Family Planning Methods as mittelschmertz (midcycle abdominal pain).

The couple must abstain from intercourse until 3

METHODS OF CONTRACEPTION days after the rise in temperature or the fourth day after the peak of mucus change, because
Individuals or couples should choose a contraceptive method carefully, considering the these are the woman’s fertile days. The symptothermal method is more effective than either the
advantages, disadvantages, and side effects of the various options. Important things to consider BBT or the cervical mucus method alone (ideal failure rate, about 2%).
when doing this are: Ovulation Detection
 Personal values  Still another method to predict ovulation is by the use of an over-the-counter ovulation detection
 Ability to use a method correctly kit. These kits detect the midcycle surge of luteinizing hormone (LH)
 How the method will affect sexual enjoyment that can be detected in urine 12 to 24 hours before ovulation. Such
 Financial factors kits are 98% to 100% accurate in predicting ovulation. Although they
 Status of a couple’s relationship are fairly expensive, use of such a kit in place of cervical mucus
 Prior experiences testing makes this form of natural family planning more attractive to
many women. Combining it with assessment of cervical mucus is
 Future plans
becoming the method of choice for many families using natural
 As nurses’ roles are to educate couples on what methods are available and how to use
family planning.
methods, understanding how various methods of contraception work and how they
Lactation Amenorrhea Method
compare in terms of benefits and disadvantages is necessary for successful
 As long as a woman is
counseling.
breastfeeding an infant, there is
 A major benefit of contraception that has occurred is that there are both fewer
some natural suppression of ovulation. Because women
adolescent pregnancies today and fewer elective terminations of pregnancy than
may ovulate, however, but not menstruate, a woman may
formerly (CDC, 2009).
still be fertile even if she has not had a period since
 With information and the ability to discuss specific concerns, clients can be better childbirth. If the infant is receiving a supplemental feeding
prepared to make the decisions that are right for them (Nettleman, Brewer, & Ayoola, or not sucking well, the use of lactation as an effective
2007). birth control method is questionable
 An ideal contraceptive should be:  As a rule, after 3 months of breastfeeding, the woman
 Safe should be advised to choose another method of contraception (Burkman, 2007).
 One hundred percent effective Coitus Interruptus.
 Compatible with religious and cultural beliefs and personal preferences of both the user  Coitus interruptus is one of the oldest known methods of contraception. The couple proceeds
and sexual partner with coitus until the moment of ejaculation. Then the man withdraws and spermatozoa are
 Free of side effects emitted outside the vagina. Unfortunately, ejaculation may occur before withdrawal is complete
 Convenient to use and easily obtainable and, despite the care used, some spermatozoa may be deposited in the vagina. Furthermore,
 Affordable and needing few instructions for effective use because there may be a few spermatozoa present in preejaculation fluid, fertilization may occur
 Free of effects after discontinuation and on future pregnancies. even if withdrawal seems controlled. For these reasons, coitus interruptus is only about 75%
Natural Family Planning and Fertility Awareness effective.
 The contraceptive approach of natural family planning (also called periodic Postcoital Douching
abstinence methods) involves no introduction of chemical or foreign material into  Douching following intercourse, no matter what solution is used, is ineffective as a
the body or sustaining from sexual intercourse during a fertile period. Many people contraceptive measure as sperm may be present in cervical mucus as quickly as 90 seconds
hold religious beliefs that rule out the use of birth control pills or devices; others after ejaculation.
simply prefer natural methods because no expense or foreign substance is Hormonal Contraception
involved. Hormonal contraceptives are, as the name implies, hormones that cause such fluctuations in a
 The effectiveness of these methods varies greatly from 25% to 85%, depending normal menstrual cycle that ovulation does not occur. Hormonal contraceptives may be
mainly on the couple’s ability to refrain from having sexual relations on fertile days administered orally, transdermally, vaginally, by implantation, or through injection.
or days on which the woman has the most likely chance to become pregnant. Oral Route
 Fertility awareness involves detecting when a woman is fertile so she can use  Oral contraceptives, commonly known as the pill,
periods of abstinence during that time. OCs (for oral contraceptive), or COCs (for
Abstinence combination oral contraceptives), are composed
of varying amounts of synthetic estrogen
• Abstinence, or refraining from sexual relations, has a theoretical 0% failure rate and combined with a small amount of synthetic
is also the most effective way to prevent STIs. However, clients, particularly progesterone (progestin).
adolescents, may find it difficult to adhere to abstinence, or they may completely  The estrogen acts to suppress follicle stimulating
overlook it as an option. hormone (FSH) and LH, thereby suppressing
ovulation. The progesterone action complements
• Because it fails as an effective birth prevention measure for so many people, use of that of estrogen by causing a decrease in the
no contraceptive has a failure rate of 85%. permeability of cervical mucus, thereby limiting
• Many sex education classes advocate abstinence as the only contraceptive
sperm motility and access to ova. Progesterone
also interferes with tubal transport and
measure, so adolescents who take these courses may know little about other endometrial proliferation to such degrees that the possibility of implantation is significantly
options. When discussing abstinence as a contraceptive method, be sure to provide decreased.
information not only on the method but suggestions of ways to comply with this  COCs must be prescribed by a physician, nurse practitioner, or nurse-midwife after a pelvic
method. examination and a Papanicolaou (Pap) smear. When used correctly, they are 99.7% effective in
Calendar (Rhythm) Method preventing conception. Women who forget to take them as scheduled, however, experience a
• The calendar method requires a couple to abstain

failure rate of 95%.
Oral contraceptives have non-contraceptive benefits such as decreased incidences of:
from coitus (sexual relations) on the days of a • Dysmenorrhea, because of lack of ovulation
menstrual cycle when the woman is most likely to • Premenstrual dysphoric syndrome and acne, because of the increased progesterone levels
conceive (3 or 4 days before until 3 or 4 days after • Iron deficiency anemia, because of the reduced amount of menstrual flow
ovulation). • Acute pelvic inflammatory disease (PID) and the resulting tubal scarring
• To plan for this, the woman keeps a diary of six •
•
Endometrial and ovarian cancer, ovarian cysts, and ectopic pregnancies
Fibrocystic breast disease
menstrual cycles. To calculate “safe” days, she • Possibly osteoporosis, endometriosis, uterine myomata (fibroid uterine tumors), and
subtracts 18 from the shortest cycle documented. progression of rheumatoid arthritis
This number represents her first fertile day. She • Colon cancer
subtracts 11 from her longest cycle. This • COCs are packaged with 21 or 28 pills in a convenient dispenser. It is generally recommended
represents her last fertile day. that the first pill be taken on a Sunday (the first Sunday after
• If she had six menstrual cycles ranging from 25 to the beginning of a menstrual flow), although a woman may
choose to begin on any day. Beginning pills as soon as they
29 days, her fertile period would be from the 7th
are prescribed this way (a Quick Start system) rather than have to
day (25 minus 18) to the 18th day (29 minus 11). To avoid pregnancy, she
wait for a set day may increase compliance.
would avoid coitus during those days
• After childbirth, a woman should start the contraceptive on the
Basal Body Temperature Method
Sunday closest to 2 weeks after birth; after an elective termination of pregnancy, she should start
• Just before the day of ovulation, a woman’s basal body temperature has ovulated. She refrains
on the first Sunday after the procedure. Because COCs are not effective for the first 7 days,
from having coitus for the next 3 days (the life of the discharged ovum). Because sperm can
advise women to use a second form of contraception during the initial 7 days on which they take
survive for at least 4 days in the female reproductive tract, it is usually recommended that the
pills.
couple combine this method with a calendar method, so that they abstain for a few days before
• A woman prescribed a 21-day cycle brand takes a pill at the same time every day for 21 days. Pill
ovulation as well. The calendar method has an ideal failure rate of 9%, a typical rate of 25%
taking by this regimen will end on a Saturday. The woman would then not take any pills for 1
(MacKay, 2009).
week. She would restart a new month’s supply of pills on the Sunday 1 week after she stopped. A
• A problem with assessing BBT for fertility awareness is that many factors, such as taking an
menstrual flow will begin about 4 days after the woman finishes a cycle of pills.
antipyretic, can affect the BBT. Changes in the woman’s daily schedule, such as starting an
• To eliminate having to count days between pill cycles, most brands of OCs are packaged with 28
aerobic program, can also influence the BBT. A woman who works nights should take her
pills—21 active pills and 7 placebo pills. With these brands, a woman starts a second dispenser
temperature after awakening from her longer sleep period, no matter what the time of day.
of pills the day after finishing the first dispenser. There is no need to skip days because of the
Cervical Mucus Method.
placebo tablets. Menstrual flow will begin during the 7 days on which she is taking the placebo
• Yet another method to predict ovulation is to use the changes in cervical mucus that occur
tablets.
naturally with ovulation. Before ovulation each month, the cervical mucus is thick and does not
• For ovulation suppressants to be effective, women must take them consistently and
stretch when pulled between the thumb and finger.
conscientiously. Women who have difficulty remembering to take a contraceptive in the morning
• Just before ovulation, mucus secretion increases. With ovulation (the peak day), cervical mucus
may find it easier to take a daily pill at bedtime or with a meal (the time of day makes no
becomes copious, thin, watery, and transparent. It feels slippery and stretches at least 1 inch
difference; it is the consistency that is important) (Box 6.5). Also, some women find that taking
before the strand breaks, a property known as spinnbarkeit.
pills at bedtime rather than in the morning eliminates any nausea they otherwise experience. Side
• All the days on which cervical mucus is copious, and for at least 1 day afterward, are considered
Effects and Contraindications
to be fertile days, or days on which the woman should abstain from coitus to avoid conception.
