Conception & Fetal Development

Chapter 11

Conception and Fetal Movement

• Fertilization--union of an ovum and a spermatozoon--upper regions of the fallopian tube

• Fertilization occurs within 24-48 hours of ovulation and within 2 to 3 days of insemination, the average durations of viability for the ovum and sperm

• Zygote: a fertilized ovum and spermatozoon

Critical Thinking

The nurse is preparing a class on reproduction. The cell division process that results in two identical cells, each with the same number of chromosomes as the original cell, should be termed:

A) Mitosis.

B) Meiosis.

C) Gametogenesis.

D) Oogenesis.

Implantation• Zygote propelled toward the uterus• Implantation occurs 7 to 10 days after fertilization• Blastocyst: trophoblast & embryoblast cells• Trophoblast cells (become placenta) allow blastocyst to

burrow into endometrium & establish communication with maternal blood system

• Implantation usually high on posterior uterine wall• Trophoblast secretes human chorionic gonadotropin (hCG)

to ensure that corpus luteum remains viable to secrete estrogen and progesterone for first 2-3 months of gestation

Fetal Development

• Ovum: ovulation to fertilization• Zygote: fertilization to implantation• Embryo: day 15 to 8 weeks• Fetus: 8 weeks to birth• Conceptus: developing embryo or fetus and

placental structures throughout pregnancy• www.youtube.com/watch?v=aRQa_LD2m4&feature=related

• www.youtube.com/watch?v=HBBNu_dAGhs&feature=related

Embryonic and Fetal Structures

• Decidua: endometrium of uterus that grows thicker and vascular to support pregnancy• Deciduas basalis: directly under embryo• Deciduas capsulari: surrounds embryonic sac

• Chorionic villi- “fingers” of connective tissue that contain fetal capillaries at core• Extend into endometrium• Instrumental in production of placental hormones such

as hCG, hPL (human placental lactogen), estrogen and progesterone

Embryonic and Fetal Structures

• Umbilical Cord--made from the amnion and chorion (inner & outer fetal membranes)• One vein: carries oxygenated blood from the

placental villi to the fetus• Two arteries: carry deoxygenated blood from

the fetus back to the placental villi• Filled with Wharton’s jelly: protects vessels

and prevents compression

Embryonic and Fetal Structures• Amniotic Fluid

• Constantly being made by amniotic membrane--never becomes stagnant. Baby drinks, “breathes”, and excretes it.• Functions: cushion embryo, control temperature, permit symmetric growth & development, prevent

adherence of fetus to the amnion & allow freedom of movement, cushion cord• Normal amount at term: 800-1200 mL• Hydramnios: too much fluid (more than 2000 ml)--GI tract problem?• Oligohydramnios: too little fluid----(less than 400 ml)-- disturbance in kidney function?

• Complications of: hypoplastic lungs, joint abnormalities

Embryonic and Fetal Structures

• Placenta• Serves as the fetal lungs, kidneys and GI tract and as a

separate endocrine organ throughout the pregnancy• Placental circulation established as early as 3rd week of

pregnancy• Grows to 15-20 separate “lobes” called cotyledons• By wk 20, covers approx. 1/2 surface of internal uterus • No direct exchange of blood between the embryo and

the mother during pregnancy--exchange is through selective osmosis

Placenta

Placental Circulation

• Maternal blood from spiral arteries enters intervillous space of endometrium

• Fetal chorionic villi reach into endometrium• Membrane of chorionic villi is 1 cell thick• Exchange of nutrients/substances across cell

membrane by selective osmosis

Placenta

Placenta

Placental Circulation• Ways nutrients cross placenta:

• Diffusion: O2, CO2, Na, Cl• Facilitated diffuson: glucose• Active transport: essential amino acids & water-soluble

vitamins• Pinocytosis: gamma globulin, lipoproteins phospholipids,

large molecules & viruses

• Placental osmosis so effective almost all substances cross from the mother to fetus

• Important to carefully screen all medications expectant mother takes

Endocrine Function of Placenta

• Human Chorionic Gonadotropin (hCG) • Maintains production of estrogen and progesterone

from the corpus luteum

• Estrogen• Develops mammary glands in for lactation and

stimulates uterine growth

• Progesterone• Maintains the endometrial lining of the uterus

• Human Placental Lactogen (hPL)• Promotes mammary gland growth and regulates

maternal glucose, protein and fat levels (for adequate fetal nutrition)

Fetal Circulation Fetus derives oxygen and excretes carbon dioxide

from oxygen exchange in the placenta, NOT lungs Specialized structures in fetus shunt blood flow

away from non-functioning lungs to supply important organs of the body, especially the brain

Foramen ovale (right to left atrium) Ductus arteriosus (pulmonary artery to aorta) Ductus venosus (umbilical vein to inferior vena cava,

bypassing liver)

Critical Thinking• During a prenatal examination, an adolescent client

asks, "How does my baby get air?" The nurse would give correct information by saying:

A) "The fetus is able to obtain sufficient oxygen due to the fact that your hemoglobin concentration is 50% greater during pregnancy."

