Chapter 12: High-Risk Newborns & Neonatal Care

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Hello and welcome back to the Deep Dive.

Today we are opening up a file that I have to say feels particularly heavy, but it's also one of the most vital areas of study for any nursing student.

It really is.

We're looking at chapter 12 of Life First Introduction to Maternity and Pediatric Nursing in Canada, and the title of the chapter is High Risk Newborns.

It is a heavy title.

It implies a lot of vulnerability, a lot of fragility.

It does.

It sounds intimidating.

For sure.

But the mission of this Deep Dive really is to take that intimidation factor away.

We want to strip back the medical jargon and really understand the physiology.

We want to get into what actually happens when a baby's transition from inside the uterus to the outside world doesn't quite stick the landing.

And it's such a complex transition, even when it goes perfectly right.

Absolutely.

I mean, you have this tiny human who has to suddenly switch on their entire respiratory system,

completely reroute their cardiovascular flow, and then kickstart their own metabolism.

It's a massive physiological to -do list for a brand new person.

A huge to -do list.

Precisely.

It is a massive physiological shift.

And the definition of a high -risk newborn is simply an infant whose health status is compromised because that transition is delayed or complicated for some reason.

So it'd be a number of things.

It could be gestational age.

It could be their size.

It could be a congenital anomaly.

But the end result is a patient who needs really intensive observation and care beyond the standard newborn.

All because that physiological shift is stalling or just struggling.

Exactly.

They need our help to get over that hump.

I want to start with how we categorize these infants because I think there's a common misconception, especially among students early on, that high risk just means small.

Right.

Like if the baby is tiny, they're in trouble.

If they're big and chunky, they must be fine.

And that is absolutely the old way of thinking.

Historically, yeah, birth weight was the only yardstick we used.

If they were small, they were premature.

End of story.

Exactly.

If they were under a certain weight, they were considered at risk.

But the modern clinical approach, and Lifer makes a very big point of this, is to prioritize gestational age and the level of maturation.

Okay.

So not just the number on the scale.

Not at all.

You have to look at how well -developed the organs are.

How ready are they to function outside the uterus?

That's what maturation really means.

The text actually has great visual for this.

It's figure 12 .1.

It shows two term infants.

So they were both in the wound for the same amount of time.

The exact same duration.

Yep.

But one is labeled small for gestational age, or SGA, and the other is large for gestational age, LGA.

They look totally different.

Right.

And this is such a crucial distinction.

You can have the baby of a diabetic mother who weighs, say, 4 ,500 grams, which is huge by newborn standards.

Almost 10 pounds.

Yeah, a big baby.

But physically and physiologically, that baby might be quite immature and very high risk.

And on the flip side.

On the flip side, you can have a tiny baby who is technically SGA, but is fully mature and ready to go.

So we really need to be precise with our dates and our assessments, not just the weight.

So let's drill down on those dates then, because we hear preterm and term thrown around pretty loosely in just, you know, regular conversation.

We do.

But in a clinical setting, these are very strict windows.

They are, and you need to know them cold.

A preterm infant is anyone born before 37 completed weeks of gestation.

Okay, before 37 weeks.

And even within that, you have a subcategory,

late preterm.

That's that 34 to 37 week zone.

They look like term babies sometimes, but they're not.

They're still at risk.

And then you hit term.

Then you hit term.

But notice, term isn't just one day or one week.

Early term is 37 weeks up to 38 weeks in six days.

Go.

Full term, which is really the gold standard we're aiming for, is 39 weeks to 40 weeks in six days.

And then of course, sometimes they go over.

Then we go over.

Late term is 41 weeks to 41 weeks in six days.

And anything beyond 42 completed weeks is officially post term.

The text makes a point to highlight a statement from the American College of Obstetricians and Gynecologists, ACOG, about that term definition.

Yes.

And this is something every student should probably put a star next to in their notes.

What's the takeaway?

They emphasize that every single week in utero, up to 39 weeks, is absolutely vital for development.

You can't just assume that because a baby hits 37 weeks, they're fully cooked and ready to come out.

That last stretch is really important.

It's crucial for brain development, for lung maturity,

for everything.

So elective deliveries before 39 weeks are really discouraged, unless there's a medical reason.

Okay, so we have these categories.

Now let's put ourselves in the shoes of a nurse.

You're in the delivery room or maybe the nursery.

You have a baby in front of you.

How do you actually determine the gestational age if the mom's dates are a bit fuzzy?

Or what if she had no prenatal care at all?

An excellent question.

And that is exactly where the Ballard scoring system comes in.

The Ballard score.

It's a standardized method that we use, usually within the first one to two weeks of life, to estimate gestational age based on what the baby actually looks like and how they move.

So you're not relying just on the calendar.

You're looking at the patient.

You're looking at the evidence in front of you.

It's essentially a detective kit for the neonatal nurse.

