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MAKILALA INSTITUTE OF SCIENCE AND TECHNOLOGY

Concepcion , Makilala Cotabato
BACHELOR OF SCIENCE IN MIDWIFERY

Course Number : CP 101 – A

Course Title : Clinical Practicum
Credit Units 3 units
Module No: 12
Instructor : Lolita A. Inot BSM, RM

Email Address : mistlolitainot@gmail.com I. LEARNING

OUTCOME:
Duration : 1 week May 22 - 28
Mobile No. Ma’am Sharon – 09981918907

Maam Inot : Smart :09103992368

Globe:09171260262
I.LEARNING OUTCOMES:
At the end of this module the students are expected to :
1. demonstrate the different procedures on immediate care of the newborn.
2. explain the appropriate intervention in giving nursing care to mother and the baby.

II.TOPIC / SUBJECT MATTER

IMMEDIATE CARE OF THE NEWBORN
1. Examine the baby
2. Care prior to discharge
3. Newborn Screening
4. Care after Discharge

III. REFERENCES:
 Myles textbook , Williams OB , Pilliteri , Sia Texbook

IV.COURSE CONTENT:
IMMEDIATE CARE OF THE NEW BORN

Lesson 1 : Examine the baby

Lesson 2 : Care prior to discharge
Lesson 3 : Newborn Screening
Lesson 4 : Care after Discharge

1. EXAMINE THE BABY

General guidelines when examining newborn:

A.ASSESSMENT OF THE NEWBORN

as in the adult, should proceed in a systematic manner, that is, from head to toe
using the cephalocaudal method finishing with neurologic examination.

Assess the newborn:

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 attitude and position of flexion first.

 It should be better to perform the examinations that would tend to upset the
infant last so that the infant would be relaxed and quiet during most part of
the procedure.
 warm and well-lit environment.
 Cooler environments stress the newborn and this can lead to inaccuracies in
assessment.
 Incorrect findings may be made if the newborn is found to look blue,have
bradycardia or cold hands and feet due to a hypothermic environment.
 Undress only the part of the body to be examined to prevent heat loss.
 Before assessment, thorough hand washing should be performed by the
examiner to prevent the risk of cross-infection.
 In addition, the newborn should be handled with gloves until after the first
bath.

B.WEIGH THE BABY:

Normal weight: 2,500 to 4,000 grams

If between 1,500 grams and 2,500 grams

 Observe Skin to Skin Contact
 Wrap baby and cover with blanket or use radiant warmer
 Do not bathe but wipe with damp cloth only after 6 hours when
temperature is stable

Refer to hospital:

 If less than 1,500 grams, refer to hospital

 If born 2 months earlier, refer to hospital

C.Assess for unusual appearance:

Molding
Shaping of the fetal head during
movement through the birth canal

Caput Area of edema over the presenting part of

succedaneum the fetus or newborn resulting from
pressure against the cervix , often called
caput.
Cephalhematom Bleeding between the periosteum and skull
a from pressure during birth , does not cross
suture lines
Strabismus and
nystagmus
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Epstein pearls Small white hard inclusion cyst are

accumulations of epithelial cells and
disappear without treatment within a few
weeks they are form of milia

Natal tooth

Occasionally the breast become engorged

Witch milk and secretes a small amount of white fluid

Pseudomenstrati A small amount of vaginal bleeding, may

on occur from sudden withdrawal of mothers
hormone at birth

First stool should be passed within 12 to 48

Meconium hours after birth
Brick spots Normal variation “brick dust” staining
of diaper ( uric acid crystal)

Lacy red or blue pattern from dilated blood

Mottling vessels under the skin it is usually normal
from vasomotor instability occurring when
the infant is exposed to cold , stressed or
overestimated , if persist it may indicate a
chromosal abnormality
Clear color division over the body with one
Harlequin’s sign side deep pink or red and other half pale or
normal color.
The cause is vasomotor instability and it is
usually transient and benign

Mongolian spot Bluish – gray marks that resemble bruises

on the sacrum , buttocks , arms shoulders
and other areas They usuaaly disappear
after few years of life , some continue to
adulthood.

