Complication

s of the
Newborn
 Term (37 0/7- 41 6/7)
Classification Preterm < 37 0/7 weeks
s of Infants
Post-term >42 0/7 weeks

By weight (SGA, AGA, LGA, IUGR)

Birth Weight
Classifications:
• SGA- weight below 10th
percentile
• AGA- appropriate for
gestational age
• LGA- Large for gestation,
weight above 10%tile
• IUGR- intrauterine
growth restriction
• Macrosomic >4000
grams
Preterm Infants
• Infants born <37 weeks gestation
• Majority are Late Preterm – Approx.
75%
• Classified by:
• Birthweight (SGA, LGA, AGA)
• Small for gestational age
• Large for gestational age
• Appropriate for gestational age
• Gestational Age
• Contributory factors
• Heredity
• Placental insufficiency
• Maternal disease processes
• Genetics
Late Preterm Infants: 34
0/7-36 6/7 weeks
• Related to medically-indicated deliveries rates (vaginal and c/s before 39
weeks generally due to maternal or fetal complications of the pregnancy
that preclude safe continuation of the pregnancy to term)
• Largest portion of preterm infants
• “Just a little small” “the great imposters”
• Increased risk for:
• Respiratory distress syndrome (RDS)
• Temp instability
• Hypoglycemia
• Apnea
• Feeding difficulties
• Hyperbilirubinemia
• Key: Identify these infants- Gestational Age Assessment
(Dubowitz/Ballard)
Common Preterm
Infant Complications:
• Respiratory Distress Syndrome (RDS)
• Bronchopulmonary Dysplasia (BPD)
• Hypothermia
• Sepsis
• Nutritional problems and Necrotizing Enterocolitis (NEC)
• Anemia of Prematurity
• Apnea of prematurity
• Hyperbilirubinemia
• Developmental delays
• Retinopathy of prematurity (ROP)
• Hemorrhage into ventricles of the brain (IVH)
Term: 38 0/7 – 40 6/7
weeks
• Best Outcomes- long and short term
• Fewest Complications- if occurring usually
short in duration
• Can be classified as LGA, AGA, SGA,
IUGR(intrauterine growth restricted),
Macrosomic
Post Term Infants >/= 42 weeks
• Can be SGA, AGA, LGA • Significant increase in fetal and
• Wasting of muscle neonatal mortality
• Placenta insufficiency: IUGR • Decreased amniotic fluid
• Skin • Perinatal asphyxia
• Little to no vernix • Prone to fetal distress:
• Absence of lanugo • Placental insufficiency
• Abundant scalp hair • Macrosomia
• Skin is often cracked, parchment like
and peeling • Meconium-stained amniotic fluid
• Long Fingernails
• Creases cover soles of feet
• Breast buds well formed
 • Term Complications can still occur: • Post-Term:
Term and • If optimal transition does not • Significant increase in fetal and
neonatal mortality
occur
Post-Term • Affected by maternal disease • Decreased amniotic fluid
• Perinatal asphyxia
or IUGR (hypoglycemia,
Infant hypothermia, RDS),
hyperbilirubinemia etc.
• Prone to fetal distress:

Complication
• Placental insufficiency
• Affected by maternal infection • Macrosomia
• More often seen in LGA, SGA
s or IUGR infants
• Meconium-stained
amniotic fluid

• Common term complications: • Common Post- Term Complications:

• RDS • Meconium-Stained Amniotic
Fluid
• Hyperbilirubinemia • Macrosomia leads to birth
trauma
• Wasted physical appearance
 Respiratory
Complications
• What are these and who do they affect?
• Meconium Aspiration Syndrome (MAS)
• Respiratory Distress Syndrome (RDS)
• Transient Tachypnea of the Newborn
(TTN)
• Bronchopulmonary Dysplasia (BPD)
• Apnea of Prematurity
Meconium Aspiration Syndrome
• Largely affects post-term infants but can be
seen in Term Infants • Can also cause chemical pneumonitis or
pneumonia resulting in:
• What is Meconium Aspiration Syndrome?
• Tachypnea and deactivation of surfactant
• Meconium is aspirated into the airways • May lead to Persistent Pulmonary
• As a result of gasping respirations in Hypertension
utero • Rarely occurs before 38 weeks gestation
• Or the initial breaths following birth • Nursing care and Priorities:
• Can lead to mechanical obstruction of • Minimize work of breathing
the airways and air trapping • Neutral thermal environment
• 8% of all newborns exposed to • Nutrition
meconium develop MAS • Comfort
Transient Tachypnea of the Newborn (TTN)
• What is TTN? • Nursing Care & Priorities
• Delayed clearance of fetal lung • Monitor respiratory rate
fluid from lungs • No or limited PO feeding
• More likely to occur in babies • Minimal exertion
delivered via c/s-labor did not occur
before birth • Supplemental oxygen
• Respiratory rate > 60 breaths/min.
• Signs/ Symptoms:
• Grunting, retracting, cyanosis
Respiratory Problems –Preemie
• Decreased number of functional alveoli
• Deficient surfactant levels
• Small airways
• Greater collapsibility or obstruction of respiratory passages
• Bones of thorax not calcified
• Weak or absent gag reflex
• Immature and friable capillaries in the lungs
• Greater distance between functional alveoli and the capillary bed
 Respiratory Distress Syndrome (RDS)
• What is RDS?
• Breathing disorder caused by immature lungs
• Lack of surfactant
• The more premature (earlier the gestation) the higher the chance of RDS
• Who is affected? RDS increases with…
• Most common in premature infants born <34 weeks
• Others affected
• IDM infants
• C/S or induced infants born before full-term
• Problems that reduce blood flow to infant
• Rapid labor, multiple pregnancy, asphyxiated infants

• RDS decreases with:

• Prolonged or premature ROM
• IUGR
• Maternal pre-eclampsia
• Prenatal corticosteroids
 Tocolysis: medications that help reduce or slow the
contractions and labor progression
Care
Priorities
for a Patient Tocolytics are contraindicated in the presence of
infection (chorioamnionitis) ruptured membranes,
Threatening or any circumstance when prolonging the
pregnancy would threaten the life/health of the
Preterm patient or fetus.

Delivery: The primary goal of tocolysis is to prolong the

pregnancy to allow for completion of antenatal
Tocolysis corticosteriods and magnesium sulfate. Both of
these drugs significantly improve outcomes in the
premature infant.
Care Priorities for A Patient
Threatening Preterm Delivery
Corticosteroids Magnesium Sulfate
• (betamethasone, 12mg IM) • IVPB infusion given if a patient threatening to deliver prior
• 2 doses to 34 weeks-if preterm delivery is imminent
• 24 hours apart • Magnesium sulfate has a neuroprotective effect on the
• Accelerates surfactant production in the preterm infant preterm infant
• Magnesium sulfate therapy decreases the preterm
• Decreases the risk of IVH (intraventricular hemorrhage)
newborn risk for:
• Decreases the risk of NEC(necrotizing enterocolitis) • intraventricular hemorrhage (IVH)
• Cerebral palsy (CP
• Risks to mom:
• Decreased incidence of substantial gross motor dysfunction
• Hyperglycemia
• Antidote is calcium gluconate
• Increased edema
• Pulmonary edema • Maternal Care:
• Vital signs
• DTRs
• I&O
 Respiratory Distress Syndrome

• S&S present 4-24 hours of life

• Signs/Symptoms:
• Rapid shallow breathing
• Retractions- sharp pulling in of the chest
• Grunting
• Nasal Flaring
• Tachypnea then apnea
• Decreased breath sounds
• Fine Rales
• Generalized cyanosis
• Shortness of breath
• Worsens over first 48 hours
• Usually Improves within 72 hours of life
RDS (continued)
• Detected by blood gas • Surfactant
• Low O2 • Fetus begins producing between
• Excess acid in body 24-28 weeks
• Chest X-ray (ground glass • Composed of lipids and proteins
appearance • Reduces surface tension
• Treatment: • Equalizes pressure between large
and small spaces
• Warm moist oxygen
• Prevents alveoli from collapsing
• Exogenous Surfactant
• Administered through the
• Occasionally the ventilator
endotracheal (ET) tube
BPD and Apnea of Prematurity
• Broncho-Pulmonary Dysplasia (BDP) • Apnea of Prematurity
• Affects premature infants • Premature infants
• Chronic pulmonary condition • Most often due to immature neurological
• Etiology: multifactorial, includes system
• Pulmonary immaturity • Can be due to infection or other causes
• Surfactant deficiency • Defined as Respiratory pauses >20 seconds
• Lung injury and stretch
associated with:
• Barotrauma
• bradycardia (<80 beats/min)
• Inflammation caused by oxygen exposure
• central cyanosis
• Inadequate nutrition
• and/or oxygen saturation <85%
• Fluid overload
• Reduction in incidence seen due to maternal
steroids
• Treatment:
• Treatment: • Control of body temperature
• Proper body position of airway
• oxygen therapy
• Extra oxygen
• Nutrition
• fluid restriction
• Medications such as caffeine
• medications (diuretics, corticosteroids, and
bronchodialators)
Neurodevelopmental Complications- IVH:

• What is Intraventricular Hemorrhage (IVH)?

• Hemorrhage into ventricles of the brain
• Occurs when tiny blood vessels rupture
• Large clots can form and obstruct flow of CSF
• Affects premature infants
• Risk Increases with decreasing gestational age.
• Decline in incidence due to prenatal steroids and postnatal use of
surfactant
• Majority diagnosed within first 2 weeks of life
• Can be asymptomatic, develop symptoms gradually, or have acute
presentation
IVH (continued)
• Signs/symptoms:
• Decreasing hematocrit
• Full anterior fontanelle
• Changes in activity level
• Decreased muscle tone

• Morbidity and mortality associated with severity of

hemorrhage and associated problems
• Care management: steroids prenatally, prompt
resuscitation
• Nursing care:
• Interventions to decrease risk of bleeding and
supportive care to infants who have bleeding
episodes.
• Ongoing assessment of vulnerable infants- monitor
oxygenation and perfusion, avoid or min activities
that increase cerebral blood flow.
• Avoid rapid infusions
 Neurodevelopmental Complications
Developmental Delays
• Preterm infants most affected due to underdeveloped neurological
system
• Increased risk for neurologic and cognitive disabilities, particularly
learning disabilities.
• Growth and development corrected for prematurity
• Catch up-> 2.5 years old
• Term/Post Term can also have delays
• Asphyxia, severe sepsis, respiratory complications, etc.
• Delays: Feeding difficulties, speech, motor, cognitive.
Hypothermia
• High risk infants are susceptible to heat loss and its complications • Signs/symptoms:
• Low birth weight infants
• Pale
• Preterm Infants
• mottled
• Due to limited capacity to increase metabolic rate
• skin is cool to touch
• Immaturity of skin Increased transepidermal water loss
• Acrocyanosis
• Treatment:
• respiratory distress
• warm bed
• prewarmed isolette • Hypoglycemia
• plastic bag to dec. heat and water loss
• skin to skin between stable infant • As hypothermia worsens infant can have apnea,
• Nursing Care: Maintain thermoneutral condition brady and central cyanosis.
Retinopathy of Prematurity (ROP)
• Only effects preemies
• Complex multifactorial disorder that affects developing retinal vessels
• Oxygen toxicity can lead to ROP
• Leads to damage and scarring of retina
• Visual impairment
• Premature infants <1500 grams at birth and/or <31 weeks should be seen by
opthamologist prior to discharge
• Management/prevention
• Closely monitor blood oxygen levels
• Treatment:
• Laser surgery
• Intra-ocular injection- inhibit vascular endothelial growth factor
Gastrointestinal Complications: Feeding
difficulties
• Can affect preterm, term and post- term infants but primarily affects preterm
infants
• Weak, absent, suck, swallow and gag reflexes
• Difficulty coordinating suck, swallow and breath
• Small stomach capacity
• Decreased gastric emptying time
• Weak abdominal muscles
• Nutrition problems -> poor weight gain
• Preterm, and SGA or IUGR term/post-term infants
• Preterm-complicated by problems with intake and metabolism
• Preterm metabolic functions are compromised by
• Limited store of nutrients
• Decreased ability to digest proteins or absorb nutrients
• Immature enzyme system

• Nursing management: continually assess infants feeding tolerance.

• May need NG/OG feeds instead of oral.
 • Blood glucose level lower than 40 in the • Signs/Symptoms:
GI: first 72 hours
• Jitteriness
Hypoglycemi
• Glucose levels stabilize by 2-3 days of life
• Lethargy
• Can lead to neurological injury if persists
• Poor feeding
a • Infants at risk for Hypoglycemia
• SGA
• Abnormal cry
• LGA • Hypotonia
• preterm • Temperature instability
• low birth weight • Respiratory distress
• Infant of Diabetic Mothers (IDM) • Apnea
• Infants who experience perinatal
stress • Seizures
• asphyxia, cold stress or • Management:
respiratory distress
• Early and frequent feeds.
• those with active infection
• Monitor blood sugar
levels in at risk infants
GI- Necrotizing Enterocolitis (NEC)
Necrotizing Enterocolitis (NEC) –

