RAK COLLEGE OF NURSING

DEPTH STUDY ON PRETERM, SMALL FOR

GESTATIONAL AGE ,POST MATURE
INFANT, AND BABY OF SUBSTANCE ABUSE
MOTHERS

SUBMITTED TO SUBMITTED BY-

MRS ANUGRAH MILTON PRABHDEEP KAUR
FACULTY MSC FIRST YEAR
RAKCON RAKCON

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INTRODUCTION
The incidence of low birth weight is generally highest in those countries where the mean birth weight is low
and as such varies from about 5–40% of live births. In India, about a third of the infants weigh less than
2500 g. The factors influencing the low birth weight of the baby, apart from the preterm birth period, are
socioeconomic status, nutritional and intrauterine environment. Ethnic background and genetic control are
also important.
Thus, it is logical to correlate birth weight and gestational age with risks of neonatal morbidity and
mortality of the individual countries or population groups

PRETERM
DEFINITION:
A baby born before 37 completed weeks of gestation calculating from the first day of last menstrual period
is arbitrarily defined as preterm baby. Babies born before 37 completed weeks usually weigh 2500 g or less.
However, in less than 5%, the babies may weigh more than 2500 g even when born before 37 completed
weeks. Preterm baby’s weight corresponds to average weight (above 10th percentile) for its gestational age.
INCIDENCE:
Preterm baby constitutes two-thirds of low birth weight babies. The incidence of low birth weight baby is
about 30–40% in the developing countries, as such the incidence of preterm baby is about 20–25%. In
affluent societies and in the developed countries, the incidence of the former is less than 10%.
ETIOLOGY:
This has been discussed in preterm labor (Ch. 22).

MANIFESTATIONS OF PREMATURITY:
 The clinical manifestations differ with the degree of prematurity. Anatomical: The weight is 2500 g
or less and the length is usually less than 44 cm.
 The head and abdomen are relatively large; the skull bones are soft with wide sutures and posterior
fontanel.
 The head circumference disproportionately exceeds that of the chest. (Normally, the head
circumference is greater than the chest circumference at birth and the difference is about 1.5 cm).
 Pinnae of ears are soft and flat. The eyes are kept closed .
 The skin is thin, red and shiny, due to lack of subcutaneous fat and covered by plentiful lanugo and
vernix caseosa.
 Muscle tone is poor. Plantar deep creases are not visible before 34 weeks.
 The testicles are undescended; the labia minora are exposed because the labia majora are not in
contact.
 There is a tendency of herniation. The nails are not grown right up to the finger tips.

COMPLICATIONS OF A PRETERM NEONATE

Preterm infants are at risk of many complications due to immaturity of various organs and also for the cause
of preterm birth. Late preterm infants (born between 34 and 37 weeks) though they appear equivalent to
term infants, they have some short-term and long-term (behavioral and learning) difficulties.
 Asphyxia—The babies are likely to be asphyxiated because of anatomical and functional immaturity.
Even minor degree of anoxia may produce subserosal hemorrhages especially in the heart, lungs and liver.

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In addition, it may produce intense congestion of the choroid plexus leading to intraventricular hemorrhage
(IVH).
 Hypothermia—A low birth weight baby has reduced subcutaneous as well as brown fat and increased
surface area. Very often the newborn fails to maintain the thermoneutral range of temperature
.  Pulmonary syndrome (23%)—This includes:
(a) Pulmonary edema
(b) Intra-alveolar hemorrhage
(c) Idiopathic respiratory distress syndrome (RDS)
(d) Bronchopulmonary dysplasia.
The first two are the effects of hypoxia; RDS is one of the major causes of death in preterm babies born
before 34 weeks. The deficient lung surfactant is the principal factor responsible for pulmonary atelectasis
leading to hypoxia and acidosis. Surfactant therapy is effective in reducing RDS.
 Cerebral hemorrhage—The causes are:
(a) Soft skull bones allow dangerous degree of moulding leading to subdural or subarachnoid hemorrhage
(b) Fragile subependymal capillaries cannot withstand minor degree of hypoxia leading to intraventricular
hemorrhage
c) Associated hypoprothombinemia.
 Fetal shock—Apart from the shock sustained during delivery, it may appear following improper
resuscitative manipulation during the first day or two.
 Hypoglycemia (blood glucose < 40 mg/dL) is observed in about 15% of infants due to lack of glycogen
stores in the liver. Cold stress, hyperinsulinemia and poor feeding, are the causes.
 Heart failure—It may be precipitated by asphyxia with rapid development of pulmonary edema which in
turn impairs pulmonary aeration. There may be patent ductus arteriosus
 Oliguria, anuria—as the immature kidneys are unable to handle water, solute and acid loads.
 Infection—Protective passive immunity is usually obtained from the mother during the later months of
pregnancy. As the transfer of protective immunoglobulins from the mother to a preterm baby is less, the
incidence of infection is increased by 3–10 folds. Both the humoral and cellular immune response is
poor.The common types of infection are bronchopneumonia, meningitis and necrotizing enterocolitis.
Respiratory syncytial virus (RSV) infection is common to cause RSV bronchiolitis.
 Jaundice—Because of hepatic immaturity, the bilirubin produced by the excessive hemolysis cannot be
conjugated adequately for excretion as bile, leading to rise in unconjugated bilirubin which is responsible for
exaggerated physiological jaundice.
 Patent Ductus Arteriosus (PDA)—Persistant PDA is inversely related to gestational age. Up to 30% of
PDA close spontaneously. Overhydration should be avoided.
 Dehydration and acidemia due to immature renal function may occur abruptly.
 Anemia—Lack of stored iron, hypofunction of the bone marrow and excessive hemolysis all contribute to
anemia.
 Apnea and Sudden Infant Death Syndrome (SIDS) is due to immaturity of the autonomic nervous
system. The risks of bradycardia, apnea and SIDS are increased.
 Retinopathy of prematurity is a multifactorial disorder of the retina caused by abnormal
neovascularization. It is an important cause of blindness for the children under 6 years.
The cause is mostly related to the liberal administration of high concentration of oxygen above 40% for a
prolonged period (1–2 days) following birth. Many other factors like extreme prematurity, hypoxia, lactic
acidosis, vitamin E deficiency and bright light have been implicated. The blindness is due to the formation
of an opaque membrane behind the lens.  Length of stay—Increased length of hospital stay especially for
the neonates who are early preterm (< 23 weeks, mortality is > 97%. The deaths are due to complications
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already mentioned and increased incidence of congenital malformations. Most of the deaths (two-thirds)
occur within 48 hours.
Long-term prognosis: Major handicaps (cerebral palsy), hearing loss, chronic lung disease and poor growth
are observed. Infants

