OB

OB

Green = Very Important

Bold = Important

High Risk Pregnancies:

*No prenatal care, pre-existing illness, pregnancy induced disease, risk for infertility*Low educational level background dont utilize resources as they should, scared

*Lot more teenage pregnancy sick, immature bodies, immature uterus (ideal age for pregnancy is 25)

*Unwanted pregnancy hangers, etc, anything to get rid of the pregnancy, people will do many different things, usually end up in the ED no matter what Reminders:

Nagels Rule [to find the estimated date of confinement]

+ 7 days, - 3 months (dont include the month you are in), + 1 year

Ex. November 7th, 2008 [the 14th and August plus 1 year, August 14th 2009]

High Risk Newborn Apgar chartScore of 0Score of 1Score of 2Component of Acronym

Skincolorblue all overblue at extremitiesbody pinkno cyanosisbody and extremities pinkAppearance

Heart rateabsent100Pulse

Reflexirritabilityno response to stimulationgrimace/feeble cry when stimulatedsneeze/cough/pulls away when stimulatedGrimace

Muscle tonenonesome flexionactive movementActivity

Breathingabsentweak or irregularstrongRespiration

1st trimester: 1 to 13 weeks

2nd trimester: 14 to 26 weeks

3rd trimester: 27 to 40 weeks

GTPAL [Gravity is # of pregnancies, parity is # of pregnancies in which the fetus or fetuses reach viability (approx 20 to 24 weeks or fetal weight of more than 500 g [2 lbs] regardless of whether the fetus is born alive or not)Gravidity number of pregnancies

Term [full] births (38 weeks or more)

Preterm (from viability up to 37 weeks)

Abortions/miscarriages (prior to viability)/stillborns

Living Children

Early fetal head compression (just monitor; when baby gets really low, most benign)

Variable cord compression (u, v, w shapes on fetal monitor), get Mommy on 8-10 L O2 and reposition Mommy on left side

Late De-cels placental/uteral insufficiency [O2]; HR drops and no re-oxygenation happens to baby and HR still decreases after contraction has ended

Tocolytics inhibit uterine contraction by suppressing smooth muscle contractionsContraindications: >34-35 weeks, fetal distress (at any gestational age), severe PIH, eclampsia, vaginal bleeding, cervical dilation > 6 cm [page 778]RN Closely Monitor

1. Pulmonary function 2. daily weights 3. I & O 4. S/S of pulmonary edema

Yutopar/ritodrine which is a beta adrenergic agonist, relaxes smooth muscle, inhibiting uterine activity and causes bronchodilation

Adverse Reactions SOB, tachy for both mommy and baby, hypotension, tachypnea, chest pain, pulmonary edema, n/v diarrhea

Nursing Management Maternal pulse >120-140, BP 5 g/L in 24 hours, oliguria which is < 400 mL/24 hours-Other symptoms like headache, blurred vision, scotomata (seeing stars in eyes), pitting edema, N/V, epigastric painLabs increased serum creatinine Eclampsia

-Characterized by

-Convulsions [can give MgSO4 for this]

-ComaTreating Preeclampsia-Home management

-Bed rest

-Check BP, UA daily

-Bi weekly NSTs

-24 hour urine collection

-Check fetal movement

-Hospital Management

-High protein, low sodium diet

-24 hour urine collection for protein and creatinine

-Fetal well being tests BPP, NST

-Anti-convulsant therapy MgSO4

-Anti hypertensive eg aldomet, Procardia, Labetelol [beta blocker] they are very common and safe antihypertensivesManaging Eclampsia [page 725 for PIH info]-Safety, Safety, Safety, Safetyyou get the idea. ;-)-Seizure management-MgSO4

-Safety precautions

Gestational Diabetes

-Carbohydrate intolerance with onset first recognized during pregnancy

Lack of maternal glycemic control before conception and in first trimester of pregnancy may be responsible for fetal congenital malformations

Maternal insulin requirements increase as pregnancy progresses and may quadruple by term as a result of insulin resistance created by placental hormones, insulinase, and cortisol

