High Risk Newborn and Perinatal Loss

High Risk Neonate

newborn, regardless of gestational age or birth weight, has greater-than-average chance of morbidity or mortality due to conditions or circumstances associated with birth and adjustments following birth

Classification of High Risk Neonate

Birthweight

Gestational age

Predominant pathophysiologic status

The Ballard Score

usually first trimester ultrasound is accurate

A standardized tool used to estimate gestational age of a newborn (helpful if dates are unknown)

contains 2 components: neuromuscular maturity and physical maturity

Neuromuscular Maturity

more flexion=more mature infant, less term is more floppy

Assesses tone and flexibility:

Posture

Square window (wrist flexibility)

Arm recoil

Popliteal angle

Scarf sign

Heel-to-ear

Physical Maturity

more defined features=more mature infant

Assesses external features:

Skin

Lanugo (fine hair)

Plantar creases

Breast tissue

Eyes/ears

Genitals (male & female differences)

Acquired and Congenital Problems

Conditions or circumstances superimposed on normal course of events associated with birth and adjustment to extrauterine existence

Birth trauma: broken clavicle, bruising

Maternal substance abuse

Infection: Chorioamnionitis

Congenital anomalies: cleft palate, club foot

Birth Injury

injury sustained during labor and birth

Ultrasonography allows antepartum diagnosis that may be treated in utero or shortly after birth

Macrosomia, hydrocephalus, and unusual presentations

Elective cesarean birth chosen for some pregnancies to prevent significant birth injury

Small percentage of significant birth injuries are unavoidable despite skilled and competent obstetric care

Especially with difficult or prolonged labor

When the infant is in an abnormal presentation

Some injuries cannot be anticipated until the circumstances are encountered during childbirth

Skeletal Injuries

Clavicle fracture: Gentle handling, containment of limb against chest

Shoulder dystocia- shoulders get stuck

Peripheral Nervous System Injuries: Erb-Duchenne paralysis (Erb palsy)

Brachial plexus injury due to stretching or pulling (shoulder-head)

Paralysis of extremity, arm limp

Tx – passive ROM, positioning of affected arm, avoid stress on muscles

3 - 6 months to resolve

Facial Nerve Paralysis

Due to pressure on facial nerve (CN VII) during birth

Usually resolves hours to days

Assist with feeding techniques, possible gavage feeding, lactation consultant, eye care

Neurological Injuries: Hypoxic-Ischemic Brain Injury

brain damage due to delivery or in utero (drugs)

Seizures, hypotonia, poor suck/swallow, apneic episodes

Treat symptoms, supportive care

Sepsis

Significant cause of morbidity and mortality

early and late onset

Sepsis: Early Onset/Congenital

Within 72 hours after birth from direct contact with organisms from maternal GI or GU

More rapid- penicillins given Clindamycin

GBS is major cause of death (normal in vaginal tract)

Sepsis: Late Onset

Approx. 7 to 30 days of age from hospital or community

Bacterial Infections

Group B streptococcus

Escherichia coli

Klebsiella

Pseudomonas

Fungal Infections

Candidiasis

Thrush

Viral Infections

Perinatally acquired

May occur in the NICU

Septicemia

Pneumonia

Bacterial meningitis

Perinatally Acquired Infections: TORCH

T: Toxoplasmosis

O: other- Gonorrhea, Hepatitis B, Syphilis, Varicella Zoster, West Nile Virus, Parvovirus B19, and HIV

R: Rubella

C: Cytomegalovirus (CMV)

H: Herpes simplex

Toxoplasmosis

fecal/oral from cats

don’t change litter from cats or animals in general

avoid animal poop

Toxoplasmosis Treatment

Maternal treatment: Spiramycin (early pregnancy)

Fetal infection confirmed: Pyrimethamine + Sulfadiazine + Leucovorin

Neonate: Same triple therapy for ~12 months

Rubella

can cause neonatal death

if pregnant and not immune; can’t give vaccine bcs its live

after birth the vaccine can be given

Rubella treatment

No specific antiviral treatment, supportive care for complications

Prevention: MMR vaccine (pre-pregnancy)

