Newborn Adaptation to

Extrauterine Life

A systemic approach to life in this world~

 The Lungs
 The most important vital organ that
needs to be adequately functional in the
neonate
 Largely dependent on maturation of the
fetus
 Website on fetal lung development
 Fetal maturation:
 20-24 wks - alveolar ducts appear
 24-28 wks - alveoli remain primitive
 28-32 wks - type II (surfactant
producing) cells increase
 35 wks - Lecithin production peaks
 Role of Surfactant
 phospholipid  L/S Ratios
 lung cell maturity  Lecithin (increases)
(PI)
 Sphingomyelin
 lowers surface
(constant)
tension (PG)
 <30 wks = low L/S
 increased lung
compliance
 30-32 wks - L/S = 1:1
 >35 wks - L/S = 2:1
 Adaptation at birth-
factors that foster that initial breath
 Mechanical–
“Vaginal squeeze” is followed by chest recoil after
birth.
 Chemical –
Transient asphyxia at birth results in
* decreased pO2
* decreased pH as low as 7.25
* increased pCO2
These changes stimulate chemoreceptors around the
aorta and carotid which tells the respiratory center in
the medulla to start breathing
 Adaptation (cont’d)
 Temperature—
The drop in temperature from a cozy 98.6 to 65-70 F.
stimulates the neonate’s CNS to breathe.

 Sensory stimuli– all 5 senses are brought to life in

the delivery room
*Noise in the delivery room
*Bright lights in the delivery room
*Tactile stimulation– drying off the baby, stroking and
caressing by parents, etc.
*Smells in the delivery room
*Taste when bulb syringe or gloved hand is introduced
into mouth, & when mom nurses the first time.
 Assessment Parameters--
Respiratory System
 Quality of respirations-- 30-60/min.
 gasping, irregular, shallow breathing is normal
at first
 periodic breathing is typical
 true apnea= >20 sec. without breathing is
abnormal
 “wet” lungs– common in the first 5 minutes of
life; if persistent, may require DeLee suctioning
 Assessment Parameters--
Respiratory System(cont’d)

 Obligate nose breathers

 Retractions– abdomen & chest wall should

rise simultaneously. “Seesaw” movements
and expiratory grunting are ominous signs
requiring intervention.
 Oxygen Transport (p. 797 Olds 8 th
ed.)

 2 types of Hemoglobin in fetus & newborn:

 Fetal Hgb: HbF—70-90%. Has  O2 affinity
which means if facilitates O2 transfer across the
placenta and into newborn’s tissues.
 Fetal PaO2—30-40mm Hg.
 Fetal Hgb level—17 g/dL—allows fetus to tolerate
relatively low PaO2 in utero, because the absolute
O2-carrying capacity of the blood is > adult Hgb.
 Adult Hgb: HbA has  O2 affinity but O2
release. HbA of 13 g/dL in adult has lower O2-
carrying capacity.
 The Heart~ Cardiovascular Adaption
 The heart goes through a series of
changes:

 increased aortic pressure and decreased venous

pressure 2ndary to clamping the umbilical cord
 increased systemic pressure and decreased
pulmonary artery pressure with initiation of
respirations and loss of placenta
 closure of the ductus venosus--fetal structure from
umbilical vein to inferior vena cava carrying O2
from the placenta
 closure of foramen ovale--fetal structure that
connects the right atrium with the left atrium
further allowing right to left shunting during
fetal life.
 closure of the ductus arteriosus-- fetal structure
connecting the pulmonary artery with the aorta
allowing right to left shunting during fetal life
Fetal Circulation

 Note: the Umbilical

Vein carries oxygenated
blood from the mother to
the inferior vena cava
where it mixes with
unoxygenated blood
from the body. This
mixed blood travels
through the heart and to
the body oxygenating all
fetal cells. The
unoxygenated blood
returns to the mother via
the umbilical arteries.
 Do you hear a MURMUR?
 Occur in 37% of all newborns
 90% are transient due to delayed
closure of ducts (PDA &/or PFO)
 These types usually disappear by 6
months of age
 Vital Sign Averages

 Birth weight: 6-9 lbs. 2500-4000g.

