Module 7: Magdalena and Michael

Question 1

The more fetuses a woman carries at once, _______ ___ ____.

Answer 1

the greater her risk. As the number of fetuses increase (twins, triplets, quadruplets, etc.), the risk of premature birth increases and birth weight decreases.

Question 2

Common complications of twin pregnancy include:

Answer 2

1. Premature birth
2. Low Birth Weight (LBW)
3. Twin-Twin Transfusion syndrome (TTTS)
4. Preeclampsia
5. Gestational Diabetes

Question 3

Premature Birth

Answer 3

• About 60 percent of twins, more than 90 percent of triplets, and virtually all quadruplets and higher-order multiples are born premature.
• The length of pregnancy decreases with each additional baby. On average, most singleton pregnancies last 39 weeks; for twins, 35 weeks; for triplets, 32 weeks; and for quadruplets, 29 weeks.

Question 4

Low birth weight (LBW)

Answer 4

• More than half of twins and almost all higher-order multiples are born with low birth weight.
• LBW can result from premature birth and/or poor fetal growth. Both are common in multiple pregnancies.

Question 5

Twin-twin transfusion syndrome (TTTS)

Answer 5

About 10 percent of identical twins who share a placenta develop this complication. TTTS occurs when a connection between the two babies’ blood vessels in the placenta causes one baby to get too much blood flow and the other too little. TTTS can be treated with laser surgery to seal off the connection between the babies’ blood vessels.

Question 6

Preeclampsia

Answer 6

Women expecting twins are more than twice as likely as women with a singleton pregnancy to develop this complication characterized by high blood pressure, protein in the urine and generalized edema. Severe cases can be dangerous for mother and baby. In some cases, the baby must be delivered early to prevent serious complications.

Question 7

Gestational diabetes

Answer 7

Women carrying multiples are at increased risk of this pregnancy-related form of diabetes. This condition can cause the baby to grow especially large, increasing the risk of injuries to mother and baby during vaginal birth. Babies born to women with gestational diabetes also may have breathing and other problems during the newborn period.

Question 8

Fraternal (dizygotic)

Answer 8

Is when two separate eggs are fertilized by two separate sperm to form two separate embryos. Fraternal twins are more common because each baby develops from a separate egg and sperm. Since each has a different egg and a different sperm, it is like siblings being born at the same time.

Question 9

Identical (monozygotic)

Answer 9

Is where one egg is fertilized and splits to form two embryos. The fetuses share the same placenta, but they also share the same genetic material.

Question 10

Monochorionic twins

Answer 10

Fetuses share a single placenta.
Are always identical twins.
Higher risk for complications because two fetuses have to grow on a single placenta.
Placenta is not always equally divided between the fetuses.
Each fetus’s blood circulation is connected through blood vessels in the common placenta and blood may pass disproportionately from one baby to the other, leading to the twin -twin transfusion syndrome (TTTS).

Question 11

Dichorionic twins

Answer 11

Fetuses each have their own placenta

Most of these twins are fraternal; only a minority of these twins will be identical

Question 12

Patent Ductus Arteriosus

Answer 12

A patent ductus arteriosus is a vascular connection that during fetal life bypasses the pulmonary vascular bed and directs blood from the pulmonary artery to the aorta (bypassing the lungs). Functional closure of the ductus normally occurs soon after birth. If the ductus remains patent after birth the direction of blood flow in the ductus is reversed (left to right) by the higher pressure aorta

Question 13

What is the direction of blood flow through Magdalena’s PDA?

Answer 13

The direction of blood flow through Magdalena’s PDA is left to right.

Question 14

From which blood vessel to which blood vessel is this blood being shunted?

Answer 14

Blood is flowing from the aorta into the pulmonary artery.

Question 15

Why is blood being shunted in this way?

Answer 15

Blood is being shunted in this way because of the pressure gradient between the pulmonary artery and the aorta. This pressure gradient is such that the pressure in the aorta is higher than the pressure in the pulmonary artery. Blood flows along the path of least resistance: away from areas of higher pressure toward areas of lower pressure.

Question 16

Why is PDA called an acyanotic heart defect?

Answer 16

Because no cyanosis results. A sufficient amount of oxygenated blood is in the circulation.

