Bilirubin:

Source

Bilirubin:

Excretion

Bilirubin:

Unconjugated

Pathalogic vs. Physiologic

Jaundice

Physiological jaundice occurs (after 24 hours > birth) as a result of an elevation in unconjugated bilirubin. Thi could be due to a variety of factors including increased RBC volume, decreased RBC survival, and more.

Pathologic jaundice occurs (within first 24 hours) due to ABO incompatibility, spherocytosis, hemolytic anemia, and decreased clearance due to errors in metabolism or drug/hormone imbalances.

Yellowish staining of the brain (especially the basal ganglia, cerebellum, and hippocampus).

Caused by pathologic jaundice - bilirubin is deposited in brain. Results in bilirubin encephalopathy.

Can be reversed in early stages by phototherapy and/or exchange transfusion. If left untreated, kernicterus can lead to cerebral palsy and mental retardation with a 50% mortality rate.

Gestational Diabetes:

Complications for Infant

Hypoglycemia: Supply of glucose from mother is no longer available, however, insulin levels remain high.

Respiratory Distress Syndrome: Increased levels of insulin interfere with production of surfactant; Macrosomia often leads to preterm birth.

Hypocalcemia: May be related to increased incidence in prematurity and/or stresses of difficult labor and birth.

Polycythemia: Decreased cellular volume and hyperglycemia stimulates production of erythropoietin and RBCs.

Infant Withdrawal:

Common S/S

1. Hyperactivity

2. Hyperirritability

3. Disorganized, vigorous suck

4. Tachypnea

Withdrawal syndrome caused by teratogenic exposure to drugs.

Typical drugs involved are opioids, SSRIs, benzodiazepines, and ETOH.

Neonatal Abstinence Syndrome:

Interventions

1. Monitor closely for hypothermia

2. Administer small, frequent feedings; Position to avoid aspiration

3. Administer medications as ordered (morphine, phenobarbital)

4. Frequent diaper changes and skin care r/t diarrhea

5. Keep infant swaddled; Keep environment quiet

A set of congenital infections passed from mother to fetus. TORCH stands for:

T = toxoplasmosis

O = other (syphilis, varicella, HIV, parovirus)

R = rubella

C = cytomegalovirus (CMV)

H = herpes

Mothers who:

Are HIV positive

Have undergone breast surgery

Are receiving chemotherapy

Are using drugs/illicit substances

Have contracted  Hepatitis C

Components of

Breastmilk

Colostrum

Transitional milk (will come in day 3 +/-)

True (mature) milk (up to 2 weeks postpartum)

    -Foremilk

    -Hindmilk

Breastfeeding Positions

1. Cradle

2. Footbal

3. Sidelying

Change position often to reduce nipple soreness.

Neonatal Assessment:

General Considerations

**Avoid compromising the infant

throughout the procedure**

** Thermal regulation

** Maintain aseptic technique (most important)

** Complete assessment in organized manner

for complete, accurate results

Neonatal Assessment:

Major Assessments

1. In the delivery room

2. Upon admission to nursery/postpartum area

3. Prior to discharge

Characteristics of

the Newborn

• Length

• Weight

• Head Circumference

• VS - axillary temp, respirations, apical pulse

• Gestational age assessment (2 hrs > birth)

• Behavior

Characteristics of

the Newborn:

Temperature

Temperature Range: 36.5 - 37 (axillary)

< 36.5 = potential distress

• do not bathe baby until temp stabilizes
• optimal stabilization 1-2 hrs (can be up to 8-10 hrs). Unstable temp causes glucose stores to be used rapidly.
• babies cannot shiver to raise body temp - dry off >birth and keep them warm
• skin-skin, warm blanket, hat
• crying may elevate temp
• temp not reliable indicator of infection; high temp may be reflective of mom's temp - baby may have low temp w/infection

Characteristics of

the Newborn:

Apical Heart Rate

Heart Rate range: 120 - 160 bpm

Variations:

• as low as 100 while sleeping

• as high as 180 when crying

• may be irregular with crying

• murmurs - may be due to transitional circulation, however **all murmurs should be followed up on and referred for evaluation**

• acrocyanosis - blue hands/feet

Characteristics of

the Newborn:

Respirations

Respiration range - 30 - 60 breaths per min

• Respirations are typically irregular

• Moist breath sounds > birth - can take a couple of hours for breath sounds to clear (use postural drainage vs. bulb syringe)
•      respiration rate may be elevated
•      may see nasal flaring & retractions
•      characteristic grunting

• Potential distress - asymmetrical chest movements; apnea > 15 sec; dim breath sounds; seesaw respirations; deep sigh; tachypnia; excessive mucus; persistenet fine crackles

Characteristics of

the Newborn:

Weight Range

Weight Range: 2500 - 4000 grams

(5 lbs 8 oz - 8 lbs 13 oz)

• weight loss > birth should be no more than 7% of birth weight

• when weight loss approaches 10% of birth weight, start to see problems with bilirubin, latch problems

Characteristics of

the Newborn:

Head Circumference

Head Circumference Range - 33-35 cm

• Head should be 2 to 3 cm larger than chest (head molding may impact these findings) Head should be measured just above eyebrows

• Chest circumference typically 30.5 to 33 cm (measure at nipple line)

Gestational Age

Assessment

Babies at a given gestational age will have

features typical for that gestational age.

