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1 Introduction

Of the approximately 4 million live births occurring annually in the United States [1] over 90% require nothing but routine care of the infant in the delivery room. The majority of these births are considered low risk, but the percentage of deliveries that are categorized as low risk has decreased in recent years. This is in part due to increasing numbers of births at the extremes of childbearing age, an increase in complications due to maternal morbidities such as obesity, and an increasing preterm birth rate.

In many cases, the need for newborn resuscitation can be anticipated. However, at every birth, the appropriate equipment should be available. Neonatal Resuscitation Program (NRP) guidelines and common sense recommend that at least one person skilled in neonatal resuscitation whose only responsibility is the management of the newborn is present at every delivery. This person does not need to be a physician, but should possess the ability to perform the initial steps in resuscitation until additional help arrives [2].

The initial steps in the management of the newborn will be discussed elsewhere in this text. Several key aspects of continuing care of the well newborn in the delivery room and during the recovery period will be discussed.

In the healthy term newborn the goal of delivery room care should be to assess the newborn for any features that may confer the need for closer monitoring and follow-up, and to promote the natural bonding between mother and infant. In this regard, much of the continuing care of the newborn can be done in such as way as to be minimally invasive to the infant and not disruptive to the mother-infant dyad.

2 Routine Assessment

2.1 Physical Exam

Every newborn should be assessed with a brief physical examination in the delivery room. The complete physical exam of the newborn will be discussed in detail in later chapters, and has a different goal. As previously stated, the purpose of the physical exam in the delivery room should be to assess the newborn for any features that may indicate the need for immediate intervention or for further investigations and followup during the nursery stay. Important findings to identify are:

  • visually patent and normally placed anus

  • normal external genitalia

  • presence of cleft lip or palate

  • intact spine and sacral area.

Most major congenital malformations are discovered during routine prenatal care, and second trimester ultrasound at 18–22 weeks gestational age remains the most common imaging modality. When performed at tertiary care or University affiliated institutions, second trimester ultrasound has been shown to have good specificity and fair sensitivity for the detection of fetal anomalies [3]. However, defects such as those listed above, especially small facial anomalies, are frequently difficult to detect with traditional 2-dimensional ultrasound techniques. As more sophisticated techniques such as 3-dimenstional ultrasound or fetal magnetic resonance imaging (MRI) come into wider use, the detection rate for these anomalies, especially spinal and facial defects, may improve [4].

It is not recommended to perform a rectal probe exam, such as a rectal temperature, to document patency of the anus. Deep suctioning of the nasally or orally is also neither necessary nor recommended to determine patency of the nares or esophagus, as this may lead to trauma or perforation of the mucosal tissues. This is supported by recommendations from The American Academy of Pediatrics (AAP) section on breastfeeding, which states that unnecessary, excessive, and overvigorous suctioning of the oral cavity, esophagus, and airways may traumatize the infant and lead to aversive feeding behavior [5]. An early physical examination of the infant can also document normal variants such as molding or caput of the scalp, Mongolian spots or sucking blisters, and reassure parents of the benign nature of such findings. The initial physical assessment of the baby can be performed while skin-toskin contact with the mother is taking place.

2.2 Thermal Regulation

Thermal regulation of the neonate, both preterm and fullterm, is one of the major challenges faced in the delivery room. Heat loss in newborns occurs through four basic mechanisms: radiation, conduction, convection and evaporation.

Heat loss through radiation is related to the temperature of the surfaces surrounding the infant but not in direct contact with the infant, and is an important mechanism in heat loss in term infants. This is the rationale behind placing the infant on a radiant warmer immediately after delivery. However, the infant may emit radiant heat to a colder source, such as walls or windows. Conduction is the transfer of heat through direct contact with a surface that is colder or warmer, such as the bedding or swaddling that the infant is initially placed in. In convection, heat transfer occurs when air currents carry heat away from the body surface. The fetus generates heat, and the temperature of the newborn is approximately 0.5°C higher than the maternal temperature. Most delivery rooms are obviously colder than the newborn, and heat is first conducted into the air and then carried away by the convective air currents. This is an especially prominent phenomenon in the operating room, where the ambient air temperature is often kept cooler for the comfort of the garbed medical staff. Evaporation occurs when water is lost from the skin. During evaporation, approximately 0.6 kcal of heat is lost for every 1 g of water lost from the body [6–8]. Reducing heat loss though evaporation is a target of intervention that is especially important in the very preterm infant. In the full-term infant, the initial step of drying the infant with warm blankets ameliorates both evaporative and conductive heat loss.

