This ppt gives you a detail knowledge about physiological changes of newborn.

2. NORMAL NEWBORN
Prepared By: Sanskriti Ojha
B.Sc.Nursing 4th year , 9th year

3. INTRODUCTION OF NEWBORN BABY
• Newborn are very sensitive in life.They have to adjust in new
environment from intrauterine life so they have adjusted in
different areas as thermal regulation, oxygenation, digestion,
excretion etc.

4. CONT…
• Every year globally, an estimated 4 million babies die before they
reach one month. Deaths are far more likely occur in early
neonatal period as during first week and also during first 24
hours.

5. CONT…
• The common causes of neonatal deaths are infection, birth
asphyxia, prematurity, hypothermia and other underlying causes
are poor pregnancy health, inadequate care during pregnancy,
inadequate care during delivery, low birth weight, inadequate
new born and postnatal care(NNHS, 2002).

6. CONT…
• Nurse’s most important responsibility is to help the neonate to
adjust in new environment because the transition period is very
important.

7. Definition of New born baby
• A baby from birth to 28th days(4 weeks) of life is called neonate
or newborn.
• The period of childhood development from birth to 28th days of
life is called neonatal period.

8. CONT….
• First week of life(<7 days or < 168 hours) is known as early
neonatal period. Late neonatal period extends from 7th to 28th
days.(O.P. Ghai)

9. CONT…
• A healthy infant born at term should have an average birth weight
(usually exceeds 2500g), cries immediately following birth,
establishes independent rhythmic respiration and quickly adapts to
the changed environment.

10. Classification of Newborn
1. Depending upon gestational age:
Full term: baby born after 37 completed weeks up to 42
completed weeks or 259 to 294 days of gestation.

11. CONT…
Preterm: baby born after 22 weeks and before 37 completed
weeks of gestation.
Post-term: baby born after 42 completed weeks of gestation.

12. 2.Depending upon birth weight:
Normal birth weight(NBW):2500-3999g
Low birth weight(LBW):<2500g
Very low birth weight(VLBW):<1500g

13. CONT…
Extremely low birth weight(ELBW):<1000g
Preemie:<750g
Micro preemie:<500g

14. Physiological Changes In Newborn
The first 24 hours of life constitute a highly vulnerable time,
during which the infant must make major physiologic
adjustments to extra uterine life.

15. 1)Initiation of Respiration
• The most critical and immediate physiological change required
by the new born is onset of breathing. Normally, the neonate
begins to breathe within 20 seconds of delivery, stimulated by
the medullary respiratory center.

16. CONT…
• The stimuli that helps to initiate respiration are primarily
chemical and thermal factors.

17. CONT…
• With the cutting of the umbilical cord, the infant must undergo
rapid and complex changes. During normal vaginal birth some
lung fluid is squeezed or drained from the new-born's trachea
and lungs. Mechanical compression of the chest during the
vaginal birth forces approximately 1/3 of the fluid out of the
lungs.

18. CONT…
• As the chest is delivered, it re-expands, generating a negative
pressure and drawing air into the lungs. Passive inspiration of air
replaces fluid. As the infant cries, a positive intrathoracic pressure
is established which keeps the alveoli open, forcing the
remaining fetal lung into the lymphatic circulation.

19. CONT…
• After respirations are established, respirations are shallow and
irregular, ranging from 30 to 60 breaths per minute, with short
period of apnea(less than 15 seconds).

20. CONT…
• In order for the respiratory system to function effectively, the
infant must have:
Adequate pulmonary blood flow
Adequate amount of surfactant
Respiratory musculature strong enough to support respiration

21. CONT…
• During the first hour of life the pulmonary lymphatic continue to
remove large amounts of fluid. Removal of fluid is also a result of
the pressure gradient from alveoli to interstitial tissue to blood
capillary. Reduced vascular resistance accommodates this flow of
lung fluid. Retention of fluid interferes with the infants ability to
maintain adequate oxygenation.

22. CONT…
• The chest circumference is approximately 30 to 33cm at birth.
Auscultation of the chest of a newborn infant reveals loud, clear
breath sounds that seem very near because little chest tissue
intervenes.

23. CONT…
• The new borns large abdomen also will affect lung space by
increasing upward pressure of the diaphragm.The structures of
the thorax, including weak intercostals muscles, horizontally
positioned ribs, and high diaphragm lung expansion space.

