Breastfeeding/Pain/High Risk Newborn Flashcards
1
Q
When should you exclusively breastfeed? When can you introduce solids? When should breastfeeding continue until?
A
Exclusive breastfeeding for first six months
Introduction of solids and other fluids at six months
Continued breastfeeding until at least 12 months
2
Q
What are the baby benefits of breastfeeding?
A
Less- GI problems, SIDS, allergies/asthma, diabetes, childhood cancers, obesity, infections
Better cognitive development, higher IQ
3
Q
What are the mother benefits of breastfeeding?
A
Promotes uterine involution, decreased risk of postpartum hemorrhage, enhanced pregnancy weight loss, bonding, decreased risk of breast cancer, decreased stress
4
Q
What are the mother financial of breastfeeding?
A
Save on average $400/year for infant medical costs
Cost of formula, bottles, etc.– On average $3-5/day for formula
5
Q
When milk is produced what occurs in the breast?
A
Breast divided into 15–20 lobes which are separated by fat, connective tissue
6
Q
What occurs r/t estrogen, progesterone, and prolactin after delivery?
A
After delivery sudden drop in estrogen and progesterone –> stimulate secretion of prolactin from anterior pituitary and breast milk is produced
7
Q
What is the role of oxytocin r/t milk production?
A
secreted by posterior pituitary and responsible for milk ejection, “Let down”
8
Q
What is the difference between casein and whey proteins?
A
Whey predominant protein in human milk
60:40 whey/casein ratio
Easily digested
More frequent feedings
Casein predominant in cow milk
20:80 whey/casein ratio
Less easily digested, forms curds
9
Q
What vitamins are in breast milk?
A
Fat soluble – A, D, E, K
Water soluble - Bs, C
10
Q
What is breast milk made of?
A
Fats (50% of calories)
Immunoglobulins - prevent infection
Vitamins
Carbs (40% of calories) - lactose
11
Q
What is the primary carbs in formula?
A
Lactose
Lactose/corn maltodextrin
12
Q
In lactogenesis stage I what kind of milk is made? What does it look like? How long is it produced for? When is production started?
A
Colostrum - liquid gold
Clear yellowish fluid
First 3-4 days
Production begins in mid pregnancy
13
Q
What does colostrum do for the baby?
A
Small amount to allow the baby to learn to suck, swallow and breathe at the same time
High in protein, immunoglobulins & minerals
High protein level facilitates bonding bilirubin
Acts as a laxative to pass meconium and pass bilirubin
14
Q
In lactogenesis stage 2 what occurs? When does this phase occur?
A
“Milk coming in” phase:
Breast milk continues to ‘mature’
Day 3-5 to day 10
15
Q
When does engorgement start to occur? Causes? Symptoms?
A
Lactogenesis stage 2
Response to hormonal changes
Milk production
Engorged blood vessels & lymphatic swelling
Full, hard, tender, warm breasts
16
Q
What are the 3 types of milk produced in lactogenesis stage 3?
A
Mature milk
Foremilk
Hind milk
17
Q
When does mature milk come in? What increased as neonate feeds?
A
Day 10
Fat content of BM increases as neonate feeds
18
Q
What is the color of fore milk? What does it contain?
A
bluish-white (60% skim & 30% whole milk)
Lactose, protein & WS vitamins
19
Q
What is hind milk? What is it for? When does it occur?
A
cream (5%)
For calories
Occurs 10-20 minutes in to feeding
Reason why you must try & ‘empty’ breast q feeding
20
Q
When would you use supplement for breastfeeding? What should be avoided?
A
Only when medically indicated
Avoid finger feed and cup feed
21
Q
What are the use of pacifiers? When should they be introduced?
A
For non-nutritive sucking
Use after breastfeeding is well established (2-4 weeks of age)
22
Q
When should the first feed occur? After the first feed how often?
A
First feeding during first period of reactivity
Feed on demand or at least q 1.5-3 hours
23
Q
When assess a breastfeeding patient, what should you assess?
A
Feeding effectiveness: LATCH score at least once a shift
Breast structure and signs of problems
24
Q
What does a low LATCH score require?
A
Assess every feeding until >6
Assist and provide education
Consult a Lactation Specialist for evaluation, assistance, and intervention
25
When providing nursing care during breastfeeding you need to be.. .
Supportive and assist patient with positioning and latch
Educate patient
Have a lot of patience
26
What does LATCH assess? A higher score means? By 12 hours what score is expected?
Assessment of the effectiveness of the breastfeeding session
The higher the score the more effective the feeding
A score of 6 or higher by 12 hours of age is expected
27
When helping with latching what should be done?
