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Newborn Adaptation to Extrauterine Life: Respiration (Nursing)

by Jacquelyn McMillian-Bohler

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    00:01 So let's talk about what happens right when the baby takes their first breath.

    00:06 So this is the review of the fetal circulation video that we did earlier in this lecture series.

    00:12 So it's right here.

    00:13 I want you to go back, watch this and make sure that you have a good understanding of what fetal circulation looks like.

    00:21 So as we move to adult circulation, you've got that fresh in your mind.

    00:26 There are three very important concepts to keep in mind as we discuss fetal circulation.

    00:32 First, in fetal circulation, the umbilical vein carries the oxygen rich blood and the umbilical artery carries the deoxygenated blood back to the placenta.

    00:43 This is the exact opposite of what happens in adult circulation.

    00:47 Number two, because the placenta takes care of oxygenating the blood and filtering out the waste products, the liver and the lungs are not fully functional in fetal circulation.

    00:59 And the third point to preserve oxygen for fetal development and neurological functioning, there are three shunts that alter the flow of blood away from certain organs.

    01:10 Number one, the ductus venosus.

    01:13 Number two, the foramen ovale.

    01:15 Number three, the ductus arteriosus.

    01:18 When we talk more about birth, and the newborn assessment, if you'll remember these elements of fetal circulation, the kinds of assessments that we do will make so much more sense.

    01:31 So let's review the points to remember.

    01:34 There are two umbilical arteries and one umbilical vein.

    01:40 Oxygen rich blood is carried from the placenta via the umbilical vein, and deoxygenated blood is carried back to the placenta via the umbilical artery.

    01:52 The ductus venosus shunts blood away from the liver.

    01:56 The foramen ovale and the ductus arteriosus shunt blood away from the lungs.

    02:03 The pulmonary system and adult circulation is a relatively low pressure system.

    02:08 But in fetal circulation, the pulmonary system is a high pressure system to help shunt the blood away from the lungs.

    02:17 So now you've got fetal circulation down again, let's talk about what happens when the baby takes their first breath.

    02:24 So after the very first breath, the lungs expand, and all that fluid that was filling up the lungs.

    02:31 Remember, it didn't matter because the baby wasn't breathing oxygen, that placenta took care of all that.

    02:36 All that fluid is going to be pushed out, that's going to allow the lungs to expand, which is ultimately going to decrease the pulmonary resistance.

    02:44 So everything in fetal circulation was geared towards keeping blood flow out of the lungs, because we didn't need it.

    02:50 Now we need to get oxygen to the lungs.

    02:53 So we're going to experience increased pressure in the left atrium.

    02:57 And that increased pressure is going to lead to closure of the foramen ovale.

    03:03 When the court is clamped, we lose the placenta.

    03:06 So that loss of placenta is going to lead to an increase in systemic resistance.

    03:12 And that systemic resistance increase is going to cause the pressure in the right atrium to actually decrease.

    03:20 And so once that happens, that right to left shunt is going to close.

    03:25 And then when we have closure of the right to left shunt, we're going to have increased oxygen levels in pulmonary circulation.

    03:33 This is what we need, because we need more oxygen to come from the lungs.

    03:37 This is all about breathing air, because the placenta is gone.

    03:41 Then we experienced closure of the ductus arteriosus.

    03:45 And that is going to complete that transition to extra uterine breathing.

    03:50 So we've gone from placenta doing all the work to clean us in their lungs doing all the work.

    03:57 Now, let's talk about one of the very first assessments that we will perform on our brand new baby.

    04:02 It's called an APGAR or APGAR Score.

    04:05 The APGAR Score was developed by an anesthesiologist named Virginia Apgar.

    04:10 And she developed this system as a way to really be able to tell when we engage in any sort of infant resuscitation if it's going well or not.

    04:20 But we still use this as a way of really noticing whether the baby is transitioning well to extra uterine life.

    04:26 So the APGAR Score is an assessment of five things: Appearance, pulse, grimace, activity, and respiration.

    04:35 Now, let's break down that APGAR Score.

    04:38 You can see on the vertical axis we have our mnemonic.

    04:42 Appearance, Pulse, Grimace, Activity, and Respirations.

    04:46 And on the horizontal axis, we have the scoring system 0, 1, or 2.

    04:51 So appearance just refers to color.

    04:54 So zero points would be a baby that is blue everywhere.

    04:58 In the central area, hands, feet, ever thing.

    05:01 However, a baby that has acrocyanosis, or maybe just blue hands and feet, but the center part of the baby is pink, then they would receive a score of one.

    05:11 Now, very rarely are babies all the way pink.

    05:14 That's just not typical, but if they were, they would earn a score of two.

    05:20 Pulse stands for the heart rate.

    05:21 If they have a heart rate of zero, they earn zero points.

    05:25 If the heart rate is less than 100 beats per minute, they earn one.

    05:30 If the heart rate is 100 or greater than they earn two points for that.

    05:36 Grimace is not just a purple man from a fast food restaurant.

    05:40 Grimace refers to a response to stimulation or a kind of like a little face like this, can you do that? A grimace that would be a zero point means that if I suction the baby or stimulate the baby, I don't get a face. I don't get anything.

    05:55 The baby just lies limb.

    05:57 If the baby however, does make a slight face, when I suction the baby or use a bulb syringe, then they would earn a point of one.

    06:06 If, however, the baby is crying vigorously, then they earn a score of two.

    06:12 Activity refers to movement.

    06:14 If again, the baby is limp and not moving, they would on a score of zero.

    06:18 If they have some flexion, they move just a little bit, but not really an exciting or aggressive way, then that would be one.

    06:25 And if they're really moving, and kicking, and screaming and moving blankets, then they would clearly get a score of two.

    06:32 And finally respirations.

    06:34 So a baby that makes no respiratory effort at all would earn a score of zero.

    06:39 A baby that has some response and some respiratory effort, but maybe they're using some accessory muscles in order to do so would earn a score of one.

    06:49 And then a baby that is actively crying or breathing well and it's unlabored, then they would earn a score of two.

    06:58 To interpret the APGAR Score, the provider will then add up all the points for each of those assessments.

    07:04 A score of seven or greater will indicate that the baby is transitioning well to extra uterine life.

    07:10 So typically, for this baby that might be doing kangaroo care, this baby will be fine to continue to stay there.

    07:17 A baby on the other hand, that scores a three or less, that baby clearly is having a difficult time transitioning and will absolutely need some supportive assistance in order to breed.

    07:29 Babies that are in the middle will likely also need some support, and they will be watched under the monitor.

    07:34 But hopefully will transition up to a 7, 8, 9, or 10.

    07:40 APGAR Scores are scored at one minute, also at five minutes.

    07:44 And for any babies that are experiencing any sort of difficulty, an APGAR Score may be taken again at 10 minutes.

    07:53 Now, let's practice and see how well you do at calculating APGAR Scores on your own.

    07:58 A neonatal client has a pink color, a pulse rate of 102, a respiratory rate of 27.

    08:07 The baby grimaces in response to stimuli and has limited muscle movement.

    08:13 Think for a minute about what you think that score will be.

    08:17 And if you need to go back and use the APGAR chart in order to calculate your result, feel free to do that.

    08:26 Let's go over our answer.

    08:28 So what we have from the clues here is that we have a baby that's pink in color.

    08:34 So it doesn't mention APGAR cyanosis.

    08:36 So technically, we'd have to go with a 2 for this score.

    08:39 The pulse rate is 102.

    08:42 It's above 100.

    08:43 So we would also give a score of 2 for that.

    08:46 The respiratory rate is 27.

    08:48 Doesn't say anything about any sort of accessory muscles or it being difficult.

    08:53 So let's read further to decide what we're going to give the baby for this respiratory rate.

    08:58 The baby does grimace in response to stimuli but it doesn't sound like it's an aggressive response and the baby has limited muscle movement.

    09:06 So let's go back through. 2 for color 2 for pulse.

    09:11 Based on the rest of our information, we may go with 1 for respiratory rate, 1 in response to stimuli, so the grimace, and limited muscle movement would also be a one.

    09:22 So if we add that together, we have 2, 4, 5, 6, 7 as an APGAR Score.

    09:30 Okay.

    09:33 Let's try a second one.

    09:35 A newly delivered infant has a pink trunk and blue hands and feet.

    09:40 A pulse rate of 60 and does not respond to your attempts to stimulate them.

    09:46 The baby also appears to be limp and taking slow gasping breaths.

    09:51 Think about this one for a minute.

    09:52 It's a little bit more tricky.

    09:58 Okay, let's go through it.

    10:00 So we have a pink trunk and blue hands and feet.

    10:03 So although this part is typical, the baby's still only going to earn a one for this.

