Chapter 23 – Physiological and Behavioural Adaptations of the Newborn

Transition to Extrauterine Life

First period of reactivity
• Lasts up to 30 minutes after birth
• HR increases to 160-180 beats/min but gradually decreases after 30 minutes
• Respirations are irregular, with a rate between 60-80breaths/min.
• Last for first 30 mins after birth, because LD nurse can see some of these transitions,
from utero to use their lungs, how well are they clearing, sometimes we make them cry
but we don’t want to make them cry too much because we can force that baby back
into fetal circulation. If baby is having a hard time staying pink, we will make them cry to
clear mucus secretions.
• We expect it to go up as babies adjust, now it must figure everything out and get
everything equalized.
• Irregular heartbeats, is the baby turning blue? Baby will look distinct whether top half is
pink, or bottom is blue. Bruising on face, never put in a blue blanket, white blanket so
we can see what’s going one, is it bruising or not oxygenated.
Period of decreased responsiveness lasts from 60 to 100 minutes
• After first period of reactivity, newborn either sleeps or has a marked decrease
in motor activity
• Last a little while afterwards, thins settle down and there are a few different
patterns with this, when was the baby born, is this something we should
continue to observe, or do we need an intervention?
• Is it in distress and need to go to NICU?
• Will usually occur in the first 6-8 hours after delivery – first hour after delivery
we are recording every 15 mins, so we have the documentation making sure
everything is correct, then 2 hours and every four hours afterwards until the
first 24 hours of age.
• First hour of extrauterine life – eyes on that baby all the time.
• Babies are very honest, if there is anything wrong with them, they will look distinct, they will
look blue, left or right, suckle or not.
• After one hour we are recording every 15 mins, and then we do vital signs 2 hour and then at
the 4-hour mark and then every 4-hours assessment for the first 12 hours of the baby
• Take away – first hour is crucial, every 15 mins
• some of the signs of distress of breathing issues = nasal flaring, neck needs to be readjusted - it
could be something as simple as repositioning,
• Babies can have normal respiratory rates, with stress, there could be congestion, we need to
work harder but have the same rate, we will be doing something else about it:
1. Nasal Flaring – baby is having stress – neck readjusted, jaw too far down
2. Audible Grunting – is a noise that sounds like a humm, readjust airway because it is not
cleared.
3. Intercostal/ Subcostal Retraction at the throat – between the ribs and the abdomen, (if it
gets here oh boy the nurse has missed a lot)
This could not change the rate of their breathing. **
Second period of reactivity
 • Occurs 2 to 8 hours after birth
• Lasts from 10 minutes to several hours
• Tachycardia and tachypnea occur
• Increased muscle tone
• Improved skin color
• Mucus production
• Meconium passed
Between 2-8 hours – babies heart rate may get higher – normal transition.
The baby will try to stretch and arm movement, kicking, squiggling, we want their color to remain pink
and if there is anything else to be concerned about, mucus, that they are dealt with.
• Acrocyanosis – hands and feet are blue color – NORMAL once they are first born – because
blood needs to be circulating throughout the body because it takes a little longer for them to be
pink, the limit is 72 hours, whether you’re looking at nail beds or hands and feet they should be
pink then.
• First stool is called: meconium, is green thick oily, that’s why we put Vaseline on the diaper
because it will stick to the bottom. Important and documented to note that this has passed
before discharged. Must tell family member if they pooped, please save the diaper, WE NEED TO
SEE IT.
• Defending on how the mother delivered, it will take longer to get through the transitions
because of the medications.
• There are variations in birth depending on the way mom delivered whether its natural and the
baby takes longer to adjust to the medications that mom had during delivery
• RESPIRATORY 30-60 breath per min is normal for babies – babies are getting bigger and thus
causes fewer breathes.
• What causes baby to start breathing? Chemical changes that happen, changes in the co2 – in
utero, causes stimulations to initiate bleeding,
• To stimulate them mechanical – some pressure on the chest, also the fact that the chest has
more room to expand
• Sensory – wiping them down, massaging the head to get extra stuff off.
• Mechanical – compression of the chest – intrathoracic pressure giving it more ability for chest to
expand. Do not spank babies on the bottom.
• We also put them under warmers to stimulate and replicate the amniotic sac.
• Fetal circulation if the baby stays cold for long time, so that’s why we put them under warmers
• Preterm baby – may not have enough surfactants in lungs to keep the alveoli open = NICU for
treatment – can have surfactant infused into the lungs.
• We don’t want them too hot or too cold so do not leave them under warmer for too long
• Tachypnea – Rapid breathing

