Word: Care for the Normal Newborn
Site ApplicabilityCare for the normal newborn occurs in the Maternal Newborn Program.Practice Level/CompetenciesBasic Skill – All Registered Nurses employed at BC Women’s Hospital Maternal Newborn Program are able to provide newborn assessment and care Policy Statement(s) The woman’s Physician/Registered Midwife arranges for the medical care of the newborn at a high risk vaginal delivery and a Cesarean Section.The Physician/ Registered Midwife examines a healthy newborn after one hour of birth.BC Women’s endorses Baby-Friendly Care as outlined in the Baby-Friendly Initiative.ProcedureAt Delivery (Vaginal birth or Caesarean birth) Wear clean gloves when handling a newborn.Delayed cord clamping occurs during all births:60 seconds or longer for vaginal birthsMinimum 30 seconds for caesarean birthsDry the newborn using a warm dry towel. Place babies in uninterrupted skin-to-skin contact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the mother wishes, unless there is a medical indication or informed parental preference to the contrary.‘Immediate’ means within the 1st 5 minutes; ‘uninterrupted’ includes separations under 5 minutes. This applies to both vaginal and C/S birth. Do not interrupt unnecessarily for routine care. Delay or separation may always occur for medical indications: Maternal Maternal history, condition or instability: e.g. pre-eclampsia, PPH, IDDM, GA, sedated, medications (MgSo4, antipsychotics, methadone, morphine, fentanyl), severe pain, fever, sepsis, vomiting, shaking and any other circumstance where mothers ability to hold infant safely is compromised. Newborn Respiratory depression, hypoventilation or apnea +/- bradycardia, respiratory distress/grunting, cyanosis etc.If the mother is unable, skin to skin contact may be with the partner/other family memberDetermine the Apgar Score Determine the Apgar score at: One minute and Five minutes of ageNote: If the five minute Apgar score is less than seven, the Physician/ Registered Midwife/Registered Nurse obtains additional scores every five minutes for up to twenty minutes, or until two successive scores are eight or more.Document the time the Physician/ Registered Midwife is notified of the request for medical care1.2Post Delivery AssessmentPerform routine vital signs with the newborn in skin to skin care The Physician/ Registered Midwife performs a complete newborn examination according to Newborn Record Part I Delay the complete newborn assessment o unless a medical indication for earlier assessment o unless parental request for earlier assessment o until completion of first feed OR for at least one hourAssess vital signs according to the Perinatal Services BC Newborn Pathway, unless it isIndicated/ordered that the newborn requires increased monitoringInform NEWBORN MRP of all pH results if <7.? MRP to request consult to Pediatrician to assessThe newborn with abnormal cord gas results Visual observation of newborn Perform a visual check of the newborn a minimum Q15 min for the first 2 hours of life, documenting respiratory effort, color, tone and safe positioning. Assessment 2.1TemperatureTake the newborn's temperature per axilla:Within 30 minutes of delivery andEvery hour for 3 hours andAt 6 hours of ageThen, assess every shiftNewborn Temperature should be within normal limits:oAxillary temperature of 36.5- to 37.4 CIf the temperature is not within normal limits, initiate interventions Put the baby skin to skin with one of the parentsConduct q 30 minute assessments until temperature is stable (greater than 36.5 C)OR place the baby under the radiant warmerRemain with infant under the warmer and conduct temperature assessments q 10-15 minutes. Temperature should increase and become stable (greater than 36.5 C) Perform a point of care blood glucose to evaluate for newborn hypoglycemia Inform physician/midwife if temperature is not within normal limits within one hour 2.2Vital SignsAssess and record the newborn's vital signs (including heart rate and respiratory rate), as per the Newborn Pathway Within 30 minutes of delivery andEvery hour for 3 hours and At 6 hours of age Then assess every shiftVital signs normal limits:Heart rate (100-160 bpm)Respiratory rate between 30-60/ minIf assessments are not within normal limitsinitiate neonatal resuscitation measures following current NRP guidelines ANDInform MRP 2.3Increased Monitoring Protocol (as prescribed by the Physician/ Registered Midwife on Newborn Admission Orders) The following are indications