Care of at - Risk/High Risk and and Sick Mother and Child Nursing Care of the Pregnant Client
Outline 4
1st Semester AY 22-23
OUTLINE
A. CESAREAN BIRTH
C. NURSING CARE AT
 Pre-op, Intra, and Post-op RISK/HIGH RISK/ SICK
Management
CLIENT NEW BORN
1. Problems related to maturity
B. HIGH
RISK  Prematurity
POSTPARTUM CLIENT
 Postmaturity
1. Post Partum Hemmorrhage 2. Problems
related
to
 Early
Post
Partum Gestational age
Hemorrhage
 Small Gestational Age
 Late
Post
Partum  Large Gestational Age
Hemorrhage
3. Acute
conditions
of
 Hypovolemic Shock
Neonates
2. Thromboembolic Disorders  Respiratory
Distress
 Superficial
Venous
Syndrome
Thrombosis
 Meconium
Aspiration
 Deep Vein Thrombosis
Syndrome
 Pulmonary Embolism
 Sepsis
3. Peurperal Infection
 Hyperbilirubinemia
 Sudden
Infant
Death
Syndrome
A. CESAREAN BIRTH
Although cesarean birth may be elected by some women, the
procedure is used most often as a prophylactic measure to
alleviate problems of birth such as cephalopelvic disproportion,
breech or multiple fetus births, or failure to progress in labor.
are sometimes necessary. An emergent cesarean birth carries
with it the same risks of any emergent surgery: The woman may
not be a prime candidate for anesthesia and may be
psychologically unprepared for the experience. In addition, the
woman may have a fluid and electrolyte imbalance and be both
physically and emotionally exhausted from a long labor.
1. Pre-operative Management
PREOPERATIVE INTERVIEW
Both a woman’s primary care provider and the team member
who will be administering the anesthesia interview a woman
preoperatively to obtain a health history and to make
assessments and decisions for safety of the procedure and the use
of anesthesia. In addition to these, a nursing assessment is also
essential. Be certain to ask about any past surgeries, secondary
illnesses, allergies to foods or drugs, reactions to anesthesia,
bleeding problems, or current medications to help establish
surgical risk, and any body piercings that need to be removed
because of the use of electrosurgery or an arterial cauterizing
machine. In addition, include questions to discover the woman’s
knowledge about:
• What the procedure will entail
• Length of hospitalization anticipated
• If she’s been told about any postsurgical equipment to be used,
such as an
indwelling catheter or intravenous (IV) fluid line
• Any special precautions that are being planned for her infant
such as high-risk
nursery care
OPERATIVE RISK FOR A WOMAN
Women who are in less than optimal physical or psychological
health are at risk for a complicated surgical outcome unless the
risk factor is identified, and special precautions are taken.
Poor Nutritional Status
Scheduled cesarean births are planned, which means there is
time for thorough preparation for the experience throughout the
antepartal period. Some women are even able to take a childbirth
preparation class specifically for cesarean birth. Women who
plan these need to be aware they will need epidural anesthesia,
and the risk of injury to them from cesarean birth is higher than
that from vaginal birth. Scheduling cesarean births this freely
also can result in preterm birth with the accompanying threats to
the fetus or newborn.
A woman who is obese because of poor nutrition is at added risk
from surgery, because tissue that contains an abundance of fatty
cells is difficult to suture, thus causing the surgical incision to
take longer to heal. A prolonged healing period increases the risk
for infection and rupture of the incision (dehiscence). Because an
obese woman’s heart has an increased workload, the physiologic
shock of surgery may place greater stress on the already
overworked organ. In addition, an obese woman often has more
difficulty turning and ambulating postoperatively than does a
woman with a lower body mass index (BMI) and therefore has
an increased risk for developing respiratory or circulatory
complications such as pneumonia or thrombophlebitis. A woman
with a protein or vitamin deficiency is also at risk for poorer
healingbecause protein and vitamins C and D are necessary for
new cell formation at the
incision site. Vitamin K is necessary to ensure blood clotting
after surgery. Pregnant women who are iron deficient (in
particular, women with a multiple gestation or women who have
not taken supplements), coupled with the blood loss from
surgery, are at high risk for extreme fatigue after surgery, which
could interfere with parent–child bonding
EMERGENT CESAREAN BIRTH
Age Variations
Emergent cesarean births are done for reasons that arise
suddenly in labor, such as placenta previa, premature separation
of the placenta, fetal distress, or failure to progress. With this
second type of cesarean birth, preparation must be done rapidly
but with the same concern for fully informing a woman and her
support person about what circumstances created the need for
the cesarean birth and how the birth will proceed. Cesarean birth
is mentioned in most childbirth classes, so any woman who has
taken such a class may at least understand that cesarean births
Age affects surgical risk because it can cause both decreased
circulatory and renal function. Fortunately, most pregnant
women fall within the young adult age group, so are excellent
candidates for surgery. A woman older than 40 years falls into a
category of slightly higher risk not because of surgery itself but
because of associated conditions such as gestational diabetes.
SCHEDULED CESAREAN BIRTH
Altered General Health
PREOPERATIVE DIAGNOSTIC PROCEDURES
A woman who has a secondary illness such as cardiac disease,
diabetes mellitus, anemia, kidney, or liver disease is at greater
than usual surgical risk, depending on the extent of her primary
disease, because the pathology from the secondary illness may
interfere with her ability to physically adjust to the demands of
surgery. Therefore, asking if the woman has a secondary illness
is an essential component of a preoperative nursing history. A
general medication history also is important because some drugs
increase surgical risk by interfering with the effect of an
anesthetic or with healing of tissue. Examples of drugs that
pregnant women might be taking and their potential
complications are shown in Box 24.5.
Preoperative assessment procedures for a woman who is to have
a cesarean birth include documentation of fetal status and
presentation and maturity by ultrasound assessment. In addition,
assessments also include circulatory and renal function and those
for all presurgery patients, including:
• Vital sign determination
• Urinalysis
• Complete blood count
• Coagulation profile (prothrombin time [PT], partial
thromboplastin time [PTT])
• Serum electrolytes and pH
• Blood typing and cross-matching
Remember blood values need to be evaluated in light of the
changes that occur with pregnancy. During pregnancy, for
example, a woman (particularly one who was in prolonged labor)
can have an elevated leukocyte count (up to 20,000 cells/mm3),
so this finding is not as helpful an indicator for the presence of
infection in the pregnant woman as it is in others.
PREOPERATIVE TEACHING
Women who are extremely worried about surgery need a very
detailed explanation of the procedure in order to reduce their
anxiety to a tolerable level. If a woman seems particularly
anxious, inform the team member who will administer the
anesthesia so that an antianxiety drug can be administered, if
necessary, to make the experience less frightening for her. In
many instances, just helping a woman acknowledge that her fear
of surgery is a normal reaction can be helpful. This does not
make the procedure any less traumatic, but the woman may then
view her feelings as expected, which can help to enhance her
self-esteem and lower anxiety.
Preoperative teaching is aimed at acquainting a woman with the
cesarean procedure and any special equipment to be used so she
is as informed as possible. Before beginning teaching, assess
how much a woman knows about her surgery. A woman who
has had a cesarean birth for her first child and now is being
admitted for a second procedure, for example, already knows
many details. Even so, she will undoubtedly appreciate having
her memory refreshed and recall confirmed. Answer all specific
questions she has and fill in gaps in knowledge as necessary. Be
certain all information you offer is accurate. Be certain not to use
hospital jargon such as “NPO.” People under stress do not
process new information well. They cannot process information
at all if they do not understand the terminology. Be certain to
explain the immediate preoperative measures that will be
necessary, such as surgical skin preparation, eating nothing
before the time of surgery, premedication (if this will be used),
and method of transport to surgery. Review the necessity for an
indwelling bladder catheter, IV fluid administration, and
placement of an epidural catheter (if this will be used for
postprocedure pain relief). For scheduled cesarean births, an
explanation of not only what is going to happen immediately but
also what activities should be performed to help maintain
respiratory and skeletal muscle function and to prevent
postsurgical complications (e.g., early ambulation) should also
be included in teaching. Women who practice exercises to
maintain good respiratory and circulatory function
postoperatively tend to experience fewer postoperative
respiratory and circulatory complications than those who do not.
These preventive exercises are best taught during the
preoperative period, when the woman is free of pain and can
concentrate on learning. Such teaching also gives a woman a
positive outlook on surgery and a sense of control over her
situation. Throughout teaching, use visual aids as necessary.
Draw pictures or show illustrations of anatomy, as needed. Be
careful, however, not to leave textbooks about cesarean
procedure techniques with a woman. Typically, these books also
describe complications, and although knowledge of possible
complications is necessary for informed consent, reading about
complications complete with color illustrations can be
overwhelming.
OPERATIVE RISK TO THE NEWBORN
Deep Breathing
Cesarean birth places a newborn at a greater risk than does a
vaginal birth. When a fetus is pushed through the birth canal,
pressure on the chest helps rid the newborn’s lungs of fluid,
making it easier for the baby to take a first breath. For this
reason, more infants born by cesarean birth develop some degree
of respiratory difficulty for a day or two after birth than those
born vaginally
Periodic deep breathing exercises fully aerate the lungs and help
prevent stasis of lung mucus from the prolonged time spent in
the supine position during surgery. Because stasis always has the
potential to cause infection, preventing this helps prevent lung
infection such as pneumonia. A typical exercise is to take 5 to 10
deep breaths every hour. The woman simply inhales as deeply as
possible, holds her breath for a second or two, and then exhales
as deeply as possible. Be certain she both inhales and exhales
fully. Otherwise, she might experience light-headedness from
hyperventilation.
Fluid and Electrolyte Imbalance
A woman who enters surgery with a lower than usual blood
volume will experience the effect of surgical blood loss more
than a woman who has a normal blood volume. A woman who
has had a long labor before a cesarean birth is scheduled may fall
into this category because she may have had little to eat or drink
for almost 24 hours. Recent vomiting, diarrhea, or a chronic poor
fluid intake compounds her risk. IV fluid replacement may need
to be initiated preoperatively and continued postoperatively to
prevent a serious fluid or electrolyte imbalance.
Fear
Incentive Spirometry
Baseline Intake and Output Determinations
A common device used three to four times a day postoperatively
to encourage deep breathing is an incentive spirometer. These
devices, which cause a small ping-pong–like ball to rise in a
narrow tube or cause lights to flash, are both easy and fun to
operate and give a woman a sense of reward for her effort. The
initial impression of most people is that the device works by
blowing into it. Because its purpose is to fully aerate lung spaces,
however, most models are triggered by inhalation, not exhalation.
A gauge can be set to monitor levels and tabs to set goals.
To reduce bladder size and keep the bladder away from the
surgical field, an indwelling urinary catheter may be prescribed
before transport for surgery or after arrival in the surgical suite.
Use good lighting so that the woman’s perineum is clearly
revealed. After catheter insertion, be certain urine drains freely
because fetal pressure on the urethra may considerably reduce
the flow of urine. During transport, be certain to keep the
drainage bag below the level of the woman’s bladder to prevent
urine backflow and the possible introduction of microorganisms
into the bladder. If catheterization is difficult before surgery, do
not traumatize the urethra by repeated attempts as catheterization
can be done in the operating room (OR) after the anesthetic
agent is given. If there will be a delay between the time the
catheter is inserted and the time of surgery, mark the level of
drainage in the bag just before surgery or empty it, so that
presurgery urine output can be differentiated from postsurgery
urine output. This is because one of the gravest dangers of any
surgical procedure is kidney failure from the physiologic stress
of surgery or lack of blood flow to the kidneys due to decreased
blood pressure. All reproductive tract surgery puts ureter flow at
risk as well because the edema that collects in the surgery area
can press on the ureters.
Turning
Be certain women understand that turning postoperatively is
important to prevent both respiratory and circulatory stasis.
Ambulation
The most effective way to stimulate lower extremity circulation
after a cesarean birth is by early ambulation. For this reason,
most primary healthcare providers prefer a woman to be out of
bed and walking as soon as the effect of the epidural anesthesia
has worn off. Helping a woman ambulate this early can be
difficult because she is both fatigued and has pain from her
incision. Help her to understand ambulation is extremely
important after cesarean birth because the edema from the low
pelvic surgery compresses circulation to the lower extremities,
thus increasing the risk for lower extremity circulatory stasis.
Some women may be prescribed sequential compression devices
(SCDs) or antiembolic stockings (thromboembolic devices
[TEDs]) to support and encourage venous return in addition to
ambulation.
IMMEDIATE PREOPERATIVE CARE MEASURES
A number of measures must be taken immediately before
surgery to help ensure a safe outcome.
Informed Consent
Obtaining operative consent is the primary healthcare provider’s
responsibility, but being certain, it is obtained prior to surgery is
everyone’s responsibility. You may be asked to witness a
woman’s signature on such a form. Before signing as a witness,
be certain that it was informed consent, or one in which the risks
and benefits of the procedure were explained in terms the
woman could easily understand. The law differs from state to
state with regard to who qualifies to be considered an
emancipated or mature minor. Emancipated minors can sign
their own permission for a cesarean birth, even though they are
legally underage.