Vernix caseosa
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Lanugo

Erythema
toxicum

D.Birthmarks
1. Strawberry marks
2. Potwine stain
3. Salmon patches
4. Café au lait

E.ASSESS FOR BIRTH INJURIES:

 Bumps on one or both sides of the head, bruises, swelling on buttocks, abnormal
position of legs (after breech presentation) or symmetrical arm movement, or arm
that does not move.
If present:
 Explain to parents that this does not hurt the newborn, is likely to disappear in a
week or two and does not need special treatment.
 Gently handle the limp that is not moving
 Do not force legs into a different position

2. Assess for congenital anomalies:

i. Club foot
ii. Cleft lip and palate
iii. Spina bifida
iv. Hip dysplasia
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2.CARE PRIOR TO DISCHARGE

Time band: after 90 minutes but before discharge

Interventions:
• Support breastfeeding
• Ensure warmth of baby
• Washing and bathing
• Sleeping
• Danger signs
• Discharge instructions

2. Support unrestricted, per demand breastfeeding, day and night

a. Keep the newborn in the room with his or her mother, in her bed or within
easy reach. Do not separate them (rooming-in).
b. Support exclusive breastfeeding on demand day and night-means the baby
feeds only breastmilk and nothing in between.
c. Baby will feed around 8 times a day. No need to give water because
breastmilk is 88% water.
d. To ensure adequate milk production and flow for 6 months of exclusive
breastfeeding, a baby needs to feed as often and for as long as he or she
wants, both day and night.
e. This is demand feeding, unrestricted feeding, or baby-led feeding.
3. Praise any mother who is breastfeeding and encourage her to continue exclusively
breastfeeding.
4. Explain the exclusive breastfeeding is the only feeding that protect her baby
against serious illness.
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A. Advantages to baby:
 Vitamin A is important for protection of the eye and for the integrity of epithelial
surfaces, and often makes the colostrum yellowish in color.
 Epidermal growth factor helps to prepare the lining of the gut to receive the nutrients
in milk.
 Bile-salt stimulated lipase facilitates the complete digestion of fat ones the milk has
reached the small intestine.
 White blood cells which can kill microorganisms.
 Whey proteins (lysozyme and lactoferrin), which can kill bacteria, viruses and fungi.
 Oligosaccharides which prevent bacteria from attaching to mucosal surfaces.

B.Advantages to mother:
 Less postpartum hemorrhage
 Less risk of a ovarian and breast cancer
 Faster return of figure
 Infertility to prevent pregnancy

5. Ensure warmth of the baby

a. Ensure the room is warm (>25°C and draft-free)
b. Explain to the mother that keeping baby warm is important for the baby to
remain healthy
 During the day, dress up or wrap the baby.
 At night, let the baby sleep with the mother or within easy reach to facilitate
breastfeeding.
 Keep the baby in skin-to-skin contact with the mother as much as possible.
 Dress the baby or wrap in soft dry clean cloth.
 Cover the head with a cap for the first few days, especially if baby is small.

Do not:
1. Put the baby on any cold or wet surface
2. Swaddle/wrap too tightly 3. Leave the baby in direct
sunlight.

c. Newborn baby is prone to develop hypothermia due to:

 Larger surface area.
 Decrease thermal insulation due to lack of subcutaneous fat (low
birth infants)
 Reduced amount of brown fat (low birth weight infants).

d. Newborn baby loses heat by four mechanisms.(read your m100 of the

definition )
 Radiation
 Convection
 Evaporation  Conduction

e. Steps of “warm chain” in hospital include:

 Warm room
 Appropriate clothing
 Breastfeeding
 Keep the baby and mother together  Postpone beeping and
weighing.

f. Routine temperature should be recorded by axillary route.

 Normal axillary temperature range is 36.5 to 37.5°c.
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 If you do not have a thermometer to measure temperature, assess

baby’s baby’ s temperature by touching the abdomen and extremities
of the baby. If you touch a baby with normal temperature, he will
have warm trunk and warm soles/palms.

6. Postpone bathing until at least the baby is 6 hours

a. Early washing can lead to:
 Hypothermia which can lead to infection, coagulation defects, acidosis,
delayed fetal to newborn circulatory adjustment, hyaline membrane
disease, brain haemorrhage.
 Infection: the vernix is a protective barrier from bacteria such as E. coli
and Group B Strep; so his maternal bacterial colonization  No
crawling reflex.

b. When washing the newborn:

 Wash your hands first.
 Wipe the face, neck and underarms with a damp cloth daily.
 What’s the buttocks when soiled.
 Dry thoroughly.
 Bathe when necessary, ensuring that the room is warm and draft-free,
using warm water for bathing and thoroughly drying the baby, then
dressing and covering after the bath.
 If the baby is small, ensure that the room is warmer when changing,
wiping or bathing.

7. Sleeping:
 Let the baby sleep on his/her back or side.
 Keep the baby away from smoke or from people smoking.
 Ensure mother and baby are sleeping under impregnated bed that if there is
malaria in the area.