• Nausea
• A woman using this method must be conscientious about assessing her vaginal secretions every
• Weight gain
day, or she will miss the change in cervical secretions. The feel of vaginal secretions after sexual
• Headache
relations is unreliable, because seminal fluid (the fluid containing sperm from the male) has a
• Breast tenderness
watery, postovulatory consistency and can be confused with ovulatory mucus.
• Breakthrough bleeding (spotting outside the
Symptothermal Method
menstrual period)
 The symptothermal method of birth control combines the cervical mucus and BBT methods. The
• Monilial vaginal infections
woman takes her temperature daily, watching for the rise in temperature that marks ovulation.
• Mild hypertension
She also analyzes her cervical mucus every day and observes for other signs of ovulation such
• Depression
• COCs are not routinely prescribed for women with a history of thromboembolic disease or a • An IUD must be fitted by a physician, nurse practitioner, or nurse-midwife, who first performs a
family history of cerebral or cardiovascular accident, who are over 40 years of age, or who smoke Pap test and pelvic examination. The device is inserted before a woman has had coitus after a
because of the increased tendency toward clotting as an effect of increased estrogen. menstrual flow, so the health care provider can be assured that
• COCs can interfere with glucose metabolism. For this reason, women with diabetes mellitus or a the woman is not pregnant at the time of insertion.
history of liver disease, including hepatitis, are evaluated individually before COCs are
prescribed. • T h e i n s e r t i o n p
• COCs may interact with several drugs such as acetaminophen, anticoagulants, and some reproductive planning clinic. The device is inserted in a collapsed
anticonvulsants, reducing their therapeutic effect so women may be advised to temporarily position, then enlarged to its final shape in the uterus when the
change their method of birth control while prescribed these drugs. inserter is withdrawn. The woman may feel a sharp cramp as the
Mini-pills device is passed through the internal cervical os, but she will not
• Oral contraceptives containing only progestins are popularly called mini-pills. The progesterone feel the IUD after it is in place.
content thickens cervical mucus and helps prevent sperm entry into the uterine cervix. Ovulation Properly fitted, such devices are
may occur but, because the endometrium does not develop fully, implantation will not take place/ contained wholly within the uterus,
• They have the disadvantage of causing more breakthrough bleeding than combination pills. They although the attached string protrudes
are taken every day, even through the menstrual flow. Because it does not interfere with milk through the cervix into the vagina.
production, they may be taken during breastfeeding. • IUDs have several advantages over other contraceptives.
Effect on Pregnancy.  Only one insertion is necessary, so there is no continuing expense.
If a woman taking an estrogen/progestin combination COC suspects that she is  The device does not require daily attention or interfere with sexual
pregnant, she should discontinue taking any more pills if she intends to continue the pregnancy. enjoyment.
High levels of estrogen or progesterone might be teratogenic to a growing fetus.Ax  It is appropriate for women who are at risk for complications
Transdermal Route associated with COCs or who wish to avoid some of the systemic hormonal side effects.
• Transdermal contraception refers to patches that slowly but continuously release a combination  They may create lighter or fewer periods.
of estrogen and progesterone. Patches are applied each week for 3 weeks. No patch is applied • Teach women to regularly check after each menstrual flow, to make sure the IUD string is in
the fourth week. During the week on which the woman is patch free, a menstrual flow will occur. place, and to obtain a yearly pelvic examination.
After the patch-free week, a new cycle of 3 weeks on/1 week off begins again. The efficiency of Side Effects and Contraindications
transdermal patches is equal to that of COCs, although they may be less effective in women who • A woman may notice some spotting or uterine cramping the first 2 or
weigh more than 90 kg (198 lb). 3 weeks after IUD insertion; as long as this is present, she should
• Patches may be applied to one of following four areas: upper outer arm, upper torso (front or use an additional form of contraception, such as vaginal foam.
back, excluding the breasts), abdomen, or buttocks. They should not be placed on any area • Occasionally, a woman continues to have cramping and spotting
where makeup, lotions, or creams will be applied; at the waist where bending might loosen the after insertion; in such instances, she is likely to expel the device
patch; or anywhere the skin is red or irritated or has an open lesion. spontaneously. Women with IUDs in place should take active steps
• Patches can be worn in the shower, while bathing, or while swimming. If a patch comes loose, the to avoid toxic shock syndrome (TSS; a staphylococcal infection from
woman should remove it and immediately replace it with a new patch. No additional contraception the use of tampons), because infection might travel by the IUD string
is needed if the woman is sure the patch has been loose for less than 24 hours. into the uterus to cause uterine infection.
Vaginal Insertion • IUDs are not recommended for
• A (NuvaRing) is a silicone ring that surrounds the cervix women with an increased risk of contracting STIs, such as
and continually releases a combination of estrogen and those who have multiple sexual partners, because this
progesterone. combination could lead to pelvic infection.
• It is inserted vaginally by the woman and left in place for 3 • They also are not recommended for women who have never
weeks, then removed for 1 week (Roumen, 2007). been pregnant (their small uterus could be punctured with
Menstrual bleeding occurs during the ring-free week. The insertion) or who have a history of having had PID. If PID is suspected, the device should be
hormones released are absorbed directly by the mucous removed and the woman should receive antibiotic therapy to treat the infection.
membrane of the vagina. • IUDs are also contraindicated in the woman whose uterus is distorted in shape (the device might
• Fertility returns immediately after discontinuing using the ring. Women may need to make out a perforate an abnormally shaped uterus).
calendar that they post conspicuously to remind themselves to remove and replace the ring. • They are not advised for women with severe dysmenorrhea (painful menstruation), menorrhagia
Implantation (bleeding between menstrual periods), or a history of ectopic (tubal) pregnancy, because their
• Five subdermal implants, rods the size of pencil lead are embedded just under the skin on the use may increase the symptoms or incidence of these conditions.
inside of the upper arm. • Women with valvular heart disease may be advised against the use of an IUD because the
• The rods contain etonogestrel, the metabolite of desogestrel, the increased risk of PID could lead to accompanying valve involvement from bacterial endocarditis.
same progestin that is used in the NuvaRing. Once embedded, Effect on Pregnancy
the implants appear as irregular lines on the skin, simulating small  If a woman with an IUD in place suspects that she is pregnant, she should alert her primary health
veins. Over the next 3 to 5 years, the implants slowly release the care provider. Although the IUD may be left in place during the pregnancy, it is usually removed
hormone, suppressing ovulation, stimulating thick cervical mucus, vaginally to prevent the possibility of infection or spontaneous miscarriage during the pregnancy.
and changing the endometrium so that implantation is difficult. The woman should receive an early ultrasound to document placement of the IUD. This can also
• The implants are inserted with the use of a local anesthetic, during rule out ectopic pregnancy, which has an increased incidence among IUD users who become
the menses or no later than day 7 of the menstrual cycle, to be pregnant with the IUD in place.
certain that the woman is not pregnant at the time of insertion. Barrier Methods
They can be inserted immediately after an elective termination of pregnancy or 6 weeks after the Barrier methods are forms of birth control that work by the placement of a chemical or other barrier
birth of a baby. The failure rate is less than 1% (Cunningham et al., 2008). between the cervix and advancing sperm so that sperm cannot enter the uterus or fallopian tubes
• A major advantage of this long-term reversible contraceptive is that compliance issues associated and fertilize the ovum. A major advantage of barrier methods is that they lack the hormonal side
with COCs are eliminated. It also offers an effective and reliable alternative to the estrogen- effects associated with COCs. However, compared with COCs, their failure rates are higher and
related side effects of COCs. Sexual enjoyment is not inhibited, as may happen with condoms, sexual enjoyment may be lessened.
spermicides, diaphragms, and natural family planning methods. Implants can be used during 1. Chemical Barriers
breastfeeding without an effect on milk production. • A spermicide is an agent that causes the death of spermatozoa before they can enter the cervix.
• A disadvantage of the implant method is its cost ($500 on average) and side effects such as: Such agents are not only actively spermicidal but also change the vaginal pH to a strong acid
• Weight gain level, a condition not conducive to sperm survival. They do not protect against STIs.
• Irregular menstrual cycle such as spotting, breakthrough bleeding, amenorrhea, or prolonged • In addition to the general benefits for barrier contraceptives, the advantages of spermicides
periods include:
• Depression • They may be purchased without a prescription or an appointment with a health care provider, so
• Scarring at the insertion site they allow for greater independence and lower costs.
• Need for removal • When used in conjunction with another contraceptive, they increase the other method’s
Injection effectiveness.