1. Nose to nipple- goal is to achieve an asymmetric latch- bottom jaw further onto areola than top jaw
2. Stimulating rooting reflex- stroke nipple downward over bottom lip
3. Newborn will open wide with tongue down and will drop head back
4. Once the mouth is open wide the BABY is brought to the breast, not breast to baby
28
What needs to be assess regarding the nipple?
Assess type of nipple
Assess for cracking, bleeding or redness because those are signs of inappropriate latch
29
What does the breast shell do? When do you use it?
Can help to cause flat or inverted nipples to protrude
Begin use in late 3rd trimester
30
What do breast shields do? What should you do before using breast shields?
Used to assist with latching
Important to work with lactation before and during use of the breast shields.
31
What are the benefits/risks of breast shields?
With continued use the milk supply can be reduced by 50% or more.
These can be beneficial for extremely damaged nipples or flat nipples.
32
What is the cross cradle hold?
Mother to sit in upright position using good body alignment and can use pillows for support
Baby placed on lap- belly to belly or baby in side-lying position with baby’s nose at nipple
Head supported with hand opposite breast she is feeding on positioned on nape of neck
Breast supported by hand on same side
33
What is the cradle hold?
Mother to sit upright using good body alignment
Baby placed on lap belly to belly position, side-lying with nose at nipple
Head cradled in crook of arm on the same side as the breast
Breast is supported by hand opposite breast she is feeding on
34
What is the football hold?
Mother to sit upright and pillows are used to raise baby’s body to breast level
Baby’s bottom rests near mother’s elbow and body turned slightly to face breast
Head supported at nape of neck and body is supported by mother’s arm
Breast is supported with hand opposite breast she is feeding on
35
What is the side lying position?
Mother lies on side and pillows used to support head and back, between bent knees
Baby placed in side-lying position next to mother, belly to belly, nose lined up with nipple, pillow or roll placed behind back
Breast supported by hand opposite breast she is feeding on (top arm)
36
What should be used, scissor hold or C-hold?
C-hold should be used
Scissors hold is discouraged because moms are unable to keep fingers at least 1 ½ inches from base of aerola
37
What are sings of effective breastfeeding?
Infant nursing ≥8 times in 24 hours
Mother can hear infant swallow
Mother’s breasts soften after feeding
Number of wet diapers increases
Infant’s stools begin to lighten and transition from meconium to breastfeeding stools
38
How many wet diapers should baby have by day 5?
6-8 wet diapers a day beginning on day 5
39
What can help comfort women with engorgment?
Empty breasts q2h; preferably by the baby
Ibuprofen, massage, ice
Not recommended to pump/hand express milk between/ after feedings causes increased milk production and worsens engorgement
If engorgement causes nipples to flatten and become hard use breast pump/hand expression just to soften nipple to allow latch
Cabbage leaves no longer recommended due to risk of food borne illness
40
What can be used to help comfort mom with cracked, bleeding and bruised nipples? What are these a sign of?
Lansinoh cream- no need to wash off
Gel pads- “soothies”
Nipple Shields until nipples are healed
signs of poor latch
41
What are s/s that patient is coping with pain?
Using breathing & relaxation techniques
Moaning, chanting
Inward focus
Says “I am coping”
Rocking, Swaying
42
What are s/s that patient is not coping with pain?
“I can’t do this”
Crying, screaming
Tremulous voice
Unable to focus
Panicky during contractions
Thrashing
Scratching, biting, writhing
Sweaty, Shaking
43
What are the causes of pain in the first stage of labor?
Cervical effacement & dilatation
Hypoxia of uterine muscle cells
Stretching of lower uterine segment
Pressure on adjacent structures (low back, thighs, buttocks, groin, iliac crest)
44
Where is the pain during the first stage of labor?
enter spinal cord at L1, T10-12
Low back and low belly
45
What causes pain in the 4th stage of labor? What could cause this pain to be worse?
“After birth pains” are those contractions of the uterus to help prevent hemorrhage and may actually exceed the pain experienced by labor contractions.
The more babies the woman has the harder the uterus has to work to contract and the worse the after birth pains may be
46
What are the physiologic response to pain in labor?
Tachycardia
Increased O2 consumption
Lactic acid
Hyperventilation (risk of resp alkalosis)
47
What psychologically occurs in labor?
Unrelieved pain may prolong labor
Post traumatic stress disorder
48
The pain and stress of labor can lead to metabolic acidosis and release of catecholamines which leads to...
maternal blood vessel to constrict, decreased O2 to baby
49
If pain management if offered too soon what occurs? Offered too late what occurs?
Offered too soon will stop/slow labor
Offered too late risk un-medicated delivery when she really wanted an epidural
50
When is the best time to offer meds for labor?
Active
Takes the “edge” off, usually does not slow labor progress, can cause decreased FHR variability
51
What helps the uterus function? What aids descent of baby? An empty bladder causes? What happens if muscles are tense? What can be as effective as narcotics?
