As the infant emerges from the intrauterine environment and the umbilical cord is clamped and severed, profound adaptations are necessary for survival. Most critical of these is the establishment of effective respirations. Most newborns breathe spontaneously after birth and are able to maintain adequate oxygenation. Preterm infants often encounter respiratory difficulties related to their immature lungs.

Initiation of Breathing

Oxygenation of the fetus occurs through transplacental gas exchange. At birth, the lungs must be established as the site of gas exchange. In utero, fetal blood was shunted away from the lungs, but when birth occurs the pulmonary vasculature must be fully perfused for this purpose. Clamping the umbilical cord causes a rise in blood pressure (BP), which increases circulation and lung perfusion. Initiation of respirations in the neonate is the result of a combination of factors: Chemical, mechanical, thermal, and sensory.

Chemical Factors

Activation of chemoreceptors in the carotid arteries and aorta results from the relative state of hypoxia associated with labor. With each labor contraction, there is a temporary decrease in uterine blood flow and transplacental gas exchange, resulting in transient fetal hypoxia and hypercarbia. The cumulative effect results in a progressive decline in PO2, increased PCO2, and lowered blood pH.  Decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in initiating neonatal breathing by stimulating the respiratory center in the medulla. As a result of clamping the cord, there is a drop in levels of prostaglandin that can inhibit respiration.

Mechanical Factors

Respirations in the newborn can be stimulated by changes in intrathoracic pressure resulting from compression of the chest during vaginal birth. As the infant passes through the birth canal, the chest is compressed. With birth, this pressure on the chest is released, and the negative intrathoracic pressure helps to draw air into the lungs. Crying increases the distribution of air in the lungs and promotes the expansion of the alveoli. Positive pressure created by crying helps to keep the alveoli open.

Thermal Factors

The extrauterine environment temperature is significantly lower. The profound change in environmental temperature stimulates receptors in the skin, resulting in stimulation of the respiratory center in the medulla.

Sensory Factors

Newborns handled by the obstetric health care provider will have their mouth and nose suctioned, they are dried by the nurses, and environmental factors (lights, sounds, smells) stimulate the respiratory center.

Establishing Respirations

At term, the lungs hold approximately 20 ml of fluid per kilogram. Air must be substituted for the fluid that filled the fetal respiratory tract. In the days preceding labor, there is reduced production of fetal lung fluid and concomitant decreased alveolar fluid volume. Shortly before the onset of labor, there is a catecholamine surge that seems to promote fluid clearance from the lungs, which continues during labor. Movement of lung fluid from the air spaces occurs through active transport into the interstitium, with drainage occurring through the pulmonary circulation and lymphatic system. Retention of lung fluid can interfere with the infant’s ability to maintain adequate oxygenation, especially if other factors that compromise respirations are present: meconium aspiration, congenital diaphragmatic hernia, esophageal atresia with fistula, choanal atresia, congenital cardiac defect, and immature alveoli.

Infants born via cesarean section, in which labor did not occur before birth, can experience some lung fluid retention, although it typically clears without harmful effects on the infant. These infants are also more likely to develop transient tachypnea of the newborn (TTN). Alveoli of the term infant’s lungs are lined with surfactant, a lipoprotein manufactured in type II lung cells. Lung expansion depends largely on chest wall contraction and adequate surfactant secretion. Surfactant lowers surface tension, therefore reducing the pressure required to keep the alveoli open with inspiration, and prevents total alveolar collapse on exhalation, thereby maintaining alveolar stability. Decreased surface tension results in increased lung compliance, helping to establish the functional residual capacity of the lungs. Absent or decreased surfactant, more pressure must be generated for inspiration, which can soon tire or exhaust preterm or sick term infants. Breathing movements that began in utero as intermittent become continuous after birth, although the mechanism for this is not well understood.

