Assessment and Management of the Newborn
I Clinical Evaluation of the Newborn (Table 26-1)
TABLE 26-1
Normal Vital Signs of the Newborn
| Range | Term | Preterm | |
| Respiratory rate, breaths/min | 30 to 60 | Close to 30 | Close to 60 |
| Heart rate, beats/min | 110 to 160 | Close to 110 | Close to 160 |
| Blood pressure, mm Hg | 50/35 to 65/40 | 65/40 | 50/35 |
| Temperature, °C | 36.5 to 37 | 36.5 to 37 | 36.5 to 37 |
1. Normal rate: 30 to 60 breaths/min
2. Determined when newborn is not crying.
3. Fluctuation of the respiratory rate is normal.
4. Respirations are not necessarily regular.
5. Preterm infants display more erratic respiratory patterns than term infants.
1. Defined as respiration interrupted by short periods of apnea.
2. Apnea can last as long as 10 seconds.
3. Not associated with other abnormalities such as cyanosis or bradycardia.
4. Periodic breathing is common in preterm infants.
5. Usually does not require treatment, but close monitoring is important.
6. Little chest wall movement is observed.
7. An accurate respiratory rate must be counted for 1 full minute.
1. Often seen in premature newborns weighing <1500 g, with respiratory rates <30 breaths/min.
2. May be accompanied by bradycardia, cyanosis, or both.
3. Newborns may respond to gentle shaking or rubbing, or respirations may return spontaneously.
4. Primary apnea may occur immediately after birth; usually associated with bradycardia.
5. Newborns with primary apnea will resume breathing with stimulation.
6. Newborns with secondary apnea do not resume breathing on their own.
7. Heart rate, blood pressure, and Pao2 level decrease during apnea.
1. Heart rate in the newborn is generally determined by auscultation.
2. It can also be determined by tightly compressing the umbilicus with the index finger and thumb proximal to the abdomen.
3. Heart rate is usually higher in preterm infants than in term infants.
4. Normal heart rate fluctuates between 110 and 160 beats/min.
5. Bradycardia is usually secondary to significant apnea.
6. Palpation of the apical pulse is an important indicator of cardiac status.
7. Palpation of the apical pulse is used to locate the position of the heart.
8. Normally felt at the fifth intercostal space in the midclavicular line.
9. Peripheral pulses are found by palpating the brachial, radial, and femoral arteries.
1. Usually measured with a Doppler apparatus and a blood pressure cuff.
2. Blood pressure cuff must be of appropriate size for an infant to obtain an accurate pressure.
3. A cuff ≤1-inch width is used, although larger infants may require a larger cuff.
4. Blood pressure is usually obtained from the leg with the cuff around the thigh, although it may be obtained from the arm.
5. Low birth weight infants’ blood pressure averages 50/35 mm Hg.
6. Infants with birth weights >2000 g have an average blood pressure of 60/35 mm Hg.
7. Infants with birth weights >3000 g have an average blood pressure of 65/40 mm Hg.
8. Peripheral pulses are an important and a quick indicator of blood pressure.
9. Weak peripheral pulses commonly indicate a hypotensive state.
1. An infant’s temperature is usually taken in the axilla or obtained via a probe placed on the infant’s skin.
2. Infant temperature is a vital component in maintaining acid-base status.
3. Maintaining thermoregulation is critical to transition after birth, more so in preterm infants than in term infants.
4. Infant temperatures usually are maintained at 36.5° C to minimize oxygen consumption and prevent acidosis.
II Signs of Respiratory Distress
1. In the newborn defined as a respiratory rate >60 breaths/min.
2. Normal fluctuations in respiratory rate in the newborn can make initial assessment difficult.
3. Close observation and accurate count of respiratory rate for a full minute are needed to quantify the need for further intervention.
1. Cyanosis, or bluish discoloration, may be localized or generalized.
2. Generalized cyanosis usually indicates a more serious problem.
3. A well-lighted environment is essential for evaluation of cyanosis.
4. Central cyanosis, involving the mucous membranes, indicates presence of excessive amounts of desaturated hemoglobin.
5. Peripheral cyanosis (acrocyanosis) of the hands and feet is common in newborns and usually dissipates several hours after birth.
6. Central cyanosis usually indicates an arterial oxygen tension of <40 mm Hg.
7. Oxygen therapy usually required but may be contraindicated if a cardiac diagnosis is made.
8. Cyanosis is more difficult to assess in nonwhite infants.
1. Involves flaring of the nostrils (alae nasi) during inspiration.
2. Believed to be a sign of air hunger.
3. The greater the negative intrathoracic pressure that must be generated to move air, the greater the degree of flaring.
