MODULE 3 THE NEWBORN POSTPARTUM ADAPTION

1. MODULE 3 THE NEWBORN POSTPARTUM ADAPTION

2. TRANSITION TO EXTRAUTERINE LIFE • NURSING ASSESSMENT OF THE NEWBORN • NEWBORN NEEDS AND CARE • POSTPARTUM ASSESSMENT • POSTPARTUM NEEDS AND CARE

3. MODULE 3 PART 1A TRANSITION TO EXTRAUTERINE LIFE

4. RESPIRATORY • FETAL LUNG DEVELOPMENT • ALVEOLI • SURFACTANT • LECITHIN/SPHINGOMYELIN RATIO • FETAL BREATHING MOVEMENTS

5. RESPIRATORY PHYSICAL (MECHANICAL) EVENTS • FLUID IN FETAL LUNGS ALMOST COMPLETELY EXPANDS LUNGS; AIR SPACES FILLED • PRODUCTION OF FLUID SHARPLY DECLINES 2-4 DAYS BEFORE LABOR • THORACIC SQUEEZE

6. RESPIRATORY ADAPTION • AFTER BIRTH CHEST WALL RECOILS, CREATES NEGATIVE INTRATHORAIC PRESSURE; AIR IS SUCKED BACK INTO LUNG FIELDS, REPLACING FLUID • AFTER FIRST INSPIRATION, NEWBORN EXHALES, CREATING POSITIVE INTRATHORACIC PRESSURE

7. RESPIRATORY ADAPTION • POSITIVE PRESSURE DISTRIBUTES INSPIRED AIR THROUGHOUT ALVEOLI • LUNGS CONTINUE TO EXPAND WITH EACH BREATH • REMAINING LUNG FLUID MOVES INTO INTERSTITIAL TISSUE

8. MODULE 3 PART 1BTRANSITION TO EXTRAUTERINE LIFE

9. CARDIOVASCULAR ADAPTION • BEFORE BIRTH • ARTERIALIZED BLOOD FROM PLACENTA • INTO FETUS THROUGH UMBILICAL VEIN AND PASSES RAPIDLY THROUGH LIVER INTO INFERIOR VENA CAVA • FLOWS THROUGH FORAMEN OVALE INTO LEFT ATRIUM TO AORTA AND ARTERIES OF HEAD WHY?

10. CARDIOVASCULAR ADAPTION • PORTION BYPASSES LIVER THROUGH DUCTUS VENOSUS • VENOUS BLOOD FROM LOWER EXTREMITIES AND HEAD PASSES PREDOMINATELY INTO RIGHT ATRIUM, RIGHT VENTRICLE AND THEN INTO DESCENDING PULMONARY ARTERY AND DUCTUS ARTERIOSUS • THEREFORE, THE FORAMEN OVALE AND DUCTUS ARTERIOSUS ACT AS BYPASS CHANNELS

11. CARDIOVASCULAR ADAPTION • THIS ALLOWS LARGE PART OF COMBINED CARDIAC OUTPUT TO RETURN TO PLACENTA WITHOUT FLOWING THROUGH THE LUNGS • AFTER BIRTH • INFANT’S FIRST BREATH INFLATES LUNGS—REDUCES PULMONARY VASCULAR RESISITANCE TO PULMONARY BLOOD FLOW

12. CARDIOVASCULAR ADAPTION • DROP IN PULMONARY ARTERY PRESSURE • DECLINE IN RIGHT ATRIUM PRESSURE • INCREASED PULMONARY BLOOD FLOW RETURNED TO LEFT SIDE OF HEART INCREASES PRESSURE IN LEFT ATRIUM • THIS CHANGE CAUSES FUNCTIONAL CLOSURE OF FORAMEN OVALE

13. CARDIOVASCULAR ADAPTION • DUCTUS ARTERIOSUS CONSTRICTS AS A RESULT OF ELEVATION OF SYSTEMIC VASCULAR PRESSURE ABOVE PULMONARY VASCULAR PRESSURE WHICH INCREASES PULMONARY BLOOD FLOW • INCREASE IN BLOOD OXYGENATION CONCENTRATION CAUSES MUSCULAR WALLS OF DUCTUS ARTERIOSUS TO CLOSE IN APRROX. 12 HOURS

14. CARDIOVASCULAR ADAPTION • CAUSE OF CLOSURE OF DUCTUS VENOSUS UNKNOWN • CLOSURE ALLOWS BLOOD TO FLOW TO THE LIVER • THOUGHT TO BE DO TO: • PRESSURE CHANGES AFTER CUTTING OF CORD • CARDIAC OUTPUT • MECHANICAL PRESSURE CHANGES

16. Figure 3–11 Fetal circulation. Blood leaves the placenta and enters the fetus through the umbilical vein. After circulating through the fetus, the blood returns to the placenta through the umbilical arteries. The ductus venosus, the foramen ovale, and the ductus arteriosus allow the blood to bypass the fetal liver and lungs.

