NEWBORN

COMPLICATIONS

Diana Barrios, RN, MSN

Merritt College ADN Program
Nursing 3A: Perinatal Nursing

CLASSIFICATION OF INFANTS
BY GA & WEIGHT

By gestational age
 Preterm/premature: < 37 weeks gestation
 Term: 38-42 weeks
 Postterm/postdate: >42 weeks

By birth weight
 SGA: below 10th percentile on intrauterine growth curves
 AGA: between 10th and 90th percentile
 LGA: above 90th percentile
 LBW: 2500 g or less
 VLBW: 1500 g or less
 ELBW: <1000 g

Gestational age and birth weight affect maturity of
infant’s body systems and likelihood to experience
health problems

THE PRETERM INFANT

The preterm infant has immature body systems
and inadequate physiological reserves, making it
difficult to adjust to extrauterine life

Degree of maturity depends on length of
gestation and birth weight

Prematurity results in immediate and/or lifelong
negative sequelae

Preterm birth causes 2/3 of all infant deaths

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 RESPIRATORY & CARDIOVASCULAR
SYSTEMS: THE PRETERM INFANT

Respiratory
Immature lungs
Inadequate amount of surfactant
Fewer functional alveolar sacs
Respiratory passages collapse or become obstructed
Immature or fragile capillaries in the lungs
Infant may experience respiratory distress or apnea;
oxygen and/or artificial ventilation may be necessary

Cardiovascular
Issues with heart rate & rhythm, color, blood pressure,
perfusion, pulses, O2 sat, acid-base balance

THERMOREGULATION:
THE PRETERM INFANT

High ratio of body surface to body weight

Poor muscle tone, less flexed posture

Little subcutaneous fat

Decreased stores of brown fat

Decreased ability to constrict superficial blood
vessels

Thinner, more permeable skin

Immature temperature regulation center in brain

Inadequate glycogen stores

Radiant warmer, incubator, or kangaroo care
may help establish a neutral thermal
environment.

CENTRAL NERVOUS SYSTEM:

THE PRETERM INFANT

Most rapid brain growth occurs in 3rd trimester

CNS vulnerable to injury related to:
Birth trauma with damage to immature structures
Bleeding from fragile capillaries
Impaired coagulation
Recurrent anoxic or hyperoxic episodes
Hypoglycemia
Fluctuating BP

Evaluate infant for signs of neuro dysfunction:
seizures, hyperirritability, CNS depression,
increased ICP, decorticate positioning

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 DIGESTIVE SYSTEM:
THE PRETERM INFANT

Ingestion, digestion, and absorption
problems

Weak/absent suck and swallow reflex

Poorly developed gag reflex increases risk
for aspiration

Immature digestive enzymes

Small stomach capacity

Oral feedings may not be possible – may
need gavage or IV feedings

GENITOURINARY &
HEPATIC SYSTEMS:
THE PRETERM INFANT

Immature kidneys lead to issues:
Maintaining fluid & electrolyte balance
Excreting metabolites and drugs
Concentrating urine
Monitor I&O, specific gravity, serum levels of meds

Hepatic system
Fewer glycogen deposits & increased risk for cold stress
 hypoglycemia
Low iron stores  anemia
Increased risk for hyperbilirubinemia & jaundice

IMMUNE SYSTEM:
THE PRETERM INFANT
Greater risk for infection:

Deficient antibodies (less passive acquired
immunity) b/c less time spent in utero

Decreased ability to make antibodies

Inability to suck or difficulty sucking affects
breastfeeding and transfer of IgA
antibodies

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 Lack of body fat, brown fat, Can be LBW, SGA, IUGR, or AGA –
posturing → hypothermia but all organs/systems are immature

Cold stress
Problems of RDS:
Hypoglycemia
Prematurity ↓Surfactant
Hypoxemia → RDS
↓ Vascularity/neuro
↓ Lung compliance
Absence of suck reflex/↑
energy expenditure > calories
for metabolic needs ↓pO2→ PDA
Increased risk of High risk of infection Anaerobic metabolism →
hyperbilirubinemia metabolic acidosis, lack of
available albumin-binding
NEC
Iatrogenic risks sites adds to
Risks of maladaptive attachment hyperbilirubinemia

