Maternal Newborn Exam 2

Based off the TA Powerpoint

Baby CARDIAC changes

Closing of foramen ovale- due to increasing systemic pressure/left side of the heart
closing of ductus arteriosus & ductus venosus, they become nonfunctional ligaments

baby RESPIRATORY changes

Aeration of lungs and establishment of gas exchange
Continued maturation of intercostal and accessory muscles

Newborn Vital Signs

HR: 110-160 bpm
RR: 30-60 bpm (brief periods of apnea not unusual)
Temp: 36.5°C to 37.5°C

Causes of Jaundice:

Failure of liver cells to break down/excrete bilirubin leads to increased levels of bilirubin in the blood stream leading to yellowing of mucous membranes and skin

Physiologic Jaundice (3rd to 4th day of life) normal

d/t relative polycythemia, a shortened RBC lifespan, immature hepatic uptake and conjugation process

Pathologic Jaundice

Appears within the 1st 24 hours
Most likely d/t a blood incompatibility

Newborn periods of reactivity:
1) First period of reactivity

a. First 30 mins-2 hours
b. alert and active! Connect and interact with baby, may be hungry - initiate breastfeeding

Newborn periods of reactivity:
2) Decreased responsiveness period

a. Begins after first period and lasts around an hour. Baby may calm and have less movement, not a good time to begin feeding.

Newborn periods of reactivity:
3) Second period of reactivity

a. Lasts 2-8 hours, baby awakens and show interest in environment. Peristalsis increases! BM/voiding?

Newborn Medications - received around 1 hour of life or sometimes before discharge

- Vitamin K: essential for blood clotting, reduces the risk for serious bleeding issues (vitamin K deficiency bleeding of the newborn)
- Takes gut ~1 week to make clotting factors
- Erythromycin eye prophylaxis: protects from bacterial conjunctivitis from CT/GC and
ophthalmia neonatorum from GC (causes
blindness)

Newborn Vaccinations

Hepatitis B: received before discharge to protect from HBV which can cause serious liver disease
- Spread through bodily fluids (if birthing person is infected)

Pathology of Jaundice

- Caused by hyperbilirubinemia from
deposition of unconjugated bilirubin
- Liver is in charge of processing
unconjugated bilirubin(fat-soluble) into
conjugated (water-soluble) bilirubin which
can be excreted through GI/GU systems

Jaundice Treatment

- Phototherapy - exposure of skin to light
- Monitor hydration, bili levels, temp
- Give eye protection!

Kernicterus

unconjugated bilirubin in the brain
- Can cause brain damage and death

RHOGAM

Given to: Rh-negative birthing parents at 28 weeks, and again if they have an Rh-positive baby postpartum – to prevent developing antibodies, which could pose
risk to future pregnancies

ECTOPIC PREGNANCIES

- Pregnancy outside of the uterus, usually in the fallopian tubes
- S/S: spotting or bleeding, cramping esp one-sided, tenderness on one side, severe
abdominal pain

HYPEREMESIS GRAVIDARUM

Severe N/V during pregnancy that can lead to significant weight loss, dehydration,
fetal malnutrition, and electrolyte imbalances. Far surpasses first trimester.

PLACENTAL ABRUPTION

- Separation of pregnancy from uterine wall BEFORE delivery
- S/S: sudden abdominal pain, vaginal bleeding, back pain, fetal movement changes (usually a decrease in movement)

PREECLAMPSIA

High blood pressure that can lead to seizures if severe
- Diagnosis: 2 elevated BPs (>140/>90) at least 4 hours apart after 20 weeks gestation
AND protein in urine or organ dysfunction
- Severe preeclampsia BP >160/>110
S/s: unrelenting headache (doesn't go away with Tylenol), visual changes, right upper quadrant pain, lower extremity edema
- MAGNESIUM SULFATE - medication given to preeclampsia patients with severe
features to prevent seizures (eclampsia)

What should BP look like postpartum in a patient who had a gestational hypertensive
disorder?

