Baby's First 48 Hours

Your baby has just been through one of the hardest battles he will ever face. It's a tough job to be pushed down the birth canal and out into the world. Often baby needs help and must be delivered with a vacuum extractor or forceps, or by Cesarean section. No matter how your baby arrives, it is wonderful to meet him.

Your newborn is amazing. When he enters the world, all his major organs are functioning. He can see, hear, smell, taste and feel. He may look like he has no awareness of what's going on, but he is very sensitive to events taking place around him. (We discuss this in depth in Week 1.)

Baby's Birth Weight

“How much does he weigh?” is one of the first questions new parents ask. What a baby weighs is influenced by many factors, including the mom’s health during pregnancy, medications, smoking, nutrition, diet, length of the pregnancy (early or late) and the size of baby’s dad.

The average weight at term is 7 pounds, 2 ounces, but this can vary widely. In addition to weight, other measurements are taken at birth, including length (average is between 18 and 22 inches), head circumference and abdomen circumference.

Your baby’s weight may fall a little in the days following delivery. Most babies lose a few ounces after birth because they are born with extra body fluid. They lose this extra fluid during the first 5 days and generally regain the weight in the next week. So before 2 weeks of age, they are usually back to their original birthweight.

From birth to 4 weeks of age, most babies gain ⅔ to 1 ounce of weight every day! By the end of 3 months, baby will have gained an average of 1½ to 2 pounds each month! Babies often double their weight by 6 months and triple their weight by a year. You’ll really see changes in him over the next few months.

When baby is born, his length is measured. Many babies lose a little length measurement in the days following birth if the birth was vaginal and his head was pointed. Over the next 3 months, baby will grow about 1 to 1½ inches a month. By age 1 year, your baby will have grown an additional 9 to 11 inches.

Birth of a Premature Baby

If your baby was born prematurely, it may have been a great shock to you. Dealing with a premature baby is not the same as dealing with a full-term infant. Because there is so much to cover—from where your baby is cared for in the hospital to when you can take him home—we have included a special discussion for you in Appendix B, page 562, covering many different aspects of life for your newborn premature baby. In addition, in Appendix B we also present a section that discusses continued development of your baby after he comes home from the hospital.

What Does Baby Look Like?

If you’re like most new parents, the first thing you do when you meet your baby is to examine him from head to toe. What does he look like? Does he have hair? Does he have 10 fingers and 10 toes? Is he normal? These concerns are universal—we felt the same way when our children were born.

If your baby is average size, he’ll weigh between 7 and 8 pounds, and be between 18 and 22 inches long.

His Head and His Face

As you check him out, you may notice that his face is puffy and his head is slightly misshapen; he may have a “mashed” or “conehead” look. It’s common for a baby’s head to look like this because the skull, which is actually made up of several bones, changes shape and molds to move through the birth canal. You may think his head looks enormous—it is! At this time, his head is 1/4 of his body, which is one reason it’s difficult for his skull to fit through the birth canal.

Your baby’s face might look a little askew, as if he’d been in a fight or slid down a slippery slide on his face. His nose may be flat, and his chin a little out of place. He may have some bruises on his face. The skin over his brow may be wrinkled and loose, and his eyes may be swollen and bloodshot. As with his misshapen head, this is due to the exertion of the birth process. His eyes will appear blue or be dark; however, his true eye color won’t be evident until he’s about 6 months old.

The two soft spots on the top of his head are called fontanelles. One is close to the crown; you’ll be able to see and to feel his pulse there. The other is above his brow on his forehead. These spots decrease in size as his bones grow together. It’s OK to touch them gently; they’re covered with a thick, protective membrane. Soft spots in the rear of the skull close at about 3 months of age. The front fontanelle stays soft until baby is between 18 and 24 months old to allow for brain growth.

You may also notice the crown of baby’s head is lumpy, swollen and discolored. This is called a caput and results from his head pushing against the mother’s cervix and the birth canal. The caput quickly disappears; it will look better every hour and may appear normal by the time you go home. However, it may take as long as 10 days for a misshapen head to look normal. Baby’s head is most vulnerable to injury in the first 4 months. His head is big, and his neck muscles are not strong enough to support it. That’s why you always need to support baby’s head and the reason you must never shake your baby.

