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CSI        Baby!Early Recognition of the Compromised Newborn 

Tanya Kamka, RNC-NIC, MSNUCSF Benioff Children’s Hospital

▪ Discuss maternal, fetal and intrapartum risk factors that contribute to a compromised newborn

▪ Describe the physiologic changes that must occur at birth for successful transition to extrauterine life

▪ Discuss the nursing assessments and interventions for an infant who becomes compromised

Course Objectives

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Recipe for Success When Caring for Compromised Newborns…(S.T.A.B.L.E.)

Anticipate Recognize Act Reassess

▪ Antenatal risk factors that can lead to a compromised newborn

▪ Maternal risk factors

▪ Fetal risk factors

▪ Intrapartum risk factors

Identifying newborns at risk

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▪ Age

▪ Lifestyle

▪ Support system

▪ Access to care

▪ Mental Health

▪ Chronic illness

▪ Genetics

▪ Stress

Maternal risk factors

• Prenatal Diagnosis– Genetics: CVS, amniocentesis

– Nuchal translucency

– Ultrasound

– Fetal ECHO

– Fetal MRI

• Entry to care• Pregnancy nutrition and weight gain

Prenatal Care

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• Obstetric History

○ Infertility

○ Past delivery history

○ Bleeding

○ PROM

○ Infection

○ Pregnancy loss

Maternal Factors

• Multiple gestation

• Abnormal growth

• Abnormal fetal position

• Abnormal placentation

• Decreased activity/FHR abnormality

• Poly/oligohydramnios

Fetal Factors

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• Fetal distress• Fetal presentation

• Premature/postmature labor

• Rapid or prolonged labor

• Rupture of membranes

• Maternal bleeding

• Cord prolapse

• Eclampsia

• Instrumentation at delivery

• Mode of delivery

• Medications

Intrapartum Factors

• Prematurity

• Low Apgars

• Encephalopathy

• Shock/pallor

• Chorioamnionitis

• Small for dates

• Large for dates

• Undiagnosed congenital anomalies/conditions

Immediate Neonatal Conditions

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▪ LBW ≤2500 gms▪ VLBW ≤1500gms▪ ELBW ≤1000gms

▪ SGA - Weight below the 10th percentile for gestational age

▪ IUGR - Fetus is unable to reach its genetically determined potential size

▪ LGA - Weight above 90th percentile for gestational age

▪ Macrosomia - Estimated fetal weight>4500gm in IDM and >5000gm in others

Birth Weight Categories & Classifications

Symmetric Asymmetric

IUGRLGASGA or IUGRAGA

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Slide 12

1 Does this make sense? I wanted to try and make a visual of the differencesTanya Hatfield, 5/18/2018

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▪Extreme prematurity ≤ 28 weeks

▪Very preterm  < 32 weeks

▪Late preterm (LPI)  34 0/7‐36 6/7 

weeks

▪Early term pregnancy  37 0/7‐38 6/7 

weeks

▪Term pregnancy  39 0/7‐40 

Maturity Classifications

Risks related to Prematurity

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Characteristics of the LPI

%

Low Birth Weight

Delay in bilirubin metabolism

Immature suck and swallow

Immature Immune system

Poor state regulation

Low tone

Low glycogen stores

Poor thermoregulation

Low Body Fat

Clinical Outcomes: Full term vs. LPI

Modified from Wang, et al. Pediatrics, 2004

%

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Post Maturity Risks

Post Maturity Risks

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Transition to Extrauterine Life

REMEMBER!Blood

follows thepath of least resistance

The fetus gets oxygen

from the placenta

Pressure in the blood vessels of the lungs is high

so blood is shunted away

Review of

FETAL SHUNTS

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Fetal Circulation▪ Gas exchange is liquid to liquid

▪ Organ of respiration is placenta

• High flow, low resistance

▪ Fetal lungs

• Low flow, high resistance

• Pulmonary Arteries constricted

▪ High right heart and lung pressures

▪ Low left heart pressures

▪ Open fetal shunts

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5 things must happen at birth:

• Lungs expand to terminal airways

• Alveoli become oxygenated

• Pulmonary Vasculature must dilate (↓ PVR)

• Cardiac output to lungs goes from 10% →100% (↑ SVR, closure of fetal shunts)

• Establishment of continuous breathing

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Transition to Extrauterine Life

• Independent breathing

• Fetal to neonatal circulation

• Non-shivering thermogenesis

• Independent glucose production

• Fluid balance shifts

Transition to Extrauterine Life

• Good news! 90% of infants transition with no

problem!

