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What to do for the baby

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HealthWiki > A Book for Midwives > Chapter 14: The first few hours after the birth > What to do for the baby


When the mother and baby are stable, usually about an hour after birth, check the baby over from head to toe. Many health problems can be prevented or cured if you find them quickly.

Wash your hands, just as you did for the birth, and put on clean gloves. It is easy for a new baby to get an infection, so everything that touches the baby must be as clean as possible. But there is no need to bathe the baby right away. Bathing, even in warm water, will make her cold. You can safely wait a few hours or even a few days. Wear gloves until the baby is clean and dry to help protect you from getting an infection.

While you examine the baby, keep her warm. Cover her head and the parts of her body you are not examining. If possible, you should warm up the room. Be gentle with the new baby. Babies feel as much as adults do and gentle care will help them feel strong and safe.

The most important things to check for a new baby are her general appearance and other physical signs. Check these as soon as you can after the birth. The other parts of the newborn exam can wait a few hours.

If you can, write down what you find on a chart. A chart will help you remember to do each step, and to notice changes that happen over time. Here is an example of a chart you can use:


Click here for a print quality version of this record of the new baby's health.

"chart for recording the baby's physical signs.

Contents

General appearance

The way a baby looks and sounds can tell you a lot about her health. Notice everything! Is the baby small or large? Fat or thin? Do her arms, legs, feet, hands, body, and head seem to be the right size? Is the baby tense or relaxed? Active or still? Listen to the baby's cry. Every baby's cry is a little different, but a strange, high, piercing cry can be a sign of illness.

Baby is limp, weak, or does not wake up

Many babies are very sleepy for the first few days after birth. They should wake up from time to time to breastfeed. When awake, the baby should respond to noise and touch. If the baby does not respond, or seems unusually weak, slow, or limp in the first few hours, she may have one of these problems:

Not enough sugar in the blood

A very weak baby may need more sugar in her blood. This is especially likely if the baby is very big or very small, if the birth was very hard or long, or if the mother has diabetes. The baby may stay cold or tremble.

Breastfeed the baby as much as possible — there is sugar in breast milk.

Keep the baby warm and close to the mother. If the baby does not seem more awake and alert in 12 hours, get medical help.

Physical signs: breathing, heartbeat, temperature

Check the baby's physical signs every hour for 2 to 6 hours after the birth, or more often if the baby is having problems.

Breathing rate

Count the baby's breaths for one full minute by watching her belly rise and fall. It is normal for breathing to slow down and speed up from moment to moment. A new baby should take between 30 and 60 breaths in a minute while she is resting.

A baby who is breathing too fast, too slow, or with difficulty may be having trouble getting enough air, or may be having other problems.

Baby has trouble breathing, or takes more than 60 breaths a minute

If a baby has trouble breathing, or if she takes more than 60 breaths a minute, it is a warning sign. It could mean that the baby has an infection, has breathed in her own stool, has drugs in her blood from the mother, or has other problems.

What to do
  • Keep the baby warm.
  • Check for signs of infection.
  • Lay the baby with her head lower than her bottom to help fluids drain. Suction the baby — especially if you think she might have breathed stool into her nose or throat.
  • Encourage the baby to breastfeed.
  • If the baby stops breathing — do rescue breathing.
  • Get medical help.

Heartbeat

A new baby's heart should beat between 120 and 160 times a minute. It may beat as slow as 100 beats a minute or as fast as 180 beats a minute.

If the baby's heartbeat is too fast, she may have an infection.

If the heartbeat is too slow, give rescue breathing. If the heart rate does not get back to normal, get medical help.

Temperature

Keep the baby warm

Babies must stay warm to stay healthy. But they cannot keep themselves warm as easily as adults can. The easiest way to keep a baby warm is to put her next to her mother's skin. The mother is exactly the right temperature for the baby. Cover them both with blankets and be sure to cover the baby's head.

If the mother cannot hold her baby for a bit (for example, if she gets up to urinate), someone else can hold the baby. This person should wash their hands well before handling the baby.

