PERINATAL NURSING
(Taken from Google Document)
1. acrocyanosis- A blue or purple mottled discoloration of the extremities, esp. the fingers, toes and/or nose. This
physical finding is associated with many diseases and conditions, such as anorexia nervosa, autoimmune diseases, cold agglutinins, or Raynaud’s disease or phenomenon. Cyanosis of the extremities may be commonly observed in newborns and in others after exposure to cold temperatures, and in those patients with reduced cardiac output. In patients with suspected hypoxemia, it is an unreliable sign of diminished oxygenation.
2. Moro- or startle reflex- a reflex seen in infants in response to stimuli, such as that produced by suddenly striking
the surface on which the infant rests. The infant responds by rapid abduction and extension of the arms followed by an embracing motion of the arms.
3. cephalhematoma- a mass composed of clotted blood, located between the periosteum and the skull of a newborn.
It is confined between suture lines and usually is unilateral. The cause is rupture of periosteal bridging veins due to pressure and friction during labor and delivery. The blood reabsorbs gradually within a few weeks of birth.
4. caput succedaneum- diffuse edema of the fetal scalp that crosses the suture lines. Head compression against the
cervix impedes venous return, forcing serum into the interstitial tissues. The swelling reabsorbs within 1 to 3 days. 5. ductus arteriosis- a channel of communication between the main pulmonary artery and the aorta of the fetus.
6. ductus venosus- the smaller, shorter, and posterior of two branches into which the umbilical vein divides after
entering the abdomen of the fetus. It empties into the inferior vena cava.
7. fontanel-anterior and posterior-where located?-why?-shape?- an unossified membrane or soft spot lying between
the cranial bones of the skull of a fetus or infant.
Anterior- the diamond-shaped junction of the coronal, frontal, and sagittal sutures; it becomes ossified within 18 to 24 months.
Posterior- the triangular fontanel at the junction of the sagittal and lambdoid sutures; ossified by the end of the first year.
8. foramen ovale- The opening between the two atria of the fetal heart. It usually closes shortly after birth as a result
of hemodynamic changes related to respiration.
9. molding- shaping of the fetal head to adapt itself to the dimensions of the birth canal during its descent through
the pelvis.
10.erythema toxicum- (papules, 24-28 hr.-newborn rash) a benign, self-limited rash marked by firm, yellow-white
papules or pustules from 1 to 2 mm in size present in about 50% of full-term infants. The cause is unknown, and the lesions disappear without need for treatment.
11.chemical conjunctivitis- most common eye infection- of the conjunctiva usually caused by chemical burns.
12.vernix caseosa- a protective sebaceous deposit covering the fetus during intrauterine life, consisting of
exfoliations of the outer skin layer, lanugo, and secretions of the sebaceous glands. It is most abundant in the creases and flexor surfaces. It is not necessary to remove this after the fetus is delivered.
13.lanugo- fine downy hairs that cover the body of the fetus, esp. when premature. The presence and amount of
lanugo aids in estimating the gestational age of preterm infants. The fetus first exhibits lanugo between weeks 13 and 16. By gestational week 20, it covers the face and body. The amount of lanugo is greatest between weeks 28 and 30. As the third trimester progresses, lanugo disappears from the face, trunk, and extremities.
14.milia- white pinhead-size, keratin-filled cyst. In the newborn, milia occur on the face and, less frequently, on the
trunk, and usually disappear without treatment within several weeks.
15.telangiectatic nevi or hemangioma- (stork bite) a benign tumor of dilated blood vessels.
16.Mongolian spots- bluish-black areas of pigmentation may appear over any part of the exterior surface of the body.
17.Apgar (know scoring)- a system for evaluating an infant’s physical condition at birth. The infant’s heart rate,
respiration, muscle tone, response to stimuli, and color are rated at 1 min, and again at 5 min after birth. Each factor is scored 0,1, or 2; the maximum total score is 10. Interpretation of scores: 7 to 10, good to excellent; 4-6, fair; less than 4, poor condition. A low score at 1 min is a sign of perinatal asphyxia and the need for immediate assisted ventilation. Infants with scores below 7 at 5 min should be assessed again in 5 more min; scores less than 6 at any time may indicate need for resuscitation. In depressed infants, a more accurate determination of the degree of fetal hypoxia may be obtained by direct measures of umbilical cord oxygen, carbon dioxide partial pressure, and pH.
18.Silverman (respiratory function test)- 5 evaluations – what are they? – (handout)
1. Upper chest. 2. Lower chest. 3. Xiphoid retractions. 4. Nares dilation. 5. Expiratory grunt. Graded 0, 1, 2
19.pseudomenstruation- withdrawal bleeding after birth, a scant vaginal discharge that reflects the physiological
response of some female infants to an exposure to high levels of maternal hormones in utero.
20.tonic neck reflex- (“fencing”) –with infant facing left side, arm and leg on that side extend; opposite arm and leg
flex (turn head to right, and extremities assume opposite postures).
21.colostrum- high in?-breast fluid that may be secreted from the second trimester of pregnancy onward but that is
most evident in the first 2 to 3 days after birth and before the onset of true lactation. This thin yellowish fluid contains a great number of proteins and calories in addition to immune globulins.
22.neonate- from birth through 28h day of life.
23.bilirubin – normal? Why higher in neonate?- normal <5 mg.dl. (usually drop to 1 mg/dl). Neonatal jaundice
occurs because the newborn has a higher rate of bilirubin production and the reabsorption of bilirubin from the neonatal small intestine is considerable.
24.physiologic jaundice – when?- 50-80% of all full-term newborns are visibly jaundiced during the first 3 days of
life.
Term: appears after 24 hours and disappears by the end of the 7th day. Preterm: evident after 48 hours and disappears by the 9th or 10th day.
25.phenylketonuria- a congenital, autosomal recessive disease marked by failure to metabolize the amino acid
phenylalanine to tyrosine. It results in severe neurological deficits in infancy if it is unrecognized or left untreated. PKU is present in about 1 in 12,000 newborns in the US. In this disease, phenylalanine and its byproducts
accumulate in the body, esp. in the nervous system, where they cause severe mental retardation, seizure disorders, tremors, gait disturbances, coordination deficits, and psychotic or autistic behaviors. Eczema and an abnormal skin odor also are characteristic. The consequences of PKU can e prevented if it is recognized in the first weeks of life and a phenylalanine restricted (very low protein) diet is maintained throughout infancy, childhood, and young adulthood.
26.petechiae- (pinpoint rash) small, purplish, hemorrhagic spots on the skin that appear in patients with platelet
deficiencies (thrombocytopenias) and in many febrile illnesses.
27.kernicterus- a form of jaundice occurring in newborns during the second to eighth day after birth. The basal
ganglia and other areas of the brain and spinal cord are infiltrated with bilirubin, a yellow substance produced by the breakdown of hemoglobin. The disorder is treated aggressively by phototherapy and exchange transfusion to limit neurological damage. The prognosis is quite poor if the condition is left untreated.
28.nevus flammeus- (port-wine stain) – a large reddish-purple discoloration of the face or neck, usually not elevated
above the skin. It is considered a serious deformity due to its large size and color. In children, these have been treated with the flashlamp-pulsed tunable dye laser.
29.Epstein’s pearls – in infants, benign retention cysts resembling small pearls, which are sometimes present in the
palate. They disappear in 1 to 2 months.
