Maternal & Child Health Nursing PDF

15610_Ch25.qxd 7/6/09 6:42 AM Page 696 696 UNIT 4 The Nursing Role During a Complication of Pregnancy, Birth, or the Postpartal Period illness (American Psychiatric Association [APA], 2000). orrhage, administration of oxytocin may be necessary to...

15610_Ch25.qxd 7/6/09 6:42 AM Page 696 696 UNIT 4 The Nursing Role During a Complication of Pregnancy, Birth, or the Postpartal Period illness (American Psychiatric Association [APA], 2000). orrhage, administration of oxytocin may be necessary to When the illness coincides with the postpartal period, it is initiate uterine tone and halt the bleeding. called postpartal psychosis (Haessler & Rosenthal, 2007). Other causes of hemorrhage include lacerations (vaginal, Rather than being a response to the physical aspects of child- cervical, or perineal) and retained placental fragments. bearing, however, it is probably a response to the crisis of Lacerations are most apt to occur with forceps birth or childbearing. The majority of these women have had symp- with the birth of a large infant. Disseminated intravascu- toms of mental illness before pregnancy. If the pregnancy had not precipitated the illness, a death in the family, loss of a job lar coagulation can also cause postpartum hemorrhage. or income, divorce, or some other major life crisis would Puerperal infection (a temperature greater than 100.4° F probably have precipitated the same recurrence. or 38.0° C) is a potential complication after any birth A woman with postpartal psychosis usually appears ex- until the denuded placental surface has healed. Retained ceptionally sad. By definition, psychosis exists when a per- placental fragments and the use of internal fetal heart son has lost contact with reality. A woman with a postpartal monitoring leads are potential sources of infection. psychosis may deny that she has had a child and, when the Thrombophlebitis, an inflammation of the lining of a child is brought to her, insist that she was never pregnant. blood vessel, occurs most often as an extension of an en- She may voice thoughts of infanticide or that her infant is dometrial infection. Therapy includes bed rest with moist possessed. If observation tells you that a woman is not func- heat applications and anticoagulant therapy. Never mas- tioning in reality, you cannot improve her concept of reality sage the leg of a woman with thrombophlebitis; doing so can by a simple measure such as explaining what a correct per- ception is. Her sensory input is too disturbed to compre- cause the clot to move and become a pulmonary embolus, hend this. In addition, she may interpret your attempt as a possibly fatal complication. threatening. She may respond with anger or become equally Mastitis is infection of the breast. The symptoms include threatening. A psychosis is a severe mental illness that re- pain, swelling, and redness. Antibiotic therapy is necessary. quires referral to a professional psychiatric counselor and an- A woman whose child is born with a physical or cognitive tipsychotic medication. challenge needs special consideration after birth. This is While waiting for such a skilled professional to arrive, do obviously a time of stress, and a woman needs supportive not leave the woman alone, because her distorted perception nursing care. might lead her to harm herself. Nor should you leave her Postpartal “blues” are a normal accompaniment to birth. alone with her infant. Postpartal depression (a feeling of extreme sadness) and Always keep in mind that postpartum psychosis does postpartal psychosis (an actual separation from reality) are exist, although it is rare. Remembering that childbearing can lead to this degree of mental illness helps you to put child- not normal and need accurate assessment so a woman can bearing into perspective. For some people, childbearing is receive adequate therapy for these conditions. such a crisis in their lives that it triggers mental illness. Certainly, it cannot be considered an everyday incident in anyone’s life. CRITICAL THINKING EXERCISES ✔Checkpoint Question 25.3 1. Mary Blackhawk, whom you met at the beginning of Which statement by Mary Blackhawk is most suggestive of a woman developing postpartal psychosis? the chapter, was having heavy vaginal bleeding at 4 hours after birth. Because she was sleeping, however, she a. “I wish my baby had more hair.” was totally unaware of it. What action on your part b. “My baby has the devil’s eyes.” would have prevented so much blood loss? What action c. “I feel exhausted since birth.” d. “Breastfeeding is harder than I thought.” would be most appropriate now? 2. Eight hours after birth, Mary Blackhawk tells you that she has frequency and burning on urination. She had a urinary tract infection during pregnancy, so she recog- Key Points for Review nizes the symptoms. She has some medicine left from pregnancy and tells you that she will take it to cure the infection. What advice would you give her? Establishing a firm family–newborn relationship may be 3. When Mary returns for a postpartal checkup, you no- difficult when a woman has a postpartal complication. tice red streaks on both legs along the course of her Investigate ways that will allow a woman to care for her veins, and she has pain on dorsiflexion of her foot. You baby, or offer necessary support to family members so that are concerned that she is developing thrombophlebitis. they can fulfill this role. Describe a plan of care that could have reduced this risk Hemorrhage (defined as a loss of blood greater than during labor and in the immediate postpartal period. 500 mL within a 24-hour period) is a major potential 4. Examine the National Health Goals related to compli- danger in the immediate postpartal period. The most cations of the puerperium. Most government-sponsored frequent cause of postpartal hemorrhage is uterine funds for nursing research are allotted based on these atony. Continuous limited blood loss can be as impor- goals. What would be a possible research topic to ex- tant over time as sudden, intense bleeding. With hem- 15610_Ch25.qxd 7/6/09 6:42 AM Page 697 CHAPTER 25 Nursing Care of a Family Experiencing a Postpartal Complication 697 Miller, D. A. (2007). Hypertension in pregnancy. In A. H. DeCherney & plore pertinent to these goals that would be applicable L. Nathan (Eds.). Current diagnosis and treatment in obstetrics and gyne- to the Blackhawk family and also advance evidence- cology (10th ed.). Columbus, OH: McGraw-Hill. based practice? Leahy-Warren, P., & McCarthy, G. (2007). Postnatal depression: preva- lence, mothers’ perspectives, and treatments. Archives of Psychiatric Nursing, 21(2), 91–100. McGarry, J., et al. (2009). Postpartum depression and help-seeking behavior. Journal of Midwifery & Women’s Health, 54(1), 50–56. CRITICAL THINKING SCENARIO Musselwhite, K. L., et al. (2007). Use of epidural anesthesia and the risk of acute postpartum urinary retention. American Journal of Obstetrics and Open the accompanying CD-ROM or visit http:// Gynecology, 196(5), 472–473. Nelson, W. L., & O’Brien, J. M. (2007). The uterine sandwich for persis- thePoint.lww.com and read the Patient Scenario in- tent uterine atony: combining the B-Lynch compression suture and an cluded for this chapter, then answer the questions to intrauterine Bakri balloon. American Journal of Obstetrics and Gynecology, further sharpen your skills and grow more familiar with 196(5), e9–e10. NCLEX style questions related to postpartal complica- Pavone, M. E., Purinton, S. C., & Petersen, S. M. (2007). Postpartum care tions. Confirm your answers are correct by reading the and breast-feeding. In K. B. Fortner, et al. (Eds.). The Johns Hopkins manual of gynecology and obstetrics. Philadelphia: Lippincott Williams & rationales. Wilkins. Poggi, S. B. H. (2007). Postpartum hemorrhage and the abnormal puer- perium. In A. H. DeCherney & L. Nathan (Eds.). Current diagnosis and treatment in obstetrics and gynecology (10th ed.). Columbus, OH: REFERENCES McGraw-Hill. Reddy, P., et al. (2007). Postpartum mastitis and community-acquired me- American Psychiatric Association (APA). (2000). Diagnostic and statistical thicillin-resistant Staphylococcus aureus. Emerging Infectious Diseases, manual (DSM-IV). Washington, D.C.: Author. 