Newborn Lecture

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Newborn Lecture

• Binnece Green MSN APNC
• www.avc.edu
• K. Frame DNSc RN

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Goals of Newborn Care

• To establish and maintain airway and
• Support respirations
• Maintain warmth and prevent hypothermia
• To identify actual or potential problems

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Newborn Transition to Extrauterine Life

• Respiratory System
• Fetus practices respirations or breathing
  patterns in utero
• O2 in utero is supplied via the placenta and
  fetal circulation
• Initial respiratory efforts serve no real purpose
  (lungs are not functional in utero)
• During a vaginal delivery, thorax is squeezed and
  most of fluid retained in lungs during
  intrauterine life is forced out Mucus and me
  conium if present can be inhaled.

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Newborn Transition to Extrauterine Life

• Respiratory System (cont)
• Small amount of fluid retained in lungs is
  absorbed
• When the chest wall expands after delivery, the
  first breath of air is inhaled
• Causes an increase in alveolar PO2 with
  subsequent relaxation of pulmonary arteries
• Pulmonary vascular resistance decreases, allowing
  increased pulmonary vascular flow
• Results in oxygenation of newborn tissues

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Newborn Transition to Extrauterine Life

• Respiratory System (cont)
• Surfactant
• Decreases the surface tension of alveolar sacs
• Allows these sacs to fill with air
• Prevents them from collapsing wit expiration
• Aids them in maintaining functional residual
  capacity
• Sufficient amount is not usually present until 36
  weeks gestation
• Converting from fetal to adult respirations is a
  major step.
• Observe Newborn closely during the first few
  hours of life to determine that this adaptation
  has been made.

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Initiation of Breathing

• Mechanical Event
• Chemical Stimuli
• Thermal Stimuli
• Sensory Stimuli

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Maintaining Respiratory Function

• Influenced by lung compliance,
• Airway resistance
• Large abdomen encroaches on diaphragm.

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Newborn Transition to Extrauterine Life

• Cardiovascular System
• Onset of respirations stimulates changes
• Clamping of the umbilical cord and stimulation of
  cold receptors
• Increased PCO2, and decreased PO2 and increasing
  acidosis
• Leads to first breath
• Decreased pulmonary artery pressure

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Cardiopulmonary Physiology

• Causes increased PO2 and closure of foramen ovale
  (pressure in left side of heart right side)
  Foramen ovale is opening between two atria
• Increased PO2 leads to closure of ductus
  arteriosus (opening between pulmonary artery and
  aorta)

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Cardiovascular Adaptation

• Closure of ductus venosus( opening between the
  umbilical vein and inferior vena cava) and
  umbilical arteries/vein r/t decreased flow.
  Closes when cord is clamped.
• Peripheral circulation is sluggish, causing
  acrocyanosis (cyanosis of hands, feet and mouth)
• Pulse 120-160 awake 100 while asleep
• Bp 72/47 (newborn), 64/39 (preterm)

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Fetal-Newborn Transition

• Increased pulmonary resistance forces most of the
  blood through the ductus arteriosus into the
  descending aorta
• Most heart murmurs heard in young babies are not
  serious and disappear in short time.
• Umbilical cord contains two arteries and one vein.

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Review of Changes

• Expansion of lungs with first breath and decrease
  pulmonary vascular resistance and increases
  pulmonary blood flow
• Increased aortic pressure and decreased venous
  pressure
• Increased systemic pressure and decreased
  pulmonary artery pressure
• Closure of foramen ovale, which is open after
  birth.permanent closure occurs within 6 months.
• Closure of ductus arteriosus occurs within 15
  hours
• Closure of ductus venosa

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Oxygen Transport

• Conditions that affect the transport of oxygen
• Alkalosis
• Hypothermia
• Acidosis
• Hypercarbia
• Hyperthermia
• HbF fetal hemoglobin 70-90
• HbA-adult hemoglobin

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Characteristics of NewbornRespirations

• Normal breathing30 to 60 breaths/min
• Periodic breathingpauses lasting 5-15 seconds,
  has no prognostic significance
• Greater than 20 second pause is abnormal

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Normal Blood Values .

