ADJUSTMENT TO EXTRAUTERINE LIFE:
will depend on the lungs as the only source of O2.
Respiratory System
• Transition from fetal /placental circulation to independent
respiration
• Chemical factors stimulate breathing
– Hypoxemia
– Hypercarbia
– Low pH (acidosis)
Thermal stimuli
• Newborn leaves warm environment to relatively cooler
atmosphere. Sensory impulses to the skin are transmitted to
respiratory center in the medulla.
• Initiation of respiration thru tactile stimulation
Newborn Respiration
• Fetal lung fluid removal
– Compression of chest with passage through birth canal
– Lymphatic vessels and pulmonary capillaries
• Expansion of alveoli
– Occurs with initiation of breathing
– Role of surfactant in keeping alveoli expanded
Newborn Circulation
• Circulatory changes allow blood to flow through lungs
• Pressure changes in heart, lungs, and vessels
• Functional closure of fetal shunts
– Foramen ovale
– Ductus arteriosus
– Ductus venosus
Sequential Circulatory Changes in the Newborn
• Inspired oxygen dilates pulmonary vessels
• Pulmonary vascular resistance decreases and pulmonary blood
flow increases
• As the lung receives blood, the pressure in RA, RV, and
pulmonary arteries decreases
• Gradual increase in systemic vascular and increase blood
volume as a result of cord clamping.
Further Circulatory Changes in the Newborn
• LA pressure > RA pressure leads to closure of foramen ovale
• Increase of pulmonary blood flow and dramatic reduction of
pulmonary vascular resistance begins to close the ductus
arteriosus
Typical Times for Newborn Circulatory Changes
• Foramen ovale: functional closure soon after birth
• Ductus arteriosus: functional closure in about 4 days after birth in
well neonate.
• Closure may delay in ill or preterm infants
• Reversible blood flow through DA result in functional murmur
occasionally heard
• Failed closure of the above shunts takes blood away from
newborn’s pulmonary circulation
• Ductus Venosus closes (FC, shunts Arterial Blood into IVC), shunts
perfusion of the liver
Physiological Changes
Before Birth:
• Only a small fraction of fetal blood passes through the fetal
lungs.
• Fetal lungs do not function as a source for O2 or as a route to
excrete CO2
• The fetal lungs are expanded in utero, but the potential air sacs
are filled fluid, rather than air.
• The BV that perfuse and drain the fetal lungs are markedly
constricted.
• Most of the blood from the right side of the heart cannot enter
the lungs because of constricted blood vessels in the fetal lungs.
• Instead, most of this blood flows through the ductus arteriosus
into the aorta.
After birth:
fcnlxa – St. Luke’s College of Nursing
• The newborn will no longer be connected to the placenta and
• Over a matter of seconds, the lungs must fill with O2, and the BV
in the lungs must relax to perfuse the alveoli and to absorb O2
and carry it to the rest of the body.
3 Major changes w/in 3 secs after birth
1. The fluid filled in the alveoli is absorbed into the lung tissue
and replaced by air. The O2 in the lungs is then able to
diffuse into the blood vessels that surround the alveoli.
2. The umbilical arteries and veins are clamped. This removes
the low resistance placental circuit and increases systemic
BP.
3. As a result of gaseous distention and increased O2 in the
alveoli, the blood vessels in the lung tissue relax.
• The relaxation together with increased in systemic BP, creates a
dramatic increase in pulmonary blood flow and decrease in
flow through D. arteriosus.
• The O2 from the alveoli is absorbed by the increased Pulmonary
blood flow, and the O2 – enriched blood returns to the left side
of the heart where it is pumped to the tissues of the newborn’s
body.
• As blood levels of O2 increase and pulmonary blood vessels
relax, the ductus arteriosus begins to constrict.
• Blood previously diverted through the ductus arteriosus now
flows through the lungs, where it picks up more O2 to transport
to tissues throughout the body.
• Initial cry and deep breaths help move fluid from airways.
Cardiovascular System
1. Take note of the physiologic changes fetal – neonatal
circulation.
2. Observe for cardiac distress in newborn (e.g. during feeding)
3. Blood values are high in NB as a response to the pulmonary
circulation. A high WBC during the newborn period is not a
sign of infection.
Hemopoietic System
• Blood volume depends on the amount of blood transferred via
the placental before clamping the cord
• FT newborn blood volume is approximately 80-85 mL/kg body
weight
• Average total blood volume for newborn = 300 mL +/- 100 mL
Fluid and Electrolytes
• Newborn body weight is 73% fluid (Adult is 58% fluid)
• Infant has higher ratio of extracellular fluid than adult
• Infant has higher level of total body Na++ and Cl +
• Infant has lower level of total body K+, Mg + + and phosphate +
• GI System
• Newborn has deficiency of pancreatic lipase which limits fat
absorption.