At birth, levels decrease dramatically; breastfeeding will affect insulin needs

Poor glycemic control before and during pregnancy can lead to maternal complications such as miscarriage, infection, and dystocia caused by fetal macrosomia

Careful glucose monitoring, insulin administration when necessary, and dietary counseling are used to create a normal intrauterine environment for fetal growth and development in pregnancy complicated by diabetes mellitus

Because gestational diabetes mellitus is asymptomatic in most cases, many women undergo routine screening during pregnancy

Maternal Risks [page 688] need to have blood glucose level the same at ALL times-Maternal hypotension causes IUGR

-Polyhydraminos increase of 2000 cc amniotic fluid from hyperglycemia -Hyperglycemia dystocia [difficult labor dysfunction, uncoordinated]-PIH-risk-Large placenta

-16 to 18 weeks AFP, tube screen

Fetal Risks

-Fetal demise d/t DKA

-Macrosomia- big juicy babies, perineal laceration or c-sect-Shoulder displacment

-IUGR because of maternal hypotension-Premie, respiratory distress [under developed lungs and check L/S ratio]->30 years, obesity, family history of diabetes or previous deliveries of large, juicy babies

Screening

-Blood drawn

-50 g random glucose test at 24 28 weeks; results > 140 require further testing

-Three hour GTT [glucose tol test] -Normal blood glucose level is 60 to 120-Educate pt to avoid caffeine before test-Fasting >95 blood sugar (draw fasting bs)

Screening sugar levels:

-1st hour >180

-2nd hour >155 to 165

-3rd hour >140 to 145

~Gestational Diabetes if 2 or more valves are high

Postpartum ComplicationsPostpartum Hemorrhage

-A blood loss greater than 500 mL in the first 24 hours after vaginal delivery-A blood loss greater than 1000 mL in the first 24 hours after C/S

Postpartum hemorrhage is most common and most serious type of excessive obstetric blood loss

Hemorrhagic (hypovolemic) shock is an emergency situation in which perfusion of body organs may become severely compromised, leading to significant morbidity or mortality rates for mothers

Causes

-Uterine atony [uterus forgets to contract]-Lacerations

-Retained Placental Fragments

-DIC

Symptoms-Increased, thready and weak pulses

-Decreased blood pressure

-Increased shallow respirations-Pale clammy skin

-Increasing anxiety

Medical Management

-LOTS AND LOTS of fluid

*Early recognition is critical

-1st = massage fundus and empty bladder

-Pitocin (10 -40 units in 1000 D5W)

-Methergine IM QID (this is to wake up uterus, cant give to HTN pt)-OR-

-Prostaglandin administration hemoabate, then-Bimanual compression literally go in vagina with knuckles and a 4 x 4, press against uterus and clean out uterus

-Blood replacement -Hysterectomy is worst case scenario-Pad change every 3 hours

Nursing Considerations

-Fundal massage

-Measure fundal height, consistency and lochia Q 4 hours

-Offer bedpan Q 4 hours

-Position pt in supine

-VS Q 15 mins

-O2 by face mask if RDS

-Dont ever leave to, stay at bedside

Subinvolution

-Incomplete return of the uterus to its pre-pregnant size and shape

Symptoms

-Late post partum hemorrhage 1 2 weeks after childbirth [about 3 to 6 weeks for it to stop]-Excessive blood loss

-Lochia fails to progress from rubra-serosa-alba

-Lochia Rubra persists after 2 weeks

Management

-Methergin or hemobate

-Antibiotics

-Frequent voiding

-Lots of fluids

-Breastfeed

-D & C if necessary

Risk factors

-Endometritis

-Placental fragments still left in uterus

Deep Vein Thrombosis

Symptoms

Edema of ankle and leg, change in LOC, low grade fever followed by chills and high fever, pain, Homans sign + or negative, peripheral pulses decreased, dyspnea and chest pain; watch mommy if she says her legs hurt; pain lower legs and or lower abdomen

