WCF Exam 2 Flashcards
The 5 P’s
Passenger (baby)
Position (of the baby)
Passageway (maternal pelvis)
Powers (physiological forces)
Psychological Response of the Pregnant Patient (includes psychosocial influences)
Fetal head molding - conehead
collection of fluid
Position
Fetal Presentation - What’s coming first?
Cephalic/vertex (head 1st), breech, and shoulder
Position
Fetal Attitude
Chin to chest = good
Chin extended = bad
Flex- chin to chest
Neutral (AKA military)- straight up and down
Extended (AKA face present)- chin extended, head tilted backwards
What fetal presentation do you opt for C-section?
breech and shoulder
What fetal attitude do you opt for C-section?
Extended
Position
Fetal Lie - Are the spines aligned?
Longitudinal, transverse (horizontal), or oblique (diagonal)
Position
Fetal Position - Direction in the pelvis?
Occiput- back of head
Sacrum- butt
Mentum- chin
Sinciput- forehead
Lie: longitudinal or vertical
Presentation: breech
Presenting part: sacrum
Attitude: flexion, except for legs or knees
Frank breech
Lie: longitudinal or vertical
Presentation: breech
Presenting part: sacrum
Attitude: flexion, except for one leg extended at hip and knee
Single footing breech
Lie: longitudinal or vertical
Presentation: breech
Presenting part: sacrum w/ feet
Attitude: general flexion
Complete breech
Lie: transverse or horizontal
Presentation: shoulder
Presenting part: scapula
Attitude: flexion
Shoulder presentation
Fetal position - Three letter designation
1) Side of pregnant patient that the baby’s body part is leaning toward - L or R
2) Baby’s body part entering the pelvis -Occiput, Sacrum, Scapula, Mentum
3) Side of the pelvis the baby’s body part is closest to - Anterior (pelvis), Posterior (tailbone), Transverse
Good contractions are every __________ minutes and last __________ seconds.
Good contractions are every 2-3 minutes and last 60-90 seconds.
How can you check the frequency/duration/intensity of contractions?
Palpate the fundus
IUPCD- intrauterine pressure catheter
No cervical change (from previous dilation/effacement)
CTX do not intensify and may space out
Can walk/talk through CTX, walking does not make them stronger
Pain medication may stop contractions (Braxton Hicks)
False labor
Cervical change
CTX get longer, stronger, closer together, & demand attention
Walking may make them stronger
Pain med may slow or speed up labor, never stop
5-1-1
True labor
What is 5-1-1?
Occurring every 5 minutes
Lasting 1 minute
Happening for 1 hour
Signs of impending labor
lightening- baby dropped, irregular contractions (braxton hicks), energy spurt (nesting), increased urinary frequency, bloody show/vaginal discharge, loss of mucus plug, pelvic pressure (mom feels the urge to poo)
Maternal response to labor
Cardiovascular system- increased BP
Respiratory system- hyperventilation, O2 consumption increased during 2nd stage of labor; use mask (not nasal cannula)
GI system- digestion slows/stops during labor; no eating during labor
PMI
Point of Maximum Intensity
Use Leopold’s maneuvers to determine fetal presentation and find PMI. This is where you place the
fetal monitor
Vaginal exam determines
dilation, effacement, fetal station/decent, and amniotic membrane/fluid status
Diameter across opening
cervical dilation
0-10cm
Percentage of ‘shortening’
cervical effacement
0-100%
Document anything 50% or greater
Descent of the fetal presenting part in the pelvis in relation to ischial spines
Pelvic/fetal station
-5 to +5
Cervical exam example:
3/90/-1
3cm dilated
90% effaced
@ -1 station
COCA
color- pale, straw colored; flecks of lanugo or vernix
odor- no odor
consistency- watery
amount- 1,000 mL around 32-36 weeks; starts to drop at 37 weeks to 700-800 mL
If there is an odor when assessing amniotic fluid, indicative of an
infection
SROM
Spontaneous rupture of the membranes
AROM
Artificial rupture of the membranes
False labor is what stage of labor?
Pre-Labor
True labor is what stage of labor?
