Midterm to Final Material Flashcards
What are the 3 stages of the newborn adapting to extrauterine life?
What can be observed in the newborn during each stage?
How long does each stage last?
In which stage is it most likely from meconium to be expelled
- First period of reactivity: Alert & active best time for breast feeding, suck is strong. tachypneic and tachycardic, lasts 30mins-1 hour after birth.
- Period of decreased Responsiveness, 2-3 hours after birth (newborn falls asleep, HR & RR decrease)
- Second period of reactivity: (4-6 hours after birth, lasts 10mins to hours). ** most likely to pass meconium
By _____ wks there is enough surfactant in the newborns lungs that they can have a good chance of survival
32 weeks
Lack of ________ is what impacted pre-matures infants ability to breath properly
surfactant
Fetal respiratory movements have been detected on Ultrasound as early as ______ weeks
11
These movements are essential for developing chest wall muscles and diaphragm
By weeks ____ to _____ some fluid moves into the trachea and into the amniotic fluid or is swallowed by the fetus
13-16 weeks
By ___ to ___ weeks rhythmic breathing movements occurs
29-32 weeks
What are the 2 types of fetal surfactant?
lecithin
sphingomyelin
_______ surfactant will increase in amount
&
________ surfactant will remain constant in amount
lecithin
sphingomyelin
L:S ratio is used to determine how ________ the fetuses lung are
mature
once the L:S ratio is 2:1 (lecithin:sphingomyelin) we can say that the fetus lungs are mature
At what point is the L:S ratio 2:1?
35 weeks gestation
what factors can delay fetal lung maturity?
gestational diabetes
What chemical reactions occur to the fetal respiratory system during labour to ‘activate the lungs’
There are chemoreceptors in the carotid arteries and aorta that are activated by the hypoxia in birth that signal the lungs to begin working
hypoxia and increased CO2 levels during birth stimulate what to kick off the respiratory system
signal to the resp center in the medulla that breathing needs to begin
What mechanical factors activate fetal respiratory adaptations after brith
intrathoracic pressure»_space; going through the birth canal. once the baby is out of birth canal pressure is released. The negative pressure helps pull air into the lungs .
Crying increases distribution of air in lungs encouraging alveoli to open.
what thermal & sensory factors activate fetal respiratory adaptations after birth
Temperature drops when fetus is born» this stimulates receptors in the skin to further stimulate receptors in the medulla.
sensory stimulation: drying the infant, skin to skin, light, air etc all helps to stimulate the resp center.
how is the fluid removed from the lungs after birth?
pressure through the birth canal pushes it out, crying opens alveoli helping to push it out.
Any remaining fluid is absorbed back into the body through bloodstream and lymphatic stream
what factors negatively impact fetal respirations after birth?
alveoli are immature»_space; risk for inadequate oxygenation
small alveoli and low in #
decreased lung elasticity»_space; this will come in time.
nose breathers (risk of airway obstructions
immature resp control ability»_space; irregular breathing pattern and periods of apnea
not able to rapidly alter the depth of their resps yet.
What are normal findings for newborn resp assessment
shallow & irregular resps
30 - 60 breaths per min
Resp rate increases w/ activity
periodic apnea, pauses should be < 20 sec
what are signs of resp distress in newborn?
nasal flaring retractions grunting apnea lasting > 20 sec RR < 30 OR 60< central cyanosis (around the mouth) ** as opposed to acrocyanosis
What 3 shunts are present during fetal life?
ductus venosus
ductus arteriosus
Foramen ovale
in utero the ________ is a ____ resistance pathway for gas exchange
placenta
low-resistance (blood flows easily)
The ductus venosus connects the umbilical _____ to the _____ vena cava
vein
inferior vena cava
the ductus arteriosus connects the main ______ artery to the ______
pulmonary artery
aorta
the foramen ovale allows blood to pump the right ____ to the left ____
right atria to left atria
closes within the first few mins of life after the pressure changes in the circulatory system push oxygenated blood through the heart
Fetal circulation is:
_____pulmonary vascular resistance (PVR)
_____ aortic systemic vascular resistance (SVR)
High PVR
Low SVR
what happens when the umbilical cord is clamped?
resistance flips
causes a rise in blood pressure»_space; increases circulation among perfusion
Pulse oximetry screening is performed___ hours to ___ hours post birth.
Why?
24-36 hours
Critical congenital Heart disease is the most common congenital heart disease.
Pulse ox is placed where on the infant?
right hand and either foot
Bacterial colonization of the gut is established within the first _______ of birth
week
Stomach capacity of a newborn is _____ on day 1
30mL (1 oz)
infants can be born with 1 or more ______.
If they are born with these, we will remove them, why?
teeth
can become a chocking hazard
by the end of the first week stomach capacity is ______
90mL
meconium is composed of
amniotic fluid and its constituents, intestinal secretions, shed mucosal cells and possibly blood
by the ____ day baby will have a transitional stool
3rd after the initiation of feeding
thin and less sticky than meconium
by day 4 baby will have ____ stool
milk
When they are born babies have a small amount of _____ and will usually pass it during birth or directly folllowing
urine
1 void/day for first 5 days
and then 6-8 voids/day following
for newborns roughly ___% of their body weight is water
75%
first few days they undergo diuresis, loss 10% of body weight in the first week and then regain
newborns are more prone to ________ and _______ imbalance
why?
acidosis
electrolyte imbalance
decreased GFR at birth (kidneys aren’t fully online) about 30-50% that of an adult
This results in problems removing things from the blood»_space; electrolyte imbalances
what is the appropriate order of the newborn physical assessment?
quiet things first
inspect their face/head/ neck
listen to heart, lungs, and abdomen
move to the things that may make them cry
What is neutral thermal environment
ideal environment where you conduct your newborn assessment; no heat loss
allows baby to maintain body temp and to minimize glucose or oxygen consumption (trying to stay warm)
What are the 4 main types of heat loss?
convection
radiation
evaporation
conduction
flow of heat from the body surface to the cooler air is called
convection heat loss
loss of heat from the body surface but not to the direct surface in contact with the infant but rather near it.
ie. basinet in front of a big window
radiation
when a liquid is converted to a vapor and heat is lost.
ie. giving a baby a bath and they are not quickly dried
evaporation
evaporative heat loss is the most significant type of heat loss in the first few days of life
loss of heat from the body surface to cooler surfaces in direct contact with the infant.
ie. infant sitting on a cooler surface
conductive heat loss
can happen when you are weighing the baby without any protective layer (blanket) on the scale surface
T or F
newborns who are placed skin-to-skin are warmer than those who are swaddled and held by their caregivers
True
What can you do to ensure heat loss is minimized during the physical assessment?