Temperature and health

A healthy baby's temperature is around 37°C (98.6°F).

illustration of the below: a baby on her back with a thermometer in her armpit;

To check the baby's temperature, gently put the silver end of the thermometer into her armpit. Then hold the baby's arm against her body for 3 minutes. If you do not have a thermometer, feel the back of the baby's neck while you touch a healthy person. If the baby does not feel as warm as the healthy person, her temperature is too low.

a baby wrapped in a blanket, lying between 2 hot-water bottles.

A baby whose temperature is 36.5°C (97.7°F) or less should be warmed quickly. Do not wait. She should warm up if she is placed skin to skin, between her breasts, wearing nothing but a diaper and hat. If she will not warm, try using hot water bottles.

Fill hot water bottles (or jars) with hot water, wrap them in cloths so you do not burn the baby, and put the bottles next to the baby's body.

If the baby does not get warmer after 1 or 2 hours, she may need medical attention.

Infection

When a baby gets an infection, she usually has a low temperature, 36.5°C (97.7°F) or below. Other signs of infection:

  • a baby who cannot keep warm even when wrapped in blankets
  • a high temperature (fever) especially one lasting more than 4 hours
  • a baby who takes more than 60 breaths a minute
  • a baby who seems ill
  • a baby who sucks poorly or stops feeding
  • a baby who has a weak, fast heartbeat


If the baby shows any of these signs of infection, get medical help. If the nearest medical help is more than 2 hours away, give the baby antibiotics on the way. See about the kind and amount of medicine to give.

Get medical help if the baby cannot warm up after several hours — even if she has no other signs of infection.

Baby does not urinate or pass stool within the first 24 hours

The baby should urinate and pass stool within the first day of birth. If the baby does not do so, her urethra or intestines may be blocked. Get medical help right away.

The baby's body

Weight

Every baby is different, but most healthy babies weigh between 2.5 and 4 kilograms (between 5.5 and 9 pounds).

You may be able to get a scale from the local health authority, buy a hanging fish scale, or make a homemade scales. But you do not need a scale to have an idea
of what a normal baby weighs. Every time you hold a baby, think about the weight. Guess whether that baby weighs more than most babies, or less, or about the same. This way, you will know when a baby is very small or very large — even without a scale.

Very small babies

Very small babies who are less than 2.5 kilograms (5.5 pounds) have a higher risk of infection, breathing problems, and jaundice. The smaller the baby, the greater the risk. Small babies also may have trouble breastfeeding and digesting their food. Some babies are small because they were born early, and some are just small.

If there is a well-equipped medical center nearby, it may be best to take very small babies there to be cared for. But if you are going to care for a small baby at home, there are some things you can do to help him stay healthy.

What to do
  1. Keep the baby warm. The best way to warm him is against his mother's skin. Place the naked baby, with a hat and a diaper, inside the mother's clothing, against her skin and between her breasts. Keep this skin-to-skin contact day and night. The mother will have to change the baby's position to breastfeed. If the mother needs to bathe, put the baby next to another person's skin until the mother is done.

  2. Give breast milk. Breast is best for all babies, but it is even more important if the baby is very small. Breast milk is easiest for the baby to digest, it gives the best nourishment, and it protects the baby from illnesses. A small baby may not be able to eat much. Keeping him close to the mother's body will help him to breastfeed often. In this way, he will get enough to eat.

    If the baby is not able to breastfeed, the mother should remove milk from her breasts by hand. The mother should feed the baby the breast milk with a very clean cup or spoon until he is strong enough to breastfeed. Give the baby as much breast milk as he will take and as often as he will take it. He must eat to grow.

  3. Visit the baby every day for the first few weeks, to check for warning signs. Be sure the mother knows the signs of jaundice, breathing problems, and other signs of infection. If the baby develops any warning signs, get medical help.


Causes of small babies
Babies come in all sizes — that is normal. But small babies are much more likely to have problems than bigger babies.

And the size of a baby is not just a matter of chance. Mothers who get enough food and care in pregnancy usually have bigger babies. Mothers who did not get enough food and care usually have smaller babies.

