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OB Exam 1 2019

Terms in this set (233)

First Period of Reactivity length
30 minutes after birth
First period of reactivity
-hr increases to 160-180 bpm (gradually decreases from this)
-infant is alert
Period of decreased responsiveness length
lasts from 60-100 minutes
Period of decreased responsiveness
-Marked decrease in motor activity or Sleeping
-Difficult to arouse or interact w/newborn
-Can be used for mother and baby to remain close & rest together.
Second period of reactivity length
- Occurs 2-8 hours after birth
-lasts 10 minutes to several hours
Second Period of Reactivity
-tachypnea and tachycardia occur
-increased muscle tone
-improved skin color
-mucous production
-meconium is typically passed
Initiation of breathing factors
-chemical
-mechanical
-thermal
-sensory
Initiation of Breathing: chemical
-activation of chemoreceptors in carotid arteries and aorta from relative hypoxia during labor
-Clamping of cord: drops levels of prostaglandins that inhibit respirations
Initiation of Breathing: Mechanical
-changes in intrathoracic pressure
-compression of chest during vag birth
-pressure of chest is released with birth, negative intrathoracic pressure draws air into lungs.
-Crying expands alveoli, pressure of crying keeps open
Initiation of Breathing: Thermal
lower temp stimulates respiratory center in medulla
Initiation of Breathing: Sensory
-touch
-sounds
-smells
Surfactant
Protein that lines the alveoli
-lowers surface tension
-prevents alveolar collapse
Signs of risk for cardiovascular problems
-persistant tachycardia
-persistant bradycardia
-skin color: pallor, cyanosis
Infant Red Blood Cells
-fetal circulation is less efficient at oxygen exchange than the lungs so the fetus needs additional RBCs for transport of oxygen in utero
-14,000-24,000 g/dl at birth, adult levels 2 weeks
Infant Leukocytes
same as adults at
birth, rise to 23,000-24,000 first day after birth
Infant Hemoglobin Level
12-24 g/dl at birth, normal in first 2 weeks
Thermoregulation
the maintenance of balance between heat loss and heat production
Heat Loss: Convection
flow of heat from body to cooler AMBIENT air
Heat Loss: Radiation
-Loss of heat from body to cooler surface not in direct contact, but close by
-avoid cribs next to windows, drafts
Heat Loss: Evaporation
loss of heat when liquid is converted to vapor
Heat Loss: Conduction
loss of heat from body surface to cooler surfaces in direct contact
Infant Wet diapers a day
-2-6 x a day for 1-2 days of life
-6-8 after
Infant Renal System
Infants are born with excess fluid
-lose it in first 3-5 days after birth, 5-7% of weight is lost
Infant Voiding
-An infant should void within 24 hours of life.
-98% of infants void within 30 hours of life.
Renal Impairment
If a newborn has not voided within 48 hours of life it may indicate a renal impairment.
Uric Acid Crystals (brick dust)
-red dust in diapers
-ok for the first week
-after the first week, may be a sign of inadequate fluid intake
Infant Stomach Capacity
-15-30mL at birth
-90 mL after day 3
Stomach is Sterile at birth
-fragile immune system
-no vitamin K production until day7
GERD
-avoid overfeeding
-burp
-elevate head
-may need meds
Signs and Symptoms of GI problems
-fullness in abdomen above umbilicus
-duodenal atresia
-distention
-sunken abdomen
-diaphragmatic hernia
-decreased bowel sounds
Pyloric Stenosis
Vomiting large amounts
meconium
-the greenish material that collects in the intestine of a fetus and forms the first stools of a newborn
-occurs within 24 hours
-progresses to normal stool
Iron Storage
Infants are born with a 6 month supply, then supplement
Infant glucose level
30-90 after birth
-gradually rise
50-60
-Below 40 - need intervention
Conjugation of Bilirubin
bilirubin + glucoronic acid in presence of enzyme glucuuonyl
Transferase of Bilirubin
happens in liver, transported into biliary tract, into duodenum, excreted in urine and feces.
