OB Final: CH 17-24 Portion

Normal respirations for the newborn

30-60 breaths per minute

Mechanisms of heat loss

• Thin skin (superficial BV’s)

• Lack of shivering ability, limited stores of metabolic substrates (glucose, glycogen, fat)

• Limited voluntary muscle activity

• Large body SA relative to body weight

• Lack of SQ fat → little ability to conserve heat via posture

Mechanisms of heat exchange

Conduction: transfer via direct contact

Convection: flow from body surface to cooler surrounding air

• intervention: cold air is to move baby

Evaporation: liquid converted to vapor

• intervention: dry baby off (quicky)

Radiation: transfer via close proximity (not direct contact)

Newborns CANNOT shiver and have limited sweating ability

• r/t limited skeletal muscle mass

• sweat glands not fully developed

Primary mechanisms for thermogenesis

metabolism of BROWN adipose tissue stores

Characteristics of newborn stool

• Stages of stool: meconium → transitional stool →milk stool

  • Breastfed: yellow-gold, loose, stringy to pasty, sour-smelling

  • Formula: yellow, yellow-green, loose, pasty or formed, unpleasant odor

IgG, IgA, IgM

IgG: cross thru placenta from mom to baby

• slowly @ 20-22 weeks gestation

IgA: colostrum/breast milk

IgM: blood/lymph

Senses at birth

1. Hearing (most developed)

2. smell

3. taste

4. touch

5. vision (least developed)

Pattern of development

Cephalocaudal: head-to-toe and center-outward

Rooting reflex

side of cheek is touched → baby’s head turns toward stimulation and opens mouth

moro/startle reflex

baby is startled → extend extremities, arch back, quickly bring arms back in

Grasp reflex

object placed in baby’s palm/foot →grasp it

Babinski reflex

foot plantar surface stroked → toes fan out

Tonic neck reflex

baby’s head turned to one side → arm on same side will extend and the opposite arm will bend at the elbow

stepping reflex

hold baby upright (in walking pose) → baby will make stepping motion

Ballard Score

Physical Maturity:

• skin texture

• lanugo (lots = early)

• plantar creases

• breast tissue

• eyes and ears

• genitals

Neuromuscular Maturity:

• posture

• square window (wrist flexion)

• arm recoil

• popliteal angle

• scarf sign: The elbow easily crosses the middle of the chest without much resistance (low muscle tone)

• heel to ear

Vitamin K

Bleeding prophylaxis (lack of dietary vit K → limited clotting ability)

• 25 g IM injection @ outer middle third of vastus lateralis

• Given within 1st 6 hours of birth (usually 1st hour)

Erythromycin Eye Ointment

Px opthalma neonatorum (neonatal conjunctivitis) caused by bacteria

• gonorrhea can cause newborn blindness

Common newborn skin variations: Congenital dermal melanocytosis

benign blue/purple splotches on the back, buttocks, or legs (usually fades)

Common newborn skin variations: Vernix

thick, white, waxy substance that protects the skin of the fetus from excess moisture

Common newborn skin variations: Stork bites/salmon patches

superficial vascular areas found commonly on the back of the neck or eyelid caused by the concentration of immature BV’s

Common newborn skin variations: Milia

pearly white unopened sebaceous glands

• @ mouth = Epstein pearls/baby teeth

Common newborn skin variations: Erythema toxicum

newborn red rash, common on the face

Common newborn skin variations: Harlequin syndrome

dilation of BV’s on only 1 side of the body

Common newborn skin variations: Nevus flammeus (portwine stain)

flat, sharply demarcated, PERMANENT

• linked to childhood CA

Common newborn skin variations: Nevus Vasculosus (strawberry mark)

raised, rough, dark red, sharply demarcated, TEMPORARY

• premies

Molding

head shaping for birth canal → conehead (benign)

Caput

soft tissue edema, CROSSES suture lines, dissipates within a few days

• more common in bigger babies

• soft tissue swelling

Cephalohematoma

collection of blood that DOES NOT cross suture line, takes weeks to dissipate

• firm

• increased r/o jaundice

Bulging fontanelle

increased intercranial pressure, hydrocephalus

Sunken fontanelle

r/t dehydration

Transient tachypnea of the newborn (TTN)

c-section/premie → excess amniotic fluid → delayed clearance → rapid breathing

• resolves within 72 hours, give supplemental O2

Cord care

• 30-60 seconds of delayed cord clamping →px anemia

• keep open to air (fold diaper underneath)

