Nursing Care: Newborn at Risk & Birth Asphyxia

Nursing Care of the Newborn at Risk

• Newborns can be susceptible to illness or even death due to prematurity, physical disorders, or birth complications.
• Predictable risk factors allow for advance identification of risks and preparation.

Care of Newborn Because of Birth Asphyxia

• Also known as hypoxic-ischemic encephalopathy.
• Caused by the baby not getting enough oxygen during the birth process.
• Examples include the mother not getting enough oxygen, high or low maternal blood pressure, placental insufficiency, umbilical cord wrapped too tightly, or prolonged/difficult delivery.
• Breathing slows or ceases as the fetus becomes asphyxiated.
• Perfusion to the brain and other organs decreases.
• Hypoxia forces cells to undergo anaerobic respiration, producing lactic acid, which does not support normal organ function.
• Infant assessment findings include cyanosis, difficult breathing, umbilical cord blood pH less than 7, and an Apgar score of less than 3 for more than 5 minutes.
• Typically requires referral to the NICU, see Table 17.1 for interventions and long-term complications

Newborns With Respiratory Distress

• Respiratory distress syndrome (RDS)
• Transient Tachypnea of the Newborn (TTN)
• Meconium Aspiration Syndrome
• Persistent Pulmonary Hypertension of the Newborn (PPHN)

Respiratory Distress Syndrome (RDS)

• Insufficient surfactant to keep alveoli open.
• Related to nervous system immaturity.
• Seen almost exclusively in premature infants.
• Signs are evident within the first 8 hours of life.
• Treatment includes NICU, oxygen therapy, CPAP, and antenatal steroids if premature birth is likely.

Transient Tachypnea of the Newborn (TTN)

• Common and usually self-limiting.
• Infants have an increased need for oxygen.
• Conditions include mild respiratory distress, sedation by maternal pain medications, prolonged labor, macrosomia, and Cesarean section.
• It usually resolves in 3-5 days of life.

Meconium Aspiration Syndrome

• Meconium is rarely found in amniotic fluid prior to 34 weeks gestation.
• Meconium can block infant bronchioles, causing poor oxygenation.
• Can lead to Pneumonia and Pneumothorax.
• There are signs of respiratory distress.
• Suction and NICU if intubated should be prepared.

Persistent Pulmonary Hypertension of the Newborn (PPHN)

• Fetal circulation persists even after delivery, such as with sepsis or congenital defects.
• Ductus arteriosus/Foramen Ovale remain open.
• Blood is shunted away from the lungs, causing inadequate blood flow for oxygen.
• Signs/Symptoms include RDS, cyanosis that does not improve with oxygen, and shock.

The Newborn With Cold Stress

• The highest risk occurs during the immediate transitional period.
• Higher risk if the newborn is delivered outside the hospital.
• Increased risk for premature infants/SGA, infants with infection or requiring resuscitation.
• See Table 17.3 pg. 286.

Neonatal Hypoglycemia

• Defined as less than 30ml/dL in the first 24 hours of life and less than 45ml/dL thereafter.
• 95% of available glucose is used for brain function.
• Long-term complications include neurological, intellectual, developmental, personality, decreased head size, or seizures.
• Risks include diabetic mothers, glucose used for heat production/asphyxia, inability to feed, and premature birth.
• See Table 17.4 pg. 287.

Newborn With Birth Injuries

• Injuries to the newborn can occur as a result of traction/compression during the birthing process.
• Injury incidence is down to about 2% because of improvements to obstetrics.
• Risk factors include fetal macrosomia, cephalopelvic disproportion, prolonged or rapid labor, use of forceps/vacuum, abnormal presentation, and large fetal head.

Birth Injuries cont. Brachial Plexus / Fracture

• Damage to the nerves that originate in the neck and branch off to form the nerves that control shoulders/arms/hands.
• Symptoms include limited movement to one side of the newborn, no Moro reflex on the affected side, claw-like appearance of the hand on the affected side, and abnormal muscle contraction on the affected side.
• Treatments include spontaneous improvement, physical therapy, and surgical intervention.
• Fracture: the clavicle is the most frequent fracture bone.
• Symptoms are similar to the brachial plexus with palpable bone irregularity; confirms diagnosis with x-ray.

Hyperbilirubinemia

• Also known as Jaundice.
• The most common condition that requires medical attention in newborns.
• When bilirubin levels become saturated, the bilirubin begins to deposit in the brain and can cause neurotoxicity: Kernicterus.
• Risks include prematurity, blood-type incompatibility, ineffective breastfeeding, and bruising from labor.
• Detection diagnosis: begins with assessment of yellow face, yellow sclera, yellow body, and transcutaneous testing.
• Definitive Diagnosis requires laboratory testing.
• Management depends on severity, GA, and weight.
• Breastfeeding, phototherapy, and exchange transfusion.

