The High Risk Neonate
M E R E D I T HW I L L I A M S ,R N , B S N
Objectives
By the end of this class, students will be able to:
Identify the factors at birth that indicate an at risk newborn
Define the specific characteristics of SGA, AGA, and LGA
infants
Discuss the potential complications and risk factors of the high
risk neonate
Compare the physical assessment characteristics of the
premature infant to a full term infant and a post term infant
Discuss the nursing interventions related to the care and
management of the high risk infant in the clinical setting
At Risk Newborns
Factors that influence birth outcomes:
Birth weight
Gestational age
Type and length of newborn illness
Environmental factors
Maternal factors
Maternal-infant separation
At Risk Newborns
Identifying a newborn at risk:
Low socioeconomic status
Limited
Why identify at risk neonates?
Monitor pregnancy closely
Start treatment as needed
Arrange to deliver in appropriate facility with the resources for
mother and baby
Newborn Classifications
Preterm: < 37 weeks
Late Preterm: 34 to 36 6/7 weeks
Term: 38 to 41 weeks
Postterm: > 42 weeks
Updated Classifications
Preterm:
Extremely Preterm: < 28 weeks
Very Preterm: 28 0/7 to 32 weeks
Late Preterm: 32 0/7 to 36 6/7 weeks
Updated Classifications
Term/Postterm:
Early term: 37 0/7 to 38 6/7 weeks
Full term: 39 0/7 to 40 6/7 weeks
Late term: 41 0/7 to 41 6/7 weeks
Postterm: 42 0/7 weeks and beyond
Growth Chart
Infant Classifications
SGA
Infants that fall below the 10th percentile
AGA
Infants that are > 10th percentile, but < 90th percentile
LGA
Infants that fall above the 90th percentile
Infant Classifications
Let’s practice!
37 5/7 weeks gestation, weighing 2954g
39 0/7 weeks gestation, weighing 3855g
40 1/7 weeks gestation, weighing 2590g
Small for Gestational Age
Less than 10th percentile for birth weight
May be preterm, term, or postterm
Under grown infants – IUGR
Commonly seen in mothers who smoke or have
high blood pressure
Increased incidence of polycythemia
and hypoglycemia
Small for Gestational Age
Intrauterine growth restriction
Nursing Management for SGA
Monitor for signs of respiratory distress
Monitor temperature > 36.4 ◦C
Monitor blood glucose > 45 mg/dl
Assess feeding
Support increased caloric needs
Support breastfeeding and milk production
Large for Gestational Age
Greater than the 90th percentile for birth weight
Often associated with maternal diabetes
Genetic predisposition – large parents, large infants
Multiparous women – 2-3 times more likely
than primiparous women
Male – usually larger than females
Infants with certain anomalies tend to be LGA
Complications of LGA
Birth trauma due to CPD
Increased incidence of C/S & oxytocin-induced birth
Hypoglycemia, polycythemia, & hyperviscosity
Nursing Management of LGA
Monitor vital signs
Screening for hypoglycemia and polycythemia
Observing for signs and symptoms of birth trauma
Assess feeding
Support breastfeeding and milk production
Nursing Management of LGA
Infants of Diabetic Mothers
Close monitoring in first hours of life
Hypoglycemia - <45 mg/dl
Hypocalcemia - <7 mg/dl
Hyperbilirubinemia – seen at 48-72 hrs, hepatic immaturity
and/or birth trauma
Birth Trauma – shoulder dystocia, brachial plexus injuries,
subdural hemorrhage, cephalhematoma, and asphyxia
Nursing Management of LGA
Infants of Diabetic Mothers cont…
Polycythemia – hyperglycemia/hyperinsulinism - increased
O2 comsumption – fetal hypoxia – increased erythropoietin
production – increased Hct – potential hyperbilirubinemia
Respiratory Distress Syndrome (RDS) – less mature lungs for
gestational age
Congenital malformations – high risk with poor glycemic
control especially during first trimester
Nursing Management of the Late Preterm
At risk for:
Dehydration
Hypoglycemia
Hyperbilirubinemia
Hypothermia
Sepsis
Respiratory instability
Failure to thrive
Nursing Management of the Late Preterm
Careful Monitoring
Encourage skin to skin
Encourage breastfeeding on demand
Initiate supplementation – expressed breast
milk (EBM) or formula if:
Birth
weight < 2500 g
< 36 weeks gestation
Poor reserve – temp instability or hypoglycemia
Poor feeding – poor latch or < 10 min at breast
Weight loss > 3% per day or > 8% total
Nursing Management of the Late Preterm
Feeding every 8-12 times/day – not > 3 hrs
between feeds
Encourage increased milk production – breast pump
or hand expression after feeds
Increased caloric intake – 5-10 ml/feed in first 24 hrs
of life; 10-30 ml/feed in 24-96 hrs of life with MD order
Use SNS or syringe feeding for supplementation
Lactation Consult – documented feeding plan
for discharge
Follow up – 1-2 days of discharge
Physical Assessment of the Newborn
What are some characteristics of the
normal newborn?
What does a newborn look like?
Physical Assessment
What does a preterm infant look like?
Physical Assessment
Preterm infant
Increased lanugo
Increased vernix
Skin – thin, translucent
Less defined creases in
hands and feet
Relaxed tone
Decreased body fat
Case Study
As a nursing student, you are working in labor and delivery and are assigned a
mother/baby couplet for your shift. The mother is 19 years old, G1P1, blood type O+,
GBS positive. She received 3 doses of ampicillin during her labor. Her pregnancy
was complicated by gestational diabetes. Her blood glucose was well controlled by
diet alone. She has no allergies and no significant health problems prior to
pregnancy. At the start of your shift, the infant is approximately 6 hours old.
According to the H&P, the infant was delivered at 36 4/7 weeks gestation. The birth
weight is 2210 g. The infant returned to the mother from the NICU after a 4 hour
observation for mild respiratory distress. Upon entering the room, you observe that
the infant is swaddled loosely in a blanket and lying on the bed next to the mother.
What risk factors do you note when caring for this couplet?
What vital signs are going to be especially important when caring for this infant?
What physical characteristics do you expect to see when you examine this infant?
What special feeding issues will you need to assess on this infant? Develop a feeding
plan that would be appropriate considering the infant’s gestational age and weight.
How will you approach this mother when teaching her about infant care,
considering that she is a teen mother?
References
Davidson, M., London, M., & Ladewig, P. (2012). The newborn at risk:
Conditions present at birth, Olds’ maternal-newborn nursing & women’s
health across the lifespan (pp. 889-937). Boston: Pearson
The American College of Obstetrics and Gynecologists. (2013). Definition of
term pregnancy. Retrieved from
http://www.acog.org/Resources_And_Publications/Committee_Opinions
/Committee_on_Obstetric_Practice/Definition_of_Term_Pregnancy
UC Davis Health System. (2014). Policies & Procedures: Late pre term/early
term protocol (34 0/7 to 37 6/7 weeks gestation). Retrieved from
http://intranet.ucdmc.ucdavis.edu/policies/ patient_ca re_standards/obste
trics/XVI-50.shtml
World Health Organization. (2013). Preterm birth. Retrieved from
http://www.who.int/mediacentre/factsheets/fs363/en/