2. OBJECTIVES
At the end of the lesson, students should be able to acquire knowledge on prematurity and apply the
knowledge to adequately nurse a baby with the condition
Specific objectives
Define prematurity
State the causes of prematurity
Outline the characteristics of a premature baby
Outline the gestational assessment of babies
Discuss the management of premature babies
Mention the complications of prematurity
Outline the prevention of prematurity
3. INTRODUCTION
Prematurity is a common condition throughout the world.
In the past, birth weight was used to define prematurity,
but now, with more accurate pregnancy dating,
gestational age is the more accurate measure of
prematurity to use
Preterm infants are at risk because their organ systems are
immature and they lack adequate physiologic reserves to
function in an extrauterine environment. The lower the
birth weight and gestational age, the fewer the chances of
survival exist among preterm infants.
4. INTRODUCTION
Preterm babies are susceptible to sequelae related to their
premature birth, among them, necrotizing enterocolitis,
bronchopulmonary dysplasia, intraventricular and
periventricular haemorrhage and retinopathy of prematurity
Preterm birth is responsible for almost two thirds of infant
deaths (Wong et al, 2006). Most preterm babies are AGA,
some SGA and a small number LGA
5. Prenatal Gestational Age
Assessment
Calculation by the mother estimated date of Delivery (EDD)
Collection of prenatal data
First fetal movement (16-20 weeks)
Fetal heart rate (20 weeks) (with doppler 9-12 weeks)
Fundal height (One cm = 1 week after 18-20 weeks)
20 weeks (fundus normally at umbilicus)
Term (fundus at xyphoid)
Amniotic fluid creatinine levels
Maternal serum and urine estriols
Fetal US
6. Prenatal Gestational Age Assessment
FETAL US MEASUREMENTS
Crown to rump length
Biparietal diameter
Femur length
Abdominal Circumference
Head Circumference
Placental grade
7. DEFINITION
Prematurity is a condition in which the baby is born
after 28 weeks of gestation but before 37 completed
weeks of gestation, counting from the first day of the
last normal menstrual period regardless of
birthweight (Fraser & Cooper, 2003)
A premature infant is a baby born before 37
completed weeks of gestation (Wong et al, 2006)
8. Incidence
Of the babies born preterm:
•84 percent are born between 32 and 36 weeks of
gestation
•About 10 percent are born between 28 and 31 weeks of
gestation
•About 6 percent are born at less than 28 weeks of
gestation
9. CAUSES OF PREMATURITY
Spontaneous causes
40% unknown
Multiple gestation
Maternal hyperpyrexia
PROM due to maternal infection
Maternal substance abuse
Maternal short stature
Maternal age and parity
Poor obstetric history, history of preterm
labour
Maternal uterine malformation
Cervical incompetence
Poor social circumstances
11. PROBLEMS OF PREMATURE BABIES
MAINTENANCE OF BODY TEMPERATURE
Susceptible to temperature instability due to;
minimal insulating subcutaneous fat
Limited stores of brown fat
Decreased or absent reflex control of skin capillaries (vasoconstriction)
Inadequate muscle mass activity
Immature temperature regulation center in the brain
Decreased ability to increase oxygen consumption
Poor muscle tone which exposes more body surface area to the cooling effects of the
environment
Decreased intake of calories
12. RESPIRATORY FUNCTION
The preterm is likely to have problems making the
pulmonary transition from intra uterine to extra uterine life
Numerous problems may affect their respiratory system,
which include;
◦Decreased number of functional alveoli
◦Deficient surfactant
◦Immature and fragile capillaries in the lungs
◦Smaller lumen in the respiratory system
◦Greater collapsibility of respiratory passages
◦Insufficient calcification of bony thorax
13. These problems can lead to the following conditions;
◦ Respiratory distress syndrome - a condition in which the air sacs
cannot stay open due to lack of surfactant in the lungs
◦ Chronic lung disease - long-term respiratory problems caused by
injury to the lung tissue
◦ Apnea (cessation of respirations for 20 seconds or more) - occurs in
about half of babies born at or before 30 weeks
Respiratory distress is manifested as flaring of the nares and expiratory grunting. In severe cases,
there is subcostal, intercostal or suprasternal retractions
14. CARDIOVASCULAR SYSTEM
Susceptible to;
◦Patent ductus arteriosus (PDA) - a heart condition that
causes blood to divert away from the lungs.
