NEWBORN TRANSITION ASSESSMENT

Mary L. Dunlap MSN, APRNFall 10

Newborn Care Period

• Physical Adaptations• Newborn Assessment• Nutrition• Discharge Assessment

Neonatal Physiologic AdaptationsRespiratory

• Breathing noted as early as 11 weeks gestation

• Fetal lung fluid necessary for development and decreases with gestational age

• Functioning lungs occurs after 26 weeks gestation

• Surfactant found in sufficient quantity around 35 weeks gestation

Respiratory Adaptations

• Chemical Stimulation

• Mechanical Stimulation

• Sensory Stimulation

• Pulmonary Blood Flow

Chemical Stimulation

• Catecholamine surge prior to labor corresponds to rapid drop in level of fluid in lung field

• Catecholamines increase the release of surfactant

Chemical Stimulation

• Decrease O2 & Increase CO2 concentration along with decrease pH stimulates aortic & carotid chemoreceptors triggering the medulla to initiation of respirations

Respiratory Adaptations

• Surfactant promotes lung expansion by preventing the complete collapsing of the alveoli with each expiration.

• Increases the lungs ability to fill with air

Mechanical Stimulation

• Compression of the chest during vaginal birth forces 1/3 of the fluid out of the lung fields

• Once the chest is delivered the re-expansion draws air into the lungs

• Crying creates positive intrathoracic pressure keeping alveoli open

Sensory Stimulation

• Tactile

• Visual

• Auditory

Pulmonary Blood Flow

• Pulmonary vasodilatation occurs as O2 enters the lungs

• The decrease in PVR allows for adequate gas exchange and transition

Respiratory Adaptations

• Established within 1 minute of birth

• Respirations should be quiet

• Diaphragmatic and abdominal muscles used

• Nose breathers

• 30-60/minute

Respiratory Adaptations

• Acrocyanosis and circumoral cyanosis 1-2hrs

• Respiratory distress nasal flaring, grunting, costal retractions and a rate less than 30 & greater than 60

Cardiovascular Adaptations

• Fetal to neonatal circulation occurs simultaneously with the respiratory adaptation

• Cessation of blood through the umbilical vessels and placenta causes the change from fetal to neonatal circulation

Cardiovascular Adaptation

• Closure of the ductus venosus, foramen ovale and the ductus arteriousus

• Shift to pulmonary circulation

Fetal to Neonatal Circulation

• Clamping the umbilical cord increases the SVR

• Closure of the ductus venosus allows blood flow through the portal/hepatic system

• Increase pressure in the left atrium from the pulmonary venous return closes the foramen ovale

• Rising O2 concentration in the blood and decreased prostaglandin levels closes the ductus arteriousus

Neonatal Circulation

• Apical pulse counted for a full minute

• PMI is at the 4th intercostal space to the left of the midclavicular line

• Heart rate at birth 120-160

• Tachycardia greater than 160

• Bradycardia less than 100

Neonatal Circulation

• Capillary refill less than 3 sec.

• Femoral/Bracial pulses palpated for symmetry, strength and rate will provide information about the change to adult circulation pattern

• Average systolic 60-80, diastolic 40-50

Neonatal Circulation

• Average blood Volume 300ml

• Late clamping of the cord can lead to polycythemia

• Hemoglobin 14-24g/dl

• Hematocrit 44%-64%

Neonatal Circulation

• RBC 4.8-7.1/mm

• WBC 9,000-30,00 per mm

• Platelets 200,000-300,00

• Factors II, VII, IX, and X are low due to the lack of Vit. K

Thermogenic Adaptation

• Balance between heat loss and production

• Newborns ability to maintain it’s temperature is controlled by external environmental factors and internal physiologic process

Thermogenic Adaptation Environmental

• Evaporation: Heat loss as water evaporates from the skin

• Convection: transfer of body heat to surrounding air ( cold del. Room)

Thermogenic Adaptation Environmental

• Conduction: transfer of heat to surface the newborn is lying on

• Radiation: loss of heat through the air to a cooler surface ( not in direct contact with the neonate)

