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THE NEWBORN

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THE NEWBORN
“I 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.”
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
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
• As the chest passes
through the birth canal
the lungs are compressed
Fluid expelled
• 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!
• 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
• 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 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
• 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 Heat
Loss 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
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
• 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 Liver
Functions
пѓ� iron storage and RBC production
пѓ�carbohydrate metabolism
пѓ�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?
Conjugation of Bilirubin
is a conversion of
Fat Soluble
Unconjugated
Water Soluble
to
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
Intrauterine
Urine 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
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
• 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
пѓ� Length = 18 - 22 inches
пѓ� Head and Chest Circumference = Head is
13”; Chest is 12”. 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
•
•
•
•
•
•
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?
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