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Introduction to Obstetrics and Care of the Newborn Infant

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Gravida- the # of times a woman has been pregnant (including this pregnancy) ... 2. Encephalocele- another. neural tube defect where the. cranium does not close and ... – PowerPoint PPT presentation

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Title: Introduction to Obstetrics and Care of the Newborn Infant


1
Introduction to Obstetrics and Care of the
Newborn Infant
  • Instructor Laurel Vanlandingham
  • RN, MSN, FNP

2
I. Terms related to Pregnancy
  • Gravida- the of times a woman has been pregnant
    (including this pregnancy), regardless of
    duration or outcome.
  • Para- the of pregnancies a woman has completed
    past 20 weeks, regardless of whether infant is
    born alive or dead (refers to number of
    pregnancies, not fetuses).

3
Other terms related to pregnancy
  • Abortion- any pregnancy loss before the 20th week
    or weighing less than 500 grams. Abortion can be
    either spontaneous (SAB) or therapeutic (TAB)
  • Term Birth-a birth occurring between the 38th and
    42nd weeks
  • Preterm Birth- a birth occurring after the 20th
    week, and before the 38th week
  • Postterm Birth- a birth occurring after the 42nd
    week
  • Trimester- a division of pregnancy into 3 equal
    parts of 13 weeks each

4
Calculation of Gravida and Para
  • Betsy Jones has had two miscarriages in the 1st
    trimester. She has one son, age five (born at 40
    weeks) and twins, age 3 (born at 35 weeks). She
    is now pregnant again, at 16 weeks.
  • What is her Gravida?
  • What is her Para?

5
  • Janice Smith is currently 24 weeks pregnant. She
    has been pregnant once before. She delivered 30
    week triplets with that pregnancy.
  • What is her Gravida?
  • What is her Para?

6
More complex method of describing Para (TPAL
method)
  • Para is often recorded in 4 numbers
  • T the number of term deliveries (after 37 weeks)
  • P the number of premature deliveries (gt 20 and lt
    37 wk)
  • A the number of abortions (either spontaneous of
    therapeutic)
  • L the number of living children

7
Adding a previx to gravida or para
  • Multipara- a woman who has given birth 2 or more
    times over 20 weeks gestation
  • Multigravida- a woman who has been pregnant more
    than once
  • Nullipara- a woman who has never completed a
    pregnancy past 20 weeks
  • Primipara- a woman giving birth for the first
    time of a pregnancy that has lasted at least 20
    weeks
  • Primigravida- a woman who is pregnant for the 1st
    time

8
Estimating due date
  • EDD- (estimated date of delivery)
  • Also called EDC (estimated date of confinement)
  • The average pregnancy gestation is 40 weeks or
    280 days from the first day of the last menstrual
    period (LMP).

9
Nageles Rule
  • Subtract 3 months from the 1st day of the LMP
  • Add 7 days
  • Correct the year if necessary
  • Example- LMP June 20th, 2005
  • Subtract 3 months- March 20th
  • Add 7 days- March 27th
  • Change the year if necessary- EDD March 27th,
    2006

10
II. Structures related to Pregnancy
  • 1. Placenta
  • Anatomy
  • Size- 6-10 across and 1 thick. Weight-1 lb. to
    1 ½ lbs.
  • Structure- Divided into sections or segments
    called Cotyledons.
  • Two sides
  • 1) Fetal side- shiny and smooth in appearance,
    the amniotic sac is attached to it (Schultz).
  • 2) Maternal side- dark red and rough in
    appearance (Duncan).

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12
Maternal side of placenta
Fetal Side of placenta
13
Physiology
  • Functions of Placenta
  • 1) Endocrine Gland produces several hormones
    necessary for normal pregnancy
  • HCG (human chorionic gonadotropin)
  • Estrogen
  • Progesterone
  • Human Placental Lactogen

14
  • 2) Site of nutrient and O2 exchange and fetal
    waste excretion
  • Occurs in the Intervillous space
  • About 150ml of the mothers blood is briefly
    outside of her circulatory system while it bathes
    the Chorionic Villi.
  • These are treelike structures that are derived
    from fetal tissue.
  • The blood is exchanged 3 to 4 times per minute in
    this space.
  • Maternal and Fetal blood do not mix

15
Intervillous space and Chorionic Villi
16
  • 3) Blocks certain harmful substances- most
    Bacteria and some Viruses are too large to pass
    through the placenta
  • 4) Maternal antibodies- many immunoglobulins are
    passed to the fetus giving passive immunity to
    diseases such as measles
  • 5) Metabolic functions- substances are
    synthesized in the placenta (glycogen,
    cholesterol, fatty acids)

17
2. Umbilical Cord
  • The lifeline between mother and fetus
  • 20-22 long, 1 thick.
  • Contains 3 vessels 2 arteries and 1 vein, which
    are protected by Whartons Jelly.
  • If abnormal of vessels present- often
    associated with fetal anomalies (heart and
    kidneys).
  • The arteries carry dirty blood away from fetus.
    The vein carries clean blood to fetus.
  • Central insertion into the placenta is normal

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20
3. Fetal Membranes
  • Called the Bag of Waters
  • Consists of two layers
  • 1) Amnion- inner membrane, next to fetus
  • 2) Chorion- outer membrane, next to mother
  • Function to house the fetus for the duration of
    pregnancy, protects from outside world, prevents
    vertical transmission of infection.

