Lecture 4 - Epidural/Newborn Assessment and Care Flashcards
What is the major complication of an epidural?
Marked maternal hypotension
–> d/t widespread vasodilation
What are some adverse effects of an epidural?
HypoTN
Pruritis
Loss of sense of control or urge to push
Increased length of labour in second stage
Increased need for augmentation
Postural puncture headache
What are the benefits of epidurals?
Relaxation, and comfort while remaining alert and able to participate
Airway reflexes remain intact
What causes pruritis with epidural analgesia?
Opioid-Induced histamine release
What is a postdural puncture headache?
When the needle used to insert the catheter punctures the Dura and causes a leaking of CSF and changes pressure changes intracranially
–> Worse when head is above heart level (upright), improved by lying down. Significantly painful.
Can last after the epidural has ended
What is nursing care prior to an epidural?
Assess coping, assure information has been provided
–> Asses VS, hydration, labour progress, FHR, platelets and CBC
–> Give 500-1000ml bolus 15-30 minutes prior
–> Assist client to void
Why do we assist clients to void prior to epidural?
The sensation of a full bladder will be inhibited after epidural, and until it is removed the client will be required to void via intermittent catheterization
Why is an IV bolus given prior to epidural? How much fluid over what time period?
500-1000 ml 15-30 minutes before epidural
Why are ephedrine and phenylephrine made available during epidural?
Vasoconstriction - increase BP
What position should patients be in during an epidural?
Comfortable position on back with pillow wedged under right buttock
–> Close to supine to facilitate even distribution of medication, wedged to prevent occlusion of vena cava
How often should a person be changing positions while receiving an epidural infusion?
q60-30 minutes
How can we prevent bladder distention for a patient with an epidural infusion?
Intermittent catheterization - sensation to void will be inhibited
What kind of anesthesia is typically used for an emergency c/s?
General Anesthesia
–> So immediate skin-to-skin will have to be with another family member
What is the purpose of an APGAR score?
To assess how the baby is doing in the moment - not indicative of course of progression or future health
When are APGAR scores given?
1&5 minutes
–> If less than 7, repeat at 10&20 minutes
What are the four factors that stimulate breathing in the newborn?
Mechanical, sensory, thermal, and chemical
What are the chemical factors that stimulate breathing in a newborn?
Lower O2, higher Co2
What are the mechanical factors that stimulate breathing in a newborn?
Negative intrathoracic pressure following vaginal delivery (or pressure from c/s) initiates first breath
Surfactant required to decrease surface tension
At what GA does a neonate have enough surfactant to not require administration
34 weeks GA
–> Premature before then would likely require surfactant administered
What are the temperature factors that stimulate breathing in a newborn?
Drop in temperature in room following delivery
What are the sensory factors that stimulate breathing in a newborn?
Suddenly being bombarded by lights, sounds, smells can make baby more alert, initiate crying
Why do newborns need patent nares?
Obligate nose breathers
When is the first period of reactivity?
First 30 minutes of life
–> HR decreases from 160-180 to consistent baseline, RR up to 80
–> Irregular RR with fine crackles, grunting, nasal, flaring (should cease by 1 hour)
Followed by sleep period
How long is the sleep period following the first period of reactivity?
60-100 minutes
What are the six states of NB consciousness?
Sleep: deep, light
Wake: Drowsy, quiet alert, active alert, crying
What is the second period of reactivity? When does it occur?
Occurs roughly 2-8 hours after birth, lasts 10 minutes-several hours
–> Increased mucus production, tachycardia/tachypnea may occur. Muscle tone increases + skin colour changes. Meconium often passes at this time.
What is the optimal state of arousal for bonding with baby?
Quiet alert
At what ages do babies have accommodation? At what age is their vision most acute
Accommodation: 3 months
Acute vision: 6 months
At what distance do babies have the best vision for at birth?
17-20 cm
How well is the sense of hearing developed in a newborn?
Similar to that of an adult once amniotic fluid drains from ears
–> Infants respond to mother’s voice
Do neonates have an intact sense of smell?
Yes. Infants can differentiate the breastmilk of their mother from another person’s milk
What taste do newborns prefer?
sweet - can be used for analgesia
To what areas are newborns most responsive to touch?
Face, hands, soles of feet.
What infections is erythromycin ointment used to prevent? When is it given?
Gonorrhea or chlamydia
–> Within 2 hours after delivery
Canadian Pediatric Society (CPS) no longer recommends routine administration to all newborns provided there has been negative STI screening in pregnancy (chlamydia and gonorrhea) and there are no risk factors for these infections post screening. Why is it still available to all parents?
It is a legal prescription for all NBs in Ontario
–> Parents have right to refuse
Why is vitamin K given to NBs?
Prevent hemorrhage by promoting clotting factor formation in the liver
–> NB does not have intestinal flora to produce vitamin K in the first week after birth
What route is vitamin K given to NBs? What dose? Under what time frame?
1.0 mg for babies > 1500g
0.5 mg of babies < 1500g
Administered IM within 6 hours after birth.
Persistent bradycardia (HR < 80) might indicate what in NB?
Congenital heart block
Persistent tachycardia (HR >180) in NB might indicate what?
RDS, pneumonia, fever
Bradypnea in NB (persistent RR < 30) may indicate what?
birth trauma or be d/t maternal narcosis from analgesics or anesthetics
Tachypnea in NB (persistent RR > 60) may indicate what?
