Problems related to Gestational Weight
Small for Gestational Age (SGA) (Microsomia)
• BW is below 10th percentile on an intrauterine growth curve for that age.
• Have experienced IUG (intrauterine growth) restriction or failed to grow at the expected rate.
• Classification:
1) Low-birthweight (LBW) infant: one weighing less than 2,500 g at birth
2) Very-low-birthweight (VLBW) infant: one weighing less than 1500 g at birth
3) Extremely-low-birthweight (ELBW) infant: one weighing less than 1,000 g at birth
• Causes:
1. Lack of adequate nutrition during pregnancy (because of vasoconstriction)
2. Placental anomaly
• Abruptio placenta
• Severe diabetes mellitus
• PIH
3. Heavy smokers
4. Use of narcotics
• Assessment:
1. Fundal height becomes progressively less than expected.
2. Sonogram
3. Non-stress test
4. Placental grading
5. Amniotic fluid amount
• Appearance:
1. If nutritional deprivation early in pregnancy:
➢Below average in weight, length & head circumference.
Early (first trimester) – development and enlargement of different organs and cells
2. If nutritional deprivation late in pregnancy:
➢Reduction in weight
What’s expected is – gaining weight
3. Small liver
• Difficulty regulating glucose, protein & bilirubin levels after birth (bilirubin is produced when
the liver breaks down old red blood cells)
4. Poor skin turgor – no develop subcutaneous fats; decrease amniotic fluid; dehydrated
5. Large head – at appears large because the body is smaller; organs not developed well
6. Skull sutures widely separated – indicator = lacking calcium
7. Dull hair & lusterless – observed if lacking in protein
8. Sunken abdomen – small internal organs
9. Cord appears dry, & may be stained yellow
• Laboratory Tests:
1. High hematocrit
• If > 65% - 70% exchange transfusion may be necessary.
• Due to lack of fluid in utero – high in hematocrit level
2. Increased RBC (polycythemia)
• Due to anoxia – increase in amount of RBC = increase viscosity
• More viscose and difficult to circulate blood
• May result to prolonged acrocyanosis
• Vessels may be blocked & thrombus formation can result – slow movement of blood there is
tendency to clot = more hypoxia to the baby
3. Hyperbilirubinemia because so many extra red blood cells break down and release bilirubin.
4. Hypoglycemia (< 40 mg/dl)
• Due to decreased glycogen stores = due to small liver
• May need IV glucose solution to sustain blood sugar until able to suck vigorously
• Nursing Dx:
• Ineffective breathing pattern r/t underdeveloped body systems at birth
Lack of protein = lack of surfactant
• Risk for ineffective thermoregulation r/t lack of subcutaneous fat
Outcome Evaluation: Infant's temperature is maintained at 36.5°C (97.8°F) axillary.
• Risk for impaired parenting r/t child’s high-risk status and possible cognitive or neurologic
impairment from lack of nutrients in utero
Outcome Evaluation: Parents express interest in infant and ask questions about what the child's
care needs will be at home; parents hold infant warmly.
• Planning & Implementation:
1. Monitor & maintain a patent airway
1. Suction mucus as needed to maintain an open airway
2. Position side-lying to facilitate drainage of mucus – prevent aspiration
3. Observe for signs of respiratory distress.
• Grunting
• Flaring of nostrils
• Sternal retractions
2. Provide warmth.
1. Keep in a heated crib until body temperature is stabilized to prevent chilling.
2. Skin should be kept clean & dry
3. Monitor V/S.
4. Weigh daily.
Large for Gestational Age (LGA) (Macrosomia)
• BW is above 90th percentile on an intrauterine growth chart for that gestational age.
• Causes:
1. Overproduction of growth hormone in utero.
2. Infants of diabetic mothers = produce more insulin the fetus, insulin serve as growth
stimulant for the baby
• Fetus is exposed to high glucose level.
3. Obese women.
4. Multiparous women
5. Beckwith syndrome
• a congenital (present from birth) growth disorder that causes large body size, large
organs.
6. Congenital anomalies such as omphalocele
• A birth defect in which an infant's intestine or other abdominal organs are outside of
the body because of a hole in the belly button (umbilical ring) area. The intestines are
covered only by a thin layer of tissue and can be easily seen.
• Assessment:
1. Uterus unusually large for the date of pregnancy.
2. Sonogram is used to confirm
3. Non-stress test – assess the fetal well being
4. Amniocentesis
• To determine lung maturity - diabetic mother = delay produce of the surfactant
5. CPD or shoulder dystocia
• Baby cannot descend through the outlet of the pelvis – difficulty in delivering the baby
• Appearance:
1. Immature reflexes
2. Extensive bruising or a birth injury such as broken clavicle or Erb-Duchenne paralysis
• Due to trauma to the cervical nerves if he/she was born vaginally.
