Neonatal Complications

Chapters 16 & 17
Diane Miller
Lecture Week Ten (OB Week 6)

Objectives (00:00:11)
● Describe pathophysiology associated with neonatal complications (CSLO 1)
● Identify critical areas of assessment for ill neonates (1)
● Plan nursing care for infants with complications (1, 3, 5)
● Provide support and discharge teaching for parents of ill neonates (1, 2)
Prematurity & Low Birth Weight (00:00:35)
● These are the second leading cause of neonatal death after congenital and
chromosomal anomalies
○ Black babies have the highest preterm birth weights
● Very premature – born at less than 32 weeks
● Premature – 32 to 34 weeks
● Late premature – 35 to 37 weeks
● Extremely low birth weight - < 1000 g
● Very low birth weight - < 1500 g
● Low birth weight - < 2500g

Assessment Findings (00:01:30)

● For the gestational age assessment, we looked at physical and
neuromuscular maturity
○ Premature infants will have:
■ Small nipple
■ No plantar creases
■ Eyelids fused until at least 2 weeks gestation
■ Testes undescended/labia minora larger than majora
● Decreased tone & flexion
○ Extremities will be more flaccid
● Translucent skin, more lanugo
● Decreased subcutaneous & brown fat
○ Effects warmth and thermoregulation
● Weak cry, diminished reflexes
● Immature suck, swallow breathing
○ Leads to increased difficulty feeding
● Apnea and bradycardia
● Hypotension
● Anemia

General nursing care (00:03:01)

● Respiratory support

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 ○ Low flow NC, high flow NC, nasal CPAP, ventilator
■ Device used depends on severity of respiratory distress
■ Heated humidity should always be used when using oxygen
support for a newborn to prevent water loss + drop in body
temperature
○ Premature infants lack sufficient surfactant and generally have
immature lungs
● Neutral thermal environment - isolette
○ Dry them carefully after delivery, apply a hat to their head
■ We can even cover the infant with plastic wrap after birth or use
chemical warming pads
○ Put in radiant warmer using servo probe - so we can program what we
want their temperature to be
○ When they are stable enough to be moved to a double-walled isolette,
the infant will finally be weaned to an open crib when they are able to
maintain the temperature on their own
● Fluid & electrolyte balance
○ I&O, umbilical artery, & umbilical vein catheters
■ I&O is measured by weighing the diapers (wet-dry wt = urine
output in grams) 1mL=1gm
■ Infants can have peripheral IVs (24 g)
■ Catheter placed in the umbilical artery can be used for blood
gases
■ Catheter placed in umbilical vein can be used for fluids and
medications
■ PICC lines can also be placed for long term placement of a line
(i.e TPN)
● Nutrition – gavage feeding if < 34 weeks
○ If >34 weeks, and they have a good suck, swallow, and breathing
pattern, then they can be given oral feedings
○ Human milk is preferred - Prevents necrotizing enterocolitis
○ Gavage feedings are transitioned over to oral feedings as the infant
matures and is able to do the suck, swallow, breath without gagging,
choking, or having apnea
■ If an appropriate suck on the pacifier is assessed, nurse may
start oral feedings slowly while continuing to monitor ability to
suck and swallow the milk while breathing in between
● Nurse looks for choking, color change, drop in pulse ox,
bradycardia
○ Bradycardia would indicate a vasovagal response
if they do start choking
○ We are looking for human cues as the infant matures
■ Will wake up and want to feed and cry
■ May also put fist in mouth

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 ○ Ensure cardio respiratory status is stable before we begin oral feedings

Gavage Feeding (00:10:36)

● Use 5Fr or 8Fr feeding tube
● Orogastric – measure from mouth, to ear, to lower part of sternum
● Insert quickly to avoid gagging and vomiting
● Check for placement
○ Inject 1-2 mL of air into syringe while listening to epigastric area
(should hear a ‘swish’)
● Secure with tape to infant face
● Measure residual - prior to a feeding
○ Note amount and color
○ Follow facility policy for either refeeding that residual or holding this
feeding if there’s too much residual
■ Too much residual indicates infant has not yet digested last
feeding, we don’t want to give them more and cause
overdistention
○ Carefully monitor residual
■ Increasing amounts of residual and inability to digest the
formula can indicate necrotizing enterocolitis
● Feed by gravity or with pump
○ Gravity - breast milk poured into 20 mL syringe and by gravity it will
then infuse into the stomach

Nursing Care for Gavage Feedings (00:12:45)

● Auscultate for bowel sounds, palpate for distention
○ Bowel sounds should be present
○ Abdomen should feel rounded but soft
● Obtain abdominal circumference
○ To ensure we don’t get too much abdominal growth, this would
indicate that something is wrong
● Assess for gastric residual & emesis
○ Emesis is a sign that baby is not tolerating the feedings
● Provide non-nutritive sucking with a pacifier
● Check stools for occult blood as ordered
○ Indicative of necrotizing enterocolitis
● Weigh daily – 10 to 20 g/kg/day weight gain

Handling Premature Infant (00:13:55)

● Ensure we are reducing the baby’s stress and promoting normal growth and
development
● Quiet setting, dim lighting
○ Helps to decrease fluctuations in HR, BP, and oxygen saturation
● Cluster nursing activities while awake

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 ○ Monitor for signs of stress & pain - avoid
● Gentle skin care
○ Bath only when dirty
○ Change diapers frequently and use a neutral pH cleanser to prevent
skin breakdown
● Reposition q 2 to 3 hrs, gently swaddle, nest
○ Nest - supports baby is a flexed position, mimics intrauterine
environment
○ Side lying and prone positions promote oxygenation and gastric
emptying
○ Elevate HOB 15 degrees, esp. after a feeding to prevent aspiration
● Kangaroo care - when parents have infant either skin-to-skin or in a little
pouch
○ infant is able to hear parent breathe, feel their heartbeat and warmth -
very comforting, mimics intrauterine environment
○ Benefits:
■ Promotes parent-infant bonding
■ Keeps temperature stable
■ Improves weight gain
■ Reduces illness and pain perception

