Revised August 2011

1. Revised August 2011 Infant Assessment and Transition Monica L. Scrudder, RNC-NIC, BSN, MSN Franciscan Health System Regional Nurse Educator, Nursery Services Poll the room. How long have they been working? What area will they be working in?Poll the room. How long have they been working? What area will they be working in?

2. Revised August 2011 Objectives Identify physiological changes that occur at birth in the newborn�s transition to extrauterine homeostasis. Identify routine care and nursing interventions for the newborn in the transition period. Identify signs and symptoms of common problems in the transition period. Identify normal characteristics of neonates and begin to develop an assessment routine. Allow time to review objectives. Ask students what they would like to learn. Allow time to review objectives. Ask students what they would like to learn.

3. Revised August 2011 What Is Transition??? Transition as defined by Merriam-Webster Online means �a passage from one state, stage, subject or place to another�. What an appropriate word for the process that takes place during a birth. Transitions are occurring on many levels involving the entire family. Today we will be focusing on the transition the fetus makes from the intrauterine environment to the extrauterine environment and all of the changes that must occur to make that transition successfully. It is an amazing process!Transition as defined by Merriam-Webster Online means �a passage from one state, stage, subject or place to another�. What an appropriate word for the process that takes place during a birth. Transitions are occurring on many levels involving the entire family. Today we will be focusing on the transition the fetus makes from the intrauterine environment to the extrauterine environment and all of the changes that must occur to make that transition successfully. It is an amazing process!

4. Revised August 2011 The Transition Period

5. Revised August 2011 Anatomy and Physiology

6. Revised August 2011 Fetal Circulation Talk about fetal circulation. Emphasize pulmonary artery constriction. Discuss each shunt and its purpose. Discuss % of blood flow to various organs due to shunting. Umbilical vein carries oxygenated blood from the placenta. Half of this blood bypasses the liver and enters the ductus venosus to the inferior vena cava. Who knows why the blood bypasses the liver?? Foramen ovale. Ductus Arteriosis. Talk about fetal circulation. Emphasize pulmonary artery constriction. Discuss each shunt and its purpose. Discuss % of blood flow to various organs due to shunting. Umbilical vein carries oxygenated blood from the placenta. Half of this blood bypasses the liver and enters the ductus venosus to the inferior vena cava. Who knows why the blood bypasses the liver?? Foramen ovale. Ductus Arteriosis.

7. Revised August 2011 Fetal Metabolism and Hematology Glucose Glycogen Brown Fat Ask about effects of maternal hyperglycemia on the fetus. Talk about brown fat�increased blood vessels, mitochondria. Metabolically active tissue. Must have oxygen to burn brown fat. Ask about effects of maternal hyperglycemia on the fetus. Talk about brown fat�increased blood vessels, mitochondria. Metabolically active tissue. Must have oxygen to burn brown fat.

8. Revised August 2011 Cardiopulmonary Adaptation at Birth Baby has been essentially a passive entity while in utero. Then we clamp the cord�.Baby has been essentially a passive entity while in utero. Then we clamp the cord�.

9. Revised August 2011 Normal Neonatal Circulation Contrast with previous picture fetal circulation.Contrast with previous picture fetal circulation.

10. Revised August 2011 Pulmonary Adaptation At Birth Stimuli for initiating respiration Stimulation of trigeminal nerve by exposure to air and movement of air against the skin.Stimulation of trigeminal nerve by exposure to air and movement of air against the skin.

11. Revised August 2011 First Breath Air enters lungs at 2x normal pressure Pulmonary vessels vasodilate in response to increased oxygen If we are giving PPV, initial breaths are giving with a higher PIP than subsequent breaths in most cases. Are there times when you would need to deliver subsequent breaths at a higher pressure? If so, why? Extreme prematurity�minimal lung volume to recruit. Lack of surfactant�prematurity, IDM as previously discussed. If we are giving PPV, initial breaths are giving with a higher PIP than subsequent breaths in most cases. Are there times when you would need to deliver subsequent breaths at a higher pressure? If so, why? Extreme prematurity�minimal lung volume to recruit. Lack of surfactant�prematurity, IDM as previously discussed.

12. Revised August 2011 Continued Pulmonary Adaptations Pulmonary vascular resistance (PVR) decreases to reach adult levels �? Lung compliance improves What do we mean by lung compliance?What do we mean by lung compliance?

13. Revised August 2011 Measurements Apgar score

14. Revised August 2011 The Apgar Score See old note page for cases. See old note page for cases.

15. Revised August 2011 Initial Assessment

16. Revised August 2011 Basics of Assessment History Examination Technique

17. Revised August 2011 Normal Newborn General Appearance Common Variations Signs of Potential Distress or Deviation from Expected Findings Well-flexed, full range of motion, spontaneous movement. Variations�legs extended with frank breech, flexed at hips� Potential distress�limp posture, asymmetry of movement, persistent tremor, twitchingWell-flexed, full range of motion, spontaneous movement. Variations�legs extended with frank breech, flexed at hips� Potential distress�limp posture, asymmetry of movement, persistent tremor, twitching

18. Revised August 2011 Vital Signs Temperature Heart rate Respiration Blood pressure Normal ranges. Common variations. Potential distress or deviation. Talk about cap refill with BP.Normal ranges. Common variations. Potential distress or deviation. Talk about cap refill with BP.

