OB quiz/test #2

Late Preterm Infants - Definition: ? weeks gestation - Complications: Inadequate or delayed transition, Up to 20% of NICU admissions, Morbidity rate doubles for every week below ? weeks - Close monitoring for at least first ? hours - Respiratory problems: - Thermal control: how does it affect brown fat and white fat? - Feeding difficulties: 4 main medical problems that late preterm infants can have? Care/Prevention/Assessments: - Feeding: how often should the late preterm baby feed? - how much skin to skin contact should they have?

- Definition: 34-36 6/7 weeks gestation - Complications: Inadequate or delayed transition, Up to 20% of NICU admissions, Morbidity rate doubles for every week below 38 weeks - Close monitoring for at least first 24 hours - Respiratory: Lungs immature, Decreased surfactant, Immature respiratory control, Decreased muscle tone - Thermal control: Decreased brown fat for thermogenesis, Decreased white fat for insulation - Feeding difficulties: Immature coordination, inadequate milk transfer, Sleepier, Low milk supply Hyperbilirubinemia - Delay in metabolism and excretion - 2X greater risk for significantly high levels - More susceptible to bilirubin toxicity Immature brain - Cortical volume increases 50% in volume between 34-40 weeks, great increase in surface area - Leads to other problems - Needs more sleep to conserve energy Hypoglycemia - Low glycogen stores - Immature pathways to make glucose Risk of Sepsis - Immature immune system Care/Prevention/Assessments: - More frequent vital signs - Assessment/Prevention: Hypoglycemia, Hyperbilirubinemia, Prevent infections, Hypothermia - Feeding: Lactation consultation, Encourage frequent feedings and assess adequacy - Unlimited skin-to-skin contact

Signs of Effective Breastfeeding - how many time should infants be nursing per 24 hours? - should it be silent or should you hear infant swallowing? - what happens to mother's breasts after feeding? - how many wet diapers should baby produce per day? what day does this ideal standard start on after birth? trend in wet diapers? - transition of infant's stool composition? Comfort Measures - for Engorgement of breasts. also what should you avoid doing that will make this worse? what "comfort measure" is no longer recommended due to risk of food borne illness? - for Cracked, bleeding, bruised nipples

- Infant nursing ≥8 times in 24 hours - Mother can hear infant swallow - Mother's breasts soften after feeding - Number of wet diapers increases...6-8 wet diapers a day beginning on day 5 - Infant's stools begin to lighten and transition from meconium to breastfeeding stools Comfort Measures for Engorgement - Empty breasts q2h; preferably by the baby - Ibuprofen, massage, ice - Not recommended to pump/hand express milk between/ after feedings causes increased milk production and worsens engorgement - If engorgement causes nipples to flatten and become hard use breast pump/hand expression just to soften nipple to allow latch - Cabbage leaves no longer recommended due to risk of food borne illness Comfort Measures for... - Cracked, bleeding, bruised nipples are signs of poor latch ----Lansinoh cream- no need to wash off ---Gel pads- "soothies" ---Nipple Shields until nipples are healed

Intrauterine Resuscitation

- Position change - IV fluid bolus - O2 @ 10L/min via non-rebreather mask - CALL FOR HELP - Notify provider and request immediate evaluation - Assess for tachysystole - Turn off Pitocin if running - Consider Terbutaline 0.25 mg SQ or IV - Check blood pressure - Correct if hypotensive- fluid bolus and meds (Ephedrine 5-10 mg IV or Phenylephrine 0.1 to 0.5 mg IV) - Cervical exam - Check for prolapsed cord, rapid cervical dilation, rapid descent - Prepare for possible amnioinfusion - Alter pushing efforts- stop, push every other contraction

1. Onset of neonatal sepsis within the first 7 days. 3. Absence of breathing for >20 sec. 5. Most severe form of anti-D antibodies crossing the placenta (2 words). 7. The type of jaundice considered a normal adaptation of fetus to extrauterine life; occurs after 24 hours, peaks around 2-5 days and lasts less than 14 days.It's main cause is lack of glucuronyl transferase. The TSB rises < 5 mg/dl/day. 9. May occur in a Rh neg mother when she is carrying an Rh positive fetus if no Rhogam is given as prophylaxis (2 words). 13. An injury to the fetus that is caused by excessive or improper traction on the head during birth (2 words). 17. Jaundice that appears in the first 24 hours and is caused by HDN, ABO incompatibility, or maternal disease processes. The TSB rises > 5 mg/dl/day. 19. Onset of neonatal sepsis 8 days to 3 months. 21. Treatment for this neonatal syndrome may include controlling the environment, small frequent feedings, promoting self-soothing and regulation by swaddling, gentle rocking, non-nutritive sucking. 23. Absence, deficiency or alteration in pulmonary surfactant (abbreviation). 25. Collection of fluid under the scalp; crosses suture lines. 27. Transmission of infection from mother to fetus via the placenta, ascent from the vagina or exposure during delivery. 29. A blood incompatibility that is a common cause of jaundice in the newborn occurring in 20-25% of pregnancies.

1. Onset of neonatal sepsis within the first 7 days. EARLY 3. Absence of breathing for >20 sec. APNEA 5. Most severe form of anti-D antibodies crossing the placenta (2 words). HYDROPS FETALIS 7. The type of jaundice considered a normal adaptation of fetus to extrauterine life; occurs after 24 hours, peaks around 2-5 days and lasts less than 14 days.It's main cause is lack of glucuronyl transferase. The TSB rises < 5 mg/dl/day. PHYSIOLOGIC 9. May occur in a Rh neg mother when she is carrying an Rh positive fetus if no Rhogam is given as prophylaxis (2 words). RH SENSITIZATION 13. An injury to the fetus that is caused by excessive or improper traction on the head during birth (2 words). BRACHIAL PLEXUS 17. Jaundice that appears in the first 24 hours and is caused by HDN, ABO incompatibility, or maternal disease processes. The TSB rises > 5 mg/dl/day. PATHOLOGIC 19. Onset of neonatal sepsis 8 days to 3 months. LATE 21. Treatment for this neonatal syndrome may include controlling the environment, small frequent feedings, promoting self-soothing and regulation by swaddling, gentle rocking, non-nutritive sucking. ABSTINENCE 23. Absence, deficiency or alteration in pulmonary surfactant (abbreviation). RDS 25. Collection of fluid under the scalp; crosses suture lines. CAPUT 27. Transmission of infection from mother to fetus via the placenta, ascent from the vagina or exposure during delivery. VERTICAL 29. A blood incompatibility that is a common cause of jaundice in the newborn occurring in 20-25% of pregnancies. ABO

2. Type of jaundice that is caused by ineffective feeding, dehydration and delayed meconium stool passage stool passage. 4. Collection of blood between the cranial bones and the periosteal membrane; does not cross suture lines. 6. A leading cause of neonatal morbidity and mortality. 8. Normal respiratory pauses lasting up to 20 seconds. 10. A blood sugar level < 40 mg/dl in a neonate. 11. An immature brain, lower resting metabolic rate, more efficient energy use, and the ability to redistribute lactate and hydrogen ions are _____ mechanisms in the neonate. 12. The chronic and permanent sequelae of untreated hyperbilirubinemia. 14. A fairly common injury in the neonate that is usually treated with immobilization for 7-10 days and pain management 16. Therapeutic ______ is a treatment of asphyxia that may decrease mortality and neurodevelopmental disability. 18. Given to the mother antenatally to promote fetal lung development and surfactant production. 21. Inability to transition to extrauterine circulation. 28. Administered after birth to the neonate to reduce the risk of RDS, pneumothorax, IVH, bronchopulmonary dysplasia, and pulmonary interstitial emphysema. 30. Failure to clear fluid in pulmonary system 32. Prevents production of anti-D antibodies. 34. This type of infection transmission may occur because of poor hand washing by neonatal care givers. 36. Jaundice that is caused by increased free fatty acids, may last several months

2. Type of jaundice that is caused by ineffective feeding, dehydration and delayed meconium stool passage stool passage. BREASTFEEDING 4. Collection of blood between the cranial bones and the periosteal membrane; does not cross suture lines. CEPHALOHEMATOMA 6. A leading cause of neonatal morbidity and mortality. SEPSIS 8. Normal respiratory pauses lasting up to 20 seconds. PERIODIC 10. A blood sugar level < 40 mg/dl in a neonate. HYPOGLYCEMIA 11. An immature brain, lower resting metabolic rate, more efficient energy use, and the ability to redistribute lactate and hydrogen ions are PROTECTIVE mechanisms in the neonate. 12. The chronic and permanent sequelae of untreated hyperbilirubinemia. KERNICTERUS 14. A fairly common injury in the neonate that is usually treated with immobilization for 7-10 days and pain management (2 words). FRACTURED CLAVICLE 16. Therapeutic HYPOTHERMIA is a treatment of asphyxia that may decrease mortality and neurodevelopmental disability. 18. Given to the mother antenatally to promote fetal lung development and surfactant production. CORTICOSTEROIDS 21. Inability to transition to extrauterine circulation. ASPHYXIA 28. Administered after birth to the neonate to reduce the risk of RDS, pneumothorax, IVH, bronchopulmonary dysplasia, and pulmonary interstitial emphysema. SURFACTANT 30. Failure to clear fluid in pulmonary system (abbreviation). TTN 32. Prevents production of anti-D antibodies. RHOGAM 34. This type of infection transmission may occur because of poor hand washing by neonatal care givers. HORIZONTAL 36. Jaundice that is caused by increased free fatty acids, may last several months (2 words). BREAST MILK

where are infants most likely to be abducted from? car seats: - Birth to age 2- - 2-4 years (or ? )- - 4-8 years (or ? )- - Best seat for these to be placed in the car? also, not near what?

55% of infant abductions occur in the mother's room Car seats: - Birth to age 2- rear facing car seat - 2-4 years (or up to 40 lbs.)- forward facing car seat - 4-8 years (or 4'9")-booster seat Best place-rear middle seat Not near air bags Must have prior to discharge

how to calculate APGAR score for a newborn? what is a "good" APGAR score? when is APGAR testing done?

A = Activity (muscle tone). 0 points is flaccid. 1 point for arms and legs flexed. 2 points for active motion. P = pulse 0 points for absent pulse. 1 point for <100bpm. 2 points for >100bpm. G = grimace (reflex irritability) 0 points for nothing 1 point for grimaces. 2 points for sneezes/coughs/pulls away A = appearance (color) 0 points for pale blue over entire body 1 point for pink body, with blue extermities 2 points for completely pink color R = respirations 0 points for absent respirations 1 point for slow, irregular respirations 2 points for regular respirations/crying Score of 7 or above=good Done at 1 and 5 minutes after birth - Repeated q 5 min if score <7

ABO Incompatibility - Type O blood contains what type of antibodies? ---If enter fetal circulation of what blood types cause clumping of RBCs? - Incidence of OA/OB incompatibility: ? % of pregnancies ---Hemolytic disease of the newborn occurs in ? % of these cases of incompatibility - Consequences of HDN: what antigen & antibodies does each blood type have? - type AB: - type A: - type B: - type O:

ABO Incompatibility - Type O blood contains anti-A & anti-B antibodies (IgM) ---If enter fetal circulation of blood types A or B cause clumping of RBCs - Incidence of OA/OB incompatibility: 20-25% of pregnancies ---Hemolytic disease of the newborn occurs in 10% of these cases of incompatibility - Consequences of HDN: Rapid destruction of fetal RBCs (Hyperbilirubinemia, Anemia, Death) what antigen does each blood type have? - type AB: A and B antigen with no antibodies - type A: A antigen with anti-B antibodies - type B: B antigen with anti-A antibodies - type O: no antigen with anti-A and anti-B antibodies

Accelerations - how to measure on a tracing strip? from what to what - requirements for pregnancies over/equal to 32 weeks: - requirements for pregnancies less than 32 weeks: - how long does the acceleration have to last to make it "prolonged"? Decelerations - abrupt vs. gradual: time for onset to nadir, what type of deceleration can each be?, relationship of each type to contractions

Accelerations - Abrupt increase above baseline - Onset to peak of increase - For pregnancies > or equal to 32 weeks.....Acme of 15+ bpm for 15+ seconds from beginning to end of increase - For pregnancies < 32 weeks.....Acme of 10+ bpm for 10+ sec Identify a well oxygenated fetus and the absence of acidemia Prolonged accelerations - Definition: lasts between 2 minutes and 10 minutes. (including the exact 2 and 10 minutes) Decelerations - it is a transitory decrease in FHR below baseline - Abrupt: Onset to nadir is less than 30 seconds. this has "variable" deceleration and occurs with or without contractions. - Gradual: Onset to nadir is 30+ seconds. this has "early" deceleration or "late" deceleration. Early decels happpen during contractions. late decels happen after contractions.

Code White

All the treatments already mentioned plus: - Support team: Interventional radiology, additional OB, blood bank, lab, anesthesia all come to the unit - Uterine balloon tamponade - Arterial embolization - Uterine suturing techniques - Ligation of arteries - Hysterectomy - And sometimes it's still not enough- Maternal death

Describe the care to provide to a newly circumcised newborn for each type (Gomco/Yellen, Mogen, and Plastibell) of circumcision. Describe the education to provide to the parents about home care of their circumcised newborn.

All types of circumcisions: - Assess for bleeding q 15-30 mins x 1 hour, then q 1 hour for 4-5 hrs - Monitor for first void after procedure Gomco/Mogen circumcision: - Apply Vaseline gauze to the penis for the first 24 hours, then apply petrolatum (Vaseline) until healed to prevent the diaper from sticking Plastibell circumcision: Do not use Vaseline or Vaseline gauze as it causes the string to degrade prematurely Describe the education to provide to the parents about home care of their circumcised newborn. - Check for bleeding with each diaper change - Observe for appropriate urination - Keep area clean...Avoid soap and diaper wipes, cleanse with warm water only to remove urine/stool - Apply Vaseline to glans after each diaper change but not if a Plastibell was used - Loosely secure diaper to avoid pressure - Check for infection - Provide comfort - Don't pull on the Plastibell ring—it will fall off after healing occurs (up to day 14)

Apnea - Definition: - May or may not be associated with ? or ? - Assess for other things: Asphyxia - definition? what exactly happens? - Protective mechanisms: - Mortality ?/1000 live births - Morbidity ---Mild- long term effects? ---Moderate to severe- - Signs and Symptoms ---Intrapartum: 2 things ---Neonatal: - Treatment:

Apnea - Definition: Periodic breathing vs. apnea - May or may not be associated with cyanosis or bradycardia - Assess for other things: Hypoglycemia, Infection, Hypoxia, Fluid imbalances, CNS abnormalities Asphyxia - Risk Factors: Antepartum factors, Intrapartum factors, Neonatal factors - Inability to transition to extrauterine circulation ---No lung expansion and respirations --> hypoxemia --> metabolic acidosis & hypercapnia ---Change from aerobic to anaerobic metabolism - Protective mechanisms: Brain is immature, Lower resting metabolic rate, More efficient energy use, Able to redistribute lactate and hydrogen ions - Mortality ~1/1000 live births - Morbidity ---Mild- no long term sequela ---Moderate to severe- depends on extent of insult. ~58% CP ~48% other abnormal outcome - Signs and Symptoms ---Intrapartum: Non-reassuring FHR in labor, Cord blood gas pH <7 ---Neonatal: No respiratory effort @ 5 min or APGAR score < 5 @ 10 min, Need for prolonged resuscitation, Deer in the headlights look or lethargic, Seizures & CNS irritability, Hypertonic or hypotonic, Poor feeding - Treatment: Rapid identification, Appropriate resuscitation, Support oxygenation & ventilation, Therapeutic hypothermia (decreased mortality and neurodevelopmental disability rates - Cool to 33.5-34.5 C...Initiated within 6 hours for >36 weeks gestation), Provide nutrition

when is the fetus's autonomic nervous system fully developed? how does the parasympathetic nervous system affect the FHR? - how is this stimulated? how does the sympathetic nervous system affect the FHR? - how is this stimulated? Fetal Autonomic Nervous System sensitive to changes in: what 3 things? - other things that contribute to the FHR?

Autonomic Nervous System- expected to be fully developed by 32 weeks Parasympathetic Nervous System - Vagus nerve stimulation slows FHR - Pressure on fetal head stimulates this parasympathetic response - May also stimulate passage of meconium Sympathetic Nervous System - Stimulation increases FHR and strength of heart contraction - Stimulated by loud noise, vibration, stimulation of scalp or pressure on maternal abdomen Fetal Autonomic Nervous System sensitive to changes in: Oxygen exchange, Carbon dioxide production, Blood pressure changes - Chemoreceptors: Located in carotid arch and CNS. Respond to changes in fetal O2, CO2, and pH levels - Baroreceptors: Located in carotid and aortic arch. Detect pressure changes. Stimulation results in vasodilation, decreased BP, reflexive HR increase - Fetal Reserves...Reserve O2 available to fetus to withstand transient changes in blood flow during labor - Utero-placental unit- ability to transfer oxygen to fetus and remove waste products - Factors affecting fetal perfusion (lots, they are all common sense)

newborn's ideal temperature range: newborn's RR: newborns need the temperature in the environment around them to be: postures of newborns that helps them retain heat vs. lose heat? is a baby's inability to maintain it's own temperature because it loses too much heat or can't produce enough heat?

Axillary temp: 97.6-99 Fahrenheit 36.5-37.2 Celsius Normal RR: 30-60 Newborns require higher ambient temperature than adults: 89.6-93.2 F is ideal Posture: Flexed promotes heat retention Extended increases heat loss Inability to maintain normal temperature is usually related to excessive heat loss not impaired heat production

Focused Postpartum Assessment - what is it? take notes on Postpartum powerpoint -- find the filled out version???

BUBBLE OR BUBBLEHE Breasts, Uterus, Bowels, Bladder, Legs, Episiotomy/laceration/c-section incision/Lochia, Homan's, Emotions

how to calculate FHR baseline? - normal FHR range? - how does FHR change with time? - requirements for calculating this? Bradycardia for FHR - ? bpm for ? minute requirement - causes? Tachycardia for FHR - ? bpm for ? minute requirement - Causes (Maternal): - Causes (Fetal): - Non-reassuring with other FHR patterns: 2 things?

Baseline FHR: - First component to be evaluated - Mean FHR during 10 minute period --- Rounded to nearest 5 bpm --- Exclude accelerations & decelerations --- Must be observed for 2 minutes of the 10 minute period - Normal: 110-160. Decreases with gestational age Bradycardia <110 bpm for at least __10__ minutes - Causes: Vagal stimulation, Drugs, Maternal hypotension, Fetal hypoxemia Tachycardia > 160 for at least _10___ minutes - Causes (Maternal): fever, dehydration, meds/drugs, infection, anemia - Causes (Fetal): infection, activity, compensation after acute hypoxemia, chronic hypoxemia, cardiac abnormalities, tachyarrhythmia, anemia tachycardia is non-reassuring with these other FHR patterns: Absent or minimal variability, Late or severe variable decelerations

Before providing any type of pain relief method need to ensure....? Timing of Interventions (pain meds) support and touch can be just as effective as...?

Before providing any type of pain relief method need to ensure there is a healthy mom AND fetus Offered too soon will stop/slow labor Offered too late risk un-medicated delivery when she really wanted an epidural Sometimes delivery happens too quickly to allow pharmacological interventions - Very rapid labors/deliveries are more difficult to cope with the intensity and rapidity of the pain Analgesic effects predicted for the various stages of labor: - Latent: May slow contractions and labor progress - Active: Takes the "edge" off, usually does not slow labor progress, can cause decreased FHR variability - Transition: not much pain relief, may be too close to birth and cause resp depression - Second stage: not much help, too close to birth side notes: - The more tense other body muscles are, the less work the uterus can do AND the more painful the contractions feel - Support & touch can be as effective as narcotics

Biophysical Profile (BPP) - how does scoring work? what is the best score? worst? - name the 5 things the scoring is based off of. what are the requirements for each? Modified Biophysical Profile - how is it different than the biophysical profile? - 2 components and what do they each show?

Biophysical Profile (BPP): Assessment of fetal reflex activities controlled by the CNS and sensitive to fetal hypoxia Score of 2 (present) or 0 (absent) given for the following: - NST and - Ultrasound of 30 minutes duration ---Fetal breathing movements: at least 1 episode of fetal breathing lasting at least 30 seconds ---Fetal movement: three or more discrete body or limb movements ---Fetal tone: one or more extension/flexion movements of extremities ---Amniotic fluid volume: at least 1 pocket of at least 2cm or AFI > 5cm Total score: 8-10/10: normally oxygenated fetus and low risk of asphyxia - continue to care/testing 6/10: possible asphyxia - repeat or possible induction 0-4/10: very worrisome - deliver Modified Biophysical Profile - Less labor intensive and less expensive than BPP - Components: NST (Indicator of short-term fetal well-being) and AFI (Indicator of long-term placental function)

Breakdown of Episiotomy/Laceration - Causes: - S&S: "I feel like...." - Tx & Rx: - Worst Case: Infection: Cesarean Incision - Causes: - Tx: - Be alert for ____ Infection: Mastitis - Diagnostic S&S: - Rx: - Tx: - Abscess: requires what? can you breastfeed?

Breakdown of Episiotomy/Laceration - Causes: Poor tissue, Poor technique, Infection unknown - S&S: "I feel like I'm gaping open!" - Tx & Rx: ---Antibiotics ---Repair (if occurs within 1st 3 days) ---Debridement (if happens after 3 days of the original repair)....In this case, healing by secondary intent is the new method. - Worst Case: Necrotizing fasciitis (Group A Streptococcus "flesh eating") Infection: Cesarean Incision - Causes: Poor tissue (diabetes, obesity), Poor technique, unknown - Tx: Debridement, Irrigation, Packing, Healing by secondary intention, Antibiotics - Be alert for paralytic ileus! She is a surgical patient..... We LIKE gas after surgery! - sidenote: Obese women can use a "peri pad" to soak up moisture and decrease risk of this. Can also use hair dryer so dry moisture. Chewing gum can speed up bowels (which is good) after a C-section. Infection: Mastitis - Diagnostic S&S: High fever, Breast tenderness, Redness over clogged and infected lobule, "Cancer of the whole body" aka will feel horrible over whole body. - Rx: Antibiotics for Staph aureus, Dicloxicillin drug of choice - Tx: Continue to breastfeed - Abscess: Requires I&D, D/C breastfeeding until healed, antibiotics - sidenote: This is milk that is stuck in the nipple, after the nipple has trauma and the milk doesn't come out. Continue breast feeding will free this milk and stop the problem. IF abscess occurs, needs surgery and stop breast feeding temporarily.

Breast Milk Jaundice - Occurs when? lasts how long? peaks when? - Cause: - Treatment: Breastfeeding Jaundice - Appears when? - Causes - Treatment Physiologic Jaundice - Appears when? peaks when? No longer apparent when? - Causes Pathologic Jaundice - Appears when? Lasts how long? - Causes

Breast Milk Jaundice - Occurs 3-5 days after mature milk - May last several months but peaks around 2-3 weeks - Cause: Increased free fatty acids in some breast milk --> Free fatty acids compete with bilirubin binding sites on albumin --> Inhibits conjugation --> Increased reabsorption of bilirubin in GI tract - Treatment: Continue to breastfeed if bili levels <20mg/dl ----Interrupt breastfeeding ? Breastfeeding Jaundice - Appears in first few days - Cause ---Ineffective breastfeeding ---Dehydration ---Delayed meconium stool passage...One good meconium stool reduces bili level ~1 mg/dl - Treatment ----Support effective breastfeeding (Frequent feedings, Lactation consultation) ----Promote stooling...Colostrum is a great laxative ----Avoid supplementation Physiologic Jaundice - Normal adaptation - Appears after 24 hours - Peaks around 3-4 days - No longer apparent by 14 days - Causes ---Increased breakdown of fetal RBCs ---Impaired conjugation of bilirubin- lack of glucuronyl transferase ---More bilirubin reabsorbed by GI tract Pathologic Jaundice - Appears within the first 24 hours - Lasts longer than 1 week - Causes ---ABO incompatibility ---Hemolytic disease of the newborn ---Maternal disease processes: Diabetes, Intrauterine infections, Drugs (sulfa, salicylates, novobiocin, diazepam, oxytocin)

when does brown fat appear? what % of infant's body weight is it? can brown fat be replenished? Four methods of heat loss - Convection - Radiation - Evaporation - Conduction Once newborn is dried most common methods of heat loss are ?

Brown Fat - Appears around 26-30 weeks gestation - Comprises 2%-7% of infant's body weight ***Once depleted, brown fat is not replenished*** Four methods of heat loss - Convection: Heat lost to cooler ambient air - Radiation: Heat lost to cooler surfaces in close proximity - Evaporation: Heat lost as skin moisture is vaporized - Conduction: Heat lost to cooler surface area in direct contact with body Once newborn is dried most common methods of heat loss are convection & radiation

Caloric needs: Water requirements: Stools - Meconium- - Transitional- - Breast milk stools: To be certain they are getting enough nutrition/volume the newborn should (after milk begins to come in): - Poop: - Pee:

Caloric needs: 105-108 kcal/ kg/ day Water requirements: 140-160 ml/ kg/ day Stools - Meconium-thick, tarry, black, very sticky - Transitional-strange colors from green to yellow to brown - Breast milk stools: Breast fed babies poop more often, not as "stinky" Yellow with curds To be certain they are getting enough nutrition/volume the newborn should (after milk begins to come in): - Poop: 1+ a day - Pee: at least 6-8 wet diapers a day

in the postpartum period, how is the mom's blood volume affected? what happens to the respiratory system of a postpartum patient?

Cardiovascular: - Blood volume decrease- 1000-1500 ml ---Blood loss and Diuresis - Cardiac output: Initial increase and then Returns to pre-pregnant levels by 6-12 weeks - While auscultating the heart of a postpartum patient what might you hear related to the physiologic changes of pregnancy and postpartum? Respiratory: - Immediate decrease in pressure on the diaphragm. - What complication are you assessing for when auscultating the lungs?

Care of Neonate Receiving Phototherapy - Positioning of lights: ? cm from infant - what clothes does infant wear? care given to the infant under the lights? - Monitor: - what should happen to TSB levels? Exchange Transfusion - Used when .... - how does it work? - Morbidity and Mortality ---In 1985- Mortality ? % ---Significant complication rate ? %. this includes:

Care of Neonate Receiving Phototherapy - Positioning of lights: 45-50 cm from infant - Maximum exposure: Frequent position changes, Naked, Limit time out - Monitor: Vital signs-especially temperature, Intake and output, Side effects (Loose stools, dehydration, hyperthermia, lethargy, rashes, impaired bonding, eye damage), TSB levels- should drop 1-2 mg/dl within first 4-6 hours - Protect eyes Exchange transfusion - Used when phototherapy ineffective or severe hemolytic disease present - Replaces 85% of RBCs...Corrects anemia --> RBCs with maternal antibodies removed & other hemolysis toxins removed - Morbidity and Mortality ---Recent statistics limited by numbers of patients ---In 1985- Mortality 0.3% ---Significant complication rate~1%. this includes: Thrombocytopenia, hypocalcemia most common Metabolic acidosis, clots

Category I, 2, 3 fetal heart rate - the requirement for the FHR to fit into that category - goal if FHR is in the category - action for each category

Category I Includes ALL of these: - Normal baseline rate: 110-160 - Moderate variability - No late or variable decelerations Early decels: + or - Accelerations: + or - Goal of category 1 - Maximize perfusion - Maintain appropriate uterine activity Actions of category 1 - Intermittent auscultation/uterine palpation if low risk and appropriate - Intermittent EFM Category II - All other patterns NOT included in Category 1 or Category 3 - goal: Prevent worsening/improve oxygenation - action: Increase frequency of FHR assessment, Continue or initiate EFM, Initiate intrauterine resuscitation Category III Include EITHER: Absent variability with ANY of these: Recurrent lates, Recurrent variables, Bradycardia ....OR... Sinusoidal pattern - goal for category 3 FHR: Correct abnormal oxygenation - action for category 3 FHR: Continuous EFM, Initiate intrauterine resuscitation, Prepare for C-section if no improvement

Causes of Pain in 1st Stage of Labor - list causes - spinal cord segment in pain? Causes of Pain in 2nd Stage - list causes - spinal cord segment in pain? pain in 3rd stage? pain in 4th stage is caused by...? - the more babies the woman has...?

Causes of Pain in 1st Stage of Labor - Cervical effacement & dilatation - Hypoxia of uterine muscle cells - Stretching of lower uterine segment - Pressure on adjacent structures: Referred pain-low back, thighs, buttocks, groin, iliac crest - Pain impulses enter spinal cord at L1, T10-12 Causes of Pain in 2nd Stage - Uterine hypoxia - Stretching of vagina, pelvic floor - Pain impulses enter spinal cord through S2-4 - Distention of lower uterine segment - Pressure on adjacent structures Don't forget there may be pain also in Stage 3 and 4 that may require management of pain Usually in stage 3 there is not significant pain and the arrival of the new baby helps to distract the woman from this pain Stage 4 and during postpartum recovery- "After birth pains" are those contractions of the uterus to help prevent hemorrhage and may actually exceed the pain experienced by labor contractions. The more babies the woman has the harder the uterus has to work to contract and the worse the after birth pains may be

when would you do a Cord Blood Gas Collection? until the newborn is bathed, you need to...?

Cord Blood Gas Collection: - Non-reassuring FHR or depressed neonate - Extra section of cord is obtained - Arterial and venous blood samples obtained for cord blood gas assessment ---pH >7 ---Base excess < -12 Until first bath is completed, use gloves when handling newborn. this will be given when temperature is stable. - Immersion baths are evidenced base... less temperature drop (0.1 vs. 0.3), tolerated better by newborn, no increased risk of cord infection, and does not increase length of time for cord drying - With males that are circumcised do sponge bath until site healed

Cord Clamping when baby is born - With first breath blood flows to lungs, what happens to umbilical arteries? how does resistance of pulmonary bed change? - what happens to umbilical vein? sequence what happens when baby takes first breath

Cord Clamping - With first breath blood flows to lungs...Umbilical arteries immediately constrict AND Pulmonary bed moves from high resistance bed to low resistance bed - Umbilical vein continues to receive blood from intervillous space -----Delayed vs. immediate cord clamping First Breath ---> Increased PaO2 ---> Increased pulmonary blood flow ---> Decreased pulmonary vascular resistance ---> --Increased blood return to left heart --Mechanical closure of ducti --Blood pumped from lungs to body --Blood returned to right side of heart --Placental system, UA/UV shut down final result = Blood is oxygenated in neonatal lungs and sent to body

state if each is normal or a potential problem in a newborn baby that is 12 hours old in a quiet-alert state: - Crackles on auscultation of the lungs - Respirations: 36 breaths/minute, irregular, shallow - Episodic pauses in respirations of 5-15 seconds - Nasal flaring and sternal retractions - Slight bluish discoloration of hands and feet - Apical heart rate: 126 bpm with a murmur - Temperature: 36 C - Regurgitation of small amount of milk following first two feedings - Two small white cysts at gum margins and on palate - Pink-tinged stains on diaper with first two voids - Boggy, edematous swelling over occiput - Overlapping of parietal bones - White pimple like spots on nose and chin - Jaundice on face - Blood glucose of 48 mg/dL - Liver palpated at 1cm below right costal margin - Absence of bowel elimination since birth - Spine straight with dimple and small tuft of hair at the base - Adhesion of prepuce; unable to fully retract foreskin - Edema of labia majora

Crackles on auscultation of the lungs = Potential problem Respirations: 36 breaths/minute, irregular, shallow = Normal Episodic pauses in respirations of 5-15 seconds = Normal Nasal flaring and sternal retractions = Potential Problem Slight bluish discoloration of hands and feet = Normal Apical heart rate: 126 bpm with a murmur = Normal Temperature: 36 C = Potential Problem Regurgitation of small amount of milk following first two feedings = Normal Two small white cysts at gum margins and on palate = Normal Pink-tinged stains on diaper with first two voids = Normal Boggy, edematous swelling over occiput = Normal Overlapping of parietal bones = Normal White pimple like spots on nose and chin = Normal Jaundice on face = Potential Problem Blood glucose of 48 mg/dL = Normal Liver palpated at 1cm below right costal margin = Normal Absence of bowel elimination since birth = Normal Spine straight with dimple and small tuft of hair at the base = Potential problem Adhesion of prepuce; unable to fully retract foreskin = Normal Edema of labia majora = Normal

Positioning for breast feeding - Cradle hold - Cross cradle hold, modified cradle, or across the belly cradle hold - Football - Side-lying For mother to hold the breast while breast feeding... best way to do it? what way is discouraged and why?

Cradle hold - Mother to sit upright using good body alignment - Baby placed on lap belly to belly position, side-lying with nose at nipple - Head cradled in crook of arm on the same side as the breast - Breast is supported by hand opposite breast she is feeding on Cross cradle hold, modified cradle, or across the belly cradle hold - Mother to sit in upright position using good body alignment...Pillows for support - Baby placed on lap- belly to belly or baby in side-lying position with baby's nose at nipple - Head supported with hand opposite breast she is feeding on positioned on nape of neck - Breast supported by hand on same side Football - Mother to sit upright...Pillows used to raise baby's body to breast level - Baby's bottom rests near mother's elbow and body turned slightly to face breast - Head supported at nape of neck and body is supported by mother's arm - Breast is supported with hand opposite breast she is feeding on Side-lying - Mother lies on side...Pillows support head and back, between bent knees - Baby placed in side-lying position next to mother, belly to belly, nose lined up with nipple, pillow or roll placed behind back - Breast supported by hand opposite breast she is feeding on (top arm) holding breast method: - best way: make a "C" with hand. this is called "C-hold". thumb on top of breast and 4 fingers below to help position/hold the breast - do NOT: use "scissors hold". this is 2 fingers above nipple and 3 fingers below. because moms are unable to keep fingers at least 1 ½ inches from base of aerola.

sleep/behavior state of the newborn: - deep/quiet sleep: eye movements, breathing pattern, movements, how easily startled? - REM sleep: eye movements, breathing pattern, movements, sucking motion, activity level, how easily startled? - drowsy alert state: eye movements, activity level, how easily startled? - wide awake: focus level, activity level - active awake: eye movement, activity level, extremities, how easily startled? feeding baby is best during which state?

Deep or quiet sleep - Closed eyes with no eye movements - Regular, even breathing - Jerky movements or startles easily REM sleep - Eyes closed with eye movements noted - Irregular breathing - Irregular sucking motions - Minimal activity - External stimuli will initiate a startle reaction Drowsy Alert - Open or closed eyes - Semi-dozing appearance - Slow regular movements - Mild startles may be noted Wide Awake - Alert and focuses on objects - Minimal motor activity - Good time to feed Active Alert - Eyes open - Intense motor activity with thrusting movements of the extremities - Startles easily and increased movement from stimuli feeding baby is best during wide awake state

One of the routine tests done on a newborn is screening for critical congenital heart disease (CCHD). - Describe how and when this screening is done. - Describe the findings from this CCHD screening that warrant further testing (include any repeat testing needed).

Describe how and when this screening for CCHD is done. - Between 24-48 hours of life or just prior to discharge from the hospital the newborn is screened for critical congenital heart defects using a pulse oximeter to measure the oxygen saturation. - Oxygen saturation is measured in the right hand and one foot and is considered normal if O2 sat is >95% in either extremity and there is <3% absolute difference between the upper and lower extremities. Describe the findings from this CCHD screening that warrant further testing (include any repeat testing needed). - Positive screens are ----O2 sat < 90% in right hand or foot ----90-95% in right hand or foot OR >3% difference between the two extremities......Retest in 1 hour up to 2 times....... If parameters remain unchanged after third time considered positive screen.........Additional testing needed for any positive screening (i.e. echocardiogram).

after giving birth, how long can decreased libido last for? when will the woman become fertile again after giving birth? Closely spaced pregnancies (where conception occurs within 0-18 months following a birth) increases risks for complications:

Diminished libido for up to a year is normal. - also... decreased lubrication, Pain, Fatigue, Body self image, Emotional exhaustion Difficult to predict return to fertility...Could be weeks, could be years Closely spaced pregnancies increases risks for complications: Early pregnancy loss, Placental abruption and/or placental previa, Anemia, Cervical weakness, Uterine rupture, Preterm delivery, Low birth weight, preeclampsia

Doppler Flow Studies - what is this? what does it measure? ---Commonly used for _______ evaluation Estimation of fetal weight in 3rd trimester - is this reliable? - Intrauterine growth restriction (IUGR): baby is below what percentile? Causes? - what is Macrosomia? Weight range for this?

Doppler Flow Studies - Ultrasound evaluation assessing placental function - Measures blood flow through umbilical artery ---Most common is systolic to diastolic ratio (S/D ratio)-absent, reversed or elevated demonstrates abnormal blood flow ---Commonly used for fetal growth restriction evaluation Estimation of fetal weight in 3rd trimester - Methods of evaluation are imprecise - Inadequate or excessive growth may indicate alterations in fetal well-being - Intrauterine growth restriction (IUGR) ---Any baby below 10th percentile ---Causes: infection, placental problems, genetic abnormalities, uteroplacental insufficiency - Macrosomia- excessive growth. Weight: 4,000-4,500 grams

Lactation Amenorrhea Method (LAM) birth control method that is not recommended for breast feeding and why? what is another big issue with this type of birth control?

Effectiveness for avoiding pregnancy can be up to 98% effective ONLY IF ALL OF THE FOLLOWING ARE TRUE: - 100% of baby's intake is from breastfeeding (no supplementation, no solids, minimal pacifier use) - Breastfeeding on demand, at least every 4 hours during the day and 6 hours at night - Menstruation has not resumed - Baby is UNDER 6 months of age Combination (E/P) Methods...Often diminish milk supply - not recommended for breastfeeding - Combined (E/P) pills (many brands) - taken daily - Patch (Ortho-Evra) - patches applied weekly - Vaginal Ring (Nuvaring) - placed into-vaginally for up to 4 weeks - another big issue: Increased risk for DVT....initiation of those methods should be delayed for 4-6weeks postpartum -Side effects: breast tenderness, nausea, vomiting

Obstetrical Anesthesia: Regional - Epidural/Spinal/Intrathecal: Used for... - Intrathecal or "walking epidural": what is it? - Pudendal: Used in ___ stage and also ___ - Para cervical Block: what does it do?

Epidural/Spinal/Intrathecal: Used for labor or c/s Intrathecal or "walking epidural": combined spinal-epidural block Pudendal: Used in second stage and repair of the perineum Para cervical Block: Blocks cervical pain sidenote Intrathecal: faster onset, wears off in 1-3 hours (good for multips closer to delivery)

Contraction Stress Test - evaluates what? - requirements for adequate testing? - 3 outcomes of this test? what does each outcome mean and what is it associated with?

Evaluates response of fetus to the stress of contractions Contractions causes decreased oxygen transport to fetus Adequate testing: Three contractions in 10 minutes lasting 40 seconds Contractions can be spontaneous, induced with Pitocin or nipple stimulation Negative CST - No significant variable or late decelerations noted - Associated with good fetal outcomes Positive CST - Late decelerations noted with at least 50% of contractions - Require further testing Equivocal CST/Suspicious - Intermittent lates or variable decelerations - Require further testing

FHR Changes - occurs with contractions or without them? - do you include accelerations/decelerations in this?

FHR Changes - May occur with or without contractions - Includes: Accelerations, Decelerations

Facial Palsy - what is it? most noticeable when? permanent? Single Transverse Palmer crease Congenital Hip Dislocation - Barlow maneuver - Ortollani maneuver - Allis maneuver Club Foot - Assessment

Facial Palsy - Asymmetry of the face due to injury of the facial nerve - Most noticeable when infant cries and the affected side is immobile - Usually disappears in a few weeks but may be permanent What is the significance of a single palmar crease? Congenital Hip Dislocation - Barlow maneuver- grasp thighs, bring knees together and press down- if there is congenital hip displacement, able to feel the femoral head slip out of the acetabulum - Ortollani maneuver- the thighs are abducted and returns the femoral head back to the acetabulum. A thunk is felt as head slips back into acetabulum - Allis maneuver- while thighs are adducted pull up on one thigh trying to feel femoral head slip out of the acetabulum club foot: To assess for club foot the newborn's foot is moved to midline—resistance indicates talipes equinovarus

Fetal spiral electrode (FSE) - Measures FHR by ... - how does this work? - Require....2 things? - Benefits: - Disadvantages: Intrauterine pressure catheter (IUPC) - Measures.... - Placed where? - Used for: how to calculate MVUs? - how to calculate contractions in Montevideo Units (MVUs)? what number is adequate for most labors to progress?

Fetal spiral electrode (FSE) - Measures FHR by reading fetal ECG - Fine wire placed under skin of presenting part - Require ruptured membranes and cervical dilation - Benefits: More accurate picture of FHR, Not affected by movement - Disadvantages: Invasive, Risk of infection Intrauterine pressure catheter (IUPC) - Measures pressure in the uterus in mmHG, frequency/duration/intensity of contractions, resting tone (tone of uterus between contractions) - Placed in uterus alongside the fetus to the fundus - Used for: evaluate effectiveness of contractions.....May also be used for an amnioinfusion - MVUs: total intensity of each contraction in 10 minute period. MVUs over 200 are adequate for most labors to progress.

Foramen Ovale - what does it do during pregnancy? - how does it close once baby is born? when is it functionally closed vs. permanently closed? what could cause it to reopen before it permanently closes? Ductus Arteriosus - what does it do during pregnancy? - how does it constrict/close once baby is born? - when does it functionally close? when does it completely close? what is the new name for it after it is completely closed? Ductus Venosus - what does it do during pregnancy? - how does it close once baby is born? ----how is the flow of blood redistributed (2 ways)? ---mechanical closure occurs with what? ---when does it permanently close and what is the new name for it?

Foramen Ovale - during pregnancy: Shunts blood from right atrium to left atrium. Shunts blood from pulmonary artery and lungs by never letting it get to the right ventricle - closure: ---With first breath... PaO2 rises and Pulmonary arteries dilate ---Increased blood returns to left atrium... Foramen ovale closes due to increased pressure gradient in left side of heart ---Functionally closed at 1-2 hours.... Crying, acidosis, cold stress or hypoxia may cause reopening ---Permanently closes by 6 months Ductus Arteriosus - pregnancy: Shunts blood away from pulmonary artery and lungs into the descending aorta. Shunts blood away from the left side of the heart - closure: ----Increased PaO2 AND drop in prostaglandins E2 from placenta cause Ductus Arteriosus to constrict ---Pressure from left heart causes mechanical closure of ductus arteriosus - Functional closure 10-15 hrs. after birth - Fibrosis of ductus arteriosus is complete within 4 weeks: becomes known as ligamentum venosum Ductus Venosus - pregnancy: Branches of umbilical vein that carries blood away from the fetal liver, directly into vena cava. - Closeure: --- Exact causes for closure is unknown --- Redistribution of blood through newborn liver ---> Flows through hepatic vein into the inferior vena cava ---> Increases blood return to right side of heart - Mechanical closure with umbilical cord clamping/cutting - Fibrosis occurs within 2 months—becomes ligamentum venosus

Fractured Clavicle - common or uncommon? - Risk factors: - Assessment: - Treatment: Brachial plexus injury - Erb's palsy: damage to what areas of body? what spinal segment? - Klumpke's- damage to what areas of body? what spinal segment? - Cause:

Fractured Clavicle - Fairly common - Risk factors: Macrosomia, Shoulder dystocia, Forceps and vacuum, Unpredictable - Assessment: Crepitus, Difficulty feeling clavicle - Treatment: Pain management, Immobilization for 7-10 days Brachial plexus injury - Erb's palsy: damage to network of nerves for arm, hand and shoulder (C5-8 and T1) - Klumpke's- nerves of forearm and hand (C8 and T1) - Cause: Excessive or improper traction on head during birth

Increased information provided by assessment of uterine contractions with an intrauterine pressure catheter includes: Ms. S. is at 39 weeks. Her pregnancy has been uncomplicated so far. She presents to L&D with complaints that her baby hasn't been moving much today. She denies any contractions, bleeding or leaking of water. What is the first method in assessing fetal well-being in this case?

Frequency, duration, intensity, and resting tone Non-stress test

Habituation: Orientation: baby prefers what to look at? baby can best see things when they are ___ and ___ inches away? can the baby respond to auditory stimuli with behavior? are babies sensitive to touch? what age can babies differentiate mother's smell? taste buds can differentiate _____? taste buds are fully developed by.... years of age? what reflex occurs when hungry?

Habituation: Eventually blocks out annoying stimuli Orientation: Follows faces, shiny objects, lights Visual - Prefers the human face and eyes - High contrast items - 8-15 inches ideal distance for focusing Auditory - Responds to auditory stimuli with organized behavior Tactile - Very sensitive to touch - May be most important Olfactory - Can differentiate mother's smell by 1 week of age Taste and suck - Able to taste sweet and sour - Taste buds not fully developed until age 4 yrs. - Suck occurs in bursts - Rooting reflex when hungry

Hematological Adaptation in newborn - blood volume in term newborns? contributing factors for this? - characteristic of fetal RBCs? Hepatic Adaptation in newborn - what is the neonate liver lacking? - the neonatal gut is ____? so this means... - how is iron handled in the neonate? - what is the liver and bilirubin relationship? Physiologic Jaundice - timeframe? peak? - normal or abnormal? - 3 causes?

Hematological Adaptation - Blood volume in term newborn ~80-85 ml/kg ---Contributing factors: Antenatal hemorrhage, Rh alloimmunization, Time of cord clamping/ level of baby R/T placenta - Fetal RBC have short half life....Contributes to physiological jaundice Hepatic Adaptation - Neonatal liver is immature ----Lack glucuronyl transferase- more difficult to conjugate bilirubin and excrete it ----Higher levels of unconjugated bilirubin leads to physiological jaundice - Neonatal gut is sterile ----No bacteria to synthesize vitamin K- ----Liver does not produce vitamin K dependent clotting factors-- factors I, VII, IX & X - Liver frequently palpable—about 40% of abdominal cavity - Iron stores from maternal intake sufficient for ~ 5 months - Bilirubin Conjugation ----Conversion of fat soluble to water soluble ----Total serum bilirubin= conjugated (direct) + unconjugated (indirect) bilirubin ----After birth, liver must conjugate bilirubin....Early feedings & getting gut moving to pass stools assists liver in removal of conjugated bilirubin Physiologic Jaundice - Appears after 24 hours and is no longer apparent by 14 days - Peaks around 3-4 days - Not pathological but a normal adaptation after birth - Causes ---Increased breakdown of fetal RBCs ---Impaired conjugation of bilirubin- lack of glucuronyl transferase....Higher levels of unconjugated bilirubin leads to physiological jaundice ---More bilirubin reabsorbed by GI tract

How is labor pain different than all other pain? List three benefits of epidural anesthesia E.A. received an epidural 20 minutes ago and now her blood pressure is 75/40. What effect might you see in her fetus and what are two nursing actions you may do to correct her hypotension? Hint one action is a medication to be given

How is labor pain different than all other pain? - Purposeful, Anticipate, Intermittent, Normal - Not associated with pathology or tissue damage List three benefits of epidural anesthesia - Good pain relief - Fully awake - Avoidance of general anesthesia if c/s is required - Mediate exhaustion and stress effects - Can provide different blockage for different stages of labor if a woman has hypotension, her fetus will have: - Late decelerations - Prolonged decelerations Nursing Actions to correct this hypotension include: - IV fluid bolus - Ephedrine 5-15 mg IV

Hyperbilirubinemia of newborn: total serum bilirubin - high risk zone: - high intermediate risk zone: - low intermediate risk zone: - low risk zone: Hyperbilirubinemia Treatment for newborn - Treatment guidelines based on 3 things - treatment based on age for phototherapy and exchange therapy - most widely used treatment & physiology behind it

Hyperbilirubinemia: total serum bilirubin - high risk zone: 95%+. repeat within 4-8 hours. - high intermediate risk zone: 75-94%. repeat within 8-12 hours. - low intermediate risk zone: 40-75%. repeat within 48 hours. - low risk zone: under 40%. follow up at 3-5 days. Hyperbilirubinemia Treatment - Most widely used treatment: Phototherapy ---Blue lights most effective ---Physiology: Converts to water soluble form...Excreted via urine and stool Phototherapy 24 hours: > 8-12 mg/dl 48 hours: > 11-15 mg/dl 72 hours: > 13.5- 18 mg/dl Exchange Transfusion 24 hours: > 15-19 mg/dl 48 hours: > 17-22 mg/dl 72 hours: > 18.5- 25 mg/dl

Susan is a term newborn who is 2 days old. She last breastfed 5 hours ago. Her mother tells the nurse that Susan is so sleepy that she just done not have the heart to wake her. - Identify one nursing diagnosis and one expected outcome appropriate for this newborn. - Discuss the approach the nurse should take with regard to this situation.

Identify one nursing diagnosis and one expected outcome appropriate for this newborn. - Nursing diagnosis: Imbalanced nutrition: less than body requirements related to infrequent feeding of newborn - Expected outcome: Mother will awaken infant every 2-3 hours during the day and every 4 hours at night to feed the infant, achieving approximately 8-12 feedings per day Discuss the approach the nurse should take with regard to this situation. - Discuss feeding cues to facilitate proper timing of feedings - Discuss techniques to wake her sleeping baby - Educate on signs of adequate intake - Discuss potential problems with infrequent feedings

Ilotycin eye ointment (erythromycin) - Legally required for....? - applied when? Vitamin K (Phytonadione) - purpose? - dose/route? Hepatitis B vaccine - purpose? - specifications? - route? where? Hepatitis B Immuglobulin - Given to newborn if.... - In addition to....

Ilotycin eye ointment (erythromycin) - Legally required for prevention of gonorrhea and chlamydia ophthalmic infections - At least ¼ inch strand - Within first hour of life- allow for period of bonding first Vitamin K (Phytonadione) - Prevention of hemorrhage... Lacks gut bacterial flora necessary for synthesizing vitamin K - One time injection of 0.5-1 mg IM in vastus lateralis. Neonatal concentration 1 mg/0.5 ml Hepatitis B vaccine - Series of 3 shots to prevent Hep B infection - Some providers will begin series in the hospital - Given IM in vastus lateralis Hepatitis B Immuglobulin - Given to newborn if mother is Hepatitis B positive - In addition to Hepatitis B vaccine

Immunological Adaptation - how is the immune system functioning? - what is NOT a reliable indicator of infection? - immunoglobulin types: IgG, IgM, IgA. from where is the newborn receiving each of these? Neurological & Sensory/Perceptual Adaptation - size of brain of newborn to adult size? - direction of maturity of neurological system? first and second period of reactivity

Immunological Adaptation - Immune system not fully activated - Fever NOT a reliable indicator of infection - Immunoglobulins: ----IgG: Only type small enough to cross placenta; passive acquired immunity from mother usually in 3rd trimester ----IgM: begin to produce on own by 15 weeks of age ----IgA: receive from breast milk especially colostrum Neurological & Sensory/Perceptual Adaptation - Brain one-quarter size of adult brain...Myelination of nerve fibers incomplete - Maturity of neurological system progresses in cephalocaudal direction (top to bottom) First period of reactivity - Birth to about 30 minutes after birth - Bonding, initiate breastfeeding - Respirations and heart rate rapid Second period of reactivity - Awake and alert - Lasts 2 to 5 hours - Physiologic responses vary - GI tract more active - Good time for bonding

Hyperbilirubinemia of newborn - incidence % in term and preterm infants? - process of bilirubin conjugation and excretion - factors that cause this in infants? - risk factors - 4 types - what direction of progression does this have? - assessment - how to decrease risk - 3 lab tests to figure this out

Incidence 50% of term neonates 85% of preterm infants Bilirubin conjugation and excretion process - RBC breakdown produces UNCONJUGATED bilirubin (fat soluble) - Transported to liver by Albumin - Liver converts to water soluble bilirubin (CONJUGATED) - Conjugated bilirubin excreted into bile duct and then into intestines - Excreted via urine and stool factors: - Short ½ life of fetal RBCs (70-90 days) - Increased red cell volume - Lack of gut bacteria & low GI motility causes increased reabsorption of bili - Decreased conjugation due to lack of glucuronyl transferase - More bilirubin produced Risk Factors - Asian, Native American, Greek, Hypoxia/asphyxia ,Use of oxytocin, Delayed feedings, excessive weight loss, Prematurity, Epidural bupivacaine, Sibling with jaundice, Ineffective breastfeeding, Maternal diabetes with macrosomia, ABO/Rh incompatibility, Birth trauma, Infections, Male gender Types - Physiological, Pathological, Breastfeeding, Breast milk Head to toe progression Assessment - Blanch skin beginning on face and moving down body - Consider lighting of room Decrease risks: Prevent cold stress, Promote early feedings, Monitor stools Lab testing - Direct Coombs test (DAT) - Total serum bilirubin (TSB)...Visually apparent jaundice=TSB of 4-6 mg/dl - Transcutaneous bilirubin level

newborn's metabolic rate is slower or faster once it's born? does muscle activity keep the baby warm? how does non-shivering thermogenesis keep the baby warm?

Increased basal metabolic rate - Result of increased glucose conversion to energy Muscular activity - Doesn't produce enough heat Non-shivering thermogenesis- major source of heat production - Stimulation of sympathetic nervous system by the cold on skin receptors causes newborn to use brown fat stores to produce heat - Unique to newborn - Facilitates metabolism of triglycerides for heat production

Ethical Issues with Epidural find answers to these??

Informed consent - Question: Can a woman in severe pain give informed consent? Epidurals lead to other interventions - Continuous fetal monitoring - ? Increased risk of C-section or assisted vaginal delivery (forceps or vacuum)

Epidural Anesthesia - injected into which exact vertebrae? - what is in this epidural medication? - 3 contradictions - advantages of epidural ----what happens to the veins

Injection of Anesthetic into epidural space - L-2 to L-4 vertebrae with a T-8 to S-5 block - Variety of "caine" drugs + narcotics Contraindications - Allergy to the agent - Clotting disorders or hemorrhage - Hx of spinal injury or abnormality Epidural Advantages - Provides good pain relief and assists with coping - Allows woman to be fully awake - Continuous epidurals...Allows for different blocking during each stage of labor. dose can be adjusted - Avoidance of general anesthesia if unplanned c/s - May mediate maternal exhaustion and stress effects and allow her to rest—wake up when ready to push - Great for women with a history of sexual abuse - Vasodilation—improve placental perfusion and decrease maternal HTN for a time

the uterus postpartum - what happens immediately? at 6 weeks? A nurse is doing a fundal assessment of a patient and finds that her uterus is 2 fingers above the umbilicus and displaced to her right. What actions should the nurse take related to this finding?

Involution - Immediate postpartum - Next 6 weeks: Cells atrophy and shrink, Returns to non-pregnant location and size, Rate of descent What actions should the nurse take related to this finding? - empty bladder and then reassess the fundus

Kangaroo reflex- if suctioning is needed for infant, do you suction nose or mouth first? Galant reflex protective reflex does newborn immediately reach 95%+ oxygenation after birth?

Kangaroo reflex- mom increases her temp until newborn's temp normalizes suction MOUTH 1st / NARES 2nd Galant reflex = aka "truncal incurvation reflex" - a newborn reflex. It is elicited by holding the newborn in face down and stroking along the one side of the spine. - normal reaction = the newborn laterally flexes toward the stimulated side. protective reflex: infant protects itself by throwing arms forward to protect itself, etc. Normal oxygen saturation in utero = 60% - Takes up to 10 minutes to be >90% oxygenation

What assessments are needed for a breastfeeding mom? Bottle feeding mom? for bowel movement, what will change for the postpartum patient? what degree laceration will warrant more treatment? Bladder - how is the bladder changed for postpartum? - Kidney function-returns to normal by ? - Ureters and renal pelvices- ??? takes 2-8 weeks to normalize - Transient increase in ?-caused by breakdown of uterine tissue

LATCH score- evaluates feeding effectiveness - The higher the score the more effective the feeding - By 12 hours of age the score should be >6 Bowels: - First BM - Decreased intestinal tone and motility- normal by 2nd week - Assess for BS: Which patients is this especially important for? Additional considerations with 3rd/4th degree lacerations Bladder - Decreased sensation. What can this decreased sensation lead to? - Kidney function-returns to normal by 1 month - Ureters and renal pelvices-hypotonia/dilation takes 2-8 weeks to normalize - Transient increase in BUN and proteinuria-caused by breakdown of uterine tissue

What procedures need to be done before the newborn can be discharged home? blood pressure on newborn?

Labs - Metabolic screening for Inborn Errors of Metabolism (IEM) - Total Bilirubin: Plotted on graph based on age to determine risk Hearing Screen - Assesses brain wave activity related to transmission of sounds - Retained amniotic fluid in ears may prevent passing the hearing screen Discharge physical by pediatric provider Follow-up appointment scheduled Blood Pressure = 70-50/45-40 mmHG at birth - May not be routinely measured on healthy newborns - If done comparison is made to upper and lower extremities which can signal cardiac abnormalities

Lactogenesis Stage I, 2, and 3

Lactogenesis Stage I - Colostrum ("Liquid gold"): first 3-4 Days. ---Clear yellowish fluid. Production begins in mid pregnancy --- Small amount to allow the baby to learn to suck, swallow and breathe at the same time --- High in protein, immunoglobulins & minerals --- High protein level facilitates bonding bilirubin --- Acts as a laxative to: Pass meconium & Pass bilirubin Lactogenesis Stage II - "Milk coming in" phase: day 3-5 to day 10 - Breast milk continues to 'mature' - "Engorgement" likely to occur at this point --- Causes of engorgement: Response to hormonal changes, Milk production, Engorged blood vessels & lymphatic swelling --- Symptoms of engorgement: Full, hard, tender, warm breasts Lactogenesis Stage III - Mature Milk: Day 10 ---Fat content of BM increases as neonate feeds - Foremilk: bluish-white (60% skim & 30% whole milk) ---Lactose, protein & WS vitamins - Hind milk: cream (5%) ---For calories ---Occurs 10-20 minutes in to feeding ---Why you must try & 'empty' breast q feeding

Neonatal Sepsis - Leading cause of ? - Risk of mortality ? %; may be as high as ? % if untreated - 15-20% residual neurologic damage in ? Joint Commission Perinatal Core Indicator - Transmission is what direction? ----Transplacentally- what type of infections? ----Ascending- R/T ? ----Delivery exposure- 2 diseases Types of neonatal sepsis - Early onset: within first ? days—??? is #1 culprit. Higher incidence with _____ - Late onset: time frame? due to what infections? Symptoms - Respiratory: - Thermoregulation: - Neurological: - feeding? glucose levels? - Cardiovascular: Evaluation - what tests/labs can you run to evaluate? ---WBCs- low or high would indicate sepsis? ---Neutrophils- low or high would show sepsis? ---Bands (immature WBC)- low or high would show sepsis? Prevention: - main prevention method? - Antibiotics: when do you start them? -Nutrition: may need a special modification?

Leading cause of morbidity and mortality - Risk of mortality-5-15%; may be as high as 50% if untreated - 15-20% residual neurologic damage in meningitis Joint Commission Perinatal Core Indicator - Transmission is Vertical or Horizontal - 3 different ways of vertical transmission ----Transplacentally-TORCH infections ----Ascending- R/T prolonged rupture of membranes ----Delivery exposure-herpes, GBS Types of neonatal sepsis - Early onset: within first 7 days—GBS #1 culprit. Higher incidence with low birth weight - Late onset: 8 days to 3 months- Staph, pseudomonas, e-coli Risk factors: Maternal, Neonatal, Environmental Symptoms - Respiratory: Apnea, grunting, tachypnea, cyanosis - Thermoregulation: Temperature instability, hypothermia - Neurological: Lethargy - Poor feeding, glucose instability - Cardiovascular: brady/tachy, hypotension, poor perfusion Evaluation - CBC ---WBCs-high or low ---Neutrophils-low ---Bands (immature WBC)-high - Blood cultures - Spinal tap - Others-c-reactive protein, urine culture, chest x-ray Prevention: Prenatally, Intrapartum, Postnatal - GOOD HAND HYGIENE - Treatment and Nursing care ---Antibiotics: start prior to blood culture results ---Nutrition-may be NPO ---Assessment- symptoms, weight, I&Os, hypoglycemia, electrolyte imbalances ---Respiratory & cardiovascular support ---Support bonding & parental education

Spinal Block Advantages - injected where? - onset time? - used for which type of birth mainly? - what level risk of failure? how much drug volume do you need?

Local anesthetic agent injected directly into spinal canal Onset of anesthesia is immediate Mostly used for cesarean birth - Can be used for vaginal delivery if delivery imminent Lower risk of failure Smaller drug volumes

what is Effleurage? What are intradermal water injections? how do they help labor pain? what is TENS unit and how does it help labor pain? does hypnosis help labor pain? Bradley breathing technique? Lamaze Breathing

Massage: Effleurage- light feather stroking of any area of body- may do herself Intradermal water injections - Reduces low back pain severity and provides relief for up to 2 hours - injected on lower back, right above butt TENS unit - Electrical stimulation of the nerves blocks pain perception, reduces excitation of central neurons and there is activation of the opioid receptors in the CNS - attached to lower back area Hypnosis When it works it works really well Bradley breathing technique = Slow and focused throughout labor Lamaze Breathing - Cleansing breath before and after: Deep breath in through nose out through mouth - Slow chest breathing: Usually used in early and active labor - Modified paced: Usually used in active labor and transition - Pattern paced- "Hee, hee, hee, hoo": Usually used in transition to pushing - Quick method: Pant-pant-blow - Puffing: Used when urge to push prior to complete dilation

Intermittent Auscultation (IA) & Palpation of Contractions - used for which population? - benefits and disadvantages of intermittent auscultation - for palpation of contraction: 3 levels of intensity for contraction? how is duration of contraction measured? how is frequency measured?

May be used for assessment especially in low risk women Requires 1:1 nurse-patient ratio and proper technique auscultation with a fetoscope or doppler Follows low risk guidelines (q 30 min & q 15min) FHR assessed before, during and after contractions Benefits - Non invasive - Does not "tie" the woman to a monitor - Increases "hands-on" patient care Disadvantages - No permanent record - Maternal size and position can inhibit ability to auscultate fetal heart rate and palpation of contractions - Difficult to assess uterine pressure quantitatively - Time intensive for palpating contractions.... - Intensity: Mild, Moderate, and Strong - Duration(seconds) length of one contraction from beginning to end - Frequency (minutes) onset of one contraction to onset of the NEXT contraction look at power point "fetal monitoring modules part 1 and 2" for a visualization of this

Amniotic Fluid Index - measures what? - average range of amniotic fluid normally? - low amount of amniotic fluid is called...? what is the requirement? associated with? - high amount of amniotic fluid is called...? what is the requirement? associated with?

Measurement of the volume of amniotic fluid with ultrasound - Amount varies through pregnancy- average 8 to 24 cm Prolonged fetal hypoxemia causes shunting of blood away from the kidneys - Decreases production of fetal urine and therefore decreased AFI Deepest pockets measured in 4 quadrants of maternal abdomen via U/S Oligohydramnios- low fluid - 5cm or less - Associated with increase prenatal mortality Hydramnios- as known as Polyhydramnios - 25cm+ - May be associate with fetal malformation Obstruction of GI tract, NTDs, or fetal hydrops

The most critical adjustment that a newborn must make at birth is the establishment of respirations. LIST the factors that are responsible for the initiation of breathing after birth. - mechanical factors - chemical factors - thermal stimuli - sensory stimuli

Mechanical o Chest compression increases intrathoracic pressure o Some fluid expelled o Fluid reabsorbed o Chest recoil causes passive air entry into alveoli Chemical o Transitory asphyxia o Rise in PCO2 o Decreased pH o Decreased O2 o Chemoreceptors stimulated & triggers respiratory center o Prostaglandin levels fall increasing respiratory drive Thermal Stimuli o Temperature of environment drops from 98.6 F to about 70F o Skin sensors stimulated o Causes rhythmic respirations Sensory Stimuli o Auditory o Visual o Touch/pain o Proprioceptor Stimulation--Baby scares itself o Helps maintain respirations

Nitrous Oxide - Mechanism of action: - how does it affect the mother? - Onset of action: - Clearance: - how is it Administered? - Concentration: - Advantages/uses: - other uses? - 2 main Side effects: - 4 Contraindications: - Effects on fetus/newborn - Patient safety and education

Mechanism of action: - Exact mechanism unknown - May stimulate endogenous endorphin, corticotropins, and dopamine release Dulls perception of pain Onset of action: - Within 30-60 seconds of inhalation Clearance: - Maternal: within 30-60 seconds of discontinuation Administration: - Self administered by the woman via inhalation - Concentration: 50% nitrous and 50% oxygen Advantages/uses: - During all stages of labor - Can be used with ambulation, hydrotherapy, etc. - Does not require IV catheter or continuous fetal monitoring - Useful for other painful procedures ---Forceps or vacuum assisted deliveries ---Manual removal of placenta or uterine exploration ---Laceration or episiotomy repairs Side effects: - Nausea & vomiting: 5-36% - Vertigo: 39% Contraindications: - Alcohol or drug impairment - Hemodynamically unstable - Cannot hold own mask - Vitamin B12 deficiency Effects on fetus/newborn: - Crosses placenta: 80% of maternal serum levels - Evidence shows: No increase in CNS or respiratory depression, APGARS unaffected, No FHR changes - Cleared rapidly with initiation of effective respirations Patient safety and education - Education on self-administration; no one may help her administer it - Will need assistance with ambulation - Supervise patient during hydrotherapy, birth ball use, and squatting - Obtain informed consent from the patient Medical team safety - All approved systems in U.S. have a scavenging system to removed exhaled gas

Hyperbilirubinemia Complications of newborn - Medical advances: 2 things - Kernicterus: not preventable or preventable? what is it? - Symptoms --- Early: which reflex is absent? --- Mild: --- Late:

Medical advances - RhoGAM - Phototherapy Kernicterus ("yellow nucleus") - Preventable - Chronic and permanent sequelae of untreated hyperbili Symptoms - Early: poor feeding, lethargy, absent Moro reflex - Mild: high-pitched cry, opisthotonos, bulging fontanel, seizures - Late: hearing loss, mental retardation, seizures, speech/movement disorders, muscle rigidity

Metabolic Adaptation of newborn - what reserve is low? - what is main source of energy 4-6 hours after birth? - changes from ___ type of metabolism to ___ type of metabolism? Genitourinary Adaptation of newborn - how fast is the glomerular filteration rate? how does this affect urine? - voids within ___ time of birth? - how many wet diapers on days 1, 2, 3+? - something to be aware of when changing diapers of little girl newborns? GI Adaptation of newborns - how are the intestinal and pancreatic enzymes functioning? - how the neonate digest proteins or fats more effectively? - how many kcal/kg/day should the neonate have? - what enters the stomach immediately after birth?

Metabolic Adaptation - Carbohydrate reserves low - Glucose main source of energy 4-6 h after birth - Fuel source consumed quickly...Stress of delivery rapidly uses up hepatic glycogen - Changes from carbohydrate metabolism to fat metabolism Genitourinary Adaptation - Glomerular filtration rate low....Limited capacity to concentrate urine, so urine may be cloudy - Bladder holds 6-44 ml - Voids within 48 hours ----In first 2 days of life produce about 15 ml/kg/day = 2 to 6 wet diapers/day ----Day 3 produce 25 ml/kg/day = 5-25 wet diapers/day - Pseudo menstruation- from maternal hormone withdrawal GI Adaptation - Adequate intestinal and pancreatic enzymes ----Proteins require more digestion ----Absorbs and digests fats less efficiently - Experienced at swallowing/sucking - Stomach capacity 50-60 ml (1-2 oz.) capacity ----Requires 105-108 kcal/kg/day ----Air enters stomach immediately after birth - Cardiac sphincter immature - 5-10% shift of intracellular fluid

Methods for FHR assessment - Intermittent auscultation with doppler or fetoscope - External ultrasound transducer - Fetal spiral electrode (FSE) Methods for contraction assessment - Palpation - External tocodynomometer "Toco" - Intrauterine pressure catheter (IUPC) Contraction terminology - Normal: requirement - Tachysystole: requirement

Methods for FHR assessment - Intermittent auscultation with doppler or fetoscope - External ultrasound transducer - Fetal spiral electrode (FSE) Methods for contraction assessment - Palpation - External tocodynomometer "Toco" - Intrauterine pressure catheter (IUPC) Contraction terminology - Normal: 5 contractions or less in 10 minutes, averaged over a 30-minute window - Tachysystole: more than 5 contractions in 10 minutes, averaged over a 30-minute window

FHR Baseline Variability - Most important predictor of ? - what does baseline variability reflect? - 4 Categories of FHR variability: range for FHR bpm, causes, concerning or safe?

Most important predictor of adequate fetal oxygenation - Reflects: interplay between fetal sympathetic and parasympathetic nervous systems - Reflects well functioning nervous system Visible irregular fluctuations in FHR above and below the baseline FHR (peak to trough) - Two or more cycles per minute - Assessed between any FHR changes Categories of FHR variability: Absent, Minimal, Moderate, Marked Absent Variability - Variation in amplitude is undetectable above or below the baseline - Causes: fetal sleep, medication effects, or fetal hypoxia and acidosis - May be concerning Minimal Variability - Variation in HR ranges detectable but < 5 bpm around baseline - Causes: same as absent variability - May be concerning Moderate Variability - Amplitude range of: 6-25 bpm above and below baseline - Highly predictive of: ABSENCE of metabolic acidemia - happy baby !!!!!! Marked Variability - Range in FHR is >25bpm - Unable to establish baseline - Causes: early or mild hypoxia, fetal activity, or effects of medications/drugs

N.O. will be using Nitrous oxide for her labor. What are three things you will educate her and her support system about or do to keep her safe? S.S. has been in and out of l & D two times during your 8 hr. shift. She is dilated to 1 cm and is exhausted from her 12 hours of contractions. What sedative can you offer her and why? E.E. is now 4 cm dilated and is requesting something for her pain. She has been vomiting for the last two hours. Other than the pain medication what else might you give her and why?

N.O. will be using Nitrous oxide for her labor. What are three things you will educate her and her support system about or do to keep her safe? - Education: ----She has to self-administer the Nitrous Oxide-No one can do it for her ----Side effects: Vertigo (most common) and Nausea ----Timing of administration-Works quickly (30-60 seconds of beginning inhalation) and clears quickly (30-60 seconds after stopping) ----Dulls perception of pain - Safety: ----Assist with ambulation ----Supervision during hydrotherapy, birth ball use, and squatting S.S. has been in and out of l & D two times during your 8 hr. shift. She is dilated to 1 cm and is exhausted from her 12 hours of contractions. What sedative can you offer her and why? - S.S. is in prodromal labor and a sedative can help with maternal exhaustion - Ambien 10 mg p.o. is preferred choice due to shorter half life than other sedatives (4.5 hrs. vs. 40 hrs. for secobarbital)- discharged home to sleep - Morphine Sulfate may also be used for prodromal labor-kept in the hospital to sleep - Benefits of Sedative use in prodromal labor ----Decreased anxiety ----Allows for rest- often wake up after several hours sleep in active labor OR she was not in labor and the contractions have resolved E.E. is now 4 cm dilated and is requesting something for her pain. She has been vomiting for the last two hours. Other than the pain medication what else might you give her and why? -Anti-emetic ----Zofran 4-8 mg (IV) ----Phenergan 25-50 mg (IV/IM) q 3-4 hrs.-Most common in active labor ----Visteral 25-100 mg (IM only) q 6 hrs.-Used more commonly in prodromal labor ----Benadryl 25-50 mg (PO/IM/IV) q 6 hrs.-- short ½ life and lasts up to 6-8 hrs.-Usually used at home for nausea and rest Benefits of anti-emetics: -Relieves nausea and vomiting -Decreases anxiety -Potentiates narcotics

NIPS Pain Scale - how to assess? - what score would intervention be necessary at?

NIPS Pain Scale - Facial expression: Grimace vs. relaxed - Cry: Vigorous, none, whimpering - Breathing: Relaxed vs. different than baseline - Alertness: Sleeping, active alert - Arms/Legs: Relaxed vs. flexed ***Arms and legs should be relaxed- opposite of what you expect- flexed means rigid and it is difficult to straighten them ***Interventions done for NIPS >3

Neonatal Abstinence Syndrome - 3 Factors affecting symptoms: - Timing of symptoms ---Alcohol: ? hours ---Narcotics: ? days ---Barbiturates: ? days Fetal alcohol syndrome (FAS)- - Facial characteristics? - deformities in what parts of the body? - ? after birth - mental status Alcohol related birth defects (ARBD) - Congenital anomalies where? Alcohol related neurodevelopmental disorder (ARND) - Small ? size - what other problems?

Neonatal Abstinence Syndrome - Factors affecting symptoms: Last exposure, half-life, type - Timing of symptoms ---Alcohol-3-12 hours ---Narcotics-2-3 days ---Barbiturates-1-14 days Fetal alcohol syndrome (FAS)- - Facial- small eyes, thin upper lip, short nose - Heart, joint, limb, finger deformities - IUGR and poor growth after birth - Mental retardation—COMPLETELY PREVENTABLE!!! - Vision and hearing problems, behavior problems Alcohol related birth defects (ARBD) - Congenital anomalies-heart, skeleton, kidneys, eyes, ears Alcohol related neurodevelopmental disorder (ARND) - Small head size, brain abnormalities, neuro, cognitive, behavioral problems

how do you explain what someone's labor pain will be like? how should you phrase the question when asking about labor pain?

No one can adequately explain what labor pain will be like for someone else Because labor pain is different than any other type of pain the woman doesn't know how she is going to respond to it until she is in actually in labor. Allow the woman to change her mind about what she needs to have the type of experience she desires Many responses to pain - Different cultures will react differently May be better to use the question "How are you coping with your labor?" rather than "Rate your Pain"

what is a major, natural way that newborns generate heat production? Cold stress in a newborn leads to....? What would indicate that a newborn is positioned and latched correctly during breastfeeding?

Non-shivering thermogenesis is a major source of heat production. Cold stress in a newborn leads to hypoglycemia, increased O2 consumption, metabolic acidosis, anaerobic metabolism, reopening of the ductus arteriosus, and reversion back to fetal circulation. - when Metabolic acidosis occurs ----pH decreases, PaO2 drops, PaCO2 rises ----Ductus arteriosus reopens ----Pulmonary vasoconstriction occurs ----Blood shunted away from lungs ----Increased pulmonary vascular resistance ----REVERTS BACK TO FETAL CIRCULATION but there is no placenta to supply O2 correct breastfeeding is shown by = The baby sucks rhythmically and swallows frequently - on the other hand, these are signs of incorrect breast feeding: ----The baby is making smacking noises ----The baby's bottom lip is curled in ----The mother is very uncomfortable during the feeding

Postpartum findings when using regional anesthesia (spinal block and epidural) Nursing Responsibilities for Regional Anesthesia 1st Most Common Positioning for spinal/epidural. 2nd most common.

Post Partum findings: - Localized tenderness (40%) - Backache (30 - 40 %) - Migraine Headache (2.9%) ---- Spinal headache with inadvertent spinal-treated with blood patch ---- Blood patch procedure: a few millimeters of the woman's blood drawn and before coagulation occurs is injected into epidural space- forms a clot and seals leak of spinal fluid providing almost instantaneous relief - Transient Neurological Deficits (0.1 %) - Elevation in temperature nursing responsibilities: - Informed Consent - Void prior to administration - IV Access - Preload with 500-1000ml IV fluids...Kinsella, et al, found no difference in incidence of hypotension with preload of fluid - Monitor vital signs, PO2, and fetal heart rate - Assist with positioning - Explain and reassure 1st Most Common Positioning for spinal/epidural = sitting up. 2nd most common = laying on side

Pudendal Anesthesia - what area of the body is injected into? - Produces anesthesia to 3 places? - produces pain relief during what time? - Complications: 3 main ones Local Anesthesia - Injection of anesthetic into where? ---Prior to _____ ---main purpose? - Does not affect ______ - not effective for what pain? General Anesthesia - common or uncommon? - what situation is it used for? - Requires _____ - High rate of ____ - Beware of ________? what preventive measure can you take? - Nursing Responsibilities:

Pudendal Anesthesia - Injection of local anesthesia into pudendal nerve --- Produces anesthesia to lower vagina, vulva, and perineum - Only produces pain relief at end of labor... Has no effect on fetus or progress of labor - Complications: Hematoma, perforation of rectum, and trauma to sciatic nerve Local Anesthesia - Injection of anesthetic into soft tissues of perineum ---Prior to episiotomy ---Repair of lacerations - Does not affect fetus or labor progression - Effect is only locally- not effective for pain prior to crowning General Anesthesia - Used rarely - For emergent C-sections with no or ineffective regional anesthesia - Requires intubation - High rate of neonatal depression - Beware of aspiration pneumonia... A laboring woman's stomach is never empty. restricting food and water is NOT evidence based...don't do it. - Nursing Responsibilities: ---IV access ---Assess when mother ate or drank last ---Administer prescribed premedication such as antacid ---Wedge under right hip ---O2 prior to surgery ---Assist with cricoid pressure. Compression of cricoid cartilage against esophagus helps prevents stomach contents from being aspirated. this is in the throat area.

Reflexes - Moro: Disappears by - Rooting: Disappears by - Sucking: Disappears by - Palmer grasp: Lessens by - Stepping: Disappears by - Tonic neck: Disappears by - Galant: ????????? - Babinski: Disappears by - Plantar grasp: Lessens by

Reflexes - Moro: Disappears by 6 months - Rooting: Disappears by 4-7 months - Sucking: Disappears by 12 months - Palmer grasp: Lessens by 3-4 months - Stepping: Disappears by 4-8 weeks - Tonic neck: Disappears by 3-4 months - Galant: ????????? - Babinski: Disappears by 12 months - Plantar grasp: Lessens by 8 months

testing Neuromuscular Maturity - resting posture: extension vs. flexion - Square Window - Scarf Sign

Resting Posture - Extension vs. flexion - premature = extension - mature = flexion Square Window - The newborn's hand is flexed toward the forearm and the angle between the hand and wrist is noted - premature: will easily bend all the way. - angle increases with maturity. Scarf Sign - Pull hand across chest towards opposite shoulder until resistance is met - In the preterm infant there may be little or no resistance so the arm looks like a scarf

Rh Antibodies - Rh positive blood types = ? antigen - Rh negative blood types = ? antigen ----With exposure to Rh positive blood, what happens? - First Rh positive fetus: what happens? - Second Rh positive fetus: what happens? - The risk of Rh immunization after the delivery of the first child to a nulliparous Rh-negative mother is ? % if the Rh-positive fetus is ABO compatible with its mother, ? % if the fetus is ABO incompatible, and ? % after an abortion. Rh Sensitization: ? cross placenta and attach to ? - Causes what to happen? - 2 conditions it can cause? which one is worse? Rh Sensitization Prevention - how? - Mechanism of action: - Provides protection for approximately ? weeks - populations that need this? - Decreases risk... - when is it no longer effective?

Rh Antibodies - Rh positive blood types = D antigen - Rh negative blood types = No D antigen ----With exposure to Rh positive blood, anti-D antibodies are produced (IgG antibodies) - First Rh positive fetus: Risk of Rh sensitization 2-16% .... Maternal immune system not adequately provoked - Second Rh positive fetus: Anti-D antibodies produced and cross placenta .... Fetus affected by hemolytic disease - The risk of Rh immunization after the delivery of the first child to a nulliparous Rh-negative mother is 16% if the Rh-positive fetus is ABO compatible with its mother, 2% if the fetus is ABO incompatible, and 2-5% after an abortion. Rh Sensitization...Anti-D antibodies cross placenta and attach to fetal RBCs - Cause hemolysis of fetal RBCs - Erythroblastosis fetalis (Anemia, Jaundice, Increased immature RBCs, Death) - Hydrops fetalis-most severe form ---Severe anemia, Multiple organ system failure, Cardiac decompensation, Generalized massive edema, Death Rh Sensitization Prevention - RhoGAM...Made from plasma - Mechanism of action: Prevents production of anti-D antibodies - Provides protection for approximately 12-14 weeks - Prophylactic administration in Rh Negative woman...At 28 weeks in every pregnancy, Miscarriage/abortion, Other (amniocentesis, abdominal trauma, ECV, when mixture is suspected), After delivery if fetus is Rh Positive - Decreases risk of hemolytic disease in fetuses in subsequent pregnancies - Once antibodies form RhoGAM is no longer effective

Sinusoidal - what is this? - requirements for this: amplitude, how many times it occurs, time frame - 2 reasons this could be happening

Smooth, regular, wavelike pattern for the FHR—looks like the letter S lying on it's side and interconnected Amplitude of 5-15 bpm and occur 3-5 times in 1 minute lasting for 20 minutes or more May be benign or pathologic Benign (pseudo sinusoidal)- not as smooth appearing -Caused by fetal sucking or medications Pathologic - Non-reassuring finding - Causes: anemia, chronic fetal bleeding, CNS malformation, twin-to-twin transfusion syndrome, isoimmunization of fetus, cord occlusion

explain what each is: - Rooting - Palmar grasp - Tonic neck - Step - Babinski - Truncal incurvation (Galant) - Plantar grasp - Moro

Rooting: Touch infant's lip, cheek, or corner of mouth with nipple or finger; turns head toward stimulus and opens mouth ready to take hold and suck. Palmar grasp: Place finger in the palm of the hand; infant's fingers curl around examiner's finger. Tonic neck: Place sleepy infant in a supine position, then turn head quickly to one side; arm and leg on side to which head is turned extend while opposite arm and leg flex. Step: Hold infant vertically, allowing one foot to touch table surface; infant alternates flexion and extension of feet. Babinski: Use finger to stroke sole of foot beginning at heel, upward along lateral aspect of sole, then across ball of foot; all toes hyperextend, with dorsiflexion of big toe Truncal incurvation (Galant): Place infant prone on a flat surface or suspended in the palm of the examiner's hand, run finger down side of back first on one side and then down the other side approximately 4-5 cm lateral to spine; trunk flexes and pelvis swings toward stimulated side. Plantar grasp: Place finger at the base of the toes; infant's toes curl downward Moro: Hold infant in semi sitting position, allow head and trunk to fall backward to angle of at least 30 degrees (with support); symmetric abduction and extension of arms, fingers fan out, thumb and forefinger form a C; arms are then adducted into an embracing motion and return to relaxed flexion and movement.

Labor Sedation - which sedative is preferred and why? what is the dose and route of it? --- benefits/risks of sedatives? - there are 2 drugs that are H1-Receptor Antagonists (anti-emetics). what is the dose and route for each? --- Benefits/ Risks of Anti-emetics

Sedatives - Ambien 10 mg PO Benefits/ Risks of Sedatives - Decreases anxiety - Allows for rest - Inhibit uterine contractions - Neonatal CNS depression Sedatives have a minimal analgesic effect and can increase response to painful stimuli - Ambien is preferable to other sedatives because it has a shorter half life H1-Receptor Antagonists (anti-emetics) Promethazine HCL (Phenergan) 25 mg IV Hydroxyzine HCL (Vistaril) 50-100mg IM ONLY Benefits/ Risks of Anti-emetics Relieves nausea & vomiting Does not relieve pain, but potentiates narcotics Decreases anxiety

when should you give supplements to your baby? - try to avoid what when doing this? what age is best to introduce a pacifier? does the hispanic population prefer breast milk or formula?

Supplements: - Use only when medically indicated - Some facilities have donor milk programs- two milk banks in CO - Try to avoid artificial nipples... you can Finger feed or Cup feed Pacifiers - For non-nutritive sucking - Use after breastfeeding is well established (2-4 weeks of age) Cultural considerations Hispanics prefer to formula and breastfeed

TTN of newborn - Risk Factors: - Caused by: - Signs and Symptoms: - Nursing Care: 3 things. what is contradicted? Respiratory Distress Syndrome - Definition: - Risk Factors: - Mortality: ? th leading cause of infant death - what is given to women in preterm labor to help prevent this? what does it exactly do? - Assessment Findings: - Management: - Surfactant administration ---Prophylaxis- within ? minutes of birth ---Rescue treatment- within ? hours of birth ---Administered via ? ---Benefits:

TTN - Resembles classic RDS - Risk Factors: C-section, Maternal diabetes and asthma, Male infants, LGA, macrosomia, Late preterm - Cause: Failure to clear fluid in pulmonary system - Signs and Symptoms: Rapid rate, Grunting, retractions, nasal flaring, Cyanosis - Nursing Care: Oxygen, Prevent cold stress, Provide calories—oral feedings contraindicated!! Respiratory Distress Syndrome - Definition: Absence, deficiency or alteration in pulmonary surfactant - Risk Factors: Prematurity (~50% Preterm newborns >30 weeks), Asphyxia, Surfactant deficiency syndrome - Mortality: 7th leading cause of infant death - Antenatal corticosteroids ----Joint Commission Perinatal core measure ----Given to women in preterm labor ----Promote fetal lung development and surfactant production - Assessment Findings: Progressive respiratory difficulty, Grunting, tachypnea, nasal flaring, retractions, Lethargy, Hypotonia, Cyanosis, Hypoxemia and acidosis, CXR-reticulograndular pattern, Increased O2 requirements - Management: Preterm birth prevention, Maintain neutral thermal environment, Respiratory support & oxygenation (Pulse Ox @ 90%), Nutrition via IV, Maintain BP, - Surfactant administration ---Prophylaxis- within 15 minutes of birth ---Rescue treatment- within 8 hours of birth ---Administered via ET tube ---Benefits- reduces risk of RDS, pneumothorax, IVH, bronchopulmonary dysplasia, pulmonary interstitial emphysema

The "Blues" - Onset: - how common? - Causes: - Tx: Postpartum Depression - how common? - Onset: - Risk factors: - Causes: - Treatment: Postpartum Psychosis - Risk Factors: - Onset: - Clinical features: - Incidence %: - Tx:

The "Blues" - Onset: first few days, resolves by 2 weeks (can be quite dramatic) - Most common form of postpartum mood change - Causes: Fatigue, Uncertainty, Frustration, Hormonal fluctuations, Unrealistic expectations, Lack of sleep and support - Tx: rest, support, reassurance Postpartum Depression - 5-25% women, 1.5-25% of men - Onset: Any time in the first year - Risk factors: History of depression or history of postpartum depression, Primips, Lack of social support (DV, poverty), Complicated labor/delivery adolescents - Causes: Hormones? Chemical imbalance? Genetic predisposition? Lack of sleep? Role transition? - Treatment - YOU NEED TO ASK THE PATIENT!, Support groups, Anti-depressants safe to use with breast feeding, Help at home, Sleep, Reassurance that she is not alone Postpartum Psychosis - Risk Factors: Hx bipolar, OCD, stress - Onset: as early as day 3 pp - Clinical features: Sleep disturbances, depersonalization, psychomotor disturbances, euphoria with hallucinations/delusions (may include SI/HI) - Incidence: 0.14%-0.26% - Tx: ----Hospitalization with baby but never left alone ----Antipsychotic medications ----therapy

The leading causes of Perinatal morbidity and mortality are: Early/Primary Hemorrhage vs. Late/Secondary Hemorrhage - time frame difference? Normal blood loss Vaginal- C-section- Maternal deaths from postpartum hemorrhage 1 in ___ maternal deaths in the U.S. Worldwide, a woman dies from PPH every _____

The leading causes of Perinatal morbidity and mortality are: - Infection - Hemorrhage - HTN - Emboli Early or Primary Hemorrhage - First 24 hours after birth Late or Secondary Hemorrhage - timing: after first 24 hours after birth and up to 6 weeks post partum - Can wake up in a bed full of blood! - Possible causes: Atony, retained placental fragments (tissue), infection, unknown - Treatment: IV access, Ultrasound of uterus to see if empty, D & C (remove tissue in uterus), Oxytoxics (Methergine, pitocin, hemabate, cytotec), Antibiotics, Ligation of uterine arteries, Hysterectomy - These women are often very sick due to delay of treatment, often in ICU. Normal blood loss Vaginal- 500mls C-section- 1,000mls Maternal deaths from postpartum hemorrhage...1 in 6 maternal deaths in the U.S. Worldwide, a woman dies from PPH every 4 minutes

what time should you first breast feed the baby for the day? what times should you continue breast feeding the baby? what is the LATCH assessment? how often should you do this assessment? what score is expected for infants 12 hours old? what should you do if mother/baby has a low LATCH score?

Timing - First feeding during first period of reactivity - Feed on demand or at least q 1.5-3 hours L = Latch - 0 points for baby too sleepy/reluctant and no latch is achieved. - 1 point for repeated attempts and baby holds nipple in mouth. stimulate to suck. - 2 points: grasp breast, tongue down, lips flanged, rhythmic sucking. A = Audible swallowing - 0 points: nothing. - 1 point: a few swallows with stimulation. - 2 points: ---if over 24 months of age: spontaneous and intermittent swallowing ---if under 24 hours old: spontaneous and frequent feeding T = type of nipple - 0 points: inverted nipples - 1 point: flat nipples: - 2 points: everted nipples (after stimulation). C = comfort (breast/nipple) - 0 points: engorged breasts. cracked/bleeding/large blisters/bruises. severe discomfort - 1 point: "filling" ?. reddened/small blisters/bruises. mild/moderate discomfort. - 2 points: soft and tender breasts H = hold (positioning) - 0 points: staff has to do a full assist for holding infant at breast. - 1 point: minimal assist from staff. (ex: elevate head, pillows for support). staff teaches one side, mother does the other. or staff holds baby and then mother takes over. - 2 points: no assist from staff. mother is able to position and hold infant. The higher the score the more effective the feeding - A score of 6 or higher by 12 hours of age is expected Lower scores- - Assess every feeding until >6 - Assist and provide education - Consult a Lactation Specialist for evaluation, assistance, and intervention

4 main causes for a postpartum hemorrhage - what is the #1 cause? - what are the treatments for each cause?

Tone: Too full, too fast, too long, too much Pitocin, meds that stop CTX's - Magnesium sulfate, grand multip, or infection. - Atony #1 cause - treatment: ----Anticipate ----Fundal massage (continue until bleeding is controlled), bimanual compression, 2nd IV-fluid replacement, empty bladder ----Medications- used to contract the uterus - Pitocin 10 units IM or 30 units in 500 ml NS "wide open" - Methergine 0.2mg IM (NO HTN) then 0.2mg PO q6h x4 (maintenance dose once PPH controlled) - Hemabate 250mcg IM q15min x3 (NO asthma) - Cytotec 800-1000 mcg Rectally ----Initiate breastfeeding when mother & baby stable - Oxytocin will be released by pituitary and will cause milk "let down" aka eject the milk. Will also help the uterus stay contracted!!! ----Pain meds - all these meds that cause contractions will cause significant cramping so mother will need pain meds Tissue: Retained placental pieces - treatment: ----2nd IV, Prep patient/family and assist with US, manual removal by putting hand into vagina and sweeping placenta pieces out Yes, that is an ARM in her vagina and uterus. ----PAIN MEDS ----NPO - might need surgery (D&C or Hysterectomy if accreta, percreta, increta) - Could this happen after a termination? Yes. You may see retained tissues or retained products of conception. Trauma: Episiotomy, lacerations, sulcus, cervical, uterine rupture, hematomas, uterine inversion - More common with operative vaginal delivery (forceps, vacuum) ---- treatment for LACERATIONS (Cervix, Vaginal side walls (sulcus tears), Perineum, Peri-clitoral).....Have suture, anesthetic, sterile gloves, good light, sponges ----HEMATOMAS (a hidden accumulation of blood) - 500 ml can accumulate in the "potential space" of the iliorectal fossa - Can occur before any vulvar bruising or discoloration noted by RN - May exhibit S & S of hypovolemia out of proportion to estimated blood loss (EBL) - Pain is disproportional to reported perineal laceration and repair - treatment for hematoma: Keep NPO, OR for evacuation, ligate "bleeder" -----UTERINE INVERSION: - Causes: Grand multiparity (5+ babies) OR Mismanagement of the 3rd stage: the person massages uterus before placenta is out, or yanks on umbilical cord very hard - Treatment: What came out first, goes back in first! - This is an emergency! Thromboembolic disorders: Labs, blood bank - Identify....No clotting on the floor or in the bucket = Problem - Anticipate....Identified prior to labor ---- have specific factors for clotting ordered to give the mother to control this problem. ---- Low platelets? Have platelets on hand if mother is already low on platelets and you can give them to her if needed.

Labor AnalgesiaOpioids/Synthetics - 3 drugs for "true narcotics"? dose/route/timing of each? which one is preferred and why? - 2 drugs for Synthetic Agonist/ Antagonists? dose/route? what is something to be aware of for these drugs? - benefits/risks of AnalgesiaOpioids/Synthetics?

True Narcotics - Fentanyl 50-100 mcg IVP Q15 minutes up to 200 mcg in 1hr - Meperidine (Demerol): 50 mg IVP Q2H - Morphine Sulfate:2.5-15 mg IV/ 8-20 mg IM q 4 hrs Synthetic Agonist/ Antagonists - Nalbuphine (Nubain): 5-10 mg IVP - Butorphanol (Stadol): 1-2 mg IVP Benefits/Risks - Pain blunting effect --> increased relaxation btw UCs - Neonatal CNS depression side notes: - Fentanyl has a rapid onset and has a short half life. There is limited placental transfer and therefore FHR variability is not affected as much as the other narcotics - Nubain and Stadol can precipitate withdrawal in drug addicted patients because they reverse the analgesic effects of other opioids or narcotics

Ultrasound transducer - Measures: - Placement: - Compare rate to.... Tocodynomometer or Tocotransducer or "Toco" - Measures: - Placement:

Ultrasound transducer - Measures FHR by reflecting high frequency sound waves off the movement of the fetal heart valves - Placement: over area of max intensity - Compare rate to maternal pulse Tocodynomometer or Tocotransducer or "Toco" - Measures: frequency and duration of uterine contractions... Does NOT measure intensity! will still need to palpate for intensity. - Placement: on fundus

Evaluation of Fetal Lung Maturity - Used prior to elective childbirth of fetus before term - If lungs immature...? - If lungs mature...? - how is this evaluation done? - Lecithin/Sphingomyelin Ratio ---what are these? ---When the L/S ratio is ____ demonstrates _____ ? - Phospatidylglycerol (PG) ---what is this? ---Appears at about ___ weeks gestation and continues to ...? ---Presence demonstrates...?

Used prior to elective childbirth of fetus before term - If lungs immature- delay delivery - If lungs mature risk of Respiratory Distress Syndrome is low Amniotic fluid obtained by amniocentesis - Lecithin/Sphingomyelin Ratio ---Two components of surfactant ---When the L/S ratio is > 2:1 demonstrates low risk of RDS and mature lungs - Phospatidylglycerol (PG) ---Another component of surfactant ---Appears at about 36 weeks gestation and continues to increase until term ---Presence demonstrates low risk of RDS

Uterine Infection: Endometritis - Most common type of ____ infection - Risks: - Begins as ______ where? - Signs/symptoms: - Tx & Rx: - Untreated, can become: Infection: Urinary Tract Infections - Causes: 2 main ones - Tx: - Rx: - Danger: ----this may affect something else...?

Uterine Infection: Endometritis - Most common type of postpartum infection - Risks: C/S, PROM, multiple SVE's, FSE/IUPC, vacuum/forceps, DM, chorioamnionitis during labor, pre-existing infections - Begins as localized infection at placental site.... Can spread to include the whole endometrium - Signs/symptoms: Maternal fever, chills, increased pulse, uterine tenderness, foul smelling lochia - Tx & Rx: ----D&C (especially if there's any retained tissue) ---- Oxytoxics ---- Antibiotics - Untreated, can become: Pelvic cellulitis (parametritis), septic pelvic thrombophlebitis, frank septicemia & death Infection: Urinary Tract Infections - Causes: ----Catherization during labor or after delivery ----Inability to urinate postpartum - Tx: UA collection for microanalysis, Culture&Sensitivity - Rx: Appropriate antibiotic safe for breast feeding - Danger: Pyelonephritis ----Can lead to Gram negative septicemia ----May require IV (v. PO bc not strong enough usually) antibiotics .... May need to disrupt breastfeeding - "pump and dump"

Vagina & Perineum - what hormone changes and what physical changes occur from that? - what evaluation should you do?

Vagina & Perineum - Changes...Decrease estrogen level causes: ---Mucosal thinning ---Decreased lubrication ---Smoothing of vaginal walls - Returns to pre-pregnancy size in 4-6 weeks Evaluation: ROLL TO SIDE TO ASSESS - Redness - Edema - Ecchymosis - Discharge or Drainage - Approximation

Variable Decelerations - what happens to FHR during these? - common or uncommon? - requirement ?bmp for ?time length - Relationship to contractions: - Caused by _____. there are 2 types of this, explain difference. Early Decelerations - describe the decel - relationship to contractions - onset to nadir time? - cause - concerning or okay? Late Decelerations - describe the decel - Onset to nadir? - Relationship to contractions - Cause: - this could be concerning or an okay scenario. describe both? Prolonged Decelerations - describe decel - Length: lasts between ? - Prolonged decels not concerning if: 3 senarios - Cause: 3 causes

Variable Decelerations - ABRUPT decrease in FHR - Most common deceleration in labor - Deceleration: 15+ bpm lasting 15+ sec but less than 2 minutes. - onset to nadir: less than 30 seconds - Relationship to contractions: WITH OR WITHOUT contractions - Caused by: cord compression ------Venous cord compression causes ↓venous return, relative hypovolemia, reflexive ↑FHR ------Arterial cord compression causes ↑ systemic vascular resistance,↑ BP & baroreceptor stimulation, vagal response, and ↓FHR Early Decelerations - GRADUAL, symmetric decrease in FHR - Relationship to contractions = WITH CONTRACTIONS ONLY --- Onset of deceleration begins at onset of UC --- Nadir occurs at the peak of the UC --- Recovery is the end of the contraction - Onset to nadir: 30 seconds+ - Cause: head compression...vagal nerve stimulation - Benign Late Decelerations - GRADUAL, symmetric FHR decrease - Onset to nadir: 30 seconds+ - Relationship to contractions Onset begins __AFTER__ UC begins Nadir always occurs __AFTER__ the peak of the UC Recovery is __AFTER__ the end of the contraction - Cause: uteroplacental insufficiency - Concerning...When associated with absent or minimal variability. Reflects hypoxia and increased risk of significant fetal acidemia - Compensatory response: Late decelerations with moderate variability is not associated with significant fetal acidemia Prolonged Decelerations - Gradual or abrupt FHR decrease - Length: lasts between 2 and 10 minutes - Prolonged decels not concerning if: Not recurrent, Normal FHR baseline before and after deceleration, Moderate variability - Cause: any mechanism that causes profound change in fetal O2 ---Uteroplacental insufficiency - tachysystole, maternal hypotension, abruption ---Umbilical blood flow interruption - cord compression, cord prolapse ---Vagal stimulation - profound head compression, rapid fetal descent

"VEAL CHOP" - type of deceleration for VEAL - corresponding cause of decel for CHOP

Variable decelerations = Cord compressions Early decelerations = Head compressions Accelerations ("A-Okay"!) = Okay ??? check this Late decelerations = Problems with placental perfusion (uteroplacental insufficiency)

Vernix Acrocyanosis "Caput" Succedaneum eye lid edema Milia stork bite, angel kisses, or Telangiectasia Nevi Epstein pearls Natal Tooth Sucking blister Polydactyly Lanugo Sacral dimple or Pilonidal dimple Over riding sutures Erythema toxicum Cephalohematoma Pseudo menstration Syndactyly Slate grey spots Nevus Flammeus

Vernix - White cheesy substance on skin - Consists of sebum & desquamated epithial cells - Protects and lubricates skin in-utero - Decreases as fetus nears term - normal Acrocyanosis. - normal. - The baby is working on it's circulation to it's core, instead of the hands and feet. With time, everything will become pink. "Caput" Succedaneum - normal - It is a collection of fluid in the scalp that crosses the suture lines Eye Lid Edema - normal - Can be from pressure from the birth. Can be aggravated by the erythromycin med we give. Goes away pretty quickly. Milia - normal - its hormonal, it is build up of sebaceous glands - Don't pick at it, don't pop them. - will clear up on own by 1 month. stork bite, angel kisses, or Telangiectasia Nevi - It has no clinical significance, it will fade usually by the second year. - More common in light skin babies - it will blanch so you know its not a bruise. Epstein pearls - As the palate of their mouth is fusing together, it overlapped? - It is normal and will go away. Natal Tooth - normal - It is a whole extra tooth. It is usually not rooted into the mouth. - Usually the hospital will pull it so it won't be an aspiration risk (choking hazard). Sucking blister - Babies will suck on anything that comes in front of their face - normal and will heal on its own - Don't pop the blister. Let it heal on its own. Polydactyly - extra fingers or toes - It will fall off on its own, it can also be tied to fall off. It can be tied to family history. - If it is the only abnormality, it is usually okay. If there is extra fingers, toes, etc. it could be part of a syndrome. - If there is no bone, it can be tied off. Lanugo - It is baby hair that keeps them warm and protect their skin in the uterus. - Premature babies will have more than term babies - will disappear as baby matures. Sacral dimple or Pilonidal dimple - May be associated with spina bifida -May need ultrasound to determine if there is a connection to spinal column -If able to see the base of the dimple there is low risk of spina bifida Over riding sutures - The bones moved during birth. The baby needed to fit out of the birth canal. - normal. It will diminish during the first few days. Erythema toxicum - normal and will go away on its own. - AKA "Newborn rash" or acne -No known cause and no treatment -Peak around 24-48 hrs. -Eruption of lesions surrounding the hair follicle -Moves around body and disappear spontaneously - Avoid lotions. Cephalohematoma - NOT normal, this is concerning. - This does NOT cross suture lines. - Baby is at risk for jaundice and hyperbilirubinemia. Pseudo menstration - Very normal in a 3-4 day old little girl - It is withdrawal of the estrogen after the girl has been birthed out of the mom. Syndactyly - Webbing of fingers or toes - can be normal, or it could also be part of a syndrome if there are multiple things wrong. - It can affect walking, doctor can cut to separate tissue. Can also be on the hands. Family history plays a part. Slate grey spots - They are normal/congenital. Normally fade away - Macular areas of blue/black pigmentation usually found on sacrum/buttocks - Dark skinned babies are more likely to have this - Can be mistaken for bruises. Needs to be documented and tell pediatrician. Tell day care providers. Nevus Flammeus - It is a birthmark. It can happen anywhere. Can be called "port wine stain" or "strawberry birthmark". - Non elevated, does not blanch and does NOT fade. - If the baby is also having seizures, it can be part of a syndrome. It is not concerning otherwise. - Sturge-Weber syndrome is suspected if port wine stain is present on the face and the newborn has convulsions—involvement of the 5th cranial nerve

vital signs that may change for a pregnant woman?

Vital Signs: Should remain "normal" besides... - HR: may see mild bradycardia r/t baroreceptor stimulation. What could be causing D.A.'s elevated heart rate? - Temperature: mild elevation (up to 100.4 F) in 1st 24 hours. Why? Last void - Why do you want to know this? Labs for mom - WBC, H/H, Rh status, Antibody screen, Kliehauer-Betke ---Common to see elevation from 12,000 to 20,000-25,000 WBCs in first 12 days ---May mask infection Why are we asking about HAs visual changes, dizziness, epigastric pain, N/V?

What are the benefits of delaying clamping the umbilical cord until it stops pulsating? Are there any disadvantages to delaying clamping of umbilical cord? Are there any situations where delayed cord clamping is contraindicated?

What are the benefits of delaying clamping the umbilical cord until it stops pulsating? - Protected transition - Prevents anemia Are there any disadvantages to delaying clamping of umbilical cord? - No Are there any situations where delayed cord clamping is contraindicated? - Meconium stained amniotic fluid - Newborn requiring immediate neonatal resuscitation**

What are 4 alternative measures you might use to help relieve back pain? List 4 causes of her Pain during 1st stage of labor? What are 4 things you can tell a woman about the effects of a narcotic on her and her baby?

What are two alternative measures you might use to help relieve her back pain? - TENS unit - Intradermal saline injections - Hypnosis - Accupressure/accupuncture 4 causes of her Pain during 1st stage of labor? - Cervical effacement and dilatation - Hypoxia of uterine muscle cells - Stretching of lower uterine segment - Pressure on adjacent structures: referred pain especially to low back, thighs, buttocks, groin, iliac crest What are three things you can tell a woman about the effects of a narcotic on her and her baby? - All systemic medications cross the placenta (Crosses by simple diffusion) - It can decrease FHR variability and respiratory effort especially if given close to her birth - Given at the right time in labor it can help her cope by easing the intensity of the pain. - Unrelieved maternal pain and stress can also have adverse effects on the fetus.

What is a common nursing procedure done prior to epidural placement that is not supported by evidence? E.A. received an epidural and she now has relief only on one side of her body. Is this normal and What can you do to help her? E.A. is considering an epidural for her labor pain. She asks 'how long DOES IT TAKE TO MAKE THIS PAIN GO AWAY?"

What is a common nursing procedure done prior to epidural placement that is not supported by evidence? - Preload with 500-1000ml IV fluids Kinsella found no difference in incidence of hypotension with preload of fluid - However most providers will still preload with fluid because it usually is not harmful to the patient E.A. received an epidural and she now has relief only on one side of her body. Is this normal and What can you do to help her? - One sided blockade is one complication that can occur with epidural anesthesia. - Place E.A. on the side that is un-anesthetized which allows for the nerves to be bathed with the anesthetic. E.A. is considering an epidural for her labor pain. She asks 'how long DOES IT TAKE TO MAKE THIS PAIN GO AWAY?" - It may take up to 30 minutes for the patient to begin to feel full relief

Pharmacological Pain Management - do all drugs given to mom for pain affect the baby? - what must be done before giving medications? - when is the perfect timing to give pain meds? Analgesic vs. Anesthetic vs. Sedation vs. Endorphins - explain difference between these - what are each of these used for? what pain level or type of labor? Know what for each medication?

Whatever she gets will affect the baby - All systemic analgesics cross placental barrier by simple diffusion some more readily than others All consent forms signed before medications Timing - Don't give medications too early as they may slow labor - Don't give too late as you will have an unhappy customer - Give when patient is complaining of pain and has demonstrated she is in active labor Analgesic: Affects perception of pain, does not take pain away. - For moderate - severe pain. Anesthetic: Deadens the pain, either by blocking a nerve, or knocking you out. - For moderate - severe pain. - When prolonged effect desired or analgesia is ineffective Sedation: For maternal exhaustion in prodromal labor Endorphins: Endogenous opiates secreted by pituitary in response to pain Know for each medication - Onset, peak, duration & t-1/2 life of medication - Side effects - Anticipate any potential problems

N.D. has a history of polysubstance Drug abuse. She will be delivering her term baby today. Why should narcan not be used for respiratory depression in this newborn? Three hours ago S.A. received spinal Anesthesia and now is complaining of an itchy nose, neck, and chest. What are you going to tell her about this and what is one medication that can be used to treat it? L.A. delivered her baby girl 20 minutes ago. Since she had an un-medicated labor and delivery what type of pain relief can you anticipate will be used to repair her perineal laceration? S.A. is a g6p5005 who presented to l&d at 7 cm dilated. She has been contracting for only 2 hours and She really wants something to take her pain away. Your hospital does not have nitrous oxide so What type of pharmacological method might be the best and why?