Question 17

Why does a PDA cause pulmonary hyperperfusion?

Answer 17

A PDA allows blood to re-enter the pulmonary circuit, thereby increasing pulmonary blood flow.

Question 18

Name 6 signs and symptoms of PDA you would expect to see in Magdalena?

Answer 18

systolic murmur – due to blood shunting through the ductus arteriosus

widening pulse pressures (difference between systolic and diastolic pressures) – increased volume of blood flowing through left heart

hypotension – due to a drop in diastolic pressure

bounding peripheral pulses – high stroke volume

active precordium – due to increased volume of blood in left heart

tachycardia – too much blood in the pulmonary capillaries which impairs gas exchange

Congestive heart failure is often listed as a sign of PDA. This is certainly true; however, it is a later sign than the six signs listed above.

Question 19

What is meant by the term “conservative management” for a patent ductus arteriosus?

Answer 19

fluid restriction
respiratory support
administration of indomethacin or ibuprofen (NSAIDS, inhibitors of prostaglandin synthesis)

Question 20

How does conservative management compare to more invasive management?

Answer 20

Invasive management of a PDA refers to surgical ligation.

NICUs in general try to close the PDA conservatively before resorting to surgical ligation.

Question 21

If the cardiologist had suggested a course of indomethacin, what assessment data would you need to gather before you gave the first dose?

Answer 21

Since indomethacin is highly nephrotoxic, overall renal function, BUN, and creatinine levels must be evaluated prior to administration. Therefore, assessing fluid balance, urine output, and serum electrolytes is essential.

Indomethacin also interferes with platelet function; therefore, its use is contraindicated when an infant has a low platelet count or bleeding disorder.

Other contraindications are necrotizing enterocolitis and IVH.

Question 22

Intraventricular Hemorrhage

Answer 22

Intraventricular Hemorrhage is the most common type of intracranial hemorrhage seen in the neonatal period. As the gestational age decreases, the risk of developing an IVH increases. This type of brain injury is “almost exclusively seen in preterm infants, particularly those weighing less those 1500 grams”

Question 23

The major risk factors for IVH in the neonate are:

Answer 23

Prematurity

-The periventricular area of the brain is growing rapidly and is richly supplied by blood vessels.
-These blood vessels are very thin.
-Pressure autoregulation is immature:
pressure autoregulation is a physiologic mechanism that functions to prevent increases in systemic blood pressure from creating increases in cerebral blood pressure
pressure autoregulation is immature in preterm infants, meaning that any increase in systemic blood pressure creates an increase in cerebral blood pressure

Hypoxia

Recall from Sarah, that hypoxia leads to redistribution of blood flow such that more blood is delivered to vital organs: heart and brain. In this way, hypoxia can lead to IVH by increasing cerebral blood flow through fragile blood vessels in the periventricular region of the brain.

Any perinatal or neonatal event that results in hypoxia or alters cerebral blood flow increases the risk of IVH.

Question 24

Why are preterm infants at risk for developing IVH?

Answer 24

Preterm infants are at risk for developing IVH for the following reasons:

They have limited abilities to autoregulate cerebral blood pressure. Therefore, increases in systemic blood pressure result in higher cerebral blood pressures.

They are at risk for hypoxia. Hypoxia, initially, causes increased blood flow to the brain (and heart).

Their blood vessels are thin walled and fragile. They rupture easily if either pressure and/or volume increase.

The periventricular (subependymal) region of the brain is growing and developing at a rapid pace and is well supplied with blood vessels. This is, therefore, the most vulnerable area for hemorrhage.

They are frequently stressed by painful, invasive, or uncomfortable procedures. Stress can lead to both hypoxia and elevated blood pressure.

They frequently need hypertonic IV solutions and medications. These can rapidly expand the intravascular space, leading to increased intracranial blood volume and pressure.

Question 25

How would you assess Magdalena in order to monitor for development of an IVH?

Answer 25

We would monitor Magdalena for the following:

increased or decreased muscle tone
level of alertness and state
apnea and bradycardia
sudden drop in hematocrit
pallor, mottling
temperature instability
full or tense fontanelle

Question 26

More importantly, how would you prevent Magdalena from developing an IVH in the first place?

