NEWBORN ASSESSMENTSECTION 1 TORCH INFECTIONSBefore beginning our assessment of the newborn, we must first consider the infections which can adversely affect the infant. The term torch infections was first used by Dr. Andre’ Nahmais who studied these organisms which could cross the placental barrier and damage the fetus. We will first talk about the organisms, then later we will present assessment aspects with which most nurses will be concerned. 1. Rubella The rubella virus has been known to cause severe damage to the fetus, and as early as 1940, it has been known to be teratogenic*. The effects are the most severe if the mother contracts rubella during the first trimester. The transplacental transmission happens before there are any symptoms. This makes the diagnosis difficult, until after the virus has already crossed the placenta. Most fetuses which are infected before the 10th week of gestation, will contract the disease. The virus will show slowed growth and fewer cells than normal. Approximately 50% of those infected will show this gross damage. Approximately 70% will show effects by age five. Other children will develop such conditions as panencephalitis around age ten, and then develop some type of neurological damage including retardation or the motor functions and/or mental retardation. Prognosis for infants infected with rubella is guarded, especially if premature, underweight, etc. Also, the virus is especially dangerous, since the effects may not show until later childhood. 2. Toxoplasmosis** Toxoplasmosis occurs only after primary maternal infection. The mother is usually asymptomatic and so is the infant at birth. However, about 15% of those infected infants will die and the other 85% show severe psychomotor retardation. Usually the most severe symptoms will appear by age 1 year, buy some symptoms do not appear until the child is older. The treatment for the infection is Daraprim and sulfadiazine. These drugs do not reverse any damage that has already been done, but does help stop further damage from occurring. The child must be observed carefully for long time periods since there is a cyst form of the parasites which cannot usually be killed, and the diseases may have an exacerbation at any time. * teratogenic—leads to an abnormal development of the embryo (fetus) 3. Hepatitis B Virus When the virus is transmitted to the fetus, there is a chance of prematurity, stillbirth and other disorders which increase infant mortality. Most infants, however, who develop the infection, usually are asymptomatic. The disease usually runs its course with few long-term complications. The virus is most often transmitted to the fetus during the last trimester, or during the delivery. The nursing considerations include preventing spread of virus and remembering that the infant will likely be a carrier. 4. Cytomehalovirus (CMV) CMV is the most common cause of perinatal infection. It is a member of the herpesvirus family. The symptoms it causes are closely similar to the Epstein-Barr virus (EBV), or mononucleosis. In the mother, the disease often causes no symptoms. However, 50% of middle-class women show evidence of having the virus at some time, the highest incidence of the virus being among the poor. Of those women who become infected during pregnancy, approximately 50% of the fetuses will become infected. The infection of the mother may have occurred during a previous pregnancy. The virus, like herpes, lays dormant and may reactivate during a subsequent pregnancy. The newborn may be affected in several different ways. Of those fetuses affected, 12-20 percent will be born with the systemic CMV inclusion disease. The gravity of the disease is unrelated to the gestational age of the fetus when infected. When infected, the infant will excrete the CMV in the urine for up to four years, making assessment of the disease easy for the nurse. Effects of the CMV include birth deformities such as hydrocephaly and microphthalmia; such other disorders as seizures, blindness, and hematological changes. About 85% of the newborns show no immediate problems related to the virus. Most of the problems show up from 3 years old to seven years of age. This age group shows lowered IQ’s, deafness, motor defects, and learning disabilities. Assessment of the newborn is important if the mother has a history of herpes, CMV, or any such related virus. There are immunizations for the CMV, however, at this time, most of the immunizations are quite toxic to the body. Other experimental drugs and treatments are being tries, but at this time none are being used on a widespread basis.