PARENT-INFANT ATTACHMENT:
THE PRETERM INFANT

Preterm infants may be separated from mom and
family for an extended period of time

Nurse should foster parent-infant bonding
Photographs of baby showing growth over time
Baby’s name on incubator
Weekly card with footprints, weight & length

Involve parents in infant care

Provide discharge teaching

THE NEWBORN AT RISK:

HEALTH PROBLEMS

Respiratory distress syndrome (RDS)

Necrotizing enterocolitis (NEC)

Hypoglycemia

Physiologic and pathologic jaundice

Hemolytic disease of the newborn

Sepsis

Infants affected by maternal drug use

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RESPIRATORY DISTRESS SYNDROME

Immature lungs lack or are unable to

produce surfactant

Without adequate surfactant, alveoli
collapse and gas exchange inhibited 
hypoxia and acidosis

RDS symptoms: tachypnea, grunting,
nasal flaring, retractions, hypercapnia,
respiratory acidosis, hypotension, shock

Ventilatory support: oxygen, CPAP,
respirator, surfactant

NECROTIZING ENTEROCOLITIS

Inflammatory disease of the GI mucosa that
leads to necrosis of the bowel

3 factors associated with NEC: intestinal
ischemia, colonization by pathogenic bacteria,
formula feeding

Symptoms: feeding intolerance, increased
gastric residuals, abdominal distention, bloody
stools

Treatment aimed at resting GI tract, preventing
bowel perforation, and controlling infection

CLINICAL PICTURE OF NEC

Neonate with NEC. Abdominal distention progresses as gas builds

up in the bowel. Continued abdominal distention further compromises
GI blood flow. Note abdominal wall erythema.

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 HYPOGLYCEMIA

Most common metabolic disorder in SGA and
LGA/macrosomic infants. May occur in IDM.

If blood glucose concentration <40 mg/dL,
initiate breastfeeding or bottlefeeding ASAP

Infant may be asymptomatic or exhibit:
jitteriness, poor feeding, hypothermia, vomiting,
pallor, weak cry, lethargy, seizure activity, coma

Monitor infant’s body temperature b/c
hypothermia leads to increased glucose
consumption  hypoglycemia

JAUNDICE

Most common abnormal physical finding in

newborn

Skin appears yellow-tinged due to a build-
up of unconjugated bilirubin, which is a
by-product of RBC breakdown

Can be categorized as physiologic or
pathologic

PHYSIOLOGIC JAUNDICE

Normal biologic response of the newborn that occurs
after 24 hours of life

Observed first in the infant’s face, then moves down to
thorax, abdomen, and extremities

Newborn care procedures that may decrease the risk for
hyperbilirubinemia:
 Maintaining normal body temp
 Encouraging early and frequent breastfeeding
 Monitoring stool
 Placing the infant in indirect sunlight for short period of time

Total serum bilirubin is normally <3 mg/dL. Jaundice
clinically visible when levels 5-7 mg/dL

Kernicterus: bilirubin levels > 25 mg/dL, results in
irreversible brain damage

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 Physiological jaundice

PATHOLOGIC JAUNDICE

Occurs within the first 24 hours of life

Primary cause: hemolytic disease of the
newborn 2o Rh incompatibility or ABO
incompatibility

Assess infants of Rh negative moms or
moms with Type O blood:
Blood type & Rh
Appearance of jaundice, esp. in first 24 hours of
life
Levels of transcutaneous and/or serum bilirubin
Coomb’s test (direct or indirect)

HEMOLYTIC DISEASE
OF THE NEWBORN

Maternal antibodies cross the placenta and cause
hemolysis of fetal RBCs.