Overall Hygiene
On admission, provide a clean hospital gown. If a woman’s hair
is long, encourage her to braid it or put it into a ponytail, so it
will more easily fit under the surgical cap she will wear; hair
contained by a cap is less likely to spread microorganisms during
surgery. Follow your institution’s procedures with regard to
removing nail polish, jewelry, contact lenses, lip or mouth
piercings, or hair ornaments before surgery. A growing number
of women wear acrylic fingernails and are reluctant to remove
them for surgery. If this is the case, ensure that the woman’s
toenails are free of polish so that toenails can be used to assess
capillary refill if this assessment is needed.
Gastrointestinal Tract Preparation
A gastric emptying agent, such as metoclopramide (Reglan), to
speed stomach emptying or a histamine blocker, such as
ranitidine (Zantac), to decrease stomach secretions may be
prescribed prior to surgery. Yet, another possibility is an oral
antacid such as citric acid and sodium citrate (Bicitra), which
acts to neutralize acid stomach secretions. These precautions are
necessary because the woman will be lying on her back during
the procedure, making esophageal reflux and aspiration highly
possible.
Hydration
Most women have an IV fluid line begun before surgery with a
fluid such as lactated Ringer’s solution. Doing so helps to ensure
a woman will be fully hydrated and will not experience
hypotension from epidural anesthesia administration, temporary
use of a supine position, or blood loss at birth. Be certain this
line is begun in the woman’s nondominant hand if possible so
she can hold her newborn after surgery without interference. Use
a large-size catheter or needle (18 or 20 gauge), so that blood
replacement therapy can be administered by the same line if
needed.
Preoperative Medication
A minimum of preoperative medication is used with a woman
having a cesarean birth to prevent compromising the fetal blood
supply and to ensure that the newborn is wide awake at birth and
can initiate respirations spontaneously. Be aware if a woman has
been in labor, what medications, if any, she has already received
to help prevent a drug interaction.
Transport to Surgery
A woman may be transferred to surgery in her bed, or she may
be helped to move to a stretcher. Urge her to lie on her left side
during transport to prevent supine hypotension syndrome.
Ensure additional safety by raising the side rails. Cover her with
a blanket or sheet to avoid her feeling chilled. Check that her
identification is secure before she leaves the patient unit. Make
certain, even though steps are being completed rapidly, that her
chart or electronic record remains secure and will be available to
OR personnel.
Role of the Support Person
In most instances, a woman’s family can be as involved in a
cesarean birth as they would be for a vaginal birth. A support
person may need more encouragement to watch a cesarean than
a vaginal birth, because he or she may believe the surgery will
be much bloodier than it actually is. Helping family members
realize cesarean birth is little different from vaginal birth not
only allows them to stay with a woman during the procedure but
also helps them progress to bonding with the infant and
incorporating the new member into their family more easily.
2. Intraoperative Management
ADMINISTRATION OF ANESTHESIA
A surgical nurse will assist a woman to move from the transport
stretcher or bed to the OR table and will remain with her while
anesthesia is administered. If the woman has an epidural catheter
in place from labor, be careful not to dislodge it while she is
being moved. During transport and while in surgery, encourage
the woman to remain on her side, or place a pillow under her
right hip to keep her body slightly tilted to the side, to prevent
supine hypotension syndrome. If a spinal anesthetic (which may
be used in an emergency) is to be administered, the
anesthesiologist usually will do this with the woman sitting up.
The anesthesiologist may then ask you to help the woman curve
her back to separate the vertebrae and facilitate entry of the
spinal needle. Remember, though, that it is difficult for a woman
having uterine contractions to remain in this position for long.
Talking to her while letting her lean against you is the most
effective means of helping her maintain this position. Epidural
anesthesia is usually administered with the woman lying on her
side. Duramorph is a form of morphine commonly used in
addition to a local anesthesia in epidurals. Its effect lasts up to 24
hours, but because it can cause late occurring respiratory
depression, respirations should be assessed every 2 hours
postsurgery.
SKIN PREPARATION
Reducing the number of bacteria on the skin before surgery
automatically reduces the possibility of bacteria entering the
incision at the time of surgery. Shaving away abdominal hair, if
indicated, and washing the skin area over the incision site with
soap and water accomplishes this. The skin preparation area for
a cesarean birth varies among agencies. Be certain to follow
agency policy. To avoid being shaved, some women who are
scheduled for a planned cesarean birth choose to have a bikini
wax done 3 or 4 days before surgery.
SURGICAL INCISION
After the anesthetic administration, a woman is positioned with a
towel under her right hip to move abdominal contents away from
the surgical field and to lift her uterus off the vena cava. Be sure
the support person is positioned at the woman’s head to provide
support. Next, a screen is placed at her shoulder level and
covered with a sterile drape to block the flow of bacteria from
her respiratory tract to the incision site. This also helps block the
woman’s and the support person’s lines of vision, thus
preventing additional anxiety caused by the sight of the incision.
The incision area on the woman’s abdomen is then scrubbed
with an antiseptic such as iodine, and appropriate drapes are
placed around the area so that only a small area of skin is left
exposed. Sponge and instrument counts are simplified by the use
of prepackaged cesarean birth components. Watching a cesarean
birth is usually the first time a father or support person has ever
witnessed surgery. Because of this, the person may be too
overwhelmed by and interested in the procedure to be of
optimum support. Prepare the woman and support person for the
sights they might see or help talk them through them as they
occur. Due in part to family and nursing staff pressure, cesarean
sections have started to become more family friendly. In the past,
babies were often delivered, went to the warmer for nursing
assessments, and were eventually wrapped up and given to the
partner to hold near the mother while surgery was finishing.
More recently, several interventions have happened to make the
experience more “gentle.” There are special sterile drapes that
allow for a clear plastic window to be exposed, so the mother
and partner can watch the baby being delivered. The opaque
drape is lowered just before delivery and replaced after the
newborn is delivered, so that the mother and her partner avoid
watching both the initial incision and the repair. Additionally,
mothers often hold their babies skin to skin after delivery, and
they can attempt to breastfeed, even though the position is not
ideal for latching. Cesarean sections are often not the ideal
solution to delivery, but these changes can help women feel
more satisfied with the experience when surgery is necessary.
Types of Cesarean Incision
In a classic cesarean incision, the incision is made vertically
through both the abdominal skin and the uterus. The incision is
made high on the uterus, so that it avoids cutting a possible
placenta previa. A disadvantage of this type of incision is that it
leaves a wide skin scar and also runs through the active
contractile portion of the uterus. Because this type of scar could
rupture during labor, if this type of incision is used, a woman
will be advised not to have a subsequent vaginal birth.
A low segment incision (commonly referred to as a low
transverse uterine incision and a Pfannenstiel skin incision) is
one made horizontally across the abdomen just over the
symphysis pubis and also horizontally across the uterus just over
the cervix. This is the most common type of cesarean incision
used today. It is also referred to as a Misgav-Ladach or a “bikini”
incision because even a low-cut bathing suit will cover the scar.
Because this type of incision is through the nonactive portion of
the uterus (the part that contracts minimally with labor), it is less
likely to rupture in subsequent labors, making it possible for a
woman to have a vaginal birth after cesarean (VBAC) in a
subsequent pregnancy. VBAC rates have waxed and waned over
the years along with its popularity among patients and providers,
but with the recent focus on preventing cesarean births, many
institutions are supportive of women who desire VBAC. The low
segment incision is preferred because it:
• Results in less blood loss
• Is easier to suture
• Decreases postpartal uterine infections
• Is less likely to cause postpartum gastrointestinal complications
The major disadvantage of this incision is that it takes longer to
perform, possibly making it impractical for an emergent
cesarean birth. In a few instances, the skin incision is made
horizontally (Pfannenstiel) and then the uterine incision is made
vertically or vice versa. For this reason, during a future
pregnancy, do not assume a woman who has a low transverse
skin incision also has had a low transverse uterine incision.
BIRTH OF THE INFANT
Once the surgical incision is complete, the uterus is then cut and
the child’s head is born manually (Fig. 24.6). The mouth and
nose of the baby may be suctioned by a bulb syringe, before the
remainder of the child is born. Oxytocin (Pitocin) is
administered via IV by the anesthesiologist as the child or
placenta is delivered to increase uterine contraction and reduce
blood loss. In many instances, a woman’s partner may be
allowed to cut the umbilical cord the same as in a vaginal birth.
After full birth, the uterus is pulled forward onto the abdomen
and covered with moist gauze or left in the abdomen for repair.
The internal cavity of the uterus is then inspected, and the
membranes and placenta manually removed. If the woman
wishes to have a tubal ligation or an intrauterine device (IUD)
inserted for contraception, either of these can be done at this
time.
INTRODUCTION OF THE NEWBORN
Once it is determined the newborn is breathing spontaneously,
he or she is shown to the mother and support person, just as is
done after a vaginal birth. Both the support person and the
mother may hold the baby immediately. The mother may have
some difficulty doing this. Assist her as necessary. Women are
able to breastfeed after cesarean births the same as after vaginal
births. However, initial breastfeeding may be delayed until the
woman has been moved to a recovery room along with her infant
because breastfeeding is difficult to do while still in the
operating room due to position and monitors or IVs attached to
the mother
3. Post-operative Management
Immediately after surgery, a woman is transferred by stretcher
from the OR table to the postanesthesia care unit (PACU) or a
postpartal room. If spinal anesthesia was used, remember that
her legs are fully anesthetized, and she will not be able to help
move them.
Nursing Diagnosis: Pain related to surgical incision
Outcome Evaluation: Patient verbalizes extent of pain (from 1 to
10) and need for relief; states level of pain is tolerable.
In the past, pain control was a major problem after cesarean birth
because pain was so intense from either the uterine or abdominal
incision that it interfered with a woman’s ability to move and
deeply breathe. This led to surgical complications such as
pneumonia or thrombophlebitis. It also made holding an infant
so painful that it threatened to impair a woman’s ability to bond
with her newborn. Today, a number of effective types of pain
management are available, so this problem is lessened. Always
use a pain rating scale to allow a woman to rate her pain. Using a
specific tool helps to ensure accuracy of the assessment in light
of a woman’s overall excitement at having a new child. Anxiety
and fear heighten a pain response. Therefore, a woman who is
concerned about her infant may rate pain higher than a woman
who feels confident that her infant is doing well. In addition, a
tense body posture also causes pressure on sutures. Women who
had a long-action morphine epidural for labor have good pain
relief up to 24 hours after birth. Others, who received a shorter
acting drug for birth, need additional analgesia to be comfortable.
Patient-controlled analgesia (PCA) or continued epidural
injections are both effective systems for maximum pain relief.
No matter what system of pain relief is used, when administering
analgesics after surgery, be certain to supplement them with
other comfort measures, such as urging a change of position or
straightening bed linen. Always ask a woman what type of pain
she is experiencing before administering a new dose of analgesia
to be certain she is describing incisional or uterine pain, not pain
in some other body part that would suggest a complication of
surgery. Check for abdominal distention, which suggests the
pain may be caused by intestinal gas rather than incision pain. If
this is so, ambulation is often the most effective method to
relieve this type of pain. Urge a woman to continue to take
adequate analgesia to effectively manage her pain after she
returns home, so she is not so distressed that she cannot nurse
her infant or ambulate.
Be certain she understands not to use acetylsalicylic acid (aspirin)
because this can interfere with blood clotting and uterine healing.
Many women who are breastfeeding are reluctant to accept any
type of analgesic, especially just before breastfeeding, for fear it
will pass into breast milk and to the infant. Although it is true
that most analgesics do pass into breast milk, the infant takes
such a small amount of breast milk (mainly colostrum) during
the first days after surgery, the amount of analgesia received is
negligible. Placing a pillow over her lap while the infant nurses
can deflect the weight of the infant from her suture line and
lessen pain. Encourage the football hold for breastfeeding as
another way to keep the infant’s weight off her incision (see
Chapter 19).
Patient-Controlled Analgesia.
With PCA, women administer doses of IV narcotic analgesia,
such as morphine, to themselves by means of an IV line as
needed. To receive a dose of analgesia, the woman pushes a
button similar to a call bell. Thisalerts the automatic pump to
deliver a set amount of narcotic into the IV line. The pump has a
“lock-out” setting that prevents a woman from administering a
larger dose or doses more frequently than would be safe (e.g.,
every 8 minutes) Patient-controlled analgesia (PCA) pump. By
pushing the button, a patient delivers a bolus of narcotic to
herself. With PCA, a fairly constant level of pain relief can be
maintained, and pain and fear of injections are eliminated. PCA
works well with postcesarean women because they feel overall
well and so are interested in self-care and self-administration of
analgesia. Because the narcotic is injected in such small amounts,
women tend to use less analgesia with a PCA system than they
would receive with intramuscular injections.
Epidural Analgesia.
Today, women who have epidural anesthesia for cesarean birth
can have morphine (Duramorph) or fentanyl added to the
epidural catheter immediately after surgery, a technique that
keeps them pain free for the next 24 hours (see Chapter 16).
