1_Newborn Complications

Newborn Complications

• Amniocentesis
• Fetal Lung Maturity (Transient Tachypnea of the Newborn (TTN) & Meconium Aspiration Syndrome)
• Jaundice
• Infection/Sepsis
• Polycythemia
• Phenylketonuria (PKU)
• Neonatal Alcohol Withdrawals (NAS)
• Intraventricular Hemorrhage
• Retinopathy
• Necrotizing Enterocolitis
• https://www.youtube.com/watch?v=gnj5vP3DmsM (Embed)
• Caption: APGAR Scoring

Amniocentesis (pg. 306 McKinney)

• What is it?
• Aspiration of amniotic fluid from amniotic sac for examination
• When is it performed?
• Best between 15 and 20 weeks due to increased amniotic fluid
• Can be done as early as 11 to 14 weeks
• Why is it performed?
• Second Trimester:
• detect fetal abnormalities such as Rh incompatibility
• AFAFP (amniotic fluid alpha fetal protein) level indicates neural tube defects (only when Maternal Serum AFP was abnormal)
• Third Trimester
• Fetal lung maturity
• Evaluate hemolytic disease of the newborn
• Reduction amniocentesis (extra fluid removed or fluid removed for evaluation of infection or harmful substances)

Amniocentesis

• How is it performed?
• woman lies supine
• FHR and maternal BP monitored
• US used to locate fetus, placenta, and location of amniotic fluid
• About 20 mL removed for analysis
• Rhogam given to Rh- women
• EFM for 30 to 60 min

Fetal Lung Maturity (amniocentesis)

• Lecithin/Sphingomyelin (L/S) ratio
• best test for estimation
• L&S are lipoproteins that make up surfactant
• Surfactant keeps alveoli open by decreasing surface tension, preventing collapse with exhalation, and reducing effort of breathing
• Interpretation: both L&S are equal until about 30 weeks, then Lecithin is produced more
• Want 2:1 ratio by week 34/36
• https://www.youtube.com/watch?v=bZcGpjyOXt0 (Embed)

Extrauterine Transition of Lungs (pg. 467 McKinney)

• Before Birth
• Fetal lungs are filled with fluid that aids in development, production of fluid decreases closer to term
• During Labor
• Fluid begins to shift from alveoli into the interstitial spaces where it can be absorbed (may last hours after birth)
• As baby cries fluid shifts into the

Transition of Lungs

• Causes of Respirations:
• Chemical stimuli (decreased oxygen, increased CO2, decreased pH)
• Thermal stimuli (temperature change)
• Sensory (touch)
• Mechanical (compression and release of thorax when passing through birth canal
• 
• Caption: Causes of Respirations

Transition of Lungs

• Babies at risk for complications
• Those under weeks 34/36
• Give mothers in preterm labor steroids to increase surfactant production
• Lungs should be clear by 24 hours

Transient Tachypnea of Newborn (TTN)

• Rapid respirations after birth d/t inadequate absorption fetal lung fluid, usually resolves within 24 to 72 hours
• Risk Factors: C-section, fast delivery, male, perinatal asphyxia, maternal diabetes or asthma
• S/S: 60 to 120 breaths/min within hours of delivery, retractions, nasal flaring, grunting, cyanosis
• DX: chest x-ray shows hyperinflation and streaking of fluid
• TX: oxygen, gavage feedings, observe for sepsis (similar S/S)

Changes in Cardiovascular System

• Ductus Venosus
• Vein carries maternal oxygenated blood past liver and into inferior vena cava that closes with cutting of the cord
• Ductus Arteriosus
• Connects pulmonary artery and aorta before delivery, is stimulated to constrict when oxygen levels rise with first breath
• Foramen Ovale
• Foramen between R and L atrium. Closes with increase pressures in L. side of heart as pulmonary vessels are utilized with breathing

Thermoregulation

• Predisposing factors:
• thin skin, blood vessels close to surface, little white (SQ) fat, increase body surfaces area related to mass
• Methods of heat loss:
• Evaporation: air drying/insensible water loss
• Conduction: removal of heat with contact of cold objects/surfaces
• Convection: transfer of heat to cooler surrounding air/drafts
• Radiation: transfer of heat to objects not in direct contact with infant
• 

Effects of Cold Stress

• Increased metabolism (loss glucose, increased oxygen needs, decreased brown fat reserves)
• Risk for respiratory distress d/t decrease in production of surfactant, increased oxygen needs, and vasoconstriction of pulmonary blood vessels
• hypoglycemia/ increased acid production
• metabolism of brown fat increases release fatty acids (further increases acidity and can interfere with transport bilirubin-lead to hyperbilirubinemia)
• Vasoconstriction of peripheral blood vessels to conserve heat
• Prevention:
• Neutral thermal environment (89-92 degrees when undressed, 75 to 80 degrees when dressed)
• NOTE: hyperthermia can also cause hypoglycemia in newborn and should be prevented

Hematologic differences in Newborns

• 
• Increased Hgb (25-24 g/dL) that also has higher affinity for oxygen!
• Increased Hct (40-70%)- Polycythemia (>65%) increases blood viscosity and risk for hyperbilirubinemia and complications of blood clots
• Glucose is lower (40-60 mg/dL day 1 and 50-90 mg/dL after)
• WBC's increased (9000-34000 at birth, falls to 12,000 by day 4 or 5)
• Clotting deficiency (little Vit. K)

Meconium Aspiration Syndrome (719)

• Meconium:
• First stool, passed within 12 hours of birth typically, 48 hours at the latest.
• Appears greenish black with a thick, sticky consistency.
• Let provider know as soon as you identify meconium in the amniotic fluid!!!!!
• MAS:
• Obstruction, air trapping and chemical pneumonitis cause by meconium in infants lungs.
• Most common on post term infants
• Caused by hypoxia that increases peristalsis of intestines during labor
• S/S:
• Respiratory distress, tachypnea, cyanosis, retractions, nasal flaring, grunting, rales, barrel chest shape with hyperinflation, see-saw breathing. May see LATE DECELERATIONS on EFM.
• Management:
• Suctioning as soon as head comes out (before stimulating breathing), warm humidified oxygen, extensive respiratory support. Physician may do AROM, have RT available.

