NORMAL NEONATES PRESENTED BY MRS DAYAL

Lesson Objectives
1) Define the key terms 2) Explain the mechanism of the first breath of the newborn 3) Outline the immediate care of the newborn 4) Define Apgar Scoring 5) Describe the physiology of the Newborn 6) Breastfeeding- anatomy & physiology

Who is a Neonate?
Also known as baby or newborn A neonate is from 1st to 28 days of life Newborn includes premature, post mature and full term babies

Physical assessment of newborn

General appearance Head Chest Abdomen External genitalia Limbs Back

Neurological examination
Abnormal movements Posture Assessment of tone Moro reflex Palmar grasp Tonic neck reflex Stepping reflex Rooting reflex

Ways of heat loss in newborns

Evaporation- loss of heat from wet skin Conduction- heat is lost when the baby is in contact with cold surfaces Radiation- transfer of heat to cold objects in the environment Convection heat loss caused by currents of cool air passing over the surface of baby

Fetal to normal circulation

Mechanism of the first breath of the newborn

At birth, baby takes a breath Blood is drawn to the lungs through the pulmonary arteries Blood is collected & returned to the Lt atrium , via the pulmonary veins Placental circulation ceases soon after birth so less blood returns to the Rt side of heart. High pressure in Lt side of heart than Rt side

Mechanism of first breath

Closure of a flap over the foramen ovale With establishment of pulmonary respiration, oxygen concentration in the bloodstream rises. This causes ductus arteriosus to constrict and close. The cessation of placental circulation results in collapse of umbilical vein, ductus venosus & hypogastric arteries.

Mechanism of first breath

These immediate changes are functional and those related to the heart are reversible in certain circumstances. Umbilical vein ligamentum teres Ductus venosus-ligamentum venosum Ductus arteiosus-ligamentum arteriosum Foramen ovale- fossa ovalis Hypogastric arteries-obliterated hypogastric arteries

Mechanism of first breath

Not only respiratory & circulatory are involved but baby has to obtain nutrition through breastfeeding, eliminate waste via kidneys and gastrointestinal system. Complex changes like communication and relationship between parents and child commence

Immediate care of Newborn

(1) Prevention of heat loss

(a) appropriate preparations: ambient temperature range 2125 C,switch off fans, close curtains (b) drying the baby, removing wet towels, wrapping baby in pre-warmed towels (c)Skin-to-skin contact with mother

(2) Clearing the airway

(a) excess mucus wiped gently from the mouth as baby s head is born (b) aspirate mouth before nose (c) time of birth & sex of baby noted and recorded

(3) Cutting the cord (a) separating the baby from the placenta

by dividing the cord between 2 clamps. (b) clamped securely to prevent blood loss (c) applying gauze over the cord while cutting will prevent blood spraying over.

(4) Skin

to-skin and initiation of breastfeeding - baby delivered on the abdomen - mom & baby covered with warm blanket at least for 30 mins. Help with attachment and initiation of breastfeeding- In line with hospital policy

(5) Identification

(a) identification name tags (b) name bands fastened securely, not too tight or loose (c) name bands should remain on baby until discharge

(6) Assessment of the baby s condition (a) using Apgar score, baby is assessed at

1 min,5 min & 10 min after birth - the higher the score, the better the outcome for the child - Apgar score to be documented in folder - Weight and measurements taken & noted

(7) Continued early care - detailed examination of baby is done to rule

out any abnormalities - maintain warm environment - Early transfer to post natal ward to minimise heat loss - Transfer baby with the mother, in her arms to avoid heat loss & promote bonding

(8) Administration of Vitamin K

- reliable & effective prophylaxis in preventing haemorrhage in newborns - normal dose- 1mg/ml stat First bath & other non-urgent procedures deferred to minimise thermal stress Mother & baby should remain together 24 hrs

PROTECTION OF NEONATES
Airway obstruction Hypothermia Infection Injury and accidents

Apgar Score
Simple and repeatable method to quickly and summarily assess the health of newborn immediately after birth. Main purpose is to determine quickly whether a newborn needs immediate care or not. If prolonged, the NB can suffer long term neurological damage & cerebral palsy Summing up of scores @ 1,5,10min of life

Apgar Score Table

Score Heart rate Respiratory effort Muscle tone Reflex irritability Colour 0 Absent Absent Limp Nil White 1 100b.p.m Irregular, slow Some flexion in limb Grimace Blue 2 100b.p.m. Regular, cry Well-flexed limb Cough/cry Pink

