Healthy newborns should with

their mother

immediate initiation of breast-

feeding and early bonding.

Avoid separation of mother and

infant.
A. Criteria for admission is a well-appearing
infant of at least 35 weeks gestational age,

B. Impeccable security in the nursery :

- protect the safety of families
- prevent the abduction of newborns.
ex :
- identification bands
- transport of infants between areas
should not occur if identification
banding has not been done.
 II. TRANSITIONAL CARE

A. The transitional period : first 4 to 6 hours after birth.

- the infant's pulmonary vascular resistance ↓,
- blood flow to the lungs is greatly increased
- overall oxygenation and perfusion improve, and
the ductus arteriosus begins to constrict or close.
B. Interruption of normal transitioning, usually due to
complications occurring in the peripartum period,
will cause signs of distress in the newborn.
C. Common signs of disordered transitioning are (i)
respiratory distress, (ii) poor perfusion with
cyanosis or pallor, or (iii) need for supplemental
oxygen.
D. Transitional care of the newborn can take place in
the mother's room or in the nursery.
1. Evaluated for problems that may disqualify
their admission to the normal nursery, such as
gross malformations and disorders of
transition.
2. Evaluated every 30 to 60 minutes during this period
: heart rate, respiratory rate, and axillaris
temperature; assessment of color and tone; and
signs of withdrawal from maternal medications.
3. When disordered transitioning is suspected, a
hemodynamic ally stable infant can be observed
closely in the nursery setting for a brief period of
time. Infants with persistent signs of disordered
transitioning require transfer to a higher level of
care.
A. Healthy newborns should be with their mothers
all or nearly all the time.
When possible, physical assessments,
administration of medications, and bathing
should occur in the mother's room.
Nursing ratio of 1:6-8
1. Assessment of gestational age ( new Ballard
score).
2. The infant's weight, frontal-occipital
circumference (FOC), and length arc-recorded.
B. The infant's temperature is stabilized with one of
three possible modalities:
1. Open radiant warmer on servo control.
2. Incubator on servo control.
3. Skin-to-skin contact with the mother.
C. Universal precautions should be used with all
patient contact.
D. The first bath : non medicated soap and warm tap
water (note: axillary temperature >36,5°C )
E. umbilical cord care . Keeping the cord dry promotes
earlier detachment of the umbilical stump.
A. Prophylaxis against gonococcal ophthalmia
neonatorum within 1 hour of birth, Prophylaxis is
administered as single ribbon tetracycline ointment
1% of bilaterally in the conjunctiva sac
B. A single, intramuscular dose of 0.5 to 1 mg of
vitamin K 1 oxide (phytonadione) before 6 hours 
prevent vitamin K deficient bleeding (VKDB).

C. The first dose of preservative-free hepatitis B

vaccine
Hepatitis B vaccine is administered by 12 hours of
age when the maternal Hep BsAg is positive or
unknown. Infants of Hep BsAg positive mothers
also require hepatitis B immune globulin
 V. SCREENING
A. Prenatal screening test results should be reviewed
and documented on the infant's chart at the time of
delivery.
Maternal prenatal screening tests typically include
the following:
1. Blood type, Rh, antibody screen.
2. Hemoglobin or hematocrit.
3. Rubella antibody.
4. Hepatitis B surface antigen.
5. Serologic test for syphilis (Venereal Disease
Research Laboratory [VDRL] or rapid plasmin
regain [RPR]).
6. Human immunodeficiency virus (HIV).
7. Gonorrhea and Chlamydia cultures.
8. Serum a-fetoprotein/triple panel.
9. Glucose tolerance test.
10. Group B streptococcus (GBS) culture.
B. Cord blood is saved up to 14-21 days, depending on
blood bank policy.
1. A blood type and direct Coombs should be
performed on any infant born to a mother who is
Rh-negative, has a positive antibody screen, or
who has had a previous infant with Coombs
positive hemolytic anemia.
2. A blood type and direct Coombs should be
obtained on any infant if jaundice is noted within
the first 24 hours of age or there is unexplained
hyperbilirubinemia (see Chap. 18).
C. Newborn metabolic screen
1. All 50 states and the District of Columbia
universally screen for four core metabolic
conditions including congenital hypothyroidism,
phenylketonuria, galactosemia, and
hemoglobinopathies.
2. Newborn screening programs vary considerably
among states. The National Newborn Screening
and Genetics Resource Center (http://genes-r-
us.uthscsa .edu/) lists currently screened
conditions, by state.
3. Routine collection of the specimen is between
24 and 72 hours of life. In some states, a second
screen is routinely performed at 2 weeks of age.
D. Group B streptococcal disease
1. All newborns should be screened for the risk of
perinatally acquired GBS disease as outlined by
the Centers for Disease Control
(http//www.cdc.gov/groupbstrep/
hospitals/hospitals-guidelines-Summary.htm).
2. Penicillin is the preferred intrapartum
chemotherapeutic agent. Intravenous
administration to the mother at >4 hours or
earlier before delivery provides adequate
neonatal prophylaxis.
3. Newborns should be managed according to the
management algorithm
E. Glucose screening
1. Infants should be fed early and frequently to
prevent hypoglycemia.
2. Infants of diabetic mothers ,SGA and LGA infants
should be screened for hypoglycemia in the
immediate neonatal period .

