Preterm and Postterm Newborns By Angela Dean

CHAPTER 13

The Preterm Newborn The preterm (also know are as premature)

newborn is the most common admission to the intensive care nursery. With increased specialization and sophisticated monitoring techniques, many infants who in the past would have died are now surviving.

The preterm newborn continued Any newborn whose quality of life or quality

of existence is threatened is considered to be in a high-risk category and require close supervision by professionals in a special neonatal intensive care unit (NICU). Preterm birth is responsible for more deaths during the first year than any other single factor. Preterm infants also have a higher percentage of birth defects.

The preterm newborn continued Prematurity and low birth weight are

concomitant, and both factors are associated with increased neonatal morbidity and mortality. In the past newborns have been classified solely by birth weight. The emphasis is now on gestational age and level of maturity because current data suggest that intrauterine growth rates are not the same for all infants and that individual factors must be considered.

The preterm newborn continued Gestational age refers to the actual time, from conception

to birth, the fetus remains in the uterus. Infants are considered preterm if born before 38 weeks gestation. Term infants are born between 38 and 42 weeks. Postterm infants are born after 42 weeks. Late preterm infants are born between 34 to 36 weeks and are considered high-risk regardless of birth weight. One standardized method of used to estimated gestational age is the Ballard scoring system, which is based on the infant s external characteristics and neurological development.

The preterm newborn continued Level of maturation refers to how well developed

the infant is at birth and the ability of the organs to function outside the uterus. An infant who is born at 34 weeks, weighs 1588 g (3.5 lb) at birth, has not been damaged by multifactorial birth defects, and has had a good placenta may be healthier than a full term , small-for-date infant whose placenta was insufficient for any of a number of reasons. Such an infant is also probably in better condition than the heavy but immature infant of a diabetic mother.

Causes Multiple births Illness of the mother The hazards of pregnancy itself, such as

gestational hypertension Premature rupture of membranes Placental previa Premature separation of the placenta Studies have also indicate a relationships between poverty, smoking, alcohol consumption, abuse of cocaine, and other drugs

Physical Characteristics The skin is transparent and loose Superficial veins may be seen beneath the abdomen and

scalp Lack of subcutaneous fat Fine hair (lanugo) covers the forehead, shoulders, and arms Vernix caseosa is abundant Extremities appear short Soles of the feet have few creases Abdomen protrudes Nails are short The genitalia are small, in girls the labia majora may be open

Related problems

Inadequate respiratory function Poor control of body temperature Hypoglycemia and hypocalcemia Increased tendency to bleed Retinopathy of prematurity Poor nutrition Necrotizing enterocolitis Immature kidneys Jaundice

Special needsNursing goals of the preterm infant Improve respiration Maintain body heat Conserve energy Prevent infections Provide proper nutrition and hydration Give good skin care Observe the infant carefully and record observations Support and encourage the parents

Prognosis In the absence of severe birth defects and

complications, the growth rate of the preterm newborn nears that of the term infant by about the second year. In general, growth and development of the preterm infant are based on current age minus the number of weeks before term the infant was born; for example, if born at 36 weeks of gestation, a month old would be at a newborn s achievement level. This calculation ensures that no one has unrealistic expectations for the infant.

Family Reaction The nurse should assist the parents to cope with

their responses to having a small, preterm infant. The parents can be taught to provide stimulation by using a black-and-white mobile, stroking gently, talking to the infant, rocking, or providing range of motion activities or kangaroo care. The nurse encourages the family to keep in touch by telephone and by visits. Since the mother is usually discharged home without the infant the nurse should do all she can to help the family form an attachment to the infant.

The Postterm Infant Postmaturity refers to the infant showing

characteristics of the postmature syndrome. The cause of postmaturity is unknown; however it is known that the placenta does not function adequately as it ages, which could result in fetal distress. The late birth is a psychological strain on the mother, father, and other family members , who are eagerly awaiting the arrival of the child.

The following problems are associated with postmaturity Asphyxia caused by chronic hypoxia while in the uterus

because of a deteriorated placenta. Meconium aspiration: hypoxia and distress may cause relaxation of the anal sphinter, and meconiumcan be aspirated into the fetal lungs. Poor nutritional status; depleted glycogen reserves cause hypoglycemia Increase in red blood cell production because of intrauterine hypoxia Difficult delivery because of increased size of the infant Birth defects Seizures as a result of the hypoxic state

Physical Characteristics The postterm infant is long and thin and look as though

weight has been lost. Skin is loose ,especially about the thighs and buttocks. There is little lanugo or vernix caseosa. Skin is dry, cracked, peeling, and is almost like parchment in texture. Nails are long and stained with meconium. The infant has a thick head of hair and appears alert. Nursing care involves observing for respiratory distress, hypoglycemia, and hyperbilirubinemia. The infant may be placed in an incubator, because fat stores have been used in utero for nourishment and the infant is vulnerable to cold stress.

Transporting the high-risk newborn Transportation of the high-risk newborn to a

regional neonatal center requires the organization and expertise of a special team. Stabilization of the infant before discharge is important. The nurse is responsible for placing an identification band on the infant before transport and for verifying the identification name and number with the mother s identification band. Once the infant has safely reached its destination, the parents are contacted by telephone.

Discharge of the High-Risk newborn Discharge planning begins at birth. Visit by the nurse to assess home care and

provide additional support are valuable. Continued medical supervise is important. The nurse must familiarize the parent with the newborn s care. The newborn s behavioral patterns are discussed, and realistic expectations concerning the preterm infant s catch-up development are reviewed.