• A single intramuscular injection of medroxyprogesterone acetate (DepoProvera [DMPA]), a • Various preparations are available, including gels, creams, sponges, films, foams, and
progesterone, given every 12 weeks inhibits ovulation, alters suppositories.
the endometrium, and changes the cervical mucus (Box 6.8). • Another form of spermicidal protection is a film of glycerin
The effectiveness rate of this method is almost 100%, making impregnated with a spermicidal agent that is folded and
it an increasingly popular contraceptive method (Chrousos, inserted vaginally. On contact with vaginal secretions or
2008). Do not massage the injection site after administration precoital penile emissions, the film dissolves and a carbon
as you want the drug to absorb slowly from the muscle. dioxide foam forms to protect the cervix against invading
Because DepoProvera contains only progesterone, it can be spermatozoa.
used during breastfeeding. • Sponges are foam-impregnated synthetic sponges that are
• Advantageous effects are reduction in ectopic pregnancy, moistened to activate the impregnated spermicide and then inserted vaginally to block sperm
endometrial cancer, endometriosis, and, for unknown reasons, reduction in the access to the cervix. Well liked by most users, they are easy to insert and have an efficiency rate
frequency of sickle cell crises (Burkman, 2007). of 80% (ideal) and a typical use failure rate of about 60% (Cunningham et al., 2008). They should
• Potential side effects are similar to those of subdermal implants: irregular remain in place for 6 hours after intercourse to ensure sperm destruction.
menstrual cycle, headache, weight gain, and depression. Depo-Provera may Side Effects and Contraindications. Vaginally inserted spermicidal products are
impair glucose tolerance in women at risk for diabetes. Because there also may contraindicated in women with acute cervicitis, because they might further irritate the cervix. They
be an increase in the risk for osteoporosis from loss of bone mineral density, are generally inappropriate for couples who must prevent conception (perhaps because the
advise women to include an adequate amount of calcium in their diet (up to 1200 woman is taking a drug that would be harmful to a fetus or the couple absolutely does not want
mg/day) and to engage in weight-bearing exercise daily to minimize this risk, rules the responsibility of children), because the overall failure rate of all forms of these products is
that are good for all women. about 20%. Some women find the vaginal leakage after use of these products bothersome.
• Two disadvantages are that a woman must return to a health care provider for a new Vaginal suppositories, because of the cocoa butter or glycerin base, are the most bothersome in
injection every 4 to 12 weeks for the method to remain reliable, and the return to fertility is often this regard.
delayed by 6 to 12 months.
Intrauterine Devices
An intrauterine device (IUD) is a small plastic object that is inserted into the uterus through the 2. Mechanical Barriers
vagina (Postlethwaite et al., 2007). IUDs became Mechanical barriers,
popular such as of
as a method a diaphragm, work
birth control by blocking the
in the
1980s, and although still a popular choice worldwide, IUDs are used by only a small number of
U.S. women. Few manufacturers continue to provide them since several lawsuits were filed in  A diaphragm is a circular rubber disk that is placed over the
association with the increased incidence of pelvic inflammatory disease (PID) in women using cervix before intercourse. A Lea’s Shield, made of silicone
one particular brand, now no longer available. rubber and bowl shaped, is a new design. Although use of a
• Today, the IUD is thought to prevent fertilization as well as creating a local sterile inflammatory spermicide is not required for diaphragms, use of a spermicidal
condition that prevents implantation. When copper is added to the device, sperm mobility appears gel with a diaphragm combines a barrier and a chemical method
to be affected as well. This decreases the possibility that sperm will successfully cross the uterine of contraception. With this, the failure rate of the diaphragm is
space and reach the ovum. as low as 6% (ideal) to 16% (typical use).
  A diaphragm is prescribed and fitted initially by a physician, nurse practitioner, or nurse-midwife obtained (proof that all sperm in the vas deferens have been eliminated,
to ensure a correct fit. Because the shape of a woman’s cervix changes with pregnancy, usually requiring 10 to 20 ejaculations).
miscarriage, cervical surgery (dilatation and curettage [D&C]), or elective termination of • They can be assured that vasectomy does not interfere with the production of
pregnancy, teach women to return for a second fitting if any of these circumstances occur. A sperm; the testes continue to produce sperm as always, but the sperm simply
woman should also have the fit of the diaphragm checked if she gains or loses more than 15 lb, do not pass beyond the severed vas deferens and are absorbed at that point.
because this could also change her pelvic and vaginal contours. The man will still have full erection capacity. Because he also continues to form
 A diaphragm is inserted into the vagina, after first coating seminal fluid, he will ejaculate seminal fluid—it will just not contain sperm.
the rim and center portion with a spermicide gel, by • .A few men develop chronic pain after vasectomy (postvasectomy pain
sliding it along the posterior wall and pressing it up syndrome); having the procedure reversed relieves this pain. Some men
against the cervix so that it is held in place by the vaginal develop autoimmunity or form antibodies against sperm, so that even if reconstruction of the vas
fornices. A woman should check her diaphragm with a deferens is successful, the sperm they produce do not have good mobility and are incapable of
finger after insertion to be certain that it is fitted well up fertilization. Men who feel a need to have their sperm available for the future can
over the cervix; she can palpate the cervical os through have it stored in a sperm bank before vasectomy.
the diaphragm. • Tubal ligation, where the fallopian tubes are occluded by cautery, crushing,
 A diaphragm should remain in place for at least 6 hours clamping, or blocking, thereby preventing passage of both sperm and ova. A
after coitus, because spermatozoa remain viable in the fimbriectomy, or removal of the fimbria at the distal end of the tubes, is another
vagina for that length of time. It may be left in place for as possible but little used technique. Tubal ligation has a 99.5% effectiveness rate
long as 24 hours. If it is left in the vagina longer than this, the stasis of fluid (Cunningham et al., 2008). Although the reason is not clear, tubal ligation is
may cause cervical inflammation (erosion) or urethral irritation. associated with a decreased incidence of ovarian cancer.
 After use, a diaphragm should be washed in mild soap and water, dried • The most common operation to achieve tubal ligation is laparoscopy. After a
gently, and stored in its protective case. With this care, a diaphragm will last menstrual flow and before ovulation, an incision as small as 1 cm is made just
for 2 to 3 years. under the woman’s umbilicus with the woman under general or local anesthesia. A
Side Effects and Contraindications. lighted laparoscope is inserted through the incision. Carbon dioxide is then pumped
Diaphragms may not be effective if the uterus is prolapsed, retroflexed, into the incision to lift the abdominal wall upward and
or ant eflexed to such a degree that the cervix is also displaced in relation to out of the line of vision. The surgeon locates the
the vagina. Intrusion on the vagina by a cystocele or rectocele, in which the fallopian tubes by viewing the field through a
walls of the vagina are displaced by bladder or bowel, may make insertion of a diaphragm laparoscope.
difficult. Users of diaphragms may experience a higher number of urinary tract infections (UTIs) • The procedure can also be done by culdoscopy (a
than nonusers, probably because of pressure on the urethra. tube inserted through the posterior fornix of the
Other contraindications include: vagina) or colpotomy (incision through the
• History of toxic shock syndrome (TSS; staphylococcal infection vagina), but the incidence of pelvic infection is
introduced through the vagina) higher with these procedures and visualization is less.
• Allergy to rubber or spermicides The woman is discharged from the hospital a few hours
• History of recurrent UTIs after the procedure. She may notice abdominal bloating for the first 24 hours, until the carbon
• A cervical cap is yet another barrier method of contraception. Caps dioxide infused at the beginning of the procedure is absorbed. This can also cause sharp
are made of soft rubber, are shaped like a thimble with a thin rim, diaphragmatic or shoulder pain if some of the carbon dioxide escapes under the diaphragm and
and fit snugly over the uterine cervix. The failure rate is estimated to presses on ascending nerves.
be as high as 26% (ideal) to 32% (typical use). The precautions for • A woman may return to having coitus as soon as 2 to 3 days after the procedure. Be certain that
use are the same as for diaphragm use except they can be kept in place longer. they understand. that tubal ligation, unlike a hysterectomy, does not affect the menstrual cycle, so
• Many women cannot use cervical caps because their cervix is too short for the cap to fit properly. they will still have a monthly menstrual flow. Be certain that women know to have no unprotected
Also, caps tend to dislodge more readily than diaphragms during coitus. An advantage is that coitus before a tubal ligation (sperm trapped in the tube could fertilize an ovum there and cause
cervical caps can remain in place longer than diaphragms, because they do not put pressure on an ectopic pregnancy).
the vaginal walls or urethra; however, this time period should not exceed 48 hours, to prevent Laparoscopy - a surgical procedure in which a fiber-optic instrument is inserted through the abdominal
cervical irritation. Cervical caps, like diaphragms, must be fitted individually by a health care wall to view the organs in the abdomen or to permit a surgical procedure.
provider. Culdoscopy - an endoscopic procedure performed to examine the rectouterine pouch and pelvic viscera
• They are contraindicated in any woman who has: by the introduction of a culdoscope through the posterior vaginal wall. The word culdoscopy is
• An abnormally short or long cervix derived from the term cul-de-sac, which means literally in French "bottom of a sac", and refers to
• A previous abnormal Pap smear the rectouterine pouch
• A history of TSS Cautery - a medical practice or technique of burning a part of a body to remove
• An allergy to latex or spermicide or close off a part of it.
