At birth the newborn must, within minutes, start breathing, switch from fetal to newborn circulation, and maintain body temperature. The first breaths expand the lungs and clear lung fluid; pulmonary vascular resistance falls, and the foramen ovale and ductus arteriosus begin to close. Initial care supports this transition, identifies infants who need help, and prevents early complications (hypothermia, hypoglycemia, infection, bleeding, and abduction or misidentification).
Heat loss is rapid because newborns have a large surface area, thin skin, and little subcutaneous fat. They produce heat mainly by nonshivering thermogenesis (brown fat metabolism), which uses oxygen and glucose — so cold stress can cause hypoxia, hypoglycemia, and acidosis.
| Mechanism | Example | Prevention |
|---|
| Evaporation | Wet skin after birth or bathing | Dry immediately and thoroughly, remove wet linen |
| Conduction | Cold scale, hands, stethoscope | Warm surfaces; skin-to-skin contact |
| Convection | Drafts, air conditioning | Keep away from drafts; cap and blanket |
| Radiation | Cold walls or windows nearby | Place crib away from outside walls; radiant warmer |
Apgar score — assessed at 1 and 5 minutes (then every 5 minutes up to 20 minutes if the 5-minute score is below 7)
| Sign | 0 | 1 | 2 |
|---|
| Heart rate | Absent | < 100/min | ≥ 100/min |
| Respiratory effort | Absent | Slow, irregular, weak cry | Good, strong cry |
| Muscle tone | Limp | Some flexion of extremities | Active motion, well flexed |
| Reflex irritability (response to stimulation, e.g., suction catheter, sole flick) | No response | Grimace | Cry, cough, sneeze, or active withdrawal |
| Color | Blue or pale all over | Body pink, extremities blue (acrocyanosis) | Completely pink |
- 7–10 = reassuring; 4–6 = moderately abnormal; 0–3 = low (5-minute score 0–3 means ongoing severe compromise)
- A 1-minute score of 7 improving to 9 at 5 minutes is a normal transition
- Temperature is not part of the Apgar score
- Respiratory effort reflects the infant's own breathing; breaths given by a ventilator do not count
- Resuscitation decisions do not wait for the 1-minute Apgar — they are based on breathing, heart rate, and tone right after birth
- Heart rate: auscultate over the apex (precordium) for 6 seconds and multiply by 10; palpating the cord base is less reliable, and an ECG monitor is most accurate during resuscitation
Normal term newborn values
| Parameter | Normal |
|---|
| Heart rate | 110–160/min (may be up to 180 when crying, down to about 90–100 in deep sleep) |
| Respiratory rate | 30–60/min, irregular with brief pauses under 20 seconds; abdominal breathing |
| Temperature (axillary) | 36.5–37.5 °C (97.7–99.5 °F) |
| Weight | 2,500–4,000 g (5 lb 8 oz – 8 lb 13 oz) |
| Length | 48–53 cm (19–21 in) — measured lying, leg fully extended, crown to heel |
| Head circumference | 33–35 cm (13–14 in), just above the eyebrows and ears around the occiput |
| Chest circumference | 30–33 cm, about 2 cm smaller than the head |
Normal findings that often worry parents
- Vernix caseosa (white cheesy coating, present at birth), lanugo (fine hair), milia (white papules on the nose)
- Erythema toxicum (blotchy red rash with small white or yellow papules, appears in the first days and resolves on its own)
- Acrocyanosis in the first 24–48 hours; congenital dermal melanocytosis (blue-gray patches over the sacrum)
- Molding of the skull; caput succedaneum (scalp edema that crosses suture lines, resolves in days) vs. cephalhematoma (blood under the periosteum that does not cross sutures, resolves over weeks, raises jaundice risk)
- Epstein pearls on the palate; breast swelling and small vaginal bleeding (pseudomenstruation) from maternal hormones
Newborn reflexes
| Reflex | How elicited / response | Typically disappears |
|---|
| Rooting | Stroke cheek → turns toward it | 3–4 months |
| Sucking | Touch lips or palate → sucks | Becomes voluntary in infancy |
| Moro (startle) | Sudden loss of support → arms extend, abduct, then embrace | 3–6 months |
| Palmar grasp | Finger in palm → grasps | 3–4 months |
| Plantar grasp | Pressure on sole → toes curl | 8–12 months |
| Tonic neck (fencing) | Head turned to one side → arm on that side extends | 4–6 months |
| Stepping | Held upright, feet touch surface → steps | 1–2 months |
| Babinski | Stroke lateral sole → toes fan, big toe extends | About 12–24 months (the last to disappear) |
Absent, asymmetric, or persistent reflexes suggest neurologic injury (e.g., asymmetric Moro with brachial plexus injury or clavicle fracture).
