Normal Fetal Adaptation at Birth
- Heat loss: Evaporation, radiation, conduction, convection.
- Heat production: Mainly through nonshivering thermogenesis (lipolysis of brown adipose tissue).
- From placenta to lungs.
- Fetal Hb allows fetus to maintain lower arterial oxygen tension (greater affinity for oxygen binding than adult Hb).
- From sporadic breathing to continuous breaths.
- Replacement of fetal lung fluid with air (decreased production and increased absorption).
- In fetus: ↑ PVR, ↓ SVR.
- At birth: SVR increases with removal of placenta; PVR decreases with replacement of fetal lung fluid with oxygen and endogenous nitric oxide production, causing vasodilation.
- Mixed circulation persists during this “transition” secondary to ductus arteriosus (closes within 2 wk, but flow decreases within a few hours of birth) and foramen ovale (right-to-left flow reverses soon after birth).
- Temperature (36.5°C–37.4°C)
- Respirations (<60 breaths/min with no signs of respiratory distress)
- HR (100–160 beats/min)
- Swelling (caput, cephalohematoma, subgaleal hemorrhage), trauma (forceps marks, scalp electrode marks), scleral hemorrhage, symmetric pupillary response, presence of red reflex, choanal atresia, cleft lip/palate, ear pits/tags, facial symmetry
- Equal breath sounds, respiratory distress (grunting, retracting)
- Nipples (supernumerary), sternal abnormalities (ie, pectus excavatum or carinatum)
- Bowel sounds, defects, organomegaly, masses, appearance, cord vessels (two arteries, one vein)
- Patent anus, ambiguous genitalia, abnormal anatomy (hypospadias, epispadias)
- Boys: Descended testicles, penile length
- Girls: Perforate hymen, clitoral length
- Tone, equal movement, perfusion, digits, Barlow and Ortolani maneuvers for hip dysplasia
New Ballard score for assessment of fetal maturation of newly born infants. (Reproduced with permission from Ballard JL, et al: New Ballard score, expanded to include extremely premature infants. J Pediatr 1991;119:417. New York: McGraw-Hill. Copyright © The McGraw-Hill Companies. All rights reserved.)
Infant evaluation at birth—Apgar score. (Reproduced with permission from Hay WW Jr, Levin MJ, Sondheimer JM, Deterding RR: Current Diagnosis & Treatment: Pediatrics, 19th ed. New York: McGraw-Hill. Copyright © The McGraw-Hill Companies. All rights reserved.)
aOne minute and 5 minutes after complete birth of the infant (disregarding the cord and the placenta), the following objective signs should be observed and recorded.
bTested after the oropharynx is clear.
Routine Newborn Care
- Encourage breastfeeding within 1 hr of birth and formula within 3 hr if baby is alert, has no abdominal distension or respiratory distress, and has a good cry.
- Term babies take 0.5–1 oz q2–4hr initially.
- Breastfeeding should occur q1-3hr (see Chapter 4).
- 0.5% erythromycin ointment to both eyes within 2 hr after birth for prophylaxis against ophthalmia neonatorum.
- The process of testing newborn babies for genetic, endocrinologic, metabolic, and hematologic diseases.
- Tests are performed by heelstick after feeds have been established, usually between 24 and 48 hr of age.
- Each state determines what screens will be performed. For a state-by-state list, see the U.S. National Newborn Screening & Genetics Resource Center (NNSGRC) website (genes-r-us.uthscsa.edu).
- Most states now utilize tandem mass spectrometry, which allows for detection of a greater number of inborn errors of metabolism.
- If an abnormality is noted, the agency performing the test is responsible for contacting the parents, physician, hospital, and/or nursery. Appropriate response varies by disease screened for, but a guide can be found with ACTion sheets at the NNSGRC website (genes-r-us.uthscsa.edu).
Early Discharge Criteria (<48 H of Life) (Institutional Practice; Adapted from Pediatrics 2010;125(2):405)
- 37-41 completed weeks’ gestation
- No findings that require continued hospitalization.
- Vital signs documented as normal (see “Newborn Exam” above).
- Infant has urinated regularly and passed at least one stool spontaneously.
- Infant has completed at least 2 successful, consecutive feeds
- No significant bleeding at circumcision site
- Risk of development of hyperbilirubinemia has been assessed and appropriate follow up arranged.
- Infant has been appropriately screened for sepsis on the basis of maternal risk factors (including GBS status and adequacy of antepartum prophylaxis).
- Maternal labs have been reviewed and found to be normal/negative (RPR, Hepatitis B surface antigen, HIV and GBS).
- Infant blood work, such as blood type, Coombs, have been reviewed (as clinically indicated)
- Initial hepatitis B vaccine administered
- Newborn metabolic and hearing screens have been completed per state regulations.
- Mother is able to provide adequate newborn care upon discharge (including feeding, normal urination/stooling patterns, cord, skin, and genital care, able to identify signs of illness, identify jaundice, and understands basic infant safety (eg, car seat safety, supine positioning for sleep)
- Maternal social and environmental risk factors are assessed (substance abuse, homelessness, abuse or neglect, domestic violence, etc.)
- A medical home for the infant is established (infants discharged <48 hours of age will follow up within 48-72 hours of discharge).
- Any potential barriers to follow up have been identified and addressed (lack of transportation, no access to telephone services, language barriers, etc.)