0cm to 10cm
1st stage
Delivery of baby is what stage of labor?
10cm to baby
2nd stage
Delivery of placenta is what stage of labor?
Baby to placenta
3rd stage
Recovery is what stage of labor?
4th stage
What stage of labor?
-Begins at onset of true labor
-Ends with cervical dilation of 10cm or complete dilation
-Three phases- latent, active, transition
1st stage
Three phases of true labor (1st stage)
latent (early), active, and transition
0-3cm w/ mild to moderate contractions is what phase of true labor?
latent (early)
4-7cm w/ moderate to strong contractions is what phase of true labor?
active
8-10cm w/ strong contractions is what phase of true labor?
transition
SVE
Sterile vaginal exam
Why should vaginal exams be limited?
Avoid infection
Nursing assessments/interventions during 1st stage of labor
-continuously monitor pain
-palpate contractions every 30 minutes (every 15 minutes during transition phase)
-EFM monitoring (intermittent if low risk/reactive, continuous if high risk/abnormal)
-SVE
-amniotic fluid @ROM (COCA, check FHR)
-assist w/ breathing
-encourage support
-prevent early pushing
-notify provider of any deviations/once 1st stage is complete
-administer medications
-document!
What stage of labor?
-Begins w/ complete or full dilation (10cm)
-“Pushing” stage
-End with delivery of baby
-duration may vary between primiparas and multiparas
2nd stage of labor
Nursing assessments/interventions during 2nd stage of labor
-maternal & fetal assessment
-vaginal exam to assess descent, pushing efforts
-remove foley if pt has an epidural
-promote effective pushing/positioning
-assist w/ delivery
-document!
Body preparation for birth during 2nd stage of labor
-bulging of perineum and rectum
-flattening and thinning of the perineum
-increased bloody show
-labia begins to separate
-burning sensation (Ring of Fire)
-intense pressure in rectum
-crowning
Types of lacerations
perineal, vaginal & urethral, cervical, and episiotomy
Episiotomy lacerations
-Median “midline”
-Mediolateral
Perineal laceration - 1st degree
First degree: Skin and structures superficial to muscles
Perineal laceration - 2nd degree
Second degree: Through muscles of perineal body
Perineal laceration - 3rd degree
Third degree: Through anal sphincter muscle
Perineal laceration - 4th degree
Fourth degree: Anterior through rectal wall
Rooter to the tooter
What stage of labor?
-Begins with birth of baby
-Ends with delivery of placenta
-Duration may last up to 30 minutes
Longer may lead to D&C due to retained placenta
-Signs that placenta is ready to deliver:
Lengthening of the cord, Gush of dark red blood (which appears after separation), Globular shape of abdomen, Patient feels “like I have to push again”
3rd stage of labor
Preparation during 3rd stage of labor
-APGAR on infant @1min, 5min, & 10min (if low score)
-watch for signs of placental separation (should occur within 30 min)
-vital signs
-baby to chest/warmer to prevent heat loss
-get lidocaine/sutures if episiotomy/laceration is present
-admin pitocin to prevent hemorrhage
-document after placenta delivers!
What stage of labor?
-May last up to 4 hours or more
-Physiologic readjustment begins
-Critical assessments by RN are done
-Fundal assessment is crucial!
Recovery stage
Three Sources of Labor Pain
-Emotional: fear, tension, and pain
-Functional: dilation and contractions
-Physiologic: maternal and fetal position
PAIN
Purposeful
Anticipated
Intermittent
Normal
Pain is serving a useful purpose, is a normal process. (not from illness or injury). Can be anticipated and prepared for with clear ending point.
Pain management in Labor
Nursing Goal
Continually assess fetus and client to ensure a safe delivery, facilitate a positive birth experience, assist in the management of pain, advocate for patient needs (patient needs may change throughout labor).
