2. Classification of common
neonatal disorders
Birth injuries
Caput succedaneum
Cephalhematoma
Fractures
Facial paralysis
Erb’s/Brachial palsy
3. Classification of common
neonatal disorders(cont…)
Disorders related to physiological factors
Hyperbilirubinemia
Hemolytic disease of the newborn
Respiratory distress syndrome
7. Injuries to the head while
birth
S - Skin
C - Close connective tissue & cutaneous vessels
& nerves.
A - Aponeurosis (epicranial aponeurosis)
L - Loose connective tissue (scalping layer)
P - Periosteum of skull bones
8.
9. Injuries to the head
CAPUT SUCCEDANEUM
A caput succedaneum is an edema of the
scalp at the neonate’s presenting part of the
head
It often appears over the vertex of the
newborn’s head as a result of pressure against
the mother’s cervix during labor.
The edema in caput succedaneum crosses the
suture lines
10. Injuries to the head
CAPUT SUCCEDANEUM
Causes
Mechanical trauma of the initial portion of
scalp pushing through a narrowed cervix
Prolonged or difficult delivery
Vacuum extraction
11. Injuries to the head
Cephalhematoma
It is a collection of blood between the
periosteum of a skull bone and the bone
itself. It occurs in one or both sides of the
head
The swelling with cephalhematoma is not
present at birth rather it develops within the
first 24 to 48 hours after birth.
Has clear edges that end at the suture lines
12. Injuries to the head
Cephalhematoma Causes
Rupture of a periostal capillary due to the
pressure of birth
Instrumental delivery
13. Injuries to the head
Nursing care management
It is directed toward assessment and
observation of the common scalp injuries and
vigilance in observing for possible associated
complications such as infection or acute
blood loss and hypovolemia.
Because of the visible injuries resolves
spontaneously, parents need reassurance of
their usual benign nature.
14. Fractured clavicle
Bone most frequently fractured during
delivery
Associated with CPD
Signs:
limited ROM,
crepitus,
cries of pain when arm is moved,
absent Moro reflex on Affected side
15. Fractured clavicle
Heals quickly, handle gently, immobilize arm,
eliciting scarf sign is contraindicated.
Any newborn that weighs more than 3855g
and is delivered vaginally should be evaluated
for a fractured clavicle.
16. Fractured clavicle
Nursing Management
Often no intervention is needed other than
maintaining proper alignment, careful
dressing and undressing of infant.
Supporting the patient from upper and lower
back other than from under the arms should
be practiced.
The parents should be involved in the care.
17. Facial paralysis:
From pressure on facial nerve
during delivery
Affected side unresponsive when
crying
Resolves in hours/days
NURSING MANAGEMENT-
a) Feedings may be given by gavage
in order to prevent aspiration
b) Since the eye on the effected side
cannot be closed completely, it is
covered with an eye shield to
prevent drying of the conjunctiva
and cornea.
18. Erb’s Palsy (Erb- Duchenne
Paralysis)
Associated with stretching
or pulling head away from
shoulder during delivery
Signs: Flaccid arm, elbow
extended, hand rotated
inward, Moro & grasp
reflexes absent on affected
side
Requires immobilization &
reposition q 2 to 3 hr.
19. Erb’s Palsy (Erb- Duchenne
Paralysis)
NURSING MANAGEMENT-
a) The goal is to prevent
contractures in the paralyzed
muscles.The arm should be
partially mobilized in a position of
maximum relaxation so that the
non-paralyzed muscles cannot
exert pull on the affected muscles.
b) By use of a splint or brace when
upper arm is paralyzed, the arm is
abducted 90 degrees and rotated
externally at the shoulder with the
elbow flexed so that the palm of
the hand is turned towards the
head.
20. Erb’s Palsy (Erb- Duchenne
Paralysis)
When any form of immobilization is used, the
fingers and the hand should be observed for
coldness and discoloration and the skin for
the signs of irritation.
21. Hemolytic disease of the
newborn Rh +ve blood – D antigen
Rh -ve blood – lacks this D antigen
22. Hemolytic disease of the
newborn
When Rh-positive blood is infused into an Rh-
negative woman through error or when small
quantities (usually more than 1 mL) of Rh-
positive fetal blood containing D antigen
inherited from an Rh-positive father enter the
maternal circulation during pregnancy, with
spontaneous or induced abortion, or at
delivery, antibody formation against D
antigen
24. Hemolytic disease of the
newborn
“Why the fetus is affected in second delivery
and not in first delivery?”
25. Hemolytic disease of the
newborn
As the mixing of blood usually occurs at the
time of delivery so by the time antibodies are
formed the baby is already delivered.
26. Hemolytic disease of the
newborn
But what if the mixing of blood occurs before
the delivery? Lets say during some procedure
like amniocentesis or chorionic villi sampling?
Now will the fetus be at risk?
28. “But why fetus ain’t at risk
during 1st pregnancy even if the
blood is mixed before delivery?”
29. Hemolytic disease of the
newborn
The answer is because of the type of
antibodies formed during first and second
delivery.