A pea-sized bump of the back of baby’s head is probably a lymph node. Don’t worry about it. If baby has a bump near the top of his head, it might be caused by overlapping bones in baby’s skull. Bumps will disappear as baby’s bones fuse together.

If he has hair, you may be surprised by the color. However, this hair is usually temporary, so don’t worry if you don’t like it. His real hair (the permanent kind) will begin to grow soon, although some babies don’t get permanent hair until they’re close to a year old (or older!).

You may notice a few blisters in your baby’s mouth. Check his thumbs and fingers for any thickened or callused areas. Most babies suck their thumbs or fingers in the uterus; your baby may have. He may have a nursing tubercle on his upper lip, which stiffens the lip and makes grasping your nipple or a bottle nipple easier for him.

At birth, the crowns of your baby’s teeth are nearly formed. They rest in the baby’s jaw bones and will gradually appear (erupt) during the first 2½ years of life.

If his chin quivers and/or his legs and arms seem shaky, it just means that more electrical impulses are being sent to muscles than are necessary, which results in these movements. This is normal, and they will decrease over the next few months.

Baby’s Skin

Next you may look at the skin on his body. Most babies are covered with a thick, white, waxy coating when they’re born, called vernix; it protected baby’s skin while he was in the uterus. When he’s cleaned up, you may be able to see the veins through his skin, which is still thin. His hands and feet may peel. He may have birthmarks. See the discussion of Birthmarks below.

A Caucasian baby’s skin color can range from purplish to pinkish gray. The pigmentation of babies of color may not be evident for hours or even a few days after birth. Many are born with light skin that darkens. If baby’s a little blue in color, it may be caused by mucus in his air passages. Most is suctioned out, and he coughs out the rest.

His skin may appear yellow-or orange-tinged by the second or third day— about half of all newborns experience jaundice. The color is caused by the inability of baby’s liver to remove breakdown products of blood cells, and the buildup causes the skin to look yellow or orange. A mild case of jaundice resolves in about a week or 10 days; it may last slightly longer if your baby breastfeeds. See the discussion in Week 1.

A baby is born with a lot of skin compared to the size of his body. Until your little one grows into his skin, he’ll be somewhat wrinkled. It’s interesting to note as you examine him that your baby’s skin is the most developed sensory organ he has right now. He’ll love it when you gently rub and stroke him.

Delivery Marks

Delivery marks occur in almost every delivery. They can occur while the baby is in the uterus, during the descent through the birth canal and during delivery. The use of forceps or a vacuum extractor to assist with delivery may increase the chance of delivery marks. Marks can vary from a misshapen head (it’s nothing to worry about and will change rapidly after birth), or a flattened ear or nose, to bumps and bruises.

Forceps may leave marks on the side of the head, in front of the ears. A vacuum extractor may leave a mark on the back or crown of the head. These marks fade and go away within a few hours to a few days. Lotion may be helpful in some situations.

Call the doctor if any of the marks get bigger or if they don’t fade within the first few days. If they become warm to the touch or hard, let your doctor know.

Birthmarks

Many different types of marks may be seen on a baby after birth. These include salmon patches or stork bites, hemangiomas or strawberry marks, Mongolian spots, café au lait spots, port-wine stains, spider veins (nevi) and pigmented nevi (beauty marks). All are discolorations or marks on the skin.

Salmon patches, also called stork bites, are pinkish areas usually found on the back of the neck, the forehead, the face or eyelids, and are caused by blood vessels in the skin. About 33% of all light-skinned babies have stork bites; most will fade by the time baby’s 18 months old. Some are permanent.

Hemangiomas, also called strawberry marks, are fairly common birthmarks. About one in 10 babies has them. A strawberry hemangioma is caused by dilated blood vessels in the top layers of baby’s skin. The condition may indicate circulation problems under the birthmark and should be examined by baby’s doctor.

Strawberry marks are often red or pinkish, as well as being raised and spongy. They may not appear until a few weeks after birth and may continue to grow somewhat during the next 6 to 12 months. Most disappear by age 10 years and leave no scar.

