week 8 Flashcards
what are the physiological adaptation of the newborn?
-Establishing and maintaining respirations
-Adjusting to circulatory changes
-Regulating temperature
in utero respirations
In utero the placenta acts as the organ of respiration for the fetus. Immediately after the birth baby has to immediately adapt to the extra uterine respiration.
Clamping the umbilical cord causes a rise in blood pressure (BP), which increases circulation and lung perfusion.
Establishing and maintaining respirations- chemical factors
-Activation of chemoreceptors in the carotid arteries and aorta due fetal hypoxia
-Contraction temporary decrease uterine blood flow and transplacental gas exchange-transient fetal hypoxia
-↓Po2 and ↑Pco2, ↓blood pH
-Stimulation of the respiratory centre
Establishing and maintaining respirations-thermal factors
-↓extrauterine environment
-stimulates receptors in the skin, resulting in stimulation of the respiratory centre in the medulla.
-Note: Cold stress may be important for initializing breathing, but prolonged exposure should be avoided
Establishing and maintaining respirations-Mechanical factors:
-Changes in intrathoracic pressure from compression of the chest during vaginal birth.
-Relieve of the pressure result in a negative intrathoracic pressure, which helps draw air into the lungs.
-Crying of baby
-increases the distribution of air in the lungs, promotes expansion of the alveoli.
-creates positive pressure which helps to keep the alveoli open.
Establishing and maintaining respirations-Sensory factors
-handling or drying the newborn, lights, sounds, and smells of the new environment can also be involved in stimulation of the respiratory centre.
-Pain associated with birth can also be a factor
Circulatory Adjustment - after birth
-Umbilical veintransport oxygenated
-Umbilical arteries transportdeoxygenated
-Ductus arteriosusis the connection between pulmonary artery and aorta-closes within 24-48 hours; permanent closure may take several weeks
-Foramen ovaleis a shunt between the right atrium and the left atrium
-Circulatory changes after birth
-Expansion of the lungs increases the baby’s blood pressure
-Resulting in a major decrease in the pulmonary pressures decreases the changes in pressure result in
-↓shunting of blood to the ductus arteriosus and closure of the ductus arteriosus
-↑ pressure in the left atrium of the heart and lower the pressure in the right atrium causing the foramen ovale to close.
-Failure may result in patent foramen ovale (hole in heart) and surgical repair is required
Thermoregulation
-Heat regulation is most critical to the newborn’s survival.
-Anatomical and physiological characteristics of newborns place them at risk for heat loss-hypothermia
-Larger body surface to body weight
-Less adipose tissue & fat in newborn
-Underdeveloped sweating and shivering mechanisms
-Blood vessels closer to skin surface – contribute to heat loss
-Environmental factors include the temperature and humidity of the air, flow and velocity of the air, and the temperature of surfaces in contact with and around the newborn.
-Goal of care is to maintain a neutral thermal environment in which heat balance is maintained.
-To allows the newborn to maintain a normal body temperature to minimize oxygen and glucose consumption.
-Axillary temp. – between 36.4 – 37.2°
Evaporation
-Loss of heat when water evaporates from the skin and respiratory tract
-heat loss is intensified by failing to completely dry after bathing
-Dry baby quickly and remove wet towels/blankets
Conduction
-Heat loss from the body surface to cooler surfaces in direct contact
-Prewarm incubator/radiant warmer to ensure warm mattress
-Cover x-ray plates and scales
-Prewarm hands, stethoscopes, blankets and other equipment
-weighing the newborn should have a protective cover to minimize conductive heat loss
-Skin to skin contact: Baby will gain heat if placed on warm surface
Skin-to-skin keep newborns warmer than swaddled
Radiation
-Heat lost to surrounding colder solid objects (not in direct contact) but in close proximity
-Keep incubator, warmer, examination table, crib cot away from outside walls and windows
-Dress baby
-Care providers need to avoid exposing the newborn to direct air drafts.
Convection
-Heat lost from the body surface to cooler ambient air
-Raise surrounding 22° and 26°C
-Cover baby’s head
-Wrap and dress baby
-Warm O2
cold stress on baby
Effects of cold stress. When a newborn is stressed by cold, oxygen consumption increases and pulmonary and peripheral vasoconstriction occur, thereby decreasing oxygen uptake by the lungs and oxygen to the tissues; anaerobic glycolysis increases; and there is a decrease in Po2and pH, leading to metabolic acidosis.
