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.”

Respiratory Changes

Intrauterine• Lungs serve no

respiratory function• Oxygen supply secured

through the placenta• Lungs are filled with

lung fluid which keeps them partially expanded

Extrauterine• Within a few minutes

after birth the vital capacity is established

• Surfactant reduces surface tension in alveoli and keeps lungs from collapsing

Respiratory Changes

Chemical

Sensory

Mechanical

InitiationInitiation ofof BreathingBreathing

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

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

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

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

Answer this !

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

Answer This!

Cardiovascular

Changes

Fetal Circulation

Placenta Umbilical Vein Liver

Ductus venosus Inferior Vena Cava

Right Atrium Foramen Ovale

Left Atrium Left Ventricle Aorta

Fetal Circulation

Enters Rt. Atrium

Foramen Ovale

Lf. Atrium

Lf. Ventricle

Aorta

To the Body

RA LA

To the body

LVRV

Fetal Circulation

or

Right Atrium Right Ventricle

Pulmonary Artery Ductus Arteriosus

Aorta Body

(Small amount goes to the lungs)

Fetal Circulation

OR• Right Atrium

• Right Ventricle

• Pulmonary Artery

• Ductus Arteriosus

• Aorta

RA

RV

LA

LV

Aorta

Ductus Arteriosus

Cardiovascular Changes1. 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.

Cardiovascular Changes

1. Pressure in RA decreases

2. Blood flows to the lungs

4. Pressure in the LA increases RT Flow of blood from the lungs

3. Ductus Arteriosusbegins to constrict

5. Increase pressurein the LA forcesthe foramen ovale to close

True / False

• An infant’s 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

Renal / Kidney Changes

IntrauterineUrine 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

Hepatic and Liver Changes

• The newborn’s liver plays a role in:– Iron storage--for new RBC production. If the mother’s

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.

Hepatic and Liver

• Iron Storage

• Carbohydrate metabolism

– 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

Conjugation of Bilirubin

Unconjugated bilirubin is a breakdown product derived from hemoglobin that is released from destroyed RBC’s.

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.

Fat Soluble

Conjugation of Bilirubin is a conversion of

to

Water Soluble

Unconjugated Conjugated

by the enzyme Glucuronyl transferase in the newborn’s liver

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

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 RBC’s

Temperature Regulation

A newborn is at a DISADVANTAGE in maintaining a normal temperature because:Larger body surface in relation to body

massSmall amount of insulating

subcutaneous fat

Minimizing HeatLoss in the Newborn is IMPERATIVE

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.

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

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!

Non Shivering ThermogenesisNon Shivering Thermogenesis

Heat MaintenanceHeat Maintenance

PeripheralPeripheralVasoconstrictionVasoconstriction

SubcutaneousSubcutaneous FatFat

Curl up in Curl up in fetal positionfetal position

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.

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 !

Clamping of the Cord

• Cord should be clamped off about 1” from base of cord.

• Inspect the cord for 2 arteries and 1 vein.

• Don’t milk the cord

Maintain Body Temperature

• Dry off

• Place in warmer

• Skin to skin contact

Apgar Score

• Scoring system to appraise the newborn

• Done at 1, 5, and 10 minutes after birth

Apgar Score

Heart Rate Absent Slow (less than 100 )

Over 100

Respiratory Effort

Absent Slow, weakirregular cry

Good Cry

ReflexIrritability

No Response Weak cry orgrimace

Vigorous Cry

Muscle Tone

Flaccid Some flexion ofExtremities

ActivemotionResists effortto extend

Color Blue / pale Body pink,extremitiesblue

Completely pink

0 1 2

Heart Rate is the most important !

Apgar Score• Score of 7 - 10 = Good Condition

• Score of 4 - 6 = Fair Condition

• Score of 0 - 3 = Poor Condition

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?

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

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 )

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.

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

Nursing Nursing AssessmentsAssessments

of theof the NewbornNewborn

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.

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.

Reflexes

• Moro

• Tonic Neck

• Palmar and Plantar grasp

• Babinski• Feeding--Rooting, Sucking, Swallowing, Gag

• Protective -- Sneezing, Blinking, Gag

SensesTouch-- 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 mom’s breast milk.

Skin

• Pink with acrocyanosis

• Desquamation

• Vernix caseosa

• Lanugo

• Erythema toxicum

• Mongolian spots

• Birth marks

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

Face

• Rounded

• Fat pads in the cheeks for sucking

Eyes

• Slate blue

• Spaced 1/3 across face

• Assess for subconjunctival hemorrhage

• Check pupils

• May have strabismus or nystagmus

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

Nose

• Check patency

• Note drainage

Mouth

• Firm Palate

• Tongue• short frenulum• Should not protrude• Extrusion reflex

• No Teeth

• Epstein pearls

• Nose -- patency

• Mouth

• Neck

• Chest

• Abdomen

• Genitals -- never retract foreskin on male

• Anus -- patency

• Cry -- loud and lusty

Behavorial / Sleep - Awake States

• Deep sleep

• Light Sleep

• Drowsy

• Quiet alert

• Active alert

• Crying

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

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

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