◦Too low or too high blood pressure
◦Low heart rate - often occurs with apnea
◦INTEGUMENTARY/GASTROINTESTINAL SYSTEM
◦Jaundice - due to immaturity of liver and poor
gastrointestinal function
15. CENTRAL NERVOUS SYSTEM FUNCTION
Susceptible to injury due to;
Birth trauma with damage to immature structures
Bleeding from fragile capillaries
Impaired coagulation process, including prolonged prothrombin time
Recurrent anoxic and hyperoxia episodes
Predisposition to hypoglycaemia
Fluctuating systemic blood pressure with concomitant variation in cerebral flow and pressure
Clinical signs may be subtle but the following signs should be evaluated; seizures, hyperirritability,
CNS depression, elevated intracranial pressure and abnormal movements
16. MAINTAINING NUTRITION
Hypoglycemia is common due to;-
Inadequate storage of glycogen in utero
Inadequate nutrition intake due to poor or absent suck and
swallowing , and gag reflexes
Small stomach capacity
Immature digestive enzymes
Other problems which increase their metabolic rate.
Signs include apnea, tremors, twitching, sweating, cyanosis,
refusal to feed and coma
17. MAINTAINING RENAL FUNCTION
Renal system is immature and is unable to;
Adequately excrete drugs and metabolites
Concentrate urine
Maintain acid-base, fluid and electrolyte balance
Hence maintaining intake and output, measuring specific gravity and laboratory assessment of acid-
base and electrolyte balance is cardinal
18. MAINTAINING HAEMATOLOGIC STATUS
Susceptible to haematologic problems due to the following;
Increased capillary fragility
Increased tendency to bleed (prolonged prothrombin time)
Decreased production of red blood cells resulting from physiologic rapid decrease in erythropoiesis
after birth
Loss of blood due to frequent blood sampling
Decreased levels of circulating albumin
Hence assessment for bleeding from puncture sites, observing for anaemia and monitoring amount
of blood drawn for labs is cardinal
19. RESISTING INFECTIONS
Premature infants are more susceptible to infection because they have a shortage of stored
maternal immunoglobulins, and impaired ability to make antibodies
They also have a compromised integumentary system, and may require antibiotics. Early
treatment of sepsis is essential for survival
Premature babies can have long-term health problems as well. Generally, the more premature
the baby, the more serious and long lasting are the health problems.
20. Characteristics of preterm babies
These will depend on gestational age
-General appearance: small scrawny baby, often weighing less than 2,500 grams, with pink or red
skin, and visible veins
Posture: flattened, hips abducted, knees and ankles flexed-hypotonic posture
Cry: weak and feeble
Head: Head is large in proportion to body with small triangular face. Skull bones soft with large
fontanelle and wide sutures. Hair is soft and silky
Ears: flat pinna with little curve
Eyes: eyes bulge with prominent orbital ridges
Chest: small and narrow
21. Breasts: nipple areola poorly developed and barely visible
Abdomen: large and prominent (spleen and liver large with poor muscle tone)
Umbilicus: low set due to cephalocaudal linear growth. Cord white, fleshy and glistening
Skin: red and transparent with little body fat. Short and soft nails
Plenty vernix caseosa and lanugo hairs
Body creases: palmar creases absent before 36 weeks gestation
Genitalia: labia majora fail to cover labia minora in girls and testes may be undescended before 37th
week in boys
22. ASSESSMENT OF THE NEWBORN
Each newborn baby is carefully checked at birth for signs of problems or complications
Assessment should include:
Apgar scoring:
The Apgar score is one of the first checks of the new born baby's health and helps identify babies
that have difficulty breathing or have a problem that needs further care.
AS is checked at one minute and five minutes after birth for heart and respiratory rates, muscle tone,
reflexes, and color.
