erythematous macula popular rash which appears on the first or second day.

 The sebaceous glands are most densely located on the scalp, face, and genitalia and produce vernix caseosa.
Plugging of the sebaceous glands cause milia.
 Because of the amount of melanin is low at birth, newborns are lighter skinned than they will be as children.
Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun.

Musculoskeletal system-

 At birth skeletal system contains large amounts of cartilage than ossified bone, although the process of
ossification is rapid during the first year. The nose for example is predominantly cartilage at birth and is frequently
flattened by the force of delivery.
 The muscular system is almost completely formed at birth. Growth in the size of muscular tissue is caused by
hypertrophy, rather than hyperplasia of cells.
Defense against infection-

 The first line of defense is the skin and mucous membrane, which protect the body from invading organism.
 The second line of defense is the cellular elements of the immunologic system, which produces several types of
cells capable of attacking a pathogen. The neutrophils and monocytes, eosinophils, the lymphocytes (T and B
cells) help in protecting the body of infant.

 The third line of defense is the formation of specific antibodies to an antigen. Infants are generally
not capable of producing their own immunoglobulins until the beginning of the second month of life but they
receive considerable passive immunity in the form of immunoglobulin G (Ig G) from the maternal circulation and
from human milk. They are protected against most major childhood diseases for about 3 months.

Endocrine system-
Newborn’s endocrine system is adequately developed but its functions are immature. E.g, the posterior lobe of
pituitary gland produces limited quantities of antidiuretic hormone, or vasopressin, which inhibits diuresis. This
renders the newborn highly susceptible to dehydration.

Neurologic system-

 The autonomic nervous system is crucial during transition because it stimulates initial respirations, helps maintain
acid base balance and partially regulates temperature control. Myelination of the nervous system follows the
cephalo-caudal (head to toe), proximo -distal (center to periphery) laws of development and is closely related to
the observed mastery of the fine and gross motor skills. Myelin is necessary for rapid and efficient transmission
of some, but not all, nerve impulses along the neural pathway. Tracts that develop myelin earliest are the sensory,
cerebellar and extrapyramidal. This accounts for the acute senses of taste, smell, and hearing, as well as perception
of pain, in the newborn. All cranial nerves are myelinated except the optic and olfactory nerves.

Sensory functions-
The newborns sensory functions are remarkably well developed and have a significant effect on growth and
development, including the attachment process.

Vision-
 At birth the eye is structurally incomplete. The cilliary muscles are also immature, limiting the eyes’ ability to
accommodate and fixate on an object for any length of time. The pupils react to light, the blink reflex is responsive
to minimum stimulus, and the corneal reflex is activated by a light touch. Tear glands usually begin to function
until 2 to 4 weeks of age.

 The newborns ability to momentarily fixate on a bright or moving object that is within 20 cm and in the midline of
the visual field.
 Infant also demonstrates visual preferences: medium colors (yellow, green, pink) over dim or bright colors (red,
orange, blue); black and white contrasting patterns, especially geometric shapes and checker boards.

Hearing
 Once the amniotic fluid has drained from the ears, the infant probably has auditory acuity similar to that of an
adult. The newborn is able to detect a loud sound of about 90 dB and reacts with a startle (moro) reflex.

 Infants have an early sensitivity to the sound of human voices and to specific speech sounds. For example, infants
younger than 3 days of age can distinguish the mother’s voice from that of other females. As early as 5 days,
newborn can differentiate between stories read by the mother’s voice (in utero) versus stories read by another
woman’s voice after birth. The internal and middle ear structures are large at birth, but the external canal is small.

 The mastoid process and the bony part of the external canal have not yet developed. Consequently, the tympanic
membrane and facial nerve are close to the surface and can be easily damaged.

Smell
Newborns react to strong odors such as alcohol or vinegar by turning their heads away. Breast fed infants are able to
smell breast milk and will cry for their mothers when the breasts are leaking. Maternal odors are believed to influence
the attachment process and successful breast feeding. Unneessary routine washing of the breasts may interfere with
establishment of early breast feeding.

Taste
The newborn can distinguish between tastes, and various types of solutions elicit differing facial reflexes. A tasteless
solution elicit no facial expression; a sweet solution elicits an eager suck and a look of satisfaction; a sour solution
causes the usual puckering of the lips; and a bitter liquid produces angry, upset expression. Newborns prefer the sweet
taste of glucose and water to sterile water.

Touch
The newborn perceives tactile sensation in any part of the body, although the face (especially the mouth), hands and
soles of the feet seem to be most sensitive. Gentle patting of the back or rubbing of the abdomen usually elicits a
calming response from the infant. However painful stimuli, such as a pinprick, elicit an upset response.

States
The reaction of the neonate to internal and external stimuli is manifested in state related behavior. Prechtl and
associates (1973) and others believe that a state is a complex phemomenon and not just a general level of arousal or
consciousness. The newborn infant can exhibit at least five different states:
1. Quite or regular sleep ( no muscular movement, regular respirations, eyelid closed)

2. REM (rapid eye movement sleep) or active sleep (minimal muscular movement, irregular respirations, eyelids
closed, rapid eye movements ).

3. Quite alert ( no muscular movement, eyelids open).

4. Active alert ( obvious muscular movement, eyelids open, no fussing)

5. Crying ( fussing, lids closed or open).

Reflexes

Rooting and sucking – Stimulation of angle of mouth or lips would initiate rooting and sucking. The baby opens his
mouth, turns towards the side of stimulus when angle of the mouth is touched it enables the infant to instinctly ‘root’
for the nipple during breast feeding.
Age of disappearance of rooting reflex - 6th week of life when the source of food can be seen.
Age of disappearance of sucking reflex - Begins to diminish at 6 months. Disappears soon after birth if not stimulated.
If a neonate cannot take oral feedings, a pacifier may be used to maintain the reflex.

Startle/Moro’s -The baby should be held supine over the right hand and arm. The flexed head is suddenly allowed to
drop by about 30°.A positive response consists of rapid abduction and extension of upper limbs and opening of hands
followed by slower adduction and flexion.
Age of disappearance - Strong upto 2 months, disappears by 3-4 months.

Tonic neck reflex (fencing position)- When the baby’s head is turned to one side, the ipsilateral arm and leg gets
extended while contralateral limbs are flexed.
Age of disappearance of sucking – 18 to 20 weeks. Tonic neck reflex is replaced by symmetric positioning of both
sides of the body.

Palmar and plantar grasp- The finger is placed on the palmar surface of fingers or plantar surface of toes of the
baby to elicit grasp or flexion of digits. Stroke dorsum of the hand to persuade the baby to open the fist.
Age of disappearance of palmar grasp- 6 weeks to 3 months. Purposeful grasp is evident at 3 months of age.
Age of disappearance of plantar grasp- 8 to 9 months, in preparation for walking. May continue to be present during
sleep.

Glabellar tap- Tapping on glabella (bridge of nose) causes eyes to close tightly.

Doll’s eye- As head is moved slowly to right or left, eyes lag behind and do not immediately adjust to new position of
head.
Age of disappearance- When fixation develops.

Stepping / dancing - Place baby in standing position, baby’s feet on the bed. Baby’s feet touched the table alternately
by both legs giving an appearance of dancing.

Age of disappearance - 3 to 4 weeks. The neonate soon thereafter can bear some weight on the legs without stepping.

Babinski’s- Stroke the sole of the foot beginning at the heel. Stroke upward along lateral aspect of the sole then move
finger across ball of foot. There is dorsiflexion of large toe with fanning of other toes.
Age of disappearance-3 months of age; variable

Nursing care of the newborn

Assesment - Physical assessment after delivery can be divided into four phases-

1.The initial assessment , which includes the Apgar scoring system-

Immediately after birth, the Apgar scores are assigned at 1 and 5 minutes. If the score is less than 7, it is assigned every
5 minute until 20 minutes or till two successive score are 7 or greater.
The scores rapidly assess the cardiopulmonary status, tell about need for resuscitation and its effectiveness. Total
scores of 0 to 3 represent severe distress, scores of 4 to 6 signify moderate difficulty and scores of 7 to 10 indicates
absence of difficulty in adjusting to extra uterine life.
Apgar score
Sign 0 1 2

Heart rate Absent Slow(<100beats /min) More than 100 beats /min
Respirations Absent Weak cry, hypoventilation Good strong cry

Muscle tone Limp Some flexion of extremities Well flexed

Reflex No response Grimace Cough or sneeze

Color Blue or pale Body pink, extremities blue Completely pink

2.Transitional assessment during periods of reactivity

3.Clinical assessment of gestational age- The new ballard scale, a revision of the original scale, can be used with
newborns as young as 20 weeks of gestation( Ballard, Khoury, Wedig and others 1991). The tool has the same
physical and neuromuscular sections but includes scores that reflect signs of extremely premature infants, such as
fused eyelids; imperceptible breast tissue; sticky, friable, transparent skin; no lanugo; and square window (flexion of
wrist) angle of greater than 90 degrees. The examination of infants with a gestational age of 26 weeks or less should be
performed at a postnatal age of less than 12 hours. For infants with a gestational age of at least 26 weeks, the
examination can be performed up to 96 hours after birth. To ensure accuracy, it is recommended that the initial
examination be performed within the first 48 hours of life.
 New Ballard Scale

Tests used in assessing gestational age-

Posture-With infant quite and in a supine position, observe degree of flexion in arms and legs. Muscle tone and degree
of flexion increase with maturity.
Score- Full flexion of the arms and legs=4

Square window-With thumb supporting back of arm below wrist, apply gentle pressure with index and third fingers
on dorsum of hand without rotating infant’s wrist. Measure angle between base of thumb and forearm.
Score- Full flexion( hand lies flat on ventral surface of forearm)=4
Arm recoil-With infant supine,fully flex both forearms on upper arms ,hold for 5 seconds; pull down on hands to fully
extend and rapidly release arms. Observe rapidly and intensity of recoil to a state of flexion.
Score- A brisk return to full flexion=4

Popliteal angle-With infant supine and pelvis flat on a firm surface , flex lower leg on thigh and then flex thigh on
abdomen. While holding knee with thumb and index finger , extend lower leg with index finger of other hand. Measure
degree of angle behind knee ( popliteal angle)
Score- An angle of less than 90°=5

Scarf sign- with infant supine, support head in midline with one hand; use other hand to pull infant’s arm across the
shoulder so that infant’s hand touches shoulder. Determine location of elbow in relation to midline.
Score -Elbow does not reach midline=4
Heel to ear- With infant supine and pelvis flat on a firm surface, pull foot as far as possible up toward ear on same
side. Measure distance of foot from ear and degree of knee flexion (same as popliteal angle)
Score- Knees flexed with a popliteal angle of less than 10°=4)

4.A comprehensive, systematic physical examination.

