Unit III- Care of

Newborn
Unit III- Care of Newborn

Classification of the newborns

High risk infants

Neonatal resuscitation.

 Nursing management of low birth weight and preterm

babies.

 Nursing management of common neonatal disorders


Classification of newborn by weight and gestational age

•Help in predict potential problems

LBW: <2500gm
VLBW: <1500gm
ELBW: <1000gm
•Term :completed 37 weeks gestation till
42 week
•Premature; less than 37 weeks gestation
 Classification of High Risk Newborns

•Gestational Age
•Gestational Age & Birth
•Preterm Weight
•(Late Preterm) •SGA
•Term
•Post term
•AGA
•LGA
High Risk Infants
Preterm – before 38 weeks gestation
IUGR – full term but failed to grow
normally
SGA -
LGA-
Infants of Diabetic mothers
Post mature babies
Drug exposed
 Preterm infants
Survive - Weight 1250 g -1500 g – 85-
90%
500-600g at birth 20% survive
Characteristics – frail, weak, limp, skin
translucent, abundant vernix & lanugo
Behavior – easily exhausted, from
noise and routine activities, feeble cry
Physiologic Challenges of the premature infant

•Respiratory and Cardiac

•Thermoregulation
•Digestive
•Renal
Physiologic Challenges of the premature infant

•Respiratory and Cardiac

•Lack of surfactant
•Pulmonary blood vessels
•Ductus arteriosus
Nursing interventions - Respiratory
• Assess for signs of Respiratory Distress
• Nasal Flaring
• Circumoral Cyanosis
• Expiratory Grunting
• Retractions
• Tachypnea
• Apneic episodes
• Administer O2
◦ Warmed and humidified
◦ Oxihood
◦ Nasal Cannula
◦ CPAP
◦ Analyze oxygen concentration.
Nursing interventions - Respiratory
Positioning
Position with head slightly elevated and neck
slightly extended
Side-lying or prone
Suctioning
Only use when necessary
Be gently so as not to damage fragile mucus
membranes
Resuscitation of the Newborn

The goals of neonatal resuscitation

are:
To prevent morbidity and mortality
associated with hypoxic - ischemic
tissue injury (brain, heart, kidney).
To establish adequate spontaneous
respiration and cardiac output.
12/07/2020 by tilaye F. 12
 The 3A’s golden rules of resuscitation

•Anticipation:- identifying newborns

that needs resuscitation.
•Adequate preparations:- skilled
manpower and any needed materials
preparation.
•Act on time:- no delay in identifying
the newborn that need resuscitation
and action immediately.
12/07/2020 by tilaye F. 13
 Materials needed for resuscitation

a. Basic material (which should be

available in all delivery)
Adequate shelf on which to lie
the infant
Radiant warmer
Suction machine
12/07/2020 by tilaye F. 14
Infant resuscitation bag (bag and mask which
is self inflation).
Oxygen with flow meter and tube or manual
infant resuscitation bag connected to
manometer or and a pressure release value
capable of delivering 100% oxygen.
Facemask.

12/07/2020 by tilaye F. 15
Stethoscope, bulb, syringe
Sterile gloves
Scissors
Various size syringe
Adhesive tape
Alcohol and iodine
Large stop clock with sweep second
hand
12/07/2020 by tilaye F. 16
Best set ups (where there is skilled person in intubation)

Oropharyngial airway (various size)

Laryngoscope (various size)
Endo tracheal tubes
I.V cannula
Umbilical catheter
Drugs I.V fluid adrenaline, calcium
gluconate.12/07/2020 by tilaye F. 17
Steps of neonatal resuscitation
Immediately after birth, the following questions must
be asked:
 Steps of neonatal resuscitations

Primary trials (initial steps)

•Dry the newborn with clean towel
Not breathe yet
•Remove secretion from the mouth and nose
•Using a clean cloth or using suction machine
Not breathe yet
• Proceed to the next step of resuscitation
12/07/2020 by tilaye F. 19
Initial Steps
Provide Warmth
Prevent heat loss
by
Placing newborn
under radiant warmer
Drying thoroughly
Removing wet towel
Preventing Heat Loss
Premature newborns
Special problems
Thin skin
Decreased subcutaneous tissue
Additional steps
Raise environment temperature
Cover with clear plastic sheeting
Opening the Airway

