Transition to Extrauterine
Life
Pulmonary System Transition
• Function of respiration switches from the
placenta to the lungs
• Factors responsible for onset of breathing
– Hypercapnia
– Hypoxia
– Acidosis
– Environment (cold, light, noise)
• Fluid in the lungs must be cleared
• Pulmonary arterioles dilate, PVR level falls
Respiratory Adapations
•
•
•
•
Mechanical changes
Chemical changes
Thermal changes
Sensory changes
Fetal and Neonatal
Circulation
Normal Term Newborn
Cord Blood
Neutral Thermal
Environmental Temperatures
Jaundice
Physiologic Adaptations
to Extrauterine Life
Newborn Urinalysis Values
Cardiac System Transition
• Pressure in right side of the heart falls and
pulmonary venous return to left atrium
increases
– Foramen ovale closes due to these changes
• Ductus arteriosis constricts and closes
functionally by 96 hours
• Ductus venosis constricts and closes
functionally by two to three days
Cardiovascular Adaptations
• Decreased pulmonary vascular resistance and
increased blood flow
• Increased systemic pressure and closure of
ductus venosus
• Increased left atrium and decreased right
atrium pressure
– Closure of foramen ovale
• Reversal of blood flow through ductus
arteriosus and increased PO2
– Closure of ductus arteriosus
Figure 28–4 Transitional circulation: conversion from fetal to neonatal circulation.
Figure 28–6 Fetal-neonatal circulation. A, Pattern of blood flow and oxygenation in fetal circulation. B, Pattern of blood flow and oxygenation
in transitional circulation of the newborn. C, Pattern of blood flow and oxygenation in neonatal circulation.
Figure 28–6 (continued) Fetal-neonatal circulation. A, Pattern of blood flow and oxygenation in fetal circulation. B, Pattern of blood flow and
oxygenation in transitional circulation of the newborn. C, Pattern of blood flow and oxygenation in neonatal circulation.
Figure 28–6 (continued) Fetal-neonatal circulation. A, Pattern of blood flow and oxygenation in fetal circulation. B, Pattern of blood flow and
oxygenation in transitional circulation of the newborn. C, Pattern of blood flow and oxygenation in neonatal circulation.
Fetal Laboratory
Value Changes
•
•
•
•
•
Decreased erythropoietin production
Rise of hemoglobin concentration
Physiologic anemia of infancy
Leukocytosis
Decreased percentage of neutrophils
Thermoregulation
• Body heat lost easily due to large body surface
area in relation to weight
• Limited neonatal fat stores
• Limited capacity for heat production
– Brown-fat metabolism is primary heat source
Thermoregulation (continued)
• Normal axillary temperature is
97°F–99.5°F
– Hypothermia is <97.0
• Goal is to keep infant in a neutral thermal
environment
Thermogenesis in
the Newborn
• Large body surface area compared to mass
• Types of heat loss
– Convection
– Radiation
– Evaporation
– Conduction
Figure 28–9 Methods of heat loss. A, Convection. B, Radiation. C, Evaporation. D, Conduction.
Figure 28–9 (continued) Methods of heat loss. A, Convection. B, Radiation. C, Evaporation. D, Conduction.
Figure 28–9 (continued) Methods of heat loss. A, Convection. B, Radiation. C, Evaporation. D, Conduction.
Figure 28–9 (continued) Methods of heat loss. A, Convection. B, Radiation. C, Evaporation. D, Conduction.