Care of normal newborn at birth
Immediate care of the normal newborn at the time of birth

1. Call out the time of birth.

2. Deliver the baby onto a warm, clean and dry towel or cloth and keep on mother’s chest and abdomen (between
the breasts).

3. Clamp and cut the umbilical cord in 1-3 minutes.

4. Immediately dry the baby with a warm clean towel or piece of cloth.

5. Assess the baby’s breathing while drying.*

6. Wipe both the eyes (separately) with sterile gauze

7. Leave the baby between the mother’s breasts to start skin-to-skin care.

8. Place an identity label on the baby.

9. Cover the baby’s head with a cap. Cover the mother and baby with a warm cloth.

10. Encourage the initiation of breastfeeding.

* - if the baby is not crying or breathing well, the next steps of resuscitation have to be carried out.
The individual steps are briefly explained below:-

1. Call out the time of birth:

It is important to tell loudly the time of birth – this helps in accurate recording of the time and more importantly, alerts
other personnel in case any help is needed.

2. Receive the baby onto a warm, clean and dry towel or cloth on a warm dry surface
The baby should be delivered onto a warm and clean towel and kept on the mother’s adomen. If this is not possible, the
baby should be kept in a clean, warm, safe place close to the mother.

3. Clamp and cut the umbilical cord in 1-3 minutes.

The umbilical cord is clamped after 1 to 3 minute using a sterile disposable clamp or a sterile tie. Using two clean
ligatures and a new blade, the first ligature is tied about 2 cm(1 inch) from the abdomen of the baby( to avoid inclusion
of any gut wall present in the cord as part of undetected omphalocele, and to leave adequate length for umbilical
catheter insertion, if required). Second ligature is tied 5 cm from the abdomen and the cord between the 2 ligatures is
cut using a sterile blade (second ligature is applied to avoid spilling of blood). One should check the cut end of cord for
normal anatomy , ie. two arteries and one vein. The cord is left dry and open; one should not apply anything on the
cord and avoid touching.
The cord blood should be collected in cases of rhesus isoimmunization, Group O mother, maternal diabetes mellitus
and small for dates babies in whom intrauterine infection is suspected.
4. Immediately dry the baby with a warm clean towel or piece of cloth
Wet skin can result in a large amount of heat loss with seriously detrimental hypothermia. Therefore one of the first
steps after birth is through drying of the baby and especially the head, which constitute a large part of the neonatal
surface area. The vernix the cheesy material stuck on newborn skin made of dead skin, hair and secretions, serve to
conserve heat and protect the delicate newborn skin from environmental stress; no attempt is made to remove this.
After examination, baby is wrapped in clothes including a cap, and given to mother to allow first breast feed and gain
heat from, mother’s proximity.
5. Assess the baby’s breathing while drying
At the time of drying, the baby’s breathing should be assessed. A normal newborn should be crying vigorously or
breathing regularly at a rate of 40-60 breaths per minute. If the baby is not breathing well, then the steps of
resuscitation have to be carried out.
6. Eye care
Eyes are cleaned with sterile normal saline soaked gauze/cotton, using separate edges or pieces for the two eyes. The
cotton is removed over the lower edge of eyelid from medial to lateral canthi. No application is recommended unless
there was evidence of gonococcal infection in mother, in which case 1% silver nitrate is applied to both eyes.
7. Leave the baby between the mother’s breasts to start skin-to-skin care

Once the cord is cut, the baby should be placed between the mother’s breasts to initiate skin-to-skin care. This will
help in maintaining the normal temperature of the baby as well as in promoting early breastfeeding.
8. Idenification
Proper identification of the newborn is essential. The nurse must verify that identifying bands( disk no.) are securely
fastened on the newborn and verify the information against the birth records and the child’s actual gender. In some
hospitals foot or palm prints of the baby are also taken as part of the baby’s identification. It is important to provide the
mother an opportunity to see and touch the baby and also note the sex before transferring the baby to the nursery.
9. Cover the baby’s head with a cap. Cover the mother and baby with a warm cloth.

Both the mother and the baby should be covered with a warm cloth, especially if the delivery room is cold
(temperature less than 25°C). Since head is the major contributor to the surface area of the body, a newborn baby’s
head should be covered with a cap to prevent loss of heat.

10. Encourage initiation of breast feeding

Breast feeding should be started within 1 hour of birth. Breast milk is the best source of nutrition for infants until 6
months of age. Information regarding breastfeeding and its technique need to be discussed with the mother, both
during antenatal and postnatal period, not just once but in every visit so that its importance is reinforced and all
maternal concerns are addressed.
Ensuring warmth, “warm chain”
‘Warm chain’
1. At delivery:

Ensure the delivery room is warm (25° C), with no draughts.

 Dry the baby immediately; remove the wet cloth.

 Wrap the baby with clean dry cloth.
 Keep the baby close to the mother (ideally skin-to-skin) to stimulate early breastfeeding.
 Postpone bathing/sponging for 24 hours.

2. After delivery:

 Keep the baby clothed and wrapped with the head covered.
 Minimize bathing especially in cool weather or for small babies.
 Keep the baby close to the mother.
 Use kangaroo care for stable LBW babies and for re-warming stable bigger babies.
 Show the mother how to avoid hypothermia, how to recognize it, and how to re-warm a cold baby.
The mother should aim to ensure that the baby's feet are warm to touch.
Initiating breast feeding

During the initial skin-to-skin contact position after birth, the baby should be kept between the mother’s breasts; this
would ensure early initiation of breastfeeding.
Initially, the baby might want to rest and would be asleep. This rest period may vary from a few minutes to 30 or 40
minutes before the baby shows signs of wanting to breastfeed. After this period, (each baby is different and this period
might vary) the baby will usually open his/her mouth and start to move the head from side to side; may also begin to
dribble. These signs indicate that the baby is ready to breastfeed.
The mother should be helped in feeding the baby once the baby shows these signs. Both the mother and the baby
should be in a comfortable position. The baby should be put next to the mother’s breast with his mouth opposite the
nipple and areola. The baby should attach to the breast by itself when it is ready. When the baby is attached,
attachment and positioning should be checked. The mother should be helped to correct anything which is not quite
right.

Prevention of infection clean chain:

1. Clean delivery (WHO six cleans):

 Clean attendant's hands (washed with soap).

 Clean delivery surface.
 Clean cord- cutting instrument (i.e. razor, blade).
 Clean string to tie cord.
 Clean cloth to wrap the baby.
 Clean cloth to wrap the mother.
2. After delivery:

 All caregivers should wash hands before handling the baby.

 Feed only breast milk.
 Keep the cord clean and dry; do not apply anything.
 Use a clean cloth as a diaper/napkin.
 Wash hands after changing diaper/napkin. Keep the baby clothed and wrapped with the head covered.

 If the eyes are sticky, 10% solution of sulphacetamide should be instilled in the eyes every 2-4 hours.
The practice of applying kajal in the eyes is not recommended because it may transmit infection like trachoma and
may even cause lead poisoning.

Observation and documentation

During the transitional period, besides the baby’s Apgar score he should be observed for presence of any obvious life
threatening congenital anomalies and birth injuries. Anomalies such as trachea-esophageal fistula, meningomyelocele,
cleft lip and palate, and imperforated anus etc. should be recognized in the labour room and appropriate measures
taken. Weight and length are recorded before transferring the baby from the labour room.
During the first hour after delivery, the baby (and the mother) should be monitored every 15 minutes. Both of them
should remain in the delivery room for the first hour to facilitate monitoring. The mother and baby should not left
alone during the first hour after delivery
The two most important parameters that need to be monitored are:

i) Breathing and

ii) Temperature or warmth

Transfer
All normal babies are transferred to the mother and nursed along with her in the postnatal area. This is called rooming-
in. However babies requiring special care should be transferred to a Neonatal Intensive Care Unit.