•B) "The lungs of the fetus carry out respiratory gas exchange in utero similar to what an adult experiences."

•C) "The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into your bloodstream."

Zygote Growth & Development

• Cephalocaudal• 3 germ layers:

• Ectoderm: CNS, & peripheral nervous system

• Entoderm: lungs, GI tract, bladder & urethra

• Mesoderm: heart, kidneys, reproductive system

• Organogenesis complete by 8 wks• Fetus vulnerable to teratogens during organ

formation

Fetal Development

Respiratory System• Alveoli & capillaries begin to form between the

24th and 28th weeks.• Surfactant, a phospholipid, is formed about the

24th week of pregnancy.• Prevents alveolar collapse and improves infant’s ability

to maintain respirations• Made up of lecithin (L) & sphingomyelin (S) which is

detected in amniotic fluid.• Surge of L at 35 wks signals lung maturity. L/S ratio

analysis then (by amniocentesis) tests fetal maturity (2:1 is maturity)

• Steroids given to mom (GA 24-34 wks) at risk of preterm delivery to help mature lungs

Fact

1 in 20 newborns has an inherited genetic disorder

Over 30% of pediatric admissions are for genetic-influenced disorders

Genetic Counseling Outline

• Genetic Counseling and considerations

• Assessment of genetic disorders: history, maternal serum screening, amniocentesis, ultrasound

• Ethical and legal considerations of genetic counseling

Genetic Disorders Inherited or genetic disorders Genetics

Study of why disorders occur Diploid: 46 chromosomes--body cells Haploid: 23 chromosomes--sperm & egg Autosomes: 22 pairs of homologous chromosomes

(matched pairs, one from each mom & dad) Sex Chromosome: last pair of XX or XY that

determines sex Karyotype: photo/pictorial analysis of person’s

chromosomes

Karyotypes

Genetic Disorders

• Problems with Number• Trisomies, monosomies, mosaicism

• Most often caused by nondisjunction (failure of paired chromosomes to separate during cell division) in egg or sperm

• Trisomy 21 (Downs), Trisomy 18, Trisomy 13

• Defect in sex chromosomes: Turner (girls, X), Klinefelter (boys, XXY)

• Problems with Structure• Translocations, deletions, additions

Modes of Inheritance

• Mendelian (single-gene) inheritance Phenotype: person’s outward appearance/expression of genes

Genotype: person’s actual gene composition

Homozygous/Heterozygous Dominant/Recessive

Phenotype vs GenotypeHomozygous vs Heterozygous

Dominant vs Recessive

Mendelian Inheritance

• Autosomal Dominant

• Affected person has affected parent

• 50% chance of passing the trait

• Males & females equally affected--dad can pass to son

• Autosomal Recessive• Can have clinically

normal parents, but both parents must be carriers

• 25% chance of affected child

• 50% chance child is carrier

• Males & females affected equally

What is the chance of my baby having the disease?

X Linked InheritanceX-Linked Recessive• No male to male

transmission• 50% chance carrier mom

passes to son who will be affected

• 50% chance carrier mom passes to daughters who become carriers

• Affected dads cannot pass to sons, but all daughters are carriers

X-Linked Dominant (Extremely rare)

• Fragile X syndrome• Heterozygous females

may be affected• No male to male

transmission• Affected fathers will

have affected daughters, but no affected sons

Genetic Counseling Purpose

Provide accurate information Provide reassurance Make informed choices Educate people about disorders

Nursing Responsibilities

Assess for signs and symptoms of genetic disorders

Offer support Assist in value

clarification Educate on procedures

and tests

Prenatal Diagnostic Testing

Prescreening counseling: Conditions detectable

by the screen Diagnostic test

available if screen is positive

Risk to mother & child of the test

Accuracy & limitations of the test

Assessing for Genetic Disorders

Ultrasound--best between 18-20 weeks• Detect head and craniospinal defects: anencephaly,

microcephaly, hydrocephalus • GI malformations: omphalocele, gastroschisis

• Renal malformations: dysplasia or obstruction

• Skeletal malformations: caudal regression, conjoined twins

• Fetal nuchal translucency: 10-13 weeks

Assessing for Genetic Disorders• Amniocentesis: 15 - 20 wks

• Risks: miscarriage, bleeding, infection• Maternal age ≥ 35• Hx of child with chromosomal abnormality• Parent carrying chromosomal abnormality• Mother carrying x-linked disease• Parent with in-born error of metabolism• Both parents carrying autosomal recessive

disease• Family hx of neural tube defects

Assessing for Genetic DisordersPg. 174, Table 7.2--Disorders diagnosed by amnio/cvs

