Normal Delivery
After delivery, immediate care includes drying the newborn, clearing the airway of secretions, and providing warmth
Assessment and disposition — A delivery room assessment of the neonate's clinical status is quickly performed by assessing the newborn’s gestational age (GA), muscle tone, and respiratory effort [1].
Newborns who meet all of the following criteria can be cared for in the normal nursery (neonatal level of care 1) [2]:
●GA ≥35 weeks
●GA ≥35 weeks
●Good muscle tone
●Strong respiratory drive (ie, crying and breathing without difficulty)
Newborns who meet these criteria do not require immediate intervention and should be given to the mother.
Well appearing newborns should remain with the mother and be placed skin-to-skin (STS) to promote infant-maternal bonding and early initiation of breastfeeding.
Medical staff should instruct and assist the mother on safe positioning of the newborn during STS and breastfeeding, and directly observe the first breastfeeding session.
Newborns <35 weeks GA generally require a higher level of care (neonatal level of care 2, 3, or 4), depending on their GA and clinical status.
Newborns who are limp and/or apneic require resuscitation, as discussed in detail separately. (See "Neonatal resuscitation in the delivery room".):
Apgar score — The Apgar score provides a universally accepted method to assess the status of the newborn infant immediately after birth.
The score is determined by assessing five variables, each of which is assigned a value of 0, 1, or 2. The Apgar score calculator may be used to determine the score (calculator 1). The following variables are included in the Apgar score:
●Heart rate
●Respiratory effort
●Muscle tone
●Reflex irritability
●Color
The Apgar score is assessed at one and five minutes after birth. If the five-minute score is ≤6, a 10-minute score should be assessed.
Approximately 90 percent of neonates have five-minute Apgar scores of 7 to 10, and generally require no further intervention. Newborns with Apgar scores in this range have spontaneous breathing or crying, good muscle tone, and good color. They can be admitted to the level 1 newborn nursery for routine care (provided they are ≥35 weeks gestation).
Infants with five-minute Apgar scores ≤6 require further evaluation and possible intervention. Approximately 1 percent of newborns require resuscitation at birth. This is discussed in greater detail separately. (See "Neonatal resuscitation in the delivery room".)
The Apgar score should not be used as a prognostic tool. Although studies have found that lower Apgar scores are associated with higher rates of neonatal mortality and morbidity [4], the Apgar score does not accurately predict outcomes in individual patients [5].
Transitional period — The transitional period between intrauterine and extrauterine life is during the first four to six hours after birth. Physiological changes that can occur during the transitional period include decreasing pulmonary vascular resistance (PVR) with increased blood flow to the lungs, lung expansion with clearance of alveolar fluid and improved oxygenation, and closure of the ductus arteriosus. (See "Physiologic transition from intrauterine to extrauterine life".)
During this time, the clinical status of the newborn should be assessed every 30 to 60 minutes to ensure further interventions and/or evaluations beyond routine care are no longer required for successful transition to extrauterine life. The following clinical parameters are monitored beginning in the delivery room and continuing in the mother/infant's room (rooming in) or nursery:
●Temperature − The normal axillary temperature should be between 36.5 to 37.5ºC (97.7 to 99.5ºF) for an infant in an open crib [1,6]. Initial hyperthermia may be reflective of maternal fever or the intrauterine environment. Persistent hyperthermia or hypothermia may be a sign of sepsis. Hypothermia may contribute to metabolic disorders such as hypoglycemia or acidosis. (See "Clinical features, evaluation, and diagnosis of sepsis in term and late preterm neonates".)
●Respiratory rate − The normal respiratory rate is 40 to 60 breaths per minute, and should be counted over a full minute. Tachypnea may be a sign of respiratory or cardiac disease. Apnea may be secondary to exposure to maternal medications (eg, maternal anesthesia or sedation), a sign of neurologic impairment, or sepsis.
●Heart rate − The normal heart rate is 120 to 160 beats per minute, but may decrease to 85 to 90 per minute in some term newborns during sleep. Heart rates that are too high or low may be a sign of underlying pathology, such as cardiac disease, sepsis, and metabolic derangements.
●Color − Central cyanosis (lips, tongue, and central trunk) may be indicative of respiratory or cardiac disease. (See "Approach to cyanosis in the newborn".)
●Tone − Hypotonia may be secondary to exposure to maternal medications or maternal fever during labor [7], or be indicative of an underlying syndrome (Down syndrome), sepsis, neurologic impairment, or metabolic derangement (eg, hypoglycemia). (See "Clinical features, diagnosis, and treatment of neonatal encephalopathy" and "Pathogenesis, screening, and diagnosis of neonatal hypoglycemia", section on 'Clinical presentation'.)
Respiratory disease and suspected cardiac disease in the newborn are discussed in greater detail separately. (See "Overview of neonatal respiratory distress and disorders of transition" and "Identifying newborns with critical congenital heart disease".)
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After delivery, dry the newborn, clear the airway of secretions, and provide warmth.
For newborns who are at increased risk of requiring resuscitation, a clinician skilled in neonatal resuscitation should be present at the time of delivery.
The identification of high-risk infants and their care is discussed separately. (See "Neonatal resuscitation in the delivery room", section on 'High-risk delivery'.)