maternity 5-3 Flashcards
Physiologic, Anatomic & Behavioral Adaptations of the Newborn
Establish / maintain respirations
Circulatory changes
Thermoregulation
Regulate weight/blood glucose
Ingest, retain, digest nutrients
Arousal / sleep pattern
Establish relationship with caregivers & environment
Process multiple stimuli
Fetal Lung Function
largely bypasses lungs
Gas exchange via placenta
Lungs filled with fetal lung fluid
INITIATION OF BREATHING (CMTS breathes)
Chemical
Mechanical
Thermal
Sensory
Chemical (chemical chemos) and prostaglandin?
Activation of chemoreceptors in the aorta and carotid arteries by hypoxia/hypercapnia Prostaglandin level drops after cord clamping
Mechanical (mechanical thorax)
: increased thoracic pressure, lung
expansion with crying, expulsion/absorption of fetal lung fluid
initiate breathing - thermal (not thermal heat)
cold stimulation
sensory (sensory touch)
handling, suctioning
Factors in Neonatal Respiration - what can go wrong - when is surfactant produced?
Vaginal vs. C/S
Surfactant: lipoprotein prevents alveolar collapse
Age (lack of surfactant):
Produced at 24-28 weeks gestation
35 weeks usually full production
Meconium
Anatomical defects: congenital heart diaphragmatic hernia
Respiratory SystemNormal Newborn Respirations - what is normal rate and rhythm?
Normal rate 30-60 / min
Shallow and irregular
Abnormal Newborn Respirations
Bradypnea or tachypnea
Abnormal breath sounds
crackles, rhonchi, wheezes, expiratory grunt
Retractions: intracostal/subcostal (high intrathoracic pressure)
Nasal Flaring
Respiratory distress syndrome (RDS): Grunt, Flaring, Retracting***
Cyanosis, mottling
Low pulse oximetry value
CARDIOVASCULAR CHANGES - what conditions are normal? (just 2)
Shunts close
Pulmonary circulation
Normal HR 110-160
Dysrhythmias common - still tell someone even though they’re normal
Murmur - common
Extra RBC’s
Fetal Circulation -cheat sheet
Placenta: Site of gas/nutrient exchange
Umbilical Cord: 1 vein (high O2), 2 arteries (low O2)
Umbilical vein delivers O2 to fetus
Liver mostly bypassed: ductus venosis (shunt 1)
High O2 blood: inferior vena cava to R atrium
High O2 blood (majority): R atrium to L atrium via foramen ovale (shunt 2)
High O2 blood: L atrium to L ventricle to ascending aorta
Low O2 blood: R atrium, bypasses lungs via ductus arteriosus (shunt 3) and back to placenta via descending aorta/umbilical arteries.
Cardiovascular System:
Changes After Delivery - resistence?
Umbilical Vein
Cord clamped
High resistance
Fetal hemoglobin: - what happens to the cells?
Fetal hemoglobin:
RBC size larger than and adult’s
RBC: greater affinity for O2
After birth:
RBC count increase
RBC cell size decreases
Newborn hemoglobin and hematocrit levels
(H and H higher in baby than adult)
Hemoglobin (size decreases by # increases): 16-18 g/dL
Hematocrit: 46-68%
Higher after birth and then gradually decline
Destruction of RBCS = greater iron stores
DELAYED CORD CLAMPINGNew ACOG/AAP guidelines - hemoglobin?
Increases Hgb levels at birth
Improves iron stores
+
Assessment of NewbornTransition (think of the pic)
Inadequate perfusion: may be due to respiratory causes, cardiovascular, or both
Assess for: signs of respiratory distress/compromised cardiac function
Assess for: mottling, cyanosis
MOTTLING OF SKIN (4 things) this mottling is stressing me out
Stress
Respiratory
Cold
can be a sign of Sepsis
Acrocyanosis - and why does the body do this?
cyanosis in extremities as blood preferentially circulates to organs during extrauterine transition.
Perioral/Circumoral Cyanosis - associated w/ what? (the circle is transient)
Blue around mouth
In 1st 24 hours associated w/ Transient Tachypnea of the Newborn (TTN or TTNB).
TTNB (transient tachypnea) usually resolves in 24-48 hrs.
Facial bruising may be mistaken for perioral cyanosis
CENTRAL CYANOSIS - what causes it? (blue baby door)
Hypoxemia
Meconium Aspiration
Pneumonia
Polycythemia - what disorders cause it? (Poly hall)
Polycythemia can increase more with
delayed cord clamping, diabetes, IUGR, and maternal HTN
Physiological Jaundice - risk factor for jaundice - blood type (you know this one)
ABO and RH incompatability
THERMOREGULATION
when the baby is cold, it tries to take in more oxygen
* Immature regulation
ability
* Thin layer of SQ fat
* Blood vessels close to
surface of skin
* Larger “surface-to-body
ratio”
Newborn response to cold - what body position?
