FNK 201 NORMAL NEONATES

OBJECTIVES: 1.DESCRIBE the PHYSIOLOGY of the NEWBORN 2.EXPLAIN the MECHANISM of the FIRST BREATH of a NEWBORN 3.DEFINE APGAR SCORING

PHYSIOLOGY of the NEWBORN At birth the Newborn must undergo rapid, profound physiologic changes to adapt to extra uterine life. Understanding these physiologic changes is important for the nurse who must assess, whether or not the Newborn is making a successful transition

IMPORTANCE of TRANSITIONAL EVENTS The day of birth is a momentous day , perhaps the most important day in an individual s life. It is important not only because it is temporally first, and all subsequent days and years of life are dependent upon its having gone well, but , more importantly, because greater physiological adjustments are required in the first hours after birth that will be necessary for the remainder of one s lifetime.

PHYSIOLOGICAL ADJUSTMENTS A Newborn s survival depends on making the correct physiological adjustments. Some babies make the transition smoothly, while for others the process is complicated. The risk of dying in those first few hours is greater than on any day ( or week or even a year after).Likewise , the risk of being damaged in the process of birth and transition is also very high.

TO ACHIEVE PHYSIOLOGICAL ADJUSTMENTS.-the adaptations necessary for the transition to extrauterine life ,the Newborn must:
1. Initiate breathing and quickly maintain regular respirations of the proper depth to meet metabolic needs for Oxygen uptake and Co2 excretion

2.Go from a fluid filled to a gas filled lungs. This involves generating enough opening pressure to overcome frictional resistance of the airways and elasticity of the chest - wall, lung tissues and curved surfaces of the millions of alveoli. 3.Redirect deoxygenated blood from the right heart that previously bypassed the lungs, sothat it all flows through the lungs. 4.Close the foetal shunts (represented by Foramen Ovale,Ductus Arteriosus, and Ductus Venosus

5.Provide Energy to maintain body temperatures and support metabolic processes. 6.Dispose of waste products produced by food absorption metabolic processes and tissue breakdown. 7.Ward off infection ( usually for the first time).

In the first two issues listed above , Rearrangements of mechanical forces within the thorax will have to take place. The second two issues involve equally profound rearrangements of flow, pressure, and resistance within the Pulmonary and Systemic Circulation Last three adjustments require a tremendous mobilisation of energy reserves and outpouring of hormones and a stimulation of enzymes

A nurse needs to understand clearly all these processes of transition in order to ; (i) Nurture and support those infants who are not making the proper adjustments, intervening to help them complete their tasks or re-right the balance as it begins to tip in the wrong direction. (ii) Appreciate how excessive birth stress, congenital defects and peri-natal diseases can interfere with these processes and (iii)Know what new problems can arise simply as a result of the baby s failure to properly make the transition.

 As you study the various physiologic adjustments or adaptations made by the neonate in transition, it is important to remember that some of the functional adaptations occur at a faster rate than others, but proper timing or order of succession is still crucial. A nurse should know how fast each of the steps should go, how one follows the other ,and how this succession is dependent upon each step s going well in order for the adaptation to reach completion.

 There are crucial interrelationships between the various processes, as one is accomplished, the others are automatically assisted in their process. So when one transitional or adaptive process is delayed, the other processes are also likely to be adversely affected . Having previously gone well, if things start to slow down in their normal progress, they might reverse direction altogether, and then spiral downward to a potentially damaging or fatal outcome. In addition , such a downward trend becomes progressively more difficult to turn back into the right direction with passing time.

 The quicker one identifies a slowing down of transition from its normal course, or a reversing of the trend in a wrong direction, the quicker one can intervene; and the quicker one intervenes, the more likely one is to achieve success thus avoiding sequelae (lasting damage) or death in this most crucial period of life.

ONSET OF BREATHING
How is it that NEWBORN BABIES NORMALLY KNOW JUST WHEN TO START BREATHING? A premature onset of gasping respirations while a baby is still in the mother would produce Aspiration Syndrome, whereas delayed onset of breathing after delivery would lead quickly to Asphyxia Neonatorum. The normal term Newborn takes his first breath within seconds after being delivered and not before by 30seconds he is breathing regularly; for a preterm, initial breath and time till regular breathing, maybe delayed 15 to 30 seconds.

RESPIRATION
Initiation of respiration is the most urgent physiological adjustment for a Newborn. Achieved in response to: Stimulation of the Respiratory centre in the Medulla oblongata by a high level of CO2 Chest wall .previously compressed by the birth canal, suddenly expands, allowing the air to rush in. Temperature change or the shock of being handled may cause baby to gasp.

CIRCULATION
Temporary structures of foetal circulation must close to provide effective circulation for extrauterine existence. Closure of the structures depends upon the beginning of respiration. The lungs expand with the onset of respiration, which opens up the Pulmonary capillary bed- creating a negative pressure.

 Cont. Blood now flows from the Pulmonary Artery through to the Lungs (to balance pressure ) for Oxygenation. The ductus arteriosus contracts as the lungs expand eventually becomes a supporting ligament in the thorax. The increased blood flow to the Lungs reduces pressure on the Right side of the Heart and increases pressure on Left side of the heart With the equal pressure in the heart the valve-like Foramen ovale is no longer being forced open, so it closes.

 Umbilical vessels contract at birth Blood clots in the; Umbilical Vein and Arteries and in the Ductus Venosus and Hypogastric Arteries these structures remain as fibrous bands .

HEAT REGULATION
The Newborn has a limited ability to regulate body temperature in relation to the environment in danger of Hypothermia unless preventive measures are taken. Important Factors to consider; Poor production of heat low metabolic rate Temperature change environment conditioned for the comfort of the labouring mother and the Accoucher. Vasoconstriction of skin vessels occurs to preserve body heat

 Cont. Baby is born wet , and so loses heat by Evaporation Has a large body surface in proportion to weight His hypothalmic temperature-regulating centre is not fully mature, so processes of Shivering and Sweating are poorly developed. The Newborn is dried as soon as it is practical to do so, and the time of his exposure to cooler environment is minimised

DIGESTION/ELIMINATION
In utero , the foetus received adequate nourishment in the simplest form. After birth, baby s digestive system must be able to digest and absorb food as well as eliminates wastes. The food designed by nature to introduce the baby s digestive system to the process of digestion is called Colostrum. Colostrum: highly nutritive,easily digested (its protein in the form of lactoglobulin),contains vitamins and immune bodies,and functions as a laxative. The process of taking in and digesting food stimulates peristalsis of bowels and results in the passage of Meconium

IMMUNITY
The mature baby has received antigens and passive immunity to certain infections from the mother in last 6 or so weeks before birth. Leaving a sterile environment he may encounter microorganisms and other antigens suddenly. To develop active immunity, may take some weeks. Maternal Immunoglobulin G crosses the placenta to give the foetus passive immunity The process of birth itself exposes the newborn to new organisms. Candida albicans (thrush ), the gonococcus and herpesvirus maybe encountered in the vagina.Hospital delivery, likely to encounter Staphylococcus aureus, an organism to which baby may have little resistance. To compensate for poorly-developed immunological status of Newborn; careful antenatal supervision and exclusion or treatment of all possible Infections, aseptic delivery techniques and extreme care exercised in all aspects of the Newborn s management, are vital