Newborn Extrauterine Life PDF

Child Health and Diseases Nursing The Newborn. 1  Objectives 1. Adjustment of the Newborn to Extrauterine Life 2. Nursing Care of the Newborn and Family 3. Some Common Problems of Newborn 2 Age-related development periods...

Child Health and Diseases Nursing The Newborn. 1  Objectives 1. Adjustment of the Newborn to Extrauterine Life 2. Nursing Care of the Newborn and Family 3. Some Common Problems of Newborn 2 Age-related development periods 0-28 day Newborn 0-1 age Infants 1-3 age Toddler 3-6 age Preschooler 6-12 age School-age child 12-18 age Adolescent 3 * New born or early neonatal period is a period from the time of birth up to 7 days of life. *Neonatal period the time of birth up to 28 days of life * A baby whose normal time has expired is called a mature (newborn). 4  Key facts Every year nearly 45% of all under 5 child deaths are among newborn infants, babies in their first 28 days of life or in the neonatal period. Three quarters of all newborn deaths occur in the first week of life. In developing countries, nearly half of all mothers and newborns can not receive skilled care during and/or immediately after birth. Up to two thirds of newborn deaths can be prevented if known, effective health measures are provided at birth and during the first week of life. 5  The most important feature that distinguishes a child from an adult It is in a continuous process of growth, development and change. 6  The Postpartal Period  It is a time of maternal changes that are both retrogressive (involution of the uterus and vagina) and progressive (production of milk for lactation, restoration of the normal menstrual cycle, and beginning of a parenting role).  Protecting a woman’s health as these changes occur is very important for preserving her future childbearing function and for ensuring that she is physically well enough to incorporate her new child into her family.  The period is popularly termed “the fourth trimester of pregnancy”. 7 What to do after the baby is born  The first minutes are very important for a healthy life.  Immediately after the baby's head is born, sterile gauze is wrapped around the finger and the secretions in the mouth are cleaned.  After the baby is born, the umbilical cord is clamped at a distance of 10-15 cm from the abdominal wall.  The second clamping is performed at a distance of 1-2 cm from this clamp and the cord is cut with a sterile scissors.  The whole body and head of the newborn are dried with a mildly heated dry cloth, and the newborn is placed on the mother's chest and skin-to-skin contact is ensured.  A dry, warm blanket is covered and the first breastfeeding attempt is made if the mother and the baby are suitable. 8 What to do after the baby is born  Apgar evaluation is done (1st and 5th minutes)  Jaundice is recorded by evaluating in terms of birth trauma and congenital anomaly.  The baby’s weigh, height and head circumference are measured.  To prevent gonococcal ophthalmia neonatorum, erythromycin or one drop of 0.5% or 1% silver nitrate is placed in the eyes.  1 mg of vitamin K is administered via I.M following delivery.  Umbilical veins are checked (must be two arteries and one vein). Physical evaluation is done  To prevent heat loss, the head is covered and soft cotton clothes are worn. The mother-baby relationship begins. 9  The postpartal period refers to the 6-week period after childbirth The pressure caused by uterine contractions and rupture of membranes during labor acts as a stimulus. Various foreign stimuli (cold, light, sound) are encountered. Breathing begins. Transition from fetal circulation to neonatal circulation. With the activation of the liver, changes occur in the metabolic process. Metabolic processes are stabilized (production of enzymes, increased oxygen saturation, reduced acidosis at birth, healing of birth-induced trauma in neurological tissues). 10 Transition to Extrauterine Life 11  Respiratory adaptation  Output of breathing: It has a complex structure depending on the stimulation of the chemical and emotional layers of the respiratory center in the brain and mechanical stimulation of the scans.  After the baby's head is born, the mother's vaginal muscles apply pressure to the fetal thorax. With this negative pressure, air passively enters the growths and approximately one-third of the fetal growth fluid is expelled.  