Abstract: Keeping up-to-date on the changes in caring for newborns is crucial to ensure that standards of care continue to be met. We review the knowledge and skills needed to provide basic neonatal care.

Newborns are often referred to as neonates until they reach 28 days of life, after which they're called infants in the research literature. Although the vast majority of births occurring in the United States are considered routine, or not high risk, many newborns can present with concerning signs and symptoms that may indicate a need for a higher level of care. Advances in neonatal care require that all nursing staff working in birthing centers, regardless of their designated level of neonatal services, are prepared to stabilize premature and sick newborns.

There are three levels of neonatal care included in the guidelines for perinatal care and endorsed by the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists. Level 1, or basic neonatal care, is the minimum requirement for any facility offering birthing services. This basic standard of care includes personnel and equipment to perform neonatal resuscitation and stabilization and coordinate the transport of premature or ill newborns to a higher level of care. All birthing centers must also evaluate and care for healthy newborns either staying in the facility's healthy newborn nursery or rooming with their mother. The knowledge and skills that a nurse needs to provide this basic standard of neonatal care are the focus of this article.

Nursing responsibilities before the birth

Preparation is the key to any successful outcome and this is doubly true for averting serious problems that most often occur immediately after birth. That's why all birthing facility nurses are expected to demonstrate neonatal resuscitation provider skills every 2 years.

Basic newborn resuscitation requires you to know how to ensure the baby's temperature is controlled and how to initiate continuous cardiopulmonary and pulse oximetry monitoring. Always have basic supplies ready to go, including a preheated warmer, an exothermic mattress (in case the baby is premature), orogastric tubes, peripheral I.V. supplies, peripheral arterial line supplies, suction equipment (including a meconium aspirator and suction catheter), endotracheal supplies and respiratory services standing by, umbilical line supplies, and a preheated isolette (or incubator), and notify your supervisor of the baby's condition.

APGAR scores: What do they mean?

All nurses working in a birthing center have an important role in assessing the newborn immediately after birth. The assessment of the neonate's appearance (color), pulse (heart rate), grimace (in response to unpleasant stimuli such as bulb suctioning the pharynx), activity (muscle tone and/or movement), and respiratory effort via the APGAR scoring system is essential to guide the baby's care (see Understanding the APGAR scoring system). The nurse is often directly responsible for assigning the APGAR scores at 1 and 5 minutes of life. Each of the five assessment areas is given a score of 0, 1, or 2. The maximum score possible is 10. Scores of 7 or above are considered normal for full-term newborns. If the total score is below 7, or any area is scored 0 at 5 minutes of life, resuscitation efforts and scoring should continue every 5 minutes until 20 minutes of life.

Beyond assessing the five components that make up the APGAR score, it's essential to understand its meaning. The APGAR score assigned at 1 minute of life reflects how the fetus tolerated the in utero environment and/or the labor and delivery process. All subsequent APGAR scores reflect the newborn's response to interventions during the transition from intrauterine to extrauterine life. These nursing interventions include keeping the baby warm, stimulating the baby to breathe, giving breaths to the baby who isn't breathing well, and performing chest compressions if needed.

The transitioning neonate

During the first few minutes and until 6 hours of life, the neonate is considered to be transitioning from the intrauterine to the extrauterine environment. Before being born, the fetus is oxygenated via the placenta and the fetal lungs are filled with fluid. Ninety-five percent of the blood flow to the fetal lungs is diverted away from the lungs via the ductus arteriosus. This is in contrast to the older child and adult for whom 100% of the blood flow passes through the lungs to pick up oxygen and drop off carbon dioxide.

During this transition, the neonate's blood flow to the lungs increases dramatically as the pulmonary vascular resistance drops in direct response to the oxygen that the newborn takes in via its first breaths. If the baby's initial breaths aren't adequate, a life-threatening condition called persistent pulmonary hypertension of the newborn can ensue. This underscores the importance of artificial (bag-valve-mask) breaths for the baby in the first 5 minutes of life if the baby isn't breathing effectively.

The importance of immediate, routine nursing interventions to support the newborn through the transition period can't be overstressed. Ensure the newborn experiences the least stress possible in the seconds to minutes immediately after birth. Neonatal stress is prevented through very basic, supportive nursing interventions. Let's take a closer look.

