THE NEWBORN

“I had heard about the negatives---the fatigue,I had heard about the negatives---the fatigue, the loneliness, loss of self. But nobodythe loneliness, loss of self. But nobody told me about the wonderful parts: holdingtold me about the wonderful parts: holding my baby close to me, seeing his first my baby close to me, seeing his first smile, watching him grow and become moresmile, watching him grow and become more responsive day by day.....For the firstresponsive day by day.....For the first time I cared about somebody else more thantime I cared about somebody else more than myself, and I would do anything to myself, and I would do anything to nurture and protect him.”nurture and protect him.”

Newborns undergo profound physiologic

changes at the moment of birth.

Within minutes after birth, a newborn has to initiate

respirations, and adapt a circulatory system to

extrauterine oxygenation. Within 24 hours, neurologic,

renal, endocrine, and gastrointestinal functions

must be operating competently for life to be

sustained.

Newborns undergo profound physiologic

changes at the moment of birth.

Within minutes after birth, a newborn has to initiate

respirations, and adapt a circulatory system to

extrauterine oxygenation. Within 24 hours, neurologic,

renal, endocrine, and gastrointestinal functions

must be operating competently for life to be

sustained.

Surfactant

•What is the function of surfactant?

•When is it produced?

•When it is sufficient to support extrauterine life?

Respiratory Changes

Chemical

Sensory/ Thermal

Mechanical

InitiationInitiation ofof BreathingBreathing

What part do each of these factors play in initiation of

respirations in the neonate?

Chemical Events

1. With cutting of the cord, remove oxygen supply

2. Asphyxia occurs

3. CO2 and O2 and pH = ACIDOSIS

4. Acidotic state-- stimulates the

respiratory center in the medulla and

the chemoreceptors in carotid artery to

initiate breathing

Mechanical Events

• As the chest passes

through the birth canal

the lungs are compressed

• Subsequent recoil of the chest wall produces passive inspiration of air into the lungs

Fluid expelled Air Enters

Mechanical Events

About 60-110 ml. of fluid is squeezed out of the lungs as the chest is compressed

The remaining fluid evaporates or is reabsorbed by the blood vessels and lymphatics surrounding the lungs.

**When a baby is delivered in a presentation other than vertex, it takes longer for the lungs to rid themselves of the fluid

Sensory / Thermal Events

Thermal--the decrease in

environmental temperature after

delivery is a major stimulus of breathing

Tactile--nerve endings in the skin

are stimulated

Visual--change from a dark world to

one of light

Auditory--sound in the extrauterine

environment stimulates the infant

Answer this !

• When a baby is born by cesarean delivery, which of the mechanisms to initiate breathing does it lack?

Answer This!

Fetal Circulation

What is the flow of blood through the fetal heart?

1. ____________

2. ____________

3. ____________

4. ____________

RA LA

LV

RV

Fetal Circulation

Fetal Circulation

• What is the stimulus for the change in

circulation?

• What are the changes in circulation from

Intrauterine to

Extrauterine?

Intrauterine to Extrauterine

1. Infant takes first breath and the lungs inflate

______________ pulmonary vascular resistance

Increased ______________ blood flow & pulmonary artery pressure _________.

2. Increase pressure in ____ atrium, ____ pressure in right atrium

_________ of foramen ovale

3. The ______ arteriosus and ductus venosus close related to pressure changes and ______ levels.

Cardiovascular Changes

1. Pressure in RA decreases

2. Blood flows to the lungs

4. Pressure in the LA increases RT Flow of blood from the lungs

3. Ductus Arteriosusbegins to constrict

5. Increase pressurein the LA forcesthe foramen ovale to close

True / False

• An infant’s first breath results in reduced pulmonary vascular resistance, decreased left atrium pressure, and increased right atrium pressure

• Increase CO2 , decreased O2, and increased pH help trigger initial breathing

Temperature Regulation

Why is the newborn at a DISADVANTAGE in maintaining

a normal temperature ?