- BP likely to increase on postpartum day 2, should normalize by 12 weeks postpartum – if it doesn’t normalize after 12 weeks = chronic hypertension
- Chronic HTN is associated with long-term cardiovascular risk as well as diabetes

CERVICAL INSUFFICIENCY

- Premature dilation of cervix due to
structural weakness
- Unknown etiology though there are many
hypotheses
- Usually occurs prior to age of viability
(23-25 weeks) and usually results in
pregnancy loss
- S/s: Typically rapid, painless, minimal
bleeding
- May have pelvic pressure, cramping,
increased discharge, loss of fluid

Gestational Diabetes

glucose intolerance
- Onset during pregnancy that is usually diagnosed in second/third trimester

Pathophysiology of Gestational Diabetes

- pregnancy creates a natural state of insulin resistance (ensures fetus has ample supply of glucose/nutrients)
- *body usually compensates and increases insulin secretion
- Human placental lactogen (hPL) increases in later pregnancy contributes to this insulin resistance
- Diabetes results when insulin demand cannot keep up and causes hypoglycemia

Risks of uncontrolled gestational diabetes to newborns:

polyhydramnios, macrosomia, birth injury, neonatal hypoglycemia, fetal growth restriction

Asthma

- Normal physiologic changes of pregnancy impacts the respiratory system, for many people pregnancy can worsen asthma
- Trouble breathing = fetus not getting well oxygenated
- Have to treat aggressively - benefits of preventing asthma attack outweigh any risk of medications (steroids are safe in pregnancy)
- Well managed asthma reduces adverse perinatal outcomes
- See care and prevent attacks!!!!

Alcohol

teratogen
- Impacts development
- Result in fetal alcohol spectrum disorder = physical, behavioral, and learning challenges

CESAREAN SECTION

- Can be lifesaving when medically necessary
- Labor dystocia (arrest of labor) is leading cause of c-sections in US

LABOR DYSTOCIA

- Prolonged or abnormal progression of labor
- Requires medical or surgical intervention
- increases risk of PPH, infection and C-section

4 Ps of Labor Dystocia

not strong enough contractions (POWER), poor positioning of PASSENGER, obstruction of the pelvis (PASSAGE) or psychological stress and anxiety (PSYCHE)

SHOULDER DYSTOCIA

Not the same thing as a labor dystocia, it is an obstruction of fetal descent by shoulders after the head has already been delivered. It is an EMERGENCY due to the risk of fracture, asphyxia, neuro damage, PPH, and death

Nursing MGMT

call for help, reposition patient
to FlipFLOP, suprapubic pressure,
communication between team members,
uterotonics, McRobert's, stay calm, Calling
out times/what is being done, documenting maneuvers, verbalizing what is being done

RISK FACTORS FOR PRETERM LABOR

Prior history, African american, Multiple gestation, Low SES, Lack of prenatal care, Drug use

BISHOPS TOOL

Used to score cervical ripeness and help patient and provider decide if cervical ripening is needed at start of medical induction; duration of labor inversely correlated with Bishop score

OPERATIVE VAGINAL BIRTHS

Vacuum assisted (VAVD) or forceps assisted (FAVD)
- Increased risk of trauma for baby and birthing person’s tissues, hemorrhage, long-term pelvic floor issues such as urinary and fecal incontinence
- Indicated with second stage arrest of labor

IUFD: Intrauterine fetal demise

loss of pregnancy after 20 weeks
Understand the significance of emotional impact on patient and family
Chaplain? Photos? Footprints? Funeral arrangements? Support groups?

Amniotic fluid embolism

entrance of amniotic fluid or fetal cells into maternal bloodstream

Uterine rupture

serious obstetric emergency when uterus tears during pregnancy or labor

Cord prolapse

umbilical cord slips in front of presenting part of fetus during labor possibly
compromising blood and oxygen flow to baby - needs emergency delivery *often occurs as membranes rupture

IUFD - intrauterine fetal demise

loss of pregnancy after 20 weeks

Induction

initiating labor before it begins naturally using methods such as oxytocin

Augmentation

Utilizing IV oxytocin to make contractions stronger and more frequent in setting of
spontaneous, protracted labor

cervical ripening

This is the process of preparing the cervix for labor by softening and thinning it
(effacing). This can be achieved through medications (like prostaglandins) or mechanical methods (like using a balloon catheter)

TOLAC and VBAC

trial of labor after cesarean and vaginal birth after cesarean (VBAC is the goal of
a TOLAC)

Postpartum Hemorrhage/Bleeding

excessive bleeding
- *leading cause of maternal death around the world
- More than or equal to 500mL vainal and 1,000 mL c/s

Nursing assessment PPH

- Awareness of risk factors: uterine atony (failure for the uterus to
contract)
- What can cause uterine atony?
- Retained fragments → manual extraction (can be a risk for PP infection)
- infection/IAI
- Uterine tone/location, vaginal bleeding, color, quantity, persistent
trickle, clots
- How can bladder impact the uterus?
- Make sure its emptied!

