OB Exam 3

Preterm renal alterations

GFR increases steadily after 34 weeks so preterm babes are not quite there in terms of GFR (low GFR) Buffering capacity is reduced predisposing the newborn to metabolic acidosis (limited abilities to concentrate urine) Excretion time of drugs is longer. (Buffering capacity reduced)

Preterm immune system alterations

Increased susceptibility to infections: Skin is easily excoriated Infection risk from many invasive procedures Most passive immunity (from mom to fetus-crosses the placenta) occurs during the last trimester. Preterm babies have less due to this and are therefore at higher risk for infections Colostrum gives passive immunity- rub on baby's lips, gums, tongue

Risk factors for hyperbilirubinemia

Jaundice within first 24 hours after birth.A sibling who was jaundiced as a neonate.Unrecognized hemolysis such as ABO blood type incompatibility or Rh incompatibility.Nonoptimal sucking/nursing.Deficiency in glucose-6-phosphate dehydrogenase, a genetic disorder.Infection.Cephalohematomas/bruising.East Asian or Mediterranean descent. Kernicterus is a type of brain damage that can result from high levels of bilirubin. (20-30 usually 25 bilirubin number) Can cause cerebral palsy and hearing loss. Can lead to problems with vision, teeth and learning disabilities

Diagnosis for Pathological Jaundice

Newborns who exhibit jaundice within the first 24 hours of life. Have a total serum bilirubin concentration increase of greater than 0.2 mg/dl per hour. Surpass the 95th percentile on the bili nomogram for age in hour. Unconjugated bilirubin (indirect) makes up ≥20% of total bilirubin lab value (unconjugated + conjugated). Have a persistent visible jaundice after one week of age in term newborn or after 2 weeks in preterm newborns. Initial diagnostic procedures are aimed at differentiating jaundice resulting from increased bilirubin production, impaired coagulation or excretion, increased reabsorption, or a combination of these factors. The TcB is a non-invasive screening tool that measures the amount of bilirubin collected in the tissues of the skin. Essential diagnostic lab

Preterm newborns

Preterm infants are those born at ≤ 37 weeks gestation. -Moderate to late preterm is an infant born 32-37 weeks -Very preterm infants are 28 to 32 weeks. -Extremely preterm infants are < 28 weeks. Premature newborns are ill-equipped to navigate the transition from intrauterine to extrauterine life because all of their systems are immature. The earlier the gestation, the higher the morbidity and mortality. Premature birth and its complications are the #1 cause of death of babies in the United States.

Injection Sites for Newborn Injections

The middle third of the vastus lateralis muscle is the preferred site for intramuscular injection in the newborn -L side for vit K and R side for Hep B Clean with alcohol, let it dry, bunch the tissue of the vastus lateralis, 25g 5/8in needle, slowly inject fluid, then cover with small round bandage.

Discharge Education

Umbilical cord typically falls off in crib or cradle between 10 days and 2 weeks Keep clean and dry, diaper folded down, no immersion baths until it falls off; discontinue clamp before discharge Hep B is given in opposite leg than the Vitamin K SIGNS OF NEWBORN DISTRESS: Respiratory issues: grunting, increased respirations (more than 60), struggling to breath, retractions, nasal flaring, excessive mucus Color changes (central cyanosis: skin, lips and tongue), pallor, mottling, ruddy Abdominal changes (distention or mass) Vomiting (of bile or excessive) Absence of meconium within 48 hours of birth Absence of urine elimination after 24-48 hours of birth Temp instability Jitteriness, irritability (hypoglycemia signs) Lethargy/ difficulty waking Weight loss of greater than 7% of birth weight PKU is done to determine if they have a defect that will allow that acid to build up in blood that can cause brain damage, failure to thrive etc. This is not optional Click TCB reader three times and compare the numbers CHD and hearing screens Bathing, breastfeeding, safety, distress education is all needed for parents

Feeding Patterns

"On-demand" feeding Cluster feeding (Cluster feeding is normal for breastfeeding babes! NOT formula fed- this would be too much content for their little bellies Cluster feeding is normal. 5 to 10 feeding episodes over 2 to 3 hours) Stimulates milk production Teach techniques to wake a sleepy baby to feed: dress baby in only diaper and place skin to skin, change diaper, sit baby in burping position and lightly stroke back, talk to baby Feeding pattern may change when mother's breasts become fuller. 1.5 to 3 hours around the clock 8 to 12 feedings per day Techniques to wake a sleepy baby Feeding pattern may change when mother's breasts become fuller. ~1.5 to 3 hours around the clock ~8 to 12 feedings per day Formula-fed infants generally feed every 3 to 4 hours; typically 6 to 8 feedings per day. Satiety behaviors same for breast/bottle Longer pauses toward end of feeding Total body relaxation Falling asleep, releasing nipple Breastfed babies that demonstrate feeding cues should be offered a breast. -The more a breastfeeding babe nurses the more milk that mom will produce! It's a supply and demand thing and the more often babe is at breast it triggers the whole milk production process to keep up. Only feed a half an ounce at birth. Only the size of a marble at birth and the size of a ping pong ball the week after. Rotate sides that you start breastfeeding on since sucking is strongest in the beginning of the feed. This can prevent engorgement of breasts.

APGAR scoring

Apgar Scoring System: used to evaluate the physical condition of the newborn at birth. (0-2 scores) Newborn is rated at one minute after birth. Newborn is rated a second time at five minutes after birth. If the second score is below 7, the newborn is rated a third time at 10 minutes. If newborn continues to be less than 7, the scoring continues every 5 minutes up to 20 minutes. Heart Rate: auscultated or palpated at the junction of the umbilical cord and skin. This is the most important assessment. If the HR is less than 100 beats per minute, immediate resuscitation is indicated. Respiratory Effort: the second most important assessment. Complete absence of respirations is termed apnea. A vigorous cry indicates adequate respirations. Muscle Tone: determined by evaluating the degree of flexion and resistance to straightening the extremities. A normal newborn's elbows and hips are flexed, with the knees towards the abdomen. Reflex/Irritability: evaluated by stroking the baby's back along the spine or flicking the soles of the feet. A cry merits a score of 2, grimace is 1 and no response is 0. Skin Color: inspected for cyanosis and pallor. Generally, newborns have a pink body with blue extremities, called acrocyanosis. Darker skin pigmentation will not be pink, they are assessed for pallor and acrocyanosis.

Small for gestational age vs IUGR

Both plot less than the 10th percentile for birth weight on the chart. Both may be pre-term, term or post-term. SGA refers to the size of the newborn compared to gestational age only. (Could be a small mother) IUGR indicates the presence of a pathological process in-utero that inhibits fetal growth. (Chemicals, drugs, smoking, alcohol, mom being sick, etc can impede growth of the baby) ALL IUGR newborns are considered SGA because they are small, but newborns with SGA can just be small because mom is small stature. IUGR involves a condition affecting the GROWTH of the baby. SGA: Proportional but small IUGR: Larger heads, skinnier bodies, malnourished looking (usually in the 3rd trimester growth is restricted and it will start to show)

Preterm infant oral feeding cues

Bottle-feeding -Requires suck-swallow-breathe pattern -Oral readiness to feed determined by engagement and hunger cues Breastfeeding -Requires suck-swallow-breathe pattern -Many benefits of breast milk -Allows mother to care for baby -Skin-to-skin benefits Nasal-gastric feeds supplement what baby can't tolerate orally -Gavage feeding send for infants with poor suck-swallow reflex or on a ventilator; can be used with bottle feeding or breastfeeding if infant tires easily, has A/B/D's with feeds, or is losing weight Babies usually have to be around 35-36 weeks to be able to have adequate suck-swallow-breathing abilities to bottle or breastfeed Want to get mother pumping within the first few hours of delivery of a premie- may take longer for milk to come in since her body was not ready to deliver yet Increase oral amount, decrease TPN with NG feeds. Supplement with TPN if the baby does not take enough orally

Breastfeeding and Breast Milk Jaundice

Breastfeeding jaundice (mechanical issue) occurs in 12.9% of breastfeeding newborns in the first days of life, with a bilirubin level greater than 12 mg/dL. Is associated with poor feeding practices, such as inadequate fluid intake and dehydration. Peaks around day 3 as enteral intake increases, then resolves. Prevention of early breastfeeding jaundice includes: Frequent breastfeedings (every 2 to 3 hours (or pump)). Avoid supplementing. Seek lactation consultation. Breastmilk jaundice occurs in 2% - 4% of term newborns between days 4 to 7. True cause is unknown. It is thought to be caused from the breast milk promoting increased bilirubin reabsorption from the intestine or hormones. This is because some women's breast milk contains higher levels of certain free fatty acids that compete with bilirubin for binding sites on albumin. This prevents conjugation, which increases the enterohepatic circulation of bilirubin. -Mother has to breast feed and formula feed for every other feeding to help get those levels down.

