8.2a Care Management - Birth through First 2 Hours Flashcards
Birth Risks that Need Assessment
- Hepatitis B and C
- HIV through maternal blood (newborn is considered contaminated)
- Wear gloves when handling newborn until blood and amniotic fluid are removed during the initial bath
Immediate Care After Birth
Goals of Term Newborn
- Establish effective respirations
IF NEWBORN HAS GOOD MUSCLE TONE, CRYING
Routine Care includes..
- Placing newborn on skin to skin contact
- Dry infant with gentle warming
- Remove wet linens and cover mom/baby in warm blanket
- Dry head and apply cap
- Wipe away nasal/oral secretions (bulb syringe)
- Assessment of neonatal breathing/color/activity
Goals of Preterm Newborn
- Poor muscle tone, not crying,
Interventions
- Immediately place under radiant warmer
- Assessments done under warmer until temperature stabilizes for skin to skin contact
Positive Signs of Good Birth
- Trunk and Lips are pink
- Blue on hands and feet is normal
- Put baby under radiant warmer and positive pressure ventilation if baby is apneic or gasping
- Pulse ox should be used on right hand instead of checking for cyanosis
Heart Rate
- Measured by grasping base of umbilical cord or auscultating chest
- Heartrate should be greater than 100 bpm
Post-birth care
- Place identical bands on newborns wrist, ankle, and mothers wrist and significant other
- ID bands should be placed before
- Security tag is given to prevent abduction
- Infant is “footprinted” with ink/scanning device within 2 hours and photograph is taken for ID
Preconception Assessments
- Age
- Pre-existing maternal conditions (obesity, diabetes, hypertension, anemia, renal disease)
- Genetics and family history
- OB History (Gravity and Parity, history of stillbirth, miscarriage, In-vitro
- Blood type and Rh
Prenatal Assessments
- When prenatal care was started
- Nutrition (weight gain, diet, obesity, eating disorders)
- Health factors (smoking, alcohol, drugs)
- Blood type and Rh
- Medications used
- STI, GPS, Hepatitis B,C
Intrapartum
- Length of gestation (preterm, early term, post term)
- External fetal monitoring, rupture of membranes, signs of fetal distress in first stage of labor
- GBS status and treatment
- Second Stage of Labor - Vagina, C-section, Length, Forceps, Vacuum, Complications (bleeding, shoulder dystocia), cord prolapse, maternal analgesia/anesthesia
Initial Physical Assessment
- Done on skin to skin contact or under radiant lamp
- Newborn stays on skin to skin for 1-2 hours and breastfeeding
APGAR Score
- Heart rate (auscultation or palpation of umbilical cord)
- Respiratory effort based on observation of chest wall
- Muscle tone based on degree of flexion and movement of extremities
- Reflex irritability (grimace, crying, or withdrawal)
- General skin color (pallid, cyanotic, pink)
APGAR Score
0-3 means severe distress
4-6 moderate difficulty
7-10 Minimal adaptation to extrauterine life
APGAR Score
- Checked and 1 and 5 minutes after birth
- Scores less than 7 at 5 minutes should be repeated every 5 minutes for 20 minutes
- APGAR score measures newborns transition to extrauterine life (does not predict neurological outcomes)
- Resuscitation needs should be assessed before 1 minute APGAR score
APGAR Score
A - Appearance (oxygenation level of blood)
0 - Pale/Cyanotic
1 - Acrocyanotic
2 - No Cyanosis
P - Pulse (Umbilical cord or apical pulse)
0 - Absent
1 - Under 100
2 - 100+
G - Grimace (Response to stimuli)
0 - No response
1 - Minimal response
2 - Cry
A - Activity (Muscle Tone)
0 - Flaccid
1 - Some muscle flexion
2 - Active
R - Respirations (Quality of breathing)
0 - No breathing
1 - Weak cry or slow/irregular breath
2 - Strong cry and normal rate in breathing
General Appearance Survey
- Determines maturity status
- Color
- Posture
- Activity
- Obvious Signs of Anomalies that can cause distress
- Presence of bruising or other birth trauma
- State of Alertness
Vital Signs
Temperature - 36.5 - 37.5 (97.7 - 99.5)
RR - 30-60 breaths a minute (exceeds 60 when crying)
(Shallow and irregular (periodic breathing) NORMAL)
(Respirations should be counted for a full minute)
(Observe symmetrical chest movement)
HR - checked at apical pulse done when baby is asleep or in quiet alert state
Awake (120-160)
Sleep (70-90) - Bradycardia is less than 80
Tachycardia - Greater than 180-200
BP - 4 BP can be assessed or when murmurs are heard
BP is higher in upper extremities
If upper extremities have bp greater than 20 mmHg above lower, than there may be a cardiac defect such as coarctation of the aorta.
