Unit 6 Flashcards
Immediate Care After Birth
What’s included in the initial physical assessment?
- The initial assessment is performed immediately after birth and may be accomplished while the infant is lying on the mother’s abdomen or chest or in her arms immediately after birth OR while the newborn is lying on the radiant warmer bed.
- Making sure the baby can transition to extrauterine life
- Baby is wiped off, bulb suction (mouth BEFORE the nose)
- Baby is handed off to mom if well enough (breathing effectively, is pink, and has no apparent life-threatening anomalies or risk factors requiring immediate attention)
- Ideally, the newborn remains skin-to-skin with the mother for at least the first 1 to 2 hours after birth, and breastfeeding is initiated during that time.
- If baby is still having to be stimulated (wiped off, rubbing), it may need to go to warmer
- First thing a baby needs to be able to do: Breathe, first thing assessed for in Apgar score.
- Cord is cut
When is Apgar scoring done?
What are the scores?
What do the total scores mean?
Assigned at 1 minute and 5 minutes
Heart Rate (palpate the umbilical stump)
- Absent: 0
- Slow <100/min: 1
- >100/min: 2
Respiratory Rate (don’t need to know rate)
- Absent: 0
- Slow, weak cry: 1
- Good cry: 2
Muscle Tone
- Flaccid: 0
- Some flexion of extremities: 1
- Well flexed: 2
Reflex Irritability
- No response: 0
- Grimace: 1
- Cry: 2
Color
- Blue, pale: 0
- Body pink, extremities blue: 1 (normal, most common reason a point is taken off)
- Completely pink: 2
Score of 7-10: the baby is transitioning well.
Score of 4-6: okay, having a little difficulty.
Score of 3 and below: not doing well, needs resuscitation.
Immediate Care of the Newborn After Birth
- Goal: assist the newborn to successfully transition to extrauterine life.
- First priority: establish effective respirations.
- If the newborn is at term, has good muscle tone, and is crying or breathing, routine care is all that is required (includes placing the newborn skin-to-skin on the mother’s chest or abdomen)
- Drying the infant with gentle rubbing removes the moisture, which helps minimize evaporative heat loss***
- Wet linens should be removed, and the mother and baby should be covered with a warm blanket.
- After drying the newborn’s head, a cap should be applied.
- Nasal and oral secretions are wiped away; the bulb syringe may be used if secretions appear to be blocking the airway.
- The nurse begins ongoing assessment of the neonate’s breathing, color, and activity
- A newborn who is not term, has poor muscle tone, or is not crying or breathing is placed immediately under a radiant warmer. Assessments are done under the warmer until the infant is stable
- Newborn should be breathing spontaneously. The trunk and lips should be pink; bluish discoloration of the hands and feet is normal. May take several minutes for newborn to “pink up” (when central cyanosis persists, put on pulse ox)
- Identification bands on mom and baby, security tag on baby
Initial Physical Assessment of the Newborn: Normal Findings
General Appearance
Respiratory System
Cardiovascular System
Neurologic System
GI System
Eyes, nose, mouth
Skin
GU System
General Appearance
- Color pink
- Acrocyanosis present
- Flexed posture
- Alert
- Active
Respiratory System
- Airway patent
- No upper airway congestion
- No retractions or nasal flaring
- Respiratory rate, 30-60 breaths/min
- Lungs clear to auscultation bilaterally
- Chest expansion symmetric
Cardiovascular system
- Heart rate >100 beats/min; strong and regular
- No murmurs heard
- Pulses strong and equal bilaterally
Neurologic System
- Moves extremities
- Normotonic
- Symmetric features, movement
- Reflexes present: Sucking, Rooting, Moro, Grasp
- Anterior fontanel soft and flat
GI System
- Abdomen soft, no distention
- Cord attached and clamped
- Anus appears patent
Eyes, Nose, Mouth
- Eyes clear
- Palate intact
- Nares patent
Skin
- No signs of birth trauma
- No lesions or abrasions
GU System
- Normal genitalia
Immediate Interventions After Birth
Airway Maintenance
- HCP immediately starts suctioning, the baby can swallow fluid as it goes through the birth canal (Mouth BEFORE nose)
- Avoid vigorous suctioning
- Auscultate breath sounds
- Fine crackles may heard for a few hours after birth, especially C/S (this is okay)
- If the bulb syringe does not clear mucus interfering with respiratory effort, deeper mechanical suction may be needed: DeeLee
- Measure how much fluid is suctioned!