30.umbilical arteries- (2) carry blood from the fetus to the placenta, where nutrients are obtained and carbon dioxide
31.umbilical vein- (1) oxygenated blood returns to the fetus through the umbilical vein.
ALTERNATE VOCAB LIST
NEWBORN VOCABULARY LIST
Abdominal Circumference: measured by placing the tape around the newborn’s abdomen at the level
of the umbilicus with the bottom edge of the tape measure at the top edge of the umbilicus.
Acrocyanosis: Cyanosis of the extremities. May be present in the first 2 to 6 hours after birth.
Condition is due to poor peripheral circulation which results in vasomotor instability and capillary
stasis, especially when the baby is exposed to cold. If the central circulation is adequate, the blood
supply should quickly return to the extremity after the skin is blanched with a finger. If hands and nails
are blue, face and mucous membranes should be assessed for pinkness indicating adequate
oxygenation.
Apgar Score: A scoring system used to evaluate infants at 1 minute and 5 minutes after birth. The total
score is achieved by assessing five signs: heart rate, respiratory effort, muscle tone, reflex irritability,
and color. Each of the signs is assigned a score of 0, 1 or 2. The highest possible score is 10. See page
670 for further detail.
Behavioral States: States in the infant sleep/awake cycle. See below for specific states. Page 1115 has a
great chart on behavioral states.
Sleep State: consists of deep or quiet sleep and light or active rapid eye movement sleep. In deep or
quiet sleep the baby has closed eyes with no eye movement, regular even breathing and jerky motion
or startles at regular intervals. Behavioral responses to external stimuli are likely to be delayed. Startles
are rapidly suppressed and changes in state are not likely to occur. Heart rate may range from 100 to
120 bpm. In active rapid eye movement (REM) sleep, the baby has irregular respirations, eyes closed
with REM, irregular sucking motions, minimal activity, and irregular but smooth movement of the
extremities. Environmental and internal stimuli initiate a startle reaction and a change of state.
Active Sleep State: Same as light or active eye movement sleep
Drowsy State: Infant may return to sleep or awaken further. Has smooth movements with variable
activity level. Eyes may open and close. Eyes may appear heavy lidded or may appear like slits. May
have no facial movement and appear still or may have some facial movements. Breathing is irregular.
Infant will usually react to stimuli but may be slowed. May change to other states such as quiet alert,
active alert or crying If infant left alone, may return to a sleep state.
Quiet Alert State: Infant is attentive to environment, focus attention on stimuli. Body activity is
minimal. Eyes are bright and wide. Facial expression is attentive. Breathing is regular. Response is
most attentive, focus attention on stimuli. In the first few hours after birth, may experience an intense
alertness before going into a long sleeping period. This state increases in intensity as the infant
becomes older.
Active Alert State: Infant’s eyes are open but not as bright as quiet alert. More body activity than quiet
alert. Smooth movements may be interspersed with mild startles from time to time. Eyes are open with
a glazed dull appearance. Facial movements may be still with or without facial movements. Breathing
is irregular. Infant reacts to stimuli with delayed responses to stimuli or may change to quiet alert or
crying state. Infant may be fussy and become more sensitive to stimuli, may become more and more
active and start crying. If fatigue or caregiver interventions disturb this state, infant may return to
drowsy or sleep state.
Crying State: communication tool, response to unpleasant stimuli from environment or internal stimuli.
Characterized by intense crying for more than 15 seconds. Increased motor activity, skin color changes
to darkened appearance, red or ruddy. Eyes may be tightly closed or open. Grimaces in facial
expression. Breathing is more irregular than in other states. Indicates that the infant’s limits have been
reached. May be able to console himself or herself and return to an alert or sleep state or may need
intervention from caregiver.
Bilirubin: pigment which causes jaundice. Most jaundice is benign but due to potential toxicity of
bilirubin, jaundiced infants must be closely monitored. Accumulated bilirubin is due to infant’s
inability to balance the breakdown of red blood cells and the use or excretion of by products.
Phototherapy is used as treatment for newborn jaundice.
Brown Fat: Also known as brown adipose tissue (BAT). Fat deposits in newborns that provide greater
heat generating activity than ordinary fat. Found around the kidneys, adrenals, and neck; between the
scapulas and behind the sternum.
Caput Succedaneum: localized, easily identifiable soft area of the scalp.This generally results from
long and difficult labor or a vacuum extraction. Fluid is reabsorbed within 12 hours to a few days after
birth.
Cephalohematoma: a collection of blood resulting from ruptured blood vessels between the surface of
a cranial bone (usually the parietal) and the periosteal membrane. Emerges as a hematoma between the
first and second day. Relatively common in vertex births and disappear within 2 weeks to 3 months.
May be associated with physiological jaundice as extra red blood cells are being destroyed within the
cephalohematoma. A large one can lead to anemia and hypotension.
Chest Circumference: Should be measured with the tape measure at the lower edge of the scapula and
brought around anteriorly directly over the nipple line. The average is 32 cm or 12.5 inches with a
range of 30 to 35 cm or 12-14 inches.
Circumcision: surgical removal of the prepuce (foreskin) of the penis.
Cold Stress: Excessive heat loss resulting in compensatory mechanisms (increased respirations and
nonshivering thermogenesis) to maintain core body temperature.
Colostrum: secretion from the breast before the onset of true lactation; contains mainly serum and
white blood corpuscles. It has a high protein content, provides some immune properties and cleanses
the newborn’s intestinal tract of mucus and meconium.
Conduction: Loss of heat to a cooler surface by direct skin contact. An infant could lose heat due to
conduction if subjected to chilled hands, equipment, scales, etc.
Convection: loss of heat from the warm body surface to cooler air currants. An example would be an
infant losing body heat because their crib is placed in an air conditioned room.
Crypytorchidism: failure of the testes to descend in a newborn male.
Ductus Arteriosus: A communication channel between the main pulmonary artery and the aorta of the
fetus. It is obliterated after birth by rising PO2 and changes in the intravascular pressure in the
presence of normal pulmonary functioning. It normally becomes a ligament after birth but sometimes
remains patent (patent ductus arteriosus, a treatable condition).
Ductus Venosus: A fetal blood vessel that carries oxygenated blood between the umbilical vein and the
inferior vena cava, bypassing the liver. It becomes a ligament after birth.
Epispadias: when the male urethral meatus occurs on the dorsal aspect of the penile shaft
Erythema Toxicum: Innocuous pink papular rash of unknown cause with superimposed vesicles: it
appears within 24 to 48 hours after birth and resolves spontaneously within a few days.
Evaporation: Loss of heat incurred when water on the skin surface is converted to a vapor. An infant is
subject to body heat loss by evaporation immediately following birth when still wet with amniotic
fluids or during bathing times.
Fetal Circulation: Blood flow from the placenta flows through the umbilical vein, enters the abdominal
wall at umbilicus, through the ductus venosus directly into inferior vena cava (small amount enters
liver instead). Blood enters right atrium, passes through foramen ovale into left atrium into left
ventricle and into aorta. Some blood returning from head and upper extremities by way of superior
vena cava enters right atrium and passes through tricuspid valve into right ventricle and small amount
goes to lungs for nourishment only. Larger portion of blood passes from pulmonary artery through
ductus arteriosus to descending aorta bypassing the lungs. Finally blood returns to the placenta via
umbilical arteries and process is repeated.
Foramen Ovale: Special opening between the atria of the fetal heart. Normally the opening closes
shortly after birth; if it remains open, it can be surgically repaired.
