Lauren PlattNewborn at

Risk

BIRTHWEIGHT VARIATIONS

• Appropriate for gestational age (AGA) – weight within 10th – 90th percentile (lowest morbidity and mortality rates)• Small for gestational age (SGA) – weight below 10th percentile (< 2,500 g or 5lb 8 oz)• Large for gestational age (LGA) – weight above the 90th percentile (> 4,000 g or 8lb 13oz)

• Low birthweight - < 2,500 g• Very low birthweight - < 1,500 g• Extremely low birthweight - < 1000 g

Factors Affecting Fetal Growth:• Maternal nutrition• Genetics• Placental function• Environment

Newborns are classified according to birthweight and weeks of gestation

Preterm Newborn• Born before 37 weeks

gestation • Can be SGA, LGA or normal• GOALS: Meet growth and

developmental needs, Recognize and manage complications

• Risk Factors Maternal age <18 or >35 Multiple gestation Hx of Preterm birth Low SES Smoking or PSA Uterine anomaly Polyhydramnios Febrile Illness, pyelonephritis

Photograph copyright Tom Stewart/CORBIS

Common Problems Associated with the

Newborn oPerinatal asphyxiaoThermoregulationoHypogylcemiaoMeconium aspirationoHyperbilirubinemiaoBirth trauma

Perinatal

Asphyxia

• Common in SGA & Preterm newborns• Causes (*think HYPOXIA*)

Stress of labor Hypoxic environment r/t placental

insufficiency Uterine contractions Difficulty adjusting to extrauterine

environment Cord compression Surfactant deficiency Immature Resp control center Inability to clear airway Small resp passages

• Findings Fetal distress (brady, decels) Low APGAR score Potential meconium passage into amniotic

fluid

Nursing Management:

• Anticipate problem

• Assess for maternal

risk factors

• Initiate

resuscitation

measures

immediately after

birth

Signs & Symptoms• Plasma glucose < 40

mg/dL• Most common in IDM, SGA,

& preterm AGA infants• Monitor glucose

frequently– preferred site is lateral heel

• Initiate early feeding (oral is best)

• Maintain fluid and electrolyte balance

• Lethargy• Jitteriness• Poor feeding• Seizures• Temp instability• Resp distress• Tremors, jerkiness• High pitched cry• Exaggerated Moro

reflex• Hypotonia

Hypoglycemia

Infant Heel Stick

Potential sites for heel sticks. Avoid shaded areas to prevent injury to arteries and nerves in the foot and the important longitudinally

oriented fat pad of the heel, which in later years could impede walking.

Meconium Aspiration

Nursing Interventions:• Assess for resp

distress• Suctioning• Ventilator support,

ECOM

• Presence of meconium in amniotic fluid

• Fluid is aspirated in utero or during first few breaths taken by newborn

• Most common in SGA, Postterm, prolonged labor

• Green amniotic fluid, green stained cord, difficulty initiating respirations

Extracorporeal membrane oxygenation (ECMO)

A process that takes blood from the body,

oxygenates it using an artificial lung, and

pumps it back into the body using an

artificial heart. Used when hypoxia cannot

be corrected with other treatments

(ventilator or supplemental oxygen).

Hyperbilirubinemia• Is an abnormally high level of bilirubin in the

blood

• Newborn serum bilirubin normally does not exceed 3-5 mg/dL

• Jaundice, a yellowish discoloration of tissues, develops from the deposit bilirubin in fatty tissues

• Role of the perinatal nurse is to identify jaundice as soon as apparent

• Differentiate between pathologic vs physiologic jaundice

Physiologic Jaundice • Normal process• Occurs during transition

from intrauterine to extrauterine life

• Occurs in 50% of healthy term and 80% of preterm newborns

• Appears after 24 hours of age

• Not visible after 10 days of age

• May require phototherapy

Pathologic Jaundice• Signs of underlying

illnesso Vomitingo Lethargyo Poor feedingo Excessive weight

losso Apneao Tachypneao Temperature

instability

• Usually caused by ABO or Rh incompatibility

• Jaundice may be present at birth

• Treatmento Phototherapy beginningo Exchange transfusionso Infusion of albumino Drug therapyo Monitor for complications of

kernicterus

• Untreated hyperbilirubinemia (due to either type of jaundice) may result in neurotoxicity

Birth TraumaMost common in LGA

infants

Nursing Interventions:

• Deformities, bruising, edema, asymmetrical movement

o Head to toe assessment

o Look for asymmetry of structure

o Assist parents in understanding

Thermoregulation Balance between heat produced and heat lost to the environment

• Normal range 97.7 – 98.6 F• Lose heat rapidly in cold environment r/t ↓ SQ fat and

thinner epidermis• Unable to shiver• Main source of heat from “brown fat”

Cold StressRisk Factors Signs & Symptoms

• SGA, LGA• Prematurity• Post-dates• Precipitous delivery• Delayed drying• Disruption in skin

integrity

• Cold extremities• Lethargy• Apnea• Tachypnea• Poor feeding• Nasal flaring• Grunting• Retractions

Neonatal Energy Triangle

(Parks, 2007)

Nursing Management

Photo courtesy of Mariano Marcos Memorial Medical Center, Philippines.

• Maintain warm environment

• Keep head dry & covered

• Preheat equipment

• Protect from conduction heat loss

• Use warm blankets

• Encourage skin-to-skin contact