OB Week 3 + 4 -- Newborn Care + Complications

Neonatal period

The time from birth through first 28 days of life

Nursing priorities for the neonate

Maintain body heat, maintain respiratory function, lower risk of infection, assist parents in hydrating/providing nutrition

How does the respiratory system chance after birth?

Compression of thorax during labor + mild hypoxia --> respiratory center is stimulated --> first breath --> crying clears more fluid --> lungs function more normally --> surfactant is produced

Where does the lung fluid go after the first breath?

It is absorbed by the blood/lymph system and excreted by the kidneys

Surfactant

A chemical in the lungs that maintains the surface tension of the alveoli and keeps them from collapsing --> maybe decreased in premature birth/maternal diabetes

Why does maternal diabetes pose a risk for low surfactant levels?

Insulin inhibits surfactant production

Gestational diabetes leads to preterm birth

Signs of respiratory distress

• Central cyanosis

• Tachypnea

• Apnea

• Grunting

• Flaring of nostrils

• Retractions of the chest wall

• Hypotonia (late sign)

Respiratory distress syndrome

A life-threatening condition --> underdeveloped alveoli and insufficient levels of pulmonary surfactant --> atelectasis

Transient tachypnea of the newborn

Respiratory distress symptoms --> incomplete reabsorption of fetal lung fluid in full term newborns --> usually disappears within 24 to 48 hours

How does the circulatory system chance after birth?

Decreased pulmonary resistance to blood flow --> increased pulmonary blood flow

Cord clamped --> less blood flow/pressure in RA --> increased systemic vascular resistance

Ductus venosus

Connects the umbilical vein to the inferior vena cava, bypassing the liver --> closes when blood flow from the placenta stops

Foramen ovale

Connects the two atria in the fetal heart --> closes due to increased systemic vascular resistance

Ductus arteriosus

Connects the pulmonary artery to the aorta, bypassing the lungs --> closes within 15 hrs of birth

Patent ductus arteriosus

Failure of the ductus arteriosus to close after birth --> abnormal opening between the pulmonary artery and the aorta --> heart murmur, tachycardia, increased work of breathing, increased O2 demand --> heart failure in not managed

How do neonates thermoregulate?

Increased metabolic rate, increased O2 consumption, increase in muscle activity (tensing up), metabolism of brown adipose tissue

Factors that prevent thermogenesis

Decreased subcutaneous fat, decreased brown fat in preterm infants, large body surface, loss of heat from convection, radiation, conduction, and/or evaporation

Evaporation

Surface liquid evaporates into a vapor --> heat loss

Convection

Movement of heat from the body's surface to drafts/movement of cooler air --> heat loss

Conduction

Direct contact with a cold surface --> heat loss

Radiation

Movement of heat from a body to a cooler surface that is close to the newborn but not touching --> heat loss

Cold stress

Excessive loss of heat --> increased respirations and non-shivering thermogenesis to maintain core body temperature

Environmental temperature ↓ , body temperature ↑, heart and respiratory rates ↑, O2 consumption, depletion of glucose and ↓ surfactant --> respiratory distress

Risk factors for cold stress

1. Prematurity

2. SGA/LGA

3. Hypoglycemia

4. Prolonged resuscitation efforts

5. Sepsis

S+S of cold stress

Low temp, cool skin, restlessness, acrocyanosis, tachypnea, grunting, hypoglycemia, ineffective feeding

Sudden unexplained postnatal collapse

An otherwise healthy newborn experiences a sudden cardiorespiratory collapse within the first week of life --> usually due to airway problems

Newborn hypoglycemia

Glucose < 45 mm/dL

Signs and symptoms of neonatal hypoglycemia

Irritability, jitteriness, hypotonia, hypothermia, and seizures

Risk factors for neonatal hypoglycemia

1. Maternal DM

2. Preemie

3. LGA or SGA

4. Stress at birth (hypothermia or hypoxia)

How does the hepatic system transition to extrauterine life?