Apgar score
Scores 3 - pale, floppy,makes no respiratory effort, pulse slow, does not respond to oral suction(needs advanced resuscitation Score 4-7 pulse below 100, irregular breaths, blue, some muscle tone and some response to suction ( needs Oxygen by bag/mask) Score 7 normal heart rate, breathes & responds to stimuli ( no resuscitation needed, can be dried & given to mom)

Physiology of Newborn
(1) Respiratory system -developmentally incomplete @ birth -continuous growth of new alveoli -narrow lumen of peripheral airways -plentiful respiratory secretions -delicate mucus membranes sensitive to trauma/oedema

-Respiratory rate 30-60br/min -diaphragmatic breathing, breathing pattern erratic, shallow & irregular -no nasal flaring, subcostal recessions,grunting -obligatory nose breathers - lusty cry, normally loud and medium pitch

(2)Cardiovascular system & Blood

HR @ birth rapid- 120-160/min -peripheral cyanosis sluggish, accrocyanosis - mottling of exposed skin - total circulating bld vol-80mls/kg/body wt. - Haemoglobin, WCC high but decreases gradually - breakdown of excess red bld cells predisposes to jaundice in the 1st wk

(3) Temperature regulation

-thermal control poor, immature hypothalmus - temperature regulation poor, vulnerable to hypothermia - unable to shiver, adopt flexed fetal position, increasing resp.rate and activity resulting in hypoglycaemia,hypoxia,acidosis -normal core temp. 36-37 C -limited ability to sweat

(4) Renal system

- kidneys functionally immature - glomerular filtration rate low & tubular reabsorption capabilities limited - unable to concentrate or dilute urine in response to various fluid - cannot compensate for high or low levels of solutes in the blood - limited ability to excrete drugs

Renal system con t

- 1st urine passed within 24 hrs - dilute urine,straw colored,odorless -cloudiness caused by mucus& urates initially until fluid intake increases - urates cause pink staining- insignificant -bladder palpable abdominally when full due to small pelvis

(5) Gastrointestinal system

- structurally complete but functionally

immature -pink & moist mucus membrane of mouth - teeth buried in gums, ptyalin secretion low -epithelial pearls present - sucking pads in cheeks give full appearance -sucking & swallowing reflexes coordinated

Gastrointestinal system con t

- stomach s capacity 15-30mls, increases rapidly in 1st wk - cardiac sphincter weak-regurgitation or posseting - long intestine in relation to size of baby - large no. of secretory glands & large surface area for absorption. - food enters stomach opening of ileocaecal valve ileum large intestine bowels open

Gastrointestinal system con t

- sterile gut, colonised within few hrs - bowel sounds present within 1 hr of birth - meconium present in large intestine - stools undergo transitional change meconium brownish yellow yellow faeces - stools passed 8-10/day or every 2-3 days - immature liver low glucuronyl transferase

(6) Reproductive system : genitalia & breasts

-Boys: testes descended in both scrotums urethral meatus opens @ tip of penis, prepuce is adherent to glans - Girls : labia majora covers labia minora, hymen& clitoris appears large - spermatogenesis does not occur until puberty - total complement of primodial follicles containing primitive ova is present in the ovaries of girls

Reproductive system con t

-both sexes, withdrawal of maternal

oestrogen results in breast engorgement, accompanied by secretion of milk by 4th-5th day -both sexes have nodule of breast tissue around nipple - girls develop pseudomenstruation for the same reasons

(7) Skeletomuscular system

-muscles complete, growth occuring by

hypertrophy rather than hyperplasia - incomplete ossification of long bones facilitates growth @epiphyses - vault of skull lack ossification essential for brain growth, moulding during labour - posterior fontanelle closes @ 6-8 wks -anterior font. Closes @18 mths

(8)Psychology and Perception

Special senses: (1) Vision : immature but structures present & functional. - sensitive to bright lights blinks/frowns - prefers black&white pattern & shape of human face - distance focused 15-20cm - no tears present

(2) Hearing: turn towards sound. High pitch sound blink or startle. Prefer the sound of human voice, gives preference to their mothers voice (3) Smell & Taste: prefer smell of milk (human) can differentiate smells of their mothers milk to others. Prefer smell of unwashed breasts. Sweet taste vigorous suckling grimace to bitter, salty or sour substances

