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Assessment of High Risk New Born
Assessment of High Risk New Born
INTRODUCTION
A newborn should have a thorough evaluation performed within 24 hours of birth to identify
any abnormality that would alter the normal newborn course or identify a medical condition
that should be addressed (e.g., anomalies, birth injuries, jaundice, or cardiopulmonary
disorders) . This assessment includes review of the maternal, family, and prenatal history and
a complete examination. Depending upon the length of stay, another examination should be
performed within 24 hours before discharge from the hospital.
The high-risk period begins at the time of viability (the gestational age at which survival
outside the uterus is believed to be possible, or as early as 23 weeks of gestation) up to 28
days after birth and includes threats to Life and health that occur during The prenatal,
perinatal, and postnatal periods.
MEANING OF NEONATE
From birth to under four weeks of age (<28 days), the infant is called neonate or newborn.
First week of life (<7 days or <168 hours is known as early neonatal period. Late neonatal
period extends from 7th to < 28th day.
A newborn regardless of gestational age or birth weight, who has a greater –than average
chance of morbidity or mortality because of conditions or circumstances superimposed on the
normal course of events associated with birth and the adjustment to extrauterine existence.
Encompasses human growth and development from the time of viability ±28 days following
birth and includes threat to life and health that occur during the prenatal, perinatal, and
postnatal periods.
Nurses in newborn nurseries should be familiar with the characteristics of neonates and
recognize the significance of serious deviations from expected observations. When providers
can anticipate the need for specialized care and plan for it, the probability of successful
outcome is increased.
IDENTIFICATION
Perinatal prevention
Resuscitation and stabilization
Evaluate and manage
Monitoring and therapeutic modalities
Family centered care
Classification of High-Risk Newborns
High-risk infants are most often classified according to birth weight, gestational age,
and predominant pathophysiologic problems.
The more common problems related to physiologic status are closely associated with
the state of maturity of the infant and usually involve chemical disturbances (e.g.,
hypoglycemia, hypocalcemia) or consequences of immature organs and systems (e.g.,
hyperbilirubinemia, respiratory distress, hypothermia).
Because high-risk factors are common to several specialty areas-particularly
obstetrics, paediatrics, and neonatology- specific terminology is needed to describe
the developmental status of the newborn.
Formerly, weight at birth was considered to reflect a reasonably accurate estimation
of gestational age; that is, if an infant's birth weight exceeded 2500 g (5.5 pounds), the
infant was considered to be mature. However, accumulated data have shown that
intrauterine growth rates are not the same for all infants and that other factors (e.g.,
heredity, placental insufficiency, maternal disease) influence intrauterine growth and
birth weight.
From these data, a more definitive and meaningful classification system that
encompasses birth weight, gestational age, and neonatal outcome has been developed
Low-Birth-Weight (LBW) Infant—An infant whose birth weight is less than 2500 g
(5.5 lb), regardless of gestational age
Very Low–Birth-Weight (VLBW) Infant—An infant whose birth weight is less than
1500 g (3.3lb)
Extremely Low–Birth-Weight (ELBW) Infant—An infant whose birth weight is less
than 1000 g (2.2 lb)
Appropriate-For-Gestational-Age (AGA) Infant—An infant whose weight falls
between the 10th and 90th percentiles on intrauterine growth curves.
Small-For-Date (SFD) Or Small-For-Gestational-Age (SGA) Infant—An infant
whose rate of intrauterine growth was slowed and whose birth weight falls below the
10th percentile on intrauterine growth curves.
Intrauterine Growth Restriction (IUGR)—Found in infants whose intrauterine
growth is retarded (sometimes used as a more descriptive term for the SGA infant)
Large-For-Gestational-Age (LGA) Infant—An infant whose birth weight falls above
the 90th percentile on intrauterine growth charts
Low Birth Weight - Birth weight less than 2500g regardless of gestational age
Moderately Low Birth Weight - birth weight is between 1501g to 2500g.
Very Low Birth Weight -birth weight is less than 1500g.
Extremely Low Birth Weight - birth weight less than 1000g.
