NCM 109 (Unit 4): Nursing Care of the High-Risk Newborn

Maternal and Child Health Nursing

Priorities in the first days of life

• initiation and maintenance of respirations

• establishment of extrauterine circulation

• maintenance of fluid and electrolyte imbalance

• control of body temperature

• intake of adequate nourishment

• establishments of waste elimination

• control of body temperature intake

• prevention of infection

• establishment of an infant-parent relationship

• institution of developmental care

Fetal death

Occurs during the first 48 hrs after birth resulting from the newborn's inability to establish or maintain adequate respirations

Reasons infants could not initiate respirations or asphyxia

• cord compression

• placenta previa

• preterm separation

• maternal anesthesia

Closed-chest massage

Emergency procedure done to a newborn that has no audible heartbeat or if the cardiac rate is below 80 bpm

Hypoglycemia

Occurs after an initial resuscitation attempt which may result from the effort exerted by the baby in an attempt to breathe

Dehydration

May result from increased insensible water loss from rapid respirations

10% dextrose in water

Medication used to restore infant's blood glucose level from hypoglycemia

Ringer’s lactate or 5% dextrose in water

Medications commonly used to maintain fluid and electrolyte levels

Neutral temperature environment

Ideal environment to provide appropriate thermoregulation to newborns; one that is neither too hot nor too cold

Necrotizing enterocolitis

Inflammation of the intestines; results to a temporary reduction on oxygen to the bowel

Danger signs of newborn distress

• difficult respiration

• tachypnea

• lethargy/ failure to suck

• cyanosis

• excessive mucus/ drooling

• sac or dimpling at the lower back over the lumbar region

• absent or sluggish Moro reflex

• twitching, seizure or tremors

• bile-stained vomitus

• yellowish discoloration of sclera, skin in the first 24 hrs

• meconium staining if skin and nails

• no passage of meconium in 1-2 days/ meconium from an inappropriate opening

Birth asphyxia

Insult to the fetus or newborn due to lack of oxygen or perfusion to various organs

Two stages of asphyxia

• primary apnea

• secondary apnea

Primary apnea

• rapid breathing at first

• then respiratory movement ceases

• HR begins to fall

• Reduced neuromuscular tone occurs

Rapid breathing

Compensatory mechanism of body when there is decreased oxygen in the system

Management of birth asphyxia

• Tactile stimulation or back rub

• Administration of oxygen

Secondary apnea

• gasping respirations

• HR falls

• BP falls

• Bradycardia

• Baby is unresponsive to stimulation

Positive pressure ventilation

Emergency procedure done to a baby who is unresponsive to stimulation and will not spontaneously resume respirations

S/sx that is indicative of fetal resuscitation

Poor APGAR score:

• Nasal flaring

• Bluish discoloration of the body

• Absence of cry

Fetal resuscitation within 2 mins

• Establish airway

• Expand the lungs

• Initiate and maintain effective ventilation

Establish an airway

Make sure there is no obstruction. Clear off all secretions in the mouth and nose

Expand the lungs

By being successful with establishing a patent airway, we are helping the baby breathe, causing the lungs to expand

Initiate and maintain effective ventilation

If the baby has no effort in breathing, we need to initiate positive pressure ventilation (PPV)

Nursing Management of birth asphyxia

• Stimulate the NB (tactile stimulation)

  • Drying the baby can stimulate them to cry

  • Touching the baby

  • Try to wake them up

• Suction the secretions in the mouth and nose

• Position the newborn in a sniffing position - ideal position in performing intubation

  • Head of the baby is extended and the neck is flexed

• Attach to pulse oximeter to monitor the O2 saturation

• Continue APGAR scoring until there is a good score

• Airway management

  • Set of maneuvers or medical procedures that is performed to prevent and relieve airway obstruction

  • Ensures an open pathway of gas exchange. between the patient’s lungs and the atmosphere

FETAL RESUSCITATION

• In the event that the baby does not respond to any of the stimulation being performed by the doctors or the nurses

Laryngoscope

has a light which serves as a guide and helps the doctor in viewing the part where the endotracheal tube is inserted so that one can establish a patent airway

APGAR SCORE

• Taken at 1 min and 5 min after birth.

• The newborn is observed and rated accdgly

• Take note of heart rate, respiratory effort , muscle tone, reflex irritability and color of the infant.
  

4 to 6 apgar score

the infant's condition is guarded and the baby may need clearing of airway and supplemental oxygen.

less than 4 apgar score

he/she is in serious danger and is in need of resuscitation

Radiant Warmer

a standee which has a probe that is attached to the baby to continuously monitor the baby’s temperature

Isolet or Incubator,

• not always available

• nowadays and is considered as obsolete

• serves as a good thermoregulating machine
  

ALTERED GESTATIONAL AGE

Fetal growth abnormalities

Classification of sizes for gestational age

• SGA

• AGA

• LGA

• IUGR
  

SGA

• small for gestational age;

• weight below 10th percentile
  

AGA

• appropriate for gestational age

• weight between 10 and 90th percentiles (between 5lb, 12oz (2.5kg) and 8lb, 12oz (4kg)
  

LGA

• large for gestational age

• weight above 90th percentile
  

IUGR

• deviation in expected fetal growth pattern

• failure to achieve potential size

• cause by multiple adverse conditions

• not all infants are SGA

preterm infant

• defined as a live born infant born before the end of 37 weeks of gestation

• weight of the baby <2,500 grams; about 5 lbs. & 8 oz.
  

