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A CASE ANALYSIS OF

PROBLEMS RELATED TO MATURITY

&

PROBLEMS RELATED TO GESTATIONAL WEIGHT

In Partial Fulfillment

Of the Requirements in the Subject:

NCM 109

Care for the Mother, Child at Risk or with Problems

(Acute and Chronic)

Submitted to:

Girlie De Luna Tayao, MAN, RN

Instructor

Submitted by:

Pangilinan, Shane G.

BSN 2-E
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Care of At-Risk/ High Risk and Sick Child

Problems related to Maturity

I. Prematurity

II. Post maturity

Problems related to Gestational Weight

III. Small for Gestational Age (SGA)

IV. Large for Gestational Age (LGA)

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PREMATURITY

A. DEFINITION

A baby born before 37 weeks of pregnancy is considered premature, that is, born before

complete maturity. Other terms often used for prematurity are preterm and "preemie."

Those babies born between 34 and 36 weeks are known as late preterm births. Babies

born between 32 and 33 weeks are known as moderately preterm. The very littlest babies are

born between 28 and 31 weeks, and even some at less than 28 weeks. These are known as very

preterm babies.

Premature babies, especially those born very early, often have complicated medical

problems. Typically, complications of prematurity vary. But the earlier the baby is born, the higher

the risk of complications.

B. RISK FACTORS

There are some known risk factors for premature birth based on factors affecting the

mother:

• Carrying more than one baby (twins, triplets, quadruplets or more).

• Having a previous preterm birth.

• Problems with the uterus or cervix.

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• Chronic health problems in the mother, such as high blood pressure, diabetes, and clotting

disorders.

• Certain infections during pregnancy.

• Cigarette smoking, alcohol use, or illicit drug use during pregnancy.

In more than 40% of the cases, doctors do not know why the baby was born premature.

C. CLINICAL MANIFESTATIONS

I. Signs and Symptoms:

• A preterm infant at 28 weeks’ gestation has a small amount of ear cartilage and/or a flattened

pinna

• A preterm infant at 33 weeks’ gestation has only an anterior crease on the sole of the foot

• A preterm infant at 28 weeks’ gestation has no breast tissue, and the areolae are barely visible)

• Genitals may be small and underdeveloped

• Small size, with a disproportionately large head

• Sharper looking, less rounded features than a full-term baby's features, due to a lack of fat stores

• Fine hair (lanugo) covering much of the body

• Low body temperature, especially immediately after birth in the delivery room, due to a lack of

stored body fat

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• Labored breathing or respiratory distress

• Lack of reflexes for sucking and swallowing, leading to feeding difficulties

D. PATHOPHYSIOLOGY

Fetus
Placenta Mother

Maternal circulation contains

Waste products of more substrate (e.g. blood
Each of the fetal metabolism 1. Provision of metabolically glucose) than the fetal
immature (e.g. heat, bilirubin, all the nutrients active and circulation
organs carbon dioxide) for growth consumes glucose

2. Elimination of
functional Promote
fetal waste acts as a barrier to infection eliminated by the
limitations. fetal growth
products through mucosal macrophages mother's excretory
and by allowing transfer of organs (i. e, liver, lung,
maternal immunoglobulins to kidneys, skin).
3. Synthesis of all the fetus beginning at 32-34
the hormones
weeks' gestation
for growth

Placental
dysfunction

Before birth, the placenta serves three major roles for the fetus: provision of all the nutrients

for growth, elimination of fetal waste products, and synthesis of hormones that promote fetal growth.

With the exception of most electrolytes, the maternal circulation contains more substrate (e.g.,

blood glucose) than the fetal circulation. In addition, the placenta is metabolically active and

consumes glucose. Waste products of fetal metabolism (e.g., heat, urea, bilirubin, carbon dioxide) are

transferred across the placenta and eliminated by the mother's excretory organs (i.e., liver, lung,

kidneys, skin).
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In addition, the placenta acts as a barrier to infection through mucosal macrophages and by

allowing transfer of maternal immunoglobulins (immunoglobulins such as immunoglobulin G [IgG])

to the fetus beginning at 32-34 weeks' gestation. Placental dysfunction is involved in the transfer of

IgG. Antibacterial activity of the amniotic fluid improves as gestational age advances.