Appropriate for Gestational Age (AGA) - birth weight falls between the 10 and 90
percentile
Small for Gestational Age ( SGA) - birth weight falls below the 10 percentile
Large for Gestational Age (LGA)- birth weight falls above the 90 percentile
Maternal diabetes
Maternal narcotics during labor
Maternal substance abuse
Fetal asphyxia
Difficult/prolonged labor causing birth trauma
Multiple gestation
Preterm or postterm delivery
Congenital anomalies
Maternal or neonatal infection
SGA or LGA
Apgar score < 6 at 1 min or < 7 at 5 min
HIGH RISK NEWBORN ASSESSMENT
SYSTEMATIC ASSESSMENT
Observational assessments of high-risk infants are made accord-ing to each infant's acuity;
critically ill infants require close observa-tion and assessment of respiratory function,
including continuous pulse oximetry, electrolytes, and evaluation of blood documentation of
the infant's status is an integral component of gases. Accurate nursing care. With the aid of
continuous, sophisticated cardiopulmonary monitoring, nursing assessments and daily care
may be coordinated to allow for minimal handling of the infant (especially VLBW or ELBW
infants) to decrease the effects of environmental stress.
GENERAL ASSESSMENT
Using an electronic scale, weigh daily, or more often if indicated. Measure length and
head circumference at birth.
Describe general body shape and size, posture at rest, ease of breathing, presence and
location of edema. Describe any apparent deformities. Describe any signs of distress-
poor color, hypotonia, lethargy, apnea.
RESPIRATORY ASSESSMENT
CARDIOVASCULAR ASSESSMENT
GASTROINTESTINAL ASSESSMENT
GENITOURINARY ASSESSMENT
NEUROLOGIC-MUSCULOSKELETAL ASSESSMENT
TEMPERATURE
APGAR SCORE
INTRODUCTION:
DR.virginiaapgar created the system in 1952 and used her name as a nemonic for
each of the five categories that a person will score .since that time the medical
professional across the world have used the scoring to assess the newborn in their
moment of life.
The medical professor use this assessment to quickly relay the status of a newborn‘s
overall condition. Low apgar score may indicate the baby needs special care such as
extra help with their breathing.
Usually after birth, a nurse or doctor may announced the apgar scores to the labor
room.
This lets all present medical personnel know how a baby is doing even if some of the
medical personnel are tending to the mom.
When a parents hears these numbers they should know they are one of many different
assessment medical provider will use. Other example: includes heart rate monitoring
and umbilical artery blood gases. However, assigning an apgar score is a quickly way
to help other understand the baby’s condition immediately after birth.
DEFINITION:
The apgar scoring is a scoring system doctors and nurse use to assess newborn one
minutes and five minutes after the are born.
The score is named for these prominent American anesthiologist Dr. Virginia apgar
(1909 – 1974). Who invented the scoring method in 1952.
APGAR SCORE:
0 1 2
Limp, flaccid =0
Some flexing or bending=1
Active motion=2
2. Heart rate:
Absent heartbeat=0
Slow heartbeat (less than 100 beats/minutes) = 1
Adequate heartbeat (more than 100 beat/ minutes) = 2
0 - little or no heartbeat.
3. Reflex:
No responds = 0
Grimace (facial expression) = 1
Vigorous cry or withdrawal=2
4. Colour:
Pake or blue =0
Normal body color, but blue extremities (arm, and legs) =1
Normal color=2 completely pink.
5. Respiration:
Breathing effort:
CLINICAL SIGNIFICANT:
INTRODUCTION
A method to determine the gestational age is New Ballard Scale (NBS). It was
proposed by Dr. Jenne L Ballard in 1991. NBS assesses 6 external physical and 6
neuromuscular signs of maturity. Assessment of gestational age from 20 to 44 weeks Scores
range from -10 to +50 .Optimal time for assessment if from birth to 90 hours
DEFINITION
Gestational age assessment means figuring out the number of weeks of your
pregnancy. A full-term pregnancy is usually 40 weeks. It's important to assess if gestational
age is uncertain or if your baby is smaller or larger than expected.
A fetus or newborn infant whose size is within the normal range for height, weight,
head size, and developmental level for a child of the same gestational age and gender. Full-
term infant is heavier than 2,5kg and lighter than 4 kg.
