FINAL EXAM Flashcards
anticipatory signs of labor
Lightening: ability to breathe easier
loss of mucous plug
ROM
Nesting: burst of energy
effacement: thinning of cervix
dilation: opening of cervix
abor Contractions Have the Following Characteristics:
They are regular
They follow a predictable pattern (such as every eight minutes)
They become progressively closer
They last progressively longer
They become progressively stronger
Each contraction is felt first in the lower back and then radiates around to the front or vice versa
A change in activity or body position will not slow down or stop contractions
Your mucus plug may appear
Membranes might rupture
Your health care provider will notice cervical changes, such as effacement (thinning) or dilation
Powers
Purpose: Dilate the cervix + aid in the expulsion of the fetus.
Contractions originate in the fundus and radiate out
Measured by: Frequency: how often are they occurring from start of 1 contraction to the start of the next.
Duration: how long 1 contraction lasts - from start to end of 1
Intensity:
Mild - fundus is able to be pushed feels like the noseo
Moderate: chin
Strong: can’t push in like forehead
Can measure by
IUPC
Mild = <40mmhg
Mod = 40-70mmhg
Strong = >70mmhg
Passageway
Route the fetus must travel
- maternal pelvis
- cervix
Types of Pelvis
Gynecoid: true female - 50% , round, shallow, open
Android: male resemblance, more heart shape - c/s
Anthropoid: narrow + deep
Platypelloid: flat, least common, wide, shallow - egg/oval
Passageway
Route the fetus must travel
- maternal pelvis
- cervix; needs to be ripe –> BISHOP SCORE
- effacement
- dilation
Types of Pelvis
Gynecoid: true female - 50% , round, shallow, open
Android: male resemblance, more heart shape - c/s
Anthropoid: narrow + deep - could do vaginal but it could be a long labor
Platypelloid: flat, least common, wide, shallow - egg/oval c/s
Cardinal Movement of Fetus
- engagement with cervix, flexion, descent
- further descent, internal rotation
- complete rotation, extension
- complete the extension
- restitution - external rotation
- delivery of anterior shoulder
- delivery of posterior shoulder
Passanger
Fetal Attitude: general flexion
Mentum: face presentation, loosely flexed legs. back arched - 13.5cm
Brow: brown at the cervix, sitting like a genie
Sinciput: head is up and not flexed on the chest 10 cm
Vertex/Occiput: fully flexed head to chest, legs flexed up; optimal position - 95% - 9.5cm
Fetal Lie: how the fetus is positioned in the womb
longitudinal: fetus spine running the same direction parallel as mother’s spine; can also be breech
transverse: positioned horizontally - CANNOT HAVE VAGINAL BIRTH
oblique: the head is against the mother’s hip, above the birth canal no parts are against the cervix
Fetal Presentation: the fetus body part that is closest to the cervix; which is presenting first
Frank: buttocks first, legs up
Full: buttocks first but less flexed
Footling: feet first and not flexed
Occiput: head first
Positon
Fetal Position: how the fetus is positioned in the womb and what part of the baby emerges first
1st letter: which way is facing
L: left
R: right
2nd Letter: what part of the body is presenting
O: occiput
S: sacrum
T: transverse
3rd: direction the fetus is facing in relation to mother
A: anterior: facing forward
P: posterior: facing backward
LOA – left, occiput, anterior = fetus is head first, angled to the left of mom’s pelvis and facing mom’s anterior
LOP: sunny side up; back pain –> counter pressure
LOT:occiput isn’t anterior or posterior
Station: relation of the presenting part in relation to the maternal pelvis
0 = engaged at the ishial spines
-5 = higher on the ishial spines
+5 = lower towards cervix
Leopold Maneuvers
To feel the fetal presentation and maneuvers
1. feels the top of the fundus
2. side of the uterus
3. suprapublic
4. only if in cephalic presentation feel for fetal attitude and extension
True Labor
contractions: strong, regular, long and close together, more intense with walking
felt in the lower back and doesn’t stop with comfort measures PAIN RADIATES
Cervix: changes - softening, effacement, dilution
Fetus: presenting parts engage the cervix, easier to breathe (lightening)
show is present
False Labor
Contractions: irregular, stops while walking or comfort measures, felt in the back or above umbilicus; only in groin + lower abdomen
Cervix: may be soft but no significant changes, no bloody show, posterior position - posterior position
Fetus: not engaging cervix
Fetal Heart Tones
Early Dec
VEAL CHOP
Variable Decelerations –> Cord Compression
Early Decelerations –> head Compressio
Accelerations –> ok
Late Decelerations –> placental insufficiency
Accelerations: want to see 2 accelerations >15 bpm for 15s
Early decels: pressure on skull; nothing can be done
Late: hypoxia, need to promote perfusion to fetus. STOP OXY and change position
Variable: change position, fetal or Trendelenburg to relieve pressure.; STIOP INFUSION, O2, amniofusion
Maternal Assessment Before birth
Materal hx: allergies, medications, hx of preg, maternal testing (blood type, Rh, hct/hg, GBS, Hepatitis B, nonstress)
Vital signs
uterine activity
Bladder I&O
Membrane status –> nitrazine (pH strip), amnisure, fern test
Response to labor
discomfort
cultural needs
Fetal Assessment before birth
Fetal presentation and station
HR
Internal: on scalp of baby
External: on top of fundus + on the baby’s spine on the outside
Looking for baseline FHR, variability, accelerations, decelerations
gestational growth + age
Fetal Heart Rate
Goal is to interpret + assess fetal oxygenation
Auscultation use of fetoscope + doppler, internal, external monitoring
Baseline: 110 - 160
Tachy
Mild: 161-180
Severe: >180
Causes: infection, increase metab, hyperthyroid, dehydration, anxiety, stress, fetal hypoxia, corchioamniotesis
Brady
Mild: 100 - 109
Moderate: 70-99
Severe <70
Cause: increase vagal tone, beta blockers, supine hypo, cardiac defects, cord prolapse, CHP
Variability = status of CNS
normal –> 6-25 bpm
Decrease = decrease CNS, alcohol, heroin, hypoxia; if sustained then fetus may need to be immediately delivered
Psyche
The way a woman handles the labor process
influenced by:
Parity
age
culture
coping mechanisms
emotional factors
length + intensity of labor
maternal + fetal position
Pain caused by dilation, pressure on cervix + tissue anorexia
THE SIX CARE PRACTICES THAT SUPPORT NORMAL BIRTH
- labor begins on it’s own
- freedom of movement
- continuous labor support
- minimize intervention
- spontaneous pushing in non supine positions
- no separation of mother and baby
Categories of FHT
Category I: normal; no intervention
2: indeterminate; requires eval + continued monitoring
3: predictive of abnormal fetus acid base, requires prompt eval and interventions
Methods of pain management
Non pharm: moving freely, position change, support system, massage, heat, water immersion, relaxation, aromatherapy, acupuncture, counter pressure, walking, sensory - aroma therapy, breathing, cognitive: hypnosis
Pharm:
Analgeis: partial + full relief from pain: opiates, morphine, stadol, nubain
Anesthesia: loss of sensation
Epidural: blocking neurotransmission —> give bolus for hyptoT
Nitrous oxide
Spinal block
Administration:
Systemic: IV, IM +inhalation; opiates can slow progression + affect fetus
Regional: epidural, spinal - risk of spinal headache, combo
Local block: pupendal + para cervical nerve block
First Stage
True labor contractions –> full dilation of cervix
- Early/Latent Phase: 0-3 cm; irregular contractions 20-40s, 10-30 min apart
woman is excited!
Actions: review plan, reinforce breathing techniques, lab tests per orders - Active: 4-7 cm; intense contractions, every 2-5 min, 45-60 s each, discomfort increases
Actions: monitor FHR, assess pain/admin analgesia, oral fluids - Transition: 8-10cm; shortest but most intense, 1-2 min 60-90 s N/V, diaphoresis
Actions: assess FHR + contractiosn Q15 min, assist with toileting, comfort + support
Second Stage
complete cervical dilation –> birth
INTENSE CONTRACTIONS Q2 min 60-90 s
URGE TO BEAR DOWN (ferguson’s reflex); don’t push until completely effaced and dilated
Actions: instruct when to bear down, monitor FHR Q5-15 / after each contraction, comfort
Third Stage
Birth –> placenta
Uterus contracts until placenta is out ~ 30 mins
You’ll know it’s coming when the uterus gets smaller and there’s a gush of blood.
Actions: assess vitals q15, utertonics as prescribed
Fourth Stage
postpartum –> 4hrs
Chills, pain fatigue,
newborn skin - skin
ASSESS FOR HEMORRHAGE
Preterm Labor
regular contractions occuring between 20-37wks with
- progressive cervical changes
- effacement >80%
- dilation > 1cm
Factors:
Infection + inflammation
decidual hemorrhage
excessive uterine stretch (multiple + polyhydraminos)
maternal or fetal stress
Greatest contributor of infant mortality <32wks
Risks:
Demographic risk: AA highest. Alaskan 11.6%, Hispanic 9.6%
Medical risk in current/ predating preg
environmental/behavioral/ psychosocial
biochemical marker –> fetal fibronectin fFn = protein that acts like a glue attaching sac to the uterine lining.
presence of fFn 24-34 indicated increased risk of preterm labor
absence is a reliable predictor of preg continuing for 2wks
Wouldn’t test if >3cm dilated
there’s vaginal bleeding
ROM
had sex or a vaginal exam 24hrs
gestational age <22wks or >35wks
suspected abruption and previa
Shortened cervix >3cm / 30 mm before 34 wks are less likely to have preterm birth than those who are <3cm
WARNING SIGNS
uterine cramping
backache
pressure on pelvis/ change in vaginal discharge
Abdominal cramping diarrhea
contraction Q10m in 1hr
general sense there is something wrong
change in fetal movement
Management
Assess for infection
restricting activity
hydration
tocolysis - Stop contractions via med
promote lung maturity - corticosteroids
Prevention; progesterone in singleton not multiples
Fetal Reserves
When O2 decreses blood flow is deferred to vital organs.
if placental reserves are depleted fetus may not be able to adapt or tolerate decreased O2 during contraction
Phases of contraction
- increment = begining
- Acme = peak
- decrement = decrease; relaxation
the resting tone is critical to return O2 to baby after contraction - <20 mmHg
Freq: how often
Duration: how long
Initiation of Labor
Must include 1+ regular phasic uterne contraction that increase in freq + intensity + progressive effacement + dilaion.
Factors:
uterine stretching – release of prostaglandins
Oxytocin release - increase contractility
decrease progesterone - inhibits contraction
increase prostaglandin
Cortoisol release inhibit prog and increase prost
placental aging
Tocolytic Therapy
Process of admin of a drug for purpose of inhibiting uterine contractions. Main goal is to stop labor long enough to get steroids to mature lungs
Contradictions:
Severe HT or preeclampsia
fetal compromise
fetal death
anomaly incompatible with life
lungs are mature
Types:
Beta-adrenergic agonist
Mg Sulfate
Ca Channel Blockers –> Nifedipine/Procardia
Prostaglandin inhibitors
Terbutaline
Beta-adrenergic Agonist
Promotion of smooth muscle relaxation
IV or SubQ -> RAPID ONSET
Side Effects:
Maternal + fetal tachy
PE
Hyperglycemia + hypokalemia
hypot
Cardiac insufficiency + arrhythmias
myocardial ischemia
maternal death
Mg Sulfate
Prevents Ca into the myometrial cells –> uterine relax + CNS depressant
USED FOR FETAL NEUROPROTECTION NOT TOCOLYSIS
SE: maternal flushing, headache, nausea, blurred vision
Toxicity
Loss of deep tendon reflexes
loss of consciousness
Respir <7
PE
Hypot
Cardiac arrhythmias
CALCIUM GLUCONATE 1g IV over 3 min
Indomethacin
ANTIINFLAM -> powerful prostaglandin synthesis and readily crosses placenta
adjunt therapy with other tocolytic therapy – Mg - oral or rectal
Prolongs preg for 48-72hrs
could close ductus arterious if admin >32wk, Nectrotizing enterocolitis, hemorrhage + renal failure
Ca Channel Blockers
Nifedipine - smooth muscle relaxer + potent vasodilator
SE: hypot, flushing, headache, tachy, nausea, dizziness, palpitation
Bethamethasone + Dexamethasone
Corticosteroids –> stimulate lung maturity
Only evidenced based rational for tocolysis
Can last 1wk and can be repeated
Nursing Care for Preterm Labor
Stopping contractions
Activity restriction + bed rest —> be aware of DVT and PE
Left side to promote perfusion to uterus
avoid sex
hydration –> dehydration stims pituitary to secrete ADH and Oxytocn
treat infection + have patient report abnormal findings
vitals
monitor FHR and contraction pattern – if tachy for a prolong period could be infection
Risk of PTL
Infections of the urinary tract, vagina, or chorioamnionitis (infection of the amniotic sac)
* Previous preterm birth
* Multifetal pregnancy
* Hydramnios (excessive amniotic fluid)
* Age below 17 or above 35
* Low socioeconomic status
* Smoking
* Substance use
* Domestic violence
* History of multiple miscarriages or abortions
* Diabetes mellitus or hypertension
* Lack of prenatal care
* Recurrent premature dilation of the cervix
* Placenta previa or abruptio placentae
* Preterm premature rupture of membranes
* Short interval between pregnancies
* Uterine abnormalities
Dystocia
Abnromal, long and/or difficult labor as related to the passenger, power, passageway or psyche
Dystocia related to powers
contractions don’t produce progressive dilation, effacement and descent of the presenting part; quantified as the # of contractions in a 10 min window avg over 30 mins
Hypotonic: Arrest of descent/dilation
need to amniotomy –> AROM
Oxytocin augmentation
overdistention – hydaminos + multiparty; must deliver at risk for cord prolapse and infection
Tachysystole: ineffective / erratic contraction pattern
>5 contractions in 10 min time/ 30 mins with less than 60 s of relaxation
–> related to stress + anxiety
Ineffective dilation or pushing
fetal deoxygentation
uterine rupture
Precipitous Labor
rapid labor, is defined as giving birth after less than three hours of regular contractions
Dystocia related to the passenger
abnormal presentation
Malposition: - posterior
Malpresenation:
brow
face
breech
transverse
Dystocia related to the passageway
Cephalopelvic disproportion: fetal head is larger than the maternal pelvic diameter
- lack of descent w. strong contractions
- prolonged labor
Shoulder dystocia –> EMERGENCY!
