isk factors

Often, the specific cause of premature birth isn't clear. However, there are known risk factors of
premature delivery, including:

 Having a previous premature birth

 Pregnancy with twins, triplets or other multiples
 An interval of less than six months between pregnancies
 Conceiving through in vitro fertilization
 Problems with the uterus, cervix or placenta
 Smoking cigarettes or using illicit drugs
 Some infections, particularly of the amniotic fluid and lower genital tract
 Some chronic conditions, such as high blood pressure and diabetes
 Being underweight or overweight before pregnancy
 Stressful life events, such as the death of a loved one or domestic violence
 Multiple miscarriages or abortions
 Physical injury or trauma

For unknown reasons, black women are more likely to experience premature birth than are
women of other races. But premature birth can happen to anyone. In fact, many women who
have a premature birth have no known risk factors.

Complications
While not all premature babies experience complications, being born too early can cause short-
term and long-term health problems. Generally, the earlier a baby is born, the higher the risk of
complications. Birth weight plays an important role, too.

Some problems may be apparent at birth, while others may not develop until later.

Short-term complications

In the first weeks, the complications of premature birth may include:

 Breathing problems. A premature baby may have trouble breathing due to an immature
respiratory system. If the baby's lungs lack surfactant — a substance that allows the lungs
to expand — he or she may develop respiratory distress syndrome because the lungs can't
expand and contract normally.

Premature babies may also develop a lung disorder known as bronchopulmonary

dysplasia. In addition, some preterm babies may experience prolonged pauses in their
breathing, known as apnea.

 Heart problems. The most common heart problems premature babies experience are
patent ductus arteriosus (PDA) and low blood pressure (hypotension). PDA is a persistent
 opening between the aorta and pulmonary artery. While this heart defect often closes on
its own, left untreated it can lead to a heart murmur, heart failure as well as other
complications. Low blood pressure may require adjustments in intravenous fluids,
medicines and sometimes blood transfusions.
 Brain problems. The earlier a baby is born, the greater the risk of bleeding in the brain,
known as an intraventricular hemorrhage. Most hemorrhages are mild and resolve with
little short-term impact. But some babies may have larger brain bleeding that causes
permanent brain injury.
 Temperature control problems. Premature babies can lose body heat rapidly. They
don't have the stored body fat of a full-term infant, and they can't generate enough heat to
counteract what's lost through the surface of their bodies. If body temperature dips too
low, an abnormally low core body temperature (hypothermia) can result.

Hypothermia in a premature baby can lead to breathing problems and low blood sugar
levels. In addition, a premature infant may use up all of the energy gained from feedings
just to stay warm. That's why smaller premature infants require additional heat from a
warmer or an incubator until they're larger and able to maintain body temperature without
assistance.

 Gastrointestinal problems. Premature infants are more likely to have immature

gastrointestinal systems, resulting in complications such as necrotizing enterocolitis
(NEC). This potentially serious condition, in which the cells lining the bowel wall are
injured, can occur in premature babies after they start feeding. Premature babies who
receive only breast milk have a much lower risk of developing NEC.
 Blood problems. Premature babies are at risk of blood problems such as anemia and
newborn jaundice. Anemia is a common condition in which the body doesn't have
enough red blood cells. While all newborns experience a slow drop in red blood cell
count during the first months of life, the decrease may be greater in premature babies.

Newborn jaundice is a yellow discoloration in a baby's skin and eyes that occurs because
the baby's blood contains excess bilirubin, a yellow-colored substance, from the liver or
red blood cells. While there are many causes of jaundice, it is more common in preterm
babies.

 Metabolism problems. Premature babies often have problems with their metabolism.
Some premature babies may develop an abnormally low level of blood sugar
(hypoglycemia). This can happen because premature infants typically have smaller stores
of stored glucose than do full-term babies. Premature babies also have more difficulty
converting their stored glucose into more-usable, active forms of glucose.
 Immune system problems. An underdeveloped immune system, common in premature
babies, can lead to a higher risk of infection. Infection in a premature baby can quickly
spread to the bloodstream, causing sepsis, an infection that spreads to the bloodstream.