In most diseases of the newborn, there has been no definite link between herpes and any congenital diseases of the newborn. However, when the mother has the primary genital herpes, there seems to be an association with prematurity, spontaneous abortion and certain congenital anomalies. In the case where the mother has open lesions in the birth canal and the infant becomes grossly contaminated with the virus, the results are different. There is a 30 to 50% infection rate for those infants delivered through a contaminated birth canal. Of these infants, about 50% will die or be severely damaged by the herpes infection. The incubation period of HV is 2 days to as long as 3 weeks. During this period, careful assessment of the infant is important in order to detect any of the first symptoms of the HV in the infant. There is no known cure for the HV, therefore it is important to prevent the contamination of the infant. Cesarean section is often indicated when there is a positive culture and active lesions in the birth canal. If the infant does become infected, there usually is not a long hospital stay indicated. They can be managed very well on an outpatient basis. They will usually be given large doses of gamma globulins, interferon stimulants, and other drugs, in an attempt to alleviate the symptoms, however, there still is no cure once infected. Summary: Assessment of the newborn with Torch Infection During the intrapartum period, the nurse must perform a careful assessment in order to facilitate the postpartum assessment. The nurse should always wear gloves when there is suspected torch infection, and be careful of disposing of articles and/or secretions. Careful hand washing is essential. Serum (needle) precautions are observed when necessary. Extra samples of the cord blood are often needed for obtaining titer levels and the placenta is sent to the lab as “contaminated” when a torch infection is present. Also do not forget the emotional support of the mother during this period. She undoubtedly will be concerned about the safety of the child and any possible deformities. Expert counseling may be necessary after the delivery. During the immediate postpartum period, there are several considerations necessary for an accurate and complete assessment. When a torch infection is suspected, the infant will usually be isolated (in most cases). The nurse should make arrangements ahead of time. Abnormal findings of the following should be noted and reported immediately: Skin lesions, eye disorders, microcephaly, hepatosplenomegaly Abnormal laboratory findings should also be noted and reported, such as thrombocytopenia, anemia, and elevated serum bilirubin levels. The above abnormalities should be reported immediately. Most of these problems will be present at birth, but not always. In some cases the nurse will see these conditions develop in the nursery within the first few hours of life of the newborn. Therefore, the MD would need to be notified of changes which occur in the nursery. The nurse must remember proper hand washing in addition to strict isolation in the cases of these infectious disorders. Patient teaching is also important. The mother and other family members should know the treatment plan for the infant. They should know how to assess the newborn themselves, for any acute distress; and they should know how to properly dispose of contaminated linens and articles, hand washing technique and referrals, if necessary. Parents should also be taught about modes of transmission of the disease, so that they do not spread it further. The nurse should be aware of appropriate agencies to refer the family about questions of breast feeding and other problems of the newborn care, when a torch infection is present. SECTION II CHEMICAL & PHYSICAL EXPOSURE AND THE EFFECTS ON THE NEWBORN(environmental pollution and drug exposure) What is the significance of environmental pollutants and drugs upon the unborn infant? This section will discuss some of the known effects and the possible effects of these hazards and the related nursing assessment of the newborn. There are numerous environmental contaminants which can affect the embryo, the fetus and the infant. The obvious cases occur when large amounts of chemicals are released, affecting all persons, adults as well as the unborn, such as cases of food additives which are discovered to be carcinogenic, but have already “poisoned” many persons. Other risks include smoking, alcohol, drugs, heavy metals, and other poisons in our environment. Specific questions regarding the nursing assessment will be discussed shortly, now however, keep in mind the factors which can harm the newborn. We will present certain facts regarding the harmful effects on common pollutants and drugs. When the nurse is aware of those conditions leading to poisoning and threats to the infant’s health, we can better assess these conditions and help to lessen their severity. We will also discuss aspects of informing the client as to health risks during pregnancy, the legal issues and ethical issues. As you look at the statistics and risks of these chemicals, keep in mind the issues of progress versus health risks, and how do we, as nurses, fit into the battle ground of those issues. Environmental toxins can affect the reproductive process in any of the phases. Man and animals can be affected from the adult germ cells to the actual gestational period and fetal development. The American Chemical Society can name over 110,000 different biologically active substances which may adversely affect development of the newborn. There are about 1,000 new chemicals Following is a chart of possible effects of exposure to toxic substances during the reproductive cycle: Reproductive Outcomes:* Altered fertility pattern, spontaneous abortion, chromosomal abnormalities, nonchromosomal congenital abnormalities, nonchromosomal congenital defects, altered sex ratio, late fetal death, neonatal