Download Newborn Health: Identifying Risks and Signs of Hypoglycemia and more Study notes Nursing in PDF only on Docsity!
C H A P T E R
C H A P T E R
The Healthy Newborn
Jeannette Zaichkin and Debbie Fraser Askin
Thomas was born 8 hours ago at 40 weeks’ gestation to a 34-year-old married
primipara. His mother had ongoing prenatal care and experienced no complications
during pregnancy, labour, or birth. Upon entering the room during a routine assessment,
the nurse finds Thomas lying on the bed, clothed in a shirt and diaper. His mother
sits in the bed next to him. As the nurse begins to take vital signs, Thomas has a
small emesis of breast milk. He gags and coughs; mucus comes through his nose. His mother is
visibly upset. “What is happening?” she asks, worriedly. “Is he choking?”
William is a full-term newborn whose parents have chosen to circumcise. The nurse is
providing the parents with instructions about the procedure. William’s father seems
concerned about how the circumcision will be done and the pain the baby will experi-
ence. He tells the nurse that he thinks it is important that he and his son are physi-
cally similar, but he feels bad about causing his child to experience any trauma. The
same nurse is providing care before, during, and after the procedure.
You will learn more about these clients as the chapter progresses. Nurses working with these and
similar families need to understand the material in this chapter to manage care effectively and
address issues appropriately. Before beginning, consider the following points related to the above
scenarios:
● How should the nurse individualize care to ensure that each family’s needs are met—not only in
terms of physical care, but also in terms of emotional and psychological care?
● What factors may be contributing to parental behaviour and reactions in these scenarios?
● Is there need for any additional assessment data or questions?
● What teaching might be appropriate for each family?
● What other health care personnel might assist in these scenarios?
On completion of this chapter, the reader should be able to:
● Identify the major differences between fetal circulation and newborn circulation.
● List three cardiopulmonary changes that must occur at birth for successful
extrauterine transition.
● Discuss immediate nursing interventions at birth for active and healthy full-term
newborns who are breathing and have pink mucous membranes.
● Describe appropriate calculation and use of Apgar scores.
● Identify signs of abnormal newborn transition.
● Describe collaborative strategies to promote normal newborn transition.
● Discuss the relationship between birthweight and gestational age.
● Describe normal and abnormal physical examination findings in newborns.
● Discuss four types of heat loss in newborns and preventive interventions for each.
● Identify two classifications of newborns at risk for hypoglycemia and six signs of
neonatal hypoglycemia.
● Explain why most healthy full-term newborns experience jaundice in the first
week of life.
● Explain why newborns are susceptible to infection.
● Identify infant behavioural states and cues.
● Identify risk factors for Sudden Infant Death Syndrome (SIDS).
● Describe an approach for assessing cultural differences in newborn care.
● List newborn care topics for parent education.
L E A R N I N G O B J E C T I V E S
acid mantle
acrocyanosis
Apgar score
apnea
approach cues
appropriate for gestational age (AGA)
avoidance cues
Ballard Gestational Age Assessment Tool
bilirubin
bradycardia
brick dust spots
brown adipose tissue
circumcision
circumoral cyanosis
cyanotic
ductus arteriosus
foramen ovale
free-flow oxygen
functional residual capacity
grunting
hypoglycemia
hypoxemia
hypoxia
indirect (conjugated) bilirubin
jaundice
lanugo
large for gestational age (LGA)
low birthweight (LBW)
meconium
meconium-stained amniotic fluid
nasal flaring
neutral thermal environment
nonshivering thermogenesis
occipital–frontal circumference
periodic breathing
petechiae
phototherapy
physiologic jaundice
pink
plethoric
postterm
preterm, premature
pseudomenses/pseudomenstruation
radiant warmer
retractions
small for gestational age (SGA)
Sudden Infant Death Syndrome (SIDS)
surfactant
tachycardia
tachypnea
term
total bilirubin
unconjugated bilirubin
vagal reflex
vernix caseosa
very low birthweight (VLBW)
witch’s milk
K E Y T E R M S
776 ● U N I T 5 Postpartum Period and Newborn Care
Clear Airways First breaths must be strong enough to move the thick fluids that fill the fetal airway from the trachea to the ter- minal air sacs. Fetal lungs hold approximately 10 to 30 mL of fluid/kg of fetal body weight. Thus, the lungs of a new- born weighing 3000 g hold approximately 30 to 90 mL of fluid (Blackburn, 2007). Fortunately, production of fetal lung fluid begins to decrease before labour begins (Blackburn, 2007). Release of catecholamines is associated with labour and may stim- ulate the lungs to stop secreting fluid (Askin, 2002), so that the baby must clear only a fraction of the original lung fluid volume at birth (Blackburn, 2007). In those cases in which the mother does not experience labour and expo- sure to catecholamines, the newborn is at risk for retain- ing lung fluid and developing transient tachypnea (Askin, 2002; Polin & Fox, 2004) (see Chap. 22). For breathing to begin, liquid in the lungs must be re- placed with an equal volume of air, and functional resid- ual capacity must be established (Blackburn, 2007). This