24. 2.Changes In Circulation
• After delivery, the baby must make major adjustments within his
circulatory system in order to divert deoxygenated blood to the
lungs for reoxygenation.This involves several mechanisms which
are influenced by the clamping of the umbilical cord and also by
the lowered resistance in the pulmonary vascular bed.

25. CONT…
• The changes in circulation is due to changes of pressure in the
lungs, heart and major blood vessels.The transition from fetal
circulation to postnatal circulation involves the functional closure
of the four special anatomical structures that are present fetal
circulation.

26. CONT…
• The special structures are:
Foramen ovale: opening between the two atria allowing blood
to flow from right to left atrium or left to right atrium.
Ductus arteriosus: a shunt between the umbilical vein and
inferior venacava.

27. CONT…
Hypogastric arteries: the branch of internal iliac arteries which
are known as umbilical arteries when they enter the umbilical
cord.
Immediate after birth, following changes occurs in these fetal
structures:

28. o Foramen ovale
• After initiation of respiration there is increased blood flow to the
lungs and return of blood to the left atrium. With this, the
pressure in right atrium, right ventricle and pulmonary artery
decreased.

29. CONT…
• At the same time there is a progressive rise in systemic vascular
resistance and an increased volume of blood as a result of cord
clamping.so the pressure in the left side of the heart is increased.
The change in pressure between two atrium causes to closure of
foramen ovale.

30. o DuctusArteriosus
Immediately after birth, when the baby cries the lung expand
and the vascular field is increased.That results in decreased
pulmonary vascular resistance and increased pulmonary blood
flow. So blood flow from the right ventricle instead of passing
through the ductus arteriosus, flows through the pulmonary
arteries to lung.

31. CONT…
Ductus arteriosus is closed functionally soon after birth but
anatomic closure from deposition of fibrin and cell products
taken longer so early functional murmur during neonatal period
is normal.

32. o DuctusVenosus
Immediately after birth, when the baby cries the lung expand
and the vascular field is increased.That results in decreased
pulmonary vascular resistance and increased pulmonary blood
flow. So blood from the right ventricle instead to passing through
the ductus arteriosus, flows through the pulmonary arteries to
lung.

33. CONT…
Ductus arteriosus is closed functionally soon after birth but
anatomic closure from deposition of fibrin and cell products
taken longer so early functional murmur during neonatal period
is normal.

34. o DuctusVenosus
The cessation of the placental circulation causes collapse od
ductus venosus and umbilical vein. Later they become
permanent and anatomical ductus venosus and ligamentum
venosus.

35. o Hypogastric Arteries
Along with these changes the hypogastric arteries also cease to
function and degrade.

36. 3.Thermal Adaptation
From a thermo constant environment of 37.7 degree C, the
baby enters a much cooler atmosphere at delivery.A delivery
room temperature of 21 degree C constrasts sharply with
intrauterine temperature and ceases rapid cooling of the infant
as amniotic fluid evaporates from his skin.

37. CONT…
• Each millilitre which evaporates removes 560 calories of heat.
The infants large surface area: body mass ratio potentiates heat
loss especially from his head which comprises 25%of his size.

38. Mechanism Of Heat Loss
Four ways a newborn may lose heat to the environment:
Radiation
Convection
Evaporation
Conduction

39. CONT…
His subcutaneous fat layer is thin and provides poor insulation,
allowing rapid transfer of core heat to the skin and to the
environment and also cooling of his blood.

40. CONT…
• In addition to heat loss by evaporation, further heat will be lost
by conduction when the body is in contact with cold surface, by
radiation to cold objects in the environment, and by convection
caused by currents of cool air passing over the surface of his
body.

41. CONT…
The heat regulating centre in the baby`s brain has the capacity to
promote heat production in response to stimuli received from
thermo receptors. However, it is dependent on increased metabolic
activity, comprising the baby`s ability to control his body
temperature, especially in adverse environmental condition.

42. CONT….
• The baby has a limited ability to shiver and is unable voluntarily
to increase his muscle activity in order to generate heat.This
means that he must depend on his ability to produce heat by
metabolism which in turn requires an increase in oxygen
consumption.