Fentanyl creates few side effects. Although epidural morphine
offers effective pain relief, side effects of administration, such as
intense itching, nausea, and vomiting, can occur. An
antihistamine such as diphenhydramine (Benadryl) may be
needed to reduce pruritus; an antiemetic such as metoclopramide
(Reglan) may be administered to counteract nausea. Even with
these annoying side effects, however, epidural analgesia can be a
very effective means of pain control after cesarean birth.
On the postpartal unit, an infusion pump is connected to the
woman’s epidural catheter, and the woman can infuse a bolus of
narcotic as additional pain relief as needed. This patientcontrolled epidural analgesia (PCEA) not only is an effective
means of relieving pain but also omits the problem of infiltration
of an IV infusion, which can occur with IV PCA.
Transcutaneous Electrical Nerve Stimulation.
Transcutaneous electrical nerve stimulation (TENS) is, as the
name implies, the transmission of an electrical current across the
skin. Small electrodes are attached to the woman’s skin near her
incision; when she feels pain, she pushes a transformer button.
Irritation or stimulation of large afferent nerve fibers by the
electrical stimulation blocks the ability of the smaller, paincarrying nerve fibers to transmit impulses (as predicted by gating
control theory). This is the same phenomenon that rubbing or
scratching skin at a point of pain achieves (see Chapter 16). The
use of TENS can provide important pain relief after a cesarean
birth because it gives a woman a sense of control over her
situation, as does PCA or PCEA
Nursing Diagnosis: Risk for deficient fluid volume related to
blood loss during surgery
Outcome Evaluation: Patient’s blood pressure is 100/60 mmHg;
pulse remains between 60 and 100 beats/min; scant to no
bleeding on surgical dressing is apparent.
The potential always exists for deficient fluid volume from
surgery due to blood loss until all blood vessels that were cut and
ligated during surgery have thrombosed, sclerosed, and
permanently sealed closed. The risk of heavy bleeding doubles
for the postpartum woman because she may not only
hemorrhage vaginally from a noncontracted uterus but also
internally from blood vessels not yet securely closed. This
danger is most acute during the first hour after surgery; it
remains an acute problem for the first 24 hours. To detect the
earliest signs of bleeding, monitor blood pressure, pulse, and
respiratory rate approximately every 15 minutes for the first hour
after surgery, every 30 minutes for the next 2 hours, every hour
for the next 4 hours, or as specifically prescribed. Signs
indicative of possible hemorrhage include:
• Falling blood pressure (more than 20 mmHg systolic), a
systolic blood pressure
• less than 80 mmHg, or a drop of 5 to 10 mmHg over several
readings
• A change in pulse rate (greater than 110 beats/min or less
than 60 beats/min)
• Respirations more rapid and distressed from previous
readings
•
Restlessness and a sense of thirst
Inspect the dressing over the woman’s surgical incision for
blood staining each time vital signs are assessed to document
there is no incisional bleeding. Observe the perineal pad for
lochia flow and palpate the fundal height each time to document
uterine contraction. Lochial discharge may be decreased in a
woman after a cesarean birth because the uterus was cleaned
following the birth, but some lochia will always be present. It
will follow a typical rubra, serosa, and alba pattern. Be certain to
help a woman turn as you assess for perineal bleeding, so you
can look under her body. Blood oozing vaginally or from a
surgical wound can pool considerably under a woman before it is
otherwise visible.
Oxytocin (Pitocin) may be prescribed to be added to the first 1 or
2 L of IV fluid after surgery to ensure firm uterine contraction. If
the rate of fluid administration should fall behind, be careful
about “catch-up” administration. Because oxytocin (Pitocin) can
elevate blood pressure by causing vasoconstriction, it may be
safer to allow the fluid to remain behind for a time rather than
risk elevating blood pressure by a more rapid infusion. Be aware
that a woman is very prone to hemorrhage at the point the
oxytocin (Pitocin) is discontinued because this is the first time
her uterus is asked to maintain contraction on its own.
Remember, a minimal but continued change in vital signs (e.g.,
pulse steadily increasing, blood pressure steadily declining) is as
ominous a sign of hemorrhage, as is a sudden alteration in
thesemeasurements. Notify a primary care provider of any
changes in vital signs that might
indicate hemorrhage so that prompt action can be taken. A
woman who has had either spinal or epidural anesthesia usually
will not experience pain on uterine palpation until the anesthesia
has worn off in approximately 4 to 24 hours. Therefore, uterine
palpation should not increase her pain. Once the effect of the
anesthesia or analgesia has decreased, palpate gently enough to
not cause increased pain but thoroughly enough to determine
uterine consistency. At the same time you assess a woman’s
uterus for firmness, assess the remainder of her abdomen for
softness. A hard, “guarded” abdomen is one of the first signs of
peritonitis (i.e., peritoneal infection), a complication that may
occur with any abdominal surgical procedure.
Nursing Diagnosis: Risk for deficient fluid volume related to
postsurgical fluid restriction
Outcome Evaluation: Patient’s urine specific gravity remains
between 1.003 and weight loss is not more than 5 to 10 lb; fluid
intake equals 2 to 3 L/day.
Adequate fluid intake is important after surgery to replace blood
loss from surgery and to maintain blood pressure and renal
function. Because the intestine is handled during surgery, it takes
approximately 24 to 48 hours before full peristaltic function is
restored and oral intake is possible. It’s important IV fluids be
infused during this time at a rate that is not too rapid (which
could lead to cardiac overload) or too slow (which could lead to
inadequate circulatory compensation). Keep an accurate intake
and output record for at least the first 24 hours to be certain an
adequate fluid balance has been achieved.
Women are kept nothing by mouth (NPO) for a time after
surgery until intestinal peristalsis has returned. To establish this
is returning, assess a woman’s abdomen at least once every 8
hours for bowel sounds, such as small “pinging” sounds heard
on auscultation at a rate of 5 to 10 per minute, as these
demonstrate air and fluid are moving through the intestines.
Passage of flatus is another indication that intestinal function is
again becoming active. As soon as these signs are present, IV
fluid therapy is usually discontinued and the woman is allowed
sips of fluid. After she begins oral intake, wait 1 hour before
removing the IV line. Waiting ensures a woman is not
experiencing nausea and vomiting, which might require
restarting IV therapy.
Introduce oral fluid slowly (e.g., ice chips for the first hour, then
sips of clear fluid such as ginger ale, Jell-O, tea, or flavored
frozen ice). Gradually advance her diet to a soft and then a
regular diet as prescribed. Teach women to continue to drink
large quantities of fluid after they return home (at least six
glasses daily), so they have adequate body fluid to make
breastfeeding successful.
Nursing Diagnosis: Constipation related to effects of
abdominal surgery and anesthesia
Outcome Evaluation: Woman voices she has a bowel movement
every 2 to 3 days or her usual pattern.
Carefully note the time of a woman’s first bowel movement
following surgery. If she has had no bowel movement by the
time of hospital discharge, her primary care provider may
prescribe a stool softener, a suppository, or an enema to facilitate
stool evacuation. You can reassure a woman who is not
receiving much food yet that it is normal not to have bowel
movements for 3 or 4 days postoperatively. Keep women’s water
pitchers full to remind them to drink fluids. Urge them to eat a
diet high in roughage and fluid and to attempt to move their
bowels at least every other day to avoid constipation after they
return home. Some women may need a stool softener prescribed
to manage this because incisional pain interferes with their
ability to use their abdominal muscles effectively. Caution them
not to strain to pass stools because this puts pressure on their
incision.
Nursing Diagnosis: Risk for impaired urinary elimination
related to surgical procedure
Outcome Evaluation: Urinary output is more than 30 ml/hr;
patient reports no pain, frequency, burning, or hesitancy on
voiding.
Voiding after surgery provides evidence the woman has
adequate renal and circulatory function because the kidneys must
have adequate blood flow through them to function. Because the
bladder was handled and displaced during surgery, its tone or
ability to sense filling may be inadequate to initiate voiding for
the first day postsurgery. For this reason, the indwelling catheter
placed before surgery is usually left in place for 4 to 24 hours to
ensure good urine drainage. Assess that the catheter is draining;
a postpartal woman has a urine output of 3,000 to 5,000 ml per
24 hours, so bladder distention can occur rapidly if the catheter
becomes blocked. Before catheter removal, a urine culture may
be requested to check for the possibility of a urinary tract
infection. After removal of the catheter, the average woman will
void in 4 to 8 more hours. Assess for bladder filling at the end of
this time by palpation, pressing lightly over the symphysis pubis
to assess fullness (Fig. 24.8A), and by percussion. On percussion,
an empty bladder sounds dull; a full bladder, resonant; and an
extended bladder, hyperresonant (Fig. 24.8B). If a bladder has
filled to capacity but cannot empty properly or if the woman is
voiding 30 to 60 ml of urine every 15 to 20 minutes, she may
have retention with overflow. This voiding pattern is potentially
dangerous because it means the woman’s bladder is held
continuously under tension. This can result in permanent bladder
damage if the condition goes undetected. In addition, the
constantly full bladder may prevent the uterus from contracting,
possibly increasing the risk of postpartal hemorrhage. The
woman will need to be catheterized or the urinary catheter to be
replaced to avoid these concerns.
To help a woman void, suggest she take her prescribed analgesic
to help relax abdominal musculature. In addition, assist the
woman to walk to the bathroom at least every 2 hours and
provide privacy. Other measures that might be effective include
pouring warm water over her vulva (measure the amount of
water used, so that it can be differentiated from urine) or running
water from a tap within hearing distance. Teach women to
continue to drink adequate fluid (at least five to six glasses daily)
to ensure an adequate fluid output and to help prevent urinary
tract infection after they return home. Be certain they know to
telephone their primary care provider if they should develop
symptoms of a urinary tract infection, such as pain with or
frequency of voiding or blood in urine.
Nursing Diagnosis: Risk for ineffective peripheral tissue
perfusion related to immobility during and after surgery
Outcome Evaluation: Capillary refill is less than 5 seconds; there
is absence of calf pain, redness, edema, or areas of warmth on
lower extremities.
Because a woman’s abdominal muscles are lax from the
stretching that occurred during pregnancy, abdominal contents
tend to shift forward and put pressure on the suture line when
she is sitting or standing, causing pain and an uncomfortable
feelingoften described as “everything falling out.” A woman
usually feels more comfortable turning and sitting up if she
supports her abdomen with one hand or splints the incision with
a pillow. Leg exercises such as flexing and extending her knees
and early ambulation are a woman’s best safeguards against
lower extremity circulatory problems. SCDs may be prescribed
to help promote venous return and prevent venous stasis. Always
allow a woman to sit on the edge of her bed for a few minutes
before helping her to a standing position to prevent orthostatic
hypotension (i.e., sudden low blood pressure that occurs with
sudden position changes). Assessing that a woman’s blood
pressure is adequate before she gets out of bed for the first time
is an additional safeguard. Before ambulation, also assess the
lower extremities for pain in the calf on dorsiflexion of the foot
(i.e., Homans sign, which may or may not be reliable) or for pain,
edema, warmth, or redness in the calf, to detect the possibility of
a thrombus. It is dangerous for a woman to ambulate if signs of a
thrombus are present. A thrombus could shift, becoming an
embolus, a potentially lethal situation. Often, it is difficult for
women to understand the importance of turning and ambulating
as soon as possible after surgery (Fig. 24.9). Still experiencing
the “taking in” postpartal phase, they may prefer to spend their
first days after surgery just resting quietly in bed. Encourage
women to use adequate analgesia during this time, so they can
move and ambulate with the least amount of pain. Reinforce the
need for continued activity balanced with rest after discharge. Be
certain a woman understands the signs and symptoms of
complications, such as thrombophlebitis.
Nursing Diagnosis: Risk for impaired parenting related to
the emergent nature of birth or discomfort from surgery
Outcome Evaluation: Parents hold and feed child and voice
positive comments about the infant.
When a cesarean birth is unscheduled, a woman does not have
much preoperative time to think about how she will feel after
surgery. Most women are surprised to realize not only how well
they feel overall but also how quickly they become fatigued and
how painful a simple surgical incision can be. Encourage women
to breastfeed, although this causes temporary uterine pain as the
uterus contracts with breastfeeding. If the woman’s baby was
born with a complication or has been placed in an intensive care
nursery or transferred to a distant hospital for tertiary care, a
woman’s postpartal course can be difficult, because she
experiences a sense of loss in addition to the pain and fatigue of
surgery. Depression, which can slow all body functions and
certainly her ability to “take hold” in the postpartal period, can
occur. Unless her baby was transferred to another site, be certain
to provide her with ample time to hold and feed her child; assist
her to visit in the hospital’s high-risk nursery if needed. The
average woman can breastfeed satisfactorily after a cesarean
birth. She may have some reason to think her baby is not quite
perfect—after all, the baby was not born “perfectly”—so she
may need additional time to inspect her baby and feel
comfortable with him or her
Nursing Diagnosis: Fatigue related to effects of surgery
Outcome Evaluation: Patient states she is pleased with level of
self-care; ambulates well by 24 hours, and sleeps restfully at
night.