The new Ballard score is commonly used to determine gestational age. Here’s
how it works
Scores are given for 6 physical and 6 nerve and muscle development
(neuromuscular) signs of maturity.
The scores for each may range from -1 to 5.The scores are added together to
determine the baby’s gestational age. The total score may range from -10 to
50.
Premature babies have low scores. Babies born late have high scores.
Newborn physical examination findings also allow clinicians to estimate gestational age
using the new Ballard score. The Ballard score is based on the neonate's physical and
neuromuscular maturity and can be used up to 4 days after birth (in practice, the Ballard score
is usually used in the first 24 hours). The neuromuscular components are more consistent
over time because the physical components mature quickly after birth.
Neuromuscular components can be affected by illness and drugs (eg, magnesium sulfate
given during labor). Because the Ballard score is accurate only within plus or minus 2 weeks,
it should be used to assign gestational age only when there is no reliable obstetrical
information about the estimated date of confinement or there is a major discrepancy between
the obstetrically defined gestational age and the findings on physical examination.
Muscle tone: progressively increases in utero as maturity proceeds. The tone in the newborn
baby is assessed by 3 parameters.
a) Posture or attitude
Joint mobility: The degree of flexion at ankle and wrist (square window) is limited in the
preterm babies because of relatively greater stiffness of joints in early gestation. As term
approaches the joints become more flexible and relaxed to allow for easy moulding during
delivery.
Certain automatic reflexes: It appears at specific ages of gestational maturity e.g. Moro
reflex appears as early as 28 to 30 weeks but lacks complete adduction phase till 38 weeks of
gestation.pupillary response to light is present after 30 weeks and infant may turn his head
towards diffuse light during 32-36 weeks of gestation. Grasp response makes its appearance
around 30 weeks but a strong grasp is elicit able after 36 weeks. neck flexors are able to
contract in response to traction around 33 weeks of maturity. Rooting and co-ordinate
sucking efforts are present by 34 weeks of gestation.
Fundus examination: The disappearance of the anterior vascular capsule of the lens has
been used to assess the gestation age. After 34 weeks of maturity anterior capsular vessels are
almost completely atrophies with graded changes in babies between 28 and 34 weeks of
gestation.
Posture. How the baby holds his or her arms and legs.
Square window. How far the baby's hands can be flexed toward the wrist.
Arm recoil. How well the baby's arms spring back to a flexed position.
Popliteal angle. How well the baby's knees bend and straighten.
Scarf sign. How far the elbows can be moved across the baby's chest.
Heel to ear. How close the baby's feet can be moved to the ears.
Posture. Score 0 if the arms and legs are extended, and score 1 if the infant has
beginning flexion of the knees and hips, with arms extended
Square window. Flex the hand on the forearm between the thumb and index finger of
the examiner. Apply sufficient pressure to achieve as much flexion as possible.
Visually measure the angle between the hypothenar eminence and the ventral aspect
of the forearm
Arm recoil. Flex the forearms for 5 s; then grasp the hand and fully extend the arm
and release. If the arm returns to full flexion, give a score of 4. For lesser degrees of
flexion, score as noted on the diagram.
Popliteal angle. Hold the thigh in the knee-chest position with the left index finger
and the thumb supporting the knee. Then extend the leg by gentle pressure from the
right index finger behind the ankle. Measure the angle at the popliteal space and score
accordingly.
Scarf sign. Take the infant's hand and try to put it around the neck posteriorly as far
as possible over the opposite shoulder
Heel to ear. Keeping the pelvis flat on the table, take the infant's foot and try to put it
as close to the head as possible without forcing it.
INFANTS OF DIABETIC MOTHERS
INTRODUCTION
Before insulin therapy, few women with diabetes were able to conceive; for those
who did, the mortality rate for both the mother and the infant was high. The morbidity
and mortality of infants of diabetic mothers (IDMs) have been significantly reduced
as a result of effective control of maternal diabetes and an increased understanding of
fetal disorders. Because infants born to women with gestational diabetes mellitus are
at risk for the same complications as IDMs, the following discussion of IDMs
includes infants born to women with gestational diabetes mellitus.
