Care of the Baby in the Delivery Room

The birth of a baby is one of life's most wondrous moments. Few experiences can compare with this event. Newborn babies have amazing abilities, yet they are completely dependent on others for every aspect of their care, such as feeding, warmth, and comfort.

Amazing physical changes occur with birth. When the baby is delivered, the umbilical cord is cut and clamped near the navel. This ends the baby's dependence on the placenta for oxygen and nutrition. As the baby takes the first breath, air moves into the lung airways. Before birth, the lungs are not used to exchange oxygen and carbon dioxide. The fetal circulation sends most of the blood supply away from the lungs. When a baby begins to breathe air at birth, the change in pressure in the lungs helps to redirect the blood supply to the lungs. Now the blood is pumped to the lungs to help with the exchange of oxygen and carbon dioxide. Some babies have excess amounts of fluid in their lungs. Stimulating the baby to cry can help bring the fluid up where it can be suctioned from the nose and mouth.

Providing warmth for the newborn:

A newborn is wet from the amniotic fluid and easily can become cold. Drying the baby and using the moms body heat can prevent heat loss. A knitted hat is placed on the baby's head and the baby is placed skin-to-skin on the mother's chest to help keep the baby warm.

Immediate care for the newborn:

Assessments of the new baby begin immediately. One of the first checks is the Apgar score. This is a scoring system designed by Dr. Virginia Apgar, an anesthesiologist, to evaluate the condition of the newborn at one minute and five minutes after birth. The physicians or the pediatricians will evaluate the following signs and assign a point value:

A Activity; muscle tone
P Pulse rate
G Grimace; reflex irritability
A Appearance; skin color
R Respiration

A score of 7 to 10 is considered normal. A score of 4 to 6 may indicate that the baby the needs some resuscitation measures (oxygen) and careful monitoring. A score of 3 or less indicates that the baby requires immediate resuscitation and lifesaving techniques.

Examination and care of the newborn in the delivery room:

A brief physical exam is performed to check for obvious signs that the baby is healthy. Other necessary procedures will be done over the next few minutes to hours. Vital signs, weight and other measurements will be taken. Small or underweight babies, as well as very large babies, may need special attention and care. Footprints are also done. Before a baby leaves the delivery room, identification bracelets with identical numbers are placed on baby, mother and father. These should be checked each time the baby comes or goes from your room.

In the first hour of two after birth, most babies are alert and wide awake. This is a wonderful opportunity for parents to get to know their new baby. Also during this time is the best time to begin breastfeeding. Newborns have an innate ability to begin nursing right after birth. Some medications and anesthesia given during labor may effect the baby's ability to suck, but most healthy babies are able to breastfeed in the first few hours. This first feeding not only stimulates the breast to begin milk production, but also causes the mother's uterus to contract, which helps prevent excessive bleeding.

Examination and care of the newborn in the OR:

Babies born by cesarean are assessed by a nurse and the pediatrician right after delivery. This is often done right near you in the operating room. Because you are usually awake you will be able to see and hear your baby.
Once the baby is assessed, a nurse will wrap the baby and bring the baby to you to see and touch. The baby will remain with you as long as you are awake. You may even breastfeed while you are recovering in the OR.

What Are The Various Forms Of Infant Formula?

Baby formula is available in three forms: ready-to-feed, concentrated liquid and powder. Ready-to-feed is used "as is." Concentrated liquid (the only liquid that comes in a 13 ounce can) and powder must be diluted with water according to instructions on the label. Ready-to-feed and concentrated liquid baby formulas are commercially sterile. Powdered formulas are not sterile. Preparation of any form of infant formula (especially powdered products) requires careful handling to prevent contamination and minimize growth of microorganisms. Manufacturer’s instructions should be followed in all cases.

A graphic depicting the addition of water and the statement "add water" are found on concentrated formula containers. Because ready-to-feed and concentrated formulas are both liquids, anyone caring for your child should be made fully aware of what form of formula you use, and whether or not water must be added. (Powdered infant formula containers also provide a graphic depicting the major preparation steps for that formula.)

What Is The Difference Between Milk-Based And Soy-Based Infant Formulas?

The protein in milk-based formulas comes from cow's milk. The sugar in milk-based formulas is lactose, unless specifically manufactured as lactose-free. Soy-based formulas are milk-free and lactose-free; the protein in these formulas comes from a soybean. If a baby exhibits signs of lactose intolerance or certain allergic reactions to milk protein, the physician may recommend a soy-based formula to help treat these conditions.

Why Shouldn't I Feed Just Plain Cow's Milk To My Baby?

