Maternal child health nursing

1. Maternal child health nursing Module 8

2. objectives • Discuss newborns • Discuss infant disorders and care

3. Intro to newborn care • Neonatal transition • Fetal to newborn circulation • Blood oxygenated through placental transfer must be oxygenated by baby’s lungs after birth • Initiation of breathing • Requires maturity of lungs for adequate gas exchange • Must be able to breathe independently after cord cut/placenta detaches from uterine wall

4. Immediate newborn needs • Airway • Suction bulb, intermittent suction w/ DeLee mucus trap

5. Immediate newborn needs • Breathing • Stimulated by physical, chemical, thermal and sensory factors • Tactile stimulation, temperature change, change from confinement to unrestrained state, change to extrauterine stimuli , breathing reflex triggers internal pressure changes that facilitate breathing

6. Immediate needs of newborn Circulation (fetal to newborn transition) • Fetal circulation bypasses lungs and gets oxygen via placenta • Areas of high pressure (fetal lungs) keep blood on lower-pressure circuit • Fetal circulation depends upon shunts (holes) • These shunts close at or after birth, re-routing blood into newborn circulation

7. Review of normal circulation

8. Fetal circulation Fetal circulation needs a way to bypass the lungs and get oxygen from placenta Fetal circulation needs a way to get deoxygenated blood and wastes to placenta • Umbilical cord • Two arteries: carry deoxygenated blood and wastes from baby to Mom • One vein: carries oxygenated blood and nutrients from Mom to baby • Umbilical cord attaches placenta to baby through baby’s abdomen • Fresh umbilical cord blood enters fetal inferior vena cava at the ductus venosus shunt, bypassing fetal liver

9. Fetal circulation 02-rich blood from Mom enters baby’s inferior vena cava -> right atrium In the right atrium, the foramen ovale shunt allows the new, 02-rich blood to go straight into the left atrium -> mitral valve -> left ventricle -> aortic valve -> aorta -> brain, coronary arteries and upper extremities and on to lower portions of body. Partially deoxygenated blood and wastes from brain, coronary arteries and upper extremities return to heart via the superior vena cava and enter right atrium

10. Fetal circulation At this point, the partially oxygenated blood from above and the freshly oxygenated blood from below are mixing somewhat in the right atrium. This mixed blood -> tricuspid valve -> right ventricle -> pulmonary artery So far, the brain, cardiac muscle and upper extremities have been oxygenated. But what about the lung tissue and the rest of the body?

11. Fetal circulation The mixed blood in the pulmonary artery splits up! A little goes to the lung tissue through the pulmonary blood vessels but high pressures in the lungs prevent much input (however, it’s enough to nourish the developing lung tissues – remember, most of the blood can bypass the fetal lungs because the blood doesn’t get its oxygen from them yet) Most of the mixed blood -> ductus arteriosus -> aorta -> to rest of body

12. Fetal to newborn circulation Birth: • No more placenta filter • Filtering now done by baby’s liver • No more placental oxygenation • Oxygenation now done by baby’s lungs • The foramen ovale closes with first breath because the lung pressure rises • The ductus arteriosus and ductus venosus close soon after birth and lose ability to re-open within days or weeks

13. Fetal to newborn circulation • If these shunts fail to close, newborn circulation doesn’t work well • Congenital heart defects • Usually, babies start breathing just fine on their own and shunts do close normally • Turbulence within the heart in the newborn may be normal -> murmurs on auscultation • Is baby tolerating them? Great! • Is baby looking cyanotic? Having respiratory problems? Get help!