Clinical Manifestations of a Preterm Infant

● Disproportionate Large head

● Ruddy skin

● Large acrocyanosis

● Extensive lanugo

● Few or no creases on soles of feet and palms

Nursing management of preterm infant

• Emergency CS in cases of fetal distress

• Oxygen administration for Pulmonary Edema & Retinopathy of Prematurity

• Monitor intake and output q 2H in absolute figures

• feeding schedules frequent with smaller amounts as these infants has a small stomach capacity as compared to term infants

• Feedings may be 1-2 ml q 2-3 hours
  

Feeding of the baby born lesser than 28 wks

feeding is addressed through IV Fluids

sniffing position

ideal position in performing intubation

Feeding of the baby 28-32 wks.

feeding is done through OGT

feeding of baby 32-34 wks.

feeding is done through cup

feeding of baby 34 wks. & above

breastfeeding as tolerated

Maternal causes of Intrauterine Growth Restriction (IUGR)

• substance abuse

• Diabetes mellitus

• Hypertension

• Exposed to TORCH infections

TORCH

• toxoplasmosis

• other agents (treponema, parvovirus, HIV)

• rubella

• cytomegalovirus

• herpes simplex

Placental causes of Intrauterine Growth Restriction (IUGR)

• Insufficiency in the placenta

• Poor perfusion

difference between IUGR and SGA

➢ IUGR has a pathologic cause

➢ SGA has no pathologic cause

Clinical manifestations of IUGR

• Overall wasted appearance

• Poor skin turgor

• Large head - due to the rest of the body being small

• Skull sutures may be widely separated from lack of normal bone growth

• Dull hair and lusterless

• Sunken abdomen and cord appear dry (may be stained yellow)

• Small liver - cause difficulty in regulating glucose, protein and bilirubin levels after birth

• Polycythemia > hyperbilirubinemia

• Hypoglycemia

Post term infant

• infant born after 42 weeks of pregnancy

Hypoglycemia mgmt for IUGR infants

• intravenous glucose to sustain blood sugar until they are able to suck vigorously enough to take sufficient oral feeding

Prevents post mature birth

Induction of labor at 2-week post term

40 weeks

Maximum weeks of effective functionality of a placenta; beyond that, the placenta will lose its ability to carry nutrients effectively to the fetus

Characteristics of post term syndrome

LGA infant

• birth weight is above 90th percentile in the intrauterine growth chart

• important that infant will be identified immediately so that the infant is given special care appropriate for their gestational age

LGA infants

• macrosomic

• may show immature reflexes and low scores of gestational age examination in relation to their size

Etiology of LGA

• Overproduction of growth hormones in the uterus

  • Often occurs in infants of mothers who have diabetes mellitus and in obese mothers

  • Extreme macrosomia

• Multiparous women

  • Prone to delivering a large baby at every succeeding pregnancy

Complications of LGA

• Cesarean section due to cephalopelvic disproportion

• Shoulder dystocia

• Erb-Duchenne paralysis

• Caput succedaneum

• Molding

• Cephalohematoma

• Rebound hypoglycemia

Caput succedaneum

• appears in LGA infants because of the unusually high pressure at birth causing edema in the loose connective tissue which can extend across a number of sutures

• disappears within 24 hours

Cephalohematoma

• the rupture of blood vessels in the sub periosteal layer (buildup of blood underneath the periosteum)

• Disappears after 2-3 days

Nursing Management for LGA

• Breastfeed the newborn immediately

Respiratory distress syndrome

• Also called Hyaline Disease Membrane

• cause is a low level or absence of Surfactant

• due to structural immaturity of fetal lungs

Surfactant

• Produced normally until the 34th week of gestation

• the phospholipids that normally line the alveoli;

• reduces the surface tension upon expiration and inhalation, which keep the alveoli from collapsing

Functions of Surfactant

➢ Decreases the surface tension.

➢ To promote lung expansion during inspiration.

➢ To prevent alveolar collapse and loss of lung volume at the end of expiration.

➢ Facilitates recruitment of collapsed alveoli.

Term babies

Preterm Babies

Have a storage of pool approx. 4-5 mg/kg surfactant at birth.