Mongolian spots are flat blue- or gray-colored marks, which look like bruises, found on the back and buttocks. They are seen most often in darkskinned and Asian babies. They are caused by a high concentration of pigment cells in the skin. These spots are not a sign of disease and should fade during childhood, but they may never disappear completely.

Café au lait spots are flat spots, usually tan to light brown in color. They can be found anywhere on the body and are usually permanent. There is no treatment for these spots, but if baby has more than six spots that are larger than 1/5 inch in diameter, have them checked out by the doctor. Café au lait spots may be found in conjunction with a rare neurological disorder.

Port-wine stains are pink to purple to red in color and usually flat. They may fade somewhat, but they are usually permanent. They may be removed by laser surgery when baby is older. If port-wine stains appear on any part of the face, they should be checked regularly. A port-wine stain on baby’s forehead or eyelid may indicate Sturge-Weber syndrome, which is a neurological disease. It’s important to have your doctor watch a port-wine stain closely.

Spider nevi are dilated blood vessels that look like a spider web; they usually fade by 1 or 2 years of age. Moles or pigmented nevi come in several colors from light brown to black. They are caused by an increase in the number of pigment cells in the skin. Moles present at birth should be watched for any change in size and color. Large moles (over 3 inches wide) may be removed to avoid risk of melanoma.

Keep an eye on any birthmarks your child has. Call the doctor if a birthmark grows or changes color. If a mark is close to the eye or on baby’s face, your pediatrician will check it. In most instances, birthmarks are watched to see if they fade or go away on their own. Laser surgery is being used in many instances to remove birthmarks and moles. Other treatments may be possible in specific cases. Discuss them with baby’s doctor if you are concerned.

Examining Other Parts of His Body

Baby’s hands and feet are so small they may amaze you. He’ll probably hold his hands in tight fists. His fingernails may be paper thin; don’t be surprised if they already need trimming!

A newborn’s legs are bowed, and his feet turn in. Often his legs are drawn up against his tummy—this is called the fetal position. If you gently pull them out, his legs may appear short. And when you let them go, it’s almost as if they were on rubber bands—they pull right up against his body! His feet have only a heel bone at this time. The cartilage that makes up the rest of his foot will become bone later.

Your baby’s heel is usually pricked for a blood sample, so it may look sore or inflamed. His hips may seem loose-jointed and crack when they move. This is normal and caused by hormones from his mother. Your pediatrician will examine your baby for signs of a dislocated hip, which can be treated.

His tummy may be prominent; this isn’t fat, it’s caused by a lack of muscle tone. This disappears as he becomes more mobile in the next few months.

Your baby’s genitals may appear swollen and enlarged; this can happen with either sex. A girl may have a vaginal discharge. See the discussion in Week 1. Don’t worry—this is normal and will clear up in a few days. These symptoms are caused by the mother’s hormones crossing the placenta.

When your baby is born, he has about 305 bones/cartilage in his body. As an adult, this will decrease to 206 bones. That’s because some of the cartilage fuses together to become bone.

In a few cases, a baby may experience a bone break or fracture, or a dislocation during delivery. These conditions heal well with no lasting result and are usually treated by bandaging them. You must use great care when lifting your baby. Dressing must be done carefully; bathing may have to wait awhile.

If you notice a hard lump between baby’s ribs, it’s a bone called the xiphoid process. Soon it will be covered with muscle and fat as baby develops, so don’t be concerned about it. Your baby may also have a hollow vertical area running down his tummy. This is caused by the two muscle bundles on either side of the abdomen—they haven’t grown together yet but will as baby grows older.

Baby’s Bowels

Even though you probably never imagined it, now that baby is here, you’ll probably find yourself concerned about his bowels. It doesn’t only mean changing diapers; your baby’s stools can be an indication of his health.

Your baby’s first bowel movement is called meconium. It consists of cellular material and other substances from his digestive tract that gathered as he developed in the womb; it looks yellow-green, brown or like black tar. Your baby must get rid of this material in the 48 hours after birth before normal digestion can begin. If he doesn’t, you doctor may be concerned about intestinal obstruction.