13(2), 298–301. Bailis, A., & Witter, F. R. (2007). Hypertensive disorders of pregnancy. In Schatzberg, A. F., Cole, J. O., & DeBattista, C. (2007). Manual of clinical K. B. Fortner, et al. (Eds.). The Johns Hopkins manual of gynecology and psychopharmacology (6th ed.). Columbus, OH: McGraw-Hill. obstetrics. Philadelphia: Lippincott Williams & Wilkins. Szymanski, L. M., & Bienstock, J. L. (2007). Complications of labor and Baker, E. G. (2008). Beyond the blues: a guide to understanding and treat- delivery. In K. B. Fortner, et al. (Eds.). The Johns Hopkins manual of gy- ing prenatal and postpartum depression. Journal of Midwifery and necology and obstetrics. Philadelphia: Lippincott Williams & Wilkins. Women’s Health, 53(1), 9. Begley, J. S., & Barnes, R. C. (2007). Group B streptococcus toxic shock- like syndrome in a healthy woman: a case report. Journal of Reproductive Medicine, 52(4), 323–325. SUGGESTED READINGS Cansino, C. D., & Lipsett, P. (2007). Critical care. In K. B. Fortner, et al. Cuijpers, P., Brannmark, J. G., & van Straten, A. (2008). Psychological (Eds.). The Johns Hopkins manual of gynecology and obstetrics. treatment of postpartum depression: a meta-analysis. Journal of Clinical Philadelphia: Lippincott Williams & Wilkins. Psychology, 64(1), 103–118. Chelmow, D., Aronson, M. P., & Wosu, U. (2007). Intraoperative and Krummel, D. A. (2007). Postpartum weight control: a vicious cycle. postoperative complications of gynecologic surgery. In A. H. DeCherney Journal of the American Dietetic Association, 107(1), 37–40. & L. Nathan (Eds.). Current diagnosis and treatment in obstetrics and gy- Porter, S. (2007). Blood loss, replacement and belief. RCM Midwives, necology (10th ed.). Columbus, OH: McGraw-Hill. 10(2), 72–75. Crombleholme, W. R. (2009). Obstetrics. In S. J. McPhee & M. A. Mahlmeister, L. R. (2007). Legal issues and risk management. Best practices Papadakis (Eds.). Current medical diagnosis and treatment. Columbus, in perinatal nursing: improving outcomes for obese and morbidly obese OH: McGraw-Hill. women during the intrapartum and postpartum periods. Journal of Flores-Quijano, M. E., et al. (2008). Risk for postpartum depression, Perinatal and Neonatal Nursing, 21(2), 86–88. breastfeeding practices, and mammary gland permeability. Journal of Mousa, H. A., & Alfirevic, Z. (2009). Treatment for primary postpartum Human Lactation, 24(1), 50–57. haemorrhage. Cochrane Database of Systematic Reviews, 2009(1) Gates, S., Brocklehurst, P., & Davis, L. J. (2009). Prophylaxis for venous (CD003249). thromboembolic disease in pregnancy and the early postnatal period. Rowan, C., Bick, D., & Bastos, M. H. S. (2007). Postnatal debriefing in- Cochrane Database of Systematic Reviews, 2009(1), (CD001689). terventions to prevent maternal mental health problems after birth: ex- Haessler, A., & Rosenthal, M. B. (2007). Psychological aspects of obstetrics ploring the gap between the evidence and UK policy and practice. and gynecology. In A. H. DeCherney & L. Nathan (Eds.). Current di- Worldviews on Evidence-Based Nursing, 4(2), 97–105. agnosis and treatment in obstetrics and gynecology (10th ed.). Columbus, Runquist, J. (2007). Persevering through postpartum fatigue. JOGNN: OH: McGraw-Hill. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 36(1), 28–37. Hay-Smith, E. J. C., & Dumoulin, C. (2009). Pelvic floor muscle training Rychnovsky, J. D. (2007). Postpartum fatigue in the active-duty military versus no treatment, or inactive control treatments, for urinary inconti- woman. JOGNN: Journal of Obstetric, Gynecologic, and Neonatal nence in women. Cochrane Database of Systematic Reviews, 2009(1), Nursing, 36(1), 38–46. (CD005654). Walker, L. O., & Sterling, B. S. (2007).The structure of thriving/distress Karch, A. M. (2009). Lippincott’s nursing drug guide. Philadelphia: among low-income women at 3 months after giving birth. Family and Lippincott Williams & Wilkins. Community Health, 30(1S), S95–S103. Keller, C., et al. (2008). Interventions for weight management in postpar- Williams, A., Herron-Marx, S., & Knibb, R. (2007). The prevalence of en- tum women. JOGNN: Journal of Obstetric, Gynecologic, and Neonatal during postnatal perineal morbidity and its relationship to type of birth Nursing, 37(1), 71–79. and birth risk factors. Journal of Clinical Nursing, 16(3), 549–561. 15610_Ch26.qxd 6/22/09 9:14 AM Page 698 Chapter Nursing Care of a Family With a 26 High-Risk Newborn K E Y T E R M S Mr. and Mrs. Atkins are apnea the parents of a 34- hyperbilirubinemia apparent life-threatening event intrauterine growth restriction week-gestation, 2-lb appropriate for gestational large for gestational age (LGA) baby boy born last age (AGA) low-birth-weight infant brown fat macrosomia night after a short, caudal regression syndrome ophthalmia neonatorum 4-hour labor. Their baby took a few developmental care periodic respirations gasping respirations at birth but then dysmature periventricular leukomalacia extracorporeal membrane postterm syndrome stopped breathing. He was resuscitated oxygenation (ECMO) preterm infants by the neonatal nurse practitioner and fetal alcohol syndrome retinopathy of prematurity respiratory therapist and then trans- gestational age shoulder dystocia hemorrhagic disease of the small for gestational age (SGA) ported to the intensive care nursery. newborn Mr. Atkins was not present for the birth hydrops fetalis because he was out of town on busi- O B J E C T I V E S ness. You notice Mrs. Atkins has not After mastering the contents of this chapter, you should be able to: visited the intensive care nursery to see 1. Define the following terms—small-for-gestational-age infant, term her son. She also refused to sign the infant, large-for-gestational-age infant, preterm infant, and postterm birth certificate because she could not infant—and describe common illnesses that occur in these and decide on a name. She said, “I don’t other high-risk newborns. 2. Identify National Health Goals related to high-risk newborns nurses want to give him our favorite name can be instrumental in helping the nation achieve. because he might die.” Mr. Atkins 3. Use critical thinking to analyze the special crisis imposed on fami- called early this morning and acted lies when alterations of newborn development or neonatal illness occur to make nursing family centered. more upset the baby was born than 4. Assess a high-risk newborn to determine whether safe transition to relieved the baby was receiving extrauterine life has occurred. intensive care. You hear him ask his 5. Formulate nursing diagnoses related to a high-risk newborn. 6. Identify expected outcomes for a high-risk newborn and family. wife, “What did you do to cause this?” 7. Plan nursing care focused on priorities to stabilize a high-risk Previous chapters described the birth of newborn’s body systems. 8. Implement nursing care for a high-risk newborn such as monitoring well newborns and care of newborns body temperature. who are well at birth. This chapter adds 9. Evaluate expected outcomes for achievement and effectiveness information on care of newborns who of care. 10. Identify areas related to the care of high-risk newborns that could are ill or have a significant variation in benefit from additional nursing research or application of evidence- gestational age or weight. Learning to based practice. recognize these infants at birth and 11. Integrate knowledge of the needs of a high-risk newborn with nursing process to achieve quality maternal and child health nursing care. organizing care for them can be instrumental in helping protect both their present and future health. What type of help do the Atkinses need to better accept what has happened to them? 698 15610_Ch26.qxd 6/22/09 9:14 AM Page 699 CHAPTER 26 Nursing Care of a Family With a High-Risk Newborn 699 During pregnancy, screening women for risk factors that has difficulty establishing respirations. Immediate, skilled could lead to illness in a newborn such as younger or older handling of any problems that occur may help to save the than average maternal age, concurrent disease conditions such newborn’s life and also prevent future problems, such as as diabetes or human immunodeficiency virus (HIV) infec- neurologic disorders (Saigal & Doyle, 2008). tion, pregnancy complications such as placenta previa, or an unhealthy maternal lifestyle such as drug abuse is essential to identify infants who may need greater-than-usual care at birth Nursing Process Overview (Pinheiro, 2007). Unfortunately, not all instances of high risk can be predicted. Even a newborn from a “perfect” pregnancy For the Family of a High-Risk Newborn may require specialized care or develop a problem over the first few days of life necessitating special interventions. Any infant Assessment who is born dysmature (before term or postterm, or who is All infants need to be assessed at birth for obvious con- underweight or overweight for gestational age) is also at risk for genital anomalies and gestational age (number of weeks complications at birth or in the first few days of life. Parents they remained in utero). Both determinations can be done need thorough education about their baby’s health because by the nurse who first examines an infant. Be certain these these problems may require rehospitalization or additional fol- assessments are made with an infant under a prewarmed low-up at home. National Health Goals related to the high- radiant heat warmer to guard against heat loss. risk newborn are shown in Box 26.1. Continuing assessment of high-risk infants involves Being able to predict an infant is at high risk allows for the use of instrumentation such as cardiac, apnea, and advanced preparation so that specialized, skilled health care blood pressure monitoring. However, no matter how personnel