ASSESSMENT & MANAGEMENT OF PRETERM BABIES .pptx

here is the ppt of assessment and management of preterm babies

1. Assessment and Management of Premature babies K. C. MEGHWAL 1 Monday, June 22, 2015

2. Introduction Premature birth is the major health problem in India. about 10-12% Indian babies are born preterm. Morbidity and mortality rate of premature babies in India is very high. About 30% death of infant in India is occurred during first month of life. K. C. MEGHWAL 2 Monday, June 22, 2015

3. Introduction… Prematurity is the main leading cause of infant mortality. The goal of assessment and management of premature babies is to provide better health care facilities and to save the life of premature babies & ultimately to reduce the morbidity & mortality of premature babies. K. C. MEGHWAL 3 Monday, June 22, 2015

4. General objectives:- At completion of teaching students will be able to:- Enhance their knowledge about the assessment and management of premature babies & apply this knowledge in their clinical practice . K. C. MEGHWAL 4 Monday, June 22, 2015

5. SPECIFIC OBJECTIVES:- After completion of teaching students will be able to:- Define preterm babies. To classify the preterm babies. Explain the causes of preterm births. Describe the physical characteristics and physiological handicaps of preterm babies. Discuss the levels of care. K. C. MEGHWAL 5 Monday, June 22, 2015

6. SPECIFIC OBJECTIVES…. Enlist the complications of premature babies. Explain the Apgar scoring . Discuss the management of premature babies. To enlist the factors affecting the survival of premature babies. K. C. MEGHWAL 6 Monday, June 22, 2015

7. DEFINITION:- Preterm baby : -A baby born with a gestational age of less than 37 completion weeks (or <259 days) regardless of birth weight is considered as preterm baby. these babies are also termed as immature, born early or premature birth weight is babies. K. C. MEGHWAL 7 Monday, June 22, 2015

8. DEFINITION… Premature baby:- A "premature" baby is one that has not yet reached the level of fetal development that generally allows life outside the womb. K. C. MEGHWAL 8 Monday, June 22, 2015

9. Incidence:- According to W.H.O. about 15% LBW babies has born each year of all live births worldwide. Nearly 93% of them in developing countries. 28% LBW babies born in India each year of all live births. Out of them 10-15% are preterm & 20-25% are IUGR. Monday, June 22, 2015 K. C. MEGHWAL 9

10. Incidence of prematurity Gestational Age Percent 34 – 37 weeks 71.2% 32 – 33 weeks 12.7% 28 –31 weeks 10% > 28 weeks 6 % K. C. MEGHWAL 10 Monday, June 22, 2015

11. PERIODS OF GROWTH AND DEVELOPMENT (A) prenatal period - It is the period from conception to birth. Pre-embryonic/Germinal (ovum)-conception to 2 weeks (0-14 days after conception) Zygote -1to 3 days Morula -4 to 7 days Blastocyst -8 to 14 days Embryonic- 2-8 weeks after conception Fetal -9 weeks to 40 weeks (till birth) K. C. MEGHWAL 11 Monday, June 22, 2015

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14. PERIODS OF GROWTH AND DEVELOPMENT… (B) Perinatal period :- It is the period extends from 20 th week of gestation to less than 7 days of life. (C) Post natal period :- It is the period from birth to onwards K. C. MEGHWAL 14 Monday, June 22, 2015

15. PERIODS OF GROWTH AND DEVELOPMENT… ( D). Neonatal period :- It is the period from birth to 4 weeks or 28 days of age. Early neonate:- It is the period from birth to less than 7 days of age. Late neonate:- It is the period from 7 days to 28 days of age after birth. Infancy :- it is the period from 1 month to 1year after birth. K. C. MEGHWAL 15 Monday, June 22, 2015

16. CLASSIFICATION OF PRETERM BABIES:- I. According to gestational age Extremely preterm baby:-(6%) born before 28 weeks of gestation Early/very preterm baby: -( 10%) born before 32 weeks of gestation Late preterm baby:- (84%) baby born between 32-37 weeks K. C. MEGHWAL 16 Monday, June 22, 2015

17. CLASSIFICATION OF PRETERM BABIES:- II. According to gestational age with birth weight Preterm with small for gestational age (SGA) Preterm with appropriate for gestational age (AGA) Preterm with large for gestational age (LGA) K. C. MEGHWAL 17 Monday, June 22, 2015

18. II. According to gestational age with birth weight Preterm with small for gestational age (SGA ):- A baby born before 37 completed weeks(or<259days) & whose birth weight falls below the 10 th percentile for the period of their gestational age . Preterm with Appropriate for gestational age (AGA) A baby born before 37 completed weeks (or <259 days) & whose birth weight falls between the 10 th and 90 th percentile for the period of their gestational age. Preterm with large for gestational age (LGA):- A baby born with 37 completed weeks ( or < 259 days) & whose birth weight falls above the 90 th percentile for the period of their gestational age. K. C. MEGHWAL 18 Monday, June 22, 2015

19. K. C. MEGHWAL 19 Monday, June 22, 2015

20. CAUSES OF PREMATURE BIRTH:- H/O HIGH RISK FACTOR’S IN MOTHER :- Teenage (<16 yr at conception) Elderly (>40 yr at conception) Under weight Low socioeconomic status Previous H/O induced / spontaneous abortion Pregnancy following assisted reproductive technique Asymptomatic bacterimia or recurrent UTI Smoking habit of mother Drinking habit/drug abuse of mother Maternal stress K. C. MEGHWAL 20 Monday, June 22, 2015

