Postpartum Nursing Care ELO C: Preterm and Post term Newborns

The Preterm Newborn

• Preterm newborns are also known as premature infants and are patients commonly admitted to NICUs.
• Prematurity and low birth weight are associated with increased neonatal morbidity.
• The emphasis has shifted towards gestatational age instead of just birth weight for classifying newborns.
• Gestational age is defined as the time from conception to birth.
• Infants born before 37 weeks are preterm, those born between 37-38 weeks, 6 days are early term, and those born between 39-40 weeks, 6 days are full term.
• Infants born between 41-41 weeks, 6 days are late term and those born beyond 42 weeks are post term.
• All of these categories are considered high-risk newborns despite birth weight.
• Low birth weight (LBW) is defined as an infant weighing 2500 grams (5.8 lb) or less.
• An infant may have a low birth weight due to intrauterine growth restriction (IUGR) or be small for gestational age (SGA), both are treated as high-risk newborns.
• Infants with lower birth weights are at higher risk during delivery and immediately afterward.
• The Ballard scoring system is a standardized method used to estimate gestational age within 1-2 weeks.
• The Ballard scale assesses neuromuscular maturity (A) and physical maturity (B) of a newborn.
• A newborn will score 45 for a 42-week gestation and 20 for a 32-week gestation.
• An accurate assessment of a newborn’s maturity aids in personalized care plans.
• Factors contributing to prematurity include: multiple births, maternal illness like malnutrition, heart disease, diabetes mellitus, or infectious conditions, hazards of pregnancy like gestational hypertension, placental abnormalities, placenta previa, and premature separation of the placenta.
• Other factors like poverty, smoking, alcohol consumption, and drug abuse are also linked to prematurity.
• Adequate prenatal care is crucial for preventing preterm birth.
• Families with preterm infants may face additional financial and emotional strain.
• Early parental interaction with the preterm infant is vital for bonding and attachment.
• Multidisciplinary care, including parent aides and other types of home support and assistance, is crucial, especially because current studies indicate a correlation between high-risk births and child abuse and neglect.

Related Problems

• Inadequate respiratory function is a common problem among preterm newborns.
• Structural changes in fetal lungs occur during the second half of pregnancy, enhancing oxygen absorption.
• Preterm newborns may have underdeveloped respiratory muscles, abdominal distention causing pressure on the diaphragm, immature respiratory centers, and weak gag and cough reflexes.
• Oxygen therapy may be required, which needs to be warmed and humidified to prevent mucous membrane drying.
• Mechanical ventilation can be necessary for preterm infants.
• Oxygen saturation levels need to be constantly monitored.
• Respiratory distress syndrome (RDS), also known as hyaline membrane disease, is a severe condition caused by lung immaturity.
• An estimated 30% of neonatal deaths result from RDS or its complications.
• RDS develops due to deficient surfactant production, which is essential for lung oxygen absorption.
• Testing for the lecithin/sphingomyelin (L/S) ratio can determine surfactant levels in amniotic fluid.
• Symptoms of respiratory distress usually manifest after birth, but may take several hours.
• RDS symptoms include increased respiration, gruntlike sounds, nasal flaring, cyanosis, and retractions.
• Mechanical ventilation may be required for treating severe RDS.
• Surfactant production can be increased through administering corticosteroids to the mother before delivery.
• For preterm newborns, surfactant can be administered via an endotracheal (ET) tube at birth or when RDS symptoms appear.
• Surfactant production can be affected by cold stress, hypoxia, and poor tissue perfusion, common in preterm infants.
• Apnea is a common occurrence in preterm infants due to nervous system immaturity.
• Apneic episodes are accompanied by bradycardia and cyanosis.
• Gentle rubbing of the infant’s feet and back, suctioning the nose and mouth, and raising the infant's head can help stimulate breathing.
• If breathing doesn't resume, an Ambu bag can be used.
• Neonatal hypoxia is insufficient oxygenation at the cellular level.
• A pulse oximetry level of 92% or greater is considered normal and should be monitored closely.
• Severely anemic infants or those with abnormal RBCs may experience severe hypoxia without exhibiting cyanosis.
• Pulse oximetry needs to be placed properly for accurate reading.
• Sepsis is a generalized bloodstream infection that is a risk for preterm newborns due to their underdeveloped immune system.
• The preterm infant's liver is immature and produces antibodies poorly.
• The underdeveloped body enzymes and lack of maternal immunity, coupled with insufficient nutrient stores, make preterm infants vulnerable to sepsis.
• Sepsis may not have local signs, making diagnosis difficult.
• Sepsis symptoms include low temperature, lethargy or irritability, poor feeding, and respiratory distress.
• Treatment involves intravenous antimicrobials, maintenance of warmth, nutrition, and close monitoring of vital signs.
• Maintaining strict Standard Precautions and separating the infant from other infants in the unit is essential.

