Childbearing
SN3180
Childbearing Family Nursing Newborn (1)
Kitty Wong
2018
1
Reading text
Chapter 27-29 of Davidson, M., London, M. and
Ladewig, P. (2016). Old’s Maternal-newborn nursing
and women’s health across the lifespan (10th
edition). Boston: Pearsons.
2
Learning Objectives
After completion of this lecture, you should be able to:
a. describe the changes of the followings that occurs during the
newborn’s transition to extra-uterine life:
– the respiratory and cardiovascular changes
– the process of thermogenesis
– the newborn’s gastrointestinal tract and liver
– the newborn’s urinary system to maintain fluid and
electrolyte balance
– the immunologic responses of newborn
b. Explain the conjugation and excretion of bilirubin in
newborns
c. identify the reasons that a newborn may develop
physiological jaundice
3
Transition to extrauterine life
• The neonatal period / newborn period
– from Birth to the 28th DAY of life
• Neonatal transition
– The first 6 to 8 hours after birth
• Transitional period between intrauterine and extrauterine existence
– Physiological adaptation
• Respiratory adaptation
• Cardiovascular adaptation
• Thermal adaptation
• Urinary adaptation
• Gastrointestinal adaptation
• Hepatic adaptation
• Immunologic adaptation
– Behavioral adaptation which will be discussed in Newborn (2)
• Period of reactivity
• Sleep-wake pattern
• State organization
5
Immediate adjustment
• Respiratory adaptations
• Cardiovascular adaptations
6
Stimulation to first inspiratory gasp
• Chemical stimuli
– A brief period of asphyxia after normal vaginal labor and birth
– Triggered by slight elevation in carbon dioxide, decrease in pH and
oxygen
– Stimulate the aortic and carotid chemo-receptors to the respiratory
center (medulla)
• Thermal stimuli
– Decrease in environmental temperature, warm environment and enter
a relatively cooler atmosphere (37 ℃ to 21-23 ℃ )
– Sudden chilling of infant Cold stimulate skin nerve endings
newborn responds with rhythmic respirations
• Sensory stimuli
– Tactile, auditory, visual stimuli
– Joint movement proprioceptor stimulation to respiratory center
sustain respirations.
7
Initiation to Breathing
To maintain life, the lungs must function immediately
after birth.
It depends on:
Reduction of surface tension of the fluid that
filled the fetal lungs and alveoli
8
9
Initiation of respiration in the newborn
Mechanical events
& reabsorptive
processes
Chemical, thermal,
mechanical, sensory
stimuli
Chest recoil
Fluid
reabsorption
Negative
intrathoracic
pressure
Activation of 1st breath
Entry of Air
Commencement of reduced
alveolar surface tension
Decrease in interstitial pressure
Increase in pulmonary vascular
volume
Increase in lymph circulation
Increase in
alveolar PO2
Opening of
pulmonary vessels
Increase in
pulmonary vascular
flow
Promotion of adequate
oxygenation
Source: Davidson, M., London, M. and Ladewig, P. (2016).
Old’s Maternal-newborn nursing and women’s health across the lifespan (10th edition). Boston: Pearsons. P.652
10
Characteristics of newborn respiration
Normal respiration
• Normal respiration rate
(RR): 30-60 breaths per
minute
• Abdomen’s movement
synchronous with the
chest movement
• Nose breathers
Abnormal respiration
• 30/ minute ≤ RR or RR ≥60
breaths/ minute when
infant at rest
• Apnea/ apnoea: cessation
of breathing > 20 sec
• Retraction of ribs (increase
use of intercostal muscles)
• Cyanosis
• Nasal flaring
• Expiratory grunting
11
12
Circulatory system
• The circulatory changes allow the blood to flow
through the lungs
• Due to pressure changes in lungs, heart, major
vessels
• Transition from fetal circulation to neonatal
circulation
https://www.youtube.com/watch?v=uwswhoKfkmM
13
Fetal circulation
https://youtu.be/9O-i6k0mGrU
Fetal circulation before birth
14
Newborn’s circulatory system
https://youtu.be/DC_wlkRPzw0
(revision use: Fetal circulation
right after birth)
15
Fetal and neonatal circulation
System
Fetal
Neonatal
Pulmonary blood Constricted with very little
vessels
blood flow;
lungs not expanded
Vasodilation and increased blood
flow;
lungs expanded; increased O2
stimulates vasodilation
Systemic blood
vessels
Arterial pressure rises due to loss of
placenta;
Increased systemic blood volume and
resistance
Dilated with low
resistance;
blood mostly in placenta
Ductus arteriosus Large with no tone;
Blood flow from
pulmonary artery to aorta
Reversal of blood flow.
Now from aorta to pulmonary artery
because of increased left atrial
pressure.
Foramen ovale
Increased pressure in left atrium
attempts to reverse blood flow and
shuts one-way valve.
Patent with large blood
flow from right atrium to
left atrium
16
Changes in fetal circulation at birth
Structure
Before Birth
After birth
Umbilical vein
Brings arterial blood to the
heart
Obliterated
Becomes ‘round ligament’ of
liver
Umbilical arteries
Bring arteriovenous blood to
placenta
Obliterated
Becomes ligaments on
anterior abdominal wall
Ductus venosus
Shunts arterial blood into
Inferior vena cava
Obliterated
Becomes ligamentum
venosum
Ductus arteriosus
Shunts arterial and some
venous blood from the
pulmonary artery to aorta
Obliterated
Becomes ligamentum
arteriosum
https://youtu.be/yT8-mSUvDw8 structure of Foramen ovale
17
Transitional circulation: Conversion from fetal to neonatal circulation (1)
Initiation of
respiration
(Lungs
expanded)
Decreased pulmonary
vascular resistance
Increased
PO2 level
Increased pulmonary blood flow
Increased pressure in left atrium
Closure of foramen
ovale
Decreased right
atrial pressure
Source: Davidson, M., London, M. and Ladewig, P. (2016).
Old’s Maternal-newborn nursing and women’s health across the lifespan (10th edition). Boston: Pearsons. P.653
18
Transitional circulation: Conversion from fetal to neonatal circulation (2)
Initiation of respiration
(Lungs expanded)
Closure of
ductus venosus
Cessation of umbilical
venous return
Increased PO2
level
Increase systemic
vascular resistance
Decreased systemic
venous return
Systemic resistance
> Pulmonary
Closure of ductus
arteriosus
Left-to-right shunt
Pulmonary resistance
< systemic
Source: Davidson, M., London, M. and Ladewig, P. (2016).
Old’s Maternal-newborn nursing and women’s health across the lifespan (10th edition). Boston: Pearsons. P.653
19
Newborn’s circulatory system
https://youtu.be/DC_wlkRPzw0
Fetal circulation right after birth
20
The normal baby : Cardiovascular system
• Heart rate : 110 – 160 beats per minute
• Blood pressure :
– 70 – 50 / 45 – 30 mmHg at birth
– 90/50 mmHg at day 10
• Compare the BP in the arm & calf, which should be equal
• Heart murmur
– produced by turbulent blood flow
– Atrial or ventricular septal defect
– Reversible flow of blood through the ductus arteriosus
during early neonatal period, functional murmur is
occasionally heard
http://www.paediatrics.co.uk/nicu/normal-ranges (show newborn’s heart rate)
21
Response of BP to changes in
neonatal blood volume
Transient birth asphyxia
Rise BP (immediate post birth)
Increase peripheral Blood volume
Increase circulating Blood volume
Decrease pulmonary vascular resistance
Subsequent increases in combined
ventricular output
Fall in BP as blood
shifts from periphery
into lungs and
water shifts into the
interstitial space from
the plasma
Slowly rising BP
22
Thermoregulation
Birthing room temperature : 21℃ vs
Intrauterine temperature: 37.7℃
Several factors predispose the newborn to
excessive heat loss:1.
2.
3.
Large surface area in relation to body mass
Thin layer of subcutaneous fat
Heat production (thermogenesis) in newborn
23
3. Heat production (thermogenesis) in newborn
Non-shivering thermogenesis (NST)
– Stimulating cellular respiration
– Use of brown adipose tissue to generate heat
– Brown fat cells promote rapid metabolism, heat
generation, heat transfer to the peripheral circulation
Increase basal metabolic rate (increase glucose & oxygen
consumption)
24
25
- Sites of brown fat
Adrenals and
kidneys
Brown fat / brown adipose
tissue
Located around the back of
neck, axillae, around the
kidneys, adrenals, and
sternum; between scapulae;
and along the abdominal aorta
It generates more heat than
white subcutaneous fat
It contains an abundant
supply of blood vessels
Blood passing through brown
fat is warmed and carries heat
to the rest of the body
Between
scapulae
sternum
26
Mode of heat loss in the neonate
Convection
Conduction
Radiation
Evaporation
27
Heat loss from
the body
surface to the
environment
Mechanism
Examples
Convection
The loss of heat from the warm
body surface to the cooler
ambient air currents
Air-conditioned rooms
Radiation
Heat losses when heat transfers
from the heated body surface to
cooler surfaces and objects not
in direct contract with the body
The cool walls of a room
or of an incubator
Evaporation
The loss of heat result in
conversion of water into vapor
Immediate after birth,
the baby is wet with
amniotic fluid / during
baths
Conduction
The loss of heat to a cooler
surface by direct skin contact
Cold examination table,
cold stethoscopes
28
29
Urinary adaptation
• Functional deficiency in the kidney’s ability to,
– concentrate urine
– cope with conditions of fluid & electrolyte
fluctuations eg. dehydration
• ~ 200 – 300 mL / 24 hours by the end of the first week
• Bladder empties involuntarily when stretched by a
volume of 15 mL
• The first voiding should occur within 24 hours
• Day1-2: void 2 – 6 time/day, urine output of 15 ml /kg / day
• The urine is colorless & odorless, specific gravity ~
1.020
30
Gastrointestinal system (1)
Digestion:
– Able to digest proteins and simple carbohydrate
– Deficient production of pancreatic amylase impaired
utilization of complex carbohydrates
– Deficient in pancreatic lipase difficulty in digestion of fat
e.g. fat in cow’s milk
Liver : immature
– ↓the enzyme glucuronyl transferase affect the
conjugation of bilirubin physiological jaundice
– ↓prothrombin & coagulation factors
– ↓liver store of glycogen
31
Gastrointestinal system (2)
Stomach capacity:
- around 90 ml (full term infant ~ 3.4 Kg)
- Regurgitation is common – due to
Immature migrating motor complex (MMC)
Decreased lower esophageal sphincter pressure
Delayed gastric emptying
MMC refers to
rapid peristaltic
waves and
simultaneous
non-peristaltic
waves occur
along the entire
intestine inbetween meals
However, longer intestine in relating to the body size
↑surface area for absorption
Avoid overfeed and B______
to prevent regurgitation
ping
ur
Progressive changes in the stooling pattern indicating a
functioning GI tract
32
Gastrointestinal adaptation (3)
•
Meconium
•
Transitional stools
– Usually appear by 3rd day after initiation of feeding
– Greenish brown to yellowish brown, thin, less sticky than meconium
– May contain some milk curds
•
Milk stool: usually appear by the fourth day
– Stool of infant fed with breast milk
• Mustard color and consistency
• sweet-sour smell
• 4 or more stool daily
– Formula-fed infant
• Pale yellow to light brown stool, firmer in consistency
• have a more offensive smell
• one to two stools daily.
– Infant’s first stool occurs within first 24 hours
– Greenish black with a thick, sticky, tar like consistency
– Consist of particles from amniotic fluid e.g. vernix, skin cells, hair, cells
from intestinal tract, bile, intestinal secretions
33
Change in stool patterns of Newborns
Meconium
Transitional Stools
34
Newborn stool
Meconium
Transitional
stool
Breast milk
stool
35
Formula-fed stool
36
Coagulation
• Liver
• Coagulation factors II, VII, IX, and X (synthesized in
the liver) activated under the influence of vitamin K
• Absence of normal flora
• Injection of vitamin K as prophylactic for bleeding
problems on the day of birth
37
Defense against infections
1. Skin & mucous membranes
2. Neutrophils, monocytes, eosinophils &
lymphocytes
3. Three major immunoglobulins :
– IgG: passive acquired via placenta during the third
trimester, also from human milk
– IgM: normally produced by fetus in utero, begin at
10 to 15 weeks’ gestation
– IgA: present in colostrum, IgA begins to be
produced by newborn in the intestinal mucosa ~ 4
weeks after birth
38
Neonatal Jaundice
Newborn develops an unconjugated serum bilirubin
≥ 30 μmol/L (18mg/dL)
Neonatal hyperbilirubinemia is very common in US
Kernicterus is its complication
Mortality (incidence of kernicterus): 0.4-2.7 cases per
100,000 births in North America and Europe, and ≥
30% of infants died in developing countries
40
HbF: Fetal
haemoglobin
Hb A: Adult
Hb
http://www.childhealth-explanation.com/jaundice-in-newborns.html
41
42
Causes
Physiological Jaundice: immature liver, caused so the job of
conjugating and removing bilirubin is not done completely
well. As the breakdown of red blood cells slows down, and
the baby's liver matures, the jaundice rapidly disappears.
Neonatal jaundice: healthy RBC can be destroyed by
http://www.pathophys.org/neonatal-hyperbilirubinemia/
haemolysis.
Polycytnemia: baby born with excess RBC.
Cephalohaematoma
Baby swallows blood during birth, absorbed in
bloodstream. With excess blood from a blood clot will
cause a rise in serum bilirubin.
GDM
Hypoxia after birth
43
44
Signs and symptoms
•
•
•
•
•
Jaundice: head, arms trunk and legs.
If severe, jaundiced below knees and over the palms
Ill looking
Fever
Poor feeding
45
Management of NNJ
• Assessment
• Observation
• Treatment
– Ensure adequate intake
– Phototherapy
– ± Intravenous immune globulin
– ± Exchange transfusion
46
Assessment History of pregnancy and
delivery:
• Maternal illness (viral or
other infection)
• Maternal drug intake
• Delayed cord clamping
• Birth trauma with bruising ±
fracture
Postnatal history of
newborn:
• Loss of stool color
• Breastfeeding
• Greater than average BW
loss
• Signs and symptoms of
hypothyroidism
• Signs and symptoms of
metabolic disease
47
Assessment 1. History taking (cont’d):
- family history of NNJ, anaemia and splenectomy
(hemolytic disorder)
2. Onset of NNJ :
o
o
o
o
o
Within 1st 24 hours: should be assumed as non-physiologic;
Day 1-2: metabolic screening for galactosemia and congenital
hypothyroidism;
Day 3-4: physiologic NNJ
D 4-7: breast milk jaundice
D 3: Breastfeeding jaundice
3. Examine under good daylight: face, chest, hands and feet.
4. Take serum bilirubin, haemoglobin, (if necessary baby’s
blood group and perform Coomb’s test.)
48
Assessment for NNJ
•
•
•
•
•
•
Yellowing of skin: checked by jaundice meter, serum Bb
Pallor, anaemic at birth
source of haemolysis
signs of infection
Feeding & hydration
Stool color
49
Management: Phototherapy
1. Explain to parents:
a. Use of visible light for the treatment of
hyperbilirubinemia in the newborn.
b. Common therapy lowers the serum bilirubin level by
transforming bilirubin into water-soluble isomers
that can be eliminated without conjugation in the
liver.
c. The dose of phototherapy largely determines how
quickly it works: is determined by the wavelength of
the light, the intensity of the light (irradiance), the
distance between the light and the infant, and the
body surface area exposed to the light.
50
Management: Phototherapy (cont’d)
2.
Effective irradiance delivery:
uncover the baby to maximize skin exposure
providing eye protection and eye care
carefully monitoring thermoregulation (T°)
maintaining adequate hydration
document intake and output
3.
Support and encourage parent-infant interaction.
51
Efficiency of Phototherapy
52
Intravenous immune globulin
- It is used for numerous immunologically mediated conditions,
e.g. Rh, ABO, or other blood group incompatibilities that
cause significant neonatal jaundice
- Studies showed that newborns received IVIG significantly
reduce the need for exchange transfusions
- Treatment: 500mg/kg given for a 2 hour period once diagnosed
with Rh/ABO incompatibility
53
References
Davidson, M.R., London, M.L., & Ladewig, P.A.W. (2008). Maternal-newborn
nursing & women’s health across the lifespan. New Jersey: Pearson Prentice
Hall.
Hockenberry, M. J., & Wilson, D. (2011). Wong’s nursing care of infants and
children. (9th ed.). St. Louis: Elsevier Mosby.
Leifer G (2007). Introduction to Maternity & Pediatric Nursing (5th ed.) St. Louis:
Mosby.
London, M.L., Ladewig, P. W., Ball, J. W., Bindler, R.C. & Cowen, K.J. (2011).
Maternal & child nursing care. (3rd ed.). New York: Pearson.
Lowdermilk D.L., Perry S.E. & Cashion, K. (2010). Maternity Nursing (8th ed.)