• Chorionic villi sampling (CVS)• Biopsy & chromosomal analysis of chorionic villi

of placenta (transvaginal or abdominally)

• 8-12 weeks (earlier than amnio)

• Risks • Limb reduction syndrome• Excessive bleeding & pregnancy loss• Infection• Rh-Negative mom needs RhoGAM

• Advantages: 1st trimester,highly accurate, quicker results than amnio

Assessing for Genetic Disorders Maternal Serum Screening

AFP (alpha-fetoprotein): done at 15-18 wks of pregnancy Abnormal value:

HIGH: suspect open neural tube defect, anencephaly, omphalocele or gastroschisis

LOW: suspect Down syndrome Detects 85-90% neural tube defects & 80% Downs Inaccurate dating of pregnancy is common cause of false

positive If positive:

Ultrasound and amniocentesis

Physiological Changes of Pregnancy (Chapter 14)

• Causes: hormonal changes, growth of the fetus, or mom’s physical adaptation

• Affect all organ systems• Allow oxygen & nutrients

for fetus and mom• Ready body for labor, birth

& lactation

Reproductive System• Amenorrhea: FSH suppressed by estrogen--no ovulation• Uterus: growth (hypertrophy & hyperplasia), increased

blood flow (1/6 of total maternal blood volume), Braxton Hicks

• Cervix: Goodell’s sign (softening), Chadwick’s sign (blue color), mucous plug seals endo cervical canal, ↑discharge (mucorrhea)

• Vagina: hypertrophy, ↑vascularization & hyperplasia, ↑secretions & acidity, Chadwick’s sign

• Breast changes: growth,↑veins, darkening & increase in size of areola, colostrum ay 12th wk

Systemic Changes

• Respiratory-↑tidal volume, ↑RR, SOB, nasal congestion, epistaxis

• Gastrointestinal- N/V, ↑saliva, smooth muscle relaxtion causes peristalsis to slow, displacement of intestines & stomach → heartburn, bloating, constipation

• Urinary-↑glomerular filtration rate & renal plasma flow, frequency, nocturia, UTIs common (can cause PTL)

• Integumentary- striae gravidarum, linea nigra, melasma, spider veins, sweat & sebaceous gland hyperactivity

Cardiovascular• Blood volume ↑ 30-50% for a single baby

• Hemodilution “pseudoanemia”• Anemia in pgncy: Hgb < 11. Hematcrit < 30%• ↑fibrinogen & clotting fx: hypercoaguable state (DVT)

• Cardiac output ↑30-50%, HR ↑15-20 BPM, palpitations

• Blood pressure ↓2nd trimester, then returns to normal baseline

• Gravid uterus causes vena cava compression (supine hypotension syndrome), Orthostatic hypotension

• Venous pressure increases in legs--edema, varicosities, hemorrhoids

MATERNAL POSITION & BLOOD FLOW

supine

side lying

Systemic Changes• Musculoskeletal: sacroiliac, sacrococcygeal & pubic joints

relax, increased lordosis (low backache), possible diastasis recti (separation of rectus abdominis)

• Metabolism increases: ↑water retention;↑absorption of protein, fats;↑insulin production; body temperature increases

• Endocrine:↑thyroid/BMR; pancreas: ↑insulin;

• Hormones of Pregnancy (corpus luteum, then placenta): human chorionic gonadotropin (hCG), human placental lactogen (hPL), estrogen, progesterone relaxin

Critical Thinkng• Which of the following are diagnostic (positive)

signs of pregnancy?

A) morning sickness, enlargement of the abdomen, fetal movement

B) an auscultated fetal heart rate, fetal movement, and a visualized fetal by ultrasound

C) positive pregnancy test, enlargement of the abdomen, nausea & vomiting

D) amenorrhea, nausea & vomiting, fetal movement

Signs of Pregnancy• Presumptive signs: N/V, fatigue, breast tenderness,

amenorrhea, urinary freq.

• Probable signs: Lab tests, Changes in pelvic organs: Chadwick’s, Goodell’s & Hegar’s signs, enlargement of abd,

• Positive signs: US evidence of fetal outline, fetal heart audible, fetal movement felt by examiner

Psychological Response to Pregnancy

• Role changes: partner?, parenting role, social roles

• Developmental stage with its own tasks

• Family dynamics very important

• Can be a crisis stage -may be cause of abuse

Psychological Responses of Mother

• Intendedness• Ambivalence: normal response• Acceptance: quickening (20 wks)--baby is “real”

Psychological Tasks of Mother

Tasks to develop self-concept as mother• Ensuring safe passage

• Seeking acceptance of child by others

• Seeking commitment and acceptance of self as mother (binding-in)--attachment formed