Types of non-pharmacologic pain relief
Hydrotherapy, birthing ball, peanut ball, cub, paced breathing & relaxation, music, guided meditation, guided imagery, aromatherapy, acupressure/counterpressure/massage, yoga, application of heat & cold
Warm water promotes comfort & relaxation
Showering or soaking in a tub or whirlpool bath
Helps decrease muscle tension
Buoyancy in tub can help with relief, increases oxytocin and endorphins
Hydrotherapy
Diminishes stress, anxiety, and tension (all which can increase sensation of pain)
When tension is reduced, patient breathes more deeply which improves oxygenation
Paced breathing & relaxation
Picture a place that is special or focus on a place where client likes to be
Nurse or labor support person can verbalize sights and sounds of the place to distract the client
Guided imagery
Use of essential oils
Rose, lavender, frankincense, and bergamot oils
Promote comfort and relaxation, decrease pain
May add to bath, to lotions, or use aromatherapy delivery device
aromatherapy
Can warm washcloths be applied to the perineum to help relieve discomfort from stretching and may help prevent tearing?
yes
Benefits of Non-Pharmacologic Pain Relief
No limitations to mobility during labor and after delivery
Fastest recovery (for both patient and baby)
Facilitates partner participation
Minimal intervention
A form of massage involving a circular stroking movement made with the palm of the hand.
Gentle strokes
Effleurage
Injection route IV or IM
Parenteral Analgesia
Analgesia
pain relief
True or False
Assessment should be completed prior to medication administration
True
Check maternal BP, fetal HR, and labor stage.
The safest and most effective form of pharmacological pain relief depends on
Stage of labor, progress of labor, medical status of client and fetus, and patient preference
Can non- pharmacological interventions for pain control be used in addition to pharmacological agents as labor progresses?
Yes, can promote relaxation and potentiate effects of meds
True or False
Opioids must be administered either more than 4 hours before delivery or less than 1 hour before delivery.
True
Advantages of Parenteral Analgesia
-Ease of administration
Dose can be titrated, Pain relief begins in minutes, No loss of consciousness, Increased relaxation, Decreased pain
-RN can administer
No waiting for anesthesia!
Antiemetics are used for
nausea/vomiting
Ex: Zofran, Phenergan-Opioid Catalyst
Opiate antagonist are used to
reverse opioid
Ex: Naloxone (Narcan)
Opioid agonists/Opioid agonist-antagonists provide
Intermittent Relief: reduce the awareness of pain
Ex: Butorphanol (Stadol) IV/IM
Meperidine hydrochloride (Demerol) IV/IM
Hydromorphone hydrochloride (Dilaudid) IV/IM
Nalbuphine (Nubain) IV/IM
Disadvantages of Parenteral Analgesia
Maternal response- may not relieve pain, cause N/V & drowsiness, confined to bed, continuous EFM
Fetal response- CNS depression (decreased FHR variability), respiration depression, decreased refluxes (sucking), can impair early breastfeeding, decreased ability to regulate temperature
-Colorless, odorless gas that is mixed 50/50 Nitrous oxide/oxygen for laboring moms
-Valuable alternative to epidural anesthesia
-When breathed in, it reduces anxiety and increases feelings of relaxation and well-being
-Inhaled though a mask or mouthpiece
-Can utilize at any stage of labor/delivery
Nitrous oxide
Advantages & disadvantages of nitrous oxide
Advantages: Does not impair patient mobility, No additional monitoring required, Self-administration provides patient with control, Medication effects stopped as soon as the mask or mouthpiece is removed
Disadvantages: Nausea and vomiting, Dizziness, Drowsiness
Safety concerns when using nitrous oxide
Risk of respiratory depression when combined with opioids
Rapidly crosses the placenta
Three types of anesthesia
Local, regional, and general
What type of anesthesia is used for episiotomy/laceration & repair?
local
Ex: lidocaine
Given immediately before birth for episiotomy or after birth for repair of lacerations
Types of regional anesthesia
-Epidural (Bupivicaine/Fentanyl on PCA Pump)
The epidural space is located between the dura mater and the ligamentum flavum.
-Spinal Intrathecal opioids (Duramorph)
Spinal anesthetic agent is administered into the CSF in the subarachnoid space.