NURSING DIAGNOSIS RELATED TO PRETERM BABY

10 nursing diagnoses related to the management of a preterm neonate according to NANDA:

1. Ineffective Thermoregulation related to immature regulatory mechanisms secondary to preterm birth.

2. Risk for Infection related to immature immune system and invasive procedures.

3. Impaired Gas Exchange related to underdeveloped respiratory system secondary to preterm birth.

4. Risk for Aspiration related to immature swallowing and gag reflexes.

5. Altered Nutrition: Less Than Body Requirements related to immature gastrointestinal function.

6. Risk for Altered Parent-Infant Attachment related to separation from parents due to hospitalization.

7. Risk for Delayed Growth and Development related to preterm birth and prolonged hospitalization.

8. Risk for Impaired Skin Integrity related to decreased subcutaneous fat and fragile skin.

9. Risk for Fluid Volume Imbalance related to immature renal function.

10. Risk for Altered Family Processes related to the stress of having a preterm infant in the neonatal
intensive care unit (NICU).

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SMALL FOR GESTATIONAL AGE INFANT
INTRODUCTION
Small for gestational age (SGA)— About 70% of infants with a birth weight below the 10th percentile are
found normally grown. They are constitutionally small and not at any increased risk for adverse outcome.
They present at the end of the normal spectrum for growth. Th e remaining 30% are truly growth restricted.
The neonates are at Low Birth Weight Baby . showing—correlation of birth weight and gestational age in
percentile increased risk for perinatal morbidity and mortality.

DEFINATION
Newborns whose weights fall below the 10th percentile on an Intrauterine growth chart for their gestational
age have experienced some impairment of the normal intrauterine growth process during the anternatal
period. These SGA newborns may be preterm, term, or post-term. However, most SGA newborns are born
at or close to term and weigh less than 2,500 g. Under the old classification, these newborns would have
been called premature, although their period of intra uterine life was not significantly shortened. Although
small, these newborns are mature in comparison with newborns of similar weight but younger gestational
age.
Growth-retarded newborns have an increased risk of perinatal morbidity and mortality. The newborn's
condition results from intrauterine insult or deprivation. This insult or deprivation begins many weeks before
birth. It is often related to abnormalities of the pregnancy or of the fetus.
 The cause, severity, and gestational age at which the deprivation or insult occurs determine how the
fetus is affected and what problems will be present.
 Fetal growth retardation may occur early or late in the pregnancy. Conditions occurring early in the
pregnancy, such as the first trimester, which affects all aspects of fetal growth, result in symmetrical
growth retardation.
 Newborns have proportional head circumference, weight, and length. Newborns affected by the
maternal TORCH (Toxoplasmosis, Other infections, Rubella, Cytomegalovirus, and Herpes)
infections may experience early growth retardation.
 Growth retardation in later stages of pregnancy often results from impaired uteroplacental function
or nutritional deficiency during the third trimester.
 These newborns experience asymmetrical growth retardation, with the head growing at a normal rate
when compared with the growth of various other body organs .
 Often the weight will be less than the 10th percentile, while the head circumference and length will
be greater than the 10th percentile.

Common Physical Characteristics of Small-for-Gestational-Age Newborn

• Decrease in subcutaneous tissue
• Loose, dry skin; poor skin turgor
• Decrease in normal chest and abdominal circumference
• Sunken abdomen
• Thin, slightly yellow, dull, dry umbilical cord
• Sparse scalp hair, dull and lusterless hairs
• Wide-eyed look
• Skull sutures widely separated (from lack of normal bone growth)

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PHYSIOLOGIC PROBLEMS
When adaptating to extrauterine life, the problems encountered by the SGA newborn are different from thise
of the AGA preterm newborn. If the problem of poor growth in utero has been detected during pregnancy
nurses and physicians skilled in resuscitation should be present at delivery. Certain disorders tend to occur
more frequently in the SGA newborn. These should be anticipated by the caregiver.

Asphyxia
Any neonate may be a victim of asphyxia during the labor and delivery process or immediately after birth.
However. SGA newborns appear to be particularly vulnerable to this inmediate neonatal complication. This
may result from one of the following mechanisms
• Lack of umbilical circulation
• Lack of placental exchange, as in abruptio placentae, or the SGA newborn's chronic hypoxia in utero
• Inadequate perfusion of the maternal side of the placenta

Neonatal asphyxia also may be the result of excess fluid in the lungs, airway obstruction, or ineffective
respiratory effort. The failure to initiate or maintain normal respira tions at birth is a severe, life-threatening
emergency that requires immediate intervention to prevent anoxic cellular damage and to save the newborn's
life.
Management of asphyxia
Nursing personnel need to be able to predict when a new born may be born with asphyxia and require a
resuscitative effort. Fetal monitoring during labor and delivery plays a significant role in that process.
Indications of fetal distress on the monitor assist the staff to prepare for the birth of a depressed newborn.
Other maternal indications include prolapsed cord, uterine rupture, abruptio placentae, placenta previa,
chorio amnionitis, premature labor, malpresentation, maternal diabetes, polyhydramnios, and efficiency
oligohydramnios. These conditions compromise fetal -experience oxygenation status and promote fetal
asphyxia. Neonates with asphyxia require immediate resuscitation at birth.

Meconium Aspiration Syndrome

Term, post term, and SGA newborns are at risk for developing meconium aspiration syndrome. Meconium
aspiration into the alveoli occurring in utero or at birth may result from fetal hypoxia. The etiology may be
multifactorial problems because fetal distress and asphyxia do not always result in meconium aspiration
syndrome. In addition to store reflex gasping, the fetus responds to hypoxia with reflex relaxation of the anal
sphincter and accelerated intestinal peristalsis, which draws the meconium into the tracheo-bronchial
system. Meconium in the respiratory tract acts like a foreign body blocking the flow of air into the alveoli.
Increasing inflation of the alveoli distal to the obstruction can lead to rupture and leakage of air into the
interstitial tissue. This mechanism leads to hypoxemia, acidosis, and hypercapnea. Physiologically, these
results lead to pulmonary vasoconstriction and ultimately, persistent pulmonary hypertension of the newborn

Management of Meconium Aspiration Syndrome

The syndrome may be prevented or minimized by prompt removal of meconium from the newborn's upper
respiratory tract immediately after birth and through appropriate obstetric management of the mother when
meconium- stained amniotic fluid is evident.
Direct visualization and suctioning, essential preventive measures, are being reevaluated .In addition, the use
of amnioinfusion during labor with women experiencing oligohydramnios may be helpful to relieve cord
compression and dilute meconium.
Despite preventive efforts, the newborn may require neonatal intensive care for stabilization and prevention
of further complications.

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Although few data exist on standardizing ventilator settings, management may include conventional assisted
ventilation. ECMO has been effective when conventional ventilation is inadequate. High-frequency jet
ventilation and surfactant therapy are still under investigation. Chest physiotherapy also may be helpful with
neonates experiencing obstruction in the respiratory tract.
Nursing care primarily focuses on continuing observations, assessments, and interventions related to the
neonate's respiratory system. In addition to ventilator care, assessment of respiratory status includes frequent
monitoring and documentation of transcutaneous oxygen or pulse oximeter readings. The nurse's knowledge
of potential complications, such as seizures, Gl bleeding, and renal failure, requires frequent, comprehensive
assessments.

Hypoglycemia
Neonatal hypoglycemia is a frequent occurrence in SGA newborns and in newborns of diabetic mothers,
stressed preterm newborns, and others Hypoglycemia is defined as a blood glucose of less than 40 mg/dL..
Hypoglycemia in the SGA neonate is considered to be the result of a high metabolic rate along with low
glycogen stimulates erythropoiesis. In addition, a placental-fetal blood shift may occur during labor or as a
result of fetal asphyxia. Polycythemia increases the cardiac workload because the neonate is less able to
circulate blood effetively. The alteration in blood viscosity leads to hypoxia and hypoglycemia. If the
polycythemia is severe, vessel blockage and thrombus formation may occur

Management and Nursing Care of hypoglycemia

With a hematocrit greater than 65% and symptoms of hypoxia and hypoglycemia present, treatment is
required. An exchange transfusion may be necessary to dilute the concentration of blood. Nursing care
focuses on maintaining a well-controlled environment to maintain the neonate's body temperature and
decrease the cardiac workload. The neonate is monitored closely for possible complications

NURSING PROCESS
The nurse uses knowledge about the SGA neonate and possible problems to plan and implement appropriate
care. The nurse institutes a plan of care that addresses accurate assessments and measures to prevent
complications and provide education and support to the parents.