Crying
Flexed position
Increase muscle activity
Acrocyanosis (hands and feet)
Unstable blood glucose
Evaporation
Heat loss through evaporation of moisture on the skin.
Convection (convect the breeze)
Heat loss through cooler local air currents
Conduction (conduct my cat)
Heat loss through contact with cooler solid object in contact with the baby
Radiation (radiate towards me)
window pulls heat away. Transfer of heat from to a cooler object not in contact with the baby
AIRWAY/BREATHINGIf infant is crying or breathing on their own - 3 things
Skin to skin
Monitor vital signs
Bulb Suction PRN (suction mouth, don’t use this too much)
If infant is apneic or poor color - do what? (think cold color)
Radiant Warmer
Assess HR
Clear airway
Stimulate
Dry vigorously
Remove Secretions
Wipe nose and mouth with gauze to help get rid of excess fluids.
Use bulb syringe if neonate had meconium staining.
No apparent anomalies.
VS for newborns - how often? (vital signs 4 by 4)
Q30 for the first 2 hours, after 1st 30 min (don’t take vital signs in 1st 30 min), the once at 3 hours, and once at 4 hours
Indications for Oxygen (what about heart and cyanosis)
- Increased respiratory
effort - Respiratory distress with
apnea - Tachycardia
- Bradycardia
- Central cyanosis
Oxygen and/or Positive Pressure Ventilation - HR? and what type of cyanosis?
Apnea
Gasping Respirations
HR <100
Persistent Central Cyanosis
No response
* CAUTION Retinopathy of Newborn
Newborn Initial Head-to-Toe Assessment
Integument: vernix, “stork bites”, vernix, milia, e. toxicum (normal NB rash), congenital dermal melanocytosis (Mongolian spots)
Head
Face: nose, mouth, eyes, ears
Neck, clavicles, and chest
Abdomen
Genitalia
Extremities and spine
Neurologic status: see Ricci 5th ed., 18.4 for reflexes
NEWBORN MEASUREMENTS - typical length?
Flat surface
Extend leg
Length range is 45-55 cm
(17.7—21.7 inches)
length measurement is not too accurate
BIRTH WEIGHT
< 2500: SGA
>4000: LGA
(this for a 40 week fetus)
how to ASSESS GESTATIONAL AGE
Maternal Record
LMP using Negele’s rule
Ultrasound, especially early in pregnancy it’s more accurate
Gestational Age Exam (Ballard Exam - looks at muscle tone, etc)
vernex
creamy substance on baby’s skin from in utero
first 24 hours, document
I/Os
copy slide
68
NEWBORN SCREENING (hearing, etc.)
Newborn screening Blood test
Newborn hearing screen
Congenital heart disease screening = “24 hour work-up” (put device on one extremity and the other - measure blood going to and from heart)
Blood test + TSB (total bilirubin) + Heart disease screening
hearing screening - Automated Auditory Brainstem Response (AABR) (in the name)
Automated Auditory Brainstem Response (AABR): Tests auditory nerve/brainstem pathways.
preimposed (not to pre-impose, but you’re the opposite)
post ductal - blood coming to the heart, deoxygenated blood
discharge teachings
ROUTINE INFANT CARE
SIDS
SHAKEN BABY
CIRCUMCISION CARE
WARNING SIGNS/DISCHARGE TEACHING
CPR
Discharge Teaching: Routine Care
Temperature
Respirations
Feeding
Pacifiers
Infant safety/Safe Sleep
Elimination
Rashes
Clothing
Cord Care
Bathing
Crying
NEWBORN BATH - how long to delay?
WHO: Delay at least 24 hours if possible
Delayed bath: linked to higher rates of BRF
Vernix: keep on skin for moisturizing/antimicrobial properties
Give first bath after umbilical site healed
Never leave baby unattended in bath
- Check for bleeding
- Void before DC: not required
- Petroleum jelly on diaper
- Clean with water
(no wipes / no soap x 5-6 d)* Check for infection - Do not remove yellow
Exudate - Comfort care
SIGNS OF ILLNESS
- Fever
- Hypothermia
- Poor feeding
- Vomiting
- Diarrhea
- Decreased BM
- Decreased urination
- Breathing difficulties
- Cyanosis
- Lethargy
- Inconsolable cry
- Infected circumcision
- Infected umbilical cord
- Eye drainage
Gut colonization/mucosal barrier - when does colonization occur? (We colonized in 6 months)
Gut colonization/mucosal barrier development takes 4-6 months
Immune system: “immature”
Diaper Rash
- Infrequent diaper changes
- Change in diet
- Breastfeeding mother eats
certain foods - Use plain water / mild
soap - Unscented baby wipes, no
alcohol - Expose to air to heal
- Zinc oxide ointment
- Candida yeast Tx
Medical Follow-Up - follow up when?
MD visit within 72
hours after DC
* Monitor weight gain
* Monitor hydration
* Monitor jaundice
* Prevent kernicterus
Fetal lung fluid
removed via birth process/reabsorption
Gas exchange directly related to cardiovascular function/fetal structures
normal newborn respirations - what sounds and apnea? (rally, that’s normal?)