Three types of DVT

-Superficial Thrombophlebitis swelling on effected leg, redness-Femoral Thrombophlebitis

-Pelvic Thrombophlebitis (VS important, will have temp, chills, first sign is them saying I cant breathe)

Management and Nursing Considerations-Prevention

-Early ambulation

-Assess peripheral pain

-Check hypotensive, chest pain

-Monitor signs of bleeding

-Warm, moist soaks while maintaining legs elevated

-Obtain clotting times

-Increase fluid intake

-Generalized petchie

-Heavy vaginal bleeding

Endometritis

Definition - Refers to an infection of the endometrium, the lining of the uterus. Bacteria gains access to the uterus thru the vagina and enters the uterus either at the time of birth or during the post-partum period.

Causes

Mommy had c/s, prolonged ROM, multiple sterile vag exams, prolonged labor, placental fragmentsSymptoms

-WBCs 20,000 to 30,000

-A rise in temperature 24 hours postpartum

-Starts 2 to 5th day post partum but before discharge

-Chills, malaise, loss of appetite

-Abdominal tenderness and strong after pains

-Lochia is dark brown and it smells, culture lochia if endometritis is suspected

-Will have delayed involution

Management and Nursing Considerations

-Antibiotics IV, broad spectrum [penicillin, gent]

-Analgesics

-Anti pyretic

-Lots of fluid

-Frequent perineal care-Positioning, sit or lay Fowler or Semi-Fowlers to promote drainage

Urinary Tract Infection

Cystitis infection in the lower urinary tract caused by E Coli

Pylonephritis infection in the upper urinary tract that causes damage to the kidney and impairs function

Causes

-Decreased bladder sensitivity-Frequent caths

-Frequent vaginal exams

-Increased bladder capacity

-Bladder trauma at birth

-Increased diuresis

Symptoms

-Over distention of the bladder

-Frequent urination of small amounts, burning, dysuria

-Hematuria

-Elevated temperature (low grade cystitis and high pyelonephritis)-Flank pain/CVT (costoverterbral flank pain)-Chills and N/V

Management and Nursing Considerations

-Culture and Sensitivity

-Admin ABX (Bactrim)

-Increase in fluids

-Monitor VS and bladder

Mastitis

-Infection of the breast connective tissue, primarily in women who are lactating

-Almost always uni-lateral

-From blocked milk duct and creates abscess

-Established after 2-3 weeks post partum

-Usual causative organisms are: Staph a, E coli, Strep

Symptoms

-Affected breast show localized pain, swelling, and redness

-Fever

-Breast milk becomes scant

-Pain

-Tender axillary lymph nodes

Management

-Broad spectrum antibiotics

-Breastfeeding continued or pumping (Q 2 -3 hrs) to promote that abscess to drain-Cold or ice compresses, supportive bra until pain subsides [45 minutes on 45 minutes off]-Frozen cabbage leaves [45 on 45 off]

-Warm compresses right before mommy breastfeedsComplications of Childbirth

Stress Factors = reduction of myometrial activity

Nursing Plan

-Comfort measures

-Relaxation/Breathing techniques

-Reassurance [always] and rapport [let her know what is going on every step of the way]Episiotomy

Midline straight down 1-2 cm-Advantages: less blood loss, less painful, heals quickly

-Disadvantages: may extend to anus (mommy has a big baby, cut straight down and can go down to anus)Midiolateral about 3-5 cm, these are big, big babies (like 8.5 lb ers)-Advantages: more room

-Disadvantages: more painful, more blood loss, takes longer to heal

Precipitate Labor

Labor that is completed in less than three hours. More common with multiparous woman. Poses risk of trauma to the fetus as well as trauma to the maternal soft tissue.

Management

-Early preparation for labor

-Support the perineum in case of delivery [all RN in L&D are ready to delivery baby if have to]Risks for Mom if mom is delivery too fast, uterine rupture is a risk, cervical vaginal rectal lacerations

For neo-nate hypoxia caused by uterus placenta insufficiency by hypertonic contractions/uterus, intra-cranial hemorrhage

Nursing considerations:

-Dont leave mommy alone!