Lab Studies for Infections

Cultures, CSF, urine

CBC

Immature to total neutrophil ratio (I/T ratio)

If the IT ratio is greater than 0.2, there are more immature than mature neutrophils in the blood stream

Normal value can r/o sepsis

Treatment for Infections

Specific to organism - antiviral, antibiotic or antifungal

Breast milk encouraged

Gonorrhea Treatment

Ceftriaxone (mother & neonate prophylaxis)

Hep B Treatment

HBIG, Hep B vaccine within 12 hrs of birth

Syphilis Treatment

Penicillin G (maternal + neonatal)

Varicella-Zoster Treatment

VariZIG (post-exposure), acyclovir

HIV Treatment

Maternal ART + neonatal Zidovudine, avoid breastfeeding

Parvovirus B19 Treatment

Supportive care, intrauterine transfusion if severe anemia

Herpes Simplex Virus (HSV) Treatment

Maternal: Acyclovir (late pregnancy suppression)

Active lesions at delivery: C-section

Neonate: Acyclovir

Neonatal Sepsis Treatment

Antibiotics: Ampicillin + Gentamicin

Supportive care: IV fluids, oxygen/ventilation support, thermoregulation

GBS Treatment

Ampicillin or Penicillin G

E. Coli Treatment

Third-gen cephalosporin

Pseudomonas Treatment

broad spectrum

Intervention for Infections

Nursing responsibility to minimize infection

Effective handwashing

Standard precautions

Cleaning of equipment

Replacement of used equipment

Appropriate disposal of linens and diapers

Avoid overcrowding

Guidelines for visitation

Infants and recreational Drug use

Marijuana, cocaine, hallucinogens, methamphetamine, inhalants, heroin

Infants Exposed to Tobacco

Most used substance during pregnancy

Low birth weight

Infants Exposed to Alcohol

Fetal alcohol syndrome (FAS)

Alcohol-related birth defects (ARBD)

Infants Exposed To Prescription Opioids

Neonatal abstinence syndrome (NAS)

Fetal Alcohol Syndrome Signs and Symptoms

facial features: Smooth philtrum, Thin upper lip, Small palpebral fissures

growth restriction

CNS Dysfunction: Developmental delay, Intellectual disability, Poor coordination

cardiac defects

Nursing management of Fetal Alcohol Syndrome

Early identification & developmental screening

Support feeding & growth

Family education & long-term support

Tobacco usage

Most common substance used in pregnancy

Causes chronic fetal hypoxia

Signs and Symptoms of Tobacco usuage

Low birth weight, IUGR

Preterm birth

Increased risk of SIDS

Irritability

Nursing management of Tobacco Use

Monitor growth & respiratory status

Safe sleep education (SIDS prevention)

Smoking cessation education for parents

Encourage breastfeeding (if appropriate)

Opioid Use

Withdrawal after birth due to loss of maternal opioid supply

Opioid Use S/S: CNS Irritability

High-pitched cry

Tremors

Seizures (severe

Opioid Use S/S: GI Dysfunction

Poor feeding

Vomiting/diarrhea

Opioid Use S/S: Automatic

Diaphoresis

Fever

Mottled skin

Opioid Use S/S: resp

Tachypnea (>60 breaths/min)

Nasal flaring

Nasal stuffiness

Opioid Use S/S: Misccellaneous

Disrupted sleep patterns

Excoriations (knees, face)

Temperature instability

Opioid Use Nursing management

Non-pharmacologic care: Swaddling, Low stimulation environment, Frequent small feeds

Pharmacologic: Morphine or methadone if severe

Marijuana (THC)