21. CAUSES OF PREMATURE BIRTH….. COMPLICATIONS IN PREGNANCY 1.MATERNAL:- Pregnancy complications Preeclampsia Polyhydramnias Premature rupture of membrane Ante partum hemorrhage Uterine anomalies Cervical incompetence Malformation of uterus K. C. MEGHWAL 21 Monday, June 22, 2015

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23. CAUSES OF PREMATURE BIRTH….. Medical & surgical illness of mother Acute fever Acute pyelonephritis Diarrhea Acute appendicitis Toxoplasmosis Abdominal operations Chronic illness ( HT, DM, ANAEMIA ) Genital tract infections K. C. MEGHWAL 23 Monday, June 22, 2015

24. CAUSES OF PREMATURE BIRTH… COMPLICATIONS IN PREGNANCY…. 2.FETAL Multiple pregnancy Congenital malformation Intrauterine death 3.PLACENTA Infarction Thrombosis Placenta praevia Placenta abruption K. C. MEGHWAL 24 Monday, June 22, 2015

25. CHARACTERISTICS OF PREMATURE BABIES:- PHYSICAL FEATURES :- Birth weight < 2500gm length < 44 cm General appearance Body looks small with relatively large head. Face is small with small chin Relaxed attitude K. C. MEGHWAL 25 Monday, June 22, 2015

26. CHARACTERISTICS… General activity Poor with weak cry. Limbs are extended. Poor recoil of flexed arm Reflexes Slow or incomplete neonatal reflexes such Moro, sucking & swallowing reflexes. Poor muscle tone. Scalp hair Scanty, wooly & fuzzy K. C. MEGHWAL 26 Monday, June 22, 2015

27. CHARACTERISTICS … Skin Shiny, oily, thin, & delicate. Plethoric. Plenty of lanugo hair. Less subcutaneous fat. Edema with visible veins & venules on abdomen. Breast nodules & nipple formation No nipple present. 2mm < 36 weeks. 4mm - 37-38 weeks. Ear cartilage Pinna feels soft &flat Cartilage not fully developed K. C. MEGHWAL 27 Monday, June 22, 2015

28. CHARACTERISTICS … eyes closed Planter creases (sole creases) Not visible before 34 weeks. Faint red marks over anterior sole. Umbilical cord Normal Genitals (male) Scrotum small with no or few rugae & light pigmentation. Testes undescended. Genitals(female) Widely separated labia majora. Prominent labia minora . Prominent clitoris . K. C. MEGHWAL 28 Monday, June 22, 2015

29. PHYSIOLOGICAL HANDICAPS: Alteration of respiratory function Impaired thermoregulations Immaturity of central nervous system Disturbances of circulatory functions Insufficient gastrointestinal & hepatic function Metabolic disturbances Increased susceptibility to infection Impaired renal function Drug toxicity K. C. MEGHWAL 29 Monday, June 22, 2015

30. LEVELS OF PREMATURE NEONATAL CARE   K. C. MEGHWAL LEVEL CRITERIA LEVEL-I ST LEVEL-II ND LEVEL-III RD Neonatal care Basic/primary neonatal care Intermediate neonatal care Intensive neonatal care Body weight <1800 gm 1200-1800 gm <1200 gm Gestational age 34 weeks or more 30-34 weeks <30 weeks Health Care provider their mothers with support from family members and under supervision of basic health professionals Trained nurses & pediatricians. skilled nurses and neonatologists 30 Monday, June 22, 2015

31. LEVELS OF PREMATURE NEONATAL CARE… LEVEL CRITERIA LEVEL-I ST LEVEL-II ND LEVEL-III RD Place/ Health Care Centre -Home -Sub centre -PHC -CHC -District hospitals -Teaching institutions -Nursing homes -Apex institutions -Regional perinatal centres % Of Neonates Require This Care 80-90% 10-15% 3-5% Basic Health Care Facilities -Provision of warmth - Maintenan ce of asepsis -Promotion of breast feeding -Immediate neonatal care -Resuscitation -Maintenance of thermo neutral environment -Intravenous infusion -Gavages' feeding -Phototherapy -Exchange blood transfusion -Provision for disposable gamma irradiate suction catheter, feeding tubes, endotrachial tubes & small vein infusion -Centralized O 2 & suction facilities -Servo-controlled incubators -Vital signs & transcutaneous monitors -Ventilators -Infusion pumps K. C. MEGHWAL 31 Monday, June 22, 2015

32. ASSESSMENT OF PREMATURE NEWBORNS Initial assessment: Apgar scoring . Transitional assessment: during the periods of reactivity. Assessment of gestational age. Systematic physical examination . K. C. MEGHWAL 32 Monday, June 22, 2015

33. APGAR SCORE INDICATOR SCORE=0 SCORE=1 SCORE=2 HEART RATE ABSENT <100BPM >100BPM RESPIRATORY EFFORT ABSENT SLOW, IRREGULAR WEAK CRY GOOD, VIGOROUS CRYING MUSCLE TONE FLACCID ,LIMP MINIMAL FLEXION OF EXTREMITIES GOOD FLEXION,ACTIVE MOVEMENT OF EXTREMITIES REFLEX IRRITABILITY NO RESPONSE MINIMAL RESPONSE(GRIMACE) RESPONDS PROMPTLY WITH CRY OR ACTIVE MOVEMENT SKIN COLOR PALLOR OR CYNOSIS BODY PINK ,EXTREMITIES BLUE PINK ALL OVER K. C. MEGHWAL 33 Monday, June 22, 2015