-Have her pant to buy some time or have her blow and distract her to decrease urge to push

-Be sure to get sterile gloves prepared

-Support the perineum

-Look at monitor for babys well being (O2 like 8-10 L of oxygen for fetal distress)

Lacerations

First - perineal skin and the vaginal mucosa - extends through the skin and most commonSecond perineal skin, vaginal mucosa, fascia, muscles of the perineal body

Third Perineal skin, vaginal mucosa, fascia, muscles of the perineal body involving the anal sphincter Fourth a third degree laceration but goes thru the rectal mucosa

Considerations

-Put mom in stir-up if see trickle of blood post partum to check sutures and pat to see where it is coming from, can even come from vaginal laceration

Nursing Considerations

-Ice

-Pain meds

-Epi foam and derma plast to put on pad for perineal care (front to back, wipe from front to back and PAT dry)

-Tucks

Perineal Hematomas

Collection of blood in the subQ layer of perineal tissue characterized by: purplish discolored area, swelling (2 to 8 cm), and feeling of pressure or tightness; usually from vacuum out baby-Mommy will say severe pain in her perineum and may not be able to close her legs

Interventions

-VS (hypovolemia)

-Monitor for abnormal pain (use of vacuum and or forceps)-Monitor mommys bottom

-Ice [15 minutes on 15 off]

-Pain meds

-I & O

-Cath mommy if she is unable to void

-Antibiotics (becomes infected, broad spectrum, prophylactic)

-If bubble is clear, it is just edema leave alone; if black and blue, will have to do I & D to evacuate hematoma so prepare for that Now, time for passenger

Mal-positionPersistent occiput posterior cause: severe back pain, increased use of forceps/vacuum, increased risk of lacerations; posteriorly presenting head does not fit the cervix as snugly as the one in the anterior position

Risks-Sacral nerve compression = severe back pain

-Increased risk of forceps and vacuum = increase risk of lacerations

-FHT are heard on lateral side on the abdomen

Nursing Plan

-Position change knee chest

-Back rub

Mal-presentation

-Breech

-Face, brow

-Transverse

-Shoulder

Treatment

-Manual rotation [there is risk involved like where cord is located; doctor goes in and internally try to move the baby]-External version [page 789; ultrasound and move baby from the outside]-C-sect

Macrosomia (large gestational age babies, big juicy babies); maternal diabetes or post term pregnancy more than 42 weeks-Shoulder dystocia shoulders are too broad to be delivered thru the pelvic outlet

Nursing Responsibilities

-McRoberts maneuver [page 811]-Prep for c-sect

-Check infant shoulders after delivery

Cesarean Birth

Reasons for c-sect:

-Mal-presentation [breech, etc]-Placenta previa or abruption

-Fetal distress

-Failure to progress [Mommy has been labor for 12 to 14 hrs] -Prior uterine scar [doesnt want to go to a VBAC]Types of incision-Classic or vertical

-Low transverse or prannestiel

Nursing Responsibilities

-Prepare client shave, Foley, pre op meds [mommy bicitra neutralize stomach acid so she wont feel like throwing up or aspirate]-Pre op and post op teaching [monitor vs, assess fundus, assess vaginal bleeding, assess abd dressing, foley cath and urine output, turn/cough and deep breath] page 800Cord Prolapse [page 812]Occurs when a loop of the umbilical cord gets in front of the presenting part [see variable decals]

Nursing Plan

-Avoid cord compression

-Trendelenberg position-Knee chest position-NEVER press the cord back in; what you do is put pressure on babys coconut so babys not putting pressure on cord and do NOT let this baby be delivered, will have to go to c-sect

Causes

-PROM

-Placenta previa

-Tumors

-Cephalic Pelvic Disproportion [CPD]

-Small baby

-Multiple gestations

Symptoms

-Cord is felt on vaginal exam

-Presence of FHR with variable decals

Management

-Ensure reassuring FHT

-Vaginal exam to push up presenting part (not the cord)

