chapter 15 the newborn at risk: conditions associated with gestational age and development copyright...

Chapter 15

The Newborn at Risk:

Conditions Associated with Gestational Age and Development

Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1

Risks for the Newborn


Objectives

Define key terms listed. Describe how gestational age is determined. Review the causes of intrauterine growth

restriction. Compare and contrast the preterm newborn,

the term newborn, and the postterm newborn. Describe the care of the preterm newborn.


At-Risk Newborn

Susceptible to illness as a result of Immaturity Physical disorders Complications during or after birth


New Ballard Score

Maturational assessment of gestational age


Classification of Newborns at Birth

Preterm or premature: before 37 weeks Term or full term: 38 to 42 weeks Postterm: after 42 weeks Low birth weight: less than 2500 g (5.5 lbs) Small for gestational age (SGA): < 10th % Appropriate for gestational age (AGA) Large for gestational age (LGA): > 90th % Intrauterine growth restriction (IUGR): failure

to grow as expected in utero


Small for Gestational Age

Weight less than the 10th percentile Contributing factors may be

Genetic Maternal factors or disease Environmental Malnutrition Placental Fetal


Types of Growth Restriction Symmetric: growth

interference during organ development; all parts of body are small, including brain Chronic maternal

hypertension Severe malnutrition Intrauterine infection Substance abuse Anemia

Asymmetric: growth interference begins later in pregnancy Compromised

uteroplacental blood flow most common cause

Gestational hypertension Smoking Maternal drug use Uncontrolled diabetes

mellitus Placental infarcts


Physical Appearance of SGA Newborn

Physical characteristics suggest IUGR Long and thin Head may appear large, but circumference is

usually normal Sutures wide apart due to impaired bone growth Face is thin

Chest and abdominal circumference reduced due to decreased subcutaneous fat


Behavior of SGA Newborn

More active than expected for size Cry is vigorous Strong suck, eats well and gains weight Wide-eyed, alert facial expression may be

caused by chronic hypoxia


Assessment and Management of SGA Newborns

Careful examination for congenital anomalies Monitor for hypoglycemia Higher caloric needs


LGA Newborn

Typically weighs 4000 g (8 lbs, 13 oz) or more

Mechanical problems for vaginal delivery May incur birth trauma

Often sluggish, hypotonic, hypoactive at birth Hypoglycemia or polycythemia

Prone to hypoglycemia


Postterm Newborn

Born after 42 weeks gestation Placental insufficiency may develop

Fetus does not receive adequate oxygen or nutrients Fetus at risk for meconium aspiration

May use subcutaneous fat in utero and appears thin at birth

Skin is cracked and dry due to lack of vernix caseosa

Little lanugo Long fingernails


Risks for Postterm Newborn

Hypoxia Meconium aspiration

Could lead to airway obstruction Hypoglycemia Polycythemia Cold stress Asphyxia


Preterm Newborn

Prematurity most common factor associated with neonatal death

Birth before 37 weeks gestation Skin often wrinkled, covered with lanugo Thin, little subcutaneous fat Prominent fontanelles and sutures of skull Cry could be weak Body appears limp with poor muscle tone Extremities in extension, not flexion


Limitations of the Body Systems in the Preterm Newborn

Depends on weeks of gestation at birth May require

Supplemental oxygen• Mechanical ventilation

Specialized incubators to maintain warmth and prevent infection


Respiratory System of the Preterm Newborn

Not fully mature until after 35th week Surfactant is usually present in sufficient

amounts to keep alveoli of lungs from collapsing

If born before 35th week, increased risk of alveolar collapse Exchange of oxygen and carbon dioxide is

reduced Leads to hypoxia and decreased pulmonary blood

flow; depletes newborn’s energy


Breathing of the Preterm Newborn

Irregular patterns, called periodic breathing At risk for apnea

If lasts longer than 20 seconds, newborn at risk for bradycardia and cyanosis

At risk for gastroesophageal reflux due to weak gag reflex Laryngospasms and apnea


Respiratory Distress in the Preterm Newborn

Retractions of chest wall Expiratory grunting Nasal flaring Changes in respiratory and heart rate Tiny nasal and respiratory passages easily

occluded by mucous plugs High concentrations of oxygen Long-term ventilatory therapy Can lead to bronchopulmonary dysplasia (BPD)


Circulatory System and the Preterm Newborn

Tendency toward persistent fetal circulation Low surfactant contributes to hypoxia

Can reopen ductus arteriosus Blood bypasses lungs, worsening hypoxia

Fragile blood vessels can rupture Increased risk for intraventricular hemorrhage


Gastrointestinal System and the Preterm Newborn

May not be able to digest saturated fats, proteins high in casein Decreased bile salts and pancreatic lipase

May have weak suck-swallow reflexes Limited stomach capacity Subject to gastroesophageal reflux and aspiration

Nonnutritive sucking (i.e., pacifier)