• Hg 15-20g/dl
• Hct 43-61
• Wbc 10,000-30,000
• Neutrophils 40-80
• Immature WBC 3-10
• Sodium 124-156

• Potassium 5.3-7.3
• Chloride 90-111
• Calcium 7.3-9.2
• Glucose 40-97

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Hepatic Adaptations

• Iron storage and re blood cell production
• Carbohydrate metabolism
• Conjugation of bilirubin
• Physiologic jaundice
• Breast milk jaundice
• Coagulation

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Iron Storage and Red Blood CellProduction

• If mothers iron intake was adequate, iron will
  be stored to last 5 months
• After 6 months, food containing iron or iron
  supplements must be given to prevent anemia.

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Conjugation of Bilirubin

• Total serum bilirubin sum of conjugated
  (conversion of yellow lipid-soluble pigment into
  water soluble pigment) and unconjugated
  (breakdown product).
• Liver is immature and unable to break down
  bilirubin. Infant has increased bilirubin at
  birth, during the first week there is further
  breakdown of hemoglobin, thereby decreasing
  bilirubin, immature liver cant handle this, so
  jaundice appears on skin and sclera and urine

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Physiologic Jaundice

• Caused by an accelerated destruction of fetal
  RBCs, impaired conjugation of bilirubin, and
  increased bilirubin reabsorption from the
  intestinal tract.
• 50 full term newborns
• 80 preterm newborn
• Skin and sclera yellow in color
• Level 4-6mg/dl

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Physiologic Jaundice

• Maintain newborns skin
• Monitor stools
• Encourage early feedings, increase water
• Natural/ bili light (shield eyes)
• If jaundice occurs before day 2, or if bilirubin
  rises above 18020mg/100ml, there could be another
  cause ie ABO or RH incompatibility.

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Breast Milk Jaundice

• 1-5 develop breastfeeding jaundice
• Levels may reach 20 to 25mg/dL
• Mother should pump and express mild during the
  interrupted nursing period.

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Coagulation

• Newborn bleeding problems are rare
• Injection of Vitamin K is given prophylactically
  on the day of birth to combat potential bleeding
  problem.
• Note It is given IM in the lateral aspect of the
  thigh.

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Newborn Transition to Extrauterine Life

• Endocrine System
• Luteal, lactogenic, and estrogenic maternal
  hormones cross placental barrier
• Causes temporary physical changes in the breast
  of the newborn
• Swelling
• Secretion
• Nervous system
• Immature nervous system leads to rapid and
  diffuse movements

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Newborn Transition to Extrauterine Life

• Nervous system
• Any response to stimuli is a reflex
• Development of peripheral nervous system and
  muscular control progresses from head to toe
• Newborn reflexes
• Maintain life
• Provide protection until the nervous system
  matures
• Present during first 3 months of life
• Nursing function assess the presence/absence of
  these reflexes

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Newborn Transition to Extrauterine Life

• Review of reflexes
• Sucking
• Swallowing
• Rooting
• Gag
• Tonic neck

• Babinski
• Moro
• Startle
• Stepping
• grasp

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Behavioral Capacities

• Auditory capacity newborn hears sounds,
• heart rate rises, startle reflex
• Olfactory Capacity newborns are able to select
  people by smell at one week
• Taste and sucking sugar increases sucking,
• Breast vs. Bottle
• Do not discourage nonnutritive sucking
• Swaddle
• Cuddle

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Newborn Transition to Extrauterine Life

• Urinary System
• Monitor urinary output of newborn
• Note time of first voiding
• Occurs within 4-6 hours of birth
• Urine is present in bladder at time of birth
• Renal system is initially unable to concentrate
  urine r/t kidney immaturity (3 months)
• Most void 2-6X per day for first 1-2 days
• After void 5-20 times

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Newborn Transition to Extrauterine Life

• Gastrointestinal System
• Fetus in utero receive nutrition via placenta
• Fetus practices swallowing in utero
• This indicates that gastric emptying and
  intestinal peristalsis are present before birth
• Digestive system does not function until after
  birth
• Stomach of newborn has a capacity of approx. 2 oz
• Gastric emptying start within few mins after
  feeding and takes 2-4 to be completed

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Newborn Transition to Extrauterine Life

• Gastrointestinal System
• Regurgitation is r/t immature nervous system
  control of cardiac sphincter
• Newborn should pass meconium within 24-48 hours
  after birth
• Meconium is formed in utero from swallowed
  amniotic fluid
• Passage of meconium is followed by transitional
  stools (loose, greenish yellow for breast fed,
  formula formed and pale yellow)

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Newborn Transition to Extrauterine Life

• Gastrointestinal System
• Transitional stools are greenish-brown and looser
  than meconium
• Within 1-2 days after transitional stools, fecal
  matter from digestion of formula or milk will be
  passed
• Normal stool pattern for each newborn is
  individual (one every 2-3 days or as many as 10
  daily), breast fed every 5-7 days.

