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Similar to chapter 3 new born care ppt.pptx
chapter 3 new born care ppt.pptx
- 1. UNIT THREE CARE OFNEWBORN Dr. Asrat
- 2. Essential Newborn Care •Majority of babies born healthy and at term • Care during first hours, days and weeks of life determine whether they remain healthy • Basic care to support survival and wellbeing is called ENC • It includes immediate care at birth, care during the first day and up to 28 days
- 3. Four basic needsof all newborns • To breath normally • To be protected • To be warm • To be fed
- 4. Essential Newborn CareInterventions • Clean childbirth and cord care – Prevent newborn infection • Thermal protection – Prevent & manage newborn hypo/hyperthermia • Early and exclusive breastfeeding – Started within 1 hour after childbirth • Initiation of breathing and resuscitation – Early asphyxia identification and management
- 5. ENC… • Eye care –Prevent and manage ophthalmia neonatorum • Immunization – At birth: bacille Calmette-Guerin (BCG) vaccine, oral poliovirus vaccine (OPV) • Identification and management of sick newborn • Provision of vit K to prevent neonatal hemmorge • Care of preterm and/or low birth weight newborn
- 6. Universal Precautions &cleanliness • Wash hands. • Wear gloves. • Protect yourself from blood and other body fluids during deliveries. • Practice safe sharps disposal. • Practice safe waste disposal. • Sterilize and clean contaminated equipment.
- 7. Care of thebaby at the time of birth (Until around 1 hour after birth) • Provide routine care at birth for all newborns • Identify and manage newborns who may need special care
- 8. Routine Care • Placebaby on mother’s abdomen • Dry baby with warm clean sheet • Wipe mouth and nose with clean cloth • Assess baby’s breathing while drying • Clamp cord after 1-3 min, cut with sterile instrument, put sterile tie • Put identity label on the baby
- 9. Routine Care… • Examinefor malformations/ birth injury • Initiate breast feeding within 1 hour • Record baby’s weight • Give eye care tetracycline eye drop • Give Inj Vit K 1mg IM ( 0.5 mg for preterm) • Cover baby’s head with cloth. • Cover mother and baby with warm cloth
- 10. Resuscitation • All babiesmust be assessed for need of resuscitation at birth • At least 1 person skilled in providing resuscitation must be present • Ventilation must start within 1 minute of birth • First golden minute
- 11. Note the time Receivebaby in dry, warm linen Is baby crying/ breathing Routine care • Dry baby on mother’s abdomen • Provide warmth (skin to skincare) • Assure open airway if needed • Cut cord in 1-2 min • Ongoing evaluation of neonate •Cut cord immediately and place under radiant warmer • Provide initial steps (Dry, position, clear airway, tactile Stimulus) Gasping/Apnea or HR<100 Initiate Ventilation using air/O2 Labored breathing/Cy anosis Insure open airway, O2, Monitoring, YES Birth 30 sec 60 sec Resuscitation Flow Diagram Assess ment A Evluation B Yes No No Yes Yes
- 12. Initiate Ventilatio using air/O2 Heart Rateafter 5 infl ations: <100 bpm? Baby breathing well and heart rate>100 bpm Look for Chest Rise; if Not • Reduce leaks • Ensure open airway • Consider increasing pressure If Heart rate < 60 bpm and chest rising • Continue PPV, add 100% oxygen • Start chest compressions: Baby breathing well and heart rate>100 bpm Post- resuscitation care PPV <1 min Observational care Evaluation C Yes No Yes No If HR not detectable or <60bpm Give Adrenaline
- 13. Harmful and Ineffective ResuscitationPractices Practices to be avoided include: • Routine aspiration of the newborn’s mouth and nose as soon as the head is born • Routine aspiration of the newborn’s stomach at birth • Stimulation of the newborn by slapping or flicking the soles of her/his feet: only enough stimulation for mildly depressed-delays resuscitation • Postural drainage and slapping the back: dangerous WHO 1998.
