CARE FOR THE FAMILY OF A HIGH-RISK NEWBORN

During pregnancy, screening women for risk factors that could lead to illness in a newborn which is essential to identify infants who need greater than usual care at birth such as: Younger or older than maternal age Concurrent disease conditions Pregnancy complications Unhealthy maternal lifestyle

In addition, an infant who is born dysmature (before term or post term, or who is underor overweight for gestational age) is also at risk for complications at birth and in the first few days of life. Unfortunately, not all instances of high risk can be predicted.

NURSING PROCESS OVERVIEW ASSESSMENT Assess for: Obvious congenital anomalies Gestational Age NURSING DIAGNOSIS Ineffective airway clearance r/t presence of mucus or amniotic fluid in airway Ineffective cardiovascular tissue perfusion r/t breathing difficulty Risk for deficient fluid volume r/t insensible water loss Ineffective thermoregulation r/t newborn status & stress from birthweight variation Risk for imbalance of nutrition, less than body requirements r/t lack of energy for sucking Risk for infection r/t lowered immune response in newborn Risk for parenting r/t illness in newborn at birth Deficit diversional activity (lack of stimulation) r/t to illness at birth OUTCOME IDENTIFICATION/PLANNING Plan care that is individualized considering a newborns developmental as well as physiologic strengths, weaknesses, and needs. IMPLEMENTATION Focus on conserving the babys energy and providing a thermoneutral environment Painful procedures should be kept to a minimum Assisting parents with participation in care ( e.g.bathing/feeding) OUTCOME EVALUATION Infant maintains a patent airway. Infant tolerates all procedures without accompanying apnea. Infant demonstrates growth and development Infant maintains body temperature Parents visit at least once and make three telephone calls Parents demonstrate positive coping skills and behaviors

NEWBORN PRIORITIES IN FIRST DAY OF LIFE A. B. C. D. E. F. G. H. Initiation and maintenance of respiration Establishment of extrauterine circulation Control of body temperature Intake of adequate nourishment Establishment of waste elimination Prevention of infection Establishment of an infant-parent relationship Developmental care or care that balances physiologic needs and stimulation for best development

THE NEWBORN AT RISK BECAUSE OF ALTERED GESTATIONAL AGE OR BIRTHWEIGHT Infants are evaluated as soon as possible after birth to determine: Weight Gestational age Birth-weight is normally plotted on a Growth Chart such as: Colorado Intrauterine Growth Chart ( LUBCHENCO CHART) a) Pre term born before term (less than the full 37th week of pregnancy) b) Full term born after the beginning of 38 weeks and before 42 weeks c) Post term born after the onset of week 43 Birthweight varies for each gestational week of age: Appropriate Gestational Age (AGA) BW within 10-90th percentile Small Gestational Age (SGA) BW is < 10th percentile Large Gestational Age (LGA) BW > 90th percentile Low Birthweight (LBW) BW < 2,500 grams Very Low Birthweight (VLBW) BW 1000-1,500 grams Extremely-VLBW 500-1000grams

THE SMALL-FOR-GESTATIONAL-AGE INFANT SGA infants are small for their age because they have experienced intrauterine growth restriction (IUGR) or failed to grow at the expected rate in utero. CAUSES: Lack of adequate nutrition Placental anomaly Systemic diseases (e.g. severe DM; PIH) Smoke heavily Use of narcotics Intrauterine infection (e.g. rubella; toxoplasmosis) Chromosomal abnormality ASSESSMENT: PRENATAL ASSESSMENT: Fundal height Sonogram Biophysical profile a) NST

b) Placental grading c) Amniotic fluid amount APPEARANCE Infant who suffers nutritional deprivation EARLY IN PREGNANCY Increase in number of body cells below average in weight, length and head circumference LATE IN PREGNANCY Increase in cell size reduction in weight Regardless of when deprivation occurs, an infant has: (1) Overall wasted appearance (2) Small liver (3) Poor skin turgor (4) Large head (5) Skull suture widely separated lack of normal bone growth (6) Dull and lusterless hair (7) Sunken abdomen (8) dry & stained yellow cord LABORATORY FINDINGS 1. Blood studies High Hematocrit level Increase RBC (polycythemia) 2. Blood glucose Hypoglycemia <40mg/dL