17. MODULE 3 PART 1C TRANSITION TO EXTRAUTERINE LIFE

18. CHEMICAL STIMULI • CHEMICAL: FIRST BREATH (GASP) DECREASES PO2 AND Ph AND INCREASES PCO2. CESSATION OF PLACENTAL BLOOD FLOW STIMULATES MEDULLA TO TRIGGER RESPIRATORY EFFORTS. • SURFACTANT REDUCES SURFACE TENSION OF LUNG MUCOSA AND ALLOWS EXHALATION WITHOUT LUNG COLLAPSE

19. THERMAL STIMULI • THERMAL: SUDDEN CHILLING OF THE MOIST INFANT STIMULATES THE SKIN SENSORY RECEPTORS TO TRANSMIT IMPULSES TO THE RESPIRATORY CENTER, WHICH STIMULATES THE INITIATION OF BREATHING. • EXCESSIVE COLD MAY RESULT IN COLD STRESS

20. SENSORY STIMULI • SENSORY: • TACTILE, AUDITORY, AND VISUAL STIMULI CAN HAVE AN EFFECT ON RESPIRATION (DRYING OF INFANT, SKIN TO SKIN CONTACT)

21. HEMATOPOIETIC SYSTEM • AFTER BIRTH RBCS INCREASE, CELL SIZE DECREASES • HEMACRIT INCREASES 1-2 DAYS AFTER BIRTH AS A RESULT OF: • PLACENTAL TRANSFUSION • LOW FLUID INTAKE • DIMINISHED EXTRACELLULAR VOLUME DECREASED % OF NEUTOPHILS LEUKOCYTOSIS

22. MODULE 3 PART 1DTRANSITION TO EXTRAUTERINE LIFE

23. THERMOREGULATION • NEONATE MUST BALANCE HEAT LOSS AND HEAT GENERATION • HEAT IS GENERATED BY METABOLISM OF BROWN FAT HEAT LOSS THROUGH: • CONVECTION • RADIATION • CONDUCTION • EVAPORATION

25. Figure 21–6 The distribution of brown adipose tissue (brown fat) in the newborn. Source: Adapted from Davis, V. (1980, November–December). Structure and function of brown adipose tissue in the neonate. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 9, 364.

26. THERMOREGULATION NEWBORNS HAVE DIFFICULTY WITH THERMOREGULATION BECAUSE: • INABILITY TO GENERATE HEAT FROM SHIVERING • THIN LAYER OF SUBCUTANEOUS FAT • DIFFICULTY CONSERVING BODY HEAT • LARGE BODY SURFACE COMPARED TO BODY MASS • LARGE BODY SURFACE COMPARED TO BODY MASS

27. THERMOGENESIS • HEAT PRODUCTION • INCREASED BMR • MUSCULAR ACTIVITY • NONSHIVERING THERMOGENESIS (NST) NEWBORNS CONSERVE HEAT WITH A FLEXED POSTURE

28. THERMOREGULATION • RELATE THE PROCESS OF THERMOGENESIS IN THE NEWBORN AND THE MAJOR MECHANISMS OF HEAT LOSS TO THE CHALLENGE OF MAINTAINING NEWBORN THERMAL STABILITY.

29. MODULE 3 PART 1ETRANSITION TO EXTRAUTERINE LIFE

30. HEPATIC ADAPTION • IRON CONTENT STORED IN LIVER • CARBOHYDRATE METABOLISM—LOW CARBOHYDRATE RESERVES • MAIN SOURCE OF ENERGY IS GLUCOSE • LIVER BEGINS TO CONJUGATEION BILIRUBIN • LACK OF INTESTINAL FLORA RESULTS IN LOW LEVELS OF VITAMIN K

31. CONJUGATION OF BILIRUBIN • TYPES OF BILIRUBIN • CONJUGATED • UNCONJUGATED • TOTAL • UNCONJUGATED BILIRUBIN IS THE BREAKDOWN PRODUCT DERIVED FROM Hgb and is not in excretable form (FAT SOLUBLE) • BILIRUBIN IS TRANSPORTED IN BLOOD VIA ALBUMIN; BINDS WITH ALBUMIN FOR EXCRETION • BILIRUBIN IS TRANSFERRED INTO THE HEPATOCYTES IN THE LIVER

32. CONJUGATION OF BILIRUBIN • UNCONJUGATED BILIRUBIN ATTACHES TO GLUCURONIC ACID IN THE LIVER AND BECOMES CONJUGATED • THE CONJUGATED BILIRUBIN CAN NOW BE EXCRETED BECAUSE IT HAS CHANGED FROM FAT SOLUBLE TO LIVER SOLUBLE • TOTAL BILIRUBIN IS BOTH THE CONJUGATED AND UNCONJUGATED BILIRUBIN < 3MG/DL