3. Caput succedaneum, cephalhematoma or molding
• Due to large head.
• Other problems:
1. Cardiovascular dysfunction
• Observe for signs of hyperbilirubinemia which resulted from absorption of blood from bruising
and polycythemia.
• Closely monitor HR
• If cyanosis is present, it may be a sign of transposition of the great vessels (pulmonary artery
and aorta) – there is an interchange of placement of anatomical placement result to thrombus
formation
If pulmonary artery – left side
If aorta – right side
2. Hypoglycemia
• Infants uses up nutritional stores readily to sustain his/her weight – big surface area so there is
increase the nutritional need
• Increase blood glucose in utero causes infant to produce elevated levels of insulin (growth
stimulant)
• Nursing Dx:
1. Ineffective breathing pattern r/t possible birth trauma.
• Increased ICP (intracranial pressure) from birth could lead to pressure on the resp. center. –
newborn so vulnerable ang blood vessels
• Diaphragmatic paralysis may occur due to cervical nerve trauma. – result to respiratory
distress
• If delivered by C/S, transient fluid could remain in the lungs. – cannot breathe unless lungs
cleared of fluids
2. Risk for imbalanced nutrition less than body requirement r/t additional nutrients needed to maintain
weight.
• Infant needs to be breastfed immediately to prevent hypoglycemia. – mother cannot produce
milk
• May need supplemental formula feedings after breastfeeding to supply enough fluid and
glucose for the first few days. – mas maayo nay maka donate ug breastmilk
Respiratory Distress Syndrome (Hyaline Membrane Syndrome)
• Occurs in:
• Preterm infants
• Infants of diabetic mother
• Infants born by C/S
• Infants with decreased blood perfusion of the lungs (i.e, meconium aspiration)
• Pathophysiology:
Low or absence of surfactant
The hyaline-like (fibrous) membrane formed from an exudate of an infant’s blood that begins to line the
terminal bronchioles, alveolar ducts & alveoli
This membrane prevents exchange of O2 & CO2 at the alveolar capillary membrane 21
Alveoli collapse with each expiration (areas of hypoinflation occurs)
Pulmonary resistance increases
Blood then shunts through the foramen ovale and the ductus arteriosus
The lungs become poorly perfused
Tissue hypoxia
Carbohydrate breaks down for energy and
Release of lactic acid
Severe acidosis
Acidosis causes vasoconstriction and decreased pulmonary perfusion from vasoconstriction further
limits surfactant production Alveoli are collapsing oxygen–carbon dioxide exchange in the alveoli is no
longer adequate to sustain life without ventilator support.
• Cause:
• Low level or absence of surfactant.
• Assessment:
1. If difficulty initiating respiration at birth:
• Resuscitation is initiated.
2. After resuscitation, subtle sign may appear:
• Decrease body temp.
• Nasal flaring
• Sternal & subcostal retractions
2. After resuscitation, subtle sign may appear:
• Tachypnea (60 bpm)
• Cyanotic mucous membrane
3. Expiratory grunting
• Caused by closure of the glottis.
4. Rales and diminished breath sounds due to poor air entry.
5. As distress increases, infant may exhibit:
1) Seesaw respirations
• Inspiration: ant. Chest wall retracts, abd. Protrude
• Expiration: sternum rises
2) Heart failure
• urine output & edema of extermities
3) Pale gray skin
4) Periods of apnea
5) Bradycardia
6) Pneumothorax (air in pleural cavity)
• Diagnoses:
1. Based on the clinical signs of:
1) Grunting
2) Cyanosis in room air
3) Tachypnea
4) Nasal flaring
5) Retractions
6) Shock
2. Chest X-ray
• Haziness
2. Blood gas studies
• Resp. acidosis
3. Culture of blood, CSF, & skin
• A betahemolytic, group B streptococcal infection may mimic RDS.
• Therapeutic Management:
1. Surfactant replacement
• Sprayed into the lungs by syringe or catheter by an endotracheal tube at birth.
• Do not suction infant’s airway after adm. Of surfactant.
• An infant who is receiving surfactant and then is placed on a ventilator needs close observation
because lung expansion can improve so rapidly, the ventilator pressure becomes too high.
2. O2 adm.
• To maintain correct pO2 & pH levels.
• Continuous positive airway pressure (CPAP) or assisted ventilation with positive end-expiratory
pressure (PEEP) will exert pressure on the alveoli at the end of expiration and keep the alveoli from
collapsing.