Long-term complications

In the long term, premature birth may lead to the following complications:
  Cerebral palsy. Cerebral palsy is a disorder of movement, muscle tone or posture that
can be caused by infection, inadequate blood flow or injury to a newborn's developing
brain either early during pregnancy or while the baby is still young and immature.
 Impaired learning. Premature babies are more likely to lag behind their full-term
counterparts on various developmental milestones. Upon school age, a child who was
born prematurely might be more likely to have learning disabilities.
 Vision problems. Premature infants may develop retinopathy of prematurity, a disease
that occurs when blood vessels swell and overgrow in the light-sensitive layer of nerves
at the back of the eye (retina). Sometimes the abnormal retinal vessels gradually scar the
retina, pulling it out of position. When the retina is pulled away from the back of the eye,
it's called retinal detachment, a condition that, if undetected, can impair vision and cause
blindness.
 Hearing problems. Premature babies are at increased risk of some degree of hearing
loss. All babies will have their hearing checked before going home.
 Dental problems. Premature infants who have been critically ill are at increased risk of
developing dental problems, such as delayed tooth eruption, tooth discoloration and
improperly aligned teeth.
 Behavioral and psychological problems. Children who experienced premature birth
may be more likely than full-term infants to have certain behavioral or psychological
problems, as well as developmental delays.
 Chronic health issues. Premature babies are more likely to have chronic health issues —
some of which may require hospital care — than are full-term infants. Infections, asthma
and feeding problems are more likely to develop or persist. Premature infants are also at
increased risk of sudden infant death syndrome (SIDS).

Physiological handicaps

Some of the problems premature babies may experience include:

 Temperature instability--inability to stay warm due to low body fat.

 Respiratory problems:
o Infant respiratory distress syndrome (previously called hyaline membrane
disease). A condition in which the air sacs cannot stay open due to lack of
surfactant in the lungs.
o Chronic lung disease/bronchopulmonary dysplasia. These are long-term
respiratory problems caused by injury to the lung tissue.
o Air leaking out of the normal lung spaces into other tissues
o Incomplete lung development
o Apnea (stopping breathing). This occurs in about half of babies born at or before
30 weeks.
 Cardiovascular:
o Patent ductus arteriosus (PDA). A heart condition that causes blood to divert
away from the lungs.
o Too low or too high blood pressure
o Low heart rate. This often occurs with apnea.
 Blood and metabolic:
 o Anemia. This may require blood transfusion.
o Jaundice. This is due to immaturity of liver and gastrointestinal function.
o Too low or too high levels of minerals and other substances in the blood, such as
calcium and glucose (sugar)
o Immature kidney function
 Gastrointestinal:
o Difficulty feeding. Many premature babies are unable to coordinate suck and
swallow before 35 weeks gestation.
o Poor digestion
o Necrotizing enterocolitis (NEC). A serious disease of the intestine common in
premature babies.
 Neurologic:
o Intraventricular hemorrhage. This is bleeding in the brain.
o Periventricular leukomalacia. A softening of tissues of the brain around the
ventricles (the spaces in the brain containing cerebrospinal fluid).
o Poor muscle tone
o Seizures. These may be due to bleeding in the brain.
o Retinopathy of prematurity. This is abnormal growth of the blood vessels in a
baby's eye.
 Infections. Premature infants are more susceptible to infection and may require
antibiotics.

Premature babies can have long-term health problems as well. Generally, the more premature the
baby, the more serious and long-lasting are the health problems.
Any neonate born before 37 weeks (<259 days) of gestation irrespective of the birth weight.