Bilirubin

• Unconjugated (Indirect bilirubin):
• not soluble in water, must be changed to water soluble form by liver by conjugation
• Fat soluble may be absorbed by SQ fat causing Jaundice
• Conjugated (Direct bilirubin): soluble in water and can be excreted and is not toxic to the body
• Jaudice is normal and occurs in about 60% of term and 80% of preterm infants!

Hyperbilirubinemia

• Causes/Risk Factors:
• Excess production of bilirubin d/t polycythemia and RBC breakdown
• Faster breakdown of fetal RBC's
• Liver immaturity
• Blood incompatibility (Rh, ABO)
• Gestation: preterm and late term have immature conjugation abilities
• Feeding: delayed feeding decreases amount of bilirubin excreted in feces
• Trauma from birth (cephalohematoma) increases RBC destruction
• Family background: native american, asian, or eskimo infants have increased risk

Types of Jaundice

• Physiological/Non-pathological:
• Appears 2nd or 3rd day
• TSB is 5-6 mg/dL
• Should be gone by 1 week!
• Breastfeeding Jaundice
• Begins first week of life, may last months
• TSB may be > 12 mg/dL
• Caused by insufficient breast milk for feeding or bad feeding patterns (decreased bilirubin excretion)
• Non-physiologic/ Pathologic:
• Appears within first 24 hours life
• Bilirubin rises fast and quick
• Caused by Rh incompatibility, infection, excessive RBC damage or problems with conjugation, and certain metabolic disorders

Complications of Hyperbilirubinemia

• Bilirubin Encephalopathy: increased bilirubin deposits in brain and can cause neurological changes
• Lethargy, decreased muscle tone, poor feeding, decreased reflexes, crying, and seizures
• Kernicterus: permanent neurological damage from bilirubin encephalopathy/prolongued untreated hyperbilirubinemia

Management Hyperbilirubinemia

• PHOTOTHERAPY (Bilirubin lights):
• begin at lower TSB levels for premies, protect eyes, keep unclothed and warm
• light conjugates bilirubin to be excreted
• Frequently check TSB levels (every 8 hours)
• Can measure TCB (transcutaneous bilirubin) with Bilirubinometer
• Exchange transfusion: removes RBC's and bilirubin and replaces with healthy blood
• Get the baby feeding!!! (Every 2 to 3 hours) increase excretion, milk also has laxative effect
• INDIRECT COOMBS TEST: identify Rh incompatibility

Infection in Neonates (pg. 724)

• Transmission:
• Before birth: rubella, cytomegalovirus, syphilis, HIV, toxoplamosis can cross the placenta
• During birth: group B streptococci (GBS), herpes, hepatitis may infect infant after ROM

Sepsis in Neonates

• Infants are at great risk d/t immature immune system!
• Common causes: GBS, E. coli, Staphylococcus, Hib, Candida albicans. Pneumonia and Meningitis most commonly seen
• Early onset Sepsis: within first 24 hours, may be first week. HIGH mortality
• Late onset Sepsis: after 1st week of life, usually a localized infection such as meningitis
• DX: CBC (WBC's might not increase, decrease in platelets), elevated C-RP, blood, urine and CSF cultures

Sepsis in Neonates

• Symptoms
• May be subtle but include temperature change, respiratory complications, altered feeding, changes in color of skin, changed blood glucose readings, lethargy, irritability, decreased muscle tone, high pitch cry
• TX
• Antibiotic therapy during labor for mother infected with GBS, antibiotic therapy after birth for infected infant, symptom management (oxygen, mechanical ventilation), gavage feedings, fluid monitoring, vitals

Prenatal Drug Exposure (pg. 729)

• Most drugs readily cross the placenta and cause a variety of problems
• NAS (neonatal abstinence syndrome)
• Symptoms depend on substance used and usually appear within first 24 to 72 hours and can last up to 4 weeks!
• Drugs that cause withdrawals: Codeine, hydroxyzine, amphetamines, antidepressants, heroin
• SX: lethargy, irritability, tremors, increased tone, easily distressed, crying, poor suck reflex, vomiting/diarrhea
• Increased risk for: SIDS, FAS, decreased growth/fetal maturity, respiratory distress, jaundice

Prenatal Drug Exposure

• Treatment:
• Specific to symptoms.
• May test infant meconium or urine to detect substance
• 50-60% need Rx therapy: Tincture of Opium, oral morphine, methadone, phenobarbitol
• Gavage or IV feedings
• Decreased stimulation (noise, light, calm/slow approach, few people at a time, swaddle)
• Breast feeding may be indicated as it contains trace amounts of substance which will help with withdrawals

Phenylketonuria (PKU)

• Genetic disorder that causes CNS injury from toxic levels of amino acid phenylaline in blood
• Deficiency in enzyme (phenylaline hydrolase) that converts phenylaline to tyrosine
• SX: digestive problems (vomiting), seizures, intellectual impairment
• TX: low phenylaline diet for life!
• All infants are screened for PKU after 24 hours before they leave the birthing center

Maternal Child Book

• McKinney, E., James, S., Murray, S., Nelson, K., & Ashwill, J. (2013). Maternal child nursing (4th ed.). St. Louis, MO: Saunders Elsevier.