Transcript Conception and Fetal Movement

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:
chromosomes
photo/pictorial analysis of person’s
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 Genotype
Homozygous 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 Inheritance
X-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 Disorders
Pg. 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
side lying
supine
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/P
P =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 GTPAL
Susie 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 Work
Pg. 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 Newborn
Vital statistics
Weight: 2.5 to 3.4 kg. Immediately after birth.
Establishes baseline. Baby may lose up to 5-10%.
Length: 18 - 21 inches
Head Circumference: 32 - 35 cm
Chest Circumference: 32 - 35 cm
Vital 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:
Convection
Conduction
Radiation
Evaporation
 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 Newborn
Reflexes
• Neuromuscular
function
•
•
•
•
Rooting reflex
Sucking reflex
Swallowing reflex
Palmar grasp reflex
Profile of a Newborn
 Neuromuscular
function
 Moro reflex
 Babinski reflex
 Crossed 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 minutes
Alert, 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 Family
Medications
• 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
11753398
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.
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 letdown 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
 Preparation
 Commercial formulas
 Formula adequacy
 Supplies needed
 Formula preparation
 Feeding techniques
• 75 to 90 ml of fluid per
pound of body weight
per day
Circumcision Care
Surgical 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 antibodycoated (sensitized) Rh-positive RBCs in the newborn
• Electrolyte levels for dehydration from phototherapy
(treatment of hyperbilirubinemia)
Nursing Assessments of
Hyperbilirubinemia
• 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 Complications
RDS (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 80120 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.