Poor Control of Body Temperature

• Preterm infants lack sufficient brown fat insulation, leading to heat loss through radiation from a large surface area.
• The immature heat-regulating center of the brain, non-functional sweat glands, weak muscles, and inactive nature make preterm infants prone to cold stress.
• Cold stress increases oxygen and glucose needs, putting already vulnerable preterm infants at risk.
• Skin temperature drops before core temperature falls, making skin probes crucial for monitoring preterm infant temperatures.
• Radiant warmers or incubators are used to create a warm environment for preterm infants.

Hypoglycemia and Hypocalcemia

• Hypoglycemia is common in preterm infants due to insufficient glycogen and fat stores.
• Hypoglycemia is aggravated by conditions like asphyxia, sepsis, RDS, and unstable body temperature.
• Plasma glucose levels below 40 mg/dL in a term infant and 30 mg/dL in a preterm infant indicate hypoglycemia.
• Frequent glucose monitoring and providing nasogastric or parenteral feedings are essential for preterm infants
• Hypocalcemia, a deficiency of calcium in the blood, is also common in preterm infants.
• Preterm infants are at increased risk for hypocalcemia due to insufficient calcium reserves.
• Hypocalcemia can be aggravated by hypoxia, birth trauma, administration of sodium bicarbonate, and maternal diabetes or low vitamin D intake.
• Early hypocalcemia can cause the parathyroid gland to fail to respond adequately to low calcium levels.
• Later hypocalcemia, usually occurring around 1 week of age, is linked to cow’s milk consumption, which increases serum phosphate levels and reduces calcium levels.
• Treatment for hypocalcemia involves intravenous calcium gluconate and administering calcium lactate powder to formula.
• Neonatal tetany can occur if calcium lactate powder is abruptly discontinued.

Increased Tendency to Bleed and Retinopathy of Prematurity

• Preterm infants are more prone to bleeding due to deficient prothrombin levels, a clotting factor.
• Fragile capillaries in the head are particularly susceptible to injury during delivery, causing intracranial hemorrhage, which can be detected through ultrasonography.
• Monitoring for bulging fontanelles, lethargy, poor feeding, and seizures is essential for preterm infants.
• Retinopathy of prematurity (ROP) is a disorder of the developing retina in premature infants that can cause blindness.
• The condition is also known as retrolental fibroplasia, but ROP is the preferred term due to its greater precision.
• ROP is the leading cause of blindness in newborns weighing less than 1500 g (3.3 lb).
• ROP is caused by a defective vascularization process in preterm infants, often aggravated by high oxygen levels needed for survival.
• ROP can lead to fibrous tissue growth behind the lens of each eye and retinal detachment, causing blindness.

Retinopathy of Prematurity (ROP)

• Premature infants born with fully developed vascular systems in the retina are typically not affected.
• Infants with unstable health conditions should be monitored for ROP.
• The American Academy of Pediatrics (AAP) recommends routine retinal exams for infants born between 1500 and 2000g or with a gestational age less than 30 weeks.
• Exams at 4 weeks of age and regular follow-ups can help detect and treat ROP early.
• Retinal ablative therapy using laser photocoagulation or intravitreal bevacizumab injections can prevent blindness.
• Follow-up for other eye issues (strabismus, refractive errors, cataracts) should occur within 4-6 months after NICU discharge.

