Oxford Handbook of Midwifery (128 page)

CHAPTER 23
Care of the newborn

602

• Ventilation
  may be needed and is mandatory in cases of GBS, due to associated pulmonary vasoconstriction and the development of pulmonary hypotension.
  
• Cardiovascular support
  . The infant will be shocked. Management of the blood pressure and perfusion are necessary. A decrease in circulating blood volume can cause prerenal failure.
  
• Peripheral perfusion and capillary refill time
  must be kept within normal limits.
  
• Volume replacement
  with plasma or blood helps to provide immunoglobulins and clotting factors.
  
• Dopamine and dobutamine and plasma
  : are used to treat hypotension.
  
• Acid–base balance
  : maintained with ventilation, fluid replacement, and inotropes.
  
• Sodium bicarbonate
  :
  use with caution to help correct acidosis where all other treatments have failed. It can improve acidaemia, myocardial contractility, surfactant production, and lower pulmonary vascular resistance.
  
• Fluid and electrolyte balance
  : record carefully. This can be complicated by the inappropriate secretion of antidiuretic hormone due to severe hypoxia or meningitis.
  
• Hyponatraemia
  can result from inappropriate antidiuretic hormone secretion.
  
• Sodium and potassium losses
  increase when the baby has NEC or the diuretic phase of acute tubular necrosis following low renal perfusion rates.
  
• Hypoglycaemia
  can occur due to increased metabolic demands.
  

  •
  Haematological management
  : keep a record of all blood taken and treatment with top-up transfusions, especially in small premature
  

  babies.
  

• Bruising, oozing, and petechiae
  due to consumptive coagulopathy: treat with platelet transfusions, plasma, and vitamin K.
  
• Exchange transfusion
  : in extreme cases this can wash out coagulation inhibitors and supply missing coagulation factors, opsonins, and increase the oxygen carrying capacity of the blood.
  ¹
  ,
  2
  

  NEONATAL INFECTION
  

  603
  

  Antibiotic therapies and sensitivities (Table 23.2)
  

  Table 23.2 Antibiotics therapies and sensitivies

  Penicillins Aminoglycosides Cephalosporins Vancomycin

  Streptococci Gram-negative Gram-negative Staphylococci organisms bacilli Pneumococci Have a synergistic Meningococci Enterococci effect when used with penicillin to treat GBS Meningococci Gonococci Gram-positive bacteria Gonococci Haemophilus Used to treat influenzae meticillin-resistant Staphylococcus aureus (MRSA) Treponema Pseudomonas spp. pallidum

Bacteroides
, and is useful for the treatment of NEC.

Staphylococcus aureus
and
Staphylococcus epidermidis
.

Pseudomonas
spp.
²

1. Boxwell G (2001). Neonatal infection. In: Boxwell G (ed.)
   Neonatal Intensive Care Nursing
   , 2nd edn. London: Routledge, pp. 260–80.
   
2. Stein CM, Dear P (1999). Infection in the newborn. In: Rennie JM, Roberton NRC (eds)
   Textbook of Neonatology,
   3rd edn. London: Churchill Livingstone, p. 1093.
   
3. Department of Health (1990).
   Guidance for Clinical Health-Care Workers: Protection Against Infection with HIV and Hepatitis Viruses: Recommendations of Expert Advisory Group on AIDS
   . London: HMSO.
   

   CHAPTER 23
   Care of the newborn
   

   604‌‌
   

   Neonatal jaundice
   

   Jaundice is one of the most common problems in the newborn period as all infants undergo changes in bilirubin metabolism at birth.
   ¹
   

   • Physiological jaundice
     is a normal process seen in about 40–50% of term and up to 80% of premature infants within the first week of life. It is a transitional change, leading to an excessive build-up of bilirubin in the blood, which gives the baby a jaundiced (yellow) colour.
     ¹
     
   • Pathological jaundice
     refers to jaundice that arises from pathological factors that alter the usual processes involved in bilirubin metabolism, such as blood-group incompatibility, excessive bruising, and sepsis.
     ¹
     

     Newborn physiological jaundice
     

   • Newborns have high haemoglobin levels 18–20g/dL.
     ¹
     
   • The short life of the baby’s red blood cells produces a high rate of haemoglobin breakdown (haemolysis) compared to adults.
     
   • Each gram of haemoglobin produces 34–35mg of indirect (unconjugated) bilirubin.
     
   • B-glucuronidase from fetal life may still be active in the gut.
     
   • This changes conjugated bilirubin into unconjugated bilirubin.
     
   • In utero
     , this would have been excreted via the placenta and the maternal circulation. This is known as the enterohepatic circulation.
     
   • After birth this unconjugated bilirubin can be reabsorbed into the enterohepatic circulation, causing a further build up in the baby's blood.
     

     Indirect unconjugated bilirubin:
     

   • Has not been unconjugated by the liver
     

     •
     Is fat soluble and cannot be excreted in the bile or urine
     

   • It builds up in the blood and can be deposited in the fatty tissue of the
     

     skin, leading to jaundice
     

   • If levels rise very high, it is deposited in the fatty tissue in the brain, which can lead to kernicterus and brain damage
     
   • The body metabolizes unconjugated (indirect) bilirubin in the liver, changing it into conjugated (direct) bilirubin.
     

     Direct conjugated bilirubin:
     

   • Is water-soluble
     
   • Can be excreted by the biliary system into the intestines and stools
     
   • A small amount can be reabsorbed in the colon and excreted in the urine.
     

     Newborns are also deficient in:
     

   • Albumin for binding, which will carry the unconjugated bilirubin to the liver
     
   • Ligandins (Y and Z carrier proteins) these are needed to transport the unconjugated bilirubin across the space of Diss, which surrounds the hepatocytes in the liver. The bilirubin is then able to cross the hepatocyte cell membrane.
     
   • Glucuronyl transferase, an enzyme in the hepatocyte, which helps to conjugate the bilirubin.
     
   • Glucose substrate is needed to provide energy for the enzyme reactions to take place.
     ¹
     –
     3
     

NEONATAL JAUNDICE

605

Patterns of jaundice

Jaundice developing within the first 24h may be due to: