compromised newborn hatfield 1.8.19.pptx [read-only] · immediate neonatal conditions. 1/9/2019 6...
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CSI Baby!Early Recognition of the Compromised Newborn
Tanya Kamka, RNC-NIC, MSNUCSF Benioff Children’s Hospital
▪ Discuss maternal, fetal and intrapartum risk factors that contribute to a compromised newborn
▪ Describe the physiologic changes that must occur at birth for successful transition to extrauterine life
▪ Discuss the nursing assessments and interventions for an infant who becomes compromised
Course Objectives
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Recipe for Success When Caring for Compromised Newborns…(S.T.A.B.L.E.)
Anticipate Recognize Act Reassess
▪ Antenatal risk factors that can lead to a compromised newborn
▪ Maternal risk factors
▪ Fetal risk factors
▪ Intrapartum risk factors
Identifying newborns at risk
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▪ Age
▪ Lifestyle
▪ Support system
▪ Access to care
▪ Mental Health
▪ Chronic illness
▪ Genetics
▪ Stress
Maternal risk factors
• Prenatal Diagnosis– Genetics: CVS, amniocentesis
– Nuchal translucency
– Ultrasound
– Fetal ECHO
– Fetal MRI
• Entry to care• Pregnancy nutrition and weight gain
Prenatal Care
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• Obstetric History
○ Infertility
○ Past delivery history
○ Bleeding
○ PROM
○ Infection
○ Pregnancy loss
Maternal Factors
• Multiple gestation
• Abnormal growth
• Abnormal fetal position
• Abnormal placentation
• Decreased activity/FHR abnormality
• Poly/oligohydramnios
Fetal Factors
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• Fetal distress• Fetal presentation
• Premature/postmature labor
• Rapid or prolonged labor
• Rupture of membranes
• Maternal bleeding
• Cord prolapse
• Eclampsia
• Instrumentation at delivery
• Mode of delivery
• Medications
Intrapartum Factors
• Prematurity
• Low Apgars
• Encephalopathy
• Shock/pallor
• Chorioamnionitis
• Small for dates
• Large for dates
• Undiagnosed congenital anomalies/conditions
Immediate Neonatal Conditions
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▪ LBW ≤2500 gms▪ VLBW ≤1500gms▪ ELBW ≤1000gms
▪ SGA - Weight below the 10th percentile for gestational age
▪ IUGR - Fetus is unable to reach its genetically determined potential size
▪ LGA - Weight above 90th percentile for gestational age
▪ Macrosomia - Estimated fetal weight>4500gm in IDM and >5000gm in others
Birth Weight Categories & Classifications
Symmetric Asymmetric
IUGRLGASGA or IUGRAGA
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Slide 12
1 Does this make sense? I wanted to try and make a visual of the differencesTanya Hatfield, 5/18/2018
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▪Extreme prematurity ≤ 28 weeks
▪Very preterm < 32 weeks
▪Late preterm (LPI) 34 0/7‐36 6/7
weeks
▪Early term pregnancy 37 0/7‐38 6/7
weeks
▪Term pregnancy 39 0/7‐40
Maturity Classifications
Risks related to Prematurity
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Characteristics of the LPI
%
Low Birth Weight
Delay in bilirubin metabolism
Immature suck and swallow
Immature Immune system
Poor state regulation
Low tone
Low glycogen stores
Poor thermoregulation
Low Body Fat
Clinical Outcomes: Full term vs. LPI
Modified from Wang, et al. Pediatrics, 2004
%
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Post Maturity Risks
Post Maturity Risks
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Transition to Extrauterine Life
REMEMBER!Blood
follows thepath of least resistance
The fetus gets oxygen
from the placenta
Pressure in the blood vessels of the lungs is high
so blood is shunted away
Review of
FETAL SHUNTS
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Fetal Circulation▪ Gas exchange is liquid to liquid
▪ Organ of respiration is placenta
• High flow, low resistance
▪ Fetal lungs
• Low flow, high resistance
• Pulmonary Arteries constricted
▪ High right heart and lung pressures
▪ Low left heart pressures
▪ Open fetal shunts
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5 things must happen at birth:
• Lungs expand to terminal airways
• Alveoli become oxygenated
• Pulmonary Vasculature must dilate (↓ PVR)
• Cardiac output to lungs goes from 10% →100% (↑ SVR, closure of fetal shunts)
• Establishment of continuous breathing
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Transition to Extrauterine Life
• Independent breathing
• Fetal to neonatal circulation
• Non-shivering thermogenesis
• Independent glucose production
• Fluid balance shifts
Transition to Extrauterine Life
• Good news! 90% of infants transition with no
problem!