Although a woman needs activity and movement after surgery,
she also needs adequate rest. Many women attempt to handle
their own and their newborn’s needs immediately after surgery
because their excitement over their baby and their new role as a
mother makes them unaware of their underlying fatigue.
However, extreme fatigue interferes with healing and possibly
increases the risk of infection. A woman can notice increased
uterine bleeding leading to excessive loss of fluid and iron stores
and, eventually, interfere with bonding. Help a woman plan a
day, therefore, that includes care of her new child as well as
periods of rest for herself. Be certain she has adequate analgesic
medication at bedtime to allow her to be pain free for the night.
Provide a space of time in the middle of the morning and again
in the afternoon for uninterrupted rest while she’s still in the
hospital. Explore her plans for care at home to be certain her
plans for rest seem realistic for a postsurgical/postpartal woman
Once she returns home, rest is often best accomplished if it is
scheduled for every time her newborn sleeps.
B. HIGH RISK POSTPARTUM CLIENT
 Late Post Partum Hemorrhage
1. Post Partum Hemmorrhage
Secondary or late postpartum hemorrhage occurs 24 hours to 12
weeks postpartum.
Hemorrhage, one of the primary causes of maternal mortality
associated with childbearing, is a major threat during pregnancy,
throughout labor, and continuing into the postpartum period.
Traditionally, postpartum hemorrhage is defined as blood loss of
500 ml or more following a vaginal birth; this occurs in as many
as 5% to 15% of postpartal women With a cesarean birth,
hemorrhage is present when there is a 1,000-ml blood loss or a
10% decrease in the hematocrit level. Although hemorrhage may
occur either early (within the first 24 hours following birth) or
late (from 24 hours to 6 weeks after birth), the greatest danger is
in the first 24 hours because of the grossly denuded and
unprotected uterine area left after detachment of the placenta.
The four main reasons for postpartum hemorrhage are uterine
atony, trauma (lacerations, hematomas, uterine inversion, or
uterine rupture), retained placental fragments, and the
development of disseminated intravascular coagulation (DIC).
These causes are generally referred to as the four T’s of
postpartum hemorrhage: tone, trauma, tissue, and thrombin—a
common mnemonic for the etiology of hemorrhage experienced
in the puerperium.
 Early Post Partum Hemorrhage
Early Postpartum Hemorrhage (EPH) is one of the leading
causes of postpartum mortality. It is defined as blood loss of at
least 500 mL after vaginal or 1000 mL following cesarean
delivery within 24 hours postpartum
 Hypovolemic Shock
Vaginal bleeding during pregnancy is always a deviation from
the normal, is always potentially serious, may occur at any point
during pregnancy, and is always frightening. It must always be
carefully investigated because it can impair both the outcome of
the pregnancy and the woman’s health or life. The primary
causes of bleeding during pregnancy are summarize.
Although vaginal bleeding may be innocent, any degree of this
during pregnancy is a potential emergency because it may mean
the placenta has loosened and cut off nourishment to the fetus.
Also, the amount of blood visualized may be only a fraction of
the blood actually being lost because an undilated cervix and
intact membranes contain blood within the uterus. A woman
with any degree of bleeding, therefore, needs to be evaluated for
the possibility she is experiencing a significant blood loss or is
developing hypovolemic shock. The process of shock due to
blood loss is shown in Figure 21.1. Because the uterus is a
nonessential body organ, danger to the fetal blood supply occurs
when a woman’s body begins to decrease blood flow to
peripheral organs (although the increased blood volume of
pregnancy allows more than normal blood loss before
hypovolemic shock processes begin). Signs of hypovolemic
shock (Table 21.2) occur when 10% of blood volume, or
approximately 2 units of blood, have been lost; fetal distress
occurs when 25% of blood volume is lost (Box 21.2). Because
“normal” blood pressure varies from woman to woman, it is
important to know the baseline blood pressure for a pregnant
woman when evaluating for hypovolemic shock.
2. Thromboembolic Disorders
venous thrombosis that repeatedly occurs in normal veins. It may
indicate a serious underlying disorder, such as cancer of an
internal organ. When migratory phlebitis and cancer of an
internal organ occur together, the disorder is called Trousseau
syndrome.
Phlebitis is inflammation of the lining of a blood vessel.
Thrombophlebitis is inflammation with the formation of blood
clots. Thrombophlebitis is classified as either superficial vein
disease (SVD) or deep vein thrombosis (DVT). When either type
occurs in the postpartum period, it tends to occur because:
• A woman’s fibrinogen level is still elevated from pregnancy,
leading to increased
blood clotting.
• Dilatation of lower extremity veins is still present as a result of
pressure of the
fetal head during pregnancy and birth so blood circulation is
sluggish.
It tends to occur most often in women who:
• Are relatively inactive in labor and during the early puerperium
because this
increases the risk of blood clot formation
• Have spent prolonged time in a birthing room with their legs
positioned in
stirrups
• Have preexistent obesity and a pregnancy weight gain greater
than the
recommended weight gain, which can lead to inactivity and lack
of exercise
• Have preexisting varicose veins
• Develop a postpartal infection
• Have a history of a previous thrombophlebitis
• Are older than age 35 years or have increased parity
• Have a high incidence of thrombophlebitis in their family
• Smoke cigarettes because nicotine causes vasoconstriction and
reduces blood
flow
 Superficial Venous Thrombosis
Superficial venous thrombosis most often affects the superficial
veins (veins located just under the skin) in the legs but may also
affect superficial veins in the groin or in the arms. Superficial
venous thrombosis in the arms usually results from having an IV.
Superficial venous thrombosis in the legs usually results
from varicose veins. However, most people with varicose veins
do not develop blood clots (thrombosis).
Even a slight injury can cause a varicose vein to become
inflamed (phlebitis). Unlike deep vein thrombosis, which causes
very little inflammation, superficial venous thrombosis involves
a sudden (acute) inflammatory reaction that causes the blood cot
(thrombus) to adhere firmly to the vein wall and lessens the
likelihood that it will break loose. Unlike deep veins, superficial
veins have no surrounding muscles to squeeze and dislodge a
blood clot. For these reasons, superficial venous thrombosis
rarely causes a blood clot to break loose (embolism).
Migratory phlebitis or migratory thrombophlebitis is superficial
Symptoms of Superficial Venous Thrombosis
Pain and swelling develop rapidly in the area of inflammation.
The skin over the vein becomes red, and the area feels warm and
is very tender. Because blood in the vein is clotted, the vein feels
like a hard cord under the skin, not soft like a normal or varicose
vein. The vein may feel hard along its entire length.
Diagnosis of Superficial Venous Thrombosis
Doctors recognize superficial venous thrombosis by its
appearance. Tests are not usually needed, although if people
have superficial venous thrombosis above the knee that
developed suddenly and not in an area of varicose veins, doctors
often do ultrasonography to see if there is a blood clot in the
deep veins.
Treatment of Superficial Venous Thrombosis
Warm compresses and analgesics for pain relief. Most often,
superficial venous thrombosis subsides by itself. Applying warm
compresses and taking an analgesic, such as aspirin or
another nonsteroidal anti-inflammatory drug (NSAID), usually
help relieve the pain. Although the inflammation generally
subsides in a matter of days, several weeks may pass before the
lumps and tenderness subside completely. Sometimes people
who have very extensive superficial venous thrombosis are also
given heparin or a different anticoagulant to help limit the
blood's clotting.
 Deep Vein Thrombosis
Deep vein thrombosis (DVT) is a medical condition that occurs
when a blood clot forms in a deep vein. These clots usually
develop in the lower leg, thigh, or pelvis, but they can also occur
in the arm. It is important to know about DVT because it can
happen to anybody and can cause serious illness, disability, and
in some cases, death. The good news is that DVT is preventable
and treatable if discovered early
Complications of DVT
The most serious complication of DVT happens when a part of
the clot breaks off and travels through the bloodstream to the
lungs, causing a blockage called pulmonary embolism (PE). If
the clot is small, and with appropriate treatment, people can
recover from PE. However, there could be some damage to the
lungs. If the clot is large, it can stop blood from reaching the
lungs and is fatal.In addition, one-third to one-half of people
who have a DVT will have long-term complications caused by
the damage the clot does to the valves in the vein called postthrombotic syndrome (PTS). People with PTS have symptoms
such as swelling, pain, discoloration, and in severe cases, scaling
or ulcers in the affected part of the body. In some cases, the
symptoms can be so severe that a person becomes disabled.For
some people, DVT and PE can become a chronic illness; about
30% of people who have had a DVT or PE are at risk for another
episode.
Risk Factors of DVT
Almost anyone can have a DVT. However, certain factors can
increase the chance of having this condition. The chance
increases even more for someone who has more than one of
these factors at the same time.
Following is a list of factors that increase the risk of developing
DVT:



Injury to a vein, often caused by:
o Fractures,
o Severe muscle injury, or
o Major surgery (particularly involving the
abdomen, pelvis, hip, or legs).
Slow blood flow, often caused by:
o Confinement to bed
(e.g., due to a medical condition or after surgery);
o Limited movement (e.g., a cast on a leg to help
heal an injured bone);
o Sitting for a long time, especially with crossed
legs; or
o Paralysis.
Increased estrogen, often caused by:





Birth control pills
Hormone replacement therapy, sometimes
used after menopause
Pregnancy, for up to 3 months after giving
birth
Certain chronic medical illnesses, such as:
o Heart disease
o Lung disease
o Cancer and its treatment
o Inflammatory bowel disease (Crohn’s disease or
ulcerative colitis)
Other factors that increase the risk of DVT include:
o Previous DVT or PE
o Family history of DVT or PE
o Age (risk increases as age increases)
o Obesity
o A catheter located in a central vein
o Inherited clotting disorders
 Raising and lowering your toes while keeping your heels on
the floor
 Tightening and releasing your leg muscles
 Wear loose-fitting clothes.
 You can reduce your risk by maintaining a healthy weight,
avoiding a sedentary lifestyle, and following your doctor’s
recommendations based on your individual risk factors.
Sympoms of DVT
About half of people with DVT have no symptoms at all. The
following are the most common symptoms of DVT that occur in
the affected part of the body:




Swelling
Pain
Tenderness
Redness of the skin
 Pulmonary Embolism
A pulmonary embolus is obstruction of the pulmonary artery by
a blood clot; it usually occurs as a complication of
thrombophlebitis when a blood clot moves from a leg vein to the
pulmonary artery. The signs of pulmonary embolus are sudden,
sharp chest pain; tachypnea; tachycardia; orthopnea (inability to
breathe except in an upright position); and cyanosis (the blood
clot is blocking both blood flow to the lungs and return to the
heart). This is an emergency. A woman needs oxygen
administered immediately and is at high risk for
cardiopulmonary arrest. Her condition is extremely guarded until
the clot can be lysed or adheres to the pulmonary artery wall and
is reabsorbed. Because of the seriousness of this condition, a
woman with a pulmonary embolism commonly is transferred to
an intensive care unit for continuing care.
3. Peurperal Infection
Infection of the reproductive tract in the postpartal period is
another major cause of maternal mortality (Galvão, Braga,
Gonçalves, et . Factors that predispose women to infection
during this time are shown in Box 25.5. When caring for a
woman who has any of these circumstances, be aware that the
risk for postpartal infection is greatly increased.
Prevention of DVT
The following tips can help prevent DVT:
 Move around as soon as possible after having been confined
to bed, such as after surgery, illness, or injury.
 If you’re at risk for DVT, talk to your doctor about:
 Graduated compression stockings (sometimes called
“medical compression stockings”)
 Medication (anticoagulants) to prevent DVT.
 When sitting for long periods of time, such as when
traveling for more than four hours:
 Get up and walk around every 1 to 2 hours.
 Exercise your legs while you’re sitting by:
 Raising and lowering your heels while keeping your toes on
the floor
Theoretically, the uterus is sterile during pregnancy and up until
the membranes rupture. After rupture, pathogens can begin to
invade; the risk of infection grows even greater if tissue edema
and trauma are present. If infection should occur, the prognosis
for complete recovery depends on such factors as the woman’s
general health, virulenceof the invading organism and portal of
entry, the degree of uterine involution at the time of the invasion,
and the presence of lacerations in the reproductive tract.
A puerperal infection is always potentially serious, because,
although it usually begins as only a local infection, it has the
potential to spread to the peritoneum (peritonitis) or the
circulatory system (septicemia), conditions that can be fatal in a
woman whose body is already stressed from childbirth.
Organisms commonly cultured postpartally include group B
C. NURSING CARE AT RISK/HIGH RISK/ SICK CLIENT
NEW BORN
streptococci, staphylococci, and aerobic gram-negative bacilli
such as Escherichia coli. The management for puerperal
infection focuses on the use of an appropriate antibiotic after
culture and sensitivity testing of the isolated organism
Box 26.3 summarizes factors associated with preterm birth.