• Learning to give of oneself on behalf of one’s child

Schedule of Prenatal Visits

• Every 4 weeks for first 28 weeks of gestation

• Every 2 weeks until 36 weeks of gestation

• Every week from 36 weeks until birth

Prenatal Care

• Essential for ensuring overall health of newborns & moms

• ↓Low birthweight babies

• ↓Complications

• Should be begun early

• Preconception visit

• As soon as woman learns of pregnancy

Purposes of Prenatal Care

• Establish baseline of present health

• Determine gestational age of fetus

• Monitor fetal development

• ID women at risk for complications

• Minimize risk of possible complications

• Provide time for education

First Prenatal Visit• Extensive health history (pg 339)• Screening tool that IDs factors that may adversely

affect the pregnancy• Family/social profile• Hx of past illness, family illnesses, current medical

history• Gynecologic history• Obstetric history• Identify high risk factors (Table 15-2, pg 342)• Establish rapport & trust

Obstetrical History--G/P

• Gravida: any pregnancy, including present• Nulligravida: never been pregnant

• Primigravida: in first pregnancy

• Multigravida: 2nd or more pregnancy

• Para: birth after 20 wks gestation (before 20 wks: spontaneous abortion (SAB)• Nullipara: never given birth at > 20 wks

• Primipara: has had 1 birth > 20 wks

• Multipara: 2 or more births > 20 wks

• Multiples such as twins are counted as ONE birth

G/P

• Susie Smart is pregnant. • She has four sons at home:

twins born in 1996 at 34 weeks,then singletons born in 1998, and 2001. She had 1 miscarriage in 2000.

What is her Gravida/Para?

G = 5

P = 3

Obstetrical History--G/PP =TPAL

• G = gravida, # of pregnancies• P is further broken down & multiples are counted:

• T = # of term infants born (37 wks+)

• P = # of preterm infants (> 20, < 37 wks)

• A = # pregnancies ending in spontaneous or therapeutic abortion (SAB/TAB)

• L = # of currently living children

G/P vs GTPALSusie Smart is pregnant. She has four sons at home: twins born in 1996 at 34 wks, then singletons born in

1998, and 2001. She had 1 miscarriage in 2000.

• What is her G/P?

G = 5

P = 3

• What is her GTPAL?

G = 5

T (term) = 2

P (preterm) = 1

A (abortions) = 1

L (living) = 4

Example

• Nancy Tam is seeing the MD for her first PN visit. She has 4 kids at home, two of whom are twins and were born at 33 wks. She has had 1 miscarriage and 1 abortion.

What is her gravida/para?• G6 P3 AB 2 (SAB 1 & TAB 1)

What is her GTPAL?• G6 T2 P1 A2 L4 or (G 6 P 2224)

????

• Tracy H. is pregnant. She has one son at home born at 38 wks. Her 2nd pregnancy ended at 10 wks gestation. She then had twins at 30 wks. One twin died soon after birth. • What is her G/P?

• G 4 P 2 AB 1

• What is her GTPAL?

• G 4 P 1112

Estimated Birth Date (EDC/EDD/EDB)

• Use LMP (last menstrual period)

First Prenatal Visit(Assessment Guide, Pg. 345)

• Complete Physical Exam• Pelvic exam: external genitals, vagina, cervix

• Signs of pregnancy (Goodells, Hegars, Chadwicks)• Pelvic measurements: diagonal conjugate, obstetric

conjugate, ischial tuberosity diameter

• Sterile speculum, pap smear (infection, discharge, growths?)GC, Clamydia cultures

Laboratory WorkPg. 349

• CBC• ABO & Rh type• Antibody screen• Rubella titer• VDRL or RPR (syphillis)• Hepatitis B surface antigen• Gonorrhea culture• Chlamydia culture• Alpha-fetoprotein @ 14 wks

• HIV screen • Urine: glucose, protein &

ketones by dipstick. • Urinalysis: RBCs,

leukocytes, bacteria• Hereditary disease

screening • Sickle cell• Tay-sachs• Cystic fibrosis

Assessment of Growth & Development(Confirm dating of pregnancy)

• Estimating fetal growth:

• Fundal height: symphysis to top of fundus

• McDonald’s Rule: Between wks 22-34 fundal height in cms should match no. of weeks gestation (± 2 cm)

• Milestones:

• 12 weeks: fundus clears symphysis

• 20 weeks: fundus at umbilicus

• 36 weeks, fundus at xyphoid

Assessing Fetal Development Fetal Movement/Heartbeat/Ultrasound

• Quickening: fetal movement felt by mom between 18-20 weeks (fetal movement record- pg 385)

Fetal heart tones by doppler (intermittent) or ultrasound transducer (continuous) Can be heard as early as 10th or 11th week of pregnancy

by Doppler Normal: 110-160 BPM

Ultrasound: gestational sac by 5-6 wks Crown-to-rump, biparietal measurements

Danger signs of Pregnancy(Table 15-3, pg 359)

• Gush of fluid from vagina• Vaginal bleeding• Abdominal pain• Temperature > 101/chills• Dizziness, blurry vision, double vision, severe headache,

epigastric pain, edema of hands/face, convulsions• Persistent vomiting• Oliguria, dysuria• Absence of fetal movement

The Amazing Newborn

Profile of a NewbornVital statistics

Weight: 2.5 to 3.4 kg. Immediately after birth. Establishes baseline. Baby may lose up to 5-10%.

