POSTPARTUM CARE OF NEWBORN

Six Criteria that define infants as physiologically stable following term vaginal delivery:
 Respiratory rate between 40-60/ min
 Axillary temperature of 36.5- to 37.4 C10 and stable heart rate (100-160 bpm)11
 Suckling/rooting efforts and evidence of readiness to feed
 Physical examination reveals no significant congenital anomalies
 No evidence of sepsis
 No jaundice developing <24 hrs

Newborn Pain
 Newborn pain is generally alleviated by interventions such as holding the baby skin-to-skin, breastfeeding,
cuddling, rocking and/or lightly swaddling.
 Although the measurement of pain is not usually required for a healthy term infant, there may be times
when newborn pain requires further assessment.

General Measurements
Age
 Term: start of 38th wk. – end of 42nd week
 Preterm: before end of 37th week
 Post term: after end of 42nd week
Weight
 2500 g – 4000g
 More or less (not good)
Length
 18-20.5 inches / 45-52.3cm.
Apgar Score
 7-10
 <7 (not good)

Newborn Normal Vital Signs

 Temperature: 36.5 -37.4 oC

 Heart Rate: 100 – 160 bpm
 Respiratory Rate: 30 – 60 /min
 Oxygen Saturation: 95% +
 Blood Pressure:
o Systolic: 67-84
o Diastolic: 35-53