Respiratory distress syndrome - RDS (00:17:23)

● Life threatening disorder of preterm infants
● Defined as: Lack of surfactant to keep alveoli open
○ Alveoli collapse at end of expiration
■ Causes atelectasis
● Generally occurs if ≤ 32 weeks, can occur later
○ Can even occur from 34-37 esp. in infants of diabetic mothers
■ These infants do not produce surfactant like they should
● Antepartum steroid administration decreases severity
○ Because it promotes production of surfactant

Assessment (00:19:49)
● Respiratory rate > 60 per/min (Tachypnea)
● Retractions – intercostal, subcostal, substernal
○ Intercostal: In between each rib
○ Substernal: Below the ribcage
● Expiratory grunting
● Nasal flaring
○ Babies are nose breathers
○ So, when their nostrils flare out, it is because they’re trying to get
more air in
● Increased levels of oxygen required to maintain saturation
● Skin color gray, cyanotic

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 ○ Assess mucous membranes
● Breaths sounds decreased
○ Due to atelectasis
● Lethargy, hypotonia
● Hypoxemia, acidosis, tachycardia

Retractions (00:22:17)
● Supraclavicular - above the clavicle
● Intercostal- between each rib
● Suprasternal- above the sternum
● Substernal- below the sternum
● Subcostal- below the ribcage

Interventions for RDS (00:22:50)

● Monitors: cardiac, respiratory, & pulse oximetry
○ Monitor vitals
○ Auscultate breath sounds frequently
○ Monitor LOC - there should be periods of alertness
■ Constant lethargy and unresponsive to stimuli - poor sign
○ Check tone - Important!
■ We want to see a flexed tone
○ Check activity level
○ Provide usual care - neutral thermal environment, I&O, daily weights,
providing a quiet environment, and clustering care
● Diagnostic tests
○ CXR - chest x-ray
■ Lungs appear speckled - ground glass appearance (true sign of
RDS)
○ Blood gases
■ Would show increasing acidosis + levels of CO2, as CO2
becomes retained in their lungs and they become more hypoxic
○ Blood cultures, CBC
■ Drawn when showing S/S of RDS
● Medications
○ Surfactant replacement
■ Survanta (Beractant), a natural surfactant, or a synthetic
surfactant, Exosurf, can be administered by ET tube and
directly into the lungs
■ Infant would need to be on a ventilator with an ET tube
● Infant should not be suctioned for 15-30 min after - to
allow surfactant to coat alveoli
■ SE: Bradycardia, decreased O2 saturation, tachycardia,
cyanosis
○ Antibiotics, sedation

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 ■ Antibiotics are given prophylactically because many of these
premature, RDS infants are more prone to infection
■ Sedation may be given if the infant is fighting the ventilator or
if they’re very agitated
● Providing sedation will help reduce their metabolic rate
and the oxygen consumption
ABG Review (00:25:58)
● pH: 7.35-7.45
○ Below: Acidosis
○ Above: Alkalosis
● PaO2: greater than 80
○ Below: Hypoxia
● pCo2: 35-45
○ Below: Exhaling too quickly, getting rid of too much CO2
(Hyperventilation)
○ Above: CO2 is being retained
● HCO3: 22-26
○ Looks at metabolic function within kidneys and ability to either retain
bicarbonate or excrete it
● Acidosis:
○ CO2 or HCO3 will attempt to correct themself because body is always
trying to get back into that normal pH range
● Disorders + Compensatory mechanisms:
○ Metabolic Acidosis (↓pH ↓HCO3)
■ In case of Metabolic Acidosis, respiratory system (CO2) will
drop in order to compensate
○ Respiratory Acidosis (↓pH ↑CO2)
■ In case of Respiratory Acidosis, metabolic system (HCO3) will
drop in order to compensate
○ Metabolic Alkalosis (↑pH ↑HCO3)
■ In case of Metabolic Alkalosis, respiratory system (CO2) will
rise in order to compensate
○ Respiratory Alkalosis (↑ pH ↓CO2)
■ In case of Respiratory Alkalosis, metabolic system (HCO3) will
rise in order to compensate
● Say infant is on the ventilator and improving, if the rate is too high and the
infant is breathing too quickly, the PCO2 can drop too low (below 35)
○ Then the infant’s pH will begin to rise above 7.45
● Generally, with RDS, the PaO2 will rise above 80, dropping the pH and
they’ll exhibit respiratory acidosis
● Ensure we’re providing enough oxygen to keep that PaO2 greater than 80 to
prevent brain damage

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● Oxygen levels in a neonate are different than an adult - to prevent
hyperoxygenation and damage to tissues such as the retina

Interventions for RDS (00:31:49)