• This makes cow’s milk indigestible.
• Human milk despite its high fat content is easy to digest and
absorb because it has lipase
GI System
• Stomach capacity varies from 5 ml to about 60ml on Day 3
• Colon has small volume leading to frequent stooling
• Has rapid intestinal peristalsis (empty time 2.5-3 hrs)
• Progressive changes in stool pattern in newborn
• Observe for feeding reflexes: rooting, sucking swallowing
• Assist mother with breastfeeding or formula feeding
• Burp newborn during and after feeding
• Assess for regurgitation and vomiting
• Position newborn on the right side after feeding
• Observe for passage of stool
Liver
• Liver is very immature in newborn
• Immature liver affects conjugation of bilirubin and contributes to
physiologic jaundice
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 • Liver is deficient in forming plasma proteins in newborns (edema
results) Musculoskeletal System
• Prothrombin and other coagulation factors are low at birth • Skeletal system contains more cartilage than ossified bone
• Liver stores of glycogen are lower at birth than later in life. • Rapid ossification in first year of life
• Newborn is at risk for hypoglycemia (importance of frequent • Muscular system almost completely formed at birth
feedings) • Muscle growth by hypertrophy rather than hyperplasia
• Liver controls the amount of circulating unconjugated bilirubin
(a pigment derived from Hgb) Immune System
• Unconjugated bilirubin can leave the vascular system permeate • Skin and mucous membranes are first line of defense from
other extravascular tissues (skin, sclera, etc) resulting to icterus invading organisms
(jaundice) • Second line of defense: cellular elements of the immunologic
• Types of jaundice: system: neutrophils, eosinophils, lymphocytes
1. Physiologic • Third line of defense: formation of antibodies
2. Pathologic – Breastmilk provides passive immunity (IgG)
3. Breast feeding associated with jaundice (early onset) • Passive immunity via placenta (IgG)
4.Breastmilk jaundice (late onset) • Passive immunity via colostrum (IgA)
• Bilirubin Values: • Increased IgM indicates infection in utero
a. Unconjugated bilirubin • Observe aseptic technique when caring for the NB
0.2 – 1.4 mg/dl (normal value) • Observe universal precautions when handling the NB
5 mg/dl (jaundice observable)
Other jaundice parameters: Endocrine System
1. timing of the appearance of jaundice • Endocrine system well developed in newborns but function is
2. Gestational age immature
3. Age in days since birth (DOL) • ADH (vasopressin) production is limited, inhibits diuresis
4. Family Hx (e.g maternal Rh factor) – Risk of dehydration
5. Evidence of Hemolysis • Effects of maternal sex hormones in newborns
6. feeding method
7. Infant’s physiologic status Neurologic System
8.Progression of serial serum bilirubin • Reflexes
• Posture, tone, head control, body movement
Renal System • Behavioral response to care
• Functional deficiency in kidney’s ability to concentrate urine – Consolability
• Total volume of UO per 24 hours is 200-300mL by the end of first – Cry: frequency and pitch
week • At birth the nervous system is incompletely integrated
• Normal newborn urine production 1-2 mL/kg/hr • Primitive reflexes
• Bladder capacity approximately 15-30 mL • Autonomic nervous system crucial during transition because it
• First void should occur w/in 24 hrs after birth stimulates initial respiration.
• Newborns may void 10-20 times/day • Myelination of nerves follows cephalocaudal and proximodistal
• Has immature kidneys – unable to concentrate urine progression
• GFR (reabsorption & filtration) low
• NB may tend to reabsorb sodium and excrete large amount of Sensory Functions
water • Vision
• Decrease ability to excrete drugs and excessive fluid loss which – Pupils react to light
can lead to acidosis and fluid imbalance – Blink reflex responsive to minimum stimulus
• Uric acid crystals may cause reddish stain the diaper – Corneal reflex activated by light touch
Implications – Tear glands minimal function until 2-4 wks age
• Rate of fluid exchange in newborn much faster than in adult • Hearing
• Rate of metabolism in newborn twice as great related to body • Smell
weight • Taste
• Acid forms quickly, leading to rapid development of acidosis • Touch
• Immature kidney cannot concentrate urine to conserve body
fluid Transitional Assessment:
Newborn Resultant Problems • 6-8 hours after birth
• Prone to dehydration • Period of Reactivity:
• Prone to acidosis 1. First Period of Reactivity
• Prone to overhydration/fluid overload – During 1st 30 mins after birth – awake, alert, cries vigorously
• Nursing intervention; – Sucks his fingers or fist and appears interested in the envi
1. Weigh newborn daily. – Eyes are usually open (opportunity to see one another)
2. Monitor I & O. Weigh diaper prn. 2. First Reactive period
3. Assess for signs of dehydration. – Last 2-4 hours
– HR, RR decrease, temperature continue to fall
Newborn Skin -– In a state of sleep and relatively calm
• Immature integumentary function in newborn – Any attempt to stimulate elicits minimal response
• Active sebaceous glands 3. Second Period of Reactivity
• Eccrine (sweat) glands – Awakes from deep sleep, last about 2-5 hours
• Apocrine glands small and nonfunctional – Provides for NB and parents to interact
• Hair follicles – NB alert and responsive
• Amount of melanin low at birth—lighter skin than in later life; UV – HR, RR increase
susceptibility – Gag reflex active
– Close observation required for changes in VS and color.
Skin
• The more mature the NB, the more mature the skin and more Behavioral Assessment
likely will be protected from heat loss and infection. • Brazelton Neonatal Behavioral Assessment Scale (BNBAS)
• Skin color depends on activity level, temperature, hematocrit • Interactive examination that assess infant’s response
levels and race. • Areas of behavior: sleep, wakefulness, activity

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 • Patterns of sleep and activity • Stroking outer sole of foot upward from heel and upward and
– State modulation across the ball of foot causes toes to hyperextend and hallux to
• Cry dorsiflex
– Communication of the newborn • Disappear at 1 year of age.
– Variations and meanings
Galant Reflex (trunk incurvation)
Assessment of Attachment Behaviors • Stroking infant’s back alongside spine causes hips to move
• Emotional bonding between parents and newborn toward stimulated side.
• En face position • Disappear by age 4 weeks
• “Falling in love” with the newborn
• Absence of attachment behaviors Grasp Reflex
– Effect on newborn • Touching palms or soles near base of digits causes flexion of
– Effect on relationship with parents hands or toes
• Palmar grasp lessens at 3 months to be replaced by voluntary
Family Involvement movement plantar grasp lessens by 8 months of age
• Family-centered maternity care
• Fathers Sucking Reflex
– Cultural influences on fathering behaviors • Infant begins strong sucking in response to stimulation, persist
– “Paternal engrossment” concept throughout infancy
• Siblings
• Grandparents/extended family Rooting Reflex
• Community • Touching or stroking the cheeks alongside of mouth causes
infant to turn head toward that side, and begin to suck
Preparation for Discharge and Newborn Care at Home • Should disappear at 3-4 months but may persist up to 12 months
• Mom/infant “dyad” concept
• “Couplet care” Extrusion Reflex:
• Discharge teaching • When tongue infant reponds by forcing it outward
• Teachable moments • Disappear at 4 months
• Follow-up care
• Car seat safety Gag Reflex
• Stimulation of posterior pharynx by food, suction or passage of
Stool Patterns in Newborns tube causes infant to gag
• Meconium • Persist throughout life.
– Should occur within 24-48 hrs after birth
– Description: green, black, sticky odorless, passed 4x/day Moro Reflex
• Transitional stools • Sudden jarring or change in equilibrium causes sudden
– Usually appear by day 3rd day of life after the initiation of extension and abduction of extremities and fanning of fingers,
feeding with index finger and thumb forming C shape followed by
– Transition from meconium to milk adduction of extremities
– Description: yellowish-green, slimmy 6x or more • Disappear at 3-4 months
• Milk stools
– Usually appear by DOL 4 Startle Reflex
– Differ in breasted and formula fed baby • Sudden loud noise causes abduction of arms with flexion of
elbows, hands remain clenched
Breastfed Baby Stool • Disappear at 4 months
• Characteristic:
– Golden yellow (mustard) Newborn Screening
– Mushy and soft • It is a screening / test for genetic congenital disorder.
– Sweet odor – due to lactic acid, high (sourmilk) • Mandated by law. R.A 9288 (the NBS Law)
– Passed every after breastfeeding (3-4 x a day) • This is a simple procedure to find out if baby has a rare metabolic
disorder.
Bottlefed Baby Stool • Baby may look healthy at birth.
• Characteristics: • If left untreated may lead to MR
– Pale yellow • Done on the 3rd DOL
– Formed • Test for: Congenital Hypothyroidism, CAH, Galactosemia, PKU,
– Offensive (foul odor) G6PD
– Passed once/ day (depends)
Newborn Nutrition
Reflexes: • Comparison of human milk and cow’s milk
• Blink/Corneal Reflex • Recommendation: No cow milk before 1 year of age
• Sucking • Commercial formulas modified from cow milk
• Rooting • Other commercial formulas
• Babinski
• Moro
• Startle Breastfeeding
• Grasp • Discuss its disadvantages
• Galant • Cultural perspectives on infant feeding
• Need for support, encouragement, and assistance
Blinking Reflex (Corneal Reflex)
• Infants blinks at sudden appearance of bright light or at Purposes of Breastfeeding
approach of object toward cornea. • Promotes bonding
• Persist throughout life • Facilitates release of colostrum and breast milk
• Stimulates production of prolactin and oxytocin.
