OB test 3 Flashcards
changes from fetal circulation to neonatal
ductus venous- open at time of birth, but shortly after it begins to narrow and shrink. Closes during the first week of life (longer in preterm babes)
Foramen ovale- increased pressure in the left atrium attempts to reverse blood flow and closes this shunt, making it a one-way valve, 1-2 hours after birth (fully closes around 6 months)
Ductus arteriosus- closes within a few days of birth- an increase in partial pressure O2 of newborn blood, triggers constriction. (fully closed 2-3 months later)
APGAR (categories and scoring)
HR, respiration, reflex irritability, muscle tone and color
*does not predict mortality or morbidity
-low score (<7 ) at the 5 minute mark reflects need for resuscitation effort
Muscle tone/Activity
2 points: spontaneous, active movmt in all extremities
1 point: flexed with little movmt
0: no mvmt, floppy
(healthy newborn looks flexed at elbows, hips and knees)
Pulse/HR
(auscultate at apex or palpate at umbilical cord/skin junction)
2 points: HR >100
1 pt: HR < 100
0: no heartbeat found
Grimace/reflex irritability
-rubbing the baby’s back with a blanket- healthy baby should cry
2 pt: cries or agitated response
1 pt: mild reaction
0: absent response
Appearance (skin color)
2 pts: completely pink newborn (rare!)
1 pt: acrocyanotic
0: pale or completely cyanotic
Respiration
2 pt: crying vigorously
1 pt: slow and irregular respirations, weak or gasping
0: not breathing
normal vital range for newborn
HR: 120-160
Resp: 30-60
Temp: axillary! 36.5-37.5 (97.7-99.4)
newborn measurements
weight- varies based on ethnicity and maternal factors- babies lose up to 10% of birth weight in the first 3 days after birth- should regain by 2 weeks (fluid shifts)
length- supine (ag is 50 cm)- grow 1.5-2.5 cm/month
head circumference- widest point of head
chest circumference
Proper newborn identification and safety
2 ID bands on baby (each ankle) and one on birthing parents wrist: sex, date and time of birth, parents last name and doctor/midwife
-another electronic security device placed on baby, sounds an alarm at any of the unit exits
-footprints, along with birthing parents fingerprint at time of birth
newborn medications
Vitamin K: one time dose w/in 6 hours after birth, IM - not naturally present in gut which causes a decrease in coag factors.
-If mom had severe HTN or HELLP- newborn is at increased risk for thrombocytopenia (plt dysfunction)
Hep B immunization (within 24H)- prevent maternal transmission to baby in birth
erythromycin?
tonic clonic
to elicit: place newborn supine, gently rotate head to one side, hold it there for 15 sec. positive response is when arm and leg extend on the facial side and flex the other
when it disappears:
moro
to elicit:
-newborn startled by loud sound or sudden movement
when it disappears: 2 months
rooting
to elicit: stroking newborn’s cheek or corner of mouth
lack of response: could indicate facial paralysis or neuro depression
when it disappears: 3-4 months
sucking
to elicit: insert gloved finger into newborn’s mouth
when it disappears:
palmar/plantar
to elicit: place finger in newborns palm
when it disappears:
babinski
to elicit: draw finger on foot
when it disappears:
walking/stepping
to elicit: leave newborn prone on birth persons abdomen and observe newborns crawl to breast using toes and knees. OR the nurse can hold the baby, place their feet on the bed and observe them trying to stand on their feet and take steps
when it disappears: 8 weeks
acrocyanosis
expected finding at birth: cyanosis of only hands and feet- may last up to a week
-due to immature cardiac system
vernix
expected
cheesy, white substance covering and protecting the skin during intrauterine life
-diminishes the closer to term the fetus gets
lanugo
expected; fine soft hair that covers the newborn’s back, shoulders, face and scalp- common in preterm babes.
disappears in 4 weeks
congenital dermal malanocytosis
(mongolian spots)- bluish gray spots that can occur across the shoulders and hips, lower back near buttocks and legs.
-common in darker pigmented bees- resolve on their own in first few years of life
-not bruises
erythema toxicum
Normal newborn rash- yellow or white papule over an erythematous base on the body (except palms). red spots too? look like flea bites
-unknown cause- may be related to awakening of the immature immune system
caput succedaneum
abnormal if edema observed on newborn’s scalp at birth and did not have an instrumental birht
normal if tools used
causes: extended pushing during vag birth, forceps/vacuum assisted birth (no complications)
cephalohematoma
serosanguineous or bloody fluid accumulates below periosteum of the skull due to instrument use
**expect hyperbilirubinemia r/t blood being broken down*
-doesnt cross suture lines
-risk for increased or prolonged bleeding, jaundice and infection
-should resolve in 2-6 weeks after birth
RF: instrument assisted births, scalp electrode placement
bulging fontanel
abnormal/concerning- pressure is increasing in baby’s skull, could mean something serious
dimple or skin tag near ear
abnormal, formed at same time as kidney- looks for renal abnormalities
low set ears
abnormal, indicative of many syndromes and genetic abnormalities
heart-shaped tongue/frenulum meets tip of tongue
abnormal, could cause issues with breastfeeding or speaking, but not usually an issue
epstein’s pearls
small, harmless, firm white cysts that contain keratin.
