Post on 07-Apr-2018
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NORMAL NEONATES
PRESENTED BY MRS DAYAL
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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
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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
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Physical assessment of newborn
General appearance
Head
Chest Abdomen
External genitalia
Limbs
Back
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Neurological examination
Abnormal movements
Posture
Assessment of tone Moro reflex
Palmar grasp
Tonic neck reflex Stepping reflex
Rooting reflex
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Ways ofheat 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
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Fetal to normal circulation
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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 soless blood returns to the Rt side of heart.
High pressure in Lt side of heart than Rt side
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Mechanism of first breath
Closure of a flap over the foramen ovale
With establishment of pulmonary respiration,
oxygen concentration in the bloodstreamrises. This causes ductus arteriosus to
constrict and close.
The cessation of placental circulation results in
collapse of umbilical vein, ductus venosus &
hypogastric arteries.
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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 arteriosumForamen ovale- fossa ovalis
Hypogastric arteries-obliterated hypogastric
arteries
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Mechanism of first breath
Not only respiratory & circulatory are
involved
but baby has to obtain nutrition throughbreastfeeding, eliminate waste via
kidneys and gastrointestinal system.
Complex changes like communicationand relationship between parents and
child commence
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Immediate care of Newborn
(1)Prevention ofheat loss
(a) appropriate preparations:
ambient temperature range 21-25C,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
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(2)Clearing the airway
(a) excess mucus wiped gently from the
mouth as babys head is born
(b) aspirate mouth before nose
(c) time of birth & sex of baby noted
and recorded
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(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.
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(4)Skinto-skin and initiation ofbreastfeeding
- baby delivered on the abdomen- mom & baby covered with warmblanket at least for 30 mins.
Help with attachment and initiation ofbreastfeeding- In line with hospitalpolicy
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(5)Identification
(a) identification name tags
(b) name bands fastened securely, not tootight or loose
(c) name bands should remain on baby until
discharge
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(6)Assessment of the babys 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
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(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
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(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
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PROTECTION OF NEONATES
Airway obstruction
Hypothermia
Infection
Injury and accidents
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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
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Apgar Score Table
Score 0 1 2
Heart rate Absent 100b.p.m 100b.p.m.
Respiratory effort Absent Irregular, slow Regular, cry
Muscle tone Limp Some flexion in limb Well-flexed limb
Reflex irritability Nil Grimace Cough/cry
Colour White Blue Pink
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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)
Score7 normal heart rate, breathes &
responds to stimuli ( no resuscitation needed,
can be dried & given to mom)
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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 totrauma/oedema
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-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
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(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
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(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. 36-37C
-limited ability to sweat
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(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
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Renal system cont
- 1st urine passed within 24 hrs
- dilute urine,straw colored,odorless
-cloudiness caused by mucus& urates initiallyuntil fluid intake increases
- urates cause pink staining- insignificant
-bladder palpable abdominally when full dueto small pelvis
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(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
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Gastrointestinal system cont
- stomachs 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 stomachopening of ileocaecal
valveileumlarge intestinebowels open
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Gastrointestinal system cont
- sterile gut, colonised within few hrs
- bowel sounds present within 1 hr of birth
- meconium present in large intestine
- stools undergo transitional
changemeconiumbrownish
yellowyellow faeces
- stools passed 8-10/day or every 2-3 days
- immature liverlow glucuronyl transferase
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(6) Reproductive system : genitalia &
breasts
-Boys: testes descended in both scrotums
urethral meatus opens @ tip of penis, prepuce isadherent to glans
- Girls : labia majora covers labia minora, hymen&clitoris appears large
- spermatogenesis does not occur until puberty
- total complement of primodial folliclescontaining primitive ova is present in the ovariesof girls
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Reproductive system cont
-both sexes, withdrawal of maternal
oestrogen results in breast engorgement,
accompanied by secretion of milk by4th-5th day
-both sexes have nodule of breast tissuearound nipple
- girls develop pseudomenstruation for thesame reasons
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(7) Skeletomuscular system
-muscles complete, growth occuring byhypertrophy rather than hyperplasia
- incomplete ossification of longbonesfacilitates growth @epiphyses
- vault of skull lack ossificationessentialfor brain growth, moulding during labour
- posterior fontanelle closes @ 6-8 wks
-anterior font. Closes @18 mths
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(8)Psychology and Perception
Special senses:
(1)Vision : immature but structures present &functional.
