Neonatal Care

Neonatal care or newborn care is the care given to a newborn infant from the time of delivery through about the first month of life. In pediatric nursing, neonatal care is a fundamental aspect, focusing on providing essential support and nurturing to newborns during their critical early days of life.

Newborn care is given following a delivery and is the role of the neonatal care nurse.

Three Phases of Newborn Care

Nursing care for the newborn focuses on promoting the baby's physical well-being and supporting the family unit. The immediate care of the newborn occurs in the delivery room. Because numerous physiologic adaptations begin right after birth, immediate nursing care is crucial. The first goal is to help the newborn make the transition to extrauterine life. The second goal is to assess and provide nursing care that supports or nurtures the newborn's health status. The third goal is to educate parents and family members on how to take care for and bond with the new baby.

The three phases of transition are:

Phase 1: Birth to 1 hour - first period of reactivity; takes place in delivery room

Phase 2: One to 4 hours - may take place in the labor, delivery, recovery, and postpartum (LDRP) room, nursery, or parents' room; when the initial detailed health assessment is completed

Phase 3: Four hours to discharge - second period of reactivity; takes place in mother's room and involves nursing interventions and family teaching

Thermoregulation

Place the baby in a neutral thermal environment. Usually, the baby is placed in a radiant warmer or placed and wrap in a warm blanket. This is to avoid hypothermia.

Do not wipe the vernix caseosa yet as it can provide antibacterial promotion and wound healing.[Source]

Suctioning

A bulb syringe may used to clean the nose or to remove mucus that has been coughed up. Most suctioning can be done this way.

Squeeze the bulb until it is collapsed.
Place the tip in the nose or mouth and release the bulb. This will create suction and bring the mucus into the bulb.
Remove the bulb syringe from the nose or mouth and squeeze it into a tissue to get the mucus out.
After use, wash the bulb syringe in hot soapy water, squeezing the bulb several times. Squeeze in clear hot water to rinse.

Suctioning is done because some clinicians believe it reduces the risk of aspiration, especially if there is meconium, and to stimulate breathing, but the evidence suggests that suctioning can stimulate the vagus nerve, which can lead to bradycardia [Source].

However, if a baby is vigorous at birth with good respiratory effort and muscle tone, they may stay with the mother to receive the initial steps of newborn care. In this case, you can clear the airway by suctioning the mouth first and then the nose with a bulb syringe or suction catheter.

Assessment

APGAR Scoring

The APGAR scoring is done during the first 1 minute and 5 minutes of life. The heart rate, respiratory rate, muscle tone, reflex irritability, and color are evaluated. Apgar score is the baseline for all future observations.

Each parameter can have the highest score of two and the lowest is 0.
The scores of the five parameters are added to determine the status of the infant.

Score Interpretations:

0-3 points: the baby is critical and need immediate resuscitation.
4-6 points: the baby’s condition is below normal and may need medical intervention.
7-10 points: are considered good or normal.

Respiratory Evaluation

The normal respiratory rate is 40-60 breaths per minute.

The Silverman and Andersen index can assess respiratory distress and its varying degrees.

There are five criteria to evaluate the newborn: chest movement, intercostals retraction, xiphoid retraction, nares dilatation, and expiratory grunt.
The highest score for each criterion is 2, and the lowest is 0.
The lowest overall score is 0, which indicates that there is no respiratory distress.
A score of 4 to 6 shows moderate distress and 7 to 10 indicates severe distress.

The scores of the Silverman and Andersen index are opposite to the APGAR scoring.

Temperature

Taking temperature may be done rectally with a rectal thermometer. Oral and rectal thermometers have different shapes and one should not be substituted for the other. Do not use oral thermometers rectally as these can cause injury. Rectal thermometers have a security bulb designed specifically for safely taking rectal temperatures.

Warning: Do not take rectal temperatures in children with leukemia or other cancers. The same goes with children with weak immune systems such those with HIV, organ transplant, or sickle cell disease.

Place the baby across the changing table, on his or her belly, facing down. Place your hand nearest the baby's head on his or her lower back and separate the baby's buttocks with your thumb and forefinger. Another way is to put the baby on his/her back with the legs pulled up to the chest.
Using your other hand, gently insert the lubricated bulb end of the thermometer one-half to one inch, or just past the anal sphincter muscle.
The thermometer should be pointed towards the child's belly button.
Hold the thermometer with one hand on the baby's buttocks so the thermometer will move with the baby. Use the other hand to comfort the baby and prevent moving.
Never leave a baby unattended with a rectal thermometer inserted.
Hold thermometer until it beeps or signals.
Remove the thermometer.
Wipe the bulb.
Read immediately and record.
Clean the thermometer with soap and water or rubbing alcohol.

Modern digital thermometers may also be used to monitor the baby's temperature.

Place the thermometer sensor in the middle of the baby's forehead.
Press and hold the scan button.
Slowly move the thermometer across the forehead toward the top of the baby's ear. Make sure it always touches the skin.
Stop at the hairline and release the scan button.
Remove the thermometer and read the temperature.

If a baby's rectal or temporal artery temperature is 100.4°F (38°C) or higher, inform the healthcare provider.

Physical Examination

Physical examination is done to detect any observable conditions and physical defects. This assessment is done quickly by the healthcare provider while noting important findings and at the same time avoids overexposing the newborn.

Measurements

Head Circumference

Use a measuring tape that cannot be stretched.

Securely wrap the tape around the widest possible
circumference of the head.
» Broadest part of the forehead above eyebrow
» Above the ears
» Most prominent part of the back of the head

Chest Circumference

Using a tape measure that cannot be stretched, wrap the tape around the baby's chest. The nipple line should serve as a guide. The tape should go through the armpit toward the back, and go through the armpit toward the front.

Abdominal Circumference

Using the same tape measure, pass the tape around the baby's bare skin at the level of the umbilicus or above the level of the umbilicus. Ensure that the nappy is not obstructing or constricting the area. If so, it will be necessary to adjust or remove the nappy.

Pass the tape around the abdomen and take the reading at the end of expiration or when the abdomen is relaxed.

Height or Length

Lay the baby down and stretch a measuring tape from the top of the baby's head to the bottom of their heel.

Weight

Place the baby on the weighing scale designed for neonates. Document the weight.

1. Cover the scale with a barrier, such as a paper pad, to prevent conductive heat loss from a cool surface; this also helps prevent cross-contamination.

2. Balance scale to zero after a barrier is placed on the scale. If using a self-adjusting electronic scale, ensure the readout is at zero.

3. With the newborn in the supine position, place your hand above the newborn as a safety measure. (With active movements, the newborn could slide off the scale.)

4. Some electronic scales will read “stable” when an accurate weight is obtained. An electronic scale displays weight both in pounds and ounces and in grams.

5. Write the weight down immediately (such as on the paper covering scale). Document on the newborn's medical record after returning the newborn to the bassinet.

Umbilical Cord Care

The umbilical cord is initially white and gelatinous in appearance. It contains two umbilical arteries and one vein in the center of the umbilical cord. Deviations in the number of vessels in the cord could indicate a congenital anomaly and must be reported to the health care provider. The cord begins drying within 1 to 2 hours after birth. Bleeding from the cord or a foul odor should be reported immediately.

After the newborn is stabilized, a disposable umbilical clamp is applied and the cord is cut to a shorter length. Before discharge, the parents are shown how to care for the umbilical cord stump at home. The cord clamp may be removed before discharge.

Steps:

Assess the cord for presence of vessels. There should be two arteries and one vein in the center of the umbilical cord. Report to the health care provider if there are deviations.
Milk the umbilical cord, by pressing the umbilical cord sides with fingers about 3-4 times, moving towards the newborn.
Apply a cord clamp to the umbilical cord about 2 cm from the bellybutton.
Apply the second clamp about 5 cm from the base of the umbilicus.
Cut the cord close to the first clamp.
Check umbilical clamp placement for tight closure. There should be no bleeding from the cord.
Keep cord dry and exposed to the air.
Using an alcohol wipe, start from the base of the cord and gently wipe upward and outward. Note that some hospitals use triple dye or other solutions. Cord care may be done with every diaper change per facility protocol.
Lift the cord away from the infant’s abdomen to facilitate cleansing of all areas.
Observe cord and abdominal area for redness, discharge, or foul odor.
Diaper infant, and be certain the upper end of diaper is folded down below the cord so it does not rub against the cord.
Document cord care and observations, solutions used to cleanse the area, condition of the cord, teaching of the parents, and their response.

