Neonatal Care Health Article

Definition

Neonatal care refers to that care given to the newborn infant from the time of delivery through about the first month of life. The term "neonate" is used for the newborn infant during this 28-30 day period.

Purpose

The purpose of neonatal care in the delivery room and newborn nursery is to:

• Assess and evaluate the newborn as s/he transitions from intrauterine life to extrauterine life.
• Evaluate and monitor the newborn system-by-system for normal versus abnormal functioning, providing maintenance of normal and potential treatment of abnormal findings.
• Foster bonding between infant and parent/s.
• Provide a safe environment at all times.

Description

Neonatal care begins as soon as the baby is born. In fact, suctioning of the nose and mouth may take place as the baby is in the process of being delivered—with the head out, and while the mother is taking a pause before the next push. In utero the infant is swimming in amniotic fluid. As he or she comes down the birth canal, the contractions exert pressure on the body and push some of the amniotic fluid out of the lungs. It is this fluid that is suctioned out during those first few moments. Shortly after delivery, the umbilical cord is clamped and then cut. Shortly after clamping, the cord will be checked for the presence of two arteries and one vein. Once the cord is clamped, the baby must breathe and function independently from the mother. The first few breaths cause several internal changes to occur. These will be discussed in the Results section below.

Because of the internal environment, the baby is very wet when born. Drying the baby off right away is critical, as the baby can lose considerable body heat through evaporation, convection, radiation, and conduction. This is especially true of the head, which has a large surface area in relation to the rest of the body. Also, head hair retains considerable moisture if not well dried. A cap placed on the head once it has been dried helps to maintain body temperature. The nurse may place the newborn on the mother's skin while drying the skin, both to begin the bonding process as well as to allow the mother's body heat to warm the infant. The rubbing that takes place to dry the infant provides tactile and sensory stimulation. The neonate may cry, bringing more oxygen into the lungs. A certain amount of pressure is needed in the heart and lungs in order to convert from fetal circulation to neonatal circulation. A color change is noticeable as the infant's skin changes from a bluish hue to pink. In some circumstances, oxygen from a mask may be placed near the mouth while the infant is being dried off to increase the initial intake of oxygen. Once dry, the infant is wrapped in several warm receiving blankets and may be placed at the mother's breast for an initial breastfeeding. If the mother will not be breastfeeding, she may choose to hold the newborn at this point.

The first breastfeeding helps to trigger the involution process of the uterus, as it stimulates the production of natural oxytocin, which helps the uterus contract. Also, in the first hour or so after birth, the neonate is usually quite alert, unless the mother was given pain medications late in labor.

While the infant is being dried off, the mother is delivering the placenta. The amniotic fluid is clear, perhaps tinged with blood. If it appears murky in any way, the baby most likely had a bowel movement during the stressful labor and delivery process. This first bowel movement is called meconium. If present in the amniotic fluid, it is possible that the infant inhaled some into its lungs. This is called meconium aspiration. The neonate with meconium in the amniotic fluid may be intubated to avoid aspiration. Meconium aspiration can lead to tachypnea (rapid respirations) and also pneumonia, and may require the neonate to spend some time under observation in the neonatal intensive care unit (NICU), instead of being kept with its mother. As the infant is being suctioned, assessed and dried, it may be placed in a slight Trendelenburg position, depending on the hospital. This downward slant of about 10 degrees allows gravity to assist in draining mucous.

At one and five minutes after birth the neonate is assessed for Apgar scores. The infant's heart rate, respiratory effort, muscle tone, reflex, irritability, and color are each given a score of 0, 1, or 2. Each score is then added together for a highest possible score of 10. The normal range is 7-10. It is rare to receive a 10, as some cyanosis in the hands and feet (called acrocyanosis) is quite normal.

In the birthing room a rapid physical examination is performed to assess any gross abnormalities as well as any heart-related problems, and to determine the need for any immediate intervention. The spine will be assessed, and should be free of any openings or dimpling. It will be flat, as the lumbar and sacral curves develop later when the child learns to sit and walk. A more detailed examination will take place about 24 hours later. The umbilical cord and placenta will also be examined for any abnormalities. Any medications given to the mother during labor and delivery are recorded in the neonate's chart, as the medication could affect the infant's respirations and its own ability for tissue oxygenation. The physician or nurse-midwife will also make sure the entire placenta has been expelled to avoid the risk of infection for the mother due to any retained tissue.