assistance: use forcepts or vacuum (unless <34wks)
Dystocia Assitance
Forceps
Vacuum
risk: succedaneum, hematoma, intracranial hemorrhage
Labor Enhancers
Pitocin - stimulates contractions
–> drug med error = injury ; lack of timely recognition
Must be medically necessary; preeclampsia, postterm hemorrhage, prom,
Contra: transverse lie, scarring, cephalopelvic, previa, herpes, cord prolapse
Caution: fetal distress, premature, overdistention
want to make sure that cervix is ripe >8 Bishop score
SE: increase contraction, resting tone, HR, decrease BP, water intoxication ICP increase, fetal tachy
Risk: ftal hypoxia, uterine rupture, abruption, hemorrhage, fetal hyptot
C/S
32% and increasing; performed because of factors related to
mother: diabetes, CD, preeclampsia, infection, dystocia, herpes
fetus: distress, malpresentation, position, anomalies
+ other
Classic: vertical: increased risk of uterine rupture in subsequent pregnancies and labor
Transverse: Pfannenstiel’s most common
Risk: infection, hemorrhage, thrombophlebitis, atelectasis
Post Op care:
pain
respir f(x)
I&O
Incision
bowel f(x)
circulation
psychological response
Shoulder Dystocia
Anterior fetal shoulder is behind the pubic bone of the mother
Risks: Fetal macrosomia >4000
diabetes
obesity
previous shoulder dystocia
McRoberts Postion: pelvis tilt orienting symphaysis more horizontally to facilitate should delivery
Cord Prolapse
umbilical cord drops down alongside or infornt of the presenting part.
This can reduce the circulation to the fetus –> vasoconstriction and resultant fetal hypoxia, which can lead to fetal death or disability if not rapidly diagnosed and managed
Care: Trendelenburg or knee-chest. to relieve pressure, elevate part with STERILE gloved hand.
IF CORD IS VISIBLE DO NOT TOUCH, cover with warm, sterile, saline soacked gauze and continuously assess FHR
Amniotic Fluid Embolism
Amniotic fluid escapes into the maternal circulation –> open sinus of the placental site
Can be fatal to the mother; amniotic fluid has debris, lanugo, vernix, meconium
Signs: dyspnea, chest pain, cyanosis, shock
Interventions: delivery, CV and Respir support
Post partum complications
- Postpartum Hemorrhage
- Complications of breast feeding
- Postpartum Infections
- Endometritis
- UTI
- Mastisis
- Wound Infection
- Thrombophlebitis
- Pulmonary Embolism
- Postpartum Psychiatric disorders
Postpartum hemorrhage
most common - 2.9% ~ 183% increase - 125,000 affected ONE OF THE ONLY COUNTRIES WHERE MATERNAL DEATH + INJURIES ARE INCREASING
* Blood loss >500mL after vag * >1000mL after C/S Early Hemorrhage: first 24hrs after delivery; atony Late: 24hrs - 6wks after; retaining of placental tissue
Causes:
1. Tone: uterine atony; overdistention, infarction, rapid labor, placental abnormality, polyhydraminos, fatigue, Pitocin, NSAIDs, anesthetics, Mg Sulfate + placenta at the lower segment of the uterus (doesn’t contract as well)
2. Tissue: retained placenta; commonly with accreta + previa
3. Trauma: damage to the genital tract spontaneously or manipulation/ cerival laceration - forceps DON’T EVER ATTEMPT WITHOUT THE CERVIX BEING FULLY DILATED
Thrombin/Clotting: clotting abnormalities; hemophilia, Von Willebrand, HELLP, abruption, DIC or sepsis
Hematomas can present as pain or as a change in vital signs disproportionate to the amount of blood loss.
Uterine rupture: most common in women who have significant uterine scarring
Risk factors for PPH
Risk Factors of PPH
* Uterine over-distention - multiple, LGA, polyhydraminos, clots
* Previous PPH
* Anesthesia or MgSO4
* Additional drugs used to make the uterus relax - nifedipine, terbutaline
* Operative birth/ assisstive device - vacuum, forceps
* Trauma
* Grand multiparity
* History of maternal anemia + hemorrhage
* Infection
* Uterine inversion or rupture
* Previa or accreta
* Abnormal labor pattern (hypotonia/hypertonic)
* Retained placenta
* Prolonged labor or fast
* Obesity
* Oxytocin admin during labor
Signs of PPH
Signs of impending Hemorrhage
* Excessive bleeding >2 pads/30-1hr; 1 pad >15mL
* Light headedness, nausea, visual disturbances
* Anxiety, pale/ashen, clammy
* Elevated HR, respir rate and or same/lower BP; you’ll see pulse elevation before BP drop – change in vital signs is a late sign of hemorrhage
=MAP = A MAP of 60 is necessary to perfuse coronary arteries, brain + kidneys; usual = 80-110
* Hematomas - 3-500mL of blood; often feel like they need to have a bowel movement due to the pressure
Interventions + medications for PPH
Interventions
* Risk assessment
* Inspect placenta
* Avoid overmanipulating of uterus - don’t want to tire out
* Active Management: Pitocin @ 3rd stage of labor to promote uterine contraction
* If at risk make sure blood match + have IV access
* Fundal massage if they begin to hemorrhage to firm up the uterus
* Empty bladder to prevent overdistrention
Medications: Oxytocin, Cytotec, Methergine, Hemabate
Oxytocin: Produces uterine contractions, vassopressive + antidiruetic.
SE: water intoxication - ADH like behaviors, NV
Conta: none if for PPH
10-49u/500-1000mL >500mL/hr titrated; 10-20mL IM
WATCH FOR BLEEDING + TONE
Methergine: sustained tetanic uterotonic effect that reduces bleeding and shorten the 3rd stage of labor.
SE: HT, Hypot, NV headache
Contra: HT, cardiac, preeclampsia
.2mg IM up to 5 doses 2-4hrs
CHECK BP Before giving don’t give if >140/90 watch bleeding
Misoprotol/Cytotec: Synthetic prostaglandin analog. Mixed results for uterine atony but used for reducing risk of GI ulcers by NSAIDs
SE: headache, NVD, fever, chills
Contra: allergies to prostaglandins
100 - 200mcg tabs – 600 - 1000mcg rectally or sublingually
Monitor bleeding + tone
Hemabate: prostaglandin similar to F2-alpha but has a longer duration. Produces myometrial contractions
SE: headache, NVD, fever, tachy, HT, fever
Contra: Asthma, HT
.25mg IM or intrauterine
Monitor
Caregivers underestimate blood loss by 50%
Most woman are healthy can tolerate blood loss - since most patients give birth doral recumbent need a lot of blood loss before the effects are felt.
Postpartum infections
Puerperal sepsis: any infections of genital canal within 28 days after abortion or birth
* occurs within 28 days after and 6 wks, on 2 successive days within the first 10 days postpartum not including the first 24hrs
* Commonly in C/S
* Leading cause of maternal morbidity + morality worldwide
Pathogens: normal vaginal, cervical or bowel organisms - GBS or E.Coli
Characterized by
* Temperature >100.4 at least 2/10 days post birth
* >101 within first 24hrs
Common infections:
1. Endometritis
2. Wound infections
3. UTI
4. Mastitis
5. Respir
Prevention:
1. Handwashing
2. Perineal hygiene
3. Antibiotic administration
4. Wound management
5. Breast care
Risk Factors Preconception
* History of previous venous thrombosis, UTI, mastitis, infection
* Diabetes
* Alcoholism
* Drug abuse
* Immunosuppression
* Anemia
* Malnutrition
Risk Factors Intrapartum
* Prolonged labor
* Poor aseptic technique
* Birth trauma
* C/S
* Prolonged ROM
* Chorioamnionitis
* Bladder catheterization
* Internal fetal/uterine pressure monitoring
* Vaginal examinations after ruptured membranes
* Epidural anesthesia
* Retained placental fragments
* PPH
* Episiotomy + lacerations
* Hematomas
Endometris/metris
- most common cause of postpartum infection
- Begins as localized infection but can spread – outside uterine cavity
Higher risk if C/S
- Begins as localized infection but can spread – outside uterine cavity
Symptoms
1. Lower abdominal tenderness + pain
2. >100.4 temp + Chills
3. Foul smelling lochia
4. Tachycardia
5. Subinvolution
Treatment
* Broad spectrum antibiotic - take cultures
* Analgesia
* Emotional support
Incidence: <3% Vag; 10-50% C/S
Interventions:
* Monitor vitals q4h
* Assess for abdominal pain
* Monitor lab values, CBC, blood cultures, sed rate
* Antibiotics
* Increase fluid intake
SEMI FOWLERS + AMBULATION = uterine drainage
Wound Infection
- Most commonly at site of incision
- Episiotomy + laceration infections occur less often; symptoms 24-48 hrs
- Aseptic wound management
- Frequent perineal pad changes
- Good handwashing
Admin antibiotic + analgesics
Complications involving breasts
Engorgement, cracked nipples + blocked ducts are increased risk of mastitis
* A sign of engorgement = poor feeding -> good latching best form of prevention of engorgement
= warmth/ warming pad and ice after breastfeed, breast massage
* Cracked nipples = poor latch, baby should feed on other nipple
=lanolin, hydrogeal disks, education on proper latch
* Plugged ducts = inadequate removal of milk from underwire bra, clothing baby should feed on other side
Mastitis: influenza like symptoms
* It can happen any time, most commonly with lactating
* Happens in the upper outer quadrant, can be both breasts most commonly unilateral
* Caused by S.aureaus, can enter through cracked nipples, engorgement + stasis of milk come before
Treatment: antibiotics, continue to breastfeed, warm compress
UTI
straight cath > indwelling = avoid CAUTI
* Frequent cervical exam in labor
* Anesthesia can cause urinary retention = stasis
* GU injury
* C/S
* Atonic bladder + urethra post delivery
Lower UTI
* Dysuria
* Urgency + Frequency
* Suprapubic pain
* Low grade fever
* Hematuria
* Cloudy + smelly urine
Upper UTI
* Pyelonnephritis
* Develops 3-4 days
* Chills + fever
* Costovertebral angle tenderness
* Nausea + vomiting
Symptoms + Treatment
* Burning + pain urination
* Lower adnominal pain
* Low grade fever
* Flank pain
* Proteinuria, hematuria, bacteriuria nitrates + WBC
Assess vitals Q4H
>fluids + I&O
Antibiotics, antipyretics, antispasmodics, antiemetics
Rest
Thromboembolic Disease
formation of blood clots inside blood vessel
1. Superficial thrombosis: involves the veins of the superficial saphenous system
2. Deep thrombosis: lower extremities
3. PE: complication of DVT
Causes: venostasis + hypercoagulation
Declining due to early ambulation
Risks: >fibrinogen, hx of DVT, increased parity, obesity, >35, immobility, C/S, tissue trauma, blood other than O, dehydration
Thrombophlebitis
Assess for hot, red painful, edematous areas of lower extremities + groin >100 temp
HOMAN CONTRA BECAUSE YOU CAN DISLODGE CLOT
Treatment: analgesics rest + elevation superficial
DVT: heparin + coumadin
PE
SS: dyspnea, sweating, pallor, chest pain, cyanosis, confusion, tachypnea, cough, temp, sense of impending death
Treatment: elevate head of bed, O2 8-10L, clot busters
Psychological Complications
- Have implications for mother, newborn + family, can interfere with the attachment + integration, can threaten the safety/ well being
Postpartum Depression - 10 -20%; first 3 mo - 1 yr- Intense, pervasive sadness
- Labile mood swings
- Intense fear, anger, anxiety
- Unable to care for self or infant
- Irritability –> violent outburst
- Rejection of infant
- Obsessive thoughts
Treatment: Edinburgh Scale, Postpartum depression scale - Depression responds best to a combo psychotherapy, medication, social support
Postpartum Psychosis - rare but immediately needs to be treated, psychiatric emergency - Depression, delusion, bizarre + irrational behavior, thoughts of harming self + infant
- Predictors = hx of bipolar or postpartum psychosis
- Risk of homicide + suicide is high
Antipsychotics + mood stabilizers = lithium
Discuss the use of illegal substances or over the counter medications and how they may affect pregnancy
Alcohol - most common
Abnormalities in brain and neuron development
LBW
Prematurity
Fetal alcohol syndrome
Leading cause of mental retardation
Cocaine
maternal cardiac events
Abruption of Placenta**
Fetal effects = vasocon + neuroexcitation
Opioids
Withdrawal - NAS
*should not immediately give narcan as infant will immediately go into withdrawal
Tobacco
Decreased fertility
Increased risk of miscarriage
Placenta Previa
IUGR
long term cognitive function + risk of brain damage
Describe how diabetes affects the pregnant woman and her fetus; identify nursing interventions
The primary concern for any woman with this disorder is controlling the balance between insulin and blood glucose levels to prevent hyperglycemia or hypoglycemia. Women with gestational diabetes are at an increased risk of complications during pregnancy and delivery.
