Lauren Platt

BIRTHWEIGHT VARIATIONS Appropriate for gestational age (AGA) – weight within 10 th – 90 th percentile (lowest morbidity and mortality rates) Small for gestational age (SGA) – weight below 10 th percentile (< 2,500 g or 5lb 8 oz) Large for gestational age (LGA) – weight above the 90 th percentile (> 4,000 g or 8lb 13oz) Low birthweight - < 2,500 g Very low birthweight - < 1,500 g Extremely low birthweight - < 1000 g Factors Affecting Fetal Growth: Maternal nutrition Genetics Placental function Environment Newborns are classified according to birthweight and weeks of gestation

Born before 37 weeks gestation Can be SGA, LGA or normal GOALS: Meet growth and developmental needs, Recognize and manage complications Risk Factors  Maternal age 35  Multiple gestation  Hx of Preterm birth  Low SES  Smoking or PSA  Uterine anomaly  Polyhydramnios  Febrile Illness, pyelonephritis Photograph copyright Tom Stewart/CORBIS

Common Problems Associated with the Newborn o Perinatal asphyxia o Thermoregulation o Hypogylcemia o Meconium aspiration o Hyperbilirubinemia o Birth trauma

Perinatal Asphyxia Common in SGA & Preterm newborns Causes (*think HYPOXIA*)  Stress of labor  Hypoxic environment r/t placental insufficiency  Uterine contractions  Difficulty adjusting to extrauterine environment  Cord compression  Surfactant deficiency  Immature Resp control center  Inability to clear airway  Small resp passages Findings  Fetal distress (brady, decels)  Low APGAR score  Potential meconium passage into amniotic fluid Nursing Management: Anticipate problem Assess for maternal risk factors Initiate resuscitation measures immediately after birth

Signs & Symptoms Plasma glucose < 40 mg/dL Most common in IDM, SGA, & preterm AGA infants Monitor glucose frequently– preferred site is lateral heel Initiate early feeding (oral is best) Maintain fluid and electrolyte balance Lethargy Jitteriness Poor feeding Seizures Temp instability Resp distress Tremors, jerkiness High pitched cry Exaggerated Moro reflex Hypotonia

Infant Heel Stick Potential sites for heel sticks. Avoid shaded areas to prevent injury to arteries and nerves in the foot and the important longitudinally oriented fat pad of the heel, which in later years could impede walking.

Meconium Aspiration Nursing Interventions: Assess for resp distress Suctioning Ventilator support, ECOM Presence of meconium in amniotic fluid Fluid is aspirated in utero or during first few breaths taken by newborn Most common in SGA, Postterm, prolonged labor Green amniotic fluid, green stained cord, difficulty initiating respirations

Extracorporeal membrane oxygenation (ECMO) A process that takes blood from the body, oxygenates it using an artificial lung, and pumps it back into the body using an artificial heart. Used when hypoxia cannot be corrected with other treatments (ventilator or supplemental oxygen).

Hyperbilirubinemia Is an abnormally high level of bilirubin in the blood Newborn serum bilirubin normally does not exceed 3-5 mg/dL Jaundice, a yellowish discoloration of tissues, develops from the deposit bilirubin in fatty tissues Role of the perinatal nurse is to identify jaundice as soon as apparent Differentiate between pathologic vs physiologic jaundice

Physiologic Jaundice Normal process Occurs during transition from intrauterine to extrauterine life Occurs in 50% of healthy term and 80% of preterm newborns Appears after 24 hours of age Not visible after 10 days of age May require phototherapy

Pathologic Jaundice Signs of underlying illness o Vomiting o Lethargy o Poor feeding o Excessive weight loss o Apnea o Tachypnea o Temperature instability Usually caused by ABO or Rh incompatibility Jaundice may be present at birth

Treatment o Phototherapy beginning o Exchange transfusions o Infusion of albumin o Drug therapy o Monitor for complications of kernicterus Untreated hyperbilirubinemia (due to either type of jaundice) may result in neurotoxicity

Birth Trauma Most common in LGA infants Nursing Interventions: Deformities, bruising, edema, asymmetrical movement o Head to toe assessment o Look for asymmetry of structure o Assist parents in understanding

Balance between heat produced and heat lost to the environment Normal range 97.7  – 98.6  F Lose heat rapidly in cold environment r/t ↓ SQ fat and thinner epidermis Unable to shiver Main source of heat from “brown fat”

Risk FactorsSigns & Symptoms SGA, LGA Prematurity Post-dates Precipitous delivery Delayed drying Disruption in skin integrity Cold extremities Lethargy Apnea Tachypnea Poor feeding Nasal flaring Grunting Retractions

Neonatal Energy Triangle (Parks, 2007)

Photo courtesy of Mariano Marcos Memorial Medical Center, Philippines. Maintain warm environment Keep head dry & covered Preheat equipment Protect from conduction heat loss Use warm blankets Encourage skin-to-skin contact