OB Exam 5 Study Guide

OB exam 5 study guide Physiologic & Behavioral adaptations of the newborn: - Neonatal period is the first 28 days of life - Transition phase is the physiologic adaptation to life outside of the uterus following delivery and clamping the cord - Respiratory system: o Internal stimuli to initiate breathing: § Decreased O2 supply to body from clamping of the cord leads to increased CO2 causing a decreased pH affecting chemoreceptors § This sends a message to respiratory center in medulla to stimulate and contract the diaphragm for baby to take first breath § IN SHORT—cord clamped- dec. O2 inc. CO2 triggers medulla to contract diaphragm causing baby to breath o External stimuli to initiate breathing: § Cold air stimulates skin receptors, light and sound too affect the respiratory center causing baby to take first birth § As baby is expelled through the vaginal canal, the chest compression and release when delivered causes air to be drawn into the lungs and stimulates breathing - - Fetal breathing movements (FBM): o Breathing-like movements begin in utero around 12-weeks gestation o This is just practice! Baby is not actually breathing o This helps develop chest wall muscles and diaphragm, and regulates lung fluid volume o FBM decrease 24-36 hours before the onset of true labor § Because of increased cortisol levels. Baby will prepare for onset of stress from labor and become “quiet” by preserving oxygen and maintaining tone § There is also a decrease of progesterone from the placenta Initiation of breathing: o Chemical stimuli: § The cord is clamped causing a cessation of placental blood flow § This decreases O2 (mild hypoxia) increases CO2 dropping the pH and causes acidosis § These changes send signals to the respiratory center in the medulla initiating baby’s first breath! Yay! § Now, when the cord is clamped, this too alters hormone levels. There becomes a decrease in prostaglandins which in return increases respirations! They are inverse of each other. § Decreased prostaglandins = increased RR o Mechanical stimuli: § - - During a vaginal delivery, the pressure from the vaginal canal causes chest/ thoracic compression allowing for fetal lung fluid to be squeezed out... this is GOOD! § On the other hand, for cesareans this does not happen and the baby will have more difficulty with breathing § As air enters the lungs it expands moving the original lung fluid into capillaries and lymphatic drainage system § Crying helps air to spread through lungs as there is increased RR § Positive intrathoracic pressure increases with breathing allowing for alveoli to remain open and expand to become more permeable allowing for dilation of pulmonary arteries § Need to understand—before the baby is born lung pressure is HIGH due to it being filled with fluid. As the baby begins to breathe, the lung pressure decreases because oxygen is a VASODILATOR! Simultaneously, the systemic blood pressure INCREASES due to release of norepinephrine to ensure proper blood flow to the lungs to receive oxygen and transport it around the body • Before birth: o High lung pressure & low systemic pressure • After birth: o Low lung pressure (O2 vasodilates) & high systemic pressure o Sensory stimuli: § Warm, dry, and stimulate § Bright lights, temperature changes (warm belly to cold room), loud noises are all external stimuli § Rubbing the baby stimulates skin receptors to stimulate breathing Surfactant and respiratory preparation for birth: o Surfactant increases from 24 weeks and peaks at 35-36 weeks gestation and will remain high until delivery o Giving steroids to increase lung maturity is only effective between 24-34 weeks § Steroids also decrease bleeding in ventricles of brain o Surfactant is composed of phospholipids (Lecithin and Sphingomyelin) -- L/S o We want L/S ratio to be 2:1 for it to be considered mature o If we know baby will be born preterm can do an amniocentesis to assess L/S ratio via amniotic fluid to determine lung maturity o If baby is already born and has low L/S, surfactant will directly be injected into the baby’s lungs! Abnormal respirations: o Grunting—can sound like a hiccup, very bad o Nasal flaring, retractions—body is working very hard to breath o Tachypnea or apnea—can be fast but shallow breaths o Circumoral (mouth) or central cyanosis (chest)b will require oxygen administration Transient Tachypnea of the Newborn (TTN) - Progressive, transient respiratory distress during transition usually 1-2 hours after birth - Risk factors: o Maternal diabetes—macrosomia baby o Maternal asthma—exhaustion o Male baby—stubborn o Cesarean—fluid is not squeezed out of lungs from vaginal pressure o Maternal sedation or induction o Poor uterine perfusion—pre-E or GHTN o Debris in trachea—meconium - Presentation: o Tachypnea > 160 bpm especially at rest o Mild cyanosis on room air o Grunting or nasal flaring o Mild retractions - Management: o Apply pulse ox o Administer O2 via blow-by—blowing O2 on their face o Hold feeds due to aspiration risk o Perform chest x-ray Meconium in Amniotic Fluid: - Green-black and viscous, contains occult blood - Fetus passed meconium while in utero - We know this is green and smelly - Can be thin or thick - Presence of respiratory distress: o Pallor, cyanotic, apnea > 20 sec, bradycardia, no flexion, low APGAR, low muscle tone - If baby is vigorous, they will be okay no need for resuscitation - May need to be transferred to NICU - Need to perform CXR, blood gas levels, antibiotics - Worst case scenario!!! The baby will require ECMO—a membrane oxygenator that acts as lungs to delivery oxygen into the baby’s blood Cardiovascular: o Ductus venous: connects the umbilical vein to the IVC. Carries mostly oxygenated blood § The duct tape for U and I (umbilical vein & IVC) o Foramen Ovale: shunts oxygenated blood from RA to LA then to LV to aorta then body § Not all blood bypasses the LV but about 90%, only 10% actually goes to the lungs o Ductus arteriosus: a tubular connection between pulmonary artery and descending aorta that bypasses the lungs. This has like moderately oxygenated blood o Steps: 1. Blood from placenta goes to umbilical vein through ductus venosus to the IVC. Blood bypasses the liver. 2. Blood enters the RA through the foramen ovale into the LA, dumped into the LV to the aorta 3. Some blood from the head and UE enters the RA to RV (the 10%), this blood goes to the pulmonary artery through the ductus arteriosus into the descending aorta bypassing the lungs The ductus venosus becomes a ligament by 2-3 months old Foramen ovale functionally closes 1-2hours after birth due to increased systemic pressure. Anatomically it closes within 30 months. § Common for baby to have transient murmur o Increased LA pressure, increased systemic pressure, and loss of prostaglandins from placenta leads to constriction of the ductus arteriosus. Functional closure happens within 24 hours and anatomic closure by 3-4 weeks. Cardiovascular adaptation: o HR up to 180 at delivery from release of epinephrine and norepinephrine o Normal HR 110-160 o BP ranges from 80/50-60/40 o Murmurs are common and transient due to foramen ovale or ductus arteriosus not completely closing o Acrocyanosis (blue hands/feet) is common during early adaptation o BP is highest right after birth and then decreases around 3 hours Hematopoietic adaptation: o Normal blood volume is 80-85 ml/kg (high) o Hgb 14-24 g/dl, again high! Remains high till about 2 weeks o Hct 51-56% high! o WBC 9,000-30,000—high! Due to release of immature WBC b/c of no immune system o Platelets 150,000-300,000 Signs of poor cardio transition: - Tachycardia at rest > 160 BPM - Bradycardia < 100 while baby is awake - Prolonged cyanosis - Pallor or grey skin appearance - Loud cardiac murmurs, S3/S4, gallops, baby will have murmur but they should be soft not loud - Management: o Give O2 for cyanosis o Take BP on extremities to compare blood pressures and perfusion o NICU transfer and studies o o Thermoregulation: - We want to keep external environment temperature safe for newborn to minimize oxygen and glucose consumption - Newborns have a thin layer of subcutaneous fat posing a higher risk for heat loss - Normal newborn temp. is 97.6-99.5 - Convection: flow of heat from the body to cooler ambient air—need a neutral temp. - Radiation: loss of body heat from a cooler nearby surface. Like being by a cold window. - Evaporation: when water is converted into vapor, common for babies in wet diapers - Conduction: loss of heat through direct contact with cold surface—mattress, scale, etc. Thermogenesis: - Neonates cannot shiver; therefore, they generate