NEWBORN TRANSITION&

ManagementChapter 17 & 18

Mary L. Dunlap MSNFall 2015

Physiologic Transitioning

Cardiovascular Adaptations

• Fetal to neonatal circulation occurs simultaneously with the respiratory adaptation

• Cessation of blood through the umbilical vessels and placenta causes the change from fetal to neonatal circulation

Fetal to Neonatal Circulation

• Clamping the umbilical cord increases the SVR

• Closure of the ductus venosus allows blood flow through the portal/hepatic system

Fetal to Neonatal Circulation

• Increase pressure in the left atrium from the pulmonary venous return closes the foramen ovale

• Rising O2 concentration in the blood and decreased prostaglandin levels closes the ductus arteriousus

• Box 17.1 pg 528

Neonatal Circulation

• Apical pulse counted for a full minute

• PMI is at the 4th intercostal space to the left of the midclavicular line

• Heart rate at birth 120-180

• Then average 120-130

• Tachycardia greater than 160

• Bradycardia less than 100

Neonatal Circulation

• Capillary refill less than 3 sec.

• Femoral/Bracial pulses palpated for symmetry, strength and rate will provide information about the change to adult circulation pattern

• Average systolic 50-75, diastolic 30 -45

Neonatal CirculationNormal Blood Values

Lab Data Normal RangeHemoglobin 17-23 g/dl

Hematocrit 46-68%

Platelets 150,000-350,000/uL

RBC’s 4.5-7.0 (1,000,000 uL)

WBC’s 10-30,000/mm³

Neonatal Circulation

• Average blood Volume 80-85ml/Kg

• Late clamping of the cord can lead to polycythemia

• Factors II, VII, IX, and X are low due to the lack of Vitamin K

Respiratory Adaptations

• Surfactant promotes lung expansion by preventing the complete collapsing of the alveoli with each expiration.

• Increases the lungs ability to fill with air

• Sufficient quantity around 35 wks. gestation

Respiratory Adaptations

• Chemical Stimulation

• Mechanical Stimulation

• Sensory Stimulation

• Pulmonary Blood Flow

Chemical Stimulation

• Catecholamine surge during labor and right after birth corresponds to rapid drop in level of fluid in lung field

• Catecholamines increase the release of surfactant

• Increase in cardiac output and contractility

Chemical Stimulation

• Decrease O2 & Increase CO2 concentration along with decrease pH stimulates aortic & carotid chemoreceptors triggering the medulla to initiation of respirations

Mechanical Stimulation

• Compression of the chest during vaginal birth forces 1/3 of the fluid out of the lung fields

• Once the chest is delivered the re-expansion draws air into the lungs

• Crying creates positive intrathoracic pressure keeping alveoli open

Sensory Stimulation

• Tactile

• Visual

• Auditory

Pulmonary Blood Flow

• Pulmonary vasodilatation occurs as O2 enters the lungs

• The decrease in PVR allows for adequate gas exchange and transition

Respiratory Adaptations

• Established within 1 minute of birth

• Respirations should be quiet

• Diaphragmatic & abdominal muscles used

• Nose breathers

• 30-60 breaths/minute

• Irregular, shallow & unlabored

• short periods of apnea <15 sec

Respiratory Adaptations

• Acrocyanosis and circumoral cyanosis first 1-2 hrs

• Respiratory distress nasal flaring, grunting, sternal retractions retractions and a rate less than 30 & greater than 60

Thermoregulation

• Balance between heat loss and production is related to rate of metabolism and oxygen consumption

• Newborns ability to maintain it’s temperature is controlled by external environmental factors and internal physiologic process

Thermoregulation

• Neutral thermal environment (NTE), body temperature is maintained without an increase in metabolic rate or oxygen consumption

• Temperature range 97.9 – 99.7

Risk Factors For Heat Loss• Thin skin; blood vessels close to the surface• Lack of shivering ability to produce heat

involuntarily • Limited stores of metabolic substrates (glucose,

glycogen, fat)• Limited use of voluntary muscle activity or

movement to produce heat• Large body surface area relative to body weight• Lack of subcutaneous fat, which provides insulation• Little ability to conserve heat by changing posture

Mechanisms of Heat Loss

• Evaporation - Heat loss as water evaporates from the skin

• Convection - transfer of body heat to surrounding air ( cold del. Room)

• Conduction - transfer of heat to surface the newborn is lying on

• Radiation - loss of heat through the air to a cooler surface ( not in direct contact with the neonate)

Thermogenic Adaptation

• Newborns have limited ability to shiver to generate heat

• Heat is produced by the metabolism of brown fat (Nonshivering Thermogenesis)

• Voluntary muscle activity: flexion of extremities, restlessness, and crying

• Assume fetal position to hold in heat

Thermogenic Adaptation

Effects of cold stress

•Increase O2 consumption can lead to metabolic acidosis

•Increase glucose utilizes leads to hypoglycemia

•Production of surfactant is decreased and respiratory distress can occur

Signs of Cold Stress

• Skin cool to touch

• Mottling of the skin

• Central cyanosis

• Decreased responsiveness

• Jittery

• Tachypnea

Hepatic Adaptation

Assumes the function of the placenta•Blood coagulation•Iron storage•Carbohydrate metabolism •Conjugation of bilirubin