THE LARGE-FOR-GESTATIONAL-AGE INFANT An infant is LGA (also termed macrosomia) if the birth weight is above 90th percentile on an intrauterine growth chart for that gestational age. CAUSES: Overproduction of growth hormone Diabetes mellitus Obesity Multiparous women Other conditions associated with LGA: Transposition of the great vessels Beckwith syndrome Congenital anomalies (e.g. omphalocele) ASSESSMENT: Uterus is unusually large for the date of pregnancy Sonogram confirms if a fetus is growing at an abnormally rapid rate Nonstress test assess the placentas ability to sustain the large fetus Amniocentesis assess lung maturity Caesarian may be necessary because of: Cephalopelvic disproportion Shoulder dystocia APPEARANCE i) Immature reflexes ii) Low score on Gestational age examinations iii) Extensive bruising & birth injury Broken clavicle

 Erb-Duchenne paralysis cervical nerve injury iv) Prominent caput succedaneum, cephalhematoma or molding LABORATORY FINDINGS 1) CARDIOVASCULAR DYSFUNCTION Hyperbilirubinemia Polycythemia Cyanosis (sign of transposition of the great vessels) 2) HYPOGLYCEMIA Assessed in the early hours of life because the infant uses up nutritional stores readily to sustain his or her weight. A PRETERM INFANT A preterm infant is usually defined as: Live-born infant born before the end of 37 weeks of gestation Weight less than 2,500 ( 5lbs 8 oz ) Immature and small but well-proportioned for age INCIDENCE: Specific problems of prematurity: Respiratory distress syndrome (RDS) Hypoglycemia Intracranial hemorrhage CAUSES: Factors associated with Preterm Birth: a. Low socioeconomic level b. Poor nutritional status c. Lack of prenatal care d. Multiple pregnancy e. Previous early birth f. Race g. Cigarette smoking h. Age of the mother i. Order of birth j. Closely spaced pregnancies k. Abnormalities of the mothers reproductive system l. Infections m. Obstetric complications n. Early induction of labor o. Elective caesarian birth ASSESSMENT: HISTORY A detailed pregnancy history may sometimes reveal the reason for a preterm birth. APPEARANCE Small and underdeveloped Disproportionately large head Ruddy skin Noticeable veins High degree of acrycyanosis Extensive lanugo Small anterior and posterior fontanelles No creases on the soles of the feet

POTENTIAL COMPLICATIONS: 1) Anemia of prematurity Normochromic, normocytic anemia (normal cells, just few in number) Immaturity of the hematopoietic system combined with the destruction of RBCs due to low levels of Vitamin E, which normally protects RBCs against oxid ation. 2) Kernicterus Destruction of brain cells by invasion of indirect bilirubin Occur at lower levels (as low as 12mg per 100mL of indirect bilirubin) 3) Persistent Patent Ductus Arteriosus Preterm infants lack surfactant, their lungs are noncompliant, so it is more difficult for them to move blood from the pulmonary artery into the lungs which lead to pulmonary artery hypertension that interferes with closure of the ductus arteriosus. 4) Intraventricular/Periventricular Hemorrhage Periventicular Hemorrhage bleeding into the tissue surrounding the ventricles Intraventricular hemorrhage bleeding into the ventricles Occurs because preterm infants have both fragile capillaries and immature cerebral vascular development. 5) Other Potential Complications Respiratory Distress Syndrome Apnea Retinopathy of prematurity Necrotizing enterocolitis THE POST TERM INFANT A postterm infant is one born after the 42nd week of a pregnancy. POSTTERM SYNDROME Is developed when the fetus who remains in utero with a failing placenta. CHARACTERISTICS: a. Dry, cracked, almost leather-like skin b. Lightweight c. Less amniotic fluid or meconium-stained d. Fingernails grown well beyond the end of the fingertips e. Alertness (like a 2-week-old baby) ILLNESS IN THE NEWBORN A. RESPIRATORY DISTRESS SYNDROME (RDS) Formerly termed, hyaline membrane disease Most often occurs in: preterm infants infants of diabetic mothers infants born by caesarian birth those who have decreased blood perfusion of the lungs (e.g. meconium aspiration) Pathologic feature: hyaline-like membrane formed from an exudate of infant blood line the terminal bronchioles, alveolar ducts, and alveoli the membrane prevent exchange of O2 and CO2 at alveolar-capillary membrane