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4. Amniotic Fluid
  • Amniotic fluid is made up mainly from fetal
    urine, fluid from maternal blood, castoff cells,
    vernix, and fetal waste products.
  • Its function is to cushion fetus and protect
    from injury, to keep infant at stable 98.6
    temperature, to allow room for fetal movement and
    growth.
  • Normal volume- 500 to 1000 ml at term.

23
Oligohydramnios
  • Too little amniotic fluid (lt500 ml)
  • Complications poor fetal lung development,
    compression syndrome
  • Associated with fetal kidney abnormalities or
    inadequate blood flow through placenta.

24
Polyhydramnios- also called Hydramnios
  • Too much amniotic fluid (gt 2000 ml)
  • Associated with fetal CNS or GI tract
    abnormalities that prevent the normal fetal cycle
    involving ingestion of amniotic fluid.

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26
Think!
  • When the umbilical cord has two vessels, the
    condition is considered to be
  • A) normal
  • B) associated with intrauterine growth
    restriction
  • C) associated with congenital fetal malformation
  • D) associated with newborn anemia

27
III. Newborn Assessment
28
General Survey
  • Appearance
  • Symmetry, any obvious deformities, size, smell,
    muscle tone, sex, posture
  • Behavior
  • Crying, lethargic, responsive, reflexes, jittery

29
Measurements
  • Normal Weight
  • 2500-4000gms
  • 5 ½lbs. 8lbs, 13 oz.
  • (AGA-appropriate for gestational age)
  • Below normal (SGA- small for gestational age)-
    lt10
  • Above normal (LGA-large for gestational age)- gt90

30
  • Normal Length- 18-22 or 48-52 cm.
  • Head circumference- 13-14 or 32-36 cm. (measure
    right above eyebrows)
  • Chest circumference- 12-13 or 30-34cm (measure
    at nipple line)

31
Vital Signs
  • Temperature- first is usually taken axillary, but
    may be taken rectally to assure anal patency
    (36.5-37.5C or 97.5-99.5F)
  • Pulse- 110-160 bpm, unless sleeping (100) or
    crying (180)
  • Respirations- 30-60 with periodic breathing
  • B/P- only if suspected heart problem or premature
    infant

32
Skin
  • Color-
  • Pink
  • Pink with blue hands and feet (Acrocyanosis)
  • Jaundiced (yellow)
  • Blue/cyanotic
  • Mottled (lacy appearance)
  • Pale (white)
  • Harlequin (pink on one side, pale or blue on
    other)

33
Acrocyanosis
Mottling
Jaundice
34
Skin Appearance
  • Vernix- white cheesy substance
  • Lanugo- fine hair (usually on shoulders, ears and
    back)
  • Milia- plugged oil glands (usually on chin or
    nose)

35
Vernix
Milia
36
Rashes/Marks
  • Erythema Toxicum (Newborn Rash)
  • Forcep marks
  • Mongolian spots
  • Birthmarks
  • Port wine stain
  • Stork bite/Nevi
  • Strawberry mark
  • Café au lait
  • Petechiae

37
Erythema Toxicum
Mongolian spot
Forcep mark
38
Port wine stain
Stork bite/ Nevi
Strawberry hemangioma
39
Cafe au lait birthmark
Petechiae
40
Head
  • Size- 1 larger than chest ( gt 1 may be
    indicative of hydrocephalus)
  • Shape
  • Round
  • Moulding (suture lines overlap and head
    elongates)
  • Caput Succedaneum (head elongates and there is
    also edema of the soft tissue)
  • Cephalohematoma (hemorrhage into the cranial
    bone, swelling and bluish color on one side of
    the head- does not cross suture line)

41
Caput
Moulding
42
Cephalohematoma
43
  • Fontanels/Sutures- 2 fontanels
  • anterior one is diamond shaped- closes at about
    18 months old
  • posterior one is triangular shaped- closes by 2-3
    months

44
  • Facial Symmetry
  • Eyes- shape, slanted, hemorrhages, edema,
    strabismus

Asymmetry
Strabismus
hemorrhages
Slanted eyes
45
  • Nose- ? patency of each nares to r/o Choanal
    Atresia

46
  • Mouth- ? for cleft lip and palate, ? for neonatal
    teeth, Epsteins pearls, Thrush