-8 to 10 L of O2

-Poss c-sect or rapid delivery

-Positioning like Trendelenberg position or Knee chest position

Dysfunctional Labor

-Hypertonia seen in early labor; painful d/t uterine muscle cell anoxia [not enough oxygenation; no normal resting phase that goes on give analgesics, O2, positioning]; ineffective and doesnt even allow cervix to dilate-Hypotonia seen in active labor; caused by medication, epidural, over stretching of uterus, or mal-position (will have to rule out CPD cephalic pelvic disproportion) will give pit to jump start uterus, ultrasound to check positioning, vacuum assisted birth and c-sect is worst case Dysfunctional labor occurs as a result of:

Hypertonic uterine dysfunction

Hypotonic uterine dysfunction

Inadequate voluntary expulsive forces-not doing what is supposed to do

Functional relations among uterine contractions, fetus, and mothers pelvis are altered by maternal positioning, which is why ultrasound done at bedside

Risk factors

-Mommy over 40

-Uterine abnormalities

-Fetal macrosomia

-Fetal mal presentation

-Multi fetal pregnancy

Uterine Rupture

May be as a result of VBAC, trauma, excess pitocin administration, fetal lie

-Symptoms: excruciating pain [sharp, abrupt, sudden], cessation of contractions [uterus wont contract anymore], drastic decrease in fetal heart rate [immediately], late decals, may have bleeding or may not have bleeding

Treatment- emergency cesarean

-O2 and fluids

-Positioning

How baby compensates: Brady (late decals(tachyCauses

-Separation of scar from previous c/s

-Intensive uterine contractions

-Over stimulation of labor with Oxytocin

-Difficult forceps assisted birth

Uterine rupture management

-Complete uterine rupture extension thru entire uterine wall tx: shock, replace fluid and hysterectomy-Incomplete uterine rupture laparotomy, repair tear, blood replacementAmniotic Fluid EmbolismOccurs when amniotic fluid gets into maternal circulation; leading cause of death during labor or the first few hours post partum, first case was in 1926; leak in amniotic fluid and goes to lungs; unpreventable situation; pt cant breath; may have meconium; maternal mortality rate is about 61% and if happens, permanent damage; baby will usually have permanent hypoxia problems [like CP] about 50%; via the endocervical veins

Symptoms

-Respiratory distress SOB, cyanosis

-Chest pain [abrupt onset]-Tachycardia

-Acute hemorrhage

-Pale to bluish/cyanosis, dyspnea, respiratory distress Treatment = maintain oxygenation and support Cardio Vascular SupportManagement

-Oxygen by mask or cannula [8 10 L]-CPR if needed-Avoid moving pt

-Death may be imminent if not caught on time

-Intubate

DIC

Over stimulation of the coagulation process triggered by underlying disease and vascular injury

Management by treating underlying cause; will see in L & D process and part of childbirthCauses

-Abruptio Placentae

-Amniotic fluid embolism

-Dead fetus syndrome [retained in utero usually about 5 to 6 weeks]-Severe Preeclampsia

-Septicemia

-Hemorrhage

Management

-Assess vaginal bleeding

-Observe for clots

-Place pt in a left lateral side lying position

-Palpate fundus

-Low platelets, low fibrogin, low protrombin, and low Factors 5 and 6

S/S

-Bleeding from the nose

-Bleeding from IV site or other areas

HELLP Syndrome

-Hemolysis

-Elevated liver enzymes [AST more than 72 [5 and 40 is normal for AST] and increase in LDH [norm 0 to 250] of more than 600]-Low platelets [less than 100,000]Treatment

-Improve platelet count

-Close observation

-Prevent bruising or bleeding

-Once baby is out, HELLP is gone

-HELLP mommies are very sick

Symptoms

-Usually more than 34 weeks, but can be under 34 weeks

-N/V

-Right upper quadrant pain or epigastric pain

-H/A

-Diarrhea

Newborn Complications

Risk factors that causes newborn complications-Prenatal or intrapartal, diabetes, narcotics analgesics, anesthesia, fetal asphyxia, difficult or prolonged labor, multiple gestation, pre term baby, post term baby, congenital anomalies, maternal infection, neonatal infection, SGA or large for gestational age