When is general anesthesia used?
stat Cesarean (C-Section), other emergencies
Most commonly used method of pain control during labor (nearly 2/3 of women in US)
Epidural
Nursing Care prior to administration of epidural
Educate, Consent, Safety check
Prepare the patient (positioning, monitors)
Report HTN, bleeding disorder, systemic infection
Administer fluid bolus to stabilize BP
Nursing care after administration of epidural
BP q 5 min or per protocol
Review labor progress, FHR & CTX patterns require continuous monitoring
Keep bladder empty (Insert Foley)
Position for Pain and Passenger- Don’t leave supine for an extended period of time!
Potential contraindications for epidural anesthesia
Structural
-Previous spinal injury/surgery
-Severe scoliosis
-BMI of 50+
-Space-occupying brain lesion (ICP)
-Local or systemic infection
Hematological
-Thrombocytopenia
-Coagulation disorders
-Actual or anticipated maternal hemorrhage
Side effects of epidural
shivering, pt is cold
hypotension
How long until pain relief begins after epidural is inserted & meds are started?
15-20 minutes
Can an epidural be inserted during contractions?
No, in between contractions
Advantages of epidural anesthesia
Indefinite Duration
-Continuous pain relief, relaxation
-Excellent coverage in labor
Titratable
-In relation to stage of labor
-Patient can administer bolus (PCA pump)
-Remain alert and participate in birth
-No blood loss, no delay in gastric emptying, respiratory reflexes remain intact
-Fetal complications rare
Disadvantages of epidural anesthesia
Risk of hypotension, strict bedrest, possible post-dural puncture headache, and longer maternal recovery
How is a post-dural puncture headache is treated?
Rare, but miserable complication. Occurs within 48 h after puncture from leakage of CSF into dura mater. Intensifies in upright position.
Blood patch: 10-20 mL of patient’s blood is slowly injected into lumbar epidural space, clot forms in hole in dura mater which seals from further CSF leakage
Other interventions: oral analgesics, dark room, caffeine, hydration
Nursing actions for hypotension
Severe maternal hypotension = drop in baseline BP more than 20% or fetal compromise
Left Side, elevate legs
Bolus of IV fluids
Monitor blood pressure and FHR every 5 min until stable
Oxygen by face mask
Summon Help (Alert provider, anesthetist)
Spinal blocks are commonly used for
C-sections
What is a spinal block?
anesthetic into CSF
What is general anesthesia?
induced unconsciousness
commonly used for unplanned, rapid C- sections
Complications of general anesthesia
-Fetal depression
Anesthetic agents reach fetus in minutes, need to deliver fetus immediately, not advised for high-risk fetus (preterm)
-Greater blood loss- Due to uterine relaxation
-Aspiration- Increased chance of emesis
-Amnesia
-Hypoxia
Nursing interventions for general anesthesia
-give antacid per-op to reduce the risk of aspiration
-wedge under r hip for l lat tilt to relieve inferior vena cava pressure
-pre-oxygenate
-IV fluid bolus,
-cricoid pressure during ET tube placement
Pueriperium
Postpartum AKA 4th trimester
immediately after childbirth and lasts for 6 weeks
When is infant physiology adapting and risks to mother of post partum hemorrhage the highest?
after delivery
This is the immediate postnatal period = first 24 hours after birth
How often do you check vitals after a vaginal delivery?
Every 15 minutes for 2 hours, every 4 hours for 8 hours, and then every 8 hours until discharge
How often do you check vitals after a C-section?
Every 30 minutes for 4 hours, then every hour for 3 hours, then every 4-8 hours
Post partum normal vital ranges
Temp: 98.6-100.4
Pulse: 50-90
RR: 12-20
BP: Baseline BP during first trimester
Assess pain
What does the acronym BUBBLE-HE(B) stand for?
Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy (perineum and hemorrhoids)
Homan’s sign (legs)
Emotional support
Bonding
What is colostrum?
the first milk, yellow fluid, filled with nutrients, optimal feed within first hour of birth
Patient education for
non-breastfeeding patient
Wear supportive bra (sports bra works well)
Ice packs to axillary area
Ibuprofen or acetaminophen can be taken for discomfort
Educate: use safe water source, mix according to directions for formula
Within 48-72 hours
Aka milk “coming in”
Breastfeed frequently to remove milk
Massage breasts before and during feeds
Cold compresses after the swelling (lymphatic and hormonal response)
Will resolve day 4-5
Engorgement for BF moms
Resolves spontaneously
Discomfort decreases within 24 to 36 hours
Breast binder or tight bra (sports bra works well)
Ice packs, mild analgesics for pain
Avoid stimulation (back to shower)
Cool washcloths, cabbage leaves
Engorgement for non BF moms
Blocked milk duct/bacteria: Unilateral breast involvement
Fever usually occurs
Treatment: Abx, moist heat, increased fluid intake, Tylenol/Motrin
Continue to breastfeed!
Mastitis
Is uterine involution normal?
Yes, uterus returns to non-pregnant state following birth
Decreased by 1cm/day
What is uterine subinvolution?
Uterus is not decreasing in size.
Uterine involution may be inhibited by multiple births, hydramnios, prolonged labor or difficult birth, infection, grand multiparity, or excessive maternal analgesia. In addition, a full bladder or retained placental tissue may prevent the uterus from sustaining the contractions needed to prevent hemorrhage or to facilitate involution.
Signs and symptoms of pelvic infection
-prolonged lochial d/c
-irregular or prolonged bleeding; sometimes hemorrhage
Give antibiotics
Afterpains education
-Most severe 2-3 days after delivery
-Similar to menstrual cramps
-Multiparas and patients with larger uterine distention (large baby) experience more vigorous contractions
-Ibuprofen or naproxen
Placenta has to be delivered within __ minutes of delivery.
30
Retained placental fragments produces progesterone. Progesterone _________ the uterus.
relaxes
Methergine PO __________ the uterus. Preventing and treating postpartum hemorrhage.
contracts
Leading cause of maternal morbidity and mortality in the U.S. and around the world
Postpartum hemorrhage
Early postpartum hemorrhage
first 24 hrs after delivery
Greatest likelihood within 4 hours after delivery
Late postpartum hemorrhage
24 hrs to 12 weeks after delivery
Usually caused by retained placental fragments
Diagnosis of postpartum hemorrhage
Vaginal Delivery= >500mL EBL
Cesarean Section= >1000mL EBL
HCT levels drop more than 10%
Need for RBC transfusion because of anemia or hemodynamic instability
Postpartum hemorrhage T’s:
Tone, trauma, tissue, & thrombin
What is uterine atony?
Leading cause of early PPH
Intermittent/Continuous dark red blood with clots, uterus soft & boggy
Caused by: Pitocin use- Induction, over distended uterus (macrosomia, multiple gestation), obesity, prolonged labor, previous history, trauma during birth, manual placental removal, use of anesthesia
Placenta previa and placenta accreta are at a higher risk for
retained placental fragments
Deficiency of platelets
thrombocytopenia
Results in delayed blood clotting
Normal platelet count is around 150,000 to 400,000 platelets per microliter (μl) of blood
How often should a fundal massage be completed the first hour following delivery?
every 15 minutes
_________ _________ is a risk factor for hemorrhage during the first hours after delivery.
Urinary retention; Ask pt to void before fundal massage, this will help promote uterine contractions
A full uterus will displace the uterus. Should you take a pt who is actively hemorrhaging to the bathroom to void?
No, insert a foley
Meds to increase uterine tone
Pitocin IV-Bolus rapidly
Cytotec PR (per rectum)-Make sure to use lubricating jelly
Methergine IM-DO NOT GIVE to HYPERTENSIVES
Hemabate IM-DO NOT GIVE to ASTHMATICS
Initial management and care for PPH
Palpate fundus: location, tone, & lochia
Massage if boggy
Express clots, note length of time to saturate pad
Assess perineum for hematoma, unrepaired lacerations
Empty bladder (bedpan, straight cath or foley)
IV – large bore 18 gauge - rapid infusion 1-liter fluids, preferably NS or LR
Pitocin 20 – 40 units/1 liter
Oxygen 10-12 L/min for compromised perfusion
PPH Med
Pitocin
Action: Stimulates contractions (uterine smooth muscle)
Route: IV, IM if no IV access
Contraindications: hypersensitivity
Nursing considerations: First line for PPH (uterine atony). Bolus can lead to hypotension and cardiac arrythmias.
