Maternity - Newborn, part 6: Preterm and Postmature Infants, Meconium Aspiration Syndrome

by Meris Shuwarger BSN, RN, CEN, TCRN November 27, 2021 Updated: June 16, 2022 8 min read 1 Comment

Full Transcript

Hi, I'm Meris with Level Up RN. And in this video, I'm going to be talking to you about premature infants, postmature infants, and meconium aspiration syndrome. I'm going to be following along using our maternity flashcards. These are available on our website, leveluprn.com. If you have a set of your own, I would encourage you to follow along with me. And if you don't have one yet, go visit leveluprn.com and grab a set for yourself. Okay. Let's get started. Okay. So first up, we are talking about preterm infants. That is going to be one who is born before 37-weeks gestational age. So we have some risk factors here. Maternal gestational hypertension is going to be one. Any time that we have hypertension in mom, we are not going to be getting appropriate blood flow to the baby, so that could put us at risk for prematurity. Cervical incompetence, which again, I've said it before, I'll say it again, what a rude term. But this is where the cervix does not do its job of staying closed high and tight. Right? It is not able to keep the baby inside the uterus. We're going to have early dilation and cervical incompetence. Then we have amnionitis so infection or inflammation of the amnion. Prior preterm delivery, so if I have had a preterm baby before, I'm automatically at higher risk for preterm delivery in the future. Uterine abnormalities, so if I have some sort of structural abnormality, that could put me at risk. PPROM which we've talked about in a previous video, but that's going to be premature rupture of membranes, and it's going to be preterm premature rupture of membranes. And placenta previa. All of those are risk factors.
Now, signs and symptoms, we have a lot here on the card, but rather than going over all of them, I would tell you to go watch my video on the new Ballard scale because it is essentially a more in-depth version than what's on this card. Now, complications, the big one is going to be related to respiration. My lungs haven't fully developed, so I'm going to have a hard time adapting to breathing in the real world. Right? So respiratory distress syndrome, bronchopulmonary dysplasia, BPD, those are going to be two really big, important ones. And remember that respiratory problems are the biggest cause of cardiac arrest in children, in pediatric patients. So it's a big deal to not be able to breathe appropriately. I mean, for everyone, but especially for kids. Anemia, necrotizing enterocolitis, hyperbilirubinemia, hypoglycemia, there's videos on all of those. Definitely check them out. And intraventricular hemorrhage.
Now, talking about nursing care of the preterm infant, we have to keep them warm. Right? Babies, universally, really don't do a good job of regulating their own heat. They have poor thermal regulation. But it's even worse when I'm premature. I have even less fat on my body. Right? I have even less of an ability to regulate my own temperature. So we're going to use a radiant warmer or an incubator to maintain the infant's body temperature, and we're going to just really keep an eye on that, make sure they're staying warm. All of the time, we say that the safe ABCs of sleep are alone, on your back, and in a crib. And that is true when you go home with your parents. Right? However, when you're a premature infant being cared for in the NICU, these babies are actually going to be placed side-lying or even prone, so laying on their belly, to improve their oxygenation. I know it seems counterintuitive, but remember that these infants are hooked up to monitoring equipment 24-7 and there are trained and educated nurses at the bedside 24-7, so it is good to position these infants in this manner but would not be okay to do once you go home.
We're going to give them oxygen and ventilatory support. Right? We're going to make sure that they are able to breathe appropriately and keep their oxygen levels as designated per order. And so we're going to monitor oxygen saturation levels. Too much oxygen can be a bad thing. It can lead to things like retinopathy blindness because of too much oxygen. So typically, there will be a prescribed level you want to keep the-- and I'm making this up. I'm not a NICU nurse. But it would say maintain SpO2 levels between 85 and 90 percent or something like that. So you would want to titrate the oxygen to effect, meaning that we would want to adjust the oxygen to keep it in that window. Again, that's going to be per order per facility policy. I'm not a NICU nurse. I just made up that example. So don't come at me if that's wrong. And then synthetic surfactants can be administered as well. Surfactant is that substance that keeps our alveoli open. Right? And the problem with prematurity is my lungs are not mature, so I don't have that surfactant to keep my lungs open. So we can actually give synthetic surfactant to help keep those alveoli open.
Clustering care and minimizing stimulation is going to be very important. So if I need to do a feeding and a diaper change and we've got to check the skin, and maybe we have to start an OG tube, all of that, we're going to try and do it all at once because these itty-bitty babies don't do well with stimulation. They're still supposed to be in the uterus. Right? And there's not a lot of external stimuli in the uterus. So things should be warm and calm and quiet for them. And then they're brought into the world, and they're in this bright, loud, crazy environment. We want to decrease that stimuli. And certainly, we have to take care of them. We have to change their diapers. We have to do these interventions. But if we can cluster that care to minimize the number of times that they are bothered, the better. So I have some friends who are NICU nurses, and they talk about how they will try to coordinate care with when the doctor comes to assess the baby. So the doctor is going to get them all riled up, right, touching them, turn them over, putting stethoscope on their back, all of that. And then they're going to try and do their nursing care immediately after so that then we can get baby calm and soothed and back to being happy. And then we may also have to give enteral feeding, meaning through a feeding tube, or total parenteral nutrition, meaning through the vascular space, to provide nutrition for this infant because they are very likely not going to be able to breastfeed due to prematurity. So we should watch their intake and their output very closely.