Types of Bilirubin
• Unconjugated bilirubin
• Conjugated bilirubin
• Total bilirubin
Conjugation and
Excretion of Bilirubin
• Bilirubin is transported in blood via albumin
• Bilirubin is transferred into the hepatocytes
• Attachment of unconjugated bilirubin to
glucuronic acid
• Excreted into bile ducts, then into the
common duct and duodenum
• Bacteria transform it into urobilinogen and
stercobilinogen
• Bilirubin is excreted in urine and stool
Physiologic Jaundice
– Accelerated destruction of fetal RBCs
• Increased amounts of bilirubin delivered to
liver
• Inadequate hepatic circulation
– Impaired conjugation of bilirubin
• Defective uptake of bilirubin from the plasma
• Defective conjugation of the bilirubin
Physiologic Jaundice
(continued)
• Increased bilirubin reabsorption
– Defect in bilirubin excretion
– Increased reabsorption of bilirubin from the
intestine
Liver Adaptations
•
•
•
•
•
Iron content stored in liver
Low carbohydrate reserves
Main source of energy is glucose
Liver begins to conjugate bilirubin
Lack of intestinal flora results in low levels of
vitamin K
GI Adaptations
•
•
•
•
•
Sufficient enzymes except for amylase
Digests and absorbs fats less efficiently
Salivary glands are immature
Stomach has capacity of 50-60 mL
Cardiac sphincter is immature
Fluid and Electrolyte
Balance
•
•
•
•
Less able to concentrate urine
Limited tubular reabsorption of water
Limited excretion of solutes
Limited dilutional capabilities
Immunologic Responses
in the Newborn
• IgG – passive acquired immunity via placenta
• IgM – usually not passively transferred
– Elevated levels may indicate fetal antigenic activity
in utero
• IgA – passive acquired immunity via colostrum
Periods of Reactivity
• First period of reactivity
• Sleep phase
• Second period of reactivity
Behavioral and Sensory
Capabilities
•
•
•
•
•
•
Habituation
Orientation
Auditory
Olfactory
Tasting and Sucking
Tactile
Nursing Interventions to
Prevent Hypothermia
• Dry infant, remove wet
blankets
• Apply a hat and warm
blankets
• Avoid placing infant on
cold surfaces
• Avoid placing infants in
drafts
Nursing Interventions to
Prevent Hypothermia (continued)
• Use heat source when bathing infants
• Place under radiant warmer if temperature is
unstable
Metabolic Transition
• Infant’s source of nutrition from
the placenta terminates at birth
• Blood sugar reaches its lowest
point one to three hours after
birth
• Glucose stabilizes by four to six
hours after birth
• Range of 45–80 mg/dl is normal
Gastrointestinal System
• At birth abdomen is flat
and bowel sounds are
absent
• Abdomen becomes
rounded and soft with
onset of respirations
• Bowel sounds usually
audible within 15
minutes of birth
First Period of Reactivity
• First minutes after birth
• Characteristics
– Alert, active, sucking activity,
tachycardia, tachypnea, transient
rales and nasal flaring
• Implications for the family
– Infant alert and responsive
– Allow quiet time for family to be
together
– Introduce breastfeeding
Period of Decreased Activity
• Follows first period of
reactivity
• Characteristics
– Less alert and active,
sleep may occur, vital
signs normalize
Period of Decreased Activity
(continued)
• Implications for the family
– Family may stay together or infant may be taken
to nursery for assessment
– Opportunity for parents to have quiet time
– Mother may use this time to rest
Second Period of Reactivity
• Infant awakens and shows increased
responsiveness to the environment
• Characteristics
– Peristalsis increases and meconium may be
passed, gagging, spitting up
• Implications for the family
– Allow time together if mother is rested
– Parents may begin to have questions or need
assistance with newborn care
Asphyxia
• Arises from inadequate or absent respiration
– Impairment of oxygen/carbon dioxide exchange
– Hypoxemia, hypercarbia, respiratory acidosis
• Assessment findings
– Poor tone, gasping or absent respirations,
bradycardia, cyanosis, low Apgar score
Asphyxia (continued)
• Management
– Tactile stimulation
