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Healthy Baby Happy Parents
Early Transition after Birth
Early transition is the term that is given for the period of time immediately after the birth of your newborn. Most babies transition immediately. In this case, we're talking about temperature stability, normal breathing, and beginning to establish feedings. A newborn is generally allowed a transition time of two hours after a vaginal birth and four hours after a cesarean birth. Mothers are encouraged to provide skin to skin care and begin breast feeding. After a cesarean delivery, the baby is assessed in the OR on the warmer and then in the nursery. The baby will be taken back for continued transition with the mother in recovery.
Problems during this period can include low temperature, respiratory distress, low saturations and/or low blood sugars. Infants demonstrating a transitional problem may be placed on a warmer (pictured at left) and have their vital signs (heart rate, respiratory rate, and saturations) monitored.
Low temperature- Since babies come from a stable warm temperature environment in the womb, they have to learn to warm themselves by shivering. This process uses their own brown fat. By slowly weaning from the warmer (or mother during skin to skin contact), newborns usually learn to maintain their temperature.. Small or low birth weight infants have less body fat and therefore, may have more difficulty maintaining their temperature.
Respiratory distress - Newborn lungs fill with air after birth but may contain residual amniotic fluid, especially in babies born by cesarean birth. Babies usually remove lung fluid by absorbing it into their bloodstream. If babies are slow to remove the fluid, they may breathe fast (tachypnea) and/or heavy (work to breathe). Sometimes the fast breathing prevents them from taking a feeding. If the fast breathing persists or they require oxygen, then admission into the NICU is warranted for observation, diagnosis, and treatment.
Low saturations - Babies in the womb get oxygen from the placenta. Newborns breathe air to get oxygen. Babies have very low saturations in the womb, but after birth, their saturations increase to the 94%-100% range. A baby that drops their saturations below 90% during the transition period may need oxygen. Typically, the oxygen is delivered from the wall oxygen source through a tube to the nose of the baby (blow-by oxygen). The nursery nurse may discontinue the blow-by oxygen after the saturations improve to the normal range. If oxygen has to be administered repeatedly, then admission to the NICU may be necessary for observation, diagnosis, and treatment.
Low blood sugars- Newborns may have a heel stick blood glucose level obtained during transition. Certain conditions like large infants, small infants, premature infants, or babies born to mothers with diabetes (or abnormal glucose tolerance test during pregnancy), may require more testing. Normal values ( >35 during the first four hours, >45 during four to 24 hours, and >50 after 24 hours of life) will assure a stable neurologic condition. A glucose gel can be given up to three times if glucose values are low. In addition, feedings may start early. Sometimes breast feeding can be supplemented with either donor breast milk or formula. Newborns that cannot maintain a glucose level in the normal range may need IV fluids in the NICU.
About ten percent of newborns will require at least a brief NICU admission. Full term infants have an admission rate of six percent. Respiratory distress, low saturations during transition, and low blood glucose values are the most common reasons for NICU admission. The majority of these infants receive a work up for infection, further investigation with blood work and x-rays, and multi-system continuous monitoring.
Premature infants are another category of infants requiring NICU admission. These infants may have a birth weight of less than four pounds, low blood sugar values, low temperature, poor feeding, and/or respiratory distress. Seventy-five percent of infants born at 36 weeks are mature enough to stay in the well nursery. Fifty percent of 35 week premature infants are able to stay in the well nursery.
The length of a newborn's stay in the NICU depends upon the problem and how fast it is resolved.
Late Transition after discharge
Newborns continue the transition process after discharge. This continuum lasts for a few months. Their physiology adjusts to life in the world as their bodies develop.
1) As discussed in the "Discharge Folder", weight decreases for 3-4 days before beginning to increase. Establishing a weight gain pattern depends upon good nutrition with feedings and a healthy body.
2) Their heart rate slowly decreases and the blood flow through their heart slowly converts to an adult-like circulatory pattern. The CCHD (Cyanotic Congenital Heart Disease) pulse oximetry screening test done before discharge from the hospital gives much comfort that a serious heart defect does NOT exist. However, in the coming weeks after discharge, babies can present with less serious (non cyanotic) heart conditions. A new heart murmur, poor feeding, and or a change in heart rate or rhythm can be clues that your Pediatrician finds.
3) Your newborn's SMS, state metabolic screen, should result within three weeks. In rare cases, a metabolic or blood hemoglobin problem is discovered. Your Pediatrician will lead you through this process as necessary.
4) Other hormonal or end organ issues can present after discharge. Your Pediatrician is especially trained to discover and treat any condition that may arise.