Which nursing action has the highest priority for an infant immediately after birth?

One of the most important functions you will perform in the postpartum period are the assessment of and interventions for the newborn. This can be divided into three phases starting with birth and leading up to the period where the newborn has appropriately transitioned to life outside the womb. In this article, we’ll be focusing on the initial assessments that occur within the first few minutes to first 24 hours of birth. 

Immediate assessment

Immediately after the infant is born, you’ll be conducting some key assessments. The most important is the APGAR score. This assessment is a quick review of the baby’s body systems and adaptation to extrauterine life. It is typically conducted at minute 1, then again at minute 5, with potential further assessment done 10, 15, and 20 minutes after birth if the score is less than 7 (though please note this can vary by policy).

With this assessment, you are looking at five components: The baby’s activity, pulse, grimace, appearance and respirations. The best possible score is a 10, but anything in the 7-10 range is generally considered normal for this immediate period after birth. A score of 4-6 tells us that baby is having some difficulty adjusting to life outside the womb. This is often due to medications the mother was given during labor or in cases of a very rapid delivery or premature delivery. A score of 0 in any area or a total score below 4 is of considerable concern. This baby may have a health problem we don’t know about yet such as a cardiac abnormality, bleeding or difficulty breathing. Additionally, this baby will need immediate resuscitation, further evaluation and likely heading to the NICU.

A baby whose APGAR score does not improve beyond the 0-3 range at the 20 minute mark has a high risk for mortality. As the “baby nurse” (the one who is caring for the baby) it is your responsibility to always immediately report APGAR scores to the attending practitioner (MD or Nurse Midwife) so appropriate interventions can be completed.

• Activity: Make note of the baby’s level of activity. It can range from no movement with flaccid muscles or vigorous movement of arms and legs. 
• Pulse: You can obtain heart rate by auscultating the heart, or palpating the junction at the umbilical cord and skin. A heart rate that is absent or less than 100 bpm requires immediate intervention. A rate less than 60 bpm requires chest compressions as this baby is in a lot of trouble.
• Grimace: With this assessment we are looking at baby’s response to stimulation. A perfect time to do this is with nasal suctioning with the bulb syringe or tapping baby’s foot.
• Appearance: We are looking for a baby with skin color appropriate for their skin tone. While the blanket term is “pink” note that a pink tone isn’t necessarily going to show on darker-skinned infants. Pallor, however, will be notable on the palms and soles of the feet. A baby who is oxygenating well and “pink” will usually have good scores for pulse and respirations as well. 
• Respiration: A crying baby is a breathing baby! If you are assessing by visualization, be sure to assess respirations by observing the rise and fall of the abdomen since newborns are diaphragmatic breathers. It is standard of practice in many facilities to measure respiratory rate by auscultation. A baby with inadequate respirations (or none at all) requires immediate respiratory intervention. 

APGAR SCORING

Nurse interventions to improve the APGAR score include: 

• Stimulating the baby to breathe or providing positive pressure ventilation (PPV) via the bag valve mask. 
• Possible bulb suctioning the airway as needed, though this is being phased out unless absolutely critical due to risk for bradycardia and aspiration.
• Normalizing temperature (usually involves keeping baby warm, but hyperthermia can occur in febrile mothers).
• Performing chest compressions as needed.
• If heart rate is less than 100 bpm, apneic or gasping, it’s a common policy to start PPV until heart rate and respiratory status improves.
• If Hr < 60, PALS guidelines indicate it is time to start chest compressions. Many facilities have an ALS team that conducts NRP (neonatal resuscitation),  though it will be initiated by the nurse at the bedside.

Other interventions during the immediate postpartum period

In addition to obtaining the baby’s APGAR score and intervening as necessary, what else will you do during those crucial moments following birth? Note the timing of these assessments and interventions will vary based on facility policy. In general, the first 24 hours after birth include the following:

As soon as possible

• Dry the infant and utilize skin-to-skin to promote bonding, prevent heat loss and help baby adjust to extrauterine life.
• Cord blood gasses may be collected based on protocols or MD order
• Cord blood is obtained to test baby’s blood type.
• Apply ID band
• Apply cord clamp (typically at 1 minute)
• VS every thirty minutes (temp, heart rate and respiratory rate). Note that it is best practice to obtain heart rate and respiratory rate via auscultation versus palpation and visualization.

In the post-partum period

• At one hour: weight, measurements, footprints, baby meds (erythromycin eye ointment) and Vit K. Some facilities may give Hep B, but it is often delayed until Day 1. 
• Assess baby for any abnormalities by conducting a thorough head-to-toe assessment.
• Check blood glucose if mother is diabetic or if mother has received certain medications in labor (Terbutaline or some beta blockers) or if baby is preterm, SGA or LGA.
• Promote bonding and breastfeeding as appropriate.

So there you have it! Your quick guide to APGAR scores and some key nursing interventions in the immediate period following birth. 

References

Encyclopedia of Children’s Health. (n.d.). Apgar testing. Encyclopedia of Children’s Health. http://www.healthofchildren.com/A/Apgar-Testing.html

Kattwinkel, J., Perlman, J. M., Aziz, K., Colby, C., Fairchild, K., Gallagher, J., Hazinski, M. F., Halamek, L. P., Kumar, P., Little, G., McGowan, J. E., Nightengale, B., Ramirez, M. M., Ringer, S., Simon, W. M., Weiner, G. M., Wyckoff, M., & Zaichkin, J. (2010). Part 15: Neonatal resuscitation. Circulation, 122(18_suppl_3), S909–S919. https://doi.org/10.1161/CIRCULATIONAHA.110.971119

Pieron, P. P. M. P., MPH, MSN, APRN-Rx. (2012). Neonatal nursing care 101. Nursing Made Incredibly Easy!, 10(5), 30–36. https://doi.org/10.1097/01.NME.0000418034.61512.67

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