resolve spontaneously within 1-2 weeks
-if loose, report to provider to minimize risk for choking
cleft palate or lip
abnormal- concerns for fetal alcohol syndrome
crepitus at clavical
abnormal
potential clavicle fracture and/or brachial palsy
intercostal retractions
abnormal- could signify respiratory disress
(also subcostal and suprasternal
no stool w/in 24H
abnormal- may have fissure or fistula, Patency issues
epi or hypospadias in male
hypo- urethral meatus is located on the ventral side of the penis
epi- urethral meatus located on dorsal side of penis
**not candidates for circumcision until they have a urology consult
pink or red ringed discharge in female
expected finding- for 3-4 days after birth
pseudomenstruation- due to maternal hormones
dimple at base of spine
abnormal, may indicate misplacement of nerves or spina bifida (might not be dx until late childhood)
typically harmless unless seen with other skin changes (lumps, tufts of hair, discoloration)
non symmetrical gluteal folds
abnormal, can suggest hip dysplasia
ballard assessment
establishes accuracy of gestational age within the first 4 hours of life
- external physical characteristics: posture, skin, lanugo, breast, eyes/ears, plantar surface, genitals
-neuromuscular maturity: wrist flexibility (square window test), arm recoil, popliteal angle (knee flexion), scarf sign (term baby’s arm will not cross midline), heel to ear (increased resistance with age)
Max score is 50 points- correlates to gestational age of 44 weeks
4 ways of newborn heat loss
Evaporation: liquid converted to vapor- amniotic fluid or blood on the infant holds water that cools the infant when exposed to air. evaporation also takes place with resp tract droplets escaping the airway with expiration.
convection: loss of heat from the body surface to the surrounding air by a current (fans, AC)- amount of time exposed, velocity of moving air and amount of body surface area exposed effects this.
conduction: loss of heat when in direct contact with a cooler surface- must warm our hands and equipment. this is also why skin to skin is helpful
radiant: heat loss occurring from transfer of heat to cool solid objects not in direct contact with the newborn (nearby windows, walls etc.- or ice bag for labs placed in bassinet)
brown fat
stores the energy useful for creating heat- newborns have very little, making it difficult to thermoregulate
cold stress
neonate loses more heat in a period than they can reproduce
- require use of compensatory mechanisms- increase respirations and non shivering thermogenesis
-increases oxygen and glucose requirements and decreases CO- can lead to pulmonary HTN and decreased surfactant production
-SNS activated- resp distress
RF: preterm neonates, IUGR
s/s: axillary temp <36.5 (97.7)
mgmt: radiant warmer, frequent temps (before and after an intervention), glucose monitoring- check temp if hypoglycemic, proper clothing, resp changes
nursing interventions for thermoregulation
radiant warmer, swaddling, encourage skin-to-skin
10 steps: warm delivery room, immediate drying, skin-to skin, breast-feeding, bathing and weighing postponed, appropriate clothing and bedding, mother and baby together, warm transportation, warm resuscitation, and training?
newborn bathing
how its done:
when its done: after baby has regulated temp
important considerations: prone to evaporative heat loss during this care- expose only necessary areas.
cord care
how its done: clamped and cut, clamp is removed when the stump dries out, before baby leaves hospital. stump falls off usually within 1-3 weeks
when its done: at birth
important considerations: keep surrounding skin clean and dry, a few drops of serous drainage or blood on the diaper is normal. If it is actively bleeding, call provider. Foul-smelling, red skin at the base, or crying when the cord is touched = call provider, get help
circumcision care
how its done: surgical. may have a device left on until it falls off in 7-10 days
when its done: prior to discharge
important considerations: clear ointment and small gauze over surgical site with every diaper change. Go to ED if bleeding doesnt stop
breastfeeding benefits
nutrients: fat, sugar, water, protein, and minerals the baby needs for growth. milk adapts and changes based on baby’s needs as it grows.
-easier to digest
-contains antibodies. longer the baby breast feeds, the better the health benefits
-maternal health benefits: reduced risk for breast and ovarian cancer, T2DM, HTN.
