Adaptation of the Newborn (PowerPoint) Flashcards
the neonatal period
begins at birth and ends at 28 days
at birth, factors that act as triggers responsible fro newborns taking their first breath
Chemical
Mechanical
Thermal
Sensory
during the neonatal period, the neonate must
adapt, coordinate, and integrate changes
physical changes the neonate must adapt, coordinate, and integrate
- Establish respirations
- Changing circulation route
- Regulate temperature
- Ingest, retain, and digest food
- Getting rid of waste
- Regulare weight
behavioral changes the neonate must adapt, coordinate, and integrate
- Regulate arousal and sleep
- Process, store, and organize multiple stimuli
- Establish relationships with caregivers and environment
environmental differences between intrauterine and extrauterine
Intrauterine:
- Quiet
- Warm
- Dark
- Comfortable
- Cozy/cramped
- Safe
- Familiar
Extrauterine:
- Loud
- Cold
- Bright
- Painful
- Unswaddled
- Vulnerable
- Unfamiliar
first period of reactivity
up to 30 minutes past birth
- HR increased at first but gradually falls back between 100-120 (may be tachy for 1st 30min)
- RR high at 60-80 (norm 40-60) and may hear fine crackles
- Audible grunting, nasal flaring, and chest retraction can be present but should be clear within 1hr
- This is the time to initiate breastfeeding and bonding
after the first period of reactivity, the baby
either sleeps or has a marked decreased in activity
- after 1st 30min, there is a period of decreased responsiveness where the baby will sleep and wake occasionally
(this lasts about 1-1.5 hours)
second period of reactivity
2-8hrs after birth (lasts 10min to several hours)
may have brief periods of
- tachycardia
- tachypnea
- increased muscle tone (really jumpy)
- increased mucus production (watch for gag and choking - may have to suction)
most critical after birth
- RESPIRATION
- Circulation
- Thermoregulation
- GI
(ABCs)
most critical adaptation after birth
Respirations
- 30-60 breaths/min
- shallow, irregular breaths
- short periods of apnea <15sec
- assessed over a full 60sec
- symmetrical chest movements
suction after birth
prevents infant from inhaling fluid when the nares are touched
(mouth then nose)
newborns prefer to breathe out
nose
established as the crucial site of gas exchange
the lungs
establishment of the lungs as the crucial site of gas exchange causes
- rise in blood pressure
- increase in circulation into the lungs for perfusion
establishing gas exchange in the lungs is facilitated by
several mechanisms occurring during birth, such as clamping the cord
stimulating respirations at birth
The most critical adjustment a newborn makes
The first breath of air initiates a sequence of cardiopulmonary changes
- Converting from fetal to neonatal circulation (clamp the cord)
- Emptying the lungs of fluid
- Retention of fluid interferes with ability to maintain adequate oxygenation (c/s delivery)
Establishing pulmonary function
- Diaphragm descends creating negative intrathoracic pressure
- Alveoli are lined with surfactant, which lowers surface tension, so alveoli stay open with less pressure (not every breath is a first breath)
- Chest and abdomen rise simultaneously with inspiration of air (seesaw respirations are not normal)
- When suctioning always suction mouth before nose (M before N)
at birth, transitions from intrauterine to extrauterine are essential and continue during the first
6-8 hours
transitions at birth are a predictable series of events, mediated by the
sympathetic nervous system
involving the heart rate, respiration, temperature, and GI function
transitions represent a time of
vulnerability requiring careful observation and timely intervention by the nurse
chemical respiratory transition/adaptation/integration
progressive - decrease in PO2 - increase PCO2 - decreased blood pH (respiratory center in medulla)
mechanical respiratory transition/adaptation/integration
compression increase intrathoracic pressure -> release of chest compression -> negative pressure -> drawing air in lungs