means that the newborn’s first breaths must be deep enough to displace the liquid in the airways and retain some air in the alveoli so that subsequent breaths are less difficult. A fatty substance acts as a surfactant and causes retention of air in the lungs, decreasing surface tension at the air–liquid interface (Blackburn, 2007). The surfactant consists of phospholipids and proteins produced by type II cells in the lining of the alveoli and secreted onto the alveolar surface. This surfactant is essential to normal lung function because it allows the alveoli to remain open instead of collapsing completely during exhalation. By 28 to 32 weeks’ gestation, the number of type II cells increases. Surfactant production peaks at about 35 weeks’ gestation. By 32 weeks, 60% of fetuses have adequate surfactant to support extrauterine respira- tion. Surfactant deficiency results in respiratory distress syndrome (Blackburn, 2007) (see Chap. 22). With the first few breaths, alveolar fluid is absorbed into the lung tissue and the alveoli fill with air. The lym- phatic system reabsorbs 10% to 20% of the lung fluid
First breath is taken
Lungs expand
Alveolar oxygen content rises
SVR rises in aorta
Foramen ovale starts to close
Ductus arteriosus starts to close and pulmonary vessels dilate
Lungs replace placenta as medium for gas exchange (^) Higher SVR provides blood flow to entire body through aorta
Falling PVR makes it easier for blood to flow to lungs
Rising SVR makes it harder for blood to flow into aorta and easier for it to flow into lungs
Fetal pattern of shunting from right to left away from lungs ceases, and some blood starts to flow toward lungs
First breath is taken
What happens on the right side (pulmonary) of the cardiac circuit when the cord is clamped:
What happens on the left side (systemic) of the cardiac circuit when the cord is clamped:
FIGURE 20.1 Transition from fetal to neonatal circulation. PVR, pulmonary vascular resistance; SVR, system vascular resistance. (From Lockridge, T. [1999]. Persistent pulmonary hyper- tension of the newborn.Mother Baby Journal, 4[2], 22.)
C H A P T E R 2 0 The Healthy Newborn ● 777
(Polin & Fox, 2004). Aeration and increased oxygen ten- sion increase alveolar blood flow and the capillaries’ abil- ity to remove fluid. When these systems work efficiently, they disperse lung fluid in the first few hours after birth (Blackburn, 2007). This explains why newborns have audible crackles for a short time after birth. Residual air is retained in the lungs from the early breaths; within 1 hour after birth, 80% to 90% of functional residual capacity is created (Blackburn, 2007).
Blood Circulation Clamping of the umbilical cord shuts off the placental circuit and causes rapid changes in pulmonary vascular resistance and systemic vascular resistance. With the low- resistance pathway removed, systemic vascular resistance increases. Other contributors include increased arterial blood volume, because the blood that previously had a placenta to return to remains in the vascular system (Blackburn, 2007). This increased systemic vascular resistance reduces right-to-left shunting and sends blood through the lungs rather than allowing it to detour through the foramen ovale and ductus arteriosus. The foramen ovale closes and seals as changes in circulatory pressures reduce pres-
sure on the right side of the heart and increase pressure on the left side. Rising oxygen levels cause the other fetal shunt, the ductus arteriosus, to begin to constrict almost immediately after birth of a healthy newborn. In most cases, the ductus arteriosus is functionally closed by 96 hours of life; full anatomic closure with formation of a fibrous strand known as the ligamentum arteriosus is complete within 2 to 3 months (Blackburn, 2007). The ductus can reopen, however, in response to hypoxia (abnormally low oxygen concentration in tissues) or increased pulmonary vascular resistance. This return to fetal circulation, called pulmonary hypertension, results in a dangerous cycle of hypoxia and pulmonary vasocon- striction (Fig. 20.2). Thus, attaining and maintaining adequate ventilation and oxygenation in newborns and avoiding procedures that cause hypoxia, such as deep suctioning, are important concerns (see Chap. 22). With gaseous distention and increased oxygen in the alveoli, the pulmonary blood vessels begin to dilate and relax. Vasodilation of these arterial vessels decreases pul- monary vascular resistance in the newborn by nearly 80%, which increases blood flow through the lungs and mini- mizes blood flow through the fetal shunts (Blackburn, 2007). Adequate oxygen is now available from the lungs
Hypoxia occurs
Pulmonary blood vessels constrict (pulmonary vasoconstriction)
Unoxygenated blood is returned to body through fetal shunts
Blood follows path of least resistance to avoid high pressure in lungs
Pressure in aorta (SVR) is lower than pressure in lungs (PVR). Blood flows to aorta in right-to-left shunt to avoid lungs
Pressure rises in lungs (PVR increases) as blood vessels constrict
FIGURE 20.2 Cycle of inadequate ventilation/oxygenation at or shortly after birth. PVR, pulmonary vascular resistance; SVR, system vascular resistance. (From Lockridge, T. [1999]. Persistent pulmonary hypertension of the newborn.Mother Baby Journal, 4[2], 23.)
