Maternal Physiologic Changes
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Terms in this set (208)
-Hemostasis achieved by compression of intramyometrial blood vessels
-Hormone oxytocin strengthens & coordinates uterine contractions
*"Afterpains ": contraction after delivery -> help to stop bleeding
*Placental site: ensure it's fully delivered
*Pelvic rest: nothing per vagina for 6 wks after delivery
*Soft immediately after birth
*Within 2 to 3 postpartum days it has shortened, become firm, and regained form
*Ectocervix (outer portion of cervix) appears bruised and has small lacerations—optimal conditions to develop infections
*Cervical os, dilated to 10 cm during labor, closes gradually: a slit may remain can indicate a previous pregnancy
*Estrogen deprivation responsible for thinness of vaginal mucosa and absence of rugae (especially if breastfeeding!)
*Vagina gradually returns to prepregnancy size by 6 to 10 weeks after childbirth
*Thickening of vaginal mucosa occurs with return of ovarian function
*Dryness and coital discomfort, dyspareunia, may persist until return of ovarian function
*Expulsion of placenta results in dramatic decreases of placental-produced hormones
*Decreases in chorionic somatomammotropin (hCS), estrogens, cortisol, and placental enzyme insulinase reverse effects of pregnancy: may not need as much insulin so check BG
*Estrogen and progesterone levels drop markedly -> stimulates release of prolactin -> initiates lactation
Pituitary hormones and ovarian function*Lactating and nonlactating women differ in timing of first ovulation and menstruation *70% of nonbreastfeeding mothers menstruate within first 12 weeks *In breastfeeding women return of ovulation depends on breastfeeding patterns *May ovulate before first menstrual cycleUrinary System*Urine components *Postpartal diuresis -Within 12 hours women begin to diurese -Profuse diaphoresis often occurs at night for first 2 to 3 days *Urethra and bladder -Excessive bleeding can occur because of displacement of the uterus if bladder is full (this is a prime patient education point!)Appetite*Most new mothers are very hungry after recovery from analgesia, anesthesia, and fatigue **keep in mind that cesarean patients may have dietary progression similar to a typical surgery patient!!!Bowel evacuation*Spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth *anticipatory guidance and nursing support is important during this time- many patients are fearful about pain with first bowel movement after delivery!!Breastfeeding mothers*Before lactation a yellowish fluid, colostrum, can be expressed from nipples *Tenderness may persist for 48 hours after start of lactation *Nonbreastfeeding mothers *Engorgement resolves spontaneously, and discomfort decreases within 24 to 36 hours *Breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfortBlood volume*Blood volume increase eliminated within first 2 weeks after birth, with return to nonpregnancy values by 6 months after delivery *Readjustments in maternal vasculature after childbirth dramatic and rapidCardiac output*Remains increased for 48 hours after birth *Cardiac output generally returns to normal by 6 weeks after birth *Stroke volume, end-diastolic volume, and systemic vascular resistance remain elevated for 12 weeks after delivery *Vital signs ** PPH/ Infections *Blood components -Hematocrit and hemoglobin (values usually assessed daily) -White blood cell count -Coagulation factors *Varicosities -Total or nearly total regression of varicosities is expected after childbirthNeurologic System*Pregnancy-induced neurologic discomforts abate after birth *Headache requires careful assessment *Postpartum headaches may be caused by gestational hypertension, stress, and leakage of cerebrospinal fluid into extradural space during placement of needle for epidural or spinal anesthesia **nurses must assess patient's pain level often!Musculoskeletal System*Reversal of pregnancy adaptations *Joints are completely stabilized by 6 to 8 weeks after birth *New mother may notice permanent increase in shoe sizeIntegumentary System*Chloasma of pregnancy usually disappears at end of pregnancy *Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth *Stretch marks on breasts, abdomen, and thighs may fade but not disappear *Vascular abnormalities, spider angiomas, palmar erythema, and epulis regress with rapid decline in estrogens *Spider nevi persist indefinitely for some *Abundance of fine hair during pregnancy usually disappears after birth -Coarse or bristly hair that appears during pregnancy usually remainsImmune System*No significant changes in maternal immune system occur during postpartum period *Mother's need for rubella, varicella & Tdap vaccination or for Rho (D) immune globulin for prevention of Rh isoimmunization is determined Don't forget to double-check rubella, varicella and Tdap and Rh factor prior to discharge! *mother is given rubella, varicella and /or Tdap vaccination prior to leaving the hospital *mother is given Rhogam injection prior to leaving the hospitalBubble HeB reasts U terus B owels B ladder L ochia E pisiotomy H oman's sign E motionsNursing Care of the Postpartum Woman*Nurse provides care that focuses on transition to parenting *Woman's physiologic recovery *Psychologic well-being *Ability to care for herself and her new baby *Needs of other family members include strategies in plan of care to assist family in adjusting to babyNursing Care Management: Physical Needs*Couplet or mother-baby care -Infant security *Prevention of infection *Prevention of excessive bleeding *Maintenance of uterine tone *Prevention of bladder distentionPlanning Future Pregnancies (vaccines)Rubella & Varicella vaccination *If woman is not immune, vaccination is recommended *Must use contraception for 1 month Tdap *Administer 1 dose of Tdap vaccine to pregnant women during each pregnancy (preferred during 27 to 36 weeks' gestation) regardless of interval since prior Td or Tdap vaccination. Rh Isoimmunization *Rh immune globulin should be given within 72 hours for R-negative women who deliver an Rh-positive infant **Educate patient about ovulation, resuming sexuality and future family planning!Nursing Care Management—Psychosocial Needs-Impact of birth experience -Maternal self-image -Adaptation to parenthood and parent-infant interactions -Family structure and functioning -Impact of cultural diversityDischarge Teaching (post pregnancy)*Self-management and signs of complications *Sexual activity/contraception *Prescribed medications *Routine mother and baby checkups *Dealing with activities of daily living at home *Dealing with visitors *Follow-up after discharge -Home visits -Telephone follow-up -Warm lines -Support groups -Referral to community resourcesDischarge: Before 24 Hours and After 48 Hours (post pregnancy)*Terms for decreasing length of stay of mothers and newborns after low risk birth -Early postpartum discharge -Shortened hospital stay -1-day maternity stay *Laws relating to discharge -Newborns' and mothers' Health Protection Act of 1996 -Advantages and disadvantages to early postpartum dischargePostpartum Hemorrhage definition-Definition and incidence ›PPH traditionally defined as loss of more than: -500 ml of blood after vaginal birth -1000 ml after cesarean birth ›Cause of maternal morbidity and mortality ›Life-threatening with little warning ›Often unrecognized until profound symptomsHemorrhage saturation amount-Peri pad (just middle): 100cc -Peri pad: 300cc -chux pad- 200cc -bed: 1000ccPostpartum Hemorrhage RF›Uterine atony (soft uterus) -Marked hypotonia of uterus (80%) ›Lacerations of genital tract (cx): cervix or vagina ›Hematomas ›Excessive Pitocin use (high dose in labor leads to less reaction during PP)/ Multiples/ High Parity ›Retained placenta: a piece stays inside -Nonadherent retained placenta -Adherent retained placentaInversion of uterus-placenta doesn't detach from the uterus ›Turning inside out of uterus ›Potentially life threatening ›1 in 2500 births -OB emergency that needs to be fixedSubinvolution of uterus-Uterus doesn't do it's job, it doesn't get smaller. It stays bulky and semi firm ›Late postpartum bleeding ›Prolonged lochial discharge and irregular bleeding -dx: with ultrasound -lining may have retained placenta -tx: D&C to get the pieces outPostpartum Hemorrhage assessment›Early recognition is critical!!!! -Patient may not be sx until a loss of 30% ›First step is evaluation of contractility of uterus- MASSAGE ›Firm massage of fundus: causes uterus to contract ›Check Bladder: empty bladder so they're not competing for space ›Vital Signs: hypovolemia, tachycardia, O2 sat low ›Administer intravenous fluids and medication to manage bleedingQuantification vs Visual Estimation hemorrhage›Underestimated up to 30% ›H/H Equilibrium -Hemo 1-1.5g/ Crit 3 pt= 500 ml EBL Example- Hematocrit- 38% to 32%- 1,000ml EBL *EBL: commutative overtime›Hypotonic uterussoft and boggy uterus -want it to clamp up and contract›Bleeding with a contracted uterus-1st fundal massage and the uterus is bleeding -check for cervical laceration or other source of bleeding -possible hematoma if laceration not foundHemorrhagic (Hypovolemic) Shock-Medical management ›Massage Uterus ›Emplty bladder ›IV fluids ›MD notification ›Meds- Pitocin, Methergine (CI: cardio condition), Hemabate (CI: asthma), citotec (in rectum to make uterus contract) ›CBC, T&C, Coag: STAT ›Pulse ox ›Surgical options- tampanod, D&C, hysterectomy if bleeding doesn't stop -Nursing interventions -Fluid or blood