can be present at the child’s birth to perform nec- many monitors are used, they never replace the role of fre- essary interventions, such as resuscitating a newborn who quent, close, common-sense observation. Carefully evalu- ate comments from fellow nurses that an infant “isn’t himself” or “breathes oddly.” These comments, although not scientific, are the same observations that parents who BOX 26.1 ✽ Focus on know their baby well report at health visits. A nurse who National Health Goals knows an infant well from having cared for a baby consis- tently over time often senses changes before a monitor or Preterm birth has the potential for leading to so many other equipment begins to put a quantitative measure- complications in newborns that National Health Goals ment on the factor. were written specifically concerning preterm birth: Reduce low birth weight (LBW) to an incidence of no Nursing Diagnosis more than 5% of live births and very low birth weight To establish nursing diagnoses for high-risk infants, it is (VLBW) to an incidence of no more than 0.9% of live important to be aware of the normal assessment parame- births from baselines of 7.6% and 1.4%, respectively. ters of newborns. Nursing diagnoses generally center on Increase the proportion of very low birth weight the nine priority areas of care for any newborn: (VLBW) infants born at level III hospitals or subspe- cialty perinatal centers from a baseline of 73% to a Ineffective airway clearance related to presence of target level of 90%. mucus or amniotic fluid in airway Reduce the rate of fetal and infant deaths during the Ineffective cardiovascular tissue perfusion related to perinatal period (28 weeks of gestation to 7 days or breathing difficulty more after birth) to 4.4 per 1000 live births from a Risk for deficient fluid volume related to insensible baseline of 7.3 per 1000 live births. water loss Reduce the rate of deaths from sudden infant Ineffective thermoregulation related to newborn status death syndrome (SIDS) to 0.23 per 1000 live births and stress from birth weight variation from a baseline of 0.67 per 1000 live births Risk for imbalanced nutrition, less than body require- (http://www.nih.gov). ments related to lack of energy for sucking Risk for infection related to lowered immune response Nurses can help the nation achieve these goals by teach- in newborn ing women the symptoms of preterm labor so that, ide- Risk for impaired parenting related to illness in ally, birth can be delayed until infants reach term. Nurses newborn at birth also need to be prepared for resuscitation at birth of Deficient diversional activity (lack of stimulation) preterm infants and to plan developmental care that can related to illness at birth help prevent conditions such as apnea, intraventricular Readiness for developmental care to decrease overstimu- hemorrhage, and periventricular leukomalacia. lation easily caused by necessary life-saving procedures Further research is needed regarding how best to position infants to promote development and prevent fa- Outcome Identification and Planning tigue, what measures can best prevent conditions such Be certain when establishing expected outcomes that they as intraventricular hemorrhage, and what measures can are consistent with a newborn’s potential. A goal that im- make parents feel most comfortable and allow them to plies complete recovery from a major illness, for example, best interact with their infants in neonatal intensive care may be unrealistic for one newborn but completely ap- units. propriate for another. Plan care that is individualized 15610_Ch26.qxd 6/22/09 9:14 AM Page 700 700 UNIT 4 The Nursing Role During a Complication of Pregnancy, Birth, or the Postpartal Period considering a newborn’s developmental as well as physi- needs, however, may require special equipment or care mea- ologic strengths, weaknesses, and needs. This helps to sures. Not all newborns will be able to achieve full wellness ensure that parents as well as the health care team un- because of extreme insults to their health at birth or difficulty derstand the newborn’s particular care priorities and po- adjusting to extrauterine life. Indications that a newborn is tential. Many families of high-risk newborns will need having difficulty making the transition from intrauterine to continued support to care for their infants at home. extrauterine life may be apparent during the intrapartum pe- They may need referral to a home health care or other riod, at birth, or at initial assessment because of a low Apgar agency. Helpful Internet sites to use for referring par- score (see Chapter 18). ents are the Web sites of the March of Dimes (http://www.marchofdimes.com), American Sudden Initiating and Maintaining Respirations Infant Death Syndrome Institute (http://www.sids.org), and Newborn Individualized Developmental Care and Ultimately, the prognosis of a high-risk newborn depends Assistance Program (http://www.nidcap.org). primarily on how the first moments of life are managed. Most deaths occurring during the first 48 hours after birth re- Implementation sult from the newborn’s inability to establish or maintain ad- Interventions for any high-risk newborn are best carried equate respirations (National Vital Statistics System [NVSS], out by a consistent caregiver and should focus on con- 2009). An infant who has difficulty accomplishing effective serving the baby’s energy and providing a thermoneutral respiratory action in the first hours of life and yet survives environment to prevent exhaustion and chilling. Painful may experience residual neurologic difficulties because of procedures should be kept to a minimum to help the in- cerebral hypoxia. Prompt, thorough care is necessary for ef- fant achieve a sense of comfort and balance. Assisting par- fective intervention. ents to participate in care such as bathing or feeding their Most infants are born with some degree of respiratory aci- infant may help make the child real to them for the first dosis. However, this is rapidly corrected by the spontaneous time and start the bonding process. onset of respirations. If respiratory activity does not begin immediately, respiratory acidosis will increase. The blood pH Outcome Evaluation and bicarbonate buffer system will fail. Newborn defense High-risk newborns need long-term follow-up so any con- mechanisms are inadequate to reverse the process. Therefore, sequences of their birth status, such as minimal neurologic the effort to establish respirations must be started immedi- injury, can be identified and arrangements for special ately after birth. By 2 minutes, the development of severe aci- schooling or counseling can be made. Examples of expected dosis is already well under way (Thilo & Rosenberg, 2008). outcomes include: Any infant who sustains some degree of asphyxia in utero, such as could occur from cord compression, maternal anes- Infant maintains a patent airway. thesia, placenta previa, or preterm separation of the placenta, Infant tolerates all procedures without accompanying may already be experiencing acidosis at birth and may have apnea. difficulty before the first 2 minutes of life. Infant demonstrates growth and development appro- priate for gestational age, birth weight, and condition. Resuscitation Infant maintains body temperature at 98.6° F (37.0° C) in open crib with one added blanket. Factors that commonly predispose infants to respiratory diffi- Parents visit at least once and make three telephone culty and so may require resuscitation are shown in Box 26.2. calls to neonatal nursery weekly. If breathing is ineffective, circulatory shunts, particularly the Parents demonstrate positive coping skills and behav- iors in response to newborn’s condition. ❧ BOX 26.2 ✽ Factors Predisposing Infants to Respiratory Difficulty in the First Few Days of Life NEWBORN PRIORITIES IN FIRST DAYS Low birth weight OF LIFE Maternal history of diabetes Premature rupture of membranes All newborns have eight priority needs in the first few days of Maternal use of barbiturates or narcotics close to life: birth 1. Initiation and maintenance of respirations Meconium staining 2. Establishment of extrauterine circulation Irregularities detected by fetal heart monitor during 3. Control of body temperature labor 4. Intake of adequate nourishment Cord prolapse 5. Establishment of waste elimination Lowered Apgar score (⬍7) at 1 or 5 minutes 6. Prevention of infection Postmaturity 7. Establishment of an infant–parent relationship Small for gestational age 8. Developmental care, or care that balances physiologic Breech birth needs and stimulation for best development Multiple birth Chest, heart, or respiratory tract anomalies These are also the priority needs of high-risk newborns. Because of small size or immaturity or illness, fulfilling these 15610_Ch26.qxd 6/22/09 9:14 AM Page 701 CHAPTER 26 Nursing Care of a Family With a High-Risk Newborn 701 ductus arteriosus, can fail to close. Because left-side heart pressure is stronger than right-side pressure, blood circulates through a patent ductus arteriosus left to right or from the aorta to the pulmonary artery, creating ineffective pump ac- tion in the heart. Struggling to breathe and circulate blood, an infant uses available serum glucose quickly and may be- come hypoglycemic, compounding the initial problem. For all these reasons, resuscitation becomes important for infants who fail to take a first breath or have difficulty main- taining adequate respiratory movements on their own. Resuscitation follows an organized process: (a) establish and maintain an airway, (b) expand the lungs, and (c) initi- ate and maintain effective ventilation. If respiratory depres- sion becomes severe, a newborn’s heart will fail. Resuscitation then must also include cardiac massage (American Heart Association [AHA], 2008). Airway For a well term newborn, usually bulb syringe suction, which FIGURE 26.1 Suctioning a newborn with mechanical suction removes mucus and prevents aspiration of any mucus and controlled by a finger valve. Suction is applied as the catheter amniotic fluid present in the mouth or nose with the first is withdrawn. If the catheter is rotated as it is withdrawn, the breath, is all that is necessary to help establish a clear airway risk of traumatizing membrane is reduced. (see Chapter 18). If a newborn does not draw in a first breath spontaneously, suction the infant’s mouth and nose with a bulb syringe again This period of halted respirations is termed primary apnea. and rub the back to see if skin stimulation initiates respira- After 1 or 2 minutes of apnea (a pause in respirations longer tions. Be certain an infant is dry, including the hair and head, than 20 seconds with accompanying bradycardia), an infant to prevent chilling. If a newborn has to attempt to raise body again tries to initiate respirations with a few strong gasps. temperature because of chilling, this will increase the need for However, a newborn cannot maintain this effort longer than oxygen, which the baby cannot supply because breathing has 4 or 5 minutes. After this, the respiratory effort will become not yet been initiated. Warmed, blow-by oxygen by face mask weaker again and the heart rate will fall further until the or positive-pressure mask may be administered. newborn stops the gasping effort altogether. The infant then If a newborn’s amniotic fluid was meconium stained, do enters a period of secondary apnea. Although usually a phe- not stimulate an infant to breathe by rubbing the back or ad- nomenon that occurs after birth, both types of apnea may ministering air or oxygen under pressure as doing so could occur in utero. push meconium down into an infant’s airway, further com- During the period of first gasps, resuscitation attempts are promising respirations. Give oxygen by mask without pres- generally successful. Once a newborn is allowed to enter a sure. Wait for a laryngoscope to be passed and the trachea to secondary apnea period, however, resuscitation measures be- be deep suctioned before giving oxygen under pressure. come difficult and may be ineffective. Because it is impossi- If deeper suctioning than by a bulb syringe is required, ble to distinguish between the two periods simply by obser- place an infant on the back and slide a folded towel or pad vation, resuscitation must always be started as if secondary under the shoulders to raise them slightly so the head is in a apnea were occurring. neutral position. Slide a catheter (8F to 12F) over the infant’s An obstetrician, pediatrician, neonatologist, anesthesiolo- tongue to the back of the throat (Fig. 26.1). Do not suction gist, or neonatal nurse practitioner skilled in laryngoscope for longer than 10 seconds at a time (count seconds as you and endotracheal tube insertion should be present at the suction) to avoid removing excessive air from an infant’s birth of all infants identified as high risk so a laryngoscope lungs. Use a gentle touch. Bradycardia or cardiac arrhythmias can be quickly passed (Raab, 2007). Laryngoscope insertion can occur because of vagus stimulation (at the posterior is easy in theory; in practice, the wide variation in the size of oropharynx) from vigorous suctioning. In most newborns, infants’ posterior pharynx and trachea and the emergency this degree of resuscitation will initiate responsive respira- conditions present make it difficult (Fig. 26.2). tions and a strong heartbeat. Color, muscle response, and re- Laryngoscopes are equipped with different-size blades. flexes will improve. Size 0 or 1 is used with newborns. The endotracheal tube An infant who still makes no effort at spontaneous respi- fits inside the laryngoscope. Infants under 1000 g need a rations requires immediate laryngoscopy to open the airway. 2.5-mm endotracheal tube; those over 3000 g need a 4.0- Once a laryngoscope has been inserted, deep tracheal suc- mm tube. Because preterm infants are prone to hemorrhage tioning can be performed. After deep suctioning, an endo- because of capillary fragility, gentle care during insertion is tracheal tube can be inserted and oxygen administered by a crucial. positive-pressure bag and mask with 100% oxygen at 40 to 60 breaths per minute. Lung Expansion In the first few seconds of life, a newborn this severely de- pressed may take several weak gasps of air and then almost Once an airway has been established, a newborn’s lungs need immediately stop breathing; the heart rate begins to fall. to be expanded. Well newborns inflate their lungs adequately 15610_Ch26.qxd 6/22/09 9:14 AM Page 702 702 UNIT 4 The Nursing Role During a Complication of Pregnancy, Birth, or the Postpartal Period (between 89.6° and 93.2° F, or 32° and 34° C) and humid- ified (60%–80%). The pressure needed to open lung alveoli for the first time is approximately 40 cm H2O. After that, pressures of 15 to 20 cm H2O are generally adequate to continue inflating alve- oli (Thilo & Rosenberg, 2008). The pressure from anesthe- sia bags is controlled solely by the pressure of a hand against the bag. Other types of bags such as the Ambu-bag can be set with a blow-off valve that limits the pressure in the appara- tus (Fig. 26.3). It is important not to let oxygen levels in a newborn fluc- tuate, as fluctuation can cause bleeding from immature cra- nial vessels. In addition, no pressure above what is necessary should be used because excessive force can rupture lung alve- oli. On the other hand, if adequate insufflation is not achieved, a newborn stands little chance of survival. To be certain oxygen is reaching the lungs with resuscitation, mon- FIGURE 26.2 Intubation. Place the head in a neutral position itor the newborn’s oxygen level with pulse oximetry in addi- with a towel under the shoulders. The blade of the laryngo- tion to auscultating the chest for the sound of breathing scope is inserted to reveal the vocal cords. An endotracheal (Shiao & Ou, 2007). tube for ventilation is then passed into the trachea, past the Be certain to listen to both lungs to be sure both lungs are laryngoscope. being aerated. If air can be heard on only one side or sounds are not symmetric, the endotracheal tube is probably at the bifurcation of the trachea and blocking one of the main-stem bronchi. Drawing it back half a centimeter will usually free it and allow oxygen to flow to both lungs. with a first breath. The sound of the baby crying is proof that When oxygen is given under pressure to a newborn this lung expansion is good because the vocal sounds are pro- way, the stomach also quickly fills with oxygen. If the re- duced by a free flow of air over the vocal cords. suscitation continues for over 2 minutes, inserting an oro- An infant who breathes spontaneously but then cannot gastric tube and leaving the distal end open will help deflate sustain effective respirations may need oxygen by bag and the stomach and decrease the possibility that vomiting and mask to aid lung expansion. The mask should cover both aspiration of stomach contents from overdistention will the mouth and the nose to be effective. It should not cover occur. the eyes, because it can cause eye injury mechanically from the mask or drying of the cornea from oxygen administra- Drug Therapy tion. Administer 100% oxygen by face mask and pressure bag at a rate of 40 to 60 compressions per minute. To pre- Stimulants have little place in newborn resuscitation unless vent cooling, oxygen should be administered both warmed an infant’s respiratory depression appears to be related to the A B FIGURE 26.3 Types of ventilation bags used in neonatal resuscitation. (A) The flow-inflating (anesthesia) bag requires a compressed gas source for inflation but is able to deliver 100% oxygen. (B) The self-inflating (Ambu) bag remains inflated at all times and is not dependent on a compressed gas source. It is limited to delivering oxygen concentration of 40%, which may be inadequate for resuscitation at birth. 