Chap 1,2,3,4 Flashcards
Normal Gestational Period
40 weeks, 9 months (3 trimesters of 3 mo.each)
Considered neonate
delivery to 1 month
Considered infant
1 month to 1 year
considered child
after 1 year
Stages of lung development
Embryonic 26-52 days
Pseudoglandular 52 days-16 weeks (structure)
Canalicular 17 - 26 weeks (I and II alveolar cells)!!
Saccular 26-36 weeks
Alveolar 36 weeks - term
I and II alveolar cells made when
17-26 weeks
Pulmonary hypoplasia
*hypoplastic lung
Underdeveloped lung tissue
Failure of the lungs to develop
Main cause of pulmonary hypoplasia
Diaphragmatic hernia: diaphragm is seperated and bowels are in thoracic cavity. Compresses lung tissue and it cannot develop adequately
Surface tension
mutual attraction of the like molecules for one another
Principle of La Place’s law as
the radius of a buble decreases the surface tension increases
soo.. a small alveoli has more surface tension and is more difficult to inflate than a large alveoli
Surfactant
a phospholipid found on the alveolar walls that lowers surface tension
- it increases compliance
- helps prevent alveolar collapse
- is produced by type II alveolar cells
- appears at approx 23-26 weeks gestation
Fetal lung fluid
20-30 ml/kg of body wt
-volume equivalent to FRC
Function of fetal lung fluid
maintain airway patency
-formation, size, and shape of air spaces
Evaluation of lung fluid
1/3 squeezed out during delivery
-the remaining fluid is absorbed by lymphatic system
lung fluid retention after C-section
transient Tachypnea of the newborn (passes fast)
What is the first major organ to develop
heart, pumps blood in 8 weeks
Which one is higher Venous or Arterial pressure
Venous pressure is higher than arterial, Right heart is stronger than left heart (opposite of us)
- High PVR
- Low placental resistance to blood flow - gets O2 from mother and rids of CO2
THREE FETAL SHUNTS
- ductus venosus- belly button
- Foramen Ovale- Hole between right and left atria
- Ductus arteriosus
Path of fetal blood flow
Placenta- umbilical vein- ductus venosus - inferior vena cava - right atrium_>
(a) Foramen ovale - left atrium - left ventricle - aorta- brain (the most oxygenated blood)
(b) Right ventricle- pulmonary artery - ductus arteriosus - aorta- body
(C) Right Ventricule - P.A. - lungs - left atrium (about 10% of the total blood supply)
Intrauterine structures
Placenta, Umbilical cord
Placental Structure
Chorionic villi exchanges the gases and nutrients from mom to fetus
Umbilical cord structure!!!
2 umbilical arteries, 1 umbilical vein, Whartons jelly
Stages of labor
Stage 1: onset of first true contraction to complete dilation and effacement
Stage 2: full dilation and effacement to delivery of the fetus
Stage 3: Expulsion of the placenta
Normal position during labor
Baby head down= vertex position
Initiation of the first breath
- Asphyxia= CO2 increases, PaO2 decreases
- Recoil of the thorax
- Environmental changes
First breath may require what pressure
-100cmH2O, less pressure needed as FRC is established
Change from fetal to adult circulation
- Clamp umbilical cord removes placenta from arterial circulation increases arterial pressure
- lung fluid replaced with air
PaO2 increaes, PaCO2 decreases -> Pulmonary vasodilation (PVR decreaess) - Closure of shunts
Closure of shunts
D.V. - no blood flow
F.O. - pressure changes (increase left atrial pressure)
D.A. Increase PaO2 -> Decrease prostaglandins -> constricts smooth muscle around D.A.
