Initial Care of the Newborn (APGAR)

In this lesson I am going to help you understand how you will provide care to the newborn right after delivery.
So the infant is born, now what? The infant should be placed skin to skin immediately as long as it’s stable. Skin to skin is awesome! Skin to skin helps stabilize the baby’s temperature, heart rate, respiratory rate, blood pressure and even blood sugar. It will help with bonding and if the mother wants to breastfeed then it is going to also help get feeding initiated. When you place the infant skin to skin it is important that they have been dried thoroughly so they do not get cold, they need a hat on, diaper on and then a blanket on their back to stay warm. Assessment of the baby is important but if that baby is stable and there is no concern then the baby should be placed skin to skin for at least the first hour of life. I will tell you that a baby might look awesome and healthy right after delivery but they can change so fast, with a snap of your fingers so giving this baby the time to stabilize itself on mom is important. They will need frequent monitoring like vital signs but should remain on mom. Vitals should be taken every 30 minutes for the first two hours of life. So temperature, heart rate and respirations.

Assessment will be really important for the baby. The very first assessment the baby gets is called the APGAR score. This is ok to be done on mom as long as baby appears stable. It is done at 1 minutes and 5 minutes on every baby. It is a mnemonic that stands for appearance, pulse, grimace, activity, and respirations. The baby is scored on each category and given 0, 1 or 2 points. The highest they can get is a 10. So you can see in this table how they are score zero if they are without a heart rate, no respiratory effort, limp, no grimace, and blue or pale. They get one point if they have a heart rate below 100, slow respirations, maybe some flexion, grimace, and pink but the extremities are blue. So this is known as acrocyanosis. It is completely normal. The hands an feet are blue and are the last to get the blood flow because the baby’s body is working so hard after delivery to get good oxygenated blood to the vital organs. It is actually really rare for the baby to have pink hands and feet until hours after delivery. Two points are given when the baby is doing everything it is supposed to. So the heart rate is over 100, it is crying, being active, showing reflexes, and completely pink. So a good score is above 7. If the 5 minute apgar score is under 7 then the baby should be stimulated and worked on to get fix respirations, heart rate or whatever the issue is and rescored again at 10 minutes.
After the APGAR score the baby needs additional assessment. We will observe respirations and clear secretions from the mouth or nares if needed. It is important for you to know that the baby will have regular irregular respirations. So what does that mean? That means they will have period of apnea and then breath fast to catch up. So they breathe, breathe, breathe, stop for 10 to 15 seconds and restart so it is irregular but regular for newborns. This is normal so don’t panic! I was a tech in nursing school and I remember giving a baby a bath in the nursery to help the nurse and I told the nurse the baby was not breathing! The nurse smiled at me and said “they do that, its normal” and she pointed out a few seconds later then the baby started breathing so fast to catch up. So I tell you that story so you won’t be concerned like I was! If the baby is pink it is ok to give it a few seconds and you will see the baby start back again. So this is important because parents will also notice this and be super worried so now you can explain this to them. So things that aren’t normal with respirations in the newborns are things like nasal flaring, grunting, or retractions. Flaring is when their nares open to suck more air in. Grunting is the baby’s way of giving itself CPAP. The baby makes these grunting noises to help increase pressures in the lungs to pop the lungs open. And retractions are when the ribs pull down as the baby breathes and this is the baby trying to suck air in. Vitals will be taken which includes temperature, respiration, heart rate. And last is our measurements. So while you do your head to toe assessment you will get the weight and length, head, chest, and abdomen measurements
So our management is going to involve promoting thermoregulation and safety of the newborn. The baby is born and if needed the physician will use a bulb syringe to suction mouth, then nares. You can also do this if needed. I say “if needed” because it used to be done on every baby no matter what and now new guidelines recommend not doing it for every case. If suctioning occurs it will be mouth before nares and this is important to remember. The reason why is because the baby’s first breath is a large inhale and he or she will suck in the fluid in the mouth. We don’t want the baby to do that, we want fluid out now right? The baby no longer needs to be swallowing or inhaling this fluid. Ok, drying. The baby is going to be dried quickly. This will be done as you are firmly rubbing their back. So two things here, the baby gets dried because amniotic fluid is no longer going to keep them warm but will make them cold by evaporation and it will stimulate their first cry or make them continue if they are not already doing so. Crying means they are breathing and it helps pop the lungs open and clears fluid. Baths should be delayed and the recommendation is for 24 hours. Each hospital will have their own practice but that is the recommendation. So I know you probably think this is gross. The baby is covered in “stuff” from the mom, blood, amniotic fluid, vernix, and even meconium if the baby had its first bowel movement in utero. But delayed baths are so important and I will explain why. If you have learned about hospice patients or those close to death you have probably heard that if they are given a bath they will probably die. This is not an old tale this truly happens. The bath relaxes them and also is stress on their body. Well same thing for the newborn. If they aren’t 100% stable it can throw them over the edge and stress their bodies. You will have a baby who you think seems great, now keep in mind they can change their status with a snap of your fingers, so a bath is done and next thing you know the baby has severe respiratory distress. So these baths should be delayed for 24 hours so they are very stable. Also they have that vernix coating on them. That white substance that you will hear people call “cheese”. You can see in this image all that white gunk is vernix and it is good stuff! This helps to moisturize and offers protection to the baby. This is why a earlier gestation or more preterm baby will have more vernix. More vernix equals more protection. Our last bit of management will be to promote golden hour. This is the first hour after delivery when the baby is skin to skin on mom and bonding occurs. So grab a fresh blanket, diaper, and cap, put baby against mom’s chest with diaper, hat and place blanket on the baby’s back to keep heat in. While the baby is there you can properly identify baby with matching hospital armbands and encourage breastfeeding if that is her chosen feeding method. Once the hour is over you will give the vitamin K and erythromycin eye ointment, which must be done at an hour of life. Vitamin K gives what is needed for blood clotting that the baby is not born with and erythromycin will protect the eyes if mom has chlamydia or gonorrhea.