Later care of newborn

Care needs to be given after baby is transferred to the postnatal ward are-
 Receiving the baby in the postnatal ward
 Initiating feeding
 Preventing infection
 Maintaining personal hygiene
 Observations/ watching for early signs of disease/ congenital anomalies
 Providing supplements and follow up
 Parental reaching

Nursing management

Nursing diagnosis Goal Planning implementation Expected outcome

1.Ineffective breathing Normal o Newborn to be placed in her back Baby cried.
pattern related to breathing with neck slightly extended by Respiratory rate 40-60
presence of secretions in pattern. placing a rolled towel under breaths per minute.
the airway. shoulders elevating 3/4th to 1 inch
off the mattress.
o The secretions of mouth and
nose to be cleaned with a piece of
gauze
o To clean the airway by suctioning
the mouth and then nose using a
bulb syringe or mechanical
Maintains suction using 12 or 14 Fr
nMaMutritional catheter.
Nutritional o The colour of the baby and
status respiratory rate, rhythm and depth
maintained. to be noted.
Mother holds the baby
2.Altered nutrition less o Baby to be put to the mother’s correctly during breast
than body requirement breast within ½ hour of birth. feeding.
related to knowledge o Health education to be given to Baby is sucking breast
deficit of mother about the mother about advantages , milk.
breast feeding. technique of breast feeding.
o To ensure that colostrums is
given to the mother.
o Mother to encouraged to give
exclusive breast feeding upto 6
Improved months of age.
3. Knowledge deficit of knowledge Adequately clothed the
mother related to care of about baby o To assess the existing baby.
the newborn. care. knowledge of the mother. Changed napkin when
o To provide information about soiled.
the care of the baby. Washed hands before
-to maintain the warmth by handling the baby.
adequately drying the baby. Breast feeding the baby
- appropriate clothing of the on demand.
baby.
Nursing diagnosis Goal Planning implementation Expected outcome
-change the napkin as soon as
soiled.
-to wash hands before handling
the baby and after changing the
napkin.
-exclusively breast fed the
newborn and burping after each
feed.
-maintain cleanliness of the room.
-to start immunization with BCG
vaccine and 0 polio.

o To receive the baby in a

prewarmed towel. Temperature 98°F.
o Stethoscope, blanket and hands of Body colour pink
the care giver should be warm to
prevent heat loss through
conduction.
o Baby to be received in a
Maintain prewarmed room, in a closed
normothermia area in one corner of labour room
4.Risk for hypothermia to prevent heat loss through
related to large surface convection and radiation.
area, thermoregulatory o Baby to be immediately dried
mechanism and thin with warm, soft, dry towels.
layer of subcutaneous fat o Baby’s axillary temperature to be
in normal newborn. checked with thermometer for
5minutes.
o The baby to be kept dried and
adequately clothed.
o Kangaroo Mother Care given.

o “5 cleans” of birthing process –

clean hands, clean delivery
surface, clean cord cut, clean cord
tie and clean cord stump
maintained Baby exhibits no
o The baby to be received in a evidence of infection.
clean room. Temperature-98.6°F,
o Thorough hand washing to be Pulse-130 beats/min
done before handling the baby. Resp-46 breaths /min
5.Risk for infection o All personnel in contact with the
related to improper Newborn is baby to be free from infection.
handling of caregiver free from o Eyes to be cleaned with sterile
and inability to produce infection. normal saline swabs for each eye
own immunoglobulin. from inner to outer canthus.
o The umbilical cord to be cut with
a sterile scissors and to leave the
cord dry.
o Vernix caseosa not to be wiped
off from the body.
Nursing diagnosis Goal Planning implementation Expected outcome
o Not to bath the baby for 48-72
hours or more after birth
depending on the condition of the
baby.
o Vital signs checked.

Conclusion -Birth of a healthy newborn is one of the finest gifts of nature. The arrival of the neonate begins as a
highly vulnerable period in which many psychologic and physiologic adjustments to life outside uterus must be made.
Baby must be provided basic care to ensure its survival and optimum growth and development. This is only possible
by adequate knowledge about the newborn.

Bibliography

1)Marlow Dorothy R,Reding Barbara A. Text book of Pediatric Nursing. 6 th ed. NewDelhi: Elsevier; 2011. p.368-70.

2)Ghai OP,Paul Vinod K,BaggaArvind. GHAI Essential Pediatrics. 7 th ed. New Delhi: CBS Publishers & Distributors
Pvt Ltd; 2009.p.753-755.
3)IGNOU.Pediatric nursing BNS107(1),NewDelhi: IGNOU; 2008.p.80-110.
4) WHO Preterm birth web sites.available at http://www.who.int/entity/mediacentre/factsheets/fs363/en/index.html.
Accessed Oct29,2012.
5)Singh Meharban. Care of the newborn. 7th ed. New Delhi: Nrinder K Sagar Publications; 2010. p.117-241.
Physical and physiological characteristics of preterm infant

Introduction - An estimated 15 million babies are born too soon every year. That is more than one in 10 babies. Over
one million children die each year due to complications of preterm birth. Many survivors face a lifetime of disability,
including learning disabilities and visual and hearing problems.
In almost all countries with reliable data, preterm birth rates are increasing. Globally, prematurity is the leading cause
of newborn deaths (babies in the first four weeks of life) and now the second leading cause of death after pneumonia in
children under the age of five.

Definition
Preterm is defined as neonates born alive before 37 weeks (<259 days) of gestation irrespective of the birth weight.
There are sub-categories of preterm birth, based on gestational age:
 extremely preterm (<28 weeks)
 very preterm (28 to <32 weeks)
 moderate to late preterm (32 to <37 weeks).
Key facts- According to WHO
 Every year, an estimated 15 million babies are born preterm (before 37 completed weeks of gestation), and this
number is rising.
 An estimated 1.1 million babies die annually from preterm birth complications.
 Preterm birth is the leading cause of newborn deaths (babies in the first four weeks of life) and the second
leading cause of death after pneumonia in children under five years.
 Three-quarters of them could be saved with current, cost-effective interventions, even without intensive care
facilities.
 Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born
Etiology- A variety of maternal and pregnancy related complications have been shown to increase the risk of preterm
delivery. The main causes of preterm birth are-
(a) Maternal factors
1. Medical disease of the mother during pregnancy.
2. Complications of pregnancy e.g., placenta praevia, abruptio placenta and antepartum hemorrhage
3. Incompetence of cervix
4. Maternal infections
5. Previous premature delivery
6. Poor socioeconomic status
7. Young mothers

(b) Fetal factors

1. Multiple pregnancy
2. Congenital malformation

(c) Medical factors

The delivery of the fetus may have to be induced before full term on medical grounds under the following
circumstances:
1. Uncontrolled diabetes mellitus in the mother.
2. Severe cardiac illness.
3. Hypertension, toxemia
4. Fetal hypoxia and fetal distress
5. Severe rhesus iso-immunization in the mother or hydrops fetalis.
6. Severe intrauterine growth retardation

(d) latrogenic

Physical characteristics-

Weight— less than 2500 grams

 Length— less than 47 cm
Head circumference— less than 33 cm
Chest circumference— less than head circumference by more than 3 cm

Activity and posture

 The general activity is poor and their automatic reflex responses, such as Moro response, sucking and
swallowing are sluggish or incomplete.
 The extremities maintain an attitude of extension and remain in any position in which they are placed due to
poor tone.

Skin
 The skin is bright pink (often transluscent, depending on the degree of immaturity), smooth and shiny (may be
edematous), with small blood vessels clearly visible underneath the thin epidermis.
 The fine lanugo is abundant over the body (depending on gestational age),and scanty vernix.
 The ear cartilage is deficient or absent with poor recoil
 Soles and palms have minimum creases.

Breast nodule is < 5 mm, areola not formed

Head-
 The head is large in proportion to the rest of the body.
 Skull bones are soft and sutures are widely separated and fontanels are wide.
 Hair are scanty, wooly, fuzzy and individual hair fibres can be seen separately
 The face appears small with small chin, protruding eyes due to shallow orbits and absent buccal pad of fat.
 The soft cranium is subject to characteristic unintensional deformation, or “preemie head”, caused by positioning
from one side to the other on a matterss. The head looks disproportionately longer from front to back, is flattened
on both sides, and lacks the usual convexity seen at the temporal and parietal areas.

Genitalia
 Male infants have few scrotal rugae, and the testes are undescended,
 In female infants, the labia majora are widely separated exposing labia minora and hypertrophied clitoris.

Physiological handicaps of preterms

The functional immaturity of various systems result in different clinical problems and their knowledge is essential for
the satisfactory management of these babies.

Central nervous system

 The immaturity of central nervous system is expressed as inactivity and lethargy, poor cough reflex and
incoordinated sucking and swallowing in babies weighing less than 1,800 gm or born before 35 weeks of
gestation.

 Resuscitation difficulties at birth and recurrent apneic attacks are common.

 The reflexes such as sucking, swallowing and moro’s may be sluggish or incomplete.

 Retrolental fibroplasia due to oxygen toxicity is limited to babies with a gestation of less than 35 weeks. On the
other hand, they are more resistant to toxic effects of hypoxia as compared to the term babies.

 They are extremely vulnerable to develop intraventricular, periventricular hemorrhage due to relative deficiency
of vitamin-K dependent coagulation factors and increased capillary fragility.

 The blood brain barrier, which is possibly a function of available serum proteins, is inefficient in preterm babies,
thus brain damage may occur at lower serum bilirubin levels.
Respiratory system
 The cuboidal alveolar lining of lungs in babies with a gestational age of less than 26 weeks results in poor
alveolar diffusion of gases and therefore the infant may not be viable.

 Cough or gag reflexes may be weak or absent.

 Respirations are shallow and irregular with periods of apnea which is sudden cessation of breathing associated
with cyanosis and bradycardia.

 The breathing is mostly diaphragmatic, periodic and associated with intercostals recessions due to soft ribs.