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Newborn Transition to Extrauterine Life

• Immune System
• Fetuses receive passive immunity when IgG crosses
  placenta
• Primarily during 3rd trimester
• Receive passive immunity to bacteria and viral
  infections to which mother has formed specific
  antibodies
• Period of immunity varies from 4-6 months to 4-6
  weeks

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Immunologic Adaptation

• Active acquired immunity pregnant woman forms
  antibodies in response to illness and
  immunization
• Newborn acquires passively immunity from IgG from
  the mother and receives additional antibodies in
  colostrum and breast milk
• Infant will develop its own antibodies during
  first three months, but is at risk for infection
  during first 6 weeks.

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Immunologic Adaptation

• Passive acquired immunity when antibodies are
  transferred to the fetus in utero from the mother
• Maternally induced antibodies to tetanus,
  diphtheria, smallpox, measles, mumps,
  poliomyelitis.

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Immediate Care of Newborn

• Apgar scoring
• Perform gestational age assessment
• Assess vital signs and physical assessment of
  newborn
• Head circumference chest circumference
• Review gestational age lecture

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Nursing Assessment of the Newborn

• Estimation of gestational age
• Assessment of neuromuscular maturity
  characteristics
• Physical assessment
• Neurological assessment status
• Brazelton's neonatal behavioral assessment

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Estimation of Gestational Age

• Resting posture
• Skin
• Lanugo
• Sole (plantar) creases
• Areola and Breast bud tissue
• Ear form and cartilage distribution
• Male genitals, female genitals

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Gestational Age (cont.)

• Vernix
• Hair
• Skull firmness
• Nails

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Assessment of Neuromuscular Maturity
Characteristics

• Recoil
• Popliteal angle
• Scarf sign
• Head to Ear extension
• Ankle dorsiflexion
• Head lag

• Ventral suspension
• Major reflexes such as
• Sucking
• Rooting
• Grasping
• Moro
• Tonic Neck
• Babinski

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Physical Assessment

• General appearance
• Weight and Measurement
• Temperature
• Skin Characteristics

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Skin Characteristics

• Acrocyanosis
• Mottling
• Harlequin sign
• Jaundice
• Erthema Toxicum

• Milia
• Skin Turgor
• Vernix Caseosa
• Forceps or Vacuum
• Extractor marks

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Birth Marks

• Telangiecctatic nevi
• Mongolian spots
• Nevus fammeus
• Nevus Vasculosus

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Head

• General appearance
• Cephalhematoma
• Caput succedaneum

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Assessments

• Eyes
• Nose
• Mouth
• Ears
• Neck
• Chest
• Cry

• Respirations
• Heart
• Abdomen
• Umbilical cord
• Genitals
• Anus
• Extremities
• Back

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Neurological Assessment

• Tonic neck
• Grasp reflex
• Moro reflex
• Rooting reflex
• Sucking reflex
• Babinski reflex
• Galant reflex

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Brazeltons Neonatal BehavioralAssessment

• Provides guidelines for assessing the
• Newborns state, changes, temperament,
• and individual behavioral patterns.

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Nursing Plan and Implementation

• Initiation of admission procedure
• Maintenance of a clear airway and stable vital
  signs
• Maintenance of thermal environment
• Prevention of complications of hemorrhagic disease

• Prevention of eye infection
• Assessment of neonatal distress
• Initiate first feeding
• Facilitate parent-newborn attachment.

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Nursing Care in the Birthing Unit

• Maintain cardiopulmonary function
• Maintain a neutral thermal environment
• Promote adequate hydration and nutrition
• Promote skin integrity
• Prevent complications and promote safety
• Circumcision
• Enhancing parent-newborn attachment

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Nursing Plan and Preparation for Discharge

• Parent teaching
• General newborn care
• Nasal and oral suctioning
• Wrapping the newborn
• Sleep and activity
• Safety
• Newborn screening and immunizations