for need for increased monitoring of the newborn Forceps/vacuum delivery (as per Subgaleal Hemorrhage Policy) GBS positive motherMaternal fever in labourNewborn less than 37 weeks gestational agePost resuscitation defined asIPPV for 30 seconds or longerCPAP for 5 minutes or longerOxygen supplementation for 10 minutes or longerApgar less than 7 at five minutesRupture of Membranes (ROM) greater than 18 hours Mother currently taking Selective Serotonin or Norepinephrine Reuptake Inhibitors (SSRI’s or SNRI’s) Umbilical Artery pH less than or equal to 7.0Presence of significant fetal stress in labour Other indication as ordered by MRP Vital signs frequency for increased monitoring Q1H for 3 hthen at 6 h then Q4H up to 24 h2.4Head to Toe AssessmentConduct a head to toe assessment of the newborn while in skin to skin care including:Behavioural StateColourEase of respirations (i.e. retractions/grunting)Tone2.5Cord Clamp Registered Nurse/DelegateApply a sterile cord clamp and a sterile kelly forcep to the cord following birth.Cut the cord with sterile scissors to within 1 centimetre of the cord clamp. Ensure the cord clamp does not inadvertently pinch the skinAssess the cord for the presence of three vessels: 2 arteries and 1 vein No extra care is required for the umbilical cord, Dry the skin around the cord following the baby bath. Do not remove cord clamp prior to discharge, unless medically indicated or maternal request (See Cord Care: Postpartum Units WW.07.08)Intervention 3.0Newborn OrdersAdminister newborn medication orders as per the Newborn Admission Orders prior to the newborn transfer to the Antepartum/Postpartum Program or on Cedar Square Administer eye prophylaxis within one hour of birth OR Indicate the parent has “Declined” Administer Vitamin K in the LEFT thigh within 2 hours of birth Vitamin K is given intramuscularly using a 25 gauge needle (ideally while skin to skin and if possible breastfeeding). The usual dosage is 1 milligram. All medications administered to a newborn infant must be checked by two Registered Nurses prior to administration. Document newborn medication administration on the Newborn Medication Administration Record (MAR) and the Newborn Record Part 1. 3.1IdentificationIdentify the newborn using a three part bracelet identification system. All band inserts are hand written.Check the name, spelling and unit numbers with the woman prior to delivery. (See Newborn Identification – Antepartum/Postpartum/Birthing (WW.07.01A). The identification numbers on the three bracelets must match. Place two bracelets on the newborn: one on the left arm and one on the left leg. Place one bracelet on the mother’s arm.For closed adoptions: do not write the birth mother’s name on the newborn’s bracelets.(See Adoption Policy WW.07.18)3.2WeightWeigh all newbornsAt birth—following one hour of uninterrupted skin to skin care or at parent’s request Once daily and Within 12 hours of discharge, unless otherwise indicated. If weight loss is greater than 10%, inform care providerA feeding plan should be in place for all babies with concerns about weight loss Do not interrupt feeding to perform newborn weighing.3.3FeedingEnsure the mother is aware of the importance of skin-to- skin care regardless of feeding method.BreastfeedingSkin to skin care should be maintained and not interrupted until completion of the first feed. Encourage and assist the mother to identify feeding cues.Provide support, as required, to initiate feeding as soon as the newborn shows feeding cues. This is usually within the first hour after birth. Provide instructions to encourage the mother’s independence with feeding. Teach hand expression within the first 6 hours Assess feeding at least once a shift. More often if risk factors or difficulties occur. Refer to breastfeeding policies Bottle feedingEncourage and assist the mother to identify feeding cues.Provide assistance to initiate feeding using the appropriate amount of formula when thenewborn shows feeding cues. Ensure family has information about responsive feeding(safety, signs of satiation, etc) use, preparation and storage of formula Refer to Perinatal Services BC “ Informed Decision Making: Having Meaningful ConversationsRegarding Infant Feeding pamphlet Urine OutputAssessment of the newborn’s urine output occurs a minimum of once a shift.Notify the MRP if the newborn has not voided (HNV) within the first 24 hours3.4Universal Bilirubin Screening A serum Bilirubin test for universal bilirubin screening is collected at the