NSG109 LEC REA A. GUADALQUIVER BS NURSING - 2C UNIT 1: Nursing Care of The High-Risk Pregnant Client FEMALE REPRODUCTIVE SYSTEM Consist of the following: • External genitalia • Internal genitalia • Accessory structure (mammary glands) EXTERNAL Also known as VULVA It includes the following: • MONS PUBIS - A pad of fatty tissue covered by coarse skin and hair - It protects the symphysis pubis and contributes to the rounded contour of the female body • LABIA MAJORA - Are two folds of tissue on each side of the vaginal vestibule. - Many small glands are located on the moist interior surface • LABIA MINORA - thin, soft folds of tissue that are seen when the labia majora are separated - Secretions from sebaceous glands in the labia are bactericidal to reduce infection and lubricate and protect the skin of the vulva • CLITORIS - a small, erectile body in the most anterior portion of the labia minora - It is similar in structure to the penis. - Functionally, it is the most erotic, sensitive part of the female genitalia • FOURCHETTE - A fold of tissue just below the vagina where the labia majora and minora meet - It is also known as the obstetrical perineum • VAGINAL VESTIBULE - Is the area seen when the labia minora are separated -It includes 5 structures • Urethral meatus • Skene ducts • Vaginal introitus • Hymen • Ducts of the Bartholin glands • PERINEUM - A strong, muscular area between the vaginal opeing and the anus - The elastic fibers and connective tissue of the perineum allow stretching to permit the birth of the fetus - It is the site of the episiotomy if performed or potential tears during childbirth - Pelvic weakness or painful intercourse(dyspareunia) may result if this tissue does not heal properly INTERNAL Consists of the following: • VAGINA - A tubular structure made of muscle and membranous tissue that connects the external genitalia to the uterus. • It has 3 functions: o Provides a passageway for sperm to enter the uterus o Allows drainage of menstrual fluids and other secretions o Provides a passageway for the infant’s birth • UTERUS - A hollow muscular organ in which a fertilized ovum is implanted, an embryo forms and a fetus develops. - It is shaped like an upside-down pear or light bulb - Lies between the bladder and the rectum above the vagina - Approx weigh 60 g (2 oz) non-pregnant - 7.5cm (3”) long - 5cm (2”) wide - 1 to 2.5 cm (.4 to 1”) thick • FALLOPIAN TUBES - Also called uterine tubes or oviducts - It extends laterally from the uterus, one to each ovary - It varies in length from 8cm to 13.5 cm (3 to 5,3”) 2 FOUR SECTIONS: ◦ ◦ ◦ ◦ • Interstitial – extends into the uterine activity and lies within the wall of the uterus Isthmus – is a narrow area near the uterus Ampulla- is the wider area of the tube and is the usual site of fertilization Infundibulum- the funnel-like enlarged distal end of the tube - Fingerlike projections from the infundibulum, called fimbriae, hover over each ovary and capture the ovum OVARIES - Are two almond-shaped glands, each about the size of a walnut - Located in the lower abdominal cavity, one on each side of the uterus (held in place by ovarian and uterine ligaments - It has 2 functions: ◦ ◦ Production of hormones, chiefly estrogen and progesterone Stimulation of an ovum’s maturation during each menstrual cycle PREGNANCY is a temporary, physiological process that affects a woman physically and emotionally. HIGH-RISK PREGNANCY is one in which complications arise before, during, or after delivery. It needs more attention than the usual pregnancy. INTRODUCTION - All pregnancies and births might be jeopardized. However, there are several situations in which both the mother and the body are endangered. 20 to 30% belong to this category All pregnant mothers are vulnerable to disease or disability. There are certain pregnant women who are more at risk of having complications. An extra dose of care will be recommended for them HIGH-RISK PREGNANCY - Is one in which a concurrent disorder, pregnancy related complication, or external factor jeopardizes the health of the woman, the fetus, or both. - One that is complicated by variables/factors that have a negative impact on the pregnancy outcome FACTORS THAT CATEGORIZE A PREGNANCY AS HIGH-RISK • Psychological • Physical • Social Pre-pregnancy (Psychological) - History of drug dependence (including alcohol) - History of intimate partner abuse - History of mental illness - poor coping mechanism - Cognitive challenged Pre-pregnancy (social) - Occupation involving of handling toxic substance - Isolated - Lower economic level - Poor access to transportation for care - Poor housing - Lack of support people Pre-pregnancy (physical) - Obesity (BMI 30 and above) - Small stature - Potential of blood incompatibility - Younger than age 18 years or older than 35 years - Cigarette smoker 3 - Substance abuser Visual or hearing challenges Pelvic inadequacy or misshape Uterine incompetency, position or structure Secondary major illnesses History of previous poor pregnancy outcome (miscarriage, stillbirth, intrauterine fetal death) UNIT 2: Medical Conditions Affecting Pregnancy Outcomes Medical Conditions Affecting Pregnancy Outcomes - Medical conditions during pregnancy, (both mother & fetus) can be at risk for complications What to do? - Close observation (maternal/fetal wellbeing) - Education about special danger signs during pregnancy - Appropriate actions to minimize complications Nursing care must focus on: - Preventing such orders from affecting the heath of the fetus - Helping a woman regain her health as quickly as possible - Prepare the mother psychologically and physically for childbirth - Helping a woman/mother learn more her chronic illness ASSESSMENT OF HIGH-RISK MOTHER Initial Screening – History Objectives of Prenatal Care: • To detect diseases which may complicate pregnancy • Educate women on danger and emergency signs & symptoms • Prepare the woman and her family for childbirth STEPS TO FOLLOW IN PRENATAL CARE 1) Immediate assessment for emergency signs. ▪ Unconscious/Convulsing ▪ Vaginal bleeding ▪ Severe abdominal pain ▪ Looks very ill ▪ Severe headache with visual disturbance ▪ Severe difficulty in breathing ▪ Dangerous Fever ▪ Severe vomiting * Attend to sick woman quickly. 2) Make the woman comfortable • Greet her, make sure she is comfortable and ask how she is feeling. • If first visit, register the woman and issue a mother and Child Book (antenatal record form) 3) Assess the pregnant woman FIRST visit: • • • • • How old is patient? Past Medical History Obstetric History: Gravidity? LMP? AOG? Alcohol/Drug/substance abuse? Ask about or check record for prior pregnancies: • Convulsions • Stillbirth or death in the first day • Heavy bleeding during or after delivery • Prior cesarean section, forceps or abortion 4 NOTE: LMP – LAST MENSTRUAL PERIOD JANUARY-MARCH +9 +7 APRIL- DECEMBER -3 +7 EDC – ESTIMATED DATE OF CONFINEMENT AOG - AGE OF GESTATION +1 SCREENING FOR GESTATIONAL DIABETES USING RISK FACTORS IS RECOMMENDED IN ALL WOMEN. a) body mass index above 30 kg/m2 b) previous macrosomic baby weighing 4.5 kg or above c) previous gestational diabetes d) family history of diabetes e) family origin with a high prevalence of diabetes such as south Asian, black Caribbean and middle eastern. BMI COMPUTATION 1. Convert weight into kilograms (divide weight in pounds by 2.2). 2. Convert height into centimeters (multiply height in inches by 2.5). 3. Convert centimeters into meters (divide result by 100). 4 4. Square height in meters. 5. Divide weight in kilograms by height in meters squared. SOURCES OF MATERNAL WEITH GAIN - Low: less than 18.5 - Normal: 18.5-24.9 - Overwt: 25 to 29.9 - Obese: 30-39.9 - Extreme obesity: 40-54 ON ALL VISITS: • Check duration of pregnancy (AOG). • Ask for bleeding/danger signs during this pregnancy • Check record for previous treatments received during this pregnancy • Prepare birth and emergency plan • Ask patient if she has other concerns • Give education and counseling on family planning and breastfeeding NOTES: MACROSOMIC BABY - newborns who’s much larger than average weight. ROLE OF NURSE IN PENATAL CARE • Assessment/ Screening • PHN: Supervise midwives in prenatal care 5 MATERNAL AGE THE PREGNANT ADOLESCENT Pregnancy Education involves: 1. Nutrition Reasons for Teenage Pregnancies: 2. Activity and Rest 1. Earlier age of menarche in girls. 3. Physiologic changes 2. Increase in the rate of sexual activity among 4. Childbirth Preparation teenagers. 5. Birth decisions 3. Lack of knowledge about contraceptives or 6. Plans for the baby abstinence. 4. Desire by young girls to have a child. Complications of adolescent pregnancy • Postpartum Hemorrhage Prenatal Assessment on Pregnant Adolescent • Inability to Adopt Postpartally (after child High Incidence of: birth) 1. PIH 2. IDA 3. Premature labor 4. Low birth weight infants 5. CPD 6. Intimate partner abuse Factors contributing to the lack of prenatal care include: 1. Denial she is pregnant 2. Lack of knowledge of the importance of prenatal care 3. Dependence on others for transportation 4. Feeling awkward in a prenatal setting (an adult setting) 5. Fear of a first pelvic examination 6. Difficulty relating to authority figures PRENATAL ASSESSMENT OF PREGNANT WOMAN Chromosomal Assessment: OVER AGE 40 Women over 35 are offered a triple-screen 1. alpha-fetoprotein (AFP) 2. Human chorionic gonadotropin • Should begin prenatal care early in 3. Unconjugated estriol levels pregnancy. • risk for Down Syndrome is so much Health history: higher ➢ Ask about their present symptoms of pregnancy. Complications Of Labor, Birth and Postpartum Period for Woman Over Age 40 High Incidence of: • Failure to Progress in Labor 1. PIH - labor maybe prolonged 2. GDM • Difficulty Accepting the Event 3. Varicosities - Hesitancy in child bearing 4. Hemorrhoids • Postpartum Hemorrhage 5. Major role changes Pregnancy Education: Physical Examination: 1. Nutrition • Inspect lower extremities 2. Prenatal Classes • Obtain a urine specimen • Assess woman’s breast • Assess for fetal heart sounds and fetal movement (hydatidiform mole) 6 THE PREGNANT WOMAN WHO IS PHYSICALLY OR Pregnancy Education COGNITIVELY CHALLENGED • Modify health teachings to meet each Pre-natal visit: woman’s specific needs. • Modifications for Pregnancy • Modifications of Labor and Birth - Explore with women the nature of their • Modification for Postpartum Care disability and their general self-image. After birth, be sure to assess and teach: • Safety is the key area of concern. ✓ Whether a woman desires contraceptive - emergency contact person information. - Suppliers of transportation ✓ Whether she needs additional support to be successful at breastfeeding. ✓ Whether she has a return appointment for both herself and her infant for follow-up care. A WOMAN WHO IS SUBSTANCE DEPENDENT • Substance Abuse • Substance dependent Common Substance Abused During Pregnancy: ✓ Cocaine ✓ Amphatamines ✓ Marijuana ✓ Opiates ✓ Alcohol 7 GESTATIONAL CONDITIONS AFFECTING PREGNANCY OUTCOMES Hyperemesis gravidarum Ectopic Pregnancy Abortion H mole Placenta Previa Premature Cervical Dilatation Hyperemesis Gravidarum - Causes: UNKNOWN Possible causes: - aka “pernicious or persistent vomiting) Persistent, uncontrollable vomiting that begins before 20 weeks of pregnancy Or occur during past week 12. It occurs at an incidence of 1:200 or 1:300 women pregnancy hormones. Helicobacter Pylori Possible causes: pregnancy hormones. “Are thyroid hormones or hCG responsible for hyperemesis gravidarum? A matched paired study in pregnant Chinese women” Etiology • Increase pregnancy related hormones (estrogen, HCG) + maternal thyroid dysfunction • Helicobacter Pylori (a type of bacteria that infects your stomach) • persistent nausea and vomiting • significant weight loss • Dehydration (dry tongue and mucous membranes, etc.) • Electrolyte and acid base imbalance • Ketonuria • Psychological factors Possible complication • Can lead to poor appetite • Weight loss • Dehydration • Electrolytes and acid-base imbalances • Preterm birth Therapeutic management • Request for lab studies: Hgb, Hct, electrolytes • Daily vitamins and mineral supplement • Antiemetic drug (metochlopramide) • Correct dehydration and acid-base imbalances (IVF) • If unsuccessful: TPN is needed Nursing consideration • Physical Assessment begins with determining the intake and output • Intake-IVF,Parenteral nutrition, oral fluids • Output- amount/character of emesis and urine output • Findings assoc. with DHN includes Decreased fluid intake (1.025) Dry skin Dry mucous membranes Nonelastic skin turgor • • • • Daily weighing Test urine for ketones Refer for dietitian Nursing Interventions focus on: Reducing nausea and vomiting Maintaining nutrition and fluid balance Providing emotional support REDUCING NAUSEA AND VOMITING • Small frequent feeding • Present foods attractively • Eliminate foods with strong odors • Low fat foods/ easily digested CHO will be introduced • Soups and other liquids: between meals • Sitting upright after meals must be advice MAINTAINING NUTRITION AND FLUID BALANCE • IVF and TPN are administered • Small oral feedings of clear liquids are started when N/V begin to subside • If oral feedings are tolerated; parenteral fluids and nutrition gradually discontinue • Advice to eat every 2-3 hours • Salting food help replace chloride lost • Encourage to eat K and Mg rich foods PROVIDING EMOTIONAL SUPPORT • Woman with HG needs to express herself how it feels to be pregnant • Needs to express the experience of N/V Observation the family dynamics of pregnant woman (This may contribute the N/V • Case conferences/ educational programs 8 Pregnancy Bleeding - Vaginal bleeding is always a deviation from normal - May occur at any point of pregnancy PRIMARY CAUSES OF BLEEDING DURING PREGNANCY 1st trimester - Abortion - Ectopic pregnancy 2nd trimester ▪ H mole ▪ Premature cervical dilatation 3rd trimester ▪ Placenta previa ▪ Abruptio placentae ▪ Preterm labor Nursing Diagnosis: Risk for deficient fluid volume related to bleeding during pregnancy 9 10 Ectopic Pregnancy ▪ ▪ ▪ ▪ Is one in which implantation occurs outside the uterine cavity It occurs in 2% of pregnancies May occur in the cervix or abdomen Fallopian tube (95%) is the most common site ◦ ◦ ◦ 80% ampullar portion 12% isthmus 8% interstitial fimbrial portion RISK FACTORS • Use of the IUD • Cigarette smoking • Vaginal douching • Anatomic and functional defects in the fallopian tubes • Previous EC has 10-20% chance for subsequent EC Use of the IUD Bacteria brought in IUD insertion + tubal infection + Tubal scarring + EP 2/10000 women per year <1% get pregnant each year with IUD ASSESSMENT: • No unusual symptoms at the time of implantation • No menstrual flow occurs • With nausea and vomiting • Pregnancy test for HCG will be positive • • • IUD 1. 2. Slow the transport of zygote Increased the incidence implantation of tubal/ ovarian Cigarette Smoking Chemicals in cigarettes + Increase the protein PROKR1(fallopian tube) + Increase the risk of implantation in the FT + EP Note: PROKR1 allows to implant the egg correctly in the uterus ETIOLOGY: Obstruction (scars,etc) + Zygote unable to travel the length of the tube + Lodges to strictured site + Implantation + EP CAUSES: • Obstructions from salphingitis • PID • Congenital malformation, scars from tubal surgery, uterine tumor MANIFESTATION: • Sharp, stabbing pain (LQ); during the rupture • Scant vaginal spotting • Cullen’s sign (bluish tinge umbilicus) ▪ hypovolemic shock • The amount of bleeding evident with ruptured EP often does not reveal the actual amount present UTZ/MRI: effective to diagnose EP ▪ If not revealed by an UTZ; at 6-12 weeks AOG ▪ Zygote grows bigger ▪ Enough to rupture the FT Extent of bleeding; depends on the number/size of the blood vessels ruptured Implantation (INTERSTITIAL) ▪ Rupture can cause severe intraperitoneal bleeding Common site of EP: Ampulla ▪ Blood vessels are smaller ▪ Less profuse bleeding THERAPEUTIC MANAGEMENT If unruptured EP (detected by early UTZ) ◦ ◦ ◦ Oral methotrexate UTZ is neede to assess the tube Mifepriztone, an abortifacient effective at causing sloughing of the tubal implantation site. Surgery to remove the products of conception Severe damage: requires removal of the entire tube ruptured EP ◦ ◦ ◦ ◦ Lab exam (Hgb, BT, X-matching) IVF (restore intravascular volume) Surgery: pelvic laparoscopy or laparotomy Rh (D) immune globulin (RhIG) to a woman with Rh(-) NURSING CONSIDERATION ▪ Monitoring of VS to identify hupovolemic shock ▪ IVF: blood replacement may be ordered ▪ Antibiotics as ordered ▪ Pain medication ▪ NPO status preop ▪ Indwelling foley catheter as ordered; Urine output is significant indicator of fluid bal;ance ▪ Bed rest prior to surgery POSSIBLE NURSING DIAGNOSIS ▪ ▪ ▪ Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy Risk for deficient fluid volume related to bleeding during pregnancy Deficient knowledge related to S/S of possible complications 11 Abortion ▪ ▪ is the medical term for any interruption of a pregnancy before a fetus is viable (able to survive outside the uterus if born at that time). Viable fetus - defined as a fetus of >20-24 weeks AOG - Weighs at least 500g Spontaneous miscarriage ◦ ◦ When the interruption occurs spontaneously, it is clearer to refer to it as a miscarriage Spontaneous miscarriage ▪ Early miscarriage: before 16 weeks of pregnancy ▪ Late miscarriage: occurs between 16 and 24 weeks CAUSES: TYPES OF ABORTION ▪ Abnormal fetal development THREATENED MISCARRIAGE ▪ Implantation abnormalities ▪ Begin as vaginal bleeding, initially scant and usually bright ▪ Systemic infection/ UTI red ▪ Ingestion of teratogenic drug ▪ Vaginal bleeding or spotting, which may be associated with mild cramps of back and lower abdomen Implantation Abnormalities ▪ Closed cervix ▪ 50% of zygotes probably never ▪ Uterus that is soft, nontender, and enlarged appropriate to implant securely gestational age ▪ Inadequate endometrial formation ▪ HCG test: ▪ inappropriate site of implantation - during the start of bleeding + - After 48 hours ▪ Placenta circulation does not ▪ Avoidance of strenuous activity for 24 to 48 hours develop adequately ▪ Complete bed rest is usually not necessary + ▪ once bleeding stops, she can gradually resume normal activities. ▪ Poor fetal nutrition ▪ coitus is usually restricted for 2 weeks after the bleeding episode ▪ 50% of women with threatened miscarriage can continue the pregnancy Systemic Infection/ UTI ▪ 50% will lead to imminent miscarriage ▪ Rubella ▪ Syphilis IMMINENT MISCARRIAGE ▪ Poliomyelitis ▪ A threatened miscarriage becomes an imminent (inevitable) ▪ Cytomegalovirus miscarriage if uterine contractions and cervical dilation occur ▪ Toxoplasmosis ▪ if no FHS are detected and an UTZ reveals an empty uterus or + Can cross the placenta Infection + Fails to grow the fetus + Estrogen and progesterone falls + Endometrial sloughing + Prostaglandin released + Uterine contraction. Cervical dilatation Ingestion of Teratogenic Drug Example: the use of isotretinoin + Taken early in pregnancy + Miscarriage/ fetal abnormality ASSESSMENT Vaginal spotting ▪ The nurse needs to assess quickly the vaginal bleedin ▪ ▪ nonviable fetus: D & E After D&E, assess for vaginal bleeding After D&E, assess for vaginal bleeding COMPLETE MISCARRIAGE ▪ The entire products of conception are expelled spontaneously without any assistance ▪ Bleeding usually slows within 2 hours and then ceases within a few days after passage of the products of conception INCOMPLETE MISCARRIAGE ▪ Part of the conceptus (usually the fetus) is expelled ▪ Placenta or membrane is retained in the uterus ▪ Profuse bleeding because retained tissue parts interfere with myometrial contractions. ▪ D&C or suction curettage to evacuate the remainder of the pregnancy from the uterus MISSED MISCARRIAGE ▪ If the pregnancy is over 14 weeks, labor may be induced by a misoprostol (Cytotec) to dilate the cervix, followed by oxytocin stimulation for elective termination of pregnancy. ▪ If the pregnancy is not actively terminated, miscarriage usually occurs spontaneously for 2 weeks ▪ Recurrent Pregnancy Loss -condition in which two or more successive pregnancies have ended in spontaneous abortion ▪ Counselling will be given 12 COMPLICATIONS OF MISCARRIAGE HEMORRHAGE INFECTION ▪ Monitor vital signs ▪ Develop in women who have lost appreciable ▪ Excessive vaginal bleeding; (supine position amounts of blood and fundal massage ▪ Danger signs of infection: - Small uterus is not palpable - Fever + - Abdominal pain or tenderness D&C will be recommended - Foul vaginal discharge ▪ Blood transfusion ▪ E.coli is responsible for infection after ▪ Direct replacement of fibrinogen or miscarriage ▪ no tampons to stop vaginal bleeding another clotting factor will be given ▪ Be careful of using this statements: ▪ Note for abnormal bleeding “You’ll have some vaginal flow now, almost ▪ medicine compliance (methergine) exactly like a menstrual flow. ▪ if the pt is bleeding: - check the VS to know if signs of Infection hypovolemic is present + Endometritis - inflammation of the endometrium. ISOIMMUNIZATION ▪ production of antibodies against Rh+ SEPTIC ABORTION ▪ After miscarriage all women with Rh ▪ An abortion that is complicated by negative blood should receive Rh (D infection antigen) immune globulin (RhIG) to ▪ Infection may occur after a spontaneous prevent the build-up antibodies in the miscarriage event the conceptus was Rh+ ▪ More common: women who tried to selfabort ▪ Uterus: warm, moist, dark cavity Disloged placenta + + ▪ Infectious organisms grow rapidly Fetal blood (placental villi) Sign & symptoms: + ▪ Fever Enter the maternal circulation ▪ Crampy abdominal pain (Rh+ fetus; Rh- mother) ▪ Tender uterus during palpation + If left untreated: Isoimmunization ▪ Toxic shock syndrome ▪ Septicemia - bacterial infection enters the ---------------------------------------------------------------During second pregnancy bloodstream + ▪ Kidney failure Antibodies produced during the 1st pregnancy ▪ Death + Destroy the fetus (second pregnancy) ▪ Complete blood count ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Serum electrolytes serum creatinine Blood typing Powerlessness or Anxiety Cross matching ▪ Sadness and grief over the loss or a feeling Foley catheter: to monitor urine output /hr that a woman has lost control of her life is IVF to be expected. Dilatation and curettage ▪ Spontaneous miscarriage can be particularly TT (SQ) Tetanus immune globulin (IM) heartbreaking for an older woman, because Prophylaxis against tetanus ▪ Usually, woman needs to be admitted to intensive care setting ▪ Dopamine (increased HR) and digitalis (control HR) ▪ Oxygen therapy she realizes that her window of childbearing is limited. ▪ Septic abortion may lead to infertility ▪ Counseling is needed (esp. for self-aborted case) 13 Premature Cervical Dilatation ▪ ▪ ▪ 1st symptom is show (a pink-stained vaginal discharge) or increased pelvic pressure This usually followed by ruptured of membranes/ discharge of amniotic fluid commonly occurs @20 weeks of pregnancy PCD is associated with: Maternal age Congenital structural defects Trauma to the cervix (D&C) ▪ May diagnosed by an early ultrasound before symptoms occur ▪ However, usually diagnosed only after the pregnancy lost - After the loss of one child due to PCD + Cervical cerclage can be performed ▪ At approximately 12 to 14 purse-string sutures are placed in the cervix by the vaginal route under regional anesthesia. ▪ Success rate: 80-90% McDonald procedure, nylon sutures are placed horizontally and vertically across the cervix and pulled tight to reduce the cervical canal to a few millimeters in diameter. Shirodkar technique sterile tape is threaded in a purse-string manner under the submucous layer of the cervix and sutured in place to achieve a closed cervix ▪ Although routinely accomplished by a vaginal route, sutures may be placed by a transabdominal route. ▪ @37 to 38 weeks: sutures will be removed This will facilitate the vaginal delivery Transabdominal approach: sutures may be left in place and CS will be performed CONTRAINDICATION: THERAPEUTIC MANAGEMENT: ▪ pregnant with twins, triplets or more. Cervical Cerclage ▪ cervix has already dilated 4 centimeters. ▪ after cerclage surgery, remain on bed rest ▪ membranes have ruptured for few days. ▪ usual activities and sexual relations can be resumed. 14 Placenta Previa - A condition of pregnancy in which the placenta is implanted abnormally in the uterus - The most common cause of painless bleeding in the third thrimeste - It occurs 4 degrees: Low-lying placenta Marginal implantation Partial placenta previa Total placenta previa ASSOCIATED FACTORS - Increased parity - advanced maternal age - past cesarean births - past uterine curettage - multiple gestation - perhaps a male fetus ASSESSMENT - UTZ performed frequently during pregnancy Placenta previa are dx before any symptoms occur INCIDENCE - - Approx. 5 per 1000 pregnancies It is thought to occur whenever the placenta is forced to spread to find an adequate exchange surface. An increase in congenital fetal anomalies may occur if the low implantation does not allow optimal fetal nutrition or oxygenation - Abrupt, painless bleeding Bright red in color Not associated with increased activity or participation in sports Stop abruptly as it began o (During clinic check-up: she is no longer bleeding) o Slow after the initial hemorrhage but continue as continuous spotting - 15 THERAPEUTIC MANAGEMENT - Bleeding with PP same with ectopic pregnancy; it is an emergency situation - Place the woman in bed rest (side-lying Position); Assess: o Duration of the pregnancy o Time the bleeding began o Woman’s estimation of the amount of blood: (cup=240 ml; T=15 ml o Whether there is accompanying pain o Color of the blood o Initial intervention of the mother o Prior cervical surgery (premature cervical The site of bleeding, the open vessels of the uterine decidua place the mother at risk o Placental loosening o Fetal O2 supply compromised o Fetus @ risk dilatation) - Inspect the perineum for bleeding Estimate the present rate of blood loss Weighing perineal pads before and after use and calculate the difference An Apt or Kleihauer-Betke test (test strip procedures) NO pelvic or rectal exam Obtain baseline VS: to deterimine symptoms of shock BP q 5 to 15 mins IVF therapy with large gauge catheter Monitor urine output q hourly Hemoglobin Hematocrit Prothrombin time, partial thromboplastin time, fibrinogen, platelet count, type and cross-match, and antibody screen if previa is 30% in UTZ (VB), - if more than 30% (method of delivery=CS) Closed observation will be done if: - - bleeding stopped, FHT is in good quality, maternal VS good, fetus < 36 AOG Woman will remains in the hospital for 48 hours o If the bleeding stops, bed rest and home care o will be advised Betamethasone may be prescribed o Hastens the fetal lung maturity Placenta previa totalis: CS - PP partialis, marginalis o Check the amout of blood loss o Check the woman’s parity o Condition of the fetus o Influence the birth decision 16 Abruptio Placenta - Premature separation of the placenta Placenta appears to have been implanted correctly o Begins to separate o Bleeding Occurs about 1 % of pregnancies Most common cause perinatal death Separation occurs late in pregnancy CAUSES: - unknown PREDISPOSING FACTORS: - Increased age and parity - Short umbilical cord - chronic hypertensive disease, - pregnancy-induced hypertension, - direct trauma - vasoconstriction (cocaine or cigarette use) CLINICAL MANIFESTATIONS: - Sudden abdominal pain - Vaginal bleeding - Uterine tenderness - Couvelaire uterus or uteroplacental apoplexy, DIC syndrome CLINICAL MANAGEMENT: - Assess the time of bleeding: - Assess whether the bleeding accompanied by pain - Assess the amount and kind of bleeding = Initial blood work: o Hgb, Bt,X-matching, fibrinogen level - Large- gauge intravenous catheter for fluid replacement - Adminester O2 - Monitor fetal heart sounds - Record maternal VS q 5 to 15 minutes - Keep the woman in a lateral position - No abdominal, vaginal or pelvic exam - Assess for the degrees of placental separation - If DIC has developed; CS could be a grave risk o IV administration of fibrinogen; to elevate the fibrinogen level prior to curgery o Worst outcome: HYSTERECTOMY ❑ To prevent exsanguination. o Infection must be observed closely during postpartum period - 17 - is rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks. cause is UNKNOWN, but it’s associated w/ infection (chorioamnionitis) POSSIBLE COMPLICATIONS OF PROM: - uterine & fetal infection ↑ pressure on the umbilical cord development of a Potter-like syndrome from pressure preterm labor = delivery Potter-like Syndrome ASSESSMENT: - sudden gush of clear fluid from her vagina Nitrazine paper test, amniotic fluid (alkaline reaction) high level of alpha-fetoprotein (AFP) in the vagina UTZ: assess the amniotic fluid index Vaginal culture avoid routine vaginal examination THERAPEUTIC MANAGEMENT: If a fetus is mature enough to survive at the time of rupture and labor does not begin within 24 hours: induced labor (IV oxytocin); before infection occurs If a fetus is not viable & labor does not begin: o bed rest o administer corticosteroid (hasten lung maturity) & broad-spectrum antibiotic 18 - cardiovascular disease now complicates only approximately 1% of all pregnancies. Ideally, a woman should visit her obstetrician before conception. When to begin prenatal care???? 1 week after the first missed menstrual period What’s the danger of pregnancy with cardiac problems?? ↑ circulatory volume CLASSIFICATION OF HEART DISEASE - A woman with class I or II heart disease can expect to experience a normal pregnancy and birth. Women with class III can complete a pregnancy by maintaining almost complete bed rest. Women with class IV heart disease are poor candidates for pregnancy because they are in cardiac failure even at rest and when they are not pregnant. CLASS DESCRIPTION - I Uncompromised. Ordinary physical activity causes no discomfort. No symptoms of cardiac insufficiency and no anginal pain. II Slightly compromised. Ordinary physical activity causes excessive fatigue, palpitation, and dyspnea or anginal pain. III Markedly compromised. During less than ordinary activity, woman experiences excessive fatigue, palpitations, dyspnea, or anginal pain. IV Severely compromised. Woman is unable to carry out any physical activity without experiencing discomfort. Even at rest symptoms of cardiac insufficiency or anginal pain are present - ASSESSMENT: PREGNANT WOMAN W/ CARDIAC DISEASE - Tachycardia Increased respiratory rate Decreased amniotic fluid from intrauterine growth restriction Poor fetal heart tone (FHT) variability from poor tissue perfusion Cough Edema from poor venous return Fatigue INTERVETION Promote Rest o women with cardiac disease need two rest periods a day. o rest should be in the left lateral recumbent position Promote Healthy Nutrition o prenatal vitamins (iron supplement to help prevent anemia) o sodium-restricted diet Educate Regarding Medication o -digoxin is sometimes administered o -beta-blockers and angiotensin-converting enzyme (ACE) inhibitors to reduce hypertension o -Nitroglycerin (angina) o -Penicillin therapy (RHD) NURSING INTERVENTION HEALTH EDUCATION: MEDICATION - Digoxin is sometimes administered - Beta-blockers and angiotensin-converting enzyme(ACE) inhibitors to reduce HPN - Nitroglycerin (angina) - Penicillin therapy (RHD 19 DIABETES MELLITUS Diabetes mellitus is a disorder in which there is inadequate insulin to move glucose from the blood into the body cells. The pancreas produces no insulin or insufficient insulin. In the woman with DM, cells are essentially starving because they cannot obtain glucose. KEY PLAYERS Insulin - is a hormone that will facilitate the glucose to enter the cell Secreted by beta cells, the center of islets of Langerhans in the pancreas Help reduce glucose in the blood stream---by binding to insulin receptor of the cells in the cell membranes like muscle cells and adipose tissue Glucagon - Secreted by the alpha cell in the periphery of the islet Help increased glucose in the blood stream Glucagon will facilitate released of glycogen (stored glucose) Liver - Store excess glucose and transform it into glycogen Released glycogen to increase glucose in case of hypoglycemia Type 1 (IDDM) - A state characterized by the destruction of the beta cells in the pancreas that usually leads to absolute insulin deficiency. - T cells attack the pancrease; genetic abnormality will allow te t cells to attack and recruit other immune cells to attack beta cell - No/losing beta cells-- less insulin– increase glucose in te blood stream 20 Type 2 (NIDDM) - A state that usually arises because of insulin resistance combined with a relative deficiency in the production of insulin. Pancreas provides normal amount of insulin Cells don’t move their glucose transporters the cell membranes (needed for glucose to get into the cell Cells have insulin resistance RISK FACTORS - Obesity - Lack of exercise - HPN - Genetics Excess adipose tissue Excess adipose tissue Signal molecules for the INFLAMMATION Insulin resistance occurs Resistance to insulin More production of insulin - Through beta cell hyperplasia (increased # of beta cells and beta cells hypertrophy ( grow in size) - Attempt to pump out more insulin Increases insulin level than normal Blood glucose level can be kept normal (Normoglycemia) Along w/ insulin, beta cells secrete ISLET AMYLOID POLYPEPTIDE or Amylin - increased amount of insulin; increased amount of amylin Amylin builds up and aggregates in the islets - Beta cells compensation overtime maxed out Exhausted beta cells Dysfunctional Hypotrophy and hypoplasia Beta cells die Lost of beta cells Decreased insulin glucose level in the blood increased Hyperglycemia Leads to: 3 Ps and glycosuria Key points: DKA doesn’t usually develop in type 2 diabetes unlike Type 1 - There still some circulating insulin in type 2 from the beta cells ; trying to compensate for the insulin resistance A condition of abnormal glucose metabolism that arises during pregnancy. disappear at the completion of pregnancy. SCREENING: GESTATIONAL DIABETES USING RISK FACTORS: BMI above 30 kg/m2 - Previous macrosomic baby weighing 4.5kg or above - Previous GD - Family history of diabetes Fasting plasma glucose 126 mg/dl and above Non fasting: 200 mg/dl & above Meets the threshold for the dx of DM 21 ASSESSMENT: PREGNANT WOMAN W/ DIABETES MELLITUS Dizziness, if hypoglycemic Confusion, if hyperglycemic Poor fetal heart tone variability and rate from poor tissue perfusion Glycosuria Polyuria, Polydipsia, Polyphagia Hydramnios Hyperglycemia Possibility of increased monilial infection (STI) Increased risk of PIH Congenital anomalies Macrosomia (CPD) Oral Glucose Challenge Test Values (Fasting Plasma Glucose Values) for Pregnancy Test Type Pregnant Glucose Level (mg/dL) * Fasting 95 1 hour 180 2 hours 155 3 hours 140 Following a 100-g glucose load. Rate is abnormal if two values are exceeded. ASSESSMENT: PREGNANT WOMAN W/ DIABETES MELLITUS Monitoring a Woman With Diabetes - a diabetic woman should meet with her obstetrician before she becomes pregnant. - glycosylated hemoglobin is used to detect the degree of hyperglycemia present. - urine culture may be done each trimester to detect asymptomatic UTI TESTS: PLACENTAL FUNCTION & FETAL WELL-BEING: - depends on the woman’s overall health. - UTZ to detect gross abnormalities - creatinine clearance test - fetal movements TREATMENT: - The non-pregnant woman is treated with a balance of insulin or an oral hypoglycemic drug, diet, and exercise. Medical therapy during pregnancy includes identification of gestational diabetes, diet, monitoring of blood glucose levels, insulin, exercise, and selected fetal assessment. 22 - Rh incompatibility occurs when a Rh-negative mother carries a fetus with an Rh-positive blood type - 15% of white; 10% African Americans – missing the Rh(D) factor in their blood (have an Rh- mother) o Rhesus (Rh) Factor – blood factor in a form of protein that attaches to the erythrocytes. If present – a blood type is Rh + If Absent – Rh Rh Incompatibility is caused by the two major factors: Expectant mother is Rh-negative. ✓ The fetus is Rh-positive PATHOPHYSIOLOGY : Theoretically: no mixing of fetal and maternal blood occurs during pregnancy o However, small placental accidents may allow a drop or two of fetal blood to enter the maternal circulation o Initiate the production of antibodies = Sensitization: also occur during: o spontaneous or elective abortion o During antepartal procedures: ▪ Amniocentesis ▪ Chorionic villus sampling Most exposure of maternal blood to fetal blood occurs during the 3rd stage of labor - 1st child is unaffected FETAL & NEONATAL IMPLICATIONS : - Erythroblastosis fetalis – severe form of this disease produces anemia in the fetus as a result of the Rh incompatibility. Kernicterus – accumulation of bilirubin in the brain tissues. Hydrops fetalis – generalized fetal edema due to anemia. 