Minimizing HeatLoss in the Newborn is IMPERATIVE

Four Avenues of Heat Loss

• Conduction --Loss of heat to a cooler surface by direct skin contact

• Convection--Loss of heat to cooler air currents

• Radiation--loss of heat to cooler surfaces and objects not directly in contact with the skin

• Evaporation-- loss of heat when water is converted to a vapor.

• What are nursing interventions to decrease each of these?

Heat Production

1. Increase in Muscular activity--shown by crying and restlessness = increases BMR

2. Non-Shivering Thermogenesis - unique to newborns. Uses the infants stores of brown fat.

Brown fat is found in the midscapular area, around the neck, in the axillas, and around the trachea, kidneys, and adrenal glands

1. Skin receptors perceive a drop in environmental temperataure

2. Transmit impulses to the central nervous system

3. Which stimulates the sympathetic nervous system

4. Norepinephrine is released at local nerve endings in the brown

5. Metabolism of brown fat

6. Release of fatty acids

7. Release of HEAT!

Non Shivering ThermogenesisNon Shivering Thermogenesis

Heat MaintenanceHeat Maintenance

PeripheralPeripheralVasoconstrictionVasoconstriction

SubcutaneousSubcutaneous FatFat

Curl up in Curl up in fetal positionfetal position

Blood Changes

• At birth, an infant has more RBC’s and higher hemoglobin and hematocrit levels than an adult

• Once proper oxygenation is established, the need for the high RBC’s diminishes

Lab values for Newborn

• hemoglobin – 14-20 g/dl• hematoctrit – 43-63%• WBC – 10,000-30,000/mm3• glucose – 45-96 mg/dl

Gastrointestinal Changes

• By 36-38 weeks of fetal life, the GI system is fully mature and ready to digest simple carbohydrates, fats, and protein.

• What is the capacity of the newborns stomach?

• What is meconium? Why is it important for the newborn to pass this?

Hepatic and LiverFunctions

iron storage and RBC production

carbohydrate metabolism

conjugation of bilirubin

 

– Coagulation--coagulation factors are under the influence of vit. K. The absence of normal flora needed to synthesize vit. K results in low levels of vitamin K and creates a transient blood coagulation alteration between the second and fifth day after birth.

Vitamin K is given prophylactically to combat potential clinical bleeding problems

Physiological Jaundice

• What is Physiological Jaundice?

• What is the main cause?

Conjugation of Bilirubin

Where do we get bilirubin?

What is the difference in Unconjugated bilirubin and conjugated bilirubin?

Why does it need to be conjugated?

Fat Soluble

Conjugation of Bilirubin is a conversion of

to

Water Soluble

Unconjugated Conjugated

by ___________________________________?

Physiological Jaundice• About 50% of all infants exhibit signs in 2 - 3 days after birth

• Bilirubin levels at birth are about 3 mg./dl and should not exceed 12 mg. Peak bilirubin levels are reached between days 3 & 5 in the term infant. Toxic levels are approximately 20mg/dl.

•  Nursing Care:

– Keep well hydrated

– Promote elimination

• early feedings tend to keep bilirubin levels down by stimulating intestinal activity thus removing the contents and not allowing reabsorption

Renal / Kidney Changes

IntrauterineUrine if formed in utero and

some excreted into the amniotic fluid

Excretion of wastes is the function of the placenta

Extrauterine• GFR is low --decrease

ability to excrete drugs• Limited ability to reabsorb

Sodium• Decreased ability to

concentrate urine• Bladder capacity is

6 - 44 ml• Void within the first 24 hrs.

and should void 6 - 10 times per day

Immunologic Adaptation

• Active acquired immunity– Pregnant woman forms antibodies herself

• Passive acquired immunity– Mom passes antibodies to the fetus– Lasts from 4-8 months

– Newborn begins to produce own immunity about 4 weeks of age

Behavorial / Sleep - Awake States

– Sleep States:• Deep or quiet sleep• Active rapid eye movement/ light sleep

– Alert States:• Drowsy• Wide awake/quiet alert• Active awake/ active alert• Crying

Which state is optimal for parent-infant interaction?