Each of the immature organs of a premature infant has functional limitations. The tasks of

caregivers in neonatal intensive care units (NICUs) are to recognize and monitor the needs of each

infant and to provide appropriate support until functional maturity can be achieved.

E. NURSING CARE

Premature babies usually need care in a special nursery called the Neonatal Intensive Care Unit

(NICU). The NICU combines advanced technology and trained health professionals to provide

specialized care for the tiniest patients. The NICU team is led by a neonatologist, who is a pediatrician

with additional training in the care of sick and premature babies.

The baby will be placed in an incubator that's kept warm to help the baby maintain normal

body temperature. Later on, a method of caring known as “kangaroo” care for premature babies using

skin-to-skin contact with the parent to aid parent-infant bonding.

Monitoring of the baby's vital signs. Sensors may be taped to the baby's body to monitor blood

pressure, heart rate, breathing and temperature. A ventilator may be used to help the baby breathe.

Having a feeding tube. At first the baby may receive fluids and nutrients through an intravenous (IV)

tube. Breast milk may be given later through a tube passed through the baby's nose and into his or her

stomach (nasogastric, or NG, tube).

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When the baby is strong enough to suck, breast-feeding or bottle-feeding is often possible. The

baby needs a certain amount of fluids each day, depending upon his or her age and medical

conditions. The NICU team will closely monitor fluids, sodium and potassium levels to make sure that

the baby's fluid levels stay on target. If fluids are needed, they'll be delivered through an IV line.

Spending time under bilirubin lights. To treat infant jaundice, the baby may be placed under a

set of lights — known as bilirubin lights — for a period of time. The lights help the baby's system

break down excess bilirubin, which builds up because the liver can't process it all. While under the

bilirubin lights, the baby will wear a protective eye mask to rest more comfortably.

Receiving a blood transfusion. The preterm baby may need a blood transfusion to raise blood

volume — especially if the baby has had several blood samples drawn for various tests.

F. PHARMACOLOGICAL MANAGEMENT

Medications may be given to the baby to promote maturing and to stimulate normal

functioning of the lungs, heart and circulation. Depending on the baby's condition, medication may

include:

• Surfactant, a medication used to treat respiratory distress syndrome

• Fine-mist (aerosolized) or IV medication to strengthen breathing and heart rate

• Antibiotics if infection is present or if there's a risk of possible infection

• Medicines that increase urine output (diuretics) to manage excess fluid

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• An injection of medication into the eye to stop the growth of new blood vessels that could cause

retinopathy of prematurity

• Medicine that helps close the heart defect known as patent ductus arteriosus

G. MEDICAL AND SURGICAL MANAGEMENT

For those babies who were born very early and may have continuing problems, there are

different treatment options available such as early intervention, therapy, medications, surgery,

education, and support.

Some of the medical management options that are used for complications of prematurity

includes:

 Blood transfusions to treat anemia or jaundice

 Surfactant and oxygen treatments to help prevent lung damage

 Equipment such as monitors and incubators to help warming and breathing

Some of the surgical treatment options that are used for complications of prematurity include:

 Inserting a tube into the brain to reduce fluid build-up in the case of bleeding

 Surgery to close the ductus artery to prevent heart failure

 Surgery to remove damage sections of the intestine in cases of severe enterocolitis

 Laser surgery or cryotherapy (freezing) to preserve vision in cases of severe retinopathy

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QUESTIONS

1. The nurse observes a neonate delivered at 28 weeks' gestation. Which finding would

the nurse expect to see?

a. The pinna of the ear is soft and flat and stays folded.

b. The neonate has 7 to 10 mm of breast tissue.

c. The skin is pale, and no vessels show through it.

d. Creases appear on the interior two-thirds of the sole.