After birth, as a reflex expansion of the chest, air fills inside the baby’s lungs. Takes in place of the excreted fluid. Crying creates positive pressure in the thorax. The alveoli open, the fluid remaining in fetal scans passes into the pulmonary capillaries and lymphatic passage.  Sensory stimuli in the newborn, such as heat, sound, light, and touch, are actually imitation stimuli that help the child's breathing. 12  Circulatory Adaptation  During the fetal life, the lungs of fetus are inactive. Blood is oxygenated and exchanged for nutrients in the placenta from where it is returned to the fetus through the umbical vein.  At birth, as long as the umbical cord is cut, the baby has to establish its own respiration.  Certain changes in the fetal circulation take place, such as closing of the ductus arteriosus, foramen ovale and the ductus venosus, as these are no longer necessary.  The newborn has to be helped in this transition. 13  Foramen Ovale In the fetus, the ductus venosus shunts a portion of umbilical vein blood flow directly to the inferior vena cava. Thus, it allows oxygenated blood from the placenta to bypass the liver. 14 Ductus Venosus In the fetus, the ductus venosus shunts a portion of umbilical vein blood flow directly to the inferior vena cava. Thus, it allows oxygenated blood from the placenta to bypass the liver. 15 Ductus arteriosis The ductus arteriosus, is a blood vessel in the developing fetus connecting the trunk of the pulmonary artery to the proximal descending aorta. It allows most of the blood from the right ventricle to bypass the fetus's fluid-filled non-functioning lungs. Upon closure at birth, it becomes the ligamentum arteriosum. 16 17 Hemopoietic Compliance  The blood volume in the term newborn is 80-85 ml/kg (Blood values in newborn’s is 80 to 110 ml per kilo, around 300 ml total).  However, these values vary according to the clamping time of the umbilical cord and the gestational age of the baby.  The number of erythrocytes is approximately 4.8-7.1 million/mm3,Hemoglobin level is 14.5-22.5 g /dl.  While the hematocrit level is 48-69% at birth, it can reach up to 44-72% on the third day. 18  Hemopoietic Compliance  Since the intestinal flora of the newborn is not yet developed at birth, vitamin K cannot be made within the body of vitamin K and a single dose of 0.5-1.0 mg vitamin K is sent to each newborn within the first 2 hours after birth for the purpose of prophylaxis of hemorrhagic disease of the newborn. Vitamin K is necessary for the formation of factor II, factor VII, factor IX and factor X. 19  Thermoregulation The 26th-28th days of pregnancy. Brown fat stored in the newborn's scapula, neck, axilla, birth and adrenals, which is stored after the first week, provides heat generation in newborns.  The term brown fat is 2-6% of body weight in a child. Since it can not be renewed, it can not provide heat generation for a long time.  A newborn not only loses heat easily by the means just described; but also has difficulty conserving heat under any circumstances. 20  Mechanism of heat loss 1.Evaporation – drying of skin causes cooling 2.Conduction – coming in contact with cool objects moves heat from body to object 3.Convection – heat transferred to surrounding area 4.Radiation – heat transferred to objects not in direct contact with body 21 Heat Loss Mechanisms 22  Thermoregulation The newborn is very close to hypothermia during the stabilization period (first 6-12 hours) after birth. Symptoms of hypothermia Decrease in activity Lethargy hypotonia Weakness in suction Powerless cry Slow and shallow breathing in the back and extremities 23  Easier and more common causes of hypothermia in newborns oLarge body surface area oThe head makes up 25% of the body surface o Small body mass to generate and retain heat oLack of ability to conserve heat by changing posture oMechanisms regulating body temperature are not fully developed oThin skin and less subcutaneous adipose tissue 24 Newborn Measures Weight: Between 2.5-4.6 kg. (Average 3.4 kg, boys>girls) In the first week, it decreases by 10% with the removal of excess extracellular fluid. Usually reaches their rebirth weight in 10 days Lengths: Varies between 48-52 cm (Average 50 cm) It grows 2.5-4 cm/month in the first 6 months and 1.5-3 cm/month in the second 6 months. 