43. CONT…
The neonate has brown adipose tissue which assists in the rapid
mobilization of heat resources, namely fatty acid and glycerol; in
times of cold stress.This mechanism is called non-shivering
thermogenesis. Brown adipose tissue is found in the
mediastinum, around the nape of the neck, between the
scapulae, along the spinal column and suprarenally.

44. CONT…
When the skin of the baby becomes cold, afferent nerves convey
the message to the heat regulating center in the hypothalamus.
Neurogenic efferent nerves in reaching the brown fat trigger the
local release of noradrenaline so that triglycerides are oxidized to
glycerol and fatty acids.The fatty acids are consumed for the
generation of heat.

45. 4.Initiation Of Digestion
The gastrointestinal changes take place at birth. He has the
ability to sucking, swallowing, digestion, absorption, and
defecation. Baby sucks and shallows the milk but the stomach
capacity is limited only 60-90ml, so frequent feeding is require
for few days. Progress of digestion indicates changing of stool
pattern.

46. CONT…
Meconium is the first stool of life. It should usually pass within
24 hours of birth. It is sticky to touch. It may completely pass 48-
72hours of birth. Colour is blackish green, contains fat, epithelial
cells and the bile. From third day, the colour of stool changes in
brownish yellow. Changes in stool pattern occur progressively.
Transitional stools usually appear by third day after initiation of
feeding.

47. CONT…
It may also contain some milk curds. By the fourth day, milk
stool appears. In breast fed infants, stool is yellow to golden, in
paste like in consistency and has an odor similar to that of sour
milk. In formula fed infants, stool is pale yellow to light brown, is
firmer in consistency and has a more offensive odor.

48. 5.Renal Regulation
The bladder is usually emptied at birth. If not at birth, it should pass
within 24 hours to 48 hours after birth.The amount and frequency of
urine may increase in first week of life. Normal bladder capacity is 20-
30ml during first week.

49. CONT….
Then it increases gradually and duration of urination becomes
long.The urine is not usually concentrated so the dark yellow
urine indicates insufficient fluid intake.

50. CONT…
The urine is colourless, odourless and has a specific gravity of
1.020.Total urinary output per 24 hours is 200 to 300ml by the
end of first week.The bladder can hold 15ml of urine and then
involuntarily empties resulting as many as 20 voiding per day.

51. 6.ReactionTo Organism
Baby receives some passive immunity from mother during
intra-uterine life and also from breast milk after birth. After some
weeks of birth, baby gets and develop own immunity power by
contamination from birth canal to nose, mouth, eyes and skin
and also from nurse`s hand, home environment or ward
environment.

52. CONT…
The baby and other human has three layers of defense:
I. First line defense is skin
II. Second line defense is immunologic system
III.Third line defense is formation of antibodies against antigen.

53. CONT…
1)The first line defense is the skin and mucous membranes which
protects from invading agents and organisms.

54. CONT…
2)The second line of defense is the cellular elements of the
immunological system which protects from foreign agents by
action of monocytes, neutrophils, eosinophil's, lymphocytes,etc.
However the tissue`s inflammatory response to localize an
infection is immature.

55. CONT…
3)The third line of defense is the formation of specific antibodies
to an antigen. Infants are generally not self-capable of
producing immunoglobulins until the beginning of second
month of life.They receive passive immunity in the form of
immunoglobulin G from the maternal circulation and from
human milk.

56. 7.Hemopoietic System
oThe blood volume depends upon the amount of placental
transfer.The blood volume is 80-85ml/kg body weight.
Immediate after birth the normal blood volume is 300ml. As
much as 100ml can ne added to the blood volume by delayed
cord clamping.

57. CONT…
oThe average RBC count is 5million/mm3. the mean Hb is 16-
20mg/dl, haematocrit is 45-60 mg/dl and WBC count is
20,000mm3.

58. 8.Fluid And Electrolyte
Changes occur in extra cellular and intra cellular fluid.The
percentage of fluid is 73-75% of total body weight.There is higher
level of extra-cellular fluid than intracellular fluid in fetus but this
shift progressively throughout postnatal life.The total body
sodium and chloride is high and level of potassium, magnesium,
and phosphate is low.

59. CONT…
The rate of fluid is 7 times greater in the infant than in the adult,
the rate of metabolism is twice in relation to body weight. As a
result the acid formation is greater leading to rapid development
of acidosis.

