This article’ s focus is on evaluations and procedures that newborn babies undergo after birth in the hospital before they are sent home.
Many parents want to know everything about medications and substances their baby will be exposed to and what kind of tests doctors and nurses will be doing on their baby. I will try to explain all that.
Of course, this should be treated only as educational material and should not be considered as any type of advice or replacement of interactions with medical professionals taking care of your baby.
For some, it may seem that the baby is born, stays with mother, she feeds him/her, and they go home together in a day or two. Although generally, it is true, you have to realize that before babies are discharged home from nurseries, we do a lot to ensure their well being. There are things we do to promote their good health and to detect if they have any medical conditions that require immediate treatment or follow up later on in their life.
I will concentrate here on care provided in the USA, to generally healthy full-term newborn babies. Various doctors, institutions, and countries may be doing things a little bit differently, so my presentation should not be considered as a standard of care.
Birth of the baby:
Personally, I call the first 10 minutes after baby’s birth the ten happy minutes. It is one of the few situations in our life when we see a baby loudly and vigorously crying, and everybody else in the room is smiling overwhelmed with joy.
It is that way because this vigorous cry is a sign of life and good health. The first thing that is done to your baby after birth is clamping and cutting the umbilical cord. Usually, the father will have the opportunity to do that. Then the nurse or somebody else will assign Apgar scores, take baby’s weight, count respiratory rate, and heart rate, and measure the baby’s body temperature.
If baby seems to be healthy, we may just give a baby to mother right after cutting the umbilical cord. Holding baby skin to skin will promote mother-baby bonding and establish a better breastfeeding routine.
Now, let’s talk more about all the initial steps:
Cutting the umbilical cord:
The umbilical cord is like a “lifeline.” It is a connection between a fetus and the mother through which delivery of nutrients, hormones, growth factors, and oxygen takes place. After a baby is born, this connection will be interrupted, and part of the umbilical cord on the baby’s side needs to be securely clamped so the baby does not lose any blood.
In the last few decades, the umbilical cord would have been clamped soon after a baby is born. Nowadays, it is suggested to extend the time between birth and clamping the umbilical cord. It is believed that the baby may benefit by acquiring some additional amount of blood from the placenta if clamping is delayed until 1-3 minutes after birth. Approach to umbilical cord clamping differs among doctors and institutions; therefore, if you have not delivered your baby yet, you may want to discuss it with your obstetrician.
I found it very interesting that Erasmus Darwin, physician and physiologist living in 18th century in England said: “thing very injurious to the child is the cutting of the navel string too soon” and further he explained: “the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to be in the child…”
What is the Apgar score?
Apgar score is a method of assessing newborn baby’s wellbeing after birth. It was developed by Dr.Virginia Apgar in 1952 and widely accepted by nurseries as a reproducible and straightforward tool to do an initial assessment.
Today, all nurseries assign Apgar scores at 1, 5, and 10 minutes after birth in 5 categories. For each element of the assessment, we can assign a value of 0, 1, or 2 (See Table 1). We add up numerical values in each category and record the final score. Apgar score of 0 means that the baby was born without any signs of life. Apgar score of 10 is the best one can achieve and means that the baby was very vigorous, spontaneously breathing without any difficulty with good tone, and was well oxygenated.
Table 1: Apgar scores calculation:
|Sign||0 points||1 point||2 points|
|Heart rate||no heart rate at all||HR < 100 /min||HR > 100 per min|
|Respiratory effort||no respirations||slow, irregular||regular, strong|
|Muscle tone||flaccid||extremities flexed||moving arms and legs|
|Reflex to stimulus||no reaction||grimace||strong reaction, cough|
|Skin color||pale, grey, blue all over||peripheral cyanosis||pink all over|
The Initial purpose of Apgar score was to detect the effects of anesthesia on babies. Soon, it got adopted as a way of identifying which babies need additional medical attention, such as more evaluation and intervention.
Most healthy babies receive Apgar scores of 7-10. A score of 10 is rather rare, so all you parents who are perfectionists, please do not be disappointed. There is always a big difference between temperatures in the mother’s womb and that in the delivery room. This temperature difference usually results in the baby having peripheral cyanosis (bluish hands and feet) and getting only one point for the skin color, thus total Apgar score will be 9 in an otherwise perfect baby.
Low Apgar score in the first few minutes of life does not predict poor long term developmental outcomes, especially if it improves rapidly by 5-10 minutes, with proper interventions. However, low Apgar scores beyond 10-15 minutes may be associated with poor neurological outcomes.
Prophylactic measures that we perform right after birth.
Prophylaxis is a term describing a procedure during which we try to prevent something from occurring. Usually, it requires some significant effort or resources; therefore, it must be a worthwhile cause before we decide to do it on a wide scale.
