Test 2 Study Guide Maternal History Obtain and interpret information relevant to newborn health including: Maternal medical,

l, nutritional, prenatal, obstetric, and intrapartal history Social/Family history Results of maternal screening tests (e.g, Rh), rubella, hepatitis B and C, serology for syphilis, HIV, tuberculosis, illicit drugs, blood type, group B streptococcus, herpes simplex virus, gonorrhea, and chlamydia Maternal medication use or substance use/abuse Results of prenatal ultrasound testing Keep in mind: The babies review of systems (really moms medical history; prenatal care? Weight gain? Nutritional issues? Hx of frequent n/v? Did she keep her prenatal appointments? Obstetric history? Previous pregnancy/losses? Intrapartal history. Did the baby have repetitive variable decelerations? This can lead to hypoglycemia. Was there fetal tachycardia? May indicate sepsis How long was she in labor? What was the babys Apgar? Is it a traditional family? Is the mom going to be going back to work or staying home w/ baby? Mothers GBS status. If positive, how many treatments of antibiotics did she receive prior to labor? Did baby grow at normal rate of speed? Babies are Smart The healthy newborn is equipped to adjust to extrauterine life The newborn is equipped at birth to survive, thrive and engage in social interaction. This is why babies will grab your hand and try to mimic you as the get older. The establishment of respirations is the most critical time of transition (from intra to extrauterine life). The change is initiated by the compression of the thorax, the lung expansion, increased alveoli oxygen concentration, and vasodilatation of the pulmonary vessels. Was it a vaginal birth or C-section? Mechanically the resp. system is stimulated to take its first breath. The biggest breath you ever take in your life is your first breath. Air will enter alveoli replacing the expelled amniotic fluid. Any fluids not initially expelled will be disbursed via the lymphatic system. The neonate starts to cry, changing the intrathoracic pressure, and it helps alveoli stay open. To avoid delays during an emergency situation: vital to ensure that equipment is in good condition before resuscitation is needed: There needs to be infant dedicated oxygen and suction Have the appropriate size masks available according to the expected size of the baby (size 1 for a normal weight newborn and size 0 for a small newborn). Block the mask by making a tight seal with the palm of your hand and squeeze the bag:

Resuscitation must be anticipated at every birth. Every birth attendant should be prepared and able to resuscitate since, if it is necessary, resuscitation should be initiated without delay. Always check room for emergency equipment. Do you have a laryngoscope? Is it working? Is the ambu bag working? If baby had meconium, will want to set up everything needed for intubation. Maintenance of clear airway Free flow Oxygen should be available Bulb syringe Maintenance neutral thermal environment Perform assessments and interventions under a radiant warmer Pre warn equipment and clothes Cap on head Pre-warm all equipment. Usually put on manual setting. It is best to do your assessment under the warmer so that the baby doesnt get cold. APGAR A appearance (skin color) P Pulse (heart rate) G grimace (reflex irritability) A activity (muscle tone) R respiration Acrocyanosis- not uncommon in hands and feet. Reflex irritability- will see when you try to suction the nose or wipe their face, they will pull away. Muscle tone- extend arms, lay flat, let go and see if they curl back up. If respiratory distress, you will see: central cyanosis, periods of tachypnea/apnea, retractions, grunting, flaring of nostrils.

Golden minute Knowing approximate gestational age is an important indicator of what you should get prepared for. If answers are no, go to provide warmth. No blankets or hat on the baby. Reposition the airway (do not hyperextend). Evaluate the respirations, heart rate, and color. Delivery Room Care A brief physical examination is performed to check for obvious signs that the baby is healthy. : temperature, heart rate, and respiratory rate measurements of weight, length, head circumference Temperature- most hospitals use axillary temp. May be able to take heart rate at umbilical cord (6 second count and add a zero).

Cord care Clamp is secure, count number of vessels Identification Bands and security Footprints If cord is greenish-yellow, question how long baby was exposed to meconium. If thin cord, baby may not have been fed very well during pregnancy. Identification bands- usually one on hand and foot Nursing Care of the Newborn Infant Eye prophylaxis - Erythromycin ophthalmic ointment 0.5% - Tetracycline ophthalmic ointment 1% Vitamin K prophylaxis - Newborn gut unable to produce it (Why??) - 0.5 1 mg given IM Try and hold off for a bit to give mom and baby some bonding time. Usually needs to be done within first couple of hours of birth. Vitamin K- given in vastus lateralis, IM, use a small needle, make sure you realize that you will only be able to hold onto needle with one hand. - Coagulation Factors II, VII, IX and X cannot be synthesized because sterile fetal gut cannot synthesize Vitamin K * persists for several days * Vitamin K must be given at birth Be sure to support the babys lead. Makes sure the needle is capped. Always wear gloves with babies (b/c they have been in moms amniotic fluid). Respiratory Adaptations Fetal Lung Development 20-24 weeks gestation alveolar ducts are formed 24-26 alveolar responsible for surfactant manufacture available Prior to 34 weeks Preterm infants administered through the endotracheal tube L/S ratio Lecithin (35 weeks) Sphingomyelin L/s ratio= indication of lung maturity Initiation of Breathing