Respiratory system
 Respiratory rate
• 30-60 breaths/min
 Initiation of breathing
• Chemical factors
• Mechanical factors
 • Thermal factors
• Sensory factors
 Signs of respiratory distress
• Nasal flaring
• Intercostal or subcostal retractions
• Audible Grunting
Tachypnea – Rapid breathing

Cardiovascular system
 Heart rate and sounds
• Resting HR 120-160 beats / minute
• Labor 110 - 160 bpm
• Bigger babies are 100 bpm
 Blood pressure
• Done only in the presence of cardiovascular symptoms
 Blood volume
 Signs of risk for cardiovascular problems
• Tachycardia grates than 160
• Bradycardia less than 120
• Color- general color of the baby
• If you are assessing a baby and it is 88, this is bradycardia, could be due to a
bigger baby.
 At labor heart of 110-160 – different variations, it’s not abnormal
 Big baby u may see a 100 bpm
 Textbook 120 – 160 = that’s that number she wants us to remember
 Question on the test
 Assessing a baby with heart rate its 88 bpm, not normal so remember the 120-160
 BP are only done when we have clear distinctions of body colors in different spots
 Blood volume = bleed within the delivery, baby may have lost some volume or pasty and come
out grey, and these babies come out gray and look half dead eyes rolling or glassy = NICU, and
will have blood transfusions to assists in restoration
 If you have a preterm baby, you are going to have a bpm over 160 and this is normal due to the
gestational age.
 Baby - 42 weeks born or more the heart rate can be lower its an older baby could be lower than
120 and this is normal.

Hematopoietic system
• Red blood cells
• Increased levels in utero to transport O2
• At birth, levels of RBC, Hgb & Hct
• Leukocytes
• Platelets
• Blood groups
 • Changes – there is practice that the doctor will have the baby out, and have the baby
attached to the cord and hold them lower and are trying to get blood to flow from the
placenta to the baby and give baby RBC but could also give Jaundice.
• How traumatized was the baby and how lowered was the baby for the extra blood.
• Heat loss question is on the exam – how to position the baby and safety – baby should
not be near the window.

Thermogenic System
• Thermoregulation – maintenance between heat loss and production
• The goal of care is to provide a neutral thermal environment for the newborn.
• Heat loss
• Ensure the mother takes off her clothes and use skin to skin, and give heated blankets,
and ensure the hair is dry and give hat to the baby, the baby can become hypoglycemic.
Because the baby does not have the ability to eat sugar.
• Babies try to warm themselves up by moving or using brown fat located around the
kidneys and above shoulder blade area around the back, but once they used this all up,
there is no more reserves.
• Brown fat – nature protecting things given to newborns when developing. In kidneys
and btwn shoulder blades and then develop own fat afterwards.

1. Convection
2. Radiation
3. Evaporation
4. Conduction
Questions related to heat loss,
Think of examples where the heart loss can happen to a baby
Go back and look at this question on the test

