NURS 4341 OB Exam 3 Study Guide _POSTPARTUM: (4th Trimester | Puerperium) From birth to return of re

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POSTPARTUM: (4th Trimester | Puerperium) From birth to return of reproductive organs to pre-pregnant state  6-12 weeks THE UTERUS AFTERPAINS Involution: uterus decent into the pelvic cavity 1-2cm Q24 hours  Contractions after childbirth that compress uterine muscle fibers to clamp  Returns to 16wk size (grapefruit) immediately after birth off myometrial blood vessels  Day 6 – halfway b/w symphysis & umbilicus o Pains are more intense in multiparas and with breastfeeding  Day 9-10 – not palpable abdominally  Putting baby to breast stimulates endogenous oxytocin release or give IV o Documentation – Firmness & Location (FF U-2) bolus.

Subinvolution: Uterus does NOT return to pre-pregnancy size over 6 o prophylactic use of oxytocics reduces PP hemorrhage by half & wks therapeutic use by 70%  Causes: Retained placental fragments | infection| long difficult labor | over distended uterus | full bladder PLACENTAL SITE LOCHIA  Constriction and thrombosis cause nodularity  Rubra – red and bloody, birth to 2-4 days PP, may have small clots  Endometrium grows over site and causes sloughing of necrotic  Serosa – pink or brown, begins 3-4 days PP and may last 22-27 days tissue, allowing normal implantation and placentation in future  Alba – Primarily leukocytes, may drain 6wks or longer PP. Average 10 – pregnancies 14 days  Usually completed by 6 weeks PP  Multiparas have heavier bleeding | bleeding may be lighter in cesarian CERVIX ENDOCRINE SYSTEM  Shortens and firms within 18 hours  Delivery of the placenta leads to reduced human chorionic  Lower segment edematous, thin, and fragile for several days somatomammotropin, estrogens, cortisol, and the placental enzyme  Ectocervix is bruised and has small lacerations insulinase *  OS closes over 2 weeks  Estrogen & Progesterone drop immediately after placenta separates and  Has a slit “fish mouth” appearance – new norm delivers VAGINA & PERINEUM  Lowest level at about 1 wks  Vagina returns to normal size over 6-8 weeks, rugae reappear in 3  Helps with lactation, diuresis of excess extracellular fluid (remember fluid weeks, but they are never as prominent again. volume doubled) – lots of sweating and increased urinary output  Reduced estrogen in lactation decreases vaginal mucous  Ovulation occurs as early as 27 days after birth in non-lactating  Introitus (opening) is erythematous and edematous women; periods may return within 6-12 weeks – remind moms that they  Hemorrhoids don’t have to have a period to get pregnant  Perineum may be swollen/bruised (ice pack, examine opening)  Ovulation occurs at an average of 6 months in breastfeeding women and PELVIC MUSCULAR SUPPORT can occur before the return of menses (mom has to feed EVERY 3 HOURS)  May take 6 months to regain tone  Prolactin levels responsible for breastfeeding - suppresses ovulation  May be injured in birth and lead to future gynecologic problems  Kegel exercises should be encouraged before and after birth THE ABDOMEN GI SYSTEM  Unfortunately – most women may still look pregnant for a bit after  Feed Mom! delivery – this can be heartbreaking for moms  Bowel tone may be reduced, but bowel function readily returns to normal  Abdominal wall is relaxed for approx. 6 weeks  Obstetric trauma can lead to incontinence  Diastasis recti may occur  Most moms have orders for stool softener – offer it!

URINARY SYSTEM CARDIOVASCULAR SYSTEM  Kidney function returns to normal within a month; urinary tract  Blood loss of 300-500 ml SVD, 700-1500 C/S structures return to normal within 2-8 weeks  Elimination of uteroplacental bed (10-15%), loss of placental hormones  BUN increases, and proteinuria may occur due to uterine that stimulate vasodilatation, mobilization of extra vascular water autolysis  Stroke volume increases for at least 48 hours due to autotransfusion –  Diuresis and diaphoresis blood is shifting back to mom  Trauma to urethra and bladder can make voiding difficult (and o HR can be decreased because mom’s heart is getting enough flow painful)  CO remains increased for 6-12 weeks  Decreased urge or inability to void – full bladder causes uterus  Physiologic flow murmur may be present inability to clamp down

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Full bladder = uterine atony = ^ bleeding CBC H & H –initially transient anemia; then rises postpartum due to plasma loss; returns to normal by 8 weeks WBCs - Can rise to 20,000-25,000 and not just because of an infection – treat symptoms not lab values.

Coagulation factors - remain hypercoagulable (remains elevated 2-3 weeks PP) – keep mom moving.

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VITAL SIGNS Temperature may rise to 100.4F/38C due to dehydrating effects of labor, within 24 hours should be back to normal. High temp isn’t a fever, it might be because she is dehydrated. Call provider if it’s at 100.5 Respirations decreases to the woman’s normal pre-pregnancy range within 6-8 weeks.

Pulse returns to nonpregnant levels within a few short days.

Blood pressure is altered slightly if at all. Orthostatic hypotension is indicated by feelings of faintness or dizziness immediately after standing up, can develop in the first 48 hours because of the splanchnic engorgement that may occur after birth.

MUSCULOSKELETAL SYSTEM Joints are completely stabilized by 6-8 weeks postpartum Some joint changes may be permanent The new mother may notice a permanent increase in her shoe size Common to have fatigue and activity intolerance

NEUROLOGIC SYSTEM Decreased edema may decrease carpal tunnel symptoms, maybe  sciatic pain  Headaches should be assessed carefully to rule out preeclampsia  or spinal/epidural headache – remember seizures can occur mostly  in the PP timeframe S/S of Preeclampsia may still be present, or may present for the first time – DTRs, scotoma, headache, chest/epigastric pain POSTPARTUM DISCHARGE & HEALTH PROMOTION PHYSICAL ASSESSMENT  B - breasts Standard adult assessment with a few pieces added (focus on  U - uterus mom, not checklist, get to know mom and let her tell you her story)  B - bowel Breastfeeding or bottle-feeding – or  B - bladder “There’s more to me than a fundus” - understand the physiologic  L – lochia adaptations of pregnancy and how they affect all systems  E – episiotomy, laceration or incision Holistic assessment consists of reviewing prenatal and admission  E – extremities (edema) labs, immunizations status (Does she need Rubella, DPT, Flu  E – epidural vaccines- what is her plan, does she want any vaccines?) Rh factor  E- emotional status (RhoGAM shot!) and all-important admission and L&D data (what happened during her labor? Trauma, long labor etc) BUBBLE: BREASTS BUBBLE: UTERUS Soft (normal), filling, engorged (touching to see how firm they are –  Fundus - firm or boggy not stimulation)  Vertical position in relation to umbilicus Stage of milk development - colostrum or true milk  Midline or shifted to right or left Nipple structure, pain, damage o Teach how to palpate, how to massage. Rub in a circular o Teach breast care, supportive bra or tight bra, no motion until it firms up and then leave it alone. soap to nipples, no need for washing nipples before breastfeeding.

BUBBLE: BOWEL BUBBLE: BLADDER  Bowel sounds (Remember to do this before you assess uterus)  Is it full? (consider fundal assessment)  Abdomen soft, distended-soft, distended-firm  Palpable?  Tympany  Emptying?  Flatus/BMs  Urine quantity, color, clarity o Teach fiber, fluids, ambulation, peri bottle for  Dysuria  Should void spontaneously within 6 hours of delivery or within 6 hours cleansing. after catheter removal of foley from C/S  Measure first several voids – should be approx. 150cc o Teach about massive diuresis, peri bottle to cleanse or

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BUBBLE: LOCHIA Character -, serosa, alba, rubra Amount - scant, light, moderate, heavy Clots Aroma - fleshy & similar to menstrual blood Teach: change pads every couple of hours, or whenever she voids o Use Peri bottle o Lochia changes over time – what is concerning (amount)? o If clots, run them between fingers, if they can’t be broken up they might be tissue fragments.

PREVENTION OF EXCESSIVE BLEEDING UTERINE ATONY is the leading cause of early PPH Uterine massage - gentle massage to firm uterus and expel clots Soft| boggy uterus. Accounts for > 90% of PP hemorrhage 2/3 of PP hemorrhages occur without any predisposing factors LATE PPH: Occurs 24 hours to 6 weeks after delivery May cause rapid onset of shock Causes - retained placental fragments, subinvolution, infection, lacerations Oxytocics if necessary, Pitocin, Hemabate, Methergine (causes vasoconstriction but NOT good if P is hypertensive) Breastfeed - Nature’s oxytocic!

