TORCH Infections and Screen - TORCH Screen - A TORCH screen is a panel that tests for the presence of antibodies to certain infections that have been linked to fetal or neonatal harm. - The TORCH screen may detect whether or not the woman had a recent infection, a past infection, or was never exposed; however, the diagnosis will be directed by history and physical exam findings as TORCH titers are not considered to be significantly helpful at this time. - For TORCH diagnosis, data at this time are considered to be helpful: maternal/prenatal history, PE of infant, directed labs/studies based on most likely diagnosis (serology, culture, histopathology, PCR) - Infections or agents that can cause birth defects are called teratogens. - TORCH infections are important primarily because they can be transmitted to the fetus. The route of transmission when an infection is transmitted from mother to fetus is called vertical transmission that occur during labor and at birth. Transplacental transmission is common with viral infections. TORCH (acronym) - Toxoplasmosis - Other [hepatitis B, syphilis, Group B streptococcus, varicella-zoster (VZV), HIV, Parvovirus B19] - Rubella - Cytomegalovirus - Herpes - Toxoplasmosis - Organism: protozoan infection • - Human acquisition of the infection - Symptoms can include prematurity, low birth weight, enlarged liver and spleen, visual defects, mental retardation, intracranial calcifications, microcephaly, or hydrocephaly - Fetal death rate higher in first trimester - Varicella - Organism: varicella zoster virus ( member of herpes virus family), which causes chickenpox - Babies infected before 20 weeks of pregnancy have about a 2% risk for being affected with congenital varicella syndrome. - Syndrome can include: - Skin scarring, defects of the muscle and limbs, microcephaly, blindness, seizures, mental retardation. Exposure at around the time of delivery causes infection in about 25% of exposed newborns. - Infected newborns develop a rash and can die if not treated. - Diagnosis: detection of an antigen (direct immunofluorescence), PCR, or by viral culture of the aspirated vesicular fluid. Treatment: acyclovir, valacyclovir or famcyclovir - Syphilis - Organism: spirochete - Potential outcomes: miscarriage, stillbirth, prematurity, low birth weight, birth of a very ill syphilitic baby, birth of a baby with latent infection - Symptoms of congenital syphilis infection include: - enlarged liver and spleen, anemia, jaundice, skin rash, mental retardation, blindness, deafness, and death - Abnormalities in skin, teeth, and bones - Diagnosis: Dark field microscopic visualization of the spirochete, VDRL, RPR, treponemal-specific antibody tests - Treatment: penicillin G benzathine IM - Rubella - Organism: rubella virus - Rubella is transmitted by contact with nasal secretions of infected individuals. - Infection during the first trimester results in a high rate of birth defects in the baby — congenital rubella syndrome. - Birth defects can include cataracts, hearing loss, heart defects, mental retardation, and growth retardation. - Prevention: Rubella vaccine is a live virus and is never given during pregnancy. - Screening: During pregnancy with antibody titer > 1:8 proves evidence of immunity. - Diagnosis: Rubella virus specific IGM antibodies - Treatment: no drug; geared to relief of symptoms - Cytomegalovirus Infection - Organism: cytomegalovirus (CMV) which is in the herpes family. - CMV can be found in all body fluids. (CMV can be transmitted through kissing, breastfeeding, and intercourse.) - About 1% of pregnant women are infected, and only a small percentage of these will have babies with clinical symptoms. - Symptoms include hearing loss, microcephaly, mental retardation, visual defects, growth retardation, hepato-splenomegaly, thrombocytopenia, intracranial calcifications. - Diagnosis: serological testing of women during pregnancy who are suspected with CMV, urine for CMV - Treatment: Gencyclovir - Herpes Simplex Virus - Type 2 - Organism: Herpes simplex virus - type 2 - Sexually transmitted infection with great incidence in women of reproductive age Risk for fetal or neonatal infection is of concern. Pregnant women with primary infection in third trimester have increased risk (30 to 50%) to transmit infection to fetus during delivery. Risk of neonatal disease is dramatically reduced by cesarean birth for active lesions or prodromal pain. Diagnosis: visualization of genital ulcers, culture, PCR DNA testing for viral shedding, blood testing Treatment: valacyclovir or acyclovir for mother Stages and Phases of Labor and Delivery - Signs of Labor: True vs. False Labor - Lightening: early but not positive sign that labor is coming - Activity: burst of activity before birth is subjective sign - Contractions/Braxton Hicks - Easy to confuse with true labor In true labor, contractions continue and become longer and stronger. Pain Should continue to get stronger - More often felt in back - Mucous plug, bloody show: presence indicates cervix is active but can occur before labor Ruptured membranes - Not indication of true labor - Most often, labor will begin very soon after - Cervical changes: cervical dilation is defining sign for true labor - Stages of labor - Stage One: Contractions - Begins at onset of labor - Ends when the cervix is 10 cm dilated and 100% effaced - Average time for primigravida ranges from 10 to 14 hr - Shorter for subsequent births - Stage One: Early (Latent) Phase Contractions Usually more than 5 min apart - Last 15 to 45 seconds - Tend to be mildly uncomfortable, similar to menstrual cramps Longest phase of labor - Cervical dilation 1 to 4 cm - Stage One: Active Phase - Contractions - 3 to 5 min apart - Last 45 to 75 seconds. - Much stronger - Sometimes pressure felt in pelvis and against cervix - Spontaneous rupture of membranes usually occurs at this point - Increase in bloody show - Cervix 5 to 7 cm dilated - Stage One: Transition Phase (Shortest phase of labor) - Contractions - Very intense - Last 75 to 90 seconds - Nearly on top of each other with less than 1 min between. - - - - Nausea/vomiting, chills, hot flashes, Increase in bloody show - Intense urge to push - Cervix 7 to 10 cm dilated Stage Two: Delivery of Baby - Mothers feel urge to push - Contractions usually farther apart than transition contractions - Mother working hard but almost feels sense of relief Stage Three: Delivery of the Placenta Should take 5 to 20 min - Assess placenta for intactness and umbilical cord for three vessels Stage Four: Stabilization and Recovery - Priority is prevention of postpartum hemorrhage. - Continually assess vital signs, fundus, lochia, perineum, and urinary output. - Administer oxytocin if prescribed to assist with uterine contractions and control bleeding - Contractions hastened by breast-feeding, which stimulates production of the oxytocin. - Assess maternal-infant bonding. Uterine Stimulants - Uterine Stimulants - Methylergonovine - Carboprost tromethamine - Oxytocin - Methylergonovine - Purpose: Sustained uterine contraction to prevent or control postpartum bleeding or hemorrhage - Contraindicated in labor - Route: IM or PO - May cause hypertension Assess BP prior to administration; hold if BP > 140/90 Carboprost - Preferred prostaglandin for stimulating the uterus - Risks: - Uterine hyperstimulation and rupture - Can cause hypotension, pulmonary edema, and intense bronchospasms in women with asthma. Because carboprost stimulates the production of steroids, it may be contraindicated in women with disorders of the adrenal gland. - GI reactions common related to stimulation of smooth muscle of the gut. - Vomiting and diarrhea & Nausea and fever are common. Oxytocin - Naturally occurring posterior pituitary gland hormone - Indications: - Induce labor - Augment labor - Control or prevent postpartum bleeding - For labor induction or augmentation - Must be on an infusion pump - Even small doses can lead to powerful contractions - Potentially Dangerous Effects of Oxytocin in Labor - Prolonged or excessively strong contractions - Fetal hypoxia/ fetal distress - Rupture of the uterus - Placenta abruptio - Antidiuretic affect - Hypertension - Nursing Considerations - Monitor fetal heart rate. - Monitor contractions (frequency, duration, intensity, resting tone). - Monitor vital signs: especially B/P and pulse. - Monitor I&O. - Monitor for water intoxication, such as lightheadedness, nausea, vomiting, headache, and malaise. - - - - Assess and reassess cervical status. Discontinue Oxytocin - Safety of Mom and baby is highest priority. - Discontinue for any signs of fetal or maternal distress. - Know protocol. - Have antidote available. - Tocolytic: Terbutaline Assisted Birth Methods - - Vacuum-Assisted Delivery - Involves use of cuplike suction device attached to fetal head. - Traction is applied during contractions to assist in descent and birth of