Indirect bilirubin

Unconjugated, water insoluble (byproduct of RBC breakdown BEFORE liver)

Direct bilirubin

Conjugated, water soluble (byproduct of RBC breakdown AFTER liver)

Transcutaneous bilirubinometer

Measures the concentration of bilirubin in the blood

Pysiological jaundice

Appears 24-48 hours after birth, TcB < 7

Pathological jaundice

Present at birth or within 24 hours

Breastfeeding jaundice

Appears 2-4 days after birth due to limited intake/output

Why are neonates at risk for hyperbilirubinemia?

Due to their underdeveloped livers --> unable to process the bilirubin from RBC breakdown

Why do neonates need vitamin K?

Many neonates are vitamin K deficient at birth due to immature intestinal flora --> vitamin K is needed to prevent hemorrhage and promote blood clotting

How often do newborns void/stool?

For the first 4 days, 1 stool and 1 void per days baby has been alive

For day 5 and beyond, 6-8 voids and 3-4 stools

Meconium

The first stool of the newborn (greenish-black)

Meconium aspiration syndrome

Asphyxia in utero --> relaxation of anal sphincter --> meconium is passed --> abnormal inhalation of meconium --> respiratory distress

Transitional stool

Thin, slimy, brownish green stool that is passed on the 3rd-6th day

Breastfed stool

Yellow and semi formed --> then it becomes golden yellow with a pasty consistency and has a sour odor

Formula fed stool

Drier and more formed that breastfed stools, paler yellow or brownish yellow and has an unpleasant odor

Diarrhea stool

Loose, watery, and green stool

Feeding cues

Sucking motions, rooting, mouthing, hand to mouth

Crying is NOT a feeding cue

Breastfeeding positioning

Body should face mom's, skin-to-skin, baby prone on mom's chest, nose toward nipple

How to latch

Stroke nipple on newborns lips, WHOLE areola should go into mouth, newborn should have fish lips, shin touches breast

How often should babies feed?

Breastfed: every 2-3 hours for 15 min each feed

Formula fed: every 3-4 hours

Formula feeding important points

Warm formula by setting it in warm water, do NOT microwave, throw away formula after an hour, NEVER prop a bottle

Passive immunity

An individual does not produce his or her own antibodies, but rather receives them directly from another source, such as mother to infant through breast milk

Active immunity

A form of acquired immunity in which the body produces its own antibodies against disease-causing antigens

Neonatal assessment components

1. APGAR scores

2. Vital signs

3. General survey

4. Head to toe

When are APGAR scores taken?

1 minute after birth and 5 minutes after birth

APGAR scores

-Activity (muscle tension)

-Pulse (HR over 100)

-Grimace

-Appearance/Color (Pink, acrocyanosis)

-Respiratory

What APGAR scores are normal?

7-10 is normal

4-6 needs re-evaluation

< 3 requires intervention (code)

Newborn vital signs

Respiratory rate: 30-60

Heart rate: 110-160

Temperature: 36.5-37.5 C

Pain score: NIPS or NPASS

Blood sugar: >45

Newborn weight

Breast fed babies lose 7-10% of their weight, formula fed babies can lose 5% of their weight

Why do newborns lose weight?

Babies lose weight due to fluid reduction, passing of meconium, and the breakdown of brown adipose tissue

Excessive weight loss (> 10%) complications

Jaundice, hypoglycemia, dehydration --> renal failure, thrombosis, shock, seizure

Newborn posture: normal and abnormal

Normal: Flexed, symmetric movement

Abnormal: Flaccid, hypertonic, asymmetric movement

Newborn skin: normal and abnormal

Normal: Pink, acrocyanosis, milia, lanugo, vernix, erythema toxicum, cafe au lait spots, blue nevus, port wine stain, strawberry hemangioma, stork bite

Abnormal: Cyanosis, jaundice, pallor, mottling, harlequin sign

Newborn head: normal and abnormal

Normal: Fontanels soft and flat, suture lines, caput succedaneum, molding

Abnormal: Cephalohematoma, bulging or sunken fontanels

Newborn face: normal and abnormal

Normal: Symmetric size + shape, movement

Abnormal: Asymmetry

Newborn eyes: normal and abnormal

Normal: Symmetric, clear sclera, blue/grey iris, PERRLA, transient crossed eyes

Abnormal: Conjunctivitis, drainage, hemorrhage, yellow sclera, tears

Newborn nose: normal and abnormal

Normal: Patent nares

Abnormal: Nasal flaring

Newborn mouth: normal and abnormal

Normal: Pink, moist membranes, movable tongue, intact hard/soft pallets, Epstein pearls

