The time of birth is the precise time when the entire body is out of the mother and must be recorded. In the case of multiple births, each birth is noted in the same way.  If the mother’s and newborn’s conditions allow, immediate skin-to-skin contact and delayed cord clamping are likely to be implemented. A cap is placed on the newborn’s head, wet blankets are removed, and the baby and woman are covered with fresh warm blankets.  It is currently recommended that the umbilical cord not be clamped until one to five minutes after birth, or until after the cord stops pulsating, to allow physiologic transfer of blood to the newborn. The optimal duration of delayed cord clamping appears to be up to three minutes unless the cord stops pulsating sooner. The delayed cord clamping allows for a placental transfusion of up to 30% of the total fetal–placental blood volume 2.5 cm above the clamp.  In another approach, referred to as lotus birth, the cord is not clamped and cut at all. Instead, the cord and placenta remain attached to the baby until the cord naturally separates from the baby several days after birth.  

Care given immediately after birth focuses on assessing and stabilizing the newborn. The Neonatal Resuscitation Program (NRP) and AWHONN recommend that at least two nurses be present for each birth. One nurse is responsible for the care of the newborn while the other helps the nurse–midwife or physician with the delivery of the placenta and care of the mother.  The nurse performs a brief assessment of the newborn immediately even while skin-to-skin contact is being performed. Assessment includes assigning Apgar scores at one and five minutes after birth.  

Major priorities for immediate newborn care include:

• Maintaining a patent airway

• Supporting respiratory effort

• Preventing cold stress by drying and preferably covering the newborn with a warmed blanket while on the mother’s abdomen/chest or, less optimally, placing them under a radiant warmer

Major adaptations associated with transition from intrauterine to extrauterine life occur during the first six to eight hours after birth. A predictable series of events during transition are mediated by the sympathetic nervous system and result in changes that involve heart rate, respirations, temperature, and gastrointestinal (GI) function. The transition period represents a time of vulnerability for the newborn and warrants careful observation.

First Period of Reactivity

• The first stage of the transition period lasts up to 30 minutes after birth and is called the first period of reactivity.

• The newborn’s heart rate increases rapidly to 160 to 180 beats/min but gradually falls after 30 minutes or so to a baseline rate of 100 to 120 beats/min. Respirations are irregular, with a rate between 60 and 80 breaths/min. Fine crackles can be heard on auscultation. Audible grunting, nasal flaring, and retractions of the chest also can be present, but these should cease within the first hour after birth. The infant is alert and may have spontaneous startles, tremors, crying, and head movement from side to side. Bowel sounds are audible, and meconium may be passed.

Period of Decreased Responsiveness

• After the first period of reactivity, the newborn either sleeps or has a marked decrease in motor activity. This period of decreased responsiveness lasts from 60 to 100 minutes.

• The infant is pink, respirations are rapid (up to 60 breaths/min) and shallow but unlabored, bowel sounds are audible, and peristaltic waves may be noted over the rounded abdomen.

Second Period of Reactivity

• The second period of reactivity occurs approximately between two and eight hours after birth and lasts from 10 minutes to several hours. Brief periods of tachycardia and tachypnea may occur. The infant may also present increased muscle tone, changes in skin color, and mucus production. Meconium is commonly passed at this time.

Features to assess in the general survey include:

• Color

• Posture

• Activity

• Obvious signs of anomalies that can cause initial distress

• Presence of bruising or other birth trauma

• State of alertness

The neonate’s maturity level can be determined by assessing general appearance. The normal resting position of the term newborn is one of general flexion.

Although most newborns make the necessary biopsychosocial adjustments to extrauterine life without great difficulty, their well-being depends on the care they receive. This lesson focuses on the assessment and care of the newborn immediately after birth until discharge from the birth setting, as well as important anticipatory guidance for parents related to ongoing infant care.

The primary goal of care in the first moments after birth is to assist the newborn to successfully transition to extrauterine life. The first priority is to establish effective respirations.

If the newborn is at term, has good muscle tone, and is crying or breathing, routine care is all that is required. Routine care includes:

• Placing the newborn skin-to-skin on the mother’s chest or abdomen

• Drying the infant with gentle rubbing to remove moisture, which helps minimize evaporative heat loss

• Removing wet linens and covering the mother and baby with a warm blanket

• Drying the newborn’s head and applying a cap

• Wiping away nasal and oral secretions - A bulb syringe may be used if secretions appear to be blocking the airway

• Starting the ongoing assessment of the neonate’s breathing, color, and activity

• If the newborn is not at term, has poor muscle tone, or is not crying or breathing, they are placed immediately under a radiant warmer. Assessments and interventions are accomplished under the warmer until the infant is stable and can be safely placed skin-to-skin with the mother. Alternatively, the infant may be transported to a nursery or neonatal intensive care (NICU) setting.

• The newborn should be breathing spontaneously. Their trunk and lips should be pink. A bluish discoloration of the hands and feet (acrocyanosis) is a normal finding. If the newborn is apneic or has gasping respirations, the newborn should be placed on the radiant warmer and positive pressure ventilation should be initiated. It may take a term newborn several minutes to “pink up.” Visual inspection of cyanosis is not reliable when central cyanosis persists; instead, a pulse oximeter should be applied to the newborn’s right hand. An oxygen saturation value as compared to the newborn’s age in minutes helps guide the use of supplemental oxygen immediately after birth.

• The heart rate is quickly assessed by grasping the base of the cord or by auscultating the chest with a stethoscope. The nurse counts for 6 seconds and multiplies by 10 to calculate the heart rate. The neonatal heart rate should be greater than 100 beats/minute. If the newborn requires respiratory or circulatory support, the nurse and other members of the health care team (e.g., neonatologist, respiratory therapist) should follow the most recent guidelines of the Neonatal Resuscitation Program, published by the American Heart Association (AHA) and the American Academy of Pediatrics (AAP).

• As soon as possible after birth, the nurse should place identically numbered bands on the newborn’s wrist and ankle, on the mother’s wrist, and in some birth settings, on the father or significant other. Identification bands should be placed prior to the newborn being separated from the mother. An electronic infant security tag or abduction system alarm should be placed on all newborns to help protect against infant abduction. Other tracking measures include footprinting the infant with ink or a scanning device within two hours of birth and taking color photographs of the infant for identification. We will discuss the prevention of infant abduction more in the next lesson.

• Contemporary birthing practices are family centered. Mother-infant contact produces physiologic benefits for the neonate and the mother. SSC promotes the physiologic stability of the newborn. Maternal levels of oxytocin and prolactin rise with SSC and early breastfeeding. Rooming in after birth until discharge from the birthing facility promotes parent-infant interaction.