Reabsorb of fetal lung fluid ~2-24 hr Thoracic squeeze C/S Hindered by respiratory depression Narcotics Meconium Initially the baby will expel most of the fluid and then absorb the rest of it. If they did not have a thoracic squeeze, they may have more fluids. Make sure mom knows how to use bulb syringe. Narcan is only used for opiate medications. If baby had meconium, was there any below the vocal cords? - Newborns chest and abdomen rise simultaneously - Pulmonary lymphatics remove large amounts of fluid from lungs during the first hour - Alveoli are lined with surfactant augmented with respiration - Decreases surface tension and keeps alveoli open As baby takes its first breath in, the surfactant is what keeps the lung cells from collapsing upon itself. The alveoli are opened a little more with each breath. Respiratory Rate Because of variations count for 1 full minute Periodic breathing = pauses of 5-15 seconds Apnea = pauses of more than 20 seconds RR 30-60 varies with state of newborn count for 60 seconds Pattern may be irregular Abdominal in nature Pauses of 20 seconds or longer =apnea Newborn is an obligatory nose breather Watch for signs of apnea (no breathing for more than 20 seconds). Babies are obligatory nose breathers. At delivery, suction mouth and then nose. After delivery, suction the nose first. Signs of respiratory distress Nasal flaring * Sternal retractions * Grunting with respirations Normal Rate 40- 60 >60 Tachypnea

Look for any substernal retractions, nasal flaring, cyanosis (look at mucous membranes). Cardiovascular System - Markedly changes at birth - Fetal lungs do not function for respiratory gas exchange so a special circulatory pathway (ductus arteriosus) bypasses the lungs - Fetal Circulatory Pathway * Oxygen-rich blood flows from placenta through umbilical vein to fetal abdomen With clamping of umbilical cord, you remove placental circulation and initially closes the ductus stenosis. The clamping of cord increases systemic vascular pressure, air enters into the alveoli and expands the lungs, decreases pulmonary vascular resistance, reduces reversal of blood flow acrosss the ductus arteriosus (that reversal leads to closure of ductus arteriosus). Increase in left atrium pressure and decrease in right atrium pressure, closes the foramen ovale. Nursing Care of the Newborn Infant When PO2 level approaches 50%, ductus arteriosus constricts and later becomes a ligament - When umbilical cord is clamped, umbilical arteries, umbilical vein and ductus venosus close * converted into ligaments

Fetal Circulation PDA

Fetal circulation- right atrium has blood crossing directly to left atrium via the foramen ovale. Adult Circulation

Heart rate Check peripheral pulses Common variations: Heart rate range to 100 when sleeping to 180 when crying Color pink with Acrocyanosis Heart rate may be irregular with crying Signs of potential distress or deviations from expected findings: Although murmurs may be due to transitional circulation-all murmurs should be followed-up and referred for medical evaluation Check apical pulse. Check brachial and femoral pulses. Both femoral pulses should be assessed at same time and should be equal. If you hear a murmur (foramen ovale being floppy is the most common). More pathological if it doesnt develop until a few days after birth. Temperature Axillary Body heat lost easily due to large body surface area in relation to weight Normal axillary temperature is 97F99.5F (36.5 to 37 C)

Common variations Crying may elevate temperature Stabilizes in 8 to 10 hours after delivery If rectal temp., be aware of how deep the thermometer is going in. Can cause lacerations. Low temp. can lead to problems with hypoglycemia. Thermal balance

Radiation, Convection, Evaporation, Conduction Four ways a newborn may lose heat to the environment st 1 way they lose heat is evaporation and then conduction (dont use or put anything on baby that is cold). Convection- when doing assessment, make sure you are not under air vent or fan. Teach moms about where to place cribs in relation to cold walls. Non-shivering thermogenesis Heat is produced by increasing the metabolism especially in brown adipose tissue Blood is warmed as it passes through the brown fat and it in turn warms the body Shivering is rarely operable in the newborn .

Temperature Regulation Neutral Thermal Environment Brown Fat/Adipose Tissue Thin Epidermis Posture (flexed)

Usually present more in full-term babies. Pre-term babies may not have much brown fat and will get cold easier.

Babies will try to curl into fetal position to stay warm and conserve energy. Hypoglycemia Plasma glucose level below 40 mg/dl Assessment findings Jitteriness, tremors, apnea, cyanosis, lethargy Risk factors SGA, preterm, perinatal stress, IDM, sepsis Management Early feeding of infants at risk Keep infant warm Glucose by nipple, gavage, or IV Recheck blood glucose 30 minutes after feeding Any baby we think may have a problem will get a heel stick. Babies, esp. breast fed babies, need to eat every 2-3 hours. A baby that sleeps long between times, we dont know if their blood sugar is down and they are lethargic? If baby hasnt awaken in 3-4 hourss since last feeding, need to wake them up and try to get them to eat. Risk factors: SGA (less brown fat), large amounts of variable decelerations can cause the baby stress after delivery. Get baby to breast during first 30 minutes of life. If there is a problem with hypoglycemia, they may give some glucose by nipple. Interventions: early feed, check blood glucose w/in 30 minutes. Hyperbilirubinemia (Jaundice)

When looking at jaundice, travel down the body. The further down the baby starts to turn yellow, the higher their bilirubin level. Hepatic Considerations-Conjugation of Bilirubin Immature liver Fetal RBC Bilirubin is a yellow lipid-soluble pigment

Conjugation refers to the conversion of bilirubin into a water-soluble pigment Unconjugated bilirubin is toxic and is not readily excreted (destroyed rbcs endproduct) What causes bilirubin levels? Immature liver (esp. if you have an immature baby) and fetal RBCs have shorter life span than adult RBCs. Rh incompatibility problems not treated with Rhogam, ABO incompatibility or other pathological conditions can result in jaundice. Hepatic Considerations-Physiologic Jaundice Pathologic if appears within the first 24 hours of life Peak bilirubin levels reached between days 3-5 of life in the term and 5-7 in the preterm Preterm babies have more problems with jaundice. Breastfeeding Jaundice Breastfeeding Jaundice- not enough fluid intake Breast milk Jaundice- related to the composition of the breast milk, some free fatty acids compete with bilirubin for binding sites on albumin and inhibit bilirubin conjugation The colostrum is high in calories but not in fluid content. An ounce of formula is 20 calories per ounce while colostrum is 65-75 calories (so baby doesnt need as much to maintain sugar so not getting as much fluid). May also be related to free fatty acids in breast milk that compete with bilirubin and inhibit bilirubin conjugation. Nursing Care of the Newborn Infant - Phototherapy * Baby placed, unclothed (lights or biliblanket) * Turned every 2 hours * Protect babys eyes * Temperatures q 4 hours * Maintain hydration Unclothed, under lights. Eyes must be covered. Are they maintaining their hydration? Biliblanket- can wrap around skin to skin (with this there are no problems with the babys eyes). GI Adaptations-Elimination Meconium, road tar, . Passed within 8-24 to 48 hours of life Transitional stool Frequency: 2-3 or as much as 10 per day NOT constipated, if stool is soft 1st stool will be meconium= dark black, road tar.

As baby gets formula or breast milk, it tends to be a little thinner and goes to a brownish color. Then goes to yellow color as the baby develops. Stool from breastfed babies has no odor. Cows milk/formula has a fragrance to it. Dont give babies enemas or suppositories. Gastrointestinal System Fetus in utero receive nutrition via placenta Stomach of newborn has a capacity of approx. 2 oz About the size of a walnut Gastric emptying start within few minutes after feeding and takes 2-4 to be completed Stomach about size of walnut. Gastric emptying starts happening a few minutes after eating. Takes 2-4 hours to be completed (which is why you shouldnt go more than 4 hours w/o feeding the baby). Urinary Function Voiding after birth is an important event to DOCUMENT, it frequently goes unnoticed Check with LD nurse about baby voiding in DR Should void by 24 hours 48 hours (renal or urinary disorders may be present otherwise) Post-circumcision spots. Pseudomenses (maternal hormone withdrawal). Document if baby voids during delivery. Voiding and Cord care Teach mom that a well fed hydrated newborn should have 6-10 wet diapers per day Clean cord are at each diaper change Diaper below umbilical cord stump A well-fed hydrated baby should have 6-10 wet diapers per day. Make sure no urine has gotten on cord. Keep cord above the diaper. Keep it dry. It will fall off w/in 2 weeks. Measurements Head circumference Fontanels Sutures Molding Chest Length Put tape over ears, right across the eyebrows. Be sure to document in centimeters. Molding