The severity of the maternal diabetes affects infant survival. The severity of maternal
diabetes is determined by the duration of the disease before pregnancy; age of onset;
extent of vascular complications; and abnormalities of the current pregnancy, such as
pyelonephritis, diabetic ketoacidosis, pregnancy-induced hypertension, and
noncompliance.
The single most important factor influencing fetal well-being is the euglycemic status
of the mother. It has been found that reasonable metabolic control that begins before
conception and continues during the first weeks of pregnancy can prevent
malformation in an IDM.
Elevated levels of hemoglobin A1c during the periconception period appear to be
associated with a higher incidence of congenital malformations. In the case of
gestational diabetes, macrosomia is the most common finding; serious complications
are rare (Mitanchez, 2010).
PATHOGENESIS
Congenital malformations
Fetal heart malformations are seen in 3%-9% of diabetic pregnancies
Most common heart defect is transposition of the great arteries followed by double
outlet right ventricle, VSD, PDA, Truncus arteriosus and Tricuspid atresia
CNS malformations include neural tube defects, Caudal regression (Specific for
IDM), spinal abnormalities and syringomyelia
Small left colon syndrome-Descending colon, sigmoid colon and rectum appears
smaller than normal. Child presents with bilious emesis and abdominal distension.
Prematurity, Intrauterine death
Macrosomia
Infants have bigger head: chest and shoulder. head ratios, more body fat and
visceromegaly. Size of all organs except brain increases.
Hairy pinna, Clefts in thigh, typical cherubic facies
Increased risk of operative deliveries, birth asphyxia and birth trauma
Metabolic abnormalities - Hypoglycemia (due to postnatal hyperinsulinemia)
Hypocalcemia (due to diminished production of parathormone after birth)
Hypomagnesaemia
Polycythemia- Increased oxygen consumption leading to increased bone marrow
response, red blood cell production, increased viscosity and decreased blood flow
leading to flushed appearance
Unconjugated Hyperbilirubinemia due to increased red cell mass
Transient Cardiomyopathy-Due to asymmetrical septal hypertrophy. May cause heart
failure during neonatal period. This condition is often resolved spontaneously by 6
months of age
Increased risk of Respiratory distress syndrome
Maternal diabetes places the fetus and newborn at risk for serious complications.
Perinatal outcome has a di- rect relationship with the severity and control of the
mother's diabetes. The diabetic woman who closely controls her blood glucose level
before conception and throughout pregnancy, particularly in the early months,
decreases her risk of having an infant with congenital anomalies. Fetal death is less
likely with excellent control.
CLINICAL MANIFESTATIONS
THERAPEUTIC MANAGEMENT
The nursing care of IDMs involves early examination for congenital anomalies, signs
of possible respiratory or cardiac problems, maintenance of adequate
thermoregulation, early introduction of carbohydrate feedings as appropriate, and
monitoring of serum blood glucose levels. The latter is of particular importance
because many infants with bypoglycemia may remain asymptomatic. IV glucose
infusion requires careful monitoring of the site and the neonate's reaction to therapy;
high glucose concentrations (212.5%) should be infused via a central line instead of a
peripheral site.
Because macrosomic infants are at risk for problems associated with a difficult
delivery, they are monitored for birth injuries such as brachial plexus injury and palsy,
fractured clavicle, and phrenic nerve palsy. Additional monitoring of the infant for
problems associated with this condition (polycythemia, hypocalcemia, poor feeding,
and hyper- bilirubinemia) is also a vital nursing function.
Some evidence indicates that IDMs have an increased risk of acquiring type 2
diabetes and metabolic syndrome in childhood or early adulthood (Ogata, 2010);
therefore, nursing care should also focus on healthy lifestyle and prevention later in
life with IDMs.
Newborns of diabetic mothers require especially careful observation. Perform early
(as soon as possible after birth) and frequent blood glucose checks.
Administer early feedings or if the newborn has respiratory distress or is otherwise ill
give IV glucose, as ordered Hypo-glycemiaia can return after treatment, so watch for
signs and symptoms.
