NUR1213

0 = No respiratory Distress
Nursing Care of at Risk, 4 – 6 = Moderate Distress
High risk, Sick newborn 7.- 10 = Severe Distress
OUTLINE
I. Problems related to Maturity. Ballard Scoring
II. Problems related to Gestational
Weight. The sum of all 12 criteria represents the
III. Acute conditions of the neonates neuromuscular and physical maturation of the
fetus

Healthy newborn

APGAR Scoring

The 1-minute score determines how well the baby

tolerated the birthing process.

The 5-minute score tells the doctor how well the I. Problems related to maturity
baby is doing outside the mother’s womb
A. Full Term Infant – delivered at 37 to 40 weeks
Score: of development in the uterus
0 – 3 = severely depressed B. Pre-Term Infant – delivered before 37 weeks of
4 – 6 = moderately depressed development in the uterus; weigh less than 5 ½
7 – 10 = good/healthy pounds (2.5 kg).

Determining the maturity of newborn

 Physical findings
 Neurologic findings that reveal gestational
age
 Mother’s report of LMP
 Sonographic estimation of gestation age

Silverman – Andersen Index – Neonatal

Respiratory Distress Grading

Grading:
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Causes q. a pliable thorax, immature lung tissue, and an
immature regulatory center
r. more susceptible to biochemical alterations
s. higher extracellular water content
t. preterm infants exchange fully half their
extracellular fluid volume every 24 hours
u. soft cranium – subject to characteristic
unintentional deformation, or “preemie head,”
caused by positioning from one side to the other
on a mattress.
v. head – looks disproportionately longer from
front to back, is flattened on both sides, and lacks
the usual convexity seen at the temporal and
parietal areas. This positional molding is often a
concern to parents and may influence their
perception of the infant’s attractiveness and their
responsiveness to the infant.
w. frequent repositioning of the infant and
positioning on a gel mattress can reduce or
minimize cranial molding.

Management!

1. Glucocorticosteroids
Characteristics of a Preterm Infant
 Severely premature infants have
a. very small and appear scrawny underdeveloped lungs and can’t produce
b. have a proportional large head in relation to their own surfactant.
the body; with scant hair  This can lead directly to hyaline membrane
c. Skin – bright pink, smooth, and shiny, with disease.
small blood vessels clearly visible underneath the  Prior to 34 weeks at least one course of
thin epidermis (Betamethasone or Dexamethasone)
d. Fine lanugo – abundant over the body but is
sparse, fine, and fuzzy on the head 2. Tocolysis
e. Ear cartilage – soft and pliable
f. Skin – bright pink, smooth, and shiny, with  Delays delivery beyond 24-48 hours to
small blood vessels clearly visible underneath the allow for transfer and give administered
thin epidermis. corticosteroids the possibility to reduce
g. Soles and palms – minimum creases neonatal organ immaturity.
h. Bones of the skull and the ribs feel soft  Calcium channel blockers and an oxytocin
i. eyes may be fused antagonist can delay delivery by 2-7 days
j. sleeping for most of the time  Beta 2 agonist drugs delay by 48 hours but
k. inactive and listless carry more side effects.
l. underdeveloped breast tissue
m. male infants – few scrotal rugae, testes are Neonatal care
undescended
n. female infants – labia minora and clitoris are 1. Keep the newborn warm
prominent
o. extremities – maintain an attitude of extension - Plastic wraps or warm mattress
and remain in any position in which they are - Radiant warmer or Incubators (isolettes)
placed. - Kangaroo care (skin to skin warming):
p, unable to maintain body temperature, have placing a premature baby in an upright
limited ability to excrete solutes in the urine, and position on a mother’s bare chest allowing
have increased susceptibility to infection.
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tummy to tummy contact and placing the i. Temperature problems
premature baby in between the mother’s
breasts. Management!