Gestational: If glucose cant get into the cell
Note signs of hyperglycemia (confusion, increased thirst, frequent urination, changes in visual acuity) or hypoglycemia (dizziness; tremors; lethargy; excessive sweating, pale, cool, moist skin).
Discuss hyperemesis gravidarum including causes, symptoms, treatment, and nursing care
Severe NV that causes dehydration, electrolyte imbalance + acid/base imbalance, starvation ketosis + weight loss.
-hypokalemia + natremia
- decrease urea
Peaks @ 9-20wks
Cause: increase of HCG, prog, + E, h.pylori, ambivalence towards preg.
Findings:
● Vomiting that may be prolonged, frequent, and severe
● Weight loss, acetonuria, and ketosis
● Signs and symptoms of dehydration including:
● Lightheadedness, dizziness, faintness, tachycardia, or inability to keep food/fluids down for more than 12 hours
● Dry mucous membranes
● Poor skin turgor
● Malaise
● Low blood pressure
Management:
IV Hydration
B6 or vitamin B6 plus doxylamine
Laboratory studies to monitor kidney and liver function
Correction of ketosis and vitamin deficiency should be strongly considered. Dextrose and vitamins, especially thiamine, should be included in the therapy when prolonged vomiting is present
Discuss hydatidform mole including risk factors, causes, symptoms, treatment, and nursing care
hydatidiform mole is a benign proliferating growth of the trophoblast in which the chorionic villi develop into edematous, cystic, vascular transparent vesicles that hang in grapelike clusters without a viable fetus.
hydatidiform moles are benign, but they sometimes become cancerous. Having one or more of the following risk factors increases the risk that a hydatidiform mole will become cancer.
Partial: may have some fetal tissue
Complete: no fetal tissue
Risk
<20 yrs >35 yrs
Previous molar preg
Risk for woman
increased risk of choriocarcinoma
Assessment:
bleeding + uterine enlargement (big for gestational age)
Anemia
NV
Ultrasound to diagnose
Treatment:
immediate evacuation with aspiration + suction
Nursing actions
no preg for 1 yr, monitor for malignancy
Discuss hypertension in pregnancy, including risk factors, causes, symptoms, treatment(especially Magnesium sulfate) , and nursing care
Hypertension is identified as systolic pressure 140 mm Hg or greater or diastolic pressure 90 mm Hg or greater. Hypertensive disorders of pregnancy are the most common complication of pregnancy, affecting 10 percent of pregnant women, and are the second leading cause of maternal death and a significant contributor to neonatal morbidity and mortality.
● Preeclampsia is a multisystem hypertensive disease unique to pregnancy, with hypertension accompanied by proteinuria after the 20th week of gestation. Eclampsia is the onset of convulsions or seizures that cannot be attributed to other causes in a woman with preeclampsia.
●Chronic hypertension with superimposed preeclampsia includes the following scenarios:
Women with hypertension only in early gestation who develop proteinuria after 20 weeks of gestation.
Women with hypertension and proteinuria before 20 weeks who develop a sudden exacerbation of hypertension,
● Gestational hypertension: Systolic BP ≥ 140/90 for the first time after 20 weeks, without other signs and systemic finding of preeclampsia
● Chronic hypertension: Hypertension (BP ≥ 140/90) before conception. High blood pressure known to predate conception or detected before 20 weeks of gestation
Treatment:
● Magnesium sulfate, a central nervous system depressant, has been proven to help reduce seizure activity without documentation of long-term adverse effects to the woman and fetus.
● Antihypert
● Assess CNS changes, visual, reflexes
Risks for Woman
● Cerebral edema/hemorrhage/stroke
● Disseminated intravascular coagulation (DIC)
● Pulmonary edema
● Congestive heart failure
● Maternal sequelae resulting from organ damage include renal failure, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), thrombocytopenia and disseminated intravascular coagulation, pulmonary edema, and eclampsia (seizures), hepatic failure
● Abruptio placenta
● Women with a history of preeclampsia have a 1.5 to 2 times higher risk of developing heart disease later in life
● obesity
● Chronic HT, kidney disease, lupus, diabetes
Fetal Risk:
● Fetal/neonatal morbidity and mortality are consequences of intrauterine growth restriction (IUGR), prematurity, and placental abruption.
● Fetal intolerance to labor because of decrease placental perfusion
● Stillbirth
At Risk: Cardiac Disease
Increases the demand for cardiac output
Demand on the heart increases – 50%
Signs cardiac issues are worsening
Progressive generalized edema
Crackles at bases of lungs
Rapid, weak irregular pulse (100 bpm or higher)
Difficulty catching breath
Cough
Increased fatigue
Care:
EKG + FHR
Anticoag: warfarin + heparin
O2 + Pulse Ox
Pain management
Make sure placenta is properly perfused
AVOID FLUID OVERLOAD
NO METHERGINE
Treatment for Heroin
Methadone: Most common in pregnancy
Buprenorphione: less side effects than methadone
Naltrexone: opioid antagonist
Diabetes
Type1 : body isnt making insulin - body attacks destroys insulin producing cells.
Autoimmunity of beta cells of the pancreas resulting in absolute insulin deficiency and is managed with insulin. About 5%-10% of patients diagnosed with diabetes are type I
Type 2: body is producing enough insulin but not properly produced overweight can’t stop insulin production. fat deposits on cell can’t open. Characterized by insulin resistance and inadequate insulin production. This is the most prevalent form of diabetes and is linked to increased rates of obesity and sedentary lifestyle. It is managed primarily with diet and exercise; the addition of oral antihyperglycemic or insulin may be indicated if hyperglycemia continues.
- glucose can’t get into cells + trys to get rid of extra w. kidney
Challenge to manage because of
HPL
P
HgH
Corticotropin-releasing hormone
Shift energy source from ketone -> free fatty acid
Treatment:
Euglycemic control
minimize complication
prevent prematurity
-> keep the lowest possible glycosylated hemoglobin w/o going into hypoglycemia
Cardinal Signs
Polyuria
Polydipsia
Weight Loss
Polyphagia
Changes of insulin during pregancy
1st Tri: decreases
2nd-3rd: rises
HPL + Somatropin - hormones from the placenta create insulin resistance
Fetal Risk with Diabetes
Macrosomia – BIG baby >5000g
- baby is big but isnt as mature
IUGR
RDS
Preterm Labor
Regular contractions of uterus resulting in changes in the cervix before 37 wks
PTB = 20 -36 wks
Leading cause of neonatal mortality
Spontaneous: unintentional/planned delivery before 37wks –> can be caused from inflam + infection
Medically Indicated: Provider recommends preterm birth – preecalmpsia
Nonmedically indicated: Elective (NOT RECOMMENDED)
Risks:
Multiple gestation
Uterine/cervical abnormalities
Fetal anomalies
Hydramnios + Oligohydraminos
Infection
Premature rupture of membranes
HT, Diabetes, clotting disorders
<17yrs or >35 yrs
Obesity
Smoking + illicit drug use
Contradictions:
Intrauterine fetal demise
Lethal fetal anamoly
nonreassuring fetal status
Severe preeclampsia + eclampsia
Chorioamnionitis
Warning signs:
Water breaks
decrease fetal movement
Increase vaginal discharge
Fever
Preterm Classifications
Late Preterm: Born 34-37wks
Very Preterm: <32wks
Viability: @ 25wks
Perviability: 40% of infant deaths 20-25wks
Cervical insufficiency
describe the inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester
Preeclampsia
Preeclampsia is a kind of high blood pressure some women get after the 20th week of pregnancy or after giving birth. s high blood pressure and signs that some of her organs, like her kidneys and liver, may not be working normally. Blood pressure is the force of blood that pushes against the walls of your arteries. Arteries are blood vessels that carry blood away from your heart to other parts of the body. High blood pressure (also called hypertension) is when the force of blood against the walls of the blood vessels is too high. It can stress your heart and cause problems during pregnancy.
Imbalance of vasodilator hormones (prostacyclin) and vasoconstrictor hormones (thromboxane)
- Leading cause of maternal death
- 20wks 140/90 @ least 4 hrs apart + proteinuria >300mg or new systemic disease.
“PREECLAMPSIA WITHOUT SEVERE FEATURES” (MILD)
“PREECLAMPSIA WITH SEVERE FEATURES” (SEVERE)
Diagnosis Criteria
>140/>90 mmhg after 20 wks
proteinuria
thrombocytopenia <100,000
renal insufficiency
impaired liver f(x)
PE
Visual symptoms
High Risk:
>35 yr
AA + low socioeconomic
previous preeclampsia with another preg
pregnant w. multiples
have diabetes + HT, kidney disease, AI
obese
GTD
SS
Headache that doesnt go away
Blurred vision
Epigastric pain
trouble breathing
NV
swelling in face + hands
weight gain - 2-5lbs per week
Proteinuria
Thrombocytopenia
Renal insufficiency
Impair live function
Pulmonary edema
Visual symptoms
Risk for fetus
Morbidity
intolerance of labor
still birth
placenta abruption
IUGR
Low birthweight
Treatment
Early detection
Delivery monitor
Hydra Liz one
Mg sulfate
Oral nifedipine
Labetalol
Consequences Maternal
w. eclampsia 20% morality rate – can occure up to 48hrs post
increase risk of
- abruptio placenta
- retinal detachment
- acute renal failure
- cardiac failure
- hemorrhage + stoke
Consequences Fetal
Fetal growth retardation
Hypoxia
Death
Multiple Gestations
+1 fetus - either from the fertilization of one zygote that subsequently divides (MONOZYGOTIC) or fertilization of multiple ova.
● Monozygotic twins are from one zygote that divides in the first week of gestation. They are genetically identical and similar in appearance and always have the same gender.
● Dizygotic twins result from fertilization of two eggs and may be the same or differing genders. If the fetuses are of differing gender, they are dizygotic and therefore dichorionic.
● Either of these processes can be involved in the development of higher order multiples.
In neonatal abstinence syndrome- which of the following potential symptoms are measured by the Finnegan scale?
