CASE ABSTRACT

This case is about immediate care of the newborn and newborn assessment. A
newborn, or neonate, is the term used to describe a child from birth to 28 days old. An infant
refers to a child between the ages of 28 days and 1 year. The assessment was done on the 6th
day of January 2011. The patient is a healthy baby girl who was born on the 5th day of January
2011 at around 3 o’clock in the afternoon at Medical Center Muntinlupa. Delivered through
normal spontaneous delivery to Ms. N, a 27 year old woman, Gravida 1, Paravida 1,
(TPAL/1001), at 40 weeks age of gestation. The mother’s past medical history is unremarkable.
She was not diagnosed with any gestational problems like pregnancy-induced hypertension,
gestational diabetes, and even venereal disease.

Baby S was given immediate newborn care such as immediate drying, skin-to-skin
contact followed by clamping of the cord after one to three minutes, non-separation of the
newborn from the mother, routine suctioning, breastfeeding initiation, administration of
Erythromycin Ophthalmic Ointment and Vitamin K prophylaxis, bacillus Calmette-Guerin (BCG)
and Anti-Hepatitis B vaccines. These standard procedures done are now based into the new
protocol launched by the Department of Health, the “Unang Yakap Campaign,” which aims to
cut down infant mortality in the Philippines by at least half. The campaign employs Essential
Newborn Care (ENC) Protocol as a strategy to improve the health of the newborn through
interventions before conception, during pregnancy, at and soon after birth, and in the postnatal
period.

Initial newborn assessment includes Apgar Score, a standard tool done at 1 and at 5
minutes after delivery to assess infant’s ability to adapt to extrauterine life, vital signs and
anthropometric measurements, and assessing gestational age using the Ballard Scale. The
Apgar score is both 9 which indicates that the baby is good and healthy. Initial vital signs and
body measurements are within normal limits. The maturity rating is 40 which signify a term
gestation. The subsequent physical assessment reveals an alert, active, and clean baby. The
newborn appears stated age and clothing is in good condition. The baby has milia, a one pin-
point white papule, found across the bridge of the nose, and lanugo, a fine downy hair, seen on
the newborn’s forehead, ears, shoulder, back, and upper arms. There is no known physiologic
jaundice and any birthmarks. The remaining assessment procedures done are within normal
findings. The newborn baby is scheduled for Newborn Screening test on the first 24 to 48 hours.
Some of the routine newborn care that will be given for baby S after hospitalization also includes
aseptic cord care, burp after each feeding, expose to early morning sunlight daily, bathe daily
with warm water and mild soap, do not put lotion, powder or cologne.