Fig. 2
C H A P T E R 2 0 The Healthy Newborn ● 779
arranged identically in every room to ensure that any member of the resuscitation team can always find them in the same location (Zaichkin, 2006). Ideally, every birth is attended by at least one per- son whose primary responsibility is the baby and who is
capable of initiating resuscitation. Either that person or someone else who is immediately available should have the skills required to perform a complete resuscitation (Assessment Tool 20.1). This means that the person des- ignated to attend the newborn has no other responsibil-
● ASSESSMENT TOOL 20.1 ???
Yes
No (^) Breathing HR > & Pink
Effective ventilation HR > & Pink
Breathing, HR > & Cyanotic
Pink
Apneic or HR <
Persistently cyanotic
HR <60 HR >
HR <
Birth
Approximate time 30 sec***
- Term gestation?
- Clear amniotic fluid?
- Breathing or crying?
- Good muscle tone?
- Evaluate respirations, heart rate, and colour
- Provide warmth
- Position; clear airway* (as necessary)
- Dry**, stimulate, reposition
Routine Care
- Provide warmth
- Clear airway (as necessary)
- Dry
- Assess colour at 90 seconds of age - Cyanotic
Observational care
- Provide positive-pressure ventilation with 100% oxygen*
- Administer chest compressions*
- Administer epinephrine*
Endotracheal intubation may be considered at several steps. Drying the skin does not apply for babies <28 weeks; these babies should be placed wet into a food-grade polyethylene bag below the neck. Evaluate respirations, heart rate and colour every 30 seconds.
- Give supplemental oxygen IF > seconds of age
- Provide positive-pressure ventilation* with 21% oxygen if <90 seconds of age OR supplemental oxygen if
90 seconds of age
Post-resuscitation care
Recheck the effectiveness of
- Ventilation
- Chest compressions
- Endotracheal intubation
- Epinephrine delivery Consider possibility of
- Hypovolemia
**
AT
780 ● U N I T 5 Postpartum Period and Newborn Care
ities at this time, is capable of assessing the need for resuscitation, and can competently perform initial steps of resuscitation, bag-and-mask ventilation, and chest com- pressions. If complex resuscitation is necessary, someone who is competent to perform procedures such as endo- tracheal intubation or medication administration should be available immediately (Kattwinkel, 2006). If a high-risk birth is anticipated, the nurse should follow the health care facility’s protocol for assembling a team of skilled resuscitation providers to attend the birth. Team composition varies, but may include a pe- diatrician, neonatologist, neonatal nurse practitioner, respiratory therapist, and neonatal nurses.
Assessment During the First Moments After Birth
The nurse assigned to care for the newborn should begin assessment as soon as the baby emerges. Although most newborns require no assistance to begin breathing, the newborn admission nurse needs to assess each baby in the first seconds and decide if he or she requires assis- tance (Kattwinkel, 2006). The nurse should ask four questions to assess the need for intervention:
- Is the amniotic fluid clear of meconium (the newborn’s first stool)? In some instances, such as fetal distress or breech birth, this thick, dark-green substance is released during labour. Meconium can enter the fetal airways in utero and be aspirated with the newborn’s first breath. If meconium is in the amniotic fluid or on the skin and the newborn is not breathing and active, special handling and airway suctioning are neces- sary to prevent life-threatening airway complications (Kattwinkel, 2006) (see Chap. 22).
- Is the baby breathing or crying?
- Is the baby demonstrating some muscle tone (flexed position)?
