Newborn Baby Care in the First 48 Hours
After being born, most babies only need routine care to live normally outside their mother’s womb. The first step is the care a newborn receives immediately after birth in the delivery room. Later, a newborn baby receives a physical examination, followed by shots aimed at preventing serious health issues. Lastly, there is an educational component for the entire family, as well as another evaluation before your baby leaves the hospital.
Care in the Delivery Room Immediately after Birth
Immediately after delivery, a newborn baby is dried off and a nurse clears the baby’s airway of any secretions.
A few things need to be answered immediately after birth.
- Is the baby full-term?
- Is the baby crying or adequately breathing?
- Is the baby’s muscle tone good?
If every answer is yes, the baby will be given back to its mother. This is also the point where a breastfeeding mom will want to try to feed her child for the first time.
If any of the above questions are no, then the baby may require further evaluation and help. Help may include:
- Receiving oxygen by placing an oxygen mask over the baby’s mouth and nose (blow by or passive ventilation) or assisted ventilation which forces air into the baby’s lungs.
- Receiving chest compressions if the baby’s heart rate remains less than 60 beats per minute for 30 seconds.
- Administration of medications like epinephrine for persistent heart rate below 60 beats per second to help speed up the baby’s heart rate.
Prior to the baby being given to the mother for the first time the Apgar Test or Apgar Score is performed. This evaluation is done one minute after birth, and then again five minutes later. The Apgar score is made up of five evaluations, all are given a value of between 0 and 2 that are added together. The Apgar score is based on the following five evaluations:
- Heart rate
- Muscle tone
- Respiratory effort
- Reflect irritability (response to physical stimulus)
Roughly, nine out of 10 newborns have an Apgar score between 7 and 10. In this case, the baby likely doesn’t need any additional care other than the routine care. Babies who fall within this category will go to what’s called the “level 1” newborn well baby nursery. These babies all share similar characteristics including good muscle tone, spontaneous crying or breathing, are full-term, or almost full-term, and are pink in color.
Babies who end up with lower scores may need extra care, including the one percent of newborns who need considerable resuscitation help right after delivery.
Video: How to Check your Newborn Baby
Baby's First 4 to 6 Hours after Birth
A baby’s transition from life in the womb, to life outside of the womb, refers to the first four to six hours after being born. Certain changes you can expect include changes in a baby’s breathing as more blood starts flowing to the lungs, as well as more oxygen getting to the lungs as the fluid starts to clear out.
This is a critical time for baby, and the newborn needs to be evaluated every half hour to every hour to make sure that extra care, besides just the routine care, isn’t needed. Starting in the delivery room and later in the mother’s room and/or nursery the following parameters will be watched closely.
- Baby's temperature - A newborn’s normal temperature, taken under the armpit, is between 97.7 and 99.5 degrees Fahrenheit for a child resting in an open crib. The baby’s temperature may be a little high at first due to mom having a fever or just from the warm environment of the womb. If the elevated temperature continues, this could be signal of an infection.
- Baby's heart rate - A newborn baby’s normal heart rate should be between 120-160 beats per minute. The rate may go down to between 85-90 beats per minute for a full-term baby during sleep. If a newborn’s heart rate is either too high or too low, it could signal some underlying heart disease or lung problem.
- Baby's respiratory rate - A newborn’s normal respiratory rate should be between 40 to 60 breaths each minute. Rapid breathing could signal a problem. A child who temporarily stops breathing may also have a problem that can be due to medications given to its mother while in labor or an overwhelming infection.
- Baby's muscle tone - The baby’s muscle tone is assessed in the early hours of life. Weak muscle tone may be a warning sign of a problem. Strong, vigorous muscle movements are very reassuring of a health newborn baby.
- Baby's color - A baby whose lips or body appear blue or purple may have some type of heart disease or respiratory disease. A blue coloration of the hands and feet right after birth is very common and normal. In a few hours the bluish coloration will leave giving rise to an all pink healthy baby.
Baby Health Section
Routine Care after Birth to Avoid Serious Problems
Common routine care procedures that are always done after birth include:
- Prophylactic eye ointment is administered to avoid eye infections
- Vitamin K is giving to avoid bleeding due to vitamin K deficiency
- Vaccination for Hepatitis B
- Care to prevent infection of the umbilical cord
- Monitoring for hyperbilirubinemia (too much bilirubin in the blood which leads to jaundice, a yellowish coloring of skin and eyes)
- Monitoring for hypoglycemia (low blood sugar levels)
With newborns, the risk of eye infections can be greatly decreased by using antibiotic eye ointment right after birth. This is a safe, easy and inexpensive way to help prevent problems with a baby’s eyesight. In the U.S., most states require this antibiotic prophylaxis to be done.