14. Immediate needs of newborn • Warmth • Heat production • Ability increases with maturity • Preterm babies may use too much fuel trying to produce heat • Brown fat • Heat retention • Large body surface for size • Heat loss • Radiation • Evaporation • Conduction • convection

15. Immediate needs of newborn • Apgar scoring: measurement of five criteria at 1 and 5 minutes after birth to estimate newborn transition • Heart rate, respiratory effort, muscle tone, reflex irritability, skin color • Resuscitation • Amount of resuscitation depends on behaviors and Apgar score • Supplemental oxygen, bag/mask ventilation, ventilation available if baby unable to breathe well • Chest compressions may be done for inadequate heartbeat

16. Apgar scale scoring

17. Apgar score sheet

18. Immediate needs of newborn • Neutral thermal environment • Neither too hot nor too cold • warmer, temperature sensor (Ohio) • Wrap well with cap • Control environment Identification • Bands may be preprinted with matching number • Ensure correct names, DOB and other information • Apply before newborn leaves mother • Mother’s fingerprint and baby’s footprint may also be done

19. Immediate needs of newborn • Parent/infant bonding • Promote breastfeeding, bonding behaviors • Control temp if parents want to inspect baby • Control crowds – ensure privacy and calm • Prophylactic care • Vitamin K IM • Hepatitis B vaccine IM • Antibiotic eye ointment • Umbilical cord care • Water, alcohol, triple dye, keep dry

20. Nursing care: newborn skin • Standard precautions • Blood (especially before first bath!) • Urine • Feces • Spit up/vomit • Mucus • Tears • Protect skin • Minimize soap, use soft textures • Protect lungs: no powder

21. Vastus lateralis injection

22. Nursing: immediate newborn care • Assess need for intervention • ABCs • Provide warmth, identification • Promote bonding/breastfeeding as soon as possible • Minimize interruptions • Keep mom and baby together as much as possible

23. Physical newborn characteristics • Weight/length • Average weight: 7 lbs, 8 oz • Average length: 20 inches

24. Physical newborn characteristics • Vital signs • Respiratory rate: 30-60/minute, nose breathers • Heart rate: 120-160 with variations by activity • Apical pulse between 4th and 5th intercostal spaces • Murmurs common • B/P: 60-80/40-50 mm/Hg all extremities • Temperature: axillary 97.6F-98.6F (36.5C-37C) • Stabilizes 8-10 hours after birth

25. Physical newborn characteristics • General appearance • Skin • Color: may be paler or redder at birth than will be later. Drier and flakier around days 2-3 • Acrocyanosis for 7-10 days • Head/neck • Fontanelles • Suture lines • Molding • Caput succedaneum • cephalhematoma

26. Physical newborn characteristics • Eyes • Edema • Ears • Should be even with corners of eyes • Chest • No retractions • May be barrel-shaped, but should be symmetric, without signs of respiratory distress

27. Physical newborn characteristics • Abdomen/back • Umbilicus should be free from bruising, redness, edema, drainage • Bowel sounds should be heard all 4 quadrants • No holes, indentations, or hairy patches

28. Physical newborn characteristics • Genitalia • Both boys and girls may have enlarged breast tissue: gynecomastia. Results from maternal hormones, common and normal. Resolves by itself • Females: edema , blood-tinged mucus (pseudomenstruation), labia majora covers labia minora in term babies • Teach parents that pseudomenstruation is common, normal and is from Mom’s hormones. Will go away by itself

29. Physical newborn characteristics • Genitalia • Males: testicles should be descended into both sides of scrotum. • Extremities • Arms/hands flexed against body in term babies • Movement should be even on both sides • Fingers and toes should not have webbing (syndactyly) or have extra digits (polydactyly) • New Ballard maturity scale • Estimates gestational age/maturity according to grading scale • Used by newborn nursery nurses to confirm estimated gestation age

30. Physical maturity: Ballard

31. Newborn variations • Skin • Jaundice • Abnormal <24 hours after birth • Usually normal 24 hours- 10 days after birth (physiologic jaundice) • Newborn H&H elevated after birth and extra RBCs will be reduced – extra fetal hemoglobin no longer needed • Hydration may help clear – encourage consistent breastfeeding • Stools may take yellow color as bilirubin discarded into feces

32. integumentary Milia rubra Stork bite

33. Newborn variations • Vernix • Ecchymosis (bruising) • Note bruising: size, location, color, blanchability • Milia • Newborn rash (erythema toxicum neonatorum) • Stork bites (telangiectatic nevi) • Port-wine stain (nevus flammeus) • Mongolian spots • Strawberry marks