Once respirations are established, breaths are shallow and irregular, ranging from 30 to 60 breaths/min, with periods of breathing that include pauses in respirations lasting less than 20 seconds. Episodes of periodic breathing occur most often during the active (rapid eye movement [REM]) sleep cycle and decrease in frequency and duration with age. Apneic periods longer than 20 seconds are abnormal and should be evaluated. Newborn infants are by preference nose breathers, which enhances the ability to coordinate sucking, swallowing, and breathing. Reflex response to nasal obstruction is to open the mouth to maintain an airway.

This response is not present in most infants until three weeks after birth; therefore, cyanosis or asphyxia can occur with nasal blockage. In most newborns, auscultation of the chest reveals loud, clear breath sounds that seem very near because little chest tissue intervenes. Breath sounds should be clear and equal bilaterally, although fine rales for the first few hours are not unusual. Neonatal respiratory function is largely a matter of diaphragmatic contraction, abdominal breathing is characteristic of newborns. A newborn infant’s chest and abdomen rise simultaneously with inspiration.

Tachypnea can result from inadequate clearance of lung fluid, and this can be an indication of respiratory distress syndrome (RDS). Tachypnea can be the first sign of respiratory, cardiac, metabolic, or infectious illnesses. Changes in the infant’s color can indicate respiratory distress. Normally, within the first three to five minutes after birth, the newborn’s color changes from blue to pink. Acrocyanosis is the bluish discoloration of hands and feet, which is a normal finding in the first 24 hours after birth. Transient periods of duskiness while crying are common immediately after birth. Central cyanosis is abnormal and signifies hypoxemia. Lips and mucous membranes that are bluish (circumoral cyanosis) can be the result of:

• Inadequate delivery of oxygen to the alveoli

• Poor perfusion of the lungs that inhibits the gas exchange

• Cardiac dysfunction

Central cyanosis is a late sign of distress, and newborns usually have significant hypoxemia when cyanosis appears. Infants who experience mild TTN often have signs of respiratory distress during the first one to two hours after birth as they transition to extrauterine life. Tachypnea with rates up to 100 breaths/min can be present along with intermittent grunting, nasal flaring, and retractions. Supplemental oxygen may be needed. TTN usually resolves in 48 to 72 hours. Symptoms of distress are more pronounced in neonates with more serious respiratory problems and tend to last beyond the first two hours after birth.

Signs of Newborn Stress

• Respiratory rates can exceed 120 breaths/min

• Moderate to severe retractions

• Grunting

• Pallor

• Central cyanosis

• Hypotension

• Temperature instability

• Hypoglycemia

• Acidosis

• Signs of cardiac problems

Congenital defects can cause severe respiratory problems such as anomalies of the great vessels, diaphragmatic hernia, and chest wall defects. Blood incompatibilities can result in a respiratory compromise, or hydrops fetalis. Common respiratory complications affecting neonates include: RDS, meconium aspiration, pneumonia, and persistent pulmonary hypertension of the newborn (PPHN).

Red Blood Cells

Because fetal circulation is less efficient at oxygen exchange than the lungs, the fetus needs additional RBCs for transport of oxygen in utero. At birth the average levels of RBCs, hemoglobin, and hematocrit are higher than those in the adult; these levels fall slowly over the first month. The source of the sample is a significant factor in levels of RBCs, hemoglobin, and hematocrit. Capillary blood yields higher values than venous blood. The timing of blood sampling is also significant; the slight rise in RBCs after birth is followed by a substantial drop. At birth, the infant’s blood contains an average of 70% fetal hemoglobin. However, because of the shorter life span of the cells containing fetal hemoglobin, the percentage falls rapidly, so that by the age of six to 12 months there is only a trace of fetal hemoglobin remaining. Iron stores generally are sufficient to sustain normal RBC production for approximately four months in the term infant, at which time a transient physiologic anemia can occur.

Leukocytes

Leukocytosis, with a white blood cell (WBC) count ranging from 9,000 to 30,000/mm3, is normal at birth. WBCs increases up to 24,000/mm3 during the first day after birth. Initial high WBC count of the newborn decreases rapidly, and a stable level of 12,000/mm3 is normally maintained during the neonatal period. Newborns are susceptible to infection. Leukocytes, especially the polymorphonuclear neutrophils, are limited in their ability to recognize foreign protein and localize and fight infection early in life. Sepsis can be accompanied by a concomitant rise in neutrophils; however, some infants initially have clinical signs of sepsis without a significant elevation in WBCs. Events other than infection can cause neutrophilia, such as:

• Prolonged crying

• Maternal hypertension

• Asymptomatic hypoglycemia

• Hemolytic disease

• Meconium aspiration syndrome

• Labor induction with oxytocin

• Surgery

• Difficult labor

• High altitude

• Maternal fever

Platelets

Platelets appear to be activated during the birth process and demonstrate improved aggregation in the first hours after birth. Platelet count ranges between 150,000 and 300,000/mm3 and is essentially the same in newborns as in adults. Levels of vitamin K–dependent clotting factors II, VII, IX, and X increase slowly after birth and reach adult levels by six months of age.

Blood Groups

The infant’s blood group is determined genetically and established early in fetal life. Cord blood samples can be used to identify the infant’s blood type and Rh status.

During the first few days, term infants generally excrete 15 to 60 ml/kg/day of urine. Output gradually increases over the first month. The frequency of voiding varies from two to six times per day during the first and second days of life and increases during the subsequent 24 hours. After day four, approximately six to eight voidings per day of pale, straw-colored urine indicate adequate fluid intake. An infant who has not voided by 24 hours should be assessed for adequacy of fluid intake, bladder distention, restlessness, and signs of discomfort. The neonatal health care provider should be notified. Urine during early infancy is usually straw-colored and almost odorless. Sometimes pink-tinged uric acid crystals or “brick dust” appear on the diaper. Loss of fluid through urine, feces, lungs, increased metabolic rate, and limited fluid intake can result in a 5% to 10% loss of the birth weight over the first three to five days. Excessive weight loss can be related to feeding difficulties or other issues. The neonate should regain the birth weight within 10 to 14 days, depending on the feeding method (breastfeeding, breast milk feeding, or infant formula).

Fluid and Electrolyte Balance

In the term neonate, approximately 75% of body weight consists of total body water (extracellular and intracellular). Reduction in extracellular fluid occurs with diuresis during the first few days after birth. Weight loss experienced by most newborns during the first few days after birth is caused primarily by extracellular water loss.  The daily fluid requirement for neonates weighing more than 1,500 g are as follows.

• 60 to 80 ml/kg during the first two days of life

• 100 to 150 ml/kg/day from the third to seventh days of life

• 120 to 180 ml/kg/day from the eighth to thirtieth days of life

At birth, the glomerular filtration rate (GFR) of a newborn is significantly lower than in the adult. GFR gradually rises to adult levels by two years of age.

Signs of Renal System Problems

Dysfunction resulting from physiologic abnormalities can range from the lack of a steady stream of urine to gross anomalies such as hypospadias, exstrophy of the bladder, and enlarged or cystic kidneys.

In the newborn, the liver can be palpated approximately 1 to 2 cm below the right costal margin because it is enlarged and occupies approximately 40% of the abdominal cavity. The liver plays an important role in iron storage, glucose and fatty acid metabolism, bilirubin synthesis, and coagulation.

Iron Storage

The fetal liver, which serves as the site for the production of hemoglobin after birth, begins storing iron in utero.

Glucose Homeostasis

In utero, the glucose concentration in the umbilical vein is approximately 70% of the maternal level. At birth, the newborn is removed from the maternal glucose supply resulting in an initial drop in blood glucose from fetal levels of 70 to 90 mg/dl to levels of 55 to 60 mg/dl between 30 and 90 minutes after birth. During this time, glucagon levels increase while insulin levels decrease and the limited hepatic glycogen stores are mobilized. The initiation of feedings helps to stabilize blood glucose levels as milk lactose is metabolized. Glucose levels are not routinely assessed in newborns unless there are risk factors or symptoms of hypoglycemia. Risk factors include small or large for gestational age, preterm, and infant of a diabetic mother.

A hypoglycemic infant can be asymptomatic or can display the classic symptoms of:

• Jitteriness

• Lethargy

• Apnea

• Feeding problems

• Seizures

Hypoglycemia in the initial newborn period is most often transient and easily corrected through feeding. Persistent or recurrent hypoglycemia necessitates intravenous glucose therapy and possible pharmacologic intervention.

Fatty Acid Metabolism

Fatty acid metabolism is an additional source of energy for the neonate in the initial hours after birth. Review the following graphic on the formation and excretion of bilirubin.

Formation and excretion of bilirubin, showing red blood cell to hemoglobin, from hemoglobin to heme and globin, from heme to iron and bilirubin; then bilirubin plus plasma protein to liver, glucuronyl transferase; from liver, glucuronyl transferase to unconjugated bilirubin plus glucuronic acid, then conjugated bilirubin glucuronide to excreted through feces or urine.

Coagulation

The liver plays an important role in blood coagulation. Coagulation factors, which are synthesized in the liver, are activated by vitamin K. A lack of intestinal bacteria needed to synthesize vitamin K results in transient blood coagulation deficiency between the second and fifth days of life. Administration of intramuscular vitamin K shortly after birth helps to prevent vitamin K deficiency bleeding (VKDB), which can occur suddenly and can be catastrophic.

Drug Metabolism

The immaturity of the liver and depressed liver enzyme systems at birth result in slower biotransformation and elimination of drugs. Liver immaturity can result in slower drug clearance, increased serum levels, and longer half-life.

Signs of Hepatic System Problems

Hypoglycemia and hyperbilirubinemia are the most common signs of hepatic system problems, with preterm infants at an increased risk due to immaturity of the liver. The hematologic status of all newborns should be assessed for anemia. For the first week of life, neonates are at risk for bleeding until the coagulation factors are well established. Male newborns who are circumcised prior to discharge from the birth facility must be monitored carefully for bleeding.

Hypoglycemia in a term infant during the early newborn period is defined as a blood glucose concentration inadequate to support neurologic, organ, and tissue function. The lower limit for normal plasma glucose levels during the first 72 hours after birth is often cited as 40 to 45 mg/dl. Most healthy term newborns experience a transient decrease in glucose levels to as low as 30 mg/dl during the first one to two hours after birth.

High-risk infants should be fed within the first hour, with glucose testing done.

The nurse should observe all newborns for signs of hypoglycemia. Glucose testing should be done on any infant with clinical signs of hypoglycemia, which include:

• Jitteriness

• Lethargy

• Poor feeding

• Abnormal cry

• Hypotonia

• Temperature instability (hypothermia)

• Respiratory distress

• Apnea seizures

Any level less than 45 mg/dl should be confirmed with a stat serum glucose level, depending on facility policy.

Infants considered to be at risk for hypoglycemia should be screened during the first several hours of life. These factors include:

• SGA or LGA

• Low birth weight

• Infants of mothers with diabetes

• Infants who experienced perinatal stress such as asphyxia

• Cold stress, or respiratory distress

Pathophysiology

Fluctuations in blood glucose levels and episodes of ketoacidosis are believed to cause congenital anomalies. The combination of the increased supply of maternal glucose and other nutrients and increased fetal insulin results in excessive fetal growth. Macrosomia or LGA refers to birthweight greater than 4000 g (8 lbs, 13 oz). LGA is a relative term defined as a birth weight greater than the 90th percentile for gestational age. Hyperinsulinemia accounts for many of the problems experienced by the fetus or newborn.  Maternal hyperglycemia can also affect fetal lung maturity.If the fetus exposed to high levels of maternal glucose, synthesis of surfactant can be delayed because of the high fetal serum levels of insulin and/or glucose; these infants should be watched for signs of an immature respiratory system or respiratory distress.. 