● Maintain airway – suction
○ May stimulate vagus nerve – bradycardia, hypoxemia
○ If they have ET tube, can suction right through there
○ Only suction for 10 sec or less + adequate oxygenation between
suctioning attempts
● Diameter of airway of premature infant is very small which increases the
risk for obstruction
■ Any little mucus plug will obstruct that airway
■ Keep a close eye on secretions, breath sounds, + pulse ox
● To assess need for suctioning
● Oxygenation - device used depends on condition + blood gases
○ CPAP (Continuous positive airway pressure)
■ Will keep alveoli open
○ Mechanical ventilation - used when CPAP is not effective
■ Baby would be intubated and it would breathe for baby, as well
as providing oxygen
○ High-frequency oscillatory ventilation - used when vent is not
successful
■ Delivers small volumes of gas at a very high rate
■ May be receiving greater than 300 bpm
■ Less traumatic on their fragile lung tissue
○ Extracorporeal membrane oxygenation - ECMO
■ Cardiopulmonary bypass machine for an infant
■ Blood is shunted from the right atrium to the aorta allowing the
lungs to heal and mature
● Nursing Care
○ Assess for breath sounds
○ Monitor for equal rise + fall of the chest for proper placement
■ If ET tube is placed appropriately, in the main stem bronchi
■ Sometimes, when the ET tube is placed, due to the anatomical
placement of the left and right bronchi, ET tube may slip down
into the right mainstem bronchi
● You’ll notice an asymmetrical rise + fall of chest with
predominant rising on the right side
○ As well as audible breath sounds on the right +
very little on the left side
● You’d need to order a chest x-ray to ensure that it is in
the main stem (adequate placement)
■ When ET tube is first placed for a newborn, we utilize a CO2
detector to ensure proper placement

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 Bronchopulmonary Dysplasia (BPD) (00:35:51)
● Chronic lung disorder, unlike RDS
○ RDS will resolve once surfactant starts to coat the alveoli and baby is
able to inspire and expire without the collapsing of the alveoli
● Involves fibrosis, atelectasis, increased pulmonary resistance &
overdistention of lung tissue
○ Causing decreased lung compliance & pulmonary function
■ This lung damage can result in pulmonary edema
● Causes
○ Mechanical ventilation
○ Oxygen for longer than 28 days
○ Less than 32 weeks gestation
● Complications:
○ Pneumonia, ear infection, CHF, developmental delays, cerebral palsy,
hearing loss, and even sudden death
● Prognosis - Depends on severity
○ May require long term oxygen (even at home) + prolonged
hospitalization

Assessment (00:37:31)
● Chest retractions
● Audible wheezing, rales, rhonchi
● Hypoxia & respiratory acidosis
● Difficulty weaning from ventilator
● Intolerance of fluids – edema, weight gain
● CXR: cardiomegaly, lung hyperinflation, & infiltrates

Interventions for BPD (00:38:00)

● Tests
○ CXR, echocardiogram
■ Echo - will show enlargement of heart or cardiac complications
○ Electrolytes, ABG
■ ABGs - will show respiratory acidosis
● Medications - can be given to help cope (we treat chronic illnesses
symptomatically) + to prevent acute exacerbations
○ Bronchodilators - reduces bronchoconstriction
○ Corticosteroids - reduces bronchospasms, edema, + inflammation of
pulmonary tissue
○ Diuretics - decreases fluid retention + risk for pulmonary edema
○ Prophylaxis against RSV (Respiratory Syncytial Virus) - premature
infants are at high risk for developing
■ It is a severe case of bronchiolitis which can lead to death

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 Interventions for BPD (00:39:26)
● Chest physiotherapy
○ Vibrating instruments on the chest that help to clear secretions from
the lungs
● Respiratory assistance & oxygen - gradually wean
● Monitor I&O, daily weight
○ Monitor for fluid overload - because they’re so prone to developing
CHF
● Meet nutritional needs
○ Have higher metabolic rate at rest
■ because they’re constantly working hard to breathe
○ Fortify formula & breast milk
■ they’ll need 22/24 cals/oz of breastmilk

Patent Ductus Arteriosus - PDA (00:40:42)

● Most common heart disorder in premature infants
● Failure of ductus arteriosus to close at birth
○ Therefore, blood will continue to be shunted away from lungs and
pushed into aorta
● Unable to pick up as much oxygen because blood is being shunted away
from the lungs

Assessment (00:41:41)
● Murmur at upper left sternal border - 2nd area of auscultation
○ Will sound like a swishing
● Widened pulse pressure & ↓ diastolic BP (Bottom #)
○ Diastolic - Pressure blood exerts within arteries between heartbeats
● Tachycardia & tachypnea, bounding pulses - if severe
● They’ll show signs of respiratory distress:
○ Apnea, increased work of breathing (WOB)
○ Difficulty weaning from vent
● Echocardiogram confirms
● CXR: pulmonary edema, enlargement of heart

Interventions for PDA (00:42:48)

● Medications
○ Diuretics - to decrease fluid overload
○ Indomethacin & ibuprofen rarely used due to SE like GI bleeding,
decreased GFR, + decreased urinary output
● Medical Intervention goal - Wait and see
○ Prevent fluid overload and see if duct closes on its own
● Nursing Interventions
○ I&O, administer oxygen - to keep sats up
○ Possibly initiate fluid restriction - to prevent overload

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● If PDA is significant and not responding to medical treatment
○ Surgical ligation - Initiate NPO for surgery
■ Cardiology consult
■ Suture, clip, or coil the duct

Intraventricular Hemorrhage - IVH (00:46:20)

● More common in infants with RDS or acidosis
○ Most of these hemorrhages occurs within the first week of life
● Occurs in germinal matrix surrounding lateral ventricles
○ Occurs in 30% to 40% of infants < 32 weeks or < 1500 gm
● Grade I to IV
○ Grade I - No functional issues
■ Bleeds within the dermal matrix
■ Not extending into the ventricles or the brain
○ Grade II - Good prognosis
■ Bleeds into the ventricles but not enough to expand size
○ Grade III - Good/bad prognosis depending on pressure on brain
■ Ventriculomegaly - Bleeds into ventricles + expands them
○ Grade IV - Functional issues that may persist
■ Venous hemorrhagic infarction + IVH
■ Involves the brain
● Prognosis:
○ Death rates - depends on size of hemorrhage
■ Very small - 5%
■ Moderate - 15%
■ Severe/Large - 50%
○ Increased chance of cerebral palsy and delayed mental development
■ If infant does not succumb to severe/large hemorrhage