1. Problems related to maturity
 Prematurity
A preterm infant is traditionally defined as a live-born infant
born before the end of week 37 of gestation. In terms of the
degree of care needed, they are further divided into late preterm
(born between 34 and 37 weeks) and early preterm (born
between 24 and 34 weeks). Neonatal assessments such as
inspection for sole creases, skull firmness, ear cartilage, and
neurologic development plus the mother’s report of the date of
her last menstrual period along with a sonographic estimation of
age all can be helpful to determine gestational age. Preterm birth
occurs in approximately 11% of live births worldwide, with the
United States having one of the highest rates of preterm births
Most preterm infants need intensive care from the moment of
birth to give them their best chance of survival without
neurologic aftereffects because they are more prone than others
to hypoglycemia and intracranial hemorrhage. Lack of lung
surfactant, because this does not form until about the 34th week
of pregnancy, makes them extremely vulnerable to respiratory
distress syndrome
No matter what their weight, the initial assessment needs to
differentiate healthy preterm babies from SGA babies (who also
may have a low birth weight but have more possibility of being
unhealthy and so require more help to adjust to extrauterine life).
In contrast to an SGA infant, a preterm infant appears immature
and has a low birth weight but is well proportioned for age
because the baby appears to have been doing well in utero. For
an unexplained reason, however, the trigger that initiates labor
was activated too early and birth resulted even though the baby
was not yet mature. Characteristics of SGA and preterm infants
are compared in Table 26.1
Important among these is a high correlation between low
socioeconomic level and early birth. In women from middle and
upper socioeconomic groups, for example, only 4% to 8% of
pregnancies are not carried to term. In women from low
socioeconomic levels, as many as 10% to 20% end before term
(Joseph, Fahey, Shankardass, et al., 2014). Risk factors
associated with preterm birth include inadequate nutrition and
smoking or alcohol use. The increasing use of assisted fertility
methods that result in multiple births, such as in vitro
fertilization, is another reason preterm births can occur because
more multiple pregnancies result in preterm birth than term
pregnancies.Iatrogenic (health-care–caused) issues, such as
elective cesarean birth or inducing labor before 39 weeks of
pregnancy (which is not recommended but sometimes necessary
because of maternal illness or fetal reasons), also result in early
births.
Assessment
Although a detailed pregnancy history may sometimes reveal the
reason for a preterm birth, the pregnancy history is often normal
up to the beginning of labor. When interviewing parents of a
preterm infant, be careful not to convey disapproval of reported
pregnancy behaviors such as cigarette smoking that may have
contributed to preterm birth. Once an infant is born, a new
mother needs a high level of self-esteem and all of her inner
resources to sustain her through this crisis and not be burdened
by guilt over what should or could have been. An accurate but
comforting answer to a direct inquiry about why preterm birth
occurs is, “No one really knows what causes prematurity.”
Etiology
At least 50% of neonatal deaths are preterm (. Infant mortality
could be reduced dramatically if the causes of preterm birth
could be discovered and corrected and all pregnancies could be
brought to term. However, even with the examples of possible
causes listed in the following, the exact cause of premature labor
and early birth is rarely exactly known.
Observing a number of physical findings and reflex testing is
used to differentiate between term and preterm newborns at birth
(Figs. 26.6 and 26.7). On gross inspection, a preterm infant’s
head appears disproportionately large (≥3 cm greater than chest
size). The skin is generally unusually ruddy because there is so
little subcutaneous fat beneath it, making veins easily noticeable;
a high degree of acrocyanosis may be present. Newborns
delivered at greater than 28 weeks of gestation are typically
covered with vernix caseosa. In very preterm newborns, however
(less than 28 weeks of gestation), the vernix will be lacking.
Lanugo is usually scant the same way in very low gestation
infants but will be extensive, covering the back, forearms,
forehead, and sides of the face in late preterm babies. Both
anterior and posterior fontanelles will be small. There are few or
no creases on the soles of the feet
The eyes of most preterm infants appear small in relation to term
infants. Although difficult to elicit, a pupillary reaction is present.
An ophthalmoscopic examination is extremely difficult and
often uninformative because the vitreous humor may be hazy. A
preterm infant has varying degrees of myopia (nearsightedness)
because of a lack of eye globe depth.
The ears appear large in relation to the head. The cartilage of the
ear is immature and allows the pinna to fall forward. The level of
the ears should be carefully inspected to rule out chromosomal
abnormalities (see Chapter 8). Neurologic function in the
preterm infant is often difficult to evaluate because the
neurologic system is still immature. Observing the infant make
spontaneous or provoked muscle movements can be as important
as formal reflex testing. If they are tested, reflexes such as
sucking with coordinated swallowing and breathing will be
absent if an infant’s age is below 33 weeks; deep tendon reflexes
such as the Achilles tendon reflex will also be markedly
diminished. During an examination, a preterm infant is much
less active than a mature infant and rarely cries. If the infant
does cry, the cry is weak and high pitched.
2. Problems related to Gestational age
 Small Gestational Age
An infant is SGA (also called microsomia) if the birth weight is
below the 10th percentile on an intrauterine growth curve for
that age.
Such infants may be born:
• Preterm: before week 38 of gestation
• Term: between weeks 38 and 42
• Postterm: past 42 weeks
SGA infants are small for their age because they have
experienced intrauterine growth restriction (IUGR) or failed to
grow at the expected rate in utero. This characteristic makes
them distinctly different from infants who are born with a less
weight than usual but their low weight is consistent for their
gestational age.
 Postmaturity
Etiology
A postterm infant is one born after the 41st week of a pregnancy .
Infants who stay in utero past week 41 are at special risk because
a placenta appears to function effectively for only 40 weeks.
After that time, it seems to lose its ability to carry nutrients
effectively to the fetus, and the fetus begins to lose weight
(postterm syndrome). Infants with this syndrome demonstrate
many of the characteristics of the SGA infant: dry, cracked,
almost leatherlike skin from lack of fluid, and an absence of
vernix. They may be SGA, and the amount of amniotic fluid
surrounding them may be less at birth than usual and it may be
meconium stained. Fingernails will have grown well beyond the
end of the fingertips. Because they are older than a term infant,
they may demonstrate an alertness much more like a 2-week-old
baby than a newborn.
A woman’s nutrition during pregnancy plays a major role in fetal
growth, so a lack of adequate nutrition may be a major
contributor to IUGR. Adolescents are prone to having a high
incidence of SGA infants because if they eat only enough to
meet their own nutritional and growth needs, the needs of a
growing fetus can be compromised. In still other instances, the
placental supply of nutrients is adequate but an infant cannot use
them because of a chromosomal abnormality or an intrauterine
infection such as rubella or toxoplasmosis. Even in light of these
nutritional influences, the most common cause of IUGR is a
placental issue: either the placenta did not obtain sufficient
nutrients from the uterine arteries or it was inefficient at
transporting nutrients to the fetus. Placental underdevelopment
or damage, such as partial placental separation with bleeding is
an example of a situation that would limit placental function
because the area of placenta that separated infarcted and fibrosed,
reducing the placental surface available for nutrient exchange.
Women with systemic diseases that decrease blood flow to the
placenta, such as severe diabetes mellitus or gestational
hypertension (diseases in which blood vessel lumens are
narrowed), are at higher risk for birthing SGA babies than others.
Women who smoke heavily or use opiates also tend to have
SGA infants
When a pregnancy becomes postterm, a sonogram is usually
obtained to measure the biparietal diameter of the fetus. A
nonstress test or complete biophysical profile may be done to
establish whether the placenta is still functioning adequately. A
cesarean birth may be indicated if a nonstress test reveals that
compromised placental functioning is apt to occur during labor.
At birth, the postterm baby is likely to have difficulty
establishing respirations, especially if meconium aspiration
occurred. Polycythemia may have developed from decreased
oxygenation in the final weeks. The hematocrit may be elevated
because polycythemia and dehydration have lowered the
circulating plasma level. In the first hours of life, hypoglycemia
may develop because the fetus had to use stores of glycogen for
nourishment in the last weeks of intrauterine life. Subcutaneous
fat levels may also be low, having been used in utero. This loss
of fat can make temperature regulation difficult, making it
important to prevent a postterm infant from becoming chilled at
birth or during transport.
Any woman is anxious when she does not have her baby on her
due date. She is apt to become extremely anxious and perhaps
angry when it is determined her baby is postterm. It seems that,
if her baby stayed so long in utero under her protection, the
baby should be extra healthy and strong. Why, then, she asks, is
her baby being transferred for special care? The mother may also
feel guilty for not providing well for her infant in the last few
weeks of the pregnancy.
Make certain a woman spends enough time with her newborn to
assure herself that although birth did not occur at the predicted
time, the baby should do well with appropriate interventions to
control possible hypoglycemia or meconium aspiration. All
postterm infants need follow-up care until at least school age to
track their developmental abilities because the lack of nutrients
and oxygen in utero may have left them with neurologic
symptoms that will not become apparent until they attempt finemotor tasks
Assessment
The SGA infant may be detected in utero when fundal height
during pregnancy becomes progressively less than expected.
However, if a woman is unsure of the date of her last menstrual
period, this discrepancy can be hard to substantiate; a sonogram
can then demonstrate the decreased size. A biophysical profile
including a nonstress test, placental grading, amniotic fluid
amount, and an ultrasound examination documents additional
information on placental function and fetal growth. If poor
placental function is apparent from such determinations, it can
be predicted that the infant will do poorly during labor during
the periods of relative hypoxia, which occur during contractions.
Cesarean birth, therefore, is the birth method of choice in such
circumstances.
Appearance
Generally, an infant who suffers nutritional deprivation early in
pregnancy, when fetal growth consists primarily of an increase
in the number of body cells, is below average in weight, length,
and head circumference. An infant who suffers deprivation late
in pregnancy, when growth consists primarily of an increase in
cell size, may have only a reduction in weight. Regardless of
when deprivation occurs, the infant tends to have an overall
wasted appearance. The infant may have poor skin turgor and
generally appears to have a large head because the rest of the
body is so small. Skull sutures may be widely separated. Hair
may be dull and lusterless. The infant may have a small liver,
which can cause difficulty regulating glucose, protein, and
bilirubin levels after birth. The abdomen may be sunken. The
umbilical cord often appears dry and may be stained yellow. In
contrast, because an infant’s age is more advanced than the
weight implies, an infant may have better developed neurologic
responses, sole creases, and ear cartilage than expected for a
baby of that weight. The infant may also seem unusually alert
and active. As a first assessment, the SGA infant needs to be
examined carefully for possible congenital anomalies that
occurred because of the poor nutritional intrauterine
environment.
Laboratory Findings
Blood studies at birth usually show a high hematocrit level (less
than normal amounts of plasma in proportion to red blood cells
are present because of a lack of fluid) and an increase in the total
number of red blood cells (polycythemia). The increase in red
blood cells occurs because anoxia during intrauterine life
stimulated excess development of them. An immediate effect of
polycythemia is to cause increased blood viscosity, a condition
that puts extra work on the infant’s heart because it is more
difficult to effectively circulate thick blood. As a consequence,
acrocyanosis (blueness of the hands and feet) may be prolonged
and persistently more marked than usual. If the polycythemia is
extreme, vessels may actually become blocked and thrombus
formation can result. If the hematocrit level is more than 65% to
70%, an exchange transfusion to dilute the blood may be
necessary. A second problem of polycythemia is
hyperbilirubinemia because so many extra red blood cells break
down and release bilirubin. Because SGA infants have decreased
glycogen stores, still another common problem that develops is
hypoglycemia (decreased blood glucose, or a level below 45
mg/dl). Such infants may need intravenous glucose to sustain
blood sugar until they are able to suck vigorously enough to take
sufficient oral feedings.
 Large Gestational Age
An infant is LGA (also termed macrosomia) if the birth weight is
above the 90th percentile on an intrauterine growth chart for that
gestational age. Such a baby appears deceptively healthy at birth
because of the weight, but a gestational age examination often
reveals immature development. It is important that LGA infants
be identified immediately so they can be given care appropriate
to their gestational age rather than being treated as term
newborns
Etiology
Infants who are LGA have been subjected to an overproduction
of nutrients and growth hormone in utero. This happens most
often to infants of women who are obese or who have diabetes
mellitus. Multiparous women may also have large babiesbecause
with each succeeding pregnancy, babies tend to grow larger.
Beckwith–Wiedemann syndrome, a rare condition characterized
by general body overgrowth and congenital anomalies such as
omphalocele, may also be a cause.
Assessment
A fetus is suspected of being LGA when a woman’s uterus
appears to be unusually large for the date of pregnancy.
Abdominal size can be deceptive, however. Because a fetus lies
in a flexed fetal position, he or she does not occupy significantly
more space at 10 lb than at 7 lb. If a fetus does seem to be
growing at an abnormally rapid rate, a sonogram can confirm the
suspicion. A nonstress test to assess the placenta’s ability to
sustain a large fetus during labor may be prescribed. Lung
maturity may be assessed by amniocentesis. If an infant’s large
size was not detected during pregnancy, it may be first
recognized during labor when the baby appears too large to
descend through the pelvic rim. If this happens, a cesarean birth
may be necessary because shoulder dystocia (the wide fetal
shoulderscannot pass; or needs significant manipulation to pass
through the outlet of the pelvis) would halt vaginal birth at that
point.