Etiology of RDS

● Prematurity

● Meconium aspiration

➢ Due to poor blood perfusion to the lungs

● Pneumonia

S/sx of RDS

● Grunting

• Due to the closure of the glottis, creating a prolonged expiratory time

● Nasal flaring

● Central cyanosis in room air

● Tachypnea

• More than 60 rpm

● Sternal and subcostal retractions

Diagnostic test for RDS

• Chest X-ray

  • Will reveal a diffused pattern of radiopaque areas, that looks like a ground glass or haziness

• Arterial Blood Gas (ABG)

  • Blood studies are taken from an umbilical vessel catheter which will reveal Respiratory Acidosis

Nursing Management for RDS

• Synthetic surfactant is sprayed into the lungs thru endo tube

• attach the baby on a ventilator through an endotracheal tube

• Continuous Positive Airway Pressure (CPAP)/ Assisted Ventilation with Positive & Expiratory Pressure (PEP)

• Extracorporeal membrane oxygenation (ECMO)

MgSO4 or terbutaline

help to prevent preterm birth for a few days because steroids appear to quicken the formation of lecithin

2 injections of bethamethasone

• Med given to mother at the 12th and 24th hours to prevent RDS in infants

• Most effective when given 24-34 weeks of pregnancy.

Meconium aspiration syndrome

An infant that may aspirate meconium either in the uterus or within their first breath after birth, which can cause severe respiratory distress

Meconium

present at the bowel of an infant as early as 10 weeks’ gestation

severe respiratory distress in 3 ways due to MAS

• Causes inflammation of bronchioles because it is a foreign substance.

• It causes blockage of small bronchioles by mechanical plugging.

• It causes decrease in surfactant production through lung cell trauma.

MAS

causes hypoxemia, CO2 Retention, & intrapulmonary and extrapulmonary shunting

S/sx of MAS

• low APGAR score

Mgmt of MAS

• amioinfusion

  • used to dilute the amount of meconium in the amniotic fluid; reduces the risk of aspiration

• CS

• Chest physiotherapy

  • With clapping and vibration may be helpful in removing remnants of meconium from the lungs

• Extracorporeal membrane oxygenation (ECMO)

• Antibiotic therapy to stall pneumonia development

Pneumonia

Secondary problem that develops from MAS

Sudden infant death syndrome

• aka crib death

• Sudden, unexplainable death during 1st yr. of life

Theories or possible contributing factors about SIDS’ cause

➢ Prolonged but unexplained apnea

➢ Viral respiratory or botulism infection

➢ Pulmonary edema

➢ Brain stem abnormalities

➢ Neurotransmitter deficiencies

➢ Heart rate abnormalities

➢ Distorted familial breathing pattern

➢ Decreased arousal response

➢ Possible lack of surfactant in the alveoli

➢ Sleeping in a prone position

Infants who died of SIDS

Infants were found to have blood-flecked sputum/vomitus in their mouth or in the bed clothes

• occur as the result of death and not as the cause

Autopsy in SIDS

Often reveals petechiae in the lungs & mild inflammation and congestion in the respiratory tract

Safe Sleep Do’s

● ASTM Certified Crib

● Baby on back

● Firm crib mattress

● Fitted pad & sheets

● Mattress encasement

● Swaddle newborns

Safe sleeps Dont’s

• crib bumpers

• Blankets

• Pillows

• Stuffed animals or toys

• Cords near the crib

Etiology of ABO/RH Incompatibility

● Incompatible RH and ABO blood type of fetus and mother

● Rh incompatibility is different from ABO incompatibility

● HDN = Hemolytic Disease of the Newborn

Rh Incompatibility

• Mother is Rh negative and fetus is Rh positive (contains D antigen)

• Introduction of the fetal blood during delivery causes sensitization to occur and the mother begins to form antibodies against the D antigen.

First 72 hrs after birth

Amt of time antibodies form against the D antigen of RH incompatibility

• there is an active exchange of fetal-maternal circulation as placental villi is loosened and as the placenta is delivered

During the 2nd pregnancy

• Time when there will be a high level of anti-D antibodies in the mother’s bloodstream in which this will act to destroy the fetal RBC early in the pregnancy if the fetus is Rh positive

ABO Incompatibility

Mother is Type O and fetus is Type A, B, or AB

• Reaction in infants with Type B is often most serious

2-4 months of age

Peak age of incidence of SIDS

Risk factors of SIDS in babies

Risk factors of SIDS in mother

IgM

These antibodies are of large class and do not cross the placental barriers

Hemolysis in ABO incompatibility

• begins with 1st birth or pregnancy when the blood and antibodies are exchanged during the mixing of maternal and fetal blood as the placenta is loosened

• May continue up to 2 weeks of age

S/sx of Rh and ABO incompatibility

• Enlarged liver and spleen

• Extreme edema

• Severe anemia

• Hydrops fetalis

• Pathologic jaundice

• Coombs test — direct and indirect

• Hypoglycemia

• Green stool, dark urine- post-phototherapy

Mgmt of Rh and ABO incompatibility

• early breastfeeding which stimulates bowel peristalsis

• phototherapy

• exchange transfusion

• erythropoietin

12-30 inches

• distance of phototherapy light above bassinet or incubator

15 mg/dL

• Term newborns generally scheduled for phototherapy when total serum bilirubin level rises to this level at 25-28 hours of age