- 14. Harmful and Ineffective ResuscitationPractices (continued) • Squeezing the chest to remove secretions from the airway • Routine giving of sodium bicarbonate to newborns who are not breathing • Intubation by an unskilled person • Some traditional practices: – Putting alcohol in newborn’s nose – Sprinkling or soaking newborn with cold water – Stimulating anus – Slapping newborn WHO 1998.
- 15. Immediate cord care •Clamp and cut cord with a sterile instrument. • Tie the cord between 2 to 3 cms from the base and cut the remaining cord. • Observe for oozing blood. • DO NOT apply any substance to stump. • DO NOT bind or bandage stump. • Leave stump uncovered.
- 16. Keeping a newbornbaby warm after delivery Method of heat loss Prevention Evaporation: Wet baby Immediately after birth dry baby with a clean, warm, dry cloth Conduction: Cold surface e.g weighing scale etc. Put the baby on the mother’s abdomen or on a warm surface Convection: Cold draught Provide a warm, draught free room for delivery at ≥25oC Radiation: Cold metallic surroundings Keep the room warm
- 17.
- 18. Definition of KangarooCare • Early, prolonged and continuous skin-to-skin contact between a mother and her newborn • Could be in hospital or after early discharge
- 19. How to UseKangaroo Care • Newborn’s position: – Held upright (or diagonally) and prone against skin of mother, between her breasts – Head is on its side under mother’s chin, and head, neck and trunk are well extended to avoid obstruction to airways • Newborn’s clothing: – Usually naked except for nappy and cap – May be dressed in light clothing – Mother covers newborn with her own clothes and added blanket or shawl
- 20. How to Use KangarooCare (continued) • Newborn should be: – Breastfed on demand – Supervised closely and temperature monitored regularly • Mother needs lots of support because kangaroo care: – Is very tiring for her – Restricts her freedom – Requires commitment to continue
- 21. Benefits of KangarooCare • Is efficient way of keeping newborn warm • Helps breathing of newborn to be more regular; reduce frequency of apneic spells • Promotes breastfeeding, growth and extra-uterine adaptation • Increases the mother’s confidence, ability and involvement in the care of her small newborn • Seems to be acceptable in different cultures and environments
- 22. KMC • Skin toskin contact, any family member can do • Not less than 1 hour at a time • useful for LBW • Provide warmth, promote BF, • Protects from infection • Emotional bonding • Physiological stability, reduces apnea
- 23. Warm chain • Warmdelivery room • Immediate drying • Skin to skin contact at birth • Breastfeeding • Bathing and weighing postponed • Appropriate clothing • Mother and baby together • Warm transportation
- 24. Breastfeeding • Help motherto initiate breastfeeding within first hour of birth • Help mother at first feed • Ensure - Good position - Good attachment - Effective suckling
- 25. APGAR SCORE • Atest developed in 1952 by Dr. Virginia Apgar • A baby’s first test • Quick assessment of the newborn’s overall well-being • Given one-minute after birth and five minutes after birth • Rates 5 vital areas
- 26.