Preterm Newborn

Definition gestational age (under 37 weeks of gestation) as well as weight less than 2500 grams (5lbs 8oz)

Preterm births can be attributed to many causes including:

-Gestational HTN

-Multiple pregnancies

-Adolescent pregnancy

-Lack of pre natal care

-Substance abuse

-Smoking

Complications-Respiratory distress syndrome (RDS) - decrease in surfactant in alveoli regardless of birth weight-Aspiration dont have an intact gag reflex, inability to suck, swallow and breathe-Apnea of prematurity

-Intraventricular hemorrhage (IVH) bleeding in or around ventricles -Retinopathy of prematurity-Patent ductus arteriosus (PDA) -Necrotizing enterocolitis (NEC) - very common, acute inflammatory bowel d/o in pre term or low birth weight babies; as soon as baby gets to NICU, get baby on breastmilk and that will help NEC which leads to perf and peritonitis -Neonatal sepsis

-Hypoglycemia especially for macrocosmic babies-Hyperbilirubenmia some babies are just born with this -12 to 15 bilirubin levels with bilirubin encephalopathy, kernicterus

-Delayed growth and development Ballard assessment assessment for premies and what they do before they go into the NICU, neuro and physical assessment

Symptoms

-Periodic breathing watch for retraction and color change, that is not normal, but periodic breathing is normal-Apnea pause longer than 10 to 15 seconds-Low birth weight -Minimal subcutaneous fat deposits

-Head large in comparison to body -Lanugo over body

-Minimal creases in the soles and palms (premies have minimal)-Flat areola without breast buds

-Heels fully moveable to the ears they are super flexible -Inability to coordinate suck and swallow -Skin is thin, smooth, skin and the smaller they are the more translucent

-Ear cartilage is very soft, in the unit, watch to make sure that they cartilage is in alignment

-Eyes may still be close

-Un descended testies

-Weak grasp reflex

-Hypotonic muscle

Nursing Interventions

-Perform resuscitative measures-Ensure thermoregulation - cant not regulate their own temp, radiant warmers, incubators-Administer respiratory support measures surfactant and oxygen -Administer nutrition and fluids

-Administer medications as prescribed

-Minimize stimulation

-Provide for non nutritive sucking

-Keeps parents informed/educated about care of their pre term newborn

-Less than 34 weeks, going to establish IV and oral gavage (when they get to 34 weeks, will start one PO 5 cc feed)-Clustered nursing care, Q 4, 6, 8 hrs

-Provide non nutritive sucking

-Inform and keep parents up to date

-Blanket rolls, swaddling, secure holding

-Goal in NICU is meeting infants growth and development needs, anticipate and manage complications in the NICU especially respiratory distress and sepsis (and cardiac system)

Discharge Planning

Home care needs of the infants parents are assessed

Information is provided about infant care

Referrals for appropriate resources

Referrals for home health assistance

Management-Bowel function

-VS

-Urinalysis

-CXR

-Arterial blood gas

-Head U/S = ultrasound (for IVH)-Echo

-Eye exams

-Serum glucose

-Calcium

-Bilirubin

Small for gestational [SGA] age newborn

Describes an infant whose birth weight is at or below the 10th percentile

Complications

-Perinatal asphyxia hypoxia -Meconium aspiration -Hypoglycemia

-Instability of body temperature

Symptoms

-Weight below 10th percentile -Reduced subQ fat

-Loose, dry skin

-Scalp hair sparse

-Wide skull sutures **inadequate bone growth (IUGR)-Wide eyed and alert prolonged fetal hypoxia that is their compensation -Sign of meconium aspiration, hypoglycemia and hypothermia

Post term newbornDefinition an infant that is born after 42nd week of pregnancy

Risks

-Decrease effectiveness of placenta increase asphyxia increase in meconium passage in uterus increase risk of meconium aspiration (MAS) inhalation of meconium into the lungs = meconium is a BIG fear-Birth injury r/t shoulder dystocia