Affects neurodevelopment

Marijuana S/S

Low birth weight

Poor feeding

Altered sleep patterns

Subtle long-term cognitive/behavioral issues

Nursing Management of Marijuana Use

Monitor feeding & weight gain

Educate parents on developmental concerns

Encourage cessation

Long-term developmental follow-up

Cocaine and Methamphetamine (Stimulants) Use

Potent vasoconstrictors leads to decreased uterine blood flow

Chronic fetal hypoxia

Increased risk: Placental abruption, Preterm birth, IUGR / low birth weight

Cocaine S/S

Irritability, high-pitched cry

Tremors, hyperactivity

Poor feeding / poor alertness

Excessive sucking

↓ head circumference (growth restriction)

Methamphetamine S/S

Withdrawal-like symptoms:

Agitation

Tremors

Hypertonia

Poor feeding

Combined Cocaine and Methamphetamine S/S: Neuro

Cognitive & behavioral concerns:

↓ attention, memory, executive function

Language & learning delays

Effects may become more apparent at school age

Nursing management for Cocaine and Methamphetamine

cluster care

Minimize stimulation (dim lights, quiet environment)

Swaddling + positioning (helps with irritability)

Monitor: Feeding tolerance, Weight gain, Neuro status

Support caregiver bonding

Avoid breastfeeding if active cocaine use

Provide substance use education & resources

Neonatal Abstinence Syndrome (NAS)

A term used to describe a set of behaviors exhibited by the infant who was exposed to chemical substances in utero

Importance of maternal screening

Early identification

No PNC a red flag- will get urine test from mom and if refused, urine test on baby/ meconium

Nursing care for NAS

Neonatal Behavioral Assessment Scale (NBAS)

Feeding ad lib

Swaddling, holding, reducing stimuli

Individualized developmental care

Hemolytic Disorders

occurs when blood groups of mother and newborn are different - blood incompatibility

Rh incompatibility

ABO incompatibility- Rhogam is given at 28 wks

Other hemolytic disorders

Rh Incompatibility

Only Rh-positive offspring of Rh-negative mother is at risk

If fetus is Rh positive and mother Rh negative, mother forms antibodies against fetal blood cells

ABO Incompatibility

Occurs if fetal blood type is A, B, or AB, and maternal type is O

Incompatibility arises because naturally occurring anti-A and anti-B antibodies are transferred across placenta to fetus

Exchange transfusions required occasionally

Other Hemolytic Disorders

Other metabolic and inherited conditions that increase hemolysis and may cause jaundice in infant

Direct Coombs Test (DAT)

Taken from cord blood or newborn

This will determine if the maternal antibodies are attached to the red blood cells

used for autoimmune hemolytic anemia, disease of newborn, or transfusion reaction

Indirect Coombs Test (IAT)

take from the pregnant person as the “antibody screen” when determining blood type

This will determine if the person might have dangerous antibodies that could affect fetus

and is necessary to know if a blood transfusion is necessary

used for pre-transfusion

Prevention and Treatment of Hemolytic Disorders

Administration of RhIG, human gamma globulin

Intrauterine transfusions

Exchange transfusions

Treatment of jaundice

Infants of Diabetic Mothers

increases risk for fetal and neonatal complications contributes to perinatal mortality

Characteristic Appearance of Infants of Diabetic Mothers

Macrosomia- due to the increase of insulin

Increased risk for birth injuries

Increase in congenital anomalies

Fetal Effect on Infants of Diabetic Mothers

Respiratory distress syndrome (RDS)

Prematurity

Hypoglycemia, hypocalcemia, hypomagnesemia

Cardiomyopathy

Hyperbilirubinemia, polycythemia

Nursing responsibilities for Infants of Diabetic Mothers

Early identification

Follow-up with complications

Monitoring blood glucose levels

Ensuring early and adequate feeding

Supporting parents

Congenital Anomalies

Reported to occur in 6% of births worldwide - WHO

Rate is higher in fetuses that are aborted

Leading cause of death in infants under one year of age

Major Congenital Anomalies

Congenital heart disease

Abdominal wall defects

Neural tube defects

Cleft lip or palate

Clubfoot

Developmental dysplasia of the hip (DDH)

Neural Tube Defects

Failure of neural tube closure (early pregnancy)

associated w/folic acid deficiency

Examples of Neural Tube Defects

Spina bifida occulta (mild, often asymptomatic)