-cost effective
-better for environment
-may help mom lose weight (back to pre-pregnancy weight)
-donor breast milk
latch
frequency of feeding
frequency:
newborn- 2-3 oz every 3-4 hours. they need to be awakened if they sleep for longer than 4-5H at a time
2 months: 4 oz Q4H
6 mo: 6-8 oz, 4 or 5 times a day
latch: stroke baby lip with nipple to elicit rooting, with infants mouth open- parent pulls infant close, nipple should be deep in baby’s mouth. Lips falanged out, chin deep into breast, bottom lip covering more of areola, head tipped back slightly to clear the nose.
milk storage
room temp up to 4 hours
fridge up to 4 days
freezer up to 12 months, 6 months is best
formula feeding benefits
feeding techniques
benefits: allows others to help feed the baby, can be prepped ahead of time and remain refrigerated up to 48H
techniques: begin feeding before baby becomes agitated, let baby take breaks and catch breath, hold baby close, make eye contact with and talk softly to baby. always hold the bottle for the baby, do not put baby to bed with bottle. teach parents signs of when baby is done feeding
storage of formula
once mixed, it needs to used within 1 hour from the start of feeding, and if not used within 2 hours of preparation, store it in fridge up to 48 hours. never store formula that has been in a bottle that the baby fed off of; bacteria growth
powder: dispose of within 1 hour of start of feeding, can be stored for 24H in fridge
newborn screening
looking for: the blood test (“PKU”) tests for uncommon and hidden health issues-
how its done: blood test (heal prick and dropped onto paper and sent to lab), hearing screening, heart screening (pulse ox on left hand and a foot, must be within 3% of each other)
when: begins 24-48H after birth, in hospital
hearing screen
looking for: conduction via the electrode
how its done: “headphones” and electrode on forehead to measure conduction of sound
when: 24H
jaundice screening
looking for: yellow tinge to skin, sclera or under the tongue. Observable if bilirubin levels reach 4-8 mg/dL
how its done: press down on various skin surfaces to observe for yellow tinge, then using the monitor if they appear jaundiced to get a lab level
when: physiologic jaundice appears within first 24H of life
blanch the skin, if yellow- take a TCB- if high, take a serum
critical congenital heart disease screening
looking for: cardiac anomalies
how its done: 2 pulse ox sensors, one on left hand the other on a foot, must be within 3% of each other for 2 minutes, and above 95%
when: 24H
car seat test
looking for: obstructive apnea, bradycardia and/or hypoxemia
- infants < 5lbs or born <37 wks of age are at increased risk for these
how its done: infant sits in car seat for 90-120 mins- HR, O2 and RR are monitored.
fail: O2 desaturated below 90% for more than 10 seconds, apnea > or = to 20 sec, brady < or = to 90bpm for longer than 10 sec
when: prior to dc
new parent newborn education
breathing and sleeping patterns, growth and development, safe sleep practices, preventing newborn injury, infant CPR, ADLs with a newborn, how to soothe a newborn, babys temp, follow up care
SGA
below 10% on birth charts- may be normal based on ethnicity or ht/wt of parents
neonatal risks: hypothermia and hypoglycemia
LGA
above 90% for growth
neonatal risks: birth injury, perinatal asphyxia, hypoglycemia
advanced (postterm) neonate findings
placenta ages and doesnt perfuse the baby well = less nutrients to baby
neonatal risks: macrosomia or SGA (loss of nutrients causes weight loss, so they are small for their advanced gestational age) Birth injuries, oligohydramnios, low APGAR scores, cerebral palsy, meconium stained fluid- aspiration/pneumonia
IUGR
usually smaller due to a pathological occurrence that impedes neonatal growth (could be a maternal, placental or fetal cause) **not the same as SGA*
neonatal risks: hypoglycemia, thermoregulation probs, respiratory distress after birth
symmetrical IUGR
head size and body symmetrical in size
causes: TORCH, maternal substance abuse, maternal anemia, chormosomal abnormality of fetus, smoking, teratogenic meds
asymmetrical IUGR
head grew at normal rate but body didn’t (large head compared to body)
causes: uteroplacental insufficiency, maternal HTN disorders, severe maternal malnutrition, select maternal genetic or acquired disease, abnormal placentation, multiple gestation
macrosomia
RF: maternal diabetes and obesity. AGA, ethnicities (hispanic, AA), AMA, postterm preg, male infants, multigravidae.