thermal respiratory transition/adaptation/integration
decreased environmental temp -> skin receptors -> respiratory center in medulla
sensory respiratory transition/adaptation/integration
handling, mouth and nose suctioning, and drying
impending respiratory problems
- Nasal flaring, grunting or retractions
- Crying
- RR <30 or >60
- Suprasternal/subclavicular retractions + stridor or gasping
- Acrocyanosis
- Seesaw or paradoxical respirations
- Skin flush or pale
- Extended posture
some of these are normal in the 1st hour, but should be assessed closely during that hour
shunt of blood from pulmonary artery to descending aorta bypassing the lungs
ductus arteriosus
- the fetal lungs do not function for respiratory gas exchange, so the ductus arteriosus created a circulatory pathway bypassing the lungs
- fetal PO2 increases from 27 mmHg (intrauterine) to 50 mmHg (extrauterine)
- ductus arteriosus constricts as a result increases O2 and prostaglandin E2 [PGE2]
- closes the Ductus arteriosus (can reopen in response to hypoxia, asphyxia, or prematurity)
valve opening allowing blood to flow directly from right to left atrium
foramen ovale
- Pulmonary pressure drops -> decrease in pressure of right atrium
- Increased pulmonary blood flow from the left side of heart increases pressure in the left atrium
- Closure of Foramen Ovale (for a few days, crying can reverse closure -> mild cyanosis)
connection of umbilical vein to inferior vena cava
shunt redirecting oxygen-rich blood into inferior vena cava bypassing liver
ductus venosus
- Umbilical vein and arteries constrict in response to cooler room temps + increased O2 from infant respirations
- Clamping + cutting cord
- Closure of Ductus venosus (within 2 hours)
*May hear a murmur until the ductus venosus completely closes
fetal circulation supplies the highest levels of oxygen and nutrients to the
head, neck, and arms
- which enhances the cephalocaudal (head-to-rump) development of the embryo/fetus
fetal circulation vs neonatal circulation
- As soon as the cord is clamped, the ductus venosus ceases to carry blood to the heart and it begins to constrict within the first few hours or days of life.
- The very first thing that happens when the fetus is born, is it takes its first breath, the lungs expand, and so the resistance, or pressure, in the lungs drop and that promotes blood flow into the lung itself
- The ductus arteriosus begins to constrict, and is typically fully closed within 24 to 48 hours of life, and blood is now then fully directed into the lung.
- As the blood returns to the left side of the heart after traversing the pulmonary circulation, picking up oxygen pressure, and left atrium rises just a bit, and the trap door of the foramen ovale, which was open before birth, now begins to close, usually within the first few days of life.
impending cardiac problems
- Persistent tachycardia
- Dyspnea
- Hypoxia
- Persistent bradycardia
- Skill pallor or cyanosis
- Jaundice
newborn temperature
97.7 - 98.9 F
thermoregulation
Ability to maintain balance heat loss vs heat production within first 12hrs after birth
homeotherms
can maintain a constant core body temperature regardless of environmental temperature
- newborns have a much narrower range than adults to which they can adapt without being stressed
shivering thermogenesis
not operable in the newborn (baby’s do not shiver)
heat production
non shivering thermogenesis
metabolism of brown fat to produce heat
- deposits of brown fat are present for several weeks after birth and are rapidly depleted with cold stress
- the less mature the infant, the less reserve of brown fat
body surface to cooler ambient air
convection (heat loss)
wrap newborn, keep nursery warm
body surface to cooler solid surface not in direct contact but in relative proximity
radiation (heat loss)
keep cribs away from windows
loss of heat when liquid is converted to a vapor
evaporation (dry infant directly after birth and bathing)
body surface to cooler surface in direct contact
conduction (heat loss)
warm crib when admitted to nursery, skin to skin contact with mother