Both the Centers for Disease Control and Prevention, otherwise known as the CDC, and the American Academy of Pediatrics recommend using the following ointments as prophylaxis treatments for gonococcal infection of the eye:
- 0.5 % erythromycin ointment (1 cm ribbon in each of baby’s eyes)
- 1% tetracycline ointment (1 cm ribbon in each of baby’s eyes)
The ointment is applied, by placing it under the lower eyelid. It needs to be gently massaged onto the eyes, then after about a minute, you wipe away the extra ointment. You don’t want to wash the eyes out right afterwards though, because it could reduce the effectiveness of the ointment.
The prophylactic antibiotic eye ointment needs to be used right after birth; within about the first hour following delivery, no matter if the baby was born vaginally or via a C-section.
The main side effect from the eye ointment is noninfectious pink eye. This usually appears during the first 24 hours after application of the ointment, and clears up by itself within 48 hours.
Normally, vitamin K is given to a newborn baby right after birth to help prevent what’s called VKDB, or vitamin K deficient bleeding. Either nurses may give vitamin K as a drink or it may be injected right into baby’s muscles.
According to the American Academy of Pediatrics, the injected version is better than the oral version because it prevents a baby from getting VKDB either within its first week of life, or later on. Parents need to know there are serious problems with possible intracranial bleeding if they decide against their baby getting vitamin K.
Umbilical cord care
If you delivery your baby in a hospital, where sterile technique is used when clamping and cutting the umbilical cord, there usually isn’t additional care needed to help prevent infection of the umbilical cord.
If the umbilical cord cannot be clamped and cut in a sterile environment then using preparations like alcohol, triple dye, chlorhexidine and sulfadiazine all provide inexpensive options for reducing the risk of infection.
Hepatitis B vaccination
Routinely vaccinating newborns against Hepatitis B, no matter whether the mother has it or not, is recommended. Infants of moms who are positive will also need a Hepatitis B antibody, along with the vaccine. It’s preferred that this happens within the first 12 hours.
Routine Newborn Screenings in the First 48 Hours
Hearing loss - Routine screenings of newborn baby includes screening for hearing loss.
It’s important to identify a baby with hearing loss as soon as possible. Early recognition and intervention will help improve your baby’s speech development. In fact, screening newborns for hearing loss is required in most parts of the US.
Genetic and metabolic disorders - All newborn babies need to be screened for metabolic and genetic disorders so that steps can be taken to help prevent disease and reduce the morbidity and mortality associated with the found disorder. Routinely, such disorders that are screened for, include a baby having problems breaking down amino acids (phenylketonuria), babies without the ability to produce the thyroid hormone (hypothyroidism), babies without the ability to use a simple sugar called galactosemia, and babies with blood disorders (hemoglobinopathies).
Glucose Screening - Although low blood sugar in newborns can lead to brain injury, healthy term babies without problems are not routinely test because they are at a low risk for developing low blood sugar.
Babies who are at risk of low blood sugar are tested. The risk factors for low blood sugar and testing include:
- Premature birth
- Small or large babies
- Babies of diabetic moms
- Mothers who were treated with anti-diabetic drugs
- Babies that are transferred to the NICU or neonatal intensive care unit
- Babies that have too many red blood cells (polycythemia)
- Have symptoms similar to those with low blood sugar including tremors, being irritable, being jittery, lack of energy, are nearly unconscious, have had periods of stopping breathing, have poor feeding habits, have decreased muscle tone, and exhibit a low body temperature or seizures.
Jaundice (Hyperbilirubinemia) - Jaundice or hyperbilirubinemia develops when there is too much bilirubin in the blood. Bilirubin is formed when red blood cells break down after birth. This is a normal process after birth, if not excessive. But when excessive the baby’s skin and eyes develop a yellow coloration called jaundice.
After delivery, your baby will have blood tests to check the bilirubin level. The blood test will be performed every eight to 12 hours and before leaving the hospital.
Routine feeding the first day of life
Babies need to be fed frequently and early to prevent low blood sugar. How much and how often depends on whether the baby is drinking formula or is breastfed. It’s important to write down, in the beginning, when a baby feeds, and how much or for how long.
Because of the known benefits for babies and their moms, breastfeeding is recommended over formula. The exception is when medical issues prevent it, including mothers with HIV and who abuse drugs.
- If you are going to breastfeed your baby, try and feed as soon after delivery as is possible. Newborn babies in the hospital need to feed between 8-12 times a day. Breastfeeding is shown to be more successful when there is a lot of skin-to-skin contact between baby and mom, when the child stays in the room with the mom and when there are frequent feedings right after delivery. Breastfeeding experts, or lactation experts, can also offer support.
- Formula babies need 20 cal/oz iron-rich formulas. These babies are also fed on demand, but you don’t want to wait more than four hours between feedings. The babies need to drink at least 0.5 oz to 1 oz each feeding during the first few days.
- Some nurseries offer pasteurized, human donor milk for breastfed newborns who need additional supplementation beyond what their mother’s can provide.
