OB High Risk newborns

Preterm infant

<37 weeks

Low birth weight

<2500 grams

very low birth weight

<1500 grams

small for gestational age

<10%

large for GA

>90%

macrosomia

>4000 g

challenges for preterm infant Respiratory

less surfactant —> harder to keep alveoli open

smaller airways —> obstruction / collapse

periodic breathing vs apnea - which one is normal? which one is abnormal

challenges for preterm infant thermoregulation

• temperature instability

  • increased body surface area, minimal fat, poor muslce tone —> heat loss

• underdeveloped brain

• work harder to maintain temp —> utilization of 02 adn glucose

phsyiological changes for preterm infant

• central nervous system

  • risk for intracranail bleeding and hypoxia

• GI/metabolic system

  • impaired feeding reflexes (suck/swallow, gag, reflex, coordination with breathing)

  • difficulty absorbign nutrients

• hematologic system

  • fragile capillaries, prolonges clotting times, less RBC’s —> brain bleed

  • risk for anemia

    • risk for hyperbilirubenemia

Corrected age

GA + postnatal age = corrected age

Example: infant born at 32 weeks and has been in nicu for 2 weels, corrected age is 34 weeks

infant born at 28 weeks adn 2 days spent 4 weeks adn 3 days in nicu, corrected agae 32 and 5

important because need to see when if infant is meeting milestoens, they will be a little behind on normal milestones

Respiratory care

• preterm infants more likely to require advanced resuscitation efforts

• oxygen therapy

• continous postivie airway pressure (CPAP)

  • delivers 02 or air to infant with added pressure to help keep alveoli open (prevent collapse)

• intubation mechanical ventilation

  • when other methods ar enot effective

• surfactant

  • can be given to preterm infant untile he / she can produce their own

thermoregulation

• pre warmed radiant warmer or incubator

• polyethylene bag

• sticker probe used ot maintain stable body temperature

• hypothermia

  • symptoms

    • acrocyanocis, cool skin, pale, hyporeactivity, low blood sugar,

  • gradeal rewarming recommended

weight gain and fluid balance weight gain and caloric needs

• caloric nutirent adn fluid requirements are higher than that of a healthy term neonate

• weight gain / loss monitored daily

  • could lose up to 15% of birth weight - Term newborn is 10% weightloss

  • dont under or over feed

• advance feeds gradually

  • Symptoms of feeding intolerance

    • throwup, spitup, vomiting, abdominal distension, discomfort, 

weight gain and fluid balance, feeding method and nutrition

• feeding method

  • oral bottle / breastfeeding

    • must have adequeate strength and GI function

  • cavage - NG tube or OG tube

    • if ifnant too sick or premature for feeding

    • via syringe or infusion pump

  • parenteral IV infusion

    • infants unable to retain addequate fluids calories byt enteral feeds

nutrition

breast milk / formula

pain assessment

• symptoms can be behavorial

  • Whimpering, chin quivering, brow furrowed,
    eyes tightly closed, thrashing, fist clenching, etc

• anticipate and manage pain without wiating for multiple sigsn to appear

non-pharmacological interventiions

• swaddling, sucking, warmth, distraction techniques

pharmacological interventions

• Morphine or fentenyal iv infusion

developmental care

• decrease stimulation

  • lights noise

• minimizxe sleep disruption

• scheduled care times —> minimize sleep disruption

parental support in NICU

Issuee = difficult bonding / relating to their infant

goal = recognize competence, self conidence in infant care

• promoting bonding / attachment

  • physical touch 

  • participate in caregivcing activities

  • updates prn (video feeds, pictures, pjone updates)

• educate about

  • equipment, medications, plan of care

  • realistic expecations fo rtheir infant - use GA

• encourage them to express feelings about labor, birth, preterm infant

preterm compliications

• respiratory distress syndrome

  • lack of pulmonary surfactant —> atelecatasis, difficultyy breathing independently

