High-Risk Newborn Overview ●​ Infections like chorioamnionitis

A high-risk newborn is one who has a

higher chance of developing severe illness
or complications after birth. Fetal Factors Associated with
Prematurity
Importance of Waiting Until 39
Weeks 1.​ Chromosomal abnormalities
2.​ Anatomic abnormalities:
●​ Delivering at 39 weeks (full term) ○​ Tracheoesophageal atresia
ensures your baby's lungs, liver, and or fistula
brain have fully developed, giving ○​ Intestinal obstruction
them the best start in life. 3.​ Placental dysfunction: Issues with
●​ Early delivery before 39 weeks may the fetoplacental unit.
be necessary if there is a health risk
to the mother or baby, but in a
healthy pregnancy, waiting is best.

Overview of High-Risk Neonates

and Preterm Infants
Factors Contributing to High-Risk
Newborns Systems Most Likely to Cause Problems
in Premature Infants
Maternal Factors
1.​ Respiratory system
●​ Poverty 2.​ Digestive system
●​ Infections during pregnancy 3.​ Thermoregulation
●​ Previous preterm delivery 4.​ Immune system
●​ Multiple pregnancies (twins, 5.​ Neurologic system
triplets, etc.)
●​ Pregnancy complications: Definition of a High-Risk Neonate
○​ Hypertension (PIH)
○​ Bleeding during pregnancy A high-risk neonate is any newborn with a
○​ Placental issues (e.g., higher-than-average chance of health
placenta previa, abruptio complications or mortality due to conditions
placenta) related to birth or adapting to life outside the
womb.
Other Complications

●​ Incompetent cervix
●​ Premature rupture of membranes
(PROM)
●​ Abnormal amniotic fluid levels:
○​ Too much: polyhydramnios
○​ Too little: oligohydramnios
Nursing Care Categories for ●​ Immature Lungs: Underdeveloped
High-Risk Newborns lungs cause breathing issues.
●​ Low Surfactant:
●​ Small-for-gestational-age infant ○​ Surfactant helps keep air
●​ Term infant sacs (alveoli) open.
●​ Large-for-gestational-age infant ○​ Premature babies produce
●​ Preterm infant less or poor-quality
●​ Post-term infant surfactant.
○​ Without enough surfactant,
alveoli collapse, causing
difficulty breathing (diffuse
Problems Related to Maturity alveolar atelectasis).
●​ Treatment:
Prematurity (Preterm Infant) ○​ Machines like positive
pressure ventilation (PPV)
●​ Definition: Born before the end of help with breathing but may
37 weeks of gestation. damage the lungs over time.
●​ Categories by Gestational Age: ●​ Complications:
○​ Late preterm: 34 to 37 ○​ Respiratory Distress
weeks. Syndrome (RDS): Caused
○​ Early preterm: 24 to 34 by surfactant deficiency.
weeks. ○​ Bronchopulmonary
Dysplasia (BPD): Chronic
lung condition due to
prolonged breathing support.
Gestational Age Classifications

●​ Early term: 37 weeks to 38 weeks

and 6 days.
●​ Full term: 39 weeks to 40 weeks
and 6 days.
●​ Late term: 41 weeks to 41 weeks
and 6 days.
●​ Post term: 42 weeks and beyond.

Summary of Complications in
Premature Babies

1. Respiratory Complications
2. Eye Problems: Retinopathy of ●​ Immature Digestive System:
Prematurity (ROP) Vulnerable intestines are prone to
damage and infection.
●​ Immature Retinal Blood Vessels: ●​ Triggers:
Premature babies' eye blood vessels ○​ Infections
are underdeveloped and sensitive to ○​ Formula feeding
oxygen. ○​ Reduced intestinal blood flow
●​ Effect of Oxygen Therapy: (ischemia)
○​ High oxygen levels ●​ What Happens:
(hyperoxia) cause retinal ○​ Inflammation damages the
blood vessels to constrict intestinal wall.
(ischemia). ○​ Severe cases can lead to
●​ Body’s Response: bowel tissue death (necrosis)
○​ The retina releases VEGF to and life-threatening
grow new blood vessels, complications.
which can result in abnormal,
fragile vessels.
●​ Risks:
○​ Fragile vessels may bleed,
damage the retina, and lead Lung Surfactant: Simplified
to vision problems or Overview
blindness.
What is Lung Surfactant?

●​ A substance that lowers surface

3. Brain Complications: tension in the lungs, helping with gas
exchange and maintaining alveoli
Intraventricular Hemorrhage (IVH)
structure.
●​ Immature Brain Blood Vessels: ●​ Made of lipids and proteins,
Fragile vessels in the brain may produced by alveolar type-II cells in
burst. the lungs.
●​ Causes: Abrupt blood flow changes. ●​ Lines the epithelium of the alveoli.
●​ Impact:
○​ Bleeding into brain tissue
around the ventricles.
○​ May affect brain development
and cause long-term
neurological issues.