• A history of pelvic inflammatory disease, cervicitis, or papillomavirus infection Toxic Shock Syndrome - a rare, life-threatening complication of certain types of bacterial infections. Often
• A history of cervical cancer toxic shock syndrome results from toxins produced by Staphylococcus aureus (staph) bacteria,
• An undiagnosed vaginal bleeding but the condition may also be caused by toxins produced by group A streptococcus (strep)
• A condom is a latex rubber or synthetic sheath that is placed over the erect penis before coitus bacteria.
to trap sperm. Condoms have an ideal failure rate of 2% and a
typical failure rate of about 15%, because breakage or spillage
occurs in up to 15% of uses (Kaplan & Love-Osborne, 2007). The Newborn
• A major advantage of condoms is that they are one of the few Profile of a Newborn
“male It is not unusual to hear the comment “all newborns look alike” from people viewing a nursery full
responsibility” birth control measures available, and no health care of babies. In actuality, every child is born with individual physical and personality characteristics
visit or prescription is needed. Latex condoms have the additional that make him or her unique right from the start.
potential of preventing the spread of STIs, and their use has I. Vital Statistics
become a major part of the fight to prevent infection with human Vital statistics measured in a newborn are weight, length, and head and chest circumference. Be
immunodeficiency virus (HIV). Recommend them for any partners who sure all health care providers involved with newborns are aware of safety issues specific to
do not maintain a monogamous relationship. newborn care when taking these measurements such as not leaving a newborn unattended on a
• To be effective, condoms must be applied before any penilevulvar bed or scale.
contact, because even preejaculation fluid may contain some sperm. A Weight
condom should be positioned so that it is loose enough at the penis tip • The birth weight of newborns varies depending on the racial, nutritional, intrauterine, and genetic
to collect the ejaculate without placing undue pressure on the condom. factors that were present during conception and pregnancy. The weight in relation to the
The penis (with the condom held carefully in place) must be withdrawn gestational age should be plotted on a standard neonatal graph, this way helps identify newborns
before it begins to become flaccid after ejaculation. If it is not withdrawn who are at risk because of their small size. This information also separates those who are small
at this time, sperm may leak from the now loosely for their gestational age (newborns who have suffered intrauterine growth restriction) from
condoms dull preterm infants (infants who are healthy but small only because they were born early).
their enjoyment of coitus;  Condoms for females are latex sheaths made of polyurethane and • Plotting weight in conjunction with height and head circumference is also helpful because it
prelubricated with a spermicide. The inner ring (closed end) covers the cervix, and the outer ring highlights disproportionate measurements. For example, a newborn who falls within the 50th
(open end) rests against the vaginal opening. The sheath may be inserted any time before sexual percentile for height and weight but whose head circumference is in the 90th percentile may have
activity begins and then removed after ejaculation occurs. Like male condoms, they are intended abnormal head growth. A newborn who is in the 50th percentile for weight and head
for one-time use and offer protection against both conception and STIs circumference but in the 3rd percentile for height may have a growth problem.
• The average birth weight (50th percentile) for a white, mature female newborn in the United
States is 3.4 kg (7.5 lb); for a white, mature male newborn, it is 3.5 kg (7.7 lb). Newborns of
• Male and female condoms should not be used together. The failure rate is somewhat greater than other races weigh approximately 0.5 lb less. The arbitrary lower limit of normal for all races is 2.5
the failure rate for male condoms, 12% to 22%. Most failures occur because of incorrect or kg (5.5 lb).
inconsistent use. • Birth weight exceeding 4.7 kg (10 lb) is unusual, but weights as high as 7.7 kg (17 lb) have been
Surgical Methods of Reproductive Life Planning documented. If a newborn weighs more than 4.7 kg, the baby is said to be macrosomic and a
Surgical methods of reproductive life planning, often called sterilization, include tubal maternal illness, such as diabetes mellitus, must be suspected (Kwik et al., 2007). Second-born
ligation for women and vasectomy for men. Tubal ligation is chosen by about 28% of all women children usually weigh more than first-born. Birth weight continues to increase with each
in the United States of childbearing age as their contraceptive of choice. Vasectomy is the succeeding child in a family.
contraceptive method of choice for about 11% of men, making these two procedures the most • After this initial loss of weight, a newborn has 1 day of stable weight, then begins to gain weight.
frequently used methods of contraception in the United States for couples older than 30 years of The breastfed newborn recaptures birth weight within 10 days; a formula-fed infant accomplishes
age. this gain within 7 days. After this, a newborn begins to gain about 2 lb per month (6 to 8 oz per
• Counseling should be especially intensive for men and women younger than 25 years of age, week) for the first 6 months of life. Length
because the possibility of divorce, death of a sexual partner, loss of a child, or remarriage could • The average birth length (50th percentile) of a mature female neonate is 53 cm (20.9 in). For
change a person’s philosophy toward childbearing in the future. In addition, mature males, the average birth length is 54 cm (21.3 in). The lower
sterilization is not recommended for individuals whose fertility is important to limit of normal length is arbitrarily set at 46 cm (18 in). Although rare,
their self-esteem. babies with lengths as great as 57.5 cm (24 in) have been reported.
• In a vasectomy, a small incision or puncture wound is made on each side of Head Circumference
the scrotum. The vas deferens at that point is then located, cut and tied, • In a mature newborn, the head circumference is usually 34 to
cauterized, or plugged, blocking the passage of spermatozoa. Vasectomy can 35 cm (13.5 to 14 in). A mature newborn with a head
be done under local anesthesia in an ambulatory setting, such as a physician’s circumference greater than 37 cm (14.8 in) or less than 33
office or a reproductive life planning clinic. The man experiences a small cm (13.2 in) should be carefully assessed for neurologic
amount of local pain afterward, which can be managed by taking a mild involvement, although occasionally a well newborn falls
analgesic and applying ice to the site. within these limits. Head circumference is measured with a
• The procedure is 99.5% effective (MacKay, 2009). Spermatozoa that were tape measure drawn across the center of the forehead and
present in the vas deferens at the time of surgery can remain viable for as long around the most prominent portion of the posterior head.
as 6 months. Therefore, although the man can resume sexual intercourse within 1 week, an Chest Circumference
additional birth control method should be used until two negative sperm reports have been
  The chest circumference in a term newborn is about 2 cm (0.75 to 1 in) less than the head meconium stool by 24 to 48 hours after birth, the possibility of some factor such as meconium
circumference. This is measured at the level of the nipples. If a large amount of breast tissue or ileus, imperforate anus, or volvulus should be suspected.
edema of breasts is present, this measurement will not be accurate until the edema has • About the second or third day of life, newborn stool changes in color and consistency, becoming
subsided. green and loose. This is termed transitional stool, and it may resemble diarrhea to the untrained
II. Vital Signs eye. By the fourth day of life, breastfed babies pass three or four light yellow stools per day. They
Vital sign measurements begin to change from those present in intrauterine life at the moment of are sweet-smelling, because breast milk is high in lactic acid, which reduces the amount of
birth putrefactive organisms in the stool. A newborn who receives formula usually passes two or three
Temperature bright yellow stools a day. These have a slightly more noticeable odor, compared with the stools
The temperature of newborns is about 99° F (37.2° C) at birth because they have been confined of breastfed babies.
in an internal body organ. The temperature falls almost immediately to below normal because of Urinary System
heat loss and immature temperature regulating mechanisms. The temperature of birthing rooms, The average newborn voids within 24 hours after birth. A newborn who does not take in much fluid
approximately 68° to 72° F (21° to 22° C), can add to this loss of heat. for the first 24 hours may void later than this, but the 24-hour point is a good general rule.
• A newborn loses heat easily because of difficulty conserving heat under any circumstance. Newborns who do not void within this time should be examined for the possibility of urethral
Insulation, an efficient means of conserving heat in adults, is not effective in newborns because stenosis or absent kidneys or ureters.
they have little subcutaneous fat to provide insulation. Shivering, a means of increasing • A single voiding in a newborn is only about 15 mL and may be easily missed in a thick diaper.
metabolism and thereby providing heat in adults, is rarely seen in newborns. Specific gravity ranges from 1.008 to 1.010. The daily urinary output for the first 1 or 2 days is
• Newborns can conserve heat by constricting blood vessels and moving blood away from the skin. about 30 to 60 mL total. By week 1, total daily volume rises to about 300 mL. The first voiding
Brown fat, a special tissue found in mature newborns, apparently helps to conserve or produce may be pink or dusky because of uric acid crystals that were formed in the bladder in utero; this is
body heat by increasing metabolism. The greatest amounts of brown fat are found in the an innocent finding.
intrascapular region, thorax, and perirenal area. Brown fat is thought to aid in controlling newborn Immune System
temperature similar to temperature control in a hibernating animal. In later life, it may influence Because they have difficulty forming antibodies against invading antigens until about 2 months of
the proportion of body fat retained. age, newborns are prone to infection. This inability to form antibodies is the reason that most
• Newborns exposed to cool air tend to kick and cry to increase their metabolic rate and produce immunizations against childhood diseases are not given to infants younger than 2 months of age.
more heat. This reaction, however, also increases their need for oxygen and their respiratory rate Newborns do have some immunologic protection, because they are born with passive antibodies
increases. An immature newborn with poor lung development has trouble making such an (immunoglobulin G) from their mother that crossed the placenta. In most instances, these include
adjustment. antibodies against poliomyelitis, measles, diphtheria, pertussis, chickenpox, rubella, and tetanus.