(4) Touch: sensitive to touch, enjoying skin-toskin, immersion in water, stroking cuddling & rocking movements. - grasp reflexes enhance relationship with mother - facial coding of pain brow bulging, eyelid squeezing, nasolabial furrowing & open lipped crying

(9) Sleeping and Waking

(1) Sleep states; (a) Deep sleep- eyes closed, reg. respiration, no eye movement,response to stimuli delayed & quickly suppressed (b) Light sleep: rapid eye movement thru closed eyelids, irregular resp, intermittent sucking movement, random movements, response to stimuli occurs readily

(2) Wakeful states: (a) Drowsy state (b) Quiet alert state (c) Active alert state (d) Active crying state (3) Crying: the only way to communicate discomfort and summon assistance.

(10) Growth and Development

Limited physiologically dependent on their mothers/caregivers for continued survival, growth and development. - this will only progress if the baby is physiologically & neurologically normal, is in safe environment, nutritional needs are met with appropriate stimulation and loving care. Care must be designed to meet needs and capabilities

Establishing maternal role

Fostering the bonding & attachment process Attachment gradual and continual growth Recognise & respond to emotional needs of parents & infant Early or immediate physical contact Psychological well being of mother Diminished confidence

Psychriatric disorders of pueperium

Blues /puerperal depression /psychosis - baby s failure to thrive - less responsive - unsettled - miserable, not consolable

Current breastfeeding recommendations

Exclusive breastfeeding for 6 months Babies should receive no infant formula or animal milk Babies should continue to breastfeed for up to 2 yrs or beyond, with increasing amounts of complementary foods and cup-fed liquids

Ten Steps to Successful Breastfeeding

Every facility providing maternity services and care for newborn infants should: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within half an hour of birth. 5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.

6. Give newborn infants no food or drink other than

breast milk, unless medically indicated. 7. Practise rooming-in - that is, allow mothers and infants to remain together - 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10.Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

Anatomy of the lactating breast

Anatomy : -composed of glandular tissue -lobes (20) -lobes divided into alveoli & ducts -alveoli contains acini cells produce milk -myoepithelial cells lactiferous sinus/ampulla -nipple erectile tissue outlet for milk -areola (pigmented area)

Anatomy of the lactating breast

Benefits of breastfeeding
Nutritional benefits Protective Health Benefits Bonding

Components of breastmilk
Fats & fatty acids Carbohydrates Protein Vitamin (fat soluble & water soluble) Minerals (iron, zinc, calcium, other minerals) Anti-infective factors

Foremilk & Hindmilk

Foremilk Beginning of a feed baby receives a high volume of low fat milk Hindmilk as feed progresses, volume of milk decreases but the fat content increases by approx. 5 times A well attached baby obtains all he needs in a very short time

Breastfeeding hormones
Prolactin - makes the alveoli produce milk - makes the mother feel sleepy & relaxed - ineffective suckling and inadequate removal of milk from breasts will lead to shut down of milk production in those parts.

How to keep prolactin level high

Good attachment, no artificial teat or dummies Frequent breastfeeding day & night Breastfeeds as long as baby wants at a feed Prolactin release is greatest when baby breastfeeds at night

Oxytocin
-Contracts the cells around the alveoli, sends milk down the ducts to the sinuses let down or milk ejection -Early postpartum, experiences uterine contractions/sudden thirst -See milk leaking from the other breast -Upon milk ejection, baby s suckling rhythm changes rapid deep slow sucks.

Oxytocin release inhibitors

Extreme pain Stress hormones doubt, embarassement, anxiety Nicotine & alcohol

Milk production
Frequent breastfeeding, no time limits Independent of nutritional status and body mass index Milk production drives appetite, hence no need to eat excessively Unaffected by fluctuations in mother s fluid intake Unaffected by exercise or low fat diet

Attachment and positioning

Attachment for effective suckling - baby s mouth is wide open - chin touching the breast - lower lip is curled outward - more areola visible above than below - baby suckles, pauses and suckles again in slow, deep sucks - can hear baby swallowing

Latching on

attachment

Twin feeding

Positioning
- mother is relaxed and comfortable - baby is calm and alert, not crying - baby s whole body is facing the mother and close to her - baby s head is supported, in a straight line with his body and facing the breast - mother s fingers away from the areola

Examples of positioning

Skin to skin

Breast problems
Sore and damaged nipples Dermatitis Anatomical problems Engorgement Mastitis Breast abscess Blocked ducts