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CHAPTER 4 Care at Birth
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89
who attended the delivery an opportunity to
have a conversation and reflect on their care,
teamwork, and communication. Debriefing
identifies aspects of the resuscitation that went
well and those that could be improved, with the
goal of practice and systems change for continuous
improvement.
CARE OF THE FAMILY AND
PERINATAL DECISION MAKING
Encouraging the presence of the father or
another mature support person at birth is
common obstetric practice and should not
interfere with care after birth. Ideally, mem-
bers of the obstetric and neonatal resuscitation
team should introduce themselves to the parents/
birth companion before the delivery. Parents
have a great deal of anxiety concerning procedures performed on their newborn; a few
moments spent describing routine procedures
will help allay their fears and avoid misinterpretation. When problems are anticipated, a calm,
professional explanation of neonatal assessment
and life-support measures is necessary. Parental
awareness that the medical and nursing staff
have anticipated and prepared for possible
problems can partially relieve their anxieties.
Care must be taken, however, to avoid instilling
undue alarm. Care providers should understand
ethical principles and the impact of their personal
moral and ethical beliefs on decisions made about
resuscitation.
If an infant requires resuscitation or prolonged
assessment and support, the attending staff ’s primary obligation is to provide this care and communicate with the parents. Parents should be
encouraged to have contact with their baby,
but the presence of the father or a support
person should not interfere with or delay the
delivery of care. The pediatric staff should tell
the parents what is happening at the earliest
possible opportunity because a lack of communication prolongs anxiety for the parents.
A few brief statements to explain the status of
the baby and procedures can relieve the anguish
of silence. Especially when a difficult resuscita-
tion is anticipated, it is ideal to designate, in
40
advance, a team member who can keep parents
informed.
When severe perinatal problems are suspected
prenatally and confirmed after birth, such as
extreme prematurity (gestational age less than 23
weeks, birth weight less than 400 g), anencephaly,
or other potentially lethal anomalies, discussions
may be held in advance with obstetric care
providers and the family about limiting the
extent of resuscitative measures (see Chapter
40,60
32).
When problems are unanticipated, information is uncertain, or there has been no time
for decision making before delivery, intervention in the delivery room may be warranted.22
This approach allows time for complete information to be gathered and discussed with the
family. If appropriate, support measures can
be withdrawn later in the nursery. When an
infant fails to respond to intensive resuscitative
measures in the delivery room, a decision, in
consultation with the parents, must be made as
to when to stop support. Survival is unlikely
if no heart rate has been obtained after 10
minutes.
15,38,49
Discontinuation of resuscitation may be appropriate if, after 10 minutes
of full resuscitative effort, there is no return
of spontaneous circulation. The data for infants
who have an inadequate response to resuscitation
remain less clear. The probability of survival
diminishes and the probability of cerebral
palsy increases with the length of time during
which Apgar scores remain below 4. For
example, if the Apgar score remains below 4 at
20 minutes, the probability of cerebral palsy in
surviving infants is greater than 50%.47 It is essential to rapidly identify remediable causes of poor
response to resuscitation.
Anticipation and recognition of fetal and neonatal problems indicating delivery room resuscitation
depend on a knowledgeable and prepared staff
working as a team to effectively and efficiently
communicate and respond in a critical situation.
By applying current evidence in performing the
skills necessary for neonatal resuscitation, evaluating the infant’s response, and taking the time to
discuss resuscitation options and outcomes with
the parents and resuscitation team, successful delivery room care and stabilization of the newborn is
more likely.
UNIT TWO Support of the Neonate90
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58. Niermeyer S. A physiologic approach to cord clamping: clinical
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IMMEDIATE NEWBORN
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5
neonate must demonstrate a condition of
well-being before being considered a normal,
A
low-risk infant. All neonatal intensive care
professionals must understand the normal neonate to care for the sick neonate. This chapter
discusses the initial assessment, transitional period,
and gestational age characteristics that are fundamental for providing quality initial care after.