- 27. Why is itdone? • To assess the baby’s vital signs quickly • The score is helpful for later evaluations • It’s fun and interesting for the parents
- 28. The 5 Signs: 1.The baby’s color Color: a. Pale or blue = 0 b. Normal color body, but blue extremities (arms and/or legs) = 1 c. Normal color = 2 – completely pink
- 29. 2. The baby’srespiratory effort Respiration: a. Not breathing = 0 b. Weak cry, irregular breathing = 1 c. Strong cry = 2 • 2 points for a strong cry • 1 point for a slow or weak cry • 0 points for no cry at all
- 30. 3. The baby’sheart rate Heart Rate: a. Absent heartbeat = 0 b. Slow heartbeat (less than 100 beats/minute) = 1 c. Adequate heartbeat (more than 100 beats/minute) = 2 • 2 = good strong heartbeat • 1 = slow but steady heartbeat • 0 = little or no heartbeat
- 31. 4. The baby’smuscle tone Muscle Tone: a. Limp, flaccid = 0 b. Some flexing or bending = 1 c. Active motion = 2 • 2 points for vigorous motion • 1 point for small flexing • 0 points for no movement
- 32. 5. The baby’sreflexes Response to Stimulation (also called Reflex Irritability): a. No response = 0 b. Grimace (facial expression) = 1 c. Vigorous cry or withdrawal = 2 • 2 points if the baby cries • 1 point if the baby grimaces (facial expression) • 0 points for no movement or sound
- 33. Results • 10 outof 10 is a perfect score • The higher the score, the better the condition • A score over 7 indicates good condition • A score of 10 is unusual • A score less than 7 may indicate some medical assistance
- 34. Limits • Quick assessment •Does not necessarily indicate a baby’s long- term behavior • Parents should not put too much emphasis on the score as a future predictor of the baby’s intellectual or physical performance
- 35. APGAR SCORING SUMMARY INDICATOR0 1 2 HEART RATE None apparent No pulse Less than 100 beats per minute Sluggish Strong heartbeat 100 beats per minute or better RESPIRATORY RATE No breaths taken No chest movement Hyperventilation Cry is weak Spirited cry Brisk movement MUSCLE TONE Limp arms and legs No movement Extremities show some flexion and bending Excellent flexion Energetic movement REFLEX IRRITABILITY No facial or verbal response to aspiration Minimal motion Signs of grimace Hearty cry COLOR Ashen or pale blue Trunk pink, but extremities may be blue Trunk and extremities are pink
- 36. Nursing management ofcommon neonatal disorders
- 37. Respiratory Distress Syndrome •Primary cause of respiratory disorders and deaths in the newborn • Most frequently occurs in premature infants • Cause of 30% of all neonatal deaths and 70% of deaths among preterm newborns • Mortality declined significantly with the introduction of exogenous surfactant • Caused by lack of pulmonary surfactant • Also called “Hyaline Membrane Disease”
- 38. Pulmonary Surfactant • Complexmaterial containing different lipids and proteins • Produced in Type II Granular Pneumocytes in the alveoli and secreted into the air surface • Decreases surface tension and establishes stable respiratory interface and lung volume
- 39. Surfactant Deficiency • Surfactantproduction starts only in late pregnancy • Insufficient amount of surfactant causes collapse of the alveoli, loss of lung volume due to the abnormally high surface tension
- 40. RDS - Treatments •RDS - is a self-limiting disease - it usually subsides within 72 hours Treatments include • Surfactant • Oxygen therapy • Thermoregulation • Ventilator support with CPAP
- 41. Meconium Aspiration Syndrome(MAS) • Meconiumstaining of the amniotic fluid is usually considered to be indicator of fetal distress. • The passage of meconium in utero accompanies 8 to 20% of all deliveries and is seen predominantly in small for gestational age and post mature infants. Five percent of such infants develop meconium aspiration pneumonia
- 42. Clinical features • Theinfant frequently exhibits the classic signs of post maturity with evidence of weight loss together with nails, skin and umbilical cord that are heavily stained with a yellowish pigment. • The infants are often depressed at birth secondary to the hypoxic insult precipitating the passage of meconium. • Respiratory distress with cyanosis, • grunting, flaring, retractions and marked tachypnea soon ensues. • Characteristically the chest acquires an over inflation appearance, and rales may be audible on auscultation.
- 43. Treatment • Depressed infantshould undergo endotracheal intubation and suction should be applied directly to the endotracheal tube to remove meconium from the airway. • Treatment includes supportive care and standard management for respiratory distress. Supportive management may include • the use of antibiotics, because bacterial sepsis may have precipitated the passage and subsequent aspiration of meconium, and bacterial pneumonia may be indistinguishable from meconium aspiration syndrome. • Oxygen suport
- 44. Prevention • The riskof meconium aspiration syndrome can be decreased by • Paying careful attention to fetal distress and initiating prompt delivery in the presence of fetal distress. • Careful, thorough suctioning of the oropharynx after the head in delivered. • Suctioning via endotracheal tube is indicated for depressed infants before initiation of positive pressure ventilation
- 45. Neonatal Jaundice & Hyperbilirubinemia •Jaundice is yellowish discoloration of the skin &/or sclera & MM due to bilirubin deposition. • •Jaundice is either excessive production or defective elimination of bilirubin • •65% of newborns develop visible jaundice with a total serum bilirubin (TSB) level higher than 6 mg/dL during the first week of life.