23 PRENATAL MANAGEMENT AND ASSESSMENT: - Blood test: to determine Blood type and Rh factor RH-: coombs test for antibody titer o Results: Negative; Repeat the test after 28 weeks o Negative results: identifies the fetus not at risk of hemolytic disease of the newborn o Results: Positive ▪ Indicates presence of antibody against Rh+ ▪ Repeat coombs test is needed to determine if the antibody is rising ▪ Indirect coombs’ test: measure antibodies in the mother’s blood. ▪ Direct Coombs’ test: umbilical cord blood is taken at delivery to determine blood type, Rh factor, and anti-D antibody titer of the newborn. ERYTHROBLASTOSIS FETALIS HYDROPS FETALIS Amniocentesis may be performed o To evaluate the density of amniotic fluid ▪ This measure reflects the presence of bilirubin in the amniotic fluid • If the optical density is high: fetus is in jeopardy PREVENTION: Administration of RhoGAM o Prevents the development of Rh antibodies which may harmful with the subsequent fetuses o Reduced the fetal and neonatal complications of Rh incompatibility POSTPARTUM Mother Rh-: umbilical cord blood is taken at the delivery o To determine the blood type and Rh factor, antibody titer Rh- unsentisized mother who give birth to Rh+ o RhoGAM IM is will be given w/in 72H o Fetal Rh antigen destroyed o No production of antibodies against Rh+ PREVENTION: NURSING CONSIDERATIONS Collect the cord blood to determine the Rh factor and blood type of the NB Follow-up to determine whether the RhoGAM is necessary Administer the injection in a prescribed time EXCHANGE TRANSFUSION: ET is needed if bilirubin levels continue to rise. The procedure involves alternatively withdrawing small amounts (2–10mL) of the infant’s blood and then replacing it with equal amounts of donor blood (1-3hrs). 24 1. What does it mean to be Rh-negative? Ans.Those who are Rh-negative lack a substance that is present in the red blood cells of those who are Rh- positive. 2. How can the expectant mother be Rh-negative and the fetus be Rh-positive? Ans.The fetus can inherit the Rh-positive factor from the father. 3. Most exposure of maternal blood to fetal blood occurs in what stage of labor? Ans.3rd stage of Labor, active exchange of fetal and maternal blood from damaged placental separation 4. What does sensitization mean? Ans.Sensitization means that the expectant mother has been exposed to Rh-positive blood and has developed antibodies against the Rh factor. 5. Do the antibodies harm the expectant mother? Ans. No,The mother is unaffected because she does not have Rh factor 6. Do Rh-positive men always father Rh-positive children? ▪ Ans. No,Rh-positive men who have an Rhpositive gene and an Rh-negative gene can also father Rhnegative children. 7. Why is RhoGAM necessary during pregnancy and following childbirth? ▪Ans. RhoGAM prevents the development of Rh antibodies, which might be harmful to subsequent fetuses. 8. What if RhoGAM is not given, what will happen to the next fetus? ▪ Ans. The mother may develop antibodies to fetal Rh-positive blood. These antibodies may destroy the erythrocytes of the next Rhpositive fetus. 9. What are possible conditions or problems of a mother that can cause antibody formation during pregnancy? ▪ Ans induced abortion, miscarriage, ectopic pregnancy, & amniocentesis 25 acquired immunodeficiency syndrome (AIDS) is a breakdown in immune function caused by the retrovirus HIV. THREE (3) MODES OF TRANSMISSION Sexual exposure to genital secretions of an infected person. Parenteral exposure to infected blood or tissue. Perinatal exposure of an infant to maternal secretions through birth. PATHOPHYSIOLO GY Cell replication and produces more viruses More normal cells cease to function Destruction on the immunity (CD4+ T lymphocytes) Opportunistic infections occur CD4+ T lymphocytes total count less than 200 cells/mm3 confirms the diagnosis of AIDS. Stage 1: acute stage occurs several weeks after HIV exposure. Flulike symptoms may develop & last a few weeks. Stage 2: middle or asymptomatic period of minor or no clinical problems follows. Characterized by continuous viral replication and CD4 cell loss. Note: Stage 1 & 2 (HIV positive) Stage 3: transitional period of symptomatic disease follows. Stage 4: crisis period of symptomatic disease (opportunistic infections) Note: Stage 3 & 4 (AIDS) - greatest risk in infant if mother has high level of HIV virus. antiretroviral treatment during pregnancy helps prevent infection to the fetus. newborn is asymptomatic @ birth most common early signs are enlargement of the liver and spleen, lymphadenopathy, failure to thrive, persistent thrush. experience chronic bacterial infection PREVENTION - Prevention is the ONLY way to control HIV infection. abstinence & condom are methods to prevent sexual transmission. MEDICAL MANAGEMENT - NO cure exists for HIV infection. Zidovudine (ZDV) is recommended for pregnant women. antepartum: oral ZDV to mother beginning after 14 weeks to 34 weeks gestation (100mg po 5x daily) intrapartum: IV ZDV starting 3 hrs before delivery, CS @ 38 weeks ZDV oral syrup to a newborn 8-12 hrs after birth for 6 weeks MIDWIFERY CARE: - Teach women risk-reduction strategies. Large crowds, areas w/ poor sanitation, infected person should be avoided. Maintain optimal nutrition and healthy lifestyle. Need information about recommended therapy. After initial exposure, the person is considered infectious during this time (3-12mons). Averaging 11 years (HIV to AIDS) NO cure but some meds can prolong the life of infected person. Transmitted by sexual contact, contact w/ infected body fluids & through placenta. 26 - Retrovirus is attracted to CD4 cells where Helper T cells has a lot of it Retrovirus also attacks: o Macrophages o Monocytes o Dendrites STATISTICS OF HIV - 79.3 million people: infected with HIV (from the start of epidemic) o 36.3 M; died from HIV o Globally, 37. 7 M were living w/ HIV at the end of 2020 (WHO) HIV TRANSMISS - Unprotected sexual intercourse Infected injection equipment Blood transfusion Accidental needle puncture Use of non-sterile tools Pregnancy Hugging, mouth sucking touching objects Holding hands Tears, sweat, saliva (w/o blood) Coughing, sneezing 27 STAGES OF HIV - Begins about couple of weeks to a month after being infected Viral load: Very high Can spread to other ACUTE INFECTION - - - - - Signs and symptoms - Flu-like symptoms Headache Fatigue Fever Swollen lymph nodes GI upset Rash Sore throat No test available to show immediate infection There must be a window period that passes o This is the time when a person is infected to when the test delivers the positive results o Hence detect antibodies against the virus (seroconversion) Combination test: antibodies and antigen o HIV antigen is p24 o Show HIV as early as 2 weeks Antibody HIV test o Show HIV as early as 2 ½ weeks Show HIV as early as 2 ½ weeks o Assess the virus; its RNA: - Demonstrates the amount of virus in the blood - Reveals HIV as early as 10 days Not routinely ordered, unless high risk and showing manifestations The cost is High CD4 count: measures the helper t cells o Normal count: 500-1500 cell/mm3 o <200 cell/mm3 • • Progressing to AIDS Risk for opportunistic infection CHRONIC INFECTION - - S/S may disappear Lower viral load but virus still active Can still transmit CD4 count is > 200 (about 500 cell/mm3) No opportunistic infections present This stage ENDS: o appearance of S/S o Increase viral load o Presence of opportunistic infections INCUBATION PERIOD HIV has a long incubation period of about 10 years in adults. HIV progress rapidly in children who received virus thru placental transmission ( not receiving tx) AIDS - Last stage Immune system destroyed by virus Viral load: VERY HIGH; can transmit easily Survival time: only a few years w/o medications CD4 count: <200 cell/mm3 Presence of OIs 28 FETAL & NEONATAL EFFECTS: - newborn is asymptomatic @ birth most common early signs are enlargement of the liver and spleen, lymphadenopathy, failure to thrive, persistent thrush. Experience chronic bacterial infection (septicemia/pneumonia) Prevention: -Prevention is the ONLY way to control HIV infection. -abstinence & condom are methods to prevent sexual transmission Medical Management: -NO cure exists for HIV infection. -Zidovudine (ZDV) is recommended for pregnant women. -antepartum: oral ZDV to mother beginning after 14 weeks to 34 weeks gestation (100mg po 5x daily) -intrapartum: IV ZDV starting 3 hrs before delivery, CS @ 38 weeks -ZDV oral syrup to a newborn 8-12 hrs after birth for 6 weeks Facts about HIV: - After initial exposure, the person is considered infectious during this time (3-12mons). - Averaging 11 years (HIV to AIDS) - NO cure but some meds can prolong the life of infected person. - Transmitted by sexual contact, contact w/ infected body fluids & through placenta 29 - - Terminology used to describe HPN in pregnancy is often non-uniform and confusing National Heart, Lung and Blood Institute categorize hypertensive disorders occurs during pregnancy ▪ Preeclampsia ▪ Eclampsia ▪ Chronic Hypertension ▪ Gestational Hypertension is a condition in which vasospasm occurs during pregnancy in both small and large arteries PREECLAMPSIA - A systolic BP of ≥140 mmHg or diastolic BP of ≥90mmHg occurring after 20 weeks of pregnancy - Accompanied by significant proteinuria o >0.3 g in a 24hr urine collection with random urine dipstick evaluation of ≥1+ o Edema (considered nonspecific; it occurs in many pregnancies not complicated by HPN) ECLAMPSIA - Progression of preeclampsia to generalized seizures that cannot be attributed to other causes - Seizures may occur postpartum CHRONIC HYPERTENSION - The elevated blood pressure was known to exist before pregnancy - Unrecognized chronic HPN may not be diagnosed until well after the end of pregnancy GESTATIONAL HYPERTENSION - BP elevation after 20 weeks of pregnancy; no accompanied proteinuria 30 PREECLAMPSIA - Affects about 5 to 8% of women in the US Major cause of perinatal death Often associated with intrauterine fetal growth restriction Vasoconstriction decreases the diameter of blood RISK FACTORS vessels Cause: Unknown + - Overweight Damage the endothelial cells and decreased the EDRF Prepregnancy diabetes + - Multifetal gestations are also more likely Impede blood flow to have preeclampsia + - Presence of immunologic disorders Elevation of BP Decreased circulation to all body organs PATHOPHYSIOLOGY Decreased blood circulation to all organs - Result of generalized vasospasm + - In a normal pregnancy, vascular volume & Decreased renal perfusion - reduce glomerular cardiac output is increased filtration rate - increased level of BUN, creatinine, uric -Despite these factors; BP does not rise acid - Decrease in peripheral vascular resistance Glomerular damage (2ndary to reduced renal blood occurs from the effects of certain flow) vasodilators: + - Prostacyclin (PGI) Allows CHON to leak across the glomerular membrane - Prostaglandin E (PGE) Loss of CHON in the kidneys - Endothelium derived relaxing factor + (EDRF) Loss of CHON in the kidneys - In preeclampsia, the peripheral vascular + resistance increased Allows fluid to shift to interstitial spaces -due to sensitivity of some women to + angiotensin II & a decreased vasodilators Fluid shift may result in hypovolemia - Increase of thromboxanne to prostacyclin -Thromboxanne: produced by kidney + causes vasoconstriction and platelet Increased viscosity of the blood; rise in Hct aggregation + -Prostacyclin: produced by placental Generalized EDEMA occurs tissue causes vasodilation and inhibits + platelet aggregation In response to hypovolemia, addt’l angiotensin II and aldosterone secreted + Trigger the retention of Na and H2O Addt’l angiotensin results in further vasospasm, HPN Aldosterone: increases the fluid retention and edema is worsened 31 PREGNANCY-INDUCED HYPERTENSION (PIH) - - classic signs of PIH: o hypertension o proteinuria o edema. the cause is still UNKNOWN. the heart is forced to pump against rising peripheral resistance. + reduces the blood supply to organs, most markedly in the kidney, pancreas, liver, brain, and placenta. + poor placental perfusion may reduce the fetal nutrient & oxygen supply + Vasospasm in the kidney increases blood flow resistance + leads to increase permeability of the glomerular membrane (proteinuria) + decreased glomerular filtration (decrease urine output & decrease creatinine clearance) + kidney tubular reabsorption of sodium (edema) + Extreme edema can lead to cerebral and pulmonary edema and seizures (eclampsia) 32 Nursing Interventions for a Woman with Mild PIH - Monitor Antiplatelet Therapy - Promote Bed Rest - Promote Good Nutrition - Provide Emotional Support. Nursing Interventions for a Woman with Severe PIH note: - a woman may be admitted to a health care facility. - *If the pregnancy is 36 weeks and w/ matured lungs? *If the pregnancy is less than 36 - Support Bed Rest - Monitor Maternal Well-Being - Monitor Fetal Well-Being - Support a Nutritious Diet - Administer Medications to Prevent Eclampsia Nursing Interventions for a Woman with Eclampsia NOTE: increased cerebral edema leads to seizure Before seizure: - sudden increase in BP (vasospasm) - temp. sharply rises - blurring of vision or severe headache - hyperactive reflexes - severe epigastric pain & nausea (vascular congestion) - oliguria Tonic-Clonic Seizure: - priority care: maintain a patent airway (O2 administration). - turn the woman on her side - give IV Mg SO4 - apply pulse oximeter (O2 sat) - apply external fetal heart monitor - check for vaginal bleeding Birth - There is some evidence that a fetus does not continue to grow after eclampsia occurs. - “The fetus should be delivered” 33 - is the illegal use of drugs, alcohol or tobacco for the purpose of producing an altered state of consciousness. substance dependent when she has withdrawal symptoms following discontinuation of the substance - BEHAVIOR ASSOCIACTED WITH SUBSTANCE ABUSE: - late prenatal visit - difficulty following prenatal instructions - poor grooming, inadequate wt. gain - the risk for hepatitis B & HIV infection increases - engage in prostitution (STI) COMMON SUSBTANCE ABUSED: 1. Tobacco 2. Alcohol 3. Marijuana 4. Cocaine 5. Amphetamine 6. Opioids TOBACCO - is the most common form of substance abuse by pregnant women nicotine causes vasoconstriction (reduces placental blood circulation) Carbon monoxide: inactivates maternal and fetal hemoglobin Both Nicotine and CO3: reduce the amount of O2 supply to the fetus Maternal Effects: - Decreased placenta perfusion, anemia, PROM, preterm labor, spontaneous abortion. Fetal or Neonatal Effects: - Prematurity, LBW, fetal demise, developmental delays, increase incidence of SIDS, neurologic problems. 34 ALCOHOL - is the most commonly used drug - known to pass easily through placental barrier (high concentration) - Fetal Alcohol Syndrome (FAS) - leading cause of mental retardation - The only cause that is preventable - Alcohol passes easily across the placenta - amount and timing of alcohol intake determines the effects on the fetus Maternal Effects: - spontaneous abortion. Fetal or Neonatal Effects: - Fetal demise, IUGR, FAS (fetal alcohol syndrome) - facial and cranial anomalies - development delay - MR - short attention span - congenital defects Alcohol intake + Affect the cell membrane Alter the organization of tissues Interfere the metabolism of nutrients + Cell growth retardation - - - - teratogenic effects of alcohol FAS; characterized in 3 clinical features: Prenatal Postnatal growth restriction Central nervous system impairment Recognizable combination of facial features Prenatal and Postnatal growth restriction Noted in length, weight and head circumference Central nervous system impairment MR Learning disabilities High activity level Short attention span Poor short-term memory Common facial anomalies are associated with FAS Not all fetuses exposed to alcohol in utero develop FAS, but no safe level of alcohol consumption during pregnancy has been established Therefore, it is recommended that women abstain from alcohol drinking 35 MARIJUANA - most commonly used illicit drugs and some women use marijuana to counteract nausea in early pregnancy. - may reduce milk production during BF and may pass in BF - Delta-9tetrahydrocannibol (THC): active component that can cross the placenta and accumulates in the fetus Maternal Effects: - ↑ CR, euphoria, ↑ incidence of anemia and inadequate weight gain Fetal or Neonatal Effects: - Hyperirritability, tremors, sleep problems, unusual sensitivity to light COCAINE - - a powerful, short-acting stimulant of the CNS - Blocks the presynaptic reuptake of the neurotransmitter’s norepinephrine and dopamine + Producing hyperarousal state + Results in euphoria, physical excitement, reduced fatigue, heightened sense of well-being and power cocaine is absorbed across the mucous membranes to affect the CNS. cocaine can be detected in urine up to 1 week after use Side Effects: - Anorexia - Hyperglycemia - Tachypnea Maternal Effects: - Vasoconstriction (↑ RR, CR, BP) - Sense of well-being, excitement - Abruptio placenta (preterm labor & fetal death) Fetal or Neonatal Effects: - ↓ FHT from poor tissue perfusion Congenital anomalies irritability and muscle rigidity learning defects fetal death AMPHETAMINE - processed in crystals to smoke; effects similar to cocaine Maternal Effects: - Malnutrition, ↑ CR, vasoconstriction Fetal or Neonatal Effects: - ↓ wt & length at birth, fetal death 36 OPIOIDS (MORPHINE/HEROIN) - are also widely abused because of their potent analgesic and euphoric effect. - CNS depressant - Appetite suppressant Maternal Effects: - malnutrition, anemia, high incidence of STIs, hepatitis and HIV exposure, preterm labor Fetal or Neonatal Effects: - IUGR, intellectual impairment, neonatal infections, neonatal death INTERVENTION: - it requires combined efforts of the health team workers - major priority is to protect fetus and expectant mother from harmful effects of drugs - EXAMINING ATTITUDE in-service education, professional consultation, and peer support are also helpful to facilitate discussion and sharing - PREVENTING SUBSTANCE ABUSE accurate information (visual aids) about maternal and fetal effects of substance abuse - COMMUNICATING W/ THE WOMAN Identify the stressors that may contribute to substance abuse. be honest, nonjudgmental and express interest and concern. - HELPING THE WOMAN IDENTIFY STRENGTHS assist in identifying personal strengths acknowledge or praise compliance w/ recommended regimen of care (prenatal classes or abstinence) - PROVIDING ONGOING CARE consider the current status of substance use, social service needs, education needs, and compliance with treatment referrals EVALUATION: Intervention have been successful if the woman: - Identify harmful effects of substance abuse on herself and on the fetus. - Discuss her strengths and her feelings about continued use of substances. - Receptive to assistance to stop using drugs PURPOSE SCREENING: - Testing should result in a medical “good”, not merely the capture and stigmatization of those with a disease. The good should pertain to the mother and the fetus. - Physicians should advocate for universal screening only as strongly as they advocate for social support and addiction care services for those subsequently identified 37 2ND TRINAL FETAL DISTRESS, SHOULDER DYSTOCIA, DYSFUNCTIONAL LABOR, CONTRACTION RING Problems of the Passenger Fetal Distress Problems with the Passageway -fetal condition resulting from fetal hypoxia. Risk Factors: • Dystocia • Cord coil, cord compression • Improper use of oxytocin, analgesia/anesthesia • DM, cardiac disease • Bleeding complications in 3rd trimester (PP & AP) • PIH • Supine hypotensive syndrome Assessment Findings: • FHT above 160 or below 120/min • Meconium-stained amniotic fluid in a non-breech presentation • Fetal hypermobility/hyperactivity Interventions: • Reposition mother to left lateral recumbent. This relieves pressure on inferior vena cava, thereby, increasing venous return resulting in increased perfusion of placenta and fetus. • Stop oxytocin drip if being infused. • Administer O2 per mask @ 6-7L/min. • Correct hypotension: *Elevate legs *IV rate (increase hydration) provided that IVF is plain and w/ no oxytocin. *Turn mother in LLR if it is a case of VCS • Monitor FHT continuously. • Notify the physician. • Prepare for emergency CS if indicated 38 Shoulder Dystocia Problems with the Passageway - is a birth problem that is increasing in incidence along with the increasing average weight of newborns. - the problem occurs when the fetal head is born but the shoulders are too broad to enter and be born through the pelvic outlet. - it can result in vaginal or cervical tears. - the cord is compressed between the fetal body and the bony pelvis. - the force of birth can result to a fractured clavicle or a brachial plexus injury for the fetus. -The condition may be suspected: • if the second stage of labor is prolonged, (arrest of descent) • when the head appears on the perineum (crowning) • it retracts instead of protruding with each contraction (a turtle sign). 