Early Neonatal Care & Physiological Changes (W/S 12&13) Flashcards
Prior to conducting a cephalocaudal examination ensure:
- Parental explanation and consent
- Wash and glove hands
- Ensure adequate lighting
- Check the baby is warm
Cephalocaudal examination - skin
- Colour
- Skin integrity
- Rashes
- Birthmark
- Bruising
- Swelling
Cephalocaudal examination - head and face
- Shape and symmetry
- Suture lines and fontanelles
Are they of normal size and appearance?
Posterior fontanelle often appears closed at birth due to the moulding. The anterior fontanelle should be palpated. - Signs of moulding and caput succedaneum, trauma
- Head circumference
- Eyes: size, shape and any slanting, ?cataracts, ?discharge, pupils; round
- Nose: may be squashed, ?nasal flaring (resp distress)
- Mouth: asymmetry could be indicative of facial palsy, ?cleft
- Palate: ?cleft, ? Epstein’s pearls (white or yellow tinted bumps/spots on gum line / roof of mouth, cyst, OK) or teeth, length of the frenulum
- Ears: correct positioning (trace an imaginary line from the outer canthus of the eyes horizontally back to the ears; the top of the pinna should be above this line). Patency of external auditory meatus, ?accessory skin
- Neck: ?swelling (e.g. sternomastoid tumour), tags, folds of skin.
- Hair
- Bruising / abrasions
Cephalocaudal examination - chest
- Movement with respiratory, recession, shape, symmetry
- Accessory nipples? Breasts may appear enlarged; this is normal and of little significance unless there are signs of infection.
- Heart rate, rhythm and sounds
- Colour
- RR
- Signs of respiratory distress
- Nipples and breast tissue
Cephalocaudal examination - abdomen
- Shape, colour and size. Rounded and soft?
- Umbilicus
- Umbilical clamp secure
- Number of cord vessels
- Presence of obvious masses
- Bowel sounds
Cephalocaudal examination - genitalia / anus
- Passage of urine
- Males
Penis, foreskin, testes (descended?), urethral meatus (central?) - Females
Vaginal and urethral orifice
Presence of clitoris
Vaginal discharge - normal - Anus
Anal patency - contraction on palpation
Passage of meconium
Cephalocaudal examination - musculoskeletal
- Arms/Hands/Digits: same length, moving freely; number of digits, polydactyly (extra) or syndactyly (webbed), palmar creases
- Legs/Feet/Digits: symmetry, size, shape and posture. Position of the feet in relation to the legs, shape of the feet should be noted, including oedema or a ‘rocker bottom’ appearance, number of toes, polydactyly (extra digits), syndactyly (webbed). Talipes?
- Neck and spine: dimples, malformations. ?spina bifida, any swelling, dimpling or hairy patches; these could indicate an abnormality of the spinal cord or vertebral
column. Assess the curvature of the vertebral column by running the fingers lightly over the spine. Gently part the cleft of the buttocks, look for any dimples or sinuses and confirm the presence of the anal sphincter. - Hips - dislocated or unstable? Barlow’s test or Ortolani’s test.
- Clavicles: ?intact (particularly if there was a
breech presentation or shoulder dystocia)
Cephalocaudal examination - neurological
- Muscle tone, posture, movements
- Test neurological reflexes
Moro - startle reflex, clap hands, “drop and catch”
Grasp - grasp finger
Rooting
Suck
Stepping
Traction Response - pulled by the arms from a lying to a sitting position, the head lags at first. The baby then flexes, lifting the head to the midline of the rest of the body before it falls forward.
Babinski - toes splay out when bottom of foot touched
Cephalocaudal examination - completion
- Record weight, length and head circumference
- Temperature: per axilla 36.5-37.3 C
- HR and sounds: listen for a softer quality to one of the sounds, or an extra sound. 110-160 bpm
- RR 40-60bpm
- Document findings
- Offer skin to skin contact
- Advise parents of findings
- Notify paed if any abnormalities detected
What are the 4 ways heat can be lost in the neonate?