23. Physical examination:
A complete physical examination is an important part of
newborn care
Each body system is carefully examined for signs of health
and normal function
The physician also looks for any signs of illness or birth
defects.
Physical examination of a newborn often includes the
assessment of vital signs and gestational assessment
Assessing a baby's physical maturity is an important part of
care.
24. -Maturity assessment is helpful in meeting a baby's
needs if the dates of a pregnancy are uncertain.
-For example, a very small baby may actually be more
mature than it appears by size, and may need different
care than a premature baby.
An examination called The Dubowitz/Ballard
Examination for Gestational Age is often used. A baby's
gestational age can often be closely estimated using this
examination.
The Dubowitz/Ballard Examination evaluates a baby's
appearance, skin texture, motor function, and reflexes.
25. PHYSICAL MATURITY
The physical maturity part of the examination is done in the
first two hours of birth
The neuromuscular maturity examination is completed within
24 hours after delivery
Information often used to help estimate babies' physical and
neuromuscular maturity is shown below
26. Physical maturity:
The physical assessment part of the Ballard Examination
assesses the physical characteristics that look different at
different stages of a baby's gestational maturity
Babies who are physically mature usually have higher scores
than premature babies
Points are given for each area of assessment, with a score of -1
or -2 for extreme immaturity to as much as 4 or 5 for
postmaturity
28. ◦Areas of assessment include the following:
◦skin textures (i.e., sticky, smooth, peeling).
◦lanugo (the soft downy hair on a baby's body) - is absent in
very immature babies, then appears with maturity, and then
disappears again with postmaturity.
◦plantar creases - these creases on the soles of the feet range
from absent to covering the entire foot, depending on the
maturity
29. ◦breast - the thickness and size of breast tissue and areola
(the darkened ring around each nipple) are assessed.
◦eyes and ears - eyes fused or open and amount of cartilage
and stiffness of the ear tissue.
◦genitals, male - presence of testes and appearance of
scrotum, from smooth to wrinkled.
◦genitals, female - appearance and size of the clitoris and the
labia.
30. EAR—The preterm infant’s ear cartilages
are poorly developed,
and the ear may fold easily; the hair is
fine and
feathery, and lanugo may cover the back
and face. The
mature infant’s ear cartilages are well
formed, and the
hair is more likely to form firm, separate
strands.
31.
32.
33. Female genitalia—The preterm female infant’s clitoris is
prominent, and labia majora are poorly developed and
gaping
Mature female infant’s labia majora are fully developed, and
the clitoris is not as prominent
34.
35. Male genitalia—The preterm male infant’s scrotum is
undeveloped and not pendulous; minimal rugae are present,
and the testes may be in the inguinal canals or in the
abdominal cavity
The term male infant’s scrotum is well
developed, pendulous, and rugated, and the testes are
well descended in the scrotal sac.
39. Posture
Total body muscle tone is reflected in the infant's preferred posture at rest and resistance to stretch
of individual muscle groups
40. MANAGEMENT OF PREMATURE BABIES
Maintenance of respirations
Respiratory interventions needed may vary from oxygen by hood to mechanical
ventilation.
Assess baby’s respiratory status
Consider cause of apnea if present
Position baby in side-lying position for oxygenation and drainage of secretions
Clear airways by gentle suction PRN
41. Administer O2 PRN by most appropriate means, e.g. by hood
Surfactant may be given to very immature babies 50-100 mg/kg stat
Monitor vital signs closely and blood gasses
Keep baby warm and well hydrated (iv fluids may be given 60ml/kg body
weight)
Avoid too much handling to reduce O2 demands by tissues
42. Management of thermoregulatory problems
Gestation age and weight will influence the type of care initiated
If less than 2 kg, incubator care is indicated with incubator temp at 30-32
degrees Celsius, and at 36-37 degrees for babies less than 1.5 kg. Cot care is
used for babies weighing 2 kg and above
Kangaroo care may be used to provide warmth
Vital signs, especially temperature should be monitored
43. Maintaining nutrition
Early feeds are given to prevent hypoglycemia, either by breastfeeding, tube
feeding or iv fluids 60 mls/kg/24 hours. NGT feeds are given 1-5 mls per feed every
2 hours
Babies should get 60 mls of feed/kg on day 1 and continue with 20 ml increment
/day
Blood sugar levels should be monitored by heel stick sample
44. Infection prevention
Scrupulous hand washing with soap by everyone handling the baby is the best way
to prevent infection
Use of gowns when handling babies and restricting number of visitors also reduces
infection
Clean incubators , equipment and linen should be used at all times
Isolate sick babies
45. Skin care
The skin of premature infants is sensitive and fragile, therefore alkaline-based soap
should not be used as it may destroy the ‘acid mantle’ of the skin.