Assessment (00:47:52)
● S/S of bleeding - this is a hemorrhage!
○ Because bleeding is in the brain tissue of the skull, there will changes
in neurological s/s
● Bradycardia, shock
● Increased oxygen requirements
● Hypotonia
● Full/tense/bulging fontanel
○ Due to increased fluid/blood inside brain ventricles
● Metabolic acidosis
● Decreased hematocrit - due to bleeding
● Hyperglycemia
● Seizures

Interventions for IVH (00:48:57)

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● Tests
○ Head US, EEG
■ Head US - indicated for resuscitated infants, and all other high
risk or premature infants
● To evaluate structures inside the brain
■ EEG - indicated in the presence of seizure activity
○ Lumbar puncture, H&H
● EBP ( Evidence based practice)
○ Fluctuations in cerebral blood flow can cause intraventricular
hemorrhage
● Ways to reduce incidence of IVH in ill neonates:
○ Administer fluid volume slowly
■ No rapid boluses - quick change in pressure can cause a
hemorrhage
○ Keep midline, supine head positioning
○ Keep HOB flat or slightly elevated
○ Keep hips below head with diaper change
■ Lifting of the legs when changing will return blood rapidly to
the infant 's head - we want to avoid this!!
○ Maintain NTE (Neutral thermal environment)
○ Minimize crying - raises pressure in the head
○ Minimize stimulation – light & noise

Necrotizing Enterocolitis - NEC (00:51:17)

● Inflammation & necrosis of bowel
○ 90% of cases in preterm infants
● Causes:
○ Altered blood flow to intestines
○ Impaired immune response of intestine to stress/injury
○ Occurs after initiation of enteral feedings
● Breast milk reduces risk of NEC
● High mortality rate - 10-30% of cases
● Bowel obstruction can occur - may need surgery
● Bowel length will be shortened - due to resecting of dead bowel

Assessment (00:52:57)
● S/S typically begin 3-10 days after birth - can occur several weeks later
● Signs of illness
○ Unstable ↓ temp, apnea, bradycardia, tachycardia
○ Lethargy, hypotension, shock
● Abdominal distention & tenderness - Important!
○ Indicates bowel is losing its blood supply
● Vomiting, increased gastric residuals
● Visible bowel loops & discoloration on abdomen

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● Bloody stools - bright red
● NEC can lead to perforation of the bowel!

Diagnostics (00:54:25)
● Labs
○ High or low WBC’s, thrombocytopenia
■ WBC’s below 4,500 or above 11,000
■ Thrombocytopenia - platelets below 150,000
○ Electrolyte imbalance
○ Metabolic acidosis
● Should obtain a stool specimen - to assess for blood + obtain a culture
● X-ray
○ Abdominal films: gas in intestine, dilated loops of bowel, air in
abdomen
○ Serial x-rays can determine whether it’s getting worse or improving
■ Will guide us in determining the need for surgery

Interventions for NEC (00:55:09)

● Hopefully we catch NEC in its early stages - infant will need bowel rest
○ Notify provider then initiate NPO!
● Medications
○ Antibiotics – ampicillin, gentamicin, & clindamycin
○ Analgesics - for any pain due to dying gut
● IV fluids, parenteral nutrition (TPN)
● Gastric decompression – OG tube previously used for feedings may now be
used to low suction
● Surgical management
○ If medical management is not working & disease is progressing

Retinopathy of Prematurity - ROP (00:56:55)

● Interruption of normal vascularization of retina from injury or stressor
○ Stressors can include receiving too much oxygen (Hyperoxygenation)
● Causes vasoproliferation into retina & vitreous body
○ Abnormal vessels leak blood & fluid causing scar tissue
■ Scar tissue pulls & distorts retina & macula
● Can cause retinal detachment
● Primarily infants < 29 weeks or under 1250 gm
● Diagnosed by ophthalmic exam
ROP Stages (00:58:37)
● Demarcation line - immature blood vessels have not reached the retina
● Stage 1 & 2 - usually have no permanent visual defects
● Stage 3 - abnormal blood vessels are invading into the retina
○ Treatment at this stage will produce good results and usually no vision
loss

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● Stage 4 - partial retinal detachment
● Stage 5 - total detachment of the retina
○ Needs immediate treatment and reattachment of the retina
○ Can result in impaired vision
○ Some will develop blindness

Decreasing Risk of ROP (00:59:30)

● Research has shown that both hypoxemia and hyperoxia can increase the
risk of developing ROP
● Maintain oxygen saturation levels
○ O2 saturation between 85% to 89% - too low + have ↑ risk of neonatal
death
○ O2 saturation ↑ 95% - too high + ↑ risk of ROP
○ Maintain O2 saturation between 87 - 94%
● Use oxygen blenders - deliver a precise amount of oxygen
○ Prevents hyperoxemia
● Avoid bright lights – cover isolette with blanket

Treatment for ROP (01:01:40)

● Babies with immature or abnormal blood vessel development should have
repeated eye exams to check on the progression
● Pediatric eye exam – 4 to 6 weeks of age indicated for:
○ All neonates less than 30 weeks or 1500 gm
○ Neonates 1500 – 2000 gm with medical complications
● Treatment - goal is to prevent blindness
○ Laser photocoagulation
■ They coagulate the avascular periphery of the retina to prevent
vessel proliferation
○ Cryotherapy
■ Supercooled probe used to prevent vessel proliferation by
freezing the avascular retina
○ Vitreoretinal surgery - reattaches retina
● Long term complications:
○ Glaucoma, cataracts, vision loss
○ May need corrective lenses as they grow older