heat by increasing muscle activity by crying, being restless, or flexion to decrease heat loss - Internal heat loss can be reduced by constriction of peripheral blood vessels—acrocyanosis - When baby is cold, there is an increase in metabolic rate that consumes glucose and oxygen— baby is at risk for hypoglycemia - Stored energy is used via brown fat and has a richer vascular and nerve supply than regular fat o Intense lipid metabolic activity in brown fat warms newborns by increasing heat production o Preemies do not have as much if any brown fat—higher risk for cold stress Hypothermia and cold stress: - Infant presents with pale, mottled, cool skin - Renal: - Hypothermia will turn into cold stress if not fixed: o RR increases—increased need for O2 doubling the consumption leading to hypoxia and intercranial hemorrhage o Metabolic rate increases eating up glucose and O2—hypoglycemia risk o BOTH metabolic and respiratory acidosis can occur and baby will code o Hyperthermia is less common > 99.5 o In babies we are worried about them being COLD! o Keep room temperature at least 75 Initial bladder volume is 6-44ml of urine Baby is not able to fully excrete excess solutes or concentrated urine till about 3 months old Most babies void in 24-48 hours, and then 2-6x/day Urine should be straw colored Uric acid crystal stains can be seen on diaper—this is harmless and normal, just the body excreting waste product GI: - Baby should be able to suck and swallow at birth - Intestines are sterile at birth until fed - Newborns can digest simple carbs, fats, proteins—breastmilk or formula only - Breastmilk is easier for the baby to digest - No solid foods for baby until 6 months as they do not digest starches - Bowel sounds present - If cardiac sphincter immature baby will have reflux - It is common for baby to lose about 10% of their weight but should be back by 2 weeks old - First 12-24 hours meconium stool - 3rd day is transitional stool—greenish brown/yellow - 4th day is like pea-soup, paler color and more formed if breastfed it will be golden yellow Hepatic: - Occupies 40% of baby belly - Roles of the liver: o Iron storage, carb metabolism and glucose production, coagulation o Conjugation of bilirubin - Neonatal bilirubin: o Physiologic destruction of RBC account for 75% of bilirubin in NB o NB produces about 2x the amount of bilirubin than adults o Jaundice—high levels of unconjugated or indirect bilirubin § Insoluble and bound to circulating albumin § Results from breakdown of RBC that converts to bilirubin then releases unconjugated from § Unconjugated bilirubin MUST become conjugated to be excreted o Conjugated or direct bilirubin: § Soluble and able to be excreted by liver § Excreted into duodenum via biliary tract system § Bilirubin converts into urobilinogen and stercobilinogen by bacterial flora § It is excreted by urine or stool o Physiologic jaundice: § Very common especially in preterm § 24 hours after life and usually increases by day 3-5 but decreases by day 7-10 § Skin turns manila envelope yellow § Prevention: • Assess I/O increase baby feeding • • o o o Breastfed babies should not be given formula unless ordered to Need to chart transcutaneous bilirubin levels with a nomogram, serum bilirubin levels on day 2 • High risk zone levels will require phototherapy o Turn off before taking blood or it will clot o Make sure baby’s eyes are covered • If not severe, parents can put baby in indirect sunlight like near a window • Will need a pediatric follow up to measure levels again Pathologic jaundice: § Develops first 24 hours of life § Mainly caused by ABO incompatibility, liver disease, bile duct obstruction or enzyme deficiency Risk factors for both jaundice: § Shortened RBC lifespan, slow liver uptake, lack of intestinal flora § Poor oral intake § Premature/ LGA baby § Maternal sulfa drugs or salicylates in 3rd trimester § ABO incompatibility—O+ mom with A+/B+ baby—very dangerous § Rh negative and isoimmunized mother Complications of jaundice: § Acute bilirubin encephalopathy—first weeks of life • Baby is lethargic, hypotonic, seizures, coma § Kernicterus—above but bilirubin deposits into brain cells • Cognitive delays, anoxic brain injury, cerebral palsy Vitamin K: - Coagulation factors (VII, IX, X) need vitamin K to be activated - Vitamin K synthesis