Lecture 3 (18 & 20)
Outcomes: Newborn Period
Infant establishes respirations of 30 to 60 breaths/min. Infant maintains temperature at 97.8ºF to 98.6ºF (36.5ºC to 37ºC). Infant breastfeeds well with a strong sucking reflex.
Left-sided heart failure
Left-sided heart failure -Orthopnea -Difficulty breathing in supine position Paroxysmal nocturnal dyspnea -Suddenly waking at night with shortness of breath
High-Risk Pregnancy: Cardiovascular System Assessment
Level of exercise Presence of cough or edema Comparison of baseline vital signs Liver size (right-sided heart failure involvement) ECG/echocardiogram Fetal size (small for gestational age) and poor response to labor (FHR decelerations)
Predicting pregnancy outcomes based on Classification of Heart Disease
Class I or II Expect a normal pregnancy Class III Normal pregnancy with special interventions (bedrest) Class IV Advised to avoid pregnancy
Where is vitamin K administered?
Administer IM injection into a large muscle, such as the anterolateral muscle of a newborn's thigh. If giving vitamin K for treatment, obtain prothrombin time before administration (the single best indicator of vitamin K-dependent clotting factors).
avg head circumference
Average = 34-35 cm The forehead appears large and prominent. • The chin appears to be receding, and it quivers easily if the infant is startled or cries. • If a newborn has hair, the hair should look full bodied; both poorly nourished and preterm infants have thin, lifeless hair. • If internal fetal monitoring was used during labor (see Chapter 24), a newborn may have a pinpoint ulcer at the point where the monitor was attached.
when it blood volume and CO the highest in pregnancy?
Blood volume and cardiac output increase up to 50%% during pregnancy (peaks at 28 to 32 weeks), which places stress on a compromised heart.
Cavernous hemangioma
Caused by dilated vascular spaces • Raised and irregular shape; resemble a strawberry hemangioma • Do not disappear with time • Some may have additional lesions on internal organs such as the spleen or liver. Most commonly appear on the face, behind the ears, and the neck Surgical removal if they interfere with sight or breathing • Steroids, interferon alfa-2a, vincristine, or radiation may reduce size of lesions; risk vs. benefit must be considered • Hematocrit levels to assess for blood loss if child has internal cavernous lesions
Craniotabes - Ping-pong consistency of bone Resolves in a few months (Ca from milk)
Craniotabes is a localized softening of the cranial bones probably caused by pressure of the fetal skull against the mother's pelvic bone in utero. It is more common in first-born infants than in infants born later because of the lower position of the fetal head in the pelvis during the last 2 weeks of pregnancy in primiparous women. With craniotabes, the skull is so soft that the pressure of an examining finger can indent it. The bone then returns to its normal contour after the pressure is removed. The condition corrects itself without treatment after a few months as the infant ingests calcium from milk
Diabetes during pregnancy
Decreased control of glucose regulation Fetal effects: Large (>10 lbs), hydramnios, macrosomic, increased risk of shoulder dystocia, high incidence of congenital anomalies (caudal regression syndrome), spontaneous miscarriage, stillbirth At birth: Fetus prone to hypoglycemia, RDS, hypocalcemia, & hyperbilirubinemia -RDS: respiratory distress syndrome -overload of glucose leads to increased insulin production which is a growth stimulant (>10lbs) -hydramnios because of fluid shift due to high glucose concentration -shoulder dystocia: shoulders too big to pass through vagina -tight control of glucose in diabetic women is crucial for first trimester (reduces risk of congenital anomalies)
Infantile hemangiomas (also called strawberry hemangiomas)
Elevated areas formed by immature capillaries and endothelial cells • Appear at birth or within 2 weeks after birth • Size may enlarge up to 1 year of age. • After 1 year of age, hemangiomas tend to be absorbed and shrink in size. By the time the child is 7 years old, 70% have involuted to a reasonable level; most involution completed by 10 years Can occur anywhere on the infant; most common on scalp, face, neck Educate parent about expected increase in size for up to one year and that they are likely to resolve with time. • Propranolol (Inderal) and corticosteroids can be used to reduce size. • Surgical excision is rarely done due to risk for complications.