 CAUSE: Low level or absence of SURFACTANT (phospholipid that normally lines the alveoli and reduces surface tension on expiration to keep the alveoli from collapsing on expiration) ASSESSMENT: Subtle signs (Initial release of surfactant) i) low body temperature ii) nasal flaring iii) sternal and subcostal retraction iv) tachypnea v) cyanotic mucus membrane As distress increases, an infant may exhibit: i) seesaw respiration ii) heart failure ( decreased urine output; edema of the extremities) iii) pale gray skin iv) periods of apnea v) bradycardia vi) pneumothorax CLINICAL SIGNS (Diagnosis of RDS) a. grunting b. cyanosis in room air c. nasal flaring d. retractions; and e. shock LABORATORY FINDINGS: a. Chest x-ray haziness b. Blood gas studies respiratory acidosis c. Culture (blood, CSF, & skin) betahemolytic, group B streptococcal infection THERAPEUTIC MANAGEMENT: 1) Surfactant replacement A preventive measure Synthetic surfactant is sprayed into the lungs by a syringe or catheter by an endotracheal tube at birth while an infant is first positioned with the head held upright and then tilted downward. 2) Oxygen administration To maintain correct Po2 and pH levels 3) Ventilation Maintain airway pressure and then intermittently jet or oscillate at a rapid rate an additional amount of air to inflate alveoli. 4) Additional therapy: Extracorporeal Membrane Oxygenation Liquid Ventilation Nitric Oxide 5) Supportive Care PREVENTION: tocolytic agents (magnesium sulfate or terbutaline) steroids (glucocorticosteroid such as betamethasone)

B. TRANSIENT TACHYPNEA OF THE NEWBORN CLINICAL MANIFESTATIONS: Rapid breathing Mild retractions but not marked cyanosis Mild hypoxia and hypercapnia Feeding is difficult CHEST X-RAY some fluid in the central lung CAUSE: Result from slow absorption of lung fluid slight decrease in production of phosphatidyl glycerol limit the amount of alveolar surface area available to an infant for oxygen exchange infant tend to increase RR and depth It occurs more often in: a) infants born via CS b) infants whose mother received extensive fluid administration during labor c) preterm infants C. MECONIUM ASPIRATION SYNDROME An infant with hypoxia in utero experiences a vagal reflex relaxation of the rectal sphincter, which releases meconium into the amniotic fluid. APPEARANCE: green to greenish black fluid An infant may aspirate meconium either in utero or with the first breath after birth. Cause severe respiratory distress in 3 ways: 1. causes inflammation of bronchioles because its a foreign substance 2. block small bronchioles by mechanical plugging 3. cause a decrease in surfactant production through lung cell trauma ASSESSMENT: Low Apgar score Tachypnea Retractions Cyanosis Barrel chest CXR bilateral coarse infiltrates in the lungs, with spaces of hyperaeration THERAPEUTIC MANAGEMENT: a. Amniotransfusion b. Tracheal suctioning c. Oxygen administration d. Ventilation e. Antibiotic therapy f. Chest physiotherapy with clapping and vibration g. ECMO

D. APNEA Apnea is a pause in respiration longer than 20 seconds with accompanying bradycardia. High incidence occurs in: preterm infants infection

 hyperbilirubinemia hypoglycemia hypothermia MANAGEMENT: (1) Gently shaking an infant or flicking the sole of the feet stimulates the baby to breathe again (2) Closely observe all NB esp. Preterm to detect apneic episodes (3) Place on a ventilator to provide respiratory coordination until he/she is more mature (4) Maintain a neutral thermal environment (5) Use gentle handling to avoid excessive fatigue (6) Always suction the secretion gently to minimize nasopharyngeal irritation (7) Use indwelling nasogastric tubes reduce the amount of vagal stimulation (8) never take rectal temperature in infants prone to apnea (9) Administer Theophylline or caffeine sodium benzoate to stimulate respirations; increase infant sensitivity to carbon dioxide ensuring better respiratory function.