The text points to figures 12 .2 and 12 .3 for this.

I love this part because it's so tangible.

You're literally looking for physical clues on the baby's body.

It's all about observation.

Let's paint a picture for the listener.

What are we looking at physically when we do this Okay, well let's compare the two extremes.

A very preterm baby versus a postterm baby.

Perfect.

First, you look at the skin.

In a preterm infant, the skin is going to be transparent, almost like gelatin.

It might be sticky, even friable.

You can see the blood vessels.

Oh yeah, you can see the veins right through it.

It's very, very delicate.

And on the other end of that spectrum,

the postterm baby.

A postterm or a fully mature infant will have skin that might be leathery or even cracked.

Why is that?

Because they've lost that protective coating of vernix.

They've basically been marinating in amniotic fluid for too long and it starts to dry out their skin.

Okay, so skin is a big one.

What's next?

Then you look at the hair, specifically the lanugo.

That's the fine downy hair, right?

Exactly.

That soft fuzz.

A preterm baby is going to have abundant lany though.

Lots of it all over their shoulders and back.

And a postterm baby.

They'll mostly bald of that body hair.

It's shed as they approach full term.

What about their feet?

I remember from my training that there's something about the soles of the feet.

Yes, the plantar surface.

This is a great indicator.

If you look at the sole of a preterm infant's foot, it's going to be really smooth.

Maybe you'll see a crease or two right up near the toes, but that's it.

Just smooth skin.

Mostly smooth, but a term infant, they have creases that cover the entire sole of the foot from the heel all the way to the toes.

Okay, so those are the physical static signs, but the Ballard score also looks at neuromuscular maturity.

This part involves actually moving the baby's limbs, doesn't it?

Correct.

This part is all about testing muscle tone.

And the rule of thumb is pretty simple.

Preterm babies are floppy, term babies are flexed.

Floppy versus flexed.

Preterm babies lack the muscle tone to fight against gravity or your manipulation.

They're just very limp.

Term babies pull themselves into that classic fetal position.

Walk us through the scarf sign.

It sounds like a fashion statement, but I know it's a clinical test.

Not quite a fashion statement, no.

For the star sign, you gently take the baby's hand and you try to pull their arm across their chest as if you're wrapping a scarf around their neck.

Okay.

In a very preterm infant, there's virtually no resistance.

The elbow will easily pass the midline of the chest going way past their chin.

It's like there's no muscle stopping you.

It just keeps going.

It just keeps going.

And a full term baby, what do they do?

They're stronger.

They resist you.

When you pull their arm across, the elbow will stop at their chin or even before it reaches the midline.

It's a direct measure of their flexor muscle tone.

There's also the popliteal angle, which involves the legs.

Right.

Same principle, different body part.

You try to extend the baby's lower leg up towards their head.

It's sometimes called the heel to ear maneuver.

So you're testing the flexibility of the knee joint.

Exactly.

A preterm baby is incredibly flexible because they don't have that muscle tone yet.

So their leg extends very easily.

You can get their foot very close to their ear.

A term infant.

A term infant will resist that extension.

Their muscles fight back.

You'll feel that tension and you won't be able to extend the leg nearly as far.

It's so fascinating that resistance is actually a sign of health and maturity in this context.

Exactly.

A floppy passive baby is an immature baby.

A baby that curls up and fights you a little bit is a baby with a more developed central nervous system.

So let's move into section two of our outline and zoom in specifically on the preterm newborn.

We've established they're born before 37 weeks.

The text says that preterm birth is the most common reason for admission to the intensive care nursery.

It is by far.

And it's responsible for more deaths during the first year of life than any other single factor.

So understanding the preemie profile is absolutely critical for any nurse.

When you look at a preemie in the isolette, what are you seeing?

You're essentially looking at a fetus that isn't finished developing yet.

They've been born before their body was ready for the outside world.

So what are the specific visual characteristics we'd see?

Well, the head is disproportionately large compared to the rest of the body.

The skin, as we said, is transparent and loose.

And there is a very distinct lack of subcutaneous fat.

That's the fat under the skin that keeps us warm and gives us energy reserves.

Exactly.

So they look quite thin, almost emaciated because they haven't had time to lay down those fat stores.

What about their posture?

You mentioned they're floppy.

They are.

Their posture is extended.

Their arms and legs are sprawled out.

Unlike the term baby who is all curled up in a tight little ball.

They're not holding that flexion.

No, they can't fight gravity yet.

And you'll also notice their genitalia are immature.

In girls, the labia majora might be open and gaping, exposing the inner structures because the fat pads haven't developed.

And for boys?

In boys, the testes might not be descended into the scrotum yet.

You might find them up in the inguinal canal.

And of course, underneath that physical appearance, all their internal systems are struggling to cope.

They

is usually the respiratory system, right?

