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OB Ch 24
Conditions in the Newborn Related to Gestational Age, Size, Injury, and Pain
| Term | Definition |
|---|---|
| Neonatal Intensive Care Equipment #1 | The neonatal intensive care unit (NICU) can be a stressful and intimidating place for parents. Nurses can help alleviate stress by explaining what equipment is and what it does. Nasogastric tubes are used for feeding and for gastric suction. |
| Neonatal Intensive Care Equipment #1 | An umbilical artery catheter is placed into the umbilical cord stump then threaded into one of the two umbilical arteries and into the aorta. It is rarely left in place more than 1 week. |
| Neonatal Intensive Care Equipment #1 | An umbilical artery catheter is used to monitor arterial blood glasses. Arterial BP, and access to the circulation for blood sampling and administration of fluid and medication. |
| Neonatal Intensive Care Equipment #2 | An umbilical vein catheter is placed into the umbilical stump and progressed through the ductus venosus and into the inferior caval vein. |
| Neonatal Intensive Care Equipment #2 | Peripherally inserted central line (PICC) is used when intermediate-term intravenous (IV) access is required. Nasal cannula are available in different sizes and allows for visualization of the baby’s face. |
| Neonatal Intensive Care Equipment #2 | An umbilical vein catheter remains in place about a week and is used for fluid and medication administration and can be used for central pressure monitoring. |
| Neonatal Intensive Care Equipment #4 | Continuous positive airway pressure (CPAP) is useful for infants unable to obtain adequate oxygenation by nasal cannula alone. Also, the pressure keeps alveoli open. |
| Neonatal Intensive Care Equipment #4 | An endotracheal tube (ET) is placed by intubation through one of the nares or the mouth of the infant. The ET tube is then attached to a ventilator by tubing. |
| Neonatal Intensive Care Equipment #4 | An oxygen hood is appropriate for infants who do not need supplemental oxygen pressure support. If the infant is removed from the hood (for example, during a feeding), oxygen should be supplied by nasal cannula. |
| Preterm Infants | A preterm infant is an infant born prior to 37 weeks of gestation. |
| Preterm Infants challenges | Respiratory distress syndrome (RDS) Bronchopulmonary dysplasia (BPD) Necrotizing enterocolitis (NEC) Delayed closure of the ductus arteriosus Hypothermia Intraventricular and periventricular hemorrhages |
| Symmetric IUGR | IUGR that is global: head, torso, extremities are symmetrically undersized. also called global growth restriction indicates that growth has been slow throughout pregnancy associated with a higher incidence of permanent neurological problems |
| Asymmetric IUGR | IUGR in which the head grows normally but the body grows slowly slowed growth of the body typically occurs in the third trimester, after normal growth in the first 2 |
| period of insult | symmetrical IUGR: earlier gestation asymmetrical IUGR: later gestation |
| incidence of total IUGR cases | symmetrical IUGR: 20-30% asymmetrical IUGR: 70-80% |
| etiology | symmetrical IUGR: genetic disorder or infection intrinsic to foetus asymmetrical IUGR: utero-placental insufficiency |
| Antenatal scan, Head circumference, Abdominal circumference, Biparietal diameter, and Femur length characteristics | symmetrical IUGR: All are proportionally reduced asymmetrical IUGR: Abdominal circumference-decreased Biparietal diameter, Head circumference, and femur length- normal |
| cell number characteristic | symmetrical IUGR: reduced asymmetrical IUGR: normal |
| cell size characteristic | symmetrical IUGR: normal asymmetrical IUGR: reduced |
| ponderal index | symmetrical IUGR: normal (more than 2) asymmetrical IUGR: low (less than 2) |
| postnatal anthropometry weight, length, head circumference | symmetrical IUGR: reductions in all parameters asymmetrical IUGR: reduction in weight; length and head circumference are normal (brain sparing growth) |
| difference between head and chest circumference in term IUGR | symmetrical IUGR: less than 3cm asymmetrical IUGR: more than 3cm |
| features of malnutrition | symmetrical IUGR: less pronounced asymmetrical IUGR: more pronounced |
| prognosis | symmetrical IUGR: poor asymmetrical IUGR: good |
| Preterm Infants: Respiratory Considerations #1: Apnea of Prematurity | Factors that contribute to respiratory issues for preterm infants include: Surfactant (responsible for alveoli expansion and facilitating gas exchange) production is decreased. Airway lumens are small. *Preterm infants lack a gag reflex. * |
