Maternity Chapter 26

Drug Therapy

Few medications are necessary for newborn resuscitation. Even if an infant's respiratory depression appears to be related to the administration of a narcotic such as morphine or meperidine (Demerol) to the mother during labor, naloxone (Narcan), a drug to reverse the action of narcotics, should not be routinely administered because it has little effect and may cause seizures in a newborn Instead, resuscitation efforts should focus on effective ventilation and airway support for the persistently apneic newborn If heart rate continues to be inadequate (less than 60 beats/min), epinephrine 1:10,000 may be administered intravenously (IV) to stimulate heart action. Preterm infants may receive surfactant to replace the natural surfactant that has not yet formed in their lungs.

Airway

For a well, term newborn, usually warming, drying, and stimulating the baby by rubbing the back is enough to initiate respirations. A rubber bulb syringe is a standard piece of equipment in most birthing rooms and was often used in the past to suction infants' noses and mouths, but because bradycardia can be associated with bulb suctioning, routine suctioning of the nose and mouth is no longer recommended unless there is concern that the airway is obstructed If a newborn does not initiate spontaneous breathing following gentle stimulation, place the infant under a radiant heat warmer in a "sniffing" position (head slightly tipped back) and rub and dry his or her back and hair again to see if this additional stimulation initiates respirations. Assess a precordial pulse over the heart and attach a pulse oximeter to monitor oxygen saturation. It is reasonable to consider the application of a 3-lead cardiac monitor during resuscitation to obtain an accurate heart rate quickly A newborn whose amniotic fluid was meconium stained at birth but is breathing does not need suctioning to clear the airway. If the newborn whose amniotic fluid was meconium stained at birth presents with poor muscle tone and inadequate breathing, it is important to begin the initial steps of resuscitation under the warmer. Positive pressure ventilation should be initiated immediately if the newborn is not breathing or the heart rate is less than 100 beats/min In most newborns, this degree of resuscitation will initiate responsive respirations and a strong heartbeat (over 100 beats/min). Color, muscle tone, and reflexes will all improve. Mechanical suctioning should occur only if there is an obstruction such as a mucus plug that is interfering with effective breathing; otherwise, it may cause bradycardia An infant who still makes no effort at spontaneous respirations after these initial steps may require insertion of an endotracheal tube to be certain the airway is not obstructed so air can be effectively administered. If the heart rate or oxygen saturation levels remain low with air, oxygen may be administered to achieve a preductal oxygen saturation close to the interquartile range measured in healthy term infants after vaginal delivery In the first few seconds of life, a newborn this severely depressed may take several weak gasps of air and then almost immediately stop breathing; the heart rate begins to fall. This period of halted respirations is termed primary apnea. After 1 or 2 minutes of apnea (defined as a pause in respirations longer than 20 seconds with accompanying bradycardia), an infant again tries to initiate respirations with a few strong gasps. Most newborns, however, cannot maintain this effort longer than 4 or 5 minutes. After this, the respiratory effort will become weaker again and the heart rate will fall further until the newborn stops the gasping effort altogether. The infant then enters a period of secondary apnea. Although usually a phenomenon that occurs after birth, both types of apnea may occur in utero. During the period of first gasps, resuscitation attempts are generally successful. Once a newborn is allowed to enter a secondary apnea period, however, resuscitation becomes difficult and may be ineffective. Because it is impossible to distinguish between the two periods simply by observation, resuscitation must always be started as if secondary apnea is the phase occurring. A healthcare provider skilled in laryngoscope and endotracheal tube insertion should be present at the birth of all infants identified as high risk so a laryngoscope can be quickly inserted into the airway as necessary. Laryngoscope insertion is easy in theory; in practice, the wide variation in the size of infants' posterior pharynges and tracheas and the emergency conditions present under which it is attempted, make it an often difficult procedure Laryngoscopes are equipped with different-size blades; a size 0 or 1 should be available for newborns. Following insertion of the laryngoscope, an endotracheal tube is slid through the laryngoscope down into the trachea. Infants under 1,000 g need a 2.5-mm endotracheal tube (think of a thin coffee straw); those over 3,000 g need a 4.0-mm tube. Because preterm infants are prone to hemorrhage because of capillary fragility, gentle care during insertion is crucial.

CONTRASTS BETWEEN SMALL-FOR-GESTATIONAL-AGE AND PRETERM INFANTS

Gestational age SGA: 24-44 wk Preterm: <37 wk Birth weight SGA: <10th percentile Preterm: Normal for age Congenital malformations SGA: Strong possibility Preterm: Possibility Pulmonary problems most apt to occur SGA: Meconium aspiration, pulmonary hemorrhage, pneumothorax Preterm: Respiratory distress syndrome Hyperbilirubinemia SGA: Possibility Preterm: Very strong possibility Hypoglycemia SGA: Very strong possibility Preterm: Possibility Intracranial hemorrhage SGA: Strong possibility Preterm: Possibility Apnea episodes SGA: Possibility Preterm: Very strong possibility Feeding problems SGA: Most likely because of accompanying problem such as hypoglycemia Preterm: Small stomach capacity; immature sucking reflex Weight gain in nursery SGA: Rapid Preterm: Slow Future restricted growth SGA: Possibly always be <10th percentile because of poor organ development Preterm: Not likely to be restricted in growth because "catch-up" growth occurs

Therapeutic Management (RDS)

Surfactant Replacement Oxygen Administration Ventilation Additional Therapy: Nitric Oxide Extracorporeal Membrane Oxygenation Supportive Care

High-Risk Infants and Child Maltreatment

When a child is born ill or preterm, the expected reaction of parents would be to protect the infant even more than the healthy infant so no further harm could occur. In actuality, particularly in reference to the preterm infant, the opposite may occur. Probably related to the feeling they are "different" or because they were separated from the parents for a long time following birth, the preterm infant may be at an increased risk for maltreatment