Nursing Assessment
Most newborns with growth retardation resemble AGA preterm newborns. During assessment of the
neonate, the nurse needs to be aware of common characteristics. Common physical characteristics of the
SGA newborn with extreme growth retardation are listed below .
However, assessment of gestational age according to physical characteristics may be altered or misleading
for several reasons.
• Vernix is often decreased or absent. Consequently, the skin is more exposed to amniotic fluid.
• Sole creases appear more mature than they actually are. Breast tissue formation is reduced in SGA
newborns.
• In girls, the adipose tissue covering the labia is decreased: thus, external genitalia appear less mature.
• Because the newborn's age is more advanced than the weight implies, the SGA newborn may have
better developed neurologic responses. T
• hus, neurologic criteria tend to be more accurate than physical criteria.
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Nursing Diagnoses
Following assessment, appropriate nursing diagnoses can be developed. Here’s a list of possible nursing
diagnoses,
• Impaired gas exchange related to meconium aspiration
• Ineffective thermoregulation related to inadequate muscle and fat stores
• Risk for injury related to
 Hypoglycemia
 Effects of treatments and therapy
• Altered cardiopulmonary tissue perfusion related to asphyxia
• Inability to sustain spontaneous ventilation related to
 Asphyxia
 Hypoxia
 Risk for altered parenting related to
 Neonate's appearance
 High-risk condition

Nursing Interventions
The nurse uses information about maternal risk factors, gestational age, weight, length, head circumference,
and other characteristic observations to anticipate interventions. Knowledge about various complications
that may occur also is crucial.
Any pertinent risk factors are identified, and the labor record is reviewed in preparation for possible
resuscitation. If any meconium-stained amniotic fluid is detected, suctioning at the time of delivery is
performed.
Ongoing respiratory and neurologic assessments are essential when monitoring the neonates status and
adaptation to extrauterine life. Nutritional requirements need to be met from the time of delivery. Parenteral
or oral nutrition is provided.
It is imperative that the nurse screen the neonate's blood glucose according to the unit protocol: glucose is
administered if necessary to prevent hypoglycemia.
Because the SGA neonate is at risk for temperature instability, frequent temperature assessments are per
formed, measures to prevent infection and cold stress and provide a neutral thermal environment are
instituted.The neonate's hematocrit is monitored for abnormal increases Any deviations from the normal
range are reported

Evaluation
When caring for the SGA neonate, the nurse determines whether care was effective. Possible anticipated
outcomes include the following:
• The neonate maintains spontaneous, unassisted, and regular respirations.
• Arterial blood gases are within normal limits.
• Pulse oximeter readings demonstrate adequate oxygenation.
• The neonate displays minimal or absent lung disease.
• The newborn tolerates adequate nutritional intake for maintenance of homeostasis.
• The neonate demonstrates appropriate weight gain.
• The neonate's glucose determinations are within normal limits.
• The neonate remains free of cold stress.
• The neonate remains free of any complications associ ated with gestational age.
• Parents demonstrate an understanding of the neonate's potential and actual needs.
• Parents demonstrate a beginning relationship with the neonate.

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POST MATURE INFANT
DEFINITION:
A pregnancy continuing beyond 2 weeks of the expected date of delivery (> 294 days) is called postmaturity
or post-term pregnancy.

INCIDENCE: The incidence of pregnancies continuing beyond 42 completed weeks (> 294 days) ranges
between 4% and 14%. The average is about 10%. Many suspected post-term pregnancies are actually
wrongly dated. Incidence varies as different criteria are used for gestational age dating (clinical and
sonography).

ETIOLOGY: So long as the complex mechanism in initiation of labor remains unknown, the cause of the
prolongation of pregnancy will remain obscure.
But certain factors are related with postmaturity.
(1) Wrong dates—due to inaccurate LMP (most common)
(2) Biological variability (Hereditary) may be seen in the family
(3) Maternal factors:Primiparity, previous prolonged pregnancy, sedentary habit, elderly multiparae
(4) Fetal factors: Congenital anomalies: Anencephaly → abnormal fetal HPA axis and adrenal hypoplasia →
diminished fetal cortisol response
(5) Placental factors: Sulfatase defi ciency → low estrogen

DIAGNOSIS :
It is indeed difficult to diagnose postmaturity when the case is first seen beyond the expected date.
The important dates to determine fetal gestational age are:
(1) Date of LMP;
(2) Early ultrasound dating and
(3) Timing of intercourse.
Every possible effort should be made with available resources to diagnose at least the maturity of the fetus,
if not the postmaturity.
The following are the useful clinical guides:
1. Menstrual history—If the patient is sure about her date with previous history of regular cycles, it is a
fairly reliable diagnostic aid in the calculation of the period of gestation. But in cases of mistaken
maturity or pregnancy occurring during lactational amenorrhea or soon following withdrawal of the
“pill”, confusion arises. I
2. In such cases, the previous well-documented antenatal records of first visit in first trimester if
available, are useful guides.
3. The suggested clinical findings when a pregnancy overruns the expected date by 2 weeks are:
4. Weight record: Regular periodic weight checking reveals stationary or even falling weight.
Girth of the abdomen: It diminishes gradually because of diminishing liquor.
History of false pain: Appearance of false pain followed by its subsidence is suggestive.

Obstetric palpation: The following findings, taken together are helpful.