- Is the baby full term (38 to 42 weeks’ gestation)? If the answer to any of these questions is “no,” the nurse should quickly move the baby to the radiant warmer for initial steps of resuscitation. A radiant warmer is a mattress on a cart, with a heat source above it, used to warm the newborn or to prevent cooling during proce- dures that require exposure (Fig. 20.3). The nurse places the infant supine with the head in “sniffing position,” the optimal position for opening the airway, and uses a bulb syringe to clear the mouth first, then the nose (wall suc- tion is usually reserved for intubation or prolonged re- suscitation). Then the nurse dries the newborn with a towel, removes the wet linen, and places the baby supine with the head in “sniffing position.” He or she should assess respiratory efforts, heart rate, and colour. If the newborn is breathing and has a heart rate of greater than 100 beats per minute (bpm) but remains dusky or cya- notic after 90 seconds, the nurse should direct free-flow
oxygen to the nose and mouth. This type of oxygen is higher than 21% and blows passively through oxygen tubing, an oxygen mask, or the mask of a flow-inflating oxygen bag. If the baby becomes and stays pink without supplemental oxygen and shows no signs of respiratory distress, the nurse may return him or her to the mother and family members. A newborn who simply requires tactile stimulation and a few moments of free-flow oxygen is considered healthy but receives observational care, which entails more frequent assessment and closer monitoring than a newborn who requires minimal intervention and receives routine care (Kattwinkel, 2006). If the baby does not respond to oxygen by turning pink, turns blue without supplemental oxygen, remains limp, or displays signs of respiratory distress, the nurse should keep the newborn under the radiant warmer for further evaluation and stabilization. If the baby is not breathing after suctioning, drying, and repositioning, the nurse should begin bag-and-mask ventilation. Most babies begin to breathe spontaneously within 30 seconds of bag-and-mask ventilation. If assessment at this point reveals apnea (no breathing for 20 seconds or more) or heart rate below 100 bpm, the nurse should provide bag-and-mask ventilation with supplemental oxygen. He or she may wish to activate the emergency response system to assemble additional members of a resuscita- tion team, especially if the heart rate is below 60 bpm and chest compressions are needed. At this point, com- plex resuscitation is under way, and the newborn is not considered healthy. Any newborn needing bag-and- mask ventilation or more complex interventions requires
FIGURE 20.3 The newborn is placed under the radiant warmer to assist with thermoregulation.
Fig. 3
782 ● U N I T 5 Postpartum Period and Newborn Care
● (^) G: Grimace (reflex irritability) ● (^) A: Activity (muscle tone) ● (^) R: Respiration (respiratory effort)
Each component is assigned a value of 0, 1, or 2; the five numbers are then added. Scoring is done at 1 minute and 5 minutes after birth. To help ensure accuracy, scor- ing should occur at the 1-minute and 5-minute marks, not retrospectively (Apgar, 1966). The Apgar score does not determine resuscitation efforts; therefore, resuscitative efforts are not delayed while waiting for the 1-minute Apgar to be determined. If the newborn does not attain a 5-minute score of at least 7, additional scores are assigned every 5 minutes up to 20 minutes (Kattwinkel, 2006). Because Apgar scoring should be objective, Dr. Apgar suggested that an impartial observer, not the delivering practitioner, assign the scores (Apgar, 1966). In most cases, the person responsible for newborn resuscitation and admission assigns the Apgar scores of a healthy newborn. If the newborn requires resus- citation, a collaborative effort from all resuscitation team members, in conjunction with narrative docu- mentation of interventions and their timing, ensures an accurate record of events. Most healthy full-term newborns receive 1-minute scores of 7 to 9 and 5-minute scores of 8 or 9. Because pink hands and feet are rare in the first few minutes of life, a perfect score of 10 is unusual. New criteria appear on the revised and expanded Apgar chart introduced by the American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) in 2006. The criteria allow for the different responses expected at birth from a preterm newborn or a baby requiring resuscitation, and more accurately describe the newborn’s responses result- ing from a resuscitation intervention (AAP & ACOG, 2006, CPS 2007c). The Apgar score alone is not sufficient evidence on which to predict neurologic outcomes in term newborns. The difference between 1-minute and 5-minute Apgar scores reflects the effectiveness of resuscitation efforts.
An Apgar score of 0 to 3 at 5 minutes may correlate with neonatal mortality but does not necessarily predict later neurologic dysfunction (AAP & ACOG, 2006). Apgar scoring is standard practice and a useful tool for documenting the newborn’s responses to the extra- uterine environment and resuscitation efforts. In addition to Apgar scores, complete documentation, including a narrative description of the newborn’s behaviour and re- sponses to interventions, is essential to a complete med- ical record.
Recall Thomas, the 8-hour-old newborn
described at the beginning of the
chapter. Suppose he had an Apgar
score of 5 at 1 minute and 6 at
5 minutes. How would the nurse proceed?
COLLABORATIVE CARE:
IMMEDIATE NEWBORN CARE
The team responsible for the newborn needs to ensure that the plan of care is clear and agreed upon before birth and well in advance of the final moments of labour. The nurse who has been involved in maternal intrapartum care and who shifts her responsibilities to the newborn should already have assessed family preferences for involvement in the first few minutes after birth. The nurse assigned to perform newborn admission may need to clarify the plan with the family and the labour and delivery team; he or she should check the prenatal and intrapartal history and clarify any risk factors. The new- born admission nurse usually asks the labour nurse if there are any new risk factors with implications for the new- born, such as abnormalities in fetal heart rate, meconium staining, maternal fever, prolonged rupture of membranes, or recent maternal narcotic administration. Family preferences may include the partner’s wish to cut the umbilical cord, the mother’s preference to re-
● ASSESSMENT TOOL 20.2 Apgar Scoring System
Score Sign 0 1 2
Colour Heart rate Reflex irritability Muscle tone Respirations
Completely pink ≥ 100 bpm Cry or active withdrawal Active motion Cry or active withdrawal
Blue or pale Absent No response Limp Absent
Acrocyanotic Slow (<100 bpm) Grimace Some flexion Weak cry: hypoventilation Source: AAP & ACOG (2006). The Apgar Score. Pediatrics, 117 (4), 1446.
C H A P T E R 2 0 The Healthy Newborn ● 783
ceive the newborn on her chest immediately after birth, or the family’s desire to wait to hold the baby until he or she has been dried. A client giving her newborn to an adoptive family may have specific wishes about seeing and holding the baby. The nurse should ask the family about cultural or spiritual beliefs that influence admis- sion procedures and adapt routine policies to accom- modate reasonable requests. The nurse’s responsibility to facilitate integration of the newborn into the family begins immediately at birth; however, if the newborn requires resuscitation or intervention, nursing and med- ical care take precedence. Following such an emergency, the nurse should make sure to include the mother and support partners in the newborn’s plan of care.
Assessment
At birth, the nurse should assess many parameters simul- taneously (Kattwinkel, 2006):
● (^) Any meconium on the newborn’s skin ● (^) Breathing ● (^) Muscle tone ● (^) Heart rate (by palpating the umbilical pulse) ● (^) Reflex irritability (grimacing response to bulb suction or gagging on mucus) ● (^) Approximate gestational age ● (^) Colour
The experienced neonatal nurse also assesses approx- imate weight and, by doing so, compares it to expected gestational age. If the newborn appears smaller or larger than average, the nurse should be prepared to address risk factors requiring immediate intervention, before a complete physical examination. He or she also should quickly inspect the baby, scanning for unusual variances or congenital anomalies that might interfere with normal transition.
Select Potential Nursing Diagnosis
The following nursing diagnosis may be appropriate dur- ing the first few moments after birth:
● (^) Ineffective Breathing Pattern related to obstructed airway, neuromuscular immaturity, perinatal compro- mise, or physiologic inability to transition to extra- uterine circulation.
Planning/Intervention
The nurse ensures that the baby’s airway is clear and dries fluids from the skin. The following findings and interventions may be appropriate:
● (^) Breathing but not pink—provide free-flow oxygen. ● (^) Limp or having acute respiratory distress—take the infant to a radiant warmer for more thorough as- sessment, remembering that ventilation is the most important intervention.
FIGURE 20.6 A family is bonding following labour and birth. (Photo courtesy of Joe Mitchell)
● (^) Apneic—stimulate the baby briefly by drying or flick- ing the soles of the feet. If there is no response, begin bag-and-mask ventilation (Kattwinkel, 2006). Newborns requiring no resuscitation or brief free- flow oxygen can usually stay with their mothers under close nursing supervision. If all appears well after assign- ment of the 5-minute Apgar score, the nurse can leave the newborn on the mother’s chest, covered with a warm dry blanket, and maintain vigilance from a short distance. The nurse should remain alert to the newborn’s needs while the family enjoys a few minutes of privacy with the baby (Fig. 20.6).
Evaluation
The healthy newborn is term, pink, and active and has minimal signs of respiratory distress soon after birth.
EARLY NEWBORN CARE PROCEDURES
The first hours after a baby’s birth are busy for perinatal and neonatal staff. The timing of procedures varies with institutional protocols and family preferences
Identification
Identical identification bands are written for mother and newborn with information including the mother’s hos- pital number, the baby’s sex, and the date and time of birth. For multiple births, each baby’s band denotes birth order; for example, “Twin A” signifies the firstborn of twins. Another team member present in the delivery room verifies the accuracy of information printed on the bands. The nurse places one band on the mother’s wrist and usually one on the newborn’s wrist and ankle. Band- ing the mother and newborn must occur before sepa- rating them for any reason. Each time the newborn is reunited with the mother, the nurse compares the identi-
Fig. 6
C H A P T E R 2 0 The Healthy Newborn ● 785
NURSING PROCEDURE 20.1 CONTINUED
Weighing the Newborn
4. Place naked newborn on the covering. Posi- tion the newborn on the scaleto minimize stress; keep one hand over the newborn body without touching the newbornto ensure safety. 5. Quickly note the weight. 6. Remove the newborn from the scale, and continue with care, removing gloves and washing hands when care is completed. 7. Document the weight in the newborn’s medical record.
EVALUATION
- Newborn is weighed without difficulty.
- Newborn experiences no evidence of cold stress.
AREAS FOR CONSIDERATION
AND ADAPTATION
Lifespan Considerations
- Keep in mind that while the newborn remains at the facility, weights are obtained daily.
- Avoid placing the naked newborn directly on the scale’s cold surface in the supine position. The newborn is more likely to be startled, to cry and move about, interfering with obtaining an accu- rate weight. Additionally, placing the naked newborn on a cold surface facilitates heat loss.
Community-Based Considerations Obtain newborn weights at each visit. Typically, parents do not have a baby scale in their home. The home care nurse needs to bring a scale to the visit.