Skin

Color should be pink or acrocyanotic with no jaundice present on the first day (hands and feet typically have acrocyanosis for us to 24 hrs due to the small blood vessels in the extremities which shrink in response to cold, and lack of mature peripheral circulation); may have a blue color and need oxygen after birth; mottled or blotchy means blood is struggling to get to the surface) Circumoral cyanosis is abnormal, and refers to the blue color around the lips of the newborn in response to lower levels of oxygen in surface blood vessels Central cyanosis is also abnormal and refers to generalized blue color in the body, due to reduced arterial oxygen saturation [Circumoral and central cyanosis may require resuscitation or application of oxygen. Usually resolves in 5-10 min after birth unless an anomaly in heart or lungs is present] Physiologic jaundice appears by the third day, but should resolve within a few days Good turgor indicated by skin springing back when squeezed lightly over clavicle Texture should be dry, soft, warm, smooth (do not use moisturizer in beginning days of life) Vernix caseosa is the thick, protective cheesy covering (remove when baby is born because it can act as a cold blanket and make baby cold if it is cold in the room) [delay bath until 24hrs because vernix provides antibacterial properties and wound healing] Lanugo (fine downy hair) found on shoulders, forehead MILIA: small white raised spots on nose, cheeks, chin; these spots disappear spontaneously, and teach parents not to squeeze them (they go away on their own) MONGOLIAN: blueish purple spots that look like bruises found on buttocks and back, sometimes if a baby is brought to the ER abuse can be assumed. Usually on babies with darker skin (make sure parents know what this is so it is not mistaken for abuse) STORK BITES: flat pink or red marks found on back of neck, nose, upper eyelids; usually fade by age 2 (sometimes they pop back up in toddlers that are mad and get red) PORT WINE: capillary Angie a below the surface of the skin that is purple or red; commonly seen on the face, and do not ever disappear (can lead to grief for parents; permanent; can not see on ultrasound) RASH (erythema toxicum): pink rash that appears suddenly anywhere on the body of a term baby; can appear up to 3 weeks old, and look exactly like pimples with a whitehead. Teach parents they resolve on their own and not to squeeze them

Sleep and Alert States

First Period of Reactivity Approximately first 30 to 60 minutes after birth. Newborn awake, active, may appear hungry, and have a strong sucking reflex. Important to encourage bonding and to initiate breastfeeding at this time. Period of Inactivity to Sleep Phase The newborn's activity will gradually decrease and will enter the sleep phase. The sleep phase may last from a few minutes to 2 to 4 hours. Newborn may be difficult to awaken and will have no interest in feeding. Sleep States Deep or quiet sleep: characterized by closed eyes. No eye movements, regular breathing. May have jerky motions or startles. Startles are supressed. Active or light sleep (Rapid-Eye Movement [REM] sleep): respirations are irregular, irregular sucking motions, minimal activity, irregular movement of extremities. Environmental and internal stimuli may initiate a startle reaction and a change of state. Alert States Drowsy or semidozing: Eyes may open and close. Eyelids may flutter. Slow, regular movements of the extremities. May display startles, but have a delayed reaction to a sensory stimulus. Quiet alert: newborn is alert and follows and fixates on objects, faces, or auditory stimuli. Minimal motor activity. Delayed external stimuli responses. Active alert: Eyes open with intense motor activity. Environmental stimuli startles. Crying: Intense crying accompanied by jerky motor movements. Several purposes for crying. Distraction from disturbing stimuli such as hunger, pain; allows newborn to discharge energy and reorganize; elicits appropriate response of help.

Assessing need for resuscitation at birth

Following birth, dry and stimulate newborn vigorously, and then pose these questions: "Are skin color, heart rate, and respirations appropriate? "Is baby breathing appropriately (effort) or crying vigorously?" "Does baby have good muscle tone?" If answers are yes, then baby does not need resuscitation; keep with mother. If resuscitation is necessary follow the most current NRP guidelines 1. CHECK HEART RATE AND RESPIRATIONS AS SOON AS THE BABY GETS TO THE RADIANT WARMER 2. BEGIN RESUSCIATION IF NO BREATHING OR MINIMAL EFFORT, OR IF HEART RATE IS LESS THAN 100. 3. START WITH 5 INFLATION BREATHS USING EITHER POSITIVE PRESSURE VENTILATION (PPV) OR CONTINUOUES POSITIVE AIRWAY PRESSURE (CPAP) (NEWER) 4. THESE BEGINNING VENTILATION BREATHS AT A RATE OF 40-60 BREATHS PER MINUTE, 0R EVERY 2-3 SECONDS. 5. CHECK HEART RATE AND RESPIRATIONS AGAIN AT 30 SECONDS 6. BEGIN VENTILATIONS AND COMPRESSIONS AT A 3:1 RATIO IF STATUS IS NOT IMPROVED, FOR ANOTHER 30 SECONDS 7. THE VENTILATION RATE CHANGES TO EVERY 2 SECONDS, OR 30 BREATHS PER MINUTE DURING THIS PERIOD 8. CONTINUE UNTIL BABY IS STABLE 9. ASSIGN APGARS AT 1 AND 5 MINUTES, OR MORE IF FIRST TWO ARE BELOW 7. CPAP decreases the work of breathing for any baby who is spontaneously breathing

Extremities/Spine

Full ROM and symmetry with spontaneous movement and equal length of limbs Extremities should be flexed with resistance to extension of both arms and legs Symmetrical gluteal folds, bowed legs and flat feet Two-thirds of the soles of the feet will have creases Hands should have normal adult like creases Nail beds should be pink without extra digits present Spine should be straight, flat, midline and easily flexed (may find pilonidal dimple which is common but benign) If there is a dimple on spine around diaper line- may be normal or indicative of spina birdie in CSF is coming out No click should be heard when checking the hips These two maneuvers check for hip dysplasia: Barlow- bring thigh inwards and apply outward pressure Ortolanis- knee 90 degrees and rotate hips

Ballard Tool

Gestational Age Assessment Tools: have two components - external physical characteristics and neurologic or neuromuscular development. The Ballard Tool: is a tool to assist in the estimation of gestational age by assessing the maturity of the newborn. Performed in the first 4hrs of birth if the newborn appears younger or older than expected or if mother has not had prenatal care Each physical and neuromuscular finding is given a value. The total score is then matched with a gestational age. The maximum score is 50 which corresponds with 44 weeks. To optimize accuracy, should be completed within the first 12 hours of birth. Maternal complications (such as, preeclampsia, diabetes, and maternal analgesia/ anesthesia) may affect certain gestational assessment components and warrant further evaluation. Maternal diabetes may appear to accelerate physical growth; however, it tends to retard maturation. Maternal HTN may slow physical growth and accelerate maturation. Other factors that may affect newborn: magnesium sulfate has poor correlation with neuromuscular criteria involving active muscle tone and edema; maternal analgesia/anesthesia may cause respiratory depression. Give a maturity rating which tells you the weeks of gestation that they are estimated to be at (30 wks vs 40 wks, etc) Know preterm vs term for test for assessment Preeclampsia, diabetes, maternal anesthesia can all affect how the baby responds to Ballard score assessment; may indicate that this needs to be held off for a while or repeated later

Interventions for IDM newborns

Goal is to have the newborn's O2, RR and effort be within normal limits Suctioning Monitor for worsening signs of respiratory distress....grunting, flared nostrils, use of accessory muscles, increased RR, cyanosis, even apnea Maintain optimal temp so that extra 02 is not going toward temp maintenance 02, Continuous positive airway pressure (CPAP) to prevent apnea, or intubation with mechanical ventilation for management of differing levels of respiratory distress Monitor glucose levels since respiratory distress eats up glucose Goal is for newborn to have normal glucose level Monitor BG levels per protocol and report levels less than 40 (can vary by hospital policy) Monitor for signs of hypoglycemia: irritability, lethargy, hypotonia, poor feeding, temp instability, tremors, jitteriness, seizures and apnea Create feeding schedule Provide glucose by one hour of age, either through orogastric tube or IV (breastmilk is best, formula often needed) Inititate breastfeeding when newborn appears ready IV may be needed if feeding does not work. Goal is for newborn to have normal bilirubin level for GA: Monitor total bilirubin levels per protocol and report levels to pediatrician Monitor for signs of jaundice in skin and sclera Initiate phototherapy as indicated and ordered. Goal is that parents bond with infant, while having realistic expectations for improvement. Emotionally support parents by helping with attachment behaviors Include parents in caring for baby, visiting often, talking to their baby, facilitate kangaroo care (basically skin to skin for as long as possible each day) Prepare for discharge by continually instructing and evaluating learning curve for parents' feeding, bathing, and attaching to baby. Educate to prevent future problems related to the IDM newborn: Tight control of maternal glucose levels before birth. Try to control with diet, but mom may need insulin Closely observe newborn after birth for hypoglycemia, which has an onset of 1-3 hours: hourly BG checks for first FOUR hours, then every 4 hours for 48 hours, or follow the neonatal hypoglycemia protocol for your facility. If BG falls below 40, give early feedings of colostrum or formula. IV may be needed if this does not work.

Desired outcome for nursing care of the IUGR newborn

Goal is to have the newborn's O2, RR and effort be within normal limits Suctioning Monitor for worsening signs of respiratory distress....grunting, flared nostrils, use of accessory muscles, increased RR, cyanosis, even apnea Maintain optimal temp so that extra 02 is not going toward temp maintenance 02, Continuous positive airway pressure (CPAP) to prevent apnea, or intubation with mechanical ventilation for management of differing levels of respiratory distress Monitor glucose levels since respiratory distress eats up glucose Goal is to maintain temp within normal limits Use skin probe to continually measure temp of newborn Adjust incubator temp to make sure newborn's temp is stable Prevent cold stress by warming 02, keep skin dry, esp right after delivery, by vigorously drying infant, keep crib away from drafts, use hat Goal is for newborn to have normal glucose level Monitor BG levels per protocol and report levels less than 40 (can vary by hospital policy) Monitor for signs of hypoglycemia: irritability, lethargy, hypotonia, poor feeding, temp instability, tremors, jitteriness, seizures and apnea Create feeding schedule Provide glucose by one hour of age, either through orogastric tube or IV (breastmilk is best, formula often needed) Inititate breastfeeding when newborn appears ready Goal is that parents bond with infant, while having realistic expectations for improvement. Emotionally support parents by helping with attachment behaviors Include parents in caring for baby, visiting often, talking to their baby, facilitate kangaroo care (basically skin to skin for as long as possible each day) Prepare for discharge by continually instructing and evaluating learning curve for parents' feeding, bathing, and attaching to baby.

Head

Head circumference should be 2-3 cm larger than the chest, and 4 cm larger can mean hydrocephalus (excessive spinal fluid within the brain cavity surrounding the brain; head circumference less than 32cm can mean microcephaly [abnormally small head] Anterior fontanelle (soft spot) should be 5 cm and diamond shaped. Posterior is smaller and triangle shaped. Both should be soft and flat, the same level as the cranial bones May bulge when the baby cries, coughs, vomits, poops; it is not normal to have bulging fontanelle otherwise, and can mean increased intracranial pressure, infection or hemorrhage. Depressed means dehydration Sutures of the newborn should be palpable, separated, and may be overlapping to make room in the birth canal to fit through (molding) (fuse by about a year) Caput succedaneum (also called cone head) is localized swelling of the soft tissues of the scalp caused by pressure on the head; it crosses the suture line and resolves in a couple of days; edema that feels mushy Cephalohematoma is a collection of blood on one side of the head, and it does NOT cross suture lines. Results from trauma from the birth process, from the baby's skull being pressed hard against the pelvis or from vacuum or forceps (PAINFUL! Baby will cry when you touch its head)

Ongoing Care Assessments

Head to toe full assessment once per shift once stable Vital signs Check umbilical cord Weight checks Feeding assessments Note all voids, amount and color of stools Ongoing assessments while in the hospital setting Extremity movements Expected reflexes Suck and swallow during feeding Temperature before and after bath Jaundice Babinski & Plantar, startle, rooting reflex -Don't forget to document your findings and report anything abnormal to your nurse Vital signs Temperature, heart rate and respirations q6-8h and prn (check for unit policy) Daily weights. At least one re-weigh prior to discharge. AT SHMC, EVERY BABY IS WEIGHED the second time AT 18 HOURS OF AGE. Compare birth weight to daily weights- More than a 7% drop in weight becomes a concern, depending on provider 0-7% of body weight being lost is normal Bath requires baby 98 degrees or more; check temp 15min after the bath as well to make sure temp goes back up. Use wrist to check temp of water; more than warm and less than hot. Most likely around 104 degrees is okay.

