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WELCOME
PRETERM
BABIESPRESENTED BY:
Dhanalakshmy. MFirst year M.Sc NURSINGGovt college of nursing
Alappuzha
Introduction
Birth weight is the single most important marker
of adverse perinatal and neonatal outcome.
Babies with a birth weight of less than 2,500g,
irrespective of their gestation are classified as
low birth weight babies.
These include both preterm and small-for-dates
babies.
Definition Preterm infants (also called premature infants) are those
born before the beginning of 38th week of gestation.
Moderately preterm infants are those born between 32
and 36 completed weeks of gestation.
Late preterm infants fall in the moderately preterm group.
Very preterm infants are those born before 32 completed
weeks of gestation. (Mehrban Singh, 2010)
Incidence
About 10 to 12 percent of Indian babies are born
preterm ( less than 37 completed weeks) as
compared to 5 to 7 percent incidence in the
west.
These infants are anatomically and functionally
immature and therefore their neonatal mortality
is high.
CAUSES OF PREMATURITY
The mechanisms initiating normal labour are not
clearly understood and much less is known about
the triggers that initiate labour before term.
Spontaneous
Induced
Spontaneous
Poor socio-economic status
Low maternal weight
Chronic and acute systemic maternal illness
Antepartum hemorrhage
Cervical incompetence
Maternal genital colonization and infections
Contd… Cigarette smoking during pregnancy
Threatened abortion
Acute emotional stress
Physical exertion
Sexual activity
Trauma
Bi-cornuate uterus
Multiple pregnancy
Congenital malformations
Induced
The labour is often induced before term when there is
impending danger to mother or foetal life in-utero.
Maternal diabetes mellitus
Placental dysfunction as indicated by unsatisfactory
foetal growth
Eclampsia
Foetal hypoxia
Antepartum haemorrhage and
Severe rhesus iso-immunization.
CLINICAL FEATURES
Measurements Their size is small with
relatively large head.
Crown-heel length is
less than 47 cm
Head circumference is
less than 33cm but
exceeds the chest
circumference by
more than 3cm.
Activity and posture The general activity is
poor
Their automatic reflex
responses such as moro
response, sucking and
swallowing are sluggish or
incomplete.
The baby assumes an
extended posture due to
poor tone.
Face and head Disproportionately
large head size
Sutures are widely
separated and the
fontanels are large
Small chin, protruding
eyes due to shallow
orbits and absent
buccal pad of fat.
Contd. Optic nerve is often un-
myelinated but presence of
papillary membrane makes
its visualization difficult.
Ear cartilage is deficient or
absent with poor recoil.
Hair appear woolly and fuzzy
and individual hair fibres can
be seen separately.
Skin and subcutaneous tissues
skin is thin,
gelatinous, shiny and
excessively pink with
abundant lanugo and
very little vernix
caseosa.
Edema may be
present.
Contd.. Subcutaneous fat is
deficient and breast
nodule is small or
absent.
Deep sole creases are
often not present.
Genitals
In male testes are
undescended and
scrotum is poorly
developed.
Contd..
In female infants,
labia majora are
widely separated
exposing labia minora
and hypertrophied
clitoris.
PHYSIOLOGICAL
HANDICAPS
Central nervous system Immaturity of central
nervous system is
expressed as inactivity
and lethargy, poor
cough reflex and
in-coordinated sucking
and swallowing
Contd.. Resuscitation difficulties at
birth and recurrent apneic
attacks.
Retinopathy of prematurity .
Vulnerable for intra-ventricular
– periventricular hemorrhage
and leuco-malacia
Inefficient blood brain barrier
Respiratory system Cuboidal alveolar lining-
poor alveolar diffusion of
gases
Hyaline membrane
disease
Breathing is mostly
diaphragmatic, periodic
and associated with
intercostal recessions
Contd… Pulmonary aspiration
and atelectasis
They are vulnerable
to develop chronic
pulmonary
insufficiency
Cardio-vascular system The closure of ductus
arteriosus is delayed.
In grossly immature
infants( less than 32
weeks) EKG shows left
ventricular
preponderance.
Risk to develop thrombo-
embolic complications and
hypertension.
Gastro- intestinal system
Due to poor and
incoordinated sucking and
swallowing.
Animal fat is not tolerated
as well as the vegetable
fat.
Regurgitation and
aspiration are common.
Hypoglycaemia
Contd.. Abdominal distention and
functional intestinal
obstruction
Entero-colitis
Immaturity of the glucuronyl
transferase system in the liver
leads to hyper-bilirubinemia.
Development of kernicterus at
lower serum bilirubin levels.
Thermo-regulation
Hypothermia is invariable.
Excessive heat loss due to
relatively large surface
area due to paucity of
brown fat in the baby who
is equipped with an
inefficient thermostat.
Infections Infections are the important
cause of neonatal mortality.
The low levels of IgG
antibodies and inefficient
cellular immunity
Excessive handling, humid
and warm atmosphere,
contaminated incubators and
resuscitators expose them to
infecting organisms.
Renal immaturity The blood urea nitrogen is
high due to low glomerular filtrate rate.
The renal tubular ammonia mechanism is poorly developed thus acidosis occurs early.
They vulnerable to develop late metabolic acidosis especially when fed with a high protein milk formula.
Concentration of urine is poor.
Contd… Preterm has to pass
4 to 5 ml of urine excrete
one milliosmole of solute
Baby gets dehydrated.
The solute retention and
low serum proteins
explain occurrence of
edema in preterm
infants.
Toxicity of drugs Poor hepatic
detoxification and
reduced renal
clearance make a
preterm baby
vulnerable to toxic
effects of drugs
Nutritional handicaps Develop anemia around 6
to 8 weeks of age.
Deficiencies of folic acid
and vitamin E.
Develop haemolytic
anemia, thrombocytopenia
and edema 6 to 10 weeks
of age.
Osteopenia and rickets
Biochemical disturbances
These babies are
prone to develop :
Hypoglycaemia
Hypocalcemia
Hypoprotenemia
Acidosis and
Hypoxia.
MANAGEMENT
Arrest of premature labor Bed rest and sedation.
Tocolytic agents
Sympathomimetic agents-beta-2-adrenergic
receptors.
Isoxsuprine (duvadilan)-beta-1 and beta-2 receptors.
Ritodrine
Salbutamol and terbutaline -beta-2 receptor
Magnesium sulphate
Indomethacin
Induction of premature labour
Maturity of fetus should be ascertained by
examination of amniotic fluid for phosphatidyl
glycerol or L/S ratio.
Corticosteroids should be administered to the
mother to enhance fetal lung maturity.
Antenatal corticosteroids
Inj.betamethasone 12mg
IM every 24 hours --2 doses
or dexamethasone 6mg IM
every 12 hours for 4 doses.
The optimal effect is seen if
delivery occurs after 24
hours of the initiation of
therapy and its therapeutic
effect lasts for 7 days.
CARE OF PRETER
M BABIES
Optimal management at birth
Delayed clamping of cord.
Elective intubation of extremely LBW babies
(<1000g).
Should be promptly dried, kept effectively covered
and warm.
Vitamin K 1mg ( 0.5mg in babies < 1500g) should be
given intra-muscularly.
Transferred by the doctor or nurse to the NICU as
soon as breathing is established.
Monitoring Vital signs .
Activity and behaviour.
Colour.
Tissue perfusion.
Fluids, electrolytes and ABG’s.
Tolerance of feeds .
Watched for development of
RDS, apneic attacks, sepsis,
PDA, NEC, IVH, etc.
Weight gain velocity.
Criteria for a healthy preterm baby
The vital signs should be stable.
The healthy baby is alert and active, looks pink
and healthy, trunk is warm to touch and
extremities are reasonably warm and pink.
The baby is able to tolerate enteral feeds and
there is no respiratory distress or apneic attacks
and baby is having a steady weight gain of 1-1.5
% of his body weight every day.
Provide in-utero milieu
Create a soft, comfortable,
“nestled” and cushioned bed.
Avoid excessive stimuli.
Effective analgesia and
sedation.
Provide warmth.
Ensure asepsis.
Prevent evaporative skin
losses.
Contd…
Provide effective and safe
oxygenation.
Partial parenteral nutrition
and give trophic feeds with
expressed breast milk
(EBM).
Provide rhythmic gentle
tactile and kinaesthetic
stimulation.
Position of the baby Thermo-neutral
environment.
Application of oil or liquid
paraffin on the skin.
Should be covered with a
cellophane or thin
transparent or thin
transparent plastic sheet.
Provide partial
kangaroo0mother-care.
Oxygen therapy
Oxygen should be administered with
a head box when SpO2 falls below
85% and it should be gradually
withdrawn when SpO2 goes above
90%.
The lowest ambient concentration
and flow rates should be used to
maintain SpO2 between 85-95% and
PaO2 between 60-80 mm Hg.
Phototherapy
Early phototherapy is
adviced to keep the serum
bilirubin level within safe
limits in order to obviate
the need for exchange
blood transfusion.
