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NURSERY CARE OF THE WELL

NEWBORN
I.

ADMISSION TO THE NEWBORN NURSERY


II.
TRANSITIONAL CARE
III. ROUTINE CARE
IV. ROUTINE MEDICATIONS
V.
SCREENING
VI. ROUTINE ASSESSMENTS
VII. FAMILY AND SOCIAL ISSUES
VIII. FEEDINGS.
IX. NEWBORN CIRCUMCISION
X. DISCHARGE PREPARATION
XI.
FOLLOW UP

I. ADMISSION TO THE NEWBORN


NURSERY
Healthy newborns should with
their mother

immediate initiation of breastfeeding and early bonding.


Avoid separation of mother and
infant.

A. Criteria for admission is a well-appearing


infant of at least 35 weeks gestational age,
B. Impeccable security in the nursery :
- protect the safety of families
- prevent the abduction of newborns.
ex :
- identification bands
- transport of infants between areas
should not occur if identification
banding has not been done.

II. TRANSITIONAL CARE


A. The transitional period : first 4 to 6 hours
after birth.
- the infant's pulmonary vascular
resistance ,
- blood flow to the lungs is
greatly increased
- overall oxygenation and perfusion
improve, and
the ductus arteriosus begins to
constrict or close.

C. Common signs of disordered transitioning


are (i) respiratory distress, (ii) poor
perfusion with cyanosis or pallor, or (iii)
need for supplemental oxygen.
D. Transitional care of the newborn can take
place in the mother's room or in the
nursery.
1. Evaluated for problems that may
disqualify their admission to the normal
nursery, such as gross malformations
and disorders of transition.

2. Evaluated every 30 to 60 minutes during


this period : heart rate, respiratory rate, and
axillaris temperature; assessment of color
and tone; and signs of withdrawal from
maternal medications.
3. When disordered transitioning is suspected,
a hemodynamic ally stable infant can be
observed closely in the nursery setting for a
brief period of time. Infants with persistent
signs of disordered transitioning require
transfer to a higher level of care.

III. ROUTINE CARE


A. Healthy newborns should be with their
mothers all or nearly all the time.
When possible, physical assessments,
administration of medications, and bathing
should occur in the mother's room.
Nursing ratio of 1:6-8
1. Assessment of gestational age ( new Ballard
score).
2. The infant's weight, frontal-occipital
circumference (FOC), and length arc-recorded.

B. The infant's temperature is stabilized


with one of three possible modalities:
1. Open radiant warmer on servo control.
2. Incubator on servo control.
3. Skin-to-skin contact with the mother.
C. Universal precautions should be used
with all patient contact.
D. The first bath : non medicated soap and
warm tap water (note: axillary
temperature >36,5C )

E. umbilical cord care . Keeping the cord


dry promotes earlier detachment of the
umbilical stump.

IV. ROUTINE MEDICATIONS


A. Prophylaxis against gonococcal
ophthalmia neonatorum within 1 hour of
birth, Prophylaxis is administered as
single ribbon tetracycline ointment 1% of
bilaterally in the conjunctiva sac

B. A single, intramuscular dose of 0.5 to 1


mg of vitamin K 1 oxide (phytonadione)
before 6 hours prevent vitamin K
deficient bleeding (VKDB).
C. The first dose of preservative-free
hepatitis B vaccine
Hepatitis B vaccine is administered by
12 hours of age when the maternal Hep
BsAg is positive or unknown. Infants
of Hep BsAg positive mothers also
require hepatitis B immune globulin

V. SCREENING
A. Prenatal screening test results should be
reviewed and documented on the infant's
chart at the time of delivery.
Maternal prenatal screening tests
typically include the following:
1. Blood type, Rh, antibody screen.
2. Hemoglobin or hematocrit.
3. Rubella antibody.

4. Hepatitis B surface antigen.


5. Serologic test for syphilis (Venereal
Disease Research Laboratory [VDRL]
or rapid plasmin regain [RPR]).
6. Human immunodeficiency virus (HIV).
7. Gonorrhea and Chlamydia cultures.
8. Serum a-fetoprotein/triple panel.
9. Glucose tolerance test.
10.Group B streptococcus (GBS) culture.