Once your baby passes the meconium, his stools will be yellow-green and look like birdseed. If you breastfeed your baby, his stools will look different from a baby’s who is fed formula.

Baby’s Senses

It may seem incredible, but soon after birth, a baby can recognize his mother’s voice and her scent. Before your baby is born, he is already sensitive to sounds, light and temperature. His senses develop quickly once outside the womb. As we’ve already mentioned, he can hear, see, feel and taste when he is born. Let’s examine what his senses are like at this time.

Taste

Your baby is born with a desire for sweet things, which is suited to the flavor of formula or breast milk. His taste for bitter, salty and sour develops later. At this time, he can distinguish bitter and sour tastes.

Hearing

Baby’s hearing is not fully developed at birth. Parts of the ear are immature, so your baby can’t hear the range of sounds you can. Low-frequency sounds can be heard by baby at birth; this includes the human voice. Even before baby was born (about 7 months into pregnancy), he was able to hear your voice. So when he is born, your baby will recognize his mother’s voice. And it will take only a few days until he also recognizes Dad’s voice.

Studies have shown that babies prefer the sound of the human voice to any other sound. To help baby develop his hearing, speak to him often in a slow, exaggerated voice. You’ll both enjoy the interaction, and you’ll help him develop his hearing.

Pay attention to how your baby reacts to sounds now and in the future. About 3 of every 1000 newborns have a serious hearing problem, and these are often difficult to diagnose. Your observations can be very important.

Sense of Smell

Researchers believe that your baby’s sense of smell is well developed at birth. It’s been found that within hours of birth, a breastfeeding baby will use his nose to find his mother’s nipple. Amazingly, it has been demonstrated that your baby’s sense of smell may be developed in the uterus—certain food flavors and odors, such as garlic, cross the placenta to the baby. If you love garlic and onion, baby may already be familiar with them! If you breastfeed, this continues because many flavors pass into your breast milk.

Your baby will learn about some smells as he grows. He will learn which smells are “good,” such as those associated with particular foods, and which smells are unpleasant. It’s interesting to note that some cultures find some odors pleasant while people of other cultures find the same odors unpleasant. Many of these preferences are due to acculturation.

Touch

From birth, a baby is sensitive to touch; as we’ve already said, his skin is the largest organ of his body. It doesn’t take long for him to become familiar with the touch of those close to him. Your touch can soothe him and stimulate him.

It’s important to know how to touch your baby. A baby likes a firm touch. It makes him feel secure. He also likes to be stroked and massaged— that’s why we include different massage techniques in the first 8 weeks of discussions. Massaging your baby has benefits for him and for you. Studies show that babies who are massaged for 10 to 15 minutes before bedtime or napping may sleep better and be less irritable.

Sight

Eyes may be quite developed by birth and capable of seeing many things. However, the baby’s brain isn’t as fully developed, so he doesn’t see as well as an adult. That’s one reason you’ll have to hold an object very close to your newborn for him to see it, about 8 to 12 inches away.

At birth, your baby’s brain is not mature enough to distinguish between different shades of color. He can distinguish light from dark and prefers black-and-white patterns. If you move an object farther away from him, his eyes may cross; he can’t focus both eyes on the same thing just yet.

Vision and Hearing Tests

Today, most hospitals and physicians are testing a baby’s hearing and vision before he leaves the hospital. A baby’s eyes are usually tested shortly after birth for eye disease and proper function, especially if there is a family history of problems. Some doctors recommend babies be examined for many types of eye abnormalities, including congenital cataracts. When found early and treated, a baby may avoid long-term problems. If a problem is discovered, your baby may need to see an ear, nose and throat specialist (ENT) or an ophthalmologist.

In the past, it was difficult to find the three in 1000 babies born with a hearing problem. Delayed language skills were the only clues that a baby might have a problem. Today, we can test newborns and help babies with hearing problems at a very early age.

A noninvasive test performed on a sleeping baby can help determine if a baby has a hearing problem. Hearing is tested by recording electrical brain activity in response to various sounds or by listening for an echo in the inner ear. At this time, the test is mandatory in 38 states. Occasionally, a healthy baby will fail the test due to junk in the ear from birth. When retested, he will pass with flying colors. If baby doesn’t pass a retest, further testing will diagnose the hearing impairment.