Immediate Interventions After Birth
Maintaining an adequate oxygen supply
Four conditions are essential for maintaining an adequate oxygen supply:
* A clear airway
* Effective establishment of respirations
* Adequate circulation, adequate perfusion, and effective cardiac function
- Changing from fetal circulation to newborn circulation (remember: things need to close -> foramen ovale, ductus arteriosus “functional closure” not permanent)
- Can hear a murmur during this period (will go away after a few hours)
* Adequate thermoregulation
Immediate Interventions After Birth
Maintaining Body Temp
Baby can stay on mom’s chest for an hour as long as mom and baby are medically okay
Regulates temperature, heart rate, breathing, blood sugar; improves temperature stability, and improves breastfeeding initiation and duration
- The ideal method for maintaining body temp: early skin-to-skin care
- The unclothed newborn is placed prone directly on the mother’s chest; both mother and infant are then covered with a warm blanket, and a cap is placed on the infant’s head.
- Other ways: drying and wrapping the newborn in warm blankets immediately after birth, keeping the head well covered, and keeping the temp of the nursery or mother’s room at 72 to 78°F
- If no SSC during the 1 to 2 hours after birth, the nurse places the thoroughly dried infant under a radiant warmer until the body temp stabilizes.
- The nurse assesses the axillary tempe of the newborn every hour (or more often as needed) until the newborn’s temperature stabilizes.
- The initial bath for an uncompromised term infant should be postponed for at least 6 hours and until the newborn’s skin temperature is stable (2 axillary temps) and should be limited to 5 min
Immediate Interventions After Birth
Eye Prophylaxis
- Erythromycin 0.5% ophthalmic ointment
- Ribbon in conjuctiva
- Do not wipe away
- Avoiding neisseria gonorrhoeae -> which if untreated and mom has it, baby can be blinded
- Mandated by law (both vaginal and C/S)
- Eye prophylaxis is usually administered within the first hour after birth.
- It may be delayed up to 2 hours until after the first breastfeeding so that eye contact and parent-infant attachment and bonding are facilitated
Immediate Interventions After Birth
Vitamin K Administration
- At birth, neonates have low vitamin K levels related to limited transplacental transfer of vitamin K and the lack of normal intestinal flora necessary for vitamin K synthesis.
- Promotes formation of clotting factors (II, VII, IX, X) in the liver.
- Recommended that every newborn receive a single dose of phytonadione 0.5 to 1 mg to prevent vitamin K–dependent hemorrhagic disease of the newborn
- IM Injection
- Parents can refuse Vitamin K
Immediate Interventions After Birth
Promoting Parent-Infant Interaction
- First hour after delivery: golden hour
- Important for the mom and partner to be a part of this -> still do this even if mom needs to be medically taken care of
- SSC with the mother beginning immediately after birth and breastfeeding within the first 1 to 2 hours after birth are important in promoting maternal-infant attachment.
- Rooming-in after birth until discharge from the birthing facility promotes parent-infant interaction.
The major adaptations associated with transition from intrauterine to extrauterine life occur during
first 6-8 hours after birth
Describe the first period of reactivity
- The first stage of the transition period lasts up to 30 minutes after birth and is called the first period of reactivity.
- The newborn’s heart rate increases rapidly to 160 to 180 beats/min but gradually falls after 30 min
- Respirations are irregular, may go above 30-60 breaths/min (60-80 breaths/min)
- The infant is alert and may have spontaneous startles, tremors, crying, and head movement from side to side.
- Tremors are normal
Describe period of decreased responsiveness
- Lasts from 60 to 100 minutes
- Heart rate “normals out” back to lower of 110-160 bpm
- During this time the infant is pink, and respirations are rapid (up to 60 breaths/min) and shallow but unlabored. “Even out”
- The newborn either sleeps or has a marked decrease in motor activity.
Describe second period of reactivity
- Occurs between 2 and 8 hours after birth and lasts from 10 minutes to several hours.
- Brief periods of tachycardia and tachypnea occur, associated with increased muscle tone, changes in skin color, and mucus production.
- Meconium is commonly passed at this time.
- The more preterm a baby is (before 34 weeks), the more likely the baby will not experience a second period of reactivity
Physical Assessment
General Appearance
- Color, posture, activity, any obvious signs of anomalies that can cause initial distress
- Presence of bruising or other birth trauma
- State of alertness
- Normal resting position of the term newborn is one of general flexion.