Without a single doubt.

The lungs are the last major organ system to fully mature.

And in a preterm infant,

the alveoli, those tiny little air sacs where gas exchange happens, might not be fully enlarged or even numerous enough.

But the critical issue isn't just the structure.

It's a chemical.

It's a chemical called surfactant.

We hear this word all the time in neonatology.

Let's break it down.

What is surfactant in simple terms?

Okay, think of the alveoli like millions of tiny wet balloons.

Surfactant is a substance, a lipoprotein that reduces the surface tension inside those balloons.

It's like a lubricant.

That's a great way to think of it.

It acts like a lubricant.

It prevents the sides of the balloon from sticking together and collapsing every single time the baby exhales.

So without it?

Without surfactant, the baby has to work incredibly hard with immense effort to pop open and de -inflate those collapsed lungs with every single breath.

And that extreme effort is what leads to respiratory distress syndrome or RDS.

Precisely.

The baby eventually just tires out from the sheer work of breathing.

They can't sustain that level of effort.

What does RDS look like to a nurse?

The text references figure 12 .5.

If I'm at the bedside, what are the red flags I'm looking for?

You need to be counting respirations first and foremost.

Tachypnea, which is rapid breathing, is defined as 60 breaths per minute or more.

60, okay.

But it's not just that it's fast, it's labored, it's hard work.

You'll often hear grunting noises on expiration.

Why do they grunt?

What does that sound?

It's actually a clever physiological trick.

They are partially closing their glottis to try and trap air in their lungs.

They're trying to keep some positive pressure in there to stop the alveoli from collapsing.

So they're creating their own peep, their own positive end expiratory pressure.

They're trying to create their own CPAP.

Exactly.

It's a sign of stress, but it's also a sign their body is trying to compensate.

That makes so much sense.

What else would we see?

You'll see nasal flaring, their nostrils get wide with each inhale.

You'll see retractions where the chest wall literally sinks in between the ribs or under the sternum because they are pulling so hard to get air in.

And then of course the color change.

And then of course cyanosis, that blue or dusky tint to the skin, especially around the mouth and on the nail beds.

There is a treatment for this and sometimes it can start even before the baby is born.

Yes.

If we know a mom is going into preterm labor and we have time, we try to give her injections of corticosteroids like beta -methasone one or two days before the birth.

Then that helps the baby.

It crosses the placenta and dramatically speeds up the baby's own surfactant production.

It can make a huge difference.

And if the baby is already born and in distress, then we can administer artificial surfactant directly into the baby's lungs via an endotracheal tube.

It's an amazing therapy.

You can often see a dramatic improvement within 72 hours.

Now, obviously a lot of these babies are going to need supplemental oxygen, but the chapter has a very serious warning about oxygen toxicity.

This is so, so important.

For a long time, the thinking was just more oxygen is better.

We now know that is dangerously wrong.

So there's no safe level if it's too high.

There is no safe level if it's too high or given for too long.

If an infant gets too much oxygen, it can cause a chronic lung condition called bronchopulmonary dysplasia or BPD.

What does that do to the lungs?

It basically thickens the lung membranes.

It causes edema and it leads to long term breathing problems.

We essentially trade an acute problem for a chronic one.

This connects directly to another respiratory issue.

Yeah.

Apnea.

And we aren't just talking about a baby holding their breath for a second or two.

No, this is a clinical definition.

Apnea in a preterm infant is the cessation of breathing for 20 seconds or longer.

20 seconds.

Or it could be a shorter pause if it's accompanied by bradycardia, a heart rate dropping below a hundred beats per minute or cyanosis.

If a baby has an apnea spell, what's the first thing the nurse does?

Do we immediately start bagging them?

Not usually.

The very first intervention is gentle stimulation.

So just touching them?

Just touching them.

You rub the infant's feet or their ankles or their back.

Often that simple sensation is enough to remind their immature brain to kickstart the breathing process again.

If that doesn't work.

If that fails, then you would move to suctioning if needed or providing positive pressure ventilation with a bag and mask.

But often just that gentle rub is it takes.

Caffeine is also sometimes prescribed as a respiratory stimulant.

And how are we monitoring for all of this?

We're using pulse oximetry.

The text actually has a specific skill box, skill 12 .1 on how to apply a pulse ox probe correctly.

It does.

And it might sound like a simple task, but getting it right is critical for an accurate reading.

Where does it usually go on these tiny babies?

You usually place the probe on the foot or a toe.

The absolute key is alignment.

The little red light emitter has to be exactly opposite the detector on the other side of the foot.

If they're not lined up.

If they aren't perfectly aligned, the reading is garbage.

And you have to make sure it's secure, but not so tight that it compromises circulation.

Okay.

So let's talk about the magic number.

What oxygen saturation are we actually aiming for in a preemie?

This is another critical piece of information.

