Apgar Scoring:

Sign 0 1 2

body pink
Appearance Pale extremities
Completely Pink
(color) blue blue
Accrocyanosis

Pulse Below above

Absent
(heart rate) < 100 bpm > 100 bpm

Grimace
Grimace cough or sneeze
(response to smell or No Response
pulls away
foot slap)

Activity Flaccid
limbs flexed active movement
(Muscle tone) limp

Respiration
Absent Slow, irregular good strong cry
(breathing)

7-10-indicates that the neonate is in good condition.

4-6- fair indicates that the neonate may have moderate central
nervous system depression muscle flaccidity cyanosis and
poor respiration.
0-3-danger, the neonate needs immediate resuscitation as
Neded.
 5 STEPS IN RECEIVING NEWBORN

1
PREVENT HEAT LOSS

Place on prewarm
crib/Radiant warmer

5 2
EVALUATE THE INFANT OPEN AIRWAY

-position the baby in

-Check the breathing trendelenburg.
-Heart rate -suction the mouth
-color then the nose.

4 3
INITIATIVE BREATHING PREVENT FURTHER HEAT LOSS

-Do the tactile -dry thoroughly

stimulation -Remove wet towel

ORGANIZATIONAL CHART
 OF WMMC

HOSPITAL DIRECTOR:
Dr. Mario Gemzon

ADMINISTRATOR:
Mr. Eric Casimiro

CHIEF NURSE:
Mrs. Maria Dolores Pacatang

Assistant Chief Nurse for Clinical Service:

Mr. Ramil Dagalea

Assistant Chief Nurse for Training Service:

Ms. Jocelyn Climaco

SUPERVISORS:

• Mrs. Abaño, Nur-Aynee

• Mrs. Madronal, Fredezwida
• Mrs. Ramos, Doris T.
• Mrs. Wahab, Lilia

NICU STAFF
( Neonatal Intensive care unit )

HEAD NURSE: Laping, Sheryll Ann C.

SN: Abdurasa, Ayeasha

Caliyo, Rosellia
PROB: Palaceos, Hazel
Toribio, Anna Rose
NA: Halili, Annabelie
Tenorio, Angelica
Partosa, Alice
VN: Delos Reyes, Floriz Mae
 Summary of the Pre-post Cord Care Procedures in
Neonatal Intensive Care Unit
(WMMC)

Preparatory phase:

HAND WASHING

NICU CRIB OR/DR CRIB

Materials Materials

1 crib cover 1 crib cover

1 mattress cover 1 mattress cover
2 blankets rolled both side 1 blanket in rect-
1 towel at the head part angular shape
2 towels hanging on the side 1 blanket for new
Of the crib born 1
blanket in triangular shape 4 towels (1 towel
1 baby dress on top of blanket to wrap the suc
1 towel in rectangular shape -bulb and 3
Botties, mittens. Cap towel for path
Dry the baby)
2 sterile gloves
(Different size)
1 kidney basin
1 medicine glass
w/ sterile water
1 NGT size 8
10 cc syringe

PREPARATORY CORD CARE SET

2 vials w/ 4 cotton balls each

1straight forceps
1 bottle soak w/ betadine
1 bottle soak w/ alcohol
 ADDITIONAL MATERIALS

1 rubber ligature
1 tape measure
1 rectal thermometer
1 scissor soak in metrixide solution

ROUTINE MEDICATION

Oxytetracycline (ophthalmic prophylaxis)

(To prevent gonorrhea & Chlamydia)
Phytomenadione/konakion (Vitamin K)
• 0.1ml in 1ml syringe-full term
• 0.05ml in 1ml syringe-preterm
Hepa B vaccine (IM vastus lateralis)

5 STEPS IN RECEIVING NEW BORN

1. Prevent heat loss - because the infant

Cannot adapt the
Environment.
-to prevent hypothermia
2. Open airway - position the baby in
Trendelenburg.
- suction the mouth
Then the nose. Infant
Are nose breather.
3. Prevent further heat loss - dry the infant tho-
Roughly and re-
Move wet towel.
4. Initiative breathing - do the tactile
Stimulation
- top the sole of the
Infant.
5. Evaluate the infant - check the breathing
- Heart rate
- Color
 Receiving New Born from OR/DR to NICU