2. A premature infant with respiratory distress syndrome receives artificial surfactant.

How would the nurse explain surfactant therapy to the parents?

a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and

carbon dioxide."

b. "The drug keeps your baby from requiring too much sedation."

c. "Surfactant is used to reduce episodes of periodic apnea."

d. "Your baby needs this medication to fight a possible respiratory tract infection."
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3. Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal

mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of

premature infants succumb to this fatal disease. Care is supportive; however, known

interventions may decrease the risk of NEC. To develop an optimal plan of care for this

infant, the nurse must understand which intervention has the greatest effect on

lowering the risk of NEC:

a. Early enteral feedings

b. Breastfeeding

c. Exchange transfusion

d. Prophylactic probiotics
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REFERENCES

Callaghan, F. & Piaggio, U. (2018, August 16) The preterm Infant. Retrieved from

https://teachmepaediatrics.com/neonatology/prematurity/preterm-infant/

Furdon et al., (2017, October 13). Prematurity. Retrieved from

https://emedicine.medscape.com/article/975909-overview

Mayo Foundation for Medical Education and Research (2017, December 21). Premature birth.

Retrieved from https://www.mayoclinic.org/diseases-conditions/premature-

birth/symptoms-causes/syc-20376730

Rice, S. C. (2016, November 6). Premature Infant. Retrieved from

https://www.healthline.com/health/pregnancy/premature-infant
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POST MATURITY

A. DEFINITION

A postmature newborn is delivered after more than 42 weeks in the uterus. Post term fetuses

usually continue to grow after the due date, so they have a greater chance of developing complications

related to larger body size and macrosomia (macrosomia is defined as a baby weighing more than

4500 grams, or approximately 10 pounds). Some post term fetuses stop gaining weight after the due

date, usually due to a problem with delivery of blood to the fetus through the placenta, leading to

malnourishment.

These infants have a distinctive appearance. Their arms and legs may be long and thin. The

skin may appear dry and parchment-like, with peeling and sometimes meconium staining. The skin

may appear loose, especially over the thighs and buttocks. Scalp hair may be longer or thicker, and the

fingernails and toenails may be long. They are typically very alert, and may have a "wide-eyed" look.

B. RISK FACTORS

In inaccurate dating based on the last menstrual period is the most common cause of post term

pregnancy. Sometimes a mother’s pregnancy due date is off because she is not sure of her last

menstrual period. Getting the date wrong may mean the baby is born earlier or later than expected.

In accurately dated pregnancies, the cause of post term pregnancy is usually unknown.

There are some risk factors that include:

 Primigravid
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 Male baby

 Older mother

 Mother or father personal history of post maturity

 BMI > 35.7

C. CLINICAL MANIFESTATIONS

I. Signs and Symptoms

Symptoms

• When post-mature the neonate has lower than normal amounts of subcutaneous fat and reduced

mass of soft tissue.

• The skin may be loose, flaky and dry.

• Fingernails and toenails may be longer than usual and stained yellow from meconium.

Signs

• Before delivery there may be reduced fetal movement.

• A reduced volume of amniotic fluid may cause a reduction in the size of the uterus.

• Meconium-stained amniotic fluid may be seen when the membranes have ruptured.
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D. PATHOPHYSIOLOGY

Fetus

receives inadequate
nutrients and oxygen
from the mother

thin (due to soft-tissue undernourished infant decreased amniotic

wasting), with depleted glycogen fluid volume
stores

In most cases, fetal growth continues until delivery. However, in some cases, the placenta

involutes as pregnancy progresses and multiple infarcts and villous degeneration develop, causing

placental insufficiency. In these cases, the fetus receives inadequate nutrients and oxygen from the

mother, resulting in a thin (due to soft-tissue wasting), undernourished infant with depleted glycogen

stores and decreased amniotic fluid volume. Such infants are dysmature and, depending on when

placental insufficiency develops and the severity of the condition, they may be small-for-gestational-

age. Although placental insufficiency with dysmaturity can occur at any gestational age, it is most

common in pregnancies that progress beyond 41 to 42 weeks.

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E. NURSING CARE

Special care of the post-term baby may include:

Checking for breathing problems caused by baby’s breathing in fluid containing the first stools

(meconium). Postmature newborns who experience low oxygen levels and fetal distress may need

resuscitation at birth.