is temporarily deficient, breastmilk and formula have a little bit - Need to give after birth to prevent bleeding Hypoglycemia: - BG 30-40mg/dl within 1-2 hours of life - If low—feed that baby! Put them on the boob! Formula! Anything! - Newborn risk factors: o LGA o Macrosomia from GDM mom o Cold stress b/c increased glucose consumption o Respiratory distress from increased metabolic rate o Premature or post-mature infant o IUGR Immune system: - Developed early during fetal life - Baby has PASSIVE immunity for first 3 months of life - In utero baby receives IgG antibodies via placenta - IgM—protects against blood-borne infections, IgM is produced by 8 weeks gestation - IgA—protects against respiratory and urinary infections, directly received from breast milk Neuro: - Fontanels should be flat and soft - Pupils should be reactive - Reactive period after birth is about 30-60 minutes - Following deep sleep, baby should be reactive for about 4-6 hours Alert states: - Drowsy—eyes barely open or closed. HR and RR decreases, reacts to stimuli slowly - Quiet-alert—eyes open, fixated on faces/objects. Minimal motor activity and reacts to stimuli slowly o Baby is just kind of there - Active-alert—eyes open and baby is active via Moro reflex and increased motor activity - Crying—allows infant to expend energy and reorganize behavior. Signals need for parents. Only way baby can communicate Sensory: - Visual acuity is low but can fixate on faces and objects. Vision is blurry and cannot see far. - Baby recognizes and prefers human voice. Hearing is good at birth. - Baby can smell breastmilk and can recognize parents by smell within first week of life - Rooting, sucking, swallowing present at birth - Tactile stimulation results in infant response—such as picking up a baby when crying o Physical comfort is very important in infants Newborn Assessment: - Perform APGAR - Need tape measurement for frontal-occipital circumference - Gestational age assessment: o Based on physical characteristics and neuromuscular maturity - AGA (average for gestational age)—birth weight between 10th-90th % - LGA (large for gestational age)—birth weight > 90th % - SGA (small for gestational age)—birth weight > 10% - Normal respirations should be 30-60 per minute Skin assessment: - Erythema neonatorum toxicum—papular rash surrounding hair follicles present at 24-48 hours. Will heal without treatment - Milia—aka “milk spots”, keratin filled cysts seen on baby’s face that clear on its own - o Mongolian spots are green/blue pigmented spots on baby’s bottom o Common in Hispanic, Asian, and African babies - Lanugo—fine baby hair that can cover baby Vernix—white pasty substance that covers baby after delivery. This is a protective substance that is antimicrobial and hydrating. Can remain on baby if mom wishes. Head assessment: - Assess shape, sutures—are they apart? molding - Fontanels—are they bulging? Sunken? - Hair distribution will tell how baby was positioned in utero - Caput: o Edematous area to scalp o Present at birth o Crosses suture lines o Absorbs 24-48 hours o This is an accumulation of WATER - Cephalohematoma: o This is a collection of BLOOD o Does not cross suture lines o Located directly on bone o Painful to touch and can take 2-3 weeks up to 3 months to heal o There is a risk for hyperbilirubin as there is increased RBC available for unconjugated bilirubin to bind o This is commonly in the parietal area and very localized o This can happen from dropping baby Face assessment: - Inspect everything basically - Check for cleft lip - Epstein pearls (cysts)—white spots on gums not teeth - Assess position of ears, does the tip of the pinna align with outer eye? o If abnormal ears, need to assess kidney function à For respirations and heart rate must assess a full minute as it will be an abnormal pattern Genital assessment: - Males: o Assess placement of urinary meatus o Check for hydrocele, epispadias, cryptorchidism, hydrocele o Swelling is very common in vaginal delivery - Female: o Assess urethral opening o Any redness? Skin tags? Mucus discharge? Swelling? Extremities assessment: - Can baby only extend one arm? This can indicate brachial plexus injury - Assess creases of palms—trisomy 21 has only one single hand crease - Check for symmetry, flexion, strong muscle tone Congenital