355 - Beyond Midterm

Front 1

Cardiac Output

Back 1

- the volume of blood ejected from the left ventricle each minute

- in children, the CO is almost completely dependent on HR until the heart muscle is fully developed at 5yo

CO = HR x SV

Adult = 5-8L/min
Kids = 2-3l/min

Front 2

Transitional Circulation

Back 2

- Changes at birth

! Gas exchange is transferred from
placenta to the lungs.

! Fetal shunts: Ductus venosus, Ductus arteriosus, Foramen ovale

- blood from mom, umbi, placenta, will dump into ductus venosis which bypasses the liver

- dumps into inferior VC into atrium

- then to LA via foramen ovale, bypassing lungs

- if some blood basses from RA - VA, blood goes to aorta via pulm art via ductus arteriousis

if these shunts remain open after birth, trouble

Front 3

Causes of Heart Defects

Back 3

Multifactorial Causes:

- teratogenic
- chance
- Familial link
- chromosomal abnormalities
-deleted chrom 22
- trisomy 21
- turners syndrome
-trisomy 13

Front 4

Congenital Cardiac Anomalies
Signs & Symptoms of CHD

Back 4

- Cyanosis
- peripheral
- central
- resp distress
- CHF
- decreased CO
- abnormal cardiac rhythms
- cardiac murmur
- FTT (failure to thrive)
====================
s1 = closure of AV valves
s2 = closure of semi- lunar (pulm/aortic)
====================
- hearing trickling/ movement of blood between s1/s2 = murmur

- indicative of congenital heart defects

Front 5

Nursing Diagnosis for Ped Cardaic Anomalies

Back 5

- dec CO
- excess fluid volume
- ineffective breathing pattern
- imbalanced nutrition
- compromised fam coping

Front 6

Nursing Interventions for Ped Cardiac Anomalies

Back 6

- meds
- maintain cardiac and resp function
- foster dev
- promote nutrition
- emotional support

Front 7

Echocardiogram

Back 7

! Ultrasound – to generate an image of the heart.

! Assesses: location and relationship of intracardiac and extracardiac structures, cardiac function, measures sizes of cardiac chambers, valve functions, size of defects, estimates gradient and blood flow direction.

Front 8

Valve insufficiency leads to:

Back 8

valve insufficiency leads to:
1. valvular stenosis (stiff- won't open/close properly)

2. valvular regurgitation (valves open up in two directions, allowing for backflow)

Front 9

Classification of Congenital Heart
Defects
Increased Pulmonary Blood Flow

Back 9

! an increased pulmonary blood flow
exists.

! Blood is shunted from Left side of
heart to the right side.

! Major complication: CHF

Front 10

Patent Ductus Arteriosis

Back 10

PDA
- patent means open therefor communication between aorta and pulmonary artery
- remember this shit should close soon after birth
=======================
! Occurs in premature infants (< 28
weeks) – 80%

! 5-10% of all defects (2002), 1/2000 of term infants

! Can be present with all other heart
defects.

Front 11

Management for Patent Ductus Arteriosis

Back 11

! Indomethacin

! Fluid restriction X 2 days then gradually increase

! Diuretics if needed

! Oxygen

! Transcatheter closure is sometimes attempted in children greater than 18 months of age.

! Surgical ligation

Front 12

Atrial Septal Defect. ASD

Back 12

- a communication btw RA and LA, resulting in increased pulmonary blood flow

- inability of foramen ovale to close

- means the heart will ahve to pump extra blood to get sufficient blood out to aorta and to tissues

Front 13

ASD Management

Back 13

! Closure of this defect depends on type of ASD

! Some will close spontaneously

! Cath Lab Closure versus open heart surgery

! Adulthood discovery.

! Asymptomatic are monitored without medications.

! Symptomatic are treated with diuretics and digoxin.

Front 14

Ventricular Septal Defect

Back 14

- a communication btw LV/AV, again putting more blood into pulm art

Front 15

Summary of Management of
Lesions

Back 15

! Complete assessments
- decreased perfusion.
- congestive heart failure.

! Medications: digoxin, diuretics, oxygen

! Elevate HOB

! Nutrition

! Cardiac catheterization and / or
Surgery, as needed

Front 16

Cyanotic Defects with
Decreased Pulmonary Blood
Flow.

Back 16

A decrease of pulmonary blood flow with the delivery of unoxygenated blood to the body results in hypoxia or a decreased volume of flow.

Front 17

Tetralogy of Fallot

Four Components to defect:

Back 17

! Ventricular septal defect (large)

! Pulmonary stenosis

! Overriding aorta

! Right ventricular hypertrophy (secondary to pulmonary stenosis)

Front 18

! TET SPELLS:

Back 18

! at risk for spells of
extreme hypoxemia
("tet spells") which
may be fatal

! Children will squat
or move into a fetal
position to make
themselves feel
better.

WHY? - increases venous return

Front 19

Treatment of TOF

Back 19

- b blocker
- morphine
- prostaglandin E1 (rarely used)
- +/- BT Shunt (Blalock-Taussig shunt)
- surgical repair

Front 20

General Management of
Decreased Pulmonary Blood
Flow Defects

Back 20

! Prostaglandin E1

! Adequate Hydration

! Supplemental oxygen

! Surgery

Front 21

Nursing Care of Pediatric
Congenital Heart Defect Patients

Back 21

complete physical assessessments (head to toe

- signs of decreased perfusion / decreased ventilation
- monitor bp\- listen to heart sounds (rate, rhythm, qualiity)
- pulses - characterisics
- fluid status: edema
- activity
- growth

Front 22

Cardiac Catheterization

Back 22

! Involves the insertion of a catheter
through an artery/vein into the heart.

! Performed under fluoroscopy (cath-lab)

Front 23

Cardiac Catheterization

What information is obtained?

Back 23

- pressures iwhtin the heart
- 02 sats
- blood flow patterns
- structural info (valves, chambers, great vessels)

Front 24

Complications of Catheterization

Back 24

- arrhythmias
- bleeding
- cardiac perforation
- CVA
- contrast agent reactions
- hypercyanotic spells
- local vascular complications
- infections

Front 25

Nursing Care Pre Catheterization

Back 25

- NPO
- Sedation

family and child anxiety
- orientate family and child to unit, cath lab information
- pre cath prep info
- procedure
- post cath care info

Front 26

Nursing Care Post Catheterization
Extremity perfusion compromise:

Back 26

Arterial perfusion compromise of extremity

Signs:
- pallor, mottling, diminished strength of extremity pulse (PPP is important), cool temp, delayed cap refill

Front 27

Venous obstruction:

Back 27

signs:
- edema of extremity, duskiness with normal cap refill
- venous congestions interferes with arterial circulation

Front 28

Nursing Care Post Catheterization

Back 28

- monitor for bleeding
- fam/child anxiety and knowledge deficit
- resp compromise
- renal function alterations
- pain
- hypothermia

Front 29

Obesity

Front 30

Classification of Overweight and Obesity in Adults

Back 30

BMI = kg/m2

underweight <18.5
Normal weight 18.5 - 24.9
overweight 25-29
Obesity >30

Front 31

Childhood obesity?

Back 31

- for kids, BMI >85 - 95% = overweight

- so we consider age, gender, height and weight

- WHO defines as abnormal fat accumalation that presents a risk to health

Front 32

Prevalence rates of obesity:

Back 32

- increases, from 10.6% to
32.6% in boys and from 13.1% to 26.6% in girls for
overweight, and from 2.0% to 10.2% in boys and from
1.7% to 8.9% in girls for obesity (Tremblay, Katzmarzyk
& Willms, 2002).

! Over a 15-year period in Canada, the prevalence of
overweight and obesity has tripled among boys (i.e.,
from 10.6% to 32.6%) and doubled among girls (i.e.,
from 13.1% to 26.6%).

! This suggests that not only have children become more
overweight in the past few decades, but overweight
children have been getting heavier.

Front 33

Complications of obesity

Back 33

Slide #10 of obesity presentation...
Think.

Psychosocial
pulmonary
GI
renal
musculoskeletal
neurological
CV
endocrine

Front 34

Health promotion in Children and Youth

Back 34

- Health of children is a product of genetics, the role models they copy, their environments, the skills and attitudes of
parents, and the adequacy of health services.

- Requires advocating and accomplishing changes in behavior of the adults
significant to the child.

" Support people to make healthy decisions

" Education in schools

" Policy and program development

" Advocacy groups

" Online resources

" Pediatric obesity clinics

Front 35

Key messages in decision making tools

Back 35

- Fully mobilizes client centred care, clients need support to participate in decision making.

- Usual approaches to decision support are not enough.

- Decision coaching tailors support to the need of the client.

Front 36

Decision support analysis tool. Knowledge

Back 36

! Do you know the benefits and harms of each option?

! Present Options: Benefits and Harms

- make it client centered

- don't put anything into his mouth or his mind

Front 37

Decision support analysis tool.
Value

Back 37

" Are you clear about which benefits and harms matter to you the most?

" Discuss importance of benefits and harms.

- how important is this shit to you?

Front 38

Decision support analysis tool.
Support

Back 38

" Do you have enough support and advice to make a choice?

" Discuss preferred role in decision making, does the client want to involve family?

" Does the client feel pressure or support from others?

Front 39

Decision support analysis tool.
Certainty

Back 39

- do you feel sure about the best choice?

Front 40

Stroke

Back 40

! Stroke strikes 3/10000 children each year in Canada

! Recent trend in pediatric strokes caused by:
-untreated ear infections,
-chicken poxs
-too much cow’s milk.

! Can also be caused by trauma: car accident

! Unknown reason…..
=======================
! A stroke is when the blood supply to any part of the brain is interrupted, resulting in tissue death and loss of brain function.

! 2 kinds:
1. Ischemic stroke &
2. Hemorrhagic

Front 41

Stroke Misdiagnosed

Back 41

" Bells Palsy (facial paralysis)

" Sore or injured leg

" Injury that occurs in infancy and are only diagnosed when the child not meeting developmental milestones.

Front 42

An ischemic stroke

Back 42

may be caused by a blood clot that forms in the brain (a
thrombus) or blood clot or plaque that travels to the brain from another location (an embolism).

Front 43

Hemorrhagic stroke

Back 43

Hemorrhagic stroke

! A hemorrhagic stroke is bleeding that occurs within ischemic brain tissue.

! Hemorrhagic stroke occurs when a blood vessel that is damaged or dead from lack
of blood supply (infarcted) ruptures.

Front 44

Signs and symptoms of pediatric stroke

Back 44

! Blindness in one eye or hearing problems in one ear

! Confusion

! Dizziness or loss of balance/coordination

! Nausea and/or vomiting

! Numbness or weakness on one side of the body – the
side opposite from where the stroke has occurred

! Seizures

! Severe headache

! Trouble speaking or understanding speech

Front 45

Diagnosis methods for pediatric
stroke

Back 45

! Physical exam

! CAT scan

! MRI

! Ultrasound

! EEG

Front 46

TREATMENT stroke

Back 46

! Aspirin

! Heparin and Low Molecular Weight anticoagulants.

! Warfarin

! Thrombolytic Agents

Front 47

Factors affecting childhood obesity

Back 47

! Access

! Socioeconomic Factors

! Lifestyle

! Technology

! The nature of the food supply

! The food industry

! Portion sizes

Front 48

Premature Rupture of Membranes

Back 48

• PROM
– Premature rupture of membranes
– Before labour begins

• Preterm PROM (PPROM)
– Before 37 weeks

• Associated with
– Infection
– Polyhydramnios
– Incompetent cervix
– Trauma
– Bleeding problems

Front 49

Risks

Back 49

• Maternal
– infection increases (Chorioamnionitis)
– malpresentation
– abruptio placenta

• Fetal-newborn
– prolapse of umbilical cord
– respiratory distress syndrome
– sepsis

• ↑↑ perinatal morbidity and mortality

Front 50

(P)PROM

Back 50

Confirm
• -nitrizine, check the acid base comp of the fluid
- monitor infection of the mom (temp, increased HR
• Sterile speculum
– Ferning on slide as
seen through microscope

If term…
– Monitor maternal and fetal vital signs
– If prolonged
• antibiotics
– Induction

Front 51

Management If preterm

Back 51

• Fetal assessment
• Maternal vital signs
– Baseline, q 4h
• Fix underlying problem and infection
• Avoid vaginal exams
• Monitor wbc
• Conservative management
• Corticosteriods to increase lung maturity (betamethasone)

Front 52

Corticosteroids in PTL

Back 52

• 24 and 34 weeks’ gestation, at risk of preterm delivery within 7 days should be considered for antenatal treatment with a single course of corticosteroids.

• reduces perinatal mortality, respiratory distress syndrome, and intraventricular hemorrhage

• Betamethasone 12 mg IM q 24 hr x 2 doses
or

• Dexamethasone 6 mg IM q 12 hr x 4 doses

Front 53

Preterm Labour / Birth

Back 53

• Rate of PTB Canada ~ 8.1%
• Rate of PTB increasing!
• Leading cause of mortality &
morbidity (~75-85%)
• Preterm infant
• Stress to family
• Costs to system
– $12,354 compared to $1,084 (2005-6)
• The earlier gestation of previous PTB, inc risk of even earlier PTB next time

Front 54

Risk Factors for PTL/B

Back 54

• Previous preterm delivery/fetal loss
• ART
• Hypertension (X6)
• Uterine / cervical abnormalities
• Multiples
• Polyhydramnios
• Antepartum bleeding (abruptio placenta)
• Leading cause of mortality and morbidity (~75-85%)

• Substance use
– Cocaine / tobacco use (>11 cig./day)

• Intra-abdominal surgery
• Medical conditions - diabetes, obesity

• Physical trauma
– domestic abuse

• Psychosocial – anxiety, depression, stress

Front 55

Preterm Labour

Common symptoms:

Back 55

– Low abdominal pain /cramps / backache
–Bleeding / spotting / show / ROM
–Pelvic pressure - baby pushing down
– Increased amount / changes in vaginal discharge
–Contractions q 10 min or more often

Front 56

Assessment

Back 56

• Maternal vital signs / FHR / contractions

• Sterile speculum exam
– Membranes intact/ruptured?
– obtain vaginal cultures – infection?

• CBC / Urinalysis - infection

• Ultrasound:
– verify gestation
– placental location / fetal presentation
– transvaginal scan - cervical length, incompetent cervix

Front 57

Diagnosis

Back 57

• Uterine contractions
(4 in 20 minutes or 8 in 1 hour)

• Cervical
– Length <25mm
– Dilatation of greater than 1 cm
– Effacement of 80% or more

• + Fetal fibronectin

Front 58

Population-based strategies include:

Back 58

• raise public awareness of problem of prematurity

• preconception preparation

• nutrition, avoidance of drugs / tobacco

• patient education on risk avoidance & recognition of early symptoms

• Early antenatal care and early detection of risk factors - bacterial vaginosis, cervical incompetence.

Front 59

Management of PTL

Back 59

• Should labour be stopped?

• Monitor VS, contractions, fetus
– Bedrest
– Magnesium Sulfate
– Sedatives

• Avoid stimulation
– Vaginal exams
– Sexual intercourse
– Nipple stimulation
– Keep bladder empty

• Hydration
- IV?

• Antibiotics RoM or infection

• Corticosteroids

• Tocolytics:
– Indomethacin anti-prostaglandin inhibits uterine
activity

• Postpone delivery x 48 hours

• Not recommended for long term use - PDA
– Calcium channel blockers - Nifedipine (Adalat)
– Beta adrenergic agonists (terbutaline, ritordrine)

• Progesterone
– Weekly IMs, helpful to prevent and reduce PTB when Hx of PTB, and other risk factors

Front 60

If labour can’t be stopped…

Back 60

• The more preterm, the greater the risk and adverse outcomes

• Where should she deliver?

