8.1a Newborn Transition and Adaptation Flashcards
1
Q
First Period of Reactivity
A
- Baby is awake and alert
- Once cord gets clamped/cut the baby uses its own heart and transfers to adult circulation.
- HR 160-180
- Not unusual for baby to have irregular respirations, crackles, retractions
- Tachycardia/Tachypnea (Up to 80 breaths a minute)
- Breastfeeding is essential as soon as possible (skin to skin immediately)
- Resuscitation should be done on mom’s chest
- Best and most important time for breastfeeding
2
Q
Period of Decreased Responsiveness
A
- After first 30 minutes baby will be sleepy for a few hours (60-100 minutes)
- Rapid and shallow respirations are common
- Acrocyanosis (Normal for the first 12-24 hours)
3
Q
Second Period of Reactivity
A
- Occurs 2-8 hours after birth (Hyperalert and responsive phase)
- Lasts 10 minutes to several hours
- Good to keep baby on skin to skin contact at all times (breastfeed)
- Increased mucus secretions that may need to be suctioned
- Often pass meconium
- Tachycardia/Tachypnea (Transient)
4
Q
Fetal Lung Development
A
- 20-24 weeks of gestation (alveolar ducts appear)
- 24-28 weeks gestation (primitive alveoli, supports gas exchange, surfactant present)
- 28-32 weeks of gestation (Active surfactant production)
- 35 weeks of gestation (peak surfactant production)
5
Q
Surfactant
A
- Composed of phospholipids which line and lower surface tension of alveoli
- Stabilizes alveoli by allowing air to remain in alveoli during expiration
L/S - 2:1 Ratio - Indicates lung maturity
Lecithin - Peak production at 35 weeks of gestation (Most abundant phospholipid in surfactant)
Sphingomyelin - Levels remain constant throughout gestation
- Synthetic surfactant can be used if lungs are not mature
6
Q
Respiratory Adaptations
A
Initiation of Breathing
- Chemical (Babies have asphyxia from vaginal birth due to squeeze and contractions. When cord is clamped, chemical factors trigger effort of respiration.)
- Mechanical (The contractions that occur push the fluid out of the babies lungs which allows baby to breathe)
- Thermal (Cooler environment stimulates baby to take a deep breath)
- Sensory (Once babies are born and exposed to loud noise, bright lights, skin stimulation, it stimulates baby to take their first breath)
7
Q
Characteristics of First Breaths
A
- Periodic Breathing - Pauses lasting 5-15 seconds followed by regular rate (no color or HR change. This is normal)
- Obligatory nose breathers (low oxygen would be put by their nose if needed)
- 30-60 breaths a minute is normal
(Always count for 1 full minute because of periodic breathing)
8
Q
Respiratory Distress
A
- Increased respiratory rate
- Grunting, Nasal Flaring, Intercostal or Subcostal Retractions
Color Change - Acrocyanosis (Lasting longer than first 24 hours ABNORMAL)
- Central cyanosis (Best place to look is mucus membranes - Hypoxemia)
- Circumoral Cyanosis (Blue around the mouth. Cardiac Disease is Worried)
9
Q
Interventions for Respiratory Adaptation
A
- Clear the airway (mouth first, nose second) - With suction
- Stimulate the newborn to cry by drying the baby
- Administer oxygen if necessary
10
Q
Integumentary Adaptations
A
- At birth skin is covered with Vernix Caseosa (yellow stuff on baby)
- Term infant may be red (erythematous) which fades at birth
- Skin may be blotchy or mottled and extremities may be slightly blue (acrocyanosis)
- Fine lanugo hair may be noted (the younger the baby the more lanugo)
11
Q
Fetal Shunts
A
- Ductus Venosus - Bypasses the liver
- Foramen Ovale - Between the atria
- Ductus Arteriosus - Between pulmonary artery and aorta
These 3 shunts, send blood away from organs that don’t need it (these make up fetal circulation)
- Minimizes blood that goes to lungs and liver
12
Q
Cardiovascular Adaptations
A
Once cord is clamped and baby takes their first breath..
- Pulmonary vascular resistance decreases (so blood starts flowing to the lungs)
- Increased systemic pressure causes closure of ductus venosus
- Increased pulmonary blood flow from left side increases pressure in left atrium and closes foramen ovale
- The ductus arteriosus closes as pulmonary circulation increases
- Sometimes the foramen ovale and ductus arteriosus can stay patent in the first 24-72 hour which cause murmurs. Babies must be watched closely.
