2.12: Assessing the Neonate

The Apgar assessment, a very quick way to assess the newborn's overall condition, is conducted one minute and five minutes after birth. Five measures are assessed: heart rate, respiration, muscle tone (assessed by touching the baby's palm), reflex response (the Babinski reflex is tested), and color. A score of 0 to 2 is given on each feature examined. An Apgar of 5 or less is cause for concern. The second Apgar should indicate improvement with a higher score (see Figure \(\PageIndex{1}\)).

Figure \(\PageIndex{1}\). APGAR scores. Image source.

Another way to assess the condition of the newborn is the Neonatal Behavioral Assessment Scale (NBAS). The baby's motor development, muscle tone, and stress response are assessed. This tool has been used around the world to further assess the newborn, especially those with low Apgar scores, and to make comparisons of infants in different cultures (Brazelton & Nugent, 1995).

Problems of the Newborn

Figure \(\PageIndex{2}\). A newborn in a neonatal unit. Image source.

Anoxia: Anoxia is a temporary lack of oxygen to the brain. Difficulty during delivery may lead to anoxia which can result in brain damage or in severe cases, death. Babies who suffer both low birth weight and anoxia are more likely to suffer learning disabilities later in life as well.

Low Birthweight: We have been discussing a number of teratogens associated with low birth weight such as alcohol, tobacco, etc. A child is considered low birthweight if he or she weighs less than 5 pounds 8 ounces (2500 grams). About 8.2 percent of babies born in the United States are of low birthweight (CDC, 2015a). A low-birthweight baby has difficulty maintaining adequate body temperature because it lacks the fat that would otherwise provide insulation. Such a baby is also at more risk for infection, and 67 percent of these babies are also preterm which can make them more at risk for respiratory infection. Very low-birthweight babies (2 pounds or less) have an increased risk of developing cerebral palsy.

Additionally, Pettersson et al. (2019) analyzed fetal growth and found that reduced birth weight was correlated with a small but significant increase in several psychiatric disorders in adulthood. These included: attention-deficit/hyperactivity disorder, autism, depression, and obsessive-compulsive disorder. Pettersson et al. theorized that "reduced fetal growth compromises brain development during a critical period, which in turn slightly increases the risk not only for neurodevelopmental disorders but also for virtually all mental health conditions" (p. 540). An insufficient supply of oxygen and nutrients for the developing fetus are proposed as factors that increased the risk for neurodevelopmental disorders.

Preterm: A newborn might also have a low birth weight if it is born at less than 37 weeks gestation, which qualifies it as a preterm baby (CDC, 2015c). Early birth can be triggered by anything that disrupts the mother's system. For instance, vaginal infections can lead to premature birth because such infection causes the mother to release anti-inflammatory chemicals which, in turn, can trigger contractions. Smoking and the use of other teratogens can lead to preterm birth. The earlier a woman quits smoking, the lower the chance that the baby will be born preterm (Someji & Beltrán-Sánchez, 2019). A significant consequence of preterm birth includes respiratory distress syndrome, which is characterized by weak and irregular breathing (United States National Library of Medicine, 2015b).

Figure \(\PageIndex{3}\). Saybie. Image source.

Saybie (name given to her by the hospital), a baby girl born in San Diego, California, is now considered the world's smallest baby ever to survive (Chiu, 2019). She was born in December 2018 at 23 weeks and 3 days weighing only 8.6 ounces (same size as an apple). After five months in the hospital, Saybie went home in May 2019 weighing 5 pounds.

Small-for-Date Infants: Infants that have birth weights that are below expectation based on their gestational age are referred to as small-for-date. These infants may be full term or preterm, but still weigh less than 90% of all babies of the same gestational age. This is a very serious situation for newborns as their growth was adversely affected. Regev et al. (2003) found that small-for-date infants died at rates more than four times higher than other infants. Remember that many causes of low birth weight and preterm births are preventable with proper prenatal care.

Postpartum Maternal Concerns

After pregnancy many women experience emotional changes. The "baby blues" are often mentioned as a common occurrence in new mothers. The baby blues are feelings of sadness that occur 3 to 5 days after having a baby, and typically disappear usually within 10 days of the birth. New mothers may have trouble sleeping, be moody, and feel let-down from the birthing experience. However, postpartum depression is not the same as the baby blues. According to the Diagnostic and Statistical Manual of Mental Disorders (5^th edition, text revision) (DSM-5-TR), (American Psychiatric Association, 2022), peripartum onset of depression, also known as postpartum depression, is a type of depression that occurs during pregnancy or in the 4 weeks following pregnancy. Approximately 1 out of 8 women experience postpartum depression and symptoms can include feelings of sadness, sleeplessness, and difficulty bonding with the newborn.

Changing hormone levels are thought to be a factor in the occurrence of peripartum depression; however, risk factors include having depression previously, a family history of depression, being younger than 20, experiencing stress, and substance use. Peripartum-onset mood disorders, both depression and mania, can present with or without psychotic features. Hallucinations and delusions are associated with postpartum psychotic episodes and have included command hallucinations to kill the infant or delusions that the infant is possessed. Psychotic features occur in approximately 1 in 500 to 1 in 1,000 deliveries, and the risk is higher for women with prior postpartum mood episodes (American Psychiatric Association, 2022).

Postpartum anxiety is also a concern for many new mothers. According to Bregel (2017), because oxytocin, a bonding hormone, rises during pregnancy, brain areas related to empathy and anxiety are heightened. Consequently, the new mother is "hard-wired" to respond to and fend for her baby, which can lead to toxic levels of stress and anxiety. These can manifest as heightened alertness, intrusive and horrifying thoughts of something terrible happening to the infant, and physiological arousal. Just as for peripartum depression and postpartum psychosis, a new mother experiencing postpartum anxiety should seek assistance from a health care provider.