risks to baby: birth trauma, RDS (and mechanical vent), low apgar, meconium aspiration, hypoglycemia, asphyxia,
MAternal: hemorrhage
gestational age variations
preterm = <37 wks
extremely preterm: <28 wk
very preterm: 28-32 wks
late preterm: 32-36 6/7
postterm: >42 wks
Postterm neonatal care
assessment of and care for birth injuries if macrocosmic, monitor BG, temp, s/s of resp distress, jaundice, feeding, and septic s/s–due to placental insufficiency (SGA infants)
bath to wash off meconium stain and peeling skin (due to increased exposure to fluid in womb- increased desquamation)
Preterm baby O2 delivery
low flow NC: <2 L
high flow NC: dosed based on infant size; about 15L is the highest
o2 hood- around head- mixes environment air and o2- allows adjusting of FiO2
cpap and intubation (ET tube)
NICU lines and tubes
-Umbilical Artery Catheter (UAC)- threads into aorta to monitor ABg. Used for blood samples, fluid and med admin
-UVC- threaded through ductus venous into hepatic vein and into inferior vena cava- used for fluids and meds
-PICC- coiled on upper arm
-tubes: NG or OG- feeding, suction, measure residuals
Preterm respiratory system
Apnea of Prematurity: (common)- considered significant if > 20sec or associated with bradycardia or desat
- cardiac monitor and CPOX
-occasionally treated with tactile stimulation (mask cup on back)
-frequent occurence indicates CPAP
-often treated with CAFFEINE CITRATE
Respiratory Distress Syndrome- insufficient surfactant and immature lungs (small airway lumens), and the lack of gag reflex contributes
-s/s: desat, decreased lung sounds, nasal flaring, grunting, use of accessory muscles
-tx: resp support, thermoregulation, adequate nutrition
preterm cardiovascular system
preterms are prone to hypotension and hypoperfusion of tissues
-Tx: blood vol. expansion with NS or blood products (albumin, FFP) and/or inotropic agents (dopamine, dobutamine, epinephrine)
Patent Ductus Arteriosus (PDA)- delayed closure of DA = >72 H
-increased risk for NEC and IVH
-s/s: depends on degree- systolic murmur, ventricular dilation, cyanosis
-tx: NSAIDS (block prostaglandins that keep the duct open- admin would close it), ibuprofen or indomethacin. may require surgery
preterm neurological system
Intraventricular hemorrhage (IVH)- bleeding in lateral ventricles of brain
RF: birth before 30 wks, preE, chorioamnionitis
-Dx with US
-complications increase wit severe cases: cerebral palsy, hydrocephalus, cognitive disabilities, and death
-tx: avoid hyper or hypotension, provide O2 and nutrition. Treat seizures and avoid alteration in cerebral blood flow
preterm immune system
preterms are at increased risk for infection
-maternal IgG (antibodies) are passed to fetus after 32 weeks- preterms may miss this
-skin and mucous membranes are thin and immature- poor integrity
-s/s of sepsis: temp DECREASE, resp distress, lethargy, glucose instability, tachy, poor perfusion, (cyanosis, pallor etc)
-tx: abx
preterm thermoregulation
@ increased risk for hypothermia
-haven’t accumulated brown fat that helps baby maintain temp
-muscle tone to maintain a flexed position
-temp center in the brain is immature
-tx: radiant warmer and/or warming mattress
-nursing: maintain warm delivery room, dry infant immediately, replace wet blankets with dry, plastic coverings for really preterm babes, avoid overheating, be conscious of surrounding heat loss mechanisms,
preterm GI system
more susceptible to bacteria due to their more permeable tract –> NEC
-beneficial bacteria isn’t established yet
-s/s: abd distention, feeding intolerance, bloody stool, increased or discolored residuals
-tx: IV fluids, TPN, abx, gastric decompression, bowel rest, surgery- ileostomy and re-anastomosis
Retinopathy of prematurity
(common)- causes blindness due to abnormal vascular growth of vessel of retina. These vessel are permeable and leak, leading to edema and hemorrhage. Causes scarring that pulls on the retina leading to distortion and detachment
-linked to low birth wt, prematurity and excess O2 after birth
-s/s: edema, hemorrhage, scarring of retina
-usually regress and resolves spontaneously
nutrition for preterm infants
- need high calorie, high nutrient feedings- fortified breastmilk and formula
-unable to coordinate, suck, swallow and breath
-if oral, feed side lying to prevent aspiration
enteral: tube feed may be continuous Q2-3H
-eval gastric residual= indirect measurement of bowl motility
-slower or low vol feeds may improve tolerance
parenteral: may improve neurodevelopment outcomes and growth. lowers risk for NEC.