| Preterm Infants: Respiratory Considerations #1: Apnea of Prematurity | common and significant if breathing stops for more than 20 seconds or is associated with either a heart rate less than 70 to 80 bpm (bradycardia) or oxygen saturation below 80% to 85% (hypoxemia). Place apnea monitor on preterm infant |
| Preterm Infants: Respiratory Considerations #2 | Continuous monitoring of preterm infants by pulse oximetry and continuous cardiac monitoring is indicated. Occasional apnea may be treated with tactile stimulation. *Frequent apnea or apnea that includes bradycardia and hypoxemia may require CPAP.* |
| Preterm Infants: Respiratory Considerations #2 | Prophylactic administration of a caffeine prior to a diagnosis of apnea in infants born before 28 weeks is routine and is associated with a reduction in infant mortality and BPD. |
| Caffeine Citrate | A central nervous system stimulant, a methylxanthine |
| Caffeine Citrate Route and dosing | Oral or Intravenous Loading dose: 20–80 mg/kg |
| Caffeine Citrate Route and dosing | Maintenance dose: 5–10 mg/kg/d once daily starting 24 h after the loading dose; may be titrated up by 5 mg/kg/d to a maximum of 20 mg/kg/d in refractory patients on the basis of clinical response and serum caffeine concentrations |
| Caffeine Citrate Care considerations | The dose listed here is of caffeine citrate, which is 50% caffeine. Thus, the loading dose of 20 mg/kg of caffeine citrate contains 10 mg/kg of caffeine. Take care to note how the dose is written prior to administration. |
| Caffeine Citrate Care considerations | Neonates should be given only caffeine citrate, not caffeine sodium benzoate. |
| Caffeine Citrate Warning signs | Signs of necrotizing enterocolitis, an adverse effect: Tachycardia Feeding intolerance Temperature instability Abdominal distention Bloody stools |
| Caffeine Citrate Warning signs | Signs of “gasping syndrome,” an adverse effect of toxicity: Respiratory distress Metabolic acidosis Gasping Seizures Hypotension |
| Preterm Infants: Respiratory Considerations #3 | Respiratory distress syndrome (RDS) is caused by insufficient surfactant and immature lungs. |
| Preterm Infants: Respiratory Considerations #3 | Signs and symptoms of RDS include: Low oxygen saturation Decreased breath sounds Retractions and nasal flaring (use of accessory muscles of breathing) Tachypneic Expiratory grunting |
| Preterm Infants: Respiratory Considerations #4 | Treatment of RDS includes respiratory support with either nasal CPAP or nasal intermittent ventilation to provide positive end expiratory pressure (PEEP) to keep alveoli open. |
| Preterm Infants: Respiratory Considerations #4 | Surfactant therapy, if necessary, is usually started within 30 to 60 minutes after birth after a trial of CPAP and is most effective within the first 2 hours of birth |
| Preterm Infants: Respiratory Considerations #4 | Supportive care is critical and includes maintaining thermoregulation and providing adequate nutrition. |
| Preterm Infants: Cardiovascular Considerations #1 | A common cardiovascular issue includes a patent ductus arteriosus (PDA). Mostly all infants born at term have complete closure by 72 hours after birth; preterm infants may have delayed closure. |
| Preterm Infants: Cardiovascular Considerations #1 | *Infants with PDAs are at higher risk for necrotizing enterocolitis and intraventricular hemorrhage.* Clinical signs may develop within 2 to 3 days after birth. |
| Preterm Infants: Cardiovascular Considerations #2 | Signs and symptoms of PDA depend on the degree of the PDA and include: Systolic murmur Ventricular dilation Bounding pulses (increased cardiac output) Cyanosis Respiratory distress |
| Preterm Infants: Cardiovascular Considerations #2 | Treatment include administration of cyclooxygenase inhibitors such as ibuprofen or indomethacin. Infants who do not respond to medications may need surgery. |
| Preterm Infants: Cardiovascular Considerations #3 | Preterm infants are prone to low blood pressure and hypoperfusion of tissues. |
| Preterm Infants: Cardiovascular Considerations #3 | Treatment includes expansion of blood volume with normal saline or blood products (albumin or fresh frozen plasma). Inotropic agents (dopamine, dobutamine, and/or epinephrine) may be trialed if volume expansion is not enough. |
| Preterm Infants: Neurological Considerations #1 | Intraventricular hemorrhage (IVH) is bleeding into the lateral ventricles of the brain and is one of the most common and dangerous causes of brain injury. |