Skin to skin - generates heat

Make sure hair is dry scrub it down with towels and get a hat on – you must clean the head and put the
that, so the head Is not wet.
More oxygen into lungs and tissues, breaking down sugars and fats – baby can go into metabolic acidosis
Thermogenesis:
• Neonate's attempt to generate heat when cold
• Done by increasing muscle activity & cellular metabolic activity
• Non-shivering Thermogenesis:
• Metabolism of brown fat
• Unresolved hypothermia will progress to cold stress
• Hyperthermia (body temperature >37.5 degrees Celsius)
• Babies try to generate here is by moving, and by using they’re between fat that is located their
kidney area, between the shoulder blade on the back.
• Brown fat – fat that is in the area in the kidney area up and along the back, naturally occurring,
to protect from heat, and goes also under the axilla area, it’s get used up and then they develop
more fat.
Renal system
• Fluid and electrolyte balance
• Daily fluid requirement:
• First 2 days 60-80ml/kg
• 3-7 days: 100-150ml/kg
• 8-30 days: 120-180 ml/kg
• An infant should void within 24 hours of life
• For the first few days it has enough nutrition on board, they get lots of calories from the
colostrum, but not that much volume, this is okay, but consider the first couple diapers they
have will be fewer, until the milk comes in and their stomach expands = more diapers, we need
baby to void for the first 24 hours or they will not go home, we may need to put a wash cloth in
diaper or we may see brick dust or uric acid in the diaper area, opposed to seeing urine there. If
you see something odd, bring to someone’s attention.
• If a newborn has not voided within 48 hours of life it may indicate a renal impairment
• Assessment for uric acid crystals or “brick dust”
• The uric acid - looks like powder, and happens because there is not enough fluid in the kidney to
clear out their system, their residual from their system from the time they were in utero, these
crystals are dried urine, so once kidneys start working, they will resume full function
• These are all normal variations, because not enough fluid in kidneys to clear out system –
residual stuff, and peeing into amniotic fluid, and its just dry urine, once they have enough
volume into their stomach and urine, it will clear crystals out once working full function.
• Daily fluid requirements – when a baby is being breast fed, we let them know not to change
baby and weigh the baby before hand and weigh them afterwards this helps us see how much
they are breastfeeding.
• Some babies will eat and eat until they throw up, some babies don’t like specific formulas and
there are 60 different types, and we just find them the right one.
• Cues for hungry baby, sucking, facing towards breast
• the nurse is not allowed to give a pacifier without the parents’ permission

Gastrointestinal system
• S & S of adequately hydrated or dehydrated infant?
• Digestion
• Avoid over feeding to prevent regurgitation – can go into ears, and neck and go
sour and break down their skin, always clean between creases and dry very well.
 • Normal newborn can digest simple carbohydrates and proteins but has limited
ability to digest fats
• Stools (see Box 23-1 pg. 468)
• Meconium
• Transitional
• Milk
• Assessment of feeding cues
• Meconium to different type of stool depends on if breast fed or formula fed. Breast and
bottle may put baby at a disadvantage, we can talk about expressing or saving for later.
Mixing both. Can cause babies to develop milk allergies or different allergies. What are
some different cues, its suckling, turning towards the breast, and it mouth, could be
hunger or urge to suck, could be not nutritive suckage