Posture
- Expected Findings
- Normal Variations
- Deviations from Normal Range
Expected Findings
- Arms, legs in moderate flexion; fists clenched
- Resistance to having extremities extended
- Cessation of crying when allowed to resume curled-up fetal position
- Normal spontaneous movement bilaterally asynchronous but equal extension in all extremities
Normal Variations
- Frank breech: legs straighter and stiff, hips may be flexed allowing legs to point toward the newborn’s head
- Prenatal pressure on limb or shoulder possibly causing temporary facial asymmetry or resistance to extension of extremities
Deviations from Normal Range
- Hypotonia, relaxed posture while awake (Preterm, Hypoxia in utero, Maternal meds, Spinal Muscular Atrophy)
- Hypertonia (Chemical dependence, CNS disorder)
- Limitation of motion in any extremity
Physical Assessment
Vital Signs
- HR: 110-160 bpm; listen at mitral for a full minute
- RR: 30-60 breaths/min; count for a FULL minute (baby can have certain periods of apnea)
- Temperature: 97.7-99.4 °F: axillary (rectal is taken if not getting a good reading)
- BP: MAP should be about equal to the baby’s gestational age
Heart Rate and Pulses
- Expected Findings
- Normal Variations
- Deviations from Normal Range
Expected Findings
- Visible pulsations in left midclavicular line, fifth intercostal space
- Apical pulse, fourth intercostal space 120-160 beats/min when awake
Normal Variations
- 80-100 beats/min (sleeping) to 160 beats/min (crying); possibly irregular for brief periods, especially after crying
Deviations from Normal Range
- Tachycardia: persistent, ≥180 beats/min (Respiratory Distress Syndrome, Pneumonia)
- Bradycardia: persistent, ≤80 beats/min (congenital heart block, maternal lupus)
Respirations
- Expected Findings
- Normal Variations
- Deviations from Normal Range
Expected Findings
- 30-60/min
- Tendency to be shallow and irregular in rate, rhythm, and depth when infant is awake
- Crackles may be heard after birth
- Breath sounds: bronchial; loud, clear
Normal Variations
- First period (reactivity): 50-60/min
- Second period: 50-70/min
- Stabilization (1-2 days): 30-40/min
- Short periodic breathing episodes and no evidence of respiratory distress or apnea (>20 s)
- Crackles (fine)
Deviations from Normal Range
- Apneic episodes: >20 s (preterm infant: rapid warming or cooling of infant; CNS or blood glucose instability)
- Bradypnea: <30/min (maternal narcosis from analgesics or anesthetics, birth trauma)
- Tachypnea: >60/min (RDS, transient tachypnea of the newborn, congenital diaphragmatic hernia)
- Crackles (coarse), rhonchi, wheezing
- Expiratory grunt (narrowing of bronchi)
- Distress evidenced by nasal flaring, grunting, retractions, labored breathing
- Stridor (upper airway occlusion)
Temperature
- Expected Findings
- Normal Variations
- Deviations from Normal Range
Expected Findings
- Axillary: 98.6°F
- Temperature stabilized by 8-10 h of age
Normal Variations
- 97.7 - 99.4 °F
- Heat loss: from evaporation, conduction, convection, radiation
Deviations from Normal Range
- Subnormal (preterm birth, infection, low environmental temperature, inadequate clothing, dehydration)
- Increased (infection, high environmental temperature, excessive clothing, proximity to heating unit or in direct sunshine, chemical dependence, diarrhea and dehydration)
- Temperature not stabilized by 6-8 h after birth (if mom received magnesium sulfate, newborn less able to conserve heat by vasoconstriction; maternal analgesics possibly reducing thermal stability in newborn)
Blood Pressure
- Expected Findings
- Normal Variations
- Deviations from Normal Range
Expected Findings
- MAP should be about equal to the baby’s gestational age
Normal Variations
- Variation with change in activity level: awake, crying, sleeping
Deviations from Normal Range
- Difference between upper and lower extremity pressures (coarctation of aorta)
- Hypotension (sepsis, hypovolemia)
- Hypertension (coarctation of aorta, renal involvement, thrombus)
Measuring physical growth
What is macrosomia?