Small babies are often born to:

  • mothers who did not get enough to eat in pregnancy.
  • mothers who had to do very hard work during pregnancy.
  • mothers who did not get good medical care in pregnancy.
  • mothers who smoke cigarettes.
  • mothers who were exposed to pesticides or toxic chemicals in pregnancy.
  • mothers who have had many babies before.
Note: A small baby does not make an easier birth. And small babies have many more health problems. For a healthy birth and a healthy baby, women must eat enough.
Baby weighs more than 4 kilograms (9 pounds)

Watch all big babies carefully for the first 2 days. If they seem tired, weak, or sick, they may not have enough sugar in the blood. Get medical help.

Some babies are big because their mothers had diabetes. These babies may have problems with the amount of sugar in their blood. Make sure these babies breastfeed often and stay warm.

Weighing a baby with a scale
Adjust the scale to 0 or weigh the cloth.

If you have a scale, you can find out exactly how much a baby weighs. (See how to make your own scale.)
If you have a hanging scale, follow these steps:

  1. Attach a cloth to the scale.
  2. Adjust the scale so that it is at 0. If there is no knob to adjust the scale, write down how much the cloth weighs (the number that the scale is at when the cloth is attached).
  3. Put the naked baby into the cloth to weigh him.
  4. If you were able to adjust the scale, it will tell you the weight of the baby.
    If there is no knob to adjust the scale, you must subtract the weight of the cloth to find out the weight of the baby.
For example:
Baby and cloth together weigh 3.25 kilograms
Cloth alone weighed - 0.25 kilograms
So baby alone weighs
  3.00 kilograms

If you have a scale that you stand on, follow these steps:

  1. Weigh yourself, and write down the weight.
  2. Get off the scale.
  3. Get back on the scale holding the baby without his clothes or blankets. Write down the weight.
  4. Subtract your weight from the combined weight of you and the baby.
For example:
You and the baby together weigh 62 kilograms
You weighed - 59 kilograms
So baby alone weighs     3 kilograms

Length

If you have a tape measure, measure the baby from the top of her head to the bottom of her heel. Most babies are between 45 and 53 centimeters (18 to 21 inches). Babies who are not within this range may have problems.

Head

If you have a tape measure, measure the baby's head, just above the ears. The normal size for a baby's head is 35 centimeters (13 to 14 inches). Write down the head size. A very large or small head can be a sign of illness or disability in the child.

Head shape, suture lines, and fontanels
the top of a baby's head, showing suture lines and 2 soft spots.
sutures
fontanels (soft spots)

The skulls (head bones) of children and adults are solid, but a new baby's skull is made of 5 separate pieces. The spaces between these 5 pieces are called sutures or suture lines. The baby's skull also has 2 larger soft areas called fontanels or soft spots.

These spaces between the skull bones allow the skull pieces to move during birth. This helps the baby's head squeeze through the mother's vagina.

Sometimes the skull bones have to overlap for the head to be born. This is called molding. When the baby is first born, his head may be be in a pointed or flattened shape. It will usually become more normal in 1 to 3 days.
illustration of the below: 4 head shapes at birth.
Here are some of the different shapes you might see at birth.


Molding is normal.

Gently feel the sutures with your fingers.
The front suture should stop at or near the top of the forehead. Notice if the sutures are a normal width or unusually wide. Also gently feel the soft spots. Are they soft, or tense and bulging? Do not push on the soft spots — you could hurt the baby.

Normal suture lines and soft spots. Not normal. Could be hydrocephalus.

If the sutures are unusually wide, if the front suture goes down to the middle of the forehead, or if the soft spots are tense or bulging, the baby may have hydrocephalus (water on the brain). Hydrocephalus can cause disabilities or other serious problems. If there are no soft spots, this can also cause problems as the baby's head grows. In either case, get medical advice.

Caputs and hematomas

Some babies have a swelling called a caput in the area that was pressed against the cervix during labor and birth. A caput usually crosses a suture line. It will go away in 1 or 2 days.

Normal:
caput crosses
suture line
Not normal:
hematoma


If you find a swelling on the head that does not cross a suture line, it may be a hematoma. This means that the birth was difficult for the baby. Hematoma can cause the baby to get jaundice as she heals. If you find a hematoma, check the baby every day for signs of jaundice until the hematoma is gone. If possible, get medical advice.

Ears

Ears above the eyes are normal. Ears below the eyes can be sign that something is wrong.