Temperature
Tone
Tremors
Excoriation
Nasal Stuffiness
https://www.thecalculator.co/health/Finnegan-Score-For-Neonatal-Abstinence-Syndrome-(NAS)-Calculator-1025.html
Whats the rationale for using Eat, Sleep, Console?
- Supports infants and mothers rooming in together during
infant hospitalization - Focuses on non pharmacologic treatments
- Increases breastfeeding rates of opioid exposed newborns (OEN)s
- Decreases pharmacologic treatment and duration of
treatment for OENs - Decreases the average length of stay (LOS) for OENs.
Pre gestational diabetes
Blood glucose is elevated but below clinical threshold
Components:
Central adiposity > 35 in
Dyslipidemia
Hyperglycemia
HT
Maternal Risk:
DKA - 2nd tri
HT
Spontaneous Abortion
Polyhydramnios
Induction of Labor
UTI, Hypergly, Postpartum, post hemorrhage
exacerbation of diabetes symptoms
Fetal Risk:
Congenital defect
Prematurity
Hypogly, cal + mag
asphyxia
respir distress
Still birth
hyperbilirubinemia
polycythemia
● Development of metabolic syndrome, prediabetes, and type II diabetes
● Impaired intellectual and psychomotor development
Gestational Diabetes
hormone made by the placenta prevents the body from using insulin effectively. Glucose builds up in the blood instead of being absorbed by the cells. insulin less effective, a condition referred to as insulin resistance
Two main contributors to insulin resistance are:
● Increased maternal adiposity
● Insulin desensitizing hormones produced by the placenta
risk:
<25 yr
HT, PCOS
Increase in maternal adiposity
insulin desensitizing hormone
Family history/ age/ race/ obesity history of macrosomia
Diagnosis: glucose testing 24-28 wk
Complications:
Macrosomia
Shoulder dystocia
HT + preeclampsia
preterm birth + stillbirth
C-section
Risks for baby
excessive birth weight
preterm
breathing difficulties
hypoglycemia
obesity + type 2 later in life
stillbirth
hyperbilirubinemia
birth trauma
RDS
Prevention:
maintain healthy lifestyle, keep active, don’t gain more weight than recommended
Findings:
Glucose screening 24-28 wks of gestation
Management:
For most women with GDM, the condition is controlled with a well-balanced diet and exercise.
● Up to 40% of women with GDM may need to be managed with insulin.
● Oral hypoglycemic agents may be used, but there is not agreement on their recommended use during pregnancy.
● Cesarean birth is recommended for estimated fetal weight >4,500 g.
● Women with GDM need to be monitored for type 2 diabetes after the birth.
Nursing Actions:
Teach the woman to test glucose four times a day, one fasting and three postprandial checks/day (suggested glucose control is to maintain fasting glucose less than 95 mg/dL before meals, and between 120 to 135 mg/dL after meals)
HELLP Syndrome
HELLP syndrome is a serious pregnancy complication that affects the blood and liver. HELLP stands for these blood and liver problems:
H–Hemolysis. This is the breakdown of red blood cells. Red blood cells carry oxygen from your lungs to the rest of your body.
EL–Elevated liver enzymes. High levels of these chemicals in your blood can be a sign of liver problems.
LP–Low platelet count. Platelets are little pieces of blood cells that help your blood clot. A low platelet count can lead to serious bleeding.
HELLP may develop in women who do not present with the cardinal signs of severe preeclampsia.
Risk for woman:
Abruptio placenta
Renal failure
liver hematoma / rupture
Death
Risk for fetus
Preterm birth
Death
Assessment:
general malaise, nausea, and right upper gastric pain.
unexplained brusing, mucosal bleeding, petechaie
Treatment:
Delivery of fetus + placenta — resolve 48hrs post partum
Eclampsia
occurrence of seizure activity in the presence of preeclampsia
- can be ante, intra + post partum
It can be triggered by cerebral vasospasm, hemorrhage, ischemia, edema
Warning:
persistent headaches
epigastric pain
NV
hyperreflexia w. clonus
restlessness
Treatment
Mg sulfate + hypertensive
Placenta Previa
1/200
The placenta attaches to the lower uterine segment near/over cervix vs. on the body of the fundus
Painless intermittent bleeding
Confirmed by ultrasound
Risk Factors:
scarring
large placenta
infertility, nonwhite, low socio, short interpreg
diabetes, smoking cocaine use
Painless bleeding
Large placenta, Multiple gestation
>35 yrs
Maternal risk:
Hemorrhagic + hypovolemia shock
Blood loos
Fetal Risk:
Disruption of blood flow
Morbidity + morality
Fetal:
Malpresentation
IUGR fetal anemia
Management:
Avoid vaginal exam
Monitor fetal vitals
Check Amniocentesis + BPP - lung maturity
When active bleeding:
* Large bore IV access
* Measure I&O
* Weigh pads — counting or visual estimate is not sufficient (1gm=1ml)
* CBC, coagulation studies, T&X
* Oxygen to keep pulse ox > 95%
* Anticipate possible emergent cesarean birth
Bright red bleeding
Placenta Abruption
Partial complete detachment of placenta
- hematoma forms + destroys the placenta around it
dark red bleeding
The major clinical findings are vaginal bleeding and abdominal pain, often accompanied by hypertonic uterine contractions, uterine tenderness, and a nonreassuring fetal heart rate (FHR) pattern
Grade:
1(mild) least amount of separation
2 (moderate)
3 (Severe) more separation + blood
Risk Factor
decreased placenta perfusion
HT
Seizure
Blunt trauma to the maternal abdomen
history of abruption
smoke/cocaine use
Risk for Fetus:
LBW, asphyxia, still birth
SS
Sudden onset of intense pain
board-like rigidity to the abdomen
uterine irritability
tachystole
vaginal bleeding
port wine stain amniotic fluid
Management
assess fundal height
girth measurement
shock
weigh pads
Restoring blood loss
Anticipation and prepare for emergency delivery.
check for DIC
Partial abruption: concealed bleeding – retroplacental
Partial abruption: marginal bleeding placenta is halfway torn - bleeding is apparent
Complete abruption: bleed could be concealed or apparent
Placenta Accreta
The partial/complete placenta invades and becomes inseparable from the uterine wall.
0 leads to hemorrhage + may need a hysterectomy
- 3000 - 5000 mL blood loss
As many as 90% of patients with placenta accreta require blood transfusion, and 40% require more than 10 units of packed red blood cells
Risk factors
myometrial damage caused by C/S
Advanced maternal age
Multiparity
Risks for woman
Hemorrhagic + hypovolemic shock ~ 25-30% morbidity
Increase risk of infection, thromboembolism, pyelonephritis, pneumoia, ARDS + renal failure
Surgical complications
Risk for Fetus
Preterm ~ normally 34-36wks
Assessment: Ultrasound
Treatment:
Planned c/s + hysterectomy
Actions:
Monitor CBC + clotting
emotional support
Abortion
Spontaneous or elective termination of pregnancy <20wks
Induced: medical/surgical abortion before fetal viability
Elective: at the request of the woman but not for a medical reason
Therapeutic: abortion because of abnormalities
Spontaneous: nonviable intrauterine preg w. either empty gestational sac or gestational sac containing embryo/fetus w/o heart activity 126/7 wks —> miscarriage
Termination of preg done transcervical by dilation of the cervix, evacuation, fetus out by cuttage, scrapping + vacuum
Meds: mifepristone +misoprostol
Ectopic Preg
Fertilized egg grows outside uterus as a result in blastocyst implanting itself other than endometrial lining
- stunted growth + will be nonviable.
- 95% happen in fallopian tube, 5% other ovary, abdominal cavity, cervix
- most are tubual + tube lacks submucosal layer but can’t support the growth of the tropoblast
Risks:
Pelvic inflam disease
infertility
endometriosis
STI
smoking
Management:
* SALPINGOSTOMY/SALPINGECTOMY
* METHOTREXATE
* MONITOR FOR BLOOD LOSS
* EMOTIONAL SUPPORT
Hydatiform Mole
Grape Like Cysts
1. complete: fertilization of empty ovum (no embryonic tissue found)
2. Partial: some fetal tissue; normal ovum but 2 sperm 1/1500birth
1/1500 pregnancies
* WOMEN WITH LOW PROTEIN INTAKE
* >35 YEAR-OLDS
* ASIAN WOMEN
* EXPERIENCED PRIOR MISCARRIAGE
* UNDERGONE OVULATION STIMULATION (CLOMID)
SS:
Rapidly growing uterus, vaginal bleeding, NV.HT. Abnormally high hcg
* NAUSEA/VOMITING
* HYPERTENSION
* ABNORMALLY HIGH HCG LEVELS
* NO FETAL HEARTBEAT
* ULTRASOUND: NO FETUS (ONLY CYSTS)
Management:
no preg for 1 yr, monitor for malignancy
Monitor of malignancy
20% BECOME MALIGNANT
Polyhydraminos
excessive amniotic fluid >2000mL
associated with fetal GI anomalies + maternal diabetes
Treatment:
remove amniotic fluid
Oligohydramnios
scanty amniotic fluid <500mL
risk: fetal adhesion + malformations
Treatment: amniofusion
Infant Danger Signs
Tachypnea
retraction of chest wall
grunting/ flaring
lethargy
abnormal temp
hypogly
abdominal distension
failure to pass meconium in 48 hrs
failure to void in 24 hrs
convulsions
jaundice <24hrs
jitteriness
cant keep constant temp
Newborn Vitals
Pulse 110 - 160 bpm (sleep <70)
Respiration 30 -60
BP: 70-50mmHg - 90/60 @ day 10
Temp: Ax 97.7-99
skin 96.8 - 97.7
97.8 - 99
Caput succedaneum
swelling under the skin of the scalp - fluid filled
crosses suture lines
Cephalhematoma
collection of blood from broken blood vessels that build up under scalp `doesnt suture line
Craniosynostosis
premature closure of suture
- restricts growth perpendicular + compensatory overgrowth in unrestricted regions
List the critical elements of performing a neonatal assessment
APGAR
Birth Weight
Measurements: Head, chest + length
Vitals: temp, pulse, respiration
Gestational assessment
Physical maturity: Ballard exam + Dubowitz
Points are given for each area of assessment. A low of -1 or -2 means that the baby is very immature. A score of 4 or 5 means that the baby is very mature (postmature). These are the areas looked at:
Skin textures. Is the skin sticky, smooth, or peeling?
Soft, downy hair on the baby’s body (lanugo). This hair is not found on immature babies. It shows up on a mature infant, but goes away for a postmature infant.
Plantar creases. These are creases on the soles of the feet. They can be absent or range up to covering the entire foot.
Breast. The provider looks at the thickness and size of breast tissue and the darker ring around each nipple (areola).
Eyes and ears. The provider checks to see if the eyes are fused or open. He or she also checks the amount of cartilage and stiffness of the ears.
Genitals, male. The provider checks for the testes and how the scrotum looks. It may be smooth or wrinkled.
Genitals, female. The provider checks the size of the clitoris and the labia and how they look.
Physical exam
General appearance. This looks at physical activity, muscle tone, posture, and level of consciousness.
Skin. This looks at skin color, texture, nails, and any rashes.
Head and neck. This looks at the shape of head, the soft spots (fontanelles) on the baby’s skull, and the bones across the upper chest (clavicles).
Face. This looks at the eyes, ears, nose, and cheeks.
Mouth. This looks at the roof of the mouth (palate), tongue, and throat.
Lungs. This looks at the sounds the baby makes when he or she breathes. This also looks at the breathing pattern.
Heart sounds and pulses in the groin (femoral)
Abdomen. This looks for any masses or hernias.
Genitals and anus. This checks that the baby has open passages for urine and stool.
Arms and legs. This checks the baby’s movement and development.
Describe reflexes present in a neonate
Moro: startle reflex - lifts arms and legs curl them back toward body and throw head back
abnormal Moro reflex which only involves one side of the body. Other babies may have no Moro reflex at all. Some causes of an abnormal or absent Moro reflex may include infections, muscle weakness, injuries from childbirth, peripheral nerve damage and spastic cerebral palsy. disappear around 6 mo.
Rooting: when you touch the cheek of an infant baby turns head
The rooting reflex in babies usually lasts for about four months. After that, rooting becomes a voluntary response rather than a reflex
Sucking: 32 weeks inside the mother’s womb. roof of the mouth is stimulated or when you place the mother’s breast or a bottle in his/her mouth, the baby will place the lips over the nipple and squeeze it between the tongue and roof of the mouth. Next, the baby will move his/her tongue to the nipple to suck and milk the breast. The sucking reflex usually lasts until the baby is four months old.