33. PHYSIOLOGICAL JAUNDICE • VERY COMMON IN NEWBORNS • APPEARS AFTER FIRST 24 HRS OF LIFE • ACCELERATED DESTRUCTION OF FETAL RBCs • INCREASED AMOUNTS OF BILIRUBIN DELIVERED TO LIVER MAY BE CAUSED BY: • INADEQUATE HEPATIC CIRCULATION • DEFECTIVE UPTAKE OF BILIRUBIN FROM THE PLASMA • DEFECTIVE CONJUGATION OF BILIRUBIN

37. MODULE 3 PART 1FTRANSITION TO EXTRAUTERINE LIFE

38. GI ADAPTION • GASTROINTESTINAL ADAPTION • LACTOSE • PROTEIN • FAT • SUFFICIENT ENZYMES EXCEPT AMYLASE • CARDIAC SPHINCTER IMMATURE • DIGESTION AND ABSORPTION • ELIMINATION • MECONIUM • TRANSITIONAL STOOLS

39. FLUID AND ELECTROLYTE ADAPTION URINARY ADAPTION • OVER 90% OF NEWBORNS VOID WITHIN 24 HOURS AFTER BIRTH • IF NO VOIDING BY 48 HOURS: • BLADDER ASSESSMENT • PAIN • RESTLESSNESS • DISTENTION FLUID AND ELECTROLYTE ADAPTION • LESS ABLE TO CONCENTRATE URINE • LIMITED TUBULAR REABSORPTION OF WATER • LIMITED EXCRETION OF SOLUTES • LIMITED DILUTIONAL CAPABILITIES

40. IMMUNOLOGIC ADAPTION • PREGNANT WOMAN FORMS ANTIGENS IN RESPONSE TO ILLNESS—ACTIVE ACQUIRED IMMUNITY • IgG—ONLY IMMUNOGLOGULIN THAT PASSES THROUGH THE PLACENTA—RESULTING IN PASSIVE ACQUIRED IMMUNITY. TRANSFERRED PRIMARILY IN THE THIRD TRIMESTER

41. IMMUNOLOGIC ADAPTION • IgM—USUALLY NOT PASSIVELY TRANSFERED • ELEVATED LEVELS MAY INDICATE FETAL ANTIGENIC ACTIVITY IN UTERO • IgA—PASSIVE ACQUIRED IMMUNITY VIA COLOSTRUM FUNCTIONS NOT FULLY UNDERSTOOD (RESEARCH: RESP., GI, EYES)

43. MODULE 3 PART 1GTRANSITION TO EXTRAUTERINE LIFE

44. PERIODS OF REACTIVITY AFTER BIRTH • FIRST PERIOD OF REACTIVITY • PERIOD OF INACTIVITY • SECOND PERIOD OF REACTIVITY

45. NEUROLOGIC &SENSORY PERCEPTION FUNCTION • FACTORS AFFECTING NEONATE’S ORGANIZATION AND QUALITY OF MOTOR ACTIVITY • SLEEP-WAKE STATES • ENVIRONMENTAL STIMULI • CHEMICAL IMBALANCE • HYDRATION STATUS • RECOVERY FROM STRESS OF BIRTH

46. BEHAVIOR STATES OF NEWBORN • SLEEP STATES • DEEP OR QUIET • ACTIVE REM • ALERT STATES • DROWSY, SEMIDOZING • WIDE AWAKE (QUIET ALERT) • ACTIVE AWAKE (ACTIVE ALERT) • CRYING

47. BEHAVIORAL STATES OF NEWBORN • HABITUATION • ORIENTATION • SELF QUIETING ABILITY • AUDITORY • OLFACTORY • TASTING, TACTILE

48. MODULE 3 PART 2ANEWBORN ASSESSMENT

49. NEWBORN ASSESSMENT • GESTATIONAL AGE ASSESSMENT • EXTERNAL PHYSICAL CHARACTERISITICS • NEUROLOGIC/NEUROMUSCULAR DEVELOPMENT THIS WILL BE PERFORMED IN CLINICAL

50. Figure 22–12 Classification of newborns based on maturity and intrauterine growth. Sources: Adapted from Lubchenco, L. O., Hansman, C., & Boyd, E., (1966). Intrauterine growth in length and head circumference as estimated from live births at gestational ages from 26 to 42 weeks. Pediatrics, 37, 403–408; Battaglia, F. C., & Lubchenco, L. O. (1967). A practical classification of newborn infants by weight and gestational age. Journal of Pediatrics, 71, 159.