head. - Vacuum cup is released and removed preceding delivery of fetal body. - Conditions for Use: - Vertex presentation - Absence of cephalopelvic disproportion - Ruptured membranes - Indications: - Maternal exhaustion - Ineffective pushing efforts - Fetal distress during second stage of labor - Risks: - Neonatal risks - Scalp lacerations - Subdural hematoma - Cephalohematoma - Maternal risks - Lacerations to cervix, vagina, or perineum - Nursing Actions - Provide teaching and support. - Assist client into lithotomy position to facilitate traction of vacuum cup when applied to fetal head. - Assess and record FHR before and during vacuum assistance. - Assess for bladder distention. Catheterize if necessary. - Nursing Interventions - Observe neonate for lacerations, cephalohematomas, or subdural hematomas after delivery. - Check neonate for caput succedaneum. Forceps-Assisted Delivery - Using an instrument with two curved, spoonlike blades to assist in delivery of fetal head. - Traction is applied during contractions. - Indications: - Fetal distress during labor - Abnormal presentations or breech position requiring delivery of head - Prolonged second stage - Maternal exhaustion - Arrest of Rotation - - Nursing Actions - Explain procedure to client and support person. - Assist client into lithotomy position. - Assess for empty bladder. Catheterize if necessary. - Assess that fetus is engaged and membranes have ruptured. - Be prepared for emergency cesarean birth. - Interventions - Assess and record FHR - Before, during, and after forceps assistance. - Cord compression between fetal head and forceps causes decrease in FHR. - Observe neonate - Bruising and abrasions - Facial nerve palsy - Facial bruising - Check mother for possible injuries after birth. - Vaginal or cervical lacerations - Urine retention resulting from bladder or urethral injuries - Hematoma formation in pelvic soft tissues from blood vessel injury Amniotomy - Artificial rupture of amniotic membranes (AROM) - May be indicated for labor induction or augmentation - May be indicated for cord compression or meconium-stained amniotic fluid necessitating AROM - Nursing Indications: - Monitor FHR prior to and following AROM to assess for cord prolapse evidenced by variable or late decelerations. - Assess and document characteristics of amniotic fluid: color, odor, and consistency. - Document time of rupture. - Limit maternal activity following AROM to reduce risk of infection or malposition of fetus. - Obtain temperature every 2 hr. Epidural - - - - - - - Epidural: Gold Standard for Pain Management - Administration of IV opioid analgesia Duramorph or Sublimaze - Catheter advanced through needle inserted into epidural space at level of fourth or fifth vertebrae - Infusion pumps necessary to administer medication Epidural for Labor Pain Relief - Eliminates all sensation from level of umbilicus to thighs. - Discomfort of uterine contractions - Fetal descent - Pressure and stretching of perineum. - Administered when client is in active labor and dilated to at least 4 cm. - Continuous infusion or intermittent injections administered through indwelling epidural catheter. Contraindications - Antepartum hemorrhage - Anticoagulant therapy or bleeding disorder - Marked hypotension - Infection at injection site - Tumor at injection site - History of spinal injury or surgery Nursing actions prior to administration - Check platelets and CBC - Preload client with IV fluids - Obtain baseline vital signs - Assess bladder status - Assist with client positioning Risks - Hypotension - Allergic reaction - Incorrect insertion Adverse Effects - Maternal hypotension - Fetal bradycardia - Inability to feel urge to void - Loss of bearing down reflex Nursing Action Immediately After Epidural - Position client on side to prevent supine hypotension syndrome. - Assess blood pressure and fetal heart rate. - Nursing Actions for Maternal Hypotension - Administer oxygen. - Increase flow of IV fluids. - Possibly administer ephedrine if hypotension is severe. Fetal Heart Rate Monitoring - Fetal Monitoring: Internal - Highly invasive - Membranes need to be ruptured - Presenting part needs to be available - Not appropriate in HIV or other infections - Most appropriate when there is fetal distress - Fetal Monitoring: External - Noninvasive - Can be used on anyone at any time - Contraction intensity - Beat-to-beat variability - Fetal Heart Patterns - Early Decelerations - Fetal head compression: reassuring - Slowing of FHR with start of contraction and return of FHR to baseline at end of contraction - No intervention required Late Decelerations - Uteroplacental insufficiency: nonreassuring - Slowing of FHR after contraction has started with return of FHR to baseline well after contraction has ended - Change client to side-lying position. - Start IV line if not in place or increase IV rate. - Stop oxytocin (Pitocin) if being infused. - Administer O2 at 8 to 10 L/min. - Notify provider. - Prepare for assisted vaginal or cesarean birth. - - Variable Decelerations - Cord compression: nonreassuring - Transitory, abrupt slowing of FHR less than 110/min, variable in duration, intensity, and timing in relation to uterine contraction - Nursing actions - Change client position. - Stop oxytocin (Pitocin) if infusing - Give mask O2 at 8 to 10 L/min - Perform or assist with vaginal examination - Assist with amnioinfusion if prescribed. Amnioinfusion - IV solution instilled into amniotic cavity through transcervical catheter introduced into uterus. - May be used for variable decelerations caused by cord compression or dilute meconium-stained amniotic fluid. - Monitor client continuously to prevent uterine overdistention and increased uterine tone, which can initiate, accelerate, or intensify uterine contractions and cause nonreassuring FHR changes. Complications of Labor - Umbilical Cord Prolapse - Risk Factors: - Rupture of amniotic membranes - Abnormal fetal presentation (any presentation other than vertex - Transverse lie - Small-for-gestational-age fetus - Unusually long umbilical cord - Multifetal pregnancy - Unengaged presenting part - Hydramnios - Polyhydramnios - Expected Findings - Visualization or palpation of the umbilical cord protruding from the introitus - HR monitoring - variable - prolonged deceleration - Excessive fetal activity followed by cessation of movement - Interventions - Call for assistance immediately. - Notify the provider. - Use a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. - Reposition the client in a knee-chest, Trendelenburg, or a side-lying position with a rolled towel under the client’s right or left hip to relieve pressure on the cord. - Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow. - Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia. - Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation. - Initiate IV access, and administer IV fluid bolus. - Prepare for an immediate vaginal birth if cervix is fully dilated or cesarean section - Inform and educate the client Labor Positions - Leopold Maneuvers - Leopold maneuvers consist of performing external palpations of the maternal uterus through the abdominal wall to determine the: - Number of fetuses Presenting part - Fetal attitude - Fetal lie - Degree of fetal descent into the pelvis - Expected location of the point of maximal impulse (PMI) - PMI is the optimal location where fetal heart tones are auscultated the loudest on the woman’s abdomen. These tones are best heard directly over the fetal back. - In vertex presentation, PMI is either in the right- or left-lower quadrant or below the maternal umbilicus. - In breech presentation, PMI is either in the right- or left-upper quadrant above the maternal umbilicus. Critical Components of Labor: The Five P’s 1. Passenger 2. Passageway 3. Powers 4. Position 5. Psychological response 1. Passageway Birth canal - Bony pelvis - Cervix - Pelvic floor - Vagina - Introitus - Size and shape of bony pelvis must be adequate to allow fetus to pass through cervix must dilate and efface Soft passage: cervix - Cervical changes - Dilation: 0 to 10 cm - Effacement: 100% - Cervix progresses from long and thick to paper thin - Hard passage: bony pelvis 2. Passenger - consists of the fetus and the placenta. The size of the fetal head, fetal presentation, lie, position, and attitude affect the ability of the fetus to navigate the birth canal. The placenta can be considered a passenger because it must also pass through the canal. - Fetal Lie - Relationship of maternal longitudinal axis (spine) to fetal longitudinal axis (spine) - Longitudinal: fetal long axis parallel to mother’s long axis - Transverse: fetal long axis horizontal to mother’s long axis - Fetal Attitude - Relationship of fetal body parts to one another - Flexion (preferred) - Extension - Presenting Part - Presentation: fetal body part entering the pelvic inlet first - Head – cephalic: longitudinal lie - Buttocks – breech: longitudinal lie - Shoulder: transverse lie - Presentations - the part of the fetus that is entering the pelvic inlet first. - It can be the back of the head (occiput), - chin (mentum) - shoulder (scapula) - breech (sacrum or feet). - Fetal Position - Relationship of presenting part of fetus in reference to directional position as it relates to one of four maternal pelvic quadrants - Labeled with three letters - First letter references side of maternal pelvis. - Right ® - Left (L) - Second letter references presenting part of fetus. - Occiput (O) - Sacrum (S) - Mentum (M) - Scapula (Sc) - Third letter references part of the maternal pelvis. - Anterior (A) - Posterior (P) - Transverse (T) - Station - Measurement of fetal descent in centimeters - Station 0 at level of ischial spines - Minus stations above ischial spines - Plus stations below ischial spines 3. Powers - Regular uterine contractions causing cervical effacement and dilation, and fetal descent - - Involuntary urge to push and voluntary bearing down in second stage for fetal birth - Measuring contractions - Duration - Frequency - Intensity - Resting tone - External tocometer - Intrauterine pressure catheter Cardinal Movements of Birth - Adaptations the fetus makes as it progresses through the birth canal during the birthing process. - Engagement - ccurs when the presenting part, usually biparietal (largest) diameter of the fetal head passes the pelvic inlet at the level of the ischial spines. Referred to as station 0. - Descent and flexion - Descent – the progress of the presenting part (preferably the occiput) through the pelvis. Measured by station during a vaginal examination, as either negative (-) station (measured in centimeters if superior to station 0 and not yet engaged) or positive (+) (station measured in centimeters if inferior to station 0). - • Flexion – when the fetal head meets resistance of the cervix, pelvic wall, or pelvic floor. The head flexes bringing the chin close to the chest, presenting a smaller diameter to pass through the pelvis. - Internal Rotation the fetal occiput ideally rotates to a lateral anterior position as it progresses from the ischial spines to the lower pelvis in a corkscrew motion to pass through the pelvis. - Extension - the fetal occiput passes under the symphysis pubis and then the head is deflected anteriorly and is born by extension of the chin away from the fetal chest. - External rotation - Restitution and external rotation – after the head is born, it rotates to the position it occupied as it entered the pelvic inlet (restitution) in alignment with the fetal body and completes a quarter turn to face transverse as the anterior shoulder passes under the symphysis. - Expulsion - after birth of the head and shoulders the trunk of the neonate is born by flexing it toward the symphysis pubis. 4. Maternal Position - Mother should change positions frequently in labor. - Position in Stage 2 determined by - Mother’s preference - Provider preference - Condition of mother and fetus - Gravity can aid in fetal descent in upright, sitting, kneeling, and squatting positions. 5. Psychological Considerations - Support from family and nurse - Physical preparation for childbirth - Sociocultural values and beliefs - Previous childbirth experiences - Individual coping mechanisms Placenta Previa and Placenta Abruptio - - Placenta Previa - Placenta lies over or near cervix - Three types - Marginal or low-lying - placenta lies more than 3 cm from cervical os - Incomplete or partial - placenta lies within 3 cm of cervical os but does not cover it - Complete or total - cervical os is completely covered by placenta - Clinical Presentation - Usually presents with painless vaginal bleeding in second or third trimester - Painless, bright-red vaginal bleeding increases as cervix dilates - Very uncommon complication - Can be associated with history of previous Cesarean section and induced abortions Placenta Abruptio - Separation of placenta from its implantation site before delivery of fetus - Two classes - Total abruption - Often results in fetal death - Partial abruption - Portion of placenta remains intact - Perfusion to fetus is possible - Clinical Presentation - May present with vaginal bleeding Abdominal pain - Vaginal bleeding that is bright red or dark - Boardlike, tender abdomen - Firm, rigid uterus with contractions (uterine hypertonicity) - Associated with - Previous abruption - Hypertension - - Cigarette smoking - Trauma (falls, motor vehicle crash) - Cocaine use - Can lead to - Massive hemorrhage - Shock - Disseminated vascular coagulation **Hallmark Symptom** - Pain is the hallmark symptom between previa and abruptio. - Presence or absence of pain is key to beginning diagnosis. ***Think Like a Nurse*** • 34-week, gravida 1, para 0 client reports vaginal bleeding and severe, constant, abdominal pain. • History of hypertension and possible drug use • Assessment - Temperature 100.2° F - Pulse 110/min - Respirations 24/min - Blood pressure 98/50 mm Hg • Platelets begin dropping. There is blood in her urine. • What is the best assessment? • Abdominal pain would not be present in previa. • Pain would not be continuous if she were in labor. • Drug and hypertension are both risk factors for abruptio. • Her vital signs reveal possible early signs of shock. • DIC is a possible complication of abruptio. Falling platelets and blood in the urine would be suspect. - Disseminated Intravascular Coagulation (DIC) - Serious blood-clotting problem - Occurs in about 10% of women with placenta abruptio - Most often, severe bleeding or fetus dies from the abruption. - Assessment of Symptoms - Client begins to perspire and report feeling uneasy and frightened. - Color is pale and client reports increasing thirst. - Nursing Actions - Thirst and restlessness are additional signs of shock and bleeding. - Assess and reassess client and fetus. - Prepare for emergency delivery. Meconium-Stained Amniotic Fluid - Meconium-Stained Amniotic Fluid - Should be considered as a warning sign of fetal distress. - Often associated with fetal hypoxia. - Fetal distress causes relaxation of the anal sphincter, which allows meconium to pass into the surrounding amniotic fluid. If the infant gasps or breathes while still in utero or immediately after birth the meconium can enter the lungs and partially or completely block the infant's airways. Meconium in the lung causes air trapping, inflammation, pulmonary vasoconstriction, impairment of surfactant, and atelectasis. Meconium aspiration syndrome is a leading cause of severe respiratory distress and death in the newborn. - Two types - Light meconium staining - normally does not present a problem. - Thick meconium staining - A probable sign of fetal distress and has the highest risk for meconium aspiration syndrome. - Risk factors for meconium aspiration - Maternal hypertension or diabetes mellitus - Maternal heavy cigarette smoking - Maternal chronic respiratory or CV disease - Post-term pregnancy - Pre-eclampsia/eclampsia - Oligohydramnios - Intrauterine growth retardation - Poor biophysical profile - Abnormal fetal heart rate pattern - Management - Ongoing maternal/fetal assessment in labor and delivery, assessment of contractions and fetal heart rates, amniotic fluid color, consistency, odor - Amnioinfusion may be done to help prevent the risk for meconium aspiration syndrome. - A sterile isotonic solution is infused into the amniotic cavity via catheter. By adding volume into the cavity, the meconium is diluted. Hyperemesis Gravidarum - - - - - What is hyperemesis gravidarum (HG)? - Characterized by severe, persistent nausea and vomiting associated with ketosis and weight loss (>5% of pre- pregnancy weight). - May lead to volume depletion, electrolyte and acid-base imbalances, nutritional deficiencies, and even death. Risk factors may include: - Previous pregnancies with HG - Greater body weight - Multiple gestations - Trophoblastic disease - Nulliparity - Maternal age younger than 20 - Vitamin B deficiencies - Transient hyperthyroidism Diagnostic Labs - Ketones and acetone in the urine - Elevated specific gravity - Electrolyte/acid-base imbalance - Low Na, K, Cl - Metabolic imbalances - Elevated hematocrit due to hemoconcentration - Elevated liver enzymes - Thyroid test indicating hyperthyroidism Treatment - Small, frequent meals and eating dry foods such as crackers may help relieve uncomplicated nausea. - Encourage the client to increase oral fluids during the times of the day when the client feels least nauseated. - Seltzer or other sparkling waters might be helpful. - The client may be taking anti- emetics and vitamin B supplements. In some cases the client may need to be hospitalized - Intravenous fluids - Enteral feeding: • Nasogastric Percutaneous endoscopic gastrostomy - Medications such as metoclopramide, antihistamines, and antireflux medications