 Pulmonary aspiration and atelectasis are common. They are vulnerable to develop chronic pulmonary
insufficiency due to bronchopulmonary dysplasia.

 Deficiency of surfactant a chemical substance that reduces the surface tension inside the air sacs, causes
collapse of the lung after each breath thus greatly reducing the vital oxygen supply. This makes the babies more
prone to develop hyaline membrane disease.

Cardiovascular system
 The closure of ductus arteriosus is delayed among preterm infants.
About one-third infants with gestational age of 34 weeks or less manifest clinical evidences
of patent ductus arteriosus(PDA) with or without congestive heart failure. Its incidence is much higher among
preterm infants with hyaline membrane disease or protracted hypoxia due to any cause.
 In grossly immature infants (less than 32 weeks) EKG shows left ventricular preponderance. They are at risk to
develop thrombo-embolic complications and hypertension due to indwelling venous and arterial catheters.

Gastrointestinal system
 Regurgitation and aspiration are common because of poor or incoordinated sucking, small capacity of stomach,
incompetence of cardioesophageal junction and poor cough reflex. Gastro esophageal reflux and its consequences
are common.

 Abdominal distension and functional intestinal obstruction are due to hypotonia.

 Enterocolitis occurs when other predisposing factors are present.

 Immaturity of glucuronyl transferase system in the liver leads to hyperbilirubinemia, which may be aggravated by
dehydration, delayed feeding and hypoglycemia. Relatively low serum albumin, acidosis and hypoxia in these
babies predispose to bilirubin levels.

 The poor hepatic glycogen stores, delayed feeding, birth asphyxia and respirator distress syndrome contribute to
the development of hypoglycemia.

Thermoregulation
 Hypothermia is invariable and life threatening unless environmental temperature is monitored.
Excessive heat loss is due to relatively large surface area and poor generation of heat due to poor muscular
activity and paucity of brown fat in a preterm baby.

Infections
 Infections are an important cause of neonatal mortality in low birth weight babies. The low levels of IgG
antibodies and inefficient cellular immunity predispose them to infections.
  Excessive handling, humid and warm atmosphere, contaminated incubators and resuscitators expose them to
infecting organisms, thus contributing to high incidence of infections.

Renal immaturity
 The blood urea nitrogen is high due to low glomerular filtration rate.

 The renal tubular ammonia mechanism is poorly developed thus acidosis occurs early.

 They are vulnerable to develop late metabolic acidosis especially when fed with a high protein milk formula.

 The maximum tubular diluting ability in the newborn is satisfactory but ability to concentrate urine is very poor.
Preterm baby has to pass 4 to 5 ml of urine to excrete one milliosmole of solute as compared to 0.7 ml by an
adult for the same purpose. Therefore the baby cannot conserve water and gets dehydrated readily. The solute
retention and low serum proteins explain occurrence of edema in some preterm infants.

Toxicity of drugs

 Poor hepatic detoxification and reduced renal clearance make a preterm baby vulnerable to toxic effects of
drugs unless caution is exercised during their administration.

Nutritional handicaps

 Low birth weight babies are prone to develop anemia around 6 to 8 weeks of age. This is due to diminished
total stores of iron due to short gestation. They may also manifest deficiencies of folic acid and vitamin E.

 Vitamin E deficiency occurs among infants weighing less than 1,500g, particularly those fed on iron fortified
milk formula. These infants are prone to develop hemolytic anemia, thrombocytopenia, and edema at 6 to 10
weeks of age. Vitamin E being an antioxidant, its deficiency state may be associated with oxygen toxicity to the
vulnerable tissues in the form of retrolental fibroplasias and bronchopulmonary dysplasia.

 Rapid growth following adequate feeding may result in osteopenia and rickets unless calcium, phosphorous
and vitamin D are administered.

Biochemical distrurbances

 These babies are prone to develop hypoglycemia, hypocalcemia, hypoproteinemia, acidosis and hypoxia. Poor
hepatic glycogen stores, delayed feeding, birth asphyxia and respiratory distress syndrome are responsible for
these. And they have a higher extracellular fluid content that renders them more vulnerable to fluid and
electrolyte derangements. Pre term infants exchange fully half their extracellular fluid volume every 24 hours
compared with one seventh of the volume turnover in adults.

Management

A..Prevention of preterm birth - High-risk mother should be identified early during the course of pregnancy and
referred for confinement to an appropriate health care facility, which is equipped with good quality obstetrical, and
neonatal care facilities. Mother is indeed an ideal transport incubator!

Arrest of premature labour

Mother at high risk should be kept under close observation and treated for the conditions responsible. The
fetus increases in weight at rapid rate during the last trimester of pregnancy The mother should be advised to take
adequate food and should be given nutritional supplement during the last trimester of pregnancy. All efforts should be
made to arrest premature labour. Tocolytic agents such as ethanol, Isoxsuprine or salbutamol and terbutaline etc are
usually advised to arrest labour.

 Ethanol though popular at one stage is rarely used now due to its dangers of inebriation, vomiting, headache,
flushing, restlessness, disorientation and diuresis.

 Magnesium sulphate is more effective and is being increasingly used though there is a potential risk of
respiratory depression in the newborn. The observational studies have shown that maternal treatment with
magnesium sulphate is associated with reduced risk of IVH, cerebral palsy and mental retardation in their
preterm babies.

 Isoxsuprine (duvadilan) is useful but its effect is mediated both through beta-1 and beta-2 receptors. Its use is
associated with untoward beta-1 receptor side effects such as apprehension, palpitation, hypotension, fetal
tachycardia and neonatal hypoglycemia. Therapy is initiated by intravenous infusion of 20 mg isoxsuprine
diluted in 200ml of 5%dextrose at a rate of 40-50 drops/minute. This is followed by intramuscular administration
of 10 mg isoxsuprine every 4 hours for 24 and 48 hours. Oral therapy is continued for atleast 2 weeks with
maintenance dose of 10 mg every 6 hours.

 The usual dose of Ritodrine is 100-400 µg/minute intravenously through an infusion pump for a period of 12
hours followed by oral Ritodrine 10 mg every 12 hours.

 Salbutamol and terbutaline are selective beta 2 receptor stimulators and are very effective tocolytic agents.
Terbutaline is administered as an intravenous bolus of 0.25mg followed by constant infusion of 10-80
µg/minute for 1- 2 hours. After control of uterine contractions, maintenance therapy is continued by
administration of 0.25 mg of terbutaline subcutaneously (or 2.5 mg orally) every 4 hours.

 Indomethacin, an inhibitor of prostaglandin- synthetase has also offered some hope in arresting premature
uterine contractions. It must be used with caution because it may also block production of prostaglandin E thus
markedly decreasing uteroplacetal perfusion and may cause closure of ductus arteriosus.

Antenatal corticosteroids

 Antenatal administration of corticosteroids is one of the most cost-effective perinatal strategies. It is associated
with 50 percent reduction in the incidence of RDS( Respiratory Distress Syndrome) due to surfactant deficiency.
It provides additional benefits by reducing the incidence of intraventricular hemorrhage and necrotizing
enterocolitis. The over all neonatal mortality is reduced by 40 percent by this simple and cheap intervention.

 Injection Betamethasone 12 mg IM every 24 hours for 2 doses.

 Dexamethasone 6 mg IM every 12 hours for 4 doses should be administered to the mother if labor starts or is
induced before 34 weeks of gestation. Betamethasone is more potent and is associated with reduced risk of side
effects.

 Optimal effect occurs after 24 h of initiating treatment. The effect of one course lasts for 7 days. The optimal
effect is seen if delivery occurs after 24 hours of the initiation of therapy and its therapeutic effect lasts for
7days. The beneficial effects are better in female babies compared to the male. The need and safety of repeat
course of antenatal steroids is controversial and is under investigation by multicentric clinical trials. Tocolytic
therapy should be continued concomitantly.

 Corticosteroids can be given even in the presence of maternal hypertension or diabetes mellitus but should
preferably be avoided if preterm premature rupture of membranes (PPROM) is associated with definitive clinical
evidences of chorioamnionitis.
B..Care of preterm babies

Optimal management at birth— When a preterm baby is anticipated, the delivery should be attended by a senior
pediatrician, fully prepared to resuscitate the baby. The delayed clamping of cord helps in improving the iron stores of
the baby. It may also reduce the incidence and severity of hyaline membrane disease.
 Elective intubation of extremely LBW babies (< 1000g) is practiced in some centers to support breathing and for
prophylactic administration of exogenous surfactant. The baby should be promptly dried, kept effectively
covered and warm.

 Vitamin K 1.0 mg ( 0.5 mg in babies<1500g) should be given intramuscularly.

 The baby should be transferred by the doctor or nurse to the NICU as soon as breathing is established.

Monitoring

The following clinical parameters should be monitored by specially trained nurses. The frequency of monitoring
depends upon the gestational maturity and clinical status of the baby.
 Vital signs with the help of multi-channel vital sign monitor (noninvasive with alarms).

 Activity and behaviour.

 Color; Pink, pale, grey, blue, yellow.

 Tissue perfusion— Adequate tissue perfusion is suggested by pink color, capillary refill over upper chest of < 3
sec, warm and pink extremities, normal blood pressure, urine output of >1.5 ml/kg/hr, absence of metabolic
acidosis and lack of any disparity between paO2 and SaO2.

 Fluids, electrolytes and ABG's.

 Tolerance of feeds by monitoring vomiting, gastric residuals, abdominal girth.

 Look for development of RDS, apneic attacks, sepsis, PDA, NEC, IVH etc.

