• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/340

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

340 Cards in this Set

  • Front
  • Back
Attachment Theory
John Bowlby
• Attachment is a motivational-behavioral control system
• BOWLBY identified that infants need one special relationship for internal development.
• Successful early attachment to one person facilitates the child to learn to cue her behavior to the subtle social cues of many.
• This experience allows the child to develop the ability to engage in social relationships, to make
friends, and, to eventually attain physical
• A child’s experience with caregivers gives a sense of worth, a belief in the helpfulness of others, and a favorable model on which to build a future relationship.
• This relationship enables the child to explore his environment with
confidence and to deal with it
effectively.
intimacy.
What are the positive affects of
attachment?
• Self- confidence
• Sense of worth
• Sense of competence
• Learn to trust
Infant Reflexes
• Moro: Startle
- abduct then adduct limbs
- disappear 4-6mths

• Rooting and sucking
- turn and suck
- 3-4 mnths rooting, 1 year sucking

• Palmar Grasp
- fingers curl tightly
- 3mths

• Babinski
- toes flare with dorsiflesion of the big toe
- 12mths

- Gallant
- entire trunk flexes toward side timulated
- 1 month

- Stepping
- infant lifts alternate feet as if walking
- 4-7 mths

- Tonic neck reflex
- Externsion of extremities on side to which head truned, with flexion on opposite side
- disappears by 4 mths

• Plantar grasp
- toes curl forward
- 8 months
Child development of a 5- year
old. Social
- Shows leadership among children
Child development of a 5- year
old. Self help
- Goes to the toilet without assistance
Child development of a 5- year
old. Gross motor
- swings on swing
Child development of a 5- year
old. Fine motor
- Prints first name
Child development of a 5- year
old. Language
- Reads a few letters, tells meaning of
familiar words.
Developmental activities 5- year old
• Encourage walking, running, skipping, jumping and dancing.
• Use paper cutting and pasting simple shapes and pictures.
• Puppets
• Painting, drawing, coloring.
Factors affecting growth and
Development
• Genetics
• Temperament
• Health-Nutrition
• Intelligence
• Gender
Erickson's Theory
Infant - Trust vs Mistrust
Needs maximum comfort with minimal uncertainty to trust himself/herself, others, and the environment

Toddler - Autonomy vs Shame and Doubt
Works to master physical environment while maintaining
self-esteem

Preschooler - Initiative vs Guilt
Begins to initiate, not imitate, activities; develops conscience and sexual identity

School-Age Child - Industry vs Inferiority
Tries to develop a sense of self-worth by refining skills

Adolescent - Identity vs Role Confusion
Tries integrating many roles (child, sibling, student, athlete, worker) into a self-image under role model and peer pressure

Young Adult - Intimacy vs Isolation
Learns to make personal commitment to another as
spouse, parent or partner

Middle-Age Adult - Generativity vs Stagnation
Seeks satisfaction through productivity in career, family, and
civic interests

Older Adult - Integrity vs Despair
Reviews life accomplishments, deals with loss and preparation for death
Piaget’s Theory
Piaget's theory of cognitive development is a comprehensive theory about the nature and development of human intelligence

• Sensorimotor
• Preoperational
• Concrete thoughts
• Formal operational

• This theory is based on the belief that the child is active, rather then reactive.
• Development is biologically based process that causes changes to the child’s mental structures.
• Intelligence is an example of biological
adaptation.
Chromosome Abnormality
• Can be numerical or structural.

• Are quite common (50% of those that abort spontaneously).

• Numerical: entire single chromosome added or missing. One or more added sets of
chromosomes.

• Structural: part of a chromosome missing or added or there is an abnormal rearrangement of material within chromosome known as
translocation.
Numerical Abnormalities
Trisomy: when each body cell contains an extra copy of one chromosome (47). An extra chromosome at every cell.
• Common trisomy is Down syndrome where each cell has three copies of chromosome 21..
• Trisomy 13 are less common and have more severe effects (mental disability, hypotonia, CHD, etc)
==============
Monosomy
• Occurs when each body cell has a
missing chromosome (45).
• Only one that is compatible with life – Turner’s Syndrome. Most common sex chromosome abnormality in females,single X chromosome.
====================
Klinefelter Syndrome
• Occurs in boys who have an extra X chromosome. May have a delay in
language development and auditory
processing.
• Diagnosed with chromosomal analysis.
Duchenne Muscular Dystrophy
• X-linked Recessive Disorder in boys; 30-50% affected children have no family history.
• Onset of symptoms usually within first 3-4
years of life
• begins with loss of endurance and
strength in the legs and pelvis, eventually progressing to include the musculature within the entire body.
Diagnostic Methods
Prenatal Diagnosis for Fetal Abnormalities and
Postnatal:
• Physical examination
• Imaging procedures
• Chromosomal analysis
• DNA analysis
• Tests for metabolic disorders (PKU, CF)
• Hemoglobin analysis (sickle cell)
• Immunologic testing for infections such as rubella, herpes.
NEC
necrotizing entero cholitis

- NEC is a potentially life-threatening inflammatory disease of the intestinal tract.

- Caused by several factors: Intestinal ischemia, bacterial or viral infection and immaturity of the gut.

Symptoms
! Feeding intolerance
! Vomiting
! Irritability
! Abdominal distention
! Bloody diarrhea
Long term complications of
NEC
! Malabsorption or inability of the bowel to absorb nutrients normally.

! Short Bowel - too little bowel to absorb all the nutrients needed by the body

! Scarring and narrowing of the bowel causing "obstruction" or blockage of the bowel

! Scarring within the abdomen causing later pain and possible female infertility

! Problems due to long term use of total nutrition by vein.
Problems with Prematurity
! Intraventricular Hemorrhage (IVH)
! Retinopathy of Prematurity (ROP)
! Feeding and Nutrition
! Anemia
! Respiratory Distress Syndrome
Central Venous Catheters
! Inserted into a large central vein with the tip placed outside the right atrium, usually in the superior vena cava.

! Used in many different case scenarios.
a. long term medication (cancer therapy)
b. Used for frequent blood work
c. Monitor central venous pressure
d. For resuscitation
i. Large volumes of fluid quickly
e. Limited peripheral venous access
Central Venous Catheters
5 types
! Short term (percutaneous)
! Tunneled
! PICC
! Implanted
! Hemodialysis
Venous Catheters
Complications
! Air embolism
! Occlusion
! Infection
! Malposition or external catheter damage.
! extravasation
BLOOD WORK
Liver enzymes
! Detecting liver damage is a simple blood test to determine the presence of certain liver enzymes in the blood.

! Under normal circumstances, these enzymes reside within the cells of the liver. But when the liver is injured, these enzymes are present in the blood stream.
Cleft Lip & Palate
! Cleft means 'split' or 'separation'.

! During early pregnancy separate areas of the face develop individually and then join
together.
Complications of Cleft lip and palate
! susceptibility to colds,
! hearing loss,
! speech defects,
! a larger than average number of dental cavities, and missing, extra,
malformed, or displaced teeth.
! otitis media
! Feeding difficulties.
management of cleft lip
- cleft lip repaired 2-10wks
- palate repared around 6-18mo
Hirschsprung (Congenital
aganglionic megacolon)
Hirschsprung's disease is the absence of autonomic parasympathetic ganglion cells of the colon that prevents peristalsis at that portion of the intestine.

! Causes obstruction of the intestine.
Hirschsprung- Symptoms
! abdominal distention
! failure to pass meconium.
! Gradual onset of vomiting
Tracheosophageal Fistula (TEF)
! Tracheoesophageal Fistula (TEF) represents an abnormal opening between the trachea and esophagus.
TEF- Diagnosis
! a catheter is gently passed into the
esophagus to check for resistance.

! A Barium Swallow test is used to diagnose the problems.
TEF- Treatment
! surgery to close the fistula and
anastomosing the esophageal segments.

! all oral feedings are stopped and
intravenous fluids are started.
Imperforated anus
! The passage of fecal material is obstructed by a structural anomaly of the anus and rectum.

! The anomaly can occur with or without a fistula.
Imperforated anus -Diagnosis
! inspection of the perineum.

! Rectal atresia (absence of anal opening) presents clinically with abdominal distension and failure to pass meconium.

! US and lower GI studies confirm the diagnosis and demonstrate the extent of the anomaly.
Intussusception
! Intussusception occurs when one portion of the bowel slides into the next.
Intussusception- Symptoms
! Currant jelly,
! gelatinous stools,
! pain
Pyloric Stenosis
! Hypertrophy of the circular pylorus muscle results in stenosis of the passage between the stomach and duodenum, partially obstructing the lumen of the stomach.
Pyloric Stenosis-Symptoms
! Symptoms become evident at 2-8 weeks.

! Projectile vomiting, irritability, failure to gain weight, signs of dehydration, child appears hungry.
MENINGITIS
! Meningitis is an inflammation of the meninges (Dura, arachnoid, pia),

! the most common infectious process affecting the CNS system.

! Many of the bacteria or viruses that can cause meningitis are fairly common and are more often associated with other everyday illnesses.

! The infection can start anywhere,
including in the skin, gastrointestinal tract, or urinary system, but the most common source is the respiratory tract.

Bacterial meningitis is less common than viral meningitis but is usually much more serious and can be life-threatening if not treated promptly.
ASEPTIC MENINGITIS
- AKA Viral meningitis

! Aseptic meningitis: characterized by headache, fever, and inflammation

! bacteria do not grow in cultures of the cerebrospinal fluid

! Viral meningitis is relatively common and far less serious than bacterial meningitis.

! Treatment for viral meningitis is symptomatic and supportive.
Brduzinski's Sign
One of the physically demonstrable
symptoms of meningitis is Brudzinski's
sign. Severe neck stiffness causes a
patient's hips and knees to flex when
the neck is flexed. (Health line)
Kernig's sign.
One of the physically demonstrable
symptoms of meningitis is Kernig's sign. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. (Health line)
MENINGITIS-SYMPTOMS
! Fever

! lethargy (decreased consciousness), confusion or
irritability.

! Bulging frontanelles, poor feeding or sucking, high pitched cry, lethargy, hypothermia, apnea,
seizures.

! Older children may complain of; a headache; photophobia (eye sensitivity to light); stiff neck;
Skin rashes

! Also may experience: Seizures, fever, agitation or drowsiness
Meningitis - DIAGNOSIS
! Lumber Puncture

! Blood work
- Do an cs, CBC, lytes, etc.
- start AB's stat
ENCEPHALITIS
! Encephalitis is an inflammation of the brain, but it usually refers to brain inflammation caused by an infection or toxin which results in edema and neurological dysfunction.

! It's a rare disease that only occurs in approximately 0.5 per 100,000 individuals
ENCEPHALITIS - Causes
! Herpes Simplex Virus (HSV). Most common in peds

! Ticks
! Mosquitoes
! Measles, mumps, chickenpox, rubella (German measles), and mononucleosis.
ENCEPHALITIS - Treatment
! Neonatal HSV can be prevented by performing csection delivery, providing contact drainage, and taking secretion precautions, as well as by providing third-trimester therapy for the mother with acyclovir 400 mg 3 times per day.

! With therapy, and if HSV is confined to the skin, the prognosis is good, with 98% of babies showing normal development at age 1 year.