Nursing Care - Nursing Assessments - Monitor I&O - Vomiting - Dehydration including labs - Weight loss - Output - Vital signs - - Hypotension - Tachycardia - Skin Turgor Nursing Interventions - NPO - IV fluids usually Lactated Ringers - In severe cases TPN or enteral nutrition - Vitamin B supplements if tolerated - Antiemetics Hypoglycemia in the Newborn - - - - - Hypoglycemia in the Newborn - Serum glucose level less than 40 mg/dL - Routine assessment of all newborns, especially newborns who are LGA and SGA, should include observing for indications of hypoglycemia High-risk Infants - Newborns greater than 4 kg or less than 2 kg (LGA, SGA, or intrauterine growth-restricted infants) - Infants born to mothers who are insulin-dependent or had gestational diabetes - Premature or postmature infants - Asphyxiated newborn - Cold Stress - Newborns suspected of sepsis - Newborn who is hypothermia & Newborns who are symptomatic Manifestations of Hypoglycemia in the Newborn - Jitteriness/tremors - Irritability - Lethargy - Hypothermia - Hypotonia - Poor feeding - Poor suck - Weak, or high-pitched cry - Exaggerated Moro reflex - Seizures/coma - Irregular respirations - Cyanosis - Apnea Diagnosis - Two consecutive plasma glucose levels - Less than 40 mg/dL in a newborn who is term - Less than 25 mg/dL in a newborn who is preterm Nursing Assessment and Interventions - Obtain blood via heel stick for glucose monitoring - Early feeding - Supplementation: oral, nasogastric, gavage, IV - Recheck blood glucose after intervention Assess blood glucose before feedings - Monitor IV if unable to orally feed; can become hypoglycemic if infiltrated - Wean from supplementation - Decrease IV rate as feedings increase - Maintain neutral thermal environment (NTE) - Monitor and treat respiratory distress - Refer to specialists as necessary Feeding the Newborn - - - - - - Breastfeeding Advantages - Faster involution, less lochia - Decreased incidence of ovarian and premenopausal cancers - Facilitates closeness and bonding - Less risk of overfeeding - Lower incidence of otitis media, diarrhea, lower respiratory tract infections - Fewer cavities - Good jaw and tooth development - Safe and readily available - Cost-effective & no equipment Breast Feeding Contraindications - Ilicit drug use - Active untreated tuberculosis - Human immunodeficiency virus (HIV) - Chemotherapy treatment - Herpetic lesions on the breast Human Milk - Easy to digest - Literally life-giving substance - Contains macrophages, lymphocytes, leukocytes, neutrophils - Passive immunization Breast Milk Composition Changes - Colostrum: first milk - Rich in immunoglobulins - Lower fat and higher protein content - Transitional milk - Third day - Mature Milk - Takes about 10 days Breastfeeding Techniques - Initiate breastfeeding as soon as possible after birth - Demand feeding - Teach mother to recognize feeding cues and not watch the clock - Provide privacy and comfort Breastfeeding Positions - Teach mother basic positions for baby - Cradle hold - Place baby on side, facing stomach and breasts. - Belly to belly. - Put head in bend of elbow. - Mother’s hands on baby’s bottom and support baby’s back. - Hold baby's mouth in front of nipple. - Side-lying hold - - - - - - Lay mother on side with pillow under mother’s head and lower arm around baby. - Place baby on side. - Stomach to stomach - Football hold - Hold baby like a football. - Put bottom of baby's head in mother’s hand and tuck baby’s body under mother’s arm. - Baby will curve into a "C" position. - Support arm and baby with a pillow. - Make sure baby's mouth is right in front of nipple. - Always position baby skin-to-skin, chest-to-chest Teach Effective Latch-On - Watch for readiness cues. - Nipple should be centered. - Instruct mother to tilt nipple to baby - Stimulate rooting reflex. - Critical to wait until baby’s mouth is open. Breastfeeding Techniques - Improper latch most common cause of nipple soreness and mastitis - Suckling at both breasts advised - Rotate starting on left or right breast - Burp between breasts Effective Breastfeeding Indicators - Hydration signs - Normal skin turgor - Moist mucous membranes - Fontanels soft and flat - Gaining weight, approximately 20 to 30 g/day - Baby relaxed during feeding and content after - Six to eight wet diapers/day after milk in - Three bowel movements/day Engorgement - To prevent breast engorgement, have mother empty breasts at each feeding. - Encourage nursing every 2 hr. - Feed at least 15 to 20 min per breast. - Breast may be emptied with breast pump. - To treat breast engorgement - Apply cool compresses after feeding or pumping. - Apply warm compresses or take warm shower prior to breastfeeding. - Cold cabbage leaves may be applied to breasts to decrease swelling and relieve discomfort. Nutrition and Fluid Requirements - No special foods required - - Need additional 500 calories/day - Fluids: 6 to 8 glasses liquid daily - Limit alcohol to 3 glasses/week - No forbidden foods Bottle-Feeding Advantages - Other family members can feed baby - Choice for HIV-positive and drug-addicted mothers - No worry during maternal illness - Specialized formulas available Newborn Vital Signs - - - - Expected Newborn Vital Signs - Body temperature — able to maintain stable 98.6 ° F (37° C) in open crib - Pulse: 100 to160/min - Breathing rate – 30 to 60/min Respirations and Breath Sounds Count respirations while infant is at rest for 1 full minute - Rate: normally 30 to 60/min, 60 to 70/min first 1 or 2 hr - Irregular breathing with brief periods of apnea normal - Breath sounds moist and equal - Nose may be congested - Keep nares patent as neonate is nose breather - Potential Problems Respirations - Grunting - Nasal flaring - Chest retractions - Diminished breath sounds - Apnea: cessation of breathing greater than 15 seconds - Bradypnea: less than 25/min - Tachypnea: greater than 60/min - Excessive mucus - Persistent fine crackles - Central or circumoral cyanosis - Desaturation measured by pulse oximetry Apical Heart Rate - Obtain apical rate for 1 full minute while infant at rest - Heart rate — 100 to 160/min - Fluctuations above and below range with sleeping and crying - May be irregular with crying - Color pink with acrocyanosis - Potential Heart Rate Problems - Murmurs - All need to be followed-up and referred for medical evaluation - Some transitory related to closing of fetal circulatory openings - Tachycardia - Bradycardia - Bounding or irregular pulses Blood Pressure - Measure while infant at rest and not crying - Systolic: 60 to 80 mm Hg - Diastolic: 40 to 50 mm Hg - Potential Blood Pressure Problems - Inaccuracies of readings related to - Crying newborn - Inaccurate cuff size - Improper position of extremity regarding heart level Hypotension or hypertension Difference between upper and lower extremity pressures - - - Temperature - Axillary 36.5° to 37.2° C (97.7° to 98.9° F) - Potential Temperature Problems - Newborn at increased risk for hypothermia related to - Thinner skin - Larger body surface in relation to body mass - Less subcutaneous fat - Unable to shiver - Newborn Thermal Adaptation - Position of flexion - Peripheral vasoconstriction - Muscle activity increase - Nonshivering thermogenesis - Non-shivering thermogenesis - Triggered by a surge in catecholamines (such as norepinephrine) released from sympathetic nervous system during times of cold stress - Metabolism of brown fat located around kidneys, adrenal glands, mediastinum, subscapular, and axillary areas - Increase in lipid metabolic activity of brown fat produces heat - Brown fat reserves deplete with cold stress - Cold Stress - May result in - Higher metabolic rate, leading to lower O2 consumption - Higher caloric consumption and lower glycogen stores - Acidosis due to pulmonary vasoconstriction - Thermal shock and DIC (more serious cases), progressing to death Pain: Fifth Vital Sign - Infants 32 weeks of gestation to 20 weeks of life - Use CRIES neonatal postoperative scale - Behavior indicators - Crying - O2 required - Vital sign changes - Expression changes - Sleepless Measurements - Head Circumference - Place tape measure on pinna of ear and over eyebrows (occipitofrontal) - - Usually 2 to 3 cm greater than chest circumference - 32 to 36.8 cm (12.6 to 14.5 in) - Chest circumference - Place tape over nipple line - 30 to 33 cm (12 to 13 in) - Length - Place tape (zero end) at top of the head (crown) to heel - Leg must be fully extended - 45 to 55 cm (18 to 22 in) Weight - Zero scale with scale paper first - Weigh at same time each day - Normal variation: 2,500 to 4,000 g - Three types: - Small for gestational age (SGA) - Weight below 10th percentile for gestational age - Appropriate for gestational age (AGA) - Weight between 10th and 90th percentiles for gestational age - Large for gestational age (LGA) - Weight above the 90th percentile for gestational age Newborn Physical Assessment - - - - - Goal - Transition newborn safely from intrauterine to extrauterine life. Expected General Appearance - Flexed - Symmetrical - Full range of motion - Strong cry - Pink Unexpected General Appearance - Lethargic or floppy - Jittery or irritable - Asymmetrical movements - Repetitive movements - High-pitched or shrill cry - Continuous cry High-Risk Infants - Large for gestational age - Small for gestational age - Preterm & Post-term - Infant of diabetic mother - Congenital defects - Chromosomal defects - Low birth weight & Very low birth weight - Cesarean delivery Measurements - Vital signs - Weight - Head and chest circumference - Length Gestational Age Assessment - Physical criteria - Skin - Lanugo - Plantar creases - Breast buds - Ear - Genitals - Neuromuscular criteria - Posture - Square window - Popliteal angle - Arm recoil - - - Scarf sign - Heel to ear Head-to-Toe Physical Assessment: Posture - Arms, legs in moderate flexion - Fists clenched - Resists attempts for extension of extremities - Normal spontaneous movement bilaterally - Problems - Hypotonia - Hypertonia - Opisthotonos - Limitation of motion in any extremity Skin - Intactness - Smoothness - Texture - No edema - Hydration - Pink - Acrocyanosis - Subcutaneous fat - Lanugo over shoulders, forehead, ear pinnae - Vernix - Skin Variations - Mottling - Harlequin sign - Plethora - Telangiectasia - Erythema toxicum - Milia - Petechiae on presenting part - Ecchymoses from forceps - Mongolian spots - Physiological jaundice after first 24 hr of life - Skin Problems - Dark red from polycythemia - Pallor, gray, cyanosis & Rashes - Petechiae over other body parts - Jaundice in first 24 hr of life - Hemangiomas - Edema on hands, tibia, feet - Skin tags - Webbing - Papules, pustules, vesicles, ulcers, maceration - - - Green from meconium Head - Size: 1⁄4 body length - Shape: molding - Fontanelles - Anterior and posterior - Soft and flat - Sutures: meet or override - Hair: silky flat - Variations - Caput succedaneum - Slight asymmetry - Lack of molding - Problem - Cephalohematoma - Severe molding - Indentation from fracture - Fontanelles bulging or depressed - Widely spaced sutures or prematurely closed Face - Symmetry - “Normal” appearance - Problems - “Odd” or “funny” appearance - Usually accompanied by other abnormal features Eyes - Eyes and space between each 1/3 distance from outer to outer canthus - Eye symmetry for size, shape - Eyelids size, shape, movement, blink - No discharge - Eyeball movement: brief focus - Eye Variations - Epicanthal folds - Edema from medications - Occasional tears - Subconjunctival hemorrhage - Strabismus - Nystagmus - Eye Problems - Epicanthal folds present with other signs (chromosomal disorders) - Purulent discharge - Absence of an eyeball - Lens opacity - Absence of red reflex - Nose - - Ears - - - - Lesions Scleral jaundice Pupils unequal, constricted, dilated, fixed Persistent strabismus Dolls eyes Sunset eyes Midline Lack of bridge, flat, broad Some mucus but no drainage Nose breathing Variations - Slight deformity from passing through birth canal Problems - Copious drainage - Malformed - Nasal flaring - Choanal atresia - Snuffles from syphilis Size & Placement - Line drawn through inner and outer canthi of eyes reaching top notch of ear at junction with scalp Cartilage amount Open auditory canal Responds to voice and other sounds Variations - Small, large, floppy - State influences response ( alert, asleep) Problems - Lack of cartilage - Low placement - Preauricular tags - Deafness Mouth - Lip movement symmetry - Pink gums - Tongue - Not protruding - Freely movable - Symmetric in shape - Sucking pads in cheeks - Palate intact - Uvula midline - - - Chin distinct Mouth moist Reflexes - Root - Suck - Extrusion - Swallow - Variations - Circumoral cyanosis - Epstein pearls - Short frenulum - Anatomical groove in palate - Problems - Cleft lip or palate - Cyanosis - Asymmetry of lip movement - Prenatal teeth - Macroglossia - Thrush - Micrognathia Neck and Clavicles - Neck - Short, thick, skin folds - No webbing - Head - Midline - No masses - Freedom of head movement - Side to side - Flexion - Extension - Trachea midline - Problems - Webbing - Restricted movement of head - Lack of head control - Masses - Distended veins - Fractures of clavicles Chest and Breasts - Circular; barrel - Size: smaller than the head - Clavicles intact - Respiratory movements - - Rib cage symmetric Nipples - Two prominent - Well formed - Symmetrically placed - Breast tissue - Listen to breath and heart sounds - Variations - Witch's milk - Engorgement - Chest and Breast Problems - Bulging chest - Unequal chest movement - Malformation of chest (funnel chest) - Lack of breast tissue - Heart murmurs - Supernumerary nipples or nipple placement - Retractions - Bowel sounds in the chest - Adventitious lung sounds Abdomen - Inspect, palpate, and smell umbilical cord - White - Gray - Odorless - Cord - 2 arteries, 1 vein (AVA) - Cord clamp - Round prominent dome shaped - No distension - Bowel sounds present in 1-2 hr after birth - Numer, amount and character - Meconium passed within 24 to 48 hr - Variations - Umbilical hernia - Diastasis recti - Problems - One umbilical artery - Meconium stained - Cord bleeding or oozing, drainage or redness - Omphalocele - Distension - Visible peristalsis - Absent bowel sounds - - - Scaphoid abdomen - Palpable masses - Palpable bowel loops Extremities, Hands, Feet - Flexion - Full range of motion all joints - Spontaneous movement - Symmetry of motion - Muscle tone - 5 fingers/toes each hand/foot - Humerus/femur intact - Arms longer than legs in newborn - Palmar and plantar grasp intact - Abnormal/asymmetrical Moro reflex - Bowing of legs - Ortolani’s maneuver: intact femur, no clicks - Gluteal folds even - Legs same length - Variants - Tremors - Acrocyanosis - Positional foot defects - Problems - Poor muscle tone - Brachial nerve trauma - Simian crease - Webbing - Polydactyly or lack of digits - Fractured humerus, femur - Phocomelia - Congenital hip dysplasia - Congenital club foot - Hypermobility of joints - Few sole creases or sole covered with creases - Asymmetrical movement Genitalia - Female - Edematous - Mucoid discharge - Hymenal or vaginal tag - Term: labia majora cover labia minora - Voiding within 24 hr - Variants - Increased pigmentation - - Male - - - - - - Edema, ecchymoses from birth - Pseudomenstruation - Uric acid crystals Problem - Ambiguous - Labia majora widely separated with preterm - Fecal discharge Meatus at penile tip Prepuce covering glans - Not retractable Term - Scrotum large, pendulous, edematous - Testes palpable Voids stream within 24 hr Variants - Increased penile size and pigmentation - Prepuce removed if circumcised - Scrotal edema, ecchymoses from birth Problem - Ambiguous - Hypospadia, epispadia - Scrotum smooth, testes undescended - Hydrocele - Inguinal hernia Back - Spine - Straight - Easily flexed - Momentarily able to raise and support head when prone - Shoulders, scapulae, iliac crests line up in same plane - Trunk flexed, pelvis moves to stimulation - Lower limbs extend to foot pressure - Back Problems - Limitation of movement - Coccygeal dimple - Pigmented nevus with soft tuft of hair anywhere on spine, often associated with spina bifida - Meningocele, myelomeningocele - Absence of trunk incurvation or magnet reflex Anus and Stools - One with good sphincter tone - “Wink” reflex of sphincter - Passage of meconium with 24 hr after birth - - - Then transitional and soft yellow stools Problems - Anal membrane causing low obstruction - Rectal atresia - Feces from vagina in female or urinary meatus in male (rectal fistula) - No stools or frequent watery stools Routine Labs - Newborn screening (PKU) - Phenylketonuria - Congenital adrenal hyperplasia - Hypothyroidism - Galactosemia - Sickle-cell anemia - Bilirubin levels Subtle Manifestations of Infection - Fever not reliable indicator of infection - Hypothermia more reliable sign of infection - Poor feeding pattern (i.e., weak suck, decreased intake) - Feeding intolerance (i.e., abdominal distention, large residual if feeding by gavage, palpable and visible bowel loops, emesis) - Suspicious drainage - (eyes, nose, umbilical stump) - Vomiting and diarrhea - Apnea, sternal retractions, grunting, nasal flaring, tachypnea - Decreased oxygen saturation, poor capillary refill - Tachycardia or bradycardia - Color changes - (pallor, jaundice, mottling, cyanosis) - Low blood pressure - Irritability and seizure activity - Poor muscle tone and lethargy - Petechiae - Acidosis Phototherapy - - Phototherapy - Primary treatment for hyperbilirubinemia - Newborn is placed under source of blue light (wavelength 425 to 550 nm), light reacts with bilirubin in blood flowing through the baby's skin. - Light promotes bilirubin excretion by altering structure of bilirubin to a soluble form for easier excretion. - Prescribed if infant’s