C O M M O N N EO N ATA L

D IS O R D ER S

Classifi
cation ofcom m on neonataldisorders

Birth injuries
Caput succedaneum
Cephalhematoma
Fractures
Facial paralysis
Erbs/Brachial palsy

Classifi
cation ofcom m on neonatal
disorders(cont )

Disorders related to physiological

factors
Hyperbilirubinemia
Hemolytic disease of the newborn
Respiratory distress syndrome

Classifi
cation ofcom m on neonataldisorders

Disorders related to infectious process

Sepsis
Necrotizing enterocolitis

Classifi
cation ofcom m on neonatal
disorders(cont )

Disorders related to maternal

conditions
Infants of diabetic mothers

Injuries to head
Caput succedenum
Cephalhematoma

Injuries to the head w hile birth

S-Skin
C-Close connective tissue &
cutaneous vessels & nerves.
A-Aponeurosis (epicranial
aponeurosis)
L-Loose connective tissue (scalping
layer)
P-Periosteum of skull bones

Injuries to the head

CAPUT SUCCEDANEUM
A caput succedaneum is an edema of
the scalp at the neonates presenting
part of the head
It often appears over the vertex of the
newborns head as a result of pressure
against the mothers cervix during labor.
The edema in caput succedaneum
crosses the suture lines

Injuries to the head

CAPUT SUCCEDANEUM
Causes
Mechanical trauma of the initial
portion of scalp pushing through a
narrowed cervix
Prolonged or difficult delivery
Vacuum extraction

Injuries to the head

Cephalhematoma
It is a collection of blood between the
periosteum of a skull bone and the
bone itself. It occurs in one or both
sides of the head
The swelling with cephalhematoma is
not present at birth rather it
develops within the first 24 to 48
hours after birth.
Has clear edges that end at the

Injuries to the head

Cephalhematoma Causes
Rupture of a periostal capillary due
to the pressure of birth
Instrumental delivery

Injuries to the head

Nursing care management
It is directed toward assessment and
observation of the common scalp injuries
and vigilance in observing for possible
associated complications such as
infection or acute blood loss and
hypovolemia.
Because of the visible injuries resolves
spontaneously, parents need reassurance
of their usual benign nature.

Fractured clavicle
Bone most frequently fractured

during delivery
Associated with CPD
Signs:
limited ROM,
crepitus,
cries of pain when arm is moved,
absent Moro reflex on Affected side

Fractured clavicle
Heals quickly, handle gently,

immobilize arm, eliciting scarf sign is

contraindicated.
Any newborn that weighs more than
3855g and is delivered vaginally
should be evaluated for a fractured
clavicle.

Fractured clavicle
Nursing Management
Often no intervention is needed
other than maintaining proper
alignment, careful dressing and
undressing of infant.
Supporting the patient from upper
and lower back other than from
under the arms should be practiced.
The parents should be involved in
the care.

Facialparalysis:
From pressure on facial nerve

during delivery
Affected side unresponsive when
crying
Resolves in hours/days
NURSING MANAGEMENTa) Feedings may be given by
gavage in order to prevent
aspiration
b) Since the eye on the effected
side cannot be closed completely,
it is covered with an eye shield to
prevent drying of the conjunctiva
and cornea.

Erbs Palsy (Erb- D uchenne Paralysis)

Associated with stretching

or pulling head away from

shoulder during delivery
Signs: Flaccid arm, elbow
extended, hand rotated
inward, Moro & grasp
reflexes absent on affected
side
Requires immobilization &
reposition q 2 to 3 hr.

Erbs Palsy (Erb- D uchenne Paralysis)

NURSING MANAGEMENTa) The goal is to prevent contractures
in the paralyzed muscles. The arm
should be partially mobilized in a
position of maximum relaxation so
that the non-paralyzed muscles
cannot exert pull on the affected
muscles.
b) By use of a splint or brace when

upper arm is paralyzed, the arm is

abducted 90 degrees and rotated
externally at the shoulder with the
elbow flexed so that the palm of the
hand is turned towards the head.

Erbs Palsy (Erb- D uchenne Paralysis)

When any form of immobilization is

used, the fingers and the hand

should be observed for coldness and
discoloration and the skin for the
signs of irritation.

H em olytic disease ofthe new born

Rh +ve blood D antigen

Rh -ve blood lacks this D antigen

H em olytic disease ofthe new born

When Rh-positive blood is infused

into an Rh-negative woman through

error or when small quantities
(usually more than 1 mL) of Rhpositive fetal blood containing D
antigen inherited from an Rh-positive
father enter the maternal circulation
during pregnancy, with spontaneous
or induced abortion, or at delivery,
antibody formation against D antigen

H em olytic disease ofthe new born

H em olytic disease ofthe new born

Why the fetus is affected in second

delivery and not in first delivery?

H em olytic disease ofthe new born

As the mixing of blood usually occurs

at the time of delivery so by the time

antibodies are formed the baby is
already delivered.

H em olytic disease ofthe new born

But what if the mixing of blood

occurs before the delivery? Lets say

during some procedure like
amniocentesis or chorionic villi
sampling? Now will the fetus be at
risk?