If your hospital doesn’t offer hearing testing for newborns, talk to your pediatrician. Ask him or her to arrange for testing with an audiologist before baby reaches 3 months of age. It’s better to do this now than to wait until baby is older and needs to catch up with his peers.

If your baby has a hearing loss, help is available. Today, hearing aids can be fitted in a baby as young as 6 months old!

Tests on Your Baby

After birth, your baby will be subjected to a variety of tests to assess his health and to provide his physician with information about any potential problems. At this time, we do not have a national standard for newborn screening tests. This allows for a great deal of variance of required tests from state to state. Most babies with problems appear normal at birth; screening tests allow doctors to discover problems and deal with them early in a baby’s life.

The purpose of routine newborn screening tests is to identify infants at risk and those babies in need of more testing. For most tests, a few drops of blood from a heel stick is all that is needed. The medical term for the testing is tandem mass spectrometry, and it simultaneously screens for 20 metabolic disorders.

To find out which tests are given in your area, check with your state health department, your local hospital or your baby’s doctor. The American College of Medical Genetics recommends that all states screen for 29 disorders. At this time, all 50 of the United States screen for the following problems:

• congenital hypothalamus
  
  
• galactosemia
  
  
• phenylketonuria
  

To learn more about screening tests for newborns, see Appendix A, page 557.

How Baby Functions after Birth

Baby’s functioning after birth includes his first attempts at breathing, coughing fluid from the lungs, sneezing, movement of legs and arms, and often passage of urine or a bowel movement. He has a lot to do very quickly!

With those first breaths, baby goes from being totally dependent on blood flow from the placenta to using his own lungs and airways to breathe. The blood flow in the heart changes—blood that was diverted from the lungs directly to the body before birth now flows through the chambers of the heart into the lungs, then into the body.

New parents are often concerned about baby’s color. “Are they always so blue?” they ask. The answer is “Yes,” but the baby soon turns pink. Hands and feet are the last areas to turn pink.

Following delivery, the baby is often quiet but is soon crying and moving. The nurses weigh, measure and evaluate your baby in the moments after his birth. During this time, baby becomes more alert. He also exhibits several reflexes, which are discussed below.

• When you touch or rub his cheek, his mouth will open and he will make a sucking motion; this is the rooting reflex. Baby outgrows this reflex by about 4 months.
  
  
• With the sucking reflex, baby sucks vigorously when you put something into his mouth—your finger, nipple or a pacifier. Baby outgrows this reflex by about 4 months.
  
  
• The baby will spread his fingers, throw his arms out and slightly forward and throw his legs out, then quickly draw them in when his position is changed suddenly. This is called the Moro reflex. Baby outgrows this reflex at about 3 months.
  
  
• The grasping reflex (also called palmar grasp) causes baby’s hand to become a fist when his fingers or palm is touched. Baby outgrows this reflex at 5 to 6 months.
  
  
• The startle reflex becomes evident as the Moro reflex fades. When startled by a loud noise, baby may look frightened and flex his arms and legs. This appears around 3 or 4 months of age and lasts until about age 1.
  
  
• With the tonic neck reflex, baby will extend his arm and leg outward when you turn his head to one side while he is lying on his back. This reflex is critical during labor and delivery because it helps baby twist and wiggle around during the birth process. Baby outgrows this reflex by about 5 months.
  
  
• The stepping reflex occurs when baby is held upright. He places one foot in front of the other, as if taking a step. Baby outgrows this reflex by about 2 months.
  
  
• When you put your baby on his tummy, he’ll move as if he were crawling. This is called the crawling reflex. Baby outgrows this reflex by about 3 months.
  
  
• With the swimming reflex, baby will hold his breath and move as if swimming if you put him underwater. Baby outgrows this reflex around 6 months.
  
  
• With the nasopalpebral reflex, when you tap the bridge of baby’s nose, he will close his eyes. This reflex disappears by about 4 months.
  
  
• The parachute reflex occurs if baby feels as if he is falling; he’ll try to grab onto something overhead. This appears around 3 months of age and lasts until about age 1.