Newborn Vitals

Heart Rate: Normal range: 110 - 160 beats/min (can go down to 100 if baby is sleeping or extremely relaxed) Pulse rate can be variable and influenced by several factors (crying, activity, temperature). Auscultation is performed over the entire heart region (precordium), below left axilla and below the scapula. Apical pulse rates should be auscultated for a full minute (preferably when infant is asleep, or you can put on a glove and let the newborn suck on your pinkie finger, upside down in their mouth, so you can stroke their palate and they start sucking on your finger) Respirations: Normal rate: 30 - 60 respirations per minute. (Listen for full minute) Respirations are primarily diaphragmatic noted with the rising and falling of the abdomen. Respiratory distress signs include: nasal flaring, intercostal or xiphoid retraction, expiratory grunt or sign (could be called singing), seesaw respirations (the abdomen lifts and the chest sinks and the reverse happens when the diaphragm relaxes), or tachypnea (> 60 breaths per minute). Temperature: Can be assessed axillary or rectally. Axillary range: 36.4 to 37.2 C (97.8 to 99.5 F). Rectal range: 36.6 to 37.2 (97.9 to 100.4 F). Rectal is assumed to be the closest to core temperature (usually done at birth since it is so invasive). In NICU- continuous skin probe

Nursing Interventions and diagnosis for phototherapy

High risk for injury related to hyperbilirubinemia. Maintain therapeutic level of phototherapy intensity. Remove all clothing except for diaper. Serial serum total bilirubin levels. High risk for impaired skin integrity related to phototherapy, eye shields, diarrhea and increased urine AEB skin breakdown. Maintain thermoregulation. Remove eye patches and inspect skin regularly. Change diapers as soon as soiled. High risk for injury to eye corneas related to possible UV light exposure and continual eye shield wearing AEB redness, edema and/or purulent discharge. Maintain eye shields during phototherapy Injury: Bili meter reading: (at least 30uW/cm2/nm) Maximum skin exposure. Assess effectiveness of therapy Skin Integrity: Hyperthermia results from lights and hypothermia results from sweating Change baby's position every 2-3 hours Ensure they're not secured too tightly; massage skin; change eye shields if soiled to prevent skin infection. Remove for feeds. Frequent voids and diarrhea irritates skin. Eye Injury: Protect eyes from high-intensity lights...make sure eyes are closed when placing shields. Below 30 on the docimeter is not effective you want it over 30 and the docimeter measures the intensity of the lights, not bilirubin level. High risk for dehydration related to phototherapy exposure AEB diaphoresis, diarrhea, increased temperature and dry mucous membranes. Offer frequent feedings. Assess for signs of dehydration. Administer IV fluids if needed. High risk for impaired parenting related to deficient knowledge of disease and prolonged separation. Facilitate family education and bonding Feedings: Adequate hydration increases peristalsis and excretion of bilirubin. Assess for dehydration Poor skin turgor Sunken fontanelles and eyes Decreased urine output (Monitor I&O) Weight loss (weigh daily) Electrolyte shift (monitor labs) IV Fluids: If oral intake isn't adequate to offset losses d/t diaphoresis and diarrhea. Impaired parenting: Goal is that parents bond with infant, while having realistic expectations for improvement. Educate parents regarding rationale for treatment and importance of maximizing exposure to phototherapy lights. Also Emphasize the importance of tactile stimulation and cuddling during feeds (sensory deprivation with eye shields) Emotionally support parents by helping with attachment behaviors ( they may be discouraged by equipment). Include parents in caring for baby, visiting often, talking to their baby and providing comfort

IUGR Newborn Complications

Hypoxia: SGA newborns have often endured chronically lower than normal O2 levels in utero= depleted reserve to handle labor and delivery= can lead to problems such as fetal distress/intolerance of labor Use of a cooling blanket for three days can reduce less brain injury from the hypoxia. Aspiration Syndrome: This hypoxia can lead cause the fetus to gasp during birth= aspiration of amniotic fluid. Passing of meconium can also occur and meconium aspiration then becomes a risk. Hypothermia: Due to lower amounts of subcutaneous fat and brown fat, newborns have compromised ability to thermoregulate and conserve heat. Hypoglycemia: Increased metabolic rate in response to heat loss and depleted glycogen storage, hypoglycemia is common. Polycythemia: They have increased amounts of RBC's due to chronic hypoxic stress in utero. Ongoing: growth difficulties and cognitive deficits

During dx of the IDM Newborn

Impaired Gas Exchange R/T impaired surfactant production and immature lung development AEB signs of respiratory distress Nutrition, Imbalanced R/T increased glucose metabolism secondary to hyperinsulemia AEB hypoglycemia Risk for Injury R/T ineffective tissue perfusion secondary to polycythemia AEB lab values and ruddy skin Risk for Injury R/T increased bilirubin levels secondary to birth trauma and polycythemia AEB lab values and jaundice Risk for impaired parenting R/T lack of knowledge of newborn care and prolonged separation due to hospitalization Diabetic babies are born early a lot of times (even though they are big and appear mature). Surfactant production in the lungs usually takes place in last month so if born 36 weeks or less they will have problems with gas exchange; diabetic babies are more likely to have immature lungs at term too because high sugar impairs surfactant production. Ruddy complexion leads to increased bilirubin because there are more RBC for the liver to process which hurts the liver

Respiratory distress syndrome

Inadequate production of pulmonary surfactant due to prematurity Surfactant required for alveolar stability Instability causes atelectasis Lack of gas exchange leads to hypoxia & acidosis SURFACTANT IS A SUBSTANCE PRODUCED IN THE LUNGS THAT KEEPS THE LUNGS FROM COLLAPSING ON INSPIRATION, AND BEGINS TO BE PRODUCED BY 24 WEEKS GESTATION OCCURS MORE OFTEN IN WHITE BABIES THAN OTHER RACES, AND BOYS TWICE AS OFTEN AS GIRLS Characteristics: Increasing Cyanosis Tachypnea (greater than 60 respirations/minute) Grunting Nasal flaring Retractions Apnea Normal respirations Nursing care: Ineffective breathing pattern R/T immature lung development or inadequate surfactant Surfactant replacement Cardiac and respiratory monitoring Monitor newborn's respiratory rate and signs of RDS Administer warm humidified oxygen through nasal cannula or CPAP Obtain arterial blood gases Attach pulse oximeter Assess need for mechanical ventilation Temperature regulation

IUGR Newborn Etiology

Intracranial-uterine growth restriction resulting from conditions that decrease oxygenation of the fetus Maternal factors : low economic status, low education, grand multiparity (>5 babies), age (<16 or >40) Maternal disease: Pre-eclampsia, and uncontrolled diabetes, sickle-cell anemia, lupus, Environmental factors: Teratogenic effects of exposure to toxins; illicit drugs, alcohol or tobacco; high altitude, x-ray exposure and hyperthermia Placental factors: Small placenta, abruption, previa, incorrect placental insertion such as velamentous or marginal insertions Fetal factors: Infections such as TORCH & syphilis; discordant twins, chromosomal abnormalities, 2-vessel cord & inborn errors of Metabolism such as PKU. Symmetric: All parts of the baby are smaller than normal. Insult occurs early in pregnancy during organ development, so cells are all smaller than normal. Worse prognosis- ominous; something went wrong in early development of the baby so all of their cells are small overall Asymmetric: Head & brain are normal size, but the rest of the body is smaller than normal. Insult occurs later in pregnancy because decrease in oxygen/nutritional supply compared to needs doesn't occur until the 3rd trimester. Better prognosis.

Newborn's First Breath

Intrauterine life: The fetus practices breathing movements that help to develop the muscles of the chest wall and diaphragm. Surfactant (a lipoprotein that coats the inner surfaces of the alveoli) begins to be produced between 24 and 28 gestational weeks, and reaches its peak at approximately 35 weeks gestation, remaining high until birth. The lungs are developed enough to maintain lung expansion and allow for adequate gas exchange. (Premie babies will always need ventilators support) The fluid in the lungs begins to diminish 2-4 days prior to birth leaving approximately 80 mL - 100 mL in the passageway of the full-term newborn. During birth, the fetal chest is compressed and the fluid is squeezed out. The Initiation of Respiration includes: Internal Stimuli Chemical: the first breath is an inspiratory gasp triggered by increased PCO2 & decreased PH levels and PO2. This triggers aortic and carotid chemoreceptors that trigger the brain's respiratory center. External Stimuli Thermal: the newborn will experience a significant change in temperature after birth which will stimulate the newborn's nerve endings which causes the newborn to respond with a rhythmic respiration. Sensory Stimuli: At delivery, the newborn receives an abundance of stimuli which includes tactile, auditory and visual. The newborn is now exposed to light, sounds are no longer damped, and it feels the effects of gravity.

Kenicterus

Kenicterus usually results from a bilirubin greater than 25 mg/dL. (Usually happens from a pathological problem) Baby gets more and more lethargic, "glowing" yellow with Kernicterus. Want to watch for blood incompatibility between Mom and newborn It can result in brain damage, cerebral palsy, blindness, deafness It is either treated with aggressive phototherapy, or possibly an exchange transfusion, to get rid of the blood which is full of bilirubin, and transfuse new blood without that issue.

