Newborn Transition to Extrauterine life

Transition to Extrauterine Life

• Review signs and symptoms of abnormal findings
• Understand what warrants the escalation of care
• Be aware of nursing interventions and actions for immediate resuscitation

Initial Assessment

• Apgar scoring involves a quick review of systems
• Reviews completed at 1 and 5 minutes of life to rule out abnormalities
• Allows for rapid assessment of extrauterine adaptation
• Helps implement appropriate nursing actions
• Apgar scores of 0-3 indicate severe distress
• Apgar scores of 4-6 indicate moderate difficulty
• Apgar scores of 7-10 indicate minimal or no difficulty adjusting to extrauterine life

Respiratory System

• Establishment of respiratory function with umbilical cord cutting is paramount
• Air inflates the lungs with the first breath
• Assess for:
  • Ease of breathing
  • Nasal patency
  • Equality of bilateral breath sounds

Abnormal Findings

• Meconium staining can indicate hypoxia
• Crackles and wheezing that are normal for the first 2 minutes only
• Periods of apnea longer than 15 seconds
• Grunting
• Nasal flaring

Complications of Neonatal Respiratory System

• Bradypnea is less than or equal to 30 breaths per minute
• Tachypnea is greater than or equal to 60 breaths per minute
• Abnormal breath sounds:
  • Expiratory grunting
  • Crackles
  • Wheezes
• Respiratory Distress:
  • Nasal flaring
  • Retractions
  • Grunting
  • Gasping
  • Labored breathing
• Airway obstruction is related to mucus

Nursing for Respiratory Distress

• Suction mouth first to prevent aspiration
• Follow up with nose suction with a bulb syringe
• Inadequate oxygen supply

Nursing Care: Stabilization & Resuscitation

• The newborn is able to clear most secretions in the airway by the cough reflex
• Routine suctioning:
  • Mouth first
  • Then nasal passages with bulb syringe
• This is done to remove excess mucus in the respiratory tract
• Use mechanical suction for clearing the airway if bulb suction is unsuccessful
• Institute emergency procedures if the airway does not clear
• Bulb suction should always be kept with the newborn
• Instruct the newborn’s family on bulb suction
• Family member should demonstrate technique

Proper Bulb Technique

• Compress the bulb
• Insert into side of the mouth
• Avoid the center of the mouth to prevent stimulation of gag reflex
• Aspirate mouth
• Aspirate one nostril
• Aspirate second nostril
• Cesarean newborns are more susceptible to fluid remaining in lungs than vaginal newborns

Circulatory System

• Changes occur due to modifications in pressure of the cardiovascular system
• Modifications are related to cutting the umbilical cord
• Occur as the newborn begins breathing independently
• Three shunts close during the newborn's transition to extrauterine life
• Closure occur via the flow of oxygenated blood in the lungs
• Closure via readjustment of atrial blood pressure in the heart

Shunts

• Ductus Arteriosus
• Ductus Venosus
• Foramen Ovale
• Auscultate the heart rate and quality of tones
• Assess the umbilical cord for one vein and two arteries (AVA)
• Ensure the clamp is on properly

Abnormal Findings

• Murmurs require documentation and reporting

The Thermoregulatory System

• Thermoregulation provides a neutral thermal environment
• Helps a newborn maintain normal core temperature
• Requires minimal oxygen consumption and caloric expenditure
• Newborns are at risk for hypothermia and hyperthermia until thermoregulation stabilizes
• Instability is related to: -Large surface-to-weight ratio -Reduced metabolism per unit area -Blood vessels close to the surface -Small amounts of insulation
• Temperature stabilizes at 37°C within 12 hours after birth if chilling is prevented
• Early skin-to-skin contact with the parent is best for promoting and maintaining temperature
• Newborns keep warm by metabolizing brown fat
• Newborns have a narrow temperature range
• Brown fat metabolism is unique to newborns
• Becoming chilled (cold stress) can increase oxygen demands
• Chilling can rapidly use brown fat reserves