 Weight gain velocity.

Criteria for a healthy preterm baby

During daily clinical evaluation of a preterm baby, the following clinical characteristics should be looked for because
they suggest that the baby is healthy. The vital signs should be stable. The healthy baby is alert and active, looks pink
and healthy, trunk is warm to touch and extremities are reasonably warm and pink. The baby is able to tolerate enteral
feeds and there is no respiratory distress or apneic attacks and baby is having a steady weigh gain of 1.0-1.5 percent
(10-15g/kg/d) of his body weight every day.

Provide in-utero milieu

Uterus provides ideal ambient conditions to the baby. All attempts should be made to create uterus like baby-friendly
ecology in the nursery.

• Create a soft, comfortable, "nestled" and cushioned bed.

• Avoid excessive light, excessive sound, rough handling and painful procedures. Use effective
analgesia and sedation for procedures.
• Provide warmth.

• Ensure asepsis.

• Prevent evaporative skin loses by effectively covering the baby increasing humidity to near 100%.

• Provide effective and safe oxygenation.

• Efforts should be made to provide atleast partial parenteral nutrition and give trophic feeds with expressed breast
milk (EBM).

• Provide rhythmic gentle tactile and kinesthetic stimulation like skin-to skin contact, interaction, music,
caressing and cuddling.

Position of the baby

Most babies love to lie in a prone position, they cry less and feel more comfortable. It relieves abdominal discomfort
by passage of flatus and reduces risk of aspiration. Prone posture improves ventilation, increases dynamic lung
compliance and enhances arterial oxygenation. Unsuperivised
prone positioning, beyond neonatal period, has been recognized as a risk factor for SIDS( sudden infant death
syndrome).

Thermal comfort

 A pre-warmed open care system or incubator should be available at all times to receive any baby with
hypothermia or with a birth weight of less than 2000g. The baby should be nursed in a thermoneutral environment
(temp 26±2°C, relative humidity above 50%) with a servo sensor geared to maintain skin temperature of mid-
epigastric region at 36.5°C so that there is virtually no or minimal metabolic thermogenesis.

 Application of oil on the skin reduces convective heat loss and evaporative water losses.

 The extremely LBW baby should be covered with a cellophane or thin transparent plastic sheet to prevent
convective heat loss and evaporative losses of water from skin.

 As soon as baby's condition stabilizes he should be covered with a perspex shield or effectively clothed with a
frock, cap, socks and mittens. After one week or so, stable babies with a birth weight of < 1200 g should preferably
be nursed in an intensive care incubator. It is associated with reduced chances of handling, better temperature
control, reduced evaporative losses from skin and better weight gain velocity.

 The mother should be encouraged to provide partial Kangaroo-Mother-Care (KMC) to prevent hypothermia, to
promote bonding and breast feeding and to transmit healing electromagnetic vibrations of love and compassion to
her baby.

Oxygen therapy

Oxygen should be administered only when indicated, given in the lowest ambient concentration and stopped as soon as
its use is considered unnecessary. It is difficult to judge the need for oxygen therapy on clinical grounds in preterm
babies. The oxygen should be administered with a head box when SaO2 falls below 85% and it should be gradually
withdrawn when SaO2 goes above 90%. The lowest ambient concentration and flow rates should be used to maintain
SaO2 between 90%-95% and paO2 between 60-80 mm Hg.

Phototherapy
Jaundice is common in preterm babies due to hepatic immaturity, hypoxia, hypoglycemia, infections and hypothermia.
Due to immaturity of blood brain barrier, hypoproteinemia and perinatal distress factors, bilirubin brain damage may
occur at relatively lower serum bilirubin levels. Early phototherapy is advised to keep the serum bilirubin level within
safe limits in order to obviate the need for exchange blood transfusion.

Prevention of nosocomial infection

A preterm baby, who survives the initial stormy and unstable period of one week, is likely to do well if protected
against infections and provided with nutrition. The handling should be reduced to bare minimum. Vigilance should be
maintained on all procedures recommended for reduction of infections in the nursery. High index of suspicion, early
diagnosis and effective treatment of infections are essential for improved survival

Feeding and nutrition of preterm baby

 The calorie needs of non-growing preterm babies during first week of life are 70-80 kcal/kg/day.
 Additional calories are needed for- growth (25 kcal/kg/day),
-activity (15 kcal/kg/day)
-cold stress (10kcal/kg/day)
-specific dynamic action of food (8kcal/kg/day)
-faecal loss (about 12 kcal/kg/day)
 After first 1 to 2 weeks of life most preterm babies require 120-150 kcal/kg/day to maintain satisfactory
growth velocity.
 After post conceptional maturity of 40 weeks, the calorie needs decrease 100-120 kcal/kg/day.

Fluid requirements of low birth weight babies (ml/Kg/Day)

Day <1000 g 1000-1500g >1500 g
1 &2
st nd
100-120 80-100 60-80
3rd &4thone
Situation 130-140 110-120 90-100
Baby is > 2000 gm and /or >34 weeks gestational age and haemodynamically stable
5th &6th FEEDING FROM
BREAST 150-160
DAY 1 130-140 110-120

7th &8th But observe170-180

for good suck-swallow-breathing
150-160 coordination,
130-140chocking.
 Advice mother for proper positioning and latching
9th onwards 190-200 170-180 150-160

Situation two
Baby is 32-34 weeks/ weight 1500-2000 gm/ Failed breast feeding and haemodynamically stable
GIVE EXPRESSED BREAST MILK BY CUP AND SPOON
 Before use, cup and spoon to be cleaned with soap ,water and then kept in boiling water for 20
min.
 Prop up baby in sitting posture before cup and spoon feeding
 Mother’s /nursing staff’s fingers should not come into contact with milk
 Do not feed a sleeping baby, gently stimulate to keep awake
 Observe amount of milk spilled
 If the baby is accepting cup and spoon feeding without spillage/ choking/ able to take full volume
then continue cup and spoon feeding
 Situation three
Baby 28-31 weeks/ weight 1000-1500 gm/ failed cup-spoon feeding and haemodynamically stable
Start OROGASTRIC / NASOGASTRIC TUBE FEEDING
 Calculate out total feed volume for the day and divide by 12 and give requisite volume 2 hourly.

 CONTINUOUS Vs BOLUS FEEDING: both has advantages and disadvantages. Continuous

feeding may be used in smaller babies if bolus feeding is not tolerated. Continuous feeding may
lead to chances of colonization of breast milk at room temperature and some 34% EBM fats stick
to syringe walls leading to less energy delivery.
 Nasogastric breathing may increase work of breathing, increased chances of desaturation.

 Tube placement must be done gently- hurried placement may lead to apnea.

 Measure abdominal circumference at the level of umbilicus or prefixed level before each feed.
Observe for vomiting (amount, colour) or abdominal distension. Prefeed suction is to be done if
abdominal circumference has increased by > 2cm.

 Feed intolerance is present if abdominal circumference> 2cm than previous one measured at the
same level, if prefeed gastric residual.25% of feed volume, vomiting, cyanosis, bradycardia,
apnea after feeds.
 If feed volumes are tolerated by gavage feeds CONTINUE gavage feeds

Situation four
For all sick babies of any gestational age/ Babies , 1000gm/ gestational age<=28 weeks
START INTRAVENOUS FLUID
 As soon as baby is less sick start trophic feeding
 If available crystalline amino acid IV to avoid tissue catabolism
 Try to advance feeds 10 ml/ kg per day if feed tolerated
 If very unstable who can’t be put on MEN in next 5-7 days, start TPN

Converting gavage to oral feeds

 This process should be slow. Try a single cup and spoon feed. Look if the baby can finish
the feed volume by 20-30 minutes, without fatigue, increased requirements etc.

 Next give one cup spoon feed every six gavage feeds Next give one cup and spoon feed for every two
gavage feeds.

 Next day alternate cup and spoon and gavage feeds Then two cups feeds for every gavage feeds and
finally all cup feeds.
 It is to be kept in mind the goal is that the baby should not be fatigued (no desaturation, apnea, poor weight
gain), each feed by cup and spoon should be finished by 20-30 mins and there should be steady weight gain

Minimal Enteral Nutrition (MEN)

Men refers to the concept of giving small volume of enteral feeding to sick but stable newborns who cannot be given
full enteral feeds.
This results in a trophic effect on the preterm babies gut leading to better tolerance of feeds later and increased
intestinal blood flow. Breast milk is suitable for MEN.
Formula doesnot contain the essential trophic factors present in breast milk like EGF, IGF 1, 2 etc.
 Briefly after ensuring baby is hemodynamically stable a feeding tube is placed ( nasogastric/ orogastric) and baby is
fed expressed breast milk 4-6 hourly with a max. feed volume of 10-15 ml/kg. Monitoring of feed tplerance should
be done as in usual practice.

Advantages of MEN
1. Faster achievement to full feed volume
2. Improves feed tolerance
3. Better gut motility-improve peristalsis
4. Faster enzyme maturation
5. Less incidence of sepsis and NEC
6. Lower incidence of TPN associated cholestasis
7. Lower oxygen requirement

Gentle rhythmic stimulation

Availability of sophisticated high technology has revolutionized the care of preterm and sick newborn babies. But the
technology should not be allowed to become a barrier against the communication, compassion and concern of the
treating team and the family.

 Gentle touch, massage, cuddling, stroking and flexing by the nurse or preferably by the mother provide useful
tactile stimuli to the baby.

 Soothing auditory stimuli can be given to the preterm baby in the form of taped heart beats, family voices or
music.