B. Cord blood is saved up to 14-21 days,


depending on blood bank policy.
1. A blood type and direct Coombs should
be performed on any infant born to a
mother who is Rh-negative, has a positive
antibody screen, or who has had a
previous infant with Coombs positive
hemolytic anemia.
2. A blood type and direct Coombs should
be obtained on any infant if jaundice is
noted within the first 24 hours of age or
there is unexplained hyperbilirubinemia
(see Chap. 18).

C. Newborn metabolic screen


1. Some states universally screen for four
core metabolic conditions : congenital
hypothyroidism, phenylketonuria,
galactosemia, and
hemoglobinopathies.
2. Newborn screening programs vary
considerably among states.
3. Routine collection of the specimen is
between 24 and 72 hours of life. In
some states, a second screen is
routinely performed at 2 weeks of age.

D. Group B streptococcal disease


1. In several countries : All newborns
should be screened for the risk of
perinatally acquired GBS disease as
outlined by the Centers for Disease
Control.
2. Penicillin is the preferred intrapartum
chemotherapeutic agent. Intravenous
administration to the mother at >4
hours or earlier before delivery
provides adequate neonatal
prophylaxis.
3. Newborns should be managed
according to the management

E. Glucose screening
1. Infants should be fed early and
frequently to prevent hypoglycemia.
2. Infants of diabetic mothers ,SGA and LGA
infants should be screened for
hypoglycemia in the immediate neonatal
period .
F. Bilirubin screening
1. Before discharge, all newborns should
be screened for the risk of subsequent,
significant hyperbilirubinemia.

2. Provide parents with verbal and written


information about newborn jaundice.
G. Routine hearing screen for congenital
hearing loss is mandated in most states .
Verbal and written documentation of the
hearing screen results should be provided
to the parents with referral information if
needed.

VI. ROUTINE ASSESSMENTS


A. The infant's physician should perform a
complete physical examination within 24
hours of birth.
B. Vital signs, including respiratory rate, heart
rate, and axillary temperature are recorded
every 8 to 12 hours.
C. Each urine and stool output is recorded in the
baby's chart. The first urination should occur
by 30 hours of life. The first passage of me
conium is expected by 48 hours of life.
Delayed urination or stooling is cause for
concern and must be investigated.

D. Daily weights are recorded in the


infant's chart. Weight loss in excess of 7%
is cause for concern and must be
investigated. Excessive weight loss is
usually due to insufficient caloric intake. If
caloric intake is thought to be adequate,
organic etiologies should be considered,
that is, metabolic disorders, infection, or
hypothyroidism.
Thank you

VII. FAMILY AND SOCIAL


ISSUES
A. Sibling visitation is encouraged and is an
important element of family-focused care.
However, siblings with fever, signs of
acute respiratory or gastrointestinal
illness, or a history of recent exposure to
communicable diseases, such as chicken
pox, are discouraged from visiting.

B. Social service involvement is helpful in


circumstances such as teenage mothers;
lack of, or limited, prenatal care; history
of domestic violence; maternal substance
abuse; history of previous involvement
with Child Protective Services, or similar
agency.

VIII. FEEDINGS.
The frequency, duration, and volume of each
feed will depend on whether the infant is
breast-feeding or bottle-feeding.
A. The breast-fed infant should feed as soon
as possible after delivery, preferably in
the delivery room and feed 8 to 12
times/day.
Consultation with a lactation specialist
during the postpartum hospitalization is
strongly recommended for all breastfeeding mothers

IX. NEWBORN CIRCUMCISION


A. The American Academy of Pediatrics (AAP) states
that scientific evidence exists that demonstrates
potential medical benefits of newborn male
circumcision; however, these data are not sufficient
to recommend routine neonatal circumcision.
Potential benefits are decreased incidence of :
- urinary tract infection ,
- development of squamous cell carcinoma
- acquiring sexually transmitted diseases
particularly
HIV infection.

B. Informed consent is obtained before


performing the procedure. The potential
risks and benefits of the procedure are
explained to the parents.
1. The overall complication rate for
newborn circumcision is approximately
0.5%.
2. The most common complication is
bleeding (~0.1%) followed by infection.
A family history of bleeding disorders,
such as hemophilia or von Will brand
disease, needs to be explored with the
parents when consent is obtained.
Appropriate testing to exclude a

3. The parents should understand newborn


circumcision is an elective procedure; the
decision to have their son circumcised is
voluntary and not medically necessary.
4. Contraindications to circumcision in the
newborn period include the following:
a. Sick or unstable clinical status.
b. Diagnosis of a congenital bleeding
disorder. Circumcision can be performed
if the infant receives appropriate
medical therapy before the procedure
(i.e., infusion of factor VIII, or IX).

c. Inconspicuous or "buried" penis.


d. Anomalies of the penis, including
hypospadias, ambiguity, chordae, or
micropenis.
e. Circumcision should be delayed in
infants with bilateral cryptorchidism.
C.
Adequate analgesia must be provided for
neonatal circumcision. Acceptable methods
of analgesia are dorsal penile nerve block,
subcutaneous ring block, and eutectic
mixture of local anesthetics (EMLA ccream):
2.5% prilocaine and 2.5% lidocaine.

D. In addition to analgesia, other methods


of comfort are provided to the infant
during circumcision.
1. Twenty-four percent sucrose on a
pacifier, per nursery protocol, should
be given to all infants as an adjunct to
analgesia.
2. The infant's upper extremities should
be swaddled, and the infant placed on
a padded circumcision board with
restraints on the lower extremities
only.

3. Administration of acetaminophen
before the procedure is not an effective
adjunct to analgesia.
E. Circumcision in the newborn can be
performed using one of three different
methods:
1. Gomco clamp.
2. Mogen clamp.
3. Plastibell device.
F. Oral or written instructions explaining
post circumcision care should be given to
all parents

X. DISCHARGE PREPARATION
A. Parental education on routine newborn care
should be initiated at birth and continued until
discharge. Written information in addition to
verbal instruction may be helpful and in some
cases it is mandated. A review of the following
newborn issues should be done at discharge:
1. Observation for neonatal jaundice.
2. Routine cord and skin care.
3. Routine postcircumcision care (when
indicated).

4. Back to sleep positioning.


5. Subtle signs of infant illness including
fever, irritability, lethargy, or a poor
feeding pattern.
6. Adequacy of oral intake, particularly
for breast-fed infants. appropriate
installation and use of an infant car
seat.
7. Smoke detectors.
8. Lowering of hot water temperature.
9. Avoidance of second-hand smoke

B. The discharge examination is reviewed in Chapter 3.


C. Discharge readiness
1. Each mother-infant dyad should be evaluated
individually to determine the optimal time of
discharge.
2. The AAP recommends that minimum discharge
criteria be met before any newborn is discharged
from the hospital. It is unlikely that fulfillment of
these criteria can be accomplished with a postnatal
stay of <48 hours.
3. Discharge before 48 hours of age should be limited
to infants who are of singleton birth, at least 38
weeks' gestational age, and who have a birth
weight that is appropriate for gestational age

Early discharge criteria include the following:

a. Uncomplicated ante partum, intrapartum,


and postpartum courses for both mother
and infant.
b. Vaginal delivery.
c. Normal, stable vital signs in an open crib
for at least 12 hours preceding discharge.
d. Passage of first urine and stool.
e. Completion of at least two successful
feedings.
f. Unremarkable physical examination,
absence of abnormalities that would
require continued hospitalization.

Assessment of risk for hyperbilirubinemia.


Maternal competence in routine newborn care.
Assessment of maternal support.
Assessment of family, environmental, and
social risk factors.
k. Review of maternal and infant blood tests.
l. Administration of initial hepatitis B vaccine.
m.Completion of hearing and metabolic screen
per state regulations.
n. No excessive bleeding at the circumcision site
for at least two hours
o. Definitive follow-up arrangements for both
mother and infant
g.
h.
i.
j.

XI. FOLLOW-UP

A. For newborns discharged within 48 hours


after delivery, outpatient follow-up should
be within 48 hours of discharge. If early
follow-up cannot be ensured, early
discharge should be deferred.
B. For newborns discharged between 48 and
72 hours of age, outpatient follow-up
should be within 2 to 3 days of discharge.
Timing will depend on the risk for
subsequent hyperbilirubinemia, feeding
issues, or other concerns.
C. The follow-up visit is designed to perform
the following functions:

1. Assess the infant's general state of health


including weight, hydration, and degree
of jaundice.
2. Identify any new problems.
3. Perform screening tests in accordance
with state regulations.
4. Review adequacy of oral intake and
assess elimination patterns.
5. Assess quality of mother-infant bonding.
6. Reinforce parental education.
7. Review results of any outstanding
laboratory tests.
8. Provide anticipatory guidance and health