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OB Unit 4
Care of the Newborn
Neonate
Term used for a child in the first 4 weeks of life
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Initial Care & Assessment of the Newborn
Immediately After
Birth
Apgar scoring and vital signs are the first things that the nurse will do following
delivery
First 24 hours are critical for the newborn. Initial care focuses largely on
monitoring and assessing the newborn’s vital signs
A. Respiration
Secretions are removed w/ bulb syringe immed.
Stimulate respirations as needed w/ tactile stimulation
The lungs must expand and fill with air on the 1st inspiration. Excess secretions in
the airway can cause aspiration pneumonia or death
Brief periods of apnea are common for up to 20 seconds at a time. If longer than
20 seconds, the baby needs to be evaluated for apnea
Breathing is diaphragmatic and should be effortless. Rate and rhythm will vary
with activity
Normal respirations are synchronized
Chest should expand as a whole
Nose breathers
Rate is 30-60 breaths/min
How does the doctor score my baby?
It's easy to remember what's being tested by thinking of the letters in the name
"Apgar": Activity, Pulse, Grimace, Appearance, and Respiration. Here's how
they're used to rate your baby:
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Activity (muscle tone)
0 — Limp; no movement
1 — Some flexion of arms and legs
2 — Active motion
Pulse (heart rate)
0 — No heart rate
1 — Fewer than 100 beats per minute
2 — At least 100 beats per minute
Grimace (reflex response)
0 — No response to airways being suctioned
1 — Grimace during suctioning
2 — Grimace and pull away, cough, or sneeze during suctioning
Appearance (color)
1
0 — The baby's whole body is completely bluish-gray or pale
1 — Good color in body with bluish hands or feet
2 — Good color all over
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Respiration (breathing)
0 — Not breathing
1 — Weak cry; may sound like whimpering, slow or irregular breathing
2 — Good, strong cry; normal rate and effort of breathing
B. Apgar Score
Assess’ neonates physical condition @ 1 & 5 minutes
Evaluates respiratory & cardiac status
Refer to pg. 687 Table 25-3
C. Heart Rate
Normal is 120-160 beats/min..
Taken apically..
1 full minute
Pulse rate averages with higher and lower variations depending on activity
Should have a regular rate and rhythm.
Auscultate between the fourth and fifth intercostal spaces.
Best done when infant is sleeping.
Mumurs are common, MD to determine whether they are significant.
Take for one full minute
BP averages 60-80 over 40-50 and should be approximately the same in all four
extremities..
A drop in systolic BP (about 15 mm hg) in the first hour after birth is common..
D. Provide Warmth (one of nursing’s first concerns)
Very susceptible to “cold stress”
Maintaining body temp is essential..
Wrap in warmed blanket..
Place cap on head
More heat is lost through head than any other body part
Newborn has limited amount of protective adipose tissue
Neonate’s temperature control center is not fully developed
The brown fat is extremely important at this time
Place preemies in isolette to keep warm and ensure thermal regulation..
Place on mother’s abdomen
Newborn warmer
Delay 1st bath until temp is stable (97.6 – 98.6)
Protect from drafts
Cover work tables and scales so that they are not cold
Organize your work so infant is not left uncovered for long periods of time.
E. Temperature
Normal axillary is 97.6-98.6 ..
Temp monitored with skin sensor
Rectal temp x 1 following birth
Anus MUST be patent
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3
Axillary is most common
Be sure temp is 98.6 before bathing
F. Identification
Done in delivery room
2 ID bands (ankle & wrist) on newborn
1 ID band on mother
Foot printing & fingerprinting
Double check ID bands before bringing baby to mother
At discharge, remove one ID from infant, place in chart, compare it’s numbers
with mother’s ID band.
Have another nurse sign chart
G. Protection of Disease
Eye prophylaxis w/ Erythromycin
For opthalmia neonatorum
Vitamin K injection..
To help with coag factors and prevent hemorrhage
Vitamin K
Neonates have low prothrombin levels at birth and are at risk for hemorrhage.
They are not able to synthesize vitamin K in the colon until they have adequate
intestinal flora
Best site used for vit K is the Vastus lateralis muscle or thigh..
