Problems of the New born PREMATURITY Mr. Mudenda, 2018 1 Introduction • 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 2 Objectives • • • • • 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 3 Definition • Prematurity is the birth of a baby before its 37th week of gestation • 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 pregnancy • Defined so, because with special care, a 28 weeks baby can survive into a normal baby 4 Risk Factors of Prematurity Exact cause is not known Can be categories as 1. Maternal 2. Placental 3. Fetal 4. Iatrogenic 5 Maternal Factors • • • • • • • • Multiple pregnancy Maternal history of preterm delivery Hydramnious Uterine anomalies More than one second-trimester abortions Incompetent cervix Infection Uterine structural anomalies 6 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 Obesity Hypertension 7 Placental Factors • Antepartum hemorrhage • Pacenta previa • Placenta abruptio 8 Fetal Causes • Multiple pregnancy • Congenital abnormalities – Hydrocephalus – Spinal bifida 9 Iatrogenic Factors • Incorrect assessment of gestation • Elective induction 10 Characteristics of a Premature Baby 11 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 12 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 13 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 14 Abdomen • 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 15 Genitalia • 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 16 Neurological system • Reflexes –sucking is present but weak before 32 weeks • Grasping is noted 28 weeks and is well established after 34 weeks • 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 17 Problems of Preterm Babies • Problems occur largely as a result of immaturity of organs as highlighted on the next few slides 18 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 19 Hypothermia • 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 20 Hypoglycaemia • This arises from: – Inadequate storage of glycogen in utero – Inadequate nutritional intake due to poor or absent sucking reflex – Any condition that increase their metabolic rate • Signs include; – Apnea – Tremors – Twitching – Sweating – Cyanosis – Refusal to feed and coma 21 Risk of infection • Preterm babies are Signs of Sepsis include vulnerable to infection due • Low or high temperature to: • Lethargy irritability – Under-developed immune • Poor feeding system • Respiratory Distress – Exposure to invasive procedures and hospital organisms 22 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 23 Bleeding Tendencies • Newborns are relatively vitamin K deficient – Low vitamin K stores at birth (vitamin K passes the placenta poorly) – 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 24 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 25 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 attacks • Position the baby in lateral position for oxygenation and raise the foot end of the incubator to aid drainage of secretions 26 Warmth • 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 27 Warmth • 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 28 Nutrition • 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 29 Nutrition • 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 samples 30 Nutrition • Discontinued IV fluids when oral intake exceeds 90mls/kg/day • Note signs of readiness for nipple feeding like rooting, sucking and presence of gag reflex with no apneic spells 31 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 times 32 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 33 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 34 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 infections 35 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 convulsions • Treat all infections promptly to prevent jaundice 36 Management of Jaundice • Phenobarbitone 20mg/kg is given to mature the liver enzyme • Monitor bilirubin levels according to the hospital policy 37 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 38 Observations • Apex beat –because the heart is immature and breathing is irregular • Respiration- because the baby is prone to respiratory problems • 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) 39 Observations • 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 40 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 41 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 environment • When the baby is feeding well on the breast 42 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 immunization • Educate her on identification of sigs of infection e.g. fever, failure to feed, foul smelling dirrhoea 43 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 feeding • 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 44 Complications • 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 45 Complications • 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 46 Complications • Intracranial birth injuries –due to extreme vascularity of the germinal layer around the ventricles which get hemorrhagic on slight trauma 47 Conclusion • 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 programming 48