replacement therapy *** OB Tool kitCoagulopathies•Idiopathic thrombocytopenic purpura- autoimmune (tends to be servere (30k-40k), tx: steroids •Gestational Thrombocytopenia •Thrombophlebitis: plates under 150k •Pulmonary Embolism: SOB, HoTN •Septic Pelvis Thrombophlebitis: blood clot forms in the gap of the pelvis (severe pain, fever) •von Willebrand's disease—type of hemophilia •Disseminated intravascular coagulation •Pathologic clotting •Correction of underlying cause: -Removal of fetus -Treatment for infection -Preeclampsia or eclampsia -Removal of placental abruptionThromboembolic Disease-Results from blood clot caused by inflammation or partial obstruction of vessel -Incidence and etiology ›Venous stasis ›Hypercoagulation Clinical manifestations Medical management Nursing interventionsPostpartum Infections•Puerperal sepsis: any infection of genital canal within 28 days after abortion or birth •Most common infecting agents are numerous streptococcal and anaerobic organisms •Endometritis: infection in the uterus (edu: early ID) •Wound infections: lacerations •Urinary tract infections •Mastitis •chorio: fever during labor and after labor (abx 24hrs)Endometritis›100.4 on 2 occasions 6 hrs apart ›1-3 % of births ›Risks: lon labor, PPROM, C/s, high EBL ›Assessment- S/sx ›Treatment- Amp/Gent until afebrile 24hrsInfant at Risk-Birth trauma -Maternal substance abuse -Infection -Congenital anomaliesBirth Injuries■Injury sustained during labor and birth ■Birth injuries may be avoidable -Ultrasonography allows antepartum diagnosis of macrosomia, hydrocephalus, and unusual presentations -Elective cesarean birth chosen for some pregnancies to prevent significant birth injury ■Small percentage of significant birth injuries are unavoidable despite skilled and competent obstetric care -Difficult or prolonged labor -Abnormal presentation ■Some injuries cannot be anticipated until the circumstances are encountered during childbirthBirth Injuries RN-Skeletal injuries -Peripheral nervous system injuries ■Erb-Duchenne paralysis (Erb palsy) ■Facial nerve paralysis ■Phrenic nerve paralysis -Neurologic injuriesNeonatal Infections Sepsis-Patterns ■Early onset or congenital ■Nosocomial infection - late onset -Septicemia ■Pneumonia ■Bacterial meningitis ■Gastroenteritis is sporadicNeonatal Infections Sepsis RN care-Prenatal risk factors -Perinatal events -Signs of neonatal sepsis -Lab studies -Treatment -AssessmentMaternal Infections (TORCH)-Toxoplasmosis -Other ■Hepatitis B ■HIV ■Parvovirus ■West Nile -Rubella -Cytomegalovirus -Herpes simplex virusDrug exposed infants■Drug addiction -Narcotics -Illicit substances -Heroin -Methadone -Other drugs ■Smoking ■Alcohol abuseNeonatal abstinence syndrome (NAS)-A set of behaviors exhibited by infants who were exposed to narcotics in utero -55% to 90% of these infants experience withdrawal -Early identification essential ■Presenting symptoms ■Toxicology screeningNeonatal abstinence syndrome (NAS) RN care-Neonatal abstinence scoring system ■Finnegan tool -Neonatal intensive care unit network neurobehavioral scale (NNNS) -Symptoms -Treatment modalitiesBlood incompatibility (isoimmunization)-Rh incompatibility ■Only Rh-positive offspring of Rh-negative mother are at risk ■If fetus is Rh positive and mother Rh negative, mother forms antibodies against fetal blood cellsABO incompatibility-Occurs if fetal blood type is A, B, or AB, and maternal type is O -Incompatibility arises because naturally occurring anti-A and anti-B antibodies are transferred across placenta to fetus -Exchange transfusions required occasionally Prevention: -Administration of RhIG, human gamma globulin -Intrauterine transfusions -Exchange transfusions -Treatment of jaundiceInfants of Diabetic Mothers■Characteristic appearance: -Macrosomia -Increased risk for birth injuries -Increase in congenital anomalies ■Nursing care management: -Adequate thermoregulation -Carbohydrate feedings as appropriate -Serum glucose levelsThe High-Risk Newborn■High-risk neonate is a newborn regardless of gestational age or birth weight has a greater chance of morbidity and mortality ■Encompasses the period from viability (23 weeks gestation) to 28 days after birthCare of the High-Risk Newborn and Family■Assessment ■Respiratory support ■Thermoregulation: -Thermal stability -Neutral thermal environment -Incubator -Skin to skin (kangaroo care) ■Protection from infection -Standard precautions ■Hydration ■Nutrition -Breastfeeding provides optimal nutrients -Enteral feedings with mother's milk -Gavage feeding -Nipple feeding ■Energy conservation ■Skin care ■Developmental outcomes -Approach behaviors ■Family support and involvement ■Facilitating parent infant relationships -Anticipatory grief ■Discharge planning and home carePreterm Infant■Infants born before 37 weeks gestation ■Immaturity of most organ systems ■Actual cause unknown ■Distinct characteristics -Small, scrawny -Large head -Translucent skin -LanugoLate Preterm Infant■Born between 34 and 36 6/7 weeks of gestation ■Referred to as late preterm rather than near term ■Higher risk for problems related to: -Thermoregulation -Hypoglycemia -Hyperbilirubinemia -Sepsis -Respiratory functionComplications of Preterm Birth■Respiratory distress syndrome -Hyaline membrane disease -Surfactant -Absence of the alveolar stability -Prolonged hypoxemia ■Oxygen therapy -Endotracheal tube -Continuous positive airway pressure (CPAP)Associated Complications with preterm■Pneumothorax ■Bronchopulmonary dysplasia -Chronic lung disease ■Retinopathy of prematurity -Inhaled nitrous oxide (INO) -Extracorporeal membrane oxygenation (ECMO) ■Necrotizing enterocolitisPostterm Infant■Gestation that extends beyond 42 weeks -3.5% to 15% of pregnancies -Cause of delayed labor is unknown -Placental dysfunction -Significant increase in fetal and neonatal mortality -Current fetal distress -Increased risk for birth injuriesNewborn Screening for Disease■Inborn errors of metabolism -Congenital hypothyroidism -Phenylketonuria ■Use of Guthrie paper -Galactosemia ■Genetic evaluation and counselingMost common major congenital anomalies:-Cleft lip and palate -Esophageal atresia, tracheoesophageal fistula -Omphalocele, gastroschisis -Congenital cardiac defects -Congenital diaphragmatic hernia -Neural tube defects, myelomeningocele -Developmental dysplasia of the hip, clubfoot -Hypospadias, disorders of sexual development, bladder exstrophyBenefits of breastfeeding: Mother•Rapid uterine involution •Early return to pre-pregnancy weight (additional 250-500 calorie expenditure per day) •Decreased risk of ovarian cancer •Decreased risk of breast cancer •Decreased risk of type II diabetes •Increased bone densityBenefits of breastfeeding: BABY§Decreased incidence of many infectious diseases including: -Bacteremia -Diarrhea -Respiratory infections -Necrotizing enterocolitis -Middle ear infections -Urinary tract infections §21% lower post-neonatal infant mortality rate in U.S. §Provides pain relief for infants during or after procedures §Higher IQ scores §Decreases length of hospitalization time for preterm infantsParts involved in breastfeeding•Alveoli - grapelike clusters of milk-producing cells •Milk Ducts - intricate system of ducts that transport milk from alveoli to the nipple •Nipple - delivery system for milk •Areola - dark circle that surrounds the nipple •Montgomery Glands -secrete a lubricating and sterilizing substance onto the areola and nippleProlactin effect on breast feeding-triggers synthesis and secretion of colostrum and milk during pregnancy and after birth -source: anterior pituitary glandEstrogen and progesterone effect on breast feeding-triggers synthesis and secretion of colostrum during pregnancy -source: anterior pituitaryOxytocin-triggers milk ejection from alveoli to nipple -source: anterior pituitary glandWhat do babies need?•Energy •Carbohydrates •Fat •Protein •Vitamins (D & K) •MineralsWhat is breastmilk?•Colostrum - a clear, yellowish fluid (day 1 to 3) -More concentrated than mature ilk -Extremely rich in immune globulins -Higher concentration of protein and minerals -Less fat than mature milk •Mature Milk - Composition changes during each feeding -Lower fat "foremilk" changes to higher fat "hindmilk" •Milk production increases as the baby grows -Growth spurts occur at 10 days, 3 weeks, 6 weeks, 3 months, and 6 monthsHow long should babies breastfeEd?-The American Academy of Pediatrics recommends that mothers breastfeed their infants for at least one year, or as long as mutually desired by mother and infant. -The World Health Organization recommends that infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond. -The American Dietetic Association recommends breastfeeding exclusively for the first six months of life, continuing in conjunction with other food at least until the newborn's first birthday.Supporting breastfeeding mothers•Positioning •Latching •Milk ejection or "let-down" •Frequency of feedings •Duration of feedings •Indicators of effective BF •Supplements, bottles, and pacifiersFeedings-Newborn = 8-12 times/day to establish a breastfeeding pattern and optimize the hormone levels. -Most newborn infants feed on average 15-20 minutes each side. -Encourage new mothers to offer both breasts at each feeding. -Start feedings on the breast on which the infant completed the last feeding. -Encourage new mothers to respond to hunger cues even if that means breastfeeding more frequently than every 2-3 hours!Latching-Infant should have wide-open mouth -Point nipple toward infant's nose to facilitate filling infant's mouth with breast tissue -Infant's top and bottom lip should be "flanged outward" -Infant's mouth should cover or -Avoid letting the infant "hang" from the nipple -Break suction by a clean, dry finger between the infant's jaw to avoid "tugging" on the nipplePositioning•Football hold - appropriate for mothers learning to breastfeed or mother's who are post-cesarean section •Cradle hold - traditional breastfeeding position; appropriate after mother has learned to breastfeed and infant has better neck control •Cross-cradle hold - baby is facing mother's stomach similar to cradle hold, but with opposite arm supporting the infant's head •Side-lying position - mother should be positioned in lateral position with infant's body facing her body, with infant's head resting on mother's arm *utilize different hold each time to help reduce pain and also help to ensure they're drinking from a different part of the nipple"How do I know my baby is getting enough milk?"