Skin, wound healing and neonatal birthmarks

Question 1

Gestation can be assessed by examining the neonates

Answer 1

Ears, Eyes, Breast, Gentalia, Plantar creases, Langugo, skin texture

Question 2

Rash of the newborn is known as:

Answer 2

Erythemia toxicum

Question 3

Which birth mark may become noticeable in the weeks after the birth

Answer 3

Haemangioma

Question 4

Which birth mark requires referral for further investigations

Answer 4

Port wine stain

Question 5

Which skin injury requires referral for further treatment

Answer 5

Scalpel marks at caesarean section

Question 6

Why is it important to document blue spot birth marks

Answer 6

Safeguarding

Question 7

List the birth injuries

Answer 7

Birth injuries
• Amniotomy marks - when trying to rupture the membranes can end up the babies head can have several marks on it.

• Fetal scalp electrode - they have a needle that goes under the skin, numerous attempts can lead to scars from the point of attachment
• Fetal blood sampling - scratch the top of the head with a blade then spots of blood from that area where they have made an incesion
• Scalpel marks -caesarean section
• Forceps marks - can be anywhere on the baby.
• Ventouse- chignon : the bruising round left following the ventous birth.
• Bruising

Question 8

Port wine stain

Answer 8

• can be anywhere in the body. It will stay the same colour. Can be associated with other conditions. Abnormality where the blood vessels are.

• Sturge-Weber syndrome - associated with port wine stain anywhere the brain might be. Associated with sight problems, epilipsey.

• MRI - of the brain for port wine stain. To ensure the blood vessels within the brain are normal.
• Laser treatment - cosemetic

Question 9

Blue spot

Answer 9

Blue spot - anyone whos from south america, mediterrian, asia, africa can have a blue spot. Monogolian blue spot.
Normal on the buttocks
Can be on the wrists or ankles
Blue spots that are more fate, by the time the child is 4-5 it will disappear
The navy spots are less likely to disappear completely

Question 10

Strawberry haemangioma

Answer 10

Resembles a strawberry

Abnormality of blood vessels

Question 11

Early haemangioma

Answer 11

When the babys first born may be very fate
Increases in size after the birth
Can be found in any part of the body

Question 12

Cafe au lait (neurofibromatosis)

Answer 12

One or two are normal
More than 5 abnormal you
need to rule out that the baby does not have neurofibromatosis - the individual develops tumours in their body. They are not cancerous but the individual will spend their life with multiple surgeries to remove the tubes

Question 13

Nevus simplex

Answer 13

Can be along the forehead, nose, top of lip and one on its neck
Known as stark marks
They are smaller and different colour than port marks and when you press the skin it will disappear
They will disappear within a year or two of life

Question 14

Erythemia toxicum

Answer 14

Common rash
The babies skin reacting to chemicals it has not come into contact with
Close contact with new material
Elbows and knees
Baby may have the odd spot on the front. The whole baby may be covered in it
Advise not to put anything on the skin

Question 15

Sucking blister

Answer 15

Sucking hand can cause blister

Can be anywhere the baby can reach to

Question 16

Skin

Answer 16

Epidermis
• Outer layer that is continuously replaced
• Protects against the environment and infection, and prevents excess water loss

Dermis
• Firm part of your skin (above the fat)
• Blood vessels deliver nutrients and regulate temperature → vasoconstriction and vasodilation
• Nerve receptors sense touch, temperature, pain, pressure etc

Question 17

What are the 4 phases of wound healing

Answer 17

Inflammation : Inflammatory response - Starts immediately after the injury is caused and lasts 0-3 days
Prevent further blood loss by vasoconstriction, which results in a blood clot or scab
Once bleeding stops, the blood vessels within the wound dilate to allow fluid carrying the cells necessary for healing to enter the wound.
Around 10-15 minutes after the injury has occurred - wound appears red, heat, swelling and pain (result of histamine when there’s injury to the skin and prostaglandins)

Destruction - The skin preparing for the healing process
Lasts 1-6 days
To prevent infection, clean the wound and provide the best conditions
for healing
White blood cells cleanse the wound by releasing chemicals that digest
any bacteria or tissue debris
White blood cells count are there to digest any bacteria and just making sure the tissue damaged does not become infected
Clean and dry, there will be moisture on the surface on the skin
Once this is complete, the white cells die off and can be seen as moist,
sticky tissue, known as slough

Proliferation : Lasts 3-24 days
New blood vessels, collagen and other connective tissue are developed
by fibroblasts
New capillaries join together in a scaffold which develop into
granulation tissue within the wound
Granulation tissue is pale pink but becomes bright red as more new
blood vessels develop
If you did not suture any area e.g. perineal suture, perineal trauma the tissue will be formed from the bottom upwards, granulation tissue and will fit into the area, heals from the bottom upwards towards the skin

Maturation : maturation – the decorators
Lasts between 21 days and two years
Epithelial cells move over the newly formed granulation tissue and
reduce the size of the wound by contracting, thereby pulling the edges
together
Macrophages re-organise the collagen to form scar tissue, which will
fade from red to white over time
Healed skin only regains 80% of the strength of non-injured skin

Advise to women about wounds the basic healing process is taking up to about 3 weeks. The remainder of the healing process can go on for a couple of years. More of the cells are being formed and the appearance of the womb area should become less red/pink
Importance to remember that the area that is damaged is meant to have 80% strength compared to skin that hasnt be injured

Question 18

Skin & pregnancy

Answer 18

Dark spots
Linea nigra - line on the abdomen.