 Music has been shown to reduce the stress of procedure and enhance weight gain velocity of preterm babies.

 Visual inputs can be provided with the help of colored objects, diffuse light and eye-to-eye contact.

Weight record
Accurate weighing of babies is a sensitive index of their well being. The weight is routinely recorded everyday but in
sick babies twice daily weight record is recommended. Most preterm babies lose weight during the first 3 to 4 days of
life and loss is upto a maximum of 10-15% of birth weight. The weight remains stationary for the next 4 to 5 days
and then the babies start gaining at a rate of 1.0% to 1.5 % of body weight (10-15 g/kg/d) per day. They regain their
birth weight by the end of second week of life. Excessive weight loss, delay in regaining the birth weight or slow
weight gain suggest that either the baby is not being fed adequately or he is unwell and needs immediate attention.
Sudden weight loss in a baby who had been gaining weight satisfactorily would suggest the possibility of
dehydration. Excessive weight gain of 100g or more per day may occur in babies with cardiac failure though
sometimes healthy babies may also gain weight more rapidly.

WHAT TO AVOID IN THE CARE OF PRETERM BABIES?

In the care of preterm babies, at times greater harm is done by unnecessary therapeutic interventions which may lead to
iatrogenic disorders. The following interventions should be avoided because they are unnecessary, useless and often
associated with serious side effects.

• Routine oxygen administration without monitoring.

• Intravenous immunoglobulins for prophylaxis of neonatal sepsis.

• Prophylactic antibiotics (except during assisted ventilation?)

 • Unnecessary blood transfusions (Definite indications include hematocrit of < 40% in a sick neonate, < 30% in a
symptomatic neonate and < 25% in an asymptomatic neonate)

• Formula feeds

• Rough handling, excessive light and sound.

Immunizations
Preterm babies are able to mount a satisfactory immune response and they can be vaccinated at the usual chronological
age like term babies. The dose of vaccine is not reduced in preterm babies. Because during their stay in the NICU,
there is no risk of contracting vaccine-preventable diseases, administer O-day vaccine (BCG, OPV, HBV) on the day
of discharge from the hospital. This policy seems more logical and appropriate to ensure more satisfactory immune
response against various vaccines.

Family support
The prolonged stay of preterm and sick newborn babies in the NICU is associated with emotional trauma, uncertainty,
anxiety and lack of bonding with the baby on the part of parents. The family dynamics are greatly disturbed apart from
tremendous physical stress and fiscal implications due
to high cost of neonatal intensive care. These issues and problems should be handled with equanimity, compassion,
concern and caring attitude of the health team.
 The frightening scene of NICU should be demystified and family should be constantly informed and involved in
the care of their baby.

 The mother should be encouraged to touch and talk with her baby and provide routine care under the guidance of
nurses.

 She should be assisted to provide partial kangaroo-mother-care to her baby in the NICU, which would enhance
bonding and promote breast feeding.

 She should provide visual and auditory stimuli to her baby and try to establish eye-to-eye contact.

 The anxiety and concern of the family should be cushioned by providing necessary emotional support and
guidance.

Discharge policy

The mother should be mentally prepared and provided with essential training and skills for handling a preterm baby
before she is discharged from the hospital.

 The mother-baby dyad should be kept in a step-down nursery where she is able to independently look after the
essential needs of her baby like maintenance of body temperature, ensuring asepsis, feeding with a cup and
spoon/paladay or breast feeding, toilet needs etc.

 The baby should be stable, maintaining his body temperature and should not have any evidences of cold stress.

 At the time of discharge, the baby should be having daily steady weight gain velocity of at least 10g/kg.
 The home conditions should be satisfactory before the baby is discharged.

 The public health nurse should assess the home conditions and visit the family at home every week for a month or
so.

Follow op protocol
After discharge from the hospital, babies should be regularly followed up for assessment of the following parameters.
 Common infective illnesses, reactive airway disease, hypertension, renal dysfunction, gastro esophageal reflux.
 Feeding and nutrition.
 Immunizations.
 Physical growth, nutritional status, anemia, osteopenia/rickets.
 Neuromotor development, cognition and seizures.
 Eyes: Retionopathy of prematurity, vision and strabismus.
 Hearing.
 Behaviour problems, language disorders and learning disabilities.

Prognosis
Prognosis for survival is directly related to the birth weight of the child and quality of the neonatal care. Over three-
fourth of neonatal deaths occur among low birth weight babies. Therefore, in countries with high incidence of LBW
babies, neonatal mortality is likely to be higher.
 The risk of neuro developmental handicaps is increased 3 fold for LBW babies and 10 fold for very LBW babies
(<1500g).

 The prognosis for mental development is good if the baby had not suffered from birth asphyxia, apneic attacks,
respiratory distress syndrome, hypoglycemia or hyperbilirubinemia Their physical growth correlates better with
their conceptional age rather than the age calculated from the date of birth. Preterm AFD babies catch up in their
physical growth with term counterparts by the age of 1 to 2 years.

 Long term follow up studies of infants with a birth weight of 1500 g and less have revealed 15 to 20 percent
incidence of neurological handicaps in the form of cerebral palsy, seizures, hydrocephalus, microcephaly,
blindness (due to ROP), deafness and mental retardation.

 The incidence of neurological handicaps is related to the quality of obstetrical and neonatal services. Neurological
prognosis is adversely affected by degree of immaturity, intrauterine growth retardation, severity of perinatal
hypoxia, intraventricular hemorrhage, periventricular leukomalacia and severity of respiratory failure demanding
assisted ventilation.

Bibliography

1)Hockenberry J.Marylin,Wilson David. Nursing care of infants and children. 8 thed. Noida,U.P: Elsevier; 2009. p.258-
377.

2)Marlow Dorothy R,Reding Barbara A. Text book of Pediatric Nursing. 6 th ed. NewDelhi: Elsevier; 2011. p.368-70.

3)Ghai OP,Paul Vinod K,BaggaArvind. GHAI Essential Pediatrics. 7 th ed. New Delhi: CBS Publishers & Distributors
Pvt Ltd; 2009.p.753-755.
4)IGNOU.Pediatric nursing BNS107(1),NewDelhi: IGNOU; 2008.p.80-110.
5) WHO Preterm birth web sites.available at http://www.who.int/entity/mediacentre/factsheets/fs363/en/index.html.
Accessed Oct29,2012.
6) Module for training of specialist in pediatrics on newborn care web sites. Available
at:www.rajswasthya.nic.in.Accessed Oct29,2012.
7)Singh Meharban. Care of the newborn. 7th ed. New Delhi: Nrinder K Sagar Publications; 2010. p.117-241.

8)Newborn Care Resource Centre. Protocol for management at sick neonatal care unit.Dept of Neonatology,
IPGMER,Kolkata; p.99-101.

Care of normal newborn at birth

Immediate care of the normal newborn at the time of birth
 1. Call out the time of birth.

2. Deliver the baby onto a warm, clean and dry towel or cloth and keep on mother’s chest and abdomen (between the
breasts).

3. Clamp and cut the umbilical cord in 1-3 minutes.

4. Immediately dry the baby with a warm clean towel or piece of cloth.

5. Assess the baby’s breathing while drying.*

6. Wipe both the eyes (separately) with sterile gauze

7. Leave the baby between the mother’s breasts to start skin-to-skin care.

8. Place an identity label on the baby.

9. Cover the baby’s head with a cap. Cover the mother and baby with a warm cloth.

10. Encourage the initiation of breastfeeding.

* - if the baby is not crying or breathing well, the next steps of resuscitation have to be carried out.
Immediate care of newborn
Introduction- The first hour after birth has a major influence on the survival, future health and wellbeing of a newly
born infant. The health workers have an important role at this time. The care they give during this period is critical in
helping to prevent complications and ensuring survival

The individual steps are briefly explained below:-

1. Call out the time of birth:

It is important to tell loudly the time of birth – this helps in accurate recording of the time and more importantly, alerts
other personnel in case any help is needed.

2. Receive the baby onto a warm, clean and dry towel or cloth on a warm dry surface
The baby should be delivered onto a warm and clean towel and kept on the mother’s adomen. If this is not possible, the
baby should be kept in a clean, warm, safe place close to the mother.