Abnormal: Cleft palate, thrush, protruding tongue, teeth

Newborn ears: normal and abnormal

Normal: Firm pinna, quick recoil

Abnormal: Low set ears, skin tags, hearing loss

Newborn neck: normal and abnormal

Normal: Short, creased, moves freely

Abnormal: Webbing, torticollis

Newborn chest: normal and abnormal

Normal: Barrel shaped, symmetrical, breast engorgement

Abnormal: Respiratory distress, retractions, grunting, clavicular fracture

Newborn abdomen: normal and abnormal

Normal: Round, soft, 3 vessel cord, BS present

Abnormal: BS absent, distended, bowel loops, visible peristalsis

Moro reflex

Infant reflex where a baby will startle and splay our their arms and legs in response to a loud sound or sudden movement

Tonic neck

Infant reflex where a baby stretches its arms out into a fencing position when its head is turned to the side

Rooting reflex

Infant reflex where a baby will turn its head and open its mouth when its cheek is stroked

Sucking reflex

An infant reflex in which the infant starts sucking when its lips are stroked

Palmar grasp

An infant reflex in which the infant grasps an object when the object is placed in the infant's palm

Plantar grasp

An infant reflex where toes curl downward when pressure is applied to the ball of the foot

Babinksi reflex

An infant reflex in which the toes spread when the lateral side of the foot is stroked

Stepping/dancing reflex

An infant reflex in which the infant steps up and down when held upright

SGA

Small for gestational age (

IUGR

Intrauterine growth restriction

IUGR causes

Infection, malnutrition, substance abuse, hypertension, medication, etc

AGA

Appropriate for gestational age

LGA

Large for gestational age (above 90th percentile)

Caused by maternal diabetes, postmature

Postmature baby

Pregnancy of 42+ weeks --> good flexion, skin dried out, more wrinkled, scrawnier, less subcutaneous fat because baby uses up glycogen stores

Intraventricular hemorrhage

Hemorrhage located within the ventricles of the brain --> more common in premature/IUGR newborns --> apnea, bradycardia, pallor or cyanosis, weak sucking ability, a high-pitched cry, seizures, lethargy, stupor, or even coma

Necrotizing enterocolitis

Serious inflammatory condition of the intestines --> most common in premature newborns --> abdominal pain and swelling, changes in vital signs, bloody diarrhea, green or yellow vomit, lethargy, and a refusal to eat, often resulting in poor weight gain

N-PASS

Neonatal pain, agitation, and sedation scale

0 is normal

Neonatal Infant Pain Scale (NIPS)

Newborn and infant pain score

0 is normal

Initial period of reactivity (the golden hour)

30 minutes post birth --> APGAR scores, dry + stimulate newborn, secure ID bands and HUGS tags, feed, skin-to-skin contact

Period of relative inactivity

30 min - 2 hrs after birth --> newborn is quiet, HR and RR will decrease

Second period of reactivity

2 to 8 hours after birth in which the newborn awakens and shows an interest in stimuli

Composition of milk

87% water

3.7% fat

4.9% carbs

3.5% protein

How do hormones control milk release?

Colostrum

Transitional milk

Mature milk

Contraindications for breastfeeding

- Maternal HIV

- Active tuberculosis

- Drug abuse

- Certain medication (e.g., tetracycline, chloramphenicol, *chemotherapy* agents)

- Baby with galactosemia

Erythromycin Ophthalmic Ointment

A medication that is put into the eye of all newborns as prophylactic to treat neonatal blindness

Hepatitis B Vaccine

If the birth giver has a Hep B surface antigen that is unknown or positive, give HB IGs within 12-hours of birth

How to put a baby to sleep safely?

Alone, on their back, in a crib

Care of the circumcised penis

Keep Vaseline gauze on wound, wash with soap and water