H. Spine & Extremities
Straight without curves
Until baby begins to stand
Dimples, tufts of hair and masses
Single crease in palm of hand
AKA Simian line, may indicate Down’s syndrome
Simian Crease
Equal length of legs
Uneven could mean hip dysplasia
I. Bonding
Promotion of attachment between neonate & family
Should begin immediately
Bonding
The infant is a socially responsive human being
Will state intently at parents faces
Prefers to look at mother’s eye
Can recognize approaching objects
Will imitate other’s facial expressions
Will reach for objects
Recognizes mother’s voice
Visual range is 8 – 10 inches
Breast feeding should begin ASAP
Characteristics of the Normal Newborn
A. Weight & Length
Weight ranges from 5.5-10 lbs.
 Length ranges from 18-22 inches
 Weight Loss
 Intracellular fluid moves outside the cell (extracellular) adding to babies blood
volume, thus increases urine output and baby loses the extra water and drops 5 –
10% of body weight due to H2O loss..
 B. Head & Body
 Lg. Head (13-14”) circumference
 Short neck
 Chest smaller than head (12-13”)
 Large protruding abdomen
 Head irregularly shaped “molded”..
 Caput succedaneum..
 Cephalhematoma..
 Both resolve on their own
 Reassure parents
 C. Fontanels
 Soft spots
 Anteriorabove forehead, diamond shaped,closes bet. 18 mos.
 Posterior@ crown of head,
Triangular, closes at 2nd mo.
 D.
Eyes
• Blue or gray @ birth..
• Appear cross-eyed, unable to focus
• Eyelids red/edematous
• No tears
•
Lacrimal glands are not functioning until 4 months
• Eye color established between 6 – 12 months..
 Eyes
 Strabismus (crossed eyes) and nystagmus (abnormal eye motion), are common
due to immature nervous system
 Vision is more acute than previously believed.
 Newborns can see best at 8-10 inches
 Prefer simple pictures in black and white and human faces
 E.
Ears
 Positioned with outer canthus of the eye
 Low set ears may indicate a chromosomal disorder..
 High pitched sounds and mothers voice generate the greatest attention..
 F.
Skin
• Rashes are common
• By 3rd day, more natural tone
• Acrocyanosis..
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Bluish coloration of hands and feet from poor circulation. Can persist for 7-10
days.
• Common when infant is cold
 Harlequin sign
4
 Half of the newborns body appears deep red and the other side of body appears
pale as a result of vasomotor disturbance with some vessels constricting while
others dilate..
 G. Jaundice
• Yellow discoloration caused by deposits of bile pigments and also know as icterus
neonatorum
• First seen on face and mucous membranes
• Abnormal during first 24 hours
• After 24 hours, it is common
• Gradually disappearing by the seventh to tenth day, and caused by the normal
reduction in the number of RBCs that are no longer needed for O2 transport
• Phototherapy and make sure eyes are covered
• Pathological  occurs w/i 24 hrs  Abnormal
• Physiologic  May occur in 2-3 days  Normal
• Immature liver
• Elevated bilirubin
 Treatment
 Freq. Feeding q 2-3 hrs
 Sunlight
 Phototherapy
 Monitor temp
 Allow for bonding
 Influences of Maternal Hormones on Neonate
 gynecomastia
 Edematous labia in females
 Pseudomenstruation..
 Bloody vaginal discharge
 Large scrotum
 Common Skin Observations
 IN THE NEWBORN…..
 Milia
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5
Small white spots on nose and chin from clogged sebaceous glands.
Disappear within few weeks..
Erythema toxicum
Newborn rash,
Hive like (Urticarial)
Elevated small white vesicles
Not contagious
Disappears without treatment
Stork bites
Flat, pink or red marks often seen on eyelids, nose or nape of neck
Caused by dilated capillaries that become more vivid when infant cries.
Not significant to health of infant
Disappears in 1 -2 years
Mongolian spots
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Areas of increased pigmentation.
Lumbar dorsal is most common sight
May appear bluish black
Most often seen in darker skinned persons
Port wine stain
Reddish purple discoloration often seen on the face
Caused by capillary angioma below the epidermis.
Will not disappear
Petechiae
Small, pinpoint hemorrhagic areas under the dermal layer
Will disappear unless a coagulopathy is present
Vernix caseosa..