Thermogenic AdaptationInternal

• Newborns have limited ability to shiver to generate heat

• Heat is produced by the metabolism of brown fat

• Voluntary muscle activity: flexion of extremities, restlessness, and crying

Thermogenic AdaptationEffects of cold stress

• Increase O2 consumption can lead to metabolic acidosis

• Increase glucose utilizes leads to hypoglycemia

• Production of surfactant is decreased and respiratory distress can occur

Signs of Cold Stress/Hypothermia

• Skin cool to touch

• Mottling of the skin

• Central cyanosis

• Decreased responsiveness

• Jittery

• Tachypnea

Renal System

• 40 ml of urine at birth• 2-6 voids/day for the first 2 days• 5-25 voids/day after 48 hours• 15-60 ml. of urine per/kg/day• Urine odorless straw color • Uric crystals cause pink staining in

diapers• One year to fully mature

Gastrointestinal System

• Audible bowel sounds within 1 hour • Stomach capacity 30-90 ml.• Uncoordinated peristaltic activity in the

esophagus for a few days • Immature cardiac sphincter • Enzymes able to digest CHO, protein & fats• 1 st meconium passed 12-24 hrs• Transitional stool passed for 1-2 days

Hepatic Adaptation

• In utero iron is stored for use in hemoglobin production after birth. If adequate will last till 5 th month without needing supplement.

• Glucose is stored as glycogen for neonatal metabolic demands

• Due to the rapid depletion of glycogen during the first 24 hours the glucose level will be between 50 to 60 mg/ml

• Feedings will help stabilize the glucose levels, which after day 3 will be between 60-70 mg/ml

Immune System Adaptation

• Neonate depends on three immunoglobins: IgA, IgG, and IgM

• IgG crosses the placenta and is found in the fetus by the 3rd trimester. It protects the newborn against bacterial and viral infections the mother has developed antibodies for ( tetanus, measles, mumps)

Immune System Adaptation

• IgM is found in the blood and lymph and is the first immunoglobulin to respond to infection. Production starts at birth. If elevated at birth may indicate exposure to intrauterine infection

• IgA is found in colostrum and can contribute to passive immunity. It limits bacterial growth in the GI tract and is produced gradually.

Normal Newborn Assessment

• Evaluate the newborns’ adjustment to Extrauterine.

• Assess for possible birth trauma

• The assessment should progress from head to toe.

Initial Assessment

• Apgar score determined

• Assess for gross abnormalities

• Apply cord clamp

• Obtain foot prints

• Apply identification bands

• Administer Vit. K & eye prophylaxis

• Promote bonding

Transition to Extrauterine Life First period of Reactivity

• Birth to 30 minutes

• Heart rate160 to 180 beats/min

• Returns to 110-160 after 30 min

• Resp. rate 60-80/crackles may be present

• Reactive to stimuli

• After this period newborn could sleep up to 60-100 min.

Transition Second Period

• 4-8 hours after birth

• 10 min to several duration

• Brief periods of Tachycardia and Tachypnea

• Increase muscle tone and color changes

• Meconium may be passed

Newborn Assessment

• Length-19 to 21 inches• Weight- average 7lb 8oz (10th to 90th %) SGA less than 5lb 8 oz (Less than the 10th %) LGA greater than 9 lb ( greater than the 90th %)• Newborns can loose up to 10% of birth weight• Head circumference- 33-38 cm• Chest circumference-31-36 cm

Newborn Assessment

• Temperature

–Normal axillary temperature 97°F–99.5°F

• Cardiovascular system

–Normal heart rate 110–160 bpm

–Observe color, pulse, murmurs

Newborn Assessment

• Respiratory system

–Normal rate is 30–60/minute

–Nose-breather

–Observe for flaring, grunting, retracting

–Auscultate for rales

Head• Measure circumference• Anterior fontanel diamond shaped closes in 18

months• Posterior fontanel triangle shaped closes in 8-

12 weeks• Fontanels need to be open and soft• Depressed fontanel indicates dehydration• Bulging fontanel may indicate increased

intracranial pressure

Head

• Molding result of fetal position in utero and pressure from passage through birth canal ( resolves in 24-48hrs)

• Cephalhematoma result from trauma (resolves in few weeks)

• Caput succedaneum pressure from delivery ( resolves in 1-2 weeks)

Head

• Inspect face for symmetry of eyes, nose, lips, mouth and ears

• Eyes usually blue or gray, permanent color established in 3-12 months

• Red reflex present cornea intact• Can see up to 2 ½ feet clearest vision is 8 to

12 inched• Subconjunctive hemorrhages may be

present due to the pressure from delivery

Head

• Nose midline with patent nares

• Ears aligned with outer canthus of eyes; pinna well formed, open auditory canal ( low set ears associated with chromosomal abnormalities)

• Mouth mucosa pink and moist; tongue mobile, strong suck, hard/soft palate intact( Epstein’s pearls may be noted on the gums or hard palate)

Neck

• Shape typically short with deep folds of skin

• Webbing associated with Down Syndrome

• Assess for full range of motion

• Palpate for abnormal masses

• Note the position of the trachea

Chest

• Shape should be cylindrical (bell shaped could be a sign of underdeveloped lungs)

• Palpate clavicle bones and ribs• Assess nipples for size, placement and number • Evaluate respiratory effort and movement• Auscultate the lung fields and heart sounds• Unequal breath sounds could be a pneumothorax

Abdomen• Umbilical cord, 2 arteries 1 vein

• Cylindrical with some protrusion

• Flat abdomen indicates diaphragmatic hernia

• Auscultate for bowel sounds

• Suprapubic area palpated for bladder distention

• Femoral pulses palpated, if unable to locate could signify coarctation of the aorta

Female Genital and Anal Assessment

• Term newborn labia majora covers labia minora and clitoris

• Mucoid vaginal discharge due to maternal hormones

• Hymental tag may be present

• Annus patent

Male Genital and Anal Assessment

• Rugae present on the scrotum• Scrotal edema may be present due to

maternal hormones• Testes descended • Check for placement of the meatus• Dorsal surface- epispadias• Ventral surface-hypospadias• Anus should be patent

Extremities

• Assess for full range of motion, symmetry and signs of trauma

• Spontaneous motion of all extremities should be present

• Assess muscle tone

• Hyperflexibility of joints associated with Down Syndrome

• Hips assessed for dislocation

Extremities• Nail beds pink- persistent cyanosis associated

with hypoxia

• Palms should have normal creases

• Simian crease (transverse palmer) suggests Down syndrome

• Count digits on extremities (more than five digits polydactyl-Digits fused together syndactyl

Spine

• Straight

• Flat

• Shoulders, scapulae and iliac crests line up in same plane

• Evaluate for dimpling or fissures

• Dimpling associated with spina bifida

Skin

• Assess color

• Check for birth marks, trauma, rashes or bruises

• Presence of lanugo

• Palpate texture ( ranges from smooth to peeling)

• Turgor ( elasticity)

Skin Assessment• Common variations

– Milia– Mongolian spots– Birthmarks

• Common problems– Petechiae– Blisters, lesions– Abnormal hair distribution– Port wine stains

Neurological System

• Infant alert, responsive, strong lusty cry in a flexed position

• Reflexes provides information on the system and maturity

• Reflexive behaviors are necessary for survival and safety

• Absence, weakness or asymmetry indicates abnormalities

Neurological Reflexes

• Sucking

• Rooting

• Grasping

• Extrusion

• Tonic neck

• Moro

• Stepping

• Crawling

• Babinski

• Truncal incurvation

• Blinking

Neurologic System

• Common problems

– Brachial plexus injury (Erb’s palsy)

– Spina bifida

– Anencephaly

– Absent or abnormal reflexes

– Seizure activity

Behavioral Assessment

• Sleep-wake cycles

• Activity

• Social interactions

• Response to stimuli

Pain Assessment

• Most common sign crying

• Changes in heart rate

• Intracranial pressure

• Respiratory rate and oxygen saturation

Pain Management

• Nonpharmacologic management: containment (swaddling), nonnutritive sucking and distraction: visual, oral, auditory, tactile

• Pharmacologic management: local and topical anesthesia, Nonopioid analgesia and opioids

Gestational Age AssessmentBallard Score

• 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

Infant Nutrition

• American Academy of Pediatrics (AAP) recommends infants be breastfed exclusively for first 6 months of life

• Breastfeeding should continue for at least 12 months

• If infants are weaned before 12 months, they should receive iron-fortified infant formula

Infant nutrition

• Human milk designed specifically for human infants; nutritionally superior to any alternative

• Breast milk considered living tissue because it contains almost as many live cells as blood