• do not submerge until remainder has fallen off

circumcision care

• shaft should look normal w/ urethral opening @ head

• can apply small amount of petroleum jelly

• keep clean and be gentle

Basic baby safety

• keep delivery/baby private on social media

• use proper car seat for baby’s weight

• blue badge when transferring babies

Discharge Teaching

D/C Requirements:

• Stable temp for at least 12 hours

• Weight loss within 7-10%

• Good feeder

• Pee/poop

D/C Concerns:

• Temp > 100.4 F

• projectile vomiting

• lethargic

• no sucking/feeding

• 2+ watery, green stools

• abdominal distension

• Dyspnea, use of accessory muscles to breathe, flared nostrils

Appropriate for gestational Age (AGA): 2500-4000 g

80% of newborns; normal height, weight, head circ, BMI

Small for Gestational Age (SGA): < 2500 g (5 lb, 8 oz), < 10th percentile

CHARACTERISTICS:

• Head disproportionately large

• Wasted extremities; loose, dry skin (reduced SQ)

  • decreased breast tissue

  • scaphoid abd

• thin umbilical cord

• poor muscle tone over buttocks and cheeks

COMMON PROBLEMS:

• perinatal asphyxia

• less SQ → difficulty thermoregulating

• hypoglycemia (overcompensating for mom’s high BG)

• placental insufficiency → polycythemia (HCT > 65%, HGB > 20 g/dL) —> hyperbilirubinemia

• meconium aspiration → distress

• birth trauma

MANAGEMENT:

• weight, length, head circ measurements

• serial BG + VS monitoring

• early + frequent PO feedings, IV dextrose 10%

• Ax S/S polycythemia

• anticipatory guidance

Polycythemia

• placental insufficiency → polycythemia → hyperbilirubinemia

• HCT > 65%, HGB > 20 g/dL

Large for gestational age (LGA): > 4000 g (8 labs 13 oz), > 90th percentile

CHARACTERICSTICS:

• large body, pump, full faced

• proportional increase in body size

• poor motor skills

• difficulty w/ behavioral regulation

COMMON PROBLEMS:

• shoulder dystocia → brachial plexus injury

• hypoglycemia (overcompensating for mom’s high BG)

• polycythemia

• Low surfactant (insulin production)

MANAGEMENT:

• VS/BG monitoring

• Initiation of PO feedings w/ IV glucose supplementation PRN

• Ax S/S polycythemia + hypoglycemia

• hydration

• phototherapy, THEN exchange transfusion (if r/o kernicterus)

Critical components of D/C planning

Dealing w/ Perinatal Loss

• any pregnancy loss/or neonatal death up to 1 month of age

• profound experience for the family

• common reaction = avoidance

• nurses must be aware of personal feelings (communicate empathy)

Transient Tachypnea of the Newborn

C-section baby → no thoracic squeeze/time for amniotic absorption

• some S/S respiratory distress

• resolves within 72 hours

• Need supplemental O2

Meconium Aspiration Syndrome (MAS)

Newborn inhales particulate meconium mixed w/ amniotic fluid while in utero of @ 1st breath

• puffy looking patches @ x-ray

• DO NOT STIMULATE CRYING (may go deeper into lungs)

• meconium: viscous green substance made of H2O & other built up GI secretions (no bacteria); can be noted as early as 10-16 weeks gestation

Persistent Pulmonary Hypertension of the Newborn

High lung BP → R to L extrapulmonary shunting & hypoxemia

• CAUSE: SSRI’s

• S/S: cyanosis, tachypnea, hypoxemia, murmur

• Tx: O2, ventilation, nitric oxide, ECMO, echocardiogram

Retinopathy of Prematurity

Premature → retinal BV’s cease development + hyperoxemia

• Mx and titrate O2 levels carefully

Bronchopulmonary Dysplasia

Prolonged vent support in premies → continued O2 after 1st 28 days

• S/S: tachypnea, retractions, wheezing, x-ray shows lung hyperinflation

• Tx: O2, steroids, diuretics, nutrition

PVH/IVH

Fragile cerebral BV’s (premies) → brain bleed @ 1st 72 hours post-birth

• S/S: apnea, seizures, lethargy, bulging fontanelle, low HCT (possible asymptomatic)