Complications of the infant of a diabetic mother

LGA: d/t high levels of maternal glucose OR IUGR if mother has vascular complications associated with severe or long-lasting diabetes Respiratory Distress: Insulin interferes with fetal lung maturation and surfactant production. Also polyhydramnios and macrosomia can lead to earlier deliveries. Hypoglycemia : BG is less than 40, Signs are tremors, cyanosis, apnea, temp instability, poor feeding, and hypotonia within 2 hours post delivery because the IDM newborn continues to secrete high levels of insulin that they did in utero due to high levels of maternal glucose. Polycythemia: Fetal hyperglycemia and hyperinsulinemia are a powerful stimulus to fetal erythropoietin production, due to increased fetal oxygen consumption. (Ruddy appearance) Hyperbilirubinemia: may be seen at 48-72 hours after birth. Many of these babies have increased red blood cell production due to hyperglycemia and decreased oxygenation. Birth trauma Includes all of the examples for the LGA newborn Congenital birth defects: The more out of control mom's blood sugar is during pregnancy the higher the risk for the newborn to have congenital birth defects (neural tube defects, transposition of the great vessels, PDA)

Mouth

Lip movements should be symmetrical with strong suck reflex Some babies are born with a weaker suck reflex even at term, but especially preterm. This makes it hard for babies to latch but it quickly develops and becomes more mature. Saliva is scant, and excessive can indicate fistula Epstein pearls are small white cysts found on the gums and at the junction of the soft and hard palates, and are normal (should flake off- calcium deposits) Tongue should move freely, be symmetrical in shape, and not protrude (protrusion indicates Down's syndrome) The soft and hard palate should be intact (if not, may have cleft palate/cleft lip) Gums and tongue should be pink. Gray white patches on tongue is thrush, a fungal infection from yeast in mom's vagina as baby passed through Milk can get engrained into their taste buds, but if you rub at it it won't bleed. Yeast would bleed if you rub it. Breasts and babies mouth should be treated with nystatin. Junction violet is acidic and will kill the yeast if nystatin does not work.

MR SOPA

M--mask adjustment R--reposition airway S--suction mouth and nose O--open mouth P--pressure increase A--airway alternative Turn oxygen up to 100 for compressions and strongly recommended to incubate before chest compressions Estimate tip-to-lip distance (nasal-tragus length or 7-9 is almost always fine) Apply leads: When auscultation is difficult and baby is not vigorous When pulse ox does not work due to low HR Consider a monitor when PPV begins Monitor is preferred method for assessing HR when compressions begin

Risk factors for a congenital heart defect

Majority are from multifactorial causes with no specific trigger. Some potential risk factors: Some maternal infections or viral illness in pregnancy Maternal Alcohol, lithium, some anticonvulsant use Mothers with phenylketonuria (P K U) who do not follow their diets Genetic disorders such as Down Syndrome (Trisomy 21) Increased incidence of specific defects can run in families

Preterm GI alterations

Marked danger of aspiration because of -poorly developed gag reflex -Incompetent esophageal cardiac sphincter -Poor sucking and swallowing reflexes -Difficulty meeting high caloric needs for growth because of small stomach/feeding issues Nutritional issues: -Feeding intolerance due to immature sucking reflex Inability to handle the increased osmolarity of formula protein because of kidney immaturity Difficulty with absorbing saturated fats Difficulty with lactose digestion Increased 02 needs from sucking exhaustion Necrotizing enterocolitis (NEC) from decreased 02 perfusion to intestinal tract (baby is not ready for food; needs TPN)

Contraindications to breastfeeding

Maternal infections H I V/A I D S Active tuberculosis, vericella, human T-lymphocyte virus 1 (H T L V1) positive Herpes on the breast Maternal habits Illicit drugs, or alchololic Smoking (**AAP recommends BF) Certain prescription medications Breast Cancer MOM MAY NOT WANT TO BREASTFEED BECAUSE IT RETRAUMATIZES HER FROM HER PRIOR SEXUAL ABUSE HISTORY. Third hand smoking is all the chemicals in the smoke that land on surfaces in the home (200 carcinogens in smoke)

Normal Elimination Patterns

Meconium (formation begins at 12 weeks, and 1/2 of it is formed in the last 8 weeks of pregnancy) [Meconium in fluid could mean baby is post term or there was some type of distress for the baby] That is why it resembles tar! Formed in utero from the amniotic fluid and its components, intestinal secretions, and shed mucosal cells. It is thick, dark green (black), and tarry in appearance. Usually passes within 8 to 48 hours after birth. Breastfed babies tend to have more frequent stools and more of a liquid consistency. Bottlefed babies stools can be more pale and thicker consistency. Frequency of bowel movements vary. Usually 2 to 3 times a day. May be as frequent as 10 per day. Important to educate parents that the newborn is not constipated as long as their stools remain soft. Voiding 90% of newborns void within the first 24 hours after birth. 99% void by 48 hours after birth. If a newborn has not had a void by 24 hours, the nurse should assess the adequacy of fluid intake, bladder distention, restlessness, and symptoms of pain. Initial bladder volume for a newborn is 6 to 44 mL of urine.

PKU newborn screening

Metabolic disorders caught early in life can warrant a change in diet that will allow them to live. Along, healthy life. Otherwise, they can be detrimental to the newborn. One of a group of hereditary disorders transmitted by mutant genes PKU is the most common of the amino acid disorders Incidence is 1 out of 12,000 births Newborns are unable to convert phenylalanine to tyrosine, and the resulting accumulation causes cognitive disabilities Newborn is fed special formula with low phenylalanine content PKU Testing completed at 24 hours of age and repeated between 1 and 2 weeks of age

Evaluation of Breastfeeding

Minimum 8 feeds in 24 hours Auditory confirmation (can hear swallowing and gulping of transitional milk) Breasts are softer (empty) after feeds Voids increase by one additional diaper per day until day 5 After day 5 = 6-8 wet diapers per day Stools transition and become lighter in color around the 3rd day after birth Initial weight loss in newborn begins to shift towards birth weight with continued increase (should be back up to birth weight)

Septal defects

Most common CHD's Ventricular septal defect; abnormal opening in the heart that forms between the heart's owner pumping chambers (ventricles). This allows oxygen-rich and oxygen poor blood to mix. Atrial septal defect If small, they can both spontaneously resolve. Otherwise, surgery is required

Neuromuscular Components Ballard Tool

Muscle tone progresses from extensor tone to flexor tone and from the lower extremities to the upper extremities; this is because the neurologic system tends to mature in a caudocephalad (tail-to-head) progression. The neuromuscular assessment can only be done when the newborn is stable. Common Ballard neuro assessments: Examine posture, square window sign, popliteal angle, leg and arm recoil, popliteal angle, scarf sign, heel-to-ear extension, ankle dorsiflexion, head lag, ventral suspension, major reflexes.

Newborn Immune System

Newborns depend on their mother's passive immunity because they lack immunologic memory and are slower to develop immune responses. Passive immunity is provided by colostrum, which contains IgA antibodies that are transferred to the gut of the infant providing local protection against disease causing bacteria and viruses until the newborn creates its own antibodies around 4weeks of age. Hypothermia is a strong sign of infection in a newborn. (Could indicate sepsis; you warm the baby up and the temp drops again) [Fever is not a reliable indicator of infection] Active acquired immunity: when pregnant woman forms antibodies in response to illness or immunization. Passive acquired immunity: when IgG antibodies are transferred across placenta because the fetus does not produce its own antibodies. Immune system kicks into gear after birth Newborn's own immunity: Breastfed newborn has passive immunity from mother. Colostrum is high in I g A. Production of secretory I g A in the intestinal mucosa begins ~ 4 weeks. Vaccinations = develop active acquired immunity. Hepatitis B given first day after birth.

Nose

Nose should be midline, flat, and broad with a lack of a bridge ("pug nose"), making it easier for baby to breathe out the sides during breastfeeding Some mucus should be present, but with no drainage Newborn will sneeze to clear his/her nose (also sneeze when overstimulated or withdrawing from illicit substances mom ingested) Babies do not get colds very easily so drainage is most likely amniotic fluid

Nursing care for At-Risk newborn

Observe continuously: CR monitors provide VS and A/B/D information Coordinate interventions: Shift-to-shift SBAR very important Decrease stress: Stimulation from sound, lights, touch; interrupted sleep Conserve energy: cluster care, look for cues while feeding-sneezing, yawning, turning away, A/B/D (PO + NG feeds) Developmentally Supportive Care (Create a womb-like environment): Positioning Nesting Swaddling Facilitated tucking (little "nest" for a confined space) Massage (PT), Touch (including kangaroo care) Non-nutritive sucking Low noise and light Bonding/Education (welcoming, normalize, empower-involve in care, educate about baby and condition, what to expect)

Preparation for Resuscitation

Obtain and maintain training in resuscitation. Maintain and check resuscitation equipment in an organized manner - ask, can I: Warm, & clear the airway? Warmed towels or blankets and hat. Pre-warmed radiant warmer. Plastic wrap or thermal mattress for < 32 weeks Bulb syringe Wall suction (80-100mm/Hg) 10 or 12F suction catheter Meconium aspirator Auscultate? Stethoscope Ventilate? Positive-pressure ventilation (PPV) device Term and pre-term sized masks 8F orogastric tube and syringe Oxygenate? Equipment to administer oxygen (self inflating bags, low inflating bags, etc) Oxygen blender set to 21% or 30% for <35 weeks Pulse oximeter with sensor and cover 10L/min start free flow at 30% but during compressions 100% Intubate? Laryngoscope w/size 0 and 1 blades ET tubes (size 2.5, 3.0, 3.5), stylet & securing device CO2 detector LMA size 1 and 5ml syringe (laryngiomask airway- nurses can place and it is a great emergency airway that is relatively non invasive to place) ECG monitor and leads Medicate? Epinephrine & syringes (fill 1mL syringes with epinephrine) Normal Saline Umbilical venous catheter

External Physical Maturity Characteristics Ballard Tool

Physical characteristics usually include sole creases, amount of breast tissue, amount of lanugo, cartilaginous development of the ear, testicular descent and scrotal rugae in the male, and labial development in the female. These are objective clinical criteria that are not influenced by labor and birth and do not change significantly within the first 12 hours of birth. Observable characteristics: Resting posture: assess as the baby lies undisturbed on a flat surface Skin: preterm newborns skin appears thin and transparent, with veins prominent over the abdomen. Term newborns skin appears opaque because of the increase in subcutaneous tissue. Vernix caseosa disappears on postmature newborns (42 weeks and those with signs of placental insufficiency) and promotes skin desquamation (peeling skin). Lanugo: fine hair that is on the body of the newborn. Decreases as gestational age increases. The amount is greatest at 28 to 30 weeks. Most abundant over back; however may be seen of face, legs, and arms. Disappears first from face, then from trunk and extremities. Sole (plantar) creases: most reliable of gestational age in first 12 hours. Development of creases begins at the top (anterior) portion of the sole and then proceeds to heel as age progresses. Plantar creases may vary with race. Areolae/Breast tissue: the tissue is measured. Term gestation should measure between 0.5 and 1 cm. Absence or decreased breast tissue indicates premature or SGA (small for gestational age) newborn. Ear form and cartilage: less than 34 weeks, ear is flat and shapeless; has little cartilage. The ear will fold over and remain in that position. By term, pinna is formed, stands away from head, and springs back quickly. Genitals: males are evaluated for size of scrotal sac, presence of rugae and descent of testes. The female's genitals depend of the amount of subcutaneous fat deposition which relates to the nutritional status of the fetus. As fetus increases in gestational age, clitoris becomes more prominent, labia majora increase in size.