Cleft lip
Cleft palate
47
Epsteins Pearls
Thrush
Neonatal teeth
48
  • Hair- fine with consistent hair pattern (abnormal
    hair patterns indicated genetic abnormalities)

49
  • Ears-
  • normal shape
  • patent
  • even with eyes (low set ears indicate
    congenital abnormalities)
  • Pits or tags





50
Major birth defects of the Head
  • 1. Anencephaly- a neural tube defect where only
    the brain stem grows and there is no brain tissue
  • 2. Encephalocele- another
  • neural tube defect where the
  • cranium does not close and
  • the meninges protrude out of the
  • head

51
  • Neck and Clavicles- is the neck thick or webbed,
    do the clavicles feel intact, no crepitus.

52
Chest
  • Size- 1 smaller than head
  • Shape- cylinder shape is normal. Asymmetry can be
    caused by Pneumothorax or Diaphragmatic Hernia
  • Nipples- location, distance apart, any accessory
    nipples

53
Pneumothorax
54
Lung Sounds
  • clear or moist, equal, bowel sounds in chest?
  • S/S of respiratory distress
  • (tachypnea, grunting, retractions, nasal flaring,
    cyanosis)
  • Rate (listen for 1 full minute)

55
Heart Sounds
  • - auscultate for rate rhythm
  • - presence of murmurs (murmurs are common in the
    newborn period- 90 are transient and considered
    normal)
  • Listen for 1 full minute
  • Report any abnormal rate, rhythms or sounds to
    pediatrician
  • If suspected heart problem- take B/P on all four
    extremities

56
  • Abdomen
  • - Size- same or smaller than chest
  • Shape- rounded, no distention
  • Any obvious deformities (Gastrochesis,
    Omphalocele)
  • Bowel sounds- present, hypo, hyper
  • Cord- color, of vessels, clamp on tight (no
    skin attached), no bleeding noted

57
Omphalocele
Gastrochesis
58
Genitalia
  • Female- labia may be swollen and red from
    delivery, hymenal tag, pseudomenses, whitish
    drainage
  • Male- testes should be descended at term, rugae
    on scrotum, check where urinary meatus comes out
  • Hypospadias- urethral opening is on the underside
  • Epispadias- urethral opening is on the upperside

59
Hypospadius with repair
60
Extremities
  • Arms Hands
  • Symmetry
  • 10 fingers
  • Simian crease
  • Polydactyly- extra digits
  • Syndactyly- webbing of digits
  • Brachial pulse

61
Syndactyly
Polydactly
Simian Crease
62
Hips- check for congenital hip dysplasia
Normal Hip
Hip Dysplasia
63
S/S of Hip Dysplasia Hip click Ortalanis
test One leg shorter Gluteal creases assymetrical
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Legs and Feet
  • Symmetry
  • 10 toes
  • Femoral pulse
  • no club feet
  • Creases on bottom of feet

66
Back and Buttocks
  • - Straight spine
  • - Spina Bifida Occulta- dimple or tuft of hair
  • Meningocele (sac with fluid only)
  • Meningomyelocele (sac with fluid and spinal cord)

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69
Neurologic
  • Reflexes (see page 533)
  • Babinski, Plantar, Moro, Rooting, Sucking,
    Stepping, Tonic neck
  • Sensory assessments
  • (do eyes track, does infant respond to sound?)

70
Gestational Exam
  • EDD is not always correct (only accurate 75-85
    of the time)
  • Performing a gestational exam helps the nurse
    evaluate for potential age-related problems.
    Should be done in the first 4 hours of life.
  • Gestational age tools have 2 components physical
    maturity and neuromuscular maturity
  • Most common tool is the Ballard
  • (see pages 538-545 in text)

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73
Lab Assessments
  • Blood Glucose (gt40 mg/dl is normal)
  • Bilirubin Level- lt 12 is normal. Peaks on 3rd day
    of life
  • Newborn Screening Test (NBS)- State required test
  • -Phenylketonuria (PKU)
  • -Hypothyroidism
  • -Galactosemia
  • -Hemoglobinopathies

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IV. Adaptation of the Newborn Infant
76
Initiation and Maintenance of Respirations
  • 1) Lung Development- as a baby nears birth, fluid
    begins to move to interstitial space. Production
    of Surfactant by 34-36 weeks. Keeps alveoli of
    lungs from collapsing when exhalation occurs.