An infant’s skeletal system undergoes rapid development during the first year of life. At birth, more cartilage is present than ossified bone.

Head and Skull

The head at term is approximately one-fourth of the total body length. The arms are slightly longer than the legs, which are approximately one-third of the total body length. The face appears small in relation to the skull. The skull appears large and heavy. Cranial size and shape can be distorted by molding (the shaping of the fetal head by overlapping of the cranial bones to facilitate movement through the birth canal during labor). Caput succedaneum is a generalized, easily identifiable edematous area of the scalp, most often on the occiput. With vertex presentation, the sustained pressure of the presenting part against the cervix results in compression of local vessels, slowing venous return. The slower venous return causes an increase in tissue fluids within the skin of the scalp, and edema develops. This edematous area, present at birth, extends across suture lines of the skull and usually disappears spontaneously within three to four days. Infants who are born with the assistance of vacuum extraction usually have a caput in the area where the cup was applied. Bruising of the scalp is often seen in the presence of caput succedaneum.

Cephalhematoma

Cephalhematoma is a collection of blood between a skull bone and its periosteum. It does not cross a cranial suture line. It is firmer and better defined than a caput. Often caput succedaneum and cephalhematoma occur simultaneously. A cephalhematoma usually resolves in two to eight weeks. As the hematoma resolves, hemolysis of RBCs occurs, and hyperbilirubinemia can result.

Subgaleal Hemorrhage

Subgaleal hemorrhage is bleeding into the subgaleal compartment. It is the result of traction or application of shearing forces to the scalp, commonly associated with difficult operative vaginal birth, especially vacuum extraction. The scalp is pulled away from the bony calvarium; the vessels are torn, and blood collects in the subgaleal space. Blood loss can be severe, resulting in hypovolemic shock, disseminated intravascular coagulation (DIC), and death. Early detection of the hemorrhage is vital. Serial head circumference measurements and inspection of the back of the neck for increasing edema and a firm mass are essential. Boggy scalp, pallor, tachycardia, and increasing head circumference can be early signs of a subgaleal hemorrhage. Another possible early sign of subgaleal hemorrhage is a forward and lateral positioning of the newborn’s ears because the hematoma extends posteriorly. Monitoring the infant for changes in level of consciousness and decreases in hematocrit is also key to early recognition and management. An increase in serum bilirubin level may be seen as a result of the degradation of blood cells within the hematoma.

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Spine

A newborn’s spine appears straight and can be flexed easily. The spine can lift the head and turn it from side to side when prone. The vertebrae should appear straight and flat. If a pilonidal dimple is noted, further inspection is required to determine whether a sinus is present. The pilonidal dimple, especially with a sinus and nevus pilosus (hairy nevus), can be associated with spina bifida.

Extremities

Infant’s extremities should be symmetric and of equal length. Fingers and toes should be equal in number (five fingers on each hand and five toes on each foot) and should have nails present. Digits may be missing (oligodactyly). Extra digits (polydactyly) are sometimes found on the hands or feet. Fingers or toes may be fused (syndactyly). An infant should be examined for developmental dysplasia of the hips (DDH). In newborns with DDH, the affected hip is unlikely to be dislocated at birth; instead, it is easily dislocatable. Postnatal factors determine whether the hip dislocates, subluxates, or remains stable. DDH occurs more often in breech presentations in first-born infants, female infants, and in infants with a family history of DDH.

