THE PRETERM NEWBORN

Tewodros T.
Definition

• Any infant of less than

37weeks’ gestation.(AAP)

WHY ARE WE CONCERNED???

• Liveborn infants delivered before 37wk from
the 1st day of the last menstrual period are
termed premature. (WHO)
• Low birthweight (LBW; birthweight of 2,500 g
or less) is a consequence of prematurity, poor
intrauterine growth (IUGR, also referred to as
SGA), or both.
 ETIOLOGY OF PRETERM BIRTH
Maternal Factors
 Socioeconomic  Behavioral
• Malnutrition • Substance abuse
• Age • Smoking
• Race • Poor or absent prenatal
 Chronic medical
care
conditions
• Heart disease
• Renal disease
• Diabetes
• Hypertension
Factors Related to Pregnancy
• Multiple pregnancy
• Low body mass index (<19.8 kg/m2)
• Abruptio placentae or placenta previa
• Incompetent cervix
• Premature rupture of membranes or
chorioamnionitis
• Polyhydramnios or oligohydramnios
• Infection
• Trauma
Fetal Factors
• Chromosomal abnormalities
• Congenital anomalies
• Nonimmune hydrops
• Erythroblastosis
• Unknown Factors
 Characteristics of the Preterm Newborn

• Compared with the term infant, the preterm

infant is tiny, scrawny, and red.
• The extremities are thin, with little muscle or
subcutaneous fat.
The head and abdomen are disproportionately
large, and the skin is thin, relatively translucent,
and usually wrinkled.
• Veins of the abdomen and scalp are more visible.
• Lanugo is plentiful over the extremities, back, and
shoulders.
• The ears have soft, minimal cartilage and thus are
extremely pliable.
• The soft bones of the skull tend to flatten on the
sides, and the ribs yield with each labored breath.
• Testes are undescended in the male; the labia and
clitoris are prominent in the female.
• The soles of the feet and the palms of the hands
have few creases (Fig. next slide).
• Many of the typical newborn reflexes are weak or
absent.
Posture—
• The preterm infant lies in
a “relaxed attitude,” limbs
more extended; the body
size is small, and the head
may appear somewhat
larger in proportion to
the body size.
• The term infant has more
subcutaneous fat tissue
and rests in a more flexed
attitude.
Ear—
• The preterm infant’s ear
cartilages are poorly
developed, and the ear may
fold easily; the hair is fine
and feathery, and lanugo
may cover the back and
face.
• The mature infant’s ear
cartilages are well formed,
and the hair is more likely to
form firm, separate strands.
Sole—
• The sole of the foot of
the preterm infant
appears more turgid
and may have only fine
wrinkles.

• The mature infant’s

sole (foot) is well and
deeply creased.
Female genitalia—
• The preterm female
infant’s clitoris is
prominent, and labia
majora are poorly
developed and gaping.
• The mature female
infant’s labia majora
are fully developed,
and the clitoris is not
as prominent.
Male genitalia—
• The preterm male infant’s
scrotum is undeveloped and
not pendulous; minimal rugae
are present, and the testes
may be in the inguinal canals
or in the abdominal cavity.
• The term male infant’s
scrotum is well developed,
pendulous, and rugated, and
the testes are well down in
the scrotal sac.
Grasp reflex—
• The preterm infant’s
grasp is weak;