Tonic Neck: fencing reflex, the tonic neck reflex happens when the baby’s head turns to one side. This is triggered when you stroke or tap the side of the baby’s spine while the baby lies on his/her stomach.
Tonic neck reflex may last until the baby is around five to six months old.
Grasp: stroking or touching the palm of a baby may cause the baby to automatically close his/her hands. The grasp reflex may last until the baby is about five to six months old.
Babinski: firmly stoke the sole of the baby’s foot. The baby’s big toe moves upward or toward the top of the foot and the other toe fans out. until the child is about two years old, but for some, it goes away after a year.
Stepping: walking or dancing reflex. Stepping reflex happens when you hold the baby upright with his/her feet touching a flat surface. You will notice that the baby will move his/her legs as if he/she is walking or trying to take steps although the baby is still too young to actually walk. lasts for about two months.
Defensive reflexes
Blinking
Cough
Gag
Sneeze
Yawn
Extrusion
Define APGAR and its indication
Test checks a baby’s heart rate, muscle tone, and other signs to see if extra medical care or emergency care is needed. Babies usually get the test twice: 1 minute after birth, and again 5 minutes after they’re born. tells the health care provider how well the baby is doing outside the mother’s womb
heart rate
0- absent
1 -60-100
2 >100
Respir
0-absent
1- slow irregular weak
2 cry
Reflex
0-no response
1-grimace
2-cry
Color
0 cyanotic
1pink and blue
2 pink
Muscle tone
0flaccis
1some flexion
2active motion
Identify critical adjustments the newborn makes in the transition to extra uterine life
EXTRAUTERINE PHYSIOLOGIC TRANSITIONS
* RESPIRATORY, CIRCULATORY, THERMOREGULATION
Identify ways to promote neutral thermoregulation
blocking avenues of heat loss, and applying adequate radiant warmth.
defined as the external temperature range within which metabolic rate and hence oxygen consumption are at a minimum while the infant maintains a normal body temperature
Screening for Gestational Diabetes
Test: 24-28 wks
POS > 140 –> 3 hr –> Fasting 95, 1hr 180, 2hr 155, 3hr 140 –> POS need 2+ values for diag Neg 1 value. retest at 32wks
NEG <140 –> routine prenatal care
RH Alloimmunization
occurs when a woman’s immune system is sensitized to foreign erythrocyte surface antigens, stimulating the production of immunoglobulin G (IgG) antibodies.
Rh- woman at risk of having baby with hemolytic anemia
Sensitized woman:
Fetal blood + maternal blood mix and Rh- mother and Rh+ fetus create IgM antibodies.
Rhogam won’t help but will help for the next pregnancy
Intervention:
Indirect Coombs - detection of Ab circulating in blood
monitor pregancy
delivery
correct fetal anemia - Intrauterine transfusion
Transfusion of erythropoietin + iron
Management:
Rhogam @ 28wks
if Rh+ newborn repeat dose of Rhogam within 72hrs NO NEED IF Rh-
GIVEN ANYTIME RISK OF BLOOD MIXING
test father
WHEN MIGHT YOU ADMINISTER RH IMMUNOGLOBULIN?
* AFTER BIRTH OF AN RH+ INFANT
* AFTER SPONTANEOUS OR INDUCED ABORTION
* AFTER ECTOPIC PREGNANCY
* AFTER INVASIVE PROCEDURES DURING PREGNANCY
* AFTER MATERNAL TRAUMA
ABO Incompatibility
MOST COMMON INCOMPATIBILITY ISSUE
Herpes Simples Virus
1/6 infected
FETAL RISK:
-spontaneous abortion
-preterm labor IUGR + infection
MUST DELIVER C/S during outbreak
Antivirals after 36wks - ACYCLOVIR want to reduce the viral load (inhibits viral shedding)
GBS
In the vaginal tract + GI
RISK: STILL BIRTH
Want to decrease the bacterial load before birth to reduce infant infection.
Medications: penicillins + antibiotics
Mg Sulfate Toxicity
- Urinary output <20ml/hr
- Blood pressure 104/62
- respiration of 7
- absent reflexes
- lethargy
- excitability
General Measurements for Infant
- WEIGHT
- AVERAGE FULL TERM (7LB 8 OZ); RANGE OF 2500-4000 G
- 70-75% NEWBORN’S BODY WEIGHT WATER
HEAD CIRCUMFERENCE
* AVG 33-35 CM
* 2 CM GREATER THAN CHEST CIRC.
* MEASURED PROMINENT PART OF SKULL
CHEST CIRCUMFERENCE
* NIPPLE LINE
ABDOMINAL CIRCUMFERENCE
* LENGTH
* AVG RANGE 18-22 INCHES (48-52 CM)
WHAT IS THE DIFFERENCE BETWEEN PHYSICAL ASSESSMENT AND
GESTATIONAL ASSESSMENT?
Gestation Age: Ballard score – number of weeks infant is during the gestational age
GESTATIONAL AGE CAN PREDICT AT-RISK INFANTS , AND CAN HELP YOU KEEP ALERT FOR PROBLEMS
Physical assessment: checking the physical appearance, auscultation, vitals muscle tone, level of consciousness
Normal Findings of Infant’s head
ANTERIOR FONTANELLE
* DIAMOND SHAPED
* CLOSES: 18 MONTHS
* POSTERIOR FONTANELLE
* TRIANGLE SHAPED
* CLOSES: 8-12 WEEKS
* WHAT’S NORMAL?
* NO BULGING
* NO DEPRESSION
Normal Findings of Infant’s eyes + ears
TEARLESS CRYING
* PERIPHERAL VISION
* CAN FIXATE ON NEAR OBJECTS
* CAN PERCEIVE FACES, SHAPES AND COLORS
* BLINK IN RESPONSE TO BRIGHT LIGHT
* PUPILLARY REFLEX IS PRESENT
Variation: subconjunctival hemorrhage
EARS
* SOFT AND PLIABLE
* READY RECOIL
* PINNA PARALLEL WITH INNER AND OUTER CANTHUS
Variation: low set ears
Skin tag
Normal Findings of Nose and Mouth
NOSE
* SMALL AND NARROW
* MUST BREATHE THROUGH NOSE
* ASSESS FOR CHONAL ATRESIA
Variation: tight frenulum
MOUTH
* LIPS PINK
* TASTE BUDS PRESENT
* FLAT PHILTRUM
* ANKYLOGLOSSIA (TONGUE TIED)
* EPSTEIN PEARLS-KERATIN CONTAINING
CYSTS – NO SIGNIFICANCE
Variations: cleft lip
Normal findings of infants chest
CHEST – CYLINDRICAL
* BREASTS – ENGORGED, WHITISH SECRETION
* RESPIRATIONS
* DIAPHRAGMATIC
* 30-60 PER MINUTE
* HEART RATE 110-160 BPM
* NORMAL HEART SOUND
* MURMUR SOUND
Signs of Respiratory Distress in Infants q
- NASAL FLARING
- INTERCOSTAL , SUBSTERNAL OR
XIPHOID RETRACTIONS - EXPIRATORY GRUNTING OR SIGHING
- SEESAW RESPIRATIONS
- TACHYPNEA
Barlow + Ortolani test
instability of the hip may be assessed/ development of dysplasia
Variations of genitals
Female:
Vaginal tag
Pseudomenstration + uric acid crystals
Male:
HYPOSPADIAS
* PHIMOSIS
* HYDROCELE - one big teste
* CRYPTORCHIDISM
Variation of skin
Acrocyanosis: CAUSED BY POOR PERIPHERAL CIRCULATION
Mottling
Jaundice
Erythema Toxicum
Milia
* VERNIX CASEOSA
* FORCEPS MARKS
* TELANGIECTATIC NEVI
* MONGOLIAN SPOTS
* NEVUS FLAMMEUS
THERMOREGULATION
EVAPORATION
*(H2O VAPOR)
* CONVECTION
* (AIR CURRENTS)
* CONDUCTION
* (DIRECT SKIN CONTACT)
* RADIATION
*(INDIRECT SOURCE)
Large body surface in relation to mass
less insulating fat
LESS ADIPOSE TISSUE
* PRETERM
* SMALL FOR GESTATIONAL AGE (SGA)
* BROWN FAT METABOLISM
Response to cold:
Increase metabolic rate + muscle activity
peripheral vasocon
metab of brown fat
Excess heat loss = hypothermia
consequences
hypogly
metabolic acidosis
decrease surfacant
respir distress
hypoxia
delayed fetal neonate circ
weight loss
risk factors
preterm
SGA
sepsis
prolonged resuscitation
hypo
neurolog, CV or endocrine
Signs:
<97.7
cool skin
lethary
pallow
jitteriness
tachypnea
grunting
hypotonia
weak suck
Behavioral characteristics extrauterine life
Period of reactivity - awake crying respirations high and irregular
period of inactivity - sleeping 2 hrs
second period of reactivity - cycle through active/quiet alert
increae in bowel activity
interested in feeding
Transition to extrauterine life – respiratory system
- Air replaces fluid
PROCESS OF LABOR
¨ INITIAL INFLATION OF LUNGS
§ MECHANICAL STIMULATION
§ FIRST BREATH/GASP
* SURFACTANT NEEDED FOR ALVEOLAR STABILITY
* DECREASES SURFACE TENSION
* INCREASES COMPLIANCE
* LECITHIN VERSUS SPHINGOMYELIN (L/S RATIO) 2:1 - onset of breathing
BREATHING STIMULATED
* CHEMICAL STIMULATION:
* ↓PH: DIRECTLY STIMULATES RESPIRATORY CENTER
* ↓PO2 AND ↑PCO2: STIMULATE RESPIRATORY CENTER VIA CENTRAL/PERIPHERAL
CHEMORECEPTORS
* PROSTAGLANDINS (SUPPRESS RESPIRATIONS) DROP WITH CLAMPING OF CORD - increase in pulmonary blood flow
BLOOD FLOW INCREASES TO LUNGS
* OXYGENATION OCCURS
compression of thorax squeezes amniotic fluid from lung - lung expansion increase O2 + vasodil
First breath: increase aveolar O2 + decrease arterial pH –> dilation of pulmonary artery –> decrease pulmonary vascular resistance –> increase blood flow –> increase O2 + CO2 exchange
Mechanical stimulation: compression of the throax; passive inspiration fluid out air in
Sensory: tactile, auditory + visual
Thermal: coming from warm aqueous environment to cooler – stimulates breath
Chemical: birth stimulates mild hypercapnea - increase CO - hypoxia/ acidosis
Transition to extrauterine life - Circulatory System
FETAL CIRCULATION
* HIGH PULMONARY VASCULAR RESISTANCE:
* OXYGENATION OF FETUS OCCURS IN PLACENTA (PLACENTA IS LOW RESISTANCE)
Neonatal circulation - MAJOR PHYSIOLOGICAL CHANGES
SYSTEMIC VASCULAR RESISTANCE INCREASES/ PULMONARY ARTERY
PRESSURE DROPS:
* AFTER CORD CLAMPED/PLACENTAL CIRCULATION LOST
Closure of fetal shunts
Foramen Ovale - closes when L atria pressure > than right
Ductus Arteriosus - connects pulmonary a w. descending aorta; closes 15hrs post birth could remain open if lungs fail to expand or when PaO2 levels drop
Ductus Venosus - closes by day 3
Cardiac Function - Neonatal
HEART RATE
* 110–160 IN FIRST WEEK OF LIFE: APICAL FOR 1 FULL MINUTE
* SLEEPING TO 100
* CRYING TO 180
* BLOOD PRESSURE (BP)
* AVERAGE 70-50/45-30 MMHG AT BIRTH
* HEART MURMURS
* 90% ARE TRANSIENT
* CARDIAC WORKLOAD
* RIGHT VENTRICLE STRONGER AT BIRTH
Difficult Transition
Maternal conditions - diabetes, HT
Fetal Conditions - congenital anomalies
Antepartum conditions - placenta/ amniotic fluid
Delivery complications
Neontal difficulties
-lack of respir effort
- Blockage
- impaired cardiac + lung f(x)
Neonatal warning signs
Tachypena
rectration of chest wall
grunting + flaring
Lethargy
Abnormal temp
Hypogly
abdominal distention
failure to pass meconium in 48 hrs
Failure to void 24 hrs
convulsions
jaundice <24hrs
jitteriness
can’t maintain temp
PKU
required metabolic testing by state.
Unable to metabolize phenyalanine – amino acid.