thermoregulation in the newborn
anatomic and physiologic characteristics increase risks for hypo/hyperthermia
- > flex position helps guard against heat loss
- > larger body surface area relative to body weight (mass)
- > blood vessels closer to the skin (decrease in room temp -> temp of the blood -> temp regulation centers in the hypothalamus)
- > brown fat used for non-shivering thermogenesis
- > neutral thermal environment
impending thermoregulatory problems
- Increased muscle activity
- Crying
- Restlessness
- Cold skin
- Acrocyanosis
- Hypoglycemia
- Skin flushing or pale
- Extended posture
effects of cold stress in newborn
- Oxygen consumption increases as oxygen and energy are diverted from maintaining normal function and growth to thermogenesis for survival
- Respiratory rate increases because of demand for oxygen
- Vasoconstriction to ensure blood flow to vital organs jeopardizes pulmonary perfusion (may reopen shunt across the ductus arteriosus)
- BMR increases and may result in anaerobic glycolysis -> increased acid production
- PO2 and pH decrease
- Excess fatty acids displace the bilirubin from albumin-binding sites -> increased level of circulating unbound bilirubin that increases the risk of kernicterus
rare kind of preventable brain damage that can happen in newborns with jaundice
(bilirubin gets too high -> brain damage)
kernicterus
where conjugated bilirubin becomes unconjugated
the intestines
in the intestines, conjugated bilirubin becomes unconjugated and recirculates through the enterohepatic system which
increases serum bilirubin levels
GI transition/adaptation/integration
- In the intestines, conjugated bili becomes unconjugated and recirculates through the enterohepatic system -> increased serum bili levels
- Sucking behavior is influenced by several factors.
- Peristaltic activity is uncoordinated at first but quickly learned.
- Stomach capacity is small (< 30 mL) on day 1 and relaxes to accommodate larger (> 90 mL) on day 3.
- Meconium is first stool. Progressive changes in stooling pattern is expected.
- Hunger cues are important to recognize and teach to mom.
newborn stomach capacity
day 1: <30mL
day 3: >90mL (stomach relaxes)
impending GI problems
- Failure to pass meconium
- Inactive rectal “wink”
- Abdominal fullness above the umbilicus
- Abdominal distention
- Scaphoid (sunken) abdomen
- Abdominal fullness below the umbilicus
- Diarrhea - forceful ejection
- Meconium from vagina or urinary meatus
- Vomiting
- Failure to pass meconium
neurologic transition/adaptation/integration
- Primitive reflexes present at birth reflect maturity and intactness of CNS
- Responsive and reactive with capacity for social interaction and self-organization.
- Brain growth requires glucose for energy and large supply of O2 for metabolism.
- Transient tremors of the mouth, chin (during crying episodes) & extremities.
- Flexed arms at the elbows and legs at the knees. Hips abducted and partially flexed. Intermittent fisting (hands) is common.
presence reflects maturity and intactness of CNS
primitive reflexes
impending neurological problems
- Absence of newborn reflex
- Facial asymmetry
- Facial paralysis
- CNS depression
- Abnormal respiration
- Hypoglycemia
- Low or high-pitched cry
- Stridor or weak cry
liver at birth
enlarged and occupies 40% of abdominal cavity
hepatic transition/adaptation/integration
- Iron storage
- Carbohydrate metabolism
- Conjugation of bilirubin
- Coagulation
Liver began storing iron in utero
- if mother had adequate iron intake, iron stores will last until 4-6 months of life (if preterm, stores will last 2-3 months)
- the bioavailability in breastmilk is superior to formula (breastfeeding newborns do not need supplemental iron, but formula fed do)
site for production of hemoglobin after birth
liver
blood glucose stabilizes within
first several hours at 50-60 mg/dL
by day 3, BG should be ~60-70 mg/dL
coagulation factors are synthesized in
the liver
coagulation factors (synthesized in the liver) are activated by
