Flashcards: maternity final exam

•Amenorrhea

•Nausea and vomiting

•Fatigue

•Urinary frequency

•Breast changes

•Quickening- “first fetal movement”(could be imaginative or gastric)

first fetal movement- noticed 16-20 weeks

•Goodell’s and Chadwick’s(blueish color of cervix)and Hegar sign

•Enlargement of the abdomen

•Braxton Hicks contractions- practice contractions(16 weeks)

•Uterine soufflé- swish sound during ultrasound- blooding pumping

•Skin pigmentation changes

•Pregnancy tests

Begin with the first day of last missed period, subtract 3 months and add 7 days and add 1 year

•Fetal heartbeat

•Fetal movement

•Visualization of the fetus

dietary folic acid

◦Underweight: 28 to 40 lb

◦Normal weight: 25 to 35 lb

◦Overweight: 15 to 25 lb

◦Obese: Approximately 11 to 20 lb

◦Twins – 46-62 lb for normal pre-pregnancy weight – adjusted according to BMI

◦First trimester: 2.2 – 4.4 lbs.

◦Second and third trimester: About 1 lb. weekly

◦Twins: Second and third trimesters: 1.5 lbs per week

◦Dieting during pregnancy can result in maternal ketosis

Increased risk of:

◦Gestational diabetes

◦Preeclampsia

◦Induction of labor

◦Cesarean birth

◦Anesthesia complications

◦Venous thrombosis

◦Postpartum hemorrhage

◦Endometritis

◦Fetal anomalies

◦Macrosomia

◦Birth injury

◦Stillbirth

◦Calories in second and third trimester

◦Protein increases  25 g daily ( 46 non pregnant + 25 )

◦Water – 3 L daily

◦Caffeine concerns

◦Mercury in fish

◦Artificial Sweeteners

◦Listeria

◦There are different types of vegetarian diets

◦Lacto-ovo vegetarians: Dairy and egg products

◦Lacto-vegetarians: Dairy products but no eggs

◦Vegans: No foods from animal sources

◦Most vegans need additional supplementation – vitamins B12, D, and calcium

placenta previa

-Hemorrhage -C- Section/ baby will not be able to pass through the cervix

dropping of baby

Complete blood count (CBC)

Blood typing

rubella titer

hepatitis B

HIV testing

STI screening

cervical smears

1-13 weeks

12-27/28 weeks

28 weeks 38-42

diabetes

folic acid deficiency

hepatitis B

HIV/AIDS

Obesity

STIs

smoking

alcohol

Fetal movement counts (kick counts)

from week 28-38

encourage mom to lay on side

encourage mom to eat

images produced by sound waves to check for possible birth defects

-to estimate gestational age, fetal weight, and growth

-location of placenta and amniotic fluid volume

-accompanying invasive procedures

-Intiated at 15 weeks

-measures blood flow changes in maternal and fetal circulation

-assessment of placental function

-if ratio is elevated may indicate baby not growing well

-looks at sys/dias of heart

If mother has diabetes or baby is not growing well

A procedure to obtain amniotic fluid

Allows testing of amniotic fluid

This test can provide information about genetic disorders and fetal maturity

Hemorrhage

Amniotic fluid embolism

Loss of pregnancy

Rh isoimmunization

Can hurt the fetus

Infection

Cause bleeding

Rupture placenta

Cramping

Large needled going into amniotic cavity

Catheter is used to withdraw a sample of placental tissue to test for chromosomal abnormalities. Test done after 10-13 weeks.

Increased risk of injury to fetus

Inability to detect neural tube defects

Risk of failure to obtain placental tissue

risk of contamination of specimen

risk of leakage of amniotic fluid

risk of intrauterine infection

risk of Rh isoimmunization

Checks the baby's risk of birth defects and genetic disorders, such as high levels for neural tube defects or low levels for Down syndrome. It is done at 15 to 22 weeks gestation.

used to assess fetal status using an electronic fetal monitor

If baby moves and heart rate increases-healthy baby

If baby heart rate goes down- unhealthy

Provides reassurance of fetal well being(movement 10 x an hour)

FHR acceleration of 15 bpm for 15 seconds in response to fetal movement after 32 weeks

for less than 32 weeks 10 bpm for 10 seconds is acceptable

Measurement of baby form crown of the head to the buttock shows if the pregnancy is dated correctly

An intravaginal ultrasound that measures fluid collection in the subcutaneous space between the skin and the cervical spine of the fetus

-Trisomy 21 -looks to see if there is to much fluid -if there is to much fluid further genetic testing is needed

BHCGPAPP-A this is complete the screening for chromosomal abnormalties

Age 35 and older family history of genetic defects blood test or ultra sound hinting at defects

can be done out patient can be done if the mother is past her due date can be done if there is a medical problem

reactive/nonreactive

lay on left side give sweets wait 30 min give the baby time baby may be sleep they are tiny humans

Given contraction to see how the baby would tolerate labor- would not be done during preterm stage or mother getting a C-section

Enables identification of fetal risk for asphyxia

Fetal monitor is used

Fetal heart rate response to contractions is noted

Healthy fetus usually tolerates contractions

Placenta is not working well because baby is not reacting well to contractions(heart rate decelerates)

- Fetal breathing - Fetal movements body and limbs -Fetal Tone( extension, flextion) - amniotic fluid volume - reactive fetal HR with Reactive NST

MOM NEEDS ROHGAM

28 weeks pregnant

RH Negative mother after amniocentesis

MUST GET RHOGAM WITHIN 72 HOURS

Can cause fetal Heart deceleration

Usually for specific circumstances

-to do a blood transfusion

-take blood out

It goes through umbilical cord

weight and blood pressure (vital signs)

urine testing for protein, glucose, ketones and nitrites

Fundal height measurement to asses fetal growth

Edema

Blood tests

assessment for quickening (fetal movement)

assessment of fetal heart rate- 110-160

spotting/ bleeding (miscarriage)

painful urination (infection)

severe vomiting (hyperemesis gravidarum)

fever higher than 100 (infection)

lower abdominal pain with dizziness and shoulder pain (indicative of ruptured or ectopic pregnancy)

regular uterine contractions (preterm labor)

pain in calf, increased foot flexion (DVT)

sudden gush or leakage of fluid from vagina(pre labor rupture of membranes)

absence of fetal movement for more than 12 hours (possible fetal distress or demise)

-sudden weight gain; periorbital or facial edema, severe upper abdominal pain; headache with visual changes (indicative of gestational hypertension and/or preeclampsia

-decrease in fetal daily movement for more than 24 hours (possible demise)

-Uterine stretch -Oxytocin increases -Increased prostaglandins -Progesterone withdrawal

Passage way ( birth canal ) Passenger ( Fetus ) , powers (contractions) , position( maternal ) , and psychological response

Stage 1 is considered true labor and consists of 3 phases Latnet 0-6cmactive 6-8cmTransition phase 8-10cm SHORTEST STAGE MONITOR FETAL HR

0-6 cm moms relaxed contractions every 5-10 min Lonest stage of labor

6-8 cm dilated contractions every 2-5 min

8-10 cm mom is ready to push

10 cm moms fully effaced Birth of the baby encourage mom to bear down when pushing

birth of placenta within 30 min Never pull umblicusduring this phase there is an increased risk of infection if placenta isn't fully removed PITOCIN

( Prevents hemmorage )

Decreased blood pressure Increased Heart Rate

1-4 hours after delivery assess : mom assess : Temerature not over 100.4 assess Hemmorage

uterus rises upward umblicus lenghtens sudden trickle of blood uterus changes to globular PLACENTA SEPERATION HAPPENS IN THE 3rd stage

Should be firm midlineleveled with umblicus check the fundus and massage it until it is firm if it is soft ( boggy )

assessment

3 x eveyr 5 min

displaced above umblicus one sided = bladder distention

medication that treats excessive bleeding after childbirth cannot be given if mom has preeclamisia or HTN

High estrogens in amniotic fluid cause crystallization of the salts ; crystals appear as a blade of fern

external fetal monitoring records the frequency and duration of the contractions placed on fundus

Fetal Heart tones bottom

cant pick up mothers contractions * obese patients * Oliohydramus * baby Heart rate decreases CERVIX MUST BE OPEN 2 CM water needs to be broken

Engage fetus in uteri position of baby presentation lie

cytotec amisaprostale cervidil - thins cervix pitocin oxytocin

Placenta separates off wall before the baby is born if this happens baby will not receive oxygen or nutrients emergency c section Cause : HTN TRAUMA

Pre labor scoring that helps predict success of induction

High bishop score

Favorable for induction 8-9

High risk for c- section cervadil medication cytotec

Gush of fluid trickle Pooling in vagina ( SROM) PH greater than 5 ( ninrazine paper) turns blue or green alkaline ph greater than 6.5

Palpation External fetal monitoring (tocotransducer)Internal Fetal Monitoring ( IUPC )

Morphine

Meperidine

Butorphanol

Nalbuphine (decreases nausea and vomiting)

Fentanyl (hypotension/ respiratory depression)

Hydroxyzine (reduces anxiety)

regional block

used for labor and cesarean births

patient receive 500 to 1000 ml of normal saline

Oxygen

left lateral position

T8 to T10 of spinal cord

Fentanyl

Sudentanil

Ropivacaine

Morphine

Variable deceleration- Cord compression

Early decelaration- Head compression

Acceleration- OKAY!

Late deceleration- Placental insufficiency

prevents additional cord compression

room temperature saline into uterus with catheter

Medication to relax uterus

Improves blood flow to uterus decreasing/stopping contractions

ex Terbutaline

used for preterm to stop labor

Left lateral side (turn)

Iv fluids

Oxygen

Notify provider

Maternal positioning

Identify labor progress

No intervention

Execute intervention

1. Change maternal position ex: if on her back turn to left side

2. Provide supplemental oxygen if indicated

3. Give IV bolus for late decelerations or Amnioinfusion for variable decelerations

4. Correct maternal blood pressure: did she just get an epidural?

5. Reduce uterine activity

Alter second stage pushing efforts 

•Maternal Hypotension

•Bladder Distention

•Prolonged Second Stage

•Catheter Migration

•Cesarean Birth

•Maternal Fever

•Nausea/Vomiting and Pruritus from Epidural Opioids

•Respiratory Depression up to 24 hours

Spotting, cramping, closed cervix, bleeding unto 24-48hrs, may resolve or pregnancy loss

Treatment: Conservative supportive treatment

Possible reduction in activity in conjunction with nutritious diet and adequate hydration

Moderate to severe bleeding cramping, abdominal pain(contractions), cervical dilatation, if rupture of membranes may need DC or DE

Treatment: Vacuum curettage if products of conception are not passed to reduce risk of excessive bleeding and infection

Prostaglandin analogs such as misoprostol to empty uterus of retained tissue (only used if fragments are not completely passed)

Intense abdominal cramping

Heavy vaginal bleeding

Cervical dilation

Treatment: Client stabilization

Evacuation of uterus via D&C or prostaglandin analog

History of vaginal bleeding and abdominal pain

Passage of tissue with subsequent decrease in pain and significant decrease in vaginal bleeding

Treatment: No medical or surgical intervention necessary

Follow-up appointment to discuss family planning

Absent uterine contractions

Irregular spotting

Possible progression to inevitable abortion

Treatment: Evacuation of uterus (if inevitable abortion does not occur): suction curettage during first trimester, dilation and evacuation during second trimester

Induction of labor with intravaginal PGE2 suppository to empty uterus without surgical intervention

History of three or more consecutive spontaneous abortions

Not carrying the pregnancy to viability or term

Treatment:Evacuation of uterus (if inevitable abortion does not occur): suction curettage during first trimester, dilation and evacuation during second trimester

Induction of labor with intravaginal PGE2 suppository to empty uterus without surgical intervention

Identification and treatment of underlying cause (possible causes such as genetic or chromosomal abnormalities, reproductive tract abnormalities, chronic diseases or immunologic problems)

Cervical cerclage in second trimester if incom

Ultrasound 

•Lab work: pregnancy test, H&H, CBC, T/X 

•Bed rest

•Abstinence from sex

•IV / Transfusion

•D & C -  Dilation and curettage  

•If beyond 12 weeks: induction of labor by oxytocin and Prostaglandins may be used. 

•Emotional support and bereavement care

•RhoGAM if Rh negative

•Progressive Abdominal pain

•Delayed menses

•Abnormal vaginal bleeding

•If rupture has occurred may experience referred shoulder pain

diagnose: ultrasound, low hcg, progesterone

Tubal surgery

•Sexually transmitted infections

PID

•Previous ectopic pregnancy

•IUD use

•Progestin-only contraceptive

•Pharmacologic treatment of infertility

•Endometriosis

•Assisted reproductive technologies

Methotrexate ( folic acid antagonist) Dissolves Pregnancy Given IM

•Must be unruptured, less than 3.5-4cm size or less

•Woman must be in stable condition, no blood , kidney or liver disease

•Surgery-salpingostomy to preserve tube or removal of tube salpingotomy

-Premature dilatation of the cervix which leads to 2^nd trimester loss around 20 weeks

-Painless dilatation

-Can be diagnosed with transvaginal ultrasounds and speculum examinations

•Premature dilatation of the cervix

•Associated with repeated second trimester spontaneous abortions

•Painless, bloodless 2^nd trimester abortion

•Minimal uterine contractions until late

•Considered an anomaly (uterine/cervical)

•Intrauterine pressure increases

•Internal cervical os dilates and membranes may protrude and rupture

•Spontaneous effacement and dilatation may occur

Symptoms

•Painless, quiet onset bright red bleeding

•Bleeding may be intermittent or continuous

•Uterus soft, palpable

•Presenting part is high and deviated to one side

•Associated with preeclampsia 

Expectant Management

-Observation and bed rest/pelvic rest if less than 36 week gestation, normal FHR and mild bleeding that resolves

-No vaginal or rectal exam

-NST/BP once or twice weekly

-Assess bleeding

-Potential emergency

Active Management

-If past 36 weeks gestation – can deliver

-If excessive or continued bleeding can deliver at any gestational age

Premature separation of normally implanted placenta from uterine wall

•Drug use; Cocaine

Symptoms

•Dark venous blood

•Abdomen rigid, hard

•Severe pain

•Sudden onset

No Vaginal Exams!! 

•Daily CBC

•Fetal well-being tests – NST

•Monitor for Contractions

•Monitor Bleeding amount

•Monitor for PROM

•Medication - Celestone

intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia.

-Conservative management in the home is the first line of treatment

-Hospitalization may be necessary to reverse the effects of severe nausea and vomiting

-fluid replacement with normal saline

-NPO for 24 – 36 hours

-Antiemetics may be administered rectally or intravenously

It is defined as an increase in blood pressure after 20 weeks gestation accompanied by proteinuria.

(edema, headache, blurry vision, dizziness muscle twitching, swollen face/hands/feet,high BP, abdominal pain, )

Fetal movement record

Nonstress test (NST)

Ultrasonography every 3 to 4 weeks for serial determination of growth.

Biophysical profile

Amniocentesis to determine fetal lung maturity.

Doppler Velocimetry beginning at 30 to 32 weeks to screen for fetal compromise

-Maintain patent airway and safety during convulsion

-Magnesium sulfate (To control seizures and will continue postpartum)

(headache, seizure, visual disturbances, generalized edema)

-Auscultate lungs to r/o pulmonary edema

-Strict Input and Output (Place foley with urimeter)

-Monitor for placental abruption/ bleeding/rigid abdomen

-Left lateral (To prevent aspiration of vomitus)

-Side rails elevated (To prevent falls)

-Plan for Delivery (IOL vs Cesarean section)

-Seizures can still occur first 48 hours postpartum

2+ (normal)

Administer calcium gluconate IV if toxicity occurs

-respiratory depression (10 breaths)

-0 deep tendon reflex

•Category of gestational hypertension that involves changes in blood components and liver function, as well as, a complication of severe preeclampsia

•H: hemolysis

•EL: elevated liver enzymes

•LP: low platelets

•Patient complains of pain, most commonly in the right upper quadrant, epigastric area, or lower chest.

•DIC

•Abruptio placentae

•Acute renal failure

•BABY:

•Insufficient blood flow

•Intrauterine growth restriction

•Death

•Increased risk of fetal hypoxia during labor

•Thrombocytopenia

•Leukopenia

Bethametasone

DEHYDRATION * everything Hypo

~pale ~Anemic ~bleeding around Iv~black and blue bruises RT UPPER QUADRANT PAIN

Causes heart to beat really fats if her hr is high hold the medication if someone has cardiac problems precaution.Helps slow labor down always monitor blood pressure if heart rate is 120 over hold the medicine.decreases potassium

~Repeated pregnancy loss ~Abortions ~Trauma to cervix

Tone

-Overdistention of uterus

-uterine infection

Tissue

-products of conception (incomplete placenta at birth)

-retained blood clots

Trauma

-lacerations

uterine inversion

Thrombom

-preexisting conditions

-traction on umbilical cord

Pitocin

Carboprost

methergine

misoprostol

oxytocin

Fundal massage

evaluate bladder

bimanual compression

low level suction

the time from the delivery of the placenta through approximately the first 6 weeks after the delivery

contraction of muscle fibers; catabolism; regeneration of uterine epithelium.

Vaginal discharge after childbirth

Occurs right after child birth lasting 3-4 days bright red dark red with small clots similar to a period flow

Lasts 3-10 days after child birth pinkish brown consistency with a lighter flow

Lasts 10-14 days after child birth Whitish yellow consistency little to no blood

1.Perennial laceration

2. Hematomas

3. decreased bladder Tone

4. Generalized swelling and bruising of perineum and tissues surrounding the meatus

1. Large amount of Iv fluid given during labor

2. decreased Antidiuretic effect of oxytocin

3. Build up and retention of extra fluids during pregnancy

4. Decreased production of Aldosterone

Excessive production of urine after child birth .

progesterone, estrogen , prolactin

prolactin / oxytocin

frequent emptying warm showers cold compress between feedings

Painful swelling of breast tissue as a result of rapid increase in milk production and venous congestion causing interstitial tissue edema; impaired milk flow results in accumulation of milk in breasts; most often occurs between the third and fifth postpartum days

7-9 weeks after birth

2-18 months

-baby blues

-post-partum depression

-post-partum psychosis

-Operative procedure (forceps, cesarean birth, vacuum extraction)

-History of diabetes, including gestational-onset diabetes

-Prolonged labor (more than 24 hours)

-Use of indwelling urinary catheter

-Anemia (hemoglobin <10.5 mg/dL)

-Multiple vaginal examinations during labor

-Prolonged rupture of membranes (>24 hours)

-Manual extraction of placenta

-Compromised immune system (HIV-positive)

• Precipitous labor (less than 3 hours)

• Uterine atony

• Placenta previa or abruptio placenta

• Labor induction or augmentation

• Operative procedures (vacuum extraction, forceps, cesarean birth)

• Retained placental fragments

• Prolonged third stage of labor (more than 30 minutes)

• Multiparity, more than three births closely spaced

• Uterine overdistention (large infant, twins, hydramnios)

• Fever >100.4°F (38°C)

• Foul-smelling lochia or an unexpected change in color or amount

• Large blood clots or bleeding that saturates a peripad in an hour

• Severe headaches

• Visual changes, such as blurred vision or spots

• Calf pain with dorsiflexion of the foot

• Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites

• Dysuria, burning, or incomplete emptying of the bladder

• Shortness of breath or difficulty breathing without exertion

• Depression or extreme mood swings

a mild postpartum mood disorder that goes away on its own lasts 4-5 days resolve 10 days

a mood disorder characterized by feelings of sadness and the loss of pleasure in normal activities that can occur shortly after giving birth Lasting longer

poor bonding alienation from loved ones violent thoughts and actions

treats postpartum uterine Hemorrhage works by contracting the uterus

-Time immediately after birth when the client needs others to meet her needs and relives the birth process first 24 hrs (range 1-2 days)

-Woman is passive – prefers nurse doing care and making decisions

-Second phase characterized by dependent and independent maternal behavior (lasts 10 days to several weeks)

-strong interest in caring for baby

-insecurity if ability to care for baby

-reestablishes relationships with other people

-accepts role of motherhood not fantasy

Breast

Uterus

Bladder

Bowel

Lochia

Episiotomy/Perineum/

    Epidural

Extremities

Emotional Status

Uterus should be midline and firm

If boggy or off to side –

  1)massage till firm,

  2)express any clots

  3)empty bladder

       Encourage breastfeeding

Labor and Pregnancy History

Bladder status

Anesthesia

Involution is enhanced by:

Uncomplicated labor and birth

Complete expulsion of placenta or membranes,

Breastfeeding

Early ambulation

¡Have a foul odor

¡Have large clots

¡Saturate a pad in less than ½ hour

-Contractions that occur after birth

-May be increased in pregnancies where uterus was -overdistended

-More increased in multiparas

-Afterpains are usually stronger during breastfeeding

-Pain should be assessed with other vital signs

-Provide comfort measures

-Consider premedicating

-Check for other reasons for pain

Pregnancy is a hypercoagulable state

-Increased risk of venous thromboembolism ( VTE)

-Pulmonary Embolism ( PE)

-Deep Vein Thrombosis ( DVT

  Factors that Increase Risk of Clot Formation

1.Stasis

2.Altered Coagulation

3.Localized Vascular damage

•Anemia

•Diabetes mellitus

•Cigarette smoking

•Obesity

•Preeclampsia

•Hypertension

•Severe varicose veins

•Pregnancy

•Multiple pregnancies

•Cardiovascular disease

•Sickle cell disease

•Postpartum hemorrhage

•Oral contraceptive use

•Cesarean birth

•Severe infection

•Previous thromboembolic disease

•Multiparity

•Bed rest or immobility for 4 days or more

•Maternal age older than 35

•Lactation is the secretion of milk by the breasts. It is thought to be brought about by the interaction of progesterone, estrogen, prolactin, and oxytocin.

•Breast milk typically appears within 4 to 5 days after childbirth.

•First 2 days postpartum breast soft non tender

•Cradle hold position: The mother’s arm cradles the baby close to the breast with their abdomens against each other and supports the baby’s head and neck with the mother’s other hand supporting the breast.

•Cross- cradle hold position: Similar to the cradle hold, but the baby is supported with the mother’s opposite arm

•Football/clutch hold position: (cesarean, large breast, small/premature, or mum with twins) Potion baby at your side in a semi sitting position facing mom with baby’s legs under mum’s arm. Use pillow to bring the baby up to the level of your nipple.

•Side lying position: (middle of night) Position baby on your side facing you, tummy to tummy. mouth in line with nipple.

1.Wash your hands before expressing milk or handling breast milk.

2.Find a quiet, clean place to express milk if returned to workplace. Use clean containers to store expressed milk. Use sealed and chilled milk within 24 hours.

3.Discard any milk that has been refrigerated for more than 24 hours.

4.Use any frozen expressed milk within 3 months.

5.Do not use microwave ovens to warm chilled milk.

6.Discard any used milk; never refreeze it.

•Cow milk protein based formulas: This formula contains cows milk that has been altered to resemble to breast milk. The formula has a lot of nutrients within it that is easier for babies to digest. The only downfall however is some babies are allergic to protein in now milk so that would require a different type of formula such as protein or soy milk etc.

•Soy Based Formulas: This formula contains protein found in soybeans. This is especially great for babies who wish to exclude animal proteins in his/her diet. It is a great option for babies who intolerant and/or allergic to cow milk formula and lactose which is a natural carbohydrate found in cow milk.

•Protein Hydrolysate Formulas: This formula contains protein that has been broken down (hydrolyzed) into tiny sizes than are those in cow milk and soybean formula. Protein hydrolysate formula are meant for babies who have a protein allergy.

•Heat or Cold

•Cabbage Leaf Compress

•Breast Massage

•Hand expression of milk

•Anti-inflammatory medication

•Wear a supportive snug bra 24 hours daily

•May take 5-7 for milk to be suppressed

•Take mild analgesics

•Don’t stimulate breasts

•Drink fluids

•Reduce salt intake

•Ice packs inside bra -  change q 30

•Infection or inflammation

•Lactating or engorged breasts

•Management

•     Heat

•     Rest

•     Empty Breast

    Antibiotics as needed

For prevention of Rh Isoimmunization

•If mother is Rh negative she receives an IM injection of Rhogam at 28 weeks gestation

•                                     and   

•If mother is Rh negative and has a  spontaneous birth, abortion ( Spontaneous or Operative, Bleeding in Preganancy, Ectopic, Trauma, External Version, Amniocentisis, Chorionic Villus Sampling , Placenta Previa or Abruption she receives an IM injection of Rhogam within 72 hours of event to prevent sensitization of the mother

•The standard dose of RhoGAM is 300 mcg given intramuscularly,

•If Rh sensitization occurs fetus can develop Hydrops

•    Fetalis

•  Fetal Edema

•  CHF

•  Jaundice ( icterus gravis)

•  Neurological Damage ( Kernicterus)

 Erthroblastosis Fetalsis ( severe hemolytic syndrome)

Respiration: 30-60 (avg 40)

Temp-Rectal: 90-99.5

Axillary: 97.6-98.6

HR: 110-160

BP-Systolic: 60-80

Diastolic: 40-50

◦Initiation of respirations: adjusting from a fluid filled intrauterine environment to gaseous extrauterine environment

◦Role of surfactant: surface tension redacting lipoprotein that prevents alveolar collapse

◦Respirations: 30-60 breaths per minute; irregular, shallow, unlabored; short periods of apnea (<15 secs); symmetrical chest movements

1.Increased aortic pressure and decreased venous pressure

2.Increased systemic pressure and decreased pulmonary artery pressure

3.Closure of foramen ovale

4.Closure of the ductus arteriousus

5.Closure of ductus venous

◦Blood Pressure:

◦varies with birth weight, gestational age, & changes in blood volume

◦average mean is 5 to 55 mm Hg, full term 3 kg newborn. (70/45 to 50/30 mm Hg)

◦Crying may elevate both systolic & diastolic blood pressure

◦Heart Murmurs: 90% of murmurs are transient, not abnormalities

◦Caused by turbulent blood flow through: narrow opening, across an abnormal valve, stenosed valve

◦Atrial or ventricle septal defect (ASD or VSD)

◦Some serious murmurs not recognized for a few weeks until patent ductus arteriosus closes

◦Limited ability to concentrate urine until about 3 months of age (urine has a low specific gravity)

◦6-8 voids a day is normal

◦Low glomerular filtration rate and limited excretion and conservation capability: affect newborn’s ability to excrete salt, water loads, and drugs

◦Intestines sterile at birth

◦Capacity of newborn stomach varies

◦Newborns prone to regurgitation, vomiting, reflux

◦Meconium formed during fetal life

◦Term newborns pass meconium first 24-48 hours after birth

◦Thick , tarry black or dark green

◦Activates after birth

◦Immature – so s/s of infection may be subtle

◦Fever is not reliable indication of infection

◦Hypothermia or irregular temperature status more reliable sign of infection!!!

◦Infants active passive acquired immunity in utero from mothers response to illness or immunization

◦At birth infant as iron stores for 4-6 months

◦At birth infants is cut off from maternal glucose

◦Meconium, then transitional stool, then milk stool

◦Breast-fed newborns: yellow-gold, loose, stringy to pasty, sour smelling

◦Formula-fed newborns: yellow, yellow-green, loose, pasty, or formed, unpleasant order

◦Infant stressed by change from warm, moist environment of uterus to dry, drafty environment of delivery room and nursery

◦Neutral thermal environment needed to prevent need for increased oxygen and calories

◦Thin skin; with the blood vessels close to the surface

◦Lack of shivering ability; limited reserve of metabolic substrates (glucose, glycogen, fat)

◦Limited use of voluntary muscle activity

◦Large body surface area relative to body weight

◦Lack of subcutaneous fat; little ability to conserve heat by changing position

◦Dry immediately with warmed blankets beginning with the head

◦ Skin to skin contact with mother or partner

◦Radiant warmer

◦Stocking cap

◦ Heat regulation is second most critical to the newborn’s survival

◦Hypothermia is a common and dangerous problem

◦Conduction: transfer of heat from object to object when the two objects are in direct contact with each other

◦Convection: flow of heat from body surface to cooler surrounding airor air circulating over a body surface/ also from drafts

◦Evaporation(most common): loss of heat when liquid is converted to a vapor

◦Radiation: loss of body heat to cooler solid surfaces in proximity but not in direct contact (cold weight)

◦Increased Metabolic Use of Calories

    • Failure to gain weight or weight loss

◦Increased Oxygen Consumption

     • May lead to hypoxia, acidosis and respiratory distress

◦Rapid Depletion of Glycogen

    • Resulting in hypoglycemia

If allowed to continue the baby may develop shock and disseminated intravascular coagulation (DIC) leading ultimately to death.

First period of reactivity

•Birth to 30 minutes to 2hours after birth

•Newborn is alert, moving, may appear hungry

Period of decreased responsiveness

•30-120mins old

•Period of sleep or decreased activity

Second period of reactivity

•2-8hrs old

•Newborn awakens and shows an interest in stimuli

•Establish and maintain an airway and respirations

•Provide warmth and prevent hypothermia

•Provide a safe environment and routine preventive measures

•Promote maternal-infant attachment

•Apgar scores

•Length/ Weight

•Vital signs

•Physical maturity

Neuromuscular maturity

•Signs indicating a problem

•Nasal flaring, chest retractions

•Grunting on exhalation, labored breathing

•Generalized cyanosis, flaccid body posture

•Abnormal breath sounds, abnormal respiratory rates

•Abnormal heart rates, abnormal newborn size

Activity

Pulse

Grimace

Appearance

Respiration

(do 1st and 5th minute of life)

8-10 = an uncompromised or distress free

4-7 = moderately compromised or asphyxiated

0-3 = severely compromised or asphyxiated

Less than 7- do it again in 10 minutes

•Initiate Neonatal Resuscitation if necessary

•Assign Apgar score ( if pediatrician not present)

•ID bracelets for baby & mother

•Footprints of baby & mother’s finger print

•Vital signs of baby (30 minutes X4)

•Assist with skin/skin & breastfeeding

•Administer Vitamin K (IM)

•Apply antibiotic eye ointment (or drops)

–Size & contours of head, including fontanels, relationship to body

–Assess breathing for flaring of nares, grunting or retractions of chest

–Posture & tone of body

–Symmetry of face, including eyes, ears, nose,

–Arms & legs equal in length, digits on hands & feet.

–Any visual abnormalities

–Obtain height & weight of newborn

Vernix- protection when baby in utero (not every baby)

Cyanotic hand and feet

Milia- little sebaceous glands

Stork Bites

Foreskin intact

Lanugo hair

Mongolian spots

Erythema toxicum

Harlequin sign

Nevus flammeus

Nevus vasculosus

blue-gray spots

Red streaks

Benign

Its the skins way reacting to new environment

Variations

•Molding

•Caput succedaneum

•Cephalohematoma

Abnormalities

•Microcephaly

•Macrocephaly

•Large, small or closed fontanelles

Anterior –

Diamond shaped

Closes at 12-18 months of age

Posterior

Triangular – may be difficult

To palpate in the newborn

Closed by the end of the 2^nd month

Boggy edematous swelling of fetal scalp(disappears w/o treatment)

No pathological treatment

soft-pits

Crosses the suture line (fluid/edema)

Boggy edematous swelling of fetal scalp(disappears w/o treatment)

No pathological treatment

soft-pits

Crosses the suture line (fluid/edema)

No treatment required

disappears within 6-8 weeks-months

soft-elastic

On one side of the suture line (positive blood)

•Sucking: (non-nutritive sucking on lips)

•Rooting: baby turns head to side of mouth or cheek that is touched, may open mouth (4 months)

•Palmer  Grasping

•Moro: lifting arms up & letting go: arms up fingers, spread out, (6 months)

•Startle

•Tonic neck: fencer position, head is turned to one side, extremities straighten on that side & flex on the opposite side (3 months)

•Babinski: gently stroke sole of foot, fanning out and extension of toes

•Stepping reflex: puts one step down in front of other, (4-8 weeks)

•Blink, Gag & Sneeze are protective reflexes

•Transient tachypnea of the newborn

(Baby breathing fast/ will go away but will still need to monitor

Starts 4-6 hrs after birth)

•Physiologic jaundice (hyperbilirubinemia)

•Hypoglycemia

•Usually results from excess fluid in lungs

•Infant breathes normally at birth but develops symptoms of respiratory distress by 4 to 6 hours of age

•Clinically can resemble RDS

•May be seen cesarean-birth newborns

•Usually resolves over 24 – 72 hours

•Providing oxygen

•Ensuring warmth

•Observing respiratory status frequently

•Allowing time for pulmonary capillaries and the lymphatics to remove the remaining fluid

•A cause of respiratory failure in term and post-term infants

•Intrauterine distress can cause passage of meconium into the amniotic fluid before birth

•Factors that promote the passage in utero include placental insufficiency, maternal hypertension, preeclampsia, fetal hypoxia, transient umbilical compression, oligohydramnios, and maternal drug abuse, especially of tobacco and cocaine

• Occurs when the newborn inhales particulate meconium mixed with amniotic fluid into the lungs while still in utero or on taking the first breath after birth

•Severe MAS can lead to persistent pulmonary hypertension and death

UNCONJUGATED BILIRUBIN

Indirect bilirubin is fat soluble and

 not easily excreted by the GI Tract or

 kidneys – accumulated in

 blood and is deposited in the skin,

sclera and mucus membranes

CONJUGATED BILIRUBIN

Direct bilirubin – easily excreted

•Blood type ABO or Rh incompatibility – Mother’s blood type is O and fetal is A,B or AB –  The infant is not born anemic, hemolysis of the blood begins with birth when blood and antibodies are exchanged as the placenta separates – red blood cells are destroyed

•Breastfeeding

•Drugs : Diazepam, Oxytocin

•Ethnicity: Asian, Native American

Maternal illness : Gestational Diabetes

•Begins after 24hours of age

•Frequent breast or formula feeding

•Phototherapy

•Monitor hydration status, stools, skin color

Pathological jaundice (before 24hrs/ SERIOUS)

•Maintain newborn skin temperature at 97.8 degrees

•Monitor stool for frequency and characteristics

•Encourage early feedings

•Monitor body temp

•Document stools

•Document wet diapers

•Turn frequently

•Observe skin integrity

•Provide eye protection

•Encourage parents to participate

• Place the newborn under the lights or on the fiberoptic blanket

•Expose as much skin as possible

•Cover the newborn’s genitals and shield the eyes

• Turn the newborn every 2 hours

•Remove the newborn from the lights only for feedings.

•Maintain a neutral thermal environment 

•Assess the newborn’s temperature every 3 to 4 hours as indicated.

•Monitor fluid intake and output

•Monitor stool for consistency and frequency. Unconjugated bilirubin excreted in the feces will produce a greenish appearance, and typically stools are loose

•Monitor serum bilirubin levels

–Delay in oral feeding development

–Central nervous system (CNS) dysfunctions most common

–Impulsivity, cognitive impairment, speech and language abnormalities

–Learning disabilities indicative of CNS involvement

Plasma glucose concentration less than 45mg/dL in the first 72hrs of life

•Rapid acting glucose source

•Dextrose gel

•Breastfeeding

•Formula feeding

•Monitor for symptoms

(When baby in utero and getting glucose from mother, baby makes insulin)

•Phenylketonuria (PKU)

•Congenital hypothyroidism

•Galactosemia

•Sickle cell anemia

•Hearing (universal screening)

•Should be done in first 24-48 hours of life but NOT before 24 hours –

•Should be done after infant has been breast/formula fed

•Puncture of newborn’s warmed heal

•Blood is collected on filter paper completely filing the circles

•Remove clamp after 24hrs, will get blk by 2^nd/3^rd day

•By day 7-10 it will fall off

•Fold diaper below it

•Never pull on it

•No bath until it falls off and heal

a surgical procedure in which the prepuce, an epithelial layer, covering tip of penis is removed

–Permit exposure of glands for easier cleaning

–Not performed on premature or compromised infant

–Local and oral pain relief medications are used

•Side effects:

–Infection

–Hemorrhage

–Pain, restlessness

–Difficulty in voiding

–Damage to urethra, stenosis may develop.

•Infant should be at least 12 hours old or older

•Infant has received standard vitamin K prophylaxis

•Infant has voided normally at least once since birth

•Infant has not eaten for at least an hour prior to the procedure

•Written parental consent has been obtained

•Correct identification of the infant brought to the procedure room

•Assess for bleeding every 30 minutes for at least 2 hours.

•Document the first voiding to evaluate for urinary obstruction or edema.

•Squeeze soapy water over the area daily and then rinse with warm water. Pat dry.

•Apply a small amount of petroleum jelly with every diaper change if the Plastibell was used; clean with mild soap and water if other techniques were used.

•Fasten the diaper loosely over the penis and avoiding placing the newborn on his abdomen to prevent friction.

•Do not remove yellow exudate from penis

Concerns

sore nipples

Engorgement

Mastitis

L: how well infant latches onto the breast

A: amount of audible swallowing

T: nipple type

C: level of comfort

H: Amount of help mother needs

Vaginal bleeding

uterine cramping

Backache

Decreasing HCG levels

Cerclage Procedures:

-McDonald procedure a purse-string technique is placed high up in the cervix and then tied closed. (12,3,6,9 and tied at 12 o’clock)

-Shirodkar procedure places a submucosal band at the level of the internal os.

-Abdominal Cerclage: band is placed around cervix through abdomen.

•Monitor for signs of preterm labor

•Monitor for backache

•Monitor for increase in vaginal discharge

•Monitor of ruptured membranes

•Education

Inform the mother that this is normal the baby might of swallowed blood in utero

~Repeated pregnancy loss ~Abortions ~Trauma to cervix

cervix will be dilating and shortening before 37 weeks

incomplete involution of uterus after birth

•Failure of uterus to return to normal size after pregnancy – lochia rubra of greater than 2 weeks duration suggests subinvolution

Caused by:

•Retained placental fragments

•Distended bladder

•Uterine myoma

•Infection

•Puerperal/Postpartum/Endometritis

Mastitis

•Risk Factors

     Prolonged ROM

    Prolonged labor

    Fetal scalp electrode or IUPC

    BV or Chlamydia infection

    Vacuum or forceps use

    Manual removal of  placenta

    Episiotomy of laceration

    Compromised health status or DM

•Most common with labor then c-section

•Bacteria from the vagina, bowel and perineum invade the uterus

•S/S start within 1-2 days of delivery; fever, tachycardia, uterine tenderness

•Antibiotics needed

Without treatment high levels of glucose can accumulate in the blood and damage organs, including blood vessels, eyes, and kidneys

Some individuals with diabetes need daily insulin injections to prevent these complications

•When the body cells lack insulin, it is unable to use the foods eaten for energy

•Glucose builds up in the blood stream

•Without available glucose for energy, the body will break down stored fats for fuel and energy

•A byproduct of the breakdown of fats—ketones will begin to circulate

•Large amounts of ketones can cause coma and death

Glucose crosses the placenta, Insulin does not

 -At 10 weeks maternal glucose levels rise fetal glucose levels are increased resulting in increased fetal insulin secretion

  -Insulin requirement may double or quadruple by the end of pregnancy

 -Renal threshold for glucose decreases

-Increased risk of ketoacidosis

 -Nephropathy and retinopathy may develop       

 -After the placenta is delivered insulin requirements decrease

•During the first trimester, less insulin may be needed because less food may be eaten

•After the third month, more insulin is needed because the placenta produces substances that weaken insulin

•Fetus has a continuous need for nutrients

•This produces a stress on the maternal system with a constant drain of glucose and amino acids potentially leading to hypoglycemia and ketoacidosis

•If the mother’s blood sugar becomes too high or too low, development of the fetus may be affected

•Research has proven that strict regulation of maternal glucose levels is essential to optimal perinatal outcome

Polyhydramnios

Hyperglycemia

Preeclampsia

Increased risk for cesarean delivery

Macrosomia

Heart defects

Spina bifida

Increased risk of miscarriage and stillbirth

Birth injuries

Babies of all diabetic women are at increased risk of health problems arising during the newborn period

1.Respiratory distress

2.Hypoglycemia

3.Low calcium levels

4.Hyperbilirubinemia; jaundice

•Women older than age 25 years

•Obesity

•Insulin resistance

•Polycystic ovary syndrome

•History of pregnancy-related diabetes mellitus

•History of a large for gestational age infant, hydramnios

•Stillbirth, miscarriage, or an infant with congenital anomalies during a previous pregnancy

•Family history of type 2 diabetes (first-degree relative)

•Ethnicity

•All pregnant women should be screened for gestational diabetes

•Screen between the 24^th and 28^th week of pregnancy

•Take a blood sample one hour after consuming a drink containing 50 grams of glucose

•Results of blood sugar >130-140 mg/dL requires follow up with a 3 hour oral glucose tolerance test (OGTT)

•Involves drawing samples 1, 2, and 3 hours after drinking 100 grams of glucose

The diagnosis of GDM is made when two values or more of the threshold are above the norm.

According to the American Diabetes Association (ADA) (2010), the normal plasma values are:

FBS less than 95mg/dL

1hr less than 180mg/dL

2hr less than 155mg/dL

3hr less than 140 mg/dL

•Once gestational diabetes is diagnosed, most women can control their blood sugar levels with diet; about 10% require insulin injections

•After delivery, blood sugar levels should return to normal

•Fetal surveillance

•Women with gestational diabetes are at increased risk of developing diabetes in the future and of developing gestational diabetes in any later pregnancy

•Requires the addition of oral medications and/or insulin, depending on the blood glucose levels.

•Ultrasounds

•NST

•Amniocentesis

•Education re: hypo and hyperglycemia

•Must see their doctor more often

•Follow a carefully prescribed diet

•Monitor blood sugar levels

•These necessary steps may lead to increased stress levels

•Support group

•Primary goal is is to control maternal glucose levels in labor to prevent neonatal hypoglycemia

•Maternal glucose levels are measured regularly

•Labor patients receiving insulin usually receive insulin on a sliding scale

•IV insulin is discontinued after the delivery of the placenta

•Gestational Diabetics usually has normal glucose values by 24 hours postpartum

•Gestational Diabetics are retested at 6 weeks postpartum

Asphyxia

Birth injury because of large size:

Shoulder dystocia: brachial plexus nerve injuries, facial paralysis, intracranial hemorrhage, fractured clavicle

Congenital anomalies

Respiratory distress

Hypoglycemia

•Macrosomatic

•Excess adipose tissue

•Cherubic round face

•Hypotonic extremities

•Reddened Appearance

•Difficulty feeding

•Jitteriness

•Twitching of the extremities

•Apnea

•Hypotonia

•Tachypnea

•Seizures

Multiple Gestation

Cervical Incompetence

Polyhydraminos

Uterine anomaly

Fetal abnormality

Febrile Illness

UTI/Pylonephritis

Previous history of

Uterine irritability

History of cervical surgery

Age < 18 or  > 35

Low socioeconomic status

Cigarette smoking

Substance abuse

STI

Anemia

IUD

•Teaching

   Recognize Symptoms of PTL

   Bed Rest

   Empty bladder

   Pelvic rest

   Palpate for contractions

   Drink water

•IV Hydration

                                                Tocolytics

   Nifedipine ( Procardia ) administered orally or sublingual few maternal side effects hypotension, tachycardia, facial flushing  and headache

   Magnesium Sulfate   

   Terbutaline

Side Effects – Tachycardia Headache/Hypotension/Increased blood glucose/pulmonary edema

   Use Terbutaline with  caution in women with diabetes mellitus and thyroid dysfunction

   Monitor B/P and pulse if pulse is > 120 bpm hold

   medication

   May need EKG prior to or with continued doses

   Initially given as sq and changed to PO maintenance when

   contractions have subsided

•Bacterial infection in the amniotic cavity

•Most commonly occurs after rupture of membranes

•Diagnosed by symptoms fever, maternal/fetal tachycardia, uterine tenderness, foul smelling amniotic fluid

•Treated with broad spectrum antibiotics

•Bacterial infection

•Found in lower GI or GU tracts

•Transmitted to fetus in utero or during childbirth

•Associated with poor pregnancy outcomes

•Results from vertical transmission from the birth canal of the infected mother to the infant during birth

Treated in labor (penicillin G or vancomycin)

Preterm Labor

   Maternal Intrapartum Fever

   Prolonged Rupture of Membranes

   Previous Birth of Infected Infant

  GBS bacteriuria in current pregnancy

•All pregnant women should be screened at 35-37 weeks gestation with vaginal/rectal swab

•Women who are GBS carriers should receive antibiotic with labor and/or ROM

   ( In urine = high colonization) they do not need to have vaginal/rectal swab done at 35-37 weeks

• If woman has had a child with GBS disease she should receive prophylaxis in labor ( no culture)

-Turning the fetus from breech to vertex

-Done Externally

-Success Rate 51% - 65%

35-36 weeks (turn baby if breech, give terbutaline- uterine relaxation)

-Reactive Non Stress Test prior

-Fetus cannot be engaged in pelvis

-IV

Terbutaline

-Ultrasound

-valid blood type and screen sample

stop procedure if:

-severe maternal pain

-fetal bradycardia

-Bleeding in the 3^rd Trimester

-Multiple gestation (twins)

-Oliohydramnios

-Uteroplacental insufficiency

-Nuchal Cord

-Previous C/S

Softening and effacing of cervix

Prostaglandins

•Cervidil

•Misoprostol (Cytotec)

•Used for PP hemorrhage

•Contraindicated for previous

•cesarean birth

Inserted in vagina, left in for 12 hrs

-monitor them for every 2 hours

•Providers administer medication

•Support and inform patient

•Continuous EFM

•Monitor for hyper stimulation

•Cervical ripening is the process of effecting physical softening and distensibility of the cervix in preparation for labor and birth.

•Induction of labor is the stimulation of uterine contractions before the spontaneous onset of labor for the purpose of accomplishing vaginal birth.

•Augmentation of labor is the stimulation of ineffective uterine contractions after the spontaneous onset of labor to manage labor dystocia.

•Stripping membranes

•Amniotomy

•Pitocin infusion

•Complementary Methods

•Sexual intercourse

•Nipple stimulation

•Herbs

Mechanical dilators

•Abruptio placentae (depends on extent of abruption and absence of maternal fetal compromise)

•Chorioamnionitis

•Fetal demise

• Gestational hypertension

• Preeclampsia

• Eclampsia

•Premature rupture of  membranes

• Postterm pregnancy

• Some maternal medical conditions

• Fetal compromise (e.g. IUGR)

•IV piggyback infusion

•Baseline vitals

•Reassuring tracing

•Continuous EFM

•RN increases or decreases Pitocin

•Discontinue Pitocin if needed

•Titrate oxytocin according to maternal & fetal response:

• Decrease dosage or discontinue medication when contractions are too frequent.

•Discontinue medication if abnormal or indeterminate FHR patterns occur.

• Increase dosage when uterine activity and labor progress are inadequate.

•Baseline Vitals

•Continuous EFM

Forceps

•Outlet Forceps

•Low Forceps

•Midforceps

Vacuum

•Apply suction cup

Negative pressure

•Use of specialized instrument with two curved blades to assist birth of the fetal head

•No more than 600 mmHg

•Three pop offs

•Total 20 minutes

-Keep patient and partner informed

-Continuous EFM

-Examine infant after birth

•Scalp lacerations

• Cephalohematoma

• Subgaleal hemorrhage

• Intracranial swelling

• Hyperbilirubinemia

• Retinal hemorrhage

•Oldest surgical procedure

Rate rising

•Repeats due to risk of uterine rupture

Request for C/S for first time mothers

Never less than 39 weeks

•Trial of labor following previous cesarean birth (TOLAC)

• Requires evaluation of potential maternal, fetal, and  neonatal risks and benefits

•Successful VBAC associated with less morbidity than cesarean birth

•Alternative to repeat cesarean

•Previous classical or T-shaped uterine incision or other transfundal uterine surgery

•Previous uterine rupture

•Medical or obstetric problem that precludes vaginal delivery

• Two prior uterine scars and no vaginal deliveries                                                                                                                          

-Hemorrhage

-Uterine scar separation

-Hysterectomy

-Surgical injuries

-Infant death

-Neurologic complications

•Continuous EFM

•IV access

•Support

•Comfort measures

•Keep family informed

Encouragement

•Artificial rupture of membranes (AROM)

•Shortens labor

•Augments labor

•Internal monitoring

Assessment of amniotic fluid

•Use of amnihook by provider

•Tears membranes

•Explain procedure to patient

•FHR assessed before and after

• Assess amniotic fluid

•Monitor temperature and perform q2h

•Pregnancy increased

•Cardiac output

•Heart rate

•Blood volume

•Assess the stress of pregnancy on the heart’s functioning

•Limitation of activity

•Monitor for signs of impending cardiac failure

•Health teaching

•Poor quality contractions

•Abnormal flexion of head

•Inadequate maternal pushing efforts – usually due to regional anesthesia

•Large fetus

EMERGENCY UMBILICAL CORD COMPLICATION

-water breaks before baby is at birth canal

-umbilical cord comes before baby (cord high risk for compression)

-Emergency c-section

-appearance of loop of umbilical cord

-pulsation of cord on v/e

-suspect in unexplained fetal distress

-variable deceleration

-prolonged bradycardia

•Assess for nonreassuring fetal status

•If a loop of cord is discovered, the examiner’s gloved fingers must remain in vagina to provide firm pressure on fetal head until physician or CNM arrives

•Oxygen via face mask

•Monitor FHR to determine whether cord compression is adequately relieved

•Woman assumes knee-chest position or bed is adjusted to Trendelenburg position

•Transport to the delivery or operating room in this position

HELPERR

Call for Help

Evaluate for Epiostomy

Legs: McRoberts Maneuber

External Pressure-suprapubic

Enter: rotational maneuvers

Remove the posterior arm

Roll the patient to her hands and knees

BECALM

Breathe, do not push; lower head of bed

Elevate legs into McRoberts

Call for help- nurses, anethesiologists

Apply suprapubic pressure- downward & lateral

Enlarge vaginal opening with episiotomy

Maneuvers

■AGA: about 80% of newborns; normal height, weight, head circumference, body mass index

■SGA: weight <2500g (5lbs, 8oz) at term or below the 10th percentile

■LGA: weight >90th percentile; weight >4000g (8lbs, 13oz) at term

■Low Birth Weight (LBW): weighing <2500g or 5.5lb

■Very Low Birth Weight (VLBW): weighing <1500g or 3.5lb

■Extremely Low Birth Weight (ELBW): weighing <1000g or 2.3lb

■Conditions affecting fetal growth

–<28wks leading to overall growth restriction

–>28wks, intrauterine malnutrition

■IUGR for some SGA newborns (asymmetric vs symmetric)

■Contributing factors (Box 23.1)

■Head is larger than body

■Wasted appearance of extremities; lose dry skin

■Reduced subcutaneous fat stores

■Decreased amount of breast tissue

■Scaphoid abdomen (Sunken)

■Wide skull sutures

■Poor muscle tone over buttocks and cheeks

■Thin umbilical cord

■Perinatal asphyxia

■Difficulty with thermoregulation

■Hypoglycemia

■Polycythemia

■Meconium aspiration

■Hyperbilirubinemia

■Birth trauma

■Weight, length and head circumference measurements

■Serial blood glucose monitoring

■Vital signs monitoring

■Early and frequent oral feeding; IV infusion of dextrose 10%

■Monitoring for signs and symptoms

■Anticipatory  guidance

■Maternal diabetes mellitus or glucose intolerance

■Multiparty

■Prior history of a macrocosmic infant

■Post dated gestation

■Maternal obesity

■Male fetus

■Genetics 

■Large body, plump, full face

■Proportional increase in body size

■Poor motor skills

■Difficulty regulating behavioral states

■Birth trauma

■Hypoglycemia

■Polycythemia

■Hyperbilirubinemia

■Vital sign monitoring

■Blood glucose level monitoring

■Initiation of oral feedings with IV glucose, supplementation as needed

■Continued monitoring for signs and symptoms of polycythemia and hypoglycemia

■Hydration

■Phototherapy for increased bilirubin

•Preterm: born before 37 weeks

•Late preterm: 34-36.6 weeks

•Term: 37-39.9 weeks

•Post dates: 40-41.6 weeks

•Post term: past 42 weeks

■Inability if placenta to provide adequate oxygen and nutrients to fetus after 42 weeks

■Dry, cracked, wrinkled in; possibly Meconium stained

■Long, thin extremities; long nails; creases over entire soles of feet

■Wide-eyed, alert expression

■Abundant hair on scalp

■Thin umbilical cord

■Limited vernix and lanugo

■Perinatal asphyxia

■Hypoglycemia

■Hypothermia

■Polycythemia

Meconium aspiration

■Blood glucose level monitoring

■Initiation of feedings Iv dextrose 10%

■Prevention of heat loss

■Evaluation for polycythemia

■Parental support

■Etiology

–Infections/inflammation

–Maternal/fetal distress

–Bleeding

–Stretching

■Body system immaturity; increased risk for complications

–Respiratory system

–Cardiovascular system

–GI system

–Renal system

–Immune system

Central nervous system

■Weight <5.5lb

■Scrawny appearance

■Poor muscle tone

■Minimal subcutaneous fat

■Undescended testes

■Plentiful lanugo

■Poorly formed ear pinna

■Fused eyelids

■Soft spongy skull bones

■Matted scalp hair

■Absent to few screamed in soles and palms

■Minimal scrotal rugae; prominent labia and clitoris

■Thin transparent skin

■Abundant vernix

■Hypothermia

■Hypoglycemia

■Hyperbilirubinemia

■Problems related to immaturity of body systems

■Oxygenation

■Thermal regulation

■Nutrition and fluid balance

■Infection prevention

■Stimulation

■Pain management

■Provide developmental care

■Parental support

■Discharge preparation

•Any pregnancy loss and/or neonatal death put to 1 month of age

•A profound experience for the family

•Avoidance is a common reaction

•Nurses must be aware of personal feelings

•Communicate empathy

•Typically occur at, or soon after, birth

•Problems or conditions experienced by the woman during pregnancy or at birth 

•Possibly no identifiable cause for the disorder 

•Present at birth; usually due to some type of malformation occurring during the ante-partal period; typically, some problem with inheritance 

•Majority with a complex etiology 

•Hypoxic-Ischemic Encephalopathy

•Transient tachypnea 

•Respiratory distress syndrome

•Meconium aspiration 

•Necrotizing enterocolitis (NEC)

•Infants of diabetic mothers

•Birth trauma 

•Newborns of perinatal substance abusing mothers

•Hyperbilirubinemia

•Newborn infections 

•Asphyxia occurs when adequate breathing is not established after birth; insufficient oxygen delivery to meet metabolic demands

Nursing Assessment:

•Risk factors, newborn's color, work of breathing, heart rate, temperature, Apgar scores

Nursing Management:

•Immediate resuscitation, continued observation, neutral thermal environment, blood glucose levels, parental support and education

•Lung maturity and lack of alveolar surfactant

Nursing assessment

•Expiratory grunting, nasal flaring, chest wall retractions, see-saw respirations, generalized cyanosis; heart rate >150-180; fine inspiratory crackles, tachypnea (>60), Silverman-Anderson index score

•Chest x-ray: hypoaeration, under expansion, and ground glass pattern 

•Supportive care; close monitoring 

•Respiratory modalities: ventilation (CPAP, PEEP); exogenous surfactant; oxygen therapy

•Antibiotics for positive cultures; corrections of metabolic acidosis 

•Fluids and vasopressors; gavage or IV feedings

•Blood glucose level monitoring 

•Clustering of care; prone or side-lying position 

•Parental support and education 

•Three pathologic mechanisms: bowel ischemia, bacterial flora, and effect of feeding 

Nursing assessment 

•Signs and symptoms: abdominal distention and tenderness, bloody stools, feeding intolerance (bilious vomiting), sepsis, lethargy, apnea, shock

•KUB: air in bowel wall; dilated bowel loops 

•High levels of maternal glucose crossing the placenta, stimulating increased fetal insulin production leading to somatic fetal growth

Nursing assessment

•Full rosy cheeks, ruddy skin color, short neck, buffalo hump, massive shoulder, distended upper abdomen, excessive subcutaneous fat tissue: hypoglycemia, birth trauma

•Hypocalcemia, hypomagnesemia, polycythemia, hyperbilirubinemia

Nursing management

•Comfort promotion; stimuli reduction 

•Nutrition 

•Prevention of complications

•Parent-newborn interaction 

•Injuries due to the forces of labor and birth

•Types: fractures, brachial plexus injury, cranial nerve trauma, head trauma (cephalohematoma, caput succedaneum)

Nursing assessment

•Physical and neurological assessment: bruising, bumps, swelling, paralysis, symmetry of structure and function 

•The spinal cord often ends at the point of the defect, resulting in absent motor and sensory function beyond that point

•Nursing management: Preventing infection, promoting urinary elimination, promoting bowel elimination, promoting adequate nutrition, preventing latex allergy reactions, maintaining skin integrity, educating and supporting the family

•Lack of normal separation of esophagus and trachea during embryonic development

•Esophageal atresia: congenitally interrupted esophagus 

•Tracheoesophageal fistula: abnormal communications between trachea and esophagus

•Nursing assessment 

•Hydramnios

•Copious frothy bubbles of mucus and drooling; abdominal distention 

•Coughing, choking and cyanosis

•Umbilical ring defect with evisceration of abdominal contents into external peritoneal sac

•Herniation of abdominal contents through abdominal wall defect (no peritoneal sac)

•Rectum ending in blind pouch or fistulas between the rectum and perineum

Nursing assessment

•Absence of anal opening, no passage of meconium, signs and symptoms of intestinal obstruction 

Nursing management

•Preparation for surgery,

•Postoperative care 

•Protrusion of bladder onto abdominal wall

•Separation of rectus muscles and symphysis pubis

•Boys also with epispadias

•Initial bladder closer within 48 hours of birth; further reconstruction at age 2-3 years old

Redness, Edema, Ecchymosis, Discharge, Approximation

Azithromycin

⁃ Doxycycline ❌ 🤰🏽

Ceftraxone IM ✅🤰🏽

⁃ Ciprofloxacin

⁃ Ievofloxacin

Benzathaine penicillin 1dose

~less then yr

⁃ Benzathaine penicillin 3x ~ more then yr

inpatient- iv antibiotics

- iv fluids

- pain meds

Out patient - cephalosporin w/ doxycycline

Tricholoroacetic Acid (TCA)

⁃ Podphyllin ❌🤰🏽

⁃ Imiquimod ❌🤰🏽

⁃ Gardadil~ before sexually active (9yrs)

Herpes

⁃ Acyclovir

⁃ Valacyclovir (36 weeks)

⁃ Famiclovir

Flagyl- metronidazole

⁃ Cindamycin cream

Flagyl- metronidazole

⁃ Tinidazole

Miconazole

⁃ Terconazol

⁃ Clotrimazol

⁃ Nystatin vaginal cream

hypertension

Rubella (live vaccine)