Gastrointestinal System

• Audible bowel sounds within 1 hour • Stomach capacity small during the first

4 days• Development of mucosal Barrier• Uncoordinated peristaltic activity in the

esophagus for a few days due to an immature cardiac sphincter and nerve control

Gastrointestinal System

• 1st meconium passed 12-24 hrs.• Transitional stool passed for 1-2 days

• Breast-fed newborns: Yellow-gold, loose, stringy to pasty, sour-smelling

• Formula-fed newborns: yellow, yellow-green, loose, pasty, or formed, unpleasant odor

Renal System

• 6-8 voids/day • Urine odorless straw color • Uric crystals cause pink staining in

diapers• Low GFR

Neurologic System Adaptations

• Neurologic development follows cephalocaudal and proximal-distal patterns

• Myelin develops early on sensory impulse transmitters

• Acute sense of hearing, smell and taste• Presence and strength of reflexes is an

important indicator of neurologic development and function

Immune System Adaptation

• Neonate depends on three immunoglobins: IgA, IgG, and IgM

• IgG crosses the placenta and is found in the fetus by the 3rd trimester. It protects the newborn against bacterial and viral infections the mother has developed antibodies for ( tetanus, measles, mumps)

Immune System Adaptation

• IgM is found in the blood and lymph and is the first immunoglobulin to respond to infection. Production starts at birth. If elevated at birth may indicate exposure to intrauterine infection

• IgA is found in colostrum and can contribute to passive immunity. It limits bacterial growth in the GI tract and is produced gradually.

Behavioral Adaptations

Behavioral Patterns

•First period of reactivity

•Period of decreased responsiveness

•Second period of reactivity

First Period Of Reactivity

Birth to 30 minutes

• Alert ,moving, may appear hungry

• Reactive to stimuli, period of alertness, sucking and rooting

• Excellent time for parents to interact with their newborn

• Encourage breastfeeding and bonding

Period Of Decreased Responsiveness

• Occurs at 30 to 120 minutes of life enters into a deep sleep

• Decrease responsiveness difficult to interact with newborn

• Let mother and newborn rest together

• Decrease in heart and respiratory rate

Second Period Of Reactivity

• Occurs from 2 to 8 hours of life

• Newborn awakens and shows an interest in stimuli

• Increase in heart and respiratory rate

• Peristalsis increases, not uncommon for newborn to pass meconium

• Increase in muscle tone

Behavioral Adaptations

Newborn Behavioral Responses

•Orientation

•Habituation

•Motor Maturity

•Self-Quieting Ability

•Social Behaviors

Normal Newborn Assessment After Delivery

• Evaluate the newborns’ adjustment to Extrauterine.

• Assess for possible birth trauma

• The assessment should progress from head to toe.

Initial Assessment (Delivery Room)

• Apgar score

• Assess for gross abnormalities

• Apply cord clamp

• Obtain foot prints

• Apply identification bands

• Administer Vitamin K & eye prophylaxis

• Promote bonding

Assessment 0 Point 1 Point 2 Point

Heart Rate Absent < 100 bpm > 100 bpm

Respiratory effort Apneic Slow, irregular, shallow

Regular 30-60 breaths/min

Strong, good cry

Muscle Tone Limp, Flaccid Some flexion, limited resistance

to extension

Tight flexion, good resistance to extension with quick response to

flexed position

Reflex irritability No Response Grimace or frown when irritated

Sneeze, cough, or vigorous cry

Skin color Cyanotic or Pale Appropriate body color; blue extremities

Completely pink

Signs of Newborn Stress

Nasal flaringChest retractionsGrunting on exhalationlabored BreathingGeneralized cyanosis Flaccid body Abnormal breath sounds& rateAbnormal heart rates

Complete Newborn Assessment

• Length-17 to 22 inches (44-55cm)• Weight- average 7lb 8 oz.• SGA less than 5lb 5 oz. • LGA greater than 9 lb. • Newborns can loose up to 10% of birth

weight by days 3-4• Head circumference-13-15 in/32-38 cm• Chest circumference-12-14 in/30-36 cm

Newborn Assessment

Temperature

•Normal axillary temperature 97.9°F–99.7°F

Cardiovascular system

•Normal heart rate 120–160 bpm

•Crying can ↑ HR to 180

•Observe color, pulse, murmurs

Newborn Assessment

Respiratory system

•Normal rate is 30–60/minute

•Nose-breather

•Observe for flaring, grunting, retracting

•Auscultate for rales

Skin Assessment

• Assess color

• Check for birth marks, trauma, rashes or bruises

• Presence of lanugo

• Palpate texture ( ranges from smooth to peeling)

• Turgor ( elasticity)

Skin Assessment

Common variations

•Milia (clogged sebaceous glands)

•Mongolian spots

•Birthmarks

•Lanugo- fine hair

•Vernex- thick white substance that protects skin

Skin Assessment

• Petechiae

• Blisters, lesions

• Abnormal hair distribution

• Port wine stains

• Mongolian spots

• Stork bites

Head• Measure circumference• Anterior fontanel diamond shaped closes

in 18-24 months• Posterior fontanel triangle shaped closes

in 6-12 weeks• Fontanels need to be open and soft• Depressed fontanel indicates dehydration• Bulging fontanel may indicate increased

intracranial pressure

Head

• Molding result of fetal position in utero and pressure from passage through birth canal (resolves in 24-48hrs)

• Cephalhematoma result from trauma

(resolves in few weeks)

• Caput succedaneum pressure from delivery (resolves in 1-2 weeks)

Head

• Inspect face for symmetry of eyes, nose, lips, mouth and ears

• Eyes usually blue or gray, permanent color established in 3-12 months

• Red reflex present cornea intact• Pupils equal, round, and react to light bilateral • Check for blink reflex• Subconjunctive hemorrhages may be present

due to the pressure from delivery

Head

• Nose midline with patent nares

• Ears aligned with outer canthus of eyes; pinna well formed, open auditory canal (low set ears associated with chromosomal abnormalities)

• Mouth mucosa pink and moist; tongue mobile, strong suck, hard/soft palate intact( Epstein’s pearls may be noted on the gums or hard palate)

Neck

• Typically short with deep folds of skin

• Webbing associated with Down Syndrome

• Assess for full range of motion

• Newborn should be able to hold head in a midline position

• Palpate for abnormal masses

• Note the position of the trachea

Chest

• Shape should be cylindrical (bell shaped could be a sign of underdeveloped lungs)

• Palpate clavicle bones and ribs

• Assess nipples for size, placement and number

• Evaluate respiratory effort and movement

• Auscultate the lung fields and heart sounds

• Unequal breath sounds could be a pneumothorax

Abdomen

• Umbilical cord, 2 arteries 1 vein

• Cylindrical with some protrusion

• Flat abdomen indicates diaphragmatic hernia

• Auscultate for bowel sounds

• Suprapubic area palpated for bladder distention

• Femoral pulses palpated, if unable to locate could signify coarctation of the aorta

Female Genital and Anal Assessment

• Term newborn labia majora covers labia minora and clitoris

• Urethral meatus located below clitoris• Mucoid vaginal discharge due to maternal

hormones ( pseudo menstruation)• Hymental tag may be present• Annus patent

Male Genital and Anal Assessment

• Rugae present on the scrotum• Scrotal edema may be present due to

maternal hormones• Testes descended • Check for placement of the meatus• Dorsal surface- epispadias• Ventral surface-hypospadias• Anus should be patent- if closed medical

emergency

Extremities

• Assess for full range of motion, symmetry and signs of trauma

• Spontaneous motion of all extremities should be present

• Assess muscle tone

• Hyperflexibility of joints associated with Down Syndrome

• Hips assessed for dislocation

Nursing proceduren18.1 pg 564

Extremities

• Nail beds pink- persistent cyanosis associated with hypoxia

• Palms should have normal creases

• Simian crease (transverse palmer) suggests Down syndrome

• Count digits on extremities (more than five digits polydactyl-Digits fused together syndactyl

Spine

• Straight

• Flat

• Shoulders, scapulae and iliac crests line up in same plane

• Evaluate for dimpling or fissures

• Dimpling associated with spina bifida

• Newborn assessment summary

Table 18.3 pg. 565

Neurological System

• Infant alert, responsive, strong lusty cry in a flexed position

• Reflexes provides information on the system and maturity

• Reflexive behaviors are necessary for survival and safety

• Absence, weakness or asymmetry indicates abnormalities

Neurological Reflexes

• Sucking

• Rooting

• Grasping

• Extrusion

• Tonic neck

• Moro

• Stepping

• Crawling

• Babinski

• Truncal incurvation

• Blinking

Neurologic System

• Brachial plexus injury (Erb’s palsy)

• Spina bifida

• Anencephaly

• Absent or abnormal reflexes

• Seizure activity

Behavioral Assessment

• Sleep-wake cycles

• Activity

• Social interactions

• Response to stimuli

Pain Assessment

• Most common sign crying

• Changes in heart rate

• Intracranial pressure

• Respiratory rate and oxygen saturation

Pain Management

• Nonpharmacologic management: containment (swaddling), nonnutritive sucking and distraction: visual, oral, auditory, tactile

• Pharmacologic management: local and topical anesthesia, Nonopioid analgesia and opioids

Gestational Age AssessmentBallard Score

• Neuromuscular maturity– Posture– Square window– Arm recoil– Popliteal angle– Scarf sign– Heel-to-ear

• Physical maturity

– Skin

– Lanugo

– Plantar surface

– Breasts

– Eye and ear

– Genitalia

New Born Assessment

• New Born Assessment

• First Bath

• Apply infant security band

Circumcision

Discharge Assessment• Determine knowledge deficits

• Educate on bathing, cord care, elimination, circumcision care, car safety, prevention of abduction and general newborn care

• Importance of Immunizations

• Follow care

• Newborn hearing screen

• PKU test