THE NEWBORN

1
THE NEWBORN
I had heard about the negatives---the fatigue,
the loneliness, loss of self. But nobody
told me about the wonderful parts holding
my baby close to me, seeing his first smile,
watching him grow and become more
responsive day by day.....For the first time I
cared about somebody else more than
myself, and I would do anything to
nurture and protect him.
2
Respiratory Changes

• Extrauterine
• Within a few minutes after birth the vital
  capacity is established
• Surfactant reduces surface tension in alveoli and
  keeps lungs from collapsing

• Intrauterine
• Lungs serve no respiratory function
• Oxygen supply secured through the placenta
• Lungs are filled with lung fluid which keeps them
  partially expanded

3
Respiratory Changes
Mechanical
Initiation of Breathing
Chemical
Sensory
4
Chemical Events

• 1. With cutting of the cord, remove oxygen
  supply
• 2. Asphyxia occurs
• 3. CO2 and O2 and pH
  ACIDOSIS
• 4. Acidotic state-- stimulates
  the
• respiratory center in the
  medulla and
• the chemoreceptors in
  carotid artery to
• initiate breathing

5
Mechanical Events

• As the chest passes
• through the birth canal
• the lungs are compressed

• Subsequent recoil of the chest wall produces
  passive inspiration of air into the lungs

Fluid expelled
Air Enters
6
Mechanical Events

• About 60-110 ml. of fluid is squeezed out of the
  lungs as the chest is compressed
• The remaining fluid evaporates or is reabsorbed
  by the blood vessels and lymphatics surrounding
  the lungs.
• When a baby is delivered in a presentation
  other than vertex, it takes longer for the lungs
  to rid themselves of the fluid

7
Sensory Events

• Thermal--the decrease in
• environmental temperature
  after
• delivery is a major stimulus
  of breathing
  
  
• Tactile--nerve endings in the skin
• are stimulated
• Visual--change from a dark world to
• one of light
• Auditory--sound in the extrauterine
• environment
  stimulates the infant

8
Answer this !
Answer This!

• When a baby is born by cesarean delivery, which
  of the mechanisms to initiate breathing does it
  lack?

9
Cardiovascular Changes
10
Fetal Circulation

• Placenta Umbilical Vein Liver
• Ductus venosus Inferior Vena Cava
• Right Atrium Foramen Ovale
• Left Atrium Left Ventricle Aorta

11
Fetal Circulation
Enters Rt. Atrium Foramen Ovale Lf. Atrium Lf.
Ventricle Aorta To the Body
To the body
LA
RA
LV
RV
12
Fetal Circulation

• or

Right Atrium Right Ventricle
Pulmonary Artery Ductus
Arteriosus Aorta Body
(Small amount goes to the lungs)
13
Fetal Circulation
Aorta

• OR
• Right Atrium
• Right Ventricle
• Pulmonary Artery
• Ductus Arteriosus
• Aorta

Ductus Arteriosus
LA
RA
LV
RV
14
Cardiovascular Changes

• 1. Oxygen enters the lungs, and pulmonary alveoli
  expand
• 2. Oxygen lowers resistence in the pulmonary
  vessels allowing blood to flow more freely to and
  from the lungs
• 3. Pressure in the right atrium decreases because
  of flow of blood to the lungs
• 4. Pressure in the left atrium increases because
  of flow of blood from the lungs
• 5. With oxygenation, the ductus arteriosus begins
  to constrict, becoming functionally closed
• 6. As pressure in the left side fo the heart
  begins to exceed that in the right side, the
  foramen ovale becomes closed.

15
Cardiovascular Changes
3. Ductus Arteriosus begins to constrict
2. Blood flows to the lungs
4. Pressure in the LA increases RT Flow
of blood from the lungs
1. Pressure in RA decreases
5. Increase pressure in the LA forces the foramen
ovale to close
16
True / False

• An infants first breath results in reduced
  pulmonary vascular resistance, decreased left
  atrium pressure, and increased right atrium
  pressure
• Increase CO2 , decreased O2, and increased pH
  help trigger initial breathing

17
Renal / Kidney Changes

• Intrauterine
• Urine if formed in utero and some excreted into
  the amniotic fluid
• Excretion of wastes is the function of the
  placenta

• Extrauterine
• GFR is low --decrease ability to excrete drugs
• Limited ability to reabsorb Sodium
• Decreased ability to concentrate urine
• Bladder capacity is
• 6 - 44 ml
• Void within the first 24 hrs. and should void 6 -
  10 times per day

18
Hepatic and Liver Changes

• The newborns liver plays a role in
• Iron storage--for new RBC production. If the
  mothers iron intake has been adequate, enough
  iron will be stored to last 5 months. After
  about 6 months of age, food containing iron or
  iron supplements must be given
• Carbohydrate metabolism--Glucose is the main
  source of energy in the first 4 - 6 hrs. of life.
  If the fetus experiences hypoxia or stress, the
  glycogen stores are used ( and may be depleted)
  to meet metabolic needs.

