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Newborn Care

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Newborn Care Julee Waldrop, MS, FNP, PNP Director Newborn Nursery UNC Definition Begins in utero and continues for 8-12 hours after birth All systems are affected ... – PowerPoint PPT presentation

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Title: Newborn Care


1
Newborn Care
  • Julee Waldrop, MS, FNP, PNP
  • Director Newborn Nursery
  • UNC

2
Definition
  • Begins in utero and continues for 8-12 hours
    after birth
  • All systems are affected
  • Biggest
  • Respiratory
  • Cardiovascular

3
Respiratory System Transition
  • Where does gas exchange take place in utero?
  • When the infant gets ready to be born, The water
    in the lungs begins to decrease
  • Increase in surfactant production
  • Chest compression doesnt play as big a role as
    previously thought

4
Decreased fluid secretion into the intraluminal
space
Hormones Vasopressin Epinephrine
Decreased Fluid in Lungs
Increased plasma protein increased oncotic
pressure
Increased intraluminal water reabsorption into
the interstitium
Increased Pulmonary Lymphatic circulation
5
  • So what infants are at most risk for difficulty
    with retained lung fluid?
  • Answer Infants who are born via scheduled
    Cesarean Section

6
Triggers to Breathe Continuously?
  • Light
  • Sound
  • Cutaneous stimulation
  • Heat loss
  • Cord clamping
  • Increase in O2 saturation

7
Respiratory red flags
  • RR gt 100
  • gt 70 after first 8 hours
  • Respirations with signs of distress after 1st 2
    hours
  • Central cyanosis after 1st 5 minutes

8
Cardiovascular System
  • Infant cries
  • Lungs expand
  • Pulmonary artery pressure decreases
  • Pulmonary blood flow begins to increase (for 1st
    weeks)
  • Ductus arteriosus starts to close

9
The Ductus arteriosus Can remain open for
variable length of time
10
Cord Clamped Removal of placental circulation
  • Systemic arterial resistance increases
  • L arterial pressure increases
  • Foramen ovale closes
  • Ductus venosus closes

11
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12
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13
Normal findings in 1st hour
  • Increased or decreased heart rate
  • Mottled/pale
  • Nasal flaring
  • Irregular respirations and shallow breathing
  • Transient grunting
  • If all is well stabilized by 1 hour

14
Transition in metabolism/glucose
  • Loss of transplacental glucose
  • No more from MOM!
  • Leads to decreased BGL
  • No more insulin from mom either!
  • Leads to decreased circulating insulin
  • Catecholamines (epi) (from labor) stimulates the
    liver to release glucagon

15
Thermoregulation and metabolism are intertwined
Stress of birth Exposure to cold
SANS Catecholamine release
Non-shivering thermogenesis
hypoxemia
Metabolic acidosis
Decreased BGL
Increased O2 consumption
16
Red flags to hypothermia
  • Prematurity
  • SGA
  • Cold LD rooms
  • Inadequate or delayed drying

17
Periods of Reactivity (i.e. good times to
initiate breastfeeding and bonding)
  • Time when baby in in quiet alert stage
  • 1st 15-30 min of life
  • In between is 60-90 minutes of age
  • Decrease in activity and hypotonia
  • 2nd 2-6 hours of life

18
Important Historical Points
  • Mothers name MR number
  • Screening Labs
  • blood type
  • serology result (during pregnancy)
  • rubella status
  • Hepatitis B status
  • GBS status
  • HIV status (if drawn)
  • Chlamydia
  • Gonorrhea

19
Important Historical Points
  • Pregnancy Complications
  • Maternal illness affecting the pregnancy
  • abnormal results from tests of fetal well-being
    and their interpretation
  • Maternal medications
  • Any substance use

20
Important Historical Points
  • Labor
  • Method of labor duration
  • Presence of
  • Non-reassuring fetal heart rate
  • prolonged ROM (gt18 hours)
  • Intrapartum maternal antibiotic therapy
  • maternal fever
  • meconium
  • resuscitation

21
Important Historical Points
  • Social History
  • substance use
  • unstable housing
  • adolescent mother
  • maternal psychiatric disease
  • domestic violence
  • history of child abuse.
  • Situations compromising lactation
  • like history of breast surgery
  • Trauma
  • previous lactation failure.

22
Gestational Age
  • Estimated from the mothers menstrual history,
    from an ultrasound done before 20 weeks
    gestation, or from a physicians assessment,
    using the Ballard (Dubowitz) assessment tool.
  • Determine if the infant is small, large or
    appropriate for gestational age.

23
Gestational Age
  • Large or small for gestational age infants are at
    higher risk for hypoglycemia and polycythemia.
  • Serum glucose and hematocrit may be indicated.

24
Newborn Care
  • Observe for signs of illness
  • temperature instability
  • change in activity
  • refusal of feedings
  • unusual skin color
  • abnormal heart or respiratory rate and rhythm
  • delayed or abnormal stool or voiding
  • abdominal distension
  • bilious vomiting
  • excessive lethargy

25
Newborn Care
  • Meconium should be passed by 24 hours of life.
    If no meconium is passed by 48 hours of age the
    lower GI tract may be obstructed.
  • Urine is usually passed by 12 hours of age.
    Failure to void by 24 hours of age may indicate
    genitourinary obstruction or abnormality.