Signs of DDH are:

• Asymmetric gluteal and thigh skinfolds

• Uneven knee levels

• Positive Ortolani test

• Positive Barlow test

Observations to make:

• Hips are inspected for symmetry

• Gluteal and thigh skinfolds should be equal and symmetric

• Legs should be of equal length

• Level of the knees inflection should be equal

• Hip integrity is assessed by using the Barlow test and the Ortolani maneuver

The Barlow test and Ortolani maneuver:

• The examiner places the middle finger over the greater trochanter and the thumb along the midthigh

• Hip is flexed to 90 degrees and adducted

• Followed by gentle downward pushing of the femoral head

• If the hip can be dislocated with this maneuver, the femoral head moves out of the acetabulum, and the examiner feels a “clunk”

• Hip is then checked to determine if the femoral head can be returned into the acetabulum using the Ortolani maneuver

• As the hip is abducted and upward leverage is applied, a dislocated hip returns to the acetabulum with a clunk that is felt by the examiner

Signs of Skeletal Problems

Abnormalities of the skeletal system can be congenital, developmental, drug induced, or the result of intrapartum or postnatal factors. Signs of DDH, additional digits or webbing of digits, and any other abnormality should be documented and reported to the neonatal or pediatric health care provider. A fractured clavicle often occurs in large infants and in those who had a difficult birth (e.g., shoulder dystocia). Unequal movement of the upper extremities or crepitus over the clavicular area can indicate a fracture. If a newborn’s feet appear to be abnormally positioned, this can indicate congenital deformity or can be related to fetal positioning in utero.

A healthy infant must accomplish behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns progress through a hierarchy of developmental challenges as they adapt to their environment and caregivers.

Select each tab to learn about the hierarchy of developmental challenges.

• Regulating the Physiologic or Automatic System Infants must first be able to regulate their physiologic or autonomic system, including involuntary physiologic functions such as heart rate, respiration, and temperature 

• Motor Organization The next level is motor organization, in which infants regulate or control their motor behavior. This includes controlling random movements, improving muscle tone, and reducing excessive activity. 

• State Regulation The third level of development is state regulation, which refers to the ability to modulate the state of consciousness. The infant develops predictable sleep and wake states and is able to react to stress through self-regulation or communicating with the caregiver by crying and then being consoled. 

• Attention and Social Interaction Finally, the infant reaches the fourth level, which is attention and social interaction. The infant is able to attend to visual and auditory stimulation, stay alert for long periods, and engage in social interaction. 

Sleep–Wake States

Healthy newborns differ in their activity levels, feeding patterns, sleeping patterns, and responsiveness. Parents’ reactions to their newborns are often determined by these differences. Infant responses to environmental stimuli and to their caregivers depend on the infant’s state or state of consciousness.

Six states form a continuum from deep sleep to extreme irritability. There are two sleep states (deep sleep and light sleep) and four wake states (drowsy, quiet alert, active alert, and crying). Each state has specific characteristics and state-related behaviors. The optimal state of arousal is the quiet alert state which is characterized by infant’s smile, vocalization, moving in synchrony with speech, watching their parents’ faces, and responding to people talking to them.

Newborns respond to internal and external environmental factors by controlling sensory input and regulating the sleep–wake states. The ability to make smooth transitions between states is called state modulation.

Infants use purposeful behavior to maintain the optimal arousal state, such as:

• Actively withdrawing by increasing physical distance

• Rejecting by pushing away with hands and feet

• Decreasing sensitivity by falling asleep or breaking eye contact by turning the head

• Using signaling behaviors such as fussing and crying

Other Factors Influencing Newborn Behavior

• Gestational Age

• Time

• Stimuli

• Medication

Sensory Behaviors

From birth, infants possess sensory capabilities that indicate a state of readiness for social interaction.

Select each tab to learn about the sensory behaviors.