Answer 26

To prevent IVH from occurring, we would do the following:

maintenance of oxygenation
regulation of acid-base balance
ensure IV fluids and medications are administered at the appropriate rates
minimize stress with pain management, comfort measures (DSC)
reduce and pace handling
maintain normal body temperature
provide adequate calories, nutrients, and fluids
protect from infection

Question 27

Hypoxic-Ischemic encephalopathy

Answer 27

Perinatal hypoxic-ischemic encephalopathy (HIE) remains a major cause of neurodevelopmental impairment. Although mostly an insult of term infants, near term infants are also at risk. “In full-term infants, HIE produces cell death in the cerebral cortex, diencephalon, brainstem, and cerebellum. Injury to the basal ganglia and thalamus also occurs. Moderate and severe HIE in term infants is associated with a high incidence of cognitive and motor dysfunction, including microcephaly, mental retardation, epilepsy, and cerebral palsy” (Aylward, 2014, p. 397). In the preterm infant, there is less effect on grey matter and more effect on the white matter - which manifests itself as periventricular leukomalacia.

HIE may be due to any condition leading to decreased oxygen supply (hypoxia) and decreased blood supply (ischemia). It is not a single event but an evolving process. Parker and Kenner (2012) explain that HIE “begins with the initial insult, progresses into a latent phase, and finally occurs as a secondary injury phase” (p.8).

Question 28

Initial insult

Answer 28

Hypoxemia and/or ischemia cause a deprivation of glucose and oxygen supply to the brain which causes a primary energy failure and initiates a cascade of biochemical events leading to cell dysfunction and ultimately to cell death.

The SNS is stimulated resulting in shunting of blood to vital organs (brain, heart and adrenals) to maintain adequate cardiac output and cerebral perfusion. As the hypoxic ischemic event progresses there is a decrease in cardiac output and cerebral perfusion, which leads to anaerobic metabolism. As the brain reverts to anaerobic metabolism it causes a rapid depletion of high-energy phosphate reserves (ATP). Cellular function is compromised resulting in an increase of intracellular sodium, calcium and water, tissue acidosis and electrical failure of neural tissue.

Question 29

Reperfusion Injury

Answer 29

This phase is where irreversible cell death begins (6-15 hours after initial insult)

The phase begins with a brief period of restored cellular function (normal vital signs, pH, absence of seizures). Clinical deterioration quickly follows because of mitochondrial dysfunction as a result of the initial insult, continued cell injury and cell death can occur.

Question 30

Periventricular Leukomalacia (PVL)

Answer 30

PVL is defined as brain white matter pathology of multifactorial etiology, primarily affecting preterm infants. PVL is the major neuropathologic form of brain injury of the white matter in preterm infants. PVL is caused by hypoxic-ischemic encephalopathy, although the actual pathogenesis is not clear, and it may occur as a result of a hemorrhage or in the absence of hemorrhage (Aylward, 2014). PVL is recognized as the leading cause of cerebral palsy in preterm infants.

Question 31

How does hypoxia complicate the neurological system?

Answer 31

Initially, cardiac output increases and redistribution of blood flow sends more blood to the heart & brain to compensate for the lack of O2. This increases the risk for IVH in the vulnerable preterm infant. Over time, prolonged hypoxia will lead to a drop in cardiac output, a drop in systemic blood pressure and decreased cerebral blood flow, increasing the risk for PVL in a preterm infant and HIE in a term/postterm newborn. As well, hypoxia further reduces auto-regulation of cerebral blood flow.

Question 32

Was Magdalena’s birth weight appropriate for gestational age? You will need to refer back to p. 95 (2006) of your textbook or p. 91 (2011).

Answer 32

Yes. Magdalena’s birth weight is appropriate for her gestational age.

Question 33

Based on the shift change report, what are your priorities when planning Magdalena’s care for this shift?

Answer 33

The first priority would be to check the IV site to make sure it is not interstitial as it seems like from report that it may be questionable.
While the IV site is being checked you could do a visual head-to-toe assessment of Magdalena.
If it was time for handling I would do a thorough head-to-toe assessment; if it is not time to handle yet I would keep Magdalena as undisturbed as possible as I checked the IV, and do a thorough assessment later.
Calculate her total fluids to make sure that they are correct.
Check to make sure that my TPN is running at the correct rate.
Check to see if she is on any medications.
Check to see if there is enough EBM for my shift.
Check what the last blood work results were and when she is due again.
Check to see if the alarms on her ECG monitor are set.
Check in with Michael’s nurse to see how he is doing.