Cow's milk (e.g., whole, 2%, 1%, 1/2% or skim) is not appropriate for children under the age of one year, according to the Committee on Nutrition of the American Academy of Pediatrics. Cow's milk is a poor source of iron, and iron deficiency anemia is the most common nutritional problem in infants. Cow's milk that has not been specially heat processed (such as the heat processing used in infant formula) can cause intestinal blood loss in some babies. Iron is lost with the blood. Also, the levels of protein and sodium in cow's milk are higher than recommended for infants. Additionally, cow's milk is low in vitamin C, vitamin E and copper. Further, cow's milk contains butterfat that is difficult for a baby to digest. For these reasons, the Committee on Nutrition recommends that breastfeeding or iron-fortified infant formula be continued during the first year of life.

Is It Ok To Add Cereal To My Baby's Bottle?

According to the American Academy of Pediatrics, “Cereal should not be added to bottles except for medically-indicated reasons (e.g., gastroesophageal reflux) because this practice deprives children of the opportunity to learn to feed themselves.” Note, “there is no nutritional indication to add complementary foods to the diet of the healthy term infant before age 4 months.”

Should I Stop Using Infant Formula When My Baby Starts Eating Solid Foods?

No. The nutrient content of various baby foods, either commercially prepared or homemade, varies considerably. Additionally, during the period of transition when an infant is gradually increasing both the type and the amount of solids being eaten, the formula still contributes substantially toward meeting the infant's nutrient requirements. During this time, either breast milk or iron-fortified infant formula can most appropriately meet these requirements. The Committee on Nutrition of the American Academy of Pediatrics recommends that either breastfeeding or iron-fortified infant formula be continued during the first year of life, even after solids have been introduced.

Should I Sterilize Bottles And Use Boiled Water When Making Infant Formula?

Sterilization of all equipment and water used in preparing infant formula is commonly recommended until a health professional decides it is unnecessary. Check with your physician. When you are preparing infant formula, your own personal cleanliness, as well as that of any utensils that you use, is important.

The American Dietetic Association does not recommend preparing formula with boiling hot water due to problems with physical stability of the formula (e.g., clumping or separation) and nutrient degradation.

Should I Use An Infant Formula Product Beyond Its Expiration Date?

No. All infant formula containers carry "use by" or "use before" dates to ensure that the consumer receives a wholesome, high-quality product. Formula should not be bought or fed beyond the expiration date. After the expiration date, some vitamin levels decrease and changes in physical properties, such as discoloration and separation of fat, may occur.

How Long Can Infant Formula Be Kept After Opening?

An open can of liquid infant formula can be kept for up to 48 hours, if tightly covered and immediately placed in the refrigerator. Bottles of formula made from liquid should be refrigerated and used within 48 hours.
Formula that is prepared from powder and placed in bottles for feeding should be refrigerated and used within 24 hours. The remaining powder should be tightly covered and stored in a cool, dry place and used within a month after opening.

How Long Can A Bottle Of Infant Formula Remain Unrefrigerated?

Baby formula that is removed from refrigeration should be used within two hours or discarded. Because of possible bacterial contamination, formula remaining in a bottle one hour after the start of feeding should also be discarded.

Should I Reheat A Bottle After Feeding Part Of It To My Baby?

No. Once a baby has nursed from a bottle, microorganisms from the baby's mouth are introduced into the formula. If any unused portion of formula is refrigerated and reheated, these microorganisms will have the opportunity to multiply. Neither refrigeration nor reheating will prevent this growth. Therefore, you should fill each bottle with only the amount of formula needed for one feeding. After feeding, if any formula remains unused in the bottle, it should be discarded.

Should Infant Formula Be Frozen?

The use of infant formula after freezing is not recommended. Although freezing does not affect nutritional quality or sterility, physical separation of the product's components may occur.

Can Infant Formula Be Heated In A Microwave Oven?

Microwave ovens should NEVER be used for heating infant formulas since there is a danger of overheating the liquid. During the microwaving process, the bottle may remain cool while hot spots develop in the formula. Overheated formula can cause serious burns to the baby.

What is the function of the cervix?

The cervix is found in the lower part of the uterus that projects into the vagina. It is made up of mostly fibrous tissue and muscle and is circular in shape. During pregnancy the cervix serves as a barrier and is longer. When labor starts, the cervix shortens and thins to merge with the uterus. The opening in the cervix dilates to an opening of 10 centimeters to allow the baby to pass through.

What is labor?

