ob / peds lecture notes (nurse / nursing)

1.

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.

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.

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.

compression against the cervix impedes venous return, forcing serum into the interstitial tissues. The swelling reabsorbs within 1 to 3 days.

5.

of the fetus.

6.

divides after entering the abdomen of the fetus. It empties into the inferior vena cava.

7.

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.

birth as a result of hemodynamic changes related to respiration.

9.

descent through the pelvis.

10.

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 burns.

12.

is most abundant in the creases and flexor surfaces. It is not necessary to remove this after the fetus is delivered.

13.

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.

frequently, on the trunk, and usually disappear without treatment within several weeks.

15.

16.

surface of the body. Commonly noted whose ethnic origins are in the Mediterranean area, Latin America, Asia, or Africa

17.

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.

1. Upper chest. 2. Lower chest. 3. Xiphoid retractions. 4. Nares dilation. 5. Expiratory grunt. Graded 0, 1, 2

19.

physiological response of some female infants to an exposure to high levels of maternal hormones in utero.

20.

opposite arm and leg flex (turn head to right, and extremities assume opposite postures).

21.

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.

23.

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.

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 10}th _day.

25.

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.

with platelet deficiencies (thrombocytopenias) and in many febrile illnesses.

27.

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.

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.

present in the palate. They disappear in 1 to 2 months.

30.

and carbon dioxide and oxygen are exchanged.

31.

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

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.

Forman 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

_{nomogram 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

_{percentile 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

_{cranial 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

_{or 3}

_{week 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

_month.

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

_{percentile 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

A. Gently palpate each breast

B. If you feel nodules in the breast, the ducts

may not have been emptied at last .

C. Stroke downward towards the nipple, then

gently release the milk by manual.

D. If nodules remain, notify the doctor.

E. 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.

A. What is the contour?

B. Are the breast full, firm, tender,

shiny?

C. Are the veins distended?

D. Is the skin warm?

E. Does the patient complain of sore

nipples?

F. Are breasts so engorged that she

requires pain medication?

2. Uterus

A. Palpate the uterus

B. Have the patient feel her uterus as you

explain the process of involution

C. If uterus is not involunting properly, check

for infection, fibroids and lack of tone.

A. Uterus should the firm decrease

approximately one finger breadth

below

B. Unsatisfactory involution may

result if there are retained

secundines or the bladder not

completely empty

3. Bladder

A. Inspect and palpate the bladder

simultaneously while checking the height

of the fundus.

B. An order from the physician is necessary

catherization may be done. An order for

culture and sensitivity test since definitive

treatment may be required.

C. Talk to mother about proper perineal care.

Explain that she should wipe from front to

back after voiding and defecating.

A. Bladder distention should not be

present after recent emptying.

B. When bladder distention does

occur, a pouch over the bladder area

is observed, felt upon palpation;

mother usually feels need to urinate.

C. 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

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

B. Inform the mother about what changes she

should expect in the lochia and when it

should cease.

C. Tell the mother about what changes she

should expect in the lochia and when it

should cease.

D. Tell the mother when her next menstrual

period will probably begin and when she

can resume sexual relations.

E. Discuss family planning at this time.

abnormal in to color or contains clots or

other small ones.

6. Episiotomy

A. Inspect episiotomy thoroughly using

flashlight if necessary, for better visibility.

B. 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.

A. Check episiotomy for proper wound

healing, infection, inflammation and

suture sloughing.

B. Is the surrounding skin warm to

touch?

C. Does the patient complain of

discomfort? Notify the C.Doctor if

any occur

7. Homan’s Sign

A. 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

A. Throughout the physical assessment, notice

and evaluate the mother’s emotional status.

B. 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.

A. Does the patient appear dependent

or independent? Is she elated or

despondent?

B. What does she say about family?

C. Are there other nonverbal

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

Human chorionic gonadatropin (hCG) • 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 Heart beat heard at 10 weeks by Doppler 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

• 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

McDonald’s method

• Measure from top of symphysis pubis over curve of abdomen to top of uterine fundus in cm.

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 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

 Abnormal color  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 3}rd _{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 3}rd _trimesters

o gain 1 pound per week

• Watch for sudden large gains- could be fluid

Physiological changes and discomforts in pregnancy

Uterus

• Hegar’s sign

o Softening of the lower uterine segment, a probable sign of pregnancy that may be present during the 2nd _{and 3}rd _{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

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

• Increase in fullness, heaviness, tenderness • 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 3}rd _{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 3 rd _{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 3}rd _{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.

• Nausea and vomiting (1st _trimester) • Gingivitis

• Increased saliva

• Increased gastric acid (heartburn/pyrosis)

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 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

• Calcium and phosphorus needs increase

• 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 3}rd _trimester • Usually resolves after delivery

• About 50% of these women develop diabetes within 22-28 years • Occurs in 2-3% of women

• Often reoccurs in later pregnancies

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

• 1 st _{trimester : Insulin sensitivity due to:} o increased estrogen and progesterone o results in:

 mom may become hypoglycemic • 2 nd _{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

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 2}nd _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 3}rd _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

• 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

• Mom is not hypertensive before pregnancy

• 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

• 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 3}rd _{trimester: 1 lb/week} • Dependant edema

o Eyes, face, fingers • 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

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

Medical management

• Prevent seizures MAGNESIUM SULFATE o Decreases neuromuscular irritability

o Decreases CNS irritability (anticonvulsant effect)

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 In women after ovulation stimulation with climiphene (clomid) 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

• 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 Produces analgesia, euphoria, respiratory depression

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

 Increasing central cyanosis  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

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:

• Due to intrauterine growth retardation (IUGR)

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

• Neonate whose birth weight is above the 90th _{percentile on the newborn} classification chart.

• Subject to overproduction of growth hormone in utero. (Insulin, if mom was diabetic)

• 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