M E R E D I T HW I L L I A M S ,R N , B S N

The High Risk Neonate

Objectives

By the end of this class, students will be able to: Identify the factors at birth that indicate an at risk

newborn Define the specific characteristics of SGA, AGA,

and LGA infants Discuss the potential complications and risk factors of

the high risk neonate Compare the physical assessment characteristics of

the premature infant to a full term infant and a post term infant

Discuss the nursing interventions related to the care and management of the high risk infant in

the clinical setting

At Risk Newborns

Factors that influence birth outcomes: Birth weight Gestational age Type and length of newborn illness Environmental factors Maternal factors Maternal-infant separation

At Risk Newborns

Identifying a newborn at risk: Low socioeconomic status

Limited or no prenatal care Preexisting maternal conditions

heart diseaseDMHTNHypothyroidrenal disease

Exposure to environmental factorstoxic chemicalsillicit drugs

At Risk Newborns

Maternal Factorsageparity

Pregnancy complicationsplacenta abruptionplacenta previaoligohydramniospreterm laborpremature rupture of membranespre-eclampsiauterine rupture

At Risk Newborns

Why identify at risk neonates? Monitor pregnancy closely Start treatment as needed Arrange to deliver in appropriate facility with the

resources for mother and baby

Newborn Classifications

Preterm: < 37 weeks

Late Preterm: 34 to 36 6/7 weeks

Term: 38 to 41 weeks

Postterm: > 42 weeks

Updated Classifications

Preterm:

Extremely Preterm: < 28 weeks

Very Preterm: 28 0/7 to 32 weeks

Late Preterm: 32 0/7 to 36 6/7 weeks

Updated Classifications

Term/Postterm:

Early term: 37 0/7 to 38 6/7 weeks

Full term: 39 0/7 to 40 6/7 weeks

Late term: 41 0/7 to 41 6/7 weeks

Postterm: 42 0/7 weeks and beyond

Growth Chart

Infant Classifications

SGA Infants that fall below the 10th percentile

AGA Infants that are > 10th percentile, but < 90th percentile

LGA Infants that fall above the 90th percentile

Infant Classifications

Let’s practice! 37 5/7 weeks gestation, weighing 2954g

39 0/7 weeks gestation, weighing 3855g

40 1/7 weeks gestation, weighing 2590g

Small for Gestational Age

Less than 10th percentile for birth weight May be preterm, term, or postterm Under grown infants – IUGR Commonly seen in mothers who smoke or

have high blood pressure Increased incidence of

polycythemia and hypoglycemia

Small for Gestational Age

Intrauterine growth restriction Maternal factors Maternal disease Environmental factors Placental factors Fetal factors

Complications of SGA

Fetal hypoxia Aspiration syndrome Hypothermia Hypoglycemia Polycythemia Congenital malformations

Nursing Management for SGA

Monitor for signs of respiratory distress Monitor temperature > 36.4 ◦C Monitor blood glucose > 45 mg/dl Assess feeding Support increased caloric needs Support breastfeeding and milk production

Large for Gestational Age

Greater than the 90th percentile for birth weight

Often associated with maternal diabetes Genetic predisposition – large parents, large

infants Multiparous women – 2-3 times more

likely than primiparous women Male – usually larger than females Infants with certain anomalies tend to be LGA

Complications of LGA

Birth trauma due to CPD

Increased incidence of C/S & oxytocin-induced birth

Hypoglycemia, polycythemia, & hyperviscosity

Nursing Management of LGA

Monitor vital signs Screening for hypoglycemia and polycythemia Observing for signs and symptoms of birth

trauma Assess feeding Support breastfeeding and milk production

Nursing Management of LGA

Infants of Diabetic Mothers Close monitoring in first hours of life Hypoglycemia - <45 mg/dl Hypocalcemia - <7 mg/dl Hyperbilirubinemia – seen at 48-72 hrs, hepatic

immaturity and/or birth trauma Birth Trauma – shoulder dystocia, brachial plexus

injuries, subdural hemorrhage, cephalhematoma, and asphyxia

Nursing Management of LGA

Infants of Diabetic Mothers cont… Polycythemia – hyperglycemia/hyperinsulinism -

increased O2 comsumption – fetal hypoxia – increased erythropoietin production – increased Hct – potential hyperbilirubinemia