• Acute inflammatory disease of the GI mucosa, commonly complicated by bowel necrosis and perforation
• Intestinal ischemia occurs as a result of asphyxia/hypoxia or redistribution of blood flow away from GI tract
(hypotension, hypovolemia, stress etc.)
• Bacterial colonization of the GI tract with harmful organisms
• Enteral feeds

More than 90% are preterm

Breastmilk and probiotics - protective effect against NEC

Mortality rate as high as 40%

GI- NEC
Signs/symptoms:
Diagnosis:
• decreased activity,
• hypotonia, • X-ray
• pallor,
• Labwork
• recurrent apnea and bradycardia,
• decreased oxygen saturation,
• respiratory distress,
• metabolic acidosis,
• oliguria, Treatment:
• hypotension,
• NPO
• decreased perfusion,
• temp instability • Decompression of stomach
• cyanosis. • Antibiotics
• May need surgery

GI symptoms:
• abdominal distention,
• increasing or bile stained residual gastric aspirates,
• grossly bloody stools,
• abdominal tenderness
• erythema of abdominal wall.
 •These can all occur with
term or preterm infants.

• Anemia
Hematology • Thrombocytopenia

complications: • Hyperbilirubinemia
Hyperbilirubinemia
• Physiologic
• Most common
• After 24 hours of age
• More common in LPI (late preterm) and preterm infants
• Rapid breakdown of RBC
• Immature liver
• Dehydration
• Pathologic
• Before 24 hours of age
• Greater than 14 days of life
• Associated with bilirubin encephalopathy or kernicterus
• Causes:
• ABO incompatibilities
• Maternal infections
• Maternal diabetes
• Maternal ingestion of sulfonamides, diazepam or
salicylates near term
Hyperbilirubinemia- Nursing Care Priorities

Phototherapy-position
Increase PO intake light at least 10 cm from Protect eyes Skin care – frequent stools
infant

Make sure no ointments

or creams applied to body
Reposition frequently Discharge Teaching Feed frequently
when receiving
phototherapy

Count number of diapers

(bilirubin is excreted
Observe for lethargy through urine & stool) Follow up appointments
• wet – 6-8/day
• soiled diapers 1/day
Hemolytic disease of the newborn
• This may occur with term, post-term or preterm infants.
• Blood group of mother and baby are different
• Occurs when maternal antibodies cross the placenta, cause hemolysis of the fetal
RBC’s -> resulting in possible hyperbilirubinemia, jaundice anemia
• If a mother is exposed to an incompatible blood type, form antibodies against the
antigen in that blood.
• 4 Major Blood groups/ Blood types
• A, B, AB, O
• Rh Factor
• Genetically determined factor present on RBC’s
• Rh factor present - positive
• Rh factor not present - negative
Hemolytic disease- ABO incompatibility
• ABO Incompatibility
• Most common cause of hemolytic disease
• Of the 20% with ABO incompatibility, only 5% with clinical effects
• Risk factors:
• Occurs with Maternal type O blood & fetal type A, B, or AB
• Mothers immune system may react -> forms antibodies against baby’s RBC
• Diagnosed by: Coombs’ test/ Direct antiglobulin test (DAT)
• If DAT +, obtain cord bili and stat bilirubin level.
• Can cause:
• Mild Anemia
• Hyperbilirubinemia
• Treatment: Phototherapy, fluids, IVIG, occasionally exchange transfusion
Hemolytic Disease- RH factor
• Rh Incompatibility
• Occurs when maternal antibodies are present or develop in response to exposure to an antigen (different blood
type)
• Maternal sensitization
• Maternal antibodies cross the placenta
• Causes hemolysis of fetal RBC’s
• Isoimmunization – leading to fetal anemia
• Erythroblastosis Fetalis – immature erythrocytes
• Worst with consecutive pregnancies
• RhoGam (immunoprophylaxis) given for Rh - mothers
• Significant decrease in incidence of Rh incompatibility
• Given at 28 weeks and if any incidence of bleeding
 Seen with preterm or term or post term infant

Preterm increased risk d/t:

• Shortage of stored maternal immunoglobulins
• Impaired ability to make antibodies
• Compromised integumentary system.