Question 34

For example, when you are assessing Magdalena’s respiratory status, there is an abundant amount of data to collect, some of which may be unclear as to the impact on her breathing.

Answer 34

Sometimes a premature infant’s respiratory status may be compromised with a full abdomen since there is upward pressure on the diaphragm and subsequently, towards the lungs.

Consequently, information about GI status (abdominal girth, amount of gastric residuals) may inform your respiratory assessment.

Question 35

Family-centered care is defined as:

Answer 35

Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families. It redefines the relationships in health care.

Patient- and family-centered practitioners recognize the vital role that families play in ensuring the health and well-being of infants, children, adolescents, and family members of all ages. They acknowledge that emotional, social, and developmental supports are integral components of health care. They promote the health and well-being of individuals and families and restore dignity and control to them.

Question 36

The core concepts of family-centered care are:

Answer 36

respect and dignity
information sharing
participation
collaboration

Question 37

Developmentally Supportive Care is defined as:

Answer 37

Within the developmental care approach, infants are viewed to be active participants in their own care and are focused on interventions that protect the immature central nervous system.
Supports the behavioral organization of each individual infant, enhancing physiological stability, protecting sleep rhythms and promoting growth and maturation.
These interventions include handling and positioning measures, reduction of noxious environmental stimuli, and cue based care.

Question 38

The aims of developmental care are:

Answer 38

reduction of infant’s stress and agitation
energy conservation and enhanced recovery
caregiver understanding of infant’s behavioral cues (signs of stability or stress)
encouragement and support of parents in the primary caregiver role
minimization of potential harm due to the extra-uterine environment
promotion of normal growth and development
prevention of abnormal postures
stabilization at each stage of infant’s neuro-developmental maturation and support of emerging behaviors and organization
enhanced family emotional and social wellbeing

Question 39

Family-centered developmental care is:

Answer 39

• an essential element of neonatal intensive care
• based on the recognition that the newborn infant is an active participant of his or her own development and that the family will be instrumental in moving this care forward

Question 40

Can you identify some positive physiologic responses of premature infants who experience skin-to-skin cuddling?

Answer 40

Infants who participate in skin­to-skin cuddling often show signs of neurobehavioral stability (stable HR, RR, sats, sleep wake states) when next to their mother’s or father’s chest.

Question 41

Do you believe, based on what you have read, that there is a link between family-centered-care and developmentally supportive nursing interventions? Give an example to support your belief.

Answer 41

It is my belief that there is a significant link between family­centered care and developmentally supportive nursing interventions.

For example, providing containment for a preterm infant during procedures is developmentally supportive and is a skill that parents can easily acquire with support from nurses. This manual skill provides comfort, motoric containment, and promotes flexion. If parents are able to provide containment for their infants during nursing care or painful procedures, then their participation in caregiving is validated and they may begin to feel as though they are contributing to their baby’s comfort: central principles of family-centered care.

Question 42

Intraventricular hemorrhage occurs within the first few hours or days of life

Answer 42

True

Question 43

In utero the ductus arteriosus directs blood to the lungs

Answer 43

False

Question 44

In response to hypoxia the ductus arteriosus will remain patent.

Answer 44

True

Question 45

A low pH indicates

Answer 45

Acidosis

Question 46

A treatment of patent ductus arteriosus consists of:

Answer 46

• admin of Nsaids
• Fluid restriction
• surgical ligation

Question 47

In preterm infants hypoxia can lead to an IVH.

Answer 47

True

Question 48

When one egg is fertilized and it splits to form two embryos the infants are:

Answer 48

Identical twins

Question 49

Complications of a twin pregnancy include:

Answer 49

• preeclamsia

- premature birth

Question 50

The CO2 represents the _________ component of a blood gas.

Answer 50

respiratory

Question 51

The core concepts of family centred care are:

Answer 51

• Respect + dignity
• Information sharing
• Participation
• Collaboration