For a preterm infant, the target is 90 to 93%.

90 to 93.

That seems quite a bit lower than what we would expect for adults or even term infants.

It is.

And here's a big safety alert from the chapter.

Do not let the saturation exceed 95 % if the baby is on supplemental oxygen.

Why not?

Because that is where the risk of oxygen toxicity really kicks in.

That's where you can cause that BPD in the lungs and also a condition called retinopathy of prematurity in the eyes.

Which can cause blindness.

Which can cause blindness.

So your alarm limits on that monitor are your absolute best friend.

Set them correctly and pay attention to them.

Okay.

Let's move to section three.

Sepsis and thermoregulation.

These feel like two of the biggest ongoing battles in the NICU.

Why are these little ones so incredibly prone to infection?

It's really a perfect storm of vulnerability.

First, their liver is immature, so it doesn't form antibodies very well.

Okay.

Second, they didn't get that full rich transfer of passive immunity from their mom that happens in the last trimester, which they missed.

And third, their skin is thin and fragile.

It's a very poor barrier against bacteria.

The text mentions that the signs of sepsis can be really vague.

It's not always obvious.

Very vague.

You won't always see a high fever like you would in an older child.

In fact, temperature instability, their temperature dropping low or just fluctuating up and down is a major sign of sepsis in a preemie.

So a low temp can be just as concerning as a high one.

More so sometimes.

You might also just see lethargy or they're not feeding well or their muscle tone is poor.

Subtle changes are key.

And there's a specific call out in the text about a common item we all carry that is a major source of microbes.

Cell phones.

Yes.

The text specifically calls them out as a source of contamination.

I think we all need that reminder.

We do.

If you are bringing a phone into the NICU, it needs to be cleaned according to standard procedures.

And of course, strict meticulous hand hygiene before touching any infant is completely non -negotiable.

Okay, let's talk about the other battle.

Keeping them warm.

Cold stress.

It sounds like they're just a bit chilly, but it's a massive metabolic danger, isn't it?

It is life threatening.

And they are set up to fail at thermoregulation.

First, preterm infants lack brown fat.

Brown fat.

That's the special fat that term babies have that can generate heat, right?

Exactly.

It's their internal furnace and preemies don't have it.

Second, they have a huge surface area, especially that big head relative to their tiny body weight.

They just radiate heat into the environment.

And their posture doesn't help.

Not at all.

Because they're extended and floppy, they expose all that skin to the cool air.

They can't curl up into a ball to conserve heat.

And to top it all off, they can't even shiver to warm themselves up.

So if they get cold, what happens inside their body?

Their metabolic rate skyrockets as they try desperately to generate heat.

They burn through their tiny glucose stores.

Leading to hypoglycemia.

Right.

And they use up precious oxygen.

Leading to hypoxia.

Exactly.

It's a dangerous dominar effect.

Cold stress triggers metabolic acidosis, which then interferes with surfactant production, making their breathing even worse.

It's a vicious downward cycle.

The text details the isolate, or the incubator, as the main tool for this.

Yes.

It's a controlled microenvironment.

It's a little bubble of warmth.

We monitor the temperature of the infant and the isolate constantly with probes.

What's the goal temperature?

The goal is to create a neutral thermal environment.

That's a very specific term.

It means the temperature at which the baby can maintain their own body heat without having to spend any extra energy to do so.

So they can use their calories for growing, not just for staying warm.

Exactly.

Growing and healing.

And there's another method for warming that's mentioned in scale 12 .2 that I absolutely love.

Kangaroo care.

This is one of the best, most evidence -based interventions we have.

It's simply skin -to -skin contact.

How is it done?

The infant, wearing just a diaper and a little cap, is placed vertically on the parent's bare chest, and then they're covered with a warm blanket.

And it's not just for bonding, although that's a huge benefit.

The bonding is huge, but it is deeply therapeutic.

The parent's body acts as a natural living incubator.

It actually regulates the baby's temperature perfectly.

Better than the machine.

Often, yes.

It stabilizes their heart rate and their breathing.

It promotes sleep.

It reduces pain perception during procedures.

The list of benefits goes on and on, and the text notes it promotes better development later on too.

Moving on to section four.

We touched on glucose briefly when we talked about cold stress, but let's dive a little deeper into the metabolic issues.

Hypoglycemia.

This is incredibly common.

Primes just didn't stay in the womb long enough to build up their glycogen stores in their liver.

So they have no backup fuel.

They have no backup fuel.

And you combine that with all the stress of birth, learning to breathe and trying to stay warm,

they just burn through their available sugar incredibly fast.

The text gives us a specific definition here.

A plasma glucose level lower than 2 .6 millimole.

Correct.

That 2 .6 is the magic number, the cutoff for intervention.

What are the symptoms a nurse should be looking for?

Tremors, jitteriness, a very weak or high pitched cry.