• Drying and wrapping newborns and placing them in warmed cribs, or drying them and placing Newborns are routinely administered hepatitis B vaccine during the first 12 hours after birth to
them under a radiant heat source, are excellent mechanical measures to help conserve heat. In protect against this disease.
addition, placing a newborn against the mother’s skin and then covering the newborn with a Neuromuscular System
blanket helps to transfer heat from the mother to the newborn; this is termed skin-to-skin care. Mature newborns demonstrate neuromuscular function by moving their extremities, attempting to
Pulse control head movement, exhibiting a strong cry, and demonstrating newborn reflexes. Limpness
The heart rate of a fetus in utero averages 120 to 160 beats per minute (bpm). Immediately or total absence of a muscular response to manipulation is never normal and suggests narcosis,
after birth, as the newborn struggles to initiate respirations, the heart rate may be as rapid as 180 shock, or cerebral injury.
bpm. Within 1 hour after birth, as the newborn settles down to sleep, the heart rate stabilizes to Newborn reflexes can be tested with consistency by using simple maneuvers.
an average of 120 to 140 bpm. Blink Reflex.
• The heart rate of a newborn often remains slightly irregular because of immaturity of the cardiac  A blink reflex in a newborn serves the same purpose as it does in an adult—to protect the eye from
regulatory center in the medulla. Transient murmurs may result from the incomplete closure of any object coming near it by rapid eyelid closure. It may be elicited by shining a strong light such
fetal circulation shunts. During crying, the rate may rise again to 180 bpm. In addition, heart rate as a flashlight or an otoscope light on an eye. A sudden movement toward the eye sometimes
can decrease during sleep, ranging from 90 to 110 bpm. can elicit the blink reflex.
• You should be able to palpate brachial and femoral pulses in a newborn, but the radial and
temporal pulses are more difficult to palpate with any degree of accuracy. Therefore, a newborn’s
heart rate is always determined by listening for an apical heartbeat for a full minute, rather than Rooting Reflex.
assessing a pulse in an extremity. If the cheek is brushed or stroked near the
Respiration corner of the mouth, a newborn infant will turn
The respiratory rate of a newborn in the first few minutes of life may be as high as 80 breaths per the head in that direction. This reflex serves to
minute. As respiratory activity is established and maintained, this rate settles to an average of 30 help a newborn find food: when a mother
to 60 breaths per minute when the newborn is at rest. Respiratory depth, rate, and rhythm are holds the child and allows her breast to brush
likely to be irregular, and short periods of apnea (without cyanosis) which last less than 15 the newborn’s cheek, the reflex makes the
seconds, sometimes called periodic respirations, are normal. baby turn toward the breast. The re Sucking
• Respiratory rate can be observed most easily by watching the movement of a newborn’s Reflex.
abdomen, because breathing primarily involves the use of the diaphragm and abdominal When a
muscles.
Blood Pressure
The blood pressure of a newborn is approximately 80/46 mm Hg at birth. By the 10th day, it
rises to about 100/50 mm Hg. Because measurement of blood pressure in a newborn is newborn’s lips are touched, the baby makes a sucking
somewhat inaccurate, it is not routinely measured unless a cardiac anomaly is suspected. For an motion. The reflex helps a newborn find food: when the
accurate reading, the cuff width used must be no more than two thirds the length of the upper arm newborn’s lips touch the mother’s breast or a bottle, the baby
or thigh. sucks and so takes in food. The sucking reflex begins to
Blood pressure tends to increase with crying (and a newborn cries when disturbed and diminish at about 6 months of age. It disappears immediately flex disappears at about the sixth
manipulated by such procedures as taking blood pressure). A Doppler method may be used to week of life.
take blood pressure Swallowing Reflex.
III. Physiologic Function The swallowing reflex in a newborn is the same as in the adult.
Cardiovascular System Food that reaches the posterior portion of the tongue is
Changes in the cardiovascular system are necessary after birth because now the lungs must automatically swallowed. Gag, cough, and sneeze reflexes also
oxygenate the blood that was formerly oxygenated by the placenta. When the cord is clamped, a are present in newborns to maintain a clear airway in the event
neonate is forced to take in oxygen through the lungs. As the lungs inflate for the first time, that normal swallowing does not keep the pharynx free of
pressure decreases in the pulmonary artery (the artery leading from the heart to the lungs). This obstructing mucus.
decrease in pressure plays a role in promoting closure of the ductus arteriosus, a fetal shunt. As Extrusion Reflex.
pressure increases in the left side of the heart from increased blood volume, the foramen ovale A newborn extrudes any substance that is placed on the anterior
between the two atria closes because of the pressure against the lip of the structure (permanent portion of the tongue. This protective reflex prevents the swallowing of inedible substances. It
closure does not occur for weeks). With the remaining fetal circulatory structures (umbilical vein, disappears at about 4 months of age. Until then, the infant may seem to be spitting out or refusing
two umbilical arteries, and ductus venosus) no longer receiving blood, the blood within them clots, solid food placed in the mouth Palmar Grasp Reflex.
and the vessels atrophy over the next few weeks. Newborns grasp an object placed in their palm by closing their fingers on it. Mature newborns
• The hematocrit is between 45% and 50%. A newborn also has an elevated red blood cell count, grasp so strongly that they can be raised from a supine position and suspended momentarily from
about 6 million cells per cubic millimeter. Once proper lung oxygenation has been established, an examiner’s fingers. This reflex disappears at about 6 weeks to 3 months of age. A baby begins
the need for the high red cell count diminishes. Therefore, within a matter of days, a newborn’s to grasp meaningfully at about 3 months of age.
red cells begin to deteriorate. Bilirubin is a byproduct of the breakdown of red blood cells. An
indirect bilirubin level at birth is 1 to 4 mg/100 mL. Any increase over this amount reflects the Step (Walk)-in-Place
release of bilirubin as excessive red blood cells begin their breakdown. Reflex.
• A newborn has an equally high white blood cell count at birth, about 15,000 to 30,000 cells/mm3 . Newborns who are held in a
Values as high as 40,000 cells/mm3 may be seen if the birth was stressful. vertical position with their
Respiratory System feet touching a hard surface
A first breath is a major undertaking because it requires a tremendous amount of pressure (about will take a few quick,
40 to 70 cm H2O). It is initiated by a combination of cold receptors; a lowered partial pressure of alternating steps. This reflex
oxygen (PO2), which falls from 80 to as low as 15 mm Hg before a first breath; and an increased disappears by 3 months of
partial carbon dioxide pressure (PCO2), which rises as high as 70 mm Hg before a first breath. age. By 4 months, babies can bear a good portion of
• All newborns have some fluid in their lungs from intrauterine life that will ease the surface tension their weight unhindered by this reflex.
on alveolar walls and allows alveoli to inflate more easily than if the lung walls were dry. About a
third of this fluid is forced out of the lungs by the pressure of vaginal birth. Additional fluid is
quickly absorbed by lung blood vessels and lymphatics after the first breath. Plantar Grasp Reflex.
• Once the alveoli have been inflated with a first breath, breathing becomes much easier for a When an object touches the sole of a newborn’s foot at the base of the toes, the toes grasp in
baby, requiring only about 6 to 8 cm H2O pressure. Within 10 minutes after birth, most newborns the same manner as do the fingers. This reflex disappears at
have established a good residual volume. about 8 to 9 months of age in
• A newborn who has difficulty establishing respirations at birth should be examined closely in the preparation for walking.
postpartal period for a cardiac murmur or other indication that he or she still has patent fetal However, it may be present
cardiac structures, especially a patent ductus arteriosus. during sleep for a longer period.
Gastrointestinal System
Although the gastrointestinal tract is usually sterile at birth, bacteria may be cultured from the Tonic Neck Reflex.
intestinal tract in most babies within 5 hours after birth and from all babies at 24 hours of life. When newborns lie on their
Most of these bacteria enter the tract through the newborn’s mouth from airborne sources. Others backs, their heads usually turn
may come from vaginal secretions at birth, from hospital bedding, and from contact at the breast. to one side or the other. The arm and the leg on the side toward
Accumulation of bacteria in the gastrointestinal tract is necessary for digestion and for the which the head turns extend, and the opposite arm and leg contract.
synthesis of vitamin K. If you turn a newborn’s head to the opposite side, he or she will often
• The first stool of a newborn is usually passed within 24 hours after birth. It consists of meconium, change the extension and contraction of legs and arms accordingly. This is also called a boxer or
a sticky, tarlike, blackish-green, odorless material formed from mucus, vernix, lanugo, hormones, fencing reflex, because the position simulates that of someone preparing to box or fence. It may
and carbohydrates that accumulated during intrauterine life. If a newborn does not pass a signify handedness. The reflex disappears between the second and third months of life.
