Obstetric Topic 48. Management of the newborn after delivery

I. Immediate Care After Birth

First Assessment

• Goal: support transition to extrauterine life → warmth, airway/breathing, circulation, feeding and early detection of disease.
• Rapid questions: term? good tone? breathing/crying? heart rate normal?
• Healthy term newborn: dry, warm, delayed cord clamping, skin-to-skin, Apgar scoring and breastfeeding support.
• Non-vigorous newborn: radiant warmer → initial resuscitation steps.

6W Approach

1. Warmth: dry baby, remove wet towels and maintain body temperature.
2. Wipe: clear visible secretions if airway is obstructed; routine deep suction is avoided in vigorous babies.
3. Wait: delayed cord clamping usually at least 1 minute, often 2-3 minutes if no urgent resuscitation is needed.
4. Watch: assess breathing, tone, color and heart rate; Apgar at 1 and 5 minutes.
5. Wrap: keep baby warm and covered.
6. Welcome: skin-to-skin with mother if stable; initiate breastfeeding within the first hour.

Cord Care

• Delayed clamping supports placental transfusion unless urgent resuscitation is needed.
• Clamp/cut cord, inspect for 2 arteries + 1 vein and observe for bleeding/infection.

II. Apgar Score and Resuscitation

Apgar Score

• Apgar score: 10-point assessment at 1 and 5 minutes; repeat if low.
• Use: documents transition/response; resuscitation is based on breathing and heart rate, not waiting for Apgar.

1. Appearance: pink body and extremities = 2; acrocyanosis = 1; blue/pale = 0.
2. Pulse: >=100/min = 2; <100/min = 1; absent = 0.
3. Grimace: cough/sneeze/cry/active response = 2; grimace = 1; no response = 0.
4. Activity: active movement = 2; some flexion = 1; limp = 0.
5. Respiration: strong cry/good breathing = 2; slow/irregular/gasping = 1; absent = 0.

• Interpretation: 7-10 normal transition; <7 abnormal/needs further evaluation and support.

Initial Resuscitation

1. No breathing or gasping: warm, dry, stimulate, position head and clear airway only if obstructed.
2. After 30 sec: apnea/gasping or HR <100/min → positive-pressure ventilation (PPV); monitor ECG/SpO2 when available.
3. If HR remains <100/min: ensure effective PPV; consider endotracheal intubation/alternative airway.
4. If HR remains <60/min after effective ventilation for 30 seconds → chest compressions + ventilation.
5. Compressions: 3:1 ratio; if HR remains <60/min despite ventilation + compressions → epinephrine via umbilical venous catheter.

Special Situations

• Meconium-stained fluid: suction only if airway obstruction or ineffective ventilation; routine intrapartum/deep suction is not used in vigorous newborns.
• Preterm newborn: higher hypothermia and respiratory distress risk → extra thermal support and respiratory support if needed.

III. Routine Newborn Care

Prevention and Identification

• Thermal care: cap, dry coverings, skin-to-skin, avoid unnecessary early bathing.
• Breastfeeding: initiate within 1 h; support latch and suck/swallow.
• Vitamin K IM → prevents vitamin K deficiency bleeding.
• Identification: label/tag before leaving delivery room; match with mother.
• Immunization follows local schedule: BCG, HBV and oral polio where used.
• Eye prophylaxis where used; parental counselling before discharge.

Measurements and Observation

• Measurements: body weight, length, head circumference; chest circumference if local routine.
• Record Apgar, resuscitation, prophylaxis, feeding, congenital findings and birth injuries.
• Urination and meconium should occur within 24 h.
• Observe danger signs: poor feeding, lethargy, temperature instability, respiratory distress, persistent cyanosis, seizures, early jaundice, vomiting or abdominal distension.

IV. Physical Examination

General Inspection

• Systematic head-to-toe exam: color, tone, activity, cry, breathing, dysmorphic features, congenital anomalies and birth injuries.
• Head/fontanelles, eyes/red reflex, ears, mouth/palate, neck/clavicles.
• Heart/lungs: HR, murmurs, pulses, perfusion, air entry, respiratory distress signs.
• Abdomen/cord, genitalia, anus patency, limbs/spine/hips.
• Neurologic: tone, Moro, suck, grasp, movement symmetry.