Yellowish, white cream cheese like substance
Protects infant’s skin from amniotic fluid
Lanugo
Soft hair
Most notable on shoulders, forehead and cheeks
Can be found anywhere except soles of hands and feet
Various birthmarks
Strawberry which are hemangiomas
They shrink spontaneously and usually disappear early in childhood
Epsteins pearls
Small white nodules on the hard palate
Caused by epithelial cells and will disappear spontaneously within a few weeks
Normal Activities and Reflexes
Of the Neonate….
Movement & Activities
Sleeps ~ 17 hrs/day
Awakens easily
Cries when hungry or uncomfortable
Arms & legs move freely & symmetrically
May startle and make sucking motions during sleep. Breathing may be regular
and even or irregular, depending on the sleep state.
The time awake is spent crying, eating, or in quiet alertness.
Most infants do not exceed 5 continuous hours of sleep for some months
Crying is the only means of communication.
Can indicate hunger, pain, or simply the need for attention.
Cry should be strong, vigorous, and of medium pitch.
A high pitched cry may indicate neurological problems and should be observed by
M.D.
Able to flex extremities
Unable to support weight of head
Reflexes
Rooting Reflex..
Head turns toward direction of stimulus
Sucking Reflex
 Dance or Step
 Grasp
 Moro or Startle..
 Extension and abduction of extremities followed by embracing motion..
 Tonic neck reflex
 Fencing position
 Babinski reflex
 Big toe fans out to side when sole is scraped from heel to toe
 Newborn movements are jerky due to immature nervous system..
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Senses
• Smell & Taste
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Not a lot is known
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There is an increase in sucking with glucose water
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They can smell mother’s breast milk
 Sight
Can see shades of light and darkness.
Can see best at 8-10 inches
Blinks with bright lights
Unable to focus
Common conditions due to immature CNS
Nystagmus
Abnormal motion of eyes
Strabismus
Crossed eyes
 Hearing
 Well developed
 Sensitive to loud noises
 Encourage parents to talk in soothing voices
 Can recognize mother’s voice
 Touch
 Well developed
 Responds to discomfort by crying and moving
 Protection of the Newborn
 Each neonate is isolated from other babies
 Specific hand washing & scrub techniques for all persons working in nursery
 Scrub suits & gowns
 For all healthcare workers
 May be used for family members
 Nurseries are very hazardous places if infections are present
 People w/ infectious diseases not allowed access
 Each neonate has own equipment/supplies (never shared)
 Nursery NEVER left unattended
 Cribs have clear sides so infant is visible at all times
 Daily Newborn Care
 Nursing
 Assessment
7
 1. Vital Signs
Respirations
 Always taken first
 Chart if baby is awake, crying or sleeping when taken
 Count for 60 seconds while taking VS, note and make assessment of
newborns appearance, behavior, and reflexes
 Observe abdomen rise & fall
 Resp. should be quiet , may be irregular
 Rate ranges from 30-60 breaths/min
Pulse
 Apically for 60 seconds
 Rapid, may be irregular
 Normal range is 120-160 beats/min
 Warm stethoscope first
Temperature
 Use the tympanic method
 Axillary method as alternative
 Rectalinsert .5 inch
 Hold probe at all times
 What do you need to be aware of at this time?
 Cover with dry diaper
 Hold probe at ALL times
 Temp range97.6-98.6
 Hold probe until it beeps
Blood pressure
 Usually low
 Use smallest cuff
 Usually placed on leg
 Range 60-80/40-50
 2. Daily Weights
 Normal to lose 5-10% of birth weight..
 Usually regain w/I 10-14 days
 Weigh daily
 3. Eyes, Nose & Ears
 Report any redness, swelling or discharge
 4. Elimination
Urination
 Usually 4-8 hrs fol. delivery
 Be sure baby voids & document
 Should have 6-8 wet diapers/day
 After the 1st 2 or 3 days, the baby voids 5-12 times daily
Stools
 Meconium1st stool
 Should occur within 24 hours of delivery
 Dark green, sticky, tarry
8
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Made up of vernix, strands of lanugo, and other substances from amniotic