Prevention of nosocomial infections
The handling should be
bare minimum.
Vigilance should be
maintained on all
procedures.
Early diagnosis and prompt
treatment of infections.
Feeding and nutrition
Intra-venous dextrose solution (
10% dextrose in babies >1000g
and 5% dextrose in babies
<1000g).
Trophic feeds with EBM through
NG tube.
Condition is stabilized - enteral
feeds.
Fluid requirement
Fluid requirements are higher in LBW
infants due to:
Greater insensible water losses
Faster breathing rates
Decreased ability to concentrate urine
Greater use of radiant warmers
Greater use of phototherapy units
Rate of administration*
Birth weight (g)
Fluid rate (ml/kg/day)
500 - 600 140 - 200
601 - 800 120 - 130
801 - 1000 90 - 110
1000 - 1500 80 - 100
>1500 60 - 80
*on first 2 days of life
Rate of administration
Fluid rate can be increased by 10-20
ml/kg/d to gradually reach 150 ml/kg/d
Fluid requirements need to be
individualized for each baby
Enteral nutrition has to be considered
once the baby is stable
Total parenteral nutritionINDICATIONS
Infants with BW ≤ 1000 g
Infants with BW ≤ 1500 g, done in
conjunction with slowly advancing enteral
nutrition
Infants with BW 1501-1800 g for whom
enteral intake is not expected for > 3 days
Total parenteral nutrition
Glucose : 6 - 8 mg/kg/min
Amino acids : 1.5 - 2 g/kg/d
Lipid : 0.5 - 1 g/kg/d
Sodium : 2 - 4 mEq/kg/d
Potassium : 2 - 3 mEq/kg/d
Chloride : 2 - 4 mEq/kg/d
Early enteral nutritionTrophic feeding/ Gut priming
Practice of feeding very small amounts of enteral
nourishment to stimulate development of the immature
GIT
Advantages:
Improves GI motility
Enhances enzyme maturation
Improves mineral absorption
Lowers incidence of cholestasis
Shortens time to regain birth weight
Enteral nutrition Breast milk or ½ or full strength preterm formula
at 10ml/kg/d by intermittent gavage/ continuous
nasogastric drip
Increase by 10-15 ml/kg/d to reach 150ml/kg/d
Increments not >20 ml/kg/d
IV fluids can be stopped once 120ml/kg/d is
reached
On reaching 150ml/kg/d,calorie density can be
increased
Feeding guidelines
PRETERMS
<1200 g/ <32 wks: IV fluids for first 2-3 days,
once stable start gavage feeding
1200-1800 g/ 32-34 wks: Start gavage feeding,
once vigorous start spoon/ breast feeding
>1800 g/ >34 wks: Start breast feeding directly;
if trial feed takes>20 mins or intake is less than
required, switch to gavage feeding
Preterm human milk
Advantages:
Higher concentrations of amino acids
Higher concentrations of essential fatty
acids
Lower renal solute load
Specific bio-active factors provide immunity
Promotes intestinal maturation
Preterm human milk
Disadvantages:
Low concentrations of
Vitamin D, Ca, P
Inadequate iron
Enteral nutrition Energy : 130 - 175 Kcal/kg/d
Protein :3.4 - 4.2 g/kg/d
Fat :6 - 8 g/kg/d
Na :3 - 7 mEq/kg/d
Cl :3 - 7 mEq/kg/d
K :2 - 3 mEq/kg/d
Ca :100 – 220 mg/kg/d
Nutritional supplements
Multivitamin drops.
Iron supplementation.
Vitamin E supplementation.
Supplements of calcium
(220mg/day) and
phosphorus (100mg/day).
Gentle rhythmic stimulation
Gentle touch, massage,
cuddling, stroking and
flexing.
Rocking bed or placing a
preterm baby on inflated
gloves.
Soothing auditory stimuli.
Visual inputs.
Kangaroo CareKangaroo care is placing a
premature baby in an upright position on a
mother’s bare chest allowing tummy to
tummy contact and placing the premature
baby in between the mother’s breasts.
The baby’s head is turned so that the ear
is above the parent’s heart.
Body temperature
Mothers have thermal synchrony with their baby.
The study also concluded that when the baby was
cold, the mother’s body temperature would
increase to warm the baby up and vice versa.
Contd…
Breastfeeding:
Kangaroo care allows easy access to the breast and
skin-to-skin contact increases milk let-down.
Contd…
Contd…
Increase weight gain
Kangaroo care allows the baby to fall into a deep
sleep which allows the baby to conserve energy
for more important things. Increased weight gain
means shorter hospital stay.