Postmature Infants (01:03:12)

● Born after 41 weeks gestation
● Aging of placenta can cause placental insufficiency
○ If placenta not working, can have hypoxia & hypoglycemia
○ If placenta is working well, could have macrosomia (LGA)

Assessment (01:04:06)
● Dry, peeling, cracked skin

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● Lack of vernix
● Profuse hair & long fingernails
● Can have thin wasted appearance - if placenta is aged
● Meconium staining
● Hypoglycemia, poor feeding

Interventions for Post Term Infants (01:04:41)

● Monitor for respiratory distress, check O2 sat
● Check blood sugar for hypoglycemia
● Check H&H for polycythemia (Hct > 65%)
● Monitor for hypothermia and poor feeding
○ Early & frequent feedings

****Beginning of Part 2 of Audio Lecture****

Meconium Aspiration Syndrome - MAS (00:00:04)

● Asphyxia in utero can cause fetus’ sphincter to relax & release meconium
into fluid
○ Meconium can be aspirated into lungs while in uterus or during
delivery
■ Will cause obstruction of lower airways & trapping of air =
hyperinflation
● They begin to develop chemical pneumonitis which inhibits surfactant
○ This causes ↑ pulmonary vascular resistance -> pulmonary
hypertension

Assessment (00:01:39)
● Meconium stained fluid, meconium visualized below vocal cords
○ Seen via laryngoscope, indicates aspiration
● Greenish or yellowish discoloration of skin, nails, cord
● Signs of respiratory distress
○ Nasal flaring, retractions, grunting, cyanosis, ↓ pulse ox readings
● Barrel shaped, over-distended chest
● Decreased breath sounds or rales/rhonchi upon auscultation
● ABG: low PaO2, respiratory & metabolic acidosis

Interventions for MAS (00:03:15)

● Suctioning oropharynx & nasopharynx at delivery of head
○ To avoid aspiration when taking first breath
● CXR – will show atelectasis & hyperinflation, after delivery
● Treatment depends on severity
○ Maintain oxygenation, severe cases will need mechanical ventilation
○ Keep infant NPO until RR is <60 to reduce incidence of aspiration
(Tachypnea = NPO)

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 ○ Surfactant replacement to reduce need for ECMO
○ Sedatives or paralytics if restless on vent
○ Antibiotics to treat pneumonia
○ Cooling therapy to reduce cerebral injury from hypoxia
● Can cause death - in very severe cases

Persistent Pulmonary Hypertension - PPHN (00:05:16)

● At birth, pulmonary vessels should relax & dilate so oxygen can be picked
up in lungs
○ In utero, pulmonary vasculature was constricted so blood would
bypass lungs
● If vessels have continued vasoconstriction, this leads to elevated pulmonary
vascular resistance
○ Leads to R ventricular hypertension and R to L shunting
■ Blood backs up into right ventricle and moves right to left
across the foramen ovale and the ductus arteriosus
● Seems to mirror fetal circulation but now neonate lacks
maternal oxygen
● More common in term infants
● Risk factors: meconium aspiration, RDS, pneumonia, sepsis delayed
resuscitation

Assessment (00:06:49)
● Respiratory issues
○ Tachypnea, retractions, grunting, cyanosis
○ Low oxygen sat even when giving high levels O2
■ Blood is not flowing to lungs so it is unable to pick up oxygen
● Cardiac issues
○ Hypotension, murmur, CHF
■ Murmur due to shunts still being open
● Metabolic issues
○ Metabolic acidosis, hypocalcemia, hypoglycemia
● Hematologic
○ DIC, thrombocytopenia
● Chest x-ray - will show infiltrates
● ECG - will show pulmonary hypertension + enlarged right side of the heart
● This can lead to possible kidney damage and death
● Long term outcomes:
○ Hearing loss, neurological deficits, and chronic lung disease

Interventions - PPHN (00:08:19)

● Echocardiogram to rule out heart defects
● Hyperoxygenation
○ Ventilator, high frequency oscillatory, or ECMO

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 ○ Keeping O2 levels low can prevent acidosis
● Umbilical catheters
○ To monitor blood gases and provide fluids
● Surfactant replacement
● Nitric oxide - Induces vasodilation of lungs
○ Reduces pulmonary resistance
Interventions PPHN (00:09:41)
● Medications
○ Vasopressors – dopamine & nitroprusside
■ Decreases R to L shunting by keeping the systemic pressure
higher than the pulmonary pressure
○ Vasodilators – prostaglandins
○ Muscle relaxants to induce paralysis - if they’re fighting vent
○ Sedatives & analgesics - if they’re fighting vent
○ Antibiotics - Ampicillin & gentamicin

Transient Tachypnea of the Newborn - TTN (00:10:22)

● Happens due to delay of clearance of fetal lung fluid
○ Alveoli with retained fluid inhibits gas exchange
● Used to be called “wet lung”
● Happens in term infants
● Self-limiting – usually resolves in 24 – 72 hrs
● More common in c-section infants
○ They lack the mechanical and chemical squeezing of a vaginal birth

Assessment (00:11:41)
● Quiet tachypnea – 60 to 90 /min
● Nasal flaring, grunting, retractions
● Hypoxia, dropping O2 sats
● CXR - prominent perihilar streaking
Intervention TTN (00:13:15)
● NPO until RR decreases below 60
● IV fluids
● Oxygen to maintain saturations 90-94%
○ Via Nasal cannula, hood (short term oxygen therapy)
● Maintain NTE (neutral thermal environment) , quiet environment
● May receive ampicillin & gentamicin IV x 48 hrs
● Any infant presenting with tachypnea @ birth gets a septic workup
○ CBC + blood cultures
■ May continue to receive antibiotics until cultures come back
negative