Jaundice
-appears when bili > 5-6 mg/dl - transcutaneous + serum
-yellowing of skin and whites of eyes
Early onset of Jaundice
Liver made too much bilirubin
Late onset of Jaundice
Delayed elimination of bilirubin
Physiologic Jaundice
-60% full term; 80% pre-term
-After 24 hours
-Peak - 3-5 days, longer for preterm
Pathologic Jaundice
- 24 hours of birth
-↑ > 6 mg/dl in 24 hours, > 15 mg/dl at any time
-Blood group incompatibility, G6PD deficiency, enclosed hemorrhage, twin to twin transfusion, delayed cord clamping
-
Breastfeeding and Jaundice
a lack of effective breastfeeding contributes to hyperbilirubinemia
breastfeeding associated jaundice
Early onset begins at 2-5 days of age. Caused by lack of effective BF.
breastmilk jaundice
Also called late-onset jaundice. Hyperbilirubinemia that occurs between 5-10 days of life, usually in a healthy breast-fed infant. Cause is unknown
Coagulation in Infants
The lack of intestinal bacteria needed to synthesize vitamin K results in transient blood coagulation deficiency between the second and fifth days of life.
Signs of Hepatic Problems
-hyperbilirubinemia
-hypoglycemia
-hemorrhage after circumcision
IgG
-Babies are born with it
-prevent virus and bacterial infections
-effective for the first 3 months
IgM
-born with 10% of adult level
-reaches adult level by age 2
-antibodies are created as antigens are encountered
IgA
-missing from respiratory and urinary tracts.
-Role in preventing allergies and food intolerance
-Breast milk provides
Mongolian Spots
-Bluish / black areas of pigmentation
-More common in dark skinned individuals
-Document!
Vernix Caseosa
-Contains sebaceous gland secretions
-Emollient, anti-microbial
-Decreases skin pH, skin erythema, improves skin hydration
Desquamation
-Peeling of skin occurs a few days after birth
-if born with its it is a sign of post-maturity
Nevus (stork bites)
superficial capillary defect - fade between first and second years
Erythema
-newborn rash
-first 24-72 hours after birth
-last up to 3 weeks
-possibly inflammatory reaction. -No harm, no intervention.
Swelling of Breast tissue
-caused by the hyperestrogenism of pregnancy
-subsides within a few days
Signs of risk for reproductive problems
-ambiguous genitalia
-hypospadias
-epispadias
Capput Succedaneum
serosanguinous, subcutaneous, extraperiosteal fluid collection with poorly defined margins caused by the pressure of the presenting part of the scalp against the dilating cervix
Cephalhematoma
Bleeding between the periosteum and skull from pressure during birth; does not cross suture lines.
subgleal hemorrhage
-bleeding in the potential space between the skull periosteum and the scalp
-crosses suture lines
Olidactyly
missing digits
polydactyl
extra digits
syndactyly
Fusion of digits
Developmental dysplasia of the Hips
-only physicians or NPs should perform the Barlow test or the Ortaloni maneuver
Who is at risk for hip dysplasia?
Breech Babies
Neuromuscular system
-almost completely developed at birth
-Normal tremors, tremors (jitteriness) of hypoglycemia, and seizure activity must be differentiated
Factors Influencing Behavior of Newborns
-gestational age
-time
-stimuli
-medication
Sensory Behaviors
-vision
-hearing
-smell
-taste
-touch
Sensory Behaviors: Vision
-clearest vision is at 8-12 inches
-preferences for faces (MOM'S)
-prefer black and white because of the contrast
-colors are visible at 3 months
Sensory behaviors: hearing
Do test by 1 month
Sensory Behaviors: smell
-prefer sweet smells
-recognize mother's smell by day 5
Sensory Behaviors: Taste
prefer sweet
Sensory Behavior: touch
-survival need
-each infant has a different need and preference
Responses to environmental stimuli
-temperament
-habituation
-consolability
-cuddliness
-irritability
-crying
MOST IMPORTANT ADAPTION
developing effective respirations
Cold Stress
Heat loss in the healthy term newborn can exceed the capacity to produce heat; this can lead to cold stress and metabolic and respiratory complications that threaten the newborn's well-being.