Maryland Heights: Mosby Elsevier.
Mattson, S. & Smith, J. E. (2011). Core curriculum for maternal-newborn nursing.
(4th ed.). Saint Louis: Saunders Elsevier.
Murray, S. S. & McKinney E. S. (2010). Foundations of Maternal-Newborn and
Women’s Health Nursing (5th ed.). Maryland Heights: Saunders Elsevier.
Ricci, S. S. (2009). Essentials of Maternity, Newborn, and Women’s Health Nursing
(2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
Riordan, J., & Wambach, K. (Ed.). (2010). Breastfeeding and human lactation. (4th
ed.). Boston: Jones and Bartlett Publishers.
54
SN3180
Childbearing Family Nursing Newborn (Part 2+3, updated)
Kitty Wong
2018
1
Learning outcomes
By the end of the lesson, students will be able to:
• Introduce the initial assessment of newborn after birth
• Describe the purpose, components and implications of APGAR
score
• Describe the subsequent physical assessment of newborn
• Describe & explain the subsequent care to newborns
• Illustrate the nursing care of newborn
• Describe the Immunization program in Hong Kong
• Briefly mention the three neonatal screening in Hong Kong
2
Neutral thermal environment –
- The ambient air temperature of the environment at
which oxygen consumption and heat production is
minimal with body temperature in normal range
- Actions will be:
1)
2)
3)
4)
5)
6)
7)
pre-warm blanket/ shawl/ hat
Transport incubator (warm isolette)
Immediate drying of infant
Skin to skin contact with mother
Early breastfeeding
defer bathing and weighing postponed
Use of radiant warmer/ heater
3
Newborn stabilization and assessment of
newborn
5
Assess newborn’s risk for resuscitation
Before action, the following information
may help:a. Gestation – term?
b. Amniotic fluid – clear?
c. Breathing or crying?
d. Good muscle tone?
Yes
Routine care,
keep warmth …
6
https://www.youtube.com/watch?v=Vtxsxv1BQek
Resuscitaire for newborn
Immediate Care
1) Clear airway ± gentle oro-naso-pharyngeal suction
2) Stimulate breathing – tactile stimulation
3) Arrange baby skin-to-skin attachment with mother
4) Prevention of heat loss – dry up the baby with paper
towel
5) Cord care – apply cord clamp, cut by sterile scissors;
observe number of vessels and any bleeding
8
Care of umbilical cord
• A sterile Hollister clamp is applied at about 4 cm from
umbilicus
• Examined for the presence of two arteries & one vein
• Observe for active bleeding
10
10
Overall management of newborn: https://youtu.be/wj3uJocmdSE (0:46- )
APGAR score
Score
1st
min
Sign
Color
(Appearance)
0
1
2
Blue, pale
at all parts
Body pink,
extremities blue
(acro-cyanosis)
< 100 bpm
Pink at body
and extremities
Heart rate
(Pulse)
0
Reflex
irritability
Grimace
No
response
Grimace on
suction or
aggressive
stimulation
Cries on
stimulation
Flaccid
Some flexion on
extremities
Well flexed with
resist extension
Muscle tone
(Activity)
> 100 bpm
11
Respiratory
effort
Apnoea/
apnea
Irregular, weak,
grasping
Regular,
lusty cry
5th
min
.
.
.
Scoring of APGAR means:
Scores 0 – 3 → severe distress
Scores 4 – 6 → moderate difficulty
Scores 7 – 10 → infant is having minimal or no
difficulty adjusting to extra-uterine life
14
14
Identification of baby
1. Show baby to mother
2. Identify sex by mother & nurse
3. Apply identification bracelets to baby’s left wrist and
foot after cross checking the bracelets with mother
15
Provide warmth
Wrap baby with warm towel/ shawl
Examine baby in incubator
16
Bonding
Skin-to-skin attachment
Start breastfeeding early within 30 minutes after
birth
17
Scoring of APGAR means:
Scores 0 – 3 → severe distress
Scores 4 – 6 → moderate difficulty
Scores 7 – 10 → infant is having minimal or
no difficulty adjusting to extra-uterine life
18
18
Neonate’s risk for resuscitation
Gestation – preterm
Amniotic fluid – meconium
stained
Crying: delayed
Muscle tone – flaccid
(APGAR)
Call paediatrican
Stand-by
Call paediatrican
At once
19
Vicker’s Resuscitaire
Newborn resuscitation
A. Initial assessment
B. Breathing
C. Circulation
D. Drug
20
21
Scoring of APGAR means:
Scores 0 – 3 → severe distress
Scores 4 – 6 → moderate difficulty
Scores 7 – 10 → infant is having minimal or
no difficulty adjusting to extra-uterine life
22
22
Examination of newborn
Aims In labour room:
To confirm baby is healthy
To identify any existing abnormalities and
To provide a baseline on which future changes
can be assessed
In postnatal ward/ NICU:
To identify and record evidence of stress, trauma,
malformation or disease during the first days of
life.
23
Gross examination of newborn
Head to toe examination
24
Gross Examination of Newborn
From head to toes
1)
2)
3)
4)
5)
6)
7)
8)
9)
General condition
Head (skull, face, eyes, nose, mouth, ears)
Neck
Chest (AR, RR)
Abdomen & umbilical cord
External genitalia (male and female)
Anus
Limbs and digits
back
25
General conditions
Items
normal
abnormal
Colour/color
Pink/ ruddy color
Pallor
Cyanosis
Rigid
flaccid
Muscle tone/
Flexed
movement/ posture Good muscle tone
Normal posture
skin
Soft and smooth
Peeling and dryness
of hands and feet
Lanugo
Vernix in skin folds
Birth mark
Bruise
Rash
haemangioma
26
General appearance
Normal general findings:
• Head is disproportionately large for
its body
• The neck looks short, as chin rests
on the chest
• Rounded chest
• Prominent abdomen
• Center of the body is the umbilicus
• Narrow hip
• Flexed position
• Good muscle tone
• short appearance of extremities
• Hand tightly clenched
27
General conditions
Comparison of resting posture
Traumatic Cyanosis
28
Muscle tone/ movement/ posture
29
Skin: Birthmark
Mongolian spots
– Macular areas of bluish black or gray-blue pigmentation on
the dorsal area and buttock
– Common in newborns of Asian and African
– Gradually fade during the first or second year of life
Haemangioma
30
Skin: General
Milia
Lanugo
Vernix
31
Skin: General
• Milia
– Exposed sebaceous glands, appear
as raised white spots on the face
usually across the nose
• Vernix caseosa
– A whitish cheese-like substance,
covers the fetus while in utero and
lubricate skin
– The skin of the term or post-term
has less vernix, dry and peeling,
especially on hands and feet
• Skin turgor
– Reveal the hydration status, need
for early feeding, and presence of
infection
– Should be elastic and return rapidly
to its original shape
• Forceps marks
– Present after difficult forceps
birth
– Reddened area over the
cheeks and jaws
– Should be resolved within 1
to 2 days
– complications: transient facial
paralysis result from the
forceps pressure
• Vacuum extractor
suction marks:
on the vertex of the scalp
32
Skin: face - Forceps marks
33
Head Assessment
1.
2.
3.
4.
5.
6.
Skull
Face
Eyes
Nose
Mouth
Ears
General appearance: head
HEAD: one-fourth of the body size
Shape:
For vaginal-born newborn, the head may appear
asymmetrical, caused by overriding of the cranial
bones during labor and birth → molding
For Breech-born newborns / born by elective
cesarean, the head round and well-shaped
Fontanels
Anterior fontanelle / fontanel is diamond-shaped
(4-5cm)→ closed within 18 months
Posterior fontanelle / fontanel is smaller and
triangular shape → closed within 8 to 12 weeks
Scalp abrasion
34
Newborn measurements
• Head circumference
• Measure the widest part
of head just above ears
and eyebrow; repeat if
molding is present
• Range: 33 – 35cm
• Chest circumference
• Measure across the
nipple line
• Range: 30.5 – 33cm
35
35
Newborn measurements
▪ Loss of 7-10% of birth weight in first week; regained in 10 – 14
days, depending on feeding method
▪ Potential signs of distress and major abnormalities:
birth weight <10th or >90th percentile
36
Check body weight
Average weight for term babies (37-41 weeks’
gestation): 3.2 kg
BW < 2.5kg: low birth weight
BW > 4.0kg: big baby
Both conditions have risks of medical problems, like
hypoglyacemia, hypocalcaemia or sepsis
37
Newborn measurements: steps
Weight:
• Balance scale
• cover scale with clean
scale paper
• place undressed infant
on scale
• keep hand hovering over
infant, never turn away.
• Range: 2500 – 4000g
Length:
• Measure from crown to
rump, then rump to
heels
• Range: 48 – 52cm
38
Head Assessment
Hydrocephalus: an
abnormal buildup of
fluid in the brain
39
Head Assessment
Microcephaly : abnormally
small head
Anencephaly: a condition that
prevents the development of
brain and skull bones. It
relates to ‘neural tube
defect’
40
Skull: Palpation of anterior fontanelle
41
Skull: Caput succedaneum vs chignon
Caput succedaneum appears over the vertex of newborn’s head
– Due to sustained pressure of the presenting part against the
cervix results in compression of local blood vessels, venous
return is interfered.
– Edematous area, cross suture lines, soft and varies in size
– Present at birth, but resolve quickly 12 to 48 hours
afterwards
Chignon: temporary swelling left on an infant's head after
a ventouse suction cap has been used in delivery
42
Skull: Caput succedaneum vs chignon
43
Skull: Caput succedaneum vs chignon
44
Caput
succedaneum
Cephalohematoma
(Hockenberry & Wilson, 2011 pp. 281)
45
Skull: Cephalo-hematoma
•
•
•
•
•
•
•
•
Bleeding between the periosteum and the skull (Cranium)
Result from pressure over the presenting part during birth
Scalp feels loose and slightly edematous
Swelling develop within the first 24 to 48 hours
Unilateral or bilateral over the parietal bone
Well-defined edges, does not cross the suture lines
Dissolve slowly 2 to 12 weeks
Infants are at greater risk for physiological jaundice
46
Skull: Cephalo-hematoma
•
•
•
•
•
•
•
•
Bleeding between the periosteum and the skull (Cranium)
Result from pressure over the presenting part during birth
Scalp feels loose and slightly edematous
Swelling develop within the first 24 to 48 hours
Unilateral or bilateral over the parietal bone
Well-defined edges, does not cross the suture lines
Dissolve slowly 2 to 12 weeks
Infants are at greater risk for physiological jaundice
47
Head: Face
• Normal appearance
– Symmetrical movement of all facial features, normal
hairlines, eyebrows and eyelashes present
• Facial paralysis
– Appears when newborn cries
– Affected side is immobile
– Fissure over eyelid widens
– Result in forceps-assisted birth /
pressure on facial nerve
– May dissolve a few days to 3 weeks / permanent
48
Head: Eyes and nose
Normal:
Nose:
symmetrical, eyeballs are present
Sclera white to bluish white
Normal:
Milia over nose
Nostrils patent
Abnormal:
•
•
•
•
absence of eyeball
corneal opacity
purulent discharge
Subconjunctival haemorrhage
Abnormal:
Flaring of nostrils
Choanal atresia
49
50
Head: Mouth and ears
Mouth
▪
• A gloved finger is
inserted into the mouth ▪
to palpate the hard &
soft palate
▪
• Abnormal:
– Cleft palate
– Cleft lip
Ears
Normal ears: soft, recoil readily
when folded and released
Position : low-set ears may
indicate chromosomal
abnormalities, mental retardation
Preauricular skin tags / sinuses
may be related to renal agenesis
because of embryologic
developmental deviations
▪ Hearing: Newborn hearing
screening
51
Head: mouth and ears
Accessory auricle
Tongue Tie
Newborn tooth
Cleft lip
Cleft palate
52
2. Neck
Normal: short, symmetrical, supple and no mass
Abnormal: limited range of motion,
webbed neck
53
3. Chest
Normal:
Round, symmetrical and
nipples normal
AR: 110-160 beats/minute
If crying- AR ≤ 180bpm
If sleep- AR ≥ 100bpm
RR 30-60/minute with breath
sound clear
Abnormal:
Fractured clavicle
Insucking chest
Hyperinflated chest
Breast engorgement
Supernumerary nipples
54
Erb’s palsy
Fracture clavicle
55
4. Abdomen
Normal: round, no distension, intact skin and no mass
palpable
Abnormal: distension, protrusion/ exomphalos
56
4. Abdomen
Normal: round, no distension, intact skin and no mass
palpable
Abnormal: distension, protrusion/ exomphalos
57
Fetal appearance: there is single right lower
limb and ruptured exomphalos major.
Journal of Postgraduate Gynaecology & Obstetrics
58
Umbilical cord
Normal: 2 arteries and one vein
Abnormal: Wharton’s Jelly cord, bleeding, cord with
one artery and one vein
59
5. External
genitalia - female
Normal: labia majora covers
clitoris and labia minora;
Vaginal opening patent
Abnormal: vaginal tag,
labial adhesion, absence
of orifice, unidentified/
ambiguous sex
60
5. External
genitalia - female
Normal: labia majora covers
clitoris and labia minora;
Vaginal opening patent
Abnormal: vaginal tag,
labial adhesion, absence
of orifice, unidentified/
ambiguous sex
61
External genitalia - male
Normal: penis straight, at midline, testes palpable in
scrotum
Abnormal: short penis, undescended testes, hydrocele,
hypospadias/ epispadias, ambiguous sex
.
.
62
6. Anus and Back
7. Back:
Anus:
Normal: present and
patent
Abnormal: imperforation
Normal: straight, at
midline, no visible defect
Abnormal: sacral dimple,
hair patch, spinal
deformity, spina bifida
63
8. Extremities and digits
•
•
•
•
•
•
Symmetry
Five fingers and five toes on each limb
Movement of arms
Hips for developmental hip dysplasia
Lower legs/feet for “club foot”
Back: curvatures, cysts or dimples
64
65
“club hand and club foot”
66
PART 3
To be continued …..
67
NEWBORN BEHAVIOUR
68
Newborn’s behavior
Period of reactivity
1. First period of reactivity (6 – 8 hrs after birth)
– 30 minutes after birth
– Awake, active, appear hungry, strong sucking reflex
2. Period of inactivity to sleep phase
– Sleep phase: few minutes to 2-4 hours
– Difficult to be awaken & show no interest in sucking
3. Second period of reactivity
– Awake and alert
– Last for 4 to 6 hours
69
Behavioral states of the newborn –
reflects the infant’s ability to respond to the environment
Sleep states
Awake states
•
• Deep sleep
– Sleep without movement,
hard to be awaken
•
• Light sleep
– Eyes closed with some eye
movement seen under lids,
active body movement;
sucking might be present
•
Quiet alert
– Alert with eyes open; attention to close
objects; little body movement
Active alert
– Inactivity with mild agitated vocalizations.
Crying
– Eyes tightly closed at times with crying;
movement of head and extremities
• Drowsy
– Transition state from sleep to
awake; eye open or closed;
lid usually heavy; active body
movement
70
Newborn sensory capabilities
•
•
•
•
Hearing: well-developed at birth; responds to noise
Vision: focuses on close-up objects
Taste: distinguishes between sweet and sour at 3rd day of age
Smell: distinguishes between .mother’s breasts and breast milk
and those of another by 5th day of age
• Touch: sensitive to pain, usually responds to tactile stimuli
71
Assessment of reflexes
• Assessment of reflexes is important to determine the health of
the newborn’s central nervous system
• Noted it’s presence, strength and whether they are
symmetrical or not
http://search.alexander
street.com/mcom/view/
work/1793913 (12401700)
72
Moro reflex
• Elicit when the newborn is
startled by a loud noise or lift
up slightly and suddenly
lowered
• The infant’s arms and legs
extend and abduct, with the
fingers fanning open and
thumbs and forefingers forming
a C position.
• The arm then return to their
normally flexed state with an
embracing motion, the legs may
also extend and then flex
• The reflex may persist until 6
months of age
73
Palmar grasping reflex
• It is elicited by stimulating the
newborn’s palm with a finger or
an object
• The newborn grasps and holds
the object or finger firmly, the
hand closes into a tight fist
• Lessens at 3 to 4 months of age
74
Rooting reflex
• When the side of the newborn’s
mouth or cheek is touched, the
head turns toward the side that
has been stroked
• It is important in feeding
• Disappeared by 4 to 7 months of
age
75
Sucking reflex
• When the mouth or
palate is touched by
the nipple or a finger,
the infant begins to
suck.
• Newborns suck even
while sleeping
(nonnutritive sucking)
→ quieting effect on
the baby
• Disappeared by 4 to 7
months of age
76
Tonic neck reflex
• the posture assumed by
newborns when in a supine
position
• The infant extends the arm and
leg on the side to which the
head is turned and flexes the
extremities on the other side
• Or called “fencing reflex” or
fencer position
• Disappeared at 3 to 4 months of
age
77
Stepping reflex
• When infants are held upright
with their feet touching a solid
surface.