Rales first hour common
Abdominal breathers
Nose Breathers
Short period of apnea < 10 sec “normal”
fetal circulation - Umbilical Cord
fetal circulation - liver
fetal circulation - high 02 path
fetal lung fluid is
filtered amniotic fluid
birth process is
period of anoxia and hypercapnia
when cord is clamped, what happens to pressure in baby’s body?
it goes from low pressure to high pressure
what keeps shunts open?
Prostaglandin
- COLD STRESS - what is it?
- COLD STRESS = 02 goes up (increased need for 02 consumption) trying to increase metabolic rate
skin to skin regulates what?
RR in baby
one way babies stay warm
Non-shivering thermogenesis:
Metabolism goes up – mainly of Brown Adipose Tissue
immediate care of the newborn (3 things) (ABT)
airway, breathing, temp
first 24 hours of life
very vulnerable time for baby
newborn stomach size
10 -25 mL in the first 24 hours
SIDS
is the leading cause of death among babies from 1 month to 1 year of age. higher w/ formula fed babies.
what age is SIDS most common? (sid is young)
1 month to 4 months old
changes after delivery - Ductus Venosus
Ductus Venosus= Not used
changes after delivery - Foramen Ovale
Foramen Ovale = greater Pressure on the L>R, closes Ductus Arteriosus
umbilical artery = circulation stops
Contract in response to increase 02 and decrease prostaglandins
delayed cord clamping - circulation?
Improve transitional circulation in preemies and reduces the need for blood transfusions
delayed cord clamping - reduces what disease? (delay the death and hemorrhage)
necrotizing enterocolitis and intraventricular hemorrhage.
central cyanosis - causes of it (PP causes CC at the blue baby door)
PPHN* (persistent pulmonary hypertension of a newborn- lungs aren’t inflating normally),
Cardiac dysfunction
central cyanosis - early or late sign of distress?
Late sign of distress
normal hematocrit
Normal HCT 51—56 %
hearing screening - Otoacoustic Emissions (OAE) (acoustic hairs)
Tests functioning of outer hair cells.
what happens with glucose initially?
it declines
bilirubin is made of
heme
colonization of gut
takes place in first 24 hours through oral intake
newborn specific gravity (same)
low specific gravity (1.001 to 1.020)
first period
reactivity (reflexes)
second period
decreased responsiveness (sleep)
second period of reactivity
baby wakes up again. may pass meconium.
habituation (habit of vision and hearing)
newborn’s ability to process and respond to visual and auditory stimuli.
fetal growth restriction - less than 28 weeks
symmetrical growth
fetal growth restriction - more than 28 weeks
asymmetrical growth - brain anrd heart are big
risk factors for Polycythemia (Poly plant)
newborns with jaundice and multiple births
meconium aspiration - LGA or SGA
sga
hyperbilirubinemia - LGA or SGA
LGA - bruising during birth trauma
LGA newborns are more difficult to
arouse to a quiet alert state
signs of hypoglycemia in LGA babies - what type of crying - and HR and breathing?
lethargy, irritability, tachypnea, weak crying, temperature instability, jitteriness, apnea, bradycardia, cyanosis, poor feeding
preterm main problem
nutrition
lanugo on preterms
Plentiful lanugo (soft, downy hair), especially over the face and back
post-term babies - appearance
wasted look due to loss of muscle and fat
post-term babies can have (2 things)
polythemia and jaundice
square window (square wrists)
flex hands to wrist
scarf sign
elbow to chest
terms (start w/ late)
Late preterm—born 34 weeks 0/7days through 36 weeks and 6 days
Early term—born 37 weeks through 38 weeks and 6 days
Full term—born 39 weeks through 40 weeks and 6 days
Late term—born 41 weeks through 41 weeks and 6 days
Post-term—born 42 weeks and beyond
stork bites
nape of neck, eyelids
mongolian spots
blue lower back and buttocks
Caput succedaneum
pressure from birth, prolonged labor
babinski
stroking bottom of foot
transient tachypnea - cause
from a lack of thoracic squeezing during c-section or CNS depressant for mom
kernicterus
unconjugated bilirubin enters the brain
hypoglycemia numbers
less than 30 mg/dL in first 72 hours of life
how many calories for newborn?
110 to 120/kg of body weight
when is sucking reflex developed?
32 weeks, so if they’re born before that, they have issues
SGA - hematocrit and hemoglobin
hematocrit over 65%, hemoglobin over 20
what color is skin of sga babies
ruddy - too many rbcs
acidosis on fetal monitor strip (acid decreases my variability)
decreased variability
polycythemia associated with what skills? (Poly has a Thick tongue and movement)
gross motor skills and speech delays
polycythemia - more of a concern with LGA or SGA? (poly is large)
LGA
behavior patterns
1st period of reactivity: alert and hungry
decreased responsiveness: sleepy
2nd period of reactivity: wakes up, temp and RR goes up
blood volume
80-100 mL/kg