  • may lead to long-term intellectual disabilities

• Nursing priority: mx head circ and neuro ax

Necrotizing enterocolitis (NEC)

Inflammation/bacterial invasion of intestines → GI tissue death

• CAUSES: bowel ischemia, bacterial flora, formula feeding

• S/S: abd distension, bloody stools, bilious vomiting, lethargy

  • KUB x-ray: air @ bowel wall, dilated bowel loops

• Tx: NPO (bowel rest), IV fluids, antibiotics, proximal enterostomy

• Px: breastfeeding!!! (build gut microbiome)

Common Problems of Mothers w/ Diabetes: Hypocalcemia

Infant serum Ca+ levels < 7 mg/dL

CAUSES: delayed PTH function after birth (regulates Ca and maternal diabetes suppresses fetal Ca regulation)

EFFECTS:

• Neuromusc irratibility (Jitters, muscle twitching/tremors, seizures)

• high-pitched cry

NURSING CARE:

• Mx S/S neuromusc irriritability

• Ax serum Ca levels, admin IV/PO Ca PRN

• Encourage early feeding

Common Problems of Mothers w/ Diabetes: Hypomagnesemia

Infant serum magnesium < 1.5 mg/dL

CAUSES:

• accompanies hypocalcemia

• maternal hypomagnesemia or newborn renal immaturity

EFFECTS:

• neuromusc irritability

• blunted response to Ca replacement

NURSING CARE:

• Ax magnesium before calcium, supplement PRN

Common Problems of Mothers w/ Diabetes: Polycythemia

Maternal hyperglycemia → Intrauterine hypoxia → compensatory increased RBC production

EFFECTS:

• Ruddy/plethoric appearance

• Poor perfusion

• cyanosis

• increased r/o hyperbilirubinemia, clots, stroke

NURSING CARE:

• Mx HCT

• Mx S/S jaundice, hypoglycemia, resp distress

• Maintain hydration

• Tx w/ partial exchange if severely sympomatic

Common Problems of Mothers w/ Diabetes: Hyperbilirubinemia

short RBC lifespan (80 days) + immature liver → infant serum bilirubin > 5 g/dL

CAUSES:

physiologic: early & late-onset breastfeeding jaundice

• 3rd to 4th day of life

• normal & temporary

pathologic: mom kills off baby’s RBC’s

• Rh isoimmunization/ABO incompatibility

EFFECTS:

• Jaundice (skin, sclera)

• r/o kernicterus → encephalopathy

NURSING CARE:

• mx bilirubin levels

• initiate phototherapy early, exchange transfusion of ineffective

• keep baby hydrated

Fetal Alcohol Spectrum Disorder

FEATURES:

• small eyes

• thin upper lip

• smooth philtrum

• growth deficiency

• neurodev delays

• slow rxn time

NO SAFE ALCOHOL LEVEL DURING PREGNANCY

Neonatal Abstinence Syndrome

withdrawal symptoms from in utero substance exposure

S/S:

• high-pitched cry

• irritability

• tremors

• poor feeding

• diarrhea

• sneezing

NURSING CARE:

• minimize stimuli, swaddle

• small, frequent feeds (poor feeders)

Risk factors for congenital heart disease

• family hx

• chromosomal anomalies (e.g., DS)

• maternal infections (rubella)

• substance use

• poor glycemic control

Neural Tube Defects: Anencephaly

Failure of neural tube to fuse @ cranial area → cerebral hemispheres missing/reduced to small masses

• most fatal neural tube defect

Neural Tube Defects: Spina Bifida (Occulta)

vertebral arches between L5 and S1 fail to fuse

• no herniation of spinal cord or meninges

• hair tuft

Neural Tube Defects: (Spina Bifida Cystica) Meningocele

Saclike protrusion containing meninges and cerebrospinal fluid

Neural Tube Defects: (Spina Bifida Cystica) Myelomeningocele

Saclike protrusion filled w/ cerebrospinal fluid, meninges, nerve roots, and spial cord

Microcephaly

Head circ > 2 SD below the mean for age/sex

• 1°: present @ birth vs 2°: develops later

Hydrocephalus

CSF overproduction or impaired circulation/absorption → compression of surrounding tissue → increased intercranial pressure