• They lift one foot and then the
other, giving the appearance that
they are trying to walk
• Disappeared at 4 to 8 weeks of
age
78
Plantar grasp reflex
• When the area below the toes is
touched, the infant’s toes curl
over the nurse’s finger
• will be lessened by 8 months
79
Babinski reflex
• Elicit by stroking the lateral sole
of the infant’s foot from the heel
forward across the ball of the
foot
• This causes the toes to flare
outward and the big toe to
dorsiflex
• Diappeared at 12 months
80
Subsequent care of Newborn
81
Subsequent care of newborn in
postnatal ward
▪
▪
▪
▪
▪
▪
Intake and output
Hygiene: first bath, umbilical cord care, care of eyes
Neonatal jaundice
Newborn hearing screening
Vaccination
Safety
82
82
Daily observation
▪ General appearance, skin color (cyanosis, signs of neonatal
jaundice)
▪ Temperature, AR, RR
▪ Nutrition (feeding)
▪ Output (urine & stool)
▪ Sleep pattern & cry
▪ Hygiene (bathing, umbilical cord care, eye care)
▪ Body weight
▪ Parent-infant bonding
83
Feeding
• Breastfeeding
– Initiate breastfeeding within half an hour after birth
– Feed on demand
– Encourage exclusive breastfeeding
• Formulary feeding
– Q3H intervals (8 times per day)
– Observe for the tolerance
84
The output of infant who’s breastfeeding should be > 8 times
per day
Day
After
birth
First
24
hours
24 to
48
hours
Day 3
Day 4
Day5
Urine
(times
per day)
1
2-3
4
5
≥6
Bowel
(times
per day)
2-3
2-3
varies
85
85
Newborn screening in Hong Kong
1. Congenital hypothyroidism
2. Glucosse-6-phosphate dehydrogenase (G-6-P-D) deficiency
3. Hearing screening
4. (Voluntary) Inborn errors of metabolism (IEM)
86
Congenital hypothyroidism
• Thyroxine : essential for fetal growth, brain
development and body metabolism
• Incidence 1:4000 lives birth in Hong Kong
• Etiology:
❑ congenital Absence of thyroid gland
❑ deficient TSH secretion
❑ maternal anti-thyroid medications
– Hypothyroidism: High TSH, Low T4
• Untreated congenital hypothyroidism can
result in mental retardation
87
Congenital hypothyroidism
Early symptoms & detection:
• Prolonged jaundice
• Large tongue (macroglossia) & hoarse voice
• Constipation
• Poor feeding
• Poor weight gain
• Inactivity – excessive sleeping, poor muscle
tone
• Low body temperature
• Delayed motor development
• If not treated, severe mental impairment,
IQ<80 in majority
Neonatal screening:
– Collection of 2.5 ml placental cord blood
at birth
– Sent to the Central Genetic Neonatal
Screening unit
- follow up by checking blood for TSH, USG
and X-ray scanning
89
Glucose-6-phosphate dehydrogenase deficiency
• G6P is essential for the converting
oxidized haemoglobin back to
haemoglobin
• X-linked recessive inherited condition
• Commonest RBC enzyme defect in
Hong Kong
• Incidence in Hong Kong, male: 4.5%,
female 0.5%
90
Lifelong avoidance of certain Chinese herbal medicines and
drugs
Haemolysis after exposure:
• Chinese herbal medicine, e.g.
Rhizoma Coptidis 黃蓮, Flos
Chimonanthi Praecocis 臘梅花, Flos
Lonicerae 金銀花 Calculus Bovis 牛黃,
Margarita 珍珠末
• Aspirin
• Sulphonamides
• Nitrofurantoin
• Nalidixic acid
• Broad beans
• Mothballs (Naphthalene)
• s/s: neonatal jaundice (early, severe
& prolonged Jaundice)
91
G6PD screening program in HK
• Placental cord blood sent to Central Genetic Neonatal
Screening Unit
• Quantitative assay of G6PD assessed
G6PD activity (U/gHb)
Normal
Borderline
Deficient
4.3 – 9.0
1.7 – 4.2
< 1.7
92
‘Inborn Errors of Metabolism’
Define: Genetic defects which prevent some essential enzymes
in the body from being produced.
The defects may further result:
a. Deficiency of certain essential components
b. Accumulation of toxic substances in the body
If UNTREATED, the newborn/ infant/child may have serious
outcome:
i.
ii.
iii.
iv.
learning difficulties
mental retardation
organ dysfunction and
death
93
IEMs’ incidence - 1: 4355 in HK
Categories for Test Screens for 30 IEMs in HK • Amino acid disorders (intoxication): 69.8%
• Fatty acid oxidation disorders: 18.6%
• Organic acid disorders: 11.6%
Pathophysiological classification:
Group-1: Intoxication – amino acid disorders, most organic acidaemias …
Group-2: Energy metabolism - fatty acid oxidation, mitochondrial disorder,
congenital lactic acidemia,, hyperinsulinism …
Group-3: Complex molecules – lysosomal storage disorder, cholesterol synthesis
defects …
94
IEMs: Typical clinical features
Group-1: Intoxication –
• Normal AN development, symptom-free
period
• acute metabolic decompensation
• Vomiting, lethargy, coma, liver failure
Group-2: Energy metabolism –
• Failure to thrive, hypotonia,
myopathy/cardiomyopathy
• Cardiac failure, sudden death
Group-3: complex molecules • Symptoms are progressive and chronic,
unrelated to intercurrent events and
without specific precipitating factors
• Dysmorphism
• organomegaly
95
IEMs: Treatment – in general:
A. different types of IEM and symptoms presented, different
replacement given, like –
a. enzyme replacement therapy for mucopolysaccharidosis;
b. oral biotin in case of biotinidase deficiency and holocarboxylase synthase
deficiency;
c. administration of levocarnitine for carnitine uptake defect (carnitine
acylcarnitine translocase deficiency).
B. Emergency management –
❑Hypoglycaemia: Intravenous glucose
❑Metabolic acidosis: bicarbonate therapy ± renal replacement therapy
❑Hyperlactataemia: Mx cardiovascular stability by bicarbonate buffered
replacement and dialysate fluid in dialysis therapy
96
IEMs: Preventive - Screening
Target: All newborns
Time/ Date: after completion of 1st oral feeding for 1st -7th day
of life, unless physically not fit.
Method: Blood for 24 (DH/HA) or 30+3 (CUHK) IEM tests
How accurate: 99% with normal results, 1% uncertain and need
to have confirmatory investigations.
Results: ‘False positive’ which lead to anxiety, may occur, but the
risk of ‘False negative’ is rare.
Supporting organizations: DH, HA hospitals (PWH QMH QEH),
Private hospital (HKBH)
97
Newborn hearing screening
• Incidence of moderate-severe deafness
– 1-2 per 1000 lives births
• Mild to moderate hearing loss
– 4-5 per 1000 live births
• Earlier identification & intervention of deafness before 6
months → better outcomes language acquisition and
communication (NIH, 1993)
• Screening in newborn period → early detection of hearing loss
• 1ST AABR screening on 1st day of life or earliest possible time
(≥35 weeks of gestational age)
98
Consequence of late detection of hearing loss
• Delays and difficulties in
– Language
– Cognitive
– Psychosocial skills
• Lifelong impact on
– Literacy
– Educational achievement
– job opportunities
99
Method for screening –
Automated Auditory Brainstem Response (AABR)
• Detect the electric response in the brainstem after received a
auditory stimulus
• Able to pick up pathologies from ear to brainstem (conductive,
sensori-neural & mixed hearing loss)
100
Immunization
Before discharge
• Hepatitis B vaccine – first dose
• Hepatitis B immunoglobulin will be given to infant who is born
to HbsAg positive mothers
• B.C.G. vaccine
• Immunization card to be given for follow up in Maternal Child
Health Centre
https://www.youtube.com/watch?v=WRVCptt-wpg (2:30)
IMI to baby
101
102
References
American Academy of Pediatrics (2004). Management of hyperbilirubinemia in the newborn infant 35 or more
weeks of gestations. Pediatrics. 114, 297-318.
Ball, J., Bindler, R., & Cowen, K. (2012). Principles of pediatric nursing. (5th ed.). Boston: Pearson.
Davidson, M.R., London, M.L., & Ladewig, P.A.W. (2012). Old’s Maternal-newborn nursing & women’s health across
the lifespan. Boston: Pearson.
Hockenberry, M. J., & Wilson, D. (2011). Wong’s nursing care of infants and children. (9th ed.). St. Louis: Elsevier
Mosby.
Lam, BCC (2006). Newborn hearing screening in Hong Kong. Hong Kong Medical Journal 12(3), 212-218.
Leifer G (2007). Introduction to Maternity & Pediatric Nursing (5th ed.) St. Louis: Mosby.
London, M.L., Ladewig, P. W., Ball, J. W., Bindler, R.C. & Cowen, K.J. (2011). Maternal & child nursing care. (3rd ed.).
New York: Pearson.
Lowdermilk D.L., Perry S.E. & Cashion, K. (2010). Maternity Nursing (8th ed.) Maryland Heights: Mosby Elsevier.
Mattson, S. & Smith, J. E. (2011). Core curriculum for maternal-newborn nursing. (4th ed.). Saint Louis: Saunders
Elsevier.
Murray, S. S. & McKinney E. S. (2010). Foundations of Maternal-Newborn and Women’s Health Nursing (5th ed.).
Maryland Heights: Saunders Elsevier.
Riordan, J., & Wambach, K. (Ed.). (2010). Breastfeeding and human lactation. (4th ed.). Boston: Jones and Bartlett
Publishers.
Porth, C. M., & Matfin, G. (2009). Pathophysiology, concepts of altered health states. (8th103ed.). China: Lippincott
Williams & Wilkins.
103
Breastfeeding
Christine Lam
N. Consultant (Breastfeeding)
Dept of O&G QEH
一個國家的嬰幼兒營養政策，
對其全體人民的健康和福祉
有著長遠的影響。
The topics:
•
•
•
•
•
•
•
•
Importance of breastfeeding
Current trends in breastfeeding in Hong Kong
Composition of breastmilk
How breastfeeding work
How to assure successful breastfeeding
Breastfeeding technique and assessment
Common breastfeeding problems in early days of life
How to support, promote and protect breastfeeding
Percentages of newborns ever breastfed
on discharge from hospitals Hong Kong, 1981-2016
10%
4
Source: Regular reports from all maternity units in public and private hospitals in Hong Kong.
Breastfeeding Rates and
4m Exclusive Breastfeeding Rate, 1997-2016
100
Breastfeeding on
Hospital discharge
Breastfeeding Percentage (%)
90
80
70
60
50
51.3
54.1
55.3
79.9
60.1
63.5
65.9
69.6
86.3
86.8
73.5
44.2
40
Exclusive breastfeeding for 4 m
26.6
30
20
10
85
6
5.8
5
1997
1998
1999
8.3
9.2
2000
2001
12.4
11.5
13.5
12.7
14.8
2002
2004
Year
2006
2008
2010
30.7
19.1
0
2012
2014
2016
5
Source: Regular reports from all maternity units in public and private hospitals in Hong Kong & BF Survey FHS,DH
2017 DH Survey Result in Breastfeeding
90
BF rate (all forms) excluded EBF
80
Breastmilk and solid food only
Rate (%)
70
EBF rate
60
50
40
44.4
36.4
86.8
24.8
18.2
30
20
33.8
33.4
30.7
27.9
28.2
10
0.9
0
Ever BF
1-month
2-month
4-month
6-month
12-month
Source: 2017 BF survey FHS, DH
The exclusive breastfeeding rate at 4-6 months
has increased about 3% in 2016 survey
100
BF Rate (all forms) excluded EBF
90
Breastmilk and solid food only
80
EBF rate
Rate (%)
70
60
42.3
50
40
86.3
44.4
30.6
86.8
36.4
23.7
24.8
15.5
30
20
30.8
10
33.8
30.4
33.4
26.6
30.7
0
2014
2016
Ever BF
2014
2016
1 month
2014
2016
2 month
2014
2016
4 month
18.2
24.3
27.9
1.2
0.9
2014
2016
6 month
25.1
28.2
2014
2016
12 month
Source: 2017 BF survey FHS, DH
母乳 相對 奶粉的成份
超過400種有益成分是奶粉裡没有的:
容易消化, 包括大量抗體、活細胞, 成長因
子、荷爾蒙、酵素等等
+ 促進嬰兒發展的成分，如必需脂肪酸、
DHA、 AA…等。各成分互相配合
哺乳是懷孕的延續
出生前
胎盤
從媽媽得到
出生後
哺乳
•
溫暖
•
營養
•
抗體保護
Composition of Breastmilk
• A perfect balance of all constituents.
• Automatically adjust to the need of our
human development.
• > 400 known constituents as well as
constituents that are not yet identified.
• Each animal has milk specific to the needs
of that species
Composition of Breastmilk - Water
• Is the major constituent of human milk.
Even in hot climates, provides sufficient
water for the exclusively breastfed infant to
remain adequately hydrated.
Composition of Breastmilk - Lipids
• About 50% of the calories come from lipids.
• The primary fats identified are phospholipids and
triacylglycerols.
• > 167 fatty acids have been identified, many of which
are long chain, polyunsaturated fatty acids.
• Contains omega-3 fatty acids, including
docosahexaenoic acid (DHA), important for brain and
retinal development and function.
• DHA:
– tissue membranes require DHA
– Human can convert linolenic acid to DHA but inefficiently
– DHA well absorbed from breast milk, poorly absorbed from
artificial milk
Composition of Breastmilk - Lipids
• Cholesterol, important to the development of
membranes, is also present in significant quantities.
• While the content of milk fat in mature human milk
usually ranges from 3.5% to 3.8%, it is important to
recognize that these figures represent an average fat
content. In reality, the fat content is variable and
influenced by a number of factors.
Differences in fats of different milks
HUMAN
Lipase
Essential
fatty acids
COW’S, FORMULA
EFA may be added
to formula
What differences do you notice here?
fat
more
-7
more
energy
HINDMILK
FOREMILK
Fat
Protein
Lactose
Colostrum
Mature Milk
Foremilk
Hindmilk
Composition of Breastmilk - Protein
• The total protein content of breastmilk, 0.9%, is the
lowest among mammals.
• Low protein content is well matched with the developing
renal function of the neonate.
• The low renal solute load places less excretory burden
on the immature system
• Two major components: whey and casein.
• Milk curd (forms from the casein when the milk pH
(normally ranging from 6.7 to 7.4) drops below 5.0) is
an insoluble calcium caseinate-calcium phosphate
complex.
Composition of Breastmilk - Protein
• Whey : water, electrolytes and important proteins:
disease resistance including alpha-lactalbumin,
lactoferrin, lysozyme and the immunoglobulins.
• Whey : casein 80 : 20
softer gastric curd, reduced
gastric emptying, facilitate digestion
– Colostrum 90:10
– Mature milk 60:40
• Human milk protein is predominantly whey.
– allowing for easy digestion and absorption as well as rapid
transit through the intestinal tract of the human infant.
– This results in the normal pattern of frequent feeding and
stooling characteristic of breastfed infants.
• Formula contains no proteins which protect against
infection.
WHO/CDR/93.6
Difference in the quality of the
proteins in different milks
COW’S
HUMAN
Anti-infective
proteins
Whey
80%
Casein
35%
Casein
Easy to digest
Difficult to digest
1/3
Protein
• !! there are a number of nitrogen containing
compounds in human milk with bioactive roles,
important to the newborn and young infant. These
include:
– epidermal growth factor - For development and
function of the intestinal mucosa
– taurine - bile acid conjugation and neurotransmission
– nucleotides - metabolic and immune functions
– carnitine - needed in the lipolysis of long-chain fatty
acids
Composition of Breastmilk - CHO
• Lactose, a disaccharide: galactose and glucose.
• Major CHO & is essential as a source of glucose.
• Also the source of galactose needed to produce galactolipids for
infant brain development.
• Other CHO include monosaccharides, oligosaccharides and
glycoproteins.
• The oligosaccharides and glycoproteins, known collectively as
the “bifidus factor”, are important in stimulating the growth,
and colonization of the newborn gut with Lactobacillus bifidus,
a non-pathogenic bacteria which protects against invasive
enteropathogens.
• Oligosaccharides also prevent the adherence of bacteria to the
mucosal surface and are considered a prebiotic.
Composition of Breastmilk - CHO
• Lactose.
–
–
Calcium and iron absorption
intestinal colonization with lactobacillus bifidus
and gut flora,
–
promote acidity GI tract inhibit growth if
pathogenic bacteria
– formula-fed baby has higher pH level
If – damage of intestinal brush border loss of lactase
temporary lactose intolerance
Composition of Breastmilk - Minerals
• All minerals needed for newborn and infant
growth well absorbed from human milk.
• The lower quantities of minerals in human milk
result in a substantially lower solute load to the
infant’s immature renal system.