Why should narcan not be used for respiratory depression in this newborn? - Can precipitate withdrawal and cause seizures in prenatally addicted newborns - Also should not be used in a newborn born to a mother on methadone maintenance for the same reason itchy nose, neck, and chest after recieving spinal anesthesia: - common side effect - Medications: ---Benadryl 25-50 mg (PO/IV/IM) q 6 hrs. ---Naloxone (Narcan) may be used because it displaces morphine-like drugs from receptor sites on the neurons ---Nubain or Stadol may also be used as they reverse the analgesic effects of other opioids L.A. delivered her baby girl 20 minutes ago. Since she had an un-medicated labor and delivery what type of pain relief can you anticipate will be used to repair her perineal laceration? - Local anesthesia is the answer. ---- usually Lidocaine without epinephrine....Injection of anesthetic into soft tissues of perineum ---- Effect is only locally- not effective for pain prior to crowning ---- Prior to episiotomy ---- Repair of lacerations ---- Does not affect fetus or labor progression S.A. would be given Spinal anesthesia-Optimal pharmacological method due to rapid onset to provide good pain relief of labor and delivery discomfort - Epidural NOT optimal because it takes longer to work and she will probably deliver before she obtains complete relief - Narcotics/synthetics/sedative NOT recommended due to rapid labor and potential for delivery in near future and risk of respiratory depression - Local and pudendal NOT optimal because will not provide relief of labor pain

Non-Stress Test - how long does this take? - reactive NST requirements for pregnancies over 32 weeks - reactive NST requirements for pregnancies over 32 weeks - non-reactive NST requirement - a reason why you may get a non-reactive NST result

With intact ANS and adequate oxygenation the FHR will accelerate in response to movement Most widely accepted method of evaluation of well-being Electronic monitoring is used for 20-40 minutes Interpretation: Reactive NST or Non-reactive NST Reactive NST - In pregnancies > 32 weeks....15bpm+ above baseline lasting 15+ seconds - In pregnancies 28-32 weeks....10bpm+ above baseline lasting 10+ seconds Non-reactive NST - Insufficient accelerations in 40 minutes - Needs follow-up testing Fetuses have sleep cycles - If NST is non-reactive in 20 minutes continue testing for additional 20 minutes - To wake fetus may use sound or vibration to stimulate movement. can use vibroacoustic stimulation- "buzzer". REMEMBER THAT NST TEST IS "REACTIVE OR NONREACTIVE" RESULTS. the contraction stress test is positive, negative, or equivocal results.

You are assisting with the vaginal delivery of a patient who is in the second stage of labor and screaming that she needs something for pain. She has not received any other analgesia or anesthesia prior to this. Which of the following would be an ideal choice for her? - Ambien, Epidural, Nitrous Oxide, Local anesthesia, or Stadol? You have been caring for g.a. all shift. She is having an emergency c-section under general anesthesia. You know that the potential complications of general anesthesia include: A. Fetal depression that is directly proportional to the depth and duration of the anesthesia B. Increased gastric motility that causes increased appetite C. Uterine relaxation that causes increased blood loss D. Itching of the face and neck E. Slower initiation of bonding and breastfeeding F. A, C, & E G. All of the above What are three signs the woman is able to cope with the pain of labor?

answer: Nitrous Oxide...May be used at any time in labor with onset of relief in 30-60 seconds and rapid clearance after discontinuing inhalation reasons the others are NOT the right answers: - Ambien: Minimal analgesic effects; given orally so no effects will be obvious until at least 1 hour and will last 4-6 hours - Epidural: Most likely won't have full effects until after delivery - Local anesthesia: Won't provide relief of contraction pain - Stadol: Potential for respiratory depression in the neonate You have been caring for g.a. all shift. She is having an emergency c-section under general anesthesia. You know that the potential complications of general anesthesia include: F. A, C, & E A. Fetal depression that is directly proportional to the depth and duration of the anesthesia C. Uterine relaxation that causes increased blood loss E. Slower initiation of bonding and breastfeeding What are three signs the woman is able to cope with the pain of labor? - Able to use her breathing and relaxation techniques, Moaning and chanting, Inward focus, Rocking, Swaying, States "I am coping"

during breast feeding, do you bring the breast to the baby or the baby to the breast? what can help to cause flat or inverted nipples to protrude? when do you start using this method? what can be beneficial for extremely damaged nipples or flat nipples? what negative outcome can come of this?

bring the BABY to the breast. breast shells can help evert nipples. can begin use in late 3rd trimester. Breast Shields - These may be used to assist with latching but it is important to work with lactation before and during use of the breast shields. - With continued use the milk supply can be reduced by 50% or more. - These can be beneficial for extremely damaged nipples or flat nipples.

Results of Decreased Placental Perfusion

decrease in PaO2 --> hypoxemia --> blood is shunted to vital organs --> tissue hypoxemia --> lactic acid --> Anaerobic metabolism in tissues --> metabolic acidosis --> decrease tissue pH --> injury or DEATH

Hypoglycemia of newborn - definition: Blood sugar level is ? mg/dl - Risk Factors: - Signs and symptoms: - Nursing Care:

definition: Blood sugar level <40 mg/dl Risk Factors: Neonate of diabetic mother, SGA/LGA, Preterm/Post-term, Hypothermia, Infection, Birth trauma, RDS, Resuscitation Signs and symptoms: Jitteriness, Poor tone, Lethargy, Temperature instability, Apnea, Irritability Nursing Care: Monitor for s/s and identify risk factors, Assess, Prevention, Provide calories

what are the health benefits of newborn male circumcision? Does the Academy of American Pediatricians recommend parents to circumcision their male newborns? Describe the types of pharmacological and non-pharmacological measures that can be used to manage the pain related to circumcision both during and after the procedure.

health benefits of newborn male circumcision: • Prevention of UTI in male infants <1 year old • Reduced risk of penile cancer • Reduced risk for heterosexual acquisition of STI's, especially HIV Despite the evidence showing the benefits of newborn circumcision, the AAP does not recommend routine circumcision of male newborns. The decision is left up to the parents to decide what is best for their child by weighing the medical information with their own religious, ethical, and cultural beliefs and practices. Nonpharmacologic: swaddle, nonnutritive sucking, skin-to-skin with parents, distraction (visual, oral, auditory, or tactile), Vaseline ointment, change diaper promptly, avoid pressure on site when holding or positioning. Pharmacologic: Local anesthesia with a penile block, topical preparations (EMLA), oral sucrose, liquid acetaminophen 10-15 mg/kg after the procedure q 4-6 hours as needed (max of 30-45 mg/kg/24 hrs)

why do late decelerations happen? are early decelerations safe? are late decelerations safe?

how late decelerations occur.... - Decrease in 02 sensed by chemoreceptors --> Vasomotor center - Peripheral vasoconstriction (gut, kidneys, limbs) - Central redistribution (brain, heart, adrenals) --> - increase BP - Baroreceptor stimulation....Parasympathetic response - Deceleration early decels are okay, late decels are NOT okay

Potential causes of late decelerations include: The goal of maternal position changes for a prolonged deceleration is:

hypotension is a cause of late decels Maximizing uterine blood flow

if a woman uses a ____ as birth control after giving birth, when will it need to be refitted? how does the sponge birth control method work? what population is this not ideal for? progesterone-only pills - what increases their effectiveness? - instructions for use? emergency contraceptions aka "plan B" - what is it? time frame for it? Depo Provera - what is this? - instructions for it? - when can you administer after giving birth? IUD's - how effective? - 2 options: - Both are.... - Can be placed when? - Most common side effects: mirena: paraguard: Nexplanon - what is it? - how effective? - May be placed when? - Lasts how long? - Most common side effect: Essure - - what is it? - what setting is it placed in? - when can it be done after birth? Tubal ligation - - what is this? - what setting is it placed in? - when can it be done after birth? Male sterilization aka Vasectomy - follow up instructions - something you should definitely tell the patient

if a woman uses a diaphragm, it needs to be refitted 6 weeks after giving birth. sponge: - Failure rates: much higher rate for women who have given birth, approximately 25% failure rates with typical use - Safe for breast feeding - Placed in the vagina, covering the cervix - works by blocking sperm and releasing spermicide Progesterone-only pills - "mini-pill" - Failure rates 9% with typical use, (increased effectiveness if breast feeding exclusively for 1st 6 months post partum) - Need to be taken at the same time each day Emergency contraception - "Plan B" - large dose of progesterone - can be taken up to 72 hours after unprotected intercourse to prevent pregnancy. Depo Provera - Progesterone-only intramuscular injection, given every 3 months - Very effective, 6% failure rate with typical use - Can be given immediately postpartum - Safe for breast feeding - May increase risk for depression - May have prolonged return to fertility period (up to 18 months) IUD's - very effective - less than 1% failure rate with typical use - 2 options: Progesterone only - Mirena (5 years) or Copper only Paraguard (10 years) - Both: Immediately reversible, Safe for breast feeding - After placement, very little to "think about or do" - Can be placed immediately postpartum or at 6 weeks - Covered by most insurance companies - Most common side effects: mirena: may skip periods paraguard: increased bleeding/cramping Nexplanon - Progesterone releasing rod, placed by health provider in inner upper arm - Less than 0.5% failure rate with typical use - May be placed immediately postpartum or at 6 weeks - Lasts up to 3 years - Safe for breast feeding - Most common side effect: irregular bleeding Essure - - Trans-cervical approach, spring-like "coils" placed in fallopian tubes, forming scar tissues which blocks tubes - Placed in outpatient setting (no incision needed) procedure at 6-8 weeks postpartum Tubal ligation - - Done in hospital 24-48 hours after delivery (requires abdominal incision) - Very easy to do during c-section Male sterilization: - Vasectomy - Need to go back for semen analysis, will continue to be fertile for up to 3 months after procedure essure, tubal ligation, and vasectomy: - Less than 0.5% failure rate for all methods - All are considered permanent and should not be considered reversible - All are hormone-free, safe to use during breastfeeding

how to assess lochia? - what is too much/too big for lochia? how to tell if it's lochia or not lochia? - color? flow rate? uterus status?

lochia consists of sloughed off necrotic tissue and blood - Assessment includes: Color, Amount, Clots, Gushing, Odor - Stages: Rubra, Serosa, Alba - Too much/Too big: > 1 pad saturated per hour Clots how to differentiate... Lochia - Slow flow from vaginal opening - More with uterine contraction, fundal massage, or breastfeeding - Pooled lochia will be darker in color and coagulated Non-lochial - Contracted/firm uterus - Constant flow - Especially heavy, bright red - What might cause this?

guidelines for maternal-fetal assessment in EFM monitoring - how often would you monitor a low risk pregnancy in the first/second stage? - how often would you monitor a high risk pregnancy in the first/second stage? on the tracing strip for the fetal heart rates, how much time happens between the bolded lines? how much time is each tiny square?

low risk: - first stage monitor every 30 minutes. - second stage monitor every 15 minutes. high risk: - first stage monitor every 15 minutes. - second stage monitor every 5 minutes. May need to assess more frequently Intermittent assessment as appropriate on tracing strip for fetal heart rate, between bolded lines = 1 min. tiny squares = 10 seconds

how is a non-stress test categorized? is electronic fetal monitoring better than intermittent auscultation?

non-stress tests are either: reactive or non-reactive Multiple controlled randomized trails have FAILED to prove that EFM is better than intermittent auscultation

What is the preferred Narcotic for use in active labor and why? - what preventative action must be taken for woman who are given narcotics during labor? N.N. received a narcotic 20 minutes ago and just had her baby. What effects might you note in the baby from that medication and what would you give to treat it? S.A. had spinal anesthesia during her planned repeat c-section yesterday. She is complaining of a horrible headache today. What procedure might be done to treat this headache?

preferred Narcotic for use in active labor and why? - Fentanyl 50-100 mcg IVP q 15 min. up to 200 mcg max per hr. - Preferred because of rapid onset, short half life and limited placental transfer FHR variability is not affected as much as other narcotics - IV route is preferred because of rapid onset of action - IV medications should be given during the contractions because there is less transfer of the medication to the fetus!!! - Being unsteady when getting up is a common side effect of narcotic medications, and a safety issue. To prevent falls, it is important that patients receiving IV narcotics ask for assistance when they are getting up. N.N. received a narcotic 20 minutes ago and just had her baby. What effects might you note in the baby from that medication and what would you give to treat it? - Neonatal CNS depression- respiratory depression - Narcan (naloxone hydrochloride) 0.1 mg/kg IV, ET, IM - Duration of narcotics often exceeds that of Narcan so may need to repeat it every 3-5 minutes S.A. had spinal anesthesia during her planned repeat c-section yesterday. She is complaining of a horrible headache today. What procedure might be done to treat this headache? - She most likely has a spinal headache - Treatment: A blood patch

AAP Recommendations for breastfeeding timeline and solid food introduction what is the physiology that simulates breast milk to be produced? what hormone causes milk "let down"? - what is the predominant protein in human breast milk vs. cow milk? - what are the vitamins in human milk? - what is another main source of energy in human milk? - what components of human breast milk make up the majority of the calories?

recommend: - Exclusive breastfeeding for first six months - Introduction of solids and other fluids at six months - Continued breastfeeding until at least 12 months After delivery sudden drop in estrogen and progesterone stimulate secretion of prolactin from anterior pituitary and breast milk is produced - Oxytocin: secreted by posterior pituitary and responsible for milk ejection, "Let down" Human Breast Milk: - Whey predominant protein in human milk = 60:40 whey/casein ratio...Easily digested for more frequent feedings - Vitamins ---Fat soluble: A, D, E, K ---Water soluble: Bs, C - Carbohydrates- other main source of energy...40% of calories in diet ---- Primary carbohydrate is lactose ---- Formulas: All lactose, lactose/corn maltodextrin - Fats ----Approximately 50% of calories ----30-50 gm/liter of human milk....Fat content variable - Immunoglobulins: Infection prevention Cow Milk: - Casein predominant in cow milk - 20:80 whey/casein ratio - Less easily digested, forms curds

Regional Anesthesia Complications - what are regional anesthesia options? - level of block for c-section versus vaginal delivery? - complications of Inadequate block: - 3 complications that cause Breakthrough pain - complications for Procedure-Related Events: - Sympathetic Nerve Blockade: how to treat maternal hypotension? how to treat urinary retention? - Itching: 2 ways to treat it?

regional anesthesia options: spinal block and epidural c-section will be numb from right under breasts to toes. while vaginal delivery will be numb from vagina to toes complications: Inadequate block: "Hot spot", One sided, Block Failure. One-sided blocks prevented/treated by changing positions from side to side. Lie on unblocked side to allow gravity to permit anesthetic to bathe the nerves. Breakthrough pain: Full bladder, complete dilation, uterine rupture Procedure-Related Events: - Nerve Root Injury (0.2 %) - Accidental Dura (spinal) Puncture (1 - 2 %) - Intravascular Injection (5 %) Sympathetic Nerve Blockade: - Maternal Hypotension (1 - 10 %)--> late decelerations. Treat with Ephedrine 5-10 mg IV and fluid bolus. Oxygen via facemask, side-lying position - Urinary Retention (15 - 35 %): use Foley - Fever ( 15 - 17 %) possibly similar to spinal cord injury Itching: Nubain or Benadryl

relationship between contractions and blood flow to the uterus?

the greater intensity the contraction, the less blood flow to the uterus