death, low birth weight, development disabilities, behavioral disorders, childhood malignancy, childhood death. Classification of Pollutants: a. Macroenvironmental: Heavy Metals, mercury, lead, cadmium, nickel, chlorinated dibenzop-diocins (TCDD), polychlorinated and polybrominated biphenyls (PCB and PBB), organochlorine pesticides, polycyclic aromatic hydrocarbons, air pollutants (natural) carbon monoxide, ozone, and radiation. b. Microenvironmental: (social environmental) Tobacco smoke, carbon monoxide, nicotine, polycyclic aromatic hydrocarbons, alcohol; The above is a summary of the different types of pollutants which might affect the fetus and/or reproduction. Following now in this text, will be an explanation of some of these more common ones with which we are more familiar. We will not present these in too great detail, or we will lose site of the objectives of this course, which is the assessment of the newborn. It is important, however, that we as nurses know the major sources of newborn disorders and then we will better be able to teach, as well as assess parents and the newborn. As you read and study this text, you should remember that part of the assessment process is a detailed history. You should discover if the parents have been exposed to any dangerous chemicals, either before or during the pregnancy, especially if the newborn is deformed in any way. Another major nursing consideration, of course, is teaching, (prevention) the parents or potential parents. * from Sullivan, F.M., and Barlow, S.M., London 1979. EXPOSURE TO COMMON POLLUTANTS: a. Heavy Metals Heavy metals present a hazard to the fetus due to their becoming concentrated in the blood and brain tissue. Once introduced into the body, the heavy metals cross the placental barrier and will damage the fetus. Lead, mercury and others are present in the environment and can cause severe brain damage in the newborn. The nurse should assess for neurological problems of any kind, such as tremors, convulsions, chorea, ataxia and other symptoms are possible. b. PCB’s and PBB’s These two chemicals are widely used as insulators and fire retardants. Although use as insulators in electrical transformers is banned in most areas, there are still many of these transformers in use today. Most are located on telephone poles in many neighborhoods. These two chemicals are still being investigated today, but it is felt that they are powerful carcinogens and toxic to the fetus. c. Carbon Monoxide Carbon monoxide is present in our air due to some natural causes, but the highest concentration is due to the gasoline engine. In some cities, due to heavy industrial activities, and vehicular use, the levels are quite high. The level of carbon monoxide in the blood of persons in these areas may get as high as if having smoked a pack of cigarettes per day. The effect upon the fetus is the effect of oxygen deprivation. Carbon monoxide binds more easily with the hemoglobin of the blood, thereby blocking oxygen from the hemoglobin. d. Ozone Ozone is a gas found naturally in our upper atmosphere. However, exposure to this gas in industry is becoming common. Exposure during flying is also known to be a hazard. Some flight attendants claim higher rates of abortion and birth defects. Ozone is a powerful oxidizer, and can cause irritation of the respiratory tract and eyes. Also, other symptoms have been reported. Ozone has also been known to cause biochemical changes in the blood of the exposed persons. e. Radiation The effects of radiation upon the newborn and the developing fetus, have been well documented. It is known that, in high doses, mutations in germ cells can and will occur. Microencephaly and mental retardation can occur due to excessive exposure. Excessive exposure can come from too many X-Rays, from hazards in the environment, such as water contamination, contaminated building materials, and other sources. Our normal “background radiation” is known to be quite minimal. Radiation in medicine should be very carefully controlled, so as to protect from excessive exposure, and especially exposing the pregnant woman to X-Rays or other sources of radiation. f. Tobacco Smoke Tobacco smoke during pregnancy has an adverse effect upon the early development of the fetus, and possibly in the later development of the child. Nicotine, carbon monoxide, nitrogen oxides, polycyclic aromatic hydrocarbons, hydrogen cyanide, and vinyl chloride are a few of the several thousand compounds found in tobacco smoke. The adverse effects upon the fetus are well known. Included in these adverse effects are: increased bleeding during pregnancy, spontaneous abortion, spontaneous rupture of the membranes, long-term growth disorders, diminished intellectual functioning, others. When assessing newborn, be aware of maternal smoking habits, amount, and frequency of smoking. EXPOSURE TO PHARMACOLOGICAL AGENTS Beginning in 1961, starting with the thalidomide epidemic, drugs and pregnancy were examined very closely. Certain drugs are now known to be toxic to the growing fetus. The list on this page represents the most common agents and the possible effects seen when administered during pregnancy. contraceptives, some pregnancy tests and androgens may cause developmental disabilities, possible increased abortions, and congenital heart defects b. Anticonvulsants may cause increased spontaneous abortions, neonatal deaths, deaths and developmental disabilities c. Antimetabolites (folate antagonists) methotrexate animopterin; may cause an increase of spontaneous abortions, developmental disabilities d. Tranquilizers some show increased spontaneous abortions, most others show increased developmental disabilities