Iron
• Fe in human milk is not large (100 μg/liter), but the
absorption is superior. (highly biological available 50% 70%)
• Lactoferrin
– contributes to iron bioavailability in human milk.
– It is a protein found in whey, it binds Fe and makes it available for
digestion and absorption by the infant.
– This binding of iron also inhibits bacterial growth (iron unavailable to
iron dependent organisms).
– Too much iron in formula which are not well absorbed and favors the
development of pathogenic gut bacteria by saturating lactoferrin
• Normal full-term infants can be “exclusively breastfed” (no
other foods or fluids) for six months without becoming iron
deficient.
• Absorption is enhanced by high lactose and Vit. C conc in
human milk
•
Fe reduce zinc and copper absorption
Breastmilk100mcg/L
Formula milk 12mg/L
Iron in milk
Formula milk
HUMAN
50%
% absorbed
4%
Zinc
• Essential mineral for humans and is important
to enzyme activity.
• Like iron, it is well absorbed from human milk
• Both iron and zinc are important to normal
brain development and function.
Composition of Breastmilk - Enzymes
• Over 30 bioactive enzymes identified.
• Some enzymes function in the synthesis of milk, some
compensate for digestive enzymes needed but not yet
produced in adequate quantity by the newborn,
• some help transport minerals, and others are antiinfective. E.g, lipase in breast milk works
synergistically with lingual lipase and gastric lipase to
form an efficient system for complete digestion of
human milk fat.
• This is particularly important during the months after
birth when pancreatic enzyme and bile salt levels are
low.
Composition of Breastmilk –
Other Important Components
• Human milk contains numerous peptide and
nonpeptide bioactive hormones:
–
–
–
–
–
–
–
thyroxine,
prolactin,
erythropoetin,
epidermal growth factor (EGF)
insulin,
leptin and gastrin.
Prostaglandins, also present, influence gastrointestinal
motility.
Composition of Breastmilk –
Cellular Components
- Human milk is a living tissue.
- contains about 4000 cells per cubic mm including
neutrophils, macrophages & lymphocytes.
- Neutrophils help prevent infection of the breast tissue
while macrophages and lymphocytes are actively
involved in providing immuno- protection for the
newborn and young infant.
- Macrophages secrete lysozyme, kill bacteria, and are
active in phagocytosis.
Summary of differences between milks
Component
Protein
Human milk
Right amount
Easy to digest
Cow’s milk
Formula
Too much
Quantity reduced
Difficult to digest Quality as cow’s
essential
Fats
EFA’s present No EFAs fatty
Lipase to digest No lipase
Some EFA added
No lipase
Carbohydrate
Lactose - plenty Lactose - less
Lactose + sucrose
Acid
Oligosaccharides Oligos not suitable Lacks oligos
(anti-infective)
Vitamins and
minerals
Adequate if
Low Vit A and C Vits/mins added
mother enough and iron
usually enough
Anti-infective
factors
IgA, lactoferrin, None
lysozyme, cells
Growth factors Present
None
None
None
Breastfeeding in the 21st century: epidemiology,
mechanisms, and lifelong effect
Children who are breastfed for longer periods have :
•
•
•
Lower infectious morbidity and mortality,
Fewer dental malocclusions, and
Higher intelligence than do those who are breastfed for
shorter periods, or not breastfed. This inequality persists
until later in life.
Growing evidence also suggests that breastfeeding
might protect against overweight and diabetes later in
life.
Breastfeeding in the 21st century: epidemiology,
mechanisms, and lifelong effect
Breastfeeding benefits mothers. It can:
• Prevent breast cancer,
• Improve birth spacing,
• Might reduce a woman’s risk of diabetes and ovarian
cancer
High-income countries have shorter breastfeeding
duration than do low-income and middle-income
countries.
However, even in low-income and middle-income
countries, only 37% of infants younger than 6 months
are exclusively breastfed.
Breastfeeding in the 21st century: epidemiology,
mechanisms, and lifelong effect
• The scaling up of breastfeeding can prevent an
estimated 823,000 child deaths and 20,000 breast
cancer deaths every year.
• Findings from studies done with modern biological
techniques suggest novel mechanisms that
characterise breastmilk as a personalised medicine
for infants.
• Breastfeeding promotion is important in both rich
and poor countries alike, and might contribute to
achievement of the forthcoming Sustainable
Development Goals.
States of Lactogensis
* Stages of lactation
(criteria devised by Peter Hartmann)
•
Mammogenesis – “priming” - growth and development
•
Lactogenesis – onset of milk production
•
Galactopoiesis – maintenance of milk production
•
Involution – decline and cessation of lactation -
of ducts and alveoli in the first 12 weeks of pregnancy the breast is prepared for lactation by 16 weeks;
- Lactogenesis I - early secretory changes - colostrum
- Lactogenesis II – production of copious mature milk
- Lactogenesis III - or simple “lactation”
- Return of mammary gland to non-lactating state
Protection against infection
(1)
Mother
infected
(4) Antibodies to
mother's infection
secreted in milk to
protect baby
(2) White cells in
mother’s body
make antibodies to
protect mother
(3) Some white cells
go to breast and
make antibodies
there
sIgA (secretory IgA)
• Most infections via the mucosal membranes (100
times large area than skin). 90% of micro-organizms
infecting humans cross the mucosa.
• Man’s mucosal immune system consist almost
exclusively of specially structured antibodies to stop
this type of infection.
• sIgA :
–
–
–
–
–
main antibodies on mucosal membranes and in human milk.
Not found in blood. Resist to proteolytic enzymes.
sIgA :80% of all antibodies.
prevent the entry of microbes into tissue.
Migrates thro the epithelial cell onto the cell surface.
sIgA (secretory IgA)
• Prevent bacterial and viruses attaching the
epithelial cells and entering the tissue.
• Anti-inflammatory reaction: prevents activation of
the tissue-damaging, energy consuming, proinflammatory defense of IgG, complement action
and phagocytes. reserve energy for growth and
development.
PSYCHOLOGICAL BENEFITS OF
BREASTFEEDING
-
Emotional bonding
Close, loving relationship between mother and baby
Mother more emotionally satisfied
Baby cries less
Mother behaves more affectionately
Less likely to abandon or abuse baby
BREAST-MILK IN THE SECOND YEAR
Energy required by age and the amount from breast milk
Energy 1200
Kcal/
day) 1000
800
600
400
200
0
0-2 m
3-5 m
Energy gap
Energy from breastmilk
6-8 m
Age ( months)
9-11 m
12-23 m
RECOMMENDATIONS
Start breastfeeding within 1 hour of birth
Breastfeed exclusively to 6 months of age
Give complementary foods to all children
from 6 months of age
Continue breastfeeding up to 2 years of age
or beyond
Some formula?
• Formula changes the gut flora in breastfed
babies by breaking down the mucosal barrier
that colostrum provides them. This violation
allows pathogens and allergens entry into the
baby’s system.
(Ogawa 1992)
• Supplemental bottle of artificial infant milk
can sensitize a newborn to cow’s milk protein
(Kalliomaki and Isolauri 2003).
DANGERS OF ARTIFICIAL FEEDING
Interferes with bonding
More diarrhoea and
respiratory infections
More allergy and milk
intolerance
Persistent diarrhoea
Increased risk of some
chronic diseases
Malnutrition Vit. A
deficiency
More likely to die
May become
pregnant sooner
Overweight
Lower scores on
intelligence tests
Increased risk of anaemia,
ovarian and breast cancer
Colostrum: all baby needs
In the first few days colostrum, a
low volume and high density food
is produced for newborns. Babies
should be exclusively breastfed
and most mothers have milk
come-in on 3rd day.
1st
day
2nd
day
Milk comes
in
COLOSTRUM
Property
Antibody rich
Many White cells
Purgative
laxative
Growth factors
Vitamin A rich
Importance
– protects against infection and
allergy
– protect against infection
– clears meconium
helps to prevent jaundice
– help intestine to mature
prevent allergy, intolerance
– reduces severity of infection
Prevent eye disease
How breastfeeding works?
Parts of the Breast
Prolactin
Secreted after
feed to produce
next feed
Sensory impulses
from nipple
Prolactin in blood
Baby suckling
* More prolactin
secreted at night
*Suppresses
ovulation
Prolactin
• After birth, ,two hormones - Prolactin and
Oxytocin become important to help
production and flow of milk.
• Under the influence of prolactin, the breasts
start to make larger quantities of milk.
• It usually takes 30-40 hours after birth
before a large volume of milk is produced
(milk comes-in).
Prolactin
• Produced from the anterior pituitary gland.
• Hormone that makes the alveoli produce milk.
• Works after a baby has taken a feed to make the
milk for the next feed.
• Can also make the mother feel sleepy and relaxed.
• Is high in the first 2 hours after birth, also high at
night.
• Breastfeeding at night allows for more prolactin
secretion.
Oxytocin Reflex (let-down reflex)
Works before or
during feed to make
milk flow
Causes smooth muscles
to contract squeezing
milk out
Sensory impulses
from nipple
Baby suckling
makes uterus contact
Oxytocin
• Controlled by the posterior pituitary gland.
• Causes the muscle cells around the alveoli to
contract and makes milk flow down the ducts.
• Essential to enable the baby to get the milk. This
process is called the “oxytocin reflex”, “milk
ejection reflex”, or “letdown”.
• It may happen several times during a feed.
Oxytocin
• Soon after a baby is born, the mother may
experience certain signs of the oxytocin reflex.
These include:
– painful uterine contractions, sometimes with a rush of
blood;
– a sudden thirst;
– milk spraying from her breast, or leaking from the
breast which is not being suckled;
– feeling a squeezing sensation in her breast.
• However, mothers do not always feel a physical
sensation.
• When the milk ejects, the rhythm of the baby's
suckling: rapid slow deep
Oxytocin
adherence
Seeing, hearing, touching and thinking lovingly about
the baby, helps the oxytocin reflex.
The mother can assist the oxytocin to work by:
- Feeling pleased about her baby and confident that
her milk is best.
- Relaxing and getting comfortable
- Gently stimulating the nipple.
- Keeping her baby near so she can see, smell, touch
and respond to her baby.
Oxytocin Reflex
Thinks lovingly
of baby
Sound of baby
Sight of Baby
CONFIDENCE
Helps reflex
Worry
Stress
Pain
Doubt
Hinder reflex
WHO/CDR/93.6
3/5
Inhibitor in Breastmilk
Feedback Inhibitor
of Lactation (FIL)
If breast remains
full of milk,
secretion stops
Feedback Inhibitor of Lactation = FIL
• If milk not removed, production decreases
• It is suppressed by a chemical inhibitor, FIL
• FIL is an autocrine, or local, regulator of breastmilk
synthesis
• FIL is a peptide (small protein) made in the breast
itself
• If milk not removed, FIL collects in alveoli
• As the concentration of FIL increases it blocks milk
secretion in the mammary cell
• If milk removed by suckling, concentration of FIL
falls and milk secretion continues
Feedback Inhibitor of Lactation
• To prevent the FIL from collecting and
reducing milk production:
– make sure that the baby is well attached;
– encourage frequent breastfeeds;
– allow baby to feed for as long as she or he wants
at each breast;
– let the baby finish the first breast before offering
the second breast;
– if baby does not suckle, express the milk so that
milk production continues.
Milk transfer from breast to baby
• The baby’s suckling controls the prolactin
production, the oxytocin reflex and the removal of
the inhibitor within the breast.
• For a mother to produce the milk that her baby
needs, her baby must suckle often and suckle in
the right way.
ROOTING REFLEX
When something
touches lips,
baby opens mouth
puts tongues down
and forward
Skill
Mother learns
to position
baby
Baby Learns to
take breast
SUCKING REFLEX
When something
touches palate, baby
sucks
SWALLOWING REFLEX
When his mouth fills with
milk, baby swallows
Early skin-to-skin contact
A very precious and significant moment
•Uterine contraction
•Decrease crying of baby
•The beginning of lactation programmed to find the
breast
– More effective suckling
– Stabilized sugar level
– Regulate Tº
•Bacteriological point of view colonized with the
familiar and friendly germs & share the same IgG with
mothers
•Thermoregulation
How long should skin-to-skin contact last?
• At least one hour or until after the first feed.
• As long as mother wishes.
Assessment of Breastfeeding
Good attachment
Poor attachment
WHO/CHD/93.4, UNICEF/NUT/93.2
Breastfeeding Counselling: a training course,
6/3
What can you see?
Good Attachment
•
•
•
•
•
•
Chin and cheek touch breast
Mouth wide open
Lower lip turned outward
Cheek round
Lower lip cover more areola
Slow and deep sucks (Change sucking from
quick shallow to deep sucks after few sucklings)
• Can see and hear swallowing
Breast engorgement and teat
may affect attachment
4 key points of
Good Attachment
Baby’s mouth open wide
(Asymmetrical Latch)
More areola seen above
the baby’s mouth
Lower lip turn out
Chin indent into the
breast
68
Poor Attachment :
* damages the nipple,
* baby cannot get
much milk
69
Insert finger into mouth to release from breast
Transitional Hold
Suits newborn and
small baby
• Bottom supported
• Body touches body
• Nose to mom’s nipples
Underarm Positon
(Football Hold)
• if she is having difficulty attaching her
baby across the front;
• Small baby
• twins;
• to treat a blocked duct
Side-Lying Position
Back well supported
Cushion to
separate knees
Use 2 pillows
for better view
His nose to mom’s nipple
Baby’s back is supported
Video
注意！
•奶水要多 →多餵、親餵
•不能親餵 →手擠奶
擠奶方法
- 乳脹
- 乳腺生病
- BB吸啜不正確/吸啜不到
- BB生病，不能吸啜
- 上班
- 乳汁減少
- 乳頭破損
「每個媽媽應學會用手擠奶」
Why is hand expressing a useful
skill for mothers?
• Can help with attachment,
• Relieves engorgement, helps deal with a blocked
duct
• Better for expressing colostrum.
擠奶技巧 Milk Expression Technique
姆指及食指相對，
離開乳頭底部約 3厘米
手指向內及向下壓
(手指切勿向前拉)
Thumb and index finger
opposite to each other
2-3 cm away
from base of nipple
Press inward and downward
(No Pulling or Sliding)
79
不要
• 拉引乳頭及乳房，
• 雙手在整個乳房上滑動推擠
母乳儲存
容器
• 有密封蓋的膠瓶
• 可急凍的貯奶袋
保存時間
1. 室温：
•
5 – 15 ˚C：24 小時
• >15 – 25 ˚C： 8 小時
• >25 – 37 ˚C： 4 小時
2. 雪櫃的冷凍部份：
• ( 2 – 4 ˚C)最多可貯存5日
* 視乎雪櫃溫度的穩定性
3. 冰奶存放：
• 單門雪櫃的冰格：2 星期
• 雙門 / 三門雪櫃的獨立冰格：( ≦ – 18 ˚C )：3 個月
• 獨立冷藏櫃： ( – 20 ˚C )：6 個月
(Reference : BFHI WHO 2006, CDC Guideline in Proper Handling and Storage of
human milk 2004, NICE Public Health Guidance II 2008)
Rev. Mar 2008
When assessing a BF what is the key information
that you need to find out?
• Signs of effective attachment:
–
–
–
–
number of feeds,
length of feeds,
baby’s behaviour on the breast,
sucking pattern.
• Baby:
– weight,
– urine and stool output (with appropriate detail).
• Mother:
– condition of breasts and nipples.
人奶吃得夠嗎?
•
•
•
•
•
首24小時最少餵食3-4次
之後平均8-12次一日
吸啜正確
小便清澈, 次數足夠
每月體重 > 0.5公斤
胎糞轉色
第一天
第二天
第三天
第四天
第五天
第六天
第七天
絕大部份母親
都能純母乳餵哺
寶寶餵飽了更
不願意吸吮乳
減慢母乳製造
可能令嬰兒產生敏感
加添奶粉
減少吸吮乳房
奶咀能導致乳頭混淆
如有需要，請你找助產士:
•檢查你寶寶的身體是否需要
加添奶粉
母親更焦慮
乳汁分泌減少
•評估你餵母乳的方法、姿勢
是否正確
•教你如何安撫孩子
寶寶得不到滿足
Responsive feeding
• BF can be used to
– feed,
Baby’s need
– comfort and calm babies.