Discharge if the cord is dry and crisp, or it may be left on at discharge and discarded when the cord falls off, which usually happens within 10 days. Parents should be taught cord care, which may include dipping a cotton swab in isopropyl alcohol, triple dye, saline, or a solution prescribed by the health care provider and using it to clean around the base of the cord where it joins the skin. The cord stump is allowed to dry.

Cleansing is done at every diaper change until the cord stump falls off. The nurse should show the parents how to fold the diaper below the level of the umbilicus so that it will not become wet with urine. A cord that is moist or red or has a discharge or a foul odor should be reported immediately to the health care provider.

Identification and Security

Matching identification (ID) bands should be placed on the newborn's wrist and ankle and the mother's wrist in the delivery room. In some hospitals, the partner also receives a wrist band with matching numbers. For security reasons, many hospitals have either an umbilical clamp or ID wrist band with an electronic sensor attached that will sound an alarm if the newborn is take out of the unit. The ID band may be checked by the nurse and mother at any time the newborn is separated or returned to the mother and before discharge. The nurse and mother verify the ID bands together.

Administering Intramuscular Injection

The newborn should receive vitamin K (phytonadione 0.5 to 1 mg). It is given intramuscularly in the mid-anterior thigh (the vastus lateralis muscle) where the muscle development is adequate. This is because newborns have no bacterial flora that help synthesize vitamin K in the intestines, and are therefore deficient in clotting factors. Vitamin K is administered as a prophylaxis to assist in clotting.

Prophylactic Eye Care

The newborn can acquire an eye infection, such as gonorrhea or chlamydia, when passing through an infected birth canal. As prophylaxis against ophthalmia neonatorum, an infection that can cause blindness, a prophylactic eye care is given. Erythromycin ophthalmic ointment is commonly used for prophylactic eye care because it produces less eye irritation than other eye medications and also destroy infectious organisms. Ideally, a single-unit dose (new tube) of ointment is used. The ointment is placed so that it reaches all areas of the conjunctival sac. This is usually achievable by placing it in the lower eyelid and squeezing a thin strip of ointment into this space. This should be done for both eyes.

An eye drop version of erythromycin may also be used.

Clothing the Baby

Clothing choices:

Fabrics: Choose soft, breathable fabrics like cotton or bamboo. Avoid synthetic materials that can trap heat and irritate the skin.
Layers: Dress the neonate in layers so you can adjust to changes in temperature or activity level. A good rule of thumb is to dress them in one more layer than you are comfortable wearing.
Types of clothing:
- Bodysuits or onesies: These are versatile and easy to put on and take off. Look for ones with front closures or envelope necks for easier dressing.
- Pants or leggings: Choose soft, stretchy pants or leggings that won't irritate the neonate's skin.
- Socks or booties: Keep the neonate's feet warm with socks or booties made from natural fibers.
- Hats: Newborns lose a lot of heat through their heads, so a hat is important in cool environments. Choose a lightweight, breathable hat that fits snugly but doesn't restrict breathing.
- Swaddling: Swaddling can help calm and soothe a newborn and can also help regulate their temperature. Use a lightweight, breathable blanket and make sure the swaddle is not too tight.

Special considerations:

Premature babies: Premature babies have even more difficulty regulating their temperature than full-term babies. They may need additional layers of clothing or special incubator care.
Neonates in the NICU: Neonates in the NICU will be monitored closely by medical staff who will adjust their clothing as needed.

Additional tips for dressing a neonate:

Dress the neonate from the bottom up to avoid chilling them.
Fasten all closures securely, but not too tightly.
Check the neonate's temperature regularly, especially if they are sick or premature.