For newborn babies, there are specific prophylactic procedures that had been instituted and mandated by many states to prevent certain medical conditions. When judging whether to establish a particular form of prevention, doctors take into account if a procedure can cause any harm or risk to a baby and what are benefits from this prophylaxis for all babies and the society.
The following are the four most common prophylactic measures done to newborn babies after birth.
The eye prophylaxis is conducted to prevent gonococcal infection of the eyes, which may lead to blindness. It is easy, safe, and ideally should be done within the first hour after birth. Most hospitals will use 0.5% Antibiotic Erythromycin eye ointment for this purpose. In some areas, Tetracycline ointment or Silver nitrate solution will be used instead. Erythromycin application is usually a well-tolerated procedure. The most common side effect of eye prophylaxis is chemical irritation of the eye, which may occur about 24 hours after application of the ointment or solution and will disappear 48 hours later.
Vitamin K intramuscular injection is given to all newborns in the US as a one-time injection to prevent severe bleedings caused by vitamin K deficiency. This condition is also known under the name: Hemorrhagic Disease of the Newborn. Babies with the condition may develop severe bleeding in their brain, sometimes resulting in death.
Some parents refuse Vitamin K prophylaxis altogether, or they want to use an oral form instead due to some concerns about a possible association between injectable vitamin K and cancer. The American Academy of Pediatrics concluded that the intramuscular form of vitamin K is superior to the oral form and that after analyzing current available studies, they did not find evidence for an association between Vitamin K and cancer.
In my mind, I have no doubt about this issue. A long time ago, I witnessed a two weeks old baby dying from the hemorrhagic disease, and that is enough for me to recommend this prophylaxis strongly unless risks of vitamin K are proven beyond any doubt.
Hepatitis B vaccine.
Hepatitis B is a viral infection that can cause liver damage, liver cancer, and ultimately may lead to death. Hepatitis B vaccine may protect you from contracting the disease. Typically you contract Hepatitis B through contact with blood or body fluids of an infected person.
Most people who received all three doses of the Hepatitis vaccine will be well protected. In the USA, the Hepatitis B vaccine is being administered to newborn babies before they are discharged home. Many times, it is given already in the delivery room. It Is a small intramuscular injection given into the muscle of buttocks or thighs. Most babies will tolerate the vaccine very well. The most common problem afterward is some swelling and soreness in the area of injection; other side effects or serious issues are infrequent. (More on Hepatitis B vaccine form CDC website here).
Umbilical cord care:
The umbilical cord is clamped and cut within minutes after delivery. Practices regarding the care of the umbilical cord vary. Some people leave it to dry on its own. In some nurseries, different agents such as triple dye, alcohol, silver sulfadiazine, and chlorohexidine are applied to it. The purpose of these agents is to prevent or reduce bacterial colonization and possibly reduce the risk of infection for babies.
After the umbilical cord dries out completely, the external piece of the umbilical cord will separate from the baby’s body and fall off. Each nursery has its policy regarding umbilical cord care, and they use one approach consistently to all newborn babies. As always in medical care, if you have any questions regarding these substances being used on your baby, or have any preferences, you should talk to your OB or pediatrician before you go into labor.
What types of blood tests do doctors order for newborn babies after birth?
Even if your baby is born as a full-term and healthy newborn, the chances are that nurses will draw blood for various tests. It may be necessary to detect conditions for which your baby may be at increased risk. I listed and explained here the most common blood tests we do after birth on babies.
Some babies are at higher risk of having low blood glucose levels after birth and need to be monitored for that eventuality. Glucose is a type of sugar that is necessary for the proper function of our brain. In situations when the glucose level is too low, babies may stop breathing, have seizures, or present with temperature instability, poor feeding, and jitteriness.
The following babies will need their glucose levels checked after birth:
- premature babies
- large or small babies for their gestational age
- infants of diabetic mothers
- infants with high red cell counts in their blood (Polycythemia)
- any baby appearing sick
Whenever a low blood glucose level is discovered, nurses or doctors will try to feed your baby or give IV fluids to maintain acceptable levels of glucose. Checking blood glucose levels involves pricking the baby’s heel and getting one drop of blood on a paper strip. After insertion of that paper into a portable machine, we get results almost immediately.
Blood type and Coombs or DAT test:
There are many blood group systems, but two are of the most concern for pediatricians: the ABO system and the Rh system. In cases when a mother is “O type” in the ABO system or “Rh-negative” in the Rh system, it is recommended to check the baby’s blood type.
In addition to that, we would also screen babies for antibodies of maternal origin and whether these antibodies react with baby’s red blood cells. The last test is called Antibody Screening Test or Coombs test.
Knowing the baby’s blood type and Coombs test helps us in the assessment of the risk for developing significant jaundice or anemia. The results of those tests will influence our decisions regarding further follow up and treatment of jaundice if needed.