• Very little difference in length of labour
• may not need to be 10 cm to deliver VLBW infant

• Narcotics rarely used – epidural

• May use forceps; not vacuum

Front 61

Incompetent cervix

Back 61

• Premature, painless dilatation of cervix
– 20-28 weeks
– 2nd trimester abortions
– Anomalies of cervix (invasive cervical biopsy, DES)
– Infections
– Multiple gestation, polyhydramnios

• Diagnosis
– Heaviness in pelvic area, membranes rupture
– Ultrasound, delivery

Front 62

Cervical Cerclage/Suture

Back 62

Shirodkar, McDonald Insertion associated with
– Infection,
– Hemorrhage
– PPROM, Preterm labour

– Damage to cervix
• Permanent narrowing or closure
• Tearing of the cervix or uterus if labour progresses with the
stitches still in place

– Not appropriate if
• vaginal bleeding
• uterine contractions
• membranes have ruptured
• C-section or suture removed

Front 63

Multiple Gestation

Back 63

- >1 fetus

- 1974: 18.2/1,000 births

- 1997: 25/1,000 births

- 340% increase in triplet births
- 25 per 100,000 births (1974 ) = 109 in 1997

2 factors:
1. assisted reproduction (ART)
- clomid treatment, superovulation, invitro fertilization, intrauterine insemination
2. increasing maternal age

Front 64

Identical-
Monozygotic

Back 64

• Develop from single fertilized ovum

• Same sex and same genotype

• Increased risk of anomalies

• Identical twins usually have common placenta

• # of amnions, chorions,
and placentas
– depends on timing of cell
division cells in 1st 2 wks

Front 65

Fraternal-Dizygotic

Back 65

• 2 separate ova fertilized
by 2 separate sperm
– 2 placentas, 2 chorions, 2
amnions
– Sometimes placentas fuse
and appear to be one
– No more similar to each
other than other siblings
– May be of same or different
sex

Front 66

• Singleton

Back 66

– 6.3% weigh <2500g
– 7% < 37 weeks
– Mortality 4.1 per 1000

Front 67

Twins

Back 67

– mean age 35.2 weeks
– 56.6% weigh <2500g
– Mortality 25.7 per 1000
– 97% < 37 weeks

Front 68

Triplets

Back 68

– mean age 32.1 weeks
– 94.1 % weigh <2500g
– Mortality 62.2 per 1000

Front 69

Quadruplets

Back 69

– mean age 29.7 weeks

Front 70

Education, DX, nutrition of a mom carrying multiples

Back 70

• Educate
– prevention and symptoms of pre-term labor

• Diagnosis
– ideally by 5th month

• Nutrition
– counselling and dietary resources to support a
weight gain of 18-27 kilos (40-60 pounds)

• when health of the mother or family situation
warrants:
– extended work leave
– bed rest support
– child care for siblings

Front 71

Effects on pregnancy/mother

Back 71

- increase intensity of all pregnancy related symptoms/complaints

.Shortness of breath
.Edema
. Nausea, vomiting, heartburn
. Insomnia, fatigue
.weight gain

• Increased risk for:
– Preterm labour
– Anemia, diabetes, hypertension, cardiac, renal
problems
– Abnormal presentation
– Twin-to-twin transfusion syndrome
– Vanishing twin - Fetal reabsorption
– Uterine dysfunction
– Abruptio placenta / placenta previa / pph
– Prolapsed cord

• Safest way to deliver?
– vaginal or C/S

Front 72

Management

Back 72

• Prenatal
– Intermittent or continuous EFM
– simultaneous auscultation / recording of
fetal heart rates
– Ultrasound
– Monitor blood sugar, blood pressure etc.
– Awareness of complications
– Rest
• Head of bed elevated, left lateral

• Delivery
– Complications
• Placenta previa, preeclampsia etc. } C/S
• IUGR, malpresentation, fetal distress, anomalies: }

– time from birth of 1st twin to birth of others

– U/S confirm presentation of 2nd twin

–Careful ID of infants / blood specimens

Front 73

Effects on family

Back 73

• PTB
– NICU

• Instant family
– Financial

• Space, equipment

• Social
–marital

• Sleep deprivation

• Time

• Loss of one fetus
–Selective terminations

Front 74

Precipitous Labour & Delivery

Back 74

- < 3 hours

Mother
. Lacerations
. PPH

Infant
. Stress or hypoxia from inc contractions
. Facial bruising
. Airway . excessive secretions
. Cerebral trauma

Will try to prevent in future
. induction

Front 75

Macrosomia

Back 75

> 4000grams
• Male
• Gestational Diabetes
• Grand Multipara
• Postdates (>42 weeks)
• Ethnicity

Front 76

• Mother/pregnancy/delivery at risk for

Back 76

– Cephalopelvic disproportion
– Shoulder dystocia
– Dysfunctional labour
– Vaginal lacerations
• 3rd 4th degree tears
– Postpartum hemorrhage

Front 77

• Fetus at risk for

Back 77

– Meconium aspiration
– Asphyxia
– Brachial plexus injury, fractured clavicles

Front 78

Shoulder Dystocia

Back 78

• Fetal shoulders impact against the mother’s symphysis pubis

• Head delivers normally, but then pulls back
– Turtle sign

• Macrosomia

• Cephalo-pelvic disproportion

• Mismanaged delivery

• Risks to baby
– Brachial plexus injury, fractured clavicles, fetal
anoxia from cord compression

Front 79

Obstetrical Emergency

Turtle Sign

Back 79

• Get help – obs (NICU)

– Techniques:
• Open pelvis (McRoberts, hands-knees)
• Dislodge 1 shoulder (Suprapubic pressure)
• Rotate the fetal shoulder girdle into the wider oblique
pelvic diameter (Woods screw)
• Posterior arm sweep

– Ideally anterior shoulder is delivered IMMEDIATELY
after head to minimize risk of cord compression

• Support patient/support person

Front 80

McRobert's Manoeuvre

Back 80

- pelvis tilts, orienting symphysis more horizontally to facilitate shoulder delivery

Front 81

Suprapubic Pressure

Back 81

• NOT fundal pressure
• Lateral pressure in direction of
fetal nose
• Protect your back
• Support/inform patient +support
person

Front 82

Shoulder Dystocia
Complications

Maternal

Back 82

- episiotomy
- extended lacerations
- hematomas
- uterine atony
- hemorrhage
- bladder injury
- rectal injury

Front 83

Shoulder Dystocia
Complications

Fetal

Back 83

- # of clavicle or humerus
- bachial plexus injury or spinal nerve damage
- Erb's palsy
- asphyxia
- mentla retardation
- death

Front 84

Persistent Occiput Posterior
(POP)

Back 84

- 25% of pregnancies at term
- Must rotate 135 o

ROP -> ROT -> ROA->OA

Maternal Risks
- intense pain in small of back
- often longer labour
- if delivers „³ 3o or 4o laceration

Front 85

POP - Nursing Implications

Back 85

• Encourage change of position

• Knee-chest or all 4’s position

• Comfort measures
–Back pain, counter-pressure, shower

• Encourage to void Q2h

• Assess stress & coping
– information about what’s happening

Front 86

Breech

Back 86

• 3-4% of births
– 25-26 weeks – 21% incidence
– 40 weeks – 3-4 % incidence

• Etiology:
– prematurity
– uterine or pelvic structural abnormaility
– placenta previa
– polyhydramnios
– multiple gestation
– fetal anomaly or abnormality
– chance

Front 87

Diagnosis of Breech

Back 87

• Maternal perception of movement

• Leopold/s Maneuver’s
– hard, ballotable part in uterine fundus

• FH auscultated above umbilicus
–pre-term or small fetus - may be below umbilicus.

• Vaginal examination

• U/S

• Thick meconium (if ROM)

Front 88

External Cephalic Version

Back 88

• 36+ weeks
• Ultrasound
• Reactive NST
• Can’t be engaged
• Tocolytic to relax uterus
• Risk of cord around neck/body
• Fetal Monitoring
• Monitor for SOL

Front 89

Term Breech Delivery -
What is the best way to deliver?

Back 89

• U/S
–Confirm position, size

• Best method of delivering an uncomplicated
term frank or complete breech singleton,
>2500 and <4000g with flexed head = vaginal
birth (2009)

• Footling=c/s
–Unless advanced labour

Front 90

Fetal Risks

Back 90

- Cord prolapse

- Traumatic injury to aftercoming head leads to intracranial hemorrhage or anoxia

- Preterm breech - footling & body may deliver before full dilatation = entrapment

Front 91

Vaginal Delivery of Breech

Back 91

• Assessment of FH / vaginal exam with
ROM
• Bladder empty
• Practitioner skilled in breech delivery,
anesthetist, NICU
• Do not pull or tug on body as delivering – maintain flexion

Front 92

Cord Prolapse

Back 92

Obstetrical Emergency
• Sudden, severe, variable decelerations or no FHR
– Feel or see cord

Causes
• Malpresentation )Breech, transverse)
• Polyhydramnios
• Premature rupture of membranes
• Amniotomy before engaged vertex
• Long cord

• Always check fetal heart after membranes rupture!!
• Get help
• Prepare for c-section

• Keep pressure off cord
– Knee-chest position
-- Keep hand in vagina
– 02
– Warm wet sterile cloth if outside vagina

• Vaginal delivery if fully dilated

Front 93

Cephalopelvic disproportion
(CPD)

Back 93

• Fetus is larger than pelvic diameters
– Size of baby
– Type of pelvis
– Other anomalies

• Dystocia
– Painful, prolonged labour
– Delayed engagement

Front 94

Management

Back 94

• Change positions
– Squat or sitting
– Increases outlet
– Knee chest, all fours, side to side

• Pain relief

• Forceps
– May make it worse

• C-section

Front 95

Assisted / Operative Deliveries

Vacuum, Forceps, C-section

Back 95

• Indications
– Fetal distress
– Maternal distress
• Exhaustion
• Anesthesia - Inability to push
• Lack of rotation

Interventions during
– Support, tell her what is happening
– Fetal heart (Oxygen)

Front 96

Prevention

Back 96

• Support throughout labour
• Mobility
• Position changes (walking)
• Rest
• Keep bladder empty
• Well hydrated and nourished

Front 97

Forceps

Back 97

Types
– Outlet
– Low
– Mid pelvis

• Rotate or traction

Must be
– Completely dilated
– Membranes ruptured
– Adequate pelvis - no CPD
– Bladder empty
- May need episiotomy

Front 98

Forceps - Complications

Back 98

• Newborn
– Bruising
– Edema
– Facial lacerations
– Cephalhematoma
– Transient facial paralysis
– Cerebral hemorrhage

• Woman
– Vaginal or perineal lacerations
– Infection secondary to lacerations
– Increased bleeding
• Risk for PPH
– Bruising and edema

Front 99

Vacuum Extractor ~14%

Back 99

- Suction to fetal head
(occiput)

- Should be progressive
descent with first two
pulls (with contractions)

- ^ risk
- cephalhematoma
- jaundice due to reabsorption of bruising
- breastfeeding

Front 100

Caesarean Section~26%+

Back 100

• Fetal distress
• Active genital herpes
• Multiple gestation (3+ fetuses)
• Umbilical cord prolapse
• Tumors that obstruct birth canal
• Lack of progress
• Maternal infection
• Pelvic size disproportion
• Placenta previa
• Previous cesarean section

Front 101

Preparation

Back 101

• Establishing IV lines

• Indwelling catheter

• Abdominal prep

• Teaching
– What to expect before, during, and after delivery
– Why is it being done
– What sensations will the woman experience
– Role of significant others
– Interaction with newborn (NICU @ delivery)

Front 102

Vaginal Birth after C-section-VBAC

Back 102

• ~75% success - depends on
– Cause of 1st section
– Type of 1st section
– Previous vaginal birth
– Maternal physical and mental health

• Trial of labour (TOL)

• Most common risks are
– Hemorrhage
– Uterine rupture 0.6% up to 9% in classical scar
– Infant death or neurological complications

Front 103

Care

Back 103

. Continuous EFM
- internal monitor

. Monitor uterine contractions

. IV fluids in progress

. Avoid oxytocin if possible
- inc risk of rupture

. Avoid cervical ripening
- Increases risk for rupture X4

. Support

. Prepared for C-section short notice
- Would have had pre-op work-up
- Type and Cross

Front 104

3 types of women…those who…

Back 104

1. prefer to give birth without any pain relief
2. sure they will want pain relief
3. unsure of their pain relief options, and how they will affect their labour and delivery

• All need support person/labour companion
– Doula, husband, someone there for her

• Your role
– support their efforts to have a natural childbirth, if that is their goal or facilitate other
plans they may have
– Optimal outcome

Front 105

Methods of Childbirth
Preparation

Back 105

• Grantly Dick-Read – childbirth without fear
– Breathing, psychoeducation, relaxation

• Lamaze
– Uses specific breathing patterns
– Controlled muscular relaxation techniques
– Disassociation relaxation
– Use of gentle touch and verbal cues
– Relaxation may also be promoted by cutaneous stimulation (Gate control theory)
– Abdominal effleurage

• Bradley
– Partner-coached childbirth
– Slow deep breathing
– 12 week education

Front 106

purpose of all methods

Back 106

– promote relaxation and save energy

– “fight or flight”
• Diverts energy away from uterus and gut

– Helps contractions and labour

– Maximum oxygen to mother and babe

– Helps to maintain alertness and presentness
• Maintain control

– Relax face, hands, bottom

– Calmly talk through each contraction

– Take over in helping with breathing or relaxation
when support person needs a break
• Ask them what you can do

Front 107

Positions

Back 107

• Impeded by monitor
– Telemetry
– regional anesthesia
– IV-induction, augmentation
– shyness

• Promote normal circulation and relaxation

• Promote labour and relieve discomfort
– Especially if baby posterior

• Keep active in early labour
– Stay home until contractions well established
– Walking

• Facilitate any position she is comfortable in
– pelvic rocking
– pillows
– slow dancing with partner
– sitting on birth ball and swaying
– Sitting on toilet
– lifting up the abdomen

**Look at pics slide #11**

Front 108

Birthing Balls

Back 108

• Helps to increase balance in pregnancy

• Eases back labour

• Sitting in a supported squat widens pelvis outlet to the maximum

Front 109

Environmental considerations

Back 109

• Dim lights

• Peaceful surroundings
– moaning and groaning

• Privacy
– Manage visitors

• Warmth or coolness, fan

• Music

• Talk quietly

• Avoid interruptions

• Clean
– Keep bed clean and dry, smooth wrinkles
– Peri care

• Safe

Front 110

Water - hydrotherapy

Back 110

• Safety getting in and out
• Buoyancy of water and
warmth-relaxing
• Positions

- been used for a long time throughout the world

Front 111

• Heat use for labor

Back 111

– deep tub bath, birthing baths, especially in difficult labours
• Can do FHR and Vital signs
• Hard to know if membranes slow leak

– Shower
• Distract, calm, refresh

– DO NOT LEAVE UNATTENDED – labour companion or nurse
• Emergency buzzer

– heated rice sock on groin or back

Front 112

Cold use for labor

Back 112

– ice packs on lower back
– cool cloth to wipe face, lips

Front 113

Massage

Back 113

• Heel of hand to press firmly on the bottom of spine, massaging in small circles

• Thumbs to massage on either side of spine

• Massage shoulders, taking care to keep the movement slow and firm.
– helps keep breathing relaxed

• Use long stroking massage down spine
– first with one hand and then the other

• Counterpressure during contractions
– Ask exactly where to push
and how hard to push
– Back, hips
– Method of communication

Front 114

Imagery for labor

Back 114

– visualize picture a peaceful place
• Beach or mountain stream
• Any place she likes to go
• Womb opening and baby moving down pelvis

Front 115

Hypnosis for labor

Back 115

– low-risk way of managing labour pain and anxiety that works for some women

Front 116

Distraction

Back 116

– early labour, walk, play cards, knit, watch TV, shower

Front 117

Non-focused awareness

Back 117

– paying attention to everything a person sees, hears, feels, smells without focusing on any

Front 118

• Acupuncture for labor

Back 118

– Few small studies - low-risk, effective way of managing
labor pain for some women

Front 119

• Acupressure for labor

Back 119

– Number of specialized sites

Front 120

Aromatherapy

Back 120

– emenogogues, promote menstrual bleeding may induce
miscarriage, oils not to be used include:
• Basil, clary sage, cedarwood, cypress, fennel, jasmine, juniper,
lemongrass, marjoram, myrrh, origanum, parsley, peppermint,
rose, rosemary and thyme. .
• chamomile and lavender must be avoided during the first
trimester, but after that can be very beneficial for certain
conditions
• Labour comfort and relaxation
– 2 drops of lavender, 2 drops of geranium and 2 drops of lemon or bergamot added to a bowl of hot water

Front 121

TENS.