A B
FIGURE 20.8 To measure the newborn’s length, the nurse extends the baby’s leg and marks the pad at the heel ( A ) and measures from the newborn’s head to the heel mark ( B ).
Step 4. Weighing the newborn while carefully guarding with the other hand.
786 ● U N I T 5 Postpartum Period and Newborn Care
record the largest finding (Fig. 20.9). Cranial moulding or scalp edema may affect the measurement. The nurse notes such findings in the medical record (Tappero & Honeyfield, 2003). Chest circumference measurement is optional, but is performed in many institutions (Fig. 20.10). The nurse measures the chest circumference around the nipples dur- ing newborn expiration (Tappero & Honeyfield, 2003), making sure that, if using a paper tape, it does not stick or tear and result in an incorrect measurement. Also, the nurse should lift the infant’s torso off the mattress to remove the tape measure from the back; pulling the tape measure out from under the supine infant can result in paper cuts on the infant’s torso.
Gestational Age Assessment
Gestational age assessment is performed to estimate a newborn’s postconceptual age (Tappero & Honeyfield, 2003). The nurse needs to know the gestational age and the appropriate growth parameters, because neonatal risks for each classification are different. A newborn’s gestational age is not evident by assessing weight alone. An infant who weighs 1800 grams at 39 weeks’ gesta- tion has a different set of risk factors and management interventions than an infant who weighs 1800 grams at 35 weeks’ gestation. Gestational age can be assessed in four ways:
- Maternal menstrual history: An average term pregnancy is 266 days (38 weeks after ovulation) or 280 days (40 weeks from the first day of the last men- strual period) (Blackburn, 2007). Assessing gesta- tional age by using the date of the last ovulation or menstrual period depends on the regularity of mater- nal menstrual cycles. Irregular cycles, failed contra- ception, and inaccurate recall by the woman can affect this method (Lynch & Zhang, 2007)
- Ultrasound examination: Fetal measurements are taken during pregnancy and, using standard formu-
lae, are compared with age-specific references. Using data derived from in vitro fertilization, researchers determined that in 95% of pregnancies, ultrasound was accurate to within 5 days, if done in the first trimester, and to within 7 days, if done in the second trimester (Kalish et al., 2003). The main criticism of ultrasound-based dating is that it does not account for normal variability (Lynch & Zhang, 2007).
- Ballard assessment: The Ballard Gestational Age Assessment Tool originated from the Dubowitz As- sessment of Gestational Age (Dubowitz et al., 1970). The Dubowitz scale consists of 11 external physical characteristics and 10 neurologic signs. Ballard and colleagues (1979) simplified the Dubowitz tool using six physical and six neuromuscular criteria. Studies have shown that, in general, these scales overestimate the gestation of infants born at less than 40 weeks, with a range of 2 weeks (Dubowitz) to 2 to 4 days (New Ballard), and underestimate the gestation when the infant is born at or past 40 weeks. In addition, the extent of the error may differ according to racial origin of the infant (Lynch & Zhang, 2007).
- Lens vascularity: Used to a limited extent, this method can help determine gestational age when differences among other methods are significant. The developing lens of the eye has a vascular system that invades and nourishes the eye during fetal growth. The vascular sys- tem appears at approximately 27 weeks’ gestation and disappears after 34 weeks’ gestation. The stages of atrophy are divided into four grades according to the pattern and presence of blood vessels visualized on the eye lens with an ophthalmoscope. The grading sys- tem must be performed between 24 to 48 hours of age (Tappero & Honeyfield, 2003).
Infant Classification
To determine infant gestational age, the nurse can use the FIGURE 20.9 Measuring head circumference. Ballard Gestational Age Assessment Tool according to
FIGURE 20.10 Measuring chest circumference.
