PRETERM NEONATE

ARUNA. A PI BATCH MSC NURSING

DEFINITION

Any neonate born before 37 weeks (<259 days) of gestation irrespective of the birth weight.

Premature birth, commonly used as a synonym for preterm birth, refers to the birth of a baby before the developing organs are mature enough to allow normal postnatal survival

ETIOLOGY

Spontaneous

Induced

Spontaneous

Health status of the mother (low socio economic status)

Multiple pregnancy:Number of multiple pregnancies are

increasing due to advanced parental age from delayed child bearing and ART.

PIH:

It is the most common complication of pregnancy and is occurring in 6- 10% of pregancies and is rising

Placental problemsPreterm labour and premature

rupture of membraneLow maternal weight

Chronic and acute systemic maternal disease

Antepartum haemorrhageCervical incompetenceMaternal genital colonization and

infectionsCigarette smoking during pregnancyThreatened abortion

Acute emotional stressPhysical exertionSexual activityTraumaBicornuate uterusCongenital malformations

Induced

Maternal diabetes mellitusPlacental dysfunction as indicated by

unsatisfactory fetal growthEclampsiaFetal hypoxiaAntepartum haemorrhageSevere rhesus iso immunization

CLINICAL FEATURES

Measurements:Size is small with relatively large

headCrown- heel length is less than 47cmHead circumference is less than 33

cmBut exceeds the chest circumference

by more than 3 cm

Activity and posture:

General activity is poorAutomatic reflex response such as

moro response, sucking and swallowing are sluggish or incomplete

Baby assumes an extended posture due to poor tone

Face and head:

Face appears smalllarge head sizeSutures are widely separatedFontanels are largeSmall chinProtruding eyes

Optic nerve is usually unmyelinatedEar cartilage is deficient or absent

with poor recoilHair appears woolly, and fuzzy and

individual hair fibres can be seen separately

Skin and subcutaneous tissues:

Skin is thin, gelatinous, Shiny and excessively pink

Abundant lanugoVery little vernix caseosaEdema may be presentSubcutaneous fat is deficientBreast nodule is small or absentDeep sole creases are often not present

Genitals:

MALE: testes undescended scrotum poorly developedFEMALES :labia majora widely separated

exposing labia minorahypertrophied clitoris

CHARACTERISTICS OF PRETERM INFANTS

Skin

Bright pink, often translucent, depending on the degree of maturity

Smooth and shiny ( may be edematous)

Small blood vessels clearly visible underneath the thin epidermis

Fine lanugo hair is abundantHair is sparse, fine and fuzzy on the

head

Ear cartilage

Soft and pliable

Soles and palms

Minimal creases

Smooth appearance

Male genitalia

Male infant’s scrotum is undeveloped and not pendulous

Minimal rugae are present

Testes may be in the inguinal canal or in the abdominal cavity

Female genitalia

Clitoris is prominent Labia majora are poorly developed

and gaping

Scarf sign

Elbow may be easily brought across the chest with little or no resistance

DIFFERENCE BETWEEN PRETERM AND TERM INFANT

CHARACTERISTICS

PRETERM TERM

Posture The preterm infant lies in a relaxed attitude , limbs more extendedThe body size is smallHead may appear somewhat larger in proportion

Term infant has more subcutaneous fat tissues and rests in a more flexed attitude

Ear

Preterm Ear Cartilages are

poorly developed Ear may fold easilyHair is fine and

featheryLanugo may cover the

back and face

Term The mature infants ear

cartilages are well formed

Hair is more likely to form firm , separate strands

Sole

pretermMore rigidFine wrinkles

termWell and deeply

creased

Female genitalia

preterm

Clitoris is prominent . Labia majora are poorly developed and gaping

termLabia majora fully

developedClitoris not prominent

Male genitalia

pretermMale infant’s scrotum

is undeveloped and not pendulous

Minimal rugae are present

Testes may be in the inguinal canal or in the abdominal cavity

termScrotum well

developedPendulousRugatedTestes well down in

the scrotal sac

Scarf signpretermElbow may be

easily brought across the chest with little or no resistance

termresisting

attempt to bring the elbow past the midline

NEUROLOGIC EVALUATION

CHARACTERISTICS

PRETERM TERM

GP REFLEX weak Strong

HEEL TO EAR MANEUVER

Heel is easily brought to the ear, meeting with no resistance

Not possible , since there is considerable resistance at the knee

COMPLICATIONS OF PRETERM BIRTHCentral nervous system:immaturity of central nervous systemPoor cough reflexIncoordinated sucking and swallowingRetrolental fibroplasiasIntra ventricular and periventricular

hemorrhage brain damage

Respiratory system

Resuscitation difficulties at birthHyaline membrane diseaseBreathing is periodic and associated

with intercostal recessions due to soft rib

Pulmonary aspirationAtlectasis broncho pulmonary dysplasia

Cardio vascular system

The closure of ductus arteriosus is delayed among preterm infants

G I system

Regurgitations and aspirationsAbdominal distention and functional

intestinal obstructionEnterocolitisHyperbilirubinemiaHypoglycemia

Thermo-regulationExcess heat loss

InfectionsRenal immaturityThe blood urea nitrogen is high AcidosisEdema

Toxicity of drugNutritional problemsanemiaDeficiencies of folic acid and vit Eosteopenia and ricketsBiochemical disturbancehypoglycemia, hypocalcemia,

hypoxia and hypoprotinemia

MANAGEMENT

ARREST OF PREMATURE LABOURBed rest and sedationTocolytic agentEthanolMagnesium sulphate

Tocolytic agents

Isoxsuprine (duvadilan)RetodrineSalbutamolTerbutaline

INDUCTION OF PREMATURE LABOURL/S ratioAntenatal corticosteroids:

Betamethasone: 12mg IM q24h for 2 doses

Dexamethasone : 6mg IM every 12 hours for 4 doses

ASSESSMENT

NEW BALLARD SCORE

Optimal management at birthThe baby should be promptly dried,

kept effectively covered and warmVit K 0.5mg IMShift to NICU

MONITORING

Vital signsActivity and behaviorColor, Tissue perfusionFluids, electrolytes and ABG’sTolerance of feedsLook for development of RDS., apneic

attacks, sepsis, PDA, NEC, IVH etcWeight gain velocity :

CARE OF NEWBORN

cushioned bedAvoid excessive light, excessive

sound, rough handling and painful procedures. Use effective analgesia and sedation for procedures

Provide warmthEnsure asepsisCover the baby appropriately

Provide effective and safe oxygenation

Nutritiontactile and

kinesthetic stimulation

Prone position Photo therapyPrevention of

nosocomial infection

Weight record

ImmunizationsFamily supportDischarge policyFollow upHome care of preterm babies

COMMON PROBLEMS OF PRETERM NEWBORNSNosocomial infectionsHypothermiaRespiratory distress syndrome AspirationPatent ductus arteriosusChronic lung disease

Necrotizing enterocolitisIntraventricular haemorrhageRetinopathy of prematurityLate metabolic acidosisNutritional disordersDrug toxicity

NURSING MANAGEMENT

Problem with respirationProblems with thermoregulationFluid and electrolyte imbalanceInfectionPainParental / maternal separation

NURSING DIAGNOSIS

impaired gas exchange ineffective thermoregulation related

to prematurityimbalanced nutritionAltered growth and development

related to hospitalization altered parentingAnxiety related to lack of knowledge

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