! 75% of patients with CNS involvement or disseminated disease either die or have
permanent neurologic impairment.
ENCEPHALITIS - Symptoms
! severe headache
! nausea and vomiting
! stiff neck
! fever
! dizziness
! ataxia
! convulsions (seizures)
! Sensory disturbances
! drowsiness
! coma
ENCEPHALITIS - Dx
! CT Scan and MRI
! EEG
! Lumber Puncture and culture of CSF
! Blood work
ENCEPHALITIS - Tx
! Antiviral Medication
! Corticosteroids
! Anticonvulsants (PRN)
! Antipyretics
ENCEPHALITIS - Prevention
! Encephalitis cannot be prevented except to try to prevent the illnesses that may lead to it.

! immunization.
SEIZURES
An involuntary contraction of muscle caused by abnormal electrical discharges.
CLASSIFICATION OF SEIZURES
Partial (focal Seizures)
! Generalized Seizures
PARTIAL SEIZURES
- no loss of consciousness
- can id a focal point
- divided into simple and complex seizures

! In partial seizures the electrical
disturbance is limited to a specific area of one cerebral hemisphere (side of the brain).

! Partial seizures may spread to
cause a generalized seizure.
SIMPLE PARTIAL seizure
! Consist of motor, autonomic or
sensory symptoms.

! No change in the level of
consciousness, and will be aware
and remember the events that
occur at the time.
COMPLEX PARTIAL seizure
! May begin with or without an
aura. (aura is a smell, sighting, feeling,etc. which tells them a seizure is about to occur)

! Symptoms may include:
Impaired consciousness; altered
mental status; tonic clonic movement on one side of the body.

! Followed by a variable period of
confusion, lethargy and sleep
GENERALIZED SEIZURE
! Generalized seizures affect both
cerebral hemispheres (sides of the
brain) from the beginning of the
seizure.

! These seizures result in a loss of
consciousness, either briefly or for a
longer period of time.

! Sub-categorized into several major
types: generalized tonic clonic;
myoclonic; absence; and atonic,
infantile spasms.
ABSENCE SEIZURES
! Absence seizures (also called
petit mal seizures) are lapses of
awareness, sometimes with
staring, that begin and end
abruptly, lasting only a few
seconds. There is no warning
and no after-effect.
Atonic seizures
! Atonic seizures produce an abrupt
loss of muscle tone. They produce
head drops, loss of posture, or
sudden collapse.
Myoclonic seizures
Myoclonic seizures are rapid, brief
contractions of bodily muscles, which usually occur at the same time on both sides of the body. Occasionally, they involve one arm or a foot, sudden jerks or clumsiness.

aka infantile spasms
TONIC CLONIC SEIZURES
! Generalized tonic clonic seizures
(grand mal seizures) are the most common and best known type of generalized seizure.

! begin with stiffening of the limbs
(the tonic phase), followed by
jerking of the limbs and face (the
clonic phase).
INFANTILE SPASMS
! Onset: 3 mos

! May occur with altered consciousness.

! Occur in clusters: 5-150/day

! Seizure increase in intensity and
duration over time.
INTRACTABLE SEIZURES
Seizures that continue to occur
despite optimal medication
management.
Causes of Seizure
! Fever (febrile seizures)
! Genetic factors or benign seizures of the newborn.
! Cerebral lesions
! Progressive brain disease (rare)
! Head trauma
! Infections
Seizure Dx
! MRI
! CT: Head
! Electroencephalogram (EEG)
Seizure Tx
! Medication (atavan, lorazepan, adalan, vallium)
! Ketogenic Diet
! Extratemporal cortical resection
! A functional hemispherectomy
KETOGENIC DIET
! Used for children under age 8
years with myoclonic and absence seizures.

! Diet: 90%fat, , adequate protein
and low intake of carbohydrates.

! The Ketosis produced by the diet
is believed to produce anticonvulsants effects.
EXTRATEMPORAL CORTICAL RESECTION
! An extratemporal cortical resection
is a resection of the brain tissue that contains a seizure focus.

! Extratemporal means the tissue is
located in an area of the brain other
than the temporal lobe.

! The frontal lobe is the most common extratemporal site for seizures.
! In some cases, tissue may be
removed from more than one area/
lobe of the brain.
FUNCTIONAL HEMISPHERECTOMY
! is a procedure in which portions of one hemisphere, which is used the least , are removed, and the corpus callosum is cut.

! This disconnects communication
between the two hemispheres,
preventing the spread of seizures to the functional side of the brain.
CEREBRAL PALSY
! is a chronic nonprogressive disorder of posture and movement.

! CP is characterized by difficulty in
controlling the muscles because of an abnormality in the extrapyramidal or pyramidal system (cortex, basal ganglia and cerebellum.
TYPES OF CEREBRAL PALSY
! Spastic
! Diskinetic
! Ataxic
! Mixed
SPASTIC CEREBRAL PALSY
About 70 to 80 percent of affected
individuals have spastic cerebral
palsy, in which muscles are stiff/
tense, making movement difficult.

! Spastic diplegia

! Spastic hemiplegia

! Spastic quadriplegia
DYSKINETIC CEREBRAL PALSY
! About 10 to 15 percent of cases.

! effects the entire body.

! Impairment of voluntary muscle control.

! characterized by fluctuations in muscle tone (varying from too tight to too loose)

! sometimes is associated with uncontrolled movements (slow and /or rapid and jerky).
ATAXIC CEREBRAL PALSY
! About 5 to 10 percent of affected
individuals have the ataxic form,
which affects balance and
coordination.

! The child may walk with an
unsteady gait with feet far apart.

! The child may appear to be clumsy.
CEREBRAL PALSY- CAUSES
! Most CP cases are believed to be caused by congenital, hypoxia, ischemia, or infectious insults to the CNS

! A small number of babies also develop brain injuries in the first months or years of life that can result in cerebral palsy.

! In many cases, the cause of cerebral palsy in a child is not known.
CEREBRAL PALSY- DIAGNOSIS
! Cerebral palsy is diagnosed mainly
by evaluating how a baby or young
child develops.

! MRI
! CT scan
! ultrasound.
CEREBRAL PALSY- TREATMENT
! A team of health care professionals works with the child and family to identify the child’s needs and create an individualized treatment plan to help the child reach his or her maximum potential.
Where does the suicide behaviour come from and what is the context?
oCognitive and developmental functioning

oFamily relationships
-Divorce, separation, moving, changes/loss
-Level of education
-Involvement of caregivers

-Other relationships – peers, school, work

o Cultural views and beliefs

o Community factors
-Community involvement
-Sense of neighborhood

o Risk factors, protective factors

o Stages are about mastering tasks before we can move on
• Purpose of suicidal Behaviour
o A method to communicate needs/wants
 something is wrong
 Life is tough
 Things are becoming unbearable

o Attention seeking
 Unacceptable means to acceptable ends

o Adolescents’ perspective
• Escalation of suicidal behaviour
o When purpose not achieved
 Failure to communicate needs
 Not being heard or understood
 Not getting the attention they need
 Ignoring
 Minimizing

o Try harder to get message across

o Behaviour increases in frequency and intensity
• Self harm behaviour
o View on a continuum
 Analyse from ideation to completion

o No self-harm contracting
 How long do you think you can keep yourself safe?
 Who can you call?
 Who are you able to talk to?
• Give them a menu
• Youth perspective RE: suicide/self harm
o What is it really about?\
 Relief of tension, anxiety, and/or pressure
 Internal pain, externalized
 Puish self/puhish others
 Need for attention
 A means of communication
 “Canary Bird” warning
• Bullying and Cyberbullying
o Bullying is repeated, systematic efforts to inflict harm through physical, verbal, or social attack on another
o Cyberbullying is when one individual targets another using interactive tech
Disordered eating
o Recent literature (2 factors that make the issue complex)
 Seek power but eventually the disease has control
 Symptoms may be seen as accomplishments by the client (weight loss acceptable to the ego… extreme thinness (emaciation) is valued)
 Distorted body image
Disordered eating s/s
 Things are separeated
• Playing with food
• Eat small amounts

 Dark circles under the eyes

 Stink

 Orange skin

 Feinting

 Sores on knuckles

o Pyysical problems associated with behaviour

o Psychological problems associated with behaviour
 Tough to deal with these guys cause it’s a control issue…
• You tell them one thing, they do the other
o What message do we want to give RE sexual abuse?
 I’m glad you told me, have you told anyone else?
 Its not your fault, this shouldn’t have happened to you.
 There is ppl that can help you
o What is the protocol for contacting child protection?
 We don’t want to contaminate the case, so we can’t really ask the questions to get the full picture quite yet

 Remember that if someone discloses to you, there is a reason they picked you. But don’t ask too much

 Remember that the rate of conviction is very low. Quite often, charges are rarely laid.
• Nobody believes the kid
• Not a credible witness
• Think about a kid on the witness stand
o Lawyers would eat them alive. Would be led to say things easily
o Physical signs of abuse
 Bruising
 Quiet and withdrawn… where is that coming from?
 They know more than what they should know about sex.
 Have sexualized behaviour
 Vaginal bleeding, small cuts, etc.
 Irritation, anal fissures… anything related to forced entry
Adolescent risk assessment: integration to practice. 5 areas of assessment
1) Stressors
o Comprehensive assessment
o Adequate data to provide a clear picture
o Family relationships, roles, communication patterns and boundaries
o Peer relationships/bullying/gender
o Loss issues and abuse
o School related issues
o Work related issues
o Metaphors
o Multiprofessinoal approach

2) Symptoms
o Isolating/withdrawing
o Sleeping/eating
o Non-participating
o Acting out/at-risk behaviour

3) Behaviour
o Non-blaming/in-depth exploration
o Interpretation
o Understanding
o Knowledge of others’ behaviour
o Reaction of others
 What?
 Expectation?
 Want/desired outcome?

4) Resources and support
o Lack of resources and support puts adolescent at highest riskd
o Id’d by youth
 Do not make assumptions
 Self – prior coping
 Others
 Community
o Menu
Spine Bifida
! Spina bifida includes any congenital
defect involving insufficient closure of
the spine.

! Is a neural tube defect that occurs
during the first month of pregnancy.
The three most common types of Spina Bifida are:
1) Spina bifida occulta
- vertical arch btw L5 and S1 fail to fuse.
- no herniation
- hair tuft

2) Spina bifida cystica: meningocele
- saclike protruision containing meninges and CSF

3) Spina bifida cystica: myelomeningocele
- saclike protrusion is filled with CSF, meninges, nerve roots and spinal cord
Symptoms of Spina Bifida
! partial or complete paralysis of the
legs, with partial or complete lack of
sensation,
! may include loss of bladder or
bowel control.
! Hydrocephalus
! visible sac-like protrusion on the
mid to lower back of a newborn
Spina bifida dx
! Neurologic examination may indicate loss of neurologic functions below the defect.

! Eighty-five percent of women carrying a fetus with spina bifid will show elevated maternal serum alpha fetoprotein.

! A prenatal ultrasound

! Amniocentesis. (also referred to as amniotic fluid test or AFT), is a medical procedure used in prenatal diagnosis of chromosomal abnormalities and fetal infections, in which a small amount of amniotic fluid, which contains fetal tissues, is extracted from the amnion or amniotic sac surrounding a developing fetus, and the fetal DNA is examined for genetic abnormalities.
spina bifida tx
! Early surgical repair of the defect is
usually recommended.
Hydrocephalus
! Develops as a result of an imbalance between the production and absorption of CSF.