Being able to predict if an infant is at high risk allows for

advanced preparation so that specialized, skilled healthcare personnel can be present at the child's birth to perform necessary interventions, such as resuscitating a newborn who has difficulty establishing respirations. Immediate, skilled handling of any problems that occur may help to save the newborn's life and also prevent future problems, such as neurologic disorders

Nursing Care of a Family With a High-Risk Newborn (the nursing process)

assessment nursing diagnosis outcome identification and planning implementation outcome evaluation

Unfortunately, not all instances of high risk can be predicted during pregnancy or birth because

even a newborn from a "perfect" pregnancy may require specialized care or may develop a problem over the first few days of life, necessitating special interventions. Any infant, especially one who is born dysmature (a newborn whose birth weight is inappropriately low for gestational age), whether preterm, term, or postterm, is at risk for complications at birth or in the first few days of life. Parents need a thorough explanation of their baby's health because these problems may require rehospitalization or additional follow-up at home. Because preterm birth, in particular, has the potential for leading to high-risk newborns, several 2020 National Health Goals directly concern preterm births

Nurses can help the nation achieve these goals by

teaching women the symptoms of preterm labor so that, ideally, birth can be delayed until infants reach term. Nurses also need to be prepared for resuscitation at birth for high-risk infants and to plan developmental care that can help prevent conditions such as apnea, intraventricular hemorrhage, and periventricular leukomalacia.

During pregnancy, screening women for risk factors such as

younger or older than average maternal age, having concurrent disease conditions such as diabetes or HIV infection, experiencing pregnancy complications such as placenta previa, or an unhealthy maternal lifestyle such as drug abuse—all of which could lead to illness in a newborn—is essential to identify infants who may need greater than usual care at birth

2020 National Health Goals for Nursing Care of a Family With a High-Risk Newborn

A preterm birth has the potential for leading to so many complications in newborns that several 2020 National Health Goals were written specifically concerning preterm birth: Reduce low birth weight (LBW) to an incidence of no more than 7.8% of live births and very low birth weight (VLBW) to an incidence of no more than 1.4% of live births from baselines of 8.2% and 1.5%, respectively. Increase the proportion of VLBW infants born at level III hospitals or subspecialty perinatal centers from a baseline of 76.1% to a target level of 83.7%. Reduce the rate of fetal and infant deaths during the perinatal period (28 weeks of gestation to 7 days or more after birth) to 5.9 per 1,000 live births from a baseline of 6.6 per 1,000 live births. Reduce the rate of deaths from sudden infant death syndrome (SIDS) to 0.5 per 1,000 live births from a baseline of 0.55 per 1,000 live births

Resuscitation

Approximately 10% of newborns require some assistance to begin breathing at birth in order to assure newborn resuscitation can be consistent from infant to infant and one facility to the next, the American Academy of Pediatrics (AAP) has instituted a Neonatal Resuscitation Program updated at intervals that lists steps and rationales for newborn resuscitation Based on these recommendations, resuscitation should follow an organized process: (a) Establish an airway (b) expand the lungs (c) initiate and maintain effective ventilation. If respiratory depression becomes so severe that a newborn's heart begins to fail (heart rate is less than 60 beats/min) despite effective positive pressure ventilation, resuscitation should then also include chest compressions

Developmental Care

Developmental care is care individually designed based on a preterm infant's behavioral cues to meet the special needs of a preterm or newborn infant. Common measures include: PARENT WELCOMING PROCEDURES Make parents feel welcome in a neonatal intensive care environment by both words and actions. Provide room around incubators or warmers for rocking chairs so parents can hold their baby comfortably. Encourage parent participation in feeding or supplying nonnutritive sucking experiences. Demonstrate the infant's capabilities and how, although immature, these are correct for the infant's age or weight. Keep parents informed of their baby's progress and the rationale for therapies. Ask parents for input into their baby's rhythm of care that will best suit them and the infant after they return home. INFANT DEVELOPMENTAL PROCEDURES Provide a consistent routine to help the infant develop sleep/wake cycles. Time infant care and feeding based on the sleep/wake cycle of the infant. Cluster aspects of care so the infant enjoys the longest possible sleep intervals to conserve energy. Provide a "nest" with blankets to offer a sense of boundaries or security. Position infants so they can self-soothe—curled on side, or hands near face, knees tucked near body, or whatever way each baby seems to prefer. Provide quiet or rest times by covering an incubator and limiting sound. Provide tactile stimulation by back stroking or massage. Provide audio and visual stimulation by the use of mobiles and music or a parent's voice. Halt procedures as soon as the infant evidences stress.

THE PRETERM INFANT

A preterm infant is traditionally defined as a live-born infant born before the end of week 37 of gestation. In terms of the degree of care needed, they are further divided into late preterm (born between 34 and 37 weeks) and early preterm (born between 24 and 34 weeks). Neonatal assessments such as inspection for sole creases, skull firmness, ear cartilage, and neurologic development plus the mother's report of the date of her last menstrual period along with a sonographic estimation of age all can be helpful to determine gestational age. Preterm birth occurs in approximately 11% of live births worldwide, with the United States having one of the highest rates of preterm births Most preterm infants need intensive care from the moment of birth to give them their best chance of survival without neurologic aftereffects because they are more prone than others to hypoglycemia and intracranial hemorrhage. Lack of lung surfactant, because this does not form until about the 34th week of pregnancy, makes them extremely vulnerable to respiratory distress syndrome No matter what their weight, the initial assessment needs to differentiate healthy preterm babies from SGA babies (who also may have a low birth weight but have more possibility of being unhealthy and so require more help to adjust to extrauterine life). In contrast to an SGA infant, a preterm infant appears immature and has a low birth weight but is well proportioned for age because the baby appears to have been doing well in utero. For an unexplained reason, however, the trigger that initiates labor was activated too early and birth resulted even though the baby was not yet mature.

