Chapter 17-Part 1 Study Guide Nursing Care of the Newborn at Risk:

Identification and Screening of the At-Risk Newborn

• Objective of Screening: During pregnancy, women must be screened for factors that could place the newborn at risk for immediate or long-term problems. Awareness and advanced planning are critical to preventing complications.

• Maternal and Pregnancy Risk Factors:

  • Premature labor.

  • Diabetes.

  • Hypertension.

  • Placenta abnormalities.

  • HIV infection.

  • Unhealthy lifestyle choices.

• Admission Procedures: Upon admission to labor and delivery, the nurse is responsible for reviewing the pregnancy health history of the woman to identify these risks.

• Goal of Care: Swift action and advanced planning may prevent long-term complications for the high-risk newborn.

Birth Asphyxia (Perinatal Asphyxia)

• Definitions and Nomenclature: Also referred to as perinatal asphyxia, asphyxia neonatorum, or hypoxic-ischemic encephalopathy. It is an acute brain injury occurring because the baby did not receive enough oxygen during the birth process.

• Possible Causes:

  • Maternal insufficiency of oxygen during labor.

  • Maternal blood pressure being too high or too low during labor.

  • Abruptio placentae: The placenta separates from the uterus too quickly, resulting in oxygen loss.

  • Umbilical cord complications: The cord is wrapped too tightly around the neck or body.

  • Fetal anemia: The fetus lacks sufficient red blood cells to tolerate the stress of labor contractions.

  • Airway blockage in the newborn.

  • Prolonged or difficult delivery.

• Pathophysiology:

  • Asphyxia leads to slowed or ceased breathing.

  • Results in a lack of blood perfusion to the brain and other organ systems.

  • Hypoxia: Insufficient oxygen reaching the cells forces them to undergo anaerobic respiration.

  • Metabolic Impact: Lactic acid forms, causing tissue damage.

  • Vital Organs: Lack of oxygen affects the brain, muscles, and heart first.

  • Cardiovascular Effects: Heart dysfunction leads to hypotension.

  • Reperfusion Injury: When adequate blood perfusion returns, the brain often swells, which causes further neurological problems.

• Signs and Symptoms:

  • Cyanosis.

  • Difficulty breathing.

  • Gasping respirations.

  • Umbilical cord pH: Less than $7$.

  • Apgar score: Less than $3$ for more than $5$ minutes.

Management and Complications of Birth Asphyxia

• Medical Management:

  • Blood pressure management using medications.

  • Ventilation support and oxygen therapy as required.

  • Careful fluid management.

  • Avoidance of hypoglycemia or hyperglycemia.

  • Avoidance of hyperthermia.

  • Treatment of seizures.

  • Hypothermia Therapy: Cooling the infant to therapeutic levels ($33^\circ C$ to $33.5^\circ C$ [$91.4^\circ F$ to $92.3^\circ F$]) for $72$ hours, followed by slow rewarming to reduce brain swelling.

• Nursing Care:

  • Administering ordered medications and fluids.

  • Monitoring the baby’s ventilation and oxygenation status.

  • Monitoring fluid balance.

  • Monitoring and reporting signs of hypoglycemia, hyperglycemia, and hyperthermia.

• Long-Term Complications:

  • Cerebral palsy.

  • Epilepsy.

  • Blindness.

  • Delayed motor development.

  • Intellectual disability.

  • Learning disabilities.

Respiratory Distress Syndrome (RDS)

• Overview: Formerly known as hyaline membrane syndrome due to the formation of hyaline membranes that line the alveoli and impair ventilation. It is caused by lung immaturity and a lack of surfactant.

• Affected Populations: Almost exclusively premature infants, but also those with birth asphyxia, infants of diabetic mothers, and those delivered by cesarean section.

• Possible Causes of Respiratory Distress:

  • Birth asphyxia.

  • Surfactant deficiency (prematurity).

  • Fluid in the lungs.

  • Meconium aspiration.

  • Pulmonary hypertension.

  • Cold stress.

  • Any condition affecting the ability to breathe.

• Pathophysiology:

  • Absence of surfactant prevents alveoli from staying open for oxygenation.

  • Leads to hypoxemia and hypercapnia (elevated carbon dioxide).