Appearance
At birth, LGA infants may show immature reflexes and low
scores on gestational age examinations in relation to their size.
They may have extensive bruising or a birth injury such as a
broken clavicle or Erb–Duchenne paralysis from trauma to the
cervical nerves if they were stressed in order for the wide
shoulders to be born vaginally (see Chapter 51). Because the
head is large, it may have been exposed to more than the usual
amount of pressure during birth, causing a prominent caput
succedaneum, cephalohematoma, or molding. Because LGA
newborn are large but often immature, they require the same
cautious care necessary for a preterm infant.
Cardiovascular Dysfunction
Polycythemia may occur in an LGA fetus as the fetus attempts to
fully oxygenate more than the average amount of body tissue.
Following birth, observe LGA infants closelfor signs of
hyperbilirubinemia that may result from absorption of blood
from bruising and breakdown of the extra red blood cells created
by polycythemia. Assess the infant’s heart rate also. If cyanosis
is present, it may be a sign of poor heart function, but it could
also be from transposition of the great vessels, a serious heart
anomaly associated with macrosomia.
Hypoglycemia
LGA infants also need to be carefully assessed for hypoglycemia
in the early hours of life because large infants require large
amounts of nutritional stores to sustain their weight. If the
mother had diabetes that was poorly controlled (the cause of the
large size), the infant would have had an increased blood glucose
level in utero to match the mother’s glucose level; this caused
the infant to produce elevated levels of insulin. After birth, these
increased insulin levels will continue for up to 24 hours of life,
possibly causing rebound hypoglycemia.
3. Acute conditions of Neonates
 Respiratory Distress Syndrome
Respiratory distress syndrome (RDS) of the newborn, formerly
termed hyaline membrane disease, is most often seen in
newborns born prematurely. Other causes of RDS include
newborns with meconium aspiration syndrome, sepsis, a
newborn who is slow to transition to extrauterine life, and
pneumonia. The pathologic feature of RDS is a hyalinelike
(fibrous) membrane formed from an
exudate of an infant’s blood that begins to line the terminal
bronchioles, alveolar ducts, and alveoli. This membrane prevents
the exchange of oxygen and carbon dioxide at the alveolar–
capillary membrane, interfering with effective oxygenation. The
cause of RDS is a low level or absence of surfactant, the
phospholipid that normally lines the alveoli and reduces surface
tension to keep the alveoli from collapsing on expiration.
Because surfactant does not form until the 34th week of
gestation, as many as 30% of LBW infants and as many as 50%
of VLBW premature infants are susceptible to this complication.
Pathophysiology
High pressure is required to fill the lungs with air for the first
time and overcome the pressure of lung fluid. For example, it
takes a pressure between 40 and 70 cm H2O to inspire a first
breath but only 15 to 20 cm H2O to maintain quiet, continued
breathing. If alveoli collapse with each expiration, as happens
when surfactant is deficient, forceful inspirations requiring
optimum pressure are still required to inflate them. Even very
immature infants release a bolus of surfactant at birth into their
lungs from the stress of birth. However, with deficient surfactant,
areas of hypoinflation begin to occur and pulmonary resistance
increases. Blood then shunts through the foramen ovale and the
ductus arteriosus as it did during fetal life. The lungs become
poorly perfused. As a result, the production of surfactant
decreases even further. The poor oxygen exchange that results
leads to tissue hypoxia, which causes the release of lactic acid.
This, combined with the increasing carbon dioxide level
resulting from the formation of the hyaline membrane on the
alveolar surface, leads to severe acidosis. Acidosis causes
vasoconstriction and decreased pulmonary perfusion from
vasoconstriction, which further limits surfactant production.
With surfactant production almost lost, the ability to stop alveoli
from collapsing with each expiration becomes more and more
difficult. This vicious cycle continues until the oxygen–carbon
dioxide exchange in the alveoli is no longer adequate to sustain
life without ventilator support.
Assessment
Most infants who develop RDS have difficulty initiating
respirations at birth. After resuscitation, they appear to have a
period of hours or a day when they are free of symptoms because
of an initial release of surfactant. During this time, however,
subtle signs may appear, such as:
• Low body temperature
• Nasal flaring
• Sternal and subcostal retractions
• Tachypnea (more than 60 breaths/min)
• Cyanotic mucous membranes
Within several hours, expiratory grunting occurs caused by
closure of the glottis as it tries to increase the pressure in alveoli
on expiration in order to help to keep them from collapsing.
Even with this attempt at better oxygen exchange, however, as
the disease progresses, infants become cyanotic and their Po2
and oxygen saturation levels fall in room air. On auscultation,
there may be fine rales and diminished breath sounds because of
poor air entry. As distress increases, an infant may exhibit:
• Seesaw respirations (on inspiration, the anterior chest wall
retracts and the
abdomen protrudes; on expiration, the sternum rises)
• Heart failure, evidenced by decreased urine output and edema
of the extremities
• Pale gray skin
• Periods of apnea
• Bradycardia
• Pneumothorax
It’s important the infant is tipped to an upright position
following administration and the infant’s airway is not suctioned
for as long as safely possible after administration of surfactant to
help it reach lower lung areas and to avoid suctioning the drug
away. Although there are almost no unfavorable reactions to
surfactant administration, some, such as mucus plugging from
the solution, do occur. An infant who is receiving surfactant and
then is placed on a ventilator needs close observation because
lung expansion can improve so rapidly, the ventilator pressure
becomes too high. Anticipate the need to adjust ventilator
settings to accommodate the vastly improved lung function.
Oxygen Administration
The administration of oxygen is often necessary to maintain
correct Po2 and pH levels following surfactant administration,
and it may be administered in a variety of ways from a simple
cannula or mask, continuous positive airway pressure (CPAP),
or assisted ventilation with positive end-expiratory pressure
(PEEP). The advantage of CPAP or PEEP is that this exerts
pressure on the alveoli at the end of expiration and helps keep
alveoli from collapsing in addition to supplying oxygen. Highfrequency, oscillatory, and jet ventilation are still other methods
of introducing oxygen to infants with noncompliant lungs. These
systems maintain airway pressure and then intermittently “jet” or
oscillate an additional amount of air at a rapid rate (400 to 600
times per minute) to inflate alveoli. A possible complication of
oxygen therapy in the very immature or very ill infant is ROP
(see discussion later in chapter) or bronchopulmonary dysplasia
(BPD) which is also known as chronic lung disease (see Chapter
40).
Ventilation
The diagnosis of RDS is made on the clinical signs of grunting,
central cyanosis in room air, tachypnea, nasal flaring, and
retractions. A chest X-ray will reveal a diffuse pattern of
radiopaque areas that look like ground glass (haziness) in the
lungs. Blood gas studies will reveal respiratory acidosis. A βhemolytic, group B streptococcal infection may mimic RDS
because this infection is so severe in newborns that it stops
surfactant production. Cultures of blood, cerebrospinal fluid, and
skin may be obtained, therefore, to rule out this condition. An
antibiotic (penicillin or ampicillin) and an aminoglycoside
(gentamicin or kanamycin) may be started while culture reports
are pending.
Normally, on a ventilator, inspiration is shorter than expiration,
or there is an inspiratory/expiratory (I/E) ratio of 1:2. It is
difficult to deliver enough oxygen to stiff, noncompliant lungs in
this usual ratio, however, without forcing the air into the lungs at
such a high pressure and rapid rate that a pneumothorax becomes
a constant concern. Infant ventilators are therefore available with
a reversed I/E ratio (2:1). These are pressure cycled to control
the force with which air is delivered. Complications of any type
of ventilation are possible, such as pneumothorax and impaired
cardiac output because of decreased blood flow through the
pulmonary artery from increased lung pressure. There is also a
possible risk of increased intracranial and arterial pressure and
hemorrhage from fluctuating blood pressures. Being certain
infants are not overhydrated is important to help prevent
increased blood pressure and increased pulmonary artery
pressure, which may delay the closure of the ductus arteriosus
and interfere with both heart and lung function.
Therapeutic Management
Additional Therapy: Nitric Oxide
Surfactant Replacement RDS can be largely prevented by the
administration of surfactant at birth for an infant at risk because
of low gestational age (Box 26.7). Immediately after birth,
synthetic surfactant is administered into an endotracheal tube by
a syringe or catheter (lung lavage).
An additional therapy that can help to oxygenate a newborn’s
lungs is the administration of nitric oxide, a potent vascular
dilator. It causes pulmonary vasodilation without decreasing
systemic vascular tone. It combines with hemoglobin in the
intravascular space to form methemoglobin. This causes
systemic vasodilation. The nitric oxide enters the alveoli on
ventilation and redirects the pulmonary blood by dilating the
pulmonary arterioles.
Extracorporeal Membrane Oxygenation
Extracorporeal membrane oxygenation (ECMO) was first
developed as a means of oxygenating blood during cardiac
surgery. Its current use has expanded to include the management
of severe hypoxemia in newborns with illnesses such as
meconium aspiration, RDS, pneumonia, and diaphragmatic
hernia. Formerly used as a mainstay of therapy for RDS, it is
now rarely needed because surfactant lavage is so effective.
Supportive Care
An infant with RDS must be kept warm because cooling
increases acidosis in newborns, and for the newborn with RDS,
acidosis may increase to lethal levels. Keeping an infant warm
also reduces the infant’s metabolic oxygen demand. Provide
hydration and nutrition with intravenous fluids and glucose or
gavage feedings because the respiratory effort makes an infant
too exhausted to suck.
Prevention
RDS rarely occurs in mature infants. Dating a pregnancy by
sonogram and by documenting if the level of lecithin in
surfactant obtained from amniotic fluid exceeds that of
sphingomyelin by a 2:1 ratio are both important ways to be
certain an infant born by cesarean birth or for whom labor is
induced is mature enough that RDS is not likely to occur. Using
a tocolytic agent such as magnesium sulfate can help prevent
preterm birth for a few days. During this time, if a woman
receives two injections of a glucocorticosteroid, such as
betamethasone, it may be possible to prevent RDS in the
newborn because steroids appear to quicken the formation of
lecithin. The administration is most effective when given
between weeks 24 and 34 of pregnancy. Unfortunately, there is
often no warning that preterm birth is imminent until hours
before birth. Because the steroid does not take effect before 24 to
48 hours, some labors and births will progress too rapidly for
this preventive measure to be effective.
 Meconium Aspiration Syndrome
Meconium is present in the fetal bowel as early as 10 weeks of
gestation. If hypoxia occurs, a vagus reflex is stimulated,
resulting in relaxation of the rectal sphincter. This releases
meconium into the amniotic fluid. Babies born breech may expel
meconium into the amniotic fluid from pressure on the buttocks.
In both instances, the appearance of the fluid at birth is green to
greenish black from the staining. Meconium staining occurs in
approximately 10% to 20% of all births; in 2% to 4% of these
births, infants will aspirate enough meconium to cause
meconium aspiration syndrome (MAS). Meconium aspiration
does not tend to occur in ELBW infants because the substance
has not passed far enough in the bowel for it to be at the rectum
in these infants.
An infant may aspirate meconium either in utero or with the first
breath at birth. Meconium can cause severe respiratory distress
(tachypnea, retractions, and grunting). The infant may also
require increased oxygen to maintain saturations in the mid to
upper 90s. This oxygen requirement usually starts in the first
couple hours after birth without any congenital anomalies that
may cause the low oxygen saturations.
Assessment
Infants with meconium-stained amniotic fluid can have difficulty
establishing respirations at birth (those who were not born
breech have had a hypoxic episode in utero to cause the
meconium to be in the amniotic fluid). The Apgar score is apt to
be low. Almost immediately, tachypnea, retractions, and
cyanosis begin. The infant should be placed on the warmer, and
resuscitation should begin including the initiation of positive
pressure ventilation as necessary. After the initiation of
respirations, an infant’s respiratory rate may remain rapid
(tachypnea) and coarse bronchial sounds may be heard on
auscultation. The infant may continue to have retractions
because the inflammation of bronchi tends to trap air in the
alveoli, limiting the entrance of oxygen. This air trapping may
also cause enlargement of the anteroposterior diameter of the
chest (barrel chest). Pulse oximetry or blood gases will reveal
poor gas exchange evidenced by a decreased PO2 and an
increased PCO2. A chest X-ray will show bilateral coarse
infiltrates in the lungs, with spaces of hyperaeration (a peculiar
honeycomb effect). The diaphragm will be pushed downward by
the overexpanded lungs.
