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Care of baby physical assessment

Immediate Care Of Baby After Delivery

Purpose

  • Ensure an airway and maintain respiration.
  • Care of Baby to prevent cold stress (hypothermia).
  • Provide a time for complete observation.
  • Stimulate circulation as adequate to maintain health.
  • Keep the skin of the baby clean and in good condition.

Scope

New born babies.

Definition-Care of Baby

Provide a baby soon after birth.  A detailed and systematic whole body examination of a stabilized newborn during the early hours of life.

Applicable Areas

Gyneac & Obstetric Department and NICU.

Responsibility

Consultant, Medical Officer, Staff Nurse, Auxillary Nurse Midwife and Head Nurse.

Equipment

  • Vacuum suction and sterile catheter and oxygen.
  • Cord ligature or clamp.
  • Warm sterile towel.
  • Sterile scissor and artery.
  • Rectal thermometer.
  • Cotton balls.
  • Spirit
  • Gauze
  • Birth record.
  • Eye drop if require.

Suctioning

  • Wash hands and wear gloves.
  • Receive newborn in warmed blanket or towel and place under radiant warmer.
  • Place newborn in trend Len burg position (extend head).
  • Do suction of oro-pharyngeal canal.
  • Oxygen may be given in care of baby.
  • Continue reinserting tube and provide suction as fluid is aspirated.
  • Avoid deep suction during early minute following delivery.
  • Do minimum naso-pharyngeal suctioning in care of baby.

General Physical Examination

  • Complete 1–minute Apgar score and complete the 5-minute Apgar score.
(Apgar Score Chart)
Mother’s Name : Date of Admission :
Time of delivery :  
Procedure Steps Zero 1 2 1 min 5 min.
Respiratory Effort Absent Slow irregular Good-cry
Heart Rate Absent Below 100 B/M Over 100 B/M
Muscle tone Flaccid Some Flexion of limbs Well flexed
Reflex No response Grimace Cough or sneeze
Colour Blue or pale Body pink, limbs blue All pink
Total
Apgar Score Risk :
1  –  4 H.R. High Risk
5  –  7 M.R. Moderate Risk
7  –  8 S.R. Small Risk
10 Normal

Vital signs

  • Apical pulse (Auscultate chest for heart beats with stethoscope for 1 min.) (put stethoscope under its nipple)

N.B. Temporal area is the most popular for new born.

  • Respiration – Observe respiratory movement rate, depth, pattern and sound and count the rate for one minute for care of baby.
  • Expiration – Count chest and abdominal movement with each inspiration.
  • Clinical / Rectal temperature
  • Shake down thermometer below 35O
  • Remove the new born towel.
  • Grasp the new born ankle firmly, placing your index finger between the ankle bones.
  • Place the bulb of the thermometer in the anus and hold it securely in place for a minute.
  • Remove thermometer, wipe it with a tissue/gauze and record the temperature.

Growth Measurement – include

  • Length
  • Weight
  • Head circumference
  • Chest circumference

Length

  • Remove the towel of the newborn.
  • Place the newborn in the supine position.
  • Grasp the knee together gently.
  • Push down on the knee until the legs are fully extended and hold the legs firmly.
  • Measure the length with a tape measure and record it.
  • Average length in cm.

Weight

  • Check to see that the scale is balanced by setting it at zero.
  • Place new born on the scale without cloth.
  • Keep hand over new born without touching in.
  • Average weight in Kg / gms.

Head circumference (at its great circumference)

Chest circumference

  • Place the tape across the nipple line.
  • Assess for any gross abnormalities, congenital defects in head, eyes, ears, chest, spine, face, nose, abdomen, anus, etc.

Cord Care

  • Wash hands before manipulating cord.
  • Use sterile plastic clamp about 2.5 cm from the abdomen.
  • Cut the cord by blunt sterile scissor after the clamp.
  • Examine umbilical cord structure.
  • Paint the end of the stump with alcohol.
  • Cover the cord with sterile gauze.

Eye Care

  • Wash hands.
  • Eye lids should be cleaned with sterile cotton ball moistened with sterile
  • Wipe from the nose outward.
  • Identification of the new born is made by labeling on wrist or ankle the mother’s name, hospital number, sex and weight of new born).
  • Wrap the baby and give to the mother.
  • Assist mother to breast feed, if she desires.
  • Complete charting, reporting and recording.
  • Replace equipment after use and care for it
g) NEUROLOGICAL REFLEXES :
Reflex Name Evoking Stimulus Response
Grasping reflex Finger placed in palm of hand. Infant’s fingers close around and grasp object.
Tonic neck reflex Head turned to one side while infant lies on back. Arm and leg are extended on the side, the infant faces.  Opposite arm and leg are flexed.
Abdominal reflex Tactile stimulation or tickling. Abdominal muscles contract.
Withdrawal reflex Slight pinprick to the sole of the infant’s foot. Leg flexes.
Walking reflex Infant supported in an upright position with feet lightly touching a flat surface. Rhythmic stepping movement.  Disappears at about 4 months of age.
Babinski reflex Gentle stroking on the sole of each foot. Fanning and extension of the toes (adults respond to this stimulation with the flexion of toes)
Plantar or toe-grasping reflex. Pressure applied with the finger against the balls of the infant’s feet. A plantar flexion of all toes.  Disappears by the end of the first year of life.
Blinking reflex Light flash Eyelids close.
Pupillary reflex Light flash Pupil constricts.
Sucking reflex Finger (or nipple) inserted into mouth. Rhythmic sucking occurs.
NEUROLOGICAL REFLEXES :
Reflex Name Evoking Stimulus Response
Rooting reflex Light touch of finger on check close to mouth. Head rotates towards stimulation; mouth opens and attempts to suck finger.  Disappears by about 4 months of age.
Moro reflex Infant lying on back: slightly raised head suddenly released, infant held horizontally, lowered quickly about 6 inch and stopped abruptly. Arms are extended, head is thrown back, fingers are spread wide, arms are then brought back to centre, convulsively with hands, clenched; spine and lower extremities are extended. Disappears by about 6 months of age.
Sterile reflex Loud noise Similar to Moro reflex, flexion in arms, fists are clenched.

Documentation

Nurse’s Observation Sheet