Head Circumference: Place the tape measure over the most prominent part of the occiput and brought
to just above the eyebrows. The measurement should be 32 – 37 cm or
12.5 – 14.4 inches or approximately 2 cm larger than chest circumference. If the infant experienced
significant head molding it is advisable to take another head measurement on the second day.
Hyposadias: when the male urethral meatus occurs on the ventral aspect of the penile shaft.
Jaundice (pathological and physiological): Jaundice refers to the yellowing of the skin and sclera
frequently seen in newborns. Physiological jaundice refers to a normal process that occurs during
transition from intrauterine to extrauterine life and appears after 24 hours of life. Is a common problem
with newborns and may be treated with phototherapy. Pathological jaundice is diagnosed in infants
who exhibit jaundice within the first 24 hours of life, have a total serum bilirubin concentration
increase of greater than 0.2 mg/dL/hour, surpass the 95
thnomogram for age in hours or have persistent
visible jaundice after 1 week of age in term infants or after 2 weeks in preterm infants.
Latch On: refers to positioning needed for a newborn to properly breast feed. Mother and infant should
be properly positioned in order to achieve optimal attachment. Infant needs to attach his or her lips far
back onto the areola, not on the nipple. To obtain a deep latch, mother needs to elicit her infant’s
rooting reflex, stimulating the infant to open the mouth as wide as possible. Once infant does this,
mother draws the infant close to her. If the infant latches onto nipple only, sore nipples may result.
Lanugo: Fine, downy hair found on all body parts of the fetus, with the exception of the palms of the
hands and the soles of the feet, after 20 weeks gestation.
Large for Gestational Age (LGA): Excessive growth of a fetus in relation to the gestational time
period. An infant considered LGA is above the 90
thpercentile when considering gestational age and
birth weight.
Let Down Reflex: Pattern of stimulation, hormone release, and resulting muscle contraction that forces
milk into the lactiferous ducts, making it available to the infant. Also called milk ejection reflex.
Meconium: Dark green or black material present in the large intestine of a full term infant; the first
stools passed by the newborn.
Milia: tiny, white papules appearing on the face of a newborn as a result of unopened sebaceous
glands; they disappear spontaneously within a few weeks.
Mongolian Spot: Dark, flat pigmentation of the lower back and buttocks noted at birth in some infants;
usually disappears by the time the child reaches school age.
Molding: an asymmetric appearance of the head at birth due to overriding of the cranial bones during
labor and birth. Diminishes a few days after birth.
Nevus Flammeus: Also known as large port wine stain. Is a capillary angioma directly below the
epidermis. Is a nonelevated sharply demarcated red to purple area of dense capillaries. Does not grow
in size or fade with time. Does not usually blanch with pressure. If accompanied by convulsions or
other neurological problems is suggestive of Sturge-Weber Syndrome with involvement of 5
thcranial
nerve (ophthalmic branch of trigeminal nerve).
Nevus Vasculosus: a capillary hemangioma. Consists of newly formed and enlarged capillaries in the
dermal and subdermal layers. A raised, clearly delineated dark red, rough surfaced birthmark
commonly found in the head region. Such marks usually grow, often rapidly during 2
ndor 3
rdweek of
life and may not reach full size for 1 to 3 months. They begin to shrink and start to resolve
spontaneously several weeks to months after they reach peak growth. Also called Strawberry Marks.
Nonshivering Thermogenesis: physiological mechanisms of increasing heat production. Include
increased basal metabolic rate, muscular activity and chemical thermogenesis.
PKU: Phenylketonuria. Is the most common of the group of metabolic disorders known as amino acid
disorders. Phenylalanine is an essential amino acid used for growth and in an normal individual any
excess is converted to tyrosine. Infant with PKU lacks this converting ability and experiences an
accumulation of phenylalanine in the blood. Excessive accumulation can lead to mental retardation.
Preterm Infant: any infant born before 38 weeks gestation
Postterm Infant: any infant born after 42 weeks gestation.
Radiation: Heat loss incurred when heat transfers to cooler surfaces and objects not in direct contact
with the body. Placing cool objects near an infant such as ice for a blood gas draw could cause this type
of heat loss.
Reflexes: See specific types listed below
Moro Reflex: elicited when the infant is startled by a loud noise or is lifted slightly above the crib and
lowered suddenly. In response, the infant straightens arms and hands outward while the knees flex.
Slowly the arms return to the chest as in an embrace. The fingers spread forming a C and the infant
may cry. This reflex may persist until about 6 months of age.
Palmar Reflex: also called the grasping reflex. Is elicited by stimulating the newborn’s palm with a
finger or object. The newborn will grasp and hold the object or finger firmly enough to be lifted
momentarily from the crib.
Plantar Reflex: elicited when pressure is applied with the finger against the balls of the infant’s feet.
Response is a plantar flexion of all toes. Disappears by the end of the first year of life.
Babiniski Reflex: a fanning or hyperextension of all toes and dorsiflexion of the big toe, occurring
when the lateral aspect of the sole is stroked from the heel upward across the ball of the foot. In
children older than 24 months, it is considered an abnormal response if there is an extension or fanning
of all the toes; in such cases indicates abnormality of upper motor neurons.
Rooting Reflex: Is elicited when the side of the newborn’s mouth or cheek is touched. In response, the
newborn turns towards that side and opens the lips to suck (if not fed recently).
Sucking Reflex: normal newborn reflex elicited by inserting a finger or nipple in the newborn’s mouth,
resulting in a forceful, rhythmic sucking.
Tonic Neck Reflex: is elicited when newborn is supine and the head is turned to one side. In response,
the extremities on the same side straighten whereas on the opposite side they flex. May not be seen
during early newborn period but once it appears it persists until about the 3
rdmonth.
Stepping Reflex: Occurs when infant is held upright with one foot touching a flat surface. The infant
will put one foot in front of the other and “walk”. This is more pronounced at birth and is lost in 4 to 8
weeks.
Small for Gestational Age: An infant who falls below 10
thpercentile in terms of birth weight, length,
occipital-frontal circumference and gestational age.
Surfactant: A substance composed of phosolipid which stabilizes and lowers the surface tension of the
alveoli during extrauterine respiratory exhalation, allowing a certain amount of air to remain in the
alveoli during exhalation.
Thermoregulation: regulation of body temperature
Vernix: a protective, cheeselike whitish substance made up of sebum and desquamated epithelial cells
that is present on the fetal skin.
8-POINT POSTPARTUM ASSESSMENT WORKSHEET
INSTRUCTIONS
SPECIAL POINTS TO NOTE
1. Breast
1. Gently palpate each breast
2. If you feel nodules in the breast, the ducts
may not have been emptied at last .
3. Stroke downward towards the nipple, then
gently release the milk by manual.
4. If nodules remain, notify the doctor.
5. Take this opportunity to explain the process
of milk production, what to do about
engorgement, how to perform self breast
examinations, and answer any questions she
may have about breastfeeding.
1. What is the contour?
2. Are the breast full, firm, tender, shiny?
3. Are the veins distended?
4. Is the skin warm?
5. Does the patient complain of sore
nipples?
6. Are breasts so engorged that she
requires pain medication?
2. Uterus
1. Palpate the uterus
2. Have the patient feel her uterus as you
explain the process of involution
3. If uterus is not involunting properly, check
for infection, fibroids and lack of tone.
1.
