Final notes Flashcards
Effects of Diabetes on Pregnancy in EARLY PREGNANCY
- Insulin release in response to serum glucose levels accelerates. As a result, significant hypoglycemia may occur, particularly in women who experience the nausea, vomiting, and anorexia that often arise during the first weeks of pregnancy.
- The availability of glucose and insulin, favors the development and storage of fat during the first half of pregnancy. Accumulation of fat prepares the mother for the rise in energy use by the growing fetus during the second half of pregnancy.
Effects of Diabetes on Pregnancy in LATE PREGNANCY
- During the second half of pregnancy, when fetal growth accelerates, levels of placental hormones rise sharply. These hormones, particularly estrogen, progesterone, and human placental lactogen (hPL), create resistance to insulin in maternal cells. which allows an abundant supply of glucose to be available for the fetus. They also have a diabetogenic effect in that they may leave the woman with insufficient insulin and episodes of hyperglycemia.
Effects of Diabetes on Pregnancy in during Birth
- Type
- Maintenance of normal maternal glucose levels is essential during birth to reduce neonatal hypoglycemia.
- Women with diabetes usually maintain their glucose testing and continue administration of doses of insulin the day before scheduled induction or cesarean birth.
- Day prior to c-section or induction - Women with an insulin pump continue using their pump through the night. After admission with nothing by mouth (NPO) after the prescribed time, their glucose level is checked and continuous infusion of insulin and glucose is started based on hourly glucose levels.
Effects of Diabetes on Pregnancy in the Postpartum Period
- The need for additional insulin falls during the postpartum period.
- Breastfeeding is encouraged not only for the newborn’s benefit but also because the added calorie intake by the mother helps lower the amount of insulin needed in women with types 1 and 2 diabetes mellitus.
- The woman with gestational diabetes mellitus (GDM) usually needs no insulin after birth but the greater risk for later development of type 2 diabetes should be emphasized with teaching before discharge.
Maternal Effects of Pre-Existing Diabetes TYPE 1
- Increased risk for hypertension, urinary tract infections, and ketosis.
Increased Maternal risks due to Diabetes Mellitus on Pregnancy
- Hypertension; preeclampsia Hypertension
- Urinary tract infections - Increased bacterial growth in nutrient-rich urine
- Ketoacidosis (risk for mother and fetus) - Uncontrolled hyperglycemia or infection; most common in women with type 1 diabetes
- Labor dystocia; cesarean birth; uterine atony with hemorrhage after birth - Hydramnios secondary to fetal osmotic diuresis caused by hyperglycemia; uterus is overstretched
- Birth injury to maternal tissues (hematoma, lacerations) - Fetal macrosomia causing difficult birth
- First trimester may have an abnormal environment such as hypoglycemia, hyperglycemia, ketosis
- This can cause an increased risk of SAB/s, fetal malformations and a two to three fold increase risk of developing - Ployhydraminos
Fetal and neonatal adverse effects of Diabetes Mellitus in Pregnancy
- Congenital anomalies
- Perinatal death
- Macrosomia (>4000 g)
- IUGR
- Preterm labor
- Overdistention of uterus caused by hydramnios
- Birth injury Large fetal size
- Fetal growth (increased or decreased)
- Hypoglycemia
- Polycythemia
- Hyperbilirubinemia
- Hypocalcemia
- Respiratory distress syndrome
Therapeutic Management of Diabetes
- Preconception Care - Control the disease
- Diet
- Self monitoring - Check/log blood glucose levels multiple times a day
- ** Blood Glucose Monitoring.
- Blood glucose levels should be evaluated to determine whether levels are normal. A common method is measurement of fasting blood glucose level (no food for the previous 4 hours) and postprandial blood glucose level (2 hours after each meal).
- If fasting capillary blood glucose levels repeatedly exceed 95 mg/ dL or postprandial values exceed 120 mg/dL, insulin therapy is started. Additional tests for glucose levels may be performed, as needed.
- Insulin therapy
Laboratory test for a pregnant woman with Diabetes
- In addition to routine prenatal laboratory examinations
- baseline renal function should be assessed with a 24-hour urine collection for total protein excretion and creatinine clearance.
- Assess for urinary tract infections, which are common in women with diabetes.
- Urine also should be checked by using a dipstick for the presence of glucose, ketones, and protein.
- Glycemic control should be evaluated on the basis of the level of glycosylated hemoglobin or hemoglobin A1c (HbA1c). With prolonged hyperglycemia, a percentage of hemoglobin will remain saturated with glucose for the life of the red blood cell (RBC). The glycosylated hemoglobin assay is an accurate measurement of the average glucose concentrations during the preceding 2 to 3 months.
The goals of therapeutic management for a pregnant woman with diabetes are to
(1) maintain normal blood glucose levels
(2) facilitate the birth of a healthy baby, and
(3) avoid accelerated impairment of blood vessels and other major organs. To achieve this outcome, an intensive, team approach to care is required.
Maternal adverse effects of gestational diabetes
- increased urinary tract infections
- hydramnios
- premature rupture of membranes
- the development of preeclampsia.
Risk Factors for Gestational Diabetes Mellitus
- Overweight (body mass index [BMI] ≥25 to 25.9) or obesity (BMI ≥30 or morbidly obese (BMI ≥ 40 or higher)
- Maternal age older than 25 years
- Previous birth outcome often associated with GDM (neonatal macrosomia, maternal hypertension, infant with unexplained congenital anomalies, previous fetal death)
- Gestational diabetes in previous pregnancy
- History of abnormal glucose tolerance
- History of diabetes in a close (first-degree) relative
- Member of a high-risk ethnic group (African-American, Hispanic or Latino, American Indian, Asian American, or Pacific Islanders) Women with any of these factors should be screened for type 2 or gestational diabetes at the first prenatal visit (ACOG,
Screening for Gestational Diabetes Mellitus
Glucose Challenge Test.
- A GCT is administered between 24 and 28 weeks of gestation, often to both low- and high-risk antepartum patients.
- . Fasting is not necessary for a GCT, and the woman is not required to follow any pretest dietary instructions.
- STEPS: The woman should ingest 50 g of oral glucose solution. A blood sample is taken 1 hour later. If the blood
glucose concentration is 140 mg/dL or greater, a 3-hour oral glucose tolerance test is recommended.
Oral Glucose Challenge Test.
- An oral glucose tolerance test (OGTT) may be used as the initial test if a woman is at high risk for GDM, but the test
is more likely to be used for diagnosis following abnormally high GCT results
- OGTT is the gold standard for diagnosing diabetes, but it is a more complex test.
- The woman must fast from midnight on the day of the test. After a fasting plasma glucose level is determined, the
woman should ingest 100 g of oral glucose solution. Plasma glucose levels are then determined at 1, 2, and 3
hours.
* GDM is the diagnosis if the fasting blood glucose level is abnormal or if two or more of the following values occur on the OGTT
• Fasting, greater than 95 mg/dL
• 1 hour, greater than 180 mg/dL
• 2 hours, greater than 155 mg/dL
• 3 hours, greater than 140 mg/dL
Signs and symptoms of maternal HYPOglycemia include:
- Shakiness (tremors)
- Sweating
- Pallor; cold, clammy skin
- Disorientation; irritability
- Headache
- Hunger
- Blurred vision Teach family members how
Signs and symptoms of maternal hyperglycemia include the following:
- Fatigue
- Flushed, hot skin
- Dry mouth; excessive thirst
- Frequent urination
- Rapid, deep respirations; odor of acetone on the breath
- Drowsiness; headache
- Depressed reflexes
Managing HYPOglycemia
- Treat hypoglycemia at once to prevent damage to the fetal brain, which is dependent on glucose.