2. Fluids and nutrition through intravenous a. Gently stimulate during periods when breathing
catheters stops
3. Oxygen supplementation b. Give caffeine preparation to help stimulate
4. Mechanical ventilator support breathing
5. Medications c. Suction children with apnea
6. Encourage breastfeeding d. Change position
7. Basic infection control measures e. Use bag and mask to help them breathe
8. Bili lights to treat newborn jaundice f. Slower feeding time
(hyperbilirubinemia) g. Give oxygen
9. Prophylactic treatments (indomethacin)
Retinopathy of Prematurity (ROP)
Anemia of Prematurity
 Blood vessels grow abnormally and
 Erythropoiesis decreases after birth randomly in the eye. These abnormal
 Increased tissue oxygenation vessels tend to leak or bleed, which leads
 Closure of the ductus arteriosus to scarring of retina.
 Scars then shrink, they pull on the retina
Signs and Symptoms causing it to detach from the back of the
eye which can cause blindness.
 Poor feeding  Immature retinal blood vessels constrict
 Rapid heartbeat and breathing when exposed to high oxygen
 Irregular breathing concentrations, leading to retinal
 Weight loss detachment and blindness.
 Failure to thrive  Infants who are most immature and most
 Paleness ill are at highest risk.
 Weakness  Preterm infant who is receiving oxygen
must have blood O2 levels monitored by
Management! pulse oximeter, transcutaneous oxygen
saturation, or blood gas monitoring.
a. DNA recombinant erythropoietin
b. Vitamin E supplement (assist in formation of Management!
RBC)
c. Blood transfusion (RBC transfusion)  Antibiotics are administered. Gentamicin,
d. Iron supplement ampicillin, and penicillin are all effective
against infections.
Apnea of Prematurity – refers to short episodes  Immunization of all women of
of stopped breathing in babies who were born childbearing are against streptococcal B
before they were due. organisms could decrease the incidence of
newborns infected at birth.
Causes  Cryosurgery or laser therapy can be
effective in preserving sight.
a. The brain is not fully developed
b. Muscles that keep the airway open are weak
c. Anemia Periventricular/Intraventricular Hemorrhage –
d. Feeding problems neurodevelopmental problems have been linked to
e. Heart or lung problems lack of maternal thyroid hormones at a time when
f. Infection their own thyroid is unable to meet postnatal
g. Low oxygen levels needs.
h. Overstimulation
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Management! – Cranial ultrasound performed  Bili lights to treat new born jaundice
after first few days of life to detect hemorrhage.  Prophylactic treatments like indomethacin

Necrotizing Enterocolitis Preterm Infants

 Very low birthweight neonates have  Infants born before 26 weeks of pregnancy
substantial hypogammaglobulinemia, the and particularly born before 24 weeks.
IgA content of breastmilk may be an  Many newborns extremely premature have
important facet of GI mucosal protection. normal intelligence, but some have
 Breastmilk promotes the growth of learning disorders
bifidobacterial, which produces acetic acid
and lactic acid that turn inhibits the growth Post Term Infants
of many pathogenic, gram-negative
organisms.  Infants born of a gestation that extends
beyond 40 weeks
Management! – encourage all mothers to initially
provide breastmilk for their preterm neonates Characteristics of Post term infants

a. Absence of lanugo
Prevention of Prematurity b. Skin is often loose, cracked, parchment like,
and desquamating
1. Eat nutritious diet c. The little vernix caseosa that remains in the
2. Avoid alcohol, tobacco, and drugs skinfolds may be stained a deep yellow or green
3. Receive early and regular prenatal care for early an indication of meconium staining.
recognition and treatments of complications d. Abundant scalp hair
e. Wasted physical appearance (intrauterine
1. Glucocorticosteroids nutritional deprivation)
f. depletion of subcutaneous fat
Infants have underdeveloped lungs, hence it can g. Elongated appearance
lead directly to RDS or Hyaline Membrane h. Long fingernails and toenails
disease in the neonate. I. umbilical cord and nails may be stained green if
meconium was present in the amniotic fluid.
Prior to 34 weeks at least one course of
glucocorticoids (betamethasone or Treatment for Post Term
dexamethasone)
1. Resuscitation
2. Tocolysis 2. If lethargic because of meconium aspiration,
intubate to suction as much meconium
Delays delivery beyond 24-48 hours to allow for 3. Mechanical ventilator may be needed to support
transfer and give administered corticosteroids the breathing
possibility to reduce neonatal organ immaturity. 4. If hypoglycemic, give glucose IV solutions and
frequent breast milk/formula feedings.
Neonatal care
II. Problems related to Gestational Weight
 Keep the newborn warm (plastic wraps,
isolletes or incubators, Kangaroo care Appropriate for Gestational age (AGA)
(skin to skin))
 Fluids and nutrition through IV  Full term infant heavier 2,500 grams
 Oxygen supplementation (about 5.5 lbs.) and lighter than 4, 000
 Mechanical ventilator support grams (about 8.75 lbs).
 Medications
 Encourage breastfeeding Small for Gestational age (SGA)
 Basic infection control
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 Birth weight falls below the 10th percentile
on intrauterine growth Large for Gestational Age (LGA)
 Caused by Intrauterine growth restriction  An infant whose birth weight falls above
or retardation (IUGR) failed to grow at the 90th percentile on intrauterine growth
expected rate in utero. charts. Also termed, Macrosomia