 Moro Reflex. cells, resulting in permanent cell damage, a condition termed kernicterus. If this occurs,
A Moro (startle) reflex can be initiated by startling a newborn with a loud permanent neurologic damage, including cognitive challenge, may result.
noise or by jarring the bassinet. The most accurate method of eliciting the • There is no set level at which indirect serum bilirubin requires treatment, because other factors,
reflex is to hold newborns in a supine position and allow their heads to drop such as age, maturity, and breastfeeding status, affect this determination. If the level rises to
backward about 1 inch. In response to this sudden head movement, they more than 10 to 12 mg/100 mL, treatment is usually considered. Phototherapy (exposure of the
abduct and extend their arms and legs. Their fingers assume a typical “C” infant to light to initiate maturation of liver enzymes) is a common therapy. If this is necessary, the
position. It is strong for the first 8 weeks of life and then fades by the end of incubator and light source can be moved to the mother’s room so that the mother is not separated
the fourth or fifth month, at the same time an infant can roll away from from her baby. Some infants need continued therapy after discharge and receive phototherapy at
danger. home (Mills & Tudehope, 2009).
the foot is stroked in an inverted “J” curve • Compared with formula-fed babies, a small proportion of breastfed babies may have more
from the heel upward, a newborn fans the toes (positive difficulty converting indirect bilirubin to direct bilirubin, because breast milk contains pregnanediol
Babinski sign) (Fig. 18.8). This is in contrast to the adult, (a metabolite of progesterone), which depresses the action of glucuronyl transferase. However,
who flexes the toes. This reaction occurs because nervous breastfeeding alone rarely causes enough jaundice to warrant therapy (Thilo & Rosenberg,
system development is immature. It remains positive (toes 2008).
fan) until at least 3 months of age, when it is supplanted by Pallor
the downturning or adult flexion response. • Pallor in newborns is usually the result of anemia. This may be caused by
(a) excessive blood loss when the cord was cut,
Magnet Reflex. (b) inadequate flow of blood from the cord into the infant at birth,
If pressure is applied to the soles of the feet of a newborn lying in a supine position, he or she (c) fetal–maternal transfusion,
pushes back against the pressure. This and the two following reflexes are tests of spinal cord (d) low iron stores caused by poor maternal nutrition during pregnancy,
integrity. or
Crossed Extension Reflex. (e) blood incompatibility in which a large number of red blood cells were
If one leg of a newborn lying supine is extended and the sole of that hemolyzed in utero. It also may be the result of internal bleeding. A
foot is irritated by being rubbed with a sharp object, such as a baby who appears pale should be watched closely for signs of blood
thumbnail, the infant raises the other leg and extends it, as if trying to in stool or vomitus.
push away the hand irritating the first leg. Harlequin Sign
Trunk Incurvation Reflex  Occasionally, because of immature circulation, a newborn who has been
When newborns lie in a prone position and are touched along the lying on his or her side appears red on the dependent side of the
paravertebral area by a probing finger, they flex their trunk and swing body and pale on the upper side, as if a line had been drawn down
their pelvis toward the touch the center of the body. This is a transient phenomenon; although
Landau Reflex. startling, it is of no clinical significance. The odd coloring fades
A newborn who is held in a prone position with a hand underneath, immediately if the infant’s position is changed or the baby kicks or
supporting the trunk, should demonstrate some muscle tone. Babies cries vigorously.
may not be able to lift their head or arch their back in this position (as B. Birthmarks
they will at 3 months of age), but neither should they sag into an It is important to be able to differentiate the various types of
inverted “U” position. The latter response indicates extremely poor hemangiomas that occur, so that you neither give false
muscle tone, the cause of which should be investigated. reassurance to parents nor worry them unnecessarily about these
Vision. Newborns see as soon as they are born and possibly lesions.
have been “seeing” light and dark in utero for the last few Hemangiomas
months of pregnancy, as the uterus and the abdominal wall were The hemangiomas are vascular tumors of the skin. Three types
stretched thin. occur.
Newborns demonstrate sight at birth by blinking at a strong light (blink reflex) or by following a A. Nevus Flammeus - is a macular purple or dark-red lesion (sometimes called a portwine stain
bright light or toy a short distance with their eyes. because of its deep color) that is present at birth. These lesions typically appear on the face,
Touch. although they are often found on the thighs as well. Those above the bridge of the nose tend to
The sense of touch is also well developed at birth. Newborns demonstrate this by quieting at a fade; the others are less likely to fade. Because they are level with the skin surface (macular),
soothing touch and by sucking and rooting reflexes, which are elicited by touch. They also react they can be covered by a cosmetic preparation later in life or removed by laser therapy, although
to painful stimuli. lesions may reappear after treatment (Berger, 2009).
Taste. Nevus flammeus lesions also occur as lighter, pink patches at the nape of the neck, known as
A newborn has the ability to discriminate taste, because taste buds are developed and stork’s beak marks or telangiectasia. These do not fade, but they are covered by the hairline
functioning even before birth. A fetus in utero, for example, will swallow amniotic fluid more and therefore are of no consequence. They occur more often in females than in males.
rapidly than usual if glucose is added to sweeten its taste. The swallowing decreases if a bitter B. Strawberry hemangioma - refers to elevated areas formed by immature
flavor is added. A newborn turns away from a bitter taste such as salt but readily accepts the capillaries and endothelial cells. Most are present at birth in the term
sweet taste of milk or glucose water. neonate, although they may appear up
Smell. to 2 weeks after birth. Typically, they are not present in the
The sense of smell is present in newborns as soon as the nose is clear of lung and amniotic fluid. preterm infant because of the immaturity of the epidermis.
Newborns turn toward their mothers’ breast partly out of recognition of the smell of breast milk Formation is associated with the high estrogen levels of pregnancy. They may continue to
and partly as a manifestation of the rooting reflex. Their ability to respond to odors can be used to enlarge from their original size up to 1 year of age. After the first year, they tend to be absorbed
document alertness. and shrink in size. By the time the child is 7 years old, 50% to 75% of these lesions have
IV. Appearance of a Newborn disappeared.
1. Skin A A child may be 10 years old before the absorption is complete.
Color Application of hydrocortisone ointment may speed the
• Most term newborns have a ruddy complexion because of the increased concentration of red disappearance of these lesions by interfering with the binding of
blood cells in blood vessels and a decrease in the amount of subcutaneous fat, which makes estrogen to its receptor sites.
the blood vessels more visible. This ruddiness fades slightly over the first month. Infants
with poor central nervous system control may appear pale and cyanotic. A gray color in
newborns generally indicates infection. Cyanosis.  Generalized mottling of the skin is common. C. Cavernous hemangiomas - are dilated vascular spaces. They are usually raised and resemble a
A newborn’s lips, hands, and feet are likely to appear blue from immature peripheral circulation. strawberry hemangioma in appearance. However, they do not disappear
Acrocyanosis (blueness of hands and feet) is so prominent in some newborns that it appears as with time as do strawberry hemangiomas. Such lesions can be removed
if some stricture were cutting off circulation, with usual skin color on one side and blue on the surgically. Steroids, interferon-alfa-2a, or vincristine can be used to reduce
other. Acrocyanosis is a normal phenomenon in the first 24 to 48 hours after birth; however, these lesions in size, although their use must be weighed in light of side
central cyanosis, or cyanosis of the trunk, is always a cause for concern. Central cyanosis effects (Edmonds, 2008). Children who have a skin lesion may have
indicates decreased oxygenation. It may be the result of a temporary respiratory obstruction or an additional ones on internal organs. Blows to the abdomen, such as those from childhood games,
underlying disease state can cause bleeding from an internal hemangioma. For this reason, children with cavernous
Hyperbilirubinemia hemangiomas usually have their hematocrit levels assessed at health maintenance visits, to
• Hyperbilirubinemia leads to jaundice, or yellowing of the skin (Beachy, 2007). This occurs on the evaluate for possible internal blood loss.
second or third day of life in about 50% of all newborns, as a result of a breakdown of fetal red Mongolian spots
blood cells (physiologic jaundice). The infant’s skin and the sclera of the eyes appear noticeably Mongolian spots are collections of pigment cells (melanocytes) that appear as slate-
yellow. This happens because the high red blood cell count built up in utero is destroyed, and gray patches across the sacrum or buttocks and possibly on the arms and legs. They tend to
heme and globin are released. occur in children of Asian, southern European, or African ethnicity (Thilo & Rosenberg, 2008).
