1

NEWBORN COMPLICATIONS

Diana Barrios, RN, MSN

Merritt College ADN Program

Nursing 3A: Perinatal Nursing

CLASSIFICATION OF INFANTS

BY GA & WEIGHT

� By gestational age�Preterm/premature: < 37 weeks gestation�Term: 38-42 weeks

�Postterm/postdate: >42 weeks

� By birth weight�SGA: below 10th percentile on intrauterine growth curves

�AGA: between 10th and 90th percentile�LGA: above 90th percentile

�LBW: 2500 g or less

�VLBW: 1500 g or less

�ELBW: <1000 g

� Gestational age and birth weight affect maturity of infant’s body systems and likelihood to experience health problems

THE PRETERM INFANT

� The preterm infant has immature body systems and inadequate physiological reserves, making it

difficult to adjust to extrauterine life

� Degree of maturity depends on length of

gestation and birth weight

� Prematurity results in immediate and/or lifelong

negative sequelae

� Preterm birth causes 2/3 of all infant deaths

2

RESPIRATORY & CARDIOVASCULAR

SYSTEMS: THE PRETERM INFANT

� Respiratory�Immature lungs

�Inadequate amount of surfactant

�Fewer functional alveolar sacs

�Respiratory passages collapse or become obstructed

�Immature or fragile capillaries in the lungs

�Infant may experience respiratory distress or apnea; oxygen and/or artificial ventilation may be necessary

� Cardiovascular�Issues with heart rate & rhythm, color, blood pressure,

perfusion, pulses, O2 sat, acid-base balance

THERMOREGULATION:

THE PRETERM INFANT

� High ratio of body surface to body weight � Poor muscle tone, less flexed posture� Little subcutaneous fat

� Decreased stores of brown fat� Decreased ability to constrict superficial blood

vessels� Thinner, more permeable skin

� Immature temperature regulation center in brain� Inadequate glycogen stores� Radiant warmer, incubator, or kangaroo care

may help establish a neutral thermal environment.

CENTRAL NERVOUS SYSTEM:

THE PRETERM INFANT

� Most rapid brain growth occurs in 3rd trimester

� CNS vulnerable to injury related to:�Birth trauma with damage to immature structures

�Bleeding from fragile capillaries

�Impaired coagulation

�Recurrent anoxic or hyperoxic episodes

�Hypoglycemia

�Fluctuating BP

� Evaluate infant for signs of neuro dysfunction: seizures, hyperirritability, CNS depression, increased ICP, decorticate positioning

3

DIGESTIVE SYSTEM:

THE PRETERM INFANT

� Ingestion, digestion, and absorption

problems

�Weak/absent suck and swallow reflex

�Poorly developed gag reflex increases risk

for aspiration

� Immature digestive enzymes

�Small stomach capacity

�Oral feedings may not be possible – may need gavage or IV feedings

GENITOURINARY & HEPATIC SYSTEMS:

THE PRETERM INFANT

� Immature kidneys lead to issues:

�Maintaining fluid & electrolyte balance

�Excreting metabolites and drugs

�Concentrating urine

�Monitor I&O, specific gravity, serum levels of meds

� Hepatic system

�Fewer glycogen deposits & increased risk for cold stress

� hypoglycemia

�Low iron stores � anemia

�Increased risk for hyperbilirubinemia & jaundice

IMMUNE SYSTEM:

THE PRETERM INFANT

Greater risk for infection:

�Deficient antibodies (less passive acquired

immunity) b/c less time spent in utero

�Decreased ability to make antibodies

� Inability to suck or difficulty sucking affects

breastfeeding and transfer of IgAantibodies

4

Problems of

Prematurity

Can be LBW, SGA, IUGR, or AGA –

but all organs/systems are immature

RDS:

↓Surfactant

↓ Vascularity/neuro

↓ Lung compliance

↓pO2→ PDA

Anaerobic metabolism →metabolic acidosis, lack of

available albumin-binding

sites adds to

hyperbilirubinemia

Lack of body fat, brown fat,

posturing → hypothermia

Cold stress

Hypoglycemia

Hypoxemia → RDS

Absence of suck reflex/↑

energy expenditure > calories

for metabolic needs

Increased risk of

hyperbilirubinemiaHigh risk of infection

NECIatrogenic risks

Risks of maladaptive attachment

PARENT-INFANT ATTACHMENT:

THE PRETERM INFANT

� Preterm infants may be separated from mom and family for an extended period of time

� Nurse should foster parent-infant bonding

�Photographs of baby showing growth over time

�Baby’s name on incubator

�Weekly card with footprints, weight & length

� Involve parents in infant care

� Provide discharge teaching

THE NEWBORN AT RISK:

HEALTH PROBLEMS

�Respiratory distress syndrome (RDS)

�Necrotizing enterocolitis (NEC)

�Hypoglycemia

�Physiologic and pathologic jaundice

�Hemolytic disease of the newborn

�Sepsis

� Infants affected by maternal drug use

5

RESPIRATORY DISTRESS SYNDROME

� Immature lungs lack or are unable to produce surfactant

�Without adequate surfactant, alveoli collapse and gas exchange inhibited �hypoxia and acidosis

�RDS symptoms: tachypnea, grunting, nasal flaring, retractions, hypercapnia, respiratory acidosis, hypotension, shock

�Ventilatory support: oxygen, CPAP, respirator, surfactant

NECROTIZING ENTEROCOLITIS

� Inflammatory disease of the GI mucosa that leads to necrosis of the bowel

� 3 factors associated with NEC: intestinal ischemia, colonization by pathogenic bacteria,

formula feeding

� Symptoms: feeding intolerance, increased

gastric residuals, abdominal distention, bloody stools

� Treatment aimed at resting GI tract, preventing bowel perforation, and controlling infection

CLINICAL PICTURE OF NEC

Neonate with NEC. Abdominal distention progresses as gas builds

up in the bowel. Continued abdominal distention further compromises GI blood flow. Note abdominal wall erythema.

6

HYPOGLYCEMIA

� Most common metabolic disorder in SGA and LGA/macrosomic infants. May occur in IDM.

� If blood glucose concentration <40 mg/dL, initiate breastfeeding or bottlefeeding ASAP

� Infant may be asymptomatic or exhibit: jitteriness, poor feeding, hypothermia, vomiting, pallor, weak cry, lethargy, seizure activity, coma

� Monitor infant’s body temperature b/chypothermia leads to increased glucose consumption � hypoglycemia

JAUNDICE

�Most common abnormal physical finding in

newborn

�Skin appears yellow-tinged due to a build-

up of unconjugated bilirubin, which is a by-product of RBC breakdown

�Can be categorized as physiologic or

pathologic

PHYSIOLOGIC JAUNDICE

� Normal biologic response of the newborn that occurs after 24 hours of life

� Observed first in the infant’s face, then moves down to thorax, abdomen, and extremities

� Newborn care procedures that may decrease the risk for hyperbilirubinemia:� Maintaining normal body temp

� Encouraging early and frequent breastfeeding

� Monitoring stool� Placing the infant in indirect sunlight for short period of time

� Total serum bilirubin is normally <3 mg/dL. Jaundice clinically visible when levels 5-7 mg/dL

� Kernicterus: bilirubin levels > 25 mg/dL, results in irreversible brain damage

7

Physiological jaundice

PATHOLOGIC JAUNDICE

�Occurs within the first 24 hours of life

�Primary cause: hemolytic disease of the newborn 2o Rh incompatibility or ABO incompatibility

�Assess infants of Rh negative moms or moms with Type O blood:�Blood type & Rh

�Appearance of jaundice, esp. in first 24 hours of life

�Levels of transcutaneous and/or serum bilirubin

�Coomb’s test (direct or indirect)

HEMOLYTIC DISEASE

OF THE NEWBORN

� Maternal antibodies cross the placenta and cause hemolysis of fetal RBCs.