These are : height of the uterus, size of the fetus and hardness of the skull bones. As the liquor amnii
diminishes, the uterus feels “full of fetus”— a feature usually associated with postmaturity.
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 Internal examination: While a ripe cervix is usually suggestive of fetal maturity, to find an unripe cervix
does not exclude maturity. Feeling of hard skull bones either through the cervix or through the fornix usually
suggests maturity.

INVESTIGATIONS:
Aims are:
To confirm the fetal maturity
 To detect placental insufficiency
Assessment of fetal maturity:  Sonography: Estimation of gestational age by early (first trimester)
ultrasound is more accurate than by LMP. This is mainly due to poor recall of LMP by most patients and
secondly LMP is not a good predictor of ovulation. Physiological variations in the duration of the follicular
phase result in overestimation of true gestational age. Early ultrasound scan can reduce the incidence of true
postmaturity .
 Amniocentesis: This invasive method has been mostly replaced by sonography. Assessment of fetal well
being is done by twice weekly nonstress test, biophysical profile and ultrasonographic estimation of
amniotic fluid volume. Oligohydramnios has been associated with abnormal fetal CTG , umbilical cord
compression and meconium stained liquor. Modified biophysical profile (NST and amniotic fluid volume) is
commonly done.
Amniotic fluid pocket < 2 cm and AFI < 5 cm indicates induction of labor or delivery. Doppler velocimetry
study of umbilical and middle cerebral arteries waveforms (see p. 123) are informative. Absence of
umbilical artery end-diastolic velocity (see p. 124) indicates fetal jeopardy.

CLINICAL CONCEPT:
The following criteria have been used to establish the diagnosis of postmaturity retrospectively, i.e. after the
birth of the baby.
 Baby—(1) General appearance: Baby looks thin and old. Skin is wrinkled. There is absence of vernix
caseosa. Body and the cord are stained with greenish yellow color. Head is hard without much evidence of
molding. Nails are protruding beyond the nail beds;
(2) Weight often more than 3 kg and length is about 54 cm. Both are variable and even an IUGR baby may
be born.
 Liquor amnii: Scanty and may be stained with meconium.
 Placenta: There is evidence of aging of the placenta manifested by excessive infarction and calcification.
 Cord: There is diminished quantity of Wharton’s jelly which may precipitate cord compression.
placental insufficiency due to placental aging. This is manifested by placental calcification and infarction.

FETAL: During pregnancy—There is diminished placental function, oligohydramnios and meconium

stained liquor. These lead to fetal hypoxia and fetal distress.
During labor—
(1) Fetal hypoxia and acidosis;
(2) Labor dysfunction;
(3) Meconium aspiration;
(4) Risks of cord compression due to oligohydramnios;
(5) Shoulder dystocia;
(6) Increased incidence of birth trauma due to big size baby and non-molding of head due to hardening of
skull bones and
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(7) Increased incidence of operative delivery. The main clinical significance of post-term pregnancy is
dysmaturity or macrosomia.

Following birth—
(1) Chemical pneumonitis, atelectasis and pulmonary hypertension are due to meconium aspiration;
(2) Hypoxia (low Apgar scores) and respiratory failure;
(3) Hypoglycemia and polycythemia and
(4) Increased NICU admissions. Perinatal morbidity and mortality is calculated in terms of stillbirth. The
risk of stillbirth is increased by about threefold from 37 weeks (0.4 per 1,000) to 43 weeks (11.5 per 1,000).

MATERNAL: There is increased morbidity, incidental to hazards of induction, instrumental and operative
delivery. Postmaturity per se does not put the mother at risk.

MANAGEMENT
Before formulating the management, one should be certain about the maturity of the fetus as previously
described. Increased fetal surveillance is maintained. Perinatal morbidity and mortality are increased when
pregnancy continues beyond 41 weeks. Induction of labor may be considered at or beyond 41 weeks. Timely
delivery reduces the risk of stillbirth. Increased fetal surveillance (twice weekly) is maintained when
conservative management is done.
For the formulation of management, the cases are grouped into:
 Uncomplicated
 Complicated

UNCOMPLICATED:
 Selective induction: In this regime, the pregnancy may be allowed to continue till spontaneous onset of
labor. Fetal surveillance is continued with modified biophysical profile twice a week .
 Routine induction: The expectant attitude is extended for 7–10 days past the expected date and thereafter
labor is induced.
Induction: Induction of labor reduces the rate of cesarean delivery and perinatal mortality. If the cervix is
favorable (ripe), induction is to be done by stripping of the membranes or by low rupture of the membranes.
If the liquor is found clear, oxytocin infusion is added to be more effective. Careful fetal monitoring is
mandatory. If the cervix is unripe, it is made favorable by vaginal administration of PGE2 gel. This is
followed by low rupture of the membranes. Oxytocin infusion is added when required. Cervical length
(TVS) < 25 mm is a predictor of successful induction of labor.
COMPLICATED GROUP: (Associated with complicating factors)
 Elective cesarean section is advisable when postmaturity is associated with high risk factors like: elderly
primigravidae, preeclampsia, Rh-incompatibility, fetal compromise or oligohydramnios. Associated
complications that are likely to produce placental insufficiency—Ideally, pregnancy should not be allowed
to go past the expected date.