39 Problems with the Powers Common Causes of Dysfunctional Labor • Inappropriate use of analgesia (excessive or too early administration) • Pelvic bone contraction that has narrowed the pelvic diameter so that a fetus cannot pass such as could occur in a woman with rickets • Poor fetal position (posterior rather than anterior position) • Extension rather than flexion of the fetal head - Inertia is a time-honored term to denote that sluggishness of contractions, or the force of labor, has occurred. A more current term used is dysfunctional labor. - The risk of maternal postpartal infection, hemorrhage, and high infant mortality in women who have a prolonged labor. • Overdistention of the uterus, as with multiple pregnancy, hydramnios, or an excessively oversized fetus • Cervical rigidity (unripe) • Presence of a full rectum or urinary bladder that impedes fetal descent • Woman becoming exhausted from labor • Primigravida status Problems with the Powers Ineffective Uterine Force • Uterine contractions are the basic force moving the fetus through the birth canal. - the influence of major electrolytes such as Ca, Na, and K - specific contractile proteins (actin and myosin) - oxytocin (a posterior pituitary hormone) - estrogen, progesterone, and prostaglandins. Hypotonic Contraction - hypotonic contractions are most apt to occur during the active phase of labor. It may occur: - after giving analgesia, especially if the cervix is not dilatated to 3 to 4 cm - if bowel or bladder distention prevents descent or firm engagement. 40 Hypertonic Contraction - occurs because the muscle fibers of the myometrium don’t relax after a contraction. - tend to be more painful than usual (tender myometrium & uterine anoxia) - A danger of hypertonic contractions is the lack of relaxation between contractions. - uterine and a fetal external monitor for 15 minutes. - If deceleration in the FHRs or an abnormally long 1st stage of labor or inadequate pushing (“second-stage arrest”) occurs, caesarean birth may be necessary. Dysfunctional Labor and Associated Stages of Labor Dysfunction at the First Stage of Labor *Prolonged Latent Phase - is a latent phase that is longer than 20 hours in a nullipara or 14 hours in a multipara when contractions become ineffective. - It occurs if the cervix is not “ripe” at the beginning of labor. - It occurs if there is excessive use of an analgesic early in labor. Management - provide adequate fluid for hydration - pain relief (morphine sulfate) - change the linen and the woman’s gown, darkening room lights, and decreasing noise and stimulation can also be helpful. - If it does not, a cesarean birth or amniotomy (artificial rupture of membranes) and oxytocin infusion to assist labor may be necessary. 41 * Protracted Active Phase -A protracted active phase is usually associated with cephalopelvic disproportion (CPD) or fetal malposition. -This phase is prolonged: -if cervical dilatation does not occur at a rate of at least 1.2 cm/hr in a nullipara or 1.5 cm/hr in a multipara. -if the active phase lasts longer than 12 hours in a primigravida or 6 hours in a multigravida. -If the cause of the delay in dilatation is fetal malposition or CPD, cesarean birth may be necessary. - After an ultrasound to show that CPD is not present, oxytocin may be prescribed to augment labor. *Prolonged Deceleration Phase - A deceleration phase has become prolonged when it extends beyond 3 hours in a nullipara or 1 hour in a multipara. - Prolonged deceleration phase most often results from abnormal fetal head position. A cesarean birth is frequently required. *Secondary Arrest of Dilatation -A secondary arrest of dilatation has occurred if there is no progress in cervical dilatation for longer than 2 hours. Again, cesarean birth may be necessary. *Prolonged Descent - Prolonged descent of the fetus occurs if the rate of descent is less than 1.0 cm/hr in a nullipara or 2.0 cm/hr in a multipara. - the contractions become infrequent and of poor quality and dilatation stops. - suddenly faulty contractions and CPD and poor fetal presentation have been ruled out by ultrasound. - rupturing of the membrane may be helpful. - IV oxytocin *Arrest of Descent - Arrest of descent results when no descent has occurred for 1 hour in a multipara or 2 hours in a nullipara. - Failure of descent has occurred when expected descent of the fetus or engagement (0 station) has not occurred. -The most likely cause for arrest of descent during the second stage is CPD. -Cesarean birth usually is necessary. 42 Contraction Rings - A contraction ring is a hard band that forms across the uterus at the junction of the upper and lower uterine segments and interferes with fetal descent. - The most frequent type seen is termed a pathologic retraction ring (Bandl’s ring). - the fetus is gripped by the retraction ring and cannot advance beyond that point. - Contraction rings often can be identified by ultrasound. - Administration of IV morphine sulfate or the inhalation of amyl nitrite may relieve a retraction ring. - A tocolytic can also be administered to halt contractions. - a cesarean birth will be necessary to ensure safe birth of the fetus. - manual removal of the placenta under GA if the retraction ring does not allow the placenta to be delivered. 43 Precipitate Labor - it is often defined as a labor that is completed in fewer than 3 hours. - Precipitate dilatation is cervical dilatation that occurs at a rate of 5 cm or more per hour in a primipara or 10 cm or more per hour in a multipara - Rapid labor is likely to occur with grand multiparity, or after induction of labor by oxytocin or amniotomy. - can be predicted from a labor graph if, during the active phase of dilatation, the rate is greater than 5 cm/hr (1 cm every 12 minutes) in a nullipara or 10 cm/hr (1 cm every 6 minutes) in a multipara. Induction and Augmentation of Labor - Induction of labor means that labor is started artificially (oxytocin or amniotomy). Augmentation of labor refers to assisting labor that has started spontaneously but is not effective. -The primary reasons for inducing labor includes: *pre-eclampsia; eclampsia; severe hypertension *diabetes *Rh sensitization *prolonged rupture of the membranes *intrauterine growth restriction *postmaturity (a pregnancy lasting beyond 42wks) all situations that increase the risk for a fetus to remain in utero. Cervical Ripening - Cervical ripening, or a change in the cervical consistency from firm to soft. Various methods to ripen the cervix: - Separating the membranes from the lower uterine segment manually, using a gloved finger in the cervix. - Possible complications:bleeding from an undetected low-lying placenta, inadvertent rupture of membranes, and the possibility of infection if membranes should rupture. - The use of hygroscopic suppositories. - the application of a prostaglandin gel (misoprostol). - Oxytocin induction may be started 6 to 12 hours after the last prostaglandin dose. Induction of Labor by Oxytocin -Administration of oxytocin initiates contractions in a uterus at pregnancy term. -oxytocin (Pitocin) is always administered IV mixed in the proportion of 10 IU in 1000 mL of Ringer’s lactate. -after cervical dilatation reaches 4 cm, artificial rupture of the membranes may be performed to further induce labor. 44 Uterine Rupture - Uterine rupture occurs when a uterus undergoes more strain than it is capable of sustaining. - Rupture occurs most commonly when a vertical scar from a previous cesarean birth or hysterotomy repair tears. - When uterine rupture occurs, fetal death will follow. - Impending rupture may be preceded by a pathologic retraction ring and by strong uterine contractions without any cervical dilatation. - If a uterus ruptures, the woman experiences a sudden, severe pain during a strong labor contraction, which she may report as a “tearing” sensation. Contributing factors: -prolonged labor -abnormal presentation -multiple gestation -unwise use of oxytocin -obstructed labor -traumatic maneuvers of forceps or traction. Management: - administer emergency fluid replacement therapy as ordered. - anticipate use of IV oxytocin to attempt to contract the uterus. - laparotomy to control bleeding and achieve a repair. 45 Uterine Inversion - refers to the uterus turning inside out with either birth of the fetus or delivery of the placenta. - it occurs if traction is applied to the umbilical cord. - if pressure is applied to the uterine fundus when the uterus is not contracted. - if the placenta is attached at the fundus -the inverted fundus may lie within the uterine cavity or the vagina. -never attempt to replace an inversion -never attempt to remove the placenta if it is still attached - an IV fluid line needs to be started - no IV oxytocin - administer oxygen by mask, & assess V/Ss. - be prepared to perform CPR - she will immediately be given GA or possibly nitroglycerin or a tocolytic drug IV. - the physician replaces the fundus manually. -oxytocin after manual replacement helps the uterus to contract -antibiotic therapy to prevent infection -cesarean birth will probably be necessary in any future pregnancy 46 PROLAPSE UMBILICAL CORD, MULTIPLE GESTATION, OCCIPITOPOSTERIOR POSITION & BREECH PRESENTATION Prolapse of the Umbilical Cord • • In umbilical cord prolapse, a loop of the umbilical cord slips down in front of the presenting fetal part. Prolapse may occur at any time after the membranes rupture if the presenting fetal part is not fitted firmly into the cervix. It tends to occur most often with: • Premature rupture of membranes • Fetal presentation other than cephalic • Placenta previa • Intrauterine tumors preventing the presenting part from engaging • A small fetus • Cephalopelvic disproportion preventing firm engagement • Hydramnios • Multiple gestation Assessment - the cord may be felt as the presenting part on an initial vaginal examination during labor. identified on UTZ if ruptured membrane occurs, the cord slides down into the vagina from the pressure exerted by the amniotic fluid (deceleration FHR pattern, cord may be visible at the vulva) to rule out cord prolapse, always assess FHSs immediately after rupture of the membranes. Therapeutic Management Note: Cord prolapse leads to cord compression. - Management is aimed at relieving pressure on the cord (fetal anoxia) - This may be done by placing a gloved hand in the vagina and manually elevating the fetal head off the cord, or by placing the woman in a knee–chest or Trendelenburg position Note: Cord prolapse leads to cord compression. - Management is aimed at relieving pressure on the cord (fetal anoxia) - Administering O2 at 10 L/min by face mask A tocolytic agent may be prescribed to reduce uterine activity and pressure on the fetus If the cord exposed to room air, drying will begin (umbilical atrophy) Do not attempt to push any exposed cord back into the vagina (may add compression) cover any exposed portion with a sterile saline compress to prevent drying If the cervix is fully dilated at the time of the prolapse, forceps delivery/VB is recommended (prevent fetal anoxia) If dilatation is incomplete, upward pressure on the presenting part, applied by a practitioner’s hand in the woman’s vagina, until the baby can be born by CS. Amnioinfusion - is the addition of a sterile saline fluid into the uterus to supplement the amniotic fluid 47 Multiple Gestation - Multiple gestation is pregnancy with more than one baby at a time. (Twins, triplets, & quadruplets). additional personnel are needed for the birth (nurses, pediatricians or neonatal nurse practitioners). increased incidence of cord entanglement and premature separation of the placenta. anemia and pregnancy-induced hypertension occur during MG. (Assess the woman’s Hct level and BP closely during labor or while waiting for CS.) - multiple pregnancies often end before full term. - monitor each FHR by a separate fetal monitor during labor. - - After the first infant is born, both ends of the baby’s cord are tied or clamped permanently (prevent hemorrhage) the first infant is identified as A, and newborn care is started. the lie of the second fetus is determined by external abdominal palpation/UTZ the placenta of the first infant separates before the second fetus is born. assess the woman carefully in the immediate postpartal period, placing her at risk for hemorrhage from uterine atony (lacking normal tone). in addition, the risk for uterine infection increases if labor or birth was prolonged. - 48 Problems With Fetal Position, Presentation, or Size Occipitoposterior Position - In approximately one tenth of all labors, the fetal position is posterior rather than anterior. That is, the occiput (assuming the presentation is vertex) is directed diagonally and posteriorly, either to the right (ROP) or to the left (LOP). - posterior positions tend to occur in women with android, anthropoid, or contracted pelvis. a posterior position is suggested by a dysfunctional labor pattern (arrested descent) position of the fetus is confirmed by vaginal examination or by ultrasound. 49 The fetus presenting in posterior: - may increase molding and caput formation - labor is somewhat prolonged - experience pressure & pain in her lower back due to sacral nerve compression Therapeutic Management - applying counter pressure on the sacrum by a back rub may be helpful in relieving a portion of the pain - applying heat or cold lying on the side opposite the fetal back or maintaining a hands-and-knees position may help the fetus rotate allow to void approximately every 2 hours to keep her bladder empty (impede fetal descent) she may need an oral sports drink or IV glucose solution FETUS MUST BE BORN BY CESAREAN BIRTH IF: - contractions are ineffective - fetus is larger than average or not in good flexion - rotation through the 135-degree arc may not be possible IF FORCEPS ARE USED TO HELP THE FETUS ROTATE: - risk for cervical lacerations, hemorrhage, and infection in the postpartum period. 50 Breech Presentation - Most fetuses are in a breech presentation early in pregnancy. However, by week 38, a fetus normally turns to a cephalic presentation. The fact that the fundus is the largest part of the uterus is probably the reason why, in approximately 97% of all pregnancies, the fetus turns so that the buttocks and lower extremities are in the fundus. 51 Breech presentation is more hazardous to a fetus than a cephalic presentation, because there is a higher risk of: - Anoxia from a prolapsed cord - Traumatic injury to the aftercoming head (possibility of intracranial hemorrhage or anoxia) - Fracture of the spine or arm - Dysfunctional labor - Early rupture of the membranes because of the poor fit of the presenting part. Assessment • FHSs usually are heard high in the abdomen. • Leopold’s maneuvers and a vaginal examination usually reveal the presentation. • UTZ clearly confirms a breech presentation Birth Technique • If an infant will be born vaginally, a woman is allowed to push after full dilatation is achieved. • it is steadied and supported by a sterile towel held against the infant’s inferior surface. 