Acute Bilirubin Encephalopathy

Acute bilirubin encephalopathy (ABE) is the destruction of brain cells by invasion of indirect or unconjugated bilirubin This invasion results from the high concentration of indirect bilirubin that forms in the bloodstream from an excessive breakdown of red blood cells at birth. Preterm infants are more prone to this condition than term infants because, with the acidosis that occurs from poor respiratory exchange, brain cells appear to be more susceptible to the effect of indirect bilirubin than usual. Preterm infants also have less serum albumin available to bind indirect bilirubin and inactivate its effect. Because of this, ABE may occur at lower levels in these infants than in term newborns At the point that indirect bilirubin levels rise and jaundice occurs, phototherapy or exchange transfusion can be initiated to prevent excessively high indirect bilirubin levels.

MAINTAINING FLUID AND ELECTROLYTE BALANCE

After an initial resuscitation attempt, hypoglycemia (decreased blood glucose) often results from the effort the newborn expended to begin breathing. Dehydration may also result from increased insensible water loss caused by rapid respirations. Infants with hypoglycemia are treated initially with intravenous 10% dextrose in water to restore their blood glucose level. Fluids such as a dilute mixture of saline and dextrose in water are commonly used to maintain glucose and fluid levels and electrolytes. Sodium, additional glucose, and potassium are added as needed according to electrolyte laboratory results. Be certain to monitor the rate of fluid administration conscientiously in high-risk newborns because a high fluid intake can lead to fluid overload, resulting in a patent ductus arteriosus or heart failure. When using a radiant warmer, remember there is a tendency for water loss from either convection or radiation. A newborn on a warmer, therefore, may require more fluid than if he or she were placed in a double-walled incubator. Monitor fluid status both by urine output and urine specific gravity values. An output less than 2 ml/kg/hr or a specific gravity greater than 1.015 to 1.020 suggests inadequate fluid intake. If hypovolemia is present immediately after birth, the cause is usually fetal blood loss from a condition such as placenta previa (see Chapter 21) or twin-to-twin transfusion. With hypovolemia, typically tachypnea, pallor, tachycardia, decreased arterial blood pressure, decreased central venous pressure, and decreased tissue perfusion of peripheral tissue, with a progressively developing metabolic acidosis, will develop The hematocrit may be normal for some time after acute blood loss, however, because blood cells present are in proportion to plasma. An isotonic solution (usually normal saline) may be administered to increase blood volume. A vasopressor such as dopamine may be given to increase blood pressure and improve cell perfusion.

REGULATING TEMPERATURE

All high-risk infants may have difficulty maintaining temperature because, in addition to stress from an illness or immaturity, the infant's body is often exposed for long periods during procedures such as resuscitation. It's important to keep newborns in a neutral-temperature environment, one that is neither too hot nor too cold because doing so places less demand on them to maintain a minimal metabolic rate necessary for effective body functioning. If their environment becomes too hot, they are forced to decrease metabolism to cool their body. If it becomes too cold, they must increase their metabolism to warm body cells. Increased metabolism can be destructive because it calls for increased oxygen, and without this oxygen available because of respiratory difficulty, body cells become hypoxic. to spare oxygen for essential body functions, vasoconstriction of peripheral blood vessels occurs so blood can be pushed into the central torso. If this process continues for too long a time, pulmonary vessels constrict and pulmonary perfusion decreases. The infant's PO2 level will fall and PCO2 will increase. As mentioned previously, a lowered PO2 level causes fetal shunts such as the ductus arteriosus to remain open. Surfactant production in the lungs can halt as well, further interfering with lung function To supply glucose to maintain increased metabolism, an infant has to resort to anaerobic glycolysis, which pours acid into the bloodstream. As the infant becomes more and more acidotic, the risk of acute bilirubin encephalopathy or kernicterus (the accumulation of unconjugated bilirubin into brain cells) increases as more bilirubin-binding sites are lost and more bilirubin is free to pass out of the bloodstream in brain cells. In short, because of becoming chilled, heart action, breathing, electrolytic balance, and possibly brain function all become compromised. In addition to covering the newborn with an infant cap, wiping the body and head dry with a towel or blanket, and using a radiant warmer or prewarmed incubator (Fig. 26.4), suggest skin-to-skin contact with one of the parents. Additional measures that can be used to ensure the infant's temperature stays between 36.5°C and 37.5°C (97.8°F and 99.5°F) axillary are plastic wrap, increasing the room temperature, and warmed mattresses. To prevent heat loss, be certain during any procedure that the infant is not placed on a cool X-ray table or scale.

assessment

All infants need to be assessed at birth for obvious congenital anomalies and gestational age (number of weeks the newborn remained in utero). Both determinations can be done by the nurse who first examines an infant. Be certain such a first assessment is done under a prewarmed radiant heat warmer to guard against heat loss. Continuing assessment of high-risk infants involves the use of technology and equipment such as cardiac, apnea, oxygen saturation, and blood pressure monitoring. Regardless of how many monitors are used, they do not replace the role of frequent, close, common sense observations by a nurse who knows an infant well from having cared for the baby consistently over time because such a nurse often senses changes before a monitor or other equipment begins to put a quantitative measurement on the change. Carefully evaluate comments from fellow nurses such as an infant "isn't himself" or "breathes irregularly." These comments, although not evidence based, are the same observations that parents who know their baby well report at healthcare visits.