Liver and Metabolic Function and the Preterm Newborn

Have reduced glycogen, fat, vitamin, and mineral stores

Increases risk of Hypoglycemia

• Blood glucose of 30 mg/dL or less

• Glycogen stores deplete more rapidly Hypocalcemia

• Twitching, seizures, high-pitched cry

Poor clearance of bilirubin More susceptible to cold stress, which releases free fatty acids Fatty acids compete for albumin-binding sites, displace

bilirubin


Renal System and the Preterm Newborn

Immature kidneys contribute to fluid and electrolyte imbalances Limited ability to concentrate urine or handle large

amounts of fluid Risk for fluid retention and overhydration

Metabolic acidosis can occur due to excessive bicarbonate loss

Poor drug clearance


Immune System and the Preterm Newborn

Receive limited passive immunity from mother, mostly in third trimester

Meticulous adherence to infection prevention and control protocols is essential


Management and Nursing Careof the Preterm Newborn

Temperature regulation Ability to produce own heat

is limited Immature temperature

regulation in brain Vessels near surface of skin Decreased glucose stores

Skin care Place on back with mattress

slightly elevated Frequent repositioning

Feeding Methods available Needs 110 to 130 kcal/day Requires more whey protein

than term newborn Breast milk 20 to 30 g/day weight gain

Fluid volume Assess for underhydration or

overhydration Monitor I&O 1 g = 1 mL of fluid


Audience Response System Question 1

Chronic maternal hypertension, severe malnutrition, intrauterine infection, and substance abuse can cause what type of growth restriction?A. Large for gestational age

B. Symmetric

C. Asymmetric

D. Small for gestational age


The Compromised Newborn


Objectives

Explain the factors that predispose the newborn to necrotizing enterocolitis.

Discuss developmentally supportive care of preterm newborns.

Outline the needs of parents who have a preterm newborn.


Common Problems of the Compromised Newborn


Retinopathy of Prematurity

Prolonged periods of hyperoxygenation produce oxygen toxicity Cause vasoconstriction in vessels of retina

• Retrolental fibroplasia

Can lead to loss of vision or blindness Monitor pulse oximeter


Bronchopulmonary Dysplasia (BPD)

Prolonged supplemental oxygen causes thickening of alveolar sacs Leads to atelectasis and scarring

Can result in long-term oxygen dependence Interventions include

Apnea monitoring Cutaneous stimulation Suctioning, positioning, and chest physiotherapy


Patent Ductus Arteriosus (PDA)

Underdeveloped musculature or hypoxia If ductus arteriosus remains open

Left-to-right shunting occurs Increases workload on left ventricle Results in pulmonary congestion and hypoxia

Administration of prostaglandin synthesis inhibitor can constrict ductus and cause it to close May require surgical intervention to close


Necrotizing Enterocolitis(NEC)

Acute inflammatory process of bowel Multifactorial disorder

Asphyxia reduces circulation Causes ischemia and necrosis of bowel Feeding precedes onset of symptoms Organisms invade

Abdominal distention Diminished or absent bowel sounds Diarrhea Occult blood

X-ray shows free air in peritoneum, perforated bowelCopyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 33

Management of NEC

Discontinue all oral feedings Nasogastric suction IV fluid Broad-spectrum antimicrobials Measure abdominal girth Auscultate bowel sounds Surgery if perforation of bowel occurs or to

remove necrotic bowel tissue


Intraventricular Hemorrhage

Potential causes Capillary fragility Increased cerebral blood flow Unstable blood gas levels

During birth process Trauma Hypoxia Asphyxia


Pain and Irritability

Signs of pain Intense cry Tightly closed eyes Grimaces Changes in vital

signs Lower oxygen

saturation levels Increased movement

of extremities

Interventions Swaddling Nesting Kangaroo care Provide pacifier Soft voice Music Rocking in vertical

position


Sedation

Does not relieve pain Often reduces infant’s ability to express pain Usually used in intubated preterms to prevent

pneumothorax Organizational phase of brain development

occurs in second trimester Drugs can influence outcome of brain

development


Developmentally Supportive Care

Integration of technology with sensitive, family-centered, hands-on nursing care

Promote growth and development based on needs of newborn Protect quiet sleep state of newborn Organize care to conserve newborn’s energy Maintain flexibility of care when newborn indicates

the need for rest


Developmentally Supportive Care (cont.)

Keep parents informed Encourage and support bonding Cover isolette to protect newborn’s eyes from

bright lights and to provide circadian rhythm Encourage self-consoling by placing infant’s

hand near mouth, using pacifier, and using nesting position


Developmentally Supportive Care (cont.)

Support family; encourage visitation and participation in care Allow for grieving; help work through emotions and

feelings of guilt Nurse prepares family for newborn’s limited

ability to respond because of all the medical equipment


CAM Therapy and the Preterm Newborn

Aromatherapy can be used to alter behavior Kangaroo care is skin-to-skin contact

between parent and newborn Music therapy is soothing and helps with

nonnutritive sucking Massage can regulate sleep patterns and

reduce motor activity


Home Care

Before discharge, parents should be given opportunity to care for newborn

Rooming-in at night helps parents learn nighttime behaviors Reviewing feeding techniques, breast pumping,

and milk storage is important Bathing, diapering, dressing, and wrapping Bonding behaviors

CPR techniques are essential


Mother-Newborn Interaction

The two components of the mother-newborn interaction that are most affected by having the preterm newborn in the high-risk nursery are sensory (touch) and caring for her infant.


Audience Response System Question 2

Which is the least life threatening to a preterm newborn?

A.Necrotizing enterocolitis (NEC)

B.Patent ductus arteriosus (PDA)

C.Retinopathy of Prematurity (ROP)

D.Intraventricular hemorrhage (IVH)


Review Key Points


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