13
Q
Cardiovascular Adaptations
A
HR
- Apical pulse should be 100-160
- During sleep it may be less than 100
Murmurs
- 90% are transient related to incomplete closure of fetal shunts
Blood Pressure (This is not routine unless their are risks)
- Vary in the first 24 hours
- Full term 60-90/40-60
14
Q
Hematologic Adpatations
A
- Fetal circulation is less efficient at oxygen exchange due to bypass of lungs so greater RBC’s are required in utero
- Average RBC, Hgb, Hct are higher than adults
- RBC’s also die at a faster rate
15
Q
Hematologic Adaptation
A
- 80% of newborns blood at birth contains fetal hemoglobin. (These cells have a shorter life resulting in dramatic RBC decrease resulting in minor brief anemia) - take some extra iron
- Leukocytosis (elevated WBC count) is normal and not a sign of infection
16
Q
Coagulation Concerns
A
- Clotting factors 2,7,9,10 are activated by Vitamin K
- Injection of Aquamephyton (Vitamin K) given at birth due to absence of flora in the intestines
- Bacteria in the gut is required to produce vitamin K. Babies have a sterile gut when they are born so they do not have vitamin K. This is why we need to supplement vitamin K at birth.
- Babies won’t have vitamin K until they start eating. Bottle feeding, normal flora takes a while to develop. Breast feeding is better.
17
Q
Factors Affecting Thermal Stability
A
- Babies have low subcutaneous fat
- Babies have a large body surface area compared to their weight
- Blood vessels are closer to the skin so it cools more quickly
- Babies cannot shiver (flexion state)
- Babies have limited brown fat
- Rate of heat loss is 4x faster than adults
18
Q
Types of Heat Loss
A
Convection - Air is blowing over baby causing heat loss
Conduction - Baby loses heat from being in touch with cold surface
Radiation - Baby are next to a cold surface which radiates cold air
Evaporation - Baby cools very quickly when they are wet
19
Q
Thermogenesis
A
- How do babies generate heat (thermogenesis)
- BMR increases to create heat (uses oxygen and glucose)
- Brown fat is used as primary heat source because babies cannot shiver (brown fat is limited)
- If baby uses up all their brown fat, they will use glucose to stay warm. It is essential to keep a baby warm to keep their blood glucose stable. Low blood glucose (baby will get cold)
Response to heat
- Warmth will cause baby to be relaxed and not tight flexion
- If a baby is extended (arms wide out) and flushed skin, it means they are too warm
- Babies have limited sweat glands so they are easily overheated
- Sweat production matured at 4 weeks
20
Q
What Happens When Baby is Cold
A
- They have increased o2 consumption which causes increased respiratory rate
- Increased respiratory rate causes both pulmonary and peripheral vasoconstriction
- Pulmonary vasoconstriction causes less oxygen uptake my lungs, which causes less oxygen to tissues, which leads to baby requiring use of anaerobic glycolysis (conversion of glucose)
- Peripheral vasoconstriction causes less o2 to tissue as well which also leads to glycolysis
- Glycolysis leads to less oxygen and less pH in the blood
- Less pH and oxygen causes acidosis in the baby
- Glucose and coldness of baby go hand in hand
21
Q
Renal Adaptations
A
- Almost all babies void in the first 30 hours
- At least 1 void is expected in the first 24 hours
- If a baby hasn’t voided in 48 hours, interventions may be needed. We wait 48 hours because sometimes babies urinate at birth but goes unnoticed because of other fluids
- Babies have a low GFR so they cannot concentrate their urine until 3 months of age. This is why we must watch a babies fluid load.
- Uric acid crystals are common (looks like brick dust spots). You need to explain this to parents
22
Q
GI Adaptations
A
- Babies can swallow, digest, metabolize, absorb simple carbs, and protein
- Coordination of breathing, sucking and swallowing reflexes are something we need to watch for
- Babies have very small stomachs (size on next slide)
- 15-30 mL per meal per day increased feedings
- Immature cardiac sphincter leads to intermittent “spitting”
- Babies may lose up to 5-10% birth weight in the first week
- Colostrum (immature milk) gives babies all the nutrients they need, but it does not have volume. Mature milk does not come in until day 3-4.
23
Q
Baby Stomach Size
A
Day 1 - 5-7 mL (Size of a cherry)
Day 3 - 22-27 mL (Size of a radish)
Day 7 - 45-60 mL (Size of a large egg)
1 Month - 80-150 mL (Size of an apricot)
24
Q
GI Adaptations
A
Stool Characteristics
- Meconium stool first 8-24 hours
- Transitional Stool (yellow/light green) day 2-3
- Breastfeed babies - Looser, watery, thin, pale, yellow (breastmilk is a natural laxative)
- Bottle fed babies - Brown and pasty
25
Hepatic Adaptation
- Baby uses moms iron stores. The iron is stored in the liver and is proportional to total hemoglobin content and length of gestation. Term infants iron storage should be sufficient for 4-6 months
- Bottle-fed babies have iron fortified formula so anemia is more common with breastfed babies
- Iron fortified formula is not better than breastfeeding because breast milk has iron stores that is more bioavailable to baby which means baby can synthesis that iron more easily
- Carbohydrate metabolism Blood glucose should ideally be greater than 40-50 mg/dL
- Glucose is lowest 30-90 minutes after birth and then begins to stabilize
- In order to conserve babies glucose stores, we keep the baby warm with skin to skin
26
Hepatic Adaptations
Types of bilirubin
- Unconjugated (Indirect) - Free flowing in the babies system (toxic and stored in the skin which causes jaundice) Jaundice starts in the head and moves down as more unconjugated bilirubin builds up.