1. Is common in the infant with hyaline membrane disease.
2. May also be seen with other disorders.
3. Is presumed to be an attempt by the neonate to maintain positive pressure on expiration and prevent alveolar collapse.
4. Grunting results from exhalation against a partially closed glottis.
5. Is an obvious sound and usually heard without the aid of a stethoscope.
1. Retractions involve inward movement of the chest wall.
2. May occur between the ribs (intercostal), above the clavicles (supraclavicular), or below the rib margins (subcostal).
3. Retractions may also occur at the top (suprasternal) or the bottom (xiphoid) margins of the sternum.
4. Retractions may occur in any age group but are more common in the newborn because of the high compliance of the chest wall.
5. Retractions become more obvious and widespread as respiratory distress worsens.
6. As the infant forcefully contracts the diaphragm in an attempt to move air, the abdomen protrudes.
7. This increased negative pressure results in the entire anterior chest wall and sternum moving inward, producing a characteristic “seesaw” or paradoxical respiratory pattern.
TABLE 26-2
| Score | |||
| Sign | 0 | 1 | 2 |
| Heart rate (beats/min) | Absent | <100 | >100 |
| Respiratory effort | Absent | Weak, irregular | Good, crying |
| Muscle tone | Flaccid | Some flexion of extremities | Well flexed |
| Reflex irritability | No response | Grimace | Cough or sneeze |
| Color | Blue, pale | Body pink, extremities blue | Completely pink |
A Evaluation of the newborn begins as soon as the infant is delivered at 1- and 5-minute intervals.
B Standard care procedures are performed, including bulb suction of the upper airway, drying and warming of the infant, and cutting and clamping of the cord.
C A preliminary assessment is done during this time.
D The evaluation uses five factors.
E The infant is given a score of 0, 1, or 2 in all categories.
F The 1-minute score is especially useful to identify the infant who needs immediate intervention.
1. An Apgar score of ≤2 indicates a severely depressed infant who requires immediate resuscitation.
2. Ventilatory assistance will be necessary.
3. If the score is between 3 and 6 the infant may need some assistance, usually more vigorous stimulation and oxygen.
4. Infants with scores of ≥7 are considered stable and require only routine care and close observation.
5. The 5-minute score is useful to assess recovery from depression and the effectiveness of any previous interventions.
6. If the infant remains depressed at 5 minutes, with a score of ≤6, concern regarding cardiopulmonary status should be exercised, and the infant should be placed under special care.
7. These infants are at high risk for further postpartum complications:
8. An Apgar score at 5 minutes of ≤7 will require another Apgar assessment at 10 minutes.
A The appropriate size mask and anesthesia (flow-inflating) bag should be used.
B The jaw is moved upward and away from the neck by placing a towel under the shoulders (if time allows).
C Ensure proper seal with mask over the infant’s nose and mouth.
D An airtight seal between the rim of the mask and the face is essential to achieve effective positive-pressure ventilation of the lungs.
E An orogastric tube may be needed to aspirate air from the stomach.
F Effective ventilation is present when:
1. Breath sounds are heard bilaterally.
2. Heart rate increases to >100 beats/min.
G If no improvement after 30 seconds:
H If inadequate response to these maneuvers, prepare to intubate.
A Intubation should be performed when:
B Estimation of endotracheal tube (ETT) sizes
1. Weight and tube size indicated.
2. Neonatal airways do not contain cuffs.
3. Proper placement of ETTs can be assessed by:
4. ETTs should be securely taped after intubation.
5. Appropriate ventilation, FIO2, and humidification should be provided.
B After obtaining equipment, suction the upper airway.
C Preoxygenate with resuscitation bag to maintain an oxygen saturation of 100%.
D Position infant properly with towel if necessary under the shoulders.
E It is important to properly align infant so that the pharynx and trachea are in the midline position.
F Insert appropriately sized blade, and visualize vocal cords.
G Insert appropriately sized ETT through vocal cords into trachea.
H After placement ventilate with pressures of 20 to 25 cm H2O.
I Evaluate position of tube by visualizing chest wall movement and auscultating with a stethoscope.
J Note centimeter mark at upper lip, and secure tube with proper tape.
K Obtain a chest radiograph to confirm correct ETT position.
L If intubation is unsuccessful after 30 seconds and heart rate decreases to <100 beats/min, reestablish oxygenation with bag/mask ventilation.