    10:08 The pulse rate is 60. So it's less than 100.

    10:12 So the baby only earns a point for that.

    10:15 The baby does not respond to any attempts to stimulation.

    10:18 So, grimace going to be zero for that.

    10:21 The baby also appears to be limp.

    10:23 That's going to be a 0 and taking slow gasping breaths.

    10:27 So there is respiratory effort here.

    10:30 But it's not a solid respiratory effort.

    10:31 So we're going to give a 1 for that.

    10:34 So the APGAR Score for this baby would be a three.

    10:37 How'd you do? Now, I want to talk about one of the most important actions that we perform as the baby transition.

    10:44 And that is skin-to-skin care.

    10:46 Now, maybe you're asking yourself, well, didn't we just do an APGAR Assessment? And that would mean the baby would have to be on the warmer.

    10:53 But that's not true.

    10:54 Unless the baby is experiencing some sort of difficulty, we can do the APGAR Score with the baby in skin-to-skin care.

    11:02 So sometimes this is called kangaroo care.

    11:05 If you've ever seen a little baby kangaroo, and you'll see how close it stays to the mother after it's born, it does that to keep warm.

    11:12 And the same thing works for humans.

    11:14 So, skin-to-skin or kangaroo.

    11:17 And what we would do is we would first dry the infant.

    11:20 We want the baby to be warm.

    11:22 And if you've ever gotten out of the shower or out of the tub, you know it's really cold.

    11:26 What's the first thing you do? You dry off.

    11:28 so we want to dry the baby and then place the baby directly on the parents bare chest not on top of the gown.

    11:36 We want to move the gown and do skin-to-skin care.

    11:39 And that skin-to-skin care should be uninterrupted for one to two hours.

    11:43 Now, of course, if the baby's having any difficulty transitioning, then we're going to need to interrupt that care.

    11:49 But short of that, then we need to have skin-to-skin, uninterrupted.

    11:54 Now, maybe the birthing person can't do the skin-to-skin for some reason.

    11:58 A partner or someone else can.

    12:00 It doesn't matter who that is.

    12:02 But skin-to-skin care is so important.

    12:04 We know that infants that receive skin-to-skin transition easier to extra uterine life.

    12:10 So remember, all those things that had to happen in order for Cletus to take that breath and maintain adult circulation, skin-to-skin makes it happen easier.

    12:19 It helps to stabilize respiration, and glucose, and temperature.

    12:24 It also for clients who are going to chest feed or breastfeed, it makes it easier to do that.

    12:30 They're actually some instinctual things that the baby has that lets them know, "Hey, I'm born. It's time to eat." And they will actually move to the breast, on their own.

    12:41 Also, the birthing person can gain more confidence about just taking care of the baby by holding the baby and being the first one to do so.

    12:49 And sometimes we have found that birthing persons who are allowed to practice skin-to-skin have an easier time transitioning into breastfeeding.

    12:57 So skin-to-skin is so important.

    13:00 Now, I also want to make this point that just because a birthing person does not experience a vaginal delivery is no reason not to initiate skin-to-skin.

    13:08 So even in the operating room skin-to-skin care immediately after delivery is possible and it should be encouraged.


    About the Lecture

    The lecture Newborn Adaptation to Extrauterine Life: Respiration (Nursing) by Jacquelyn McMillian-Bohler is from the course Newborn Assessment (Nursing).


    Included Quiz Questions

    1. To carry oxygenated blood from the placenta to the fetus.
    2. To carry deoxygenated blood back to the placenta.
    3. It shunts blood away from the liver.
    4. To carry deoxygenated blood back to the fetus.
    1. Expansion of lungs
    2. Expulsion of fluid
    3. Increased pressure in the left atrium
    4. Decreased systemic resistance
    5. Decreased pressure in the left atrium
    1. Appearance
    2. Pulse
    3. Grimace
    4. Temperature
    5. Bowel sounds
    1. 3
    2. 2
    3. 1
    4. 4
    5. 8
    1. 6
    2. 3
    3. 4
    4. 7
    1. Also called "kangaroo care"
    2. Stabilizes glucose
    3. Stabilizes respirations
    4. It should be uninterrupted for 4–6 hours
    5. The baby should not breastfeed at this time

    Author of lecture Newborn Adaptation to Extrauterine Life: Respiration (Nursing)

     Jacquelyn McMillian-Bohler

    Jacquelyn McMillian-Bohler


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