-prolonged withdrawal from feeds may contribute to intestinal atrophy
NICU physical assessment
vitals, diaper, abdominal girth, gastric residual
Neonatal pain
-if untreated, it affects how they deal with pain for the rest of their life
-encounter 5-15 painful procedures daily
-pain mgmt: breastfeeding, pacifier, skin-to-skin, oral sucrose, topical anesthesia, and last resort is meds: tylenol or opioids (post-op, or uncontrollable pain), nerve block lidocaine
NIPS
pain scale
-based on facial expression (relaxed or grimace), cry (NA, whimper, vigorous), breathing, arms (flexed or relaxed), legs, alertness (sleeping/awake or fussy)
-max pain is 7 points
NICU- feeding tolerance assessment
NICU schedule of cares/feeding
tube feedings may be Q2-3H or continuous, oral feedings, on their side every 3-4 hours?
cluster cares
NICU discharge criteria
DC around original due date and must be able to:
- maintain normal body temp
able to control respirations w/o apnea >20 sec or bradycardia
-able to feed orally
-growing properly
-can sleep on back w.o being compromised
-parents can room-in for a night to try out cares
-same screenings as with healthy newborn
-education to parents: CPR, when to call doc, follow up (clinic for 2 yrs on NICU baby)
Transient Tachypnea of the Newborn (TTN)
what: poor or delayed clearance of lung fluid- leads to transient pulmonary edema, resolved by 72H
affects on baby: tachypnea (140 bpm), retractions, grunting, mild cyanosis (circumoral), nasal flaring
MILD DISTRESS, Minimal intervention
nursing considerations: cluster cares- minimal stimulation, neutral thermal environment, gavage feedings (asp, risk), O2, fluids
babies at risk: c-section baby (swallowed lots of fluid?), late-pre term baby (35-36 wk)
Respiratory distress syndrome (RDS)
what: not enough surfactant
causes: preterm, persistent pulmonary HTN, TTN, meconium asp. syndrome
affects on baby: similar to TTN- tachypnea (140 bpm), retractions, grunting, mild cyanosis (circumoral), nasal flaring
WORSEN DISTRESS, Minimal intervention
nursing considerations: more aggressive resp support- ventilation, high flow NC, abx, prone or sidling, surfactant administration (intubate and instill synthetic version)
cluster cares- minimal stimulation, neutral thermal environment, gavage feedings (asp, risk), O2, fluids
Bronchopulmonary Dysplasia
what:
affects on baby:
nursing considerations:
meconium aspiration syndrome
what: meconium in lungs results in airway obstruction, inflammation and chemical irritation, infection and inactivation of surfactant
RF: stained amniotic fluid, nails, skin or umbilical cord. prematurity or SGA or post-term
affects on baby: resp/neuro depression at birth, resp distress, cyanosis, rales/ronchi, pneumothorax (alveoli rupture), persistent pulmonary HTN
nursing considerations: supportive care (ventilation, O2, gavage feeding, abx, surfactant, nitric oxide, ECMO (lungs),
hyperbilirubinemia
what: breastmilk jaundice appears in 1st week of life- yellowing of the skin and eyes
causes: small vol. feeds, slow passage of stool (where bilirubin is excreted)
affects on baby: increased risk for developing pathologic jaundice
nursing considerations: Prevention is key!- assess feedings and frequency
pathologic jaundice
immature liver can’t conjugate (excretion) broken down RBCs- reabsorbed into intestines
- can lead to KERNICTERUS- NEVER EVENT- perm brain damage
RF: preterm, poor feeding, ABO or Rh-factor incompatible, bruising, diabetic mom
Assess: @ birth and Q8-12- blanch skin on forehead and chest- yellowed
- if jaundice before 24H, higher risk for severe hyperbili
-screen with transcutaneous and confirmed with total serum bilirubin
Tx: phototherapy- converts bilirubin into a more soluble form that doesn’t need to be conjugated in the liver- excreted in bile
-monitor baby temp, serum bili, hydration, exposure time (more= better)
-exchange transfusion
hypoglycemia
affects on baby: jittery, tremors, diaphoresis, temp instability lethargy, poor feeding, seizures
nursing considerations: prevention!! frequent feeds, monitor BG
tx: IV glucose, neural thermal environment, feeding as tolerated
increased risk for: baby >4000g (LGA), preterm, diabetic maternal
Birth trauma
what:
-bruising (self-limiting but may contribute to hyperbilirubinemia)
-lacerations (c-section, operative- serious ones can require plastic surgery)
-fracture (clavicle- usually heals spontaneously)
-subconjunctival hemorrhage (looks alarming- ocular bleed- very common in neonates, resolve spontaneously within 2 wks)
-brachial plexus injury- unilateral nerve damage occurs from stretching and traction on brachial plexus- can recover spontaneously over months or may require extensive treatment
-facial nerve trauma- prolonged pressure against moms pelvis or forceps
-spinal cord injury- forceps or vag. breech delivery. prognosis depends off severity
fetal alcohol syndrome
amount of ETOH used determines impact
- low birth weight, growth, cardiac/klidney/brain problems, behavioral and intellectual disabilities
- face: small jaw, thin upper lip, no nose divot, small eyes, low nasal bridge
neonatal abstinence syndrome
neonatal withdrawal from opioids (due to maternal use)
- complications: trauma, abuse, mental and behavioral disorders are more common in kids who were tx for NAS as a baby
-s/s: irritable, high-pitch cry, sleep/wake disturbances, failure to thrive (can’t gain weight)
- mvmt altered: hypertonia, hyperactive reflexes, tremors, skin breakdown
-GI: disorganized feeding, committing, frequent loose stool
-autonomic dysfunction: sweating , sneezing, mottled skin, fever, nasal stuffy, yawning
-tx: reduce s/s, morphine to wean off after stable for 24H
-D/c: eval of home safety, is mom using anything else
sepsis
-s/s: temp DECREASE, resp distress, lethargy, glucose instability, tachy, poor perfusion, (cyanosis, pallor etc)
-tx: abx
congenital diaphragmatic hernia
abdomen contents herniate into chest cavity, through diaphragm defect
-affects cardiac and lung development
findings: barrel chest, scaphoid abdomen (concave), absent/decreased lung sounds L side, cardiac sounds shift R, resp distress
mgmt: intub and ventilation, NG, UAC/UVC, hemodynamic support- fluids and meds, Surgery!