25 Newborn Measures Respiratory rate: 30-60/min. Heart Rate: 120-160 /min. Temperature: 36.5-37.0 BP: 80-(+) 15(s) 46-(+) 15 (d) 26  Respiratory rate Increasing breathing up to 80/minutes in the first minute Average respiratory rate is 30-60/minutes It governs the depth, rate and rhythm of breathing. Sudden dyspnea and cyanosis in a normally breathing baby may be a congenital anomaly or a pathological condition. Performs major diagrammatic breathing and uses abdominal muscles for breathing. Since a baby also breathes through the nose, she/he experiences acute respiratory breaths when her/his nose is blocked. Prolonged crying may cause tachypnea and may tire the resuscitation system. 27 The pulse rate of fetus is 120 – 160 bpm. During and immediately after delivery it can jump up to 180 bpm. During the 1st hour after the birth, it stabilizes at 120 – 140 bpm. When the newborn sleep his\her pulse rate can decrease till 90 to 110 bpm. However, when the child cries, the pulse rate increasing till 180 bpm. 28 Better to palpate femoral pulse rate, than temporal and radial 29 Temperature The most preferred route is the axillary route. Body temperature is 36.5-37 degrees when measured by the axillary route If the baby is not kept warm after birth, the body temperature drops below normal very quickly due to immature body temperature regulation mechanisms and heat loss. Prolonged hypothermia is a harbinger of infection/sepsis in the newborn. Therefore, if the body temperature is not stable after birth, necessary precautions should be taken. 30 Blood pressure Initially, the blood pressure is 80/45 mmHg. In the days following birth, a slow rise is observed, reaching 100/50. Hypotension due to hypovolemia may develop after birth. Hypotension seen within the first 12 hours after birth indicates congenital heart disease, septic shock or internal bleeding. 31  General View NB has a position similar to the intrauterine posture. This position of the newborn Indicates normal muscle tone. 32 Back, arms and legs Mild feet depending on the position in the intrauterine period can be directional. It is expected to gradually return to normal in following months. 33 34  SKIN Normal newborn skin is pink and soft. The skin is usually covered with vernix caseosa, a gray-white substance attached to the skin. This substance protects the baby from maceration of the amniotic fluid in intrauterine life and from heat loss in the hours following birth. The newborn's shoulders, back, extremities, and forehead are covered with fine hairs called laguna. It is less in newborns and more in preterm babies. Wine stains; they are dark pink or red spots that occur due to capillary dilatation and congestion. They are often seen in the face and neck region. Colors do not fade over time. 35  SKIN MILIA WINE VERNIX STAIN CASEOZ A 36 Lanugo 37 Vernix Caseosa water (80%), lipid (10%), protein (10%) and antimicrobial peptide…. 38 Milia – by 2 -4 weeks of age sebaceous glands mature and drain. Teach parents to not squeeze the papules 39 Within 24 hours after birth the skin of most newborns has become extremely dry 40  Erythema Toxicum (no treatment needing) Toxic erythema: These are red-colored rashes seen in the chest, abdomen, back and gluteal region of the newborn. It appears 1-3 days after birth, disappears in 2 weeks. 41 Forceps Marks (disappears in 1-2 days) 42  STRAWBERRY LANUGO HEMANGIOMIA SKIN Telangiectasis Moles 43  Hemangiomas Hemangiomas are vascular tumors on the skin. Some may fade gradually, while others may be permanent. Types of hemangiomas: Nevus flammeus Strawberry hemangiomas Cavernous hemangioma Mongolian spots 44  Head Head Circumference: 32.6-37.2 cm (Average 35 cm). The cranium consists of 8 interconnected bones. 45 Caput Suxadenum It is diffuse edema of the scalp. 46 Cephalhematoma  It is the collection of blood between the cranial bones and the periosteum.  Disappeared 1-2 weeks 47 Fontanelles (anterior – 3 -4 and 2-3 cm, posterior 1 cm) 48 Sutures (closes at about 2 years) 49  Newborn’s eyes Eyelids may be edematous for about 2 days after birth. Pressure during the birth can cause small subconjunctival hemorrage  The infant during first three month usually crying tearlessly (lacrimal duct do not fully mature) Pupils are equidistant and responsive to light. 