Newborn Transition, Hypertension & High-Risk Birth PDF

Newborn Transition Can take up to two hours to transition in a normal newborn 3 things that a newborn needs after the delivery 1. Stimulate cry 2. Clear airway 3. Dry and provide heat Initiate triangle 1. Thermoregulation (36.5-37.5 C) ➔ 4 ways babies lose h...

Newborn Transition Can take up to two hours to transition in a normal newborn 3 things that a newborn needs after the delivery 1. Stimulate cry 2. Clear airway 3. Dry and provide heat Initiate triangle 1. Thermoregulation (36.5-37.5 C) ➔ 4 ways babies lose heat Evaporation: babies wet and the water evaporates Conduction: direct contact (wrap the baby in a cold blanket) Convection: moving air (fan, general breeze) Radiation: close to something cold (bassinet near a cold window) ➔ Baby's temperature drops = baby burns calories ➔ Oxygen + glucose = burn calories (increases temperature) ➔ Oxygen = increased work of breathing ➔ Signs of a baby being cold ★ Irritable ★ Lethargic ★ Cool skin ➔ Practice Question: A baby with a temperature of 36.2. What’s the priority? Assess respiratory function and glucose 2. Blood glucose (>40) ➔ Oxygen + glucose = burn calories (increases temperature) ➔ Glucose = produce more insulin (lowers blood sugar), metabolize glycogen in liver and eat food ➔ Babies can be born with really high insulin levels = hypoglycemia at birth ➔ Signs of hypoglycemia ★ Lethargic ★ Irritable ★ Tremors ★ Poor feeders 3. Respiratory (30-60) ➔ Signs of respiratory distress (tachypnea + any of the four characteristic symptoms) ★ Tachypnea ❖ Only symptom → TRANSIENT TACHYPNEA OF THE NEWBORN → not concerning ★ Grunting (on expiration) ★ Flaring (on inspiration)  ★ Retractions ★ Cyanosis ➔ Causes of respiratory distress ★ Low surfactant ❖ Premies ★ Fluid in their lungs ❖ C-section babies ★ Obstruction ❖ Meconium ★ Medications ❖ Narcotics ❖ magnesium ★ Difficult birth ❖ forceps/vacuum ❖ Distress in labor ❖ Emergency c-section Babies that struggle with transitioning ➔ Premature ( 140/90 on two separate occasions ➔ Before 20 weeks ➔ Labetalol PO ➔ NST’s ➔ BP monitoring at home Gestational hypertension ➔ >140/90 on two separate occasions ➔ After 20 weeks ➔ Resolves with the completion of pregnancy ➔ Labetalol PO: only administer until delivery ➔ NST’s ➔ BP monitoring at home Preeclampsia ➔ Definition ★ Systemic vasoconstriction disorder that is unique to pregnancy and it is cured by delivery ★ Hypertension + proteinuria ★ >20 weeks ➔ Pathophysiology ★ Spiral arteries do not dilate in the placenta ★ Placenta compensates by releasing a certain toxin ★ Certain toxin causes ❖ Systemic vasoconstriction of the arteries ❖ Increase CNS reactivity ❖ Increase endothelial (capillaries) permeability ❖ Filtered through the liver ➔ Signs and symptoms ★ Hypertension (vasoconstriction) ★ Visual disturbances (vasoconstriction) ★ Headache (vasoconstriction) ★ DTR’s +3-4 (normal is +2) (increase CNS reactivity) ★ Seizures aka eclampsia (increase CNS activity) ❖ Fetal distress ❖ Brain damage for mom and/or baby ★ Edema (increase permeability) ❖ Hands ❖ Face  ❖ Perineum ❖ Pitting edema ★ Proteinuria (increase permeability) ★ Altered kidney function (increase permeability) ★ Altered liver function → Epigastric pain (filtration) (MOST OMINOUS SIGN OF AN IMPENDING SEIZURE) ➔ Diagnose ★ BP >140/90 ★ Proteinuria ★ >20 weeks ➔ Treatment ★ Mild ★ severe Mild preeclampsia ➔ >140/90 on two separate occasions ➔ proteinuria ➔ After 20 weeks or postpartum ➔ At home : BP monitoring, 24 hour urine, modified bed rest ➔ NST, BPP, Growth ultrasound Severe preeclampsia ➔ >160/110 or blood chemistry changes (ALT, AST, CREATINE, BUN, URIC ACID) ➔ Proteinuria ➔ After 20 weeks or postpartum ➔ In patient ➔ Goal is to move towards delivery ➔ Risk : seizure ➔ Magnesium sulfate ➔ Preterm: buy mom 48 hours to get steroids on board ➔ >36 week = delivery HELLP ➔ Low hematocrit ➔ High AST, ALT ➔ Low platelet ➔ Severe subset of preeclampsia ➔ After 20 weeks or postpartum ➔ Risk : postpartum hemorrhage, seizure ➔ Deliver as quickly as possible, try and avoid c-section  Magnesium Sulfate Antidote = calcium gluconate Need two nurses to administer Secondary line pump MOA ➔ Smooth muscle relaxer→ relaxes the uterus ➔ CNS depressant → prevents a seizure Indication ➔ Stops preterm labor ➔ Preeclampsia Therapeutic range ➔ 4-8 mg/dl Overdose Toxicity ➔ Decreased lung sounds in the bases (first sign of respiratory depression) ➔ Preeclampsia → pulmonary edema ★ High pressure in the vessels ★ High permeability ★ Low pressure inside the alveoli ★ Fluid moves out of the blood vessels and into the alveoli ★ Surfactant washes away Preeclampsia ➔ Continue magnesium 24 hours after delivery ★ Seizures can occur during the actual birth ★ Seizures can occur within 24 hours after delivery Risk for patients who are going to labor and deliver ➔ Toxicity ➔ Respiratory distress for the baby ➔ Postpartum hemorrhage (uterine not contracting) Signs and symptoms  Below therapeutic Therapeutic range Above therapeutic Red flags range range 8 mg/dl Definition Progression of Arrest of Toxicity +Indications preterm labor dilation Respiratory Seizure in (labor has depression preeclampsia stop) Seizure prophylaxis Clinical Contractions Normal Decreased Lung Manifestations every 3 min SpO2 LOC sounds: Clonus +1 beat (>95%) Decreased depth of RUQ pain Arrest of lung sounds resp. DTR’s +3 cervical in base FHT: Vaginal dilation SpO2 93% decrease bleeding DTR’s +1 Urine variability Requires output DTR assist to 25ml/hr I + O’s bathroom Absent SpO2 Nausea DTR’s Absent Respiratory clonus 11 BP 105/60  High Risk Birth Prolapsed umbilical cord ➔ Risk ★ Polyhydramnios ★ Small baby ★ Having multiples ★ Ruptured membrane ➔ Signs and symptoms ★ Pulsating tissue ★ Variable decels ➔ Nursing intervention ★ Push the baby up into mom off of the cord ★ Check or visualize cord ★ Keep hand in until the baby comes out via c-section Shoulder dystocia ➔ Risk ★ Macrosomia (big baby) ★ Maternal obesity ★ Primiparity (first birth) ★ Maternal diabetes ➔ Signs and symptoms ★ Fetal head has been delivered but the shoulder is not able to be delivered ➔ Nursing interventions ★ McRoberts position (20 degree angle, knees to ears) ★ Suprapubic pressure ★ Note time ★ NICU notified Uterine rupture ➔ Risk ★ Previous c- section ★ Trauma ★ Grand multiparity (>5 births) ➔ Signs and symptoms ★ Massive blood loss ★ Massive abdominal pain ★ Hypovolemic shock ★ Loss of FHT  ★ Presence of fetal movement outside the uterus ➔ Nursing interventions ★ C section ★ Total hysterectomy DIC ➔ Risk ★ Sepsis (systemic infection throws off everything) ★ Severe preeclampsia (altered blood chemistry circulating throughout body) ★ Placental abruption (mixing of maternal and fetal blood) ➔ Signs and symptoms ★ Spontaneous bleeding from IV site, eyes ★ Microclots (black spots on body) ➔ Nursing interventions ★ DIC protocol Chorio ➔ Risk ★ Rupture membrane >18 hours ★ Multiple vaginal exams ★ Internal fetal monitors ➔ Signs and symptoms ★ Maternal tachycardia ★ Fetal tachycardia ★ Maternal fever ★ Abdominal pain ★ Foul smelling amniotic fluid ★ GBS positive ➔ Nursing interventions ★ Triple IV antibiotics ○ Ampicillin, clindamycin, gentamicin Uterine inversion ➔ Risk ★ Grand multiparity ★ Forceful traction on the umbilical cord  ➔ Signs and symptoms ★ Massive hemorrhage ➔ Nursing interventions ★ Nothing, the HCP will do a bi manal compression or hysterectomy Amniotic fluid embolism (PE, massive histamine response, and anaphylaxis ) ➔ Risk ★ sepsis ★ Severe preeclampsia ★ Placental abruption ➔ Signs and symptoms ★ No warning signs ★ Patients code’s ➔ Nursing interventions  Gestational Diabetes Diagnosis ➔ Third trimester ➔ One hour glucola ★ >140 = 3 hour glucola 2 abnormal results = gestational diabetes Risk Factors ➔ Obesity ➔ Hypertension ➔ Family history ➔ African American ➔ Native American Treatment ➔ Diet and exercise Fetal complications ➔ Macrosomia (big baby) ➔ Hypoxia ➔ Intrauterine growth restriction Delivery ➔ Baby is going to have increased insulin ➔ Baby is going to have decreased glucose levels ➔ Baby is going to have increased adipose tissue ➔ Baby is going to have decreased surfactant Newborn complications ➔ Large for gestational age (>4000 grams) ➔ Trauma ➔ Respiratory distress ➔ Hypoglycemia ➔ Poor feeding  Hyperemesis Gravidarum Can resolve in the third trimester Can cause depression Risk Factors ➔ Multiple gestation ➔ Primip’s ➔ Diabetics ➔ Stress Diagnostic criteria ➔ Weight loss of 5 % ➔ Dehydration with electrolyte imbalance ➔ Clinical malnutrition Labs ➔ Hypoalbumin ➔ High specific gravity ➔ pH may fluctuate Fetal complications ➔ Decreased perfusion → hypoxia ➔ Intrauterine growth restriction Medications ➔ Vitamin B6 ➔ Zofran ➔ Metoclopramide ➔ Phenergan (can cause some CNS adverse effect) ➔ IVF therapy Management ➔ Avoid greasy food ➔ Avoid odorous food ➔ Eat salty crackers ➔ Can be at home or inpatient ➔ If vomiting persist : NPO 24 hours ➔ NG tube or TPN  Placenta Abruption and Placenta Previa Bleeding disorders > 20 weeks Complications ➔ Hypovolemic shock ➔ Late decelerations Placenta Abruption Placenta Previa Acute event Chronic condition Premature separation of the placenta while Placenta implants and grows over the cervix the baby is inside of mom Cervical changes cause a tearing in the placenta causes/risk therefore blood loss ➔ Trauma: fall, domestic violence, MVA Cause/risk factors ➔ Significant vasoconstriction: ➔ History of C-section preeclampsia, smoking, cocaine, ➔ History of previa hypertensive crisis ➔ Short interval pregnancy (< 12 months) Diagnose ➔ Uterine scarring ➔ US ➔ IUD ➔ Bleeding Diagnose ➔ Lab: KB test (positive or negative) ➔ Anatomy ultrasound (18-20 weeks) ★ Positive: mixing of maternal ➔ Repeat ultrasound in the third trimester fetal blood Things to avoid Symptoms ➔ Intercourse ➔ Silent abruption (blood is leaking into ➔ Cervical exams the amniotic fluid) : port wine fluid ★ Scenario : 30 weeks, vagnial ➔ Hematoma: no bleeding bleeding ➔ Tearing on the edge of placenta: dark ★ Yes, prenatal care = do cervical red blood with clots exam ➔ Sharp, stabbing abdominal pain ★ No, prenatal care = no cervical ➔ Uterine irritability exam, must do an ultrasound ➔ Increase in abdominal circumference ➔ Pitocin ➔ Increased fundal height ★ No CST ➔ Increased in uterine tone ➔ Vaginal delivery Management Symptoms ➔ Emergent c-section ➔ Painless associated with the bleeding ➔ Bright red bleeding Management ➔ Planned c-section at 36 weeks ➔ NST ➔ Activity restriction depends on the amount of bleeding ➔ Betamethasone steroids  Neonatal withdrawal Symptoms ➔ CNS ★ High pitched cry ★ Disturbed sleep ★ Hyperactive reflexes : moro reflex ★ Undisturbed tremors ★ Increased muscle tone: clenched fist, flexed wrist, exaggerated fetal position ➔ GI ★ Poor feeders ★ Loose stools → excoriation ★ Vomit or regurgitate ★ Have trouble gaining weight ➔ Metabolic ★ Fever ★ Frequent yawning and sneezing ★ Sweating ★ Nasal stuffiness ★ Tachypnea Neonatal abstinence scoring -NAS ➔ To determine if the baby is withdrawing ★ Yes withdrawing = treat baby’s pain with morphine ➔ To determine the morphine dosage ➔ Use meconium to determine if baby was exposed to drugs ➔ Goal: treat baby’s pain and reunify with parents ◆ Phenobarbital- seizures ◆ Nutrition - high calorie formula, encourage breastfeeding if she's in a different drugs (methadone they can breastfeed???) ◆ Low stimulation  Congenital Anomalies Diagnose ➔ Anatomy ultrasound ➔ Second trimester Cleft Lip Palate ➔ Can't' feed or breastfeed until further direction ➔ Assess hard palate with finger Diaphragmatic Hernia ➔ Hole in the diaphragm, organs develop in the chest, lungs cannot grow appropriately ➔ Fatal ➔ Absence of breath sounds ➔ Sunken abdomen (scaphoid abdomen) Neural Tube Defects ➔ Spina bifida, meningocele, myelomeningocele ➔ Keep baby prone ➔ Cover with a sterile wet dressing ➔ Risk for infection Gastroschisis ➔ Herniation at the umbilical cord, GI herniate outside of the body ➔ Deliver vaginally ➔ Keep baby supine ➔ Cover with a sterile wet dressing ➔ Silo contraption → surgery ➔ Risk for infection Hydrocephalus ➔ Bulging fontanelle (movable skull pallets) ➔ High pitched cry, irritability, tremors ➔ Poor feeders ➔ Withhold feeding ➔ Ultrasound Esophageal Atresia ➔ Immediate regurgitation (projectile vomiting) ➔ Observe the first feed Tracheoesophageal Fistula ➔ Choking ➔ Cyanosis ➔ Coughing ➔ Observe the first feed  Pregnancy Loss Bleeding < 20 weeks = threaten abortion Recurrent miscarriages = >3 → evaluate for an incompetent cervix Incidence ➔ 1 in 5 pregnancies end in miscarriage ➔ 25 % of women ➔ Under reported ➔ Miscarrige is not a risk factor Cause ➔ Congenital anomalies ➔ Anatomical issues: incompetent cervix ➔ Infection ➔ Teratogens : temperature, drugs, alcohol, medications Safety concerns ➔ Hemorrhage ➔ Infection Grief and comfort ➔ Treat like normal delivery ➔ Make memories: photos, footprints ➔ Allow grieving ➔ Do not focus on the future Ectopic pregnancy ➔ Ectopic pregnancy always is a loss ➔ Definition ★ Implantation outside of the uterus ★ Patient will experience normal pregnancy symptoms ★ Patient will have a positive pregnancy test ➔ Risk factor ★ IUD ★ History of ectopic pregnancy ★ Endometriosis, PID ★ Infections: STI ➔ Diagnosis ★ First trimester ultrasound ➔ Treatment ★ Remove preganacy ★ Preserve fertility ➔ Patient education ★ Stop taking prenatal vitamins ★ Start methotrexate  ★ Schedule surgery: with in 7-10 days ★ postop ❖ Schedule follow up to check HCG levels HCG must be 0 before trying to conceive again Increase risk of molar pregnancy if a pregnancy begins with elevated HCG Molar pregnancy Tumor Increased fundal height Hyperemesis 25 % chance of metastasis Treatment: evacuate Patient education: avoid pregnancy for one year and be evaluated for the possibility of metastasis for one year Imcompetent cervix ➔ Cervix is opening instead of remaining close ➔ Second trimester ➔ Cerclage ★ Prophylactic ★ First trimester ★ Sow the cervix shut ★ When they get to term (35-36 weeks) they will remove the sutures ★ Complications to monitor for ❖ Signs for rupture membranes ❖ Bleeding ❖ Labor