Length: 18 - 21 inchesHead Circumference: 32 - 35 cmChest Circumference: 32 - 35 cmVital Signs: Heart Rate 120-160 bpm; Respirations

30-60 breaths/minute; Temperature 97.6- 98.6 axillary

Profile of a Newborn

Temperature: Can be unstable. Guard against loss due to:

ConvectionConductionRadiationEvaporation

Dry immediately with warm blankets

Cardiovascular Changes after Birth

• Closure of the ductus arteriosus/fetal shunts occurs when a neonate takes in oxygen through the lungs for the first time and when the lungs inflate, pressure in chest decreases (pulmonary artery)

• Common to have acrocyanosis, investigate central cyanosis (look at mucous membranes)

• Transition from fetal to postnatal circulation: “transitioning”

Critical Thinking• During a prenatal examination, an adolescent client

asks, "How does my baby get air?" The nurse would give correct information by saying:

A) "The fetus is able to obtain sufficient oxygen due to the fact that your hemoglobin concentration is 50% greater during pregnancy."

•B) "The lungs of the fetus carry out respiratory gas exchange in utero similar to what an adult experiences."

•C) "The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into your bloodstream."

Acrocynanosis

Cyanosis

Respiratory

• Breathing is a result of replacement of air for fluid• Takes longer for a c-section baby to initially

establish effective respirations because excessive fluid blocks air exchange space (baby’s chest not compressed and squeezed in birth canal)

Factors predisposing respiration problems

• Maternal history of diabetes

• Premature rupture of membranes

• Maternal use of barbiturates or narcotics close to birth

• Non-reassuring fetal monitoring strip

• C-section birth

• Cord prolapse• Low APGAR• Meconium staining• Prematurity• Postmaturity• Small for gestational age• Breech birth• Chest, heart or

respiratory tract anomalies

Newborn Assessment: Respiratory Distress

• 5 symptoms of respiratory distress• Tachypnea• Cyanosis • Nasal flaring• Expiratory grunting• Retractions

• Transition period (1-2 hrs post birth) vs signs of respiratory distress that persist

Sleep Wake Cycle

• Supine position decreases risk for SIDS

• Sleep 16 out of 24 hours, avg. of 3-4 hours at a time (wake q 2-3 for feeding)

• Don’t add cereal to diet till 4-6 months of age

• Infants should never sleep in parents’ bed

Gastrointestinal

• Accumulation of bacteria in GI tract necessary for digestion and synthesis of vitamin K

• Uncoordinated peristalsis• Limited ability to digest fats & starch (deficient enzymes)• Immature cardiac sphincter-regurgitates easily• Stools-

• 1st meconium, sticky tarlike• 2nd-3rd day- transitional (diarrhea like)• BF: 3-4 light yellow/day. Formula: 2-3 bright

yellow/day• Infants receiving phototherapy have bright green stools

as a result of increased bilirubin excretion

Urinary

• Very important to observe for first void• Urine light colored and odorless--kidneys do not

concentrate urine well

Immune System

• Prone to infection• Inability to form antibodies until 2 months of age:

most immunizations delayed until then• Born with passive antibodies (protect against diseases

such as polio, measles, diphtheria, pertusis, chickenpox, rubella & tetanus)

• Hepatitis B vaccine: babies exposed early in life have ↑risk of chronic liver problems• Positive mom: HBIG (Hep B immune globulin) and

vaccine for baby

Profile of a NewbornReflexes

• Neuromuscular function• Rooting reflex• Sucking reflex• Swallowing reflex• Palmar grasp reflex

Profile of a Newborn

Neuromuscular functionMoro reflexBabinski reflexCrossed extension

reflex

Moro or “startle” reflex

Senses

• Hearing- yes

• Vision- “light” and “dark” in the first months. Approx 18” range.

• Touch- well-developed

• Taste- can discriminate

• Smell- well-developed

Appearance of a Newborn

• Skin: Color should be pink• Cyanosis: mottling, acrocyanosis normal.

Investigate central cyanosis. Look at mucus membranes

• Hyperbilirubinemia: yellow tone to skin, sclera

• Pallor: usually caused by anemia: blood loss?, blood incompatibility?, internal bleeding?

