Canadian Maternity Newborn and Womens Health Nursing Chapter

From Fetus to Newborn • Review of fetal circulation – During fetal life: fetal lungs; two shunts in fetal heart; resistance to blood flow; fetal circulation functions; blood passes through foramen ovale and ductus arteriosus to the fetal aorta; adult PVR low Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

From Fetus to Newborn (cont’d) • Respiratory and circulatory transitions at birth – Respiration: vaginal birth; clamping of umbilical cord; temperature; normal handling and drying – Clear airways: first breaths strong enough to move thick fluids; surfactant deficiency; crackles audible in newborn’s lungs – Blood circulation: foramen ovale; rising oxygen levels Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Immediate Nursing Management of the Newborn • Prenatal and intrapartal history – Assess prenatal and intrapartal history – Anticipate risk factors – Prepare for resuscitation – Assess during newborn’s first moments Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Immediate Nursing Management of the Newborn (cont’d) • Immediately after vaginal birth – Provide warmth, clear the airway, and dry the baby quickly and thoroughly – Skin-to-skin contact preferred to maintain warmth Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Immediate Nursing Management of the Newborn (cont’d) • Immediately after cesarean birth – Follow regular resuscitation and admission procedures – Immediately receive newborn at the radiant warmer; suction, dry, and position baby for further assessment – Apgar scoring Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Collaborative Care: Immediate Newborn Care • Assessment • Select potential nursing diagnoses • Planning/intervention