- Conjugated (Direct) - Processed in the liver and water soluble. Excreted in stool and urine
- Total
- Babies will have higher bilirubin because fetal RBC's have shorter lifespans and they die more quickly.
Physiologic Jaundice - Normal newborn jaundice (starts 24 hours baby is born and goes from head to toe)
Pathologic Jaundice - Starts before baby is 24 hours old due to something wrong with liver.
27
Bilirubin Pathway
- Red blood cell gets broken into hemoglobin
- Hemoglobin gets broken into heme and globin
- Heme gets broken into iron and bilirubin
- Bilirubin and plasma protein get brought to the liver to be conjugated
- Conjugated bilirubin gets excreted in feces and bile
- Unconjugated bilirubin stays in the system
28
Physiologic Jaundice
- Seen in 50% of full term infants and 80% of preterm infants
- More often in preterm infants due to immaturity of liver
SIGNS
- Yellow appears after 24 hours
- Starts in the head and goes lower
- Danger lies in Kernicterus (bilirubin crosses the BBB and causes cognitive deficits, hearing loss and blindness)
- Babies can also be lethargic with high bilirubin
29
Physiologic Jaundice
Causes
- Accelerated destruction of RBC's
- Liver Immaturity
- Trauma that produces increased hemolysis
Interventions
- Assess skin color by blanching, sclera color, color of stools
- Encourage early breastfeeding to allow baby to have enough fluid to flush bilirubin out
- Bilirubin is measured with how much bilirubin the baby has crossed with how old they are
30
Immunologic Adaptations
- Unable to recognize bacterial invasion
- Active acquired immunity from mom in utero
- Passive acquired immunity through immunoglobins
IgG - via placenta
IgA - via colostrum in breastmilk
IgM - Is not passively transferred (fetus starts developing it around 10-15 weeks and takes about a year to fully develop)
31
Vaccines Given
In the hospital
| - Hepatitis B given before discharge (series of 3 shots)
32
Neuromuscular Adaptation
- Myelination is incomplete (means CNS is very immature and babies will have tremors, jumpy)
Flex position - Term baby will lie in a flexed position (if they are not there may be something wrong)
- Pseudo strabismus (cross-eyed) will go away when babies muscles strengthen
- Lusty cry is a good adaptation
33
Behavioral and Sensory Adaptation
- Habituation - Newborn processes and responds to auditory and usual stimuli. They get used to and can ignore repetitious usual stimuli (light and sounds).
- Orientation - Newborn babies have the ability to alert themselves and follow/fixate to stimuli. full maturity happens at around 8 months of age.
- Hearing is pretty developed but fluid in their ears can cause hearing deficit.
- Babies can recognize moms smell within 5 days
- By 5 days they can also tell the difference between sweet and sour taste.
- They use their own resources to calm themselves like sucking on their hands and thumbs (consolability).
34
Behavioral Characteristics
Responses to stimuli
Temperament
Habituation - Getting used to regular stimulus to prevent overstimulation
Cuddliness - Babies are cuddly
Irritability - Babies have different irritable thresholds but can get very irritated with overstimulation. This is especially apparent from babies who are withdrawing from drugs (nicotine/alcohol)
Crying - Is a babies way of communication (it is their language)
35
Behavioral Characteristics
- Sleep-Wake States
Assess baby to make sure they sleep deeply, if they cry they can self calm themselves, how is their wake state, are they alert?
Other factors that influence behavior
- CNS is immature for pre-term babies causing blunted reactions. Stress can cause a preterm baby to sleep/hiccup/yawn. They have different responses than term babies
- Time since birth also affects behavior or time since feeding
- Stimuli and their ability to handle stimuli. Babies can sense tension in their environment, so it is important that mom is relaxed especially when feeding baby
- Baby withdrawing from medication will affect behavior. They can even have withdrawal from anti-anxiety medication. Labor meds can cause baby to be sluggish.
36
Physiologic Adaptations
- Establish and maintain respirations
- Adjust to circulatory changes
- Regulating temperature
- Retaining/digesting nutrients
- Eliminating waste and regulating weight
37
Behavioral Adjustments
- Establishing/regulating tempo independent of mother
These include
- Self regulating arousal
- Self monitoring changes in state and pattern of sleep
- Processing/storing/organizing multiple stimuli
- Establish relationship with caregivers in the environment
38
Neonatal Period
- Birth until 28 days of life
- Major adaptations to extrauterine life happen 6-8 hours after birth
- Events during transition are mediated by the sympathetic nervous system which cause a change in HR, RR, temperature, and GI function
- Careful observation is needed during the transition period by the nurse
