2. THE NEWBORN I had heard about the negatives---the fatigue, “I had heard about the negatives---the fatigue, the loneliness, loss of self. But nobody the loneliness, loss of self. But nobody told me about the wonderful parts: holding told me about the wonderful parts: holding my baby close to me, seeing his first my baby close to me, seeing his first smile, watching him grow and become more smile, watching him grow and become more responsive day by day.....For the first responsive day by day.....For the first time I cared about somebody else more than time I cared about somebody else more than myself, and I would do anything to myself, and I would do anything to nurture and protect him.” nurture and protect him.”

4. Newborns undergo profound physiologic changes at the moment of birth. Within minutes after birth, a newborn has to initiate respirations, and adapt a circulatory system to extrauterine oxygenation. Within 24 hours, neurologic, renal, endocrine, and gastrointestinal functions must be operating competently for life to be sustained. Newborns undergo profound physiologic changes at the moment of birth. Within minutes after birth, a newborn has to initiate respirations, and adapt a circulatory system to extrauterine oxygenation. Within 24 hours, neurologic, renal, endocrine, and gastrointestinal functions must be operating competently for life to be sustained.

6. Surfactant What is the function of surfactant? When is it produced? When it is sufficient to support extrauterine life?

7. Respiratory Changes Chemical Sensory/ Thermal Mechanical Initiation Initiation of of Breathing Breathing What part do each of these factors play in initiation of respirations in the neonate?

8. Chemical Events 1. With cutting of the cord, remove oxygen supply 2. Asphyxia occurs 3. CO 2 and O 2 and pH = ACIDOSIS 4. Acidotic state-- stimulates the respiratory center in the medulla and the chemoreceptors in carotid artery to initiate breathing

9. Mechanical Events 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 Fluid expelled Air Enters

10. Mechanical Events sAbout 60-110 ml. of fluid is squeezed out of the lungs as the chest is compressed s The remaining fluid evaporates or is reabsorbed by the blood vessels and lymphatics surrounding the lungs. s**When a baby is delivered in a presentation other than vertex, it takes longer for the lungs to rid themselves of the fluid

11. Sensory / Thermal 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

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

14. Fetal Circulation What is the flow of blood through the fetal heart? 1.____________ 2.____________ 3.____________ 4.____________ RA LA LV RV

15. Fetal Circulation

16. What is the stimulus for the change in circulation? What are the changes in circulation from Intrauterine to Extrauterine?

17. Intrauterine to Extrauterine 1. Infant takes first breath and the lungs inflate ______________ pulmonary vascular resistance Increased ______________ blood flow & pulmonary artery pressure _________. 2. Increase pressure in ____ atrium, ____ pressure in right atrium _________ of foramen ovale 3. The ______ arteriosus and ductus venosus close related to pressure changes and  ______ levels.

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

19. True / False An infant’s first breath results in reduced pulmonary vascular resistance, decreased left atrium pressure, and increased right atrium pressure Increase CO 2, decreased O 2, and increased pH help trigger initial breathing

21. Temperature Regulation  Why is the newborn at a DISADVANTAGE in maintaining a normal temperature ?

22. Minimizing Heat Loss in the Newborn is IMPERATIVE

23. 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. What are nursing interventions to decrease each of these?

24. 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

25. 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! Non Shivering Thermogenesis

26. Heat Maintenance PeripheralVasoconstriction Subcutaneous Fat Fat Curl up in fetal position

28. Blood Changes At birth, an infant has more RBC’s and higher hemoglobin and hematocrit levels than an adult Once proper oxygenation is established, the need for the high RBC’s diminishes

29. Lab values for Newborn hemoglobin – 14-20 g/dl hematoctrit – 43-63% WBC – 10,000-30,000/mm3 glucose – 45-96 mg/dl

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. What is the capacity of the newborns stomach? What is meconium? Why is it important for the newborn to pass this?

33. Hepatic and Liver Functions  iron storage and RBC production  carbohydrate metabolism  conjugation of bilirubin

34. –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

35. Physiological Jaundice What is Physiological Jaundice? What is the main cause?

36. Conjugation of Bilirubin  Where do we get bilirubin?  What is the difference in Unconjugated bilirubin and conjugated bilirubin?  Why does it need to be conjugated?

37. Fat Soluble Conjugation of Bilirubin is a conversion of to Water Soluble UnconjugatedConjugated by ___________________________________?

38. 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. Peak bilirubin levels are reached between days 3 & 5 in the term infant. Toxic levels are approximately 20mg/dl. 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

39. Renal / Kidney Changes 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

40. Immunologic Adaptation Active acquired immunity –Pregnant woman forms antibodies herself Passive acquired immunity –Mom passes antibodies to the fetus –Lasts from 4-8 months –Newborn begins to produce own immunity about 4 weeks of age

41. Behavorial / Sleep - Awake States –Sleep States: Deep or quiet sleep Active rapid eye movement/ light sleep –Alert States: Drowsy Wide awake/quiet alert Active awake/ active alert Crying

42. Which state is optimal for parent-infant interaction? Quiet Alert

43. Sensory Visual –Can follow and fixate on visual stimuli for short period of time Hearing –Alert to and searches for auditory stimulus Olfactory –Able to select people by smell Taste –Able to respond to different tastes Tactile –Sensitive to touch, cuddling, and being held

45. 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 !

46. Clamping of the Cord Cord should be clamped off about 1” from base of cord. Inspect the cord for 2 arteries and 1 vein.

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

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

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

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

51. 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?

52. 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

53. 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 )

54. 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.

55. 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

57. 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.

58. 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.

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

60. Daily Nursing Care  Need for warmth and dry  Need for protection from infection  Need for food  Need for attachment and loving  Need for bathing and cord care

61. Nutritional Needs The newborns diet must supply nutrients to meet the rapid rate of physical growth and development Daily caloric intake should be 110 - 120 calories / kg. / day

62. Circumcision It is not medically necessary. It is a personal decision of the parents. What is the priority nursing assessment following a circumcision? Explain? What is important to teach parents about care?