NEWBORN ASSESSMENT

Assess Normal Findings Variations

VITAL SIGNS Vital signs and include– General Temperature instability
history and risks  Centrally pink and good Heart murmur
Frequency of tone Weak/absent femoral
assessment following Temperature
or brachial pulses
organization’s policy  Axilla 36.5 – 37.4oC Mucousy/ noisy
Circulation
1. Temperature respirations that are not
 Heart rate: 100 – 160
2. Respirations  Femoral and brachial improving
o Rate pulses palpated Signs of respiratory
o Respiratory  SpO2: ≤ 1 h ≥88% distress
effort  > 1 h >94% o Indrawing
3. Circulation Respirations o Grunting
o Heart rate  Effortless 30 – 60/min
o Heart o Nasal flaring
 Clear sounds Poor colour
sounds  May be irregular
Poor Feed
 Some mucus
 Easy respirations when
mouth close
HEAD Shape Head round, symmetrical Bulging Fontanelle: ^
Size  May have moulding, some ICP (brain swells do to
Fontanelles overlapping of sutures fluid buildup.
Circumference prn  Anterior & posterior Depressed Fontanelle:
fontanelles flat and soft Dehydration
 Neck short and thick Caput succedaneum:
 Full range of motion (swelling) crosses suture
lines (edema caused by
sustained pressure of
occiput against cervix)1
Cephalohematoma:
collection of blood
between skull bone &
periosteum caused by
pressure against maternal
pelvis or forceps
 Bruising,
excoriation,
lacerations
NARES Symmetry Nose breathers Nasal Congestion
Air entry both nares  Symmetrical, no nasal
flaring
 Thin, clear nasal
discharge, sneezing
common
 After mucous and
amniotic
fluids are cleared from
nasal passages, infant
differentiates pleasant
from unpleasant odors
 Nares patent
 Milia present on nose
EYES Symmetry Outer canthus aligned with Hazy, dull cornea
Placement upper ear Pupils unequal, dilated
Clarity  Dark or slate blue color constricted
Risks for eye / vision  Blink reflex present Yellowing- Jaundice
problems (family history)  Edematous lids
 Sclera clear
 No tears
 Pupils equal and reactive
to light
 May see subconjunctival
hemorrhage
 Administer eye
prophylaxis (after
completion of initial
feeding or by 1 hour
after birth)
 promotes initiation of
feeding and
maternal/infant eye
contact
EARS For well-formed cartilage Well-formed cartilage Unresponsive to noise
Ears level with the eyes  Ears level with eyes – top Ear tags, ear pits: could
of pinna on horizontal indicate a brachial cleft
plane with outer
duct or cyst (risk for
canthus of eye
 May have temporary infection and may need
asymmetry from surgical intervention)
unequal intrauterine Low set ears
pressure on the sides of
the of head
 Startles/reacts to loud
noises
MOUTH Lips for colour Mucosa moist smooth and pink Tight frenulum (tongue
Tongue midline  May have epithelial pearls tie) or heart shaped
Frenulum  Tongue midline and can tongue
Palate extend out to edge of
Cleft lip/palate
Reflexes lower lip
Oral health and care  May have noticeable Short or protruding
sublingual frenulum tongue-large
 Intact lips tongue (macroglossia)
 Jaw symmetrical Small receding chin
 Intact palate (soft, hard) (micrognathia)
Reflexes Dry mucosa (may be dry
 Rooting
after crying)
 Sucking
Mouth drooping or opens
asymmetrically (may be
facial palsy)
CHEST Symmetry  Circumference about 1cm Mucousy / noisy
Shape < head circumference respirations
Respirations  Round, symmetrical; Signs of respiratory
Heart rate protruding xiphoid
distress
Cardiovascular function process
 Clavicle intact  Retractions
 Chest sounds clear  Grunting
 Hiccoughs and sneezing  Nasal flaring
common  Tachypnea
Deviation in chest
shape
ABDOMEN/ Symmetry Abdomen One artery
UMBILICAL Bowel sounds  Slightly rounded, soft and Umbilical hernia
Cord symmetric Masses
Umbilical area  Bowel sounds present
Bleeding
 Skin: pink, smooth,
opaque Drainage
 A few large blood vessels Absent bowel sounds
may be visible Sensitive with palpation
Green emesis &/or feeding
Cord intolerance
 Two arteries and one vein Bright blood emesis
 Cord clamp secure
S & S infection – redness
 Clean and dry or slightly
moist or swelling >5mm from
umbilicus, fever, lethargy,
and/or poor feeding
SKELETAL / Symmetry  Symmetrical in size, Asymmetrical
EXTREMITIES Intact and straight spine shape, movement & extremities
Full range of motion flexion Fractures
 Intact, straight spine
Poor range of motion
 Full range of motion
 Clavicles intact Hypertonia/ contractures
 Bow-legged, flat-footed of extremities
 Equal gluteal folds Skeletal abnormalities
 Equal leg length Talipes equinovarus
(club foot)
Congenital hip dislocation
SKIN Skin color  May have (acrocyanosis) Pallor (may be genetic)
Turgor peripheral cyanosis Generalized cyanosis or
Integrity  Skin intact – may be dry increased cyanosis with
Factors that increase with some peeling;
activity
newborn risk for jaundice lanugo on back; vernix
in the creases Unexplained skin
rashes/ lacerations/
breaks in skin
  May have erythema Petechia
toxicum (newborn rash) Bruising (ecchymosis)
milia, Jaundice
 Skin pinch immediately
 Risk factors present
returns to original state
 Skin is sensitive to touch for evidence of
jaundice (such as
family history of
jaundice, LBW,
preterm, bruising)
 Infant difficult to
rouse
 Feeding poorly
 Parent does not
demonstrate ability
to monitor feeding,
output, behavior and
colour
NEURO Muscle tone and movement  Extremities symmetrical, Asymmetrical
MUSCULAR Reflexes are present and full range of motion facial/limb movement
appropriate for (ROM), flexed, good Abnormal foot posture
developmental/ muscle tone
Limbs not flexed
Infant reflexes present
Lack of muscle tone/
resistance (hypotonicity)
Seizure activity
Jitteriness – rule out low
blood sugar (<2.6mmol/L)
Abnormal or absent
reflexes

 APGAR scores between

7 and 10 at 5 minutes
GENITALIA Genitalia Anus patent Female
Females  Fusion of labia
 Labia swollen Male
 Labia majora to midline
 Urethral opening
 Urethral open behind
clitoris – in front of below/above tip
vaginal opening of penis
 Clitoris maybe enlarged (hypospadius)
 present between labia  Unequal scrotal size
 Whitish mucoid or
pseudomensus
Males
 Scrotum swollen – rugae
present
 Testes descended
palpable bilaterally
 Central urethral opening
 Foreskin not retractable
 Epithelial pearls may be
present on penile shaft
 Erections common
 ELIMINATION Bladder output and color of  One clear void with No voiding in 24 hrs
– URINE urine is normal for baby’s possible uric acid Urine concentrated
age. crystals Inadequate hydration/
Adequate hydration/ (orange/brownish color)
elimination
elimination (refer to  Urine pale yellow and
breastfeeding) odorless Yellowing of the skin
Voids within 24 hours
2-3 Wet Diapers after 24 hr
After that: Many wet diapers

