PREMATURITY

PREMATURITY

The premature infant is a live- born infant born before the end of
week 37 of gestation.

Accounts for the largest amount of admissions in the NICU.

• Late preterm – born between 34 and 37 weeks

• Early preterm – born between 24 and 34 weeks

 ETIOLOGY

1. Low socio-economic status

2. Poor nutritional status
3. Lack of prenatal care
4. Multiple pregnancy
5. Previous early birth
6. Race – higher incidence in non-white
7. Cigarette smoking
8. Age – younger than 20 years old
9. Order of birth – higher in first pregnancy & beyond 4th
pregnancy
• 10. closely spaced pregnancies
• 11. Abnormalities of the mother’s reproductive system such as
intrauterine septum
• 12. Infections – UTI
• 13. pregnancy complications – PROM, Placenta previa,
abruptio placenta, PIH
• 14. Maternal hypertension
• 15. early induction of labor
• 16. Elective cesarean birth
 NURSING ASSESSMENT

Characteristic of preterm infants:

Preterm Full term

Posture Lies in a “relaxed attitude”, limbs more Fullterm infants has more
extended, body size is small, head larger in subcutaneous fat tissue and
proportion to body size. rests in a more flexed
attitude.
Ear Ear cartilages are poorly developed, and the The mature infants ear
ear may fold easily, hair is fine and leathery, cartilages are well formed,
and lanugo covers the back and face. and the hair is more likely
Large in relation to head to form firm, separate
strands.
 Preterm
Sole Appears more turgid and
may only have one wrinkle
Female genitalia Clitoris is prominent, labia
majora are fully develop
and gaping.
Male genitalia Scrotum is underdevelop
and not pendulous, minimal
rugae are present, testes
may be in the inguinal
canal or in the abdominal
cavity.
Scarf sign Infant's elbow may be
easily brought across the
chest with little or no
resistance.
Full term
Foot’s sole is well and
deeply creased.
Labia majora is fully
develop, clitoris is not as
prominent
Scrotum is well develop,
pendulous and rugated,
testes are well down in the
scrotum.
Infants elbow may be
brought to the midline of
the chest, resisting attempts
to bring the elbow past the
midline
 Preterm Full term
Grasp reflex Grasp is weak Grasp is strong allowing
the infant to be lifted up
from the mattress
Heel- to – ear maneuver Heel is easily brought up to This maneuver is not
the ear, meeting with no possible in the full term
resistance infant, since there is
considerable resistance at
the knee.
• Head appears disproportionately large
• Skin is ruddy – decreased subcutaneous fat, visible vein,
acrocyanosis
• vernix caseosa - More than 28 weeks - Covered
• - Less than 28 weeks – lacking
• Small fontanelles
• Few or no creases
• small eyes
• Present pupillary reaction
PREMATURE INFANTS AND ASSOCIATED
PROBLEMS
1. Large body surface area; loses heat easily, especially via head
2. CNS function is mainly reflexive
3. Lungs lack surfactant and tend to collapse easily
4. All muscles- less well develop; limp posture
5. Prone to hyperbilirubinemia and hypoglycemia
6. Kidneys- unable to concentrate urine well
7. Unable to conserve heat as well as term infants since lacks brown fat
8. Testes may not be descended to scrotal area
9. Susceptible to infection. More immature inflammatory response. Signs
of infection usually subtle and generalized
10. Has greater total body water- to weigh ratio- most is extracellular,
metabolic rate in relation to weight twice that of an adult.
• 11. weak suck /swallow reflex until 33-34 weeks gestation and
poor gag/cough reflex
• 12. immature production of clotting factors
• 13. lack of immunoglobulins from the mother
• 14. prolonged drug metabolism
• 15 . prolonged drug excretion
 POTENTIAL COMPLICATIONS

• 1. Respiratory distress syndrome (RDS) is the most common

problem seen in premature infants.
• Babies born too soon have immature lungs that have not
developed surfactant, a protective film that helps air sacs in
the lungs to stay open.
• With RDS, breathing is rapid and the center of the chest and
rib cage pull inward with each breath.
• Extra oxygen can be supplied to the infant through tubes that
fit into the nostrils of the nose, or by placing the baby under an
oxygen hood
• In more serious cases, the baby may have to have a breathing
tube inserted and receive air from a respirator or ventilator.
• A surfactant drug can be given in some cases to coat the lung
tissue.
• Extra oxygen may be need for a few days or weeks, depending
on how small and premature the baby was at birth.
• Bronchopulmonary dysplasia is the development of scar tissue
in the lungs, and can occur in severe cases of RDS.
• 2. Necrotizing enterocolitis (NEC) is a further complication of
prematurity.
• In this condition, part of the baby's intestines are destroyed as
a result of bacterial infection.
• In cases where only the innermost lining of the bowel dies, the
infant's body can regenerate it over time; however, if the full
thickness of a portion dies, it must be removed surgically and
an opening (ostomy) must be made for the passage of wastes
until the infant is healthy enough for the remaining ends to be
sewn together.
• Because NEC is potentially fatal, doctors are quick to respond
to its symptoms, which include lethargy, vomiting, a swollen
and/or red abdomen, fever, and blood in the stool.
• Measures include taking the infant off mouth feedings and
feeding him or her intravenously; administering antibiotics;
and removing air and fluids from the digestive tract via a nasal
tube.
• Approximately 70% of NEC cases can be successfully treated
without surgery.
• 3. Periventricular / Intraventricular hemorrhage - is another
serious complication of prematurity.
• It is a condition in which immature and fragile blood vessels
within the brain burst and bleed into the hollow chambers
(ventricles) normally reserved for cerebrospinal fluid and into
the tissue surrounding them.
 CLASSIFICATIONS OF IVH