34. APGAR SCORING Total score Menifestation Intervention 7-10 No depression No intervention required except to support newborns spontaneous efforts 4-6 Mild depression Gently stimulate, rub newborns back, administer oxygen to newborn 0-3 Severe depression Newborn requires resuscitation 34 K. C. MEGHWAL Monday, June 22, 2015

35. 2.Transitional Assessment: Periods Of Reactivity First period of reactivity ( for 6-8 hrs after birth) -Stage of alertness ( birth-30 minutes) - Stage of sleep & rest ( 30 minutes-2-4 hrs) Second period of reactivity ( 2-5 hrs) Third period of stabilization of physiologic systems K. C. MEGHWAL 35 Monday, June 22, 2015

36. 3. Assessment of gestational age after birth Definition :-Gestation is the period of time between conception and birth. During this time, the baby grows and develops inside the mother's womb. I. Physical assessment:- The physical assessment is performed based on 7 fundamental observations Ear cartilage Hair Breast nodule Skin Lanugo Genitals Sole creases K. C. MEGHWAL 36 Monday, June 22, 2015

37. Assessment of gestational age after birth… II.Neuromuscular assessment The neuromuscular assessment is performed based on 4 fundamental observations. I ) Muscle tone :-this is assessed by 3 parameters Posture Active tone:-traction & recoil. Passive tone- Poplitial angle, scarf sign. ii) Joint mobility Square window (wrist) K. C. MEGHWAL 37 Monday, June 22, 2015

38. Assessment of gestational age after birth… III) Fundus examination:- the anterior vascular capsule of the lense of the eye helps us to identify the gestational age of the infant. The anterior capsule is completely vascularised in infants with less than 28 weeks after 34 weeksof maturity anterior capsular vessels are almost completely atrophied. IV) Certain automatic reflexes:- the presence of certain reflexes such as moro reflex, pupillary reflex (response to light), blinking reflex, and grasp reflex help us to identify the gestational age because these reflexes are developed at various gestational periods.eg. K. C. MEGHWAL 38 Monday, June 22, 2015

39. Assessment of gestational age after birth … Reflexes Weeks Moro reflex 28-30 weeks Pupillary reflex After 30 weeks Blinking reflex (blink response to glabellar tap) 29 weeks Grasp response 30 weeks Rooting & sucking efforts 34 weeks K. C. MEGHWAL 39 Monday, June 22, 2015

40. NEW BALLORD SCALE The New Ballard score is a set of procedures used to determine gestational age through physical and Neuromuscular assessment of a newborn baby. It is developed by Dr. Jeanne L. Ballard MD, associate professor of pediatrics, obstetrics & gynecology at the University of Cincinnati College of medicine. K. C. MEGHWAL 40 Monday, June 22, 2015

41. NEW BALLORD SCALE… I. Physical Maturity II. Neuromuscular Maturity Assessed by the 6 external physical signs/characteristics Skin Lanugo Breast Eye/Ear Planter Surface & Genitals Assessed by the 6 tests like Posture Arm Recoil Squire Window (Wrist) Poplitial Angle Scarf Sign Heel To Ear Monday, June 22, 2015 K. C. MEGHWAL 41

42. NEW BALLORD SCALE… I. Physical Maturity Signs :- i ) Skin:- K. C. MEGHWAL SIGN PHYSICAL MATURITY SCORE SIGN SCORE -1 1 2 3 4 5 Skin Sticky, friable, transparent gelatinous, red, translucent  smooth pink, visible veins superficial peeling &/or rash, few veins cracking, pale areas, rare veins parchment, deep cracking, no vessels leathery, cracked, wrinkled 42 Monday, June 22, 2015

43. New Ballord Scale… I. Physical maturity signs ii) Lanugo :- Lanugo is a fine downy hair on the body of the fetus & newborn baby K. C. MEGHWAL SIGN PHYSICAL MATURITY SCORE SIGN  SCORE -1 1 2 3 4 5   Lanugo      None      Sparse   Abundant Thinning Bald areas Mostly bald               43 Monday, June 22, 2015

44. New Ballord Scale… I. Physical maturity signs… iii) Planter surface:- planter Crease is a line on the planter surface made by folding of skin. K. C. MEGHWAL SIGN PHYSICAL MATURITY SCORE SIGN SCORE -1 1 2 3 4 5 Plantar Surface   Heel-toe   40-50mm: -1 <40mm: -2 >50 mm no  crease Faint red marks Anterior   transverse crease only Creases ant. 2/3 Creases   over entire sole                     44 Monday, June 22, 2015

45. New Ballord Scale… I. Physical Maturity Signs… iv) Breast:- K. C. MEGHWAL SIGN PHYSICAL MATURITY SCORE SIGN SCORE -1 1 2 3 4 5 Breast Imperceptable Barely perceptable Flat areola no bud Stippled areola 1-2 mm bud Raised areola 3-4 mm bud Full areola 5-10 mm bud                          45 Monday, June 22, 2015

46. New Ballord Scale… I. Physical maturity signs… V) Eye/ear:- K. C. MEGHWAL SIGN PHYSICAL MATURITY SCORE SIGN  SCORE -1 1 2 3 4 5 Eye / Ear Lids fused loosely: -1 tightly: -2 Lids open pinna flat stays folded Slightly. curved pinna;  soft; slow recoil well-curved pinna;  soft but ready recoil formed & firm instant recoil thick cartilage ear stiff                   46 Monday, June 22, 2015

