Normal Neonates

8/6/2019 Normal Neonates

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NORMAL NEONATES

PRESENTED BY MRS DAYAL


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Lesson Objectives

1) Define the key terms

2) Explain the mechanism of the first breath of

the newborn 3) Outline the immediate care of the newborn

4) Define Apgar Scoring

5) Describe the physiology of the Newborn

6) Breastfeeding- anatomy & physiology


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Who is a Neonate?

Also known as baby or newborn

A neonate is from 1st to 28 days of

life

Newborn includes premature, post

mature and full term babies


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Physical assessment of newborn

General appearance

Head

Chest Abdomen

External genitalia

Limbs

Back


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Neurological examination

Abnormal movements

Posture

Assessment of tone Moro reflex

Palmar grasp

Tonic neck reflex Stepping reflex

Rooting reflex


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Ways ofheat loss in newborns

Evaporation- loss of heat from wet skin

Conduction- heat is lost when the baby is

in contact with cold surfaces Radiation- transfer of heat to cold

objects in the environment

Convection heat loss caused by

currents of cool air passing over the

surface of baby


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Fetal to normal circulation


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Mechanism of the first breath of the

newborn

At birth, baby takes a breath

Blood is drawn to the lungs through the

pulmonary arteries Blood is collected & returned to the Lt atrium ,

via the pulmonary veins

Placental circulation ceases soon after birth soless blood returns to the Rt side of heart.

High pressure in Lt side of heart than Rt side


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Mechanism of first breath

Closure of a flap over the foramen ovale

With establishment of pulmonary respiration,

oxygen concentration in the bloodstreamrises. This causes ductus arteriosus to

constrict and close.

The cessation of placental circulation results in

collapse of umbilical vein, ductus venosus &

hypogastric arteries.


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These immediate changes are functional and

those related to the heart are reversible in

certain circumstances.

Umbilical vein ligamentum teres

Ductus venosus-ligamentum venosum

Ductus arteiosus-ligamentum arteriosumForamen ovale- fossa ovalis

Hypogastric arteries-obliterated hypogastric

arteries


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Not only respiratory & circulatory are

involved

but baby has to obtain nutrition throughbreastfeeding, eliminate waste via

kidneys and gastrointestinal system.

Complex changes like communicationand relationship between parents and

child commence


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Immediate care of Newborn

(1)Prevention ofheat loss

(a) appropriate preparations:

ambient temperature range 21-25C,switch off fans, close curtains

(b) drying the baby, removing wet towels,

wrapping baby in pre-warmed towels

(c)Skin-to-skin contact with mother


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(2)Clearing the airway

(a) excess mucus wiped gently from the

mouth as babys head is born

(b) aspirate mouth before nose

(c) time of birth & sex of baby noted

and recorded


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(3)Cutting the cord

(a)separating the baby from the placenta

by dividing the cord between 2 clamps.(b) clamped securely to prevent blood

loss

(c) applying gauze over the cord while

cutting will prevent blood spraying over.


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(4)Skinto-skin and initiation ofbreastfeeding

- baby delivered on the abdomen- mom & baby covered with warmblanket at least for 30 mins.

Help with attachment and initiation ofbreastfeeding- In line with hospitalpolicy


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(5)Identification

(a) identification name tags

(b) name bands fastened securely, not tootight or loose

(c) name bands should remain on baby until

discharge


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(6)Assessment of the babys condition

(a) using Apgar score, baby is assessed at

1 min,5 min & 10 min after birth- the higher the score, the better the

outcome for the child

- Apgar score to be documented in folder

- Weight and measurements taken & noted


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(7)Continued early care

- detailed examination of baby is done to rule

out any abnormalities- maintain warm environment

- Early transfer to post natal ward to minimise

heat loss- Transfer baby with the mother, in her arms

to avoid heat loss & promote bonding


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(8)Administration of Vitamin K

- reliable & effective prophylaxis in

preventing haemorrhage in newborns- normal dose- 1mg/ml stat

First bath & other non-urgent procedures

deferred to minimise thermal stress Mother & baby should remain together

24 hrs


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PROTECTION OF NEONATES

Airway obstruction

Hypothermia

Infection

Injury and accidents


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Apgar Score

Simple and repeatable method to quickly

and summarily assess the health of newborn

immediately after birth.

Main purpose is to determine quickly

whether a newborn needs immediate care or

not. If prolonged, the NB can suffer long

term neurological damage & cerebral palsy

Summing up of scores @ 1,5,10min of life


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Apgar Score Table

Score 0 1 2

Heart rate Absent 100b.p.m 100b.p.m.