Builds up phenydryrovic + acetic acid = brain damage
before discharge
Hep B and IgG should be administered within 24hrs
PKU
Congential heart screen
hearing screen
Parental Edu
5 rights of teaching: time, context, goal, content method
feeding cues
bathing
holding infant
changing diaper
cord care/circumcision
normal voiding + stooling
Car seat safety - r infant or toddler should ride in a rear-facing car safety seat
shaken baby
sleep position
SIDS
Signs of illness
Timing + Frequency of Assessmesnts
30s of life
- evaluating transition
NEONATAL RESUCITATION PROGRAM
-Thermoreg
-APGAR
-Physical examination
- newborns gestational classification
Admission Assessment:
Physical Assessment
General measurement
Gestational age - within 4hrs – predicts at risk infants
On going
Progress of adaptation
nutritional status - ability to feed
behavioral state
Ballard Score
6 physical and 6 nerve and muscle development (neuromuscular) signs of maturity. The scores for each may range from -1 to 5. The scores are added together to determine the baby’s gestational age.
Posture: no flexion 0 arms and legs very flexed 5
Square window: >90 -1 0 -4
Arm recoil: 180 -1, <90 4
Popiteal: >180 -1 <90 5
Scarf: can over cross arm -1 can cross midline 4
heal to ear: all the way -1 only to hip 4
skin: transparent -1 leathery 5
lanugo: none -1 mostly bald 4
plantar: smooth -1 creases 4
breast imperceptible -1 full areola 4
eye/ear: fully fused -1 thick cartilage 4
genitals: smooth/ prominent clitoris -1 rugage disent + majora covers 4
Behavioral States
Deep Sleep
Light sleep
drowsiness
quiet alert
active alert
crying
Behavioral response
Habituation: prevents overstimulation
Orienting response: ability to follow objects
motor organization: spontaneous movement
consolability: ability to self sooth
cuddliness: response to being held
Metabolic system
Glucose values decrease within1 hr but stabilize 2-3hrs
-optimal 70-100mg
-hypo = <40mg/dl
Risks:
diabetic mom
>4000g or LGA
Hypothermia
neonatal infection
Respir distrress
post/pre term
SGA
neonatal resuscitation
birth trauma
SS
jitteriness
apnea
hypotonia
irritability
lethary
temp instability
Latch score
Latch
Audible swallow
Type of nipple
Comfort
Hold
0 -2
0 too sleepy
1 attempt
2 grasps breast
Hematopoietic adaptations
blood vol = 80-90 ml/kg of body weight – delaying cord clamp can increase to 100ml
erythropoietin secreted
RBC lifespan shorter than an adult - 90 days
leukocytosis is normal
Hepatic Adaptation
40% of abdomen + is palatable
iron storage; 5-6 mo
Regulation of glucose; ability to convert glycogen to glucose >40mg/dl
Coag of blood
Bilirubin conjugation –> needs to be conjugated in order to be excreted.
Hyperbilirubinemia
HEME (IRON) + GLOBIN (PROTEIN)—–’HEME’ FRAGMENTS
FORM UNCONJUGATED/INDIRECT BILIRUBIN (FAT
SOLUBLE—CAN’T EXCRETE)
BILIRUBIN ENZYMATICALLY CONVERTED (CONJUGATED) IN LIVER
* WATER SOLUBLE FORM (DIRECT BILIRUBIN) – ELIMINATED IN URINE AND STOOL.
- NEED ACTIVE INTESTINAL ELIMINATION AND HEPATIC CIRCULATION
- REQUIRES ADEQUATE CALORIES AND HYDRATION
- A DELAY IN FEEDS CAUSES RE-ABSORPTION FROM INTESTINE» INCREASES SERUM LEVELS
Newborn at risk because
more destruction of RBC
ABO/Rh incompatibility
Delayed cord clamping
bruising + birth trauma
decreased liver f(x)
drugs
maternal enzymes
Breastfeeding Jaundice: poor feeding dehydration peaks 2-4 days of life
Breastmilk jaundice - appears healthy peak 2-3 wks stop feeding for 12-24
genetic componet related to milk consumption
Car seat safety
In order to pass the infant care seat challenge, the premature neonate must be able to maintain adequate oxygenation, heart rate, and respiratory rate during trial.
Conditions Present At Birth
IUGR
SGA/LGA
Preterm
Diabetic
CHD
Errors of metab
Substance abuse
Classification on size
LBW - low birth weight <2,500 but greater than 1,500
VLBW - very low <1,500
AGA - avg gestational age
SGA - small for gest. age - newborn is normal but small; may have had delayed growing asym IUGR
LGA - large for gest age
IUGR Assoc Factors
Fetal factors:
Conditions that affect growth: chromosomal, TORCH, malformation
Maternal: Chronic HT, Age <15, >35, drug exposure, use + asthma
Placental: inadequare delivery of nutrients; abruption utero insufficiency
Patterns;
Symmetrical: <28wks
organs of normal size
symmetrically small
chromosomal abnormalities
Asymmetrical: >28wks - rapid cell proliferation
hyperplasia/hypertrophy
malnutrition
Normal # cells
Brain Heart larger
problems could be corrected by proper nutrition
SGA Assessment
Head is disproportionally large in comparison to rest of body
wasted appearance of extremities
reduced subcutaneous fat
scaphoid abdomen
wide skull sutures
Poor muscle tone
loose dry skin
thin umbilical cord
Complications
Chronic hypoxia; decrease tolerance to labor–> could lead to organ dysfunction
Hypogly; not enough glycogen reserves not enough fat
Hypothermia
Polycythemia - response to chronic hypoxia - bone marrow stim to create RBC
Factors contributing
Congenital malformation - more severe IUGR more severe malformation
Intrauterine infection - TORCH (toxo, rubella, CMV, herpes)
Hypoxia - learning disabilities / cognitive difficulties
Interventions
free of respir compromise
stabilize temp + hypogly
LGA Assessment
> 90% of babies >4000g
ANTICIPATE PLAN FOR DELIVERY
Birth trauma : cephalopelvic disproportion, macrosomia, brachial injury, nonreassuring FHR, body dytocia
increased risk of c/s
hypogly
polycythemia - type of blood cancer. It causes your bone marrow to make too many red blood cells. These excess cells thicken your blood, slowing its flow, which may cause serious problems, such as blood clots
Infant of diabetic mother
complications: hypogly, hypcalcemia, hyperbili, birth trauma, polycythemia, RBS, malformation
Post Term Baby
> 42 wks - 4-14% of pregnancies
-Post maturioty syndrome due to deterioration of placenta f(x)
Risk of perinatal asphyzia + meconium passage
polycythemia
Hypogly
decrease in amniotic fluid = cord compression at risk for MAS
Maturity classification
Term: 37-40 weeks
Postterm: 42+ wks
Late preterm: Your baby is born between 34 and 36 completed weeks of pregnancy.
Moderately preterm: Your baby is born between 32 and 34 weeks of pregnancy.
Very preterm: Your baby is born at less than 32 weeks of pregnancy.
Extremely preterm: Your baby is born at or before 25 weeks of pregnancy.
FAS
IUGR, Facial anomalies - .5 -2 / 1000
Small head <10%
Effects of exposure to alcohol
Phenotypic - include growth restriction + CNS abnormalities + facial dysmorphology
- small eyes, smooth philtrum, thin upper lip
Cognitive + behavorial disabilities
Interventions: reduce stimuli, extra feeding time, reinforce parenting
Immunological Adaptations
NOT FULLY ACTIVATED
* FEVER NOT RELIABLE INDICATOR OF INFECTION
* IGG CROSSES PLACENTA
* PASSIVE ACQUIRED IMMUNITY
* TRANSFERRED PRIMARILY IN THIRD TRIMESTER
* BEGIN IMMUNIZATIONS AT 2 MONTHS OF AGE
* IGA IN COLOSTRUM
* PROVIDES PASSIVE IMMUNITY
A neonate is born at term and the nurse is teaching the parents how to avoid cold stress after discharge. Which suggestions does the nurse give the parents to help avoid cold stress? Select all that apply.
Keep the baby wrapped in a warm blanket.
Position the baby away from vents and drafts.
Place a stocking cap on the neonate’s head.
Change wet clothing immediately.
A patient delivers a term neonate and expresses concern about the reason for giving the neonate an injection. Which information from the nurse is accurate?
Vitamin K is needed to activate clotting factors.
A patient in the first stage of pregnancy is discussing the options for feeding her infant, and asks the nurse, “Which is the most important reason I should consider breastfeeding my baby?” How does the nurse respond?
Human milk contains multiple antibodies, enzymes, and immune factors.
The nurse is assessing a newborn’s reflexes. Which response should concern the nurse?
Asymmetrical Moro reflex
This response may be related to temporary or permanent birth injury to clavicle, humerus, or brachial plexus. This reflex disappears by age 6 months. This is a priority reflex to assess in a newborn.
A mother who is breastfeeding expresses concern about whether her infant is getting enough milk. Which concrete indicator demonstrates that the baby is getting enough milk?
There are at least eight wet diapers and several stools per day.
The most concrete indicator that the breastfeeding baby is receiving enough milk is at least eight wet diapers and several stools per day.
A breastfeeding mother is planning to return to work 3 months after her baby is born. The mother is planning to use an electric breast pump and freeze some breast milk for use later. Which information does the nurse need to provide?
Breast milk can be kept in a deep freezer for 6 to 12 months.
Breast milk can be safely kept in a deep freezer for 6 to 12 months; in a freezer attached to a refrigerator, it can be safely stored for 3 to 6 months.
Fetal Heart
foramale ovale: small hole in the septum of upper part of heart
ductus arteriosus: bv in the developing fetus that connects trunk of pulmonary artery to proximal descending aorta
Ductus venosus: bv that shunts a portion of umbilicord blood flow to ivc
pulmonary bv: high resistance in utero
Benefits of breastfeeding
HEALTHY PEOPLE 2020 GOALS;
◦ 81.9% OF MOTHERS INITIATE BREASTFEEDING IN THE EARLY POSTPARTUM
PERIOD
◦ 25.5% EXCLUSIVELY BF AT 6 MONTHS
◦ 34% CONTINUE AT 1 YEAR
INITIATE BREAST-FEEDING WITHIN 1 HOUR OF BIRTH
§BREAST ONLY – NO BOTTLES, ARTIFICIAL NIPPLES, PACIFIERS
§ROOMING-IN WITH UNRESTRICTED BREAST-FEEDING
§NO FOOD OR DRINK OTHER THAN BREAST MILK UNLESS
MEDICALLY INDICATED
Contradictions of BF: HIV, untreated TB, T-cell Leukemia, toxic chemicals, illicit drug use, babies with galactosemia antimetabolites + chemo
Newborn nutrition requirments
CALORIES 100-120KCALS/KG/DAY
* PROTEIN FOR CELL GROWTH: WHEY AND CASEIN
* CARBOHYDRATES FOR ENERGY
* FAT FOR BRAIN AND CNS DEVELOPMENT
* FLUIDS 100-150 ML/KG/DAY
* IRON: RESERVES DEPLETED BY 5-6 MONTHS; FLURIDE
* VITAMIN D, K
Types of milk
COLOSTRUM
◦THICK WATERY CONSISTENCY,
YELLOW
◦HIGHER IN PROTEINS, FAT SOLUBLE
VITAMINS, AND MINERALS THAN
MATURE MILK
◦EASY TO DIGEST
◦MATERNAL ANTIBODIES
TRANSITIONAL MILK
IMMUNOGLOBULINS AND PROTEIN DECREASE
LACTOSE, FAT AND CALORIES INCREASE
VITAMIN CONTENT EQUAL TO MATURE MILK
20 CAL/OUNCE
PROVIDES NUTRIENTS FOR FIRST 4-6MONTHS
8-12 FEEDINGS IN A 24 HOUR PERIOD
Mature Milk - adjusts to infant’s needs
Newborn at risk
High risk newborn can be defined as a newborn, regardless of
gestational age or birth weight, who has a greater-than-average
chance of morbidity (illness) or mortality (death) because of
conditions present at birth or the stress of birth itself.
High risk period encompasses human growth and development
from age of viability up to 28 days after birth.