Back 121

Transcutaneous Electrical Nerve Stimulation

• Electrical Analgesia

• Pulses prevent the pain signals from uterus and cervix from reaching brain
– stimulate release of endorphins
• Can take up to one hour to work effectively
- therefor practice and use beforehand

Front 122

Pharmacologic use

Back 122

• Provide maximum pain relief with minimum risk to mother and fetus

• Remember
– All systemic drugs used in labor for pain relief cross placental barrier by simple diffusion
– Drug action in body depends on rate at which substance is metabolized by liver
– Fetus has inadequate ability to metabolize analgesic agent

Front 123

Medications

Back 123

• Labour established or may establish!

• Demerol, Fentanyl, and Morphine
– 1st stage of labour
– Patches, IM, or IV at the peak of the contraction

• Side effects
– sedative effect and makes women drowsy and their
breathing shallow.
– nausea
– cross the placenta to the baby may cause fetal respiratory depression at birth if given too late in labor
• Narcan, opoid receptor antagonist, IV
– Caution use in addicted mother…..

Front 124

Nitrous Oxide N2O

Back 124

• “Laughing gas”
• ENTONOX
– 50% oxygen/ 50% nitrous oxide
• Self-administered
• Quick relief
• At onset of contraction not pain
• Rapidly eliminated
• Short effect to fetus
• All stages of active labour and
postpartum
• Claustrophobia, mask fear

Front 125

Epdidurals

Back 125

• May delay or speed up labour
– Timing of administration

• > 4cm

• May impede breastfeeding

• Mothers may spend more time in bed and less time with baby in the hospital

• Pushing during second stage of labour may be impaired due to lack of sensation

• anesthetic (bupivacaine) or analgesic (morphine or fentanyl) injected into epidural space

• Active labour >4cm and <6cm

• Produces little or no feeling to area from uterus downward

• May preload with crystalloid solution bolus
– NS or RL

• May need urinary catheterization due to loss of
bladder sensation

• Assess sensation motor control and orthostatic blood pressure

• Assess level of effect

Front 126

Continuous Epidural Analgesia
“walking epidural”

Back 126

- Allows for ambulation and mobility promote contractions

- ^ control over body compared to classic anesthesia
epidural
- Cocktail of medications
- Narcotic e.g. fentanyl, morphine, a local anesthetic and
epinephrine used in smaller amounts than the regular epidurals

- Designed to provide pain relief still be aware of
contractions
- will not mask extraordinary pain that we need to be aware of
- e.g. abruptio

- Not all women will be able to walk
- refuse (15-25%), leg weakness "not feeling normal", hypotension

Front 127

Combination spinal-epidural

Back 127

• before the epidural line is installed, medication is injected into the spinal fluid around the spinal cord
– This spinal injection acts more quickly than epidural
– Then the epidural line is placed and used for
continuous anesthesia

Front 128

Spinal Block

Back 128

• Local anesthetic (analgesic) injected directly into spinal canal

• Quick acting

• Level of anesthesia dependent upon level of administration

• May be administered higher for cesarean birth or lower for vaginal birth

• Onset of anesthesia is immediate
– Takes time to set up

• Protect legs from injury for 8 to 12 h postpartum due to decreased movements and sensation

• Total spinal anesthesia
– Respiratory and cardiac arrest

Front 129

Potential Complications with Anesthesia

Back 129

- Regional anesthesia

- spinal or epidural, similar possible complications
- Maternal hypotension
- bolus IV fluid and notify anesthetist
- Bladder distension
- Inability or reduced ability to push during 2nd stage
- Elevated temperature with epidural anesthesia
- Possible neurological damage
- Wet tap: needle inadvertently enters the subarachnoid
space = rapid leakage of CSF „_ headache.
- Epidural Blood Patch (EBP). 15-20 ml of patient¡¦s own blood
injected into the epidural catheter after epidural block had worn off completely

Front 130

Pudendal Block

Back 130

• Local anesthesia
– inject pudendal nerve
– anesthesia to lower
vagina, vulva, perineum

• End of labour

• No effect on fetus or
progress of labour

• Potential complications
– hematoma, perforation
of rectum, trauma to sciatic nerve

Front 131

Local Anesthesia

Back 131

• Anesthesia (lidocaine) injected into perineum prior to episiotomy

• Provides pain relief only for episiotomy incision

• There is no effect on maternal or fetal vital signs
– If done correctly

• Requires large amounts of local anesthetic agents

Front 132

General Anesthesia

Back 132

Urgent or Emergency situations
- C-section, fetal distress, retained placenta, failed regional

Challenges in the pregnant woman
- Increased mortality and morbidity
- Changes in oral mucosa, edema, obesity
- Higher Mallampati Classification
- amount of the posterior pharynx visible
- Increased esophageal reflux
- Delayed gastric emptying in labour
- Not NPO
- ^ O2 consumption, „` functional respiratory capacity
- Positioning

Front 133

Nursing Care

Back 133

• Monitor fetal heart EFM
– Disconnect from wall (also unplug bed!)

• Assess when last ate or drank

• Administer prescribed pre-medication
– Antacid (sodium citrate)
– Antihistamine ? Impact on breastfeeding

• Avoid supine hypotension

• Oxygenate

Front 134

CRICOID Pressure

Back 134

CRICOID only upper airway cartilaginous structure that is
complete ring, prevents passive regurgitation and aspiration of
gastric contents during induction of anaesthesia

FIGURE 20–7 Proper position for applying cricoid pressure “Sellick’s manoeuvre” until a cuffed endotracheal tube is inserted.

The cricoid cartilage is depressed 2 to 3 cm posteriorly so that the esophagus is occluded

Front 135

IV Considerations

Back 135

• Ensure IV access is established and maintained
– Large bore #18

• Urinary catheter

• EKG pads

• Tell them what is happening

• Reassure, touch…

Front 136

Major Complications

Back 136

• Fetal depression
– If mother receives general anesthesia = infant respiratory depression
– Avoid when infant is considered high risk

• Uterine relaxation
– Most general anesthetic agents cause some
uterine relaxation
– Synoticinon

• Monitor pp

• Vomiting / Aspiration
– Stomach may not be emptied prior to anesthesia
– Anesthetic agents may also cause vomiting and aspiration

Front 137

Many ways to help the woman in
labour

Back 137

• Many things can happen not according to their plan or their ideal
– Fetal distress
– Physicians or other care providers
– Respect their decisions

• Always reassure them they have done well
– Allay anxiety

• Explain

• Support

• Assess
– Be there for and with her

Front 138

Definitions of Pain

Back 138

1.IASP (International Association for the Study of Pain) - genesis of pain –mind, body, spirit

2. McCaffery- Expert on pain is the person experiencing it.

Front 139

History of Pain

Back 139

Interventions date back and are recorded in the book of Genesis.

Historically how people viewed the mechanisms of pain influenced the strategies to treat pain.

Front 140

Theories of Pain

Back 140

Specific Theory of Pain

Pattern Theory

**Gate-Control Theory**

=================
- theories are testable but not the absolute truth

Front 141

Factors that Influence the Gate

Back 141

Open gate increases nociceptive impulses


Partially or closed gate decreases nociceptive impulses

Front 142

Assessment & Measurement of Pain

Back 142

Consider=

- Developmental level of child
- Child’s own assessment of pain
- What is the stimulus for pain
- Parents assessment of their child’s pain
-The child’s language for pain

Front 143

ABC’s of Pain Assessment in children

Back 143

1. Always evaluate the child’s

2. Be careful to assess the physical aspects of the child’s pain, as an integral part of the physical exam

3. Consider the impact of family, health care, and environmental factors on the child’s pain.

4. Document the child’s pain severity on a regular basis. Use a pain scale that is appropriate.

5. Evaluate the effectiveness of pain interventions regularly and modify the treatment plan as necessary until the child does not have pain.

Front 144

Practice Tips

Back 144

1. Be honest

2. Use appropriate language

3. Clinicians should be competent with children (no students doing shit!!!)

4. When possible procedures conducted in a designated treatment room

5. Parents should be present if they wish

6. Parents should not be asked to restrain their child.

7. Child should be given the opportunity to ask questions.

8. Appropriate drug therapy

9. Treatment should always be holistic

Front 145

Modern pain management

Back 145

- prevent pain

- utilize new drugs and combinations

- titrate with individual pts

- use timed dosing

Front 146

Traditional pain management

Back 146

- palliate pain

- stay with a few tried & true drugs

- stay with low dose

- use PRN dosing

Front 147

Adjuvant drug classes

Back 147

- antihistamines

- anticonvulsants

- antidepressants

- anxiolytics

Front 148

Number 1 side effect of opiates is...

Back 148

- CONSTIPATION!!!

- resp depression only happens if you give the wrong dose

Front 149

Demerol / Mperidine

Back 149

- synthetic drug
- supposed to have less addictive qualities then the real shit
- supposed to replace morphine

- metabolism creates nor - mperidine
- builds up on receptor sites
- clings to the sites, therefor more drug = more bi- product
= ppl start to get twitchy = seizures
- and over time, you get less pain relief because it keeps binding up on sites
*** A dirty drug ***

Front 150

Bleeding During the First and
Second Trimester

Back 150

• Abortion
– Expulsion of the fetus before 20 weeks’ gestation
– < 500g
– Spontaneous:
• Occur naturally
• Uncertain number up to 30%
–50% due to abnormal chromosomes

– Induced
• medical or surgical
• Genetic, social

– Threatened, imminent, incomplete

Front 151

3 Types of Abortion Cases

Back 151

1. Threatened

2. Imminent

3. Incomplete

Front 152

Care for a Bleeding Lady

Back 152

Threatened abortion or miscarriage

Bed rest ?abstinence from sex

Support , explain

Persistent bleeding:
- Hospitalization
- IV therapy or blood transfusions
- Dilatation and curettage (D&C) or suction evacuation

Front 153

Ectopic pregnancy ‘tubal pregnancy”

Back 153

Implantation of fertilized ovum outside uterus
- 0.4-1.9 % pregnancies, prevalence increases

Initially symptoms of pregnancy
- Positive hCG

Chorionic villi
- grow into tube wall or implantation site

Rupture and bleeding into the abdominal cavity occurs
- Result is sharp unilateral pain and syncope
- Referred shoulder pain
- Lower abdominal pain Vaginal bleeding

Medical: IM methotrexate (stops growth of rapidly growing cells) if
future pregnancy desired

Monitor: hCG levels

Surgical: Salpingostomy or salpingectomy

Front 154

Bleeding During the Second
Part of Pregnancy

Back 154

Two main types
–Placenta previa
–Abruptio placentae

Front 155

Abruptio Placentae

Back 155

1 in 1000 births
• is increasing

Marginal placental abruption.

Placenta separates at its edges.

Blood passes between fetal membranes and uterine wall.

Blood escapes vaginally

Slides #8-9

Front 156

Causes of Abruptio Placentae

Back 156

• Decreased placental blood flow
– Hypertension, pre-eclampsia
– Smoking
– Cocaine
– Alcohol

• Trauma
– MVA, IVP

• Multiple gestation

• Increased Parity

• Maternal age

Front 157

Maternal Implications

Back 157

• Intrapartum and postpartum hemorrhage

• DIC (Disseminated intravascular coagulation)

• Hypofibrinogenemia

• Ruptured uterus
– overdistention

• Hemorrhagic shock

• Renal failure

Front 158

Fetal-Neonatal Implications

Back 158

• Sequelae of prematurity
• Hypoxia
• Anemia
• Brain damage
• Fetal demise

Front 159

Immediate Care--one-one care for a Bleeder

Back 159

Assess maternal
– Vital signs Q 5-15 minutes
– Monitor blood pressure and pulse frequently
– Observe signs of shock
• Colour, skin, consciousness
– Assess type & amount of bleeding over time period
– NPO

Prepare 2 large bore IV sites
– Fluids and blood products as ordered

Monitor fetus and uterine activity electronically
– Assess resting tone Q 5-15 minutes
– Continuous EFM
• Assess fetal status Q 5-15 minutes

Front 160

Nursing Care for a Bleeder

Back 160

• Oxygen per mask/prongs

• Review and evaluate diagnostic tests
– Hgb, PT/PTT, Type and Cross match

• Prepare for cesarean, as needed

• Assess coping mechanisms of woman and family
– Crisis
– Provide information and emotional support

• Neonatal resuscitation team, as needed

• Pain relief, as needed

Front 161

Placenta Previa

Back 161

• 4 in 1,000 births

I LOW LYING
– implanted in lower segment
close to os baby can still be
born vaginally

II MARGINAL
– lower edge touches cervical
os but does not cover it, baby
may be born vaginally

III PARTIAL
• partially covers os. C/S

IV TOTAL
• completely covers os. C/S

Front 162

Placenta previa
• Detection

Back 162

– Routine ultrasound

– Must be monitored
• 80+% migrate during pregnancy

– 34 weeks+ with painless vaginal bleeding as lower uterine segment forms

• Goal is to get to 36-7 weeks gestation

Front 163

Placenta previa associated with

Back 163

• Previous placenta previa

• Abnormal uterus shape
– Fibroids - age

• Multiparity

• Previous C-section or other uterine surgery

• Smoking, cocaine use

• Unknown

Front 164

Implications for Placenta Previa

Back 164

• Maternal psychological stress

• Transverse lie common

• Changes in FHR

• Meconium staining

• Fetal compromise (hypoxia)

• Cesarean birth

• Neonatal anemia

Front 165

Nursing Care

Placenta Previa

Back 165

• Bed rest

• Avoid Constipation

• Avoid sexual activity

• No vaginal exams!