- sensitive to bright lightsblinks/frowns
- prefers black&white pattern & shape of
human face
- distance focused 15-20cm
- no tears present
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(2)Hearing: turn towards sound. High pitchsoundblink or startle. Prefer the sound ofhuman 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 tastevigorous suckling
grimace to bitter, salty or sour substances
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(4)Touch: sensitive to touch, enjoying skin-to-
skin, immersion in water, stroking cuddling &
rocking movements.
- grasp reflexes enhance relationship with
mother
- facial coding of painbrow bulging, eyelid
squeezing, nasolabial furrowing & open lipped
crying
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(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
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(2)Wakeful states:
(a) Drowsy state
(b) Quiet alert state(c) Active alert state
(d) Active crying state
(3)Crying: the only way to communicatediscomfort and summon assistance.
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(10) Growth and Development
Limited physiologically dependent on theirmothers/caregivers for continued survival,growth and development.
- this will only progress if the baby isphysiologically & neurologically normal, is insafe environment, nutritional needs are metwith appropriate stimulation and loving care.
Care must be designed to meet needs andcapabilities
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Establishing maternal role
Fostering the bonding & attachment process
Attachment gradual and continual growth
Recognise & respond to emotional needs ofparents & infant
Early or immediate physical contact
Psychological well being of mother Diminished confidence
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Psychriatric disorders of pueperium
Blues /puerperal depression /psychosis
- babys failure to thrive
- less responsive- unsettled
- miserable, not consolable
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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
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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.
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6. Give newborn infants no food or drink other thanbreast 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 calleddummies or soothers) to breastfeeding infants.
10.Foster the establishment of breastfeeding supportgroups and refer mothers to them on dischargefrom the hospital or clinic
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Anatomy of the lactating breast
Anatomy :
-composed of glandular tissue
-lobes (20)
-lobes divided into alveoli & ducts
-alveoli contains acini cellsproduce milk
-myoepithelial cells lactiferous sinus/ampulla
-nipple erectile tissueoutlet for milk
-areola (pigmented area)
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Anatomy of the lactating breast
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Benefits of breastfeeding
Nutritional benefits
Protective
Health Benefits
Bonding
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Components of breastmilk
Fats & fatty acids
Carbohydrates
Protein Vitamin (fat soluble & water soluble)
Minerals (iron, zinc, calcium, other
minerals)
Anti-infective factors
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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
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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 thoseparts.
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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 babybreastfeeds at night
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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, babys suckling rhythm
changesrapiddeep slow sucks.
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Oxytocin release inhibitors
Extreme pain
Stress hormones
doubt, embarassement, anxiety Nicotine & alcohol
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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 mothers fluid
intake
Unaffected by exercise or low fat diet
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Attachment and positioning
Attachment for effective suckling
- babys mouth is wide open
- chin touching the breast
- lower lip is curled outward
- more areola visible above than below
- baby suckles, pauses and suckles againin
slow, deep sucks
- can hear baby swallowing
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Latching on
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attachment
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Twin feeding
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Positioning
- mother is relaxed and comfortable
- baby is calm and alert, not crying
- babys whole body is facing the mother andclose to her
- babys head is supported, in a straight line
with his body and facing the breast- mothers fingers away from the areola
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Examples of positioning
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Skin to skin
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Breast problems
Sore and damaged nipples
Dermatitis
Anatomical problems Engorgement
Mastitis
Breast abscess Blocked ducts
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