PELVIC HEMATOMA Perineal, pelvic, or rectal pressure - sometimes bleeding extends into the labia Difficulty voiding Bulging, bluish swelling painful to palp

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BUBBLE: EPISIOTOMY Roll Mom to her side and separate the buttocks to visualize the perineum Check for REEDA Check for hemorrhoids – separate buttocks and take a good look Check for hematomas If applicable, assess cesarean incision Teach about sitz bath after 24 hours, helps increase circulation to promote healing, wiping gently from front to back

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PPH 5-8% of vaginal births Accounts for 25% of maternal deaths >500 ml blood loss in SVD or >1000 ml in cesarean section Or 10% decrease in Hct between admission labor vs postpartum Hct Or need for transfusion after birth – air hunger, dizzy, mental status changes, saturation of pad within 15 mins or less, pallor, diaphoresis, low pulse ox.

Saturating a perineal pad in 15 or less and collection of blood under patient The 4 T’s Tone (atony) | Trauma (lacerations, expanding hematoma or uterine rupture) | Tissue (tissue, retained placental fragments) | Thrombin (clots) UTERINE ATONY - RISK FACTORS Over distended uterus – macrosomia, multifetal pregnancy, polyhydramnios, Anesthesia and analgesia H/O uterine atony High parity Prolonged labor; oxytocin induction Trauma during labor and birth – operative abdominal or vaginal delivery Prevent bladder distention - assist to bathroom, teach mother importance of emptying bladder fully; ice pack to perineum in early postpartum period to prevent swelling Catheterize if necessary MANAGEMENT Massage, Breastfeeding Bimanual Massage Compression Oxytocin (Syntocinon® Pitocin®) Methylergonovine (Methergine®)  (causes vasoconstriction NOT good if P is hypertensive) Ergometrine (Ergonovine®) Prostaglandin F2alpha – (Hemabate®) Misoprostol – (Cytotec®) – off-label use Last resort – Hysterectomy PERINEAL LACERATIONS Vaginal bleeding in the presence of a firm uterus – think laceration 1st Degree - extends through the skin and structures superficial to the muscles 2nd Degree - extends through muscles 3rd Degree - continues through anal sphincter muscle (NO rectal suppositories, enemas) 4th Degree - extends through anterior rectal wall (NO rectal suppositories) o Moms will be uncomfortable and worried about having a BM after 3rd and 4th degree.

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VAGINAL ABRASIONS  sidewall lacerations Assessing Incisions o R - redness o E - ecchymosis o E - edema o D - drainage o A - approximation Risk factors - macrosomia, rapid delivery, operative delivery, nulliparity, congenital abnormalities of maternal soft parts; contracted pelvis, skill level of delivery attendant INFANT SECURITY Inform parents of infant security plan Instruct not to give baby to anyone without proper identification Always match bands Prevention of Infection  handwashing - for all staff, reminding parents, and reminding visitors Teach mother perineal care (peri bottle) Teach mother to change pads with each trip to bathroom Remove and replace pad front to back REPRODUCTIVE TRACT INFECTIONS ENDOMETRITIS - infection of uterine lining, fever, chills, flu-like symptoms, prolonged afterpains, uterine tenderness, foul lochia PARAMETRITIS - pelvic cellulitis, infection into the broad ligaments, usually unilateral o may progress to pelvic abscess which requires surgery PERITONITIS - infection of the peritoneum, may lead to ileus

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Risk Factors Cesarean Section – most significant risk PROM | Manual extraction of placenta Multiple vaginal exams | trauma | Internal Monitors Compromised health status | Chorioamnionitis | vaginal infections

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COMFORT MEASURES relaxation, heat, cold, sitz baths, witch hazel pads, peri bottles Gas pain can be common – get mom up and moving to promote bowel function Medications - NSAIDS, narcotics o Assess pain frequently Cluster Care | Don’t Interrupt Manage pain appropriately – use cough pillow, TCDB Discuss “Superwomen” phenomena – remind them that it’s ok that laundry and dishes pile up PROMOTING NUTRITION Feed the Mom! Have fam bring her fav foods. Encourage them to be nutritious Communicate nutritional needs and preferences to dietary department H & H returns to normal by about 6 weeks; many women benefit

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LACERATION MANAGEMENT Surgical repair Ice to perineum for 24 hours Sitz bath after 24 hours Analgesics only if needed.

Assessment Schedule o q 15 minutes in recovery o On admission to postpartum o q 4 hours or q shift (if stable) POSTPARTUM INFECTION S/S - maternal temp >100.4 on 2 successive PP days, not including the 24 hours after delivery Risk factors - vaginal exams and procedures, trauma, hemorrhage o Pathogens – commonly streptococci and anaerobic organisms S/S - fever, localized pain, redness, swelling, purulent discharge, dysuria Management - remove sutures to drain wound, antibiotics, analgesics o Some need packing and dressing changes – will have to educate about it MASTITIS Pain, swelling, redness & axillary adenopathy | local breast tenderness | Flu-Like symptoms Antibiotics are prescribed Maintain lactation by emptying breast q 2-4 hours and discarding the milk – safe and OK to let baby continue to breastfeed.

Affects about 1% of women soon after childbirth, most of whom first-time mothers who are breastfeeding Almost always unilateral and develops after milk flow established Prevention o Good prenatal nutrition o Good maternal hygiene/handwashing of staff and visitors too o Promotion of Comfort  Assess for pain frequently PROMOTING AMBULATION Assess that mom is ok to stand by having her bridge in the bed for a few seconds without wobbly issues to ensure the epidural has worn off.

Reduces the risk of postpartum complications, including thrombi Instruct mother to call for help the first time she gets up Remember all your med-surg prevention strategies for preventing DVTs – how do you assess?

Use great care when patient has had epidural!

Insure she has full mobility of legs before allowing her to get OOB Ambulation after cesarean requires greater assistance; usually done 12 hours after delivery PROMOTING COMPETENCE IN PARENTS! Don’t do for them – teach them how! – have them do things! Teach, show, demonstrate.

Moms and dads may need to relive/talk through the labor/delivery process – let them tell their story and talk to them about their experience.

Increase their self-esteem – given them love and attention.

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from extra iron and continued use of prenatal vitamins Return to pre-pregnant weight by about 6 months – this is a GOAL, but it doesn’t need to be rushed. The body needs to rebuild in a healthy way Cultural traditions involving food should be assessed – ask in order to learn Non-nursing mothers can return to a healthy pre-pregnancy diet Safe to continue with prenatal vitamins and Iron Nursing moms need additional o Calcium – 1200mg/day – should be high quality calories. o Iron - given to replenish maternal stores; not a significant component of breast milk o Fluids – 8 – 10 glasses of water.

DISCHARGE TEACHING Self-care and signs of complications  excessive bleeding, pain, swelling of one leg (DVT) o sometimes they have more bleeding on 1st day at home because they are moving around a lot  Promote breastfeeding or teach about lactation suppression  Sexual activity - pelvic rest for 6 weeks – make sure to talk about it  Contraception - consider lactation  Prescribed medications  Check-ups and follow-ups for mom and baby  Resources - telephone follow-up, nurse lines, support groups, community resources – lactation specialists  Varicella vaccination before d/c and at 1st PP visit  TDAP vaccine or flu vaccine  Rubella vaccination - requires maternal consent; avoid pregnancy for 1 month TRANSITION TO PARTENTHOOD ATTACHMENT & BONDING THE CLAIMING PROCESS Process where parents come to love and accept a child and a child  Identify the child in terms of likeness to other family members comes to love and accept a parent. o In terms of differences/uniqueness o A specific and enduring affective tie to another person.  Explores infant to make sure all parts are present The crucial period shortly after birth when mothers and fathers  Touch: Typically proceeds from fingertip exploration to palmar touch and must have close contact with their infant for later development to stroking be optimal. o proceeds from touching head and extremities to touching trunk – 1. Parents have a fantasy of what baby will look like and how varies with culture they will act  Eye-to-Eye Contact 2. Parent(s) become acquainted with infant o Varies with culture - eye contact cements relationships in American 3. Identifies infant as an individual culture, may be considered rude or immodest in other cultures 4. Claims infant as a member of the family  En-face position - face-to-face Preconditions for Attachment  Voice: Infants respond to voices immediately 1. Parent’s emotional health o Become more alert in response to higher-pitched voices 2. Social support system o Become calm in response to lower-pitched voices 3. Competent level of communication and care giving skills  Odor: Babies can distinguish their own mother’s milk; Mother’s comment 4. Parental proximity to infant on the smell of their babies 5. Parent-infant fit INFLUENCES THAT MAY HINDER ATTACHMENT SOCIAL INTERACTION & LANGUAGE Sick infant – must stay in nursery or NICU  Reciprocity - responding appropriately to one another’s clues – Fussy or irritable infant (Colic)  Synchrony - the fit between infant’s cues and parents’ response Physical anomalies o knowing a hunger cry from I just want held cry TRANSITION TO FATHERHOOD SIBLINGS Stage 1: Expectations  Positive behaviors - interest in the baby; increased independence Stage 2: Reality  Negative behaviors - regression, aggression, increased attention Stage 3: Transition to mastery seeking and whining Remember – they usually have much less social support and the  Preparing the siblings, sibling classes ability to discuss “feelings” in determining “How to parent”  Involvement in planning and care Factors Influencing Parental Responses  Acquaintance process o Gender GRANDPARENT ADAPTATION o Age  Contributes to family continuity o Social Support 

Culture Socioeconomic conditions Personal aspirations Diversity in Transitions to Parenthood Adolescent mother or father: unrealistic expectations of the infant o Maternal or paternal age older than 35 years: sandwich generation (caring for her parents as well as the infant) o Social support o Socioeconomic conditions o Personal aspirations ASSESSING ATTACHMENT You must evaluate in cultural context!!