• Harlequin sign: normal, immature circulatory system. Dependent side red, upper side pale.

Appearance of a Newborn

Skin• Birthmarks

• Hemangiomas: vascular tumors of skin

• Erythema toxicum: innocuous, pink, papular neonatal rash

• Milia: unopened sebaceous glands--tiny, white, pinpoint papules on nose, etc.

Erythema toxicum-newborn rash

Birthmarks• Mongolian Spots: hyperpigmentation (usually

disappear by school age)

Appearance of Newborn

• Skin•Vernix caseosa: white, cream cheese-like

substance, natural lubricant

•Lanugo: fine downy hair on body

•Desquamation: dry, peeling

Appearance of a Newborn

Head: large-1/4 body length

• Fontanelles

• Sutures

•Molding

• Caput succedaneum

• Cephalhematoma

Head• Fontanelles: Anterior closes at 12 to 18 mos. Posterior

closes at 2 mos.• Sutures: separation indicates ↑ intracranial pressure. Fused

sutures abnormal--evaluate• Molding: common in vaginal births. Resolves in first few

days of life• Caput succedaneum: edema of the scalp-- crosses suture

lines. Disappears by day 3-4.• Cephalhematoma: blood between periosteum of skull bone

and bone itself. Does not cross suture line. Appears 24 hours after birth. May take weeks to disappear. May ↑ jaundice.

Appearance of a Newborn• Eyes: gray/blue. Permanent color after 3 mos.

Erythromycin (gonorrhea/chlamydia infection)

• Ears: level, recoil, newborn testing

• Nose: patency, choanal atresia?

• Mouth: symmetrical opening, inspect/palpate palate

• Neck: short, free rotation?, rigidity?, masses?

• Chest: symmetrical, no masses, retractions

Appearance of a Newborn• Abdomen: appears slightly protuberant, bowel sounds,

bulges/masses?, 3 vessels in cord stump?

• Anogenital area: imperforate anus• Male genitalia: meatus at tip, (hypo- or epi-spadias), testes descended• Female genitalia: pseudomenstruation

• Back: appears flat, for completion (no pinpoint opening, ✓sinus or dimpling)

• Extremities: all moving and symmetrical, legs bowed, clubfoot (talipes equinovarus), subluxated hip/hip dysplagia: check thigh & gluteal creases

Assessment for Well-Being• Apgar scoring--10 is perfect score

Done at 1, 5 & 10 minutes• Heart rate• Respiratory effort• Muscle tone• Reflex irritability• Color

• Normal Apgars at 1 minute: 7 to 10

Immediate Care at Birth

• Keep the newborn warm

• Promote adequate breathing pattern

• Inspection and care of umbilical cord

• Eye care

• Infection precautions

Critical Thinking•

The nurse is planning care for a newborn. Which of the following nursing interventions would best protect the newborn from the most common form of heat loss?

A) Pre-warming the examination table

B) Placing the newborn away from air currents

C) Drying the newborn thoroughly

D) Removing wet linens from the isolette

Care of Newborn At Birth

• Identification and Registration

• Identification Band• Birth Registration• Birth Record

Documentation (vitals, meds,labs)

Continuing Assessment for Well-Being

• Respiratory evaluation

• Physical examination• Height and weight

• Laboratory studies: cord blood collected

• CBC,

• ABO type & Rh,

• Direct Coombs if mom Rh - or Type O• C reactive protein if risk for infection

Assessment for Well-Being

• Gestational age – neuromuscular & physical maturity• Ballard Scale• Dubowitz Maturity Scale

• Useful in determining large for gestational (LGA) and small for gestational age (SGA)

• LGA/SGA: at risk for hypoglycemia BS < 40 mg/dL → feed immediately s/s: jitteriness, lethargy, seizures

SGA (IUGR) vs LGA babies

Periods of Reactivity (P. 690, Pilleterri)

• First Period 15-30 minutesAlert, acrocyanosis, body temp falls, irregular respirations,

vigorous reaction to stimuli

• Resting Period 30-120 minutes• Color, temperature stabilizing; respirations, HR slowing;

sleeping (hard to wake up)

• Second Period 2-6 hours• Quick color changes with crying/movement; temperature

increases; irregular respirations, HR; awake and responsive; first meconium passed

Nursing Care: Newborn and Family

• Initial feeding• Bathing• Sleeping pattern• Diaper area care• Newborn Screening Test

(PKU)

• Test for metabolic disorders

(inborn errors of metabolism)

• Done 24 hrs after first feeding

Nursing Care: Newborn and FamilyMedications

• Erythromycin opthalmic ointment• Vitamin K administration

• GI tract unable to produce Vitamin K (needed for blood coagulation)

• O.5 mg to 1mg IM in thigh• Side effects- local irritation

• Hepatitis B vaccination prior to discharge• HBIG if needed (first 12 hours)• Circumcision- per parent’s consent

Nutritional Allowances• Calories: 110 calories x kg/24 hours

• Protein: 2.2 g x kg/24 hours

• Fat: need linoleic acid

• Carbohydrates: lactose intolerance rarely present in newborn--switch to soy-based formula

• Fluid: supplied by breast milk or formula,

**do not supplement with water

Nutritional Allowances

• Minerals•Calcium• Iron: supplement formula-fed babies

• Fluoride: breastfeeding mom should drink fluoridated H2O. Make formulas with fluoridated H2O. Can supplement.