If these problems do not occur, the major goal is to provide good nutrition so that postmature

newborns can catch up to the weight that is appropriate for them.

F. PHARMACOLOGICAL MANAGEMENT

 Endotracheal intubation should be reserved for infants who need ventilatory assistance.

Infants with meconium aspiration syndrome may require assisted ventilation; high-frequency

ventilation is sometimes helpful. Sedation is often necessary.

 Surfactant treatment does not decrease overall mortality but does reduce the likelihood of the

need for treatment with extracorporeal membrane oxygenation (ECMO), so surfactant is

frequently used in infants with significant respiratory distress.

 Persistent pulmonary hypertension is treated with supportive therapies and inhaled nitric

oxide or other pulmonary vasodilators.

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G. MEDICAL AND SURGICAL MANAGEMENT

In most cases, a health care provider will recommend tests on the fetus if the pregnancy

extends beyond the due date. These tests give information about the health of the fetus and about the

risks of allowing the pregnancy to continue.

These tests are begun at or beyond 41 weeks of gestation. Many experts recommend twice

weekly testing, including a measurement of amniotic fluid volume. Testing may include observing the

fetus's heart rate using a fetal monitor, called a nonstress test or observing the baby's activity with

ultrasound called a biophysical profile.

Postmature and dysmature infants are at risk of hypoglycemia and should be monitored and

managed accordingly.

For infants with perinatal asphyxia, management depends on the severity of the disease

process. Therapeutic hypothermia may help infants with moderate or severe encephalopathy who

had severe acidosis at birth, a low Apgar score at ≥ 5 minutes, and/or a need for prolonged

resuscitation.
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QUESTIONS

1. A woman who has given birth to a post term newborn asks the nurse why her

baby looks so thin, with so little muscle. The nurse responds based on the

understanding about which of the following?

a. The newborn was exposed to an infection while in utero.

b. The newborn aspirated meconium, causing the wasted appearance.

c. A post term newborn has begun to break down red blood cells more

quickly.

d. With post term birth, the fetus uses stored nutrients to stay alive, and

wasting occurs.

2. A nurse completes the initial assessment of a newborn. According to the due date

on the antenatal record, the baby is 12 days postmature. Which of the following

physical findings does not confirm that this newborn is 12 days postmature?

a. Increased amounts of vernix.

b. Absence of lanugo.

c. Meconium aspiration.

d. Hypoglycemia.
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3. A macrosomic infant is born after a difficult forceps-assisted delivery. After

stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6

ounces). The nurse's most appropriate action is to:

a. Leave the infant in the room with the mother.

b. Take the infant immediately to the nursery.

c. Perform a gestational age assessment to determine whether the infant is large

for gestational age.

d. Monitor blood glucose levels frequently and observe closely for signs of

hypoglycemia.
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REFERENCES

Norwitz, E.R. (2020, December 16) Patient education: Postterm pregnancy (Beyond the

Basics). Retrieved from https://www.uptodate.com/contents/postterm-pregnancy-beyond-the-

basics#:~:text=Although%20pregnancy%20is%20said%20to,last%20menstrual%20period

%20(LMP)

Standford Children’s Health. (n.d.) Postmaturity in the Newborn. Retrieved from

https://www.stanfordchildrens.org/en/topic/default?id=postmaturity-in-the-newborn-90-P02399

Stavis, R.L. (2019, July) Postterm and Postmature Infants. Retrieved from

https://www.msdmanuals.com/professional/pediatrics/perinatal-problems/postterm-and-

postmature-infants
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SMALL FOR GESTATIONAL AGE

A. DEFINITION

Small for gestational age is a term used to describe babies who are smaller than number for the

number of weeks of pregnancy. These babies have birth weight below the 10th percentile. This means

they are smaller than many other babies of the same gestational age. Many babies normally weigh

more than 5 pounds, 13 ounces by the 37th week of pregnancy. Babies born weighing less than 5

pounds, 8 ounces are considered low birth weight.

Most newborns who are moderately small for gestational age are normal babies who just

happen to be on the smaller side. However, some have had their growth restricted by various factors.