congenital esophageal atresia
esophagus doesn’t connect to stomach
s/s: polyhydramniosm copious amounts of saliva.mucous, frothy bubbles
3Cs with feeding: coughing, choking, cyanosis. NG/OG won’t advance to stomach
mgmt: O2 and suction, NPO, prep for surgery, IV fluids, NG/OG to relieve distention and prevent stomach contents from coming into lungs
support and eduction for parents
congenital omphalocele
intestines in a pouch that is part of the umbilical cord
mgmt: wrap/cover bowel with warm sterile saline dressing- clear plastic wrap. airway support, OG tube to decompress stomach, IV access for fluids, nutrition, abx, keep warm, positioning, prep for surgery, support./educate parents
congenital gastroschisis
intestines outside of abd wall (R side of umbilical cord)
mgmt: wrap/cover bowel with warm sterile saline dressing- clear plastic wrap. airway support, OG tube to decompress stomach, IV access for fluids, nutrition, abx, keep warm, positioning, prep for surgery, support./educate parents
Spina bifida occulta
deep dimple, hair tuff, absence of bone
congenital meningocele
form of spina bifida with a pouching cyst-like sac that contains only meninges- minor MSK or neuro deficit
pre-op- cover sac, prone position- open diaper, hips flexed in abduction, manage I/O, temp, nutrition, infection control, latex free sign
post-op- wound integrity, I/O, temp, nutrition, infection control, pain meds, caregiver education
ongoing care: shunting hydrocephalus, increased risk for UTI, orthotic, assistive devices, wc. growth development, multidisciplinary team
congenital myelomeningocele
form of spina bifida with pouching sac that contains meninges and spinal cord nerves.
-more severe deficits- many develop hydrocephalus and paralysis is likely
pre-op- cover sac, prone position- open diaper, hips flexed in abduction, manage I/O, temp, nutrition, infection control, latex free sign
post-op- wound integrity, I/O, temp, nutrition, infection control, pain meds, caregiver education
ongoing care: shunting hydrocephalus, increased risk for UTI, orthotic, assistive devices, wc. growth development, multidisciplinary team
pap smear
most common screening form for cervical cancer
- collects cells from the cervix which are examined for abnormal cell changes
-start screening at age 21- cytology Q3 years
breast cancer screening
mammogram starting at age 40, every 1-2 years after age 50
women’s health promotion
women’s health- general wellbeing
IPV
Violence or abuse within an intimate relationship, such as physical assault, sexual violence, emotional or psychologic abuse, controlling behaviors, and economic abuse,
human trafficking
Recruiting, transporting, transferring, harboring, or receipt of persons through force, fraud, or coercion for exploitation
sexual violence
Any nonconsensual sexual act or behavior, including rape, sexual assault, sexual harassment, and coerced or forced sexual acts
trauma informed care
family planning- selecting a method
-pt goals with contraception
-methods used in the past- would they use them again?
-how important is it to prevent pregnancy?
-how well does someone remember to do something daily
-planning a pregnancy? when?
natural contraceptive methods
Natural awareness methods- monitor menstruation cycle and fertile window and avoiding sex then.
-calendar rhythm method (time between beginning of the shortest cycle to the end of the longest cycle- about 2 weeks to remain abstinent)
-standard days method- good for consistent/regular periods between 26-32 days- avoid sex between day 8-19
-billings ovulation method- assess cervical mucous- clear/copious/stretchable discharge at time of ovulation- avoid sex for 5 days at the start of this (until it becomes thick and sticky again)
-basal body temperature- wake at the same time every day- before sitting up- obtain temp with BBT therm. During ovulation, BBT rises 0.5-1 degree F (0.3-0.6 C)
-symptothermal method- combine BBT, cervical mucous change, menstrual cycle days, and intercourse timing.