Open the airway by

• Positioning on back or side
• Slightly extending neck
• “Sniffing” position
• Aligning posterior pharynx, larynx and trachea
Opening the Airway
12/07/2020 by tilaye F. 25
Management of Meconium
Meconium Present and Newborn Vigorous
• Respiratory effort is strong,
If:
and
• Muscle tone is good, and
• Heart rate is greater than
100 bpm
• Use bulb syringe or large-
Then
:
bore suction catheter to
clear mouth and nose
Meconium Present and Newborn Not Vigorous

Tracheal suction
• Administer oxygen
• Insert laryngoscope, use 12F or 14F suction catheter
to clear mouth
• Insert endotracheal tube
• Attach endotracheal tube to suction source
• Apply suction as tube is withdrawn
• Repeat as necessary
 Clear Airway: No Meconium Present

Suction
mouth first,
then nose.
Dry, Stimulate to Breathe, Reposition
Tactile Stimulation
 Potentially Hazardous Forms of Stimulation
•Slapping the back
•Squeezing the rib cage
•Forcing thighs into abdomen
•Dilating anal sphincter
•Hot or cold compresses or baths
•Shaking
Free-flow Oxygen

If the newborn is breathing but central cyanosis

is present, give free-flow oxygen.

flow-inflating bag oxygen mask oxygen

tubing
 Delivering Free-flow Oxygen

•Heated and humidified (if given for

longer than a few minutes)
•Flow rate at approximately 5 L/min
•Enough oxygen for newborn to
become pink
Evaluation: Respirations, Heart Rate, Color
Evaluation: Vital Signs Abnormal
12/07/2020 by tilaye F. 37
 Secondary trial

Depend on the three clinical

parameters
•Heart rate
•Respiratory effort
•Colour
12/07/2020 by tilaye F. 38
A. Respiratory effort  absent or Gasping bag and mask ventilation

• Good
 
B. Heart rate <100/min bag and mask ventilation
 

>100/min

C. Color central cyanosis free flow oxygen

• Pink or peripheral Cyanosis

12/07/2020 by tilaye F. Observe 39
Tertiary trial

•Lie the baby on board like table

•Apply the two fingers or thumb on
the lower third of sternum.
•Do the chest compression with the
rate of 120/min.
•Don’t remove the fingers or thumb in
between compression.
12/07/2020 by tilaye F. 40
 Chest Compressions

Temporarily increase
circulation
Must be accompanied by
ventilation
 Indications
HR less
than 60
despite 30
seconds of
effective
positive-
pressure
ventilation
 Compress heart against spine
 Increase intrathoracic pressure

 Circulate blood to vital organs

 Chest Compressions:2 People Needed
One
person
compresses chest
One person
continues
ventilation
Techniques of chest Compression
Comparison of Chest Compression Techniques
Thumb Technique (Preferred)
•Less tiring
•Better control of compression depth
Two-Finger Technique
•More convenient with only one rescuer
•Better for small hands
•Provides access to umbilicus for medications
 Chest Compressions: Positioning of Thumb or
Fingers
Apply pressure to
lower third of
sternum
Avoid xyphoid
process
 Chest Compressions:Thumb Technique

Thumbs

compress
sternum
Fingers support
back
 Chest Compressions
Thumb technique
Pressure must remain on sternum
 Chest Compressions: Two-finger Technique

 Tipsof middle finger

and index or ring
finger of one hand
compress sternum
 Other
hand
supports back
Chest Compressions: Two-finger Technique
 Compression Pressure and Depth
Depress sternum one third of the anterior-
posterior diameter of chest
 Chest Compressions: Technique
 Durationof downward stroke shorter than
duration of release
 Chest Compressions: Potential Complications
Laceration of
liver
Broken ribs
Chest Compressions: Coordination With Ventilation
Chest Compressions: Coordination With Ventilation
A four event cycle should take
approximately 2 seconds
Approximately 120 “events” per
minute (30 breaths and 90
compressions)
 Chest Compressions: Stopping Compressions
After 30 seconds of compressions and ventilation, stop
and check the heart rate for 6 seconds
 Chest Compressions: Newborn Not Improving
Ifheart rate less
than 60 bpm
despite adequate
ventilation and
chest compressions
for 30 seconds,
administer
epinephrine.
•The extent of compression of the
sternum is ½ to ¾
•If you are using bag and mask apply it
every third chest compression.
•Feel the pulse and stop chest
compression if the heart rate is above
80/min.
12/07/2020 by tilaye F. 59
Drug therapy