If heart murmur is heard palpate peripheral pulses and check oxygen saturation
Weight
Average is 6-9 pounds
Head Circumference and Body Length
- Head is measured with occipitofrontal diameter (widest area)
- Tape measure placed above eyebrows
- Average circumference 32.5 - 37.5 cm
- Head to heel length typically 48-53 cm
Gestational Age Assessment
- Perinatal mortality and morbidity relate to gestational age and birth weight
- New Ballard Score is typically used (as young as 20 weeks)
- Assess 6 physical and 6 neuromuscular signs
Birth Weight with Gestational Age
- Provides an accurate measure of infant mortality/morbidity
- AGA (appropriate for gestational age) means birthweight is between 10-90th percentile
(Normal growth rate) - LGA (Large gestational age) - above 90th percentile presumed to have grown at an accelerated rate in intrauterine life
- SGA (Small gestational age) - Below 10th percentile grown at a restricted rate during intrauterine life
- Gestational age is an important predictor of survival
Gestational Age
Late preterm - 34 0/7 through 36 6/7 weeks
Preterm - Before 37 0/7 weeks of gestation
Early Term - 37 0/7 to 38 6/7
Full Term - 39 0/7 to 40 6/7
Late Term - 41 0/7 to 41 6/7
Post Term - 42 0/7+
Early-Term Infant
- 37 0/7 to 38 6/7
- Increased risk of morbidity and mortality
HIGHER RISK OF - Hypoglycemia
- Respiratory Distress Syndrome
- Transient Tachypnea (TTN)
- Greater likelihood of NICU admission
Late Preterm Infant
- Majority of preterm is between 34 0/7 - 36 6/7
- “Great Imposters” Often treated as normal infants because they are normal size and weight
INCREASED RISK OF - Respiratory distress
- Temperature instability
- Hypoglycemia
- Apnea
- Difficulty feeding
- Hyperbilirubinemia
Post Term
- 42 0/7 weeks or above
- AGA but some show characteristics of placental insufficiency
- Little vernix caseosa, absence of lanugo, abundant scalp hair, long fingernails
- Skin is cracked and parchment like (peeling)
- Wasted physical appearance that reflects placental insufficiency
- Depletion of subq fat gives them elongated look
- Stained deep yellow or green skinfolds (because of meconium in amniotic fluid)
- Increase in risk of fetal mortality
- Very prone to fetal distress, placental insufficiency, macrosomia, meconium aspiration syndrome
Airway Maintenance
- Most secretions move by gravity and coughed up (then drained)
- Bulb syringe used to suction obstructions
- Auscultate lung sounds for stridor
- Crackles common in c-section babies several hours after birth
How to use Bulb Syringe
- Keep bulb easily accessible
- Suction mouth first then nose (to prevent aspiration)
- When suctioning, avoid center of mouth to avoid gag reflex (use 1 side of mouth)
- Nasal passages suctioned one at a time
- Clean bulb with soap and water after each use
Conditions of Meeting Adequate Oxygen
- Clear airway
- Effective establishment of respirations
- Adequate circulation, perfusion, cardiac function
- Adequate thermoregulation
Maintaining Body Temperature
- Skin to skin contact in first hour is the best to increase baby glucose, temperature stability, and improve breast feeding
- Dry and wrap baby in warm blankets immediately after birth
- Keep head covered
- Keep nursery temperature at 22-26 (72-78)
Radiant Heater
- Placed under radiant warmer if skin to skin contact not available
- Set radiant heater to 36-37 (96.8-98.6) to maintain adequate temp 36.5-37 (97.7-98.6)
- Thermistor Probe - Placed on upper abdomen to detect temperature change in skin
- Servo controller - Adjusts temperature on warmer
- Axillary temperature measured every hour
Baths
- Postponed for 6 hours or until temperature stabilizes (above 36.8 (98.2))
- Bath should be limited to 5 minutes
Eye Prophylaxis
- Used on the eyes to prevent ophthalmia neonatorum or neonatal conjunctivitis (inflammation caused by sexually transmitted bacteria through vaginal birth)
- Recommended for all newborns (including c-section)
- Erythromycin 0.5% Ointment
- Without prompt treatment can lead to blindness
- Administered within 1st hour of birth or delayed 2 hours for breastfeeding and eye contact with baby
Vitamin K Prophylaxis
- Lack of intestinal bacteria causes lack of vitamin K
- Flora appears at 7 days of age
- Phytonadione is given to prevent vitamin K hemorrhage
- Delay injection for skin to skin contact
Parent-Infant Interaction
- SSC (skin to skin contact) promotes physiologic stability of infant
- Oxytocin and Lactose rise with SSC
- Rooming in after birth promotes parent-infant interactions