- Newborn metabolic (blood spot) screening — heel stick, usually after 24 hours of age (after protein feeding) and before discharge
- Hearing screening (otoacoustic emissions or automated auditory brainstem response) before discharge
- Critical congenital heart disease (CCHD) pulse oximetry at or after 24 hours: right hand and one foot; pass if ≥ 95% in either site with a difference of 3% or less; < 90% in either site = fail and needs evaluation; intermediate results are repeated per protocol
- Bilirubin screening before discharge (transcutaneous or serum)
- Point-of-care glucose for at-risk infants (large or small for gestational age, preterm, infant of a diabetic mother, symptomatic)
- Gestational age assessment (New Ballard Score) when dates are uncertain or size is abnormal
Immediate care of a vigorous term newborn
- Dry, stimulate, and place skin-to-skin on the mother's chest; cover with a warm blanket and cap
- Defer cord clamping for at least 60 seconds in term and preterm newborns who do not need immediate resuscitation (drying, stimulation, and airway clearing can be done during this time)
- Routine suctioning is not recommended; clear the mouth then nose (bulb syringe) only if secretions obstruct breathing
- Newborns who are not breathing, are gasping, or have a heart rate below 100/min after initial steps need positive-pressure ventilation within the first minute (the "Golden Minute"); chest compressions begin if the heart rate stays below 60/min despite 30 seconds of effective ventilation (3 compressions : 1 breath)
Prophylaxis
| Agent | Purpose | Nursing points |
|---|
| Vitamin K (phytonadione) 0.5–1 mg IM, single dose | Prevents vitamin K deficiency bleeding (newborns have low vitamin K and sterile gut) | Vastus lateralis, soon after birth (can follow the first skin-to-skin period); oral regimens are less effective. IV use carries a rare risk of severe hypersensitivity, so the IM route is standard. If parents refuse, teach warning signs of bleeding |
| Erythromycin 0.5% ophthalmic ointment | Prevents gonococcal ophthalmia neonatorum | Ribbon from inner to outer canthus in each eye; do not rinse; may cause temporary blurring |
| Hepatitis B vaccine (with HBIG when indicated — see below) | Prevents perinatal hepatitis B | IM vastus lateralis; within 24 hours of birth for all medically stable infants ≥ 2,000 g (US universal birth dose in effect; see Country Notes) |
Hepatitis B vaccine and hepatitis B immune globulin (HBIG) by maternal status and birth weight
- Mother HBsAg-positive: vaccine + HBIG within 12 hours, regardless of weight
- Mother's status unknown: vaccine within 12 hours; add HBIG within 12 hours if the infant weighs under 2,000 g; if 2,000 g or more, give HBIG within 7 days only if the mother tests positive
- Mother HBsAg-negative: infants of 2,000 g or more receive the universal birth dose within 24 hours; infants under 2,000 g receive the first dose at 1 month of age or hospital discharge, whichever comes first
- A dose given at birth to an infant under 2,000 g does not count toward the series
Listed in priority order.
- Airway and breathing — position with the neck slightly extended ("sniffing"); suction only if obstructed; watch for tachypnea, grunting, nasal flaring, retractions, central cyanosis
- Thermoregulation — dry, skin-to-skin, cap; radiant warmer for procedures; delay the first bath (WHO recommends waiting at least 24 hours, or at least 6 hours if a full day is not possible) and give it only when the temperature is stable
- Apgar at 1 and 5 minutes; full vital signs at least every 30 minutes until stable for 2 hours, then per protocol
- Identification and security — matching ID bands on infant and mother (and partner) before leaving the birth room; footprints or photos per policy; staff wear visible ID; teach parents never to hand the baby to someone without proper ID
- Early feeding — support breastfeeding within the first hour; watch for hypoglycemia signs in at-risk infants (jitteriness, poor feeding, lethargy)
- Prophylactic medications — vitamin K, eye ointment, hepatitis B vaccine per protocol and consent
- Complete physical examination head to toe, including measurements, reflexes, hips (Ortolani, Barlow), spine, anus patency, palate, clavicles
- Monitor elimination — first void within 24 hours; meconium within 24–48 hours (delay suggests obstruction, Hirschsprung disease, or cystic fibrosis)
- Cord care — keep the cord clean and dry (dry cord care), fold the diaper below it; routine alcohol is no longer recommended in most settings (chlorhexidine is used where neonatal infection risk is high); the stump usually falls off in 1–2 weeks