serum bilirubin - Greater than 15 mg/dL prior to 48 hr of age - Greater than 18 mg/dL prior to 72 hr of age - Greater than 20 mg/dL at any time Jaundice - Types - Physiologic jaundice - Benign - Results from normal newborn physiology of increased bilirubin production due to the shortened lifespan and breakdown of fetal RBCs and liver immaturity - A newborn with physiological jaundice will exhibit an increase in unconjugated bilirubin levels 72 to 120 hr after birth, - Rapid decline to 3 mg/dL 5 to 10 days after birth. - Pathologic jaundice - Underlying disease. - Appears before 24 hr of age or is persistent after day 14. - In the term newborn, bilirubin levels increase more than 0.5 mg/dL/hr, peaks at greater than 12.9 mg/dL, - Is associated with anemia and hepatosplenomegaly. - Usually caused by a blood group incompatibility - May be result of RBC disorders - Jaundice: Complication - Kernicterus (bilirubin encephalopathy) - Can result from untreated hyperbilirubinemia with bilirubin levels at or higher than 25 mg/dL. - Neurological syndrome caused by bilirubin depositing in brain cells. - Neonates may develop cerebral palsy, epilepsy, mental retardation, learning disorders, or perceptual-motor disabilities. - Assessment for Jaundice - Observe infant's skin color from head to toe, sclerae, and mucus membranes in natural daylight - Jaundice progresses from head to toe - Do not assess for jaundice while infant is under light. - - Phototherapy: Advantages - Noninvasive - External therapy Nursing Care - Infant's skin must be fully exposed to adequate amount of light source. - Monitor infant’s vital signs. - Set up phototherapy if prescribed. - Maintain eye mask over newborn’s eyes for protection of corneas and retinas. - Keep newborn undressed only leave diaper. - Avoid applying lotions or ointments to infant. - Absorb heat - Can cause burns - Remove newborn from phototherapy every 4 hr. - Unmask newborn’s eyes. - Check for indications of inflammation or injury. - Provide eye care as necessary. - Facilitate parental bonding - Encourage parents to feed and hold baby. - Reposition newborn every 2 hr to expose all body surfaces to phototherapy lights and prevent pressure sores. - Check lamp energy with photometer per unit protocol. - Turn off phototherapy lights before drawing blood for testing. - Monitor, report, and record bilirubin levels. - Assess and record transcutaneous bilirubinometry reading per unit protocol. - Observe for phototherapy side effects - Bronze discoloration – not a serious complication - Maculopapular skin rash – not a serious complication - Development of pressure area - Dehydration - Poor Skin Turgor - Dry Mucous Membranes - Decreased Urinary Output - Elevated temperature - Monitor newborn’s axillary temperature every 4 hr during phototherapy, because phototherapy can increase body temp. - Monitor skin temperature with skin probe if infant in isolette or on radiant heat warmer. - Feed newborn early and frequently – every 3 to 4 hr to promote bilirubin excretion in stools. - - - Continue to breastfeed newborn. Supplementing with formula may be prescribed. Reassure parents that most newborns experience some degree of jaundice. Phototherapy can make baby sleepier than usual and less eager to eat. To prevent dehydration, be sure baby drinks enough fluids. Wake baby for feedings at least every 3 to 4 hours or as prescribed. Some babies need IV to get enough fluids while being treated. Monitor elimination and daily weights, watching for indications of dehydration Babies receiving phototherapy may have frequent dark green, black, tarry, or watery stools as the bilirubin is being removed from the body. Keep baby's skin clean, especially in diaper area. Biliblanket - Fiber optic system - Flexible panel - No eye patch necessary if single therapy - More portable - Convenient for mother and home therapy - Can be combined with fluorescent blue overhead lights Documentation - Accurate charting is an important nursing responsibility. - Times phototherapy is started and stopped - Proper shielding of eyes - Type of fluorescent lamps - Number of lamps - Distance between surface of lamps and infant - Should be no less than 18 inches - Use of phototherapy in combination with an incubator or open bassinet - Occurrence of side effects - Loose, greenish stools - Transient skin rashes - Hyperthermia - Increased metabolic rate - Dehydration - Electrolyte disturbances as hypocalcemia - Skin color & Skin turgor - Fontanel assessment - Changes in tone, activity level, or feedings - Characteristics of stool - Additional fluid volume needed - Parental instruction Postpartum Blues, Depression, Psychosis - - Postpartum Blues - Day 1 to 10 - Experienced by 50% to 70% of women during the first few days after birth - Peaks on day 5 - Mild sadness, tearfulness - Anxiety - Irritability, often for no clear reason - Fluctuating moods - Increased sensitivity - Insomnia, fatigue - Lack of appetite - Let-down feeling - Will not harm baby or self - Risk Factors - Hormonal changes with rapid decline in estrogen and progesterone levels - Postpartum physical discomfort and/or pain - Individual socioeconomic factors - Anxiety about new role as mother - History of major depression - Difficult labor - Premature labor - Severe PMS - Low self-esteem - Unwanted or unplanned pregnancy - Lack of social support - History of intimate partner violence - Anticipatory guidance - Blues are normal. - Get rest. Nap when baby naps. - Let friends know when to visit. - Use relaxation techniques. - Teach mother to do something for herself (e.g., take a walk). - Plan day out of house and take baby or leave baby with entrusted person. - Seek help from community agencies (i.e., La Leche League) Postpartum Depression (PPD) - Occurs within 6 months of delivery - Characterized by persistent feelings of sadness, intense mood swings. - Intense, pervasive sadness - Experienced by 10% to 15% of women after delivery - Very underdiagnosed - Women hide manifestations due to guilt - Symptoms: - - Hopelessness - Guilt, inadequacy feelings - Difficulty concentrating & Irritability - Anxiety - Intense mood swings - Fatigue persisting beyond reasonable amount of time - Feeling of loss - Lack of appetite - Persistent feelings of sadness - Sleep pattern disturbances Risk of Suicide - Usually no risk of direct harm to infant - May harm infant through neglect and inability to care for baby - Treatment - Professional help - Antidepressants - Antianxiety agents - Counseling - Support groups Postpartum Psychosis (PPP) - Very rare - Mean time to onset 2 to 3 weeks postpartum - Symptoms - Pronounced sadness - Paranoia, auditory hallucinations - Disorientation, confusion - Mood shifts - Delusions often associated with God and Devil (infant possessed) - Complaints of fatigue, insomnia, restlessness - Tearfulness, emotional lability - Grossly disorganized behavior - Suspiciousness, incoherence, irrational statements - Often associated with bipolar disorder - Management of PPP - Psychiatric emergency - Real risk of harm to baby, self - Inpatient treatment required - Safety priority - Psychotherapy - Antipsychotics - Mood stabilizers - Counseling - Assess infant for failure to thrive secondary to inability of mother to provide care. Postpartum Fundal Assessments - - - - - - Involution - Involves the return of the uterus to a non-pregnant state after birth. - It begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle. - Process of autolysis begins: self-destruction of excess hypertrophied tissue of the uterus. - Contractions of uterine muscle around the intramyometrial blood vessels helps to prevent bleeding. Uterine involution - Uterus must contract to prevent bleeding at placental attachment site. - It descends into the pelvic cavity at a rate of 1 cm/day (approximately one fingerbreadth). - By day 10-14, the uterus is no longer palpable. - Assessments: position (in relation to midline); consistency (firm, boggy); tone; height (in relation to the umbilicus) Factors slowing uterine involution - Prolonged labor - Anesthesia or excessive analgesia - Difficult birth - Full bladder - Grand multiparity - Incomplete expulsion of the placenta or membrane fragments - Multifetal pregnancy - Infection Factors enhancing involution - Breastfeeding, which stimulates oxytocin release - Administration of oxytocin IV - Early ambulation - Uncomplicated birth - Proper nutrition Assessing the fundus - To palpate fundus position and height, put client flat on her back (supine). - Then place one hand at the base of the uterus above the symphysis pubis in a cupping manner (to support the lower uterine ligaments). - Then, gently press in and downward with the other hand at the umbilicus until making contact with a hard, globular mass. Fundal massage - - - - Massage the fundus every 15 minutes during the first hour post delivery, every 30 minutes during the next hour, then every hour