Routine Weight loss of Newborn Baby - Losing weight is common for babies after delivery, especially those who are breastfed. Keep in mind, though, losing more than 7% means your baby needs medical attention. Typically, a normal baby will stop losing weight after about five days, and start regaining their birth weight by days 10-14. Normal weight loss is up to 7%.
Family Education before Leaving the Hospital
Parents, or the child’s primary caregiver, need to have some training regarding certain infant care. This includes:
- Benefits and importance of breastfeeding
- Knowledge about how often the child should urinate and defecate, and what it should look like. Stools without bile that are either pale in color or white can be an early indication of a liver problem.
- Knowledge surrounding the common signs of newborn problems including problems with jaundice and infections.
- The proper positioning, plus how to make sure your baby latches-on and swallows if you are breastfeeding.
- Skin, genital and umbilical cord care
- Infant safety, including the best sleeping position, which is on the back, as well as sleeping on a firm surface and installing/using a car seat correctly.
Length of the Hospital Stay
How long you stay in the hospital depends on both the mother and the baby. It needs to be enough time to detect any newborn problems, and to make sure the parents know how to take care of the baby at home. The mother’s health, the health of the baby, and the confidence of a mother in caring for her baby, as well as any home support systems and follow-up care will all be taken into consideration. The typical length of hospital stay for a normal vaginal delivery is 48 hours and 96 hours for a Cesarean Birth.
Discharge from the Hospital
Discharge from the hospital is a decision made between the family, the mother’s doctors and the baby’s providers. There are certain situations in which there may be a longer hospital stay, including first time moms, an ill mother, a newborn illness, issues with breastfeeding, mothers who didn’t have quality care during pregnancy and those without proper support around them.
According to the American Academy of Pediatrics Committee on Fetus and Newborn, there are minimum conditions and criteria, which need to be met before a newborn leaves the hospital. These include:
- No newborn problems that require additional hospitalization were detected while at the hospital or at the physical exam leading to discharge.
- The baby’s vital signs have been within a normal range and stable for at least 12 hours leading to discharge.
- The baby urinated and then passed at least one stool on their own. Most full-term babies do this within the first 24 hours.
- The baby successfully does at least two feedings, and can swallow, suck and breathe while feeding.
- If the baby had a circumcision, there’s been no excessive bleeding in the area for a minimum of 2 hours.
- If the baby had jaundice, there are plans for management and follow-up care.
- The baby has undergone screening and been watched for signs of group B streptococcal infection.
- The mother has been trained and can show she knows how to care for her child.
- The mother has support and doctors that will help her after getting out.
- Tests on the moms including syphilis and hepatitis B have occurred, and in some states, she’s been screened for HIV. Also, if there were any tests for the baby’s blood type, the cord or anemia tests, the results were reviewed.
- A first hepatitis B vaccine was given.
- Hearing screening, as well as screening for heart disease.
- An assessment of any family, social or environmental factors have been done. This may include domestic violence, lack of income, child abuse, substance abuse or mental illness.
- Anything preventing follow-up care, such as lack of a telephone or transportation has been addressed.
- If there’s a need for continued baby care, a medical home has been found and information about the baby’s birth has been sent over. If the baby leaves the hospital before 48 hours, there needs to be a follow-up appointment by a doctor at least 72 hours later, 48 hours if there are any known risk factors. If there’s no guarantee of a follow-up, then discharge needs to be put on hold.
Most of the time, these things can’t happen before the baby is 48 hours old. Considering getting out of the hospital before then should only happen if the baby is born at between 38-42 weeks of pregnancy, is a normal weight for their age, and can meet the guidelines above.
Due to the concern over early discharge, and the impact on both the mom and baby’s health, the federal government and state governments passed some discharge laws in the late 1990’s. The Newborns’ and Mothers’ Health Protection Act, or NMHPA, is aimed at preventing overly short hospital stays. Generally, the laws make insurance companies cover the costs of up to 48 hours for vaginal births and 96 hours for C-sections. These laws have increased the length of time moms and babies are staying in the hospital, and have seemingly made the rate of being readmitted to the hospital, or visiting the ER, go down.
Generally, a follow-up can be in either a medical office or a home, just so long as a competent health care worker can check on the baby and report the information to the baby’s doctor.
A follow-up will include:
- Assessing the newborn’s general health. This will include weighing the baby, looking for any signs of dehydration, looking for any new problems, finding out about the baby’s feeding schedule as well as urination and stools, and checking on jaundice.
- Assessing the mother’s interaction with her baby
- Assessing the baby’s behavior
- Talking about the best ways to feed a baby, making sure the baby is sleeping on his or her back, going over child safety seat rules, and talking about the benefits of breastfeeding.
- Reviewing any new lab tests, including the newborn screening
- Conducting any tests needed to check bilirubin in a baby with significant jaundice
- Verifying the healthcare maintenance and medical home plan
- Assessing the parents, including looking for signs of postpartum depression in the mom