Quiet Alert

Sensory

• Visual– Can follow and fixate on visual stimuli for short

period of time• Hearing

– Alert to and searches for auditory stimulus• Olfactory

– Able to select people by smell• Taste

– Able to respond to different tastes• Tactile

– Sensitive to touch, cuddling, and being held

Immediate Care of the Newborn

• Ensure a Patent Airway– Position on side

– Suction mouth then nares

– supply warmed oxygen is necessary

**Always have bulb suction in view !

Clamping of the Cord

• Cord should be clamped off about 1” from base of cord.

• Inspect the cord for

2 arteries and 1 vein.

Maintain Body Temperature

• Dry off

• Place in warmer

• Skin to skin contact

Apgar Score

• Scoring system to appraise the newborn

• Done at 1, 5, and 10 minutes after birth

Apgar Score

Heart Rate Absent Slow (less than 100 )

Over 100

Respiratory Effort

Absent Slow, weakirregular cry

Good Cry

ReflexIrritability

No Response Weak cry orgrimace

Vigorous Cry

Muscle Tone

Flaccid Some flexion ofExtremities

ActivemotionResists effortto extend

Color Blue / pale Body pink,extremitiesblue

Completely pink

0 1 2

Heart Rate is the most important !

Apgar Score

• Score of 7 - 10 = Good Condition

• Score of 4 - 6 = Fair Condition

• Score of 0 - 3 = Poor Condition

Score This !

• Baby girl Doe has a heart rate of 102, with slow, irregular respirations. She grimaces when stimulated. She has some flexion in her extremities and her skin color is pale.

• What is her Apgar Score?

Identification of the Newborn

Mother and infant should have

matching “identibands”.

Bands should be placed on infant prior to leaving the delivery room

Footprint of infant and fingerprint of the mother

Eye Care

• Legal requirement that all newborns have treatment to prevent Ophthalmia neonatorium which can lead to newborn blindness.

• Treated with antibiotic eye medication either ointment or drops

(Tetracycline or Erythromycin )

Hemorrhage Prophylaxis

• Administration of Vitamin K (AquaMEPHYTON)

• This promotes liver formation of clotting factors

• The newborn does not have bacteria in the GI tract to synthesize vit. K.

• By 5 - 8 days after birth, it is formed.

Transfer to the Nursery

• Identification checks

• Full report must be given to the nursery nurse by the L & D nurse– Condition of the neonate– Labor and Birth record– Antepartal history– Parent-newborn interaction

Physical Assessment

• Temperature - 97.6 - 98.6

• Heart Rate - 120 - 160 BPM. Regular rate. PMI

on the left side of the chest

• Respirations- 30 - 60 breaths / min. Diaphragmatic with a shallow, irregular rate and rhythm. Chest and abdominal movements should synchronize. Periodic Breathing is normal. They are nose breathers. Tachypnea is abnormal

• Blood Pressure - 80-60 / 45-35.

Measurements and Weights

Length = 18 - 22 inches

Head and Chest Circumference = Head is 13”; Chest is 12”. Head is larger than the chest by one inch or 2 cm.

Weight - 6 - 9 lbs average. Newborns lose 5% - 10% of birth weight the first few days after birth.

Reflexes

• Moro• Tonic Neck• Palmar and Plantar grasp• Babinski• Feeding--Rooting, Sucking, Swallowing, Gag

• Protective -- Sneezing, Blinking, Gag

Daily Nursing Care

Need for warmth and dry

Need for protection from infection

Need for food

Need for attachment and loving

Need for bathing and cord care

Nutritional Needs

• The newborns diet must supply nutrients to meet the rapid rate of physical growth and development

• Daily caloric intake should be 110 - 120 calories / kg. / day

Circumcision

It is not medically necessary. It is a personal decision of the parents.

• What is the priority nursing assessment following a circumcision?

Explain?

• What is important to teach parents about care?