Low risk prematurity, pediatric and high risk

Pediatric course on premature

1. PREMATURITY AGGIE MONGWE RN,RM,BSC,MSC STUDENT MATERNAL AND CHILD HEALTH

2. PREMATURITY

3. Preterm delivery is the most frequent cause of infant deaths. Some premature babies require special care and spend weeks or months hospitalized in a neonatal intensive care unit (NICU). INTRODUCTION

4. Prematurity is a term used to describe when a baby is born early. Most pregnancies last around 40 weeks but some are shorter and some are longer. Babies that are born between 37 weeks and 42 weeks are called full term. Babies born before 37 weeks are called premature or preterm Introduction cont’s

5. Define prematurity State the predisposing factors to prematurity Outline characteristics of a preterm baby Outline the problems of a preterm baby Discuss the management of a preterm baby SPECIFIC OBJECTIVE

6. A premature infant is one born after 28 weeks of gestation but before 37 weeks of gestation are completed, calculated from the first day of the last menstrual period regardless of the birth weight( Fraser and Cooper,2003 ) DEFINITION

7. Prematurity is the condition in which the baby is born before 37 completed weeks of pregnancy, but after 28 th week of gestation regardless of the birth weight (Myles, 2006). Definition cont.'s

8. NOTE that this depends on the country’s viability age zambia-28 th week UK- 24 th week South- 26 th week

9. The real causes remain unknown but there are numerous factors associated with prematurity M aternal factors 1.Maternal age This is seen in young primi gravidae aged below 20 years of age where the abdominal muscles are stiff and rigid and as the pregnancy grows at a certain age of gestation the uterine muscles can not stretch anymore and there is stimulation of the onset of premature labour. PREDISPOSING FACTORS

10. 2. Previous obstetrics history of prematurity Its common experience for women who have had preterm labour to have another experience of premature labour due to maybe cervical incompetency Maternal causes cont’s

11. 3 . Premature rapture of membranes(PROM) This will cause premature labour in that there will be increased pressure on the cervix after draining of liquor amnii causing mechanical stimulation of the onset of premature labour   Maternal causes cont’s

12.   4. Polyhydramnios This will lead to preterm labour due to over distension of the uterine muscle which will stimulate uterine contraction before pregnancy is term   Maternal causes cont’s

13. 5. Anaemia In this condition, there is maternal hypoxia due to reduced amount of haemoglobin which in turn causes reduced placental perfusion ending in preterm labour Maternal causes cont’s

14. 6. Local uterine causes Such as uterine fibroids, malformed uterus such as in bicornuate uterus, uterine septus or where the space is not enough for fetal growth. Uterine contractions are initiated and preterm labour occurs Maternal causes cont’s

15. 7. Elective causes of prematurity These are conditions which will call for termination of pregnancy due to maternal or fetal conditions and include; pregnancy induced hypertension, pre-eclampsia, renal or cardiac disease, placenta preavia and placenta abruption. Maternal causes cont’s

16. 1 . Multiple pregnancy This is the gestation of more than one fetus in utero and results in the overstretching of uterine muscles leading to the onset of preterm labour. There is also increased weight of the fetuses exerting larger pressure on the cervix leading to stimulation of the cervix Fetal causes

17. 2. Babies of diabetic mothers These babies tend to outgrow their gestation age .There is overstretching of the abdominal muscles leading to the onset of preterm labour, usually these babies weight does not correspond with their maturity Fetal causes cont’s

18. 3. Congenital fetal abnormalities This will call for the induction of labour even before term so that the deformed fetus could be delivered. The defects can be hydrocephalus , encephalay and conjoined twins( Fraser and cooper 2003 ) Fetal causes cont’s

19. 3. Rhesus incompatibility Where the mother is rhesus negative and the fetus is rhesus positive .there is increasing production of anti-bodies to destroy Red blood cells in subsequent pregnancy. This may result into preterm labour ( Fraser and cooper 2006) Fetal causes cont’s

20. 4. Intra uterine growth retardation Induction of labour is done prematurely to terminate pregnancy. because of placental insufficiency there will be reduced growth but if the fetus remains longer in utero it may result in fetal death Fetal causes cont’s

21. Fetal causes Multiple pregnancy Diabetes babies Congenital fetal abnormalities Rhesus incompatibility Predisposing factors cont’s