-First pregnancies; gravida 1

-Etiology is unknown why mommy goes post term

-Mommy had a previous post term, may happen again

Symptoms

-SGA or large birth weight

-What happens depends on the placenta

-Absence of vernix (younger they are the more vernix they have), minimal lanugo -Dry, cracked skin r/t metabolism of fat to energy need in utero

-Hypoglycemia (metabolism of glycogen to meet energy needs in utero)

-Minimal subcutaneous fat because baby has to compensate on their own-Skin and cord stained yellow/green (caused by meconium)

-Long fingernails, scratches on the face, trunk

Nursing Management

-Blood sugar levels

-Hemocrit

-Complete Blood Panel-Obtain VS

-Complete blood count

-ABG

-CXR

Hypothermia

-Increased consumption of calories = loss of weight

-Increased oxygen consumption hypoxia - acidosis pulmonary construction

-Utilization of fat for energy lack of surfactant RDS

-Increased glucose consumption hypoglycemia

Hypothermia is a good indication for sepsis

Management

-Wrap and dry baby after ensuring airway, have to dry baby up!

-Reduce or eliminate heat lost thru drafts and contact with cold objects

-Postpone initial bath until temp has stabilized

-Dry infant immediately after birth and bathing

-Keep axillary temp between 97.6 and 99.2 F

Management complications

-If axillary temp is less than 97.6 F

-Put hat on infants head

-Wrap newborn with warm blankets

-Assess O2 and hypoglycemia status

-Re warm infant slowly (hypotension and apnea)

-Hypothermia is an early sign of sepsis

Hypoglycemia

Definition blood glucose less than 40 mg/dl in an term infant [30 to 80 mg/dl is normal blood glucose in baby]; all stressed babies have a risk for being hypoglycemicCauses

-Infants of diabetic mommys, SGA, premies, experiencing cold stress, hypothermia, delayed feedings, respiratory distressSymptoms

-Tremors, jitteriness

-Lethargy

-Decreased muscle tone

-Apnea

-Anorexia

-Weak cry

-Can lead to seizures

Management

-Check blood glucose on all infants by one hour of age and 30 mins on infants with IDM moms

-Treat hypoglycemia by breast feeding immediately or administering D5W, D10W PO or IV (Dont attempt to feed po an infant who is lethargic at risk for aspiration)

-If treatment has been started, recheck blood glucose level before the next feeding

Neonatal sepsis

Definition is a generalized infection that has spread through the blood stream

Pathophysiology

-Immature immune system (inability of the body to localize infection)

-Lack of IgM immunoglobin (protects against bacteria and does not cross the placenta)

-Manifests itself 24 hours after birthCauses

-Prolonged ROM-Difficult, long labor

-Resuscitation, invasive procedures

-Maternal infection (UTI and GBS)-Beta hemolytic strep causes (meningitis and sepsis)

-Aspiration of amniotic fluid, formula or mucus

-Nosocomial infections

-Meconium

-HIV mommies

-Low birth weight babies

Symptoms

-Temperature instability (hypothermia)

-Feeding intolerance (weak suck and low intake)-Behavioral changes ex. lethargy, pallor or seizures

-Respiratory distress (grunting, flaring, retractions)-Hyperbilirubenmia

-Jaundice

-Tachycardia apnea bradycardia [because of compensation]-Drainage [eyes, umbilical stump]

-Loose stool

-Vomiting

-Abdominal distention-Oral gavage large residual

Management

-Obtain cultures, blood urine, and CSF, before starting antibiotic therapy [complete septic work up]-Administer antibiotics

-Obtain VS and temp

-Observe for changes in physical assessment

-Will probably have fluid/electrolyte imbalance

[Usually will be poly-microbial, usually steph, E coli, Hem influenza, group B strep]

Hyperbilirubenmia

Definition term refers to excessive bilirubin in the blood characterized by jaundice; give yellow to their urine and brown to their stoolLab Values