E. SUDDEN INFANT DEATH SYNDROME SIDS is a sudden unexplained death in infancy. It tends to occur at a higher-usual-rate in: infants of adolescent mother infants of closely spaced pregnancies underweight infants preterm infants PEAK AGE OF INCIDENCE: 2 to 4 months age POSSIBLE CONTRIBUTING FACTORS: 1. Viral respiratory or botulism infection 2. Pulmonary edema 3. Brain stem abnormalities 4. Neurotransmitter deficiency 5. Heart rate abnormalities 6. Distorted familial breathing patterns 7. Decrease arousal responses 8. Possible lack of surfactant in alveoli 9. Sleeping prone F. APPARENT LIFE-THREATENING EVENT An episode wherein some infants have been discovered cyanotic and limp in their beds but have survived after mouth-to-mouth resuscitation by parents. G. PERIVENTRICULAR LEUKOMALACIA PVL is abnormal formation of the white matter of the brain. Caused by an ischemic episode that interferes with circulation to a portion of the brain Occurs most frequently in preterm infants who experience cerebral ischemia H. HYPERBILIRUBINEMIA An elevated level of bilirubin in the blood It results from destruction of red blood cells by either a normal physiologic process or the abnormal destruction of red blood cells. I. HEMOLYTIC DISEASE OF THE NEWBORN hemolytic derived from the Latin for destruction (lysis0 of RBCs.

The mother builds antibodies against an infants red blood cells, leading to hemolysis of the cells which causes severe anemia and hyperbilirubinemia CAUSES: Rh Incompatibility

Mother is RH(-) and the fetus is RH(+) Placental villi break Drop or two of maternal blood enter maternal circulation Introduction of maternal blood causes sensitization to occur The mother begins to form antibodies Antibodies destroy the fetal red blood cells ABO Incompatibility Maternal blood type is O and fetal blood type is A, B, AB Antibodies to A and B call types naturally occur Birth (when blood and antibodies are exchanged during the mixing of maternal and fetal blood as the placenta is loosened) Hemolysis of the blood ASSESSMENT: Rh incompatibility Positive direct Coombs test Progressive jaundice within the first 24 hours of life Enlarged liver and spleen Extreme edema Severe anemia heart failure Hydrops fetalis hydrops (edema); fetalis (lethal state) ABO Incompatibility Progressive jaundice within the first 24 hours of life Kernicterus brain damage Progressive hypoglycemia Decrease hemoglobin THERAPEUTIC MANAGEMENT: a) Initiation of Early Feeding b) Phototherapy c) Home Phototherapy d) Exchange Transfusion

J. HEMORRHAGIC DISEASE OF THE NEWBORN It results from a deficiency of Vitamin K (essential for the formation of prothrombin by the liver) Lack of Vitamin K causes decreased prothrombin function and impaired blood coagulation

High Risk for the condition: babies born to mothers receiving anticonvulsive medications (interfere with Vitamin k formation) ASSESSMENT: Petechiae Conjunctival, mucous membrane, or retinal hemorrhage Vomit fresh blood Black tarry stools GI bleeding Prolonged prothrombin Prolonged coagulation time PREVENTION/TREATMENT: a. Vitamin K administration ( IM or IV) b. Blood transfusion (if bleeding is severe)

K. TWIN-TO-TWIN TRANSFUSION It is a phenomenon that can occur if twins are monozygotic and if abnormal arteriovenous shunts occur that direct more blood to one twin than the other. The results of this shift of blood leads to: a. Anemic twin SGA; prone to hypoglycemia; pale b. Polycythemic twin prone to hyperbilirubinemia LABORATORY DIAGNOSIS Sonogram Hgb count THERAPY: Blood transfusion

L. NECROTIZING ENTEROCOLITIS The bowel develops necrotic patches, interfering with digestion and possibly leading to a paralytic ileus. M. RETINOPATHY OF PREMATURITY An acquired ocular disease that leads to partial or total blindness in children, is due to vasoconstriction of immature retinal blood vessels. THE NEWBORN AT RISK BECAUSE OF MATERNAL INFECTION OR ILLNESS A. MATERNAL INFECTION A number of infections in newborns are spread to the fetus across the placenta in utero. a) Beta-hemolytic, Group B Streptococcal Infection Major cause of infections in newborns This gram-positive bacterium is a natural inhabitant of the female genital tract. (+)GBS ampicillin IV at 28weeks and again during labor ASSESSMENT: Risk Factors: Born after prolonged ROM Mothers vaginal culture is GBS(+) Early onset type (first day of life) Signs of pneumonia

