Transition and Stabilization of the Newborn

Letha Nix RNC

How long should it take to transition

from intrauterine life to extrauterine life?

A.) 1-2 hours

B.) 2-3 hours

C.) 3-6 hours

D.) 6-12 hours

D.) 6-12 hours

A newborn can take up to 12 hours to

transition from placental support to

extrauterine support.

Definition

• Transition is a process of physiologic change in the newborn infant that begins in utero as the child prepares for transition from intrauterine placental support to extrauterine self-maintenance.

Objectives• Identify primary features of fetal and

newborn circulation.

• Identify physiologic changes during transition to extrauterine life.

• Identify routine care considerations for a newborn during the transition period.

• Identify signs and symptoms of common problems during transition period.

• Discuss methods for parental support.

Transition begins before delivery

Depending on….

• Gestational age

• placenta health/condition

• maternal health

• Any limitations to major organs

• physical defects/anomalies

Transitional begins before delivery

The infant prepares by…

• Fetal breathing (producing surfactant at 34 weeks)

• storing glycogen in the liver

• producing catecholamines

• depositing brown fat

Transition begins before delivery

During Labor…

• placenta

• stress hormones

Review: Placental Circulation

• Exchanges O2 and CO2 by simple diffusion

• Eliminates waste products

• Does the work of the lungs in utero• Uterine venous blood has

PCO2=38 mmHg

PO2=40-50 mmHg

pH=7.36

Review: Fetal Circulation

• One Umbilical Vein-oxygenated blood

• Two Umbilical Arteries-deoxygenated blood

• Three Fetal Shunts… Ductus Venosus- hepatic system Foramen Ovale- between right & left atrium Ductus Arteriosus- vein connects pulmonary

artery to descending aorta

Fetal Circulation

Foramen Ovale Shunt Right atrium Left atrium Right Ventricle

Fetal Circulation

Ductus Arteriosus Shunt Unsaturated blood Pulmonary Artery Aorta

Fetal Circulation

Fetal Lungs Fluid filled Resistant Nourishment

Fetal Circulation

Systemic Vascular Resistance Pulmonary Vascular Resistance Pulmonary Arterioles Resistant

Transition to Extrauterine Life begins when the cord is CUT.

• Placenta no longer works as lungs

• Lungs begin to exchange gases

• First breath inflates lungs and causes circulatory changes

• Lungs inflate - resistance to blood flow through lungs & blood flow from pulmonary arteries

• This results in Newborn Circulation.

Newborn Circulation

Umbilical cord is clamped Placenta is separated systemic blood pressure Three major shunts close

Newborn Circulation

Circulatory Changes Fetus separation mother/placenta Lungs begin to function First breath

Newborn Circulation

Lung fluid cleared Lungs fill with O2

Systemic vascular resistance increases Initiation of respiration Pulmonary arterioles Pulmonary Vascular Resistance Pulmonary Blood flow

Newborn Circulation

Blood flow resistance Blood flows through pulmonary

arteries Foramen ovale closes Blood pressure increases

Newborn Circulation

Left atrial pressure Right atrial pressure Foramen functional closure Ductus arteriosus

Newborn Circulation

Postnatal Right Atrium, SVC, IVC

Poorly oxygenated blood Right ventricle, pulmonary artery,

pulmonary circulation

Oxygenated blood Left atrium, pulmonary veins Left ventricle, aorta, systemic circulation

Physiologic Changes During Transition

• Cardiovascular

• Respiratory

• Hematologic

• Gastrointestinal

• Renal

• Immunologic

Considerations For Newborns in Transition Period

History…

• Maternal…Medications

Illness

• Labor and Delivery…

Fetal Distress

Delivery Complications

Types Delivery

• Resuscitation Measures

Assessment

Vital Signs Measurements Gestational Age Assessment Head to Toe Exam Glucose/Feeding

Assessment-continued

Normal head to toe assessment findings for infant in transition Skin Head Respirations/Breath Sounds Heart Sounds Intestines Urine Extremities

Thermoregulation

normal ranges 97.7F - 98.6F results of cold stress: O2

consumption & use of glucose stores radiant warmer/isolette bathing

Medications• 0.5% Erythromycin eye ointment

give within 1 hr of birth!

Vitamin K (phytonadione) give within 1 hr of birth!

Hepatitis B vaccine & Hepatitis B immunoglobulin (HBIG) give within 12 hrs if mom + or

unknown vaccine only at d/c if negative

Glucose Needs & Feeding

• Delivery stress conversion of fats and glycogen to glucose for energy

At 1-2 hours of age glucose level falls Baseline glucose 30 mins-1 hr of age

• Goal-Glucose level

> 40 ml/dl on first day

>40-50 ml/dl thereafter

Glucose Needs & Feeding-continued• Risk Factors for Hypoglycemia

Asphyxia Cold stress work of breathing Sepsis Premature or SGA Infants of mother with diabetes or

gestational diabetics LGA babies

Glucose Needs & Feeding-continued• S/S of Hypoglycemia

• Treatment of Hypoglycemia Feed early on demand in first hour

• Evaluation before feeding

• Contraindication before nipple/breast feeding

• Contraindications to gavage feeding

• Guidelines for feeding

• Indication for IV glucose infusion

Recognition of the Sick Newborn• Perinatal History

• Physical Assessment Skin Respiratory Cardiovascular Central Nervous System Morphologic Features GI Tract

Tools Used to Diagnosis?

With MD order of course!!!

Common Problems Seen In Transition

• Birth Trauma

• Birth Asphyxia

• Pulmonary

• Cardiovascular

• Hemodynamics

• Metabolic Problems

• Infection

• Congenital Anomalies

Stabilization of the Transitioning Newborn

Use Mnemonics!

• S = Sugar

• T = Temperature

• A = Artificial Breathing

• B = Blood Pressure

• L = Labs

• E = Emotional Support for the Family

Parental Support

• Before Delivery

• At Delivery

• During Transition

• Transfers

Review

• Transition period can last 6-12 hours

• Three phases of transition Phase One- “Period of Reactivity”

1-2 Hours Phase Two- “Sleep Period”

1-4 Hours Phase Three- “Second Period of

Reactivity”

2-8 Hours

Any Questions ?