30. Prevention of hemolytic
disease.
Prevention: Rhogham/Anti-
RhD in un-sensitized mothers
Treatment of a mother with
Anti-RhD antibodies prior to
and immediately after trauma
and delivery destroys Rh
antigen in the mother's
system from the fetus
31. Hemolytic disease of the
newborn
Diagnosis:
Indirect coombs test in mothers-antigen
direct coombs test in infants with Rh-ve
mothers-antibodies
32. Hemolytic disease of the
newborn
Treatment: IVIG is given in infants, exchange
transfusion and phototherapy.
33. Hemolytic disease of the
newborn
Nursing management:
1. Early recognistion of Jaundice
2. If an exchange transfusion is
required then the nurse
prepares the infant and family
and assists the physician.
3.The nurse documents the
blood volume exchange.
34. Hemolytic disease of the
newborn
4. Signs of blood
transfusion reaction are
need to be monitored.
5.Throughout the
procedure infant’s
thermoregulation need
to be monitored.
6. After the procedure the
nurse monitors the
umblical cord for any kind
of bleeding.
35. Neonate Respiratory distress
syndrome/ hyaline membrane
disease
RDS occurs primarily in premature infants;
its incidence is inversely related to gestational
age and birth weight.
It occurs in 60–80% of infants less than 28 wk of
gestational age,
In 15–30% of those between 32 and 36 wk,
In about 5% beyond 37 wk,
and rarely at term.
36. Neonate Respiratory distress
syndrome
The condition occurs due to lack of
pulmonary surfactant because of immaturity
of the lungs.
Surfactant helps in reducing the surface
tension of alveoli.
When surfactant active material is deficient in
the alveoli, there is alveolar collapse during
expiration
37. Neonate Respiratory distress
syndrome
The pulmonary immaturity of the fetal lungs
can be assessed by determination of
lecithin/sphingomyelin ratio in the amniotic
fluid
L/S ratio is 2 or more suggestive of adequet
lung maturity, while a ratio of less than 1.5 is
often associated with HMD
38. Neonate Respiratory distress
syndrome
Clinical features
This is characterized by a triad of tachypnea,
expiratory grunt and inspiratory retractions in
a preterm.
These symptoms may begin at birth or within
6 hours of birth.
There is a gradual worsening of retrations,
grunting and cyanosis.
39. Neonate Respiratory distress syndrome/ hyaline
membrane disease
Management
Premature labor should be arrested by
appropriate tocolytic therapy to gain
pulmonary maturity.
The induction of labor should be delayed
as far as the lung maturity is confirmed by
l/S ratio.
When premature labor below 34 weeks of
gestation is unavoidable, the mother
should be given betamethasone 12mg IM
every 24hrs for two days or
dexamethasone 6mg IM four doses at an
interval of 12hrs.
40. Neonate Respiratory distress
syndrome
The infant should be nursed in a
thermoneutral env and administered
oxygen through head box.
An IV line should be established to
maintain fluid and electrolyte balance, for
correction of acidosis and administration
of drugs.
Intratracheal administration of surfactant
should be done
SPo2 should be monitored
If infant cant monitor Spo2 above 90
despite of giving oxygen via hood the
infant should be put on CPAP
41. Neonate Respiratory distress
syndrome
If CPAP is also ineffective then the
infant should be put on IPPV
Acid-base parameters should be
monitored
Unmonitored oxygen levels may lead
to retinopathy of prematurity to
oxygen toxicity.
42. Neonate Respiratory distress
syndrome
Antibiotics are given in case of
superadded infections
The management of HMD requires
supportive care by trained nurses and
the availability of high technology to
monitor and manage the hypoxia due
to ineffective ventilation.
43. Neonate Respiratory distress
syndrome/ hyaline membrane
disease
Nursing management
Effective ventilation and oxygen
therapy
Equipment should be ready and in
working condition
Oxygen must be warm and humidified
The condition of the infant can change in
a fraction of a second so it is vital for the
nurse to monitor neonate’s color, level of
activity and to note blood gas
measurements.
When o2 is given, tracheal and
nasopharengial suctioning and chest
physical therapy is required.
44. Neonate Respiratory distress
syndrome/ hyaline membrane
disease
Optimal environmental temperature:The
nurse has a important role in providing
regulation of surrounding temperature.
Adequate nutrition: proper gavage
feedings at proper intervals is necessary
nursing action.
Minimal handling of critically ill infants.
Use of aseptic techniques.
Infants should be positioned with head
elevated to decrease pressure on
diaphragm.
45. Necrotising Enterocolitis (NEC)
This is characterized by necrosis of intestinal
wall , is a serious life threatening condition
that is being diagnosed with increasing
frequency in premature infants.
46. Necrotising Enterocolitis (NEC)
Factors that place the infant at risk of this
disease include:
Perinatal asphyxia
Low apgar score
IRDS
Sepsis
Enteral feedings
Congenital cardiac disease
Relative ischemia of the intestinal tract that is due to
hypotension
Use of umbilical catheters
Exchange transfusion
47. Pathophysiology
Factors
Depletion of the normal
blood flow
Ischemia with a reduction
in the protective mucosa.
