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THE NEWBORN- 24hrs (most critical stage)

NICU (Neonatal intensive care unit)

PHYSIOLOGIC ADAPTATION OF THE NEWBORN

1. RESPIRATORY ADAPTATION

FETUS - lungs are uninflated; fluid filled (Amniotic Fluid)

NEWBORN - lungs must inflate, oxygen exchange begins

PROCESS OF LABOR - stimulates SURFACTANTS production

VAGINAL SQUEEZE - helps clear airway, lung expansion

2. CARDIOVASCULAR ADAPTATION (search 3 shants)

FETUS - pressure in the Right Atrium is more than in the left, Blood flow through foramen ovale

High pressure in the lungs routes blood through Foramen Ovale and Ductus Arteriosus away from the
lungs

DUCTUS VENOSUS shunts fetal blood away from the liver

NEWBORN- pressure in the Left Atrium is more causing foramen ovale to close

DEOXYGENATED BLOOD that enters the heart directs blood to the lungs for gas exchange

Higher oxygen content of blood contributes to closing of Ductus Arteriosus

Nutrient rich blood from gut circulates through the NB's liver, ductus venosus closes

3. THERMOREGULATORY ADAPTATION

-process by which the body balances heat production with heat loss

-COLD STRESS - exposure to temperature cooler than N body temp

-ratio of body mass to the body surface is smaller than adult

-not readily able to produce heat

-Protection: Flexed fetal position, burn brown fat

HEAT LOSS MECHANISMS


CONVECTION- flow of heat from the body surface to cooler surrounding airr

Intervention: eliminating drafts such as windows or air con reduces convection

CONDUCTION-§transfer of body heat to a cooler solid object in contact with the baby

Intervention:covering surfaces with a warmed blanket or towel helps minimize conduction heat loss

*RADIATION - the transfer of heat to a cooler object not in contact with the baby

Intervention: cold window surface or aircon: moving as far as from the cold surface, reduces heat loss

*EVAPORATION - loss of heat through conversion of a liquid to a vapor

Intervention: from amniotic fluid: NB should be dried immediately

4. METABOLIC ADAPTATION

GLUCOSE- carries out metabolic processes and produce energy

NEONATAL HYPOGLYCEMIA - blood glucose levels drop to 50 mg/dL

Any conditon that puts physiologic stress on the NB depletes glycogen stores

Stresses affects: Prolonged labor, maternal infection, respi distress, cold stress

-Early signs: jitteriness, poor feeding, irritability, low temperature, weak/high pitched cry

-Late signs: RD, apnea, seizures, coma

5. HEPATIC ADAPTATION

BILIRUBIN- yellow pigment released as blood cells are broken down

CONJUGATED BILIRUBIN - makes it water soluble, excreted in the feces

UNCONJUGATED BILIRUBIN- fat soluble

*HYPERBILIRUBINEMIA (sakit)

- high levels of bilirubin in the bloodstream - Jaundice. Serum level of 4-6 mg/dL or greater: head, face,
trunk, extremities

*JAUNDICE

- under natural light

-blanch skin over the chest or tip of nose

*PHOTOTHERAPY UNITS or bililights(check for spelling)


Nursing Responsibilities- cover eyes and sex organs

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PHYSIOLOGIC JAUNDICE - peaks on days 3 and 5, doesn't rise rapidly

PATHOLOGIC JAUNDICE - occurs within 24 hrs

Liver- manufactures clotting factors : II, VII, IX, X

NB receive Vitamin K (AQUAMEPHYTON) - prevents Hemorrhagic Disease of the Newborn

BEHAVIORAL AND SOCIAL ADAPTATION

Neonatal Behavioral Assessment Scale- developed by Dr. T. Berry Brazelton 1973

Based on personality, individuality and ability to communicate

NB is a social organism capable of communicating trhough behavior and controlling his/her responses to
environment