Ensure infant covered, surfaces covered that infant is on, infant is dry, not near a window or cold area
What are safety precautions to consider?
Safety Precautions –
Need to check ID
Ensure is warm with head covering
Good lighting
Infection control procedures – washing hands, cleaning stethoscope etc.
Privacy – this is generally done in the mothers room so close the door or pull the curtain
Which aspects of the assessment and procedures require quiet? What can you observe? Do these first.
Observe: Breathing, infant state and movement, look at face and head and body, shape and symmetry of head, ears, and eyes, skin colour, perfusion, range of spontaneous movement, posture, muscle tone, look for edema and or trauma,
After observing you auscultate, what will you auscultate
heart, lungs, bowels
Perform procedures that may be upsetting to the newborn last. What may these be?
auscultation, reflexes and palpating the abdomen
What are normal newborn VS:
temperature
HR (where do we auscultate)
RR
temp: taken in the axilla 36.5 - 37.5
HR: 110-160 @ birth, can be as low as 90 during sleep and up to 180 when infant is crying.
Auscultate at the 4th intercostal space to the left of midclavicular line.
RR 30-60 (shallow, irregular in rate, rhythm and depth)
What do we teach the parents about heat loss and how to protect the baby?
skin to skin with light blanket
keep a cap on the baby
if baby is hot to touch. might be too warm
when bathing baby dry quickly. and wash hair separate from the body. wash first and place cap n head.
What are the 6 sleep-wake states of the baby
deep sleep
light sleep
drowsy
quiet alert (best time for baby to learn)
active alert
crying
** normal for baby to have a fussy period in the late afternoon and crying peaks between months 2-4
why do some babies look a little cross-eyed at birth?
eyes are structurally complete but muscles around the eyes are not
accommodation improves over the first few months
Clearest visual distance for baby ____ to____ cm (distance from baby breastfeeding to moms face)
17-20cm
can see up to 50cm away
by ____ months of age babys can detect color
2 months
newborns are more attracted to black and white patterns when they are first born
by ___ months baby’s vision is as acute as that of an adult
6 months
is newborn hearing similar to that of an adult?
yes, as soon as the amniotic fluid drains away
Do newborns have a highly developed sense of smell?
yes, they can differentiate their mother from other lactating women through smell
what are the 4 primary purposes of bathing baby?
- cleansing
- comfort for baby
- observing sensory development of baby
- family child interaction
how do we maintain the skin-acid mantel of the baby?
neutral pH soap
why is immersion technique the preferred method for bathing baby?
less heat loss
less crying
*You want to immerse up until the shoulders
when would you not bathe a baby?
when they are unstable.
if they are experiencing heat loss, cardiac or respiratory issues
does a baby need to be bathed daily?
no. not necessary and typically dries out skin.
cleaning the perineum after a diaper change and face wash daily should be sufficient
- typically we delay bathing in the hospital for 24 hours
what are the benefits of delaying bathing for newborns?
keep the vernix caseosa on them for longer, where they can absorb nutrients and improve rates of breast feeding.
can also prevent hypoglycemia and hyperthermia
why don’t we use baby powder any more
- the dust is so fine the infants can inhale it
2. the powder can become moist and lead to a diaper rash
How often should parents be wiping baby’s gums?
after each feeding
What are some key elements to washing the baby’s hair during bath time
Do not use running water to wash hair as temperature could change suddenly.
Area over the fontanels CAN be washed
Wash the head/hair before or after the body to prevent heat loss
A mild soap or shampoo should be used
what is cradle cap?
scalp desquamation. we place a cap on baby’s head when they are coated in the vernix which can become dry and matted.
can apply baby oil or mineral oil 1 hour before bathing and it will help remove it
what are key things for infant cord care
Clean cord with plain water and a q-tip
Assess for signs of infection – redness, swelling, exudate, pain in area
Notify healthcare provider if any signs of infection noted
Use an absorbent gauze to remove excess moisture
Roll diaper below umbilicus
Allow area to air dry
The area may be loosely covered with clothing
when will the umbilical cord fall off
10-14 days
may see a few drops of blood.
Parents should notify HCP if there is anything other than a few drops of blood
if a diaper rash persists for more than 3 days what might it be?
fungal in nature and will need different treatment.
could have gotten a fungal infection from the mom if she has thrush on her nipples
when will the foreskin or uncircumcised babies retract?
not until 3 years of age
T or F
Once healed a circumcised penis does not require any special care other than normal cleansing during diaper changes
True
What is a simple measure that can aid in minimizing diaper rash and helping it heal should a baby get one?
exposing the bottom to open air.
place baby on tummy with absorbent towel underneath and allow bottom to be exposed to the air
this will help dry things out
what are the most common minor complications associated with circumcision
bleeding and infection
Important teaching aspects for parents caring for an infant who has been circumcised
takes 7-10 days to heal
gently wash penis w/ warm water after each diaper change
put petroleum jelly on incised area as directed by physician
fasten diaper loosely
a thin yellow form will form over incision area - this is normal leave it
instructions for parents on when to call the doctor, post-circumcision procedure for their infant
Baby has a fever
If there is severe swelling and redness; a red streak on the shaft of the penis; or a thick, yellow discharge.
Bleeding or has a bloodstained area larger than the size of a quarter on a diaper or on the circumcision site dressing.
Babyis very fussy or cranky, has a high-pitched cry, or refuses to eat.