Tachypnea Apnea Signs of shock (decreased urine output, extreme paleness, hypotonia) CXR is almost indistinguishable from that of RDS

Late onset type (2to4 weeks of age) Meningitis Lethargy Fever Loss of appetite Bulging fontanelles ( increased intracranial pressure) Neurologic consequences THERAPEUTIC MANAGEMENT: Administration of antibiotics (e.g. gentamicin, ampicillin and penicillin) b) Opthalmia Neonatorum An eye infection that occurs at birth or during the first month Causative organisms: Neisseria gonorrhoeae extremely serious form of conjunctivitis because if left untreated, the infection progresses to corneal ulceration and destruction, resulting in opacity of the cornea and severe vision impairment. Chlamydia trachomatis ASSESSMENT: Generally bilateral Fiery red conjunctivae with thick pus Edematous eyelids PREVENTION: Prophylactic instillation of erythromycin ointment THERAPEUTIC MANAGEMENT: gonococci intravenous ceftriaxone (Rocephin); penicillin chlamydia erythromycin ophthalmic solution c) Hepatitis B Virus Infection HBV can be transmitted to the newborn through contact with infected vaginal blood at birth when the mother is positive for the virus (HBsAg+) PREVENTION: Immune serum globulin (HBIG) d) Generalized Herpesvirus infection A herpes simplex virus type 2 (HSV-2) infection, is contracted from the vaginal secretions of a mother who has active herpetic vulvovaginitis at the time of birth. ASSESSMENT: Herpes vesicles (clustered, pinpoint in size, and surrounded by a reddened base) Severe neurologic damage

Loss of appetite Low-grade fever Lethargy Stomatitis Extremely ill Dyspnea Jaundice Purpura Convulsions Shock

approximately day 4 to day 7 after birth

after the vesicles appear

THERAPEUTIC MANAGEMENT: Acyclovir (Zovirax) a drug that inhibits viral deoxyribonucleic acid synthesis. e) Human Immunodeficiency Virus Infection HIV and AIDS can be caused by placental transfer or direct contact with maternal blood during birth. B. AN INFANT OF A DIABETIC MOTHER Typically longer and weighs more than other baby (macrosomia) Greater chance of having a congenital anomaly (cardiac anomaly) Caudal regression syndrome (hypoplasia of the lower extremities) APPEARANCE: Cushingoid Lethargic or limp Macrosomia RDS COMPLICATIONS: Birth injury (neck & shoulder) Cephalopelvic disproportion Severe hypoglycemia Hyperbilirubinemia Hypocalcemia THERAPEUTIC MANAGEMENT: Fed early with formula Administer a continuous infusion of glucose C. AN INFANT OF A DRUG-DEPENDENT MOTHER If the mother is dependent on a drug, an infant will show withdrawal symptoms (neonatal abstinence syndrome) shortly after birth. SIGNS: Irritability Disturbed sleep pattern Constant movement Tremors Frequent sneezing Shrill, high pitched cry Possible hyperreflexia and clonus Convulsions Tachypnea Vomiting and diarrhea

D. AN INFANT WITH FETAL ALCOHOL SYNDROME Alcohol crosses the placenta in the same concentration as is present in the maternal bloodstream. This results in fetal alcohol exposure and fetal alcohol syndrome. CHARACTERISTICS: Pre- and postnatal growth restriction CNS involvement (cognitive challenge, microcephaly, & cerebral palsy) Distinctive facial feature of a short palpebral fissure and thin upper lip. Tremulous Fidgety Irritable Weak sucking reflex Sleep disturbances (either always awake or always asleep) Behavior problems (e.g. hyperactivity)

Submitted by: Elaisa Mae C. delos Santos BSN- II

Submitted to: Leonila Antonio, RM, RN, MAN