until the client is ready for transfer. - Chart fundal height. Evaluate from the umbilicus using fingerbreadths. This is recorded as two fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth. The fundus should remain in the midline. If it deviates from the middle, identify this and evaluate for distended bladder. - Inform the charge nurse or physician if the fundus remains boggy after being massaged. - NOTE: A boggy uterus many indicate uterine atony or retained placental fragments. Boggy refers to being inadequately contracted and having a spongy rather than firm feeling. This is descriptive of the post-delivery status of the uterus. Cesarean delivery - A mother who has had a cesarean birth should be medicated, if possible, prior to assessment of the fundus; and the health care provider should use the minimal amount of pressure necessary to locate her fundus. Lochia assessment - Color of blood (timing): rubra, serosa, alba. - Amount on pad: scant, light, moderate, heavy. - Presence of clots vs. constant trickle of bright red lochia. - Observe and report foul-smelling lochia. - Observe absence of lochia. Lochia amount Postpartum Hemorrhage - - - - Postpartum Hemorrhage - Postpartum hemorrhage is considered to occur if the client loses more than 500 mL of blood after a vaginal birth or more than 1,000 mL of blood after a cesarean birth. - Complications - Hypovolemic shock - Anemia Early vs. Late Postpartum Hemorrhage - Early: within 24 hours of delivery - Late: 24 hours to 6 weeks after delivery Risk Factors for Postpartum Hemorrhage - Placenta previa or abruptio - Grand multiparity - Cesarean birth - Multiple gestation - Prolonged, difficult, or rapid labor and birth - Incomplete expulsion of placenta or membranes - Magnesium sulfate during labor - nstrumental vaginal delivery - Uterine inversion - Subinvolution - Coagulopathies (DIC) Causes of Postpartum Hemorrhage - Tone: Uterine atony - Most common cause - Typical cause in the first 4 hr after delivery - Overdistended uterus - multiple gestation, fetal macrosomia, polyhydramnios - Fatigued uterus - prolonged labor, use of uterine tocolytics like magnesium - Obstructed uterus - retained placenta, or an overly distended bladder - Trauma: Cervical or vaginal laceration - Second most frequent cause - Associated with instruments and prolonged second stage - Tissue: Retained placental fragments - Difficult Delivery Of Placenta - Thrombosis: Clotting disorders (coagulopathy) - Secondary to DIC, severe preeclampsia - Or pre-existing hematological disease - Traction: Inversion of the uterus - - - Inversion prevents the myometrium from contracting and retracting, and it is associated with life-threatening blood losses as well as profound hypotension from vagal activation. Assessment: - Physical Data - Uterine atony - Blood clots larger than a quarter - Perineal pad saturation in 15 min or less - Return of lochia rubra once lochia has progressed to serosa or alba - Constant oozing, trickling, or frank flow of bright red blood from the vagina - Tachycardia and hypotension - Skin that is pale, cool, and clammy with poor turgor and pale mucous membranes - Oliguria - Labs - CBC - Coagulation labs (PTT, aPTT, INR) - BUN, creatinine - Type and crossmatch - Fibrinogen - LFTs - Lactate Management of Bleeding - Review risk factors (atony, bladder distention) - Oxygen 2-3 L via NC - Massage uterus and very gently expel clots. - IV fluids: isotonics, colloid volume expanders, blood products - Assess lochia: quantity, presence of clotting. - Vital signs: Maintain airway and remain alert for signs of impending hypovolemic shock - Provide oxytocic drugs - Foley for accurate output - Elevate legs 20-30 degrees - If Patient Continues to Bleed - Notify provider and team and prepare client for surgery. - Provider will attempt to find and repair any lacerations. - Provider will attempt to find and remove retained placenta. - If needed, provider will replace blood products. - If needed, provider will pack uterus. - If all else fails, provider may need to remove uterus (hysterectomy). Postpartum Infections - Definition of Postpartum Infections - Occurs up to 28 days following childbirth or a spontaneous or induced abortion - Fever of 38° C (100.4° F) or higher for 2 consecutive days during the first 10 days of the postpartum period. - Infection can be in bladder, uterus, wound, or breast. - Risk Factors for Postpartum Infection - Prolonged labor - Prolonged ruptured membranes - Multiple vaginal exams - Cesarean section or episiotomy - Anemia - Internal fetal monitor - History of infection (STIs) - Instruments (forceps, vacuum extraction) - Postpartum hemorrhage - 6 Types of Postpartum Infections 1. Endometritis - Most serious postpartum infection - Infection of uterine lining or endometrium - Most frequently occurring puerperal infection - Usually begins on second to fifth postpartum day - Generally starts as localized infection at placental attachment site - Spreads to include entire uterine endometrium - Risk for sepsis - Risk Factors: - Cesarean birth - Retained placental fragments and manual extraction of placenta - Prolonged rupture of membranes - Chorioamnionitis - Internal fetal/uterine pressure monitoring - Multiple vaginal examinations after rupture of membranes - Prolonged labor - Postpartum hemorrhage - Assessment - Persistent spiking chills, fever (101° F [38.4° C]) - Purulent, foul-smelling lochia - Increased or decreased lochia - Lower abdominal pain and distension - Chills, headache, malaise, and anorexia common - Uterine subinvolution and tenderness - Tachycardia - Delayed treatment can result in - Peritonitis - Septic shock - Deep-vein thrombosis, pulmonary embolism - Chronic pelvic infection - Tubal blockage and infertility. - Death - Interventions - Collect vaginal and blood cultures. - Administer IV antibiotics. - Administer analgesics. - Keep bed in semi-Fowler’s position. - Prevents ascending infection. - Promotes drainage. - Encourage ambulation to promote drainage. - Change perineal pads frequently. - Teach hand hygiene techniques. - Reinforce perineal care. - Encourage mother to maintain interaction with infant. - Educate client about signs of worsening conditions to report. - Provide comfort measures, such as warm blankets or cool compresses. - Encourage a diet high in protein to promote tissue healing. 2. Mastitis - Infection of the breast involving interlobular connective tissue - Usually unilateral - May progress to an abscess if untreated - Occurs most commonly in mothers breastfeeding for the first time - Well after establishment of milk flow - Usually 2 to 4 weeks after delivery - Staphylococcus aureus usually infecting organism - Organisms transferred from client/staff hands or newborn mouth to breast - Organisms enter breast through small cracks, fissures, or injured areas on nipple or breast tissue - Risk Factors: - Inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis - Engorgement - Clogged milk ducts - Cracked or bleeding nipples - Assessment: - General sudden flulike clinical findings - Fever - Malaise - Chills - Painful or tender, localized hard mass - Reddened area, usually on one breast - Fatigue - Axillary adenopathy in affected side - Enlarged tender axillary lymph nodes - Inflammation area may be red, swollen, warm, tender - Preventative Interventions - Provide education regarding breast hygiene to prevent mastitis. - Wash hands prior to breastfeeding. - Maintain clean breast pads. - Allow nipples to air-dry. - Prevention - Proper infant positioning and latching-on techniques - Nipple - Areola - Release infant’s grasp on nipple prior to removing infant from breast. - Completely empty breasts during each feeding for prevention of milk stasis (medium for bacterial growth). - Interventions - Use ice or warm packs on affected breasts for discomfort. - Continue breastfeeding frequently (at least every 2 to 4 hr), especially on affected side. - Manually express breast milk or use breast pump if breastfeeding is too painful. - Encourage the client to allow nipples to air-dry. - Begin breastfeeding from unaffected breast first to initiate letdown reflex in affected breast that is distended or tender. - Need rest, analgesics, and fluid intake at least 3,000 mL/day. - Wear well-fitting bra. - Report redness and fever. - Administer antibiotics and teach importance of completing entire course of antibiotics. - Analgesics as needed 3. Wound infection - Common postpartum infections but often develop after discharge - Sites of wound infections - Cesarean incisions - Episiotomies - Lacerations - Trauma wounds in birth canal following labor and birth - Assessment - Wound—REEDA (redness, ecchymosis, edema, discharge, and approximation) - Warmth - Erythema - Tenderness - Pain - Edema - Seropurulent drainage - Dehiscence or evisceration - Fever - Interventions - Complete wound care—use of wound vacuum after cesarean delivery. - Comfort measures - Sitz baths - Perineal care - Warm or cold compresses - Teach good hand hygiene techniques - Changing perineal pads from front to back - Hand hygiene before and after perineal care 4. Urinary tract infection Common secondary to bladder trauma - Incurred during the delivery or a break in aseptic technique during bladder catheterization. - Potential complication - Progression to pyelonephritis with permanent renal damage leading to acute or chronic renal failure. - Risk Factors - Postpartum hypotonic bladder and/or urethra (urinary stasis and retention) - Epidural anesthesia - Urinary bladder catheterization - Frequent pelvic examinations - Genital tract injuries - History of UTIs - Cesarean birth - Assessment: - Urgency, frequency, dysuria, and discomfort in pelvic area - Fever - Chills - Malaise - Change in vital signs, elevated temperature - Urine - Cloudy - Blood-tinged - Malodorous - Sediment - Urinary retention, hematuria, pyuria - Pain in suprapubic area - Costovertebral angle tenderness - Interventions - Random or clean-catch urine sample - Complete entire course of antibiotics - Perineal hygiene - Fluid intake 3,000 mL/day - Cranberry juice to promote urine acidification - If ordered by physician, acetaminophen may be taken to reduce discomfort and pain associated with a urinary tract infection. 