PERFORM PROPER IDENTIFICATION of the WGO principle of Essential Newborn Care.

-Do not separate the

baby from the mother as much as possible.
1. Test way to identify the newborn is by means of an ankle ID band,
not by foot printing, which can cause infection due to the common
stamp pad.The mother also wear an identical ID band or bracelet. The
identification bracelet should contain: A. MAINTANRESPIRATION

 Mother's name Continue measures to clear the airway as necessary; promote lung
 Mother's hospital number expansion.
 Date of delivery
 Time of delivery 1. The newborn is an obligate nasal breather; ensure that his/her nostril
 Sex of the baby are patent.

2. Identify the newborn properly in the delivery room and not in the 2. Gently stimulate the cry and turn every two hours to fully inflate the
Nursery. alveoli. To stimulate crying in newborn, gently rub his/her back slap
his/her soles.
RATIONALE: The identification of the newborn is done before the
newborn is separated from the mother. This is to prevent possibility of B. KEEP WARM
switching, misidentification or abduction.
1. Maintain body heat and prevent heat loss.
SAFETY ALERT: Each newborn must first be properly identified before
 Wrap the newborn, you may cover the head with a fabric-
she/he is separated from the mother. The nurse practitioners must be
insulated/ knitted bonnet.
familiar with the infant security system used in their unit/area of
practice. As for home birth, it is very important that the newborn is
RATIONALE: The newborn's temperature stabilizes in 8 to10 hours.
properly identified before she/he is transported to a health facility.
Until then, he/she must be kept warm. The head is one-fourth of the
length, and he/she will lose a lot from the big surface area if exposed;
keep it covered.
PROMOTE EARLY BONDING/ATTACHMENT
 Place the newborn under a droplight to gain added heat from
1. Allow parents to hold the newborn to promote bonding. Encourage radiation.
breastfeeding right at the table.  Maintain a temperature between 36.5C and 37.5 C.
Hypothermia is a condition wherein the newborn's
2. Delay eye prophylaxis or Crede's prophylaxis for 1to 2 hours after temperature falls below 36.5C.
birth.  Check the initial temperature per axilla not per rectum.

RATIONALE: Eye prophylaxis is usually delay in order not to interfere High- risk newborns (i.e, premature, SGA, with congenital defects) are
with the bonding process. The blurred vision that follows the usually placed in incubators for effective thermoregulations. The
application of eye ointment or silver nitrate does not permit eye-to-eye Kangaroo hold may be used in the absence of incubators.
contact, the most important prerequisite to early bonding.

3. Implement early rooming -in. An infant delivered by normal

spontaneous delivery NSD) may be roomed in 30 minutes after birth; C. PERFORM CREDE'S PROPHYLAXIS
an infant delivered by a caesarian section may be roomed in as early
1. Admission eye care is prophylaxis against ophthalmia neonatorum or
as 4 hours after birth, barring any maternal infant complication/
gonorrhea conjunctivitis, which may lead to neonatal blindness.
contraindication.
2. A legal responsibility is given to all newborns, whether or not the
mother has gonorrhea.
EARLY ESSENTIAL NEBORN CARE(EENC, WHO, 2022c)
3. Drugs used:
A. Early Essential Newborn Care(EENC) is essential package that
 A. Ointment tetracycline (Tetracyn) 1% or Erythromycin
includes immediate skin-to-skin contact between the mother and her
(ERYC) 0.5% apply 1 cm from the inner canthus of each eye,
baby shortly after the baby is born.
or 2.5% povidone-iodine drops (one drop on each
B. EENC transfers life-saving warmth, placental blood, and protective conjunctival sac) after the newborn has located the breasts.
bacteria from the mother to the newborn.  All medications may be cause chemical conjunctivitis of the
eyes within the first 24 hours after application ( Littleton &
C. EENC promotes a natural bond between a mother and baby. Engebretson, 2006)

D. EENC initiates exclusive breastfeeding, where babies are provided 4. Rinse the eyes before the application; no rinsing after. Do not wash
with all the essential nutrients, antibodies, and immune cells to protect away the eye antimicrobial.
them against diseases. Prolonged skin-to-skin contact is recommended
for no less than 90 minutes. 5. Eye care may be delayed for 1 to 2 hours after delivery in order not
to interfere with the bonding process. If bonding is promoted early in
E. EENC improves the condition of all babies, including those who are the DR, then there is no need to delay eye prophylaxis.
premature, sick or born by cesarian section.