The baby has not passed urine within 12 hours after the circumcision was completed.
what is the recommended time frame for collecting blood sample for universal metabolic newborn screening
24-48 hours
it is a heel stick to collect the blood sample
SIDS peaks between __ to ___ months of age
2-4 months
SIDS is higher for these 3 categories of babies
male babies
low birth weight babies
premature babies
What are the modifiable risks to try and prevent SIDS
sleeping on their backs is best
exposure to cigarette smoke
prenatally & postnatally
What are some factors that can protect an infant from SIDS
breastfeeding for at least 2 months
pacifiers
vaccinations
What is positional plagiocephaly
flattened area that may develop on the head when infants are left supine while awake or in an infant seat
Shaken baby syndrome has been changed to
THI - CM
traumatic head injury - child maltreatment
what are some of the VS changes that can arise form THI-CM
lethargy, vomiting, inability to cry, hypotension
** inconsolable crying is the # 1 trigger
a yellow - orange bile pigment produced by the breakdown of red blood cells
bilirubin
bilirubin is conjugated by the _______
what does this mean?
liver
Conjugated (joined) with glucuronic acid
Conjugated form (direct bilirubin) is soluble and can be excreted through urine and stool
why can we palpate a newborns liver?
why is the liver so important?
because it takes up about 40% of the space in the abdominal cavity
- iron storage
- conjugates bilirubin
- metabolizing carbohydrates
- coagulation
during pregnancy the placenta conjugates bilirubin and removes it, once the baby is born the _____ takes over this function
liver
Describe the process of RBC breakdown
RBC reaches the end of their life cycle
will be phagocytosed by macrophages» broken down into HEME & GLOBIN
the HEME»_space; further broken down into Iron & UNconjugated bilirubin.
** bilirubin cannot be excreted on its own, needs to be conjugated (joined with albumin to become soluble and excretable
Unconjugated bilirubin is also called _________ bilirubin
indirect
most unconjugated bilirubin will bind to albumin to be excreted, if it does not bind to albumin what happens to it?
unconjugated bilirubin will leave the vascular system and enter extravascular tissues:
skin, sclera, oral mucosa
** can cross the BBB»_space; neurotoxicity
Urobilinogen is excreted via _____
Stercobilin is excreted via ______
urine
stool
yellowing of the skin, sclera and mucous membranes
Jaundice
d/t increased bilirubin blood levels
physiologic jaundice is common in term newborns(___%) and ____% of preterm infants
60%
80%
physiologic jaundice appears ___ hours of age.
* usually resolves without treatment
pathophysiological jaundice appears before ___ hours of age
24 hours
24 hours
peak bilirubin levels are reached between days ___ and ____
3-5 days
jaundice typically appears when serum bilirubin levels exceed ____ to ____ umol/L
85-102 umol/L
what are the 4 physiologic reasons for jaundice
- high RBC mass, short RBC lifespan
- Reduced ability of liver to conjugate
(liver can only conjugate about 2/3 of the circulating bilirubin in the first few days of life) - Fewer bilirubin binding sites (bc newborns have lower serum albumin levels)
- Conjugated changes in unconjugated in intestines
____________ refers to elevated serum bilirubin levels and its toxic to the brain
hyperbilirubinemia
acute bilirubin encephalopathy
high levels of serum bilirubin
symptoms include: lethargy, irritability, hypotonia, seizures, coma, death
if hyperbilirubinemia is left untreated it can lead to ______
kernicterus
irreversible long term consequences of bilirubin toxicity
hypotonia
delayed motor skills, hearing loss and gaze abnormalities
what are some contributing factors to hyperbilirubinemia
hemolysis of excessive RBCs (erythrocytes)
short RBC life
liver immaturity; cannot process all the breakdown of RBCs
lack of intestinal flora to help process
delayed feeding, which promotes meconium and excretion of bilirubin
fatty acids from cold stress or asphyxia
trauma resulting in bruising or cephalohematoma
how do fatty acids contribute to hyperbilirubinemia
fatty acids will displace bilirubin preventing them from binding to albumin and becomes conjugated (ready for excretion)
what are some risk factors for jaundice
premature baby
birth trauma or bruising
baby is Asian or Indigenous
baby’s siblings had newborn jaundice
__________________occurs when serum levels of unconjugated bilirubin rise beyond normal limits.
Hyperbilirubinemia
- In high concentrations, bilirubin is toxic to the brain. _______ refers to the irreversible, long term consequences of bilirubin toxicity, such as delayed motor skills and hearing loss
_Kernicterus____
- In newborns, the _____ plays a major role in the metabolism of bilirubin and conjugates it.
__liver___
- _______bilirubin is also called indirect bilirubin, which is ________ soluble, has not yet been metabolized by the liver, and is bound to circulating albumin in the blood stream.
_Unconjugated__
____lipid_
_______ bilirubin, also called direct bilirubin, is ______ soluble.
Conjugated
_water____
Two ways in which we can help the newborns reduce serum levels of unconjugated bilirubin
phototherapy and exchange blood transfusions
- _________ bilirubin is the sum of the indirect and direct bilirubin values.
Total Serum_
- Any delay in intestinal movement or ________ in intestinal flora increases the risk of direct bilirubin to convert to indirect bilirubin, thus necessitating re-entry to the liver to begin the excretion process again.
decrease
T or F
Jaundice in lighter-skinned newborns may be assessed by blanching the skin over a bony prominence.
True
T or F
In darker-skinned newborns, the oral mucosa, hard palate, and conjunctival sacs may be assessed for yellow pigmentation.
True
T or F
Jaundice progresses from lower extremities, to the trunk and then face.
FALSE] – MORE NOTICEABLE IN EYES AND FACE FIRST
T or F Transcutaneous bilirubinometry (TcB) monitors may be used to screen clinically significant jaundice and decreases the need for serum bilirubin levels. [TRUE]
True
T or F
The nomogram, used to determine risk zone, depicts the bilirubin value recorded on the TcB monitor on one axis and the postnatal gestational age (in weeks gestation) on the other axis.