4. Digestive Problems: Necrotizing

Enterocolitis (NEC)
Functions of Surfactant Administration Details:

1.​ Aids Lung Expansion at Birth ●​ Delivered through a thin catheter

○​ Deficiency can lead to (ETT or SALSA) into the trachea.
Respiratory Distress ●​ Administered by a medical
Syndrome. practitioner or neonatal nurse
2.​ Prevents Lung Collapse practitioner (NNP) in the NICU, with
○​ Keeps alveoli open during a registered nurse assisting (per
breathing. hospital policy and after training).
3.​ Stabilizes Alveoli Size ●​ Total dose is usually given in less
○​ Prevents over-expansion or than 1 minute.
collapse of alveoli. ●​ Additional doses (2nd or 3rd) may
4.​ Keeps Lungs Expanded be needed if respiratory distress
○​ Without surfactant, extreme continues.
pressure (-20 to 130 mm Hg)
would be needed to maintain Possible Complications:
lung expansion.
●​ Endotracheal tube blockage.
5.​ Prevents Pulmonary Edema
●​ Pulmonary hemorrhage.
○​ Keeps alveoli dry by reducing
●​ Transient bradycardia.
fluid accumulation.
●​ Oxygen desaturation.

Post-Administration Care:

Pneumothorax: Collapsed Lung ●​ Monitor chest movement, oxygen

saturation, and heart rate for at
What Happens? least 30 minutes.
●​ Avoid suctioning the infant’s airway
●​ Air escapes from the lung into the
for at least 1 hour.
space between the lung and chest
wall.
●​ This air buildup exerts pressure on
the lung, preventing it from
expanding properly during breathing.

Surfactant Administration for

Premature Infants with RDS

Purpose:​
Surfactant helps premature infants with
respiratory distress syndrome (RDS)
breathe by improving lung function.
 ○​ Anti-VEGF injections
(Anti-Vascular Endothelial
Bronchopulmonary Dysplasia (BPD) Growth Factor).

●​ Definition: Chronic lung disease in

newborns, primarily premature
infants requiring oxygen therapy. Intraventricular Hemorrhage (IVH)
●​ Cause: Damage to lungs and
airways (bronchi), leading to tissue ●​ Definition: Bleeding into the
destruction in alveoli (tiny air sacs). fluid-filled brain ventricles, common
●​ Treatment (Tx): in premature infants due to fragile,
○​ Oxygen therapy (O₂ therapy) underdeveloped brain blood vessels.
○​ Medications: steroids, ●​ Key Facts:
antibiotics, diuretics, ○​ Risk increases with smaller,
surfactant more premature infants.
○​ Intravenous fluids (IVF) ○​ Rarely present at birth;
○​ Nasogastric tube feeding occurs within the first few
(NGT) days of life.
●​ Recovery: Prolonged; may result in ●​ Normal vs. Affected:
lung scarring or permanent damage. ○​ Normal: Clear ventricles.
○​ Affected: Blood fills the
ventricles.

Retinopathy of Prematurity (ROP)

●​ Definition: Abnormal blood vessel

growth in the retina (light-sensitive
layer in the eye). Common Symptoms in Premature
●​ Stages: Infants
○​ Stage 1 & 2: Mild/moderate;
typically resolves without ●​ Breathing pauses (apnea)
treatment. ●​ Decreased muscle tone
○​ Stage 3: May require ●​ Decreased reflexes
treatment to prevent retinal ●​ Excessive sleep
damage or detachment. ●​ Lethargy
○​ Stage 4: Severe; causes ●​ Weak suck
partial retinal detachment,
severe vision loss, or
blindness (urgent treatment
needed). Diagnostics
●​ Treatment (Tx):
○​ Stop abnormal blood vessel ●​ Routine head ultrasound
growth. ●​ CT scan
○​ Laser therapy.
Prognosis ●​ Constipation
●​ Diarrhea/dark bloody stools
●​ Depends on: ●​ Lethargy or reduced activity
○​ Severity of bleeding ●​ Unstable temperature
○​ Hydrocephalus (may require
shunts if indicated) Interventions:

1.​ Stop feedings (NPO).

2.​ Insert a nasogastric tube for bowel
Treatment Overview decompression.
3.​ Administer IV broad-spectrum
1.​ Standard Resuscitation antibiotics.
○​ Support airway, breathing, 4.​ Provide total parenteral nutrition
and circulation. (TPN) if necessary.
2.​ Fluid Resuscitation
○​ Administer fluids for
hypotension.
3.​ Respiratory Failure Management Problems Related to Prematurity
○​ Consider endotracheal
intubation and mechanical Assessment: Signs of Prematurity
ventilation if needed.
1.​ Physical Appearance:
4.​ Resuscitation in Circulatory
○​ Very small size
Collapse
○​ Disproportionately large head
○​ Follow Pediatric Advanced
(head > chest size by >3 cm)
Life Support (PALS)
○​ Ruddy skin due to lack of
guidelines.
subcutaneous fat, with visible
veins
○​ Possible acrocyanosis
(bluish discoloration of
hands/feet)
Necrotizing Enterocolitis (NEC)

●​ Definition: Life-threatening
condition in neonates with up to a
50% mortality rate. Causes
inflammation, bacterial invasion, and
necrosis of the intestines and colon.

