Editing Maternal and Newborn Nursing (section)

== Newborn Care ==

=== Immediate transition and the Apgar score ===

At birth the newborn must clear lung fluid, establish spontaneous respiration, and shift from fetal to neonatal circulation as pulmonary vascular resistance falls and the ductus arteriosus, foramen ovale, and ductus venosus close. The first priorities in the delivery room are, in order, '''warmth, airway, and breathing''': dry the infant, remove wet linens, provide skin-to-skin contact or a radiant warmer, position the airway, and stimulate.

The '''Apgar score''' is assigned at 1 and 5 minutes (and every 5 minutes to 20 minutes if the score stays below 7). Five parameters scored 0, 1, or 2: '''heart rate, respiratory effort, muscle tone, reflex irritability, and color'''. A total of 7 to 10 is reassuring, 4 to 6 indicates moderate difficulty, and 0 to 3 indicates severe distress. '''The Apgar score describes transition; it does not dictate resuscitation.''' Resuscitation is started based on respirations, heart rate, and tone, not on waiting for a score.

=== Normal newborn values and assessment ===

* Heart rate '''110 to 160''' bpm awake (may drop to about 90 in deep sleep and rise to 180 when crying); respiratory rate '''30 to 60''' per minute, irregular, with periodic breathing and short pauses under 20 seconds; axillary temperature '''97.7 to 99.5 degrees F (36.5 to 37.5 degrees C)'''; blood pressure roughly 60 to 80 over 40 to 50.
* Weight roughly 2,500 to 4,000 g at term. A weight loss of up to about 7 to 10 percent in the first days is expected, regained by 10 to 14 days.
* '''Normal findings often mistaken for problems''': acrocyanosis (blue hands and feet) in the first 24 to 48 hours, milia, erythema toxicum, congenital dermal melanocytosis (formerly Mongolian spots), vernix caseosa, lanugo, molding, pseudomenstruation and breast engorgement from maternal hormones, transient tachypnea, and epstein pearls.
* '''Abnormal findings requiring report''': '''central cyanosis or circumoral cyanosis, grunting, nasal flaring, retractions, sustained respiratory rate above 60, apnea longer than 20 seconds, temperature instability, jitteriness, a single umbilical artery''' (normal cord has '''two arteries and one vein'''), and '''jaundice in the first 24 hours'''.
* '''Caput succedaneum''' is scalp edema that '''crosses suture lines''', is present at birth, and resolves in days. '''Cephalhematoma''' is subperiosteal bleeding that '''does not cross suture lines''', appears hours after birth, resolves over weeks, and '''increases the risk of hyperbilirubinemia''' as the blood breaks down.
* '''Fontanels''': anterior (diamond) closes at 12 to 18 months; posterior (triangle) closes by about 2 to 3 months. They should be soft and flat. Bulging suggests increased intracranial pressure; sunken suggests dehydration.
* '''Reflexes''': Moro (startle), rooting, sucking, palmar and plantar grasp, Babinski (fanning is ''normal'' in infants), tonic neck (fencing), and stepping. An '''asymmetric Moro''' suggests clavicle fracture or brachial plexus injury.
* '''Elimination''': first void within 24 hours and first meconium stool within 24 to 48 hours; failure to pass either is reported. Stools progress from meconium to transitional to yellow seedy (breastfed) or pale yellow to tan and firmer (formula fed).
* Gestational age is estimated with the '''New Ballard score'''; infants are classified as small, appropriate, or large for gestational age.

=== Thermoregulation ===

Newborns lose heat rapidly because of a large surface area to mass ratio, thin subcutaneous fat, and thin skin, and they '''cannot shiver'''. They generate heat by '''nonshivering thermogenesis''', metabolizing '''brown adipose tissue''' located around the neck, scapulae, axillae, mediastinum, and kidneys.

Four mechanisms of heat loss and their nursing countermeasures:
* '''Evaporation''' (moisture on skin): dry immediately after birth and after baths; remove wet linens.
* '''Conduction''' (contact with a cooler surface): prewarm the scale, mattress, stethoscope, and hands.
* '''Convection''' (moving air): keep away from drafts, air vents, doorways, and open portholes.
* '''Radiation''' (heat transfer to a nearby cooler surface without contact): move the crib away from cold exterior walls and windows.

'''Cold stress''' is a cascade, not just a low temperature: increased oxygen consumption and metabolic rate leads to '''hypoglycemia''', anaerobic metabolism leads to '''metabolic acidosis''', which causes pulmonary vasoconstriction, worsening respiratory distress, and can impair bilirubin binding. Preterm, small-for-gestational-age, and infants of diabetic mothers are at highest risk. Skin-to-skin contact is both effective and preferred; delay the first bath until the temperature is stable.

=== Hypoglycemia ===

Institutional thresholds vary, but blood glucose below about 40 to 45 mg/dL in the first hours is commonly used as the treatment trigger. At-risk infants include those who are '''large for gestational age, small for gestational age, preterm or late preterm, infants of diabetic mothers, and any infant with cold stress, sepsis, or asphyxia'''. '''Signs are nonspecific and easy to miss: jitteriness or tremors, poor feeding, lethargy, hypotonia, weak or high-pitched cry, temperature instability, apnea, cyanosis, and seizures.''' Management for an asymptomatic at-risk infant is usually early feeding and a repeat glucose; symptomatic or very low values require IV dextrose. '''Jitteriness in a newborn is checked with a glucose level, not reassured away.'''

=== Routine prophylaxis and screening ===

* '''Vitamin K (phytonadione) IM in the vastus lateralis''' shortly after birth to prevent vitamin K deficiency bleeding. Newborns are deficient because the gut is sterile at birth and little vitamin K crosses the placenta.
* '''Erythromycin ophthalmic ointment''' to both eyes to prevent gonococcal ophthalmia neonatorum. It may be delayed up to about an hour to allow initial bonding and eye contact.
* '''Hepatitis B vaccine'''; if the mother is HBsAg positive, the infant also receives '''hepatitis B immune globulin''', ideally within 12 hours of birth.
* '''Newborn metabolic screening''' by heel stick, typically at 24 to 48 hours of age, for conditions such as phenylketonuria, congenital hypothyroidism, galactosemia, sickle cell disease, and cystic fibrosis. Adequate feeding before the screen matters for accuracy. Use the '''lateral heel''' to avoid the calcaneus, and warm the heel first.
* '''Hearing screening''' and '''pulse oximetry screening for critical congenital heart disease''' (right hand and either foot, usually after 24 hours).

=== Jaundice ===

'''Physiologic jaundice''' appears '''after 24 hours''' of age, peaks around days 3 to 5, and resolves without treatment. It results from a high red cell mass with a short red cell lifespan and an immature hepatic conjugating system. '''Pathologic jaundice''' appears '''within the first 24 hours''', rises rapidly, or persists, and suggests hemolysis such as Rh or ABO incompatibility, infection, or metabolic disease. Unconjugated bilirubin is fat soluble and can cross the blood-brain barrier, causing '''acute bilirubin encephalopathy and kernicterus''', which is permanent.

Nursing care: plot bilirubin against age in hours on a risk nomogram, '''promote frequent feeding''' (8 to 12 times in 24 hours) because bilirubin is excreted in stool and delayed passage increases enterohepatic reabsorption, and for '''phototherapy''' maximize skin exposure, provide eye protection, monitor temperature and hydration, and monitor for loose green stools and rash. Water supplementation does not lower bilirubin and is not given.

=== Feeding ===

* '''Breastfeeding''': colostrum comes first (high in protein and immunoglobulin A, laxative effect that promotes meconium passage); mature milk typically comes in at about 2 to 5 days. Feed '''8 to 12 times per 24 hours''' on demand, watching for early hunger cues (rooting, hand to mouth, lip smacking) rather than waiting for crying, which is a late cue.
* '''Signs of an effective latch''': a wide open mouth taking in the nipple and a good portion of the areola, flanged lips, the chin touching the breast, audible swallowing, and comfort for the mother. '''Nipple pain and cracking usually mean a shallow latch, not too much feeding.''' Break suction with a clean finger in the corner of the mouth before removing the infant.
* '''Signs of adequate intake''': at least 6 wet diapers per day by about day 4 to 5, 3 or more stools per day in the early weeks, appropriate weight gain, and audible swallowing.
* '''Engorgement''' care differs by goal: for a breastfeeding mother, use warmth before feeding to promote letdown, feed or pump frequently, and use cold compresses after feeding for comfort. For a mother who is not breastfeeding, avoid all nipple stimulation, wear a supportive bra, use cold compresses, and do not pump.
* '''Formula feeding''': hold the infant semi-upright with the nipple full of formula, never prop the bottle, and never microwave formula. Prepared formula follows manufacturer dilution exactly; overdilution causes water intoxication and hyponatremia, and underdilution stresses immature kidneys. '''No cow's milk, honey (botulism risk), or solids before the recommended ages.'''
* Contraindications to breastfeeding are limited but include maternal HIV in settings where safe replacement feeding is available, active untreated tuberculosis (until treated, though expressed milk may be given), certain medications and chemotherapy, active herpes lesions on the breast, and infant galactosemia.

=== Discharge teaching ===

* '''Safe sleep''': '''always on the back''', on a firm flat surface, in the infant's own space, with no pillows, bumpers, blankets, or soft toys. '''Room sharing without bed sharing''' is recommended. Avoid overheating and secondhand smoke.
* '''Car seat''': rear-facing in the back seat, never in front of an active airbag.
* '''Cord care''': keep clean and dry, fold the diaper below the cord, expect it to detach in about 7 to 14 days, and report redness spreading onto the abdomen, purulent drainage, or foul odor.
* '''Circumcision''': after a Plastibell, do not remove the ring (it falls off in about 5 to 8 days); after other methods apply petroleum gauze as ordered. A yellowish exudate on the glans after a day or two is normal healing and is '''not''' wiped off. Report bleeding more than a few drops or failure to void within 6 to 8 hours.
* '''When to call''': axillary temperature at or above 100.4 degrees F (38 degrees C) in an infant under about 3 months is an emergency requiring immediate evaluation; also report poor feeding, lethargy, fewer wet diapers, persistent vomiting, jaundice that worsens or reaches the abdomen and legs, and any breathing difficulty.