increase of late fetal deaths, neonatal deaths, developmental disabilities f. Oral anticoagulants increase in late fetal deaths and developmental disabilities g. Heroin h. Alcohol fetal alcohol syndrome, increased female developmental disabilities i. Smoking increased spontaneous abortions with fetal defects, increased late fetal deaths, increased neonatal deaths, increased low birth weight and premature infants, increased developmental disabilities. This is for reference only. There are many other specific effects by many other drugs; i.e. anesthetics, can have adverse effects upon fetus when used. Use an up-to-date reference if in doubt about any drugs. SECTION III INTRAPARTUM PERIOD ASSESSMENTA. Family-centered Newborn Care in Hospitals Family-centered case is defined as the delivery of safe, quality health care while recognizing, focusing on, and adapting to both the physical and psychosocial needs of the patient and the family. The emphasis is on providing health care which fosters family unity, while maintaining physical safety. The family-centered program is very popular in many large hospitals today, as a way of keeping the patient’s support system close. The father or other significant person (s) may stay with the mother as much as possible throughout the childbirth process. Most nurses are quite familiar with the physical layout of the program center, which includes birthing room, labor rooms, diagnostic room and/or admitting rooms. All support services are close to the birthing room, should they be necessary. The nurse should become familiar with all the available services of your particular hospital. Assessment of the newborn will take place in the birthing room. The infant will usually stay with the mother and the family from the time of birth. However, if there is a problem with the delivery, or with the newborn, the infant will have to be moved immediately to another area. The newborn assessment will include all the “normal” parameters, which we will discuss in the next section, in addition to an awareness of the nurse to include the parents as much as possible. Teaching is also an important role during assessment, as the parents will usually be quite anxious to learn all that they can. The last consideration of the assessment is the discharge planning. During the normal assessment, the nurse should keep in mind that discharge of the mother and infant. The physician will attempt to discharge the infant as soon as possible. We all know that the “well” infant does not need to “hang around” the hospital and catch an infection. This is another reason that the nursing assessment must be thorough, so that the infant is not discharged with any condition that was overlooked. Review the next section of this text, covering the assessment of the normal newborn, in order to detect any of these (and other) following conditions: All delivery rooms must be equipped to handle the life-threatening birth injuries which can occur, especially with a difficult delivery. The nurse must be able to assess the situation quickly and help the physician in attendance to prevent serious complication of the particular injury. The focus of this section will be to familiarize the nurse with the most common types of birth injuries and the assessment of the infant, along with the nursing care needed to prevent serious complications. There are many possible birth injuries which can occur. Many do not need any special nursing care except to observe the condition to see if it becomes worse. We will present the seven most common in this section, but always remember that many more injuries are possible This condition is a swelling of the presenting portion of the fetal head. It occurs as pressure is exerted upon the presenting part of the head, especially during prolonged labor, and before the cervix is fully dilated. The venous blood flow from the part is obstructed by pressure and by the tight squeeze. This results in soft, circumscribed swelling consisting of serum, and/or blood above the periosteum of the skull bone in the presenting part. If the swelling extends across the suture lines, the head has elongated appearance. Petechiae, pupura or ecchymoses are often present over the swollen area. Nursing considerations: There is usually no treatment for this condition. The nurse will constantly assess the size, shape and markings of the head. Observe for any further swelling and hematoma formation. Assess this condition carefully, to be sure that it is not a condition called cephalhematoma, which will be presented. The condition of caput succedaneum will usually resolve itself in several days. Occasionally this condition can cause anemia due to blood loss into the scalp. Assess the patient for signs of anemia, and transfusions may be required in rare cases. CEPHALHEMATOMA This is a condition of bleeding between the cranial bones and overlying periosteal membrane. The cause is usually a difficult and/or prolonged labor and possibly from the use of forceps. These problems can cause rupture of the blood vessels located under the periosteum. On assessment, the nurse can palpate a soft, irreducible mass on the scalp. It is usually unilateral, but sometimes it can be bilateral. The hematoma does not cross suture lines, therefore, only one bone is usually involved. However, if more than one mass is palpated, it can mean that more than one bone has been traumatized. The masses can vary in size. They may become larger in the first several days, due to the slow nature of the bleeding which usually occurs. There may even be noticed a linear fracture of the skull on X-Ray under the hematoma. This disorder usually causes no harmful sequelae, even when there is a fracture. The nurse will assess the patient for signs of anemia, which can develop due to the blood loss. Hyperbilirubinemia may also develop, requiring use of the photo-therapy lights for the resultant jaundice. Always remember to assess carefully for anemia and signs of severe hemorrhage which rarely can happen. This condition usually disappears in 2 weeks to 3 months. It takes that long for the hematoma to be absorbed. If there are complications due to fracture or jaundice, it may take longer.