Labor is a series of continuous, progressive contractions of uterus. This helps the cervix to open (dilate) and to thin (efface), which allows the baby to move through the birth canal. No one knows exactly what triggers the onset of labor, but it usually starts two weeks before or after the estimated date of delivery.

What defines true labor vs. false labor?

True labor is having regular contractions and showing cervical change. Sometimes there maybe regular contractions but there will be no change to the cervix. True labor also continues to come in regular intervals regardless of your activity. The intensity of the contractions increases, along with their frequency and duration. Contractions typically are felt in the lower back and radiate around to the front, with cervical change being made.
False labor is defined as contractions that may come and go with change in activity which may be uncomfortable, but with no cervical change.

What are the signs of labor?

Signs of labor may vary from woman to woman and each woman experiences labor differently. Some of the common signs of labor include:

Bloody show

• A small amount of mucus, mixed with a small amount of blood, may be expelled from the vagina

Contractions

•  Contractions are uterine muscle spasms that occur at intervals that are usually less than ten minutes. These contractions will become more frequent and strong as labor progresses.

Rupture of amniotic sac membranes (bag of waters)

• Sometimes labor begins with a gush or leaking of the amniotic fluid from the vagina. Women that experience a gush or leaking of fluid should contact their physician or the hospital immediately. Most women with ruptured membranes with go into labor within 24 hours. If labor has not begun after 24 hours, a woman may need to be induced. This step is often taken to prevent infections and delivery complications.

If a woman feels unsure if labor is begun, she should always call her physician or midwife.

What are the different stages of labor?

Each labor is different. However, labor typically is divided into three stages:

First Stage

The first phase of the first stage of labor is called the latent phase. Some women may not recognize that they are in labor if their contractions are mild and irregular. Contractions are usually 5 to 20 minutes apart and discomfort is minimal. The cervix dilates to approximately three to four centimeters.

The latent phase is usually the longest and least intense phase of labor. Women usually are asked to come to the hospital when contractions are 5 to 10 minutes apart, lasting 60 seconds for an hour.

The second phase of the first stage is called the active phase. Here the contractions become longer, more severe and more frequent (usually 3 to 4 minutes apart). The cervix dilates from 4 to 7 centimeters.

The third phase is called transition and is the last phase of the first stage. Contractions are very strong, occur every 2 to 3 minutes and last 60 to 90 seconds. The cervix dilates from 8 to 10 centimeters and most women feel the urge to push.

In most cases, the active and transition phases are shorter than the latent phase.

Second Stage

During the second stage the cervix is completely open and ends with the delivery of the baby. It is also know as the “pushing” stage. Here the woman becomes actively involved by pushing the baby through the birth canal to outside the vagina. When the baby's head is visible at the opening of the vagina, it is called “crowning.” Pushing is usually shorter than the first stage and may take between 30minutes to two hours for a woman's first pregnancy.

Third Stage

During the third stage of labor the baby has been delivered and the final part is the delivery of the placenta (the organ that has nourished the baby inside of the uterus). This usually lasts just a few minutes and involves the passage of the placenta out of the uterus , through to vagina.

Each labor experience is different, as is the amount of time in each stage will vary. However, labor in a first pregnancy usually lasts about 12 to 14 hours. With each subsequent pregnancies, labor is generally shorter.

What is induction of labor?

Sometimes labor has to be “induced.” This is a process of stimulating labor to begin. There are many reasons for inducing labor. Some common reasons for induction include the following:

• the mother and /or baby are at risk the
• pregnancy has continued too far past the due date
• the mother has pre-eclampsia, eclampsia, or chronic hypertension

Some common techniques of induction include the following:

• inserting a vaginal suppository that contains a prostaglandin hormone to stimulate contractions.
• Administering an intravenous infusion of oxytocin (a hormone produced be the pituitary gland that stimulates contractions).
• rupturing (artificially) the amniotic sac membranes (bag of waters).

What are pain management options during labor?