-lactational amenorrhea- used by someone breastfeeding at least ever 4-6 hours, amenorrhea and within first 6 moths after childbirth. high prolactin levels induced by breastfeeding keep ovulation at bay- if feeding pattern changes for any reason- fertility can return quickly
Abstinence
pulling-out
barrier contraceptive methods
-internal and external condoms
-contraceptive gel- prescription only- spermicidal
-diaphragm- silicone cup around cervix, use with spermicide
-cervical cap- smaller, covers cervix, use with spermicide
-contraceptive sponge- impregnated with spermicide, barrier to cervix and traps/absorbs pserm. wt with water, make suds,
short-acting reversible hormonal contraceptive methods
-oral- estrogen/progesterone pills- inhibits release of ovum, atrophy of endometrium, maintaining thick cervical mucous. has placebos for medically-induced bleed
-RF: MI, VTE, stroke, HTN, gallbladder disease, cholestatic jaundice, hepatic neoplasms, melasma
-transdermal hormonal contraception- releases progesterone and estradiol daily. change weekly for 3 weeks, left off for 4th- medical induced bleed. (doesnt work on pt over 198 lbs)
-vaginal contraceptive ring- releases hormones for 3 weeks, removed for the 4th
-progesterone only contraception- inhibit ovulation, thicken cervical mucous, and alters endometrium to inhibit implantation. (s/e: irregular bleeding, HA, nausea, breast tender, weight gain, ovarian cysts (IM LAI)
-progestin-only orals pills- taken daily, no off week. (s/e: irregular bleeding, HA, nausea, breast tender, weight gain, ovarian cysts)
long-acting reversible hormonal contraceptive methods
-LNG-IUC- alters endometrial environment and prevents fertilization by changing cervical mucous viscosity
s/e: irregular bleeding, ovarian cysts, HA, vulvovaginitis
-paragard- acts as a foreign body that causes inflammation in the uterus, making it a toxic environment for sperm. Menstural bleeding is heavier than prior insertion
-nexplanon-subdermal on underside of arm- suppresses ovulation, thickens mucous and alters endometrial lining
s/e: abnormal bleeding, changes in menstrual cycle, including amenorrhea, gastrointestinal difficulties, headaches, vaginitis, and ovarian cysts. acne, weight gain.
emergency contraception
Yuzpe (estrogen/progesterone)- must take within 72H of sex, ella- contains ulipristil, prevents follicular rupture and delays proliferative phase if ovulation has already occurred-works best within 72H but still effective til 120H, plan B-progesterone only tablet that inhibits ovulation
sterilization
-tubal ligation- tie tubes/clipped or removed
complications: bowel perforation, pain, infection, hemorrhage, adverse anesthesia effects
-vasectomy- local anesthesia, outpatient, ligation or cautery of vas deferens prevents sperm from reaching ejaculate. Confirmed success with ejaculate sperm count test in clinic.
reanastomosis is available.
menstrual disorders
amenorrhea- absence of menstruation.
-primary: absence of period by age of 16
causes: preg, endocrine tumors or lesions, congenital abnormalities, hypogonadotropic hypogonadism
-seoncdary: absence of 3 or more cycles in people with previous regular cycles
causes: preg, zwieght loss, anovulation, pituitary or ovarian tumors, hormonal abnormalities like Cushings
Dysmenorrhea- painful menstruation without a root cause.
-primary- before or during a period
-secondary- caused by an underlying condition
s/s: cramping abdominal pain that may radiate to the lower back and thighs, nausea, vomiting, fatigue, headache, and diarrhea
premenstrual syndrome (PMS)- common, cyclic, and multifaceted disorder that occurs during the luteal phase- typically 1-2 weeks before menstruation- physical, emotional and behavioral symptoms.
s/s: mood swings, irritability, anxiety, fatigue, breast tenderness, bloating, and changes in appetite or sleep patterns
Premenstrual dysphoric disorder- more extreme presentation of PMS- extreme depression and anxiety
Abnormal uterine bleeding- menorrhagia (heavy periods), hypermenorrhea (prolonged periods), metrorrhagia (irregular cycles), bleeding or spotting after sex, irregular periods that vary in length by more than 7 to 9 days, menstrual cycles longer than 35 days or shorter than 21 days, intermenstrual bleeding (between periods), and bleeding after menopause
perimenopause
-transitional period leading up to menopause, during which a person’s body undergoes hormonal fluctuations and reproductive changes
- s/s: irregular periods and decline in ovarian function leading to decreased estrogen, progesterone and testosterone. hot flashes, night sweats, mood swings, fatigue, sleep disturbances, vaginal dryness, changes in libido, cognitive changes, depression,
-about 4-9 years before menopause (mid-40s)
menopause
permanent cessation of ovarian function, signaling the end of reproductive capability
s/s: hot flashes, night sweats, vaginal dryness, mood swings, sleep disturbances, urinary changes, changes in sexual function, and changes in bone density
-throughout these stages: arteries stiffen, muscles lose flexibility and strength, cataracts grow, vaginal wall becomes thin, dry and less elastic. Increased risk of for vag infections. urinary incontinence. loss of bone mass- kyphosis
endometriosis
endometrial-like tissue outside the uterus
s/s: pelvic pain, dysmenorrhea, dyspareunia, and infertility.