CARE DURING LABOR:

Whether spontaneous or induced, the labor is expected to be prolonged because of a big baby and poor
molding of the head. More analgesia is required for pain relief. Possibility of shoulder dystocia is to be kept
in mind. Careful fetal monitoring with available gadgets is to be done. If fetal distress appears, prompt
delivery either by cesarean section or by forceps/ventouse is to be done .

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NURSING PROCESS
The nurse uses knowledge about the post-term newborn and possible problems and complications to plan
and implement appropriate care. The nurse institutes a plan of care that is geared toward accurate
assessments and measures to prevent complications and provide education and support to the parents.

Nursing Assessment
To aid in determining whether a newborn is post-term, it is essential to verify the date of the mother's last
menstrual period and confirm the estimated date of delivery.
• The antenatal history also is received for findings that suggest a post-term newborn.
• These include maternal weight loss (3 lb [1.3 kg) or more per week) in the last weeks of pregnancy,
reduction in fetal and uterine growth, palpation of a hard fetal head, meconium-stained amniotic
fluid, or oligohydramnios.
• A gestational assessment tool is used to ascertain that the pregnancy is at 42 weeks or longer and to
verify the post-term status.
• The nurse assesses the newborn for characteristic physiologic abnormalities and potential
physiologic complications.
• Physical characteristics of postmature newborns include decreased or absent vernix caseosa or
lanugo: abundant scalp hair; dry, cracked, thin skin; little subcutaneous fat; yellow staining of skin,
nails, and cord; and an alert, wide-eyed look.

Nursing Diagnoses
Following assessment, appropriate nursing diagnoses that may apply to the post-term newborn can be
developed.
• Impaired gas exchange related to meconium aspiration
• Ineffective thermoregulation related to diminished subcutaneous fat stores
• Risk for injury related to
o Hypoglycemia
o Vaginal delivery of a large newborn (birth trauma)
• Knowledge deficit (parental) related to condition treatment, and possible complications associated
with post term birth
• Risk for altered parenting related to newborn's condition

Planning and Intervention

When planning for the post-term newborn, the nurse prepares for injuries that may result from birth trauma
or asphyxia.
Using the Apgar score and immediate observations, the nurse in the delivery area may need to provide
resuscitation and other immediate support measures for the neonate.
Parenteral and other forms of nutrition are provided as soon as possible after birth.
Heel stick glucose determinations are monitored frequently to detect hypoglycemia.
The newborn's hematocrit is closely monitored, and any deviations from the normal are reported The
temperature is assessed frequently, and measures to ensure appropriate environmental temperature are
provided. The nurse informs the parents about the newborns condition and provides support and resources as
needed

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Evaluation
When caring for the post-term newborn, the nurse determines whether the care was effective. Possible
anticipated outcomes include the following:
• The newborn experiences minimal or no birth trauma
• The newborn maintains spontaneous, unassisted, and regular respirations.
• Arterial blood gases are within normal limits.
• Pulse oximeter readings demonstrate adequate oxygenation.
• The newborn tolerates adequate nutritional intake for the maintenance of homeostasis.
• The newborn's blood glucose determinations are within normal limits.
• The newborn remains free of cold stress.
• The newborn remains free of any complications associated with postterm birth.

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SUBSTANCE ABUSE DURING
PREGNANCY
The most commonly abused substances include Alcohol, marijuana, cocaine, and opiates (heroin and
ethadone). Periodic episodes of cerebral anoxia. repetitive in withdrawal of the abused the substance, can
cause permanent brain damage . Withdrawal from the addicting agents can also after birth, causing
multiple physiologic problems for the neonate. In addition, the neonate may demonstrate a number of
behavioral and attachment and often has difficulty adjusting to enviornmental stimuli such as noises
and bright lights Problems.

Drug Abuse
Nursing Collaborative Assessment of the pregnant woman must include a history of drug use during
pregnancy. Unfortunately, this ise the another is difficult to obtain with accuracy because the mother may
be reluctant to share any details or maybe an unreliable historian. Identification of drugs used
immediately prior to delivery isof utmost importance too. Drugs crossing the placenta may seriously
compromise the neonate's ability to adjust to extrauterine life immediately after birth.

Recognition of the most common signs of drug withdrawal in the neonate, sometimes called neonatal
abstinence syndrome, is an important part of ongoing nursing assessment. Neonates exhibit central
nervous system, gastrointestinal, respiratory, and vasomotor symptoms as a result of drug withdrawal.
Most neo- nates exhibit signs of withdrawal in the first 24 to 72 hours of life. Many nurseries have special
checklists on which withdrawal symptoms can be quickly

Nursing and Collaborative Assessment.

Assessment of pregnant women includes maternal history of alcohol use before and during
pregnancy.