• The term infant’s

grasp is strong,
allowing the infant to
be lifted up from the
mattress.
Preterm

Term
 Complications of the Preterm Newborn

• Respiratory Distress Syndrome

• Intraventricular Hemorrhage
• Cold Stress
• Retinopathy of prematurity (ROP)
• Necrotizing enterocolitis (NEC)
• Jaundice
• Infection
 Respiratory Distress Syndrome
• It occurs because the lungs are too immature
to function properly.
 Pathophysiology
• At birth, infants must initiate breathing and
keep the previously fluid-flled lungs inflated
with air.
• At the same time, the pulmonary capillary
blood flow must be increased approximately
10-fold to provide for adequate lung perfusion
and to alter the intracardiac pressure that
closes the fetal cardiac structures.
• Most full-term infants successfully accomplish
these adjustments, but preterm infants with
respiratory distress are unable to do so.
• Although numerous factors are involved,
immaturity of the surfactant system plays a
central role.
 Clinical Manifestation
• Typically, respirations will be increased, usually >
60 bpm.
• Nasal flaring and retractions may be noted.
• Mucous membranes may appear cyanotic.
• Seesaw-like respirations
• Breathing becomes noticeably labored, the
respiratory rate continues to increase, and
expiratory grunting occurs.
• Breath sounds usually are diminished, and the
newborn may develop periods of apnea.
 Treatment and prevention
• If premature delivery is expected, an attempt
may be made to prevent RDS.
• Through amniocentesis, lecithin
• Glucocorticosteroid drug (betamethasone)
• The infant begins to produce surfactant about
72 hours after birth
• Infants who survive the first 4 days have a
much improved chance of recovery.
• After birth, surfactant replacement therapy with
synthetic or naturally occurring surfactant
• Surfactant is administered as an inhalant through
a catheter inserted into an endotracheal tube, at
or soon after birth.
• Oxygen through continuous positive airway
pressure, using intubation.
 Intraventricular Hemorrhage
• Is a complication of preterm birth that occurs
more often in the newborn of less than 32
weeks’ gestation.
• Due to the preterm infant's fragile capillaries
in the periventricular area, immature cerebral
vascular development, and poorly supported
vascular bed, these infants are at an increased
risk for intracranial bleeds.
• CT, MRI and US can be used to determine if
bleeding has occurred.
• Causes of rupture of the capillaries leading to
IVH vary and include
– Fluctuations in systemic and cerebral blood flow,
increases in cerebral blood flow from hypertension,
intravenous infusion, seizure activity, increases in
cerebral venous pressure due to vaginal delivery,
hypoxia, and respiratory distress.
• The smaller the newborn is, and the more
premature, the higher the risk of developing
IVH.
 Clinical manifestation
• Signs of possible IVH include hypotonia,
apnea, bradycardia, a full (or bulging)
fontanelle, cyanosis, and increased head
circumference.
• Neurologic signs such as twitching,
convulsions, and stupor are also possible
warning signs.
• However, mild bleeding can occur without
these symptoms.
• Complications of IVH include development of
hydrocephalus, periventricular leukomalacia
(an ischemic injury resulting from inadequate
perfusion of the white matter adjacent to the
ventricles), cerebral palsy, and intellectual
disability.
• The size and severity of the IVH is measured
using a grading system.
Preventing IVH
• Focuses on avoiding situations that increase or
cause fluctuations in the cerebral blood pressure.
• Appropriate measures include
– Keeping the head and body in alignment when moving
and turning the newborn (avoiding twisting the head
at the neck),
– Reducing procedures that cause crying (as a result of
pain), and
– Minimizing endotracheal suctioning.
• Any unnecessary disturbances of the newborn