– Positive pressure ventilation with 100% oxygen
Meconium Staining
• Caused by distress, usually asphyxia
• Risk is that fetus/infant may aspirate
– Obstruction, chemical pneumonia may result
• Assessment findings
– Respiratory distress, hypoxemia
• Prevention
– Suctioning nose/mouth before delivery of the
chest
– Appropriate suctioning post delivery
Transient Tachypnea
of the Newborn
• Characteristics
– Grunting, retracting, tachypnea
• Risk factors
– Cesarean delivery, precipitous delivery
• Management
– Oxygen therapy
– IV fluids
– Short-term ventilation
– Antibiotics if sepsis is suspected
Hypoglycemia
• Plasma glucose level below 40 mg/dl
• Assessment findings
– Jitteriness, tremors, apnea, cyanosis, lethargy
• Risk factors
– SGA, preterm, perinatal stress, IDM, sepsis
Hypoglycemia (continued)
• Management
– Early feeding of infants at risk
– Keep infant warm
– Glucose by nipple, gavage, or IV
– Recheck blood glucose 30 minutes after feeding
Transition of the Premature Infant
• Pulmonary system
– Inadequate alveolar development, lack of
surfactant
• May require ventilatory support
• Administration of surfactant
• Cardiac system
– Persistent ductus arteriosis (PDA)
• Indomethacin given to facilitate closure
Resuscitation and Stabilization
in the Delivery Room
• Dry and provide warmth, tactile stimulation
• Clear airway
• Resuscitation for compromised infants
– Place under radiant warmer, stimulate
– Position to ensure a patent airway
– Suction using appropriate technique
– Evaluate respirations, heart rate, color
Resuscitation and Stabilization
in the Delivery Room (continued)
• Resuscitation for compromised infants
(continued)
– Administer oxygen if indicated
– Bag-mask ventilation if apneic
– Medications may be indicated if infant does not
respond
Nursing Care of
the Normal Newborn
Chapter 30
The Normal Newborn:
Needs
and Care
Assessment Data:
Condition of the Infant
•
•
•
•
•
•
Apgar scores at 1 and 5 minutes
Resuscitative measures
Physical examination
Vital signs
Voidings
Passing of meconium
Signs of Newborn Transition
Neonatal Distress
Newborn Care
Newborn Care
When to Call for Help
Assessment Data:
Infant Complications
• Excessive mucus
• Delayed spontaneous respirations or
responsiveness
• Abnormal number of cord vessels
• Obvious physical abnormalities
Assessment Data:
Labor and Birth
• Duration and course
• Status of mother and fetus
• Analgesia or anesthesia
Assessment Data:
Labor and Birth Complications
•
•
•
•
•
Prolonged rupture of membranes
Meconium-stained amniotic fluid
Nuchal cord
Precipitous birth
Use of forceps or vacuum extraction assisted
device
• Fetal distress
Assessment Data: Maternal Complications
•
•
•
•
•
•
Preeclampsia
Spotting
Illness
Recent infections
Rubella status
Serology results
Assessment Data: Maternal Complications
(continued)
•
•
•
•
Hepatitis B screen results
Exposure to group B streptococci
History of maternal substance
Human immunodeficiency virus (HIV) test
result
Assessment Data: Family
•
•
•
•
•
Parents’ interactions with their newborn
Their desires regarding infant care
Information about other children in the home
Available support systems
Patterns of interaction within each family unit
Physiologic Alterations
•
•
•
•
Respiratory distress
Pallor
Hypothermia
Alterations in feeding and elimination
Nursing Care: Assessment
•
•
•
•
•
•
Airway clearance
Vital signs
Body temperature
Neurologic status
Ability to feed
Evidence of complications
Figure 30–2 Temperature monitoring for the newborn. A skin thermal sensor is placed on the newborn’s abdomen, upper thigh, or arm and
secured with porous tape or a foil-covered foam pad. SOURCE: Photographer, Elena Dorfman
Nursing Care: Assessment
(continued)
•
•
•
•
•
•
Review of prenatal and birth information
Gestational age
Newborn’s adaptation to extrauterine life
Weight and measurement
Vital signs every 30 minutes
Assessment of Hct or blood glucose if
warranted
Figure 30–1 Weighing a newborn. The scale is balanced before each weighing, with the protective pad in place.