•Epinephrine(0.1-0.3 ml/kg of a 1:10,000

solution IV for failure to respond 30 sec of
combined resuscitation).
•Epirephrine:- strength or initiates cardiac
contractions
•Sodium bicarbonate:- counteracts
respiratory acidosis
•2-3mg/kg every 5minute of arrest time
12/07/2020 by tilaye F. 60
•Atropine reduce bronchial secretions &
hence helps to keep the air way clear
•Also reduce the vagus nerve effect
relieving bradycardia
•Dose: 0.01 to 0.03mg/kg administer IV
•Calcium increases cardiac contractibility
and may be used in place of epinephrine
with it
12/07/2020 by tilaye F. 61
 U …
N K YO
T HA
 common neonatal
disorders and its
management.
common neonatal disorders and
its management
•Neonatal Sepsis
•Hyperbilirubinemia
•Common congenital
anomalies in newborns
Neonatal
Sepsis
 Neonatal Sepsis
• Introduction:
The newborn infant is uniquely susceptible to
acquire infection, whether bacterial, viral or
fungal.
• Bacterial sepsis and meningitis continue to be major
causes of morbidity and mortality in the newborn.
• The mortality rate due to sepsis ranges from 20% to as
high as 80% among neonates.
• Surviving infants can have significant neurologic squeal
because of CNS involvement.
Definition:-Neonatal sepsis is a disease of

neonates (who are younger than one

mo.0nth) in which they are clinically ill and

have a positive blood culture.0

Risk Factors:
I) Maternal risk factors:
- e.g.: Premature rupture of membrane.
II) Neonatal risk factors:
- e.g.: Prematurity (less immunologic ability to resist
infection + more liable to penetrate their defensive
barriers).
Bacteria can reach the fetus or newborn and cause infection in
one of the following ways:
• Bacteria can pass through the maternal blood through placenta
as rubella, toxoplasma, and syphilis.
• Bacteria from the vagina or cervix can enter the uterus, as
groups B streptococci.
• The newborn may be come contract with bacteria as it passes
through the birth canal as gram negative organisms.
• The newborn may come in contact with bacteria in its
environment after birth (Coagulate positive or negative
staphylococci.)
• When a susceptible host acquires the pathogenic organism, and
the organism proliferates and overcomes the host defense,
infection results.
Classification of neonatal sepsis:
Neonatal sepsis may be categorized as early or late
onset.
Newborns with early-onset infection present within 24
hours till 7th day. Early-onset sepsis is associated with
acquisition of microorganisms from the mother
during pregnancy (transplacental infection), or
during labor (an ascending infection from the cervix).
Late-onset sepsis; occurs beyond the
first one week of life and is acquired
from the care giving environment
(Nosocomial infection).
Clinical presentation of neonatal sepsis:
Physical findings may be nonspecific and
are often subtle.
e.g.: apnea , Jaundice , Hypothermia ,
Bulging or full fontanel , Seizures ,
hypotonia
Management of Sepsis:
- Prevention: through proper application to
infection control practices.
- Early onset sepsis; give intrapartum
antimicrobial prophylaxis (IAP) to the mother.
- Neonates with clinically suspected sepsis:
*) Culture should be obtained first.
*) The recommended antibiotics are ampicilin and gentamicin.
*) Third generation cephalosporins (Cefotaxime) may replace gentamicin if
meningitis is clinically suspected or if gram-negative rods are dominant in
the unit.
- Late onset neonatal sepsis:
Vancomycin in combination with either gentamicin or cephalosporins should be
considered in penicillin resistant cases.
Note: Administer all medications IV.
Nursing consideration

• Prevention

• Curative
Prevention
1- Demonstrate the effect of hand washing upon the
prevention of the noscomical infections.
2 -Standard precautions should be applied in the nursery for
infection prevention.
3- Instillation of antibiotics into newborn’s eye 1-2 hours after
birth is done to prevent the infection.
4- Skin car should be done using worm water and may use
mild soup for removal of blood or meconium and avoid the
removal of vernix caseosa.
5- Cord care should be cared out regularly using alcohol or an
antimicrobial agent.
 Curative

• Encourage breast feeding from the mother.

