Unit 4: Newborn

neonatal period

• from birth to day 28 of life

newborn physiologic taksks to extrauterine life involve

• establishing & maintaining respirations

• adjusting to circulatory changes

• regulating temp

• ingesting, retaining and digesting nutrients

• eliminating waste

• regulating weight

• establishing & maintaining respirations

• # 1 priority

• bag and mask respirations if needed or mouth to mouth (over mouth and nose)

• babies usually will never need compressions

adjusting to circulatory changes

• ductus venous, foramen ovale, and ducts arteriosus close after birth

• may stay open for 24 hours & heard as a murmur - normal

• unless accompanied by other s/s (poor feeding, aepnic periods over 20 seconds, cyanosis , pallor)

regulating temp

• #2 priority after breathing

• a cold baby has low sugar - causes issues with the brain

• naked under radiant warmer OR skin to skin with mom if he’s healthy (with hat & blanket)

eliminating waste

• babies need to void and stool at least once in 24 hours after birth (may not happen if baby is nit eating well)

• After day 4, six to eight voidings per day of pale straw-colored urine indicate adequate fluid intake.

regulating weight

• babies will lose up to 10% of weight in the first 3 days, should return in 10-14 days

• assess if he’s eating well

• weigh babies the at the same time, same way each time according to policy (naked or just diaper)

• blanket on the scale to avoid heat loss

newborn behavioral tasks to adjust to extrauterine life

• establishing a regulated behavioral tempo independent of mom, involving regulations self arousal, self monitoring changes in state and patterning sleep

• processing,storing and organizing multiple stimuli

• establishing relationships with caregiver/ environment

predictable series of events 6-8 hours after birth

• involve sympathetic NS

• changes in HR, Respirations, temp, GI function

• baby is very vulnerable - watch closely!

first period of reactivity

• how long?

• HR, RR LOC of baby?

• Bowel sounds? movement?

• lasts for 30 minutes after birth

• 1st stage of transition

• baby is awake - great time for feeding if baby can go straight to mom

• HR - increases to 160-180 bpm but will gradually decrease

• RR - may be irregular, can be as high as 60-80

• Bowel sounds can be heard, may pass meconium

• can have startle tremors, movement , good tone

if we hear abnormal lung sounds/ see abnormal breathing in the first period of reactivity?

• fine crackles, audible grunts

• nasal flaring, retractions

• give him time to resolve (about 1 hr), baby is still expelling fluid but watch closely

• get him to cry - expels fluid and opens lung

how do we elicit cries

• dry him off after birth for heat conservation - it bothers him

• back rub

• flick feet

• wash face with warm water

period of decreased responsiveness

• LOC? RR? Bowel sounds/?

• 60 -100 minutes

• very sleepy

• marked decrease in motor activity

• skin should stay pink

• RR - rapid, up to 60, shallow and unlabored

• Bowel sound present

2nd period of reactivity

• 2-8 hours post birth

• can last from 10 minutes to many hours

• common to pass mec

• improved skin color

• mucous production

• increased muscle tine

• very preterm - will not have this stage

once baby is out

• cut cord in between 2 clamps to avoid bleeding, cause rise in BP & lung perfusion

• most important is establishing effective respirations

• prxtermers may have difficulty

chemical factors of breathing initiation

• it is thought that from cutting the cord, prostoglandins drop

• helps with the initiation of breathing

mechanical factors of breathing initiation

• pressure of baby coming out vaginal Canal expels fluid out of the lungs

• crying opens alveoli

thermal factors of breathing initiation

• colder outside the uterus

• stimulates breathing

sensory factors of breathing initiation

• suctioning with bulb syringe right when head is out

• suction mouth before nose (1 side of mouth, then each nostril)