47. New Ballord Scale… I. Physical maturity signs… vi) Genitals:(Male) K. C. MEGHWAL SIGN PHYSICAL MATURITY SCORE SIGN SCORE -1 1 2 3 4 5 Genitals (Male) scrotum  flat, smooth scrotum empty, faint rugae testes in upper canal, rare rugae testes descending, few rugae testes down, good rugae testes pendulous, deep rugae                  47 Monday, June 22, 2015

48. New Ballord Scale… I. Physical maturity signs… vi) GENITALS (Female) K. C. MEGHWAL SIGN PHYSICAL MATURITY SCORE SIGN SCORE -1 1 2 3 4 5 Genitals (Female) Clitoris prominent & labia flat Prominent clitoris & small labia minora Prominent clitoris & enlarging minora Majora & minora equally prominent Majora large, minora small Majora cover clitoris & minor 48 Monday, June 22, 2015

49. New Ballord Scale… II . Neuromuscular maturity signs i ) Posture K. C. MEGHWAL SIGN NEURO-MUSCULAR MATURITY SCORE SIGN SCORE -1 1 2 3 4 5 Posture                                  49 Monday, June 22, 2015

50. New Ballord Scale… II . Neuromuscular maturity signs … ii) Squire window (wrist) K. C. MEGHWAL SIGN NEURO-MUSCULAR MATURITY SCORE SIGN SCORE -1 1 2 3 4 5 Square Window                       50 Monday, June 22, 2015

51. New Ballord Scale… II . Neuromuscular maturity signs … iii) Arm Recoil K. C. MEGHWAL SIGN NEURO-MUSCULAR MATURITY SCORE SIGN SCORE -1 1 2 3 4 5 Arm Recoil                                          51 Monday, June 22, 2015

52. New Ballord Scale… II . Neuromuscular maturity signs … iv) Poplitiel angle K. C. MEGHWAL SIGN NEURO-MUSCULAR MATURITY SCORE SIGN SCORE -1 1 2 3 4 5 Popliteal Angle 52 Monday, June 22, 2015

53. New Ballord Scale… II . Neuromuscular maturity signs … v) Scarf sign K. C. MEGHWAL SIGN NEURO-MUSCULAR MATURITY SCORE SIGN SCORE -1 1 2 3 4 5 Scarf Sign                53 Monday, June 22, 2015

54. New ballord Scale… II . Neuromuscular maturity signs … vi) Heel to ear K. C. MEGHWAL SIGN NEURO-MUSCULAR MATURITY SCORE SIGN SCORE -1 1 2 3 4 5 Heel To Ear   54 Monday, June 22, 2015

55. PHYSICAL MATURITY SN Score signs -1 1 2 3 4 5 Given score 1 skin Sticky Frible Transparant Gelatinous Red translucent Smooth Pink Visible veins Superficial peeling &/ or rashFew veins Cracking Pale areas Rare veins Perchment deep cracking No vessels Lathery Cracked wrinkled 2 Lanugo None sparse abundant thinning Bald area Mostly bald - 3 Planter surface Heel to toe -40-50mm:-1 <40mm:-2 >50mm No crease Faint red marks Anterior transeverse crease only Crease anterior 2/3 Crease over entire sole - 4 Breast imperceptible Barely imperceptible Flat areola No bud Stippled areola 1-2mm bud Raised areola 3-4mm bud Full areola 5-10mm bud - 5 Eye/Ear Lids fused -loosely:-1 -tightly:-2 Lids open Pinna flat Stays folded Slightly curved pinna Soft slow recoil Well curved pinna Soft but ready recoil Formed & firm instant recoil Thick cartilage Ear stiff - 6 Genitals (male) Scrotum flat Smooth Scrotum empty Faint rugae Testes in upper canal Rare rugae Testes descending Few rugae Testes down Good rugae Testes pendulous Deep rugae - Genitals (female) Clitoris prominent Labia flat Clitoris prominent Small labia minora Clitoris prominent Enlarging minora Majora & minora equally prominant Majora large Minora small Majora covers clitoris &minora - K. C. MEGHWAL 55 Monday, June 22, 2015

56. NEUROMUSCULAR MATURITY SIGN SCORE SIGN SCORE -1 1 2 3 4 5 1 .Posture -   -     2 .Square Window -     3 .Arm Recoil -   -     4 .Popliteal Angle   5 .Scarf Sign -     6 .Heel To Ear -     TOTAL NEUROMUSCULAR SCORE   K. C. MEGHWAL 56 Monday, June 22, 2015

57. Maturity score I. Neuromuscular maturity score= II. Physical maturity score = Total maturity score= Gestational age (in weeks):- By dates= By ultra sound= By examination= K. C. MEGHWAL Total maturity score Gestational age in weeks -10 20 -5 22 24 5 26 10 28 15 30 20 32 25 34 30 36 35 38 40 40 45 42 50 44 57 Monday, June 22, 2015

58. 4. SYSTEMIC PHYSICAL EXAMINATION General activity & appearance General activity is poor Cry is week Size small with relatively large head Limbs are extended due to hypotonia with poor recoil of flexed forearm when it is extended Attitude lies in a relaxed attitude K. C. MEGHWAL 58 Monday, June 22, 2015