hip dysplasia: - The hips pop out or isn’t stable - Barlow maneuver: adducting the hip to the midline and gently applying posterior force - Ortolani’s maneuver: gentle hip abduction Back assessment: - Check color, palpate along the spine - Check for dimpling—can indicate opening to spinal cord Newborn reflexes to assess: - Startle/Moro reflex—gently drop baby while supporting and baby will extend arms like they’re falling - Palmar/plantar reflex—baby will grasp object with hand or foot - Babinski reflex—baby should curl toes not fan them out - Stepping/crawling reflex—baby should naturally try to put weight forth towards walking - Rooting and sucking reflex—does baby move mouth towards things to try to eat? Newborn procedures: - Newborn hearing screening: o Performed by audio technologist, basically nurse just makes sure it gets done - Critical congenital heart disease: o Performed at 24-48 hours of age o Pulse ox applied to right hand and a foot to determine if there is a difference in blood flow § Needs to be > 97% in any extremity - Hep. B administration - Newborn screening—heel stick most of the time, venipuncture for larger amount Circumcision: - Parent’s choice - Baby must be at least 12 hours old with vitamin K shot - Must void before procedure - Major concerns are bleeding and abnormal voiding - Sucrose and comfort—skin to skin, swaddling, rocking Infant abduction: - Usually, a female of childbearing age who has problems with conceiving or lost her baby - They visit maternity units often to get familiar with the layout - Pretends to be a healthcare worker, grabs first opportunity—not a particular baby - They often use staircase for escape not elevator - Need to teach parent to be cautious, observative, follow unit policy - Never leave baby alone in the room - Request a 2nd staff member to identify if baby needs to leave room - Don’t post your hospital stay on social media—people are weird! Discharge education: - Don’t soak baby in bath until cord has fallen off—sponge baths only - Let cord fall off on its own, don’t do anything to it - Have baby sleep in crib with nothing else it in, not even a blanket - Car seat safety—proper positioning - Dress baby appropriately for weather and bed time—prevent cold stress! High risk newborn: Preterm infants: - < 37 weeks gestation - They have immature systems and lack adequate nutrient reserves - Their body was not matured enough in a sense - They may have physiological disorders and anomalies depending on how preterm they were - Equipment and staff need to be available for immediate care after delivering the baby - Depending on how the baby presents, may need extended hospital stay in NICU which is $$$ Classification of high-risk infant: - Low birth weight (LBW) is <2500gm - Very low birth weight (VLBW) is < 1500gm - Extremely low birth weight (ELBW) is < 1000gm - Small for gestational age is typically from IUGR - Late preterm—34-36.6 weeks—dangerous! Baby is not fully matured - Early term—37-38.6 weeks - Full term-- 39-40.6 weeks - Late term-- 41-41.6 weeks - Post-date— born after 42 weeks—dangerous! Hormonal changes, IUGR, overextended uterus Respiratory function in preterm baby: - Lungs lack adequate surfactant - Non-compliant leads to higher risk for atelectasis - Increased energy is required to breathe leading to shallow rapid respirations - There is a more-narrow respiratory passage so not enough air is allowed in - Weak respiratory muscles Cardiovascular function: - Need to monitor HR, BP, O2, pulse, ABG’s - Monitor for hypovolemia and shock—hypotension, slow capillary refill, respiratory distress, potential tachycardia - BP is very important to diagnose cardiorespiratory disease in baby Thermoregulation: - Factors affecting heat loss: o Large body surface area R/T body weight—more area for heat to be lost o Minimal subcutaneous fat—no insulation, limited brown fat § Therefore, baby will break down whatever possible to help including O2 and glucose—cold stress! Hypoglycemia! o Their skin is thinner and more permeable, more fragile o Poor muscle tone—baby will be in hypotonic frog position § Lack of tone leads to lack of control in a sense, they cannot fight this position § o o Since they were preterm, they did not have the “snug” fit in mom’s belly, being small they had room to move not flexed and midline like a normal term baby would be § We need to keep baby swaddled and prevent them from remaining in frog position for too long to prevent joint dysfunction Decreased ability for vasoconstriction of capillaries—decreased amount of blood moving to lungs for oxygen What do we do as nurses? § Maintain a neutral thermal environment (NTE) usually 75+ § Keep infant in radiant warmer or incubator § Minimize hypothermia § Avoid hyperthermia!! Central Nervous System: - These babies are more prone to injury all around - Risk factors for CNS injury: o Premature o Birth trauma—difficult labor, traumatic delivery, forceps o Breech delivery o Birth asphyxia, hypoxia - Clinical manifestations to evaluate: o Seizures o Hyperirritability o CNS depression o ICP o Abnormal movements such as decorticate posturing Their renal system is immature and cannot maintain electrolyte balance—strict I/O monitoring Preterm babies bleed easily! They have fragile capillaries Because of the weak immune system, higher risk for infections Care management for preterm baby: - We want to promote normal growth and development - - - Need an interdisciplinary team Ongoing assessment of physiologic status Incubator, O2, electronic monitors, assistive devices for positioning, low stimuli, parental fluids, IV access for antibiotic therapy, blood work monitoring Need to maintain temperature by: o Transfer post-delivery immediately into warmer or incubator o Skin-skin contact if they are stable o Maintain thermoneutral condition o Rewarm infants if they get cold o Keep a hat on baby o Baby can be placed in a polyethylene bag if needed Respiratory care: o Do they need resuscitation? o How old is the baby? How was the amniotic fluid? o What is their APGAR? o Neonatal resuscitation: § Provide warmth, open airway by positioning the head back and clearing the airway § Provide ventilation and start compressions § Give epi or volume expansion o Oxygen therapy: § Needs to be given warm and humidified § Hood therapy—infants that don’t require mechanical pressure support • The air is just blown through the hood onto the baby § Nasal canula for babies that need low amount of oxygen § CPAP: noninvasive ventilation • Used for baby that cannot maintain adequate oxygenation despite using other means • O2 is infused under direct pressure using nasal prongs or face mask • Orogastric tube is inserted to decompress the stomach when nasal prongs are used § Mechanical ventilation: • When ALL means have failed to maintain oxygenation including CPAP • Used when ABG’s indicate severe hypoxemia or severe hypercapnia • Also used for RDS—respiratory distress syndrome or congenital defects • Delivers a predetermined amount of oxygen during spontaneous respirations and mechanical ventilation • This decreases the complication risk § Other therapies: • Surfactant—given in babies <34 weeks, directly injected into lungs • Nitric oxide—causes pulmonary vasodilation o Can be used with surfactant, ventilation, and ECMO • ECMO—used to sustain life in babies with respiratory or heart failure L o Supplies blood to circulation allowing the lungs to rest o Not used in babies <34 weeks How do we wean baby off of respiratory support? o Very gradually, they must have spontaneous respiratory effort o Extubated then put on CPAP then weaned to O2 hood or NC o Then basically monitor until they can handle breathing on their own Weight/fluid loss: - Must do daily weights! Insensible water loss (IWL)—evaporative loss through skin and respiratory tract o Usually 20ml/kg/day in water loss for term baby, it is more for preterm - Need to be giving correct amount of fluids, document and weigh each void, stool - Treat underlying cause and adjust incubator temp Feeding methods: - Gavage feeding—breastmilk/formula through NG tube - Gastrostomy feeding—surgical feeding tube through abdomen into stomach - Parental nutrition—supplemental feeding to infant that can’t tolerate enteral o Enteral—mouth and GI tract eating o Parental—IV feeding - Feedings are based on baby tolerance, weight, sucking reflex, toleration Pacifiers: - Typically offered while baby is having TPN or gavage feedings or between oral feeds - Benefits: o Sucking improves O2 o Reduces restlessness and increases weight gain o Improves sucking technique o Eases transition from gavage to