mgmt: NSAIDs for pain, hormonal therapy (oral contraceptives, progestins, and gonadotropin-releasing hormone agonists to suppress endometrial growth
-laparoscopic surgery can be considered to remove lesions
PCOS
hormonal imbalances that lead to a variety of reproductive, metabolic, and cardiovascular disturbances- symptoms effect various aspects of health beyond their reproductive years
causes: elevated androgen levels and insulin resistance
s/s: vary per person
irregular menstrual cycles
hyperandrogenism, causing hirsutism (excessive hair growth), acne, and alopecia
polycystic ovaries seen on ultrasound, obesity
-diagnostic tool for PCOS is the Rotterdam criteria, which require the presence of two out of three factors: menstrual irregularity, evidence of hyperandrogenism (by either clinical symptoms or laboratory testing), and polycystic ovaries visualized on ultrasound
complications: insulin resistance and diabetes, metabolic syndrome, hypertension, high cholesterol and triglycerides, endometrial cancer due to excessive endometrial growth from irregular menstrual cycles, depression and anxiety, obstructive sleep apnea related to being overweight, cardiovascular disease, non-alcoholic fatty liver disease, and infertility
pelvic floor disorders
conditions that cause a decrease in the integrity of pelvic musculature
RF: pregnancy, increased parity, vag deliveries, connective tissue disorders, disorders that cause chronic coughing, obesity, chronic constipation, previous surgeries (hysterectomy)
Cystocele- bladder bulges into the anterior wall of vagina
s/s: vaginal pressure, lower back pain and decreased sexual satisfaction, frequent urination
rectocele- rectum bulges into the posterior wall of the vagina.
S/s: vaginal pressure, a feeling of fullness, the feeling that something is falling down or out of the pelvis. Lower back pain, decreased sexual satisfaction or pain, constipation, trouble with stool becoming trapped in the rectocele, and urinary and bowel dysfunction.
uterine prolapse- pelvic floor is so weak, it can’t support the uterus, it descends and protrudes out the vagina
s/s: urinary incontinence, full vaginal feeling, bulging of the vagina, constipation and back pain
dx: rule out infection, cystoscopy, urodynamics, colonoscopy
tx: surgery- reinforce bladder or rectum, or uterus removal. pelvic floor strengthening, bladder training, pessary, hormone replacement
vaginal fistula- opening to surrounding structures (rectovaginal fistula, urethrovaginal fistula)
causes: obstetric trauma, operational delivery, episiotomy repairs
s/s: leaking stool or urine from vagina, frequent urinary or vaginal infections, and foul odor
tx: small ones can heal on their own, most require surgery
benign growths
fibroids- solid tumor in smooth muscle tissue of uterus. seen on US
-50% asymptomatic, other s/s include heavy menstrual bleeding, pain in pelvis, urinary frequency
tx: IUD or antifibrinolytic meds- tranexamic acid. or surgery
polyps- growth derives from inner lining of uterus
can cause irregular or heavy periods.
dx: transvaginal US
tx: hormones that cause anolvulation to reduce estrogen and progesterone, surgery
ovarian cyst- fluid-filled sac on ovary. can sometimes burst and cause pain in abdomen. If cyst is bleeding or causes the ovary to twist Ovarian torsion), surgery may be required
cervical growths: mucous cyst, polyps or warts-
s/s: increased post-sex bleeding
vulvar and vaginal growths: bartholin’s cyst: obstruction in the gland
tx: warm compress, sitz bath. abx if it gets larger, inflamed or infected
cervical neoplasms
cause: HPV infection
RF: HPV, HIV, and cigarette smoking
s/s: often none, found with routine screenings/exams. occasionally, unusual vaginal discharge.
dx: pap smear, may need colposcopy and biopsy
tx: cryotherapy, ionization (to remove cone shape that has all the cancer cells on it), LEEP
breast neoplasms
-discovered by mammogram
dx: needle biopsy
tx: surgery- mastectomy, chemo, radiation, hormone
uterine neoplasms
can originate from lining of uterus (endometrial cancer) or in the muscle of the uterus
RF: exposure to unopposed estrogen (PCOS, HRT), infertility and nulliparity
s/s: unusual bleeding, bleeding after sex, between periods or after the start of menopause
dx: uterine biopsy
tx: hysterectomy, potentially fallopian tubes and ovaries as well
STIs