Signs/Symptoms (S/S):

●​ Swollen belly
●​ Red, blue, or gray discoloration of
the belly
●​ Trouble feeding
Anemia of Prematurity Acute Bilirubin Encephalopathy
(ABE) - Simplified Review
Definition: Normocytic normochromic
anemia (normal-sized, normal-colored red What is ABE?
blood cells, but fewer in number).
●​ Caused by high levels of indirect
(unconjugated) bilirubin in the
blood due to excessive breakdown
Causes: of red blood cells (RBCs) at birth.
●​ Kernicterus: A rare but serious
●​ Immature hematopoietic system:
neurological condition caused by
Effective red blood cell production
severe jaundice, where bilirubin
doesn’t start until ~32 weeks of
deposits in brain tissue lead to
gestation.
irreversible brain damage.
●​ RBC destruction: Low levels of
Vitamin E, which normally protects
RBCs from oxidation.
Types of Neonatal Jaundice

Signs: 1.​ Physiological Jaundice

○​ Appears 2–3 days after
●​ Pale appearance birth.
●​ Lethargy ○​ Usually resolves without
●​ Loss of appetite (anorexia) treatment.
2.​ Pathological Jaundice
○​ Appears in the first 24–48
hours or lasts more than 2
Management: weeks.
○​ Common causes:
1.​ Minimize blood loss: ■​ Bacterial infections
○​ Coordinate blood extractions (major cause).
to reduce frequency. ■​ Obstructive
○​ Maintain a record of blood jaundice.
loss. ■​ Hemolytic jaundice,
2.​ Delayed cord clamping: breast milk jaundice,
○​ Allows extra blood from the etc.
placenta to enter the infant.
3.​ Blood transfusions:
○​ Provide red blood cells,
Vitamin E, and iron
(supplements as needed).
Why is Bilirubin Dangerous? infants experience functional
closure of the ductus arteriosus
●​ Toxic to brain cells. within 9 to 12 hours after birth.
●​ High bilirubin levels can lead to
acute bilirubin encephalopathy.

Management of PDA

Signs of ABE ●​ Medications for closure:

○​ Indomethacin or ibuprofen
●​ Listlessness. are used for term infants to
●​ Difficulty waking up. help close the patent ductus
●​ High-pitched crying. arteriosus (PDA), which
●​ Poor sucking or feeding. makes breathing easier.
○​ Important for premature
infants: These medications
should be used carefully in
Management of ABE preterm infants because they
can cause:
1.​ Phototherapy: Light therapy to ■​ Decreased renal
break down bilirubin in the skin. function
2.​ Exchange Transfusion: Replacing ■​ Lower platelet count
the baby's blood to remove excess (leading to bleeding)
bilirubin. ■​ Gastric irritation
●​ Monitoring:
○​ Keep track of urine output.
○​ Watch for bleeding at the
injection site if medication is
given.
Persistent Patent Ductus
●​ Ibuprofen vs. Indomethacin:
Arteriosus (PDA) ○​ Ibuprofen works similarly to
indomethacin but has fewer
●​ What it is:​
side effects and is just as
In preterm infants, the lungs are less
effective in closing the
flexible due to a lack of surfactant,
ductus.
which makes it hard for blood to
move from the pulmonary artery into
the lungs. This can lead to
pulmonary artery hypertension
and prevent the closure of the
ductus arteriosus (a blood vessel
that normally closes after birth).
●​ Oxygen's role:​
Oxygenated blood helps close the
ductus arteriosus. Most full-term
Common Long-Term Problems for 2.​ Newborn maintains normal breathing
Premature Infants rate (30-60 breaths per minute)
without needing help.
●​ Hearing problems 3.​ Oxygen levels stay at or above 95%
●​ Vision loss or blindness (measured by pulse oximetry).
●​ Learning disabilities
●​ Physical disabilities
●​ Delayed growth and poor
coordination Respiratory Function in Preterm
●​ Behavioral and psychological Infants
issues
●​ Lack of surfactant: Lungs aren’t
ready to expand properly.
●​ Non-compliant lungs: Hard to
breathe in (lungs don’t expand
easily).
Common Long-Term Problems in ●​ Atelectasis: Lungs can collapse
Premature Babies (alveoli).
●​ Breathing requires more energy:
1.​ Respiratory Function It's harder to breathe.
2.​ Thermoregulation ●​ Weak reflexes: Poor cough/gag
3.​ Nutrition reflex.
●​ Narrow airways: Smaller passages
for air.
●​ Weak respiratory muscles: Harder
Nursing Diagnoses (Concerns to to breathe effectively.
address)

●​ Ineffective Airway Clearance

●​ Risk for Aspiration (food or liquid
entering the lungs)
●​ Ineffective Breathing Pattern
●​ Impaired Spontaneous Ventilation
(inability to breathe independently)
●​ Impaired Gas Exchange (inefficient
oxygen exchange)

Outcome Evaluation (Goals to

achieve)

1.​ Newborn starts breathing on their

own after resuscitation.
Signs of Respiratory Distress 2. Maintain Patent
(Hypoxemia) Airway/Breathing Pattern