Factors identifying a high-risk pregnancy
Preterm birth, less than 37 weeks gestation
Alcohol
Smoking
Cocaine
Hypertension (preclampsia)
Diabetes
Infection: herpes simplex, Hep B, HIB, Group B streptococcus
Placental abnormalitites
Placenta previa- may be partial or total (covered placenta)- might need C section
Placental abruption- Premature separation of the placenta from the uterine wall
Umbilical Cord problems
Cord compression
Prolapse (comes out first)- leading to cord compression
Nuchal (around neck)
First sign of a baby with hypoxia
bradycardia- lack of blood flow
Amnion and Amniotic fluid
Polyhydramnios (from increased swallowing defect)
Oligohydramnios (from decrease renal/ urinary defect)
Amniotic Fluid functions
- Protect fetus from trauma
- Thermoregulation
- Facilitate fetal movement
- Dilation and effacement of the cervix
Preterm Birth Complications
Sepsis RDS IVH ROP-blind too much O2 BPD- on vent/ o2 NEC- dying of gut Corticosteroids given to mom to speed up fetal lung maturity
Tocolysis
Process of stopping premature labor
- Beta-adrenergic drugs: Ritodrine (yutopar), Terbutaline (Brethine), Manesium Sulfate (reduces smooth muscle contractility- also used for asthma), Indomethacin (decrease prostoglandins)
- Corticosteroids
Post Term Birth Complications
Meconium aspiration= toxic/ obstruction-> sev. pneumonitius
Placenta insufficiency
Antenatal Assessment (before birth assessment of fetus)
Ultrasonography, Amniocentesis, Fetal Biophysical Profile
Amniocentesis
A. L:S ratio (lung maturity!
B. Rh isoimmunization (blood incompatibility)
C. Bilirubin level (hemolytic disorders) (blood disease)
D. Chromosomal disorders (downs)
E. Enzyme Deficiencies
F. Genetic mutation
Fetal Biophysical profile
Contraction stress test
Nonstress test
Fetal movement
Biophysical profile (see how baby is doing)
Delivery positions
Normal, head down
Breech, Any position but normal
Assisted vaginal delivery, forceps
Cesarean Delivery: indications
- Previous C sections: not absolute
- Failure to progress
- Malpresentation: breach
- Placenta Previa: covered
- Non reassuring fetal status: straps on belly, watch HR
- Multiple gestations
Multiple gestations
Increased incidence of premature delivery
Second twin is often more compromised
female twins generally more healthy than male twins
Fetal Heart rate
BASELINE: 120-160 bpm
Variability- normal variability is 5-10 bpm
Fetal Bradycardia/ tachycardia
Brady: <100 or drop 20bpm below baseline- most dangerous cause of fetal bradycardia is asphyxia
Tachy: Baseline consistently > 180, sign of infection
Fetal HR Acceleration/ decelerations
a. Accelerations
FHR exceeds 160 for <2 min
-Accelerates during contractions and are benign
b. Decelerations
FHR drops below 120 for less than 2 min
-early decelerations closely follow contractions and are benign
-Late decelerations occur 10-30 sec after the onset of contraction -indicate fetal asphyxia C SECTION ASAP
-Variable decelerations occur independent of contractions usually indicate cord compression
Fetal Scalp pH
Used when fetal asphyxia is suspected (low O2 or high CO2 leads to acidosis)
Normal pH > 7.25
slight asphyxia 7.20-7.25
severe < 7.20
Stabilization of the neonate
- maintain warmth and dry (first thermoregulation! lose heat rapidly)
- Provide and maintain an airway
- stimulation (should breathe well or cry within 30 sec)
- Apgar score (ranks babys activity/ muscle tone)
Apgar score
done at 1 min and 5 minutes, dont withhold care to wait for the 1 or 5 minutes
-respiratory effort/ rate
-heart rate
-skin color
-Reflex irritability : grimace
-Muscle tone
(Activity,pulse, grimace, appearance, respiration)
Gestational age assessment