Physical and physiologic changes occur so rapidly after birth that the assessment of the newly
born can be divided into four distinctive periods:
delivery, transition, the first 24 hours of life, and
discharge. Each of these assessments has a specific
purpose. These evaluations occur in relation to the
age of the newborn infant (minutes, hours, days, and
weeks) rather than the location of the mother and
infant in the hospital or arbitrary nursery routines.
The evaluation at delivery is aimed at determining the condition of the infant at the time
of birth and at detecting potentially life-threatening emergencies. The examination during the
next few hours (transitional period) is used to
evaluate the infant’s adjustment to extrauterine
life. The complete newborn examination by a
qualified health care provider should ideally be
delayed until after initiation of breastfeeding,
but completed by 12 to 24 hours.8 It is the most
important examination, because many findings can
be treated or complications can be avoided. Finally,
the assessment/evaluation at discharge is of the
utmost importance. Although it is not as detailed as
the complete examination, it is aimed at establish-
ing the infant’s readiness to leave the hospital
and to be cared for by the mother.
Both the initial complete examination and
the discharge examination can be performed
with parents present to demonstrate the baby’s
CARE AFTER BIRTH
SANDRA L. GARDNER AND SUSAN NIERMEYER
unique abilities and to answer the parents’ questions. These are excellent opportunities to provide
support and encouragement as the parents begin to
incorporate the new member into their family.
ASSESSMENT AND CARE AT
BIRTH
Before the birth, one should obtain pertinent facts
about the pregnancy, such as parity, gravidity, fetal
losses, estimated birth weight (BW) and gestational
age (GA) of the fetus, and, of course, any problems
present in the current pregnancy.
of prenatal screening tests should be available to
the clinician at birth. Health care providers should
note whether the mother was screened for group B
streptococcus and whether she received any antibiotic treatment.
During labor, one can observe the frequency
and duration of contractions and the maternal and
fetal reaction to contractions. Fetal distress, passage
of meconium, prolonged rupture of membranes,
malodorous fluid, and other signs will alert the
attendants to impending problems.
At birth, the most common way to assess the
infant’s condition is to use the Apgar scoring system.10 This score provides a comprehensive, objective
measure of the state of an infant at given times after
birth, traditionally at 1 and 5 minutes (see Chapter
4, Figure 4.7). The Apgar score standardizes ini-
tial newborn assessment and continues to be a
predictor of neonatal survival.
score should not be used as the primary indicator for
resuscitation because it is not normally assigned until
1 minute of age. Immediate assessment of respi-
ratory effort is paramount to begin resuscitative
8,44
116
10,146,182
The results
The Apgar
BLUE type highlights content that is particularly applicable to clinical settings.
93
UNIT TWO Support of the Neonate94
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procedures if the infant is limp and not breathing
(see Chapter 4). If the baby is vigorous, the care pro-
vider may place him or her on the mother’s abdomen or in her arms; the first Apgar assessment can be
done with the infant in skin-to-skin during the delay
before umbilical cord clamping. Scoring is repeated
at 5 minutes. Between the 1- and 5-minute Apgar
scores, one systematically evaluates the baby for
potential or apparent medical emergencies.
Most infants are vigorous, cry at birth, and breathe
easily thereafter. A healthy, vigorous infant generally
does not even need suctioning after birth. With
appropriate ongoing monitoring, most infants can
be given directly to the mother for skin-to-skin
care after birth without compromising the infant.
Shortly after birth, a quick estimate of GA is done.