Uterus functions effectively when well hydrated & fed
Contractions and descent of the presenting part are aided by position changes
An empty bladder allows more room in the pelvis for the head to come down
The more tense other body muscles are, the less work the uterus can do AND the more painful the contractions feel
Support, touch and hydrotherapy can be as effective as narcotics
52
What are non-pharm pain relieving methods?
Childbirth preparation
One-on-one support
Relaxation
Breathing
Massage & Acupressure
Hydrotherapy
Alternative therapies (Hypnosis, TENS unit, Sterile water papule)
53
What are some things mom can do to prepare for childbirth?
Awareness of the labor & birth process
Relaxation Techniques
Visualization Techniques
Breathing Techniques
Consumer information
54
How does visualization/guided imagery help with birth pains?
Visualize sights, sounds, feelings of a pleasant place
a “focal” point helps to focus concentration away from pain
Closing eyes vs. keeping eyes open
Visualizing the cervix opening or the baby moving down can be helpful to the progress
55
Why does helping mom loosen up her muscles help with pain?
The more tense other body muscles are, the less work the uterus can do AND the more painful the contractions feel
55
What does hydrotherapy do for pain in labor?
relax muscles, decreases pain perception and decreases length of labor
56
What types of massage can be done to decrease pain in labor?
Effleurage- light feather stroking of any area of body- may do herself
Counter pressure applied for back pain-place fist against back and apply constant pressure
Knead arm and leg muscles from proximal to distal and encourage release of tension (flowing out of body) as digits are reached
57
What does movement, adulation and position changes for for labor?
Shorten labor
Lessens pain
Promotes fetal descent
58
How can birthing balls help with labor?
Increase the diameter of pelvis
Assists with fetal rotation and descent
59
What do sterile water papules do for pain in birth?
Reduces low back pain severity and provides relief for up to 2 hours
60
What is the TENS unit? How does it do?
Electrical stimulation of the nerves
Blocks pain perception, reduces excitation of central neurons and there is activation of the opioid receptors in the CNS
61
What are the benefits of breathing techniques?
Increases pain threshold
Encourages relaxation
Provides distraction
Enhanced coping ability
More efficient uterine functioning
62
When should breathing techniques be initiated? When do they work best?
Don’t start any technique too early- she will exhaust herself
Best if learned and practiced prior to labor
63
What is lamaze breathing?
Cleansing breath before and after - Deep breath in through nose out through mouth
Slow chest breathing - Usually used in latent and active labor
Modified paced - Usually used in active labor and 2nd stage
Pattern paced- “Hee, hee, hee, hoo” - Usually used active labor and 2nd stage
Quick method - Pant-pant-blow
Puffing - Used when urge to push prior to complete dilation
64
When is it too late for an epidural?
patient unable to sit still for procedure
pushing the baby out
65
IV pain meds will have what effect on labor?
will not slow down labor if given in latent labor
66
When giving pain meds, they affect mom and ____
Baby - cross placental barrier by simple diffusion some more readily than others
67
How do analgesics help with pain in labor?
Affects perception of pain, does not take pain away
68
How do anesthetics help with pain in labor?
Deadens the pain, either by blocking a nerve, or knocking you out
69
What sedative could be used in labor? Why a sedative?
Ambien 5-10 mg PO
Maternal exhaustion in prodromal albor
70
What are the benefits for sedation? Risks?
Decreases anxiety
Allows for rest
Inhibit uterine contractions (good for prodromal labor)
Neonatal CNS depression
Maternal response
71
What antihistamine is used in labor? Why?
Benadryl 25-50 mg PO
Induces relaxation and sleepiness
72
What H1 receptor antagonist is used in labor? Why?
Promethazine HCL (Phenergan) 12.5 25 mg IM or PO
Relieves nausea & vomiting
Does not relieve pain, but potentiates narcotics
Decreases anxiety
73
What true narcotics are used in labor?
Fentanyl 50-100 mcg IVP Q10-15 minutes x 5 doses
Morphine Sulfate:2 mg IV + 10 mg IM with PO Phenergan for prodromal labor
74
What partial opioid agonist is used in labor?
Nalbuphine (Nubain): 5-10 mg IVP
75
How does fentanyl affect fetus? What is the 1/2 life? Onset?
Fentanyl has a rapid onset and has a short half life.
There is limited placental transfer and therefore FHR variability is not affected as much as the other narcotics
76
What is the MOA of nitrous oxide?
Exact mechanism unknown
May stimulate endogenous endorphin, corticotropins, and dopamine release
Dulls perception of pain
77
What is the onset of nitrous oxide? Clearance? Administration?