34. Physical newborn characteristics • Head • Fontanelles (soft spots) • Anterior: larger, diamond-shaped, joins frontal bone (forehead) with parietal bones (sides of skull). Closes around 18 months. • Posterior: smaller, triangular, joins parietal bones with occipital bone (back of skull). Closes around 2 months. • Sutures • The tough connective tissue bands holding skull bones together

35. Sutures and fontanelles

36. Newborn variations • Head • Molding • Reshaping of skull bones to allow safe passage through birth way • Resolves within a day or so after birth • Caput succedaneum • Edema from pressure of labor • Felt over suture lines • Resolves without treatment • Cephalhematoma • Bleeding within periosteum over skull bone – REPORT! • Does not cross suture lines

37. Molding of newborn head

38. Cephalohematoma vscaput succedaneum

39. Newborn variations • Eyes • Crossed eyes (strabismus) • Nystagmus (abnormal motion) • Ears • Low-set may indicate chromosomal problems • Mouth • Epstein’s pearls, teeth • Candida albicans • Chest • Retractions indicate respiratory problems – REPORT! • Crepitus or uneven feel of collarbone: fracture

40. Newborn variations • Genitalia • (boys) Undescended testes (chryptorchidism): preterm • (girls) Labia minora showing: preterm • Extremities • Crepitus, uneven movement: injury

41. Newborn reflexes • Feeding: • Rooting • Sucking • Extrusion • Palmar and plantar grasp • Tonic neck (fencer) • Startle reflex (Moro) • Galant • Stepping • Babinski’s

42. Behavioral characteristics • Reactivity periods • 1st period • About 30 minutes after birth • Optimum period for breastfeeding initiation • Sleep period • Next few hours • Second reactive period • After first deep sleep • Responsive, alert

43. Behavioral characteristics • Sleep states • 16-20 hours/day • Startle, suck reflexes present • Regular or irregular breathing • Early arousal cues optimal time to prepare for feeds • Alert states • Quiet • Crying

44. First bath and cord care • First bath • Delay if possible after first breastfeed • Warmth and safety • Air, surfaces, water, time, thoroughly dry infant • Safety precautions (falls, water, temperature, etc) • Vital signs done beforehand • Remove blood, minimize soap/shampoo, rinse well • Some vernix may remain • Cultural considerations and family involvement

45. First bath and cord care • Cord care • Antisepsis • Daily cleansing • Clamp • 2 arteries, 1 vein, Wharton’s jelly, color

46. Circumcision • Procedure • Only legal on males in United States • Done in hospital, within first 23-48 hours • Consents and care teaching • Sterile procedure • Sterile instrument tray • Gomco, Plastibell • Vaseline gauze • Sterile gloves • Lighting • Restraint board • Lidocaine, sugar water, pacifier, bulb syringe

47. Circumcision • Nursing care • Safety, comfort of infant • Ensuring parent education and consent • Sterile field setup and maintenance • Anesthetic preparation on time • Privacy • Assess for edema, urine output, s/s infection, protection of site • Alcohol or water cleansing • Yellow exudate, scant bleeding normal • Record

48. Circumcision • Cultural considerations • Religion, aesthetics, hygiene • Education • May be done later in life • Yellow crust normal – do not remove • Scant initial bleeding and bleeding after cleansing normal – report increase or unusual amount, edema, failure to urinate, increased fussiness, crying, pain response, exudate, redness, increased temperature

49. Nutrition • Nutritional needs of newborn • Breastfeed Q 2-3 hours or more frequently, about 8-12 times/24 hours • Babies digest formula more slowly, so their feeds may be Q 3-4 hours • Avoid teaching schedule against baby’s cues, needs • No foods/fluids other than breast milk or formula for first six months • Formula with appropriate amounts of basic components but without key immune, nutritional, growth and development, anti-allergy and maternal benefits unique to human breast milk

50. Nutrition • Human breast milk components, benefits • Immunity • Immunoglobulins, lymphocytes, bifidus factor, maternal antibody response to infant illness, antivirals, • Nutrition • Protein, fats, carbohydrate ratios adjust according to gestational age and infant needs • Well-absorbed • Growth/development • Growth factors, digestive enzymes, proteins • Promotes better tooth/jaw alignment • Oxytocin release promotes mother/baby bonding