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8. Prematurity

Problems of the New born
Mr. Mudenda, 2018
• It is expected that a baby is delivered between 37 and 42
weeks of pregnancy
• Such a baby is termed as a term baby
• This baby is fully physiologically and anatomically ready to
survive the extra-uterine life
• Some babies however are born before the 37th week
• This lesson looks at such babies, termed premature, and
their care
Define prematurity
Explain the risk or contributing factors of prematurity
Outline the problems of a premature infant
Describe the management of a premature infant
State the complications of prematurity
• Prematurity is the birth of a baby before its 37th week of
• A premature or preterm baby is thus a baby born before 37
weeks gestations regardless of weight
• Strictly put, a premature baby is born after 28 weeks of
• Defined so, because with special care, a 28 weeks baby can
survive into a normal baby
Risk Factors of Prematurity
Exact cause is not known
Can be categories as
1. Maternal
2. Placental
3. Fetal
4. Iatrogenic
Maternal Factors
Multiple pregnancy
Maternal history of preterm delivery
Uterine anomalies
More than one second-trimester abortions
Incompetent cervix
Uterine structural anomalies
Maternal factors
Premature rupture of membranes
Maternal substance abuse especially cocaine
Maternal age less than 18 years
Poor nutrition
Lack of prenatal care
Diabetes mellitus
Placental Factors
• Antepartum hemorrhage
• Pacenta previa
• Placenta abruptio
Fetal Causes
• Multiple pregnancy
• Congenital abnormalities
– Hydrocephalus
– Spinal bifida
Iatrogenic Factors
• Incorrect assessment of gestation
• Elective induction
Characteristics of a Premature Baby
The Head
• Skull bones are soft with wide sutures and fontanelles
• The head is large in proportion to the body with a small
triangular face which appears worried
• Hair is soft and silky and individual strands are relatively
wide for the small head.
• Eyes are usually closed
• Ears are small and cartilage is soft and the pinna stays
folded prior to 34 weeks
Skin and subcutaneous tissue
• Skin is thin, red, easily broken and appears wrinkled due to
lack of subcutaneous tissue
• Body structures (blood vessels) are easily seen with poorly
developed skin creases
• Lanugo is plentiful with sparse vernix caseosa
• Breast nodules are small or absent (depending on gestation).
• Short and soft easily broken nails
Respiratory system
• Thoracic cage is relatively small
• Breathing is abnormal, usually irregular and shallow with
periods of apnea
• Cough reflex is weak or absent
• Nostrils are small and easily blocked
• Crying maybe weak
• The abdomen is relatively large and distended
• The viscera can be palpated through the thin wall
• Umbilicus looks low set with plenty of Wharton's jelly
• Males – testes maybe felt in the inguinal canal by 32 weeks
and in the scrotum by 36 weeks
• There is little or no rugae on the scrotum
• Female –clitoris and labia minora are prominent and labia
majora are poorly developed
Neurological system
• Reflexes –sucking is present but weak before 32 weeks
• Grasping is noted 28 weeks and is well established after 34
• Posture
• The baby is lethargic and lies in a frog like position due to
generalized hypotonia (poor muscle tone)
• Behaviour –The baby sleeps most of the day, stretches
often yawns and is always drowsy
Problems of Preterm Babies
• Problems occur largely as a result of immaturity of organs
as highlighted on the next few slides
Respiratory Distress
• Due to inadequate surfactant production and poor cough reflex
• Signs are
– Tachypnea
– Nasal flaring
– Grunting respiration
– Apnea and xiphoid and
– intercostal retraction
• Apnea and asphyxia are due to immature respiratory center in
the central nervous system
• The preterm baby is very small, can easily lose heat due to;
– Immaturity of heat regulating center
– Inadequate storage of brown fat in utero
– Poor generation of heat due to reduced activity
– Evaporation heat loss due to open posture adopted by
preterm babies
• This arises from:
– Inadequate storage of
glycogen in utero
– Inadequate
intake due to poor or
absent sucking reflex
– Any
increase their metabolic
• Signs include;
– Apnea
– Tremors
– Twitching
– Sweating
– Cyanosis
– Refusal to feed and coma
Risk of infection
• Preterm
are Signs of Sepsis include
vulnerable to infection due
• Low or high temperature
• Lethargy irritability
– Under-developed immune
• Poor feeding
• Respiratory Distress
– Exposure to invasive
procedures and hospital
Neonatal Jaundice
• The preterm baby is at risk of developing jaundice due to
immaturity of the liver
• It may result from:
– Reduced hepatic function with immature enzyme system and
– Reduced glucuronyl transferase
– Hypoalbuminemia
• Signs include: yellow discoloration of the skin and mucous
membranes, irritability and lethargy
Bleeding Tendencies
• Newborns are relatively vitamin K deficient
– Low vitamin K stores at birth (vitamin K passes the placenta
– The levels of vitamin K in breast milk are low and
– The gut flora has not yet been developed (vitamin K is normally
produced by intestinal bacteria)
• Preterm babies are at an increased risk of this deficiency
• They can easily bleed from the umbilicus, skin, nose or GIT
Maintenance of Respirations
• Respiratory interventions needed may vary from oxygen
hood to mechanical ventilation
• Assess the baby’s respiratory status, rule out apnaea
• Keep the baby warm and well hydrated
• However, avoid prolonged use of oxygen to prevent
retinopathy of prematurity
• Surfactant maybe given to the very immature babies 50100mg/kg stat
Maintenance of Respirations
• Monitor vital signs closely and blood gases
• Minimize handling to reduce oxygen demands by the
tissues leading to disturbed respirations and tachypenic
• Position the baby in lateral position for oxygenation and
raise the foot end of the incubator to aid drainage of
• If less than 2kg, incubator care is indicated with
temperature at 30-34 degrees and at 36-37 degrees for
babies less than 1.5kg and humidity of 65%
• Cot care is used for babies weighing 2kg and above
• Surface of the cot mattress should be lined with cot bed
sheet to prevent loss of heat through conduction if left to lie
on cold surface
• The incubator should always be left closed to prevent cold
air or draught
• Where there are no incubators, hot water bottles, electric
blankets or loose flannel can be used
• Kangaroo care maybe used to provide warmth
• Temperature of the baby, room and incubator should be
monitored closely
• The baby should not be unduly starved unless the condition
is not stable
• NG tube can be inserted to aspirate gastric contents before
introducing feeds
• If the condition is stable early feeds are given 8-12 hours
after delivery to prevent hypoglycemia
• The feeds can either be fed by breast feeding, tube feeding
or IV fluids 60mls/kg/24hours
• Nasogastric tube feeds are given 1-5mls/feed/2hourly
• The baby should get 60mls/kg on day one
• The feeds are first given in small amounts at first 0.5mls
6hourly, 4-hourly then 2-hourly and then continue with
20mls increment per day as the baby tolerates
• Blood sugar levels should be monitored by heel stick
• Discontinued IV fluids when oral intake exceeds
• Note signs of readiness for nipple feeding like rooting,
sucking and presence of gag reflex with no apneic spells
Prevention of Infection
• Scrupulous hand washing with soap and by everyone
handling the baby is the best way to prevent infection
• The environment should be kept clean by mopping the floor
and dump dusting every day
• Use of gowns when handling the baby and restricting
visitors also reduces infection
• Clean incubators, equipment, and linen should be used at all
Prevention of Infection
• The nurse should not only be experience but should have
quality of patience, devotion and observant to notice any
signs of infection
• Ensure aseptic technique when doing sterile procedures e.g.
commencing IV fluids, injection administration, code care
• Sick babies should be isolated
• Maintain warmth and nutritional status
Prevention of Infection
• Ensure aseptic technique when doing sterile procedures e.g.
commencing IV fluids, injection administration, cord care
• Sick babies should be isolated
• Maintain warmth and nutritional status
Prevention of Infection
• Preterm babies are potentially infected, they are managed
on antibiotics
– Cephotaxime 100mg/kg BD or
– Ciprofloxacin 10mg/kg BD to prevent infection
• Top and tail is done to promote hygiene
• Blood for culture is done to detect causative organisms for
Management of Jaundice
• The goals of treatment is to prevent kernicterus
• Place the baby on phototherapy to treat jaundice
• Observe the skin, sclera and mucous membrane to note
reduction or deepening of jaundice
• Observe the baby for signs of kernicterus e.g. lethargy and
• Treat all infections promptly to prevent jaundice
Management of Jaundice
• Phenobarbitone 20mg/kg is given to mature the liver
• Monitor bilirubin levels according to the hospital policy
Prevention of Bleeding
• Give vitamin A at birth
• Ensure the umbilical cord is well secure
• Observe cord, mucus membranes and skin for bleeding,
especially injection sites
• Encourage feeding as soon as possible to promote growth of
gut flora which starts vitamin K formation
September 2007 Edition 3
Module 6: Initiating ART
• Apex beat –because the heart is immature and breathing is
• Respiration- because the baby is prone to respiratory
• Observe oxygen salutation using an oxymeter
• Colour –this is a clinical guide to oxygenation
• Tone and reflexes –these are diminished in ill babies
• Observe signs of infection (rash, discharging eyes and cord)
• Feeding –observe amount of feed, whether it is being
tolerated or not, vomiting
• Stool and urine –because of the gut and kidneys that are
immature, check frequency, consistency and colour
• Oedema –the baby tend to retain fluids
• Weight gain –baby should regain birth weight in two weeks
• Observe the incubator performance thrice daily
• Monitor HB at birth, then weekly to exclude anemia
Psychological Care
• Orient parents to the ward and help build the bond between
the baby and mother
• Involve them in the care of the baby during hospital stay so
that they gain the skill to continue the care at home
• Counsel them on the care of the baby e.g. feeding, warmth,
hygiene and medical reviews
• Allow parents to ask questions regarding their child’s care
Discharge Plan
Plan to discharge the baby when:
• Parents are competent to continue care on their own
• When the baby is constantly gaining weight at 1030grams/day
• When the baby maintains a stable temperature in an open
• When the baby is feeding well on the breast
Discharge Plan
• Educate the mother on prevention of infection whilst in the
hospital so that she can be able to carry on:
– hand washing, changing soiled linen, minimizing visitations.
• Discuss with the mother the importance of taking the baby
for children’s clinic for growth monitoring and
• Educate her on identification of sigs of infection e.g. fever,
failure to feed, foul smelling dirrhoea
Discharge Plan
• Advice to bring the baby for weekly weight checking so
that the baby is closely monitored.
• Advice her on the importance of practicing exclusive breast
• She should keep the review date and if the baby falls sick or
something goes wrong, she should take to the nearest clinic
for advice
• Asphyxia Neonatorum –due to immature respiratory center
• RDS– due to lack or insufficient surfactant
• Necrotizing enterocolitis – due to destruction of intestines
by bacteria or hypoxia
• Retinopathy of prematurity – due to damage of the
immature blood vessels by too much arterial oxygen
• Kernicterus – due to neonatal jaundice
• Hypoglycemia –due to low glycogen stores
• Infection –low immunity due to less effective immunoglobulin
and white cell reaction
• Anemia –due to inadequate iron stores, hemorrhagic disease
Poor mental and intellectual development
• Cardiopulmonary failure due to poor circulation
• Aspiration pneumonia –due to poor or absent cough or
swallowing reflex
• Intracranial birth injuries –due to extreme vascularity of the
germinal layer around the ventricles which get hemorrhagic on
slight trauma
• Managing preterms not only requires experience but also a high
degree of patience, devotion and observance
• This is so because any hope of survival for the baby depends
entirely on the nurses’ commitment in care
• The unit-in-charge must build a team of critical thinkers, not a
bunch of robots which can’t think beyond their daily