Growth restriction can be classified as:

Symmetric: The newborn is proportionately small, that is, its weight, length, and head size are

similarly low or small.

Asymmetric: Only weight is affected.

In symmetric growth restriction, the cause probably occurred early in the pregnancy when it

would affect all of the cells in the newborn’s body. Asymmetric growth restriction probably results

from problems that occur later in pregnancy because some tissues develop sooner than others and

not all would be affected equally.

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B. RISK FACTORS

Risk factors for growth restriction include those involving the mother’s underlying health, and

those involving the pregnancy and/or the fetus.

Maternal risk factors

The risk of having a small-for-gestational-age (SGA) baby is increased for mothers who are

very young or very old or who have had other SGA babies.

Pregnancy risk factors

• Having more than one fetus, for example, twins or triplets (Twins grow at the same rate as single

fetuses until about 32 weeks. After that, twins grow more slowly and may be SGA at birth. For triplets,

slower growth begins at about 28 weeks.)

• Use of assisted reproduction to conceive the pregnancy

• Preeclampsia

• Early separation of the placenta (placental abruption)

• Use of alcohol or cigarettes

• Use of certain drugs such as amphetamines, anticonvulsants, certain cancer drugs, cocaine, or

opioids

• Severe malnutrition
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Fetal risk factors

• Birth defects that involve the brain, heart, or kidneys

• Certain infections in the fetus, including Zika virus, cytomegalovirus (CMV), or rubella (German

measles)

• Genetic abnormalities, such as trisomy

C. CLINICAL MANIFESTATION

I. Signs and Symptoms

Small for gestational age babies may look mature, but they are smaller than other babies of the

same gestational age. They may be small all over. Or they may be of normal length and size but have

lower weight and body mass.

Many small for gestational age babies have low birth weight. But not all are premature. They

may not have the same problems as premature babies. Other babies, especially those with

intrauterine growth restriction, may look thin and pale, and have loose, dry skin. The umbilical cord is

often thin and dull-looking rather than shiny and fat.

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D. PATHOPHYSIOLOGY

Fetus

Increase the chance redirects blood Total body fat, lean reduced muscle
of survival flow from less mass, and bone mass lower fetal plasma
vital organs and mineral content are glucose and insulin
placenta reduced, concentrations.
reducing its overall
size
nitrogen and protein
content are lower
the brain, heart, resulting in a wasted
preserving brain glycogen content is
adrenal glands, appearance in infants
growth decreased in skeletal
and placenta with severe SGA
muscle and liver

increasing red
blood cell
production

accelerating lung
maturation

In SGA, the nutrient supply to the fetus is compromised. The fetus, in order to increase its

chance of survival, responds by reducing its overall size, preserving brain growth, accelerating lung

maturation, and increasing red blood cell production. The fetus redirects blood flow from less vital

organs to the brain, heart, adrenal glands, and placenta. Total body fat, lean mass, and bone mineral

content are reduced, resulting in a wasted appearance in infants with severe SGA. Nitrogen and

protein content are lower because of reduced muscle mass. Glycogen content is decreased in skeletal

muscle and liver because of lower fetal plasma glucose and insulin concentrations.
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E. NURSING CARE

Nursing Management includes:

• Provide adequate fluid and electrolytes and nutrition.

• Provide a high calorie formula for feeding to promote steady weight gain.

• Provide small frequent feedings.

• Provide a neutral thermal environment.

• Decrease iatrogenic stimuli.

• Monitor glucose screening.

• Provide early feedings.

• Provide frequent feedings (every 2 to 3 hours)

• Administer IV glucose if blood sugar does not normalize with oral feedings.

• Maintain a neutral thermal environment.

• Monitor serum hematocrit (normal is 45% to 65%).

• If an initial high hematocrit was obtained by heel stick capillary sample, a follow-up sample should

be done by venipuncture.

• Observe for signs, symptoms, and complications of polycythemia

• Provide adequate hydration to prevent hyper viscosity

• Assess the prenatal history for possible toxoplasmosis, rubella, cytomegalovirus, and herpes

simplex infections during pregnancy. Assess maternal and infant antibody titers. Use isolation

precautions when congenital infections are suspected.

