Transition and Normal Newborn Care

Monica L. Scrudder, RNC-NIC, BSN, MSNFranciscan Health System

Regional Nurse Educator, Nursery Services

Objectives

• Identify primary features of fetal circulation.• Identify physiological changes that occur at

birth in the newborn’s transition to extrauterine homeostasis.

• Identify routine care for the newborn in the transition period.

• Identify signs and symptoms of common problems in the transition period.

• Identify nursing intervention that promote parental bonding.

What Is Transition???

The Transition Period

• Birth to 6 hours of age• Physiological change from placental

support to self-maintenance• Fetus prepares for transition over the

course of gestation• Transition depends on gestational age

and quality of placental support

The Cardiac Puzzle

Anatomy and Physiology

• Placental Fetal Circulation• Blood follows the path of least

resistance• Low pulmonary blood flow (only 8-10%

of right ventricular output secondary to high pulmonary vascular resistance

The Fetal Circulation

Ductus Venosus

Foramen Ovale

Ductus Arteriosis

Fetal Lungs

Fetal Metabolism and Hematology

• Glucose– Fetal concentrations 70-80% of maternal

glucose concentrations

• Glycogen– Large glycogen stores provide large energy

reserves to sustain newborn through transition period

• Brown Fat– Unique to newborn– Metabolized for heat

Cardiopulmonary Adaptation at Birth

Cardiovascular Adaptations At Birth

• Umbilical cord is clamped.• Three major shunts functionally close

during transition– Ductus Arteriosis– Foramen Ovale– Ductus Venosus

Pulmonary Adaptation At Birth

• Stimuli for initiating respiration– Mild hypercapnia, hypoxia and acidosis– Light, noise, touch– Thoracic squeeze during vaginal delivery

• Empties approximately 1/3 of fetal lung fluid

First Breath

• Air enters lungs at 2x normal pressure– 40-80 cm H2O

• Pulmonary vessels vasodilate in response to increased oxygen– Pulmonary vascular resistance decreases– Pulmonary blood flow increases

Continued Pulmonary Adaptations

• Pulmonary vascular resistance (PVR) decreases to reach adult levels at 2-3 weeks of age

• Lung compliance improves

Measurements

• Apgar score– Done at 1 minute and 5 minutes of age– If apgar less than 7 at 5 minutes of age,

continue every 5 minutes until greater than 7 for maximum of 20 minutes

The Apgar Score

Sign 0 1 2Heart rate Absent Slow (<100

bpm)> 100 bpm

Respirations Absent Weak cry,Hypo-ventilation

Good, strong cry

Muscle Tone Limp Some flexion Active motion

ReflexIrritability

No response Grimace Cough or sneeze

Color Blue or pale Body pink,Extremities blue

Completely pink

Assessment Findings During Transition

• Head circumference, length, weight• Gestational age assessment• Skin• Head• Respiratory assessment• Cardiac assessment• Gastrointestinal assessment• Extremities

Medications in Transition

• Erythromycin Ointment • Vitamin K (AquaMEPHYTON)• Hepatitis B vaccine/Hepatitis B

Immunoglobulin

Glucose Needs

Feeding

Contraindications to Feeding

• Cyanosis• Shock or asphyxia• Increased work of breathing • Ongoing oxygen requirement

Routine Care Considerations

AAP/ACOG/AWHONN Guidelines

• Proper identification of newborn• Initial assessment within 2 hours of birth• Develop a plan of care• Document observations at least every 30 minutes until stable

for 2 hours• Prophylactic eye care within 1 hour of birth• Primary health care provider

– Perform initial physical exam no later than 24 hours of birth– Perform physical exam within 24 hours before discharge

• Document daily weight• Perform metabolic screening• Instruct parent in care of infant

Guidelines (Cont)

• Implement emergency measures, including resuscitation, when necessary using such programs as the Neonatal Resuscitation Program

• Observe parent-infant interactions• Identify with parent(s) the appropriate facility for follow-up• Inform parent(s) of importance of immunizations• Identify high-risk mothers• Evaluate home environment

Nursing Considerations

• Observations must be documented every 2 hours according to the State of Washington.– Follow hospital policy regarding this

guideline.• Vital sign routine• Daily weight• Physician notification• Timing of metabolic screening• Specific teaching issues for population

Nursing Observations

• Cardiac and Respiratory Status• Feeding• Temperature• Color• Tone • Activity• Output• Parent-infant bonding

Parent-Infant Bonding

• Bonding• Attachment• “En face”• “Parentese”• Red Flags

Assess Parenting Styles and Abilities

• Parents’ level of knowledge• Family’s communication• Parental expectations• Infant’s responses to parenting activities• Parental feelings about self and infant• Parental support• Cultural beliefs• Potential need for referral

Routine Care and Documentation

• Documentation of birth• Measurements• Medications• Physical assessment• Abduction prevention• Bathing/Hygiene• Cord Care• Feeding assessment• Metabolic screening• Elimination

Discharge Criteria

• Feedings• Discharge weight• Metabolic screening• Birth certificate worksheet/paternity

papers• Teaching documented• Hearing screening

Discharge Teaching

• Begins on admission• Assess Mother’s readiness to learn• Assess Father’s involvement• Involve Grandparents, siblings, and

other significant people

Teaching Documentation

• Thermoregulation• Holding and Positioning• Hygiene• Feeding• Bulb syringe• Choking• Elimination• Circumcision Care• Safety• When to Call the Physician

References

• Askin, DF. (2002) Complications in the Transition from Fetal to Neonatal Life. JOGNN 31(3): 318-27

• Buschbach, D., Schaub-Bordeaux, M. (2002) Newborn Physiological and Developmental Transitions: Integrating Key Components of Perinatal and Neonatal Assessment. Association of Women’s Health, Obstetric and Neonatal Nurses.

• Kenner, C., Wright-Lott, J. (2003) Comprehensive Neonatal Nursing: A Physiological Perspective. Philadelphia:Saunders

• Sansoucie DA, Cavaliere, TA. (1997) Transition from Fetal to Extrauterine Circulation. Neonatal Network, 16(2):5-12

• Verklan,TM, Walden, M., editors (2004) Core Curriculum for Neonatal Intensive Care Nursing (3rd ed.) St. Louis:Elsevier

References (2)

• http://www.cayuga-cc.edu/people/web_pages/greer/biol204/heart4/heart4.html

• http://dic.academic.ru/pictures/enwiki/80/Patent_ductus_arteriosus.jpg

• http://www.007b.com/breastfeeding_pictures.php

• http://pregnancy.about.com/od/newbornbabies/ig/Newborn-Photo-Gallery/index.01.htm