Hepatic system
• Iron storage:
• At birth, enough to last 4-6 months
• Breast feeding, they are okay, but at this time they are supplemented or start on
other types of foods which they will get their iron from, some will breast feed
for first year and they will have their teeth and what not. We need to go slowly
to give gut the ability to develop and the enzymes to break them down. Any
baby given a formula is given and iron supplement included in the formula, they
also have iron free incase there is an issue in the family genetically with iron.
• Coagulation – this is generated by the liver and given a dose of vitamin K - ****
it is because the GUT IS STERILE** KICK STARTS THE GUT
• Carbohydrate metabolism
• Reduced levels of glucose due to increased energy needs, diminished supply
• Expected time frame and S & S of hypoglycemia
• Coagulation
• Synthesized by liver; activated by Vitamin K
• Iron storage; if they are breastfeeding they are ok, if not they have to be supplemented, either
from vitamins and or food at the 6 months mark
• Coagulation – generated by the liver
• Vitamin K – to increase coagulation and it’s to the gut is sterile ********* to kick start the gut ,
and to get things moving , there is nothing in the gut
• Jaundice:
• Yellowish color of skin and sclera d/t elevated unconjugated bilirubin levels
(hyperbilirubinemia) – if not resolved and can eventually go into Kernicterus –
rare – progression of bad, could only be diagnosed by autopsy and jaundice in
the brain, but now they can detect it earlier and can be treated successfully.
Could have sight, brain issues etc.
• What is the cause, how is it resolving what are the other issues with it?
• Conjugation of bilirubin
• Physiologic jaundice
• Most common – typically resolves without treatment
 • Pathologic (high risk for developing):
• Kernicterus
• Acute bilirubin encephalopathy
• Jaundice associated with breastfeeding
• If jaundice is not resolved it goes into the kernicterus
• Sniffles, cold, and we have huge implications
• Occur in 60% of newborn, self resolves, do they get enough fluid, sometimes they don’t want to
drink, forcing fluids and depends on how babies respond.
• Pathological jaundice – is the transitory ones, and it appears within 24 hours – skin sclera –
check the chest for cap refill to see how it goes down but that’s where you check 1st
• You press on the chest, and you see, and you check in different areas to see how far it’s gone
• Want it excreted through feces and urine and ensure the mother has a pencil for the mother to
record each time the newborn requires a change.

Immune system
• Antibodies from maternal circulation – gets most from mother, colostrum and signs of
infection.
• Breast milk
• Risk for infection
• Early S & S of infection. Key thing is problems with thermoregulation, they can’t keep
their temperature up – cold baby could also have an issue with their sugar
• We then don’t want to give a bath; we don’t need to rush to that
• What does the baby look like, what they have gone through, warm blanket, we do not
give a bath at this time, every time you have a baby who has not have their first bath,
baby must be stable.
Integumentary system
• Vernix caseosa
• Sweat glands (milia)
• Desquamation
• Vernix Caseosa = white gold, protects the skin, we dry it off we don’t scrape it off, it moisturizes
their skin, we leave it and we let it be absorbed – moisturize and hydrate the skin. Will still have
some in their creases, its normal.
• Postdate – vernix already absorbed – dry skin and cream could be ordered, does not change the
state of the baby. Discourage lotions and anything with a scent.
• Milia – on nose, natural variations, white heads, will be self-absorbed, do not pick, they are
sebaceous glands. go alone
• Desquamations - cracking and pealing
• Mongolian spot - bluish black skin pigments, darker colored skin, looks like a bruise
• Core clamp – the first 4 hours after delivery, you can still feel a pulse between the cord and the
umbilicus and feel a pulse for the first hour or two. This dries off and fall off, usually cut off
before the baby goes home.
• Nevi vs birthmark, blanches easy and will go away
• Mongolian spots
• Bluish black areas of pigmentation
• No big deal
• Darker colored skin
• Can look like a bruise.
• Could be one or more spots from legs to back, specifically in the back.
• Nevi
• “stork bites” – pink and easily blanched
• Pink – blanches easy and will go away quickly, these will be above the nose or
upper or bottom lip.
• Normal and natural
• Erythema toxicum
• Newborn rash - inflammatory response
• Sounds and looks horrible, it is a response to the environment, it is not linked to
anything, they are normal
• Raised rash look, weeping, transitory
• Erythema – can look horrible but normal, it’s a just a response to the environment and is not
linked that the baby will have sensitive skin or anything, it’s just the baby being adjusted to the
environment