The Newborn With An Infection

• Exposure to infection can be from the mother through organisms entering the vaginal canal.
• Can be from contaminated hospital personnel or equipment, or from family or visitors.
• Immature immune system; illness can easily become systemic; newborns may exhibit subtle symptoms; should be reported immediately.

Neonatal Sepsis

• Blood infection occurs within the first 28 days of life.
• The most common cause is group B streptococcus (GBS) and Escherichia coli (e-Coli).
• Also caused by Herpes.
• Antibiotics are not effective against viruses.
• A scheduled Cesarean Section is required if active herpes is present.

Problems Related To Gestational Age

• Specific terminology is created to identify preterm, term, and post-term infants.
• Preterm: less than 37wk, 6days.
• Earl Term: 37wk, 6days – 38wk, 6days.
• Full Term: 39wk – 40wk, 6days.
• Late Term: 41wk - 41wk, 6days.
• Post Term: 42wks and beyond.

Small Gestational Age (SGA)/ Intrauterine Growth Restriction (IUGR) Newborn

• SGA: weight is less than the 10th percentile.
• Cause(s): abnormal placenta, maternal hypertension, severe maternal diabetes, poor maternal nutrition, maternal drug use, smoking, exposure to teratogenic substances, alcohol, multi-gestation, parents of small stature.
• IUGR: limited fetal growth; weight/length/head circumference all less than the 10th percentile.
• Diagnosed during pregnancy through ultrasound.
• If poor placental perfusion is the cause, labor may be induced for an early delivery.
• Characterized by a large head related to the body, thin extremities and trunk, loose skin because of absent fat, thin cord.

Term SGA Infant Complications

• Perinatal asphyxia during labor if the SGA was caused by placental insufficiency.
• Meconium aspiration.
• Hypoglycemia because of a lack of stored glycogen.
• Hypothermia because of a lack of subcutaneous fat.

Large for Gestations Age (LGA) Complications

• Weight is greater than the 90th percentile.
• Predominant cause is Maternal Diabetes.
• Shoulder Dystocia, Fracture Clavicle/Limbs, Perinatal asphyxia, Meconium aspiration, Respiratory distress, and Hypoglycemia.

The Preterm Newborn

• Nearly 12% of all newborns in the US are preterm.
• Cause is not known but Risk Factors include low socioeconomic status, cigarette smoking, prior premature births, multiple abortions, poor nutrition, untreated infections, pre-eclampsia, and multiple gestation.
• Thin skin, arteries, and veins are visible.
• Skin is fragile and looks smooth and shiny.
• Fingernails and toenails may only be partially formed.
• Ears may fold over with less developed cartilage.
• Less muscle tone.
• Have more vernix than a full term.

The Preterm Newborn: Potential Complications

• Respiratory distress syndrome (RDS)
• Hypothermia
• Heart problems
• Intraventricular hemorrhage in the brain
• Necrotizing enterocolitis
• Anemia
• Infection
• Fluid/Electrolyte Imbalances
• Apnea
• LONG TERM: Retinopathy of Prematurity (ROP), Cerebral Palsy, Delayed development.

The Post Term Newborn

• Born >42 weeks.
• The cause is unknown; Risks include previous post-term delivery, results in a large infant, and placental insufficiency.
• Characteristics; more alert, decreased subcutaneous fat, loose skin, dry and peeling skin, long fingernails and toenails, and meconium stain on the umbilical cord.
• Complications include Stillbirth or neonatal death, large body size causing prolonged labor or birth trauma, hypoglycemia, and meconium aspiration.

Infant of Diabetic Mother (IDM)

• Good control in pregnancy minimizes problems in the newborn.
• Major newborn problems include macrosomia (LGA) causing birth injury, hypoglycemia, polycythemia (increased RBC), hypocalcemia, hypomagnesemia, and fetal malformations.
• Spina bifida: is 20x higher for the IDM.
• Suspected Fetal macrosomia.
• An infant weighing more than 4,000g.
• High levels of maternal glucose during pregnancy cause increased growth of the fetus.
• Closely Observe for: hypoglycemia signs of birth injuries gestational aging.

Chemically Exposed Infants

• Substance abuse is a significant problem in the US.
• Almost all drugs cross the placenta and have an effect on the fetus.
• Early gestation: cause structural birth defects.
• Later gestation: alterations in neurotransmitter and receptors and brain organization.
• NICU for IV support, and withdrawal management.
• Both short-term and longer-term complications are likely.