PERFORM CORD DRESSING

IMMEDIATE CARE IN THE NURSERY
1. Done within 1-3 minutes after (or while in SSCDelay cord clamping
KEY POINT: With worldwide recognition of the benefits to both mother or implement non-immediate cord clamping in order to reduce the
and infant of immediate mother - baby-skin-to-skin contact (SSC), early incidence of anemia in term newborns, and intraventricular
breastfeeding and rooming in and the experience major disadvantages- hemorrhage (IVH) in preterm newborns.
Physiologic, psychosocial and economic- the rule of thumb now is to
reserve the nursery for high-risk newborns. Normal newborn should be 2. Observe strict asepsis in cord dressing to prevent infections:
near the mother, preferably in the Kangaroo hold, and even newborn
Tetanus neonatorum caused by clostridium tetani, and omphalitis, a
procedures should be done, preferably near the mother in observance
specific bacterial infection of the cord.
3. Check the number of cord vessels: one bigger vein and two smaller
arteries; the presence of a single cord artery requires further
evaluation of the newborn for a genitourinary or kidney anomaly.

4. Observe for oozing of blood, as there is a bleeding tendency in

newborn. Bleeding from the cord is termed omphalanghia.

5. Promote drying up: 70% alcohol application once or twice a day or

PRN. The cord stump drop off by 7-10 days; if not, silver nitrate
cauterization is employed.

E. INJECT VITAMIN K

1. Vitamin K (1.0 mg IM) is given to all newborns to prevent bleeding

due to a deficiency in the clotting factor vitamin K. Offer oral vitamin K
if parents decline intramuscular injections. RATIONALE: The newborn's
gastrointestinal tract is initially sterile-no bacteria (E. coli) to stimulate
the production of vitamin K, a cofactor in the normal clotting process;
absent/low vitamin K level; poor blood clotting; neonatal hemorrhage.

2. Best Site. Anterolateral aspect of the thigh Vastus Lateralis);

alternate site :

 medial thigh ( Rectus femoris)

 Dose: usually 1mg;
 Stock dose: 10mg/ml; 0,1 ml given IM.

PROVIDE SKIN CARE

1. A newborn's first bath is given primarily to cleanse the skin of blood,

amniotic fluid, vaginal secretions, and other residues on the skin to
prevent infection. Care must be observed to ensure that the baby is
kept warm and dried quickly to prevent cold stress. The WHO
recommends bathing the newborn at least 6 hours, after birth. At birth,
gently wipe the newborn until it is dry.

2. The admission bath uses warm water and mild soap.

3. An oil bath is given to high-risk newborn and to those with plenty of

vernix caseosa a thick cheesy substance) on the skin. Spreading vernix
caseosa over the newborn's skin surface helps prevent the loss of body
heat.

ESSENTIAL NON-IMMEDIATE NEWBORN CARE from 90 minutes

to 6 hours.

1. Give vitamin K prophylaxis 1mg of IM

2. Inject hepatitis B vaccine IM and BCG vaccine intradermally.

3. Examine the newborn thoroughly, checking for any injuries,

malformation or defects.

4. Provide cord care.

 Put nothing on the cord stump; do not touch it unnecessarily.

 Fold the diaper below the stump. Keep the cord stump
loosely covered with clean clothes. Do not bandage the
stump or abdomen.

Assessment of The Newborn

• Initial Physical Examination:

A. General Guidelines:

 Keep the NB warm during the examination.

 Begin with general observations and then perform
assessment that are least disturbing to the NB first.
 Initiate nursing interventions for abnormal findings.
 Document all abnormal findings.
PHYSICAL ASSESSMENT MILIA

Chest circumference:  Newborn sebaceous gland is

immature.
1. Vital Signs Should be equal to or 2-3 cm Less than the  At least one pin-point white
HC papule (a plugged or unopened
A. PULSE - 1 full minute; use apical pulse sebaceous gland) can be found In
the cheek or across the bridge of
• Irregular, rapid 160-180 at birth
the nose of every newborn.
Physiologic weight loss
 Disappears by 2-4 wks of age as
NORMAL: 120-160 bpm
the sebaceous glands mature and
- 5-10 % in 10 days
During sleep - 90-110 bpm drain.
Causes  Parents should be instructed to
If crying, up to 180 bpm avoid scratching or squeezing the
1. No longer under Influence of maternal papules to prevent secondary
hormones infection.