vitamin K (injection of vit K shortly after birth helps prevent clotting problems)
newborn bilirubin levels
direct: <0.5 mg/dL
total: <2.8 mg/dL (cord blood)
jaundice that appears after 24hrs of age and usually resolves without treatment
physiologic jaundice
occurs in about 60% of newborns
unconjugated hyperbilirubinemia usually appearing within 24hrs of birth
(caused by excessive production of bilirubin through hemolysis)
pathologic jaundice
some causes:
- Maternal newborn ABO incompatibility (NOT Rh incompatibility)
- Cephalhematoma
- Polycythemia
- Delayed passage of meconium
- Delayed feeding
- Altered hepatic clearance
- G6PD (glucose-6-phosphate hydrogenase deficiency)
impending liver problems
- Jaundice = total bili >2.5 mg/dL
- Restlessness
- BG <40 mg/dL
- Jitteriness
- Lethargy
- Apnea
- Feeding problems
- Seizures
- Bleeding
renal transition/adaptation/integration
- 98% of newborns void within the first 30 hours
- 1st-2nd day = 2-6 voids/day
- 3rd-4th day = 5-25 voids/day
- > 4 days = 6-8 voids/day
- Pale, straw-colored -> cloudy (mucus content) -> straw-colored & odorless
renal system at birth
75% of body weight consists of water
Urinary system is structurally complete but physiologically immature
- unable to concentrate urine
- water losses are greater
- water requirements per kg of body weight are greater (125-150mL/kg per day will produce 100mL of urine per 24hrs)
- decreased ability to remove waste products from the blood (GFR 30% compared to 50%)
- decreased ability to handle high osmolarity
40% of body weight is extracellular (adult = 20%)
Bladder capacity is ~30mL (may not void for 12-24hrs
- 1-2 day = 2-6x/day
- after day 2 = 5-25x/day
impending renal problems
- Inadequate fluid intake
- Restlessness
- Bladder distention
- Pain
- Pink or orange stains on diaper “brick dust”
- Lack of steady stream
- Gross anomalies (hypospadias, exstrophy of the bladder)
- Enlarged or cystic kidneys
hypospadias
urethra in area other than tip of penis
bladder on the outside between umbilicus and genital area
exstrophy of the bladder
musculoskeletal transition/adaptation/integration
- Appears out of proportion because newborns develop cephalocaudal (head-to-rump).
- Extremities should be symmetrical with equal number of fingers and toes.
- Pink nail beds
- Molding
- Caput Succedaneum
- Cephalohematoma
(often, caput and cephalohematoma occur simultaneously)
musculoskeletal at term (head, arms, legs)
- head is 1/4 of the total body length
- arms slightly longer than the legs
- legs are 1/3 of total body length but 15% of total body weight
overlapping of cranial bones to facilitate birth
molding
overlapping of cranial bones to facilitate birth
molding
edematous swelling extending across suture lines disappearing in 3-4days
caput succedaneum
collection of blood between skull and periosteum that does NOT cross cranial suture lines resolving in 3-6weeks
cephalohematoma
impending musculoskeletal problems
- Developmental dysplasia of the hip (DDH)
- Oligodactyly (digits missing)
- Polydactyly (extra digits)
- Syndactyly (fused)
- Blue nail beds
- Limited hip abduction
- Allis sign
- Ortolani maneuver “click”
- Galeazzi sign
asymmetry of gluteal and thigh folds + shortening of the thigh
galeazzi sign
apparent shortening of the femur indicated by the level of the knees in flexion
allis sign
immune transition/adaptation/integration
- At around 14 weeks, mom sends immunoglobulin (IgG) [passive immunity] via placenta producing antimicrobial protection to newborn for 3 months.
- By 8th week, small amounts of IgM is produced by the fetus.
- Adult levels are produced by 2 years of age.
- There is more of a gradual production of IgA, IgD, & IgE with maximum levels not reached until early childhood.
- IgA (membrane protective) is missing in respiratory, urinary, and gastrointestinal tracts unless BREASTFED.
- IgA (found only in human milk) acts in the intestines to neutralize bacterial and viral pathogens.
- Believed to lessen risk of allergy and food intolerance through modulation of exposure to foreign milk protein antigens.
