OB: Newborn Nutrition & High Risk Pregnancy part 2

What are the Nutritional Needs of the newborn?

• 105-108 kcal/kg/day​

• Formula fed babies gain weight faster than breast fed babies​

• Lose weight first 3-4 days​

• Weight gain about 10g/kg/day or 5-7 oz./week​

• Breast milk is digested more easily

What are the signs of dehydration in a newborn?

• Depressed fontanelles​

• Rapid, weak pulse​

• Elevated low-grade temperature​

• Dark, concentrated urine​

• Dry, hard stools​

• Dry skin with little turgor​

• Elevated specific gravity (1.020)

How does the breast make milk?

• Ducts and alveoli grow during pregnancy under influence of progesterone and estrogen​

• Small amounts of colostrum (1-2 teaspoons) per feed​

• Delivery of placenta triggers hormones prolactin and oxytocin​

• Prolactin-produces milk​

• Oxytocin-milk let down reflex (ejection of milk)​

• Stimulation of Breast ​

• The more often breast is emptied, the more milk is made (Supply and Demand)

What would interfere w/ the milk supply?

Anything that interferes with growth of alveoli and ducts, progesterone levels or other hormone levels, or breast stimulation

What is Colostrum?

• Yellowish creamy fluid​

• Thicker than milk​

• Contains: low fat, high protein, fat-soluble vitamins​ minerals ​

• Coats and protects baby’s digestive tract​

• Laxative effect​

• Passive immunity​

• Develops during pregnancy lasting several​ days after delivery

What is Transition Milk?

• Produced from end of colostrum until 2 weeks postpartum​

• Changes appearance and composition​

• Contains: more fat, sugar, vitamins, and calories

What is Mature Milk?

• Looks thinner and more watery than cow’s milk​

• White, can be slightly blue-tinged in color​

• Foremilk- beginning of feeding contains more water, less fat higher lactose​

• Hindmilk-higher fat content​

• 20kcal/oz.​

• Recommended for first 6-12 months of life

What is the Golden Hour?

• Baby alert and ready to feed within 1-2 hours after birth​

• Optimum place for baby to recover from birth is skin to skin on mother’s chest​

• Baby will instinctively root and seek out breast​

• Recovery sleep

What are the Advantages of Breast Milk?

• Inhibits bacteria growth​

• Easy digestion of lactose, lipids, fatty acids, amino acids​

• Varies in content and need of newborn​

• Helps with maternal-newborn attachment​

• Convenient, safe, and free of cost

What are the Disadvantages of Breastfeeding?

• Medications passed from mother to newborn​

• HIV or AIDS of mother​

• Excludes the father​

• Working mothers

What is the Hamburger latch (or C-hold)?

breastfeeding technique where you hold your breast like a burger, supporting it from underneath between your thumb and other fingers, to help your baby latch deeply and effectively (Google)

• Prevents sore nipples ​& cracked nipples​

• Allow efficient ​milk transfer

What are the typical feeding patterns of a newborn?

• On Demand​​

• Every 2-3 hours​

How should you store milk?

• Room Temperature​

• Refrigerator​

• Freezer

How do you prep milk?

• Never use microwave!​

• Warm water

How do you know if the newborn is successfully breastfeeding?

• Nursing at least 8 times in 24 hours​

• Infant swallowing​

• Breast appear soften after breastfeeding​

• Wet diapers​

• Stools​

• Weight gain

What are the 10 steps to Successful Breastfeeding?

1. Have a written breastfeeding policy that is routinely communicated to all health care staff. ​

2. Train all health care staff in the skills necessary to implement this policy. ​

3. Inform all pregnant women about the benefits and management of breastfeeding. ​

4. Help mothers initiate breastfeeding within one hour of birth. ​

5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. ​

6. Give infants no food or drink other than breast-milk, unless medically indicated. ​

7. Practice rooming in - allow mothers and infants to remain together 24 hours a day. ​

8. Encourage breastfeeding on demand. ​

9. Give no pacifiers or artificial nipples to breastfeeding infants. ​

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.

What is Formula Feeding?

• Based on cow’s milk, soy protein, other special formulas​

• Must be prepared correctly with right proportions, clean water, and bottles​

• Allergic reactions​

• Used up to one year of age​

• Expensive

What are the advantages of Formula Feeding?