! CSF builds up causing abnormal
enlargement of the ventricles in the brain.
hydrocephalus s/s
! An unusually large head
! A rapid increase in the size of the head
! Bulging anterior fontanel
! Vomiting
! Sleepiness
! Irritability
! Seizures
! Eyes fixed downward (sunsetting of the eyes)
! Blurred or double vision
Causes of hydrocephalus
! Obstructive (noncommunicating)- results from an obstruction within the ventricular system of the brain that prevents CSF from flowing or "communicating" within the brain.

! Nonobstructive (communicating)- results from problems with the production or absorption of CSF.
Neurogenica Bladder and Bowel
Neurogenic bladder & bowel is a
dysfunction that results from interference with the normal nerve pathways or damage to the nervous system.
VP shunt
Ventriculoperitoneal shunting

- Ventriculoperitoneal shunting is surgery to relieve increased pressure inside the skull due to excess cerebrospinal fluid (CSF) on the brain (hydrocephalus).
VP shunt complications
1) Mechanical failure
! under drainage or over drainage.
! blockage of the proximal or distal
catheter
! failure of the shunt valve system.
! It is estimated that the highest incidence of shunt failure occurs in the first few months after surgery.

2) Infection
! Infection is a regular complication of a shunt.
! About 40% of shunt infections are caused by staphylococcus epidermidis and about 20% by
staph aureus.
! Other organisms are less frequent such as streptococci and gram negative organisms.
Blocked VP Shunt
! An MRI or CT scan is often used to determine the cause and confirm the diagnosis.
! Intracranial pressure may be measured during a spinal tap (lumbar puncture).
! It may also be measured by a intraventricular catheter inserted into the anterior frontanelle. The normal ICP pressure is 1 – 10 mmhg.
! A level over 15 mmhg is considered abnormal.
External VP shunt
! Clamp shunt every time child is picked up.
! Head must remain at same level as the body.
! Sterile Technique when accessing the shunt for specimens.
! Measure CSF output Q1H.
Vancomycin
! Treatment of patients with Infections due to MRSA, Meningitis, endocarditis,
osteomyelitis.

! Infections associated with CVLs, VP shunts vascular grafts and prosthetic heart valves.
Prevention of Spina Bifida
! Folic Acid.

! Dose: 400mcg/day
Scoliosis
Scoliosis is a curving of the spine. The spine curves away from the middle or sideways

Measured in Degrees
! 10-20 degrees: slight curve

! 20-40 degrees: medical management requires bracing.

! More than 40: usually requires surgery and spinal fusion.
There are three general causes of scoliosis:
1) Congenital (present at birth) scoliosis is due to a problem with the formation of the spine bones (vertebrae) or fused ribs during development in the womb or early in life.
*

2) Neuromuscular scoliosis is caused by problems such as poor muscle control or muscle weakness, or paralysis due to diseases such as cerebral palsy, muscular dystrophy, spina bifida, and polio.
*

3) Idiopathic scoliosis is scoliosis of unknown cause. Idiopathic scoliosis in adolescents is the most common type.
Scoliosis Risk Factors
! Growth
! Sex
! Age
! Angle of the curve
! Location
Scoliosis dx
! Physical examination
! X-rays, MRI, CT and bone scanning
Scoliosis tx
! Observation
! orthopedic bracing
! surgery
Anattomical and Physiological differences of airway
- infant airway is 4mm; adult is 20mm
- during the first 5 years, the trachea increased in length rather than iameter
- infants are nose breathers until 4 wks
- bronchioles are fewer in number (increase in size after 8yo)
- higher metabolic rate = increase 02 consumption
PEWS
Pediatric
Early
Warning
System

heart rate, respiratory rate, blood pressure, oxygen saturation, and fluid therapy, Dr. Duncan said. A normal assessment for the child's age and size would produce a score of zero. Points would be added if the critical measures were above or below normal.
Asthma
- chronic inflammaoty disease of the lungs
- cannot be cured, but can be managed with tx
- inflammation of airways and increase of mucous
- inflammation causes increased airway responsiveness to stimuli
- constriciton of bronchial smooth muscle causing spasm
Remission
the state of absence of disease activity in patients with a chronic illness, with the possibility of return of disease activity
Asthma Risk Factors
- during fetal dev and fist 3-5 years of life
- fam hx of allergy
- passive smoke exposure
- indoor air contaminants (pet dander, mites)
- outdoor air pollutants
- recurrent viral infections
- low birth weight and rep distress syndrome
Causes of Asthma
- environmental exposures
- viral illnesses
- allergens
- genetic predisposition

- that occur at a crucial timem in the dev of the immune system
Protective Factors of Asthma
- large family size (dirtier = builds up immunity)
- later birth order
- childcare attendance
- dog in the family
- living on farm

**basically, the more transmission you are exposed to, the better your immune system - Dwight Schrute**
smoking and asthma
- exposure during childhood years increases risk for asthma
Assessment of an Asthmatic
1. body position
2. Visible movment- chest/ABD
3. RR
4. Resp effort: inspiratory vs expiratory ratio, indrawing

5. Airway sounds: intensity over lung field
Adventitious Lung sounds
1. Stridor - upper airway
2. Crackles - secretions in bronchioles and alveoli
3. Wheeze - constricted bronchioles
4. Grunt - resistance to expiration (ie: epiglottis)
5. Rub - inflamed pleural membrane
2 Factors that provoke asthma
1. Triggers
result in tightening of the airways (bronchoconstriction

2. Inducers
- result in infammation of the airways
Triggers
- irritate the airways and result in bronchoconstriction
- do not cause inflammation , therefor do not cause asthma
- s/s immediate, short lived and rapidly reversible
- airways will react more quickly to triggers if inflammation is already present in the airways

eg:
exercise\cold air
hot humid air
strong fumes
scents
dust emotional upsets
smoke, 2nd and 3 rd hand
allergens
Inducers
- cause airway inflammation and airway hyper-responsiveness
- last longer
- not as reversible as triggers
Allergens
- inhalant allergens are most important inducer / cause of inflammation

eg:
pollen
animal secretions
molds
house dust mites

*** Cause immediate symptoms: coughing, wheezing, runny nose
Resp Infection
- may cause a deterioration in a child's asthma
- probably one of the most common causes of exacerbation
Asthma Medication
Step 1: Intermittent Asthma
- short acting beta agonist (bronchodilation)

Step 2: Persistent Asthma
- lo-dose inhaled corticosteroid (antiinflammatory)

Step 3: Persistent Asthma
- Lo or med dose corticosteroid and long acting beta-agonist

Step 4-5: Persistent Asthma
- ICS and long acting beta agonist or leukotriene receptor

Step 6: Persistent Asthma
- ICS and LABA and oral systemic corticosteroids
Ventolin
- bronchodilator
- dose: 2.5mg diluted up to 4mls
- neb w 02
- 4-8 puffs every 20min for 3 doses then every 1-4 hours with aerochamber
Flovent
- a corticosteroid
- long term control of persistent bronchial astham
- not indicated for relief of acute bronchospasm
- rinse like a mofo
Flovent Dose
<12
low: 50mcg 2-4 puffs/day
med: 50mcg 4-10 puffs/day
hi: 125mcg > 4puffs/day

>12
low: 50mcg 2-6 puffs/day
med 125mcg 2-6puffs/day
hi: 1256 >6puffs/day
Methylprednisone
- anti-inflammatory / immunosuppressant agent
- used in the treatment of allergic, inflammatory and autoimmune disorders
Nursing Dx re Asthma
Priority DX
- impaired gas exchange r/t ...
- ineffective breathing pattern r/t
- risk for impaired/inadequate perfusion
- altered blood gases
- knowledge deficit
- ineffective management of therapeutic regime
- inadequate fluid intake
Nursing interventions re Asthma
- 02 treatment (humidied)
- pt education
- medication
- monitoring s/s
- suctioning
- accurate assessment
systems assessment re Asthma
- hx
- vital signs (get them comfy so as not to eff them up
- respiratory (auscultation, breathing pattern and quality [nasal flaring?], indrawing [intercostal, subcostal, substernal, etc.], ABD breathing, 02 delivery)
- CVS check
- CNS check (LOC)
- medication given and response to it
Respiratory Syncytial Virus (RSV)
- most common cause of lower resp tract infections in kids
- all kids get it by 3
- leading cause of pneyumonia and bronchiolitis, pathogenesis of asthma

- PEAK during cold winter months
- shorter airway puts them at risk
- narrow airways lead to dire consequences
- obligate nasal breathers so lots of saline and suctioning
RSV Management
- hydration
- reliee s/s
- antiviral med (ie: ribavirin
- 02
-tx of other infections
- humidity
Para Influenza
- large % of ped resp infection s (URTI's, croup, bronchiolitis and pneumonia)

- colonizes in the nose and nasopharynx
- invades epithelium, results in cell damage, edema, and loss of cilia
- resulting airwy obstruction and laryngeal muscle spasm account for the typical s/s of croup
Para influenza s/s and dx
- low grade fever
- common cold with fever
- nasal congestion
- sneezing,
- sore throatd
- cough
- epiglossitis
- croup
- bronchiolitis
- pneumonia
- inspiratory stridor
Hemophilus influenza B
- bacterial infection
- meningitis, severe throat and lung infection
Hemophilus influenza B
- meningitis
- fever
- stiff neck
- drowsiness
- extreme irritability
- sudden vomiting
- fever
- s/s at site of infection
Prevention of HIB
- HIB vaccine is gevent at 2,4,6,18mo
Influenza
- AKA flu
- contgious disease
- attacks the resp tract in humans
- diff from cold

- worse than the cold
- become more lethargic, can't cope with daily life
- bed ridden, fevrile, in a world of shit
- may need supp 02
Influenza s/s and dx
- fever
- headache
- tiredness
- dry cough
- sore throat
- nasal congestion
- body aches
Pertussis
- bacterial, highly contagious
- affects resp sys, produces coughing spasms that usually end in a high pitched sounding deep inspiration (the "whoop")
Pertussis dx
- a culture of secretions from nose and mouth
- a throat swab culture
- CBC with an elevated WBC characyerized by large #'s of lymphocytes
- serologic tests for Bordetella pertussis
Pertussis tx and prevention
- erythromycin if caught early enough
- 02 tent with high humidity
- IV fluid
pertussis vaccine

*cough syrup no good!!**
Prevnar - Pneumococcal conjugate
- disease is caused by bacteria
- spread by nasal droplets
- leading cause of pneumonia and acute middle ear infections
- leading cause of childhood meningitis
HPV - Human Papillovirus
- vaccine 100% if givin within one year
Active vs Passive Immunization
Active = VaCCINes

Passive = by admin of performed antibodies derived from human or animals
Immune globulin (human)
- obtained from pooled human plasma and contains mainly IgG with small amounts of IgA and IgM
Trimesters
40 weeks of gestation divided into 3 trimesters
•1-12 6/7 weeks………….1st trimester

13-26 6/7weeks………...2nd trimester

27-40+2 weeks.……..3rd trimester

Also
–Preconception •12 weeks
-Postpartum •6 weeks
Preconception
Before conception
–3 months

Preconception counselling for the couple

Women of Childbearing age 15-44+
–50-75% of pregnancies unplanned
–∴many sexually active women preconceptual at any given time!
Preconception Care
Opportunity to positively impact on health of woman and decrease risk factors impacting on the pregnancy and the fetus
–Optimizing weight and nutrition, exercise
–Modifiable risk factors –smoking, alcohol, drugs
–Folic acid and multivitamin with iron
–Dental health
–Control of medical conditions
–Genetic counselling
–Spacing of childbearing & family planning
–Screening for social risk factors
Signs of Pregnancy
•Presumptive
–Least reliable
–Subjective changes reported by woman