77
Factors that initiate Respirations
  • 1) Chemical Factors- ?in O2 and ? in CO2 causes
    impulses to stimulate the respiratory center in
    the medulla of the brain.
  • 2) Thermal Factors- abrupt temperature change
    sends impulses to brain
  • 3) Mechanical Factors- fetal chest is compressed
    during birth, forcing fluid out.
  • 4) Factors that maintain respirations-
    surfactant, functional residual capacity

78
Cardiovascular Adaptation Transition from fetal
to neonatal circulation
  • What is fetal circulation?
  • A combination of structures/vessels that are
    present only during the fetal period, which help
    shunt the highest oxygenated blood to the head,
    brain and heart.
  • 1) Ductus Arteriosus
  • 2) Foramen Ovale
  • 3) Ductus Venosus

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At birth, after the first few breaths, the
following cardiovascular changes occur
  • 1) Ductus Arteriosus closes in response to ?O2
    and ? resistance in lungs
  • 2) Pulmonary blood vessels dilate in response to
    demand in lungs
  • 3) Foramen Ovale is forced to close because of
    increased pressure in left side of heart
  • 4) Ductus Venosis constricts when umbilical cord
    is clamped

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Neurologic Adaptation Thermoregulation
  • The maintenance of body temperature is a major
    task for the NB infant (normal temperature is
    97.7-98.6)
  • 1) their skin is thin and blood vessels are close
    to the surface
  • 2) they have little SQ fat to serve as a barrier
    to heat loss
  • 3) they have 3x the surface to body mass as an
    adult
  • 4) Preterm infants are especially susceptible to
    heat loss because their tone is poor and they
    have even less fat and thinner skin than full
    term babies.

83
Methods of Heat Loss
  • 1) Evaporation-occurs when wet surfaces are
    exposed to air.
  • 2) Conduction- occurs when the NB comes in direct
    contact with objects that are cooler than their
    skin.
  • 3) Convection- occurs when heat is transferred to
    air that surrounds the NB.
  • 4) Radiation- occurs when there is a transfer of
    heat to cooler objects that are not in direct
    contact with the infant.

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Effects of Cold Stress
  • 1) ?Metabolic Rate leads to ? use of glucose and
    ? production of Surfactant. This can lead to
    hypoglycemia and respiratory distress.
  • 2) Non-Shivering Thermogenesis-metabolism of
    Brown fat. This leads to increased production of
    free fatty acids, which leads to metabolic
    acidosis and jaundice.
  • 3) Vasoconstriction leads to pale, mottled skin
    and shut down of pulmonary vessels, which leads
    to fetal circulation patterns.

86
Brown Fat
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88
Neutral Thermal Environment
  • NTE helps prevent heat loss in newborns.
  • Maintains stable temp without an increase in
    oxygen or metabolic rate.
  • In healthy unclothed NBs, 89.6? to 92.3?.

89
Hematologic Adaptation
  • 1) Blood Values-
  • RBCs- Newborns have a higher of RBCs than
    adults, and their RBCs are larger in order to
    receive adequate O2 to cells. Polycythemia a
    high RBC count. Increases risk of jaundice and
    brain infarct.
  • Hematocrit- higher than in the adult. 48-69 is
    normal (heel stick) 65 venous blood

90
  • WBCs- Elevation is normal, because the stress of
    birth increases production.
  • Infection can cause either decreased or increased
    WBCs with large of immature WBCs (Bands or
    Stabs).
  • 2) Risk of Clotting deficiencies- the NB is at
    risk because they lack Vitamin K, which activates
    several clotting factors in the body- factors 2,
    7 and 10.
  • To decrease this risk, NBs are given an
    injection of Vitamin K at birth.

91
Gastrointestinal System Adaptation
  • 1) Stomach- capacity is low at birth, but expands
    to about 90ml within a few days. The cardiac
    sphincter is relaxed, which causes a tendency to
    regurgitate.
  • 2) Intestines- sterile at birth, once the infant
    takes in food, bacteria enters the GI tract.
  • 3) Digestive enzymes- deficient in amylase and
    lipase until 3-6 months of age. Breast milk has
    these two enzymes.
  • 4) Stools- 1st stool is meconium, which has
    accumulated in the intestines throughout
    gestation. Usually the 1st Meconium stool is
    passed within first 24 hrs of live. Passage
    during labor is a sign of fetal stress.

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Hepatic System Adaptation
  • 1) Blood Glucose Maintenance- glucose is stored
    in the liver during the last 4-8 weeks of
    pregnancy. This is used for the energy of birth,
    heat production and stores until the first
    feedings are taken.
  • Normal blood glucose for infants is 40-60. lt 40
    is considered hypoglycemia.
  • Infants at risk for hypoglycemia
  • SGA, LGA, stressful deliveries, infection, cold
    stress.

94
2) Conjugation of Bilirubin
  • Bilirubin is a byproduct of the breakdown of
    RBCs.
  • It is released in the unconjugated form.
  • Unconjugated bilirubin is fat-soluble and is
    absorbed by the SQ fat, causing a yellowish
    discoloration of the skin, called jaundice.
  • The liver must conjugate the bilirubin (change it
    into a water-soluble form) in order for the body
    to excrete it through the urine and the stool.