(wt. Loss of 5-10% of birth wt.in 1st 3-4 days is expected.
Should regain birth weight by 2 week check-up.)
 Length: 18-21 in. (45-52.5cm)
 Head Circumference: 13-14 in.(33-35cm)
 Chest Circumference:12-13 in. (30-33cm)
should be ~2-3cm. < head circumference
 Blood Pressure: ave. 78/42 (less for premie, more if
crying. * Cause for concern: Diastolic <25 or >60
 Vital Sign Averages (cont’d)
 Pulse: 110-160 bpm. Assess apically for 30 sec.
180 if crying
100 if sleeping
 Temp: Rectal: 36.6 – 37.2 C
97.8 - 99 F
Axillary: 36.5 – 37.0C
97.7 – 98.6F
If axillary temp is <36.5C, you recheck the other axilla. If it
remains low, take babe out and do ‘skin-to-skin’ or double-
wrap infant with hat on and recheck temp in 1 hour. If
still low, place child in radiant warmer for 30 minutes and
recheck temp. Temp rechecks can be done axillary.
 Respirations: 30-60/min. Assess for 1 full minute.
 Newborns & Heat Loss
 Factors that predispose a newborn to heat loss
 Large surface area (especially head!)
 Limited ability to control their metabolic rate
 Blood vessels of the newborn are closer to the skin
than adults
 Decreased insulation due to less fat
 It is essential to maintain a neutral thermal
environment (NTE) to minimize O2
consumption.
 NTE range for naked newborn~ 32-34C (89.6-93.2F)
 NTE range for adults~ 26-28C (78.8-82.4F)
 Temperature Decrease
(Hypothermia)
Anaerobic
In c re a s e s Glycolysis
pO2 and  pH
m e ta b o lic r a te

In c re a s e s In c re a s e s In c re a s e s
O 2 c o n s u m p ti o n s tre s s o n b a b y O 2 dem and

Pulmonary
Respiratory Rate Vasoconstriction
 Heat Production

 Vasomotor control—constriction of
peripheral vessels manifested as acrocyanosis

 ”Non-shivering thermogenesis”– primarily

occurs through “brown fat” metabolism.
Brown fat cells are larger than white fat cells
& are easily broken down to produce heat.
 Heat Production (cont’d)
 Shivering- late sign of hypothermia.
Indicates that metabolic rate has
doubled, increased O2 consumption,
increased motor activity that ultimately
leads to heat production
 Insulation- 11-17% of total body wt. of
term neonates. Appears after 32 weeks
gestation.
 Heat Loss

 evaporation - water to vapor

 radiation - body to cold object
 conduction - direct skin contact
 convection - body to cooler air
GOAL: Keep baby in a neutral thermal
environment: where the baby's metabolic
rate, and therefore O2 consumption, is
minimal, but the body temperature remains
within the normal range.
 The Liver: Hepatic Functions
 Conjugates bilirubin
 Stores fetal iron
 Stores liver glycogen for energy
 coagulation
 Physiologic Jaundice
 Why does this happen?
 immature liver cannot conjugate bilirubin
 increased breakdown of RBC’s (normal Hct - 55%,
RBC's = 5-7 million/ul, Hgb = 15-20g/dl)
 decreased clearance of bilirubin by liver due to
inhibition of glucuronyl transferase = less conjugated
bilirubin
 reabsorption of bilirubin stuck in the intestines
 obstruction or delayed meconium
 hypoxia/CHD raise bilirubin levels
 infection delays bilirubin excretion
 Common symptoms of jaundice
 Yellowish tinge to skin or sclera of eyes
 Test by blanching skin on bony
prominence as forehead, or sternum
 Treatment of Physiologic Jaundice

 Phototherapy –
Bililights overhead in hospital setting
Quartz high intensity lights in hospital
Wallaby blanket wrapped around infant at
home