Deviations from normal finding
Head circumference
- Micocephaly (maternal rubella, toxoplasmosis, cytomegalovirus, fused cranial sutures)
- Hydrocephaly: sutures widely separated
- ≥4 cm more than chest circumference (infection)
- Increased intracranial pressure (hemorrhage, space-occupying lesion)
Chest circumference
- Deviation: prematurity
Weight (grams and pounds)
- Weight ≥4000 g is considered macrosomia (large for gestational age, maternal diabetes, heredity)
- Weight ≤2700 g (preterm, small for gestational age, rubella syndrome)
- Weight loss more than 10% (growth failure, breastfeeding difficulty, dehydration)
Length (head to heel)
- <48 cm or >53 cm (Chromosomal Abnormality, Heredity; Skeletal dysplasias, Achondroplasia)
Plot on growth chart
Describe initiation of breathing
- At birth, the lungs must be established as the site of gas exchange.
- Clamping the umbilical cord causes a rise in blood pressure (BP), which increases circulation and lung perfusion.
- The initiation of respirations in the neonate is the result of a combination of chemical, mechanical, thermal, and sensory factors
Initiation of Breathing
Chemical Factors
Decreased level of O2 and increased level of CO2 stimulates the respiratory center in the brain (medulla).
Another chemical factor may also play a role; it is thought that as a result of clamping the cord, there is a drop in levels of a prostaglandin that can inhibit respirations.
Initiation of Breathing
Mechanical Factors
- When a baby is born vaginally, there is pressure exerted on the intrathoracic cavity
- The compression of the chest is a mechanical factor that helps stimulate breathing (this doesn’t happen with C/S).
- Compression of the chest also helps get out the fluid that the baby swallowed (concerned about C/S babies having more fluid in the lungs because they don’t have this).
- ## Crying increases positive pressure and helps the lung stay inflated (keeps alveoli open)
Initiation of Breathing
Thermal Factors
With birth the newborn enters the extrauterine environment in which the temperature is significantly lower.
The profound change in environmental temperature stimulates receptors in the skin, resulting in stimulation of the respiratory center in the medulla.
Initiation of Breathing
Sensory Factors
Sensory stimulation occurs by…
- Handling by the obstetric health care provider
- Suctioning the mouth and nose,
- Drying by the nurses. Environmental factors (lights, sounds, smells) stimulate the respiratory center.
Describe periods of apnea in a newborn
What is important to avoid in infants that could obstruct their airway?
- Short periodic breathing episodes and no evidence of respiratory distress or apnea (>20 s) are normal
- Anything greater than 20 seconds is BAD. Notify HCP
- Babies are nose breathers, do not obstruct the nose.
- The reflex response to nasal obstruction is to open the mouth to maintain an airway. This response is not present in most infants until 3 weeks after birth, therefore cyanosis or asphyxia can occur with nasal blockage.
Signs of respiratory distress
- Nasal flaring
- Intercostal or subcostal retractions
- Suprasternal or subclavicular retractions with stridor or gasping most often represent an upper airway obstruction.
- Grunting: usually occurs on expiration
- Apneic episodes can be related to events such as rapid increase in body temperature, hypothermia, hypoglycemia, or sepsis. (Bad if > 20 s)
- Tachypnea: Listen to lungs front and back to see if they have any fluid. Percussion: turn baby on side and pat it on the back. Rub with heel of hand -> moves fluid out of system. Could also be due to RDS
- Report a RR of <30 or >60
- Report Seesaw or paradoxic respirations (exaggerated rise in abdomen with respiration as the chest falls)
Heart sounds
- Expected Findings
- Normal Variations
- Deviations from Normal
Expected Findings
- First and second sound sharp and clear
Normal Variations
- Murmur, especially over base or at left sternal border in interspace 3 or 4
- Can hear murmur first 1-5 minutes if there is no functional closure of ductus arteriosus and foramen ovale
*** Should not hear 1-2 hours later
Deviations from Normal
- Murmur (possibly functional)
- Dysrhythmias/irregular rate
- Distants sound (pneumopericardium)
- Poor quality
- Extra sound
- Heart on right side of chest (dextrocardia, often accompanied by reversal of intestines)
Peripheral Pulses
Expected Finding
Deviations From Normal
Expected Finding
- Peripheral pulses equal and strong
Deviations From Normal
- Weak or absent peripheral pulses (decreased cardiac output, thrombus, possible coarctation of aorta if pulses not equal from side to side or upper to lower, bounding)
Describe blood volume in a newborn
- Around 100 mL per kilogram
- Delayed cord clamping: can help with blood volume (wait 30-60 seconds)
- Delayed cord clamping (DCC) expands the blood volume from the so-called placental transfusion of blood to the newborn by as much as 100 mL, depending on the length of time to cord clamping and cutting.