- Woman experiencing hypoglycemia should ingest 15 g of carbohydrate if she can swallow food.
Examples of foods that supply this are 3 glucose tablets or glucose gel, 1 2 cup of fruit juice or SAFETY - Teach family members how to inject glucagon in the event that the woman cannot swallow or retain food.
- Notify the physician at once.
- IV glucose will be administered if she is hospitalized.
*****If untreated, hypoglycemia can progress to convulsions and death. To prevent hypoglycemia, instruct the woman to have meals at a fixed time each day and to plan snacks at 10 am, 3 pm, and bedtime. Suggest that she always carry glucose tablets or gel or some crackers with her.
Managing HYPERglycemia
- Because infection is the most common cause of hyperglycemia, pregnant women must be instructed to notify the physician whenever they have an infection of any type.
- Untreated hyperglycemia can lead to ketoacidosis, coma, and maternal and fetal death.
- notify the physician at once so that treatment can be initiated.
- Hospitalization often is necessary to monitor blood glucose levels, for IV insulin administration to normalize glucose levels, and for treatment of any underlying infection.
Congenital Heart Diseae
Atrial Septal Defect - Pulmonary hypertension occasionally develops in uncorrected atrial septal defects because the additional blood that moves to the right side of the heart is transported to the lungs through the pulmonary artery
Ventricular Septal Defect - Bacterial endocarditis is common with unrepaired defects, and antibacterial prophylaxis is recommended
Patent Ductus Arteriosus. - The patent ductus arteriosus tends to become infected, so antibiotic prophylaxis before labor is recommended
Mitral Valve Prolapse. Mitral valve prolapse is one of the most common cardiac conditions among the general population. In mitral valve prolapse, the leaflets of the mitral valve prolapse into the left atrium during ventricular contraction.Some physicians consider mitral valve prolapse to be a significant risk factor for bacterial endocarditis and administer prophylactic antibiotics before and during labor and delivery. Beta-blockers such as atenolol
Rheumatic Heart Disease
Rheumatic heart disease is a complication that sometimes follows streptococcal pharyngitis (“strep throat”). Even one bout of rheumatic fever may cause scarring of the heart valves, resulting in stenosis (narrowing) of the openings between the chambers of the heart.
- The mitral valve is the most common site of stenosis. Mitral stenosis obstructs free flow of blood from the left atrium to the left ventricle. The left atrium becomes dilated, and as a result, pressure in the left atrium, pulmonary veins, and pulmonary capillaries is chronically elevated. This elevation may lead to pulmonary hypertension, pulmonary edema, or CHF.
- The first warnings of heart failure include persistent rales at the base of the lungs, dyspnea on exertion, cough, and hemoptysis. Progressive edema and tachycardia are additional signs of heart failure.
Signs and Symptoms of Heart Disease
- Dyspnea,
- Syncope (fainting) with exertion
- Hemoptysis (coughing up of blood)
- Paroxysmal nocturnal dyspnea
- Chest pain with exertion.
-
** Additional signs that confirm the diagnosis are
(1) cyanosis;
(2) clubbing;
(3) diastolic, presystolic, or continuous heart murmur;
(4) cardiac enlargement;
(5) a loud, harsh systolic murmur associated with a thrill; and
(6) serious dysrhythmias
Therapeutic Management for Class I or II Heart Disease
- Limit physical activity. the woman should remain free of symptoms of cardiac stress such as dyspnea, chest pain, and tachycardia.
- Avoid excessive weight gain. Excessive weight increases demands on the heart. A diet adequate in protein, calories, and sodium is necessary. A low-sodium diet may be advised to avoid CHF.
- Prevent anemia. Anemia decreases the oxygen-carrying capacity of the blood and results in a compensatory increase in heart rate that a diseased heart may be unable to tolerate. Most anemia is prevented by administration of iron and folic acid.
- Prevent infection. Immunizations for influenza, pertussis, and pneumonia are available. Prevention may include administration of prophylactic antibiotics.
- Undergo careful assessment for the development of CHF, pulmonary edema, and cardiac dysrhythmias. Characteristics of heart failure may include persistent basilar rales, often accompanied by a cough during the night as the woman tries to sleep, sudden inability to carry out usual activities, dyspnea, cough, hemoptysis, increasing edema, and tachycardia.
Therapeutic Management for Class III or IV Heart Disease
The PRIMARY goal of management is to prevent cardiac decompensation and development of CHF.
- Also, every effort is made to protect the fetus from hypoxia and IUGR, which can occur if placental perfusion is inadequate.
- In addition to the precautions listed for classes I and II heart disease, the woman may require bed rest, especially during the last trimester, because she has little reserve to tolerate rising metabolic demands.
- Reduced activity increases the maternal risk for thrombus formation and will require prophylaxis such as elastic compression stockings or a serial or boot compression device.
- Prophylactic anticoagulation may be needed.
Drug therapy for Heart Disease in Pregnant women
Anticoagulants. During pregnancy, clotting factors normally increase and thrombolytic activity decreases. These changes predispose the pregnant woman to thrombus formation.
- Warfarin (Coumadin) is associated with fetal malformations and should be restricted throughout pregnancy.
* *** Postpartum anticoagulation is continued with warfarin
- Subcutaneous heparin, which does not cross the placental barrier, is an effective alternative anticoagulant for most.
* ******Heparin is withheld during labor & resumed 6 hs after vaginal birth and 18 - 24 hrs after cesarean
- Enoxaparin (Lovenox), a LMWH, may be used instead of standard heparin because it requires less-frequent monitoring for bleeding complications.
* **** Enoxaparin and heparin are not interchangeable. Both are given subcutaneously, but only heparin may be given intravenously.
Antidysrhythmics
- In addition to controlling the dysrhythmias, beta-blockers and calcium channel blockers may be used to control
maternal hypertension.
- Digoxin, adenosine, and calcium channel blockers appear to be safe.
Drug therapy for Heart Disease in Pregnant women
Anticoagulants. During pregnancy, clotting factors normally increase and thrombolytic activity decreases. These changes predispose the pregnant woman to thrombus formation.
- Warfarin (Coumadin) is associated with fetal malformations and should be restricted throughout pregnancy.
** Postpartum anticoagulation is continued with warfarin
- Subcutaneous heparin, which does not cross the placental barrier, is an effective alternative anticoagulant for most.
**Heparin is withheld during labor & resumed 6 hs after vaginal birth and 18 - 24 hrs after cesarean
- Enoxaparin (Lovenox), a LMWH, may be used instead of standard heparin because it requires less-frequent monitoring for
Bleeding complications.
** Enoxaparin and heparin are not interchangeable. Both are given subcutaneously, but only heparin may be given intravenously.
Antidysrhythmics
- Digoxin, adenosine, and calcium channel blockers appear to be safe.
- Beta-blockers have been associated with neonatal respiratory depression, sustained bradycardia, and
hypoglycemia when administered late in pregnancy or just before delivery but may be needed in selected cases.
- The beta-blockers atenolol and metoprolol may be preferred because they do not cause the uterine stimulation
that other drugs of this class may cause
Antiinfectives.
- A woman with an increased risk for bacterial endocarditis may receive prophylactic antibiotics such as amoxicillin,
penicillin, ampicillin, and gentamicin at delivery.
- Ceftriaxone or vancomycin also may be given for acute endocarditis.
Diuretics - Drugs for heart failure
- Carefully monitor electrolytes and water balance to avoid adverse effects on mother and fetus
- IUGR has been associated with furosemide, and neonatal jaundice, thrombocytopenia, anemia, and hypoglycemia
have been associated with thiazide diuretics
Intrapartum Management for women with Heart Disease
- Careful management of IV fluid administration is essential to prevent fluid overload.
- The woman should be positioned on her side, with her head and shoulders elevated.