B. RESPIRATIONS 2. Voids and passes out stools

• 1 full minute 3. relatively low nutritional Intake ERYTHEMA TOXICUM

• Irregular, shallow, rapid w/ brief apneic 4. beginning difficulty establishing sucking In most normal mature infants, newborn
spells < 15s rash.

60-80 breaths/min at birth  It usually appears in the 1st to

Immediate Assessment of the Newborn 4th day of life, but may appear up
NORMAL: 30-60/minute to 2 wks of age
General appearance  Also called Flea bite rash
 One of the chief characteristic of
- Skin the rash is the lack of pattern.
C. BLOOD PRESSURE - not usually - Head
measured - Eyes Lesion are most noticeable at 48H After
- Ears birth but may appear as late as 7-10 days
80-60/45-40 mm Hg at birth - Neck
- Chest BENIGN RASH resolves spontaneously
100/50 mm Hg at day 10
- Abdomen
- Genitalia
- Back
- Extremities CUTIS MARMORATA
D. TEMPERATURE

General Appearance Mottling lacy pattern may be seen in the

Normal range: 36.5C-37.5C (axilla)
healthy infant Or with
Axillary: 36.4C-37.2C  Full term newborns have a flexed
posture 1. cold stress
 The head is flexed 2. Hypovolemia
Skin: 36.0 C-36.5C
 Arms le flexed on the chest 3. Sepsis
Rectal: 36.6C-37.2C  Legs are flexed on the abdomen
Persistent mottling-referred to as cutis
* Temperature 37.2 at birth marmorata

SKIN

Anthropometric Measurements  Plethora (deep, rosy red color) CANDIDA ALBICAN RASH
more common in infants with
(Vital Statistics) Appear erythematous plaque
polycythemia vera but can be
seen in an over oxygenated or
BW: 2.5-3.4 kgs With sharply demarcated edges
overheated infant.
 Vernix caseosa - a white creamy Sin fold are involved
(5.5 - 7.5 lbs)
substance may thinly cover the
skin. Treatment:
* 1K = 2.2 Ibs
 Lanugo - fine downy hair, may
BL: 47.5 - 53.75 cm still be seen on the forehead and - Nystatin ointment of cream
shoulders or it may all - Applied to the rash 4x daily for 7-
(19 - 21 1/2 in) disappeared. 10 days
 Pinkish red
Average: 50.8 cm/20 in  Vernix caseosa
 Lanugo
* 1 inch = 2.54 cm  Milla ACNE NEONATORUM
 Dry peeling skin
HC: 33 - 35 cm  Lesion typically seen over the
 Cyanosis - Hypothermia
check, chin and forehead
- Hypoglycemia
CC: 31 - 33 cm  Benign and requires no therapy
- Infection
 Severe cases may require
- Cardiac
AC: 31 - 33 cm treatment with mild keratolytic
- Respiratory
- Neurological abnormalities
 agent such as 3 % sulfur salicylic  Telangiectatic Nevi (stork EYES
acid bites) - disappear age 2yrs.pale
pink or red, flat, dilated capillaries  Symmetrical and clear
 Nevus Flammeus (port- wine  Pupil equal, round, react lo light
stain) by accommodation
FORCEPS MARK - No fading with time  Blink reflex present
- Require surgery in the future  Strabismus common - weak EOM
 There may be a circular or linear  Ability to track and fixate
- Common on face
contusion matching the rim of the momentarily
- Non elevated, sharply
blade of the forceps on the  Red reflex present
demarcated red to purple dense
infants cheek.  Eyelid often edematous
area of capillaries
 The mark disappears in 1-2 days  Visual acuity = 20/200;20/800
 Nevus Vasculosus
along with the edema that
( strawberry mark)
accompanies it. EARS
- Disappear © 7-9 yrs old
- Common in head
JAUNDICE  Symmetrical
- Dark red
 Firm cartilage with recoil
Types:  Mongolian Spot
 Pinna on or above line drawn
- fades 1-2 years old
from canthus of eye.
1. Physiologic Jaundice / Icterus - Bluish black pigmentation
 sense of Hearing - highly
Neonatorum - Lumbar dorsal area or buttocks
developed in NB
 2 day- 7th day - TERM (12mg/d- HEAD
NOSE
indirect bilirubin)
 2 day- 10th day - PRE-TERM  25% of the body length
 Nasal obligates
(cephalocaudal development).
 Note for marked flaring of alae
2. Pathologic Jaundice- before the first 24 Larger Part
nasi.
hours of life  Sutures are palpable
- Indicative of airway obstruction
 Fontanels are unossified
Causes: membranous tissue at the
Causes of obstruction:
junction of the sutures
 Infection  Molding is asymmetry of the head 1. Secretions
 Hemolytic disorders resulting from the pressure in the 2. septal deviation
 Inability of the newborn to birth canal, overlapping of
conjugate bilirubin sagittal and coronal suture line * Sense of smell - least developed