• Objectively and subjectively assess
– blood loss, pain, uterine contractility

• With active hemorrhage
- Continuous external monitoring of FHR and
uterine activity - NO internal monitoring

Front 166

If contractions never go away... Most likely have

Back 166

- Abruptio

Front 167

Succenturiate Placenta

Back 167

– One or more accessory lobes of fetal villi develop on placenta = PPH

Front 168

Circumvallate Placenta

Back 168

– Double fold of chorion and amnion form ring around umbilical cord on fetal side of placenta

– increased risk of late abortion, APH, preterm labor

– May also cause IUGR, prematurity, fetal death

Front 169

Battledore Placenta

Back 169

– Umbilical cord is inserted at or near placental margin

– This leads to increased chance of preterm labour and bleeding

– May also cause prematurity and nonreassuring fetal status

Front 170

Velamatous Insertion

Back 170

– Vessels of umbilical cord
divide some distance from
placenta in placental
membranes

– If one vessel is torn=
hemorrhage

– leads to nonreassuring
fetal status and/or
hemorrhage in fetus

Front 171

Retained Placenta

Back 171

• Retention of placenta
beyond 30 minutes after
birth
– Mismanaged 3rd stage

• Occurs in 2% to 3% of all
vaginal births

• If not expelled
– Manually removed
– if woman does not have an
epidural anesthesia in
place, general anesthetic

Front 172

Placenta Accreta

Back 172

• Chorionic villa attach directly to
myometrium of uterus

• May result in maternal hemorrhage and failure of placenta to separate from uterus

• May result in need for hysterectomy at time of birth

• Incidence of placenta accreta is 10% to 25% in presence of placenta previa

Front 173

Postpartum Hemorrhage

Back 173

• >500ml

• >1,000ml
– severe, woman will be compromised, BP may be stable

• Bleeding affects 5-15% births

• 4 Ts
1.Tone (70%)
2.Trauma (20%)
3.Tissue (10%)
4.Thrombin(<1%)

• Immediate
– 3rd stage

• Later
– 4th stage up to 6 weeks

Front 174

1. TONE - Uterine Atony

Back 174

• Lack of uterine muscle tone
– Overdistended uterus
• Twins, polyhydramnios, macrosomia
– Grandmultipara
– Preeclampsia and MgS04
– Over use of syntocinon during labour
– Infection

• Fundal expression & massage
– check for clots and tissue

• Severe
– Bimanual expression

• Administer uterine stimulants
– Oxytocin IV
– Hemabate IM

Front 175

Subinvolution

Back 175

• Usually occurs 1 to 2 weeks after birth
– Failure of uterus to return to normal size after pregnancy
– lochia rubra of greater than 2 weeks duration

• Provide mother with discharge
instructions and information about possible complications

Front 176

2. TRAUMA - Lacerations

Back 176

• Cervical or vaginal lacerations suspected when bright-red bleeding in presence of contracted uterus
– Precipitous delivery
– Forceps
– Vacuum
– Prepare for
• Exploration
• Surgery
– IV, etc….

• Usually repaired immediately after delivery Hematomas
– May not severe hemorrhage but bleed, pain, ecchymosis

Risk for:
•Infection
•Blood loss
•Pain management
•Keep bladder empty

Front 177

3. TISSUE
- Retained Placental Fragments

Back 177

• 3rd stage mismanagement common cause

– “Fundal fiddling”

– Bleeding
• firm fundus and no lacerations

– Inspect placenta thoroughly after its delivery
• Missing lobes
– Insertion of vessels
– Infarcts

Front 178

4. THROMBIN

Back 178

• DIC
• Other bleeding disorders

Front 179

Signs of PPH

Back 179

- excessive or bright red bleeding
- a boggy fundus that does not respond to massage
- abnormal clots
- any unusual pelvic discomfort or backache
- persistend bleeding in the presence of a firmly contracted uterus
- rise in the level of the fundus of the uterus
- increased or decreased pulse/bp
- hema toma formation or bulging/shiny skin in the perineal arean
- decreased level of consciousness

Front 180

General care for PPH

Back 180

Bleeding won’t stop
– IV
• Oxytocin
• Hemobate
• Blood transfusions
– Vital signs
• Signs of shock
– Pack uterus
– Cauterization
– Hysterectomy

Front 181

the main cause of PPH PP day 15 is...

Back 181

- retained products of conception

Front 182

Polyhydramnios/Hydramnios

Back 182

• Excessive amniotic fluid > 2000ml

• Associated with
–Maternal
• Diabetes
• Rh sensitization
– Large placenta

Front 183

Fetal Anomalies

Back 183

– Hydrops fetalis
• fluid accumulation in the fetus from congestive heart failure, obstructed lymphatic flow

– Anencephaly

– Cardiac anomalies

– Esophageal or duodenal atresia

– Neural tube defects
• Exposed meninges

– Twins

Front 184

Assessment for amniotic fluid

Back 184

• Fundal height
– disproportionately large for dates

• Difficulty palpating fetus and auscultating FHR

• Tense, tight abdomen on inspection
– Straie gravidarum

• Large spaces between fetus and uterine wall on ultrasound

Front 185

Implications of PolyHydraminos

Maternal

Back 185

- sob
- edema
- problems with mobility, sleep
- greatle increased cesariean rate
- uterine dysfunction
- abruptio placentae
- PPH

Front 186

Implications of PolyHydraminos

Fetal - Neonatal

Back 186

- preterm birth
- increased mortality rate
- prolapsed cord
- malpresentation
- premature rupture of membranes

Front 187

Care for Polyhydraminios

Back 187

• Provide information
– Ruptured membranes, cord prolapse

• Emotional support

• Maintain absolute sterility during amniocentesis

• Social work/perinatal loss team if fetal defect identified

Front 188

Oligohydramnios

Back 188

• <500ml

• Postmaturity

• IUGR
– secondary to placental insufficiency

• Major renal malformations
– Renal agenesis
– Dysplastic kidneys
– Lower urinary tract obstructions

Front 189

Assessment

Oligohydramnios

Back 189

• Fundal height
• Fetus easily palpated and outlined
• Fetus not ballotable
• Variable decelerations (- increased risk of compressing the cord, not enough fluid around to buffer it)
• Reduced amniotic fluid volume
– AFV on ultrasound

Front 190

Implications

Oligohydramnios

Back 190

• Dysfunctional labor with slow progress

• Fetal deformation defects
– Adhesions
– Skin and skeletal abnormalities
– Pulmonary hypoplasia
– Dysmorphic facies
– Short umbilical cord

• Umbilical cord compression

• Head compression

Front 191

Amniotic bands

Back 191

• Folds of amniotic sac or premature rupture of membranes that have sealed over
– Anomalies
– Associated with increased risk of club foot, cleft palate and lip

• Can lead to
– amputation of digits
– permanent bands
– malpresentation-breech

Front 192

Care for oligohydraminos

Back 192

• Provide information and encourage questions

• Evaluate EFM tracing for _________ _________

• Reposition mother to relieve cord compression

• Assist with amnioinfusion
– 500ml, sterile normal saline

• Evaluate newborn
– Anomalies
– Pulmonary hypoplasia
– Postmaturity

Front 193

Amniotic Fluid Embolism

Back 193

• Amniotic fluid, fetal cells, hair, or other debris enter maternal circulation

• Symptoms
– Sudden onset respiratory distress
– Acute hemorrhage
– Circulatory collapse
– Hemorrhagic shock
– Coma and maternal death*
– Fetal death if birth not immediate
• Dyspnea
• Cyanosis
• Frothy sputum
• Chest pain
• Tachycardia
• Hypotension
• Mental confusion
• Massive hemorrhage

***Emergency!!!***

Front 194

Care

Amniotic Fluid Embolism

Back 194

• Emergency team
• Positive pressure oxygen delivery
• Large bore IV
• CPR as needed
• Prepare for cesarean birth
• Prepare for CVP line insertion
• Administer blood

Front 195

Grand Multipara

Back 195

>5 pregnancies to viable age 20 weeks
– age-related anomalies

• Anemia

• Malpositions and malpresentations
– Operative delivery

• Antepartum hemorrhage - 2 fold increase

• Postpartum hemorrhage - 4 fold increase

Front 196

Obesity

Back 196

Toronto-1994 and 2000
# overweight mothers rose by 37% over the seven years
# obese women went up 70%
# severely obese jumped 80%, to 1/ 200 women

• Associated with
– Fertility problems
– Increased malformations
– Complications
– increased difficulty with anesthesia
– C-sections (>50%)
• Infections
• Mobility
– Maternal and fetal morbidity, mortality
– Fetal anomalies, risk linked to amount overweight

Front 197

Adolescent
pregnancy

Back 197

Increased risk Factors
- substance, poverty, education
- less prenatal visits
- increased complications
- increased hospitalizations

Psychosocial
- support
- school
- intergeneratinoal household

Front 198

Older Gravida

Back 198

• >35

• Decline in fertility

• Increase in chronic diseases
– Hypertension, cardiac, thyroid, cancers etc.

• Increased difficulties in pregnancy
– May be 1st episode of these problems or exacerbate them

• Increased risk of c-section

• Increased anomalies

• Increased risk in general

• Keeping up with baby!

Front 199

INFECTIONS

Back 199

• TORCH
–TOxoplasmosis
–Rubella
–Cytomegalovirus
–Herpes Simplex

Some resources substitute:
–Other (Syphilis, HIV, Hepatitis B)

Front 200

Toxoplasmosis: Protozoan

Back 200

• Transmission – raw meat, cat feces

• ~23% people are seropositive
– If infected before pregnancy no problems, but if infected during pregnancy then risks to fetus
– CNS damage, hydrocephalus, microcephaly…

• Treatment
– Sulfadiazine and pyrimethamine
– Given after the 1st trimester

Front 201

Rubella: Virus

Back 201

Transmission: Across placenta to fetus
– Rubella syndrome
• Cataracts/congenital glaucoma, congenital heart
disease (patent ductus arteriosus or peripheral
pulmonary artery stenosis), loss of hearing, pigmentary
retinopathy
• Purpura, splenomegaly, jaundice, microcephaly,
mental retardation, meningoencephalitis,
radiolucent bone disease

• Treatment: Prevention
– Vaccination of all children
– Vaccination of women of reproductive age

Front 202

A woman's rubella titre is <1:8 at 8wks gestation.

would her doctor order a rubella vaccine postpartum?

Back 202

-Yes

-Then after that, tell her to not get pregnant for at least 3 months or else you could eff up the baby

Front 203

Cytomegalovirus

Back 203

• >40% of people are seropositive

• If acquire primary CMV in pregnancy - fetal neurological, eye, ear, and liver damage

• No treatment, prevent with good handwashing and avoid crowds of young children

Front 204

Herpes

Back 204

• Transmission congenital or intra or postpartum

• ↑ 70% transmitted during asymptomatic shedding

• increased spontaneous abort, preterm, lbw, microcephaly,
CNS complications

• Asymptomatic at birth
~ 2 weeks may develop fever, vesicles

• Suppressive antivirals ~36 wks – acyclovir

• ROM - 40% vertical transmission

• Vaginal birth unless active or prodromal symptoms

• Breastfeeding check (unless active lesions on breast)

• Hand washing++

Front 205

Bacterial Vaginosis -- BV

Back 205

• 10-25% of all women

• 50% asymptomatic
– lactobacilli and more Gardnerella vaginalis,
anaerobes, and mycoplasmata
– itching, burning, copious white discharge

• Infections =
– Spontaneous abortions
– Preterm delivery
– Maternal and fetal morbidity and mortality

Front 206

Group B streptococcal
infection-GBS

Back 206

• 15-40% women colonized
– Urine, uterus=pain
– Rectum, vagina = asymptomatic

• 40-70% pass on to baby

Risk
• Preterm labour (with or without ROM)
• PROM --PPROM
• Unexplained T in labour
• Previous baby with GBS infection
• Bladder or kidney infection
– GBS bacteria
– Culture

Front 207

Baby 1-2% babies affected by GBS

Back 207

1. Early onset: especially preterm, 1st week
– Temperature dysregulation, fever, seizures, respiratory distress, unusual behaviour,
stiffness, extreme limpness
– Up to 25% mortality

2. Late onset: 2-4 weeks
– Problems feeding, meningitis, grunting resp, fever, seizures, extreme limpness
– 10% mortality
– Up to 20% of the babies who survive GBS related meningitis - permanently handicapped

Front 208

Treatment for GBS

Back 208

• Prevention and early identification
– Screen ~ 35-37 weeks

• IV antibiotics
– IV -- penicillin G, erythromycin, clindamycin

• Neonatal infection treated with antibiotics

Front 209

Hepatitis C - HCV

Back 209

• 0.2-0.5% pregnant women in Canada

• Vertical transmission 5-6%

• Acute and chronic liver disease
– HELLP

• Universal screening for HCV is not recommended
– should be offered to all women falling into any at-risk
category

• Treatment
– Interferon and ribavirin therapy – teratogenic

• Breastfeeding check

Front 210

Hepatitis B

Back 210

• Vertical transmission

• Breastfeeding
– avoid if cracked or bleeding

• May not be symptomatic
– Be a carrier for life
– Permanent liver damage, death

• Immunization
– (Birth), 2, 4, 6 month

Front 211

Human Immunodeficiency Virus
(HIV) 0.1% of pregnancies

Back 211

Fetal/neonatal risk
– Passes through placenta (25%) 8 weeks, blood
transfer at birth
– Antiretroviral therapy has decreased infection rates

– Following birth
• Positive antibody titer
• Passive transfer of maternal antibodies rather than HIV infection

– Passes through breastmilk
• NO Breastfeeding (~ 3rd world countries - ok)

Front 212

HIV Care

Back 212

• No tx=25% risk of HIV

• Three-part Zidovudine (AZT,ZDV,Retrovir) prophylaxis regimen
–Pregnancy - Oral ZDV daily
– Labor - Intravenous ZDV during labor and until birth
– Infant - Oral ZDV
• Start 8 to 12 hours after birth
• Continue for 6 weeks

Front 213

H1N1 flu virus

Back 213

• May or may not more likely to get the flu
– But less likely to take flu shots
– Decreased lung capacity
– Systemic suppression of cell-mediated immunity -
immunologic shift

• If pregnant woman does catch H1N1, especially in 3rd trimester
– pneumonia and severe respiratory distress
– complications = abortion or early delivery

• Tamiflu and Relenza within 48hrs of symptoms

• Decrease chance of exposure

Front 214

Postpartum
Infections

Back 214

• C-section - wound infections

• Perineal cellulitis
– pain

• Mastitis – fever, engorement

• Respiratory complications from anesthesia

• Retained products of conception
– Foul lochia

• UTIs

• Endometritis
– lower abdominal tenderness one or both sides, tenderness
elicited with bimanual examination, T>38.3°C

Front 215

a woman who is 31 wks gestation akss you about taking seasonal flu vaccine, how would you reply?

Back 215

- make sure your husband gets it
- its recommended for preggos

Front 216

Risks for puerperal infection

Back 216

Bacterial infections
• C-section - 1
• Frequent pelvic exams -2
• Prolonged rupture of membranes
• Pre-existing infection
• Hemorrhage, anemia
• Obesity
• Diabetes – UTI, Vaginal infections
• Nutritional deficits
• Delivery room cleaning practices

Front 217

There are two types of injuries:

Back 217

1. Intentional – the result of violence such as suicide attempts, rape, and assaults

2. Unintentional – result from falls, burns, drowning, motor vehicle incidents, and other
situations commonly referred to as ‘accidents’

Front 218

Pediatric injuries

Back 218

Injuries thought of as “Accidents” or “freak accidents” implies that nothing can be done.

However, injuries are preventable and predictable events…to reduce the risk of the
potentially devastating effects of
unintentional injury, preventions steps must be taken

Front 219

accidents/injuries in Saskatchewan

Back 219

! Every year approximately 775 children under 6 are hospitalized and 15 die in Saskatchewan

! Injuries are the leading cause of
hospitalization and death in children and youth in SK

Front 220

When caring for children and youth, keep in mind.

Back 220

! Kids are really not just small adults

! airway and shock mgt paramount

! head injury: increased morbidity & mortality

! forces over small area = multisystem injury

! little or no external injury

! kids die from hypoxia and resp arrest

! increased heat loss, glucose & fluid requirements

! psyche sequelae – you not only have an injured child, but also an injured family!