Includes the prenatal, perinatal and postnatal periods
Complications
Common problems that can appear
in newborn period Gestational age and birthweight –related issues
Drug exposure
Congenital anomalies
Hypothermia
Hypoglycemia
RDS
TTN
MAS
PPHN
Sepsis
Hyperbilirubinemia
Identifications of risk
Mortality: neonatal period 1-28 days
Morbidity: risk decreases as gestational age and birthweight increase
Clinical manifestations of withdrawal in newborns
CNS:
hyperactivity
hyperirritability
increased muscle tone
exaggerated reflex
tremors + jerks
sneezing hiccups yawning
short unquieted sleep
fever
Respir
Tachy >60
excessive secretions
GI:
disorganized vigorous suck
vomit
droooling
sensitive gag reflex
hyperphagia
diarrhea
poor feeding <15ml for 1st day of life + 30mins or more
Vasomotor:
Stuffy nose, yawning sneezing
flushing
sweating
sudden circumoral pallor
Cutaneous signs
excoriated buttocks, knees elbows
facial scratches
pressure point abrasions
Nursing Plan and Implementation for Infants of Substance
Abusing Mothers
ospital-based nursing care
◦ Reducing withdrawal symptoms
◦ Promote adequate respiration, temperature, nutrition◦ Carefully monitoring pulse and respirations
◦ Monitoring temperature for hyperthermia
◦ Providing small, frequent feedings,
◦ Administering medications as ordered
◦ Swaddling
·EAT, SLEEP, CONSOLE: prioritizes a
newborn’s inability to take an age-
appropriate volume of food, sleep
more than one hour after feeding, or
be consoled within ten minutes.
·Finnegan Symptom Prioritization
Signs of Hypoglycemia
Signs of hypoglycemia:
Jittery
Tachypnea
Diaphoresis
Hypotonia
Lethargy
Apnea
Temperature instability
Hyperbilirubinemia
The majority of bilirubin is produced from the breakdown of Hb into
unconjugated bilirubin (and other substances). Unconjugated bilirubin binds to
albumin in the blood for transport to the liver, where it is taken up by
hepatocytes and conjugated with glucuronic acid by the enzyme uridine
diphosphogluconurate glucuronosyltransferase (UGT) to make it water-‐soluble.
The conjugated bilirubin is excreted in bile into the duodenum. In adults,
conjugated bilirubin is reduced by gut bacteria to urobilin and excreted.
Neonates, however, have sterile digesive tracts. They do have the enzyme β-‐
glucuronidase, which deconjugates the conjugated bilirubin, which is then
reabsorbed by the intestines and recycled into the circulation. This is called
enterohepatic circulation of bilirubin
PHYSIOLOGIC JAUNDICE
Hyperbilirubinemia commonly occurs ager first 24 hours (typically 2-‐5 days)
Increased bilirubin related to rela:ve polycythemia and short life span of fetal red bloods (80 days)
Decreased uptake of bilirubin by the liver
Decreased enzyme ac:vity and ability to conjugate bilirubin –low levels of enzyme to conjugate
Decreased ability to excrete bilirubin
Increased enterohepatic circulation-‐increased B-‐glucoronidase (a deconjuga:ng enzyme)
Breast feeding
ATHOLOGICAL JAUNDICE
Jaundice that occurs within the first 24 hours of life.
Total serum bilirubin levels above 12 mg/dL in a term neonate or 15 mg/dl in a preterm baby or >95th % on nomogram
Total serum bilirubin levels that increase by more than 5 mg/dL per day (or 0.2 mg/dL per hour)
Conjugated bili >2 mg/dl
Jaundice lasting >1 wk term/ > 2k premature
Bilirubin Encephalopathy
Unconjugated bilirubin in excess of that which can bind to albumin can cross the BBB
Can cause neurotoxicity-‐ signs:
Lethargy, irritability
Arching of neck (retrocollis) and
trunk (opisthonos)
Kernicterus-‐ movement disorder, athetoid form
Of CP, Deafness, seizure, coma, limited upward
gaze
Interventions of Jaundice
Phototherapy
TcB
Exchange Transfusion
◦ If newborn has active hemolysis, unconjugated bilirubin
level of 14 mg/dl, weighs less than 2500g, less than 24
hours old… exchange transfusion may be best
◦ If mom O blood type or Rh (-‐) –check direct coombs and cord
blood bili in baby
Nursing care
Assessments (VS, feedings, check BM status)
Warmth (cold stress & acidosis)
Phototherapy (eye patches, cover genitalia)
Tactille simulation important
Positioning-‐q2h
Parental ques:ons/concerns/contacts
Interventions of Jaundice
Phototherapy
TcB
Exchange Transfusion
◦ If newborn has active hemolysis, unconjugated bilirubin
level of 14 mg/dl, weighs less than 2500g, less than 24
hours old… exchange transfusion may be best
◦ If mom O blood type or Rh (-‐) –check direct coombs and cord
blood bili in baby
Nursing care
Assessments (VS, feedings, check BM status)
Warmth (cold stress & acidosis)
Phototherapy (eye patches, cover genitalia)
Tactille simulation important
Positioning-‐q2h
Parental questions/concerns/contacts
Newborns with Infection
Assess for sepsis 1-2/1000 10x higher in LBW
Immature immune system
Vertical transmission - transplacental + acensind prolonged ROM, intrapartal
Horizontal: nosocomial infection
Maternal factors:
Poor prenatal nutrition
Low socioeconomic status
Hx STI’s
Prolonged ROM >12 hrs
Vaginal Group B strep
Chorioamnionitis
The maternal temperature in labor
Premature labor
Difficult or prolonged labor
Fetal scalp electrode use
Invasive procedures during labor and delivery
Maternal UTI
Fetal factors
Prematurity
Birth weight <2500 g
Difficult delivery
Birth asphyxia
Meconium staining
Congenital anomalies
Male neonate
Multiple gestatin
Invasive procedures
Length of stay
Humidification in incubator or ventilator care
Use of broad spectrum antibiotics
Nursing Interventions
Nosocomial infections are preventable
◦ Hand hygiene! EDUCATION
Screening
◦ Antepartum/Intrapartum infection
Blood Cultures, CBCD, Urine culture
◦ ophthalmic prophylaxis
Supportive Care
◦ Resp, Cardio, fluid/electrolytes, hypoglycemia, acidosis
Respiratory Distress Syndrome
Hyaline membrane disease
primary absence of pulmonary surfactant
indicates failure to synthesize surfactant
Assessment: grunting, flaring, retracting, tachy, skin grays, hypoxemia, acidosis
Management
O2, Pulse ox, surfactant replacement, CPAP, mechanical ventilation ECMO
Transient Tachypnea of Newborn
Failure to clear fluid of out lunfs
Exhibits distress shortly after birth
SS:
Expiratory grunting and nasal flaring
subcostal retractions
slight cyanosis
Maintain adequate respir, nutritional, hydration status and education
Meconium Aspiration Syndrom
Mechanical obstruction of airways
chemical pneumonitis
vasocon of pulmonary vessels
inactivsation of natural surfactant
assess for complications
maintain respir + nutrition + hydration
Preterm Birth
20 0/7 wk - 36 6/7 wks
decreasing in US @9.5% 2015
highest among AA + hispanic
Spontaneous Preterm Labor
unintentional delivery <37wk
Cause: infection or inflammation
Non-Medically indicated
C-section/ labor absence of medical need
Medically indicated
healthcare provider recommends preterm labor delivery
Cause: preeclampsia
Cervical insufficiency
the inability of cervix to retain preg in absence of sign/symptoms of contractions, labor or both in 2nd tri
Multiple Gestation
1+ fetus from fertilization of 1 zygote
- divides or fertilization of 2 ova
monozygotic twin = 1 egg that divides at 1st week of gestation
dizygotic = 2 eggs fertilized
Placenta types
- monochorionic (1 chorion) - 70% monozygotic
- dichorionic (2 chorions) - always dizygotic
Twin pregnancy complications
Spontaneous delivery
HT + Preeclampsia
gestational diabetes
Antepartum hemorrhage
acute fatty liver
Abruptio placentae
Hyperemesis Gravidarum
Severe NV that causes dehydration, electrolyte imbalance + acid/base imbalance, starvation ketosis + weight loss.
-hypokalemia + natremia
- decrease urea
Peaks @ 9-20wks
Cause: increase of HCG, prog, + E, h.pylori, ambivalence towards preg.
Diabetes
Presentational - 1/2
Gestational - glucose intolerance (placenta creates HPL that antagonizes insulin, sparing glucose for fetus.)
Type1 : body isnt making insulin - body attacks destroys insulin producing cells
- glucose can’t get into cells + trys to get rid of extra w. kidney
Type 2: body is producing enough insulin but not properly produced overweight can’t stop insulin production. fat deposits on cell can’t open.
Challenge to manage because of
HPL
P
HgH
Corticotropin-releasing hormone
Shift energy source from ketone -> free fatty acid
Treatment:
Euglycemic control
minimize complication
prevent prematurity
-> keep the lowest possible glycosylated hemoglobin w/o going into hypoglycemia
Pregestational Diabetes
Blood glucose is elevated but below clinical threshold
Components:
Central adiposity > 35 in
Dyslipidemia
Hyperglycemia
HT
Maternal Risk:
DKA - 2nd tri
HT
Spontaneous Abortion
Polyhydramnios
Induction of Labor
UTI, Hypergly, Postpartum, post hemorrhage
exacerbation of diabetes symptoms
Fetal Risk:
Congenital defect
Prematurity
Hypogly, cal + mag
asphyxia
respir distress
Still birth
hyperbilirubinemia
polycythemia
Gestational Diabetes
a hormone made by the placenta prevents the body from using insulin effectively. Glucose builds up in the blood instead of being absorbed by the cells. insulin less effective, a condition referred to as insulin resistance
risk:
<25 yr
HT, PCOS
Increase in maternal adiposity
insulin desensitizing hormone
Family history/ age/ race/ obesity history of macrosomia
Diagnosis: glucose testing 24-28 wk
Complications:
Macrosomia
Shoulder dystocia
HT + preeclampsia
preterm birth + stillbirth
C-section
Risks for baby
excessive birth weight
preterm
breathing difficulties
hypoglycemia
obesity + type 2 later in life
stillbirth
Prevention:
maintain healthy lifestyle, keep active, don’t gain more weight than recommended
Preeclampsia
Preeclampsia is a kind of high blood pressure some women get after the 20th week of pregnancy or after giving birth. s high blood pressure and signs that some of her organs, like her kidneys and liver, may not be working normally. Blood pressure is the force of blood that pushes against the walls of your arteries. Arteries are blood vessels that carry blood away from your heart to other parts of the body. High blood pressure (also called hypertension) is when the force of blood against the walls of the blood vessels is too high. It can stress your heart and cause problems during pregnancy.
- Leading cause of maternal death
- 20wks 140/90 @ least 4 hrs apart + proteinuria >300mg or new systemic disease.
High Risk:
>35 yr
AA + low socioeconomic
previous preeclampsia with another preg
pregnant w. multiples
have diabetes + HT, kidney disease, AI
obese
family history of preeclampsia
SS
Headache that doesnt go away
Blurred vision
Epigastric pain
trouble breathing
NV
swelling in face + hands
weight gain - 2-5lbs per week
Proteinuria
Thrombocytopenia
Renal insufficiency
Impair live function
Pulmonary edema
Visual symptoms
Risk for fetus
Morbidity
intolerance of labor
still birth
placenta abruption
IUGR
Low birthweight
Treatment
Early detection
Delivery monitor
Hydra Liz one
Mg sulfate
Oral nifedipine
Labetalol
HELLP syndrome
HELLP syndrome is a serious pregnancy complication that affects the blood and liver. HELLP stands for these blood and liver problems:
H–Hemolysis. This is the breakdown of red blood cells. Red blood cells carry oxygen from your lungs to the rest of your body.
EL–Elevated liver enzymes. High levels of these chemicals in your blood can be a sign of liver problems.
LP–Low platelet count. Platelets are little pieces of blood cells that help your blood clot. A low platelet count can lead to serious bleeding.