Admission Procedures
•
•
•
•
•
•
Newborn bath
Vitamin K
Eye prophylaxis
Observation for distress
Initiate feeding
Facilitate parental-infant attachment
Figure 30–3 Procedure for vitamin K injection. Cleanse area thoroughly with alcohol swab, and allow skin to dry. Bunch the tissue of the upper
thigh (vastus lateralis muscle) and quickly insert a 25-gauge 5/8-inch needle at a 90-degree angle to the thigh. Aspirate, then slowly inject the
solution to distribute the medication evenly and minimize the baby’s discomfort. Remove the needle and massage the site with an alcohol
swab. SOURCE: Photographer, Elena Dorfman
Figure 30–5 Ophthalmic ointment. Retract lower eyelid outward to instill a 1/4-inch strand of ointment from a single-dose ampule along the
lower conjunctival surface.
Eye prophylaxis
Vitamin K administration
First bath
Daily Assessments
•
•
•
•
•
•
Vital signs
Weight
Overall color
Intake and output
Umbilical cord
Circumcision
Daily Assessments
(continued)
• Newborn feeding
• Attachment
Daily Newborn Care
•
•
•
•
•
•
Assist with feedings
Thermoregulation
Skin care
Cord care
Prevention of infection
Security
Figure 30–6 The umbilical cord base is carefully cleaned.
Common Concerns
•
•
•
•
•
How to pick up a newborn
Holding and feeding the infant
Changing the diaper
Interpreting newborn cues
Bathing the newborn
Figure 30–11 A father demonstrates competence and confidence in diapering his newborn daughter.
Common Concerns
(continued)
• Cord and circumcision care
• Normal voiding and stooling pattern
Parent Education
• Periods of reactivity and expected newborn
responses
• Normal physical characteristics of the newborn
• The bonding process
• The infant’s capabilities for interaction
• The role of touch in facilitating parent-infant
interaction
• Comforting techniques
Parent Education
(continued)
• Progression of infant behaviors
• Information about available educational
materials and support
Family Education
•
•
•
•
•
Newborn care videos
Newborn care classes
Individual instruction
Observation of parent-infant interaction
Role modeling
Discharge Education
•
•
•
•
•
•
Safety measures
Voiding and stool characteristics
Circumcision care
Cord care
Waking and quieting the newborn
Car safety
Figure 30–9 Following circumcision, petroleum ointment may be applied to the site for the next few diaper changes.
Figure 30–13 Steps in wrapping a baby.
v
Figure 30–14 Infant car restraint for use from birth to about 12 months of age.
Discharge Education
(continued)
• Immunizations
• Signs of illness
Signs of Illness
• Temperature above 38oC or below 36.6oC
axillary
• Continual rise in temperature
• Forceful or frequent vomiting
• Refusal of two feedings in a row
• Difficulty in awakening baby
• Cyanosis with or without a feeding
Assessment After Transition
• Temperature
– Normal axillary temperature 97°F–99.5°F
• Cardiovascular system
– Normal heart rate 120–150 bpm
– Observe color, pulse, murmurs
Assessment After Transition (continued)
• Respiratory system
– Normal rate is 30–60/minute
– Nose-breather
– Observe for flaring, grunting, retracting
– Auscultate for rales
General Nursing Care
• Eye prophylaxis
– Prevents gonorrhea and chlamydia
– Erythromycin or tetracycline ointment
• Vitamin K prophylaxis (0.5–1.0 mg)
– IM into lateral thigh
– Prevents bleeding due to Vitamin K deficiency
• First bath
– Institute measures to prevent hypothermia
General Assessment
• Position
– Flexion of upper and lower
extremities
– Symmetrical movement
• Color
– Acrocyanosis
– Jaundice