- Skin care — plain warm water or mild pH-neutral cleanser; sponge baths until the cord separates; not every day with soap
- Safe sleep from the first nap — on the back, flat firm surface, no soft objects (never routinely side-lying)
- Feeding cues and frequency (8–12 feeds per 24 hours for breastfed infants)
- Expect weight loss of up to about 7–10% in the first days; birth weight regained by about 10–14 days
- Voids and stools: at least 6 wet diapers per day by day 5–6
- Cord care, sponge bathing, nail care, diapering
- Safe sleep (back to sleep, own flat surface in the parents' room) and rear-facing car seat from the first ride home
- Call for: temperature 38.0 °C (100.4 °F) or higher or below 36.5 °C (97.7 °F), jaundice in the first 24 hours or spreading, poor feeding, lethargy, breathing difficulty, redness or foul drainage at the cord
- Central cyanosis (lips, tongue), grunting, persistent tachypnea over 60/min, apnea over 20 seconds
- Hypothermia → hypoglycemia, respiratory distress, metabolic acidosis
- Heart rate persistently below 100/min while awake, or above 180/min at rest
- Jaundice within the first 24 hours (always pathologic)
- No void by 24 hours or no meconium by 48 hours; bilious vomiting
- Absent or asymmetric Moro reflex; bulging fontanel; high-pitched cry
- Bleeding from the cord, circumcision site, or puncture sites (vitamin K deficiency)
- Failed CCHD or hearing screen — needs follow-up, not repeat reassurance
- Apgar = heart rate, respiratory effort, muscle tone, reflex irritability, color; not temperature
- Apgar at 1 and 5 minutes; 7–10 reassuring; 0–3 at 5 minutes = severe ongoing compromise; resuscitation is guided by breathing, heart rate, and tone, not the Apgar
- HR ≥ 100 = 2 points; acrocyanosis = 1 point; cough or sneeze to stimulation = 2 points
- Newborn heart rate: auscultate 6 seconds × 10
- Normal HR 110–160, RR 30–60, axillary temperature 36.5–37.5 °C (97.7–99.5 °F)
- Moro disappears by about 3–6 months; Babinski lasts longest (to 12–24 months)
- Vernix is present at birth; erythema toxicum appears in the first days — both normal
- Caput crosses sutures; cephalhematoma does not
- Vitamin K IM prevents bleeding; eye ointment prevents gonococcal ophthalmia
- Delay the bath; dry cord care; back to sleep from the first nap
- CCHD screen: ≥ 95% and ≤ 3% difference = pass; < 90% = fail
Country Notes
United States
- Hepatitis B birth dose: the universal birth dose within 24 hours is the recommendation in effect for all medically stable infants of 2,000 g or more, with the maternal-status rules above. Changes made from 2025 to January 2026 (including a December 2025 vote making the birth dose an individual decision for infants of HBsAg-negative mothers) were stayed by a federal court on March 16, 2026 and are under appeal — check the current CDC/AAP schedule before teaching.
- Ocular prophylaxis is required by law in many states; newborn metabolic, hearing, and CCHD screening are performed in all states (panels vary by state).
Philippines
- DOH Essential Intrapartum and Newborn Care ("Unang Yakap"): immediate thorough drying, early and uninterrupted skin-to-skin contact, properly timed cord clamping (after cord pulsations stop, about 1–3 minutes), and non-separation of mother and newborn for early breastfeeding.
- Republic Act 9288 (Newborn Screening Act of 2004): the heel-prick sample is collected after 24 hours of life and not later than 3 days (by 7 days for infants in intensive care); the expanded panel is now standard.
- Sick, preterm, low-birth-weight, and transfused newborns follow the Newborn Screening Center–NIH (UP Manila) Newborn Screening Facility Protocol 24.1 (2025). This is an operational protocol, not law; it notes that its filter-card replacement rules are subject to change, so check the current version.
- Collect the screening sample before any transfusion of whole blood, packed red blood cells, fresh frozen plasma, or platelet concentrate.
- If the baby was transfused with whole blood or packed red cells before sampling, three repeat samples are taken: at 2 days, 2 weeks, and 120 days after the transfusion. After fresh frozen plasma, two repeat samples are needed, at 2 days and 2 weeks after the transfusion.
- Preterm, sick, and low-birth-weight newborns have a repeat sample on the 28th day of life.
- Republic Act 10152 requires the hepatitis B birth dose within 24 hours for infants born in facilities; the local schedule also gives BCG at birth. Republic Act 9709 requires hearing screening before discharge. Republic Act 7600, as amended by Republic Act 10028, promotes rooming-in and breastfeeding.