50  Nose and Mouth  Nose is always big  Mouth is always opens while baby crying and opens symmetrical In the mouth of newborn can be present candida and viral infection 51  Chest and abdomen of newborn  Till the 2 years the head of infant bigger than chest  The breast of newborn can secrete fluid (witch’s milk), because influence of mother hormones  The alveolis open during 24 – 48 hours (in auscultation hearing sound of air passing the mucus)  Bowel sounds should be present the 1th hour after birth  Liver and spleen palpable 1 to 2 cm below the costal margin 52 Chest It is bell shaped. Chest circumference is 2 cm less than head circumference. Breasts may be edematous 53 The Umbilical Cord Swelling, foul-smelling and purulent discharge in the umbilical cord. It may be a sign of infection. It starts to dry on the first day of life and turns brown/black in color. It dies 7-10 days after birth. It should be checked that there are two arterial veins. 54  Gastrointestinal system  First stool as usually passed after 24 hours after birth  Meconium – sticky, tarlike, blackish-green, odorless material formed from mucus, vernix, lanugo, hormones and carbohydrates  Transition stool – in second or third day of life stool becoming green and loose  On the fourth day of life breast-feed baby’s stool became yellow with sweet smell 3 -4 times a day The gastric capacity is 30-60 cc at birth, and the emptying time of the stomach varies between 2-4 hours. The immaturity of the cardiac sphincter and the immature neural control of the stomach can cause uncoordinated peristaltic activity and frequent regurgitation. 55  Urinary System  The average newborn voids within 24 hours after birth (if newborn taking enough fluid) The urine as usually light color and odorless  Voiding is 15 ml  First 1 or 2 days is about 30 to 60 ml total  By week 1, total daily volume rises to about 300 ml  The first voiding can be pink because of uric acid crystals  Small amount of protein can be in urine for first days Kidneys fail to functionally concentrate urine and maintain fluid and electrolyte balance. The glomerular filtration rate is lower than in adults. 56  Androgenital Area  In boys all two testes should be present in scrotum  The vulva in girls can be swollen because of the maternal hormones  Pseudomenstruation (some girls have a mucus vaginal secretion with blood) 57 Immune System  During first 2 months newborns have difficulty forming antibodies, are prone to infection  The most part of immunizations against childhood disease not given before 2 month  Administer hepatitis B vaccine during the first 12 hours after birth 58 Newborn Measures 59 What is APGAR? 60  APGAR Scoring System It is used to evaluate the adaptation of the newborn to extrauterine life. A ctivity/ Muscle Tone P ulse/ Heart Rate G rimace/ Reflex Irritability/ Responsiveness A ppearance/ Skin Color R espiration/ Breathing Mesuring in the minute 1 and 5 after birth 61  Apgar scoring system CRITERIA 0 1 2 Respiration Absent Slow, irregular Good, crying Heart rate Absent Slow (Below More than 100 100) Muscle tone Flaccid Some flexion Active body of extremities movements Reflex response No response Grimace Cry Skin color Blue, pale Body pink, Completely pink extremities blue 62  Score interpretation Score Interpretation Nursing Interventions 7 to 10 Well baby Rarely needs resuscitation Requires 4 to 6 At risk resuscitation INFANT NEEDS Suction INTENSIVE CARE Dry immediately Ventilate until stable Careful observation Intensive 0 to 3 resuscitation ET/ Sick baby PROGNOSIS Ambu bag Ventilate FOR NB IS with 100% O2 CPR 63  Newborn Reflexes Catching Reflex Stepping Reflex4. 3.-4. disappears per month. It disappears in the month. Moro Reflex Babinski reflex 4-6. disappears per month. It disappears at the age of 2 years. Tonic-neck Reflex Sucking Reflex It becomes evident in 1-2 3.-4. disappears per month. months.4.