If you palpated this babys head, would probably find some overriding sutures (not uncommon). Anterior fontanel- diamond shape Posterior fontanel- triangular shape Depressed fontanel= dehydration Bulging fontanel= increased intracranial pressure Nursing Care of the Newborn Infant Cephalohematoma

* Collection of blood between a skull bone and its periosteum * Does not cross suture lines * Comparison of Caput Succedaneum and Cephalohematoma Top picture= Caput (edema between scalp and periosteum; the edema crosses across the suture line!!! That fluid will be absorbed. Cephalohemtoma- blood; does not cross the suture line; may be due to rapid delivery or use of forceps. Face Eyes -distance, drainage Nose-patent

 Neck (webbing) Are the eyes even? Any hemorrhage in the sclera? Are the eyes fully visible? Sunset eyes- only see half of eyes; sometimes happens with down syndrome Any drainage in the eyes? Is nose patent? Have baby suck on your finger and you should see movement of both nostrils. Palpate the neck. Any webbing? Are the clavicals straight? If you do feel any problems, make sure you have an equal moro reflex. Ears - location, pits Hearing test Pits are associated with hearing problems and skin tags may be tied off or surgically removed. Make sure baby has hearing test before being discharged. Skin tags are usually just sutured (circulation is cut off). The tissue will just fade away. Less scarring if you do at birth rather than later in life. (SEE PICTURE) Rooting Reflex Tickle the babys cheek and he/she should turn its head towards your finger. When teaching a mom how to breast feed, tell her not to stroke babys face b/c baby will turn away from her breast due to the hand stimulation. Mouth Thrush = White patches cannot be removed Due to Maternal yeast infections If breastfed baby, colostrum is yellow. Feel the palate. Is in intact? Good sucking pads on both sides of cheek? Any teeth? Chest Respiratory Effort Quality of RR and HR Symmetry Engorged breast- wnl R/T maternal hormones Supernumerary Nipples Retractions, expiratory grunting symmetry. Supernumeraray nipples- usually blanches later on in life; usually has no breast tissue to go with it Anus Patent Tone First stool? Check tone- wipe a 4x4 across anus and should see a wink with the rectal sphincter When did they pass first stool? Back Straight?

Pilonidal dimple associated with spina bifida Mongolian spots

Spina Bifida After delivery, they would put a sterile saline cover on it and take baby to the NICU to evaluate for surgery. Extremities: Arms & Hands Equal Movement Symmetry, count digits Polydactyly-extra digits Syndactyly=webbing Single palmer crease-simian line R/T Downs Brachial palsy-R/T trauma at brachial plexus during birth (Erbs-upper arm most common) Talipes deformity=clubfoot-positional, fixed Symmetry of gluteal folds Count toes and fingers!!! If you see an extra digit, do you feel bone in it? Is it just skin? They may tie it off and ligate it (let it fall off). Feet/ Hips Deviations Do you have equal gluteal folds? Unequal gluteal folds is an indication of a possible congenital hip dysplasia. To further assess this, turn baby on back and do the Ordolani maneuver where you bring knees to chest and rotate hips out and listen for hip clicks. If you keep your fingers on trochanter as your rotate hips, you may feel a slippage of the hip. Extremity Reflexes Moro=startle Grasp=holds hand Babinski=hyperextension of toes to heel stroke Plantar Skin Acrocyanosis=blue hands & feet Lanugo=downy hair Vernix caseosa cheesy covering of old cells & sebum Milia=white spots-sebaceous glands Do not try to scrub milia away. The tissue will be reabsorbed. Lanugo- some ethnicities have more hair (very fine) Vernix caseosa- natures baby lotion while in the uterus; should be absorbed by delivery in a full-term baby - Desquamation (post-term infants)- peeling of skin - Marks * Mongolian spots * Stork bites

* Erythema toxicum * Strawberry mark * Port wine stain Mongolian Spots Mongolian spots=bluish-black spots over buttocks-back (fades spontaneously) Fade by age 2 Document Do not blanch. Document them so they are not confused with bruises. Port Wine Stain Nevus flammeus =port wine stain does not fade does not blanch does not grow It will be there for the rest of their life. Strawberry Mark Nevus Vasculosus strawberry mark Capillary hemangioma Raised, rough borders, grow then shrink Do not pick at this b/c baby will bleed. Erythema toxicum What are the symptoms? Some splotchy red patches. Some have firm yellow or white bumps surrounded by a flare of red. The rash tends to come and go, shifting its location across the body. The palms and soles are often left out. Is it contagious? No Comes and goes fairly rapidly. It is not contagious. When removing umbilical cord clamp, assess the cord and make sure it is dry, crusty, and hard. Take the remover, insert it into the small ring, clamp the cord, and peel it apart. Document the removal of the cord clamp. Difficult Births Forcep May concern parents Fx clavicle Likely to develop jaundice Assess for forcep marks and fractured clavicles. Baby is more likely to get jaundice b/c of the bruising. Male Genitalia Urinary meatus at tip of glans penis Palpable testes in scrotum