Respiratory effort Absent Irregular, slow Regular, cry

Muscle tone Limp Some flexion in limb Well-flexed limb

Reflex irritability Nil Grimace Cough/cry

Colour White Blue Pink


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Apgar score

Scores 3- pale, floppy,makes no respiratory

effort, pulse slow, does not respond to oral

suction(needs advanced resuscitation

Score 4-7 pulse below 100, irregular breaths,

blue, some muscle tone and some response to

suction ( needs Oxygen by bag/mask)

Score7 normal heart rate, breathes &

responds to stimuli ( no resuscitation needed,

can be dried & given to mom)


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Physiology of Newborn

(1) Respiratory system

-developmentally incomplete @ birth

-continuous growth of new alveoli-narrow lumen of peripheral airways

-plentiful respiratory secretions

-delicate mucus membranes sensitive totrauma/oedema


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-Respiratory rate 30-60br/min

-diaphragmatic breathing, breathing pattern

erratic, shallow & irregular-no nasal flaring, subcostal recessions,grunting

-obligatory nose breathers

- lusty cry, normally loud and medium pitch


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(2)Cardiovascular system & Blood

HR @ birth rapid- 120-160/min

-peripheral cyanosis sluggish, accrocyanosis

- mottling of exposed skin- total circulating bld vol-80mls/kg/body wt.

- Haemoglobin, WCC high but decreases

gradually- breakdown of excess red bld cells

predisposes to jaundice in the 1st wk


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(3)Temperature regulation

-thermal control poor, immature hypothalmus

- temperature regulation poor, vulnerable to

hypothermia- unable to shiver, adopt flexed fetal position,

increasing resp.rate and activity resulting in

hypoglycaemia,hypoxia,acidosis

-normal core temp. 36-37C

-limited ability to sweat


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(4) Renal system

- kidneys functionally immature

- glomerular filtration rate low & tubular

reabsorption capabilities limited

- unable to concentrate or dilute urine in

response to various fluid

- cannot compensate for high or low levels of

solutes in the blood- limited ability to excrete drugs


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Renal system cont

- 1st urine passed within 24 hrs

- dilute urine,straw colored,odorless

-cloudiness caused by mucus& urates initiallyuntil fluid intake increases

- urates cause pink staining- insignificant

-bladder palpable abdominally when full dueto small pelvis


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(5) Gastrointestinal system

- structurally complete but functionally

immature

-pink & moist mucus membrane of mouth- teeth buried in gums, ptyalin secretion low

-epithelial pearls present

- sucking pads in cheeks give full appearance

-sucking & swallowing reflexes coordinated


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Gastrointestinal system cont

- stomachs capacity 15-30mls, increases

rapidly in 1st wk

- cardiac sphincter weak-regurgitation or

posseting- long intestine in relation to size of baby

- large no. of secretory glands & large surface

area

for absorption.- food enters stomachopening of ileocaecal

valveileumlarge intestinebowels open


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Gastrointestinal system cont

- sterile gut, colonised within few hrs

- bowel sounds present within 1 hr of birth

- meconium present in large intestine

- stools undergo transitional

changemeconiumbrownish

yellowyellow faeces

- stools passed 8-10/day or every 2-3 days

- immature liverlow glucuronyl transferase


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(6) Reproductive system : genitalia &

breasts

-Boys: testes descended in both scrotums

urethral meatus opens @ tip of penis, prepuce isadherent to glans

- Girls : labia majora covers labia minora, hymen&clitoris appears large

- spermatogenesis does not occur until puberty

- total complement of primodial folliclescontaining primitive ova is present in the ovariesof girls


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Reproductive system cont

-both sexes, withdrawal of maternal

oestrogen results in breast engorgement,

accompanied by secretion of milk by4th-5th day

-both sexes have nodule of breast tissuearound nipple

- girls develop pseudomenstruation for thesame reasons


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(7) Skeletomuscular system

-muscles complete, growth occuring byhypertrophy rather than hyperplasia

- incomplete ossification of longbonesfacilitates growth @epiphyses

- vault of skull lack ossificationessentialfor brain growth, moulding during labour

- posterior fontanelle closes @ 6-8 wks

-anterior font. Closes @18 mths


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(8)Psychology and Perception

Special senses:

(1)Vision : immature but structures present &functional.

- sensitive to bright lightsblinks/frowns

- prefers black&white pattern & shape of

human face

- distance focused 15-20cm

- no tears present


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(2)Hearing: turn towards sound. High pitchsoundblink or startle. Prefer the sound ofhuman voice, gives preference to their

mothers voice(3)Smell & Taste: prefer smell of milk (human)

can differentiate smells of their mothers milk

to others. Prefer smell of unwashed breasts.Sweet tastevigorous suckling

grimace to bitter, salty or sour substances


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(4)Touch: sensitive to touch, enjoying skin-to-

skin, immersion in water, stroking cuddling &

rocking movements.