Therapeutic Management
Amnioinfusion can be used to dilute the amount of meconium in
the amniotic fluid and has shown to improve the outcomes for
the newborn with meconium in situations where perinatal
observation is limited. The benefits may be related to dilution of
the meconium or having an effect on the oligohydramnios
(Hofmeyr, Xu, & Eke, 2014). If deeply stained amniotic fluid is
identified during labor, the infant may be scheduled for a
cesarean birth. After birth, infants may need to be treated with
oxygen administration and assisted ventilation. Antibiotic
therapy may be prescribed to forestall the development of
pneumonia as a secondary problem. If lung compliance is poor,
surfactant may be administered. If lung noncompliance
continues, this may necessitate high inspiratory pressure.
Unfortunately, this can cause a pneumothorax or
pneumomediastinum (air in the chest cavity). Observe the infant
closely, therefore, for signs of trapping air in the alveoli because
the alveoli can expand only so far and then will rupture, sending
air into the pleural space (pneumothorax). Yet, a further
complication that can occur because of increased pulmonary
resistance is the ductus arteriosus remaining open, causing blood
to shunt from the pulmonary artery into the aorta and
compromising cardiac efficiency and increasing
hypoxia. To detect this, observe an infant closely for signs of
heart failure such as increased heart rate or respiratory distress.
Maintain a temperature-neutral environment to prevent the infant
from having to increase metabolic oxygen demands. A chest
physiotherapy with percussion and vibration may be helpful to
encourage the removal of remnants of meconium from the lungs
(see Chapter 40). Some infants may need to be administered
nitric oxide or maintained on ECMO to ensure adequate
oxygenation
 Sepsis
Newborns are susceptible to infections during pregnancy and at
birth because their ability to produce antibodies is immature. A
number of infections in newborns, such as toxoplasmosis,
rubella, syphilis, and cytomegalovirus infections, spread to the
fetus across the placenta in utero and are discussed in Chapter 12
with other complications of pregnancy. Other infections, such as
those discussed in the following sections, are not contracted in
utero but are contracted from exposure to vaginal secretions at
birth.
β-HEMOLYTIC, GROUP B STREPTOCOCCAL
INFECTION
A serious cause of infection in newborns is the gram-positive βhemolytic, group B streptococcal (GBS) organism, a natural
inhabitant of the female genital tract. Between 50 and 300
infants out of every 1,000 live births display a positive culture
for the organism (AAP, 2011a). It also may be spread from baby
to baby if good hand washing technique is not used in caring for
newborns. If a woman is found to be positive for GBS during
late pregnancy (see Chapter 21), ampicillin administered IV
during pregnancy and again during labor helps to reduce the
possibility of newborn exposure.
Assessment
Universal screening is recommended for pregnant women at 35
to 37 weeks of gestation to see if they have GBS organisms in
their vaginal secretions. Typically, a newborn at risk, such as
one born after prolonged rupture of membranes or if the
woman’s vaginal culture is positive for GBS, will be screened at
birth for infection by a specialized GBS blood culture.
Colonization by GBS can result in either an early-onset or a lateonset illness. With the early-onset form, signs of pneumonia
such as tachypnea, apnea, extreme paleness, hypotension, or
hypotonia become apparent within the first day of life.
Decreased urine output can occur from the hypotension. A chest
X-ray may not be diagnostic because the changes seen are
almost indistinguishable from those of RDS (a ground-glass
appearance). Without therapy, the disease progresses so rapidly,
as many as 20% of infants who contract the infection die within
24 hours of birth. A late-onset type occurs at 2 to 4 weeks of age.
With this, instead of pneumonia being the infection focus,
meningitis tends to occur. Typical signs include lethargy, fever,
loss of appetite, and bulging fontanelles from increased
intracranial pressure. Mortality from the late-onset type is not as
high as that from the early-onset form (15% vs. 20%), but
neurologic consequences can occur in up to 50% of infants who
survive.
Therapeutic Management
If a newborn displays signs of infection or a blood screening test
is positive, antibiotics such as penicillin, cefazolin, clindamycin,
or vancomycin are all effective against the GBS organism.
Parents may have difficulty understanding how their infant could
suddenly have become this ill, and they may need a great deal of
support to care for their infant. This is even more important if
the newborn survives the infection but is left neurologically
challenged. In the future, immunization of all women of
childbearing age against streptococcal B organisms could
decrease the incidence of newborns infected at birth.
OPHTHALMIA NEONATORUM
Ophthalmia neonatorum is an eye infection that occurs at birth or
during the first month of life. The most common causative
organisms are Neisseria gonorrhoeae and Chlamydia trachomatis,
which are contracted from vaginal secretions. An N.
gonorrhoeae infection is an extremely serious form of infection
because, if left untreated, the infection progresses to corneal
ulceration and destruction, resulting in opacity of the cornea and
severe vision impairment.
Assessment
Ophthalmia neonatorum is generally bilateral. The conjunctivae
become fiery red and covered with thick pus. The eyelids appear
edematous. Although this usually occurs on day 1 to day 4 of life,
it should be considered as a possibility when conjunctivitis
occurs in any infant younger than 30 days of age.
Prevention
The prophylactic instillation of erythromycin ointment into the
eyes of newborns prevents both gonococcal and chlamydial
conjunctivitis. In the past, eye prophylaxis was given
immediately after birth so it was never forgotten. Now it is more
customary to delay the administration of the ointment until after
the first reactivity period so the newborn can clearly see the
parents during this important attachment period. This makes it
easy for administration to be forgotten, so use some type of a
checklist as a reminder of this important prophylaxis. Infants
born outside the hospital also need prophylaxis to prevent
ophthalmia neonatorum, the same as for infants born in a
birthing room.
Therapeutic Management
If conjunctivitis occurs, therapy is individualized depending on
the organism cultured from the exudate. If gonococci are
identified, intravenous ceftriaxone (Rocephin) and penicillin are
effective drugs. If Chlamydia is identified, an ophthalmic
solution of erythromycin is commonly used. Use standard and
contact infection precautions when caring for this newborn. In
addition to systemic antibiotic therapy, sterile saline solution
lavage to clear the copious discharge from the eyes may be
prescribed. When irrigating eyes, use a sterile medicine dropper
or bulb syringe and use barrier protection, including goggles to
avoid splashing any solution into your own eye. The solution
should be at room temperature. Direct the stream of the
irrigation fluid laterally so it does not enter and contaminate the
other eye. The mother of the infected infant needs treatment for
gonorrhea or chlamydia before fallopian tube sterility or pelvic
inflammatory disease can result. Sexual contacts of the mother
should be treated also so the spread of the disease can be halted.
With either infection, parents can be assured with early diagnosis
and treatment that the prognosis for normal eyesight in their
child is good.
HEPATITIS B VIRUS INFECTION
Hepatitis B virus (HBV) can be transmitted to the newborn
through contact with infected vaginal blood at birth when the
mother is positive for the virus (positive for the surface antigen
of the hepatitis B virus [HBsAg+]). Hepatitis B is a destructive
illness with greater than 90% of infected infants becoming
chronic carriers of the virus as well as the risk of developing
liver cancer later in life (Ni, 2011). To reduce the possibility of
HBsAg being spread to newborns in the future, parents are asked
if they would like their infant vaccinated against hepatitis B at
birth (Kurosky, Davis, & Krishnarajah, 2016). If the mother is
identified as HBsAg+, her infant should be bathed as soon as
possible after birth to remove HBV-infected blood and
secretions. Gentle suctioning is necessary to avoid trauma to the
mucous membrane, which could allow HBV invasion. To further
protect against infection, the infant is administered serum
hepatitis B immune globulin (HBIG) in addition to the HBV
vaccination. Although the virus is transmitted in breast milk,
once immune globulin has been administered, women may
breastfeed without risk to an infant. Hepatitis B is further
discussed in Chapter 45 because it shares common symptoms
with other liver disorders and also occurs in older children.
GENERALIZED HERPESVIRUS INFECTION
A herpes simplex virus type 2 (HSV-2) infection, which is most
prevalent among women with multiple sexual partners, can be
contracted by a fetus across the placenta if the mother has a
primary infection during pregnancy. More often, however, the
virus is contracted from the vaginal secretions of a mother who
has active herpetic vulvovaginitis at the time of birth. Between
15% and 30% of women of childbearing age demonstrate
antibodies to this virus or have the potential to have active
lesions during labor;.
Assessment
If the infection was acquired during pregnancy, an infant may be
born with vesicles covering the skin. The long-term prognosis of
the child is guarded because severe neurologic damage may have
occurred simultaneously with the development of the lesions. If
infants don’t acquire the infection until birth, by day 4 to day 7
of life, they show a loss of appetite, perhaps a low-grade fever,
and lethargy. Stomatitis (ulcers of the mouth) or a few vesicles
on the skin appear. Herpes vesicles always cluster, are pinpoint
in size, and are surrounded by a reddened base. After the
vesicles appear, infants become extremely ill. They develop
dyspnea, jaundice, purpura, convulsions, and hypotension. Death
may occur within hours or days. Between 25% and 70% of
newborns who survive generalized herpesvirus infections have
permanent central nervous system sequelae. To confirm the
diagnosis, cultures are obtained from representative vesicles as
well as from the nose, throat, anus, and umbilical cord. Blood
serum is analyzedfor IgM
antibodies.
Therapeutic Management
An antiviral drug such as acyclovir (Zovirax), a drug that
inhibits viral DNA synthesis, is effective in combating this
overwhelming infection. Prevention, however, is the newborn’s
best protection. Antenatal antiviral prophylaxis reduces viral
shedding and recurrences at birth and reduces the need for
cesarean birth. Women with active herpetic vulvar lesions are
advised to have cesarean birth rather than vaginal birth to
minimize the newborn’s exposure. Infants with an infection
should be separated from other infants in a nursery. Although
transmission from this source is rare, women with herpes lesions
on their face (herpes simplex I, or cold sores) need to be
assessed before they hold their newborns to be sure lesions are
crusted and, therefore, are no longer contagious. Healthcare
personnel who have herpes simplex infections should not care
for newborns until the lesions are crusted. Although facial herpes
simplex lesions are probably caused by herpesvirus type 1,
limiting contact does not seem excessive in light of the severity
of HSV-2 disease. Urge a woman who is separated from her
newborn at birth to view her infant from the nursery window and
participate in planning care to aid bonding.
HIV INFECTION
HIV infection and AIDS can be caused by placental transfer or
direct contact with maternal blood during birth. Because older
children can also be exposed to this disease, the care of children
with this infection is discussed in Chapter 42.
 Hyperbilirubinemia
The term “hemolytic” is Latin for “destruction” (lysis) of red
blood cells. A certain degree of lysis of red blood cells in the
newborn results from the destruction of red blood cells by a
normal physiologic process as the newborn breaks down excess
red blood cells formed in utero (see Chapter 18). Hemolytic
disease is present when there is excessive destruction of red
blood cells, which leads to elevated bilirubin levels
(hyperbilirubinemia). In the past, hemolytic disease of the
newborn was most often caused by an Rh blood type
incompatibility. Because the prevention of Rh antibody
formation has been available for almost 50 years, the disorder is
now most often caused by an ABO incompatibility. In both
instances, because the fetus has a different blood type than the
mother, the mother builds antibodies against the fetal red blood
cells, leading to hemolysis of the cells, severe anemia, and
hyperbilirubinemia.
Rh Incompatibility
In every pregnancy, a few red blood cells enter the maternal
circulation. If the mother’s blood type is Rh negative and the
fetal blood type is Rh positive, this introduction of fetal blood
causes sensitization to occur and the woman to begin to form
antibodies against the specific antigen (most commonly the D
antigen). Few antibodies actually form this way during
pregnancy, however. Most form in the woman’s bloodstream in
the first 72 hours after birth because there is an active exchange
of fetal–maternal blood as placental villi loosen and the placenta
is delivered. Because of this surge in antibody formation after a
pregnancy, in a second pregnancy, there will be a high level of
antibody already circulating in the woman’s bloodstream. This
will then act to destroy the fetal red blood cells beginning early
in the next pregnancy if the new fetus is Rh positive, leading to
the fetus being severely compromised by the end of that
pregnancy. Rh incompatibility is not commonly seen today
because if Rh-negative women receive Rho immune globulin
(RHIG or RhoGAM) (passive Rh antibodies) within 72 hours
after birth of an Rh-positive newborn, the process of antibody
formation will be halted and sensitization will not occur. The
possibility Rh incompatibility could exist, however, must be
assessed for during pregnancy and again at birth because some
women (especially those who received prenatal care in another
country) may not have received RHIG following the birth or
miscarriage of a former Rh-positive fetus.
ABO Incompatibility
In most instances of ABO incompatibility, the maternal blood
type is O and the fetal blood type is either A or B type blood.
Hemolysis can become a problem with a first pregnancy in
which there is an ABO incompatibility because the antibodies to
A and B cell types are naturally occurring antibodies or are
present from birth in anyone whose red cells lack these antigens.
