![]() Generally, by 6 hours postpartum, infant behavior is more predictable and less labile. This second interval of increased activity is more moderate than the first. After 1–2 hours of diminished activity, a resurgence occurs for approximately 15–30 minutes heart and respiratory rates are again elevated, and muscle tone is again increased. Cardiac and respiratory rates decrease, spontaneous movement is infrequent, and muscle tone is noticeably diminished. After 30–60 minutes, the infant usually sleeps or appears quite relaxed. The infant's demeanor is one of irritation: muscle tone is increased, tremors may occur, and spontaneous jerking movements of the extremities may be frequent. 3 The neonate's eyes are often open, and spontaneous movements are frequent. The first 30–60 minutes are characterized by hyperactivity, including a heart rate that may vary from 160 to 180 beats per minute and a respiratory rate of 60–80 breaths per minute. Spontaneous activity of healthy infants waxes and wanes for several hours following birth. An accurate evaluation of the infant is gratifying and reassuring to all families. The obstetrician, who has been intimately involved with the parents for several months during prenatal care, is considered the parents' first reliable source of information when the infant is born. When all is not well, firm and discrete support is essential. Even when all has gone well, at the very least, parents require guidance. The parents' overriding emotional stake in a pregnancy is embodied in their infant. There should be sensitivity to indications of suboptimal parent-infant rapport, the attitudes of parents and siblings to the newborn, and the provision of information on parenting. The neonate is observed for the onset of jaundice, tolerance of feedings, patterns of voiding and defecation, and other signs that suggest normal or abnormal adaptation to extrauterine life. In the nursery, the neonate continues to adapt to the extrauterine environment. Abnormalities that are discerned in the nursery usually require special neonatal care that is less urgent. The evaluation for major abnormalities can be accomplished rapidly in the delivery room before the infant is given to the parents or transferred to the nursery. *A total score of 7–10 at 5 min is considered normal 4–6, intermediate and 0–3, low. Although traditionally performed at 1 and 5 minutes after birth, it is effective for assessment in the delivery room at other times thereafter. ![]() In the delivery room, the Apgar score is an effective indicator of the infant's progress in adapting to extrauterine life (Table 1). ![]() American Academy of Pediatrics and American Heart Association, Appendix 2006) (Adapted from Neonatal Resuscitation Textbook, 5th edn. Below is an algorithm for neonatal resuscitation. Most causes involve asphyxia or respiratory depression. This number increases as birth weight decreases. In this context, frequent comparison to significant pathologic findings is unavoidable.Īpproximately 8–12% of neonates require some degree of resuscitation at delivery. The list of such normal variations is long the discussion in this chapter is largely concerned with this type of physical finding. Specific examples are parental anxieties over cephalhematoma, small anterior fontanel during the first day of life, erythema toxicum, physiologic jaundice, caput succedaneum, genital edema, or hydrocele. Some unimportant variants may impress parents dramatically, and these findings must be identified as insignificant, transient, or normal variants. If neither is found, the next consideration is to evaluate for the variant and minor abnormalities that are often discerned in otherwise normal infants. Immediately after birth, the obstetrician needs to ascertain, from a brief assessment of the infant, whether there is illness or malformation. Today's normal signs may be tomorrow's abnormalities. One additional facet of global assessment is the relation of physical findings to the time of their occurrence. Assessment also requires understanding of the aftermath of intrauterine and parturitional experience, and it further requires comprehension of the phenomena of extrauterine adaptation (particularly cardiovascular and respiratory) and the impact of the environment of the infant (particularly thermal factors). What happened before the infant was actually seen? The historic considerations concern familial predispositions to disease states, maternal status, the course of pregnancy, and the nature of labor and delivery. Circumspect assessment of a neonate is no different from that of older patients: it must first consider an informative history.
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