Through:
- Evaporation
- Radiation
- Convection
- Conduction
Describe evaporative heat loss in the neonate and how to reduce/prevent it.
Heat loss occurs through evaporation of water from the skin and respiratory tract, (and is highest immediately following delivery and bathing).
Heat loss can be reduced if:
– the baby’s head is dried after birth and following a bath
– a hat is put on the baby
– wet towels are removed quickly following birth
– the bath is delayed until the baby’s temperature is stable and above 36.8°C.
Describe convection heat loss in the neonate and how to reduce/prevent it.
(Current) Heat is lost to moving air or fluid around the neonate. The amount of heat lost depends on the difference between the skin and air or fluid temperature, the amount of body surface exposed to the environment, and the speed of air or fluid movement.
Heat loss can be prevented by:
- increasing the birthing room temperature
- keeping room temperature above 25C when the baby is naked
- covering the baby with a blanket.
Describe radiation heat loss in the neonate and how to reduce/prevent it.
Heat is radiated from the skin to surrounding colder solid objects such as windows or incubator walls. This
is the predominant mode of heat loss after the first week of life in babies born before 28 weeks and in all other babies throughout the neonatal period.
Heat loss can be prevented by keeping the baby
away from windows, draughts and cold solid objects.
Describe conduction heat loss in the neonate and how to reduce/prevent it.
Babies conduct heat to cold objects they come into contact with such as a cold mattress, scales and radiograph plates.
Heat loss can be prevented by:
- warming the resuscitaire and bedding
- covering the scale with a sheet or blanket prior to weighing the baby
Cold stress may cause _________ and unless rectified will lead to ___________________________.
jitteriness and unless rectified will lead to hypothermia, hypoglycaemia, hypoxia, acidosis, lethargy and eventually death.
Feeding is essential to help prevent hypothermia
When is the guthrie conducted?
After 48hr post birth.
What is involved in the daily examination of the newborn (baby check)?
- Frequency of feeds: 2-3 hourly
- Passing urine and bowels open (mec..changing…mustard)
- Observations
- Settled between feeds?
- Alert and waking for feeds?
- Cord
- Colour of skin
- Eyes
- Weight 3rd (should be <10% bw) and 5th day (should have gained <50g)
- Guthrie after 48 hours
What are some minor disorders of newborn?
- Sticky eyes
- Urticaria neonatorum
- Milia
- Pyoderma (staphylococcal infection)
- Paronychia (nail bed infections)
- Infected cord
- Newborn sneezes/snuffles
- Head misshape / swelling
What is sticky eyes caused by and what is the treatment?
Blocked tear duct - with amniotic fluid or skin cells
If sclera of eye is white, no redness - not concerning.
- One wipe per cotton ball
- Hand hygiene
- Sterile water
- Colostrum
What is urticaria neonatorum and what is the treatment?
- Generally normal and goes away on own
- Moves around the body
- Red patches, red dots, pimples on rash
- Could potentially be an infection - keep an eye on it. - - Could be staph infection - often bigger dots…
- Can last 6-8 weeks
- No treatment
What is Pyoderma and what is the treatment?
- Staphylococcal infection
- One lesion may be treated topically with Chlorhexidine
- Antibiotics necessary for multiple lesions
What are milia and what is the treatment?
- Small cysts that form on the skin (blocked from vernix)
- Look like whiteheads / small white bumps
- Not concerning
- No treatment needed
What is Paronychia and what is the treatment?
- Nail bed infections
- Usually staph aureus
- Requires abs
- Caused by cutting nails (Put mittens on rather than trying to cut, peel, bite them. Wait til its long enough that there is space between nail and skin.)
What does a cord infection look like and how can it be prevented?
- Inflamed red area around cord stump
- Fold nappy down to air it - will also help it drop off sooner. Dry area following bath
Are newborn sneezes/snuffles concerning?
