1. Newborn Adaptation to Extrauterine Life
A systemic approach to life in this world~

2. The Lungs
The most important vital organ that needs to be adequately functional in the neonate
Largely dependent on maturation of the fetus
Website on fetal lung development

3. Fetal maturation: 20-24 wks - alveolar ducts appear
24-28 wks - alveoli remain primitive
28-32 wks - type II (surfactant producing) cells increase
35 wks - Lecithin production peaks

4. Role of Surfactant L/S Ratios phospholipid lung cell maturity (PI)
lowers surface tension (PG)
increased lung compliance
L/S Ratios
Lecithin (increases)
Sphingomyelin (constant)
<30 wks = low L/S
30-32 wks - L/S = 1:1
>35 wks - L/S = 2:1

5. Adaptation at birth- factors that foster that initial breath
Mechanical– “Vaginal squeeze” is followed by chest recoil after birth.
Chemical – Transient asphyxia at birth results in * decreased pO2 * decreased pH as low as 7.25 * increased pCO2 These changes stimulate chemoreceptors around the aorta and carotid which tells the respiratory center in the medulla to start breathing

6. Adaptation (cont’d)
Temperature— The drop in temperature from a cozy 98.6 to F. stimulates the neonate’s CNS to breathe.
Sensory stimuli– all 5 senses are brought to life in the delivery room *Noise in the delivery room *Bright lights in the delivery room *Tactile stimulation– drying off the baby, stroking and caressing by parents, etc. *Smells in the delivery room *Taste when bulb syringe or gloved hand is introduced into mouth, & when mom nurses the first time.

7. Assessment Parameters-- Respiratory System
Quality of respirations /min.
gasping, irregular, shallow breathing is normal at first
periodic breathing is typical
true apnea= >20 sec. without breathing is abnormal
“wet” lungs– common in the first 5 minutes of life; if persistent, may require DeLee suctioning

8. Assessment Parameters-- Respiratory System(cont’d)
Obligate nose breathers
Retractions– abdomen & chest wall should rise simultaneously. “Seesaw” movements and expiratory grunting are ominous signs requiring intervention.

9. Oxygen Transport (p. 655-6; 10th ed).
2 types of Hemoglobin in fetus & newborn:
Fetal Hgb: HbF—70-90%. Has  O2 affinity which means if facilitates O2 transfer across the placenta and into newborn’s tissues.
Fetal PaO2—30-40mm Hg.
Fetal Hgb level—17 g/dL—allows fetus to tolerate relatively low PaO2 in utero, because the absolute O2-carrying capacity of the blood is > adult Hgb.
Adult Hgb: HbA has  O2 affinity but O2 release. HbA of 13 g/dL in adult has lower O2-carrying capacity.

10. The Heart~ Cardiovascular Adaption
The heart goes through a series of changes:
increased aortic pressure and decreased venous pressure 2ndary to clamping the umbilical cord
increased systemic pressure and decreased pulmonary artery pressure with initiation of respirations and loss of placenta

11. closure of the ductus venosus--fetal structure from umbilical vein to inferior vena cava carrying O2 from the placenta
closure of foramen ovale--fetal structure that connects the right atrium with the left atrium further allowing right to left shunting during fetal life.
closure of the ductus arteriosus-- fetal structure connecting the pulmonary artery with the aorta allowing right to left shunting during fetal life

12. Fetal Circulation
Note: the Umbilical Vein carries oxygenated blood from the mother to the inferior vena cava where it mixes with unoxygenated blood from the body. This mixed blood travels through the heart and to the body oxygenating all fetal cells. The unoxygenated blood returns to the mother via the umbilical arteries.

15. Do you hear a MURMUR? Occur in 37% of all newborns
90% are transient due to delayed closure of ducts (PDA &/or PFO)
These types usually disappear by 6 months of age

16. Vital Sign Averages
Birth weight: 6-9 lbs g. (wt. Loss of 5-10% of birth wt.in 1st 3-4 days is expected. Should regain birth weight by 2 week check-up.)
Length: in. ( cm)
Head Circumference: in.(33-35cm)
Chest Circumference:12-13 in. (30-33cm) should be ~2-3cm. < head circumference
Blood Pressure: ave. 78/42 (less for premie, more if crying. * Cause for concern: Diastolic <25 or >60

17. Vital Sign Averages (cont’d)
Pulse: bpm. Assess apically for 30 sec if crying if sleeping
Temp: Rectal: 36.6 – 37.2 C F Axillary: 36.5 – 37.0C – 98.6F If axillary temp is <36.5C, you recheck the other axilla. If it remains low, take babe out and do ‘skin-to-skin’ or double-wrap infant with hat on and recheck temp in 1 hour. If still low, place child in radiant warmer for 30 minutes and recheck temp. Temp rechecks can be done axillary.
Respirations: 30-60/min. Assess for 1 full minute.

18. Newborns & Heat Loss Factors that predispose a newborn to heat loss
Large surface area (especially head!)
Limited ability to control their metabolic rate
Blood vessels of the newborn are closer to the skin than adults
Decreased insulation due to less fat
It is essential to maintain a neutral thermal environment (NTE) to minimize O2 consumption.
NTE range for naked newborn~ 32-34C ( F)
NTE range for adults~ 26-28C ( F)

19. Temperature Decrease (Hypothermia)
Anaerobic Glycolysis
pO2 and  pH
Pulmonary Vasoconstriction
Respiratory Rate

20. Heat Production
Vasomotor control—constriction of peripheral vessels manifested as acrocyanosis
”Non-shivering thermogenesis”– primarily occurs through “brown fat” metabolism. Brown fat cells are larger than white fat cells & are easily broken down to produce heat.

