CCCTC



Chapter 13Preterm and Postterm NewbornsThe Preterm NewbornPreterm birth is the cause of more deaths during the first year of life than any other single factorHigher percentage of birth defectsThe less the preterm weighs at birth, the greater the risks to life during delivery and immediately thereafterGestational AgeActual time from conception to birth that the fetus remains in the uterusPreterm is less than 38 weeksTerm is 38 to 42 weeksPostterm is greater than 42 weeksStandardized method used to determine gestational age is Ballard scoreUses external characteristics and neurological developmentLevel of MaturationHow well-developed the infant is at birthAbility of organs to function outside of uterusCauses of Preterm BirthMultiple birthsMaternal illnessHazards of actual pregnancy (e.g., GH)Placental abnormalitiesPlacenta previaPremature separation of the placenta from uterine wallPossible Physical Characteristics of a Preterm InfantSkin transparent or looseSuperficial veins visible on abdomen and scalpLack of subcutaneous fatLanugo covering forehead, shoulders, and armsVernix caseosa abundantExtremities appear shortSoles of feet have few creasesAbdomen protrudesNails are shortGenitalia are smallIn the female, the labia majora may be openRelated Problems of Preterm BirthsInadequate Respiratory FunctionDuring second half of pregnancy, structural changes occur in the fetal lungsAlveoli (air sacs) enlargeCloser to capillaries in the lungsIf born prematurely, the muscles that move the chest are not fully developedAbdomen is distended, increasing pressure on diaphragmStimulation of the respiratory center in the brain is immatureGag and cough reflexes are weak due to immature nerve supplyRespiratory Distress Syndrome (RDS) Type 1Also called hyaline membrane diseaseResult of immature lungs, leads to decreased gas exchangeSurfactant is a fatty protein that is high in lecithin, its presence is necessary for the lungs to absorb oxygenBegins to form at 24 weeks gestation and by 34 weeks, if fetus is delivered, should be able to breathe adequatelyIf infant is premature, the surfactant level is insufficientManifestations of RDSCan take up to several hours after birth to be manifestedRespirations increase to 60 breaths/min or higher (tachypnea)The tachypnea may be accompanied by gruntlike sounds, nasal flaring, cyanosis, as well as intercostal and sternal retractionsEdema, lassitude, and apnea occur as the condition worsensMechanical ventilation may be necessaryTreatment for RDSIf amniocentesis of mother while fetus is still in utero shows a low L/S ratio, the mother may be given corticosteroids to stimulate lung maturity 1 to 2 days before deliveryIn preterm infants, surfactant can be administered via ET tube at birth or when symptoms of RDS occurImprovement in the neonate’s lung function is generally seen within 72 hours after administrationSurfactant ProductionCan be alteredDuring cold stressHypoxiaPoor tissue perfusionNursing Care of Infant with RDSMonitor vital signsMinimal handling of infant to help conserve energyIntravenous fluids are prescribedObserve for signs of under- or overhydrationOxygen therapyMonitor pulse oximetryInfant on supplemental oxygen is at high risk for oxygen toxicityBronchopulmonary Dysplasia (BPD)Toxic response of lungs to oxygen therapyRisksAtelectasisEdemaThickening of membranes, interferes with ventilationOften a result of prolonged dependence on supplemental oxygen and ventilatorsOften has long-term complicationsApnea in the Preterm InfantCessation of breathing for 20 seconds or longerNot uncommon in pretermsBelieved related to immaturity of nervous systemMay be accompanied byBradycardia (heart rate <100 beats/min)Cyanosis Neonatal HypoxiaInadequate oxygenation at the cellular levelDegree can be measured via pulse oximetryOxygen on Hgb in circulating blood divided by the oxygen capacity of the hemoglobinSaturation levels 92% or above is normalSeverely anemic infant may have severe hypoxia and not manifest clinical symptomsAbnormal fetal Hgb can also cause hypoxia because fetal Hgb does not readily release oxygen to the tissues and end organsSepsis in the Preterm InfantGeneralized infection of the bloodstreamAt risk due to immaturity of many body systemsLiver is immature, poor formation of antibodiesBody enzymes are inefficientSome symptoms includeLow temperatureLethargy or irritabilityPoor feedingRespiratory distressTreatment of SepsisAdministration of intravenous antimicrobialsMaintenance of warmth and nutritionClose monitoring of vital signsCare should be organized to help infant conserve as much energy as possibleFollowing Standard Precautions, including strict hand hygiene, is essentialPoor Control of Body TemperatureLack of brown fat (body’s own “insulation”)Radiation