H em olytic disease ofthe new born

But w hy fetus aint at risk during 1 st pregnancy

even ifthe blood is m ixed before delivery?

H em olytic disease ofthe new born

The answer is because of the type of

antibodies formed during first and

second delivery.

Prevention ofhem olytic disease.

Prevention:

Rhogham/Anti-RhD in
un-sensitized mothers
Treatment of a mother
with Anti-RhD antibodies
prior to and immediately
after trauma and
delivery destroys Rh
antigen in the mother's
system from the fetus

H em olytic disease ofthe new born

Diagnosis:
Indirect coombs test in mothersantigen
direct coombs test in infants with Rhve mothers-antibodies

H em olytic disease ofthe new born

Treatment: IVIG is given in infants,

exchange transfusion and

phototherapy.

H em olytic disease ofthe new born

Nursing management:
1. Early recognistion of
Jaundice
2. If an exchange
transfusion is required
then the nurse prepares
the infant and family and
assists the physician.
3. The nurse documents
the blood volume
exchange.

H em olytic disease ofthe new born

4. Signs of blood

transfusion reaction
are need to be
monitored.
5. Throughout the
procedure infants
thermoregulation need
to be monitored.
6. After the procedure
the nurse monitors the
umblical cord for any
kind of bleeding.

N eonate Respiratory distress syndrom e/

hyaline m em brane disease

RDS occurs primarily in premature infants;

its incidence is inversely related to

gestational age and birth weight.

It occurs in 6080% of infants less than 28
wk of gestational age,
In 1530% of those between 32 and 36 wk,
In about 5% beyond 37 wk,
and rarely at term.

N eonate Respiratory distress syndrom e

The condition occurs due to lack of

pulmonary surfactant because of

immaturity of the lungs.
Surfactant helps in reducing the
surface tension of alveoli.
When surfactant active material is
deficient in the alveoli, there is
alveolar collapse during expiration

N eonate Respiratory distress syndrom e

The pulmonary immaturity of the

fetal lungs can be assessed by

determination of
lecithin/sphingomyelin ratio in the
amniotic fluid
L/S ratio is 2 or more suggestive of
adequet lung maturity, while a ratio
of less than 1.5 is often associated
with HMD

N eonate Respiratory distress syndrom e

Clinical features
This is characterized by a triad of
tachypnea, expiratory grunt and
inspiratory retractions in a preterm.
These symptoms may begin at birth
or within 6 hours of birth.
There is a gradual worsening of
retrations, grunting and cyanosis.

N eonate Respiratory distress syndrom e/hyaline

m em brane disease

Management
Premature labor should be arrested

by appropriate tocolytic therapy to

gain pulmonary maturity.
The induction of labor should be
delayed as far as the lung maturity is
confirmed by l/S ratio.
When premature labor below 34
weeks of gestation is unavoidable,
the mother should be given
betamethasone 12mg IM every 24hrs
for two days or dexamethasone 6mg
IM four doses at an interval of 12hrs.

N eonate Respiratory distress syndrom e

The infant should be nursed in a

thermoneutral env and administered

oxygen through head box.
An IV line should be established to
maintain fluid and electrolyte
balance, for correction of acidosis
and administration of drugs.
Intratracheal administration of
surfactant should be done
SPo2 should be monitored
If infant cant monitor Spo2 above 90
despite of giving oxygen via hood
the infant should be put on CPAP

N eonate Respiratory distress

syndrom e
If CPAP is also ineffective then

the infant should be put on

IPPV
Acid-base parameters should
be monitored
Unmonitored oxygen levels
may lead to retinopathy of
prematurity to oxygen toxicity.

N eonate Respiratory distress syndrom e

Antibiotics are given in case of

superadded infections
The management of HMD
requires supportive care by
trained nurses and the
availability of high technology
to monitor and manage the
hypoxia due to ineffective
ventilation.

N eonate Respiratory distress

syndrom e/hyaline m em brane
disease
Nursing management
Effective ventilation and oxygen
therapy
Equipment should be ready and in
working condition
Oxygen must be warm and
humidified
The condition of the infant can
change in a fraction of a second so it
is vital for the nurse to monitor
neonates color, level of activity and
to note blood gas measurements.
When o2 is given, tracheal and
nasopharengial suctioning and chest
physical therapy is required.

N eonate Respiratory distress

syndrom e/hyaline m em brane
disease
Optimal environmental temperature:

The nurse has a important role in

providing regulation of surrounding
temperature.
Adequate nutrition: proper gavage
feedings at proper intervals is
necessary nursing action.
Minimal handling of critically ill infants.
Use of aseptic techniques.
Infants should be positioned with head
elevated to decrease pressure on
diaphragm.

N ecrotising Enterocolitis (N EC)

This is characterized by necrosis of

intestinal wall , is a serious life

threatening condition that is being
diagnosed with increasing frequency
in premature infants.