- 46. • Bilirubin isproduced by the breakdown of heme (iron protoporphyrin) in the reticulo- endothelial system and bone marrow • Heme is cleaved by heme oxygenase to: • iron, which is conserved; • carbon monoxide, which is exhaled; and • biliverdin, which is converted to bilirubin by bilirubin reductase. • Each gram of hemoglobin yields 34 mg of bilirubin
- 47. Neonatal Jaundice &Hyperbilirubinemia • Hyperbilirubinemia is a common and in most cases a benign problem in neonates. • The most common type is unconjugated (indirect reacting) hyperbilirubinemia. • It is the type of pigment found in physiologic jaundice and in pathologic states in which there is increased production, decreased hepatic conjugation, or decreased hepatic uptake of bilirubin. • Conjugated hyperbilirubinemia (direct reacting) is far less common in neonates and most often denotes a serious derangement of hepatic function.
- 48. • The unconjugatedform is neurotoxic for infants at certain concentrations. • Conjugated bilirubin is not neurotoxic but indicates potentially serious disorder
- 49. Etiology Causes of unconjugatedhyperbilirubinemia • Increased load of bilirubin • Damage or reduction of the activity of transferase enzyme • Blockage of the transferase enzyme (drugs) • Absence or decreased amount of the enzyme (genetic defect, prematurity) Causes of conjugated hyperbilirubinemia include • Sepsis • Intrauterine infection • Biliary atresia and • Hepatitis
- 50. Clinical Manifestations • Jaundicemay be present at birth or may appear anytime in the neonatal period • Jaundice usually begins on the face, and as the serum level increases, progresses to the abdomen and then the feet • Jaundice due to deposition of indirect bilirubin tends to be bright yellow or orange. • Jaundice due to direct bilirubin appears to be greenish or muddy yellow • Affected infants may appear lethargic or may feed poorly.
- 51. Physiologic jaundice • Physiologicjaundice is the result of increased bilirubin production following breakdown of fetal red blood cells combined with transient limitation in conjugation of bilirubin by the liver. • Jaundice becomes visible on the 2nd-3rd day usually peaking between the 2nd and 4th days at 5-6 mg/dl, and decreasing between the 5th and 7th day of life.
- 52. Pathological jaundice • Jaundiceshould be considered phatologic if: – It appears in the 1st 24 hours of life – Serum bilirubin is greater than 12 mg/dl in full term or 14 mg/dl in preterm infant – Jaundice persists after 10-14 days of life or – Direct reacting bilirubin is greater than 2 mg/dl – Kernicterus
- 53. • Kernicterus isa neurologic syndrome resulting from the deposition of unconjugated bilirubin in brain cells. • The risk of kernicterus increases with a rise in serum unconjugated bilirubin, preterm newborns have a greater susceptibility to kernicterus
- 54. Clinical manifestation • Signsand symptoms usually appear 2-5 days after birth in term infants and as late as 7th day in preterm infants. • Common initial manifestations include lethargy, poor feeding, and loss of Moro reflex. • bulging fontanel and a high pitched cry may follow • Convulsions occur in advanced cases. • Many infants who progress to these severe neurologic sings die.