Newborn Priorities in the First Days of Life

All newborns have a number of needs in the first few days of life that take priority. They include: -Initiation and maintenance of respirations -Establishment of extrauterine circulation -Maintenance of fluid and electrolyte balance -Control of body temperature -Intake of adequate nourishment -Establishment of waste elimination -Prevention of infection -Establishment of an infant-parent/caregiver relationship -Institution of developmental care or care that balances physiologic needs and stimulation for best development These same needs are also the primary needs of high-risk newborns. Because of small size or immaturity or illness, however, fulfilling these needs may require special equipment or care measures. Not all newborns will be able to achieve full wellness because of extreme insults to their health during pregnancy or at birth or difficulty adjusting to extrauterine life. Indications a newborn is having difficulty making the immediate transition from intrauterine to extrauterine life may be first apparent by a low Apgar score rating

Assessment (preterm)

Although a detailed pregnancy history may sometimes reveal the reason for a preterm birth, the pregnancy history is often normal up to the beginning of labor. When interviewing parents of a preterm infant, be careful not to convey disapproval of reported pregnancy behaviors such as cigarette smoking that may have contributed to preterm birth. Once an infant is born, a new mother needs a high level of self-esteem and all of her inner resources to sustain her through this crisis and not be burdened by guilt over what should or could have been. An accurate but comforting answer to a direct inquiry about why preterm birth occurs is, "No one really knows what causes prematurity." Observing a number of physical findings and reflex testing is used to differentiate between term and preterm newborns at birth On gross inspection, a preterm infant's head appears disproportionately large (≥3 cm greater than chest size). The skin is generally unusually ruddy because there is so little subcutaneous fat beneath it, making veins easily noticeable; a high degree of acrocyanosis may be present. Newborns delivered at greater than 28 weeks of gestation are typically covered with vernix caseosa. In very preterm newborns, however (less than 28 weeks of gestation), the vernix will be lacking. Lanugo is usually scant the same way in very low gestation infants but will be extensive, covering the back, forearms, forehead, and sides of the face in late preterm babies. Both anterior and posterior fontanelles will be small. There are few or no creases on the soles of the feet The eyes of most preterm infants appear small in relation to term infants. Although difficult to elicit, a pupillary reaction is present. An ophthalmoscopic examination is extremely difficult and often uninformative because the vitreous humor may be hazy. A preterm infant has varying degrees of myopia (nearsightedness) because of a lack of eye globe depth. The ears appear large in relation to the head. The cartilage of the ear is immature and allows the pinna to fall forward. The level of the ears should be carefully inspected to rule out chromosomal abnormalities Neurologic function in the preterm infant is often difficult to evaluate because the neurologic system is still immature. Observing the infant make spontaneous or provoked muscle movements can be as important as formal reflex testing. If they are tested, reflexes such as sucking with coordinated swallowing and breathing will be absent if an infant's age is below 33 weeks; deep tendon reflexes such as the Achilles tendon reflex will also be markedly diminished. During an examination, a preterm infant is much less active than a mature infant and rarely cries. If the infant does cry, the cry is weak and high pitched.

ESTABLISHING EXTRAUTERINE CIRCULATION

Although establishing respirations is the first priority at a high-risk infant's birth, lack of cardiac function may be present concurrently or may develop if respiratory function cannot be quickly initiated and maintained. If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats/min, chest compressions should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both thumbs on the lower third of the sternum, approximately one third of its depth (1 or 2 cm) at a rate of at least 100 times per minute Lung ventilation at a rate of 30 times per minute should be coordinated with chest compressions at a rate of 90 compressions per minute at a ratio of three compressions to one ventilation. If a newborn's heart rate is greater than 60 but less than 100 beats/min, chest compressions can be stopped but ventilations should be continued. Ensuring adequate ventilation is the major priority and should continue until the heart rate is greater than 100 beats/min. Continue to monitor pulse oximetry to evaluate respiratory function and cardiac efficiency. If the pressure and the rate of chest compressions used are adequate, it should be possible, in addition, to palpate a femoral pulse. If the heartbeat is not above 60 beats/min after at least 30 seconds of coordinated positive-pressure ventilation and chest compressions, intravenous epinephrine to stimulate heart action may be prescribed Following cardiopulmonary resuscitation, newborns should be transferred to a transitional or high-risk nursery for continuous cardiorespiratory observation and care to be certain cardiac function is maintained.

ESTABLISHING WASTE ELIMINATION

Although most immature infants void within 24 hours of birth, they may void later than term newborns because, as a result of all the procedures for resuscitation, their blood pressure may not be adequate to optimally supply their kidneys. Carefully document any voidings that occur during resuscitation because this is proof that hypotension is improving and the kidneys are being perfused. Immature infants also may pass stool later than the term infant because meconium has not yet reached the end of the intestine at birth.

THE SMALL-FOR-GESTATIONAL-AGE INFANT

An infant is SGA (also called microsomia) if the birth weight is below the 10th percentile on an intrauterine growth curve for that age. Such infants may be born: -Preterm: before week 38 of gestation -Term: between weeks 38 and 42 -Postterm: past 42 weeks SGA infants are small for their age because they have experienced intrauterine growth restriction (IUGR) or failed to grow at the expected rate in utero. This characteristic makes them distinctly different from infants who are born with a less weight than usual but their low weight is consistent for their gestational age.

Etiology

At least 50% of neonatal deaths are preterm. Infant mortality could be reduced dramatically if the causes of preterm birth could be discovered and corrected and all pregnancies could be brought to term. However, even with the examples of possible causes listed in the following, the exact cause of premature labor and early birth is rarely exactly known. Important among these is a high correlation between low socioeconomic level and early birth. In women from middle and upper socioeconomic groups, for example, only 4% to 8% of pregnancies are not carried to term. In women from low socioeconomic levels, as many as 10% to 20% end before term Risk factors associated with preterm birth include inadequate nutrition and smoking or alcohol use. The increasing use of assisted fertility methods that result in multiple births, such as in vitro fertilization, is another reason preterm births can occur because more multiple pregnancies result in preterm birth than term pregnancies Iatrogenic (health-care-caused) issues, such as elective cesarean birth or inducing labor before 39 weeks of pregnancy (which is not recommended but sometimes necessary because of maternal illness or fetal reasons), also result in early births.

outcome identification and planning

Be certain when establishing expected outcomes that they are consistent with a newborn's potential. A goal that implies complete recovery from a major illness, for example, may be unrealistic for one newborn but completely appropriate for another. Be certain plans for care are individualized considering a newborn's developmental level as well as physiologic strengths, weaknesses, and needs. Many families of a high-risk newborn will need support to care for their infant at home and therefore may need a referral to a home health care or other agency. Direct patients to helpful websites and other resources when appropriate

Potential Complications

Because of immaturity, preterm infants are prone to several specific conditions.

Persistent Patent Ductus Arteriosus

Because preterm infants may lack surfactant, their lungs are noncompliant, so it is more difficult for them to move blood from the pulmonary artery into the lungs. This condition leads to pulmonary artery hypertension, which then interferes with closure of the ductus arteriosus. Always administer intravenous therapy cautiously to preterm infants, therefore, because increasing blood pressure could further compound this problem. In term infants, indomethacin or ibuprofen may be used to cause closure of a patent ductus arteriosus, making ventilation more efficient; however, indomethacin is given cautiously to preterm infants because it has been associated with adverse effects such as decreased renal function, decreased platelet count, and gastric irritation Carefully monitor urine output and observe for bleeding, especially at injection sites, if this is prescribed.

Follow-Up of the High-Risk Infant at Home

Each time parents visit a special/intensive care nursery, assess their level of knowledge about their child's condition and development. For parents whose child has a complex concern, additional education and referral to a home care agency may be necessary to help them continue with the level of care required when the infant is discharged home Before discharge, the safety of their home for the care of an infant that has healthcare needs (physical or developmental) should be evaluated. Transporting a preterm infant in a car, for example, will require special measures, including a commercial head support because a very small infant does not fit securely into a standard infant car seat. Although not well documented regarding when or why it occurs, some preterm infants experience episodes of oxygen desaturation, apnea, or bradycardia when seated in standard car safety seats. To detect if this will occur, the AAP recommends all preterm infants be assessed for cardiorespiratory stability in their car seat prior to discharge from the healthcare facility—the "car seat challenge"

outcome evaluation

High-risk newborns need long-term follow-up so any consequences of their birth status, such as minimal neurologic injury, can be identified, and arrangements for special schooling or counseling can be made. Examples of expected outcomes include: Infant maintains a patent airway. Infant demonstrates an ability to suck effectively. Infant tolerates procedures without accompanying apnea, bradycardia, or oxygen desaturation. Infant demonstrates growth and development appropriate for gestational age, birth weight, and condition. Infant maintains a body temperature of 98.6°F (37.0°C) in an open crib with one added blanket. Parents visit at least once and make three telephone calls to the neonatal nursery weekly. Parents demonstrate positive coping skills and behaviors in response to the newborn's condition and ability to care for their newborn.

ANTICIPATING DEVELOPMENTAL NEEDS

High-risk newborns need special care to ensure the amount of pain they experience during procedures is limited to the least amount possible and that they also receive adequate stimulation for growth. Most high-risk infants experience "catch-up" growth once they stabilize from the trauma of birth or whatever caused them to be considered high risk. They quickly move to playing with age-appropriate toys and interacting with parents. Some parents may need support before and after their infant is discharged home so they can begin to view their child as well and capable of doing all the things the infant is now capable of doing. Discussing usual growth and development of infants can help prepare them and look forward to the next developmental step.

The Newborn at Risk Because of Altered Gestational Age or Birth Weight

Infants need to be evaluated as soon as possible after birth to determine their weight, height, head circumference, and gestational age to determine their immediate healthcare needs and to help anticipate possible future problems. Birth weight is normally plotted on a growth chart such as the Colorado (Lubchenco) Intrauterine Growth Chart, a special chart for newborns Term infants are those born after the beginning of week 38 and before week 42 of pregnancy (calculated from the first day of the last menstrual period). Approximately 90% of all live births fall into this category. Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants regardless of their birth weight. nfants born after the end of week 41 of pregnancy are classified as postterm infants or postmature Normally, birth weight increases for each additional gestational week of age. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small for gestational age (SGA). Those who fall above the 90th percentile in weight are considered large for gestational age (LGA). Other terms used include: Low-birth-weight (LBW) infant: one weighing less than 2,500 g at birth Very-low-birth-weight (VLBW) infant: one weighing less than 1500 g at birth Extremely-low-birth-weight (ELBW) infant: one weighing less than 1,000 g at birth Infants in all of these classifications have immediate needs that are different from or that are more pronounced than the needs of AGA term newborns. Each of these categories also carries its own set of potential risks.

ESTABLISHING ADEQUATE NUTRITIONAL INTAKE

Infants who experienced severe asphyxia at birth usually receive intravenous fluids so they do not become exhausted from sucking or until necrotizing enterocolitis has been ruled out, which can result when there is a temporary reduction of oxygen to the bowel If an infant's respiratory rate remains so rapid that the infant cannot suck effectively, gavage feedings may be introduced Others with a long-term nutrition concern may have gastrostomy tubes placed. Preterm infants should be fed breast milk if at all possible because of the immune protection this offers If breastfeeding is not possible because the infant is too immature to suck effectively, a mother can manually express breast milk or use a breast pump to initiate and continue her milk supply until the time the infant is mature enough or otherwise ready to breast feed. Her expressed breast milk can then be used in the infant's gavage feeding Be certain when bottled breast milk is supplied by the mother that it is well marked with the infant's name, date and time it was pumped, and medical record number or breast milk errors can occur the same as medication errors It should be stored in polycarbonate- (bisphenol A) free plastic bags or bottles, which can leech into stored milk and possibly lead to endocrine disruptions Preterm infants reveal hunger by the same signs as term infants, such as rooting, crying, and sucking motions. All babies who are gavage or gastrostomy fed need oral stimulation from nonnutritive sucking and so seem to enjoy a pacifier at feeding times In immature infants, this may actually help them develop an effective sucking reflex. In mature infants, pacifier use has also been shown to be a deterrent to sudden infant death syndrome xceptions to pacifier use are for infants too immature to have a sucking reflex; infants who must not swallow air, such as those with a tracheoesophageal fistula awaiting surgery; or infants mature enough to breastfeed.

PREVENTING INFECTIONS

Infections in high-risk newborns may occur from prenatal, perinatal, or postnatal causes. In some instances, such as preterm premature rupture of the membranes, the risk of adverse neurodevelopmental outcomes from the infection is what places the infant in a high-risk category Contracting an infection has the potential to drastically complicate a high-risk newborn's ability to adjust to extrauterine life, another reason breastfeeding is good for such infants because, beginning with colostrum, it supplies important immune protection Infection, like chilling, has the detrimental effect of increasing metabolic oxygen demands as well as stressing an immature immune system, thus lowering defense mechanism protection. Common viruses that affect infants during intrauterine life are cytomegalovirus and toxoplasmosis virus. An infant born after contracting either of these infections may be born with congenital anomalies from the virus invasion The most prevalent perinatal infections are those contracted from the vaginal canal during birth such as herpes simplex 2 and hepatitis B. Early-onset sepsis is most commonly caused by group B streptococcus, Escherichia coli, Klebsiella (a gram-negative rod that causes pneumonia), and Listeria monocytogenes (a gram-positive bacteria associated with nausea, vomiting, and possibly meningitis). Late-onset, or hospital-acquired, infections are more commonly caused by Staphylococcus aureus, Enterobacter, and Candida. Late-onset infections are probably most commonly spread to newborns from healthcare personnel, which is the reason all persons coming in contact with or caring for infants must observe good hand washing techniques and standard precautions to reduce the risk of infection transmission. Healthcare personnel with infections have a professional and moral obligation to refrain from caring for newborns or wear protective measures such as a face mask to avoid spreading infections.

implementation

Interventions for any high-risk newborn are best carried out by a consistent caregiver and should focus on conserving the baby's energy and providing a thermoneutral environment to prevent exhaustion and hypothermia. Painful procedures should be kept to a minimum to help the infant achieve a sense of comfort and balance. Assisting parents to participate in care such as bathing or feeding their infant can help make the child real to them for the first time and can set the stage for effective bonding.

ESTABLISHING PARENT-INFANT BONDING

It is helpful if all women who are diagnosed as having a high-risk pregnancy are offered a tour of a neonatal intensive care unit (NICU) during pregnancy, so if their infant should be admitted to a NICU, they will be more comfortable in the high-tech environment. Be certain the parents of a high-risk newborn are kept informed of what is happening during resuscitation at birth. They should be able to visit the special nursing unit where the infant is admitted as soon as possible and as often as they choose, and, after washing their hands and in some situations wearing a gown, hold and touch their infant, both of which are actions that help make the infant's birth more real to them. Should an infant not survive an initial illness, these interactions can also help make the death more real and can help parents work through their feelings to accept this event. Most parents handle newborn babies tentatively until they have "claimed" them or have become firmly acquainted. If an infant was ill at birth, it may take days or weeks before the parents are able to handle their baby comfortably and confidently because of the number of tubes involved in care and their fear of doing something that could hurt the infant. Urge parents to spend as much time with their infant in the intensive care nursery as possible, especially as the infant is improving and is able to begin interacting with them. Be certain parents have continuing access to healthcare personnel after discharge so they can care confidently for the infant at home. If an infant dies despite newborn resuscitation attempts, parents need to see the infant when no longer attached to equipment. Viewing the baby can help reassure them the baby was a perfect newborn in every other way except lung function or whatever was the infant's specific fatal disorder. Believing this is one way they may be able to develop confidence to plan for other children or simply to continue their lives after such a devastating experience.

GUIDELINES FOR PARENTS OF A NEWBORN IN INTENSIVE CARE

Learn the name of your child's primary healthcare provider and primary nurse or care manager. Make a point of talking to them when you visit so the information you receive is consistent and so these important people can get to know you. Discuss with your child's primary nurse the time you will usually visit so she or he can schedule your baby's procedures and rest times other than when you visit so there is time for you to hold your child and interact with him uninterrupted. Ask for explanations of any equipment or medications being used with your child so you understand the plan of care. Insist on being included in care decisions. The nurses are always nearby and will be happy to explain what can be touched and moved and what should be left alone for now. Any day you are unable to visit, call the nursery and ask to talk to your child's primary care nurse. Such telephone calls are not viewed as a bother but are welcomed as the mark of a concerned parent. Ask if you can supply expressed breast milk for your infant as soon as feedings are started so you can feel you're having a greater part in your baby's care. You might supply a tape recording of your voice so your baby can learn to recognize it, as well as supply a small toy for your baby's bed. These actions not only supply auditory and visual stimulation for your infant but also help to give you a more "normal" feeling toward infant care. Use your baby's name when you talk about him (not "the baby") to help you gain a firm feeling that this is your baby, not the nursery's. If your child is hospitalized a distance from home, ask if transfer to a local hospital in a less technical environment will be possible as soon as he's not so ill.

Factors Predisposing Infants to Respiratory Difficulty in the First Few Days of Life

Low birth weight Intrauterine growth restriction Maternal history of diabetes Premature rupture of membranes Maternal use of barbiturates or narcotics close to birth Meconium staining Irregularities detected by fetal heart monitor during labor Cord prolapse Lowered Apgar score (<7) at 1 or 5 minutes Postmaturity (postterm) Small for gestational age Breech birth Multiple birth Chest, heart, or respiratory tract anomalies

Common Factors Associated With Preterm Birth

Low socioeconomic level Poor nutritional status Lack of prenatal care Multiple pregnancy Previous early birth Race (non-Whites have a higher incidence of prematurity than Whites) Cigarette smoking Age of the mother (highest incidence is in mothers younger than age 20 years) Order of birth (early birth is highest in first pregnancies and in those beyond the fourth pregnancy) Closely spaced pregnancies Abnormalities of the mother's reproductive system, such as intrauterine septum Infections (especially urinary tract infections) Pregnancy complications, such as premature rupture of membranes or premature separation of the placenta Early induction of labor Elective cesarean birth

