Chapter 26 MCN

• Newborn


  Birth to under four weeks of age (<28 days)
• Early neonatal period


  First week of life (<7 days or <168 hours)
• Late neonatal period


  Extends from 7th to <28th day
• Classification of Newborns


  • Birth Weight
  • Gestational Age
  • Physical Characteristics
  • Medical Status
• Preterm infant


  Infant born before completion of 37 weeks of gestation, regardless of birth weight
• Late-Preterm Infant


  An infant born between 34 and 36 weeks of gestation, regardless of birth weight
• Post term infant


  An infant born after 42 weeks of gestational age, regardless of birth weight
• Full term Infant


  An infant born between the beginning of 38 weeks and the completion of 42 weeks of gestation, regardless of birth weight
• Birth Weight Classification

  • LBW infant = Less than 2,500 grams (5 pounds, 8 ounces)
  • VLBW infant = Less than 1,500 grams (3 pounds, 5 ounces)
  • ELBW: Less than 1,000 grams (2 pounds, 3 ounces)
• Physical Characteristics

  • SGA (Newborns who are smaller than expected for their gestational age)
  • LGA (Newborns who are larger than expected for their gestational age)
  • AGA (Newborns whose weight falls within the normal range for their gestational age)
• Medical Status


  • Healthy newborns: Those born without any complications or medical conditions
  • High-Risk Newborns: infants who have a greater likelihood of experiencing health problems or complications compared to the general newborn population
• APGAR Score


  Used to assess the newborn's overall health and well-being at 1 and 5 minutes after birth, based on criteria such as heart rate, respiratory effort, muscle tone, reflexes, and color
• Mortality


  • Live Birth - Birth in which the neonate manifests any heartbeat, breathes, or displays voluntary movement, regardless of gestational age
  • Fetal Death - Death of the fetus after 20 weeks of gestation and before delivery, with absence of any signs of life after birth
  • Neonatal Death - Death that occurs in the first 27 days of life; early neonatal death occurs in the first week of life; late neonatal death occurs at 7 to 27 days
  • Perinatal Mortality - Describes the total number of fetal and early neonatal deaths per 1000 live births
  • Postnatal Death - Death that occurs at 28 days to 1 year after birth
• Newborn Assessment


  1. All newborns need to be assessed at birth for obvious congenital anomalies and gestational age

  2. Initial assessment is performed under a prewarmed radiant heat warmer to prevent heat loss

  3. Cardiac monitor

  4. O2 saturation

  5. BP
• Newborn Priorities


  • Initiation and maintenance of respirations
  • Establishment of extrauterine circulation
  • Maintenance of fluid and electrolyte balance
  • Control of body temperature
  • Intake of adequate nutrition
  • Establishment of waste elimination
  • Prevention of infection
  • Establishment of newborn-parent relationship
  • Anticipating Developmental Needs
• Normal respiration


  • Respiratory Rate: A normal respiratory rate for a newborn is typically between 30-60 breaths per minute
  • Breathing Patterns: Newborns may exhibit periodic breathing, which involves short pauses followed by a burst of rapid breathing. This pattern is considered normal in the first few weeks of life
  • Breath Sounds: Clear breath sounds without any wheezing, crackles, or other abnormal sounds are typical
  • Color: Newborns usually have a pink or slightly bluish tint to their skin. Central cyanosis (blueness around the lips and mouth) is abnormal and may indicate respiratory distress or other issues
  • Chest Movement: The chest should rise and fall symmetrically with breathing. Any retractions (sucking in of the chest wall) or nasal flaring can indicate respiratory distress
  • Oxygen Saturation: Normal oxygen saturation levels are typically above 95%. Lower levels may indicate respiratory compromise
  • Breath Sounds: Clear and equal breath sounds bilaterally without any adventitious sounds (such as crackles or wheezes)
  • Respiratory Effort: Effortless breathing without grunting or visible signs of distress is normal
• Factors predisposing infant to Respiratory Difficulty


  • Low birth weight
  • Cord prolapse
  • Small for gestational age
  • Lowered APGAR Score (<7) at 1- or 5-minute intervals
  • Chest, heart, respiratory tract anomalies
• Resuscitation


  • Resuscitation is important for both newborns who fail to take first breath and for those who have difficulty maintaining adequate respirations on their own
  • Approximately 10% of newborns require assistance to begin breathing at birth
  • AAP instituted Neonatal Resuscitation Program that lists steps and rationales for newborn resuscitation
  • Establish airway
  • Expand the lungs
  • Initiate and maintain effective ventilation
  • If respiratory depression becomes so severe that a newborn's heart begins to fail ( HR <60 bpm), resuscitation should also include compression
• Suctioning


  • Bulb syringe is a standard piece of equipment in most birthing rooms
  • No longer recommended due to risk of bradycardia
  • Performed when there is a concern that the airway was blocked
  • If newborn does not initiate spontaneous breathing following drying and stimulating, place newborn under radiant warmer in a sniffing position
  • Positive pressure ventilation should be initiated immediately if newborn is not breathing, or HR is <100 bpm
  • Mechanical suctioning should occur only if there is obstruction such as mucus plug that is interfering with effective breathing
  • A full-term newborn who still makes no effort at spontaneous respirations after these initial steps may require insertion of an endotracheal tube
• Lung Expansion