- History of pregnancy and delivery
- Ultrasound
- postnatal physical exam (ballard, physical exam)
Physical exam (to assess gestational age): Ballard
Vernix (not on new ballard score): protects skin Skin maturity Lanugo: hair Ear/ eye Breast tissue Genitalia Plantar surface (sole creases)
Respiratory test
Silverman anderson
quiet exam
-General Assessment
-Vitals: BP HR RR/ Rhythm Temp
-Color/ Skin: Cyanosis central or acrocyanosis
Capillary refill
Mottling or pale
Jaundice
-Meconium: first bowel
-Activity
-Resp Status
RR
40-60 and apnea (apnea >20 sec)
-assess resp status during quiet breathing (silverman anderson index)
Signs of resp distress
- Nasal flaring
- grunting
- Retractions , upper and lower chest (see ribs)
Chest and cardiovascular
- Malformations (pectus excavatum and pectus carinatum
- PMI: point of max impulse
- Ausculate: BS- Squeeky
- Transillumination of the chest to check for pneumothorax(will light up chest, norm will send halo)
Pectus excavatum/ carinatum
Excav-inward, Carinatum- outward(pigeon chest)
Diaphragmatic hernia
flat abdomen, gut in chest with resp distress
Fontanelles
soft spots
Nose, occlude each nostril for
choanal atresia- block back of throat =baby continuously crying
Reflex tests
Rooting reflex-turn towards
Suck Reflex
Moro Reflex-drop
Stepping reflex
Neonatal Cardiopulmonary system (how it differs from adult): Upper Airway
-Larger tongue: nursing, oblig nose breathers
-more lymphoid tissue
-larger epiglottis (in proportion to larynx)
-Narrowest portion at cricoid (adult is glottis) under laryn-croup
-Trachea 4mm diameter at birth (adult 16mm)
-Chest -ribs and sternum mostly cartilage)
to increase VE must increase RR not able to increase VT (reasons they have retractions: lack of structure in chest)
Neonatal Cardiopulmonary system (how it differs from adult): Metabolism
Higher metabolic rate in neonate 100 cal/kg neonate 40-50 cal/kg adult proportionally higher O2 requirements=burn more cal unpredictable response to med dosage
Neonatal Cardiopulmonary system (how it differs from adult): other
larger body surface area - increase heat loss
80% body weight is H2O- fluid balance precarious (I/O)
Examination and assessment of the peds: history
CC Hx of present illness past medical history review of symptoms family hx social and environmental histories: housing
Exam of the peds pulmonary system
Keep them calm if possible
- vitals
- Inspection
- Palpation
- percussion
- Auscultation
Peds vitals exam
HR: count using 6 sec pulse
RR
Temp
O2 sat: big toes-> best way to check o2 levels
Peds Inspection during exam
- Respiratory distress: tachypnea, breathlessness, head bobbing, grunting, nasal flaring, retractions
- Chest wall: shape, muscle mass and stregnth, adipose tissue(hard to see chx movement)
Peds palpation during exam
- Neck: masses or adenopathy, trachea
- Chest: Fremitus(rumbling), motion with deep breathing
Peds percussion during exam
- Hyper-resonance: more air, pneumothorax
- Dullness: fluid, hemothorax
- Crepitus: crunchy sound, feel in chx
Auscultation during peds exam
-Audible: hear without steth.. grunting, stridor, stertor(on exp, low pitched, wet), wheezes
-Breath sounds: Symmetry, intensity, location: lobes/segs, Phases: insp/exp/both
Adventitious sounds: Crackles, wheezes, monophonic or polyphonic
monophonic and polychonic
mono- localized, poly- asthma
low crackles
rhonchi
peds muscle weakness or atrophy
waste away of muscles
peds abdominal distension
babies= crying - swallowing air
dermatitis (allergy)
irritation of skin, more prone to asthma
edema
hear failure- fluid overload
Peds lab tests
CXR PFT inc bronchial challange SpO2 with exercise Sweat chloride-CF CBC ABG, you gotta really want them