Fig. 9
Fig. 10
788 ● U N I T 5 Postpartum Period and Newborn Care
● ASSESSMENT TOOL 20.3 Ballard Scoring With Instructions (Continued)
RECORD SCORE HERE
NEUROMUSCULAR MATURITY SIGN
NEUROMUSCULAR MATURITY
TOTAL NEUROMUSCULAR MATURITY SCORE
SCORE
POSTURE
–1 0 1 2 3 4 5
SQUARE WINDOW (Wrist)
ARM RECOIL
POPLITEAL ANGLE
SCARF SIGN
HEEL TO EAR
Neuromuscular Total
Score Weeks
Physical
SCORE
MATURITY RATING
RECORD SCORE HERE
PHYSICAL MATURITY SIGN
PHYSICAL MATURITY
TOTAL PHYSICAL MATURITY SCORE
SCORE
SKIN
–1 0 1 2 3 4 5 sticky, friable, transparent
none sparse abundant thinning (^) abareldas^ mo basldtly heel-toe 40–50 mm: – <40 mm: –
50 mm no crease
faint red marks
anterior transverse crease only
creases ant. 2/ 3
creases over entire sole impercep- tible
barely perceptible
flat areola no bud
stippled areola 1–2 mm bud
raised areola 3 –4 mm bud
full areola 5–10 mm bud lids fused loosely: – tightly: –
lids open pinna flat stays folded
sl. curved pinna; soft; slow recoil
well-curved pinna; soft but ready recoil
formed and firm instant recoil
thick cartilage, ear stiff scrotum flat, smooth
scrotum empty, faint rugae
testes in upper canal, rare rugae
testes descending, few rugae
testes down, good rugae
testes pendulous, deep rugae clitoris prominent and labia flat
prominent clitoris and small labia minora
prominent clitoris and enlarging minora
majora and minora equally prominent
majora large, minora small
majora cover clitoris and minora
gelatinous, red, translucent
smooth, pink, visible veins
superficial peeling and/or rash, few veins
cracking pale areas, rare veins
parchment, deep cracking, no vessels
leathery, cracked, wrinkled
LANUGO
PLANTAR SURFACE
BREAST
EYE-EAR
GENITALS (Male)
GENITALS (Female)
- 0 5 10 15 20 25 30 35 40 45 50
20 22 24 26 28 30 32 34 36 38 40 42 44
● (^) A term infant is 38 to 41 weeks’ gestation. ● (^) A postterm infant is more than 42 weeks’ gestation. ● (^) A low-birthweight infant weighs less than 2500 g and can be preterm, term, or postterm.
Chapter 22 provides an illustrated comparison of the differences in Ballard screening characteristics for preterm and term infants. Next, the nurse plots the infant’s weight on the growth curve chart (Fig. 20.11). Weight is on the verti- cal axis; gestational age is on the horizontal axis. The
nurse notes whether the plot point falls into the shaded area denoting less than the 10th percentile ( small for gestational age [SGA]), between the 10th and 90th per- centile ( appropriate for gestational age [AGA]), or above the 90th percentile ( large for gestational age [LGA]). For example, if the infant is 37 weeks’ gestation and weighs 1800 g, the infant is preterm and SGA. Any newborn whose plot point falls into the SGA shading is below the 10th percentile for growth, which means that the newborn is smaller than 90% of all other babies of the same gestational age.
Fig. 11
24
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
24 0
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
0
400
600
800
1000
1200
1400
1600
1800
2000
2200
2400
2600
2800
3000
3200
3400
3600
3800
4000
4200
Appropriate for gestational age (AGA)
Large for gestational age (LGA)
Small for gestational age (SGA) Age at exam
First exam (X) Second exam (O)
Signature of examiner
Week of gestation
Week of gestation
Pre-term Term Post-term
Length cm
cm
cm
hrs hrs
90%
50%
10%
Head circumference
cm
cm 90% 50%
10%
Weight cm 90%
50%
10%
FIGURE 20.11 Sample growth curve charts for newborns.
C H A P T E R 2 0 The Healthy Newborn ● 789
Weight and gestational age combine to describe an infant who is:
● (^) Preterm and SGA, AGA, or LGA ● (^) Term and SGA, AGA, or LGA ● (^) Postterm and SGA, AGA, or LGA
After plotting the weight, the nurse marks the length and head circumference on the corresponding charts and notes if an SGA infant has not grown at the expected rate for one, two, or all three growth parameters. The SGA new- born who experienced growth restriction late in gestation is usually SGA for weight only. This is termed asymmetric growth restriction. The infant less than the 10th percentile for weight and length suffered from limited growth earlier
in gestation than the newborn lacking in weight only. If all three parameters are in the 10th percentile, the infant is referred to as having symmetric or proportionate growth restriction. This type of growth restriction has a poor prog- nosis, given the factors that may have caused diminished growth early in gestation, such as viral infections, single- gene defects, and chromosome disorders (Tappero & Honeyfield, 2003). However, asymmetric growth restric- tion, particularly if it is associated with maternal hyper- tension, has a more optimistic prognosis (Resnik, 2002). An infant at 36 weeks’ gestation who weighs 3200 g is LGA and preterm, likely to be the infant of a mother with diabetes, and at risk for hypoglycemia, respiratory distress syndrome (RDS), and slow feeding. An infant of 40 weeks’ gestation weighing 1200 g is term and SGA
C H A P T E R 2 0 The Healthy Newborn ● 791
NURSING PROCEDURE 20. 2
Bathing the Newborn
PURPOSE
To clean the newborn
ASSESSMENT AND PLANNING
- Organize supplies for bathing:
- Basin of warm water
- Several washcloths
- Several towels at one end of the radiant warmer
- Soap
- Comb
- Small cup for pouring water at or very near to the sink
IMPLEMENTATION
1. Wash hands and put on gloves. Keep gloves on until you have dried the baby. 2. Lay the infant under the prewarmed radiant warmer; unwrap and unclothe him or her. Change the wet or soiled diaper, if necessary. Rediaper and swaddle the newborn in a warm blanket, leaving only the head exposed. 3. Take the infant to the sink and regulate the running water temperature. 4. Use a clean washcloth to gently wash the face without soap. Include behind and inside the ears. Gently pat the face dry. 5. Wash the head and hair. Because of the possibility of fluctuating water temperature and pressure, do not hold the head directly under the running water. It is safer to collect the
Continued
disturbs the balance of protective skin flora. The term infant recovers the acid mantle approximately 1 hour after bathing. In many hospitals some type of soap or mild antiseptic is used for the initial bath because of con- cerns about pathogens in maternal fluids, such as hepati- tis B and HIV. If an antiseptic solution is used for the first bath, it should be thoroughly rinsed from the in- fant’s body (Blackburn, 2007).