• But...10% require some assistance

• 1% require extensive resuscitation

• Remember… difficulty transitioning in one area will

affect the others

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What are the goals of Resuscitation?

● Maintain temp 36.5-37.5-Room 25C/77F-Skin to skin-Servo-Thermal devices

● Support breathing● Gentle ventilation● Judicious use of oxygen● Support cardio-respiratory transition● Normoglycemia

Do you know…???

A naked newborn exposed to an environmental temperature of 23°C (73.4°F) suffers the same

heat loss as a naked adult in 0°C (32°F)

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The function of brown fat is to:

a) generate heat when it is metabolized.b) provide a rapidly available source of glucose in the first day of life.c) provide an insulating layer of fat in the first month of life.

Cold Stress Response

• Peripheral and core sensors detect cold stress

• Hypothalamus signals norepinephrine release which leads to:

– Peripheral and pulmonary vasoconstriction

– Increased metabolic rate

– Increased 02 and glucose consumption

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The mother-baby unit is extremely busy today. An infant born several hours ago at 37-weeks gestation has the following vital signs:

Temperature 36.0°C (96.8°F) Heart rate 170 Respiratory rate 65You have a heavy patient load and need to bathe the infant. Should the infant be bathed at this time?

a) No, the vital signs are not in a normal range and the bath should waitb) Yes, providing a radiant warmer is used so the infant doesn't get coldc) Yes, the vital signs are in an acceptable range and the infant is term

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▪ Interventions• Delay interventions at birth that increase heat

loss (temp. affects other VS too)• Skin to skin care with mother immediately after

birth and as frequently as medical condition allows

• Dress infant with hat, double blankets if necessary

• Use servo-control and temp. probe while in warmer/incubator

Temperature Instability

▪ Interventions• Document ambient temperature/clothing

necessary to maintain optimal body temp• Assess carefully for cause of changes in

temperature

‒ Primary thermo-regulation vs. sepsis, respiratory issues, hypoglycemia

• Warm consistently: incubator, servo-control, monitor NTE, slow transition to OC, additional clothing when in open crib

• Notify provider of episodes of hypothermia

Temperature Instability

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Initial Assessments

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Cortical Thumb

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Port Wine Stain

Café Au Lait

36

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Sacral Skin Tag

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Sacral Dimple

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Size

▪ Alertness/activity level

▪ Symmetry of movement

▪ Response to stimuli

▪ Posture

▪ Tone

▪ Reflexes

Neurological Assessment

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Abnormal Newborn Exam

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Tone? Activity?

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Sarnat scoring (for encephalopathy)

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Assessment of the Baby at Risk for Encephalopathy

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Seizures▪ Quality of movement

• Tonic - stiff posturing

• Clonic – rhythmic single body part

• Subtle (ex bicycling, orofacial movements, tremulous movements)

• Myoclonic - rapid “shock-like”

• Erratic, non-rhythmic

▪Body part

▪ Level of consciousness

▪Response to stimulus: Extinguishable?

▪Duration

Seizures: what else could it be?Benign Neonatal Sleep Myoclonus

Typical presentation:• 1st DOL to 1st 3 weeks

of life• Distal parts of upper

extremities• 10-20 seconds• Can worsen with

restraint• Stops when awakened

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Seizures

▪Check Calcium and Glucose

▪ Lorazepam 0.1 mg/kg IV

▪Phenobarbital 20mg/kg IV

“This baby seems jittery…”

▪What is the history

▪When is the onset

▪Are there electrolyte abnormalities?

○ Hypoglycemia

○ Hypomagnesemia

○ Hypocalcemia

▪Hyperviscosity

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Hypoglycemia

How low is too low?

How low is too low for too long?

Hypoglycemia-Who is at Risk?▪Preemies

▪SGA

▪ IUGR

▪LGA

▪ IDM

▪Sick babies

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▪ High risk groups

• Inadequate glycogen stores and decreased glucose production

• Hyperinsulinemia

• ALL sick babies

‒ Metabolic acidosis/increased energy demands

‒ ↑ work of breathing, thermal regulation, etc

‒ Lack of excess oxygen for conversion

Hypoglycemia

Hypoglycemia

▪Abnormal cry

▪Apnea

▪Cyanosis

▪Feeding Difficulty

▪Grunting, Tachypnea

▪Hypothermia

▪Hypotonia

▪ Irritability

▪Jitteriness, tremors

▪Lethargy

▪Seizures

▪Diaphoresis

▪Tachycardia

▪NO SYMPTOMS

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UCSF NC2 Asymptomatic Infants/at-risk

UCSF NC2 Asymptomatic Infants-at risk