are to be avoided.
• In addition, analgesics may be administered to
relieve or reduce discomfort and lessen the
danger of increased intracranial blood pressure.
 Retinopathy of prematurity (ROP)
• A disorder characterized by rapid growth of
retinal blood vessels in the premature infant.
• In the fetus, retinal vascularization begins at 4
months and progresses until completion at 9
months or shortly after birth.
• The premature infant is born with incomplete
retinal vascularization, yet new vessels
continue to grow between the vascularized and
nonvascularized retina.
• Commonly associated with the preterm
newborn.
• It results from the growth of abnormal
immature retinal blood vessels.
• Preterm birth may be a factor contributing to
this growth.
• In addition, the use of high concentrations of
oxygen has been identified as a major cause.
– How???
Ans.
• The immature blood vessels constrict when
high levels of oxygen are given, depriving the
retinal tissues of adequate nutrition.
• These events lead to varying degrees of
blindness.
• Prevention of this complication is key by
monitoring the preterm newborn’s blood oxygen
level and keeping it within normal limits.
• Levels greater than 100 mm Hg greatly increase
the risk of ROP.
• If left untreated it could cause myopia, glaucoma,
and blindness.
• Strabismus may occur even in cases of regressed
(resolved) ROP.
Mgt.
• Premature infants should have serial
examinations by an ophthalmologist until the
ROP has regressed and normal vascularization
is seen.
• If ROP continues to progress, laser surgery may
be necessary to prevent blindness.
• In the first year of life, ophthalmologic
examinations should occur frequently so that if
corrective lenses are needed, they may be
prescribed at the earliest possible time.
 Necrotizing Enterocolitis (NEC)
• Is an acute inflammatory disease of the
intestine.
• The cause is not clearly defined.
• Precipitating factors are hypoxia, causing
– Poor tissue perfusion to the bowel;
– Bacterial invasion of the bowel; and
– Feedings of formula, which provide material on
which bacterial enzymes can work.
 Clinical manifestations
• Distention of the abdomen, return of more
than 2 mL of undigested formula when the
gastric contents are aspirated before a
feeding, and
• Occult blood in the stool.
• The newborn feeds poorly and may
experience vomiting and periods of apnea.
• This disorder usually occurs within the first 10
days of life.
 Dx & Rx
• Diagnosis is confirmed by abdominal radiographs.
• The infant with NEC is gravely ill and must be cared
for in the NICU.
• Initially, oral feedings are discontinued and
nasogastric suction, IV fluids, and antibiotics are
given.
• There is a danger that a necrotic area will rupture,
causing peritonitis.
• A temporary colostomy may be needed to relieve the
obstruction, and surgical removal of the necrotic
bowel may be necessary.
 Nursery Care of the Preterm
• At birth, the measures needed for
clearing the airway, initiating breathing,
caring for the cord and eyes, and
administering vitamin K are the same in
immature infants as in those of normal
weight and maturity.
 Improving Respiratory Function
• Not all preterm newborns need extra
oxygen, but many do.
• Isolettes are made with oxygen inlets and
humidifiers for raising the oxygen
concentration inside from 20% to 21% (room
air) to a higher percentage like 40%.
• Measure the rate of respiration and identify
retractions to help determine proper oxygen
concentrations.
 Maintaining Body Temperature
• Isolettes (incubators) or radiant warmers can
be used to maintain body temperature.
• The optimal environmental temperature for
minimal heat loss and oxygen consumption for
an unclothed infant is one that maintains the
infant's core temperature at 36.5-37.0°C.
• It depends on an infant's size and maturity
Keeping warm at home
Well covered newborn
 Keeping warm in hospital