- Oxygen is administered to increase blood oxygen saturation and is monitored with pulse oximetry.
- Bonnie says Epidural is recommended - Discomfort should be reduced to a minimum
- The environment is kept as quiet and calming as possible to decrease anxiety, which can cause tachycardia
- Maternal signs of cardiac decompensation (tachycardia, rapid respirations, moist rales, and exhaustion) should be reported immediately to the physician.
- Vaginal birth is recommended for a woman with heart disease unless there are specific indications for a cesarean birth.
- Vacuum extraction or outlet forceps are often used to minimize maternal pushing and use of the Valsalva
maneuver and to limit prolonged labor, which can add to the hemodynamic stress for the woman with cardiac
disease.
- Vacuum extraction or outlet forceps are often used to minimize maternal pushing and use of the Valsalva
- The fourth stage of labor is associated with special risks. After delivery of the placenta, about 500 mL of blood is returned to the intravascular volume. To minimize the risks of overloading the heart, abrupt positional changes should be avoided. Moreover, the uterus should not be massaged to expedite separation of the placenta. Careful assessment for signs of circulatory overload, such as a bounding pulse, distended neck and peripheral veins, and moist rales in the lungs, is performed throughout labor and the postpartum period.
Signs and symptoms of CHF include the following:
- Cough (frequent, productive, hemoptysis)
- Progressive dyspnea with exertion
- Orthopnea
- Pitting edema of legs and feet or generalized edema of face, hands, or sacral area
- Heart palpitations
- Progressive fatigue or syncope with exertion
- Moist rales in lower lobes, indicating pulmonary edema
IRON DEFICIENCY ANEMIA
- The total iron requirement for a typical pregnancy with a single fetus is approximately 1000 mg.
- Signs and Symptoms - Pallor, fatigue, lethargy, and headache, inflammations of the lips and tongue, Pica
- The primary sources of iron are meat, fish, chicken, liver, and green, leafy vegetables.
- Therapy = Iron supplements - Ferrous sulfate, 325 mg, one to three times per day is commonly prescribed.
** Many women experience less gastrointestinal discomfort if iron supplementation is taken with meals, although
absorption is less.
**Taking iron supplementation with 500 mg of vitamin C may enhance absorption.
- Therapy is often continued for about 6 months after the anemia has been corrected.
Folic Acid Deficiency (Megaloblastic)
- Anemia Folic acid, which functions as a coenzyme in the synthesis of deoxyribonucleic acid (DNA), is essential for cell duplication and fetal and placental growth. It also is an essential nutrient for the formation of RBCs.
- Maternal needs for folic acid double during pregnancy in response to the demand for greater production of erythrocytes and fetal and placental growth.
- A deficiency in folic acid results in a reduction in the rate of deoxyribonucleic acid (DNA) synthesis and mitotic activity of individual cells, resulting in the presence of large, immature erythrocytes (megaloblasts).
- Folate deficiency is associated with increased risk of spontaneous abortion, abruptio placentae, and fetal anomalies.
- Folic acid deficiency often is present in association with iron deficiency anemia.
THERAPEUTIC MANAGEMENT
- The best sources of folic acid are fortified greens; beans such as black beans and lentils; peanuts; and fresh, dark-green, leafy vegetables (see Table 9-4). Folic acid often is destroyed in cooking THUS 400 mcg (0.4 mg) of folic acid daily is recommended
- This supplementation should be increased to 600 mcg (0.6 mg) when pregnancy is confirmed.
- Women who have had a previous child with a neural tube defect should take 4 mg (1 gram says ) of folic acid for 1 month before and during the first trimester of pregnancy
Systemic Lupus Erythematosus
- Sometimes its not diagnosed until a woman has had several miscarriages
- associated with increased incidences of spontaneous abortion and fetal death during the first trimester.
* ***After the first trimester, the prognosis for a live birth is higher if no active disease exists. - Newborn risks include preterm birth, often resulting from preterm rupture of the membranes, and growth restriction.
- The most serious potential complication for the neonate is a congenital heart block, which usually is permanent and will require a pacemaker
Hypothyroidism/ Hashimotos Thyroiditis
- Hypothyroidism in pregnancy increases risk for miscarriage, preterm birth, and preeclampsia.
- Maternal hypothyroidism during pregnancy can adversely affect the child’s mental development.
- Thyroid-stimulating hormone (TSH) level should be tested before or in early pregnancy and hypothyroidism corrected within the first trimester
Neurologic Disorders - SEIZURES
- Women with epilepsy have a higher-than-normal incidence of stillbirth, and some studies have shown a higher incidence of preterm labor.
- Maternal bleeding may occur because of a deficiency of clotting factors associated with anticonvulsant drugs such as hydantoins (Dilantin) and phenobarbital.
- Anticonvulsant drugs also compete with folate for absorption, which may result in folate deficiency.
- Most anticonvulsants are classified as pregnancy category C or D.
***** A major concern is the teratogenic effects of anticonvulsant drugs. A specific syndrome known as fetal hydantoin
syndrome, which includes craniofacial abnormalities, limb reduction defects, growth restriction, intellectual disability,
and cardiac anomalies, has been described.
Bell’s Palsy
- a sudden unilateral neuropathy of the seventh cranial (facial) nerve that causes facial paralysis with weakness of the forehead and lower face.
- It is three times more common during pregnancy and generally occurs in the third trimester. Although the reason for the increase during pregnancy is unknown, one theory suggests that estrogen-induced edema causes pressure on the facial nerve, making the pregnant woman more vulnerable to the condition. Most women recover within 3 to 6 weeks after birth
- Treatment is controversial. Some physicians prescribe steroids within the first few days. Supportive care includes applying a patch over the eye and applying ointment or eye drops to prevent dryness or injury to the exposed cornea. Facial massage may be helpful,
Cytomegalovirus
- Common place to be infected Daycare centers - CMV has been isolated from urine, saliva, blood, cervical mucus, semen, breast milk, and stool.
- Can cross the placenta and effect the fetus
- 10% of babies are symptomatic at birth
- Another 10% of the group showing CMV infection at birth will develop late-onset signs such as developmental delay, seizure activity, enlargement of the spleen and liver, chorioretinitis, dental defects, and hearing loss
- Most concerning when its a primary infection
Rubella
- Crosses the placenta
- Greatest risk is during the first trimester at this time, approximately one third of these cases will result in spontaneous abortions, and surviving fetuses may be seriously compromised. Deafness, developmental delay, cataracts, cardiac defects, IUGR, and microcephaly are the most common fetal complications.
- A rubella titer of 1 :8 or greater provides evidence of immunity.
- Do not get pregnant within 28 days of vaccine
- Worst in first trimester
Varicella-Zoster
- The greatest risk for development of congenital varicella syndrome occurs during 13 to 20 weeks of gestation
- Clinical findings include limb hypoplasia, cutaneous scars, chorioretinitis, cataracts, microcephaly, and IUGR.
- After 20 weeks transplacental passage of maternal antibodies usually protects the fetus
- Maternal complications with VZV include preterm labor, encephalitis, and varicella pneumonia,
- Women and infants with varicella are highly contagious and should be placed in airborne and contact isolation
- Acyclovir is the primary drug used to treat varicella quickly.
- Babies can be contagious after born
Herpes Simplex Virus
- TRANSMISSION - Vertical transmission (from mother to infant) generally occurs in one of two ways:
(1) after rupture of membranes, when the virus ascends from active lesions
(2) during birth, when the fetus comes in contact with infectious genital secretions or when the fetal skin is punctured such as with a fetal scalp electrode. - Neonatal herpes infection is uncommon but potentially devastating. The neonate may have infection that is limited to skin lesions or systemic infection.