60. CONT…
Except that the immature kidney cannot sufficiently
concentrate urine to conserve body water.These three factors
lead to prone for development of dehydration, acidosis, and
possible over hydration.

61. 9.Gastrointestinal System
The ability of the new born to digest, absorb and
metabolize food is started but limited in certain functions.
Enzymes are to catalyse the foods.

62. CONT…
The liver is immature so the liver enzymes are deficient which
lead to physiological jaundice. Liver store less glycogen so
newborn are prone to develop hypoglycemia. Edema is easily
seen because of deficiency of liver enzyme.

63. CONT…
Liver is also deficient in forming plasma proteins causing low
plasma protein concentration which probably plays a role in
edema seen at birth. Prothombin and other coagulation factors
are also low.

64. CONT…
Salivary glands are functioning but begin to secrete saliva after 2-
3months. So drooling is present after that period.
The stomach capacity is limited up to 90ml so the infant need
frequent feeding.There is frequent stool pass in first week but
the pattern is change after second week.

65. CONT…
• The intestine is longer in relation to body size than adult
therefore there is large number of secretory glands are available
and the absorption area is also large.

66. CONT…
Infants have rapid and immature peristaltic waves, decreased
lower esophageal sphincter pressure, inappropriate relaxation of
the lower esophageal sphincter and delayed gastric emptying
which makes regurgitation common.

67. CONT…
The colon also has a small volume, so the newborn may have a
bowel movement after each feeding.

68. 10.Renal System
All structural components are present but there is functional
deficiency.
Total volume of urine output in 24 hours is 200 to 300ml.
First urine should pass within 24 hours of delivery. Urine is
colourless and odourless.

69. CONT…
The bladder can hold 15ml of urine so frequent urination occurs
with more than 20 times in 24 hours.
Urines specific gravity is 1.020 as compare to water.

70. 11.Integumentary System
Two layers of skin as epidermis and dermis are loosely bound
to each other and very thin so slight friction can cause
breakdown and blister formation.

71. CONT…
The sebaceous glands are very active in late fetal and early
infant life because of high level maternal androgen.They are
mostly located in scalp, face, and genitalia and produce greyish
white, greasy vernix caseosa that covers the infant at birth.
Blocking of sebaceous gland cause milia.

72. CONT…
The sweat gland(apocrine gland) remains small and nonfictional
until puberty.
The exocrine glands which produce sweat are functional at birth,
and produce sweat in response to heat or emotional stimuli.
Observing palmer sweating on crying is helpful to assess pain.

73. CONT…
The amount of melanin is low so they have lighter skin than old
children and also prone to have harmful effect of skin.

74. CONT…
During the first few months, the synchrony between hair loss
and growth is disrupted resulting in overgrowth of hair or
alopecia.
Boy`s hair grows faster than the girls.

75. 11.Musculoskeletal System
• At birth, the skeletal system contains more cartilage than
ossified bone, although the process of ossification is fairly rapid
during the first year(e.g. nose, skull bone). Nose is predominantly
cartilage at birth and may be temporarily flattened or
asymmetric because of the force of delivery.

76. CONT…
• The six skull bones are relatively soft and not yet joined/ or
separated only by membranous seams.
• The sinuses are incompletely formed in newborns.

77. CONT…
• The muscular system is almost completely formed at birth.
Growth in size of muscular tissue is caused by hypertrophy,
rather than hyperplasia, of cells.

78. 13.Endocrine System
The development of endocrine system is adequate but the
functions are immature i.e. posterior pituitary gland produce
limited amount of ADH this render to higher the susceptibility of
dehydration.

79. CONT….
• Because of the effect of maternal hormone, the labia area is
hypertrophied and breast are enlarge with hypertrophied and
breast are enlarge with collection of milk, pseudo-menstruation
may occur in female because of sudden drop in estrogen and
progesterone hormone.

80. 14. Neurologic System
• At birth, the nervous system is incompletely integrated but
sufficiently developed to sustain extra uterine life, but most of
the primitive reflexes are functioning.

81. CONT….
• The autonomic nervous system is crucial during transition
because it stimulate to initiate respiration, help to maintain acid
base balance and partially regulate temperature control.