• Adequate fluid and caloric intake should be
administered by gavage feeding or intravenous fluid
as ordered.
• Extra-measure for hypothermia or hyperthermia that
may take place to the newborn.
• Administering medications as it is order.
• Follow the standard precautions.
• Monitoring intravenous infusion rate and antibiotics
are the nurse responsibility.
• Administer the medication in the prescribed dose, route,
and time within hour after it is prepared to avoid the
loss of drug stability.
• Care must be taken in suctioning secretions from the
newborn as it may be infected.
• Isolation procedures are implemented according to the
isolation protocols of the hospital.
• Observe for the complication e.g. meningitis and septic
shock.
• Encourage in-service programs and continuing
education of nurses regarding the infection control
precautions.
 Neonatal jaundice

•is a yellowish discoloration of the skin

and or sclera due to bilirubin deposition.
•In newborns jaundice appears when
total bilirubin (TB) is more than 7 mg /dl
and > 60% healthy full term babies have
biochemical hyperbilirubinemia.
•It could be physiologic or pathologic
heme- biliverdin
unconjugated bilirubin
Unconjugate bilirubin Albumin
liver combines with glucose and
glucuronic acid
Transferase enzyme Conjugated
bilirubin bacteria urobin
excreted via feaces/urine.
12/07/2020 by tilaye F. 80
 Comparison b/n physiological from Pathological Jaundice
No Features Physiologic Jaundice Pathological Jaundice

1 Clinical onset of jaundice (after birth) >24 hrs <24 hrs

2 Jaundice still clinically visible (day after Term < 8 days Term ≥8 days
birth) Preterm < 14 days Preterm > 14 days

3 Peak TSB Term < 12 mg/dl Term > 12 mg/dl

Preterm < 15 mg/dl Preterm > 15 mg/dl

4 Rise in TSB < 5mg/dl/24 hrs > 5mg/dl/24 hrs

5 Conjugated serum bilirubin level <2mg/dl >2mg/dl or 15 % of TB

 Causes of Jaundice

• Isoimmunization
• RH incompatibility,
• ABO incompatibility,
• Other blood group incompatibility
• Infection
• Bacterial, viral, protozoal
• Sequestered blood
• Subgalial hemorrhage, cephal hematoma, ecchymosis,
hemangioma
• Erythrocyte biochemical defect
• G6PD deficiency, Hexokinase deficiency
Clinical manifestations

•yellowish discoloration of sclera,

skin, mucus membranes
•a newborn may present with
signs of biluribin encephalopathy.
Risk factors for bilirubin encephalopathy

•Prematurity
•Metabolic acidosis,
•Hypoglycemia,
•Sepsis,
•Temperature instability,
•Significant lethargy
•Low serum albumin
Investigations

•Total bilirubin
•Direct and indirect bilirubin
•Maternal and neontal blood group
and RH
•Direct/indirect Coombs test
•Hemoglobin (Hgb) or hematocrit
(HCT)
•Peripheral RBC morphology
 Investigations

•Reticulocyte production index(RPI)

•Serum albumin level
•albumin to bilirubin ratio
•Liver function test (LFT)
•Septic work up.
•Abdominal ultrasound with
indication.
Principles of treatment

•Phototherapy
•Exchange transfusion
•Other medical managements
•Note: Use Butanic curve for
choosing the management
options.
 Phototherapy
• Use Bhutanic curve for determinination of the
management of hyperbiluribinemia
• Bilirubin absorbs light maximally in the blue range (420-
470 nm).
• Use either
• blue, or special narrow-spectrum (super) blue lights
• Cover the baby’s eye and put diaper with maximum body
surface area being exposed.
• Measure weight daily.
• Increase fluid intake by 25 %
• Give a bolus of fluid with Normal saline 20ml/kg if bilirubin
remains high.
 Side effects of phototherapy

•Insensible water loss

•Watery and frequent stool
•Retinal damage
•Erythema and increased blood
flow
•Interferes with maternal infant
bonding
 Double Volume Exchange transfusion

• The amount of blood volume to be exchanged is

equivalent to 2x the blood volume of the baby
(85ml/kg )
• Use fresh blood less than 24 hours
• Do procedure after umbilical catheterization
using aseptic technique
• Heparinize the catheter
• The amount of blood to be removed at a time is
5ml to 20 ml
12/07/2020 by tilaye F. 92
 Type of blood to be transfused

•Rh hemolytic disease

• give blood group compatible to the
baby and RH of the mother.
•ABO hemolytic disease
• give blood group of the mother and Rh
compatible to the newborn
•O negative blood is the most
preferred type of blood for
exchange transfusion.
 Monitoring