Assessing Attachment – How do you know if attachment is happening?

What do the parents do when infant brought into room?

Do they provide for stimulation and interaction with the infant when he is awake? (Without overstimulating) How do they try to comfort, or do they just ignore him? o o o o o

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Intergenerational relationships shift Involvement depends on cultural and familial factors

FACILITATING ATTACHMENT Early contact Early skin-to-skin contact Promotes early and effective breastfeeding May facilitate attachment process Extended contact Couplet care or rooming in Optimize family-centered care Allow the parent to parent – don’t do for them – help them become competent parents while WITH you  Teach the parents about their infant- the normal infant reflexes POST- PARTUM MENTAL HEALTH: LOOKING AT POST- PARTUM BLUES AND POST-PARTUM DEPRESSION POST-PARTUM BLUES POSTPARTUM DEPRESSION (PPD) “The Blues” – teary, weepy, sadness (normal phenomena) –  DEPRESSION occurring within 6 months of childbirth lasting longer than irritable, anxiety postpartum blues o Crying for no apparent reason “I don’t feel sad”  Can interfere with the ADL’s and caring for infant  May be caused by biological, psychologic, situational or multifactorial o A letdown feeling, irritability and anxiety  May be influenced by estrogen fluctuations Does not interfere with caring for self or newborn  Frequently have had prior major depressive disorder or personal and Usually peaks day 2-3 and lasts up to 2 weeks family history of psychiatric disorders Mood and anxiety disorders likely to start in or present itself in the  NEED TO look for post-partum patients who are agitated, overactive, PP time frame. confused, complaining or suspicious. – these are extreme situations.

Can impact how mother and family adapt to the fact of the newborn May confuse the mother and those close to her since this should be a happy time PPD RISK FACTORS PPD TREATMENT Prenatal depression, low self esteem  Psychotherapy, antidepressants, or antianxiety medications Unresolved feelings about the pregnancy  Encourage her to ask for help from friends, family, SO (remember the lack Single with multiple life stressors of support system is a factor in developing PPD.) Fatigue from delivery and change in sleep patterns  Sleep, exercise and nutrition help – increase coping skills.

Lack of social support Difficult infant temperament – baby that has colic who cries and cries. Baby doesn’t respond to mom. Be careful about how you talk about the newborn.

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assistance Overwhelming sense of guilt and inadequacy (help the mother to mother!!)

(Our vocabulary??) “Oh, you should be so excited……” – increase in mothering abilities.

POSTPARTUM DEPRESSION (PPD) w/ Psychotic Features Usually presents itself in first 2 weeks PP Includes auditory or visual hallucinations, elements of delirium, poor impulse control and judgment Increased risk of suicide &/or homicide May have auditory hallucinations related to injuring or killing infant Considered a medical emergency and may need hospitalization Better prognosis with early identification and treatment Treated with antipsychotics and mood stabilizers (Lithium) Common complaints include some of the same types of complaints of any pp woman: fatigue, insomnia, tearfulness.

Move to delirium or hallucinations They also have other features not common in pp women: inability to move or work, incoherence, irrational statements and obsessive concerns about infant.

FDA has not approved any psychotropic medications for use during lactation.

All psychotropic meds are excreted in breastmilk.

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CONTRACEPTION Pregnancy prevention until next planned pregnancy.

Contraception planning should be decided before discharge because waiting until 6wk checkup is possibly too late.

What do they know? Want to know?

Need to know the risks/benefits of each form TYPES OF CONTRACEPTION Permanent: Tubal Ligation or vasectomy Natural family planning (may include breastfeeding) Intrauterine BARRIER may interfere with spontaneity, NO STI protection Diaphragm and Spermicide (remeasured after delivery or major change in weight) Cervical Cap (needs to be remeasured after delivery or major change in weight) Sponge Condoms – Male and female – with or without spermicide HORMONAL Birth Control Pills – variety of strengths with varying amounts of a combination of hormones – requires prescription, taken daily – when started?

Injectables – given every 12 weeks – starting 5 days after

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PP PSYCHOSIS WITH BIPOLAR DISORDER Commonly seen together In manic state may be so geared up they forget to provide child care – manic episodes that interfere with caring for the baby. (obsessive cleaning + forgetting to feed the baby) manic episode is followed by a depressive episode Mom doesn’t understand why everything isn’t just great  afraid to mention their symptoms – “They should be happy – this is a great time” Screening important – risks increases if Hx of PPD  Mothers and family members/support persons Family and friends may not know what to say or how to act (remind them to be non-judgemental) Assess for safety of mom and baby –is mom at risk for harming self or baby? ASK! Remember – this will affect the whole family Does mom need admitted (voluntarily or involuntarily) to ensure her safety?

Sometimes hospitalization may be without their consent. Lithium can be common.

Be careful with antipsychotics during breastfeeding.

NATURAL Abstinence – most effective, decreased risk of STI Rhythm – Not having intercourse during “fertile timeframe” – may be hard to know when this is immediately after delivery. Requires understanding of the menstrual cycle. Also know as calendar method Coitus Interruptus – withdrawal prior to ejaculation – least effective method Basal Body temp – temp prior to getting out of bed every morning. Temp drops at the time of ovulation. Temp can be influenced by many things.

EMERGENCY CONTRACEPTION Taken within 72 hours of unprotected intercourse, use back up form of contraception between this and her next period Can cause N/V due to high doses of hormones Don’t use with unknown pregnancy status or undiagnosed vaginal bleeding.

Educate women to seek care if period doesn’t start within 21 days Does not prevent STI

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delivery/menstrual period Implantable: Lasts approx. 3 years - Started @ 6wk checkup IUDs – Lasts 5-10 yrs, with or without hormones Risk of adverse effects: thromboembolism NO STI protection NORMAL NEWBORN PHYSIOLOGIC ADAPTATION INITIATION OF BREATHING Every Major System Undergoes a Change  Reflex triggers: pressure changes, cold, noise, light, tactile stimulation o From fluid filled to air filled lungs, that must be capable of (rubbing and touching)  Chemical triggers: gas exchange o Cord clamping o Blood must go through the lungs to be oxygenated vs o Increased PO2 bypassing them as a fetus o Liver must start filtering and detoxifying blood o Increased PCO2 o Must maintain stable temp in an unfriendly (cool) o Decreased pH – NB is usually acidotic on delivery environment CARDIOVASCULAR: CHANGES INITIAL CARE & ASSESSMENT Ductus venosis closes- blood goes to liver  Thermoregulation- in a neutral thermal environment O2 consumption Foramen Ovale closes stopping shunt between L & R atrium and metabolism are minimal Ductus Arteriosus closes forcing blood to lungs for oxygenation  Decrease temp = increase O2 demand = increase RR o O2 #1 factor in controlling closure!  Cold Stress leads to ^ O2 demands, respiratory distress or worsening RDS, ^ glucose utilization = hypoglycemia, metabolic acidosis, jaundice, Cardiovascular Changes with first breath (see box 17.1) hypoxia, and decreased surfactant production. o Increased systemic vascular resistance  Place on pre-warmed surface or skin to skin with mother o Decreased pulmonary resistance  Know how the infant loses heat (conduction/convention etc.) o Should be done withing 15 seconds.  Dry and stimulate (90% of infants)  Initiate resuscitative measures PRN – Free flow O2, PPV, Narcan if mom was given a narcotic pre delivery APGAR SCORING MEDICATION ADMINISTRATION Performed in the DR at 1 & 5 minutes (10,15 & 20 min PRN)  Mandated eye prophylaxis: erythromycin opthalmic ointment, o Success of neonatal resuscitation (tetracycline opthalmic ointment & silver nitrate drops were previously used) o The infant's general well being  Vitamin K injection – helps normalize GI flora o Success of transition  Hepatitis B vaccine – concern when mom is (+) and she declines. Provide o *Apgars are NOT to be used to determine the need for teaching resuscitation  HbIg – If mom is + and baby gets hep B vaccine and HbIg then baby can breastfeed IM Injections  5/8 inch needle  45 degree angle (for SQ) and 90 degree angle (for IM)  Fix leg in place | make sure to clean skin adequately!!  Quick stick  Cover injection site PHYSICAL ASSESSMENT HISTORY VITAL SIGNS Prenatal Hx: Risk factors or complications of pregnancy (HTN,  Count for 1 full minute IDM, drugs), fetal monitoring strip  Respiratory rate: 30-60 bpm, periodic breathing apnea (15 seconds) Maternal labs: Blood type, HBsAg, HIV, Rubella, GBS, STDs LISTEN to breath sounds Delivery record: Intrapartum medications, internal monitoring,  Heart rate:100-160, PMI 4th ICS, left of MCL, sinus arrythmia and route of delivery, complications, APGARS, resuscitation, placenta murmurs and cord assessment  BP: 60-80 systolic, 40-50 diastolic (Upper and Lower extremity checks)

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GENERAL APPEARANCE Color: pink, acrocyanosis vs central cyanosis, physiologic vs pathologic jaundice Respiratory effort: What does their WOB look like?

Tone Symmetry, morphology Sleep-wake states/cycles

HEAD General shape: Molding, caput (should cross the suture line), cephalohematoma (collection of blood that stops at the suture line), subgaleal bleed, FOC Hair: pattern Fontanelles: anterior & posterior; flat, depressed, or bulging Sutures: approximated, overriding, ballotable, Lacerations or lesions, Fetal scalp electrode site, Forceps or vacuum extractor, Amnihook mark EYES Lids Iris Red reflex Absence of tears Scleral hemorrhage/subconjunctival hemorrhage Edema Drainage NECK Symmetry ROM Tonic Neck reflex Webbing

ARMS & HANDS Symmetry, movement Brachial & radial pulses Arm recoil Hands o Palmar creases o Palmar grasp Fingers o Number o Webbing o Syndactyly, polydactyly, skin tags

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o varies significantly with age, size, and activity Temperature: Rectal or axillary, 36.5 – 37.2 | Temp stabilizes by 8-10 hours of age SKIN Vernix caseosa – white cheese Lanugo – hair Rashes or lesions Birthmarks, mongolian spots, café au lait spots, strawberry hemangiomas Erythema toxicum (flea bite) Parchment skin – looks like dry skin (do not use lotion) Nails Veins Mottling: blotchy look of the skin FACE Facial symmetry Glabellar reflex (tap forehead/blink) Milia Nose Patency of nares Nasal flaring

Palate and lips o clefts Epstein’s Pearls Precocious teeth Rooting reflex Sucking reflex Extrusion reflex

MOUTH

CHEST & RESPIRATORY Clavicles – intact or crepitus Symmetry Retractions BBS Breast tissue Capillary refill – check on the chest not extremities Cardiac Assessment ABDOMINAL General appearance o Diastasis recti o Tender vs nontender o Round, distended, scaphoid – should be round and protruding o Hernias Umbilicus o Cord has 2 arteries and one vein o S/S of infection o Pulsations Bowel sounds

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GENITOURINARY (FEMALE) CORD CARE & CIRCUMCISION CARE (SIGNS OF HEALING) Labia majora should cover labia minora  Should dry out and shrink up approx. 24 hours after delivery Identify clitoris, urethra, and vagina  Fold diaper under cord Discharge – white discharge, pseudomenstruation (tiny bit of  Patroleum jelly and gauze before applying diaper blood from withdraw from mom’s hormones)  Check for bleeding Skin tags GENITOURINARY (MALE) Urethral opening o Hypospadias o Epispadius Testes - descended vs undescended Scrotum o Rugae or shiny o Edema GENITOURINARY/ANUS & RECTUM HIPS, LEGS & FEET Should urinate within 48 hours (preferably 24)  Symmetry Normal production is 1-3ml/kg/hr  Gluteal folds should line up 1st 2-3 days of life urine output is minimal due to small oral intake  Toes: number, spacing & webbing of fluids  Sole creases – Term on entire foot, preterm possibly halfway Urine may have “brick dust” reddish color  Reflexes – Plantar grasp, Babinski (stroke outer edge to ball of foot), Rectal temp and passage of meconium to check for patent anus Stepping, Moro (Startle reflex) Imporforate anus CHECK THE BACK Stork Bite Mongolian Spots – dark/grey spots over back and hiney o More common in babies of color o May cover buttocks, back, and shoulders Bruises don’t blanch Spine o Straight and intact Tuft of hair – spinabifida if hair is here.

Deep dimples or pilonidal sinus Trunk incurvation reflex – turn toward the side of stroke.

Gluteal folds CONSTITUTIONAL MEASUREMENTS WEIGHT LENGTH & WEIGHT >2500 gms is normal wgt  >90th percentile = LGA 1500-2500 gms is LBW  10th–90th percentiles = AGA 1000-1500 gms is VLBW  <10th percentile = SGA <1000 gms is ELBW  Head circumference (FOC)  Chest circumference – 2cm < FOC  Abdominal circumference  Initial weight changes GESTATIONAL AGE ASSESSMENT NEUROMUSCULAR MATURITY New Ballard Scale  Posture o Predictor of survival  Square Window  Arm Recoil o NBS is accurate as early as 20 weeks gestation  Popliteal Angle o NBS is accurate within 1 week of actual gestation  Scarf Sign o Perform no later than 96 hours postnatal age  Heel to Ear

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PHYSICAL MATURITY Skin Lanugo Plantar Creases – footprint all the way down. Shiny heel indicates preterm Breast buds Eye & Ear Genitals PAIN IN NEONATES High pitched cry Facial expression Flexion and abduction of limbs Changes in VS Nonpharmacologic management o swaddling, nonnutritive sucking, sucrose (24%), skin-toskin contact with Mom

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HYPOGLYCEMIA Infant of a diabetic mother LGA or > 4000 grams Preterm birth SGA or LBW (<2500 grams) or VLBW (<1500 grams) Post-term with evidence of wasting (skinny) Exposure to stress – hypoxia in utero (late decels), cold stress, sepsis SYMPTOMS jitteriness or lethargy (increased sleeping) BG <40 mg/dl 24-hour glucose testing protocol: LGA will get BG check Q4hr – if 2 norm BG then ok to stop testing Warm heel before stick Early feeds SCREENING TESTS Hearing Screen – many newborns fail first screen Newborn Metabolic screening • PKU • Congenital Hypothyroidism: give synthroid • Congenital Adrenal Hyperplasia • Galactosemia: unable to breakdown milk proteins • Sickle Cell disease

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IMPORTANCE OF GESTATIONAL AGE ASSESSMENT gathering information for decision making anticipation of problems and resolution determining pharmacokinetics of certain drugs preparing for discharge from the hospital – test by having them in the car in a car seat on the monitor THERMOREGULATION Blood vessels are closer to the skin Larger surface area: body mass ratio Cannot shiver Non-shivering thermogenesis by metabolism of brown fat HEAT LOSS – majority through the head.

Radiation: Loss from infant to cooler object not in contact with them Conduction: Loss of heat from directs contact Convection: Loss of heat via moving air Evaporation: Loss of heat via evaporation of water from skin and MM ROUTINE CARE Bathing – when infant has a stable temperature (usually 24 hours after birth) Neonatal skin care Cord Care Bonding, bonding, bonding Feeding Parent/Family education

NEWBORN SCREENING State mandated screening Metabolic disorders (heel stick) o ~24-48 HOL (hours of life) and ~10 DOL (days of life) – must have had first feed!

Hearing Screen – reported to the state lab

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THE HIGH-RISK NEONATE RANGE IN GESTATIONAL AGES WEIGHT DIVISION Viable When >23 Weeks (Don’t have to know the numbers – just  Low Birth Weight (LBW) (<2500g)  Very Low Birth Weight (VLBW) (<1500g) the concept)  Extremely Low Birth Weight (ELBW) (<1000g)  23 weeks: 500 grams (1 lb 1.63 oz)  SGA (below 10th%)  26 weeks: 760 grams (1 lb 10.8 oz)  AGA (10-90th%)  30 weeks: 1300 grams (2 lb 13.85 oz)  LGA (>90%)  36 weeks: 2600 grams (5 lb 11.71 oz) ASSESSMENT OF PRETERM INFANT (JUST LIKE TERM INFANTS) General Condition  Color, Activity (Crying, Asleep, Lethargic), Tone/Posture (APGAR’S) | Blood Pressure/vitals Auscultate  Heart, Lungs, Abdomen, AF & liver Palpate  Fontanels, Abdomen Prenatal and delivery history | Head to Toe Exam

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ASPHYXIA Impaired gas exchange o Failure to establish adequate &/or maintain sustained breathing leading to hypoxemia, ^CO2 and acidosis o Can occur before, during or after delivery May require additional assistance with breathing at delivery Any process that interferes with maternal oxygenation will impact fetal gas exchange As O2 level decreases, acidemia increases (and myocardial O2 <) Do we wait on the 1 minute APGAR? MUST get him warm/dry, provide O2 or ventilation. If that doesn’t stimulate him to breathe - Don’t waste valuable time continuing to stimulate!!

Establish effective ventilation!!!!!!!!

S/S: apnea, tachypnea, gasping, grunting, nasal flaring, retractions TYPES RESUSCITATION Ventilators o HFOV (High flow oxygen ventilator) o Conventional Ventilator o HFJV (High flow jet ventilator) – infuses puffs of air 600/bmp vs. Oscillator CPAP NC, HFNC, (Nasal cannula, high flow nasal cannular) Used to correct the acid/base imbalance and respiratory effort in the neonate.

Ventilation vs Oxygenation TEMPERATURE MAINTENANCE

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WHAT INCREASES RISK TO NEWBORN? Pregnancy: Diabetes, hypertensive disorders, maternal infections, preterm labor or PPROM, maternal substance abuse, poor prenatal nutrition Congenital: NTD, chromosomal abnormalities, in-born errors of metabolism Acquired: Asphyxia, RDS, ROP, infection, birth trauma, hypovolemia Review maternal history: maternal diabetes, maternal obesity, multiparity, prior history, postdates - hypoglycemia, hyperbilirubinemia, polycythemia LINES | TUBES | EQUIPMENT Cardiorespiratory Monitoring Oxygen Saturation Monitoring | Oxygen (Bag, Mask, Source) BP Monitoring (Invasive: external and noninvasive: UAC or PAC) - uterine venous or uterine arterial/peripheral circulation o UAC or PAL – can monitor BP, blood sampling for labs, and infusion of fluids PIV | PICC ETT | Chest tubes NG/OG | Suction | Ventillation Isolettes RW Open Crib

KANGAROO CARE Skin to Skin contact – DADS too!

Improves physiologic self-regulation, decreases stress/crying, decreases pain, and helps with neonatal development Improves milk supply (skin to skin)

ADDITIONAL RISKS TO NEWBORNS

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Newborns have a very large surface area: body mass ratio and can  Failed or prolonged transition lose heat easily through several means  Unusual neurological symptoms Heat is transferred from the infant’s body to the environment  Congenital cardiac defects Premature infants are extremely susceptible to hypothermia  Genetic Anomalies because they cannot control their body temperature  Birth depression or Asphyxia Non-Shivering Thermoregulation  Anemia or Polycythemia (sludgy blood, hard for heart to pump) Premies must be able to maintain temperature AND weight  Chorio when moved to open crib (step-down bed) Must be able to nurse/bottle feed entire volume in 30 minutes or less Getting cold = increased calorie & O2 demands (learn how to suck & swallow) Formulas in the NCIU are MED ORDERS EXPRESSED BREASTMILK DIFFERENCES BETWEEN PRETERM & TERM EBM Advantages of EBM for preterm infants  Preterm EBM has: o Protect from NEC o Increased protein o Infection prevention o More anti-infective properties o Increase feeding tolerance o Specific lipid content o Decreases risk for allergies o Increased IgA concentration o Tailored for gestational age  Lactose in preterm EBM allows for increased metabolic absorption Can use Donor EBM if needed and consent given Help mom stay motivated and stick to pumping schedule if needed INFANT CONDITIONS IN THE NICU TTN (Transient Tachypnea of the Newborn) PERSISTENT PULMONARY HYPERTENSION (PPH) Delayed reabsorption of the normal lung fluid – usually occurs  Pulmonary hypertension causing R to L shunting (deoxygenated out to within hours of birth circulation) and hypoxemia Generally seen in term/late preterm infants with history of C Remember – normally the initial breathes increase O2 concentration section resulting in decreased pulmonary vascular resistance S/S: respiratory distress, tachypnea, retractions, grunting, flaring  In this case = increase resistance = shunting of blood and fetal shunt (DA) o Tx: usually oxygen, Will usually self-resolve in 72 hours fail to close = murmur and low O2 level despite 100% O2 being given RESPIRATORY DISTRESS SYNDROME (RDS) RDS TREATMENT Due to immature lungs with lack of surfactant  Surfactant History of prematurity, C-Section, asphyxia, IDM, sepsis,  CPAP- nasal/endotracheal Surfactant protein deficiency  Ventilator- intermittent or synchronized On Exam: Will have tachypnea, grunting, flaring, retractions,  High frequency oscillation or jet ventilator decreased breath sounds, rales, decreased SpO2 (right to left  Oxyhood, nasal cannula shunting R/T pulmonary vascular resistance from acidemia)  Inhaled Nitric Oxide: causes pulmonary vasodilation, but still experimental CXR “White-Out” (ground glass) or reticulogranular pattern, air tx bronchograms MECONIUM ASPIRATION SYNDROME (MAS) CHRONIC LUNG DISEASE/ BRONCHOPULMONARY DYSPLASIA Passage of fetus’s first stool in utero, possibly from hypoxic event (CLD/BPD) Black, tarry, sterile – thick black (This is normal if passed after  “Chronic” phase of RDS, will see increased respiratory distress delivery)  VLBW infants who need supplemental oxygen at 28-30 DOL or cannot When inhaled, can cause blockage of airway leading to hypoxia wean off ventilator by 36 wks inflammation of airways and chemical pneumonitis, decreases  Will see impaired gas exchange surfactant production  Due to constant/recurrent lung injury such as when they are on Delay Feeding with ALL Respiratory Distress ventilation.

Either because suck/swallow impairment d/t prematurity, maternal medications, or tachypnea

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Or while infant having respiratory issue = blood diverted away from gut Baby must be able to SUCK, SWALLOW, BREATHE CLD/BPD Caused by oxygen toxicity and barotrauma – ween O2 delivery ASAP S/S: tachypnea, rales, retractions, increased WOB, oxygen requirement Tx: centered on reducing the factors that cause injury and allow the lung to heal- make take years to do so Will often discharge home on oxygen Risk for URI Often need bronchodilators, steroids and diuretics More than 50% are hospitalized within the first 2 years with RSV May place trach if cannot wean off of ventilator

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Strategies to Decrease CLD/BPD Steroids to mom before delivery, possibly to infant after delivery Don’t automatically intubate premies May be OK to use air vs O2 Minimize amount of O2 utilized, accept lower SaO2’s

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PATENT DUCTUS ARTERIOUS (PDA) The DA is a normal pathway in fetal circulation to bypass the lungs It usually closes within a few hours to several days after birth but this is delayed in the premature infant PDA can lead pulmonary over circulation and volume overload May have a murmur PDA-TX & DIAGNOSIS Diagnosis: X-ray and ECHO Asymptomatic infants do not require management: close on it’s own Medication: Indomethacin or Ibuprofen Ligation S/S OF PDA Mottling and cyanosis – poor perfusion Active precordium – pulse is visible on chest wall Bounding pulses/tachycardia Tachypnea/crackles HSM (Hepatosplenomegaly) and cardiomegaly Increased FiO2 needs / Metabolic Acidosis Decreased UOP HYPERBILIRUBINEMIA Jaundice is the obvious sign of Hyperbilirubinemia Cause: breakdown of RBC and infant’s livers inability to repackage (conjugate -convert into water soluble pigment) it to be excreted Anything that increases RBC breakdown – increases risk Infant RBCs live approximately 70 days vs 90 for adult RBC – so must conjugate faster Start in face and moves down

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RETINOPATHY OF PREMATURITY (ROP) Develops in 84% of preterm infants less than 28 weeks In 80% of cases, ROP regresses without visual loss – damage d/t O2 given With increased oxygen, retinal vessels constrict and become necrotic. This causes a stimulation of vessels to proliferate to reestablish circulation.

May extend into vitreous and cause retinal scar formation, traction on the retina, detachment, and blindness Considered a disease of prematurity because once vascularization is complete, the retinal vessels cannot be injured The best treatment is prevention via monitoring O2 saturations with O2 administration.

Use ranges of acceptable oxygen saturations based on gestational age and disease process.

Tx: laser therapy. The laser light coagulates the retinal tissue and stops abnormal vessel growth.

Infants who meet specific criteria will be examined by an ophthalmologist throughout their hospitalization and afterwards.

Different classifications based on location, degree of abnormality and extent of developing vasculature.

INFANT OF DIABETIC MOTHER (IDM) risk of congenital malformation if uncontrolled in 1st trimester (Cardiac**, skeletal, CNS, GI, GU) May have complications from placental issues (poor nutrition, swollen placental bed – interferes with nutrient and gas exchange) LGA – risk for birth traumas, shoulder dystocia, C/S birth, RDS, hyperbilirubinemia Lethargic after birth (not always related to hypoglycemia) Monitor for birth trauma – treat appropriately Monitor F&E balance Risk for hypoglycemia – (less than 40mg/L lethargic, irritable, tachypnea, poor feed, hypotonia, seizures)- monitor within 30 minutes then AC and if symptoms Treat hypoglycemia: early to breast or bottle feeding, IV dextrose if feeding not correcting with PO feeds

PHYSIOLOGIC JAUNDICE Normal peak about 3-4 DOL Rate of decline slower in breastfed infants vs bottle fed – most likely due to slight decrease in feeding volume early on. (Hint: early and frequent breastfeeding) PATHOLOGIC JAUNDICE** Usually appears in first 24 hours with higher llevels seen (most commonly

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HYPERBILIRUBINEMIA TX Phototherapy (conjugates bilirubin)-expose as much skin as possible, eye protection, turn q 2 hrs, monitor temp and I&O, daily weights, feed q 2-3 hours – Feed early and frequently to get babies to poop bili out Prevent Rh isoimmunization with Rhogam Intrauterine or newborn transfusion (exchange transfusion) Baby will be under lights in diaper – monitor temps ASSESSMENT FINDINGS: Feeding intolerance, abdominal distention, bloody stools, lethargy, shock, cyanosis, respiratory compromise, metabolic acidosis Free air on KUB (kidney, ureter, bowel) with perforation NEC-DIAGNOSIS & TREATMENT Abdominal films CBC, CRP NPO/TPN/Lipids Respiratory support Bowel resection with or without ostomy – to let gut heal PAIN – The 5th Vital Sign S/S: elevated HR, BP, RR crying, grimacing, withdrawing Nonpharmacologic vs pharmacologic management Pain Scales: used to measure reaction to pain in the neonate (PIPS, NIPS) Sucrose with or without non-nutritive sucking (24% solution), MSO4, Fentanyl Swaddle, Kangaroo care, breastfeeding Decrease environmental stimuli (dim lights, cover isolette, quiet) If a procedure would require pain management in an adult – it needs managed in an infant Sedation is not the same thing as pain management Assess, reassess, reassess……

LATE PRETERM (Near term) Newborns EGA: 34 to 36+6 – Not just a small normal newborn - look term, but: Increased RDS, LOS, $$$, thermo-regulation issues, risk brain bleed/injury ^ Risk Hyperbilirubinemia, hypoglycemia, sepsis ^ risk of psycho-social disorders (ADHD, developmental delays) OTHER CONGENITAL CONDITIONS: Congenital Diaphragmatic Hernia – hole in diaphragm and bowl up in chest cavity. (Sunken belly) Congenital Heart Disease – persistent murmur, cyanosis NTD (spina bifida/anencephaly – missing brain) – cover and apply

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from Rh isoimmunization** and ABO incompatibility, polycythemia and acidosis) – Mom O- and Baby is O+ Bilirubin encephalopathy: yellow brain staining – causes severe neurologic sequela NECROTIZING ENTEROCOLITIS (NEC) Acute inflammatory disease of the GI tract Shunting blood away from the bowel d/t respiratory distress – this is why we don’t feed RD baby Complications: sepsis, perforation Occurs in 5% of infants of VLBW llloo Contributing factors: asphyxia, RDS, UAC, transfusion, formula feeds, hyperosmolar feeds (fluid pulled into the bowel), PDA, CHD, polycythemia/anemia, shock, sepsis INFECTION: VIRAL, BkACTERIAL, FUNGAL Prevention is key mortality can reach 50% - EVERYONE WASH HANDS Acquired prenatally, during delivery or lpostnatally Non-specific: Temp instability (low temps), hypotension, lethargy, hypotonia, or irritability, feeding intolerance, A’s & B’s, GI sx (lots of loose stools) DX: CBC, BC, LP, CRP, urine cx Antibiotics (even before organism is identified), respiratory support, fluids, hemodynamic support Sepsis can by life threatening - wash your hands, scrub injection area well before newborn meds and use common sense about going to work when ill!!

DEVELOPMENTAL CONCERNS/CP/DD Parental involvement-music, pictures, communication, touch, caring for infant. Facilitating bonding process.

Kangaroo care, clustering care Positioning (sides and stomach – not when they are at home) twins together Preventing IVH (Intraventricular hemorrhage – brain bleed) – don’t lift bottom when changing diaper hypoxia/asphyxia OT/PT/ST

DISCHARGE PLANNING Start teaching for home care from the beginning – don’t wait until DOD to start!!! (as appropriate for infant condition) CPR, Meds, F/U appts, DME, therapies Ensure all screenings are done (metabolic, hearing and car seat test)

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NS Cleft Lip/palate – challenges to breastfeeding Microcephaly/hydrocephalus (CSF built up) – protruding or wide fontanels Omphalocele (bowel in the umbilical cord) & Gastroschisis (bowel on outside of the body) – put intestines in a bag and hang over the baby NURSING CARE FOR HIGH-RISK INFANTS Warm & Dry!!!!!

CIRCULATION AIRWAY & BREATHING  IV fluids Vent/Suction/CPAP-ET or nasal  Feedings-BF, PO, NG/OG, GT Hood/Blow-by Oxygen/Nasal Cannula  Support of breastfeeding Assess lungs, monitor VS, CBG/ABG, vent/O2 settings, provider  Strict I and O notification  Thermoregulation: isolette/warmer, crib Safety-Ambu bag with appropriate mask DRUGS EDUCATION & FAMILY Maintain BP/precautions  Communication with family  Update frequently Maintain RR/HR/precautions  Teach all care and administration of drugs Antibiotics Monitor for adverse effects, monitor VS/O2 sats, drug levels, blood  CPR/Apnea monitoring  O2 administration at home cultures, lab values, cultures, notify provider of changes and  Support groups results of labs Assess fluid status, CBG/ABG, electrolytes/glucose, CBC, notify MD  Counseling-divorce  Grief counseling of changes  Sibling support NEONATAL ABSTINENCE SYNDROME (NAS) a group of problems that occur in a newborn who was exposed to Amphetamines addictive illegal or prescription drugs while in the mother’s womb. Barbiturates Babies of mothers who drink during pregnancy may have a similar Benzodiazepines (diazepam, clonazepam) condition (Fetal Alcohol Syndrome).

Cocaine The rate of current illicit drug use among pregnant women has Marijuana been reported as:ages 15 to 17 - 16.2%ages 18 to 25 - 7.4%ages Opiates/Narcotics (heroin, methadone, codeine) 26 to 44 - 1.9%Among pregnant women aged 15 to 44 who  These and other substances pass through the placenta to the baby during reported alcohol use: 10.8% reported current alcohol use, 3.7% pregnancy. The placenta is the organ that connects the baby to its mother reported binge drinking, and 1.0 percent reported heavy drinking in the womb. The baby becomes addicted along with the mother. with 10.1 percent of pregnant women reporting binge drinking  At birth, the baby is still dependent on the drug. Because the baby is no during the first trimester.* longer getting the drug after birth, symptoms of withdrawal may occur MECONIUM DRUG SCREEN SIGNS & SYMPTOMS Meconium is easier to collect than neonatal urine  May occur within 3-5 days (most within 72 hours) or as late as 1-2 weeks Provides a much longer window of exposure of up to 20 weeks.  Depends on type, amount frequency and duration of maternal drug used A sample of 3 grams (1 teaspoon) of meconium is needed for  Timing and severity of withdrawal symptoms also depends on infants maximum sensitivity. gestational age.

Amphetamines Cannabinoids  May be benign (sweating, mottled skin) to severe (Seizures, tachypnea, Cocaine Opiates poor ability to feed = slow/low wgt gain Significant CNS irritability Phencyclidine Methadone  (We already know that drug/alcohol use in pregnancy can result in Barbiturates Benzodiazepines congenital anomalies, increased risk of PTL/PTB, SGA, IUGR, IUFD and Propoxyphene Oxycodone SIDS) Meperidine Tramadol Buprenorphine SEVERITY CONSIDERATIONS

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Depends on: *gestational age at time of exposure *substance itself – type, purity, other adulterated substances present. *frequency of exposure, route of exposure *dosage of exposure, poly drug usage & *how long ago mom used

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METABOLIC, VASOMOTOR, & RESPIRATORY SIGNS RR >60bpm, nasal flaring, nasal congestion, frequent sneezing, yawning, apnea, diaphoresis, skin mottling, and fever GI SIGNS Poor feeding, frantic sucking or rooting, severe diarrhea (skin irritation) projectile vomiting – risk for aspiration Acute symptoms can last for several weeks Subacute symptoms (irritability, sleep disturbances, hypertonicity, and feeding difficulties) can last 4-6 months If mom already has poor coping skills – how might these symptoms affect her ability to bond/care for infant? NICU stay. CPS report. Siblings removed from home.

Remember: Some of the signs and symptoms may be misleading – poly drug usage Can have physical anomalies or medical conditions related to the drug use during pregnancy (CVA, NTD, IUGR, PTL, microcephaly, ambiguous genitalia) Differential diagnosis: hypoglycemia, sepsis, hypoxia, CNS disorders NURSING DIAGNOSIS Risk for injury R/T hyperactivity, Sz secondary to passive narcotic addiction Imbalanced nutrition: less than body requirements R/T CNS irritability, poor suck reflex, vomiting, diarrhea Risk for deficient fluid volume R/T diarrhea and vomiting Ineffective maternal coping, anxiety, powerlessness R/T drug use, infant distress during withdrawal Diarrhea R/T NAS Nursing Diagnosis Alter skin integrity R/T diarrhea, excitability, dehydration, seizures, poor nutritional intake Disturbed sleep pattern R/T NAS Risk for disorganized infant behavior Risk for Impaired parenting Risk for impaired parent-infant attachment DISCHARGE The infant is taking oral feeds and gaining weight satisfactorily.

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If drug use/abuse known or highly suspected: Do NOT use Narcan to NB – can lead to seizures in neonate (unless very depressed) May need to remain hospitalized 3-5 days to monitor for withdrawal symptoms Treatment usually supportive (vent, meds for diarrhea, high calorie feeds, phenobarb for siezures) May require usage of Morphine or methadone – strict tapering dosages based on symptoms CNS SIGNS Tremors, seizures, hyperactive reflexes, restlessness, hypertonicity, shrill high pitched cry and sleep disturbances (when does infant grow and resettle CNS functions?) – cluster care MANAGEMENT: INCLUDE THE PARENTS!!

Decreased noise, light, stimulation (touch) Tight swaddle, side lying, spine and legs flexed, hands in midline High calorie feeds (small, frequent) Non-nutritive sucking (pacifier even with breastfeeding – to counter poor organizational response to stimuli = increases potential for seizures) Breastfeeding (if drug use not ongoing and risk of HIV small) (position in sitting position with chin tucked down) Infection control F&E balance – STRICT I&O! Rock in vertical position – decreases irritability and seizure potential Encourage kangaroo care Cluster care activities Skin care

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MEDICATION MANAGEMENT Pharmacological treatment is commonly started when the 3 scores is 8 or more on the Finnegan scale May use Morphine, Methadone, Paregoric, Neonatal Tincture of Opium Other meds for symptoms (seizures) No “best” since research can never be “pure” (polydrug use) – ethics Be non-judgmental - establishes trust and support – you may well be the only one who isn’t Include the parents – encourage their efforts Assess parents understanding of infant’s special needs Assess mother’s perception of her ability to care for infant and special needs of infant Does she know how access substance abuse programs?

Support drug rehab (encourage and reinforce her progress – you may be the only form of encouragement and support she’s ever had) Assess her social support network

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ADDITIONAL CONSIDERATIONS What came first? The risk factors or the lifestyle that lead to the risk

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factors??

Infections (needle sharing or STI), malnutrition, anemia, homelessness,  socioeconomics, unemployment, late or no PNC  Should every mother be screened?  What should happen if they admit they are using drugs?   Should they be “confined” if they admit or test positive?  Should they automatically lose custody of this (and/or other children?)  What about alcohol? Marijuana? Prescription meds use/abuse?? (Legal??)

SUSPISCION OF ILLICIT PRENATAL DRUG USE  Maternal history of sexually transmitted diseases  History of multiple abortions, both spontaneous and elective, and unexplained fetal demise  Late or inadequate prenatal care  History of chaotic living arrangements, such as shelters or homeless  Precipitous labor and delivery and/or placental abruption  Maternal cerebrovascular accidents or myocardial infarctions  Unexplained intrauterine growth retardation (IUGR)  Premature labor  Atypical vascular incidents in the otherwise healthy full-term newborn, such as CVA’s, myocardial infarction, and necrotizing enterocolitis Neonatal signs and symptoms consistent with drug exposure or withdrawal NEWBORN NUTRITION & BREASTFEEDING INFLUENCES ON CHOOSING A FEEDING METHOD BREASTFEEDING HEALTH BENEFITS  Prenatal preparation THE RECOMMENDED NUTRITION: Exclusive for the first 6 months  Cultural beliefs Primary source for next 6 months as breastfeeding continues to at least the  Societal barriers baby’s first birthday, and thereafter as mom and baby desire.  Look for convenience Advantages: Many for mom and baby – decreased risk of cancers and  Want fathers involved obesity, decreased ear and GI infections, easy to prepare, low cost |  Confidence of woman decreasing bleeding, helping uterus clamp down after delivery.  Modesty issues  Seeing other mothers breastfeeding BREASTFEEDING CONTRAINDICATIONS (Few) NUTRITION  Active, untreated TB  300-600 calories burned per day  HIV/AIDS  Produce 750-1000 ml of milk/ day  Cancer  Mom needs increased Protein, Vitamins & Minerals o Chemotherapy medications HOW WILL I KNOW MY BABY IS GETTING ENOUGH? o Radiation therapies  Audible or visible swallows  Certain medications – Manual Medications & Mother’s Milk  Breasts are softer after feeding (once the mature milk is in)  Current alcoholism or illicit drug use  Signs of satiety after feeding  Active Herpes Simplex lesion on maternal breast  Varicella (onset within 5 days prior to or 48 hours after delivery, or  Wet and Soiled diapers  Signs of normal hydration until she is no longer infections)  Adequate weight gain  Mothers with human T-cell lymphotropic virus type I or type II  Stable temperature and blood glucose  Infant galactosemia  Bilirubin level with acceptable limits (Nomogram) STAGES OF MILK BREASTS COLOSTRUM  Lactogenesis I EXTERNAL  Easy to digest  Areola  Clear to yellow in color o Darker area  Thick consistency/concentrated o 2-3 inches diameter 

The infant is physiologically stable (has normal vital signs including blood pressure).

The infant is showing neurobehavioral recovery (can reach full alert state, responds to social stimuli, and can be consoled with appropriate measures).

All necessary assessments have been completed because adherence to follow-up schedules cannot be ensured.

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Initially occurs with or without suckling by infant ^ frequent stimulation at breast creates more prolactin receptors and enhances milk volume Beings during pregnancy and stimulated by endocrine control o Upon delivery of the placenta  Progesterone & estrogen levels drop  Prolactin levels begin to rise  Stimulates alveolar cells to make milk High in protein  stabilizes glucose levels Nutrients and quantity for newborns o First 24 hours= 30 ml total or about a spoonful at a feeding Laxative to help move stools – moves bilirubin + matures intestines Immune protection TRANSITIONAL MILK Changes from colostrum to a transitional milk about day 3 As the mature milk comes-in Becomes more dilute, until all the colostrum is gone, and only the mature milk remains MATURE MILKLactogenesis II Nutrients are more readily useable than formula (greater bioavailability) More volume = lower fat content Greater volume in early morning Less volume, but higher fat content, in the evenings Prolactin levels are higher at night - feeding at night increases this even more FOREMILK VS. HINDMILK Foremilk o Beginning of a feeding o Lower in fat o Quenches thirst o Wet diapers Hindmilk o End of a feeding o Higher in fat content is 4-5 times higher o Quenches hunger o “Satiety” o Soiled diapers MAKING THE RIGHT AMOUNT OF MILK Each time the baby feeds at the breast, prolactin levels rise the baby should feed 8-12 times or more per 24 hours To Increase milk supply Feed more frequently at the breast Empty the breasts more thoroughly at each feeding Use massage/compression during feedings Express milk after feedings Skin to skin care with the baby If mom leaves milk in the breast

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o Most sensitive part Montgomery Glands o Bumpy places on the Areola o Lubricates skin o Lower’s pH of skin o Odor and dark color draw baby to the nipple o May stimulate infant oral cavity Nipples o 4-10 openings appear on surface which secrete milk INTERNAL

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Ducts o o

Transport’s milk Alveoli to nipple openings

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Groups of alveoli 7-10 in each breast

Lobes Alveoli o o Alveolus o o o

Cluster of alveolus Resembles a cluster of grapes Lactocytes Milk producing cells Interior lumen for milk storage

MILK TRANSFER & THE INFANT: POSITIONING & LATCH Positioning is Important  Support baby at breast level  Keep baby’s body snuggled into mom’s  Nose opposite nipple  Infants’ ear, shoulder and hip in alignment Latch Is Critical  Baby’s gums over the milk ducts  Compresses the breast and pushes the milk out  Baby’s tongue moves in a wave-like motion

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There is a Feedback Inhibitor of lactation (FIL) in the breast Involution begins

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SIGNS OF A GOOD LATCH        

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Flanged lips Tongue may be visible when bottom lip is pulled down Cheeks are rounded Audible swallowing Breast compression Nipple is non-distorted Emptying of the breast is noted Infant ends feeding with signs of satiety REMOVING THE BABY FROM THE BREAST Break suction o Placing a finger in baby’s mouth o Don’t pull or tug at baby Burp between breasts FORMULA FEEDING Most brands are similar in composition Cow’s milk or soy based With or without Iron Long-chain fatty acids o Deposited in the brain of the fetus during the last trimester o Growth & brain development 20 Kcal/cc or higher FORMULA PREPARATIONS Ready to serve  most expensive (no water needed) Concentrate  Moderate priced Powder  Least expensive

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Propels the milk through the ducts & out the nipple toward the back of baby’s throat Baby then swallows SIGNS OF A BAD LATCH Lips rolled in Cheeks are dimpling Breast slides in and out of infant’s mouth Mother’s nipple is flattened or creased Little or no breast changes after feeding Inadequate stools and or voiding for age

PREPARING & STORING FORMULA Wash hands Clean/Sterilize equipment Boil tap water Store in refrigerator Do not warm in microwave Discard unused formula if not consumed within an hour FEEDING TECHNIQUE   Similar to breastfeeding – follow baby’s cues, feed on demand  Stimulate rooting reflex   Hold bottle up to avoid swallowing of air  never prop it up   Discard unused formula if not used within 1 hour   Alternate which side you hold baby on  Burping BREAST CARE Breast Feeding  Good supportive nursing bra Flat or Inverted Nipples (typically d/t scar  Assess Bottle Feeding  tight fitting bra  Avoid artificial nipples (binky/pacifier) Teach: Have shower water come over shoulder from behind, no soap.  Teach mom to roll nipple out Common Problems  Breast pump or syringe to pull nipple out Sore Nipples (commonly latch issues)  Nipple shield  Redness, bruised  Breast Shells worn last few weeks of pregnancy, not close to delivery d/t  Crack nipple/oxytocin stimulation  Blister/Scab  Compression stripe  Mishapened oral structure  Lanolin Cream | Antibiotic Cream | Hydrogel Pads  MOST IMPORTANT!  Assess infant’s suck pattern & oral structure ENGORGEMENT PLUGGED MILK DUCTS  Heavy breasts, firm, warm to touch  Develops gradually  Skin is stretched, may look shiny  Localized pain  Nipples may flatten from full breast  Palpable lump or “knot”    

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 Leaking may not occur  Discomfort/Pain  Maternal temperature elevation Onset  3-5 days postpartum  Lasts 1-10 days  May interfere with feeding and if not resolved in a timely manner, can decrease milk supply Treatment  Bedrest with infant  Warm compress BEFORE feeding (1-2 minutes)  Cool compress AFTER feedings  Reverse pressure softening  Hand expression prior to feed  Gentle massage during feed  Rotate positions  Pump as needed  Pain Medications-ibuprofen  Cabbage leaves o After feedings o Leave on for 15-20 minutes  Discontinue Cabbage Leaves o Breasts begin to soften o Milk begins to drip from nipples o “Tingly” sensation in breasts (Letdown) MASTITIS  Onset is commonly 2-3 weeks after delivery  Most cases- first 12 weeks Symptoms  Fever and flu-like symptoms Treatment  Efficient emptying of the breast;  Frequent feedings  Antibiotics  Increased fluids  Pain Meds  Rest  CONTINUE BREASTFEEDING!!

NPO

Respiratory distress can cause blood to divert from gut ^ risk of NEC, IV and/or gavage infant with tachypnea = feedings, can’t suck and swallow ^ maintain risk of aspiration hydration and calories

 May decrease in size with milk removal Those at risk:  Skipping feedings  Poor latch  Anatomic variations  Over-abundant milk supply  Poor fitting bra  Treatment  Frequent nursing  Moist heat PRIOR to feed  Massage during feeding  Infant’s chin pointed toward plug  Refer to HCP if no improvement in 2-3 days

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BREAST PUMPS STORAGE GUIDELINES o Room Temperature= 6 hrs. o Refrigerator= 5 days o Freezer= 6months o Deep Freeze= 12 months o Always store milk in back of refrigerator or freezer Do not refreeze breastmilk that has been thawed

Always maintain NB’s temperature monitor glucose (extra WOB ^ glucose use)

On CP monitors, pulse-ox, cluster care activities, keep parents informed about ALL changes good and bad and encourage their participation, cluster care to allow rest time and decrease O2 demand,

Watch pulse-ox & blood gases, Keep O2 as low as possible while maintaining appropriate SaO2

ALWAYS keep infant warm!!

May need antibiotics, vasopressors and pulmonary vasodilators

Condition

Cause

S&S

TX

TTN (Transient Delayed reabsorption of Respiratory distress, tachypnea, Usually oxygen, NPO, Will usually Tachypnea of the normal lung fluid retractions, grunting, nasal spontaneously resolves 24- 72 Newborn) flaring, decreased breath sounds hours

Pulmonary hypertension causing R to L shunting and hypoxemia. Normally the initial breathes increase O2 concentration resulting in decreased pulmonary vascular PPH (Persistent resistance Pulmonary Hypertension) In this case, that does not occur = increase resistance = shunting of blood and fetal shunt fail to close

Tachypnea within 12 hours of birth, marked cyanosis, grunting, respiratory distress, retractions, harsh murmur, hypotension

consider sedation to decrease O2 demand

Miscellaneous

More common with C/S

Echocardiogram, IV, possible treatment with respiratory support or ECMO

RDS (Respiratory Due to immature lungs Tachypnea, expiratory grunting, Surfactant!

More common in preterm Distress with lack of surfactant flaring, retractions, decreased CPAP, nasal/endotracheal infants, male infants, infant of Syndrome) Ventilator- intermittent or diabetic mothers, C/S, sepsis History of prematurity, C- breath sounds, rales, seesaw respirations, decreased SpO2 synchronized Section, asphyxia, IDM, (left to right shunting R/T High frequency oscillation or jet sepsis, Surfactant protein pulmonary vascular resistance ventilator deficiency from acidemia) Oxyhood, nasal cannula Inhaled Nitric Oxide: causes pulmonary vasodilation, but still CXR “White-Out” (ground glass) or reticulogranular pattern, air experimental tx, worsens without treatment – starts to improve bronchograms

within 72 hours

MAS (Meconium Aspiration Syndrome)

CLD (Chronic Lung Disease)

Aspirating meconium

Caused by lung injury from surfactant deficiency, pulmonary edema, lung immaturity, barotrauma from mechanical ventilation and O2 toxicity – resulting in chronic inflammation of the lung

Meconium stained amniotic fluid or stained infant, progressing respiratory distress, airway obstruction, grunting, cyanosis, surfactant dysfunction, hypoxia= can lead to PPH and death, R to L shunting, PDA. CXR patchy fluffy infiltrates, marked hyper aeration with areas of atelectasis.

Tachypnea, rales, retractions, increased WOB, oxygen requirement

O2, ECMO, ventilator, possible surfactant. ET intubation and suctioning in a non-vigorous infant with signs of distress

Since this is from chronic insult, primary measure is prevention.

(Antenatal steroids) Start with low O2/air when resuscitating term infant, when O2 required – wean as quickly as infant condition allows. Pressures as low as possible on vents, Surfactant, diuretics,

Risk factors: post-term, prolonged or dysfunctional labor, maternal hypertensive disorders, maternal diabetes, oligohydramnios, IUGR, prolapsed cord

White male infants at higher risk, more common in preterm, LBW infant

RSV immunization

ROP (Retinopathy of Prematurity)

Prevention!

Wean O2 as quickly as infant condition allows.

O2 use, acidosis and Exposure to high O2 shock in premies, LBW, No early signs - all premies have concentration =severe retinal damage to ongoing ophthalmology vasoconstriction = endothelial Not a respiratory underdeveloped vessels examinations while in NICU and Decrease environmental lights in damage and vessel NICU disorder – of the retina after discharge. obliteration. This causes however- is a abnormal vessels to develop – common Early, less severe may resolve on these are immature and bleed Maternal smoking, May cause severe vision condition in our its own. More severe conditions and scar and cause retinal hypertension, substance changes and or blindness infants with a may need surgical intervention, detachment abuse respiratory laser photocoagulation or disorder. cryotherapy.