3. Clamp and cut the umbilical cord in 1-3 minutes.

The umbilical cord is clamped after 1 to 3 minute using a sterile disposable clamp or a sterile tie. Using two clean
ligatures and a new blade, the first ligature is tied about 2 cm(1 inch) from the abdomen of the baby( to avoid inclusion
of any gut wall present in the cord as part of undetected omphalocele, and to leave adequate length for umbilical
catheter insertion, if required). Second ligature is tied 5 cm from the abdomen and the cord between the 2 ligatures is
cut using a sterile blade (second ligature is applied to avoid spilling of blood). One should check the cut end of cord for
normal anatomy , ie. two arteries and one vein. The cord is left dry and open; one should not apply anything on the
cord and avoid touching.
The cord blood should be collected in cases of rhesus isoimmunization, Group O mother, maternal diabetes mellitus
and small for dates babies in whom intrauterine infection is suspected.
4. Immediately dry the baby with a warm clean towel or piece of cloth
Wet skin can result in a large amount of heat loss with seriously detrimental hypothermia. Therefore one of the first
steps after birth is through drying of the baby and especially the head, which constitute a large part of the neonatal
surface area. The vernix the cheesy material stuck on newborn skin made of dead skin, hair and secretions, serve to
conserve heat and protect the delicate newborn skin from environmental stress; no attempt is made to remove this.
After examination, baby is wrapped in clothes including a cap, and given to mother to allow first breast feed and gain
heat from, mother’s proximity.
5. Assess the baby’s breathing while drying
At the time of drying, the baby’s breathing should be assessed. A normal newborn should be crying vigorously or
breathing regularly at a rate of 40-60 breaths per minute. If the baby is not breathing well, then the steps of
resuscitation have to be carried out.
6. Eye care
Eyes are cleaned with sterile normal saline soaked gauze/cotton, using separate edges or pieces for the two eyes. The
cotton is removed over the lower edge of eyelid from medial to lateral canthi. No application is recommended unless
there was evidence of gonococcal infection in mother, in which case 1% silver nitrate is applied to both eyes.
7. Leave the baby between the mother’s breasts to start skin-to-skin care

Once the cord is cut, the baby should be placed between the mother’s breasts to initiate skin-to-skin care. This will
help in maintaining the normal temperature of the baby as well as in promoting early breastfeeding.
8. Idenification
Proper identification of the newborn is essential. The nurse must verify that identifying bands( disk no.) are securely
fastened on the newborn and verify the information against the birth records and the child’s actual gender. In some
hospitals foot or palm prints of the baby are also taken as part of the baby’s identification. It is important to provide the
mother an opportunity to see and touch the baby and also note the sex before transferring the baby to the nursery.
9. Cover the baby’s head with a cap. Cover the mother and baby with a warm cloth.

Both the mother and the baby should be covered with a warm cloth, especially if the delivery room is cold
(temperature less than 25°C). Since head is the major contributor to the surface area of the body, a newborn baby’s
head should be covered with a cap to prevent loss of heat.

10. Encourage initiation of breast feeding

Breast feeding should be started within 1 hour of birth. Breast milk is the best source of nutrition for infants until 6
months of age. Information regarding breastfeeding and its technique need to be discussed with the mother, both
during antenatal and postnatal period, not just once but in every visit so that its importance is reinforced and all
maternal concerns are addressed.
Ensuring warmth, “warm chain”

‘Warm chain’
1. At delivery:

Ensure the delivery room is warm (25° C), with no draughts.

 Dry the baby immediately; remove the wet cloth.

 Wrap the baby with clean dry cloth.
 Keep the baby close to the mother (ideally skin-to-skin) to stimulate early breastfeeding.
 Postpone bathing/sponging for 24 hours.

2. After delivery:

 Keep the baby clothed and wrapped with the head covered.
 Minimize bathing especially in cool weather or for small babies.
 Keep the baby close to the mother.
 Use kangaroo care for stable LBW babies and for re-warming stable bigger babies.
 Show the mother how to avoid hypothermia, how to recognize it, and how to re-warm a cold baby.
The mother should aim to ensure that the baby's feet are warm to touch.
Initiating breast feeding

During the initial skin-to-skin contact position after birth, the baby should be kept between the mother’s breasts; this
would ensure early initiation of breastfeeding.
Initially, the baby might want to rest and would be asleep. This rest period may vary from a few minutes to 30 or 40
minutes before the baby shows signs of wanting to breastfeed. After this period, (each baby is different and this period
might vary) the baby will usually open his/her mouth and start to move the head from side to side; may also begin to
dribble. These signs indicate that the baby is ready to breastfeed.
The mother should be helped in feeding the baby once the baby shows these signs. Both the mother and the baby
should be in a comfortable position. The baby should be put next to the mother’s breast with his mouth opposite the
nipple and areola. The baby should attach to the breast by itself when it is ready. When the baby is attached,
attachment and positioning should be checked. The mother should be helped to correct anything which is not quite
right.

Prevention of infection clean chain

‘Clean chain’

1. Clean delivery (WHO six cleans):

 Clean attendant's hands (washed with soap).

 Clean delivery surface.
 Clean cord- cutting instrument (i.e. razor, blade).
 Clean string to tie cord.
 Clean cloth to wrap the baby.
 Clean cloth to wrap the mother.

2. After delivery:

 All caregivers should wash hands before handling the baby.

 Feed only breast milk.
 Keep the cord clean and dry; do not apply anything.
 Use a clean cloth as a diaper/napkin.
 Wash hands after changing diaper/napkin. Keep the baby clothed and wrapped with the head covered.

Observation and documentation

During the transitional period, besides the baby’s Apgar score he should be observed for presence of any obvious life
threatening congenital anomalies and birth injuries. Anomalies such as trachea-esophageal fistula, meningomyelocele,
cleft lip and palate, and imperforated anus etc. should be recognized in the labour room and appropriate measures
taken. Weight and length are recorded before transferring the baby from the labour room.
During the first hour after delivery, the baby (and the mother) should be monitored every 15 minutes. Both of them
should remain in the delivery room for the first hour to facilitate monitoring. The mother and baby should not left
alone during the first hour after delivery
The two most important parameters that need to be monitored are:

i) Breathing and
 ii) Temperature or warmth

Transfer
All normal babies are transferred to the mother and nursed along with her in the postnatal area. This is called rooming-
in. However babies requiring special care should be transferred to a Neonatal Intensive Care Unit.

Later care of newborn

Care needs to be given after baby is transferred to the postnatal ward are-
 Receiving the baby in the postnatal ward
 Initiating feeding
 Preventing infection
 Maintaining personal hygiene
 Observations/ watching for early signs of disease/ congenital anomalies
 Providing supplements and follow up
 Parental reaching

Receiving the baby in the postnatal ward

After careful assessment all the normal newborns should be transferred to the mother and are nursed in a bassinet
beside the mother’s bed. Rooming in has the following advantages-
 Provides opportunity for the mother-infant interaction and promotes bonding between the two.
 Promotes breast feeding.
 Provides opportunity for the mother to learn the care of the newborn.
 Reduces the incidence of infection.
The baby should be received in the postnatal ward after checking the respiration, colour, temperature and the cord, in a
sterile sheet and well covered.
Mother’s role in the care of her baby
The health and survival of the newborn baby depends upon the health status of the mother and her awareness,
education and skills in mother craft. Mother is the best primary health worker. She has the advantages of instinct,
concern and interest to look after her baby. Early involvement of mother in the care of her baby is the best way to
promote and encourage breast feeding. Mother is the best person to identify minor developmental deviations and early
evidences of disease process because she is constantly and closely watching her baby
Initiating breast feeding

 Baby should be put to the breast within ½ hour of birth. There is no need for any prelacteal feed
such as honey, glucose water etc. The baby may receive just a few drops of colostrums but the sucking stimulates
oxytocin which helps in uterine contractions and promotes mother infant bonding. The nurse must ensure that the baby
receives colostrums which is secreted during the first 2-3 days of birth because it is reach in energy, proteins, protective
antibodies and cellular elements. The physiological inadequacy of lactation during first three days of nursing should
never be considered as an excuse for supplementing breast feeding because it does not impose nay hazards to a healthy
newborn baby. The term neonate has a large pool of extracellular fluid volume and enough quota of glycogen in the
liver. There is thus no risk of dehydration or hypoglycemia due to physiologic inadequacy of lactation at this stage.
 During first six months of life the baby should receive exclusive breast feeding and there is no need to give any water
even during summer months because all the fluid requirements of the baby are met through milk.
 The child should be on demand feeding. The baby should be allowed to suck at the breast till he
is satisfied which usually takes 15-20 minutes. During each feed one breast must be emptied completely before the baby
is put to the other breast. The breast which was partially emptied during the last feed should be offered first at the next
feed. The mother should actively interact with the baby while breast feeding The baby is considered to have adequate
feeds if he sleeps well after a feed for at least 2 hours, gains weight regularly on an average of 30 gm per day( after the
first week of life)and voids urine six or more times in a day.
 During the first four to six weeks most babies need to fed round the clock and after that gradually
the night feeds can be reduced to one late night feed and one early morning feed.
  The mother must be advised to burp the child after each feed to safeguard against the risk of regurgitation. During
lactation mother should be advised to take extra liquids and additional 450 calories per day and supplements of
micronutrients in order to maintain her own health
and nutrition and improve the nutritional quality of milk.
Maintenance of body temperature
 The body temperature of newborn infant is particularly vulnerable to develop hypothermia in winter. The baby
bath should not be given at birth and delayed till next day when his temperature has stabilized. The child should be
kept dried and adequately clothed.

 The baby should be nursed in close proximity to the mother so that the baby gains heat from maternal warmth.

 In winter the linen and clothes of the baby should be prewarmed. Baby should be provided with a cap, socks and
mittens.

 The room should be kept warm. The mother and the health worker should be trained to assess the temperature of
the baby by touch alone. When trunk is warm to touch and extremities are warm and pink it is reassuring that baby
is not having any cold stress.

Preventing infection
Newborn babies have not developed any defense against disease and are very susceptible to infections. Therefore,
particular care must be taken to protect them from infection. Some important points to be followed are-
 Hands should be washed with soap and water following 6 steps of hand washing.
 All articles used in the care of the newborn should be clean.
 The hygiene of the mother and the baby is to be maintained.

Immunization- BCG and first dose of OPV and hepatitis B vaccine are given at birth or before the baby is discharged
from the hospital. The OPV may preferably be given after 3 days because colostrums may interfere with its uptake.
The BCG site should be checked for ‘take’ response after 4-6 weeks. If there is no ‘take’ response by 6 weeks, repeat
BCG vaccine is given. Persistent and recurrent ulceration at the site of vaccination or regional adenitis responds to oral
administration of erythromycin in a dose of 30 mg/kg/day for 14 days or INH 10 mg/kg per day for 3 months.
Maintaining personal hygiene

Skin care and baby bath

 The baby must be cleaned of blood, mucus and meconium before he is presented to the mother. Effective cleaning
and drying of skin at birth minimizes the risk of potential infection by microorganisms such as hepatitis B virus,
HIV and herpes simplex virus. The barrier nursing with separate articles for each baby in their individual lockers is
desirable.