fluid
Transitional stoolgreenish yellow
Breast fed stool  pale green to golden yellow, smooth, pasty or “seedy” w/
less odor
Sometimes passed with each feeding
Formula fed stoolbrighter yellow, more formed
Should pass two stools per day, then increase to 3 per day after first few
weeks
If no stool in 24 hours
Consider
Imperforate anus
Inspissated meconium
Hardened stool causing bowel obstruction
These conditions need surgical intervention
5. Cord Care..
Observe for redness, drainage & sx of infection
Cleanse w/ alcohol w/ each diaper change
Leave open to dry outside of diaper
Avoid getting cord wet (except during first bath) with subsequent bathing
Tub bathing is delayed until the fully dried cord drops off at about 10 days
Drying process of cord is called mummification
Mortification, producing a dry hard mass
The cord is an excellent portal of entry for infection until it heals
Alcohol reduces the chances of infection
6. Maintaining Warmth
Caps
Clothing
Blankets
Warmer
Incubator
Isolette.. (especially for preemies)
7. Cleansing the Newborn
1st bath after Temp = 98.6
Assess skin color; assess for blemishes, rash, abnormal jerking, twitching,
bleeding, or congenital abnormalities during bathing..
Temp of room should be 75 degrees or more
Bath quickly and pad all cold surfaces
Reassess temp 30 minutes after completion of bath
Newborn skin is usually bright red, especially when crying, due to > of RBCs
present in blood..
Wipe eyes from inner to outer corner
Fol. By face & ears
Rinse & dry hair
Work from head down
Use a non medicated mild soap for initial bath
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Washing with warm water is sufficient for first week
Use mild soap and warm water after each diaper change
Vernix is attached to the upper layer of skin
Do not vigorously rub
You could remove protective skin layer
It could be left on for 48 hours
Baby’s skin has a pH of 5 soon after birth
This slightly acidic skin surface has bacteriostatic effects
Therefore, only warm water with a mild soap should be used
Alkaline soaps such as Ivory, oils, powder and lotions are not used due to pH
altering effect which provides a better environment for bacteria
 Talcum has added risk of aspiration if applied too close to face
 Use mild soap sparingly..
 Special attention to skin folds
 Observe for bleeding at circumcision site first 12 hrs..
 DO NOT use lotion, petroleum jelly or powder
 DO NOT wet unhealed cord
 Treat cord as ordered
 Dress and wrap in blanket
 8. Care of the Penis
 Only retract foreskin if ordered
 Very small opening phimosis
 Smegma secretions that accum. Under foreskin
 Circumcision
 Part or all of foreskin is removed
 Ritual for all Jewish babies
 Must be kept clean
 Assess for bleeding, swelling, & voiding
 Gomco Clamp
 Sterile petroleum gauze is usually applied after Gomco circumcision and left in
place for 24 hours
 Reapply fresh petroleum gauze after each cleansing with soiled diapers
 Plastibell
 Hollister Plastibell Technique
 No need for petroleum gauze
 The plastic bell that covers the glans will not stick to diaper
 Never place on stomach fol.
Circumcision
Assess q 15 min for 4 hours
 9. Sleep
 Newborns sleep most of the time
 Except when hungry or uncomfortable
 Place on side or back
 No pillows
 Most do not exceed 5 continuous hours of sleep for some months
 10. Holding the Newborn
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Wrap in blanket
Support head, neck & buttocks
Football hold gives you a free hand
11. Baby’s Responses
Cries & tightens muscles in response to sudden, loud noise
Crying is only way to ask for help
Lusty cry is a strong healthy cry..
Hunger cries are healthy, demanding cries
May put fingers in mouth as sign of hunger
12. Infant Feeding
Suck & swallow reflexes are present at birth
Feed on “demand”..
Every 3-4 hrs
Breast fed babies do best on “on demand” schedule (1-3 hour intervals)
Bottle fed babies tend to eat less (2-4 hours) because formula is digested more
slowly
Breastfeeding
Colostrum decreases allergies
Superior nutrition
Economical
Readily available
Promotes transfer of maternal antibodies
3 Stages of Breast Milk
Colostrum..
first substance produced
Creamy and yellow white in appearance
Contains more protein, minerals, and fat soluble vitamins than mature breast
milk
Contains high levels of immunoglobulins which transfer some immunity to
newborn
Transitional Milk..
Milk supply comes in at 3-4 days
Transitional milk is produced for about 1 week..