26
Eye Care
  • Prophylaxis against gonococcal ophthalmia
    neonatorum is mandatory.
  • A number of acceptable alternatives
    erythromycin (UNC uses this) tetracycline, or
    ophthalmic povidone-iodine.
  • Application can be delayed up to 1 hour after
    birth, usually after the time of the first
    breastfeeding.

27
Vitamin K
  • Every infant should have a single parenteral dose
    of natural vitamin K1 oxide (phytonadione) within
    1 hour of birth.
  • Prevents vitamin-K dependent hemorrhagic disease
    of the newborn.
  • Oral vitamin K does not work as well.
  • No oral vitamin K preparation is available in the
    USA.

28
Skin Care
  • Delay first bath until the babys temperature
    stability is ensured.
  • Use universal precautions until after the first
    bath.

29
Umbilical Cord
  • No evidence for superiority of any particular
    technique.
  • Indeed, theres no evidence that any cord
    treatment does anything at all.

30
Hepatitis B Immunization
  • The best web site for information is
    http//cdc.gov/mmwr/preview/mmwrhtml/00033405.htm.
  • And the AAP policy at http//aappolicy.aappublica
    tions.org/cgi/content/full/pediatrics112/1/193
  • Particularly useful is the chart on page 196 of
    the policy.
  • A complicated topic that deserves review of the
    entire statement above.
  • A few important points follow.

31
Hepatitis B Immunization
  • Infants of Hepatitis B negative mothers should
    receive their first immunization in the nursery.
  • Infants of Hepatitis B positive mothers should
    receive both Hepatitis B vaccine and HBIG as soon
    as possible after birth, but within 12 hours,
    given at different sites.

32
Hepatitis B Immunization
  • If the mothers Hepatitis B status is unknown she
    should be tested and the infant should receive
    the Hepatitis B vaccine as usual. If she returns
    Hepatitis B positive the HBIG should be given as
    soon as possible but within 7 days of birth.

33
Hepatitis B Immunization
  • One important and easily overlooked point
    infants less than 2000 grams (which we will
    sometimes get in the newborn nursery) born to
    mothers with an unknown Hepatitis B status
    should get both the Hepatitis B vaccine and HBIG
    before 12 hours of age, as if the mother were
    known to be Hepatitis B positive. If the mother
    is found to be Hepatitis B positive, these
    infants will require 4 doses of the Hepatitis B
    vaccine rather than the usual three.

34
Neonatal Screening
  • North Carolina requires screening for 34
    different metabolic or genetic abnormalities (we
    have MS/MS). For all the disorders tested for in
    NC
  • http//slph.state.nc.us/Newborn/NBS_DisordersTeste
    d.pdf
  • Testing usually done at 24 hours of age for more
    accurate analysis.
  • Some tests requiring metabolite accumulation so
    may not be as accurate before 24 hours of age

35
Newborn Screening
  • A rapidly evolving field with much state to state
    variation regarding the number of diseases for
    which testing is required.
  • Results are reported to the infants documented
    primary care provider in 1-2 weeks time (in NC)
  • Repeat testing should be performed if clinically
    indicated regardless of the initial screening
    results.

36
Universal Hearing Screening
  • If passes, follow hearing clinically at well
    child visits.
  • If fails, repeat before discharge (sometimes
    multiple times)
  • If fails again, inform parents that Newborn
    Screening Nurse will schedule out-patient recheck.

37
Discharge Requirements
  • Family risk factors should be assessed, such as
    parental substance abuse or a positive urine
    toxicology, history of child abuse or neglect,
    mental illness in a parent, lack of social
    support especially for single first-time mothers,
    no fixed home, history of domestic violence, or
    adolescent mother.
  • Discharge may need to be delayed until they are
    resolved or a plan to safeguard the infant is in
    place.

38
Discharge Requirements
  • No evidence of excessive jaundice, by clinical
    and laboratory measures.
  • Transcutaneous bilirubin assessment done
  • The mothers or parents knowledge, ability, and
    confidence to provide adequate care of the
    newborn are documented.
  • Usually not considered until at least 24 hours of
    age.

39
Discharge Requirements
  • The infant has at least two successful feedings,
    with documentation of suck, swallowing, and
    breathing when feeding.
  • If breastfeeding an actual feeding should be
    observed by a caregiver knowledgeable in
    breastfeeding with documentation of success made
    in the medical record.
  • No physical examine finding requiring continued
    hospitalization.

40
Discharge Requirements Parental Teaching Needs
  • Condition of the neonate
  • Feeding assessment and advice
  • Umbilical, skin, and genital care.
  • Temperature assessment and measurement with a
    thermometer.
  • Signs of illness and common newborn problems,
    like jaundice.
  • Car seat mandatory
  • SIDS prevention advice
  • sleeping position on back only
  • Avoid passive smoke
  • Shaken Baby Syndrome prevention

41
Discharge Requirements
  • Maternal RPR done
  • Newborn metabolic screening and hearing screening
    done.
  • Hepatitis B vaccine given or documented why
    omitted.
  • Primary care Provider identified and parents
    advised to set up first newborn visit within 48
    hours of discharge.
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