Vision

• The clearest visual distance is 17 to 20 cm (8 to 12 inches), which is approximately the distance between the mother’s and infant’s faces during breastfeeding or cuddling

• Newborns seem to have a preference for faces and can recognize the mother’s face

• Will engage the mother or caregiver with eye contact

• Can imitate facial expressions and motions such as protruding the tongue

• Prefer complex patterns over nonpatterned stimuli

• Prefer black and white, possibly because of the greater contrast

Hearing

• Term newborns Can hear and differentiate among various sounds

• Will turn toward a sound and attempt to locate the source

• Recognize and respond readily to the mother’s voice and show a preference for high-pitched intonation

• Respond to rhythmic sounds

• Routine hearing screening is recommended for all newborns before hospital discharge.

Smell

• Highly developed sense of smell capable of detecting and discriminating between distinct odors

• Breastfed infants are able to smell breast milk and can differentiate their mothers from other lactating women

Taste

• Young infants are particularly oriented toward the use of their mouths, both for meeting their nutritional needs for rapid growth and for releasing tension through sucking

• Infants have a preference for sweet solutions

Touch

• Responsive to touch on all parts of the body

• Skin-to-skin contact with the mother promotes tactile interaction and stimulation

• Touch and motion are essential to normal growth and development

Response to Environmental Stimuli

Each neonate has a unique repertoire of behaviors that are influenced by various factors including temperament, sensory threshold, ability to habituate, and consolability.

• Temperament:  Temperament refers to individual variations in the reaction pattern of newborns. 

• Habituation: Habituation is a protective mechanism that allows the infant to become accustomed to environmental stimuli. 

• Consolability: Infants vary in the ability to console themselves or be consoled. 

• Cuddliness: Cuddliness is especially important to parents because they often gauge their ability to care for the child by the child’s responses to their actions.  The degree to which newborns relax and mold into the contours of the person holding them varies.

• Irritability: Some newborns cry longer and harder than others. 

Crying

Crying is the language an infant uses most often to communicate needs. It can signal hunger, discomfort, pain, desire for attention, or fussiness. Infants may cry in response to environmental stimuli such as being cold, being overstimulated, or being held by multiple persons. Responsiveness of the caregiver to the crying creates trust as the infant learns to associate the caregiver with the removal of discomforts.

The gestational age of an infant at birth is an important predictor of survival. Infant morbidity and mortality are inversely related to gestational age.

Infants may also be classified in the following ways according to gestational age:

• Preterm, or premature—born before 37 0/7 weeks of gestation, regardless of birth weight

• Late preterm—34 0/7 through 36 6/7 weeks

• Early-term—37 0/7 through 38 6/7 weeks

• Full-term—39 0/7 through 40 6/7 weeks

• Late-term—41 0/7 through 41 6/7 weeks

• Postterm—42 0/7 weeks and beyond

• Postmature—born after completion of week 42 of gestation and showing the effects of progressive placental insufficiency

Late-Preterm Infant

• The majority of preterm births are considered late preterm, occurring from 34 0/7 through 36 6/7 weeks of gestation

• Vaginal and cesarean births before 39 weeks have contributed significantly to late-preterm birth rates in the United States

• “The great impostors” because they are often the size and weight of term infants and, unfortunately, are often treated as term newborns

• Increased risk for respiratory distress, temperature instability, hypoglycemia, apnea, feeding difficulties, and hyperbilirubinemia

Early-Term Infant

• 37 0/7 through 38 6/7 weeks

• Increased risk for morbidity and mortality

• Associated with higher risk for hypoglycemia, respiratory problems such as respiratory distress syndrome and transient tachypnea of the newborn (TTN), and a greater likelihood of NICU admission

Postterm or Postmature Infant

• Infants born at 42 0/7 weeks of gestation or beyond are considered postterm, regardless of birth weight

• Some infants are AGA but show characteristics of progressive placental insufficiency

• Infants are labeled as postmature and are likely to have little if any vernix caseosa, absence of lanugo, abundant scalp hair, and long fingernails