Several tables, charts, and graphs have been developed
over time to assist the clinician in performing this
task. With practice and experience, the professional
will be able to identify approximate GA from the
physical appearance. Additional discussion on GA is
presented later in this chapter. Immediately follow-
ing birth, a brief but complete initial examination
should be performed on each newborn to assess
the condition of the infant and to ensure that
there are no major anomalies or birth injuries, that
the infant is pink, and that breathing is normal. The
entire body must be assessed, including overall
size, proportionality and contour, respiratory pattern and presence of distress, posture, tone, and
state of alertness. This usually allows the clinician to
reassure parents that their infant is well and appears
normal. A more detailed evaluation/examination is
described later.
The most severely ill neonates are usually
apparent after birth. Most of them will have
been identified prenatally (e.g., serious congenital
anomalies, extreme prematurity), their presence
anticipated, and a management plan is made before
delivery (see Chapter 4).
EVALUATION AND CARE
DURING THE TRANSITIONAL
PERIOD
Physiologic Changes and Clinical
Stages
The initial evaluation, assessment, and management
of a newborn must be directed toward promoting
and facilitating normal adaptation to extrauterine
life and early detection of significant health problems so that they can be evaluated and treated
promptly and appropriately.
The obligatory change of environment at
birth necessitates adjustment to the extrauterine
environment in a complex series of changes
essential for survival. Every infant must complete this process of transition successfully to
survive in the extrauterine environment. For a
small percentage of newborns, transition is never
achieved; for a slightly larger number, transition is
delayed or complicated. For most newborns, transition is so smooth it appears uneventful.
With the first breath, all neonates begin the
transition from intrauterine to extrauterine life.
Three major changes take place at birth. First, fluid
in the alveoli is reabsorbed and air fills the alveoli,
allowing for gas to diffuse into and out of the pulmonary blood vessels. Second, when the umbilical
arteries and vein are clamped, the low-resistance
placental circuit is gone and systemic blood pressure increases. Third, pulmonary vascular resistance
decreases as a result of mechanical distention of
the alveoli and increased alveolar oxygen content.
Oxygen is a potent pulmonary vasodilator.
During the first few hours after birth, the
normal newborn progresses through a fairly
predictable sequence of events, recovering from
the stress of birth and adapting to extrauterine
life. Intrapartum and immediate neonatal events
result in sympathetic discharges reflected in changes
in heart rate, color, respiration, motor activity, gastrointestinal function, and temperature. Awake and
sleep states affect a neonate’s behavior and ability to respond to the environment. A newborn
may go from one state to another quite frequently
after birth and at home (see Critical Findings:
Newborn States and Considerations for Caregiving
in Chapter 13). Fig. 5.1 shows the classic descrip-
tion by Desmond of the transitional period,
which includes the three stages shown in Box
5.1. Failure to establish this pattern of transition
requires careful observation and investigation.
91
Management of the Newborn during
Transition
Traditionally, “normal newborn” care was based on
the optimistic assumption that most newborns have
no difficulty with transition after birth and that
CHAPTER 5 Immediate Newborn Care After Birth
Minutes after birth Hours after birth
Respiration
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SD 1034
Apgar 9
Birth weight: 3586 g
Respiration rate (breaths/min) Heart rate (beats/min)
95
Color
Heart
sounds
Motor
activity
Brief
cyanosis
Rales
Flaring
Grunting
Retractions
Loud
Forceful
Irregular
First period
of reactivity
Alerting
PresentMucus
Sounds absent
Birth 5101530 1246810
Flushing with
cry
Barreling
of chest
Regular
Sleep
Absent
Sounds presentBowel
Swift color changes
Labile
Second period
of reactivity
Variable
(gagging, arching)
Present
Meconium passage
100
80
60
40
200
180
160
140
120
100
80
Temperature (°C)
39
37
35
FIGURE 5.1 Critical findings: Neonatal transitional period. (From Desmond MM, Rudolph AJ, Phitaksphraiwan P, et al. The transitional
care nursery: a mechanism for preventive medicine in the newborn, Pediatr Clin North Am. 1966;13:651.)
term infants, in particular, do exceedingly well.91
Individualized newborn care recognizes the
complexity of transitioning to extrauterine life,
the need to support that transition, and the reality of serious disease, even in term newborns.