Front 221

What makes children more susceptible to accident/injury?

Back 221

Airway:
Anatomy increases obstruction risk
! Large head
! Short neck
! Small mandible
! Large, posteriorly-placed tongue
- think about the effects of these anatomical features to incubation
======================

Front 222

Pediactric Breathing

Back 222

! Increased respiratory rate
! 30/min = ? normal for small child
! Slowing rate = impending arrest

Small thorax
! Transmitted breath sounds
! Misleading findings on auscultation
! Inspection, palpation more reliable

! Diaphragm breathers

! Pliant chest walls

! Weak accessory muscles

! Limited respiratory reserve

Front 223

Leading Cause of
Pediatric Cardiac Arrest

Back 223

Resp Failure

Front 224

Pediatric circulation

Back 224

! Small blood volume

! Rapid control of blood loss essential

! Good initial compensation for hypovolemia

========================
BP monitoring
! Poor method
-low BP LATE sign: kids
compensate well
> 25% loss of blood volume (think s/s of hypovolemic shock)

*****minimum acceptable systolic BP: 70 + (2 x age)******

Front 225

Pediatric abdomen injuries

Back 225

Spleen, liver = Most common injuries
! High, broad costal arch
! Relatively larger organs
! Poor abdominal muscle development = poor protection

Front 226

C-Spine Injuries

Back 226

! Less common in children, higher mortality

! falls>MVA>sports (trampolines)

! <8 yr: 2/3 above C3

Front 227

Spinal Cord Injury

Back 227

! Spinal cord injury causes myelopathy or damage to white matter or myelinated fiber tracts that carry sensation and motor signals to and from the brain.

! It also damages gray matter in the central part of the spinal, causing segmental losses of interneurons and motorneurons.

Front 228

Each segment of spinal cord innervates...

Back 228

Slide #16 of pediatric trauma lecture

Front 229

Complete spinal cord injury

Back 229

! A complete spinal cord injury produces total loss of all motor and sensory function below the level of injury.

! Almost one half of all spinal cord injuries are complete.

! Even in complete spinal cord injuries, the spinal cord is rarely cut or transected

Front 230

Incomplete spinal cord injury

Back 230

! An incomplete injury means that there is some functioning below the primary level of the injury.

! A person with an incomplete injury may be able to move one limb more than another, may be able to feel parts of the body that cannot be moved, or may have more functioning on one side of the body than the other.

Front 231

Prognosis

Back 231

! The level of injury is very helpful in predicting what parts of the body might be affected by paralysis and loss of function.

! incomplete injuries there will be some variation in these prognoses.

! Cervical (neck) injuries usually result in quadriplegia. Injuries at C-3 and above level requires ventilator support.

! C-5 injuries often result in shoulder and biceps control, but no control at the wrist or hand. Diaphram function is present when
injury at C-5.

! C-6 and C-7: Quadriplegia, some function of upper extremities.

! Sensory level lost below the sternum.

! Injuries at the thoracic level and below result in paraplegia, with the hands not affected.

! T-1 to T-8 there is most often control of the hands, but poor trunk control as the result of lack of abdominal muscle control.

! Lower T-injuries (T-9 to T-12) allow good trunk control and good abdominal muscle control. Sitting balance is very good.

! Lumbar and Sacral injuries yield decreasing control of the hip flexors and legs.

! other changes may occur such as: bowel and bladder dysfunction.

! Sexual functioning also may occur with SCI males may have their fertility affected, while women's fertility is generally not affected.

! Other effects of SCI may include low blood pressure, inability to regulate blood pressure effectively, reduced control of body
temperature, inability to sweat below the level of injury, and chronic pain

Front 232

Spinal injury dx

Back 232

! A neurologic
examination indicates
the location of the
injury, if it is not
immediately evident.

! The reflexes may be
abnormal or may be
absent in affected
areas of the body.
Spine X-rays

! A CT scan or MRI

Front 233

Spinal injury tx

Back 233

! Corticosteroids, such as dexamethasone or methylprednisolone, are used to reduce swelling that may damage the spinal cord.

! Surgery: This may include surgery to remove fluid or tissue that presses on the spinal cord
(decompression laminectomy).

! Bedrest may be needed to allow the bones of the spine, which bears most of the weight of the body, to heal.

! Treatment will address muscle spasms, care of the skin, and bowel and bladder dysfunction.

! Extensive physical therapy, occupational therapy, and other rehabilitation interventions
are often required after the injury has healed.

Front 234

Autonomic dysreflexia

Back 234

! Hypertension, severe headaches, pallor below
and flushing above the injury, and seizures occur due to impaired Autonomous Nervous System.

! Can be triggered by a full bladder.

Front 235

Immobility

Back 235

Central Nervous System
! Depression is a normal response to progressive loss of muscle function and impaired mobility.
! Hospitalization can result in social isolation
that may compound feelings of depression.

Cardiovascular
! Poor circulation
! Impaired blood flow can also lead to blood clot formation.

Respiratory
! secretions in the lungs may accumulate and thicken, causing mucus plugs and increased
respiratory difficulty.
! Secretions in the lungs also harbor bacteria that may cause pneumonia.

Muscle Skeletal
! atrophy
! Joint stiffness and pain.
! Contractures

GI/GU
! Urinary tract infections
! kidney stones.
! Constipation

Integument
! Pressure sores or ulcers

Front 236

Nursing interventions for immobility

Back 236

! Stretching and range-of-motion exercises to each of the joints everyday, and several times a day.

! Proper body alignment, and change positions at least every two hours.

! Deep Breathing and coughing

! Maintain an adequate fluid intake.

! Maintain regular contact with people and do not allow immobility or embarrassment to be a barrier to interacting with others.

Front 237

Other complications of spinal cord injury.

Dehydration

Back 237

Early signs of dehydration include:
! Increased thirst.
! Dry mouth and sticky saliva.
! Reduced urine output with dark yellow urine.
- give 100cc/kg/day

Symptoms of moderate dehydration include:
! Extreme thirst.
! Dry appearance inside the mouth and the eyes don't tear.
! Low urine output. Less than 1-2 mls per hour.
! Urine is dark amber or brown.
! Lightheadedness that is relieved by lying down.

Severe dehydration is life-threatening.
! Altered behavior, such as severe anxiety, confusion,
or not being able to stay awake.
! Faintness
! Weak, rapid pulse.
! Cold, clammy skin or hot, dry skin.
! Little or no urine output.
! Loss of consciousness.
! Poor skin turgor
! Low blood pressure
! Delayed cap refill

Front 238

GU differences

Back 238

Kidneys mature in the first year

Neonates have limited ability to concentrate urine

Normal Urine Output:
Infant – 2 ml/kg/hr
Child = 1 ml/kg/hr
Adolescent/Adult = 0.5 ml/kg/hr

Kidney function
! determines the secretion of drugs

Front 239

Urine output

Back 239

! 1-2 mls/kg/hr
! 1ml/hr*45kg=45mls/hr
! 45mls/hr*24 hrs=1080mls/24 hours
! Minimum Output in 24 hours: 1080mls
! Actual output: 800mls

Front 240

Electrolyte differences

Back 240

Glucose:
! Infants have high glucose needs and low glycogen stores. They often become hypoglycemic during periods of stress
! Hypoglycemia and hyperglycemia may be an early sign of sepsis
! Glycosuria may be an early sign of infection in the child.
! IV solution of choice is a dextrose based solution

Front 241

IV solutions: Isotonic

Back 241

! Have a concentration of dissolved particles equal to the intracellular pressure.

! osmotic pressure is the same in and out of the cells.

! Examples of Isotonic solutions are: Normal Saline, D5W, Ringers lactate

Front 242

Hypertonic

Back 242

! Hypertonic solutions draw fluid from the intracellular space, causing cells to shrink and the extracellular space to expand.

! Examples of hypertonic solutions are: D51/2NS, D5NS, D10W

Front 243

Hypotonic

Back 243

! Hypotonic solutions should be given with caution as fluid moves from the extracellular
space into the cells, causing the cells to swell.

! Example: 0.45 normal saline and 2/3 – 1/3

Front 244

UTI's

Back 244

Risks of UTI
! Females are especially susceptible to UTIs.
! Low oral fluid intake
! critically ill patients
! intermittent or indwelling catheter.
! Any abnormality of the urinary tract that obstructs the flow of urine (eg, kidney stones or an enlarged prostate)
! Congenital anomaly of the urinary tract.

Types of Infection
! Escherichia coli ( E Coli) is the most common infecting organism in patients with
uncomplicated UTIs
! Other gram-negative microorganisms
! Gram-positive pathogens
! Other microorganisms

Diagnosis
! Urinalysis:
! Culture and Sensitivity Test
! Voiding cystourethrogram
! Renal ultrasound

Nursing Interventions
! Increased fluid intake
! 100% pure Cranberry juice and vitamin C (ascorbic acid) supplements inhibit the
growth of some bacteria by acidifying the urine.
! A heating pad and pain relief medication are helpful for pain management.
! antibiotics.

Front 245

Perinatal Mood and
Anxiety Disorders
(PMAD)

Back 245

– Pregnancy and 1 year postpartum
- Depression

- Anxiety
• Obsessive Compulsive Disorder (OCD)
• Post Traumatic Stress Disorder (PTSD)

–Bipolar Disorder

–Psychosis

–Pinks and Baby Blues
• not disorders, but may indicate vulnerability

Front 246

Depression

Back 246

•Depressed mood most of the day

•Anhedonia - severely diminished interest or pleasure in activities
“What do you like about being pregnant/being a mother?”

•Weight changes

•Insomnia or hypersomnia

•Psychomotor; restless, agitated, slowed

•Diminished energy level
•Feelings of worthlessness or excessive guilt

•decreased concentration, increaesd indecisiveness

•Recurrent thoughts of death or suicide

Front 247

Perinatal
depression
symptoms

Back 247

• Irritability and anger

• Overwhelmed

• Hopeless and helpless

• Guilt and shame

• Sadness

• Lack of feelings toward the
baby

Sadness, crying

• Inability to cope, take care of self or family

• Suicidal thoughts

• Appetite changes

• Loss of interest, joy, or pleasure

• Sleep disturbances

• Poor concentration/focus

• Anxiety

• “I don’t feel like me”

• Mood swings

Front 248

Antenatal Depression

Back 248

“Melancholia in pregnancy”
• 1840s

• 1970s
– ‘protective’
– decreased Hospitalization rates (Kendell, 1976)
–Hormones (Kornstein, 2002)
–decreased psychosis & suicide (Brockington, 1996)
• 40% of depressed women had suicidal thoughts (Bowen et al., 2009; Levey, 2004)

• 2010
• ~20% of women

Front 249

Pinks

Back 249

•11%, 44% high risk

•Elation hours/days after birth (Glover et al., 1994).

•Normal to be happy and excited
• but extremes in mood in either direction need to be monitored

•Early discharge

•Sleep

•Bipolar

•Expectations of pregnancy

Front 250

Postpartum blues

Back 250

- normal, transient, emotional response

- up to 85% of women spontaneously recover by 2 weeks

- Depressed 2-3 days increased PPD 4-8 weeks (Dennis, 2003; Hannah, 1992; Teissedre,
2004)

- Social support

**Confirms need for increased
awareness, early identification, and timely intervention

• 60% of women experience their first major depression in PP

• Idealization of birth and motherhood (Beck, 2001; Fergerson, 2002)

• Hormones, thyroid, cholesterol, folate, anemia, stress

Front 251

Anxiety in mom

Back 251

• May be equally detrimental to fetus and maternal functioning as depression

• Predominant component in antenatal depression

• Comorbid and temporal relationship depression
– PPD
– Younger women

• 4-15% of women. Up to 24% in pregnancy (Sutter-Daly, 2004, Heron, 2004)

• inability to relax, persistent arousal

• fearfulness, phobic

• preoccupied / over-concern with baby

• high parenting expectations

• panic attacks - tension, sweats, palpitation

Front 252

Preggo Obsessive
Compulsive Disease
(OCD)

Back 252

- Intrusive, repetitive thoughts
• harm coming to baby

• Guilt, worry, shame

• Cleaning

• Checking
• Baby, house

• Hypervigilent

• Counting

• Behaviours to avoid harm
or minimize triggers

• Ordering

• Obsession with germs, cleanliness

• Assure
• Thought ≠ action

Front 253

Post Traumatic
Stress Disorder
(PTSD)

Back 253

• ~ 3% of births • Risk
~partial -25%

• Anxiety disorder
• Post terrifying event where grave harm occurred or was threatened

• Birth complications -
mother or baby
• Hemorrhage
• Emergency C/S
- preterm birth
-NICU baby

Birth
• Powerless
• Uncared for
• No trust
• Poor communication

Previous PTSD

• Previous Sexual Abuse

Front 254

Psychosis

Back 254

•1-2 in 1,000 postpartum women
- of those 5% Suicide and 4% Infanticide

•First 2-3 weeks after delivery or later postpartum

•Risk - History of Bipolar Disorder

•Delusions (baby possessed by devil)

•Hallucinations (seeing angels)

•Insomnia (no sleep for days)

•Rapid mood swings (>non-postpartum psychoses)

•Waxing/waning (can appear and feel normal between)

Front 255

Mental health aboriginal preggos

Back 255

. Birth rate 1.5 times higher

. 40% depressed in pregnancy

. Experience > adverse social factors increased risk for
depression

. Important to know more about maternal depression, anxiety, and mood problems in Indigenous women

Front 256

Qualitive data for mental health preggos

Back 256

• Ambivalence & conflict about motherhood (also in Aboriginal women)

Best of times-worst of times…

Themes
– Becoming a mother
– Being a mother
– Partnership: being and feeling alone
– Lack of support
– Lack of choices
– Lack of culture

Front 257

Mental health preggos Risk Factors

Back 257

Sociodemographic
-Gender, age, income, single, new immigrant, ethnicity

History of depression - psychiatric problems
- Own and family
- Mood reactions to hormonal changes

Social
- Unplanned, lack of social support, relationship issues,
partner and substance abuse

Medical
Fertility problems, obstetrical difficulties-previous
losses, thyroid, anemia, pain

Lack of sleep
Mother issues
20% OF ALL WOMEN ARE VULNERABLE

Front 258

Cortisol

Back 258

“the stress hormone”

•“Normalize” worry in childbearing women

•Hypothalamic-pituitary-adrenal HPA axis-placental neuroendocrine axis

•Maternal stress can affect fetal development

•Sustained pattern of stress reaction throughout life

•Neuronal death and abnormal development of fetal
brain structures

- increased stress = increased carbohydrate ingestion
- cortisol = blood sugar irregularities = fatigue, immune
system deficiencies, anxiety, panic attacks, depression

Immune system balance
- altered fetal immune function
- +++ = shrinking hippocampus decreased memory

Interferes with serotonin & dopamine
- low mood, cognition

Sleep disturbance
- Early morning surge and insomnia

Blood pressure

Other hormones

Fertility, estrogens

Front 259

Mental health effects on mother

Back 259

. Increases and worsens with parity

. GI - Irritable bowel

. Cardiac - comorbidities

. Cognitive problems - Hippocampus

. Sleep = ¨decreased coping, postpartum psychosis

. Relationship - Partners 50% more depression

. Social - Isolation-substance use-decisions

- Relationship - Partners10% of men overall, 75% if wife severely depressed (Goodman, 2004)

- Gestational hypertension (Kurki, 2000)

- Abruptio placenta (H 1994 K h Hanna, 1994; Kahn, 2002)

- increased Epidural, operative, and preterm deliveries (Ch Chung, 2001)

- Less prenatal care, prenatal vitamins
(Bonari, 2004; Zuckerman, 1989)

- increased Alcohol, smoking (Homish, 2004; Zhu, 2003)

Front 260

Mental health effects on baby

Back 260

. Preterm

. decreased Apgar

. decreased birth weight and weight gain

. Less and shorter duration of breastfeeding

Behaviour
. More withdrawn, irritable, less consolable, depressed

. Pattern of stress reaction

. 3.3 times the risk of Sudden Infant Death Syndrome (Mitchell, 2008)

Effects of lifestyle
. alcohol ?FASD, smoking, poor diet, prenatal care, etc.