- Symptoms usually appear within the first week, and the disease progresses rapidly. The likelihood of death or serious sequelae in infants who have systemic herpes infection is about 50%.
- Treatment - 6 weeks prior to due date Prophylaxis Acyclovir may be given during late pregnancy to a woman with a recurrent outbreak to reduce the possibility of her having active lesions at the time of birth.
Parvovirus
- Erythema infectiosum (also called fifth disease), caused by human parvovirus B19, is an acute, communicable disease characterized by a highly distinctive rash. The rash starts on the face with a “slappedcheeks” appearance, followed by a generalized maculopapular rash. Other symptoms include fever, malaise, and joint pain. Erythema infectiosum is most contagious before the rash is evident.
- When infection occurs during pregnancy, fetal death can result, usually from failure of fetal RBC production, followed by severe fetal anemia, hydrops (generalized edema), and heart failure.
- The risk to the fetus is greatest when the mother is infected in the first 20 weeks of pregnancy.
- Therapeutic Management
- exists. Starch baths may help reduce pruritus, and analgesics may be necessary to relieve mild joint pain.
Murray, Sharon Smith; McKinney, Emily Slone. Foundations of Maternal-Newborn and Women’s Health Nursing - E-Book (Page 560). Elsevier Health Sciences. Kindle Edition.
Hepatitis B
- Hepatitis B is transmitted via blood, saliva, vaginal secretions, semen, or breast milk and readily crosses the placenta.
- Hepatitis B is preventable with a vaccine, which is safe during pregnancy. Newborn vaccination against hepatitis B starts before discharge, with the second dose given 1 to 2 months later and the third dose given at 6 to 18 months.
- The risk of prematurity, low birth weight, and neonatal death increases when the mother has hepatitis B infection during pregnancy.
- pregnancy. Infection of the newborn whose mother is known to be HBsAg-positive usually can be prevented by administration of hepatitis B immune globulin (HBIG, Hep-B-Gammagee), followed by hepatitis B vaccine (Recombivax HB, Engerix-B) within 12 hours of birth.
- The newborn must be carefully bathed before any injections are given to prevent infections from skin surface contamination by the virus.
HIV
- Antiretroviral therapy during pregnancy should include three drugs, the primary antiretroviral being zidovudine (ZDV, also abbreviated AZT).
- Mothers who receive no or minimal HIV care during the prenatal period may have higher rates of infected infants. Infant infection may occur during pregnancy, during labor and birth, or after birth if the infant is breastfed
- An infected newborn is typically asymptomatic at birth, but signs and symptoms may become obvious during the first year of life. Early signs may include enlargement of the liver and spleen, lymphadenopathy, failure to thrive, persistent thrush, and extensive seborrheic dermatitis (cradle cap). Infected infants often have bacterial infections such as meningitis, pneumonia, osteomyelitis, septic arthritis, and septicemia.
Toxoplasmosis
- Toxoplasmosis is a protozoan infection caused by Toxoplasma gondii. Infection is transmitted through organisms in raw and undercooked meat, through contact with infected cat feces or soil, and across the
- Maternal signs - of fatigue, muscle pains, and swollen glands,
- Fetal and Neonatal Effects - 50% of affected infants may be asymptomatic at birth, but others have serious effects such as low birth weight, enlarged liver and spleen, jaundice, and anemia or coagulation disorders. Severe complications may develop several years after birth and include chorioretinitis that leads to blindness, deafness, seizures, hydrocephalus, and microcephaly
- Maternal treatment of toxoplasmosis during pregnancy is essential to reduce the risk for congenital infection. Sulfonamides can be used alone but are less effective than combination therapy. Spiramycin is successfully used in Europe for maternal toxoplasmosis and may be used according to specific guidelines within the United States
- No cat box
Group B Streptococcus (TEST)
- Group B Streptococcus (GBS) is a leading cause of life-threatening perinatal infections in the United States. The gram-positive bacterium colonizes the rectum, vagina, cervix, and urethra of pregnant as well as nonpregnant women.
- Maternal effects - Often, these women are asymptomatic, although symptomatic maternal infections can occur. These infections include urinary tract infection, chorioamnionitis, and metritis. Most women respond quickly to antimicrobial therapy
Early-onset newborn GBS disease occurs during the first week after birth, often within 48 hours.
- early-onset GBS Sepsis, pneumonia, and meningitis are the primary infections in early-onset GBS disease.
Late-onset
- GBS disease occurs after the first week of life, and meningitis is the most common clinical manifestation.
* ****neurologic consequences are more likely in infants who survive meningeal infections
- Optimal identification of the GBS carrier status is obtained by vaginal and rectal culture between 35 and 37 (BONNIE SAYS 34 - 36) weeks of gestation.
THERAPEUTIC MANAGEMENT
- Penicillin is the first-line agent for antibiotic treatment of the infected woman during birth. Cephazolin is the alternative for the patient with non–life-threatening penicillin allergy. Clindamycin is used for the woman at high risk for anaphylaxis.
Tuberculosis
- TRANSMISSION - fetus swallowing or aspirating infected amniotic fluid.
- Diagnosis is made by finding the bacilli in the gastric aspirate of the neonate or in placental tissue.
- Signs of congenital TB include failure to thrive, lethargy, respiratory distress, fever, and enlargement of the spleen, liver, and lymph nodes
- Treatment of TB is based on two principles. First, more than one drug must be used to prevent the growth of resistant organisms. Second, treatment must continue for a prolonged period.
*****The preferred treatment for pregnant women with active TB is isoniazid (INH), rifampin (RIF), and ethambutol (EMB)
daily for 2 months, followed by INH and RIF daily or twice weekly for 7 months, for 9 months of total treatment
duration. Pyridoxine (vitamin B6) should be given with isoniazid to prevent fetal neurotoxicity and because
pregnancy itself increases the demand for this vitamin - If the mother’s sputum is free of organisms, the infant does not need to be isolated from the mother. Breastfeeding is safe, and drugs may be secreted in breast milk. However, the maternal antituberculosis drugs in breast milk are not adequate for infant treatment.
LATE PRETERM INFANTS
- Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late preterm infants (LPIs)
AT RISK FOR
- Respiratory disorders
- Thermal instability
- Hypoglycemia
- Hyperbilirubinemia
- Feeding difficulties
- Infections
- Acidosis
DISCHARGE
- they should not be discharged earlier than 48 hours after birth.
- Before discharge, nurses should ensure that infants are feeding adequately and have had normal vital signs for at least 24 hours.
- Bilirubin levels should be assessed before discharge
Preterm infants
- Infants born before the beginning of the 38th week of gestation.
- low birth weight (LBW), which refers to infants weighing 5 lb, 8 oz (2500 g)
- Very-low-birth-weight (VLBW) infants weigh 3 lb, 5 oz (1500 g) or less at birth.
- Extremely-low-birth-weight (ELBW) infants weigh 2 lb, 3 oz (1000 g) or less at birth.
Characteristics of Preterm Infants - APPEARANCE
- Preterm infants often appear frail and weak, and they have less developed flexor muscles and muscle tone compared with full-term infants.
- Their extremities are limp and offer little or no resistance when moved.
- Typically lie in an extended position
- The infant’s head is large in comparison with the rest of the body.
- Preterm infants lack subcutaneous or white fat, which makes their thin skin appear red and translucent, with blood vessels being clearly visible.
- The nipples and areola may be barely perceptible, but vernix caseosa and lanugo may be abundant.
- Plantar creases are absent in infants of less than 32 weeks of gestation
- The pinnae of the ears are flat and soft and contain little cartilage (see Figure 20-28). They lack the rolled-over appearance of the pinnae of a full-term infant.
- In the female infant, the clitoris and labia minora appear large and are not covered by the small, separated labia majora.
