HIGH RISK NEWBORNS
from intrauterine to extrauterine life are
Risk Factors – young/older maternal age,
DM, HIV, Placenta previa, Drug abuse
Dysmature – new born low gestational age
Assessment – assess congenital anomalies
& gestational age (# of weeks born remain
in utero) done under prewarm radiant
heart warmer to guard against heat loss
Implementation – provide thermoneutral
environment to prevent exhaustion &
hypothermia
-painful procedure kept minimum to
balance & comfort
- assess parents to participate in
bathing/feeding to make child real to them
& effective bonding
Newborn priorities in 1st days of life.
-Initiation & maintenance of respiration,
establish extrauterine circulation, maintain
fluid & electrolyte balance, control body
temp, intake adequate nourishment,
establish waste elimination, prevention of
infection, establish infant parent
relationship, institute development of care
that balance physiologic needs and
stimulation for development
-Indication of newborn different transition
breath & has difficulty maintaining
apparent by low apgar score rate
Initiating & maintaining respiration
-Most death occurs in first 48hrs after
birth due to inability to maintain adequate
respiration
-Infant who has different effective
breathing may experience residual
neurologic morbidities as result of cerebral
hypoxia
-Most are born with respiratory acidosis
-After birth by 2mins, severe acidosis is
underway
-Infants who sustain asphyxia due to cord
compression, maternal anesthesia,
intrauterine growth restriction or
premature separation of placenta which
have difficulty before first 2mins of life
-In ineffective respiration theres failure of
fetal circulatory shunts in ductus arteriosis
because of left side heart pressure is
stringer than right side of pressure
-Struggling to breathe and circulate blood,
use serum glucose to become
hypoglycemic
-Resuscitation, who infants fail to take first
adequate respiratory on their own.
RESUSCITATION – American academy of
pediatrics (AAP) institute neonatal
resuscitation program
Process: establish airway, expand lungs
initiate & maintain effective ventilation
-Chest compression for respiratory
depression: heart rate 60bpm less
AIRWAY – in well term newborn, warming
drying stimulating baby by rubbing the
back is enough to respiration
-in past, rubber bulb syringe is used to
suction nose and mouth of infant but is
associated with bradycardia
- if newborn doesn’t breath, use radiant
heat warmer in sniffing position & rub &
dry the back and hair to see stimulation
initiate respiration
- 3-lead cardias monitor during
resuscitation to obtain accurate heart rate
quickly
If amniotic fluid was meconium stained
with poor muscle tone & inadequate
breathing, begin resuscitation under
warmer, positive pressure ventilation
should be initiated if heart rate is less
100bpm
- Mechanical sunction occur only if theres
obstruction like mucus plug otherwise may
cause bradycardia
- if still no efforts, insertion of
endotracheal ube
-primary apnea: halted respiration of
several weak gasps of air then
immediately stope breathing, heart rate
begins to fade.
- after 1-2 mins apnea pause in
respirations longer tan 20sec with
bradycardia, tries to initiate respiration
with few strong gasps
- most new born cant maintain efforts
longer than 4-5mins
-Secondary apnea: after respiratory effort
it will become weaker again, heart rate
will fall until newborn stops gasping effort
altogether.
-both type of apnea may occur in utero
- resuscitation in primary are successful,
difficulty on secondary apnea
-healthcare provider skilled in
laryngoscope and endotracheal insertion
should be present.
Laryngoscope of size 0 or 1 should be
available for newborns
- endotracheal tybe slid through
laryngoscope down to trachea
- infants under 1000g need 2.5mm ET,
3000g needs 4.0mm ET
- preterm are prone to hemorrhage
because of capillary fragility
Lung expansion
-sound of crying is proof of lung expansion
is good
-air should be administered at 40-60
ventilator per min, warm 32-34degress,
humidified 60-80%
- pressure to open lung alveoli is 40cm
h2O after that 15-20cm h2O is adequate to
continue inflating alveoli
-self inflating (ambu) set with blow off
value by gentle pressure applied
- flunctuation can cause bleeding from
immature cranial vessels
- applying pressure above can rupture lung
alveoli
Assess: monitor oxygen saturation, pulse
oxi, auscultate chest for sounds.
-if air is heard only one side, ET is at or
below bifurcation of trachea (where
trachea slits into half into L-R main stem
bronchi), you should pull tube back half
centimeter to allow oxygen on both lungs
- can be confirm if correct by Co2
MONITOR & Xray
-orogastric tube through mouth to help
deflate stomach & better ventilator of
lungs and decrease possibility of
comminating and aspiration from
overdistention
Drug Therapy
-infant respiratory depression, Morphine
or Meperidine (Demerol)
- mother during labor, Naloxone (Narcan)
- if heart rate still inadequate, epinephrine
1:10,000 (IV)
- preterm infants may receive surfactory
Ventilation Maintenance
-increase respiratory rate, grunting, nasal
flaring are 1st signs of obstruction on
respiratory compromise
- if present, undress baby chest and look
for intercostal retraction (inwards sucking
anterior wall on aspiration)
- place newborn in radiant warmer to
prevent cooling & acidosis, clothing should
be removed for better resporation and
observation
- position infant on the back of the hand of
mattress elevated 15degress for
abdominal contents to fall away from
diaphragm & increase breathing space
- if secretion accumulating appear to
innefective breathing, bagging infant with
mask & positive pressure ventilation bag
for minute before sunctional to improve
exygen level & prevent desaturation
Establishing Extrauterine Circulation
- if no heart beart or less 60bpm, chest
compression
-hold infant with fingers encircling chest &
wrap around back & depress the skin on
one third of its depth (1-2cm) atleast 100
times per min
- lung ventilation at 30 per minute should
be with chest compression at 90
compression per min at ratio of 3
compression to 1:ventilation
-if heart heart greater than 60, but atleast
100bpm, chest compression should stop
but ventilation is continued
- monitor pulse, oxi to evaluate respiratory
function and cardias efficiency, palpate
femoral pulse, IV epinephrine to stimulate
heart action
- in cardiopulmonary resuscitation, infants
should be transferred to
transitional/highest nursery.