Large, edematous, pendulous scrotum, with rugae Common variations Prepuce covering urinary meatus Erections Edema and ecchymosis after breech delivery Use one hand to palpate testes. Babys born by breech, may have some bruising on the bottom. Male babies tend to have an erection prior to voiding. Circumcision Informed consent Restraints Comfort measure Assess for bleeding q 30 minutes Apply petroleum jelly or antibiotic ointment Document post procedure voiding Do not rub during bathing Teach parent s/s of infection Circumcision requires consent. Baby is put on a constraint board. May give them a sugar nipple. Afterwards, a pressure dressing with a couple of 2x2s and vaseline or ointment will be applied. May initially have a little bit of bleeding. Be sure to follow up on any bleeding. Dont have to remove the new pressure dressing unless there is blood. Teach mom the s/s of infection. Female Genitals Edematous labia and clitoris Labia majora are larger and surrounding labia minora Common variations: Pseudo menstruation Ecchymosis and edema after breech birth If breech, may have some edema or bruising. Labia majora should be larger than labia minora. Periods of Reactivity 1st period of reactivity: after birth of baby, bursts of rapid movements. Quiet times during this period are ideal for breastfeeding & interacting Deep Sleep - lasts 60-100 minutes 2nd period of reactivity: occurs 4-8 hrs after birth lasts 10 min to several hours. Periods of tachycardia & tachypnea. Increased muscle tone, skin color, mucus production, pass meconium (first stool) 1st period of reactivity: around first 30 minutes of life; baby will go to breast and suck the best during this time. Behavioral states Brazelton 2 sleep states

 Deep sleep Light sleep-REM sleep Awake states Drowsy Quiet alert Active alert Crying * Response to Environmental Stimuli - Temperament * Consolability * Cuddliness * Irritability * Crying How easily can mom console the baby? Babys withdrawing from drugs will not be very cuddly (will be irritable). Behavioral Adaptations Habituation=capacity to ignore repetitious stimuli Orientation=ability to alert and attend to visual stimuli fixates on an image Self-quieting ability- hand to mouth, sucking & attending to stimuli Drug positive newborns often exhibit abnormal sleep patterns (may have excessive sucking; swaddle them tight and keep in a quiet environment) Baby will habituate to ignore repetitious stimuli. If mom keeps the house really quiet, the baby will get used to the silent state and will have problems once more activity and sound is introduced into the household. Can they self-quiet themselves? Teach the mom methods of self-quieting. Techniques for waking and quieting newborn Loosen clothing Hand express breast milk onto babys lips Talk to baby while making eye contact Baby sit ups Patty cake Stimulate rooting reflex Check for soiled diaper Swaddle Use slow calming movements Speak softly Sing or music Screenings PKU Hearing Glucose if ordered Medications Vitamin K Hepatitis B

Hearing screening- done in nursery Glucose- use lateral side of feet (not the bottom) Try and give vitamin K and hep B in opposite thigh Recommended Infant Nutrition AAP recommends exclusive breastfeeding of human milk for the first 6 months and continued for at least 12 months During the second 6 months, appropriate complementary solid foods are added to diet If infants are weaned from breast milk before 12 months they should receive ironfortified formula, NOT cows milk Can store breast milk in the freezer. Do not recommend that moms breast and bottle feed simultaneously. Considerations in Choosing a Feeding Method Breastfeeding Advantages Do not introduce bottle feeding until breast milk is fully operational Reasons for not breast-feeding Formula Reasons for formula feeding Teach them of ways to protect their privacy. Listen to her reasons for not breastfeeding. Make sure if she is formula feeding, be sure to address the type of bottles and making sure she burps the baby. Calories 110-110 kcal/kg daily Breast milk/formula contain 20 kcal/oz May lose less than 10% of birth weight Weight regain Nutrients Carbohydrates Proteins Fats Vitamins/minerals Water Breast changes during pregnancy Milk production Hormonal changes at birth Prolactin Oxytocin Continued milk production Preparation of breasts Prolactin- involved in milk production Oxytocin- involved in milk let down or excretion **Know these!!!!