•Most breastfed infants should have 3-4 stool diapers by 4th day of life, and stool should no longer be meconium-like, but yellow in color. •Infant seems content between feeds.Common concerns with breastfeeding-Diet -Engorgement -Sore nipples -Insufficient milk supply -Plugged milk ducts -Mastitis -Follow-up after hospital dischargeDiet for breastfeeding mom•Fish to avoid: Shark, swordfish, king mackerel, and tilefish •Fish and shellfish recommended amounts: -Limit 6 oz per week: albacore tuna, tuna steaks, freshwater tuna -Limit 12 oz per week: any ocean, coastal and other commercial fish (canned tuna) •Nutrients of concern: Vitamin A, B6, D and B12 •Vitamin recommendations: -Calcium -Folic Acid -Iron •Alcohol and caffeineBreastfeeding Complications•Engorgement - swelling of the breast tissue as a result of increased blood and lymph supply •Sore nipples •Thrush - treat mom and baby with anti-fungal!! •Mastitis •Plugged Ducts - stasis of milk in the milk duct; causes "pea-like", painful lump in the breast; common with engorgement; breastfeed more often, and apply warm packs and massage the plugged duct to facilitate clearance. •Breast Abscess •Educate patients to identify and manage challenges!storing breastmilk•Never thaw frozen milk in the microwave! •Do not re-use milk that has been introduced to the baby's mouth. •All unfinished bottle milk must be disposed of. •Thaw frozen breastmilk in a pan of warm water, bottle warmer or refrigerator.storing breastmilk expiration-room temp: 4hrs -fridge: 5-7 days -freezer: 3 months and 6 months in a deep freezerContraception during breastfeeding•Breastfeeding only prevents ovulation if the mother is breastfeeding on schedule (q 2-3 hrs). •Decreased estrogen levels cause vaginal dryness. •Oxytocin is secreted with orgasm.Weaning breastmilk•Gradual weaning is facilitated by substituting a cup or bottle for a breastfeeding little by little •The mid-day feeding is usually the easiest to eliminate. •"Cold turkey" or sudden weaning may lead to breast engorgementFormula Feeding•Amount depends on age and nutritional needs •Wide variety of specialty formulas •Educate parents on preparation •Feed every 4-5 hours initiallyBreastfeeding Contraindications•HIV positive mother •Mother receiving chemo or radiation (until milk is cleared) •Mother using "street drugs" •Infant with classic galactosemia •Mother with untreated tuberculosis •Active herpes lesion on the breastChildbirth Trauma-3rd & 4th Degree Laceration or Episiotomy -Diastasis of Symphysis Pubis: a support belt around the hips to help decrease the pain -Uterine displacement and prolapse ›Posterior displacement, or retroversion ›Retroflexion and anteflexion ›Prolapse a more serious displacement: uterus coming out of the vagina -Urinary incontinence -Cystocele and rectocele -Genital fistulasCystocele and rectocele›Cystocele: protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injured ›Rectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum *Cele: loosen, issues with painful sex, incontinenceGenital fistulas›May result from congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infection types: -Vesicovaginal: between bladder and genital tract -Urethrovaginal: between urethra and vagina -Rectovaginal: between rectum or sigmoid colon and vaginaPostpartum Psychologic Complications-Mental health disorders in postpartum period have implications for mother, newborn, and entire family ›Interfere with attachment to newborn and family integration ›May threaten safety and well-being of mother, newborn, and other childrenBaby Blues›70% of women experience a mild depression or "baby blues" -Last days: usually right after birth; crying and don't know why -Self resolving ›Some women have more serious depression (post partum depression) -Can eventually incapacitate them to point of being unable to care for themselves and their babiesPostpartum depression (without psychotic features)›Begins ~ 2wks and can last 6months or longer (may start see s/sx in 3rd trimester) ›Postpartum depression: an intense and pervasive sadness with severe and labile mood swings ** irritability hallmark sign: pervasive sadness, severe irritability ›Treatment options -Antidepressants (Wellbutrin), anxiolytic agents, and electroconvulsive therapy -Psychotherapy focuses fears and concerns of new responsibilities and roles; monitoring for suicidal or homicidal thoughtsPostpartum Psychosis- (Postpartum depression with psychotic features)›Postpartum psychosis: syndrome characterized by depression, delusions, and thoughts of harming either infant or herself ›Mean onset 2-3wks but can begin within days of delivery ›Psychiatric emergency; may require psychiatric hospitalization ›Antipsychotics and mood stabilizers such as lithium are treatments of choicePP Depression RN care›On postpartum unit ›In home and community ›Referrals ›Providing safety ›Psychiatric hospitalization ›Psychotropic medications ›Other treatments for postpartum depressionLoss and Grief forms-Losses of what was hoped for, dreamed about, and/or planned -Any perception of loss of control during the birthing experience -Birth of child with handicap -Maternal death -Fetal or neonatal deathLoss and Grief RN care-Cluster of painful responses -Overlapping phases in grief process ›Acute distress: Denial ›Intense grief: Guilt/helpless ›Reorganization: Bittersweet grief ›Help mother, father, & siblings actualize their loss ›Help parents with decision making ›Help bereaved to acknowledge & express their feelings ›Normalize grief process and facilitate positive coping ›Meet the physical needs of postpartum bereaved mother (bind breast to stop milk production, Ice or cold showers) ›Create memories for parents to take home ›Cultural and spiritual needs of parents ›Provide culturally sensitive care at and after discharge ›Provide postmortem care respecting parents wishes -Funeral- 20.1wks or born alive must make arrangementsMaternal Death-Rare for woman to die in childbirth -Families are at risk for developing complicated bereavement & altered parenting of surviving baby and other children in family -Emotional toll on nursing and medical staff must be addressed -Leading causes of maternal death: ›Emboli ›Hemorrhage ›Pre-EclCare ManagementBirth Through the First Two Hours•Immediate care after birth -Apgar scoring and initial assessment •Physical assessment- •General appearance- -Vital signs -Baseline measurement of physical growth -Neurologic assessmentAPGAR-activity: 2 (active) 1 (arms and legs flexed) -pulse: 2 (>100) 1 (<100) -grimace: 2 (Sneeze, cough, pulls away) 1 (grimaces) -appearance: 2 (Normal over entire body) 1 (normal except extremities) 0 (cyanotic or pale) -respiration: 2 (good, crying) 1(slow, irregular) *repeat scoring Q5 minutes for 20 minutes if score is less than 7Initial newborn assessmentAirway maintenance -bulb syringe-of mouth and nose-as needed (bulb always with mom) -delee suction-not routinely recommended (deep only when really needed) Temperature Maintenance -drying-while delayed cord clamping in progress -mom's/caregiver's chest-skin to skin -radiant warmer-for stabilization *skin to skin right after birth easier to breast feed; if no initial skin to skin harder to breast feed laterNIPS toolused to assess infant pain; if score above a 3 intervention is neededMonitor for signs and symptoms of respiratory complications•Bradypnea- •Apnea •Tachypnea •Abnormal breath sounds •Respiratory distress •Grunting •Flaring •Retractions •IF ANY OF THESE SYMPTOMS ARE NOTED-ASSESS LUNG SOUNDS!Birth Through the First Two Hours interventions•Airway maintenance •Maintaining body temperatureImmediate interventions with new born•Skin to Skin with Mother/Caregiver •Eye prophylaxis-prevents eye infection/blindness: from mom's with ginharrea (may have a slight delay so they can see breast in order to BF) •Vitamin K prophylaxis-prevents hemorhage RT inability to synthesize Vit K due to their sterile bowel: RF hemorrhage, synthesis starts on day 7 •Promoting parent-infant interaction -Document attachment issues such as not making eye contact/not holding/insensitivity to infant needs and cues of crying -Document teaching of strategies to facilitate bondingNewborn meds•Eye prophylaxis: Mandated by law -Protects against gonorrhea and chlamydia (chlamydia is oral erythromycin) •Vitamin K -To prevent hemorrhagic disease •Hepatitis B Vaccine -Must have consent signed •Parents must sign AMA form if they refuse the 'Eyes & Thighs'Gestational Age Assessment•Ballard Scale •Physical and neuromuscular characteristics •20-44 weeks •If less than 26 weeks within 12 hours, otherwise 96 hrs •Very Subjective Exam •Newborn classification by gestational age and birth weight •AGA - Appropriate for gestational age= =between 10th & 90th % •LGA - Large for gestational age: above 90th percentile -Hypoglycemia protocol!! •SGA - Small for gestational age: below 10th percentile -Hypoglycemia protocol!!Early term infant•37 0/7 weeks to 38 6/7 weeks •Increased Number of infants in this category may be due to elective inductions and cesarean birthsLate preterm infant•34 0/7 weeks to 36 6/7 weeks •The great "imposter": looks and acts term •Respiratory distress, temperature instability, feeding difficulties, hyperbilirubinemiaClassification of newborns by gestational age and weight•Large for gestational age (LGA): -more than 90 percentile for birth weight •Small for gestational age (SGA): -less than 10 percentile for birth weight •Preterm or premature: -born before completion of 37 weeks •Term: -born between beginning of 37 weeks and the end of week 42 of gestations •Early term infant:37 0/7 to 38 6/7 weeks •Late Preterm infant:34 0/7 and 36 6/7 (71% of preterm birth in US) •Postterm: born after completion of week 42 of gestationNormal Range of Vital Signs of Term Newborn•Respirations: 30 to 60 b/min •Heart rate:100 to 160 beat/min, listen for a full minutes •Blood pressure: 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic •Temperature: 36.5 to 37.2 C (97.7 to 98.9 F)Birth trauma•Any physical injury sustained by the newborn during labor and birth •Prolonged labor or precipitous labor •Fetal macrosomia difficult presentation, multiples •Forceps or vacuum deliveries bruising -: RF hemolysis -> RF jaundiceCommon problems in newborns•Pathologic Jaundice: Jaundice occurring within 24 hours •Physiologic Jaundice: Occurs after 24 hours •Head to toe •Transcutaneous monitoring •Serum monitoringHyperbilirubinemiaPrevention is key •Early and frequent breastfeeding •Assessment: -cephalocaudal, proximodistal progression) •Coombs Test-ABO incompatibility-mom/baby with different blood/Rh types -Indirect Coombs-performed on mother prior to birth -Direct Coombs-performed on infant after birth •Bilirubin: greater than 13 to 15 mg/dL Phototherapy: effectiveness related to distance bw baby and light; improvements seen 4-6hrs level should decrease, w/in 24hr decrease by 30-40% •Bank light •LED •Blanket -can be out of the light for 20min Q3hrs Exchange transfusion •Bilirubin encephalopathy/kernicterus (bilirubin deposits in brain): phototherapy no longer effective Increased RF: • <38wk, BF only, sibling had jaundice, ABO incapatibility, hemolytic disorder, E. indian descent •At RF rebound, blood drawn 12hrs after taken out under lightHypoglycemia and HypoCaHypoglycemia: •Maternal source of glucose is cut off •INITIAL Glucose level less than 45 (can be as low as 30 when cord is cut) •Signs and symptoms: tremors, diaphoretic, agitated •Dr order not needed to check their blood level Hypocalcemia: is mom is DM or on anticonvulsants •Serum calcium <7mg/dL •Early-VS-late onset -early: within first 3 days and asymptomatic (usually self limiting) -late: severe, day 5-10; jittery, seizure, apnea *IV gluconate givenNewborn screen•All states have programs for newborn screening, but they vary by state •Test for inborn errors of metabolism •Helps prevent further delays and morbidities •ensure baby has adequate feeds before tests •test repeated at 2 wks to see if results have improved or normalizedLaboratory and diagnostic tests for newborns•Universal newborn screening & Inborn errors of metabolism-done at time of transfer to hospital if a newborn or at 24-36 hours of life •Genetic diseases •Critical congenital heart disease-prior to discharge or PRN •Newborn hearing screening-prior to discharge -Don't pass initial will test again in hospital -If fail again more testing is neededScreen for Congenital Heart Defects•Pulse oximetry screening on all newborns before hospital discharge -rt hand used and a pass is 95% or higher -any foot and less than a 3% difference (if they fail test repeated in 3hrs) -This cannot detect all cases of CHD. -A negative result does not exclude the possibility that a newborn has a congenital heart defect. •Blood pressure in all four extremities if auscultate a murmur. -If upper extremities are more than 20 mm Hg or greater than lower extremities may indicate coarctation of the aortaSudden unexpected postnatal collapse-sudden resp/cardio failure that happens first week of life -related to entrapment or suffocationCircumcision•Recommendations: not universally recommended, it's an aesthetic procedure •Parental decisions •Procedure: no bottle feed before surgery, needs vit K shot •Care of the newly circumcised infant -water to cleanse area -assess for bleeding: larger than quarter size is too much, apply pressure for 5 minutes and assess -petroleum jelly when changing diapers (CI for bell) -assess for infection -no emersion in tub until healed and umbilical cord healed •Personal parental choice •Requires signed consent •Performed prior to discharge from hospital •NPO 2-3 hours prior •Gomco Clamp vs Plastibell (no ointment bc can slip and strangle penis) vs Mogen •Positioning and comfort with Sucrose •Care of the circumcision •Vitamin K given???? •Patient TeachingBathing neonate•Once the temperature has stabilized >98.2 F or 36.8 C and the infant is at least 1 hour of age-know hospital policy!! •HIV+, HEP B+, COVID+-immediate after delivery do bath!! (no skin to skin, bath ASAP) •A complete sponge bath should be given at least 2 hours after birth (under radiant warmer) •Use gloves with bathing to avoid exposure to body secretions •For late preterm infants (34 - 36 6/7 weeks of gestation) thermal stability is reached approximately 2-4 hours after birth is recommendedBathing Environment:•Have all equipment ready •Never leave baby alone •Room should be warm: 79-81 F (26-27 C) •Bath water 100 F to <104 F (38 to <40 C)(Turn down water heater to 49 C or 120.2 F) •Avoid drafts or chilling of the newborn •Expose only body part being bathed •Dry the newborn thoroughly to prevent chilling and heat loss •Keep the duration of the bath as short as possible (5-10 minutes)Bathing action•Begin with eyes (use only water) inner canthus to outer canthus and use different section of wash cloth for each eye •Face (use only water) •Each area of the newborn's body should be washed, rinsed, and dried with no soap left on the skin. •Wrap the newborn in a towel, and swaddle using football hold to shampoo hair. Rinse shampoo from newborn's head and dry to avoid chilling •In male newborns, cleanse an uncircumcised penis with soap and water and rinse the penis. The foreskin should not be forced back or constriction may result. •In female newborns, wash the vulva by wiping from front to back to prevent contamination of the vagina or urethra from rectal bacteriaDiapering•To avoid diaper rash, the newborn's diaper area should be kept clean and dry. •Diapers should be changed frequently, and the perineal area cleaned with warm water or wipes and dried thoroughly to prevent skin breakdown. •No baby powder to perineal arealCord Care•Before discharge, the cord clamp is removed •Prevent cord infection by keeping the cord dry, and keep the top of the diaper folded underneath it •Sponge baths are given until the cord falls off (10 to 14 days after birth) •Cord infection can result if cord is not kept clean and dry •Monitor for symptoms of a cord that is moist and red, has a foul odor, or has purulent drainage. •Notify the provider immediately if findings of cord infections are presentCar Seat Safety•Use an approved rear-facing care seat in the back seat •Preferably in the middle (away form air bags and side impact) •Keep infants in rear-facing car seats until age 2. Do not use a used or second-hand car seatCar seat test-<2500g, less than 37wks, and on O2 for sustained period of time will need to do the car seat challenge -fail: <85% SpO2, distressed, tachypneicSigns of Illness in neonate•Fever (100.4 degrees F)axillary •Hypothermia (below 97.7 degrees F) •Poor feeding •Vomiting: •more than one episode of forceful vomiting or frequent vomiting (over a 6 hr period) •Diarrhea: •Decreased bowel movement •Decreased urinationFirst period of reactivity•Lasts up to 30 minutes after birth •Newborn's heart rate increases to 160 to 180 beats/min -Decreases after 30 minutes to baseline of 100-120 bpm -Respirations have irregular rate of 60-80 breaths/minute -Fine crackles may be auscultated •Grunting, flaring, retracting may be noted and resolve within one hour •Infant is alert and has spontaneous startles, crying, and head movement •Audible bowel sounds, passage of meconiumPeriod of decreased responsiveness•Lasts from 60 to 100 minutes •Infant is pink •Respirations are rapid and shallow/unlabored, up to 60 breaths per minute •Sleeps or has a marked decrease in motor activity •Audible bowel sounds, peristaltic waves may be noted over abdomenSecond period of reactivity•Lasts from 10 minutes to several hours •Occurs between 2 and 8 hours after birth •Brief episodes of tachycardia, tachypnea occur •Meconium passed •Increased muscle tone, changes in skin color, and mucus productionSix Behavioral States of the Newborn•Form a continuum from deep sleep to extreme irritability called sleep-wake states •Each state has specific characteristics & corresponding behaviors -Two deep sleeps: deep sleep and light sleep -Four wake states: drowsy, quiet alert, active alert, crying •Optimal state of arousal=quiet alert state: baby ready to interact -Infants smile, interact, vocalize, move in synchrony with speech, watch parents faces, respond to those talking to them •Infants respond to internal & external environmental factors by controlling sensory input and regulating their sleep-wake statesOther factors influencing behavior of newborns•Gestational age -State modulation=the infants ability to make smooth transitions between states and is essential to their neurobehavioral development; term infants are better modulators RT CNS maturity •Time-since birth -Attempt to become more organized -Time elapsed between feedings -Time of day •Stimuli-responds to animate & inanimate stimuli -Loud noises, bright lights, alarms, other infants crying, tension, the parent •Medication-no conclusive data on effect of maternal analgesia or anesthesia on infantSensory and Perceptual Functioning of the NewbornSensory capabilities to indicate readiness for social interaction & impact of "baby appearance" to rouse feelings of protection & interactionVision•see up to 2.5 feet; clearest=8-12 inches (feeding time) •Infants have a preference for faces; recognize mother's face •Facilitates interaction & bonding by maintaining eye contact •Imitate facial expressions & motions like tongue protrusion •Prefer complex patterns over nonpatterned stimuli •Prefer black & white ?more contrast? By 2-3 months-discriminate colors *erythromycin in eye: baby unable to see so timing is importantHearing•can hear and differentiate among sounds=integral for bonding, possibly more important than vision •Turn toward a sound; attempt to locate the source •Recognizes & responds readily to mother's voice •Shows a preference for high-pitched intonation •Respond to rhythmic sounds-in utero heard mother's heartbeat •Respond to sounds and relax in response to heartbeat stimulator/sounds including lullabies •Hearing screen recommended for all newborns prior to hospital dischargeSmell•highly developed & can discriminate distinct odors •Preterm infants as early as 28 weeks can react to odors •React to strong odors (vinegar, alcohol) by turning heads away •Attracted to sweet smells (mother's milk high in sugar content) •Can differentiate their mother's milk from other lactating women •By fifth day of life recognize mother's smellTaste•particularly oriented to the use of their mouths •Meet nutritional needs for growth •Release tension by sucking •Nonnutritive need to suck: lasts about a year •Early development for circumoral sensation, sucking, taste, muscle activity-preparation for survival •Can distinguish among tastes with preference for sweet solutionsTouch•responsive to touch on all body parts •Face (especially mouth), hands, soles of feet most sensitive •Reflexes elicited by stroking •Response to touch suggests sensory system well prepared to receive and process tactile messages •Touch & motion=essential to normal growth & development •Birth trauma, stress, maternal ingestion of depressant drugs decrease infant's sensitivity to touch/painful stimuliTemperament•individual reactions and variations •Personal characteristics affect selective responses to stimuli in internal & external environments •Some infants are quiet by nature, remain still for long periods of time, little difficulty settling down for feeding •Other infants are more active, constant motion, excited and interested in exploring faces and sounds-tend to need assistance in settling down via swaddling, pacifiers, physical contact, boundariesHabituation•a protective mechanism that allows infant to become accustomed to environmental stimuli •A psychologic & physiologic phenomenon where response to constant or repetitive stimulus is decreased (shining light in eyes elicits a startle first 2-3 times, then eventually ceases to respond) •Allows infant to select stimuli that promote continued learning about social world and to avoid overstimulation •Intrauterine environment seems to have prepped infant to be especially responsive to human voices, soft lights & sounds, sweet tastes •Newborn quickly learns sounds in home environment •Selective responses indicate cerebral organization capable of memory, making choices •Ability to habituate depends on state of consciousness, hunger, fatigue, & temperament which in turn affect consoloability, cuddliness, irritability, & cryingConsolability•varies among infants •When crying, many infants initiate one of several ways to reduce stress •Sucking, hand-to-mouth movements, being alert to voices/noises/visual stimuli •Some consoled only when held, swaddled, rocked, suckingCuddliness•important to parents to gauge their ability to care for infant based on infant's responses to their actions •Degree to which newborns relax, mold into person holding them varies; some infants resist, thrash, stiffen; other infants relax & mold •Less extreme behavior noted in passive infants when held and moldIrritability•some newborns cry longer/harder than other infants •For some infants, their threshold seems low •Some easily upset by unusual noises, hunger, wetness, new experiences=respond intensely •Infants with high sensory threshold require great deal more stimulation/variation to reach active, alert stateCrying•the infant's language to communicate its needs •Can signal hunger, discomfort, pain, desire for attention, fussiness •May cry in response to environmental stimuli (cold, overstimulation, being held by multiple persons) ***•Responsiveness of care given to crying creates trust as infant learns to associate caregiver with comfort and meeting needs •Amount/tone of crying vary based on gestational age, weight, and reason for cry (hunger/pain) •High-pitched cry can be sign of neurological disorder •Some mothers can distinguish/decode their infants cries •Breastfeeding mother's respond physiologically by "milk let-down," and some even "let-down" to the cry of other infants •Duration of crying varies in every infant (minutes to hours) ***•Amount of crying peaks in second month then decreases •Diurnal phenomenon of crying in evening hours (bewitching hours): usually stops around 6 monthsRespiratory system•Initiation of effective breathing=most critical event -Initiation of respiration is related to chemical, thermal, mechanical and sensory factors: the process of dressing, cleaning can cause this -Clamping the cord=rise in BP=increases circulation and lung perfusion •Signs of respiratory distress: grunting, flaring, retractions; often accompanied with low BP, temp instability, hypoglycemia, acidosis, signs of cardiac issues •Central cyanosis=lips & mucous membranes are blue (circumoral cyanosis)=late sign of distress with significant hypoxemia *grunting: push air against vocal cords and push out alveolar to allow breathing; creates own CPAP indication that they may need to be put on CPAPCommon respiratory complications•RDS: surfactant given to baby to help them breath to prevent alveolar collapse; usually corrects on own, but if 3 days pass without improvement surfactant is given •Meconium aspiration: don't suction deep bc it can push it down •Pneumonia •Persistent pulmonary hypertension of the newborn (PPHN): xray and echo used to dx; decrease perfusion to lungs, cyanosis and low O2 stat and BP •TTN-usually resolved 24-48 hours: transient tachypneic of newborn; 7-10 days and usually self resolved; IV fluids and O2Cardiovascular system•Heart rate range=120-160 bpm (brady<80; tachy>160) •heart sounds PMI=4th intercostal space and to left of midclavicular line; often visible and easily palpable=called precordial activity; S1=1st sound and is louder and duller than S2; S3 & S4 are not audible; most murmurs resolve without intervention; murmurs in the presence of poor feedings, tachypnea, apnea, pallor, cyanosis=evaluate and report •Blood pressure: systolic range 60-80; diastolic range 40-50; MAP should be equal to gestation!! •Delayed cord clamping (DCC) beneficial RT blood volume expansion via placental transfusion by as much as 100cc and increased BP, reduced intraventricular hemorrhage & necrotizing enterocolits (NEC)Signs of risk for cardiovascular problems•Persistent tachycardia >160bpm can be RT anemia, hypovolemia, hyperthermia, sepsis •Persistent bradycardia <80bpm can be RT congenital heart block or hypoxemia •Unequal/absent/bounding pulses with decreased or increased BP can indicate cardiovascular issues •Pallor=may be RT anemia, marked peripheral vasoconstriction rt asphyxia or sepsis •Cyanosis with/without increased work of breathing=may be RT cardiac or respiratory problems •Jaundice may be RT ABO/RH incompatibilityHeart defects•Most serious-tetralogy of Fallot with sx of dyspnea, cyanosis, hypoxia (Tet babies=known as Squatters as a compensatory mechanism to increase vascular resistance to diminish the right to left shunting of blood and increase pulmonary blood flow) •Ventricular septal defects often less serious and asymptomatic •Maternal ingestion of drugs, rubella illness, diabetes associated with heart defectsCardio drugs-Prostaglandin E: prevent ductus arterousus from closing or to open it if it closed -Indomethacin: used to close ductus arterious since it didn't close on it's ownHematopoietic system•In utero-extra red blood cells are needed of O2 transport and higher level at birth= 4.6-5.2 million/mm3; hemoglobin= 14-24 g/dl •Polycythemia= hct>65%-can be RT DCC, maternal diabetes/HTN, and IUGR •Platelets similar to adults=150,000-300,000/mm3 •Blood groups-genetically predetermined; watch for RH/ABO incompatibility and jaundice •Leukocytes-initially high WBC=9,000-30,000mm3, decreases rapidly •Infants prone to infection=neutrophils have limited ability to recognize and fight foreign protein; increase in neutrophils can signal sepsis; other causes of neutrophilia RT meconium aspiration, maternal HTN, asymptomatic hypoglycemia, maternal fever)Thermogenic system***•Thermal stability=critical for survival after establishing respiratory & effective extrauterine circulation •At risk of heat loss RT thin layer of subcutaneous fat & blood vessels close to skin's surface & RT larger BSA; x4 types •Convection-flow of heat from body surface to cooler ambient air •Radiation-loss of heat from body surface to cooler solid surface NOT in direct contact but close proximity •Evaporation-loss of heat when liquid converted to vapor=insensible heat loss=MOST common cause of heat loss in first few days of life=completely dry infant! •Conduction-loss of heat from body surface to cooler surfaces in DIRECT contact ie. Place under radiant warmer or place protect cover on scales/surfacesHypothermia & Cold stress•Temperature drop=vasoconstriction to conserve heat •May appear pale or mottled •Skin= cool to touch •If uncorrected, progresses to cold stress •Cold stress=increases basal metabolic rate & physiologic demands with subsequent increased respiratory rate in response to need for O2 •O2 consumption & energy are diverted from maintaining brain & cardiac function & growth to survival=anaerobic glycolysis, metabolic acidosis, respiratory acidosis, hypoglycemia *can lead to deathThermogenesis•in response to cold, infant attempts to generate heat via flexion of body- to diminish body surface & guard against heat loss; increasing muscle activity, crying, constricting peripheral blood vessels •Vasoconstriction=increased O2 and glucose consumption RT increased cellular metabolic activity in brain, heart & liver!! Check to see if skin is cool to touchHyperthermia•not as common-if increased temp is noted-act! •Temp >99.5F requires action (investigate & act, unswaddle, phototherapy, sunlight, excessive clothing, decrease radiant warmer/isolette temp, check ambient room temp=rule out reasons) •Can be sign of sepsis •Clinical appearance may give clues to cause •Infant assumes posture of extension to reduce heat: baby's stretching •Infant with sepsis often acts irritable, stressed, skin vessels constricted, pallor, hands/feet are cool •Hyperthermia develops more rapidly in infants than adults RT larger surface area; sweat glands do not function well •Can cause neurologic injury including risk of seizures, heat exhaustion •Severe case=heat stroke/deathRenal system@ term, kidneys occupy large portion of posterior abdominal wall; in infants-almost all palpable masses are renal in origin; bladder lies close to anterior abdominal wall & is BOTH an abdominal & pelvic organ •Bladder capacity-holds about 40cc urine (full-term infant) •Voiding •First few days excrete 15-60cc/kg/day urine-depending on intake •Output gradually increases over first month •Frequency varies 2-6 times per day initially; then 6-8 times thereafter •Should be straw-colored, odorless •Recording voids=important •No voiding within 24 hours=assess intake, bladder distention, restlessness, discomfort=no circumcision performed unless infant has voided! *may need to assess how they're BF bc may not be effectiveSpecific gravity•limited capacity to concentrate urine until about 3 months=low specific gravity <1.004 •After first void, urine can appear cloudy RT mucus with higher specific gravity which decreases as fluid intake increases •Pink-tinged urine=uric acid crystals AKA "brick dust"=normal finding in first week of life with breastfeeding infants=sign of dehydration/inadequate intakeWeight•Weight loss via urine, feces, lungs, increased metabolic rate, limited intact can account for 5-10% of initial loss birth weight in first 3-5 days •Excessive weight loss RT feeding issues, NPO status •Birthweight regained by 10-14 days depending on feeding method *Only BF may take longer to get to birth wt *if mom was on opioids on last trimester, baby on 5 day hospital stay to observe withdraw, wt loss due to irritability and diarrhea after feedingFluid and electrolyte balancein term infant about 75% of body weight=total body water (extracellular & intracellular) •Reduction of extracellular fluid RT diuresis in first few days •Initial weight loss RT extracellular water loss Daily fluid requirements for neonate >1500g •60-80ml/kg for first 2 days of life •100-150ml/kg/day for days 3-7 of life •120-180ml/kg/day for days 8-30 of life Glomerular Filtration Rate (GFR) initially is low but rise by 2-4 weeks/life & reaches adult levels by 2 years of age; low GFR=decreased ability to remove nitrogenous wastes from blood •Infant's decreased renal threshold for bicarbonate and capacity for reabsorption=lower serum bicarbonate and plasma PH levels •Buffering capacity = decreased = reduced ability to cope with stressful events (cold stress) that can lead to acidosisSigns of risk for renal problems•range from lack of steady urine stream to anomalies including: hypospadias epispadias exstrophy of bladder enlarged/cystic kidneys identified as palpable abdominal masses • Pregnancy US often identifies renal issuesGastrointestinal systemfull-term infants can swallow, digest, metabolize & absorb proteins, simple carbohydrates & emulsifying fats •Except for pancreatic amylase-all digestive enzymes are present •Mucous membranes are moist/pink in adequately hydrated infant •Hard & soft palates are intact •Epstein pearls (small white areas) may be found on gum margins, hard & soft palates •Cheeks are full RT well-developed sucking pads •Labial tubercles (sucking calluses) may be present on upper lip, disappear around 1 year when sucking period ceases; fluoride in water influences tooth development •Teeth development in utero with enamel formation continuing until age 10; development influenced by neonatal/infant illnesses & maternal illnesses/medications ingested; some born with natal teeth with poorly formed roots-teach parents to watch for aspiration/consider removalDigestion•Intestinal mucosal barrier not mature until 4-6 months; allows bacteria/antigens to cross intestinal wall into systemic circulation= **increased risk for allergies/infection-there's a reason breastmilk is the gold standard and why foods are not recommended until six months! •Intestinal flora/gut microbiota=established within first week of life ***•Normal intestinal flora help synthesize vitamin K, folate, biotin •Evidence of maternal/fetal coexist with commensal/symbiotic microbes •Microbial presence in amniotic fluid, placenta meconium •Mode of birth likely plays role in microbial colonization in neonate ***•Vaginally-born=initially colonized by vaginal microbes ***•Cesarean-born=initially colonized by maternal skin microbes •Initial colonization plays role in establishing intestinal flora •Infant's microbiome influenced by diet, antibiotics, environmental factors!Breastfeedingcrucial in establishing intestinal microbiome in neonate •Human milk contains variety of microbes that originate in maternal GI tract •Oligosaccharides in human milk may have prebiotic function to facilitate growth of beneficial bacteria in neonate's GI tractStomach capacitydepends on size of infant; can hold <10cc on day1; 30cc (1oz) by day 3; 60cc by day 7 •Stomach becomes increasingly compliant/relaxed to accommodate larger volumes •Factors such as time/volume/milk temperature affect stomach emptying time •Reflux RT normal intermittent relaxation of lower esophageal sphincter=place HOB up, burp frequently, thicken milk; usually must be severe to treat by surgery/RX to reduce gastric acidity with antacids, histamine—blocking RX (Tagamet/Pepcid), proton-pump inhibitors (Nexium/Prevacid/Prilosec)Digestion in newbornenzymes help digest simple carbohydrates, fats, proteins •Mammary lipase in human milk aids in digestion of fats •Pacreatic amylase & lipase non-functional until about 3 months when amylase is produced by salivary glands then by pancreas around 6 months •Amylase needed to convert starch into maltose and present in colostrym •Lipase secreted by pancreas; necessary for fat digestion •Lactase levels are higher in infants than in adults; necessary for digestion of lactose=major carbohydrate in human milk and commercial formulaStoolsmeconium fills lower intestine at birth; formed in utero around 3 months from amniotic fluid, intestinal secretions, cells •Meconium-blackish green, viscous, contains occult blood •Usually passed within 24-48 hours •Amount passed varies, increases between 3-6 days •Early intact-early stooling •Colostrum has a natural laxative=eases passage of stool •Progressive changes in stool=normal •Meconium drug screens tell history of drug use!! •Infant's intolerant of formula=watery stools, diarrhea, rash=can lead to fluid/electroyte imbalance/aversionFeeding behaviorsvariations in food interest, signs of hunger, amount ingested in a feeding & depends on chronological & gestational age, weight, hunger level, alertness •Random-hand-to-mouth movement with sucking of fingers=well developed at birth, intensifies with hunger •Teach parents to watch hunger cues, especially with breastfeeding infants who feed on demand and do not know how to tell time!Signs of Gastrointestinal Problemsoften based on time, color, character of stool, or lack of stooling •Failure to pass stool=can be bowel obstruction RT inborn error metabolism (cystic fibrosis), congenital disorder (Hirschsprung's), imperforate anus •Active 'anal wink'=contraction of anal sphincter muscle to touch=sign of good tone •Passage of stool from vagina, urinary meatus=fistula from rectum •Fullness above abdomen= likely hepatomegaly, duodenal atresia, distention; fullness below abdomen likely full bladder •Abdominal distention at birth likely indicates serious issue (ruptured viscus from abdominal wall defects, tumors •Distention later can be RT overfeeding, GI disorder •Scaphoid/sunken abdomen with bowel sounds in chest (& respiratory distress) RT diaphragmatic hernia •Careful documentation of vomiting/diarrhea quality, quantity, characteristics is crucial especially if projectile vomiting=pyloric stenosis; green vomit=NEC/twisted gut=surgical emergency *pyloric stenosis: palpable olive shape massHepatic Systemcan be palpated1-2cm below right costal margin; immature at birth; occupies 40% abdominal cavity; plays role in iron storage, glucose and fatty acid metabolism, bilirubin synthesis, coagulationIron Storageliver= site of hemoglobin (HGB) production after birth •Begin storing iron in utero, proportional to total body HGB content & gestation •At birth, term infant has iron store to last 4 months; preterm infant and small for gestational age (SGA) infants often have lower iron stores, depleted sooner •Bioavailability of iron stores in human milk=superiorCarbohydrate Metabolismliver=responsible for blood glucose regulation; in utero glucose concentration in umbilical vein=70% of maternal level •Within 1 hour of birth, infant removed from glucose supply with initial drop in glucose 70-90mg/dl to 55-60mg/dl (why baby needs to be fed ASAP) •Glucagon levels increase, insulin decreases, limited hepatic glycogen levels mobilize •Initiation of feeding=crucial to stabilize blood glucose levels as milk lactose is metabolized •Glucose production also occurs via glucogenolysis and glucogenesis with gradual rise in glucose levels that stabilize by day 2/3 of life (>70) •Glucose levels routinely assessed if LGA, SGA, preterm, infants of diabetic mothers, extramural (outside hospital) deliveries and born <37 weeksHypoglycemiacan be asymptomatic!! •SX include: jitteriness, lethargy, poor feeding, apnea, seizures •Most often transient, easily corrected via feeding •Persistent/recurrent hypoglycemia=IV glucose!! (D10/D12.5/D25; anything >D10=caustic to veins=need UVC/PICC line) •Remember to prevent cold stress cascade which leads to hypoglycemia *if baby eats and is still hungry check they BGFatty Acid Metabolismadditional source of energy in initial hours •Catecholamine release increases rate of lipolysis=production of fatty acids for oxidation and ketone body synthesis •Hepatic ketogenesis=increased in first 3 days of term newbornsBilirubin Synthesisliver=responsible for liver conjugation=results from breakdown of RBCs; liver changes bilirubin to a form body can eliminate=AKA conjugated bili/direct bili (when RBC are broken down) •When RBCs reach end of life=membranes rupture=HGB released •HGB phagocytosed by macrophages=splits into heme & globin •Heme=broken down by reticuloendothelial cells, converted to bilirubin, released in unconjugated form=indirect bili=insoluble/bound to albumin (a plasma protein) ***•Unbound bili=free from albumin=easily crosses blood-brain-barrier=neurotoxicity=acute bilirubin encephalopathy/kernicterus •Unconjugated bili must be conjugated to become soluble/excretable •Bilirubin=excreted in feces, urine; bili feces=dark green=dependent on adequate hydration, stooling (why colostrum=important) *want to encourage feeds so the bili leaves the systemBilirubinwhen levels of unconjugated bili exceed ability of liver to conjugate it=increase plasma levels=jaundice!!! •Jaundice=visible yellowing of skin, sclera, appears if >6mg/dl •First noticed on face; progresses to thorax, abdomen, extremities •Infant at risk of hyperbilirubinemia RT: higher RBC mass at birth, shortal lifespan of neonatal RBCs=creates need for greater bili synthesis; ability of liver to conjugate bili=reduced after birth,; fewer bili binding sites RT lower albumin levels •In intestine=conjugated bili becomes unconjugated and recirculated through enterohepatic circulation=increased bili=increased yellowing of skin *at risk: mom and baby with different blood typesphysiologic jaundice•Occurs in 60% newborns •Appears after 24 hours •Resolves without treatment *Physiologic adaption breastfeeding jaundicepathologic jaundice•Appears withing 24 hours of life •Bili>95% for age/hours •Clinical jaundice lasts >2 weeks •Usually caused by excessive production of bili through hemolysis-hemolytic disease of newborn-ABO/RH incompatibility •Can be caused by G6PD=glucose-phosphate deyhydogenase deficiency-common among Asians/Native-Americans •Untreated=kernicterus=irreversible=lethargy, hypotonia, irritability seizures, delayed motor skills, cerebral palsy, hearing loss, gaze abnormalities, brain damage, coma, death=prevention!!Breastfeeding-associated Jaundice•Early onset-2-5 days of life •Breastfeeding does NOT cause it •Lack of effective breastfeeding=dehydration=< stooling •Hepatic clearance of bili=reduced=reabsorbed bili from intestine back to blood and must be conjugated to be excretedBreastmilk Jaundice•Late-onset jaundice-5-10 days of life •Typically feeding well, gaining weight •Rising levels unconjugated bili peak in second week then decreases •No sign of hemolysis/liver dysfunction •Cause=unknown-seems to be RT factors in breastmilk (pregnanediol, fatty-acids, B-glucuonidase) that wither inhibit conjugation of bili or decrease excretion of biliCoagulationliver plays role in blood coagulation •Coagulation factors=synthesized in liver=activated by Vitamin K •Lack of intestinal bacteria to synthesize Vitamin K results in transient blood coagulation deficiency between 2-5 days of life •Coagulation factors slowly increase to adult levels by 9 months •IM Vitamin K after birth=crucial to prevent vitamin deficiency fleeding=can occur suddenly=catastrophic •Bleeding problems in newborn=report immediately! •No circumcisions without Vitamin-K!!! *baby doesn't have a sterile bowelDrug Metabolismliver immaturity=slower biotransformation and elimination of drugs, increased serum levels, longer half-livesSigns of Hepatic System Problems•Hypoglycemia & hyperbilirubinemia=most common liver-related problems!! •Usually transient, require minimal treatment •Preterm infants @ increased risk •Hematologic status of all newborns should be assessed for anemia •First week of life life=at risk for bleeding until coagulation factors are well-establishedImmune System in newbornsbegins in utero to respond to foreign antigens, but immune response is reduced=susceptibility •Circulating immunoglobulins are low compared to adults •Transfer of antibodies from mother around 14 weeks gestation, greatest in third semester •By term, IgG levels are higher than maternal •Passive immunity via placental transfer mostly provides sufficient immunity during first 3 months of life •Production of adults levels IgG reached by 4-6 years •Fetus capable of producing IgM by 8th week gestation, low levels <10% present at term; reaches adult levels by 2 years •Production of IgA, IgD, IgE more gradual, maximal levels not attained until early childhood -IgA missing from GI tract unless infant is breastfed-breastmilk has antimicrobial factors like oligosaccharides, lysozyme, lactoferrin to aid microbial clearance -Breastfed infants have greater response to vaccines -Long-term effects breastmilk on immune system =demonstrated by lower-risk of immune-mediated conditions like allergies, inflammatory bowel disease, type-I diabetes •WBCs slow to respond to bacteria; neutrophils response=slow; B&T cells are present, but immatureRisk for Infectionat high risk of infection, leading cause of morbidity/mortality; cannot mount huge response against pathogens •Early signs of infection must be recognized/treated promptly •Temperature instability-can be first sign of sepsis •Other symptoms of sepsis=poor feeding, lethargy, irritability, vomiting/diarrhea; respiratory problems including grunting, flaring, retracting, tachypnea; unusual discharge, rash •Greatest protection for infant=proper hand hygiene by staff/prents •Greatest risk infection RT prematurity (immature immune system), premature/prolonged rupture of membranes, maternal fever, chorioamnionitis, asphyxia (antenatal/intrapartal), stress, invasive procedures, congenital anomaliesIntegumentary System-protection/thermoregulation•Vernix caseosa present around 35 weeks=fused with epidermis=protective covering=do NOT rub it off! Contains emollient/antimicrobial properties •Leaving vernix can decrease skin pH and skin erythema, improve skin hydration •Acrocyanosis=normal, resolves 7-10 days, hands and feet are blue •Fine lanugo •Simian crease on hands=rule out Down's syndrome •More creasing over foot-increased maturitySweat glandspresent at birth, do NOT usually sweat in first 24 hours; will sweat around day 3; sweat=a function of temperature regulation to environmental temperature/emotional response •Milia=white sebaceous glands •A sweating/diaphoretic infant may indicate need to check glucose • Desquamation-peeling of skin a few days after birth unless postmature=born with peelingNeviSalmon patches/stork bites/angel kisses-result of capillary defect occurring in 80% of newborns •Usually small, flat, pink, easily blanched •Mostly on nape on neck, upper eyelids, forehead, nose, upper lip •Tend to be symmetric=both eyelids •No clinical significance, no treatment •Facial lesions usually fade by 2nd year •Neck lesions visible into adulthoodPort-wine stain/nevus flammeusvisible at birth RT asymmetric postcapillary venule malformation; pink/flat; darkens with time; true port-wine=does not blanch/disappear; found on face,neckInfantile hemangioma-strawberry hemangiomadilated newly formed capillaries in dermal, subdermal layers with associated connective tissue hypertrophy; may be present at birth or develop afterwards •Raised, sharply demarcated, rough-surface •Bright/dark-red •Common sites-scalp, face, back, anterior chest •Reach maximal growth about 6 months with involution over 5-10 years *if they have a lot they may be pretermErythema Toxicum-newborn rash-flea-bite dermatitistransient rash; appears in 72 hours after birth, lasts about 3 weeks •Different stages-gets worse before improving •Thought to be inflammatory response-eosinophils=help decrease inflammation=are found in the vesicles •No treatment •Reassure parents this is normal, self-resolvingSigns of Integumentary Problems•Signs of pallor, plethora (beefy red baby), petechiae, central cyanosis, or jaundice •Document signs of skin injuries, birth trauma, bruising, forcep/vacuum marks, skin tags (familial trait) •Petechiae can be sign of low platelet count/infection/sepsisReproductive System: Female•Increase of maternal estrogen during pregnancy followed by drop after birth=causes females to develop white, mucoid vaginal discharge, even bleeding (pseudomenses) •External genitalia edematous, increased pigmentation •Term: majora covers minora •Preterm: equally prominent, widely separated, or clitoris prominent •Vaginal, hymenal tags=common; absence of hymenal tag=vaginal agenesis •If born breech, external genitalia may be swollen, bruised •Urethral opening located behind clitoris-document deviation especially if any deviation suggests clitoris is a small penis, occurs with adrenal hyperplasia •Fecal discharge from vagina=rectovaginalfistula=report! *don't excessively wipe vaginal discharge can cause rash and irritationReproductive System: Male•In uncircumcised male, foreskin/prepuce completely covers glans, adheres to glans until about age 3-4; scrotum darker pigmentation •Urethra should be at tip -Hypospadias-urethra located on underside=no circumcision -Epispadias-urethra located on topside, often associated with extrophy of bladder=no circumcision (use foreskin for repairs) •Epithelial pearls-white firm lesions on tip of prepuce-normal •By 28-36 weeks gestation, testes palpated in inguinal canal, few rugae •36-40 weeks, testes palpable in scrotum, rugae cover scrotum; postterm=pendulous •Cryptorchidism=undescended testes=typically descend without intervention but urology referral to prevent sterility! Primary risk=prematurity, LBW •Bluish scrotum=medical emergency=torsion (RF sterility) •Infants born breech=bruising/swelling of scrotum, resolves few days •Hydrocele-collection of fluid around testes, can be transilluminated, usually resolves without interventionSigns of Reproductive System Problems•Observe, document ambiguous genitalia, other abnormalities •Inguinal hernias present, more common in African-American infants, usually no treatmentSwelling of Breast Tissuefound in both genders; caused by hyperestrogenism of pregnancy •"Witch's milk" thin discharge from nipples, normal, resolves •Nipples-should be symmetric Breast tissue, areola size increase with gestationSkeletal Systemrapid development in first year •More cartilage present at birth than ossified bone •Head at term=1/4 of total body length •Arms slightly longer than legs •Legs are 1/3 of total body length •Face appears small compared to skull •Skull is large, heavy •Cranial size, shape may be distorted after birth RT moldingCaput succedaneum•Generalized scalp edema usually on occiput •Common with vertex presentation RT sustained scalp pressure against cervix •Results in compression of local vessels, slowing venous return=increase in edema within skin •Extends across suture lines of skull, disappears 3-4 days •Vaccum extraction=often results in caput with bruising likely (watch for jaundice!)CephalohematomaUnlike caput succedaneum, this is a collection of blood between skull bone & periosteum **•DOES NOT cross suture lines **•Firmer, better define than caput **•Occur occurs with caput •Resolves 2-8 weeks, during which time hemolysis of RBCs occurs=watch for jaundice; need frequent follow-up visits with pedi after dischargeSubgaleal hemmorhagebleeding into subgaleal compartment=a potential space with loosely arranged connective tissue •Located beneath galeal aponeurosis-a tendonous sheath connecting frontal & occipital muscles forming inner surface of scalp •Subgaleal hemorrhage (SH) results from traction, application of shearing forces (forceps, vacuum extraction), commonly seen in operative vaginal birth; CT/MRI confirms diagnosis •Scalp is pulled away, vessels torn, blood collects in subgaleal space •Blood loss can be servere=hypovolemic shock, DIC •Early detection, treatment=essential •Serial FOCs, frequent assessment of scalp, neck for increasing edema, firm mass (phototherapy) •Boggy scalp, pallor, tachycardia, increasing FOC, forward, lateral positioning of ears=early signs of SH •TX=IVF, blood transfusion, replacement of clotting factors •Notify MD of changes in LOC, decreased HCT, increase bili=degradation of blood cells within hematoma=jaundiceSpinebones in vertebral column form two primary curvatures: one in thoracic region, one in sacral region-both are forward, concave •As infant develops head control, a secondary curvature appears in cervical region (around 3 months) •Spine appears straight, flexible •Newborn can lift, turn head when prone •Vertebrae appear straight, flat •Pilonidal dimple with a sinus and hairy nevus requires further assessment, possible ultrasound, close follow-up to rule out spina bifida (hair right above butt crack)Extremitiesshould be symmetric, equal length, equal number of fingers, toes with nails present -Missing digits=oligodactyly -Extra digits=polydactyly -Fused digits=syndactyly •Developmental dysplasia of hip (DDH)=affected hip unlikely to be dislocated at birth=close follow-up if easily dislocatable, especially with breech presentations; usually occurs in first-born females with family history of DDH -Signs of DDH: asymmetric gluteal, thigh skinfolds, unequal knee levels, positive Ortolani's & Barlow's tests -DO NOT CHECK FOR ORTOLANI'S & BARLOW'S!!!( MD/NNP)Neuromuscular Systemalmost fully developed at birth; term newborn is responsive, reactive, social, self-organization present; control is limited •Brain-follows predictive rapid growth pattern during infancy, childhood -Growth more gradual in first decade, minimal during adolescence -End of first year, cerebellum ends growth spurt which began at 30 weeks gestation •Requires glucose, oxygen for growth, metabolism •Spontaneous motor activity=transient tremors of mouth, chin=WNL with crying, not when quiet; resolves 1 month -Persistent tremors=may be pathologic/seizures=document & report!Signs of Skeletal Problemsabnormalities may be congenital, developmental, drug-induced, or related to intrapartum/postnatal issues; Document & Report any abnormalities •Fractured clavicle: common in macrosomic infants, shoulder dystocia -Document, report unequal, absent movement of arms, crepitus, •Feet may be abnormally positioned; may be related to deformity, fetal positioning in utero -If foot can be turned inward to normal position=WNL-teach PT to parent during diaper changes -If foot turns inward, fixed plantar-flexion=document, report, follow-up to rule out club foot (talipes equinovarus)Tremors/Jitteriness•Easily elicited by motions, voice •Cease with gentle restraint of body part •Passive flexion, repositioning of tremulous extremity reduces/stops activity •Tremors/jitteriness are NOT associated with autonomic changes: apnea, tachycardia, pupil changes, increased salivationSeizures•Seizure activity continues despite gentle restraint •Associated with ocular changes: eye deviation, staring •Associated with autonomic changes: apnea, tachycardia, pupil changes, increased salivationPosture•term newborn indicates flexion of arms at elbows and legs at knees; hips are abducted, partially flexed, intermittent fisting=common •Muscle tone, strength are related; if normal, will resist passive movement -Hypotonic=little resistance='rag doll' -Hypertonic=increased resistance -Attempt to hold head in line with body if raised by armsNewborn reflexesprimitive reflexes; dependent on maturity, intact nervous systemBehavioral adaptationsinfant needs to accomplish behavioral, biologic tasks for normal growth, development; the basis of Brazelton Neonatal Behavioral Assessment Scale (Box 22.2) •Behavioral tasks=for social development •Progress through developmental challenges with caregivers/environment •Must be able to first regulate physiologic or autonomic system including involuntary physiologic functions like heart rate, respirations, temperature regulation •Next, must be able to regulate motor organization, behavior including controlling random movements, improving muscle tone, reducing excessive activity •Third level of regulation=state regulation-ability to modulate state of consciousness-predictable sleep, wake cycles, react to stress via self-regulation, communication with caregiver via crying, being consoled •Fourth level of attention, social interaction via visual, auditory stimulation, staying alert for long periods, engaging in social interaction