Uterus should the firm decrease
approximately one finger breadth
below
2. Unsatisfactory involution may result if
there are retained secundines or the
bladder not completely empty
3. Bladder
1. Inspect and palpate the bladder
simultaneously while checking the height of
the fundus.
2. An order from the physician is necessary
catherization may be done. An order for
culture and sensitivity test since definitive
treatment may be required.
3. Talk to mother about proper perineal care.
Explain that she should wipe from front to
back after voiding and defecating.
1. Bladder distention should not be
present after recent emptying.
2. When bladder distention does occur, a
pouch over the bladder area is
observed, felt upon palpation; mother
usually feels need to urinate.
3. It is imperative that the first three
post-partum voidings be measured and
should be at least 150cc. Frequent
small voidings with or without pain and
burning may indicate infection or
retention.
4. Bowel Function
1.
Question patient daily about bowel
movements. She must not become
constipated. If her bowels have not
functioned by the second postpartum day,
the doctor may start her on a mild laxative
2. Inform the mother about what changes she
should expect in the lochia and when it
should cease.
3. Tell the mother about what changes she
Notify the doctor if the lochia looks abnormal
in to color or contains clots or other small
ones.
should expect in the lochia and when it
should cease.
4. Tell the mother when her next menstrual
period will probably begin and when she
can resume sexual relations.
5. Discuss family planning at this time.
6. Episiotomy
1. Inspect episiotomy thoroughly using
flashlight if necessary, for better visibility.
2. Check rectal area. If hemorrhoids are
present, the doctor may want to start on sitz
bath and local analgesic medication.
Reassure patient and answer questions she
may have regarding pain, cleanliness, and
coitus.
1. Check episiotomy for proper wound
healing, infection, inflammation and
suture sloughing.
2. Is the surrounding skin warm to touch?
3. Does the patient complain of
discomfort? Notify the C.Doctor if any
occur
7. Homan’s Sign
1. Press down gently on the patient’s knee
(legs extended flat on bed) ask her to flex
her foot
Pain or tenderness in the calf is a positive
Homan’s sign and indication of
thrombophlebitis. Physician should be notified
immediately.
8. Emotional Status
1. Throughout the physical assessment, notice
and evaluate the mother’s emotional status.
2.Explain to the mother and to her family that
she may cry easily for a while and that her
emotions may shift from high to low. The
changes are normal and are probably caused
by the tremendous hormonal changes
occurring in her body and by her realization
of new responsibilities that accompany each
child’s birth. NOTE: Be sure that the mother
has emptied her bladder and that she is lying
in supine position on a flat bed before
beginning assessment.
1. Does the patient appear dependent or
independent? Is she elated or
despondent?
2. What does she say about family?
3. Are there other nonverbal responses?
Antepartal nursing
Antepartal nursing
• Period of pregnancy between conception and onset of labor, used in reference to the mother.
Pre-embryonic development
• Two week period that includes: o Fertilization (conception) o Implantation
Miscarriage is a problem at this stage.
Embryonic development
• 3-8 weeks
• major functions of this period: o Cell multiples and grow o Cells differentiate and grow
o By the end of week 8, all organ systems and external structures are present. • Primary germ layers develop
o Ectoderm (brain, nervous system) o Medoderm (heart, bones)
o Endoderm (lungs, intestinal organs • Fetal membrane develops
o Amnion ◊ inner lining ◊ produces amniotic fluid
o Chorion ◊ outmost linging ◊ chorionic villi develop into placenta • Amniotic fluid
o Function: shock absorber
o Amount: 1500ml or more
• Placenta
o Provides “food” and secretes hormones that continue the pregnancy o Circulation: Mom and baby’s circulation is completely separate! o Metabolic function Respiration Nutrition Excretion Storage • Umbilical cord o Lifeline to mom o 2 arteries unoxygenated blood o 1 vein oxygenated o Wharton’s jelly
Outer covering of umbilical cord (protects cord)
Hormones
• Supplied by corpus luteum
• Detected in mom’s blood 8-10 days after conception • Keeps corpus luteum active which supplies:
o Estrogen o Progesterone
• The placenta takes the place of the corpus luteum around the 16th week of pregnancy
Human placental lactogen (hPL) • Acts as a growth hormone
• Stimulates mom’s metabolism (mom needs extra energy)
• Increases mom’s resistance to insulin (sends more sugar to baby)
• Facilitates glucose transport across placental membrane
• Stimulates breast development to prepare for lactation
Progesterone
• Maintains endometrium
• Decreases contractibility of uterus
• Breast development
Estrogen (by 7 weeks)
• Stimulates uterine growth and blood flow between uterus and placenta (uteroplacental)
• Breast development
An important point
• Placental function depends on maternal blood pressure
• If there is interference with circulation with the placenta, the following develops:
o Vasoconstriction (blood flow to baby is decreased) Maternal hypertension
Maternal smoker Cocaine abuse
Fetal development
• Fetal period is 9 week to birth
• Rapid growth and organ development
Some dates/terms related to fetal growth: • Integumentary
o Lanugo:
Downy hair covering the body
Appears at 13 weeks, disappears at 36 weeks o Vernix caseosa
Protects skin; most abundant in the creases (neck) and flexor surfaces. • Cardiovascular
o Heard at 16 weeks via fetoscope • Respiratory
o Surfactant matures by 36th week
Surfactant permits expansion of the lungs • GI system
o Meconium (tarry stool) • Urinary system
o By 5th month, fetus urinates into amniotic fluid
o 2nd half of pregnancy: urine makes up major part of amniotic fluid • Sexual
o Can identify male/female by 16th week
Emotional responses to pregnancy
• Ambivalence (contradictory feelings) • Grief
• Self-centered; feels need to protect her body • Introversion or extroversion
• Body image changes • Stress
• Mood changes
• Sexual desire changes • Couvade syndrome
o The father experiences the physical symptoms; morning sickness or backache; the “empathy” belly.
Three Psychological tasks of pregnancy
• 1st trimester: accepting the pregnancy • 2nd trimester: accepting the baby
• 3rd trimester: preparing for parenthood; nesting
Terms related to pregnancy
• Para : number of babies born after 22 weeks
• Gravida : A woman who is or has been pregnant
• Primigravida : a woman who is pregnant for the 1st time
• Primipara : A woman who has delivered one child after 22 weeks • Multigravida : A woman who has been pregnant previously
• Multipara : A woman who has carried 2 or more pregnancies after 22 weeks • Nulligravida : A woman who is not pregnant and is not currently pregnant.