Heat is generated by the newborn primarily though non-shivering thermogenesis. Non-shivering thermogenesis is the production of heat that does not occur through muscle activity. In neonates, this occurs primarily though the metabolism of brown fat. Brown fat, found in infants greater than 30 weeks, contains a high concentration blood vessels and sympathetic nerve fibers, and its metabolism causes an increase in sympathetic activity leading to an increase in norepinephrine, thyroid-stimulating hormone, T4 and T3. These mediators cause increased fat oxidation and heat production [6–9].

There are several ways to reduce heat loss and prevent resultant cold stress. The simplest method is that of skin-to-skin contact. The mother is an optimal heat source for the infant. Skin-to-skin contact has been well studied in many different cultures and resources settings, and has been shown to successfully maintain normal temperature of healthy term neonates. This type of contact can also alleviate mind hypothermia. It has been shown to promote bonding and facilitate both the initiation and continuation of breastfeeding [5, 6]. Other methods of preventing hypothermia in the newborn include placing a cap on the infant, and keeping the temperature of the delivery room such that heat loss due to evaporation and conduction, respectively, are minimized.

2.3 Initiation of Breastfeeding

The full physiology and nutrition of breastfeeding and breast milk will be discussed in Section III. For the purpose of the care of the infant in the delivery room, the initiation of breastfeeding may be considered one of the most important contributions to the health and well-being of a newborn. Briefly, the AAP recommendations for breastfeeding and breast milk include:

  • breast milk for all infants for whom it is not medically contraindicated

  • exclusive breastfeeding for the first 6 months of life

  • continuation of breastfeeding for at least one year

  • peripartum practices that facilitate breastfeeding.

The alert, healthy newborn infant is capable of latching on to a breast without specific assistance within the first hour after birth [5, 10]. In keeping with the previous discussion on temperature regulation, the AAP recommendations to promote breastfeeding in the delivery room encourage that well, fullterm infants be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished [5, 10]. Weighing, measuring, bathing, and other non urgent interventions should be delayed until after the first feed is completed. For both bonding and breast feeding purposes, the newborn infant should remain with the mother throughout the recovery period. A Cochrane review confirms that institutional changes in maternity care practices effectively increased rates of breastfeeding initiation and duration [11]. Institutional policies surrounding routine care of healthy newborn should be developed with the goal of safety and the promotion of the mother infant bond, as opposed to convenience of the medical and ancillary staff.

3 Vital Signs and Measures

3.1 Vital Signs

Non-invasive vital signs, such as heart rate, respiratory rate and temperature, as well as the procedure of weighing and measuring the infant, are often performed in the delivery room. Some institutions also have protocols involving more invasive measures, such as screening for oxygen saturation, hypoglycemia, anemia or polycythemia.

A vigorous term infant who has been ascribed good APGARS is unlikely to have major derangements in pulse or respiratory rate. Mild tachypnea may be a physiologic part of the transition from fetal to extrauterine life. The increased pulmonary vascular resistance of the newborn as manifest by oxygen saturation takes time to normalize. Studies have demonstrated that healthy full-term neonates rarely reach oxygen saturations of greater than 90% until after the first 10 minutes of life, and may have lower post-ductal saturations for an even longer period [12, 13].

3.2 Hemoglobin and Hematocrit

Healthy full-term infants have, in past years, been targeted for treatment of anemia or polycythemia based on values obtained from routine screening at birth. This can be troublesome from several perspectives. The definition of both anemia and polycythemia can vary. Most practitioners define anemia as a greater than 2 standard deviations below the mean hemoglobin, or less than the fifth percentile. For full-term neonates, this is approximately 13 g/dL from a sample of blood drawn centrally, or 14.5 g/dL drawn from capillary sampling. Symptoms of anemia in the immediate newborn period may range from pallor to tachypnea to severe respiratory distress and circulatory collapse. Polycythemia can be defined in a similar manner, but has traditionally been diagnosed as a hematocrit greater than 65% drawn centrally or 70% drawn from a capillary specimen. Risk factors include macrosomic infants, or infants who are born to mothers who have conditions that affect placental blood flow, as a compensatory mechanism from the fetus.

Symptoms of polycythemia include central nervous system (CNS) manifestations such as lethargy and tremulousness, hypoglycemia, as well as evidence of organ failure such as respiratory distress, renal failure, congestive heart failure, or intestinal symptoms. Both obstetric practices, such as method of delivery, timing of cord clamping and positioning of the infant relative to cord clamping, can affect these values, as do the timing of blood draw relative to delivery [14, 15]. The degree to which an individual infant is symptomatic at a particular hemoglobin or hematocrit is extremely variable. It is also very difficult to differentiate the clinical effects, both short and long-term, of polycythemia and anemia in an asymptomatic infant, from the effects of the cause of the abnormal indices. Especially for polycythemia, there is no evidence to suggest that the treatment modality, partial exchange transfusion, of an asymptomatic infant improves outcome. The most sensible approach would be to consider screening infants who are at risk for anemia from fetal or intrapartum complications, and may warrant closer follow-up, or for any infant who displays symptoms of abnormal hemoglobin or hematocrit [15].