15610_Ch26.qxd 6/22/09 9:14 AM Page 703 CHAPTER 26 Nursing Care of a Family With a High-Risk Newborn 703 BOX 26.3 ✽ Focus on BOX 26.5 ✽ Focus on Pharmacology Pharmacology Naloxone (Narcan) Surfactant (Survanta) Classification: Naloxone is a pure narcotic antagonist. Action: Surfactant restores naturally occurring lung sur- Action: Administered parenterally to reverse the ef- factant to improve lung compliance. fects, such as respiratory depression, that may occur Pregnancy risk category: X with opioid narcotic agents (Karch, 2009). Dosage: 4 mL/kg intratracheally; four doses in first Pregnancy risk category: B 48 hours of life Dosage: Initially 0.01 mg/kg IV. Dosage may be re- Possible adverse effects: Transient bradycardia, rales peated at 2- to 3-minute intervals. Possible adverse effects: Hypertension, irritability, Nursing Implications tachycardia Suction infant before administration. Nursing Implications Assess infant’s respiratory rate, rhythm, arterial blood gases, and color before administration. Assess respiratory status carefully, including rate, Ensure proper endotracheal tube placement before depth, and character of respirations. dosing. Anticipate the need for repeat doses. Change infant’s position during administration to Maintain a patent airway at all times. encourage drug to flow to both lungs. Have emergency resuscitation equipment readily Assess infant’s respiratory rate, color, and arterial available and prepare to resuscitate if necessary. blood gases after administration. Do not suction endotracheal tube for 1 hour after administration, to avoid removing drug. administration of a narcotic such as morphine or meperidine (Demerol) to the mother during labor. In these instances, a narcotic antagonist such as naloxone (Narcan) injected into an Ventilation Maintenance umbilical vessel or intramuscularly into a thigh will relieve the depression (Box 26.3). The dose of naloxone is determined by To allow a newborn to adjust to and maintain cardiovascular institutional policy but is usually 0.01 to 0.1 mg/kg body changes, effective ventilation (continued respirations) must be weight (Karch, 2009). If there is suspicion of maternal drug maintained. Healthy newborns accomplish this task on their abuse, naloxone is used cautiously because it might cause acute own. All infants, especially those who had difficulty establish- withdrawal in the neonate. Other drug therapies in addition to ing respirations at birth, should be carefully observed in the naloxone are shown in Boxes 26.4 and 26.5. next few hours to be certain respirations are maintained. BOX 26.4 ✽ Focus on Pharmacology Drugs Used in Resuscitation at birth (see Box 26.5). Some newborns need adminis- Drugs commonly used in newborn resuscitation include: tration of additional surfactant to prevent symptoms of Atropine: Reduces bronchial secretions, keeping the respiratory distress syndrome. airway clear during resuscitation. Reduces vagus Nitric oxide: Nitric oxide is a potent vascular dilator. nerve effects, relieving bradycardia. Because it dilates the capillaries next to alveoli, it re- Calcium chloride: Increases heart contractility. duces the pulmonary resistance and therefore in- Dopamine: Increases systemic blood perfusion by in- creases oxygenation and lung function (Barrington & creasing blood pressure through beta-agonist action. Finer, 2009). Epinephrine: Strengthens or initiates cardiac contrac- Liquid ventilation: Liquid ventilation is the instillation of tions; increases heart rate and blood pressure. liquid fluorocarbon (Perflubron) into the lungs. It fills Lidocaine: Counteracts ventricular arrhythmias by de- and clings to alveoli. Perflubron is not absorbed by creasing automaticity of ventricular cells. the body but instead leaves the lungs by evaporation. Sodium bicarbonate (NaHCO3) or tromethamine: Although studies in young infants are few in number, Corrects metabolic acidosis. Caution: Do not give liquid ventilation has the potential to reduce lung these agents unless ventilation is adequate or acidosis disease (Davies & Sargent, 2009). It acts as an anti- can be increased by retained CO2. inflammatory and reduces oxygen toxicity and per- haps infection because bacteria cannot live in the Many preterm infants have such respiratory distress at medium. Adverse effects may be pneumothorax and birth that they need continued therapy, including: mucus plugging. Surfactant: All preterm infants weighing less than 1500 g receive surfactant administered by endotracheal tube 15610_Ch26.qxd 6/22/09 9:14 AM Page 704 704 UNIT 4 The Nursing Role During a Complication of Pregnancy, Birth, or the Postpartal Period An increasing respiratory rate in a newborn is often the The rate of fluid administration must be carefully moni- first sign of obstruction or respiratory compromise. If the res- tored because a high fluid intake can lead to patent ductus ar- piratory rate is increased, undress the baby’s chest and look teriosus or heart failure. When using a radiant warmer, there for retractions (inward sucking of the anterior chest wall on is an increase in water loss from convection and radiation. A inspiration). Retractions of this type reflect the difficulty the newborn on a warmer, therefore, will require more fluid than newborn is having in drawing in air (tugging so hard to inflate if he or she were placed in a double-walled incubator. the lungs that the anterior chest muscles are drawn inward). Dehydration may be monitored by urine output and urine A newborn who is having difficulty with maintaining respi- specific gravity measures. An output less than 2 mL/kg/hr or rations should be placed under an infant warmer and have the a specific gravity greater than 1.015 to 1.020 suggests inade- weight of clothing removed from the chest. Keeping the infant quate fluid intake. Elevated specific gravity may also be caused warm is important to prevent acidosis. Positioning an infant by inappropriate antidiuretic hormone secretion or kidney on the back with the head of the mattress elevated approxi- failure because of a primary illness. mately 15 degrees allows the abdominal contents to fall away If an infant has hypotension without hypovolemia, a vaso- from the diaphragm, offering additional breathing space. pressor such as dopamine may be given to increase blood pres- If secretions are accumulating in the respiratory tract, they sure and improve cell perfusion. If hypovolemia is present, the must be suctioned. If the newborn has an endotracheal tube in cause is usually fetal blood loss from a condition such as pla- place, perform tracheal suctioning. “Bagging” an infant for a centa previa (see Chapter 21) or twin-to-twin transfusion. minute before suctioning can improve the infant’s oxygen level With hypovolemia, typically tachypnea, pallor, tachycardia, and prevent it from dropping to dangerous levels during suc- decreased arterial blood pressure, decreased central venous tioning. Use pulse oximetry or transcutaneous oxygen moni- pressure, and decreased tissue perfusion of peripheral tissue, toring to monitor oxygen level if available (see Chapter 40). with a progressively developing metabolic acidosis, will be The cause of the respiratory distress must be determined and present. The hematocrit may be normal for some time after appropriate interventions undertaken to correct the difficulty acute blood loss because blood cells present are in proportion (see Chapter 40). to plasma. Normal saline or Ringer’s lactate may be adminis- tered to increase blood volume. Control the rate carefully to Establishing Extrauterine Circulation prevent heart failure, patent ductus arteriosus, or intracranial hemorrhage from fluid pressure overload. Although establishing respirations is the usual priority at a high-risk infant’s birth, lack of cardiac function may be present ✔Checkpoint Question 26.1 concurrently or may develop if respiratory function cannot be quickly initiated and maintained. If an infant has no audible Baby Atkins was given a drug at birth to reverse the effects of heartbeat, or if the cardiac rate is below 80 beats per minute, a narcotic given to his mother in labor. What drug is commonly closed-chest massage should be started. Hold an infant with used for this? fingers supporting the back and depress the sternum with two a. Sodium chloride fingers (see Chapter 41). Depress the sternum approximately b. Morphine sulfate one third of its depth (1 or 2 cm) at a rate of 100 times per c. Penicillin G minute (AHA, 2008). Lung ventilation at a rate of 30 times d. Naloxone (Narcan) per minute should be continued and interspersed with the car- diac massage at a ratio of 1:3. Regulating Temperature Continue to monitor transcutaneous oxygen or pulse oximetry to evaluate respiratory function and cardiac effi- All high-risk infants may have difficulty maintaining a nor- ciency. If the pressure and the rate of massage are adequate, it mal temperature. This is because, in addition to stress from should be possible, in addition, to palpate a femoral pulse. If an illness or immaturity, the infant’s body is often exposed heart sounds are not resumed above 80 beats per minute after during procedures such as resuscitation and blood drawing. 