●​ Breathing rate: > 60 or < 30 ●​ Positioning:

breaths/minute. ○​ Lay the infant on their side or
●​ Abnormal breath sounds: stomach (prone) to help drain
Crackles, rhonchi, wheezing. secretions and prevent
●​ Tachycardia: Fast heart rate (early aspiration.
sign). ○​ Change the infant’s position
●​ Stridor: Harsh, high-pitched sound. frequently.
●​ Bradycardia: Slow heart rate (late ●​ Supine position: If the infant must
sign). lie on their back:
●​ See-saw respirations: Chest and ○​ Place a small roll under the
abdomen move opposite directions. shoulders to straighten the
●​ Apnea: Breathing stops for > 20 airway.
seconds. ○​ Elevate the head of the bed
●​ Cyanosis: Blue skin, especially and turn the infant’s head to
around mouth. the side.
●​ Retractions: Skin pulling around
ribs and neck while breathing.
●​ Nasal flaring: Nostrils widen when
breathing.
●​ Grunting: Short, sharp sounds
when exhaling. B. Thermoregulation (How the
body controls temperature)

Causes of Heat Loss in Newborns:

1.​ Thin skin – skin doesn't provide

Administer Oxygen much insulation.
2.​ Little fat under the skin – not
●​ When to give oxygen: If signs of enough fat to keep heat in.
respiratory distress are present, or 3.​ Blood vessels near the skin – heat
PaO2 ≤ 60 mmHg and SaO2 ≤ 92%. escapes easily.
●​ How to give oxygen: Use a hood, 4.​ Large skin surface area – more
nasal cannula, positive-pressure skin means more heat loss.
mask, or endotracheal tube. 5.​ Heat loss from internal organs –
●​ Note: Do not use free-flowing body heat escapes more easily.
oxygen in the incubator (it’s hard to 6.​ Poor temperature regulation in
control the amount). early life – newborns can't control
●​ Oxygen care: Make sure oxygen is their body temperature well in the
warmed and humidified to avoid cold first days.
stress and to moisten the airway.
Why this happens: ●​ Poor feeding or trouble tolerating
feeds.
●​ A newborn's temperature drops ●​ Lethargy (feeling weak or tired).
quickly because of heat loss and ●​ Irritability (easily upset).
undeveloped body temperature ●​ Low muscle tone.
regulation. ●​ Cool skin.
●​ Delivery room temperature: ●​ Mottled (patchy) skin.
Around 68°F (21-22°C).
●​ Newborns are wet from birth, which
causes heat loss when the
amniotic fluid on their skin Outcome Evaluation:
evaporates.
●​ Goal: Maintain the infant’s
temperature at 97.6°F (36.5°C)
measured by axillary temperature.
Heat Loss Methods:

1.​ Convection: Heat flows from the

body to cooler air around it. Nursing Interventions:
○​ Example: Heat lost when
baby is exposed to cool air. 1.​ Neutral Thermal Environment:
2.​ Conduction: Heat is transferred ○​ Use a radiant warmer or
from the body to a cooler object in isolette (incubator) with
direct contact. closed portholes.
○​ Example: Baby placed on a ○​ Monitor the infant’s
cold surface, like a counter or temperature continuously
warming unit. with a skin probe and axillary
3.​ Radiation: Heat is transferred from temperature.
the body to a nearby cooler object, 2.​ Prevent Evaporation (Heat Loss):
but without contact. ○​ Keep the infant dry.
○​ Example: Air conditioning ○​ Use plastic blankets over
cooling the baby indirectly. the warmer bed and hats
4.​ Evaporation: Heat is lost as liquid when outside the incubator.
changes to vapor. 3.​ Prevent Convection (Heat Loss
○​ Example: Sweat or moisture from Air Movement):
on skin evaporates. ○​ Close portholes to prevent
drafts.
Signs of Inadequate ○​ Use warmed oxygen.
Thermoregulation: 4.​ Prevent Conductive Heat Loss:
○​ Keep hands and equipment
●​ Hypoglycemia (low blood sugar) warm (e.g., stethoscope).
and respiratory distress may ○​ Pad surfaces with warmed
indicate low body temperature. blankets.
 ○​ Monitor for: coughing,
gagging, vomiting, cyanosis,
Causes of Poor Nutrition in changes in heart rate or
Infants: breathing, apnea

●​ Lack of nutrient stores

●​ Poor absorption of nutrients
●​ Difficulty coordinating sucking and Parenteral Feeding
swallowing
●​ Easily fatigued ●​ Definition: Feeding through a route
other than the digestive tract (e.g.,
injection)
●​ Types:
Nursing Diagnoses: ○​ TPN (Total Parenteral
Nutrition): Nutrients (sugar,
1.​ Imbalanced Nutrition Less Than vitamins, minerals) given via
Body Requirements IV.
2.​ Impaired Swallowing ●​ Care:
3.​ Ineffective Infant Feeding Pattern ○​ Monitor the IV site.
4.​ Ineffective Breastfeeding ○​ Use strict aseptic techniques
5.​ Risk for Aspiration when cleaning the IV site.
6.​ Risk for Unstable Blood Glucose ○​ Weigh the infant daily (same
7.​ Risk for Electrolyte Imbalance scale each time).
○​ Monitor TPN nutrition closely.