• Vitamins: No supplementation needed until 6 mos.

Breastfeeding Promotion

• WHO promotes Breastfeeding around the world

• APA advocates breastfeeding for 12 months

• Baby Friendly initiatives in hospitals

↑breastfeeding rates and duration

Breastfeeding

• Prolactin produced (stimulates milk production) when progesterone levels fall after placenta is delivered

• Colostrum- First milk produced: thick, creamy, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins and maternal antibodies--digestible. Has laxative effect to aid baby to excrete meconium.

11753398

Breastfeeding• Milk flows from lactiferous

sinuses

• Fore milk- constantly formed milk. Low in fat.

• As infant sucks, oxytocin is released from the posterior pituitary. Produces let-down reflex

• Let-down reflex- stimulation of baby at breast, sound of baby. Hind milk ejected.

• Hind milk is formed after the let-down reflex. Higher in fat and calories.

Infant Advantages in Breastfeeding

• Less infection: mom’s antibodies passed, breast milk has elements that prevent absorption of viruses & bacteria from GI tract and that kill/inhibit bacteria & viruses

- ↓ gastroenteritis and ↓ ear infections

• Ideal composition for human baby: electrolytes, minerals, linoleic acid, trace elements, hypoallergenic--reduces allergies

• Easy to digest• Reduces obesity, diabetes later in life

Maternal Advantages of Breastfeeding

• Protective function in breast cancer prevention• Release of oxytocin from the posterior pituitary

gland aids in uterine involution• Empowerment effect• Reduces economic costs• Bonding• Breast milk contains lysozymes that are involved in

destroying bad bacteria

Breast Feeding and Jaundice

• Jaundice occurs in 15% of breast fed babies• Pregnanediol (breakdown product of progesterone)

depresses an enzyme that converts indirect bilirubin to direct bilirubin (accumulation of indirect bilirubin)

• Encourage frequent feedings because colostrum is a natural laxative and helps promote passage of meconium and bile

Baby who is feeding well--”getting enough”

Breastfeeding

• Every 2-3 hours in first weeks• Promote adequate sucking• Provide support• Techniques for burping• Multiple infants• Engorgement

Problems in Breastfeeding

• Sore nipples• Supplemental feedings• Working outside of the home• Weaning• Engorgement• Mastitis

Formula Feeding

PreparationCommercial formulasFormula adequacySupplies neededFormula preparationFeeding techniques• 75 to 90 ml of fluid per

pound of body weight per day

Circumcision CareSurgical Removal of Foreskin

• Site covered with sterile petroleum

• Assess bleeding q 15 mins. for 1st hour, then q hour for 24 hr

• Note first voiding

• Apply diapers loosely to prevent irritation

• Teach parents to keep area clean & check diaper q 4 hours

• Notify provider for redness, discharge, swelling, strong odor, tenderness, decrease in urination or excessive crying of infant.

• Yellowish mucus “crust” may form over glans--normal, don’t wash off

• Avoid premoistened towlettes--use only water to wash

Circumcision Care

• Heals in a couple of weeks

• Monitor for complications: hemorrhage, cold stress/hypoglycemia, infection, urethral fistula, delayed healing and scarring, fibrous bands.

• Provide discharge instructions to parents about sign & symptoms to report to provider.

Discharge Teaching

• When to call healthcare provider:• Baby’s axillary temp > 100.4• > 1 episode of forceful (projectile) vomiting or frequent

vomiting over 6-hr period• Refusal of 2 feedings in a row• Lethargy, difficulty awakening baby• Cyanosis with or without feeding• Absence of breathing > 20 secs• Inconsolable crying or continuous high-pitched cry• Discharge/bleeding from umbilical cord, circumcision• No wet diapers for 18-24 hrs or < than 6-8 wet

diapers/day• Eye drainage

Hyperbilirubinemia• Hyperbilirubinemia: results from destruction

of red blood cells • Physiologic jaundice

• Normal physiologic process• Does not occur in first 24 hours of life• Home care

• Pathologic jaundice• Abnormal destruction of RBCs• Occurs in first 24 hours of life or persists after 1 week• Causes: hemolytic disease of newborn: Rh or ABO

blood incompatibility (mom Rh - or type O)

Hyperbilirubinemia

Physiological Jaundice (p. 690)• 2nd or 3rd day of life.• Breakdown of fetal red blood

cells.• Heme and globin realeased.