95
The conjugation of Bilirubin by the Liver
96
Hyperbilirubinemia
  • Definition excessive levels of bilirubin in the
    blood gt12 mg/dl.
  • Extremely high levels gt25 mg/dl can lead to brain
    damage because the brain tissues are stained
    (Kernicterus)
  • Two types
  • 1) Physiologic Jaundice
  • 2) Pathologic Jaundice

97
1) Physiologic Jaundice
  • Timing Occurs after 24 hrs
  • Peaks on 3rd day of life
  • Incidence Occurs in 60-80 of NBs
  • Etiology Caused by breakdown of excessive RBCs
    after birth. The immature liver cant handle them
    all, so build up of unconjugated bilirubin
    occurs, and skin becomes yellow.
  • Bruising, cephalohematoma, or poor feeding
    (dehydration) worsens this normal occurrence
  • Breast Milk Jaundice- sleepy infants who have a
    poor suck do not receive enough colostrum
    (laxative effect clears bilirubin rich meconium)

98
  • Treatment If level goes gt 12mg/dl
  • 1. Phototherapy lights are started- high
    intensity flourescent lights that convert the
    bilirubin under the skin so that it can be
    excreted in the stool.
  • The eyes and the genitals of the infant must be
    protected.
  • 2. Feedings are increased to promote stooling and
    urination (with breast milk jaundice- formula is
    given for 24-48 hours)
  • 3. IV fluids may be needed if infant not feeding
    well.

99
Phototherapy Bed
100
Phototherapy Blanket
Phototherapy Lights
101
2) Pathologic Jaundice
  • Timing Occurs in the first 24 hours of life,
    some infants born jaundiced. Level reaches 12
    mg/dl by 24 hrs.
  • Etiology anything that causes the destruction of
    RBCs
  • 1) Incompatabilities between maternal and fetal
    blood
  • Rh Incompatability
  • ABO Incompatability
  • 2) Infection
  • 3) Metabolic Disorders

102
Rh Incompatability
  • This occurs when the expectant mother is Rh-, the
    father is Rh and the fetus is Rh.

Rh
Rh-
Rh
103
Pathophysiology
  • People who are Rh have the Rh antigen on their
    RBCs. People who are Rh- do not.
  • If blood that is Rh enters the body of a person
    who is Rh-, the body reacts as it would to any
    foreign substance, and develops antibodies that
    destroy the invading antigen (this is called
    sensitization)

104
A sensitized mother who has built up antibodies
105
  • Theoretically, there is no mixing of fetal and
    maternal blood during pregnancy.
  • However, small placental accidents can occur
    (usually at the time of birth) that allow a drop
    or two of fetal blood to enter the maternal
    circulation.
  • This can also occur during a spontaneous or
    elective abortion, or during antepartal
    procedures, such as amniocentesis, or with
    placental problems, such as abruptio placenta.

106
  • Maternal antibodies cross the placental barrier
    and cause massive destruction of the fetus
    RBCs.
  • To destroy the Rh antigen (which exists as part
    of the RBC), the antibody must destroy the entire
    RBC.

107
Fetal and Neonatal Implications
  • 1) Pathophysiology
  • Once the mother is sensitized and has developed
    antibodies, the current fetus (if occurs early in
    pregnancy) and any subsequent Rh fetus will
    develop a condition called Erythroblastosis
    Fetalis.
  • 2) S/S
  • Infant born severely anemic and jaundiced
  • Infant has generalized edema because of the
    profound anemia -Hydrops Fetalis
  • Congestive heart failure
  • Ascites
  • High risk for death

108
Treatment
  • Phototherapy
  • IV fluids
  • Exchange Transfusion
  • Cardiac support (Dopamine)
  • Infusion of Albumin

109
Maternal Implications
  • All pregnant women tested for Blood type and Rh.
  • Any Rh- woman also tested for Coombs Test
    (determines presence of Rh antibodies in maternal
    blood).
  • If unsensitized A Rh Immunoglobulin (RhoGAM) is
    given at 28 weeks.
  • If sensitized Coombs test is repeated
    throughout pregnancy to determine if the titer is
    rising. Any increase means this infant is Rh and
    is in jeopardy. Amniocentesis is done to
    determine fetus Rh factor. Fetal diagnostic
    tests are done weekly to determine fetus
    well-being. Intrauterine transfusion and/or early
    delivery may be needed.

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Postpartum Management
  • Infant is tested from cord blood to determine
    blood type and Rh, also a Coombs test is done.
  • If infant is Rh, mother must receive another
    dose of RhoGAm within 72 hrs of birth to prevent
    antibody formation.
  • If infant is Rh-, no treatment is needed.