  • symptoms

    • grunting, wheezing, retractions, nasal flaring

  • treatment

    • oxygen, ventilation (prn), surfactant

preterm complicatiosn retinopathy of prematuirty (ROP)

• hypoxi —> scarring, capillary hemorrhage in retina vessels —> visual impairment

• early detection with ophthalmologist (31-32 weeks)

• prevention - monitor blood oxygen levels maintain adequate 02 sats

Preterm complications intraventricular hemorrhage (IVH)

• small capillaries in brain susceptible to fluctaitons in BP —> hemorrhage —> damage

• associated with GA <32 weeks, hypoxia, birth asphyxia, RDS, pneomothorac

• interventiosn

  • thermoregulation, reduce handling (72hrs) elevated HOB (head of bed), monitor BP closely

Preterm complications Necrotizing enterocloitiz

• inflammatory disease of the GI mucose —> bowel necorsis and perforation

  • progression: hypoxic event bacteria in GI tract, and enteral feedin

• rarelty among infants who are exclusively BF

• interventiosn 

  • bowel rest, parenteral nutrition ,orogastric tube with suction, antibiotics, surgery

preterm compkcatiosn neonatal sepsis

• significant cause of infant morbidity adn death

• early onset <72 hours after birth (maternal intrapaturm transfer

• late onset >72 hours after brith ( likely hospital aquired post natal)

• symptoms

  • lethargy, poor feeding, hypotonia, hypothermia, tachypnea, apnea, grunting, tachycardia

infant of diabetic mother

• significant impact on neonatal morbidity/mortality

• pathophysiology

  • maternal hyperglycemia —> high fetal insulin production

  • maternal supply cut off (delivery ) —> fetal hypoglycemia

• complications

  • Macrosomia/ LGA – enlarged organs

    • Birth injury/ hypoxia

    • Congenital anomalies – early hyperglycemia – 3-5x increased risk

    • Polycythemia & Hyperbilirubinemia

    • Respiratory Distress Syndrome

hypoglycemia

• inadequate blood glucose levels to support normal functioning

  • level < 40 mg/dl (in a newborn)

• main risk factor

  • LGA, SGA, LBW

  • IDM

  • maternal beta blocker

• usualyt within first 6 huors of brith 

• symptoms

  • Jittery

  • Lethargic

  • Poor feeding

  • Hypotonia

  • Apnea / cyanosis

  • High-pitched or weak cry

  • Seizures (late)

• Hypoglycemia Protocol (Condensed)

  1. Check glucose (screen at-risk infants).

  2. If <40 mg/dL (early) or <45 mg/dL (later) →
     Feed immediately (breastfeed or expressed milk).

  3. Recheck glucose in 15–30 min.

  4. If still low → oral glucose gel + feed.

  5. If persistently low or symptomatic → IV D10W bolus or infusion.

  6. Monitor until three normal readings in a row.

neonatal abstinence syndrome

• symptoms r/t intrauterine exposure to opioids

• closer drugs use to birht —> more severe symptoms and delayed onset

• symptoms

  • hyperiirtablity - crying, jittery

  • GI dysfucntion - diarhhea 

  • autonomic instability - sweating, temperature instability, faster respiratory rate 

• scoring tools - finnegan NAS scale, eat, sleep console

• treatment

  • non pahrmocaologic vs pharmacologic

  • breastfeeding recommended for women who are stable on meds

NAS scoring and management

Hemoltyci anemia

• destruction of RBC’s faster than the body can repoduce them

• Rh incompatibility

  • Rh motehr and Rh+ fetus

  • maternal Rh antibodies corss placenta —> lysis of fetal RBC’s —> anemia

  • prenatal prevention method

    • rhogam 

• ABO incompatibilyiy 

  • maternal blood type O exposed to fetabl blood type a, b or ab

  • result - hyperbilirubinemia

COOMBS test / direct antiglobulin test (DAT)

• tests for presence of antibodies on fetal RBC’s

• antibodies can be related to RH factor OR blood type

• blood

  

• Postiive = antibodies present

  • which places the newborn at high risk for hyperbilirubinemia