Anemia of Prematurity

Many preterm infants develop a normochromic, normocytic anemia (normal cells, just few in number), which can make infants appear pale, lethargic, and anorectic. Anemia occurs from a combination of immaturity of the hematopoietic system (the effective production of red cells with an elevated reticulocyte count may not begin until 32 weeks of pregnancy) combined with the destruction of red blood cells because of low levels of vitamin E, a substance that normally protects red blood cells against oxidation. Excessive blood drawing for electrolytes, complete blood counts, or blood gas analysis after birth can potentiate the problem. For this reason, it's important to see that blood draws in preterm infants are coordinated to the fewest possible and a record of the blood loss for these tallied. Delaying cord clamping at birth to allow a little more blood from the placenta to enter the infant may also help reduce the development of anemia

Incubators

Newborns needing both warmth and visual observation may also be cared for in incubators. By placing the baby in such a steady, warm environment, the need for clothing can be eliminated, so the observation for any respiratory difficulty, possible color changes, or unusual movements (such as seizures) can be readily observed. The temperature of incubators varies with the amount of time portholes remain open and the temperature of the area in which the incubator is placed. Placing one in direct sunlight or near a warm radiator, for example, can increase the internal temperature markedly. Placing it near a cold window can decrease the temperature. For these reasons, a newborn's temperature must be assessed at frequent intervals when in an incubator to be certain the temperature level designated is being maintained. Use of an additional acrylic shield inside the incubator helps prevent radiation and convection heat loss when portholes are opened and may be necessary for very immature infants. Similar to radiant warmers, some incubators have servo control mechanism units that monitor the infant's temperature once the probe is placed on their abdomen and automatically changes the temperature of the incubator as needed. Portholes must remain closed to keep the servo control operating efficiently. As infants become both medically stabile and old enough to maintain a steady body temperature, they can be weaned from an incubator. Dress the infant as if he or she were going to be in a bassinet and then set the incubator about 2°F (1.2°C) below the infant's temperature. After a half hour, assess whether the infant is able to maintain body temperature. If so, lower the incubator temperature another 2°F and continue until room temperature is reached. If an infant cannot maintain adequate temperature as the incubator temperature level is lowered, it suggests the infant is not yet ready for room-temperature air, and the weaning process should be slowed or stopped until the baby is more mature or better able to self-regulate temperature.

Lung Expansion

Once an airway has been established, a newborn's lungs need to be expanded. Well newborns inflate their lungs adequately independently with a first breath. The sound of the baby crying loudly is proof that lung expansion is good because the vocal sounds are produced by a free flow of air over the vocal cords. If an infant needs air or oxygen by bag and mask to aid lung expansion, be certain the mask covers both the mouth and the nose. However, it is important to make sure it doesn't cover the eyes because eye injury could occur from either pressure of the mask on the eyes or from drying of the cornea from air or oxygen administration. Air (or oxygen if needed) should be administered at a rate of 40 to 60 ventilations per minute. To prevent unnecessary cooling or drying, the oxygen that is administered should be both warmed (between 89.6° and 93.2°F [32° and 34°C]) and humidified (60% to 80%). The pressure needed to open lung alveoli for the first time can be as high as 40 cm H2O. After that, pressures of 15 to 20 cm H2O are generally adequate to continue inflating alveoli The pressure from anesthesia bags is controlled solely by the pressure a healthcare provider uses when the hand squeezes against the bag. Other types of bags such as the self-inflating (Ambu) bag can be set with a blow-off valve that limits the pressure in the apparatus to be certain only gentle pressure is applied It is important not to let oxygen levels in a newborn fluctuate greatly because fluctuation can cause bleeding from immature cranial vessels. In addition, applying pressure above what is necessary could rupture lung alveoli. If adequate ventilation is not achieved, however, a newborn stands little chance of survival. To be certain air is reaching the lungs with resuscitation, monitor the newborn's oxygen saturation with pulse oximetry in addition to auscultating the chest for the sounds of air movement Be certain to listen to both lungs to verify both lungs are being aerated. If air can be heard on only one side or sounds are not symmetric, the endotracheal tube is probably at or below the bifurcation of the trachea (where the trachea splits into the left and right main-stem bronchi) and the tube is likely blocking the air from entering one of the main-stem bronchi. Pulling the tube back half a centimeter will usually allow oxygen to flow to both lungs Correct placement of the endotracheal tube in the trachea and not the esophagus can be confirmed by a CO2 monitor (no CO2 will return if the tube is in the esophagus) immediately after insertion. An X-ray will confirm proper placement and depth in the trachea. When air is given under pressure to a newborn this way, the stomach also quickly fills with air. If the resuscitation has continued for over 2 minutes, insert an orogastric tube (through the mouth to the stomach instead of through the nose to the stomach because babies are obligate nose breathers). Leaving the distal end open helps deflate the stomach, which allows for better ventilation of the lungs and decreases the possibility that vomiting and aspiration of stomach contents from overdistention will occur.

Skin-to-Skin Care

Originally referred to as kangaroo care, skin-to-skin care is the use of skin-to-skin contact with a parent to maintain body heat. Provide a quiet setting with lights dimmed. Undress the infant except for a diaper and a cap. Assist the parent to sit comfortably in a chair and hold the infant snugly against his or her unclothed chest, skin to skin. Place a blanket over the infant for added warmth. This method of care not only supplies heat but also encourages parent-child bonding

Other Potential Complications

Preterm infants are also particularly susceptible to several illnesses in the early postnatal period, which can also occur in term infants, including respiratory distress syndrome, apnea, and retinopathy of prematurity (all discussed later in this chapter), as well as necrotizing enterocolitis