•Probable
–Stronger indicator
–Objective findings documented by examiner

•Positive
–Caused only by pregnancy
Naegele’s rule
–Regular cycle
–1st day of last menstrulal (LMP)
–add 1 year
–subtract 3 months
–add 7 days
GP; TPAL
G = Gravida
Number of pregnancies –no matter how long

P = Para
Number of births of viable age (>20 weeks)

T = Term
Number of births >37 weeks

P = Preterm
Number of births <37 weeks

A = Abortus
Induced or spontaneous abortion (<20 weeks)

L = Living
Number of living children

***Twins count as one birth
Primipara
Primigravida“primip”“nullip”
Multigravida
multipara, “multip”
Prenatal Care
•Pregnancy is a state of health

•Assumption that prenatal care
–Makes a difference

•Prenatal classes
–Varying length, times (early bird)
–Different groups-single women, high-risk, adolescent, culture and languages, VBAC, methods, lamaze, bradley
–Tour of hospital
–Preparation for birth
•Education
–Physical changes, emotional challenges, birth process
•Breathing, relaxation and pain control
•Breastfeeding
•Operative deliveries
•Postpartum adjustment
•Infant care

•Breastfeeding classes
Frequency of Prenatal Visits
•Every 4 -6 weeks at beginning of pregnancy until ~30 weeks
•From ~30 -36 weeks, every 2 -3 weeks
•After ~36 weeks, every one to two weeks
•More frequent visits may be needed depending on risk factors
1st trimester
•Confirm and adjust to pregnancy
•Discomforts
–NVP (Nausea/Vomitting of Pregnancy)
–Pelvic, breast, skin
Assessments on the 1stPrenatal Visit
•Initial visit after confirming pregnancy LMP, EDC (Expected date of Confinement), ultrasound if not sure
–Obtain obstetrical history for
all previous pregnancies (TPALG)
–Obtain relevant medical, social,
psychological, Rx and family history
–Counseling re: Drug use, alcohol consumption, smoking
–Complete physical exam, and vital signs (BP*), baseline weight, height (BMI)
–pelvic exam, PAP smear if needed
Prenatal Visits
•Assessments at each visit include:
–Blood pressure
–Uterine size (symphiseal-fundalheight)
–Checking urine for protein, glucose, ketones, bacteruria
–Fetal heart rate
–Weight gain
–Health teaching

•Later visits include vaginal exam (36+ weeks)
Table Guidelines for Gestational Weight Gain Ranges(
BMI < 20
12.5 -18.0 (28-40lbs)

BMI 20 -27
11.5 -16.0 (25-35lbs)

BMI > 27
7.0 -11.5 (15-25lbs)

Overweight, gain less, underweight, gain more
Why is the recommended weight gain 30 lbs if the baby only weighs 7 lbs?
Fetus –7lbs
Placenta –1.5 lbs
Breasts –2 lbs
Uterus –2.5 lbs
Blood Volume –3.5 lbs
Amniotic Fluid –2 lbs
Extravascular Fluids –4 lbs
Maternal Reserves –7 lbs
Screening in Pregnancy
For mother...
•Blood: group and Rhtype, hemoglobin
•Infectious diseases: STI, HIV, Hepatitis B&C, Rubella
•Gestational Diabetes (Glucose Tolerance Test) 24-28wk
•Maternal Serum Screening 15-16 wks
•Group B streptococcus 35-37wks
•Asymptomatic Bacteruria


For fetus...
•Fetal movement
•Ultrasound
•Special tests for high risk -can include Biophysical profile, amniocentesis, chorionic villus testing
Chorionic Villus Sampling
•Obtain chorionic villus-which will eventually develop into fetal placental tissue

•Genetic and other studies
–Done trans-abdominally or vaginally
–~10 weeks results in 2 weeks
–Increased risk of miscarriage
2nd trimester 13-26 weeks
•Feeling of wellness
–nausea and vomiting↓
–Uterus out of the pelvis

•Monitor health
–Fetal and maternal
–Screening -genetic etc

•As it progress…↑ stress on the body as baby, placenta grow
Symphyseal-Fundal height (SFH)
Top of symphysis to top of fundus of uterus
•Tape measure
•One person

•McDonald’s Rule
–Gestation +/-1-3cm
- eg: 26 wks should measure 23-29cm

–Why do it?
•IUGR(Intrauterine growth restriction) refers to the poor growth of a baby while in the womb,
- multiples
Physiologic / Anatomic Changes of Pregnancy
• Cardiovascular / Hematological
– inc blood volume , inc cardiac output by 40% -50%
- warning Those with CV disease at inc risk
–Peripheral vasodilatation maintains normal BP
–Physiological anemia
–Supine hypotension (vena cavalsyndrome or aortocavalcompression)
– inc in clotting factors / fibrinogen, fibrinolysisinhibition leads to hypercoagulablestate, inc risk for thrombus formation
–inc WBC’s 2nd & 3rd trimester (16,000/mm3 by 3rdtrimester
Aortocaval Compression
•Decreased venous return while supine position leads to supine hypotension, light headiness, and bradycardia~10% of pregnant women

•Reduced blood flow to placenta → fetal hypoxia and distress

•Avoid supine, promote LEFT LATERAL
Maternal Serum Screening-MSS
Offered to women to determine risk of carrying an infant with Down Syndrome, Trisomy18, neural tube defect

–15 to 16 weeks
–Counselling
–Should include consideration of further testing
•Amniocentesis
•Detailed ultrasound-exclude anomalies
Risks for genetic disorders and maternal age
inversely proportional
Ultrasound
Check pregnancy/fetal status

When?
–All womenshould have an ultrasound
–18 and 22 weeks gestation. (SOGC)

Why?
–confirm pregnancy and EDC dates
–# of fetuses
–size for gestational age
–how the baby’s internal organs are growing
–woman's uterus, fallopian tubes, ovaries
–check for signs of a possible genetic problem –detailed ultrasound
–Position of baby, placenta
–Biophysical profile
Amniocentesis
•Genetic ~15-16 weeks, 2-3 weeks for results
–Down syndrome (trisomy 21) and other fetal anomalies in women >35 or high risk women
–Triple test: Neural tube defects (AFP-alpha-fetoprotein), human chorionic gonadotrophin (hCG), unconjugated estriol (UE3)

•Decisions about pregnancy ~18+ wks
–Difficulty after 20 weeks for termination
Care for preggo
•Support
–Guilt
–May have difficult decisions ahead of them
–May have already suffered with fetal loss or have child with health challenges
–Worry about effects to fetus

•And…
–WinRhoimmune globulin for Rh-women
–Fetal heart rate during and after
–Check for bleeding or leaking of amniotic fluid
–S&S of infection
3rd Trimester 27-40+ weeks
•Visits usually visits q 2 -3weeks then q1 week after 35-36 weeks
–Blood pressure
–Weight
–Urine for sugar and ketones
–SF height
•Supine Hypotension

–Ultrasound
•During amniocentesis
•Fetal wellness part of the biophysical profile
•Fetal and placental position
Late 3rdtrimester
•35-40 weeks
–Vaginal examinations, look for cervical changes that indicate labourimminent
•Softening
•Thinning
•Opening
•Moves forward

•37 weeks
–GBS screen
–No treatment until labour

•40+ weeks
–post-term, postdates, postmature
–Fetal health
–Induction
–Confirm dates,
Amniocentesis In the 3rd trimester…
•Fetal maturity

•L/S ratio (Lecithin/Sphingomyelin) 2:1=>35 weeks
•2 components of surfactant which line alveoli of lungs and reduces surface tension when the infant exhales

•Phosphatidylglycerol(PG)
•Appears ~ 35 weeks
Fetal fibronectin ƒFN
•Glycoprotein released into cervical/vaginal fluid in response to inflammation or separation of amniotic membranes from decidua
•Normally found in cervico-vaginal secretions until 22 weeks gestation and again near the time of labour
•Negative =Lack of fFN = pregnancy is likely to continue for at least another two weeks (98%)
•Positive ƒFN = present 24 through 34 weeks gestation indicates ↑ risk of preterm delivery
•Swab of cervicovaginal fluid
–24h after vaginal exam
Group B Streptococcus GBS
•Common bacteria often found in the vagina, rectum, or bladder
•15 -40% women
•Preterm labourbefore 37 weeks gestation (with or without ruptured membranes) or Term >18 hrs
•Unexplained, mild fever during labour
•Previous baby with GBS infection
•Previous or present GBS bacteruria
•Screening by vaginal/rectal culture @35-37 weeks
•Treat with antibiotics in labour
•Screen and treat all women who are GBS + or Treat based on risk factors
BPP Score
A biophysical profile (BPP) test measures the health of your baby (fetus) during pregnancy. The results are scores on five measurements in a 30-minute observation period.
1. Nonstress test
2. Breathing movement
3. Body Movement
4. Muscle tone
5. Amniotic fluid volume

BPP Score
8 to 10 points = baby is healthy.
5 to 7 points = retest in 12 -24 hrs.
4 or less = baby at risk for problems →further testing
Teaching in Pregnancy
•Normal Changes
•Nutrition (folic acid)
•Alcohol/smoking
•Dental Health
•Emotional Health
•Birth Preparation
•Signs of concern
–Bleeding, decreased FM, sudden gush of fluid, severe cramps, urinary tract infection, severe headache, dizziness, edema
Transfer to postpartum: Initial Assessment
1.Report with labour & delivery nurse
–time, events of labour & birth
–Complications of pregnancy, labour, birth, neonate
–Psychosocial issues
–Identification of baby/mother

2.Vital Signs –baseline, q shift

3.Perineum
–Flow, hematomas, episiotomy

4.Medications
–IV, other

5.Blood Loss
–At delivery

6.Assess pain
–Last pain medication
–Need for ice or oral medication

7.Bladder
–When last voided?

8.Nutrition
–Fluids, snack

9.1st ambulation

10.Initial teaching
–Pericare
BUBBLERS 8-point check
•Breasts
•Uterus
•Bladder
•Bowels
•Lochia
•Episiotomy
•Reaction (emotions)
•Signs (Homan’s sign, Vital signs, Pain)
Breasts
Breastfeeding
–Assess nipples for soreness, comfort, bruising, blisters, cracking
–Shape -inverted
–Palpate breasts for softness, filling, full, engorged
–Any signs of mastitis–puerperal
•blocked milk ducts, not emptying
•redness, soreness,
•fever, general malaise
•massage and compression
•warm compresses or shower
•antibiotics

•Not breastfeeding
–Assess
–Comfort
–Avoid stimulation of nipples, bra
Uterus
•INVOLUTION
–Sealing off of placental site
–Return of uterus to pre-pregnancy size
–Enhanced by: breastfeeding, early ambulation, uncomplicated birth, empty bladder

–Impeded by: overdistendeduterus
•exhausted uterus
•anesthesia or excessive analgesia
•full bladder
•multiparity(grand)
•Multiple pregnancy
•incomplete expulsion of the placenta or membrane fragments
•“Boggy” uterus
–blood & clots collect, contraction interrupted
Afterpains
•Involution–contractions
•Usually not with 1stdelivery
•**During breastfeeding**
•If fundusis painful to palpate –infection

Comfort measures
•Pain medication ½ hr before feed is expected or prn
•Empty bladder
•Lay on side to feed
Diastasis Recti Abdominis
rectus abdmoninis muscles separated
Cesarean Birth/C-Section
Major abdominal surgery –25%+
–Previous c/s, fetal distress, cpd, hemorrhage, elective…

LSCS = Low segment cesarean section (horizontal cut)

Classical Incision = Vertical cut
Cesarean Birth Care
•Dressing
–Shower day 2

•Foley
–Observe flow & urine output
–Out day 1

•IV
–syntocinon: Syntocinon injection contains a synthetic version of the naturally-occurring hormone oxytocin. It works in the same way as the natural hormone.

