High Risk Neonates Definition The high risk neonate

High Risk Neonates

Definition • The high risk neonate can be defined as a newborn, regardless of gestational age or birth weight, who has a greater than average chance of morbidity or mortality because of threats to life and health that occur during prenatal, perinatal and postnatal period.

Factors Predisposing to High-Risk Neonate: • Maternal Factors: High-risk pregnancies as in lack of antenatal care, poor socioeconomic condition, previous history of obstetric complications as abortion, toxemias, placental insufficiency, stillbirth. Medical illness of mother as diabetes mellitus, heart and kidney diseases and severe infection. Complications of labor and delivery as prolonged rupture of membranes, cesarean section and stillbirth.

• Neonatal Factors: As neonatal asphyxia, neonatal infection, congenital anomalies, prematurity, post-maturity, low Apgar score, hypoglycemia and others. • Definition of Gestational Age: The course of time from day one of menstrual cycle in which conception occurred till birth.

Methods used in Determination of Gestational Age: • • • Physical and neurological examinations. L. M. P. Obstetric history. Lab tests. Fetal ultrasonic scanning.

Classification of Newborn: • Classification According to Gestational Age: – Preterm (premature) infant – An infant born before completion of 37 weeks of gestation – Full-term infant – An infant born between the beginning of 38 weeks and the completion of 42 weeks of gestationt – Postterm (postmature) infant – An infant born after 42 weeks of gestational age

When using gestational age and birth weight, newborn can be classified as: • Small for gestational age (SGA): when plotted on intrauterine growth chart, they lie below 10 th percentile. • Appropriate for gestational age (AGA): When plotted on intrauterine growth chart, they lie between 10 th and 90 th percentile. • Large for gestational age (LGA): When plotted on intrauterine growth chart, they lie above 90 th percentile.

• Classification According to Size: • Low- birth-weight (LBW) infant – An infant whose birth weight is less than 2500 gm, regardless of gestational age. • Very-Low-Birth weight (VLBW) – An infant whose birth weight is less than 1500 gm. • Very-Low-Birth-Weight (VVLBW) or extremely low (ELBW) – An infant whose birth weight is less than 1000 gm.

• Moderately-Low Birth Weight (MLBW) – An infant whose birth weight is 1500 - 2500 kg. • Appropriate for Gestational Age (AGA) infant – An infant whose weight falls between the 10 th – 90 th percentiles. • Small- for-Date (SFD) or Small for. Gestational Age (SGA) Infant – An infant whose intrauterine growth was slowed and whose birth weight falls below the 10 th percentile on intra-uterine growth curves.

Intrauterine Growth Retardation (IUGR) – Found in infants whose intrauterine growth is retarded (sometimes used as a more descriptive term for the SGA infant). Large for Gestational Age (LGA) infant – An infant whose birth weight falls above the 90 th percentile on intrauterine growth charts.

Classification According to Mortality: • Live birth – Birth in which the neonate manifests any heartbeat, breathes, or displays voluntary movement, regardless of gestational age • Fetal death – Death of the fetus after 20 weeks of gestation and before delivery, with absence of any signs of life after birth

• Neonatal death – Death that occurs in the first 27 days of life; early neonatal death occurs in the first week of life; late neonatal death occurs at 7 to 27 days • Perinatal mortality –Describes the total number of fetal and early neonatal deaths per 1000 live births • Postnatal death – Death that occurs at 28 days to 1 year after birth

Problems Associated with Preterm, SGA and Post term infants: • Preterm Problems: • Size: As temperature instability- hypothermia. • Immaturity: Such as; Respiratory Problems: - Apnea. Respiratory Distress Syndrome. (RDS) • Metabolic Problems: - Hyperbilirubinemia - Hypoglycemia. • Hematological Problems: - intracranial Hemorrhage. • Other problems: - Infections. • - Congenital Abnormalities.

• SGA Problems: • Congenital –Congenital abnormalities, intrauterine infection. • Metabolic – Hypoglycemia. • Hematological – Pulmonary Hemorrhage. • • Post Term Problems: • Intrauterine Asphyxia. • Meconium Aspiration.

Assessment of Clinical Gestational Age: • by Ballard, Novack and Driver (1979, It assesses six external physical and six neuromuscular signs. Physical signs as, skin, lanugo, planter surface, breast, eye/ear and genitals (male), genitals (female). Neuromuscular signs as posture, square window (wrist), arm recoil, popliteal angle, scarf sign and heal to ear sign. Each sign has a number score, and the cumulative score correlates with a maturity rating for 26 -44.

Systemic Assessment of High-Risk Neonates: • General assessment: – Weigh daily, measure length and head circumference. – Describe general body shape and size, posture at rest, presence and location of edema. – Describe any apparent deformities. – Describe any signs of distress: Poor color, mouth open, grimace-furrowed brow.

Respiratory assessment: – Describe shape of chest (barrel, concave), chest tubes or other deviation. – nasal flaring or substantial, intercostal or subclavicular retractions. – Determine respiratory rate and regularity. – Describe breath sounds: – Determine whether suctioning is needed. – Describe cry if not incubated. – If incubated, describe size of tube, type of ventilator and setting, and method of securing tube. • Determine oxygen by pulse oximetry.

Cardiovascular assessment: – Determine heart rate, heart sounds, including any murmurs. – Describe infant’s color: cyanosis, pallor, plethora, jaundice- assess the color of the lips, nail beds, mucous membranes. – Determine blood pressure and cuff size. • Describe monitors, their parameters and whether alarms

Gastrointestinal assessment: – Determine presence of abdominal distention, increase in circumference, shiny skin and state of umbilicus. – If Nasogastric tube in place, describe type of suction, drainage (color, consistency). – Describe amount, color, consistency and odor of any emesis. – Palpate liver margin. – Describe amount, color and consistency of stools, check for occult blood. • Describe bowel sound: presence or absence.

Genitourinary assessment: – Describe any abnormalities of genitalia. – Describe amount, color, PH, lab stick finding, and specific gravity of urine. • Check weight (the most accurate measure of hydration)

Neurologic- Musculoskeletal assessment: – Describe infant’s movement: – Describe infant’s position or attitude: flexed, extended. – Describe reflexes: Moro, sucking, Babiniski, plantar reflex and other expected reflexes. – Determine level of response. • Determine changes in head circumference: size and tension of fontanels, suture lines.

• Temperature: – Determine skin and axillary temperature. – Determine relationship to environmental temperature. • Skin assessment: – Describe any discoloration, reddened area, signs of irritation, abrasions. with skin. – Determine texture and turgor of skin; dry, smooth. – Describe any rash, skin lesion or birthmarks. – Determine whether intravenous infusion device is in place and observe for sign of infiltration.

• Monitoring physiological data: – Vital signs: – Temp: 36. 5 -37. 3°C. – Pulse: 120 -150 beat /min. – Respiration: 40 -60 cycle/ Min. – Blood examination is a necessary part of the ongoing assessment and monitoring of risk newborn’s progress. The tests most often performed are blood glucose, Bilirubin, calcium, and hematocrit and blood gases. – Blood glucose (protocol of hypoglycemia). •

• Ineffective breathing pattern related to pulmonary and neuromuscular immaturity, decreased energy and fatigue. • Ineffective thermo-regulation related to immature temperature control and decreased subcutaneous body fat. • High risk for infection related to deficit immunologic defenses. • Altered nutrition: less than body requirement related to inability to ingest nutrients because of immaturity or illness.

Admission Criteria for High Risk Unit: • • Preterm. Post term. Hyperbilirubinemia. Respiratory disorders. Hemolytic disorders. Neonatal seizures. Sepsis. Hypoglycemia.

Prematurity The premature newborn is a baby born before completion of 37 weeks of gestation. The cause of pre-maturity is unknown.

Predisposing Factors of Premature Newborn: • • Mothers' age less than 17 years or over 35 years. Toxemia of pregnancy. Multiple births; Ante-partum hemorrhage. Premature rupture of membrane. Chronic maternal malnutrition. Cardiac disease and hypertension of the mother.

• • • Maternal diabetes mellitus. Acute or chronic infection. Inadequate antenatal care. Abnormality of the pelvis. Exposure to radiation during pregnancy. Fetal abnormality.

Characteristics of Premature Newborn: Premature newborn is small in size with large head • in proportion to the whole body. Hair is fine and fuzzy on the head. • Subcutaneous tissue is deficient. • Skin is thin, wrinkled, red, and smooth and clearly • visible blood vessels. Excessive lanugo and no or/ little vernix caseosa. • Eyes are prominent and the ear cartilage is soft and • easily folded. Thorax is less firm. •

-Breast tissue is minimal (less than 10 mm in diameter), nipple flat and barely seen. -Abdomen is protruded. -Extremities and muscles are thin and small. -Small genitalia, as male newborn have few scrotal rugae and testes are un-desecnded. Female newborn has separated libia majora and libia minora are protruding. -Soles and palms have minimal creases. -Short and soft finger nails and toe nails. -Premature newborn is inactive and has a weak cry with extremities extended.