Contd.. Increased intimacy and attachment
Utility of corticosteroids
A single dose of
dexamethasone 0.2mg/kg IV at
4 hours of age.
Inhaled steroids.
Prevention, early diagnosis and prompt management of common
problems Nosocomial infections Hypothermia Respiratory distress syndrome Aspiration Patent ductus arteriosus Chronic lung disease NEC & IVH ROP & Late metabolic acidosis Nutritional disorders Drug toxicity
Weight record Loss is upto a maximum of 10
to 15 percent.
Regain their birth weight by
the end of second week of life.
Excessive weight loss, delay in
regaining the birth weight or
slow weight gain- suggest
baby is not being fed
adequately or unwell and
needs immediate attention.
What to avoid in the care of preterm babies??
Routine oxygenation without monitoring.
Intravenous immuno-globulins. Prophylactic antibiotics. Prophylactic administration of
indomethacin or high doses of vitamin E.
Unnecessary blood transfusions.
Formula feeds. Rough handling, excessive
light and loud sound.
Immunizations It is desirable to administer
0-day vaccines(BCG, OPV,
HBV) on the day of discharge
from the hospital.
If mother is HBV carrier and
is e-antigen positive-
hepatitis B vaccine and
hepatitis B specific
immunoglobulins within 72
hours of age.
Contd…
Live vaccines should be
avoided in symptomatic HIV-
positive mothers.
WHO recommends that BCG
and oral polio vaccine can be
given to asymptomatic HIV-
positive infants.
Family support The family dynamics are
greatly disturbed. The problems and issues
should be handled with equanimity, compassion, concern and caring attitude of the health team.
Encouraged to touch and talk with her baby.
Provide kangaroo-mother-care.
Emotional support and guidance.
Transfer from incubator to cot
A baby who is feeding from the
bottle or cup and is reasonably
active with a stable body
temperature, irrespective of his
weight, qualifies for transfer to
the open cot.
Discharge policy The mother should be
mentally prepared and provided with essential training and skills.
The mother- baby dyad should be kept in step-down nursery.
The baby should be stable, maintaining his body temperature and should not have any evidences of cold stress.
Contd.. At the time of discharge,
the baby should be having daily steady weight gain velocity of at least 10g/kg.
The home conditions should be satisfactory before the baby is discharged.
The public health nurse should assess the home conditions and visit the family at home every week for a month or so.
Follow-up protocol Common infective illnesses,
reactive airway disease,
hypertension, renal dysfunction,
gastro-oesophageal reflux.
Feeding and nutrition.
Immunizations.
Physical growth, nutritional
status, anemia, osteopenia/
rickets.
Contd.. Neuro-motor development,
cognition and seizures.
Eyes: Retinopathy of
prematurity, vision,
strabismus.
Hearing.
Behavioural problems,
language disorders and
learning disabilities.
Home care of preterm babies
She must be explained about the importance of asepsis.
Keeping the baby warm and ensuring satisfactory feeding routine.
The services of postpartum programme public health nurse and social worker can be utilized.
Environmental control The infant should be effectively covered taking care to
avoid smothering.
Woollen cap, socks and mittens should be worn.
The infant should preferably lie next to the mother.
In winter, the room can be warmed with a radiant
heater or angeethi.
A table lamp having 100 watt bulb can be used to
provide direct radiant heat.
Hot water bottle should never come in contact with the
baby.
Contd.. The cot of the mother and infant should be located
away from the walls . The mother and health worker should be trained to
assess the temperature of the newborn baby by touch.
The visitors and handling of the infant should be restricted to the bare minimum.
The hands must be washed before touching or feeding the baby.
The emotional urge for kissing the baby should be curbed.
The linen should be clean and sun-dried.
Feeding Whenever feasible, breast feeding is ideal and
must be encouraged. When infant is unable to suck from the breast,
EBM should be given with a bottle or dropper or spoon or paladay depending upon his maturity.
Formula for premature babies is recommended. If cow’s or buffalo’s milk is unavoidable it should
be given after 3:1 dilution. Mother must be given detailed instructions and
practical demonstration for maintenance of bottle hygiene to prevent contamination of feeds.
Prognosis The risk of neurodevelopmental
handicaps is increased 3-fold for LBW
babies and 10-fold for very LBW
babies(<1500g).
The prognosis is good if no birth
asphyxia, apneic attacks,RDS,
hypoglycaemia and hyperbilirubinemia.
Preterm AFD babies catch up in their
physical growth with term counterparts
by the age of 1 to 2 years.
Contd..