 During summer month, the baby can be given a bath. The room should be reasonably warm and free of any
draught. Avoid deep bath still the cord has fallen. Mild unmedicated soap should be used. The infant should
promptly dried with a soft towel to prevent damage to the delicate skin of the baby. During winter month the baby
should preferably be sponged rather than bathed to avoid the risk of exposure. The use of talcum powder is
unnecessary except for aesthetic purposes. Talcum powder should be taken on the fingers or cotton ball and
applied over the axilla and groin taking care that it is not sprinkled over the eyes and nostrils. Bathing provides a
good opportunity to the nurse and mother to identify any developmental peculiarities and superficial infection
which could be brought to the notice of the physician.

Care of the umbilical stump-

 The cord must be inspected after 2 to 4 hours of birth. Bleeding commonly occurs at this time due to shrinkage of
cord and loosening of ligatures. The dressing should not be applied. The stump need not be kept moistened in
babies with future need for exchange transfusion but precautions should be taken to keep the stump bacteria free.
 The cord normally falls after 5 to 10 days but may take longer, if it is dry and shriveled or when infected. The
delayed falling of the cord is also a useful marker of immune deficiency state.

Care of the eyes-

 Eyes should be cleaned daily with sterile cotton swabs soaked in normal saline, using one swab for each eye.
 If the eyes are sticky, 10% solution of sulphacetamide should be instilled in the eyes every 2-4 hours.
 The practice of applying kajal in the eyes is not recommended because it may transmit infection like trachoma and
may even cause lead poisoning.

Dresses for the baby

The clothes should be loose, soft and preferably made of cotton. They should be open on the front or back for ease of
wearing. Avoid the use of large buttons which may hurt the tender skin of the baby. The nappies should be made of
thick, soft and absorbant material in order to readily soak the urine and stools.
Body massage

Body massage is culturally accepted and has several scientifically proven benefits. Oil massage of the baby should be
postponed till baby is 3 to 4 weeks old and his body weight is more than 3 kg. It improves the circulation and tone of
the muscles, gives comfort to the baby, strengthen maternal bonding and provides additional energy to the baby
because oil can get absorbed from the thin skin of the baby. It prevents dryness and chaffing of the skin. Use a non
irritating vegetable oil like olive oil, coconut oil or sesame oil but avoid mustard oil in infants because it is pungent to
the eyes and irritating to the delicate skin of the baby. In winter massage is best done by placing the baby in front of a
closed window through which sunrays are peeping in the room. The exposure of the skin to sun rays is an important
source of endogenous production of vitamin D in the skin. The massage should be done by using gentle pressure and
smooth rhythmic movements by the mother and not by an aggressive nurse aide or ayah.
Observations and watching for early signs of disease

The nurse and pediatricians should be vigilant in the maternity ward to diagnose neonatal abnormalities at the earliest.
Most healthy term babies do not pose any serious health problems except appearance of certain developmental
peculiarities and minor problems which needs identification, reassurance and advice to the mother. The danger signs
which should be closely watched and brought to the notice are
 Bleeding from any sight
 Appearance of jaundice within 24 hours of age or deep jaundice
 Failure to pass meconium within 24 hours and urine within 48 hours
 Vomiting or diarrhea
 Poor feeding
 Undue lethargy or excessive crying
 Excessive frothiness or drooling
 Cocking during feeding
 Respiratory difficulty
 Apneic attacks and/ or cyanosis
 Seizures
 Sudden rise or fall in the blood pressure
 Superficial infections (conjunctivitis, pustules, umbilical sepsis and oral thrush etc.)

Weight record- Most babies lose weight during first 2 to 3 days of life. The weight loss varies between 5%-8% of
birth weight. The weight remains stationary during next 1 to 2 days and birth weight is regained by the end of first
week. The factors contributing to initial weight loss include removal of vernix, mucus, and blood from skin, passage
of meconium and reduction of extracellular fluid volume. The transition from in-utero parental nutrition to postnatal
oral feeding is associated with transient interruption in the physical growth of babies. Deliberate starvation and delayed
feeding is associated with excessive.

Supplements and follow-up-

 Human milk of healthy mothers receiving adequate nutrition and supplements of micronutrients is a complete food to
look after all the nutritional needs of their healthy normal weight babies. Vitamin K 1.0 mg IM is given to all babies
at birth to prevent occurrence of hemorrhagic disease of the newborn. Human milk is likely to be deficient in vitamin
D if mother has inadequate exposure to sunlight or is dark skinned. There is enough evidence to recommend routine
supplementation of vitamin D in a dose of 400 iu/day to all breast fed babies. The infants should be followed up in the
Well Baby Clinic for evaluation of their growth and development, immunizations, nutritional advice, early diagnosis
of abnormalities and guidance to the parents for the management of day to day problems of their children. When
complementary feeds are started after 6 months of age, supplements of vitamins and minerals should be provided.
Parent teaching-

The period in the hospital postnatal ward should be utilized to teach the mothers all aspects of baby care. Special
instructions should be given about holding the baby, baby bath, hygiene, hand washing, observations of baby’s
condition, feeding and nutritional supplements, immunization and follow up. The parents are also educated about
some danger signs in the child for which they should take the child to the health centre/ hospital immediately e.g. a
child who is breathing faster than normal, who is not feeding well, etc.

Nursing management

Nursing diagnosis Goal Planning implementation Expected outcome

1.Ineffective breathing Normal o Newborn to be placed in her back Baby cried.
pattern related to breathing with neck slightly extended by Respiratory rate 40-60
presence of secretions in pattern. placing a rolled towel under breaths per minute.
the airway. shoulders elevating 3/4th to 1 inch
off the mattress.
o The secretions of mouth and
nose to be cleaned with a piece of
gauze
o To clean the airway by suctioning
the mouth and then nose using a
bulb syringe or mechanical
Maintains suction using 12 or 14 Fr
nMaMutritional catheter.
Nutritional o The colour of the baby and
status respiratory rate, rhythm and depth
maintained. to be noted.
Mother holds the baby
2.Altered nutrition less o Baby to be put to the mother’s correctly during breast
than body requirement breast within ½ hour of birth. feeding.
related to knowledge o Health education to be given to Baby is sucking breast
deficit of mother about the mother about advantages , milk.
breast feeding. technique of breast feeding.
o To ensure that colostrums is
given to the mother.
o Mother to encouraged to give
exclusive breast feeding upto 6
months of age.
Improved
3. Knowledge deficit of knowledge Adequately clothed the
o To assess the existing
mother related to care of about baby baby.
the newborn. care. knowledge of the mother. Changed napkin when
o To provide information about soiled.
the care of the baby. Washed hands before
Nursing diagnosis Goal Planning implementation Expected outcome
-to maintain the warmth by handling the baby.
adequately drying the baby. Breast feeding the baby
- appropriate clothing of the on demand.
baby.
-change the napkin as soon as
soiled.
-to wash hands before handling
the baby and after changing the
napkin.
-exclusively breast fed the
newborn and burping after each
feed.
-maintain cleanliness of the room.
-to start immunization with BCG
vaccine and 0 polio.

o To receive the baby in a

prewarmed towel. Temperature 98°F.
o Stethoscope, blanket and hands of Body colour pink
the care giver should be warm to
prevent heat loss through
conduction.
o Baby to be received in a
Maintain prewarmed room, in a closed
normothermia area in one corner of labour room
4.Risk for hypothermia to prevent heat loss through
related to large surface convection and radiation.
area, thermoregulatory o Baby to be immediately dried
mechanism and thin with warm, soft, dry towels.
layer of subcutaneous fat o Baby’s axillary temperature to be
in normal newborn. checked with thermometer for
5minutes.
o The baby to be kept dried and
adequately clothed.
o Kangaroo Mother Care given.

o “5 cleans” of birthing process –

clean hands, clean delivery
surface, clean cord cut, clean cord
tie and clean cord stump
maintained Baby exhibits no
o The baby to be received in a evidence of infection.
clean room. Temperature-98.6°F,
o Thorough hand washing to be Pulse-130 beats/min
done before handling the baby. Resp-46 breaths /min
5.Risk for infection o All personnel in contact with the
related to improper Newborn is baby to be free from infection.
handling of caregiver free from o Eyes to be cleaned with sterile
and inability to produce infection. normal saline swabs for each eye
own immunoglobulin. from inner to outer canthus.
o The umbilical cord to be cut with
Nursing diagnosis Goal Planning implementation Expected outcome
a sterile scissors and to leave the
cord dry.
o Vernix caseosa not to be wiped
off from the body.
o Not to bath the baby for 48-72
hours or more after birth
depending on the condition of the
baby.
o Vital signs checked.

Bibliography

2) Singh Meharban. Care of the newborn. 7th ed. New Delhi: Nrinder K Sagar Publications; 2010. p.121-24.

3) Basic newborn care and resuscitation programme training manual. Navjaat Sishu Suraksha Karyakram web sites.
Available at: www.nihfw.org/pdf/NCHRC. Accessed Dec 23,2012.

Physical and physiological characteristics

of
term and preterm babies.
Immediate and late care of newborn babies