  • The sound of the neonate crying is proof that lung expansion is adequate because the vocal sounds are produced by a free flow of air over the vocal cords
  • Mask should cover both mouth and nose
  • Ambu bag = pop-off valve to limit pressure (40%)
  • Anesthesia flow-inflating bag = (100%)
• Drug Therapy


  • If respiratory depression appears to be due to narcotic administration such as morphine or meperidine (Demerol), Naloxon (Narcan), a drug to reverse narcotics, should still not be given because it may cause seizures
  • Resuscitation efforts should focus on effective ventilation and airway support
  • <60 bpm = epinephrine 1:10,000 to stimulate heart action
• Establishing Extrauterine Circulation


  • Lack of cardiac function may develop if respirations cannot be quickly initiated and maintained
  • No beat or <60 bpm = chest compressions
  • If the newborn's heart rate is greater than 60 but less than 100 bpm, chest compressions can be stopped but ventilations should be continued
  • Ventilations should continue until the heart rate is greater than 100 bpm
  • If the heart rate is not above 60 beats per minute after at least 30 seconds of coordinated positive pressure ventilation and chest compressions, intravenous epinephrine to stimulate heart action
• Hypoglycemia


  Often comes after resuscitation attempts due to the newborn's effort to begin breathing
• Dehydration


  May also result from increased insensible water loss caused by rapid respirations
• Maintaining Fluid and Electrolyte Balance

  1. D10W

  2. Monitor rate of administration

  3. When using radiant warmer, remember potential for water loss due to radiation or convection

  4. Hypovolemia = fetal blood loss

  5. PNSS
• Controlling Body Temperature


  • Neonate's body is often exposed for long periods of time during procedures like resuscitation
  • Should be in neutral temperature environment to maintain minimal metabolic rate
  • Cover head with cap
  • Drying baby
  • Placing in a radiant warmer
  • Suggest skin to skin contact
  • Plastic wrap
  • Increasing room temperature
  • Warmed mattress
• Intake of Adequate Nutrition

  • Newborns who experience severe asphyxia at birth usually receive intravenous fluids initially
  • If neonate's respiratory rate remains so rapid that they cannot suck effectively, gavage feedings may be introduced
  • Others with long-term nutrition concern may have gastrostomy tubes
  • Babies who are premature and too small or weak to suck enough from the breast or bottle
  • Babies who have a problem coordinating their suck and swallow
  • Babies who have a problem with their throat, or esophagus
  • Babies, who may have lung and heart problems, are breathing too hard or too fast to be able to suck and swallow
• Establishment of Waste Elimination


  • Neonates void within 24 hours
  • Urinary track obstruction
  • Renal dysfunction
  • Anuria
  • Meconium is the infant's first poop. Black and tarry looking
  • Hirschsprung's Disease
  • Intestinal Atresia
  • Meconium Plug Syndrome
  • Meconium Ileus
  • Imperforate Anus
• Prevention of Infection


  • Colostrum supplies important immune protection
  • Common viruses that affect neonates during IUL: Cyclomegalovirus, Toxoplasmosis, Late onset infections
• Establishment of Newborn-Parent Relationship

  • Be certain the parents of high-risk newborns are kept informed of what is happening during resuscitation
  • They should be able to visit special unit where neonate is admitted to make it more real to them
  • Urge parents to spend as much time as possible with the baby
  • If the neonate dies despite resuscitation attempts, parents need to see the neonate when no longer attached to equipment
• Anticipating Developmental Needs


  • High risk newborns need special care and planning to ensure the amount of pain they experience during procedures is limited to the least amount possible
  • Parent support
• The Newborn At Risk Because of Altered Gestational Age


  Part of the study material that focuses on newborns with altered gestational age and associated risks

  
• Classification of neonates


  • Term neonates
  • Preterm neonates
  • Post-term or postmature neonates
• Growth parameters


  • Birth weight plotted on growth chart
  • Birth weight typically increases with each additional gestational week
• Classification based on weight percentiles

  • Appropriate for gestational age (AGA): 10th to 90th percentile
  • Small for gestational age (SGA): Below 10th percentile
  • Large for gestational age (LGA): Above 90th percentile
• Classifications based on birth weight

  • Low-birth-weight (LBW) infant: < 2,500 g
  • Very-low-birth-weight (VLBW) infant: < 1,500 g
  • Extremely-low-birth-weight (ELBW) infant: < 1,000 g
• Preterm infant


  Traditionally defined as infants born before the completion of 37 weeks of gestation or weighing less than 2500 g (5 lb 8 oz) at birth

  
• Further classification of preterm infants

  • Late preterm: born between 34 and 37 weeks
  • Early preterm: born between 24 and 34 weeks
• Special care needs of preterm newborns

  • Require intensive care for survival
  • More prone to hypoglycemia, infections, and intracranial hemorrhage
  • Vulnerable to respiratory distress syndrome (RDS) due to lack of lung surfactant
• Determining Gestational Age


  Gestational age assessment involves physical examination findings, maternal report of the last menstrual period, sonographic estimations, and neurological assessments