112
ABO Incompatability
  • 1) Occurs when the mother is type O blood and the
    infant is A, B, or AB.
  • 2) not as severe as Rh incompatability, but can
    lead to jaundice in the NB.
  • 3) Pathophysiology Type A, B, or AB blood has an
    antigen that is not present in type O blood.
    People with type O develop anti-A or anti-B
    antibodies naturally as a result of exposure to
    antigens in foods, or to infections by
    gram-negative bacteria. IgG or IgM antibodies are
    formed. The IgG antibodies cross the placenta and
    cause hemolysis in the fetus.

113
  • The first fetus can be affected.
  • IgG are the only antibodies that can cross the
    placental barrier, and usually most of the
    antibodies formed are IgM, so this condition is
    usually much milder than the Rh issue.
  • At birth, the coombs test will detect whether
    antibodies are present. If so, serial bilirubin
    level checks are done, and the infant is watched
    closely for jaundice.

114
Other Liver functions
  • 4) Iron Storage- Iron is stored from the mother
    in the last weeks of pregnancy. If the infant is
    full term, enough iron should be present to last
    4-6 months. By then the infant should be started
    on foods that have iron, such as infant cereal.
  • 5) Metabolism of drugs- NBs metabolize drugs
    slower than older children because their liver is
    immature. Any drug taken in labor may take a
    while to get out of the babys system. Also,
    breastfeeding women need to be cautious what they
    take.

115
Urinary System Adaptation
  1. Blood flow to the kidneys increases following
    birth, because of decreased resistance in the
    Renal blood vessels.
  2. 1st void should occur within 24 hrs.
  3. Absence of urine could indicate hypovolemia,
    absence of kidneys, or kidney anomalies.
  4. Usually Oligohydramnios is also present when
    there is a kidney dysfunction.

116
Psychosocial Adaptation
  • Behavioral States
  • 1) Quiet sleep- deep sleep, no eye movement,
    resp. quiet and slower
  • 2) Active sleep-rapid eye movements, may move
    extremities or stretch
  • 3) Drowsy- transitional period, yawns, eyes
    glazed
  • 4) Quiet alert-infant able to focus on objects or
    people, tuned into environment
  • 5) Active alert-restless, starting to fuss,
    faster respirations, more aware of discomfort
  • 6) Crying- follows quickly if parent doesnt
    intervene during active alert state.

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V. Care of the Newborn
  • 1) Vitamin K- 1 mg. given IM (Vastus Lateralis)
    to promote clotting factor formation.
  • 2) Eye treatment- Antibiotic eye ointment is
    given to protect against organisms contracted in
    the birth canal.
  • Gonorrhea and Chlamydia cause Opthalmia
    Neonatorum, a serious eye infection that can
    cause blindness if not caught early.

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  • 3) Blood glucose
  • Checked on all babies who are SGA, LGA, have low
    temperatures, are jittery, or who had a stressful
    delivery.
  • If below 40 mg/dl, start feeding protocol per
    hospital.
  • 4) Circumcision
  • Pros/Cons
  • Techniques (Gomco or Plastibell- page 563)
  • Pain Relief
  • Nursing Responsibilities

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Plastibell method
Gomco method
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  • 5) Bathing-
  • remember Thermoregulation
  • Good time to observe for any missed abnormalities
  • Sponge bath until cord falls off
  • 6) Cord care-
  • Alcohol, Betadine, Triple dye
  • Teach parents how to care for cord and when to
    expect it to fall off

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  • 7) Protection of Infant- Security, ID badges,
    observation of any suspicious looking people
  • 8) Teaching Parents
  • NB Care
  • Feeding
  • When to call the Doctor
  • Lab tests
  • Hearing Screen

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VI. Care of the High Risk Newborn
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Levels of Care
  • Level 1 nurseries- Newborn
  • Care for minor problems and transitional issues
    (TTN, Jaundice, hypothermia)
  • Level 2 nurseries- care of preterm infants 32
    weeks or gt, conditions that will resolve rapidly
    (sepsis, mild RDS)
  • Level 3 nurseries- care of severely preterm and
    infants with long term problems
  • Level 4 nurseries- Tertiary centers that do
    specialty care, such as heart surgery

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Infants at risk because of gestational age or size
  • SGA/IUGR- an infant born at lt10 normal weight
    for its gestational age.
  • -Symmetric growth restriction indicates long-term
    complications because the total of cells are
    decreased. Caused by congenital anomalies,
    exposure to infection or drugs early in pregnancy
  • -Asymmetric growth restriction (head looks big in
    comparison to body) Brain and heart size are
    normal, other organs may be small. Growth problem
    starts in the 3rd trimester. These babies
    generally catch up.