3.3 Monitoring of Glucose

There has been much discussion in recent years as to the measurement and management of glucose levels in the low risk infant.

The fetus has a complete and continuous supply of glucose from the mother from placental transfer, via carrier mediated facilitated diffusion. After birth, when this supply is abruptly cut off, there are several mechanisms to maintain adequate energy to the infant:

  • glycogenolysis

  • gluconeogenesis

  • lipolysis

  • fatty acid oxidation and ketogenesis

  • hormonal/endocrine regulation of these systems.

Serum glucagon, catecholamines and growth hormone rise after cord clamping and insulin levels fall, favoring glycogenolysis, lipolysis and gluconeogenesis. Full-term infants are born with adequate glycogen stores, but these are depleted within the first several hours after birth unless feeding is established. Lipolysis can occur shortly after birth, and releases free fatty acids that can be used as an energy source by many tissues, although not by the brain. Fatty acid oxidation and ketogenesis take place in the liver, and produces β-hydroxybutyrate, acetoacetate and ketones which can be used by as an energy source for the brain. Several of the major hormones required for control of these systems rise in the first few hours of life, leaving the production of usable energy from both gluconeogenesis and hepatic ketogenesis delayed. This leaves free fatty acids from lipolysis and glucose from breakdown of glycogen stores as the major energy sources immediately after birth [8, 16]. In infants with poor stores of adipose tissue or glycogen, such as preterm or growth restricted infants, maintaining an adequate supply of fuel for the metabolic needs of the brain becomes of great concern. Infants who are well may also be at risk. Non-shivering thermogenesis is the major mechanism of heat production in the neonate, and cold stress in the delivery room can occur. A newborn infant left unattended in an environment at typical “room temperature” experiences energy losses of approximately 150 kcal per minute, rapidly using up energy stores [6]. Delay in enteral feeding for routine newborn care can also exacerbate hypoglycemia. This provides further evidence for care to be performed skin-to-skin with the mother with early initiation of breastfeeding.

Many nurseries still monitor serum glucose levels in low risk, healthy infants as part of routine care. A problem can then arise, as debate occurs about what level of serum glucose should be considered abnormal and require intervention in an asymptomatic, otherwise well newborn. When it was first recognized as a pathologic state, hypoglycemia was defined as less than 20 mg/dL (1.1 mmol/L) in preterm infants and less than 30 mg/dL (1.7 mmol/L) in full-term infant. Cohort studies later showed that infants with symptomatic hypoglycemia had poorer neurodevelopmental outcomes [17]. Since that time, there has been little agreement about minimum acceptable level of glucose in healthy term infants. Some authors contend that 45 mg/dL (2.5 mmol/L) is the lower limit for all infants [18, 19]. Other maintain that due to the key time in development, and lack of evidence for compensatory mechanisms that protect the neonatal brain from hypoglycemic injury, glucose values should be the similar in newborns as in older children, greater than 60 mg/dL or 3.3 mmol/L [16]. Symptoms from hypoglycemia include tremulousness, lethargy, seizures, hypothermia, or can mimic respiratory distress. Infants who are considered at risk for hypoglycemia are those who are small or large for gestational age, or who have maternal risk factors for abnormal glucose such as gestational diabetes or medications affecting glucose metabolism. Also at high risk for sequelae from hypoglycemia are those infants who have evidence of infection, hypothermia, polycythemia or hypoxiaischemia [18, 19]. It is generally accepted that healthy term infants, either breast-fed or formula-fed, who do not have risk factors for compromised metabolic adaptation and who are asymptomatic need not have routine glucose monitoring [15]. Any infant who appears symptomatic from hypoglycemia, or in whom risk factors for increased altered glucose metabolism exist should be evaluated and treated as necessary.