Physiologic jaundice

Physiologic jaundice: nonpathologic unconjugated hyperbilirubinemia. This means that there is no pathological reason for the increased levels, but a natural biological response of the newborn. Develops after the first 24 hours postnatally which differentiates it from Pathological jaundice which is seen at birth or within the first 24 hours of postnatal life. The bili levels will tend to increase after birth because there is an increased bilirubin production, a delay in bilirubin elimination, and/or there is a recirculation of bilirubin. Newborns will reach a peak in bilirubin levels at between 3-5 days while pre term babies reach their peak bili level 5-7 days. Possible causes: The span life for RBCs are considerably shorter for a newborn; therefore, they have a 2 to 3 times greater production or breakdown of the bilirubin. Bruising from a delivery can increase the amount of bilirubin that must be processed through the liver. Newborns can have a low volume and inadequate caloric intake from their initial feedings. This can increase the reabsorption of bilirubin from the aggravation caused from the decrease of gastrointestinal activity. If the levels continue to increase and are not treated, it can lead to kernicterus - bilirubin neurotoxicity (enters the brain). Levels are checked by total serum bilirubin (blood draws) or transcutaneous bilirubin measurements with a risk score (at 18hrs of age). Jaundice develops in a cephalocaudal pattern - first seen in the face then travels down the trunk. (Head to toe development; nipple line or above is usually less than 12- bilirubin lights may be ordered to break down the bilirubin and help it excrete easier)

Nursing Care goals for the preterm infant

Physiologic nursing care goals: Maintain respiratory function. Maintain neutral environment. Balance fluids and electrolytes. Provide adequate nutrition. Prevent infection. "Recreating the Womb" (provide an environment where they do not need to work hard to breathe, stay warm, and eat so they can focus on healing) Psychosocial nursing care goal: Promote parent‒infant attachment and bonding using Kangaroo Care. Either parent holds their diapered baby on their bare chest, or between breasts A blanket goes over the baby's back Benefits for the newborn Benefits for the parent Depending on the hospital, it is started once the newborn is medically stable, or from birth onward Benefits for the newborn Keep his body warm Keep his heart and breathing regular Helps him to gain weight Spend more time in deep sleep state Spend more time peaceful rather than crying while awake Increases breastfeeding success Benefits for parents Increases breastmilk production Reduces stress Reduces PPD Improve bonding with newborn Builds confidence

Disadvantages of breastfeeding

Possible pain due to nipple tenderness or engorgement Leaking milk when breasts are full Embarrassment about breastfeeding Stress from juggling work or school with breastfeeding Unequal feeding responsibilities/fathers left out Birth control options while breastfeeding: progestin-only birth control options can be used (estrogen & progesterone combo birth control can decrease milk supply) Depo-Provera is an option as it is a progestin only injection. Should wait 6 weeks to start so that a good milk supply has been established. -Vaginal dryness may occur due to a low level of estrogen while lactating. This is temporary and a water-based lubricant should be recommended. -Mom should check in with her HCP before taking any medication while breastfeeding Soothie in the hospital for moist wound healing (rub colostrum and then apply); Vit E oil can help as well. Both of these interventions can help with pain during breastfeeding.

Transient tachypnea of the newborn (TTN)

Progressive, mild respiratory distress that resembles RDS, but it is self-resolving, usually within ~72 hours Sometimes due to failure to clear lung fluid and mucus No thoracic squeeze during a C/S Usually newborn experiences little or no difficulty at the onset of breathing Exhibit signs of distress shortly after birth In-utero, the baby's lungs are filled with fluid. Near term, the lungs begin to absorb the fluid. Some fluid also may be squeezed out during birth as the baby passes through the birth canal. After delivery, as a baby breathes for the first time, the lungs fill with air and more fluid is pushed out. Any remaining fluid is then coughed out or slowly absorbed through the bloodstream and lymphatic system. Babies with TTN have extra fluid in their lungs or the fluid leaves too slowly. So they must breathe faster and harder to get enough oxygen into the lungs. Risk factors: Large for gestational age (larger babies more likely to have polyhydraminios because they urinate larger amounts) Term and late preterm Maternal diabetes/asthma Macrosomia Male newborns Cesarean section delivery S/S: Expiratory grunting Nasal flaring Retractions Mild cyanosis Tachypnea by 6 hours of age, up to 80-110 RR Mild respiratory and metabolic acidosis Increase in anterior-posterior diameter of chest Improvement of symptoms around 12-24 hours Resolution ~ 72 hours Nursing care: Diagnosed with multiple x-rays (chest x-ray for RDS baby would show hypo-inflation, a TTN baby would look hyper-inflated) Administer supplemental oxygen. I V administration of fluid and electrolytes Oral feedings contraindicated

Nursing Care of Newborn at Birth

Quickly and completely dry the newborn Vital Signs Cardiopulmonary assessment Safety Vitamin K Eye prophylaxis Initiate feeding Facilitate parental-infant attachment (Eye-to-eye contact, skin to skin contact for all nursing care. If distress, bonding can proceed normally as soon as mother and baby are stable. Interactive bath (usually around 18hrs of age)) its very important to keep a bulb syringe nearby, and possibly a even a wall suction newborn catheter, to clear secretions Why is vitamin K injection necessary? This is to prevent Vitamin K deficiency bleeding and hemorrhage. This can happen because of low prothrombin levels in the first few days of life. This is a one time only prophylactic dose of 0.5 to 1.0 mg (Aquamephyton) and it is given IM in the vastus lateralis. (Born w a sterile gut so vit K is not produced yet) -Most often given in the L&D room fairly quickly after birth along with the prophylaxis eye ointment but it can be delayed for 6 hours. -Eye prophylaxis to prevent infection (Neisseria gonorrhea & chlamydia) passed from mom during delivery. Applied into the lower conjunctival area of each eye. Spread but try not to touch tip of tube on eye. Possibly wait until after first breastfeed.

Nursing care to decrease pathological jaundice

Recognize prenatal risks such as ABO-Rh incompatibility. Maintain newborn skin temperature ≥ 97.8F or 36.5C Cold stress increases acidosis, which decreases serum albumin sites and binding, which increases conjugated bilirubin. Encourage early breastfeeding - the laxative effect of colostrum increases the excretion of stool (and bilirubin). Early feedings increase bacterial colonization in the intestines for increased excretion of unconjugated bilirubin. Early feedings make more hepatic proteins available for increasing the conjugation of bilirubin in the liver. Mother's blood type is determined during pregnancy. And Rh- receive Rhogam at ~27-28 weeks. Cord blood tube sent with every delivery for baby's blood type and coombs status.

Eyes

Should be symmetrical in size and shape Color is usually bluish gray, with permanent eye color established in 3-12 months Lacrimal glands are immature in a newborn, resulting in tearless crying Subconjunctival hemorrhage may result from pressure during birth, causing a solid red color in the eye Pupillary and red reflex should be present Eyeballs can demonstrate random rolling movements (Especially in premies because muscles are weak)

Reflexes

Sucking/rooting reflex: birth to four months this reflex is elicited by stroking the baby's cheek or edge of mouth. The newborn will turn his head toward the side that is touched, and will start to suck. This reflex may not be present in premature babies, and develops later. Palmar grasp: birth to six months Place an object in the baby's palm and they will grasp Plantar grasp: birth to eight months Touch sole of foot and baby will curl toes down around the object Moro reflex (startle): birth to four months Lightly bump a surface the baby is lying on; baby will extend arms and legs symmetrically, and his fingers will make a C; primitive protective movement Tonic neck reflex (fencer position): birth to 3-4 months Turn baby's head to one side; will respond by extending arm or leg on that side, and flex arm and leg on opposite side Babinski's reflex: birth to one year Stroke outer edge of the baby's sole of foot, moving up to the toes; toes should fan upward and out Stepping: birth to four weeks Hold newborn upright with feet touching a flat surface. Baby will make stepping movements

Signs of illness in the newborn

Temp above 100.4 or below 97.8 More than one episode of forceful vomiting Refusal of two feedings in a row once breastfeeding is well established Lethargy Central cyanosis Absence of breathing greater than 20 seconds

Anogenital

The anus should be present, patent, and not covered by a membrane (GI abnormalities are linked to meth use; if anus is not patent they need surgery) The genitalia of a male newborn should include rugae on the scrotum, testes descended into the scrotum, and the urinary meatus located at the penile tip The genitalia of the female should include the labia majora, covering the minora and clitoris. Usually edematous, possible blood-tinged discharge, due to mom's hormones Urine and meconium should be passed within 24-48 hours after birth Uric acid crystals can color the urine orange (normal state of dehydration in the first couple of days and will no longer occur when milk comes in)

Newborn with pathological jaundice

The breakdown of red blood cells produces bilirubin. Bilirubin is yellow. It is unconjugated and fat soluble. In-utero, unconjugated bilirubin is cleared by the placenta, so the total bilirubin of newborns is usually <3mg/dl at birth. Once born, the newborn must conjugate the bilirubin in their liver. Not a problem for the healthy term newborn with an uncomplicated birth. Serum albumin binds with the bilirubin and ushers it to the liver. Cellular proteins in the liver take the bilirubin into the liver where glucuronic acid conjugates the bilirubin and it becomes water-soluble. The conjugated bilirubin is then sent to the kidneys to be excreted in the urine or to the intestines to be excreted in stool. If there isn't enough gut bacteria to act on the bilirubin to move it through the intestine, it will deconjugate and return back to the blood stream and need to be processed again. The rate and amount of conjugation depends on: The rate of hemolysis-more hemolysis occurs with birth trauma, polycythemia and ABO Rh incompatibility. The presence of albumin binding sites - Acidosis decreases albumin binding sites and weakens its binding ability (hypoglycemia, hypothermia). Pre-terms have less albumin. The availability of proteins in the liver - Decreased caloric intake reduces the available proteins The presence of bacterial colonization and motility in the intestine- The absence of the bacteria and active elimination causes bilirubin to re-conjugate and recirculate in the blood stream. Exclusive BF and antibiotic use decreases bacteria. When any of the processes cause an increase in unconjugated bilirubin in the bloodstream, pathologic jaundice can occur. Unconjugated bilirubin deposits in fatty cells such as the skin and eye sclera; cerebral tissue as well.