Assisting with Breastfeeding Interventions Assist with first feeding Teaching Position of mothers hands Latching-on Suckling pattern Removal from breast Frequency and length of feeding Preventing problems Sore nipples is most often a result of the baby not latching-on correctly. The best thing to do for it is to take some of the breast milk and rub it on the nipple afterwards. Cabbage leaves helps reduce edema. Wear a support bra and not one with a plastic liner. If bottle feeding, wear a tight support bra or breast binder to keep milk from coming in. Common Breastfeeding Concerns Maternal Concerns Breast problems Illness in mother Medications Breast surgery Employment Milk expression Storing milk Multiple births Weaning Home care Should Parents call the HCP Temp above 100.4 (38)or below 97.8 (36.6) More than one episode of forceful vomiting Refusal to eat 2 times in a row Lethargy (difficult to wake up) Cyanosis Inconsolable infant Discharge for umbilical stump Green watery stools No wet diaper in 19-24 hours Eye drainage Neonatal Care The neonatal period is considered to be the first 28 days of life. When you think of having a baby, most people expect a normal pregnancy at term gestation, which is usually at 40 weeks. These babies need minimal support at delivery and usually go home within 3 days.

Care of High Risk Neonates I was asked to talk about high risk neonates. These are infants who are either born too early and are immature, or infants who have had problems during the labor and delivery process. Other infants who are high risk are infants whose mothers are identified as high risk during the pregnancy. Mothers with medical problems, such as high blood pressure, those who smoke cigarettes, or abuse drugs or alcohol are considered at high risk to deliver a premature or low birth weight infant. Definitions Prematurity gestational age less than 37 weeks gestation Viablility 24 weeks gestation 500 grams ( 1 lb 1oz) As I said term gestation is considered to be 40 weeks. There are some instances where babies are born past term, but not generally more than 2 weeks, The placenta which provides all the nutrients to the baby during the pregnancy, begins to loose its effectiveness after 40-42 weeks. How small is too small??? Point of viability Post-term- >42 weeks Anything less than 23 weeks gestation or less than 400 grams= non-viable; will not resuscitate Low Birth Weight infant: Birth weight less than 2500 grams (5lb 8 oz) Very Low Birth Weight infant: Birth weight less than 1500 grams (3lbs 5 oz) Extremely Low Birth Weight infant: Birth weight less than 1000 grams (2lb 3 oz) Infants are high risk if born premature, but birthweight also plays an important role in the outcome of babies. An infant can be born at term, but still be LBW. This can be seen if the mother has chronic high blood pressure, smokes cigarettes, abuses alcohol or drugs. There are also some viral infections if contracted during the pregnancy that can cause low birth weight. This is a baby with a birth weight at about 4 lbs. HE is receiving some oxygen by nasal cannula and has a feeding tube. (see picture) This is the size of a vlbw baby and this baby weighs about 1500 grams, 3 lbs (see picture) This is a ELBW infant you can get an idea of how small he is by noting the beanie baby positioned next to him. These babies are perfectly formed, but all organ systems are immauture. (see picture) Regionalization of Perinatal Care What is regionalization? A coordinated, regional approach to assuring access to risk-appropriate perinatal care

Perinatal care deals with the mother and infant during the pregnancy. It is important that pregnant women receive prenatal care and are followed closely during the pregnancy for any problems that may develop. MUHA- is a regional care center Regionalization Recommendations from the American Academy of Pediatrics and American College of Obstetricians and Gynecologists Guidelines for Perinatal Care Definitions Level I provides basic obstetrics and newborn care Level II provides care to some premature and low birth weight infants Level III provides all aspects of perinatal care Regional Perinatal Center Level I provides basic obstetrical and newborn care, Some of the community hospitals fit this description. Level II units care to premature infants 32 weeks gestation and higher. They can provide ventilator support for short periods of time. Any infant requiring complex management will need to be transferred to a Level III perinatal center. Can keep babies ventilated up to 6 hours. Level III provides all aspects of perinatal care, but in SC do not accept infants born in other facilities. Infants being transported generally go to the Regional Perinatal Center. The types of personnel required in each level of facility is different. For instance, there needs to be a maternal fetal specialist or perinatologist at the Regional center. Baby on echmo- this pump does everything for the baby. There are specially trained echmo nurses and perfusionists that take care of the pump itself. (see picture) Why is this important? Very Low Birth Weight infants represent 1.6% of all live births but account for 59% of all infant deaths Initial care received at birth and during the first hours is critical AN infant who is high risk needs to be born in a hospital where there are trained personnel to respond to any problems the baby may have. The initial care at birth and during the first few hours after birth is critical in preventing further complications from a premature or difficult birth. The main goal is the prevent premature delivery. First few hours is critical to the survival of these infants. Golden hour- that first hour and what is done during that hour is critical. Why is this important? Neonatal morbidity is significantly lower for infants born in Level III perinatal center Cost of hospitalization and length of stay is less compared to those transferred to a Level III unit after birth