Calculate age by (decreasing order of accuracy):

• calculation from a known date of conception

• calculation from Dubowitz/Ballard assessment (important for preterm infants)

• estimation by experience

Gestational Age Assessment:

Classifications

• SGA (small) <2500 grams at term

• AGA (average) 2500 - 4000 grams at term

• LGA (large) >4000 grams  *these neonates can be premature. Near term LGA babies need to be treated as preterm.

Ballard Scale of

Physical and Muscular Maturity

• Posture - F/T babies well flexed; very P/T babies are flaccid
• Square Window - F/T babies can flex wrist so fingers touch forearm; P/T only 90 degrees flex
• Recoil from flex - F/T recoil quickly/tightly
• Popliteal angle
• Heel to ear angle - F/T baby won't allow
• Scarf sign - P/T baby will allow arm across neck
• Skin quality - transparent to opaque; cracking
• Lanugo - F/T baby has little to none
• Plantar surface - P/T baby has no creases; look at how far down foot baby has creases
• Breast tissue
• Ear fold - P/T baby ear will stay folded; F/T if fold ear, it will spring back
• Genitals - quality

Adaptations to

Extrauterine Life:

Respiratory

• Chemical stimuli - elevation in PCO2, decrease in pH and PO2, temporary asphyxiation cause by severing of cord; Oxygen stimulates production of surfactant

• Thermal stimuli - abrupt change in temp

• Tactile stimuli - pressure changes, light, noise

"Thoracic squeeze" pushes out about 1/3 of fliud.

With first deep breaths, most of the remaining fluid is pushed from air spaces into interstitial space, to be excreted via lymph system.

Baby can still have wet breath sounds for a few hours after birth, almost always gone within 12-24 hours.

Normal Newborn

Values:

Blood Pressure

65/41

Can increase by 20 (both systolic and diastolic) during crying

Normal Newborn

Values:

Hemoglobin & Hematocrit

Hemoglobin: 14 - 20

Hematocrit: 43 - 63

Normal Newborn

Values:

White Blood Cells

Normal Newborn

Values:

Cord Blood Values

Glucose:  45 - 96

Calcium: 8.2 - 11.1

Chloride: 98 - 110

Potassium: 5.6 - 12

Sodium: 126 - 166

Brown fat: Promotes rapid metabolism (of triglycerides), heat generation, heat transfer to periphery. Non-shivering thermogenisis uses brown fat to provide heat.

Heat loss happens through the following methods:

• evaporation
• radiation
• convection
• conduction

Normal Newborn

Values:

Bilirubin

< 3 mg/dL

when serum bilirubin reaches 4 - 6,

yellowing of skin and sclera occur

(this happens in approximately 50%

of newborns by the 2nd or 3rd day)

Nursing Interventions:

Prevention of Jaundice

• Maintain temp 36.5 or above

• Monitor stool for frequency and characterisitcs

• Encourage early feedings to promote intestinal elimiation and bacterial colonization

Characteristics of

the Newborn:

Stool

Meconium: typically during first 8-24 +/- hours,

but nearly always by 48 hours, infant

will pass meconium stool.

Black, tarry - will stick to baby's skin.

Normal Stooling:

Breast-fed newborns - stool is pale yellow to green, more often than bottle fed

Frequency can range from 1 stool every 2 - 3 days to 10 stools per day.  Babies are not

constipated if stool is soft.

Characteristics of

the Newborn:

Urine

First 2 days postnatal - urinate 2-6 x per day,

volume is roughly 15 ml per day

> 2 days, urination increases to 5 - 25 x day,

volume is roughly 25 ml per kg per day

Characteristics of

the Newborn:

Length

19 - 21 inches / 48 - 53 cm

Measure flat with legs and feet extended

Adaptations to

Extrauterine Life:

Cardiovascular

2 things MUST happen to develop normal newborn circulation: pulmonary ventilation and increased pulmonary circulation

1. As pulmonary vascular risistance decreases, vascular flow increases rapidly, and reaches 100% normal flow within 24 hours of life.

2. Delivery of greater blood supply to the lungs contributes toward development of

normal newborn circulation.

3. Shunting in the newborn period is responsible for the unstable transition period in cardiopulmonary function.

First Period of

Reactivity

Eye to Eye

First hour of newborn life:

alert & attentive; strong desire to suckle;

optimal time for parental bonding

Skin to skin with mom

2. Delay eye medication

Second Period of

Reactivity

Exaggerated response to internal and external stimuli.

Wide swings in HR, resp irregular, thick secretions may cause gagging, often has firsst meconium stool, may appear hungry

After one hour of eye to eye, and skin to skin, newborn has little response to external stimuli.

Lasts minutes to hours (2-4 hours typical)

HR & resp rate slow, color stabilizes

Immediate Nursing Care

of Newborn

• General survery of appearance
• Vital signs
• Measurements - length, head & chest circumference
• Eye prophylaxis (erythromycin for protection against maternal STDs)
• Vitamin K (for blood clotting)
• Inspect and care for umbilical cord
• Bath
• Blood glucose monitoring
• Newborn identification and registration