8. Instruct mother to bring a newborn to clinic if any of the following danger

signs is present:
a. Signs of serious illness
 Fast breathing (> 60 breaths per minute)
 Slow breathing (<30 breaths for per minute)
 Severe chest in-drawing
 Grunting convulsions
 Floppy or stiff
 Fever (temperature greater than 38°c)
 Temperature less than 35°c or not rising after re-warming
 Umbilicus draining pus
 More than 10 skin pustules or bullae, or swelling, or redness, or hardness of
skin (sclerema)
 Bleeding from stump or cut  Pallor

b. If any of the above is present, consider possible serious illness:

 Start resuscitation, if necessary
 Re-warm and keep warm during referral for additional care.
 Give first dose of two IM antibiotics: the two intramuscular antibiotics
to be given before referral to a hospital of a young infant with very severe
disease are: ampicillin and gentamycin  Stop bleeding.
 Give oxygen, if available.
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8.Teach how to treat local bacterial infection manifested by red umbilicus, pus in
umbilicus and skin pustules.

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IV.Activity /Exercises

Activity 1
Name: Section: Date

Instructions:
9. Write your complete name clearly
10. Read the question carefully
11. Send your soft copy answer to E mail address of ma’am Lolit ( section A )
Ma’am Sharon ( Section B ) NOT to group chat or messenger.
4. Or your hard copy answers to Midwifery Dept. office.

A.ESSAY:

1. Discuss the advantages of exclusive breastfeeding to mother and the Baby( 10points )
2. What are those following danger signs that needs to be refer to the hospital for immediate
treatment ( 10points )

A. Give an appropriate oral antibiotic.

 Amoxicillin: give three times daily for 5 days.
 Cotrimoxazole: (Trimethoprim + sulphamethoxazole) Give two times daily for 5 days.
Avoid cotrimoxazole in infants less than one month of age who are premature or
jaundice.

B.Teach the mother to treat local infections at home.

Treatment of thrush with Nystatin or Gentian Violet.

The mother should do the treatment four times daily for seven days:

 Wash hands
 Wash mouth with clean soft cloth wrapped around the finger and wet with
salt water.
 Give 1 mL 4 times a day or paint with diluted 0.5% gentian violet  Wash
hands
C.Treatment for skin pustules or umbilical infection, the mother should do the
treatment twice daily for 5 days:

 If less than 10 pustules, consider local skin infection: teach mother to treat skin
infection. If more than 10 pustules, refer for evaluation
 Wash hands
 Gently wash off pus and crusts with soap and water  Dry the area
 Paint with full strength f Gentian Violet (0.5%)
 Wash hands
 Tell her to do the treatment twice daily. She said should return to the clinic if the
infection worsens.

D.Treatment for Gonococcal eye infection

 Give single dose of appropriate antibiotic for eye infection.

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 Teach mother to treat eyes

 Wash eyes with cool boiled water 6-8 times a day
 Apply 5% tetracycline eye ointment three times a day

E. Assess and treat mother and her partner for possible gonorrhea
 Watch her as she does the first treatment in the clinic.
 Follow up in two days. If pus or swelling worsens or does not improve her for
urgently.
Discharge instructions:

A.Advise the mother to return or go to hospital immediately if baby has any of the
following:
 Jaundice to the soles
 Difficulty feeding
 Convulsions
 Movement only when stimulated
 Fast or slow or difficult breathing (e.g., severe chest in-drawing)  Temperature
greater than 37°C or less than 35. 5°C.
B.Schedule or routine visits as follows:

Postnatal visit 1: at 48 to 72 hours of life

Postnatal visit 2: at 7 days of life
Immunization visit 1: at 6 weeks of life
C.Schedule additional follow-up visits depending on baby’s problems:
After two days:
1. if with breastfeeding difficulty
2. Low Birth Weight in 1st week of life
3. Red umbilicus
4. Skin infection
5. Eye infection
6. Thrush or other problems

D.Advice Newborn Screening

The Newborn Screening Reference Center (NSRC) is an office under the National
Institutes Of Health (NIH), University of the Philippines Manila created under our
RA 9288 – The Newborn Screening Act of 2004
The law mandates the newborn screening be performed after 24 hours of life up to
3 days except for patient in intensive care, must be tested by 7 days

A. Disorders covered by newborn screening:

• Congenital hypothyroidism
• Congenital adrenal hyperplasia
• Galactosemia
• PKU (Phenylketonuria)
• G6PD deficiency

2.CARE AFTER DISCHARGE

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Time Band: Care after discharge but before seven days.

Interventions:
• Support breastfeeding
• Ensure warmth of baby
• Look for signs of very severe disease

1.Support on restricted, for demand exclusive breastfeeding, day and night.