All skin products should be used with caution, and the skin thoroughly rinsed with
water as these substances may cause irritation and chemical burns, and may be
absorbed due to increased permeability of the skin.
Care must be taken to avoid damage to the delicate skin, as it easily gets excoriated
46. Drug administration
The computation, preparation and administration of drugs in minute amounts often
require collaboration between nurses, physicians and pharmacists to reduce the
chance of error
In addition, immaturity of the baby’s detoxification mechanisms and inability to
demonstrate symptoms of toxicity complicate drug therapy and require that nurses
be particularly alert to signs of adverse reactions
The principles of drug administration should be meticulously adhered to in preterm
babies. The commonly given drugs are antibiotics and vitamin K
47. Developmental care
Early developmental intervention is necessary when caring for preterm infants.
Infants respond to a great variety of stimuli and the atmosphere and activities of
the NICU are over stimulating.
Noise has been correlated with incidence of intracranial hemorrhage especially
in the extremely immature infants, and nursing care activities e.g. taking vital
signs, changing nappies etc have been associated with hypoxia.
48. Therefore the NICU should be noise free and procedures grouped together to allow the infant to
rest and develop normally. If possible, the NICU should be dimmed in the night to allow for
normal sleep and sleep periods should be undisturbed for at least 50 minutes to allow complete
sleep cycles. Use curtains or blinds during the day to protect infants from direct sunlight
The baby should be handled with slow controlled movements to prevent instability and jerking
limb movements.
49. Family support and Discharge planning
Explain the condition to the parents when the baby is born
Teach them by demonstration on how to take care of a preterm baby
Involve them in caring for the baby so that they gain confidence
Allow them to express their fears and ask questions
Support them emotionally as the birth of a preterm infant is usually unexpected
and stressful. Parents are also anxious regarding the viability and survival of
their infant
Inform them how the baby is progressing
50. IEC on discharge
Teach them the importance of the following;-
Warmth
Feeding
Infection prevention
Immunization
Adhering to the review dates for follow-up of the infant
Teach them danger signs in the preterm baby (feeding difficulty, lethargy,
hypothermia or hyperthermia, tachypnoea, chest indrawing, convulsion)
51. When to discharge a premature baby
from hospital
-serious illnesses have been resolved
- stable temperature - able to stay warm in an open crib
-taking all feedings by breast or cup
-consistently gaining weight at a rate of 10-30 g/day
- no recent apnea or low heart rate
- parents are able to provide care including medications and feedings
52. COMPLICATIONS OF PREMATURITY
Respiratory distress syndrome
Patent ductus arteriosus due to poor oxygenation and low levels of circulating prostaglandins
Periventricular-intraventricular haemorrhage
Necrotizing enterocolitis
Retinopathy of prematurity
Chronic lung disease
54. conclusion
Prematurity is a serious problem in Zambian communities but adequate and appropriate care of
preterm infants, with parent involvement leads to excellent survival rates for the preterm
babies.
It is therefore important for health workers to have knowledge and skill in care of these babies
and be able to advise parents and caretakers on management of preterm infants.
55. REFERENCES
Fraser, D. M. & Cooper, M. A. (2003). Myles textbook for midwives. 14th edition. Churchill
Livingstone. Edinburgh
Wong, D. L., Hockenberry, M. J., Perry, S. E., Lowdermikl, D. L., Wilson, D. (2006). Maternal Child
Nursing care. 3rd edition. Mosby. missouri