 Frequent feedings to expel meconium more

quickly from intestines
 Coagulation & Vitamin K
 The absence of normal flora in newborn
gut needed to synthesize Vitamin K
results in low Vitamin K levels until 5th
day of life
 every newborn gets injected with Vit. K
(AQUA MEPHYTON or PHYTONADIONE)
to prevent bleeding problems.
Coagulation & Vitamin K

 Dose:
 1mg (0.5ml) IM >1500 gm

 0.5mg(0.25ml)IM<1500 gm
GI Adaptation - COOL facts...
 BEFORE BIRTH, baby has already swallowed
and peristalsis begins
 stomach holds 50-60 ml (2 ounces)
 GI tract mature 36-38 wks gestation
 By 24 hours, the intestines are air filled
 Saliva is hardly produced until 3 months
 Babies regurgitate due to immature sphincter
 Newborns lose 5-10% body wt. in 5-10 day
 insensible water loss & low caloric intake
 Meconium
POOP!
 Transitional
 Fecal
 Breastfed
 Urinary Adaption
 Kidneys mature by 35 wks gestation
 Limited ability to dispose of excess
fluid
 Most void immediately after birth
 First 2 days: 2-6 times/day
 After that: 5-25 times/day!!!!
 Cool facts...
 first void is cloudy due to mucous
 “brick dust” urine- noted in diaper
from urates (uric acid crystals)—
may indicate dehydration
 Pseudomenstruation = Vaginal
discharge noted as blood in diaper
Neuromuscular Status
Examples of neonatal reflexes
 Reactivity States in the Newborn
 First period of reactivity - first 40 min.
Baby is alert,responsive, eager to explore the
world
 Sleep period - 1-3 hours after birth. May
continue for 3-6 hrs. Baby is in a deep sleep,
difficult to arouse. Resp. rate & heart rate decrease.
 Second period of reactivity – 3-6 hours after
birth. Baby is awake, respirations are rapid,
irregular, and may have periods of apnea. May
cough and regurg mucus, etc. Keep bulb syringe
handy. Heart rate again increases.
Brazelton’s NBAS
Each baby is born with their own
traits and personality. This scale
helps parents identify and get to
know what is special and unique
about their newborn.
Temperament
1.) easy child
2.) slow-to-warm-up child
3.) difficult child
 
 6 categories of the NBAS
 Habituation  Variation
 Orientation  Self-quieting
 Motor  Social
maturity behaviors
Read about each of these in your OB text--
Pp.749-750. Link from March of Dimes
Brazelton’s Infant State Chart
 SLEEP states
 Deep or quiet
 Active REM-light
 ALERT states
 drowsy
 quiet alert (wide awake)
 active alert
 crying
Know the characteristics of these states
and when is the BEST time for
interaction with the neonate!! (Pp.701-2)
 What to Teach Parents
Bathing Skin Care Thermo-
regulation

Nutrition Burping Bonding

Bulb syringe Cord care Circ care

Sx of airway Behavior Taking their

obstruction states temperature
 Newborn Screening
One little heel stick tests for...
 Congenital hypothroidism
 Galactosemia—what implications does a positive
result have for breastfeeding moms?
 Maple syrup urine disease--
 PKU – Phenylketonuria—why does baby have
to be at least 24 hours old for this test?
 Hemoglobinopathies
 Sickle Cell Anemia
 Thalessemia
 Homocysteinuria
 Cystic Fibrosis (new screening)
 Congenital Adrenal Hyperplasia
 Biotidinase Deficiency
 More info at this link
 Newborn SAFETY
 Bathing your baby--video
 Positioning— “Back to Sleep”
 Car seat rules—from the AAP, here are all
the recommendations for car seats for parents.
Remember that NO BABY leaves the nursery
without being in a car seat.
 CPR instruction—Here is a review of infant
CPR with a quick quiz, if you need a review! 
 Immunization schedule—2013
Schedule
Fetal Development in utero
Fetal Development Continuum
 That’s it!!

Aren’t babies a miracle??