-Normal Values for Newborns

Birth to 24 hours = 6 mg/dl

Day 1 to 2 = 8 mg/dl

Day 3 to 5 = 12 mg/dl

Types -Un conjugated/indirect fat soluble, physiologic jaundice [can turn into karnictus]

Most commonly seen in newborns; from trauma at birth-Conjugated/direct water soluble, pathologic in origin [this is the bad one!]Suggests hepatic problems ex biliary astresia, tumors, damaged liver cellsManagement

-Conjugated hemolytic disease fo the newborn

-Un conjugated 50 80% babies have this

**Look at eyeballs first! If below nipple line, not quite a concern as eyeballsJaundiceManagement

-Phototherapy

-Exchange transfusion used to treat infants who has raised levels (above 20), used when bili cant be controlled by phototherapy (replacement of 75 to 80% infants blood of recipients blood by donor blood)Phototherapy Management

-Cover infants eyes and remove covers Q 2 hrs

-Change position q2hrs and assess skin

-Assess stools (green stools are indicative of bilirubin being excreted thru the stools)

-Increase fluid intake to prevent dehydration

-Assess temp Q 2 hrs (hyperthermia)

-Monitor bilirubin levels prescribed

Respiratory Distress Syndrome

Causes/Risks

-Lack of surfactant

-Surfactant is a phospholipids that keeps/assist alveoli from collapsing and allowing gas to be exchanged ex cervanta

-Preterm infants

-Meconium aspiration (term or post term)

-Transient tachypnea of the newborn (TTN) cause from delayed absorption of fluid in the lungs from delivery; typically preterm and post term infant

Symptoms

-Grunting

-Cyanosis

-Tachypnea (more than ro RR/min)

-Nasal flaring

-Respiratory acidosis

-Retractions: sternal and subcostal

Newborn of addicted mother

Symptoms

-Withdrawal symptoms may occur as early 12 to 24 hours after birth or as late as up to 7 to 10 days post delivery

S/S

-High pitched cry

-Irritable (difficult to console)

-Decreased sleep pattern

-Hyperflexia

-Tachypnea

-Vomiting and diarrhea

-Uncoordinated suck

Management

-Position of infant on side (facilitates drainage)

-Burp them a lot to prevent aspiration, LOTS of patients

-Maintain sats

-O2

-Suction prn

-Decrease environmental stimuli and swaddle for comfort

-Obtain meconium and urine (drug screening)

-Monitor I & O and weight

-Administer meds eg methadone and Phenobarbital

-Control seizures

-Offer pacifier for non-nutritive sucking

-Assess: RR, weight, reflexes, CNS hyper-irritability

**There is no breastfeeding from addicted mommy to baby

Fetal alcohol syndrome (FAS)/ETOH Related Birth DefectsS/S

-Craniofacial anomalies short eyelid openings, flat forehead, upper lip grove flat-Microcephaly small head-Hyperactivity

-Developmental delays

-Poor sucks

-Congenital heart defects

-Mental disorders

-Attention deficits

*Education is key!

Management

-Position of infant on side (facilitates drainage)

-Burp them a lot to prevent aspiration, LOTS of patients

-Maintain sats

-O2

-Suction prn

-Decrease environmental stimuli and swaddle for comfort

-Obtain meconium and urine (drug screening)

-Monitor I & O and weight

-Administer meds eg methadone and Phenobarbital

-Control seizures

-Offer pacifier for non-nutritive sucking

-Assess: RR, weight, reflexes, CNS hyper-irritability

Metabolic ConditionsPhenylketonuria (PKU)-An inherited disorder that affects the bodys protein utilization caused by abnormal metabolism of the amino acid phenylalanine

-If the disease is not detected early the infant can loose 10 pts in IQ in the first month and can lead to mental retardation

Management

-Protein restricted diet

-Formula modified protein hydrolysate and limited phenylalanine or free phenylalanine

Assessment

-Obtain PKU after 48 hours of birth and no later than 7 days (infants need at least 24 hours of feeding to show adequate protein level)

-Normal levels are