Sleep and activity patterns

1. Deep Sleep - quiet, nonrestless sleep state, hard to awaken

2. Light sleep - eyes are closed but more activity is noted

3. Drowsy- eyes open and close; eyelids look heavy; with body activity, with intermittent fussiness

4. Quiet Alert - quiet state with little body movement but eyes are open, attentive to people or things
close to him

5. Active Alert- eyes are open, active body movements, responds to stimuli with activity

6. Crying - eyes tightly closed, thrashing movements

APGAR SCORE

Developed by Dr. Virginia Apgar, an anesthesiologist

A method of assessing the newborns adjustments to extrauterine life

*Taken at first minute and first five minutes of the newborns life

One minute score- used to indicate the necessity for resuscitation


Five minutes - more reliable in predicting mortality and neurologic deficits

IMMEDIATE CARE OF THE NEWBORN

Goals

1. To establish, maintain and support respiration

*POSITION UPRIGHT - after the flyid has drained

*SUNCTION MOUTH - deflate first before putting on the mouth

2. To provide warmth and prevent hypothermia

3. To ensure safety, prevent injury and infection

4. To identify actual or potential problems that may require immediate attention

"A crying infant is a breathing infant"

-normal infant cry is loud and husky

ABNORMAL CRY

High, pitched cry -indicates hypoglycemia, increased intracranial pressure

Weak cry - prematurity

Hoarse cry - laryngeal stridor

FACILITATE DRAINAGE

*TRENDELENBURG POSITION - head lower than the body

*SIDE LYING POSITION - place infant in side lying position to permit drainage of mucus from the mouth

PROVIDE WARMTH
*DRY THE BABY- immediately adter delivery, the baby should be dried

*PROVIDE DROP LIGHT - prevent hypothermia

*WRAP THE BABY

Note : clean frist the Face, trunk, head

CORD CARE - very important in the care of the newborn

Plastic umbilical Cord - is cut 1/2 inch to 1 inch (first clamping)

Cord is clamped (wait for the last pulsation before clamping)

MILKING- (away from the body) towards the placenta para di mag burst out yung blood pag nacut

Kelly clamp - 2 to 5 cm from the base

Umbilical clamp - 1 to 2 cm from the base

7-10 days - healing of the umbilical cord

CORD CARE

*CLAMPING THE CORD - stimulates the first breath, hence, establishment of independent respirations

*Clean with sterile cottonballs and antiseptic solutions (betadine or 70% isoprophyl alcohol from base
up)

*Check for Artery Veins Artery

(artery- red, has thicker walls; veins- blue, thinner walls)

*Wharton's Jelly - (search) inside the umbilical cord

Surfactant - increases friction in the lungs

WATCH OUT!

*If you notice the cord be bleeding, apply firm pressure and check cord clamp if loose and fasten

*Report any unusual signs and symptoms which indicates infection

-foul odor in the cord


-presence of discharge

-redness around the cord

-the cord remains wet and does not fall off within 7 to 10 days

-newborn fever

Note: (bleeding at the umbilical cord mismo, bc of wrong cutting) (nasagad yung cut)

Neonates- first 28 days of life

WEIGH THE NEWBORN

Average Weight = 2.5 kgs - 3.5 kgs

*AGA (appropriate gestational age) - when newborns weight falls between 10th and 90th percentiles
expected for gestational age

*SGA (Small) - above the 90th percentiles (Maternal DM)

*LGA (large) - below the 10th percentiles (premature, IUGA)

OBTAIN ANTHROPOMETRIC MEASUREMENT

*head circumference (brows) - 34-25 cms

*Chest circumference (nipples) - 32-33 cms

*Abdominal circumference (umbilical) - 30-32 cms

*Lenght - 46-52 cms

CREDE'S PROPHYLAXIS

-Carl Siegmund Franz Crede (German gynecologist and obstetrician)

*EYE PROPHYLAXIS

-prevent gonococcal ophthalmia neonatorum and clamydial conjunctivitis

-1% tetracycline opthalmic ointment


-0.5% erythromycin opthalmic ointment (this also prevents chlamydial infections)

Note: Neiseria Gonorrhea ( std)

VITAMIN K - (left thigh) a single injection of 0.5 to 1.0 mg of natural vitamin K can help prevent HDN
(Hemorrhagic Disease of Newborn)

1 ampule - 1 mg

10mg - 1ml

.5mg - 0.05 ml (tuberculin syringe)

VASCUS LATERALIS - upper outer left thigh

Proper IDENTIFICATION

-obtain footprints (permanent identification for official record)

-placement of wristlet (plastic bracelet pink/blue) blue-male, left foot pink-female, right foot