• Strictly monitor the vital signs during the

procedure.
• Determine post transfusion HCT 4-6
hours after the procedure.
• Determine bilirubin 4 hourly after the
procedure.
• Monitor RBS every 30-60 minutes
during the procedure and 2-4 hourly for
the first 24 hours after procedure.
 Monitoring

•Calcium gluconate slowly via a peripheral

vein under strict cardiac monitoring after
every 100ml of blood is exchanged.
•Cloxacillin 50mg/Kg bid for 2- 3 days and
gentamicin 5mg/kg BID for 2-3 days.
•Keep baby NPO for 4 hours before and
after procedure.
 Other treatment modalities

•Phenobarbital 5 mg/kg to stimulate liver

enzyme in Crigler – Najjar syndrome.
•High dose of IV immunoglobulin.
•In case of Breast milk jaundice
discontinuation of breast milk for 1-3days
 Summary

•Jaundice is yellowish discoloration of mucus

membranes and skin
•Isoimmune Hemolytic disease is the leading
cause of pathologic jaundice
•The feared complication of hyper
biluribinemia is kernicturus.
•Management is mainly by phototherapy and
sometimes double volume exchange
 Common congenital anomalies in newborns
Congenital abnormalities of GIT
Cleft lip and palate.
Esophageal Atresia (EA)
Tracheoesophageal Fistula (TEA)
Congenital Hernia
 Developmental dysplasia of hip
• When to assess for developmental dysplasia
• Barlow’s and Ortolani’s test
Central nervous system defects
Congenital abnormalities of cardiovascular system
Defects of genitourinary tract
Causes of congenital anomalies

99
Congenital abnormalities

100
 Central nervous system defects
Hydrocephalus
•Hydrocephalus is not a specific
disease; rather, it represents a
diverse group of conditions that
result from impaired circulation &
absorption of CSF
101
Non-communicating (intarventricular or
obstructive) hydrocephalus there is a
blockage b/n the ventricular & sub
arachinoid systems, resulting in an
interference with the circulation of CSF
Communicating (extraventricular) is an
interference with the absorption of CSF

102
Clinical features

• When the sutures are separated, the “cracked pot”

sound can be heard as the skull is percussed
• The bones of the cranium become thin & the
fontanels large & possibly tense
• The infant becomes less able to move the head
• Serial measurements of the occiputo-frontal
circumference of the head are necessary for early
diagnosis.
• Nystagmus (an involuntary rapid movement of the
eye ball) 103
 Clinical features

•The muscle tone of the extremities is

frequently abnormal, & spasticity of the
lower extremities may become evident
•Irritability, anorexia, & vomiting occur
•Sucking becomes difficult
•The cry is high-pitched, convulsions may
occur 104
Diagnostic procedure

•Diagnostic tests are done to

differentiate hydrocephalus
from the conditions that
cause an enlarged head.
105
 Surgical management consists of:
• The removal of the obstruction to the flow of CSF
• shunting of CSF from the ventricle to an area outside
the CNS, an extra-cranial body compartment
• Ventricul operitoneal shunt
• Ventriculo atrial shunt
• Medical management consists :- acetazolamide
(Diamox) to reduce CSF secretion.
106
 Complication

•Bacterial infection (staphylococcus

epidermidis), proteus.
•Kinking, plugging, displacement of
the shunt tubing
•Acute shunt failure cause
progressive increase in intracranial
pressure. 107
 Anencephaly

•Anencephaly is a congenital
abnormality in which both cerebral
hemispheres are absent.
•Many affected infants are stillborn.

108
Spina bifida
• Is congenital defect of the spinal column due to
failure of the fusion of vertebral arches with or with
out protrusion and dysplasia of the cord and
meanings.
• Is a birth defect that involves the incomplete
development of the spinal cord or its coverings
• It occurs at the end of the first month of pregnancy
when the two sides of the embryo’s spine fail to join
together, leaving an open area
• It is also called “split spine” or open spine. 109
 Types of spina bifida

1.Spina bifida occulta (Hidden)

• The commonest and mildest form
• Occulta means hidden, meaning that the defect
is covered by skin and not open
• There is a tiny gap b/n the vertebrae of the spine
• Most people with spina bifida occulta have no
symptoms or very mild symptoms and are not
aware they have it.
110
 2.Spina bifida cystica

•The visible signs are a sac or cyst,

rather like a large blister on the
back, covered by a thin layer of
skin.
•There are two types
111
 A. Myelomeningocele

