Exam 3 - ob:peds 2 PDF

Exam 3 Chapter 16: Labor and Delivery Delivery Venue Options: Hospitals: o Most births occur in hospitals. o Provides access to key personnel, equipment, pain control options, and emergency services. Home births: o Many choose home births because of n...

Exam 3 Chapter 16: Labor and Delivery Delivery Venue Options: Hospitals: o Most births occur in hospitals. o Provides access to key personnel, equipment, pain control options, and emergency services. Home births: o Many choose home births because of negative hospital experiences. o Patient may feel more comfortable, empowered, and in control at home. Birthing centers: o Generally freestanding centers are not located in a hospital. o Midwives attend most births in birthing centers. o Cater to patients with low-risk pregnancies. o Transfer agreements with local hospitals. Five Ps of Labor: Labor consists of five components, referred to as the five Ps. Dysfunction in any one of the five components can cause complications that require intervention. The five Ps of labor include: o Power—refers to uterine contractions and pushing efforts. o Passageway—refers to the anatomy of the patient’s bony pelvis and soft tissues. o Passenger—refers to the fetus. o Psyche—refers to patient’s state of mind. o Position—refers to patient position Five Ps of Labor: Power: Primary powers of labor are the involuntary uterine contractions. Secondary powers are the voluntary action of pushing. Primary powers occur in the upper two-thirds of the uterus and apply pressure to the fetus. In response to the pressure, the cervix dilates and effaces, allowing for passage of the fetus. Contraction frequency, duration, and intensity affect power. Oxytocin can be administered to augment contraction power. o Oxytocin is commonly administered during labor to augment (strengthen) uterine contractions when they are not strong enough or are irregular. Secondary powers are the maternal pushing efforts after the cervix is completely dilated. Effective pushing should occur with the contractions and may require coaching from the nurse. Notes: During labor, the cervix dilates (opens) and effaces (thins) to allow the baby to pass through the birth canal. Dilation: The cervix gradually opens from 0 to 10 centimeters. Effacement: The cervix shortens and becomes thinner, measured in percentage (0% to 100%). Five Ps of Labor: Passageway #1: Boney Pelvis: Passageway in Labor: The passageway is the route through which the fetus must travel to be born vaginally. It consists of both the bony pelvis and soft tissues. o Bony Pelvis: The bony pelvis is relatively unyielding, meaning it doesn’t stretch or expand like soft tissues. Its structure is critical in determining how easily a baby can pass through. ▪ True Pelvis: This is the actual bony passageway the fetus must navigate. It’s made up of three main parts: Inlet: The upper opening of the true pelvis, where the fetus first enters. Midpelvis: The middle portion, where the fetus moves further down. Outlet: The lower opening, which the fetus exits during birth.  o Soft Tissues: ▪ The soft tissues include the cervix, pelvic floor muscles, and vaginal canal. ▪ These structures adjust, stretch, and thin (efface) to allow for the passage of the fetus, unlike the bony pelvis, which remains fixed. Pelvic Shapes and Their Influence on Labor: Each woman’s pelvis shape affects the likelihood of a smooth vaginal delivery. There are four basic pelvis shapes: o Gynecoid: ▪ Known as the "true female pelvis" because it’s the most common in women (found in 40%). ▪ This shape provides the most ideal passageway for vaginal birth due to its round, wide inlet and spacious midpelvis and outlet. This shape allows for easier descent and rotation of the fetus. o Android: ▪ This is the "typical male pelvis" shape but occurs in about 20% of women. ▪ It has a heart-shaped inlet and a narrower pelvic cavity, making it harder for the fetus to rotate and descend. ▪ Labor progress may be slow, and there’s a higher chance of needing interventions due to difficulties with fetal rotation. o Anthropoid: ▪ Common in men but seen in about 25% of women. ▪ This shape has a longer, oval inlet that’s narrow side-to-side but deep front-to-back. ▪ While it can often allow for vaginal birth, it may come with challenges based on the baby's positioning and descent. o Platypelloid: ▪ This is the least common shape, found in about 3% of women. ▪ It has a wide, flat shape with a narrow inlet, which often leads to labor complications, such as arrest at the inlet where the baby cannot descend further. ▪ This shape often requires a C-section due to the difficulty in the baby passing through. Note: Most women have a combination of these four basic pelvis shapes rather than one pure type. Additional Considerations for Pelvic Shape and Labor: o History of Pelvic Fracture: If a woman has had a pelvic fracture, her pelvis shape and dimensions might be altered, which could complicate labor by restricting space for the fetus to pass. o Compatibility of Fetal Size and Positioning: ▪ Regardless of the pelvic shape, the newborn can often still be delivered vaginally if the fetus’s size and positioning are compatible with the available space in the pelvis. ▪ However, if there’s a size mismatch or the baby is in a challenging position (e.g., posterior or breech), labor may be more difficult. Five Ps of Labor: Passageway #2: Soft Tissue of the Pelvis: Soft Tissue: Plays a role in allowing the fetus to pass. It usually stretches well but can be problematic if there’s scar tissue from previous gynecological surgery.  Pelvic Floor Muscles: Help guide and turn the fetus through essential movements needed for delivery, called the cardinal movements. Five Ps of Labor: Passageway #3: Fetal Station = Relationship of the presenting part to the level of the maternal ischial spines Fetal Station: Measures the position of the baby’s presenting part (usually the head) in relation to the mother’s ischial spines. 0 Station: Presenting part is level with the ischial spines. This is called engagement, meaning the baby is positioned to move through the birth canal. (-) Station: Presenting part is above the ischial spines. The higher the number (e.g., -3), the further up the baby is. (+) Station: Presenting part is below the ischial spines. Higher positive numbers (e.g., +3) mean the baby is closer to delivery. Floating: If the presenting part is not engaged and still freely movable above the pelvic inlet, it is referred to as "floating." Five Ps of Labor: Passenger: Passenger refers to the fetus and its relationship to the birth canal. Key factors include the presenting part, head size, presentation, attitude, lie, and position. Key Terms and Concepts o Presenting Part: The fetal part that first enters the pelvis. o Cephalic (head-first): Most common and ideal for vaginal birth (95% of pregnancies). o Breech (buttocks or feet-first): Occurs in about 3% of pregnancies, often requires C-section. o Shoulder (transverse lie): Rare, less than 1% of births; typically requires C-section. Fetal Head and Skull Adaptations o Fetal Head: Largest and least compressible part, which assists with dilation once the head is engaged. o Sutures: Gaps between skull bones that allow overlapping for head molding during birth. o Fontanels: Intersections of sutures that aid in identifying fetal head position. o Key Diameters: Occipitofrontal, occipitomental, suboccipitobregmatic, and biparietal diameters affect how the head fits through the pelvis. Types of Fetal Presentations o Cephalic Presentation (Head-first, ideal for vaginal birth): ▪ Vertex: Head is fully flexed; optimal for delivery. ▪ Military: Neutral position, head neither flexed nor extended. ▪ Brow: Head partly extended; can change to face or vertex position. ▪ Face: Head fully extended, with occiput near fetal spine; challenging for vaginal birth. o Breech Presentation (Buttocks or feet-first, higher C-section likelihood): ▪ Frank Breech: Legs extended up towards shoulders; most common breech type. ▪ Full Breech: Fetal legs flexed opposite of cephalic presentation.  ▪ Footling Breech: One or both legs extended into pelvis; high risk of cord prolapse, usually requires C-section. o Shoulder Presentation (Transverse lie): Fetal shoulder or side presents first; mother’s abdomen appears wider than normal. Fundal height may measure smaller. Advantages and Disadvantages o Advantages of Cephalic Presentation: ▪ Head is the largest part, so once it’s born, the rest of the body typically follows easily. ▪ Molding of skull bones helps the head adapt to the birth canal. ▪ Smooth, round head shape helps with cervical dilation. Disadvantages of Breech Presentation: ▪ Increased risk of umbilical cord prolapse since head isn’t covering cervix. ▪ Less effective in dilating cervix since presenting part isn’t as firm as the head. ▪ Risk of cord compression after body is delivered but head is delayed due to lack of molding. Additional Fetal Characteristics o Fetal Attitude: The position of fetal body parts relative to each other, ideally flexed (arms and legs tucked in). o Fetal Lie: The orientation of the fetus’s spine to the mother’s spine (longitudinal or transverse). Five Ps of Labor: Passenger #2: The fetal part that first enters the pelvis is termed the presenting part Five Ps of Labor: Passenger #3: Fetal Attitude= posturing as seen with flexion & extension of the cephalic presentation o Fetal attitude is how the fetus is positioned during labor, either flexed (chin to chest) or extended (brow or face presenting). Complete Flexion: o Chin to Chest o Benefits: Smallest diameter; easier labor. Moderate Flexion: o Chin not touching chest o Position: Alert or "military position." o Benefits: Better than extension but less optimal than complete flexion. Extension: o Brow or Face presenting o The fetal brow (forehead) is the part presenting to the birth canal. o Benefits: Larger diameter; can lead to longer, more difficult labor. Importance of Positioning: o The position of the fetal head significantly affects labor duration and difficulty. o Complete flexion is the most favorable position for efficient labor. Five Ps of Labor: Passenger #4: Fetal LIE is the orientation of the long axis of the fetus to the long axis of the woman (spine to spine) Definition: Fetal lie refers to the orientation of the fetus's long axis (spine) in relation to the mother's long axis (spine). Types of Fetal Lie: o Types of Fetal Lie: ▪ Longitudinal (99% of pregnancies): Description: The fetal spine is parallel to the mother's spine. Positions: The fetal head or buttocks enter the pelvis first. ▪ Transverse (fewer than 1% of pregnancies): Description: The fetal spine is perpendicular to the mother's spine. Positions: The head and tailbone form a 90-degree angle with the mother. ▪ Oblique: Description: The fetal spine is at an angle between longitudinal and transverse.  Positions: Any angle that is neither parallel nor perpendicular to the mother’s spine. Five Ps of Labor: Psyche Overview: A patient's mental state can significantly influence the progression of labor. Factors such as anxiety, stress, and fear can slow down labor, while relaxation can enhance it. Factors That Can Slow Labor: o Anxiety o Stress o Fear o Pain Tolerance Reasons Stress and Anxiety Slow Labor: o Hormonal Interference: ▪ Stress hormones (e.g., cortisol, catecholamines) can inhibit the production of oxytocin, which is necessary for uterine contractions. ▪ This can lead to: Slower labor Longer labor Increased need for augmentation with Pitocin (synthetic oxytocin) o Evolutionary Mechanism: ▪ Elevated catecholamines may activate the "fight or flight" response, hindering labor progress. ▪ This is why labor may slow down when a woman arrives at the hospital. o Environmental Factors: ▪ Hospital settings may create mental or emotional blocks, such as: Harsh lighting Overwhelming presence of staff Distractions from other patients ▪ Importance: Reducing these factors can help facilitate labor. o Effects of Stress in Early Labor: ▪ Catecholamines can stop or slow labor progress. ▪ Fear of pain, the hospital environment, or the unknown can lead to: Strong but difficult contractions. Weaker contractions, resulting in labor that fails to progress. Five Ps of Labor: Position of Client: Overview: Contractions are generally more effective when the patient is in an upright position, as gravity aids in successful labor and delivery. Key Positions and Their Benefits: o Upright Position: ▪ Effectiveness: Contractions are generally more effective. ▪ Gravity: Assists with labor and delivery.  o Squatting: ▪ Benefits: Enlarges the pelvic inlet and outlet diameters. Provides a favorable angle of the pelvis for birth (hips sharply flexed). o Kneeling: ▪ Benefits: Reduces pressure on the maternal vena cava. Helps rotate the fetus from a posterior to an anterior position for easier delivery. o Lithotomy Position: ▪ Description: A common position for birth where the patient lies on their back with legs elevated. ▪ Considerations: More for the convenience of the practitioner than the comfort of the patient. Discouraged as it may hinder effective contractions and labor progress. o Encouraging Movement: Importance → Movement into comfortable positions is associated with improved labor outcomes. Signs of Labor: Overview: The mechanisms that initiate labor are not fully understood and involve various factors. Signs of Impending Labor: o Contractions become regular, and there may be a presence of bloody show (blood-tinged mucus). o The fetus may descend into the birth canal (lightening - signals that the body is getting ready for labor.), which can occur about two weeks before labor for first-time mothers. o Expect a nesting impulse, gastrointestinal distress (like heartburn, nausea, or diarrhea), and a weight loss of 1 to 3 pounds just before labor. Labor Confirmation: Labor is confirmed by cervical changes, specifically dilation and effacement. Notes: Nesting Impulse: sudden burst of energy and an instinctive urge to prepare for the arrival of a baby. True vs. False Labor: True Labor (TRUE): o Involves processes that expel the products of conception, beginning with contractions that cause cervical dilation and effacement, ending with placental delivery. o Contractions may start as back pain or menstrual cramps, moving to the lower abdomen. o Tend to increase with walking and follow the Cardinal Movements of Labor. False Labor (FALSE): o Comprises contractions without significant cervical dilation or effacement. o Can mimic early labor but has inconsistent contractions that do not change with activity; they may even decrease.  o Discomfort is typically felt in the abdomen and groin, often more annoying than painful, and cervical changes are minimal. Nursing Management: Nursing Data Base: Includes Information On: o Contractions (frequency, length, intensity) o Effacement and dilation of the cervix o Fetal station o Status of membranes Management of Early (True) and False Labor o Relaxation: Use a warm tub and warm drinks, followed by a back rub. o Rest: Encourage the patient to rest or sleep. o Supportive Care: Provide understanding and patience. o Diversion Activities: Engage in activities to distract and occupy the patient. o Walking: Have the patient walk for 1-2 hours; if no cervical change occurs, evaluate whether to send her home. o Education: Inform the woman and her partner about labor signs and processes. Nurse’s Role: o Assess for changes in labor status. o Offer support and encouragement. o Facilitate rest, as maternal exhaustion can slow labor. Am I in Labor Yet? True Labor: o Contraction Timing: Regular, closer together (4–6 min apart), lasting 30–60 seconds. o Contraction Strength: Gets stronger over time; vaginal pressure is often felt. o Discomfort: Starts in the back, radiates around to the front of the abdomen. o Activity Changes: Contractions persist regardless of position changes. o Stay or Go?: Stay home until contractions are 5 min apart, lasting 45–60 sec, and strong enough to prevent conversation. False Labor: o Contraction Timing: Irregular, not close together. o Contraction Strength: Weak, does not strengthen with time; may vary (strong followed by weak). o Discomfort: Felt mostly in the front of the abdomen. o Activity Changes: Contractions may slow down or stop with movement or position changes. o Stay or Go? Drink fluids, walk around to assess any change. If contractions reduce in intensity, stay home. Note: In true labor, contractions get stronger and don’t ease up, even with relaxation or a shower. Stages and Phases of Labor: Four Stages of Labor: o First Stage: Dilation and effacement of the cervix. ▪ Latent Phase: 0 to 6 cm dilation. ▪ Active Phase: 6 to 10 cm dilation. ▪ Transition Phase: 8 to 10 cm dilation. o Second Stage: Begins with complete cervical dilation and ends with the birth of the baby. o Third Stage: Starts with the birth of the baby and ends with the delivery of the placenta. o Fourth Stage: Begins with the delivery of the placenta and lasts for 4 hours or until the patient becomes clinically stable. This stage is characterized by the onset of true labor contractions and ends with complete cervical dilation. o Nursing Care During Labor ▪ Monitor: Assess maternal and fetal conditions throughout labor. ▪ Support: Provide emotional and physical support to the mother and family.  ▪ Coach: Assist and coach the mother as needed during labor. o Role of Contractions ▪ Contractions involve rhythmic tightening of the uterine muscles that: Promote fetal descent and rotation. Facilitate cervical effacement and dilation. Aid in the separation and expulsion of the placenta. Help constrict the uterus to prevent postpartum hemorrhage. How to Time Labor Contractions: Stages and Phases of Labor: First Stage: Latent Phase o Duration: Longest phase of labor. o Contractions: Mild, feel like menstrual cramps. o Patient’s Response: Excited and talkative. Active Phase o Duration: Shorter than the latent phase. o Contractions: More regular and painful; moderately strong. o Patient’s Response: Becomes more focused, anxious, or restless. Transition Phase o Duration: Shortest phase of labor. o Contractions: Strong and very close together. o Patient’s Response: May feel out of control, irritable, or dependent. Second Stage: Pushing: Delayed until the patient feels an urge. Duration: Lasts 20 minutes to 2 hours. Fetal Descent: Fetal head rotates and descends through the birth canal.  Cardinal Movements: o Engagement: Fetal head reaches ischial spines. o Descent: Fetus moves past the ischial spines. o Flexion: Fetal chin touches chest due to maternal pressure. o Internal Rotation: Fetal head rotates for alignment. o Extension: Fetal chin lifts, neck arches as head is born. o External Rotation (Restitution): Head rotates again as shoulders align. o Expulsion: Body is delivered. Third Stage: Duration: Completed within 5 to 30 minutes. Placenta Delivery: Uterus contracts to expel the placenta. Post-Placenta Delivery: Uterus continues contracting to close blood vessels in the decidua, reducing the risk of hemorrhage. Key Complication: o Uterine Atony: Failure of the uterus to contract, a primary cause of postpartum hemorrhage. Fourth Stage: Nursing Assessments: o Uterine Position: Ensure uterus is firm and in proper position. o Vaginal Bleeding (Lochia): Monitor for normal bleeding. o Vital Signs: Regularly check blood pressure, pulse, and temperature. Pain Management: o Administer pain medication as needed for comfort. Supportive Care: o Facilitate skin-to-skin contact to promote bonding. o Assist with initiating breastfeeding. Nursing Care During Labor: IV Access: Start 18-gauge IV line. Lab Tests: Draw blood and collect urine. Vital Signs: Monitor maternal vital signs. Fetal Monitoring: Provide continuous/intermittent monitoring. Urination: Encourage voiding every 2 hours. Labor Progress: Assess cervical dilation and progress. Support: Provide emotional and physical support. Education: Offer pain management and labor process info. Pain Meds: Administer and assess pain relief. Fetal Monitoring: Fetal Monitoring Overview o Purpose: Assess fetal heart rate (FHR) patterns for fetal compromise. Normal vs. Abnormal Patterns o Normal (Reassuring): Positive outcomes for the neonate. o Abnormal (Nonreassuring): Associated with hypoxemia and risk of hypoxia. Monitoring Types o Intermittent Monitoring: ▪ Active Labor: Auscultate FHR every 15-30 minutes. ▪ Second Stage: Every 5-15 minutes. o Continuous Monitoring: ▪ Low-Risk: Assess every 30 minutes in the first stage, every 15 in the second stage. ▪ High-Risk: Review fetal monitor strips more frequently. FHR Characteristics o Baseline Rate: 110-160 bpm (assessed over 2 minutes in a 10-minute period). o Variability: Irregular fluctuations in baseline. ▪ Moderate Variability: 6- bpm over 10 minutes. Accelerations: Increase of at least 15 bpm lasting 15 seconds. Decelerations: o Late: Poor placental perfusion. o Variable: Cord compression. o Early: Head compression (benign). o Prolonged: Decrease of at least 15 bpm lasting 2-10 minutes. Interventions for Abnormal Decelerations o Change maternal position. o Discontinue oxytocin if applicable. o Administer oxygen (8-10 L via nonrebreather mask). o Correct hypotension. o Notify provider. VEAL CHOP Mnemonic o V: Variable Decelerations → C: Cord Compression o E: Early Decelerations → H: Head Compression o A: Accelerations → O: OK (reassuring)/ O2 sufficient o L: Late Decelerations → P: Placental Insufficiency  Variable Decelerations – From Umbilical Cord Compression o Variable decelerations are sudden drops in FHR, often with a V, U, or W-shaped pattern, caused by umbilical cord compression. These decelerations can happen with or without contractions, and the FHR may drop below 100 bpm before returning to baseline. o Interventions: ▪ Position Change: Relieves pressure on the umbilical cord, improving blood flow and FHR. ▪ Stop Oxytocin: Reduces contractions, which can worsen cord compression. ▪ Oxygen: Improves fetal oxygenation, helping manage the effects of reduced blood flow due to cord compression. ▪ Notify MD/CNM: A serious sign of cord compression that requires immediate evaluation and intervention. ▪ Vaginal Exam: Used to check for cord prolapse, a complication where the cord slips ahead of the baby, causing compression. ▪ Amnioinfusion: Provides fluid into the uterus to cushion the umbilical cord and relieve compression. ▪ Delivery: If variable decelerations persist despite interventions, early delivery (vaginal or C-section) may be necessary to protect the fetus. Early Decelerations: Fetal Head Compression: o Cause: Head compression (e.g., from uterine contractions, vaginal exams, fundal pressure, internal monitoring, or fetal descent).  o Clinical Significance: Normal pattern, no risk of fetal hypoxemia or low APGAR scores. o Nursing Interventions: None needed, except to prepare for delivery and document. FHR Acceleration: normal pattern → signifies fetal well-being o Causes of Accelerations: Fetal accelerations can be triggered by various factors, including spontaneous fetal movements, vaginal exams, or external stimuli like uterine contractions or abdominal palpation. Certain fetal presentations (e.g., breech, occiput posterior) can also influence fetal heart rate patterns. o Nursing Interventions: No immediate intervention is needed for accelerations unless there's an underlying concern. Documentation is essential to note the presence and context of accelerations. o Clinical Significance: The presence of accelerations is generally a positive sign, indicating that the fetus is not in distress and has a good acid-base balance. This means the absence of metabolic acidosis (a state of low oxygen or blood pH). Late Decelerations: uteroplacental insufficiency o Cause of Utero-Placental Insufficiency: ▪ Maternal conditions (e.g., hypertension, diabetes), placental abruption, smoking, IUGR o Clinical Significance: ▪ Associated with fetal hypoxemia, low APGAR scores, and acidosis ▪ Worsens with fetal tachycardia and loss of variability o Nursing Interventions: ▪ Palpate uterus for tachysystole: Check for excessive uterine contractions, which may indicate uterine overactivity. ▪ Elevate legs to correct hypotension (Trendelenburg): Raise the legs to help improve blood flow and increase blood pressure in cases of maternal hypotension. ▪ Change maternal position to lateral: Shift the mother to a side-lying position to improve blood flow to the placenta and reduce pressure on the vena cava. ▪ Increase IV fluids ▪ Discontinue oxytocin ▪ Administer oxygen at 8-10 L/min ▪ Notify MD or CNM (certified nurse midwife) ▪ Consider internal monitoring ▪ Assist with birth if pattern persists o  Category Baseline FHR Variability Decelerations Accelerations Interpretation Normal, no immediate Moderate (5- None or early Present or Category I 110-160 bpm concern for fetal well- 25 bpm) decelerations absent being May be normal or Variable or late Requires further Minimal or Absent or Category II slightly outside decelerations (not monitoring, possible absent intermittent range persistent) interventions < 110 bpm or > Late or variable Abnormal, immediate Absent or Category III 160 bpm decelerations (persistent) Absent intervention required minimal (persistent) or sinusoidal pattern (e.g., delivery) Pattern Cause (CHOP) What It Means What the FHR Strip Looks Like (VEAL) FHR drops with contractions, Abrupt decrease in FHR with sharp dips that V - Variable C - Cord caused by the umbilical cord vary in timing and depth, usually with Decels Compression being squeezed. contractions. FHR drops during contractions Gradual decrease in FHR, with the lowest point E - Early H - Head due to pressure on the baby’s matching the peak of the contraction, then Decels Compression head. returns to baseline after the contraction. FHR increases for a short time, A- O - Oxygen is Sharp increase in FHR of more than 15 bpm for usually a sign that the baby is Accelerations good! at least 15 seconds, often with fetal movement. doing well. FHR drops after contractions, Gradual decrease in FHR that starts after the P - Placental L - Late Decels often due to problems with the contraction begins and returns to baseline after Issues placenta. the contraction ends. Labor Pain: Factors Affecting Pain Tolerance: o Fear, previous labor experiences, support system, fatigue Pain Manifestations: o Contraction pain: Abdomen, low back, thighs o Occiput-posterior position: Continuous low back pain  o Placental abruption: Continuous abdominal pain Labor Pain Management Nonpharmacological Methods: Focused breathing Hypnotherapy Position changes Cutaneous stimulation Aromatherapy & Music Counterpressure Pharmacological Methods: Opioids (e.g., Fentanyl, Morphine, Nalbuphine, Butorphanol): o Respiratory depression, CNS depression, decreased FHR variability Antiemetics (e.g., Hydroxyzine, Promethazine): o Reduces nausea, potentiates opioids Benzodiazepines (e.g., Diazepam, Midazolam): o Sedation, amnesia, risk of newborn depression Nitrous Oxide (Laughing gas): o Self-administered, decreases pain perception, side effects: nausea, dizziness Medication Guidelines in Pregnancy General Rule: o Use the smallest effective dose o All medications cross the placenta and affect the fetus o Some medications excrete in breast milk o Maternal control of medication increases satisfaction & reduces use Regional Analgesia/Anesthesia Epidural Block: Used for active labor Can cause complications like nausea, vomiting, fetal distress, and hypotension Contraindicated in women with spinal abnormalities, coagulation defects, infections, or anticoagulation therapy CSE (Combined Spinal-Epidural): Rapid onset of pain relief (3-5 mins), can last 3 hrs Preserves motor function & allows ambulation (“walking epidural”) Complications: hypotension, inadequate block, postdural puncture headache Pudendal Block & Intrathecal Analgesia: Local anesthesia for episiotomy, second stage, or cesarean birth General Anesthesia Used for emergency delivery when regional anesthesia isn't feasible Management of Side Effects Hypotension: Position the woman in semi-Fowler, administer IV fluids, and provide oxygen to manage changes in fetal heart rate (FHR) Chapter 22: Complications Occurring During Labor and Delivery Group B Streptococcus (GBS) – Key Points for Nursing Students Overview of GBS: Group B Streptococcus (GBS) is a bacterium that can colonize the vaginal or rectal area. Asymptomatic in patients but devastating for infants if transmitted during labor and delivery. Signs and Symptoms of GBS Infections in Neonates (Infant/Neonate Sepsis Risk) Sepsis o Fever, lethargy, poor feeding, irritability. Pneumonia o Rapid breathing, difficulty breathing, cough, grunting. Meningitis o High fever, lethargy, poor feeding, bulging fontanel, neck stiffness. Screening and Management for GBS: 1. Screening: o Timing: Screen all pregnant patients at 35-37 weeks of gestation. o Method: Vaginal and rectal swab to identify GBS colonization. 2. Treatment: o If GBS-positive: Administer antibiotics during labor. ▪ Timing: Start at least 4 hours before delivery for effectiveness. o If Preterm Labor ( 90 mm Hg - HR < 120 bpm Routine Monitoring - RR < 30 breaths/min - O₂ ≥ 95% - Urine ≥ 30 mL/hr Breastfeeding Start in delivery room. Bladder Catheter Remove as soon as possible after patient can ambulate. Ambulation Encourage within 6 hours post-anesthesia. Diet Regular as tolerated. - Remove dressing 24-48 hrs post-op (per protocol). Wound Care - Staples removed in 4-10 days if applicable. Activity Gradual increase; avoid heavy lifting and squatting for 1-2 weeks. Labor and Delivery: Complications and Interventions Obstetric Emergencies: Uterine Rupture and Umbilical Cord Prolapse Uterine Rupture Risk Factors: TOLAC, Pitocin induction/augmentation, abdominal trauma (e.g., MVA). Symptoms: Sudden Category II/III FHR, weakened contractions, abdominal pain. Fetal Monitor: o FHR: Severe fetal bradycardia, variable decelerations, loss of variability. o Contractions: May weaken or stop. Nursing Assessment: o Monitor for changes in FHR and contraction patterns. o Assess for sudden abdominal pain or tenderness. Nursing Management: o Immediate notification of provider. o Prepare for emergency cesarean birth. o Support patient and family, and prepare for possible hysterectomy if severe bleeding occurs. Umbilical Cord Prolapse Pathophysiology: Cord precedes fetal head, causing occlusion and rapid fetal deterioration. Signs: Severe bradycardia, variable decelerations in FHR. Nursing Assessment: o Continuous FHR monitoring for early detection of bradycardia or variable decelerations. o Assess and identify high-risk clients for proactive monitoring. Nursing Management: o Prompt Recognition: Act immediately upon identifying prolapse. o Relieve Compression: Manually lift presenting part off the cord. o Minimize Cord Handling: Prevent spasm by avoiding direct contact with the cord. o Positioning: Place patient in knee-chest or Trendelenburg to relieve pressure on the cord.  o Immediate Cesarean Birth: Prepare for rapid delivery to prevent hypoxia. Risk Factors: o Long cord, malpresentation, transverse lie, unengaged presenting part, polyhydramnios, multiple gestation. Signs: o FHR decelerations, cord felt/seen. Nursing Management: o Recognize: Monitor FHR and signs. o Position: Knee-chest, Sims, Trendelenburg, elevate hips. o Relieve Pressure: Push presenting part up. o Do Not: Reinsert cord. o Oxygen: Administer 8-10 L/min. o IV Fluids: Start/increase fluids. o Prepare for Delivery: Organize for delivery. Variable Decelerations  umbilical cord compression Aspect Details Causes Prolapsed cord, low amniotic fluid, nuchal cord, true knot U, V, or W-shaped decels; FHR may drop 15,000 cells/mm³). Treatment: o Broad-Spectrum Antibiotics: Ampicillin and gentamicin are standard; clindamycin or metronidazole may be added after C-section. → To reduce post-surgical infection. Complications: o Maternal: Prolonged labor, postpartum hemorrhage, sepsis. o Neonatal: Sepsis, cerebral palsy, meningitis, and neurodevelopmental delays. Nursing Care: o Monitor maternal temperature, fetal heart rate, and uterine tenderness. o Educate on the signs of infection and stress the importance of immediate treatment to prevent neonatal complications. Note: Chorioamnionitis can cause complications for both the patient and the fetus.(True) Postterm Pregnancy (≥42 Weeks)  Definition: Pregnancy that reaches or exceeds 42 weeks' gestation. Maternal Risks: Cesarean birth, dystocia, birth trauma, postpartum hemorrhage, infection. Fetal Risks: Macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome, cephalopelvic disproportion. Management: o Expectant Management: Monitor fetus twice weekly with NST and amniotic fluid or biophysical profile starting at 41 weeks. o Induction of Labor: May be considered based on maternal and fetal condition. Bishop Score (Cervical Readiness for Induction) Factors Assessed: Dilation, effacement, station, consistency, position. Score Interpretation: o Score 9: Spontaneous labor likely. o Score >8: Greater likelihood of successful induction. o Score 1,000 mL despite uterine massage & first-line uterotonics (e.g., oxytocin). Typical Blood Loss: o Vaginal: 500 mL o Cesarean: 1,000 mL Severity: o Major: >1,000 mL o Severe: >2,000 mL Types of PPH Primary (Early): Within 24 hrs of birth Secondary (Delayed): 24 hrs–12 weeks postpartum Physiologic Mechanism: Hemostasis via uterine contraction & clotting within myometrium. Causes (The "4 T's") 1. Tone: Uterine atony (most common) 2. Trauma: Birth injury 3. Tissue: Retained placenta 4. Thrombin: Coagulopathies Postpartum Hemorrhage Risk Factors: Postpartum Early Warning Criteria: Criteria used to help nurses serving postpartum patients include: o Vital Signs: ▪ Heart Rate: >110 bpm ▪ Blood Pressure: Systolic 160 mmHg; Diastolic >100 mmHg ▪ Respiratory Rate: >30 breaths per minute ▪ Temperature: >38°C (100.4°F) o Bleeding: ▪ Excessive Blood Loss: Soaking a pad within an hour ▪ Hematoma: Rapidly forming or enlarging perineal area o Pain: ▪ Severe Uncontrolled Pain: Despite analgesia, particularly in the abdomen, chest, or legs o Mental Status: ▪ Altered Mental Status: Confusion, agitation, or restlessness o Other Symptoms: ▪ Shortness of Breath: Sudden or increasing ▪ Oliguria: Urine output 1,000 mL of blood after vaginal birth or >1,500 mL after cesarean. Primary (early) PPH: Occurs within 24 hours of birth. Secondary (delayed) PPH: Occurs 24 hours to 12 weeks after birth. Causes: 1. Uterine Atony: Most common cause; uterus fails to contract after delivery. 2. Trauma: Lacerations, episiotomies, uterine rupture. 3. Coagulopathies: DIC, clotting disorders. Symptoms: Excessive vaginal bleeding (>1,000 mL). Tachycardia, hypotension. Pale, cool, clammy skin. Weak pulse, oliguria, restlessness (signs of shock). Treatment: 1. Fundal Massage: For a boggy uterus to stimulate contractions. 2. Assess for Lacerations/Hematomas: Check if fundus is firm but bleeding persists. 3. Bladder Catheterization: If unable to void (to prevent uterine displacement). 4. Oxytocin (Pitocin): 10–40 U IV in 500–1,000 mL saline or 10 U IM. o First-line uterotonic to stimulate uterine contraction. o Side effects: nausea, vomiting, water intoxication. 5. Other Uterotonics: o Methylergonovine (Methergine): 0.2 mg IM for severe bleeding (Caution with hypertension). o Misoprostol: 800–1,000 mcg rectally. o 15-Methyl prostaglandin F2α (Hemabate): 0.25 mg IM (Caution with asthma). 🩺 Hypovolemic Shock Signs: Hypotension: BP < 90 mm Hg or a decrease of >40 mm Hg from baseline. Tachycardia: Early sign; compensates for volume loss. Tachypnea: Due to metabolic acidosis. Oliguria: 5 mg/dL. Cause: Imbalance in bilirubin production (from RBC breakdown) and elimination. Process: 1. Hemoglobin Breakdown: Bilirubin is formed from RBC breakdown. 2. Transport: Bilirubin binds to albumin and moves to the liver. 3. Conjugation: Liver converts bilirubin to a form that can be excreted. 4. Excretion: Conjugated bilirubin goes into bile, then the digestive tract. Newborn Factors: Immature liver and sterile intestines may lead to reabsorption of bilirubin, resulting in physiological jaundice. Types of Hyperbilirubinemia 1. Physiologic Jaundice o Timing: Appears 3-4 days after birth. o Cause: Common in newborns; due to immature liver. o Duration: Peaks by 3-5 days, declines over weeks. o Assessment: Monitor feedings, urine, stool output (4-6 wet diapers, 3-4 yellow stools/day by day 4). o Prevention: Frequent feeding to promote bilirubin excretion. 2. Pathologic Jaundice (more concerned) o Timing: Appears within the first 24 hours of life. o Criteria: Bilirubin >17 mg/dL or rising >5 mg/dL/day. o Causes: Conditions like polycythemia, blood incompatibility, or acidosis. o Risks: High bilirubin can lead to kernicterus (bilirubin encephalopathy), causing severe brain damage. o Intervention: Requires immediate medical treatment. Special Conditions Kernicterus: A serious complication from toxic bilirubin levels leading to brain damage (cerebral palsy, hearing loss). Rh Isoimmunization: Immune reaction from Rh blood incompatibility between mother and baby. ABO Incompatibility: Blood type mismatch causing RBC breakdown. Breastfeeding-Related Jaundice Breastmilk Jaundice: Starts 3-5 days after birth, peaks at 2 weeks. Breastfeeding Failure Jaundice: Due to poor feeding and slow bilirubin clearance, leading to reabsorption. Nursing Role Monitoring: Check feeding effectiveness, urine, and stool output. Intervention: Ensure frequent feedings to help bilirubin clearance and prevent pathological jaundice. Jaundice Assessment 1. Early Detection o Significance: Jaundice within the first 24 hours could indicate a serious condition; report to healthcare provider (HCP) immediately. o High-Risk Factors: Infants with early jaundice are at higher risk for severe hyperbilirubinemia, often due to blood incompatibilities (ABO or Rh). 2. Visual Inspection o Frequency: Assess for jaundice every 8-12 hours. o Pattern: Jaundice starts on the face and forehead, moving downwards (cephalocaudal progression). It resolves in the opposite direction (feet to head). 3. Screening and Confirmation o Universal Screening: Many institutions use transcutaneous bilirubin (TcB) as an initial test. o Confirmation: High TcB results are confirmed with total serum bilirubin (TSB) tests. 4. Risk for Preterm Infants o Increased Risk: Preterm infants (70% of baseline. ▪ TcB is above the 75th percentile on Bhutani nomogram. ▪ TcB < 13 mg/dL at follow-up. ▪ Infant is actively undergoing phototherapy. o Maternal Tests: ABO and Rh blood type, isoimmune antibodies. o Other Tests: Hemoglobin/hematocrit (H/H), reticulocyte count. 4. Nursing Management o Comprehensive Approach: Adjust care based on gestational age. o Feeding: Encourage breastfeeding to reduce bilirubin. o Bilirubin Reduction: ▪ Early, frequent feedings. ▪ Phototherapy. ▪ Exchange transfusions if necessary. o Phototherapy Care: ▪ Cover eyes. ▪ Expose as much skin as possible. 5. Education and Support o Educate parents on phototherapy and its importance. o Provide guidance for home care if needed. Additional Notes Hyperbilirubinemia: Excess bilirubin in the blood, a yellow pigment from RBC breakdown, can lead to jaundice if not processed or excreted efficiently.  Cephalohematoma: Bleeding under the skull from birth trauma (e.g., vacuum-assisted delivery) may cause extra bilirubin, raising the risk of hyperbilirubinemia. Respiratory Distress Syndrome (RDS): Definition: RDS is a respiratory condition most commonly seen in premature infants. Symptoms: o Tachypnea (rapid breathing) o Nasal flaring o Expiratory grunting o Retractions (inward movement of the chest wall) o Cyanosis (bluish skin color) o Pallor (pale skin) Causes Surfactant insufficiency Immature lungs Prematurity Management and Treatment Assisted Ventilation: o Continuous Positive Airway Pressure (CPAP) o Positive End-Expiratory Pressure (PEEP) Surfactant Therapy: Administer exogenous surfactant to improve lung function. Supportive Therapy: o Oxygen therapy as needed o Antibiotics for positive cultures and monitoring for sepsis o Correction of metabolic acidosis o Maintain thermoregulation Suctioning: Clear mouth, nose, and trachea as needed. Nutrition and Fluids: o Maintain nutrition with gavage or IV feedings o Administer fluids and vasopressors if necessary Blood Glucose Monitoring: Important to prevent hypoglycemia, which can worsen respiratory status.  Clustering of Care: Organize activities to minimize stress on the infant. Positioning: Prone or side-lying position to improve respiratory function. Parental Support and Education: Provide guidance and reassurance to parents. Progression RDS typically progresses for 48 to 72 hours and may resolve within a week. Conditions That Present as Respiratory Distress Bronchopulmonary dysplasia Persistent pulmonary hypertension of the neonate Transient tachypnea of the newborn Meconium aspiration syndrome Bronchopulmonary Dysplasia (BPD): Definition: BPD is a lung condition that can develop as a complication of artificial respiratory support in premature infants. Symptoms: o Tachypnea: Rapid breathing o Retractions: Inward movement of the chest wall while breathing o Rales: Abnormal lung sounds (like crackles) o Wheezing: A high-pitched whistling sound when breathing Cause: o Lung Damage: BPD is caused by injury to the lungs from mechanical ventilation or oxygen therapy in preterm infants. Care: o Respiratory Support: Infants with BPD require ongoing respiratory support, which may include supplemental oxygen or ventilators. Prognosis: o Improvement: Most infants with BPD improve within 2 to 4 months, but some may need continued respiratory support beyond that time. Persistent Pulmonary Hypertension of the Neonate: Overview Definition: PPHN is characterized by high pulmonary vascular resistance leading to right-to-left shunting of blood and hypoxemia. It occurs in neonates, particularly those born at 34 weeks of gestation or later. Etiology Normal Transition: At birth, the fetal circulation transitions to extrauterine circulation, closing the ductus arteriosus and foramen ovale. Pulmonary vascular resistance decreases while systemic vascular resistance increases. Pathophysiology: If pulmonary vascular resistance remains high compared to systemic vascular resistance, PPHN occurs, resulting in right-to-left shunting and severe hypoxemia. Causes 1. Underdevelopment of the Lungs: o Conditions: Renal agenesis, congenital pulmonary malformations, congenital diaphragmatic hernia, intrauterine growth restriction (IUGR). 2. Maldevelopment of the Lungs: o Condition: Normal lung structure but with thickened muscle layers around pulmonary arterioles. Common in postterm infants and those with meconium aspiration syndrome (MAS). 3. Maladaptation: o Condition: Normal pulmonary vascular anatomy but vasoconstriction due to factors like hypoxia and acidosis, often triggered by infections or lung disease. Risk Factors Advanced maternal age, obesity, diabetes during pregnancy. Exposure to SSRIs or SNRIs in utero. African ancestry, meconium-stained amniotic fluid (MSAF), prolonged premature rupture of membranes. Birth weight extremes (small or large for gestational age). Commonly Associated Conditions Sepsis, pneumonia, respiratory distress syndrome (RDS), congenital diaphragmatic hernia, MAS, perinatal asphyxia, and other pulmonary disorders. Signs and Symptoms Onset: Within 24 hours of birth. Symptoms: o Cyanosis o Respiratory distress (tachypnea, grunting, retractions, nasal flaring) o Prominent apical impulse o Split S2 heart sound o Systolic murmur (over the tricuspid valve) Prognosis Mortality Rate: Approximately 7% to 10%. Long-term Effects: Survivors are at increased risk for hearing deficits, developmental delays, and cerebral palsy. Assessment Diagnosis: Echocardiography (Doppler studies) to identify right-to-left shunt. Pulse Oximetry: Difference of >10% in oxygen saturation between pre- and postductal locations (e.g., right thumb vs. great toe) indicates potential PDA. Arterial Blood Gases: Vary based on the underlying cause of PPHN. Treatment 1. Supportive Care:  o Adequate oxygenation, nutrition, circulatory support, correction of acidosis (IV sodium acetate), and temperature regulation. 2. Specific Interventions: o Inhaled Nitric Oxide: Vasodilatory agent for severe PPHN not responding to supportive measures. o ECMO: May be necessary if pulmonary vascular resistance does not improve. 3. Oxygen Therapy: Administer 100% oxygen briefly to reverse pulmonary vasoconstriction; aim for oxygen saturation of 90%-95%. 4. Address Underlying Causes: o For conditions like RDS and MAS, surfactant therapy may be indicated. Care Considerations Long-term Monitoring: Infants with severe PPHN, especially those treated with nitric oxide or ECMO, should undergo regular assessments for hearing deficits, developmental delays, and cerebral palsy during infancy and early childhood. Transient Tachypnea of the Newborn (TTN): Overview: Definition: TTN is a respiratory condition in newborns caused by the failure to clear fluid from the lungs, typically seen in late preterm or postterm infants. → or cesarian. Etiology Pathophysiology: TTN occurs when pulmonary fluid clearance is inadequate after birth, leading to fluid retention in the alveoli and causing difficulty in breathing. Symptoms Onset: Symptoms typically manifest shortly after birth. Common Signs: o Tachypnea: Rapid breathing o Nasal Flaring: Widening of the nostrils during breathing o Expiratory Grunting: A sound made during exhalation o Retractions: Indrawing of the chest wall during inhalation o Cyanosis: Bluish discoloration of the skin due to low oxygen levels Diagnosis Primarily clinical, based on observed symptoms and the history of the infant, particularly in relation to gestational age. Treatment Supportive Care: o Monitor vital signs and oxygen saturation. o Provide oxygen supplementation as needed to maintain oxygen saturation above 90%. Prognosis Resolution: TTN typically resolves within 72 hours, with most infants recovering without complications. Meconium Aspiration Syndrome (MAS) Overview Definition: o Occurs when a newborn inhales meconium mixed with amniotic fluid, leading to airway obstruction, inflammation, and surfactant inactivation. Etiology Pathophysiology: o Causes airway obstruction o Leads to chemical irritation and inflammation o Increases risk of infection o Results in inactivation of surfactant, potentially causing atelectasis (lung collapse) Symptoms Common Signs: o Meconium-stained amniotic fluid o Respiratory or neurological depression at birth o Postmature or small for gestational age infants o Respiratory distress (tachypnea, retractions) o Cyanosis (bluish skin) o Abnormal lung sounds (rales and rhonchi) o Increased anterior-posterior (AP) diameter of the chest o Possible pneumothorax or pneumomediastinum o Associated with persistent pulmonary hypertension of the newborn (PPHN) Diagnosis Clinical Assessment: o Based on symptoms, history of meconium-stained amniotic fluid, and signs of respiratory distress Management Initial Care: o Neonatal resuscitation team present at birth, continuing care until infant stability o Avoid suctioning the mouth and nares on the perineum Suctioning Protocol: o Non-vigorous infants: perform endotracheal suctioning o Vigorous infants: do not suction unless respiratory distress is present Assessment of Condition: o Evaluate for mechanical obstruction if infant is depressed and meconium is suspected in the airway Treatment Supportive Care: o Maintain adequate oxygenation and respiratory support Medications: o Antibiotics for infection prevention or treatment o Surfactant replacement therapy to improve lung function o Inhaled nitric oxide for managing pulmonary hypertension o ECMO for severe cases Nursing Management Supportive Care: o Monitor respiratory status and provide oxygen support as needed  Continuous Assessment: o Regular evaluation of respiratory effort, oxygen saturation, and overall stability (KNOW THIS CHART) Retinopathy of Prematurity (ROP): Overview Definition: o Retinopathy of prematurity (ROP) is a leading cause of blindness in children in the United States, characterized by abnormal vascular growth in the retina of premature infants. Etiology Causes: o Abnormal vascular growth of retinal blood vessels in premature infants o Permeable vessels that leak, causing: ▪ Edema ▪ Hemorrhage of the retina ▪ Scarring that can lead to distortion or detachment of the retina Risk Factors: o Low birth weight o Prematurity o Excessive oxygen exposure after birth Signs and Symptoms Clinical Manifestations: o Edema of the retina o Hemorrhage within the retinal layers  o Scarring of the retina o Retinal distortion or detachment Prognosis Natural Course: o ROP can regress and resolve spontaneously in some cases particularly in mild instances. o An ophthalmologist can perform a thorough examination of the infant's eyes to diagnose ROP and assess its severity. Treatment Indications for Treatment: o Required only for severe disease cases Treatment Options: o Laser photocoagulation: A procedure that uses laser energy to target and destroy abnormal blood vessels o Antivascular endothelial growth factor (VEGF) monoclonal antibodies: Medications that inhibit abnormal blood vessel growth Necrotizing Enterocolitis (NEC) Definition: o NEC is a serious condition where parts of the intestines become inflamed and die due to lack of blood flow. It is a gastrointestinal emergency in newborns. Signs and Symptoms First Sign: o Feeding intolerance (the baby has trouble digesting food). Other Symptoms: o Swollen belly (abdominal distension) o Breathing problems (respiratory failure) o Episodes of stopping breathing (apnea) o Low blood pressure (hypotension) o Unstable body temperature (temperature instability) Nursing Management Assessment: o Monitor vital signs (temperature, heart rate, blood pressure) frequently. o Check bowel sounds regularly to assess gut function. Fluid and Nutrition: o Ensure the baby is well-hydrated and getting the right nutrition. o Implement bowel rest (no feedings) to give the intestines time to heal. o Administer IV fluids and antibiotics to treat infection. Treatment Medical Management: o Antibiotics: Used to treat or prevent infections. o Laboratory Tests: ▪ Regularly check blood tests (CBC, electrolytes, BUN, creatinine, acid- base balance) to monitor the baby’s health. o Radiology: Perform X-rays every 6 to 12 hours to see how NEC is progressing (gas pockets)  Surgical Intervention: o If NEC is severe, surgery may be needed to create a stoma (proximal enterostomy) or remove damaged intestine (bowel resection), which can lead to malabsorption issues. Family Education and Support Educate Families: o Teach them about NEC, its symptoms, and the importance of monitoring. Provide Support: o Offer emotional support and answer questions throughout the treatment process. Signs and Symptoms o Baseline changes of VS o Abd. Distention and tenderness o Decreased Bowel Sounds o Bloody or hemoccult positive stools o Feeding intolerance o Sepsis o Lethargy o Apnea/RDS o Shock o KUB xray shows air in bowel Neonatal Abstinence Syndrome (NAS) Overview NAS is the result of withdrawal symptoms in newborns exposed to substances in utero, primarily opioids (e.g., methadone, buprenorphine, oxycodone, hydrocodone). Other substances, including nicotine, antidepressants, antipsychotics, alcohol, and benzodiazepines, may mimic or worsen NAS symptoms. Risk Factors Difficult to pinpoint; however, potential risk factors include: o Trauma and abuse o Mental and behavioral disorders in children with a history of NAS Goals of Treatment Reduce withdrawal symptoms in the newborn. Wean off opioids after stabilizing the infant for at least 24 hours. Nursing Care and Multidisciplinary Approach 1. Assessment o Monitor for withdrawal symptoms using signs listed in the WITHDRAWAL tool. o Differentiate Intrauterine Growth Restriction (IUGR) vs. Small for Gestational Age (SGA) to identify additional concerns. 2. Pharmacologic Treatment o Maintain fluid and electrolyte balance, nutrition, infection control, and respiratory support. o Administer opioids (e.g., methadone) and anticonvulsants as needed for 2+ weeks, with gradual dose reduction. 3. Education o Inform the family about short- and long-term effects of NAS. o Educate caregivers on safe sleep practices to help reduce the risk of Sudden Infant Death Syndrome (SIDS). 4. Social Support o Collaborate with social services to evaluate the home environment and maternal substance use. o Include social work in discharge planning to ensure a safe, supportive home environment. 5. Breastfeeding Considerations o Assess if breastfeeding is appropriate based on the type of drug exposure and maternal substance use. o If breastfeeding is approved, encourage small, frequent feedings and daily weight checks. 6. Environmental Care o Reduce environmental stimuli (light, noise) to support comfort and manage symptoms. Focused NAS Assessment and Management Assessment 1. Maternal History: Review for substance use and risk behaviors. 2. Newborn’s Behavior (WITHDRAWAL tool): o Wakefulness, Irritability, Tremors, High-pitched cry, Diarrhea, Rapid breathing, Apneic spells, Weight issues, Alkalosis, Lacrimation. Management 1. Comfort: Reduce noise/light; swaddle gently. 2. Feeding: Offer small, frequent feedings; essential for infants struggling with sucking and swallowing (especially common in cocaine-exposed infants). 3. Prevent Complications: Monitor for dehydration, infection, and growth concerns. 4. Parent-Infant Bonding: Teach parents techniques for soothing and caring for their baby. Important Note Cocaine-exposed infants are often fussy, irritable, and may have difficulty with sucking and swallowing, making feedings challenging. Maternal Substance Abuse: Fetal Alcohol Overview Alcohol exposure in utero is the leading cause of preventable birth defects and developmental disabilities. Prenatal alcohol exposure may lead to Fetal Alcohol Spectrum Disorder (FASD), which presents as a variety of physical, mental, cognitive, and behavioral issues. No safe amount of alcohol has been established in pregnancy; even small amounts can cause developmental delays. Alcohol is a central nervous system teratogen, affecting fetal brain development. Effects of Fetal Alcohol Spectrum Disorder (FASD) Physical abnormalities Cognitive impairments Behavioral challenges Developmental delays Care Considerations An interprofessional approach is essential for managing FASD, involving: o Social work for family support and resources o Occupational therapy to aid in daily functioning skills o Physical therapy to improve motor skills o Speech therapy for communication support o Nursing, medicine, and psychology for comprehensive care and management Chapter 42: Child with Gastrointestinal Disorders Cleft Lip & Cleft Palate Mnemonic to Remember Basics: “LIPS CRACKED” L: Lip tissue doesn’t fully join (Cleft Lip) I: Inside roof doesn’t fully close (Cleft Palate) P: Present from birth S: Surgery required for repair C: Caused by genes, smoking, infection, meds (Topiramate, Valproic acid) R: Routine ultrasound can detect before birth A: After birth diagnosis, especially for cleft palate C: Complications (Feeding, Speech, Hearing) K: Keep baby upright when feeding E: Emotional support needed D: Diet gradually reintroduced after surgery Diagnosis Prenatal ultrasound, postnatal observation, or later detection in life Management & Nursing Care (Post-op) 1. Pain Control: Liquid acetaminophen 2. Positioning: Infant seat (keeps baby upright) 3. Minimize strain: Limit crying; use special feeders; no objects in mouth for 3 weeks 4. Diet: Clear liquids (Week 1) ➔ Soft foods (Week 2) ➔ Normal diet (Week 3) Complications Feeding difficulty, dental issues, speech delays (25-35% need therapy), hearing problems (common), chronic ear infections Dehydration Mnemonic to Remember Symptoms and Key Points: “DRY KIDS” D: Dry skin & mucous membranes R: Rapid weight loss Y: You’ll see sunken fontanelles in infants K: Kidneys immature; unable to conserve fluids I: Increased breathing rate increases fluid loss D: Diarrhea or vomiting as common causes S: Sunken eyes, sluggish cap refill Assessment Monitor vitals, weight, cap refill, fontanelles, LOC Management 1. Mild-Moderate: Oral Rehydration Therapy (ORT), e.g., Pedialyte 2. Severe: IV rehydration (NS or RL bolus 20-30 mL/kg) 3. Avoid: Sugary drinks (exacerbate diarrhea) Gastroenteritis Mnemonic for Core Concepts: “HANDS SAFE” H: Hand hygiene prevents spread A: Assess for dehydration (skin turgor, eyes, fontanelles)  N: Note hydration status (I&O, daily weights) D: Diarrhea is often watery; look for electrolyte imbalances S: Skin care (frequent diaper changes) S: Spread is often fecal-oral A: Avoid high-sugar drinks (exacerbates diarrhea) F: Fluid replacement is crucial E: Education on vaccination (rotavirus) & prevention Management ORT for mild dehydration, IV fluids for severe Encourage bland diet, avoid carbonation (can worsen symptoms) Pyloric Stenosis Mnemonic to Remember Key Symptoms: “VOMIT” V: Vomiting projectile, non-bilious, forceful O: Olive-shaped mass (right of umbilicus) M: Moves food through narrow pylorus; delayed emptying I: Irregular peristalsis can lead to hunger & irritability T: Treatment is surgical (Pyloromyotomy) Pre-op Care Hydration, electrolyte balance, and document feeding patterns Post-op Care 1. Positioning: Keep infant upright during feeding 2. IV fluids for first 24-48 hrs; then small, frequent feedings Hirschsprung Disease Mnemonic for Symptoms: “NO PASS” (indicates no bowel movement) N: No ganglion cells in the intestine (causes obstruction) O: Often affects rectosigmoid area P: Palpable fecal mass A: Abdominal distention S: Stools are ribbon-like or absent (no meconium in first 48 hours) S: Surgery required for correction Pre-op Care Bowel prep, NPO, and IV fluids; for older children, enemas and colonic irrigation Post-op Care 1. NG Tube: Low intermittent suction for decompression 2. Assess: Watch for bowel sounds, infection signs, and pain Chapter 43: Nursing Care of the Child With an Alteration in Urinary Elimination/Genitourinary Disorder 1. Epispadias and Hypospadias Definitions Epispadias: A congenital condition where the urethral opening is on the upper (dorsal) surface of the penis in boys or abnormal location near the clitoris in girls. Hypospadias: A congenital condition where the urethral opening is on the underside (ventral surface) of the penis in boys, or abnormally positioned near the vaginal opening in girls. Diagnosis Visual inspection at birth for the abnormal positioning of the urethral opening. May include imaging if other urinary tract abnormalities are suspected. Assessment Look for incomplete or abnormal urinary stream due to misplaced urethral opening. Check for chordee (downward curve of the penis), which is often associated with hypospadias. Potential issues with urinary control or incontinence in severe cases. Management and Treatment Surgical Repair: Usually performed between 6 to 12 months of age to correct the position of the urethral opening and any penile curvature. Postoperative Care: Catheter care and preventing infection are critical. Delay circumcision if hypospadias repair is planned, as foreskin may be needed for reconstruction. Nursing Interventions and Considerations Educate parents on catheter care and signs of infection. Avoid straddle toys and limit physical activity post-surgery. Provide emotional support and discuss possible impact on body image as the child grows. 2. Urinary Tract Infections (UTIs) Definition Infection of any part of the urinary system (kidneys, ureters, bladder, or urethra), often caused by bacteria like E. coli. Diagnosis Urinalysis: Presence of white blood cells, bacteria, and possibly nitrites. Urine Culture and Sensitivity: Identifies the specific bacteria and appropriate antibiotic. Assessment Infants and Young Children: Fever, irritability, poor feeding, vomiting. Older Children: Dysuria (painful urination), frequency, urgency, foul-smelling urine, and abdominal or flank pain. Management and Treatment Antibiotics: Oral or intravenous, depending on the severity. o Typical course is 7-14 days, though shorter courses (2-5 days) may be effective. Supportive Care: Pain management, adequate hydration. Nursing Interventions and Considerations Educate parents and children on the importance of completing the full antibiotic course. Teach preventive practices:  o Wipe from front to back for girls. o Encourage frequent urination and complete bladder emptying. o Avoid bubble baths and tight clothing. o Ensure adequate fluid intake. o Cotton underwear and good hygiene, especially for sexually active adolescents. 3. Nephrotic Syndrome Definition A kidney disorder where damaged glomeruli allow proteins (primarily albumin) to leak into the urine, leading to proteinuria, hypoalbuminemia, hyperlipidemia, and edema. Diagnosis Urinalysis: Proteinuria of 3+ to 4+ on a urine dipstick, indicating high levels of protein. Blood Tests: o Hypoalbuminemia: Low serum albumin (