But again, it can be very subtle.

They might just be lethargic or have poor muscle tone.

Why is treating it so critical?

Because the brain needs glucose.

It is the brain's primary fuel.

Prolonged or severe hypoglycemia can cause permanent irreversible brain damage.

That's why we do frequent heel stick blood tests.

That's why we test frequently and treat promptly either by encouraging feeding or giving IV fluids with dextrose.

The chapter also mentions hypocalcemia low calcium.

Right.

Calcium, like so many other things, is mostly transferred across the placenta in the third trimester.

So again, preemies miss out.

How do we treat that?

Treatment is usually IV calcium

gluconate.

But, and this is a big safety alert in the text,

if you are giving calcium intravenously, you must monitor the heart rate very, very closely.

Why?

What can it do?

It can cause severe bradycardia, a dangerously slow heart rate, so you infuse it slowly and watch that cardiac monitor like a hawk.

Let's talk about bleeding.

The text mentions an increased tendency to bleed.

Another consequence of immaturity.

Their blood is deficient in prothrombin, which is a key clotting factor that's synthesized in the liver.

Plus, the capillaries in their head are incredibly fragile.

And this combination is what leads to the risk of intracranial hemorrhage.

Yes.

Bleeding into the brain or the ventricles of the brain, we have to be so gentle with these babies.

So what are the nursing interventions to prevent that?

The text recommends keeping the bed in a slight fowler's position so their head is slightly elevated to reduce intracranial pressure.

And you want to avoid any unnecessary or rough handling that could cause spikes in their blood pressure.

And you're monitoring for signs like barging fontanelles or seizures.

There's one specific sensory issue mentioned that is a huge concern.

ROP retinopathy of prematurity.

This is the leading cause of blindness in these babies.

It is.

It happens when the delicate blood vessels in the retina develop abnormally.

They can proliferate, become fragile, and then leak or even cause the retina to detach.

And this is closely linked to what we talked about earlier.

High oxygen levels.

It's one of the biggest risk factors.

So keeping those O2 sats below 95 % isn't just about the lungs.

It's actually vision -saving care.

It is absolutely vision -saving care.

We screen for it routinely in very low birth weight infants starting around 31 weeks postnatal age.

An ophthalmologist will come and examine their eyes.

And if they find it?

If they catch it early, they can treat it with laser photocoagulation or with medications like Avastin.

But prevention through careful oxygen management is the nurse's primary and most important role.

Let's look at section 5.

Nutrition and the gut.

Feeding a preemie isn't as simple as just offering a bottle when they seem hungry.

Not at all.

First, their stomach capacity is tiny.

We're talking a few milliliters at a time.

But more importantly, the critical reflexes—suck, swallow, and breathe—are not coordinated.

The suck -swallow -breathe pattern.

Right.

That complex sequence isn't usually mature until about 33 to 34 once gestation.

If you try to bottle feed a 30 -weeker, they're at very high risk of aspirating fluid into their lungs.

So we have to use gavage feeding.

That's a feeding tube that goes down the nose or the mouth correctly into the stomach.

It is.

It's a way to provide nutrition safely until their reflex is mature.

But how do we know the tube is in the right place?

You don't want to be putting milk into the lungs.

Absolutely not.

Before every single feeding, you have to check placement.

The gold standard is to aspirate a small amount of the stomach contents and check the pH with a test strip.

And what pH are we looking for?

The text specifies the pH should be 5 .5 or less.

That tells you the tube is in the acidic environment of the stomach and not in the lungs or the esophagus.

Now, there's a very scary condition related to the gut called necrotizing enterocolitis, or NEC.

NEC is probably one of the most feared diagnoses in the NICU.

It's an acute inflammation that leads to necrosis, which means tissue death of the bowel.

It can be devastating.

It can be.

It can lead to perforation, sepsis, and death.

What causes it?

The exact cause is complex, but hypoxia is a major factor.

When a baby is stressed, blood is shunted away from the gut to the vital organs like the brain and heart.

So the gut suffers ischemia or lack of blood flow.

And feeding plays a role.

It does.

Formula feeding is a known risk factor.

Breast milk is highly protective against NEC.

The book mentions a fascinating and simple sounding intervention called oral immune therapy.

Yes,

this is such a wonderful practice.

It involves taking just a tiny drop of the mother's colostrum on a little swab.

Just the first milk.

Just that liquid gold, and you just swab it on the inside of the baby's cheeks and gums.

Even if they can't eat yet.

Even if they're MPO, nothing by mouth.

That interaction with the mucous membranes provides powerful immune protection like IgA that helps protect the gut lining against NEC.

That is just incredible.

A single drop on the gums can help save their gut.

It really shows you the power of breast milk components.

It's not just nutrition.

It's medicine.

Okay, section six.

Let's talk about elimination, jaundice, and skincare.