- The male infant may have undescended testes, with a small, smooth scrotal sac
Behavior of preterm infants
- poor development of flexion and little excess energy for maintaining muscle tone.
- Easily exhausted by noise and routine activities.
and respond with lowered oxygenation levels, an increase in metabolism and an increase in stress
Problems with Respiration Preterm Infants
- Immature lungs. SURFACTANT IS NOT IN ADEQATE AMOUNTS UNTIL 34 WEEKS GESTATION.
- addition, preterm infants have a poorly developed cough reflex and narrow respiratory passages, which increase the risk for respiratory difficulty.
- Prone to PERIODIC BREATHING & APNEIC SPELLS
- PERIODIC BREATHING - cessation of breathing for
5 to 10 seconds without other changes followed by
10 to 15 seconds of rapid respirations - APNEIC SPELLS - absence of breathing lasting
more than 20 seconds or less if accompanied by
cyanosis, pallor, bradycardia, or hypotonia
- PERIODIC BREATHING - cessation of breathing for
- POSITIONING - SIDE LYING or PRONE
- PRONE - increases oxygenation, enhances
respiratory control, improves lung mechanics and
volume, and reduces energy expenditure- SIDE LYING
Problems with THERMOREGULATION Preterm Infants
- Temp control center in brain not fully developed
- Their skin is thin with blood vessels near the surface,
- little subcutaneous white fat for insulation. As a result, heat loss is rapid.
- The preterm infant’s shorter time in the uterus allows less brown fat to accumulate before birth, impairing the infant’s ability to produce heat.
- The preterm infant’s extended extremities increase exposure to air and thus heat loss. T
COMPLICATIONS FROM HEAT LOSS - hypoglycemia, respiratory problems, metabolic acidosis, pulmonary vasoconstriction, impaired surfactant production, and more respiratory difficulty.
- In addition, calories used for heat production are unavailable for growth and weight gain. A
- The infant’s temperature as shown on the monitor should be recorded every 30 to 60 minutes initially and every 1 to 3 hours when the infant is stable.
- The axillary temperature for a preterm infant should remain between 97.3°F and 98.4°F (36.3°C and 36.9°C), slightly lower than the temperature for full-term infants (Brown & Landers, 2011).
***** If the infant has accumulated brown fat, a normal axillary temperature when the monitor shows a decreased skin temperature may indicate that heat from brown fat in the axillary space is being used to maintain the infant’s core temperature.
- Before infants are dried, place those who are less than 29 weeks of gestation in a polyethylene bag or wrap that covers the body from the shoulders down.
Indications of inadequate thermoregulation
- poor feeding or intolerance to feedings in an infant who previously had little difficulty, irritability, lethargy, poor muscle tone, cool skin temperature, and mottled skin
- Hypoglycemia and respiratory distress may be the first signs that the infant’s temperature is low.
Signs of Fluid Imbalance in the Newborn - DEHYDRATION
- Dehydration Urine output <1 mL/kg/hr
- Urine specific gravity >1.01
- Weight loss greater than expected
- Dry skin and mucous membranes
- Sunken anterior fontanel
- Poor tissue turgor
- Blood: elevated sodium, protein, and hematocrit
levels Hypotension
Signs of Fluid Imbalance in the Newborn - OVERHYDRATION
- Urine output >3 mL/kg/hr
- Urine specific gravity <1.002
- Edema Weight gain greater than expected
- Bulging fontanels
- moist breath sounds Difficulty breathing
** Blood: decreased sodium, protein, and hematocrit levels
Problems with FLUID AND ELECTROLYTE BALANCE Preterm Infants
- Preterm infants lose fluid very easily, and the loss increases with the degree of prematurity.
CAUSES
- The rapid respiratory rate and the use of oxygen increase fluid losses from the lungs.
- Their thin skin has little protective subcutaneous white fat and is more permeable than the skin of term infants.
- The large surface area in proportion to body weight and lack of flexion further increase transepidermal water losses.
- Radiant warmers raise insensible water losses by 40% to 50% compared with loss in an incubator
- Heat from phototherapy lights causes even more fluid to be lost through the skin.
- Normal urinary output is 1 to 3 mL/kg/hr for preterm infants for the first few days. After 24 hours of life, output less than 0.5 mL/ kg/hr is considered oliguria
- Electrolyte regulation by the kidney’s is poor
Problems with INFECTIONS - Preterm Infants
- 3 to 10 times more at risk than term infants to have infections
- Many have one or more episodes of sepsis during hospitallization
- Exposure to many invasive procedures place them at higher risk for infections
- Lack adequate passive immunity of IgG from mother during 3rd trimester and have an immature response to infections
Problems with SKIN - Preterm Infants
- Skin is very fragile, permeable and easily damaged
- Removal of adhesive tape may strip the epidermal layer of the skin, causing pain and increasing transepidermal water loss and the risk of infection.
- Diaper rash or yeast infection due to diapers or positioning, especially on the head can be source of infection
Problems with PAIN - Preterm Infants
- Crying can increase intracranial pressure which can increase the risk of intraventricular hemorrhage
- Other risks include hypoxia, changes in metabolic rate, and adverse effects on growth and wound healing.
- Stress and pain in the newborn may alter pain thresholds and cause permanent changes in neural pathways
- Tissue injury occurring early in development may lead to higher sensitivity to pain at the involved site and the surrounding areas
Common Signs of Pain in Infants
- Increased or decreased heart and respiratory rates, apnea Increased blood pressure
- Decreased oxygen saturation
- Color changes: red, dusky, pale
- High-pitched, intense, harsh cry
- Whimpering, moaning “Cry face”
- Eyes squeezed shut
- Mouth open Grimacing
- Furrowing or bulging of the brow
- Tense, rigid muscles or flaccid muscle tone
- Rigidity or flailing of extremities
- Sleep-wake pattern changes
Signs of Overstimulation in Preterm Infants - Behavior Changes
- Stiff, extended arms and legs
- Fisting of the hands or splaying (spreading wide apart) of the fingers
- Arching
- Alert, worried expression
- Turning away from eye contact (gaze aversion)
- Regurgitation, gagging, hiccupping
- Yawning
- Fatigue signs
Signs of Overstimulation in Preterm Infants - Oxygenation Changes
- Blood pressure, pulse, and respiratory instability
- Cyanosis, pallor, or mottling
- Flaring nares
- Decreased oxygen saturation levels
- Sneezing, coughing
Problems with NUTRITION- Preterm Infants
- Digestive system is immature, stomach volume holds less and are not able to absorb fats as well
- Higher risk for hypoglycemia
- Ability to suck, swallow and breath is not well coordinated until 34-35 weeks
- The sucking pads of the mouth and the strength of the jaw are weakened still
- More energy, oxygen, and glucose are used when feeding
- Enteral feedings
Effects of Placental function decreases for POST TERM FETUS
- decreased amniotic fluid volume (oligohydramnios) and compression of the umbilical cord may occur.
- Decreased oxygen and nutrients
- This condition results in hypoxia and
malnourishment in the fetus and is
called postmaturity syndrome
- This condition results in hypoxia and
- Fetal intolerance of labor
- When labor begins, poor oxygen
reserves may cause fetal compromise.
- When labor begins, poor oxygen
- Risk for meconium aspiration
- The fetus may pass meconium as a
result of hypoxia before or during
labor.
- The fetus may pass meconium as a
Appearance of Postterm baby
- may be thin with loose skin and little subcutaneous fat.
- little or no vernix caseosa, but the infant generally has abundant hair on the head and long nails.
- The skin is wrinkled, cracked, and peeling
- If meconium was present in the amniotic fluid, the cord, skin, and nails may be stained yellow green, indicating that meconium was present for some time.
- The umbilical cord is thin with little Wharton’s jelly.
Causes of SMALL FOR GESTATIONAL AGE INFANTS
- Congenital malformations, chromosomal anomalies, genetic factors, multiple gestations, and fetal infections such as rubella or cytomegalovirus may cause FGR.
- Poor placental function resulting from aging of the placenta, small size, separation, or malformation may interfere with fetal growth.
- Illness in the expectant mother, such as preeclampsia or severe diabetes, restricts uteroplacental blood flow and decreases fetal growth.
- Smoking, drug or alcohol abuse, and severe maternal malnutrition also impair fetal growth.
SYMMETRIC GROWTH RESTRICTION
- Symmetric growth restriction involves the entire body. More commonly related to congenital anomalies, genetic disorders, exposure to infections or drugs early in pregnancy, or normal genetic predisposition.
- Although the infant’s weight, length, and head circumference are all below the 10th percentile, the body is proportionate and appears normally developed for size.
SYMMETRIC GROWTH RESTRICTION
- Asymmetric growth restriction is caused by complications such as preeclampsia that begin in the third trimester and interfere with uteroplacental function.
- The head is normal in size but seems large for the rest of the body.
- Brain growth and heart size are normal. The length is normal, but the weight is below the 10th percentile for gestational age.
- The abdominal circumference is decreased because the liver, spleen, and adrenals are smaller than normal
- The infant appears long, thin, and wasted.
- The dry, loose skin has longitudinal thigh creases from loss of subcutaneous fat.
- The infant has a sunken abdomen, sparse hair, a thin cord, and the facial appearance of being elderly. The anterior fontanel may be large with wide or overlapping cranial sutures
****These infants generally “catch up” in growth, particularly in the first 2 years, if they are adequately nourished after birth.
High- Risk Newborn - Respiratory complications
- ASPHYXIA -.
- TTN- TRANSIENT TACHYPNEA
- MECONIUM ASPIRATION
- PERSISTENT PULMONARY HYPERTENSION
Respiratory complications - ASPHYXIA
- Asphyxia is insufficient oxygen and excess carbon dioxide in the blood and tissues
- MATERNAL CAUSES of Asphyxia - Hypertension, infection and drug use. Asphyxia in utero may be caused by placenta previa, abruptio placentae, or post maturity.
- INFANTS AT RISK - Cord problems, infection, premature birth and multifetal gestation. Expectant mother receives narcotics shortly before birth.
- Manifestations of Asphyxia-
- PRIMARY APNEA- rapid respirations followed BY
cessation of respirations and a rapid fall in heart
rate. Stimulation, alone or with oxygen, may restart
respirations.- SECONDARY APNEA- the oxygen levels in blood continue to decrease, the infant loses consciousness, and stimulation is ineffective. *****Resuscitative measures must be initiated immediately to prevent permanent injury to the brain or death. - METABOLIC ACIDOSIS - Lack of oxygen transported to the cells leads to anaerobic metabolism and the production of lactic acid. Metabolic acidosis develops when inadequate bicarbonate is available to buffer the accumulating acids. - RESPIRATORY ACIDOSIS - occurs as carbon dioxide accumulates.
- Neonatal circulation can revert to the fetal
circulation (PERSISTENT NEONATAL
CIRCULATION) - Pulmonary hypertension
- Neonatal circulation can revert to the fetal
Respiratory complications - Transient Tachypnea of the Newborn (Retained Lung Fluid)
- Inadequate absorption of fetal lung fluid
- Usually resolves within 24 - 48 hrs
- RISK FACTORS - cesarean birth with or without labor, macrosomia, multiple gestation, excessive maternal sedation, prolonged or precipitous labor, male gender, and maternal diabetes or asthma. Mild immaturity of surfactant production
- Manifestations In TTN, tachypnea develops within 6 hours of birth. Grunting, retractions, nasal flaring, and mild cyanosis also are present. Chest radiography demonstrates hyperinflation, perihilar streaking that shows engorged lymphatics, and the presence of fluid in the fissures between the lobes and in the pleural space.
- Therapeutic Management Treatment
- supportive and may include oxygen for cyanosis.
- Gavage feeding may be given when the respiratory
rate is high to prevent aspiration and conserve
energy. . - Antibiotics may be given until sepsis is ruled out.
Respiratory complications - Meconium Aspiration Syndrome
- condition in which there is obstruction, chemical pneumonitis, and air trapping caused by meconium in the lungs.
- occurs most often in infants who are postterm, small for gestational age, and are compromised before birth by placental insufficiency with decreased amniotic fluid and cord compression
- MAS occurs most often when hypoxia causes increased peristalsis of the intestines and relaxation of the anal sphincter before or during labor.
Respiratory complications - Persistent pulmonary hypertension
- (PPHN) is a condition in which pulmonary vasoconstriction occurs after birth and elevates vascular resistance of the lungs.
- Normal changes to neonatal circulation are impaired which leads to persistent fetal circulation (patent arterious ductus & formen ovale)
- The cause may be abnormal lung development or maternal use of nonsteroidal antiinflammatory drugs or selective serotonin reuptake inhibitors, or it may be unknown. It is often associated with hypoxemia and acidosis from conditions such as asphyxia, MAS, sepsis, polycythemia, diaphragmatic hernia, and RDS
Hyperbilirubinemia - Pathological Jaundice
- Seen withing the first 24hs
- If untreated it can lead to kernicterus-chronic and permanent result of bilirubin toxicity
- MOST COMMON CAUSE - Rh negative mother forms antibodies to a Rh positive fetus, usually from a previous pregnancy
- Other causes - ABO incompatibility, infection, hypothyroidism, polycythemia, macrosomic infants born to diabetic mothers
- TREATMENT - close monitoring, phototherapy, sometimes blood transfusions
Hydrops Fetalis
Rh incompatibility which leads to erythroblastosis fetalis (agglutination and hemolysis of fetal erythrocytes from maternal-fetal blood incompatibility. In severe cases hydrops can develop, a severe anemia that results in heart failure and generalized edema.
Sepsis Neonatorum - EARLY-ONSET SEPSIS
EARLY ONSET SEPSIS
- is acquired during birth, often from complications of labor such as prolonged rupture of membranes, prolonged labor, or chorioamnionitis.
- Infants often show signs during the first hours after birth, and 90% show signs within 24 hours
- Rapidly progressive multisystem illness with high mortality and morbidity rates.
- Pneumonia and meningitis are commonly present.
Sepsis Neonatorum - LATE-ONSET SEPSIS
- Occurs from 8 to 90 days after birth in healthy term infants or after 72 hours of life in very-low-birth-weight infants
- It is acquired during or after birth, before or after hospital discharge. It usually is a localized infection such as meningitis, and serious long-term effects are common.
SEPSIS NEONATORUM - LAB RESULTS
- A CBC count with differential may show decreased total neutrophils, increased bands (a form of immature neutrophils), an increased ratio of immature neutrophils to total neutrophils, and decreased platelets.
- Elevated levels of leukocytes are normal in newborns. However, a sudden rise or fall in leukocyte levels compared with previous results is abnormal. A leukocyte count below 4000 to 5000/mm3 or above 24,000 to 30,000/mm3 suggests infection but is not diagnostic (Blackburn, 2013).
- The presence of elevated IgM levels in cord blood or shortly after birth indicates that infection was acquired in utero because this immunoglobulin does not cross the placenta. It often indicates transplacental infection.
SEPSIS NEONATORUM
- Infection that occurs during or after birth may result in sepsis neonatorum, a systemic infection from bacteria in the bloodstream.