• Many newborns have such immature liver function that indirect bilirubin cannot be converted to They disappear by school age without treatment. Be sure to inform parents that these are not
the direct form; it therefore remains indirect. As long as the buildup of indirect bilirubin remains in bruises; otherwise, they may worry their baby sustained a birth injury.
the circulatory system, the red coloring of the blood cells covers the yellow tint of the bilirubin. C. Vernix Caseosa
After the level of this indirect bilirubin has risen to more than 7 mg/100 mL, however, bilirubin Vernix caseosa is a white, cream cheese–like substance that serves as a skin lubricant in utero.
permeates the tissue outside the circulatory system and causes the infant to appear jaundiced. Usually, it is noticeable on a term newborn’s skin, at least in the skin folds, at birth. Document the
• Observe infants who are prone to extensive bruising (large, breech, or immature babies) carefully color of vernix, because it takes on the color of the amniotic fluid. For example, a yellow vernix
for jaundice, because bruising leads to hemorrhage of blood into the subcutaneous tissue or skin. implies that the amniotic fluid was yellow from bilirubin; green vernix indicates that meconium was
A cephalhematoma is a collection of blood under the periosteum of the skull bone. As the bruising present in the amniotic fluid. Until the first bath, when vernix is washed away, handle newborns
in these locations heals and the red blood cells are hemolyzed, additional indirect bilirubin is with gloves to protect yourself from
released and can be another cause of jaundice (Nicholson, 2007). exposure to this body fluid. Never use harsh rubbing to wash away vernix. A newborn’s skin is
• If intestinal obstruction is present and stool cannot be evacuated, tender, and breaks in the skin caused by too vigorous attempts at removal may open portals of
intestinal flora may break down bile into its basic components, entry for bacteria.
leading to the release of indirect bilirubin into the bloodstream D. Lanugo Lanugo is the fine, downy hair that covers a newborn’s shoulders,
again. Early feeding of newborns promotes intestinal movement back, and upper arms. It may be found also on the forehead and ears. A
and excretion of meconium and helps prevent indirect bilirubin baby born between 37 to 39 weeks of gestation has more lanugo than a
buildup from this source. newborn of 40 weeks’ gestational age. Postmature infants (more than 42
• The level of jaundice in newborns may be judged grossly by weeks of gestation) rarely have lanugo. Lanugo is rubbed away by the
estimating the extent to which it has progressed on the surface of friction of bedding and clothes against the newborn’s skin. By 2 weeks of
the infant’s body, as it is noticed first in the head and then spreads age, it has disappeared.
to the rest of the body. E. Desquamation
• Treatment for physiologic jaundice or the routine rise in bilirubin in Within 24 hours after birth, the skin of most newborns has become
newborns is rarely necessary, except for measures such as early extremely dry. The dryness is particularly evident on the palms of the hands and soles of the feet.
feeding to speed passage of feces through the intestine and prevent This results in areas of peeling similar to those caused by sunburn. This is normal, however, and
reabsorption of bilirubin from the bowel. needs no treatment. Parents may apply hand lotion to prevent excessive dryness if they wish.
• Above-normal indirect bilirubin levels are potentially dangerous F. Milia
because, if enough indirect bilirubin (about 20 mg/100 mL) leaves All newborn sebaceous glands are immature. At least one pinpoint white
the bloodstream, it can interfere with the chemical synthesis of brain papule (a plugged or unopened sebaceous gland) can be found on the
 cheek or across the bridge of the nose of almost every naris at a time with your fingers. Note any discomfort or distress while breathing this way. Nasal
newborn. Such lesions, termed milia, disappear by 2 to 4 flaring upon inspiration is another indication of respiratory distress and should be further
weeks of age, as the sebaceous glands mature and evaluated. Also record any evidence of milia on the nose.
drain. Teach parents to avoid scratching or squeezing 6. Mouth
the papules, to prevent secondary infections. A newborn’s mouth should open evenly when he or she cries. If one side of the mouth moves
G. Erythema Toxicum more than the other, cranial nerve injury is suggested. A newborn’s tongue appears large and
In most normal mature infants, a newborn rash called erythema toxicum can be observed. This prominent in the mouth. Because the tongue is short, the frenulum membrane is attached close to
usually appears in the first to fourth day of life but may appear up to 2 weeks of age. It begins the tip of the tongue, creating the impression that the infant is “tongue tied.”
with a papule, increases in severity to become erythema by the second day, and then disappears Inspect the palate of a newborn to be sure it is intact. Occasionally, one or two small,
by the third day. It is sometimes called a flea-bite rash because the lesions are so minuscule. round, glistening, well circumscribed cysts (Epstein’s pearls) are present on the palate, a result
One of the chief characteristics of the rash is its lack of pattern. It occurs sporadically of extra calcium that was deposited in utero. Be sure to inform parents that these pearl-like cysts
and unpredictably and may last hours rather than days. It is caused by a newborn’s eosinophils are insignificant, require no treatment, and will disappear spontaneously within 1 week.
reacting to the environment as the immune system matures. It requires no treatment. Otherwise, a parent may mistake them for thrush, a Candida infection, which usually appears on
H. Skin Turgor the tongue and sides of the cheeks as white or gray patches and needs therapy with an
Newborn skin should feel resilient if the underlying tissue is well hydrated. If a fold of the skin is antifungal drug (Subramanian et al., 2008).
grasped between the thumb and fingers, it should feel elastic. When it is released, it should fall 7. Neck
back to form a smooth surface. If severe dehydration is present, the skin will not smooth out The neck of a newborn is short and often chubby, with creased skin folds. The head
again but will remain in an elevated ridge. Poor turgor is seen in newborns who suffered should rotate freely on it. If there is rigidity of the neck, congenital torticollis, caused by injury to
malnutrition in utero, who have difficulty sucking at birth, or who have certain metabolic disorders the sternocleidomastoid muscle during birth, might be present. In newborns whose membranes
such as adrenocortical insufficiency. were ruptured more than 24 hours before birth, nuchal rigidity suggests meningitis.
2. Head A newborn’s head appears disproportionately large because it is about one fourth of the total The neck of a newborn is not strong enough to support the total weight of the head
body length; in an adult, a head is one eighth of total height. The forehead of a newborn is large but in a sitting position, a newborn should make a momentary effort at head control. When lying
and prominent. The chin appears to be receding, and it quivers easily if an infant is startled or prone, newborns can raise the head slightly, usually enough to lift the nose out of mucus or spit-
cries. Well-nourished newborns have full-bodied hair; poorly nourished and preterm infants have up formula. If they are pulled into a sitting position from a supine position, the head will lag behind
thin, lifeless hair. If internal fetal monitoring was used during labor, a newborn may exhibit a considerably.
pinpoint ulcer at the point where the monitor was attached. 8. Chest
Fontanelles The chest in some newborns looks small because the head is large in proportion. It is
The fontanelles are the spaces or openings where the skull bones join. The anterior actually approximately 2 inches smaller in circumference and as wide in the anteroposterior
fontanelle is located at the junction of the two parietal bones and the two fused frontal bones. It diameter as it is across. Not until a child is 2 years of age does the chest measurement exceed
is diamond shaped and measures 2 to 3 cm (0.8 to 1.2 in) in width and 3 to 4 cm (1.2 to 1.6 in) in that of the head. The clavicles should be straight. A crepitus or actual separation on one or the
length. The posterior fontanelle is located at the junction of the parietal bones and the occipital other clavicle may indicate that a fracture occurred during birth and calcium is now being
bone. It is triangular and measures about 1 cm (0.4 in) in length. deposited at that point.
The anterior fontanelle can be felt as a soft spot. It should not appear indented (a sign Overall, a newborn’s chest should appear symmetric side to side. Respirations are
of dehydration) or bulging (a sign of increased intracranial pressure) when the infant is held normally rapid (30 to 60 breaths per minute) but not distressed. A supernumerary nipple (usually
upright. The fontanelle may bulge if the newborn strains to pass a stool or cries vigorously or is found below and in line with the normal nipples) may be present. If so, it may be removed later for
lying supine. With vigorous crying, a pulse may additionally be seen in the fontanelle. The anterior cosmetic purposes although this is not necessary.
fontanelle normally closes at 12 to 18 months of age. In some newborns, the posterior fontanelle In both female and male infants, the breasts may be engorged. Occasionally, the
is so small that it cannot be palpated readily. The posterior fontanelle closes by the end of the breasts of newborn babies secrete a thin, watery fluid popularly termed witch’s milk.
second month. Engorgement develops in utero as a result of the influence of the mother’s hormones. As soon as
Sutures the hormones are cleared from the infant’s system (about 1 week),
The skull sutures, the separating lines of the skull, may override at birth because of the extreme the engorgement and any fluid that is present subside.
pressure exerted on the head during passage through the birth canal. If the sagittal suture Retraction (drawing in of the chest wall with inspiration)
between the parietal bones overrides, the fontanelles are less perceptible than usual. The should not be present. An infant with retractions is using such
overriding subsides in 24 to 48 hours. strong force to pull air into the respiratory tract that he or she is
Suture lines should never appear widely separated in newborns. Wide separation suggests pulling in the anterior chest muscle. An abnormal sound, such as
increased intracranial pressure because of abnormal brain formation, abnormal accumulation of grunting, suggests respiratory distress syndrome; a high, crowing
cerebrospinal fluid in the cranium (hydrocephalus), or an accumulation of blood from a birth injury sound on inspiration suggests stridor or immature tracheal
such as subdural hemorrhage. Fused suture lines also are abnormal; they require radiographic development.
confirmation and further evaluation, because they will prevent the head from expanding with brain 9. Abdomen
growth. The contour of a newborn abdomen looks slightly protuberant. A scaphoid or sunken
Molding appearance may indicate missing abdominal contents or a diaphragmatic hernia (bowel
The part of the infant’s head that engaged the cervix (usually the vertex) molds to fit the cervix positioned in the chest instead of the abdomen). Bowel sounds should be present within 1 hour
contours during labor. After birth, this area appears prominent and asymmetric. Molding may be after birth. The edge of the liver is usually palpable 1 to 2 cm below the right costal margin. The
so extreme in the baby of a primiparous woman that the baby’s head appears as a dunce cap. edge of the spleen may be palpable 1 to 2 cm below the left costal margin. Tenderness is difficult
The head will restore to its normal shape within a few days after birth. to determine in a newborn. If it is extreme, however, palpation will cause the infant to cry, thrash
Caput Succedaneum about, or tense the abdominal muscles to protect the abdomen.