Most regional perinatal centers have transport teams to pick up infants delivered at outlying hospitals and transport them either by ground or air to the Perinatal center. If a baby is born in an outlying hospital, they will have more issues (ex. trouble being intubated). Babies born in house do better and have a decreased length of stay. Infants Requiring Level III Care All premature infants between 24 and 32 weeks gestation Infants requiring prolonged ventilatory support Full term infants with respiratory, cardiovascular or other organ system disturbance Infants with congenital anomalies Infants who require pediatric subspeciality or surgical intervention Infants who require Extracorporeal Membrane Oxygenation (ECMO) ECMO only used for infants greater than 35 weeks gestation. There are some strict criteria for placing an infant on ECMO due to the risks associated with the procedure. Some infants require ECMO for up to 2 weeks. (see picture) Aspects of Neonatal Care Respiratory care Temperature regulation Cardiovascular support Nutritional support Respiratory distress is them most common problem we see in the NICU. Premature infants have immature lungs and therefore have difficulty maintianing adequate oxygen levels. They can breathe on their own, but it is not effective due to their small airways and poor muscle tone. Due to their size, and lack of fat, and immautre skin, premature infants are at risk for cold stress, so maintaining temperature control is a high priorty for these infants. The use of incubators and high humidity in the incubator is used for temperature and fluid and electrolyte management. Maintaining the babys thermoregulatory needs is one of the most important things we can do. MUSC used total body cooling to reduce the metabolic rate and then increase gradually. All infants are on heart rate, respiratory and blood pressure monitors, Oxygen saturation is measured continuously. Fluids are delivered by small volume IV pumps. We encourage all our moms to breast feed their infants, or provide the breast milk for the premature infants. We use IV nutrition until the baby can tolerate feedings, but breast milk is superior. Starting feeding (trophic feeds?)low birth weight babies at 6 hours of life (to get the gut moving), preferably with maternal breast milk, and then start to increase gradually. At the same time, we are providing these babies to total parenteral nutrition. If you fall behind in getting nutrtion to these low birth weight babies, it is very hard to catch up. VLBW in an incubator. This baby is on a ventilator and one thing to notice is that she has blankets tucked around her to give her some boundaries, and something to kick against. Just like when she was in the uterus. This type of positiong helps with muscle and bone development. (see picture)

It is important to touch and talk to these babies. They recognize their parents voices, and I have seen many premies sleep when their parents are at the bedside, and wake up just as the parents are getting ready to leave. I really believe they feel safe when their parents are at the bedside. Even this small they recognize their parents. This baby is on CPAP- they can stay on CPAP for weeks. (see picture) Once the babies are stable we dress them in regular clothes. This little girl is alert and actually holding onto her endotracheal tube. It is amazing but they can pull out these tubes and IVs. We also encourage the families to bring in toys like the one you see here. We use them to help position the babies. In neonatal units, babies are put on their stomach b/c it is easier for them to breathe (they dont have to fight gravity). However, as getting ready for d/c, educate parents on importance of putting baby on back to sleep. Teach parents: put hand on head and hand of feet to contain the baby instead of patting/rubbing. (see picture) Aspects of Neonatal Care Developmental care Developmentally supportive care is important when caring for critically ill infants. The immature brain continues to develop in response to the environment. By providing an environment that is quiet, dark and minimizing procedures we can help these babies develop normally. Positoning is an important aspect of care. Positioning the baby in a fetal or tucked position and providing boundaries allow the infant to comfort himself by putting his hands to his face, and develop muscle and bone by kicking against the boundaries, like he would have done in the uterus. (see picture) This baby has patches on his eyes to protect them from the phototherapy lights used to treat jaundice. HE is also on a ventilator but again has his hands positioned close to his face. (see picture) Touching is important and providing containment with hands helps comforts the baby.. Due to immaturity of the nervous system, rubbing or stroking may be uncomfortable to really small babies. We teach the parents to do hand containment (see picture) This baby is positioned with her curious george toy. The hat on the toy is the size for a full term infant (see picture) Babies are dressed and held when stable. It is important not to stress these infants with too much stimulation. Premies will show signs of stress when they have had enough stimulation. Some of their stress signs are closing their eyes, turning their heads or putting out hands like stop. (see picture) This baby is alert and intent and interacting with her mother.(see picture)