- COMMON CAUSES - agents of neonatal sepsis include bacteria such as GBS, Escherichia coli, coagulase-negative Staphylococcus, Staphylococcus aureus, Haemophilus influenzae, and fungi such as Candida albicans
- Infection. In the newborn, early signs of infection are not as specific or obvious as those in the older infant or child. Instead, they tend to be subtle and could indicate other conditions.
SEPSIS NEONATORUM - SIGNS & SYMPTOMS
GENERAL SIGNS
- Temperature instability (usually low)
- Nurse’s or parents’ feeling that the infant is not doing well
- Rash
RESPIRATORY SIGNS
- Tachypnea
- Respiratory distress (nasal flaring, retractions, grunting)
- Apnea
Cardiovascular Signs
- Color changes (cyanosis, pallor, mottling)
- Tachycardia
- Hypotension
- Decreased peripheral perfusion
- Edema
Gastrointestinal Signs
- Decreased oral intake
- Vomiting Excessive gastric residuals
- Diarrhea
- Abdominal distention
- Hypoglycemia or hyperglycemia
Neurologic Signs
- Decreased or increased muscle tone
- Lethargy -
- Jitteriness
- Irritability
- Full fontanel
- High-pitched cry
SEPSIS IN THE NEWBORN - Signs That May Indicate Advanced Infection
- Jaundice Evidence of hemorrhage (petechiae, purpura, pulmonary bleeding) Anemia Enlarged liver and spleen Respiratory failure Shock Seizures
Signs of Intrauterine Drug Exposure*
- Irritability
- Jitteriness, tremors, seizures
- Muscular rigidity, increased muscle tone
- Restless, excessive activity
- Exaggerated Moro reflex
- Prolonged high-pitched cry
- Difficult to console
- Poor sleeping patterns
- Yawning
A pregnant women is generally considered anemic if her hemoglobin level is less than?
10.5-11g/dL
Respiratory distress syndrome (RDS)
- is a condition caused by insufficient production of surfactant in the lungs.
- Signs of RDS begin during the first hours after birth. They include tachypnea, tachycardia, nasal flaring, xiphoid and intercostal retractions, and cyanosis. Audible grunting on expiration is characteristic.
-
Surfactant Production
- Enough surfactant is usually produced beginning at 34 to 36 weeks of gestation to prevent respiratory distress syndrome
NAS Neonatal Abstinence Syndrome
a disorder in which infants exposed to maternal drugs before birth demonstrate signs of drug withdrawal.
When drug exposure is suspected, what may be collected for analysis ?
Cord blood, urine and meconium
POLYCYTHEMIA
- In polycythemia, infants have a hemoglobin level greater than 22 grams per deciliter (g/dL) and a hematocrit greater than 65% .
- The increased viscosity of the blood causes resistance in the blood vessels and decreases blood flow. Blood flow to all organs is impaired. Organ damage from ischemia and microthrombi, elevated pulmonary vascular resistance, stroke, renal vein thrombosis, necrotizing enterocolitis, and congestive heart failure may result
- Polycythemia also may result in hyperbilirubinemia as the excessive RBCs break down after birth.
Causes of Polycythemia
- May occur when poor intrauterine oxygenation causes the fetus to compensate by producing more erythrocytes than normal.
- It is more common in infants who are postterm, LGA, or SGA or have fetal growth restriction (FGR).
- It also occurs in infants of mothers who smoke or have hypertension or diabetes. Delayed cord clamping or a transfusion from one twin to another may also cause the condition.
Manifestations of Polycythemia
- Most infants have minimal or no signs of polycythemia.
- Symptomatic infants may have a plethoric color, lethargy, irritability, poor tone, and tremors. Abdominal distention, decreased bowel sounds, poor feeding, hypoglycemia, and respiratory distress may also be present.
Therapeutic Management of Polycythemia
- Treatment is primarily supportive. Infants who are asymptomatic are observed and receive increased hydration.
- Partial exchange transfusions may be performed if the hematocrit is above 70%
- Blood is replaced with normal saline to decrease the total number of RBCs. Phototherapy is used to treat the
jaundice.
HYPOCALCEMIA
Hypocalcemia is a total serum calcium concentration of less than 7 mg/dL. It is divided into early-onset (in the first 72 hours of age) and late-onset (1 week of age) forms
- Early-onset hypocalcemia occurs most often in infants of diabetic mothers (IDMs), and infants with asphyxia, prematurity, maternal anticonvulsant therapy, and delayed nutrition. Late-onset hypocalcemia is caused by hyperparathyroidism, malabsorption, low magnesium levels, diuretic therapy, and rickets
TREATMENT OF HYPOCALCEMIA
- A cardiac monitor is necessary when IV calcium is given because bradycardia can occur.
Nursing Considerations - The nurse must be alert for signs of hypocalcemia. IV calcium should be administered slowly and stopped immediately if bradycardia or dysrhythmia develops.
- The IV site should be assessed frequently because infiltration can cause necrosis and ulceration.
TREATMENT OF HYPOCALCEMIA
Nursing Considerations
- A cardiac monitor is necessary when IV calcium is given because bradycardia can occur.
- IV calcium should be administered slowly and stopped immediately if bradycardia or dysrhythmia develops.
- The IV site should be assessed frequently because infiltration can cause necrosis and ulceration.
Signs of Intrauterine Drug Exposure* Relating to Feeding
- Exaggerated rooting reflex
- Excessive sucking
- Uncoordinated sucking and swallowing
- Frequent regurgitation or vomiting
- Diarrhea
- Weight loss
PHENYLKETONURIA
- a genetic disorder that causes CNS injury from toxic levels of the amino acid phenylalanine in blood.
-
Signs of Intrauterine Drug Exposure* - Other Signs
- Hypertension
- Fever
- Diaphoresis
- Excoriation
- Mottling
Hemoglobin values
Hematocrit
10.5 - 11
33%
Thalassemia
- Disorder with the synthesis of RBC membrane Decreases lifespan of RBC
- Mothers are usually mildly anemic and the fetus can also be anemic if fetal hemoglobin is not produced
Vertical Transmission
This occurs before or during birth from the mother
Horizontal transmission
Occurs after birth from family members, hospital staff, contaminated equpiment
Asymmetric growth restriction
Asymmetric growth restriction is caused by complications such as preeclampsia that begin in the third trimester and interfere with uteroplacental function. In asymmetric restriction, the head is normal in size but seems large for the rest of the body. Brain growth and heart size are normal. The length is normal, but the weight is below the 10th percentile for gestational age. The abdominal circumference is decreased because the liver, spleen, and adrenals are smaller than normal
What is TORCH?
(T)oxoplasmosis
(O)ther Agents
(R)ubella (or German Measles)
(C)ytomegalovirus
(H)erpes Simplex.