• Provide education and emotional support.

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• Explain the possible causes of intrauterine growth retardation.

• Inform parents of the infant’s goal weight for discharge.

• Provide instruction on managing the infant at home.

• Explain how to prepare a higher calorie formula or breast feeding.

The nurses will ensure that patient’s vital signs are monitored and also will assist in providing

education to the parents and family members. Infants needing extensive monitoring are admitted to

the neonatal intensive care units.

F. PHARMACOLOGICAL MANAGEMENT

There is no specific treatment for small-for-gestational-age newborns, but underlying

conditions and complications are treated as needed. Growth hormone injections are sometimes given

to certain SGA infants who remain quite small at 2 to 4 years of age. This treatment must be given for

several years and must be considered on a case-by-case basis.

Newborns with polycythemia are given intravenous (IV) fluids, and newborns with

hypoglycemia are treated with frequent feedings or IV glucose.

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G. MEDICAL AND SURGICAL MANAGEMENT

Once SGA has been detected, the management of the pregnancy should depend on a surveillance

plan that maximizes gestational age while minimizing the risks of neonatal morbidity and mortality.

This should include steroid administration when at all feasible, based on the monitoring and delivery

strategies discussed below. Fetal lung maturity studies by amniocentesis, in fetuses greater than 34

weeks’, may additionally influence delivery timing.

At birth

• Infants with severe SGA, particularly in association with fetal distress, are at risk of meconium

aspiration syndrome, hypoxemia, hypotension, mixed metabolic and respiratory acidosis and

persistent pulmonary hypertension.

Hypothermia

• Nurse in a thermoneutral environment.

Hypoglycemia

• Monitor blood glucose.

• Commence early enteral feeds or intravenous glucose infusion.

Necrotizing enterocolitis (NEC)

• Infants, particularly preterm SGA, found to have placental insufficiency and abnormal umbilical

artery Doppler studies may be at particular risk of developing NEC or gastrointestinal perforation.
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• Enteral feeding should be increased gradually.

Polycythemia

• Partial volume exchange may be required for symptomatic infants.

Babies with SGA may be physically more mature than their small size indicates. But they may

be weak and less able to tolerate large feedings or to stay warm. Treatment of the SGA baby may

include:

 Temperature controlled beds or incubators

 Tube feedings (if the baby does not have a strong suck)

 Checking for hypoglycemia (low blood sugar) through blood tests

 Monitoring of oxygen levels

Babies who are SGA and are also premature may have additional needs including oxygen and

mechanical help to breathe. They may need oxygen and a breathing machine (ventilator).
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QUESTIONS

1. The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent
which of the following?

a. Asphyxia
b. Meconium aspiration
c. Hypoglycemia
d. Polycythemia
e. Hypoglycemia

2. The small-for-gestation neonate is at increased risk for which complication during the
transitional period?

a. Hyperthermia due to decreased glycogen stores

b. Polycythemia probably due to chronic fetal hypoxia
c. Hyperglycemia due to decreased glycogen stores
d. Anemia probably due to chronic fetal hypoxia

3. A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant
is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is
microcephalic. On the basis of her infant's physical findings, this woman should be questioned
about her use of which substance during pregnancy?

a. Alcohol
b. Cocaine
c. Heroin
d. Marijuana
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REFERENCES

Ministry of Health Malaysia. (2017, October 31). Small for Gestational Age (SGA). Retrieved

from http://www.myhealth.gov.my/en/small-for-gestational-age-sga/

Standford Children’s Health. (n.d.) Small for Gestational Age. Retrieved from

https://www.stanfordchildrens.org/en/topic/default?id=small-for-gestational-age-90-P02411

University of Rochester Medical Center Rochester, NY (n.d.) Small for Gestational Age. Retrieved

from https://www.urmc.rochester.edu/encyclopedia/content.aspx?

