Extrauterine Adjustment -Physiological Adaptation of Newborn

Extrauterine Adjustment/Physiological Adaptation of newborn

The fetus is entirely reliant on the mother during the intrauterine stage for all essential needs, including oxygen, feeding, and waste elimination. The placental circulation is interrupted immediately after birth, which results in the loss of all metabolic support, particularly the supply of O2 and the removal of CO2.

The successful transition from intrauterine to extrauterine life is dependent upon significant physiologic changes that occur at birth. In almost all infants, these changes are successfully completed at delivery without requiring any special assistance. However, about 10 percent of infants will need some intervention, and less than 1 percent will require extensive resuscitative measures at birth. The major physiological adaptations to extrauterine life are as follows:

• Respiratory Adjustment/Adaptation.
• Circulatory Adjustment/Adaptation.
• Thermal Adjustment/Adaptation.

Respiratory Adaptation

The start of spontaneous breathing is the newborn's most important and immediate physiological need. A newborn often begins breathing on its own 20 seconds after birth. The following circumstances cause breathing to begin:

• Physical/Mechanical Factor: As the fetus descends the birth canal, there is compression on its chest, which causes a significant amount of its lung fluid to leak out (from mouth and nose). The chest wall recoils as soon as the child is born since the birth canal's pressure on the fetal chest has been relieved. Negative intrathoracic pressure is produced as the chest contracts, and the reduced pressure from the expanded chest pushes air into the lungs.
• The placental supply of oxygen is cut off when the umbilical chord is clamped, which is a chemical factor. It causes the newborn's blood oxygen levels to drop and carbon dioxide levels to rise.
• Blood pH will drop (a transitory asphyxia). The ensuing acidosis activates the medulla's respiratory center, which in turn activates respirations. A brief asphyxiation stimulates breathing, while chronic asphyxia can depress the respiratory center, necessitating resuscitation.
• Thermal effect When a newborn leaves the warm intrauterine environment (98.6 F) and enters a slightly cooler environment, they experience an abrupt cooling (70-75 ) The sensory nerve ending in the skin is excited by the quick change in temperature, and this stimulation is sent to the respiratory center to start breathing.
• Sensory factor: The newborn's respiratory center is stimulated by the aural and visual birth-related cues as well as the usual handling during delivery and drying, which all help to start breathing.
• Surfactant: This substance is crucial for the respiratory adaption. The phospho-lipoprotein known as surfactant, which is present in the lungs of mature fetuses, keeps the alveoli from collapsing when they initially expand. The fetus typically has enough surfactant by the end of the 35th week of gestation to breathe without lung collapse.

Circulatory Adaptation

The cardiovascular system needs to adapt quickly just after delivery. Only a small portion of the blood that travels to the lungs throughout fetal life is sent there; the majority is diverted elsewhere. Only the blood required to provide oxygen to the lung tissue flows to the lungs because the blood that normally circulates to the heart has already been oxygenated by the placenta. Blood that has lost its oxygen supply to the placenta must travel to the lungs for gas exchange. The circulation of a newborn resembles that of an adult. The foramen ovale, ductus arteriosus, and ductus venosus are the three fetal shunts that must be functionally closed in order for the newborn circulation to switch from the fetal to the newborn state.

The newborn's lungs fill with air and expand as it takes its first breath. The blood can flow freely through the lungs for oxygenation because of the reduced pulmonary vascular resistance and pulmonary artery pressure caused by lung expansion. The foramen ovale closes as a result of the change, which causes the pressures in the right and left atria to reverse, rerouting blood to the lungs.

The blood's oxygen saturation rises as pulmonary circulation is established. This prompts the ductus arteriosus to close, eventually forming a ligament. When placental circulation stops, the ductus venosus also closes.

Thermal Adaptation

Newborns go from a warm environment within the womb to the chilly, erratic conditions outside. The baby faces the difficulty of creating as much heat as is lost in order to maintain an adequate body temperature just after delivery. Thermoregulation is the process through which heat production and heat loss are balanced. Heat loss, heat generation, and heat retention are the three basic variables that affect thermoregulation.