Maintaining fluid & electrolyte balance
-Hypoglycemia (decrease blood glucose)
result from newborn expanded to begine
breathing (treatment) IV dextrose 10%
water, dilute mix glucose fluid &
electrolyte sodium, additional glucose &
potassium are added.
- dehydration from water loss by rapid
respiration
- high fluid intake can result to heart
failure/patent ductus arteriosis
- in using radiant water, request more fluid
placed in double walled incubator
- monitor fluid status, less 2ml/kg/hr or
gravity greater than 1.015 to 1.020 is
inadequate fluid intaker
- if hypovalemia is present due to fetal
blood loss from placenta previa, twin to
twin transfusion, develop metabolic
acidosis, may administer isotonic solution
to increase bind pressure & improve cell
perfusion.
Regulating Temperature
- due to stress exposed long period of time
resuscitation
-keep infant in neutral temperature
- lower po2 level cause fetal shunt such
suctus arteriosus to remain open
- to supply glucose to maintain
metabolism, infant result to anaerobic
glycosis which pours acid into bloodstream
with risk for acute bilirubin
encephalopathy or kernicterus
(Accumilation of unconjugated bilirubin
into brain cell)
Prevention: cover newborn with infant
cap, wiping body & head dry with towel or
blanket and using radiant or prewarmed
incubator, suggesting skin to skin (36-
37degress)
Radiant heart source
- abdominal skin utero should be 95-97
(35.5-36.5)
- infant laying on his back, you tape the
probe or disk onto infants abdomen
between umbilicus and xuphoid processor
- tape underside, falsely high reading
-warming pad under infants necessary for
preterm.
Incubator
-Use acrylic shiled inside incubator helps
prevent radiation and heatloss
Procedure: dress infant and set incubator
2F (1.2f) below infant temp. after an hour,
if able to maintain bodytemp, lower
incubator of 2F, if unit temp room temp is
reached, if not infant isn’t ready for room
temp air.
Skin to skin care – kangaroo care (heat +
parent child bond)
Establishing adequate Nutritional intake
-Infants with severe asyphycia, IV Fluids as
received until necrotizing enterocolitis is
ruled out which can result to temporary
reduction of ixygen to bones
- If respiratory is rapid, gavage feeding is
introduced.
- If long term concern, gastrostomy tube is
placed
- Breastmilk is stored in polycarbonate –
(bisphenol A) free plastic bag bottles which
lead to endocrine disruption
-Reveal hunger by rooting, crying, sustains
motions
-In mature infant, pacifier use to defeat
sudden infant death
-Infants who must not swallow air are with
tracheoesophageal fistula surgery
Establishing Waste Elimination – most
immature void within 24hrs, document
proof of hypotension is improving.
Preventing Infection
-In PROM, risk for adverse
neurodevelopmental outcome
-Colostrum, suppliers important immune
protection
-Common virus during intrauterine life:
cytomegalovirus & taxoplasmosis, result
for congenital anomalies
- Most prevalent perinatal infection –
herpes simplex 2, heap B
-early onset of sepsis is caused by group b
Streptococcus, E.Coli, Klebsiella (gram
negative rod cause pneumonia), Listeria
monocytogenes (gram positive associated
with nausea, vomiting, menigitis)
-late onset of infections are spread of
heathcare personnel such as
staphylococcus aureus, enterobacte and
candida
- to prevent infection in hospital, wear
protective face mask
Postterm Infants – Born after 41wks of
pregnancy
-lose ability to carry nutrients effectively to
the fetus & fetyus lose weight (postterm
syndrome)
ASSESS: dry, craded, almost leatherlike
skin & absence of vernix, can be
meconium stain
-demonstrate alertness more like 2week
old baby than newborn
MANAGE: Sonogram to measure biparietal
diameter of fetus
-nonstress test or complete biophysical
profile to see if placenta still functioning
adequately
-at birth, postterm baby likely have
difficulty establishing respirations mostly if
meconium aspiration occurred.
Polycethemia have develop from decrease
oxygenation in final flow.
-Hemotocrit is elevated by polycythemia &
dehydration have lowered the circulating
plasma level
-hypoglycemia may develop in first hours
of life because of stored glycogen
-appropriate intervention is needed to
control possible hypoglycemia or
meconium aspiration.