VERNIX CASEOSA- cheesy white substance found at neck and armpit

-depends on the color of amniotic fluid

-provides warmth to the baby

ESSENTIAL NEWBORN CARE - (Unang yakap program)

-A new program to address neonatal deaths in the country

-WHO formulated the ENC

ENC is set to revolutionize the delivery practices in the country

Has the potential to avert approximately 70% of newborn deaths that are due preventable

-DOH released an AO 2009-0025 mandating the application of a new protocol (ENC-P) on delivering
babies that could bring a sharp decrease in the childhood death rate in the country

-Under the umbrella of Unang Yakap Campaign:


ENC is an evidenced based strategic intervention

-PHILIPPINES is one of the 42 countries accounting for 90% of all global under-five mortality

Young babies die at an estimated rate of 40,000 annually

Filipino children die an estimate of 82,000 annually before their 5th birthday

More than 1/3 (37%) of these

-NEONATAL DEATHS

Highest number occurs in the first two days of life : Birth apshyxia, Complications of prematurity, sepsis

Millennium Development Goal 4 - aims to reduce under five mortality by 2/3 by 2015

ENC PROTOCOL

-is a series of time bound, chronologically-ordered, standard procedures that a baby receives at birth

-includes preventive measures which are needed to ensure the survival of the newborn

-there is growing evidence for simple interventions that can improve newborn survival

Preparations prior to the delivery of a newborn

-At perineal bulging, prepare for the delivery

1. Check temperature of the DR

2. Notify appropriate staff

3. Arrange needed supplies in linear fashion

4. Check resuscitation equipment

5. Wash hands with clean water and soap

6. Double glove just before delivery

FOUR CORE STEPS OF ENC

-
1. immediate and thorough drying

2. early skin to skin contact

3. properly timed cord clamping

4. non-separation of the newborn and mother for early initiation of breastfeeding

TIME BOUNDED INTERVENTIONS

1. immediate and thorough drying

-drying with rapid assessment of the newborn's breathing

-time-bound: within 30 secs

-call out the time of birth

-dry the newborn thoroughly for atleast 30 secs

@Wipe the face, eyes, head, front, back, arms and legs

*Do a quick check of breathing while drying

Note:

Do not wipe of vernix

Do not bathe the newborn

Do not Do footprinting

No Slapping

No Hanging upside down

No Squeezing of chest

*remove the wet cloth

2. Early skin to skin comtact

-initiate immediate uninterrupted skin ti skin contact


-time bound : after 30 secs

-position the Newborn prone on the mothers abdomen or chest

-cover the newborns back with a dry blanket

-cover the newborn head with a bonnet

Note:

Avoid any manipulation (routine suctioning)

Place identification band on ankle

Skin to skin contact in doable even for CS

3. Properly timed cord clamping

- practice properly timed cord clamping

Time bandth: 1 to 3 mins

- remove the first set of gloves

- after the umbilical pulsation

-clamp the cord using a sterile plastic clamp or tie at 2 cms from the umbilical base. Then clamp again at
5cms from the base.

*cut the cord close to the plastic clamp

Note:

-Do not milk the cord towards the baby

-after the first clamp, you may "strip" the cord of blood before applying the second clamp

-Cut the cordclose to the plastic clamps so that there is no need for 2nd trim

-Do not apply any substance onto the cord

4. Non separation of newborn from mother for early breastfeeding


-initiate early breastfeeding

-time band: within 90 mins

- leave the newborn in skin to skin contact

- observe for feeding cues including tonguing, licking and rooting

Point this out to the mother and encourage her to nudge the newborn towards the breast

Counsel on positioning

-NB neck is either flexed or twisted

-NB is facing the breast

-NB body is close to mothers baby

-NB whole body is supported

Counsel on attachments and sucking

-mouth wide open

-lower lip turned upwards

-Baby's chin touching breast

-Suckling is slow, deep with some pauses

-Weighing, bathing, eye care, examinations, injections (hepatitis B, BCG) should be done after the first
full breastfeed is complete

From 90 mins to 6 hours

1. Intervention : perform eye care

-apply tetracycline ointment to both eyes

2. Interventions : administer vitamin K

-inject vit k to vastus lateralis (outer anterior