•DB&C
–Spirometer
–Obese

•Early ambulation
•Pain relief –no codeine, positioning

•Involution
–Do not palpate the fundusafterwards
•Assess flow only
•*also for postpartum tubal ligation
Bladder
• inc bladder capacity
•↓bladder tone
•↓ sensation
•+ swelling/bruising = ↑ risk of urinary retention, UTI
•PP diuresis
•fluid also lost through diaphoresis
•esp. at night

Uterus is displaced, deviated to the right when the bladder is full
Bowels
•Monitor bowel function
–Bowel sounds for C/S
–Spontaneous bowel movement may not occur for 2 to 3 days after delivery due to:
____________ _____________
–Elimination usually returns to normal within one week
•Constipation
–Administer colace as ordered
–Dietary
•Hemorrhoids
•Flatulence
Lochia
- vag blood

NORMAL
–heavy flow expected immediately after delivery
•heavy (1 pad/hr)
•moderate(<6”)
•light(<4”)
•scant(<1”)
–Increases w ambulation & breastfeeding

ABNORMAL
–foul smell, large clots, heavy, reappearance of red lochia, lasts > 4wks
Normal lochia --changes
–Rubra 2-3 days
•dark red, bloody, fleshy, musty, stale non-offensive odor; clots < loonie; composition: blood and smamts mucus, shreds of decidua, epithelial cells, leukocytes; may contain fetal meconium, lanugo, or vernixcaseosa
•Persistence of lochia rubra indicates sub-involution

–Serosa 4-7 days
•pinkish brownish
•contains less old blood, serum, leukocytes, and tissue debris

–Alba 10-14 days+
•yellow to white
•contains leukocytes, decidua, epithelial cells, mucus, serum, bacteria
•3-6 weeks
Fundal massage and manual expression of uterus
•Promote uterine contraction
•Expel clots
•Hurts!
Perineal Care
•Periwash bottle
•Wipe/pat front to back
•Change pads frequently
•Sitzbath
•Ice pads/packs
•Donuts
•Pain medication
Episiotomy
•Visually inspect for tears and incisions
–REEDA = redness, edema, ecchymosis, drainage, approximation
REEDA
–REEDA =

redness,
edema,
ecchymosis,
drainage,
approximation
Vaginal tears
1 - vag tear
2 - perineal muscles torn
3 - perineal and anal sphincter torn
4 - perineal, anal sphincter and rectum torn
Hematoma
•Accumulation of blood in perineum
•Soft tissue of perineum offers little resistance
•Can readily accumulate 250-500mls of blood
•Early application of ice can help to prevent

RELENTLESS PAIN cardinal sign!
Perineal Tone
•Kegelexercisesstrengthen the pubococcygeusmuscle
–improves support to the pelvic organs
–compare to elevator, 1-4 floors
–stop flow of urine
–done any time, any where
REACTIONS
Emotional/Psychological

•“Taking-in” (Rubin)
–1st PP day or 2
–preoccupied /c own needs
–tells her story; passive, independent
–touches & explores infant

•“Taking-hold”
–2nd or 3rd day ready to resume control
–eager to learn
–obsessed with body functions
–anticipatory guidance most effective
–rapid mood swings
–mothering functioning established

•Letting Go
–sees infant as unique person, allows others to care
Psychological issues
•Initial attachment behavior
–mother explores infant with fingertips, palms, & then enfolding newborn with hands & arms
–holds infant in en faceposition, face-to-face position about 20cm, same plane; mother uses soft, high-pitched voice

•Bonding
–process by which parentsform emotional relationship with infant over time

•Baby Blues
Challenges for new moms
–finding time for self
–feelings of incompetence
–fatigue from sleep deprivation
–loss of freedom/added responsibility
–baby care
–integrating baby into family (siblings)
–nurses can enhance informedchoice
Physiologic Adaptation
•Cardiovascular/hematologic
–returns to prepregnantstate within 2 wks
–1st 48 hrs greatest risk for PP hemorrhage
–BP -baseline
–Activation of clotting factors •Inc in fibrinogen → ↑ risk of thrombus and phlebitis
–WBC count is often elevated •nonpathologicleukocytosis; an ↑ of > 30% in 6 hrs indicate pathology
–Bradycardiais normal for the first 6–10 days.
–Hemostaticsystem reaches prepregnantstate in 3–4 weeks

•Endocrine/other
–Estrogen & progesterone, Cholesterol ↓ rapidly
–Thyroid

•Vagina
–smooth walls, edematous, multiple small lacerations
–↓ estrogen → ↓ vaginal lubrication & vasoconstriction 6 –10 wks → painful intercourse
•Water based lubrication for intercourse
Cervical changes
•soft, irregular, edematous
–May be bruised-looking
–multiple small lacerations

•closes to 2 -3 cm in a few days

•admits fingertip in 1 week
–Use of tampons

•permanent change to os
–1st delivery to slit-like opening
Ovulation & Menstruation changes
•Non-lactating
–6-8 wks
–delayed, but not reliable form of birth control

•Exclusive breastfeeding
–→ can be longer

•Can get pregnant before having a period!!
Contraception
•Depo-Provera
–estrogen free, can be given if breast-feeding

•Estrogen-free “mini-pill”
–especially if doubt woman will abstain until the postpartum check-up or return for the visit
–can be given if breast-feeding

•Condom
–may need lubricant

•Diaphragm or cervical cap
–Refit after birth or 5kg weight gain/loss

•Intrauterine device
–Mirena –progesterone
Other considerations to help ensure healthy delivery and care
•Rhneg
–mom may get WinRho(RhoGAM)
–only if baby positive
–within 72 hours of delivery

•Rubella
–If non-immune, (<1:20) offer vaccine
–Advise not to get pregnant for 3 months

•Hgb
–2ndday pp
–Anemia

•Nutrition
–300-500+ cal for breastfeeding
PP Tubal Ligation-PPTL
–Permanent vs. tie, clips, cautery

–Done 1st -2ndday pp
•Fallopian tubes accessible
•Already in hospital
•Send for biopsy
•Go to delivery room

–Do not palpate the fundus afterwards
•Assess flow only
•may have syntocinon running

–Some discomfort
•Tylenol extra strength
Symptoms to Report for mom
Symptoms to report
•Lochia-foul smelling, heavy flow, clots
•Chills or fever -T>38oC
•Constant pain in lower abdomen
•Pain, burning, urgency or difficulty voiding
•Legs -Redness / swelling / pain
•Unexplained shortness of breath or chest pain
•Headache or problems seeing
•Fainting or feeling dizzy
•Tender red area in breast with flu-like symptoms
•Episiotomy or C/S incision -hot, red, painful, draining, dehiscence
•Feeling overwhelmed / depressed when caring for babySymptoms
PP Follow up
•“Healthy and Home” SHR
–Phone call, visit 2-3 days
•primips, adolescent, any complications
–Breastfeeding centres
–Baby health, weight
–Mum -flow, breasts, mood, etc
.
•Other regions –information sent out
–Public health nurses

•Doctor
–~1-3 weeks for babe
–6 week postpartum check for Mom
4 P’s plus of labor and delivery
•Passage
•Powers
•Passenger
•Phases

Plus
•Psychology
PASSAGE
•Ability of pelvis and cervix to accommodate passage of fetus

•True pelvis
–bony canal through which fetus must pass
–Divided into three sections: inlet, pelvic cavity, outlet

•Four classical types of pelvis
–Gynecoid
–Android
–Anththropoid
–Platypelloid
PASSENGER
•Ability of fetus to complete birth process

•Molding: cranial bones overlap under pressure of the powers of labour and demands of pelvis
Important structures of fetal skull
- occipital bone
- lambdoidal suture
- sagittal suture
- anterior fontanelle bregma
landmarks that have significance duringbirth.
- sinciput (forehead)
- Vertex (crown of head... the sweet spot
- Occiput (occipital bone)
Typical anteroposterior diamters of the fetal skull
- **Biparietal = 9.25cm**

- Bitemporal = 8cm

- submentobregmatic = 9.5cm

- **Suboccipitobregmatic = 9.5cm**

- Occipitofrontal = 11.75cm

- Occipitomental 13.5cm
Fetal lie
lierefers to relationship fetal cephalocaudal axis (tailbone) to maternal cephalocaudal axis
–longitudinal, transverse
Fetal attitude
-refers to relation of fetal parts to one another –“fetal position”
-well flexed
Fetal presentation
Fetal presentation determined by fetal lie and by body part of fetus that enters pelvic passage first

Face
Brow
Vertex**
Breech**
Shoulder**
Position of fetus in relation to pelvisR
R=right L=left O=occiput, S=sacral, M=Mentum

** ROA; LOA **
ROT; LOT
ROP; LOP

RMA; LSA
RMP; LSP
LMA
Station
Station relationship of presenting part (head, buttocks) to imaginary line drawn between ischial spines of maternal pelvis

Head at “0” station is “engaged”
Engagement
Engagement largest diameter of presenting part reaches or passes through pelvic inlet
Dipping
Dipping.The fetal head dips into the inlet but can be moved away by exerting pressure on the fetus.
Engaged
Engaged.The biparietal diameter (BPD) of the fetal head is in the inlet of the pelvis.

In most instances the presenting part (occiput) is at the level of the ischial spines (zero station).
POWERS
•Characteristics of contractions and effectiveness of expulsion methods

•Primary and secondary powers
–work together to achieve birth of fetus, fetal membranes, placenta

•Primary power
–uterine muscular contractions

•Secondary power
–use of abdominal muscles to push during second stage of labour
Hormones…
•Progesterone causes relaxation of smooth muscle tissue

•Estrogen causes stimulation of uterine muscle contractions

•Prostaglandins contribute to cervical ripening and dilation

•Connective tissue loosens and permits softening, thinning, opening of cervix
Contractions
•Pressure of fetal head increases cervical dilation and effacement

•Rectum and vagina are drawn upward and forward with each contraction

•During second stage, anus everts

•Women experience a range in physical sensations-each, each woman, each baby unique
–very mild -"menstrual cramp" to severe discomfort, some don't feel any discomfort at all (rare)
Contraction duration
- start - end of one contraction
Contraction frequency
- start-start of another contraction
effacement of Cervix
Thinning –effacement of Cervix

•Muscles of upper uterine segment shorten and cause cervix to thin and flatten

•Necessary for delivery of term infant
Effacement of the cervix in the primigravida. Beginning of labour-end
- no cervical effacement or dilatation

--fetal head is cushioned by amniotic fluid

-as the cervix begins to efface more amniotic fluid collects below the fetal head

-Cervix about one half effaced (50%) and slightly dilated.