-6. disappears per month. Rooting 64  Nursing care of a newborn or neonate Review of the mother’s pregnancy history  Physical examination of a infant  Analysis of laboratory reports such as hematocrit and blood type  Assessment of parent-child interaction for the beginning of bonding 65 Nursing care of a newborn or neonate Assessment of a newborn or neonate (a baby in the neonatal period) includes a review of the mother’s pregnancy history; physical examination of the infant; analysis of laboratory reports such as hematocrit and blood type, if indicated; and assessment of parent–child interaction for the beginning of bonding. Assessment begins immediately after birth and is continued at every contact during a newborn’s hospital or birthing center stay, early home visits, and well-baby visits. Teaching parents to make assessments concerning their infant’s temperature, respiratory rate, and overall health is crucial so that they can continue to monitor their infant’s health at home 66  Nursing Care Planning nursing care should take into account both the newborn’s needs during this transition period and a mother’s need for adequate rest during the postpartal period. Try to adapt teaching time to the schedules of the mother and her newborn. Although the woman must learn as much as possible about newborn care, she also must go home from the health care setting with enough energy to practice what she has learned. Important planning measures for newborns include helping them regulate their temperature and helping them grow accustomed to breastfeeding or bottle feeding. 67 Nursing Care Supporting the mother and her baby in the prenatal, natal and postnatal period. Helping to develop bonds between family and baby to prevent physiological complications during the newborn's adaptation to extrauterine life. Recognizing the deviations from the normal in the findings of the newborn to maintain optimum care of the newborn. 68 A newborn loses 5 % to 10 % of birth weight during the first few days after birth. A breast feed newborn recaptures birth weight within 10 days, a formula fed infant – 7 days. The 75 % to 90 % of new born weight is fluid 69  Nursing Care  After the birth, a suitable environment should be prepared to establish a close relationship between the parents and the newborn.  With the first sensual contact, the mother-baby bonding process begins. They make eye-to-eye contact. During the first reactive phase of these first interactions, the infant is awake. Getting started is very important.  After the first sensual contact, the baby should be immediately held to the mother's breast and supported to suckle. 70  Ensuring Clarity in Airways During the birth of the head in the newborn, when the birth canal compresses the thorax of the fetus, some of the fluid in the airway cavities is expelled and 20-40 ml of air is drawn into the lungs instead. As soon as the baby's head comes out at birth amniotic fluid in the mouth with sterile gauze, blood or mucus is cleared. 71  Baby radiant warmermouth and then nose is aspirated. Excessive and deep aspiration should be avoided. Because; traumatic mucosal edema can lead to laryngospasm If the fluids in the nose are aspirated first, breathing of the newborn will be stimulated. ASPIRATION RISK 72 Kangaroo care is recommended for newborns from the first hour after birth. Kangaroo care is a best one way to transfer heat from mother to a newborn 73 Do not forget about identification band 74 Phenyl Ketonuria (PKU) Test: A blood sample is taken from the heel of the newborn after feeding (must be fed within the first 24- 36 hours). PKU is a genetically related autosomal recessive protein problem where the level of amino acid, phenyl-alene in the blood is high. With early diagnosis, it is treated with diet and mental retardation of the newborn can be prevented. 75 Initial Hearing Test: this test is evaluated in the quiet-awake state of the newborn. Clap or ring a bell near the newborn's ear. 76 Sleeping Position for newborn 77  Sudden infant death syndrome Risk factors Prone sleeping position is the primary postnatal risk factor. Bed sharing and co-sleeping are identified risk factors for SIDS (more in mothers who smoke) Sleeping in the same room with parents reduces risk compared to sleeping in a separate room It has been reported that pacifier use can reduce the risk of SIDS. Insufficient evidence for development of SIDS after immunization 78 Safe Sleeping Area Suggestions It should be laid in the lower end of the crib. Pillows should not be used as it may cause bending of the neck due to head shift. Bed rails must be available The baby's face should not be covered with any object. The baby's room should be 22-24º. Sudden infant death syndrome is also associated with extreme heat. 79 Sleeping Position for newborn (on the back without pillow) 80 Bathing In order to minimize the risk of hypothermia, it should be done after the baby's vital signs and body temperature have stabilized. WHO (2009) should be done 6 hours after birth. AWHONN (2009) postpartum 2.