You will have several options for managing discomfort that may occur during labor and the birth of your baby. Together mothers, physicians and midwives have a plan of care that uses the safest and most effective method of pain relief for both mother and baby. The choice will be determined by:

• the physicians or midwives recommendation
• the health of the patient
• the health of the baby
• patient and family preference

There are three main types of pain management during the labor and birthing process:

• non-medicated measures- these provide comfort and relieve stress. Women learn special techniques to help them feel more comfortable and in control during the labor and birthing process, sometimes referred to as natural childbirth. Some of these techniques include:
  • relaxation - a technique in which one can direct attention to various muscle groups and relax them in a series.
  • Touch - this includes both massage and/or light stroking (effurage) to relieve tension. A shower or jacuzzi tub during labor may also be an effective way to relieve pain or tension.
  • Heat or cold therapy- this is used to help relax tensed or painful areas.
  • Imagery- a technique of using the mind to form mental pictures that help create a relaxed feeling
  • Meditation or focused thinking- by focusing on an object or task such as breathing helps direct the mind away from pains and discomforts
  • Positioning and movement- changing positions and moving around during labor helps relieve discomfort and may even speed labor along. Rocking in a rocking chair, walking, sitting on a special “birthing ball”, knee chest and even swaying may be helpful. Your labor nurse can help you find a comfortable position that is not only helpful but safe for you and your baby.
• Analgesics- medications to relieve pain. Your physician or midwife will decide what kind and how much to give you after you are examined. These drugs cross the placenta to the baby very easily and need time to clear from the baby's system before birth.
• Anesthesia- these are medications that are used to reduce sensation. This includes local block, pudendal block, epidural analgesic, spinal anesthesia and general anesthesia.
• Local Block- anesthesia that is injected in to the perineal area (the area between the vagina and rectum) to numb the area for repair or episiotomy.
• Pudendal block- this is also a type of local anesthesia that is injected into the vaginal area (affecting the pudendal nerve), causing complete numbness in the vaginal area without affecting the contractions of the uterus. Women can remain active in pushing the baby through the birth canal without feeling the burning of stretching tissue.
• Epidural analgesia- sometimes called a “walking” epidural. This involves infusing medication through a thin catheter that has been inserted into the space that surrounds the spinal cord in the lower back. The most common complication of a epidural is a low blood pressure. This is one reason you will need to have intravenous infusion of fluids before you received your epidural. The anesthesiologist will discuss the risks, benefits and other methods of pain relief with you.
• Spinal Anesthesia- this involves a single dose of medication that is injected directly into the spinal cord canal. It acts very quickly and causes complete loss of sensation and loss of movement of the lower body. It is often used for cesarean deliveries.
• General anesthesia- this type of pain relief involves administering an anesthetic agent that causes the woman to go to sleep. This is used for emergency cesarean deliveries.

• Analgesics – Drugs that help relieve pain without causing unconsciousness.
• Amniotic fluid – Fluid surrounding the baby. There is approximately a quart of fluid at full term. About one third of this fluid is continuously replenished every hour.
• Areola - the darker skin of the breast which is around the nipple in a circular area.
• Braxton-Hicks contractions – Uterine contractions that are usually painless and may occur from about the fifth month on. The will occur more frequently and become stronger in intensity as the mother gets closer to the start of true labor.
• Colostrum – The first secretions of the breast. Colostrum has a high protein content and provides some immunity properties.
• Contractions – The rhythmic tightening and relaxing of the uterine muscles that results in effacement and dilation of the cervix. True labor contractions usually come in a regular pattern, gradually get closer together and gradually increase in intensity. The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction.
• Cervix – The lowest portion of the uterus that thins out and opens during labor for the delivery of the baby.
• Dilation – The opening up of the cervix for delivery of the baby. Dilation is measured in centimeters from 0-10.
• Eclampsia - Coma or convulsions in a patient with pre-eclampsia, occurring in late pregnancy, during labor, or within 24 hours after birth.
• Effacement – The thinning and shortening of the cervix. Effacement is measured in percentages from 0- 100%.
• Engorgement – Excessive fullness, usually referring to the breasts.
• Episiotomy – A small incision of the perineum made to enlarge the vaginal opening. If an episiotomy is necessary, it is done just before the birth of the baby.
• Fetal Heart Tones (FHT) – The baby's heart beat heard through the abdominal wall with a Doppler.
• Knee-Chest- The patient rests on their knees and upper chest. This position uses gravity to rotate the baby out of a posterior position (causes back labor).
• Lamaze – The registered name for a program that teaches childbirth education.
• Leopold's Maneuvers - a series of four steps used in palpating the abdomen of a pregnant woman to determine position and presentation of the fetus.
• Lightening – The sensation the mother feels when the baby “drops” down or gradually settles into the pelvis.
• Induction – The process of starting labor by artificial means.
• Pre-eclampsia -A condition in pregnancy characterized by a sharp rise in blood pressure, leakage of large amounts of the protein into the urine and swelling of the hands, feet, and face. It is the most common complication of pregnancy. It affects about 5% of pregnancies. It usually occurs after 20 weeks of pregnancy.
• Preterm Labor – Labor that starts before thirty seven weeks gestation.