N ecrotising Enterocolitis (N EC)

Factors that place the infant at risk of

this disease include:

Perinatal asphyxia
Low apgar score
IRDS
Sepsis
Enteral feedings

Congenital cardiac disease

Relative ischemia of the intestinal tract that

is due to hypotension
Use of umbilical catheters
Exchange transfusion

Pathophysiology

N ecrotising Enterocolitis
(N EC
Clinical manifestations:
Abdominal distention
Decreased bowel sounds
Poor feeding
Increased gastric residuals
Blood streak bile vomiting
Bloody or mucoid stools

N ecrotising Enterocolitis
(N EC
Nursing management
As soon as the diagnose of NEC
is made the oral feedings are
discontinued and peripheral IV
fluids are given to the infant.
Palpation of abdomen,
abdominal girth are checked
daily
Bowel sound monitoring
TPN is to be started

N ecrotising Enterocolitis
(N EC
I/v antibiotics are started

to against gram negative

enteric organisms
Rectal temperature is not
taken so as to prevent
rectal perforation
Affected infants are to be
placed in isolation

N ecrotising Enterocolitis
(N EC
These infants are not diapered

because of the increased risk of

intra-abdominal pressure.
These infants are nursed on their
back as much as possible to
reduce the external pressure on
the abdomen
Postoperatively , as the suture
line is close to stoma so
measures should be taken to
avoid any infection to suture line.

N ecrotising Enterocolitis
(N EC
Fecal material can be

drained into urine

collecting devices.
Psychological support
should be given to
parents.

N eonatalSepsis

Systemic bacterial infections

of newborn infants are termed

as neonatal sepsis
They are the most common
cause of neonatal deaths in
Indianatal sepsis
This is a generic term which
incorporates neonatal
septicemia, pneumonia,

N eonatal Sepsis
Neonatal sepsis can be divided
into two types
Early onset: this happens in first
72 hours of life
This is mainly due to
organisms present in:
the genital tract or
in the labor room or
in maternity operation

N eonatal Sepsis
Late-onset: this is caused by
the organisms thriving in
exter
The infection is often
transmitted by the care
givers.

N eonatal Sepsis
The predisposing causes of LOS are
:
Lack of breast feeding
Superficial infections
Aspiration of feeds
Disruption of skin integrity with
needle pricks and use of IV fluids
External env of homes or hospital.

N eonatal Sepsis
Clinical features: The
manifestations of neonatal
sepsis are often vague and
nonspecific demanding high
index of suspicion for early
diagnosis.
Any altern in feeding patterns
Active baby suddenly becoming
lethargic

 Hypothermia in preterms and

fever in term babies especially

in association with gram
positive infections and
meningitis.
Diarrhea, vomiting and
abdominal distention
Jaundice and
hepatosplenomegaly may be
present
Episodes of apneic spells with

N eonatal Sepsis

Management:
The infant should be
managed in a thermo
neutral env and started
on intravenous
antibiotics

N eonatal Sepsis
Nursing Management:
Hand washing and thorough
scrubbing with soap and water
upto elbows for at least
2mons, gowning and change
of shoes are mandatory.
Rings, bangles and
wristwatches should be
removed
Strict hand washing for 20
secs and use of antiseptic
solution in between handling
babies.

N eonatal Sepsis
Babies should be fed
early and exclusively on
breast milk.
5. Careful attention
should be paid to
hygiene of the katori and
spoon.
6. The umblical stump
should be left open.
Local application of spirit
reduces colonization.
4.

N eonatal Sepsis
All procedures
should be done
wearing mask.
Unnecessary needle
pricking should be
avoided.
Strict housekeeping
routines for washing ,
disinfection, cleaning
of cots/incubators
should be ensured .

Infants of diabetic m others ID M

There has been

continuing
improvement in
the care of
mothers with
diabetes mellitus
and their
neonates,
resulting in a
decline in the

Infants of diabetic m others ID M

Clinical manifestations of IDM:
Large for gestational age
Very plump and full faced
Abundant vernix caseosa
Pleothora
Listlessness and lethargy
Large placenta and umblical
cord
Possibly meconium stained
at
birth

Infants of diabetic m others ID M

Therapeutic management
The most common management of
IDMs is careful monitoring of serum
glucose levels and observation for
accompanying complications such as
RDS.
Studies confirm that maintaining blood
glucose level more than 50mg/dl in
IDMs with hypoglycemia prevent serious
neurological conditions.
Oral and IV backup may be titrated to
maintain adequate blood glucose levels.

 Nursing care management

Early introduction of carbohydrate

feedings as appropriate
Serum glucose monitoring.
Because macrosomic infants are at
high risk for problems associated
with difficult delivery, they are
monitored for birth injuries.
There is some evidence that IDMs
have an increased risk of acquiring
type 2 DM during childhood or
early adulthood therefore a nurse
should also focus on healthy
lifestyle and prevention later in life
with IDMs.

References

WONGS ESSENTIAL OF PAEDIATRIC

NURSING 8TH EDITION

NELSONS TEXTBOOK OF PEDITRICS
15TH EDITION
http://www.imedicine.com /display
topic
DOROT HY R.M.MARLOW AND
BARBARA A. REDDINGS TEXTBOOK
OF PEDIATRIC NURSING 6TH EDITION
Www.wikipedia.org
Textbook of Indian academy of
pediatrics

Any questions