Front 261

child readiness

Back 261

associated with

Behaviour
.anxiety in pregnancy = increased 3 X ADHD in boys and
depression in girls
. Emergency room visits, somatic complaints
. Social and school difficulties
. Criminality

Mothers less attentive to safety and stimulation
.Injuries and hospitalizations

Front 262

Father role in mental health in preggos

Back 262

–10% depressed perinatally

–Up to 50%↑ paternal depression in PPD
• No reason to expect it will be any less prenatally

–Similar effects on child (Goodman, 2004;
Ramchandani, 2005)
–Non-depressed partner important to child development

Front 263

Parenting effects d/t mental illness

Back 263

• Less responsive to baby’s cues

•Attachment problems begin (Spinelli, 2001)

• Less attention to stimulating child and safety issues

• Siblings

Front 264

Feelings in Pregnancy and
Motherhood Study

Back 264

Phase 1: October 2004-August 2006
Socially high-risk women - 39%

Phase 2: December 2005-Dec 2008
- General population – 14%
- Saskatoon and Five Hills Health Regions

Front 265

Who most at risk of preggo mental illness?

Back 265

•History of depression 5Xs

•Mood swings 2-3 Xs

•Stress 2Xs

•Unplanned pregnancy – Time 1

•Dissatisfaction with relationship – Time 2

•Smoking

•Social support

Front 266

Mother First

Back 266

Maternal Mental Health Strategy:

2 initiatives to improve maternal mental health

1. Increase awareness in Saskatchewan

2. Building capacity in Saskatchewan

Front 267

1. Increasing Awareness

Back 267

• Materials

• Available

• Saskatchewan Prevention Institute

• Healthline online

• Healthline 1-877-800-0002
– Fridge magnet

• Saskatchewan Drug Information Services
– 1-800-665-DRUG (3784)

• Visits to regions, groups

• Evaluate process

Front 268

2. Building Capacity

Back 268

PPD ‘Unmasking Postpartum Depression’ conference – Smiling Mask
• October 2009, Regina
• Started momentum - priorities for action
• Government invited our recommendations

Formed Working Group
• Regions, First Nations groups, Government, Professions, Prevention Institute, Health Quality Council, Healthline
• H1N1
• WebEx q 1-2 weeks
• Recommendations started right away May 2010-press conference

Front 269

RECOMMENDATION #1

Back 269

Education - Increase awareness
• Materials available
– Prevention Institute
www.skmaternalmentalhealth.com

• Ensure in curriculum of health professionals, schools

• E-Learning event – DVD - - ongoing learning

• Promote positive maternal mental health

Promote Positive Mental Health
• Exercise ( Bowen, 2009) e c se o e , 00 )
• Walking, swimming
• Sleep – 6 hours in 24
• Nutrition
• Simplify life
• Yoga or other relaxation

Support quitting self-medication
• smoking, drinking, drugs

Front 270

RECOMMENDATION #2

Back 270

Universal Screening - normalize – we care about all aspect s of your health – physical
and mental

Edinburgh Postnatal Depression Scale
>=12 probable depression
• 2 times in Pregnancy
- 1st visit, 28-34 weeks
• 3 times in Postpartum
- prior to discharge from early visit program (2-3 weeks) and
within public health and immunization visits 2 months (4
if not 2) and 6 months

Front 271

Why screen?

Back 271

Can’t always tell by looking or may not have time for in-depth mental health assessment
• busy with physical assessment or baby fussy

Can help to identify those at high-risk or in immediate distress

Inexpensive, quick, and easy

Can be educational, opens communication
• Review form with woman to promote treatment

Treatment can alleviate symptoms
• Unethical not to??

Front 272

Edinburgh Postnatal Depression Scale

EPDS

Back 272

• Perinatal depression screening tool -1987

• Screen for the probability of depression
DOES NOT diagnose depression reflects past 7 days

• Takes out physical symptoms

• Self report, free

Validated
• pregnant, hospital, and community populations
• languages/dialects
• Aboriginal women in Regina

• Picks up anxiety and poor coping

• Rapid identification of self-harm thoughts

• Can be used with partner…

• 10-11 -- possible mild
depression
• >12 -- probable depression
• Anxiety > 4 on items 3, 4, 5

Front 273

What Self harm thoughts….

Back 273

Reassure

“Given that things are so difficult for you right now, it would
be surprising if you didn’t have the occasional thought of
not wanting to be here”

“Are you feeling so angry you might be afraid of harming your
baby or yourself?”

“We are here to help you”

• Don’t leave positive #10 alone

• Suicide check

• Any thoughts of harming baby or others?

Front 274

Postpartum suicide

Back 274

• Suicide
–Risk postpartum increased 70-fold
–Presence of clinical disorder

• Follow-up on all positive responses or even non-positive if there is high score or history

- “Just want to check with you. Any thoughts of harming yourself?”

Front 275

Positive #10….Assess:

Back 275

1. Previous history – ideation and attempts
2. Type of thoughts – present and future
3. Intention/Plan/Level of risk
4. Presence of self-harming behaviours
5. Risk and protective factors
6. Support network
7. Safety planning
8. Emergency contacts

Front 276

Assess Risk of Harm to Baby

Back 276

• Adapt a “Question 11”
– “Has the thought of harming your baby or others occurred in the last week?”
NOTE (does NOT contribute to score)

• What kind of thoughts?

• Behaviours

• Maladaptive and adaptive coping

• Social support

Front 277

When to screen?

Back 277

• First or 2nd prenatal visit
• 28-34 weeks
• Within first 2-3 weeks
• At immunization visits
• Any time you feel there is a need

Front 278

Golden Triangle of mental illness

Back 278

1. Alcohol

2. Abuse - "How do you handle problems?"

3. Depression/anxiety

Front 279

RECOMMENDATION # 3

Back 279

• Prioritize pregnant and
postpartum women in MHS

Accessible in each region
– Inventory of services and supports

Increase treatment options
• Something…

Healthline
• Immediate

Front 280

Maternal Mental Health Program

Back 280

• Psychiatrist, psychologist, nurse therapist
– Clinic once/month
– Nurse 4hr/week
– Support to GPs
– Family physician residents

•Advisory Group

• PPD group,
breastfeeding
centre

Front 281

Interventions

Back 281

Interpersonal therapy
• Cognitive Behavioral Therapy
• Significantly > education

Groups
• Support, psychoeducation

Support
• Home visitor “listening visits”
• Peer

• Electroconvulsive Therapy – ECT

• Bright Light therapy

• Hormones

• Alternate treatments - Limited information
• Food and supplements
• Folic acid
• Omega 3 Fatty Acids (EPA - eicosapentaenoic)
• Grapefruit juice (when no meds)
• Vitamin D?
• St. John’s Wort contraindicated in pregnancy
• Placenta….

Acupuncture, massage, meditation

Front 282

Medication of preggo mental illness

Back 282

First thought is to come off
•up to 50-75% will relapse (Cohen, 2007)
•35% of pregnant women who are taking medications, are
taking psychotropic medications
•Up to 50% pregnancies are unplanned

1st month most critical
•Teratogenesis – when might not know pregnant ***
•preconceptual couselling

If start medication during pregnancy
•Not likely to begin until after 1st few weeks
•Is increased risk of bleeding

Neonatal adaptation syndrome - transitory

SSRIS
- Keep on one that they are stabilized on
Sertraline . low transfer to fetus and through breastmilk
Wellbutrin, Zyban - helps with depression and quitting
smoking

Atypical antipsychotics
- Anxiety

Bipolar
. Treatment ca n be problematic
. Valproic acid/Epival and other anticonvulsants can ª risk for NTD
. increased preconceptual and pregnancy Folic Acid
. Lamotragine better tolerated
. Lithium, neutral . limit in labour

Dosing
– Always aim for the lowest, most effective dose
•undertreatment
– ‘tapering’ (lithium)
– Depressive symptoms tend to increase as delivery approaches – hemodilution
• if woman has decreased or discontinued medication, closely monitor symptoms

• Combination of approaches

• Meds may be needed help to
stabilize mood so that other
approaches can work

Front 283

Promote Positive
Mental Health

Back 283

• Self-esteem
“Look how the baby listens to you”

Exercise (Bowen, 2009)
• Walking, swimming

• Sleep – 6 hours in 24

• Nutrition

• Simplify life

• Yoga or other relaxation - massage

• Support quitting self-medication

• smoking, drinking, drugs

Front 284

RECOMMENDATION #4

Back 284

Sustainability and Accountability
Maternal Mental Health Committees

• Provincial

• Regional
• Intersectoral
– Bring supports/treatment services together
– Identifiable place to get help with Maternal Mental Health

Front 285

Symptoms of depression

Back 285

• Less interest in things you usually like

• Crying for no reason

• Irritable, angry, or more sensitive

• More tired or feeling hyper

• Not sleeping or sleeping too much

• Problems concentrating

• Not able to cope

• Anxious or panicked

• Thoughts of harming yourself, your baby, or others

Front 286

Diabetogenic Effect of Pregnancy

Back 286

Glucose mother„_baby

1st trimester
- Rise in hormones stimulate insulin production &
increase tissue response to insulin
- 1st trimester - insulin needs frequently decreases

2nd and 3rd trimester
- Human placental lactogen hPL
- increased resistance to insulin and decreased glucose tolerance
- Insulin needs increase (2-3Xs by end of pregnancy)
- increased insulin required

Front 287

GDM

Back 287

Pregnancy/Maternal Effects
- Polyhydramnios
- PROM, premature rupture of membranes
- Preterm labour

Worsening myopathies
- vascular, renal, retinal

- Pre-existing diabetes increase Ketosis
- increased Gestational Hypertension
- increased Type 2 Diabetes later in life

Front 288

GDM
Fetal effects

Back 288

• Macrosomia
• Intrauterine growth restriction
• Hypoglycemia
• Hyperbilirubinemia
• Immature respiratory development = RDS
• Congenital Anomalies
• Fetal demise

Child effects
– Increased risk of developing diabetes
– Obesity

Front 289

Effects on fetus

Back 289

• Cardiovascular
– Transposition of great vessels
– Septal defects

• Skeletal
– Cordal regression syndrome
– Spina bifida

• GI
– Tracheoesophaegeal fistula
– Imperforate anus

• CNS
– Meninogmyocele
– Anencepahly
– Microcephaly

• GU
– Polycystic or absent kidneys

Front 290

10 Risk Factors

Back 290

1. Hx
2. Family hx
3. Previous or suspected macrosomia(>4,000 g)
4. Previous unexplained stillbirth, miscarriage
5. Previous hypoglycemia or hyperbilirubinemia
6. Advanced maternal age
7. Obesity
8. Repeated glycosuria in pregnancy
9. Polyhydramnios
10.Culture

Front 291

Screening for GDM

Back 291

Current CDA guidelines suggest routine screening of all women

• 24–28 weeks of gestation

• 50 g glucose challenge test (GCT), using a threshold of 7.8 mmol/L (140 mg/dL)

SOGC guidelines
• screen only those w risk factors at 24-28 wks

Front 292

Goal for GDM interventions

Back 292

maintain euglycemic state

Pregnancy
• Team approach

• Monitor
– Glucose
– Infections
– Fetal development and health

• Diet

• Insulin as needed

• Oral antihyperglycemics
– ______indicated

• Gentle exercise
– Walks after meals

Front 293

Insulin requirements intra/post - partum

Back 293

Intrapartum
. Balance insulin with need for increased energy in
labour
. Often maternal insulin requirements decrease in
labour

Postpartum
. insulin requirements decrease significantly
. rarely diabetic immediately postpartum

Front 294

Hypertensive Disorders of
Pregnancy HDP

Back 294

AKA
- Pregnancy Induced Hypertension - PIH
- Gestational Hypertension – GH
- Pre-eclampsia

5 - 7% of pregnancies
insidious or sudden onset

Front 295

Gestational Hypertension Risk Factors

Back 295

• Nullipara or first pregnancy with a new partner
• Personal or family history of hypertension (pregnancy)
• Poor nutrition
• Obesity
• Culture (east indians and filipinos have narrow veins)
• Advanced maternal age (> 35)
• Multiple gestation (i.e. twins, triplets, etc)
• Diabetes

Front 296

GHTN Classification

Back 296

Pre-Existing 1%
. predates pregnancy or before 20 weeks

Gestational 5%
- Diastolic . 90 mmHg
- after 20 weeks and up to 12 weeks PP
*Accuracy in BP measurement*

Preeclampsia 1-2%
-Proteinuria (>2+)
- or 1 or more adverse conditions

Severe Preeclampsia
- >160/110 mmHg
- Heavy proteinuria
- 1 or more adverse conditions

Eclampsia
- seizure

Front 297

GHTN Adverse Conditions

Back 297

• Headache
• Visual Disturbances
• Abdominal Pain
• Nausea/Vomiting
• Chest pain/SOB
• Abnormal maternal lab values
• Fetal morbidity
• Edema / Weight gain
• Reflexes

Front 298

GHTN Pathophysiology

Back 298

Increased peripheral vascular resistance

Decreased resistance to effects of angiotensin II

Decreased levels of vasodilators - nitric oxide

Loss of normal vasodilation capability

Increased levels of vasoconstrictors (partially
produced by placenta)

Concurrent vasospasm

Decreased renal perfusion and glomerular filtration

Decreased intravascular volume = increased blood
viscosity = increased hematocrit

Front 299

GHTN Maternal Risk

Back 299

• Seizures, renal failure and damage
• Abruptio placentae
• Ruptured liver and pulmonary embolism
• Disseminated intravascular coagulation (DIC)
• HELLP syndrome
• Cesarean section
• Chronic hypertension
• Stroke

Front 300

GHTN Fetal-Neonatal Risks

Back 300

Vasospasm
- decreased blood flow to placenta/baby
- decreased oxygen available = fetal distress

Preterm delivery/Premature

Abruptio Placentae

Hypermagnesemia - MgSo4
- Hypotonic

Increased morbidity and mortality
- Fetal demise
- IUGR/SGA

Front 301

GHTN Management

Back 301

• Home monitoring
– BP, weight, urine, NST~weekly

• Stress reduction

• Diet
– Avoid excess weight gain but no dieting
– Calcium, no restrictions (NaCl, protein)

• Baseline bloodwork
– enzymes, clotting, electrolytes
– ekg in pre-existing

• Treat nausea & vomiting

• Treat blood pressure
– Quit smoking
– ?low dose ASA

Front 302

In-patient: severe or preeclampsia tx

Back 302

• Bed rest – Left lateral position - ambulation

• Fetal evaluation (EFM, BPP)

• Hourly I&O
– 24-hour urine collection –creatinine ratio

• Frequent BP, pulse, resp

• Blood work
– Liver enzymes, electrolytes, clotting

• Consider seizure prophylaxis
– MgSo4

• Assess for adverse conditions
– Abdominal discomfort, visual disturbances, headache, weight, edema

• Assess deep tendon reflexes and clonus

• Timing / mode of delivery
– Ripen and Induce
• Ergometrine (not given b/c it will cause bp to increase)
– C/section
– Anesthesia
• Coagulation

Front 303

GHTN Anti-Hypertensives

Back 303

Labetalol - B adrenergic blocker

Aldomet (Methyldopa)-Centrally-acting sympatholytic

Nifedipine (Adalat) - calcium channel blocker

Hydralazine (Apresoline) - Arteriolar dilators

ACE inhibitors Atenolol (and prazosin) contraindicted
- Neonatal renal failure, IUGR, preterm, fetal/neonatal demise

Front 304

GHTN Anti-Convulsants

Back 304

Magnesium Sulfate MgSO4
4-6 g loading dose followed by 1-2 g q 1hr IV
. Can slow labour
. Muscle weakness
. Lack of energy and drowsiness
. Respiratory depression
. Lower blood pressure
. Tachycardia

**Goal - decrease CNS irritability and prevent seizures

Front 305

Magnesium Toxicity

Back 305

• CNS Depression
– Respiratory rate <12
– Oligouria <30mls/hr
– Diminished or absent DTR
– Serum magnesium 4.8 - 9.6 mEq

• Antagonist
– Calcium Gluconate
• 1gm over 3 min

Front 306

Eclampsia = SEIZURE. What to do?