Keeping the baby warm

First, dry the baby with prewarmed blankets to prevent hypothermia. Don't dry an extremely preterm baby (less than 30 weeks' gestation); instead, place the newborn in food-grade plastic wrap with an activated exothermic mattress under it to prevent hypothermia and dehydration. Next, stimulate the baby to breathe effectively if vigorous crying upon delivery is absent by rubbing the back or flicking the feet. Bulb suction the back of the throat (not the oral cavity itself) only if copious secretions are present.

Keep the baby's temperature within normal limits after birth by immediately placing the full-term baby on warmed blankets either on the mother's abdomen or on an infant warmer (prewarmed). Babies born preterm are at very high risk for hypothermia; the exothermic mattress is designed to keep them warm from below, as well as the radiant warmer warming them from above. When using an exothermic mattress, activate the disposable mattress before use by bending the small metal tab inside of it and "mixing" the contents inside the mattress until it's uniformly opaque in color and feels warm. Only use exothermic mattresses designed for newborns; never substitute a heating pad meant for adult use.

Assessing heart rate

If the baby is crying at 1 minute of life, the heart rate is greater than 100 beats/minute. If the baby isn't crying at 1 minute of life, measure the heart rate by auscultation or palpation. Often, the umbilicus is used to palpate the heart rate. Use your index finger and thumb to "tap" out the heart rate, holding up your index finger so all can see the taps. Tapping the heart rate nonverbally communicates to the rest of the team if interventions are working, quickly evaluating whether resuscitation efforts are effective.

If the heart rate is less than 100 beats/minute (25 taps in 15 seconds) at 1 minute of life, continue stimulating the baby to breathe and immediately begin giving artificial or bag-valve-mask breaths, now referred to as positive pressure ventilation (PPV). Use the lowest possible pressure to get the baby's chest to rise. The higher the pressure used, the higher the risk of rupturing alveoli by forcing air into the lungs. Ruptured alveoli lead to air entering the pleural space, also known as a pneumothorax. Each subsequent breath can cause the pneumothorax to increase in size and the entire lung to collapse (tension pneumothorax). Pressures higher than 25 to 30 mm Hg used to force air into the baby's lungs can easily cause a life-threatening pneumothorax.

The 2011 neonatal resuscitation guidelines now recommend using room air or 21% oxygen for PPV. (Before 2011, 100% oxygen was recommended.) Stop PPV when the baby is breathing on his or her own and the heart rate is greater than 100 beats/minute. If the baby needs PPV beyond 5 minutes of life, attach an oxygen saturation monitor to the right wrist by placing the probe on the baby before connecting it to the pulse oximeter. After pulse oximetry is started, if 30 to 60 seconds of PPV with room air doesn't bring up the oxygen saturation level, blend in oxygen as needed. You must remember that oxygen is a medication that can have serious side effects, especially for preterm infants, prompting the change away from using 100% oxygen for neonatal resuscitation unless the baby requires this much oxygen to reach the goal level of oxygen saturation.

If the heart rate is less than 60 beats/minute (15 taps in 15 seconds or less than 1 beat/second) and not increasing despite the use of PPV, start chest compressions. With two fingers of one hand or your two thumbs (and the rest of your hands encircling the chest), press down on the sternum one-third to one-half the depth of the chest just below the nipple line to give chest compressions. Make sure to continue with effective and coordinated PPV because only adequate respirations will increase the heart rate.

Monitoring temperature

Next, take the baby's axillary temperature after stabilization (5-minute APGAR score or subsequent APGAR score of greater than or equal to 7, or greater than 6 for preterm neonates). Place a warm cap on the baby's head and bundle the baby with warm blankets or place the baby skin to skin on the mother if the temperature is low and the baby is stable. If the hypothermic full-term baby is too compromised (5-minute APGAR score of less than 7), use an infant warmer, warm cap on the head, and possibly an exothermic mattress. Preterm, small-for-gestational-age, and sick newborns are at a much higher risk for hypothermia, so take their temperatures more often and start continuous cardiopulmonary (attaching chest leads to the cardiac monitor) and pulse oximetry monitoring.

A high temperature at birth often reflects maternal fever and places the newborn at risk, warranting close observation regardless of the baby's gestational age. If the baby's temperature is above normal, take off layers, starting with the baby's cap. If the baby is naked, skin to skin with the mother, and too warm, place a layer or two of clothing or a blanket between the mother and baby.