Newborn Should Be Treated as a
Recovery Patient
SKILLED PROVIDERS SHOULD CARE FOR
THE NEWBORN
Current standards of care8 require skilled
health care providers (24 hours/day) to care
for newborns during the first minutes after
birth (e.g., in the delivery room, at the birth
center) and in the transitional period (e.g.,
in the birth room, mother-baby area, newborn
nursery).91 All personnel caring for the newborn
must be familiar with the transitional changes
after birth and deviations from normal transitional events. After a normal, low-risk pregnancy
and birth, primary evaluation and care of the
newborn must be provided by nurses with
neonatal-perinatal competencies who consult
advanced practice nurses and/or physician(s)
when appropriate.
8,91
BOX
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5.1
UNIT TWO Support of the Neonate96
TRANSITIONAL PERIOD
First Stage (0 to 30 Minutes) = First Period of Reactivity
• Rapid increase in heart rate to the range of 160 to 180 beats/min (0 to
15 min)
• Gradual decrease in heart rate over 30 minutes to baseline rate between
100 and 120 beats/min
• Irregular respirations (first 15 minutes), peak respiratory rates between
60 and 80 breaths/min
• Rales present on auscultation
• Grunting, flaring, and retractions may be noted, and brief periods of
apnea (<10 seconds in duration)
• Plethora
• Alert with spontaneous startle reactions, gustatory movements, trem-
ors, crying, and side-to-side head movements
• Decrease in body temperature
• Generalized increase in motor activity, with increased muscle tone
• Bowel sounds absent, and abdomen distended
• Production of saliva minimal
Second Stage (30 Minutes to 2 Hours) = Period of Decreased
Responsiveness
• Newborn either sleeps or has a marked decrease in motor activity
• Muscle tone returns to normal, but responsiveness is diminished
• Fast, shallow, synchronous breathing (60 breaths/min) without dyspnea occurs
• Newborn’s color is pale but pink with excellent perfusion and capillary
refill
• Increase in anterior-posterior diameter (barreling) of the chest is usually
present
• Heart rate decreases into the range of 100 to 120 beats/min or lower;
the newborn is relatively less responsive to external stimuli
• Abdomen is rounded, and bowel sounds are audible; peristaltic waves
may be visible, and meconium may be passed
• Oral mucus is absent
• Spontaneous jerks and twitches are common, but the newborn quickly
returns to rest
Third Stage (2 to 8 Hours) = Second Period of Reactivity
• Return of and possible exaggeration of responsiveness
• Labile heart rate: periods of tachycardia
• Brief periods of rapid respirations: At 2 hours of age: median respiratory
rates: 46 breaths/min; 95th percentile respiratory rates of 65 breaths/
min; 5th percentile: respiratory rates 30 to 32 breaths/min.
higher when awake, rather than asleep, boys higher than girls, and after
heavy meconium staining of amniotic fluid; no difference in rate between
vaginal versus cesarean birth.
• Abrupt changes in tone, color, and bowel sounds
• Possible prominence of oral mucus; gagging and vomiting not unusual
• Possible clearing of meconium from the bowel
• Increased responsiveness to endogenous and exogenous stimuli
• Newborn hunger cues; quiet alert periods when maternal bonding is
established
186
186
Rates
Modified from Hernandez JA, Thilo E. Routine care of the full-term newborn. In: Osborn LC, DeWitt TG, First LR, et al, eds. Pediatrics. St Louis, MO: Mosby; 2005.
STANDARDS FOR ROUTINE CARE AND
PHYSIOLOGIC MONITORING DURING
TRANSITION MUST BE MAINTAINED
Parent-infant bonding, skin-to-skin care, early
breastfeeding, and careful neonatal monitoring during the transitional period should be
addressed in delivery/birth room and other
facility routines. After birth, the stable, pink new-
born whose Apgar score is greater than 7 at 5 minutes can remain skin-to-skin with the mother.