-oxygen consumption and energy are diverted from maintaining normal brain and cardiac function and growth to thermogenesis for survival
-decreased pulmonary perfusion and oxygen tension can maintain or reopen the right-to-left shunt across the ductus arteriosus.
-cold stress is protracted, anaerobic glycolysis occurs, resulting in increased production of acids.
Transition to Extra Uterine Life- 1st period of reactivity
-Lasts up to 30 minutes after birth
-Newborn’s heart rate increases to 160 to 180 beats/min
-Respirations irregular: 60 to 80 breaths/min
-Decrease in motor activity after first period
-Period of decreased responsiveness
-Lasts 60 to 100 minutes
Transition to Extra Uterine Life- second period of reactivity
-Occurs 2 to 8 hours after birth
-Lasts 10 minutes to several hours
-Tachycardia, tachypnea occur
-Meconium commonly passed
-Increased muscle tone, changes in skin colour, and mucus production
Immediate Newborn Assessment-Apgar Scoring
-Immediate assessment of the newborn done at 1 and 5 minutes after birth
-Scores of 0 to 3-indicate severe distress,
-Scores of 4 to 6 indicate moderate difficulty
-Scores of 7 to 10 indicate that the newborn is having minimal or no difficulty adjusting to extrauterine life
-Reassessment is at 10 and 20 minutes if the score is less than 7 at 5 minutes
-Resuscitation may occur at any point when the newborn is compromised and should not wait until the initial 1-minute Apgar score
what does APGAR scoring stand for?
a-appearance
p-pulse
g-grimace
a-activity
r-respiration
Respiratory System -assessment
-Respirations
-Observe rise/fall of chest for 1 full minute
-Auscultate lung sounds
-Normal – 30-60 bpm,
-shallow & irregular;
-apneic periods of 5-10 seconds as fluid is being –absorbed/expelled
-Possible crackles - 1st hr. after birth
-Acrocyanosis – normal finding during transition
-Look for signs of respiratory distress
-Chest retractions
-Grunting with expirations
-Increase use of the intercostals muscles
-Nasal flaring
-Respiratory rate < 30 or > 60 breaths/min should be reported
Cardiovascular system-assessment
-heart rate between 110 and 160 beats/min
-Heart rate <110 or >160 re-evaluate after 30 t0 1 hour
-Heart murmurs heard during the first few weeks have -no pathologic significance
-murmurs disappear by 6 months
-Average systolic BP is 60 to 80mm Hg, and average diastolic BP is 40 to 50mm Hg
-Fetal Hb – high affinity for oxygen to promote oxygenation while infant begins producing own Hb postnatally
-Hb level 14-24 g/dl
-Blood volume 300mls
-Time taken to clamp cord
Sign of Cardiovascular concern
-Persistent tachycardia (more than 160 bpm)
-anemia, hypovolemia, hyperthermia, or sepsis.
-Persistent bradycardia (less than 100 bpm) congenital heart block, hypoxemia, normal sinus bradycardia, or hypothermia.
-Unequal or absent pulses, bounding pulses, and decreased or elevated blood pressure can indicate cardiovascular concerns
body measurement -weight
-Female: 3 400g
-Male: 3 500g
-Acceptable weight loss: 10% or less in first 3–5 days
-Regaining of birth weight within first 2weeks
-Weight ≤2 500g (preterm, small for gestational age, rubella syndrome)
-Weight ≥4 000g (large for gestational age, maternal diabetes, heredity—normal for these parents)
-Weight loss 10–15% (growth failure, dehydration); assess breastfeeding
Body Measurement-length
-45–55cm
<45cm or >55cm may be due to chromosomal abnormality or heredity—normal for these parents
Head circumference
– distance around head –
-33–35cm
-Circumference of head and chest approximately the same for first 1 or 2 days after birth
< 32 –microcepahly
-Microcephaly: head ≤32cm (maternal rubella, toxoplasmosis, cytomegalovirus, Zika virus, fused cranial sutures
[craniosynostosis])
-Hydrocephaly: sutures widely separated, circumference ≥4cm more than chest circumference
-infection
-Increased intracranial pressure (hemorrhage, space-occupying lesion) due
to extra fluid or extra tissue (tumour etc.)