Babinski Reflex • Prevent jaundice

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Breastfeeding • Management:
• Human milk is the preferred form of nutrition for newborn 1. Give feeding per demand.
• WHO promotion of breastfeeding world wide 2. Tell mother to burp the baby at least 2x during feeding.
• Baby Friendly Hospital Initiative (BFHI) 3. Feed baby upright position. Burp. Place on right side
• Economical lying position.
• Always available 4. Change MF per doctor’s order
• Breast cancer incidence significantly lower in women who have 5. Reduce sugar content of formula.
breastfed
• May also offer protection to child from obesity, allergy, diabetes, Spitting Up
atherosclerosis • Due to poorly developed cardiac sphincter, common among
bottle fed
Physiologic Benefits of Human Milk • Management:
• Species specific food for newborn humans 1. Feed the baby upright
• Digestibility 2. Position in right side lying
• Immunologic properties cannot be duplicated in commercial
formulas Skin Irritation
• Availability/Infection control • May be due to either poor hygiene or irritation from urine, feces,
and some laundry products.
Promotion of Successful Breastfeeding • Management:
• Frequent and early breastfeeding (within first hr of life is 1. Expose to air – most important
important) 2. Careful hand washing and rinsing away of irritating soap
• Promotion of skin-to-skin contact from skin
• Feeding on demand schedule 3. Starch bath if it is due to miliaria
• Careful control of drugs (maternal and newborn) • Seborrheic dermatitis / cradle cap
• Significance of nurses in breastfeeding success o Involves the sebaceous glands due to poor hygiene.
• Clothing
Keys to Breastfeeding Success o Rule of thumb. If mother feels warm keep baby cool; if the
• Correct sucking technique mother feels cold keep the baby warm.
• Correct positioning of infant at breast • Sleeping pattern
• Absence of a rigid feeding schedule o Sleep varies it grows. Babies 16-20 hours day.

Commercial Formulas Newborn Care and Hygiene

• Lactose based • Bathing
• Lactose-free • Umbilical care
• Soy based • Circumcision
• Other specialty formulas • Skin care and skin concerns
• Calorie content of formula
• Preparation of formula Bathing:
• It can be done any time of the day that is convenient for the
Bottle Feeding mother. Bathe the baby in a warm room before feeding.
• Techniques • All equipment needed should be prepared prior to activity.
• Equipment • Make bathing enjoyable for both the infant and mother.
• Positions
• Preparation of formula Cord Care:
• Feeding schedules • Initial Cord Care
• Behaviors during feeding • Routine Cord Care:
1. Teach mother how to perform cord care
Infant Stimulation 2. Keep cord care clean and dry after each diaper change.
• Newborn prefers human face for stimulation Use water only. Expose to air
• Visual benefit of black and white objects for newborn stimulation 3. Assess the cord for odor, swelling or discharge.
• Stimulation of human voice 4. Sponge bath the NB until cord falls off.
• Importance of tactile stimulation
Circumcision
Common Problems • Not routinely done. Done per request of the parents
• Regurgitation • Procedure:
o Common in newborn due to multiple factors Infant is restrained. Penis is cleansed with soap and water.
– Intestine longer in relation to body size than adult Betadine applied. Yellen clamp or Gomco clamp is
– Rapid peristaltic waves and simultaneous nonperistaltic used.Petrolatum gauze dressing is applied to prevent
waves along esophagus adherence of the circumcised site to the diaper while
– Decreased sphincter tone in lower esophagus applying pressure to prevent bleeding.

Nursing Care:
GI Problems a. Check hourly for bleeding (common complication during
• Constipation the 1st day).
o More common among bottle fed infants b. If a small amount of bright red is present apply gentle
• Management: Offer fluids in between feedings pressure to the area w/ a sterile gauze.
c. Do not attempt to remove exudates which persist for 2-3
Loose Stools days. Just wash with warm water.
• Careful Hx taking. Management depends on the cause. d. Diapers must be pinned loosely during the 1st 2- 3 days
when the base of penis is tender.
Colic
• It is the paroxysmal abdominal pain common in infants below 3
months of age.
• Causes: overfeeding, gas distention, too much CHO in MF, tense
and unsure mother
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