PPH Med
Methylergonovine maleate (Methergine)
Action: Stimulates contractions (uterine and vascular smooth muscles)
Route: IM followed by PO
Contraindications: Hypersensitivity, history of HTN or current high BP
Nursing considerations: do not mix with other meds
PPH Med
Carboprost tromethamine (Hemabate)
Action: Stimulates contractions (myometrium)
Route: IM or directly into uterus
Contraindications: Asthma, hepatic, renal, cardiac disease
Nursing considerations: VERY expensive. Do not administer if patient demonstrating s/s of shock.
PPH Med
Misoprostol (Cytotec)
Action: Stimulates powerful contractions (myometrium)
Route: rectal, PO, sublingual
Contraindications: Hypersensitivity to prostaglandins
Nursing considerations: Rectal much slower than IV.
PPH Med
Dinoprostone (Prostin E2)
Action: Stimulates powerful contractions (myometrium)
Route: Vaginal or rectal suppository
Contraindications: Hypersensitivity to prostaglandins, severe HTN
Nursing considerations: If vaginal bleeding, vaginal suppository likely ineffective. Fever is common.
Hypovolemic shock caused by PPH
Classic signs
-Maternal dyspnea, tachycardia, thready pulse
-Dropping blood pressure, increasing tachycardia
Nursing interventions for hypovolemic shock
-Summon help: Especially Anesthesia
-#1 Massage fundus (atony)
-Assessment: Must know client’s risk factors!
-Rapid infusion of crystalloids: NS/RBC’s
-Airway – O2
-Monitor status
How to have the best postpartum poo experience?
Increase water intake, don’t ignore the urge, pamper the perineum, use stool softener, take walks, and eat healthy
What is the lochia progression?
Rubra –> Serosa –> Alba
Lochia
Dark red, lasts 3-4 days
Rubra
Lochia
Pink/brown, lasts 4-10 days
Serosa
Lochia
Whiteish-yellow, lasts 10-28 days
Alba
Can the lochia progression go in reverse?
No, should never go in reverse
What does REEDA stand for? What is it used for?
Assessing episiotomy healing
Redness
Edema
Ecchymosis (bruising)
Discharge
Approximation
Nursing interventions for perineal discomfort
Assess perineum for hematoma, bleeding, s/s of infection
Ice Pack
Ice-filled glove wrapped in wash cloth (avoid latex gloves if patient allergic)
Peri bottle
Sitz baths to start after first 24 hours
Instruct patient: Nothing in the vagina for a minimum of 6 weeks
Kegel Exercises
Give stool softener
What pts typically feel perineal discomfort?
Patients who would experience perineal discomfort experienced a fast and expeditious delivery, had an episiotomy, or a long, difficult vaginal delivery
Transient period of depression
Occurs first week or two after birth
Mood swings, anger, weepiness, anorexia, sleeping problems, feeling letdown, fatigue
Functioning not impaired
Normal and usually resolves naturally esp. with support and understanding
Baby blues
Abnormal intense, pervasive sadness with severe and labile mood swings, fear, anger, anxiety - persists past 2 weeks PP
Sleep difficulty
Impaired: Unable to care for self or baby
Medical management: psychotherapy/medication
Rarely seek help and feel guilty: 10-15% of mothers
Postpartum depression
What scale is used to assess postpartum emotions?
Edinburgh Postpartum Depression Scale
Risk factors for postpartum depression
Chronic/Prenatal depression
Low self-esteem
Stress of childcare
Prenatal anxiety
Life stress
Lack of social support
History of depression (HIGH ALERT)
Multiple births / fatigue
-Abnormal depression, delusions, thoughts of harming infant or self
-Usually evident within first 8 weeks
-May present with symptoms of PPD
-Signs: hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, loss of touch with reality
-Possible suicide and/or infanticide
-Psychiatric emergency: Hospitalization and medical management necessary
-Most improve with treatment (antidepressants, antipsychotics, antianxiety meds, long term therapy)
Postpartum Psychosis
Bonding questions
Does the patient seem eager to care for her infant?