– when the mother’s breasts feel full or when
she would just like to sit down and rest. Mom’s need
• BFs can be long or short,
• BF babies cannot be overfed or ‘spoiled’ by too
much feeding
Feed Responsively:
Apply to both
breastfeeding &
bottle feeding
Common breastfeeding problems
in early days of life
Most medications are
compatible with Breastfeeding
Protection against infection
(1)
Mother
infected
(4) Antibodies to
mother's infection
secreted in milk to
protect baby
(2) White cells in
mother’s body
make antibodies to
protect mother
(3) Some white cells
go to breast and
make antibodies
there
Sore nipples：
Causes：Mainly due to poor incorrect
position
Management:
Treat early
Correct positioning
Bring baby out carefully
Use breastmilk for soreness
乳頭破損
Engorgement
• Increased blood and lymph circulations
• Milk inflammatory reaction (congestion of fluid in
tissues)
• Low grade fever, chills, hard and painful breast
• Decrease milk flow
• Swollen areola makes attachment more difficult
• Untreated sore nipple, frustrated mother and baby
谷奶時，先擠奶至乳暈柔軟才餵哺
Causes and prevention
of breast engorgement
CAUSES
PREVENTION
• Plenty of milk
• Delay starting to breastfeed
• Start breastfeeding soon
after delivery
• Poor attachment to breast
• Ensure good attachment
• Infrequent removal of milk
• Encourage unrestricted
breastfeeding
• Restriction of length of
feeds
Separation with baby
Express colostrum
within 6 hrs
As
Express every 3 hours
Total within 30 mins
Use hand in initial days
Can use breastpump
when milk “comes-in”
it
.
/
hand expression
96
Cup Feeding
• Baby-led. Baby must be alert and
shows cues of feeding
• Baby can smell the milk
• Help digestion and learning
• Can be used for preterm baby
• Involvement of the tongue
• Sit upright
• Rest the cup on the lower lip,
don’t press too heavy
• No pouring of milk
How to assure successful
breastfeeding?
THE WHO 10 STEPS TO SUCESSFUL BREASTFEEDING
1. Have a written breastfeeding policy that is
routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to
implement this policy.
3. Inform all pregnant women about the benefits
and management of breastfeeding.
4. Help mothers initiate breastfeeding within a halfhour of birth.
5. Show mothers how to breastfeed, and how to
maintain lactation even if they are separated
form their infants.
6. Give newborn infants no food or drink other than
breastmilk, unless medically indicated.
7. Practise rooming-in – allow mothers and infants
to remain together – 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called
dummies of soothers) to breastfeeding infants.
10.Foster the establishment of breastfeeding
support groups and refer mothers to them on
discharge from the hospital or clinic.
Hospital Policies:
% of mothers, breastfed < 6 weeks
Increased number of “Baby-Friendly” Hospital practices
in place decreases risk of breastfeeding cessation
30.0%
26.9%
21.5%
15.5%
Steps measured:
Early bf initiation
Exclusive breastfeeding
Rooming-in
On-demand feedings
No pacifiers
Information provided
13.7%
6.2%
0
1
2
3
4
5
3.2%
6
Number of Baby-Friendly steps mothers reported
experiencing
DiGirolamo, Pediatrics, 2008
Duration of any breastfeeding by number of
baby‐friendly steps experienced
Tarrant, M. Impact of baby‐friendly hospital practices on
breastfeeding in Hong Kong. Birth, 38(3).
Protect Breastfeeding
• International Code of Marketing of
Breast-Milk Substitutes
– Formula milk
– Bottle & Teat
– Cereal and baby food
Compliance with the WHO international code of
marketing of breast milk substitutes means;
•
•
•
•
•
•
•
NO advertising.
NO donations.
Of Breastmilk
NO free samples.
Substitutes
NO promotion.
NO gifts.
NO pictures idealising formula feeding.
NO use of equipment sponsored or produced by formula
companies.
The International Code on the
Marketing of Breastmilk Substitutes
is widely violated in Hong Kong.
Marketing of Formula Milk in Hong Kong 2013
(From DH, Hong Kong)
Breastfeeding/Provision of Human Breast
Milk=Primary Prevention!
Think!
• What practice will damage breastfeeding?
–
–
–
–
–
Government
Community
Commercial
Family
……
Breastfeeding Myths
• Breastmilk is not enough for babies
• Mother doesn’t have enough milk because her
breasts are small, she is old, she ….
• Mother should not breastfeed when: she is ill, she
takes medication, she has breast problems, she is
C/S, ……
• Babies should not be breastfed when he has NNJ, he
is X months old, he is sick, he has teeth, …..
Good Professional, consistent advice helps
mothers to breastfeed for longer
How to sustain breastfeeding
•
•
•
•
Promotion
Initiate breastfeeding
Establish breastfeeding
Sustain breastfeeding
Mother may stop breastfeeding
because
• Of the attitudes and beliefs in their community
• They have to resume work outside home
• Because health care practices are not supportive
Support Breastfeeding & Work
Two half hour breastfeeding break for staff
Breastfeeding
Friendly
Premies
Neonatal Jaundice
Neonatal Jaundice (Hyperbilirubinaemia)
Definition:Increase serum bilirubin
visible yellowing of skin,
sclera …
Bilirubin
• In the fetus –the placenta eliminate most of
the lipid-soluble bilirubin.
• In the newborn –bilirubin must be conjugated
in the liver to a water-soluble form, before it
can be excreted in the bile.
• An endogenous ‘anti-oxidant’ produced in the
body.
3
Metabolic Pathway of Bilirubin
Red Blood Cell
Breakdown of RBC
Haemoglobin
Haem
Iron
Bilirubin
(unconjugated, fat-soluble)
Globin
Unconjugated Bilirubin (Blood)
Activity of
enzymes
Physiological
jaundice
Conjugation in Liver
Portal circulation
Prematurity
Infection
Conjugated Bilirubin (Direct Bilirubin)
Hypothyroidism
(water soluble)
Bile
Bile Duct
Enterohepatic
Circulation
Stool / Urine
Reabsorption & rehydrolysed
•Biliary atresia
•Choledocal cyst
Dark color urine
• In normal metabolism, lipophilic bilirubin, which results
predominantly from the catabolism of red cells, circulates
in blood mainly as a noncovalent conjugate with serum
albumin.
• After uptake by the liver, it is converted into two isomeric
monoglucuronides and a diglucuronide (direct bilirubin) by
the enzyme uridine diphosphate glucuronosyltransferase.
Premature Infants
At a higher risk for problems:
• Have a lower plasma albumin level
• Have a lower albumin binding capacity
• Blood-brain barrier –more porous to the
bilirubin (e.g. anoxia)
Bilirubin levels in pre-term infants peak later
at 5 to 7 days of life.
11
Breastfeeding Preterm or Late Preterm Infants
• Jaundice in late preterm infants results from:
– Increased bilirubin due to increased bilirubin production
– Decreased bilirubin elimination
– Insufficient breast milk intake even when mom’s milk
established
– Inability to ingest larger volumes of breast milk
• Hyperbilirubinemia in late preterm infants:
– Increased incidence
– Increased severity
– Longer course
– Increased risk of deleterious consequences
12
Breastfeeding & Jaundice
•
•
•
•
•
•
•
•
Not enough Breast milk Jaundice/ Breastfeeding Jaundice
Hospital routines which lead to insufficient breastfeeding
Baby poorly latched-on
Mother’s milk take longer to ‘come in’(not common)
Breast Milk Jaundice
?Etiology
Onset after day7
Thriving baby
Peaks at 10-21 days, lasts for 2-3 months
An extension of physiological jaundice
13
Management of NNJ
• Assessment
• Observation
• Treatment
– Ensure adequate intake
– Phototherapy
– Exchange transfusion
Findings
• History taking
• Onset of NNJ, any onset within 1st 24 hrs
should be assumed as serious.
• Examine under good daylight: face, chest,
hands and feet.
• Take blood for serum bilirubin,
haemoglobin, (if necessary baby’s blood
group and perform Coomb’s test.)
Assessment for NNJ
•
•
•
•
Yellowing of skin
Pallor
Any source of haemolysis
Hydration of baby
Phototherapy
• PT is the use of visible light for the treatment of
hyperbilirubinemia in the newborn.
• This relatively common therapy lowers the serum
bilirubin level by transforming bilirubin into watersoluble isomers that can be eliminated without
conjugation in the liver.
• The dose of phototherapy largely determines how
quickly it works; the dose, in turn, is determined by
the wavelength of the light, the intensity of the light
(irradiance), the distance between the light and the
infant, and the body surface area exposed to the light.
Phototherapy
• Effective irradiance delivery:
–
–
–
–
–
–
maximizing skin exposure,
providing eye protection and eye care,
carefully monitoring thermoregulation,
maintaining adequate hydration,
promoting elimination, and
supporting parent-infant interaction.
NNJ and BF
• Breastfeeding Jaundice
– Developed in early days
– ↓ BF performance
– Not enough breastmilk
intake
– Overlap with
physiological jaundice
– NNJ resolved if BF
improves
• Breastmilk Jaundice
–
–
–
–
Develop around D10-14
Thrival babies
BF well
Arise from the pathway
of conjugation
– Subside gradually, can
last for few months
How to help a baby with NNJ
• Early and effective breastfeeding
• Frequent feeding
• Assess and ensure mother’s feeding technique and
baby’s effectiveness in getting mother’s milk
• Ensure FOLLOW UP in the first week of life
• Increase baby’s intake
– More feeding
– Extra express breastmilk to baby is baby is sleepy
SN3180: Childbearing Family Nursing
Puerperium –
Psychological & physiological changes
Kitty Wong
2018
–1
Learning outcome
By the end of the study, students should be able to:
1.
2.
3.
4.
5.
6.
Define puerperium
Describe in details: physiological changes in the reproductive system of
a woman in puerperium
Describe physiological changes that takes place in endocrine, CVS, GI,
urinary, musculoskeletal and integumentary systems of a woman in
puerperium
Describe the process of acquaintance between the newborn & parents
Describe Rubin’s 3 phases in puerperium
Define, describe the predisposing factors, characteristics &
management of:
- Postpartum blues/ baby blues
- Postpartum depression
–2
I. Physiological changes
Puerperium defines as the first 6 weeks after the birth
of an infant.
Many of the physiological changes:
retrogressive, i.e. return to non-pregnant state
progressive changes, e.g. initiation of lactation
–3
Changes: reproductive system
The Uterus (size increased by
15-20%)
Fundus of uterus:
Firm & contracted
Descent of uterine fundus:
palpated at umbilicus in
midline at 1 hr afterbirth
palpated 1 cm above
umbilicus within 12 hrs
decrease in height by 1 cm per
day
not palpable in abdomen at
Day 10
Source: Murray,S.S. & McKinney, E.S. (2006). Foundations of maternal-newborn nursing (4th
ed.). St. Louis: Saunders
–4
Changes: reproductive system
The Uterus
1. Uterine involution depends on 3 processes –
i. Contraction of muscle fibres
ii. Catabolism
iii. Regeneration of uterine epitheliem
2. Afterpains
3. Lochia – 3 stages (discuss it later)
–5
Changes: reproductive system
The Uterus
–6
Changes: reproductive system
The Uterus -
Placenta & endometrium
–7
Changes: reproductive system
The Uterus -
Amnion & chorion
–8
Changes: reproductive system
Involution of uterus - 3 processes:
A. Contraction of muscle
fibres
stops bleeding,
especially at area
where attached
placenta;
decreases uterine
size
Blood vessels
Source: Coad, J. & Dunstall, M. (2001). Anatomy & physiology
for midwives,p.314. Edinburgh: Mosby
Myeometrial
spiral fibres
B. Catabolism
undergo autolysis
Myometrial cells
reduce in size not in
number
Source: Coad, J. & Dunstall, M. (2001). Anatomy & physiology
for midwives, p.361.Edinburgh: Mosby
–9
Changes: reproductive system
The Uterus
C. Regeneration of uterine epithelium
a. Outer portion: expelled with placenta
b. Remaining portions will separated into 2 layers within 2-3
days:
Superficial: shed as lochia
Basal layer: contains “residual endometrial glands” remains
intact as endometrium
–10
Changes: reproductive system
The Uterus -
Basal layer
–11
Changes: reproductive system
The Uterus
Afterpains
•
•
Muscle cramps & pains occur after delivery
Commonly occur in multiparas & breastfeeding mothers
Lochia
– contains decidua, blood & lymph (leukocytes, mucus,
vaginal epithelial cells)
- 3 stages:
lochia rubra: day 1-3, red
lochia serosa: day 3-10, pink to brown-tinged
lochia alba: day 10-14, yellow-white
–12
How to record: amount of lochia rubra
Scanty
light
moderate
< 2.5 cm/ hr
< 10 cm/ hr
heavy
Saturated
pad/ hr
Excessive
Saturated
pad/ 15 min
< 15 cm/ hr
Source: Scoggin,J.(2004) Physiology & psychological changes. In Mattson & Smith (ed.) Core curriculum
for maternal-newborn nursing (3rd ed.) p.371-386. Philadelphia: Saunders
–14
Changes: reproductive system
The Cervix
After 3rd stage, Cervix becomes thin, bluish & oedematous ±
lacerations, open 3- 4 cm
External os widens
& presents with a
transverse “slit” by 4
weeks
internal
os to
normal
by 2
weeks
Source: Scoggin,J.(2004) Physiology & psychological changes. In Mattson & Smith (ed.) Core curriculum for maternal-newborn nursing (3rd ed.)
p.371-386. Philadelphia: Saunders
–13
Changes: reproductive system
The Vagina:
After vaginal delivery, it becomes oedematous + lacerations
rugae reappear
3-4 wks
return to pre-pregnant
size
6-8 wks
6-10 wks
epithelium
recover
normal vaginal
mucous
production
when ovulation
occurs
6 - X wks
childbirth
4. Ovulation: - depends on prolactin level, in …
Lactating mothers
80%,
Non-lactating
mothers
50%,
the first few cycles are
anovulatory.
–15
Changes: reproductive system
5. Return of menstruation:
Non-lactating mothers: 6-8 wks
Lactating/ breastfeeding mothers: 12 - 14 months relating to
breastfeeding status
6. Perineum:
is lax after delivery, but regains most of its muscle tone by Day 5
normal muscle tone of pelvic floor & ligaments of uterus regain
due to circulating progesterone
–16
7. Changes: Breasts
Lactiferous sinus
Lactiferous duct
↓ oestrogen &
progesterone levels
↑prolactin level
↑breast vascularity &
engorgement
Engorgement:
- occurs in 48 to 72 hours
- reduced when baby begins
to suck
- return to pre-pregnant state
by 2 wks in non-lactating
women
–17
Source: McKinley, M. & O’Loughlin, V. (2006). Human Anatomy. Boston: McGraw-Hill Co. Inc.
Breasts: Physiology of lactation
1. Production of breast milk Prolactin initiates
production of lactoalbumin, casein, lactose in
the epithelial cells of
mammary alveoli.
Stimulation of local nerve
endings by baby suckling in
turn induces secretion of
prolactin (from the
anterior lobe of the
pituitary gland)
breast milk.
Source: Coad, J. & Dunstall, M. (2001). Anatomy & physiology for–midwives.
18
p.361.Edinburgh: Mosby
Breasts: Physiology of lactation
2. Ejection of milk
Oxytocin
a. released from the
posterior lobe of the
pituitary gland in response
to sucking - the let-down
reflex
b. causes contraction of the
myoepithelial cells in the
mammary alveoli, forcing
milk into the lactiferous
ducts
c. Oxytocin also causes
uterine muscle contraction
Source: Coad, J. & Dunstall, M. (2001). Anatomy & physiology
for midwives. p.353 Edinburgh: Mosby
–19
Changes in endocrine system
1. Expulsion of placenta
rapidly circulating human
chorionic gonadotrophin, human placenta
lactogen, oestrogen, progesterone
2.
oestrogen
prolactin to act upon mammary
alveoli to stimulate production of milk
i. Breastfeeding mothers: prolactin level, but no
follicle stimulation in ovary (anovulatory)
ii. Non-lactating mothers: prolactin within 2-3
wks
follicle-stimulating hormone (FSH) act
upon ovary
oestrogen & progesterone
resume ovulation & menstruation
–20
Changes in Cardiovascular system
Heart position: return to normal
(apex move back from 4th rib level
to 5th one)
Cardiac output (CO) after 24
hrs due to:
i.
withdrawal of oestrogen
allows a diuresis
ii.
progesterone helps to
reduce fluid retention in
tissues during pregnancy
& delivery
CO returns to normal by 2-3 wks
Coagulation: haemoconcentration
risk of
deep vein thrombosis (DVT)
Plasma volume immediately at
delivery by:
a) diuresis
b) diaphoresis: profused
perspiration
Blood values:
Haemoglobin at delivery but
.
stabilizes in Day
2-3;
Haemocrit immediately at
delivery due to plasma
volume & dehydration
Blood values normally return to prepregnant value by
4-6 wks
–21
Changes in Urinary system
Prone to urinary retention @
Day 1 for vaginal delivery
induced oedema to bladder
neck, urethra and urinary
bladder
diuresis begins at first hour
after delivery up to one week
returns to normal function by 46 wks, though dilation of renal
pelvis, calyces and ureters may
last for 3 months
presence of acetones & protein
in urine which indicate
dehydration & result of
catabolism accordingly in the
first few postnatal days
Source: Murray,S.S. & McKinney, E.S. (2006). Foundations of
maternal-newborn nursing (4th ed.). P.399 St. Louis: Saunders
–22
Changes in GI system
Appetite returns to normal after delivery
Constipation occurs due to:
a. sluggish muscle tone (progesterone effect)
b. restrict intake (delivery)
c. discomfort/ pain at perineal area (laceration/ episiotomy)
1st Bowel movement resumes by 2-3 days; & normal pattern
regains by 8-14 days
haemorrhoids
–23
Changes in integumentary system
Hair:
loss peaks at 3-4 months after delivery
regrowth occurs by 9 months after birth
Hyper-pigmentation
- gradually disappeared after delivery
- Linea nigra
disappeared
(not striae): fade to silvery line but not
Diaphoresis – common, especially at night in
the 1st week after delivery
–24
Changes in Musculoskeletal system
∆ stretched muscles &
softened ligaments
normal by 6-8 wks
∆ except rectus abdominus
remains separated
Source: Murray,S.S. & McKinney, E.S. (2006). Foundations of
maternal-newborn nursing (4th ed.). P.399. St. Louis: Saunders
–25
Increase in Body temperature
Within the 1st 24 hours after delivery,
– Maternal temperature ↑ to 380C (100.40F) due to
exertion & dehydration
– An ↑ temp. to 37.8-390C may occur after the
mother’s milk comes in
If women not meets these criteria, ↑ temperature may
indicate infection.