The Newborn Exposed to HIV

• Transmitted from mother to child during pregnancy, labor and delivery, or breastfeeding.
• Risk is 25% - 40% without intervention, ex. antiviral therapy.
• Nursing interventions include strict precautions to avoid exposure, gloves worn by anyone handling the newborn until the first bath, administering medications as ordered, educating parents on the importance of following the drug plan, and advising the mother not to breastfeed.

Care of the Family of At-Risk Newborn

• Emotions to expect include fear of the unknown (NICU environment), anger, guilt, loss of bonding and attachment time, loss of control, frustration, jealousy of other families, anxiety, and helplessness.
• Nursing Interventions: provide opportunities for parents to hold and bond with the newborn, develop a therapeutic relationship with parents, provide positive reinforcement for concerns, encourage parents to talk to the NICU, avoid interrupting parents, answer questions honestly, demonstrate care for the baby, refer to the baby by name, allow parents to provide care (bathing/feeding), teach home care before discharge, allow skin-to-skin contact whenever possible.

Preventative Health Screening for Women

• Goals include prevention and early detection of illness, avoiding disabling conditions, lessening the severity of disabling conditions, and including disorders exclusive or dominant in women.
• See Table 3.1 pg. 29.

Menstrual Disorders

• Amenorrhea
• Dysmenorrhea
• Dysfunctional Uterine Bleeding
• Midmenstrual Cycle Pain
• Premenstrual Syndrome
• Premenstrual Dysphoric disorder
• Endometriosis

Amenorrhea

• Absence of menstrual periods.
• Classifications include primary which is the failure of menses to occur by age 16 and secondary which is the cessation sometimes after the first menstrual period lasting three consecutive cycles or a time period of more than 6 months.
• Most common cause is Pregnancy.
• Other Causes: excessive weight loss, excessive exercise, ovary failure, disorders of the pituitary, disorder of the hypothalamus, or emotional stress.

Dysmenorrhea

• Refers to painful menstrual cramps that occur immediately before or during the early part of the menstrual period.
• Endometriosis: uterine tissue has grown outside the uterus.
• Fibroids: benign tumors in the inner wall of the uterus.
• Management: NSAIDs, heat pad, warm bath, and seeing a healthcare provider for severe symptoms.

Dysfunctional Uterine Bleeding

• Irregular bleeding occurs in the absence of a pelvic disorder, medical disease, or pregnancy.
• The bleeding is unpredictable and can be excessively heavy or very light. It can be prolonged, short, frequent, or random.
• Management: Hormone therapy, oral contraceptives, endometrial ablation(procedure that destroys the uterine lining), or hysterectomy.

Midmenstrual Cycle Pain

• Pain occurs midway through the menstrual cycle.
• This is a normal finding.
• Treat with ibuprofen or acetaminophen.
• Requires physician if severe, potentially a suspected ovarian cyst.

Premenstrual Syndrome (PMS)

• Variety of Symptoms: Difficulty Sleeping, Irritability, Crying Spells, Depression, Wight Gain, Acne, Dysmenorrhea, Hot flashes, Angry Feeling, and Mood Swings.
• Includes Headache, Abdominal Bloating, Breast Tenderness, Swelling of the Extremities, Cravings for Sweet or Salty Food, General Aches and Pains.
• Treatments: Lifestyle Changes, Medications, and Nutritional Substances.

Premenstrual Dysphoric Disorder (PMDD)

• This is a severe form of PMS.
• Additional Symptoms: Decrease Interest in social activities, Difficult Concentrating, Lack of Energy, Insomnia, Feeling Overwhelmed, Change in Appetite, and Abdominal Bloating.
• Treatments: Hormone Therapy, Anxiolytics, Acupuncture, Relaxation Techniques, Light Therapy, and CBT.

Endometriosis

• Endometrial-like tissue is outside the uterus.
• The tissue responds to hormones & bleeds.
• Bleeding causes inflammation & scarring.
• Symptoms include dysmenorrhea, pain, pressure, inflammation, dyspareunia (painful intercourse), and infertility.
• Treatment: medical, surgical, or both.

Nursing Care for Women With Menstrual Disorders

• Nurses should teach about the normal menstrual cycle, teach how to keep record of bleeding, normal and abnormal occurrences.
• They should discuss avoiding salt, caffeine, and sugary foods that contribute to PMS.
• Patients should have adequate nutrition and should avoid excessive exercise.
• Discuss management of menstrual pain.
• Provide information about diagnostic procedures and regular examinations and tests.

Family Planning

• Includes contraceptive choices.