Caput succedaneum is edema of the scalp at the presenting part of the head. For the first hour after birth, the stump of the umbilical cord appears as a white,
It may involve wide areas of the head, or it may resemble a large egg. The gelatinous structure marked with the blue and red streaks of the umbilical vein and arteries. When
edema, which crosses the suture lines, is gradually absorbed and disappears the cord is first cut, the vessels are counted to be certain that one vein and two arteries are
at about the third day of life. It needs no treatment (Nicholson, 2007). present.
Cephalhematoma Inspect the cord clamp to be certain it is secure. After the first hour of life, the cord
A cephalhematoma, a collection of blood between the periosteum of a skull begins to dry and shrink, and it turns brown like the dead end of a vine. By the second or third
bone and the bone itself, is caused by rupture of a periosteal capillary day, it has turned black. It breaks free by day 6 to 10, leaving a granulating area a few
because of the pressure of birth. Swelling usually appears 24 hours after birth. Although the centimeters wide that heals during the following week.
blood loss is negligible, the swelling is usually severe and is well outlined as an egg shape. It may The base of the cord should appear dry. A moist or odorous cord suggests infection.
be discolored (black and blue) because of the presence of coagulated blood. If present, infection should receive immediate treatment or it may enter a newborn’s bloodstream
A cephalhematoma is confined to an individual bone, so the and cause septicemia.
associated swelling stops at the bone’s suture line. It often To finish the abdominal assessment, elicit an abdominal reflex. Stroking each
takes weeks for a cephalhematoma to be absorbed. It might be quadrant of the abdomen will cause the umbilicus to move or “wink” in that direction. This
supposed that the blood could be aspirated to relieve the superficial abdominal reflex is a test of spinal nerves T8–T10. The reflex may not be
condition. However, such a procedure would introduce the risk demonstrable in newborns until the 10th day of life.
of infection and is unnecessary, because the condition will 10. Anogenital
subside by itself. As the blood captured in the space is broken Area Inspect the anus of a newborn to be certain it is present, patent, and not covered by a
down, a great amount of indirect bilirubin may be released, membrane (imperforate anus). Test for anal patency by gently inserting the tip of your gloved and
leading to jaundice. lubricated little finger. Also note the time after birth at which the infant first passes meconium. If a
Craniotabes newborn does not do so in the first 24 hours, suspect imperforate anus or meconium ileus.
Craniotabes is a localized softening of the cranial bones that is probably caused by pressure of Male Genitalia
the fetal skull against the mother’s pelvic bone in utero. It is more common in firstborn infants The scrotum in most male newborns is edematous and has rugae (folds in the skin). It may be
than in infants born later, because of the lower position of the fetal head in the pelvis during the deeply pigmented in African American or dark-skinned newborns. Make a practice of pressing
last 2 weeks of pregnancy in primiparous women. With craniotabes, the skull is so soft that the your nondominant hand against the inguinal ring before palpating for testes, so they do not slip
pressure of an examining finger can indent it. The bone returns to its normal contour after the upward and out of the scrotal sac as you palpate.
pressure is removed. The condition corrects itself without treatment after a few months, as the Both testes should be present in the scrotum. If one or both testicles are not present
infant takes in calcium in milk. (cryptorchidism), referral is needed to establish the extent of the problem. This condition could
3. Eyes be caused by agenesis (absence of an organ), ectopic testes (the testes cannot enter the
Newborns usually cry tearlessly, because their scrotum because the opening to the scrotal sac is closed), or undescended testes (the vas
lacrimal ducts do not fully mature until about 3 months of age. deferens or artery is too short to allow the testes to descend).
Almost without exception, the irises of the eyes of newborns Elicit a cremasteric reflex by stroking the internal side of the thigh. As the skin is stroked, the
are gray or blue; the sclera may be blue because of its testis on that side moves perceptibly upward. This is a test for the integrity of spinal nerves T8–
thinness. Infant eyes assume their permanent color between 3 and 12 months of age. To inspect T10. The response may be absent in newborns who are younger than 10 days. The penis of
the eyes, lay the newborn in a supine position and lift the head. This maneuver causes the baby newborns appears small, approximately 2 cm long. If it is less than this, the newborn should be
to open the eyes. A newborn’s eyes should appear clear, without redness or purulent discharge. referred for evaluation by an endocrinologist. Inspect the tip of the penis to see that the urethral
4. Ears A newborn’s external ear is not as completely formed as it will be eventually, so the pinna opening is at the tip of the glans, not on the dorsal surface (epispadias) or on the ventral surface
tends to bend easily. In the term newborn, however, the pinna should be strong enough to recoil (hypospadias).
after bending. The level of the top part of the external ear should be on a line drawn from the Female Genitalia
inner canthus to the outer canthus of the eye and back across the side of the head. Ears that are The vulva in female newborns may be swollen because of the effect of maternal hormones. Some
set lower than this are found in infants with certain chromosomal abnormalities, particularly female newborns have a mucus vaginal secretion, which is sometimes blood-tinged
trisomy 18 and 13, syndromes in which low-set ears and other physical defects are coupled with (pseudomenstruation). Again, this is caused by the action of maternal hormones. The discharge
varying degrees of cognitive challenge. disappears as soon as the infant’s system has cleared the hormones. The discharge should not
A good practice is to test a newborn’s hearing by ringing a bell held about 6 inches from each ear. be mistaken for an infection or taken as an indication that trauma has occurred.
A hearing infant who is crying will stop momentarily at the sound. If quiet, a newborn who can 11. Back
hear will blink the eyes, appear to attend to the sound, and possibly startle. Although this method The spine of a newborn typically appears flat in the lumbar and sacral areas. The curves seen in
of testing is not highly accurate, a negative response (lack of response) is unusual. an adult appear only after a child is able to sit and walk. Inspect the base of a newborn’s spine
5. Nose carefully to be sure there is no pinpoint opening, dimpling, or sinus tract in the skin, which would.
Anewborn’s nose tends to appear large for the face. As the infant grows, the rest of suggest a dermal sinus or spinal bifida occulta. True neural tube defects in newborns are greatly
the face grows more than the nose does, and this discrepancy disappears. Test for choanal decreased in incidence because of the recognition that lack of folic acid during pregnancy leads
atresia (blockage at the rear of the nose) by closing the newborn’s mouth and compressing one to these (De Wals et al., 2007).
 A newborn normally assumes the position maintained in utero, with the back rounded and the
arms and legs flexed on the abdomen and chest. A child who was born in a frank breech position
tends to straighten the legs at the knee and bring their feet up next to the face.
12. Extremities
The arms and legs of a newborn appear short. The hands are plump and clenched into fists.
Newborn fingernails are soft and smooth, and usually long enough to extend over the fingertips.
Test the upper extremities for muscle tone by unflexing the arms for approximately 5 seconds. If
tone is good, an arm should return immediately to its flexed position after being released. Hold
the arms down by the sides and note their length. The fingertips should reach the proximal thigh.
Unusually short arms may signify achondroplastic dwarfism. Observe for unusual curvature of
the little finger, and inspect the palm for a simian crease (a single palmar crease, in contrast to
the three creases normally seen in a palm). Although curved fingers and simian creases can
occur normally, they are commonly associated with Down syndrome (Elias, ChunHui, &
Manchester, 2008).
Assess for webbing (syndactyly), extra toes or fingers (polydactyly), or unusual spacing of toes,
particularly between the big toes and the others (this finding is present in certain chromosomal
disorders, although it is also a normal finding in some families). Test to see whether the toenails
fill immediately after blanching from pressure. Normally, newborn legs are bowed as well as
short. The sole of the foot appears flat because of an extra pad of fat in the longitudinal arch. The
foot of a term newborn has many crisscrossed lines on the sole, covering approximately twothirds
of the foot. If these creases cover less than two-thirds of the foot or are absent, suspect
immaturity.
With a newborn in a supine position, both hips can be flexed and abducted to such an extent (180
degrees) that the knees touch or nearly touch the surface of the bed. If the hip joint seems to lock
short of this distance (160 to 170 degrees), hip subluxation (a shallow and poorly formed
acetabulum) is suggested (McCarthy & MacEwen, 2007).
A further test for subluxation can be
elicited by holding the infant’s leg with the
fingers on the greater and lesser
trochanter and then abducting the hip; if
subluxation is present, a “clunk” of the
femur head striking the shallow
acetabulum can be heard
(Ortolani’s sign). If the hip can be felt to
actually slip in the socket, this is Barlow’s
sign. Subluxated hip may be bilateral but
is usually unilateral. It is important that hip
subluxation be discovered as early as
possible, because correction is most
successful if it is initiated early.