Bilirubin

The breakdown of the heme portion of hemoglobin causes the production of a yellow pigment (bilirubin) Unconjugated bilirubin is fat soluble and is NOT in an excretable form = potentially toxic. (Fetal unconjugated bilirubin crosses the placenta to be excreted) Conjugation is the conversion of unconjugated bilirubin (indirect) into the water soluble pigment (excretable, direct) conjugated bilirubin. Fetal unconjugated bilirubin crosses the placenta to be excreted The newborn's liver must then begin to conjugate bilirubin after birth Total Bili (combo of both types) is usually less than 3mg/dl at birth The longer the direct bilirubin stays in the newborn's gut, the higher the chance it has of becoming deconjugated (where the enzyme splits off the bilirubin from glucuronic acid if it has not been acted on by the gut bacteria to produce urobilinogen. -The sooner the newborn establishes gut motility and active stooling through early and frequent feeding, the less likely they are to develop physiologic jaundice (Normal; before 24hrs). -The newborn liver has less activity in the first few weeks than an adult liver and this makes it hard for the newborn to keep up with a relatively large bilirubin amount (this decreases the liver's ability to conjugate the bilirubin).

Neck

The neck should be short, thick, surrounded by skin folds and have no webbing (that indicates a syndrome) The neck should move freely from side to side and up and down, with free range of motion (ROM) Absence of head control may indicate prematurity or Down's syndrome Chest should be barrel shaped Respirations are diaphragmatic without retractions Clavicles should be intact (crepitus if damaged) Nipples should be prominent, well-formed, and symmetrical with breast nodules ~ 6mm and may be edematous related to maternal hormones Lift baby up by arms, term babies should be able to hold head straight. If head goes back their muscles are too weak

Thermogenesis

Thermogenesis is the production of heat. Can include basal metabolic rate, muscular activity, and chemical thermogenesis (aka non-shivering thermogenesis- important for production of heat in newborn). Non-shivering thermogenesis (NST) is an important production of heat for the newborn. Skin receptors will perceive a drop in temperature in the newborn's environment. The newborn responds by transmitting sensations to stimulate the sympathetic nervous system. The NST uses the brown adipose tissue (BAT) to provide the heat (primary source of heat in hypothermic newborn. It is deposited in the midscapular area, around the neck, and in the axillas. Also found around the trachea, esophagus, abdominal aorta, kidneys, and adrenal glands. Increases in fetus at about 25-30wks Increases until 3-5wks after birth of term newborn

Infants born the HIV/AIDS infected mothers

This low risk of maternal-child transmission is due to: Prenatal testing (still voluntary) Antiretroviral medications for the mother Viral load measurements Scheduled cesarean sections The preferred test for diagnosis of HIV in newborns is the bDNA PCR assay and HIV RNA assays - a positive result within 48 hours suggests in-utero transmission. Complications: Prematurity (womb environment is hostile) S G A Failure to thrive Signs & Symptoms of disease: Enlarged spleen and liver (swollen abdomen) [body working hard since it is immune compromised) Swollen glands Recurrent respiratory infections Diarrhea UTIs Thrush Interstitial pneumonia Opportunistic diseases such as gram-negative sepsis and the complications of prematurity are the primary causes of mortality in HIV infected babies. Nursing care: Emotional support for parent(s) Retrovir started as soon as possible, given for 6 weeks Avoid breastfeeding since it has a high risk of transmission Educate parent(s)on s/s of potential HIV virus in newborn

Safety for the Newborn

Two ID bands are applied at birth, usually both on the ankles Corresponding bands are put on mom and significant other, or relative if mom is single The bands have permanent locks that must be cut to be removed, and they include the mom's name, gender of baby, date, time of birth, and mom's hospital number Each time the newborn is taken to his mother, the ID band should be verified against the mom's ID band Facility staff who assist in caring for newborns are required to wear picture ID badges Many units are locked or the ID band has a sensor that sounds an alarm if the baby is brought near an exit

Abdomen

Umbilical cord has two arteries and one vein (AVA) Umbilical cord should be odorless and exhibit no intestinal structures Abdomen should be round, dome-shaped, and non-distended Bowel sounds should be present 1 hour following birth (Hard, distended abdomen means something is wrong with intestines)

Normal Visual Sensory-Perceptual Abilities

Visual Capacity: Newborns are nearsighted with a visual distance of 8 to 15 inches (Perfect distance to Mom's face when breastfeeding). Orientation: newborn's ability to be alert to, to follow, and fixate on appealing objects. They prefer human faces, eyes, and high-contrast objects and patterns. As object comes into vision, eyes get wide, limbs become still, and fixed staring. Auditory Capacity: Respond to auditory stimulation. Give appropriate stimulus for state of newborn (rattle for light sleep, voice for awake, and a clap for deep sleep). Heart rate rises, may see a minimal startle reflex. If the sound is appealing, newborn will search for it. Hearing should be evaluated before discharge. (Might be fluid in the ears that will cause baby to fail, but they can get tested again when it drains) Olfactory Capacity: Able to select and differentiate their mother through smell. Taste and Sucking: Can distinguish between sweet and sour at 3 days of age. Breastfed newborns suck in bursts with frequent regular pauses Bottle fed newborns suck at a regular rate with infrequent pauses. Displays rapid searching motions in response to rooting reflex. Uses non-nutritive sucking as a self-quieting activity which assists in development of self-regulation (learn this in utero). Tactile Capacity: Sensitive to touch, cuddling, and being held. Makes touch the most important of all the senses. Swaddling, placing a hand on abdomen, or holding the arms to prevent a startle reflex are soothing methods for the newborn. The settled newborn is able to interact with the environment. Touch may be used to rouse a drowsy newborn for feeding.

Fetal Circulation Prior to Birth

While the fetus is still in the womb, the placenta is the organ that controls the gas exchange. In utero, the fluid-filled lungs have a higher vascular resistance while the placenta has a lower vascular resistance. This results in four different shunts that assist in fetal circulation. 1. Highly oxygenated blood flows from the placenta, through the umbilical vein, and through the ductus venosus. This shunt allows the majority of the oxygenated blood to flow into the inferior vena cava towards the right atrium while a small amount perfuses the liver. 2. Oxygenated blood mixes with deoxygenated blood from the superior and inferior vena cavas into the right atrium. During the fetal circulation, the pressure is higher in the right atrium compared to the left atrium. This is the foramen ovale, an opening in the septum between the atriums, which allows oxygenated blood to flow into the left atrium, which then travels to the left ventricle and then to the ascending aorta so that it can deliver oxygenated blood better to the myocardium and brain. 3. A small amount of blood travels from the right ventricle into the pulmonary arteries. The fluid-filled lungs have a higher vascular resistance which causes more than 60% of the blood from the right ventricle to bypass the lungs and pass through another shunt, the ductus arteriosis. This is an opening between the pulmonary artery and the descending aorta. The blood then travels to the lower extremities and returns to the placenta through the umbilical arteries. At the placenta, carbon dioxide and waste products are released and oxygen and nutrients are collected.

Preterm cardiopulmonary alterations

-Inadequate surfactant production; Surfactant is necessary to compliance of the lungs (ability to fil with air easily). Not enough surfactant leads to ineffective exchange of O2 and carbon dioxide= hypoxic Muscular coat of pulmonary blood vessels is not completely developed; Under developed muscular coat of pulmonary vessels leads to decreased pulmonary vascular resistance= leads to left-to-right shunt of blood through the Ductus Arteriosus= which increases the blood flow back into the lungs, leading to pulmonary congestion and respiratory distress. Greater risk for the ductus arteriosus to remain open Use magnesium sulfate or terbutaline to slow labor; betamethasone may be given

5 S's

-Swaddle -Side/stomach position (reverse breastfeeding hold, football hold, over the shoulder hold) Shhhh sound triggers calming reflex -Swinging (start out fast and jiggly, allow the head to wiggle like jello, follow the babies lead) -Sucking (to eat or for non nutritive reasons; produces natural pain relieving hormones)

Four Major Actions of Cardiopulmonary Adaptation

1. Increased systemic vascular resistance and decreased pulmonary vascular resistance. Due to the loss of the placenta, the systemic vascular resistance increases causing a greater systemic pressure. Pulmonary blood flow is increased and pulmonary vessels dilate. The combination of vasodilation and increased pulmonary blood flow decreases the pulmonary vascular resistance. This allows the pulmonary vascular beds to open, systemic vascular pressure to increase, thus enhancing perfusion to the other body systems. 2. Closure of the Foramen Ovale The foramen ovale closes due to the changing arterial pressures. In utero, the pressure in the right atrium is greater which allows the blood to flow from the right atrium to the left atrium. Once the pressure changes, the left atrium has greater pressure which causes the foramen ovale to fuctionally close with in 1-2 hours after birth. Anatomic closure occurs within 30 months. 3. Closure of the ductus arteriosus. An increase in PO2 triggers the ductus arteriosus to constrict. Functional closure of the ductus arteriosus starts within 18 hours after birth. Anatomic closure occurs within 2 to 3 weeks after birth. 4. Closure of the ductus venosus. Closure is related to the mechanical pressure changes from severing the cord, redistribution of blood, and cardiac output. Occurs within 2 months and becomes known as the ligamentum venosum.