Nursing care for Preterm Infants - Nutrition & Necrotizing Enterocolitis (NEC)

• Premature infants have small stomach capacity and immature sphincter muscles, leading to regurgitation and vomiting.
• They have immature sucking and swallowing reflexes.
• Preterm infants have poor fat absorption, including fat-soluble vitamins.
• Limited nutrient stores and increased glucose and nutrient needs contribute to nutritional challenges.
• Orogavage feedings are preferred over nasal gavage due to newborns being obligatory nose breathers.
• Monitor abdominal girth and bowel sounds for early signs of NEC.
• Oral feeding readiness is signaled by a strong gag reflex, sucking, and rooting reflexes.
• Start nipple feedings slowly, weight loss may occur initially due to feeding energy expenditure.
• Positioning the baby on their right side or abdomen after feeding promotes gastric emptying and reduces aspiration risk.
• NEC is an acute bowel inflammation leading to necrosis.
• Premature newborns are at high risk due to compromised bowel lining blood supply, leading to mucosal damage and bacterial invasion.
• Feeding milk formula or hypertonic gavage feeding can provide a medium for bacterial growth.
• NEC signs include abdominal distention, bloody stools, diarrhea, and bilious vomit.
• Nursing responsibilities include monitoring vital signs, maintaining infection control, and cautiously resuming oral fluids as ordered.
• Treatment involves antibiotics and parenteral nutrition to allow the bowel to rest.
• Surgical removal of necrosed bowel may be necessary.

Immature Kidneys and Jaundice

• Preterm infants have immature kidneys, leading to ineffective waste elimination and electrolyte imbalances.

• Dehydration occurs easily, salt tolerance is limited, and edema susceptibility is increased.

• Documentation of intake and output for all preterm infants is essential.

• Urine output should be 1-3 ml/kg/hr.

• Closely monitor preterm infants for signs of dehydration or overhydration.

• Document fontanelle status, tissue turgor, weight, and urine output.

• Jaundice (icterus) is caused by liver immaturity in newborns.

• Jaundice causes yellow discoloration of the skin and whites of the eyes.

• The liver cannot efficiently clear bile pigments from the blood.

• Serum bilirubin levels (mg/dL) indicate the severity of jaundice and the risk of neurological damage.

• A bilirubin increase exceeding 5mg/dL within 24 hours or levels greater than 12.9 mg/dL require thorough evaluation.

• Physiological jaundice is common and usually resolves on its own.

• Pathological jaundice is more concerning, appearing within 24 hours of birth, and is often linked to ABO-Rh incompatibility.

• Preterm infants have slower bilirubin rise and prolonged jaundice duration, increasing the risk of hyperbilirubinemia.

• Breastfed infants may have higher jaundice levels, especially early onset.

• Late onset jaundice in breastfed infants may be due to breast milk inhibiting bilirubin conjugation; formula substitution may be needed.

• Total serum bilirubin levels peak 3-5 days after birth.

• Early discharge necessitates follow-up visits within 2 days to assess bilirubin levels.

• The main goals of hyperbilirubinemia treatment are to prevent kernicterus (bilirubin encephalopathy) and halt further bilirubin elevation.

• Nursing care includes:

  • Observing jaundice progression, particularly from face to abdomen and feet.
  • Monitoring and reporting bilirubin lab values.
  • Documenting the infant’s response to phototherapy.

Nursing Goals for the Preterm Newborn

• Improve respiration
• Maintain body heat
• Conserve energy
• Prevent infection
• Provide proper nutrition and hydration
• Give good skin care
• Observe the infant carefully and record observations
• Support and encourage the parents

Thermoregulation

• Incubators provide a neutral thermal environment.
• Temperature, air, radiating surfaces, and humidity are controlled.
• The incubator’s temperature is adjusted to maintain the infant’s temperature between 97.1-98.6°F (36.2-37°C).