• Bacteriologically safe and always fresh

• Nutrients in breast milk more easily absorbed than those in formula

Contraindications of Breastfeeding

• Maternal cancer therapy/ radioactive isotopes

• Active tuberculosis

• HIV

• Maternal herpes simplex lesion

• Galactosemia in infant

• Cytomegalovirus (CMV)

• Maternal substance abuse

Choosing a Feeding Method

Nurse must provide information to parents in nonjudgmental manner and respect their decision

• Provide Factual information about nutritional and immunologic needs met by human milk

• Potential benefits to infant and mother

• Inherent risks with infant formulas

Choosing a Feeding Method

• Cultural beliefs and practices are a significant influences

• Immigrants from poorer countries often choose to formula feed because they believe it a better, “modern” method

• Others formula feed because they want to adapt to American culture and perceive it the custom to bottle feed

Lactation• Female breast composed of 15 to 20

segments (lobes) embedded in fat and connective tissues, well supplied with blood vessels, lymphatic vessels, and nerves

• Within each lobe are alveoli, the milk-producing cells, surrounded by myoepithelial cells that contract to send the milk forward into the ductules

Lactation

• Ductules enlarge into lactiferous ducts and sinuses, where milk collects behind nipple

• Each nipple has 15 to 20 pores through which milk is transferred to the suckling infant

• After birth, precipitate decrease in estrogen and progesterone levels triggers release of prolactin from anterior pituitary gland

Lactation • Prolactin highest first 10 days

• Gradually decline, but remain above baseline levels for duration of lactation

• Prolactin produced by infant suckling and emptying of the breasts

• Breasts never completely empty

• Milk production supply/demand

Lactation

– Oxytocin: other hormone essential to lactation

– As nipple is stimulated by suckling infant, posterior pituitary prompted by hypothalamus produces oxytocin

• Responsible for milk-ejection reflex (MER), or let-down reflex

– Nipple-erection reflex is integral to lactation

Lactation • Colostrum, a clear yellowish fluid birth to

48hrs.• More concentrated than mature milk• Extremely rich in immunoglobulins• Higher concentration of protein and

minerals• Less fat than mature milk • Coates and protects the stomach and

intestines from invading organisms

Lactation

• Transition milk 48-72hrs

• High levels of fat, lactose and water soluble vitamins

• Higher calorie content

• Larger volume

Lactation• Mature milk produce by 10th to 15th day• Two types of milk: foremilk and hind milk• Hind milk higher in fat which is needed for

growth• 90% water which maintains newborns fluid

balance• Remaining 10% contains carbohydrates,

proteins and fats

Lactation Frequency/Duration

• A newborns stomach is the size of a small marble and can hold 5-7 cc’s. This is matches the amount of colostrum produced

• From 7-10 days it increases to the size of a golf ball and can hold 1.5 to 2 oz

Lactation Frequency/Duration

• Newborns nurse on average 8-12 times/24hrs

• Feed by cue signs about every 1-3 hours

• Should have no more than one 4 hr period

Lactation Education

– Positioning

– Latch-on

– Let-down

– Frequency of feedings

– Pumping

– Milk storage

– Duration of feedings

– Supplements, bottles, and pacifiers

– Diet

– Breast care

Breast feeding Special Considerations

• Sleepy baby- use gentle stimulate to

bring to alert state

• Fussy baby- use calming techniques

• Slow weight gain- evaluate

breastfeeding

Breastfeeding• Engorgement noted when milk comes in and

is bilateral (increase feedings to q2hrs)• Sore nipples usually result of poor

latch on• Plugged milk ducts result of inadequate

emptying or underwire bra/apply warm compresses prior to nursing

• Mastitis infection characterized by sudden flu like symptoms usually effects only one breast

Formula-Feeding

• Personal preference

• Influence by significant family members

• Lack of familiarity with breastfeeding

• Contraindications present

Formulas

• Ready to feed

• Concentrated

• Powdered

• Cow’s milk–based

• Soy-based

• Casein/ whey

• Amino acid

Formula-Feeding Education

• Types of formula

• Formula Preparation

• Feeding patterns

• Feeding techniques

• Bottles preparation

Discharge Assessment

• Determine knowledge deficits

• Educate on car safety

• Importance of Immunizations

• Follow care

• Newborn hearing screen

• Collect blood for PKU