| Preterm Infants: Neurological Considerations #1 | Risks for developing IVH include: Birth prior to 29 weeks gestation Breech birth Intrapartum asphyxia Signs and symptoms are varied. Often diagnosed with routine ultrasonography. |
| Preterm Infants: Neurological Considerations #1 | The more severe the IVH, the increased risk for complications. Treatment incudes supportive care such as avoiding hyper- or hypotension, providing adequate oxygen and nutrition, and treat seizures to avoid alterations in cerebral blood flow. |
| Clinical Manifestations of Intraventricular Hemorrhage | Saltatory manifestations, appearing over hours or days: reduced movement disturbed respirations altered level of consciousness hypotonia |
| Clinical Manifestations of Intraventricular Hemorrhage | Catastrophic manifestations, appearing over minutes or hours: flaccidity fixed pupils and other abnormalities of cranial nerves from pressure on cranial nerves seizures hypoventilation/apnea coma metabolic acidosis from poor oxygen profusion |
| Clinical Manifestations of Intraventricular Hemorrhage | Catastrophic manifestations, appearing over minutes or hours: decreased hematocrit levels due to bleeding hypotension bradycardia bulging of the anterior fontanelle |
| IVH (Intraventricular Hemorrhage) Consequences | Post-hemorrhagic hydrocephalus Ventriculo-peritoneal shunt Periventricular leukomalacia Cerebral palsy Neurodevelopmental impairment |
| IVH (Intraventricular Hemorrhage) Predisposing Factors | genetic factors pneumothorax PDA extreme prematurity outborn low APGAR score male gender mechanical ventilation |
| Indomethacin | inhibits the cyclooxygenase (COX) pathways of prostaglandin synthesis, attenuates cerebral vascular hyperemic responses from hypoxia and hypercapnia, prevents ischemia-related impaired cerebral perfusion, and increases blood-brain barrier permeability |
| ECMO (extracorporeal membrane oxygenation) | removing blood from the heart, filtering out carbon dioxide from it, and oxygenating it, thus serving as an artificial heart and lung machine. used in preterm neonates with respiratory distress syndrome. |
| Preterm Infants: Immune System Considerations #1 leading to Sepsis | Preterm infants are at high risk for sepsis. Maternal immunoglobulin G (IgG) is transferred to the fetus via the placenta after 32 weeks gestation. (under 37 weeks can get sepsis despite IgG) |
| Preterm Infants: Immune System Considerations #1 leading to Sepsis | The skin and mucous membranes are thin and immature and have poor tissue integrity, and thus provide less of a barrier to infection. |
| Preterm Infants: Immune System Considerations #1 leading to Sepsis | Signs of sepsis are often nonspecific and subtle and include: Respiratory distress Glucose instability Tachycardia Poor perfusion (cyanosis, pallor, poor capillary refill) |
| Preterm Infants: Immune System Considerations #2 | Late signs of sepsis include: Lethargy Irritability Bradycardia Hypotension Pallor |
| Preterm Infants: Immune System Considerations #2 | Antibiotics are the primary treatment for sepsis. Some infants over 34 weeks gestation may require ECMO. Supportive care measures and careful hand hygiene are effective in minimizing infections associated to care. |
| Hand Hygiene in Healthcare regarding neonates | Designate a stethoscope to use with each neonate and clean it prior to and after each use. Wash hands prior to and after each contact with the infant, regardless of glove use. |
| Preterm Infants: Temperature Considerations #1 | Preterm infants are at high risk for hypothermia because they do not have accumulation of body fat, the muscle tone to maintain a flexed posture, and the temperature center in the brain is immature. |
| Preterm Infants: Temperature Considerations #1 | Hypothermia is relatively rare after the temperature has been stabilized in the NICU. If hypothermia is present, though, the infant may appear pale, mottled, or cyanotic and be cool to the touch. |
| Preterm Infants: Temperature Considerations #1 | Treatment of mild hypothermia is slow rewarming. Severe hypothermia (temperature below 95°F [35°C]) may be treated with more rapid rewarming. Rewarming is often accomplished by radiant warmer and/or warming mattress. |
| Preterm Infants: Temperature Considerations #2 | Heat loss may happen via evaporation, conduction, convection, and/or radiation |
| Nursing considerations to avoid temperature instability: | Maintaining a warm delivery room. Drying the newborn immediately after birth. Replacing wet blankets with dry ones. Performing assessments and interventions on skin-to-skin with the mother or under a prewarmed radiant heater. |