Heat Loss

In order to avoid heat loss, newborns have thin skin, blood arteries that are close to the skin's surface, and little subcutaneous fat. The newborn's enormous surface area makes it easier for heat to escape to the outside by convection, conduction, radiation, and evaporation.

Conduction

• Direct touch with a cooler item causes heat to be lost. Heat is lost when a newborn is in contact with cold surfaces, such as a weighing scale, icy hands, or a cold stethoscope.
• Warming the baby's surroundings, putting the baby in a warmed blanket, or keeping the baby in skin-to-skin contact with the mother can all help reduce heat loss.

Convection

• The heat lost by air movement. Heat is transferred to the air through air currents, which move the air. Heat loss is accelerated by air currents from open windows or doors, air conditioners, and people moving about.
• For the newborn right after birth, a radiant warmer is frequently used to stop convectional heat loss. Heat loss in the newborn can be stopped by wrapping him or her in a blanket, dressing them in hats, gloves, and socks, and keeping them away from drafts.

Evaporation

• The loss of heat through evaporation occurs when the newborn's skin is wet. Heat is lost along with the moisture as it evaporates from the surface of the body.
• The newborn should be dried as soon as possible after birth, and wet clothes and diapers should be changed as soon as possible.

Radiation

• The process of losing heat to a neighboring, cold object without coming into touch. A baby put close to a chilly window will lose heat via radiating to the crib's sides and the window. The baby loses heat if the incubator's walls are chilly.
• By putting cribs and incubators away from chilly windows, heat loss can be avoided.

Heat Production

Through general metabolism, muscular activity, and nonshivering thermogenesis, the newborn generates heat (thermogenesis). activity.

The metabolic rate increases to produce more heat when the newborn is in a chilly environment and needs it. When chilled, the infant may cry and show signs of muscle activity. If the baby's body temperature is not sufficiently raised by a faster metabolism, nonshivering thermogenesis, or brown fat metabolism, starts. Only neonates have an unique type of fat called brown fat. It starts to develop at around 26 to 30 weeks of pregnancy and grows till 2 to 5 weeks of age (unless depleted by cold stress). Brown fat has a brown color because it is heavily vascularized. The brown fat is found in the axilla, between the scapula, between the kidneys and adrenal glands, behind the neck, between the scapula, around the heart, and around the abdominal aorta.

Heat Retention

Naturally, newborns adopt a flexed posture. This reduces the amount of skin exposed to the environment and retains body heat in the core. In order to keep warm, they also use the peripheral vasoconstriction mechanism, which reduces blood flow to the skin.

Essential Newborn Care

Every newborn receives essential newborn care from the time of delivery until 28 days old. Each newborn is different and delicate, going through a significant shift from a secure intrauterine environment to a potentially dangerous extrauterine environment. Most newborns start breathing on their own right away, scream loudly, and keep their body temperatures neutral. However, a small percentage of newborns require some assistance to adjust or to start breathing.

Purpose of Essential Newborn Care

• To provide for the infant's fundamental medical needs (warmth, normal breathing). 2. Ensuring that the infant breastfeeds for the first hour.
• To encourage/advise the mother to breastfeed only.
• To look for warning signals of issues so that action can be taken quickly.
• To give the mother and family advice on how to care for the newborn and danger signs.
• To prepare for ongoing care (immunizations, growth monitoring etc.)

Essential Newborn care includes

• Newborn care given right away at birth
• Full-time 24-hour care
• Up to 28 days of care

Immediate newborn care at birth

"Early management of the infant in the delivery room or in a nursery immediately after the birth" is what is meant by "immediate newborn care." Care for newborns must begin right away:

• To begin, continue, and assist breathing.
• To keep you warm and shield you from hypothermia.
• To evaluate the newborn's health.
• Prevent injuries and illness to ensure safety.
• To find problems—real or hypothetical—that might demand quick attention.

Equipment and supplies for immediate Newborn care .