Eclampsia
occurrence of seizure activity in the presence of preeclampsia
- can be ante, intra + post partum
It can be triggered by cerebral vasospasm, hemorrhage, ischemia, edema
Warning:
persistent headaches
epigastric pain
NV
hyperreflexia w. clonus
restlessness
Treatment
Mg sulfate + hypertensive
Placenta Previa
1/200
The placenta attaches to the lower uterine segment near/over cervix vs. on the body of the fundus
Risk Factors:
scarring
large placenta
infertility, nonwhite, low socio, short interpreg
diabetes, smoking cocaine use
Painless bleeding
Maternal risk:
Hemorrhagic + hypovolemia shock
Blood loos
Fetal Risk:
Disruption of blood flow
Morbidity + morality
Management:
Avoid vaginal exam
Monitor fetal vitals
Check Amniocentesis + BPP - lung maturity
Placenta Abruption
Partial complete detachment of placenta
- hematoma forms + destroys the placenta around it
Grade:
1(mild) least amount of separation
2 (moderate)
3 (Severe) more separation + blood
Risk Factor
decreased placenta perfusion
HT
Seizure
Blunt trauma to the maternal abdomen
history of abruption
smoke/cocaine use
SS
Sudden onset of intense pain
board-like rigidity to the abdomen
uterine irritability
tachystole
vaginal bleeding
port wine stain amniotic fluid
Management
assess fundal height
girth measurement
shock
weigh pads
Placenta Accreta
The partial/complete placenta invades and becomes inseparable from the uterine wall.
0 leads to hemorrhage + may need a hysterectomy
- 3000 - 5000 mL blood loss
Abortion
Spontaneous or elective termination of pregnancy <20wks
Induced: medical/surgical abortion before fetal viability
Elective: at the request of the woman but not for a medical reason
Therapeutic: abortion because of abnormalities
Spontaneous: nonviable intrauterine preg w. either empty gestational sac or gestational sac containing embryo/fetus w/o heart activity 126/7 wks —> miscarriage
Termination of preg done transcervical by dilation of the cervix, evacuation, fetus out by cuttage, scrapping + vacuum
Meds: mifepristone +misoprostol
Ectopic Pregnancy
Fertilized egg grows outside uterus as a result in blastocyst implanting itself other than endometrial lining
- stunted growth + will be nonviable.
- 95% happen in fallopian tube, 5% other ovary, abdominal cavity, cervix
- most are tubual + tube lacks submucosal layer but can’t support the growth of the tropoblast
Risks:
Pelvic inflam disease
infertility
endometriosis
STI
smoking
Gestational Trophoblastic Disease
Spectrum of placental-related tumors
- group of rate disease in which abnormal cells grow inside the uterus after conception
MOLAR: hydatidiform mole cili turn into cyst in uterus ~ grape like
NONMOLAR: gestational trophoblastic disease- almost always malignant
SS: Bleeding, NV, HT, no fetal heartbeat +movement
Substance Abuse during Preg
Most prevalent in 1-2tri; may be associated w. abnormalities like still birth, fetal growth restriction, neurological development - hyperactivity
Screening for gestational diabetes
1 Hr - if over 140 test at 3hrs if positive if they have 2+ criteria (fasting 95mg, 1hr 180 mg, 2hr, 155, 3hr 140). If neg retest at 32 wks
If neg at 1 hr - routine prenatal; care
Glycosylated hemoglobin alc should be less than or equal to 6%
Preg Complications
RH Factor
ABO Incompatibility
Ectopic Preg
HSV
GBS
Preeclampsia
Gestational Trophoblastic Disease
Rh Alloimmunization
Rh is inherited protein found on the surface of RBC
Rh- doesnt have protein
Rh+ has protein
Rh- women at risk of having baby w. hemolytic anemia w/o treatment fetus will have jaundice, anemia, brain damage, HF + death
Sensitized woman when Rh+ from infant mixes with Rh- mother = creation of Ab
Cause: molar preg, ectopic pre, spontaneous abortion, therapeutic, manual removal of placenta, amniocentesis + CVS
Tests: indirect coombs (Ab screen), testing father/amnio, early birth, intrauterine transfusion(Correct anemia), exchange transfusion(erythropoietin+ fe)
Prevent sensitization
give RhoGam at 28 wks + 72 hrs after birth
ABO Incompatibility
Mother type O infant A/B
Maternal serum Ab cross placenta
- hemolysis of fetal RBC
- mild anemia
-jaundice
Not treated antenatally or prophylactic
GBS
Group B Strep.
In GI/GU
Treatment: decrease the bacterial load to limit exposure to fetus
Hydatiform Mole
Grape Like Cysts
1. complete: fertilization of empty ovum (no embryonic tissue found)
2. Partial: some fetal tissue; normal ovum but 2 sperm 1/1500birth
SS:
Rapidly growing uterus, vaginal bleeding, NV.HT. Abnormally high hcg
Management:
no preg for 1 yr, monitor for malignancy
Polyhydraminos
excessive amniotic fluid >2000mL
associated with fetal GI anomalies + maternal diabetes
Treatment:
remove amniotic fluid
Oligohydramnios
scanty amniotic fluid <500mL
risk: fetal adhesion + malformations
Treatment: amniofusion
Neonatal assessment
2hrs after birth - general survey, physical assessment, gestational assessment + pain assessment
Dubowitz Neurological Exam
assessed 33 responses in 4 areas
1. habituation - response to repetitive light/sound stimuli
2. movement + muscle tone
3. reflexes
4. neurobehavioral items
Ballard Maturation
assesses physical + neuromuscular activity + maturity
- less time than dubowitz
classifies if neonate is avg for gestational weight, lga or sga
Periods of reactivity/inactivity
cycle through
initial period of reactivity 15-30 mins post birth
increased respiration, rapid HR, grunting, flaring
Relative inactivity - 30 mins -2hrs infant will sleep
Second period of reactivity cycle through active/quiet alert
interested in feeding/sucking
Brazeiton Neonatal Behavioral Assessment Scale
28 behaviors items, 18 reflex - 6 categories
1. habituation: decrease stim from repetitive stim protects from overstim
2. orientation: the ability to focus on visual auditory stim
3. motor maturity: control/coordinate motor activity
4. self quieting: comforting self
5. social behaviors: response to cuddling
6. sleep wak states - 2 sleep 4 wake
Infant Danger Signs
Tachypnea
retraction of chest wall
grunting/ flaring
lethargy
abnormal temp
hypogly
abdominal distension
failure to pass meconium in 48 hrs
failure to void in 24 hrs
convulsions
jaundice <24hrs
jitteriness
cant keep constant temp
Ballard Tool
Assessment of physical maturity characteristics
- skin
transparent friable -1
gelatinous translucent -0
smooth pink visible veins 1
superficial peeling rash few veins 2
cracking pale areas 3
parchment deep cracking 4
leathery cracked wrinked 5
lanugo - diabetic moms have babies w. more hair on back
non
sparse
abundant
think
bald areas
mostly bald
Sole
smooth sole / small foot
>50mm no crease
faint red marks
anterior transverse cease only
creases anterior 2/3
cracked lethary
Ear/eye formation
lids fused loosely -1 / tightly -2
lids open pinna flat stays folded
Slightly curved pinna, soft recoil
well curved pinna soft ready recoil
formed and firm instant recoil
thick cartilage
Genitals
Smooth flat scrotum/clitoris prominent
clit prominent small minora/scrotum empty
tests in upper cancl rare rugue/ clitoris prominent, enlarging minora
majora + minora equally prominent/testes descending
testes down good rugae/ majora large
testes pendulous deep rugae/ majora covers clit and minora
Breast
imperceptible
barley
flat areola no bud
stippled areola
raised areola
full areola 5-10mm
Neuromuscular
Posture
Square window
arm Recoil
Popliteal angle
scarf sign
heal to ear
Newborn Vitals
Pulse 110 - 160 bpm (sleep <70)
Respiration 30 -60
BP: 70-50mmHg - 90/60 @ day 10
Temp: Ax 97.7-99
skin 96.8 - 97.7
97.8 - 99
Caput succedaneum
swelling under the skin of the scalp - fluid filled
crosses suture lines
Cephalhematoma
collection of blood from broken blood vessels that build up under scalp
- doesnt suture line
Craniosynostosis
premature closure of suture
- restricts growth perpendicular + compensatory overgrowth in unrestricted regions
plaglocephaly
develops when an infant’s soft skull becomes flattened in one area, due to repeated pressure on one part of the head
Milia
white dots on skin
Erythema Toxicum
papules on skin last up to 5 days
Skin Variations
Vernix Caseosa
Forceps marks
telangiectatic nevi
mongolian spots
nevus flammeus
stork bites
Reflexes
Tonic-neck
Moro
Grasping
Rooting
Sucking
Babinski
Trunk incurvation
Protective
Blink
yawn
cough
sneeze
extrusion reflex
Discharge teaching
thermoregulation
feeding practices
skin/cord care
prevention of infection
security
stool/void patterns
safety - car seat sleep position, sids
Illness - >100 and <97.7, frequent vomiting refusal of 2x feeding, difficult awakening, breathing difficulties, cyanosis w/wo feeding, inconsolable, no wet diapers for 24 hrs
Before discharge
Hep B + HBig
PKU
Hearing screening
CHD
CDC newborn screen
Apgar
HR + Auscultation
respiration rate
muscle tone
relex irritability
color
Score:
o-3 - severe distress
4-6 moderate difficulty
7-10 stable
Neonatal period
birth - 28 days
need to maintain bodyheat
respiration f(x)
decrease risk of infection
proper hydration + nutrition
Proper care
First breath
increase aveolar O2 + decreased Aterial pH –> dilation of pulmonary artery -> decrease vascular resistance -> increase blood flor -> increase O2 + Co2 exchange
Signs of Respir distress
Cyanosis
abnormal resp pattern - tachy + apnea
retraction of chest wall
grunting
flaring
hypotonia
3 Phases of transition
- reactivity 1-2 hrs
- sleep 1-4
- 2nd period of reactivity 2-8 hrs
Circulatory changes
Systemic vascular resistance increase / pulmonary artery pressure - after cord clamp
Closure of shunts - foramen ovale, ductus arteriosus, ductus venosus
difficult transition
Maternal conditions - diabetes, HT
Fetus conditions - congenital anomalies
Antepartum - placenta / amniotic fluid
Delivery complications
Neonatal difficulties - lack of respir effort, blockage, impaired cardiac lung f(x)
Hematopoietic adaptations
Blood vol 80-90 ml/kg
increase of erythropoietin secreted
leukocytosis is normal - increase WBC
GI adaptations
small stomach - marble
as milk transitions fat increases more enzyme amylase lipase
meconium 8-24 hrs
weight loss 3-4 day; 3.5% formula, 7% BF
Urinary Adaptation
limited capacity to concentration of urine
- cant reabsorb water to maintain organ f(x)
- void 24 hrs
-brick dust stains
Hepatic Adaptation
40% of abdomin
iron storage
regulation of blood glucose– glycogen -> glucose >40mg
coagulation of blood
bilirubin conjucation
Immunologic Adaptation
passive immunitiy
- Ab pass through placenta ; IgG by third tei
Active immunity
IgA in colostrum
Newborn nutrition
Rapid weight gain
by 4-6 mo 2x weight
1yr 3x
100-120/kg /day
Signs of effective breastfeeding
feeding >8 in 24 hrs
swallowing
Soft breasts after feeding
# of wet diapers increase
Stools begin to lighten
Baby bottle syndrome
cavities when putting juice/soda in bottle. Hold baby while feeding.
Alcohol use
Abnormal brain and neuron development
Lbw
Premature
FAS
leading cause of mental retardation
Cocaine use
Cardiac maternal events - death
Abruption
Fetal effects - vasoconstriction neuroexfitation
Opioid use
Withdrawal symptoms from neonate
Smoking Tobacco
Decreased fertility
Increased risk of miscarriage
Previa
IUGR
cognitive impairment
Cardinal signs of diabetes
Polyuria
Polydipsia
Weight loss
Polyphagia
TD1 what are signs and symptoms of hypoglycemia
Diaphoresis and disorientation
Newborn appears LGA while scoring low for neurological maturation what explains that outcome
Maternal diabetes
Herpes simplex virus
1/6 infection
Fetal risk:
Spontaneous abortion
Preterm labor IUGR neonatal infection
Antiviral therapy after birth - acyclovir
Mg sulfate toxicity
Urinary output 20mL/hr
Blood pressure 104/62
Respiration of 7
Absent reflex
Lethargy
Excitability
NRP
N: provide warmth clear airway dry stimulate - rapid assessment
R; assess breathing
p: assess heart rate
Evaporation
Cooling of moisture with air
Convection
Heat from body is taken away from air
Conduction
Heat is transferred to an object that you are touching
Radiation
Heat is lost to an object further away
Why is surfactant needed
Avelolar stability
Decreases surface tension
Increases compliance
L/S ratio
APHAR SCORE
heart rate
0- absent
1 -60-100
2 >100
Respir
0-absent
1- slow irregular weak
2 cry
Reflex
0-no response
1-grimace
2-cry
Color
0 cyanotic
1pink and blue
2 pink
Muscle tone
0flaccis
1some flexion
2active motion