[FALSE] – POSTNATAL GESTATIONAL AGE IS MEASURED IN HOURS
T or F
Exposing newborns to sunlight or placing the newborn in a bright, sunlit room, is recommended to treat jaundice.
[FALSE]
T or F
It is recommended that healthy infants (35 weeks’ or greater) receive assessment of bilirubin between 24 and 72 hours of life.
TRUE
T or F
Adequate hydration increases peristalsis and excretion of bilirubin in the newborn.
TRUE
T or F
The purpose of phototherapy is to reduce the level of circulating conjugated bilirubin.
[FALSE] –“LEVEL OF CIRCULATING UNCONJUGATED BILIRUBIN”
T or F
Phototherapy causes constipation in the newborn. [FALSE] – PHOTOTHERAPY MAY BE ASSOCIATED WITH LOOSE STOOLS
[FALSE] – PHOTOTHERAPY MAY BE ASSOCIATED WITH LOOSE STOOLS
T or F
During phototherapy, the newborn should be placed supine for maximum exposure to the light source.
[TRUE]
What are some of the factors that contribute to hyperbilirubinemia?
- Hemolysis of excessive RBC
- Short RBC life
- Liver immaturity (liver is what processes bilirubin)
- Lack of intestinal flora
- Delayed feeding (unable to pass their meconium)
Fatty acids from cold stress or asphyxia ( FA displace bilirubin- and it is unable to bind to albumin as well).
-trauma resulting in bruising or bleeding ie. cephalohematoma - build up of RBC
What are the 8 key checklist items that are required to evaluate / assess a baby for risk of hyperbilirubinemia?
- Was the baby premature
- Did the baby experience birth trauma or bruising?
Is the baby of Asian or Indigenous ethnicity? - Did the baby’s siblings have newborn jaundice?
- Is the baby being exclusively or partially breastfed?
Are fewer than 6 diapers saturated w/ urine each day ? dehydration»_space; prevents urobilin - Is the baby a boy?
- Is the mother Rh negative or blood type O
Why is breastfeeding so important to prevent hyperbilirubinemia ?
breastfeeding should be started within the first hour, and then infant should be fed 8-12 times within the first 24 hours.
colostrum is a laxative which promotes stooling and helps the baby pass meconium
What is the best therapy for hyperbilirubinemia?
Prevention
What is the TCB (transcutaneous bilirubin screening) tool used for?
It is measuring the amount of bilirubin via light refraction.
placed on the sternum of the newborn. 3 measurements are taken
TcB can reduce the need for a blood serum test TSB . more accurate at lower levels and no longer accurate once phototherapy is initiated.
What would we check if the mother is Rh negative or Type O ?
DAT (direct antiglobulin test).
Which checks to see if there are antibodies that can cause hemolytic disease of the newborn.
DAT is used to determine whether the newborn RBCs have been attacked by the mother’s antibodies.
DAT is also referred to as a Coombs test.
what is the purpose of phototherapy?
used to reduce the amount of circulating unconjugated bilirubin.
It uses blue wavelengths to change the shape of unconjugated bilirubin so it is more easily excreted
physiologic jaundice peaks at what days?
days 3-5
Why are newborns at higher risk of thermal dysregulation
Thin layer of subcutaneous fat and blood vessels are close to the surface of their skin
newborns have brown fat reserve
What will happen physiologically if the newborn is cold?
They will cry and wiggle to try and generate heat (thermogenesis)
increase in cellular metabolism which increases oxygen and glucose demand
newborn will assume the position of flexion»_space; to decrease heat
Newborns typically do not shiver, what do they do to warm themselves?
non-shivering thermogenesis, metabolize their brown fat supply.
reserves of brown fat are quickly depleted with cold-stress.
Also term infants have greater stores of brown fat than preterm infants.
Is heat lost or gained?
- Baby’s naked, dried body is placed on mom, skin-to-skin
- Warm, wet newborn covered with amniotic fluid is delivered
- Baby is removed from incubator for a procedure
- Baby is placed in an incubator with warm, circulating air
- Baby is bathed
- Baby is placed near a cold exterior wall
- A cool stethoscope is used when determining the newborn’s heart rate
- Gained - best if covered with a blanket
- Heat loss – evaporation
- Convection - heat loss
- Heat Gain - convection
- Evaporation – heat loss
- Radiation – heat loss
- Conduction- heat loss
`
How is non-shivering thermogenesis triggered?
Usually triggered at a mean skin temperature of 35-36° C
↓
Thermal receptors in the skin perceive a drop in environmental temperature and transmit impulses to the hypothalamus
↓
Stimulates the sympathetic nervous system
↓
Release of norepinephrine
↓
Stimulates brown fat metabolism by the breakdown of triglycerides
↓
Generates heat
↓
Increases body temperature
What are the physiological adaptations that occur when the newborn experiences cold stress?
Peripheral vasoconstriction less activity, lethargy, hypotonia depleted brown fat stores respiratory distress Metabolic acidosis >> kidneys are unable to remove acid Hypoglycemia
What are the differing displays of hyperthermia in a newborn for external vs internal sources?
External source (too many blankets): flushed skin, hands and feet warm to touch, posture of extension
Internal source (d/t sepsis): pale from vasoconstriction, hands and feet are cool
When does the newborn experience the peaks of hypoglycemia post birth?
30-90 minutes after the cord is cut
we want to see newborns glucose stabilize within the first 3 hours of life 2.5-3mmol/L
and by the third day should be between 4-5mmol/L
“The _______ period begins after the delivery of the placenta and lasts approximately 8 weeks.
puerperium
Acronym for the post-partum assessment of the mother.
BUBBLE Breasts & Nipple Uterine Bladder Bowel Lochia Legs Episiotomy/Laceration Emotional status / Energy Level
What are the physiological changes that occur with the following hormones to directly following delivery of the placenta:
- Progesterone
- Estrogen
- Prolactin
- hPL
- decrease
- decrease
- increases
4 decreases
What causes significant drops in insulin of the mother directly after birth
decrease in hPL
a type diabetic mother will need less insulin
HCG disappear from the maternal system pretty quickly after birth
What impacts a womans serum prolactin levels?