30 seconds of combined positive-pressure ventilation and car- It is important to keep newborns in a neutral-temperature diac compressions, 0.1 to 0.3 mL/kg epinephrine (1:10,000) environment, one that is neither too hot nor too cold, as may be sprayed into the endotracheal tube to stimulate cardiac doing so places less demand on them to maintain a minimal function (AHA, 2008). Newborns who have difficulty main- metabolic rate necessary for effective body functioning. If the taining cardiac function need to be transferred to a transitional environment is too hot, they must decrease metabolism to or high-risk nursery for continuous cardiac surveillance. cool their body. If it is too cold, they must increase metabo- lism to warm body cells. The increased metabolism required Maintaining Fluid and Electrolyte Balance calls for increased oxygen; without this oxygen available, body cells become hypoxic. To save oxygen for essential After an initial resuscitation attempt, hypoglycemia (de- body functions, vasoconstriction of blood vessels occurs. If creased blood glucose) may result from the effort the newborn this process continues for too long, pulmonary vessels be- expended to begin breathing. Dehydration may result from come affected and pulmonary perfusion becomes decreased. increased insensible water loss from rapid respirations. Infants An infant’s PO2 level falls and PCO2 increases. The decreased with hypoglycemia are treated initially with 10% dextrose in PO2 level may open fetal right-to-left shunts again. Surfactant water to restore their blood glucose level. Fluids such as production may halt, which may further interfere with lung Ringer’s lactate or 5% dextrose in water are commonly used function. To supply glucose to maintain increased metabo- to maintain fluid and electrolyte levels. Electrolytes (particu- lism, an infant begins anaerobic glycolysis, which pours acid larly sodium and potassium) and glucose are added as neces- into the bloodstream. An infant becomes acidotic, and with sary, depending on electrolyte analysis. acidosis comes the increased risk of kernicterus (invasion of 15610_Ch26.qxd 6/22/09 9:14 AM Page 705 CHAPTER 26 Nursing Care of a Family With a High-Risk Newborn 705 brain cells with unconjugated bilirubin) as more bilirubin- binding sites are lost and more bilirubin is free to pass out of BOX 26.6 ✽ Focus on Evidence- the bloodstream into brain cells. In short, because of becom- Based Practice ing chilled, heart action, breathing, and electrolytic balance are all affected. Does placing a cap on a low-birth-weight infant guard To prevent a newborn from becoming chilled after birth, against hypothermia? wipe an infant dry, cover the head with a cap, and place the It is critical to guard against hypothermia in low-birth- baby immediately under a prewarmed radiant warmer or in a weight infants because they are unable to increase their warmed incubator (Fig. 26.4) or skin-to-skin against the metabolism rate to warm themselves again. To investi- mother. Additional measures are the use of plastic wrap, plas- gate whether the simple act of covering the infant’s head tic shields, or warmed mattresses. Air, incubator, or radiant with a cap prevents enough evaporation and heat loss warmer temperatures should be kept regulated to maintain to prevent hypothermia, researchers reviewed six stud- an infant’s axillary temperature at 97.8° F (36.5° C). Be cer- ies with a total of 304 infants comparing different meth- tain that during procedures an infant is placed on a radiant ods of guarding against newborn cooling. Conclusions heat warmer or a chemical warming pad, not placed directly of this meta-analysis revealed that plastic wraps or on cool x-ray tables, scales, or an unheated radiant warmer to bags, skin-to-skin care, and warmed mattresses all keep prevent heat loss (Box 26.6). preterm infants warmer, leading to higher temperatures on admission to neonatal units. Stockinette caps alone do not provide this same protection. Radiant Heat Sources Based on this study, at the birth of a low-birth-weight in- Radiant heat warmers are open beds that have an overhead ra- fant, would you omit a cap or use it in addition to other diant heat source. Such units have servocontrol probes, which measures? when placed on an infant’s skin continually monitor his or her temperature. Abdominal skin temperature, when mea- Source: McCall, E. M., et al. (2009). Interventions to prevent sured this way, should be 95.9° to 97.7° F (35.5° to 36.5° C). hypothermia at birth in preterm and/or low birth weight infants. If an infant’s temperature falls below this level, an alarm will Cochrane Database of Systematic Reviews, 2009(1), sound. Be certain to tape the probe or disk onto the infant’s (CD004210). abdomen between the umbilicus and the xiphoid process. Do A B FIGURE 26.4 Neutral thermal environment. (A) A neonate in the intensive care bed with overhead radiant warmer can be examined periodically with ease. (B) Use of an incubator allows maintenance of a neutral thermal environment for neonates not requiring minute-to-minute intervention. 15610_Ch26.qxd 6/22/09 9:14 AM Page 706 706 UNIT 4 The Nursing Role During a Complication of Pregnancy, Birth, or the Postpartal Period not tape it under an infant or it will register a falsely high reading. Be sure it is not over the rib cage, where the thin sub- cutaneous tissue will not allow an accurate reading. Also do not place it over the liver, because increased metabolism may lead to falsely high readings. A plastic bridge or shield placed over the child will better preserve heat by reducing convection and radiation losses; plastic wrap placed over an infant will produce this same effect. When performing care or leaning over an infant, be careful your head does not block the heat from an overhead source and keep it from reaching the baby. An additional warming pad placed under an infant may be necessary for very preterm infants or for lengthy procedures to maintain body heat. Incubators After an initial resuscitation attempt, newborns may be cared FIGURE 26.5 Infants who are ill at birth often need supple- for in incubators. The temperature of incubators varies with mental feedings by nasogastric or gastrostomy tube. the amount of time portholes remain open and the tempera- ture of the area in which the incubator is placed. Placing it in direct sunlight or near a warm radiator can increase the in- been ruled out, gavage feeding may be introduced (Fig. 26.5). ternal temperature markedly. For this reason, a newborn’s Preterm infants should be breastfed if possible because of the temperature must be checked at frequent intervals when in immune protection this offers. If breastfeeding is not possi- an incubator to be certain the temperature level designated is ble because the infant is too immature to suck effectively, a being maintained. Use of an additional acrylic shield inside mother can manually express breast milk or use a breast pump the incubator helps prevent radiation and convection heat to initiate and continue her milk supply until the time the in- loss when portholes are opened for care. fant is mature enough or otherwise ready for effective sucking. Similar to radiant warmers, some incubators have servo- Her expressed breast milk can be used in the infant’s gavage control mechanism units that monitor the infant’s tempera- feeding ( Jones & Spencer, 2007). Be sure when bottled breast ture and automatically change the temperature of the incu- milk is supplied by parents that it is well marked with the bator as needed. Portholes must remain closed to keep the infant’s name or breast milk errors can occur the same as servocontrol operating efficiently. medication errors (Drenckpohl, Bowers, & Cooper, 2007). As infants’ conditions improve, they can be weaned from It should be stored in nonshiny plastic bags or bottles to an incubator. Dress the infant as if he or she were going to be avoid the infant being exposed to polycarbonate, which can in a bassinet, then set the incubator about 2° F (1.2° C) below leech into stored milk and possibly cause chromosomal aber- the infant’s temperature. After a half-hour, assess whether the rations (Raloff, 2007). infant is able to maintain body temperature. If so, lower the in- Preterm infants reveal hunger by the same signs as term cubator temperature another 2° F and continue until room infants, such as rooting and crying and sucking motions. All temperature is reached. If an infant cannot maintain adequate babies who are gavage fed and need oral stimulation from non- temperature as the incubator temperature level is lowered, the nutritive sucking seem to enjoy a pacifier at feeding times and, infant is not yet ready for room-temperature air, and the wean- in immature infants, this may help them develop an effective ing process needs to be slowed or stopped until the baby is sucking reflex. Exceptions are infants too immature to have a more mature or better able to self-regulate temperature. sucking reflex and infants who must not swallow