FACIAL NERVE PARALYSIS This is a temporary type of palsy which occurs due to pressure on the infant from forceps or pressure from labor pushing against the mother’s sacrum. It can also be caused from intracranial bleeding. The two types of paralysis are: 1. Central Facial Nerve Paralysis This affects the lower portion of one side of the face. It is a spastic paralysis where the affected side appears smooth and full, the nasolabial fold is eliminated and the corner of the mouth drops. When the infant cries, its mouth is drawn toward the normal side. The movements of the forehead and eye are not affected. 2. Peripheral Facial Nerve Paralysis This usually affects the entire side of the face, including the forehead and eye. When crying, the affected side is smooth, as in Central Nerve Paralysis, but the forehead and eye are involved. The eye usually will also remain open, due to paralysis of the orbicular muscle. Nursing considerations include care of the open eye. The cornea may be damaged from the constantly open eye. Artificial tears should be put in the eye frequently to prevent drying of the cornea, sclera and conjunctiva. Feeding should be done carefully due to the difficult sucking of the infant.* * Breast feeding mothers will need help for the infants with this disorder. Be sure to prevent aspiration, and continue to assess the progress of the infant. The nursing assessments are important to chart the progress of the disorder. Always carefully document your findings. Each hospital will have its own method of charting, so be familiar with it and use it. Infants, who still have symptoms which are severe, after one week, may be referred to an acute care center for evaluation and treatment. BRACHIAL PALSY Paralysis to certain muscles of the arm may occur with an injury to the network of nerve fibers in neck and shoulder areas, the brachial plexus. The injury can be caused by edema, stretching or hemorrhage at the brachial plexus. During delivery, the plexus can be injured; especially in a vertex or breech delivery, if the head is laterally flexed. These are the three main type of Brachial Palsy: 1. ERB-DUCHENNE (upper arm) PARALYSIS This is the most common form, an injury to the fifth and sixth cervical roots. The arm lies limp at the side in a position of extension and inward rotation. The palm of the hand faces down or ever rotated outward with the thumb down. Moro reflex is weak or absent due to flexion of arm at the level of the shoulder. The grasp reflex is intact. 2. KLUMPKE (lower arm) PARALYSIS This is a rare form, an injury to the eighth cervical and first thoracic roots. The hand and wrist are paralyzed, grasp reflex is absent, but deep tendon reflexes are intact. Sensory impairment along ulnar side of forearm and hand is present. Dependent edema of the hand can develop, along with cyanosis and changes in fingernails. 3. PARALYSIS OF THE ENTIRE ARM Usually the arm is motionless, flaccid and hangs limply to one side. All reflexes are absent and the sensory deficit may extend to the shoulder. NURSING CONSIDERATIONS Prognosis depends upon the type of injury and the site injured. Upper arm injuries usually heal in 3 to 6 months. Lower and total arm injuries usually leave some type of permanent paralysis.
PHRENIC NERVE PARALYSIS The most common cause of this injury is a difficult breech delivery. The 3rd and 4th, and 5th cervical spinal roots are the ones usually damaged by the lateral hyperextension of the neck during the delivery. The paralysis is usually unilateral, causing irregular and labored respirations, cyanosis, and no abdominal respirations which are usually present when there is no injury to the diaphragm. This disorder is often accompanied by brachial palsy. In severe cases, apnea and tachypnea may be present. NURSING CONSIDERATIONS Assessment of this infant is vitally important. Always assess the respiratory rate and rhythm. Oxygen is usually administered along with the placing the infant on the affected side. Feeding can be started, depending upon the condition, by nipple or gavage. If symptoms are severe, the infant will be transported to the ICU. If the condition is stable, the infant will still need close observation for a period of time. Most infants recover spontaneously in 6 weeks to 3 months. If the damage is severe and permanent however, the infant may need surgery to correct the collapsed lung or the pneumonia which can develop. CLAVICLE FRACTURE This is one of the most common injuries which occur during delivery. They usually occur during a difficult delivery of vertex or breech positions where the shoulders are extended, or they are forcefully manipulated. A fracture will be suspected if Moro reflex is absent on affected side and there is limited movement of the arm. The treatment is usually to immobilize the arm and relieve pain. The nurse will observe the infant closely for the first few days for complications. Assessment includes level of pain, respiratory assessment, immobilization, and teaching the parents the proper way to hold and lift the baby. Prognosis is good unless complications arise. ECCHYMOSES This is usually caused by a traumatic or breech delivery. These bruises can also be caused by pressure and/or clotting defects or severe systemic infections. Most commonly, forceps can cause the bruises on the face and the scalp. Ecchymoses usually resolve spontaneously in about one week. However, if the cause is something other than “normal” birth trauma, there may be concern for prognosis. Assessment is very important. The nurse must watch for signs of increasing ecchymosis or bruising. Signs of anemia may be indicated if there are large amounts of bleeding into the tissues. Jaundice may also develop, again, due to large blood loss. Serum bilirubin exams may be performed routinely, watch for any abnormal findings. Phototherapy may be necessary if hyperbilirubinemia is present. Pre-term infants should be assessed even more frequently than full-term infants. They may need special care if large ecchymosis is present. The nurse’s careful assessment of all these factors and possible complications is essential to the well-being of the infant and the family. IN SUMMARY… The nursing assessment of all these cases is important in order to prevent complications and to promote the infant’s struggle back to their optimal health. Teaching the parents is another important function, and can best be accomplished in most cases, while the nurse is assessing the infant…just show the parents what you are doing. They will also have a better sense of well-being if they feel they are participating in the care of their infant. POSTPARTUM TRANSITIONAL PERIODDELIVERY ROOM ASSESSMENT The transitional period for the neonate is usually considered to be the first 24 hours of life. Other authorities will use a different definition for the transitional period, so do not be confused. Transition refers to adjustments which must be made by the infant in order to survive the world outside the uterus. The first 24 hours is usually the most crucial period for the infant. The adjustments which must be made include respiration, circulation, and changes to the liver, kidneys, and to the metabolic process. The nursing assessment of the newborn involves more than just meeting the basic needs of the infant, it includes periodic assessment of all systems and recording them, so that the appropriate medical and nursing intervention can be initiated if necessary. The assessment begins with a detailed history of the mother and the course of the pregnancy. As we discussed earlier, there are many factors during pregnancy which can affect the infant. There should also be a record of the labor and delivery, including the type of anesthesia, etc. The first assessment is made immediately after the delivery. The Apgar score is taken and recorded. If the infant needs special care or resuscitation, he/she will be transferred to the ICU. However, the normal healthy infant will be taken to the normal newborn nursery soon after the The next major assessment is performed in the nursery within the first 6 hours after delivery. Hospitals have various time limits for the performance of this exam, so always check your own hospital policy. The newborn’s physiological status is assessed along with the heart and respiratory rates, also the gestational age. The third assessment is a complete physical examination, which is performed within the first 24 hours of life, or when the infant’s condition is stable. The following table summarizes the items on the assessment in the first 24 hours of life:
REACTIVITY PERIOD The initial period of reactivity is the first 30 minutes of life. It is characterized by rapid, fluctuating heartbeat and alertness. The respirations are being established and the infant reacts to stimuli. There may be slight cyanosis, but it soon disappears. During this period, the infant should be assessed for all of the above items. The nurse should be ready to use resuscitation equipment if needed. During this time, it is also important that the mother have contact with the infant. The nurse should make the assessment and then let the mother hold the infant for as long as possible. You should always follow established procedures, but this contact with the mother is known to be very important. Also keep in mind that there are many variations of normal. Some infants do not easily tolerate handlings, so perform the exam as quickly and thoroughly as possible.
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