Assessment - Diabetes Mellitus
Fasting plasma glucose ≥ 126 mg/dl Non-fasting plasma glucose ≥ 200 mg/dl Oral glucose challenge test FBS (AM) - fasting blood sugar Drink 100-g glucose solution Venous sample @ 1,2, & 3 hrs post If 2 of the 4 values >95 mg/dl = Diabetes confirmed
• Convection is the flow of heat from the newborn's body surface to cooler surrounding air. Eliminating drafts, such as from air conditioners, is an important way to reduce convection heat loss. • Radiation is the transfer of body heat to a cooler solid object not in contact with the baby, such as a cold window or air conditioner. Moving an infant as far from the cold surface as possible helps reduce this type of heat loss. • Conduction is the transfer of body heat to a cooler solid object in contact with a baby. For example, a baby placed on the cold base of a warming unit quickly loses heat to the colder metal surface. Covering surfaces with a warmed blanket or towel is necessary to help minimize conduction heat loss. • Evaporation is loss of heat through conversion of a liquid to a vapor. Newborns are wet when born, so they can lose a great deal of heat as the amniotic fluid on their skin evaporates. To prevent this type of heat loss, lay a newborn on the mother's abdomen immediately after birth and cover with a warm blanket for skin-to-skin contact In addition, drying the infant—especially the face and hair—also effectively reduces evaporation because the head, which is a large surface area in a newborn, can be responsible for a great amount of heat loss. Covering the hair with a cap after drying further reduces the possibility of evaporation cooling.
Figure 18.3 Heat loss in the newborn. (A) Convection. (B) Radiation. (C) Conduction. (D) Evaporation.
The arms and legs of a newborn appear short in proportion to the trunk. The hands seem plump and are typically clenched. Test the upper extremities for muscle tone by unflexing the arms for approximately 5 seconds then letting them return to their flexed position (which typically occurs immediately if muscle tone is good). Next, hold the arms down by the sides and note their length. The fingertips on both sides should reach as far as the mid-thigh. Unusually short arms may signify achondroplasia (dwarfism) and would require further evaluation. Observe for curvature of the little finger, and inspect the palm for a simian crease (a single palmar crease). Although curved fingers and simian creases can occur normally, they are commonly seen in children with Down syndrome. When a newborn moves, the arms and legs should move symmetrically (unless the infant is demonstrating a tonic neck reflex). Asymmetry suggests birth injury, such as injury to a clavicle or to the brachial or cervical plexus or fracture of a long bone. Assess for webbing (syndactyly) between fingers as well as missing or extra fingers (polydactyly)
Newborn legs appear bowed and short. The sole of the foot is flat because of an extra pad of fat in the longitudinal arch. The foot of a term newborn has many crisscrossed lines on the sole, covering approximately two thirds of the foot. If these creases cover less than two thirds of the foot or are absent, it suggests the infant is preterm. Move the ankle through a range of motion to evaluate that the heel cord is not unusually tight. Check for ankle clonus by supporting the lower leg in one hand and dorsiflexing the foot sharply two or three times by pressure on the sole of the foot with the other hand. After the dorsiflexion, one or two continued movements are normal. Rapid alternating contraction and relaxation (clonus) is not normal and suggests neurologic or calcium insufficiency. If a foot does not align readily or will not turn to a definite midline position, a talipes deformity (clubfoot) may be present and warrants specialty referral. To test if the femur is situated comfortably in the hip socket, with a newborn in a supine position, flex both hips and abduct the legs as far as they will go (typically 180 degrees or the knees touch or nearly touch the surface of the bed) (Fig. 18.22). If the hip joint seems to lock short of this distance (160 to 170 degrees), it suggests hip subluxation (Sankar, Horn, Wells, et al., 2016). Confirm subluxation by holding the infant's legs with the fingers on the greater and lesser trochanters and then abduct the hips; if subluxation is present, a "clunk" of the femur head striking the shallow acetabulum can be heard (Ortolani sign). If the femur can be felt to actually slip in and out of the socket, this is a Barlow sign. A subluxated hip may be bilateral or unilateral. Like talipes disorders, it is important that a hip subluxation be identified early because correction is most successful if initiated early. Lastly, inspect the feet for missing or extra toes or unusual spacing of toes, particularly between the big toe and the others; although this finding can be a normal finding in some families, it is also present in certain chromosomal disorders. When placed on their abdomen, newborns should be capable of bringing their arms and legs underneath them and raising their stomach slightly off the bed. The preterm newborn is not able to do this.
Risk Factors for Gestational Diabetes
Obesity Age over 25 years History of large babies (10 lb or more) History of unexplained fetal or perinatal loss History of congenital anomalies in previous pregnancies History of polycystic ovary syndrome Family history of diabetes (one close relative or two distant ones) Member of a population with a high risk for diabetes (Native American, Hispanic, Asian) -gestational diabetes fades at the completion of pregnancy but risk of developing TYPE 2 diabetes later in life increases by 50%-60%
Oral glucose challenge test FBS (AM) - fasting blood sugar Drink 100-g glucose solution Venous sample @ 1,2, & 3 hrs post If 2 of the 4 values >95 mg/dl = Diabetes confirmed
Oral glucose challenge test FBS (AM) - fasting blood sugar Drink 100-g glucose solution Venous sample @ 1,2, & 3 hrs post If 2 of the 4 values >95 mg/dl = Diabetes confirmed
The chest Looks small at birth bc the head is so big Circular appearance bc anteroposterior and lateral diameters are about equal (30-33 cm) Chest and abdomen should rise and fall in synchrony, NOT seesaw pattern Bronchial sounds heard during auscultation Nipples prominent and often edematous; milky secretions (witch's milk) common Breast Tissue Present Clavicles need to be palpated to assess for fractures
Respirations are normally rapid (30 to 60 breaths/min) but not distressed. Retraction (drawing in of the chest wall with inspiration) should not be present. An infant who is breathing with retractions is using such a strong force to pull air into the respiratory tract that he or she is pulling in the anterior chest muscle as well. This breathing is not sustainable for a long period of time, and immediate help such as oxygen, is needed.