A nonjudgmental, conversational calm approach is the best method for obtaining anaccurate history.
Certain questions may be useful in identifying the alcohol- using mothers.
• Have you had any beer, wine, wine coolers, or any other alcoholic beverage since youbecame
pregnant or began trying to get pregnant?
• When was the last time you drank beer, wine, or wine coolers or any other alcoholicdrink?
• Do you recall how much you had to drink at that time?
• Was this what you usually drink? Please describe.
• How often do you think you drink too much?
• How often have you had alcoholicbeverages since you became pregnant?
• Please describe any other drugs used along with alcoholic beverages.
• Do you feel you have or ever had a drinking problem? If so, in what ways have youtried to deal
with your drinking?
• Does anyone in your family have a drinking problem? Please describe an unbornbaby? Are
you aware that alcoholic drinks can affect ypur baby?
• Are you currently receiving help for a problem? If not, would you like help

Some clients may not be aware of the effects alcohol can have on their unborn child.into the high-risk
group of heavy alcohol consumption require additional information, by a port directed multidisciplinary
Clients and intervention team.
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Nurses reinforce the importance of continued prenatal When appropriate, nurses can refer these clients top
ing women. Maintaining contact throughout the programs.

FETAL ALCOHOL SYNDROME

Reference to the association between fetal malformations and maternal alcoholism can be found in Greek
and Roman mythology. Laws in Carthage and Sparta forbid consumption of alcohol by couples on their
wedding night to prevent the conception of children with defects. Documentation of the fetal alcohol
syndrome (FAS) can be foundin the literature since the early part of the eighteenth century.

Fetal alcohol syndrome (FAS) is the term for group of abnormalities found in neonates who a exposed to
unsafe levels of alcohol during pregnancy that is live births; however, the incidence is higher among certain
believed A Fl in the general population communities

.Predictable patterns of fetal and neonatal dysmorphogenesis are attributed to severe, chronic alcoholism in
women who continue to drink heavily during pregnancy .The pattern of growth deficiency begun in prenatal
life persists after delivery, especially in the linear growth to rate of weight gain, and growth of head
circumferences.

Ocular structural anomalies, such as short palpebral fissures, ptosis, strabismus, and occasionally
microphimia, are frequent findings. Limb anomalies such as altered palmarcreases and joint disorders, ety
of cardiocirculatory anomalies, especially ventricule

FEATURES OF FETAL ALCOHOL SYNDROME

Central nervous system dysfunction
Intellectual:Mild to moderate Mental retardation
Neurologic:Microcephaly (small head size),Poor coordination,Decreased muscle tone

Behavioral:Irritability in infancy,

Hyperactivity in childhood Growth deficiency Prenatal:Less than 3% for length and weight

Postnatal:Less than 3% for length and weight ,Failure to thrive,Disproportionate-diminished adipose

tissue

Facial characteristics :Eyes :Short palpebral fissures (small eye openings) Strabismus, ptosis, myopia
Short and upturned nose, Hypoplastic philtrum (flat or absent groove above upper lip)

Mouth: Thinned upper vermillion (upper lip),Retrognathia in infancy (receding jaw)

Abnormalities in other systems

Cardiac: Murmurs (Atrial septal defects, ventricular septal defects, great-vessel anomalies, tetralogy of
Fallot)

Skeletal: Limited joint movements (especially fingers/elbows and hip dislocations)

Aberrant palmar creases ,

Pectus excavatum
,Renogenital Kidney defects, Labial hypoplaslia, Cutaneous Hemangiomas, septal defects, mental
retardation (IQ of 79 or below 1 years of age), and fine motor dysfunction (poorhand mouth coordination,
weak grasp) add to the handicap problems that maternal alcoholism can impose. Genital normalities are
seen in daughters of alcoholic mothers

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Two thirds of newborns with fetal alcohol syndrome an girls; the cause of this altered sex birth ratio is
unknown.

NURSING DIAGNOSIS.

Nursing diagnoses for the neonate with PAS are based on a comprehensive assessment.Examples of
nursing diagnoses include:

 Problem-oriented diagnoses:

 Altered growth and development, related to teratogenic effects of alcohol on fetus

 Altered nutrition: less than body requirements, related to weak neonatal sucking ability

 Altered family processes, related to alcohol- impaired interactions

 Wellness-oriented diagnoses:
 Potential for enhanced neonatal development, related to participation in infant development
program
 Potential for progressive family coping, related to parental participation in treatment and in
support groups

Narcotic drug dependence

Drug abuse implicates many preparations. However, the morphine derivatives or synthetic opium
derivatives are the most serious for the newborn whose mother is narcotic dependent. The perinatal
mortality of newborns whose mothers are dependent on narcotics is six to eight times higher than that of
a control group. Abortion, premature birth, stillbirth, and neonatal complications are the major reasons.

THE MOTHER

The number of pregnant narcotic addicts has increased considerably over the last decade. Early
recognition of the addict, awareness of potential problems, and institutionof care for the woman and her
unborn infant is of great im- portance.

Many addicts are poorly nourished, consume excessive alcohol, and frequently have sexually-transmitted
diseases. all factors that have a deleterious effect on the developingfetus. These women are particularly
prone to cellulitus, superficial abcesses, and septic phlebitis. Pulmonary dis- ease with acute pulmonary
edema is a frequently encountered complication.

It has been estimated that 75% of pregnant addicts do not seek prenatal care until laborbegins. They will
take the drug of addiction just before seeking admission, therefore widthdrawl symptoms (anxiety,
nervousness, jittery behavior, anorexia, rhinorrhea, hypotension and hypoglycemia) can be delayed 6 to
12 hours after delivery.