• Grade 1 – periventricular matrix region or germinal matrix,

occuring in one ventricle.
• Grade 2 – with-in the lateral ventricle without dilation of the
ventricle.
• Grade 3 – causes enlargement of the ventricles.
• Grade 4 – in the ventricles & intraparenchymal hemorrhage.
• Physicians grade the severity of IVH according to a scale of I-
IV, with I being bleeding confined to a small area around the
burst vessels and IV being an extensive collection of blood not
only in the ventricles, but in the brain tissue itself.
• Grades I and II are not uncommon, and the baby's body
usually reabsorbs the blood with no ill effects. However, more
severe IVH can result in hydrocephalus.
• 4. Apnea of prematurity is a condition in which the infant
stops breathing for periods lasting up to 20 seconds.
• It is often associated with a slowing of the heart rate.
• The baby may become pale, or the skin color may change to a
blue or purplish hue.
• Apnea occurs most commonly when the infant is asleep.
Infants with serious apnea may need medications to stimulate
breathing or oxygen through a tube inserted in the nose.
• Some infants may be placed on a ventilator or respirator with a
breathing tube inserted into the airway.
• As the baby gets older, and the lungs and brain tissues mature,
the breathing usually becomes more regular.
• A group of researchers in Cleveland reported in 2003,
however, that children who were born prematurely are 3-5
times more likely to develop sleep-disordered breathing by age
10 than children who were full-term babies.
• 5. Persistent Patent ductus arteriosus
• - is a condition in which the duct that channels blood between
two main arteries does not close after the baby is born.
• In some cases, a drug, indomethacin or ibuprofen, can be
given to close the duct ( term infant).
• Surgery may be required if the duct does not close on its own
as the baby develops.
• 6. Retinopathy of prematurity is a condition in which the
blood vessels in the baby's eyes do not develop normally, and
can, in some cases, result in blindness.
• 7 . Premature infants are also more susceptible to infections.
They are born with fewer antibodies, which are necessary to
fight off infections.
• 8. Anemia of prematurity – due to immaturity of
hematopoietic system and destruction of RBC due to
decreased vitamin E.
• - excessive blood drawing for CBC, electrolytes
• 9. Acute Bilirubin Encephalopathy (ABE)
• - destruction of brain cells by invasion of indirect or
unconjugated bilirubin.
• - phototherapy/ exchange transfusion
• Obtain accurate body measurements.
• Head circumference frontal-occipital circumference one finger above
eyebrows, using parallel lines of tape around head.
• Abdominal girth one finger above umbilicus, mark location.
• Heel to crown.
• Shoulder to umbilicus used to calculate proper length of catheter for
umbilical arterial catheter placement.
• Weight in grams.
• Assess gestational age (see Figure 38-5) using a tool such as
the Ballard scoring system (recommended by Committee of
Fetus and Newborn of American Academy of Pediatrics):
• Observation of physical and neurologic characteristics that change
predictably with growth and maturation. Ideally done in the first 12 to
24 hours of life.
• Later, adjusted, or corrected age will be determined once the neonate
reaches term (40 weeks after conception). Chronological age is adjusted
for prematurity by taking gestational age 40 plus chronologic age =
developmental or corrected age. This is the age the neonate would have
been if he had been born at 40 weeks' gestation.
• Assist with laboratory testing as indicated for blood gases,
blood glucose, complete blood count or hemoglobin and
hematocrit, electrolytes, calcium, bilirubin.
• Monitor closely for respiratory or cardiac complications.
• Respirations above 60 per minute may indicate respiratory difficulty.
• Expiratory grunting, retractions, chest lag, or nasal flaring should be
reported immediately (see Figure 38-6, page 1252).
• Watch for cyanosis (other than acrocyanosis coldness and cyanosis of
hands and feet) and other signs of respiratory distress.
• Increased (more than 180 bpm) or irregular heart rate may indicate
cardiac or circulatory difficulties.
• Muscle tone and activity should be evaluated.
• Hypotension, indicated by blood pressure measurement, may be caused
by hypovolemia.
• Hypoglycemia may result from inadequate glycogen stores, respiratory
distress, and cold stress.
• Institute cardiac monitoring and care for infant in isolette or
radiant heater. Omit bath until infant's temperature has
stabilized.
• Observe for early signs of jaundice and check maternal history
for any blood incompatibilities. Also be aware of maternal
factors that can lead to additional complications, such as drug
use, diabetes, and infection.
• Once the infant is admitted to the nursery, be aware that the
first 24 to 48 hours after birth is a critical time, usually
requiring constant observation and intensive care
management. Make the following observations:
• Note bleeding from the umbilical cord apply pressure, and notify health
care provider.
• Note first voiding may occur up to 36 hours after birth; after first
voiding, report any 4- to 6-hour period when voiding does not occur.
• Note stools abdominal distention and lack of stool may indicate
intestinal obstruction or other intestinal tract anomalies. Measure
abdominal girth at regular intervals.
• Note activity and behavior look for sucking movement, and hand-to-
mouth maneuver, which can help to determine oral feeding initiation.
• Observe for a tense and bulging fontanelle; feel suture lines, noting
separation or overriding may indicate intracranial hemorrhage. Be alert
to twitching and seizures.
• Note color skin for cyanosis and jaundice, rashes, paleness, ruddiness.
• Carefully monitor, record, and report vital signs.
• Monitor for apnea versus periodic breathing
(regular repetition of breathing pauses of less than
15 seconds, alternating with breaths of regularly
increasing then decreasing amplitude for 10 to 15
seconds). Theophylline may be given to reduce
apneic episodes.
• Protect the infant from infection by following scrupulous
hand-washing policy, minimizing neonate's contact with
unsterile equipment, and minimizing the number of people
who come in contact with the neonate.
• Provide good skin care using water for bathing, an approved
emollient for the skin, avoiding adhesives, and providing
adequate hydration.
• Avoid cranial deformity by using gel head pillow, frequent
turning, and upright position.
• Protect the neonate's eyes from bright lights.
• Continue to provide I.V. and oral feedings, gavage feeding,
TPN according to neonate's needs. Assist the mother with
breast pumping as needed, and encourage both parents to hold
and feed infant.
• Continue to monitor for complications.
• Do not neglect the needs of the parents. Instead, make every
effort to include them in the infant's care and update them
frequently on the infant's condition.
• Have available resuscitative equipment, oxygen, and suction apparatus.
• A rubber ear bulb syringe is usually all that is necessary for clearing the mouth.