Is the patient touching the baby, making skin-to-skin contact?
What is the patient’s response when the baby cries?
Does she make eye contact when holding and feeding her baby?
Does the mother show warning signs of appearing dazed and detached?
Mothering Role
Phase 1
Taking-In
Day 1-2
Recovering from immediate exhaustion of labor
Relatively dependent on others to meet physical needs
Expressions of excitement
Mothering Role
Phase 2
Taking-Hold
Day 2-3
Starts to initiate action and to begin some of the tasks of motherhood
Mothering Role
Phase 3
Letting-Go
Weeks 2-6
Mother is redefining her new role
Able to focus on partner, other children, family issues
Partial or complete separation of the six-pack muscles which meet at the midline of the stomach, they separate because as the uterus stretches and baby grows, the muscles have to accommodate
Return to pre-pregnancy state ~ 6 weeks+
Abdomen/ Diastasis Recti Abdominus
Late sign of hemmorhage
BP drop
Delivery of the baby, expulsion of the placenta, and loss of amniotic fluid can create cardiovascular __________.
When does cardiac output return to normal?
instability
Within 2-4 weeks after birth
When is APGAR completed?
@ 1 min, 5 min, and again every 5 minutes if score is low (under 7).
Medications for baby at birth
Erythromycin
Vitamin K
Hep B
Normal respiratory assessment findings of newborn
Shallow, irregular breathing
30-60 breaths/min
Short pauses less than 20 seconds (If over 20 seconds, that is apnea)
Abdominal breathers —> nasal obligate breathers
Abnormal respiratory assessment findings of newborn
70+ breaths/minute
Nasal flaring
Grunting (singing)
Retractions
Paradoxical breathing
When baby takes first breath, pulmonary vascular resistance decreases, increasing pulmonary blood flow. This increases pressure in L atrium and decreases pressure in R atrium –>
Closure of Foramen ovale
Increased systemic vascular resistance, closure of ductus venosus via umbilical vein, increased aortic pressure –>
Closure of Ductus arteriosus
Normal cardiovascular assessment findings of newborn
Murmurs if asymptomatic
Most not pathological
Over half disappear by 6 months
Abnormal cardiovascular assessment findings of newborn
If murmur occurs with apnea, cyanosis/pallor, poor feeding
Murmur sounds like a washing machine
Perfect APGAR score is
10 (rare)
Most babies APGAR score is 9, losing 1 point for
color
Acrocyanosis
Acrocyanosis
Bluish discoloration of extremities
May persist up to 24 hours until peripheral circulation improves
Normal temp for infant
36.5-37.5C (97.7-99.5F)
Can occur during birth or bathing from moisture on skin, as a result of wet linens or clothes, and from insensible water loss
Evaporation
Occurs when the infant comes in contact with cold objects or surfaces such as a scale, a circumcision restraint board, cold hands, or a stethoscopre
Conduction
Occurs when drafts come from open doors, air conditioning, or even air currents created by people moving about
Convection
Heat is lost when the infant is near cold surfaces. Thus, heat is lost from the infant’s body to the sides of the crib or incubator and to the outside walls and windows
Radiation
What does the Vitamin K injection do?
stimulates blood clotting
What is the Opthalmic Erythromycin ointment used for?
Prevent gonococcal ophthalmia neonatorum and chlamydial conjunctivitis
Newborn Head to Toe exam includes
Vitals
Weight
Measurements
Initial Assessment- Fontanelles, Palate, Fingers/Toes, Back, Testes, & Anus
Ballard scoring is useful for discrepancies with
LMP or no prenatal care
Umbilical cord consists of
2 arteries and 1 vein
What is lanugo?
fine hair
Most often on premies, helps anchor vernix caseosa
What is vernix caseosa?
Vernix caseosa is a white, creamy, naturally occurring biofilm covering the skin of the fetus during the last trimester of pregnancy.