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 Small for gestational Age - SGA (00:16:14)
● SGA – weight less than 10th percentile for gestational age
● Symmetric IUGR
○ Reduction of size all structures, occurs early in pregnancy
■ Weight, length, + head circumference = all small
○ Can be ID’d by US as early as 2nd trimester
○ Usually results from exposure to teratogenic substances, congenital
infections, or genetic problems
● Asymmetric IUGR
○ Larger head, decreased weight
○ Happens later in the pregnancy due to ↓ placental blood flow
■ From things such as preeclampsia, placental infarctions, or
severe malnutrition
○ If placenta is not working as well and the baby is not getting the
required nutrients for growth, those nutrients are preferentially going
to go to the brain
■ Head will grow but rest of body will be left out
● Outcomes
○ Inadequate oxygen reserves for labor - may be unable to tolerate labor
○ May have thin extremities and a trunk
○ Loose skin due to lack of SubQ fat
○ More prone to hypoglycemia, hypocalcemia, hypothermia
Large for Gestational Age - LGA (00:21:10)
● Weight above 90th percentile for gestational age
● Causes – maternal diabetes, prolonged pregnancy, multiparity
● Outcomes:
○ CPD (Cephalopelvic disproportion): C-sections or operative vaginal
delivery
○ Birth trauma
■ (shoulder dystocia, fractured clavicles, brachial nerve damage,
facial nerve damage, depressed skull fractures, intracranial
hemorrhage, and cephalohematomas)
○ Prone to Hypoglycemia
■ Esp those of diabetic mothers
○ Polycythemia, hyperbilirubinemia
■ They have more RBC!
● Nursing Interventions:
○ Assess for signs of injury
○ Monitor for blood sugars
○ Feed them early + often
■ Some feed poorly & need gavage feedings

Hyperbilirubinemia = Jaundice! (00:22:58)

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● Increased levels of bilirubin in blood
○ Effects 60% of term neonates
○ Effects 80% of preterm neonates
● Yellow tint in the skin + sclera
○ Progresses from newborn head downward
● Assess by pushing on newborn nose or forehead
○ Yellow pigment would appear when you release
● Two type of Bilirubin:
1. Unconjugated bilirubin – lipid soluble, deposits in tissues
a. Can cross the BBB and actually attach to brain tissue
2. Conjugated bilirubin – water soluble, can be excreted
a. Can be excreted in the urine and the stool
○ Liver can convert unconjugated to conjugated so that it can attach to
albumin and be excreted
● Can lead to kernicterus
○ Brain damage due to high levels of unconjugated bilirubin depositing
into brain tissue
■ Can lead to deafness, delayed motor skills, hypotonia, +
intellectual deficits
● Significance based on: (Plotted on Bhutani Curve)
○ Gestational age
■ Preterm infants are at ↑ risk for developing jaundice and ↑ risk
for it developing into kernicterus and causing brain damage
○ Hours of age
○ Total serum bilirubin level

Bhutani Curve Term Newborn (00:25:31)

● The older the baby gets, the less concerned we are about elevated levels
● Premature infants will always have treatment started at lower levels due to
their higher risk

Physiologic Jaundice (00:27:08)

● Normal breakdown of large amounts of RBCs
○ Uterus is a hypoxic environment that has a lot of RBC so the baby is
able to get sufficient oxygen
■ Once delivered, extra RBC are not needed so they breakdown -
releasing bilirubin
○ Liver too immature too convert all bilirubin
(overwhelmed)
● Starts after 24 hours, peaks at 3rd day of life (term)
● There’s not something wrong with the baby, this simply indicates a normal,
immature liver of a neonate
○ Bilirubin will continue to be reabsorbed in the intestines and released
back into the blood until the liver is able to catch up

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● Premature infants have an even more so immature liver so their jaundice will
peak @ 5th-6th day of life

Pathological Jaundice (00:29:18)

● Presents within first 24 hours of life
● Bilirubin can increase by more than 5mg/dL per day
● Can last for more than 1 week (term)
● Causes:
○ Rh/ABO incompatibilities - most common cause
○ Bleeding, bruising, cephalohematoma - 2nd MCC
■ Including IVH
○ Infections, polycythemia, hypoxia
○ Hepatic, metabolic, hematologic disorders
■ Hepatic congenital malformations - very rare!
● such as biliary atresia, liver tumors, hepatitis contracted
from mother, G6PD deficiency
Diagnostic Tests (00:31:07)
● Total bilirubin drawn
○ Direct bilirubin (conjugated) - water soluble
○ Indirect bilirubin (unconjugated) - lipid soluble
■ This one we hope is not high, can embed into brain
● Coombs test - antibody test
○ Positive: indicates an antibody on RBC which leads to ↑ hemolysis
(RBC breakdown)
■ Happens with Rh- infants + Type O mom with A or B infant
● Transcutaneous bilirubinometry - Noninvasive
○ Point device to forehead and it gives you an estimate of bilirubin
levels
■ If elevated, may have a standing order to draw labs
● CBC - to check hct levels for polycythemia
Phototherapy (00:33:01)
● Treats Jaundice - Converts bilirubin molecules to water soluble so can be
excreted in the stool & urine
● Fluorescent lights – bank or spot light (Shines down on infant)
○ Removed for feeding + bonding
● Bili blanket – fiber optic blanket wrapped around infant’s bare skin
○ Can be left on at all times + is removed for bathing
● Phototherapy can be ordered as single, double, or triple
○ Single - 1 light, Double - 2 lights, Triple - 2 lights + bili blanket
● Another treatment:
○ Exchange transfusion (very extreme)

