Every family looks forward to the birth of a healthy newborn. It is an exciting time with so much to look forward to.

In some cases, though, unexpected difficulties and challenges occur along the way. Some newborns are considered high risk. This means that a newborn has a greater chance of complications because of conditions that occur during fetal development, pregnancy conditions of the mother, or problems that may occur during labor and birth. Some complications are unexpected and may occur without warning. Other times, there are certain risk factors that make problems more likely. Fortunately, advances in technology have helped improve the care of sick newborns. Under the care of specialized physicians and other healthcare providers, babies have much greater chances for surviving and getting better today than ever before.

Assessments for Newborn Babies

Assessments for newborn babies:
Each newborn baby is carefully checked at birth for signs of problems or complications. A complete physical assessment will be performed that includes every body system. Throughout the hospital stay, physicians, nurses, and other healthcare providers continually assess a baby for changes in health and for signs of problems or illness. Assessment may include:

Apgar scoring: The Apgar score is one of the first checks of your new baby's health. The Apgar score is assigned in the first few minutes after birth to help identify babies that have difficulty breathing or have a problem that needs further care. The baby is checked at one minute and five minutes after birth for heart and respiratory rates, muscle tone, reflexes, and color. Each area can have a score of zero, one, or two, with ten points as the maximum. A total score of ten means a baby is in the best possible condition. Nearly all babies score between eight and ten, with one or two points taken off for blue hands and feet because of immature circulation. If a baby has a difficult time during delivery, this can lower the oxygen levels in the blood, which can lower the Apgar score. Apgar scores of three or less often mean a baby needs immediate attention and care. However, only 1.4 percent of babies have Apgar scores less than seven at five minutes after birth.

Sign Heart Rate Respiratory Effort Muscle Tone

Score = 0
Absent

Score = 1
Below 100 per minute Weak, irregular, or gasping

Score = 2
Above 100 per minute Good, crying

Absent

Flaccid

Some flexion of arms and legs

Well flexed, or active movements of extremities Good cry

Reflex/Irritability Color

No response

Grimace or weak cry Body pink, hands and feet blue

Blue all over, or pale

Pink all over

Birthweight and measurements: A baby's birthweight is an important indicator of health. The average weight for term babies (born between 37 and 41 weeks gestation) is about 7 lbs. (3.2 kg). In general, small babies and very large babies are at greater risk for problems. Babies are weighed daily in the nursery to assess growth, fluid, and nutrition needs. Newborn babies may lose as much as 10 percent of their birthweight. This means that a baby weighing 7 pounds 3 ounces at birth might lose as much as 10 ounces in the first few days. Premature and sick babies may not begin to gain weight right away. Measurements: Other measurements are also taken of each baby. These include the following:

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head circumference (the distance around the baby's head) - is normally about one-half the baby's body length plus 10 cm abdominal circumference - the distance around the abdomen length - the measurement from crown of head to the heel

Physical examination: A complete physical examination is an important part of newborn care. Each body system is carefully examined for signs of health and normal function. The physician also looks for any signs of illness or birth defects. Physical examination of a newborn often includes the assessment of the following:

vital signs:

temperature - able to maintain stable body temperature 98.6 F (37 C) in normal room environment pulse - normally 120 to 160 beats per minute breathing rate - normally 30 to 60 breaths per minute

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general appearance - physical activity, tone, posture, and level of consciousness skin - color, texture, nails, presence of rashes head and neck:

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appearance, shape, presence of molding (shaping of the head from passage through the birth canal) fontanels (the open "soft spots" between the bones of the baby's skull) clavicles (bones across the upper chest)

face - eyes, ears, nose, cheeks mouth - palate, tongue, throat lungs - breath sounds, breathing pattern heart sounds and femoral (in the groin) pulses abdomen - presence of masses or hernias genitals and anus - for open passage of urine and stool

arms and legs - movement and development

Gestational assessment: Assessing a baby's physical maturity is an important part of care. Maturity assessment is helpful in meeting a baby's needs if the dates of a pregnancy are uncertain. For example, a very small baby may actually be more mature than it appears by size, and may need different care than a premature baby. An examination called The Dubowitz/Ballard Examination for Gestational Age is often used. A baby's gestational age often can be closely estimated using this examination. The Dubowitz/Ballard Examination evaluates a baby's appearance, skin texture, motor function, and reflexes. The physical maturity part of the examination is done in the first two hours of birth. The neuromuscular maturity examination is completed within 24 hours after delivery. Information often used to help estimate babies' physical and neuromuscular maturity are shown below. Physical maturity: The physical assessment part of the Dubowitz/Ballard Examination looks at physical characteristics that look different at different stages of a baby's gestational maturity. Babies who are physically mature usually have higher scores than premature babies. Points are given for each area of assessment, with a low of -1 or -2 for extreme immaturity to as much as 4 or 5 for postmaturity. Areas of assessment include the following:

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skin textures (i.e., sticky, smooth, peeling). lanugo (the soft downy hair on a baby's body) - is absent in immature babies, then appears with maturity, and then disappears again with postmaturity. plantar creases - these creases on the soles of the feet range from absent to covering the entire foot, depending on the maturity

breast - the thickness and size of breast tissue and areola (the darkened ring around each nipple) are assessed. eyes and ears - eyes fused or open and amount of cartilage and stiffness of the ear tissue. genitals, male - presence of testes and appearance of scrotum, from smooth to wrinkled. genitals, female - appearance and size of the clitoris and the labia.

Neuromuscular maturity: Six evaluations of the baby's neuromuscular system are performed. These include:

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posture - how does the baby hold his/her arms and legs. square window - how far the baby's hands can be flexed toward the wrist. arm recoil - how far the baby's arms "spring back" to a flexed position. popliteal angle - how far the baby's knees extend.

scarf sign - how far the elbows can be moved across the baby's chest. heel to ear - how close the baby's feet can be moved to the ears.

A score is assigned to each assessment area. Typically, the more neurologically mature the baby, the higher the score.

When the physical assessment score and the neuromuscular score are added together, the gestational age can be estimated. Scores range from very low for immature babies (less than 26 to 28 weeks) to very high scores for mature and postmature babies. All of these examinations are important ways to learn about your baby's well-being at birth. By identifying any problems, your baby's physician can plan the best possible care. The following are some factors that can place a baby at high risk and increase the chances of being admitted to the NICU. However, each baby must be evaluated individually to determine the need for admission. High-risk factors include the following:

maternal factors:

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age younger than 16 or older than 40 years drug or alcohol exposure diabetes hypertension (high blood pressure) bleeding sexually transmitted diseases multiple pregnancy (twins, triplets, or more) too little or too much amniotic fluid premature rupture of membranes (also called the amniotic sac or bag of waters)

delivery factors: delivery factors:

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fetal distress/birth asphyxia (changes in organ systems due to lack of oxygen) breech delivery presentation (buttocks delivered first) or other abnormal presentation meconium (the baby's first stool passed during pregnancy into the amniotic fluid) nuchal cord (cord around the baby's neck) forceps or cesarean delivery

baby factors:

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birth at gestational age less than 37 weeks or more than 42 weeks birthweight less than 2,500 grams (5 pounds, 8 ounces) or over 4,000 grams (8 pounds, 13 ounces)

small for gestational age medication or resuscitation in the delivery room birth defects respiratory distress including rapid breathing, grunting, or apnea (stopping breathing)


infection such as herpes, group B streptococcus, chlamydia seizures

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hypoglycemia (low blood sugar) need for extra oxygen or monitoring, intravenous (IV) therapy, or medications need for special treatment or procedures such as a blood transfusion

Who will care for your baby in the NICU?

The following are some of the specially trained healthcare professionals who will be involved in the care of your baby:

neonatologist - a pediatrician with additional training in the care of sick and premature babies. The neonatologist supervises pediatric fellows and residents, nurse practitioners, and nurses who care for babies in the NICU. respiratory therapists occupational therapists dietitians lactation consultants

pharmacists social workers hospital chaplains

The members of the NICU team work together with parents to develop a plan of care for high-risk newborns. Ask about the NICUs parent support groups and other programs designed to encourage parental involvement.