22. Length- 49cm or less Posture- baby is lethargic and lies in a frog like position due to generalized hypotonia or poor muscle tone HEAD Head is large in proportion to body with small triangular face because of the pointed chin. Hair is soft and silky Characteristics of a Preterm B aby

23. Head circumference- less than 34cm skull bones are soft with wide sutures and fontanelle Ears have soft cartilage and pinnae stay folded Characteristic cont.'s

24. Skin and subcutaneous tissue Skin is thin, red, easily broken and appears wrinkled due to lack of subcutaneous tissue Bony structures are easily seen with poorly developed skin creases Characteristic cont.'s

25. Blood vessels are easily visible under the skin Lanugo is plenty with little vernix caseosa Reflexes are poor, may be present and weak, and sometimes absent especially sucking and swallowing Nails are short and soft Characteristics cont’s

26. Breast nodules are small or absent Chest and abdomen- chest is small and narrow while the abdomen is relatively large and easily distended. The umbilicus looks low set with plenty of Wharton’s Jelly characteristic cont’s

27. Breathing is abdominal and usually with irregular rate and depth of breathing with periods of apneic spells Characteristic cont.'s

28. Genitalia Undescended testes (in males) before 36 weeks Clitoris and labia minora prominent, labia majora underdeveloped (females) Sleeps most of the time but often stretches and yawns Hands and feet are often oedematous Characteristics cont.'s

29. Respiratory difficulty : Because of inadequate surfactant production to aid in good lung expansion Poor body temperature regulation: Because of lack of subcutaneous fat tissue Problems of preterm babies

30. Feeding problems: Because of lack of sucking and swallowing reflexes. If at all they are present, they are usually poor. Physiological jaundice: Because of increased normal break down of excess red blood cells Problems of preterm babies cont.'s

31. Susceptibility to infections: Because of low immune antibodies transferred from the mother via the placenta Bleeding tendencies: Because the liver is not fully developed to manufacture adequate clotting factors to aid in the coagulation mechanism Problems of preterm babies cont.'s

32. Have all equipment for resuscitation at hand e.g. suction machine, ambu bag, oxygen cylinder, endotracheal tube, Intravenous fluids, emergency drugs like Naloxone, Vitamin K and ,adrenaline MANAGEMENT

33. functioning clock, weighing scale, warm wrappers, warm portable resuscitaire, needles, syringes, strapping and butterfly cannulae

34. investigations Blood gas analysis to rule out conditions like Respiratory Distress Syndrome. Full blood count to rule out anemia Glucostix test to rule out hypoglycemia Management cont.'s

35. Administer oxygen 30-40 % to keep baby pink. Artificial ventilation in severe distress and cyanosis Sodium bicarbonate 4.2% 1ml/kg body weight to correct acidosis Vitamin K 1mg/kg body weight to prevent bleeding tendencies Prophylactic antibiotics such as gentamycin T reatment

36. Tetracycline eye ointment to prevent ophthalmic Neonatorum Suction gently to prevent trauma. 10% 3-5mls Dextrose for nutrition, then ½ strength Darrow’s solution for maintenance of fluids and electrolytes. Treatment cont.'s

37. Aims To maintain a clear airway To maintain body temperature within normal To provide adequate nutrition and hydration To prevent infection To maintain skin integrity To provide support to the family Nursing management

38. position to improve oxygenation Suction to remove accumulated mucus from nasal pharynx Administer Oxygen as prescribed 1l/min by nasal prong Assess oxygen saturation using pulseoximeter TO MAINTAIN RESPIRATIONS

39. The Four modalities by which the infant loss his / her body temperature: 1-     Evaporation: Heat loss that result from expenditure of internal thermal energy to convert liquid on an exposed surface to gases, e.g.: amniotic fluid, sweat. Prevention: Carefully dry the infant after delivery or after bathing. TO MAINTAIN OPTIMAL THERMOREGULATION

40. 2- Conduction: Heat loss occurs from direct contact between body surface and cooler solid object. Prevention: Warm all objects before the infant comes into contact with them. Heat loss cont’s

41. 3- Convection: Heat loss that result from exposure of an infant to direct source of air. Prevention: ·         Keep infant from out open air ·        Close one end of heat shield in incubator to reduce velocity of air . No fans   Heat loss cont’s

42. 4- Radiation: It occurs from body surface to relatively distant objects that are cooler than skin temperature. Heat loss cont’s