same time as the Newborn Metabolic Screen. The newborn must be a minimum of 24 hours of age, It is recommended that newborns who are discharged prior to 24 hours have a serum bilirubin test done with the outpatient Newborn Metabolic Screen.For a newborn that is visibly jaundiced prior to 24 hours of age, the physician/registered midwife must be notified A bilirubin test should be performed at that time. 3.5Critical Congenital Heart Disease ScreeningAll newborns are assessed for the presence of Critical Congenital Heart Disease using the pulse oximeter to assess pre and post ductal saturation readings. Refer to Pulse Oximetry Screening for Critical Congenital Heart Disease (CCHD) policy on ePOPS.3.6Hypoglycemia Screening and Management All newborns are assessed for presence of hypoglycemia If the newborn shows clinical signs of Hypoglycemia, perform a blood sugar using point of care meter and call MRP for management Clinical Signs of Hypoglycemia*Temp <36.5 degrees (persistent- 2 or more readings 30 minutes apart)Jitteriness/tremorsCyanotic episodesConvulsionsApnea or periodic breathingTachypnea (>60 bpm at rest) Weak or high pitched cryLimpness or lethargy Difficulty feeding/weak suckEye rolling SweatingSudden PallorThe Most Responsible Provider assesses all newborns for the presence of risk factors for the presence of hypoglycemia and follow the Algorithm on the back of the Newborn Admission Orders Weight less than 10th percentile SGA – Small for gestational age infantsIntrauterine growth restrictionWeight over the 90th percentile LGA – Large for gestational age infantsInfants of mothers with diabetes Pre-term infants - less than 37 weeks gestational ageUA pH ≤7.0/ Perinatal asphyxia/ post-resuscitation (defined as)IPPV for 30 seconds or longerCPAP for 5 minutes or longerOxygen supplementation for 10 minutes or longerApgar less than 7 at five minutesInfants of mothers who are taking Beta-Blockers (eg. Metoprolol, Labetalol)Metabolic conditions (eg. CPT-1 deficiency)Syndromes associated with hypoglycaemia (eg. Beckwith-Wiedemann) 3.7Newborn Hearing Screening All newborns receive a Newborn Hearing Screening Assessment prior to dischargeThe test is performed by dedicated Hearing ScreenersIf a newborn is discharged prior to the hearing test being conducted, an outpatient follow up appointment is provided DocumentationPSBC Clinical Pathway NewbornInterprofessional NotesLabour and Birth SummaryNewborn Record Part I and IINewborn Admission Prescriber’s Orders Newborn Medication Administration Record (MAR) Patient & Family Engagement/EducationBaby’s Best Chance ()Low Blood Glucose in Newborn Babies ReferencesBreastfeeding Committee for Canada (2017) BFI Ten Steps and WHO Code Outcome Indicators 2017 of Breastfeeding Medicine ABM Clinical Protocol #22: Guidelines for Management of Jaundice in the Breastfeeding Infant 35 Weeks or More of Gestation—Revised 2017 Volume 12, Number 5, 2017 DOI: 10.1089/bfm.2017.29042.vjf Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks gestation. Pediatrics. 2011;128(4):e1046-e1052Barrington, K. J., & Sankaran, K. (Reaffirmed 2018). Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants Posted: Jun 1 2007 | Reaffirmed: Feb 28Canadian Paediatric Society, 12. Retrieved from Newborn Identification-Antepartum/Postpartum/ BirthingNational Institute for Health and Clinical Excellence. Jaundice in newborn babies under 28 days Clinical guideline [CG98] Published date: May 2010 Last updated: October 2016 , S., Hockenberry, M., Lowdermilk, D., Wilson, D, Keenan-Lindsay, L., & Sams, C. (2017). Maternal Child Nursing Care in Canada, 2nd Edition. Elsevier Canada.Perinatal Services BC. (2015).Newborn Guideline 13 Newborn Nursing Care Pathway Services BC (2017) Informed Decision Making: Having Meaningful Conversations Regarding Infant Feeding Health Organization, Family and Reproductive Health Division of Child Health and Development (1998). Evidence of the Ten Steps of Successful Breastfeeding. who.int/child-adolescent- health/publications/NUTRITION/who_CHD_98.9.htmDeveloped byBCW Maternal Newborn Program – Senior Practice LeaderVersion HistoryDATEDOCUMENT NUMBER and TITLEACTION TAKEN23-Jul-2019C-06-12-60331 Care for the Normal NewbornApproved at: Perinatal Best Practice Committee22-Dec-2020““DisclaimerThis document is intended for use?within?BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document.?This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.? ................
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