52 Breech Presentation -A frank breech position infant tends to keep his or her legs extended and at the level of the face for the first 2 or 3 days of life. -A footling breech infant may tend to keep the legs extended in a footling position for the first few days. Face Presentation -A fetal head presenting at a different angle than expected is termed asynclitism (face or chin/mentum). -A face presentation is confirmed by vaginal examination when the nose, mouth, or chin can be felt as the presenting part. -A fetus in a posterior position, instead of flexing the head as labor proceeds, may extend the head, resulting in a face presentation -Usually occurs in a woman with a contracted pelvis or placenta previa. -It also may occur in the relaxed uterus of a multipara or with prematurity, hydramnios, or fetal malformation. -UTZ is done to confirm the abnormal presentation. -If the chin is anterior and the pelvic diameters are within normal limits (vaginal birth). -If the chin is posterior (CS; method of choice) -Face presentation may result to facial edema and may be purple from ecchymotic bruising. -Observe the infant closely for a patent airway. (lip edema is so severe that they are unable to suck for a day or two) -Gavage feedings may be necessary to allow them to obtain enough fluid until they can suck effectively. -They may be transferred to a NICU for 24 hours. -Reassure the parents that the edema is transient Brow Presentation -It is the rarest of the presentations. It occurs in a multipara or a woman with relaxed abdominal muscles. -cesarean birth will be necessary to birth the infant safely. Brow presentations also leave an infant with extreme ecchymotic bruising on the face. 53 Transverse Lie Transverse lie occurs in women with: • pendulous abdomens • uterine fibroid tumors that obstruct the lower uterine segment • contraction of the pelvic brim • with congenital abnormalities of the uterus, or with hydramnios. • infants with hydrocephalus or another abnormality that prevents the head from engaging. • prematurity if the infant has room for free movement, in multiple gestation (particularly in a second twin), or if there is a short umbilical cord. Assessment - on inspection, the uterus is found to be more horizontal than vertical. - the abnormal presentation can be confirmed by Leopold’s maneuvers. - an ultrasound may be taken to further confirm the abnormal lie and to provide information on pelvic size. - a mature fetus cannot be delivered vaginally from this presentation. - often, the membranes rupture at the beginning of labor. Because there is no firm presenting part, the cord or an arm may prolapse, or the shoulder may obstruct the cervix. - Cesarean birth is necessary. 54 Oversized Fetus (Macrosomia) - - Size may become a problem in a fetus who weighs more than 4000 to 4500 g (approximately 9 to 10 lb). Babies of this size complicate up to 10% of all births (gestational diabetes) An oversized infant may cause uterine dysfunction during labor or at birth because of overstretching of the fibers of the myometrium. it can cause fetal pelvic disproportion or even uterine rupture from obstruction cesarean birth becomes the birth method of choice. Pelvimetry or ultrasound can be used to compare the size of the fetus with the woman’s pelvic capacity. a large infant born vaginally has a higher-than-normal risk of cervical nerve palsy, diaphragmatic nerve injury, or fractured clavicle because of shoulder dystocia. Postpartally, the woman has an increased risk of hemorrhage (overdistended uterus may not contract) 55 Postpartal Hemorrhage -any blood loss from the uterus greater than 500 mL within a 24-hour period. -may occur within the first 24-hr or anytime after the first 24-hr (puerperium) -5 main causes for postpartal hemorrhage: uterine atony, lacerations, retained placental fragments, uterine inversion, and DIC. Uterine Atony - relaxation of the uterus, is the most frequent cause of postpartal hemorrhage. - the first step in controlling hemorrhage is to attempt uterine massage. - if a uterus cannot remain contracted, IV infusion of oxytocin (Pitocin) 56 • If a uterus cannot remain contracted, physician or nurse-midwife probably will order a dilute intravenous infusion of oxytocin (Pitocin) • Carboprost tromethamine (Hemabate), may be repeated every 15 to 90 minutes up to 8 doses • Methylergonovine maleate (Methergine), may be repeated every 2 to 4 hours up to 5 doses • Rectal misoprostol, a prostaglandin E1 analogue, may be administered rectally • The usual dosage of oxytocin is 10 to 40 U per 1000 mL of a Ringer’s lactate solution. • When oxytocin is given intravenously, its action is immediate oxytocin has a short duration of action, approx.1 hour, so symptoms of uterine atony can recur quickly after administration of only a single dose. • Methylergonovine causes increased blood pressure so it is contraindicated with a woman with hypertension (generally a blood pressure over 140 mm Hg systolic) -offer a bedpan or assist the woman with ambulating to the bathroom at least q4hr. (A full bladder pushes an uncontracted uterus into an even more uncontracted state.) -administer oxygen by face mask at a rate of about 4 L/min. (respiratory distress from decrease blood volume) -monitor VS frequently & interpret accurately. Management •Bimanual Massage - If fundal massage and administration of oxytocin or methylergonovine are not effective in stopping uterine bleeding, a sonogram may be done to detect possible retained placental fragments. - inserts one hand into a woman’s vagina while pushing against the fundus through the abdominal wall with the other hand - Uterine packing may be inserted during this procedure to help halt bleeding. •Prostaglandin Administration - sustained uterine contractions. IM •Blood Replacement - Blood transfusion to replace blood loss - Iron therapy may be prescribed to ensure good hemoglobin formation. - Extensive blood loss is one of the precursors of postpartal infection because of the general debilitation that results. - For any woman who has experienced more than a normal loss of blood, observe for changes in lochia discharge •Hysterectomy or Suturing - extreme uterine atony, sutures or balloon compression may be used to halt bleeding - Embolization of pelvic and uterine vessels by angiographic techniques may be successful. - ligation of the uterine arteries or a hysterectomy may be necessary - can no longer bear children 57 Retained Placental Fragments - a placenta does not deliver in its entirety; fragments of it separate and are left behind. - retained placental fragments may also be detected by ultrasound. - a blood serum sample that contains (hCG), reveals that a placenta is still present. MOSTLY LIKELY IN SUCCENTURIATE PLACENTA—a placenta with an accessory lobe ACENTA ACCRETA—a placenta that fuses with the myometrium because of an abnormal decidua basalis layer Assessment - If retained fragment is large, *Bleeding is apparent - If the fragment is small, *Bleeding is detected 6 to 10 postpartum, abrupt & large amounts of blood. Note: uterus is not fully contracted Therapeutic Management - dilatation and curettage (D&C) is performed to remove the placental fragment. - Methotrexate may be prescribed to destroy the retained placental tissue. Note: continue to observe the color of lochial discharge. Subinvolution - subinvolution is incomplete return of the uterus to its prepregnant size and shape. - at a 4- or 6-week post partal visit, the uterus is still enlarged and soft - Subinvolution may result from a small retained placental fragment, a mild endometritis (infection of the endometrium), or uterine myoma that is interfering with complete contraction. Therapeutic Management - oral administration of methylergonovine, 0.2 mg qid to improve uterine tone and complete involution - if the uterus is tender to palpation, suggesting endometritis (oral antiobiotic) - a chronic loss of blood from subinvolution will result in infection or anemia and lack of energy. Puerperal Infection - infection of the reproductive tract is another leading cause of maternal mortality. - it only begins as local infection = spread to the peritoneum (peritonitis) = circulatory system (septicemia) - Organisms commonly cultured postpartally include group B streptococci and aerobic gram-negative bacilli such as Escherichia coli - Staphylococcal infections are the cause of toxic shock syndrome, an infection similar to puerperal infection in its ability to cause death and morbidity MANAGEMENT focuses on the use of an appropriate antibiotic after C/S testing of the isolated organism Conditions That Increase a Woman’s Risk for Postpartal Infection • Rupture of the membrane (>24hrs) bacteria may have started to invade the uterus while the fetus was still in utero • Retained placental fragments the tissue necroses and serves as an excellent bed for bacterial growth •Postpartal hemorrhage the woman’s general condition is weakened •Dysfunctional labor trauma to the tissue may leave lacerations or fissures for easy portals of entry for infection •Uterus is explored after birth infection was introduced with exploration 58 Endometritis - Endometritis is an infection of the endometrium, the lining of the uterus. - this may occur with any birth, but the infection is usually associated with chorioamnionitis and cesarean birth. - Bacteria gain access to the uterus through the vagina and enter the uterus either at the time of birth or during the postpartal period Assessment - The fever of endometritis usually manifests on the 3rd or 4th postpartal day. - WBC counts is increased to 20,000 to 30,000 cells/mm3 - oral temperature 38°C for two consecutive 24-hour periods (febrile condition) • Infection should be suspected - chills, loss of appetite, general malaise, noncontracted & tender uterus can be manifested. - lochia is dark-brown and foul odor. - It may be increased in amount because of poor uterine involution, but if the infection is accompanied by high fever, lochia may be scant or absent Management - antibiotic (clindamycin); culture form lochia - oxytocic agent such as methylergonovine, to encourage uterine contraction. - sitting in a Fowler’s position or walking is recommended. encourages lochia drainage by gravity and helps prevent pooling of infected secretions - wear gloves when changing perineal pads. (drainage is contaminated) Note: - the danger of endometritis is that it can lead to tubal scarring and interference with future fertility. - fertility assessment (hysterosalpingogram) the woman desires more children Infection of the Perineum - infections of the perineum usually remain localized. They are revealed by symptoms similar to those of any sutureline infection, such as pain, heat, and a feeling of pressure. - notify the woman’s physician of the localized symptoms (for C/S) Management - the perineal sutures may be removed - open lesion packing (iodoform gauze) - a systemic or topical antibiotic & analgesics are given - sitz baths, moist warm compresses, or Hubbard tank treatments may ordered - change perineal pad frequently - wipes front to back after a bowel movement If infection occurs, the prognosis for complete recovery depends on: • Virulence of the invading organism • The woman’s general health • Portal of entry • Degree of uterine involution at the time of the microorganism invasion • Presence of lacerations in the reproductive tract Peritonitis or infection of the peritoneal cavity, usually occurs as an extension of endometritis. - It is one of the gravest complications of childbearing and is a major cause of death from puerperal infection. - The occurrence of a rigid abdomen (guarding) is one of the first symptoms of peritonitis. - often accompanied by paralytic ileus (blockage of inflamed intestines). 59 Thrombophlebitis - Phlebitis is inflammation of the lining of a blood vessel - Thrombophlebitis is inflammation with the formation of blood clots. - it is usually an extension of endometrial infection. - classified as superficial vein disease (SVD) or deep vein thrombosis (DVT). It tends to occur if: • A woman’s fibrinogen level is still elevated from pregnancy, leading to increased blood clotting. • Dilatation of lower extremity veins is still present as a result of pressure of the fetal head during pregnancy and birth. • The relative inactivity of the period or a prolonged time spent in delivery or birthing room stirrups leads to pooling, stasis, and clotting of blood in the lower extremities • Obesity from increased weight before pregnancy and pregnancy weight gain can lead to relative inactivity and lack of exercise • The woman smokes cigarettes. Women most prone to thrombophlebitis: • obese • varicose veins • have had a previous thrombophlebitis • older than 35 yrs. old with increased parity • family history Preventions - good aseptic technique during birth - ambulation and limit stay on stirrups - wearing support stockings for the first 2 weeks after birth - drink adequate fluids - quit smoking Femoral Thrombophlebitis - the femoral, saphenous, or popliteal veins are involved. - decreased circulation, along with edema, gives the leg a white or drained appearance. I - formerly called as “white inflammation” Assessment - increase temp, chills, pain, & redness in the affected leg about 10 days after birth - positive Homan’s sign (pain in the calf of the leg on dorsiflexion of the foot) - Doppler UTZ /contrast venography Management - bed rest with the affected leg elevated, anticoagulants, fibrinolytics, and application of moist heat. Note: Never massage the skin over the clot - this could loosen the clot, causing a pulmonary or cerebral embolism. - administer anticoagulants: • Heparin (IV/SQ) - to dissolve the clot through the activation of fibrinolytic precursors and prevent further clot formation. • Protamine sulfate, the antagonist for heparin, should be readily available any time heparin is administered. • A woman can continue to breastfeed while receiving heparin. • If she does not wish to breastfeed, she can be switched to warfarin (an oral coumarin derivative). • The antidote to warfarin is vitamin K. • A woman has to discontinue breastfeeding during therapy with coumarin, because coumarin-derived anticoagulants are passed in breast milk. • No salicylic acid (Aspirin) intake -because salicylic acid prevents blood clotting by preventing platelet aggregation and clot formation • However, some women may be prescribed aspirin every 4 hours as a preventive measure if they are at high risk for recurrent thrombophlebitis. • If this is so, be certain you do not interpret aspirin used this way as a PRN analgesic order and withhold it depending on the woman’s level of pain. 60 Anomalies of the Placenta - the placenta and cord are always examined for the presence of anomalies after birth. - The normal placenta weighs approximately 500 g and is 15 to 20 cm in diameter and 1.5 to 3.0 cm thick - Its weight is approximately 1/6 that of the fetus. - A placenta may be unusually enlarged in women with diabetes. - If the uterus has scars or a septum, the placenta may be wide in diameter because it was forced to spread out to find implantation space. Placenta Succenturiata - a placenta that has one or more accessory lobes connected to the main placenta by blood vessels. - No fetal abnormality is associated with this type • However, it is important that it be recognized, because the small lobes may be retained in the uterus after birth, leading to severe maternal hemorrhage. • On inspection, the placenta appears torn at the edge, or torn blood vessels extend beyond the edge of the placenta. • The remaining lobes are removed from the uterus manually to prevent maternal hemorrhage from poor uterine contraction. Placenta Circumvallata - Ordinarily, the chorion membrane begins at the edge of the placenta and spreads to envelop the fetus; no chorion covers the fetal side of the placenta. - In placenta circumvallata, the fetal side of the placenta is covered to some extent with chorion - The umbilical cord enters the placenta at the usual midpoint, and large vessels spread out from there. - They end abruptly at the point where the chorion folds back onto the surface, however. (In placenta marginata, the fold of chorion reaches just to the edge of the placenta.) • In placenta marginata, the fold of chorion reaches just to the edge of the placenta. • Although no abnormalities are associated with this type of placenta, its presence should be noted Battledore Placenta - the cord is inserted marginally rather than centrally. - This anomaly is rare and has no known clinical significance either. Velamentous Insertion of the Cord - is a situation in which the cord, instead of entering the placenta directly, separates into small vessels that reach the placenta by spreading across a fold of amnion. This form of cord insertion is most frequently found with multiple gestation. Vasa Previa • In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus. • The vessels may tear with cervical dilatation. • Avoid insertion of any instrument to prevent accidental tearing of a vasa previa as tearing would result in sudden fetal blood loss. - Vasa previa is a rare pregnancy complication that can lead to severe blood loss for fetus if it’s not carefully managed. - unprotected blood vessels from the umbilical cord travel across the opening of your cervix (or cervical os). - When water breaks during labor, the exposed blood vessels can burst, causing severe blood loss for fetus or even death Placenta Accreta - is an unusually deep attachment of the placenta to the uterine myometrium so deeply the placenta will not loosen and deliver - Hysterectomy or treatment with methotrexate to destroy the still-attached tissue may be necessary. 61 Anomalies of the Cord - The absence of one of the umbilical arteries is associated with congenital heart and kidney anomalies. Inspection of the cord as to how many vessels are present must be made immediately after birth A normal cord contains one vein and two arteries Two-Vessel Cord - The absence of one of the umbilical arteries is associated with congenital heart and kidney anomalies. - because the insult that caused the loss of the vessel may have affected other mesoderm germ layer structures as well. Unusual Cord Length - short umbilical cord can result in premature separation of the placenta or an abnormal fetal lie. long cord may be easily compromised because of its tendency to twist or knot It is not unusual for a cord to wrap once around the fetal neck (nuchal cord) but, again, with no interference to fetal circulation. 62 3RD TRINAL STRUCTURAL DISORDERS OF THE REPRODUCTIVE SYSTEM PHIMOSIS - Is a condition in which the foreskin cannot be retracted back over the glans penis. 