Fortunately, unlike the antibodies formed against the Rh D factor,
these antibodies are of the large (IgM) class and so do not cross
the placenta. An infant of an ABO incompatibility, therefore, is
not born anemic, as the Rh-sensitized child could be. Hemolysis
of the blood begins with birth, when blood and antibodies are
exchanged during the mixing of maternal and fetal blood as the
placenta is loosened; destruction may continue for as long as 2
weeks. Interestingly, preterm infants do not seem to be affected
by ABO incompatibility. This may be because the receptor sites
for anti-A or anti-B antibodies do not appear on red cells until
late in fetal life. Even in the mature newborn, a direct Coombs
test may be only weakly positive because of the few anti-A or
anti-B sites present. The reticulocyte count (immature or newly
formed red blood cells) is usually elevated as the infant attempts
to replace destroyed cells.
Assessment
Rh incompatibility of the newborn can be predicted by finding a
rising anti-Rh titer or a rising level of antibodies (indirect
Coombs test) in a woman during pregnancy. It can be confirmed
by detecting antibodies on the fetal erythrocytes in cord blood
(positive direct Coombs test) by percutaneous umbilical blood
sampling (see Chapter 9) or at birth. The mother in this situation
will always have Rh-negative blood, and the baby will be Rh
positive.
With Rh incompatibility, an infant may not appear pale at birth
despite the red cell destruction that occurred in utero because the
accelerated production of red cells during the last few months in
utero compensates to some degree for the destruction. The liver
and spleen may be enlarged from attempts to destroy damaged
blood cells. If the number of red cells has significantly decreased,
the blood in the vascular circulation may be hypotonic to
interstitial fluid, causing fluid to shift from the lower to higher
isotonic pressure by osmosis, resulting in extreme edema.
Finally, the severe anemia can result in heart failure as the heart
has to beat at a faster rate than normal to push the diluted blood
forward. Hydrops fetalis is a Greek term that refers to a
pathologic accumulation of at least two or more cavities with a
collection of fluid in the fetus.
Most infants do not appear jaundiced at birth because the
maternal circulation has evacuated the rising indirect bilirubin
level. With birth, progressive jaundice, usually occurring within
the first 24 hours of life, will begin, indicating in both Rh and
ABO incompatibility that a hemolytic process is occurring. The
jaundice occurs because, as red blood cells are destroyed,
indirect bilirubin is released. Indirect bilirubin is fat- soluble and
cannot be excreted from the body. Under usual circumstances,
the liver enzyme glucuronyl transferase converts indirect
bilirubin to direct bilirubin. Direct bilirubin is water-soluble and
combines with bile for excretion from the body through feces. In
preterm infants or those with extreme hemolysis, the liver cannot
convert all of the indirect bilirubin produced into direct bilirubin
fast enough, so jaundice occurs.
Normally, cord blood has a total serum bilirubin (TsB) level of 0
to 3 mg/100 ml. An increasing bilirubin level becomes
dangerous if the level rises above 20 mg/dl in a term infant and
perhaps as low as 12 mg/dl in a preterm infant because brain
damage from bilirubin-induced neurologic dysfunction (BIND),
a wide spectrum of disorders caused by increasingly severe
hyperbilirubinemia ranging from mild dysfunction to acute
bilirubin encephalopathy (ABE) (invasion of bilirubin into brain
cells), can occur.
A second concern that arises from excessive red blood cell
destruction is that an infant is forced to use glucose stores to
maintain metabolism in the presence of anemia. This can cause a
progressive hypoglycemia, compounding the initial problem. A
decrease in
hemoglobin during the first week of life to a level less than that
of the cord blood is a later indication of blood loss or hemolysis.
Therapeutic Management
Bilirubin levels in blood may be measured by either a blood
draw (TsB) or by holding a transcutaneous meter against the
infant’s skin (transcutaneous bilirubin [TcB]). The initiation of
early feeding (urge mothers to breastfeed 8 to 10 times a day for
the first 2 days), use of phototherapy, and exchange transfusion
all may be measures necessary to reduce the TsB level in an
infant affected by a blood incompatibility. In infants with severe
hemolytic disease, the hemoglobin concentration can continue to
drop during the first 6 months of life, or their bone marrow may
fail to increase production of erythrocytes in response to
continuing hemolysis so they need an additional blood
transfusion to correct this late anemia. Therapy with
erythropoietin to stimulate red blood cell production is also
possible.
The Initiation of Early Feeding
Bilirubin is removed from the body by being excreted through
the feces. Therefore, the sooner bowel elimination begins, the
sooner bilirubin removal begins. Early feeding (either breast
milk or formula), therefore, stimulates bowel peristalsis and
helps to accomplish this.
Phototherapy
A fetus’s liver processes little bilirubin in utero because the
mother’s circulation does this for the fetus. With birth, exposure
to light is believed to trigger the liver to assume this function.
Additional light supplied by phototherapy appears to speed the
conversion of unconjugated (fat-soluble) into conjugated (watersoluble) bilirubin. Phototherapy exposes the infant to continuous
specialized light such as quartz halogen, cool white daylight, or
special blue fluorescent light. The lights are placed 12 to 30 in.
above the newborn’s bassinet or incubator.
Term newborns are generally scheduled for phototherapy when
the TsB level rises to 10 to 12 mg/dl at 24 hours of age; preterm
infants may have treatment begun at levels lower than this
(Bhardwaj, Locke, Biringer, et al., 2017). Although the results of
the therapy are mixed, the administration of intravenous
immunoglobulin (IVIG) has been used in neonates with
hemolytic disease in combination with phototherapy, especially
in ABO incompatibility to try and extenuate the effect of
phototherapy. Continuous exposure to bright lights by
phototherapy may be harmful to a newborn’s retina, so the
infant’s eyes must always be covered while under bilirubin lights.
Commercial phototherapy masks or eye coverings must be used
at all times when the infant is under phototherapy (with the use
of bilirubin blankets, eye protection is not usually necessary if it
is a full-term newborn). Check the eye covering/mask frequently
to be certain it has not slipped. Infants are most apt to dislodge
the eye covering when they cry as they wake for a feeding. Urge
parents to respond quickly, therefore, if the infant is in their
postpartum room to avoid eye damage and possible suffocation
by the infant pushing the eye covering down over the nose.
The stools of an infant under bilirubin lights are often bright
green because of the excessive bilirubin being excreted as the
result of the therapy. They are also frequently loose and may be
irritating to the skin. Urine may be dark colored from
urobilinogen formation. Monitor the infant’s axillary
temperature to prevent him or her from overheating under the
bright lights. Assess skin turgor and intake and output to ensure
dehydration is not occurring from the warm environment. Infants
receiving phototherapy should be removed from under the lights
for feeding so they continue to have interaction with their mother.
Remove the eye patches while the infant is out from under the
lights for a period of visual stimulation. To prevent a lengthy
hospital stay, infants may be discharged and continue therapy at
home.
Specialized fiber optic light systems incorporated into a fiber
optic blanket also have been developed and are ideal for home
care. The light generated by the blanket has the same effect on
bilirubin levels as banks of overhead lights. The infant is
undressed except for a diaper to protect the ovaries or testes and
so as much skin surface as possible is exposed to the light. Two
big advantages are that an infant can be held for long periods
without interrupting the phototherapy, and eye patches are
unnecessary. Parents need an explanation of the rationale for
phototherapy and why their infant needs it. Although
phototherapy has not been used long enough that long-term
effects can be studied, there appears to be minimal risk to an
infant from the procedure, provided the infant’s eyes remain
covered and dehydration from increased insensitive water loss
does not occur. Even though there is no evidence so far that
infants who received phototherapy are at greater risk for
developing skin cancer, all infants who receive phototherapy
should (as should all infants) have sunscreen applied when they
are in the sun and follow-up assessments in coming years to
detect skin cancer that
possibly could occur from the therapy (Oláh, Tóth-Molnár,
Kemény, et al., 2013).
Exchange Transfusion
The use of intensive phototherapy in conjunction with hydration
and close monitoring of serum bilirubin levels has greatly
reduced the need for exchange transfusions. If this is done, small
amounts (2 to 10 ml) of the infant’s blood are drawn from the
infant’s umbilical vein and then replaced with equal amounts of
donor blood. The therapy may be used for any condition that
leads to hyperbilirubinemia or polycythemia. When used as
therapy for blood incompatibility, it removes approximately 85%
of sensitized red cells. It reduces the serum concentration of
indirect bilirubin and can prevent heart failure in infants with
severe anemia or polycythemia. A transfusion should be done
under a radiant heat warmer to keep the infant warm during what
can be a lengthy procedure to prevent energy expenditure from
having to maintain body temperature.
Donor blood must be maintained at room temperature, or
hypothermia from the cold insult could result. Use only
commercial blood warmers to warm blood, not hot towels or a
radiant heat warmer, to avoid destroying red cells. The type of
blood used for transfusion is O Rh-negative blood, even if an
infant’s blood type is positive; if Rh-positive or type A or B
blood were given, the maternal antibodies that entered the
infant’s circulation would destroy this blood also, and the
transfusion would be ineffective. If the baby will be transported
to a regional center for the exchange transfusion, a sample of the
mother’s blood should accompany the infant, so cross-matching
on the mother’s serum can be done there. After a transfusion,
closely observe the infant to be certain vital signs are stable and
there is no umbilical vessel bleeding or inflammation of the cord
if this was the transfusion site, which would suggest infection.
Report any changes in vital signs. Monitor bilirubin levels for 2
or 3 days after the transfusion to ensure the level of indirect
bilirubin is not rising again and that no further phototherapy or
transfusion is necessary.
 Sudden Infant Death Syndrome
Sudden infant death syndrome (SIDS) is a sudden unexplained
death in infancy. It tends to occur at a higher than usual rate in
infants of adolescent mothers, infants of closely spaced
pregnancies, and underweight and preterm infants. Also prone to
SIDS are infants with BPD, twins, Native American infants,
Alaskan Native infants, economically disadvantaged Black
infants, and infants of narcotic-dependent mothers.
The peak age of incidence is 2 to 4 months of age. Although the
cause of SIDS is unknown, in addition to prolonged but
unexplained apnea, other possible contributing factors include:
• Sleeping prone rather than supine
• Viral respiratory or botulism infection
• Exposure to secondary smoke
• Pulmonary edema
• Brainstem abnormalities
• Neurotransmitter deficiencies
• Heart rate abnormalities
• Distorted familial breathing patterns
• Decreased arousal responses
• Possible lack of surfactant in alveoli
• Sleeping in a room without moving air currents (the infant
rebreathes expired
carbon dioxide)
Typically, affected infants are well nourished. Parents may
report an infant had a slight head cold. After being put to bed at
night or for a nap, the infant is then found dead a few hours later.
Infants who die this way do not appear to make any sound as
they die, which indicates they die with laryngospasm. Although
many infants are found with blood-flecked sputum or vomitus in
their mouths or on the bedclothes, this seems to occur as the
result of death, not as its cause. An autopsy often reveals
petechiae in the lungs and mild inflammation and congestion in
the respiratory tract. However, these symptoms are not severe
enough to cause sudden death. It is lear these infants do not
suffocate from bedclothes or choke from overfeeding,
underfeeding, or crying. Since the AAP made the
recommendation to put newborns to sleep on their back, the
incidence of SIDS has declined almost 50% to 60%. Other
recommendations include the use of a firm sleep surface;
breastfeeding; room sharing without bed sharing; routine
immunizations; consideration of using a pacifier; and avoidance
of soft bedding, overheating, and exposure to tobacco smoke,
alcohol, and illicit drugs
Although it was once thought having infants sleep with a fan in
their room to keep air moving might decrease the incidence of
SIDS, the AAP has noted that, currently, there is insufficient
evidence to recommend the use of a fan as a SIDS riskreduction strategy. Parents have a difficult time accepting the
death of any child. This can be especially difficult when it
happens so suddenly and to an infant. In discussing the child,
they often use both the past and present tense as if they are not
yet aware of the death. Many parents experience a period of
somatic symptoms that occur with acute grief, such as nausea,
stomach pain, or vertigo. Parents should be counseled by
someone who is trained in counseling at the time of the infant’s
death; it helps if they can talk to this same person periodically
for however long it takes to resolve their grief.
The American Sudden Infant Death Syndrome Institute, listed at
the beginning of the chapter, offers suggestions for counseling.
Autopsy reports should be given to parents as soon as they are
available (if toxicology tests are included in the autopsy, results
will not be available for weeks). Reading that their child’s death
was unexplained can help to reassure parents the death was not
their fault. They need this assurance if they are to plan for other
children. If there are older children in the family, they also need
assurance SIDS is a disease of infants and the strange
phenomenon that invaded their home and killed a younger
brother or sister will not also kill them. If they wished the infant
dead, as some children wish siblings were dead occasionally,
they need reassurance their wishes did not cause the baby’s
death.
When another child is born, parents can be expected to become
extremely frightened at any sign of illness in their child. They
need support to see them through the first few months of the
second child’s life, particularly until past the point at which the
first child died. Some parents may need support to view a second
child as an individual child and not as a replacement for the first
child. A new baby born to a family in which a SIDS infant died
can be screened using a sleep assessment as a precaution within
the first 2 weeks of lifeor, if the parents’ level of anxiety is acute,
before hospital discharge. The baby may then be placed on
continuous apnea monitoring pending the results of the sleep
assessment.