Melasma - brown and grey patches on the skin can be due to hormone changes

Striae gravidarum - stretch marks. 1st pregancy will look pink. Tissue will change to a more sliver apperance

Spider nevi - capillaries

Varicosities - due to relaxing walls of blood vessels, similar to varicose veins they are more noticeable on the skin, pressure of the weight within pelvic cavity that area may be problems with venous return - blood returing back to the heart. Women with varicose veins should keep legs up to help get blood back up

Non-pitting oedema - collection of fluid, fluid retention within tissues. Associated with eclampsia/ preclampsia. Non-pitting means when you press the tissue and there are no dents left however pitting is when you press the tissue and your dents are left for a few seconds

Pruritus - itching

Obstetric cholestasis
Go to do with live function
Up to 2.4% of pregnant women in 3rd trimester
Any itchness in the skin should be investigated for women in their 3rd trimester

Question 19

Pressure ulcers

Answer 19

Epidural , immorbility
Pressure ulcers occur over bony prominences - sacrum, heels, ankles, knees, hips and elbows

Causes
Shearing forces
Friction
Moisture - amniotic fluid or lochia
Risk factors
Significantly limited mobility – regional anaesthesia, induction of labour and electronic fetal monitoring
Significant loss of sensation – regional anaesthesia
Previous or current pressure ulcer
Malnutrition – high or low BMI
Significant cognitive impairment
Incontence e.g. women wearing pads. Dampness women who drain amniotic fluid, can lead to risk factors

Question 20

Preventing pressure ulcers

Answer 20

Any pain or discomfort reported by the patient
Skin integrity in areas of pressure
Colour changes or discoloration. Loss of circulation to any area there will be darkening of the skin
Variations in heat, firmness and moisture
Keep as mobile as possible
Changing position every 2 hours
Change wet pads/sheets regularly
Keep a record of how the skin looks, if it looks like the skin is breaking down appropriate skin care/wound care will be provided

Question 21

Perineal trauma

Answer 21

1st degree tear - skin
2nd degree tear - skin and muscle
3rd/4th degree - skin, muscle anal sphincter
4th degree - lining of the rectum has been storn

Question 22

Common risk of perineal trauma

Answer 22

P0
Increasing maternal age
Afro carribean women have less perineal trauma and have intact perineum
Asian women are more likely to have severe perineal trauma

Question 23

Perineal wound infection

Answer 23

Early detection of perineal wound infection is important
Perineal pain
Heat, redness & erythema
Wound dehiscence - wound breaks down due to infection
Purulent vaginal discharge
Offensive odour
Systemic signs of infection - sepsis - raised temperature and pulse
Maternal mobility - perpul sepsis in the postnatal section
Clinical management
Expectant – increased perineal care
Swabs
Antibiotics
Surgical debridement

Question 24

Caesarean section wounds

Answer 24

Prophylactic antibiotics
Pain relief
Dressing removal around 24 hours if appropriate
Advice on wound care
Removal of sutures if needed
Sutures can be dissolvable or not. Absorbable sutures, or dissolvable stitches, do not need to be removed.

Question 25

Early detection of CS wound infection

Answer 25

Wound pain
Heat, redness & erythema
Wound dehiscence - wound ruptures
Offensive odour
Systemic signs of infection - raise temperature and pulse, headache
Clinical management
Expectant – increased perineal care
Swabs - to localise the infection to determine which antibiotic to take.
Antibiotics
Surgical debridement - removing tissue that is damaged , pressure ulcers as well.
Elective c section women are swabed for bacteria.

Question 26

Breast wounds

Answer 26

Sore nipples, cracked nipples, baby bite, or milk blister
Engorgement - no flow of milk, blocked ducts, mastitis - break down on surface, inflammed can lead to infection, abscess - antiobiotics
Surgery to drain abscess to removed infected part.
Most common cause - baby is not positioned and attached effectively

Question 27

Treatment for breast wounds

Answer 27

Treatment – sore cracked nipples
• Small amount of purified lanolin : cream treatment to let it dry on sore cracked nippled
• Breastmilk
Treatment - engorgement
Continue to breastfeed & frequently
Warmth before feeding/expressing can help milk flow more easily
Hand expressing some milk at the start of feeds
Further expression after feeding to soften the breast until
comfortable