21. Heat Production (cont’d)
Shivering- late sign of hypothermia. Indicates that metabolic rate has doubled, increased O2 consumption, increased motor activity that ultimately leads to heat production
Insulation % of total body wt. of term neonates. Appears after 32 weeks gestation.

22. evaporation - water to vapor
Heat Loss
evaporation - water to vapor
radiation - body to cold object
conduction - direct skin contact
convection - body to cooler air

23. GOAL: Keep baby in a neutral thermal environment: where the baby's metabolic rate, and therefore O2 consumption, is minimal, but the body temperature remains within the normal range.

24. The Liver: Hepatic Functions
Conjugates bilirubin
Stores fetal iron
Stores liver glycogen for energy
coagulation

25. Physiologic Jaundice Why does this happen?
immature liver cannot conjugate bilirubin
increased breakdown of RBC’s (normal Hct - 55%, RBC's = 5-7 million/ul, Hgb = 15-20g/dl)
decreased clearance of bilirubin by liver due to inhibition of glucuronyl transferase = less conjugated bilirubin
reabsorption of bilirubin stuck in the intestines
obstruction or delayed meconium
hypoxia/CHD raise bilirubin levels
infection delays bilirubin excretion

26. Common symptoms of jaundice
Yellowish tinge to skin or sclera of eyes
Test by blanching skin on bony prominence as forehead, or sternum

27. Treatment of Physiologic Jaundice
Phototherapy – Bililights overhead in hospital setting Quartz high intensity lights in hospital Wallaby blanket wrapped around infant at home
Frequent feedings to expel meconium more quickly from intestines

28. Coagulation & Vitamin K
The absence of normal flora in newborn gut needed to synthesize Vitamin K results in low Vitamin K levels until 5th day of life
every newborn gets injected with Vit. K (AQUA MEPHYTON or PHYTONADIONE) to prevent bleeding problems.

29. Coagulation & Vitamin K
Dose:
1mg (0.5ml) IM >1500 gm
0.5mg(0.25ml)IM<1500 gm

30. GI Adaptation - COOL facts...
BEFORE BIRTH, baby has already swallowed and peristalsis begins
stomach holds ml (2 ounces)
GI tract mature wks gestation
By 24 hours, the intestines are air filled
Saliva is hardly produced until 3 months
Babies regurgitate due to immature sphincter
Newborns lose 5-10% body wt. in 5-10 day
insensible water loss & low caloric intake

31. POOP!
Meconium
Transitional
Fecal
Breastfed

32. Urinary Adaption Kidneys mature by 35 wks gestation
Limited ability to dispose of excess fluid
Most void immediately after birth
First 2 days: 2-6 times/day
After that: times/day!!!!

33. Cool facts... first void is cloudy due to mucous
“brick dust” urine- noted in diaper from urates (uric acid crystals)— may indicate dehydration
Pseudomenstruation = Vaginal discharge noted as blood in diaper

34. Examples of neonatal reflexes
Neuromuscular Status
Examples of neonatal reflexes

35. Reactivity States in the Newborn
First period of reactivity - first 40 min. Baby is alert,responsive, eager to explore the world
Sleep period hours after birth. May continue for 3-6 hrs. Baby is in a deep sleep, difficult to arouse. Resp. rate & heart rate decrease.
Second period of reactivity – 3-6 hours after birth. Baby is awake, respirations are rapid, irregular, and may have periods of apnea. May cough and regurg mucus, etc. Keep bulb syringe handy. Heart rate again increases.

36. Brazelton’s NBAS
Each baby is born with their own traits and personality. This scale helps parents identify and get to know what is special and unique about their newborn.
Temperament
1.) easy child
2.) slow-to-warm-up child
3.) difficult child

37. 6 categories of the NBAS Habituation Orientation Motor maturity
Variation
Self-quieting
Social behaviors
Read about each of these in your OB text-- Pp (10th ed). Link from March of Dimes

38. Brazelton’s Infant States
SLEEP states
Deep or quiet
Active REM-light
ALERT states
drowsy
quiet alert (wide awake)
active alert
crying
Know the characteristics of these states and when is the BEST time for interaction with the neonate!! Pp (10th ed).

39. What to Teach Parents

40. Newborn Screening One little heel stick tests for...
Congenital hypothroidism
Galactosemia—what implications does a positive result have for breastfeeding moms?
Maple syrup urine disease--
PKU – Phenylketonuria—why does baby have to be at least 24 hours old for this test?
Hemoglobinopathies
Sickle Cell Anemia
Thalessemia

41. Homocysteinuria
Cystic Fibrosis (new screening)
Congenital Adrenal Hyperplasia
Biotidinase Deficiency
More info at this link

42. Newborn SAFETY Bathing your baby--video Positioning— “Back to Sleep”
Car seat rules—from the AAP, here are all the recommendations for car seats for parents. Remember that NO BABY leaves the nursery without being in a car seat.
CPR instruction—Here is a review of infant CPR with a quick quiz, if you need a review! 
Immunization schedule—2015 Schedule

43. Fetal Development in utero

44. Fetal Development Continuum

45. Aren’t babies a miracle??
That’s it!!
Aren’t babies a miracle??