maternity chapter 17: complications of newborn

perterm neonates - most important predictors of an infants health and survival are:

• period of gestation

• birth weight

what are the leading causes of infant death in the U.S. AFTER congenital malformations

• prematurity

• LBW

nonmodifiable risk factors for preterm labor and birth

• previous PTB

• mult. gest.

• uterine or cervical anomaly

• race or ethnic group

• pregnancy induced HTN

• short interval btwn. pregnancies

• Premature ROM

• Bleeding in thr second or third trimester

• Family history of premature birth

modifiable risk factors for PTL/PTB

• age pregnancy at <17 or >35 yo

• unplanned preg.

• low socioeconomic status or poverty

• low education level

• domestiv ciolence, unsafe environment

• life stress

• IVF and pregnancy after IVF

• low prepregnancy weight or obesity

• health problems that can be treated: HTN, diabetes, clotting problems, anemia

• STI or other infections along GU tract

• substance or alcohol use

• cig smoking or second hand smoke

• long hours of work or standing

• late or no prenatal care

• airpollution or exposure to other toxins such as lead or paint

ballard gest. age assessment and tool

figures 15-5 and 15-7 in Durham XD

what is the brazelton neonatal behavioral assessment scale

• evaluates the neonates responses to the environment

what is the neuromuscular assessment of gest. age on ballard score

• posture

• square window

• arm recoil

• popliteal angle

• scarf sign

• heel to ear

Posture: ballard score, in preterm infant

• have immature flexor muscles, floppy

Posture: ballard score, in full term infant

• hold their arms close to the body with elbows sharply flexed

ballard score: square window test on pre term infant

ballard score: square window test on fullterm infant

arm recoil on baby : ballard score

popliteal angle on preterm baby

popliteal angle on term baby

scarf sign in term baby

scarf sign in preterm baby

heel to ear in term baby

heel to ear in preterm baby

physical characteristics in ballard score assessment

• skin

• lanugo

• plantar surface

• breasts

• eyes and ears

• genitals

skin in preterm baby

• transluscent because it is thin and has little sq fat beneath surface. skin is red, sticky, fragile, veins visible

skin in term baby

• thicker, color is paler, few veins visible, vernix only present in creases

• peeling, cracking of skin - check out ankles and feet

skin in post term baby

• deep cracked skin and dry and thick as leather

lanugo in preterm baby

• increases in amount until 28 wks

• mostly shed by 32-36 weeks

lanugo in term baby

• may still seen in upper bacl, shoulders, ears, sides of forhead

lanugo in post term baby

• usually no lanugo

plantar surface in preterm baby

few creases seen across the entire foot

pantar surface of postterm baby

deep creases

breasts with preterm baby

• nipples, areola, and size of breast buds are not visible

breast with term baby

• breast buds may enlarge until they are ~1 cm at term

ears and eyes in preterm baby

ears and eyes in term baby

female genitals in preterm baby

labia majora doesnt rly cover minora and clitoris at all

female genitals in term baby

labia majora cover minora and clitoris compleltely

male genitals in term baby

• pendulous scrotum with deep rugae

male genitals in preterm baby

• testes may not be descended and rugae are few

gestational age and infant size

• small for gest age: below 10th percentile

• large for gestaional age: above 90th percentile

• appropriate for gest. age: btwn 10th and 90th percentile

  • monitor for complications common to age and size of infant

behavioral changes: orientation

• ability to pay attentuon to interesting visual or auditory stimuli

behavioral changes: habituation

• infants response to bisual, auditory, or tactile stimulation

  • infants typically habituae to unpleasant stimuli such as bright lights

behavioral changes: self consoling activities

• normal newborns are able to self console

• bringing hands to mouth, sucking on dists, listening to voices, watch objects in environment

• preterm infants, il, exposed to drugs prenatally are less likely to self console

behavioral changes: parents response

• nurse should note parents response to infants behavior and facilitate attachment and bonding

deep sleep

• no body movement except an oaccasional startle reflex

• external stimuli are less likely to awaken the infant

• no eye movements occur

light sleep

• makes up the largest portion of sleep

• neonate may easily startle, may smile or make brief fussy sounds

• have random body movemnts and display rapid eye movement (REM)

• neonate will be much easier to wake up than while in deep sleep

drowsy

• intermitten body movement occurs

• eyes open and close and have a dul, heavy-lidded appearance

• external stimuli will most likely wake the noenate

quiet alert

• neonates eyes are wide open with a bright look

• infant is relaxed and most attentive to environment and caregivers present

• providing visual or other pleasurable stimuli often can maintain this state

active alert

• there is a considerable body movement with periods of fussiness or irritability

• neonate response to disturbing stimuli (such as excessive noise or activity, cold, fatigue, or hunger) with incr. motor activity and fussiness

• consoling or correcting interventions may settle the infant back to a quiet alert state

crying state

• there is a high motor activity and the noenate is difficult to calm

• eyes are opened or tightly closed and there is an extreme response to unpleasant stimuli