To check the baby's ears, look straight into her face. Imagine a line across her eyes. Some part of each ear should be above this line.

Some babies with low or uneven ears have other problems inside their bodies. A baby with low ears should be watched carefully. If both ears are below the line, the baby may have kidney problems and you should get medical advice.

To check the baby's hearing, softly clap near the baby's ear. Most babies will move when they hear a sound. If the baby does not seem to hear, get medical advice.

A little blood in the white part of the eye is normal.

Eyes

Look at the baby's eyes. Notice if they seem normal, and if they move together. A little bit of blood under the surface of the white part of the eye is normal. The blood should go away in a few days.

Put medicine in the baby's eyes to prevent blindness

If a mother has chlamydia or gonorrhea, she may pass it to her baby during birth. The infection gets into the baby's eyes, and can cause blindness. Many, many women have chlamydia or gonorrhea and do not know they have it. Unless the mother has had a test to show that she does not have these infections, give the baby medicine in the eyes to prevent blindness.

To prevent blindness
  • put a line of erythromycin 0.5% to 1% eye ointment in each of the baby's eyes, within the first 2 hours after the birth
or
  • put a line of tetracycline 1% eye ointment in each of the baby's eyes, within the first 2 hours after the birth
or
  • drop 2.5% solution of povidone-iodine in each of the baby's eyes, within the first 2 hours after the birth
In some areas, people use silver nitrate (or other "silver" eye medicines) in the baby's eyes. These medicines stop gonorrhea blindness, but they do not stop the blindness that comes from chlamydia. Silver nitrate also irritates the baby's eyes for a few days. If you can get erythromycin or tetracycline
eye medicine, use one of them. But use silver nitrate if that is all you have.


Nose and mouth

First check if the baby can breathe easily through his nose. If not, try suctioning the baby.

Then, gently stroke the baby's cheek. He should turn his head toward your finger. This is called the rooting reflex. Put a very clean finger inside the baby's mouth. The baby should suck on your finger. If there is no rooting reflex, and if the baby does not suck, he may be very weak or sick. Get medical help.

cleft lip cleft palate
Babies with cleft lip (harelip) and cleft palate

A cleft lip is an opening or gap on the baby's upper lip, often connecting to the nose. A cleft palate is a split in the roof of the baby's mouth. These problems can be fixed by an operation when the baby is older. Cleft lip is often repaired when the baby is 4 to 6 months old. Cleft palate is often repaired when the baby is about 1½ years old.

Babies with cleft lip or cleft palate may need some help breastfeeding. For babies with cleft lip, the nipple should go deep into the baby's mouth, so the breast fills up the cleft. If there is still a space in the lip, the mother can put her finger over it.

For babies with cleft palate, the nipple should go as far back into the baby's mouth as possible. Point the nipple to the side of the cleft. The baby should drink with his head up so that milk does not go into his nose. If the baby cannot breastfeed, the mother can remove milk from her breasts by hand and feed the baby with a very clean spoon.

Babies with cleft lip or cleft palate may also have more ear infections and other health problems as they get older. Be sure the mother knows this. Also, a baby with a cleft lip may look unusual, and some parents feel upset when they first see their child. It is important to listen to how these parents feel, and also to remind them of the beauty of their children.

Neck

Check the neck for swelling and lumps. Also, the baby's head should move freely. If you find any problems, get medical advice.

Chest

Breathing

Watch the baby breathe. If the skin between and under the baby's ribs sucks in when he takes a breath, the baby is having trouble breathing.

Listen to the baby's breathing. Use a stethoscope or fetoscope if you have one. If not, just use your ear. You should hear breathing sounds on both sides of the chest, and on both sides of the back. If you do not hear breathing sounds on both sides, one lung may not be working. Get medical help immediately.

Count the baby's breaths when she is quiet, not breastfeeding or crying. If the baby breathes more than 60 breaths a minute, she may have an infection and need medical help.

Heart sounds

If you have a stethoscope or fetoscope, use it to listen to the baby's heart sounds too.

It is hard to describe heart sounds in a book. If possible, someone should teach you what normal heart sounds are like. But listen to the baby's heart sounds even if you are not skilled. Over time you will learn what sounds normal, and will be able to notice unusual sounds. If the heart sounds unusual, get medical advice.