All abnormal temperatures require immediate intervention to get the baby's temperature within normal limits. Take and document follow-up vital signs minimally every 30 minutes, until at least two to three consecutive temperatures are within normal limits.

If neonatal stress isn't prevented by these basic life supportive or resuscitative interventions, the baby can quickly become hypoxic. Neonatal hypoxia immediately after birth is caused by ineffective respirations or thermal instability. This hypoxia can quickly trigger the potentially lethal persistent pulmonary hypertension of the newborn if not quickly reversed and addressed during the first minutes to hour of life.

Potential complications

Often, respiratory symptoms, hypoglycemia, and poor feeding are the presenting signs telling us the full-term newborn is ill.

Respiratory problems

Tachypnea (respirations more than 60 breaths/minute at rest or while sleeping) and/or increased work of breathing at rest is considered abnormal after the initial 4 to 6 hours of life. Signs of increased work of breathing or labored respirations include suprasternal, intercostal, substernal, or subcostal retractions; nasal flaring; and/or grunting or vocalizations with each breath. Document a full head-to-toe assessment, including vital signs at 2 hours and again at 4 hours of life.

Notify the newborn's healthcare provider if signs of increased work of breathing and/or tachypnea are present, regardless of time of life. This will allow time for the healthcare provider to evaluate the newborn and provide some basic interventions. At 6 hours of life, the healthcare provider will initiate transfer to a higher level of care if the baby's breathing or other issues haven't resolved. In this case, you'll work with the healthcare provider to complete the necessary tasks to prepare for the baby's transfer to another facility.

Apnea is defined as an unexplained episode of no breathing for 20 seconds or longer, or a shorter respiratory pause causing bradycardia, cyanosis, pallor, and/or poor muscle tone. An interruption of breathing can be caught by the nurse during routine assessment of the newborn, underscoring why you must count a newborn's respirations for a full minute. Apnea is always considered abnormal in full-term newborns (greater than or equal to 37 weeks' gestation). If you observe an apneic episode, or if the family reports a blue or dark color change in the newborn, regardless of how many hours old the newborn is, report and document these findings immediately.

Periodic breathing-breathing pauses shorter than 20 seconds and not accompanied by oxygen desaturation and/or bradycardia, with no color changes-is often confused with apnea. Again, observing and counting the newborn's respirations for a full minute along with noting the quality of the respirations (whether retractions or nasal flaring are present) and the baby's color is critical.

If you notice tachypnea, retractions, nasal flaring, apnea, periodic breathing, or you're simply unsure and worried about the baby, take off the baby's shirt, place the baby on a warmer, and start continuous cardiopulmonary monitoring. Next, place a pulse oximeter to the preductal, or right, upper extremity for continuous monitoring while the baby is on the warmer, ensuring the temperature is within normal limits. These actions allow the respirations to be closely monitored until the healthcare provider has examined the newborn. If alarms are triggered by tachypnea, labored respirations, periodic breathing, or apnea, you can review the heart rate, respiratory rate, and corresponding oxygen saturation levels leading up to the alarm in the recording history of the cardiopulmonary monitor to help determine the cause.

If babies are working hard to breathe (experiencing retractions, nasal flaring, and/or tachypnea), they can quickly tire out. Newborn fatigue causes ineffective respirations (not moving enough air in and out), which can be accompanied by, or confused with, apnea and periodic breathing. Regardless of the type of breathing issue the baby has, the standard of care is to place the baby on a warmer and begin continuous cardiopulmonary and pulse oximetry monitoring.

Hypoglycemia

Premature neonates, those who are large (measurements greater than the 95th percentile on a standardized growth chart) or small (measurements less than the 5th percentile on a standardized growth chart) for their gestational age, neonates of mothers with diabetes, and sick neonates are all at high risk for hypoglycemia shortly after birth. All standing orders for newborns should include glucose testing (based on prematurity, large or small for gestational age, whether maternal history is positive for diabetes, and/or nursing assessment findings or concerns). Don't hesitate to obtain a bedside glucose test if you're concerned in any way about the baby (see When bedside glucose testing is warranted).