air, such as those with a tracheoesophageal fistula awaiting surgery. The Skin-to-Skin Care techniques of gavage feeding, intravenous feeding, and gas- trostomy feeding are discussed in Chapter 37. Originally referred to as kangaroo care, skin-to-skin care is the use of skin-to-skin contact to maintain body heat. Establishing Waste Elimination Provide a quiet setting with lights dimmed. Undress the in- fant except for a diaper and perhaps a cap. Assist the parent Although most immature infants void within 24 hours of to sit comfortably in a chair and hold the infant snugly against birth, they may void later than term newborns because, as a re- his or her chest, skin to skin (Moore, Anderson, & Bergman, sult of all the procedures that may be necessary for resuscita- 2009). Place a blanket over the infant for added warmth. This tion, their blood pressure may not be adequate to optimally method of care not only supplies heat but also encourages supply their kidneys. Carefully document any voidings that parent–child bonding. occur during resuscitation. This is proof that hypotension is improving and the kidneys are being perfused. Immature in- Establishing Adequate Nutritional Intake fants also may pass stool later than the term infant because meconium has not yet reached the end of the intestine at birth. Infants who experienced severe asphyxia at birth usually re- ceive intravenous fluids so they do not become exhausted from Preventing Infection sucking or until necrotizing enterocolitis (NEC) has been ruled out, as this could result from the temporary reduction in Contracting an infection could drastically complicate a high- oxygen to the bowel (see Chapter 45 for a discussion of NEC). risk newborn’s ability to adjust to extrauterine life. Infection, If an infant’s respiratory rate remains rapid and NEC has like chilling, increases metabolic oxygen demands, which the 15610_Ch26.qxd 6/22/09 9:14 AM Page 707 CHAPTER 26 Nursing Care of a Family With a High-Risk Newborn 707 stressed newborn may not be able to meet. In addition, infec- ulation for growth. Most high-risk infants enjoy “catch-up” tion stresses the immature immune system and already stressed growth once they stabilize from the trauma of birth or what- defense mechanisms of a high-risk newborn. Infections may ever caused them to be classified as high risk. They quickly have prenatal, perinatal, or postnatal causes. In some instances, move to playing with age-appropriate toys. Some parents may such as preterm rupture of the membranes, it is an infection need support before and after their infants are discharged such as pneumonia or skin lesions that place the infant in a home to begin to view them as well and capable of doing all high-risk category (Herbst & Kallen, 2007). the things they are now capable of doing. Anticipatory guid- Common viruses that affect infants in utero are cy- ance helps them to be ready for the next developmental step. tomegalovirus and toxoplasmosis virus. An infant with either of these infections may be born with congenital anomalies Follow-up of High-Risk Infants at Home from the virus invasion (see Chapter 12). The most prevalent perinatal infections are those contracted from the vagina dur- Each time parents visit a high-risk nursery, assess their level ing birth. Early-onset sepsis is most commonly caused by of knowledge about their child’s condition and development. group B streptococcus, E. coli, Kelbsiella, and Listeria mono- Thorough education and referral to a home care agency may cytogenes. Late-onset, or nosocomial, infections are more be necessary to help parents continue with the level of care commonly caused by Staphylococcus aureus, Enterobacter, and that is required when their infant is discharged home (see Candida. These late-onset infections are probably most com- Chapter 4). Before discharge, the safety of their home for the monly spread to newborns from health care personnel. For care of such a small infant needs to be evaluated. Transporting this reason, all persons coming in contact with or caring for a preterm infant in a car requires special care, including a infants must observe good handwashing technique and stan- blanket or commercial head support, because a very small in- dard precautions to reduce the risk of infection transmission. fant does not fit securely in a standard infant car seat. Health care personnel with infections have a professional and Although not well documented regarding when or why it moral obligation to refrain from caring for newborns. occurs, some preterm infants experience episodes of oxygen desaturation, apnea, or bradycardia when seated in standard car safety seats (DeGrazia, 2007). To detect if this will occur, Establishing Parent–Infant Bonding the American Academy of Pediatrics (AAP, 2009) recom- It is helpful if all women who are diagnosed as having a high- mends that all preterm infants be assessed for cardiorespira- risk pregnancy are offered a tour of a neonatal intensive care tory stability in their car seat prior to discharge—the “car seat unit (NICU) during pregnancy so if their infant should be challenge.” admitted to a NICU, they will be more comfortable in the high-tech environment. High-Risk Infants and Child Abuse Be certain that the parents of a high-risk newborn are kept informed of what is happening during resuscitation at birth. When a child is ill or born preterm, the expected reaction of They should be able to visit the special nursing unit to which the parents would be to protect the child even more than the the child is admitted as often as they choose, and, after wash- average child so no further harm can result. In reality, par- ing and gowning, hold and touch their child. This helps to ticularly in reference to preterm children, the opposite may make the child’s birth real to them. Should a child not sur- occur. Preterm children are at high risk for abuse (Sirotnak vive an initial illness, these interactions can help make the & Krugman, 2008). This is probably because of the separa- death more real. Only when both birth and death seem real tion of the child from the family at birth, which interferes can parents begin to work through their feelings and accept with bonding. Child abuse is discussed in Chapter 55. these events. All parents handle newborn babies tentatively until they What if... Mrs. Atkins is about to visit her preterm new- have “claimed” them or have become better acquainted. It born for the first time and states, “I’m so scared. He’s may be months before the parents of a child who has been ill so tiny and frail. How can I even hold him?” How since birth can handle their baby comfortably and confi- should you respond to this new mother to make her dently. Urge parents to spend time with their infant in the visit easier? intensive care nursery as the infant improves. Be certain that parents have access to health care personnel after discharge to help them care confidently for the child at home. If an infant dies despite newborn resuscitation attempts, parents need to see the infant without being covered by a THE NEWBORN AT RISK BECAUSE OF myriad of equipment. This is a time for parents to reassure ALTERED GESTATIONAL AGE OR themselves their newborn was a perfect baby in every other BIRTH WEIGHT way except lung function or whatever was the infant’s fatal disorder. Thinking this way can give them confidence to plan Infants need to be evaluated as soon as possible after birth to for other children or simply to continue their lives after such determine their weight and gestational age as classification by a stressful experience. growth charts and gestational history is important to deter- mine immediate health care needs and to help anticipate pos- Anticipating Developmental Needs sible problems. Birth weight is normally plotted on a growth chart such as the Colorado (Lubchenco) Intrauterine Growth High-risk newborns need special care to ensure that the Chart (see Appendix E). Infants born after the beginning of amount of pain they experience during procedures is limited to week 38 and before week 42 of pregnancy (calculated from the least amount possible and that they receive adequate stim- the first day of the last menstrual period) are classified as term 15610_Ch26.qxd 6/22/09 9:14 AM Page 708 708 UNIT 4 The Nursing Role During a Complication of Pregnancy, Birth, or the Postpartal Period infants. Approximately 90% of all live births are term. Infants Assessment born before term (less than the full 37th week of pregnancy) account for approximately 7% to 19% of all births and are The SGA infant may be detected in utero when fundal classified as preterm infants, regardless of their birth weight. height during pregnancy becomes progressively less than ex- Infants born after the onset of week 43 of pregnancy are clas- pected. However, if a woman is unsure of the date of her last sified as postterm, dysmature, or postmature (Fortner, Althaus, menstrual period, this discrepancy can be hard to substantiate. & Gurewitsch, 2007). A sonogram can then