Etiology of SGA Etiology of LGA

1. placental anomaly 1. overproduction of growth hormone

2. women with systemic diseases that decreases 2. Macrosomia: poorly controlled diabetes
blood flow to the placenta resulting to high glucose levels
3. infants with uterine infections 3. Multiparous women
4. mothers who smoke heavily or use narcotics 4. Large parents
5. babies with chromosomal abnormalities 5. Genetic factors
6. maternal nutrition during pregnancy
7. pregnant adolescents a. Beckwith-Wiedemann syndrome
8. parents are small - Macrosomia
- Continues weight gain until age of 8
Characteristics/Appearance of SGA - Macroglossia

1. Below average in weight, length, and head b. Sotos’ syndrome

circumference - Cerebral gigantism
2. Reduction in weight - Extraordinary physical growth until 2 to
3. Overall wasted appearance 3 years
4. Have small liver, which causes difficulty - Subtle mental retardation, autistic
regulating glucose, protein, and bilirubin levels. behavior, motor skills delays, cognitive
5. Poor skin turgor disorder, muscle tone, and dysarthria.
6. Large head because the rest of the body is so
small Characteristics of LGA
7. Skull sutures may be widely separated from
lack of normal bone growth 1. May show immature reflexes
8. Hair is dull and lusterless 2. Low scores on gestational age examinations in
9. Abdomen may be sunken relation to size
10. Cord often appears dry may be stained yellow 3. Extensive bruising
11. Skull may be firmer 4. Birth injury: Broken clavicle, Erb-Duchenne
12. Hematocrit level is more than 65% to 70% paralysis
5. Prominent caput succedaneum,
SGA and LGA are at increased risk of the cephalhematoma, or molding
following problem:

1. Meconium aspiration
2. Excess red blood cells (polycythemia)
3. Low blood sugar levels (hypoglycemia)
4. Difficulty regulating body temperature
5. An impaired immune system
6. Cardiovascular Dysfunction