Hemorrhage Risk Factors for
- Grand Multipara
- Asian, HIspanic, Native Americans, Alaska Natives
- Prolonged labor
- Precipitate labor
- Induced labor
- Cervical laceration
- history of hemorrhage
- hypertension PIH
- Overdistention of the uterus
- Anemia
- Infection
- Manual removal of placenta
Early Hemorrhage takes place within 24hrs and risk factors include
- Relalted to uterine Atony
- Trauma - hematomas, retention of placental fragments,
- Placental accreta
Late Hemorrhage takes place after 24hrs to 6 weeks and risk factors include
- Retained placenta
- Subinvolution - delayed return of the uterus to its nonpregnant size and consistency
- Usually occurs after discharge home and can be dangerous for the unsuspecting mother
- Nurses must teach mothers when to seek medical care of unusually heavy bleeding
Danger signs that women need to seek emergency care POST BIRTH
Pain in chest
Obstructive Breathing
Seizures
Thoughts of hurting yourself or baby
Bleeding
Incision that’s not healing
Temp over 104
Headache that does not get better
Signs &Symptoms to watch Postpartum
Excessive bright red bleeding
- Boggy fundus deviated to the right
- Difficult to locate the fundus
- Fundus above expected level
- Large clots
- Backache
- Elevated Temp, Pulse, Resp; low B/P
- If hematoma; perineal pain
Prevention is the best treatment of Hemorrhage, this can be done by
- Inspect placenta
- Explore uterus
- Avoid over manipulation of uterus
- Type and cross for those at risk
Patient teaching regarding HEMORRHAGE
- Void 1-2 hrs after delivery
- Fundal massage - teach patient
- Encourage breastfeeding
- Patient teaching report clots/excessive bleeding
Postpartum Hemorrhage interventions
- CALL FOR HELP
- Monitor Fundus
- Monitor bleeding - weigh pads etc
- Check Uterine Tone
- Measure blood loss - 1 gram = 1ml
- A drop of 1 gram in Hgb or 3% drop in Hct is = 500 ml of blood loss
Medications used for Hemorrhage
- Oxytocin 10-40 units (10 units im if not IV access)
- Cytotec (misoprostol) PO, Rectally- 800mcg, Vaginally
- Methergine - 0.2mg IM, IV, or PO
- Prostin (Hemabate) IM 250mcg - Diarrhea, elevated diastolic fever flushing, (DON’T GIVE IF PT HAS ASTHMA)
Bimanual Compression
Hand is placed in vagaina and uterus is squished by hand in vagina and hand on the abdomen
Interventions for Hemorrhage
- D&C - dilation and curettage (stretching of the cervical os to permit suctioning or scraping of the walls of the uterus)
- Manual removal of placenta
- Bakri Balloon - A balloon may be inserted into the uterus to apply pressure against the uterine surface to stop bleeding
- Hysterectomy is a last resort to save the life of a woman with uncontrollable postpartum hemorrhage.
Comparison of hematocrit before and after birth
- If the hematocrit is lower after delivery, the woman lost the amount of blood added during pregnancy and an additional 500 mL for each 3% drop in the hematocrit value
Early signs and symptoms of shock
- Pallor
- Diaphoresis
- Oliguria
- Anxiety/ restlessness
- ## Air hunger
Changes in Vital signs during Hypovolemic shock
- Increased Respirations and Heart rate
- Hypotensive - Large amounts of blood loss
Nursing interventions for Hypovolemic Shock
- Elevate legs, lower the head of the bed
- Increase Oxygen - make sure they have pulse ox on
- Increase IV fluids
- LR or NS
- Transfusion: PRBC
Signs and Symptoms of Hematoma
- Severe unrelieved pain
- Difficulty voiding
- Mass felt on vaginal exam
- Abdominal distention
- Shock - systemic signs of concealed blood loss, such as tachycardia or
decreasing blood pressure, when the fundus is firm and lochia is within
normal limits.
Treatment of a Hematoma
- Ice
- Incision & Drainage
- Packing
- Monitor V/S
Current “definition” of postpartum hemorrhage includes blood loss of more than _____ mL after vaginal birth or ______mL after cesarean birth, a decrease in hematocrit of __% or more since admission, the need for a blood transfusion or saturated pad in less than ___ min
- 5600
- 1000
- 10%
- 15min
What is Puerperium
The period of about 6 weeks after childbirth during which the mother’s reproductive organs return to their original nonpregnant condition
What is Involution
The shrinkage of an organ (uterus)
The uterus involutes at ___Finger breaths/ cm per day
1
Immediately after delivery, the uterus is about the size of a large grapefruit. The fundus can be palpated midway between the symphysis pubis and umbilicus and in the midline of the abdomen. Within 12 hours the fundus rises to approximately the level of the _____________
umbilicus
The fundus descends by approximately 1 cm, or one fingerbreadth, per day. By the ____day, it has descended into the pelvic cavity and cannot be palpated abdominally
14th
Days 1-3: lochia rubra
- Red, mucus, small clots
Bloody; small clots; fleshy, earthy odor; dark red or red-brown
Days 3-10:
-Pink-brown, sero-sanguinous
lochia serosa Decreased amount; serosanguinous; pink or brown-tinged
Days 10-14 (or up to 3rd to 6th week): lochia alba
White, cream, or light yellow color; decreasing amounts
Murray, Sharon Smith; McKinney, Emily Slone. Foundations of Maternal-Newborn and Women’s Health Nursing - E-Book (Page 329). Elsevier Health Sciences. Kindle Edition.
Risks for subinvolution
- Grandmultiparus
- Chorioamnionitis
- Retained placental fragments/ amniotic sac
- Polyhydraminos in pregnancy
- Multifetal pregnancy
Afterpains ( Intermittent uterine contractions that occur to help control bleeding) are seen more frequently in ….
- More acute for multiparas than primipara
- More acute if retained blood clots, filling or full bladder, overdistended uterus
- More acute for some mothers with breastfeeding
Nursing interventions for Afterpains
- Analgesics such as;
- Ibuprofen, tylenol can be helpful - Heat to the abdomen
- Keep bladder empty
Peripad blood loss measurements
< 1 inch in hour = Scant
< 4 inches in 1 hr = Light
< 6 inches in 1 hr = Moderate
> 6 inches in 1hr = HEAVY
Nursing consideration
critical to remember regarding LOCHIA
- Lochia should be decreasing in amount every day.
- If it should increase in amount or become more bright red, a woman needs to rest more.
- If a woman increases her bleeding to where it soaks a pad in one hour, even if she is 1 day-4 weeks postpartum, this needs to be evaluated immediately.
- This could be a sign of retained placenta/ amniotic sac
By the end of the first week the external cervical OS is ____ in diameter
1 cm
Best to wait at least 6 weeks before resuming intercourse. If not willing then;
- Wait until bleeding stops
- Pain of epis/ lac gone
- Use lubricant, condom, woman on top
- Be prepared for milk let down if breast feeding.
Episiotomies and lacerations heal in 3-4 weeks, during this time one should observe for REEDA which stands for?
- Observe for REEDA
- Redness
- Edema
- Ecchymosis
- Discharge
- Approximation
Promote healing of episiotomy
Peri cleansing after each void/defecation
Pat perineum dry
Dry front to back
Hand wash before and after hanging pads
Apply pads without touching side that contacts perineum
Sitz baths- add epsom salts
Apply and remove pads from front to back
Kegel to strengthen perineal muscles
Diet high in protein and vitamin C
Change pads q2-3 hrs while awake until lochia ceases.
What should you look
- how long was her bag ruptured before delivery
- Laceration or episiotomy
- How much blood loss
- Vaginal birth or c-section
- Assisted delivery - (forceps/ suction)
- Prenatal lab work (RH, H&H)
- Immunizations (rubella)
- breast feeding bottle feeding
Mom should pee every __-__hrs after birth
2 - 3 hrs
Vital signs are accessed ever ___min in the first hour and every ___ min in the 2nd hour
- 15min
- 30 min
Pulse
Mother can be bradycardic or Tachycardic
BUBBLE HEP
Breast Uterus Bowels Bladder Lochia Episiotomy
Homans
Emotions
Pain
Bonding
- The process of the rapid initial attaction felt by parentes for their infant
- Unidirectional from parent to child
- Enhanced w/ tougch and interaction during first hour after birth
- quiet aleert state
- skin to skin
Attachment
- Process of an eduring bond /b/ a parent and child is developed through satisfying interaction
- Begins in preg and extends for many months after childbirth
- Infant receives warmth, food and security
- Parents accepts responsibility for the infants care and places its need above their own
- Baby and parent bond
Maternal touch
- mothers progress thgough discovery phase about their infants through touch
- Holds in a enface position
- Fingertipping, then stroking
Letting Go (>7 days)
- Mothers are moving on to new life with a baby