ELIMINATION Normal stooling for baby’s  Active bowel sounds Abdominal distension
- STOOL age >1 meconium passed within 24 Absence of bowel sounds
hours No stools passed within
5 - 10+ yellow diapers / day
24 hours
 Watery, mustard color
 Mild odour ≤ 1 stools passed within
 May pass stool with each 48 hr
feed Diarrhea
Green, foul smelling,
mucousy stool

WEIGHT Weigh baby naked  Normal birth weight for Excessive weight loss
on tummy on a warm term: 2500 – 4000 gm may be due to
blanket Evidenced-base expected weight o poor feeding
Weight gain/loss for loss and when weight should
(inadequate milk
appropriate age start to be regained are not yet
Signs of adequate intake established transfer),
 Consensus that return o poor latch,
to birth weight by about o poor suck,
2 weeks o infrequent feeds
 Weight gain of 20-30 o low maternal milk
gm/day production
Less than 37 weeks: weight
o illness
daily

BEHAVIOURAL ASSESSMENT

1. Behaviour

 Alert for the 1st 1 – 2 hours after birth

 Sleeps much of the remaining POS (transition to extrauterine life)
 May be sleepy or unsettled due to delivery
 Responds to consoling efforts
 Cry – strong and robus
 Demonstrates:
o Early feeding cues: infant wiggling, moving arms and legs, mouthing, rooting, fingers
or hands to mouth
o Later feeding cues: fussing, squeaky noises,restlessness, progressing to soft
intermittent crying
o Organized state movement from quiet alert to crying
o Minimal crying but is strong and robust (if occurs)
o Responds to consoling efforts

2. Crying
 Minimal crying but is strong, robust
 Responds to consoling – includes feeding

INFANT FEEDING ASSESSMENT

1. Breastfeeding
  Skin-to-skin immediately after birth
 Offer breast when he/she shows signs of readiness (usually with in first 1 – 2 hours)
 Baby latchs and begins to suck
 Actively feeds
 Tolerates feeds
 After initial feed baby may not be interested in further feeding during this period.
 May have small emesis of mucous or undigested milk following feeds (10 mls or less)

2. Bottle Feeding
 Skin-to-skin for all babies regardless of feeding method
 Tolerates feed Every 2 – 4 hr
 Cue based feeding
 Signs of fullness

HEALTH FOLLOW-UP

 Vitamin K given IM based on birth weight

 Administer after completion of initial feeding (within 6 hr of birth) 86 while skin-to- skin
 Parents/caregiver have a plan for follow-up with PHCP
 Newborn ready to move to be cared for by parent (caregiver)
 Parents/caregiver aware when discharged <48 hr after birth:
o arrangements made for evaluation (as per clinical care paths for assessment and care) within 48
hours of discharge by a Health Care Professional

HEARING SCREENING

 Newborn Hearing Screening completed by Hearing Screening Program (in smaller facilities screening
of infants done in the community)

NEWBORN BLOOD SPOT SCREENING

 Newborns screened between 24 and 48 or prior to hospital discharge. If not completed during this
timeframe, collection should be done no later than 7 day

TEACHING

Eye Care
 Clean from inner canthus to outer edge with warm water when bathing

Ear Care
 Cleaning of ears e.g. do not use a cotton tipped swab

Skin Care
 Skin care – avoidance of perfumed products
 Delay first bath until baby stable and completed transition period
 Parents encouraged to do the first bath with nursing support

Bathing
 Refer to vital signs re stability
 Not required every day
 Immersion preferable to sponge bath (less chance for heat loss)
 Amount of water, lukewarm temperature, soap can be irritating, use unscented lotions/oils