Is thinner and more watery
High in fats, lactose, and water soluble vitamins
Contains more calories than colostrum
Mature Milk
Generally established by 2 weeks PP
Appears very thin and watery
Provides 20 kcal/oz and contains lactose, proteins, minerals, and vitamins
Enhances bonding
Speeds involution
1st feeding is immed. p birth
Best NOT to supplement with bottle
Tickle mouth to trigger rooting reflex
Entire areola in mouth not just nipple
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Place finger in mouth to break suction
Offer both breast at each feeding
Start with breast used last at previous feeding
Treat engorgement w/ frequent feeding
Diet when breastfeeding
Inc. calories by 500/day..
Inc. Milk (1qt./day)
Inc. fluids
ETOH inhibits let-down reflex & found in breast milk
Caffeine is transferred
Consult MD re: medications
Bottle feeding
1-3 oz per feeding1st wk
Total of 15 oz in 24 hrs
Intake increases rapidly after 3 wk
Always hold infant when feeding..
The first feeding is usually 15 – 30 ml of sterile water to insure infant can
swallow normally
Do NOT prop bottle
Wash hands before & after
Right side-lying to prevent regurgitation..
13.
Burping
During and after each feeding
Done whether breast or bottle feeding
Hold upright on knee or against shoulder
Important to burp at intervals to remove air from stomach
Will increase feeding
DISORDERS OF THE NEONATE
Group B Strep ( GBS)
Life threatening infection
Caused by bacterium
Common cause of sepsis and meningitis and pneumonia in newborns
GBS
Before preventative measures were widely used, approximately 8000 babies were
stricken each year
1 in 20 babies dies
Babies that survived, especially those with meningitis, may have long term
problems such as hearing or vision loss or learning disabilities
Diagnosis & Treatment
Vaginal swab at 35-37 wks
Women with +GBS are given antibiotics at time of labor
PCN is safe and effective for Mom
Erythromycin if allergic to PCN
PCN or Ampicillin  newborns
Most M.D.s do not treat because it may not prevent GBS in newborns unless the
GBS is identified in the urine
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13
GBS in urine should be treated at time of discovery
Gestational Age
Preterm..
0 - 37 weeks
Problems with hypothermia
Keep in isolette
Term
38 – 42 weeks
Post term
42 or more weeks
If the exact gestational age of neonate is unknown, most facilities have
assessment procedures to determine age
For the first hour the infant is recovering from the stress of birth and this is
reflected in muscle movement
After 48 hours, some responses change significantly
Highest death rate is within first 28 days
Gestational Size
A.G.A. (Appropriate for Gestational Age)
Weight between 10th and 90th percentile
S.G.A. (Small for Gestational Age)
Below 10th percentile
L.G.A. (Large for Gestational Age)
Above 90th percentile (DM moms)
L.B.W. (Low Birth Weight)
Less than 2500 gms
Normal is 5.8 to 8.5 pounds
The SGA infant may be a result of problems occurring during the first trimester,
such as infections or chromosomal abnormalities or a later reduction in the fetal
O2 supply or nutrition as a result of smoking ,hypertension or malnutrition
Problems could be asphyxia, meconium aspiration syndrome, hypoglycemia, and
hypothermia
LGA infants have hypoglycemia, resp distress, birth injuries and asphyxia
Nursing Considerations
With Preterm
Neonates
Conserve Energy
Handle as little as possible..
Delay bathing
Special care to keep warm
Heat Conservation
Lack of subcutaneous fat, large surface area relative to body weight, and poor
reserves of glucose and brown fat (source of heat unique to neonates that is
capable of greater thermogenic (heat producing) activity than ordinary fat), all
contribute to problems with heat conservation
Feeding
No food for 36 hrs
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14
Very small amounts on a 2-3 hr
Reflexes may be weak or absent..
Gavage (NG) or expressed milk using a nipple..
The digestive system is formed, but problems with absorption of nutrients
are common. Could cause distention
Gag, suck, and swallow reflexes may be absent or atypical
Elimination
Kidneys not fully developed
Weigh diaper before & after they urinate
The renal system is immature and ineffective
Fluid and acid/base imbalance is frequently observed
Color and Skin
Ruddy
Cyanotic
Very thin, translucent skin
Obvious blood vessels and little sub-q fat
Respiratory Status
Nasal flaring
Retractions of sternum and intercostal muscles
Grunting
Air hunger
All common due to insufficient amounts of surfactant
Infection Prevention
Good handwashing
Contacts with people other than parents is limited
Special Care Nursery
Respiratory Distress Syndrome (RDS)
Leading cause of death
Inadequate oxygenation
Cause of RDS is unknown
Deficiency in pulmonary surfactant
Atelectasis is common
RDS
Major cause of M/M in the neonate period.