- 55. - Treatment Goal of therapyis to avoid kernicterus - Phototherapy - Exchange transfusion
- 56. Nursing management For Pre-termand Low birth weight
- 57. Definitions • Preterm: Liveborn infants born before 37 completed weeks • Low birth Weight: - An infant with a birth weight less than 2500 gram • Very low birth weight: - An infant with a birth weight less than 1500 gram • Extremely low birth weight: - An infant with a birth weight less than 1000 gram
- 58. Cont… • Prematurity andintrauterine growth retardation (IUGR) are associated with increased neonatal morbidity and mortality.
- 59. Causes of pretermbirth Fetal - Fetal distress - Multiple gestation - Erythroblastosis Placental - Placental dysfunction - Placenta previa - Abruptio placentae Maternal - Preeclampsia - Chronic medical illness - Infections - Drug abuse Other - Premature rupture of membranes - Polyhydramnios
- 60. Main causes ofdeath in LBW infants • hyaline membrane disease • intraventricular hemorrhage • septicemia • asphyxia • birth injuries (Principally cerebral) • malformations Main problems of preterm newborns • hyaline membrane disease • apnea • hypoglycemia • hypocalcemia • hyperbilirubinemia • anemia • bacterial sepsis
- 61. In addition preterminfants frequently have – Weak and uncoordinated ability to feed – Prolonged failure to gain weight and – Late metabolic acidosis
- 62. • Problems ofIUGR infants - perinatal asphyxia - hypoglycemia - hypothermia - pulmonary hemorrhage - meconium aspiration • At birth the measures needed for clearing the airway, initiating breathing, care of the cord and the eyes, and administering vitamin K are the same in immature infants as in those of normal weight and maturity.
- 63. Additional consideration 1- Needto monitor temperature, and respiration 2- Need for increased oxygen and 3- Need for special attention to the details of feeding
- 64. Thermal management • Thepreterm newborn encounters the problem of severe heat loss for several reasons. • large body surface area relative to body mass • the tiny baby's small size presents a much smaller heat sink to store thermal reserve • minimal shivering during exposure to cold and • poor reserve of brown fat
- 65. • Heat losscan be minimized by keeping infants in a thermo neutral environment. This could be achieved by using radiant warmers, blankets, heating lamps and by controlling the temperature and humidity of the room.
- 66. Supplementation with oxygen •Administering oxygen is indicated in newborns with tachypnea, apnea or cyanosis. Initiation of feeding • The main principle in feeding premature infants is to proceed cautiously and gradually. • Weight < 1500 g • Infants weighing less than 1500 g require tube feeding because they are unable to coordinate breathing, sucking and swallowing.
- 67. Intestinal tract readinessfor feeding may be determined by:- • active bowel sounds • -passage of meconium • - absence of abdominal distention and • -no bilious aspirate or emesis • For infants under 1000g the initial feedings are breast milk or preterm formula at 10 ml/Kg/24 hrs given by intermittent gavage every 2-3 hrs. • If the initial feeding is tolerated, the volume increased by 10-15 ml/Kg/24 hrs.
- 68. • Weight >1500 g • Feeding is initiated at a volume of 20-25 ml/Kg/24 hr of breast milk or preterm formula every 3 hours • Total daily formula volume increments should not exceed 20 ml/kg/24 hrs. • Weight gain may not be achieved for 10-12 days, and a daily intake of 130-150 ml/kg or more may be necessary for some infants.
- 69. Fluid requirements • *Term newborn • - Day 1: 60-70 ml/kg/d • - After day 2: 100-120 ml/Kg/d • * Preterm newborns • - Day 1: 70 -100 ml/kg/d • - After day 2: 150 ml/kg/d • This higher fluid requirements in preterms in due to high insensible water loss and they are less able to concentrate urine; thus, their fluid intake required to excrete solutes increases. Type of fluid • Day 1 - 10 % Dextrose • Thereafter - N/s in 10 % dextrose
- 70. Discharge from Hospital •Prerequisites for discharge from a hospital • Feeding should be tolerated • Steady increments in Weight of approximately 10-30 g/24 hr • Stabilization of body temperature and • Resolution of acute life- threatening illnesses • Required weight for discharge: 1800 grams
- 71.