Signs the Infant is Ready for

Nursing Interventions: Nipple Feeding:
Maintain Nutrition: ●​ Strong sucking and swallowing.
●​ Gag reflex is present.
●​ Methods of Feeding:
●​ Rooting reflex.
○​ Parenteral (Intravenous) –
●​ Respiratory rate <60 breaths per
nutrients given directly into
minute.
the bloodstream
●​ Preparation: Offer a pacifier during
○​ Enteral (GI Tract) – feeding
gavage feeding to help associate
through the digestive system
sucking with comfort.
○​ Bottle Feeding – using a
bottle
○​ Breastfeeding
●​ Important Considerations:
○​ Know the infant’s needs and
physiological characteristics
○​ At least 32 weeks gestation
for oral feeding (sucking and
swallowing coordination)
2. Oral Feeding until about 40 weeks. After that, it
becomes less effective, and the
●​ Preferred Feed: Breast milk. fetus may lose weight. This condition
●​ Bottle Feeding: is called Postterm Syndrome.
○​ Use soft nipples.
○​ High-calorie formulas
(24kcal/oz).
○​ Feed slowly, burp frequently, Effects on the Fetus
and let the infant rest.
●​ Post-feeding Care: ●​ Small Gestational Age (SGA)
○​ Place the baby on the right Characteristics:
side for 1 hour with the head ○​ Dry, cracked skin (like
elevated 30° to help leather) due to lack of fluid
digestion. ○​ No vernix (the protective
coating on skin)
When Can a Premature Infant Be ○​ Long fingernails that extend
beyond the fingertips
Discharged?:
○​ More alert than a newborn,
1.​ Can breastfeed or bottle-feed. like a 2-week-old baby
2.​ Can breathe without support.
3.​ Can maintain body temperature and
weight.
Diagnostic Exams

1.​ Ultrasound: Measures the size of

the fetus (especially the biparietal
Post-Maturity Problems
diameter of the head).
●​ (Not further detailed in the text, but 2.​ Nonstress Test or Biophysical
can refer to complications that may Profile: Checks if the placenta is still
arise from babies born after 42 working well.
weeks.)

Management

●​ Cesarean Birth: If the placenta isn’t

Postmaturity / Post-Term Birth working well, a C-section may be
necessary.
●​ Definition: A post-term infant is one
born after 41 weeks of pregnancy. If
the fetus stays in the uterus past this
time, it is at special risk.
●​ Why is this risky?​
The placenta, which supplies
nutrients to the fetus, works best
Newborn Care and Conditions to
Expect:
Small for Gestational Age (SGA)
Common Newborn Issues: Infants:
1.​ Difficulty Breathing ●​ Definition:
○​ Newborns may have trouble ○​ An infant is considered SGA
starting to breathe right after if their birth weight is below
birth. the 10th percentile for their
2.​ Polycythemia gestational age.
○​ The baby might have more
red blood cells than normal Possible Gestational Status for SGA
because of low oxygen levels Babies:
in the last weeks of
pregnancy. 1.​ Preterm:
3.​ Increased Hematocrit ○​ Born before 38 weeks of
○​ Hematocrit (percentage of pregnancy.
red blood cells in blood) is 2.​ Term:
high due to polycythemia and ○​ Born between 38 and 42
dehydration. weeks.
4.​ Hypoglycemia (Low Blood Sugar) 3.​ Post-Term:
○​ Babies may have low blood ○​ Born after 42 weeks.
sugar during the first hour of
life because they used up
their stored glucose in the
womb.
5.​ Low Subcutaneous Fat
○​ Babies may have less fat
under the skin because they
used it in the womb, leading
to hypothermia (cold body
temperature).

Management (What to do):

1.​ Immediate Newborn Care:

○​ Provide quick care after birth.
2.​ Allow Mother-Newborn Bonding:
○​ Let the mother spend time
with her newborn to
encourage bonding.
3.​ Follow-Up Care:
○​ Regular check-ups until the
child reaches school age to
monitor development.
ISGA (Intrauterine Growth ○​ Small liver (may cause
Restriction) Infants: difficulty with glucose,
protein, and bilirubin
Characteristics: regulation).
○​ Sunken abdomen and dry
●​ Infants are smaller than expected for umbilical cord.
their age due to growth restrictions ●​ Developmental Signs:
or failure to grow in the womb. ○​ Better neurologic responses.
○​ Well-developed ear cartilage
Causes of IUGR: and sole creases.
○​ Active and alert.
1.​ Poor Maternal Nutrition: Lack of
nutrition for the mother affects fetal
growth.
○​ Common in teenage
pregnancies where the
mother eats only for her own
needs.
2.​ Chromosomal Abnormalities: The
baby’s body is not utilizing nutrients
properly.
3.​ Placental Problems:
○​ Placenta doesn’t get enough
nutrients from the uterine
arteries or doesn’t transport
nutrients efficiently.
4.​ Maternal Health Issues: Women
with systemic diseases can cause
IUGR in the baby.