ContentTypeID=90&ContentID=P02411
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LARGE FOR GESTATIONAL AGE

A. DEFINITION

Large for gestational age (LGA) is used to describe newborn babies who weigh more than usual

for the number of weeks of pregnancy. Babies may be called large for gestational age if they weigh

more than 9 in 10 babies (90th percentile) or more than 97 of 100 babies (97th percentile) of the

same gestational age. Babies born earlier than 40 weeks are considered LGA at lighter weights. Babies

born after 40 weeks are considered LGA at slightly higher weights.

B. RISK FACTORS

Maternal Diabetes

One of the primary risk factors of LGA is poorly-controlled maternal diabetes, particularly

gestational diabetes (GD), as well as preexisting diabetes mellitus (DM) (preexisting type 2 is

associated more with macrosomia, while preexisting type 1 can be associated with microsomia).The

risk of having a macrosomic fetus is three times greater in mothers with diabetes than those without

diabetes.] DM increases maternal plasma glucose levels as well as insulin, stimulating fetal growth of

subcutaneous fat. The LGA newborn exposed to maternal DM usually only has an increase in weight,

not a change in body length or head size.

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Genetics

Genetics plays a role in having an LGA baby. Taller, heavier parents tend to have larger babies.

Genetic disorders of overgrowth (e.g. Beckwith–Wiedemann syndrome, Sotos syndrome, Perlman

syndrome, Simpson-Golabi-Behmel syndrome) are often characterized by macrosomia.

Other risk factors:

Gestational age: pregnancies that go beyond 40 weeks increase incidence of an LGA infant

Fetal sex: male infants tend to weigh more than female infants

Obesity prior to pregnancy and maternal weight gain above recommended guidelines during

pregnancy

Multiparity: giving birth to previous LGA infants vs. non-LGA infants

Frozen embryo transfer as fertility treatment, as compared with fresh embryo transfer or no artificial

assistance

B. CLINICAL MANIFESTATION

Clinical manifestations include:

 Complications associated with maternal diabetes

 Birth injuries due to disproportionate size of newborn to birth passageway

 Fractured clavicle

 Facial nerve injury

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 Erb-Duchenne palsy or brachial plexus paralysis

 Klumpke paralysis

 Phrenic nerve palsy

 Possible skull fracture

Signs and Symptoms:

Symptoms of LGA can be difficult to detect and diagnose during pregnancy. The primary sign

for babies born large for gestational age is that their weight is more than 9 in 10 babies or 97 of 100

babies born at the same gestational age. A larger than usual fundal height of the fetus is a sign of LGA

baby. Presence of more than expected amniotic fluid is also a sign that your baby may be larger than

average. LGA babies, when born at 40 weeks of gestation, weigh more than 4000 grams or 9 pounds at

birth, which is higher than average.

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C. PATHOPHYSIOLOGY

Large for
Gestational
Age Infant

overproduction of
growth hormone
in utero

diabetic mothers multiparous

who are poorly pregnancies
controlled

with each
pregnancy tend to
grow larger

transposition of Beckwith congenital

the great vessels, syndrome anomalies

Infants who are large for gestational age have been subjected to an overproduction of growth

hormone in utero. This most frequently happens with infants of diabetic mothers who are poorly

controlled. It may also occur in multiparous pregnancies because with each pregnancy babies tend to

grow larger.

Other associated conditions include transposition of the great vessels, Beckwith syndrome and

congenital anomalies
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D. NURSING CARE

 If IDM, observe for potential complications

 Monitor for, and manage, birth injuries and complications of birth injuries.

 Assess the infant for crepitus, hematoma, or deformity over the clavicle; decreased movement

of arm on the affected side; and asymmetrical or absent.

 Limit arm motion by pinning the infant’s sleeve to the shirt.

 Manage the pain

 Assess for symmetry of mouth while crying.

 Assess for adduction of the affected arm with internal rotation and elbow extension. The Moro

reflex is absent on the affected side. The grasp reflex is intact.

 Klumpke paralysis. Assess for absent grasp on the affected side. The hand appears claw-

shaped.