1. Four clean clothes or towels
   • one to dry the infant and another to wrap it
   • If CPR is required, a flat surface and two layers of clothing: 1 to roll up and place beneath the infant's shoulder, and 1 to cover the area
2. Suction, Ambu bags, masks, and stethoscopes are among the tools and materials used in infant resuscitation
3. Gloves, an apron, and safety eyewear (if available)
4. Tools for cutting and tying the cord.
   • Cord ties, two artery forceps, or a single cord clamp.
   • A fresh blade of razor or sterile scissors.
5. Covering the infant with warm clothing or a blanket
6. Socks, gloves, and a cap in clean baby clothes.
7. Balance scale
8. A birth certificate and newborn record form

Steps of Immediate Newborn Care at Birth

Step 1: Dry, stimulate and wrap the baby

• As soon as the baby is delivered, place it on the mother's tummy.
• Dry the baby completely from head to toe with a warm cotton towel. The infant is aroused while it dries. While the baby is still enveloped in the clean, warm blanket, rub its back from top to bottom. This will help the baby maintain body temperature control and give him or her tactile stimuli to start breathing.
• Don't remove the vernix since it shields the skin and may help prevent infection. Another clean cotton towel should completely encircle the baby's body and head to prevent heat loss.

Step 2: Assess the Baby's breathing and color

• While drying them off, make whether the infant is breathing normally or not. Look at the baby's face and chest; it should be pink, not bluish or gray.

Step 3: Decide if the Baby needs Resuscitation

• If an infant is not breathing, is breathing less than 30 breaths per minute, or is gasping, resuscitation is necessary.
• If so, quickly clamp the cable or tie it before cutting it, leaving a stump that is at least 10 cm long. Start CPR right away after setting the infant down on a flat surface.
• If the baby doesn't need resuscitation, move on to the next step.

Step 4: Tie and cut the cord

• Continue to swaddle the baby, then clip the chord after one to three minutes, exposing only the cord region. a sterile cord clamp and tie on the cord. The umbilical cord should be clamped three fingers from the abdomen if "cord clamp" is available. If thread is used, firmly tie the cord in three places as follows:
  • The first knot is placed two fingers away from the infant's belly.
  • The second tie is positioned three fingers away from the baby's belly.
  • The third knot is positioned four fingers from the infant's belly.
• Between the second and third ties, cut the rope using a clean device (fresh razor blade or sterile scissors). To stop blood splashes, wrap the exposed part of the cord with a small piece of fabric or gauze. Take cautious not to hurt or cut the infant. Place your hand between the cutting edge and the baby's abdomen, or cut away from the infant.
• Wearing gloves, apply 4% chlorhexidine gel over the stump of the umbilical cord.

Step 5: Place the baby in skin-to-skin contact with the mother

• To begin skin-to-skin contact, place the infant between the mother's breasts. It is strongly advised to place the infant in skin-to-skin contact on the mother's chest so that the warmth of the mother can easily reach the infant and help to regulate temperature.
• Make sure to drape a cloth over the infant's head. Put a warm cloth or blanket over the mother and the infant together. Inform the mother of the significance of keeping the infant warm.
• Dry and wrap the baby, then wrap its head in a cloth if the mother does not want direct skin-to-skin contact (following LSCS, due to pain and discomfort). Then place the baby next to the mother. It's crucial to postpone or delay the first bath; even if the baby's temperature is stable, baths shouldn't be administered until 24 hours have passed.

Step 6: Have the mother start breastfeeding

• Do not separate the mother and child, not even for weighing before breastfeeding. Help the mother start nursing as soon as possible by providing encouragement (within the 1 hour of birth).
• Make sure the infant is in a good position, attached, and sucking effectively. Limitless breastfeeding gives the baby the energy to stay warm, the nutrition to grow, and the antibodies to fight infection. Therefore, breastfeeding should begin as soon as possible.
• Help the mother express breast milk if necessary.

Step 7: Put identification tag on the baby

• An identification tag should provide the mother's name, the baby's birthdate, and its gender.
• Help the mother express breast milk if necessary.

. Step 8: Give eye care:

• Give eye care immediately upon breastfeeding or within an hour of the birth. To clean the eye, use regular saline or cool, boiling water. Apply prescribed antimicrobial medication to a baby's infected eyes.