 Ask the mother exactly what the baby fed on in the past 24 hours before the visit.
Ask about water, vitamins, local foods and liquids, formula and use of bottles and
pacifiers. Ask about stooling and wet diapers.
 Praise any mother who is breastfeeding and encourage her to continue exclusively
breastfeed.
 (Re-) explain that exclusive breastfeeding is the only food that protects her baby
against serious illness.
 Define that exclusive breastfeeding means no other food or water except for breast
milk.
 Reassure her that she has enough breastmilk for her baby’s needs.
Advise the mother to:
 Keep the newborn in the room with her, in her bed or with an easy reach
 Exclusively breastfeed on demand day and night (greater than or equal to 8 times
in 24 hours except in the first day of life when newborn sleeps a lot).
 Observe a breastfeed, if possible ,ask the mother to alert you if she has
breastfeeding difficulty, pain or fever
Observe, treat and advise:
 Is nipple(s) is/are sore or fissured, and the baby is not well attached, in addition to
the above:
 Reassess after 2 feeds (within the same day).
 Advise the mother to smear hind milk over sore nipple after a breastfeed  Check
the baby’s mouth for candida thrush to treat baby and mother.
 If not better, teach the mother how to express that breastmilk from the affected
breast and feed baby by cup until breast(s) is/are better.
 If breasts are swollen but the milk is dripping. Reassure the mother, that this is
normal breast fullness and will improve with frequent breast-feeding in 36 to 72
hours.
 If breast are swollen, shiny and the milk is not dripping, mother’s temperature is
less than 38°C and the baby is not well attached, treat and advice for
engorgement. In addition to the above:

Breastfeed more frequently

Reassess after two feeds (within the same day).
If not better, teach and help the mother expressed enough
breastmilk to relieve the discomfort.
 If breast(s) are swollen, painful, there is patchy redness, and mother’s temperature
is greater than 38°C, treat and advise for mastitis. In addition to the above:
Give Cloxacillin 500 mg Q6 hours for 10 days.
If severe pain, give paracetamol.
Reassess in 2 days. If no improvement or worse, refer to
hospital.

2. Ensure warmth for your baby:

 Explain to the mother that babies need an additional layer of clothing
compared to older children or adults.
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 Keep the room or part of the room warm, especially in a cold climate.
 During the day, dress up or wrap the baby.
 At night, let the baby sleep with a mother or within reach easy reach to
facilitate breastfeeding.
 Ensure additional warmth for the small baby (or twin)

3. Look for signs of very severe disease:

A.Signs of very severe disease include any one of the following times:
 Yellow skin to the soles
 History or difficulty feeding
 History of convulsions
 Movement only when stimulated
 Respiratory rate greater than 60 per minute
 Severe chest in-drawing
 Temperature greater than 37.5°C (per local expert opinion)
 Temperature less than 35. 5°C

B. Intervention
A. Give first dose of intramuscular antibiotics.

1. GENTAMICIN:
Dose: 2.5 mg per kilogram.
 Add 6 ml sterile water to 2 mL vial containing 80 mg = 8 mL at 10
mg/mL.

2. BENZYLPENICILLIN:
Dose: 50,000 units per kilogram.
 Add 3.6 mL sterile water 4.0 ML at 250,000 units per mL.
B.Referral is the best option for a young infant
classified with :

1. Possible Serious Bacterial Infection.

 If referral is not possible, give benzylpenicillin and gentamicin for at least
five days.
 Give benzylpenicillin every 6 hours plus gentamicin every 8 hours. For
infants in the first week of life, give gentamicin every 12 hours.

2. Treat to prevent low blood sugar: give 30-50 mL of milk or sugar water before
departure.

 To make sugar water: dissolve 4 level teaspoons of sugar (20 g) in a 200 mL cup of
plain water
3. Advise mother how to keep the infant warm on the way to the hospital.

4. Provide skin to skin contact or keep the young infant clothed or covered as much
as possible all the time. Just a young infant with extra clothing including hat,
gloves, socks and wrap the infant in a soft dry cloth and cover with a blanket.

5. REFER BABY URGENTLY TO THE HOSPITAL:

 After emergency treatment, explain the need for referral to the
mother/father.
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 Organize safe transportation.

 Always sends the mother with the baby, if possible.
 Send the referral note with the baby.
 Inform of the referral center, if possible by radio or telephone

VI. ASSESSMENT / EVALUATION EXAMINATION

1.ESSAY

1.What are Some important consideration in giving health teaching on the following :

1. Care prior to Discharge ( 10points )

2. Care after discharge ( 10points )

II. Enumeration

1. The 5 Disorders covered by newborn screening

2. Give at least 5 unusual appearance during the assessment of the newborn