Skin-to skin method
 Warm room, fire

or electric heater
 Warmly wrapped

Radiant warmer

Heated water-filled mattress Air-heated Incubator

• An infant should be weaned and then
removed from the isolette or radiant warmer
only when the gradual change to the
atmosphere of the nursery does not result in a
significant change in the infant's temperature,
color, activity, or vital signs.
 KANGAROO MOTHER CARE
• Refers to care of preterm or low birth weight
infants by placing the infant in skin-to-skin
contact with the mother or any other caregiver.
• Consists of specific frog like position of LBW
new born with skin-to-skin contact with
mother, in between her breasts in a vertical
position.
COMPONENTS OF KMC
• The provider must keep herself in a
semi-reclining position to avoid
gastric reflux in the infant.
• Maintained 24 hrs. a day ,
till it gains at least 2000g.
 Preventing Infection
• Primary means of preventing infection is hand
washing.
• Regular cleaning or changing of humidifier water, IV
tubing, and suction, respiratory, and monitoring
equipment.
• The NICU is separate from the normal newborn
nursery and usually has its own staff.
• This separation helps eliminate sources of
infection.
• Personnel in this area usually wear scrub suits or
gowns.
Observe for S/s of infection including:

• Temperature instability (decrease or increase)

• Glucose instability and metabolic acidosis
• Poor sucking
• Vomiting
• Diarrhea
• Abdominal distention
• Apnea
• Respiratory distress and cyanosis
Fluid Requirements
• Fluid intake in term infants is usually begun at 60-
70 mL/kg on day 1 and increased to 100-120 mL/kg
by days 2-3.
• Smaller, more premature infants may need to start
with 70-80 mL/kg on day 1 and advance
gradually to 150 mL/kg/day.
• Fluid volumes should be titrated individually,
although it is unusual to exceed 150 mL/kg/24 hr.
 Maintaining Adequate Nutrition
• When born, a preterm newborn may be too
weak to suck or may not yet have developed
adequate sucking and swallowing reflexes.
• Premature newborns are likely to have problems
with aspiration because the gag reflex does not
develop until about the 32nd to 34th week of
gestation.
• As a result, gavage feedings may be necessary.
Gavage Feeding
 Maintaining Adequate Nutrition
• Extremely small amounts of fluid are needed,
perhaps as little as 5 to 10 mL/hour or even
less.
• Daily weights, urine, and serum urea nitrogen
with electrolytes should be monitored
carefully to determine water balance and fluid
needs.
• Clinical observation and physical examination
are poor indicators of the state of hydration of
premature infants.
 Preserving Skin Integrity
• Assess skin integrity frequently but at least every
shift for changes in
• color, - turgor,
• texture, - vascularity, and
• signs of irritation or infection.
• A preterm newborn’s skin is extremely fragile
and can be injured easily.
• Changing the diaper as soon as possible after
soiling will maintain clean and dry skin.
 Reducing Parental Anxiety
• How can they learn to know and love the
strange, scrawny creature that now lives in that
plastic box?
• These feelings are normal, but studies have
shown that if these feelings are not expressed
and resolved, they can damage the long-term
relationship of parents and child, even resulting
in child neglect or abuse.
• Explain what is happening to the newborn in the
NICU
TEST
• When is a newborn classified as preterm?
• What is observed on the hands and feet of a
preterm newborn?
• Which complication associated with preterm
newborns is due to a surfactant deficiency?
THE POST-TERM NEWBORN

When pregnancy lasts longer than 42

weeks, the infant is considered to be post-
term (post mature), regardless of birth
weight.
Contributing Factors
• The cause of post-term birth or post maturity
is unknown.
• However, some predisposing factors include
– First pregnancies between the ages of 15 and 19
years,
– The woman older than 35 years with multiple
pregnancies, and
– Certain fetal anomalies, such as anencephaly.
 Clinical Manifestations
• Some have an appearance similar to term infants,
but others look like infants 1 to 3 weeks old.
• Little lanugo or vernix remains, scalp hair is
abundant, and fingernails are long.
• The skin is dry, cracked, wrinkled, peeling, and
whiter than that of the normal newborn.
• These infants have little subcutaneous fat and
appear long and thin. This lack of subcutaneous
fat may lead to cold stress.
• They are threatened by failing placental function
and are at risk for intrauterine hypoxia during
labor and delivery.
• Thus, it is customary for the physician or nurse-
midwife to induce labor or perform a cesarean
delivery when the baby is markedly overdue.
• Many believe that pregnancy should be
terminated by the end of 42 weeks.
Potential Complications

• Meconium aspiration
• Hypoglycemia
• Polycythemia
 Rx
• To reduce the chances of meconium aspiration, upon
delivery of head and just before the baby takes his first
breath, suction the infant’s mouth and nose and also check
for respiratory problems related to meconium aspiration.
• Typically, postmature newborns are ravenous eaters at
birth.
• Provide a thermoregulated environment, such as a radiant
heat warmer or isolette, and use measures to minimize
heat loss.
• If polycythemia is suspected, a partial exchange
transfusion may be done to prevent hyperviscosity.
Transient Tachypnea of the
Newborn (TTN)
 TTN
• Occasionally called respiratory distress
syndrome type II
• Involves the development of mild respiratory
distress in a newborn.
• It typically occurs after birth, with the greatest
degree of distress occurring approximately 36hrs.
after birth.
• TTN commonly disappears spontaneously around
the 3rd day.
• TTN results from a delay in absorption of fetal lung
fluid after birth.
 Contributing Factors
• TTN is commonly seen in newborns born by
cesarean delivery.
• Newborns who are preterm or SGA or whose
mothers smoked during pregnancy or have
diabetes also are at risk for TTN.
 Clinical Manifestations
• Mild respiratory distress
• RR > 60 bpm
• Mild retractions
• Nasal flaring, and some expiratory grunting
may be noted.
• However, cyanosis usually does not occur.
• Difficulty feeding
 Diagnosis and Treatment
• ABG
• A chest x-ray
• Unless an infection is suspected, medication therapy
usually is not given.
• IV fluids and gavage feedings may be used to meet the
newborn’s fluid and nutritional requirements.
• Oral feedings typically are difficult because of the
newborn’s increased respiratory rate.
• Supplemental oxygen often is ordered, and oxygen
saturation levels are monitored via pulse oximetry.
 Nursing Care
• Monitor the newborn’s vital signs and oxygen
saturation levels closely, being alert for changes
that would indicate that the newborn is
becoming fatigued from the rapid breathing.
• Administer IV fluids and supplemental oxygen
as ordered.
• Assist the parents in understanding what their
newborn is experiencing to help allay any fears
or anxieties that they may have.
Meconium Aspiration Syndrome
(MAS)
Meconium Aspiration Syndrome (MAS)

• Refers to a condition in which the fetus or

newborn develops respiratory distress after
inhaling meconium mixed with amniotic fluid.
• Meconium is a thick, pasty, greenish-black
substance that is present in the fetal bowel as
early as 10 weeks’ gestation.
• Meconium aspiration occurs when the fetus
inhales meconium along with amniotic fluid.
• The fetus may aspirate meconium while in
utero or with his or her first breath after birth.
• The meconium can block the airway partially
or completely and can irritate the newborn’s
airway, causing respiratory distress.
 Contributing Factors
• Typically, meconium aspiration syndrome is associated
with fetal distress during labor.
• Most commonly, the fetus experiences hypoxia, causing
peristalsis to increase and the anal sphincter to relax.
• The fetus then gasps or inhales the meconium-stained
amniotic fluid.
• Additional factors that contribute to the development
of MAS include a maternal history of diabetes or
hypertension, difficult delivery, advanced gestational
age, and poor intrauterine growth.
 Clinical Manifestations
MAS is suspected whenever amniotic fluid is stained
green to greenish black. Other manifestations include:
• Difficulty initiating respirations after birth
• Low Apgar score
• Tachypnea or apnea
• Retractions
• Hypothermia
• Hypoglycemia
• Cyanosis
Diagnosis and Treatment
• Chest x-ray that shows patches or streaks of
meconium in the lungs.
– Air trapping or hyperinflation also may be seen.
• Treatment begins with suctioning the
newborn during delivery, before the shoulders
are delivered.
• Tracheal and bronchial suctioning may be
indicated to remove any meconium plugs that
may be lower in the respiratory tract.
Nursing Care
• Newborns with MAS are extremely ill and
often require care in the NICU.
• Nursing care focuses on observing the
neonate’s respiratory status closely and
ensuring adequate oxygenation.
• Measures to maintain thermoregulation are
key to reducing the body’s metabolic demands
for oxygen.
• Be prepared to administer respiratory support
and medication therapy as ordered.