� Rh incompatibility & maternal sensitization�Process of antibody formation in Rh negative mom, in

response to Rh positive fetus

�Concern is not with 1st pregnancy, but subsequent pregnancies

�Fetal RBC destruction � hyperbilirubinemia, jaundice, anemia

�Erythroblastosis fetalis, hydrops fetalis

� ABO incompatibility�Mom blood type O and infant blood type A, B, or AB

�Occurs more often than Rh incompatibility, but results in less severe problems in the infant

�Rarely causes anemia, commonly causes hyperbilirubinemia

8

SEPSIS

� Presence of microorganisms or their toxins in the infant’s blood or other tissues

� Early-onset sepsis occurs within 48 hours of life. Caused by microorganisms from normal flora of maternal vaginal tract (GBS, E. coli, H. influenzae, S. pneumoniae)

� Late-onset sepsis occurs 2 weeks after birth. Caused by bacteria from birth canal or environment (S. aureus, S. epidermidis, Pseudomonas, GBS)

� Measures to prevent infection: STD screening, sterile technique with vag exams during labor, intrapartal use of IV antibx in GBS+ moms, erythromycin eye ointment

� Signs & symptoms of infection� Lab studies if infection suspected

CLINCAL PICTURE OF SEPSIS

Although infrequently seen, an exaggerated arched position of the

head and neck, termed opisthotonos, can be indicative of meningitis.

TORCH INFECTIONS & GBS

� TORCH infections - Box 27-1, page 894�T: toxoplasmosis

�O: other – gonorrhea, syphilis, varicella, hep B, HIV

�R: rubella

�C: cytomegalovirus

�H: herpes simplex virus

� GBS infection - page 899� 1 out of 4 women are GBS positive – not harmful to mom, but

can be very harmful to baby (leads to meningitis and sepsis)

�Early GBS screening (@ 35-37 weeks GA) and administration of antibiotics to GBS + moms during labor has decreased incidence of neonatal morbidity and mortality r/t GBS disease.

9

Neonatal syphilis lesions on hands and feet

Neonatal herpes simplex virus (HSV) skin infection

HSV oral lesions

EFFECTS OF ALCOHOL

ON THE INFANT

�Alcohol-related birth defects (ARBD),

formerly known as fetal alcohol syndrome. 3 criteria:

�Prenatal and postnatal growth restriction

�CNS malfunctions

�Craniofacial features – microcephaly, small

eyes, thin upper lip, flat midface

� Issues faced by ARBD children: lower IQ,

ADD, diminished fine motor skills, poor speech

10

INFANT WITH ARBD:

EFFECTS OF CIGARETTE SMOKING &

MARIJUANA ON THE INFANT

� Cigarette smoking during pregnancy responsible for 21-39% of LBW babies

� Smoking increases risk for miscarriage and PTL� Negative neurobehavioral effects in the infant

�Decreased intellectual and emotional development

�Fine motor tremors

�Increased muscle tone

�Decreased verbal comprehension

�Increase rate of SIDS

� Marijuana is linked to shorter gestation & IUGR; negatively impacts fetal growth & infant weight/length

EFFECTS OF COCAINE

ON THE INFANT

� Cocaine use during pregnancy leads to neurobehavioral depression or excitability in the infant

� Symptoms of depressed infant: lethargy, poor suck, hypotonia, weak cry, difficulty in arousal

� Symptoms of excited infant: high-pitched cry, hypertonicity, rigidity, irritability, inability to be consoled

� Smaller head circumference, decreased birth length, decreased weight

� Long-term effects

11

EFFECTS OF HEROIN

ON THE INFANT

� Heroin use during pregnancy causes IUGR and stillbirths

� Infants born to heroin addicts experience heroin withdrawal symptoms 50-75% of the time

� Infant may start out depressed and then exhibit withdrawal symptoms�Jitteriness or hyperactivity

�Shrill cry

�Frequent yawns or sneezes

�Increased reflexes, except Moro

�Poor sucking and feeding

�Abnormal sleep cycles

THINGS TO KEEP IN MIND

� Most births involve healthy outcomes with healthy infants.

� Nurses should be knowledgeable about problems related to GA as well as acquired and congenital problems affecting the newborn.

� Nurses should support the physiologic functioning and psychoemotional development of the newborn.

� Nurses should provide patient education and adopt a caring & non-judgmental attitude.