Newborn at risk pt 1

• Newborns at risk


  Newborns who are susceptible to morbidity (illness) or mortality (death) due to: Dysmaturity, Immaturity, Physical disorders, Antepartum conditions, Complications during or after birth
• Predictable risk factors

  • Low socioeconomic level of mother
  • Limited access to health care
  • Exposure to environmental issues
  • Maternal conditions
  • Health problems
  • Age
  • Parity
  • Pregnancy complications
• Gestational age

  • Preterm: less than 36 weeks & 6 days
  • Late Preterm: 34-36 weeks & 6 days
  • Early Term: 37-38 weeks & 6 days
  • FULL Term: 39-40 weeks & 6 days
  • Late Term: 41- 41 weeks & 6 days
  • Post-term: 42 weeks and beyond
• Small for gestational age (SGA)


  Any infant who is less than the 10th percentile for birth weight
• Large for gestational age (LGA)


  Any infant who is at or above the 90th percentile for birth weight
• Intrauterine growth restriction (IUGR)


  Fetus with limited growth potential during pregnancy due to a variety of factors
• Infants of diabetic mothers (IDM)


  Any infant of a mother with either pre-existing diabetes or gestational diabetes
• Maternal Factors leading to SGA or IUGR

  • Multiples
  • Smoking
  • PIH or CHTN
  • Maternal age < 16 or > 40
  • Grand multiparity (> 6 pregnancies)
  • Malnutrition
  • Heart disease
  • Substance abuse
  • Diabetes
  • Sickle cell
• Environmental factors leading to IUGR

  • Living at High altitude
  • Exposure to x-rays
  • Exposure to toxins
  • Maternal use of medications such as anticonvulsants
  • Maternal use of drugs such as opioids and many others
• Placental factors leading to IUGR

  • Small placenta
  • Infarcted areas
  • Placenta previa or thrombosis
  • Abnormal cord insertion
  • Single umbilical artery (rather than the normal pair)
• Fetal factors contributing to IUGR

  • Congenital viral infections such as TORCH infections: Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes
  • Congenital malformations
  • Metabolic issues
  • Chromosomal issues
• Symmetric IUGR


  Caused by long term maternal conditions, chronic growth restriction throughout pregnancy, baby is small all over including organs, length, body weight, head circumference, discovered as early as second trimester (by sono)
• Asymmetric IUGR


  Caused by acute compromise of uteroplacental blood flow, may not be discovered until third trimester, baby appears disproportionate, head circumference and length may be WNL, abdominal circumference and weight will be decreased
• Factors leading to LGA

  • Genetic predisposition
  • Large parents often have large babies
  • Male infants are larger on average than female infants
  • Multiparity
  • Much more common after the first pregnancy
• Additional Factors leading to LGA

  • Erythroblastosis fetalis
  • Beckwith-Weidmann syndrome
  • Transposition of the great vessels
  • Maternal diabetes that is poorly controlled during pregnancy*
• Macrosomia

  May occur in 40-50% of diabetic pregnancies, due to high levels of glucose crossing the placenta which is stored as fat by the growing fetus
• Infant with postmaturity syndrome

  Those newborns delivered after 42 weeks gestation who have problems associated with an extended pregnancy, the placenta may begin to deteriorate after about 41 weeks, this can lead to poor blood flow, decreased nutrients and decreased oxygen to baby, baby may not tolerate labor well
• Characteristics of Post-Mature Newborn

  • Dry, cracked, peeling skin (parchment like)
  • Long fingernails/hair
  • No vernix
  • No lanugo
  • Body long, thin, wasting
  • Head circumference and length typically WNL
  • Meconium staining
• Rh incompatibilities

  Rh positive infants of Rh negative mothers at risk for destruction of red blood cells resulting in jaundice and hyperbilirubinemia (or worse)
• ABO incompatibilities


  Infants with blood Type A, B, or AB whose mother is blood type O are at similar risk
• Common Complications of at Risk Newborns

  • Cold stress
  • Hypoglycemia
  • Jaundice
• Cold stress


  Occurs when newborns lose more heat than their bodies can produce
• Hypoglycemia


  Low blood sugar
• Jaundice

  A yellow discoloration of the skin & sclera caused by elevated levels of bilirubin
• Signs of cold stress

  • Increased movements
  • Increased respirations
  • Decreased skin temp.
  • Decreased peripheral perfusion
  • Hypoglycemia
  • Metabolic acidosis
• Nursing interventions for cold stress

  • Warm baby slowly, using isolette or radiant warmer
  • Warm IV fluids before infusion
  • Warm oxygen sources
  • warm hands, equipment remove wet clothing/linen/diaper
• Newborns routinely screened for hypoglycemia


  • Newborns of diabetic mothers
  • LGA & SGA newborns
  • Newborns with IUGR
  • Other at risk newborns
• Hypoglycemia intervention


  -Necessary if the newborn's blood glucose drops to less than 45-47 mg/dL, or anytime symptoms are present

  -early feedings in the first hour of life, recheck after 30 minutes

  -may need continuous iv fluids

  -feed ever 2-3 hours and check glucose before each feed for 12 hours

  -dextrose gel for asymptomatic infants with glucose of 20-40
• Hypoglycemia symptoms

  • Lethargy, sleepiness
  • Poor feeding/vomiting
  • Poor sucking/swallowing
  • Temperature instability
  • Apnea/dyspnea/cyanosis
  • Limpness
  • Tremors/jitteriness
  • High pitched cry
  • Exaggerated Moro reflex
• Hypoglycemia nursing interventions

  • Prevention is best, so promote early and regular feedings
  • Perform heel stick to obtain blood sample for blood glucose testing
  • IV infusion of dextrose solution may be necessary
• Physiologic jaundice

  Appears after the first 24 hours of life and typically resolves within 1 week
• Breastfeeding jaundice


  Can occur in the first few days of life and is related to inadequate fluid intake
• Hyperbilirubinemia


  A more serious condition which also causes jaundice, and requires intervention. Sometimes caused by ABO or Rh incompatibility. Intervention is necessary if bilirubin exceeds 13-15 mg/dL.
• Jaundice symptoms

  • Bilirubin level > 4-6 mg/dL
  • Yellow tint to skin when blanched at forehead or sternum
• Jaundice interventions


  • Prevention is best with early and frequent feedings to keep baby hydrated and help eliminate bilirubin via urine and stool
  • Phototherapy (protect baby's eyes)
  • Exchange transfusion
• Newborn Growth Chart Activity

  1. Chart the growth of a specific newborn based on information provided

  2. Decide if newborn is SGA, AGA, LGA

  3. Based on risk factors decide what additional problem(s) this infant may have

  4. Identify complications to look for

  5. Identify priority nursing interventions for this baby

  6. Discuss measures that could prevent or reduce risk factors
• Ways to prevent cold stress after exam

  • Reswaddle
  • baby hat
  • educate parents
• Two types of jaundice

  physiological or newborn

  • after 24 hours of life
  • usually due to increase in red cell mass and short RBC lifespan, slower uptake of bilirubin lack of intestinal bacteria, poor hydration
  • Peaks at at 3-5 days

  pathological jaundice

  • before 24 hours of life
  • cause is usually hemolytic diseases
  • peak is variable
• LGA

  • large for gestational age
  • Risk factors - diabetics, multipare, males, erythroblastosis fetalis, beckwith-weidman syndrome, transportation of great vessels
  • complications- birth trauma, hypoglycemia, polycythemia, hyperviscosity