5. Vaginitis 6. Pneumonia Hypertensive Disease in Pregnancy - Types include: 1. Gestational hypertension 2. Preeclampsia a. Mild b. Severe 3. Eclampsia 4. HELLP syndrome - Risk Factors For Gestational Hypertensive Disorders - First pregnancy - Age under 19 and over 40 years - African American and Hispanic women - Chronic or essential hypertension - Hypertension in previous pregnancy - Multifetal pregnancy - Morbid obesity - Familial history of preeclampsia - Diabetes Mellitus 1. Gestational Hypertension - Begins after the 20th week of pregnancy - Blood pressure 140/90 mm Hg or greater on two occasions at least 4 hours apart, - No proteinuria or edema - Blood pressure returns to baseline by 6 weeks postpartum 2. Preeclampsia a. Mild Preeclampisa - Gestational hypertension with addition of proteinuria of 1 to 2+ (300 mg/24 hr) and weight gain of more than 2 kg (4.4 lb) per week in second and third trimesters - Mild edema appears in upper extremities or face - No seizures, coma, or hyperreflexia - Report of a transient headache may occur b. Severe Preeclampsia - Blood pressure 160/100 mm Hg or greater - Proteinuria 3 to 4+ (500 mg/24 hr Oliguria - Elevated serum creatinine greater than 1.1 mg/dL - Cerebral or visual disturbances (headache and blurred vision) - Hyperreflexia with possible ankle clonus - Pulmonary or cardiac involvement - Extensive peripheral edema - Hepatic dysfunction - Epigastric and right upper-quadrant pain - Thrombocytopenia (< 100,000 platelets/mm3) - HELLP syndrome 3. Eclampsia - Severe preeclampsia symptoms with onset of seizure activity or coma. - Warning signs of probable convulsions - Headache - Severe epigastric pain - Hyperreflexia - Hemoconcentrations 4. HELLP Syndrome - Variant of gestational hypertension, which is diagnosed through lab values - H: Hemolysis resulting in anemia and jaundice - EL: Elevated liver enzymes, epigastric pain, and nausea and vomiting - LP: Low platelets (less than 100,000/mm3) resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly disseminated intravascular coagulopathy - Classic Signs - Hypertension - Proteinuria - Generalized edema - Nursing Management - Assess level of consciousness. - Obtain pulse oximetry. - Obtain clean-catch urine sample to assess for proteinuria. - Obtain daily weights. - Monitor vital signs (blood pressure, pulse, respirations). - Encourage lateral positioning. - Assess contraction status. - Perform NST and daily kick counts Assess fetal heart patterns for decreased variability and late decelerations. - Assess for progressive symptoms of preeclampsia - Observe for edema. - Assess deep-tendon reflexes. - Assess I&O. insert urinary catheter for accurate measurement. - Maintain bed rest and quiet environment. - Assess well being of fetus (NST, fetal kick counts, biophysical profile, FHT, ultrasound, Doppler blood flow) - Assess continuing status. - Assess for impending seizure. - Maintain seizure precautions. - Administer medications as appropriate. - Obtain and assess labs as ordered. - Medications used for Gestational Hypertension Disease - Anticonvulsant Medications - - Magnesium Sulfate is the medication of choice for prophylaxis to depress the CNS. - Nursing Considerations: - Use an infusion control device to maintain a regular flow rate. - Inform the client that she can initially feel flushed, hot, and sedated with the magnesium sulfate bolus. - Monitor blood pressure, pulse, respiratory rate, deep tendon reflexes, level of consciousness, urinary output (indwelling urinary catheter for accuracy), presence of headache, visual disturbances, epigastric pain, uterine contractions, and fetal heart rate and activity. - Place the client on fluid restriction of 100 to 125 mL/hr, and maintain a urinary output of 30 mL/hr or greater. - Monitor for signs of magnesium sulfate toxicity. - Absence of patellar deep tendon reflexes - Urine output less than 30 mL/hr - Respirations less than 12/min - Decreased level of consciousness - Cardiac dysrhythmias - If toxicity is suspected: - Immediately discontinue the infusion - Administer antidote calcium gluconate or calcium chloride - Prepare for actions to prevent respiratory or cardiac arrest. ANTI HYPERTENSIVE MEDICATIONS - Methyldopa - Nifedipine - Hydralazine - Labetalol - Avoid ACE inhibitors and angiotensin II receptor blockers. Umbilical Cord Care - - - - - Cord Basics - One large umbilical vein carries oxygenated blood and nutrients to baby from placenta - Two arteries return deoxygenated blood and waste products from baby back to placenta - Think “AVA” for 2 arteries & 1 vein - Substance wrapped around vessels inside cord is Wharton's jelly and is a rich source of stem cells Parent Teaching - Hand washing is imperative when providing newborn care. Provide teaching to parents. - Keep stump dry. - Expose stump to air to help dry out the base. - Keep front of baby's diaper folded down to avoid covering stump. - Change wet or soiled diapers quickly to prevent irritation. - Avoid dressing baby in bodysuit- style undershirts until cord has fallen off. - In warm weather, dress baby in diaper and T-shirt to improve air circulation. Parent Teaching: Sponge Bath - Best way to clean baby until umbilical cord falls off. - Keep the cord dry during the sponge bath. - Sponge baby with warm, wet, soft cloth. - Wring out excess water. - If needed, mild soap can be used in water. - Wipe baby's skin gently. - Start at baby's head and work down to rest of body. - Pay special attention to skin creases and diaper area. - Rinse baby with clean warm water and dry completely Cord Appearance - Right after birth, umbilical cord stump usually looks white and shiny. - May feel slightly damp - As stump dries and heals, it may look yellowish green to brown, gray, or even black. (This is normal.) - Usually no problems develop as long as area is clean and dry. - The cord usually falls off within 10 to 14 days. High Risk for Infection Umbilicus is excellent medium for bacterial growth - Major portal of entry for infection; Site for local infection - Increases risk for sepsis - - - - - - Signs of infection at the umbilical cord - Redness, edema, tenderness of skin around cord extending more than 5 mm from umbilicus - Foul-smelling purulent drainage - Fluid continuing to ooze from site after cord falls off - Stump swollen, smelly, weepy, bleeding - Signs of generalized sepsis - Fever - Lethargy - Poor feeding Removal of Cord Clamp - Done by nurse at approximately 24 up to 48 hrs of age, prior to discharge - Nursing assessment to ensure cord is dry and monitor for signs of infection. Keep Cord Clean and Dry - No creams, lotions, oils, or bandages on cord - Alcohol delays time for cord to fall off - Dry cord care: belief that stump will heal faster if left alone. - If stump becomes soiled, can be washed with mild soap and water. Dry well. - Hold clean, absorbent cloth around the stump or use low setting on hair dryer, being careful to hold dryer a safe distance from baby. Cord Shrinkage - Just before umbilical cord falls off, it is very dry. - Cord will begin to shrivel immediately. - Each day, will get smaller and pull away from center of soon-to-be navel. Parent Teaching - Active bleeding usually occurs when cord is pulled off too soon. - Allow cord to fall off naturally, even if only hanging on by a thread. - Teach parents to notify provider if cord actively bleeds. After Cord Falls Off - Navel area may look pink or yellow. - Can take several days or weeks to heal completely. - Continue to keep area clean and dry. - Baby may have a tub bath, but dry navel area thoroughly afterward.