First, let's do some nursing math.

The kidneys.

Immature kidneys.

They don't concentrate urine well, so they're at high risk for dehydration and fluid and electrolyte imbalances.

So trating output is critical.

What's the target?

The goal for urine output is between one and three milliliters per kilogram of body weight per hour.

And to measure that, we are meticulously weighing every single diaper.

Every single one.

You take the wet weight of the diaper and subtract the dry weight of a clean diaper.

And the general rule is that one gram of weight equals roughly one milliliter of urine.

Got it.

Now, jaundice.

This is a huge topic for all newborns, but especially preemies.

We have physiological versus pathological jaundice.

What is the key difference?

The timing.

Timing is everything.

Physiological jaundice is considered normal.

It happens a bit later, maybe on day two or three of life, as the baby's immature liver learns to process the bilirubin from breaking down red blood cells.

Pathological.

Pathological jaundice happens within the first 24 hours of life.

That is always a red flag.

That is B -A -D.

What does it usually mean?

It usually means there's some underlying process that is causing rapid destruction of red blood cells, like a blood incompatibility between mom and baby.

And if the bilirubin level gets too high, we run the risk of connectoris.

Connectoris is the nightmare scenario.

It's bilirubin encephalopathy.

It's when the bilirubin levels get so high that it crosses the blood -brain barrier and deposits in the brain tissue.

Causing permanent brain damage.

Yes.

Causing cerebral palsy, hearing loss, and cognitive deficits.

We want to avoid that at all costs.

Which is why we use phototherapy.

We've all seen the pictures of the babies under the blue lights looking like they're in a little tanning bed.

Right.

How does that light actually work?

It's pretty amazing, actually.

The specific wavelength of blue light is absorbed by the skin, and it changes the shape of the bilirubin molecule in the blood vessels near the surface.

It changes the shape.

It can vault it into a water -soluble form that the body can then excrete in the urine and stool, bypassing the need for the liver to conjugate it.

But there is very specific nursing care required for a baby under the lights.

Care Plan 12 .2 in the book outlines this.

Absolutely.

You must cover the eyes with patches.

The light is intense and can cause retinal damage.

What else?

You must monitor their temperature closely because the lights can be warm and cause hypothermia.

You have to increase their fluid intake because they lose a lot of water through their skin and from the loose green stools that phototherapy causes.

And you want to expose as much skin as possible.

Maximum skin exposure.

So they're usually naked except for a diaper and their eye patches, and you have to turn them frequently.

The text also mentions nesting.

When it comes to positioning these babies, what is that?

This is all about comfort, security, and promoting proper development.

You use rolled up blankets to create a little boundary, a little nest around the baby in the isolate.

To mimic the feeling of the uterus.

Exactly.

It mimics the confines of the uterus.

It helps keep their limbs flexed and close to their body, which makes them feel more secure rather than being all sprawled out and vulnerable.

It helps with their neuromuscular development.

Section seven deals with the prognosis, and just as importantly, the family.

We absolutely cannot ignore the parents in this situation.

No, the parents are our other patient.

They're often terrified.

They see this tiny fragile looking baby hooked up to all sorts of machines and alarms.

They might feel guilty or helpless or just completely overwhelmed.

So what is the nurse's role in helping them?

Our role is to be a guide and a facilitator.

We encourage them to touch and talk to their baby.

We explain what every piece of equipment is for in simple terms.

To demystify the environment.

Exactly.

And as soon as it's possible, we get them involved in the care helping with the diaper change, taking a temperature, doing kangaroo care.

It builds their confidence and their bond.

The text mentions the concept of adjusted age.

This seems really important for managing parents' expectations down the line.

It's crucial.

You have to explain this.

If a baby is born three months early, then when they are chronologically six months old, they might only be meeting the developmental milestones of a three -month -old.

You subtract the weeks or months of prematurity.

Right.

You subtract the time they missed in the womb from their chronological age.

That helps parents understand that their baby isn't delayed.

They're just on their own unique timeline.

And eventually the goal is to get the baby home.

When does that happen?

What are the discharge criteria?

The discharge criteria are very strict.

The baby has to be medically stable,

obviously.

They have to maintain their oxygen saturations above 90 % in room air without any support.

They need to be apnea free for a set period, usually 72 hours.

They have to be able to maintain their own temperature in a regular open cot.

And they have to be consistently gaining weight with whatever feeding method they're using.

Let's pivot now.

We've spent a lot of time talking about the tiny preemies.

But section eight of the chapter covers the other extreme, the post -term newborn.

This is the baby born beyond 42 weeks.

Right.

Why is staying in the womb for too long a problem?

It seems counterintuitive.

It does, but the placenta basically has an expiration date.

After around 40 or 41 weeks, it starts to age.

It becomes less efficient at delivering oxygen and nutrients to the fetus.