- Immunoglobulin G (IgG) is produced in adult concentrations by age 4-6
impending immune problems
- Temperature instability
- Lethargy
- Irritability
- Poor feeding
- V/D
- Decreased reflexes
- Eye, nose, or mouth discharge
- Grunting/retracting
- Pale/Mottled skin
- Apnea/tachypnea
distended, small, white sebaceous glands on the newborn’s face
milia
a raised, sharply demarcated, bright or dark red, rough-surfaced swelling
nevus vascularis or “strawberry” hemangioma
red to purple and is various sizes, shapes, and locations
nevus flammeus or “port-wine stain”
an inflammatory response during the first 3 weeks requiring no treatment
erythema toxicum or “newborn rash”
integument at birth
- Skin is erythematous for a few hours after birth and then fades to normal
- Brown fat (subcutaneous fat) accumulates during 3rd trimester and serves as insulation after birth
a protective covering for the skin and a product of the sebaceous glands (white, cheese-like)
vernix caseosa
- Term newborns have vernix in the creases of the neck, axilla, and the groin
- Post-term will have little vernix
After 35 weeks, covers the skin but decreases with age and sheds into amniotic fluid
Lanuga (face, shoulders, back) lessens with maturity -> appears after 12th week and helps hold vernix
creases on the newborn
located on palms and soles
- The simian line (a single palmar crease) is often seen in asian infants and infants with Down syndrome
- More creases will appear as the skin dries
- The number of creases correlates with greater maturity (premature newborns will have few, if any)
found on upper eyelids, nose, upper lip, lower occipital area, and nape of the neck
- pink and easily blanched
telangiectatic nevi or “stork bites”
bluish black areas of pigmentation most commonly found on back and buttocks
Mongolian spots
impending skin problems
- Jaundice
- Pallor
- Forceps marks
- Birth injuries
- Central cyanosis
- Plethora
- Bruises
- FHR monitor lesions
- Petechiae
deep purplish color from increased RBCs
plethora
indication of extrauterine transition
APGAR score
APGAR
- Appearance (general skin color -pallid, cyanotic, or pink skin color)
- Pulse (auscultated or felt via umbilical cord)
- Grimace -> reflex irritability (response to suctioning of nares or nasopharynx)
- Activity -> muscle tone (degree of flexion and movement)
- Respiration (observed movement of chest wall)
when is APGAR score taken
1 and 5 minutes after birth
- The change in score from 1-5min is a useful index of the effectiveness of resuscitation efforts
- There is poor correlation between the 1 and 5min score and future neurologic outcome
- Correlation increased when the score is 0-3 at 10, 15, and 20 min
why take APGAR score
- physiologic state of neonate
- rapid need assessment for resuscitation
how APGAR is scored
Appearance (color)
0 = blue, pale
1 = body pink, extremities blue
2 = all pink
Pulse (heart rate)
0 = absent
1 = slow <100
2 = >100
Grimace (reflex irritability)
0 = no response
1 = grimace
2 = cry
Activity (muscle tone)
0 = flaccid
1 = some flexion
2 = well flexed
Respiration (movement of chest wall)
0 = absent
1 = slow, weak cry
2 = good cry
level of difficulty transitioning score: minimal (7-10)
Minimal (7-10) -> normal, neonate in good condition; possible suctioning of mouth and nose, observation
- Dry
- Provide warmth
- Clear airway
- Ongoing evaluation
level of difficulty transitioning score: moderate (4-6)
Moderate (4-6) -> moderately depressed neonate who will need some resuscitation and close observation
- Vigorous stimulation
- Oxygen (blow by or by ambulance bag)
- Narcan if indicated (positive pressure)
level of difficulty transitioning score: severe (0-3)
Severe (0-3) -> severely depressed neonate who will need resuscitation, possible ventilatory assistance
- CPR
- Intubate if no respiration
- Resuscitation drugs
extrauterine adaptation physical characteristics
Vital Signs
- HR = 110-160 (1st 30min, HR increased 160-180 then to 110-120)
- RR = 30-60 (1st 30min RR increased 60-80 then to 60)
- Temp = 97.5-99
Weight = >2500g but <4000g (5.5lb-8.5lb)
Head Circumference = 33-35cm
Chest Circumference = 2-3cm
immediately after delivery