--increasing amount of amniotic fluid exerts hydrostatic pressure

-Complete effacement and dilation.
Bishop’s Score
Bishop score, also Bishop's score, is a pre-labour scoring system to assist in predicting whether induction of labour will be required. It has also been used to assess the odds of spontaneous preterm delivery

Position
Consistency
Effacement (%)
Dilation (cm)
Baby's Station
Psychosocial Considerations
•Understanding and preparation for childbirth experience

•History and experiences
–Previous pregnancies
–This pregnancy

•Amount and type of support from others
•Present emotional status
•Beliefs and values
•Age, general wellness
Premonitory Signs of Labour
•Lightening
–Fetus descends into pelvic inlet -engaged

•Braxton Hicks contractions
–Irregular, intermittent, „practice‟ contractions that occur throughout pregnancy
–no cervical changes
–go away with change of activity, movement,
~ hydration
–Cause more discomfort closer to onset of labour

•Cervical changes
–Cervix begins to soften and weaken (ripening)

•Bloody show
–Loss of cervical mucous plug
–Causes blood-tinged discharge

•Rupture of membranes
–If rupture prior to onset of labour in a term pregnancy
•good chance labour will begin within 24 hours

•Sudden burst of energy
–“Nesting”
–Usually occurs 24 to 48 hours before start of labour

•Loss of 0.5-1kg

•Diarrhea, indigestion, nausea, vomiting
PHASES -stages
•First Stage
–Early or latent phase: 0-3 centimeters (cm)
–Active phase: 4-7 cm
–Transition: 8-10 cm

•Second Stage
-Fully dilated

•Third
–Delivery of placenta

•Fourth
–Adaptation
First Stage –cervical Latent Phase 0-3 cm
•physiologic
–Regular, mild contractions begin and increase in intensity and frequency
–Cervical effacement and dilation begins
–0-3 cm

•psychological
–Relief that labour has begun
–High excitement with some anxiety
Active Phase 4-7cm
•physiologic changes
-Contractions
–increase in intensity, frequency, and duration
–Q 2-3 min, 45-60 sec
•Cervical dilation
–4 to 7 cm
•Fetus begins to descend into the pelvis

•psychological changes:
•Fear of loss of control
•Anxiety increases
Transition Phase 8-10cm
Physiologic
–Contractions
•increase in intensity, duration, and frequency
•1 ½ -2 minutes, 60-90 sec

–Cervix
•thins and stretches
•8 to 10 cm

–Fetus descends rapidlyinto the birth passage

–may experience
•rectal pressure
•nausea and/or vomiting

==============
•Psychological
–Increased \anxiety
–Irritability
–Eager to complete birth experience
–Need to have support person or nurse at bedside throughout each contraction
Second Stage –pelvic
•physiologic
–Begins with complete cervical dilation and ends with birth of infant
–Crowing
•Head visible, does not retract between contractions-pain
–pushing due to pressure of fetal head on nerves
–Woman uses intra-abdominal pressure to push
–Perineum begins to bulge, flatten, and move anteriorly as fetus descends

•psychological
–May feel a sense of purpose
–May feel out of control, frightened, and irritable
–Tired and exhausted
Mechanisms cardinal movements of labour
A and B, Descent.
C, Internal rotation.
D, Extension.
E, External rotation.
Syntocinon
Syntocinon injection contains a synthetic version of the naturally-occurring hormone oxytocin. It works in the same way as the natural hormone.

-usually syntocinon, 5 units IV or 10 units IM
Third Stage 5-30 min
physiologic
–Placental separation
•Uterus contracts and placenta begins to separate
–lengthening of the cord
–slight blood loss
–strong uterine contractions
–uterus smaller, rounder and firmer
–fundus rises to the abdomen becoming harder and more mobile
–woman may feel pressure to bear down
–Placental delivery
•Woman bears down and delivers placenta
–-may need slight traction on cord to assist delivery of placenta

•psychological
–relief at completion of birth
–twighlight
–focused on welfare of baby
•may not recognize that placental expulsion is occurring
4th Stage -1-2 hrs after 3rd
physiologic changes
–↑pulse and ↓ blood pressure
–Uterus: located between umbilicus and symphysis pubis
–Woman may experience a shaking chill
–Urine may be retained due to decreased bladder tone and possible trauma

psychological changes
–May be euphoric and energized at birth of baby
–May be thirsty and hungry
Fetal Responses
•Normal labour
–no adverse effects in healthy fetus

•Fetal heart rate
–decrease as head pushes against cervix

•Blood flow
–decreases to fetus at peak of each contraction leading to decrease in pH
–Further decrease of pH occurs during pushing due to woman holding her breath
Fetal Heart Rate
• Auscultation “listen”

• As effective as electronic
+ Can be up and about
- No permanent record
- Skill of practitioner, time
- Rate and regularity

• Leopold’s maneuvers
– fetal position

• Identify fetal back and listen
– 60 seconds

• Check maternal pulse

• Palpate uterine activity
Electronic Fetal Monitoring EFM
• Monitor (Internal or External)
• Continuous printout-correlate with contractions
– NOT for routine use in low-risk women
– Used if maternal or fetal risks such as
• any abnormal FHR

- External on tummy
- Internal on baby
• IUGR, multiple, breech, meconium staining, prolonged
rupture of membranes, preterm/postdates
• Gestational hypertension, diabetes, antepartum
hemorrhage
• VBAC
• Induction
Non Stress Test -- NST
– Assess fetal wellbeing
– Not in labour, no contractions
• Done antenatal
– Response to fetal movement
– Part of biophysical profile
Stress Test
– Contractions present
• Assess how fetus responds to stress
– Oxytocin
FHR Baseline
• Approx. mean rounded to 5 bpm in 10 minutes

• Normal FHR - 110 to 160 bpm
– Rate above 160 bpm is tachycardia
– Rate below 110 bpm is bradycardia
Fetal Tachycardia
• Sustained rate >160 bpm for at least 10 mins

ATYPICAL
• If >160 for >30mins but <80 mins

ABNORMAL
• If >160 for >80 mins
Causes of fetal tachycardia
– Early fetal hypoxia
– Maternal fever
– Maternal dehydration
– Amnionitis
– Maternal hyperthyroidism
– Beta-sympathomimetic drugs
– Fetal anemia
– Prematurity
Ominous sign if tachycardia is accompanied by
– Late decelerations
– Severe variable decelerations
– Decreased variability
Fetal Bradycardia
Sustained rate < 110 bpm for at least 10 mins

ATYPICAL
• 100-110 beats per minute

ABNORMAL
• <100 beats per minute
Fetal Bradycardia Causes
– Profound hypoxia in fetus
– Maternal hypotension – supine, epidural
– Prolonged umbilical cord compression
– Fetal arrhythmias
– Uterine hyperstimulation
– Abruptio placentae
– Uterine rupture
– Vaginal stimulation in second stage of labor
FHR Variability
Fluctuations in baseline FHR >2 cycles/minute

Visually quantified amplitude of peak to trough in bpm

– Absent = A = undetectable
– Minimal = MN = ≤5 bpm
– Moderate = MD = 6-25 bpm
– Marked = MK = >25 bpm


** Moderate Variability is reassuring**
Accelerations
• Abrupt increases in fetal heart rate
– at least 15bpm above baseline for at least 15sec
- May differ depending if <32 weeks (10x10)

Normal – presence of spontaneous accels and accels present with scalp stimulation

Atypical – Absence of accels with fetal scalp stimulation

Abnormal – Absence of accels

** Accelerations are reassuring**
Decelerations
– periodic dec in FHR from baseline at least 15bpm
for at least 15sec

– 3 types: variable, early, late, prolonged
• relationship with contractions and abruptness

– Important to differentiate to determine fetal wellbeing and required interventions
VARIABLE Decelerations
= CORD COMPRESSION

• A visually apparent abrupt FHR ↓
≥15bpm below baseline for ≥ 15 secs

• Classified as Uncomplicated or
Complicated

Uncomplicated:
– last less than 2 minutes
– V-shaped or W-shaped
– variable decelerations occur throughout
pregnancy, transiently
– most common deceleration in labor

Complicated:
• Deceleration <70 bpm >60 sec
• Loss of “variability” in trough
• Overshoot
• Slow return to baseline
• Lower baseline after decel
• Presence of tachycardia or bradycardia
EARLY Decelerations
= HEAD COMPRESSION

A gradual ↓ in FHR (onset to peak ≥ 30 sec) associated with uterine contraction
– onset, nadir, and recovery coincide with contraction
– usually related to fetal head compression or stimulation
– uniform in shape, benign
– NORMAL usually do not require
intervention
LATE Decelerations
=UTEROPLACENTAL INSUFFICIENCY

A gradual ↓ in FHR (onset to peak in ≥ 30 secs) associated with a uterine contraction

–Onset, nadir, and recovery occur after the contraction
– OMINOUS
–ATYPICAL or ABNORMAL
PROLONGED decelerations
reflect profound changes in fetal environment

• Visually apparent ↓ in FHR below baseline > 15 bpm

• Deceleration lasts > 2 min but <10 min
Normal Intrapartum EFM
• Formerly Reassuring or Reactive

- Baseline 110 - 160 bpm
– Variability 6 - 25 bpm

– Accelerations
• 15 beats/15 sec
• Present with fetal movements
– 3 in 10 min
• Response to stimulation

– Decelerations
• Absent or early or variable with good return
Atypical and Abnormal
(formerly Nonreassuring FHR)
• Absent or Minimal Variability
• No accels or no response to scalp stim
• Complicated variable decels
• Prolonged decelerations
• Late decels
• Decreased variability
• Prolonged deceleration (> 60-90 seconds)
Nursing Interventions
ABNORMAL FHR
UTERINE RESUSCITATION
• Maternal Repositioning (repeated)
• Correct hypotension if present
• Oxygen
• Administer IV fluids as needed
• Decrease or discontinue oxytocin
• Nitroglycerine if uterine hyperstimulation and
bradycardia
• Initiate continuous EFM monitoring
• Vaginal Exam
• Support/Explain
• Notify
• Document
Fetal Blood Sampling or
Internal monitor
• Nonreassuring but not ominous tracing
• Fetal scalp electrode
• Presenting part <–2 station
• Cervix > 2 cm dilated
• Ruptured membranes
• Nonemergent situation
• No abnormal bleeding
• Rarely done here, difficult to get accurately
Documentation: EFM Strip
• Hospital label
– Name, doctor, number

• Date

• Time on/off
– Why? up for walk, sleeping…

• Vaginal exams
– Dilatation, effacement, station, who done by

• Membrane status
– Any changes, ruptured, amniotomy, who, time, colour etc.