So the environment isn't as good anymore.

The environment starts to fail.

So the fetus can actually start to lose weight or suffer from hypoxia while they are still inside the uterus.

What does a post -term baby look like when they're born?

They often look like little old men.

They can be long and thin because they've started to use up their own fat stores in the womb.

Their skin is loose and saggy.

And the skin itself is different.

Very different.

It's dry.

It's cracked.

It's parchment -like.

There's no vernix or lanugo left at all.

And they often have very long fingernails and toenails.

And sometimes they're stained a greenish color.

Yes, that's meconium staining.

Because of the stress or hypoxia in utero, they might pass their first stool, which is meconium, into the amniotic fluid.

Which leads to the major risk for these babies.

Meconium aspiration.

Exactly.

If they take a breath and inhale that thick, tarry meconium stain fluid into their lungs, it can cause a severe chemical pneumonia and respiratory distress.

Section 9 briefly touches on transporting the high -risk newborn.

Because not every hospital has a high -level NICU.

Correct.

The key word here is stabilization.

You must stabilize the baby before you move them.

Get their temperature stable, their vital signs stable, and their blood glucose stable before that transport team even arrives.

And what about the parents?

This must be an incredibly traumatic time.

It's awful for them.

The nurse's role is to support them.

Let them see and touch the baby before the transport team whisks them away.

Give them a picture.

Make sure they know exactly where their baby is going and have the phone number.

It's a very stressful moment.

Moving to Section 10.

Perinatal conditions.

Specifically, hemolytic disease.

This is usually about Rh incompatibility, right?

That's the classic example.

This happens when you have an Rh negative mother who is carrying an Rh positive fetus.

And their blood types are just incompatible.

They are.

If some of the fetal Rh positive blood cells leak into the mother's circulation, which can happen during birth or even a small bleed during pregnancy.

Her body sees them as foreign.

Her immune system sees that Rh factor as a foreign invader and starts to create antibodies against it.

It doesn't usually hurt that first baby, though, right?

Usually not.

The sensitization often happens right at the end of the first pregnancy.

But for the next pregnancy, if that fetus is also Rh positive, the mom's antibodies, which are now primed and ready, will cross the placenta and attack the fetus's red blood cells.

Causing hemolysis.

The destruction of those blood cells.

Yes.

And that condition is called erythroblastosis fetalis.

The fetus becomes severely anemic and can go into heart failure, which is called hydroxyfetalis.

And after birth, they have extreme jaundice from all the bilirubin released by the destroyed red cells.

But thankfully, we have a way to prevent this now.

We do.

WinRho, or RhoD, immune globulin.

We give it to all Rh negative moms preventatively at around 28 weeks, and then again within 72 hours after they give birth to an Rh positive baby.

How does it work?

It basically tricks her immune system.

It destroys any fetal red cells in her circulation before her body has a chance to recognize them and form her own permanent antibodies.

How do we diagnose it if it's already happening?

The text mentions the Coombs tests.

There are two.

The indirect Coombs test is done on the mother's blood to see if she has circulating antibodies.

The direct Coombs test is done on the infant's cord blood at birth to see if those maternal antibodies are already attached to the baby's red blood cells.

And if the baby is affected and severely jaundiced, the treatment might be an exchange transfusion.

It's a dramatic but life -saving procedure.

It's exactly what it sounds like.

They slowly remove small amounts of the baby's blood and replace it with donor blood.

And the goal of that?

The goal is to wash out the high levels of bilirubin and the damaging maternal antibodies and to replace the baby's vulnerable red cells with healthy donor cells.

Section 11 covers a bit of a grab bag of other specific clinical conditions.

We already mentioned intracranial hemorrhage.

What are the signs of a seizure in a newborn?

The text says it's not always a classic convulsion.

It's very, very subtle.

You have to be a sharp observer.

It might just be lip smacking or chewing motions.

It could be bicycling movements of the legs or swimming movements with the arms.

Even just persistent abnormal eye blinking can be a seizure.

So you have to know what you're looking for.

You really do.

Other signs of neurological issues are a high -pitched shrill cry or forceful vomiting.

Then there's TTN transient tachypnea of the newborn.

The book calls it wet lung.

This is often seen in babies born by C -section.

They didn't get that good squeeze through the birth canal that helps push the fluid out of their lungs.

So they have some fluid left over.

They do.

And they have to breathe fast for a while to clear it.

It's transient, meaning it usually resolves on its own within about three days with some supportive care.

And then there is NOWS neonatal opioid withdrawal syndrome.

Sadly, a very common diagnosis now.

This is a baby who is withdrawing from opioids or other substances the mother was using during pregnancy.

What are the signs of withdrawal?

They are hyper irritable.

Tremors, a constant high -pitched cry that's hard to console, sneezing, yawning, diarrhea.

They're just miserable.

And the nursing care is really about managing their environment.