How frequently and much she breast feeds
How long breastfeeding goes for
woman who doesn’t breastfeed, prolactin levels decrease rapidly and return to pre-pregnancy levels in 3 weeks
What changes occur to menstruation after birth
woman who is not breastfeeding, menstruation will return within 27 days after birth
woman who is breastfeeding it will return in about 6 months
The term ______________ is used to describe the return of the uterus to a nonpregnant state following birth.
How does the fundal shape change?
puerperium
becomes a globular shape that returns to below the level of the pelvis
_______________ is any slowing of uterine descent (failure of the uterus to return to a nonpregnant state) which may be a result of retained placental factors or ___________.
uterine atony
bladder distention
what factors enhance involution (movement of the uterus back into its pre-pregnancy state)
what slow it?
breast feeding & fundal massage
full bladder and placenta fragments that remain
What are after pains? Who is more likely to experience afterpains? Why? How can they be relieved?
cramping of the uterus
more likely to experience, if the baby was really big, polyhydramnios, anything that causes uterus to be over-extended.
women with multiple pregnancies will get more after-pains
heating pad, lying prone.
After pains are more severe before and after breast feeding so any pain meds should be given 30 mins before breastfeeding.
___________ medication decreases the flow of lochia.
Why is there less lochia with C-sections
oxytocic medications
The surgeon sucks out a lot of the blood and clears the uterine lining
what is the transition of lochia?
lochia rubra: dark red
lochia serosa: pinking brown
lochia alba: creamy white
How do we determine if a clot that has been expelled with lochia is a true clot?
we don gloves and try to pull it apart.
if it doesn’t pull apart it could be placental tissue: this is a concern and needs to be discussed with the physician
not all bleeding is lochial bleeding, what are some other potential causes of bleeding?
How can you tell the difference between them
if there are tears or lacerations they can bleed.
Lochial bleeding tends to trickle from the vagina.
non-lochial bleeding: bloody discharge will spurt and be excessive and bright red
What are signs of excessive blood loss
pad soaked through in 15 mins and blood pooling under the buttocks
what are the changes of the cervix after birth?
soften immediately after birth, will be 2-3 cm after 3 days and typically returns to no dilation after 1 week.
the cervical os never returns to its normal shape and will look like a ‘slit’»_space; ‘fish mouth’
how long does it take for the episiotomy to heal?
can take 4-6 months for the incision to be completely healed
What nursing care and patient teaching may we provided associated with prevention of perineal infection and promotion of comfort?
peri bottle to cleanse after going to the bathroom
sitz bath
ice packs for the first 24 hours
anesthetic spray (prescribed by the physician)
tux pads: witch hazel on them
hemorrhoid cream
what are the 3 types of vaginal hematomas?
Vulvar: most common generally visible
Vaginal: associated w/ forceps, episiotomy or primigravidity
retroperitoneal: least common»_space; may be life threatening»caused by laceration of one of the vessels that are attached to hypogastric artery.
what are some of the common complaints from the women that we would suspect vaginal hematoma?
lots of rectal pain
persistent peritoneal pain
internal pain/ache
what are some ovarian changes that occur for lactating women?
- prolactin levels remain high for 6 months
ovulation is delayed in women who breastfeed exclusively
a woman needs to consider their contraceptive options
what are some ovarian changes that occur for lactating women?
70% of non-lactating women with experience first period 7-9 weeks post partum.
some start as early as 27 days postpartum
when can a post-partum woman resume sexual intercourse?
once perineal area is comfortable and lochia has stopped
Breastfeeding is not a reliable contraceptive method.
persistent or recurrent genital pain that occurs just before, during or after sex
dyspareunia
what changes happen to the urinary system post-partum?
should void spontaneously within first 6-8 hours
need to measure first few voids should be at least 150mL / void
Reduced renal function postpartum Kidney function returns to normal within 1 month Urine components glycosuria disappears BUN ↑ pregnancy induced proteinuria resolves ketonuria may occur
Postpartal fluid loss – postpartal diuresis (d/t estrogen decrease)
if a woman is voiding spontaneously after child birth the bladder should return to normal tone __ to __ days after child birth
5-7
What is happening in the first weeks postpartum that attributes to an additional 2-3 kg weight loss?
there is fluid loss from perspiration and increased urinary output
Why may there may a decreased sensation to void?
What may impede urination?
How can bladder distension be prevented?
trauma during birth
give her a bedpan, encourage voiding, listening to running water, pain control meds
** if she does not void we need to do an in and out cath
What nursing care and patient teaching may be provided associated with gaseous distension? Constipation? Hemmorhoids?
BM can take up to 2-3 days
important to educate for increased fluid, hydration, mobility and potentially stool softener.
gaseous distention is more common with C-section. encourage mobility and no carbonated beverages
generally hemorrhoids decrease in size within___ weeks
6 weeks
what foods are important for constipation
kiwi fruit oats fruits whole grains carrots, celery
What is the normal progression of breast filling for a breastfeeding mother post-partum
irst 24 hrs → little or few changes in breast tissue
On palpation:
Days 1-2: soft
Days 2-3: slightly firm (associated with filling)
Days 3-5: full, soften with breastfeeding
Colostrum
Mild Engorgement: common on days 2-3 and is associated with milk coming in.
manually expression of milk and standing a hot shower can help the milk flow. feeding frequently is the best option
ave. blood loss:
vaginal birth, single fetus \_\_\_\_ to \_\_\_\_\_ ml
(10% of blood volume)
Cesarean birth \_\_\_\_\_ ml to \_\_\_\_\_ ml
(15-30% of blood volume)300 - 500ml
500 -1000ml
CO remains increased for 48hrs after birth d/t increased stroke volume
and increased vascular fluid
What are some abnormal findings to VS post-partum
Temp: greater than 38C after 24 hrs
Rapid pulse
hypoventilation
pregnancy induced hypertension
what are some of the changes that occur to blood components in post-partum women
Hematocrit
with average blood loss during birth, level drops moderately for 3-4 days
reaches nonpregnant level by 8 weeks
White Blood Cell Count
↑ in first 10-12 days after childbirth
may obscure diagnosis of acute infection
why is the woman in a hypercoagulable state post partum, what is she at risk of , how can we minimize the risk?