Jaundice is a condition in which the skin of a newborn baby turns yellow, and it is due to an increased level of a chemical called bilirubin. The majority of newborn babies have some degree of jaundice, but for most of them, it is a benign, physiologic, and transient condition that does not require any treatment (My article on Physiologic Jaundice).
In some babies, though, due to various factors, levels of bilirubin may rise very high, creating a potentially dangerous situation. Very high levels of bilirubin may lead to severe neurological problems. Nowadays, almost all nurseries screen babies for jaundice either by measuring transcutaneous bilirubin level (which means through the skin without any needle sticks) or by checking bilirubin level in the blood.
Depending on the baby’s age at the time of the test and the bilirubin level, doctors will decide if there is a need for treatment or further follow up tests.
The following babies are at higher risk of developing significant jaundice. These babies will have bilirubin blood or skin tests done sooner after birth and probably more often:
- babies with jaundice present in the first 24 hours of life
- babies with blood group incompatibilities
- gestational age below 39 weeks
- babies exclusively breastfed
- babies with the previous sibling who needed treatment for jaundice
- babies born with bruises and cephalhematoma (cephalhematoma=accumulation of blood under the scalp in one area of the baby’s skull)
- babies of East Asian origin
Blood culture, CBC, CRP.
Blood tests that are done in newborns when we suspect an infection: CBC (CBC = complete blood count), blood culture, CRP (C-reactive protein).
A newborn baby may require tests for infection in several situations. The first one would be when a mother has specific risk factors that increase the baby’s chances of acquiring infection. Examples of these situations are: mother already developed an infection and is clinically ill, or she carries bacteria (GBS colonization) in her body that does not cause disease in her but is potentially harmful to the baby.
When we talk about babies, for them, almost any type of abnormal behavior or finding may be an early sign of infection. Problems such as irregular breathing, temperature instability, glucose problems, and poor feeding may prompt us to evaluate a baby for infection.
There are three standard tests we may order if we suspect infection in a baby. Two of them, CBC (complete blood counts) and CRP (C – reactive protein), are indirect tests. They do not give you certainty. If they are abnormal, they only raise your level of suspicion of infection. On the other hand, the third one, blood culture – is the most important. If blood culture is positive, it always means that the baby has an infection in its body, and such a baby needs urgent treatment and further evaluation.
Newborn State Screen or Metabolic State Screen.
Newborn state screen is a screening test performed on all newborn babies in the USA. It is a test that may reveal if your baby has a severe metabolic, genetic, or hematologic disease — various states test for a different number of diseases. In olden days we tested only for 4-5 disorders, nowadays with new laboratory techniques states test for 50 or more conditions that otherwise would have been undetected for a long time until baby becomes symptomatic.
Examples of diseases that we screen in Newborn State Screen are:
- congenital adrenal hyperplasia
- organic academies
The idea behind the State Newborn Screening is that many of the disorders tested for can be modified and treated successfully if detected early.
Newborn Test Screen is performed by taking a few drops of blood from the baby’s heel and placing them on special laboratory paper. Those samples are sent to the state lab, and results are given to the birth hospital or your baby’s pediatrician. As a parent, you should always ask and confirm with your pediatrician if your baby’s state newborn screening is normal (You can learn more about Newborn Screens from NIH website here).
Screening for Cyanotic Congenital Heart Disease (CCHD) using a pulse oximeter.
All babies before discharge home undergo pulse oximetry screening. The test is performed by placing two sensors on the baby: one on the right hand and another on foot. We do the testing for CCHD usually at 24 hrs of life or earlier if the baby is going home sooner than 24 hrs. If the readings are abnormal, one should suspect congenital heart disease and immediately conduct a more specific evaluation to confirm or rule out that diagnosis.
Abnormal screening for congenital heart disease is an urgent situation and always requires consultation with a neonatologist or pediatric cardiologist.
You can read my whole article on the subject of screening for cyanotic congenital heart diseases here.
In the US, we screen all newborn babies for hearing deficits before they are discharged home. The test is performed by placing leads on the baby’s head, and connecting those leads to a special machine. The testing machine can read brain waves created in response to sounds and assess if the baby has a hearing deficit. The test serves only as a screening, so if a baby fails the test, we refer baby for a repeat hearing test within a month or for more formal evaluation by audiologist or ENT. (More information on the hearing deficits in children in my article here).
As you can see, there are a lot of tests and procedures we do to newborn babies after birth, before we discharge them home with parents. All those things are done to ensure that your little one will be healthy and thriving at home without any problems. However, if any of these tests, vaccines, or medications make you uncomfortable, you should discuss your reservations with your baby’s nurse and doctor.
This article is only for general information purposes. It should not be viewed as any kind of medical advice. There is a small chance that information here may be inaccurate. You should always discuss all health-related matters with your doctor before making any decisions that may affect your health or health of your family members.