THE NEWBORN вЂњI had heard about the negatives---the fatigue, the loneliness, loss of self. But nobody told me about the wonderful parts: holding my baby close to me, seeing his first smile, watching him grow and become more responsive day by day.....For the first time I cared about somebody else more than myself, and I would do anything to nurture and protect him.вЂќ 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 вЂў What is the function of surfactant? вЂў When is it produced? вЂў When it is sufficient to support extrauterine life? Respiratory Changes What part do each of these factors play in initiation of respirations in the neonate? Mechanical Initiation of Breathing Chemical Sensory/ Thermal 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 вЂў As the chest passes through the birth canal the lungs are compressed Fluid expelled вЂў Subsequent recoil of the chest wall produces passive inspiration of air into the lungs Air Enters Mechanical Events пЃі About 60-110 ml. of fluid is squeezed out of the lungs as the chest is compressed пЃі The remaining fluid evaporates or is reabsorbed by the blood vessels and lymphatics surrounding the lungs. пЃі **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 ! Answer This! вЂў When a baby is born by cesarean delivery, which of the mechanisms to initiate breathing does it lack? Fetal Circulation What is the flow of blood through the fetal heart? 1. ____________ 2. ____________ 3. ____________ RA LA LV 4. ____________ RV Fetal Circulation Fetal Circulation вЂў What is the stimulus for the change in circulation? вЂў 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 пѓЎ ______ levels. Cardiovascular Changes 3. Ductus Arteriosus begins to constrict 1. Pressure in RA decreases 2. Blood flows to the lungs 4. Pressure in the LA increases RT Flow of blood from the lungs 5. Increase pressure in the LA forces the foramen ovale to close True / False вЂў An infantвЂ™s first breath results in reduced pulmonary vascular resistance, decreased left atrium pressure, and increased right atrium pressure вЂў Increase CO2 , decreased O2, and increased pH help trigger initial breathing Temperature Regulation п‚§ Why is the newborn at a DISADVANTAGE in maintaining a normal temperature ? Minimizing Heat Loss in the Newborn is IMPERATIVE Four Avenues of Heat Loss вЂў Conduction --Loss of heat to a cooler surface by direct skin contact вЂў Convection--Loss of heat to cooler air currents вЂў Radiation--loss of heat to cooler surfaces and objects not directly in contact with the skin вЂў Evaporation-- loss of heat when water is converted to a vapor. вЂў 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 Non Shivering Thermogenesis 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! Peripheral Vasoconstriction Heat Maintenance Subcutaneous Fat Curl up in fetal position Blood Changes вЂў At birth, an infant has more RBCвЂ™s and higher hemoglobin and hematocrit levels than an adult вЂў Once proper oxygenation is established, the need for the high RBCвЂ™s diminishes Lab values for Newborn вЂў вЂў вЂў вЂў hemoglobin вЂ“ 14-20 g/dl hematoctrit вЂ“ 43-63% WBC вЂ“ 10,000-30,000/mm3 glucose вЂ“ 45-96 mg/dl Gastrointestinal Changes вЂў By 36-38 weeks of fetal life, the GI system is fully mature and ready to digest simple carbohydrates, fats, and protein. вЂў What is the capacity of the newborns stomach? вЂў What is meconium? Why is it important for the newborn to pass this? Hepatic and Liver Functions пѓ� iron storage and RBC production пѓ�carbohydrate metabolism пѓ�conjugation of bilirubin вЂ“ 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 вЂў What is Physiological Jaundice? вЂў What is the main cause? Conjugation of Bilirubin п‚§ Where do we get bilirubin? п‚§ What is the difference in Unconjugated bilirubin and conjugated bilirubin? п‚§ Why does it need to be conjugated? Conjugation of Bilirubin is a conversion of Fat Soluble Unconjugated Water Soluble to Conjugated by ___________________________________? Physiological Jaundice вЂў About 50% of all infants exhibit signs in 2 - 3 days after birth вЂў 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. вЂў Nursing Care: вЂ“ Keep well hydrated вЂ“ Promote elimination вЂў early feedings tend to keep bilirubin levels down by stimulating intestinal activity thus removing the contents and not allowing reabsorption Renal / Kidney Changes Intrauterine Urine if formed in utero and some excreted into the amniotic fluid Excretion of wastes is the function of the placenta Extrauterine вЂў GFR is low --decrease ability to excrete drugs вЂў Limited ability to reabsorb Sodium вЂў Decreased ability to concentrate urine вЂў Bladder capacity is 6 - 44 ml вЂў Void within the first 24 hrs. and should void 6 - 10 times per day Immunologic Adaptation вЂў Active acquired immunity вЂ“ Pregnant woman forms antibodies herself вЂў Passive acquired immunity вЂ“ Mom passes antibodies to the fetus вЂ“ Lasts from 4-8 months вЂ“ Newborn begins to produce own immunity about 4 weeks of age Behavorial / Sleep - Awake States вЂ“ Sleep States: вЂў Deep or quiet sleep вЂў Active rapid eye movement/ light sleep вЂ“ Alert States: вЂў Drowsy вЂў Wide awake/quiet alert вЂў Active awake/ active alert вЂў Crying Which state is optimal for parent-infant interaction? Quiet Alert Sensory вЂў Visual вЂ“ Can follow and fixate on visual stimuli for short period of time вЂў Hearing вЂ“ Alert to and searches for auditory stimulus вЂў Olfactory вЂ“ Able to select people by smell вЂў Taste вЂ“ Able to respond to different tastes вЂў Tactile вЂ“ Sensitive to touch, cuddling, and being held Immediate Care of the Newborn вЂў Ensure a Patent Airway вЂ“ Position on side вЂ“ Suction mouth then nares вЂ“ supply warmed oxygen is necessary **Always have bulb suction in view ! Clamping of the Cord вЂў Cord should be clamped off about 1вЂќ from base of cord. вЂў Inspect the cord for 2 arteries and 1 vein. Maintain Body Temperature вЂў Dry off вЂў Place in warmer вЂў Skin to skin contact Apgar Score вЂў Scoring system to appraise the newborn вЂў Done at 1, 5, and 10 minutes after birth Apgar Score 0 1 H e a rt R a te R e s p ira to ry E ffo rt R e fle x Irrita b ility M u s c le Tone C o lo r Absent Absent S lo w (le s s th a n 1 0 0 ) S lo w , w e a k irre g u la r c ry N o R e s p o n s e W e a k c ry o r g rim a c e F la c c id B lu e / p a le 2 O ve r 1 0 0 G o o d C ry V ig o ro u s C ry S o m e fle x io n A c tive of m o tio n E x tre m itie s R e s is ts e ffo rt to e x te n d B o d y p in k , C o m p le te ly e x tre m itie s p in k b lu e Heart Rate is the most important ! Apgar Score вЂў Score of 7 - 10 = Good Condition вЂў Score of 4 - 6 = Fair Condition вЂў Score of 0 - 3 = Poor Condition Score This ! вЂў 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. вЂў What is her Apgar Score? Identification of the Newborn п‚§ Mother and infant should have matching вЂњidentibandsвЂќ. п‚§ Bands should be placed on infant prior to leaving the delivery room п‚§ Footprint of infant and fingerprint of the mother Eye Care вЂў Legal requirement that all newborns have treatment to prevent Ophthalmia neonatorium which can lead to newborn blindness. вЂў Treated with antibiotic eye medication either ointment or drops (Tetracycline or Erythromycin ) Hemorrhage Prophylaxis вЂў Administration of Vitamin K (AquaMEPHYTON) вЂў This promotes liver formation of clotting factors вЂў The newborn does not have bacteria in the GI tract to synthesize vit. K. вЂў By 5 - 8 days after birth, it is formed. Transfer to the Nursery вЂў Identification checks вЂў Full report must be given to the nursery nurse by the L & D nurse вЂ“ Condition of the neonate вЂ“ Labor and Birth record вЂ“ Antepartal history вЂ“ Parent-newborn interaction Physical Assessment вЂў Temperature - 97.6 - 98.6 вЂў Heart Rate - 120 - 160 BPM. Regular rate. PMI on the left side of the chest вЂў 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 вЂў Blood Pressure - 80-60 / 45-35. Measurements and Weights пѓ� Length = 18 - 22 inches пѓ� Head and Chest Circumference = Head is 13вЂќ; Chest is 12вЂќ. Head is larger than the chest by one inch or 2 cm. пѓ� Weight - 6 - 9 lbs average. Newborns lose 5% - 10% of birth weight the first few days after birth. Reflexes вЂў вЂў вЂў вЂў вЂў вЂў Moro Tonic Neck Palmar and Plantar grasp Babinski Feeding--Rooting, Sucking, Swallowing, Gag Protective -- Sneezing, Blinking, Gag Daily Nursing Care п‚§ Need for warmth and dry п‚§ Need for protection from infection п‚§ Need for food п‚§ Need for attachment and loving п‚§ Need for bathing and cord care Nutritional Needs вЂў The newborns diet must supply nutrients to meet the rapid rate of physical growth and development вЂў Daily caloric intake should be 110 - 120 calories / kg. / day Circumcision It is not medically necessary. It is a personal decision of the parents. вЂў What is the priority nursing assessment following a circumcision? Explain? вЂў What is important to teach parents about care?