Coagulation Factors
clotting factors and fibrinogen remain elevated
“hypercoaguable state”
increased risk of thromboembolism (esp with C-section)
compression stockings, mobilization, exercises in bed (flexion/extension, rotating ankles) if she doesn’t wish to get up and moving
What women are at higher risk of thromboembolism.
- women who are obese
- unexpected C section
- had any problem such as this during pregnancy
will likely be put on low-molecular weight heparin.
What changes occur to the respiratory system post partum??
Following birth, breathing becomes easier
Intra-abdominal pressure decreases
Diaphragmatic pressure decreases
What changes occur to the integumentary system post pregnancy
chloasma: lines on the face
linea nigra: goes away
stretch marks: will fade but don’t go away completely
After birth some women made need these two vaccines
rubella and varicella
Baby blues is experienced by ______ of women
50-80%
When do postpartum blues normally occur?
What are symptoms of postpartum blues?
What patient teaching can help a new mother (and her family) cope with postpartum blues?
tends to peak around the 5th day
anxious, sad, emotionally on edge, lots of tears etc.
tends to go away by 10-14 days
normalize this
educate the parents
What are Rubin’s 3 phases
- Taking- in first 24-48 hours dependent behavior, accepting of help and comfort
- taking-hold: begins: 2-3rd day ; lasts 10 days. becomes preoccupied with the present. trying to adjust and adapt
- letting go: forward movement of the family as a unit. re-established relationships with other people and moves forward
what is the nurses role in dealing with postpartum blues for new mothers
Educate mother and family on what PP blues is, and how to cope with it with rest, relaxation, taking a break, sharing feelings, monitoring for signs of depression and what to do about it.
Refer to community resources.
PPD tends to begin around __ weeks.
and affect ___ to ___ % of women
4 weeks
8-23%
What are some of the clinical manifestations of PPD
low mood/energy irritability lack of enjoyment sleep disturbances feelings oof hopelessness & guilt Negative attitudes/rejection of infant
What is the typical treatment for PPD
antidepressant and antianxiety meds psychotherapy ECT psychosocial intervention support groups alternative: massage etc
incidence of paternal postpartum depression is __ to ___ %
10-50%
What are some treatment options for Post-partum anxiety disorders
CBT SSRIs Education Anticipatory guidance family & social supports sensory interventions: music therapy
What are the 3 primary 3 post-partum mood disorders that can occur?
- postpartum blues (last about 2 weeks- very normal)
- postpartum depression (13% of mother in the 1st year)
- postpartum psychosis (0.01% mothers in first 3 months)
If a post-partum mom is agitated, delusional and experiencing hallucinations with low insight and high levels of suspicions we would suspect what diagnosis?
Postpartum psychosis
if caught within the first year and treated aggressively it can be addressed.
This is an emergency and they need inpatient treatment.
3 common physiological complications that occur postpartum
hemorrhage
infection
thromboembolic disease
A blood loss greater than ____ml with a vaginal delivery and _____ ml with a cesarean section
500mL
1000mL
healthy women can ______ for post-partum hemorrhage and it often goes unrecognized until it is too late
compensate
Reasons for PPH
What are the 4Ts
Tone: uterine atony»leading cause of PPH
tissue: retained placenta
Trauma: of genital tract
Thrombin: abnormalities of coagulation
Uterine _______ is the leading cause of PPH
Atony
75-90% of PPH is d/t Uterine atony
what are the 2 types of PPH
- Early (acute. primary)
Occurs within first 24 hours after childbirth - Late (secondary)
Occurs more than 24 hours to 6 weeks after childbirth
*d/t retained products, trauma or both
Key ways in which we can address and attempt to minimize PPH.
prevention, early detection and prompt intervention
Oxytocin w/ the delivery of the anterior shoulder.
What factors influence uterine tone?
multiple pregnancies polyhydramnios fetal macrosomia multi fetal gestations uterus becomes over stretched and does contract properly after birth Rapid or prolonged labour chorioamniotis : infection of the uterus
What factors affect the potential of trauma leading to PPH
lacerations: can occur from rapid birth, if the fetus is deeply engaged in the pelvis before birth
uterine rupture
uterine inversion (uterus turning inside out)
Pelvic hematomas
What are some interventions to prevent PPH
- Routine oxytocin admin after the delivery of the anterior shoulder
- Delayed cord clamping
- Gentle cord traction
- Immediate fundal massage after the complete birth
If it takes longer than ____ mins to deliver the placenta the risk of PPH increases ____ fold
30 mins
6 fold
90% of PPH result from _______ ________
uterine atony
Interventions:
fundal massage, ensuring the bladder isn’t distended
expression of any clots
What is bimanual compression?
Insertion of a fist into the vagina, knuckles pressing on the outside wall of the uterus to try and get it to contract.
What compensatory mechanisms occur with the BP after a
1. 500 to 1000 ml blood loss (10 – 15%)
- 1000 to 1500 ml blood loss (15 – 20 %)
- 1500 to 2000 ml blood loss
(25 - 35%) - 2000 to 3000 ml blood loss (35 – 45%)
1. No BP changes occur Signs & symptoms may include: Palpitations Dizziness Tachycardia
2 Slight fall in BP (80-100 mmHg) Weakness Sweating Tachycardia
3.Marked fall (70-80 mmHg) Restlessness Pallor Oliguria
4. Profound fall (50-70 mmHg) CV Collapse Air Hunger Anuria
What is the main causes of LATE (secondary) PPH
Generally result of subinvolution (failure to return to normal size) of the placental site or retention of placental fragments
Rarely poses same risk as immediate PPH
Much less common than early PPH
S&S: prolonged lochia discharge, foul odor to lochia discharge, main complain of prolonged ongoing pain, complain of a fever, irregular or excessive bleeding, larger than normal or boggy uterus.