from a surface area that is large in proportion to body weightHeat-regulating center of brain is immatureSweat glands are not functioning to capacityPreterm is inactive, has muscles that are weak/less resistant to cold; unable to shiverPreterm body position is one of leg extensionHigh metabolism, prone to low blood glucose levelsCan result in cold stressSafety AlertSigns and symptoms of cold stressDecreased skin temperatureIncreased respiratory rate with periods of apneaBradycardiaMottling of skinLethargy HypoglycemiaPlasma glucose levels <40 mg/dL in a term infant and <30 mg/dl in preterm infantPreterm infants have not remained in utero long enough to build up stores of glycogen and fatAggravated by increased need for glycogen in the brain, heart, and other tissuesAny condition that increases metabolism increases glucose needsEnergy requirements place more stress on the already deficient storesHypocalcemiaCalcium transported across placenta in higher quantities in third trimesterEarly hypocalcemia occurs when the parathyroid fails to respond to the preterm infant’s low calcium levelsLate hypocalcemia occurs about 1 week in infants who are fed cow’s milk, as it increases serum phosphate levels causing serum calcium levels to fallIncreased Tendency to BleedBlood is deficient in prothrombinFragile capillaries of the head are susceptible to injury during birth, which can lead to intracranial hemorrhageNursing care includesMonitoring neurological statusReport bulging fontanels, lethargy, poor feeding, seizuresSlight Fowler’s positionUnnecessary stimulation can increase intracerebral pressureRetinopathy of Prematurity (ROP)Separation and fibrosis of the retina, can lead to blindnessDamage to immature retinal blood vessels thought to be caused by high oxygen levels in arterial bloodLeading cause of blindness in infants weighing <1500 gramsHas several stagesMaintaining sufficient levels of vitamin E and avoiding excessively high concentrations of oxygen may help prevent ROP from occurringCryosurgery may reduce long-term complicationsPoor NutritionStomach capacity is smallSphincters at either end of stomach are immatureIncreased risk of regurgitation and vomitingSucking and swallowing reflexes are immatureAbility to absorb fat is poorIncreased need for glucose and other nutrients to promote growth and prevent brain damage are contributing factorsParenteral or gavage feedings may be needed until infant’s systems are more matureNecrotizing Enterocolitis (NEC)Acute inflammation of the bowel that leads to bowel necrosisFactors includeDiminished blood supply to bowel liningLeads to hypoxia or sepsisCauses a decrease in protective mucusResults in bacterial invasionSource of bacterial growth if receiving milk formula or hypertonic gavage feedingsSigns of NECAbdominal distentionBloody stoolsDiarrheaBilious vomitusNursing Care of Infant with NECObserving vital signsMeasuring abdomenAuscultating for bowel soundsCarefully resuming fluids as orderedMaintaining infection prevention and control techniquesSurgical removal of the necrosed bowel may be indicatedImmature KidneysCannot eliminate body wastes effectivelyContributes to electrolyte imbalance and disturbed acid-base relationshipsDehydration occurs easilyTolerance to salt is limitedSusceptibility to edema is increasedNursing Care of Infant with Immature KidneysAccurate measurement of intake and outputWeigh diapers per hospital proceduresUrine output should be between 1 and 3 mL/kg/hrObserve for signs of dehydration or overhydrationDocument status of fontanels, tissue turgor, weight, and urinary outputJaundiceImmature liver, contributes to condition called icterusCauses skin and whites of eyes to assume a yellow-orange castLiver unable to clear blood of bile pigments which result from the normal postnatal destruction of RBCsThe higher the serum bilirubin level, the higher the jaundice and the greater the risk for neurological damageJaundice (cont.)An increase of >5 mg/dl in 24 hours or a bilirubin level above 12.9 mg/dl requires careful investigationPathological jaundiceIf occurs within 24 hours of birth, may be related to an abnormal condition such as ABO incompatibilityBreastfed infants can show signs of jaundice about 4 days after birthTotal serum bilirubin levels typically peak about 3 to 5 days after birthGoals of Treating JaundicePrevent kernicterus by preventing the rising bilirubin levels from staining the basal nuclei of the brainNursing care goals should be toObserve skin, sclera, and mucous membranes for signs of jaundiceReport the progression of jaundice from the face to the abdomen and feetMonitor and report any abnormal lab resultsResponse to phototherapySpecial Needs of the Preterm InfantNursing Goals for the Preterm NewbornImprove