F. Bilirubin screening
1. Before discharge, all newborns should be
screened for the risk of subsequent, significant
hyperbilirubinemia.
2. Provide parents with verbal and written information
about newborn jaundice.

G. Routine hearing screen for congenital hearing loss

is mandated in most states .
Verbal and written documentation of the hearing
screen results should be provided to the parents
with referral information if needed.
A. The infant's physician should perform a complete
physical examination within 24 hours of birth.
B. Vital signs, including respiratory rate, heart rate,
and axillary temperature are recorded every 8 to 12
hours.
C. Each urine and stool output is recorded in the
baby's chart. The first urination should occur by 30
hours of life. The first passage of me conium is
expected by 48 hours of life. Delayed urination or
stooling is cause for concern and must be
investigated.
D. Daily weights are recorded in the infant's chart.
Weight loss in excess of 7% is cause for concern and
must be investigated. Excessive weight loss is
usually due to insufficient caloric intake. If caloric
intake is thought to be adequate, organic etiologies
should be considered, that is, metabolic disorders,
infection, or hypothyroidism.
 VII. FAMILY AND SOCIAL ISSUES

A. Sibling visitation is encouraged and is an important

element of family-focused care. However, siblings
with fever, signs of acute respiratory or
gastrointestinal illness, or a history of recent
exposure to communicable diseases, such as
chicken pox, are discouraged from visiting.
B. Social service involvement is helpful in
circumstances such as teenage mothers; lack of, or
limited, prenatal care; history of domestic violence;
maternal substance abuse; history of previous
involvement with Child Protective Services, or
similar agency.
The frequency, duration, and volume of each feed will
depend on whether the infant is breast-feeding or
bottle-feeding.
A. The breast-fed infant should feed as soon as
possible after delivery, preferably in the delivery
room and feed 8 to 12 times/day.
Consultation with a lactation specialist during the
postpartum hospitalization is strongly
recommended for all breast-feeding mothers
 IX. NEWBORN CIRCUMCISION

A. The American Academy of Pediatrics (AAP) states that

scientific evidence exists that demonstrates potential
medical benefits of newborn male circumcision; how-
ever, these data are not sufficient to recommend
routine neonatal circumcision. Potential benefits are
decreased incidence of :
- urinary tract infection ,
- development of squamous cell carcinoma
- acquiring sexually transmitted diseases particularly
HIV infection.
B. Informed consent is obtained before performing the
procedure. The potential risks and benefits of the
procedure are explained to the parents.
1. The overall complication rate for newborn
circumcision is approximately 0.5%.
2. The most common complication is bleeding
(~0.1%) followed by infection. A family history of
bleeding disorders, such as hemophilia or von
Will brand disease, needs to be explored with
the parents when consent is obtained.
Appropriate testing to exclude a bleeding
disorder must be done before the procedure if
the family history is positive.
3. The parents should understand newborn
circumcision is an elective procedure; the decision
to have their son circumcised is voluntary and not
medically necessary.
4. Contraindications to circumcision in the newborn
period include the following:
a. Sick or unstable clinical status.
b. Diagnosis of a congenital bleeding disorder.
Circumcision can be performed if the infant
receives appropriate medical therapy before the
procedure (i.e., infusion of factor VIII, or IX).
 c. Inconspicuous or "buried" penis.
d. Anomalies of the penis, including hypospadias,
ambiguity, chordae, or micropenis.
e. Circumcision should be delayed in infants with
bilateral cryptorchidism.
C. Adequate analgesia must be provided for neonatal
circumcision. Acceptable methods of analgesia are
dorsal penile nerve block, subcutaneous ring block,
and eutectic mixture of local anesthetics (EMLA
ccream): 2.5% prilocaine and 2.5% lidocaine.
D. In addition to analgesia, other methods of comfort
are provided to the infant during circumcision.
1. Twenty-four percent sucrose on a pacifier, per
nursery protocol, should be given to all infants
as an adjunct to analgesia.
2. The infant's upper extremities should be
swaddled, and the infant placed on a padded
circumcision board with restraints on the lower
extremities only.
 3. Administration of acetaminophen before the
procedure is not an effective adjunct to
analgesia.
E. Circumcision in the newborn can be performed
using one of three different methods:
1. Gomco clamp.
2. Mogen clamp.
3. Plastibell device.
F. Oral or written instructions explaining post
circumcision care should be given to all parents
A. Parental education on routine newborn
care should be initiated at birth and
continued until discharge. Written
information in addition to verbal instruction
may be helpful and in some cases it is
mandated. A review of the following
newborn issues should be done at
discharge:
1. Observation for neonatal jaundice.
2. Routine cord and skin care.
3. Routine postcircumcision care (when
indicated).
4. Back to sleep positioning.
5. Subtle signs of infant illness including
fever, irritability, lethargy, or a poor
feeding pattern.
6. Adequacy of oral intake, particularly for
breast-fed infants (see Chap. 11). This
includes minimum of eight feeds per day;
one wet diaper per day of age, constant at
the sixth day of life; two stools in a 24-hour
period.
7. Appropriate installation and use of an
infant car seat.
8. Smoke detectors.
9. Lowering of hot water temperature.
10. Avoidance of second-hand smoke
B. The discharge examination is reviewed in Chapter
3.
C. Discharge readiness
1. Each mother-infant dyad should be evaluated
individually to determine the optimal time of
discharge.
2. The AAP recommends that minimum discharge
criteria be met before any newborn is
discharged from the hospital. It is unlikely that
fulfillment of these criteria can be
accomplished with a postnatal stay of <48
hours.
3. Discharge before 48 hours of age should be
limited to infants who are of singleton birth, at
least 38 weeks' gestational age, and who have a
birth weight that is appropriate for gestational
age
Early discharge criteria include the following:
a. Uncomplicated ante partum,
intrapartum, and postpartum courses
for both mother and infant.
b. Vaginal delivery.
c. Normal, stable vital signs in an open
crib for at least 12 hours preceding
discharge.
d. Passage of first urine and stool.
e. Completion of at least two successful
feedings.
f. Unremarkable physical examination,
absence of abnormalities that would
require continued hospitalization.
g. Assessment of risk for hyperbilirubinemia.
h. Maternal competence in routine newborn
care.
i. Assessment of maternal support.
j. Assessment of family, environmental, and
social risk factors.
k. Review of maternal and infant blood tests.
l. Administration of initial hepatitis B vaccine.
m. Completion of hearing and metabolic screen
per state regulations.
n. No excessive bleeding at the circumcision
site for at least two hours
o. Definitive follow-up arrangements for both
mother and infant
A. For newborns discharged within 48 hours
after delivery, outpatient follow-up should
be within 48 hours of discharge. If early
follow-up cannot be ensured, early
discharge should be deferred.
B. For newborns discharged between 48 and
72 hours of age, outpatient follow-up
should be within 2 to 3 days of discharge.
Timing will depend on the risk for
subsequent hyperbilirubinemia, feeding
issues, or other concerns.
C. The follow-up visit is designed to perform
the following functions:
1. Assess the infant's general state of health
including weight, hydration, and degree of
jaundice.
2. Identify any new problems.
3. Perform screening tests in accordance with
state regulations.
4. Review adequacy of oral intake and assess
elimination patterns.
5. Assess quality of mother-infant bonding.
6. Reinforce parental education.
7. Review results of any outstanding laboratory
tests.
8. Provide anticipatory guidance and health care
maintenance
American Academy of Pediatrics.
American College of Obstetricians and
Gynecologists.
Guidelines for Perinatal Care, 6th ed. Elk
Grove Village, IL, 2007. CDC National
Immunization Program
http://www.cdc.gov/nip/recs/Child-
Schedule.htm