Now, on the flip side, let's talk about postmature infants. And postmature infants are those born after 42 weeks. So the expected gestational length is 40 weeks. However, it's okay to go up to 42. There may be some interventions and things like we may implement non-stress tests. Depending on the size of mom, we may encourage induction. But up to 42 weeks is still considered a mature infant. Postmaturity happens after 42 weeks. So risk factors would be maternal obesity or prior prolonged pregnancy. So if you did it once, you're already at risk to do it again. Signs and symptoms, though, I mean, the biggest sign and symptom is going to be that you're past 42 weeks. But let's say we didn't know how far along mom was at the time of delivery, meconium-stained amniotic fluid is going to be a big deal here. That is going to be a big sign and symptom and also a risk for something else we'll talk about in a minute. Long hair and nails of the baby. Hypoglycemia in the baby. Polycythemia, so increased red blood cell levels. Loose, wrinkled, leathery skin. That's going to be one of those as well. Loss of subcutaneous fat. And little to no vernix caseosa. That is not a Harry Potter spell. That is actually the kind of cheesy substance that coats an infant. So vernix would be expected to be found on a mature infant but typically just in the creases. But in a postmature infant, we're going to have almost none. Right?
Complications. Fetal hypoxia is going to be one as well. Meconium aspiration is going to be a huge one, and we'll talk about that more in a moment. LGA, which is large for gestational age, meaning that they are macrosomic. You can watch a video on that as well. And birth trauma. The baby keeps growing. I've got a big baby with a big body and a birth canal that does not change. It doesn't get bigger just because the baby's bigger. So we're at risk for birth trauma. So nursing care, anytime we talk about hypoglycemia or macrosomic infants, we're going to say early and frequent feedings and closely monitoring blood glucose. And then we want to, with all babies but especially postmature infants, we're going to try to prevent heat loss.
Lastly, let's talk about meconium aspiration syndrome. Meconium aspiration syndrome is what it sounds like. It is when the infant has aspirated or inhaled meconium, which is the infant's first stool. Typically, meconium is passed following birth, usually in the first 24 hours of life. However, some infants, especially post-mature infants, can actually have their first stool while in utero. We would see that green-brown stained amniotic fluid. That would be your biggest sign there. But we can also see staining of the nails can happen as well. And when I inhale-- I mean, think about this. I just inhaled amniotic fluid that is tinged with poop, essentially. Right? Now, that's in my lungs. And that's not good for anyone, but it's especially not good for an infant who is trying to adapt to living in the real world. Right? That's going to be really difficult. So they are at risk for a lot of respiratory problems. Right? They can have airway obstruction. They can inactivate their own surfactant. That would be terrible. And they can develop pneumonia as well. And that is really scary and life-threatening for an infant of that age. So if we see green stained amniotic fluid or if we see that the baby has fetal distress or staining of those nails-- excuse me, I meant respiratory distress. We're getting concerned. We're concerned about this, and we're going to investigate. So if I know that we are at risk for meconium aspiration because I saw mum's membranes get ruptured, and the fluid that came out was green stained, I'm thinking we're at risk for meconium aspiration. I'm going to prepare the resources, meaning I'm going to tell respiratory therapy, I'm going to call the NICU, I'm going to make sure that the neonatologist were all aware that this is possible. Right? And then also literally preparing the resources like resuscitative equipment and things like that for deep suctioning. I want to make sure that everything is ready for once this baby comes. But we're not suctioning every baby who might have meconium aspiration. We're only doing it if there is airway obstruction. We can administer oxygen. We can also give synthetic surfactant. And nitric oxide is also a medication frequently used in NICU that can be indicated for a baby with meconium aspiration.
I hope this review was helpful. I'm going to ask you some quiz questions so that you can test your knowledge on some key facts that I provided to you, so be sure to let me know how you do in the comments. So first, I want you to tell me what is a preterm birth? Define preterm birth for me? Secondly, I want you to think which newborn is at higher risk of having experienced a birth injury, a baby born at 29 weeks gestation or one born at 43 weeks gestation? Which one is more likely to sustain birth injury? Lastly, I want you to think, upon seeing green stained amniotic fluid, what complications should the nurse anticipate is possible? Let me know how you did in the comments. Thanks so much and happy studying.


1 Response

johanna
johanna

May 04, 2022

very well explained!!! I should have known earlier before I started my OB class

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