(Davidson et al, 2012:992)
–7
II. Psychological changes
Relationship between infant & parents
•
•
•
•
Bonding
Attachment
Maternal touch
Verbal behaviours
Would the woman recover from stress of pregnancy
& delivery ?
Role changes: who would assume the responsibility
for care of infant ?
–27
Psychological changes –
Relationship between infant & parents
Process of acquaintance:
1. Bonding
a rapid initial
attraction felt by the
parents afterbirth;
unidirectional
(parents
infant)
this sensitive period:
first 30-60 minutes
afterbirth
–28
Psychological changes
… Process of becoming acquainted
2. Attachment
an enduring bond between parents & infant is
developed
Interactive between parents and infant
parents accept responsibilities for infant’s care
–29
Psychological changes
… Process of becoming acquainted
while the infant receives
warmth, food and security,
she/he will show
reciprocal attachment
behaviors:
e.g. eye contact, move
their eyes & attempt to
track parent’s face; grasp
and hold parent’s finger;
root, latch onto the breast
& suck
–30
Psychological changes
… Process of becoming acquainted
3.
4.
Maternal touch:
‘fingertipping’: hold the
newborn closer, try to
explore infant’s face,
fingers, toes…
‘binding-in’: identify
specific features of
newborn to related family
members
Verbal behaviors: from “it”
in prenatal visit
“she/he”
“baby’s name”
–31
Psychological changes: maternal
adaptation
Puerperal phases
(Rubin,1975) :
1. Taking-in phase
2. Taking-hold phase
3. Letting-go phase
1. Taking-in phase:
occurs @ first 1-2 days
a period of dependent
behaviour
• focus on ‘Self’
• needs for food and sleep
• ask many questions &
talk a great deal about
delivery experience, e.g.
on the phone with her
relatives & friends
–32
Psychological changes … Puerperal phases
2. Taking-hold period:
dependent independent
begin to focus on the needs of infant
take on maternal role & learn to take care the infant
experience fatigue ± baby blues
last for 4-5 weeks
–33
Psychological changes … Puerperal phases
3. Letting-go phase:
interdependent
relinquish the infant of their fantasy & accept the real
infant
recognize the infant as separate from self
refocus the relationship with partner
–34
Psychological changes
Normal physiologic in oestrogen & progesterone
levels
aggravated by fatigue and social support, high
expectation of a mother’s role
Postpartum depression ranges:
baby blues/ postpartum blues
postpartum
depression
postpartum psychosis
–35
Psychological adjustment
- Postpartum blues (transient depression)
a maternal adjustment reaction
mild & transient mood disturbance
usually begins@ Day 3 after delivery,
& may last for a few hours to 2-3 weeks
cause: unknown
characterized by altered mood, anxiety, irritability &
tearfulness; & usually unrelated to actual circumstances
Rx: support from the partner, family, relatives, & friends …
health professionals
https://www.youtube.com/watch?v=SXxjqRAf-zM (06:32 min. Postpartum Blus vs. PPD)
–36
Postpartum major mood disorder
- Postpartum depression (PND)
10-20% of incidence in all postnatal women
60-70% of incidence from the first 3 weeks to 3-6
months, or any time within the first year after delivery
characterized by:
i.
ii.
iii.
iv.
v.
tearful & despondent
unable to cope, anger & generalized fatigue
interest in food & appetite & body weight loss
difficult to concentrate & sleep disturbances
unable to feel pleasure or love, though she holds her
baby in a caring manner
vi. a sense of loss of self & hopelessness
since they have overwhelming feelings
of guilt and worthlessness prone to commit suicide.
–37
Predictors for PPD Personal factor(s):
Family/ social support:
i.
1.
Hormonal fluctuations after
birth
ii. Medical problem during
pregnancy e.g. PET, GDM
iii. Personal/family history of
depression
iv. Personal characteristic e.g.
low self-esteem
v. Fatigue, sleep deprivation
vi. Alcoholism
2.
3.
4.
5.
6.
Ambivalence/anger about the
pregnancy
Marital dysfunction, i.e. lack
of support from significant
other
Feeling of isolation, lack of
social support
Multifetal pregnancy
Birth of an infant with illness/
anomalies
Financial worries
–38
Groups: be aware of postnatal depression
Vulnerable groups:
personal history of depression & PN depression
family history of psychiatric disorders before pregnancy
High risk group:
Marital difficulties and relationship difficulties
poor social support
very young, fatherless
unexpected pregnancy
–39
PND - treatment
1. Counseling - most effective treatment
2.
☂
☂
3.
4.
☂
☂
Antidepressant therapy
may be continued to use > 6 months with serotonin
reuptake inhibitors which has side effects & suitable for
breastfeeding women
diazepam & benzodiazeprines are contraindicated in
breastfeeding
Hormone therapy
Contraception:
natural progesterone injections
IUCD (intra-uterine contraception device)
–40
PND - treatment
5. Support
from family, friend, and health related professional
hotline service/ easy access centres
6. Remarks:
educate health care workers about PN Depression
screen & educate pregnant women during AN visits
use of “postnatal depression score” in PN wards
refer to self-help group
https://www.youtube.com/watch?v=XnYP89Av_Wg (4:15 min – how dad can help)
–41
Reference
Davidson, M., London, M.L. & Ladewig, P. (2012). Old’s maternal-newborn nursing & women’s health. Boston:
Pearson
Coad, J. & Dunstall,M. (2006). Anatomy and physiology for midwives. Edinburgh: Churchill Livingstone
McKinley, M. & O’Loughlin, V.D. (2006). Human Anatomy. New York: McGraw-Hill
Murray,S.S. & McKinney, E.S. (2006). Foundations of maternal-newborn nursing. St. Louis: Saunders
Ndala, R. (2005). Physiology in child bearing with anatomy and related biosciences (edited by Stables, D. &
Rankin,J.). Edinburgh: Elsevier
Rubin,R. (1975). Maternal task in pregnancy. Maternal-child Nursing Journal,4(3),143-153
Sherwen,L.N., Scoloveno, M.A., & Weingarten, C.T. (1995). Nursing Care of the Childbearing family. Norwalk:
Appleton & Lange
Turley, G.M. (2004). AWHONN: Core Curriculum for maternal-newborn nursing (edited by Mattson, S & Smith,
J.E.). St. Louis: Saunders
–42
SN3180: Childbearing Family Nursing
Puerperium/ Postpartum –
Nursing Management & care
Kitty WONG
2018
1
Learning outcome
By the end of the study, students should be able to:
1.
2.
3.
4.
5.
describe the essential components of postnatal care
understand how to promote maternal psychological wellbeing
explain the psychosocial adaptation of the parents
provide postnatal care, patient education and teaching
describe the common complications in puerperium and
provide appropriate nursing care
2
Terms
❑Postpartum Care
❑Postnatal Care
❑Postpartal Care
❑Puerperal Care
Puerperium is the first 6-week
period after delivery, i.e. the
body systems return to
their pre-pregnant state
The care refers to both medical
& nursing care to a woman from
the time of delivery until her
body return to its non-pregnant
state
3
Essential components of postnatal care
Care should
cover
▪Physical need
▪Emotional need
▪Social need
to woman & her
newborn
▪Husband
Health care
professionals
in 1st 10 days
▪Family
members
4
In H.K.,
❑
❑
“early discharge” allows mothers to return to their
normal home environment for early family
integration & adjustment
support from health personnel:
Community Nursing Service (CNS)
~ Maternal and Child Health Services (MCH)
~
❑
Hotlines – a/v in most hospitals to deal with the
adjustment problems
5
Promotion of maternal psychological well-being
oDelivery & having a new baby cause emotional stress
especially to a new mother
omood swings & tearfulness are common in early postnatal
period
In taking-in period, mother focuses on physical
needs,…
nurse should protect & provide food, fluid,
blanket & rest to her; listen to her experience
during labour to help her integrate it & clarify her
concerns.
6
Promotion of maternal psychological well-being
In taking-hold period, the mother begins to concern
her ability to be a successful parent
provide constant reassurance & encouragement
In letting-go period:
assist mother (& father) in unwrapping the baby
to encourage bonding & allow acquaintance with
the real baby, & replace parents’ fantasy baby
7
Psychosocial adaptation of the parents
1.
Maternal role attainment
- influenced by:
age at first birth
perception of birth experience
early mother-infant contact
social support
personality traits, self-concept &
competency
childrearing attitudes
health status
8
Psychosocial adaptation of the parents
2. Paternal role adaptation
- how father views his new role
is influenced by:
❖
his participation in childbirth,
❖
his family role
❖
his sex role identification
❖
degree of competency in
performing the role
❖
his cultural background
3.
Adjustment of siblings and
grandparents
9
Physiological changes and support
10
Provision of postnatal care
❖ Comprise a continuous process of
i.
ii.
iii.
iv.
❖
assessment
planning
intervention
Evaluation
are significant in the 1st few days during
hospitalization
Aim - early identification of potential problems
help to prevent complications from arising
11
Assessment
1. maternal & newborn conditions
2. factors that may affect postnatal experience
3. factors that may increase risks for postnatal
complications
Psychosocial adaptation of the parents
12
Assessment
(1): Maternal condition
1)
2)
3)
4)
5)
6)
psychological/ emotional state
general condition of the mother
e.g. vital signs, color, blood pressure
presence of discomforts from e.g. headache, wound
pain, afterpains, breast engorgement
breasts & lactation state
involution of the uterus: fundal height, lochia
(amount & characteristics)
wound (perineal or abdominal)
13
Assessment
(1): Maternal condition (con’t)
7)
8)
9)
10)
11)
intake & nutrition
elimination: bladder & bowel
rest & sleep
Sexual life
knowledge & ability in self care & infant care
Assessment: Newborn condition
- Discuss it at neonatal lessons
15
Assessment
(2): Factors affecting the postpartum experience
1)
2)
3)
4)
5)
prenatal preparation for parenting
past experiences with parenting & child rearing
nature of labor & delivery & the birth outcome
social network & support
sensitivity & effectiveness of nursing care
16
Assessment
(3): Factors
a.
b.
c.
risk of postpartum complication
Maternal medical condition, e.g. cardiac problem,
diabetes, hypertension
Complicated labour and delivery e.g. intrapartum
haemorrhage, retained placental product, perineal tear
Poor outcomes of delivery e.g. perinatal death, neonatal
requiring intensive medical care, congenital
abnormalities
17
Assessment – used to screen out
Discomfort/ minor problems
❑
Physical
❖
❖
❖
❖
❑
pain:
- wound, perineum, afterpains
breast engorgement
diuresis
fatigue
Complications:
❑
1. postpartum haemorrhage
2. postpartum infections:
▪
genital tract,
▪
breast (mastitis),
▪
other systems
Psychological:
➢
➢
Physical
emotional disturbance
postpartum blues
❑
Psychological:
▪
▪
postpartum depression
psychosis
18
Planning:
General aims of postnatal care
1. Promote a recovery of general & reproductive
2.
3.
4.
5.
systems
Prevent PN complications on
psychological & physical aspects
Facilitate maternal self-care & newborn
Promote integration of the newborn into the
family
Support parenting skills & facilitate bonding
19
Planning: Common problems found in PN 1) anxiety
2) body image
disturbance
3) risk for infection
4) risk for injury
5) knowledge deficit
6) self care deficit
7)
8)
9)
10)
sexual dysfunction
pain
constipation
altered patterns of
urinary elimination
11) altered parenting
12) altered role
performance
20
Interventions
A. Nurse monitors maternal condition e.g.
observation chart
B. Nurse supports mother on:
•
•
•
•
•
pain management: by comfort measures
general hygiene: perineal care
bladder & bowel
intake & nutrition
sleep & rest
21
Interventions
C. Psychological support to mother &
spouse/significant others
•
•
•
explanation & anticipatory teaching to psychological
adaptation during puerperium, the normal & danger
signs of complications
watch out for S/S of postpartum blues
note for risk factors to postpartum depression
22
Intervention
(1) Patient education & teaching on Self-care
❑
❑
❑
❑
❑
❑sexual activity and family
General hygiene, breasts,
planning
perineum, episiotomy
wound
❑Observe for:
nutrition & intake
▪ transitory s/s in early
bladder & bowel
postnatal period e.g.
bradycardia, hypotension,
exercise & rest
diaphoresis, diuresis
lochia & involution of uterus
▪ s/s of complications
❑postnatal FU
23
Intervention
(2) Patient education & teaching on Infant care
1.
2.
3.
4.
5.
6.
7.
General hygiene: bathing and napkin ..
Specific care: eyes, umbilical cord & skin
Nutrition & fluid intake – breast/ formula feeding
Observation on:
- bladder & bowel functions
- pattern of infant stool
- infant’s activity & resting pattern
Expected developmental milestones
S/S of complications: jaundice, infection
How to obtain a birth certificate for infant
24
Complications in puerperium
1) Postpartum haemorrhage
2) Infection:
i.
ii.
postnatal uterine infection
wound infection
3) Others:
i.
ii.
Postnatal thromboembolic disease
Postnatal depression
25
Complications in puerperium –
1. Postpartum haemorrhage
Postpartum haemorrhage (PPH)
1.
Define as A loss of blood > 500 ml
–
Types:
❖
Early/ primary PPH (within the 1st 24 hrs)
❖
Late/ secondary PPH (after the 1st 24 hrs)
1)
2)
3)
4)
5)
6)
Signs of PPH:
Excessive or bright red bleeding (saturation of more
than one pad per hour)
Uterus: boggy fundus that does not respond to
massage
Abnormal clots, high temperature, ↑pulse, ↓BP
An unusual pelvic discomfort or backache
Persistent bleeding
Haematoma formation or bulging/shiny skin in the
peineal area
(Davidson et al, 2012:1123)
26
PPH - Causes:
1)
2)
3)
4)
5)
6)
7)
8)
uterine atony
lacerations on vagina, cervix & perineum
retained gestational products
vulvar, vaginal and pelvic haematoma
uterine inversion (due to laxed ligaments/ anaethesia)
uterine rupture
coagulation disorders (coagulopathies)
subinvolution of uterus (especially in secondary/ late PPH)
(Davidson et al, 2012:1120)
27
Uterine atony
28
Factors that retard uterine involution
• Prolonged labour : Muscles relax due to prolonged time
of contraction during labour
• Anesthesia : Muscles relax
• Difficult birth : The uterus is manipulated excessively
• Grandmultiparity : Repeated distention of uterus during
pregnancy & labour leads to muscle stretching,
diminished tone, & muscle relaxation
• Full Bladder : Uterus is pushed up, pressure on it
interferes with effective uterine contraction
29
Factors that retard uterine involution
• Incomplete expulsion of placenta or membranes : The
presence of even small amounts of tissue interferes
with ability of uterus to remain firmly contracted
• Infection : Inflammation interferes with uterine muscle’s
ability to contract effectively
• Over-distention of uterus : Overstretching of uterine
muscles with conditions, e.g. multiple gestation, very
large baby
(Davidson et al, 2012:992)
30
Preexisting and intrapartum risk factors for
PPH
Source: Pavord, S. & Maybury, H. Blood 2015;125:2759-2770
31
Blood loss
>500 ml
BP/P drops
resuscitation
Tone of uterus
Bimanual uterine
massage/ Infusion
Oxytoxin
trauma
check lower
genital tract/
suturing
lacerations/
drain
haematoma
tissue
Inspect placenta
MROP
thrombin
Observe clotting; take
CBC/ type & screen,
coagulation screen.
Fluid / plasma
replacement
Massive Haemorrhage [blood loss >10001500ml]
1.
2.
3.
4.