demonstrate the decreased size. A bio- Normally, birth weight varies for each gestational week of physical profile including a nonstress test, placental grading, age. Infants who fall between the 10th and 90th percentiles amniotic fluid amount, and ultrasound examination can pro- of weight for their age regardless of gestational age are con- vide additional information on placental function. If poor sidered appropriate for gestational age (AGA). Infants who placental function is apparent from such determinations, it fall below the 10th percentile of weight for their age are con- can be predicted the infant will do poorly during labor be- sidered small for gestational age (SGA). Those who fall cause of periods of relative hypoxia during contractions may above the 90th percentile in weight are considered large for result. Cesarean birth is the birth method of choice in such gestational age (LGA). Infants weighing under 2500 g are circumstances. low-birth-weight infants. Those weighing 1000 to 1500 g are very-low-birth-weight infants (VLB). Those born weighing Appearance. Generally, an infant who suffers nutritional de- 500 to 1000 g are considered extremely very-low-birth-weight privation early in pregnancy, when fetal growth consists pri- infants (EVLB). Preterm infants may be AGA, SGA, LGA, marily of an increase in the number of body cells, is below av- low birth weight, VLB, or EVLB. erage in weight, length, and head circumference. An infant All such infants have immediate needs that are different who suffers deprivation late in pregnancy, when growth con- from or more pronounced than the needs of term newborns. sists primarily of an increase in cell size, may have only a re- Each of these categories carries its own set of potential risks. duction in weight. Regardless of when deprivation occurs, an infant tends to have an overall wasted appearance. The child may have a small liver, which can cause difficulty regulating The Small-for-Gestational-Age Infant glucose, protein, and bilirubin levels after birth. The infant An infant is SGA if the birth weight is below the 10th per- also may have poor skin turgor and generally appear to have centile on an intrauterine growth curve for that age. SGA in- a large head because the rest of the body is so small. Skull su- fants may be born preterm (before week 38 of gestation), term tures may be widely separated from lack of normal bone (between weeks 38 and 42), or postterm (past 42 weeks). SGA growth. Hair is dull and lusterless. The abdomen may be infants are small for their age because they have experienced sunken. The umbilical cord often appears dry and may be intrauterine growth restriction (IUGR) or failed to grow at stained yellow. the expected rate in utero (Rahimian & Varner, 2007). This In contrast, because an infant’s age is more advanced than characteristic makes them distinctly different from infants the weight implies, a child may have better-developed neuro- whose weight is low but who are average for gestational age. logic responses, sole creases, and ear cartilage than expected for a baby of that weight. The skull may be firmer, and the Etiology infant may seem unusually alert and active for that weight. The SGA infant needs careful assessment for possible con- A woman’s nutrition during pregnancy plays a major role in genital anomalies occurring as a result of the poor nutritional fetal growth, so lack of adequate nutrition may be a major intrauterine environment. contributor to IUGR. Pregnant adolescents have a high inci- dence of SGA infants. Because adolescents must meet their Laboratory Findings. Blood studies at birth usually show a own nutritional and growth needs, needs of a growing fetus high hematocrit level (less than normal amounts of plasma in can be compromised. However, the most common cause of proportion to red blood cells are present because of a lack of IUGR is a placental anomaly: either the placenta did not ob- fluid in utero) and an increase in the total number of red tain sufficient nutrients from the uterine arteries or it was in- blood cells (polycythemia). The increase in red blood cells efficient at transporting nutrients to the fetus. Placental dam- occurs because anoxia during intrauterine life stimulates the age, such as partial placental separation with bleeding, limits development of red blood cells. The polycythemia that re- placental function because the area of placenta that separated sults causes increased blood viscosity, a condition that puts becomes infarcted and fibrosed, reducing the placental sur- extra work on the infant’s heart because it is more difficult to face available for nutrient exchange. A developmental defect effectively circulate thick blood. As a consequence, acro- in the placenta can also prevent it from functioning properly. cyanosis (blueness of the hands and feet) may be prolonged Women with systemic diseases that decrease blood flow to and persistently more marked than usual. If the poly- the placenta, such as severe diabetes mellitus or pregnancy- cythemia is extreme, vessels may actually become blocked induced hypertension (both are diseases in which blood ves- and thrombus formation can result. If the hematocrit level is sel lumens are narrowed), are at higher risk for delivering more than 65% to 70%, an exchange transfusion to dilute SGA babies than others. Women who smoke heavily or use the blood may be necessary. narcotics also tend to have SGA infants (Rahimian & Varner, Because SGA infants have decreased glycogen stores, one 2007). of the most common problems is hypoglycemia (decreased In other instances, the placental supply of nutrients is ad- blood glucose, or a level below 45 mg/dL). Such infants equate but an infant cannot use them because the infant has may need intravenous glucose to sustain blood sugar until contracted an intrauterine infection such as rubella or toxo- they are able to suck vigorously enough to take sufficient plasmosis or has a chromosomal abnormality. oral feedings. 15610_Ch26.qxd 6/22/09 9:14 AM Page 709 CHAPTER 26 Nursing Care of a Family With a High-Risk Newborn 709 size. Because an infant tires easily in the first few weeks Nursing Diagnoses and Related of life, urge them to space play periods with rest peri- Interventions ods or hypoglycemia or apnea can occur. All infants ✽ with IUGR need continued follow-up after hospital dis- charge as they may have neurologic deficits that will in- Nursing Diagnosis: Ineffective breathing pattern re- terfere with learning at school age (Leitner et al., 2007). lated to underdeveloped body systems at birth Outcome Evaluation: Newborn maintains respirations at a rate of 30 to 60 breaths per minute after resusci- ✔Checkpoint Question 26.2 tation at birth. Why are small-for-gestational-age newborns at risk for difficulty Birth asphyxia is a common problem for SGA infants, maintaining body temperature? both because they have underdeveloped chest mus- a. They are preterm so they are born relatively small in size. cles and because they are at risk for developing meco- b. They are more active than usual so they throw off covers. nium aspiration syndrome as a result of anoxia during c. They do not have as much fat stores as do other infants. labor. Fetal hypoxia causes a reflex relaxation of the d. Their skin is more susceptible to conduction of cold. anal sphincter and increased intestinal movement. When gasping for breath in utero, the fetus draws meco- nium that was discharged from the intestine into the am- The Large-for-Gestational-Age Infant niotic fluid down into the trachea and bronchi. Acting as An infant is LGA (also termed macrosomia) if the birth a foreign substance, this blocks airflow into the alveoli, weight is above the 90th percentile on an intrauterine growth leading to hypoxemia, acidosis, and hypercapnia. For chart for that gestational age. Such a baby appears deceptively this reason, many SGA infants require resuscitation at healthy at birth because of the weight, but a gestational age birth. Closely observe both respiratory rate and charac- examination will reveal immature development. It is impor- ter in the first few hours of life. Underdeveloped chest tant that LGA infants be identified immediately so that they muscles can make SGA infants unable to sustain the can be given care appropriate to their gestational age rather rapid respiratory rate of a normal newborn. than being treated as term newborns (Lawrence, 2007). Nursing Diagnosis: Risk for ineffective thermoregula- tion related to lack of subcutaneous fat Etiology Outcome Evaluation: Infant’s temperature is main- Infants who are LGA have been subjected to an overproduc- tained at 36.5° C (97.8° F) axillary. tion of growth hormone in utero. This happens most often SGA infants are less able to control body temperature to infants of women with diabetes mellitus or women who than other newborns because they lack subcutaneous are obese (Strehlow et al., 2007). Extreme macrosomia oc- fat. A carefully controlled environment is essential to curs in fetuses of diabetic wome