-4. should be done between hours. Especially for babies younger than 36 weeks, bathing should be delayed until after 24 hours. (WHO 2009) 81  Bathing  In most hospitals, newborns receive a complete bath to wash away vernix caseosa within an hour after birth.  Thereafter, they are bathed once a day, although the procedure may be limited to washing only the baby’s face, diaper area, and skin folds.  Wear gloves when handling newborns until the first bath, to avoid exposing your hands to body secretions.  Babies of mothers with human immunodeficiency virus (HIV) infection should have a thorough bath immediately, to decrease the possibility of HIV transmission. 82  Bathing  Bathing of an infant is best done by the parents under a nurse’s supervision. Be sure the room is warm (about 75° F [24° C]), to prevent chilling.  Bath water should be approximately 98° to 100° F (37° to 38° C), a temperature that feels pleasantly warm to the elbow or wrist.  If soap is used, it should be mild and without a hexachlorophene base.  Bathing should take place before, not after, a feeding, to prevent spitting up or vomiting and possible aspiration. 83 MINOR PROBLEMS OF NEWBORN Vomiting: common. The difference between vomiting and regurgitation should be known. Regurgitation: not strong. It is the condition that a small amount of food comes right after the baby is fed. Improper nutrition causes air swallowing. If there is a long-lasting, gurgling, bile-containing fever and abdominal distension, it should be treated immediately. 84 Infantile colic Rule of thirds (Wessel et al. 1954) in the first three months more than three weeks at least three days a week more than three hours a day described as restlessness and crying spells 85 Infantile colic digestive system immature nervous system immature reasons swallowing air while feeding Gas producing foods excessive stimulus Reflux allergic reactions suddenly starts crying pulls her legs towards sympto her stomach blushes can close their eyes ms completely His belly swells and becomes tense shakes hands 86  back and wrapping the forth in the baby in a stroller soft blanket taking a warm Embrace bath hug White noise, massaging lullaby, your belly singing, with warm playing oil music rocking in lap or cradle 87 Diarrhea Breastfed babies have frequent and soft stools due to the high lactose content of breast milk. Their diapers should be changed 8-10 times a day. Giving sugary water or honey to the baby, not following the hygiene rules during feeding, overfeeding and bottle feeding can cause diarrhea. 88 Cloth Dermatitis Mostly seen in formula-fed newborns Keeping the diaper wet and dirty for a long time, lack of hygiene, diarrhea, antibiotic use, diaper allergic conditions and fungal infections cause diaper rash. The area can be treated by keeping the baby's bottom dry, allowing it to come into contact with the air, and using oily pomades. 89  Baby With Hypoglycemia Hypoglycemia is present when the newborn’s blood glucose concentration is lower than the body’s requirement for cellular energy and metabolism. However, the precise definition of hypoglycemia for every newborn in regard to gestational age, birth weight, metabolic needs, and illness or wellness state remains unknown. 90 Baby With Hypoglycemia 91 92  Treatment If the newborn has a blood glucose below 36 mg/dl (2.0 mmol/L), intervention such as breast- or bottle-feeding should be instituted. If levels remain low despite feeding, intravenous dextrose is warranted. Infants who are at increased risk for developing hypoglycemia should have their blood glucose measured within 1 hour after birth 93  Nursing Care Management Much of the nursing responsibility for the infant with hypoglycemia involves identification of the problem through careful observation of physical status. Another concern is to reduce environmental factors, such as cold stress and respiratory distress, which predispose the infant to the development of a decreased blood glucose level. An important nursing intervention is to assist the mother and infant in establishing successful breastfeeding. 94 Thank you for your attention 95