• Body size
• Reactivity
• Identification
Physical Examination
• Weight
2,500–4,300 g
• Length
45–54 cm
• Head circumference
33–38 cm
• Vital signs
Gestational Age Assessment
• Neuromuscular
maturity
–
–
–
–
–
–
Posture
Square window
Arm recoil
Popliteal angle
Scarf sign
Heel-to-ear
• Physical maturity
–
–
–
–
–
–
Skin
Lanugo
Plantar surface
Breasts
Eye and ear
Genitalia
Skin Assessment
• Normal findings: color pink
• Common variations
–
–
–
–
Milia
Erythema toxicum
Mongolian spots
Birthmarks
Mongolian spot
• Common problems
–
–
–
–
Petechiae
Blisters, lesions
Plethara
Abnormal hair distribution
Birthmark
Head, Eyes, Nose, and Throat
Assessment
• Normal findings
– Symmetry in appearance, normal placement
– Anterior fontanel open
• Common variations
–
–
–
–
Molding
Caput succedaneum
Cephalhematoma
Teeth
Head, Eyes, Nose, and Throat
Assessment (continued)
Caput succedaneum
Cephalhematoma
Head, Eyes, Nose, and Throat
Assessment (continued)
• Common problems
– Low-set ears
– Discolored sclera (yellow, bluish)
– Cleft lip, palate
– Absent red reflex
– Microcephaly, hydrocephaly
– Craniostenosis
– Features characteristic of FAS
Respiratory System Assessment
• Normal findings
– Symmetrical expansion
• Common variations
– Accessory nipples
– Gynecomastia
• Common problems
– Retractions
– Tachypnea
– Rales
Clearing the infant’s mouth
with a bulb syringe
Cardiovascular Assessment
• Normal findings
– Color pink
– Normal rate and rhythm
• Common variations
– Murmurs
– Acrocyanosis
Cardiovascular Assessment (continued)
• Common problems
– Persistent murmurs
– Cyanosis
– Tachycardia, bradycardia
Abdominal Assessment
• Normal findings
– Round, full, symmetrical, plus bowel sounds
– Two arteries, one vein in cord
• Common variations
– Hernia
Abdominal Assessment (continued)
• Common problems
– Two-vessel cord
– Distension, absent bowel sounds
– Discharge/leakage from the cord
– Abdominal mass
Genital and Anal Assessment
• Normal findings
– Patent anus
– Testes descended
– Stool and urine by 24 hours after birth
• Common variations
– Hydrocele
– Hymenal tag and vaginal discharge
Genital and Anal Assessment
(continued)
• Common problems
– Undescended testes
– Epispadius, hypospadius
– Imperforate anus
Circumcision
• Risks
– Bleeding, infection, adhesions, pain
• Benefits
– Decreased incidence of UTIs
– Prevention against penile cancer
• Nursing care after circumcision
– Observe for bleeding
– Observe for voiding difficulties
Musculoskeletal Assessment
• Normal findings
– Normal tone, flexion,
symmetrical movement
• Common variations
– Hip click
– Club foot
Musculoskeletal Assessment
(continued)
• Common problems
– Fracture (clavicle most common)
– Hip dysplasia
– Syndactyly/polydactyly
– Asymmetrical movement
– Simian crease
Neurologic System
• Normal findings
• Common problems
– Normal reflexes (suck, rooting, grasp, Moro,
Gallant, gag, Babinski’s)
– Brachial plexus injury (Erb’s palsy)
– Spina bifida
– Anencephaly
– Absent or abnormal reflexes
– Seizure activity
Periodic Shift Assessment
•
•
•
•
•
Vital signs
Weight
Feeding and elimination
Hydration status
Respiratory and cardiac
function
• Hip movements
Factors Placing the Infant at Risk
• Physical
– Birth injuries, congenital
conditions, temperature control
• Psychological
– Interferences in interaction
between parents, newborn
• Family
• Environment
• Illness and infection
Nutritional Comparison:
Breast Milk
• 90% water
• Same weight gain or greater during first 3-4
months
• Fat is variable
• Primary carbohydrate is lactose, trace