19
Hepatic and Liver

• Iron Storage
• Carbohydrate metabolism

20

• Coagulation--coagulation factors are under the
  influence of vit. K. The absence of normal flora
  needed to synthesize vit. K results in low levels
  of vitamin K and creates a transient blood
  coagulation alteration between the second and
  fifth day after birth.
• Vitamin K is given prophylactically to
  combat
  potential clinical bleeding problems

21
Conjugation of Bilirubin

• Unconjugated bilirubin is a breakdown product
  derived from hemoglobin that is released from
  destroyed RBCs.
• Unconjugated bilirubin is not in an excretable
  form and is a potential toxin, so it must be
  conjugated, made water-soluble, in order to be
  excreted from the body.

22
Conjugation of Bilirubin is a conversion of
Fat Soluble
Water Soluble
to
Unconjugated
Conjugated
by the enzyme Glucuronyl transferase in
the newborns liver
23
Physiological Jaundice

• About 50 of all infants exhibit signs in 2 - 3
  days after birth
• Bilirubin levels at birth are about 3 mg./dl
  and should not exceed 12 mg.
• Nursing Care
• Keep well hydrated
• Promote elimination
• early feedings tend to keep bilirubin levels down
  by stimulating intestinal activity thus removing
  the contents and not allowing reabsorption

24
Blood Changes

• By the 6th month the bone marrow has become chief
  site of blood formation
• The infant is born with a large number of RBCs

25
Temperature Regulation

• A newborn is at a DISADVANTAGE in maintaining a
  normal temperature because
• Larger body surface in relation to body mass
• Small amount of insulating subcutaneous fat

26
Minimizing Heat Loss in the Newborn
is IMPERATIVE
27
Four Avenues of Heat Loss

• Conduction --Loss of heat to a cooler surface by
  direct skin contact
• Convection--Loss of heat to cooler air currents
• Radiation--loss of heat to cooler surfaces and
  objects not directly in contact with the skin
• Evaporation-- loss of heat when water is
  converted to a vapor.

28
Heat Production

• 1. Increase in Muscular activity--shown by crying
  and restlessness increases BMR
• 2. Non-Shivering Thermogenesis - unique to
  newborns. Uses the infants stores of brown fat.
• Brown fat is found in the midscapular area,
  around the neck, in the axillas, and around the
  trachea, kidneys, and adrenal glands

29
Non Shivering Thermogenesis

• 1. Skin receptors perceive a drop in
  environmental temperataure
• 2. Transmit impulses to the central nervous
  system
• 3. Which stimulates the sympathetic nervous
  system
• 4. Norepinephrine is released at local nerve
  endings in the brown
• 5. Metabolism of brown fat
• 6. Release of fatty acids
• 7. Release of HEAT!

30
Peripheral Vasoconstriction
Subcutaneous Fat
Heat Maintenance
Curl up in fetal position
31
Gastrointestinal Changes

• By 36-38 weeks of fetal life, the GI system is
  fully mature and ready to digest simple
  carbohydrates, fats, and protein.
• The newborns stomach holds about 50 - 60 cc.
• Pass meconium in 24 - 48 hours after birth. This
  shows the GI tract is patent.

32
Immediate Care of the Newborn

• Ensure a Patent Airway
• Position on side
• Suction mouth then nares
• supply warmed oxygen is necessary
• Always have bulb suction in view !

33
Clamping of the Cord

• Cord should be clamped off about 1 from base of
  cord.
• Inspect the cord for 2 arteries and 1 vein.
• Dont milk the cord

34
Maintain Body Temperature

• Dry off
• Place in warmer
• Skin to skin contact

35
Apgar Score

• Scoring system to appraise the newborn
• Done at 1, 5, and 10 minutes after birth

36
Apgar Score
0 1 2
Heart Rate is the most important !
37
Apgar Score

• Score of 7 - 10 Good Condition
• Score of 4 - 6 Fair Condition
• Score of 0 - 3 Poor Condition

38
Score This !

• Baby girl Doe has a heart rate of 102, with slow,
  irregular respirations. She grimaces when
  stimulated. She has some flexion in her
  extremities and her skin color is pale.
• What is her Apgar Score?