82. CONT…
• Myelination of the nervous system follows cephalocaudal-
proximodistal (head-to-toe center-to-periphery) laws of
development and is closely related to observed mastery of fine
and gross motor skills.

83. CONT…
• Tracts that develop myelin earliest are the sensory, cerebellar
and extrapyramidal.

84. CONT….
• This explains for acute senses of taste, smell and hearing as well
as the perception of pain in the new born.
• All cranial nerves are myelinated except the optic and olfactory
nerves.

85. 15.Sensory Functions
The newborn sensory functions are well developed and have a
significant effect on growth and development including the
attachment process.

86. a)Vision
At birth eye is structurally incomplete.The ciliary muscle is
also immature limiting the accommodation ability.
The pupil react to light, blink on stimuli and corneal reflex is
activated by light touch.

87. CONT…
Tear glands is not function up to 2 to 4 weeks of age.
The ciliary muscles are immature, limiting the eye`s ability to
accommodate and fixate on an object for any length of time.

88. CONT…
Has ability to momentarily fixate on bright light within 20cm
distance and in the midline of visual field.
This ability to fixate or coordinate movement is greater in first
hour of life than in succeeding several days.

89. CONT…
Visual acuity is between 20/100 and 20/400 depending on the
vision measurement technique.

90. CONT…
The newborn also demonstrates visual preferences.They prefer
medium colours( yellow, green, pink) over dim or bright
colours(red, orange, blue); black and white contrasting patterns,
geometric shapes; large objects over small objects and reflecting
objects over dull ones.

91. b)Hearing
• After the amniotic fluid has drained from the ears, infants
probably have auditory acuity similar to that of adults.
• Neonates react to loud sounds of about 90 decibels with a startle
reflex.

92. CONT…
• The internal and middle ear is large at birth, but the external
canal is small.

93. CONT…
• The mastoid process and the bony part of the external canal have
not yet developed.
• Consequently, the tympanic membrane and facial nerve are
facial nerve are very close to the surface and can be easily
damaged.

94. c)Smell
Newborn react to strong odour by turning their head away.
Breast fed infant are bale smell breast and will cry when their
mother`s breast is engorged and leaking. Can differentiate the
mother`s and other women`s breast milk and maternal odours
are believed to influence to attachment.

95. d)Taste
• Newborn can distinguish between tastes by gustafacial nerves.
• A tasteless solution elicits no facial expression; sweet solution
elicits eager suck and a look of satisfaction; sour solution causes
the usual puckering of the lips and the bitter solution produces an
angry, upset expression. E.g. newborn prefers glucose water to
sterile water.

96. e)Touch
Perceives tactile sensation at all body parts but face, hand and
feet are more sensitive.
Research suggest that touch and motion are essential to normal
growth and development.

97. CONT…
Gentle patting of the back or rubbing of the abdomen provides
calming response however pain stimuli elicit angry and upset
response.

98. Characteristics Of Normal Newborn
1)General Appearance
• posture: flexed of head and extremities which rest on chest and
abdomen

99. CONT…
• Skin: Bright red to pink, puffy, smooth-pink, flaky dry. Presence
of cyanosis at limbs (accrocyanosis). Presence of vernix caseosa,
lanugo, and edema around eye, face, leg, labia and scrotum are
typical in body.

100. CONT…
2)General Measurement
• Average weight at birth is 3kg(2.5-3.9), weight in range is 2.5 to
4kg.
• Average head to heel length at birth is 50cm, length in range;
48 to 53cm, and head to rump length: 31-35cm.

101. CONT…
• Head circumference: approximately 34cm at birth, range; 32 to
35cm.
• Chest circumference: approximately 31cm(3cm less than head
circumference) at birth, range; 30 to 33cm.

102. 3)Vital Signs
• Temperature: the infant`s axillary temperature is maintained at
36.4 to 37.2 degree.
• Heart rate: 120 beat to 140 beat per minute.

103. CONT…
• Respiration: 30 to 60 breaths per minute.
• Blood pressure: 65-85/45-55mm of Hg( age from 0-3 months).

104. 4)Head
• Skull shows moulding with parietal bones slightly overriding the
occipital and the frontal bones.
• Anterior fontanel is formed by the junction of the sagittal,
coronal and the frontal sutures is diamond shape and measure
2.5-4cm.