Infection Risk factors for infection:

• Maternal source: Positive GBS, low SES, late or no prenatal care, poor
nutrition, substance abuse, recently acquired STI, untreated focal infection
(UTI, vaginal or cervical), systemic infection, fever.
• Intrapartum: Prolonged or premature rupture of membranes, maternal
fever, chorioamnionitis, prolonged or preterm labor, use of fetal scalp
electrode, Positive group B strep with insufficient treatment in labor
• Neonatal: multiple gestation, male, birth asphyxia, meconium, congenital
anomalies of skin or mucus membranes, metabolic disorders, low birth
weight, preterm birth, malnourishment, formula feeding, prolonged
hospitalization, mech vent, umbilical or central lines.
 Signs of neonatal sepsis:
• Earliest signs can be non-specific and include: lethargy, poor feeding
and temperature instability.
• May see signs of anemia or hypoglycemia
• May also see: irritability, lethargy, poor feeding, apnea, abnormal
temp, bleeding problems, cardiovascular, cyanosis, GI, jaundice,
respiratory distress
• Parent may just say infant not doing well.

Infection Diagnose:
• Lab studies: bloodwork, cerebrospinal fluid(CSF) and urine culture.
CBC with diff. (leukocyte not reliable indicator of sepsis but can look
at neutrophil count and platelets ) and CRP.

Prevention: hand hygiene, antibiotic ointment to eyes,

cord care
 Neonatal GBS
Group B streptococcal infection
• GBS part of normal vaginal flora
• 25% of pregnant women positive
• Vertical transmission during labor/birth
• Most common cause of neonatal early onset sepsis
• Pregnant women screened between 35-37 weeks for GBS
• Treated with antibiotics during labor
• Adequate treatment at least 1 dose of PCN G greater than or equal to 4
hours prior to delivery
• Occurs in the first 7 days of life, usually first 24 hours (early onset)
• Risk Factors:
• Low birth weight
• Preterm birth
• ROM
• Maternal fever
• Previous infant with GBS sepsis
• Maternal GBS bacteriuria
• Internal fetal monitoring
Signs/Symptoms of GBS sepsis
(majority symptomatic by 12-24 hours)

• Respiratory distress (tachypnea)

• Tachycardia
• Temperature instability
• Poor feeding pattern
• Cyanosis
• Poor tone/lethargy
• Apnea
• Hypotension
• Can rapidly develop Pneumonia, shock, meningitis
• Mortality rate 5-20%
Evaluation &Treatment- GBS sepsis

• CBC with differential

• Blood cultures
• Arterial blood gas
• Urine culture- no longer routinely done in early infection
• CXR: chest x-ray
• Spinal Tap
• Respiratory support
• Antibiotics: need to cover both gram + and - (ex: ampicillin & gentamycin)
• ECMO in severe cases ( extracorporeal membrane oxygenation. ECMO is similar to
the heart-lung by-pass)
Neonatal Abstinence
Syndrome (NAS)

• Opiods readily cross the placenta and

affect the fetus
• Neonates exposed drug withdrawal
• Neonatal Abstinence Syndrome-
describes the clinical signs associated
with withdrawal from opiods
• Withdrawal worst with larger amounts
of drugs for longer periods
• Severity related to timing of maternal
drug use.
Treatment/Nursing Care for the Infant with NAS

Treating NAS Nursing Care for the Family Experiencing NAS

• IV hydration • Anticipatory guidance: provide education

• Tapering down of narcotic to reduce regarding care, warning signs, feeding,
withdrawal symptoms difficulty soothing

• Assistive feedings, prn • Referrals for support services

• Close observation for complications • Benefits of skin to skin, creating and

maintaing a peaceful environment
• Skin to skin
Complications & Long-Term Implications
of NAS
Complications Long-Term Implications
• Developmental delays. Motor
• Low birth weight (SGA) problems. These are problems with
your baby’s bones, muscles and
• Jaundice movement.
• Seizures • Behavior and learning problems.
• SIDS: sudden infant death • Speech and language problems
syndrome • Sleep problems
• Feeding difficulties • Ear infections
• Vision problems
• Problems with nutrition and growth
Congenital Anomalies Present at Birth
• Genetic or environmental • Cardiac anomalies most common
• Structural or functional • Weeks 3-8 of fetal development
• 3% of births • CNS
• Leading cause of death in infants in • Range from anencephaly to NTD
the first year of life • Folic acid deficiency
• Microcephaly
• Hydocephalus
• Respiratory System
• Congenital diaphragmatic hernia
Congenital Anomalies Present at Birth
• Gastrointestinal • Musculoskeletal
• Cleft Lip and Palate • Hip dysplasia
• Esophageal Atresia
• Clubfoot
• Tracheo-esophageal Fistula
• Omphalocele – bowel in umbilical cord
• Polydactyly
• Gastroschisis – bowel outside abdomen • Syndactyly
• Imperforate anus
• Genitourinary
• Hypospadias/epispadias
• Exstrophy of the bladder
Questions?????