It's all about reducing stimuli, swaddling them tightly, keeping the room dark and quiet,

small frequent feeds.

And surprisingly, breastfeeding is often encouraged, if not otherwise contraindicated, as it can help soothe the symptoms and reduce the severity of the withdrawal.

Let's talk about the infant of a diabetic mother.

We mentioned they can be LGA or large for gestational age.

Macrosomia, yes.

They're often big, puffy babies with a round, cushingoid face.

But the real danger for them happens right after birth.

It's the sugar crash.

Explain that mechanism for us.

Okay.

In utero, the mother had high blood glucose levels.

That sugar crossed the placenta to the baby.

In response, the baby's pancreas produced very high levels of insulin to handle all that sugar.

So their body is used to a high -sugar, high -insulin state.

Then the cord is cut.

The sugar supply from mom is suddenly gone, but the baby's pancreas is still pumping out that huge amount of insulin.

And the insulin makes their blood sugar plummet.

It plummets.

They become severely hypoglycemic very quickly after birth.

So for these babies, we need to be watching them like a hawk for those first few hours.

Absolutely.

Frequent glucose checks are mandatory.

You have to catch that hypoglycemia early and treat it with feeding.

Section 12 moves into birth defects and chromosomal abnormalities.

The most common chromosomal one discussed in the chapter is Down syndrome or trisomy 21.

Right.

And as nurses, we need to be able to recognize the common physical features.

They include closed set, upward slanting eyes, a small head, a protruding tongue, and the simian crease, which is a single straight line that goes all the way across the palm of the hand.

You might also see a curved little finger in a wide space between the first and second toes.

What are the specific nursing challenges for a baby born with Down syndrome?

One of the biggest is hypotonia, which means low muscle tone.

They feel very limp, almost like a ragdoll.

How does that affect them?

Well, it makes them lose heat easily because they can't maintain that flexed posture.

So you need to swaddle them well.

It also makes them accumulate mucus because they have a poor cough reflex.

So you might need to use a bulb syringe to clear their airway frequently.

And the protruding tongue can be an issue.

It can interfere with feeding, making it hard for them to get a good latch and seal.

So feeding can be slow and require a lot of patience.

Finally, we arrive at section 13, metabolic defects.

These are inborn errors of metabolism.

The big one that every nursing student needs to know is PKU, venal catenuria.

PKU is a genetic defect where the body can't metabolize an amino acid called phenylalanine, which is found in protein.

And if it builds up?

If it builds up in the blood, it becomes a neurotoxin and causes severe, irreversible cognitive disability.

But the baby looks completely normal at birth.

That's the tricky part.

And that's why we have mandatory newborn screening.

In Canada, we use the death retest.

It's a heel stick blood test that's done after the baby is 24 to 48 hours old.

Why do you have to wait for them to be feeding for a day or two?

That's a key point.

The baby needs to ingest protein first from breast milk or formula for the phenylalanine to build up in their blood.

If you test them too early, you could get a false negative.

And if they test positive for PKU, what is the treatment?

The treatment is a special diet for life, a diet that is very low in phenylalanine.

They use special formulas like Luffanolac.

And there's a safety alert about a common artificial sweetener.

Yes, they must avoid aspartame, which is sold as NutraSweet because it's metabolized into phenylalanine in the body.

There are a couple of others mentioned briefly.

Maple syrup urine disease.

And it is exactly what it sounds like.

A defect in amino acid metabolism causes the urine and sweat to literally smell like maple syrup.

It can be life -threatening if not treated.

And galactosemia.

This is a disorder where the body can't use galactose, which is a component of lactose, the sugar in milk.

So the treatment is?

The treatment is crucial.

No breastfeeding.

Breast milk contains lactose.

These babies need a special soy -based lactose -free formula for life.

We have covered an absolutely immense amount of ground here.

From the fragile, transparent skin of a 28 -weeker to the dry, cracked skin of a 42 -weeker.

From sugar crashes to genetic screenings, it's a lot.

It is a lot.

But if you strip it all back, the fundamental role of the neonatal nerves is consistent across all these conditions.

It is about observation.

The text calls it subtle clinical observations.

Exactly that.

It's noticing the slight jitteriness that signals hypoglycemia.

It's noticing the small drop in temperature that could be the first sign of sepsis.

It's noticing the faint yellowing of the eyes that signals rising bilirubin.

These babies can't tell you what's wrong.

They cannot tell you in words what is wrong.

You have to be their eyes and their ears.

You have to see it for them.

And when you see it and you connect it to all this knowledge we've discussed, you can intervene and you can save a life.

That is the power and the privilege of neonatal nursing.

Well, that brings us to the end of this very deep dive into lifers chapter 12.

Thanks for diving deep with us.

A warm thank you from the last minute lecture team.

Good luck with your studies and we'll see you next time.