• Also written as meningomyelocele

• Is the most common form of spina bifida cystica (90-95%)
• it can present any where on the mid line but commonly in
the lumbosacral area.
• There is protrusion of the meanings with dysplasia of the
spinal cord.
• Clinically this is always accompanied by neurological sign.
• A cyst or sac can usually be seen on the back, covered by
skin.
• The cyst contains tissues and also nerves.
112
Cont…
• The spinal cord is damaged or doesn’t develop
properly
• Babies with this form of spina bifida usually have
some nerve damage or paralysis in some areas,
depending on where the cyst is found
• They may never be able to walk or control their
bladder
• Most babies with this form of spina bifida will also
have hydrocephalus 113
Presenting feature:-

•A Sac is midline, any where on the

back
•Size of sac is variable
•It is covered by thin skin
•May be associated with gross
kyphosis and scoliosis.
•Neurological deficit 114
 B. Meningocele

• Involves the meninges

• Is less serious than meningomyelocele
• it is relatively uncommon lesion 4-5%.
• A cyst contains membranes which can rupture easily
• There is protrusion of the meninges only, which forms
a sac filled with C.S.F.
• There are no dysplasia of the spinal cord.
• The sac is covered with full thickness skin .
• on clinical examination there is no neurological
deficit. 115
Causes
•Unknown
•Neural tube defects due to genetic
predisposition
•Nutritional and environmental factors
Eg. Folic acid supplementation decrease
neural tube defect
116
 Clinical manifestations
•Babies who are born with spina bifida
occulta often have no outward sign and
symptoms
•The spinal cord does not protrude
through the skin, although a patch of
hair or a dimple may be present on the
skin over the lower spine 117
 Cont…

• Babies who are born with meningocele form have

a fluid filled sac visible on the back.
 The sac is often covered by a thin layer of the skin
and can be small or large
• Babies with myelomeningocele also have a sac
like mass that bulges from the back, but a layer of
skin may not always cover it
In some cases, the nerves of the spinal cord may be
exposed
• 118
119
120
 Diagnosis

•The presence of intraspinal

lesion is confirmed by myelogram
•Ultra sound
•MRI
•CT Scan
•X-ray 121
 Treatment

• Children with spina bifida occulta seldom need

treatment
• Surgery during infancy for meningocele - which
are pushing meninges back and closing the hole
in the vertebrae
• Babies with myelomeningocele need more
immediate attention and often have surgery with
in 1 to 2 days after birth
• Treatment of hydrocephalus if available 122
Congenital abnormalities of cardiovascular system

Overview Fetal Circulation

1. ____________
2. ____________
3. ____________
4. ____________ LA
RA

LV
RV
Why does blood
flow In this route?
12/07/2020 by tilaye F. 123
 Introduction

•Globally CHD affects over one

million live births annually and
is the leading cause of death.

Federal Democratic Republic of Ethiopia 124

 Classification of Congenital Cardiac
CHD Defects(Heart lesion)
Shunting
Stenotic Right→Left Left→Right Mixing
Tetralogy Patent ductus Truncus
Aortic stenosis arteriosus
Pulmonic Transposition Ventricular septal TAPVR
stenosis defect
Coarctation of Tricuspid Atrial septal HLH
the aorta atresia defect
125
HLH, hypoplastic left heart syndrome; TAPVR, total anomalous pulmonary venous return.
Congenital abnormalities of cardiovascular
system
Acyanotic congenital heart disease (with left
to right shunt)
•This is a condition in which there is no
central cyanosis (cyanosis is absent)
•Commonly:
I. Patent Ductus arteriosus
II. Ventricular septal defect
III. Atrial septal defect 126
127
After birth

After delivery
Blood oxygen levels
rise
Ductus arteriosus
constricts
Blood flows through
the lungs to pick up
oxygen 128
 Patent Ductus Arteriosus (PDA)

•This defect allows blood to mix between

the pulmonary artery and the aorta. 
•Before birth an open passageway (the
ductus arteriosus) exists between these
two blood vessels. 
•Normally this closes within a few hours of
birth 129
 Remark (fetal circulation )

R.A R.V  Pulmonary ArteryDuctus

Arteriosus  Aorta  systemic circulation
Immediately after birth, due to expansion of
lungs and establishment of pulmonary circulation
very little blood goes through the Ductus
Arteriosus.
130
•A higher pressure in the
aorta shunts blood from
that vessel into the
pulmonary artery which
continues throughout the
cardiac cycle.
131
 C/M –
•Repeated chest infections