Four Mechanisms of Heat Loss

• Conduction: This is heat loss due to direct contact with solid surfaces
• Convection: This is heat loss to currents of air
• Evaporation: Heat loss when water evaporates from skin or breath
• Radiation: Heat loss through electromagnetic waves from skin to surrounding surface

Conduction

• Directs heat loss resulting from direct contact with a cooler surface
• Preheat radiant warmer
• Warm:
  • stethoscope
  • instruments
• Pad a scale before weighing the newborn
• Place the newborn on the client's chest
• Cover with a warm blanket

Convection

• Transfers heat from the body surface to cooler environmental air
• Place the bassinet out of line with fans or air conditioning vents
• Swaddle the newborn in a blanket
• Keep the head covered
• When a newborn needs to be uncovered, do it under a radiant warmer
• Keep the temperature of the nursery and client's room at 22-36 degrees Celsius (72-78 degrees Fahrenheit)

Evaporation

• Surfaces exposed to cooler air converting to vapor results in loss of heat
• Dry the newborn gently after delivery with a warm sterile blanket
• Standard precautions must be taken
• Postpone the initial bath until the newborn's skin is 36.5 degrees Celsius if struggling with thermo regulation
• Expose only one part of the body to water when bathing to avoid heat loss

Radiation

• Heat moves from the body surface to a cooler surface that is nearby
• Keep newborns away from cold windows and air conditioners

Abnormal Findings: Cold Stress

• Increased oxygen demands and acidosis can occur
• Newborns who have respiratory distress are at a higher risk of hypothermia

Nursing Actions

• Monitor for manifestations of cold stress:
  • Pallor with mottling of the skin
  • Cyanotic trunk
  • Tachypnea
• Warm the newborn slowly over 2-4 hours
• Correct hypoxia with oxygen administration
• Correct acidosis and hypoglycemia

Hypothermia

• Monitor axillary temperature every hour
• Should be between 36.5-37.5 degrees Celsius
• Newborns experiencing this may appear cyanotic and have an increased respiratory rate
• Use radiant warmer or skin-to-skin contact if experiencing instability
• Perform all exams and assessments under the radiant warmer or in skin-to-skin contact

Metabolic System: Hypoglycemia

• Metabolic System: Hypoglycemia
• Occurs in the first few hours as the body uses energy to maintain body temp/respirations
• The following are more at risk for hypoglycemia:
  • Mothers with diabetes
  • Small/large for gestational age
  • Less than 34 weeks of gestation
  • Late preterm newborns
• Check blood glucose by heel stick

Nursing Actions

• Check for jitteriness, twitching, weak/abnormal cry, irregular respiratory pattern, cyanosis, lethargy, eye rolling or seizures
• Brain damage can result if brain cells are depleted of glucose

Abnormal Findings

• Hypoglycemia is blood glucose of less than 40 mg/dL
• Hyperglycemia is blood glucose of greater than 60 mg/dL

Equipment for Newborn Assessment

• Bulb Syringe:
  • Used to suction excess mucus from mouth, then nose
  • Squeeze, place tip in mouth corner, release bulb
• Stethoscope:
  • Evaluate heart rate, breath sounds, bowel sounds
• Axillary Thermometer:
  • Monitors body temperature, prevents hypothermia
  • Do not use rectal temperature-taking!
• Blood Pressure Cuff:
  • An electronic cuff is needed
  • Can evaluate cardiac problems in all 4 extremities
• Scale with Protective Cover:
  • Set scale to 0
  • Weigh pounds, ounces, and grams
• Tape Measure:
  • Should measure in centimeters
  • Measure from crown of head to heel for the length
  • Measure head, chest, and abdominal circumferences
• Clean Gloves:
  • Needed for all physical assessments until discharge

Gestational Age Assessment/Classification

• Assessment should be done in 48 hours after birth
• Neonatal morbidity and mortality is impacted by this assessment
• Assessment uses measurements and the New Ballard Score
• Estimate gestational age, establish development baseline