Meningocele (meninges protrude)

Myelomeningocele (spinal cord + meninges protrude → most severe)

Abd Wall Defects: Omphalocele

Organs protrude into umbilical cord

Covered by a membrane

Abd Wall Defects: Gastroschisis

Organs protrude outside abdomen

No protective membrane → higher infection risk

cover using sterile plastic to avoid air drying it out

Abd Wall Defects: Diaphragmatic Hernia

Abdominal organs herniate into chest cavity

Causes lung compression → respiratory distress at birth

Congenital Heart Defects

Most common congenital anomaly

Examples: Tetralogy of Fallot, Atrial septal defect, Ventricular septal defect, Aortic coarctation

Can lead to cyanosis, heart failure, poor feeding

Cleft Lip/Palate

Failure of facial structures to fuse

Impacts feeding, speech, airway

Clubfoot

Foot turned inward/downward

Requires early intervention (casting/surgery)

Nursing Care for Congenital Anomalies

Collaborative approach to care

Surgical intervention may be necessary

Morbidity and mortality is higher in infants than older children or adults

Highly skilled health care team

Referral to appropriate agencies, i.e., March of Dimes

Necrotizing Entercolitis

Acute inflammatory disease of the bowel

Damage to mucosal lining of bowel wall with diminished blood supply to the cells

can cause tissue death

breast milk can be used to prevent

Bronchopulmonary Dysplasia

immature alveoli/resp tract or alveolar damage from lung disease or prolonged exposure to mechanical ventilation

blend O2 and titrate it down

Intraventricular and Periventricular Hemorrhage

bleeding in the brain

can occur because of labor

vitamin K can prevent this

Retinopathy of Prematurity

can also occur due to too much O2

Severe vascular constriction with hypoxemia

Preterm Infants

Organ systems are immature and lack adequate physiologic reserves to function in extrauterine environment

Potential problems and needs of preterm infant weighing 2000 g differ from those of term, postterm, or postmature infant of equal weight

Varying opinions exist about practical and ethical dimensions of resuscitation of extremely low–birth-weight infants, 1000 g

Specific Problems of Infants That are born prematurely

Breathing problems.

Feeding difficulties.

Cerebral Palsy.

Developmental delay.

Vision problems.

Hearing impairment

Late Preterm Infants

Born between 34 weeks and 36 weeks and 6 days of gestation

Referred to as late preterm rather than near term

High Risk Problems of late Preterm Infants

Respiratory function: Surfactant

Thermoregulation

Hypoglycemia

Hyperbilirubinemia

Feeding problems

Neurodevelopmental problems

Infection/sepsis

Meconium Aspiration Syndrome

Appears in 10% to 15% of all births

Primarily in term and post term births probably

due to mature gut

Persistent Pulmonary Hypertension of the Newborn

failure of the normal circulatory transition that occurs after birth.

Combined findings of pulmonary hypertension, right-to-left shunting, and a structurally normal heart

Postterm Infants

Born after 42 weeks of gestation

Postterm or postmature regardless of birth weight

Significant increase in fetal and neonatal mortality compared to those born at term

chances of stillbirth increases

may not fit through pubic opening

Dysmaturity syndrome

progressive placental dysfunction

happens in postterm infants

can start calcification and cut off nutrition supply

Intrauterine Growth Restriction (IUGR)

occurs when the fetus does not reach its expected growth potential

symmetrical and asymmetrical

Symmetrical IUGR

Head and body are proportionately small

Growth restriction begins early in pregnancy

Usually due to intrinsic fetal factors

Common causes: chromosomal abnormalities, congenital infections, maternal substance use, severe malnutrition

Asymmetrical IUGR

Head size is relatively preserved compared with body

“Head-sparing” pattern- head is bigger than body

Growth restriction usually occurs later in pregnancy

Often caused by uteroplacental insufficiency

Common causes: maternal hypertension, preeclampsia, placental insufficiency, chronic hypoxia

safer because head is developed and body can later catch up