| Cold Stress | Cold stress occurs with uncontrolled hypothermia when blood vessels constrict to conserve heat. The metabolic rate increases as does oxygen consumption. |
| Cold Stress | Prolonged cold stress can lead to respiratory distress, respiratory acidosis, hypoglycemia, and reopening or failure to close of the ductus arteriosus. Treatment for cold stress is the same as for hypothermia. |
| Infant Feeding | Preterm infants have high energy needs and an immature ability to take in and process nutrition. Preterm infants are often too immature to coordinate sucking, swallowing, and breathing. Delayed feedings or reducing starting volume may improve tolerance. |
| Infant Feeding | Infants who are unable to obtain sufficient nutrition by enteral feeding (gastrointestinal feeding) may have parenteral feeding. Tube feedings by syringe are typically every 2 to 3 hours. |
| Infant Feeding | Parenteral nutrition may improve neurodevelopmental outcomes and growth while reducing the risk of NEC. However, prolonged withholding of enteral feeds may contribute to intestinal atrophy. Generally, not used for infants > 34 wks. gestation |
| Assessment Findings for Feeding Intolerance | Abdominal exam findings: Decreased or absent bowel sounds Abdominal tenderness or distention Vomiting |
| Assessment Findings for Feeding Intolerance | Stool-related findings: output, characteristics: Change in frequency of defecation Presence of blood |
| Assessment Findings for Feeding Intolerance | Gastric residual fluid findings (used less frequently now if there is an absence of other symptoms): Increased volume of fluid Green fluid Red fluid |
| Late Preterm Infants | Infants born from 34 0/7 to 36 6/7 weeks are considered late preterm. Although their size may appear to be term, late preterm infants have higher morbidity and mortality due to immaturity. |
| Late Preterm Infants | Orobuccal strength and the ability to coordinate sucking, swallowing, and breathing are not fully developed. |
| Late Preterm Infants | Late preterm infants are at high risk for: Hypothermia Hypoglycemia Respiratory distress Jaundice Feeding difficulties |
| Clinical Signs of Hypoglycemia | Neurogenic: Irritability Jitteriness/tremors Pallor Sweating Tachypnea |
| Clinical Signs of Hypoglycemia | Neuroglycopenic= when the brain doesn't have enough glucose Change in level of consciousness (coma, lethargy): Hypotonia Poor feeding and/or poor suck Seizures Weak or high-pitched cry |
| Neuroglycopenia | condition that occurs when the brain doesn't have enough glucose, which can lead to brain damage and death if left untreated. It's often caused by hypoglycemia, which is when blood glucose levels are low. |
| Neuroglycopenia Symptoms | confusion, dizziness, headache, blurred vision, loss of fine motor skills, speech impairment, fatigue, seizures, and coma. |
| Neuroglycopenia Causes | Hypoglycemia (blood glucose levels below 70 mg/dL): The most common cause of neuroglycopenia Brain injury: Prolonged or recurrent neuroglycopenia can damage the brain. |
| Neuroglycopenia Treatment | If left untreated, neuroglycopenia can lead to neuronal dysfunction and death. |
| Postterm Infants | Postterm infants are born beyond 42 weeks of gestation. Postterm infants may be macrosomic or small for gestational age (SGA) because of the aging placenta. |
| Postterm Infants | Complications for postterm infants include: Birth injuries Oligohydramnios Low Apgar scores Cerebral palsy Meconium fluid |
| Small for Gestational Age (SGA) Infants | SGA infants fall below the 10th percentile on growth charts. SGA may be normal based on ethnicity or the height and weight of the parents or it could be due to environmental or pathological genetic reasons. |
| Small for Gestational Age (SGA) Infants | SGA infants are at risk for hypoglycemia, polycythemia, impaired thermoregulation, impaired immune function, respiratory distress, jaundice, poor feeding, sepsis, and hypocalcemia. |
| Small for Gestational Age (SGA) Infants | Do not achieve full growth potential when in uteroç intrauterine environment or a genetic pathology Fetal growth restriction (FGR) refers only to infants who are SGA due to environmental or pathological genetic reasons. |
| Small for Gestational Age (SGA) Infants | FGR divided into symmetric and asymmetric If suspected prenatally, labor may be induced. Increased risk for prematurity, RDS, NEC |
| SGA FGR Types: Symmetric | Onset earlier in pregnancy, typically from a chromosomal abnormality, infection or poor nutrients All organ systems affected so are affected equally so head and body are proportionate |