Estimated Delivery date
Nagele’s rule
• Begins with 1st day of last menstrual period, subtract 3 months, and add 7 days
• Measure from top of symphysis pubis over curve of abdomen to top of uterine fundus in cm.
o Helps determine gestation week
o Gives indication of IUGR, twins, hydramnios (excess amniotic fluid) o 12-16 weeks, just above the symphysis pubis
o 20-22 weeks, at umbilicus
Pregnancy tests
• Measure hCG (human chorionic gonadatropin) o 95-98% accuracy
o blood and urine tests
Danger signs of pregnancy—call M.D. for ALL of these
• Sudden gush of fluid from vagina
• Vaginal bleeding (however, a little spotting can be normal due to fluctuating hormones) • Abdominal pain
• Apigastric pain (placenta may be tearing away from uterine wall) • Signs of toxemia/pre-eclampsia
o Dizziness, blurred vision, diplopia (double vision), see spots o Severe headache
o Edema of the hands, face, legs, and feet o Muscular irritability, seizures
• Oliguria (decreased urine output) • Dysuria (Painful or difficult urination)
• Temp above 101 and chills (could mean sepsis) • Persistent vomiting
• Absence of fetal movement (12 hours)
Prenatal Health assessment
• hCG confirms pregnancy • Complete health history
o genetic disorders o chronic illnesses o meds
o obstetrical history o personal habits • Complete physical exam
o VS
o Weight/height o Pelvic exam
o Assess size/shape of boney pelvis • Lab tests
o Serology
o Hematocrit and hemoglobin
N: 38-47% and 12-16 g/dl
o Sickle cell trait o WBC
N: 4,500-11,000
o ABO and Rh typing (indirect coombs)
N: Rh neg
Rationale: check for presence of Rh antibodies
o Rubella, Hep B, and Varicella titers
N: Increased titer indicates immunity o Urinalysis
Protein, RBC’s, WBC’s
Glucose: small vs. large amount • Subsequent visits
o Physical assessment o Measure fundal height • Fetal heart tones
o Fetoscope
16 weeks, and almost always by 19 or 20 weeks o Doppler
10-12 weeks • Prenatal visits
o Q 4 weeks for 1st 28 weeks o Q 2 weeks until 36 weeks, then o Q 1 week until childbirth
Nutrition during pregnancy
• Who the hell knows from that damn handout. This is all I know: o Vitamin D and Folacin (folic acid) is increased 100%
o Iron is HUGE, need 433% due to that pseudoanemia
Pseudoanemia is a drop in hematocrit during pregnancy. The increase in circulating blood volume reflects an altered ratio of serum to RBC’s; plasma volume increases by 50%, whereas the RBC count increases by 30%.
• 2nd and 3rd trimesters need to increase 300 kcals/day
Fluids and Fiber
• Drink 8 glasses of fluid daily (water is best fluid)
• No alcohol, limit caffeine • Limit artificial sweeteners • Fiber is good!
o Fights constipation o Lowers cholesterol
Weight
• Recommended weight gain during pregnancy:
o 25-40 lb
• 1st trimester
o gain 1 pound per month • 2nd and 3rd trimesters
o gain 1 pound per week
• Watch for sudden large gains- could be fluid
Physiological changes and discomforts in pregnancy
Uterus
o Softening of the lower uterine segment, a probable sign of pregnancy that may be present during the 2nd and 3rd month of pregnancy.
o The lower part of the uterus is easily compressed between the fingers placed in the vagina and those of the other hand over the pelvic area.
o Due to the softening of the uterus related to increasing vascularity and edema and because the fetus does not completely fill the uterine cavity at this point, so the space is empty and compressible.
• Braxton Hick’s
o Changes in contractibility
o
“
False labor”; does not cause dilation and effacement of the cervix. Effleurage (massage) and rest
• Ballottement
o A diagnostic maneuver in pregnancy. The fetus rebounds when displaced by a light tap of the examining finger through the vagina.
• Quickening
o Initial awareness of the movement of the fetus within womb o Felt 16th-18th week
• Lightening
o The descent of the presenting part of the fetus into the pelvis. Feels as if the baby is “dropping”.
o Happens around the 36th week
Cervix
• Goodell’s sign
o Softening of the cervix (due to increasing vascularity and edema)
• Chadwick’s sign
o Deep blue-violet color of the cervix and vagina
• Mucus Plug “Operculum”
o The plug of mucus that fills the opening of the cervix on impregnation
o Prevents bacteria from getting into uterus
Ovaries
• No ovulation
• Corpus luteum increases until week 16; then replaced by placenta
• Increased estrogen and progesterone inhibit the release of LH and FSH.
Vagina “VaJay-jay”
• Chadwick’s sign
• Preparing for stretching during labor and birth: o Connective tissue loosens
o Hypertrophy o Lengthens
o Luekorrhea
White, thick secretions
• pH in vagina becomes more acidic
o fights off bacteria, but,
o promotes fungus/yeast infections
bathe daily, wear absorbent cotton panties no crossing legs or douching
Breasts
• Nipples darken
• Thin and watery secretions • Montgomery’s tubercles
o Sebaceous glands in the areola surrounding the nipple of the female breast
o Prevention of nipple cracking
• Blood vessels more visible
• Estrogen and progesterone cause these changes
• During 2nd and 3rd trimesters, most growth due to mammary glands o Wear a well fitting bra for breast tenderness
Cardiovascular
• Blood volume in mom increases by 1500ml or 40-50% above pre-pregnancy levels. o Changes due to hormones, meet woman’s and growing fetus’ needs
o Cardiac output increases 30-50% o Heart rate increases 10-15 BPM
o RBC’s increase, but cannot keep up with the pace of the plasma volume; decreased hemoglobin and hematocrit occur. This is called pseudoanemia. Know it and love it. • Blood pressure :
o First trimester : no change
o Second trimester : systolic and diastolic decrease 5-10 mm Hg
o 3rd trimester : Returns to first trimester levels.
o Supine hypotension syndrome can occur in the 2nd half of pregnancy (vertigo,
decreased BP).
Palpitations and murmurs can cause an issue for these issues. Encourage mom to take naps, have partner assist with housework, get to bed early, and good nutrition. Teach mom that that these symptoms are normal. If mom feels faint, tell her to lower head between legs, lie down, rise slowly, avoid standing long periods. Avoid lying on back, instruct to lie on side (due
to compressed inferior vena cava). • WBC are elevated in the 2nd and 3rd trimester of pregnancy
o Could mask infection.
• Varicose veins
o Due to the compression of the iliac veins and inferior vena cava by uterus; increases venous pressure and decreases blood flow to the legs.
Interventions: Exercise, don’t cross legs; wear support hose; keep legs and hips up; exercise feet.
Respiratory
• Increased tidal volume
• Increased oxygen consumption
• Slight elevation in respiratory rate (18-20 in pregnancy; 12-20 is normal)
• Nasal stuffiness (1st trimester)
• SOB (not hubby, breath) 2nd trimester • Dyspnea
o Estrogen causes upper respiratory tract to become more vascular. As capillaries fill, edema develops in the nose.
Interventions: Use cool air vaporizer NO SPRAYS
Proper position; semi-Fowlers when sleeping.
Gastrointestinal
• Nausea and vomiting (1st trimester) • Gingivitis
• Increased saliva
o Causes are due to the cardiac sphincter relaxes; increased progesterone; gastric displacement; hCG levels
Interventions: Avoid greasy, highly seasoned food, eat small meals
frequently, eat dry toast or crackers before arising. Warm sprite and ginger ale can be helpful.
Sit upright 1 hour after eating Sodium bicarb after eating 6-8 glasses of water every day • Decreased motility ◊ constipation (2nd half)
o Causes are due to the iron supplement most women are on; displacement of the intestines.
Interventions: Exercise qid, increase fluids/bulk, be regular • Hemorrhoids (2nd half of pregnancy)
o Productions of relaxin
Avoid constipation, prolonged standing, constricting clothing Use topical meds, warm soaks, anesthetic agents
• Flatulence (2nd half o I don’t know why?
Avoid gaseous foods, chew thoroughly, exercise.