bottle feeding Infant discharge considerations: - Ability to raise their head - Vigorous cry when hungry - Appropriate weight gain - Good neurological responses Developmental care: - Positioning—less flexed. Keep baby side-lying or prone?? Interesting o Swaddle baby, use blanket rolls, keep extremities close to body—prevent frog! - Reduce stimuli—decreased noise and dim lights - Observe behavioral cues—facial expressions, posture, etc. - Infant stimulation—cuddling, singing, talking to baby, pacifier - Kangaroo care benefits—O2 maintenance, bonding, comfort, trust, temperature regulation o Skin to skin Respiratory distress syndrome (RDS): - Life threatening lung disorder affecting 90-98% of preemies - Signs of respiratory distress - Need to provide respiratory support - Retinopathy of prematurity (ROP): - Retina is not fully vascularized and is at risk for stress or injury - Nursing: reduce risk of ROP by giving correct O2 doe, keep lighting at a minimum to prevent harm to the eyes - Need to have a follow up appt. with ophthalmologist Intravascular hemorrhage: - Most common intracranial bleeding in preemie usually < 34 weeks - Present with signs of shock, RDS, lethargy - Nursing: monitor infant for any changes, give O2 and fluids, support the parents Necrotizing enterocolitis: - Acute inflammation and necrosis of GI mucosa - Presents with RDS, unstable temperature, shock - Nursing: prevent progression of NEC, no oral or tube feedings only IV (since it bypasses GI system), support the family Sequelae of preterm babies/birth: - Mental retardation, learning issues, behavioral problems, cerebral palsy, vision/hearing loss Late preterm infants: - More than likely don’t need NICU - They will be more developed - Still need to assess for common risk factors for preterm infant Postmature infants: - Dry cracked skin, firm long nails, depleted fat—they look like a granny - SGA or IUGR can be common, perinatal asphyxia - Prevent worsening condition Acquired problems of the newborn: Birth traumas: - Bruising to face, genitalia, or bottom, petechiae on trunk due to tight cord, forceps/vacuum - Damage to skull, clavicle, humerus, or femur is common - Brachial plexus injury, phrenic nerve, facial paralysis—bell’s palsy - CNS—subdural and subarachnoid hemorrhages Infections: - Sepsis: o Can be maternal, intrapartum, neonatal o Must assess all systems of baby o Give antibiotics or antiviral and breastfeed that baby! Liquid gold!! o Prevention is hand hygiene and standard precautions Viral infections: - Cytomegalovirus & HSV—microcephaly, chorioretinitis, intellectual disability - Varicella—mild-no infection J - Rubella—cataract, glaucoma, hearing loss, heart defects, congenital rubella syndrome - Hep. B & HIV—asymptomatic; Hep. B vaxx given 12 hours post-delivery & antiretroviral therapy Bacterial infections: - GBS—neonatal pneumonia, meningitis - E. coli—gastroenteritis or septicemia - Staph—usually develops after birth - Chlamydia/gonorrhea—eye infection - Listeriosis—meningitis if not treated Other infections: - Syphilis—congenital syphilis - Toxoplasmosis: o Usually from cats o Mom can’t change the litter box while pregnant o Hydrocephalus, preterm birth, IUGR, petechiae rash or maculopapular rash - Candida diaper dermatitis—perineal edema/ redness Signs of infection in baby: - Respiratory—apnea, grunting, retractions, tachypnea, cyanosis - Thermoregulation—hypothermia or fever, temp. instability - CV—bradycardia, tachycardia, hypotension - Neuro—tremors, lethargy, irritability, high-pitch cry, bulging fontanels, seizures - GI—poor feeding, N/V/D, abdominal distention - Skin—rash, pustules, pallor - Metabolic—glucose instability, metabolic acidosis Substance abuse: - Tobacco—smaller head, cleft palate/lip, low IQ, increased risk for SIDS, preterm baby - Alcohol—facial abnormality, microcephaly, mental retardation, fetal alcohol syndrome - Opioids—preterm baby, microcephaly, increased SIDS risk o Heroine, methadone, morphine, oxycontin - Weed—social interaction problems, attention deficit disorder - Cocaine—congenital anomalies, preterm baby - IUGR is common for any substance abuse!! - Clinical presentation of NAS: o RDS o Irritability, tremors, high-pitch cry, hyperactivity, seizures o Frequent yawning and sneezing o Abnormal feeding pattern, disorganized sucking