Radiant Heat Cribs

• Radiant heat cribs offer easier patient access while maintaining a neutral thermal environment.
• The use of a Plexiglas shield with the radiant warmer is discouraged as it may block infrared heat.
• A reflective patch should cover the skin temperature probe to prevent interference from the radiant warmer's infrared heat.

Kangaroo Care

• This involves skin-to-skin contact between the infant and parent for warmth and bonding.
• The infant rests on the parent's bare chest, wearing just a diaper and cap.
• The parent wears a gown open in the front exposing their chest.
• Kangaroo care promotes infant stabilization and later development.

Feeding of the Preterm Newborn

• Feeding methods vary based on gestational age and health status.
• The ability to coordinate breathing, sucking, and swallowing doesn’t develop before 34 weeks of gestation.
• Very preterm infants may require gavage feedings (tube through the nose or mouth into the stomach).
• Infants heavier than 1500g (3.3lbs) may tolerate bottle feeding with a small, soft nipple with a large hole.
• Human milk is ideal, as fat is easily absorbed.
• Intravenous fluids can supplement for fluid, calorie, and electrolyte needs in smaller, weaker infants.
• Early feeding initiation reduces the risk of hypoglycemia, hyperbilirubinemia, and dehydration.
• Monitor bowel sounds and meconium passage for intestinal readiness for oral feedings.
• If gavage feeding, aspirate stomach contents before feeding.
• Feeding can proceed if only mucus or air is aspirated.
• If liquid residue is present, notify the physician before feeding.

Close Observation of the Preterm Newborn

• Preterm infants require close observation of physical and behavioral responses.
• Observations include:
• General activity
• Fontanelles
• Eyes
• Respirations
• Pulse
• Abdomen
• Cord
• Feeding
• Voiding
• Stools
• Mucous membranes
• Color
• Skin

Positioning and Nursing Care

• Positioning on the side or prone with slight head elevation (unless contraindicated) allows for better breathing, drainage of secretions, and reduced aspiration.
• Propping on the side or prone position can reduce respiratory effort, improve oxygenation, promote organized sleep, and conserve energy.
• Nesting can provide a calming, supportive environment promoting body flexion.
• Gradually wean the infant from the prone position as condition stabilizes, and transition to the supine position before NICU discharge.
• Teach parents about the "back-to-sleep" concept to prevent SIDS.
• Avoid prolonged positioning due to discomfort and potential lung harm.
• Change position regularly to prevent pressure sores on delicate skin.
• Use air exposure and appropriate ointments for diaper rash as prescribed.
• Avoid harsh soaps, alcohol, and medicated wipes on sensitive skin.
• Use hydrocolloid adhesives, gauze, or cotton under tape.
• Maintain hygiene with daily eye, mouth, and diaper cleansing and baths two to three times weekly with emollients.
• Create a quiet environment and coordinate care to minimize overstimulation.
• Use blankets, dimmer lights, and eye patches to protect the infant.
• Awaken the infant slowly and gently for procedures and care, using gentle movement and maintaining flexion of the arms.
• Encourage non-nutritive sucking.
• Co-bedding of twins may enhance growth and development but requires further research for infection risks.

Use of Complementary Medicine in the NICU

• Aromatherapy is used to enhance comfort by placing a mother’s clothing with her natural scent near the infant.
• Other aromatherapy applications are under research.
• Music therapy can calm infants and enhance language development, particularly through parent singing.
• Gentle therapeutic touch and massage offer numerous benefits to preterm infants by reducing motor activity, conserving energy, and promoting bonding with parents.

Prognosis of the Preterm Infant

• Preterm infants typically catch up in growth by the second year of life, unless severe birth defects or complications are present.
• Very-low-birth-weight infants may experience challenges and require additional support to achieve normal growth development.
• Parents should expect and be prepared for comments from relatives about the infant's size and development.
• Growth and development of the preterm infant are determined by adjusting for the weeks of prematurity; for example, a one-month-old infant born at 36 weeks of gestation will be at a newborn's developmental level.