Natural Family Planning

• Most widely used methods are low cost, hormone-free, and acceptable for most religious or cultural beliefs.
• These methods rely on regular ovulation patterns to prevent pregnancy.
• These methods are less effective than other types of contraception.
• Coitus interruptus.
• Periodic abstinence.
• Lactational amenorrhea.
• Cervical mucus monitoring.
• Body-based temperature monitoring.

Barrier Methods of Contraception

• Male Condom
• Female Condom
• Spermicides
• Sponge
• Diaphragm or cervical cap
• Available OTC w/o Rx and are inexpensive.

Hormonal Contraceptives

• Contain progesterone alone or combinations of estrogen and progesterone to prevent ovulation.
• Safety Concerns; can activate the blood-clotting mechanism that higher risk of thrombosis, can raise blood pressure, or cause vasoconstriction in women who smoke.
• Contraindicated for women over age 35, smoking, or a history of breast cancer, DVT, or PE.
• Examples include Combined Oral Contraceptives “the-pill,” Progestin-Only Pill “mini-pill,” Implants, Transdermal Patches, vaginal rings and Injectable Depot Medroxyprogesterone Acetate.

Intrauterine Device Contraceptive

• An IUD is a T-shaped device implanted into the uterus.
• A Copper device releases a small amount of copper that prevents sperm from fertilizing the egg.
• Usually, does not interfere with the menstrual cycle.

Permanent Contraception

• Tubal Ligation for Women: is usually done after Cesarean Section and surgery is required and is not reversible.
• Vasectomy for men: is less permanent but can be reversed.

Nursing Care Related To Family Planning

• Provide information that can help them select a birth control method appropriately and educate on the correct administration or use of her chosen method.
• Provide education about side effects and the effectiveness of contraception.
• Encourage patients to report side effects promptly.

Infertility Care

• Infertility is categorized as the failure to conceive after 1 year of unprotected intercourse.
• Common Risk factors include a maternal age greater than 35 years, smoking, stress, scar tissue (STI), alcohol, obesity, low BMI, and excessive exercise.

Infertility Cont.

• The female test hysterosalpingography.
• Female Causes include early menopause, ovulation problems, reproductive tract abnormalities, endometriosis, thyroid problems, and cancer treatments.
• Male Causes: Inadequate sperm production, sperm delivery problems, exposure to toxins, exposure to excessive heat, and cancer treatment.

Nursing Care

• Involves providing a supportive role and encouraging communication.
• Nurses should encourage the expression of feelings and suggest coping strategies such as support groups and stress management.

Female Reproductive Tract Disorders

• Uterine fibroids (leiomyomas)
• Causes are unknown
• Size ranges from a pea-size to a melon
• Symptoms:
  • Heavy menstrual bleeding
  • Severe menstrual cramping
  • Passing of large clots during menses
  • Prolonged menstrual periods
  • Pelvic pressure or pain
  • Infertility
• Management usually consists of watching and waiting to see if they grow or shrink during menopause.
• If they are too large a healthcare provider with interfere

Female Reproductive Tract disorders Cont.

• Ovarian cysts: Fluid-filled sacs in the Ovary
• Symptoms:
  • Pressure or swelling in the abdomen
  • Problems emptying the bladder or bowels
  • Dull aching in the lower back
  • Pain during sexual intercourse
  • Painful menstrual periods
  • Abnormal bleeding

Polycystic Ovary Syndrome (PCOS)

• This affects the entire body not just the reproductive system
• Hormonal imbalances causing high levels of androgens in a woman's body that prevents the ovaries from releasing eggs.
• Symptoms:
  • Irregular or absent menstrual periods
  • Extra hair growth on the face
  • Acne that is difficult to resolve
  • Weight gain and difficult losing weight
  • Parches of dark skin on the neck and other areas such as under-arms and groin

Infectious Disorders of Reproductive Tract/ STIs

• Trichomonas vaginalis
• Chlamydia
• Gonorrhea
• Syphilis PID
• HPV
• HSV
• HIV
• SEE Table 3.2 pg. 43

Toxic Shock Syndrome

• 50% of people with TSS are menstruating women.
• Toxin producing Staph aureus that is trapped in the reproductive tract.
• S & S - sudden high fever, “flu-ish,” hypotension, generalized rash with peeling.
• Nursing implications includes teachin proper tampon & diaphragm use and not leaving either in place too long.

Pelvic Floor Disorders

• Damage from childbirth, aging, and decreased estrogen at menopause.
• Cystocele: prolapse of the bladder into the vagina.
• Rectocele: prolapse of the rectum into the vagina.
• Uterine prolapse: downward displacement of the uterus into the vagina.
• Prolapse of Vagina: the upper part drops into the lower part, causing the vagina to turn inside out.