RDS, TTN, CDH
Suboptimal temperature in the NB might indicate what?
Infection, dehydration
Increased temperature in a NB might indicate what?
Infection, chemical dependence, diarrhea, dehydration
Why are NBs are risk of hypothermia?
Unable to shiver
Larger surface area ratio
Born wet in a cold room
Blood vessels are superficial
Smaller energy stores
How do NBs create heat?
Fetal position
Brown fat & glycogen stores
–> Breakdown can produce heat
What are the different ways a NB can lose heat?
Convection, radiation, evaporation, conduction
Cold stress can lead to which complications?
Increased need for energy leads to hypoglycemia and glycolysis which leads to acidosis
Hyperbilirubinemia d/t increased metabolic rate that results from glycolysis and FFAs that will compete to bind to albumin
Decreased pulmonary perfusion, resp distress, return of fetal circulation d/t increased O2 consumption
What causes hypoglycemia in newborns with cold shock?
Increased energy expenditure
What causes respiratory distress, decreased pulmonary perfusion, and return of fetal circulation with cold shock in NB?
Widespread vasoconstriction and increased oxygen consumption
What causes glycolysis and acidosis in NBs with cold shock? What else does this lead to?
Increased metabolic rate d/t vasoconstriction and hypoglycemia
–> Hyperbilirubinemia d/t fatty acid breakdown attaching to albumin instead on bili
Newborns are weighed when?
At birth and at discharge
What loss in weight in the NB is acceptable for discharge?
10%
What is the average birth weight at term?
2500-4000 g
When is head circumference taken in a NB?
At birth
What is Nevus Simplex (Stork Bite)? Does it fade?
Large immature blood vessels below the surface
–> Can fade over time
What is erythema toxicum neonatorum (NB rash)? Does it fade?
Blotchy papules
–> Immune response to extrauterine environment
–> Will fade
What is congenital dermal melanocytosis? Does it fade?
Melanocyte development in the dermis
–> often fades, should be documented clearly in chart
What is milia in the NB?
Small white bumps, often on nose. Buildup of keratin
–> Fade on their own
What is caput succedaneum? Does it extend across the suture line? When does it disappear?
Edema of the scalp - common in long or vacuum assisted delivery
–> Extends across suture line
–> Disappears spontaneously within 3-4 days
Is molding a normal finding?
Yes, variation of normal after vaginal delivery
What could cause bulging of the fontanels?
Hemorrhage, hydrocephalus
What is cephalohematoma? Does it extend across the suture line? When does it disappear?
Collection of blood between skull and periosteum - occurs with pressure against bony pelvis or with forceps extraction
–> Does not cross suture lines
–> Resolves in 3-6 weeks
Often occurs with caput succedaneum - irreducible fullness that does not bulge with crying
What is subgaleal hemorrhage? What causes it?
Bleeding in the subgaleal compartment - associated with difficult operative vaginal delivery, especially with vacuum assist.
What are the complications of a subgaleal hemorrhage?
Hypovolemic shock, DIC, death - medical emergency
How is a subgaleal hemorrhage detected? What are early and diagnostic signs?
Signs: boggy scalp, pallor, tachycardia, increasing head circumference
Diagnose with CT or MRI to confirm diagnosis
How is subgaleal hemorrhage treated?
Replace lost blood, clotting factors may be needed
What might it indicate if the pinna of the ear does not recoil quickly?
Assesses GA - will not recoil quickly in premature infant
What is transient tachypnea of the newborn?
Signs of respiratory distress seen during first 1-2 hours following birth
–> Tachypnea > 100 rpm
–> Grunting + nasal flaring + mild retractions
How can mild transient tachypnea of the newborn be treated?
Supplemental oxygen or non-invasive ventilator support
Respiratory distress in newborns is more serious if…
–> Extends beyond first 2 hours of birth
–> RR > 120 rpm
Respiratory distress in newborns is often accompanied by what other else?
HypoTN, temp instability, hypoglycemia, acidosis, signs of cardiac issues
What might a pilonidal sinus/sacral dimple indicate?
Spina bifida - especially with a tuft of hair present
What are the s/s of biliary atresia?
Pale stool
Jaundice lasting > 2 weeks
Irritability
Weight loss
Abdominal distension
How is biliary atresia treated?
Surgically
What is physiological jaundice?
Starts after 24 hour mark
–> Normal finding with NBs d/t immature livers
What is pathological jaundice?
Prior to 24 hours
–> Indicates something is going wrong
What are some risk factors for jaundice?
Injury that results in bleeding
Pre-term
Poor feeding - breastfeeding increases risk d/t delay in milk let down
ABO incompatibility
Sepsis
Previous siblings with jaundice
What is kernicterus?
Brain damage caused by bilirubin crossing BBB
What is the Moro reflex?
Startle reflex - arm adduction + c-shaped hands
–> 3-6 months
What is part of the 24 hours screening for newborns?
Bili levels
NB metabolic screening
CCHD screening
Hearing screening - handout given to parent
+ CMV, weights (At TOH, not on slides)
How soon are the follow up appointments in the medical model?
Baby: 48-72 hours after discharge
Maternal: 1-2 weeks c/s; 6 weeks vaginal delivery
How soon are the follow up appointments in the midwife model?
Home visits within 24 hours and during first week - usually 6 visits in the first 6 weeks.