• Maternal vital signs
– BP, TPR

• Also
– Position changes, up to BR
– Intake, IV bags, additives, oral intake
– Medications given-epidural
– Oxygen applied
– Blood sugar, Urine testing
– Bleeding
Priority Needs of the Newborn
•Initiation & maintenance of respirations
•establishment of extrauterine circulation
•control of body temperature
•adequate nutrition intake
•establishment of waste elimination
•prevention of infection
•establishment of an infant -parent relationship
•developmental care which balances physiologic and neurodevelopmental needs
Adaptation of the Newborn:Respiration
•Production of lung fluid decreases 2 to 4 days before labour
•80 to 100 mL remain in the air passage of a full-term newborn
•During birth, fetal chest is compressed and squeezes fluid --Vaginal vs. c-section
•First breath = inspiratory gasp
–triggered by
•increased PCO2
•decrease in pH and PO2
Assessments made Immediately after birth
•Rapid assessment
breathing or crying
muscle tone
term infant
clear of meconium

•Be prepared to intervene as necessary to ensure open airway / effective ventilation
•Assign Apgar score-(HR, color, respirations, tone, reflex irritability @1 and 5 min.)
•Signs of compromise - dec HR & BP, dec resp. effort, dec muscle tone, cyanosis
APGAR score
The Apgar score was devised in 1952 by the eponymous Dr. Virginia Apgar as a simple and repeatable method to quickly and summarily assess the health of newborn children immediately after birth

-Heart rate
0 - Absent
1- Slow <100
2- Above 100

Respiration
0- Absent
1- Slow-irregular
2- Good crying

Muscle tone
0- Flaccid
1- Some flexion
2- Active motion

Reflex irritability
0- None
1- Grimace
2- Vigorous cry

Colour
0- Pale, blue
1- Body pink, extremities blue
2- Completely pink

**1, 5, 10 minutes after birth**
Cord Blood Gases
Arterial–unoxygenated / Venous –oxygenated

•Metabolic acidosis
–pH < 7.2, base excess >12 mEq /Land APGAR<3 for 5 minutes = ↑ risk of anoxia brain damage
Newborn Care Immediately after Birth
•Assess vital signs q1h during first hours of transition
•Assess color and level of alertness/activity/flexion
•General top to toe assessment -observe for evidence of trauma, congenital anomalies
•Ensure accurate infant identification
•Provide opportunities to promote family interaction & bonding
•Warmth
Medications at birth
•Vitamin K
–lacks intestinal bacterial flora necessary for production of vitamin K
–Prothrombin levels low during first few days of life
–Risk for hemorrhage
•Hemorrhagic disease of the newborn
•Especially if trauma or circumcision is intended
–1 mg.IM

•Erythromycin, Tetracycline, silver nitrate 1% ungt to each eye
•Prevention of opthamlia neonatorum
–Family centered care guidelines
•Up to 2hr delay, usually within an hour of birth
•Single application tube
NORMAL NEWBORN Assessments
•Vital signs
–Temperature
–Pulse
–Respirations

•Weight
•Length
•Head
•Chest
WARMTH for newborn
•Maintenance of normal temperature
–Balance heat production w heat loss to maintain body temperature within a certain “normal” range.

–Why is newborn at risk?
big head

–Maintain Neutral thermal environment (NTE)
–Axillary temperature -36.6 -37.2
–Heat production in Neonates•
Non-shivering thermogenesis

-How fast can an infant be chilled?
•0.2 –1.0oC / minute
Risk factors for altered thermoregulation
•First 8 -12 hours of life
•Premature
•Small for gestational age
•Infants with CNS problems
•Prolonged resuscitation efforts
•Sepsis
Signs of Cold Stress
–Vasoconstriction –acrocyanosis, pallor
–Tachypnea / tachycardia
–Fussiness / hyperactive
Preventing Cold Stress
•Area for delivery –23 –25oC
•Dry quickly (**head) —remove wet linens, hat?
•Use pre-warmed warm blankets
•Skin-to-skin contact with mother
•If needed, provide radiant warmer heat; do not block heat
•Keep away from drafts, air conditioning vents, cold windows
•Warm items –scales, stethoscope
•Guard against hyperthermia –
–First 24 hrs –often d/t overheating, flushed
–After 24 hrs, may be sign of sepsis –mottled, pale, cool extremities d/t vasoconstriction
Thermogenesis
•Nonshivering thermogenesis
–skin receptors perceive a drop in environmental temperature

•Newborn shivers
–metabolic rate doubles

•Increase muscle activity

•BAT is primary source of heat in hypothermic newborn
–Appears in fetus at 26 to 30 weeks
–Increases until 2 to 5 weeks after birth
Heat Loss: 4 ways
1.Evaporation
•wet with amniotic fluid

2.Convection
•removed from incubator

3.Radiation
•placing cold objects near incubator, window

4.Conduction
•cold stethoscopes
Neonatal Hypoglycemia -Glucose Regulation
•Glucose is the main source of energy for brain cells
–No glucose = Neurological compromise

•Healthy babies effectively respond to low blood glucose for first hour after delivery

•Hypoglycemia
–Not a single value of glucose
–Repeated levels of < 2.6 mmol/L or single reading of < 1.8 mmol/ L in high-risk infant need intervention (Canadian Pediatric Society)
Infants at Risk for Hypoglycemia
•SGA Small for gestational age
- dec glycogen stores

•LGA Large for gestational age
-hyperinsulinism

•IDM Infant of the diabetic mother
- hyperinsulinism

•Premature
- dec glycogen stores

•Stressed or sick or cold
- increased glucose utilization
Symptoms of Hypoglycemia
•Jitteriness
•Hypothermia
•Temperature instability
•Lethargy, hypotonia
•Apnea, irregular respirations
•Poor suck or refusal to eat
•Vomiting
•Cyanosis
•High-pitched or weak cry
•Seizures
Treating Hypoglycemia
•Asymptomatic
–Feeding interventions
•inc frequency of Breastfeeding
• supplementation with BM, BM fortifier, or formula
–Evaluate for response in 1 hr.

•Symptomatic
–IV infusion of glucose
–Target 2.6 mmol/l or inc
First Period of Reactivity
•Period lasts about 30 minutes
•Newborn is awake and active
•Appears hungry and has a strong reflex
•Natural opportunity to start breastfeeding
•Encourage face-en-face
•Vital signs are elevated
Inactivity to Sleep Phase
•After 30 minutes, newborn's activity gradually decreases
•Heart rate and respirations decrease as newborn enters sleep phase
•Will be difficult to awaken and will show no interest in sucking
Second Period of Reactivity
•Period of reactivity lasts 4 to 6 hours in normal newborn

•The heart and respiratory rates increase, nurse needs to be alert for apneic periods
–Newborn passes meconium
–Newborn sucks, roots, and swallows
Transfer to unit
•Time and type of delivery
–SVD, forceps, elective C-section
–Any pregnancy, labour and delivery complications

•APGAR scores

•Any resuscitation efforts
–Suction, oxygen, compressions, medication, NICU team

•Vital signs
–Weight, temp

•Breast fed or other
General Newborn Care
•Vital signs q1h x 4, q4h x 24 -48 hours , then BID.
•“Head to toe” assessment BID
•Weight at birth, then prior to d/c (BID if <2500 grams or >10 % drop in birth weight).
•Intake & output –monitor feeds, diapers.
•Cord care –air dry, falls off 5 -15 days, risk for infection.
•Metabolic screen
•Facilitate family’s efforts to care NB
Head-Toe Physical Assessment - infant
•Vernixcaseosa
•Lanugo
•Milia
•Erythematoxicum(newborn rash)
•Cephalohematoma
•Caput succedaneum
•Mongolian spots
•Acrocyanosis
•Epstien’s pearls
•Telangiectatic nevi (stork bites)
•Molding

•Colour
–Pink, acrocyanosis, pale, jaundice

•Skin
–Dry, anomalies, stork bite

•Tone
–Flexed, limp

•Cord
–Clamped, transponder attached
–Care, dry to air or alcohol

•Fontanelles
–Anterior, Posterior
•Open, sunken, bulging
–Sutures
•Overlapping, gaping
Fontanelles
•Anterior fontanellevaries from 1-4cm in any direction.
–diamond-shaped
–junction of the coronal frontal and sagitta lsutures
–ossified within 18-24months.

•Posterior fontanelleshould be less than 1cm.
–triangular fontanel
–junction of the sagittaland lambdoidsutures
–ossified by end of 1st year.
Hip Dysplasia dx
•Ortolani (knees out)
•Barlow (knees across midline)
•Symmetry of creases
Assessment of Reflexes / Neurological
•Sucking
•Rooting
•Grasping (palmar and plantar)
•Moro (startle)
•Tonic Neck (fencing)
•Babinski
•Stepping
•Galant
Visual Ability
•Normal visual sensory-perceptual abilities of newborn
–alert, follows, and fixates on complex visual stimuli for short periods of time
–Orientation
Auditory
•Normal auditory sensory-perceptual abilities of newborn are
–alert and search for appealing auditory stimulus
–process and respond to visual and auditory stimulation
–Habituation
Olfactory, Taste, Suckling, Tactile
•Olfactory
–able to select people by smell

•Taste and suckling
–able to respond selectively to different tastes

•Sensitive to being touched, cuddled, and held

•Attend to and interact with environment
Teaching about care of the newborn
•Bathing, Cord Care
•Feeding –frequency -BF assessment form / Amount
•Voids / Stools -characteristics, frequency
•Diapering
•Circumcision / care of foreskin
•Jaundice
•Safe Sleeping
•Coping with crying (SBS)
•Signs of illness & common infant problems
Bath
•Check TEMP first ~37°C
•No drafts or interruptions
•Basin, low water level, lounge chair
•Elbow warmth
•Non-tearing shampoo, body wash
•Have all equipment, clean clothes, diaper ready

•Clean to dirty
–Corner of facecloth
–Inside to outside of eyes, ears
–Rest of body

•Dry well, cord area, creases
•Vaseline to buttocks
•Bath, feed, nap….
Stools
•Color, type, and number of expected stool -Normal progression of stool changes
–Meconium -usually passes within 48 hrs
–Transitional stools (thin, brown to green)
–Breastfed infant: yellow gold, soft, seedy, or mushy stool after 2-3 days
–Formula-fed infant: pale yellow, formed and pasty stools

•No stool
–Imperforate rectum
–Anal thermometer –1st only

Female
– pseudomenses
Voiding
•93% void by 24 hours after birth
–initial bladder volume is 6 to 44 mL of urine

•1st void documented

•If does not void within 48 hours
–assess adequacy of intake, bladder distention, restlessness, symptoms of pain

•Brick coloured urine
-Urate crystals, normal in first week of life

•Normal colour of urine and appropriate number of voids
–~ 6 per day after day 6
–Pale to clear urine
Sleep
•Back
–Reduces SIDS

•Plagiocephaly
–'flat head'
•Turn head
•Supervised tummy times

•No bumper pads, pillows, or heavy quilts
•Co-sleeping
Symptoms to report: Baby
•Activity change
–very sleepy / listless / restless / continuous crying

•Difficulty breathing
•Fever ( T>38 degrees)
•Increasing jaundice, sleepiness, sclera
•Frequently vomiting large amounts, projectile
•Diarrhea

•Feeding problems
–refusing to eat several feeds in a row

•Less than 6 wet diapers / day after day 6
Neonatal Infection
•Neonates have an immature immune system —placing them at higher risk for infection,

•Neutrophils battle bacterial infection and may become depleted in sepsis

•Risk factors for infection include:
–Premature labour/birth
–Premature rupture of membranes
–Recent maternal illness or infection
–Prolonged rupture of membranes > 18 hours
–Long labour
–Invasive procedures after birth
Clinical signs of neonatal infection
•Respiratory distress
•Temperature instability(inc or dec)
•Feeding intolerance

•Abnormal:
–Skin perfusion
–Heart rate
–Blood pressure
–Neurological status
Infant: Outcome Criteria -Physiological
•Vital signs stable, WNL
•Feeding established; feeds at least8x/24 hrs, content, sleeps between most feeds
•At least 2 feeds managed independently or arrangements made for referral, support & follow-up
•No jaundice in first 24 hours
•Meconium stool in first 24 hrs, functioning BM’s
•Regular urination, urine pale / colorless
•Metabolic screen done / arrangements to have done
•If circumcision to occur, referral or plans made
•No more than 10% weight loss of birth weight first week
Infant: Outcome Criteria -Safety
•Indication by parents that a regulation crib and car seat have been obtained