Gestational Size

• AGA or Appropriate Gestational Age: 10th-90th percentile for weight.
• SGA or Small Gestational Age: less than 10th percentile
• LGA or Large Gestational Age: greater than 90th percentile
• LBW or Low Birth Weight: weight is under 2500 g at birth
• IUGR or Intrauterine Growth Restriction: growth rate does not meet norms
• Term = birth is between 37 - 42 weeks
  • Early Term = 37 0/7 - 38 6/7
  • Late Term = 41 0/7 - 41 6/7
• Preterm = born before 37 weeks gestation
• Postterm = born after 42 weeks gestation with signs of placental insufficiency
  • Placenta will appear calcified

Ranges

• weight: 2500-4000 grams or 5.5-8.8 lbs
  • Use the same scale to measure daily
• length: 45-55 cm or 18-22 in
• Head Circumference: 32-36.8 cm or 12.6 - 14.5 in
• Chest Circumference: 30-33 cm or 12-13 in

New Ballard Score

• is a maternity rated newborn score
• used to assess neuromuscular and physical maturity
• each section measures growth at 6 different development ranges
• a number is assigned between -1 and 5, added together for maturity rating
• A lower score means a lower gestational age

Vital Sign Assessment

• Use this sequence: respiration, then other vitals
• Take initial set every 30 minutes X’s 2, follow up every hour X’s 2, then every 8 hours

Newborn Vital Signs

• RR: 30-60 breaths per minute May have short apnea period under 15 seconds
• HR: 110-160 BPM Assess apical pulse over one full minute
• BP: 60-80 systolic / 40-50 diastolic
• Temperature: 36.5 - 37 C or 97.7 - 99.5 F

Physical Exam Considerations: Posture

• Curled-up with arms & legs in moderate flexion
• extremities should have resistance to extension

Physical Exam Considerations: Skin

• Initially deep red to purple with acrocyanosis
• Skin color fades to the patient’s genetic background
• Secondary to increased bilirubin; may see jaundice on day 3
• Skin should spring back immediately; quick turgor and hydration noted
• Should be dry, soft, smooth
• Cracks can be documented in hands/feet
• Desquamation(peeling) occurs days later in full-term infants

Physical Exam Considerations: Head

• Should be slightly larger in circumference than the chest 2-3 cm or 0.8 - 1.2 inches
• Head circumference greater than 4 cm or 1.6 inches in comparisons with chest
  • May indicate hydrocephalus
• Head circumference less than 32 cm
  • Can indicate microcephaly

Physical Exam of Head

• Anterior fontanel: palpable, 5 cm on average, diamond-shaped
• Posterior fontanel: triangle-shaped, smaller
• Soft and flat; may bulge when the infant cries/coughs/throws up
• Bulging fontanels at rest indicate higher intracranial pressure, infection or hemorrhage
• Depressed fontanels indicate dehydration

Cranial Features

• Sutures should be:
  • Palpable
  • Separated
  • Overlapping
• Caput Succedaneum: Swelling of the soft tissue caused by pressure during labor Found as a soft mass that crosses suture line Generally resolves in 3 - 4 and does not require treatment
• Cephalohematoma: Collection of blood between the periosteum & skull bone Not across the suture line Result of trauma during birth like fetal head against the maternal pelvis for prolonged or difficult labor Occurs within 1-2 days after and resolves in 2-8 weeks

Exam of Eyes

• Should have symmetrical eyes in size and shape
• Third measurement = one-third the distance across both eyes
  • Rules out genetic disorders
• Usually blue or gray after birth
• Glands immature with minimal tears
• Subconjunctival hemorrhages or broken blood vessels are possible after the pressure of birth
• Must have present pupillary and red reflex
• Jerky, random movement

Exam of Ears

• Draw a line from the canthus to the other
  • Should be even with the notch of the newborn’s ear and where the ear meets the scalp
  • If low set may indicate genetics or kidney disorder
• Firm, well-formed cartilage
• Responds to outside smells and sounds
• Check for skin tags