Watch for signs of respiratory distress. Anticipate supplemental oxygen and surfactant
therapy. Some infants need ventilator support.
Monitor electrolytete levels, especially magnesium and calcium,ordered. Assist the
RN to perform a gestational agassessment, as these infants can be deceptively large
and still be preterm. Watch for and report any heart murmurs or other signs of cardiac
dysfunction.
INTRODUCTION
Alcohol and illicit drug use by the mother during preg- nancy can lead to many
problems in the newborn. The newborn of a woman who uses alcohol is at risk for fe-
tal alcohol syndrome (FAS). The newborn of a chemi- cally dependent woman may
be SGA and/or experience withdrawal symptoms.
Unfortunately, identifying the pregnant woman who abuses alcohol or drugs is often
difficult. Many of these women have no prenatal care or only infrequent care. They
may not keep appointments because of apathy or simply because they are not awake
during the day. As a result, many of these infants suffer prenatal insults the result in
intrauterine growth retardation, congenital abnormalities, and premature birth.
FETAL ALCOHOL SYNDROME ALCOHOL
Fetal Alcohol Syndrome Alcohol is one of the many teratogenic substances the readily cross
the placenta to the fetus. Many newborn exposed to alcohol in utero exhibit withdrawal
symptoms during the first few hours after delivery. FAS is often apparent in newborns of
mothers with chronic alcholism and sometimes appears in newborns whose mothers are low
to moderate consumers of alcohol. Binge drinking appears to be more harmful to the
developing fetus than does drinking small amounts every day Because we do not know
exactly how much alcohols safe, the woman should stop drinking at least 3 months before she
plans to become pregnant.
PATHOGENESIS
Clinical Manifestations
The newborn that is withdrawing from alcohol typically, is hyperactive, irritable, has trouble
reping, and may have tremors or seizures. Characteristics of FAS include LBW, small height
and head comference, short palpebral fissures (eyelid folds), reduced ocular growth, and a
flattened nasal bridge. This newborns prone to respiratory difficulties, hypoglycemia,
hypocalcemia and hyperbilirubinemia. Growth during infancy, and childhood continues to
fall below age growth rates. Unfortunately, the brain damage that occurs during fetal
development is permanent, result in mental retardation.
Signs
o SGA
o Small eyes
o Flat midface
o Long, thin upper lip
o Flat upper lip groove
o Irritable
o Hyperactive
o High pitched cry
NURSING CARE
FAS is highly preventable. Societal intentions, of which nurses can be a part, include
increasing the public's awareness of the detrimental effects of alcohol use during pregnancy.
Other helpful interventions include screening women of reproductive age for alcohol
problems and encouraging women to obtain adequate prenatal care and use appropriate
resources for decreasing alcohol use.
Nursing care for the newborn that is withdrawing from alcohol includes the
supportive interventions of swaddling, decreasing sensory stimulation, and ensuring
adequate nutrition. Keep the newborn's environment quiet and dark during the first
few days of withdrawal Administer benzodiazepine or other anticonvulsants, as
ordered, to prevent or treat seizure activity. Adequate nutrition is key to supporting
weight gain. The newborn's sucking reflex may be weak, and he or she may be too
irritable to feed. Give small amounts of formula or breast milk frequently. Monitor the
newborn's daily weight, intake, and output. Encourage the parents to feed the
newborn. This measure also helps to promote bonding.
The newborn of the woman addicted to cocaine, heroin, methadone, or other drugs is born
dependent upon these substances. Newborns may also be born dependent on a certain class of
antidepressants, serotonin reuptake inhibitors. Many of these infants suffer withdrawal
symptoms during the early neonatal period. However, the time of onset varies widely. For
example, the newborn experiencing withdrawal from opioids typically experiences
withdrawal symptoms within 24 to 48 hours after birth. However, it may take up to 2 weeks
before the newborn exhibits any symptoms.
Clinical Manifestations
NURSING CARE
CONCLUSION
Some newborns are considered high risk. This means that a newborn has a greater
chance of complications because of conditions that occur during fetal development,
pregnancy conditions of the mother, or problems that may occur during labor and
birth.