Rh incompatibility & maternal sensitization
 Process of antibody formation in Rh negative mom, in
response to Rh positive fetus
 Concern is not with 1st pregnancy, but subsequent pregnancies
 Fetal RBC destruction  hyperbilirubinemia, jaundice, anemia
 Erythroblastosis fetalis, hydrops fetalis

ABO incompatibility
 Mom blood type O and infant blood type A, B, or AB
 Occurs more often than Rh incompatibility, but results in less
severe problems in the infant
 Rarely causes anemia, commonly causes hyperbilirubinemia

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 SEPSIS

Presence of microorganisms or their toxins in the infant’s
blood or other tissues

Early-onset sepsis occurs within 48 hours of life.
Caused by microorganisms from normal flora of maternal
vaginal tract (GBS, E. coli, H. influenzae, S.
pneumoniae)

Late-onset sepsis occurs 2 weeks after birth. Caused by
bacteria from birth canal or environment (S. aureus, S.
epidermidis, Pseudomonas, GBS)

Measures to prevent infection: STD screening, sterile
technique with vag exams during labor, intrapartal use of
IV antibx in GBS+ moms, erythromycin eye ointment

Signs & symptoms of infection

Lab studies if infection suspected

CLINCAL PICTURE OF SEPSIS

Although infrequently seen, an exaggerated arched position of the

head and neck, termed opisthotonos, can be indicative of meningitis.

TORCH INFECTIONS & GBS

TORCH infections - Box 27-1, page 894
 T: toxoplasmosis
 O: other – gonorrhea, syphilis, varicella, hep B, HIV
 R: rubella
 C: cytomegalovirus
 H: herpes simplex virus

GBS infection - page 899
 1 out of 4 women are GBS positive – not harmful to mom, but
can be very harmful to baby (leads to meningitis and sepsis)
 Early GBS screening (@ 35-37 weeks GA) and administration
of antibiotics to GBS + moms during labor has decreased
incidence of neonatal morbidity and mortality r/t GBS disease.

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 Neonatal syphilis lesions on hands and feet

Neonatal herpes simplex virus (HSV) skin infection

HSV oral lesions

EFFECTS OF ALCOHOL
ON THE INFANT

Alcohol-related birth defects (ARBD),
formerly known as fetal alcohol syndrome.
3 criteria:
Prenatal and postnatal growth restriction
CNS malfunctions
Craniofacial features – microcephaly, small
eyes, thin upper lip, flat midface

Issues faced by ARBD children: lower IQ,
ADD, diminished fine motor skills, poor
speech

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 INFANT WITH ARBD:

EFFECTS OF CIGARETTE SMOKING &

MARIJUANA ON THE INFANT

Cigarette smoking during pregnancy responsible
for 21-39% of LBW babies

Smoking increases risk for miscarriage and PTL

Negative neurobehavioral effects in the infant
Decreased intellectual and emotional development
Fine motor tremors
Increased muscle tone
Decreased verbal comprehension
Increase rate of SIDS

Marijuana is linked to shorter gestation & IUGR;
negatively impacts fetal growth & infant
weight/length

EFFECTS OF COCAINE
ON THE INFANT

Cocaine use during pregnancy leads to
neurobehavioral depression or excitability in the
infant

Symptoms of depressed infant: lethargy, poor
suck, hypotonia, weak cry, difficulty in arousal

Symptoms of excited infant: high-pitched cry,
hypertonicity, rigidity, irritability, inability to be
consoled

Smaller head circumference, decreased birth
length, decreased weight

Long-term effects

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 EFFECTS OF HEROIN
ON THE INFANT

Heroin use during pregnancy causes IUGR and
stillbirths

Infants born to heroin addicts experience heroin
withdrawal symptoms 50-75% of the time

Infant may start out depressed and then exhibit
withdrawal symptoms
Jitteriness or hyperactivity
Shrill cry
Frequent yawns or sneezes
Increased reflexes, except Moro
Poor sucking and feeding
Abnormal sleep cycles

THINGS TO KEEP IN MIND

Most births involve healthy outcomes with
healthy infants.

Nurses should be knowledgeable about
problems related to GA as well as acquired and
congenital problems affecting the newborn.

Nurses should support the physiologic
functioning and psychoemotional development
of the newborn.

Nurses should provide patient education and
adopt a caring & non-judgmental attitude.

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