Babies with breathing problems shortly after birth are stressed, will have difficulty feeding, and are at risk for using more glucose than they've stored or can consume. Report and document hypoglycemia (glucose level of less than 55 mg/dL) immediately. Be prepared to place an orogastric tube to feed the baby and/or initiate I.V. access, depending on the healthcare provider orders. Often, healthcare providers will prefer to tube feed the hypoglycemic neonate or give I.V. dextrose rather than allow the baby to nurse, especially if the baby also has respiratory symptoms.

Abnormal respirations and/or hypoglycemia are the most common initial signs of illness or prematurity in newborns during their first hours of life. Other signs that you need to look for, document, and report promptly to the healthcare provider include whether the baby is preterm; is large or small for gestational age; has no interest in eating or is feeding poorly from the breast or bottle; has an abnormal body temperature despite interventions; is vomiting (after every feeding and beyond "wet burp" volumes); has abdominal distension; has no stool during the first 48 hours of life; has bradycardia (less than 100 beats/minute) at rest; has pale, gray, or yellow (jaundice) color of the skin; or has tremors and/or seizures.

The workup workout

If the newborn you're caring for has abnormal respirations, hypoglycemia, thermal instability, or any concerning symptoms, expect the healthcare provider to order a sepsis workup. This minimally involves a complete blood cell count with differential and a blood culture to be drawn. Expect a chest X-ray to be ordered for respiratory abnormalities.

If antibiotics are ordered, they're always given I.V., so expect to start an I.V. line. Start the antibiotics only after the blood culture, and any other cultures ordered, have been collected. If I.V. medication is ordered, it's often helpful to get the blood work and drop of blood for the glucometer at the same time as the I.V. is started. This prevents multiple stressful pokes to the baby and saves peripheral veins should long-term I.V. access be needed.

Up-to-date care

Working in a birthing center, you're expected to know the basics of neonatal resuscitation and stabilization, including nursing interventions to support the newborn during the transition from the intrauterine to extrauterine environment and establish normal respirations. You're also expected to know how to assess for thermal instability, respiratory difficulties, and hypoglycemia.

Neonatal nursing is an exciting field in which research is driving evidence-based medical and nursing care. For this reason, guidelines have changed enormously during the last 20 years. Keeping up with changes is crucial to ensure the standards of neonatal care continue to be met.

did you know?

Check the baby's blood glucose level at 1 hour, 2 hours, and 4 hours of life if any of the following situations apply:

* prematurity (less than 37 weeks' gestation at birth)

* large for gestational age (measures greater than 95th percentile on growth chart)

* small for gestational age (measures less than 5th percentile on growth chart)

* mother with diabetes (regardless of type)

* respiratory distress (apnea, tachypnea, and/or increased work of breathing)

* thermal instability (abnormal temperature despite basic nursing interventions)

* full-term newborn not interested in feeding every 3 to 4 hours or who appears lethargic (difficult to arouse and/or keep awake during feeding)

* if the baby has signs of jitteriness and/or your suspect seizures are present

* if you're worried about the baby for any reason not listed above (for example, if the baby doesn't look "right" to you, prenatal ultrasounds had abnormal findings, the labor and delivery process was difficult or prolonged, or the baby was born with birth defects).

Learn more about it

American Academy of Pediatrics. Guidelines for Perinatal Care. 6th ed. Washington, DC: American Academy of Pediatrics; 2007.

American Academy of Pediatrics, American Heart Association. Textbook of Neonatal Resuscitation. 6th ed. Washington, DC: American Academy of Pediatrics; 2011.

American Academy of Pediatrics, Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. The Apgar score. Adv Neonatal Care. 2006;6(4):220-223.

Committee on Fetus and Newborn, Adamkin DH. Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics. 2011;127(3):575-579.

Karlsen KA. The S.T.A.B.L.E. Program: Post-resuscitation Stabilization Care of Sick Infants: Guidelines for Neonatal Healthcare Providers. 5th ed. Washington, DC: American Academy of Pediatrics; 2006.

Staebler S. Regionalized systems of perinatal care health policy considerations. Adv Neonatal Care. 2011;11(1):37-42.

Stark AR, American Academy of Pediatrics Committee on Fetus and Newborn. Levels of neonatal care. Pediatrics. 2004;114(5):1341-1347. Reaffirmed May 2009.

Zaichkin J, Weiner GM. Neonatal Resuscitation Program (NRP) 2011: new science, new strategies. Adv Neonatal Care. 2011;11(1):43-51.