Intestinal enzymes further
destroy the mucosal layer
48. Bacteria increases in the
presence of carbohydrate in
the infants feeding and form
gas
Intestines become dilated,
become necrotic
Necrosis may involve the full
thickness of the intestinal
wall leading to ultimate
perforation
50. Necrotising Enterocolitis
(NEC
Nursing management
As soon as the diagnose of NEC is
made the oral feedings are
discontinued and peripheral IV
fluids are given to the infant.
Palpation of abdomen, abdominal
girth are checked daily
Bowel sound monitoring
TPN is to be started
51. Necrotising Enterocolitis
(NEC
I/v antibiotics are started to
against gram negative enteric
organisms
Rectal temperature is not taken
so as to prevent rectal
perforation
Affected infants are to be
placed in isolation
52. Necrotising Enterocolitis
(NEC
These infants are not diapered
because of the increased risk of
intra-abdominal pressure.
These infants are nursed on their
back as much as possible to
reduce the external pressure on
the abdomen
Postoperatively , as the suture
line is close to stoma so
measures should be taken to
avoid any infection to suture
line.
54. Neonatal Sepsis
Systemic bacterial infections of
newborn infants are termed as
neonatal sepsis
They are the most common cause of
neonatal deaths in Indianatal sepsis
This is a generic term which
incorporates neonatal septicemia,
pneumonia, meningitis and urinary
tract infections
55. Neonatal Sepsis
Neonatal sepsis can be divided into two
types
Early onset: this happens in first 72
hours of life
This is mainly due to organisms
present in:
the genital tract or
in the labor room or
in maternity operation
56. Neonatal Sepsis
Late-onset: this is caused by the
organisms thriving in exter
The infection is often transmitted
by the care givers.
57. Neonatal Sepsis
The predisposing causes of LOS are
:
Lack of breast feeding
Superficial infections
Aspiration of feeds
Disruption of skin integrity with
needle pricks and use of IV fluids
External env of homes or hospital.
58. Neonatal Sepsis
Clinical features:The manifestations
of neonatal sepsis are often vague
and nonspecific demanding high
index of suspicion for early
diagnosis.
Any altern in feeding patterns
Active baby suddenly becoming
lethargic
59. Hypothermia in preterms and fever in
term babies especially in association
with gram –positive infections and
meningitis.
Diarrhea, vomiting and abdominal
distention
Jaundice and hepatosplenomegaly
may be present
Episodes of apneic spells with
cyanosis may also be one of the sign.
61. Neonatal Sepsis
Nursing Management:
Hand washing and thorough
scrubbing with soap and water
upto elbows for at least 2mons,
gowning and change of shoes
are mandatory.
Rings, bangles and
wristwatches should be
removed
Strict hand washing for 20 secs
and use of antiseptic solution in
between handling babies.
62. Neonatal Sepsis
4. Babies should be fed
early and exclusively on
breast milk.
5. Careful attention should
be paid to hygiene of the
katori and spoon.
6.The umblical stump
should be left open. Local
application of spirit
reduces colonization.
63. Neonatal Sepsis
All procedures should
be done wearing mask.
Unnecessary needle
pricking should be
avoided.
Strict housekeeping
routines for washing ,
disinfection, cleaning of
cots/incubators should
be ensured .
64. Infants of diabetic mothers IDM
There has been
continuing
improvement in the
care of mothers with
diabetes mellitus and
their neonates,
resulting in a decline
in the morbidity and
mortality rates
65. Infants of diabetic mothers IDM
Clinical manifestations of IDM:
Large for gestational age
Very plump and full faced
Abundant vernix caseosa
Pleothora
Listlessness and lethargy
Large placenta and umblical
cord
Possibly meconium stained at
birth
66. Infants of diabetic mothers IDM
Therapeutic management
The most common management of IDMs
is careful monitoring of serum glucose
levels and observation for accompanying
complications such as RDS.
Studies confirm that maintaining blood
glucose level more than 50mg/dl in IDMs
with hypoglycemia prevent serious
neurological conditions.
Oral and IV backup may be titrated to
maintain adequate blood glucose levels.
67. Nursing care management
Early introduction of carbohydrate
feedings as appropriate
Serum glucose monitoring.
Because macrosomic infants are at
high risk for problems associated
with difficult delivery, they are
monitored for birth injuries.
There is some evidence that IDMs
have an increased risk of acquiring
type 2 DM during childhood or
early adulthood therefore a nurse
should also focus on healthy
lifestyle and prevention later in life
with IDMs.
68. References
WONG’S ESSENTIAL OF PAEDIATRIC
NURSING 8TH EDITION
NELSON’STEXTBOOK OF PEDITRICS
15TH EDITION
http://www.imedicine.com /display
topic
DOROT HY R.M.MARLOWAND
BARBARAA. REDDING’STEXTBOOK
OF PEDIATRIC NURSING 6TH EDITION
Www.wikipedia.org
Textbook of Indian academy of
pediatrics