Education is important. New parents have this awesome baby and no idea what to do. So they need to know how to use the bulb syringe. You aren’t going to be in the room the whole time with them so they need to know how to use it if the baby starts to spit up any secretions. They need to know the importance of skin to skin. I’ve had so many patients that think they are going to be grossed out when the baby is born because the baby will be covered in blood and vernix and they say they don’t want the baby on them. So having a conversation before the baby is born about how important skin to skin is and how they probably won’t care once they lay eyes on their baby. Skin to skin is just the best way to regulate a baby and keep them safe. I have had babies on a warming table that are grunting or having some mild respiratory distress and you put them on the mother’s chest and they instantly stop. Its crazy and amazing! Medication education is needed. You are giving the baby vitamin K and erythromycin and ordinarily when you give medicine you educate the patient, right? Well now we are educating the parent on this. And last is is really important that they know to keep a hat on the baby and have a blanket covering back or swaddled when not skin to skin. So many visitors come and they want to see the whole baby. All the fingers and toes, the hair, the size. The parents need to know that the baby had to stay covered to stay warm.

Safety, thermoregulation and clinical Judgment are our concepts. Caring for this newborn is all about safety and we have to make a lot of clinical judgement to determine how the baby is doing now that it is living on the outside of the uterus and thermoregulation is huge because if we cannot keep temperatures stable then it can cause the baby to go into cold stress and spiral in the wrong direction.
Ok let’s review the important things! Bulb suctioning is done to clear the airway. We need it clear so the baby can breathe right? Skin to skin is done to regulate everything! Temperature, blood sugar, blood pressure, heart rate, and respiratory rate. And we want to do this for the first hour of life if we can. Thermoregulation is very important to keeping the baby stable. So ensure the baby is dry and a hat is on the baby to keep heat in and a blanket is on the back or if not skin to skin. The APGAR score is the first assessment done and it happens at 1 minute and 5 minutes. Remember it is a mnemonic for appearance, pulse, grimace, activity, and respiratory. Initiation of feeding is begun in the first hour, whichever method they have chosen. And frequent monitoring is done usually every 30 minutes for the first 2 hours we are getting vitals. After golden hour medications and measurements are done. So vitamin K and erythromycin and measurements are weight, length, and head, chest, and abdomen.
Make sure you check out the videos attached to this lesson and review the key points as well as deciphering the APGAR score. Now, go out and be your best selves today. And, as always, happy nursing.