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Etiology of SGA/IUGR
  • Maternal factors
  • Maternal disease
  • Environmental factors
  • Placental factors
  • Fetal factors

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Nursing considerations
  • 1. Assess for hypoglycemia
  • Feedings- early and more frequent
  • 2. Assess for hypothermia
  • Extra clothing and blankets, overhead warming
    units, isolettes

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LGA
  • Definition an infant whose birth weight is at or
    above the 90th at any week of gestation.
  • Etiology Most commonly infants born to Diabetic
    mothers

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Common complications of the LGA newborn
  • 1) Birth trauma increased incidence of cesarean
    births
  • 2) Hypoglycemia
  • 3) Polycythemia Hyperviscosity
  • 4) Respiratory Distress syndrome
  • 5) Congenital birth defects- particularly in the
    Infant of a Diabetic mother

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Nursing Considerations
  • 1. Assess for birth injuries
  • Fractured clavicles, brachial palsy
  • 2. Assess for hypoglycemia
  • Follow hospital protocol for obtaining blood
    glucose by heel stick
  • 3. Assess respiratory functioning
  • Rate, effort, breath sounds

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Post term Infants
  • Definition an infant born p 42 weeks.
  • 12 of all pregnancies
  • 5 of these infants exhibit Postmaturity
    syndrome, caused by decreased placental
    functioning which leads to low oxygen levels and
    nutrition transport.
  • S/S Hypoxia, malnourished, loose skin, long
    nails, wrinkled and cracked, peeling, meconium
    stained cord, skin and nails.

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Common complications of the post-term newborn
  • 1) Hypoglycemia
  • 2) Meconium aspiration
  • 3) Polycythemia
  • 4) Seizures
  • 5) Cold Stress/Hypothermia

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Nursing considerations
  • Assess respiratory functioning (especially if
    meconium was passed)
  • Assess for hypoglycemia- early and more frequent
    feedings
  • Assess for hypothermia- blankets, warming units,
    etc.
  • Assess for polycythemia which can increase the
    risk for hyperbilirubinemia

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Preterm Infants
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Scope of Problem
  • In 2004, 12 of all births were preterm. This
    has not decreased, in spite of advances in
    technology to save these infants.
  • In fact, since 1982, there has been a 27
    increase in premature births
  • Some of the reasons for this increase
  • ? rate of births to women 35 years old
  • ? rates of multiple births (ART)
  • ? substance abuse in childbearing women
  • ? Stress

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Survival rates of Preterm Infants
  • Birth weight of 1000-1500gms 85-90
  • Birth weight of 500-600gms 20
  • In terms of medical expense, lost potential and
    suffering of infants and their parents,
    prematurity is very costly
  • 1 cause of neonatal mortality (1st four weeks)
  • 1 cause of infant mortality (1st year)
  • 1 cause of black infant mortality
  • Major cause of childhood disabilities
  • Total U.S. hospital charges for infant stays due
    to prematurity/LBW 11.9 Billion

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Etiology and Risk Factors for Premature Birth
  • Etiology Unknown
  • Risk Factors
  • Infection
  • Multifetal pregnancy
  • Hx of previous preterm delivery
  • Maternal disease PIH, Diabetes, heart disease
  • Low socioeconomic status of mother
  • Substance abuse
  • Maternal age lt17 or gt35 years old

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Prevention of Premature Birth
  • Adequate prenatal Care
  • Identification of high risk mothers/ fFN test
  • Identify and treat infections early
  • Teach mothers s/s of premature labor
  • Adequate nutritional state of mother
  • Early identification of substance abuse
  • March of Dimes (5 year Campaign to decrease
    Prematurity)
  • Professionals and Researchers

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Common problems in the Preterm Infant
  • 1) RDS- Respiratory Distress Syndrome (also
    called Hyaline Membrane Disease)
  • Etiology Insufficient production of Surfactant
    (allows alveoli to remain open with exhalation).
  • Pathophysiology When surfactant is insufficient,
    the alveoli collapse each time the infant
    exhales. The lungs become stiff and resistant
    to expansion. Atelectasis and hypoxia eventually
    occur, along with respiratory acidosis.

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  • 20 of Neonatal deaths in the U.S. are from RDS.
  • Signs/Symptoms of RDS
  • 1) Grunting on expiration
  • 2) Tachypnea
  • 3) Retractions
  • 4) Cyanosis
  • 5) Nasal Flaring
  • 6) Respiratory Acidosis

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  • Diagnosis Made by s/s and Chest X-ray (ground
    glass appearance)

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Treatment
  • Supportive (mechanical ventilation, correction of
    acidosis, IV fluids)
  • Surfactant Replacement (can be repeated several
    times)
  • Infants treated with Survanta have higher
    survival rates and fewer complications of RDS

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Nursing Care of the Patient with RDS
  • Strict I O
  • Watch blood sugar
  • Maintain Umbilical catheter
  • Draw and interpret blood gases, and work with
    respiratory therapist in adjusting ventilator or
    O2 settings
  • Watch for complications Pneumothorax, worsening
    RDS, Intraventricular Hemorrhage