Chest compressions

2 thumb technique 100% oxygen Head of bed compressions One-and-2-and-3-and-breathe-and Cardiac monitor recommended Continue for 60sec prior to checking HR Note the position change for airway provider and compressions, making room for pediatrician to insert emergency UVC Medications: Epinephrine IV or IO preferred ET x 1 while achieving IV access Normal saline or type- O Rh-negative blood

Pre-Feed assessment and Early feeds

Active alert is a great state for feeds. Don't want to wait until baby is angry- super hard to get angry baby to feed! May need to calm and then try to feed PRE-FEEDING Readiness to feed Lusty cry that quiets and is replaced with rooting and sucking when a stimulus is placed near the lips EARLY FEEDINGS: Skin-to-skin contact can begin immediately after birth. Breastfeeding can begin in the birthing room. Formula-fed infants are fed according to hospital policy and when they demonstrate feeding cues. For both breastfeeding and bottle-feeding mothers, early feeding: Enhances maternal‒newborn attachment. Stimulates peristalsis, helping to eliminate the by-products of bilirubin conjugation, which decreases risk of jaundice.

Patent ductus arteriosis

An unclosed opening between the aorta and pulmonary artery. Normal in fetal circulation, but closes shortly after delivery. Most common preterm CHD. Blood shunts from aorta to the pulmonary artery MURMUR BOUNDING PERIPHERAL PULSES PULMONARY CONGESTION WITH PINK TINGED SECRETIONS RIGHT SIDED HEART FAILURE TREATED WITH 02 THERAPY, FLUID RESTRICTION, DIGOXIN, AND DIURETICS SMALL HOLES OFTEN CLOSE ON THEIR OWN, BUT IF LARGER OR DO NOT CLOSE, ARE CURED WITH SURGICAL INTERVENTION

Nursing management for congenital heart defects

As a postpartum or neonatal nurse, your primary goals for CHD are to identify abnormalities early, and initiate a referral to the physician right away. Manifestations: Cyanosis Detectable heart murmur Congestive heart failure s/s: Tachycardia Tachypnea Diaphoresis CHD Screening tool is now used regularly, prior to discharge CHF SIGNS: RESPIRATORY DISTRESS, PULMONARY CONGESTION, PINK SECRETIONS, LETHARGY, POOR FEEDING DUE TO WEAKNESS

Weight Calculation

Baby J is born at 7 lbs 6 oz. (Calculate this as 7x16= 112 oz plus 6 oz = 118 oz) Lbs x 16= oz At 18 hours, he has dropped to 6 lbs 11 oz (6x16 = 96 oz plus 11 oz = 107 oz) Subtract 118 oz - 107 oz = 11 oz Divide 11 oz by original weight of 118 oz = 9.3% weight loss Since this is greater than 7%, it needs nursing interventions such as more frequent feeds or supplementation with formula if parent is unable to pump not adequate amounts of colostrum. NEVER use a bottle for this supplementation. Use an SNS or a syringe connected to a small catheter which goes in the infant's mouth. Teach self expression and rub colostrum on babies lips SNS encourages the baby to latch on better. Nurse pushes a little bit of formula while baby is breastfeeding to encourage it to feed better and get more calories. Want tip of nipple to touch roof of mouth, so shields can help mom's with flatter nipples and their babies latch on. Can create a bridge from no breastfeeding to great breastfeeding.

Nursing Interventions for Jaundice

Bilirubin Chart: Tested at 18hrs of age; some hospitals test at 24hrs Use transcutaneous bilirubin reader first and compare it on the chart If they hit 6 at 18hrs phototherapy would be recommended. Depends on skin tone of baby for how easy jaundice is to see. Keep newborn temperature above 36.5 degrees Celsius (97.8F). If newborn gets too cold, the stress results in acidosis which can cause elevated unconjugated bilirubin levels. Encourage breastfeeding every 2 to 3 hours. Frequent feedings promote intestinal elimination and bacterial colonization and promote caloric intake. Provide emotional support to the parents. Explain the condition to them and help them understand. Phototherapy If the bilirubin levels are getting too high, usually when the baby hits a bilirubin level of 12 (this is usually yellow down to the nipple line), it may be necessary to place baby "under the lights." Special fluorescent lights help breakdown the bilirubin to decrease the jaundice. The baby then excretes the bilirubin out through stool and urine. Phototherapy treatment is very pediatrician dependent. Some will begin tx at bilirubin 12, others wait until 15.

Stages of human milk

Colostrum Initial milk, small volume so baby nurses frequently and establishes strong milk supply Thick and creamy with protein, vitamins, low fat, high IgA Laxative qualities that help baby pass meconium Transitional milk 32-96 hours postpartum, usually day 3-4 Light yellow but larger quantities Contains more fat, lactose, and calories Mature milk White or blue tinged in color 2 weeks postpartum 13% solids and 87% water

Breastfeeding positions/latching

Cross (modified) cradle Cradle Football (or clutch) hold Side-lying Breastfeeding is not always a "NATURAL" and easy thing! Mom's don't often know this and can feel so very frustrated and disappointed. This is where we can come in and encourage and support and help! It takes time and practice. USE PILLOWS TO POSITION BABY AT THE RIGHT HEIGHT, AND SO BABY DOES NOT PULL ON MOM'S NIPPLE AND CAUSE BREAKDOWN. ROTATE POSITIONS TO DECREASE NIPPLE SORENESS Latching On: 1. Use pillows to raise baby up to breast height. 2. Face baby towards mom's tummy 3. Stroke lip of baby with mom's nipple 4. We want to encourage baby to open up wide and then mom should bring baby to her (not bring herself to baby!) 5. Notice the wide open mouth which allows for the taking in of a lot of breast and not just the nipple. 6. The lips should be flanged out on top and bottom (check for curled bottom lip- often hidden!). 7. Infant needs to attach lips to as much of the areola as possible, not just the nipple.....will cause nipple damage.

Preterm feeding regimens

Early feedings help maintain normal metabolism and decrease complications based on the infant's weight/stomach capacity. Consider TPN is unable to tolerates feeds Supplements include multivitamins, medium-chain triglycerides, amino acids, and lipids.

How does a newborn become hypothermic?

Evaporation Example: amniotic fluid drying from skin creates heat loss Convection- transfer of body heat to surrounding air Examples: removal from incubator, or birth into a cold room Conduction- transfer of heat to surface the newborn is lying on Example: cold stethoscopes, cool crib mattress Radiation- loss of heat through the air to a cooler surface Example: placing cold objects near incubator

Nursing dx for IUGR

Impaired Gas Exchange R/T amniotic fluid or meconium aspiration AEB signs of respiratory distress Ineffective thermoregulation R/T less subcutaneous fat AEB low temperature Risk for Injury R/T decreased glycogen stores Risk for Injury R/T increased bilirubin levels Risk for impaired parenting R/T lack of knowledge of newborn care and prolonged separation due to hospitalization

Benefits of Breastfeeding

INFANT NUTRITIONAL BENEFITS: Human breast milk provides an ideal balance of nutrients that are efficiently absorbed. Contains specific nutrition for human baby Contains over 200 distinct components High lactose content Contributes to brain and central nervous system (C N S) development OTHER INFANT BENEFITS: Protective factors against (also includes immunologic advantages- see link!): Type 1 and type 2 diabetes mellitus Lymphoma, leukemia, and Hodgkin disease Obesity Hypercholesterolemia Asthma Protects against ear infections Immunologic advantages due to Secretory IgA in Breast Milk Secretory Immunoglobulin A (IgA) is a special immunoglobulin. It's the main antibody found in your breast milk. IgA is considered the most important immunoglobulin in breast milk. Babies are born with low levels of IgA. Then, as the weeks and months go on, a baby's immune system makes more IgA and the levels slowly rise. But, when a baby breastfeeds during this early period of life, he gets high levels of IgA from breast milk. IgA is important because it coats and seals your baby's respiratory and intestinal tract to prevent germs from entering his body and his ​bloodstream. The IgA antibodies can protect your child from a variety of illnesses Mother Reduced risk of: Postpartum bleeding and a more rapid uterine involution Protective against premenopausal breast cancer and ovarian cancer May be associated with a decrease in type 2 diabetes, rheumatoid arthritis, hypertension Psychosocial results Can increase mom's self-esteem by being able to adequately nourish her infant. I do want to point out though that we want to support mom's feeding decision whatever that might be. Of course we can educate but we don't want to be pushy or come off as non-supportive. Decreased stress for mother and infant Sense of accomplishment Release of prolactin and oxytocin Makes mother feel affectionate toward infant Improves letdown response Breastfeed more frequently and longer (If feeds become spread out greater than every 3 hours than prolactin levels can drop and supply can be affected) Cost savings No preparation

IVIG for pathologic jaundice

Intravenous Gamma Globulin May be used as an adjunct therapy for newborns suffering isoimmune hemolytic disease (ABO Rh incompatibility). Blocks the receptor sites on baby's RBCs to prevent destruction by maternal antibodies. Considered safe and generally well-tolerated by AAP. Reduces the need for an exchange transfusion. IVIG Side Effects: Fever and rash Cyanosis and hypotension Hypothermia Irritability and vomiting IVIG: 1g/kg over 4 hours, and repeated in 12 hours if needed.