Management includes:

 X-ray studies of the shoulder and upper arm to rule out bony injury

 Examination of the chest to rule out phrenic nerve injury

 Delay of passive movement to maintain range of motion of the affected joints until the nerve

edema resolves (7 to 10 days)

 Splints may be useful to prevent wrist and digit contractures on the affected side

 Assess for respiratory distress with diminished breath sounds.

 Provide pulmonary toilet to avoid pneumonia during the recovery phase (1 to 3 months).
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 Assess for soft-tissue swelling over fracture site, visible indentation in scalp,

cephalohematoma, positive skull x-ray, and CNS signs with intracranial hemorrhage (e.g.,

lethargy, seizures, apnea, and hypotonia).

E. PHARMACOLOGICAL MANAGEMENT

There is no specific treatment for large-for-gestational-age newborns, but underlying

conditions and complications are treated as needed.

Newborns with polycythemia are given intravenous fluids. If the polycythemia is severe, the

physician may remove some blood and replace it with plasma (partial exchange transfusion), which

dilutes the remaining red blood cells.

Newborns with hypoglycemia are treated with frequent feedings, or sometimes are given

glucose by vein.

Respiratory distress and meconium aspiration are treated with supplemental oxygen or other

supportive devices such as continuous positive airway pressure (CPAP—a technique allows newborns

to breathe on their own while being given slightly pressurized oxygen) or a mechanical ventilator,

depending on the severity of the problem.

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F. MEDICAL AND SURGICAL MANAGEMENT

Prenatal care is important in all pregnancies, especially to monitor fetal growth when a baby

seems to be too small or too large. Examinations during pregnancy that show a large baby can help

identify a mother who may have undetected diabetes, or other problems. Careful management of

diabetes and proper weight gain, according to your doctor's recommendations, can help lower some

of the risks to the baby.

Specific treatment is based on the baby’s condition and needs. Basically, an LGA baby would

need:

 Checking for birth defects / birth injuries

 Monitoring of blood glucose

 Early and frequent feeding

Some babies may require admission to the neonatal ward for:

 Intravenous fluids / dextrose (fluids given into the veins)

 Respiratory support

 Blood exchange

 Phototherapy

 Physiotherapy
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QUESTIONS

1. The nurse weighs the new infant and calculates his measurements. The new
mom asks, "Did my baby grow well? The doctor said he was LGA: What does that
mean?" What is the best explanation?

a. "That means your baby is over the 90th percentile for weight."
b. "That means your baby is in the 5th percentile for weight."
c. "That means that your baby is lazy sometimes."
d. "That means your baby is average for gestational age."

2. A client with diabetes delivers a full-term neonate who weighs 10 lb., 1 oz (4.6
kg). While caring for this large-for-gestational age (LGA) neonate, the nurse
palpates the clavicles for which reason?

a. Clavicles are commonly absent in neonates of mothers with diabetes.

b. Neonates of mothers with diabetes have brittle bones.
c. LGA neonates have glucose deposits on their clavicles.
d. One of the neonate's clavicles may have been broken during delivery.

3. When reviewing the medical record of a newborn who is large for gestational age

(LGA), which of the following factors would the nurse identify as having

increased the newborn’s risk for being LGA?

a. Fetal exposure to low estrogen levels

b. Low weight gain during pregnancy
c. Maternal pregravid obesity
d. Low maternal birth weight
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REFERENCES:

Ratnam, G. (2020, September 18) Large for Gestational Age Babies – Causes, Symptoms, and

Treatment. Retrieved from https://parenting.firstcry.com/articles/large-for-gestational-age-babies-

causes-symptoms-and-treatment/

Stavis, R.L. (2019, June). Large-for-Gestational-Age (LGA) Newborn. Retrieved from

https://www.msdmanuals.com/home/children-s-health-issues/general-problems-in-

newborns/large-for-gestational-age-lga-newborn

University of Rochester Medical Center Rochester, NY (n.d.) Large for Gestational Age. Retrieved from

https://www.urmc.rochester.edu/encyclopedia/content.aspx?

ContentTypeID=90&ContentID=P02383#:~:text=Large%20for%20gestational%20age%20(LGA)

%20is%20used%20to%20describe%20newborn,of%20the%20same%20gestational%20age