• crying is the noenates communication signal that limits have been reached

• self consoling can occur, whereas other times the caregiver will need to intervene

neutral thermal environment

• premature neonates are unable to protect themselves against fluctuations in environmental temp because of thin, immature skin and limitef stores of subcutaneous brown fat

• nurses must implement interventions to maintain a neutral thermal environment (NTE) and prevent cold stress

nursing actions of neutral thermal environemnt

• dry infant immediately after birth

• place plastic barriers made of polythylene over preterm neonates (less than 32 wks gestation) after birth to prevent heat loss

• use of a chemical warming mattress

• prewarm all supplies and equipment

• control environmental temperature with use of the servo control setting on transpor equipment, radiant warmers, and incubators

what is respiratory distress syndrome (RDS)

• life threatening lung disorder that results from small, underdeveloped alveoli and insufficient levels of pulmonary surfactant > cause an alteration in elveoli surface tension that eventually results in atelectasis

• Incidences of RDS are inversely related to gestational age and birth weight, affecting 51% of neonates bron weighing less than 1000 g

complications of RDS

• patent ductus arteriosus

• pneumothorax

• bronchopulmonary dysplasia

• pulm. edema

• hypotension

• anemia

• oliguria

• hypoglycemia and altered calcium and sodium levels

• retinopathy of prematurity

• seizures

• intraventricular hemorrhage

assessment findings of RDS

• RDS varies based on degree of prematurity

• resp. difficulty begins immediately or within a few hours after the deluvery

• tachypnea

• retractions

• audible expiratory grunting

• nasal flaring

• skin color is gray or dusky

• breath sounds are decr. and + crackles

• tachycardia

nursing actions for RDS

• provide resp. support

  • maintain patent airway

  • if noenate is intrubated, assess for correct placement of endotracheal tube

    • listen for equal breath sounds

  • admin O2 as per order

• Minimize O2 demand by maintaining a neural thermal environment and decr. risk of cold stress

• Monitor I&Os

what are postmarture neonates

• neonates born >=42 wks of GA

  • can result in an LGA or SGA infant

  • LGA - unknown reason

  • SGA - placenta is no longer functioning optimally and fetus is forced to use its SQ fat and glycogen stores

risk factors for post mature neonates

• anencephaly

• history of post term pregnancies

• first pregnancy

• grand multiparous women

complciations of postmature neonates

• meconium aspiration

• fetal hypoxia r/t placental insufficiency

• neurological complications seizures r/t fetal hypoxia

• hypoglycemia r/t decr. glycogen stores

• hypothermia r/t loss of SQ fat

• polycythemia r/t compensatory response caused by altered oxygenation

assessment findings of postmature neonates

• dry, peeling, cracked skin

• lack of vernix

• profuse hair

• long fingernails

• thin, wasted appearance

• meconium staining (green or yellow staining on skin, nail beds, or umbilical cord)

• hypoglycemia

• poor feeding behavior

nursing actions of post mature neonates

• assess the prenatal record and intrapartum history including APgard scores for risk factors

• Assess the noenate for:

  • GA with use of gestational age scoring system

  • Respiratory distress

  • Cyanosis

  • O2 sat if resp. distress or cyanosis is present

  • signs of meconium staiing

  • Blood glucose levels

  • Vitals

  • weight

  • gross anomalies

• Monitor for hypoglycemia

  • Jitteriness, irritability, poor feeding, apnea, grunting, lethargy

• Provide early and frew. feedings if resp. status is stable

  • early and frew. feeding reduce the risk of hypoglycemia

• Monitor I&Os

  • Postterm infants may be poor feeders and thus at risk for inadequate fluid intake

what is meconium aspiration syndrome

• is a cause of repsiratory failure in term and post term neonates

assessment findings of meconium aspiration

• meconium stained AF

• greenish or yellowish discoloration of skin, nails, umb. cord

• Resp. depression

• Low APGAR scores

• Signs of resp. distress

• Chest may appear barrel shaped

• Atelectasis

nursing actions of meconium aspiration

• assist with suctioning and resuscitation at the time of delivery

• assess neonate for:

  • Resp. distress such as grunting, flaring, retracting, cyanosis, and tachypnea

  • Complications of MAS, such as acidosis, hypoglycemia, hypocalcemia, pneumonia, pneumothorax, BPD, and persistent pulmonary hypertension

  • Neurological problems secondary to asphyxia

• admin O2 or assisted ventilation as per order

• monitor blood glucose

  • Complication of resp. distress is an incr. metabolic rate and thus a higher incidence of hypoglycemia

• manage neonates receiving cooling, iNO, or ECMO

hyperbilirubinemia

• neonatal jaundice is the yellow orange tint that can visualized in the sclear and skins of neonates with hyperubinemia (incr. bilirubin in the blood)

hyperbilirubinemia is categorized into 2:

• physiological jaundice

• pathological jaundice

unconjugated (also called indirect) + conjugated (Direct) =

total serum bilirubin (TSB)

unbound (unconjugated) bilirubin

• can deposit into tissue and cross the blood brain barrier

  • it cannot be excreted and can settle in tissues, causing jaundice

  • kernicterus: accumulation in baby’s brain = brain damage

conjugated bilirubin

• is bound to albumin and once bound is water soluble

  • it is nontoxic and can be exceted through the GI tract

serum bilirubin

• cannot be excreted until it is conjugated

physiological jaundice

• hysiological jaundice results from hyperbilirubinemia that commonly occurs after the first 24 hours of birth and during the first week of life

• it is caused by the breakdown of RBCs (hemolysis)

phys. jaundice: incr. risk for hemolysis is due to:

• neonates reabsorb incr. amounts of unconjugated bilirubin in the intestine due to lack of intestinal bacteria,d ecr. GI motility, and incr. beta-gluuronidase ( a deconjugating enzyme)

• diminished cnjugation of biirubin in the liver

• higher RBC mass relative to body weight than adults

• shorter RBC life span of 70-90 days, compared with 120 days in adults

• high bilirubin production

assessment findings of physiological jaundice

• phys. jaundice is typically visible after 24 hours of life

• TSB levels generally peak on day 3 of life in term neonates and on days 5-6 in preterm neonates

• jaundice is characterized by a yellowish tint to the skin and sclera of the eyes

• As TSB levels rise, jaundice will progress from the newborns head down toward the trunk and lower extremities

what is pathologic jaundice

• results when various disorders exacerbate physiological processes that lead to hyperbilirubinemia of the newborn

  • such disorders can result in pathological unconjugated or conjugated hyperbilirubinemia

  • because conjugated hyperbilirubinemia is always pathological, further investigation must be done to determine its cause

pathologic jaundice: common cause of conjugated hyperbilirubinemia include -

• parenteral nutrition (most common cause in the NICU, especially in preterm infants)

• idiopathic neonatal hepatitis

• biliary atresia

• bile duct stenosis

• metabolic and genetic defects

• endocrine disorders

• infection

• some medications

• shock

pathologic jaundice: common cause of unconjugated hyperbilirubinemia include -

• breastfeeding jaundice (early onset)

• breast milk jaundice (late onset)

• Rh and ABO incompatibilities

• Glucose-6-Phosphate dehydrogenase (G6PD) deficiency

• Hemoglobinopathies

• Blood sequestration (bruising, cephalohematoma, intracranial bleeding)

• polycythemia

• metabolic and endocrine disorders

• GI obstruction

• infection

pathologic jaundice assessment findings

• criteria to differentiate pathological jaundice from phsyiological jaundice in a full term neonate:

  • Jaundice that occurs within the first 24 hours of life

  • TSB levels that incr. > 0.2 mg/dL per hour

  • jaundice lasting >2 weeks

  • TSB exceeding rhe 95th percentile for age in hours

  • A high direct bilirubin (1.5-2 mg/dL)

• Risk factors, med management, and nursing actions are similar for both physiological and pathological jaundice

maternal risk factors - pathologic jaundice

• american indian, east asian, or mediterranean descent

• ABO incompatbility (e.x. the mother has blood type O and neonate has blood type A or B)

• Rh incompatibility (mother is Rh neg and the neonate is Rh positive)

• Breastfeeding

• Diabetes

• Use of oxytocin or bupivacaine during labor

neonatal factors - pathologic jaundice

• delayed cord clamping, which incr. RBC volume

• Hypoxia, asphyxia, acidosis, and temperature instability

• delayed or infrequent feedings, or lethargy

• excessive weight loss after birth

• bruising or cephalohematoma

• Prematurity

• G6PD deficiency

• bacterial or viral infection

care of neonate receiving phototherapy

• assess degree of jaundice with use of transcutaneous meter per unit policy

• visually assess degree of jaundice by using a finger to blanch the neonates skin on the face, upper trunk, abdomen, thigh, and lower leg and feet. the skin will appear yellow after the pressyre is released and before skin returns to normal color

• document the assessment findings

  • how rapidly the degree of jaundice progresses guides the method of treatment

• Implement phototherapy as ordered

  • intensive phototherapy lights should be positioned 12-16 inches from the infant and 2 inches fom the top of an incubator

  • a photometer should be used to measure irradiance of lamps to facilitate optimal treatment

  • vitals including temp monitoring should be done per agency protocol

  • monitor I&Os, phototherapy results in incr. insensible fluid loss

assess side fx of phototherapy

• observe eyes for discharge and tearing

• animal studies have indicated that retinal damage may occur so opaqye eye shields must be used to prevent potential eye damage

• assess position of eye shield to ensure it does not occlude nares

• loose stools

• dehydration

• hyperthermia

• lethargy

• skin rashes

what is group b strep

• primary cause of neonatal meningitis and sepsis in the U.S.

assessment for GBS

• anterpartum screning: rectovaginal swab at 36 0/7 to 37 6/7 weeks of gestation

• If positive, need intrapartum antibiotic prophylaxis

• no abx needed if a pt has a scheduled c-sec is perfomred in the setting of intact membrances

• infants with early onset GBS sepsis become symptomatic by 12-24 hours of age