59. 4. SYSTEMIC PHYSICAL EXAMINATION … Vital signs Temperature - may be below normal (more prone to develop hypothermia) Pulse - rapid weak pulse (tachycardia) Respiration -rapid, shallow irregular with periods of apnea & cyanosis (techypnea) BP- usually low BP K. C. MEGHWAL 59 Monday, June 22, 2015

60. 4. SYSTEMIC PHYSICAL EXAMINATION … Anthropometry Weight :- K. C. MEGHWAL Gestational Weeks = Estimated Fetal Weight Percentile Chart [  A fetus is considered normal if they are between 10th and 90th percentile  ]   Average  Estimated Fetal Weight  +/-  SD 1.28 Gestational Weeks EFW 10th% 90th% 20 331 g 275 387 21 399 g 331 467 22 478 g 398 559 23 568 g 471 665 24 670 g 556 784 25 785 g 652 918 26 913 g 758 1068 27 1055 g 876 1234 28 1210 g 1004 1416 29 1379 g 1145 1613 30 1559 g 1294 1824 31 1751 g 1453 2049 32 1953 g 1621 2285 33 2162 g 1794 2530 34 2377 g 1973 2781 35 2595 g 2154 3036 36 2813 g 2335 3291 37 3028 g 2513 3543 60 Monday, June 22, 2015

61. 4 . SYSTEMIC PHYSICAL EXAMINATION … Anthropometry HEIGHT/length :- Average fetal length (crown to heel) K. C. MEGHWAL Gestational age Length  (cm) 20 weeks 25.6 cm 21 weeks 26.7 cm 22 weeks 27.8 cm 23 weeks 28.9 cm 24 weeks 30 cm 25 weeks 34.6 cm 26 weeks 35.6 cm 27 weeks 36.6 cm 28 weeks 37.6 cm 29 weeks 38.6 cm 30 weeks 39.9 cm 31 weeks 41.1 cm 32 weeks 42.4 cm 33 weeks 43.7 cm 34 weeks 45 cm 35 weeks 46.2 cm 36 weeks 47.4 cm 37 weeks 48.6 cm 38 weeks 49.8 cm 61 Monday, June 22, 2015

62. 4. SYSTEMIC PHYSICAL EXAMINATION … Anthropometry Head circumference - head circumference is less than 33 cm but exceeds the chest circumference by more than 3 cm K. C. MEGHWAL Gestational age Head circumference, in inches (centimeters) 40 weeks 14 (35.5 cm) 35 weeks 12.6 (32 cm) 32 weeks 11.8 (30 cm) 28 weeks 10.2 (26 cm) 24 weeks 8.7 (22 cm) 62 Monday, June 22, 2015

63. SYSTEMIC PHYSICAL EXAMINATION… K. C. MEGHWAL Chest Circumference-usually < than head circumference Anthropometry 63 Monday, June 22, 2015

64. 4. SYSTEMIC PHYSICAL EXAMINATION … Examination of head, Neck and Face Head - Size - head is large in proportion to the rest of the body Skull bones- soft. Sutures -widely separated Anterior fontanel - fontanel's are wide Posterior fontanel - -----do---- Hair distribution - hair is scanty, wooly and fuzzy Face -face appears small with small chin K. C. MEGHWAL 64 Monday, June 22, 2015

65. 4. SYSTEMIC PHYSICAL EXAMINATION … Examination of eyes Eyes are fused before 25 weeks gestation Pupillary reflex present after 30 weeks of gestation. Blinking reflex is present after 29 weeks of gestation. Retinopathy of prematurity may present due to O 2 toxicity K. C. MEGHWAL 65 Monday, June 22, 2015

66. 4. SYSTEMIC PHYSICAL EXAMINATION … Examination of ears Pinna flexible & cartilage deficient or absent Recoil may be poor K. C. MEGHWAL 66 Monday, June 22, 2015

67. 4. SYSTEMIC PHYSICAL EXAMINATION … Examination of mouth and throat Sucking, gag, rooting, yawning, and cough reflexes Palate Uvula Lips K. C. MEGHWAL 67 Monday, June 22, 2015

68. 4. SYSTEMIC PHYSICAL EXAMINATION … Examination of neck Short, thick, symmetric neck Tonic-neck reflex Head movements Range of motion K. C. MEGHWAL 68 Monday, June 22, 2015

69. 4. SYSTEMIC PHYSICAL EXAMINATION … Examination of skin and Nails Skin is thin, shiny and excessively pink with abundant lanugo Very little vernix caseosa Edema may be present Subcutaneous fat is absent Dry skin with poor turgor K. C. MEGHWAL 69 Monday, June 22, 2015

70. 4. SYSTEMIC PHYSICAL EXAMINATION … Examination of chest Size Shape Sounds K. C. MEGHWAL 70 Monday, June 22, 2015

71. 4. SYSTEMIC PHYSICAL EXAMINATION … Examination of abdomen Full, soft & round with prominence veins K. C. MEGHWAL 71 Monday, June 22, 2015

72. 4. SYSTEMIC PHYSICAL EXAMINATION … Examination of upper extremities Nails are short & not grown up to finger tips No. of fingers Symmetry of extremities Range of motion K. C. MEGHWAL 72 Monday, June 22, 2015

73. 4. SYSTEMIC PHYSICAL EXAMINATION … Examination of lower extremities No Deep sole creases, or Single Deep crease over anterior 1/3 rd of sole Symmetry of extremities range of motion K. C. MEGHWAL 73 Monday, June 22, 2015