APGAR
appearance, pulse, grimace, activity, respiration
APGAR frequency
1 minute and 5 minute
APGAR scoring
A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations (strong cry, weak cry, absent)
-0=bad
-10=good
Baseline Measurements of Physical Growth
-Weight
-Body Length
-Head Circumference
First 2 Hours: Physical Assessment
-General Appearance
-Vital Signs
First 2 Hours: Neurologic Assessment
Test for reflexes
First 2 Hours: Gestational Age
Dubowitz scale and New Ballard scale
Classification of Newborns by Gestational Age and Birth Weight
-Appropriate for gestational age (AGA)
-Large for gestational age (LGA)
-Small for gestational age (SGA)
Preterm or Premature
born before completion of 37 weeks of gestation, regardless of birth weight
Late preterm
34 0/7 through 36 6/7 weeks
Early Term
37 0/7 through 38 6/7 weeks
Full Term
39 0/7 through 40 6/7 weeks
Late Term
41 0/7 through 41 6/7 weeks
Postterm
42 0/7 weeks and beyond
Post mature
born after completion of week 42 of gestation and showing the effects of progressive placental insufficiency
The Great Imposters
-late preterm
-increased risk for respiratory distress, hypoglycemia, apnea, feeding difficulties, hyperbilirubinemia
Neonatal Interventions
-Airway maintenance
-maintain adequate oxygen supply
-maintain body temperature
Bulb Syringe
Always in the crib
-MOUTH BEFORE NOSE
Fine Crackles heard in the first few hours
It is okay, more common in c/s baby
Immediate interventions
-eye prophylaxis to prevent neonatal conjunctivitis transmitted from mom to infant
-vitamin K administration
Birth Injuries
-Retinal and subconjunctival hemorrhages
-Soft-tissue injuries: erythema, ecchymoses, petechiae
-Trauma secondary to dystocia (broken clavicle)
-Accidental lacerations
Jaundice Screening
-test all bili levels
-test q8-12 hours
-Serial checks if above 12
-try to get baby breast-fed in the first hour
Phototherapy
-Conjugates bilirubin so that it can be excreted
-Bilirubin levels should decrease within 4-6 hours
-Protect eyes
-↑ stools = ↑ potential for skin breakdown
-Turn q 2-3 hours
-Intermittent = ok
-May need pad / blanket between fiberoptic device & skin
Hypoglycemia
-< 45 mg/dl
-At risk infants - fed within 1 hour, check bg in 30 minutes
-S/S = lethargy, jitteriness, poor feeding, abnormal cry, hypothermia
-May need IV dextrose if bg does not improve after feeding
Hypocalcemia
-↑ risk = hx of asphyxia, trauma, diabetes, mothers on anti-convulsants, lbw, ptb
-Serum calcium levels of less than 7.8 to 8 mg/dl in term infants and slightly lower (7 mg/dl) in preterm infants
Laboratory and Diagnostic Tests done before discharge
-Universal Newborn Screen
-Hearing screen
-CCHD screen
Universal Newborn Screen
-Mandated by U.S. law
-Early detection of genetic diseases that result in severe health problems if not treated early
-do after 24 hours
-31 core disorders, 26 secondary
Newborn Hearing Screen
-Done before 1 month old
-healthy ears echo click sounds back to microphone in earpiece
Screening for critical congenital heart disease (CCHD)
-24-48 hours
-pulse ox - right hand and one foot - -passing = 95%, < 3% difference
Collection specimens
-Heel stick: small amount of blood needed
-Venipuncture: large amount of blood needed (23-25 butterfly)
-Urine: analysis within 1 hour
Safety Interventions
-Protective environment
-Environmental factors
-Infection control factors
-Fall preventions
Immunization site
IM given on thigh
cirumcision
excision of the prepuce (foreskin) from the penis
-yellen clamp
-mogen clamp
-plastibell
Circumcision Pain Management
SubQ lidocaine, EMLA cream, sweeties, swaddling
Neonatal Response to pain: Behavioral
Vocalization or crying
Neonatal Response to Pain: Physiologic
-Changes in heart rate
-Blood pressure
-Intracranial pressure
-Vagal tone
-Respiratory rate
-Oxygen saturation
Assessing Neonatal Pain
-Neonatal Infant Pain Scale (NIPS)
-Premature Infant Pain Profile (PIPP)
-Neonatal Pain Agitation and Sedation Scale (NPASS)
-CRIES (used in NICU)
CRIES Scale
- for neonates
-Crying (0-2)
-Requiring increased oxygen (0-2)
-Increased vital signs (0-2)
-Expression (0-2)
-Sleeplessness (0-2)
-Used in NICU
-0= no pain; 10=worst pain
Nonpharmacological Pain Management
-Containment (swaddling)
-Nonnutritive sucking
-Oral glucose
-Skin-to-skin contact
-Breastfeeding
Pharmacologic Pain Management
-Local and topical anesthesia
-Nonopioid analgesia (Acetaminophen)
-Opioid analgesia (Morphine, Fentanyl)
promoting parent-infant interactions
-assess attachment behaviors
-support and educate parents
-cultural considerations
Discharge Teaching: temperature
dress one layer warmer than adults
Discharge Teaching: Respirations
-Do not allow peeps with URIs around baby
-no excess bedding (like bumpers)
-ABC - alone, on back, in crib
-always have a bulb syringe
Discharge Teaching: Feeding Patterns
-2-3 hours with breast
-3-4 hours with formula
Discharge Teaching: Elimination
-6-8 pees days 1-3
-8-12 after
-BMs - 3 x a day breastfed
-formula - 1 q.o.d. = ok.