• But...10% require some assistance
• 1% require extensive resuscitation
• Remember… difficulty transitioning in one area will
affect the others
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What are the goals of Resuscitation?
● Maintain temp 36.5-37.5-Room 25C/77F-Skin to skin-Servo-Thermal devices
● Support breathing● Gentle ventilation● Judicious use of oxygen● Support cardio-respiratory transition● Normoglycemia
Do you know…???
A naked newborn exposed to an environmental temperature of 23°C (73.4°F) suffers the same
heat loss as a naked adult in 0°C (32°F)
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The function of brown fat is to:
a) generate heat when it is metabolized.b) provide a rapidly available source of glucose in the first day of life.c) provide an insulating layer of fat in the first month of life.
Cold Stress Response
• Peripheral and core sensors detect cold stress
• Hypothalamus signals norepinephrine release which leads to:
– Peripheral and pulmonary vasoconstriction
– Increased metabolic rate
– Increased 02 and glucose consumption
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The mother-baby unit is extremely busy today. An infant born several hours ago at 37-weeks gestation has the following vital signs:
Temperature 36.0°C (96.8°F) Heart rate 170 Respiratory rate 65You have a heavy patient load and need to bathe the infant. Should the infant be bathed at this time?
a) No, the vital signs are not in a normal range and the bath should waitb) Yes, providing a radiant warmer is used so the infant doesn't get coldc) Yes, the vital signs are in an acceptable range and the infant is term
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▪ Interventions• Delay interventions at birth that increase heat
loss (temp. affects other VS too)• Skin to skin care with mother immediately after
birth and as frequently as medical condition allows
• Dress infant with hat, double blankets if necessary
• Use servo-control and temp. probe while in warmer/incubator
Temperature Instability
▪ Interventions• Document ambient temperature/clothing
necessary to maintain optimal body temp• Assess carefully for cause of changes in
temperature
‒ Primary thermo-regulation vs. sepsis, respiratory issues, hypoglycemia
• Warm consistently: incubator, servo-control, monitor NTE, slow transition to OC, additional clothing when in open crib
• Notify provider of episodes of hypothermia
Temperature Instability
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Initial Assessments
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Cortical Thumb
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Port Wine Stain
Café Au Lait
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Sacral Skin Tag
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Sacral Dimple
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Size
▪ Alertness/activity level
▪ Symmetry of movement
▪ Response to stimuli
▪ Posture
▪ Tone
▪ Reflexes
Neurological Assessment
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Abnormal Newborn Exam
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Tone? Activity?
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Sarnat scoring (for encephalopathy)
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Assessment of the Baby at Risk for Encephalopathy
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Seizures▪ Quality of movement
• Tonic - stiff posturing
• Clonic – rhythmic single body part
• Subtle (ex bicycling, orofacial movements, tremulous movements)
• Myoclonic - rapid “shock-like”
• Erratic, non-rhythmic
▪Body part
▪ Level of consciousness
▪Response to stimulus: Extinguishable?
▪Duration
Seizures: what else could it be?Benign Neonatal Sleep Myoclonus
Typical presentation:• 1st DOL to 1st 3 weeks
of life• Distal parts of upper
extremities• 10-20 seconds• Can worsen with
restraint• Stops when awakened
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Seizures
▪Check Calcium and Glucose
▪ Lorazepam 0.1 mg/kg IV
▪Phenobarbital 20mg/kg IV
“This baby seems jittery…”
▪What is the history
▪When is the onset
▪Are there electrolyte abnormalities?
○ Hypoglycemia
○ Hypomagnesemia
○ Hypocalcemia
▪Hyperviscosity
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Hypoglycemia
How low is too low?
How low is too low for too long?
Hypoglycemia-Who is at Risk?▪Preemies
▪SGA
▪ IUGR
▪LGA
▪ IDM
▪Sick babies
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▪ High risk groups
• Inadequate glycogen stores and decreased glucose production
• Hyperinsulinemia
• ALL sick babies
‒ Metabolic acidosis/increased energy demands
‒ ↑ work of breathing, thermal regulation, etc
‒ Lack of excess oxygen for conversion
Hypoglycemia
Hypoglycemia
▪Abnormal cry
▪Apnea
▪Cyanosis
▪Feeding Difficulty
▪Grunting, Tachypnea
▪Hypothermia
▪Hypotonia
▪ Irritability
▪Jitteriness, tremors
▪Lethargy
▪Seizures
▪Diaphoresis
▪Tachycardia
▪NO SYMPTOMS
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UCSF NC2 Asymptomatic Infants/at-risk
UCSF NC2 Asymptomatic Infants-at risk