74. 4. SYSTEMIC PHYSICAL EXAMINATION … Examination of genitalia male genitalia Testes are undescended before 28 weeks of gestation Testes start descending from abdominal cavity to inguinal canal from 28 weeks At 36 weeks one testes descends into scrotum At about 40 weeks both testes descends into scrotum Scrotum is poorly developed with poor pigmentation K. C. MEGHWAL 74 Monday, June 22, 2015

75. 4. SYSTEMIC PHYSICAL EXAMINATION .. Examination of genitalia female genitalia Labia majora are widely separated exposing labia minora C litoris is hypertrophied & prominent K. C. MEGHWAL 75 Monday, June 22, 2015

76. 4. SYSTEMIC PHYSICAL EXAMINATION … Respiratory system Tachypnea Breathing is mostly diaphragmatic Diaphragmatic breathing, abdominal breathing, belly breathing or deep breathing is breathing that is done by contracting the diaphragm, a muscle located horizontally between the chest cavity and stomach cavity. Air enters the lungs and the belly expands during this type of breathing. This deep breathing is marked by expansion of the  abdomen  rather than the  chest  when breathing Recurrent apnea attacks may be seen K. C. MEGHWAL 76 Monday, June 22, 2015

77. 4. SYSTEMIC PHYSICAL EXAMINATION … Central nervous system Inactive & Lethargic Poor cough reflexes In coordination in sucking & swallowing in babies born before 35 weeks of gestation K. C. MEGHWAL 77 Monday, June 22, 2015

78. 4. SYSTEMIC PHYSICAL EXAMINATION … Cardiovascular system Tachycardia (120 beats/min), Closure of Ductus Arteriosus is delayed 1/3 of babies born before 34 weeks manifests clinical evidence of patent Ductus Arteriosus It is common in preterm who weigh < 1.5 kg. K. C. MEGHWAL 78 Monday, June 22, 2015

79. 4. SYSTEMIC PHYSICAL EXAMINATION … Digestive system Difficulties in feeding (due to in coordinated sucking & swallowing) Abdomen distention & functional intestinal obstruction is common (due to hypotonia) Jaundice may occur due to immaturity of liver Hypoglycemia may occur due to poor hepatic glycogen stores, delayed feeding, birth asphyxia & respiratory distress syndrome. Vulnerable to toxic effects of drug due to poor hepatic detoxification K. C. MEGHWAL 79 Monday, June 22, 2015

80. 4 . SYSTEMIC PHYSICAL EXAMINATION … Renal system BUN is high due to low GFR Vulnerable to develop metabolic acidosis Dehydration may occur due to poor capacity to conserve water Edema may occur due to solute retention & low serum proteins Vulnerable to toxic effects of drug due to reduced renal clearance   K. C. MEGHWAL 80 Monday, June 22, 2015

81. Management Of Preterm Neonates MEDICAL MANAGEMENT Exams and Tests Common tests performed on a premature infant include: A rterial B lood G as analysis(ABG) Blood tests to check glucose, calcium, and bilirubin levels Chest x-ray Continuous cardio respiratory monitoring (monitoring of breathing and heart rate) K. C. MEGHWAL 81 Monday, June 22, 2015

82. K. C. MEGHWAL Mean hematologic values in preterm and term babies:- Determination Preterm Term 28 weeks 34 weeks Cord blood Day1-day14 HB (gm/dl) 14.5 15 16.8 18.4-16.8 Hematocrit 45 47 53 58-52 RBC (cumm 10 6 ) 4 4.4 5.2 5.8-5.1 MCV (u3) 120 118 107 108-96 MCH (pg/cell) 40 38 34 35-31 MCHC (%) 31 32 31.7 32-33 Reticulocyte (%) 5-10 3-10 3-7 3-7 to 0-1 Nucleated RBC’S - - 500 200-00 WBC 13000-16000 18000-22000 Platelet count(mm3) 100-400 150-400 150-400 82 Monday, June 22, 2015

83. K. C. MEGHWAL 83 Monday, June 22, 2015

84. Supportive care Specialized supportive care for baby may include Being placed in an incubator.   Incubator :- An incubator  is an apparatus used to maintain environmental conditions suitable for a neonate (newborn baby). It is used in preterm births or for some ill full-term babies. K. C. MEGHWAL MEDICAL MANAGEMENT 84 Monday, June 22, 2015

85. K. C. MEGHWAL 85 Monday, June 22, 2015

86. MEDICAL MANAGEMENT… Monitoring of baby's vital signs (TPR & BP, O2 Saturation ) By vital signs monitors By pulse oxymetry K. C. MEGHWAL 86 Monday, June 22, 2015

87. MEDICAL MANAGEMENT… Tube feeding.   At first baby may receive fluids and nutrients through an IV tube. Breast milk may be given later through a tube passed through baby's nose and into his or her stomach (nasogastric or NG tube). When baby is strong enough to suck, breast-feeding or bottle-feeding is often possible K. C. MEGHWAL 87 Monday, June 22, 2015

88. MEDICAL MANAGEMENT… Administration of IV fluids .   baby needs a certain amount of fluids each day, depending upon his or her age and medical conditions. The NICU team will closely monitor fluid, sodium and potassium levels to make sure that your baby's fluid levels stay on target. If fluids are needed, they'll be delivered through an intravenous (IV) line. K. C. MEGHWAL 88 Monday, June 22, 2015

89. MEDICAL MANAGEMENT… Phototherapy.  To treat infant jaundice, baby may be placed under a set of lights — known as bilirubin lights — for a period of time. The lights help baby's system break down excess bilirubin, which builds up because the liver can't process it all. While under the bilirubin lights, baby will wear a protective eye mask. K. C. MEGHWAL 89 Monday, June 22, 2015