Within 30-60 seconds of inhalation
Maternal: within 30-60 seconds of discontinuation
Self administered by the woman via inhalation
Concentration: 50% nitrous and 50% oxygen
78
What are the advantages of nitrous oxide?
During all stages of labor
Can be used with ambulation, hydrotherapy, etc.
Does not require IV catheter or continuous fetal monitoring (but this may be dependent on institution)
Useful for other painful procedures (Forceps or vacuum assisted deliveries, manual removal of placenta or uterine exploration and laceration or episiotomy repairs)
79
What are the SE of nitrous oxide?
Nausea & vomiting-5-36%
Vertigo-39%
80
What are the contraindications for nitrous oxide?
Alcohol or drug impairment
Hemodynamically unstable
Cannot hold own mask
Vitamin B12 deficiency
81
What effects does nitrous oxide have on the fetus/newborn?
Crosses placenta-80% of maternal serum levels
No increase in CNS or respiratory depression
APGARS unaffected
No FHR changes
Cleared rapidly with initiation of effective respirations
82
What patient safety and education should be given with nitrous oxide?
Education on self-administration; no one may help her administer it
Will need assistance with ambulation
Supervise patient during hydrotherapy, birth ball use, and squatting
Obtain informed consent from the patient (done by anesthesia)
83
What is a walking epidural?
Epidural without lidocaine
84
Does a spinal or epidural have a faster onset? Which lasts long?
Epidural - Continuous dose throughout labor. Takes longer to take affect
Spinal - Faster onset, lasts 1-3 hours
85
What is used for a c-section?
Spinal
86
What is an epidural inject? What does it block? What kind of drug is used?
L-2 to L-4 vertebrae
T-8 to S-5 block
Variety of “caine” drugs + narcotics
87
What are the contraindications of an epidural?
Allergy to the agent
Clotting disorders or hemorrhage
Hx of spinal injury or abnormality
Sepsis
Hypertension
Local or systemic infection
Uncorrected hypovolemia
Increased intracranial pressure (ICP)
88
Where is the epidural space?
between the Dura mater and the ligamentum flavum, extending from the base of the skull to the end of the sacral canal
89
What are the advantages of epidurals? (6)
Provides good pain relief and assists with coping
Allows woman to be fully awake
Avoidance of general anesthesia if unplanned c/s
May mediate maternal exhaustion and stress effects and allow her to rest—wake up when ready to push
Great for women with a history of sexual abuse
Vasodilation—improve placental perfusion and decrease maternal HTN for a time
90
Because it epidural is continuous....
Allows for different blocking during each stage of labor
Dose can be adjusted
91
What are the advantages for spinals?
Local anesthetic agent injected directly into spinal canal
Onset of anesthesia is immediate
Mostly used for cesarean birth but can be used for vaginal delivery if delivery imminent
Lower risk of failure
Smaller drug volumes
92
What is the difference between level of anesthesia for a vaginal vs. c-section
c/s: above fondus
Vaginal: at the hips
93
What are the complications of regional anesthesia?
Inadequate block
Breakthrough pain
Procedure-Related Events
Sympathetic nerve blockade
Itching
PP findings of localized tenderness, backache, migraine, increased temp
94
What are the nursing responsibilities of regional anesthesia?
Informed Consent
Void prior to administration
IV Access
Preload with 500-1000ml IV fluids (dependent on hospital)
Monitor vital signs, PO2, and fetal heart rate
Assist with positioning
Explain and reassure
95
What are types of inadequate blocking?
"Hot spot”
One sided
Block Failure
96
What are 3 instances that breakthrough pain can occur?
Full bladder
Complete dilation
Uterine rupture
97
What are procedure-related events that are associated with anesthesia complications?
Nerve Root Injury (0.2 %)
Accidental Dura (spinal) Puncture (1 - 2 %)
Intravascular Injection (5 %)
98
What are 3 things that occur d/t sympathetic nerve blockade?
Maternal Hypotension (1 - 10 %) --> late decelerations
Urinary Retention (15 - 35 %) - treat w/ Foley
Fever ( 15 - 17 %) possibly similar to spinal cord injury
99
How do you treat maternal hypotension d/t sympathetic nerve blockade?
Ephedrine 5-10 mg IV
Fluid bolus
Oxygen via facemask
Side-lying position
100
What is the treatment of itching r/t regional anesthesia?
Nubain or Benadryl
101
What are some PP complications r/t regional anesthesia?
Localized tenderness (40%)
Backache (30 - 40 %)
Migraine Headache (2.9%)
Transient Neurological Deficits (0.1 %)
Elevation in temperature
102
What is a spinal HA treated with?
Blood patch
a few millimeters of the woman’s blood drawn and before coagulation occurs is injected into epidural space- forms a clot and seals leak of spinal fluid providing almost instantaneous relief
103
What interventions on fetus could an epidural lead to?
Continuous fetal monitoring
Increased risk of C-section or assisted vaginal delivery (forceps or vacuum)
104
Where is pudendal anesthesia inject? Where does it provide anesthesia to?
Injection of local anesthesia into pudendal nerve (near vaginal lips)
Produces anesthesia to lower vagina, vulva, and perineum
105
When does a pudendal anesthesia give relief? Effects on labor or fetus?
Only produces pain relief at end of labor
Has no effect on fetus or progress of labor
106
What are the complications of pudendal anesthesia?
Hematoma
Perforation of rectum
Trauma to sciatic nerve
107
Where is local anesthesia injected? When is it used?
Injection of anesthetic into soft tissues of perineum
Prior to episiotomy
Prior to de-infibulation
Repair of lacerations
108
How does local anesthesia affect fetus/labor? What type of effect? What pain does it not help?
Does not affect fetus or labor progression
Effect is only locally
Not effective for pain prior to crowning
109
When is general anesthesia used? What does it require? Risks? What should you be aware of?
Used rarely only for emergent C-sections with no or ineffective regional anesthesia
Requires intubation
High rate of neonatal depression
Beware of aspiration pneumonia b/c laboring woman’s stomach is never empty
110
What are the nursing responsibilities for general anesthesia?
IV access
Assess when mother ate or drank last
Administer prescribed premedication such as antacid
Wedge under right hip
111
RBC breakdown to become ____. They are transports by _____ to the _____.
RBC breakdown produces UNCONJUGATED bilirubin (fat soluble)
Transported to liver by Albumin
112
What occurs once unconjugated bilirubin gets to the liver? Where is it excreted?
Liver converts to water soluble bilirubin (CONJUGATED)
Conjugated bilirubin excreted into bile duct and then into intestines
Excreted via urine and stool
113
What causes hyperbillrubinemia?
Short ½ life of fetal RBCs (70-90 days) and increased red cell volume -->
More unconjuguated bilirubin produced -->
Decreased conjugation d/t lack of glucuronyl transfused in liver -->
Lack of gut bacteria and low GI motility causes increased reabsorption of bili
114
How common is hyperbilirubinemia?
50% of term neonates
85% of preterm infants
115
What are modifiable risk factors of hyperbilirubinemia? (10)
Delayed/ineffective feedings
Excessive weight loss
Iatrogenic prematurity/ Prematurity
Rh incompatibility (give RhoGAM)
Use of oxytocin
Infections
Epidural bupivacaine
Hypoxia/asphyxia
Birth trauma
Maternal diabetes
116
What are non-modifiable risk factors of hyperbilirubinemia?
Male gender
Sibling with jaundice
Race: Asian, Native American, Greek
ABO incompatibility
117
What are the 4 types of hyperbilirubinemia?
Physiological
Pathological
Breastfeeding
Breast milk
118
What is the progression of hyperbilirubinemia?
Head to toe progression
119
When is breast milk jaundice? How long does it last/peak?
Occurs 3-5 days after mature milk
May last several months but peaks around 2-3 weeks
120
What are the causes of breast milk jaundice?
Increased free fatty acids in some breast milk
Free fatty acids compete with bilirubin binding sites on albumin
Inhibits conjugation
Increased reabsorption of bilirubin in GI tract
121
What is the treatment for breast milk jaundice? When does total serum bilirubin peak?
Continue to breastfeed if bili levels <20mg/dl
Interrupt breastfeeding and formula feed for few days if bili 20 mg/dl
Peaks at 5-10 mg/dl by 2-3 weeks
122
When does breastfeeding jaundice appear in a newborn? Causes?
Appears in first few days
Ineffective breastfeeding
Dehydration
Delayed meconium stool passage (one good meconium stool reduces bili level ~1 mg/dl)
123
How do you treat breastfeeding jaundice?
Support effective breastfeeding by Frequent feedings and Lactation consultation
Promote stooling (Colostrum is a great laxative)
Avoid supplementation
124
What is physiologic jaundice? When does it appear? Peak? Resolve?
Normal adaptation
Appears after 24 hours
Peaks around 3-5 days
No longer apparent by 14 days
125
What are the causes of physiologic jaundice?
Increased breakdown of fetal RBCs
Impaired conjugation of bilirubin- lack of glucuronyl transferase
More bilirubin reabsorbed by GI tract
126
When does pathologic jaundice appear? How long does it last?
Appears within the first 24 hours
Lasts longer than 1 week
127
What causes pathologic jaundice?
ABO incompatibility
Hemolytic disease of the newborn
Maternal disease processes such as diabetes, intrauterine infections, drugs-sulfa, salicylates, novobiocin, diazepam, oxytocin
128
What is phototherapy? What does it do?
Blue lights most effective
Converts to water soluble form
Excreted via urine and stool
129
What circumstances is exchange transfusion used? What does it do?
Used when phototherapy ineffective or severe hemolytic disease present
Replaces 85% of RBCs
Corrects anemia
RBCs with maternal antibodies removed
Other hemolysis toxins removed
130
What are the complications of an exchange transfusion?
Thrombocytopenia, hypocalcemia most common
Metabolic acidosis, clots
131
What is the correct positioning of the lights for phototherapy? How do you make sure maximum exposure?
45-50 cm from infant
Frequent position changes
Naked
Limit time out
132
What should you monitor during phototherapy?
Vital signs-especially temperature
Intake and output
Side effects
TSB levels- should drop 1-2 mg/dl within first 4-6 hours
Protect eyes
133
What are side effects of phototherapy? (7)
Loose stools, dehydration, hyperthermia, lethargy, rashes, impaired bonding, eye damage
134
where does the blanching begin for hyperbilirubinemia?
Blanch skin beginning on face and moving down body
135
How do you decrease the risk of hyperbilirubinemia?
Prevent cold stress
Promote early feedings
Monitor stools
136
What lab testing should be done on patients with suspected hyperbilirubinemia? When is it visually apparent?
Cord blood typing for newborns of mother’s with O blood types
Direct Coombs test (DAT)
Total serum bilirubin (TSB) - visually apparent jaundice=TSB of 4-6 mg/dl
Transcutaneous bilirubin level
137
Can RhoGAM be used to help treat hyperbilirubinemia?
YES
138
What is kernicterus? Is it preventable?
Preventable
Chronic and permanent sequelae of untreated hyperbili
139
What are the early s/s of kernicterus?
Extreme jaundice
Absent startle/moror reflex
Poor feeding or sucking
Extreme sleepiness (lethargy)
140
What are the mid s/s of kernicterus?
High-pitched cry
Arched back with neck hyperextended backward
Bulging fontanel (soft spot)
Seizures
141
What are the late s/s of kernicterus?
High-frequency hearing loss
Mental retardation
Muscle rigidity
Speech difficulties
Seizures
Movement disorder
142
What does type O blood contain? What is the concern with this?
Type O blood contains anti-A & anti-B antibodies (IgM)
If enter fetal circulation of blood types A or B cause clumping of RBCs
143
What are the consqueces of HDN? Is it preventable?
Rapid destruction of fetal RBCs --> Hyperbilirubinemia, Anemia and Death
No available prevention
144
What is the difference between Rh positive and Rh negative blood?
Positive: D antigen
Negative: No D antigen and with exposure to Rh positive blood anti-D antibodies are produced (IgG antibodies)
145
What occurs when anti-D antibodies cross placenta and attach to fetal RBCs?
Cause hemolysis of fetal RBCs
Erythroblastosis fetalis
Hydrops fetalis
146
What is hydrops fetalis? S/S?
most severe form
Severe anemia
Multiple organ system failure
Cardiac decompensation
Generalized massive edema
Death
147
What is erythroblastosis fetalis? S/S?
Anemia
Jaundice
Increased immature RBCs
Death
148
How should Rh sensitization be prevented? What is the MOA? How long does it protect for? When is it not effective
RhoGAM - Made from plasma
Prevents production of anti-D antibodies --> decreases risk of hemolytic disease in fetuses in subsequent pregnancies
Provides protection for approximately 12-14 weeks
Once antibodies form RhoGAM is no longer effective
149
When should RhoGAM because give to a Rh negative mom?
At 28 weeks in every pregnancy
Miscarriage/abortion
Other—amniocentesis, abdominal trauma, ECV, when mixing suspected
After delivery if fetus is Rh Positive
150
What is late preterm? What are the complications of being late preterm? How long do they need close monitoring for?
34-36 6/7 weeks gestation
Inadequate or delayed transition
Up to 20% of NICU admissions
Morbidity rate doubles for every week below 38 weeks
Close monitoring for at least first 24 hours
151
What a patient is late preterm what occurs in their lungs?
Lungs immature
Decreased surfactant
Immature respiratory control
Decreased muscle tone
152
How is thermal control altered in late preterm newborns?
Decreased brown fat for thermogenesis
Decreased white fat for insulation
153
What causes feeding difficulties in late preterm infants?
Immature coordination
Inadequate milk transfer
Sleepier
Low milk supply
154
Are late preterm infants at increased risk for hyperbilirubinemia? why?
2X greater risk for significantly high levels
More susceptible to bilirubin toxicity
Delay in metabolism and excretion
155
Does a late preterm infant have any differences in their brain? Any changes this causes?
Cortical volume increases 50% in volume between 34-40 weeks, great increase in surface area
Needs more sleep to conserve energy
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Why do late preterm infants have hypoglycemia?
Low glycogen stores
Immature pathways to make glucose
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Why do late preterm infants have an increased risk for sepsis?
Immature immune system
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What special care should a late preterm infant have?
Close monitoring for at least 24 hours
More frequent vital signs
Feeding - lactation consultation and encourage frequent feedings and assess adequacy
Unlimited skin-to-skin contact
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What should be prevented in a late preterm infant?
Hypoglycemia
Hyperbilirubinemia
Prevent infections
Hypothermia
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What needs to be completed prior to discharge of a late preterm infant?
Car seat challenge prior to discharge
161
What are the risk factors of a fractures clavicle in birth?
Macrosomia
Shoulder dystocia
Forceps and vacuum
Unpredictable
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If a baby has cephalohematoma what should they be monitored closely for?
Monitor closely for jaundice
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What is the cause of neurological injuries at birth?
Excessive or improper traction on head during birth
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What are two locations for a branchial plexus injury?
Erb’s palsy-damage to network of nerves for arm, hand and shoulder (C5-8 and T1)
Klumpke’s- nerves of forearm and hand (C8 and T1)
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What are risk factors for hypoglycemia in a newborn? (10)
Neonate of diabetic mother
SGA
Preterm
Hypothermia
Birth trauma
RDS
Resuscitation
Macrosomia/LGA
Postdates
Maternal chorioamniotis
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What is considered hypoglycemia in a newborn?
Blood sugar <40-45
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What are s/s of hypoglycemia in a newborn?
Jitteriness
Poor tone
Lethargy
Temperature instability
Apnea
Irritability
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What is the leading cause of morbidity and mortality in a newborn?
Neonatal sepsis
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What are ways that neonatal sepsis is transmitted?
Vertical:
1. Transplacentally-TORCH infections
2. Ascending- R/T prolonged rupture of membranes
3. Delivery exposure-herpes, GBS
Horizontal
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What are the two types of sepsis? Causes of each?
Early onset- within first 7 days—GBS #1 culprit
Higher incidence with low birth weight
Late onset- 8 days to 3 months- Staph, pseudomonas, e-coli
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What can be used to predict the risk of sepsis in a neonate?
Neonatal early onset sepsis calculator
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What are the s/s of neonatal sepsis?
Respiratory-Apnea, grunting, tachypnea, cyanosis
Thermoregulation-Temperature instability, hypothermia
Neurological- Lethargy
Poor feeding, glucose instability
Cardiovascular-brady/tachy, hypotension, poor perfusion
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What tests should be ordered r/t neonatal sepsis?
CBC:
1. WBCs-high or low
2. Neutrophils-low
3. Bands (immature WBC)-high
Blood cultures
Spinal tap
Others: c-reactive protein, urine culture, chest x-ray
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Can neonatal sepsis be prenatally prevented? Intrapartum? Postnatal?
Prenatally: screen/treat infections, education
Intrapartum: GBS, limit # of VE, avoid AROM too early, avoid PTD
Postnatal: education and good hand hygiene
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What is the treatment for neonatal sepsis?
Antibiotics- start prior to blood culture results
Nutrition-may be NPO
Assessment- symptoms, weight, I&Os, hypoglycemia, electrolyte imbalances
Respiratory & cardiovascular support
Support bonding & parental education
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If fetus has apnea what else should be assessed? (7)
Hypoglycemia
Infection
Hypoxia
Fluid imbalances
CNS abnormalities
Cyanosis
Bradycardia
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What is the cause of transient tachypnea of the newborn (TTN)? What dies is resemble?
Failure to clear fluid in pulmonary system
Resembles classic RDS
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What are the risk factors for TTN?
C-section
Maternal diabetes and asthma
Male infants
LGA, macrosomia
Late preterm
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What are the s/s of TTN?
Rapid rate
Grunting, retractions, nasal flaring
Cyanosis
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What is the nursing care for TTN? (3)
Oxygen
Prevent cold stress
Provide calories—oral feedings contraindicated
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What is asphyxia?
Inability to transition to extrauterine circulation
No lung expansion and respirations --> hypoxemia --> metabolic acidosis & hypercapnia
Change from aerobic to anaerobic metabolism
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What are the antepartum risk factors for asphyxia? Intrapartum? Neonatal?
Antepartum factors: anything affecting placental perfusion
Intrapartum factors: prolonged labor, cord issues, assisted delivery, malposition
Neonatal factors: prematurity, male gender, infant of diabetic mother, SGA/macrosomia
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What are the protective factors for asphyxia?
Brain is immature
Lower resting metabolic rate
More efficient energy use
Able to redistribute lactate and hydrogen ions
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What is the morbidity associated with asphyxia?
Mild- no long term sequela
Moderate to severe- depends on extent of insult
~58% CP
~48% other abnormal outcome
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What are the intrapartum s/s for asphyxia? What are the neonatal s/s for asphyxia?
Intrapartum:
Non-reassuring FHR in labor (category 3)
Cord blood gas pH <7
Neonatal:
No respiratory effort @ 5 min or APGAR score < 5 @ 10 min
Need for prolonged resuscitation
Stunned look or lethargic
Seizures & CNS irritability
Hypertonic or hypotonic
Poor feeding
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What is the treatment for asphyxia?
Rapid identification
Appropriate resuscitation
Support oxygenation & ventilation
Therapeutic hypothermia
Decreased mortality and neurodevelopmental disability rates
Provide nutrition
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When can therapeutic hypothermia be used? What does this include?
For 36 or more weeks gestation
Cool to 33.5-34.5 C
Initiated within 6 hours
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What is the cause of respiratory distress syndrome? (RDS)
Absence, deficiency or alteration in pulmonary surfactant
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What is the role of surfactant? What if there is not surfactant?
Lowers surface tension --> reduces pressure required to keep alveoli open with inspiration
Prevents total alveolar collapse on exhalation --> maintains alveolar stability
Decreased surface tension --> increased lung compliance
Helps to establish functional residual capacity of lungs
Without surfactant --> more pressure must be generated for inspiration --> can tire or exhaust preterm or sick infants
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When does surfactant start to develop? When should babies have naturally occurring surfactant?
develop around 24-28 weeks
By 35 weeks most babies have enough naturally occurring surfactant to keep the alveoli from collapsing
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What are the risk factors for RDS?
Prematurity
~50% Preterm newborns < 30 weeks
Asphyxia
Infant of a mother with diabetes
Surfactant deficiency syndrome
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What do corticosteroids do for RDS? When are they recommended?
Promote fetal lung development and surfactant production
IM injection when in preterm labor and repeated in 24 hours
Recommended to give Corticosteroids if the woman is expected to deliver within the next 7 days:
24 0/7-33 6/7 weeks
34 0/7-36 6/7 weeks for women who have not previously received corticosteroids
23 0/7-23 6/7 weeks based on parents desires for resuscitation
A single repeat series can be given if < 34 weeks
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What assessment finding would be expected for RDS?
Progressive respiratory difficulty
Grunting, tachypnea, nasal flaring, retractions
Lethargy
Hypotonia
Cyanosis
Hypoxemia and acidosis
CXR-reticulograndular pattern
Increased O2 requirements
194
What is the management of RDS?
Preterm birth prevention
Maintain neutral thermal environment
Respiratory support & oxygenation to maintain pulse ox @ 90%
Nutrition via IV
Maintain BP
Surfactant administration
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When is surfactant administered? How? Benefits?
Prophylaxis- within 15 minutes of birth
Rescue treatment- within 8 hours of birth
Administered via ET tube
Benefits- reduces risk of RDS, pneumothorax, IVH, bronchopulmonary dysplasia, pulmonary interstitial emphysema
196
With use of illicit drugs, alcohol & tobacco increased risks for issues?
Poor or no prenatal care
Poor weight gain
STIs
OB complications
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What factors affect neonatal abstinence syndrome? What is the timing of s/s for alcohol? Narcotics? Barbituates?
Last exposure, half-life, type
Alcohol-3-12 hours
Narcotics-2-3 days
Barbiturates-1-14 days
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What effects does fetal alcohol syndrome have on the neonate?
Facial- small eyes, thin upper lip, short nose
Heart, joint, limb, finger deformities
IUGR and poor growth after birth
Cognitive impairment—COMPLETELY PREVENTABLE!!!
Vision and hearing problems, behavior problems
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What is affected with alcohol related birth defects?
Congenital anomalies-heart, skeleton, kidneys, eyes, ears
200
What is alcohol related neurodevelopment disorder?
Small head size, brain abnormalities, neuro, cognitive, behavioral problems
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When reviewing the records, what are you looking for?
look for potential exposure
Assess for withdrawal and anomalies
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What would urine vs cord vs stool tell you about exposure?
Meconium – shows longer exposure
Urine – more recent exposure
Cord – long exposure
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What is different about the nutrition of a baby exposure to substances?
Poor feeders
Small, frequent feedings
Higher calorie formula?
204
If baby is hypoglycemic, what should be done?
Provide calories
Reassess glucose in hours
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Nursing care of the neonate with exposure?
Review records
Obtain toxicology –meconium and urine screening, cord tissue sampling
Control environment - Dim, quiet, group care activities
Nutrition
Promote self-soothing/regulation with swaddling, gentle rocking, non-nutritive sucking
Promote bonding