| SGA FGR Types: Asymmetric | Later onset in the third trimester or the late second trimester Cause= low nutrient supply |
| SGA FGR Types: Asymmetric | Growth of body is asymmetric with the body -> head circumference preserved (appearing abnormally large) but weight and length are compromised cranial sutures are wide with large fontanelles face may appear sunken; umbilical cord thinner |
| SGA FGR Types: Asymmetric | Growth of body is asymmetric with the body -> meconium staining may be present skin may appear loose and peeling muscle mass and subcutaneous fat are diminished. |
| Large for Gestational Age (LGA) Infants | LGA infants are above the 90th percentile for growth. The term macrosomia is based on weight regardless of gestational age and is defined as a birth weight greater than 4,000 g or 4,500 g. |
| Large for Gestational Age (LGA) Infants | LGA infants are at high risk for RDS, mechanical ventilation, low Apgar scores, hypoglycemia, polycythemia, perinatal asphyxia, and birth injury (shoulder dystocia). |
| Large for Gestational Age (LGA) Infants | Most common in infants of patients with obesity, diabetes, and excessive weight gain in pregnancy. Assessment: Polycythemia and hypoglycemia related to macrosomia should be assessed for and managed |
| LGA/Macrosomia | Risk Factors Increased for: RDS Mechanical ventilation from perinatal asphixia low APGAR scores hypoglycemia polycythemia birth injury <- shoulder dystocia |
| Birth Trauma Assess newborns for: | Bruising—generally self-limiting but may contribute to hyperbilirubinemia. Fat necrosis—generally self-limiting but may lead to hypercalcemia |
| Birth Trauma Assess newborns for: | Lacerations—may be obtained during a cesarean or operative vaginal birth. May be serious enough to require plastic surgery. Fractures—most common is a clavicle fracture and generally heals spontaneously. |
| Birth Trauma: Newborns should be assessed for birth injuries such as | Subconjunctival hemorrhage—looks alarming (ocular bleed) but are very common in neonates and resolve spontaneously within 2 weeks. Intracranial hemorrhage—rare but may be associated with forceps or vacuum-assisted birth |
| Birth Trauma: Newborns should be assessed for birth injuries such as | Brachial plexus injury—typically unilateral nerve damage that occurs from stretching and traction on the brachial plexus. May recover spontaneously over a few months or may require more extensive treatment. |
| Birth Trauma: Newborns should be assessed for birth injuries such as | Facial nerve trauma—occurs due to prolonged pressure against the maternal pelvis or due to forceps birth. The result is reduced movement on the side of the injury and generally begins to resolve in a few hours, but complete recovery may take months. |
| Birth Trauma: Newborns should be assessed for birth injuries such as | Facial nerve trauma may cause feeding difficulties. |
| Birth Trauma: Newborns should be assessed for birth injuries such as | Spinal cord injury—rare but may be caused by forceps or vaginal breech birth. Prognosis depends on the location and severity of the injury. |
| Neonatal Pain #1 | Not treating neonatal pain adequately can have long-term effects on how the neonate responds to pain throughout the infant’s life. Infants admitted to the NICU experience an average of 10 to 15 painful procedures every day. |
| Neonatal Pain #1 | Repeated pain exposure can cause neurodevelopmental changes that result in cognitive delay, hormonal dysregulation, and neuroprocessing deficits. Providing skin-to-skin contact is a role for either parent. |
| Neonatal Pain #1 | Oral sucrose and nonnutritive sucking can be provided by a parent, as can cuddling and rocking, when appropriate. |
| Parameters for Neonatal Pain Assessment | Physiologic: vital signs: change in HR, RR, BP respiratory: change in breathing pattern, O2 sat Integumentary: sweating of palms, change in skin color Other: increased ICP, change in HR variability, change in pupil size |
| Parameters for Neonatal Pain Assessment | Behavioral responses: Crying: change in crying pattern, acoustic features of cry, consolability Movement: change in facial expression (brow bulge, eye squeeze, nasolabial furrow, open mouth), hand and body movements, changes in muscle tone |
| Neonatal Pain #2 | Pain management for neonates include: Breastfeeding Nonnutritive sucking (pacifier) Swaddling Skin-to-skin contact Oral sucrose Topical anesthesia Acetaminophen or opioid analgesics Nerve block with lidocaine Deep sedation |
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