• Frequent suctioning of the pharynx may not be necessary.

• Position neonate to allow for easy ventilation, paying careful attention to maintaining
body alignment and facilitating hand-to-mouth positioning.
• Elevate head and trunk to decrease pressure on diaphragm from abdominal organs.
• Change position from side to side.
• Provide oxygen therapy with moisture in the percentage necessary to maintain
appropriate blood gas values.
• Monitor oxygen with analyzer continuously to ensure consistency in percentage
used.
• Pulse oximeter correlates well with oxygen (O2) saturation of arterial hemoglobin) of
the blood.
 NURSING ALERT

• Prone positioning has been shown to increase the risk of

sudden infant death syndrome. The American Academy of
Pediatrics recommends that all healthy infants be positioned
supine for sleep. Prone positioning offers some advantage for
oxygenation in preterm neonate with respiratory compromise.
During the initial phase of illness, these infants are cared for
with cardiorespiratory monitoring and may be placed prone
according to your facility's policy. Before discharge, these
neonate should become accustomed to sleeping supine and
supine positioning should be reinforced with the neonate's care
providers.
 NURSING DIAGNOSIS

1. Impaired gas exchange r/t lack of surfactant

2. Fluid volume deficit r/t insensible water loss and inadequate fluid intake
3. Alteration in nutrition; less than body requirement r/t actual intake less
than caloric requirement
4. Impairment in skin integrity r/t tapes and other abrasive materials used
with monitoring devices
5. High risk for injury: cold stress r/t immature temperature-regulating
mechanism
6. High risk for infection r/t immature immune system
7. Anticipatory grieving of parents r/t loss of perfect infant
8. Altered comfort r/t invasive. Painful procedures
9. Parental knowledge deficit r/t care of the preterm infant
 THERAPEUTIC MANAGEMENT

• When delivery of preterm infant is anticipated, The NICU is

alerted and a team approach implemented.
• Ideally, a neonatologist or a neonatal nurse practitioner, a staff
nurse, and a respiratory therapist are present for the delivery.
• Infants who do not require resuscitation are immediately
transferred in a heated incubator to the NICU. Where they are
weigh, where IV access, oxygen therapy and other
interventions are initiated. Resuscitation is conducted in the
DR until the infant is safe to be transported to the NICU.