Immediate skin-to-skin contact in the first hours
after birth facilitates early initiation of breastfeeding in the setting of a stable neonate under
continuous monitoring. After birth, at 15-minute intervals, every newborn must be assessed
for general condition, respiratory effort, color,
muscle tone, and temperature; all assessments
must be documented.91 The mother and infant
should not be left alone in the first hours after
birth.
Skin-to-skin care benefits parents, premature
neonates, and full-term neonates after vaginal,
operative vaginal, and cesarean birth (see Table
5.1 and Fig. 5.2). Skin-to-skin care not only
prevents hypothermia26 but also is effective in
treating hypothermia.
of skin-to-skin versus incubator care for rewarming
148
low-risk hypothermic neonates, skin-to-skin care
131
In a randomized study
was shown to be more effective (90%) than incubator care (60%)51 (see Chapter 6).
Even newly born, low-birth-weight (LBW)
infants (1500 to 2500 g) transitioned by skin-toskin care with their mothers have been shown
to stabilize their cardiorespiratory function better
than LBW infants cared for in incubators. This
randomized controlled trial (RCT) also found that
TABLE
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5.1
BENEFITS OF SKIN-TO-SKIN CARE FOR PARENTS AND NEWBORNS AFTER VAGINAL AND CESAREAN
SECTION BIRTHS
BENEFITS AFTER VAGINAL BIRTH BENEFITS AFTER CESAREAN BIRTH
Psychological (Parental)
Promotes maternal and paternal infant bonding as a result of increased
release of oxytocin
Facilitates the process of becoming a parent; either restores or drains energy
Increases positive activities with the newborn and growing infant
47,58,143,148
148
12,13
Psychological (Parental)
Enhances family bonding, attachment, and satisfaction
Increases vocal interaction with newborn
Decreases expense because infant formula does not have to be purchased
174
192
Psychological (Maternal)
Enhances birth experience
Increases confidence and competence
Decreases postpartum cortisol levels, postpartum depression28 and
58
anxiety
More positive maternal interactions at 1 week, 2 months, and 3 months
29
of age
Decreases maternal pain during episiotomy repair
93
148
163
Psychological (Paternal)
Promotes parental role attainment
Increases involvement and sensitivity toward newborn
Exhibits more caring
191
Increases confidence and comforting behaviors toward neonate
Facilitates more equal parenthood
Decreases cortisol levels, stress, and anxiety
Decreases relationship problems with mother of baby
164
and interactive behaviors
143
58,164
191
164
130
Physiologic (Maternal)
Decreases postpartum hemorrhage
58,157
secretion
with breastfeeding
Breastfeeding
Earlier initiation of breastfeeding
29,50,84,194
duration
Assists in resolution of early breastfeeding problems such as latch-on
Increases breastfeeding self-efficacy
Full Term Newborn
Novel bioactive substances in human colostrum may assist in postnatal
adaptation related to thermoregulation, vascular adaptation, glucose metabolism, lung function, and fluid homeostasis
Breastfeeding within the first hour of life decreases neonatal mortality by 33%
Higher breastfeeding rates
128,163
weeks,
1 month,
More likely to breastfeed successfully during first feeding
Enhances breastfeeding benefits: fewer postnatal infections (ear, gastrointestinal, and respiratory); decreased incidence of SIDS and chronic illnesses
(obesity, diabetes, cardiovascular)
Dose-dependent relationship between the use of fentanyl administered by
epidural and synthetic oxytocin and the inability of the newborn to initiate
suckling in the first hour of life while skin-to-skin with mother.
157
as a result of increased oxytocin
50,84,88,114,193
153
and breastfeeding exclusivity at 6
115,128
4 months,
179
5,138
32
128
and 6 months of age.