Because the neonate has difficulty maintaining its temperature, any examination that is immediately needed usually takes place under a source of radiant heat. During the first 24 hours the neonate is adjusting to extrauterine life and some normal fluctuations are expected. It is for this reason that the more thorough examination will take place a bit later on, once the initial fluctuations stabilize. The expected findings of the head-to-toe neonatal assessment will be discussed in the Results section below.

Before leaving the delivery room the nurse will:

• Place an identification band on the neonate's hands and feet.
• Place an ID band with the same number as the baby's on the mother's (and in some hospitals) on the father's wrist.
• Take a foot print of the infant (in some hospitals).
• Give an intramuscular (IM) injection of vitamin K to the neonate.
• Administer an antibacterial eye ointment into both eyes.

To assist the neonate's blood's ability to clot in its early life, infants receive an IM injection of vitamin K in the delivery room. The injection is usually given in the thigh muscle, as this is the largest and safest muscle in which to give an infant an injection. The antibacterial eye ointment used prevents contracting an infection from one present in the birth canal, such as gonorrhea or chlamydia.

Hospitals differ in which identification system they use, but the premise is the same: before the infant leaves the delivery room, he or she should receive an ID band with a number on it. The same ID number is on a band for the mother, as well as possibly for the father. Before leaving the baby with the parents, the bands should be checked by the nurse or nursing student to avoid any mix-up. Some hospital ID bands contain a microchip in it that causes an alarm bell to ring if the infant is taken out of a certain area. Also, some hospitals require that if the mother is going to take a nap or a shower, the infant must be returned to the nursery so that the infant is not unattended in the mother's room. Some hospitals use a band on each of the baby's hands and feet, so that if one or two fall off, proper ID still remains on the neonate. In addition to the ID band, a print of the infant's foot is made along with the mother's fingerprint. Both are recorded on the same sheet of paper.

If the neonate appears physiologically unstable, she will be taken either to the nursery or to the NICU for further evaluation or treatment. Once the mother's condition is stable, she may be wheeled to the infant's location if she desires.

Weight and length are measured, either in the birthing room or in the newborn nursery, vital signs are closely monitored and skin color is assessed for signs of jaundice. Jaundice that appears in the first 24 hours is of a different nature than that which sets in after 24 hours. If undressed, the infant is kept under radiant heat to assist in maintaining proper body temperature. Temperature may be regulated for several hours with a monitor attached to the chest skin. A rectal temperature may be taken to check for a patent anus. After any examinations, the infant will be swaddled in several layers of receiving blankets, a cap will be placed on the head to further reduce loss of body heat, and the newborn is placed in a bassinette either on its side, with a rolled blanket behind the back to prevent tipping, or on its back. To prevent sudden infant death syndrome (SIDS), infants should not be placed on their stomach.

Most insurance plans allow hospital stays of only 48 hours after an uncomplicated vaginal delivery, so much takes place within that time. Twenty-four to seventy-two hours after the neonate's first intake of protein her blood is checked via a heel-stick for the presence of phenylketonuria (PKU), a protein metabolism disorder that requires strict nutritional guidelines for treatment to avoid central nervous system (CNS) damage. Neonates whose mothers had gestational diabetes will have their blood sugar monitored in the nursery. During the second day of life the infant will have a detailed physical assessment done cephalocaudal (head-to-toe). The normal ranges for this will be discussed in the Results section. Parents who wish to have their male infants circumcised in the hospital will make those arrangements. The nursery nurses will monitor the circumcised infant for any signs of infection or abnormal bleeding.

Hospitals may differ in terms of how much time the infant spends with the mother in her room. The aim is for a balance between the mother's need for rest to ensure more rapid healing, the need for the parents and baby to form a strong bond, and the safety of the infant if unattended. Most hospitals bring the breast-feeding infant to the mother on demand. Formula-fed babies may spend more time in the nursery with staff feeding the baby, if the mother needs more rest time after a difficult delivery.

In July 1999 the Centers for Disease Control (CDC) determined that hepatitis B immunizations, which had been routinely given to newborns, should no longer be administered to neonates until the preservative thimerosal is removed from vaccines. Since thimerosal is derived from ethylmercury, and even though there is no evidence that exposure to low levels of thimerosal is harmful, concerns about the exposure to mercury compounds led to the decision as a precautionary measure.