Transferring to the PP Unit

Maternal hx, birth hx, how newborn is adapting, vitals, initial assessments, APGAR's, if they needed Ballard done, etc Anything I need to be concerned about as the nurse taking over the care of this newborn? SGA, LGA? Tone- floppy baby? Skin color Weight and height Extremity movement Gestational age classification Evidence of complications

Newborn Classification and Neonatal Mortality Risk Chart

Neonatal morbidity can be anticipated based on birthweight and GA. Prior to this chart, weight alone (2500 g/5.5#) was sole criteria for prematurity: LGA, AGA or SGA by weight and GA (OFC and length). Chart should correlate to geographical location. Preterm, Late preterm (32-36.6), Term, Late term, and post term Anticipate different needs: 2000g @ 40 weeks vs 2000g @ 30 weeks (preemie is AGA and term baby is SGA) or LGA at 41 weeks vs LGA 32 weeks Intrauterine growth restriction could be a reason for SGA baby LGA is usually due to a mom with uncontrolled GDM

Preterm nervous system alterations

Neurologic: Preterm babes may be hypotonic and unreactive, and about 50% of extremely premature babies will sustain an IVH (intraventricular hemorrhage) whereas only about 15% of older premature babies will have an IVH. Most rapid brain growth occurs in third trimester Behavioral: Stable preterm infants do not demonstrate same behavioral states as term newborns; more disorganized. Delayed or absent reactivity

Fetal/neonatal risk factors for asphyxia

Non-reassuring FHR pattern during labor (late decels) Poor placental perfusion Significant intrapartum bleeding Prolonged, difficult birth Narcotic use later in labor Meconium in fluid Prematurity SGA or LGA baby IDM Multiple births Congenital heart disease Rapid assessment questions: "What is the gestational age?" "Is amniotic fluid clear of meconium and evidence of infection?" "How many babies are expected?" "Are there other risk factors?"

Complications of the LGA Newborn

Plots greater than the 90th percentile for birth weight on the chart Body is characteristics proportional, except for newborns of diabetics whose OFC and length are normal, with a greater body weight Most often associated with GDM, genetically large parents, or amount of weight gained during pregnancy [macrosomic fetus] Cephalo-pelvic Disproportion CPD) head too big for pelvis Birth trauma: Increased bruising Shoulder dystocia/fractured clavicles Nerve damage (brachial or phrenic nerve palsy, facial paralysis) cephalohematoma intracranial hemorrhage Hypoglycemia Hyperbilirubinemia Hypoxia in utero

Initial steps of newborn care

Provide warmth Position head and neck Suction if needed Dry (or cover in plastic) Stimulate Assess breathing If breathing, assess HR If apneic start PPV If HR <100 start PPV When a newborn is in primary apnea, any form of stimulation (e.g., drying, suctioning, or tactile stimulation) will induce breathing. If the newborn continues to remain apneic, and no amount of stimulation works, this is secondary apnea. The next appropriate step is to initiate PPV immediately to avoid the danger of prolonging anoxia. As a general rule, the longer a baby has been in secondary apnea, the longer it will take for spontaneous breathing to resume. If initial attempts fail to reverse apnea, it is vital to remember that prolonged and vigorous stimulation is not helpful and a delay in initiating PPV can cause serious injury to the newborn.2,3 It is vital for healthcare professionals and newborn resuscitation providers to be cognizant of these basic principles while resuscitating a compromised apneic newborn and implement appropriate actions during the first 60 seconds after birth Sniffing position- neutral, nose pointing up (not hyper or hypo extended) 20-25cm water initially; full term may require 30-40cm water; stand at the baby's head

Transposition of the great arteries

Requires surgery to correct Maintain patent foramen ovale and ductus arteriosus until ready for surgery (oxygen poor blood is better than oxygen depleted blood!) Rich get richer and the poor get poorer because the pulmonary artery and aorta are mixed; oxygen poor blood gets pumped through system over and over and it is not life sustaining

Care of newborn at risk for Asphyxia

Resuscitation required for newborns: 10% will need drying, stimulation, and oxygen to begin breathing 3% need positive pressure ventilation 1% need full resuscitation Due to lack of first breath, the normal cardiopulmonary changes do not occur, leading to: Hypoxemia (decreased 02 in the blood) Metabolic acidosis (low pH of the blood, below 7.2 Hypercarbia (Excess C02 in the blood) If sustained, hypoxia (poor perfusion of tissues and organs) Severe prolonged hypoxia leads to brain damage or death of newborn Drying and stimulation is standard in caring for the newborn and getting them to cry so we know their respiratory system is working effectively Secure the airway! Especially for babies because it is all about their breathing

The Five Fetal Adaptations

SO The Five Fetal Adaptations 1. Umbilical Arteries (2) - Carries unoxygenated blood from fetus to placenta. 2. Umbilical Vein (1) - Carries oxygenated blood from placenta to fetus. 3. Foramen Ovale - connects right and left atrium to allow oxygenated blood to supply brain, heart and kidneys. 4. Ductus Venosus - Carries oxygenated blood from umbilical vein to inferior vena cava bypassing the fetal liver. (Short cut) 5. Ductus Arteriosus - connects the pulmonary artery and the descending aorta and carries oxygenated blood which mostly bypasses the fetal lungs

When pathological jaundice can cause serious harm

Severe neonatal hyperbilirubinemia is associated with neurologic damage known as bilirubin-induced neurologic dysfunction (BIND), which occurs when unconjugated bilirubin crosses the blood-brain barrier. Binds to the basal ganglia and brainstem nuclei. Causes acute bilirubin encephalopathy. Can progress to a permanent neurologic dysfunction known as Kernicterus ("yellow nucleus") Occurs in 0.5-2/100,000 live births. Most commonly results from ABO-Rh incompatibility (causes erythroblastis fetalis). Less common today due to increased monitoring and aggressive treatment with phototherapy and exchange transfusion. Cord blood testing includes coombs

Desired outcomes for the IDM newborn

Stable respiratory status Glucose homeostasis Bilirubin levels normal for GA Family bonding and education facilitated

Phototherapy for pathological jaundice

The application of high-intensity light in the blue-light spectrum that conjugates bilirubin collected in skin cells through photo-oxidation. Photo-oxidation creates photoisomers that conjugates bilirubin independent of the usual process in the liver, and is more easily excreted through urine and stool as well. Phototherapy does not alter the underlying cause of hyperbilirubinemia. Phototherapy lights come as a bank of lights (overhead), a blanket or in a mattress- they can be used in combination. When is phototherapy started? For ≥35 weeks (and ≥2500g or 5#5oz) Or 95% range on the Bili nomogram For <35 weeks: Per provider orders. Supplies Needed: Phototherapy Lights Eye patches

Birth Weight Percentiles

The nurse is able to consider the gestational age determination and the birthweight and can then identify the newborn as: Small for gestational age (SGA): below the 10th percentile Appropriate for gestational age (AGA) Large for gestational age (LGA): above the 90th percentile EPIC has a built in charting function where you put in this information and it will tell you where the newborn falls. There are certain protocols for newborns who fall outside of AGA. For example, LGA and SGA babeis have to follow the blood glucose monitoring protocol.

Delayed Cord Clamping

The standard of care has been to immediately clamp the umbilical cord after birth. The World Health Organization was the first to recommend the delay of the cord clamping. ACOG (American College of Obstetricians and Gynecologists recommend delaying the cord clamping for 30-60 seconds. Pros for Delayed Cord Clamping Term Newborns Newborns can receive approximately 80 mL - 100 mL of extra blood. May assist their transition from fetal circulation to newborn circulation. Newborns have a significantly higher levels of hemoglobin and ferritin than newborns with the cord clamped immediately. Preterm Newborns Fewer babies required blood transfusions for anemia and/or low blood pressure. Reduction in the incidence of intraventricular hemorrhage and less risk of necrotizing enterocolitis. Cons for Delayed Cord Clamping Term and Preterm Newborns Higher need for phototherapy due to jaundice. (More RBC to break apart and filter out= more bilirubin (higher potential for jaundice)) Could hinder resuscitation efforts in a timely manner for neonates that are asphyxiated or with cardiopulmonary failure or other medical reasons. How TO: Hold newborn at or below level of placenta Can place skin to skin with mom - new research has shown does not alter transfusion.

Exchange transfusion for pathologic jaundice

The withdrawal and replacement of the newborn's blood with donor blood to treat anemia due to hemolytic disease. Modified O- whole blood (red cells and plasma) Cross-matched to mom and compatible with baby Removes sensitized RBCs Removes serum bilirubin Provides bilirubin-free albumin Indications*: Serum bilirubin levels not adequately controlled by phototherapy >0.7mg/dl/hr rate of rise To prevent >20mg/dl for term (less for pre-terms). Procedure: Order modified blood for transfusion and warm. The amount for each transfusion is 2x baby's blood volume, ~80-85ml/kg. -30 minutes prior to transfusion, albumin (1g/kg) can be administered to newborn to increase binding sites for conjugated bilirubin. -Blood should be administered either through a peripheral IV site and withdrawn through a UVC site; or administered through the UVC and withdrawn through a UAC. -Blood administration and withdrawal should be performed simultaneously if possible.

Therapeutic management pathological jaundice in the newborn

Treatment: Phototherapy Intravenous Gamma Globulin (IVIG) Exchange transfusion Goals: Reduce serum bilirubinemia Minimize consequences of hyperbilirubinemia Alleviate anemia Remove maternal antibodies and sensitized erythrocytes Increase serum albumin Supportive Lab work: Coombs (detects antibodies present destroying RBCs. Increased bilirubin indicates infection and/or Rh incompatibility) Serum bilirubinemia (total and direct) every 12 hours CBC with differential (Increased reticulocytes and/or sed rate suggest hemolytic disease Spherocytes suggest ABO incompatibility RBC fragments indicate DIC Infection indicated w/WBC<5000, increased bands (immature WBC) or decreased platelets)

Preterm alteration in thermogenesis

Unavailability of glycogen and brown fat High ratio of body surface area to body weight Little subcutaneous fat, which is insulation Thinner, more permeable skin Loses heat from blood vessels close to skin Extended position increases (exposed) body surface area, increasing heat loss Decreased ability to vasoconstrict superficial blood vessels & conserve heat in the core

Tetralogy of Fallot

Ventricular septal defect Pulmonary stenosis Misplaced aorta Thickened right ventricular wall Requires surgery to correct Heart muscle gets ginger/thicker because it is working too hard

Ears

When examining the placement of the newborn's ears, draw an imaginary line through the inner to the outer canthus of the eye. The eye should be set even with the upper tip of the pinna of the newborn's ear. Ears that are low set can indicate a chromosomal disorder such as Down's syndrome, or a renal disorder In term newborns, cartilage will be firm and well formed. Lack of cartilage indicates prematurity Newborn should respond to voices, especially mom, dad and siblings that they heard through mom's abdomen

Coarctation of the aorta

narrowing of the descending portion of the aorta, resulting in a limited flow of blood to the lower part of the body Usually required surgery to correct