amounts of other carbohydrates
Milk Comparisons
Milk Comparisons
Breastfeeding and
Formula-feeding
Breastfeeding and
Formula-feeding
Successful Breastfeeding
Evaluation
Pumping Instructions
Types of Pumps
Storage Guidelines
Water Sources
Baby-friendly Requirements
Nutritional Comparison:
Formula
• 90% water
• Greater weight gain after 3-4 months
• Lactose is only carbohydrate
Components of Breast Milk
• Whey/Casein ratio changes according to infant
needs
• Whey components include alpha-lactalbumin,
serum albumin, lactoferrin, immunoglobulins,
and lysozyme
• Low in vitamin D, adequate vitamin C & B
complex
• Mineral content similar
• Iron absorption: 50-60%
Components of Formula
• Whey/Casein ratio is 60:40
• Whey components are beta-lactoglobulin and
alpha-lactalbumin
• Adequate amounts of vitamins
• Mineral content similar
Advantages of
Breastfeeding
• Species specific
• Cholesterol in breast milk plays a role in
myelination and neurologic development
• More efficient metabolism of cholesterol
• Composition varies according to gestational
age
• Iron is more readily absorbed
Infant Benefits
• Reduced risk of
– Type I or type II diabetes mellitus
– Lymphoma, leukemia, & Hodgkin’s disease
– Obesity
– Hypercholesterolemia
– Asthma
Infant Benefits:
Immunologic
• Protection from
– Respiratory tract and gastrointestinal tract
infections
– Necrotizing enterocolitis
– Urinary tract infections
– Otitis media
– Bacterial meningitis
Infant Benefits:
Immunologic (continued)
• Protection from
– Bacteremia
– Allergies
Maternal Physical Benefits
•
•
•
•
Decreased postpartum bleeding
More rapid uterine involution
Burns additional calories
Decreased risk of developing
– Breast and ovarian cancer
– Postmenopausal osteoporosis
Maternal Psychosocial
Benefits
•
•
•
•
•
Improved maternal-infant attachment
Skin-to-skin contact
Tactile communication
Learn behavioral cues and needs
Prolactin increases feelings of relaxation and
euphoria
• Oxytocin heightens responsiveness and
receptivity toward infant
Disadvantages to
Breastfeeding
•
•
•
•
Pain due to nipple tenderness
Leaking milk when breasts are full
Embarrassment about breastfeeding
Feeling tied down to the demands of
breastfeeding
• Unequal feeding responsibilities/fathers left
out
• Perceptions about diet restrictions
Disadvantages to
Breastfeeding (continued)
• Limited birth control options
• Vaginal dryness
• Concerns about the safety of medications and
breastfeeding
Feeding Interventions:
Birthing Room
•
•
•
•
Assess for signs of readiness to feed
Place newborn on mother’s chest
Breastfeeding may begin in birthing room
Assess infant physiologic status during feeding
Feeding Interventions
•
•
•
•
Monitor progress
Education
Anticipatory guidance
Evaluate the need for follow-up after
discharge
Infant Feeding Education
•
•
•
•
•
“On Demand” feeding pattern
Infant feeding cues
Normal feeding/sleeping patterns
Satiety behaviors
Growth patterns
Breastfeeding Education
•
•
•
•
Positioning
Latching
Breast milk pumping and storage
Supplementation
Formula Feeding Education
•
•
•
•
•
Intake and output expectations
Preparation and storage of formula
Feeding technique
Equipment
Safety precautions
Growth Rates
• Both breastfed and formula-fed infants
experience growth spurts requiring increased
feedings
• Breastfeeding mother should nurse more
frequently
• Formula feeding mother should slightly
increase amount of feeding
Influence of Culture
on Infant Feeding
• Perception of breasts as sexual organ
• Perceptions of colostrum
• Language