8th week of gestation (Embryologically) first 3 years of life, congenital adhesions The inability to retract foreskin is normal in infancy caused by adhesions between the foreskin and glans, separate naturally with penile erections and are not an indication for circumcision. poor hygiene and chronic infection. CAUSES: Congenital From inflammation From edema 2 forms of phimosis Physiologic Children are born with tight foreskin at birth and separation occurs naturally over time. Phimosis is normal for the uncircumcised infant/child and usually resolves around 5-7 years of age, however the child may be older. Pathologic occurs due to scarring, infection or inflammation Forceful foreskin retraction can lead to bleeding, scarring, and psychological trauma for the child and parent. If there is ballooning of the foreskin during urination, difficulty with urination, or infection, then treatment may be warranted MANIFESTATIONS: Edema Erythema Tenderness of the prepuce Purulent discharge Inability to retract foreskin MANAGEMENT: Balanitis (Balanoposthitis) - local application of heat; this can be carried out with warm wet soaks or warm baths. - local antibiotic ointment may be prescribed - If phimosis (a tight foreskin) appears to be contributing to the condition circumcision may be advocated after the inflammation subsides to prevent the condition from recurring - Any discharge should be cultured to rule out an STI such as gonorrhea - Penis should be elevated for short period before gentle attempt is made to reduce pain MANAGEMENT: Circumcision of newborns is no longer routinely advised but is used to relieve phimosis IN CASE OF CIRCUMCISION: - Teach how to change dressing. - Observe for signs and symptoms of infection and bleeding. - If severe bleeding: Apply firm dressing, and inform AP. - If bleeding persists: resuturing of the wound is done. - Estrogen preparation is given to adult patient to prevent painful erections. COMPLICATIONS: Interfere with voiding Develop balanoposthitis - inflammation of the glans and prepuce of the penis. - caused by poor hygiene and may accompany a urethritis or a regional dermatitis. Balanitis - Glans Inflammation Posthitis - Prepuce Paraphimosis - the inability to replace the prepuce over the glans once it has been retracted. This is an emergency situation to address before circulation to the glans is impaired 63 HYPOSPADIA/EPISPADIA HYPOSPADIA - A congenital condition in which the urethral meatus is located on the ventral side or undersurface of the penis. - The meatus may be near the glans, midway back, or at the base of the penis This anomaly is fairly common, occurring in approximately 1 in 300 male newborns. (1:200 CDC) It tends to be familial or may occur from a multifactorial genetic focus The abnormal opening can form anywhere from just below the end of the penis to the scrotum EPISPADIA - A congenital condition in which the urethral meatus is located on the dorsal portion of the penis a similar defect in which the opening is on the dorsal surface of the penis occurs in 1 in 117,000 newborn boys and 1 in 484,000 newborn girls Very rare – more often associated with bladder exstrophy Need early referral for parental counseling Patient may be totally incontinent CLASSIFICATION: Glanular: positioned on the glans Penile: positioned along the shaft Penopubic: near the pubic bone • The position of the meatus is important because it predicts the degree to which the bladder can store urine (continence). • Note: The closer the meatus is to the base of the penis, the more likely the bladder will not hold urine Anterior Epispadia – urethral opening may be small and situated behind the glans Posterior Epispadia – a fissure may extend the entire length of the penis and into the bladder neck. Epispadias is associated with bladder exstrophy - an uncommon birth defect in which the bladder is inside out, and sticks through the abdominal wall - Nearly all boys with bladder exstrophy will also have epispadias. - Most girls with exstrophy also have epispadias. - Epispadias can occur in both boys and girls who are otherwise healthy with no other abnormalities ASSESSMENT: - Be certain to inspect all male newborns at birth for hypospadias or epispadias as part of the routine physical examination. - The degree of hypospadias may be minimal (on the glans but inferior in site) or maximal (at the midshaft or at the penalscrotal junction) - Many newborns with hypospadias have an accompanying short chordee a fibrous band that causes the penis to curve downward often called a cobra-head appearance - Sex cell karyotyping if sex determination is unclear Not difficult to diagnose because of the visual anomaly. Inspection would show abnormal placement of the urethra. (Hypospadias is usually diagnosed during a physical examination after the baby is born.) - Not difficult to diagnose because of the visual anomaly. Inspection would show abnormal placement of the urethra. (Hypospadias is usually diagnosed during a physical examination after the baby is born.) 64 CAUSES: - Exact cause known Possible genetic factors Defects in testosterone synthesis Environmental factors Chordee or penile torsion may accompany cases of hypospadias Penile Torsion – is the rotation of the penile shaft to either right or left. Age and weight: Mothers who were age 35 years or older and who were considered obese had a higher risk of having a baby with hypospadias. Fertility treatments: Women who used assisted reproductive technology to help with pregnancy had a higher risk of having a baby with hypospadias. Certain hormones: Women who took certain hormones just before or during pregnancy were shown to have a higher risk of having a baby with hypospadias. Women who took certain hormones just before or during pregnancy were shown to have a higher risk of having a baby with hypospadias. ASSESSMENT and DIAGNOSIS: - Not difficult to diagnose because of the visual anomaly. Inspection would show abnormal placement of the urethra. - The male infant cannot void with the penis in the normal elevated position; females, the urine dribbles from the vagina Hypospadias: Epispadia: - Altered angle of urination - Urethral opening located on the topside - Normal urination impossible with penis elevated of penis due to chordee (band fibrous tissue causing - Exstrophy of the bladder penis curvature) - Exposed bladder appearing bright red - Urethral opening located on underside of penis and obvious at birth - Urine seeping onto the abdominal wall TREATMENT: from abnormal urethral openings - Avoid circumcision TREATMENT: - Meatomy (surgical procedure performed to - Surgery requiring mutiple procedure extend the urethra in normal position) - Associated bladder extrophy closed - Surgery to release the chordee preferably within the few days of life Surgical reconstruction may be required - Second phase of surgery involving the beginning before age 1. lengthening and straightening of the - If the repair will be extensive, all surgery may be penis and the creation of a more distal delayed until the child is 3 to 4 years of age. urethra - Apply testosterone cream/ daily injections of cream encourage penis growth make the procedure easier - It is important that hypospadias be corrected before school age so the child looks and feels like other children - If left untreated, in later years it will: • Interfere with fertility- does not allow sperm to be deposited close to the cervix during coitus • Repair must be done to prevent subfertility GOALS for SURGERY: - A straight penis when erect to facilitate intercourse in adult. - Uniform urethra of adequate caliber to prevent spraying during urination. - A cosmetic appearance satisfactory to individual. - Repair completed in as few procedures as possible Nursing Responsibilities prior to surgery: - Explain all diagnostic tests before their occurrence and prepare the parents and child for surgery. - Emphasize that the parents or child are not to be blamed for the illness. Nursing Responsibilities after to surgery: - After surgical repair, a urethral urinary drainage catheter will be inserted to allow urine output without - putting tension against the urethral sutures. The child may notice painful bladder spasms as long as the catheter is in place (3 to 7 days). • An analgesic such as acetaminophen (Tylenol) • antispasmodic medication such as oxybutynin (Ditropan) 65 NURSING INTERVENTIONS: - Monitor daily intake and output. Assess patient’s skin turgor and mucous membranes for signs of dehydration. Observe and record characteristics of urinary drainage, occurrence of bladder spasms, and appearance of dressing and the incision. Explain all diagnostic tests before their occurrence and prepare the parents and child for surgery. Emphasize that the parents or child are not to be blamed for the illness Maintain child in bed in a supine position for 2-3 days with limited activity in bed for several more days to prevent disruption of the of surgical site. Use bed cradle as necessary Administer analgesics as needed and anticholinergics for sharp painful bladder spasms Encourage fluids and high fiber diet to prevent constipation associated with bed rest Provide diversional activity and reassurance while on bed rest Advise parents to report curvature of the penis, decreased force of urinary stream, nor any change in voiding that may indicate complication requiring dilation or other surgical intervention EDUCATION and HEALTH MAINTENANCE: - Teach prompt diaper changes and cleaning of the skin after bowel movements to prevent irritation of skin and contamination of healing wound. Encourage long-term follow-up to ensure healing and acceptable cosmetic appearance. Advise parents to report curvature of the penis, decreased force of urinary stream, nor any change in voiding that may indicate complication requiring dilation or other surgical intervention. How does the male reproductive system form? The penis includes: • glans (the head), • corona (the ridge between the head and the shaft) and • shaft (the long part of the penis). • The urethra is the opening at the tip The testicles are two organs that hang in a pouch-like skin sac (the scrotum) below the penis. • These organs are where sperm and testosterone (the male sex hormone) are made The scrotum is designed to keep the testicles cool, away from the body. This is because sperm can't grow at body temperature Sperm start growing in the testicles and gain movement and maturity while traveling through the epididymis. CRYPTORCHIDISM - Congenital disorder in which one or both testes fail to descend into the scrotum, remaining in - the abdomen or inguinal canal or at the external ring of the inguinal canal. Most commonly affects the right testis although it may be bilateral True undescended testes: testes remain along the path of normal descent Ectopic testes: testes deviate from the path of normal descent. Normally, the testes descend into the scrotal sac during months 7 to 9 of intrauterine life They may descend any time up to 6 months after birth; they rarely descend after that time About 17% of premature infants and 3% to 4% of full-term infants are born with undescended testes Occurs in 30% of premature male neonates, but in only 3% of those born at term In about 80% of affected infants, testes descending spontaneously during the 1st year; in the rest, testes possibly descending later. PATHOPHYSIOLOGY: - In the male fetus, testosterone normally stimulates the formation of the gubernaculum (a fibromuscular band that connects the testes to the scrotal floor) - This band probably helps pull the testes into the scrotum by shortening as the fetus grows. - Disorder may result from inadequate testosterone levels or a defect in the testes or the gubernaculum - Spermatogenesis is impaired (leading to reduced fertility 66 CAUSES: UNCLEAR - It may be associated with caffeine intake - - during pregnancy Fibrous bands at the inguinal ring or inadequate length of spermatic vessels may prevent descent low level of testosterone production Genetic predisposition Hormonal factor Structural factor Testosterone deficiency Undescended testicles are also linked to a higher risk of - Testicular cancer in adulthood - Testicular torsion (twisting of the blood vessels that bring blood to and from the testis) - Inguinal hernia (a hernia that develops near the groin ASSESSMENT FINDINGS: - Early detection of undescended testes is - - - - important, • warmth of the abdominal cavity may inhibit development of the testes, ultimately affecting spermatogenesis After puberty, sperm production deteriorates rapidly in undescended testes, and the testes may even undergo a malignant change • Anchoring the testes in the scrotal sac may not prevent malignancy, but it will allow the boy to perform preventive measures such as testicular selfexamination It is more common for the right testes to remain undescended than the left one In approximately 20% of all boys, both testes remain undescended If the child is supine or the examining room is chilly, the scrotal sac may appear to be empty • Excessive palpation or stroking of the inner thigh may also stimulate the cremasteric reflex and cause retraction • In these instances, testes descend when the child is standing or after a warm bath An undescended testes may be at the inguinal ring (true undescended testis) or ectopic (still in the abdomen). Laparoscopy is effective in identifying undescended testes Because testes arise from the same germ tissue as the kidneys, the kidney function of a child with ectopic testes is usually evaluated NURSING CARE: - Use an anatomically correct picture to - - - - point out the exact site at which surgery will be performed. Reassure the boy that the penis itself will not be cut. The child may not voice a fear of mutilation, but you can assume that it exists, especially in preschool children Encourage the parents of the child with undescended testes to express their concern about his condition Tell the parents the rubber band may be taped to the patient’s thigh for about 1 week after the surgery to keep the testes in place. Scrotum may swell but shouldn’t be painful. After surgery, monitor the patient’s vs, I&O, operative site NURSING DIAGNOSIS: - Deficient knowledge related to parents’ and child’s inexperience with surgical procedure and postoperative treatment plan - Disturbed body image related to change in physical appearance EVALUATION: - Postoperative evaluation should reveal that the suture line is healing well and that both testes can be palpated in the scrotum. - It should also address the boy’s feelings about the surgery and the changes in his body. - He may need an opportunity to express his fears about mutilation or castration by playing with puppets or dolls after surgery. - Even after a repair, boys who had bilateral cryptorchidism may be less fertile as adults. - When boys reach puberty, teach them testicular self-examination to assess any early symptoms of malignancy, such as nodules or abnormal growth 67 HYDROCELE - - - Is the presence of abdominal fluid in the scrotal sac At birth, the collection of fluid makes the scrotum of the newborn appear enlarged During development, the testes are formed retroperitoneally in the abdomen and proceed to descend into the scrotum via the inguinal canal in the third gestational week. This descent of the testes into the scrotum is accompanied by a fold of peritoneum of the processus vaginalis. - is the peritoneal tunnel through which the testes migrate from the retroperitoneum toward the scrotum during embryological development A primary hydrocele causes a painless enlargement in the scrotum on the affected side and is thought to be due to the defective absorption of fluid secreted between the two layers of the tunica vaginalis (investing membrane). A secondary hydrocele is secondary to either inflammation or a neoplasm in the testis. usually occurs on one side. The accumulation can be a marker of physical trauma, infection or tumor, but the cause is generally unknown. Description: - Normally, the proximal portion of processus vaginalis gets obliterated while the distal portion persists as the tunica vaginalis covering the anterior, lateral, and medial aspects of the testes. - The tunica vaginalis is a potential space for fluid to accumulate - Provided the proximal portion of processus vaginalis remains patent and results in free communication with the peritoneal cavity + leads to congenital hydrocele • Is the presence of abdominal fluid in the scrotal sac • This can be revealed by prenatal UTZ • At birth, the collection of fluid makes the scrotum of the newborn appear enlarged • On transillumination (the shining of a light through the scrotal sac), the area is illuminated by the water and shines or glows CAUSES: Congenital malformation Trauma to the testes or epididymis Infection of the testes DIAGNOSTIC TEST FINDINGS: Transillumination – is used to distinguish between a fluid-filled and solid mass Ultrasonography – is used to visualize the testes and determine the presence of a tumor Fluid Biopsy – determines the cause and differentiates between normal and cancerous cells Abdominal x-ray – distinguish acute hydrocele from incarcerated hernia DESCRIPTION: - If uncomplicated; can be reabsorbed and no treatment is needed - Hydrocele may form later in life due to inguinal hernia abdominal contents extruding into the scrotum through the inguinal ring, with accompanying fluid + - If this happens, the hernia must be repaired for the hydrocele to be reabsorbed - Injection of a drug to decrease fluid production (sclerotherapy) may also be effective TREATMENT: - The accumulation should generally be removed surgically. - Hydrocelectomy - accumulation should generally be removed surgically the tunica vaginalis is excised, the fluid drained, and the edges of the tunica are sutured to prevent the reaccumulation of fluid NURSING INTERVENTIONS: - Place a rolled towel between the patient’s legs, and elevate the scrotum to help reduce severe swelling. - Advise the patient with mild or moderate swelling to wear a loosefitting athletic supporter lined with soft cotton dressings - Encourage sitz baths, and apply heat or ice packs to the scrotum to decrease inflammation - The need to avoid tub baths postoperatively for 5-7 days - Administer analgesics as ordered. 