Occurs almost exclusively in the preterm and LBW infant
More often in males and C/S babies
Other factors
DM moms, asphyxia, maternal hemorrhage and shock
Surfactant Deficiency
Surfactant reduces surface tension of fluids that line the alveoli, thereby
permitting expansion of the lungs and alveolar inflation
Without surfactant the lungs are unable to stay inflated and the alveoli collapse at
the end of expiration resulting in
Hypoxia
Atelectasis
Respiratory acidosis
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15
Symptoms
Dyspnea
Cyanosis
tachypnea
Flaring nares
Chest retractions
Tachycardia
Expiratory grunt
Low body temperature
In severe cases, infants may die within hours of onset of symptoms. Those
who survive, show improvement by the 4th day
Dx based on X-rays, ABGs, clinical assessment
Treatment
Oxygen & humidity
Antibiotics
Exogenous pulmonary surfactant..
Corticosteroids
Minimal handling..
RDS
Tx directed at correcting imbalances
O2 therapy continually monitored
Exogenous surfactant administered via ETT shortly after birth
Betamethasone to the mother pre-delivery may increase surfactant levels in
preemie
Survival beyond 96 hours indicates good survival potential
Newborns fed via gavage or central line to prevent aspiration
Retrolental Fibroplasia..
Often led to blindness in preterm newborns
Occurs when oxygen concentration is > 40 % for long periods of time
Monitor Oxygen bld levels..
Excessive O2 levels must be avoided
Potential Complications
of High Risk
Newborns
Meconium/Amniotic Fluid Aspiration
In hypoxic fetus, anal sphincter relaxes meconium passes into amniotic
fluid
Can occur in utero or @birth
If first breath is taken prior to suctioning  aspiration
Aspirated fluid Can lead to :
Atelectasis
Pneumonia
Pulmonary problems
Treatment
Oxygen
Encourage fluids
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16
Regulate temperature
antibiotics
Cyanosis
Blue or dusky color
At least 5 Gms of hemoglobin are not combined with O2
Happens very quickly
Caused by:
Prolapsed cord during delivery
Congenital heart defect
Medications (analgesics)
Treatment is Crucial and must be Prompt
Suction
Oxygen
Postural drainage
Rub back
GI Disturbances
Vomiting, Diarrhea
Dehydration
Vomiting
Congenital defects
Birth injury
Intracranial hemorrhage
Infection
Distinct difference between Vomiting & spitting up
Diarrhea
Most commonly caused by bacteria
May be formula or an allergy
Stool is formless, greenish-yellow & foul smelling
Isolate baby
Obtain stool cultures
Dehydration can occur quickly
Leads to electrolyte imbalance
Treat quickly w/ IV, and oxygen
Treatment must be immediate or infant will die
Necrotizing Enterocolitis
Bowel wall necrose & die
Common in preterm babies especially if early ROM of if infant suffered from
anoxia
SX: lethargy, abd. Distention, hypothermia, apnea & irritability
Bottle fed babies are more susceptible
Treatment
NG tube to suction to rest bowel
Frequent X-rays
Barium swallows
IV fluids
TPN
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Antibiotics
Surgical resection PRN
Hypoglycemia
Blood sugar < 40mg/100ml
All babies have the potential
LGA babies From DM Moms are at greatest risk
S/S : tremors
irritable
jittery
apnea & tachycardia
Treatment
10-15% glucose water
Decrease amounts as newborn can tolerate feedings
Hemolytic Conditions
Result from Rh or ABO incompatibility
Erythroblastosis Fetalis
Occurs when Rh- mother has an Rh+ feturs..
Condition is uncommon today
Preventable with RhoGAM
Phototherapy used on mild cases
May have exchange transfusions
ABO Incompatibility
Mother has O type blood
Newborn has A,B, or AB
Disease is mild
Sx are jaundice & enlarged spleen. TX=phototherapy
ABO Incompatibility
Possible if mother is A and infant is B, or vice versa
No sensitization is require and it may infect the first and all successive
pregnancies
Mother shows no symptoms
Hemolysis may occur in utero and Dx made on amniotic fluid or maternal
diagnostic tests
Jaundice present at birth or within 24 hours
Phototherapy (if bilirubin 12-15) or exchange transfusion
Birth Injuries
Fractures
Fractured clavicle most common
Sx: asymetrical Moro reflex and crying when affected arm is moved
Fx will heal w/o difficulties
Intracranial Hemorrhage
Primarily problem of preterm newborns
Other causes: dystocia, precipitate labor & delivery or prolonged labor
Symptoms..
