INITIAL CARE OF THE WELL NEWBORN
In accordance with the American Heart Association (AHA) and the American Academy of Pediatrics (AAP), at least one person skilled in neonatal assessment and resuscitation should be available at every delivery to care for the newborn.
Every delivering physician should be familiar with the ini-tial assessment, resuscitation, and care of a newborn infant.
Immediately following delivery, the newborn infant should first be assessed to decide whether resuscitation is necessary. Four characteristics define a newborn who requires no additional resuscitation:
· A full-term infant
· Clear amniotic fluid with no evidence of meconium and infection
· Spontaneous breathing and crying
· Good muscle tone
In an effort to predict which newborns will require more intensive resuscitation, the gestational age should be esti-mated as accurately as possible prior to delivery. This allows the appropriate neonatal team to be present and prepared for resuscitation. It is also possible to assess the infant after delivery using the Ballard scoring system, which evaluates neuromuscular and physical maturity (Fig. 10.1).
The Apgar Scoring system is commonly used as an objective means to assess the newborn’s condition (Table 10.1). Five signs are given scores of 0, 1, or 2, for a total of up to 10. Scores are assigned at 1 and 5 minutes, and at every 5 minutes until 20 minutes thereafter, if the 5-minute Apgar score is less than 7. Although these continued assess-ments are not part of the original Apgar scoring system, many clinicians find them to be of value in evaluating how an infant is responding to resuscitation. An Apgar score of 7 to 10 is indicative of an infant who requires no active resuscitative intervention; a score of 4 to 7 is considered indicative of a mildly to moderately depressed infant; and a score of less than 4 is suggestive of a severely depressed infant who requires immediate resuscitative efforts.
The Apgar score should not be used to define birth asphyxia, because it is not designed to do so and, indeed, does not pro-vide such information.
Likewise, the Apgar score cannot be used to identify the causes of the newborn illness. In general, a low 1-minute Apgar score identifies the newborn who requires particu-lar attention. The 5-minute Apgar score can be used to evaluate the effectiveness of any resuscitative efforts that have been undertaken, or to identify an infant who needs more evaluation and management. It should not be used to predict neurologic outcome in term infants.
Basic routine care is necessary for all newborn infants, regardless of the need for resuscitative efforts. For infants who do not require resuscitation at birth, routine care is performed immediately following delivery.
First, the newborn infant is thoroughly dried to main-tain appropriate body temperature. Warm blankets, skin-to-skin contact with the mother, or a radiant warmer can all accomplish this task.
For healthy, vigorous, term neonates, skin-to-skin contact promotes maternal–infant bonding and initiation of breast-feeding in the first hour or life.
Premature infants have more difficulty maintaining their body temperature and are more susceptible to cold stress. These infants require warming pads, heated towels, and a preheated radiant warmer to stay warm.
Second, after the umbilical cord is clamped and cut, it is left exposed to air to facilitate drying and separation. Local application of antimicrobial agents (e.g., triple-dye, iodophor ointment, hexachlorophene powder) is com-mon. The umbilical cord loses its bluish-white appearance within the first 24 hours after delivery. After a few days, the blackened, dried stump sloughs, leaving a granulating wound. If cord blood banking has been requested, the sample should be obtained and stored at this time.
Another essential component of routine care is the assessment of vital signs. An infant’s temperature, heart and respiratory rate, core and peripheral color, level of alertness, tone, and activity should be monitored at deliv-ery and every 30 minutes thereafter until these measures are stable for at least 2 hours.
If the mother plans to breastfeed, the newborn should be placed at the breast in the delivery room within the first hour after delivery. In general, healthy neonates should remain with their mothers.