  • Results in respiratory acidosis, which causes vasoconstriction and damages lung epithelium, forming hyaline membranes.

• Signs and Symptoms (Onsets at birth or within 8 hours):

  • Tachypnea.

  • Dyspnea.

  • Grunting with expirations.

  • Nasal flaring.

  • Intercostal retractions.

  • Cyanosis.

• Medical and Nursing Management:

  • Antenatal corticosteroids.

  • Transfer to the Neonatal Intensive Care Unit (NICU).

  • Surfactant therapy and oxygen therapy.

  • Continuous positive airway pressure (CPAP).

  • Mechanical ventilation if required.

  • Vapotherm: Use of heated and humidified high-flow oxygen via nasal cannula.

  • Neonatal CPR if indicated.

  • Continuous monitoring of respiratory and oxygenation status.

Transient Tachypnea of the Newborn (TTN)

• Definition: A common, self-limiting condition involving tachypnea, increased oxygen needs, and mild respiratory distress.

• Etiology: Caused by incomplete reabsorption of fetal lung fluid. It usually resolves within $3$ to $5$ days.

• Risk Factors: Infants sedated via maternal pain medications, prolonged labor, macrosomia, and cesarean section delivery.

• Medical Management:

  • Supportive care with IV fluids.

  • Gavage feedings until the respiratory rate decreases enough for oral feeding (safe bottle/breastfeeding).

  • Oxygen support to maintain saturation above $93\%$.

  • Diagnostics: Chest x-ray and Arterial Blood Gas (ABG) assessments.

• Nursing Interventions:

  • Monitoring oxygenation (assessment, ABGs, $O_2$ saturation).

  • Administering gavage feedings.

  • Minimizing stimulation.

  • Preventing hypothermia or hyperthermia.

  • Supporting bonding and breastfeeding after resolution.

Meconium Aspiration Syndrome (MAS)

• Pathophysiology: Fetal distress causes decreased oxygen, leading the fetus to pass meconium into the amniotic fluid. If inhaled, meconium can block bronchioles, resulting in poor oxygenation, pneumonia, or pneumothorax (collapsed lung).

• Affected Populations: Primarily affects term and post-term newborns.

• Signs and Symptoms:

  • Greenish-yellow staining of the skin, nail beds, or umbilical cord.

  • Tachypnea, retractions, nasal flaring, and grunting.

  • Decreased oxygen saturation and decreased breath sounds.

• Treatment:

  • Thorough suctioning with the first breath.

  • Endotracheal intubation and mechanical ventilation if indicated.

  • NICU transfer.

Persistent Pulmonary Hypertension of the Newborn (PPHN)

• Pathophysiology: Fetal circulation remains as it was in the uterus (persistent). The Ductus arteriosus and/or foramen ovale remain open. Blood is shunted away from the lungs due to high pulmonary pressure, resulting in inadequate oxygenation.

• Common Causes: Perinatal asphyxia, RDS, neonatal sepsis, or congenital heart/lung defects.

• Signs and Symptoms:

  • Similar to RDS.

  • Cyanosis that does not improve even with oxygen administration.

  • Signs of shock: Low blood pressure and tachycardia.

  • Presence of a heart murmur.

• Management and Outlook:

  • Requires immediate NICU transfer.

  • Infants are at higher risk for neurosensory hearing loss and neurodevelopmental problems later in life.

Thermoregulation and Cold Stress

• Risk Period: Highest during the immediate transitional period after birth, especially if born outside the hospital environment.

• Normal Rectal Temperature (Term and Preterm): $36.5^\circ C$ to $37^\circ C$ ($97.7^\circ F$ to $98.6^\circ F$).

• Nursing Goal: Maintain normothermia and educate parents on environmental conditions.

Neonatal Hypoglycemia

• Definition: Plasma glucose level less than $30\,mg/dL$ in the first $24$ hours of life, and less than $45\,mg/dL$ thereafter.

• Physiology: $95\%$ of available glucose in a newborn is used for brain function.

• Causes of Drop: No glycogen stores in the liver, exhaustion of stores for heat production or birth stress, hyperinsulinism (Infant of Diabetic Mother - IDM), or feeding insufficiency.