43. Nurse the neonate in the incubator with temperature 36-37.2C. If less than 2.0 kg, incubator care is indicated ,Cot care is used for babies weighing between 2 kg and 2.5kg in a room temperature of 24 degrees Celsius. Change soiled linen Warm hands before touching the neonate Maintance of optimal thermoregulation cont.'s

44. Dry the baby after delivery and bathing keep warm in warn beddings Quarter hourly check of vital signs during the critical period Encourage Kangaroo care to provide warmth- skin to skin contact with the parent. Maintance of optimal thermoregulation cont.'s

45. Give expressed breast milk when the neonate is ready to take 150mls/kg hourly on day 1 in Nasal gastric tube in 24hrs then change to 2 hourly Monitor fluid intake Monitor output Give the prescribed IV fluids-10% dextrose 3-5ml/kg TO MAINTAIN ADEQUATE NUTRITION AND HYDRATION

46. Wash hands before attending to the neonate Isolate infants with infection Ensure all equipment’s are clean Clean incubator Change linen TO PREVENT INFECTION

47. Encourage clean nipples Administer prescribed drugs Restricting number of visitors Top and tail  

48. Top and tail baby in clean water Change soiled linen Keep your fingers nails short Use petroleum based ointments only Use transparent adherence dressings to secure IV TO MAINTAIN SKIN INTEGRITY

49. When a baby is in the Special Care Baby Unit (SCBU) it is a very emotional and traumatic time for both the parents. Encourage parents to ask questions Be honest in answering TO PROVIDE SUPPORT TO THE FAMILY

50. Encourage parents to visit the baby Allow the parents to spend time with infant  

51. Place baby on phototherapy to treat Jaundice Observe , skin , sclera and mucous membranes to note reduction in, or deepening of the Jaundice Observe baby for signs of kernicterus, like lethargy and convulsions management of jaundice

52. Treat all infections promptly to prevent Jaundice. Phenobarbitone 20 mg/kg may be given to help mature liver enzymes

53. Involve parents in care of baby during hospital stay so they gain the skill to continue the care at home Counsel them on care of baby- feeding, warmth, hygiene, medical reviews Plan to discharge baby when;- Parents are competent to continue care on their own Discharge plan

54. Baby is consistently gaining weight at a rate of 10-30 g/day Baby maintains stable temp in an open crib Baby has had no recent apnea or bradycardia All medical conditions have been attended to and resolved Baby is breastfeeding well Discharge plan cont’s

55. Respiratory Distress Syndrome: Because of inadequate surfactant production in the baby’s immature lungs Hemorrhagic disease of the new born: the immature liver is unable to manufacture adequate clotting factors to aid in the clotting mechanism Susceptibility to infections: Because of low immune antibodies transferred from the mother via the placenta complication

56. Dehydration: Because of inadequate fluid intake Physiological jaundice: Because of increased normal break down of excess red blood cells Anemia: Because of poor iron stores by the immature liver Hypoglycemia: Because of poor glycogen stores by the immature liver Complications cont.'s

57. Prematurity is a serious problem worldwide and more so in Zambia. Appropriate management of preterm infants will increase survival rates. It is therefore imperative for health personnel to have updated knowledge and skills in the management of these babies. Quality care means involving the parents and planning for continued care at home. CONCLUSION:

58. ASSIGNMENT Read on gestational age assessment

59. Fraser, M" Cooper, M,A & Nolte,A . G. W (2003) Myles Textbook for Midwives , 14 th Edition. Churchill l.ivingstone.Edinburgh . Fraser, M" Cooper, M,A & Nolte,A . G. W(2006), Myles Textbook jot Midwives, African Edition , Churchill Livingstone. Edinburgh. http://en.wikipeadia.org/wiki/preterm-birth. Leifer , G (1999). Introduction to Maternity and Paediatric Nursing , 4 th Edition, Saunders. St.Louis . Ministry of Health. Pregnancy, Childbirth, Postpartum and Newborn care guidelines - Agenda for essential practice in Zambia.-Lusaka, Zambia. Ministry of Health . Essential Newborn Care – Module 1. Lusaka, Zambia. Sally B. Maria L. Patricia W, Maternal- Newborn Nursing , 5 th edition,1996, Addison Wesley,California Encarta 2006 REFERENCE

60. ANY QUESTIONS?

61. Thank you