Seizures
Respiratory distress
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18
Cyanosis
Shrill cry
Muscle weakness
All symptoms of increase intra-cranial pressure
Treatment
HOB slightly elevated
Oxygen
Vitamin K
Antibiotics
Anticonvulsive meds
Sedatives
Fed by gavage
Brachial Plexus Injury
Results from trauma during a difficult delivery
C5 –C6
SX: unable to elevate arm, hand or forearm
TX: ROM, splinting
Prognosis depends on degree of nerve damage
Facial Paralysis
Bell’s Palsy
Result of forceps delivery
One side of face affected
Sucking reflex impaired
Most cases are temporary
Could be permanent
Saline irrigation or patching to keep eye moist
May need plastic surgery
Congenital Disorders
Abnormality that exists
at birth
MUSCULOSKELETAL
Congenital Disorders
Talipes (Club Foot)
One or both feet turn out of normal position
Occurs more often in boys
Excellent prognosis
Tx: braces, casts, special shoes
Congenital Dislocated Hip
More frequently in girls
Treat early to prevent permanent damage
Limitation of abduction is 1st sign..
One leg shorter than other
Skin folds are asymmetrical
X-ray needed to confirm
TX: stabilizing head of femur
Triple fold diapers
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19
Thick foam pads or splints
Cast
Hip click– Ortolani’s sign
Polydactylism
Extra finger or toe
Suture used to tie off appendage
Occ. Surgery is necessary
Polydactyly
Syndactylism
Fusing together of two or more digits
Surgery may be necessary to separate
Syndactyly
Nervous System Disorders
That would make an Infant “High Risk”
Hydrocephalus..
Overabundance of CSF
Enlarged head, bulging fontanels, irritability
TX: VP shunts inserted into ventricles to drain..
Measure head circumference daily..
Spina Bifida
Vertebral spaces fail to close
Spinal contents herniate into a sac
Meningocele
Myelomeningocele
Surgery to correct
Prognosis depends on deformity’s extent
Folate(Folic Acid) reduces the risk for neural tube defects
Down Syndrome
Trisomy 21
Physical and mental manifestations range from mild to severe
Mental retardation & heart defects also exist
Most common chromosomal abnormality, 1 in 800 births
Small rounded skull with flat occiput
Upward slanting eyes
Broad flat nose
Short protruding tongue
Low set ears
Simian crease
Prone to URIs
Trisotomy 21
Anencephally
Part or all of the brain is missing
Skull is flat
Newborn will live for only a short time
Microcephaly
Abnormally small head
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Brain does not develop normally
Almost always mentally retarded
Cardiovascular Disorders
That would make an infant “High Risk”
Patent Ductus Arteriosus
Ductus Arteriosus remains open
Oxygenated blood returns to the pulmonary circulation
TX: Indocin
ASD & VSD
Abnormal openings exist between respective chambers
TX: Teflon patch
Tetrology of Fallot
Four major heart defects occur simultaneously
Pulmonary stenosis
VSD
Overriding aorta
Hypertrophy of r. ventricle
Coarctation of the Aorta
Aorta narrows as it leaves the heart
Surgery consists of excising the coarctation & suturing the two ends together
or using a bl. Vessel graft
Respiratory Disorders
That would make an infant
“High Risk”
Choanal Atresia
Nostrils are closed at the throat entrance
Quickly corrected w/ surgery
G.I. Disturbances
That would make an infant
“High Risk”
Esophageal Atresia
Esophagus ends in a blind pouch
Immediate surgery
TPN in interim for nutrition
Tracheoesophageal Fistula
Opening between esophagus & trachea
1st sign Choking with first feed..
Life threatening
Emergency surgery
Pyloric Stenosis
Pyloric opening constricts
Food cannot pass through into intestines
Projectile vomiting classic symptom
Surgical correction is nec.