Periventricular/Intraventricular Hemorrhage

Preterm infants are prone to periventricular hemorrhage (bleeding into the tissue surrounding the ventricles) or intraventricular hemorrhage (bleeding into the ventricles) because of fragile capillaries and immature cerebral vascular development. When there is a rapid change in cerebral blood pressure, such as could occur with hypoxia, intravenous infusion, ventilation, or pneumothorax (lung collapse), capillary rupture could occur; brain anoxia then occurs distal to the rupture. Intraventricular hemorrhage occurs most often in VLBW infants and is classified as: Grade 1, bleeding in the periventricular germinal matrix regions or germinal matrix, occurring in one ventricle Grade 2, bleeding within the lateral ventricle without dilation of the ventricle Grade 3, bleeding causing enlargement of the ventricles Grade 4, bleeding in the ventricles and intraparenchymal hemorrhage A long-term effect of hemorrhage may be the development of hydrocephalus if there was bleeding into the narrow aqueduct of Sylvius Preterm infants usually have a cranial ultrasound performed after the first few days of life and again at different intervals based on the gestational age of the infant to detect if a hemorrhage has occurred. Infants with grade 1 or 2 bleeds have a good long-term prognosis; the prognosis of those with more intense bleeds is guarded until further complications are ruled out

Radiant Heat Sources

Radiant heat warmers are open beds that have an attached overhead source of radiant heat and provide both warmth and visibility for observation. Such units have small probes, covered by a small shield, often silver metallic, which when placed on the baby's skin, register the baby's temperature. Abdominal skin temperature, when measured this way, should be 95.9° to 97.7°F (35.5° to 36.5°C). If an infant's temperature falls below this level, an alarm on the unit can be set to sound. Be certain, with the infant laying on his or her back, you tape the probe or disk onto the infant's abdomen between the umbilicus and the xiphoid process. Do not tape it on the underside of an infant or it will register a falsely high reading. Be certain as well it is not over the liver because the heat generated by the liver can lead to false high readings or over the rib cage where the thin subcutaneous tissue and ribs are also apt to yield an inaccurate reading. When performing care or leaning over the infant, be careful your head does not block the heat from the overhead source so it no longer reaches the baby. An additional warming pad placed under an infant may be necessary for very preterm infants or for lengthy procedures to maintain body heat.

nursing diagnosis

To establish nursing diagnoses for high-risk infants, it is important to be aware of the usual parameters of newborns. Examples of nursing diagnoses that center on the priority areas of care for all newborns include: Ineffective airway clearance related to the presence of mucus or amniotic fluid in the airway Ineffective tissue oxygenation related to breathing difficulty Ineffective thermoregulation related to immature status Risk for deficient fluid volume related to insensible water loss Risk for imbalanced nutrition, less than body requirements, related to the lack of strength for effective sucking Risk for infection related to lowered immune response due to prematurity Risk for impaired parenting related to illness in newborn at birth Deficient diversional activity (lack of stimulation) related to illness at birth Readiness for developmental care to decrease overstimulation easily caused by necessary lifesaving procedures

Ventilation Maintenance

To allow a newborn to adjust to and maintain the cardiovascular changes that occur at birth, effective ventilation (continued respirations) must be maintained. Healthy newborns accomplish this task on their own. Those who have difficulty establishing respirations at birth need to be carefully observed in the first few hours after birth to be certain respirations are maintained. Use of pulse oximetry is crucial to be certain oxygen saturation remains adequate; infants this young do not have dramatic skin color changes as do older infants and can be mildly hypoxic (low in oxygen) without becoming cyanotic. A steadily increasing respiratory rate, grunting, and nasal flaring are often the first signs of obstruction or respiratory compromise in newborns. If these are present, undress the baby's chest and look for intercostal retractions (inward sucking of the anterior chest wall on inspiration). Pulling in the chest muscle this way reflects the degree of difficulty the newborn is having in breathing in air (tugging so hard to inflate the lungs that the anterior chest muscles are pulled inward). Place a newborn who is having difficulty with maintaining respirations under an infant radiant warmer to help prevent cooling and acidosis; under a warmer, the clothing (except diaper) should be removed to promote better respiration and observation while keeping the newborn warm. Positioning an infant on the back with the head of the mattress elevated approximately 15 degrees can also help because it allows the abdominal contents to fall away from the diaphragm, thus increasing breathing space. If secretions accumulating in the respiratory tract appear to be creating ineffective breaths, an infant may need additional suctioning. "Bagging" the infant with a mask and positive-pressure ventilation bag for a minute before suctioning will usually improve the infant's oxygen level and prevent it from desaturating to dangerous levels during suctioning. As a final step, the cause of the respiratory distress must be determined and appropriate interventions must be undertaken to correct the difficulty

INITIATING AND MAINTAINING RESPIRATIONS

Ultimately, the prognosis of a high-risk newborn depends primarily on how the first moments of life are managed because most deaths occurring during the first 48 hours after birth result from the newborn's inability to establish or maintain adequate respirations An infant who has difficulty accomplishing effective breathing may experience residual neurologic morbidities as a result of cerebral hypoxia. Therefore, prompt, thorough, and immediate care is necessary for the best outcome. Most infants are born with some degree of respiratory acidosis. However, this initial acidosis is rapidly corrected by the spontaneous onset of respirations. If respiratory activity does not begin immediately, respiratory acidosis not only doesn't improve but also increases in amount so much that the blood pH and bicarbonate buffer system can fail. Newborn defense mechanisms then become inadequate to reverse the process. This means the effort to establish respirations must be started immediately after birth because, by 2 minutes, the development of severe acidosis is already well under way Any infant who sustains any degree of asphyxia in utero, such as could occur from cord compression, maternal anesthesia, placenta previa, intrauterine growth restriction, or premature separation of the placenta, may already be experiencing acidosis at birth and may have difficulty before the first 2 minutes of life. An additional concern that ineffective respirations creates is the failure of fetal circulatory shunts, particularly the ductus arteriosus, to close. Because left-side heart pressure is stronger than right-side pressure, blood then circulates through the patent ductus arteriosus from the left to right or from the aorta to the pulmonary artery, thus creating ineffective pump action in the heart. Struggling to breathe and circulate blood, the infant is forced to use available serum glucose quickly and so may become hypoglycemic, compounding the initial problem even further. For all these reasons, resuscitation is important for both infants who fail to take a first breath and for those who have difficulty maintaining adequate respirations on their own