Heme breaks down into protoporphyrin which breaks down into indirect bilirubin & is excreted by liver in feces

• Baby’s liver is immature

Pathologic Jaundice

• Before 24 hours or persistent after day 7• Bilirubin increases more than 0.5 mg/dl/hr, peaks at

greater than 13 mg/dl or associated with anemia and hepatosplenomegaly

• Rh incompatibility/isoimmunization, infection, RBC disorder. ABO incompatibility: positive coombs test (test babies when mom O−/O+)

• Kernicterus (bilirubin encephalopathy) can result from untreated hypergbilirubinemia with bilirubin levels at or higher than 20 mg/dl → mental retardation

Risk Factors for Hyperbilirubinemia

• ↑ RBC production or breakdown (cephalohematoma, extensive bruising from birth trauma)

• Rh or ABO incompatibility• Ineffective breastfeeding & dehydration• Certain medications (aspirin, tranquilizers, and

sulfonamides)• Maternal enzymes in breast milk- fairly uncommon• Hypoglycemia• Hypothermia• Decreased liver function• Anoxia

Lab Testing

• Elevated serum bilirubin (direct and indirect)• Blood group incapability between the mother and

newborn• Hemoglobin and hematocrit• Direct Coomb’s test--reveals presence of antibody-

coated (sensitized) Rh-positive RBCs in the newborn• Electrolyte levels for dehydration from phototherapy

(treatment of hyperbilirubinemia)

Nursing Assessments ofHyperbilirubinemia

• Yellowish tint to skin, sclera and mucus membranes--observe by window

• Press infant’s skin lightly and release and notice yellowish tint

• Note time of jaundice (integral in differentiating between physiologic and pathologic jaundice)

• Treatments: early feedings, phototherapy, exchange transfusion

Neonatal ComplicationsRDS (Respiratory Distress Syndrome)

• Pathophysiology: • Low-level or absent surfactant • Inspiratory effort to inflate alveoli remains high• Pulmonary resistance prevents fetal shunts from

closing • Lungs are poorly perfused and tissue hypoxia

occurs with resultant acidosis

• Surfactant not formed until week 34

Neonates at Risk for Respiratory Distress Syndrome (RDS)

• Preterm infants• Infants of diabetic mothers• Infants born by cesarean • Perinatal asphyxia

• Decreased O2 tension in the lungs (one cause is meconium aspiration)

• Maternal factors: PROM, barbiturate/narcotic use, hypotension, bleeding

Assessment of Infants with RDS

• S/S usually don’t develop immediately post birth. First S/S are subtle:• Low body temperature• Nasal flaring • Expiratory grunting• Sternal and subcostal retractions• Tachypnea (> 60 respirations per minute)• Cyanotic mucous membranes

Assessment of Infants with RDS

• As distress continues:• Seesaw respirations• Heart failure• Pale, gray skin• Periods of apnea• Bradycardia• Pneumothorax

Therapeutic Management

• Administer surfactant through ET tube

• Oxygen administration (CPAP or assisted ventilation with PEEP)

• Ventilation

• Indomethacin or ibuprofen to close patent ductus arteriosus

Prevention of RDS

• Tocolytics (Magnesium Sulfate, Terbutaline, Procardia), corticosteroids (Betamethasone) usually given between 24-34 weeks

• L:S (lecithin:sphingomyelin) ratio is 2:1 in amniotic fluid (indicates fetal maturity)

Transient Tachypnea of Newborn

• When respiratory rate continues to remain high (between 80-120 breaths/min) after 1 hour mark

• Usually infant doesn’t appear distressed but instead tired from breathing too fast

• Usually mild retractions but no cyanosis• Feeding difficulties• Usually occurs from a slow absorption of lung fluid• More common in C-section babies & preterm infants• Peaks at 36 hours and usually resolves at 72 hours• TX: close observation, O2

Critical Thinking• The mother of a three-day-old infant calls the clinic and

reports that her baby's skin is turning slightly yellow. The nurse should explain to the mother that:

A) The baby is yellow because the bowels are not excreting bilirubin. B) The newborn's liver is not working as well as it should.

C) The yellow color indicates that brain damage may be occurring. D) Physiologic jaundice is normal and peaks at this age.

Critical Thinking• The nurse is caring for a newborn with jaundice. The parents question

why the newborn is not under the phototherapy lights. The nurse explains that the fiber optic blanket is beneficial because: (Select all that apply.)

A) The lights can be turned off intermittently.

B) The eyes do not need to be covered.

C) The lights will need to be removed for feedings.

D) Newborns do not get overheated.

E) Weight loss is not a complication of this system.