Early Newborn Care Procedures • Identification • Weight • Measurements • Gestational age assessment • Infant classification • First bath • Medication administration • Full physical examination Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Newborn Transitional Period • Behavioural changes • Behavioural states • Behavioural cues • Neonatal sensory abilities • Physiologic adaptations – Thermoregulation – Glucose metabolism Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Newborn Transitional Period (cont’d) • Physiologic adaptations (cont’d) – Hematopoietic system – Hepatic system – Gastrointestinal system – Immunologic system – Integumentary system – Renal system Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Newborn Transitional Period (cont’d) • Promoting normal transition – Gentle handling – Use of containment – Avoidance of gastric suction – Use of ambient or dim light – Use of axillary temperature Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Newborn Transitional Period (cont’d) • Differentiating normal versus abnormal transition – Well newborn: no history of prenatal or intrapartal risk factors – Sick newborn: clear risk factors related to gestational age, size for gestation, and prenatal and/or intrapartal history – At-risk newborn: risk factors related to size for gestation and prenatal and intrapartal history Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Newborn Transitional Period (cont’d) • Signs of abnormal newborn transition – Respiratory distress: most common manifestation of abnormal transition • Signs of normal transition – Respiratory distress: expiratory grunting, nasal flaring, and retracting—mild and intermittent—unaccompanied by pallor, heart murmur, lethargy; resolve in first 30 to 60 minutes of life Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Collaborative Care: The Transitional Period • Assessment – Assess axillary temperature – Assess for jaundice – Document medical record – Notify pediatric provider Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Collaborative Care: The Transitional Period (cont’d) • Select potential nursing diagnoses – Risk for injury – Risk for imbalanced body temperature – Risk for infection – Risk for impaired skin integrity – Risk for deficient/excess fluid volume Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Collaborative Care: The Transitional Period (cont’d) • Planning/intervention – Never leave a newborn exposed – Promote thermoregulation – Be aware of prenatal and intrapartal risk factors – Encourage early and effective feeding – Recommend follow-up examination in home or clinic Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Collaborative Care: The Transitional Period (cont’d) • Evaluation – Axillary temperature range – Maintain newborn with a stable temperature – Maintain blood glucose level of at least 2. 5 mmol/L – Document results of bedside screening and laboratory tests Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Ongoing Assessments • Assess the newborn’s resting position, respiratory status, colour, and state • Record assessments of vital signs and indicators of well-being • Describe interventions and their associated outcomes • Note variations on infant hospital flow sheets Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Basic Care of the Healthy Newborn • Cultural aspects • Care of the newborn following home birth • Infant security • Temperature assessment • Use of the bulb syringe • Voiding and stools • Diapering • Cord care • Clothing Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Basic Care of the Healthy Newborn (cont’d) • Wrapping • Holding • Comforting • Parental stress • Sleep positioning and sudden infant death syndrome (SIDS) Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Basic Care of the Healthy Newborn (cont’d) • Bathing the newborn – Sponge bathing – Never leave the infant alone – Avoid lotions, oils, and talcum powders – After the initial bath, soap rarely needed – Parents must file their fingernails Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Additional Parent Education • Circumcision – Surgical removal of the foreskin from the end of the penis – Surgical consent is required; risk for bleeding and infection exists – Additional analgesic interventions o Swaddling and padding o Sucrose pacifier o Postoperative care Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Additional Parent Education (cont’d) • Immunizations – Adverse or allergic reaction may result – Reasons for delay or decision not to give a child a hepatitis B vaccination: 1. Child has severe allergy to baker’s yeast; life-threatening reaction from previous dose; moderate or severe illness on the day of vaccination Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Additional Parent Education (cont’d) • Signs of newborn illness – Respiratory distress; abdominal distention – Forceful vomiting that shoots out several inches – Muscle weakness; jitters of the whole body – Watery white or mucus discharge; sticky eyelashes; eye discharge Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Additional Parent Education (cont’d) • Car seats – Nurse’s role: o Offer advice; provide teaching on safety of the newborn in the car o Provide verbal instructions to parents o In some facilities, nurses play an active role: they place car seat in vehicle and place the infant in the car seat Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Additional Parent Education (cont’d) • Siblings – Toddlers o Feel jealous and displaced by the new baby; may seek attention by misbehaving or displaying regressive behaviours – Preschoolers o Parents should include preschoolers in preparations for the newborn Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Additional Parent Education (cont’d) • Siblings (cont’d) – School-age children and adolescents 1. Parents should schedule special time alone with older siblings, reassuring them with plenty of love and attention • Pet safety – Parents should prepare pets for a new baby’s arrival – Pet may feel jealous and misbehave or act aggressively toward other pets Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Additional Parent Education (cont’d) • Dangers of secondhand smoke – Passive smoking is harmful to children’s respiratory health; it increases rates of lower respiratory illness, middle ear effusion, asthma, SIDS, and development of cancer in adulthood – Precautions help protect the baby’s health Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Readiness for Hospital Discharge • Newborn metabolic screening – Purpose: prevent complications of genetic diseases; early identification and treatment – Nurse should understand that metabolic screening tests are not diagnostic – Newborn metabolic screening tests occur before hospital discharge Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Readiness for Hospital Discharge (cont’d) • Auditory screening – Various causes of hearing loss o Heredity o Very low birthweight o Congenital infections o Ototoxic drugs o Bacterial meningitis Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Readiness for Hospital Discharge (cont’d) • Post-discharge follow-up – Any newborn discharged before 48 hours of age must be examined again within 48 hours – Frequency of subsequent visits varies for healthy term newborns – Every province mandates healthcare professionals report suspected child abuse – Immunizations are administered according to the childhood immunization schedule Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • Is the following statement true or false: – The acronym APGAR for newborn assessment stands for: o A: Alertness o P: Pulse o G: Gage o A: Activity o R: Respiration Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer False. – APGAR stands for: o A: Appearance (colour) o P: Pulse (heart rate) o G: Grimace (reflex irritability) o A: Activity (muscle tone) o R: Respiration (respiratory effort) Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • Which of the following statements regarding fetus to newborn respiratory and circulatory transitions is not true? – a) Rising oxygen levels cause the foramen ovale to begin to constrict and functionally close by 96 hours of life. – b) Newborns have audible crackles for a short time after birth. – c) Surfactant is essential to normal lung function. – d) Clamping of the umbilical cord causes rapid changes in pulmonary vascular resistance and systemic vascular resistance. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer a) Rising oxygen levels cause the foramen ovale to begin to constrict and functionally close by 96 hours of life. – Rising oxygen levels cause the ductus arteriosus to begin to constrict almost immediately after birth of a healthy newborn. In most cases, the ductus arteriosus is functionally closed by 96 hours of life. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • Is the following statement true or false: – Immediately following a vaginal birth, the nurse should not take the healthy newborn to a radiant warmer or another location for observation and admission. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer True. – Taking a healthy newborn immediately to a radiant warmer or other location for observation and admission is outmoded and hinders attachment. – The nurse can place the baby directly on the mother’s abdomen or chest, covering both with a dry, warm blanket. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins