OB/Peds Test 2

breast feeding definition

process of feeding mother’s breast milk to her infant either directly from breast or expressing milk and bottle feeding it to the infant

timeline for milk production- hormones

• progesterone

• estrogen

• prolactin

• oxytocin

timeline for milk production- placenta delivery

• event triggers release of prolactin and oxytocin

• prolactin stimulates milk production

• oxytocin triggers milk ejection

timeline for milk production- mammary development

• in pregnancy, the mammary glands grow and mature

• estrogen and progesterone affect this

timeline for milk production- breast stimulation

• infant sucking stimulates the anterior pituitary gland, releases oxytocin and prolactin

• milk is produced and ejection occurs

phases of breast milk

• colostrum

• transitional milk

• mature milk

→ fore milk

→ hind milk

colstrum

• develops during pregnancy and last days after pregnancy

• yellow, thick, small amount

• nutrient dense: low fat, high protein, many vitamins and antibodies

• helps prevent jaundice

transition milk

• produced after colostrum milk until around 2 weeks postpartum

• quantity increases, changes in appearance

• contains more fat, sugar, vitamins, calories

mature milk

• thinner and waterier

fore milk- beginning of feeding, more water and lactose

hind milk- end of feeding, higher fat content

golden hour

• baby is alert and ready to fed within 1-2 hours after birth

• post delivery recover skin to skin contact on mother’s chest

• baby will root and seek breast

• recovery sleep

early hunger cues

mouth open, licking lips, rooting

mid hunger cues

eating hands, more active and wiggling

late hunger cues

crying, agitated

newborn nutrition needs

• 100-110 kcal/kg/day

• feed on demand, about every 2-3 hours

advantages of breastfeeding

• immunologic properties

• easy digestions

• content varies per need

• helps with attachement

• reduces risk of SIDS

• Free

• better neurodevelopment

disadvantages of breastfeeding

• medications pass through breastmilk

• HIV transmission

• limits partner involement

• employment and childcare

• maybe stressful and painfull

signs of successful breasfeeding

• nursing at least 8 times in 24 hrs

• adequate latch

• 6-8 wet diapers daily

• 3+ stools daily

• infant weight gain

• baby is satisfied after a feeding

mastitis

• inflammation of mammary gland, infection related to impaired skin intergrity and milk stasis

• flu like symptoms, and red tender breasts, hot to the touch, treat with NSAIDs and antibiotcs

engorgement

• distention and swelling of breast tissue, breast become hard and tender

• may occur during let down or ineffective emptying of breast milk

• treat using massage, hand expression, heat/cold packs, NSAIDs

signs of infant dehydration

• depressed fontanelles

• rapid pulse and respirations

• low grade temp

• few wet diapers, dark urine

• prolonged capillary refill

• dry skin/mucosa

• sunken eyes

• lethargy

preparing breast milk

• can be given at room temp

• don’t use microwave

• feed semi upright and burp regularly

• discard leftover after 1 hr

suppressing lactation

• absence of stimulation eventually decreases supply, most women experience engorgment, leakage, and discomfort before lactation ceases

• snug bra 24 hr

• avoid breast stimulation

• do not restrict fluid intake

• reduce salt intake

• take mild analgesics to reduce discomfort

• use cool compress or ice packs

• make take 5-7 days

APGAR score

A-appearance (color)

P- pulse (heart rate)

G- grimance (reflex irritability)

A- activity (muscle tone)

R- respirations (respiratory effort)

vital signs newborn

temp- 97.7 - 99.5

HR- 110-160 murmurs

RR- 30-60 bpm

BP- 50-70 systolic, 30-45 diastolic

immediate newborn care

• clear airway

• thermoregulation

• vitamin K

• erythomycin

• Hep B

• first feeding

• parent newborn attachment

newborn distress

• retractions

• nasal flaring

• grunting

• facial grimacing

• cyanosis

• abdominal distension

• vomiting

• jitteriness (glucose less than 40)

neonatal transition

• increase cardiac output and contractility

• surfactant release and promotion of pulmonary fluid clearance

• thermoregulation and cold stress

reflex breathing triggers

• low blood oxygen levels

• increase blood carbon dioxide levels

• low blood pH

• temperature changes

• drying

newborn respiratory

normal- 30-60 bpm

periodic breathing lasting 5-15 seconds

abnormal- apnea lasting more than 20 seconds

fetal cardiac shunts

ductus venosus

foramen ovale

ductus arteriosus

neonate/infant heat loss

convection- exposure to cool air

radiation- exposure to cool objects near infant

evaporation- wet body surface

conduction- cold table surface, scale, hands

infant cold stress

lethargy, hypotonia, can lead to apnea and respiratory distress

infant face/eyes/ears

• symmetry is important

• eyelids are edematous during first few days of life

• mouth should be pink

unconjugated (indirect) bilirubin

• breakdown of hemoglobin from RBCs, fat soluble

• not an excretable form and a potential toxin

conjugated (direct) bilirubin

• converted version of yellow indirect bilirubin, water soluble pigment

• excreted by kidneys and in feces

jaundice

• benign, normal variation

• intervention is to increase number of breastfeedings, warmth, phototherapy, strict I&Os

hyperbilirubin

• untreated can cause kernicterus (brain damage)

interventions- monitor VS and I&Os, phototherapy with eyemask

* extremely high levels transfer to NICU for transfusion

infant urination

• within first 24hr

• 6-8 wet diapers a day

meconium stool

first stool, black tarry

causes of high risk newborns

• maternal age (>18, <40)

• maternal obesity

• low socialeconomic status

• lack of prenatal care

• smoking

• substance use

• maternal disease

• psychological stress

level 1 newborn

well newborn nursery, healthy term newborns, basic stabilization

level 2 newborn

special care nursery, late preterm or midly ill infants

level 3 newborn

NICU, premature/critically il, advanced technology and specialist

level 4 newborn

regional NICU, highest acuity, surgical care and sub specialities on site

NICU team

• neonatologist

• neonatal nurse practioner

• pharmacist

• OT/PT/Speech

• neonatal nurse

• Respiratory therapist

• dietian/lactation

• social worker/case manager

Training NICU nurse

• unit orientation

• neonatal resuscitation program

• S.T.A.B.L.E (suagr, temperature, airway, blood pressure, lab work)

NICU - emergencies

1- anticipate

2- assign roles

3- check equipment

4- simulate and drill

5- debrief

micro preemie

<26 weeks

preterm

<37 weeks

late preterm

34-36 6/7 weeks

term baby

38-40 weeks

post term

>42 weeks

birth weight AGA

10th - 90th percentile

2,500 - 4,000 g

birth weight LGA

> 90 percentile

>4,000 g

birth weight SGA

< 10th percentile

<2,500 g

high risk condition- respiratory

• transient tachypnea of the newborn

• respiratory distress syndrome - surfactant deficiency

• meconium aspiration syndrom

• bronchopulmonary dysplasia- chronic lung disease

high risk condition- GI

• necrotizing enterocolitis - bowel inflammation/necrosis (emergency)

high risk condition- neurological

• intraventricular hemorrhage (IVH) - bleeding in the brain (preterm)

high risk conditions- other

• hyperbilirubinemia - elevated biliribin, phototherapy

• hypoglycemia- infant of diabetic mother, small of gestational age

• sepsis

• apnea of prematurity

transient tachypnea of the newborn

cause- retained lung fluid, common after C section or LGA

signs- tachypnea, grunting, mild retractions soon after birth

management- O2, resolves in 24-72 hrs

respiratory distress syndrome

cause- surfactant deficiency in premature lungs

signs- grunting, nasal flaring, retractions, cyanosis

management- surfactant, CPAP, O2, supportive care

Meconium aspiration syndrome

cause- meconium aspirated into airways, post term infants

signs- respiratory distress, barrel chest, stained skin/nails

management- airway clearence, oxygen/ventilation, antibiotics

bronchopulmonary dysplasia

cause- chronic lung injury from prolonged ventilation/oxygen trauma

signs- ongoing oxygen need beyond 28 days, retractions, poor growth

management- gentle ventilation, nutrition, diuretics, slow weaning

intraventricular hemorrhage

cause- bleeding in fragile germinal matrix vessels, risk rises with prematurity

signs- apnea, lethargy, bulging fontanelle, falling hematocrit

management- supportive care, minimize handling, serial head ultrasounds

hypoxic ischemic encephalopathy

cause- brain injury from hypoxia/ischemia, often birth related

signs- altered tone, seizures, poor feeding, depressed reflexes

management- theraputic hypothermia, seizure and supportive care

hydrocephalus

cause- excess cerebrospinal fluid accumlation increasing intracranial pressure

signs- rapid head growth, bulging fontanelle, sunset eyes

management- serial imaging, ventriculoperitoneal shunt if needed

necrotizing enterocolitis

cause- intestinal inflammation/necrosis- true neonatal emergency

signs- distended abdomen, bloody stools, temp instability, feeding intolerance

management- stop feedings, nasogastric decompression, antibiotics, possible surgery

feeding intolerance

cause- immanture motility and digestion, common in premature infants

signs- large residuals, abdomial distension, emesis, poor weight gain

management- adjust volume/rate, trophic feeds, monitor, rule out necrotizing enterocolotis

infant thermoregulation

• neutral thermal environment

• incubator for preterm infants

• warm hands, hats, blankets to reduce heat loss

infant positioning

• neutral head position, midling alignment

• flexed limbs with boundaries/nesting

• promotes normal musculoskeletal developmental

infant family centered care

• open visitation

• included in rounds

• breastfeeding/pumping

• parental support

• skin to skin care

infant stress cues

• color changes- mottling, pallor, dusky

• gaze aversion

• hiccupping/yawing

• splayed fingers/arching

response: pause care, dim lights, reduce noise, cluster care

infant care discharge planning

1. begin early

2. teach the family

3. CPR training

4. follow up

high risk pregnancy factors

• genetic/chromosomal conditions

• cardiovascular distress

• infection

• diabetes

• illicit drug use

• smoking, alcohol, substance use

• maternal obesity

• age <15, >35

placenta previa

• placenta implants in the lower uterine segment

• painless, bright red vaginal bleeding

risk factors- advanced maternal age, multiple gestation, infertility treatment

management- bedrest, pelvic rest, no vaginal exams, monitor fetal heart tones, c section

placenta abruption

• premature separation of a normally implanted placenta from the uterine wall

• bleeding may be visible (external) or concealed (internal)

signs- sudden onset pain, rigid uterus, dark red bleeding, fetal distress

risk factors- ama, trauma, short umbilical cord, hypertension (most common)

* emergency

abortion

• loss of pregnancy prior to 20 weeks

• may be spontaneous (miscarriage) or elective

risk factors- genetics/chromosomal, uterine abnormalities, hormone imbalance

abortion classifications

threatened- bleeding, cervix closed, fetus viable

inevitable/imminent- cervix dilating, loss unavoidable

complete- all products of conception expelled

incomplete- partial expulsion, misoprostol/mifepristone, D&C may be needed

missed- fetal demise without expusion

recurrent pregnancy loss- 3+ consecutive pregnancy lossess

septic- infection of uterine contents, emergeny, life threatening

ectopic pregnancy

• implantation outside the uterine cavity (fallopian tube, ovary, peritoneal cavity, or cervix)

interventions- methotrexate stops cell growth and allows the body to to absorb the pregnancy tissue, RhoGAM if Rh(-) for future pregnancies

stillbirth

• fetal death after 20 weeks of gestation, 1 in 160 pregnancies

cervical insufficiency

• premature, painless dilation of the cervix without labor or contractions

cord prolapse

• umbilical cord falls through cervix ahead of the presenting part

emergency intervention- manually hold the presenting part off the cord while client is positioned in trendelenburg or knee chest. deliver via emergency c section

preterm labor

• labor 20-37 weeks of gestation

• #1 cause of neonatal morbility

• bedrest, hydration, tocolytic therapy, corticosteroids, magnesium sulfate

tocolytic drugs

• nifedipine

• indomethacin- NSAID, <32 weeks only beause it may cause premature closure of the ductus arteriosus

• atosiban- oxytocin antagonist

magnesium sulfate

• CNS depressant, calcium antagonist- relaxes smooth muscles

mag toxicity signs- respiratory depression, confusion, cardiac arrest

antidote- calcium gluconate IV push

hypertension in pregnancy

chronic- pre exisiting before 20 weeks

gestational- onset after 20 weeks, no proteinuria

preeclampsia- HTN and proteinuria or organ dsyfunction, occurs after 20 weeks

eclampsia- preclampsia and seizures, life threatening emergency

preeclampsia

signs- severe headache, visual disturbances, decreased urine output

mild management- bedrest, low sodium. fetal monitoring

severe management- bedrest, anticonvulsants, antihypertensives, delivery is the only cure

eclampsia

• preeclampsia and seizures

management- maintain airway, prevent injury, only cure is to delivery placenta

HELLP syndrome

• HTN absent in 10-15% of cases

symptoms- N/V, flu like symptoms, epigastric pain, jaundice

• commonly misdaignosed (gastroenteritis, hepatitis)

diabetes in pregnancy

• pregnancy increases insulin demand for fetal growth, placenta (endocrine organ) causes insulin resistance

• gestational (GDM): onset during pregnancy occurs in up to 10%

• may resolve postpartum or progress into type 2

screening- 75g GTT between 24-28 weeks, >120 mg/dL → 3 hr test

fetal effects of diabetes in pregnancy

• LGA

• poorly controlled insulin dependent

• congenital abnormalities

• neonatal hypoglycemia

• hyperbilirubin

• polyhydroamnios

• shoulder dystocia risk

• respiratory distress

vulnerable populations- adolescent pregnancy

• rates declining but still elevated in southern states and ethnic minorities

• lack of contraceptive use or knowledge

• listen more than you talk, build trust

• assess self esteem, mental health, decision making skills

• education on nutrition, prenatal care, parenting skills

vulnerable populations- substance use disorder pregnancy

• no safe amount during pregnancy

torch infections - other

• syphilis, gonorrhea, HIV, Hep B, varicella

• group B strep is leading cause of neonatal sepsis

torch infections - rubella

pregnant women cannot receive MMR (live vaccine)

torch infections - cytomegalovirus

risks- mental impairment, hearing/vision loss

torch infections- herpes simplex (HSV)

• c section if active outbreak at labor

• acyclovir after 36 weeks to prevent outbreak

HIV in pregnancy

• modern ART is highly effective, transmission risk is <1% with meds and formula feeding

• c section indicated only if high viral load, above 1,000 copies/mL

• start AZT or combo ART in1st trimester

• newborn- AZT syrup for first 6 weeks of life

cardiovascular disease in pregnancy

increase risk- increased cardiac output in pregnancy strains compromised hearts

anemia reduces O2 delivery to fetus

hyperemesis gravidarum in pregnancy

severe N/V impacting hydration and nutrition (beyound usual morning sickness)