Shoulders, arms, and hands

Look at the baby's arms and hands. Do they look normal? Does the baby move them normally?

Sometimes a baby's shoulder, collarbone, or arm breaks during the birth. Feel them to see if there are any odd lumps or breaks. A baby with a broken bone may cry in pain, but he may not. Simple breaks will usually heal on their own, but if possible, get medical help. Use a cloth to wrap the arm across the front of the body so it moves as little as possible and is not injured more when you go to get help.

Belly

Look at the belly. Does it look normal? What happens to the area around the cord when the baby cries? If some of the baby's insides push the skin out, this means the belly muscles are not connected. This is called an umbilical hernia. Get medical advice.

Next, feel the belly. When the baby is not crying, the belly should be soft. Check for lumps, cysts (round sacs of fluid), or other odd shapes under the skin. If you find anything unusual, get medical advice.

Note: The freshly cut cord can easily become infected. To prevent infection, keep it clean and dry. Always wash your hands before touching the cord and do not cover it or put anything on it. Check to see if the cord has stopped bleeding. If it is still bleeding, clamp or tie it again.

Genitals and anus

Look at the baby's genitals. All babies' genitals look swollen after birth. If the baby was breech, the genitals may be very swollen.

Make sure that the anus is really an opening, and not covered over with skin. If the baby has had a bowel movement, you know that this part of the body works. If the baby has no anus, or if it is closed, get medical help right away.

For a boy

First look at the baby's scrotum. The scrotum is the sac under the penis. Inside the sac, there are 2 smooth, firm balls called testicles which will make sperm when the boy is older. During pregnancy, the testicles form inside the boy's body and they usually drop down (descend) into the scrotum before birth. You should be able to feel the testicles and move them down with your fingers.

Feel the testicles.
penis
scrotum
the scrotum, showing the 2 oval-shaped testicles inside.
If you could see through the scrotum, the testicles would look like this.

If you cannot find one or both testicles, ask the baby's parents to check again in a month or so. If the testicles still have not come down, get medical advice.

Next, check to see if the hole at the end of the penis seems in the right place. If the penis does not look normal, get medical advice.

Male circumcision

Circumcision is an operation to remove the skin around the tip of the penis (foreskin). Sometimes the baby boy is circumcised right after birth, or a few months after birth. Sometimes he is not circumcised until he becomes a young man. Some boys are not circumcised at all.

uncircumcised
penis
circumcised
penis

Circumcision is important in many cultures and religions. It is not medically necessary but it may provide some protection for a man against sexually transmitted infections, including HIV. For a baby, it can help prevent infections of the bladder and kidneys. The risks of circumcision are infection, bleeding, injury or less sensitivity of the penis, and pain and trauma to the baby. Only a skilled person with sterile tools should circumcise a baby.

Parents of uncircumcised babies should clean their baby's penis as they do the rest of the baby's body. They should not pull back the foreskin to clean under it until it pulls back easily, usually after a few years.

a girl's genitals, with parts labeled.
inner
lips
clitoris
outer
lips
For a girl

Make sure that the girl has both outer and inner "lips" of her genitals. She should also have a small opening to her vagina. If she does not have an opening, she may need an operation. She should get medical help right away. Tell the parents that it is common for girls to have a small amount of blood from the vagina for 1 to 2 days after birth.

Hips and legs

a baby with a dislocated hip.

First, look at the baby's hips. Compare the two legs. If one hip is dislocated, that side may show these signs:

  • the upper leg partly covers part of the body
  • there are not as many skin folds
  • the leg may seem shorter, or turned at an angle
Hold both legs with the knees bent, like this:
Then, open
them wide, like this:
click
If you feel or hear clicking, the hip is dislocated.

If there is a click when you move the baby's hips, get medical advice.