• Easy ready to use​

• Father can feed​

• Working mothers

What are the Disadvantages of Formula Feeding?

• Less skin to skin contact​

• Less immunity passed to baby​

• Refrigeration system necessary​

• Clean water and bottles needed

What is the most frequently missed diagnosis in maternity care?

Substance use

What are the most commonly used illicit substances in pregnancy?

• Alcohol​

• Nonmedical pain relievers​

• Marijuana​

• Phencyclidine (PCP)​

• MDMA (ecstasy)​

• Heroin

What are some Maternal Complications from substance use during pregnancy?

• Delay in seeking prenatal care​

• Poor nutrition​

• PIH​ (pregnancy-induced hypertension)

• Bleeding Disorders​

• STD’s​

• Withdrawal​

• Psychological Reactions

What are some Fetal/Neonatal Implications in relation to substance use?

• Genetic, Teratogenic effects​

• Spontaneous abortion​

• IUGR​ (intrauterine growth restriction)

• Prematurity​

• Withdrawal​

• Abuse and Neglect

What are the signs of Withdrawal during pregnancy for newborn?

• Listless​

• Poor muscle reflexes​

• Poor feeding​

• High pitched cry​

• Jitteriness/tremors​

• Restless​

• Inability to be consoled when crying

What is Fetal Alcohol Spectrum Disorder (FASD)?

wide range of physical, behavioral, and cognitive impairments that occur due to alcohol exposure before birth (Google)

How soon can Defects related to alcohol occur?

as early as 3-8 weeks gestation

What facial characteristics can be seen in a child who has Fetal Alcohol Spectrum Disorder?

• Small head

• Low nasal bridge

• Epicanthal folds

• Small eye openings

• Flat midface

• short nose

• smooth philtrum

• thin upper lip

• underdeveloped jaw

How does marijuana exposure affect the newborn?

• 15% of pregnant women use​

• -tremors​

• -prolonged startles​

• -irritability

How does Cocaine exposure affect the newborn?

• May cause: HTN, hallucinations, respiratory failure, spontaneous abortions, abruptio placenta, preterm birth, stillbirth, ​

• The newborn usually weighs less at birth and smaller head circumference​

• Also irritable, jittery, tremors, high-pitched cry, and excessive suck​

How does opiates and narcotics affect the pregnant mom?

• CNS Depressant​

• May cause: poor nutrition, PIH, abnormal implantation of placenta, abruptio placenta, PROM, preterm labor

How does opiates and narcotics affect the baby?

at risk for preterm birth, IUGR, withdrawal symptoms after delivery, irritability, high-pitched cry, vomiting and seizures – Neonatal Abstinence Syndrome

How do infections enter the uterus?

• 1) Through the placenta​​

• 2) Ascend from the vagina into​ the uterus through the​ cervix

What does TORCH stand for?

​

• T – Toxoplasmosis​

• O – Other infections​

• R – Rubella​

• C – Cytomegalovirus​

• H – Herpes simplex virus-2

How do you get Toxoplasmosis?

• Eating raw or poorly cooked meat​

• Unpasteurized goat’s milk​

• Feces of infected cats

How does Rubella (German Measles) affect the newborn?

• Pregnant women cannot be vaccinated​

• Clinical signs in infants include congenital cataracts, congenital heart defects, deafness, mental impairment, cerebral palsy

How do you catch the Cytomegalovirus while pregnant?

• Most common viral cause of intrauterine infection ​7 per 1000 births​

• Found in urine, saliva, cervical mucus, semen and breast milk​

• Able to be transmitted by asymptomatic women across the placenta or by cervical route during birth​

• No effective therapy

What are the Cytomegalovirus risks to the fetus/newborn?

• Mental impairment​

• Hearing loss​

• Learning disabilities​

• Fetal death​

• Hydrocephaly​

• Cerebral Palsy​

• No Damage at all

What do you do if a pt is in labor and has a Herpes Simplex Virus outbreak?

• C-section is warranted

• Antiviral Therapy recommended after 36 weeks - Acyclovir

What are the Herpes Simplex Virus symptoms in the newborn?

• Fever​

• Jaundice​

• Seizures​

• Poor feeding​

• Vesicular skin lesions

What other infections could affect baby?

• Hepatitis B​

• Syphilis (congenital syphilis)​

• Herpes Zoster, the virus that causes chickenpox

What is Group Beta Strep and how does it get transferred to baby?

A bacterial infection found in the lower GI or urogenital tract​

• Transmit GBS in utero or during childbirth​

• Leading infectious cause of neonatal sepsis and mortality today​

• 10% to 30% of pregnant women are carriers​

• Colonization

How would you treat mom who has Group Beta Strep?

• Intrapartum prophylaxis (anyone who test positive for GBS receives antibiotics while in labor or prior to C-section)​

  • -Penicillin G 5 million units IV initial​

  • -followed by: Penicillin G 2.5 million units every 4 hours​

  • -Ampicillin 2g initial then 1g

How can an HIV positive woman transmit the virus to her baby?

• During pregnancy, labor & delivery, breastfeeding

• If she takes no preventive drugs and breastfeeds then the chance of her baby becoming infected is around 20-45%.

How do you reduce transmission of HIV?

• Combined with other interventions, including formula feeding, a complete course of treatment can cut the risk of transmission to below 2%. ​

• Even where resources are limited, a single dose of antiretroviral medication given to mother and baby can cut the risk in half.

What are some factors about HIV and Conception?

• An HIV positive woman with an HIV negative partner can become pregnant without endangering her partner by using artificial insemination. ​

• Provides total protection for the man, but does nothing to reduce the risk of HIV transmission to the baby.​

• If the man has HIV then the only effective way to prevent transmission is sperm washing.​

• Involves separating sperm cells from seminal fluid, and then testing these for HIV before artificial insemination or in vitro fertilization.

What does a CD4 test do?

• determines how much HIV has weakened the immune system​

A high CD4 count denotes a strong immune system.​

What does a Viral load test do?

• determines how much HIV is in the blood.​

A pregnant HIV positive woman with a low viral load is less likely to have an HIV positive baby than a woman with a high viral load.

How does Zidovudine work for mom and baby?

• Has been shown to be particularly useful for preventing HIV from being passed from a mother to her child.​

• AZT or combination therapy is usually taken two or three times daily, starting after the first trimester sometime between 14 to 34 weeks of pregnancy, as well as being taken during labor.

What medication can be given to a newborn of an HIV+ mother?

• If an HIV positive woman is taking AZT then it will probably be recommended that her baby is given AZT (usually as a syrup) for:​

• the first six weeks of its life ​

• starting 8-12 hours after birth

What criteria decides if an HIV+ mother can birth vaginally or not?

• Vaginal delivery is the first choice if woman has taken ARV drugs and has a low viral load​

• C/S delivery is first choice for high viral load

What Cardiovascular diseases can be seen in pregnant moms?

• Congenital Heart Defects​

• Rheumatic Heart Disease​

• Peripartum Cardiomyopathy​

• Mitral Valve Prolapse

What other complications can pregnant women w/ heart disease be at risk for?

heart failure​

arrhythmia​

stroke ​

• Women with congenital heart disease now comprise the majority of pregnant women with heart disease. ​

• The next largest group includes women with rheumatic heart disease. ​

How do you manage heart disease in the pregnant woman?

• define the diagnosis and sequelae ​

• assess functional status   ​

• genetic counseling when relevant  ​

• although new recommendations do not require prophylaxis, assess need for endocarditis prophylaxis during labor and delivery

How does the nurse care for patients w/ heart disease?

• Anticipate vaginal delivery in almost all cases, unless there are obstetrical contraindications  ​

• Early epidural anesthesia  ​

• Modify labor and delivery to reduce cardiac work - oxygen, side lying, forceps ​

• Postpartum monitoring, sometimes in a coronary or intensive care unit setting

For multiple gestations, what does Dizygotic mean?

From two ovum

hereditary ​

-Same or different genders

For multiple gestations, what does Monozygotic mean?

From one ovum

For multiple gestations, what does Dichorionic-diamniotic mean?

own chorion, amnion, placenta

For multiple gestations, what does Monochronionich-monamniotic mean?

Twins lie in same amniotic sac

What are the risks associated w/ multiple gestations?

• Spontaneous Abortion​

• HTN​

• Hydramnios​

• PROM​

• Incompetent Cervix​

• IUGR​

• PP hemorrhage​

• Abnormal Presentations​

• If share sac-increase chance of cord entrapment, twin-to twin transfusion, fetal demise