 PRETERM NEONATE ARUNA. A P I BATCH MSC NURSING

 2. DEFINITION Any neonate born before 37 weeks (<259 days) of gestation irrespective of
the birth weight.
 3. Premature birth , commonly used as a synonym for preterm birth, refers to the birth of a
baby before the developing organs are mature enough to allow normal postnatal survival
 4. ETIOLOGY
 Spontaneous
 Induced
5. Spontaneous :
 Health status of the mother (low socio economic status)
 Multiple pregnancy: Number of multiple pregnancies are increasing due to advanced
parental age from delayed child bearing and ART.
 PIH: It is the most common complication of pregnancy and is occurring in 6- 10% of
pregancies and is rising
 Placental problems
 Preterm labour and premature rupture of membrane
 Low maternal weight
 Chronic and acute systemic maternal disease
 Antepartum haemorrhage
 Cervical incompetence
 Maternal genital colonization and infections
 Cigarette smoking during pregnancy
 Threatened abortion
 Acute emotional stress
 Physical exertion
 Sexual activity
 Trauma
 Bicornuate uterus
 Congenital malformations

 9. Induced
 Maternal diabetes mellitus
 Placental dysfunction as indicated by unsatisfactory fetal growth
 Eclampsia
 Fetal hypoxia
 Antepartum haemorrhage
 Severe rhesus iso immunization

 10. CLINICAL FEATURES

 Measurements:
 Size is small with relatively large head
 Crown- heel length is less than 47cm
 Head circumference is less than 33 cm
 But exceeds the chest circumference by more than 3 cm
  Activity and posture:
 General activity is poor
 Automatic reflex response such as moro response, sucking and swallowing are
sluggish or incomplete
 Baby assumes an extended posture due to poor tone

 Face and head:

 Face appears small
 large head size
 Sutures are widely separated
 Fontanels are large
 Small chin
 Protruding eyes
 Optic nerve is usually unmyelinated
 Ear cartilage is deficient or absent with poor recoil
 Hair appears woolly, and fuzzy and individual hair fibres can be seen separately
 Skin and subcutaneous tissues:
 Skin is thin, gelatinous, Shiny and excessively pink
 Abundant lanugo
 Very little vernix caseosa
 Edema may be present
 Subcutaneous fat is deficient
 Breast nodule is small or absent
 Deep sole creases are often not present

 Genitals:
 MALE:
 testes undescended
 scrotum poorly developed
 FEMALES :
 labia majora widely separated exposing labia minora
 hypertrophied clitoris

 16. CHARACTERISTICS OF PRETERM INFANTS

 Skin
 Bright pink, often translucent, depending on the degree of maturity
 Smooth and shiny ( may be edematous)
 Small blood vessels clearly visible underneath the thin epidermis
 Fine lanugo hair is abundant
 Hair is sparse, fine and fuzzy on the head

 Ear cartilage
 Soft and pliable
 Soles and palms
 Minimal creases
  Smooth appearance

 Male genitalia
 Male infant’s scrotum is undeveloped and not pendulous
 Minimal rugae are present
 Testes may be in the inguinal canal or in the abdominal cavity

 Female genitalia
 Clitoris is prominent
 Labia majora are poorly developed and gaping

 Scarf sign
 Elbow may be easily brought across the chest with little or no resistance

 22. DIFFERENCE BETWEEN PRETERM AND TERM INFANT

CHARACTERISTICS PRETERM TERM Posture

The preterm infant lies in a relaxed attitude , limbs more extended The body size is small Head
may appear somewhat larger in proportion.

Term infant has more subcutaneous fat tissues and rests in a more flexed attitude

Ear
Preterm: Ear Cartilages are poorly developed
Ear may fold easily
Term :The mature infants ear cartilages are well formed

Hair is fine and feathery :Lanugo may cover the back and face
Hair is more likely to form firm , separate strands

Sole
preterm :More rigid
Fine wrinkles

term :
Well and deeply creased

Female genitalia
preterm :Clitoris is prominent . Labia majora are poorly developed and gaping
term :Labia majora fully developed .Clitoris not prominent