•Demonstration by patent of ability to feed, clothe and nurture infant

•Indication that referral or follow-up will identify professional concerns re: potential parent isolation, lack of parental competence/confidence, violent home situation or neglect
Nursing Diagnoses
Mother
•Readiness for enhanced family coping
•Altered patterns of urinary elimination
•Constipation
•Pain
•Sleep pattern disturbance
•Fatigue
•Knowledge deficit
•Effective / Ineffective / Interrupted breastfeeding
•Impaired skin integrity
•Infection
•Ineffective tissue perfusion
Nursing Diagnoses baby
•Ineffective airway clearance
•Ineffective cardiovascular tissue perfusion
•Ineffective thermoregulation
•Imbalanced nutrition, less than body requirements
•Risk for deficient fluid volume
•Effective / Ineffective breastfeeding
•Infection
•Readiness for enhanced family coping
Onset of Labor
• Normal
– Term = 38 and 40th week
========================
• Cause of onset is not completely understood

– Progesterone
• withdrawal → relaxation of the myometrium, whereas estrogen
stimulates myometrial contractions and production of
prostaglandins

– ProstagIandin → the connective tissue in the cervix to
soften, thin, and dilate
• Prostaglandin E is used to induce labor

– Oxytocin
• a hormone produced by the pituitary, plays a major role in the
onset and maintenance of contractions during the labor process

– Corticotropin-releasing hormone
• makes the uterus more sensitive to oxytocin and the
prostaglandins
When to come to hospital
• Contractions 5-7 min apart for
one hour
– or 7-10 min apart if not 1st baby
– Rural

• Membranes have ruptured

• Anytime if
– Vaginal bleeding
– dec or change in baby’s movements
Admission-Risk Screening
On admission to antenatal/labour unit

• TRIAGE
– Behaviour of woman

• Assess labor and fetal status
– Need QUICK accurate assessment
• Has the baby moved?
• How long in labour?

– May need to institute interventions
• Fetal distress
• Maternal distress
• Comfort measures
• or Not admit
Q's to ask preggo when she comes.
• When are you due?
• What pregnancy is this for you?
• Any contractions?
• When did last feel the baby move?
• Did your water break?
• Did you notice any bleeding?
• Any complications in pregnancy? Allergies?
• Anything else I need to know?
History and high risk-factors
• Prenatal sheet
– if not, Fax from Dr office

• Database
– Allergies to medications, foods, and other
substances
– Note prescribed, OTC medications
– History of substance abuse
• Alcohol, drugs, tobacco
* if no or decreased prenatal care
– Intimate partner violence/Woman Abuse
Initial Assessment
• Baseline
– FHR, BP, TPR,
– Contractions
– Bleeding
– Cervix
– Membranes
– Edema
– Other anomalies
– Note weight change
– Assess urine
• glucose, ketones, protein
• possible urinary tract infections

• Last menstrual period (LMP)
• Estimated/establishe date of confinement (EDC)

• Laboratory Findings
– Evaluate complete blood count (CBC)
• infection, blood dyscrasia, or coagulation problems

• Evaluate results of serologic testing
– Blood type and group, antibodies
– HIV, Hep B, C

• Ultrasound and other tests done
– GBS - Group B Strep
Membranes
• Intact or Ruptured
SROM-Spontaneous rupture of membranes
• Term

– AROM-artificial rupture of membranes
• Amniotomy, committed to delivery
• Monitor FH during procedure

– PROM-Premature rupture of membranes
• <37 weeks
• Infection, malpositions/presentations

– PPROM (Preterm PROM)
Amniotic Fluid characteristics
– Time

– Amount
• normal 800-1000ml @ term
• Trickle or huge gush
• Keeps producing

– Colour
• Clear, Whitish, White flecks
-older = clearer
-younger = milky b/c of vernix

• Green – Meconium – indicates fetal distress, except in breech – Thick, thin, old, particulate

• Bloody – Streaks are normal, frank fresh bright red is not

– Odour
• Distinct, not foul
Ferning positive
Nitrazine
Blue - positive
Yellow - negative
Umbilical Cord
• Wharton’s jelly

• 3 vessels
• 2 arteries, 1 vein
• 1 vein, 1 artery
– Kidney, cardiac or other genitourinary malformations
• Count and record

• Length
– 55 cm
• long> 70 cm – Around neck, body, prolapse, true knots
• Short <40 cm – Rare, see fetal heart changes as descends

• Cord blood sample sent for blood gases
Care in the 1st Stage of labour
• 0-10 cm

• Vital signs Q1h in early, Q 30 mins in active
– BP, temp, pulse(- FHR = fetal heart rate - if feverish, baby heart rate increases 170-175 is cause for concern)
– Contractions, FHR
– Avoid vaginal exams
– Ask about bleeding, discharge

• Promote voiding q 2h

• Nutrition - active phase
– Clear fluids - Popsicles, apple juice, gingerale

• Teach peri care
– Front to back, peri bottle warm water

• Establish rapport with woman and support person
– Support the supporter

• Discuss expectations of labour and delivery
– Tour of unit
– Assess coping ability, knowledge

• Provide for privacy
– Promote rest
– Walks
Transition
• 7-10 cm

• Vital signs
– BP, pulse, fhr, during and after contractions
– Contraction pattern
– q 15-30 minutes, depending on risk, progress

• Greater amount of support
– one-one care
Care during the 2nd Stage
• 10cm- fully dilated to the time of delivery
• Help woman find effective pushing pattern
• Fetal heart Q 5min or q contraction or following each contraction

• note EFM pattern
– response to contractions, variability
– Pattern of accelerations/decelerations

• Support woman’s attempts to rest between pushes

• Get help
– Another nurse
– Contact delivery person
– Tell pertinent information
Care in 3rd stage - Two nurses
1. Baby
• Maintain respiration
• Promote warmth, dry baby off
• Prevent infection
• Cord blood sample
• Clamp cord
• Apgar Score 1, 5, 10 minutes

2. Mum
• Gently place hand on fundus

• Signs of separation of placenta
1- cord gets longer
2- trickle of blood
3- uterus gets harder and rises up
**don't massage or touch! Just monitor and vital signs**

• Vital Signs

– Administrative
• Register birth
• ID bands
– 2 baby, 1 mum, matching numbers
Care in 4th Stage
Up to 2 hrs after delivery of placenta

– Stabilize before transfer to postpartum unit

– Vital signs q15 for 1 hour
• BP, Pulse, temp

– Fundus – BUBBLERS…
• Firmness
• Position

– Bleeding
• Assess flow

– Suturing of episiotomy, tear
• Assist

– Breastfeeding
• Attachment; help w uterus; contraction; bond with baby
get some colostrum into baby

– Nutrition
• Tea/toast

– Shower
Cervical Ripening
Use of pharmacological other means to soften, efface and/or dilate the cervix to increase likelihood of vaginal
delivery when induction is indicated
Induction:
the initiation of contractions in
the pregnant woman not in labour
Augmentation:
enhancement of contractions in the pregnant woman already in labour
THe most important contributor to the success of induction
A cervix that is soft & effaced is THE MOST important contributor to the success of induction.

Bishop Score - numerical score; Unfavourable is score ≤6
Indications to Induce Labour
• Postmaturity
• Ruptured membranes (no labor)
• Abruptio placenta, APH
• Maternal medical problems - severe hypertensive disease diabetes, cardiac, renal disease, infection (chorioamnionitis)
• History (previous hypotonic uterine dysfunction)
• Size of fetus
• Logical psychosocial reasons or logistical reasons
• Fetal demise
Cautions for Induction
• Grand multiparity - G5
• Vertex not engaged or fixed in the pelvis
• Unfavourable or unripe cervix
• Brow or face presentation
• Over distension of uterus
– polyhydramnios or multifetal pregnancy
• Previous c-section
– Lower segment uterine scar
• Pre-existing hypertonus
• Hx of difficult labour and/or traumatic delivery
• Availability of Cesarean section delivery
Contraindications to Induction
• Placental - complete placenta previa
• Cord - presentation / prolapse
• Fetal malpresentation (transverse lie, breech)
• History
– Previous uterine surgery or classical C/S
– Pelvic abnormalities / absolute CPD
– Active genital herpes
– Gyne/Obs/Medical conditions
– Convenience
*Any contraindication to labour or vaginal delivery*
Methods to induction
• Mechanical
– Stripping/sweeping of membranes
– Amniotomy (ARM/AROM)
– Dilatation
•  Bleeding, RoM, infection
– Seaweed laminaria
– Foley #18, 30-60cc
» 24hr or falls out
– Cervical balloon

• Pharmacological
– Cervical ripening - prostiglandin
– Induce contractions – oxytocin
Cervical Ripening
• Increases chances of labour in next 12-24hr
• Decreases chances of epidural, c-section, and operative delivery
• Caution in c-section

• Prostaglandin E2
- Intravaginal Prostin gel 1-2mg or intracervical Prepedil 0.5mg
– Posterior fornix - continuous slow release Cervidil 10 mg

• Prostaglandin E1 synthetic-tablet Misoprostol/Cytotec

• Q 6-12h

• Caution
– Allergies-rash, wheeze
– Hyperstimulaiton/tonus – generally not used for induction
Stripping/Sweeping Membranes
• Mechanical separation of membranes from cervix or uterus
• Does not require monitoring or other assessments
• Effectiveness
– questionable
• Risks
– bleeding
Amniotomy - AROM
WHY?
• Augment or induce labor
• Committed to delivery
• Apply internal fetal or pressure monitors
• Obtain fetal scalp blood sample for pH monitoring
• Empty bladder, peri care
• Monitor
– FHR – pre/post procedure
– Colour, odour, amount
Other ways to induce
• Nipple Stimulation - oxytocin
• Sexual intercourse - prostaglandin & oxytocin

• Acupuncture ?
– Upper ankle

• Enema
• Castor oil ?
• Herbs
– Basil, oregano, red raspberry
– Evening primrose oil, blue/black cohosh gtts sublingually
Oxytocin (Syntocinon/Pictocin)
• Used for both induction and augmentation but not cervical ripening
• Caution with previous c-section
• Half-Life ≈ 7-12 minutes
• Given IV via pump always as secondary line
• Protocol varies with institution
– gradual ↑ q30 min. to 20mu/min
Contraction status
Assess resting tone and fetal heart rate

• Hyperstimulation
- excessive uterine activity often with atypical or abnormal FHR tracing

• Tachysystole
- >5 contractions in 10 minutes 10 in 20)

• Hypertonus
- Abnormally high resting tone

• Tetanic
- Contraction >120 seconds
Hyperstimulation
• Abruption of placenta, hypoxia to fetus, precipitous delivery, pp uterine atony

• Care:
– Remove cervical ripening agent
– Stop oxytocin
– Open main line IV
– Left lateral
– O2 per mask
– Continue monitor
– Administer ordered tocolytic
• Nitroglyicerine IV or spray, Terbutaline
Postpartum effects of induction
- Risk of Postpartum Hemorrhage (PPH)/ PP atony is increased with induction:
– difficulty in establishing labour, need for exogenous oxytocin
– uterine fatigue - prolonged labour requiring augmentation
– Rapid, precipitous labour

• Consider continued infusion of
oxytocin titrated to fundus /flow
Uterine Rupture
• Life threatening event

• Early labour

• Previous c-section- classical scar or uterine surgery

• Induction or augmentation
– May or may not feel pain
– Intra-abdominal bleeding, shock
– Fetal distress

• Immediate c-section
– hysterectomy