Integumentary
• Increased skin pigmentation
o Melanocyte-stimulating hormone o Facial mask (melasma)
o Linea ligra (dark line from pubis to umbillica)
o Vascular spider nevi
o Stretch marks on abdomen (striae gravidarum)
Stretching ruptures small segments of connective tissue o Rectus diastasis: Blue groove after pregnancy
Abdominal wall separates
o Increased sweat glands (problems with perspirations Increased estrogen levels
o Palmar erythema
Increased estrogen
Use lotions
Renal
• Fluid retention: Aids with increased blood volume • Increased water absorption
• Increased aldosterone
• Increased diameter of uterers
• Increased bladder capacity (urinary frequency and urgency (symptoms disappear at 12 weeks, then reappear 3rd trimester)
o Estrogen and progesterone cause this
o Mom gets rid of own waste and fetus’; compression of the bladder and uterers
o Ankle edema
Decrease fluid intake in the evening, limit caffeine; empty bladder Q2h to prevent distention and stasis; kegal exercises
Avoid tight garments; elevate legs; do dorsiflexion of the feet while standing or sitting for prolonged time
• May be slight (trace) spilling of glucose (glucouria)
Musculoskeletal
• Changes in gravity
• Later in pregnancy, gradual softening of pelvic ligaments and joints • Lordosis
o Caused by relaxin and progesterone o Leg cramps (late pregnancy)
o Backache (late pregnancy)
Good nutrition, rest with legs elevated, wear warm clothing.
During leg cramp, pull toes up toward the leg while pressing down on the ankle
Use proper body mechanics; avoid high hells (duh)
Endocrine
• Placental hormones
o Estrogen : breast/uterine enlargement
o Progesterone : maintains endometrium; inhibits uterine contractibility; lactation
o hCG : stimulates corpus luteum to produce estrogen and progesterone until placenta takes over.
o hPL (Human placental Lactogen): antagonist to insulin (frees fatty acids for energy so glucose is available)
o Relaxin : Inhibits uterine activity; softens cervix and collagen in joints.
o Prostaglandins : May trigger labor
• Pituitary gland
o Oxytocin
o Prolactin: lactation
• Thyroid increases in size o Increased BMR
o Better use of calcium and vitamin D • Adrenal glands
o Aldosterone • Pancreas:
o Insulin; additional glucose available for fetus
Immune system
• Resistance to infection during each trimester
• 1st trimester: 3-5 pounds • 2nd trimester: 12-15 pounds • 3rd trimester: 12-15 pounds
Gestational diabetes
Gestational Diabetes
• Occurs during pregnancy
• Pancreas cannot meet demands for insulin production during pregnancy, or
• Certain hormones block the action of insulin… insulin resistance.
• Occurs during 2nd and 3rd trimester • Usually resolves after delivery
• About 50% of these women develop diabetes within 22-28 years • Occurs in 2-3% of women
Risk Factors
• Obesity • Age
• Family history of type 2 DM • Obstetric history of:
o Infant wt >4000g (9 pounds) o Unexplained stillbirth
o Miscarriage
o Congenital anomalies
Hormonal influences during pregnancy
• 1st trimester : Insulin sensitivity due to: o increased estrogen and progesterone o results in:
decreased glucose in mom
mom may become hypoglycemic • 2nd trimester : Insulin breakdown due to:
o Human placental lactogen (hPL)
o Increased breakdown of insulin due to: Placental insulinase
o Overall effects:
Increased plasma glucose levels = hyperglycemia Increased insulin requirements
Insulin needs
• Diabetogenic effect on pregnancy o Is usually a good thing
o Increased insulin needs to be released to cover glucose in laboring moms
Effects on mom when she doesn’t have enough insulin
• Difficult labor
• Increased risk of pregnancy induced hypertension
• Polyhydramnios : amniotic fluid > 2000 ml (remember, 1500 ml is the regular)
• Postpartum hemorrhage • UTI
• Ketoacidosis ◊ death of mom and baby
• If mom has extra glucose circulating, it goes directly to the baby • Remember, mom and baby share glucose, but not insulin.
Effect on baby (not enough insulin)
• Macrosomia : “large body”
• Insulin does not cross placenta, which results in:
o Increased insulin production from baby
o Acts as a growth hormone
• Hypoglycemia
o When umbilical cord is cut, the glucose from mom stops.
o The result is a newly born, very hypoglycemic baby.
• Difficult birth
o Shoulder dystocia or other injury due to macrosomia (large baby) • Congenital anomalies
• Intrauterine growth retardation (IUGR) • Lungs less mature
• Fetal death
Management of Gestational Diabetes
Detection and diagnosis
• Screen pregnant women at high risk for GDM for diabetes o 24-28 weeks
50gm oral glucose tolerance test (GTT) Pre-gestational diabetes (HbA1c)
Goals for GDM
• Maintain normal glucose levels o Fasting glucose levels <105
o 2 hr postmeal (postprandial) <120
o During sleep, no less than 70.
• Maintain normal weight gain; for most women with GDM, this is:
o Weight gain of 22-30 lbs (different norms; remember that mom without gestational diabetes is 25-40 lbs)
• Prevent hyper and hypoglycemia
Goals achieved through:
• Office visits • Diet
• Blood glucose monitoring • Insulin • Exercise • Education More on Goals… • 1st and 2nd trimester o every 1-2 weeks • 3rd trimester (after 32 weeks)
o 1-2 times a week
• At each office visit, mom is assessed for: o Hypoglycemia
o Hyperglycemia
o Glycosuria (glucose in urine) o Hypertension
o Vaginal infections and bleeding o UTI
o Retinopathy—spots/blurring (symptoms are more long term) • Fetus assessed for:
o Macrosomia o Hydramnios
This happens in 25% (fetal polyuria)
Increase in amniotic fluid • Tests to determine fetal condition
o Ultrasound
o Daily fetal movement count (DFMC)
o Alpha fetal protein (AFP)- neural tube defect o Biophysical profile
o Contraction stress test (to see how well baby responds to contractions) o Amniocentesis
• Diet
o Dietary modifications (30-35 kcal/kg/day)
2200 cal/day (1st trimester)
2500 cal/day (2nd and 3rd trimester)
3 meals, 3 snacks, including bedtime snacks eat at the same time each day
• Blood glucose monitoring o If on insulin:
Accuchecks ac, hs, 2 hrs after meals
Check urine ketones on awakening, during illness, if BS is elevated o Not on insulin
May do accuchecks weekly or at office apts. • Insulin
o Cannot take oral hypoglycemic agents
o 50% with GDM require insulin o Reg and NPH 2 or 3 times a day
Check blood glucose as stated above • Exercise
o Walking after a meal o Swimming
o Stationary bicycling
o Carry glucose when exercising
o Whatever their body has been used to in the past
Teaching mom and dad
• Teach signs of hypo and hyperglycemia
o <60mg/dl drink or eat a “glucose booster” o Call M.D. if still <60 after 15 minutes
o Call M.D. if 2 or more episodes are in a week
Monitoring during labor and delivery
• Monitor glucose Q 1-2 hours and maintain 100mg/dl or less
• Continuous fetal and mother monitoring
Monitoring during post-partum
• Insulin requirements decrease • 98% revert to normoglycemia
• Do a glucose tolerance test in 6-12 weeks as follow-up
Gestational Hypertensive Disorders
Pregnancy Induced hypertension or PIH
• Hypertension and other symptoms that occur due to pregnancy • Disappear with birth of fetus and placenta
High risk factors
• Chronic renal disease • Chronic hypertension • Family history
• Primagravidas (a woman who is pregnant for the 1st time) • Twins • Mom <19 and >40 • Diabetes • Rh incompatibility • Obesity • Hydatidiform mole Pathophysiology
• Can progress from mild to severe
• Aterial venospasms decrease diameter of blood flow, which results in:
o Decreased blood flow
o Increased BP Classifications • Transcient Hypertension • Preeclampsia o Mild o severe • Eclampsia • HELLP syndrome Transcient Hypertension • BP > 140/90
• Develops during pregnancy • No proteinuria
• No edema (other than “normal” places like ankles)
• BP returns to normal by 10th day postpartum
Mild Preeclampsia
• BP > 140/90 x 2 at least 4-6 hours apart
• Weight gain
o +2 pounds/wk in 2nd trimester, or o +1 pound/wk in 3rd trimester, or
o sudden weight gain of 4 pounds/week anytime Norms
1st trimester: 1 lb/month 2nd and 3rd trimester: 1 lb/week • Dependant edema
• Proteinuria
• Urine output > 30ml/hr
Nursing care for Mild Preeclampsia
• Patient at home
• Bedrest (with BR privileges); side-lying position
• Mom and family will be taught to monitor: o Daily weight
o Urine dipstick o BP
o Fetal movements
• Diet: Regular with no salt restrictions
• If symptoms progress to severe Preeclampsia ◊ Hospital!
