Chapter 13Chapter 13

Preterm and Postterm NewbornsPreterm and Postterm Newborns

The Preterm NewbornThe Preterm Newborn

• Preterm birth is the cause of more deaths during the first year of life than any other single factor

• Higher percentage of birth defects• The less the preterm weighs at birth, the

greater the risks to life during delivery and immediately thereafter

Gestational AgeGestational Age

• Refers to actual time from conception to birth that the fetus remains in the uterus

• Preterm: gestational age less than 38 weeks• Term: gestational age is 38-42 weeks• Postterm: gestational age beyond 42 weeks• Level of maturation: refers to how well

developed infant is @ birth and ability of the organs to function outside the uterus

Causes of Preterm BirthCauses of Preterm Birth

• Multiple births• Maternal illness• Hazards of actual pregnancy (e.g., GH)• Placental abnormalities

– Placenta previa– Premature separation of the placenta from

uterine wall

Possible Physical Characteristics Possible Physical Characteristics of a Preterm Infantof a Preterm Infant

• Skin transparent or loose• Superficial veins visible on abdomen and scalp• Lack of subcutaneous fat• Lanugo covering forehead, shoulders, and arms• Vernix caseosa abundant• Extremities appear short• Soles of feet have few creases• Abdomen protrudes• Nails are short• Genitalia are small• In the female, the labia majora may be open

Respiratory Distress Syndrome (RDS)Respiratory Distress Syndrome (RDS)

• Result of immaturity of the lungs• Deficiency of surfactant – necessary for absorption of

O2 (34wks usually have enough)• s/s: R up to 60/min or more; gruntlike sounds, nasal

flaring, cyanosis, intercostal & sternal retractions• Tx prenatally: Possible to increase production of

surfactant by giving corticosteroid injections 1 or 2 days before delivery

• Preemies can be given surfactant via ET tube @ birth or when RDS occurs, with improvement in 72 hrs.

Nursing Care of Infant with RDSNursing Care of Infant with RDS

• Monitor vital signs• Minimal handling of infant to help conserve

energy• Intravenous fluids are prescribed

– Observe for signs of under- or overhydration• Oxygen therapy

– Monitor pulse oximetry– Infant on supplemental oxygen is at high risk for

oxygen toxicity

Bronchopulmonary Dysplasia Bronchopulmonary Dysplasia (BPD)(BPD)

• Toxic response of lungs to oxygen therapy• Risks

– Atelectasis– Edema– Thickening of membranes, interferes with

ventilation• Often a result of prolonged dependence on

supplemental oxygen and ventilators• Often has long-term complications

Apnea in the Preterm InfantApnea in the Preterm Infant

• Cessation of breathing for 20 seconds or longer• Not uncommon in preterms• Believed related to immaturity of nervous system• May be accompanied by

– Bradycardia (heart rate <100 beats/min)– Cyanosis

• Treat by gentle rubbing of feet, ankles, or back to stimulate breathing (Suction/Ambu)

Sepsis in the Preterm InfantSepsis in the Preterm Infant

• Generalized infection of the bloodstream

• At risk due to immaturity of many body systems

• Liver is immature, poor formation of antibodies

• Body enzymes are inefficient

• Some symptoms include– Low temperature– Lethargy or irritability– Poor feeding– Respiratory distress

Treatment of SepsisTreatment of Sepsis

• Administration of intravenous antimicrobials• Maintenance of warmth and nutrition• Close monitoring of vital signs• Care should be organized to help infant

conserve as much energy as possible• Following Standard Precautions, including

strict hand hygiene, is essential

Poor Control of Body TemperaturePoor Control of Body Temperature

• Lack of brown fat (body’s own “insulation”)• Radiation from a surface area that is large in

proportion to body weight• Heat-regulating center of brain is immature• Sweat glands are not functioning to capacity• Preterm is inactive, has muscles that are weak/less

resistant to cold; unable to shiver• Preterm body position is one of leg extension• High metabolism, prone to low blood glucose levels

Cold StressCold Stress

• Preterm newborn is vulnerable• Symptoms

– decreased skin temp– increased R rate with apnea– Bradycardia– Mottling– lethargy

• Interventions– place infant under radiant warmer or in incubator adjusted

so infant is kept at 97 to 98 degrees.

HypoglycemiaHypoglycemia

• Plasma glucose levels <40 mg/dL in a term infant and <30 mg/dl in preterm infant

• Preterm infants have not remained in utero long enough to build up stores of glycogen and fat– Aggravated by increased need for glycogen in the

brain, heart, and other tissues• Any condition that increases metabolism

increases glucose needs• Energy requirements place more stress on the

already deficient stores

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Signs of HypoglycemiaSigns of Hypoglycemia

• Tremors• Weak cry• Lethargy• Convulsions

HypocalcemiaHypocalcemia

• Calcium transported across placenta in higher quantities in third trimester

• EarlyEarly hypocalcemia occurs when the parathyroid fails to respond to the preterm infant’s low calcium levels

• LateLate hypocalcemia occurs about 1 week in infants who are fed cow’s milk, because it increases serum phosphate levels causing serum calcium levels to fall

Increased Tendency to BleedIncreased Tendency to Bleed

• Blood is deficient in prothrombin• Fragile capillaries of the head are susceptible to

injury during birth, which can lead to intracranial hemorrhage

• Nursing care includes– Monitoring neurological status– Report bulging fontanels, lethargy, poor feeding, seizures– Slight Fowler’s position– Unnecessary stimulation can increase intracerebral

pressure

Retinopathy of PrematurityRetinopathy of Prematurity

• Separation & fibrosis of retina• Thought to be caused by ^ O2 levels of

arterial blood• Leading cause of blindness in preemies• Nursing Interventions

– Careful monitoring of O2 with pulse ox is high priority!