reflex - Withdraw symptoms: o Alcohol—3-12 hours after birth o Narcotics—48-72 hours after birth o Barbiturates—1-14 days after birth - Nursing: o Give IV fluids for nutrition o Obtain specimen for toxicology screening o Use NAS screening tool for signs of withdrawal o Provide nonjudgmental supportive care to the mother o Quiet environment with low stimuli to baby—let them relax o Swaddle baby in flexion positioning o Assess the baby Hemolytic disorders & congenital anomalies: What causes hemolytic disorders? - Maternal antibodies develop against fetal blood as it joins maternal circulation. Maternal IgG crosses the placenta and begins to destroy fetal RBC’s - Rh incompatibility or isoimmunization - ABO incompatibility—hemolytic disease Care management: - Give Rhogam - Obtain blood work on newborn to determine blood type and +/- Phototherapy—convert bilirubin to conjugated form - Exchange transfusion—removing infant’s blood and replacing with donor blood o Replaces all of baby’s blood very slowly Congenital Heart defects: - Structural abnormalities of the heart or intrathoracic vessels - Present at birth - Affect cardiac function - Signs/symptoms: o Cyanosis at birth—not relieved by oxygen o The quality of the cry is different o Acyanotic but not pale o Mottling of the skin o Restlessness o irregular heartbeat, murmur Critical congenital heart defects: - screening: o baby needs to be at least 24 hours old o baby needs to be awake and quiet o put probe on baby’s right hand (preductal) and foot (post-ductal) o light emitter portion of the probe should be on top of hand or foot Myelomeningocele: - herniation of spinal cord and neural elements through opening of spine, with or without skin or vertebral opening. This can tear and leak CSF - nursing: protect the sac, keep baby prone, skin care Hydrocephalus: - overproduction of CSF or decreased absorption. Usually from too much CSF in ventricles due to obstructed flow - presents with bigger head, increasing FOC (frontal-occipital circ.), larger fontanels that are full or bulging - baby will possibly need surgery to insert shunt, needs to be in a quiet room Choanal Atresia: - absence or narrow opening of posterior nares by bony or soft tissue obstruction - respiratory issues with rest but O2 increases with crying - NGT to check for obstruction - Mgmt. oral airway, prone positioning, CT scan Congenital diaphragmatic hernia: - Defect in the diaphragm, the abdominal organs end up in thoracic cavity blocking respirations - Presents with respiratory distress, heart shifted to the right, barrel chest - Will need surgical repair, suction to decompress GI, may need ECMO Cleft lip/ Palate: - Causes: genetic, environmental, infections, DM, some drugs - Cleft lip is surgically repaired around 6 months - Cleft palate usually gets surgery around 9-12 months - there is special feeding for babies with cleft palate - emotional support for family Esophageal atresia & tracheoesophageal fistula: - EA—ends in blind pouch with no continuous passageway to the stomach o Baby’s food gets stuck and will vomit it out - TEF—abnormal connection between esophagus and trachea - Mgmt.: o Manage respiratory problems o Maintain position o Surgical intervention Omphalocele: - Covered herniation of abdominal contents into base of umbilical cord - Can contain intestines, liver, or spleen. Gastroschisis: - Herniation of bowels through the abdominal wall with no membrane covering the contents - IUGR present, is not associated with other anomalies - High occurrence in teen moms - Mgmt.—protect abdominal contents, positioning, strict I/O Inborn errors of metabolism: - Phenylketonuria: o autosomal recessive genetic disorder caused by deficiency of hepatic enzyme phenylalanine hydroxylase o S/S—vomiting, poor feeding, FTT (failure to thrive), musty smelling urine o Mgmt.—lifelong dietary restriction of phenylalanine - Galactosemia: o Enzyme to convert galactose to glucose is missing and baby can’t metabolize lactose o S/S—vomiting, hypoglycemia, poor weight gain o Mgmt.-- lifelong lactose restriction to prevent intellectual disability, liver disease, and cataracts - Congenital hypothyroidism: o Absent or underdeveloped thyroid gland o S/S—large tongue, open post fontanel, hypothermia o Mgmt.—lifelong thyroid replacement drugs and monitoring of hormones