• dry baby off to get all the fluid off and to warm him

• environment around him stimulates baby

if fluid is retained

• interferes with baby’s ability to maintain respiration & oxygen

• transient tachypnea

• if baby has aspirated on meconium in utero, it will affect his breathing

• transient tachypnea

• respiratory distress up to 2 hrs post brith,

• may go up to 100bpm

• goes to NICU

• will need supplemental O₂

• will resolve on 48-27 hrs

Normal respirations

• shallow

• 30-60 normal range (but may go up if he’s crying a lot)

• may have aepnic periods up to 20 seconds - anything longer abnormal

s/s of respiratory distress

• nasal flaring

• intercostal or subcostal retractions

• grunting

what can case abnormal apnea

• hyper or hypothermia

• hypoglycemia

• sepsis - babies will usually present with a low temp if septic

tachypnea

• comes form inadequate clearing of fluid

• may be first sign of illness

• can be result if respiratory distress syndrome (generally in premature babies or babies of diabetic moms, bc of lack of surfactant)

acrocyanosis

• normal finding in the first 24 hours

• blue on hands and feet

central cyanosis

• blueness of lips, mucous membranes (circumoral)

• abnormal

• significant hypoxia

• late sign of distress, inadequate oxygenation, poor tissue perfusion, cardiac dysfunction

signs of respiratory distress

• nasal flaring , retractions, grunting

• RR under 30 or over 60 - needs evaluation!

• apnea

• hyper or hypothermia

• hypoglycemia

• sepsis

• tachypnea

• color changes

cardiovascular system adaptations

• CO duoubles

• blood flow increases to lungs , kidney , heart , GI

• pulmonary artery pressure drops

• normal HR 120-160, can drop if baby is sleeping, can go up if baby is crying

• umbilical cord becomes ligament

foramen ovale closure

• increase in pulmonary blood flow from the left slide of the lungs to close foramen ovale

• crying - can reverse the closure of the Forman ovale

ductus arteriosus closure

• functionally closes within 24 hours

• permanently closes within 2-3 months, turns into a ligament

• may reopen if O₂ levels are low as a protective measure - detected as murmur

pallor can indicate

• anemia or bleeding

jaundice

• can either be from hyperbillirubinemia

• tx: phototherapy

• may also be from Rh factor or ABO incompatibility with mom

delayed cord clamping

• delayed cord clamping (3min) increases blood volume and clamping

• also decreases risk of intro ventricular hemorrhage

• decreases risk of necrotizing enterocolitis

• both preemie problems

• ma cause hyperbillirubinemia

increase in blood volume

• can happen from delayed cord clamping

• can cause polycythemia - high RBC and H&H

Thermogenic system

• #2 most important after respiratory

• thermoregulation: the

convection

• the flow of heat from the body surface to cooler ambient air

• babies need to swaddled in crib and with hat to prevent heat loss by convection

• keep babies away from windows and open doors

radiation

• loss of heat from the body surface to a cooler solid surface not in direct contact but in relative proximity.

• keep babies away from windows and open doors to prevent heat loss by radiation

Evaporation

• the loss of heat that occurs when a liquid is converted to a vapor

• keep babies dry! sponge baths in sections & dry after birth with clean, dry linens each time

conduction

• the loss of heat from the body surface to cooler surfaces in direct contact

• scale, circumsicion restraint board, cold hands , cold stethoscopes

• pre warm the radiant warmer

• blanket on the scale

skin to skin reduces which heat loss

conduction and radiation

thermogenesis

• baby trying to produce their own heat - non shivering

• uses stores of brown fat - less in preterm babies

hypothermia and cold stress effects

• vessels vasoconstrict

• makes extremities cool

• imposes physiologic and respiratory demands

• RR increases

• O₂ and energy diverted away form normal brain and cardiac function

• hypoglycemia

hyperthermia

• temp of 99.5 or more

• caused by too hot of a warmer, or swaddled in the warmer

• can cause neurologic issues, seizures, death from heat stroke

an infant who has not voided by 24 hours should be assessed for

• adequacy if fluid intake

• bladder distention

• restlessness / s/s of discomfort

renal problmems

• s/s: lack of steady stream , can indicate:

• hypospadias - the urethral opening forms on the underside of the penis rather than the tip

• epispadias - the urethral opening forms on the upper side of the penis rather than the tip, or between clitoris and labia in girls

feeding behavior is related to

• gestational age

• neuromuscular maturity

• maternal medications

• type of initial feeding

Meconium

• First stool: composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood (ingested maternal blood or minor bleeding of alimentary tract vessels).

• Dark, olive green in color; viscous and sticky (like tar), almost odorless.

• Passage of meconium should occur within the first 24–48 h, although it can be delayed up to 7 days in very low-birth–weight infants.

• Passage of meconium can occur in utero and can be a sign of fetal distress

back stools after meconium has passed

• sign of upper GI bleed - not good

• red blood - lower GI blood

Transitional Stools

• Usually appear by third day after initiation of feeding.

• Greenish brown to yellowish brown; thin and less sticky than meconium; can contain some milk curds

Milk Stool

• Usually appears by the fourth day.

• Breastmilk: yellow to golden, pasty in consistency; resemble a mixture of mustard and cottage cheese, with an odor similar to sour milk.

• Commercial infant formula: stools pale yellow to light brown, firmer consistency, stronger odor than breast milk stools.

GI problems

• non-patent anus

• stool coming from anywhere but the rectum can indicate fistula

risks for hyperbillirubinemia

• Preterm

• Breastfeeding: especially if exclusively breastfeeding and weight loss is excessive

• Rh or ABO incompatibility or other known hemolytic disease (e.g., G6PD deficiency)

• Polycythemia

• Asian or Native American race

• Bruising related to birth trauma

• Previous sibling who received phototherapy for hyperbillirubinemia

Vitamin K

• 1 IM shot @ birth for coag synthesis

• do no develop for 9 months

• all newborns at risk for bleeding until coags have developed

• all circumcised babies - at risk for bleeding

Immune system

• immune response is decreased @ birth & immunoglobulins are low

• makes babies succeptible to pathogens

• breastmilk - passes immnunoglobuin A

s/s of infection in newborns

• temp instability - usually hypothermic

• lethargy

• irritability

• poor feeder

• vomiting (not spit up)

• diarrhea (not normal soft stools)

• decreased reflexes

• pallor / mottled skin (red and patchy)

• discharge from eyes , nose, mouth

• some rashes

• dyspnea if respiratory infection

desquamation

• skin peeling

• leave the vernix to protect skin

milia

• Distended, small, white sebaceous (sweat) glands noticeable on the newborn face

• babies do not sweat for 24 hours

slate gray nevi

• aka mongolian spot

• blue/black area - not a bruise

• more common on dark skin

• may takes months or years to fade

• usually seen on buttocks area but can be seen on arms and legs

nevi simplex

• seen in 80% of newborns

• superficial capillary defect

• aka stork bite

• usually small, flat, and pink and are easily blanch-able

• common sites are the upper eyelids, nose, upper lip, and nape of the neck.

nevus flammeus

• aka port wine stain

• doesn't blanch

• darkens over time - purple color

Infantile hemangiomas

• newly formed capillaries that are dilated

• come from dermal and subdermal layers

• may be present at birth or come after

• raised red bumps, rough to touch

• goes away in 5-10 years

Erythema toxicum

• transient newborn rash - comes and goes and moves around the body

• appears in term neonates during the first 24 to 72 hours after birth and can last until up to 3 weeks of age.

• no need to Treat

s/s of integumentary problems

• pallor

• petechia - not significant in first 24 hours

• cyanosis

• birth injuries

female reproductive system

• genitalia usually edematous

• vaginal tags common

• leave vernix between the labia if any to not aggravate

• stool - remove with warm washcloth

male reproductive system

• foreskin should completely cover glans penis

• urethra should be @ tip (abnormal - hypospadias or epiespadas)

• if he has hypospadias, he will not be circumcised in the hospital (needs to be repaired and the foreskin is used in that)

• palpate testes to make sure they are descended

• asses for rugae - lines on scrotum sac

Hydrocele

• caused by an accumulation of fluid around the testes, can be present.

• Hydroceles can be easily transilluminated with a light (pen light shines through )

• usually resolve without treatment

how do moms hormones affect baby

• both boy and girls may have swelling int he breast tissue from moms hormones

• may cause psuedomenses in girls - not a period

ambiguous genitalia

• cannot tell if the baby is male or female

• usually needs continuing care past postpartum stay

• may get surgery in the future

Caput succedaneum

• considered birth injury

• generalized edematous area of scalp

• most often on occiput

• extends across suture line

• resolves in 3-4 days

Cephalhematoma

• considered birth injury

• collection of blood between skull and periosteum

• does not cross suture line

• resolves in 2-8 weeks

• raises risk for hyperbillurubinemia (hemolysis of RBCs)

Subgaleal hemorrhage

• bleeding into subgaleal compartment

• associated with difficult operative births (vaccum)

• scalp is pulled away from bone, vessels torn and blood collects

• blood loss can be severe → hypovolemic shock

• may result in Disseminated intravascular coagulation (DIC) - severe bleeding, life threatening

• early detection is vital - continue to measure head circumference

• feels boggy to touch

• tachycardia, pallor, increase bilirubin level, may need transfusion of blood or clotting factors

spine

• straight, symmetrical and easily flexible

• no opening or pilonidal dimple - checking for spina bifida

polydactyl and oligodactlyl

• polydactyl - more than 10 finger

• oligodactyl - less than 10 fingers

hip dysplasia s/s

• instability or dislocation of the hip joint caused by a shallow socket

• asymmetric gluteal and thing fold

• uneven knees

neuromuscular system

• almost completely developed @ birth

• brain requires glucose to grow rapidly

• sutures allow for that growth

• tremors can be normal

• jitteriness of upper extremities - hypoglycemia

what would cause hypoglycemia

• not eating

• cold

• stress

• illness

• baby of a diabetic mom

rooting

• do it before feedings, bc they won’t if they are not hungry

sleep-wake states

• Variations in the state of consciousness of infants

• The six states form a continuum from deep sleep to extreme irritability

• the ability to make smooth transitions between states is called state modulation

habituation

• ability to respond to and then inhibit responding to discrete stimulus (e.g., light, rattle, bell, pinprick) while asleep

• baby wakes up less and less to the same stimuli bc he has processes that information

Orientation

quality of alert states and ability to attend to visual and auditory stimuli while alert

Motor performance

quality of movement and tone

Range of state

measure of general arousal level or arousability of infant

Regulation of state

how infant responds when aroused

Autonomic stability

signs of stress (e.g., tremors, startles, skin color) related to homeostatic (self-regulator) adjustment of the nervous system

immediate care after birth

• respirations - only 10% of babies need extra help (O₂ usually )

• warmth - skin to skin with hat & blanket

Apgar scores include

• heart rate

• respiratory rate

• muscle tone

• reflex irritatabiltiy

• generalized skin color

• made @ 1 minute and at 5 minutes

• sometimes @ 10 minutes

most babies will not get a full 10 because ?

• they lose points due to skin color

a baby will no go to the warmer if

• it is a preterm baby

• has poor muscle tone

• baby is not breathing

how can you asses the heart rate

• stethoscope

• palpating umbilical cord

baby with Apgar score 7-10

baby has no difficulty transitioning

baby with Apgar score 4-6

• baby is having moderate difficulty transitioning

baby with Apgar score 0-3

severe difficulty transitioning

newborn vitals usually include

• temp, hr and respirations

• usually not a BP or SpO2