Respiratory Distress Syndrome (RDS) – less mature lungs for gestational age

Congenital malformations – high risk with poor glycemic control especially during first trimester

Nursing Management of the Late Preterm

At risk for: Dehydration Hypoglycemia Hyperbilirubinemia Hypothermia Sepsis Respiratory instability Failure to thrive

Nursing Management of the Late Preterm

Careful Monitoring Encourage skin to skin Encourage breastfeeding on demand Initiate supplementation – expressed

breast milk (EBM) or formula if:Birth weight < 2500 g< 36 weeks gestationPoor reserve – temp instability or hypoglycemiaPoor feeding – poor latch or < 10 min at breastWeight loss > 3% per day or > 8% total

Nursing Management of the Late Preterm

Feeding every 8-12 times/day – not > 3 hrs between feeds

Encourage increased milk production – breast pump or hand expression after feeds

Increased caloric intake – 5-10 ml/feed in first 24 hrs of life; 10-30 ml/feed in 24-96 hrs of life with MD order

Use SNS or syringe feeding for supplementationLactation Consult – documented feeding

plan for discharge

Follow up – 1-2 days of discharge

Physical Assessment of the Newborn

What are some characteristics of the normal newborn?

What does a newborn look like?

Physical Assessment

What does a preterm infant look like?

Physical Assessment

Preterm infant Increased lanugo Increased vernix Skin – thin, translucent Less defined

creases in hands and feet

Relaxed tone Decreased body fat

Physical Assessment

What does a postterm infant look like?

Physical Assessment

Postterm infant Dry, cracking skin Decreased vernix Decreased lanugo Long fingernails Increased scalp hair Wasted

appearance – decreased fat storage

Meconium staining – skin, nails, umbilical cord

Well-defined creases in hands

and feet

Ballard Exam

Case Study

As a nursing student, you are working in labor and delivery and are assigned a mother/baby couplet for your shift. The mother is 19 years old, G1P1, blood type O+,GBS positive. She received 3 doses of ampicillin during her labor. Her pregnancy was complicated by gestational diabetes. Her blood glucose was well controlled by diet alone. She has no allergies and no significant health problems prior to pregnancy. At the start of your shift, the infant is approximately 6 hours old.According to the H&P, the infant was delivered at 36 4/7 weeks gestation. The birth weight is 2210 g. The infant returned to the mother from the NICU after a 4 hour observation for mild respiratory distress. Upon entering the room, you observe that the infant is swaddled loosely in a blanket and lying on the bed next to the mother.

What risk factors do you note when caring for this couplet? What vital signs are going to be especially important when caring for this

infant? What physical characteristics do you expect to see when you examine this

infant? What special feeding issues will you need to assess on this infant?

Develop a feeding plan that would be appropriate considering the

infant’s gestational age and weight. How will you approach this mother when teaching her about

infant care, considering that she is a teen mother?

References

Davidson, M., London, M., & Ladewig, P. (2012). The newborn at risk: Conditions present at birth, Olds’ maternal-newborn nursing & women’s health across the lifespan (pp. 889-937). Boston: Pearson

The American College of Obstetrics and Gynecologists. (2013). Definition of term pregnancy. Retrieved from http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Definition_of_Term_Pregnancy

UC Davis Health System. (2014). Policies & Procedures: Late pre term/early term protocol (34 0/7 to 37 6/7 weeks gestation). Retrieved from http://intranet.ucdmc.ucdavis.edu/policies/patient_care_standards/obste trics/XVI-50.shtml

World Health Organization. (2013). Preterm birth. Retrieved from

http://www.who.int/mediacentre/factsheets/fs363/en/