- Adaptation to extrauterine life
At the end of
pregnancy, the fetusmust take the journey of childbirthto leave the reproductive femalemother.Upon its entry to the air-breathing world, the newbornmust begin to adjust to life outside the uterus.
Breathing and circulation
Perfusing its body by breathing independently instead of utilizing
placental oxygenis the first challenge of a newborn.With the first breaths, there is a fall in pulmonary vascular resistance, and an increase in the surface area available for gas exchange. At the same time that the pulmonary vascular resistance drops there is a corresponding increase in systemic vascular resistance ( total peripheral resistance) due to the loss of the low-resistance placental circulation. These two changes result in a rapid redirection of blood flow into the pulmonary vascular bed, from approximately 4% to 100% of cardiac output. This in turn leads to an increase in oxygenation of the blood. The increase in pulmonary venous return results in left atrial pressure being slightly higher than right atrial pressure, which closes the "foramen ovale". The flow pattern changes results in a drop in blood flow across the " ductus arteriosus" and the higher blood oxygen content stimulates the constriction and ultimately the closure of this fetal circulatory shunt.
All of these
cardiovascular systemchanges result in the adaptation from fetal circulation patterns to an adultcirculation pattern. During this transition, some types of congenital heart disease that were not symptomatic " in utero" during fetal circulation will present with cyanosisor respiratory signs.
Following birth, the expression and re-uptake of
surfactant, which begins to be produced by the fetus at 20 weeks gestation, is accelerated. Expression of surfactant into the alveoli is necessary to prevent alveolar closure ( atelectasis). At this point, rhythmic breathing movements also commence. If there are any problems with breathing, management can include stimulation, bag and mask ventilation, intubationand ventilation. Cardiorespiratory monitoring is essential to keeping track of potential problems. Pharmacologicaltherapy such as caffeinecan also be given to increase heart rate.A positive airway pressure should be maintained, and neonatal sepsismust be ruled out.
Potential neonatal respiratory problems include
apnea, transient tachypnea of the newborn(TTNB), respiratory distress syndrome(RDS), meconium aspiration syndrome(MAS), airway obstruction, and pneumonia.
Energy metabolism in the
fetusmust be converted from a continuous placental supply of glucoseto intermittent feeding.While the fetus is dependent on maternal glucose as the main source of energy, it can use lactate, free-fatty acids, and ketone bodies under some conditions.Plasma glucose is maintained by glycogenolysis. Glycogen synthesisin the liverand musclebegins in the late second trimesterof pregnancy, and storage is completed in the third trimester. Glycogenstores are maximal at term, but even then, the fetus only has enough glycogen available to meet energy needs for 8-10 hours, which can be depleted even more quickly if demand is high. Newborns will then rely on gluconeogenesisfor energy, which requires integration, and is normal at 2-4 days of life. Fatstores are the largest storage source of energy.At 27 weeks gestation, only 1% of a fetus' body weight is fat.At 40 weeks, that number increases to 16%.
glucosesubstrate can lead to hypoglycemia, fetal growth restriction, preterm delivery, or other problems.Similarly, excess substrate can lead to problems, such as infant of a diabetic mother(IDM), hypothermiaor neonatal sepsis.
Anticipating potential problems is the key to managing most neonatal problems of energy metabolism.For example, early feeding in the delivery room or as soon as possible may prevent
hypoglycemia.If the blood glucoseis still low, then an intravenous(IV) bolus of glucose may be delivered, with continuous infusion if necessary.Rarely, steroids or glucagonmay have to be employed.
Newborns come from a warm environment to the cold and fluctuating temperatures of this world.They are naked, wet, and have a large surface area to mass ratio, with variable amounts of insulation, limited metabolic reserves, and a decreased ability to
shiver. Physiologic mechanisms for preserving core temperature include vasoconstriction (decrease blood flow to the skin), maintaining the fetal position (decrease the surface area exposed to the environment), jittery large muscle activity (generate muscular heat), and "non-shivering thermogenesis". The latter occurs in "brown fat" which is specialized adipose tissue with a high concentration of mitochondria designed to rapidly oxidize fatty acids in order to generate metabolic heat. The newborn capacity to maintain these mechanisms is limited, especially in premature infants. As such, it is not surprising that some newborns may have problems regulating their temperature.As early as the 1880s, infant incubators were used to help newborns maintain warmth, with humidified incubators being used as early as the 1930s.
Basic techniques for keeping newborns warm include keeping them dry, wrapping them in blankets, giving them hats and clothing, or increasing the ambient temperature.More advanced techniques include
incubators (at 36.5°C), humidity, heat shields, thermal blankets, double-walled incubators, and radiant warmers.
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