- grasp reflexes enhance relationship with

mother

- facial coding of painbrow bulging, eyelid

squeezing, nasolabial furrowing & open lipped

crying


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(9) Sleeping and Waking

(1)Sleep states;

(a)Deep sleep- eyes closed, reg. respiration,

no eye movement,response to stimuli

delayed & quickly suppressed

(b)Light sleep: rapid eye movement thru

closed eyelids, irregular resp, intermittent

sucking movement, random movements,

response to stimuli occurs readily


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(2)Wakeful states:

(a) Drowsy state

(b) Quiet alert state(c) Active alert state

(d) Active crying state

(3)Crying: the only way to communicatediscomfort and summon assistance.


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(10) Growth and Development

Limited physiologically dependent on theirmothers/caregivers for continued survival,growth and development.

- this will only progress if the baby isphysiologically & neurologically normal, is insafe environment, nutritional needs are metwith appropriate stimulation and loving care.

Care must be designed to meet needs andcapabilities


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Establishing maternal role

Fostering the bonding & attachment process

Attachment gradual and continual growth

Recognise & respond to emotional needs ofparents & infant

Early or immediate physical contact

Psychological well being of mother Diminished confidence


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Psychriatric disorders of pueperium

Blues /puerperal depression /psychosis

- babys failure to thrive

- less responsive- unsettled

- miserable, not consolable


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Current breastfeeding

recommendations

Exclusive breastfeeding for 6 months

Babies should receive no infant formula or

animal milk

Babies should continue to breastfeed for up to

2 yrs or beyond, with increasing amounts of

complementary foods and cup-fed liquids


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Ten Steps to Successful Breastfeeding

Every facility providing maternity services and care for newborn

infants should:

1. Have a written breastfeeding policy that is routinely

communicated to all health care staff.

2. Train all health care staff in skills necessary to implement this

policy.

3. Inform all pregnant women about the benefits and

management of breastfeeding.

4. Help mothers initiate breastfeeding within half an hour of

birth.

5. Show mothers how to breastfeed, and how to maintain

lactation even if they should be separated from their infants.


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6. Give newborn infants no food or drink other thanbreast milk, unless medically indicated.

7. Practise rooming-in - that is, allow mothers and

infants to remain together - 24 hours a day.8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers (also calleddummies or soothers) to breastfeeding infants.

10.Foster the establishment of breastfeeding supportgroups and refer mothers to them on dischargefrom the hospital or clinic


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Anatomy of the lactating breast

Anatomy :

-composed of glandular tissue

-lobes (20)

-lobes divided into alveoli & ducts

-alveoli contains acini cellsproduce milk

-myoepithelial cells lactiferous sinus/ampulla

-nipple erectile tissueoutlet for milk

-areola (pigmented area)


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Anatomy of the lactating breast


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Benefits of breastfeeding

Nutritional benefits

Protective

Health Benefits

Bonding


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Components of breastmilk

Fats & fatty acids

Carbohydrates

Protein Vitamin (fat soluble & water soluble)

Minerals (iron, zinc, calcium, other

minerals)

Anti-infective factors


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Foremilk & Hindmilk

Foremilk Beginning of a feed

baby receives a high volume of low

fat milk Hindmilk as feed progresses,

volume of milk decreases but the fat

content increases by approx. 5 times

A well attached baby obtains all he

needs in a very short time


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Breastfeeding hormones

Prolactin

- makes the alveoli produce milk

- makes the mother feel sleepy & relaxed- ineffective suckling and inadequate

removal of milk from breasts will lead to

shut down of milk production in thoseparts.


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How to keep prolactin level high

Good attachment, no artificial teat or

dummies

Frequent breastfeeding day & night

Breastfeeds as long as baby wants at a

feed

Prolactin release is greatest when babybreastfeeds at night


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Oxytocin

-Contracts the cells around the alveoli, sends

milk down the ducts to the sinuses let down

or milk ejection

-Early postpartum, experiences uterine

contractions/sudden thirst

-See milk leaking from the other breast

-Upon milk ejection, babys suckling rhythm

changesrapiddeep slow sucks.


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Oxytocin release inhibitors

Extreme pain

Stress hormones

doubt, embarassement, anxiety Nicotine & alcohol


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Milk production

Frequent breastfeeding, no time limits

Independent of nutritional status and body

mass index

Milk production drives appetite, hence no

need to eat excessively

Unaffected by fluctuations in mothers fluid

intake

Unaffected by exercise or low fat diet


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Attachment and positioning

Attachment for effective suckling

- babys mouth is wide open

- chin touching the breast

- lower lip is curled outward

- more areola visible above than below

- baby suckles, pauses and suckles againin

slow, deep sucks

- can hear baby swallowing


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Latching on


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attachment


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Twin feeding


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Positioning

- mother is relaxed and comfortable

- baby is calm and alert, not crying

- babys whole body is facing the mother andclose to her

- babys head is supported, in a straight line

with his body and facing the breast- mothers fingers away from the areola


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Examples of positioning


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Skin to skin


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Breast problems

Sore and damaged nipples

Dermatitis

Anatomical problems Engorgement

Mastitis

Breast abscess Blocked ducts


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Normal Neonates