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 ■ An umbilical line is placed on infant and blood is infused into
the infant from a donor and the baby’s blood is then removed
■ This removes bilirubin in the blood + RBC with antibodies
present to reduce hemolysis

Side Effects of Phototherapy (00:35:43)

● Eye damage
○ Which is why we place patches on babies’ eyes while under the bank
or spot
● Loose stools
○ Change diapers frequently, baby may need A+D ointment or zinc
oxide
● Dehydration
○ Due to loose stools and heat from phototherapy devices
● Hyperthermia
● Lethargy - esp. If dehydrated
● Skin rashes
● Thrombocytopenia
● Bronze baby syndrome
○ When baby develops a dark gray/brown pigmentation of the skin that
disappears after the phototherapy is discontinued

Nursing Care for Phototherapy (00:36:52)

● Photometer should be used to measure level of irradiance in bank or spot
lights
● Neonate only to wear diaper & protective eye goggles to ensure maximum
light exposure
● Reposition infant every 2 to 3 hrs to increase areas of exposure
● Feed q 2 to 3 hrs, monitor I&O & weight - push fluids!
○ Lights will cause insensible fluid loss
○ Adequate fluid intake prevents dehydration + promotes excretion of
bilirubin
○ May need to supplement nursing if not feeding adequately
● Monitor temp for hyperthermia
○ May need to drop temperature of isolette to maintain NTE
● Remove eye goggles for feeding - bonding
Central Nervous System Injuries (00:40:39)
● Can be caused by Intracranial hemorrhage (subdural hematoma,
subarachnoid hematoma, intracerebral hemorrhage)
○ Bleeding is more common in preterm infants
■ Can cause hydrocephalus and neurological deficits
● Hypoxic-Ischemic encephalopathy

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 ○ Decreased blood supply to the brain in utero or during labor and birth
process causing brain edema and tissue necrosis
● Periventricular leukomalacia
○ Necrosis of periventricular white matter resulting from ischemia
○ The outcome depends on the location and extent of the injury
■ There can be motor and visual deficits, lower limb weaknesses,
and intellectual impairment
● Assessment
○ Apnea, bradycardia
○ Lethargy or irritability, full fontanel
○ S/S of ↑ intracranial pressure
■ Changes in LOC, tone, reflexes, and behavior
○ Seizures

Treatment (00:42:04)
● Identify and treat comprised fetus
● CT or MRI of brain
● Possibly a lumbar puncture
● EEG, if seizures
○ Medications to treat seizures
● Total body or head cooling - relatively new
○ Helps to improve the survival and neurological development
○ They place a cap on their head, that has cool water running through it,
and it keeps the head at a lower temperature to help prevent brain
damage

Infants of Diabetic Mothers (00:43:04)

● Complications are r/t ↑ levels of maternal glucose which can cross the
placenta to the infant
○ Congenital anomalies (problems with heart, skeletal, or bowel)
■ If the hyperglycemia occurs in the first trimester, like in Type 1
or uncontrolled type 2
○ IUGR, perinatal asphyxia, SGA
■ If the placenta ages quickly, because of damage to blood
vessels with poorly controlled diabetes, then the baby lacks
placental nutrients
○ Hyperinsulinism, macrosomia, obesity
■ If mother is hyperglycemic in the 3rd trimester, like in
uncontrolled gestational diabetes, babies are born with extra
glucose in their system causing them to grow uncontrollably
■ Their pancreas excrete a lot of insulin in an attempt to stable
their glucose levels in utero and when the extra maternal
glucose is cut off after birth, they become hypoglycemic
● Assessment

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 ○ Macrosomia – LGA
○ Fractured clavicle or brachial nerve damage
○ Hypoglycemia, hypocalcemia, poor muscle tone & feeding
■ S/S of hypoglycemia: Hypotonia, jitters, poor feeding, lethargy
● Earliest sign= tremors
○ Polycythemia, jaundice
○ ↑ incidence of RDS due to delayed production of surfactant
■ Infants of diabetic moms born @ 34-37 weeks, where we
usually no longer see RDS, may indeed be born with it

Interventions (00:46:11)
● Monitor blood glucose per heel stick
○ Normal - 70-100, concerned when ↓40
● Feed q 2-3 hrs, gavage if unable to take oral
● If BS was low, check again 30 min after feeding
○ To see if it has gone up
● IVF D10W or 40% dextrose gel buccally (in the gum line)
○ Indications:
■ Unable to take oral feedings, feeding poorly
■ RR > 60 so NPO
■ BS ↓ + not responding to feedings
● Assess for birth trauma, x ray as needed

Neonatal Infection (00:48:05)

● Can occur anytime within the neonatal period (1st 28 days)
○ Early onset – first 7 days – vertical transmission from mom
■ ↑ mortality rate
● Microcephaly from exposure
● CMV or ZIka virus
● Rash from chicken pox or rubella
○ Late onset – after 7 days – lower mortality rate
○ Very late onset – after 3 months – premature, nosocomial
■ Due to placement of catheters or other devices during treatment
● Vertical transmission - passing of infection from mom to baby
1. Transplacental transfer – syphilis, CMV, Zika
a. Can cross the placenta
2. Ascending infection – ascends into uterus with PROM
3. Intrapartal exposure – during birth process - herpes
● Horizontal transmission – nosocomial

Sepsis Assessment - very important! (00:50:33)

● Respiratory – signs of distress
○ Flaring, retracting, grunting, tachypnea
● Thermoregulation – hypothermia, fever