Remember Thomas, the newborn from
the beginning of the chapter. Imagine
that he is 2 hours old and is to receive
his first bath. The nurse is demonstrating
the bath to his mother, who says, “I found a really nice
fragrant soap at the bath shop that I’m going to use when
I bathe him at home.” How should the nurse respond?
The bathing procedure exposes the newborn to cooling and stress. Nurses take every precaution to limit adverse reactions. An efficient and organized procedure ensures that the bath, including hair washing, is completed in less than 10 minutes.
Illustrated guidelines for the initial bath appear in Nursing Procedure 20.2. The newborn may be bathed under the protection of a radiant warmer. In this proce- dure, the infant’s temperature has been taken to ensure stability within normal limits, and no transitional distress is present (Teaching Tips 20.1).
Medication Administration
Canadian newborns routinely receive two medications at birth: intramuscular vitamin K and an antibiotic agent for eye prophylaxis. Parents may refuse either or both; how- ever, it is important to document the reasons for refusal as well as information given to parents about the risks of foregoing recommended treatment. Some facilities have specific forms for parents to sign should they refuse stan- dard procedures recommended for newborn care.
Vitamin K The nurse administers intramuscular vitamin K (phyto- nadione) within 6 hours of birth (Canadian Paediatric Society [CPS] and College of Family Physicians of Canada [CFPC], 2004) (Nursing Procedure 20.3). If par- ents refuse intramuscular Vitamin K, an oral dose can be (text continues on page 000)
NP
TT
NP
792 ● U N I T 5 Postpartum Period and Newborn Care
NURSING PROCEDURE 20.2 CONTINUED
Bathing the Newborn
water in a cup or small pitcher and slowly pour it onto the infant’s head over the sink. If the parent is uneasy about pouring, thoroughly soak a washcloth in running water and use it to wet the hair.
6. Use a small amount of soap and massage it gently into the scalp. Do not rub vigourously to remove tenacious vernix. (Some vernix may remain firmly attached to the baby’s skin.) Comb soap through the hair to loosen and remove blood, if necessary. 7. Rinse the hair thoroughly and gently dry the head with a towel. Cover the baby’s head with the towel and return the infant to the radiant warmer. 8. Wash the body: a. Lay the infant under the radiant warmer. Positioning the infant with the head and feet across the width of the warmer provides room for a basin of clean water and supplies at the head of the warmer. Remove the baby’s blanket and diaper. Expose the head to the radiant heat to help ensure drying by the end of the bath. b. Quickly moisten the infant’s body with a wet washcloth. Do not worry about wetting the blanket underneath the baby. Work quickly and finish washing the baby’s body within 1 or 2 minutes. c. Rub the soap into a lather with your gloved hands. Quickly massage the soap over the infant’s body with your gloved hands (hands reach into infant folds faster and more efficiently than a bulky washcloth), starting at the neck creases and working down. Wash the arms, armpits, and fingers. Wash the chest. Roll the infant onto the side to wash the back. Then wash the legs and feet. Do not wash the buttocks or genitals yet. d. Thoroughly wet a clean washcloth and rinse the infant, ensuring that you rinse soap from neck and armpit creases. If the infant is lying on top of soaked towels at this time, remove those towels and place the baby on a dry towel. e. Now use this clean wet washcloth to wash the genital area. Wipe vernix and secretions out of thigh creases. For girls, separate the labia and wipe front to back to remove secretions. Always use a clean portion of the washcloth for a front-to-back maneuver. For uncircumcised boys, do not attempt to retract the foreskin. Gently and quickly move around the geni- tal area, remembering to lift the scrotal sac and clean the skin underneath. f. Clean the bottom last. Rinse any soap remaining in this area. 9. Lift the newborn off the radiant warmer to remove the waterproof pad (and with it, the wet linen on top); lay it aside or place it in- side a nearby linen receptacle. Do not throw linen on the floor.
Step 5. Using a washcloth to wet the baby’s hair.
Step 6. Massaging the soap into the baby’s scalp.
Step 8b. Bathing under the newborn’s neck.
Continued