In addition to these various reflexes, a newborn has a very strong grip. His grip is so strong, in fact, that he can support his own weight!

Baby’s Care in the Hospital

Visit by the Pediatrician

Your baby will be visited in the hospital by the pediatrician you have already chosen, if you chose one. If you did not select someone, a pediatrician on call for the hospital will examine baby.

The pediatrician will examine the baby, perform a circumcision if you request it and meet with you and your partner. He or she will lay out a schedule of follow-up visits in his or her office. Be sure you know how to contact the pediatrician or the pediatrician’s office if you have any questions or problems.

If you have questions, be sure to ask your pediatrician or obstetrician. No question is “dumb,” so ask! You may want to make sure your partner is present when you ask a question. It’s always good to have two sets of ears at such an exciting and stressful time as this is.

Circumcision

As parents, you may decide to have your son circumcised, which means the foreskin of his penis is removed by a surgical technique. This is usually performed at the hospital as a surgical procedure, or a clamping device may be used to remove the foreskin. However, if you are Jewish or Muslim, it may be done as part of a religious ceremony, outside of the hospital.

Today, about 65% of all male babies are circumcised—in the 1970s, that number was as high as 80%. It is not unusual today for a couple to decide not to have their son circumcised.

Other than for religious purposes, infant boys are circumcised for two reasons. First, many couples don’t want their son to look different from his father or other boys his age at school. The second reason is health related, including reducing urinary-tract infections (UTIs) in the first year of baby’s life and reducing a man’s chances of developing cancer or contracting syphilis or HIV in later life. A recent study suggests that circumcision does reduce the risk of contracting HIV. The study showed that uncircumcised males were 8 times more likely to become infected with HIV when they were exposed than men who were circumcised. In addition, the reduction in UTIs falls from 1 in a 100 for an uncircumcised male to 1 in 1000 for a circumcised infant during baby’s first year.

The American Academy of Pediatrics (AAP) has taken a neutral stand on circumcision. It has concluded there is no right or wrong answer to the question. The association believes the decision is up to the parents and is based on medical reasons and cultural and religious beliefs. However, the AAP does state that pain relief is essential when a newborn is circumcised. Studies show that nearly 85% of all physicians now use anesthesia when performing a circumcision. Various techniques are available and recommended, including dorsal penile nerve block, the subcutaneous ring block or a topical anesthetic cream.

Risks with the procedure are minor and include some bleeding and local infection. The wound usually heals in about 10 days.

If you decide to have your son circumcised, performing the surgery at this early age will have little effect on him. (Postponing it until later years can be significantly more painful and can carry higher risks.)

If your son was born prematurely, you may be able to have him circumcised before he leaves the hospital. However, some doctors prefer to wait until he is a few weeks older to perform this procedure. The doctor in the NICU (neonatal intensive care unit) will advise you.

If you decide not to have the procedure performed, your child will not be the only child who is uncircumcised as he grows up. Statistically, about ⅓ of his male friends and acquaintances will also be uncircumcised. Circumcision requires surgical permission from you and your partner; it won’t be done without your consent.

When you meet with your pediatrician before baby’s birth, circumcision may be a subject you want to cover. If you don’t have that opportunity, you can always discuss it before baby leaves the hospital

Dislocated Hips

Dislocation of a baby’s hip(s) occurs more often in baby girls and in babies delivered in the breech position. About one in 60 newborns is affected; 85% of these are girls.

When your baby is examined by the pediatrician in the hospital, his hips are checked to see that the upper leg bone (femur) fits in the hip socket (pelvic bone). If a hip is dislocated, a “hip click” (a clicking sound) may be heard when the legs are pulled apart. Skin folds on the buttocks may not be symmetrical or one leg may appear shorter than the other. If left uncorrected, he may limp when he begins to walk.

Today, surgery is rarely required to correct the problem. Splints are usually used for a few months, sometimes called pillow or diaper splints; they keep the hips widely separated. It’s like wearing three or four diapers at one time. In some cases, plaster splints (like a cast) or braces are used. In most cases, the problem is corrected before the end of the first year.