Management of PPH

- Identify the underlying cause
- Fundal massage! = first action!
- Uterotonics: Pitocin (1st line), methergine (not given with hypertension) Hemabate (not given with asthma), misoprostol,
TXA (tranexamic acid); antibiotics PRN
- assess bleeding, number of pads, QBL
- IV fluid mgmt
- monitor vitals q15 for signs of shock
- watch bladder: insert foley cath
- Labs: CBC, T&S, cross match, coags
- blood transfusion
- support during repairs and manual removal if needed

Postpartum psychosis (Definition, Risk factors, and manifestations)

severe mental health condition that occurs in weeks following childbirth
- Risk factors: substance use, lack of social supports, life stressors
- Manifestations: delusions, hallucinations, disorganized thinking
- Early symptoms can resemble depression and then escalate

Pulmonary Embolism

Manifestations: sudden onset of SOB, severe chest pain, apprehensive, diaphoretic, tachypnea, tachycardia, decreased O2 stat, fever
- Avoid estrogen after birth!

Mastitis (Definition, Risk factors, and manifestations, treatment)

unilateral breast inflammation and infection
- Risk factors: milk stasis, nipple trauma, poor latch
- Manifestations: pain, flu like symptoms, fever
- Treatment: assess latch, ice, feed on demand, hydration/rest/antibiotics, tylenol/ibuprofen

What to monitor for in LGA infants?

Birth trauma, hyperbilirubinemia, jaundice, hypoglycemia, cardio problems

Neonatal Abstinence Syndrome (NAS)

Opiate withdrawal
S/S: high pitched cry, incessant crying, difficult to soothe, tremors, irritability, yawning, sweating, poor feeding, regurgitation, diarrhea, excessing and uncoordinated sucking

Long term complications of NAS:

Feeding problems, CNS dysfunction, ADD, Language abnormalities, Microcephaly, Delayed growth development, Poor maternal-newborn bonding

How does premature delivery affect the infant respiratory system and infection risk?

- Surfactant deficiency, narrow respiratory passages, immature respiratory control in CNS, unstable chest wall (more at risk for RDS, atelectasis, apnea, obstruction)
- Premature infants at higher risk for infection because IgG transfers at 34 weeks, immune system is immature, Limited protective barrier: thin skin, fragile blood vessels

Respiratory Distress Syndrome
(Def, manifestations, treatment)

- Results from surfactant deficiency in lungs and is characterized by poor gas
exchange and ventilatory failure
- Manifestations of respiratory distress: grunting, flaring, retractions, cyanosis,
tachycardia
- Diagnosis: clinical picture, ABG, r/o sepsis/infection

Tracheoesophageal fistula/esophageal atresia

- Esophageal atresia - esophagus ends in a blind pouch/does not connect to
stomach
- Tracheoesophageal fistula - abnormal opening between the trachea and
esophagus
- excessive mucus secretions and drooling, cyanotic episodes and choking,
abdominal distention, immediate regurgitation

Cleft lip and palate

- Opening in lip or palate
- Need specialized nipple for feeding, can breastfeed with changes in position, feed upright (decrease aspiration risk), feed slowly, burp often, clean mouth with water after feedings

Substance-exposed newborns

Expected findings: high pitched cry, incessant crying, difficult to soothe, tremors, irritability, yawning, sweating, poor
feeding, regurgitation, diarrhea, excessive and uncoordinated sucking

Retinopathy of Prematurity

- High oxygen therapy in the newborn
- Caused by prolonged assistive ventilation and high oxygen
exposure
- Leads to retinal vasoconstriction and endothelial damage

Transient Tachypnea of the Newborn (TTN)

- Self-limiting, mild degree of respiratory distress
- Risk factors: Cesarean birth causes liquid in lungs to be removed slowly or incompletely