Increases incidence and
180
167
128
128
34
Psychological (Maternal)
Enhances perception of own health, quality of life, and satisfaction with
birth experience
Decreases anxiety and pain;
for anxiety and pain
Rise in maternal salivary alpha-amylase directly after delivery when baby
held skin-to-skin intraoperatively
Decreases maternal oxidative stress
Describes skin-to-skin care with father as the formation of the family
Prefers father to provide skin-to-skin if mother unable, rather than newborn
be alone on a radiant warmer
79
148,198
198
decreases administration of medications
107
207
78
78
Psychological (Paternal)
Increases conversation with mother
Facilitates more equal parenthood
enables the father to immediately and gradually change to “father” as he
assumes the primary parenting responsibility and role with his newborn
No influence on initiation of breastfeeding or exclusive breastfeeding rates
at 3 or 6 months of age when compared to maternal skin-to-skin contact.
192
139
because togetherness with infant
70
Physiologic (Maternal)
Significant reduction in blood pressure and respiratory rate
Breastfeeding
Initiates earlier breastfeeding, infants were exclusively or predominantly
breastfeeding at discharge, 3 months,
79,85
and 6 months of age.85
More likely still breastfeeding at 1 month and 4 months of age/more
128
successful
139
85
Continued
UNIT TWO Support of the Neonate98
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TABLE
5.1
BENEFITS OF SKIN-TO-SKIN CARE FOR PARENTS AND NEWBORNS AFTER VAGINAL AND CESAREAN
SECTION BIRTHS—CONT’D
BENEFITS AFTER VAGINAL BIRTH BENEFITS AFTER CESAREAN BIRTH
Physiologic (Neonatal)
Full-Term Newborn
Decreases cortisol levels resulting from less birth stress
decline in neurosteroid levels with more skin-to-skin contact
Improves thermal stability: less hypothermia, improved ability to remain in
thermal neutrality
140,164,172,193
Promotes earlier cardiopulmonary stabilization:
slower heart rate combined with a slower increase in the first 3 minutes;
Less tachycardia and more bradycardia in the first minutes after birth
Improves blood glucose regulation; higher blood glucose levels.
Nonpharmacologic intervention for neonatal pain resulting in less crying and
lower pain scores
1,83,164
122,181
128,181
Higher Spo2 and
and a larger
122
166
128
Physiologic (Neonatal)
Full-Term Newborn
Decreases newborn stress
of starting skin-to-skin care with father),71 calmer and better relax-
71,144,192
ation
Reaches drowsy state sooner (within 60 minutes after birth)
Prefeeding behaviors facilitated
Initiates vocalization with parents (within 15 minutes of initiating skin-toskin care), which further promotes bonding and attachment
Thermal stability
Lower transfer rates to NICU
Fewer suspected neonatal infections
22,79
159
resulting in less crying (within 15 minutes
150,158
Premature Newborn
Improves physiologic stability: better temperatures, oxygen saturations,
heart rate and blood glucose levels;
141
similar first body temperatures
and blood glucose levels in moderately preterm infants (34–35 weeks
gestational age) when compared to incubator care
Nonpharmacologic intervention for neonatal pain
110
141,142
Decreases late preterm infant’s cortisol reactivity to handling, improves
concordance between mother/infant salivary cortisol levels
130
Improves infant-to-parent bonding because of close proximity
71
71
192
150
LBW infants transitioned with skin-to-skin care
had less need for respiratory support, intravenous
fluids, and antibiotics during their hospitalization.49
Because of the extensive research evidence, the World
Health Organization (WHO), American Academy
FIGURE 5.2 Skin-to-skin care and family bonding in the first hours after birth.
of Breastfeeding Medicine (ABM),2 American
Academy of Pediatrics (AAP),
Women’s Health, Obstetric and Neonatal Nurses
(AWHONN).13 International Childbirth Education
Association (ICEA),96 Neonatal Resuscitation
8,73
Association of
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