Umbilical Care
 Wash hand with soap and water before and after contact with umbilical area
 Clean cord with water & air dry
 Water on cotton tipped applicator or washcloth to clean gently around the base of the cord
 Clean around the base of the cord after bathing and at diaper changes
 Fold diaper below the cord to prevent irritation and to keep it dry and exposed to air

Oral hygiene
 Look into baby’s mouth regularly
 Wipe gums with soft, clean damp cloth daily prior to the eruption of the first teeth
 Prevention of tooth decay

Neuro Muscular Care

  Encourage skin-to-skin and breastfeeding – if concerned about risk for low blood sugar
 Baby’s alertness and readiness to feed
 Positioning, movement, reflexes, muscle tone
 Jitteriness vs seizure activity – jittery movements stop when infant is held

Genitalia Care
 Keep baby clean & dry
 Females
o Do not remove vernix
o Clean from front to back
 Males
o Do not retract foreskin
o Provide information to support informed decision making re circumcision prn
o Circumcision not covered under Medical plan

Urine Elimination
 Relationship between feeding and output – elimination is a component of feeding assessment (normal
voiding for the first 72 hours)
 Assessing for adequate hydration
 Encourage use of elimination record prn

Stool Elimination
 Assess feeding/oral intake
 Relationship between feeding and output- elimination is a component of feeding assessment
 Encourage
o Breastfeeding
o Skin-to-skin
o Hand expression of colostrum
 Expected stool pattern – colour, consistency, amount, changes
 Encourage intake of colostrum– acts like a laxative

How To
 How to clear mucous
o Prone, head lowered, and stroke back
o Avoiding the use of mechanical aids in nose E.g. cotton tipped applicators & bulb aspirators
 Heat control in infants
o Skin-to-skin with blanket over infant and mother
o Loosely wrap baby with hands free – avoid swaddling Feeling back of neck to determine if
baby is too warm
Weight
 Weight is only one component of a newborn’s wellbeing andthe feeding assessment
 Mother aware that hydration &elimination affect weight (intake and output)
 Feeding indicators of adequate hydration
 Normal expected weight loss to day 3 – 4 (especially with exclusive breastfeeding)
 Normal expected weight gain after day 3 – 4 (especially withexclusive breastfeeding)
 Discharge weight prn

Behavior
 Deep sleep: if aroused will not feed
 Quiet sleep
 Drowsy
 Quiet alert: optimal state for feeding and infant-parent interactions
 Active alert: time for feeding
 Crying: late feeding cue

Crying
 Is a late feeding cue
 Assist parents in developing soothing techniques
 Soothing and consoling techniques to establish trust/bonding
o Skin-to-skin
o Feeding
o Showing mother’s face
o Talking in a steady, soft voice
o Holding arms close to body
o Movement: swaying, rocking, walking
 Discuss
 o That infants cry
o Importance of responding to infant crying, but that infant may continue to cry despite soothing
efforts
o Discuss normal feeling of frustration and potential anger when infant inconsolable

Breastfeeding
 The benefits of skin-to-skin during the establishment of breastfeeding
 Assist mother to watch/look for feeding cues
o Wiggling arms and legs
o Hands to mouth
o Rooting
o Mouthing
 Normal newborns eat 15±11gms over the first 24 hours
 Duration varies for each feeding and mother-infant dyad (may last ~20 – 50 min)
 Discuss that a satiated infant is relaxed, sleepy & disengages from breast
 Signs of effective feeding:
o 8 or more feedings after the first 24 hours
o Hear a “ca” sound during feeding
o Coordinated suck and swallow
o Refer to elimination re numbers of wet diapers and bowel movements
o Returns to birthweight by about two weeks
o Evidence of milk transfer

Formula Feeding
 Choice of formula (ready-to-feed and concentrated are sterile until opened; powdered formula is
not sterile)
 Equipment
o Equipment needed
o Cleaning of equipment
o Preparation, storage and warming formula (refer to BC Health File)
o Safety at room temperature
 Positioning:
o Hold baby close during feeding
o Have baby’s head higher than body, supporting baby's head
o Hold bottle so most of the artificial nipple is in baby’s mouth and formula fills the nipple
o Never prop the bottle