MASSES FROM BIRTH TRAUMA

Breastfed babies have longer physiologic  CAPUT SUCCEDANEUM - edema MOUTH

jaundice because human milk has of the soft tissue over bone
PREGNANEDIOL, which depresses the (crosses over suture line)  Pink, moist gum
action of glucuronyl transferase (enzyme - No treatment subside in few days  Soft and hard palates intact
responsible for converting indirect bilirubin  CEPHALOHEMATOMA - Is  Epstein pearl (small, white cyst)
to direct bilirubin) swelling caused by bleeding into that may be present on hard
an area between the bone and Its palate
periosteum (does not cross over  Uvula on midline
suture line )  Symmetrical and free moving
Goal of treatment: to decrease the bilirubin
- Absorbed within 6 weeks tongue
levels
- No treatment  Sucking & crying movement
 CRANIOSYNOSTOSIS - suture symmetrical
Management:Bililight (Phototherapy)
lines separated or fontanels  Able to swallow
Nursing Care: prematurely closed; leads to  Gag reflex present
mental retardation.
1. Cover eyes with an opaque mask  CRANIOTABES - localized
to prevent blindness. softening of cranial bones;
indented by pressure of a finger. NECK
2. Maintain a distance of about 18-
20 inches from source of light. - Corrects w/o treatment in weeks
 Thyroid gland not palpable
3. Monitor V/S especially temp. or months.
 Soft, palpable and creased with
4. Cover the genitalia to prevent - Common to first born because of
skin folds
PRIAPISM (continuous erection), early lightening
 Head - rotate freely on the neck
5. Turning the baby q2hours.  HYDROCEPHALUS - anterior
and flex forward and back.
6. Hydration. fontanel open after 18 months
 MICROCEPHALY - small growing
(+) rigidity of the neck- CONGENITAL
NURSE ALERT!!! brain.
TORTICOLLIS (injury to SCM)
 ANENCEPHALY - absence of
Most accurate method of assessing the cerebral hemisphere • NB whose membranes ruptured 24 hours
presence of jaundice: Use natural light and
before birth ->nuchal rigidity → meningitis.
blanch skin on the chest or tip of the nose.  SEBORRHEIC DERMATITIS - "
Cradle cap"
 Acrocyanosis - Scaling greasy appearing salmon
 Harlequin sign colored patches, seen on the CHEST
- Deep pink or red color develop scalp behind ears and umbilicus
over one side while the other side - CAUSE:  Circular appearance - AP and
remain PALE or normal color o Improper hygiene Lateral diameter are about EQUAL
- Indicative of shunting of blood - Mgt:  Diaphragmatic respiration
with cardiac problem or sepsis o Proper hygiene  Bronchial sounds heard on
 Birthmarks auscultation
o Oil before shampoo
 Nipples prominent & edematous
BIRTH MARKS
  Milky secretion common (witch ›Establish and Maintain AIRWAY D. Ductus Venosus
milk) (Respiration)
 Breast tissue present - cord clamped→ blood ceases flowing from
 Clavicles need to be palpated to Test for Patency umbilical vein to ductus venosus and into
assess for fracture IVC→ blood now flows through the LIVER
A. Suctioning and is filtered as in adult circulation