4 Common Routine Treatments

4.1 Eye Care

Neonatal ophthalmia is defined as conjunctivitis that occurs within the first 28 days of life. It is a relatively common illness, occurring in 1–12% of newborn infants. Originally, neonatal ophthalmia referred to conjunctivitis in the newborn caused by infection with Neisseria gonorrhoeae, but now the term refers to any conjunctivitis in this age group, regardless of the cause [20]. Gonococcal ophthalmia was, in the past, a leading cause of blindness, but is now rare in most developed populations with access to treatment and screening during pregnancy. It is for this historical reason that delivery room prophylaxis was geared towards prevention of blindness from this pathogen. Since the diminishment of gonococcal ophthalmia, there has been debate about which agent, if any, to use as prophylaxis against conjunctivitis in the delivery room. Most cases of conjunctivitis in the neonatal period are due either to chemical conjunctivitis or non sexually transmitted colonizing bacteria. Chlamydia trachomatis also causes a portion of ophthalmia, depending on local incidence. With the exception of gonococcal and chlamydial conjunctivitis, the condition is mild, and usually responds well to local treatment with no long-term sequelae with appropriate therapy. It is the consensus from the AAP, as well as the Canadian Paediatric Society (CPS) that eye prophylaxis, in the form of 1% silver nitrate, 0.5% erythromycin, or 1% tetracycline drops or ointment be given. The medication should be instilled as soon as possible in the delivery room, and should not be wiped off. There is no data suggesting that delaying administration until after the first breastfeed in any way affects efficacy. Erythromycin ointment has replaced other forms of prophylaxis in the US, as some initial data suggested that there may be protection against chlamydial species. Later studies disproved this [21] probably due to the fact that local treatment will not eradicate nasophargyngeal colonization of the organism. Many US physicians feel that erythromycin causes less chemical conjunctivitis than silver nitrate and the drug remains in wide usage. This is not the case in other countries, where aminoglycoside, chloramphenicol, or no prophylaxis is used. As demonstrated by Guala et al [22], agents used as prophylaxis against neonatal ophthalmia vary widely between centers and are functions of local practice and tradition, as opposed strictly to evidence based medicine.

4.2 Vitamin K

Due to limited stores at birth, neonates are prone to vitamin K deficiency if no sufficient intake is provided. The clinical syndrome associated with vitamin K deficiency has been termed hemorrhagic disease of the newborn, and comprises three distinct presentations. The very early form presents within 24 h of birth and is almost exclusively seen in infants of mothers taking drugs which inhibit vitamin K. These drugs include certain anticonvulsants, some antibiotics and vitamin K antagonists, many of which are now avoided in pregnancy. Clinical presentation can be severe, with cephalohematomas, intracranial and intra-abdominal hemorrhage. Classical vitamin K deficiency occurs between 24 h and 7 days of life and is associated with delayed or insufficient feeding. Clinical presentation is often mild, with bruises, gastrointestinal bleeding, or bleeding from the umbilicus and puncture sites. The late presentation of vitamin K deficiency is associated with exclusive breast-feeding. It occurs between the ages of 2 and 12 weeks and infants can be gravely ill, with a mortality rate of 20%. Intracranial hemorrhage occurs in up to 50% of those affected [23]. After the discovery of vitamin K in the mid 20th century, it was shown that treatment with vitamin K could abolish hemorrhagic disease of the newborn. It then became standard practice to administer the drug soon after birth to all infants. Controversy has arisen about this practice for several reasons. Both classic and late vitamin K deficiency are relatively rare: recent reviews cite estimates of 0.01–0.44% in the general population for the classic form, and between 4.4/100,000 and 7.2/100,000 births for the late form in fully breast-fed infants who did not receive vitamin K at birth [23]. The present dose of 1 mg represents a very large amount when compared to the daily requirement of 5–10 µg in infants. The dose of 1 mg appears to have been chosen fairly arbitrarily, with no formal studies being performed to establish what dose might be appropriate. Intramuscular form became the route of choice based primary on the available formulation at the time [24]. In the 1990s, a study from Britain linked the administration of intramuscular vitamin K at birth to childhood cancers and leukemia [25]. Later studies failed to confirm this association, but the guidelines for universal prophylactic vitamin K were revised in many countries to include enteral dosage. It is universally accepted that vitamin K is necessary to prevent all forms of clinical disease in newborns. However, the method of administration and timing remain non-uniform across guidelines. For infants at risk from maternal medications, traumatic delivery or prematurity, the intramuscular route is preferred. For healthy term newborns at low risk, the CPS recommends that vitamin K should be given as a single intramuscular dose of 1.0 mg to all newborns within the first 6 hours after birth. For infants whose parents refuse an intramuscular injection, an oral dose of 2.0 mg of vitamin K at the time of the first feeding with dosages repeated at 2–4 weeks and 6–8 weeks of age may be used [26]. Some countries have investigated the use of a small daily dose of enteral vitamin K in lieu of large doses less frequently in breastfeeding infants who did not receive the injection at birth, with apparent success [23]. Parents choosing oral dosing should be advised of the necessity of follow-up doses and be cautioned that their infants remain at an increased risk of late vitamin K deficiency (including the potential for intracranial hemorrhage) using the oral as opposed to parenteral route [26].

5 Conclusions

A 1995 study performed across several Italian nurseries showed that despite the availability of evidence based national and international guidelines pertaining to routine newborn care, practices were guided by long standing habit and previously developed experiences [22]. This can be extrapolated to many aspects of neonatal care. However, in the low risk, well newborn, the guiding principle should be to ensure the health and well-being of the baby, and facilitate practices that will encourage continued health through maternal child interaction.