105. CONT…
• Posterior fontanel is formed by the junction of the sagittal and
lamboid suture gives triangular shape and measure 0.5-1cm.

106. CONT…
5)Ears
• Symmetrical, pinna flexible, cartilage present
6)Eye
• Largely covered by eyelids edematous, closed, absence of tear
and pupillary reflex in response to light.

107. CONT…
7)Nose
• Patent, nose, nasal discharge, sneezing present.

108. CONT…
8)Mouth andThroat
• Intact high arched palate, uvula in midline, frenulum of tongue
and upper lip, scant saliva

109. CONT…
9)Neck
• Short, usually surrounded by skin fold

110. CONT…
10)Chest
• Antero-posterior, lateral diameter equal, breast enlarged, xiphoid
process evident
11)Abdominal
• Cylindrical in shape, liver and spleen palpable

111. CONT…
12)Genitalia
• Female: edema present, labia minora larger than majora urethral
meatus behind large clitoris.
• Male: urethra opens at tip of glans of penis, testes palpable in
each scrotum, scrotum large, edematous and pendulous.

112. CONT….
13)Extremities
• Ten fingers and toes, full range of motion, symmetry of
extremities.
• Equal muscle tone bilaterally

113. 14)Urine and Stool
• Urine is passed during or shortly after birth, 94% newborns pass
urine by 24hrs.
• The first stool which is black, thick, viscid is known as meconium
and is passed within 24 hrs.

114. 15)Back and Rectum
• Spine intact, no opening, masses or prominent curve
• Patent and opening

115. 16)Feeding
• Newborn is ready to feed within the first hour after birth.

116. 17)Reflexes
1. Rooting reflex:
Examination: touching the baby`s cheeks
Normal response development: the baby turns his mouth
towards source that touches his cheek.

117. CONT…
• Appearance/disappearance: present at utero in 24 weeks,
disappears 3-4 months after birth, disappears 3-4 months after
birth, may persist during sleep 9 to 12 months.

118. CONT….
2.Sucking reflex and swallowing reflex:
Examination: touching baby`s lip or breast is brought in contact
with lip or tongue.

119. CONT…
Normal response development: sucks vigorously, creating
vacuum by cheeks, lip and tongue. Swallowing reflex is followed
by sucking reflex.
Appearance/Disappearance: present after 28 weeks of gestation
and well developed after 34 weeks.

120. 3.Gag Reflex
Examination: when the baby takes more milk than he can
swallow.
Normal response development: gag reflex is elicited to remove
one the milk.

121. 4.Grasp Reflex
Examination: place an object or finger on the newborns palm
Normal response development: flex or close fingers tightly
around the object or fingers.
Appearance/Disappearance: present at 32 weeks of gestation
and disappears 3-4 months after birth.

122. 5.Moro Reflex
Examination: grasp the baby`s hands in supine position; lift the
shoulder few centimetres while keeping the back of the head in
bed. Sudden and gently drop newborns head backward.

123. CONT…
Normal response development: sudden extension and abduction
of all extremities. Altered response in neurological problem.
Asymmetric response is seen in Erb`s palsy.
Appearance/Disappearance: it is present after 32 weeks of
gestation and disappears after 12 weeks.

124. 6.Tonic Neck Reflex
Examination: place the newborn on his back and quickly turn his
head to one side.
Normal response development: cause baby to extend limbs(arm
and leg) on that side and flex the opposite arm and leg.

125. CONT…
Appearance/Disappearance: it is present at birth and disappears
after 4 months of age.

126. 7.Dancing(stepping) Reflex
Examination: hold the newborn and touch one foot lightly to a
flat surface.
Normal response development: makes walking/ dancing motion
with both feet.

127. CONT…
Appearance/Disappearance: present at birth and disappears after
2-4 months.

128. 8.Babinski(planter)Reflex
Examination: stroke outer sole of foot upward from heel and ball
of the foot.
Normal response development: hyperextension of toes, dorsiflex
of great toe, and fans the toe upward.

129. CONT…
Appearance/Disappearance: present at birth and disappear at 9-
10 months.

130. 9.Glabellar Reflex
Examination: tape briskly on glabella(junction between nose and
forehead).
Normal response development: cause tight closure of eye.