68 NURSING INTERVENTIONS FOR POSTOPERATIVE CARE INCLUDE: - Assess for wound infection - Maintain a good hydration status - Promoting comfort (analgesic and apply ice bags and use scrotal support to help relieve and swelling, if prescribed). - Support the parents NURSING MANAGEMENT Nursing responsibilities for postoperative care include: - Assess for wound infection - Maintain a good hydration status - Promoting comfort (analgesic and apply ice bags and use scrotal support to help relieve and swelling, if prescribed). - Support the parents 69 NEWBORN (neonate) - A baby born alive; ages 0 up to the 28 days of life extra – utero - Regardless of the AOG, BW and method of delivery Under the Newborn Screening Act (RA 9288) the NB is a child from time of complete delivery to 30 days old (neonatal stage) - NBS perform immediately after 24H - This is to detect metabolic disorders Introduction - All infants need to be assessed at birth for obvious congenital anomalies and gestational age - Both determinations can be done by the nurse who first examines an infant. - Be certain these assessments are made with an infant under a prewarmed radiant heat warmer to guard against heat loss - Continuing assessment of high-risk infants involves: - the use of instrumentation such as: cardiac apnea blood pressure monitoring Note: monitor equipment cannot replace the role of frequent, close, common-sense observation Nursing Diagnosis: o Ineffective airway clearance related to presence of mucus or amniotic fluid in airway. o Ineffective cardiovascular tissue perfusion related to breathing difficulty. o Risk for deficient fluid volume related to insensible water loss o Ineffective thermoregulation related to newborn status and stress from birth weight variation o Risk for imbalanced nutrition, less than body requirements related to lack of energy for sucking o Risk for infection related to lowered immune response in newborn o Risk for impaired parenting related to illness in newborn at birth o Deficient diversional activity (lack of stimulation) related to illness at birth o Readiness for developmental care to decrease overstimulation easily caused by necessary life-saving procedures Implementations: - Interventions for any high-risk newborn are best carried out by a consistent caregiver and should focus on conserving the baby’s energy and providing a thermoneutral environment to prevent exhaustion and chilling - Painful procedures should be kept to a minimum to help the infant achieve a sense of comfort and balance. - Assisting parents to participate in care such as bathing or feeding their infant may help make the child real to them for the first time and start the bonding process All newborns have eight priority needs in the first few days of life: 1. Initiation and maintenance of respirations 2. Establishment of extrauterine circulation 3. Maintaining fluid and electrolyte balance 4. Control of body temperature 5. Intake of adequate nourishment 6. Establishment of waste elimination 7. Prevention of infection 8. Establishment of an infant–parent relationship 9. Developmental care, or care that balances physiologic needs and stimulation for best development 70 Priorities for the first days of life 1. Initiation and maintenance of respirations - Most deaths occurring during the first 48 hours after birth result from the newborn’s inability to establish or maintain adequate respirations. + results to neurologic difficulties because of cerebral hypoxia RESUSCITATION - Establish and maintain an airway expand the lungs initiate and maintain effective ventilation Note: If respiratory depression becomes severe, a newborn’s heart will fail. Resuscitation then must also include cardiac massage Establish and maintain an airway usually bulb syringe suction, removes mucus and prevents aspiration of any mucus and amniotic fluid present in the mouth or nose with the first breath - If a newborn’s amniotic fluid was meconium stained: 1. do not stimulate an infant to breathe by rubbing the back or 2. No administration of air or oxygen under pressure 3. could push meconium down into an infant’s airway 4. further compromising respirations What you will do? - Give oxygen by mask without pressure - Wait for a laryngoscope to be passed and the trachea to be deep suctioned before giving oxygen under pressure - If deeper suctioning than by a bulb syringe is required - Do not suction for longer than 10 seconds at a time (count seconds as you suction) to avoid removing excessive air from an infant’s lungs. - Use a gentle touch - In most newborns, this degree of resuscitation will initiate responsive respirations and a strong heartbeat Lung Expansion the baby’s crying is a proof that lung expansion is good because the vocal sounds are produced by a free flow of air over the vocal cords - An infant who breathes spontaneously but then cannot sustain effective respirations may need oxygen by bag and mask to aid lung expansion. - The mask should cover both the mouth and the nose to be effective. - It should not cover the eyes, because it can cause eye injury mechanically from the mask or drying of the cornea from oxygen administration Initiate and Maintain Effective Ventilation - To allow a newborn to adjust to and maintain cardiovascular changes, effective ventilation must be maintained 2. Establishment of extra-uterine circulations. - If an infant has no audible heartbeat, or if the cardiac rate is below 80 beats per minute, closed-chest massage should be started. - Newborns who have difficulty maintaining cardiac function need to be transferred to high-risk nursery for continuous cardiac surveillance 3. Maintaining fluid and electrolyte balance Hypoglycemia may result from the effort the newborn expended to begin breathing - Mgt: fluids (lactated ringers & D5W); electrolytes (K, Na, glucose) Dehydration may result from rapid respirations. Dehydration may be monitored by urine output and urine specific gravity measures. - Dehydration may be monitored by urine output and urine specific gravity measures. - specific gravity greater than 1.015 to 1.020 suggests inadequate fluid intake Note: if an infant has hypotension without hypovolemia, a vasopressor such as dopamine may be given to increase blood pressure and improve cell perfusion. - 71 - Normal saline or Ringer’s lactate may be administered to increase blood volume Control the rate carefully to prevent heart failure, patent ductus arteriosus, or intracranial hemorrhage from fluid pressure overload Priorities for the first days of life - The rate of fluid administration must be carefully monitored because a high fluid intake can lead to patent ductus arteriosus or heart failure. 4. Regulating temperature - Keep newborns in a neutral temperature environment (increased metabolism required cells for increased oxygen) - skin-to-skin care is originally referred to as kangaroo care, the use of skin-to-skin contact to maintain body heat (encourages parent–child bonding) 5. Establishing adequate nutritional intake. - Preterm infants should be breastfed, if possible, because of the immune protection. - if BF is not possible, expressed breast milk can be used in the infant’s gavage feeding. NOTE: Infants who experienced severe asphyxia at birth usually receive intravenous fluids so they do not become exhausted from sucking or until necrotizing enterocolitis (NEC) has been ruled out, as this could result from the temporary reduction in oxygen to the bowel Necrotizing enterocolitis (NEC) is a serious gastrointestinal problem that mostly affects premature babies. - The condition inflames intestinal tissue, causing it to die. A hole (perforation) may form in your baby's intestine - If an infant’s respiratory rate remains rapid and NEC has been ruled out, gavage feeding may be introduced 6. Establishment of waste elimination. - most immature infants void within 24 hours of birth, they may void later than term newborns - As a result of all the procedures that may be necessary for resuscitation, their blood pressure may not be adequate to optimally supply their kidneys - immature infants also may pass stool later than the term infant - Carefully document any voidings that occur during resuscitation - This is proof that hypotension is improving and the kidneys are being perfused 7. Preventing infection. - Infection stresses the immature immune system and already stressed defense mechanisms of a highrisk newborn - The most prevalent perinatal infections are those contracted from the vagina during birth. • Early-onset sepsis - most commonly caused by group B streptococcus, E. coli, Kelbsiella, and Listeria monocytogenes. • Late-onset, or nosocomial infections - more commonly caused by Staphylococcus aureus, Enterobacter, and Candida - observe good handwashing technique and standard precautions to reduce the risk of infection transmission - Health care personnel with infections have a professional and moral obligation to refrain from caring for newborns. 8. Establishment of an infant-parent relationship. - Mother should be able to visit the special nursing unit (after washing and gowning, hold and touch their child). - Urge parents to spend time with their infant in the intensive care nursery as the infant improves 9. Developmental care, or care that balances physiologic needs and stimulation for best development. - Thorough education and referral to a home care agency may be necessary to help parents continue with the level of care that is required when their infant is discharged home. - Before discharge, the safety of their home for the care of such a small infant need to be evaluated - Transporting a preterm infant in a car requires special care, including a blanket or commercial head support, because a very small infant does not fit securely in a standard infant car seat. - preterm children are at high risk for abuse. 72 Assessment of the High-Risk Newborn: PERFORMING APGAR SCORING - Gives a numerical expression of the newborn’s adaptation to extra uterine life at 1 and 5 min. - after birth a 10-minute APGAR is performed (under 7) 1-minute scoring: detects the cardio-respiratory function of the newborn, general condition, need for resuscitation (initiated immediately). 5-minute scoring: detects the newborn’s adjustments to the new environment; detects prognosis; basis for NCP making. 10-min apgar is perfomed when the 5-min score is under 7 - APGAR scoring involves 5 aspects: Heart rate Respiratory effort Muscle tone Reflex irritability Color Total Score of • 0-3 Critically low (esp. in preterm infants) • needs resuscitation • 4-6 Below Normal • it indicates that the baby likely requires medical intervention. • need suctioning and O2; condition guarded • 7+ are considered normal NOTE: The Apgar score is repeated every additional 5 minutes, until a minimum score of 7 is reached Interpretation of APGAR Score - Heart rate is the most important APGAR score Color is the least important APGAR score; a color of means acrocyanosis (sluggish peripheral circulation at 1st 24h); stimulate cry. Reflex irritability; cry or sneezing; demonstration of reflexes (Moro reflex) Good cry means breathing is well. No need to count the RR. 73 Assessment of the High-Risk Newborn: POOR APGAR SCORE The following points should be considered in obtaining the APGAR scoring: ◦ ◦ ◦ ◦ ◦ ◦ Heart Rate: Auscultating the NB heart is the BEST way to determine heart rate. Respiratory effort: a newborn usually cries spontaneously at about 30 seconds after birth Muscle tone: mature newborns hold the extremities tightly flexed, simulating their intrauterine position. They should resist any effort to extend their extremities. Poor muscle tone - is observed when the infant shows no flexion of the arms and legs - extremities “flop” back to the mattress when manipulated or flexed Reflex Irritability: One of two possible cues is used to evaluate this point; - Response to a suction catheter in the nostrils Cough or sneeze - Response to having the soles of the feet slapped. Cry and withdrawal of foot fanning of tarsals when tickled Color: ALL INFANTS appear cyanotic at the moment of birth. They grow pink with or shortly after the first breath. The color of the newborns thus corresponds to how well they are breathing. - ACROCYANOSIS – cyanosis of the hands and feet; common in newborns that a score of 1 in this category can be thought of as normal Respiration - The newborn is evaluated whether the newborn breathes well or crying normally. - Irregular breathing pattern in newborn is common in newborn baby The indicator of a newborn that breaths well is a vigorous cry - Respiratory Evaluation An aspect in newborn assessment tool (APGAR) which has the highest priority in newborn care. Silverman-Andersen score can be used to determine respiratory status of newborns specifically the degree of RESPIRATORY DISTRESS. - ALTERED RESPIRATION In this assessment, the newborn is observed and then scored on each of five criteria: Chest movement Intercostal retraction Xiphoid retraction Nares dilatation Expiratory grunt 74 Each item is given a value of 0, 1, or 2; the values are then added. - A total score of 0 indicates no respiratory distress. - Scores of 4 to 6 indicate moderate distress. - Scores of 7 to 10 indicate severe distress NOTE: Scores of this index run opposite to those of the Apgar: an Apgar score of 7 to 10 would indicate a well infant Causes of alteration in respiration or poor gas exchange: - Prematurity - Congenital Anomalies - Obstruction of airway due to: Deviation in nasal septum Secretions Tumor ALTERED RESPIRATION: INTERVENTION - Assess respiratory rate every 15 minutes for 1 hour. Report any increase in rate, retractions, or development of nasal flaring or grunting. - Provides baseline for evaluating changes. - Increases in RR and retractions, accompanied by nasal flaring, and grunting indicates distress - Position the newborn on his side with head slightly lower than the rest of the bod - Positioning in this manner facilitates drainage of secretions from airway. - Suction mouth and then nose with bulb syringe as indicated. - Gentle suctioning removes secretions that may collect in these areas. - Suctioning the mouth before the nose prevents possible aspiration of oral secretions - Change position frequently. - Position changes facilitate drainage of secretions, thus enhancing lung aeration and expansion. - Inform the parents that the rapid respiratory rate is common in some newborns after birth because of unabsorbed lung fluid - Providing information helps to allay parents’ anxieties and fears - Monitor newborn’s temperature and keep warm. Wrap the newborn loosely in a blanket and place warm clothing - Newborns have difficulty conserving body heat - Exposure to cold increases the metabolic rate, increasing the need for oxygen and further increasing the respiratory rate. 75 PREMATURITY Preterm Infants - Defined as a live-born infant born before the end of week 37 of gestation. - Another criterion is a weight of less than 2, 500 grams (5lbs 8 ounce) at birth - Infants born before term (less than the full 37th week of pregnancy) account for approximately 7% to 19% of all births • Intensive care will be applied to all preterm infants • This is to provide them with chance of survival without neurologic effects • Extremely vulnerable to respiratory distress syndrome due to lack of lung surfactant Preterm infants may be: - AGA, SGA, LGA, low birth weight, VLB, or EVLB - <2500g are low-birth-weight infants. - 1000 to 1500 g are very-low-birth-weight infants (VLB). - 500 to 1000 g are considered extremely very-low-birth-weight infants (EVLB) Ballard’s scoring ETIOLOGY - Preterm infant deaths account for 80% to 90% of infant mortality in the first year of life it can be reduced with early discoveries of the cause However, the exact cause of premature labor/ early birth is rarely known There is high correlation between the level of socioeconomic status and early pregnancy termination It doubles the percentage of low economic status women the risk of having an early termination of pregnancy compare with the middle or upper groups Major influencing factor: inadequate nutrition ETIOLOGY: Common factors assoc. with preterm birth - Low socioeconomic level - Poor nutritional status - Lack of prenatal care - Multiple pregnancy - Previous early birth - Race (nonwhites have a higher incidence of prematurity than whites) - Cigarette smoking - Age of the mother (highest incidence is in mothers younger than age 20) 76 Assessment • When interviewing parents of a preterm infant, be careful not to convey disapproval of reported pregnancy behaviors such as cigarette smoking or working a 12-hour shift that may have contributed to preterm birth. • Once an infant is born, a new mother needs a high level of self-esteem and all of her inner resources to sustain her through the crisis • Sometimes it’s hard for the mother to determine that she is having a true labor. • Even multipara may miss the signs of early labor Physical characteristics - Preterm infant appears small and underdeveloped - The head is disproportionately large ≥ 3cm greater than chest size - Skin is transparent and loose - Skin is ruddy due to less subcutaneous fat, thus veins are easily noticeable ▪ Superficial veins may be seen beneath the abdomen and scalp. ▪ Lack of subcutaneous fat, and fine hair (lanugo) covers the forehead, shoulders, and arms ▪ Abundant vernix caseosa ▪ Short extremities ▪ Few sole creases and the abdomen protrudes ▪ Short nails, small genitalia (in girls, labia majora may be open) - The ears appear large in relation to the head - The cartilage of the ear is immature and allows the pinna to fall forward. - The level of the ears should be carefully inspected to rule out chromosomal abnormalities Potential Complications: Anemia of prematurity - Preterm develops normocytic anemia - • Normal cells, but few in numbers Low reticulyte count • Bone marrow does not increase its production until approx. 