respirationMaintain body heatConserve energyPrevent infectionProvide proper nutrition and hydrationGive good skin careObserve infant carefully and record observationsSupport and encourage the parentsIncubatorsIt is important for the nurse to know how to use the various types of incubators available in their health care facility in order to provide safe and effective care to the infant who is in oneRadiant Heat WarmersSupplies overhead heatAllows easier access to infantKangaroo CareUses skin-to-skin contactInfant wears only a diaper (and sometimes a cap) and is placed on the parent’s naked chestThe skin warms and calms the childPromotes bondingProviding Nutrition to the Preterm InfantMay require Parenteral feedingsGavage feedingsMay use bottles forBreast milkFormula Early initiation of feedings reduces the risk of hypoglycemia, hyperbilirubinemia, and dehydrationNursing Care Related to NutritionObserve and record bowel sounds and passage of meconium stoolsFor gavage feeding, aspiration of gastric contents prior to feeding is importantIf no residual received, it’s safe to start the feedingIf a higher-than-ordered limit of gastric contents is received, feeding may need to be held and the health care provider notifiedPositioning and Nursing CarePreterm is placed on the side or prone with head of mattress slightly elevatedDecreases respiratory effort, improves oxygenationPromotes more organized sleep pattern and lessens physical activity that burns up energy needed for growth and developmentShould be compatible with drainage of secretions and prevention of aspirationDo not leave infant in one position for a long period of time, as it increases the risk of skin breakdownPrognosis for Preterm InfantGrowth rate nears the term infant’s about the second year of life, but very-low-birth weight infants may not catch up, especially if chronic illness, insufficient nutritional intake, or inadequate caregiving has occurredGrowth and development of the preterm infant are based onCurrent age minus the number of weeks before term the infant was bornThis calculation helps prevent unrealistic expectations for the infantFamily Reaction to a Preterm InfantParents will need guidance throughout the infant’s hospitalizationMay believe they are to blame for infant’s conditionMay be concerned about their ability to care for such a small infantParents are taught how to provide appropriate stimulation without overtiring their infantDischarge Planning of the Preterm InfantBegins at birthParents will need to demonstrate and practice routine and/or specialized careHome nursing visits may be required to assess home, infant, and familyThe Postterm NewbornBorn beyond 42 weeks gestationPlacenta does not function well after a certain point Can result in fetal distressMortality rate of later-term infants is higher than that of term newbornsMorbidity rates also higherProblems Associated with Postterm DeliveryAsphyxiaMeconium aspirationPoor nutritional statusIncrease in red blood cell productionDifficult delivery due to increased size of fetusBirth defectsSeizuresPhysical Characteristics of the Postterm NewbornLong and thinWeight may have been lostSkin is loose (especially around buttocks and thighs)Little lanugo or vernix caseosaSkin is dry, cracks and peelsNails are long and may be stained from meconiumThick head of hair and looks alertNursing Care of the Postterm NewbornCareful observation forRespiratory distressHypoglycemiaHyperbilirubinemia Cold stressTransporting the High-Risk NewbornStabilization of the newborn prior to transport is essentialBaseline data such as vital signs and blood work should also be obtained and provided to the transport team membersCopies of all medical records are made, including the mother’s prenatal history and how the delivery progressedTransporting the High-Risk Newborn (cont.)Ensure infant is properly identified and that the mother has the same identification number bandProvide parents with name and location of the NICU the infant is being transported to, including telephone numbersIf possible, allow parents a few moments with their infant prior to transportingIf possible, take a picture of the baby and give to parentsDischarge of the High-Risk NewbornParents must be familiar with infant’s careThe newborn’s behavioral patterns are discussed and realistic expectations are reviewedCommunication can be maintained with the hospital through “warm lines”Social services may be of help in ensuring the home environment is satisfactory and special needs of the infant can be metSupport group referrals are givenNewborn CPR techniques are reviewedQuestion for ReviewWhat are the differences in the appearance of a preterm infant and a postterm infant? ................
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