• Risk Groups:

  • Premature or postmature infants.

  • Infant of a Diabetic Mother (IDM).

  • Small-for-gestational-age (SGA) and Large-for-gestational-age (LGA) infants.

  • Stressed infants (cold stress, asphyxia).

• Signs and Symptoms: Jitteriness/tremors, lethargy, irritability, hypotonia, weak or high-pitched cry, apnea, hypothermia, and poor feeding.

• Interventions:

  • Heel-stick blood sample immediately for high-risk infants.

  • Monitoring schedule for high-risk (if initial is normal): $30$ minutes, $1$ hour, $2$ hours, $4$ hours, $8$ hours, and $12$ hours after birth.

  • Reading $30-40\,mg/dL$: Breastfeed or bottle-feed; recheck glucose in $20$ minutes.

  • Reading < $30\,mg/dL$: Notify provider, STAT blood draw, glucose gel, or IV administration of $D10W$ ($10\%$ dextrose in water).

• Long-Term Complications: Neurological damage, intellectual disability, developmental delays, personality disorders, decreased head size, and seizures.

Birth Injuries (Birth Trauma)

• Definition: Physical injuries occurring due to traction and compression during the birthing process.

• Risk Factors: Fetal macrosomia, cephalopelvic disproportion, prolonged or rapid delivery, use of forceps/vacuum, abnormal presentation (breech), and large fetal head.

• Soft Tissue Injuries: Abrasions and lacerations usually resolve within days.

• Brachial Plexus Injuries:

  • Mechanism: Traction force to the network of nerves in the neck area during delivery (e.g., shoulder dystocia).

  • Incidence: $0.5$ to $5$ per $1,000$ live births.

  • Signs: Limited movement on one side, absent Moro reflex on the affected side, claw-like hand, and abnormal muscle contractions.

  • Nursing Care: Protect the arm from dangling; do not lift the infant under the axillae; use rolled blankets for support; maintain good body alignment.

• Fractures:

  • Clavicle: Most frequently fractured bone, often due to macrosomia/large shoulders.

  • Signs: Lack of movement in the arm, palpable bone irregularity.

  • Healing: Usually takes $7$ to $10$ days; requires immobilization.

Hyperbilirubinemia (Jaundice)

• Types: Physiologic jaundice vs. non-physiological (pathological) jaundice.

• Pathological Jaundice: Serum bilirubin rises excessively. If bilirubin deposits in the brain, it causes neurotoxicity (kernicterus).

• Signs and Symptoms: Visible at levels of $5$ to $6\,mg/dL$ starting on the face and spreading downward; yellow-tinted sclera.

• Risk Factors: Prematurity, blood-type incompatibility, ineffective breastfeeding, and excessive bruising.

• Diagnosis: Transcutaneous bilirubinometer (estimate) and laboratory testing (definitive).

• Management:

  • Feedings: Breastfeed $8-12$ times/day or bottle-feed $8-10$ times/day to encourage excretion via stool and urine ($6$ wet diapers/$3$ stools daily).

  • Phototherapy:

    • Thresholds: $\ge 15\,mg/dL$ ($25-48$ hours old); $\ge 18\,mg/dL$ ($49-72$ hours old); $\ge 20\,mg/dL$ ( > $72$ hours).

    • Function: Converts bilirubin to water-soluble compounds using blue light.

    • Care: Covered eyes to protect retina; expose maximum skin (except genitals); monitor for irritability/lethargy (brain irritation) and hypothermia.

  • Exchange Transfusions: Required in the NICU if kernicterus occurs or levels do not drop.

Neonatal Infection and Sepsis

• Neonatal Sepsis: Blood infection within the first $28$ days of life, causing systemic inflammation.

• Common Pathogens: Group B streptococcus (GBS), Escherichia coli (E. coli), and Herpes.

• Herpes Infection:

  • Types: Type 1 (oral) and Type 2 (genital/most common in newborns).

  • Transmission: Fetal exposure during birth canal transit if active lesions are present (scheduled C-section is indicated).

  • Symptoms: Skin blisters/crusts. If systemic, manifestations are identical to neonatal sepsis.

  • Management: Same as sepsis but uses antiviral medications instead of antibiotics.