90. MEDICAL MANAGEMENT… blood transfusion.  Because preemie may have an underdeveloped ability to make his or her own red blood cells, a blood transfusion may be needed to raise blood volume — especially if baby has had several blood samples drawn for various tests . K. C. MEGHWAL 90 Monday, June 22, 2015

91. MEDICAL MANAGEMENT… Medications Medications may be given to baby to promote maturing and to stimulate normal functioning of the lungs, heart and circulation. Depending on the baby's condition, medication may include: A liquid (surfactant), to help them mature Fine-mist (aerosolized) or IV medication to strengthen breathing and heart rate Antibiotics if infection is present or if there's a risk of possible infection Medicines that increase urine output (diuretics) to help the lungs and, sometimes, the circulation K. C. MEGHWAL 91 Monday, June 22, 2015

92. SURGICAL MANAGEMENT… Surgery A feeding problem, by placing a central line to deliver IV nutrition Necrotizing enterocolitis , by removing the damaged part of the intestines Patent ductus arteriosus , when medications fail to work, by closing a blood vessel near the heart Retinopathy of prematurity , by using a laser to reverse abnormal blood vessel development and limit further risks to vision Worsening hydrocephalus , by placing a plastic tube, called a shunt, to drain excess fluid in the brain K. C. MEGHWAL 92 Monday, June 22, 2015

93. NURSING MANAGEMENT IMMEDIATE CARE FOLLOWING BIRTH :- Monitoring of parameters:- Vital signs with the help of multi-channel vital sign monitor Activity and behavior Color-pink, pale, grey, blue, yellow Tissue perfusion Fluids electrolytes and ABG‘s Tolerance of feeds by monitoring vomiting, gastric residuals, & abdominal girth The baby should be watched for development of RDS, PDA, NEC, IVH, apnea attacks, sepsis etc. Weight gain velocity Blood sugar K. C. MEGHWAL 93 Monday, June 22, 2015

94. NURSING MANAGEMENT… Establishment & maintenance of respiration :- Oropharynx & nasopharynx should be suctioned immediately by mucus sucker or by catheter connected with suction. Infant should be positioned on the back or abdomen with head lowered at 15-30 degree to facilitate mucus drainage. Keep the body warm. Provide oxygen if necessary. Transfer the neonate to NICU K. C. MEGHWAL 94 Monday, June 22, 2015

95. NURSING MANAGEMENT O 2 therapy:- Should be administered only when indicated Should be administered with head box (hood) Should be administered when SaO 2 falls below 85% Should be stopped when SaO 2 goes above 90% PaO2 should be between 60-80 mm Hg K. C. MEGHWAL 95 Monday, June 22, 2015

96. NURSING MANAGEMENT… Stabilization & maintenance of body temperature :- Dry the hair & skin with warm, soft, dry towel. Place the baby on the mother’s body or wrap the baby in blanket or put the baby in a heated environment such as a radiant warmer. Bathing should not be done until the temp. Is normal or stable. Record the temp. By axilla . Temperature should be maintained with in normal range i.e.97.9 F to 99.5 .F K. C. MEGHWAL 96 Monday, June 22, 2015

97. K. C. MEGHWAL 97 Monday, June 22, 2015

98. NURSING MANAGEMENT… Prevention of infection & injury:- Environment should be kept as clean as possible. Thorough hand washing by all caregivers including parents is essential before handling the neonate. All clothing's linens & equipments used for the infant should be clean. Vit.k 1.0 mg water soluble injection IM in the vastus lateralis muscle soon after delivery should be given to baby. 1% silver nitrate 1-2 drops prophylactically to prevent gonococcal ophthalmia . Cord should be tied before cut. The cord stump develops dry gangrene & falls off between 7 to 10 days. K. C. MEGHWAL 98 Monday, June 22, 2015

99. NURSING MANAGEMENT… Provision of optimal nutrition:- Breast feeding should provide as soon as possible after birth if reflexes is positive. Tube feeding of breast milk can be given if the baby is unable to suck & swallow. Intra venous dextrose should be started if above is not possible. K. C. MEGHWAL 99 Monday, June 22, 2015

100. NURSING MANAGEMENT.. Skin care:- Avoid alkaline based soap to use. Alcohal or povidine iodine should be used with caution as they may cause irritation or chemical burn. Avoid excessive use of adhesive tap. Use emollients to provide skin integrity & to prevent dry, cracking, peeling skin. Maintain clean, dry, skin; use absorbent diapers & change regularly. Use emollient in groin & thigh area to reduce urine irritation. K. C. MEGHWAL 100 Monday, June 22, 2015

101. NURSING MANAGEMENT… Administration of medications:- Computation, preparation, & administration of drugs in minute amounts often require collaboration between nurses, physicians, & pharmacists to reduce the chance of error. Apply safety measures while administration of therapeutic agents, IV infusions & oxygen. Oral & parenteral medication should be sufficiently diluted to prevent complications. Nurses must be extremely vigilant when administering medications to preterm & high risk neonates. K. C. MEGHWAL 101 Monday, June 22, 2015