Sutures The skull sutures, the separating lines of the skull, may override at birth because of the extreme pressure exerted on the head during passage through the birth canal. If the sagittal suture between the parietal bones overrides, the fontanelles are less perceptible than usual. The overriding subsides in 24 to 48 hours.
Sutures The skull sutures, the separating lines of the skull, may override at birth because of the extreme pressure exerted on the head during passage through the birth canal. If the sagittal suture between the parietal bones overrides, the fontanelles are less perceptible than usual. The overriding subsides in 24 to 48 hours.
The blood pressure of a newborn is approximately 80/46 mmHg at birth. By the 10th day, it rises to about 100/50 mmHg and remains at that level for the infant year.
The blood pressure of a newborn is approximately 80/46 mmHg at birth. By the 10th day, it rises to about 100/50 mmHg and remains at that level for the infant year.
The respiratory rate of a newborn in the first few minutes of life may be as high as 90 breaths/min. As respiratory activity is established and maintained over the next hour, this rate will settle to an average of 30 to 60 breaths/min. Respiratory depth, rate, and rhythm are likely to be irregular, and short periods of apnea (without cyanosis), sometimes called periodic respirations, are also common and normal during this time. Respiratory rate can be observed most easily by watching the movement of a newborn's abdomen because breathing primarily involves the use of the diaphragm and abdominal muscles. Coughing and sneezing reflexes are present at birth and help clear the airway. Newborns are obligate nose breathers and show signs of distress if their nostrils become obstructed. Short periods of crying, which increase the depth of respirations and aid in aerating deep portions of the lungs, may be beneficial to a newborn. Long periods of crying, however, exhaust the cardiovascular system, become fatiguing, and serve no purpose.
The respiratory rate of a newborn in the first few minutes of life may be as high as 90 breaths/min. As respiratory activity is established and maintained over the next hour, this rate will settle to an average of 30 to 60 breaths/min. Respiratory depth, rate, and rhythm are likely to be irregular, and short periods of apnea (without cyanosis), sometimes called periodic respirations, are also common and normal during this time. Respiratory rate can be observed most easily by watching the movement of a newborn's abdomen because breathing primarily involves the use of the diaphragm and abdominal muscles. Coughing and sneezing reflexes are present at birth and help clear the airway. Newborns are obligate nose breathers and show signs of distress if their nostrils become obstructed. Short periods of crying, which increase the depth of respirations and aid in aerating deep portions of the lungs, may be beneficial to a newborn. Long periods of crying, however, exhaust the cardiovascular system, become fatiguing, and serve no purpose.
Nevus flammeus
Two types: ○ Benign macular purple or dark-red lesion (also called a port-wine stain) (see Fig. 18.14A) ○ Light-pink patches: stork bites or telangiectasia Port wine: face, thighs May spontaneously fade ○ Cosmetically cover ○ Laser later in life • Stork bites: nape of neck • Stork bites: do not fade; no treatment because usually covered by hair
High-Risk Pregnancy: Cardiovascular Issues
Valve damage with or without valve replacement Congenital anomalies Coronary artery disease (CAD) Chronic hypertensive vascular disease Venous thromboembolic disease Peripartum heart disease
Neonate HR
Within 1 hour after birth, as the newborn settles down to sleep, the heart rate stabilizes to an average of 120 to 140 beats/min.
Caput Succedaneum Caput succedaneum (Fig. 18.19A) is edema of the scalp that forms on the presenting part of the head. It occurs in cephalic births and can either involve wide areas of the head or be so confined that it's the size of a large egg. The edema, which crosses the suture lines, is gradually absorbed and disappears within several days. No treatment is needed
crosses the sutures
Cephalohematoma A cephalohematoma, a collection of blood between the periosteum of a skull bone and the bone itself, is caused by rupture of a periosteal capillary because of the pressure of birth (see Fig. 18.19B). Although the blood loss is negligible, edema, which appears by 24 hours after birth, appears severe and is well outlined as an egg shape. It may be discolored (black and blue) because of the presence of coagulated blood underneath the periosteum. Unlike a caput, a cephalohematoma is confined to an individual bone, so the associated swelling stops at the bone's suture line. Cephalohematomas will subside without treatment. It may take weeks for the blood under the periosteum to be absorbed. As the blood breaks down, the infant needs to be observed for jaundice that can occur from the large amount of indirect bilirubin that may be released
doesn't cross the sutures