Stork
 Stork bites, this is extreme, check the book

Reproductive system
• Female
• Pseudo menstruation (fake-period) – r/t to hormone extremely high,
will go away once hormones normalize and adjust.
• Male
• Hypospadias(does not reach tip, but somewhere else along the bottom
of penis)
• Epispadias (top of penis – epi more common in boys)
• where the urethra is on the male and the opening to the
urethra is the upper side and the lower side, but not central and
baby cannot have a circ and save foreskin for repair and can
effect fertility if not addressed. The baby will grow, and skin will
be stretched.
• Hydrocele
• Swelling of breast tissue (both boys and girls – witches’ milk, squeeze the areola natural)
– r/t hormones – this is normal and natural and will go away.
• Ambiguous genitalia – can’t tell if girl or boy and use genetic testing or parents get a
vote in what they prefer
• Bruises or petici – head was not positioned correctly for easy delivery, so baby had a lot
to deal with, want it in white blanket
• Hormones being extremely high
• Look into the book
• Opening of the urethra – the urethra is not midline,
• look in the blood for the hypospadias and epispadias
• When the urethra is not central – baby cannot have circumcision
• Ambiguous – they do genetic testing
The hair on the shoulder’s to back towards back of shoulder blades lanugo – going across the back and
forehead, baby is born early – help keep baby warmer, eventually this will fall of in term babies.

Premature baby girl

Preimun, the labia majora is not covering the labia minora,
We have discharge
Jaundice, cord clamp cut off and dry
Breach baby depending on the way legs are, legs flip up and one is down, we ensure we have both legs
down when we support it.

Skeletal system
• Signs of risk for skeletal problems
• Molding
• Caput succedaneum – swelling of the scalp in the newborn, it is most often
brought on by pressure from the uterus or vaginal wall during a head-first vertex
delivery
• Cephalhematoma – blood that collects between a newborns scalp and skull,
hematoma means blood pooling outside of vessel, Cephalo refers to head,
pressure on babies head cause a rupture of blood vessels in the scalp.
• Developmental dysplasia of the hip (DDH)
• Fractured clavicle
• Spine – pilonidal dimple
• Extremities
• Molding – how doesn’t the head changes its shape to get though the pelvis
• Teston these, so read in the book) Caput succedaneum (fluid) and cephalhematoma – (bleeding)
• one goes across the suture line (saccadium) the other does not (hematoma)
• Teaching to the family when do they go away?
• Dysplasia of the hip to look for it, pull the hips straight and see if they knew sand the ankles
align, and the butt cheeks align, that’s how to assess,
• Fractured clavicle = if the baby gets stuck, they will break the clavicle, heals super quickly
• Spine – is it straight, or deep, fluid coming out, dimple, hair this is more than just having a
dimple this means there is a problem and has an issue with spine abiffita, is the baby well flexed.
TERM BABY WILL ALWAYS BE WELL FLEXED.
• Ballor – gestational age of baby
• Hip dysplasia – pull legs straight to see if their legs align, ankles align etc.
• If baby gets stuck, they will break clavicle and it will heal in a couple days.
• extremities, pull them out and look if they are pilling them in, TERM BABY IS WELL FLEXED - if
the baby goes back to normal position, it’s called well flexed,
 • We are also looking for webbing on digits if they are the same length, fused, or missing,

This is molding and this resolves and will have a normal head
Back to sleep program, flat head, SIDS prevention
• Neuromuscular system
• Transient tremors are normal in the neonate – should subside by 1 month of age
• Newborn reflexes
• See table 23-1 (page 477)
• Sucking & rooting; Moro; Babinski
• Reflex, Babinski for baby – toes fan out, rooting, startle, gaging, startle moral – clapping
• Mouth = We have rooting, and suck, and gag,
• Startle reflex, you can clap
Sleep-Wake states
• 6 states:  two sleep states (deep then light sleep) and four wake states (drowsy, quiet
alert, active alert, and crying)
• Other factors influencing behavior of newborns
• Gestational age
• Time of day
• Stimuli (Ex. Environmental)
• Medication (Ex. Labor anesthesia)
• Babies can see best at the distance of holding baby in your arms, they can focus the best,
• Hearing = startle reflex, maybe debris if they don’t hear you, hearing test at the hospital.
Sensory behaviors
• Vision
• Hearing
• Smell – well-developed
• Taste
• Touch
Response to environmental stimuli
• Temperament
• Habituation – protective mechanism that allows the infant to become accustomed to
environmental stimuli
• Consolability
• Cuddliness
• Irritability
• Crying