Discharge Teaching: Diaper Rash
regular changes, open to air, barrier cream if necessary
Discharge Teaching: Nonnutritive Sucking
-do not give for 3-4 weeks if baby is breastfeeding
-helps prevent SIDS
Discharge Teaching: Bathing
Every other day at most
-no lotion
-use mild soap
-keep cord dry
Nursing care immediately after birth
maintain airway, prevent heat loss, promote parent and infant interaction
Where does newborn assessment data come from?
prenatal, intrapartal, and postnatal periods.
Benefits of breastfeeding for infant
-Decreased incidence of infectious diseases
-Reduced infant mortality including SIDS
-Decreased incidence of type 1 and type 2 diabetes
-Decreased incidence of leukemia and lymphomas
-Reduced risk of obesity and hypercholesterolemia
-Decreased incidence of asthma and allergies
-Enhanced cognitive development
-Analgesic effect for painful procedures
Benefits of Breastfeeding for MOM
-Decreased postpartum bleeding
-More rapid uterine involution
-Reduced risk of ovarian and breast cancer
-Lower risk of hypertension and cardiovascular disease
-Earlier return to prepregnancy weight
-Decreased risk of osteoporosis
-Unique bonding experience
Benefits of Breastfeeding to Society
-Convenient, ready to feed
-No bottles or other equipment
-Less expensive than infant formula
-Less parental absence from work because of ill infant
-Reduced environmental burden related to disposal of formula cans
Choosing infant feeding method
-Breastfeeding is a natural extension of pregnancy and childbirth
-Women tend to select the same feeding method for all their children
-Support by family and partner is a major factor in feeding choice
Breast Feeding Contradictions
-Galactosemia
-Active tuberculosis
-HIV infection
-Chemotherapy
-Radioisotopes
Supporting BF mothers
-Education and anticipatory guidance
-Prenatal classes
-La Leche League and Mocha Moms
-WIC
-Baby-Friendly Hospital Initiative
-include the father
-promote confidence
Cultural influences on infant feeding
-Beliefs and practices are a significant influence
-Immigrants from poor countries tend to formula-feed
-Belief in the harmful nature of colostrum
-Los dos: practice of combining formula and breastfeeding by Mexican women
-Specific food intake to foster milk production
Lactogenesis
-Prolactin prepares the breast to secrete milk
-Supply-meets-demand system
-Oxytocin
-Milk ejection reflex (MER)
-Nipple-erection reflex
-Inverted nipples
Uniqueness of human milk
- Composition changes during each feeding
- Fat content of breast milk increases
- Provides primarily lactose, protein, and water soluble vitamins
- Contains antimicrobial factors (IgA is the major antibody in human milk)
- Hindmilk or cream usually let down 10-20 mins into feeding
Antimicrobial Factors of Breastmilk
-Immunoglobulin A (IgA) major antibody
-IgG, IgM, IgD and IgE are also present
Colostrum
-more concentrated than mature milk and extremely rich in immunoglobulins
-Higher concentrations of protein and minerals but less fat than mature milk
Care of Breastfeeding Mother
-diet
-weight loss
-rest
-breast care
-flat or inverted nipples
-breast support
Common concerns of breastfeeding mom
-Engorgement
-Sore nipples
-Monilial infections
-Plugged milk ducts
-Mastitis
-Follow-up after hospital discharge
Types of infant formula
-cow milk based
-iron fortified
-soy-based
-amino acid formula
-casein or whey formula
Formula Preparation
-Ready to feed
-Concentrated liquid
-Powdered
When should baby be breastfed?
as soon as possible after birth and at least 8 to 12 times per day thereafter
Postpartum Period
interval between birth and return of the reproductive organs to their nonpregnant state
Postpartum Uterus
-Involution process
-Contractions
-Afterpains
-Placental site
-tone
Lochia
postpartum uterine discharge
Lochia Rubra
Composed of blood, shreds of fetal membranes, decidua, vernix caseosa, lanugo and membranes. It is red in color because of the large amount of blood it contains, lasts 3 to 5 days after birth.
Lochia Serosa
as thinned and turned brownish or pink in color. It contains serous exudate, erythrocytes, leukocytes, cervical mucus and microorganisms, lasts until about day 10
Lochia Alba
whitish or yellowish-white. It typically lasts from the second through the third to sixth weeks after delivery. It contains fewer red blood cells and is mainly made up of leukocytes, epithelial cells, cholesterol, fat, mucus and microorganisms
Assessing the Perineum
-have patient lay on their side
-use a light
-check for hemorrhoids
-episiotomy and lacerations
Interventions for postpartum hemorrhage
-ALWAYS HAVE THEM EMPTY THEIR BLADDER
-uterine massage
-respond quickly
-pitocin (IV or IM)
-breast feeding
-cytotech
-misoprostol
-methergine (do not give If BP is elevated
- Carbaprost (causes diarrhea)
Risk for PP hemorrhage
-on Mg Sulfate
-multiple children
-anemia
-taking blood thinners
Placental hormones
Estrogen and progesterone levels decrease
Pituitary hormones
Prolactin remains elevated in women who breastfeed
Ovarian function
-Ovulation in 27 days after birth for nonlactating women
-Ovulation in 70 to 75 days for lactating women
-may or may not have a period
Urethra and Bladder
excessive bleeding can occur if bladder is distended, have mom pee every two hours after birth
Urine Components
-Pregnancy induced renal glycosuria disappears in 1 week
Peri Care after Birth
-use a peri bottle
-blot, don't wipe
-use TP roll to prevent splashing on tears
PP Bowel evacuation
-offer stool softeners!!
-first BM occurs 2-3 days after birth
-anal sphincter lacerations are associated with postpartum incontinence
Breastfeeding Mothers PP
-First 24 hours colostrum
-Transitions to milk in 72 to 96 hours
-Engorgement comfort measures for lactating mothers
Non breastfeeding mothers pp
engorgement resolves in 24-36 hours after milk comes in
Coagulation factors PP
-more likely for blood coagulation
-c-section is at a higher risk
-Walk as much as possible after birth to avoid clotting
-increased risk for DVT
PP Blood volume
blood volume is increased during pregnancy, hemoglobin may not be able to catch up, causing anemia
PP Respiratory Systems
-Immediate decrease in intraabdominal pressure at birth
-Decreased pressure on the diaphragm
-Reduced pulmonary blood flow
-Chest wall compliance increases
-The decline in progesterone that occurs with loss of the placenta causes Paco2 levels to rise.
PP Neurologic System
-Changes result from reversal of maternal adaptations to pregnancy and from trauma during labor and childbirth.
-Pregnancy-induced neurologic discomforts abate after birth.
-Headaches are common in the first postpartum week, however watch for s/s of pre-eclampsia, spinal h/a
Signs of pre-eclampsia
-happens when you sit up
-medication does not relieve pain
-visual changes
-BP of 140/80 on 2 readings
PP Musculoskeletal System
-adaptations of this system are reversed
-joints are stable 6-8 weeks after birth
PP Abdomen
-Returns to prepregnancy state 6 weeks after birth
-Striae may persist
-Return of muscle tone
-Previous tone
-Adipose tissue
-Diastasis recti abdominis
PP Integumentary System
-Melasma (mask of pregnancy) disappears (does not in 30% of women)
-Vascular abnormalities regress
-Hair loss often reported during the first 3 months postpartum
PP Immune System
-Mildly suppressed during pregnancy
-Now gradually returns to its prepregnant state
-This rebound of the immune system can trigger "flare-ups" of autoimmune conditions
Assessing Fundal Height
essential to monitor the progress of normal involution and to identify potential problems
How long does the body take to return to pre-pregnancy state?
6 weeks
What is responsible for physiologic changes postpartum?
The rapid decrease in estrogen and progesterone levels after expulsion of the placenta
Uterine Involution
The uterus involutes rapidly after birth and returns to the true pelvis within 2 weeks.
Gendered Violence
Intimate partner violence, reproductive coercion, sexual assult
intimate partner violence
physical, sexual, or psychological harm by a current or former partner or spouse
Rate of Intimate Partner Violence
1 in 4 women, 1 in 7 men
#1 cause of unnatural fetal death
intimate partner violence during the pregnancy and prenatal period
Precipitating factors of IPV
drug and alcohol misuse, inadequate prenatal care, depression, anxiety
reproductive coercion
Includes, but not limited to: taking condom off during sex, refusing to wear condom, destroying / hiding birth control, pulling out IUD, pressuring to become pregnant, pressuring to continue pregnancy, pressure to have abortion, threaten to abuse person / leave person / cheat on person if they do not...
What to do about IPV?
-Screen all, normalize
-Ask about behaviors, such as HITS:
-Does your partner: hit you, threaten you, scream at you?
-Believe
-Refer
-1800-799-SAFE
-Have patience - it is not about you
-Know that you are not the expert, the patient is
Herpes in Pregnancy
- investigate all unknown vulvar/vaginal itching, irritation, lesions. Safer sex. With diagnoses - medicate at 36 weeks until birth with anti-viral (Acyclovir, etc.) C/S with lesions.
-Can be deadly to babies
-can cause fetal malformation
Herpes Prevalence
8-15%
More common in women
Signs and Symptoms of Herpes
S/S
Small vesicles (M= 4 days after exposure)
Dysuria
Genital irritation
*Fever, body aches, swollen lymph nodes
Testing for Herpes
-Culture is gold standard, but frequently false negative
-Serologic not recommended in general population
Preventing Herpes
Safer sex, use of insertive condom dental dams
Antiviral treatment for infected partner
Avoid contact with prodromal symptoms
Treating Herpes
-Episodic treatment - Acyclovir, Famciclovir
-Suppressive treatment - Valacyclovir, Acyclovir, Famciclovir,
-Suppressive treatment in late pregnancy (36+)
-Diet, stress
Consequences of Herpes on the neonate
-No vaginal delivery with active lesions
-Most infants with HSV infection have mothers who did not know that they were infected
-Transmission risk 30-50%
-Skin lesions
-Disseminated
-Encephalitis, concomitant involvement of the skin, eyes, and mouth
-Mortality 50-85%
-Systemic Acylovir for 14-21 days
Rubella Vaccine
-Client should not get pregnant for 1 month following the immunization
-can deform the child if born to a mom with rubella
Varicella Vaccine
Women who are not immune to varicella should be immunized in the postpartum period. Instruct client to use reliable form of contraception and avoid pregnancy for 3 months.
Tdap Vaccine
-to prevent pertussis, pp, and if they did not get in 3rd trimester
-given between 27&36 weeks
-passes the protection on to baby
-Given during all pregnancies
RhoGAM
Used to prevent an immune response to Rh positive blood in people with an Rh negative blood type child
-give at 28 weeks
-protects against antibodies in pregnancy 2
Harm Reduction
efforts to minimize the harmful effects caused by drug use
-take small steps
-sense of hope
-self and life-management
Why do women start using substances?
-Traumatic life events
-coping with memories of abuse or past trauma
-initiation from male partner
-psychiatric conditions
Unique characteristics women with PSUP have
-younger, more isolated, fewer friends or supportive relatives
-lower education and income level
-rely o social assistance, partners or illegal activities for financial income
Why do women use drugs and or alcohol
-relieves emotional and physical pain
-numb them out
-forced by a partner
-medicates against anxiety and panicked feelings
-makes them feel in control
-makes them feel powerful
-makes them feel accepted
-part of their culture
-experimentation
-prescribed drugs
-helps them lose weight
-appeases abuser
-socially accepted
-only way they have to cope
-fun in a not fun world
Women-Centered Care Strategies
-put woman's safety first
-focus on empowerment
-minimize system risks
-recognize diversity and complexity of women's lives
-respect her choices
-believe her
-be honest
-advocate for her
-give her information to help her make choices
-support her decisions
-maintain confidentiality
-always obtain consent
-partner with community support services
Barriers to PSUP Women's care
-health system is difficult to navigate
-feelings of fear, guilt and shame due to misuse
-lack of compliance with appointments
-negative and harsh attitudes from providers
-prejudicial treatment causing feelings of judgement
-male-dominated help programs
-prisons are easy places to access drugs
Woman-Centered care for PSUP
-slips in recovery are seen as learning opportunities and normalized in the transition process
-openness and acceptance of providers encouraging woman to disclose drug use
-respecting choices and offering support
-encouraging women to report to social services themselves
Role of Social Services
-usually are viewed as negative
-negative views can extend to those from nurses and government
-Stories of horrific child apprehensions by aggressive case workers do not endear women with PSUP
-Women who contact SS themselves often feel more positive and experience more control through their proactive consultation
-For women who have had negative past experiences, anxiety may always be present
Social Services
-can be a major support for women, especially those in need of housing, financial assistance and counseling
-Often caught between doing what is best for the woman and following agency guidelines
-If they do not follow guidelines and something happens to the infant/child they are directly in the line of fire
-
Risks of Opioid Dependence
-Opioid withdrawal can trigger uterine contractions leading to an increased risk of spontaneous abortion (miscarriage) in the first trimester, premature labor in the third trimester
-Maternal complications include pre-eclampsia (pregnancy related high blood pressure) and antenatal bleeding
-Heroin can lead to intrauterine growth restriction
What is Dependence
-Tolerance: no longer gets 'high'
-Frightened of withdrawal
-Significant amount of time devoted getting and taking the drug
-Little time or energy for family, friends
-Survival sex (using sex to pay for her drugs
Tolerance to Opioids
-Most women on prescription opioids don't develop dependence - may stay on the same dose for years
-Neurobehavioral adaptation
-Tolerance to analgesic effects develops slowly
-Rapid tolerance to psychoactive effects
-Highly tolerant women can function on massive amounts of opioids
-Tolerance disappears within days (resuming usual dose after a period of abstinence can be lethal)
Psychological Opioid Withdrawal
-Intense anxiety, agitation
-Intense craving for opiates
-Restlessness, insomnia, fatigue
Physical opioid withdrawal
-In pregnancy: uterine irritability
-Muscle aches, flu-like symptoms "dope sick"
-Nausea, vomiting, cramps, diarrhea
-Sweating, goose bumps
-Dilated pupils
-Runny eyes
Risk of opioid dependence in pregnancy
Opioid dependence during pregnancy has been associated with numerous adverse fetal outcomes secondary to the drug itself, as well as, secondary to poor nutrition and inadequate prenatal care
Poor neonatal outcomes of opioid dependence
-Intrauterine growth restriction
-Lower birth weight
-Preterm prelabor rupture of membranes
Opioid Tapering during Pregnancy
-Some OB providers taper patients off opioids to avoid neonatal abstinence syndrome
-Slow tapering may be attempted in non-addicted patients on low to moderate doses
-best to start opioid-addicted pregnant patients on buprenorphine +/- naloxone or methadone
Why is opioid tapering rarely successful in addicted patients?
-They usually relapse because they can't tolerate the severe withdrawal symptoms that accompany tapering
-Relapse during pregnancy can have catastrophic consequences - child apprehension, family break-up, etc.
Methadone therapy in pregnancy
-Methadone is a long-acting opioid with a half-life of 24- to-36 hours
-Can be initiated in hospital or in an outpatient setting
-Women on methadone are less likely to experience withdrawal symptoms and drug cravings
-Methadone-maintained pregnancies have reduced obstetrical complications and improved outcomes
Buprenorphine and Pregnancy
-safe in pregnancy
-moms who take it during pregnancy had higher birthweight babies and less exposure to marijuana than patients taking other opioids during pregnancy
-associated with good maternal outcomes, and shorter and milder neonatal abstinence syndrome than methadone
-literature around safety of Buprenorphine/naloxone is still early
-Pregnant patients who do not get adequate relief of cravings and withdrawal from buprenorphine should be switched to methadone
Neonatal withdrawal
-Not related to methadone/buprenorphine/naloxone dose
-Occurs 2-4 days after birth, can last a couple of weeks
-Poor feeding, irritability, mottled skin, crying, jitteriness, inability to gain weight
-Comfort measures usually sufficient, morphine may be necessary
-Remember to look for other serious problems: sepsis, hypoglycemia, etc. in an unstable infant - do not assume signs due to neonatal withdrawal
-Suggest neonatology/pediatrics consult in hospital with at least Level II capabilities if infant is unstable
Breastfeeding and PSUP
-Safe to breastfeed on methadone/buprenorphine/naloxone regardless of dose
-Ensure close follow-up of mother and baby
-Rooming-in is the best option to encourage attachment and good parenting
-If baby needs to go to the nursery, parents should accompany and be encouraged to hold and cuddle infant 24/7 if possible
Postpartum care and PSUP
-Assess social support, ensure community supports in place before discharge
-Provide ongoing care for substance use/Continue to provide care to women
-Ensure safety, food, shelter, baby supplies
-Regular ongoing support by stable team of caregivers is best predictor of good outcome
-Link parents to community supports and parenting resources
Caring Theory
knowing, being with, doing for, enabling, maintaining belief
Types of Perinatal loss
-Miscarriage
-Fetal death (Early, Late, Stillbirth)
-Death of live-born infant (Early neonatal death, Late neonatal death, Infant death)
-serious fetal diagnosis
-pregnancy termination (TOPFA, selective reduction)
Perinatal care settings where nurses encounter loss
Perinatal palliative care
Miles's Model of Parental Grief Responses
-acute distress
-intense grief
-reorganization
Intense Grief
-guilt
-anger
-resentment
-disorganization
-irritability
-physical symptoms include fatigue, headaches, dizziness and aches and pains
Reorganization
-better able to function at home and work
-a return of self-esteem and confidence
-can cope with new challenges
-recovery is not an appropriate term because Grief related perinatal loss can continue for life
Grandparents and Grief
Complicated by emotional pain witnessing and feeling immense grief of their child
siblings and Grief
Young children respond more to the reactions of parents.
What is the most important part of helping women with the aftermath of loss
Simple, unambiguous, and consistent language is crucial
Holding the fetus after death
-Research evidence supports the importance of parents' seeing or holding their fetus or infant, but they should never be made to feel they "should" see or hold their baby.
-explain what to expect
-treat the baby as if it was a live baby
What to say to bereaved parents
- "I'm sad for you"
- "How are you doing with all of this?"
- "This must be hard for you"
- "What can I do for you?"
- "I'm sorry"
- "I'm here, and I want to listen"
What not to say to bereaved parents
-"God had a purpose for her."
-"Be thankful you have another child."
-"The living must go on."
-"I know how you feel."
-"It's God's will."
-"You have to keep on going for her sake."
-"You're young; you can have others."
-"We'll see you back here next year, and you'll be happier."
-"Now you have an angel in heaven."
-"This happened for the best."
-"Better for this to happen now, before you knew the baby."
-"There was something wrong with the baby anyway."
Helping parents decide to do with the body of their infant
-Autopsy
-Personal, cultural, and religious views
-Organ donation
-Spiritual rituals
-Respectful disposition of the body
-Memorial or funeral service
-Do not rush the family into making decisions
Helping the bereaved parents acknowledge and express their feelings
-Validate the experience and feelings of the parents.
-Encourage them to tell their stories.
Listen with care.
-Offer helpful versus unhelpful responses.
-Allot enough time to engage with them without being rushed.
Helping the bereaved family understand differing responses to loss
-Reassure them that their responses are normal.
-Prepare them for grief's potentially lengthy process.
-Educate about the grief process, including the physical, social, and emotional responses of individuals and families.
-Recognize that there my be incongruent grieving in couples.
Meeting the physical needs of the bereaved mother in the postpartum period
-The mother should decide if she wants to remain on the maternity unit or to move to another unit.
-Physical needs are the same as those of any woman who has given birth.
-Lactation issues
-Postpartum care instructions
Addressing cultural and spiritual needs of parents
-The nurse must be sensitive to the responses and needs of parents from various cultural backgrounds and religious groups.
-The nurse needs to be aware of his or her own values and beliefs.
-Culture and religious beliefs influence the customs following death.
Providing sensitive discharge and follow-up care for the bereaved family
-Sensitivity about time and manner of discharge from hospital
-Follow-up care
-Finding a perinatal or parent grief support group
-The focus of the group needs to match the parents' needs.
complicated grief
-Also called complicated bereavement, prolonged grief, pathologic grief, or pathologic mourning
-Differs from what is considered normal grief in its duration and the degree to which behavior and emotional state are affected
attachment to the idea of a baby
can begin before pregnancy with many hopes and dreams for the future and can become more pronounced over the course of pregnancy.
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