Other care

Administration of Vitamin K Injection

• Injection One milligram of vitamin K is injected intramuscularly (IM) into the newborn's vastus lateralis muscle (lateral anterior thigh).
• Since the newborn's intestine is sterile at birth, it lacks the intestinal bacteria necessary to produce vitamin K. The newborn is more likely to bleed as a result. The production of clotting factors, which stop bleeding, depends on vitamin K.

Record the weigh the baby

• Tally the infant's weight and keep a record of it. Make sure to cover the weighing pan with a warm cloth while taking the weight.

 After immediate newborn care

• Keep a record of all newborns and their initial needs.
• Send a report to the proper party.
• Inform the mother and family of the findings.

Care during first 24 hours (first day)

The first four to six hours following birth are the transitional period between intrauterine and extrauterine life. To enable a smooth transition to extrauterine life, the newborn's clinical state should be checked every 30 to 60 minutes throughout this time. Beginning in the delivery room and continuing in the postnatal ward (mother and newborn's room (rooming in) or nursery), the following clinical parameters are observed:

1.Evaluation of the newborn:
Starting in the delivery room and continuing in the postnatal ward or nursery, the following clinical indicators are tracked:

• Temperature
  For a baby, the typical axillary temperature ranges from 36.5 to 37.5°C (97.7 to 99.5°F). Sepsis may be indicated by prolonged heat or hypothermia. Acidosis and hypoglycemia are two metabolic diseases that hypothermia may exacerbate.
  • The average respiratory rate is between 40 and 60 breaths per minute, and it should be recorded over the course of a full minute. Keep an eye out for tachypnea (rapid breathing), grunting, grasping, and chest indrawing; if observed, these symptoms should be reported right away. Tachypnea could indicate a respiratory or cardiac condition.
• Colour
  Pink is the typical color of newborns. While in the hospital, central cyanosis (lips, tongue, and central trunk) is regularly checked for the beginning and progression of jaundice every 8 to 12 hours as part of what may be a sign of respiratory or cardiac disease. Every newborn should receive the standard newborn care.
• Tone
  A newborn's muscular tone should be normal (strength in extremities). A neonate with hypotonia may be suffering from infection, neurological damage, or hypoglycemia.

2. Physical examination
Quickly check the infant for delivery injuries and malformations. To detect any life-threatening congenital defects such meningomyelocele, trachea-oesophageal fistula, anal atresia, and omphalocele, quick yet complete clinical screening is crucial.

3. Care of newborn

• Warm up the newborn:
• Keep skin-to-skin contact (kangaroo mother care)
• Keep the infant in the mother's bed or room.
• Wrap the mother and the infant in a blanket.
• Put a cloth or cap over the infant's head.

Support Breastfeeding:
Keep encouraging the woman to breastfeed and instruct her in proper technique. The likelihood of effective breastfeeding is increased by living together, skin-to-skin contact, frequent demand feedings in the early postpartum period, and lactation support. Newborns need to eat at least 8 to 12 times a day, each time spending 10 to 15 minutes on each breast. The effectiveness of breastfeeding is demonstrated by the child's sustained weight gain, regular bowel movements, and adequate urine output (six to eight wet diapers per day). Only when the mother shouldn't or is unable to breastfeed her child (due to maternal drug usage) can formula be given to the kids.

Umbilical Cord Care:
Check for bleeding from the cord, if bleeding present tie the cord tightly again. If there is an increased risk for omphalitis, apply antiseptic agents (4% chlorhexidine gel) over the umbilical cord stump, if not applied before.

Vaccination:
At birth, newborns receive a single dose of the BCG vaccine.

Postnatal parental education:

The following newborn care duties should be explained to and understood by the parents:

• The value and advantages of breastfeeding.
• Skin, genital, and umbilical cord care.
• Recognizing the symptoms of common newborn diseases, including sepsis and hyperbilirubinemia.
• Good infant safety practices, such as supine sleeping position, using a fir mattress, and maintaining good hand hygiene (to prevent infection).