Severe Preeclampsia
• Presence of any of the following in a woman diagnosed with Preeclampsia: o BP > 160/110 (x2) 4-6 hours apart
o Weight gain—same as mild Preeclampsia o Proteinuria >4+ dipstick
o Urine output < 30 ml/hr
o Generalized edema, may also include pulmonary edema
Crackles heard in lungs
o Cerebral (headache) or visual (blurred vision) changes o Liver involvement
o Thrombocytopenia (decrease in number of platelets) with low platelet count (same thing?)
o Cardiac involvement o Hyperreflexia >3+
o Development of HELLP syndrome
Hemolysis (destruction of RBC’s) H Elevated liver enzymes EL
Low platelets LP
o Fetus growth severely shunted
Care of patient with severe Preeclampsia/HELLP syndrome
• Hospitalized until baby is delivered • Bedrest on side
• Bed near nurse’s station with code cart nearby • Quiet, calm environment
• Siderails up, padded
• Frequent assessments to include: o BP, P, R
o Daily weight o Assess edema o Deep tendon reflexes
o Assess for headache, visual disturbances, epigastric pain (liver is getting involved)
o Insert foley o Strict I and O
o Evaluate urine for protein o Monitor fetal well-being
o Assess labs; platelets, liver enzymes
• Prevent seizures◊ MAGNESIUM SULFATE
o Decreases neuromuscular irritability
o Decreases CNS irritability (anticonvulsant effect)
o Promotes maternal vasodilation, better tissue perfusion
o Watch for magnesium toxicity Loss of knee-jerk reflexes Respirations <12
Urine output <30ml/hr Cardiac or respiratory arrest Toxic serum levels >9.6mg/dl Sign of fetal distress
Calcium Gluconate is the antidote
• Control hypertension o BP meds via IV
o Continue observations 24-48 hrs after birth
o Symptoms usually resolve within 48 hours after birth
Eclampsia
• Onset of seizure activity or coma in person with PIH • Assessment findings
o Increased hypertension precedes seizures followed by hypotension and collapse o Coma may occur
o Labor may begin, putting fetus in great jeopardy
• Treat with magnesium sulfate and above measures for severe Preeclampsia
HELLP syndrome
• Occurs in 4-12% of patients with PIH; life-threatening situation to mom and/or baby. No known cause.
• Treatment:
o Give platelets
o Deliver infant ASAP
o All usually returns to normal after the delivery
Complications of Pregnancy
Hydatiform Mole
• Proliferation and degeneration of trophoblasts (the outer layer of blastocyst) • Cells fill with fluid
• Resembles a bunch of grapes due to the fluid filled (hydropic) vesicles • Mole
o Vessels grow rapidly ◊ large uterus
o Mole has no fetus, no placenta, no amniotic fluid or membrane • 1 in 2000 pregnancies in US
• higher incidence in Asia and tropics • Most often seen:
o Early teens or perimenopausal o Lower socioeconomic groups
o Risk of 2nd mole 4-5 x higher than the first • Signs and symptoms:
o Bleeding during 1st trimester Dark brown/prune juice
o Unusual uterine growth
o No fetal parts can be palpated o No FHT
o Snowstorm pattern on ultrasound o Abnormal labs
Very high serum hCG
o PIH
• Medical management
o Many moles abort spontaneously o Suction curettage to evacuate mole o One year following:
Serum hCG levels
Physical and pelvic exams
3-20% of cases progress to choriocarcinoma
pregnancy should be avoided for one year
Hyperemesis Gravidarum
• Extreme nausea and vomiting during first half of pregnancy that is associated with: o Dehydration
o Weight loss
o Electrolyte imbalance • Relatively rare
• Worse than “morning sickness” • Usually lasts beyond week 12
• Increased levels of hCG
Pathology of Hyperemesis Gravidarum
• Dehydration
• Fluid-electrolyte imbalance
o Hypokalemia
• Alkalosis due to loss of HCL
• Protein deficiency
• Starvation with muscle wasting
Fetus is at risk for:
• Abnormal development
• Intrauterine growth retardation (IUGR) • Death
Diagnosis:
• History of intractable vomiting in the first half of pregnancy • Dehydration
• Ketonuria
• Weight loss of 5% pre-pregnancy weight • Other signs and symptoms of dehydration
Medical therapy
• Control vomiting • Correct dehydration
• Restore electrolyte imbalance • Maintain nutrition
• If mom is NPO, usually 24-48 hours • IV fluids, 3000 ml or more first 24 hours
• Antiemetics • Antihistamines
• If no vomiting in 24 hours, started on clear liquids; mom sent home usually with a referral for home care
• Eventually goes to soft diet, then regular
• If vomiting occurs, will usually start TPN in the home
Urinary Tract Infection
• Affects 10% of all pregnant women
• Frequent site: dilated, flaccid, and displaced ureter • May cause premature labor if severe
Assessment findings
• Frequency and urgency of urination • Suprapubic pain
• Flank pain (if kidney involved) • Hematuria (blood in urine) • Pyuria (purulent pee) • Fever and chills
Nursing interventions
• Encourage high fiber intake
• Provide warm baths to relieve discomfort and promote perineal hygiene • Administer and monitor intake of prescribed medications
• Monitor for signs of premature labor from severe or untreated infection
Substance Abuse
• Alcohol, no safe level
o Displaces other nutritional food intake o Fetus may show signs of:
IUGR
CNS dysfunction
Craniofacial abnormalities (FAS) • Cocaine
o Causes vasoconstriction, elevated BP, tachycardia
o May cause seizures
o May cause spontaneous abortion, fetal malformation, neural tube defects o Newborn: irritability, hypertonicity, poor feeding patterns, increased risk of SIDS • Opiates
o Newborns experience withdrawal within 24-72 hours after delivery o High-pitched cry, restlessness, poor feeding seen in the newborn • Nursing care:
o Provide quiet environment o Wrap infant and hold snuggly o Observe for seizures
o Administer anticonvulsants, sedatives as ordered o Difficult to quiet
Care of the pregnant adolescent
• Over 1 million teenage pregnancies per year US • Developmental tasks:
o Body image o Sexual identity o Values
o Independence from parents o Decision making skills o An adult identity • Current problems—STD/HIV
o STD’s continue to rise rapidly in teenagers
Highest incidence of gonorrhea and syphilis are in the 15-19 year group o Researchers predict that HIV will increasingly be found in the adolescent population • Family reactions to adolescent pregnancy
o Shock, anger, shame, guilt, sorrow
• The pregnant adolescent o Incidence of:
LBW infants Infant mortality Abortion
o Poor compliance with meds—Vit/Fe
o Children taking care of children
High Risk Newborn
High risk newborns are at an increased risk for illness or death due to: • Prematurity
• Gestational age problems • Physical problems
• Birth complications
Assessing gestational age
• Preterm: 0-37 completed weeks • Term: 38-41 completed weeks