What are important Nursing care and intervention for PPH
Evaluate prenatal history and labour and birth experience
Identify risk factors for PPH
Nursing interventions after birth (admin of oxytocin, inspection of placenta, uterine massage, monitoring lochia)
Assess for signs of PPH
Teach self-care
Most common PP infection:
infection of the lining of the uterus
Endometritis
more common after C-section births
What are some self-care techniques / teachings to prevent infections
- Using peri squeeze bottle to clean with
- bandaging as appropriate
- maintain hydration
- clean hands
- assessing to perineum to determine early signs of infection.
- wiping front to back
Immunization introduces an _______(a foreign substance, that triggers an immune system response) in the body allowing immunity against a disease to develop.
antigen
The person produces _______ which are proteins capable of responding to specific antigen
antibodies
also referred to as immunoglobulins
ANTIBODIES PROTECT THE BODY FROM DISEASE BY:
- binding to the surface of the antigen to block its biological activity (neutralization)
- binding to the antigen that coats the surface of the infectious agent to make it more susceptible to clearance (phagocytosis) by phagocytes (opsonization)
- binding to specialized cells of the immune system, allowing them to recognize and respond to the antigen
- activation of the complement system to directly cause disintegration (lysis) of the infectious agent (pathogen) to enhance its phagocytosis, and to attract other immune cells towards the pathogen.
In _______ immunity, antibody production is stimulated without causing actual disease. The antigen is given in the form of a vaccine
active
In _______ immunity, antibodies are produced in another human or animal host; protection is limited, usually a few weeks or months.
passive
transplacental transfer
_________immunity - Example
The mother has acute or chronic hepatitis B infection
The infant, born to the infected mother, receives an IM dose of HBIg immediately after birth (within 12 hours)
AND
the first dose of the three-dose course of Hepatitis B vaccine
Passive
HBIg provides short term protection
Hep B vaccine provides long term protection
Introducing a person to a germ (whether it is from a natural infection or from a vaccine) creates ________ _________
immune memory
Through ______ immunity, immunization against many diseases also prevents the spread of infection in the community and indirectly protects infants too young to be vaccinated, those who can’t be immunized, or those who don’t adequately respond to immunization.
herd
What are the 4 primary components of a vaccine
- Immunogen
- Adjuvant: substance that is added to a vaccine that enhances immune response and increases B & T cell response. (required for immunological memory)
aluminum salts - Preservative: chemicals added to prevent a serious bacterial infection from the vaccine. thimerosal
- Additives: minute amounts of chemicals» potassium or sodium salts that support the stability of the vaccine.
eggs or yeast proteins. formaldehyde used to inactivate any toxins
___________ is a Preservative used in some vaccines
No longer in childhood vaccines since 2001 (except influenza vaccine)
**this was controversial as individuals originally thought to cause autism ** not true this has been debunked.
Thimerosal
__________ is Used in production process to kill/inactivate viruses and bacteria
Vaccines are then purified
There is more ________ in body than in a vaccine as it is essential for DNA synthesis
formaldehyde
________________ is an adjuvant used to enhance the immune response after immunization
Aluminum salts
This is a common salt in air, food and water
this additive is used as a stabilizer
gelatin “porcine in original
very low rates of anaphylaxis from gelatin.
Muslim & Jewish communities have agreed that transformation of porcine products into gelatin makes them safe for consumption.
In Canada how can we assess for issues with vaccines in the general population?
IMPACT centers across Canada
Pediatric hospital based surveillance program for vaccination associated adverse effects
monitor vaccine safety and monitor adverse effects (hospitalizations) in relation to vaccines
__________ (inactivated) - Contains micro-organisms (bacteria/viruses) that have been killed, but still capable of inducing the body to produce antibodies
Killed vaccine
_________ A toxin treated by heat or chemical to weaken its toxic effects but retains its antigenicity
Toxoid
Diphtheria and Tetanus
___________ - Vaccine contains a microorganism in live, but attenuated, or weakened form
Live Virus Vaccine virus is attenuated or in a weakened form measles, mumps, rubella (MMR) Chicken pox- varicella Yellow Fever Rotavirus
create long lasting immune response but they don’t travel well. Need very specific storage state.
________ - An organism has been genetically altered for use in vaccines
Recombinant Forms
Hep B, influenza, HPV
strong immune response
_________ - An altered organism joined with another substance to increase the immune response
Conjugated Forms
pneumococcal
meningococcal
influenza type B
Booster shots are needed
Can be used on those with weakened immune systems.
Prior to _______vaccine Canada would see roughly 60,000 cases a year
measles
Measles is caused by contagious virus called
_________
morbillivirus
How is measles spread?
contaminated droplets that are spread through the air, with coughing and sneezing.
Typical signs and symptoms of measles
appear 7-14 days after exposure; high fever, cough , runny nose and watery eyes
measles rash appears 3-5 days after the first symptoms.
Which viruses do these vaccines prevent against
DTaP
IPV
Hib
Diphtheria, tetanus, acellular pertussis
Inactivated Polio
Hemophilus influenza type B (can cause bacterial meningitis for kids)
when do children get the MMR- Var vaccine
12 months
Rotavirus causes ____________ issues in children
gastroenteritis
mumps is spread by _____
droplets.
causes inflammation testes and ovaries
varicella is _________
spread by airborne and droplet from shed ______ _______
chicken pox
skin cells
adults and pregnant women are at risk of severe disease: TSS, stroke etc
Every ____ years you should get your tetanus and diphtheria vaccines updated
10 years
Td
tetanus is a _________
spread in the spores of animals and soil
neurotoxin
symptoms: extreme muscle spasms that can lead to serious complications and death.
_____management tends to be a big concern for parents when their children get vaccines
pain
after immunization we get individuals to wait ____mins
if they have a hx of reactions we ask that they wait _____ mins
15 mins
30 mins
potential precautions to monitor when an individual is getting a vaccine?
allergy to part of the vaccine
anaphylactic rxn to vaccine in the past
Contraindication for a vaccine
anaphylactic rxn to vaccine in the past
which vaccine are unsuitable for pregnant women?
Live attenuated vaccines
MMR
NACI recommends that immunization with_____ vaccine should be offered in _______ pregnancy, irrespective of ________ _________immunization history.
Tdap (tetanus, diphtheria, pertussis)
every
previous Tdap
NACI recommends that immunization with Tdap vaccine should ideally be provided between ____ and _____ weeks of gestation.
Can be provided from _____ weeks up to the time of delivery
27 and 32
13 weeks
T or F
No evidence of an adverse influence on maternal or infant immune response
True
two non-routine vaccines that are not recommended in breastfeeding women as the safety is not known
yellow fever
oral typhoid vaccine
most instances of anaphylaxis to a vaccine occur when?
within 30 minutes from administration
what are the signs and symptoms of anaphylaxis?
typically occur over several minutes. so if someone is going into anaphylaxis you have time to act.
- involves 2 body systems ie (GI and Resp or Skin and Resp) combo of 2 body systems
- Cardinal features: itchy red rash, progressive painless swelling in the nose and mouth
- resp system: sneezing, coughing, wheezing, narrowing and inflammation of the upper airway»_space; labored breathing
- GI: crampy abdominal pain and N&V (45%)
- Cardiovascular symptoms occur in about 45% of pts: chest pain, tachycardia
- CNS: dizzy, nervous, confused
Risk factors for anaphylaxis to vaccine:
very young and very old, pregnancy and cardiac issues, asthma.
certain cardiac meds (ACE inhibitors, B-blockers)
How do you tell the difference btw syncope and anaphylaxis
Fainting: vasovagal syncope»_space; typically anxious and hyperventilating
Breath holding typically happens in very young children. upset and crying will become silent. may faint but start to breath again once they pass out.
SYNCOPE: occurs within seconds/minutes, pale nausea, dizzy, ringing in ears, blurred vision, sweating, rhythmic jerking in limbs, can become unconscious in a few minutes, place in recumbent position.
ANAPHYLAXIS: Develops over several mins, usually involves 2 body systems, pt does not pass out immediately,»_space; treatment = epinephrine
steps for basic management of anaphylaxis in a non-hospital setting.
- Assess circulation, airway, breathing, mental status, skin, and body weight (mass). Secure an oral airway if necessary. Direct someone to call 911(where available) or emergency medical services.
- Position the vaccine recipient on their back or in a position of comfort if there is respiratory distress; elevate the lower extremities. Place the vaccinee on their side if vomiting or unconscious.
- Inject epinephrine intramuscularly in the mid-anterolateral aspect of the thigh: 0.01 mg/kg body weight of 1:1000 (1 mg/mL) solution
ADOLESCENT or ADULT: maximum - 0.5 mg
CHILD: maximum - 0.3 mg
Record the time of the dose.
Repeat every 5 to 15 minutes as needed, for a maximum of three doses
- Stabilize vaccinee; perform cardiopulmonary resuscitation if necessary, give oxygen and establish intravenous access if available and give adjunctive treatment (i.e. diphenhydramine hydrochloride or Benadryl®) if indicated.
- Monitor vaccinee’s blood pressure, cardiac rate and function, and respiratory status.
- Transfer to hospital for observation.
** helpful if you can have someone writing this all down. Need the time for when the epinephrine was administered.
Important things to remember when giving a vaccine:
No gloves are required
Aspiration for blood return in not required
Z-tracking is Not required.
Cannot pre-load syringes, doses need to be prepared just before administration
cold-chain needs to be maintained
always check the basics: expiration date, cloudy vs clear solution,
What is the cold chain for vaccine maintenance
All equipment and procedures used to ensure that vaccines are protected from inappropriate temperature and light, from the time of transport from the manufacturer to the time of vaccine administration
Most products should be stored at +2° C to +8° C
also most vaccines are not meant to be exposed to light
we only store 1 month of vaccine supplies and not on the door shelf.
tools for reducing pain and anxiety in children when immunizing
Breastfeeding Cuddling with parent Skin to skin contact with mother Diversion of attention Sweet tasting solution Proper Positioning Topical Local Anesthetics Oral Analgesics Injection without aspiration Order of vaccine >> give the most painful injection last. administration
3 primary types of Caesarean Births
Unplanned: emergency
Elective
Scheduled
Reasons for a scheduled C-section could include
Active genital herpes infection
Placenta previa
Breech
Not able to induce labor d/t hypertensive states
What is the major concern with VBAC
uterine rupture
Maternal contraindications for VBAC
Specific cardiac disease
Specific respiratory disease
Conditions associated with increased intracranial pressure
Mechanical obstruction of the lower uterine segment
Mechanical vulvar obstruction History of two or more previous Caesarean births
Elective Caesarean birth
Fetal contraindications for VBAC
Abnormal fetal heart rate (FHR) or pattern
• Malpresentation (e.g., breech or transverse lie)
• Active maternal herpes lesions
• Maternal human immunodeficiency virus (HIV) with a viral load of more than 1000 copies/mL
• Congenital anomalies
Maternal-fetal contraindications for VBAC
Dysfunctional labour (e.g., cephalopelvic disproportion, “failure to progress” in labour)
Placental abruption: placental pulls away from the uterus too soon»_space; during the labour
Placenta previa»_space; placenta is over the vaginal opening»_space; baby can’t come out. need surgery
Cesarean birth risks for mother and fetus
Maternal:
Higher maternal mortality rate than a vaginal birth
Other risks
Fetus :
Increase in neonatal respiratory problems
Injuries from surgery
fetal asphyxia can occur, especially if there is maternal hypotension from the sedative.
What is the most common type of Cesarean section incision
Lower (transverse) uterine segment …. thinnest & narrowest portion… less blood loss in comparison to other uterine incisions, e.g., classic
What would be some reasons for the physician choosing a vertical cesarean section incision
under developed lower uterine segment transverse lie preterm breech presentation anterior placental previa vertical; classical incision
** has a higher chance of uterine rupture with subsequent pregnancies.