No, common. Smaller nasal passages so need to clear more frequently and way to get rid of excess fluid (e.g. from birth)
- Shows reflex working well
- If additional symptoms, investigate further e.g. fever, not feeding well, lethargic
What is the difference between Caput succedaneum and Cephalhaematoma?
Caput succedaneum - A swelling of blood and
serum above the periosteum and under the scalp
due to pressure during the birth process.
Pits on pressure.
Can cross suture line.
Present at birth
May last 24-48hrs.
Cephalhaematoma - A swelling of blood underneath the periosteum and over the skull due to friction during the birth process causing the periosteum to be torn from the skull bone.
Swelling is firm, does not pit on pressure.
Cannot cross suture line.
Develops 12 hours after birth.
Will go away on its own but may take 6 weeks. It needs to be reabsorbed slowly as it’s underneath the periosteum.
What 5 safe sleeping recommendations should be provided to parents?
- Sleep baby on the back, not on the tummy or side, at the bottom of the cot.
- Sleep baby with face uncovered (no doonas, pillows, lambs wool, bumpers or soft toys)
- Avoid exposing babies to tobacco smoke before birth and after
- Provide a safe sleeping environment (safe cot, safe mattress, safe bedding) (no waterbeds or beanbags for babies or toddlers)
- Sleep baby in their own safe sleeping environment next to the parent’s bed for the first six to twelve months of life
Taking baby into an adult bed may be unsafe if baby:
- Gets caught under adult bedding or pillows.
- Is trapped between the wall and the bed.
- Falls out of bed.
- Is rolled on by someone who sleeps very deeply or who is affected by drugs or alcohol.
The respiratory and cardiovascular changes occur immediately after birth and are mutually dependent. Most babies take their first extrauterine breath
at the time of birth triggered by:
- uterine contractions in the second stage of labour
- chemoreceptor stimulation by reduction in oxygen and increase in carbon dioxide in the blood
- external stimuli such as cold, light noise and touch.
The precise mechanism that triggers the first active breath is not yet fully understood.
Describe fetal blood flow …
Umbilical vein carries oxygenated blood through the
umbilical cord –> through ductus venosus –> inferior vena cava
Majority flows from right atrium –> through foramen ovale –> to left atrium —> down to left ventricle —> aorta bypassing pulmonary circulation
Some flows from inferior vena cava –> directly into right ventricle –> pulmonary arteries –> ductus arteriosis shunts majority of blood into –> aorta
Deoxygenated blood moves from the aorta –> through the internal iliac arteries –> to the umbilical arteries –> re-enters the placenta
Describe the adaptive changes (redirection of blood flow) in the newborn. How is pulmonary separated from systemic circulation?
The expansion of air into the lungs causes pressure changes that redirect the flow of blood in the newborn infant.
- Ductus arteriosus closes and becomes ligamentum arteriosum (breaks off the connection between the aorta and the pulmonary artery)
- Foramen ovale closes and becomes fossa ovalis (breaking off connection between right and left atria)
- Ductus venosus becomes ligamentum venosum
- Umbilical (hypogastric) arteries become medial umbilical ligaments
Describe the cardiovascular transition following birth.
Pulmonary oxygenation of blood
In utero, 5%–10% of cardiac output enters the pulmonary circulation to meet pulmonary cellular growth and nutrition needs.
High pulmonary vascular resistance and the patent ductus arteriosus ensure that the remainder of the cardiac output enters the arterial system.
At birth, adjustments occur to ensure that deoxygenated blood flows to the lungs for oxygenation.
The expansion of the lungs and lowered pulmonary vascular resistance with the first breath enables heart’s entire output to enter the pulmonary circulation.
Oxygenated blood returns to the heart via the pulmonary veins increasing pressure in the left atrium.
This triggers the closure of the foramen ovale.
The ductus arteriosus is usually functionally closed by 8–10 hours after birth, but will not anatomically close for several more months.