15 to 20 % incidence of
neurological handicaps in the
form of CP, seizures, ROP,
hydrocephalus, deafness and
MR.
There is high incidence of
minor neurologic disabilities.
Neurological prognosis is
adversely affected by degree
of immaturity.
Nursing management
Obtain detailed antenatal,
intra-natal history.
Assess the gestational age and
birth weight of the baby.
Assess the features of clinical
immaturity.
Assess the behaviour of
preterm neonate.
Assessment of common
problems.
Nursing diagnosis and interventions
1. Impaired gas exchange related to immaturity of lungs and deficiency of surfactant
Assess the respiratory pattern and colour of the baby
Observe for any apneic episode. Oxygen hood is often used for able to breathe
alone but need extra oxygen. Oxygen also may be given by nasal cannula to
the infant who breathes alone. Humidify the oxygen CPAP may be necessary to keep the alveoli open
and improve expansion of lungs
2.Impaired breathing pattern : distress related to immaturity and surfactant deficiency
Assess the respiratory rate, heart rate and chest retractions
Position the child for maximal ventilatory efficiency and airway patency
Provide humidified oxygen Spo2 monitoring Provide suctioning Provide chest physiotherapy Administer bronchodilators Administer anti inflammatory medications Administer antibiotics
3. Activity intolerance related to increased work of
breathing secondary to distress
Arrange to provide routine care
Schedule periods of uninterrupted rest
Determine infant’s stress level
Reduce nonessential lighting
Use positioning devices
4. Ineffective airway clearance related to excessive
trachea-bronchial secretions
Assess the child’s breathing pattern
Check the vital signs
Provide suctioning
Provide humidified oxygen
Assess the ABG analysis
Provide C-PAP using mask /hood/nasal prongs
Observe for risks of C-PAP
Assist in CMV with PEEP if needed
5. Hypothermia related to immature thermoregulation
system
Monitor vital signs frequently
Wrap the baby well and keep warm
Provide small and frequent breast feeding as
tolerated
Look for hypoglycemia
Administer IV fluids if not tolerating the feed
Monitor the vital signs and blood pressure
Assess the skin tone, pallor and signs of dehydration
Administer IV fluids
6. Imbalanced nutrition less than body requirement
related to feeding difficulty, respiratory distress, or
NPO status
Assess the sucking and swallowing ability of the
newborn
Assess the tolerance of the child
Monitor the blood glucose level frequently
Administer IV fluids if not tolerating oral fluids
Administer human milk fortifier if the child is
preterm
7. Fatigue related to increased demand for
nutrients and deterioration of the general condition
of the baby
Assess the general condition of the baby
Assess the level of activity
Monitor the blood glucose level
Breast fed the baby
Check for from any part of the body
Provide top up feed
8. Risk for complications hypotension, shock, cerebral
hypoxia related to progression of the disease condition
Assess the vital signs, respiratory rate, pulse rate,
temperature and blood pressure
Check blood culture and sensitivity and sepsis
screening
Monitor for any signs of dehydration
Administer IV fluids or blood as necessary
Assess the serum electrolyte values and ABG values
Closely monitor for the early signs and symptoms of
complications
9. Anxiety of parents related to the outcome of the
newborn condition
Assess the mental status, anxiety and knowledge of
family members
Assess the supporting system for the family
Assess the coping strategies of the family members
Explain the disease process to the family members
Explain each and every procedure to the care giver
Provide psychological support to the family members
10. Interrupted mother-child bonding related to
infectious process
Assess the breast feeding ability including
sucking and swallowing ability
Keep the child with the mother if possible
Provide frequent breast feed 2 hourly
If breast feeding is not tolerated give EBM
Allow the mother to visit the child
Provide kangaroo mother care in case of pre term
if tolerated
11. Interrupted family process related to
hospitalization of the newborn
Assess the mental status, anxiety and
knowledge of family members
Encourage mother-child bonding if possible
Assess the coping strategies of the family
members
Explain the disease process to the family
members
Explain each and every procedure to the care
giver
Allow the family members to visit the child
12. Knowledge deficit regarding care of the baby
and treatment modalities
Assess the knowledge level of the care giver
Explain disease condition and it’s progress to the
family members
Educate regarding treatment and its prevention
Educate about the monitoring of the baby
Provide adequate explanation regarding
nutritional need of the baby
Clarify their doubts and promote understanding
Summary Definition and incidence
Causes of prematurity
Clinical features
Physiological handicaps
Management
Care of preterm babies
Prognosis
Nursing assessment
Nursing diagnosis and interventions
CONCLUSION….