Imperforate Anus
Rectum ends in a blind pouch
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21
Suspect, if newborn does not pass a stool within 24 hours of delivery
Surgery to correct
Imperforate Anus
PKU(Phenylketonuria)
Baby cannot use the protein, phenylalanine
Substance builds in blood
Can cause brain damage & mental retardation
No cure exists
All newborns are tested prior to discharge and at 6 wk
Testing is mandatory
PKU
Inborn error of metabolism in which baby can not breakdown amino acid called
Phenalynine
It collects in the blood and can cause severe retardation
Found in most foods, especially milk
Testing is mandatory
Can be prevented by diet
1 in 15,000 births
How do we test..
Heel stick upon discharge from hospital
Should be repeated in 3-5 days because results depend upon how long baby has
been on milk..
What type of diet
Restricted phenalynine
Difficult to eliminate all phenalynine because it is in most foods
Formula is LofenalacAvoid animal products, aspartame and wheat
Galactosemia
Cannot digest galactose (a milk sugar)
Galactose builds up & damages brain, liver & eyes
SX:vomiting,poor weight gain, yellow color to skin
TX: lactose free diet
1 in 60,000 births
May lead to severe brain or liver damage
Maternal Conditions Affecting the Neonate
Sexually Transmitted Diseases
Syphilis
Law requires testing of pregnant women
If + penicillin is used early in pregnancy
Untreated syphilispremature labor
S/S
Skin eruptions of rose spots, blebs on soles and palms, nasal discharge,
hoarse cry, ulcerations around mouth and anus
Positive blood test
Congenital Syphilis
Mulberry Molar
Saber Shins
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Congenital infection
Anomalies (defects)
stillbirth
Gonorrhea
Law requires antibiotic ointment to eyes after birth to prevent ophthalmia
neonatorum(cau. By gonorrhea organism)
 Causes bil. Conjunctivitis
 Can lead to blindness
 Herpes Simplex Virus 2
 If virus is active prior to 20th wkspontaneous abortion will result
 Active virus later in pregnancypremature labor or local infection of eyes,
skin, or mucous membrane
 AIDS
 HIV can be transmitted through placenta or during delivery
 May be stillborn
 Nearly all infants will test HIV+
 Rubella
 German Measles
 Dangerous  fetus  congenital rubella syndrome
(catarracts, deafness, heart defects, cardiac disease, &
Mental retardation)
 Toxoplasmosis
 Parasite (found in cat feces & uncooked meat)
 Possible neonatal effects :
 Stillbirth
 Premature delivery
 Microcephaly
 Hydrocephaly
 Mental retardation
 Thrush
 Yeast infection
 Candida albicans
 Transmitted from mother to baby during delivery if mother has yeast
infection
 Infected neonate is isolated
 Rx with mycostatin
 Cytomegalovirus (CMV)
 Belongs to herpes virus group
 Effects on newborn:
 SGA
 Microgephaly & hydrocephaly
 Mental retardation
 Chemically Dependent Newborn
 Drugs reach fetus through placenta
 Newborn experiences withdrawal symptoms
 Newborn is likely to be preterm or LBW
22
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23
May have intellectual impairment
Fetal Alcohol Syndrome
Effects include :
Growth deficiency
Microcephaly
Facial abnormalities
Cardiac anomalies
Mental retardation
Cocaine & Crack
Dependent newborns experience significant withdrawal syndrome
Lasts 2-3 wks
Marijuana
Crosses the placenta
May cause shortened gestation or precipitate labor
Higher incidence of meconium aspiration
Neonatal Abstinence Syndrome
Generalized disorder
Signs appear w/i 72 hours after birth
Lasts from 8-16 wks or longer
More than 2/3 of babies born to addicted mothers will exhibit signs of NAS
More severe if mother is chronic user
Rx
Paragoric
NAS Commom Signs
Neurological signs
Hypertonia, tremors, hyper-reflexia, irritability and restlessness, high pitched
inconsolable cry, sleep disturbances, and seizures..
Autonomic Nervous Signs
Yawning, nasal stuffiness, sweating, sneezing, low grade fever, skin mottling
GI Abnormalaities
Diarrhea, vomiting, poor feeding, regurgitation, dysmature swallowing, excessive
sucking,
Respiratory Signs
Tachypnea
Miscellaneous
Skin excoriation, behavior irregularities