Signs of Neonatal Narcotic Withdrawal

W = wakefulness = irritability

T = tremulousness, temperature variation, tachypnea

H = hyperactivity, high-pitched cry, hyperacusis, hyperreflexia,hypertonus, hiccupsD =diarrhea,

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 diaphoresis, disorganized suck

R=rub marks (excoriations on knees and face), regurgitation (vomiting)

A = apneic spells, autonomic dysfunction W = weight loss (or failure to gain weight) A =alkalosis

(respiratory)

L = lacrimation

S = stuffy nose, sneezing, seizures and attitude

SUMMARY OF NURSING ACTIONS: NARCOTIC

DEPENDENT MOTHER PRENATAL PERIOD
Assessment/analysis
Intake interview

A. The nurse or physician takes a history of the drug abuse (95% are addicted to heroinor methadone),
type of drug and mode of administration, and participation (if any) in drug programs; assesses the
woman's feelings and plans for this pregnancy (infant); anddetermines the date of the last tetanus
Immunization.

B. The social worker or psychiatric social worker is brought in to evaluate the woman'ssocial, eco-
nomic, home, and ethnic problems; welfare requirements; and educationalor vocational status and needs.
Physical examination and laboratory assessment, especially: A Nutritional status.

C. Hematologic status.

D. Urine test for thin-layer chromatography for detection of drugs.Serology.

Papanicolaou smear for cytology.

Evidence of Infection:

1. Urinalysis for urinary tract Infection (UTI) pye- lonephritis.

Chest x-ray study for pulmonary disease (hilar lymphadenopathy in 95% of addicts,pulmo nary edema,
bacterial pneumonia, foreign body emboli).

3. Smears of vaginal secretions for Candida, Trichomonas, Neisseria gonorrhoeae; swelling of

Bartholin's glands.

4. Blood cultures for Staphylococcus aureus and Pseudomonas aeruginosa, which may be impli cated in
bacterial endocarditis, and for hepatitis B antigen. Assessment of peripheral paresthesia and/or decreased
vascular system: burning or absent peripheral pulses in the extremity used for self-injection. assessment of
abstinence symptoms nausea, lacrimation, perspiration, tremors, yawn- vomiting diarrhea, cramps, and
dilated malalse

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NURSING DIAGNOSIS
10 nursing diagnoses for a baby born to a substance-abusing mother:

1. Neonatal Abstinence Syndrome (NAS) related to exposure to substances in utero.

2. Risk for Infection related to compromised immune system due to maternal substance abuse.

3. Altered Nutrition: Less Than Body Requirements related to poor intrauterine nutrition and potential
feeding difficulties.

4. Risk for Impaired Gas Exchange related to maternal smoking or substance abuse.

5. Altered Parent-Infant Attachment related to maternal substance abuse, potential separation due to
hospitalization, and possible maternal-infant bonding issues.

6. Risk for Altered Growth and Development related to the impact of substance exposure on fetal
development.

7. Hypothermia related to decreased subcutaneous fat and potential withdrawal symptoms.

8. Risk for Neglect related to maternal substance abuse and its potential impact on caregiving abilities.

9. Risk for Altered Neurodevelopment related to the impact of substance exposure on the developing
nervous system.

10. Risk for Injury related to the effects of withdrawal symptoms and potential neglect during maternal
substance abuse.

Plan/implimentation
1. Assist in recruitment of addicts through community agencies and media and establisha therapeutic at
mosphere in the clinic or physician's office.

II. Assist with medical management of Infections, anemia, assessment of fetal statusand well-being
surgical conditions, and tetanus immunization.

III. Refer the pregnant addict to one or more of the following:

A. Antenatal education program.

B. Psychiatric program-Individual or group therapy.

C. Detoxification program or methadone program.

D. Community health agency for home supervision and/or guid- ance in antenatal andinfant care or for
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putting Infant up for adoption.

E. Day-night center care program or halfway house.

F. Vocational guidance.

IV. Use an antenatal teaching guide for pregnant women.

V. Encourage participation in problem solving toward achieving mutually de- rivedgoals.

Provide information as desired regarding drug abuse and detoxification andInfections (etiology, therapy,
etc)

BIBLIOGRAPHY
1. Raman AV, Maternity Nursing, Wolwer Kluwer, pg675-652
2. May K A, “Comprehensive Maternity Nursing,” Lippincott Company, pg 345-356.
3. Marshs JE, Myles Textbook for Midwives,16th edition.
4. Dutta D.C ,Text Book of Obstetrics Including Perinatology and Contraception, 7 th Edition, pg 402-
417
5. Reeder r. Sharon et al, “Maternity Nursing”, 13th edition Lippincott Company,pg567-589
6. Sherwen LN et al., Maternity Nursing Care for Child Bearing Family, 3 rd Edition, USA: Jones and
Bartlett Publishers, pg567-579
7. Sharma JB, Midwifery & obstetrical nursing, edition first edition, publisher Avichal publication
company page 225-230
8. Kaur S, text book of Midwifery & obstetrical nursing, forth edition, publisher CBS Publisher, page
253-260
9.

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