It is protective. Try to keep some on after birth for at least 6-24 hours.
Mongolian spots are
congenital birthmarks, not bruises
Blood pools beneath scalp, crosses suture lines (like a cap!)
Can result from vacuum birth.
Caput
Blood below periosteum of skull, does not cross suture lines
Results from trauma to the skull. Common in large babies, instrument assisted, head not in optimal position, or scalp electrode.
Cephalohematoma
Startle reflex
Moro
This reflex starts when the corner of the baby’s mouth is stroked or touched. The baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This helps the baby find the breast or bottle to start feeding.
Rooting
Positive when toes fan up and out when stroked
Normal until around 2 years old
Babinski
When a baby’s head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow.
Tonic neck
AKA fencing
This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his or her feet touching a solid surface.
Stepping
When pressure is put on an infant’s palm & they reflexively curl their fingers to grasp whatever is in their palm.
Palmar
Why should talc powders not be used to treat diaper rash?
can cause respiratory issues
The normal total serum bilirubin level at birth is
3 mg/dL or less
Renal function fluid requirements
60-80 mL/kg
First stool is called
meconium
Dark, tarry poop
Can babies have water?
No.
Only drinking formula or BM! Cannot digest other liquids.
Behavioral transition phases
Phase 1: 0-30 minutes
Reactivity
Phase 2: 60-100 minutes
Sleep
Phase 3: 10 minutes to several hours
Reactivity & Readjustment
Behavioral transition - Phase 1
Increase in HR, irregular respirations, might have some grunting and retractions, spontaneous startle with tremors and side to side head movements, increasing muscle tone
Behavioral transition - Phase 2
Decreased responsiveness, sleeps, normal tone, fast shallow breathing, HR 100-120, spontaneous jerks and twitches but returns to rest quickly
Behavioral transition - Phase 3
Return of exaggerated responsiveness, periods of tachycardia, brief periods of rapid respirations, newborn hunger cues
Family Care
Encourage bonding
Skin-to-skin care
Rooming in = demand feeding
Baby care and safety = changing diapers, learning cues, burping, getting comfortable holding
Circumcision
Preferences (feeding, pacifier, etc.)
What does skin to skin do?
Calms and relaxes, regulates baby’s heart rate and breathing, stimulate digestion and interest in breastfeeding, helps milk production, regulates temp, reduces cortisol levels, regulate blood sugar, less crying, bonding for parents and baby
It is recommended to exclusively breastfeed until
6 months, can go longer if mutually desired
When can solid foods be introduced?
around 6 months of age
Breastfeeding positions
cradle, cross-cradle, laid back, side-lying, pillow, football
Breastmilk storage parameters
Label that pumped milk!
Fresh milk
Room Temp 4-6 hours
Refrigerator 3-8 days
Freezer 6-12 months
Deep freezer 12 months+
Thawed milk good for 24 h. Don’t refreeze.
Contraindications for breastfeeding
Infant with galactosemia, PKU
Mother with HIV, illicit drug use
Mother with active TB, active influenza, or active herpes on the breast
Normal Intake in the first 96 hours
In 1st 24 hrs- 2-10 mL
24-48 hrs- 5-15 mL
48-72 hrs- 15-30 mL
72-96 hrs- 30-60 mL
Feeding cues
crying, rooting, closed fists, open mouth, awake, tongue movements
Satiety cues
lets go of breast, opens hands, falls asleep
Types of formula
Cow based: made with cow’s milk altered to resemble breast milk
Soy based: useful to exclude animal protein based on preference or baby not tolerating cow-based
Protein hydrolysate: don’t tolerate either of the above, option for babies with protein allergies
Indications of intolerance to formula
GERD
Vomiting
Bad mood
Discharge prep & education
discharge measurements, confirm pediatrician appointments are scheduled, Critical congenital heart defect (CCHD) apparent in first 24 hrs of life, car seat safety, education using bulb syringe & thermometer, signs of jaundice, umbilical cord care, and when to call doctor
Umbilical cord care info
-keep dry
-no alcohol or lotion
-no submerged baths
-diaper placement