>Take note the time when the baby is outside the womb.
> then observed five step in receiving Newborn’s infant
>When the baby stabilized, transfer to the admission to the NICU.
>Then take note the time of admission.
>When the baby comes inside the NICU, put aside NICU crib.
>Dry the sole of baby’s foot (left & right foot)
>After drying, stamp w/ stamp pad on.
>Stamp the left foot at the back of the physicians appraisal of the
Newborn infant as well as the right foot.
>proceed to cord care procedure.
>Open cord care set.
>get 2 cotton balls w/ betadine and 2 cotton balls w/ alcohol.
>Stroke from tip down to the base in circular motion.
>discard used cotton ball on the trash can.
>After cleaning of 2 cotton balls, get the rubber ligature and insert
The forceps faces upward.
>Clamp the cord 1-2 inches above the base.
>Then get the scissors from metrixides solution then rinse it w/ sterile
Water.
>cut just above were the rubber ligature is being place
>After cutting, pull the black thread & secure it properly to the cord
Then release the clamp.
>After that clean w/ 1 cotton ball of betadine (in circular motion) then
discard it
>Then clean w/ 1 cotton ball w/alcohol then discard it
>get towel & soak it w/ lactacyd.
>Clean face, then head, neck, chest, and axilla, inguinal and lower
Extremities then back.
 New Born Bath

- check temperature of water thru elbow(lukewarm)

- hold baby in foot ball position
- close baby’s ear w/ fingers
- pour water on face, head, allow the Newborn infant to sit on the basin
- turn the baby towards you
- turn and rest on your wrist use 4 fingers holding the axillary’s part & back
- place the newborn infant OR/DR crib
- reverse the blanket to dry or clean part
- using the same crib and dry the baby thoroughly
- suction the baby if there’s a secretion
- check for patency of the anus at the same time check the temperature
- after checking the potency measure:
a) Head circumference-lift the head to locate occipital
Area above eyebrow using cm.
b) Chest circumference-nipple line
c) abdominal-above the umbilicus
d) Length-from the crown down to the heel following
Shape of baby or contour
- weighing of baby scale is zero
- take out the OR/DR crib, replace the NICU crib
- after weighing put it on the NICU crib, clean w/ 1 cotton ball
Of betadine + 1 cotton ball of alcohol
- dressed up the new born infant, put on diaper, mittens, botties,
Cap and the name tag at the left foot
- apply teramycin to both eye from inner to outer canthus
- Vitamin k in vastus lateralis, upper outer thigh IM
- Then take note the time when giving medication
- Properly wrap the baby
- Position the newborn in trendelenburg position(to promote drainage
secretion)
- Check drop light is still on
- Take initial vital sign(RR, HR only)
- Record the vital sign on TPR sheet
- All pertinent data should should be recorded on the newborn’s record
- Before and after hand washing
 Adaptation to extra uterine life

At the end of pregnancy, the fetus must take the journey of childbirth to leave the reproductive female
mother. Upon its entry to the air-breathing world, the newborn must begin to adjust to life outside the
uterus.

Breathing and circulation

Perfusing its body by breathing independently instead of utilizing placental oxygen is the first
challenge of a newborn. With the first breaths, there is a fall in pulmonary vascular resistance, and an
increase in the surface area available for gas exchange. At the same time that the pulmonary vascular
resistance drops there is a corresponding increase in systemic vascular resistance (total peripheral
resistance) due to the loss of the low-resistance placental circulation. These two changes result in a
rapid redirection of blood flow into the pulmonary vascular bed, from approximately 4% to 100% of
cardiac output. This in turn leads to an increase in oxygenation of the blood. The increase in pulmonary
venous return results in left atrial pressure being slightly higher than right atrial pressure, which closes
the foramen ovale. The flow pattern changes results in a drop in blood flow across the ductus
arteriosus and the higher blood oxygen content stimulates the constriction and ultimately the closure of
this fetal circulatory shunt.

All of these cardiovascular system changes result in the adaptation from fetal circulation patterns to an
adult circulation pattern. During this transition, some types of congenital heart disease that were not
symptomatic in utero during fetal circulation will present with cyanosis or C signs.