 Turn the baby's head to one side Obliterate : @ 2 months become

ABDOMEN  Suction gently and quickly (5 to Ligamentum venosum
10 seconds). Prolonged and deep
 Umbilical cord suctioning of the nasopharynx
- monitor cord for meconium during the first 5 to 10 minutes of
staining life will stimulate the VAGUS Nutrients Human Cows Milk
- Assess for umbilical hernia NERVE (located in the esophagus) Milk
- Note for abdominal depression and cause bradycardia Fe 0.5 0.5
- Assess for abdominal distention Linoleic (+) (-)
POSITIONING OF THE NEWBORN Acid
- Monitor bowel sound - occur 1-2H
Vit D 22 14
after birth Vit A 1898 1025
 The position when suctioning
Vit C 43 11
ANUS should be one that promotes
Vit K 15 60
drainage of secretions -
- Ensure anal opening is patent - HEAD LOWER THAN THE REST OF
- First stool meconium should pass THE BODY BUT head should be WASTE ELIMINATION
within first 24h higher than the rest of the body
3 types of stools passed by NB:
GENITALS C.I if there are signs of increased ICP:
1. Meconium - greenish-blackish viscous; -
 Female: - Vomiting amniotic fluid, intestinal secretions and cells
- Labia edematous, clitoris - Bulging, tense fontanels shed from mucosa
enlarged - Dilated scalp veins
- Pseudomenstruation (+) - Abnormally large head - take note of time when meconium first
- First voiding occur within 24H - Increased BP passed (Normally : 24-36H)
 Male: - Decreased PR and RR
- Prepuce covers glans skin - Widening pulse pressure Failure to Pass:
- Scrotum is edematous - Swill, high-pitched cry- late sign
- Verify meatus at tip of penis THINK OF HIM
- Testes descended, retract @cold
temp. 1. Hirschsprung disease
- Assess for hernia or hydrocoele Establishment of extra uterine 2. Imperforate Anus
- First voiding occur w/in 24H circulation 3. Meconium Ileus

SPINE CIRCULATION 2. Transitional - passed from 3rd to 10th

day
 straight - several circulatory changes are necessary
 Posture flexed for successful changes from FETAL 3. Milk stool
 Supportive of head momentarily circulation to NEONATAL circulation
 Breast fed Infant stool - loose
when prone
A. Pulmonary Blood vessel golden yellow in color with sweet
 Arms and legs flexed
odor; 2-3 times a day
 Chin flexed on upper chest
- dilation, begins at first breath  Bottle fed infant stool - formed,
 Well-coordinated, sporadic
pale yellow with a typical odor;
movement results : lower pulmonary resistance this usually passed 1-2 times a day
 Hypotonic or hypertonic→ allows the blood to freely circulate through
indicate CNSdamage the lungs to be oxygenated. DIFFERENT STOOL
EXTREMITIES B. Ductus Arteriosus Jaundice Baby Light Stool
Under Bright Green
 Flexed - reversal blood flow→ Increased pressure in Phototherapy
 Symmetrical movement aorta and Increase 02 in the blood -> more Mucus mixed with Milk Allergy
 Fists clenched blood flowing through the pulmonary stool
 Ten finger, 10 toes arteries for oxygenation. Obstruction to bile Clay Colored
 Leg bowed duct
 Creases on soles of feet  closure complete w/in 24H After Barium Chalk Clay Colored
 Pulse palpable  permanent: 3-4 weeks enema
 Slight tremor common but could GIT bleeding Black Stool
be sign of hypoglycemia Anal Fissure Blood flecked stool
Intussusceptions Currant jelly stool
 Assess for hip dysplasia- no click
C. Foramen Ovale Hirschsprung Ribbon like stool
should be heard
Malabasorption Steatorrhea (fatty
syndrome (cellac, foul smelling stool)
BACK - closes within minutes after birth →
cystic fibrosis)

 On prone appears flat, (curves because of the higher pressure in the LA

start to form when child learns to than in the RA→ increase blood flow In the
sit or stand) lungs → decreases pressure in the RA→ the
 Note: for mass, hairy nodule and return of blood from the lungs increases the
a dimple along axis. This may be pressure in the LA
Indicative of Spina Bifida.
- Closure: permanent
I. Care of the Newborn at the DELIVERY approximately 3 months
ROOM - Failure to close becomes ASD