Assessment of SGA (Small for

Gestational Age) Infants:

Physical Inspection after Birth:

●​ Appearance:
○​ Below-average weight,
length, and head size.
○​ Wasted body with poor skin
turgor (skin looks loose).
○​ Large head compared to the
body.
○​ Dull, lifeless hair.
Polycythemia (High RBC count) compared to others of the
same age).
●​ Causes: Occurs due to low fluid ○​ Fetal macrosomia is based
levels (dehydration) and lack of on absolute weight,
oxygen during pregnancy. regardless of gestational
●​ Effects: age.
○​ Increased RBC production ●​ Characteristics:
due to lack of oxygen ○​ Can appear healthy at birth,
(anoxia) during intrauterine but may have immature
life. development.
○​ Thicker blood → makes it ●​ Causes:
harder for the heart to pump, ○​ Obese mothers: Extra
causing acrocyanosis nutrients lead to larger
(bluish color of extremities). babies.
○​ If polycythemia is severe, it ○​ Diabetic mothers: High
can block blood vessels blood sugar causes
and form clots. increased growth.
●​ Management: ○​ Overproduction of growth
○​ Exchange transfusion hormones.
(dilutes blood to reduce
viscosity).
○​ Hyperbilirubinemia (yellowing
of the skin) can be a Macrosomia: Overview of Fetal
long-term problem. Complications
○​ Hypoglycemia (low blood
sugar) can occur due to low Macrosomia refers to a fetus larger than
glycogen stores. 4000-4500 grams.
○​ Management for low blood
sugar: IV glucose until the
baby can feed on its own.

Large for Gestational Age (LGA)

Infants

●​ Definition: Babies who weigh more

than the 90th percentile for their
gestational age.
●​ Difference from Fetal
Macrosomia:
○​ LGA is based on percentile
(how big the baby is
Key Fetal Complications (epinephrine/glucocorticoid
release), and activation of
1.​ Shoulder Dystocia fetal sodium channels.
○​ Cause: Discrepancy 5.​ Respiratory Issues
between fetal shoulders and ○​ Transient Tachypnea of the
maternal pelvic inlet. Newborn:
○​ Mechanism: Anterior ■​ Caused by delayed
shoulder becomes impacted resorption of fetal
behind the symphysis pubis lung fluid.
during delivery. ■​ Risk increased by
○​ Risk: Common in infants of stress response
diabetic mothers. during delivery.
○​ Injuries due to Shoulder 6.​ Polycythemia and Neonatal
Dystocia: Jaundice
■​ Brachial Plexus ○​ Cause: Fetal hypoxia leads
Injury to increased production of
■​ Clavicular Fracture erythropoietin.
■​ Humeral Fracture ○​ Outcome: Higher RBC
2.​ Preterm Birth production, leading to
○​ Risk: Infants with polycythemia and jaundice.
macrosomia may have an 7.​ Hypoglycemia
increased risk of preterm ○​ Cause: Fetal hyperinsulinism
birth. from maternal diabetes.
○​ Associated Complications: ○​ Mechanism: Excess glucose
■​ Surfactant supply in utero leads to
Deficiency → excessive insulin production.
Respiratory Distress After birth, the supply of
Syndrome (RDS) glucose is cut off, leading to
3.​ Hypoxia / Asphyxia hypoglycemia.
○​ Cause: Umbilical cord 8.​ Meconium Aspiration Syndrome
compression or reduced ○​ Risk: Increased risk in
oxygen supply to the fetus. macrosomic infants due to
○​ Consequences: Infant may fetal distress or hypoxia.
gasp, leading to perinatal
aspiration of stained amniotic
fluid.
4.​ Cesarean Deliveries
○​ Risk: Increased rate of
cesarean section in
macrosomia cases due to
difficult labor.
○​ Factors: Labor
duration/absence of labor,
maternal stress
Risk Factors & Associations ○​ Clavicular Fracture
○​ Humeral Fracture
●​ Maternal Diabetes: Most common
cause of macrosomia.
○​ Fetal Hyperinsulinism:
Occurs due to high maternal Other Complications:
glucose levels.
○​ Increased Glucose 1.​ Respiratory Issues:
Utilization: Fetal body ○​ Surfactant Deficiency:
compensates with excess ■​ Common in preterm
insulin, suppressing liver infants.
glucose production. ■​ Can lead to
●​ Complications Increase with Birth Respiratory Distress
Weight: Risk of stillbirth increases Syndrome (RDS).
above 5 kg. ○​ Hypoxia/Asphyxia:
●​ Other Causes of Macrosomia: ■​ Caused by umbilical
○​ Post-term pregnancy. cord compression or
○​ Genetic conditions. poor oxygen delivery.
■​ Leads to infant
gasping or breathing
difficulties.
Macrosomia: Fetal Complications ■​ Perinatal Aspiration
of Stained Amniotic
Definition: Fluid (Meconium
Aspiration
●​ Macrosomia: A fetus weighing Syndrome).
>4000–4500 grams. 2.​ Transient Tachypnea of the
Newborn (TTN):
○​ Cause: Delayed resorption
of fetal lung fluid.
Key Fetal Complications: ○​ Factors:
■​ Cesarean delivery.
1.​ Shoulder Dystocia
■​ Release of maternal
○​ Cause: Discrepancy
epinephrine and
between fetal shoulders and
glucocorticoids.
maternal pelvic inlet.
○​ Outcome: Anterior shoulder
becomes impacted behind
the symphysis pubis during
delivery.
○​ Associated Risk: Infants of
diabetic mothers (see
Gestational Diabetes slide).
2.​ Injuries Due to Shoulder Dystocia:
○​ Brachial Plexus Injury
Metabolic Complications: Tests to Check Fetal Health:

1.​ Polycythemia: ●​ Ultrasound: Checks fetal size and

○​ Increased erythropoietin due position.
to fetal hypoxia. ●​ Non-Stress Test (NST): Monitors
2.​ Neonatal Jaundice: baby’s heart rate for 20-30 minutes
○​ Common in macrosomic to see how it reacts to fetal
infants due to polycythemia. movement and contractions.
3.​ Hypoglycemia: ●​ Biophysical Profile (BPP):
○​ Cause: Fetal hyperinsulinism Assesses fetal health through
due to maternal diabetes or ultrasound and NST.
excessive nutrients. ●​ Amniocentesis (usually after 32
○​ Occurs when the maternal weeks): Checks for lung maturity by
glucose supply stops after measuring surfactants
delivery. (lecithin/sphingomyelin ratio - L/S
ratio).

Additional Information:
L/S Ratio:
●​ Macrosomia Risk Factors:
○​ Maternal diabetes (especially ●​ Purpose: Helps assess lung
poorly controlled). maturity.
○​ Hyperinsulinism: May be ○​ Low L/S Ratio (1.5 or less):
absent if macrosomia is Less mature lungs, higher
caused by other factors (e.g., risk of respiratory distress
post-term or genetic syndrome (RDS).
conditions). ○​ Normal L/S Ratio (1.5 -
●​ Stillbirth Risk: 1.80): Transitional lung
○​ The risk of stillbirth increases maturity.
when birth weight exceeds 5 ○​ High L/S Ratio (1.80 - 2.0):
kg. Mature lungs, lower risk of
RDS.
●​ Why is it important?
○​ Determines the best time for
delivery to reduce RDS risk.
○​ Surfactants like lecithin and
sphingomyelin reduce lung
surface tension, making
Assessment (MOTHER) breathing easier after birth.

Signs of Large Fetus (LGA):

●​ Woman's uterus is larger than

expected for pregnancy date.
Management: ●​ Birth Injuries: Look for broken
bones, nerve damage, or other
●​ Post-Birth Assessment (Physical injuries.
Examination): ●​ Assess for Genetic/Structural
○​ Appearance: Check for Abnormalities.
signs of immaturity or
injuries.
○​ Common Issues:
■​ Bruising/Fractures: Treatment of Complications:
Possible clavicle
fractures or nerve ●​ Polycythemia:
injuries (e.g., Erb ○​ Treat with IV fluids. In
Duchenne paralysis). severe cases, a partial
■​ Caput exchange transfusion
Succedaneum: (removing some blood and
Swelling of the baby’s replacing it with plasma)
head from pressure might be done.
during delivery. ●​ Hypoglycemia:
■​ Cephalohematoma: ○​ Treat with frequent feedings
Blood buildup in the or glucose through IV.
head.
■​ Meconium Staining:
Presence of
meconium in the Respiratory Distress & Meconium
amniotic fluid. Aspiration
●​ Cardiovascular Issues:
○​ Polycythemia: Increased ●​ Treatment:
red blood cells due to lack of ○​ Supplemental oxygen or
oxygen. supportive devices like:
○​ Hyperbilirubinemia: ■​ Continuous Positive
Jaundice from bruising and Airway Pressure
breakdown of extra RBCs. (CPAP): Helps babies
○​ Hypoglycemia: Low blood breathe on their own
sugar in large babies, with slightly
especially those born to pressurized air.
diabetic mothers. ■​ Mechanical
ventilator: Used for
severe cases.

Post-Birth Monitoring:

●​ Blood Sugar: Check for

hypoglycemia.
Nursing Diagnosis: Risk for
Imbalanced Nutrition
Assessment & Body
●​ Related to: Measurements
○​ Extra nutrients needed to
maintain weight and avoid ●​ Obtain Accurate Measurements:
hypoglycemia (low blood ○​ Head Circumference (HC)
sugar). ○​ Abdominal Circumference
●​ Outcome Evaluation: (AC)
○​ Baby’s weight follows the ○​ Chest Circumference (CC)
growth curve. ○​ Length
○​ Skin is well-hydrated (good ○​ Weight
skin turgor).
○​ Serum glucose levels are
above 45 mg/dL.
●​ Importance: 2. Laboratory Tests
○​ Low blood sugar for a long
time can cause brain ●​ Assist with tests for:
damage and lead to ○​ Blood gases
long-term developmental or ○​ Blood glucose
learning issues. ○​ Complete Blood Count
(CBC)

Care for Large for Gestational Age

(LGA) Infants:

●​ Feeding:
○​ Breastfeed immediately to
prevent hypoglycemia.
○​ May need supplemental
formula after breastfeeding
to ensure enough fluids and
glucose for the first few days.
●​ Challenges with Bottle Feeding:
○​ Newborns offered bottles
may struggle to learn
breastfeeding.
●​ Support:
○​ Help both mother and baby
to succeed with
breastfeeding.
3. Monitor for Respiratory or ●​ Important Observations:
Cardiac Issues ○​ Bleeding from the
umbilical cord: Apply
●​ Respiratory Signs to Watch For: pressure and inform the
○​ RR > 60/min: Respiratory attending physician (AP)
difficulty ○​ First voiding: Should occur
○​ Grunting, retractions, within 36 hours of birth. If no
chest lag, or nasal flaring: void in 4-6 hours, report it.
Report immediately ○​ Stool: Lack of stool or
○​ Cyanosis (excluding abdominal distention could
acrocyanosis): Watch for indicate intestinal problems.
signs of respiratory distress Measure abdominal
●​ Cardiac Signs to Watch For: circumference (AC).
○​ Heart rate > 180/min or ○​ Activity & Behavior: Look
irregular: Possible for sucking motions and
circulatory issues hand-to-hand movements to
●​ Other Signs: determine if oral feeding can
○​ Watch muscle tone and start.
activity ○​ Fontanel (head soft spot):
○​ Hypoglycemia: Due to Tense or bulging fontanel
inadequate glycogen stores, could indicate intracranial
respiratory distress, or cold hemorrhage. Watch for
stress twitching or seizures.
○​ Vital Signs: Regularly
monitor and record.

4. Monitoring & Care in an Isolette

●​ Provide cardiac monitoring

●​ Avoid giving a bath during this time

5. Observe for Jaundice & Blood

Incompatibilities

●​ Check for signs of jaundice

●​ Review maternal history for blood
incompatibilities

6. Critical Nursery Care (First

24-48 hours)
Rh Incompatibility 1.​ Hemolytic Disease of the
Newborn (HDN):
●​ What is it? ○​ After birth, the baby's red
○​ It happens when a mother's blood cells may continue to
blood and baby's blood are break down.
incompatible because of the ○​ This can lead to HDN, a
Rh factor. condition where the baby's
●​ What is the Rh factor? liver can't handle the bilirubin
○​ It's a protein found on red (waste from broken red blood
blood cells. cells).
○​ Rh-positive: The protein is 2.​ Jaundice:
present. ○​ Jaundice happens when too
○​ Rh-negative: The protein is much bilirubin builds up in
absent. the baby's body, causing the
●​ When does Rh incompatibility skin and eyes to turn yellow.
occur? 3.​ Hydrops Fetalis:
○​ It occurs when: ○​ This is a severe condition
■​ The mother is where the baby’s organs
Rh-negative. can't manage the anemia.
■​ The baby is ○​ The heart may start to fail,
Rh-positive. and large amounts of fluid
●​ What happens during Rh collect in the baby’s organs
incompatibility? and tissues.
○​ The mother's immune system ○​ Hydrops fetalis is a serious
sees the baby's Rh-positive risk, and the baby could be
blood cells as foreign. stillborn.
○​ The mother's body produces 4.​ Kernicterus:
antibodies that attack the ○​ If the bilirubin levels get too
baby's red blood cells. high, it can lead to brain
○​ These antibodies can cross damage.
the placenta and damage the ○​ This may cause seizures,
baby’s red blood cells. hearing loss, and even
●​ What is the result? death.
○​ The baby’s red blood cells
are destroyed, which can
lead to serious health issues.
Erythroblastosis Fetalis

●​ Definition: Destruction of red blood

cells due to an antigen-antibody
reaction. This causes hemolytic
Fetal Anemia and Related anemia and/or hyperbilirubinemia in
Conditions the baby.
Diagnosis ●​ Bilirubin Levels: High bilirubin
levels in the baby's umbilical cord
●​ Indirect Coombs' test: Detects blood.
antibodies in the mother’s blood. ●​ Red Blood Cell Destruction: Signs
●​ Direct Coombs' test: Detects of RBC breakdown in the baby’s
antibodies on the baby’s red blood blood.
cells.
●​ Amniotic Fluid
Spectrophotometry: Measures
bilirubin levels in amniotic fluid. For the Mother:

●​ Prevention:
○​ RhoGAM: A medication that
Assessment prevents your body from
making antibodies that attack
●​ Anemia: Check if the baby has low Rh-positive blood cells.
red blood cell count.
●​ Jaundice: Look for yellowing of the For the Infant:
skin or eyes.
●​ Edema: Look for swelling, especially ●​ Treatment depends on how
in the baby's body. severe the condition is:
1.​ Phototherapy: Using special
lights to treat high bilirubin
levels.
Nursing Interventions 2.​ IV Immune Globulin: A
treatment to boost the
1.​ Administer RhoGAM: Prevents infant's immune system.
immune response against the baby’s 3.​ Exchange Transfusion: In
red blood cells. severe cases, blood may be
2.​ Monitor Transfusion: Ensure the exchanged to replace the
baby receives an exchange infant's blood and lower
transfusion, either after birth or via bilirubin levels.
intrauterine transfusion.
3.​ Hyperbilirubinemia Care: Provide
treatment if bilirubin levels are high.

Exams & Tests

●​ Amniotic Fluid Changes: The

mother may have extra fluid around
the baby (polyhydramnios).
●​ Direct Coombs' Test: May show a
positive result.