Following birth, the expression and re-uptake of surfactant, which begins to be produced by the fetus at
20 weeks gestation, is accelerated. Expression of surfactant into the alveoli is necessary to prevent
alveolar closure (atelectasis). At this point, rhythmic breathing movements also commence. If there are
any problems with breathing, management can include stimulation, bag and mask ventilation,
intubation and ventilation. Cardiorespiratory monitoring is essential to keeping track of potential
problems. Pharmacological therapy such as caffeine can also be given to increase heart rate. A positive
airway pressure should be maintained, and neonatal sepsis must be ruled out.C

Potential neonatal respiratory problems include apnea, transient tachypnea of the newborn (TTNB),
respiratory distress syndrome (RDS), meconium aspiration syndrome (MAS), airway obstruction, and
pneumonia.

Energy metabolism
Energy metabolism in the fetus must be converted from a continuous placental supply of glucose to
intermittent feeding. While the fetus is dependent on maternal glucose as the main source of energy, it
can use lactate, free-fatty acids, and ketone bodies under some conditions. Plasma glucose is
maintained by glycogenolysis.

Glycogen synthesis in the liver and muscle begins in the late second trimester of pregnancy, and
storage is completed in the third trimester. Glycogen stores are maximal at term, but even then, the
fetus only has enough glycogen available to meet energy needs for 8-10 hours, which can be depleted
even more quickly if demand is high. Newborns will then rely on gluconeogenesis for energy, which
requires integration, and is normal at 2-4 days of life.

Fat stores are the largest storage source of energy. At 27 weeks gestation, only 1% of a fetus' body
weight is fat. At 40 weeks, that number increases to 16%.
Inadequate available glucose substrate can lead to hypoglycemia, fetal growth restriction, preterm
delivery, or other problems. Similarly, excess substrate can lead to problems, such as infant of a
diabetic mother (IDM), hypothermia or neonatal sepsis.

Anticipating potential problems is the key to managing most neonatal problems of energy metabolism.
For example, early feeding in the delivery room or as soon as possible may prevent hypoglycemia. If
the blood glucose is still low, then an intravenous (IV) bolus of glucose may be delivered, with
continuous infusion if necessary. Rarely, steroids or glucagon may have to be employed.

Temperature regulation
Newborns come from a warm environment to the cold and fluctuating temperatures of this world. They
are naked, wet, and have a large surface area to mass ratio, with variable amounts of insulation, limited
metabolic reserves, and a decreased ability to shiver. Physiologic mechanisms for preserving core
temperature include vasoconstriction (decrease blood flow to the skin), maintaining the fetal position
(decrease the surface area exposed to the environment), jittery large muscle activity (generate muscular
heat), and "non-shivering thermogenesis". The latter occurs in "brown fat" which is specialized adipose
tissue with a high concentration of mitochondria designed to rapidly oxidize fatty acids in order to
generate metabolic heat. The newborn capacity to maintain these mechanisms is limited, especially in
premature infants. As such, it is not surprising that some newborns may have problems regulating their
temperature. As early as the 1880s, infant incubators were used to help newborns maintain warmth,
with humidified incubators being used.

Basic techniques for keeping newborns warm include keeping them dry, wrapping them in blankets,
giving them hats and clothing, or increasing the ambient temperature. More advanced techniques
include incubators (at 36.5°C), humidity, heat shields, thermal blankets, double-walled incubators, and
radiant warmers.
 Assessment
of the Newborn

Vital Signs:

Temperature - range 36.5 to 37 axillary

Common variations:
 Crying may elevate temperature
 Stabilizes in 8 to 10 hours after delivery

Heart rate - range 120 to 160 beats per minute

Common variations:
 Heart rate range to 100 when sleeping to 180 when crying
 Color pink with acrocyanosis
 Heart rate may be irregular with crying

Respiration - range 30 to 60 breaths per minute

Common variations:
 Bilateral bronchial breath sounds
 Moist breath sounds may be present shortly after birth

Blood pressure - not done routinely

Factors to consider:
 Varies with change in activity level
 Appropriate cuff size important for accurate reading
 Average newborn (1 to 3 days) oscillometry pressure value: 65/41 in both upper and lower
extremities

Anthropometric Measurements:

Head circumference - 33 to 35 cm

Chest circumference - 30.5 to 33 cm

Common variations:
 Molding of head may result in a lower head circumference measurement
 Head and chest circumference may be equal for the first 24 to 48 hours of life

Weight range - 2500 - 4000gms (5 lbs. 8oz. - 8 lbs. 13 oz.)