- Cord milking: “milking” the blood into baby (increases blood volume)
- Increases hematocrit and baby’s iron stores -> lower risk for anemia
Color
- Expected Findings
- Normal Variations
- Deviations from Normal
Expected Findings
- Generally pink
- Acrocyanosis (trunk is pink, extremities are blue) common for the first 48 h after birth
Normal Variations
- Mottling
- Harlequin sign
- Plethora
- Nevus simplex
- Erythema toxicum/neonatorum (“newborn rash”)
- Milia
- Petechiae over presenting part
- Ecchymoses from forceps in vertex births
- Mongolian Spot
Deviations from Normal
- Dark red (preterm, polycythemia)
- Gray (hypotension, poor perfusion)
- Pallor (cardiovascular problem, CNS damage, blood dyscrasia, blood loss, twin-to-twin transfusion syndrome, infection)
- Cyanosis (hypothermia, infection, hypoglycemia, cardiopulmonary diseases, neurologic or respiratory malformations)
- Generalized petechiae (clotting factor deficiency, infection)
- Generalized ecchymoses (hemorrhagic disease)
- Nevus flammeus (port-wine stain)
- Infantile hemangioman (nevus vascularis)
Signs of Cardiovascular Problems
Central Cyanosis, Blue lips
- NEVER Okay
Pallor of the skin
- Cardiac issue, hypoxia during labor
- Anemia, peripheral vasoconstriction (asphyxia, sepsis)
Persistent tachycardia
- Anemia, hypovolemia, hyperthermia, or sepsis
Persistent bradycardia
- Congenital heart block or hypoxemia
Unequal or absent pulses, bounding pulses, and decreased or elevated BP
- Cardiac issue
Describe hematology of newborns
Red blood cells
Leukocytes
Platelets
Blood groups
Red blood cells
- When babies are born, they have a higher level of RBCS than we do
- Newborn RBCs are immature and break down easily (shorter life span)
Leukocytes
- Normal for leukocytosis at birth: ranging from 9000 to 30,000/mm3
- The initial high WBC count of the newborn decreases rapidly, and a stable level of 12,000/mm3 is normally maintained during the neonatal period
- Newborns are susceptible to infection.
Platelets
- Vitamin K to jumpstart clotting factors
Blood Groups
- Cord blood is taken to figure out blood type and Rh
Thermogenic System
What is thermoregulation?
How is it done?
What puts infants at higher risk for heat loss?
- Thermoregulation is the maintenance of balance between heat loss and heat production.
- Preferably done on Mom’s chest
- Skin-to-skin contact with the mother is an effective means of reducing conductive and radiant heat loss
- Drying the infant quickly after birth is essential to prevent hypothermia
Babies are at higher risk of heat loss… - Newborns have a thin layer of subcutaneous fat. The blood vessels are close to the surface of the skin.
- Newborns have larger body surface–to–body weight (mass) ratios than children and adults.
Describe how does Heat Loss occurs in newborns and how to manage it
- Convection: Flow of heat from the body surface to cooler ambient air
- Newborns in open bassinets are wrapped to protect them from the cold
- A cap may be worn to decrease heat loss from the infant’s head. - Radiation: loss of heat from the body surface to a cooler solid surface not in direct contact but in relative proximity.
- Bassinets and examining tables are placed away from outside windows
- Avoid direct air drafts. - Evaporation: loss of heat that occurs when a liquid is converted to a vapor. In the newborn: result of moisture vaporization from the skin
- Dry newborn after birth
- Careful when bathing (stable temp, limited to 5 min) - Conduction: loss of heat from the body surface to cooler surfaces in direct contact
- The newborn is placed on a prewarmed bed
- The scales used for weighing the newborn should have a protective cover
Describe thermogenesis
Babies can’t shiver.
When temp lowers…
1. Increased metabolic rate -> lowers blood glucose
1. Muscle activity increases (general flexion) leads to increased O2 consumption -> tachypnea
1. Vasoconstriction
2. Use Brown Fat (increased cellular metabolic activity to brain, heart, liver) = nonshivering thermogenesis
3. If that doesn’t work = cold stress (BAD) Reserves of brown fat, usually present for several weeks after birth, are rapidly depleted with cold stress.