Tx: early shunting ASAP after birth

Choanal Atresia

Membranous/bony tissue causes narrowing of nasal airway

• unilateral or bilateral

• accompanies heart/CNS abnormalities

Congenital diaphragmatic hernia

Failed full development of diaphragm → some/all abd organs protrude into thoracic cavity → impaired fetal lung development

• associated w/ other organ system anomalies, single-gene disorders, or other chromosomal abnormalities

S/S:

• bowel sounds @ chest

• Impaired O2 status

Cleft Lip & Palate

fissure @ lip or roof of mouth

• most common craniofacial birth defect

Mx:

• lip surgical repair @ 6-12 weeks

• palate repair @ 6-18 months

Nursing Mx:

• provide adequate nutrition and parental education

• promote parental bonding

Esophageal atresia & esophageal fistula

Lack of normal separation of the esophagus and trachea during embryonic development

Atresia: congenitally interrupted esophagus

• drooling

Fistula: abnormal communication b/w trachea and esophagus

S/S:

• hydramnios

• copious frothy mucus bubbles

• coughing, choking, cyanosis

• Confirm via ultrasound

MANAGEMENT:

• pre-op: NPO, head-elevation, hydration, fluids, comfort, O2/suction available

• post-op: TPN, antibiotics, PO feedings within 1 week

Omphalocele

Umbilical Ring defect with evisceration of abdominal contents into external peritoneal sac

Gastroschisis

Herniation of abdominal contents through abdominal wall (NO SAC)

Omphalocele & gastroschisis nursing management

PRE-OP CARE:

• px hypothermia

• mx perfusion to abd content

• protects exposed contests from trauma/infection

• px abdominal distension

• maintain F&E balance

POST-OP CARE:

• parent-newborn interaction

Imperforate Anus

rectum ending in blind pouch or fistulas between rectum and perineum

NURSING AX:

• absence of anal opening

• no passage of meconium

• S/S GI obstruction

• distended abdomen

NURSING MX:

• surgery prep

• post-op care

Hypospadias

urinary meatus @ VENTRAL/UNDERSIDE of penis/glans

• no circumcision

RISK FACTORS

• maternal diabetes

• placental insufficiency

• prematurity

• fetal growth restriction

• AMA

• IVF

Epispadias

Rare defect where urinary meatus is on DORSAL/TOP of penis/glans

• may be associated w/ bladder exstropy

Bladder Exstrophy

Protrusion of bladder in abd wall, separation of rectus muscles and symphysis pubis

• epispadias

TX:

• initial bladder closure within 48 hours of birth; further reconstruction @ 2-3 years

• px infection & bladder damage w/ wet gauze + thermoregulation

Congenital clubfoot

Talipes varus: heel inversion

Talipes equinus: foot plantarflexion (heel doesn’t touch ground)

Cavus: plantarflexion of forefoot of the hindfoot

Forefoot adduction w/ supination: forefoot inversion w/ slightly upward turning

Tx:

• serial casting (Δ Q5-7 days)

  • if ineffective: surgery @ 4-9 months old

Developmental dysplasia of the hip

Abnormal growth or development of the hip that results in instability

• unstable, subluxation, or dislocated (luxated) hip + malformed acetabulum → femoral head easily displaced from acetabulum

RISK FACTORS:

• female

• breech

• Native American; runs in families

• oligohydramnios

• firstborn

• swaddling (forces hips to be adducted)

TX:

Ortolani maneuver: elicits sensation of dislocated hip reducing

Barlow maneuver: detects the unstable hip dislocating from the acetabulum (“clunk”)

Pavlik harness: px adduction while allowing flexion + abduction

• worn continuously until hip stable (months)

  • if ineffective, try surgery

Phenylketonuria (PKU)

Genetic metabolic disorder → body lacks phenylalanine hydroxylase → phenylalanine accumulation → intellectual disability

• mx w/ low phenylalanine diet

• detect via newborn screening

Congenital hyperthyroidism

Insufficient T4 production → severe intellectual disability + growth failure

• tx w/ levothyroxine

Galactosemia

Rare inherited d/o → lack of GALT enzyme → body can’t break down galactose

TX: eliminate galactose from diet (formula feeding)

• w/o tx: liver damage, kidney failure, sepsis, infant death

Universal Hearing Screening

Routine, detects hearing loss early → timely intervention for language development

• otoacoustic emissions (OAE)

• automated auditory brainstem response (AABR)