THE NEWBORN

1. 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.”

2. 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

3. Respiratory Changes Mechanical Initiation of Breathing Chemical Sensory

4. 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

5. 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 Mechanical Events Fluid expelled Air Enters

6. 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

7. 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

8. Answer this ! Answer This! • When a baby is born by cesarean delivery, which of the mechanisms to initiate breathing does it lack?

9. Cardiovascular Changes

10. Fetal Circulation Placenta Umbilical Vein Liver Ductus venosus Inferior Vena Cava Right Atrium Foramen Ovale Left Atrium Left Ventricle Aorta

11. Fetal Circulation Enters Rt. Atrium Foramen Ovale Lf. Atrium Lf. Ventricle Aorta To the Body To the body LA RA LV RV

12. Fetal Circulation or Right Atrium Right Ventricle Pulmonary Artery Ductus Arteriosus Aorta Body (Small amount goes to the lungs)

13. Fetal Circulation Aorta OR • Right Atrium • Right Ventricle • Pulmonary Artery • Ductus Arteriosus • Aorta Ductus Arteriosus LA RA LV RV

14. Cardiovascular Changes 1. 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.

15. Cardiovascular Changes 3. Ductus Arteriosus begins to constrict 2. Blood flows to the lungs 4. Pressure in the LA increases RT Flow of blood from the lungs 1. Pressure in RA decreases 5. Increase pressure in the LA forces the foramen ovale to close

16. 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

17. Intrauterine Urine 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 Renal / Kidney Changes

18. 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.

19. Hepatic and Liver • Iron Storage • Carbohydrate metabolism

20. 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

21. 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.

22. Conjugation of Bilirubin is a conversion of Fat Soluble Water Soluble to Unconjugated Conjugated by the enzyme Glucuronyl transferase in the newborn’s liver

23. 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

24. 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

25. Temperature Regulation • A newborn is at a DISADVANTAGE in maintaining a normal temperature because: • Larger body surface in relation to body mass • Small amount of insulating subcutaneous fat

26. Minimizing Heat Loss in the Newborn is IMPERATIVE

27. 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.

28. 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

29. Non Shivering Thermogenesis 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!

30. Peripheral Vasoconstriction Subcutaneous Fat Heat Maintenance Curl up in fetal position

31. 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.

32. 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 !

33. 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

34. Maintain Body Temperature • Dry off • Place in warmer • Skin to skin contact

35. Apgar Score • Scoring system to appraise the newborn • Done at 1, 5, and 10 minutes after birth

36. Apgar Score 0 1 2 Heart Rate is the most important !

37. Apgar Score • Score of 7 - 10 = Good Condition • Score of 4 - 6 = Fair Condition • Score of 0 - 3 = Poor Condition

38. 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?

39. 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

40. 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 )

41. 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.

42. 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

43. Nursing Assessments of the Newborn

44. 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.

45. 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.

46. Reflexes • Moro • Tonic Neck • Palmar and Plantar grasp • Babinski • Feeding--Rooting, Sucking, Swallowing, Gag • Protective --Sneezing, Blinking, Gag

47. Senses • Touch-- 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.

48. Skin • Pink with acrocyanosis • Desquamation • Vernix caseosa • Lanugo • Erythema toxicum • Mongolian spots • Birth marks

49. 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

50. Face • Rounded • Fat pads in the cheeks for sucking