– Sufficient levels of vitamin E

Poor NutritionPoor Nutrition

• Stomach capacity is small• Sphincters at either end of stomach are

immature• Increased risk of regurgitation and vomiting• Sucking and swallowing reflexes are immature• Ability to absorb fat is poor• Increased need for glucose and other nutrients

to promote growth and prevent brain damage are contributing factors

• Parenteral or gavage feedings may be needed until infant’s systems are more mature and can tolerate oral feedings

Necrotizing Enterocolitis (NEC)Necrotizing Enterocolitis (NEC)

• Acute inflammation of the bowel that leads to bowel necrosis

• Factors include– Diminished blood supply to bowel lining

• Leads to hypoxia or sepsis• Causes a decrease in protective mucus

– Results in bacterial invasion– Source of bacterial growth if receiving milk

formula or hypertonic gavage feedings

NEC (cont.)NEC (cont.)

• Signs & Symptoms– Abdominal distention, Bloody stools, Diarrhea, Bilious

vomitus• Nursing Interventions

– Observing vital signs– Measuring abdomen– Auscultating for bowel sounds– Carefully resuming fluids as ordered– Infection control measures– Surgical removal of necrosed bowel

Immature KidneysImmature Kidneys

• Cannot eliminate body wastes effectively• Contributes to electrolyte imbalance• Dehydration occurs easily• Nursing Interventions

– Accurate I & O, weigh diapers– Urine output should be between 1 and 3 mL/kg/hr– Observe for signs of dehydration or overhydration– Document status of fontanels, tissue turgor, weight,

and urinary output

JaundiceJaundice

• Immature liver, contributes to condition called icterus

• Causes skin and whites of eyes to assume a yellow-orange cast

• Liver unable to clear blood of bile pigments which result from the normal postnatal destruction of RBCs

• The higher the serum bilirubin level, the higher the jaundice and the greater the risk for neurological damage

Jaundice Jaundice (cont.)(cont.)

• An increase of >5 mg/dl in 24 hours or a bilirubin level above 12.9 mg/dl requires careful investigation

• Pathological jaundice– If occurs within 24 hours

of birth, may be related to an abnormal condition such as ABO incompatibility

• Breastfed infants can show signs of jaundice about 4 days after birth

• Total serum bilirubin levels typically peak about 3 to 5 days after birth

• Physiological jaundice

Goals of Treating JaundiceGoals of Treating Jaundice

• Prevent kernicterus (causes brain damage) by preventing the rising bilirubin levels from staining the basal nuclei of the brain

• Nursing care goals should be to– Observe skin, sclera, and mucous membranes for

signs of jaundice– Report the progression of jaundice from the face to

the abdomen and feet– Monitor and report any abnormal lab results– Response to phototherapy

Nursing Goals for Nursing Goals for the Preterm Newbornthe Preterm Newborn

• Improve respiration• Maintain body heat• Conserve energy• Prevent infection• Provide proper nutrition and hydration• Give good skin care• Observe infant carefully and record observations• Support and encourage the parents

Prognosis for Preterm InfantPrognosis for Preterm Infant

• Growth rate nears the term infant’s about the second year of life, but very-low-birth weight infants may not catch up, especially if chronic illness, insufficient nutritional intake, or inadequate caregiving has occurred

• Growth and development of the preterm infant are based on– Current age minus the number of weeks before term the

infant was born– This calculation helps prevent unrealistic expectations for the

infant

Family Reaction to a Preterm Family Reaction to a Preterm InfantInfant

• Parents will need guidance throughout the infant’s hospitalization

• May believe they are to blame for infant’s condition

• May be concerned about their ability to care for such a small infant

• Parents are taught how to provide appropriate stimulation without overtiring their infant

Discharge Planning of Discharge Planning of the Preterm Infantthe Preterm Infant

• Begins at birth• Parents will need to demonstrate and

practice routine and/or specialized care• Home nursing visits may be required to

assess home, infant, and family

The Postterm NewbornThe Postterm Newborn

• Born beyond 42 weeks gestation• Placenta does not function well after a certain

point • Can result in fetal distress• Mortality rate of later-term infants is higher

than that of term newborns– Morbidity rates also higher

Problems Associated with Problems Associated with Postterm DeliveryPostterm Delivery

• Asphyxia – Chronic hypoxia while

in uterus bc of deteriorated placenta

• Meconium aspiration• Poor nutritional status

– Hypoglycemia• Increase in red blood

cell production

• Difficult delivery due to increased size of fetus

• Birth defects• Seizures

Physical Characteristics of the Physical Characteristics of the Postterm NewbornPostterm Newborn

• Long and thin– Weight may have been lost– Skin is loose (especially around buttocks and

thighs)• Little lanugo or vernix caseosa

– Skin is dry, cracks and peels– Nails are long and may be stained from

meconium• Thick head of hair and looks alert

Nursing Care of the Postterm Nursing Care of the Postterm NewbornNewborn

• Careful observation for– Respiratory distress– Hypoglycemia– Hyperbilirubinemia – Cold stress

Discharge of the High-Risk Discharge of the High-Risk NewbornNewborn

• Parents must be familiar with infant’s care• The newborn’s behavioral patterns are discussed

and realistic expectations are reviewed• Communication can be maintained with the hospital

through “warm lines”• Social services may be of help in ensuring the home

environment is satisfactory and special needs of the infant can be met

• Support group referrals are given• Newborn CPR techniques are reviewed

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