Some complications are unexpected and may occur without warning. Other times,
there are certain risk factors that make problems more likely.
Fortunately, advances in technology have helped improve the care of sick newborns.
Under the care of specialized physicians and other healthcare providers, babies have
much greater chances for surviving and getting better today than ever before.
NEONATAL COMPLICATIONS IN INFANTS BORN TO DIABETIC MOTHERS
Abstract
Place and duration of study: Federal Government Services Hospital, Islamabad and
National Institute of Child Health, Karachi, from August 1999 to January 2000.
Subjects and methods: All IDMs born during the study period were immediately admitted
to the neonatal intensive care unit after delivery. Maternal history was obtained and a detailed
physical examination was performed to detect congenital abnormalities. Babies were
screened for hypoglycemia, hypocalcemia, hyperbilirubinemia, birth asphyxia, respiratory
distress syndrome (RDS) and birth trauma. Outcome of IDMs and relative frequencies of
various complications were evaluated. Results were analyzed using statistical package for
social sciences (SPSS) version 11.
Results: A total number of 40 babies with IDM were included in the study. Out of diabetic
mothers, only 19 (47.5%) were taking insulin albeit irregularly. No mother was taking oral
hypoglycemic agents, 5 (12.5%) were following only dietary advice while 16 (40%) were not
following any advise for control of diabetes. Twenty-two (55%) mothers were delivered by
C-section and 18 (45%) had vaginal delivery. Seven (17.5%) mothers experienced birth
injuries, all of them were delivered vaginally and majority of them were large babies. Fifteen
percent IDMs suffered from birth asphyxia. Most (82.5%) were delivered vaginally.
Congenital anomalies were found in 10 (25%) babies. Eighteen (45%) were macrosomic, 20
(50%) were appropriate for gestational age (AGA) and 02 (5%) were small for gestational
age (SGA) or growth retarded. Hypoglycemia was noted in 35% and hypocalcemia in 15%.
Hyperbilirubinemia was observed in 12 (30%) newborns. Mortality was 7.5%.
Conclusion: The results of this study show a high frequency complications in IDMs. The
diabetic mothers should have regular antenatal follow-up and maintain good glycemic control
throughout pregnancy. Cesarean section may be allowed more liberally, especially with
clinical evidence of macrosomic baby, to avoid birth injury and asphyxia. All deliveries of
diabetic mother should be attended by pediatrician to minimize complications.
Abstract
The effect of in utero exposure to drugs of abuse on certain neurological and behavioral
characteristics of the newborn was studied in 10 infants of drug-dependent mothers. Fourteen
newborns of mothers not receiving drugs served as matched controls. Infants exposed to
drugs of abuse during fetal life exhibited a high level of arousal and irritability, and extreme
muscle tone fluctuations--i.e., a predominant hypertonicity (rigidity) alternating with short
periods of a very low tone (flaccidity). These newborns were also highly active, tremulous,
and motorically immature, and displayed near-constant crying and disturbed sleep patterns.
However, their orientation to external stimuli and the findings on neurological examination
were similar to those of control neonates.
Pender’s model focuses on three areas: individual characteristics and experiences, behavior-
specific cognitions and affect, and behavioral outcomes. The theory notes that each person
has unique personal characteristics and experiences that affect subsequent actions. The set of
variables for behavior specific knowledge and affect have important motivational
significance. The variables can be modified through nursing actions. Health promoting
behavior is the desired behavioral outcome, which makes it the end point in the Health
Promotion Model. These behaviors should result in improved health, enhanced functional
ability and better quality of life at all stages of development. The final behavioral demand is
also influenced by the immediate competing demand and preferences, which can derail
intended actions for promoting health.
BIBLIOGRAPHY
Meharban Singh, Care of Newborn. 6th ed. Jaypee brothers medical publisher,pvt
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D.K.Guha, Book of neonatology principles and practice ,2nd edition,Jaypee brothers
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Hockenberry JM, Wilson D Wong’s nursing care of infant’s and children. 8 th ed.
Missouri: Elsevier; 2007. p.271-80
Dutta AK, Sachdeva A Advances in paediatrics. 1st ed. New Delhi: Jaypee;2007.p.89-
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