Describe cold stress and what to do
If you see tachypnea, lowered blood sugar -> check temperature!
If temperature isn’t fixed, nonshivering thermogenesis begins.
Cold stress makes the increased metabolic rate, increased O2 consumption, hypoglycemia worse.
Increased O2 consumption could lead to hypoxia and peripheral vasoconstriction, which could lead to metabolic acidosis.
Hypoglycemia leads to decreased surfactant production.
All of this could lead to respiratory distress.
Describe hyperthermia
Describe differences in the causes
99.5°F or above
If hyperthermia is due to environmental factors (too many blankets, mom is hot, too many clothes on)
- Skin vessels dilate, which causes the baby to appear flushed
- Hands and feet are very warm to touch
- Baby extends arms and legs
Hyperthermia due to sepsis
- Skin vessels are constricted
- Color is pale
- Hands and feet are cold to touch
Renal System
Describe when an infant should void and how often
- An infant should void within 24 hours of life.
- 98% of infants void within 30 hours of life.
- If a newborn has not voided within 48 hours of life it may indicate a renal impairment.
- Number of voids = number of days (Day 2 = 2 voids, Day 3 = voids) .
- After day 4, there needs to be 6-8 voids per day
Renal System
Describe Fluid and Electrolyte Balance (weight after delivery)
- Normal for babies to lose 5-10% of weight after delivery
- Should NOT lose more than 10%
- Breastfeed babies tend to lose more than formula fed babies (still less than 10%)
- Babies should regain however much they lost within 14 days of delivery
- 75% of newborn’s weight is water
Describe GI System in newborns
Feeding
Development
- The neonate is unable to move food from the lips to the pharynx; therefore placing the nipple (breast or bottle) well inside the baby’s mouth is necessary.
- Babies can’t fight back bacteria like we can; make sure feeding supplies are clean
- Intestines are not mature until 4-6 months
- Capacity of the stomachs grown exponentially in the first week.
Hold 10 mL on day 1
By end of the week, the stomach can hold about 90 mL - All babies spit up, this is normal. Keep baby upright after feeding to help decrease spit up
Describe Stools in a Newborn
(types)
Meconium
* Greenish black and viscous and contains occult blood.
* Composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood
* Passage of meconium should occur within the first 24-48 h, although it can be delayed up to 7 days in very low birthweight infant
Transitional Stools
* Usually appear by third day after initiation of feeding
* Greenish brown to yellowish brown; thin and less sticky than meconium; can contain some milk curds
Milk Stool
* Usually appears by the fourth day
* Breastmilk: yellow to golden, pasty in consistency; resemble a mixture of mustard and cottage cheese, with an odor similar to sour milk
* Commercial infant formula: Stools pale yellow to light brown, firmer consistency, stronger odor than breast milk stools
Signs of risk for gastrointestinal problems
- Concerning if first stool isn’t passed within first 24-48 hours (sign of obstruction)
- Look at anus. An active “wink” reflex means baby has sphincter control
- Forceful vomiting and forceful diarrhea is not normal
Liver regulation of glucose
Describe glucose levels after birth
40-60 mg/dL: normal blood glucose for baby
- In utero, the baby gets glucose from mom
- Once baby is cut off from mom, the baby gets glucose from breast or bottle
- Before feeding, the baby is not getting any glucose.
- 30-90 minutes after delivery: low point of glucose
Signs/Symptoms of low blood sugar (<40 mg/dL)
Interventions
Jittery/Irritable
Lethargic
Apnea
- Feed baby before glucose gets to low point ** feeding within the first hour can avoid the baby experiencing hypoglycemia
- Signs baby is ready to eat: moves to nipple, rooting reflex, tongue movement
- LATE sign of hunger: crying **
Describe formation and excretion of bilirubin in a newborn
- Newborn RBCs are immature and easily broken down
- Since RBCs have a shorter lifespan and there’s more of them, there is an increased production of Bilirubin
- RBC is broken down to heme and globin
- Heme is broken down to iron and bilirubin
- Bilirubin can be conjugated or unconjugated
- Conjugated bilirubin is excreted easily
- Unconjugated bilirubin needs to bind to albumin to be excreted
What interventions decrease bilirubin in a newborn?
What causes jaundice?