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● Cardiovascular - ↑ or ↓ pulse & BP
● Neurological – lethargy, hypotonia, seizures, bulging fontanel
○ Lethargy = won’t wake up for feedings
● Gastrointestinal – poor feeding, vomiting, diarrhea
● Skin – rash, pustules, vesicles, petechiae

Sepsis Laboratory Findings (00:52:15)

● CBC
○ WBC < 1750 or > 25,000
○ L shift – increased number of bands
○ Thrombocytopenia – platelets < 100,000
● Blood culture
○ Can only be diagnosed with a positive blood culture
○ Workup done if suspected
● Lumbar puncture - checks for meningitis
● C-reactive protein - ↑ with inflammation or infection

Group B streptococcus - GBS (00:53:12)

● Primary cause of neonatal meningitis and sepsis
○ 15-40% of all mothers are asymptomatic carriers in the urogenital and
lower GI tract
● All pregnant women should be screened @ 35 to 37 weeks
○ With a vaginal + rectal swab
○ Women with a scheduled C-section and no ROM do not need
prophylactics
● If GBS+ or unknown = receive antibiotics in labor or ROM
○ Pen G 5 mill. un. IV given as a loading dose, then 2.5 mill. un. IV q
4h until delivery
■ Ampicillin can also be used
■ Clindamycin can be given if allergies to Pen/Ampicillin
● Goal: Mom receives 2 doses of antibiotics while in labor
○ If mom receives 2 doses of abx while in labor, and the baby appears to
be well, neonates can be observed for 48 hr
● Infants < 35 weeks get a septic workup (CBC + blood culture) & 48 hrs
observation
● At any gestational age, if there are any symptoms of infection,
○ Baby needs a septic workup & ampicillin/gentamicin

Interventions for Infection (00:55:45)

● IV fluids
● Antibiotics after cultures obtained (Ampicillin & gentamicin)
○ If cultures are negative, antibiotics are stopped in 48-72 hrs
○ If cultures are positive, antibiotics are continued for 10-14 days
■ 21 days if they have meningitis

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● Monitor glucose & electrolytes
● Oxygen & respiratory support as needed
● Strict handwashing must occur in nursery to prevent nosocomial
infection
Substance Abuse Exposure (00:57:08)
● Cigarettes – 15.9% pregnant women
○ Can cause IUGR, stillbirth, SIDS
● Alcohol – 8.5% pregnant women
○ Can cause fetal alcohol syndrome
○ Infant will exhibit withdrawal symptoms
● Illicit drugs – 5.9% pregnant women
○ Infant will exhibit withdrawal symptoms, even with weed
● Heroin & prescription drug misuse on rise
● Withdrawal will occur after birth - Monitor!!!
Neonatal Abstinence Syndrome - Withdrawal symptoms (00:59:10)
● These babies are in pain :(
● Excessive crying, high pitched cry, frantic sucking
● Fever, tachypnea
● Tremors, hyperreflexia, hypertonia
● Nasal congestion, sneezing, yawning - for opiates
● Wakefulness, irritability
● Diarrhea, poor feeding, failure to gain weight

Interventions (01:00:05)
● Urine or meconium toxicology screen
○ Many states require RN to report + to DCFS
● Diagnostic test – head US, EEG
○ Head US - checks for brain abnormalities
○ EEG - checks for seizure activity
● Neonatal abstinence scoring tool - determines level of withdrawal and need
for treatment
● Medications
○ Morphine, methadone, phenobarb. Benzodiazepines for ETOH
(alcohol)
● Frequent, small feedings, high calorie formula
○ Breastfeeding not recommended, substance can cross breast milk
● Quiet environment, swaddling, slow rocking
● Important to provide non-judgemental care
○ Remember that mother has an addiction problem - offer counseling
and referrals for treatment centers
■ Teach mother how to respond to infant cues in order to help her
be able to help the infant through withdrawal

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 ○ Assess maternal-newborn interactions

Discharge Planning from NICU (01:02:36)

● May involve interdisciplinary teams - esp. for preemies or congenital
anomalies
○ They’ll be in need of frequent follow up
● Criteria: (What infant needs to be capable of before discharge)
○ Stable temp in open crib
○ Tolerate feedings, gaining weight
○ Stable respiratory status
● Pass infant car seat challenge, if infant is <37 weeks
○ Infant is secured snuggly in a car seat at a 45 degree angle for a
specified amount of time and they’re able to maintain a adequate HR,
RR, and Pulse ox reading
● Assess family readiness – ensure their understanding of newborn care
instructions
● Family may need CPR training or extra equipment @ home
○ i.e. monitors, oxygen, suctioning
■ Ensure parents know how to use

Psychosocial Needs of Parents (01:04:39)

● Delay of attachment
○ Often seen with infants who experienced issues and are placed in the
NICU
● Guilty feelings
○ They may feel they caused their child to be ill
● Emotional distancing
○ If they don’t get attached to the baby, they’ll do better if the baby does
not make it
○ Parents won’t visit as they should - to decrease bonding
● Anger at loss of control
● Disruption of family life
● Disappointment – loss of ideal of perfect baby
● Nurses can help parents by orienting them to the NICU, explaining all
procedures, and letting the parents express their concerns and feelings
○ Ask how they’re coping
○ Encourage the parents to participate in care
■ Touch, hold, feed infant
○ Encourage picture taking to send to other family members
○ Praise them for all their involvement in the care

Loss & Grief (01:06:29)

● Parents will go through grief stages
● Allow parents to express grief

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● Refer to baby by name
● Provide parents with memorabilia
○ Because this is all they will have of the baby
● Allow them to spend as much time as they want with baby
○ No need to rush baby off to the morgue
○ Give them a private space + invite family in
● Contact clergy
○ Feel free to pray with them, if you wish to

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