To treat a dislocated hip
The parents will need to keep the baby's knees high and open. They can:

use many
layers of
diapers.
lay the baby on his belly
with his legs open.
a baby with legs wide open in a sling on a woman's hip.
or carry
the baby
like this:

Also, try to feel the baby's pulse in the place where the leg and genitals come together. A skilled person may have to teach you. If a skilled person cannot find this pulse, the baby may not have good blood flow to the legs. Get medical advice.

a baby with 1 foot turned inward.
club
foot

Feet

Look at the baby's feet. If one foot turns inward and cannot be straightened, he may have a club foot. This can usually be fixed with a cast if the baby gets help in the first few days. The book Disabled Village Children has more information on treating club foot.

Back

Turn the baby over and look at her spine. Look for holes, sores, cysts, growths,
or tufts of hair.

Gently move your fingers down the baby's spine to feel the bumps of her spinal bones. Can you feel a flat spot in the spine? Are there any holes in the skin at the bottom of the spine where the baby's buttocks begin?

If you find any holes, sores, growths, or tufts of hair, get medical advice.

Skin

Look carefully at the baby's skin. Some babies have spots on their skin. For example, the baby might have large, dark patches on the lower back or bottom. Other babies have red patches on their faces. These spots are not harmful. Other spots, like small red rashes, can be a sign of infection. If you are not sure, get medical advice.

Color

The baby should be a normal color within a few hours of the birth.

If the baby stays blue

  • If a baby's hands and feet are still blue, but the baby is warm, there is probably not a problem. Some babies' hands and feet stay blue for 1 or 2 days after the birth.
  • If the baby's lips or face are still blue one hour after birth, the baby may have a problem with his heart or lungs. He may also need oxygen. Place the baby skin to skin with the mother, and cover them to stay warm. Go to the hospital now.

If the baby looks yellow
If the baby seems yellow less than a full day and night after the birth, he may have jaundice or an infection Get medical help.

If the baby is pale
A pale, limp baby may be anemic or have other problems. Get medical help now.

If the baby is very red
A very red baby may be OK. Watch him carefully for a week for signs of jaundice. Get medical help as soon as possible if the baby becomes yellow, starts breathing fast, or has trouble breastfeeding.

Baby has birth defects

When you look a baby over from head to toe, you may see signs that she has an illness or disability. Or you may see that the baby is somehow different from other babies. These differences or disabilities may be called birth defects. Birth defects are sometimes small, and not dangerous, like cleft lip. Or they may be very serious and life threatening, like a large opening in the spine (spina bifida). If you find anything unusual, get medical help.

If the baby has a disability, the parents may be very accepting, or they may not. Some parents think that disabilities are caused by curses or bad luck. Others feel sad that their child is not the way they imagined, or not like other children. They may feel overwhelmed by the extra help that they may need to give a disabled child. Parents of disabled children often need extra support.

Help the parents:

  1. find good medical care for their child.
  2. learn about the child's special needs.
  3. learn about the child's strengths. For example, a child who will not walk because her legs are not formed normally, may have very strong arms and hands and be able to do many useful things with them. The same child may also be very intelligent and able to do useful things with her mind.


There are many helpful books for parents and caregivers of children with disabilities. Disabled Village Children, Helping Children Who Are Blind, and Helping Children Who Are Deaf are all available from the Hesperian Health Guides.

Immunizations given at birth

Hepatitis B vaccine Hepatitis B is a serious infection that can cause fatal liver disease. Hepatitis B can be passed from an infected mother to a baby during birth, and later is spread by contact with infected blood or body fluids, like HIV is. The vaccine is very effective for prevention. For best protection the first of 3 injections (sometimes 4) should be given at birth.

BCG vaccine In some places where there is a lot of tuberculosis (TB), a vaccination called BCG is given to all babies at birth to prevent severe (disseminated) TB. In other places this vaccination is only given at birth to babies of mothers who have TB. BCG vaccination does not always work, so people who have been vaccinated should still be careful not to be exposed. Babies who are HIV positive and have any signs of illness should not be given the BCG vaccine.

If you do not give these vaccines yourself, help the mother have the baby immunized as soon as possible. For a complete listing of childhood immunizations, see Where There Is No Doctor, page 147.

Clean up and answer the family’s questions

Clean up the birth area. Anything that has blood on it, including the placenta, must be disposed of so it does not spread germs. Learn how to safely dispose of tools and wastes.

Make sure the parents have all of their questions answered before you leave.


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