Transfuse RBC/ platelets/ clotting factors
Support BP with vasopressors
ICU support
Operations e.g. hysterectomy
32
Management of PPH – primary/ early (specific)
- Check urinary bladder – empty it if full
- Check bleeding origin
- manage according to the source:
1. Uterine atony:
i. Massage uterine fundus if atony;
ii. bimanual uterine massage if still bleeding
2. Genital lacerations/ tears: Ligation/ embolization of artery
3. Retained placenta (due to placenta accreta): Manual removal
of gestational products or curettage
4. Unexplained haemorrhage: ligation of uterine vessels,
hysterectomy
5. Uterine inversion (myometrial weakness): manual
replacement of uterus and give IV oxytocin
6. DIC (rare): remove placenta retained, ICU and blood products
33
Management of uterine atony
34
Ruptured uterus
Incidence: 1:1500 deliveries
Signs:
a.
b.
c.
d.
e.
abnormal CTG
lower abdominal pain
cessation of contractions
change of contour
Maternal collapse
Mx:
▪ maternal resuscitation
▪ urgent laparotomy for
delivery of fetus
36
Inverted uterus
Incidence: 1:20,000 deliveries
Causes:
1. Uterine atony (40%)
2. Increase in intraabdominal pressure
3. Fundal attachment of
placenta (75%)
4. Short umbilical cord
5. Placenta accrete
6. Excessive cord traction
37
Management of PPH – primary/ early
(General)
- Continuous monitoring of client’s vital signs, conscious level
to detect signs of shock
- Drugs: give IV infusion of Oxytocin for uterine atony
- NPO
- Set up IV line for blood transfusion, blood products &
if
Operation
replacement of fluid volume
is
- Type & screening of blood
expected
- Prepare for operation if bleeding from laceration
39
Complications in puerperium –
2. INFECTION
1.
▪
▪
▪
2.
Postpartal uterine infection:
- occurs at 24-36 hours; 1-3% in women with NSD, 27%
women with Caesarean Section
- Clinical feature:
Uterine tender
fever: saw-teeth pattern 38.3 to 40°C
Vaginal discharge: bloody, foul smell, scanty/ profuse
– Group B Streptococcus associated with Chlamydia
trachomatis; but odorless in ß-haemolytic
streptococcus
Wound infection
– perineal/ Caesarean wound
40
40
Complications in puerperium –
3. OTHERS
1.
Postpartal thromboembolic diseases
2.
e.g.
Superficial leg vein disease (e.g. thrombophlebitis of
Saphenous vein),
Deep Vein Thrombosis
Pulmonary embolism
Disseminated Intravascular Coagulation
Postpartum depressive conditions
i.
ii.
iii.
iv.
41
Minor disorders
• Breast engorgement
• Sore nipples
• Mastitis
42
breastfeeding problem
Breast engorgement: management
For lactating mothers 1)
2)
2)
3)
4)
5)
6)
Early and frequently feed the baby, or express breast milk if
breastfeeding in not available (discussed in Guest lecture)
apply cool pack to breasts between breastfeeding (BF) to reduce
swelling & pain
soften areola and nipple with breast milk
Massage of breasts can relief milk duct blockage and ↑ speed of milk
release
take warm showers, massage & apply heat pad/ towel before BF to
increase breastmilk flow
wear a well-fitting brassiere
pain medication according to doctor’s prescription
**to prevent engorgement by early frequent feeding on demand
43
Describe how you would support a mother
with hand expressing?
• Stimulate breast with massage and nipple rolling.
• Place finger and thumb about 3 cm from the nipple in a Cshape.
• Using forefinger and thumb compress in a steady rhythm
without sliding fingers
• Milk may take a few minutes to flow, if milk doesn’t flow
move fingers slightly up or down the breast and try again.
• Rotate fingers around the breast if necessary.
• When milk flow slows/ceases express the other breast.
From Ms Christine Lam,
(All needed)
Nurse Consultant of Lactation, QEH
Breast engorgement:
For NON-lactating mothers – management
occurs Day 3 after baby birth
put on brassiere for support
apply ice/ cool packs on upper chest if
engorged
avoidance of nipple stimulation
oral analgesics p.r.n. to relieve pain
45
Breastfeeding problem
Sore nipples in lactating mothers Possible causes:
1.
improper positioning
and latch-on
2.
not breaking suction
before removing baby
from breast
3.
breast engorgement,
4.
prolong exposure to
moist
5.
Improper use of breast
pads
46
breaking suction before removing baby from breast
47
Breastfeeding problem
Management of Sore nipples in lactating mothers 1.
2.
3.
4.
5.
6.
7.
8.
9.
Position the infant appropriately
Change baby’s position during nursing
Attachment : Area of nipple directly in line with baby’s nose and chin
Offer the breast which is less sore first
Express some milk before feeding to enable the infant latch onto the nipple more
easily
Massage the breasts during breastfeeding to enhance milk flow
Use breaking suction before removing baby from breast
Apply breast milk to nipples after feeding to help healing
Expose the nipples to air dry in between feedings
48
Breastfeeding: (guest speaker)
Assessing baby to have enough milk
• Can hear baby swallowing frequently during feedings
• Breast is getting softer during feeding
• Milk can be seen in baby’s mouth or dripping
• Feeding 10 to 12 times per day initially
• For exclusively BF baby, 6 or more soaked nappies a
day, and a weight gain of 0.5 kg per month after the
initial physiological weight loss in the first few days
(HKDH, 2006; Wong, 2012)
49
Breastfeeding problem
Mastitis in lactating mothers
'
inflammation
of
Mammaryglands
1.
occurs 2-3rd wks postpartum, 5% of BF mothers
affected
2.
S/S: high fever, chills, localized redness & pain,
hard & tender on ONE breast
50
Breastfeeding problem
Mastitis in lactating mothers
Cause:
3.
by Staphylococcus aureus -> on hands of mothers/
health care staff -> the mouth of baby -> crackle ->
stasis of breast milk
Treatment :
4.
i.
ii.
iii.
iv.
v.
vi.
penicillin, erythromycin, analgesics
surgical drainage of the abscess if abscess occurs
Moist heat / cold packs
Breast support
Bed rest
Increase fluid intake
52
Postnatal Follow Up (~ 6 weeks)
- to evaluate maternal condition on:
• general health status, vital signs, BP, urinalysis, skin color,
edema
• wound condition, presence of vaginal discharge
• involution of the uterus, duration of lochia
• return of menstruation
• baby feeding & lactation
• emotional states, morale & parenting ability
• Postnatal exercises for muscle strength & overall wellness
• resumption of sexual activity
• use of contraceptive devices
53
Evaluation: the client can 1. have normal uterine involution process & show no signs
of physical complications
2. shows confident & demonstrates ability in self care &
infant care/ feeding
3. verbalize how to take care on self & infant at home
4. verbalize the s/s of complications or difficult issues in
daily care
5. use community resources for support if required
6. obtain legal documents for the child (birth certificate)
7. show stable emotional state
8. adjust & integrate to the arrival of the newborn
54
Documentation in ward
i.
ii.
A daily observation chart is used to note all the
observations on the maternal condition
Other observations on mother’s emotional state
are also recorded
55
Postnatal exercise
Advantages/significance:
• promote involution of uterus
• promote healing
• restore muscle tone
• improve circulation
• prevent complications (e.g. prolapse of cervix)
• quicker return to fitness & body figure
• improve appetite
56
Supplementary: Postnatal exercise
Advice:
For women with NSD – begin as soon as possible
For women after CS – usually from Day 4, but consult
doctor for exercise regimen
i.
suggest:
- a new exercise can be added daily
- begin with easy exercise
- 10 minutes twice daily
ii. no vigorous exercise until the lochia is clear
iii. continue the exercise until the end of puerperium to
have maximum benefit
iv. avoid fatigue
57
Suggested exercises
58
Reading materials/ reference
Davidson, M.R., London, M.L., & Ladewig, P.W.(2014). Old’s maternalnewborn nursing & women’s health across the lifespan. [Chapter 34-38]
NJ: Pearson
Murray,S., and McKinney,E. (2006). Foundations of maternal-newborn
nursing. St. Louis: Saunders
Mattson, S., and Smith, J. (2004). Core Curriculum for maternal-newborn
nursing. St. Louis: Saunders
Kegel exercise: https://www.pelvicexercises.com.au/how-to-kegel/
Diastasis recti: https://www.youtube.com/watch?v=uzIrt82maws
59
SN3180: Childbearing Family Nursing
- Safe sex and contraceptive methods
Kitty Wong
Nov 2018
Importance of SAFE sex
1.
2.
3.
To prevent sexual transmitted infections
To reduce the risk of having cervical cancer
(HPV)
To prevent unwanted pregnancy
1. TO PREVENT STI AND INFECTIONS
THROUGH SEXUAL TRANSMISSION
Agents may cause
sexually transmitted infection
Bacterial :
– Syphillis (Treponema pallidum)
– Gonorrhoea (Neisseria gonorrohoeae)
– Chlamydia (Chlamydia trachomatis)
– Chanchroid (Haemophilus Ducreyi)
Protozoan:
- Trichomoniasis (Trichomonas vaginalis)
Agents may cause
sexually transmitted infection (cont’d)
Viral:
Viral hepatitis B
Herpes simplex (Type II)
Human Papillomavirus (HPV)
Human Immunodeficiency Virus (HIV)
Fungal:
Candidiasis (yeast infection)
• Parasite:
– Crab louse (pubic lice)
– Scabies
2. TO REDUCE THE RISK OF HAVING
CERVICAL CANCER
Unsafe sex and cervical cancer
Higher risk of developing cervical epithelial abnormality in
those:
Multiple sexual partners
Higher chance to contact with HPV
Unprotective sex
Onset of sexual activity
less than aged 18
↑denudation of stratified
epithelium
↑exposure of the basal layer
to HPV
Prolonged use of oral
contraceptives
Direct contact of
penis with HPV virus
(Louie et al., 2009), (Wong et al., 2011)
3. TO PREVENT UNWANTED
PREGNANCY
Factors leading to unwanted pregnancy
•
•
•
•
Unplanned sexual activity
Unprotected sex
Inaccurate use of contraceptive methods
Defective contraceptive articles, etc
Principles of contraception
1. Avoid combination or encounter of sperm
and egg
2. Avoid zygote implantation
3. Control ovulation
Office of National Statistics (ONS) in UK –
10 most popular types of contraception:
1.
2.
3.
4.
5.
Contraceptive pills
Male condom
Vasectomy
Female sterilization
Intrauterine contraceptive
device (the coil)
6. Withdrawal method
At ¥ I
7.
8.
8.
10.
11.
Rhythm method
Contraceptive injection
Skin patch
Cap/ diaphragm
Implant
12. Female condom
13. Vaginal ring
28
Oral contraceptives
- contain estrogen and progesterone
Use: Suppress ovulation and cause thickening of the cervical
mucus to block sperm penetration
Reliability: 92-99%
Directions:
For 28 days packet
Take one tablet daily for
28 days in the order
specified in the packet.
Start a new packet the
day after taking the 28th
tablet.
For 21 days packet
One tablet daily for 21 days.
After 21 days, stop for 7 days.
Menstruation period may come
after stopped for 1~2 days.
Follow the instruction to restart
another packet of pills, e.g. start on
the 5th or 7th day.
Oral contraceptives
Advantages:
i.
Continuous protection for preventing pregnancy
ii.
regular and shorter menstrual periods
iii. Able to resume pregnancy
iv. Protects against ovarian and endometrial cancer
Disadvantages:
a. May decrease vaginal lubrication or diminish libido
b. Must remember to take daily
c. Possible side effects: nausea, breast tenderness, mild headaches, weight
gain or loss.
d. Higher health risks for women over 35 who smoke (eg. Stroke)
e. ADD barrier methods during the period in taking 1st packet of
contraceptive pills
f. No protection against STI
Male condom
It forms a barrier to prevent sperms go to vagina
Reliability :
Contraception: 98%
Prevent 80% to 95% of HIV transmission
Male condom (cont’d)
Advantages:
Protection against STI
inexpensive
Easy to access
Disadvantages:
May fall off, leak or break if not used properly
Embarrassed to purchase or to apply condoms
Less protection against infections that are transferred by skin
contact (e.g. HPV)
Very few side effects, unless one is allergic to latex or to the
lubricant or spermicide
IUCD
Intrauterine contraceptive device
- last for 5 - 12 years vs. types of IUCD
[hormonal, copper]
- It will be inserted with surgical procedure
done by doctor at clinic
- Insert after a thorough physical and vaginal
assessment
Contraindications for IUCD
1. Have pelvic infections or abortions in the past 3
months
2. Have / may have STI
3. Have/ may get pregnant
4. Unexplained bleeding from vagina
5. Pelvic tuberculosis
6. Uterine perforation during insertion
Periodic abstinence
The various methods used for estimating the fertile period
Correct use:
Avoid sexual intercourse during fertile period
Estimated by the calendar method, charting daily basal body
temperature, or detecting changes in cervical mucus
Reliability:
97.9% effective only when an electronic hormonal
fertility monitor is correctly used & correct cervical mucus
observations (Fehring, Schneider & Raviele, 2007).
(The Family Planning Association of Hong Kong, 2012)
Periodic abstinence
Advantages:
Costless
No side-effects
only method acceptable to some couples with
religious beliefs.
Disadvantages:
Not for women with irregular cycles
Does not protect STI
difficult to abstain from sexual intercourse during
fertile period
Need careful instruction
Withdrawal method
To pull one’s penis out of the vagina before ejaculation
also known as coitus interrupts.
(Pull Out Method - Withdrawal Method, 2012)
Reliability:
18% of couples will become pregnant in a year
(Kost, Singh & Vaughan, 2008).
Only reliable when men can pull out accurately before
ejaculation
Pregnancy can still happen if pre-ejaculate, or pre-cum occurs.
Withdrawal method (cont’d)
Advantages:
Costless
No side effects
Efficacy increases with higher educational background
(Güngör, Başer & Göktolga, 2006).
Disadvantages and potential restrains:
Requires great self-control, experience, and trust
Not for men who ejaculate prematurely
Not for teens and sexually inexperienced men
Pregnancy is possible
Does not protect against STI
Depot medroxyprogesterone acetate
(Depo-Provera/DMPA)
Reliability: 99.7%
Direction:
• Injection for every 3months
• Contains progestin
• Cause uterine lining to be
dry and brittle
• Require a visit to healthcare
provider for every year
Advantages:
• Convenient for those who has
low risk of getting STI
• Very low chance of getting
pregnant (Sterilization with
0.5%)
Disadvantages:
• Does not protect client from
STI
• Withdrawal bleeding
• Weight gain
• Depression
• Increased risk of osteoporosis
(Cromer, 1999)
(Cropsey, Matthews, Campbel, Ivey & Adawadkar, 2010)
Emergency contraceptive pills(ECPs)
Levonorgestrel-only or combined estrogen-progestogen
Actions:
öPrevent an unintended pregnancy
öInhibit ovulation
öCause thickening of the cervical mucus
Reliability:
60-90% effective, but failure rate increases progressively
each additional day between unprotected intercourse and
taking the pills
Emergency contraceptive pills(ECPs)
Use:
• Should be taken as early as possible
after unprotected
intercourse, within 72 hours.
• Effectiveness is reduced with increased lapping time
• Cannot act as an abortifacient
Emergency contraceptive pills
Advantages
To prevent pregnancy after unprotected vaginal intercourse
Disadvantages
Many side effects : breast tenderness, fatigue, headache,
nausea, abdominal pain and dizziness
Not effective once implantation has begun
Not suitable for women with blood clotting disorders, breast
cancer, diabetes, hypertension or with past history of CVDs
Next menses may be early or late
Not suitable for regular use (once a year)
Does not protect against STI
Contraceptive
method
Condom
Pills
Periodic abstinence
Withdrawal
Picture
Reliability
98%
92-99+%
97.9%
82%
function
Use a latex layer
to separate sperms
and ovum
Use pills to inhibit
ovulation/integrate
Avoid sexual
activity when
ovulation period
pull penis out
before ejaculation
Advantages
- Cheap
-Few side effects
-Safe
-Can against STD
-Reliable
-Almost 100%
reliable
- x pregnancy after
unprotected sexual
activity
- Costless
-No side effects
-Safe
-Convenient
- Costless
-No side effects
-Safe
-Convenient
Disadvantages -Allergy
/
-Affect enjoyment
Complications -break or slip off
-Drug allergy
-Need to consult
doctor
-with more S/E
-induce health risks
-not protect from STI
-Need the normal
work of hormone
-Not reliable with
irregular cycles
-not protect from
STI
- difficult to control
-Affect enjoyment
-Not reliable
-not protect from
STI
Note
- May
reduce menstrual
discomfort
May be the only
method of birth
control to some
religion
The fluid secretes
before ejaculation
also have sperms
It has different
texture/ taste to
increase exited
Conclusion
Different people have different characteristics and
preferences ,it leads to various contraceptive methods.