Length range - 48 to 53cms (19 - 21 inches)

Skin:

Expected findings:
 Skin reddish in color, smooth and puffy at birth
 At 24 - 36 hours of age, skin flaky, dry and pink in color
 Edema around eyes, feet, and genitals
 Vernix caseosa
 Lanugo
  Turgor good with quick recoil
 Hair silky and soft with individual strands
 Nipples present and in expected locations
 Cord with one vein and two arteries
 Cord clamp tight and cord drying
 Nails to end of fingers and often extend slightly beyond

• Acrocyanosis - result of sluggish peripheral circulation

• Mongolian spots in infants of African-American descent
• Petechiae/ bruises over presenting part
• Skin tags usually around ears or digits (tied off)
• Harlequin color change

Head:

Expected findings:

 Anterior fontanel diamond shaped 2-3 - 3-4 cms

 Posterior fontanel triangular 0.5 - 1 cm
 Fontanels soft, firm and flat
 Sutures palpable with small separation between each

Eyes:
Expected Findings:

 Slate gray or blue eye color

 Fixation at times
 Red reflex
 Blink reflex
 Distinct eyebrow
 Pupils equal and reactive to light

Ears:

Expected findings:

 Pinna top on horizontal line with outer canthus of eye

 loud noise elicits Startle Reflex
 Flexible pinna with cartilage present

Nose:

Expected findings

 Nostrils patent bilaterally

 Obligate nose breathers
 No nasal discharge

Mouth and Throat:

Expected findings

 Mucosa moist. Shortly after birth may visualize sucking calluses on central portions of lips.
 Palate high arched
 Uvula midline
  Minimal or absent salivation
 Tongue moves freely and does not protrude
 Well developed fat pads bilateral cheeks
 Sucking reflex
 Rooting reflex
 Gag reflex
 Extrusion reflex

Neck:

Expected findings:

 Short and thick

 Turns easily side to side
 Clavicles intact
 Tonic neck reflex present
 Neck-righting reflex present
 Some head control

Chest:

Expected findings;

 Evident xiphoid process

 Equal anteroposterior and lateral diameter
 Bilateral synchronous chest movement
 Symmetrical nipples

Abdomen:

Expected findings:

 Dome-shaped abdomen
 Abdominal respirations
 Soft to palpation
 Well formed umbilical cord
 Three vessels in cord
 Cord dry at base
 Liver papable 2 - 3 cms below right costal margin
 Bilaterally equal femoral pulses
 Bowel sounds auscultated within two hours of birth
 Voiding within 24 hours of birth
 Meconium within 24 - 48 hours of birth

Female Genitalia:

Expected findings:

 Edematous labia and clitoris

 Labia majora are larger and surrounding labia minora
 Vernix between labia

Male Genitalia:

Expected findings

 Urinary meatus at tip of glans penis

  Palpable testes in scrotum
 Large, edematous, pendulous scrotum, with rugae
 Smegma beneath prepuce
 Stream adequate on voiding

Back and Rectum:

Expected findings:

 Intact spine without masses or openings

 Trunk incurvature reflex
 Patent anal opening
 "Wink reflex" present

Extremities:

Expected findings:

 Maintains posture of flexion

 Equal and bilateral movement and tone
 Full range of motion all joints
 Ten fingers and ten toes
 Legs appear bowed
 Feet appear flat
 Palmar creases present
 Sole creases present
 Negative hip click
 Grasp reflex present
 NORMAL NEWBORN VITAL SIGN
HEART RATE: 120-160 beats/minute
RESPIRATORY RATE: 30-80 breads/minutes
TEMPERATURE: 37.2 C (99 F)
BLOOD PRESSURE: 60/40-80/50 mmhg

ANTHROPOMETRIC MEASUREMENT
HEAD CIRCUMFERENCE- 33-35cm
CHEST CIRCUMFERENCE-30-33cm
ABDOMINAL CIRCUMFERENCE-31-33cm
LENGTH-46-45
WEIGHT-2400-4000