Family Reaction to the Preterm Infant

• Nurses play a crucial role in supporting parents to cope with the challenges of caring for a preterm infant.
• Parents may experience emotions such as sadness, guilt, fear, and difficulty bonding with the infant.
• The nurse should encourage the mother to participate in infant care, starting with basic activities like diapering, bathing, and feeding.
• Encourage parents to express their feelings and provide education on home care.

Characteristics of the Post Term Infant

• A post-term infant is born after 42 weeks of gestation.
• The primary goal is to identify infants who are not tolerating the extended time in the uterus.
• Post-maturity refers to the infant exhibiting characteristics of the post-mature syndrome.
• The placenta ages and may not function adequately as the pregnancy progresses, potentially causing fetal distress.

Problems Associated with Postterm Infants

• Asphyxia due to chronic hypoxia in the uterus.
• Meconium aspiration, which can occur if the infant experiences hypoxia and distress.
• Poor nutritional status and hypoglycemia related to depleted glycogen stores.
• Polycythemia due to intrauterine hypoxia.
• Difficult delivery due to the increased size of the infant.
• Birth defects.
• Seizures as a result of the hypoxic state.

Physical Characteristics of the Post Term Infant

• Long and thin appearance with a potential for weight loss.
• Loose skin, especially around the thighs and buttocks.
• Little lanugo (downy hair) or vernix caseosa, leading to dry, wrinkled skin.
• Long nails that may be stained with meconium.
• Thick head of hair and alert appearance.

Nursing Care of the Post Term Infant

• Labor induction or Cesarean delivery may be recommended if the pregnancy is past 42 weeks or there are signs of fetal distress.
• Close monitoring of infants is essential, including respiratory distress, hypoglycemia, and hyperbilirubinemia.
• Post-term infants may require an incubator due to their vulnerability to cold stress.

Transporting the High-Risk Newborn

• High-risk newborns may require transportation to a regional neonatal center, involving a specialized team.
• Before transport, it's important to stabilize the infant with vital signs, glucose levels, blood gases, and weight.
• Copies of all records, including maternal prenatal history and delivery information, are necessary.
• A transport incubator should be prepared with fully charged batteries.
• Ensure accurate identification of the infant with matching identification bands.
• Keep parents informed of the transport process and provide opportunities for bonding.

Discharge of the High-Risk Newborn

• Discharge planning begins at birth and includes educating parents on routine and specialized care.
• Nurses should provide home visits and support for families caring for high-risk newborns.
• Emphasis should be placed on well-baby examinations, immunizations, infection prevention, and good prenatal care for subsequent pregnancies.
• Communication and support group referrals are crucial for families.

Neutral Thermal Environment

• Maintaining a neutral thermal environment is crucial for preterm infants to conserve energy and prevent heat loss.
• This can be achieved through methods like radiant warmers, skin-to-skin contact (kangaroo care), and minimizing exposure to cold surfaces.

Gavage Feeding

• Gavage feeding may be necessary for infants who are unable to feed orally.
• The feeding tube should be inserted carefully and positioned correctly to minimize the risk of complications.

Nursing Care of Infants with Jaundice Receiving Phototherapy

• Infants with jaundice may receive phototherapy to reduce bilirubin levels.
• Nurses should closely monitor the infant's progress, protect the infant's eyes, and ensure adequate hydration while under phototherapy.

Kangaroo Care and Skin-to-Skin Therapy

• Kangaroo care involves skin-to-skin contact between the parent and infant to regulate temperature, promote bonding, and provide comfort.
• This approach can be beneficial for infants with various conditions, including prematurity.

Discharge Teaching for Families of Infants in the NICU

• Prior to discharge, it's important to educate families on the infant's specific needs, including monitoring, feeding, medications, and developmental milestones.
• Ensuring that all necessary equipment and resources are available for home care.
• Provide contact information for healthcare professionals and support groups.

Review of Main Points

• Preterm newborn care includes close monitoring of their health, providing comfort and support to the infant and family.
• The nurse should be aware of potential complications of prematurity.
• Postterm newborn care focuses on identifying and managing potential issues associated with prolonged gestation.
• Discharge planning and follow-up care are important aspects of managing high-risk newborns.