Generally, people are based on the following criteria to choose
their own suitable contraceptive method:
•
•
•
•
•
•
•
Reliability
Existing Material
Safety/ Side effect
The enjoyment during the process
Age/ Pregnancy before or not
Temporary/Permanent
Religion
SN3180
Pregnancy related issues:
Infertility
Kitty Wong
Nov 2018
1
Learning outcomes:
students should be able to I. List and describe the types and its possible causes of infertility
II. Briefly describe the management of infertility related to:
a. investigation
b. management
c. prevention
III. Briefly describe the nursing management in supporting the couple
with infertility issue
2
Review: reproductive systems of man and
woman
3
Fertility
• Women
– From menarche to menopause
– At birth, each ovary contains roughly 500,000 ovarian follicles [also
called Graafian follicles] (these follicles are the immature form of
ovum)
– For a female, < 500 ova produced from puberty to her reproductive
years
• Men
– Sperms: from onset of puberty → his life span
– Capacity to reproduce
sexual excitement, penile erection &
ejaculation
4
Essential Components of Fertility in Women
1. Normal ovaries and ova
2. Patent fallopian tubes, normal
fimbria(e) with peristaltic
movements
3. Endometrium functions normal
for implantation
4. Adequate reproductive hormones
5. Favorable cervical mucus for
survival of spermatozoa
5
Cervical secretions favours sperms passing through -
7
Essential Components of Fertility in Men
1) Testes must produce
spermatozoa of normal
quality, quantity, and
motility
2) Unobstructed male
genital tract
8
Essential Components of
Fertility in men:
1. Male genital tract secretions:
normal
2. Ejaculated spermatozoa must be
deposited in the female vagina
into cervix
3. Semen and sperms
9
Semen and sperms
During ejaculation, it receives fluid from seminal vesicles and the prostate
glands
⇝ ~ 2 – 5 ml per ejaculation
⇝ spermatozoa and fructose-rich nutrients
⇝ sperm counts: 20 million spermatozoa / ml or more
⇝ sperm movement: 60 - 80% of the sperm show normal forward
movement after 1 hour
⇝ sperm morphology: > 30% of the sperm have normal shape
⇝ pH : 7.1 – 8.0
10
Semen and sperms
⇝ Effective transportation of sperm requires adequate nutrients, an
adequate pH (about 7.5), a specific concentration of sperm to fluid, and
an optimal osmolarity
⇝ appearance: thick, whitish
⇝ odour: musty
⇝ Once ejaculated, sperm can live only 2 or 3 days in the female genital
tract (sperm may be stored in the male genital system up to 42 days,
depending primarily on the frequency of ejaculations)
11
Infertility
13
Define Infertility is defined by the failure to achieve a successful pregnancy
after 12 months or more of regular unprotected intercourse.
Types:
1. Primary - biological inability of a person to contribute to conception
2. Secondary – couples who have been unable to conceive after one or
more successful pregnancies
3. Subfertility – a couple having difficulty conceiving because both
partners have reduced fertility
14
Define Sterility is a term applied when there is an absolute factor
preventing reproduction
Types:
- Postpartum Sterilization (PPS)
- Tubal ligation
- vasectomy
15
Causes of infertility
Cause
%
Tubal factor
11
Endometriosis
6
Ovulatory dysfunction
6
Diminished ovarian reserve (DOR)
7.9
DOR refers to the condition of having a low number
of normal oocytes or having poor quality oocytes.
Uterine factor
1.3
Male factors
18.5
Multiple factors (female)
11.7
Multiple factors (female and male)
18.4
Others (immunologic problem, chromosomal abn.,
7
cancer chemotherapy, serious illness)
Unexplained causes
found in either partner)
(no cause of infertility
12
Gordon et al (2007). Obstetrics, gynecology and infertility: Handbook for clinicians. (6th ed.).
VA: Scrub Hill Press. Page 522
16
Infertility: Physical Factors in female clients
– Hormonal problem (thyroid) affect
ovulation
– tubal blockage (PID, STI)
– Endometriosis
– structural disorders (bicornuate or septate
uterus), uterine displacement
– Tumor/ uterine fibroid(s)
– congenital anomalies
– cervical floor problem
17
Infertility: physical factors in male clients
Male Partner:
- sperm count & motility, ejaculation
Coitus: impaired sexual technique & poor timing
Mixed factors
21
Retrograde ejaculation
Mechanism of erection of penis
Other factors led to infertility:•
•
•
•
•
Chemicals: toxins, pesticides
Alcohol
Tobacco smoke,
Medications, e.g. steriods
Cancer on chemotherapy/
radiation
• Hot bath, sauna
24
Diagnostic evaluation of infertile couple
1. History
a. Family history of endometriosis, early menopause
b. Previous surgeries
c. Menstrual irregularity
d. Dysmenorrhoea, dyspareunia
e. Sexual dysfunction
2. Physical assessment
3. Laboratory tests
4. Laparoscopy
25
Initial Infertility Physical Work-Up and Laboratory
Evaluation
Female
a. Physical examination
b. PV & bimanual examination
or recto-vaginal examination
b. Laboratory investigations
Male
a. Physical examination
i. Urologic examination
– any phimosis
ii. Rectal examination
– Prostates
– Seminal vesicles
b. Laboratory test on semen
analysis – morphology, motility &
sperm count
26
Test for infertility
In Female Clients:
1. Evaluation of ovulation factors
1.1 Basal Body Temperature (BBT) method:
• Body temperature recording to identify the Follicular & Luteal phases of
ovarian cycle
1.2 Blood for hormonal assessment: prolactin & TSH
1.3 Endometrial biopsy: endometriosis
1.4 Transvaginal USG: anatomical defects
29
1. Basal temperature record
30
2a. Cervical factors: thickness & pH
31
2b. Cervical mucus – check and record thickness
Cervical mucus: dry / +ve
32
3. Laparoscopy
3. Laparoscopy: for uterine
structures and tubal
patency
– Hystero-salpingography
(hysterogram)
– Hysteroscopy
– Laparoscopy
Infertility: Management
Underlying pathology
2. Tubal insufflation –
3. Pharmacologic agents:
a. Hormonal Therapy/ Ovulation Induction
- in woman with normal ovaries, normal prolactin level, an intact
1.
pituitary gland, clomiphene citrate (Clomid) is often used as firstline therapy to induce ovulation
b. Gonadotropin therapy – for women with history of anovulation
34
Infertility: Artificial Reproductive Technologies (ART):
a. Intrauterine insemination (IUI):
Artificial insemination husband/donor semen
https://www.youtube.com/watch?v=qCdIiLLF0vw (00:40-01:53 min)
b. Artificial Reproductive technologies:
✓ In-vitro fertilization & Embryo Transfer (IVF-ET)
https://www.youtube.com/watch?v=GeigYib39Rs (00:49-02:39 min)
✓ Assisted reproductive technologies:
ö
ö
Gamete/ Zygote intrafallopian transfer (GIFT/ ZIFT)
Egg freezing: Oocyte cryopreservation
35
Collection of sperms in Artificial inseminated husband/
donor for ART
36
Zygote-intrafallopian transfer
- Zygote is a cell which contains a diploid no. of chromosomes
1
2
4
3
38
Gamete Intra-fallopian Transfer (GIFT)
39
In-vitro fertilization & embryo transfer (IVF-ET)
Indications:
1. tubal factors, mucus abnormalities
2. male infertility
3. unexplained infertility
–
–
–
–
woman’s eggs are collected from her ovaries
fertilized in the laboratory
Placed into her uterus after normal embryo development has begun
3 to 4 embryos used (fertility drugs used to induce ovulation)
40
In-vitro fertilization & embryo transfer
1
2
1. Ovulation induction
2. Collection of ova
3. Fertilized in lab with
prepared sperms
4. Transcervical Embryo
replacement
4
3
41
Summary
What to be returned?
When?
How many?
Where?
IVF
GIFT
ZIFT
Embryos
Gametes
Zygotes
10-14 days
1-2 days
Not more than 4
lots
uterus
Fallopian tube
42
Nursing management
43
Assisted Reproductive Technologies will lead to issues
like:
✓ Hyper-stimulation of the ovaries
✓ Multiple pregnancies: complications & discomfort
✓ Fetal abnormality
✓ Ethical concerns: donor’s sperms
✓ Psychological
✓ Financial
✓ Recurrent Pregnancy loss [distinct from infertility, defined by 2 or more
failed pregnancies]
44
Nursing diagnosis related to Impaired Fertility
• Anxiety related to unknown outcome of diagnostic workup
• Disturbed body image or situational low self-esteem related to impaired
fertility
• Risk of ineffective individual/family coping related to
– Methods used in the investigation of impaired fertility
– Alternatives to therapy: child-free living or adoption
45
Nursing diagnosis related to Impaired Fertility (cont’d)
• Interrupted family process related to unmet expectations for pregnancy
• Acute pain related to effects of diagnostic test (or surgery)
• Ineffective sexuality patterns related to loss of libido secondary to
medically imposed restrictions
• Deficient knowledge related to factors surrounding ovulation/fertility
46
Nursing Process:
Care of couple with infertility
a) Assessment:
address couple’s emotional needs associated with their infertility, its
treatment, outcomes of the therapy
b) Analysis:
situational low self-esteem related to loss of control 2° infertility &
management of care
32
Nursing Process:
Care of couple with infertility (cont’d)
c) Planning:
- express feelings of their own both –ve & +ve
- explore ways to increase control
- identify aspects of self that are +ve
d) Intervention:
❑ Assist in communication
❑ Increase couple sense of control
❑ Reduce isolation
❑ Promoting a positive self-image
e) Evaluation
48
References
Davidson, M.R., London, M.L., & Ladewig, P.A. (2016). Olds’ maternal-newborn nursing and women’s
health across the lifespan. (9th ed.). NJ: Pearson. Chapter 12, page 242-275.
Davidson, M.R., London, M.L., & Ladewig, P.A. (2010). Olds’ maternal-newborn nursing and women’s
health across the lifespan. NJ: Pearson
.
Dorland’s pocket medical dictionary(25th edition). Philadelphia: Saunders
Gordon et al (2007). Obstetrics, gynecology and infertility: Handbook for clinicians. (6th ed.). VA: Scrub
Hill Press. Page 522.
49
Human Sexuality
Kitty Wong
Nov 2018
1
Human sexuality is:
- the capacity to have erotic experience & responses
A Greek word means desire which
refers to a state of sexual arousal,
sensuality and romantic love.
2
Human sexuality
Humans have evolved 3 core brain systems for mating and
reproduction:
Lust – the sex drive or libido
Romantic attraction – romantic love
Attachment – deep feelings of union with a long term partner
.
- Prof. Helen Fisher
.
3
While a couple have sex, what happened inside their brain?
Probably responsible at brain for
excitement & feeling of
attachment & sex
A study with 49 men and women into a brain
scanner to understand the ecstasy:
#
Pfa
€ Sex drive: testosterone 睾丸素 Igt
€ Romantic love: increased dopamine 多巴胺 &
norepinephrine
serotonin 血清素 (optimal)
)
€ Deep attachment: oxytocin & vasopressin
Fisher, H. (2004).Why we love: The nature & chemistry of romantic love. NY: Henry Holt & Co.
4
Pleasure & desire
Different in cultures and different in persons!
Sexual desire can be directed at a specific gender, body part,
personality trait, …
Sexual pleasure can range from mental fantasies, to
masturbation of the genitals, to a simple touch of a partner’s
fingertips – consent (willingness to engage in sex)
Kinsey, A., Pomeroy, W. & Martin, C. (1975). Sexual behaviour in human male. Bloomington: Indiana University Press.
5
The human sexual response cycle
(4-stage-model)
1. excitement phase (initial arousal)
Vaginal lubrication vs. erection of penis
2. plateau phase (at full arousal)
Outer 1/3 of vagina markedly engorged, clitoris retracts
3. orgasm
Contractions in the outer 1/3 of the vagina, uterine contractions begin,
rate, respiration, blood pressure
heart
4. resolution phase (after orgasm)
– Masters, W. & Johnson, V. (1966). Human sexual response. NY: Ishi Press International
6
Male sexual response cycle
6/20/2016
School of Nursing, The Hong Kong Polytechnic University
7
Female sexual response
Phase 1:murmur
excitement phase
- last from a few minutes to several hours, include the following:
•
•
•
•
•
Muscle tension increases.
Heart rate quickens and breathing is accelerated.
Skin may become flushed (blotches of redness appear on the chest and back).
Nipples become hardened or erect.
Blood flow to the genitals increases, resulting in swelling of the woman's clitoris and
labia minora (inner lips), and erection of the man's penis.
• Vaginal lubrication begins.
• The woman's breasts become fuller and the vaginal walls begin to swell.
• The man's testicles swell, his scrotum tightens, and he begins secreting a lubricating
liquid.
9
Phase
2: Plateau
murmur
- extends to the brink of orgasm as below:
• The changes begun in phase 1 are intensified.
• The vagina continues to swell from increased blood flow, and the vaginal walls turn a
dark purple.
• The woman's clitoris becomes highly sensitive (may even be painful to touch) and
retracts under the clitoral hood to avoid direct stimulation from the penis.
• The man's testicles are withdrawn up into the scrotum.
• Breathing, heart rate, and blood pressure continue to increase.
• Muscle spasms may begin in the feet, face, and hands.
• Muscle tension increases.
10
Phaseummm
3: Orgasm
- climax of the sexual response cycle
- the shortest of the phases and generally lasts only a few seconds.
Involuntary muscle contractions begin.
Blood pressure, heart rate, and breathing are at their highest rates, with a rapid intake of
oxygen.
Muscles in the feet spasm.
There is a sudden, forceful release of sexual tension.
In women, the muscles of the vagina contract. The uterus also undergoes rhythmic
contractions.
In men, rhythmic contractions of the muscles at the base of the penis result in the
ejaculation of semen.
A rash, or "sex flush" may appear over the entire body.
11
Phasehmmm
4: Resolution
• During resolution, the body slowly returns to its normal level of functioning, and
swelled and erect body parts return to their previous size and color.
• This phase is marked by a general sense of well-being, enhanced intimacy and,
often, fatigue.
• Some women are capable of a rapid return to the orgasm phase with further sexual
stimulation and may experience multiple orgasms.
• Men need recovery time after orgasm, called a refractory period, during which
they cannot reach orgasm again. The duration of the refractory period varies among
men and usually lengthens with advancing age.
12
Think before sexual intercourse ..
• Love
• Attitudes towards sex: intimacy or act
• What about after sex …
Factors affecting human sexuality
•
•
•
•
Psychological factors – motivation
Organic factors: DM, HT, arthrosclerosis
Hormones
Drugs: e.g. Selective Serotonin Reuptake Inhibitor (SSRI)
14
Common issues in men:
Sexual desire:
low libido
o inhibited sexual interest
o disparate desires
o
Erectile dysfunctions
Ejaculation problems: rapid, delayed, retrograde
15
Common issues in women:
Low sexual interest, inhibited sexual desire, disparate desires
Vaginismus - Inability to achieve penetration of the penis into the
vagina due to involuntary spasm of the muscles of the pelvic floor
Dyspareunia (painful intercourse)
Orgasmic dysfunction
16
Advice on sexual activity in pregnancy and the
puerperium (1)
i.
*
Women reduce interest in sex during pregnancy o Hormonal fluctuations
o Fatigue and minor symptoms, like nausea, backache, wt gain
ii.
Couple worries about miscarriage
How to improve sexuality during pregnancy?
trimester
Method
2-3
NEPHITE
Position
b Baek
b
Safe?
embolism
t
's
U
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:
.
"
"
17
Advice on sexual activity in pregnancy and the
puerperium (2)
iii. No contra-indication to intercourse throughout pregnancy
except:
APH
Premature rupture of membranes (PROM)
History of premature labour or of PROM
vaginal infections, if the obstetricians specifically advise
against intercourse for a specific reason
preterm
Advice on sexual activity in pregnancy and the
puerperium (3)
iv. In the puerperium, intercourse may be resumed when:
vaginal cuts or lacerations healed usually by 3-4 week
blood-stained discharge (lochia) will be ceased usually by 2-3 week
↳
prevent
infection
Reference: sexuality
Basson, R. (2006). Sexual desire and arousal disorders in women. The New England Journal of Medicine 354: 1497-1506
Clayton,A. (2010). The pathophysiology of hypoactive sexual desire disorder In women. International Journal of Gynecology and Obstetrics 1 (10), 711.
Fisher, H. (2004). Why we love: The nature and chemistry of romantic love. New York: Henry Holt and Company.
Granot M., Zisman-llani Y., Ram E., Goldstick O., and Yovell Y. (2010). Characteristics of attachment style in women with dyspareunia. Journal of Sex &
Marital Therapy, 37:1, p.1-16
Lindberg, L.D., Jones, R. and Santelli, J. S. (2008). Noncoital sexual activities among adolescents. Journal of Adolescent Health 43(3), p.231-238
McCarthy B.W. (1999). Relapse prevention strategies and techniques for inhibited sexual desire. Journal of Sex and Marital Therapy, 25: 297-303.
20
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