Neonatal Period Flashcards
- Weeks 25-30, Type II alveolar cells begin production
- Mature amount at 35-37 weeks gestation
- Phospholipid
Surfactant
- Decrease surface tension of pulmonary fluids
- Prevents alveolar collapse at end of expiration
- Facilitates gas exchange
- Lower inflation pressures needed to open airway
- Improves lung compliance
- Decreases labor of breathing
Functions of Surfactant
Marker of fetal lung maturity; test of fetal amniotic fluid to assess for fetal lung immaturity; surfactant
lecithin–sphingomyelin ratio ( L/S ratio): 2:1 or >
A phosphatidic acid that is a constituent in human amniotic fluid and is used as an indicator of fetal lung maturity when present in the last trimester of gestation (36 weeks)
Phosphatidyl glycerol
- Secreted by lungs, amniotic cavity, trachea
- Air must replace lung fluid
- 1/3 removed at birth; 2/3 pulmonary circulation and lymphatic system
- Total time to clear = 6-24 hours after vaginal delivery
- Inadequate clearance = TTN
Lung fluid
- Term
- Delivery route - cesarean birth
- Low dose oxygen thereapy
- Rapid improvement (3 days)
TTN - Transient Tachypnea of Newborn
- Mild asphyxia in normal birth - high carbon dioxide and low oxygen
- Others: thermal, tactile stimulation (flicking the soles of the feet; rubbing the back gently), lights, noise, cord occlusion
Breathing stimuli at birth
Respiratory rate in neonates
30-60
- Diaphragmatic, shallow, irregular depth and rhythm
- Abdominal, synchronous with chest movement
- Short periods of apnea
- Deep sleep - regular breathing
- REM sleep - periodic breathing
- Crying/ motor activity - grossly irregular
Characteristics of respirations in neonates
Until age 3 weeks, obstruction → respiratory distress (sleep on the back)
Reflex takes over
Relation to SIDS (Sudden infant death syndrome)
Oral mucus secretions, cough/gag
Obligatory Nose Breathers
Assessment tool to determine the degree of respiratory distress (0,1 or 2) ; > 7 - severe respiratory distress Features observed: 1. Chest movement 2. Intercostal retraction 3. Xiphoid retraction 4. Nares dilation 5. Expiratory grunt
Silverman-Anderson Index - RDS : respiratory distress syndrome (resulting from lung immaturity and lack of alveolar surfactant )
Purposes:
Decrease blood flow to fetal lungs
Direct blood to the placenta
Increase blood flow to head & heart
Fetal Circulation
Fetal pulmonary BP > adult pulmonary BP
Diverts blood flow away from non-functioning fetal lungs
Decrease Blood Flow to Fetal Lungs
Fetal systemic BP lower than adult
Flow leads to the placenta readily
Direct Blood to the Placenta
- Umbilical vein - oxygenated blood from the placenta to the fetus
- Umbilical artery - waste
- Wharton’s jelly - keep vein and artery from tangling ; keep them separated
Umbilical Cord
Ductus venosus
Ductus arteriosus
Foramen ovale
Increase Blood Flow to Head and Heart
Shunts arterial blood into inferior vena cava
Functional closure - few hours after birth
Anatomic closure - turns into ligament
Ductus venosus
Shunts arterial and some venous blood from pulmonary artery to aorta; allows blood to go around lungs
Functional closure
Anatomic closure
Ductus arteriosus
Leads to abnormal blood flow between the aorta and pulmonary artery, two major blood vessels that carry blood from the heart.
Patent Ductus Arteriosus (PDA)
Connects right and left atria ( allows more than half the blood entering the right atrium to cross immediately to the left atrium, passing the pulmonary circulation)
Usually obliterated within hours after birth
Pressure highest right atrium
Foramen ovale
Umbilical cord clamped - neonate draws first breath - Systemic vascular resistance increases- Blood flow through ductus arteriosus decreases - Most of right ventricular output flows through lungs, boosting pulmonary venous return to the left atrium - Left atrial pressure rises in response to the increased blood volume to the lung - This, combined with increased systemic resistance causes functional closure of foramen ovale
Changes to Neonatal Circulation
Neonatal Heart Rate
Check apical for full minute
Also evaluate peripheral pulses (brachial, femoral)
120-150 awake
Range: 70-90 asleep, 180 crying
Blood Pressure
Sensitive to changes in blood volume that occur with transition to neonatal circulation
Most accurate: measure in quiet newborn
At term, 60-80/40-50 mm Hg. (75/42 avg.)
Turbulent blood flow, transient
Abnormal valve, ASD (atrial septal defect) or VSD (ventrical) , too high a blood flow across normal valves
Check all 4 extremity BPs if heard, record MAP, pulse ox.
Heart Murmurs
- blotchy and mottled skin in the extremities; feels “chilly”
- first few hours after delivery
- response to exposure to cold - normal and intermittent
Acrocyanosis
Blue around philtrum & lips
Tongue & mucous membranes pink
Type of acrocyanosis
Resolves spontaneously
Perioral (Circumoral) Cyanosis
10-15% total body weight
Low O2 tension of maternal blood stimulates fetal RBCs (↑ HCT)
About 300 ml.
Mode of delivery effects TBV
Vaginal vs. C/S
- clamping of the umbilical cord : early ( before 30-40 sec) vs late (after 3 min additional 150 ml of blood)
Total Blood Volume
- clamping of the umbilical cord : early ( before 30-40 sec) vs late (after 3 min additional 150 ml of blood)
↓ anemia →↓ transfusions
Stem cells
↓ disorders R/T prematurity
Delayed Cord Clamping benefits
R/T normal destruction of fetal RBCs
Bilirubin transported to liver for conjugation
Immature livers
50%+ develop
Physiologic Jaundice
Hemolysis of erythrocytes (normal after birth) - bilirubin - liver - water soluble pigment - GI system via bile - feces + urine
Bilirubin
Predisposition: Asians, Greeks, Native Americans
Less likely: African-Americans
Differentiate from pathologic jaundic
- if not treated - kernicterus - brain damage - death
Physiologic Jaundice
Yellowish skin , mucous membranes, and sclera within the first 3 days of life ; asses by pressing gently with a fingertip on the bridge of the nose , sternum, or forehead - if present the blanched area will appear yellow before the cap refill
Visual Inspection for Jaundice
Involves exposing the newborn to ultraviolet light , which converts unconjugated bilirubin into products that can be excreted through feces and urine
Phototherapy ( Light changes the angle of bonds within bilirubin molecule, making it easier to excrete it
(unconjugated) in the bile)
is a way to find out how much bilirubin is in the blood; The test sends a quick flash of light through the skin; The measurement is usually taken by gently pressing the meter against the sternum or forehead ; no blood test.
Transcutaneous Bilirubin Measurement
Place the automated lancing device on the appropriate area on the side of the heel
Heelstick
First 24 hours of life Rises 5 mg/dL every 24 hours Premature neonates LBW neonates Rh or ABO incompatibility G6PD deficiency: x-linked recessive High H/H 17-20 g/dL, 52-63% normal
Pathologic Jaundice
Bilirubin neurotoxic at high levels
Crosses blood-brain barrier, causes irreversible CNS damage
Kernicterus
Watch temperature
Watch hydration status
Protect eyes and genitals
Positioning
Nursing Care of Neonate “Under the Lights”