Male genitalia
preterm :Male infant’s scrotum is undeveloped and not pendulous
Minimal rugae are present
Testes may be in the inguinal canal or in the abdominal cavity
term :
  Scrotum well developed .
 Pendulous
 Rugated
 Testes well down in the scrotal sac
Scarf sign
preterm :Elbow may be easily brought across the chest with little or no resistance
term :resisting attempt to bring the elbow past the midline

NEUROLOGIC EVALUATION:
CHARACTERISTICS PRETERM TERM
GP REFLEX weak Strong
HEEL TO EAR MANEUVER Heel is easily brought to the ear, Not possible , since
meeting with no resistance there is considerable resistance
at the knee

COMPLICATIONS OF PRETERM BIRTH

 Central nervous system:
 immaturity of central nervous system
 Poor cough reflex
 Incoordinated sucking and swallowing
 Retrolental fibroplasias
 Intra ventricular and periventricular hemorrhage
 brain damage
 Respiratory system
 Resuscitation difficulties at birth
 Hyaline membrane disease
 Breathing is periodic and associated with intercostal recessions due to soft rib
 Pulmonary aspiration
 Atlectasis
 broncho pulmonary dysplasia

 Cardio vascular system

 The closure of ductus arteriosus is delayed among preterm infants
 G I system
 Regurgitations and aspirations
 Abdominal distention and functional intestinal obstruction
 Enterocolitis
 Hyperbilirubinemia
 Hypoglycemia
 Thermo-regulation :Excess heat loss
 Infections
 Renal immaturity
 The blood urea nitrogen is high
 Acidosis
 Edema
  Toxicity of drug
 Nutritional problems
 anemia
 Deficiencies of folic acid and vit E
 osteopenia and rickets
 Biochemical disturbance
 hypoglycemia, hypocalcemia, hypoxia and hypoprotinemia

 35. MANAGEMENT
 ARREST OF PREMATURE LABOUR
 Bed rest and sedation
 Tocolytic agent
 Ethanol
 Magnesium sulphate
Tocolytic agents
 Isoxsuprine (duvadilan)
 Retodrine
 Salbutamol
 Terbutaline

 INDUCTION OF PREMATURE LABOUR

 L/S ratio
 Antenatal corticosteroids:
 Betamethasone: 12mg IM q24h for 2 doses
 Dexamethasone : 6mg IM every 12 hours for 4 doses

 ASSESSMENT

NEW BALLARD SCORE

 Optimal management at birth

 The baby should be promptly dried, kept effectively covered and warm
 Vit K 0.5mg IM
 Shift to NICU

MONITORING
 Vital signs
 Activity and behavior
 Color, Tissue perfusion
 Fluids, electrolytes and ABG’s
 Tolerance of feeds
 Look for development of RDS., apneic attacks, sepsis, PDA, NEC, IVH etc
 Weight gain velocity :

CARE OF NEWBORN :
 cushioned bed
  Avoid excessive light, excessive sound, rough handling and painful procedures. Use
effective analgesia and sedation for procedures
 Provide warmth
 Ensure asepsis
 Cover the baby appropriately
 Provide effective and safe oxygenation
 Nutrition
 tactile and kinesthetic stimulation
 Prone position
 Photo therapy
 Prevention of nosocomial infection
 Weight record
 Immunizations
 Family support
 Discharge policy
 Follow up
 Home care of preterm babies

COMMON PROBLEMS OF PRETERM NEWBORNS

 Nosocomial infections
 Hypothermia
 Respiratory distress syndrome
 Aspiration
 Patent ductus arteriosus
 Chronic lung disease
 Necrotizing enterocolitis
 Intraventricular haemorrhage
 Retinopathy of prematurity
 Late metabolic acidosis
 Nutritional disorders Drug toxicity

NURSING MANAGEMENT
 Problem with respiration
 Problems with thermoregulation
 Fluid and electrolyte imbalance
 Infection
 Pain
 Parental / maternal separation

NURSING DIAGNOSIS
 impaired gas exchange
 ineffective thermoregulation related to prematurity
 imbalanced nutrition
 Altered growth and development related to hospitalization
 altered parenting
 Anxiety related to lack of knowledge