Physiological Reasons for Premature Newborn Maladaptation: Respiratory function: -Decreased number of alveoli. -Deficient surfactant levels. -Smaller lumen in the respiratory system. -Greater collapsibility of respiratory passages. -Immature and friable capillaries in the lungs.

Cardiovascular function: The nurse must be prepared to intervene if symptoms of hypovolemia, or shock, are present as indicated by decreased blood pressure, slow capillary refill and continued respiratory distress.

Central nervous system function: -The premature newborn CNS is susceptible to injury from various sources: -Birth trauma with damage to immature structures. -Bleeding from fragile capillaries. -Impaired coagulation process, including prolonged prothrombin time.

Renal function: The premature newborn immature renal function is unable: -To concentrate the urine. -To maintain the balance in acid-base, fluids, or electrolytes.

Hematologic status: -The premature hematologic problems raised as a result of the following factors: -Increased capillary friability. -Increased tendency to bleed. -Slowed production of red blood cells (because of rapid decrease in erthyropoiesis after birth). -Loss of blood from frequent laboratory tests. -Decreased red blood cell survival related to relatively larger size of the RBC and increased permeability to sodium and potassium.

• Therapeutic Management: Newborns who do require resuscitation are transferred immediately to the NICU in a heated incubator where they are weighed. Intravenous lines, 02 therapy, and otherapeutic interventions are initiated as needed. Subsequent care is determined by the status of newborn. • Nursing Consideration: (see nursing care of high -risk newborn).

Postmaturity Post-term newborns are those born after 42 weeks of gestation, calculated from the mother's last menstrual period.

Etiology Postmaturity • Placenta develops completely by 5 th month of gestation and achieves peak function by 36 week's gestation. Placental growth continues then at a slow rate, with a decrease noted after 42 week’s gestation, which may lead to post maturity.

• Delay placental maturation due to maternal systemic diseases, uterine anomalies, placenta abnormalities, and fetal factors (e. g. multiple gestation), which alter placental function. • Placental dysfunction results in compromised blood supply to the fetus. • The fetus is at risk for: • Nutritional deficiency. • Hypoxia. • Asphyxia.

post-mature characteristics: -Pale, dry, cracked, wrinkled skin. -Skin maceration, especially skin in folds. -Loose skin, especially around the thigh and buttocks, giving them the appearance of having recently lost weight. -Long nails. -Absent lanugo hair.

-Abundant hair (scalp hair). -Hardness of skull. -Decrease or absence of vernix caseosa. -Long, thin arms and legs, decreased subcutaneous tissue. -Meconium -stained nails, skin, vernix, and umbilical cord. - Appearance of hypoglycemia: -Assess raised problems such as meconium aspiration, hypoglycemia, and hypocalcaemia.

Nursing Diagnosis: • Altered growth and development related to placental insufficiency as evidence by postmaturity syndrome. • High risk for respiratory distress; hypoglycemia, hypocalcaemia. • High risk for impaired 'skin integrity related to altered nutritional state (post-maturity syndrome).

Implementation • - Provide care individually according to each newborn's needs. • Observe signs and symptoms of respiratory distress. • Take temperature. • Monitor serum glucose. • Observe signs and symptoms of hypoglycemia because of limited glycogen stores. • Monitor serum calcium.

If oral calcium is ordered, give the medication with enteral feeding because it may cause gastric irritation. • If calcium is ordered IV, monitor the heart rate during administration, administer slowly, and stop it if bradycardia or arrhythmia occurs. • Provide skin care, wash with non alkaline soap or water only and allow skin to slough naturally. •

Methods of Heat Loss and Gain: Convection: Where heat loss is aided by surrounding air currents (keep baby away from drafts and fans). Conduction: Involves loss of heat from the body because of direct contact of skin with a cooler solid objects. Evaporation: Heat is lost by evaporation of amniotic fluid from the skin surface immediately after birth. Insensible water loss and visible sweat.

Radiation: Loss of heat to cooler solid objects in the environment that are not in direct contact with the newborn. Loss of heat through radiation increases as these solid objects become colder and closer to newborn. So, keep the newborn in the center of the room (away from cold external walls).