Back 306

Anticonvulsants:
- Bolus of magnesium sulfate

Sedation and other anticonvulsants: Dilantin

Diuretics to treat pulmonary edema
- Furosemide (Lasix)

Digitalis (for heart)

Intensive nursing care

DELIVER
- if fetus <34 weeks give corticosteroids to increase
fetal lung maturity (Betamethasone)

Front 307

HELLP Syndrome

Back 307

• 10-20% women with severe pre-eclampsia

• Sudden, without warning
– GI pain

HELLP
• Hemolysis
• ELevated Liver Enzymes
• Low Platelets – thrombocytopenia
– Platelets aggregate at sites of vascular damage
– Be ready to administer platelets if < 20 109/L
– Epidural anathesia may not be an option if low
platelets

Front 308

DIC – Disseminated
Intravascular Coagulation

Back 308

• Can be caused by pre-eclampsia, hemorrhage, intrauterine fetal demise,
amniotic fluid embolism, sepsis, HELLP, etc.

• Over-activation of normal clotting mechanism

• Mini clots develop

• Depletes platelets and clotting factors = EXCESSIVE BLEEDING

Front 309

DIC Postpartum

Back 309

• Monitor BP, blood work
• Kidney liver function
• 6 weeks pp
• Monitor BP ongoing
• Spacing of next child 2-10yrs pp
• Weight management
• Increased risk for cardiovascular problems later life

Front 310

Rh Alloimmunization

Back 310

Rh- mother Rh+ fetus

Fetal rbc = maternal circulation
- usually occurs at birth, abortion

1st pregnancy not affected
- Unknown abortions

Subsequent pregnancies
- Maternal antibodies = fetal circ
= Hemolysis of fetal rbc = fetal

Front 311

Rh Fetal and Neonatal Risks

Back 311

• Anemia
• Hemolytic syndrome
• Erythroblastosis fetalis
– Marked fetal edema, called hydrops fetalis
– Congestive heart failure
– Marked jaundice
– Severe fetal compromise

Front 312

Rh Prevention

Back 312

• Screen for Rh incompatibility and sensitization
– History
– Antibody screen (indirect Coombs’ test)
• sensitization

Give Rh immune globulin (RhoGam, WinRho)
– Pregnant Rh-women with no antibody titer
• At 28 weeks’ gestational age
– Baby’s father Rh+ or unknown
– After abortion & within 72 hours postpartum
– Amniocentesis, APH

Front 313

ABO Incompatibility

Back 313

Mother O blood type -- infant A, B, or AB
– Anti-A and anti-B antibodies occur naturally
– During pregnancy maternal antibodies cross
placenta

– Cause hemolysis of fetal rbc
• hyperbilirubinemia

– Unlike Rh incompatibility
• 1st infant involved
• no antepartal treatment or prevention

Front 314

Anemia

Back 314

Hemoglobin (Hgb)
• < 100g/L
• Fatigue, paleness, malaise

Implications for woman
• Depression
• Increased risk for infections
• Fatigue
– Mothering challenged
– Breastfeeding

• Further complications
– Embolisms
– Permanent damage to heart
– Future pregnancies

Implications for the infant
• Low birth weight
• Prematurity
• Stillbirth

Treatment
• Dietary
• Iron supplements
• Avoid transfusions

Front 315

Heart Disease

Back 315

1% of pregnancies
- 40% inc cardiac output by 20-24 weeks
- Pulse inc10+ bpm
- dec cardiac reserve
- dec capacity to handle pregnancy workload

¡E Congenital heart defects

¡E Rheumatic heart disease - mitral stenosis

¡E Mitral valve prolapse

¡E Peripartum cardiomyopathy
- Multiparas, pre-eclampsia, twins, (inc edema) older, obesity

Front 316

Preggo Heart Disease Care

Back 316

. Assess the stress of pregnancy
on the heart

. Limit activity

. Calm atmosphere

. Head of bed up
- Avoid supine hypotension

. Monitor for signs of impending
cardiac failure
- Embolism
- Vital signs

. Fetal assessment

. Family support and education

Front 317

Hyperthyroidism

Back 317

0.15% pregnancies

1st trimester
- Very high levels of hCG (similar to TSH)
- multiple pregnancies, molar pregnancy

Uncontrolled hyperthyroidism=
- preeclampsia, depression
- fetal tachycardia, morbidity, mortality, SGA, preterm

Worsens again pp
- Postpartum thyrotoxicosis, thyroiditis,psychosis

Antithyroid drugs, cross the placenta Tx both

Front 318

Hypothyroidism

Back 318

• Associated with 4% population
– maternal anemia, myopathy, chf, pre-eclampsia, aph, pph, and depression
– Poorer neonatal outcomes
• lbw
• fetal brain development – cretinism

• Care
– Medication needs greatly increase in pregnancy
– Thyroid hormones, levothyroxine and liothyronine
(quick onset)
– prenatal vitamins (iron, calcium) may inhibit absorption of L-T4A, take vit 4hr post med

Front 319

Epilepsy

Back 319

Estrogen is epileptogenic

Seizures can put fetus and pregnancy at risk

Anticonvulsant drugs (Valproate) associated with malformations, dec IQ 10 point

Vitamin K supplement during the last trimester

Control of nausea and management of vomiting

Promote lifestyle factors that can dec risks for seizures

Front 320

Trauma During Pregnancy

Back 320

• Types of trauma
– Blunt trauma
– Penetrating injuries
– Gunshot wounds
– Motor vehicle accident
– Uterine rupture is rare
– Falls
– Direct assaults

• Impact
– Traumatic separation of
the placenta
– High rate of fetal mortality
– Premature birth
– Early rupture of membranes
– Maternal shock
– Premature labor or spontaneous abortion
– Placental abruption

Front 321

preggo trauma care

Back 321

• Life-saving measures for woman

• Fetus near term and uterus damaged
• Cesarean section

• Fetus immature
- Uterus can be repaired
- Pregnancy continue to term

• Minor injuries

Front 322

Substance use/abuse

Back 322

18.9% socially high-risk pregnant women use recreational
drugs, 11% daily

Front 323

Cocaine and Crack
• Adverse maternal effects

Back 323

Adverse maternal effects

– Seizures and hallucinations

– Pulmonary edema and cerebral hemorrhage

– Respiratory failure and heart problems

– Increased incidence of spontaneous abortion

– Abruptio placentae, preterm birth, and stillbirth

Front 324

Cocaine and Crack Fetal neonatal effects

Back 324

– Increased risk of intrauterine growth restriction (IUGR)
– Small head circumference
– Cerebral infarctions
– Altered brain development
– Shorter body length
– Malformations of the genitourinary tract
– Lower Apgar scores
– May have neurobehavioral disturbances
– Marked irritability
– An exaggerated startle reflex
– Labile emotions

Front 325

Newborns exposed to cocaine in utero

Back 325

– Increased risk of sudden infant death syndrome (SIDS)
–Cocaine crosses into breast milk
–May cause symptoms in the breastfeeding infant
– Extreme irritability and vomiting
–Diarrhea, dilated pupils, and apnea
–Cocaine use after childbirth
• Prohibits breastfeeding

Front 326

Marijuana

Back 326

• Impaired coordination, memory, and critical thinking ability
– Self-care, prenatal care

• No strong evidence that marijuana is teratogenic

• Risks are dose related

• Increased risk of intrauterine growth restriction

• Sudden infant death syndrome (SIDS) in infants

• Impact of heavy marijuana use on pregnancy is difficult to evaluate – complex problems
– postmaturity

Front 327

Ecstasy

Back 327

• MDMA
(methylenedioxymethamphetamine)
– produces euphoria and feelings of empathy for others
• Deaths
• Little is known about the effects on pregnancy
• may be critical issue during fetal brain development

Front 328

Heroin

Back 328

• CNS depressant
– narcotic

• Alters perception and produces euphoria

• An addictive drug, generally IV administered

• Associated with malnutrition, poor, late or no prenatal care

Front 329

Fetus of heroin-addicted woman

Back 329

• Increased risk for IUGR and meconium aspiration

• Hypoxia

• Restlessness and shrill, high-pitched cry

• Irritability and fist sucking

• Vomiting and seizures

• Signs of withdrawal usually appear within 72 hours
– May last for several days

Front 330

Methadone

Back 330

• Blocks withdrawal symptoms
– Reduces or eliminates the craving for narcotics
– Crosses the placenta

• Associated with pregnancy complications and abnormal fetal presentation

• Prenatal exposure
– Reduced head circumference and lower birth weight
– Withdrawal symptoms

Front 331

Alcohol

Back 331

• Central nervous system (CNS) depressant

• Potent teratogen
– FASD

• Maternal effects
– Malnutrition
– Bone marrow suppression
– Increased incidence of infections
– Liver disease
– Withdrawal seizures

• Pregnancy
– May inhibit labour

Front 332

Care

Back 332

Mother
– Watch for signs of withdrawal
– Use
• Leave unit, leave baby unattended, high

Baby
– Watch for signs of withdrawal
– Active use
• NICU for observation and treatment

Front 333

Common complications of pre-term births

Back 333

• Prematurity
• Thermoregulation
• Respiratory Distress
• Hyperbilirubinemia
• Hypoglycemia
• Sepsis
• Neonatal Abstinence Syndrome

Front 334

Preterm Birth Survival

Back 334

Gestation Survival %
23 weeks 15-30
28 weeks 85-90

Front 335

The Pre-term Infant

Back 335

Respiratory:
- Lack of surfactant
- respiratory distress syndrome (RDS)
- apnea
- bronchopulmonary dysplasia (BPD)

Cardiovascular:
- Patent ductus arteriosis (PDA)
- inc respiratory effort
- CO2 retention

Thermoregulation:
- dec brown fat, dec brown fat & subcutaneous fat, poor muscular development, less flexed tone, inability to shiver, thin skin, inc
BSA, inc exposure during resuscitation

Gastrointestinal:
- Small stomach, immature feeding reflexes
- Necrotizing Enterocoitis (NEC)

Renal:
- dec ability to concentrate urine
- dec ability to excrete drugs/medications

Hepatic / Hematologic:
• Immature liver = dec conjugate bilirubin = inc jaundice
• At risk for hypoglycemia
• Limited iron stores = anemia
• Blood volume is less

Neurological:
• Intraventricular hemorrhage (IVH)

Front 336

Preterm Temperature Control

Back 336

Less able to produce heat - higher ratio of body surface to body weight

Lack of brown fat

Thin skin
- insensible water loss

Lack of flexion increases heat loss

Resuscitation efforts

Birthing room or OR ambient temperature

Maintain room temperature ~ 25° - 26°C

put them in a baggy and keep them moist

Front 337

Late Preterm Infant
34 – 36 completed weeks

Back 337

Often overlooked
• do not appear dramatically sick

Immature
• < 4 – 6 wks of the 3rd trimester

Brain size at 34 – 35 wks
• 60% of that of infant @ term

Largest proportion of preterm births

• Respiratory distress syndrome (RDS)

• Transient Tachypnea of the Newborn

• Pulmonary infection

• Recurrent apnea

• Temperature instability

• Jaundice (discharge delay)

• Re-hospitalization for various Dx.,

• Feeding difficulties

• Long-term behavioural
difficulties

• Mortality

Front 338

Neonatal Respiratory Distress

Back 338

Signs
- tachypnea
- apnea
-cyanosis
- grunting
- nasal flaring
- retractions
- poor feeding
- increased effort to breathe
- hyper capnia
- dec BP and shock

Common Causes
- respiratory distress syndrome (RDS)
- meconium aspiration (MSAF, MAS)
- transient tachypnea of the newborn (TTN)

Front 339

Risk Factors for RDS

Back 339

-20% of neonatal deaths (0-28d)
-Lack of surfactant
-Prematurity **
• Maternal diabetes (type 1 & 2)
-Stress a protector
• Acidemia
• Multiples, 2nd
• Hypovolemia
• Male infant
• Genetic predisposition
• C/S without labour
• Caucasian
• APH
• Hydrops fetalis

Front 340

RDS Management

Back 340

Management
• Antenatal Corticosteroids
• Exogenous Surfactant

Endotracheal
• Continuous positive airway pressure (CPAP) and
positive end-expiratory pressure (PEEP)
• Fluids and other supportive care

Nursing assessment
• Respirations
 ?
• Colour
 ?
• Edema

Front 341

Meconium Stained Amniotic Fluid
(MSAF)

Back 341

Why does MSAF occur in ~ 12% of live
births
● Fetal stress/hypoxia ● Breech ● Post Term

Fluid aspirated (thin, thick, particulate)
●Amount and consistency varies
●During first few breaths taken by newborn (?)
●Does suctioning at perineum help?

4-5% of MSAF result in MAS

Front 342

Complications of Meconium
Aspiration Syndrome
(MAS)

Back 342

• RDS
• Pneumothorax
• Pneumonia
• Irritation
• PPHN

Front 343

Care with Meconium Aspiration

Back 343

Prevent
• avoid post maturity
• amniotic infusion
• endotracheal suction by trained individual (?)

