Transition and Stabilization of the Newborn Letha Nix RNC

How long should it take to transition from intrauterine life to extrauterine life? A.) 1-2 hours B.) 2-3 hours C.) 3-6 hours D.) 6-12 hours

A newborn can take up to 12 hours to transition from placental support to extrauterine support.

Definition Transition is a process of physiologic change in the newborn infant that begins in utero as the child prepares for transition from intrauterine placental support to extrauterine self- maintenance.

Objectives Identify primary features of fetal and newborn circulation. Identify physiologic changes during transition to extrauterine life. Identify routine care considerations for a newborn during the transition period. Identify signs and symptoms of common problems during transition period. Discuss methods for parental support.

Transition begins before delivery Depending on…. Gestational age placenta health/condition maternal health Any limitations to major organs physical defects/anomalies

Transitional begins before delivery The infant prepares by… Fetal breathing (producing surfactant at 34 weeks) storing glycogen in the liver producing catecholamines depositing brown fat

Transition begins before delivery During Labor… placenta stress hormones

Review: Placental Circulation Exchanges O 2 and CO 2 by simple diffusion Eliminates waste products Does the work of the lungs in utero Uterine venous blood has PCO 2 =38 mmHg PO 2 =40-50 mmHg pH=7.36

Review: Fetal Circulation One Umbilical Vein-oxygenated blood Two Umbilical Arteries-deoxygenated blood Three Fetal Shunts…  Ductus Venosus- hepatic system  Foramen Ovale- between right & left atrium  Ductus Arteriosus- vein connects pulmonary artery to descending aorta

Fetal Circulation Foramen Ovale  Shunt  Right atrium  Left atrium  Right Ventricle

Fetal Circulation Ductus Arteriosus  Shunt  Unsaturated blood  Pulmonary Artery  Aorta

Fetal Circulation Fetal Lungs  Fluid filled  Resistant  Nourishment

Fetal Circulation  Systemic Vascular Resistance  Pulmonary Vascular Resistance  Pulmonary Arterioles Resistant

Transition to Extrauterine Life begins when the cord is CUT. Placenta no longer works as lungs Lungs begin to exchange gases First breath inflates lungs and causes circulatory changes Lungs inflate -  resistance to blood flow through lungs &  blood flow from pulmonary arteries This results in Newborn Circulation.

Newborn Circulation Umbilical cord is clamped  Placenta is separated   systemic blood pressure  Three major shunts close

Newborn Circulation  Circulatory Changes  Fetus separation mother/placenta  Lungs begin to function  First breath

Newborn Circulation  Lung fluid cleared  Lungs fill with O2  Systemic vascular resistance increases  Initiation of respiration  Pulmonary arterioles   Pulmonary Vascular Resistance   Pulmonary Blood flow

Newborn Circulation  Blood flow resistance  Blood flows through pulmonary arteries  Foramen ovale closes  Blood pressure increases

Newborn Circulation  Left atrial pressure   Right atrial pressure   Foramen functional closure  Ductus arteriosus

Newborn Circulation  Postnatal  Right Atrium, SVC, IVC  Poorly oxygenated blood  Right ventricle, pulmonary artery, pulmonary circulation  Oxygenated blood  Left atrium, pulmonary veins  Left ventricle, aorta, systemic circulation

Physiologic Changes During Transition Cardiovascular Respiratory Hematologic Gastrointestinal Renal Immunologic

Considerations For Newborns in Transition Period History… Maternal…Medications Illness Labor and Delivery… Fetal Distress Delivery Complications Types Delivery Resuscitation Measures

Assessment  Vital Signs  Measurements  Gestational Age Assessment  Head to Toe Exam  Glucose/Feeding

Assessment-continued Normal head to toe assessment findings for infant in transition  Skin  Head  Respirations/Breath Sounds  Heart Sounds  Intestines  Urine  Extremities

Thermoregulation  normal ranges 97.7F F  results of cold stress:  O 2 consumption & use of glucose stores  radiant warmer/isolette  bathing

Medications 0.5% Erythromycin eye ointment  give within 1 hr of birth!  Vitamin K (phytonadione)  give within 1 hr of birth!  Hepatitis B vaccine & Hepatitis B immunoglobulin (HBIG)  give within 12 hrs if mom + or unknown  vaccine only at d/c if negative

Glucose Needs & Feeding Delivery stress  conversion of fats and glycogen to glucose for energy  At 1-2 hours of age glucose level falls  Baseline glucose 30 mins-1 hr of age Goal-Glucose level > 40 ml/dl on first day >40-50 ml/dl thereafter

Glucose Needs & Feeding-continued Risk Factors for Hypoglycemia  Asphyxia  Cold stress   work of breathing  Sepsis  Premature or SGA  Infants of mother with diabetes or gestational diabetics  LGA babies

Glucose Needs & Feeding-continued S/S of Hypoglycemia Treatment of Hypoglycemia  Feed early on demand in first hour Evaluation before feeding Contraindication before nipple/breast feeding Contraindications to gavage feeding Guidelines for feeding Indication for IV glucose infusion

Recognition of the Sick Newborn Perinatal History Physical Assessment  Skin  Respiratory  Cardiovascular  Central Nervous System  Morphologic Features  GI Tract

Tools Used to Diagnosis? With MD order of course!!!

Common Problems Seen In Transition Birth Trauma Birth Asphyxia Pulmonary Cardiovascular Hemodynamics Metabolic Problems Infection Congenital Anomalies

Stabilization of the Transitioning Newborn Use Mnemonics! S = Sugar T = Temperature A = Artificial Breathing B = Blood Pressure L = Labs E = Emotional Support for the Family

Parental Support Before Delivery At Delivery During Transition Transfers

Review Transition period can last 6-12 hours Three phases of transition  Phase One- “Period of Reactivity” 1-2 Hours  Phase Two- “Sleep Period” 1-4 Hours  Phase Three- “Second Period of Reactivity” 2-8 Hours

Any Questions ?