39
Identification of the Newborn

• Mother and infant should have matching
  identibands.
• Bands should be placed on infant prior to leaving
  the delivery room
• Footprint of infant and fingerprint of the mother

40
Eye Care

• Legal requirement that all newborns have
  treatment to prevent Ophthalmia neonatorium which
  can lead to newborn blindness.
• Treated with antibiotic eye medication either
  ointment or drops
• (Tetracycline or Erythromycin )

41
Hemorrhage Prophylaxis

• Administration of Vitamin K (AquaMEPHYTON)
• This promotes liver formation of clotting factors
• The newborn does not have bacteria in the GI
  tract to synthesize vit. K.
• By 5 - 8 days after birth, it is formed.

42
Transfer to the Nursery

• Identification checks
• Full report must be given to the nursery nurse by
  the L D nurse
• Condition of the neonate
• Labor and Birth record
• Antepartal history
• Parent-newborn interaction

43
Nursing Assessments of the
Newborn
44
Physical Assessment

• Temperature - 97.6 - 98.6
• Heart Rate - 120 - 160 BPM. Regular rate. PMI
  
• on the left side
  of the chest
• Respirations- 30 - 60 breaths / min.
  Diaphragmatic with a shallow, irregular rate and
  rhythm. Chest and abdominal movements should
  synchronize. Periodic Breathing is normal. They
  are nose breathers. Tachypnea is abnormal
• Blood Pressure - 80-60 / 45-35.

45
Measurements and Weights

• Length 18 - 22 inches
• Head and Chest Circumference Head is 13
  Chest is 12. Head is larger than the chest by
  one inch or 2 cm.
• Weight - 6 - 9 lbs average. Newborns lose 5 -
  10 of birth weight the first few days after
  birth.

46
Reflexes

• Moro
• Tonic Neck
• Palmar and Plantar grasp
• Babinski
• Feeding--Rooting, Sucking, Swallowing, Gag
• Protective -- Sneezing, Blinking, Gag

47
Senses

• Touch-- most significant in first few weeks
• Vision -- can see objects 8 - 12 inches from
  their eyes. They like faces the most,
  particularily the eyes. Follow objects. Like
  yellow and red.
• Hearing -- they will turn toward the sound of a
  voice. Alert more to a high pitched voice
• Taste -- can discriminate tastes. Sweet /
  non-sweet.
• Smell -- ability to smell increases over first
  few days of life. Smell moms breast milk.

48
Skin

• Pink with acrocyanosis
• Desquamation
• Vernix caseosa
• Lanugo
• Erythema toxicum
• Mongolian spots
• Birth marks

49
Head

• Large. 1/4 size of body
• Fontanels and sutures
• Fontanels should be soft and flat
• bulging increased intracranial pressure
• depressed dehydration
• Molding
• Cephalhematoma- bleeding between bone and
  periosteum that does not cross sutures
• Caput succadenum - edema (fluid) under the skin
  of the scalp that crosses sutures

50
Face

• Rounded
• Fat pads in the cheeks for sucking

51
Eyes

• Slate blue
• Spaced 1/3 across face
• Assess for subconjunctival hemorrhage
• Check pupils
• May have strabismus or nystagmus

52
Ears

• Assess placement
• should align with canthus of eye and where ear
  attaches to the head
• low set ears renal or chromosomal problems
• Assess Appearance
• Pinna of ear should have incurving
• No skin tags
• Note Gestation
• Rapid recoil

53
Nose

• Check patency
• Note drainage

54
Mouth

• Firm Palate
• Tongue
• short frenulum
• Should not protrude
• Extrusion reflex
• No Teeth
• Epstein pearls

55

• Nose -- patency
• Mouth
• Neck
• Chest
• Abdomen
• Genitals -- never retract foreskin on male
• Anus -- patency
• Cry -- loud and lusty

56
Behavorial / Sleep - Awake States

• Deep sleep
• Light Sleep
• Drowsy
• Quiet alert
• Active alert
• Crying

57
Daily Nursing Care

• Need for warmth and dry
• Need for protection from infection
• Need for food
• Need for attachment and loving
• Need for bathing and cord care

58
Nutritional Needs

• The newborns diet must supply nutrients to meet
  the rapid rate of physical growth and development
• Daily caloric intake should be 110 - 120 calories
  / kg. / day

59
Circumcision

• It is not medically necessary. It is a personal
  decision of the parents.
• Nursing Care
• Assess for bleeding and voiding
• Apply vaseline
• Position on side not abdomen