Assisted ventilation

Surfaxin, Steroids

Close observation, supportive, nutrition
• Respiratory distress
• crackles, rhonci

Front 344

Transient Tachypnea of Newborn
(TTNB)

Back 344

"wet lung syndrome¨

Excess fluid in the lungs or delayed reabsorption of fetal lung fluid

~ 1% of all deliveries

Normal @ birth -develops respiratory distress
symptoms in 4-6 hours

May be related to aspiration of amniotic fluid, excess secretions or tracheal fluid
- C-section
- Preterm

Resembles RDS

Nursing care involves
- Oxygen
- Intravenous fluids for fluid and electrolyte requirements
- Restrict oral feedings until respiratory status improves

Usually resolves within 12-72 hrs

Front 345

HYPERBILIRUBINEMIA

Back 345

Hyperbilirubinemia
• excessive concentration of bilirubin in the blood

Jaundice - bile pigment deposited in the skin,
mucous membranes and sclera =
- Cephalocaudal (head to toe) progression
- Well lit area, preferably natural daylight
- Gentle pressure to blanch skin to reveal
underlying color of skin/subcutaneous tissue

Front 346

Physiological Jaundice

Back 346

Most common cause of jaundice - 50-60% newborns:

Primary mechanism:
- inc RBC volume, short RBC life span = inc RBC hemolysis
after birth = inc bilirubin load

Additional mechanisms include:
- Decreased clearance of bilirubin from plasma
- liver immature, dec ability to excrete inc conjugated bilirubin
- immaturity of bilibrubin conjugation in the liver at birth

Usually peaks at 3 - 5 days

Typically resolved by day 8

Front 347

Pathological Jaundice –within 1st
24hr

Back 347

Excessive erythrocyte destruction

inc Extravascular blood

Polycythemia

Other

Front 348

Breastfeeding Jaundice

Back 348

~ 0.5% to 2.4% of all newborns

mild jaundice that occurs or persists past one week of life in an otherwise healthy and thriving breast-fed infant

? factors in the breast milk block
certain proteins in the liver that break down bilirubin

? runs in families

Front 349

Severe Hyperbilirubinemia

Back 349

Risk factors include:
Č Visible jaundice

Č Previous sibling with jaundice

Č Visible bruising / cephalhematoma

Č Exclusive / partial Breastfeeding

Č Certain ethnic backgrounds

Č Dehydration / weight loss after birth

Č Infant of Diabetic Mother (IDM)

Front 350

Bilirubin Encephalopathy- kernicterus

Back 350

Neurological effects of unconjugated bilirubin in the brain may be reversible or
permanent

deep-yellow staining of neurons andneuronal necrosis of the basal ganglia and brainstem nuclei

Front 351

Guidelines for Testing (CPS, 2007)

Back 351

TSB - Total Serum Bilirubin
- Severe >340 μmol/L at any time during 1st 28 days
- Critical >425 μmol/L during 1st 28 days

only 50% of babies with a TSB concentration greater than 128 μmol/L appear jaundiced

(TcB) transcutaneous bilirubin measured in infants 24 h -72 h
• results plotted to risk of progression to severe
hyperbilirubinemia

Front 352

Phototherapy

Back 352

Eye patches
• remove q shift

Temperature
• Isolette and baby

Expose
• maximum skin surface

Serum bilirubin levels
• Turn lights off while blood is drawn & protect sample from light

Change position q2h
• Prevent and assess for pressure sore

Front 353

Other Treatment (jaundice)

Back 353

Early and frequent feedings
• Promote breastfeeding
• increase excretion through feces & urine

Prevention of dehydration
• supplemental fluids when phototherapy

Exchange transfusion for severe cases

Front 354

Hypoglycemia

Back 354

IDMs, SGA infants, Preterm AGA, LGA

Stressed, infection

Asymptomatic
- Feeding interventions
- inc frequency of Breastfeeding
- supplement-BM, BM fortifier, formula
- Evaluate for response in 1 hr

Symptomatic or < 2mmol/L
- IV infusion of glucose
- Target 2.6 mmol/l or „´ (CPS)

Blood glucose
- Q 1-4h in high risk
- Varies with institution
- At or below 2.5/2.6 mmol/L

Front 355

Symptoms of Hypoglycemia

Back 355

1. Jitteriness or tremors

2. Apathy

3. Episodes of cyanosis

4. Convulsions

5. Intermittent apneic spells

6. Tachypnea

7. Weak or high-pitched cry

8. Limpness or lethargy

9. Difficulty in feeding

10. Eye rolling

11. sweating, sudden pallor, hypothermia, and cardiac arrest and failure also occur

Front 356

Newborn Sepsis

Back 356

Immature immune system

Exposure to Bacteria (GBS)

PPROM

Maternal fever

Chorioamnionitis

Early onset
- within 24-48 hrs
- usually respiratory (pneumonia)

Late onset
- after 48 hrs
- usually meningitis and bacteremia

Subtle behavior changes
- not doing well
- Lethargic or irritabilitable
- Feeding intolerance

Temperature INSTABILITY

Tachycardia

Poor Peripheral Circulation
¡E Pallor ¡´Duskiness ¡´Cyanosis

Respiratory Distress

Hyperbilirubinemia

Front 357

Parents of Newborn with
Complications

Back 357

Sick or preterm baby may have
• Delayed or lack of periods of reactivity due to
poor condition of newborn
• More disorganized in sleep-wake cycle

Assess
• knowledge of infant's condition or anomaly

Communication
• Keep informed about infant condition

Promote care
• Flexible visits
• Skin to skin care
• Breastfeeding/pumping

Front 358

NAS “Withdrawal” from opiates

Back 358

Withdrawal

Irritability

Tremors, tight tone, trouble with sleep &temp

Hyperactive, high pitched cry, hypotonia

Diarrhea, diaphoresis, dehydration, disorganized suck

Respiratory distress, rhinorrheoa,

Apneic attacks

Weight loss

Alkalosis – respiratory

Lacrimation

Front 359

Heroin, other opiates (Oxycontin,
Percocet), including methadone

Back 359

- Significant withdrawal in the baby
- NICU care to stabilize and observe
- Withdrawal can start at 2 hrs, depending on last dose by mom
- Lasts up to 6 months
- *Administer drug to wean baby off drug over 1-2 months
- Avoid naloxone, can induce seizures
- Seizures ¡V phenobarbital
- Polydrug use etc.
- Increased need to suck, frantic movement, diarrhea, sleep deprivation

Front 360

Cocaine and Methamphetamine effect on newborn

Back 360

Different mechanism for addiction than heroin and different effects on newborn

Amphetamines (crystal meth, crank)
- inc HR and BP, vasoconstriction dec blood flow to fetus
- Low birthweight, IUGR, prematurity, intracranial
hemorrhage
- No withdrawal symptoms like optiates but rather poor
suck and feed, lethargy, ¡õ tone

Cocaine
- Similar to amphetamines but also
- Abruptio
- Anemia, fetal death, Neonatal SIDS

Long term-language delays until 2+ years & behavioural
problems unless add support @ home (i.e. mom clean)

Front 361

Marijuana

Back 361

• Postdates, SGA
• dec prolactin affects breastfeeding
• Inattentiveness to baby afterwards

Front 362

Alcohol

Back 362

- FASD/FASE
- withdrawal symptoms may start at 2 hours (depending on last drink) and last up to 18 months

Front 363

Nicotine

Back 363

• SGA

• SIDS, respiratory, behavioural problems, headaches

Front 364

Care for drug baby

Back 364

Manage newborn complications

Serologic tests for
• syphilis, HIV, hepatitis B

Meconium, cord, or urine drug screen

Social service referral

Nutritional support

Reduce withdrawal symptoms

Promote adequate respiration,
temperature, and nutrition, second-hand
smoke/drugs

Front 365

Therapeutic handling

Back 365

1. Reduce stimulation
• Calm subdued
environment (↓ light, ↓
noise)
• Avoid eye contact
• Soother
• Take cues from baby

2. Swaddling to help
control body and tremors

3. “C” position to feed and
cuddle
• Hold baby and move up &
down carefully with baby
held away from person
swaddled in c position

Front 366

Treating Withdrawal

Back 366

 Opium
 Morphine
 Methadone
 Phenobarbital
***Wean Slowly!!!***

Naloxone (Narcan)
- Contraindicated in addicted baby
- rapid withdrawal & seizures

Front 367

Parents of drug babies

Back 367

High levels of stress/anxiety
• More in 1st week
• More for mother - Guilt, own recovery, grief
• Financial – esp if out of region

PTSD
• delivery

NICU
• Stressful environment
• Buddy
• Social work
• Discharge nurse
• LC

Front 368

As baby recovers…

Back 368

Ensure parents understand
• routine well-baby care
• special procedures
• expected growth and development of
infant

Referral
• infant screening procedures
• follow-up care
- Team approach
• special equipment required at home

Front 369

Cancer

Back 369

! Cancer is diagnosed in an average of 1300 children every year in ages ranging from 0-19 years of age

! Leukemia accounted for 25% of new cancer cases and is the most common childhood cancer.

! Since the 1950’s, mortality rates for childhood cancer have declined more then 50%.

! Approximately 85% of Canadian children and adolescents with acute ALL are alive 5 years after diagnosis.

Front 370

Assessment

cancer

Back 370

! Unusual mass or swelling

! Unexplained paleness and loss of energy

! Spontaneous bruising

! Prolonged, unexplained fever

! Headaches in morning

! Sudden eye or vision changes

! Excessive – rapid weight loss

Front 371

Cancer Dx

Back 371

! X-ray, Skeletal survey

! CT scan

! Ultrasound

! MRI

! Bone marrow aspiration

! CBC with absolute neutrophil count

! Urinalysis

! Lumbar puncture

! Urine catecholamines

Front 372

Cancer Treatment for children

Back 372

! The improvement in childhood survival rates reflects biological differences in adults compared to children, and differences in treatment approaches.

! The success of clinical trials in identifying new agents and treatment approaches has been significant.

! A shift towards multidisciplinary approach has improved overall outcomes and decreased mortality

Determined by:
! Type of cancer
! Location
! Extent of disease

Front 373

Osteosarcoma

Back 373

! Also called osteosarcoma, osteogenic sarcoma is one of
the most common types of bone cancer in children.

! The disease usually occurs in the long bones, such as
the arms (humerus), legs (femur/tibia), and pelvis.

! It rarely occurs in the jaw and fingers, but often occurs
at the ends of these bones near growth plates.

! Peak incidence is during rapid growth years.

! Bone tissue produced by osteosarcoma never matures
into compact bone.

! At the time of diagnosis, most children hav emetastases.

Front 374

Osteosarcoma

Symptoms

Back 374

! Pain

! Swelling

! Pulmonary metastasis occurs in 20% of cases. When lung metastasis is the only site, lung resection may be successful for treatment.

! Disseminated metastases and bone lesions have poorer prognosis.

Front 375

Leukemia

Back 375

! In leukemia, the bone marrow, for an unknown reason, begins to make white blood cells that do not mature correctly, but continue to reproduce themselves.

! With leukemia, these cells do not respond to the signals to stop and reproduce, regardless of space available.

! Leukemia can occur at any age, although it is most commonly seen in children between 2 and 6 years of age.

! The disease occurs slightly more frequently in males than in females.

Front 376

Leukemia
ALL

Back 376

! Acute lymphocytic leukemia (ALL), also called
lymphoblastic or lymphoid, accounts for about 75 to
80 percent of the childhood leukemias.

! The low death rate in ALL reflect the major advances
in treating the cancer.

! In this form of the disease, the lymphoid cells are
affected.

Front 377

Leukemia
AML

Back 377

! Acute myelogenous leukemia (AML), also called
granulocytic, myelocytic, myeloblastic, or myeloid.

! accounts for about 20 percent of the childhood leukemias.

! Acute myelogenous leukemia is a cancer of the
blood in which too many granulocytes are
produced in the marrow.

Front 378

Leukemia

Symptoms may include:

Back 378

! Anemia

! Bleeding and/or bruising

! Recurrent infections

! Bone and joint pain

! Abdominal distress

! Swollen lymph nodes

Front 379

Nursing Diagnosis

Back 379

! Potential for Pain
! Potential for nutrition deficit.
! Impaired physical mobility
! Disturbed body image
! Knowledge Deficit

Front 380

Nursing Interventions

Back 380

! Support

! Systems assessment- Monitoring pain, mouth sores,
hydration

! Ensure adequate fluid intake.

! Monitor output

! Pain and antiemetic medications

! Monitor blood work

Front 381

Chemotherapy

Back 381

! Chemotherapy is a medication that can help fight cancer.

! Chemotherapy stops the growth of cancer cells, either
by killing the cells or by stopping the cells from dividing.

! Often a combination of chemotherapy drugs are used
to fight a specific cancer ( PO, IV or intrathecal).

Front 382

Chemo Precautions

Back 382

! Gloves

! Special storage and disposal of body fluids and Chemo
products.

! Pregnant women should not handle Chemo meds.

Front 383

Side effects of Chemotherapy

Back 383

! Bone marrow suppression
! Mouth sores
! Nausea
! vomiting and diarrhea
! Hair loss, also called "alopecia“

Front 384

Goals of Chemotherapy include:

Back 384

a) Cure
b) Control
c) Palliation
d) Prophylaxis

Front 385

Radiation Therapy

Back 385

! The use of ionizing radiation to break apart bonds
within a cell causing cell damage and death.

! External beam therapy accounts for the majority of
radiation treatments in children.

! Problems: radiation beams cannot distinguish between
malignant cells and healthy cells.

Front 386

Side effects of radiation

Back 386

! Hair loss, also called "alopecia"
! Bone growth
! Skin changes
! Diarrhea, nausea, and vomiting

Front 387

Delivery of Medications and
Fluids

Back 387

Portacatheters

! Two decades ago, CVAD were introduced as an integral part of the pediatric oncology patient’s
treatment plan.

! Used to deliver chemotherapy, blood components, antibiotics, fluids, TPN, medications and blood sampling.

Front 388

Portacatheter

Back 388

! Single/double lumen

! Sometimes difficult to access

! Decrease risk of infection

! Totally implanted: cannot be pulled out by client and easy to bathe client.

! Requires an incision to remove

Front 389

Growth and Development cancer kids

Back 389

! Promote normal G & D

! Allow decision making

! Establish daily routines

! Play therapy

! Friends

! School attendance or tutor

Front 390

Caring for Families

Back 390

! Trusting relationship with nurse
! Open communication
! Daily contact with oncology team
! Support groups

Patient / family education
! Begins at time of diagnosis
! Continues through treatment phases
! Maintained in post-survival years
! Support if death of child

Front 391

Stages of Grief

Back 391

The stages Kubler-Ross identified are:

! Denial (this isn't happening to me!)
! Anger (why is this happening to me?)
! Bargaining (I promise I'll be a better person if...)
! Depression (I don't care anymore)
! Acceptance (I'm ready for whatever comes)

Front 392

Potential Feelings of children &
Parents diagnosed with cancer

Back 392

! Anger
! Guilt
! Depression
! Loneliness
! Fear of death

Front 393

Nursing interventions to assist families to cope with a loss of a child or pending death.

Back 393

! Take time to spend with the family

! Allow family time to Cry. Allow family time alone.

! Try to assist parents to retain healthy behaviors.: ie enough sleep. Eat a healthy diet. Going outside in the sunshine for exercise or a mild walk.

Front 394

Nursing Interventions

Back 394

! Encourage family to seek help from others. Reassure that Now is not the time to try to do everything by yourself.

! Seek out grief counseling

! Remember that grief is individual. Not everyone’s grief
is identical.

! Families can share some similarities with others, but
grieving is a very personal and very individual process.

Front 395

Wilms

Back 395

! Wilm's tumor, also called nephroblastoma, is a
malignant (cancerous) tumor originating in the cells of
the kidney.

! It is the most common type of renal (kidney) cancer
and accounts for about 6 percent of all childhood
cancers.

Front 396

Rhabdomyosarcoma

Back 396

! Rhabdomyosarcoma is a cancerous tumor that
originates in the soft tissues of the body, including the
muscles, tendons and connective tissues.

! The most common sites for this tumor to be found include the head, neck, bladder, vagina, arms, legs and trunk.

Front 397

Ewing Sarcoma

Back 397

! Ewing sarcoma is a cancer that occurs primarily in the
bone or soft tissue.

! Ewing sarcoma can occur in any bone, but is most
often found in the extremities and can involve muscle
and the soft tissues around the tumor site.

Front 398

Neuroblastoma

Back 398

! Neuroblastoma is a cancerous tumor that begins in nerve tissue of infants and very young children. The abnormal cells are often found in the nerve
tissue that is present in the unborn baby and later
develops into a detectable tumor.

! The tumor usually begins in the tissues of the adrenal gland found in the abdomen, but may also begin in nerve tissue in the neck, chest or pelvis.

Front 399

Lymphoma

Back 399

! Lymphoma is the second most common group of cancer in children.

! Sixty percent of lymphomas are non-Hodgkin's lymphomas.

! Approximately 17% of new cases of cancer.