• Skin is often cracked, parchmentlike, and peeling

• Common finding in postmature infants is a wasted physical appearance that reflects placental insufficiency

• Depletion of subcutaneous fat gives them a thin, elongated appearance

• Scant amounts of vernix caseosa that remain in the skinfolds may be stained deep yellow or green, which is usually an indication of meconium in the amniotic fluid

• Significant increase in fetal and neonatal mortality in postmature infants compared with those born at term

• Especially prone to fetal distress associated with placental insufficiency, macrosomia, and meconium aspiration syndrome

Venipuncture

Venous blood samples (requiring >1 ml) can be drawn from antecubital, saphenous, superficial wrist, and rarely, scalp veins. A 23- or 25-gauge butterfly needle or hypodermic needle with a syringe is used. Pressure must be maintained over these sites with a dry gauze square for three to five minutes to prevent bleeding from the site after specimen collection.

Providing a Safe Environment

The provision of a protective environment is basic to the care of the newborn. Current health care trends and the focus on nonseparation of mothers and babies (rooming-in) have prompted many hospitals to abandon having a separate newborn nursery.

Environmental factors to consider include:

• Adequate space

• Appropriate lighting

• Elimination of potential fire hazards

• Safety of electrical appliances, adequate ventilation

• Controlled temperature and humidity

Infection Prevention

Measures to control infection in newborn nurseries include:

• Adequate floor space to permit the positioning of bassinets at least three feet apart in all directions

• Practice of good hand hygiene

• Appropriate cleaning and decontamination of the physical environment

• Promotion of breastfeeding

• Limiting the number of visitors

• Cohorting infants who are colonized with the same pathogen

• Limiting the number of invasive procedures

• Only specified personnel directly involved in the care of mothers and infants are allowed in these areas

• Siblings and grandparents are expected to perform hand hygiene before having contact with infants or equipment

• Individuals with infectious conditions are excluded from contact with newborns or must take special precautions when working with infants:

  • People with upper respiratory tract infections

  • Gastrointestinal tract infections

  • Infectious skin conditions

As part of standard precautions, all health care workers should wear gloves when handling infants until blood and amniotic fluid have been removed by the initial bath. Gloves should also be worn any time the nurse is drawing blood or handling urine, stool, or bloody drainage, as might occur when changing a circumcision dressing.

Fall and Drop Prevention

Newborn infants are at risk for injury as a result of falling.

Fall: “[A] sudden, unintentional descent, with or without injury to the patient that results in the patient coming to rest on the floor on or against another surface, on another person or object.”

Drop: “[A] fall in which a baby being held or carried by a health care professional, parent, family member, or visitor falls or slips from that person’s hands, arms, lap, etc.”

Infants who experience a fall or drop, even from low-level surfaces such as beds or chairs, are at risk for sustaining head injury that can include skull fracture. Factors that have been identified as possible contributors to this type of injury include:

• Maternal medications (e.g., opioids)

• Exhaustion in parents

• Lightheadedness

• Incoordination

Parents need to be educated that bed-sharing is not a safe sleep practice and should be made aware of the potential risks related to this practice.

Staff members may conduct more frequent rounds to monitor for fall risks.

Newborns are always transported in their bassinets and are never carried in arms outside the mother’s room.

Sudden Unexpected Postnatal Collapse

• Sudden unexpected postnatal collapse (SUPC) refers to any condition that results in temporary or permanent cessation of respirations or cardiorespiratory failure. 

• When SUPC occurs, the infant collapses suddenly to the point of needing intermittent positive-pressure ventilation and dies. SUPC requires intensive care and may result in encephalopathy.

• The vast majority of SUPC cases occur during the first two hours after birth and appear to be related to suffocation or entrapment. SUPC has occurred when newborns are held prone on the mother’s chest or abdomen during skin-to-skin contact, and when mothers are not paying close attention to the infant as they are breastfeeding or holding the infant.