Fontanelles
-Anterior fontanel 5-cm diamond, increasing as moulding resolves
-Closes within 12-18 months
-Posterior fontanel triangle 0.5x1 cm, smaller
than anterior
-Closes within 8-12 weeks after birth
Sutures (Allow for brain growth)
-Should be palpable and separated suture, possible overlap of sutures with moulding
-Widely spaced (hydrocephaly)
-Premature closure (fused) (craniosynostosis)
Sign Fontanels concerns:
Full, bulging (tumour, hemorrhage, infection)- due to increased pressure, hemorrhage, a
lot of fluid
* Large, flat, soft (malnutrition, hydrocephaly, delayed bone age, hypothyroidism)
* Depressed (dehydration
Cephalohematoma
-Collection of blood between a skull bone and its periosteum. caused by external
-Pressure during L & D
- Forceps delivery
▪ Largest on the second or third day,
▪ Feels boggy, edemtous to touch
▪ Does not cross suture lines
▪ Resolves in 3 to 6 weeks
▪ Not aspirated due to risk of infection
Caput Succedaneum
▪ During vacuum assisted delivery
▪ Not as bulging as the hematoma one, usually to do with the suture and increased fluid
▪ Localized edematous area the soft tissues of scalp.
-Presenting part causes compression of local vessels slowing venous return
-in increase in tissue fluids within the skin of the scalp
-edematous swelling develops.
▪ Extends across the suture lines of the skull* major difference then the hematoma one
▪ Disappears spontaneously within 3 to 4 days.
-due to increase fluid
eyes
Size & shape should be symmetric
- Eyes close together can be linked to down syndrome
◼ Space between eyes is one-third the distance from outer (left) to outer (right) canthus
◼ Iris is usually blue or gray for light skinned; brown for darker skinned newborns.
◼ Immature lacrimal ducts – tears only produced at around 2 months
◼ Blink reflex -elicited by bright lights, lightly touching eyelid
◼ Pupils equal, reactive to light
◼ Eyelids may be edematous for the first few days
◼ Colour vision after 1 st three months
◼ Epicanthal folds when present with other signs (chromosomal disorders such as Down,
cri-du-chat syndromes)
◼ Discharge: purulent (infection)
◼ Permanent colour occurs later
◼ Lacrimal ducts can become clogged – respond to manual pressure on nasal bridge
◼ Eyelids edematous from pressure of face through vaginal canal during birth
◼ Acuity - distance from infant at breast to mother’s face
◼ Colour vision after three months – explains why infants are attracted to dark & light
contrasts vs. brightly coloured objects
ears
-Firm, well formed cartilage of pinna in term infant
-Well-formed, firm cartilage
-Small, large, floppy, soft and pliable
-Correct placement: line drawn through inner and outer canthi of eyes reaching to top notch
of ears (at junction with scalp)
-Hearing assessed by responsiveness to loud noise without vibration
ear anomalies
-Agenesis
-Lack of cartilage (preterm)
-Low placement (chromosomal disorder, cognitive impairment, kidney disorder)
-Preauricular tag or sinus
-May indicate renal disorders
nose
Midline
◼ Slight deformity (flat or deviated to one side) from passage through birth cana
◼ Newborns – nose breathers in first few months
◼ Narrow passageways, easily obstructed with mucous & amniotic fluid
◼ Some mucus but no drainage
◼ Sneezing as reflex to clear passageways.
◼ response to overstimulation of autonomous nervous system
◼ Smell is present in newborns.
◼ Allows newborns to turn to milk
◼ Infants prefer mother’s milk to other mothers’ milk
◼ Infants react to noxious smells shortly after birth
mouth
-Lips should be symetrical
-Pink, moist lips and mucosa
-Sucking blisters - from breastfeeding latch
-Saliva not excessive
-Intact hard and soft palate; freely moving tongue
-Tongue not protruding; freely movable; symmetrical in shape, movement
-Sucking pads inside cheeks
-Soft and hard palates intact
-Uvula in midline
-Anatomical groove in palate to accommodate nipple, disappearance by 3–4yr of age
Epstein’s pearls:
small, firm white cysts on gums. Resolve on own during first weeks
common mouth conditions
-Thrush: White plaque – similar to milk curds, does not easily scrape off
-Precocious tooth: premature eruption of a tooth, often around lower incisors.