•Dyspnea on exertion
•Tiredness
•CHF in large shunts 132
 Dx
•Chest X-ray findings shows
Dilatation of pulmonary artery
Left a trial and ventricular
enlargement
Enlarged and pulsatile aorta
133
134
Managment;

•Surgical ligation and

exclusion of the duct as
early as possible, usually
results in a complete cure.
135
 Ventricular septal Defect (VSD)

•The ventricle is divided into two chambers by a

septum, which grows upwards along the
anterior and posterior margin in the 2 month
nd

of intrauterine life
•A bout 90% of cases of VSD is due to the failure
of closure of the inter ventricular foramen
•Because of the higher pressure in the left
ventricle, the blood is shunted from left to right
ventricle 136
137
Clinical features

•Mild exercise intolerance

•Repeated respiratory infection
•Congestive heart failure
•Pan systolic murmur with maximum intensity
in the left 3 and 4 interspaces.
rd th

•A thrill accompanies the murmur in 90% of

cases
•Audible 3rd heart sounds 138
Diagnosis
•Dx- X-ray – Shows enlargement of left
ventricle with prominent pulmonary
artery
•Enlargement of left atrium
•ECG- Shows incomplete right bundle
branch pattern in large defects
•Left ventricular hypertrophy
•Biventricular hypertrophy in sever cases
139
 Management -
•Small defects may close
spontaneously
•Repair of other defects under direct
vision (suture for bigger defects)
•Pulmonary banding as a palliative
measure
•Pre and postoperative nursing care
140
 Atrial septal Defect (ASD)

•At the end of the 1 month of fetal

st

life, the posterior superior portion of

the common atrium a septum divide
into left and right (Septum primum). A
defect in the lower portion of septum
primum is ostium primum
141
142
Clinical features

•There may be no symptom during

child hood; however, the following
are present.
•Dyspnea on exertion
•Palpitation and weakness
•Feeding difficulties and Growth
retardation
•Recurrent respiratory infection 143
•Dx. – X-ray:
•Shows cardiomegally
(enlarged right ventricle and
right atrium)
•Enlarged pulmonary artery
144
Cyanotic congenital heart Diseases with
Reversed

• Cyanotic congenital heart diseases are

congenital anomalies in which there is a central
cyanosis, largely due to shunts of blood from the
right to the left side of heart

145
Transposition of Great vessels

•Transposition of great vessels

is a congenital anomaly in
which the pulmonary artery
arise from left ventricle, while
the aorta arise from right
ventricle. 146
C/M
•Cyanosis is deep at birth
•CHF usually after three weeks of age
•Progressive Rt. Ventricular enlargement
•Development of Rt. Ventricular failure

147
•Dx- Rt. ventricular hypertrophy
on Electrocardiogram
•X-ray shows narrow base and
cardiomegally
148
149
Tetralogy of Fallot

150
 - To suspect and diagnose the presence of Critical
congenital heart disease (CCHD).
• Apply Nada’s criteria to evaluate a newborn for CHD
• Do physical examination
• If Nada’s criteria is Positive investigate the baby with :-
- Hyperoxic test
- Radiography (CXR)
- Electrocardiography (EKG)
- Echocardiography
• Refer those who needs especial care and follow up
Federal Democratic Republic of Ethiopia 151
Nada’s Major Criteria

 Systolic murmur with thrill

 Any diastolic murmur
 Cyanosis (central)
 Congestive cardiac failure
Federal Democratic Republic of Ethiopia 152
 Nada’s Minor Criteria

•Systolic murmur without thrill

•Abnormal P2 (accentuated P2)
•Abnormal BP (hypo / hypertension)
•Abnormal CXR
•Abnormal ECG
Federal Democratic Republic of Ethiopia 153
•According to Nada’s criteria the
presence of 1 Major or 2 Minor
Criteria indicates Presence of
CHD.
Summary of Key Points
•Evaluate all sick newborns for possible CHD
•Nada’s criteria with the presence of 1 Major
or 2 Minor Criteria indicates Presence of
CHD.
•Investigation modalities include:-
- Radiography (CXR)
- Electrocardiography (EKG)
- Echocardiography
Federal Democratic Republic of Ethiopia 155
 U …
N K YO
T HA