• Post term: greater than 42 weeks • SGA: Small for gestational age • AGA: average for gestational age • LGA: large for gestational age
• Two components:
o Physical maturity
o Neurologic and/or neuromuscular development evaluations • A score is given in each area
• Added up = gestational age • Other assessments needed
o Weight
o Head circumference o Length
The preterm infant
• Born before the end of 37 weeks
• Weight less than 2500 grams (5 lbs, 8 oz) • Maternal causes: o Age o Smoking o Poor nutrition o Placental problems o Preeclampsia/eclampsia • Fetal causes: o Multiple babies o Infections • Other: o Socioeconomic status
o Exposure to harmful substances • Severity of problems
o Related to baby’s age
o Great chance of complication the earlier the infant is born • Major complications:
o Respiratory distress syndrome (RDS) o Temperature regulation o Conserving energy o Infection o Hemorrhage Assessment/Interventions • Respiratory system
o Alveoli begin to form at 26-28 weeks; therefore lungs are poorly developed. o Not enough surfactant
Respiratory distress syndrome Chronic bronchopulmonary dysplasia • Respiratory distress syndrome- RDS
o
“
Hyaline Membrane disease”o Due to decreased surfactant
o Overtime, alveoli rub against each other, scar tissue develops in the lungs ◊ hyaline membrane
Hyaline: a glassy appearance/cartilage
o Symptoms: RR >60 Retractions Grunting Cyanosis Nasal flaring
Hypoxia ◊ lactic acid production Increased CO2 ◊ acidosis
Hemoglobin unable to carry O2 molecule X-ray’s show “white out” of the lungs
Increased HR Hypothermia
Decreased activity level
Medical management
• Prevent preterm birth
o Aggressive treatment of premature labor o Bethmethasone (steroid) to mom
Enhances fetal lung development
Needs to be given within 24 hours of birth • Surfactant replacement therapy
o Administer surfactant via E-T tube at birth for all preemies • Must establish ventilation and administer oxygen
o Ventilator via ET tube
Thermal regulation
• Poor thermal stability in preemie
o Large surface area in comparison to body weight
o Reduced muscle and fat deposits Brown fat begins after 28 weeks o Poor glycogen and lipid stores
o Limited ability to shiver o Usually less active
• Posture is flaccid ◊ increasing surface area exposed • Increase in insensible fluid loss ◊ dehydration • Respiratory distress◊ fosters more work of breathing
• Delivery rooms 62-68* F • Cold stress results in:
o Hypoxia
o Metabolic acidosis o Hypoglycemia
o Interventions for cold stress:
Isolette or warmer
Minimize drafts
Prewarm all surfaces
Bathing: keep covered; water warm
Knitted caps and booties
If oxygen is used, warm and moisturize it
Keep isolette covered—light is a stimulus
Nutritional Status
• Digestive system o Small stomach
o Poor muscle tone – cardiac sphincter Can cause vomiting
o Gag and cough reflexes are poor Aspiration is a problem o Decreased absorption of fat
o Limited ability to convert glucose to glycogen
o Lacks sucking until 32-34 weeks
o Gavage feedings may be necessary until sucking reflex occurs
o Give baby a soft preemie nipple to stimulate sucking as they are receiving gavage feedings.
Skin
• Decreased subcutaneous fat • Reddened
• Translucent
Immature liver
• Cannot conjugate bilirubin: Jaundice. o Treatment is phototherapy
• Cannot store or release glucose ◊ hypoglycemia
• Decrease in hemoglobin and production of blood ◊ anemia
• Does not make or store vitamin K ◊ hemorrhage
Immature kidneys
• Increased Na excretion ◊ hyponatremia
• Decreased ability to concentrate urine ◊ dehydration
Infections
• Immature immune system and other reasons
Neuromuscular
• Poor muscle tone • Weak reflexes • Weak, feeble cry
Developmental considerations
• Encourage bonding with parents
• Encourage visiting with parents and siblings • Kangaroo care
o Skin-to-skin touch • Twin co-bedding
• Positioning
Small for gestational age (SGA)
• Less that 10% on the newborn classification chart.
Causes:
Two types: • Symetric
o Infant looks normal but is very small
o Usually problem happens during first trimester (infections) • Asymmetric
o Later in pregnancy
o Long arms/legs; looks like a “skinny old man” o Usually weight <10%; length and HC >10%
Factors contributing to SGA: • Maternal causes:
o Poor nutrition (especially in last trimester) o Advanced diabetes
Vessels are constricted in mom; not enough blood/nutrients going to fetus. o PIH
o Smoking and drug (cocaine) use. o Age over 35
Due to physiological changes in mom • Placental causes:
o Partial placental separation o Malfunction
Unable to obtain or transport nutrients for baby (Decreased blood flow) • Fetal causes:
o Intrauterine infection
o Chromosomal abnormalities and malformations
Assessment findings for SGA (mostly asymmetrical) • Skin
o Loose and dry o Little fat
o Little muscle mass • Small body
o Skull appears larger
• Sunken abdomen
o Thin, dry umbilical cord
• Little scalp hair • Wide scalp sutures • Respiratory distress • Hypoglycemic • Tremors • Weak cry • Lethargic
Interventions for SGA:
• Similar to those of the preterm infant
Large for gestational age; LGA
• Neonate whose birth weight is above the 90th percentile on the newborn classification chart.
• May be preterm, term, or post-term
Causes of LGA:
• Mother with poorly controlled diabetes • Multiparity
• Infant with transposition of the great vessels (unknown cause) • Genetic predisposition
Problems associated with LGA: • May require C-section
• Higher incidence of birth trauma with vaginal delivery
o Fractured clavicle, brachial plexus palsies, depressed skull fractures, cephalhematomas
• Fetal distress during prolonged difficult second stage labor (respiratory distress) • Hypoglycemia
• Polycythemia◊ look for hyperbilirubinemia
Physical findings in LGA infant
• Weight greater than 4000 grams (8lb, 14.5 oz) • Caput succedaneum (goes over suture)
o Edema on top of head where it is pushed against cervix during labor (fluid).
• Cephalhematoma (does not go over suture)
o Blood collection due to rupturing during birth
• Facial nerve damage
o Unsymmetrical face (mostly seen while crying) • Infant at risk for pre and postnatal complications
• Hypoglycemia is a major problem (serum glucose <40 mg/dl) • Other symptoms:
o Jitteriness and tremors, brain depends on glucose
o Lethargy: flaccid, doesn’t want to eat
o Tachypnea, irregular respirations o Hyperbilirubinemia (>12)
o Feeding difficulties
Interventions for the LGA infant: • Monitor glucose levels
o At birth
o Every 2 hours for the first 8 hours
o Every 4 hours for 24 hours or until stable
• Offer glucose, breast milk, or formula before 4 hours of age o Gavage if respirations >60
o Glucose infusion if necessary Has to be done in the NICU
Maternal Infections