-Cleft lip/palate Cyanosis, circumoral pallor (respiratory distress, hypothermia)
-Asymmetry in movement of lips (seventh cranial nerve paralysis)
-Teeth: predeciduous or deciduous (hereditary)
Short lingual frenulum (ankyloglossia- tongue-tie
neck
-Short with skin folds
– Neck muscles not fully developed to handle the baby head, that is why, when
we hold the baby, making sure to support the neck
- Putting baby on belly so the baby moves their head up and down for
development
-Freely mobile range of motion
-Head lag is associated with prematurity
Genito-urinary System- Urinary system
◼ 40 mls may present in the bladder at birth
◼ Void within 24 hours, may void during delivery
◼ At 1 day of age, a minimum of one void
◼ At 1 week six to eight voidings per day.
◼ First and seconds day -2-5 times, afterwards 2-8 times per day
◼ Amount per void 15 to 60 mL/kg/day
◼ pale straw-coloured urine are indicative of adequate fluid intake
Daily fluid requirement for newborns weighing more than 1 500 g:
-60 to 80 mL/kg/day during the first 2 days of life
-100 to 150 mL/kg/day from 3 to 7 days
-120 mL/kg/day to 180 mL/kg/day from 8 to 30 days
Female genitialia
-Labia – examined for size. Labia majora develops close to term
-Assess to ensure that labia not fused
-Assess ambiguous genitalia
-Milky vaginal discharge- due to circulating maternal hormones (normal after delivery)
-Pseudomenses: blood tinged mucous – due to hormones of pregnancy
-Vaginal tag: (hymenal tag) usually disappears in first few weeks after birth
- Swelling of the breast tissue in term newborns of both sexes-due to hyperestrogenism in
utero
o few newborns a thin discharge can be seen.
-Ambiguous geneialia – when clitoris excessively prominent; vaginal opening not clearly patent
Male genitalia
-Hypospadias: Urinary meatus on ventral surface of penis (underside).
-Circumcision is contraindicated in the presence of hypospadias or epispadias
since the foreskin is used in repair of these anomalies
- Epispadias: Meatus on the dorsal surface
- Phimosis: Foreskin cannot be fully retracted A tightprepuce(foreskin) is common in
newborns and completely covers the glans
- Hydrocele: Collection of fluid around testes
- Discoloration of testes – assess for testicular torsion
- Crepitus in groin or scrotal sac indicates hernia
- Undescended testes; (cryptorchidism)
- Failure of testes to descend into scrotal sac in term infant
Abdominal
-Rounded, prominent, and domed shaped
-Bowel sounds within 2 hrs. post birth
-Patent anus
-Meconium passed within first 24 hrs.
-Umbilical cord-whitish grey – 2 arteries & 1 vein
-Definite demarcation between cord and skin; no intestinal structures within cord
-Bowel sounds present within minutes after birth in healthy term newborn
-Meconium stool passing within 24–48hour after birth
- This is to check for if bowel sounds are working
- Roll the baby to check if the anus is normal or perforated
- Cord status
abdominal anomalies
- One artery (renal anomaly)
- Meconium stained (intrauterine distress)
- Bleeding or oozing around cord (hemorrhagic disease)
- Redness or drainage around cord (infection, possible persistence of urachus)
- Hernia: herniation of abdominal contents through cord opening (e.g., omphalocele);
o defect covered with thin, friable membrane, possibly extensive - Scaphoid, with bowel sounds in chest and severe respiratory distress (congenital
diaphragmatic hernia) - Gastroschisis: herniation of abdominal contents to the side or above the cord
Meconium
- Meconium is the newborn’s first stool, composed of amniotic fluid and its constituents,
intestinal secretions, shed mucosal cells - Meconium is greenish black and viscous and contains occult blood.
- Pass meconium within 12 to 24 hours of life, and almost all do so by 48 hours.
- Failure to pass meconbowel obstruction
- small or large bowel atresia,
- an inborn error of metabolism (e.g., cystic fibrosis),
- congenital disorder (e.g., Hirschsprung disease or an imperforate anus).