• Complication:
• Retinopathy of prematurity
• Bronchopulmonary dysplasia
• Therapeutic Management:
3. Ventilation
• Normal:
• Inspiration is shorter than expiration
• Ratio I/E 1:2
• For infants with non-compliant lungs:
• Reversed I/E ratio of 2:1
• High-frequency, oscillatory, and jet ventilation are other methods of introducing oxygen to these
infants.
4. Administration of Indomethacin or Ibuprofen
• Cause closure of patent ductus arteriosus making ventilation more efficient.
5. Muscle relaxants (Pancuronium)
• allows mechanical ventilation to be accomplished at lower pressure.
• Pneumothorax is reduced while pO2 is increased
• Atropine & Prostigmin should be immediately available (reverse the effects of Pancuronium). 34
6. Extracorporeal Membrane Oxygenation (ECMO)
• Blood is removed from the baby by gravity using a venous catheter advanced into the right atrium of
the heart.
• Blood circulates from catheter to the ECMO machine where it is oxygenated and rewarmed.
• Blood is returned to an aortic arch by a catheter advanced through the carotid artery. 35
7. Liquid ventilation
• When perfluorocarbons are introduced into lungs that inflate poorly because they are deficient with
surfactant, the weight of the fluid helps to distend the lungs.
• As the liquid moves into a lung, O2 is carried along with it; an exchange of O2 occurs.
8. Nitric Oxide
• Causes pulmonary vasodilation thus increasing blood flow to the alveoli.
• Prevention:
• Prevent preterm delivery:
1. Tocolytic agent (Terbutaline)
2. Glucocorticosteroid (Betamethasone)
• Quicken the formation of lecithin
• Given between 24 – 34 weeks of pregnancy.
MECONIUM ASPIRATION SYNDROME
• Meconium is present in the fetal bowel as early as 10 weeks of gestation.
• If hypoxia occurs, a vagus reflex is stimulated, resulting in relaxation of the rectal sphincter.
• This releases meconium into the amniotic fluid.
• Babies born breech may expel meconium into the amniotic fluid from pressure on the buttocks.
• In both instances, the appearance of the fluid at birth is green to greenish black from the staining.
• Meconium staining occurs in approximately 10% to 20% of all births; in 2% to 4% of these births,
infants will aspirate enough meconium to cause meconium aspiration syndrome (MAS) (Wyckoff et al.,
2015).
• Meconium aspiration does not tend to occur in ELBW infants because the substance has not passed far
enough in the bowel for it to be at the rectum in these infants.
• An infant may aspirate meconium either in utero or with the first breath at birth.
• Meconium can cause severe respiratory distress (tachypnea, retractions, and grunting).
• The infant may also require increased oxygen to maintain saturations in the mid to upper 90s.
• This oxygen requirement usually starts in the first couple hours after birth without any congenital
anomalies that may cause the low oxygen saturations (Lindenskov, Castellheim, Saugstad, et al., 2015).
• Assessment
1. difficulty establishing respirations at birth (those who were not born breech have had a hypoxic
episode in utero to cause the meconium to be in the amniotic fluid).
2. Low Apgar score.
3. Almost immediately, tachypnea, retractions, and cyanosis begin.
➢The infant should be placed on the warmer, and resuscitation should begin including the initiation of
positive pressure ventilation as necessary.
4. After the initiation of respirations, an infant’s respiratory rate may remain rapid (tachypnea) and
coarse bronchial sounds may be heard on auscultation.
5. The infant may continue to have retractions
➢because the inflammation of bronchi tends to trap air in the alveoli, limiting the entrance of oxygen.
5. The infant may continue to have retractions
➢This air trapping may also cause enlargement of the anteroposterior diameter of the chest (barrel
chest).
6. Pulse oximetry or blood gases will reveal poor gas exchange evidenced by a decreased PO2 and an
increased PCO2.
7. A chest X-ray will show bilateral coarse infiltrates in the lungs, with spaces of hyperaeration (a
peculiar honeycomb effect).
8. The diaphragm will be pushed downward by the overexpanded lungs.
• Therapeutic Management
1. Amnioinfusion
➢An isotonic fluid (Normal Saline) is instilled into the uterine cavity via a transcervical intrauterine
catheter.
➢can be used to dilute the amount of meconium in the amniotic fluid
➢The benefits may be related to dilution of the meconium or having an effect on the oligohydramnios
(Hofmeyr, Xu, & Eke, 2014). 46
2. If deeply stained amniotic fluid is identified during labor, the infant may be scheduled for a cesarean
birth.
3. After birth, infants may need to be treated with oxygen administration and assisted ventilation.
4. Antibiotic therapy may be prescribed to forestall the development of pneumonia as a secondary
problem.
5. If lung compliance is poor, surfactant may be administered (Wyckoff et al., 2015).
6. If lung noncompliance continues, this may necessitate high inspiratory pressure.
➢Unfortunately, this can cause a pneumothorax or pneumomediastinum (air in the chest cavity).
7. Observe the infant closely, therefore, for signs of trapping air in the alveoli
➢because the alveoli can expand only so far and then will rupture, sending air into the pleural space
(pneumothorax).
➢Yet, a further complication that can occur because of increased pulmonary resistance is the ductus
arteriosus remaining open – non-compliant lung = no expand alveoli (collapse) tendency pulmonary
artery there is increase pressure then ductus arteriosus will remain open
▪ causing blood to shunt from the pulmonary artery into the aorta and compromising cardiac efficiency
and increasing hypoxia.
➢To detect patent ductus arteriosus, observe an infant closely for signs of heart failure such as:
1) increased heart rate
2) respiratory distress.
8. Maintain a temperature-neutral environment to prevent the infant from having to increase metabolic
oxygen demands.
9. A chest physiotherapy with percussion and vibration may be helpful
➢to encourage the removal of remnants of meconium from the lungs
10.Some infants may need to be administered nitric oxide or maintained on ECMO to ensure adequate
oxygenation (Chettri, Bhat, & Adhisivam, 2016).
Sepsis Neonatorum
• Sepsis
• is a term for severe infection that is present in the blood and spreads throughout the body.
• In newborns, it is also called sepsis neonatorum or neonatal septicemia.
• The infection may be only in the bloodstream, or may spread to the lungs (pneumonia),
brain(meningitis), bone (osteomyelitis), joints, or other organs in the body.
• Sepsis in a newborn is more likely to develop when the mother has had pregnancy complications that
increase the likelihood of infection.
1. premature rupture of the membranes (amniotic sac), or membrane rupture for anextended length of
time;
2. bleeding problems;
3. a difficult delivery;
4. infection in the uterus or placental tissues, and
5. fever in the mother
• Overview, Causes, & Risk Factors
• Sepsis can develop following infection by microorganisms including:
1. bacteria (Escherichia coli (E.coli)
2. Candida and Group B streptococcus (GBS)
3. viruses (rubella, respiratory syncytial virus (RSV), cytomegalovirus (CMV), varicellazoster virus
(chickenpox virus), herpes simplex virus, Haemophilus influenzae type b (Hib), Listeria monocytogenes
enterovirus)
4. fungi, and parasites.
• Early-onset neonatal sepsis most often appears within 24 hours of birth.
• The baby gets the infection from the mother before or during delivery.
• The following increases an infant's risk of early-onset sepsis:
1. Group B streptococcus (group b strep) infection during pregnancy
2. Preterm delivery
3. Rupture of membranes (placenta tissue) that lasts longer than 24 hours
4. Infection of the placenta tissues and amniotic fluid (chorioamnionitis) 57
• Babies with late-onset neonatal sepsis get infected after delivery.
• The following increase an infant's risk of sepsis after delivery:
1. Having a catheter in a blood vessel for a long time
2. Staying in the hospital for an extended period of time
• Laboratory tests may include:
1. Blood culture
2. C-reactive protein (CRP)
• Checks for inflammation in the body.
3. Complete blood count (CBC)
4. A lumbar puncture (spinal tap) will be done to examine the cerebrospinal fluid for bacteria.
5. If the baby has a cough or problems breathing, a chest x-ray will be taken.
6. Urine culture tests are done in babies older than several days.
• Symptoms of infection may include the following:
1. apnea (stopping breathing) or difficulty breathing;
2. bradycardia (decreased heart rate);
3. decreased temperature or temperature instability;
4. weak suck;
5. jaundice
• Treatment:
• Babies in the hospital and those younger than 4 weeks old are started on antibiotics before lab results
are back. (Lab results may take 24- 72 hours.)
• ampicillin administered IV during pregnancy and again during labor helps to reduce the possibility of
newborn exposure.
• Nursing Interventions:
1. Assess for periods of apnea or irregular respirations
2. Adm. O2 as ordered
3. Monitor V/S
4. Maintain warmth
5. Provide isolation as necessary
6. Assess for hypothermia or hyperthermia
7. Monitor I & O; observe for dehydration
8. Weigh daily
9. Monitor for diarrhea
10. Assess feeding & sucking reflex
11. Assess for jaundice
12. Assess for irritability & lethargy (CNS involvement)
13. Administer antibiotics as ordered.
Meconium Aspiration Syndrome
Extremely Low Birth Weight
95 above – dapat maoy e maintain OxySat ar
birth
7-10 normal
Ambo bag – longer ang inspiration kaysa
sa expiration = purpose – allow oxygen to enter the alveoli
sign of narrowing---
prominent and chest
