Newborn Immediate Care: Assessment and First Steps

The First 30 Seconds

As soon as the baby is delivered:

1. Deliver to a warm, dry surface or directly onto the mother's abdomen while the cord is still intact.

2. Dry vigorously. Use a prewarmed, dry towel. Dry the head, trunk, and extremities rapidly and thoroughly. The act of drying is simultaneously stimulating — it triggers the baby's first breath in most cases.

3. Remove the wet towel. A wet towel maintains cold. Replace with a dry towel or blanket immediately after drying.

4. Assess in the first 30 seconds:

• Is the baby breathing or crying?
• Is there good muscle tone? (Arms and legs should be flexed, not floppy)
• What color is the skin? (Peripheral cyanosis — blue hands and feet — is normal initially. Central cyanosis — blue lips and trunk — is abnormal.)

If the baby is breathing, crying, and has good tone: proceed with routine care. If the baby is not breathing despite drying and stimulation at 30 seconds: begin resuscitation.

Temperature Management

This is the number one ongoing priority. Newborns have a large surface area relative to body mass, no body fat, and limited ability to generate heat (they cannot shiver effectively). A term newborn in an unheated room can reach dangerous hypothermia within minutes.

Normal newborn temperature: 36.5-37.5°C (97.7-99.5°F)

What maintains temperature:

• Skin-to-skin contact with the mother: the most effective warmer available. Place the naked baby directly against the mother's bare chest. Cover both with a blanket.
• Warm room if available
• Warm dry blankets or clothing
• Hat: a significant amount of heat loss in newborns occurs through the uncovered head

Signs of hypothermia: Skin feels cold, baby lethargic and not interested in feeding, skin appears mottled (blotchy purple-white pattern), pale

Signs of hyperthermia (less common, but possible if over-wrapped): skin hot to touch, sweating (uncommon in newborns — take seriously), flushed

Airway Management

Most newborns clear their own airway. Aggressive suctioning is no longer recommended as standard practice — the pressure of birth squeezes fluid from the airway, and the baby's own cough and cry clears the rest.

When to suction:

• Meconium-stained amniotic fluid (dark green fluid) that covers the baby's face at delivery
• Visible secretions at the mouth or nose that the baby appears to be struggling around
• Baby with depressed respirations who is not responding to stimulation

How to suction:

• Bulb syringe: squeeze, insert gently (do not go beyond 1cm into the nares or 2cm into the mouth), release to suction
• Suction the mouth first, then the nose — stimulating the nose causes an involuntary gasp, which sucks secretions deeper if the mouth is not yet clear
• Do not deep suction aggressively — stimulating the posterior pharynx causes vagal bradycardia (slows the heart rate)

Cord Care

Delayed cord clamping: Leave the cord intact and pulsing for at least 1-3 minutes. The cord pulsation delivers blood from the placenta to the baby — delayed clamping improves the baby's iron stores and blood volume.

Clamping: Clamp in two places (2cm and 5cm from the baby's abdomen) after the cord stops pulsing. Cut between the clamps with clean scissors or a knife.

Cord stump care:

• Keep it clean and dry
• Fold diaper below the cord stump — do not cover it
• Allow it to air-dry
• Do not apply creams, powders, or treatments to the stump unless instructed by a medical provider (WHO recommendation: dry cord care)
• The stump will turn yellow, then brown, then black, and fall off in 1-2 weeks
• Signs of infection requiring treatment: redness spreading from the stump onto the abdominal skin (omphalitis — potentially serious), pus, foul odor, fever

Eye Care

In medical settings, erythromycin ophthalmic ointment is applied to prevent ophthalmia neonatorum (gonococcal eye infection from passage through infected birth canal). In a field setting without this medication, ensure the eyes are cleaned of amniotic fluid and blood.

If purulent (pus-forming) eye discharge develops in the first days of life, this suggests infection requiring antibiotic eyedrops.

Assessment: Apgar Score

The Apgar score is assessed at 1 minute and 5 minutes after birth. A score of 7-10 at 5 minutes is reassuring. Below 7 at 5 minutes: resuscitation or close monitoring indicated. Below 5: active resuscitation required.

| Category | 0 | 1 | 2 | |---|---|---|---| | Appearance | Blue/pale all over | Blue extremities, pink trunk | Pink all over | | Pulse | Absent | Below 100/min | Above 100/min | | Grimace | No response | Grimace only | Cry, cough, sneeze | | Activity (tone) | Limp | Some flexion | Active | | Respirations | Absent | Weak, irregular | Strong cry |

Newborn Resuscitation: When Needed

The NRP algorithm applies when the newborn is not breathing or not maintaining adequate heart rate despite drying and stimulation.

30 seconds: Assess If not breathing/crying and no tone: begin Positive Pressure Ventilation.

Positive Pressure Ventilation (PPV):

• Position the head in neutral "sniffing position" — slight neck extension to open the airway
• Cover both mouth and nose with your mouth or a face mask
• Provide 40-60 breaths per minute
• Breaths should be small — just enough to see the chest rise. Newborn lungs are small; adult-sized breaths cause damage.
• Look for chest rise with each breath

If no improvement at 30 seconds of PPV:

• Adjust mask fit, reposition head, ensure airway is clear
• Continue PPV

If heart rate below 60/min despite PPV:

• Begin chest compressions: two thumbs on the lower third of the sternum, other fingers encircling the chest
• Compress 1/3 of the chest diameter
• 120 compressions per minute
• 3:1 ratio: 3 compressions then 1 ventilation breath (this 3:1 ratio for newborns differs from adult CPR)

If no recovery in 10 minutes: Prognosis is extremely poor.

Feeding in the First Hour

Breastfeeding should begin within the first hour. The first milk (colostrum) is small in volume but dense in antibodies (IgA) and protective proteins. Colostrum provides the newborn's immune system with its first external support.

Breastfeeding triggers:

• Baby's gut colonization with beneficial bacteria
• Maternal oxytocin release (reduces PPH risk)
• Baby's blood glucose stabilization

Most healthy term newborns will root and feed vigorously in the first hour. A newborn who is not interested in feeding after a rest period, or who feeds very briefly and ineffectively, should be assessed for temperature (hypothermia causes feeding suppression), blood glucose (if the mother is diabetic), or other issues.

The First 24 Hours

Voiding: First void (urination) should occur within 24 hours. First meconium stool (dark, tarry) within 24-48 hours. Failure to void or stool within these timeframes may indicate a structural issue (meatal stenosis, Hirschsprung's disease) — requires evaluation.

Jaundice (hyperbilirubinemia): Yellow tinge to skin and whites of eyes beginning 24-72 hours after birth is physiologic jaundice — common and usually benign. Jaundice appearing in the first 24 hours is pathologic and requires urgent evaluation. Treatment (phototherapy) for jaundice requires medical equipment. Field exposure to natural sunlight has historically been used but is not equivalent to phototherapy.

Temperature monitoring: Check temperature every 1-2 hours for the first 12 hours, then every 4 hours. Any temperature below 36.5°C: increase warming measures. Any fever above 38°C in the first week of life: potential infection, requires evaluation.

Feeding assessment: By 24 hours, the newborn should have fed 6-8 times. If feeding is not establishing or the newborn appears dehydrated, evaluate.