- Ability of body to get rid of unconjugated bilirubin depends on digestion and stooling pattern -> if peristalsis is good, things are coming out
- Good feeding practice is a good way to get rid of bilirubin (and gets meconium out faster)
- Feeding every 2-3 hours
- If levels of unconjugated bilirubin gets high -> jaundice
Physiologic Problems
Hypoglycemia
Screening
Blood glucose < 40 mg/dl
Not every baby is screened.
Automatically screen if mom is diabetic, baby is small for gestational age or large for gestational age
May do another screening after baby is fed
Physiologic Problems
Hypocalcemia
Levels
Signs
- Serum calcium < 7.8 to 8 mg/dl in term infants and slightly lower (7 mg/dl) in preterm infants
- Can present similarly to hypoglycemia (if interventions for hypoglycemia are not working, check for hypocalcemia)
- Symptoms are same as hypoglycemia EXCEPT for high-pitched cry in hypocalcemia
- Usually self-resolving
Hyperbilirubinemia (Jaundice)
Physiologic Jaundice
Assessment and Screening
What is key to preventing jaundice?
- Appears after 24 hours of age
- Commonly peaks at 3-5 days of life
- Occurs in over half of newborns, 80% of preterm babies
- Commonly due to increase in RBCs
- Assess in good lighting
- Sclera and mucous membranes: common place to see jaundice first
- Screening: usually every 8 to 12 hours
- You can figure out if it’s jaundice by blanching the skin area (if jaundice it comes back yellow, then pinky red)
- Feeding is key to preventing jaundice
- First milk of breastfeeding (colostrum) acts as a laxative
Risk Factors for Jaundice
- Breastfeeding exclusively (true milk takes a while to come in, or if baby is not latching on well)
- Preterm babies or any baby <38 weeks
- Diabetic mom
- Bruising (difficult birth)
- Sibling had jaundice
- Hematoma
- East Indian Race
- Excessive weight loss
- Hypoxia, acidosis, hypothermia, hypoglycemia
- Delayed or infrequent feedings
Coagulation in Newborns
- Liver plays an important role in blood coagulation
- Coagulation factors, which are synthesized in the liver, are activated by vitamin K
- The lack of intestinal bacteria needed to synthesize vitamin K results in transient blood coagulation deficiency between the second and fifth days of life.
- The administration of intramuscular vitamin K shortly after birth helps to prevent vitamin K deficiency bleeding (VKDB)
Describe Immune System in Newborns
IgG
IgA
IgM
IgG
- Location: Blood, ECF
- Passive Immunity
- Important to fight infection (bacteria, viruses)
IgA
- Location: Breastmilk
- Passive Immunity
- Neutralize bacterial and viral pathogens in intestines
- Lessen the risk for allergy and food intolerance
IgM
- Location: Blood
- 8th week of gestation
- Important to fight blood-borne infection
Signs of infection in newborns
Infection is one of the leading causes of morbidity and mortality
- Irritability
- Lethargy
- Poor Feeding
- Vomiting or Diarrhea
- Tachypnea
- Pale/mottled skin
- Decreased reflexes (hypotonia)
What is Vernix caseosa?
Desquamation?
- A cheeselike, whitish substance that is fused with the epidermis and serves as a protective covering
- A complex substance that contains sebaceous gland secretions.
- It has emollient and antimicrobial properties and prevents fluid loss through the skin; it also has antioxidant properties
- Removal of the vernix is followed by desquamation of the epidermis
- There is evidence that leaving residual vernix intact after birth has positive benefits for neonatal skin
- Desquamation (peeling) of the skin
What is Lanugo?
Sweat glands; milia?
Mongolian spots?
Lanugo
- Fine lanugo hair may be noted over the face, shoulders, and back.
Milia
- Distended, small, white sebaceous glands noticeable on the newborn face are known as milia
Mongolian Spots
- Bluish black areas of pigmentation. hey are most common on the back and buttocks
Describe types of nevi seen in newborns
Nevus simplex: also known as salmon patches, telangiectatic nevi, “stork bites” or “angel kisses”
- Usually small, flat, and pink and are easily blanched
- Common sites are the upper eyelids, nose, upper lip, and nape of the neck
Nevus Flammeus
- Port-wine Stain
- It is usually pink and flat at birth but darkens with time, becoming red or purple and pebbly in consistency.
- They are found most commonly on the face and neck
What is Erythema toxicum?
AKA erythema neonatorum, newborn rash, or flea bite dermatitis.
It has lesions in different stages: erythematous macules, papules, and small vesicles
“Newborn acne”