- Dry the baby and take off wet towels
- Start 1min APGAR at time of delivery
- Check HR and RR
(the following can be done at different intervals depending on institution policy and procedures or if resuscitation is required)
- Weight
- Length
- Place ophthalmic ointment and vitamin K shot
- Head circumference
- Chest circumference
- Rubella vaccine
- PKU
ophthalmia neonatorum
eye infection that can cause blindness
most common infectious agent that causes ophthalmia neonatorum in the US
Gonococcal or Chlamydia
- the vagina is not sterile -> when an infant is delivered it is in contact with different types of bacteria in the vagina
when to do a PKU test
not until the baby has eaten well for 24hr (gut)
heel test, on permanent record, can cause permanent brain damage and is done in bed office if not done on PP
crosses suture lines
caput (edema)
does not cross suture lines
cephlahematoma
assessment of newborn
- Complete assessment done within 24hrs
- Done after temp stabilizes or under radiant warmer
- Assessment includes maternal record review (prenatal, intrapartal history, type of analgesia and anesthesia, history of substance abuse)
estimating gestational age
Physical Exam
Neuromuscular Exam
why estimate gestational age
- Perinatal morbidity and mortality are related to gestational age and birthweight
- Relationship between birthweight and gestational age provides a classification system that is reliable whether the neonate is preterm, term, or postterm (designated as SGA, AGA, LGA)
history of GA assessment
- Assessment based on the work of Dubowitz and colleagues in 1950
- Ballard modified the Dubowitz tool in 1979 (assessment of neonates 35-42 weeks)
- New Ballard Score (20-44wks) further refined instrument includes criteria for extremely premature infants and allows for a more accurate assessment of more mature infants
reliability of estimating GA
- Reliable immediately after birth and within the 1st 24hrs
- May be used up to 3-5days after birth then becomes unreliable because of maturational changes (new Ballard)
- For infant <26 weeks gestation is most valid within 1st 12hrs of life
parameters of estimating GA (new Ballard assessment)
- 12 assessment parameters (6 neuromuscular & 6 physical maturity)
- Maturity rating
Neuro:
- Posture
- Square Window
- Arm Recoil
- Popliteal Angle
- Scarf Sign
- Heel to Ear
Physical:
- Skin
- Lanugo
- Plantar Surface
- Breast
- Eye/Ear
- Genitals
how to determine maturity rating
use GA to plot weight, length, HC
- SGA, AGA, LGA is based on plotted weight
Skin = leathery, cracked, wrinkled
No lanugo present
Deep plantar creases
postmature
care of circumcision
- Wash hands before touching newly circumcised penis
- Check for bleeding every hour for first 12 hours
- If bleeding occurs apply gentle pressure with a folded sterile 4x4
- Notify physician if bleeding doesn’t stop
- Observe for urination – wet diaper 6-10 times in 24 hrs
- Keep area clean – change diaper at least every 4 hours; wash penis gently with warm water to remove urine or stool. Fan fold diaper.
- Check for infection – yellow exudate is normal for first 2-3 days. Do not attempt to remove it. - Redness, swelling, discharge indicate infection. Notify provider.
- Provide comfort – painful procedure. Handle area gently.
- Provide extra holding, feeding, non-nutritive sucking for a day or two
“I notice that baby jumps a lot when we make noise or touch him… is something wrong?”
Neuromuscular control in the newborn is limited.
- Spontaneous motor activity may be seen as tremors in the extremities, notable arms and hands
- These are normal
genetic testing (heel stick)
- This is a routine test done on all babies regardless of family history
- We are testing for 3 metabolic diseases (PKU, galactosemia, and hypothyroidism) that can result in severe mental retardation, failure to thrive, and sometimes death if not treated early
baby sleeping in bed with parents
- Sleeping in your bed is not recommended - parents have been known to roll over on their infants during sleep and suffocate the infant
- Until you can get a baby bed, you can make a substitute sleeping area (open drawer padded with a blanket, open box, etc.)