Exam of Nose

• Should be midline, flat, broad, without a bridge, little to no drainage, mucus is common
• Obligate nose breathers until 3 weeks old:
• An obstruction/blockage from nasal can result in cyanosis/asphyxia
• Sneeze to clear

Exam of Mouth

• Assess sucking strength and palate
• Scant saliva normal
• Excess may indicate Tracheoesophageal fistula
• Epstein’s pearls: yellowish/white cysts in gums and junction of hard/soft palate Result from epithelial accumulation and resolve a couple weeks Expected find
• Tongue moves freely or symmetrically and does not protrude
  • Protrusion can mean Down’s syndrome
• Soft and hard palate should be intact
• Check for “thrush”- fungal infection acquired vaginally- gray/white patches on gums/tongue

Exam of Neck

• Short, thick, covered by skin folds
• No webbing
• Moves up/down and side to side freely without assistance
• Head control absence likely means pre-term or Down syndrome

Considerations for the Chest

• Barrel shaped
• Primary diaphragmatic respirations
• Intact clavicles
• Absence of retractions
• Prominent/symmetrical/well-formed nipples
• Possible Breast, 3-10mm nodules

Conditions of Abdomen

• Umbilical odorless & only exhibits intestine
• Observe for bleeding from umbilical cord Properly secured clamp is needed to prevent hemorrhage
• Round, dome-shaped, non-distended
• Bowel sounds active minutes after birth

Exam Considerations for Anogenital & Urinary

• Anus patent & present, without membrane covering, and passes meconium in first 1 to 2 days
• Scrotum has Rugae & Testes present in Men
• Urehtal meatus found at the tip of the pénis of Males
• In women: Labia majora covering the minora & clitoris, edematous There may be some blood tinged vaginal discharge, normal caused by hormones Hymenal Tag present
• Urine passed within first 24hrs with Uric acid crystals producing rust color

Exam Considerations for Extremities

• Full/symmetrical motion & have normal spontaneous movement
• Flexed
• Bowed legs and flexed feet caused by developing lateral muscles

Exam for Hips and Spine

• Check for unusual clicking with hip abduction
• Gluteal folds well-lined over ⅔ of feet
• Bed is Pink, without extra digits
• Spine should be flat, midline and easily flexed

Exam of Senses

• Vision- focusing with 8-12 inches in front face
  • Sensitive & prefers dim settings
  • Pupils reactant to light
  • Track contrasted objects, black and white patterns
  • Discriminate colors within 2-3 months
• Hearing- similar to adults once fluid drains
  • selective to familial voices/intrauterine life/sounds
  • they do turn to sound direction
• Touch- respond to pain and tough on feet, mouth and hands
• Taste- Like sweet
• Smell- sweet smells, like mom

Pain Scales

• Habituation: mechanism where newborn accustoms to environmental stimuli
• CRIES
• SUN
• NIPS

Behavioral Indicators of Pain

• alteration in sleep-wake cycles
• fussiness / irritability
• limb/fist clenching
• grimacing
• Crying / groaning / whimpering
• Increases:
• Vitals, BP, pallor, glucose & decreased Ph
• MISC include dilated pupils/increased muscle tone

Diagnostic and Therapeutic Procedures

•Blood drawn at birth to understand Rh status •Capillary stick: anemia, polycythemia, or clotting problems •Blood glucose checked to evaluate hypoglycemia •12-24 Hgb •44-64 Hct •150/300,000 for platelets •40/60 GLU •RBC •Bilirubin with a high of mg/dl •WBC

Common newborn characteristics

•Vernix which is a protective covering, thick, cheesy •Lanugo which is a downy hair of ears, shoulders & forehead •Milia pearly raised spots and clears up on its own •Mongolian where pigment are grey/black and may indicate genetics so document

Telangiecatatic Nevi

•Bite-like stork bits and may fade

4 Main Newborn Reflexes

Suckling & Rooting: birth to 3-4m Grasp: or Palmar, birth to 3-4m Plantar Grasp: birth to 8 mom Moro

Other reflexes

•Tonic neck reflex: from 3-4 •Babinski: Up to 1y •Stepping: To 4w