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Other considerations
  • Position Infant for Optimal Neurological
    Development

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Promote Bonding with Parents (Kangaroo Care)
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Other common problems of the premature infant
  • 1) Apnea
  • 2) Thermoregulation
  • 3) Poor feeding/ GI infections (Necrotizing
  • Entercolitis)
  • 4) Bronchopulmonary Dysplasia (BPD)
  • 5) Intraventricular Hemorrhage
  • 6) Retinopathy of Prematurity
  • 7) Poor parent-infant bonding

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Nursing Interventions to promote bonding
  • 1) give photographs
  • 2) place infants first name on the incubator
    ASAP
  • 3) provide information on infants progress
  • 4) involve parents in decision making
  • 5) teach parents about unique behavioral clues of
    the preterm infant
  • 6) Kangaroo care
  • 7) allow to do cares when infant is stable

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Infants at risk because of maternal substance
abuse
  • Identifying drug-exposed infants (Red flags!)
  • - lack of prenatal care
  • - placental abruption (cocaine or speed)
  • - abnormal behavior of mother

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Abnormal s/s of infant
  • irritable
  • jittery
  • restless
  • prolonged high-pitched cry
  • difficult to console
  • poor feeding (uncoordinated suck, frequent
    vomiting)
  • diarrhea
  • poor sleep patterns
  • yawning
  • sneezing nasal stuffiness
  • tachypnea
  • seizures

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Narcotic Abstinence Syndrome (NAS)
  • Seen in infants who have been exposed to opiates,
    such as Heroin or Methadone
  • Infants experience severe withdrawal symptoms
  • Drug therapy is used to control s/s-
    Phenobarbital, oral morphine, paregoric, tincture
    of opium, methadone (drug dosage is tapered over
    time)

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Nursing considerations
  • Substance testing when suspicious- urine or
    meconium is obtained
  • Scoring on Abstinence Scale
  • ? stimulation Swaddling, lights low, group cares
    together, quiet spot in Nursery
  • Medication if needed

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Legal and Parental Considerations
  • Maternal drug test can only be done with consent
  • Infant drug test can be done without consent,
    based on suspicions because of mothers behavior
    or infants s/s.
  • A positive drug test usually results in a CPS
    referral. They interview mother, and then
    determine placement of child.
  • Nurses need to promote bonding and document
    mothers visits and behavior well.

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Infants at risk because of Infection
  • Bacterial infection of the newborn affects 1-4 in
    every 1000 live births.
  • NBs acquire infection in one of two ways
  • 1) Vertical transmission- In utero, either by
    passage across the placenta, or during labor, as
    organisms ascend the vagina.
  • 2) Horizontal transmission- After birth, from
    hospital staff or equipment (Nosocomial), or
    family members

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Common organisms
  • Group B strep
  • E. coli
  • Haemophilus influenzae
  • Staph Aureaus
  • Viral (CMV, herpes, HIV, Rubella)
  • Syphillis, Gonorrhea
  • Toxoplasmosis

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Signs/Symptoms
  • Temperature instability (usually with low
    temperatures, rather than high)
  • Respiratory problems
  • Feeding Intolerance
  • Lethargy
  • Hypoglycemia
  • Apnea

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Therapeutic Management
  • 1) Testing- blood cultures, urine samples, CBC,
    CSF, C-reactive Protein
  • 2) Broadspectrum Antibiotics (Ampicillin and
    Gentamicin)
  • 3) Supportive Care- fluids, oxygen, warmth,
    glucose stabilization

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Infants at risk because of respiratory problems
  • 1) Transient Tachypnea of the Newborn (TTNB)
  • Etiology Retained lung fluid
  • Risk Factors Cesarean Birth, asphyxia at birth,
    maternal analgesia, bleeding, diabetes.
  • S/S Tachypnea (as high as 120/min), retractions,
    nasal flaring, may or may not have grunting, mild
    cyanosis. Chest X-ray shows streaking and
    presence of fluid in the lungs.
  • Condition is self-limiting and treatment is
    supportive.

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Same baby with TTNB, x-rays are 24 hours apart
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2) Meconium Aspiration Syndrome (MAS)
  • MAS develops when meconium in the amniotic fluid
    enters the lungs during fetal life, or at birth.
  • Risk Factors Postterm infants, Intrauterine
    asphyxia
  • Meconium in the lungs causes obstruction of the
    airways and air trapping. This can result in
    pneumothorax and/ or respiratory distress.

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Therapeutic Management
  • At birth, the airway must be cleared. The
    obstetrician suctions the mouth and pharynx, then
    the NICU team intubates the trachea, and deep
    suctioning is done (prior to the infant
    crying/breathing).
  • Treatment includes respiratory support (oxygen,
    ventilation), Antibiotics, and possible ECMO.

163
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