Management! III. Acute conditions of the Neonates

 Exchange transfusion to dilute blood Respiratory Distress Syndrome

 IV glucose to sustain blood sugar until
they are able to suck vigorously enough to  Surfactant deficiency and physiologic
take sufficient oral feedings. immaturity of the thorax
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 Hyaline Membrane Disease Distress increases
 Between 24 and 28 weeks of gestation, a  Seesaw respiration/Shallow breathing
fetus begins producing surfactant in the  Heart failure
lungs.  Low UO and edema on extremities
 Usually by 35 weeks, a fetus has  Pale gray skin
developed enough surfactant for the lungs  Lethargy, irregular breathing, and apnea
to function normally.  Bradycardia
 During the last trimester of pregnancy,  Pneumothorax
preterm infants born with numerous
underdeveloped and many uninflatable Diagnostic and laboratory procedures
alveoli.
 Complications: Hypoxia, Respiratory 1. ABG
acidosis, Metabolic acidosis 2. Blood Glucose
3. Blood serum calcium
Etiology of RDS 4. Pulse oximetry
5. Chest x-ray
1. Delivery before 37 weeks AOG 6. Tests of fetal lung maturity
2. Precipitous delivery 7. Blood, CSF, and Skin culture and sensitivity
3. Sepsis
4. Cardiac defects Management!
5. Airway obstruction
6. Hypoglycemia  Head elevated
7. metabolic acidosis  Proper suctioning
8. Multiple pregnancy  Oxygen administration with increased
9. Maternal diabetes humidity
10. Perinatal asphyxia  Client will be placed on continuous
11. Preeclampsia or eclampsia positive airway pressure
12. Maternal hypertension
 Positive end expiratory pressure
13. Prolonged rupture of membranes
 Caffeine citrate to prevent apnea
14. Maternal corticosteroids use
15. Previous birth of baby with HMD
Monitor and Assess
14. CS delivery or induction of labor before full
term
15. Cold stress  Respiratory rate and rhythm, pulse blood
16. Perinatal infection pressure and activity
 Skin color, signs of cyanosis, duskiness
Signs and Symptoms! and pallor
 Sucking, swallowing, gag and cough reflex
Early signs
 Low body temperature Meconium Aspiration Syndrome (MAS)
 Nasal flaring
 Suprasternal, sternal, and subcostal  Before and during labor and delivery
retractions (early signs)  Infants born at term and post term
 Tachypnea
Meconium
 Cyanotic mucous membranes
- First intestinal discharge from newborns
- A sterile viscous, dark green substance
Several hours later
composed of lanugo, swallowed amniotic
 Expiratory grunting
fluid, and intestinal secretions.
 Cyanotic – central (late sign)
 PO2 and O2 saturation fall in room air Factors that promotes the passage meconium to
 Auscultation: Fine rales, Diminished the utero
breath sounds
1. Placental insufficiency
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2. Maternal hypertension 5. Invasive procedures (placement of IV lines and
3. Preeclampsia ET tubes)
4. Oligohydramnios 6. Administration of TPN
5. Maternal drug abuse 7. Nosocomial exposure
6. Intrauterine distress
7. Maternal infection/chorioamnionitis. Types of Sepsis
8. Fetal hypoxia
A. Early-onset sepsis
Signs and Symptoms
- less than 3 days after birth
 Cyanosis - acquired in perinatal period
 Grunting - infection occur from direct contact with
 Alar flaring organisms from the maternal GI and GU
 Intercostal retractions
 Tachypnea B. Late-onset sepsis
 Barrel chest
- 1 to 3 weeks after birth
 Auscultated rales and rhonchi
- Primary nosocomial
 Yellow-green staining of fingernails,
umbilical cord, skin
Clinical Manifestations
 Green urine observed less than 24 hours
after birth 1. Hypothermia
2. Diarrhea
Management! 3. Low blood sugar
4. Swollen belly area
 Close monitoring of fetal status 5. Vomiting
 amnioinfusion with warm, sterile saline 6. Jaundice
 Intubation and immediate suctioning of the 7. Poor sucking
airway to remove much of the aspirated 8. Sudden episodes of apnea 9. Unexplained
meconium. desaturation
 Suction for no longer than 5 seconds
 Dry, stimulate, reposition, and administer Hyperbilirubinemia
oxygen as necessary
 Maintain an optimal thermal environment  Jaundice of the newborn
 Minimal handling because these infants  Neonatal hyperbilirubinemia
are easily agitated  Bili lights – jaundice
 Complications: Kernicterus - indirect
Sepsis Neonatorum (Septicemia) bilirubin levels as high as 20 mg/100m

 Refers to a generalized bacterial infection Causes

in the bloodstream that occurs in an infant
younger than 90 days old 1. ABO Incompatibility
 Microorganisms transmitted: 2. Rh Incompatibility
a. Cytomegalovirus 3. Sepsis
b. Toxoplasma gondii 4. Extensive bruising
c. Treponema pallidum 5. Cephalhematoma

Factors increasing the risk of infection Factors increasing the risk of Hyperbilirubinemia

1. Transplacental transfer 1. Postnatal age

2. Prematurity 2. Total Serum Bilirubin value 3. Prematurity
3. Congenital anomalies 4. Health of the neonate
4. Acquired injured that disrupt the skin or 5. SGA
mucous membranes
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Symptoms

1. Jaundice causes a yellow color of the skin.

2. The color begins on the head to feet fashion
3. Lethargy
4. Poor sucking

Management!

1. Early feeding
2. Pharmacologic: Phenobarbital
3. Fiberoptic panel / blanket
4. Intravenous immunoglobulin
5. Phototherapy (no less than 18 inches from
lamps)

- Eyes are shielded by an opaque mask.

- Temperature is closely monitored
- Flexed position with rolled blankets along
with the sides of the body
- Minimal clothing and turn patient
- Accurate charting

6. Exchange transfusion

Minor Side Effects

 Loose, greenish stools

 Bronze baby syndrome - Infants develop a
dark, gray-brown discoloration of skin,
urine, and serum due to the accumulation
of porphyrins and other metabolites
 Frying effect
 Purpura or bullae