19. Revised August 2011 General Measurements Weight Head Circumference Chest Circumference Length Expected findings�head should be 2-3 cm larger than chest. Common variations�molding, H&C may be equal for first 24 hours. Expected findings�head should be 2-3 cm larger than chest. Common variations�molding, H&C may be equal for first 24 hours.

20. Revised August 2011 Skin Expected Findings Potential Deviations

21. Revised August 2011 Head and Neck Normal Normocephalic OFC >10% and <90% Anterior fontanel: soft, flat Normal suture location Significant abnormalities�bruising, caput secundum, cephalohematoma, molding, lacerations, micrognathia, overlapping/widely spaced sutures, hydro, micro & anencephaly.Significant abnormalities�bruising, caput secundum, cephalohematoma, molding, lacerations, micrognathia, overlapping/widely spaced sutures, hydro, micro & anencephaly.

22. Revised August 2011 Ears and Nose Normal Shape and position Presence of canals Abnormalities of ears are often related renal abnormalities.Abnormalities of ears are often related renal abnormalities.

23. Revised August 2011 Eyes Normal Normal appearance and placement Normal red reflex

24. Revised August 2011 Mouth Normal Palate intact Symmetrical movement of mouth Tongue, symmetric Normal appearance

25. Revised August 2011 Neck Normal Without masses Free range of motion observed Clavicles intact

26. Revised August 2011 Chest Normal Symmetrical Normal shape Breast tissue placement WNL

27. Revised August 2011 Respiration Normal Normal rate and rhythm Breath sounds equal and clear Adequate air entry Auscultate anterior, subaxillary, and posterior regions

28. Revised August 2011 Heart Normal Normal rate and rhythm intensity Normal first and second heart sounds Normal PMI Without murmurs

29. Revised August 2011 Pulses Normal Brachials=femorals bilaterally Normal volume

30. Revised August 2011 Abdomen Normal Soft, round Normal shape Bowel sounds present

31. Revised August 2011 Umbilicus Normal Three vessel cord

32. Revised August 2011 Genitalia-Female Normal Normal vaginal opening Labia majora covers minora

33. Revised August 2011 Gentalia-Male Normal Normal appearance Testes in scrotum

34. Revised August 2011 Anus Normal Patent Normal placement

35. Revised August 2011 Spine Normal Intact Straight

36. Revised August 2011 Extremities Normal Free range of motion Without deformities

37. Revised August 2011 Hips Normal Stable

38. Revised August 2011 Neurological Normal Primitive automatisms Reflexes

39. Revised August 2011 Tone Normal Good flexion Recoil Ventral suspension WNL Head control

40. Revised August 2011 Behavior Normal Activity level Sleep/awake states

41. Revised August 2011 Feeding

42. Revised August 2011 Contraindications to Feeding Cyanosis Shock or asphyxia Increased work of breathing Ongoing oxygen requirement

43. Revised August 2011 Routine Care Considerations

44. Revised August 2011 AAP/ACOG/AWHONN Guidelines

45. Revised August 2011 Guidelines (Cont)

46. Revised August 2011 Legal Considerations

47. Revised August 2011 Parent-Infant Bonding

48. Revised August 2011 Assess Parenting Styles and Abilities

49. Revised August 2011 Discharge Criteria

50. Revised August 2011 Discharge Teaching

51. Revised August 2011 Teaching Documentation

52. Revised August 2011 References Askin, DF. (2002) Complications in the Transition from Fetal to Neonatal Life. JOGNN 31(3): 318-27 Buschbach, D., Schaub-Bordeaux, M. (2002) Newborn Physiological and Developmental Transitions: Integrating Key Components of Perinatal and Neonatal Assessment. Association of Women�s Health, Obstetric and Neonatal Nurses. Kenner, C., Wright-Lott, J. (2003) Comprehensive Neonatal Nursing: A Physiological Perspective. Philadelphia:Saunders Sansoucie DA, Cavaliere, TA. (1997) Transition from Fetal to Extrauterine Circulation. Neonatal Network, 16(2):5-12 Verklan,TM, Walden, M., editors (2004) Core Curriculum for Neonatal Intensive Care Nursing (3rd ed.) St. Louis:Elsevier

53. Revised August 2011 References (2) http://www.cayuga-cc.edu/people/web_pages/greer/biol204/heart4/heart4.html http://dic.academic.ru/pictures/enwiki/80/Patent_ductus_arteriosus.jpg http://www.007b.com/breastfeeding_pictures.php http://pregnancy.about.com/od/newbornbabies/ig/Newborn-Photo-Gallery/index.01.htm