102. NURSING MANAGEMENT Promote parent infant bonding:- Allow the parents to see their infant prepare parents for their infant’s appearance, the equipments attached to the neonate When possible phototherapy can be temporarily discontinued & eye patches removed to permit eye to eye contact. help parents deal with feeling of guilt, anxiety, helplessness, inadequacy, anger & ambivalence (opposite emotions). encourage & reinforce parents during their care giving activities & interactions with their infants to promote healthy parent-child relationship. K. C. MEGHWAL 102 Monday, June 22, 2015

103. Complications to preterm babies I . Short term problems:- 1.Immature lungs RDS (Respiratory distress syndrome) BPD (bronco pulmonary dysplasia) Transient tachypnea Pneumonia Apnea Birth asphyxia 2.Heart problem PDA (patent ductus arteriosus) K. C. MEGHWAL 103 Monday, June 22, 2015

104. Complications to preterm babies… 3.Brain problems Intra-ventricular hemorrhage Hydrocephalus 4.Thermoregulation problems Hypothermia 5.GIT problems NEC (necrotizing enterocolitis ) Neonatal jaundice K. C. MEGHWAL 104 Monday, June 22, 2015

105. Complications to preterm babies… 6.Blood problems Anemia Neonatal jaundice Low blood pressure 7.Metabolism problem Hypoglycemia 8.Immune system problem Infection K. C. MEGHWAL 105 Monday, June 22, 2015

106. Complications to preterm babies… II. Long term problems:- Cerebral palsy Impaired cognitive skills Vision problem ROP (retinopathy of prematurity) Hearing problem hearing loss Dental problem delayed tooth eruption tooth discoloration improper aligned teeth Behavioral & psychological problems attention deficit hyperactivity disorder depression K. C. MEGHWAL 106 Monday, June 22, 2015

107. Factors affecting premature babies survival/viability Viability is the ability for a baby to survive outside the mothers womb. the factors affecting viability are:- 1.Gestation 2.Birth weight 3.Infant condition at birth 4.Multiple pregnancies 5. Antenatal steroids 6.Place of delivery 7.Gender K. C. MEGHWAL 107 Monday, June 22, 2015

108. Factors affecting premature babies survival… Gestation K. C. MEGHWAL Length of Pregnancy Likelihood of Survival 23 weeks 17 % 24 weeks 39 % 25 weeks 50 % 26 weeks 80 % 27 weeks 90 % 28-31 weeks 90-95 % 32-33 weeks 95 % 34 + weeks Almost as likely as a full-term baby 108 Monday, June 22, 2015

109. Factors affecting premature babies survival… Birth weight K. C. MEGHWAL Birth weight survival 500-750 gms 74% 751-1000 gms 82% 1001-1250 gms 92% 1251-1500 gms 95% 109 Monday, June 22, 2015

110. Factors affecting premature babies survival… Multiple pregnancies K. C. MEGHWAL Multiple pregnancies % of preterm birth & average duration of most pregnancies survival Singleton 9.5% (36-39 weeks) 95-100 % Twins 60% (35 weeks) 95-100% Triplets 90% (32 weeks) 95% Quadruplets 95-100% (29 weeks) 90-95% 110 Monday, June 22, 2015

111. Youngest preterm survive in the world Name - Amillia Taylor DOB -24-10-2006 DOD -24-2-2007 Gestational age -21 weeks 6 days Stay in hospital -4 months (NICU) Birth weight -280 Gms Length at birth -22.9 cm Place -Miami Florida Hospital -Baptist children's hospital K. C. MEGHWAL 111 Monday, June 22, 2015

112. Conclusion Incidence of premature birth and mortality rate of premature babies is very high in India. By proper screening of high risk pregnancies, proper care during antenatal period & early diagnosis & treatment of complications, proper investigation, delivery at proper place & proper level by well qualified health care providers with well equipped intensive neonatal care unit may decrease the incidence, morbidity & mortality rate among premature babies. K. C. MEGHWAL 112 Monday, June 22, 2015

113. Bibilography : - Ghai , Op-essential Paediatrics, 7 th Edition Page No.128-136 Marlow’s –Textbook Of Paediatric Nursing, 6 th Edition Page No.386-437 Dutta , Parul - Pediatric Nursing, 2 nd Edition Page No.66-71,103-114 Wong’s-essentials Of Pediatric Nursing Page No.197-239,251-318 Dutta , Dc –Textbook Of Obstetrics Including Perinatology &Conception, 7 th Edition Page No 444-467. Park, K- Textbook Of Preventive & Social Medicine, 21 st Edition Page No.-492-495. Ignou -trends In Pediatric Nursing, Newborn &Infant Care, Edition Jan.2006, Page No. 104-116. Singh Meharban, Care Of The Newborns, 17 th Edition April 2010 Page No.4-7, 234-242, 496-498 Www.Lil Aussie Prems .Com Www.Ballord Score.Com Www.Mayo Clinic Staff.Com Www.Baby 2 See. Com Miscarriage. About.Com Www.Preemise.About.Com Http://Www.Mayoclinic.Com Http://Www.Babyzone.Com Http://News.Bbc.Co.Uk K. C. MEGHWAL 113 Monday, June 22, 2015

114. Topic Related Ques. In Exam. Q.Write short notes any FOUR 4X4 Characteristics of LBW baby ( B.Sc. ( N) Pt.III March-2015) Q.Write difference between (any two) ( c) Term & preterm baby B.Sc.N . pt-III Exam Feb.2014 ) Q.Write short notes on any four of the following: Care of premature child B.Sc.N . pt-III Exam august 2008) Monday, June 22, 2015 K. C. MEGHWAL 114

115. Thank you K. C. MEGHWAL 115 Monday, June 22, 2015