32 weeks infant will appear pale, lethargic, & anorectic Low levels of vit. E • Vit E protects RBC against oxidation • Keep a record of the amount of blood withdrawn for analysis • Excessive blood extraction can potentiate the problem • Administration of DNA recombinant erythropoiten • Stimulates RBC production • Blood transfusion • To supply needed RBC, Vit E, Fe Kernicterus - Preterm have less serum albumin 1. Serum albumin will bind to indirect bilirubin 2. Inactivate its effect 3. Kernecterus may occur - If jaundice occurs Phototherapy exchange transfusion Persistent Patent Ductus Arteriosus • Preterm infants – lack of surfactants - • Lungs are non-compliant • Difficult to move blood from the pulmonary artery into the lungs + Pulmunary HPN + Interfere closure of the ductus arteriosus Administer intravenous therapy with extra caution increase the blood pressure compounding the problem Administer indomethacin or ibuprofen Can close the patent ductus artersiosus Monitor urine output Indomethacin SE : oliguria 77 Periventricular/ Intraventricular Hemorrhage - Bleeding into the tissue surrounding ventricles - Bleeding into ventricles - Occurs in 50% of very low BW Preterm infants have both: • fragile capillaries • Immature cerebral vascular development - rapid change in cerebral blood pressure due to: • Hypoxia • Intravenous infusion • Ventilation or pneumothorax + • Capillaries will RUPTURE After the rupture: • Brain anoxia • hydrocephalus - Cranial UTZ will be performed • First few days of life to detect presence of hemorrhage • Strict monitoring Until prognosis is improving after intracranial bleed • Respiratory Distress Syndrome • Apnea • Retinopathy of prematurity • Necrotizing enterocolitis Respiratory Distress Syndrome - formerly termed hyaline membrane disease, - most often occurs in: - - • preterm infants • infants of diabetic mothers • infants born by cesarean birth • With decreased blood perfusion of the lung Pathologic feature: • Hyaline-like membrane formation - from an exudate of an infant’s blood that begin to line the terminal bronchioles, alveolar ducts and alveoli - This membrane prevents exchange of )2 and CO2 at the alveolar-capillary membrane Low level or absence of surfactant + Phospholipid that normally lines the alveoli Reduces surface tension to keep the alveoli from collapsing on expiration + Atelectasis Why LBW and the VLBW are more susceptible with RDS? Answer: surfactant does not form until 34th week of gestation - Diagnostic Evaluation • A chest radiograph will reveal a diffuse pattern of radiopaque areas that look like ground glass (haziness). • Blood gas studies (taken from an umbilical vessel catheter) will reveal respiratory acidosis. Therapeutic management - Drugs to be given • antibiotic (penicillin or ampicillin) • aminoglycoside (gentamicin or kanamycin) - Administration of surfactant thru endotracheal tube - Oxygen administration: • Continuous positive airway pressure (CPAP) or • assisted ventilation with positive end-expiratory pressure (PEEP) • This will exert pressure on the alveoli at the end of expiration and keep the alveoli from collapsing • A possible complication of oxygen therapy in the very immature or very ill infant is retinopathy of prematurity 78 Related Problems: Inadequate Respiratory Function - Occurs before the previability period, which leads to many neonatal deaths o Muscles that move the chest are not fully developed. o Abdomen is distended causing pressure on the diaphragm. o Respiratory stimulation in the brain is immature. o Respiratory stimulation in the brain is immature. RESPIRATORY DISTRESS SYNDROME – most common problems of newborns with inadequate respiratory function - All preterm infants need intensive care from the moment of birth to give them their best chance of survival without neurologic after-effects. - A lack of lung surfactant makes them extremely vulnerable to respiratory distress syndrome - Preterm infant deaths account for 80% to 90% of infant mortality in the first year of life - Infant mortality could be reduced dramatically if the causes of preterm birth could be discovered and corrected and all pregnancies brought to term. - However, the exact cause of premature labor and early birth is rarely known APNEA - is a pause in respirations longer than 20 seconds with accompanying bradycardia Beginning cyanosis also may be presen Many preterm infants have periods of apnea as a result of fatigue or the immaturity of their respiratory mechanisms High incidence of apnea seen in: Hypoglycemia Hypothermia Hyperbilirubinemia Simple measures - Gentle shaking - Flicking the sole of the infant’s foot - RESUSCITATION will be made if the infant does not respond to these simple measures - Maintain a neutral environment - Gentle handing of the baby to avoid excessive fatigue - Gentle suction to minimize nasopharyngeal irritation Can cause bradycardia due to vagal stimulation - No rectal temp taking (infants prone to Apnea) Stimulate vagus nerve---lead to reduce HR----APNEA Sepsis - Is a generalized infection of the bloodstream. Common among premature infants due to immaturity of body systems Liver of the infant is immature and forms antibodies poorly. body enzymes are inefficient There is no or little immunity received from the mother Stores of nutrients, vitamins, and iron is insufficient. Signs and symptoms: - Low temperature - Lethargy or irritability - Poor feeding - Respiratory distress Increased Tendency to Bleed - Premature infants blood has deficient PROTHROMBIN, a factor of the clotting mechanism. Due to lack of vit k 79 Poor control of body temperature Hypoglycemia - The fetus has not remained in the uterus long enough to acquire sufficient stores of glycogen and fat. Hypocalcemia - Calcium is transported across the placenta throughout the pregnancy, but greater amounts during 3rd trimester Early Hypocalcemia – parathyroid fails to respond to preterm infant’s low calcium levels. Late Hypocalcemia – occurs about age 1 week in newborn or preterm infants who are fed cow’s milk. Cow’s milk increases serum phosphate levels, which cause calcium levels to fall. Signs and symptoms: Tremors Weak cry Lethargy Convulsions Plasma glucose lower than 40 mg/dl. Treatment: - Intravenous calcium gluconate – monitor newborn for bradycardia. - Calcium Lactate Powder added to formula milk – monitor newborn for neonatal tetany Retinopathy of Prematurity (Retrolental Fibroplasia) - A condition in which there is separation and fibrosis of the retina, which can lead to blindness. this problem may develop in a premature newborn especially if O2 is given at high concentration Poor Nutrition 1 reason why preterm newborn has poor nutrition - The stomach capacity of the preterm is small. - The sphincter muscles at both ends of the stomach are immature, which contributes to regurgitation and vomiting. - Sucking and swallowing reflexes are immature Necrotizing Enterocolitis - The bowel develops necrotic paches, interfering with digestion and possibly leading to a paralytic ileus Perforation and peritonitis will follow Necorosis occurs as a result of ischemia or poor perfusion of blood vessels in sections of the bowel The incidence of NEC is high in: - immature infants - Suffered anoxia - Shock - Fed by enteral feedings - Breastfed infants have lower incidence of acquiring NEC compared with formula milk Intestinal organisms grows rapidly with cow’s milk Cow’s milk has no antibodies Response to protein from cow’s milk will starts the necrotic process Manifestations: Appear in the first week of life - Distended abdomen - Stomach not fully empty by next feeding time Due to poor intestinal action - Stool ; + occult blood - Signs of blood loss 9intestinal bleeding) - Lower blood pressure - Inability to stabilized temp - Abdominal x-ray films show a characteristic picture of air invading the intestinal wall; if perforation has occurred, there will be air in the abdominal cavity. - Abdominal girth measurements made just above the umbilicus every 4 to 8 hours increase 80 Therapeutic management: - If NEC recognized, BF and formula feeding will be discontinued - Infant will shift to IV or TPN To rest the GI tract w/ addt’l supplement of enteral probiotics - Antibitioc will be given; limit the secondary infection - Handle the abdomen gently; lessen the possibility of bowel perforation - Surgery to remove the bowel that affected - If large portion of bowel is removed; infant may be prone to “SHORT BOWEL” syndrome Problem with digestion in the future - If bowel where perforates, peritoneal drainage or laparotomy is necessary Remove fecal secretions from abdomen - Temporary colostomy will be performed to allow bowel function - The prognosis is guarded until the infant can again take oral feedings without bowel complications. Immature Kidneys Effects - Improper elimination of the body wastes contributes to electrolyte imbalance and disturbed acidbase relationships - Dehydration can occur easily. - Limited tolerance to salt. - Susceptibility to edema Jaundice - The liver is unable to clear blood of bile pigments that result from normal postnatal destruction of the blood cells RESTING POSTURE The premature infant is characterized by very little, if any, flexion in the upper extremities and only partial flexion of the lower extremities. • The full-term infant exhibits flexion in all four extremities. WRIST FLEXION. The wrist is flexed, applying enough pressure to get the hand as close to the forearm as possible. A. Exhibit a 9O degree angle B. Possible flexion of hand onto the arm SCARF SIGN. Hold the baby supine, take the hand, and try to place it around the neck and above the opposite shoulder as far posteriorly as possible. A. Assist this maneuver by lifting the elbow across the body. B. See how far across the chest the elbow will go Score according to location of the elbow: • elbow reaches opposite anterior axillary line 0; • elbow between opposite anterior axillary line and midline of the thorax 1; • elbow at midline of thorax 2; • elbow does not reach midline of thorax 3; • elbow at proximal axillary line 4. HEEL TO EAR. With the baby supine, draw the baby’s foot as near to the ear (no forcing). In the premature infant very little resistance will be met. In the full-term infant there will be marked resistance; it will be impossible to draw the baby’s foot to the ear SOLE (PLANTAR) CREASES. The sole of the premature infant has very few or no creases. With the increasing gestation age, the number and depth of sole creases multiply, so that the full-term baby has creases involving the heel BREAST TISSUE. In infants < 34 weeks’ gestation the areola and nipple are barely visible. Also, an infant < 36 weeks’ gestation has no breast tissue. An infant of 39–40 weeks will have 5–6 mm of breast tissue, and this amount will increase with age MALE GENITALIA. In the premature male the testes are very high in the inguinal canal and there are very few rugae on the scrotum. The full-term infant’s testes are lower in the scrotum and many rugae have developed FEMALE GENITALIA. A premature female has very prominent clitoris and the labia majora are very small and widely separated. The full-term infant, the labia minora and the clitoris are covered by the labia majora 81 Post term - Post term infants are those who are born after the 42nd week of gestation. Some post term fetuses grow to more than 4000g (8 lb, 13 oz), placing them at risk for birth injuries or CS. Placental functioning decreases when pregnancy is prolonged. Postmaturity syndrome – results from hypoxia and malnourishment of the fetus • Fetus may pass meconium as a result of hypoxia before or during labor, ↑ the risk of meconium passage and possible aspiration at delivery. The following problems associated with postmaturity: • Asphyxia – caused by chronic hypoxia because of deteriorated placenta. • Meconium aspiration – hypoxia and distress causes relaxation of the anal sphincter • Poor nutritional status - depleted glycogen reserves cause hypoglycemia. •Difficult delivery, birth defects, seizure Characteristics: • Long and thin and looks as though weight has been lost. • Skin is loose (thighs and buttocks) • Skin is dry, cracked, almost leather-like skin (lack of fluid) • Little lanugo or vernix caseosa • Nails are long stained with meconium. • Infant has thick head of hair and looks alert • Elevated Hct; lowered polycythemia and DHN lowered the circulating volume 82 Congenital Heart Disease (CHD) - occurs in 1/125 live births Most common birth defects Occur during the 1st 8 wks. of fetal development. Majority have no known cause CONTRIBUTING FACTOR: - 85 to 90 % of cases, there is no identifiable cause for the heart defect + generally considered to be caused by - multifactorial inheritance - The usual cause of congenital heart disorders is failure of a heart structure to progress beyond an early stage of embryonic development - Usually both genetic and environmental MATERNAL FACTORS: - seizure disorders w/ intake of anti-seizure medications - intake of lithium for depression - uncontrolled IDDM - lupus - German measles (rubella) – 1st trimester of pregnancy Chromosome abnormalities: - 5 to 8 % of all babies with CHD have a chromosome abnormality - Includes Down syndrome, trisomy 18 and trisomy 13, Turner’s syndrome. - CHROMOSOME is an organized structure of DNA and protein that is found in cells CLASSIFICATION: - Acyanotic heart disease Cyanotic heart disease HUMAN HEART CIRCULATION 83 84 FETAL CIRCULATION: •Umbilical vein – carries oxygenated blood from the placenta to the fetus •Umbilical arteries – carry deoxygenated blood from the fetus to the placenta. •Foramen ovale - serves as an opening in the septum between the two atria of the heart. •Ductus arteriosus – connects the pulmonary artery to the aorta, allowing the blood to bypass the lungs •Ductus venosus – carries oxygenated blood from the umbilical vein to the inferior vena cava, bypassing the liver - Only a very small amount of blood is directed through the right and left pulmonary arteries to the lungs The transformation from fetal to neonatal circulation involves two major changes: 1.A marked increase in systemic resistance caused by loss of the low-resistance placenta. 2. A marked decrease in pulmonary resistance caused by pulmonary artery dilation with the neonate’s first breaths - With the first breaths of air the baby takes at birth, the fetal circulation changes. A larger amount of blood is sent to the lungs to pick up oxygen. Because the ductus arteriosus(the normal connection between the aorta and the pulmonary valve) is no longer needed, it begins to wither and close off The circulation in the lungs increases and more blood flows into the left atrium of the heart + increase pressure causes the foramen ovale to close and blood circulates normal 85 ACYANOTIC CONGENITAL HEART DEFECTS This involves heart or circulatory anomalies that involve either: - a stricture to the flow of blood or - a shunt that moves blood from the arterial to the venous system (oxygenated to unoxygenated blood, or left-to-right shunts) - These disorders cause the heart to function as an ineffective pump and make the child prone to heart failure - Occurs when blood is shunted from the venous to the arterial system as a result of abnormal communication between the two systems (deoxygenated blood to oxygenated blood, or right-to-left shunts CLASSIFICATION - This classification led to difficulties in identifying the cyanotic and acyanotic - Children with acyanotic heart disease can develop cyanosis - Children with cyanotic disease may not exhibit cyanosis until they are seriously ill - Increased pulmonary blood flow - Obstruction to blood flow leaving the heart - Mixed blood flow (oxygenated and deoxygenated blood mixing in the heart or great vessels) - Decreased pulmonary blood flow • • • • L - R shunts cause CHF and pulmonary hypertension. This leads to RV enlargement, RV failure These babies present with CHF and respiratory distress They are not typically cyanotic Patent Ductus Arteriosus (PDA) Ventricular Septal Defect (VSD) Atrial Septal Defect (ASD) Coarctation of the Aorta 86 ATRIAL SEPTAL DEFECT (ASD) - an abnormal communication between the two atria, allowing blood to shift from the left to the right atrium - allows oxygenated (red) blood to pass from the left atrium, through the opening in the septum, and then mix with unoxygenated (blue) blood in the right atrium - Blood flow is from left to right (oxygenated to deoxygenated) because of the stronger contraction of the left side of the heart - causes an increase in the volume in the right side of the heart and generally results in ventricular hypertrophy and increased pulmonary artery blood flow, the same as with a VSD - EFFECTS: When blood passes through the ASD from the left atrium to the right atrium + a larger volume of blood than normal must be handled by the right side of the heart + extra blood then passes through the pulmonary artery into the lungs + pulmonary hypertension and pulmonary congestion - During fetal heart development + the partitioning process does not occur completely, leaving an opening in the atrial septum Occur in 4-10% of all infants w/ CHD It is more common in girls than boys TYPES OF ASD - Ostium primum (ASD1) Opening is in the lower end of the septum - Ostium secundum (ASD2) Opening is in the center of the septum 87 MANIFESTATION: - child tires easily when playing - infant tires easily when feeding - fatigue - sweating - tachypnea, tachycardia - shortness of breath, crackles - poor growth - murmur DIAGNOSTIC TEST - CXR – enlarged heart - ECG - 2D echo – show pattern of blood flow through the septal opening, determine how large the opening - Cardiac catheterization - 20% of atrial septal defects will close spontaneously in the first year of life - Usually, an ASD will be repaired if it has not closed on its own by the time the child starts school - pulmonary arteries become thickened and obstructed due to increased flow, from left to right for many years (pulmonary vascular obstructive disease) TREATMENT: - Medical management DIGOXIN - helps strengthen the heart muscle, enabling it to pump more efficiently DIURETICS – relieve pulmonary congestion - Infection Control - prophylactic antibiotics to prevent bacterial endocarditis before dental procedures and other invasive procedures - Surgical repair -Closure is important because without it, a child is at risk for infectious endocarditis and eventual heart failure - Surgery in which the edges of the opening in the septum are approximated and sutured may be completed with cardiac catheterization technique if the defect is small - the patient is placed on cardiopulmonary bypass (the heart-lung machine), the right atrium is then opened to allow access to the atrial septum below. - defect may be closed with stitches or a special patch - the material utilized for patch closure of ASDs may be the patient’s own pericardium, commercially available bovine pericardium, or synthetic material (Gore-Tex, Dacron) - Transcatheter management - This technique involves implantation of one of several devices (basically single or double wire frames covered by fabric) using cardiac catheterization - Cardiac catheterization - involves slowly moving a catheter (a long, thin, flexible, hollow tube) into the heart. The catheter is initially inserted into a large vein through a small incision made usually in the inner thigh (groin area) and then is advanced into the heart - An ASD closure device is moved through the catheter to the heart and specifically to the location of the heart wall defect - Within a few days, the body’s own tissue will begin to grow over the device. By 3 to 6 months, the device is completely covered by heart tissue and at that point becomes a part of the wall of the patient’s heart 88