Aspects of Neonatal Care Family Most parents dont expect to have a baby in the NICU. It is a stressful time whether the baby is there for a few days or months. Encouraging parents to visit and take part in the infants care continues the attachment process that began during the pregnancy. Kangaroo care was first used in Bolivia due to overcrowding of the NICU there. Infants held by their parents this way maintain their temperature and often sleep comfortablely during this time. Dads can also kangaroo. The moms milk matures faster than the baby (which is why you had to add fortifiers and supplements). (see picture) This baby even though really small is not on any respiratory support or oxygen, and is resting very quietly with her mom. Parents can hold the infant for 30 minutes to 1 hour and sometimes longer depending on the baby. The NICU has some reclining chairs so that the moms can be comfortable and spend some quiet time with their baby. (see picture) Dads kangaroo too with big brother watching (see picture) This baby was 26 weeks at birth and in this picture was about 6 months old. His mother was in the NICU eveyday during his critical times and as he got closer to going home, she came and learned to give his medications and other treatments that he needed. (see picture) This baby was full term and spent several days in the NICU (see picture) Staffing Neonatologist Pediatric Residents Pediatric Subspecialty care Neonatal Nurse Practitioners Doctor of Pharmacy Staff Nurses Respiratory Therapist Nutritionist Social Worker Maternal-fetal specialist in Regional Perinatal Center

Neonatal Resuscitation Cheryl A. Carlson PhD, APRN, NNP-BC Neonatal Resuscitation Program (NRP) Developed 1987 as learning program To ensure at least 1 trained person at every hospital delivery American Academy of Pediatrics(AAP) and American Heart Association (AHA) recommendations NRP 2011 Use of simulation and debriefing as part of course Learners work their way through scenario without coaching or prompting Errors are discussed during debriefing session Errors are discussed in way to decide what could have been done better? Practice changes in NRP Resuscitation of term infant with room air initially Use of pulse oximetry For PPV or use of oxygen anticipated Provision of blended oxygen Oxygen is a drug. In utero their stats are only around 60-65%. Pulse ox always goes on the right extremity. After delivery: if baby is blue try stimulate them, if they not breathing and their heart rate is down you need to start positive pressure ventilation with room air (ambu bag), if that doesnt help you need to give them blended oxygen (increase gradually). Practice changes in NRP Manometers with PPV device Use of laryngeal mask ETT allowed 30 seconds No free flow oxygen for baby not breathing Intubation before chest compressions Increase in FiO2 with chest compressions Get them breathing and THEN start compressions (1:3 ratio). ALWAYS VENTILATION FIRST!

Epinephrine is most commonly administered (recommended to be given through umbilican venous line, although if there is not one in place, you can give through endotracheal tube)

What you do to get ready for a baby coming onto the unit. Towels and blankets- decrease evaporative heat loss Use bulb syringe to clear airway. Only intubate with meconium if baby is depressed (not crying or responding). We no longer suction once the head presents with a bulb syringe (if they are in distress b/c it stimulates them to breathe in more meconium). If baby is fully developed and vigorous, they may then be suctioned to remove oropharyngeal secretions. Plastic bag/wrap for any baby less than 29 weeks gestation. Transport incubator needs to be pre-warmed.

Heart rate less than 100- make sure you are ventilating adequately With a self-inflating bag, make sure you are getting gentle chest movement. If it stays below 60, consider intubation,chest compressions, coordinate with positive pressure ventilation. Learn how to bag a baby correctly! PPV with Mask MR SOPA Mask adjustment Re-adjust mask

Suction mouth and nose Open mouth Pressure increase Alternative airway ETT or laryngeal airway Problems that occur with inadequate ventilation.

Care of the High Risk Neonate Cheryl Ann Carlson PhD, APRN, NNP-BC Oxygen Transport Physical dissociation in plasma Attachment to hemoglobin molecule Body desires to maintain a dynamic balance - Physical dissociation in plasma accounts for 2 % - Attachment to hemoglobin moleculeaccounts for 98% - If more dissolved oxygen is added to the system, more oxygen will bind with HGB until hgb is completely saturated. - If more oxygen is taken from the plasma by metabolically active tissues, more oxygen is released by the hgb molecule. Balance between these 2 states is represented by the Oxygen -Hemoglobin Dissociation curve. HGB is the primary transport for oxygen. Types of Hemoglobin Fetal Hemoglobin (HBF) 75% of hemoglobin in term fetus Higher affinity for oxygen and releases less to the tissues Adult Hemoglobin (HGA) Synthesis begins 32 weeks Decreased affinity for oxygen, increased amount of oxygen released to the tissues - 2.3 DPG is an organic phosphate the competes with oxygen for hbg binding sites. - FETAL HBG, Since the globin portion interacts poorly with 2,3 DPG, it will bind to oxygen and release less to the tissues. SO the PAO@ is 30 while the sat is 70 % Fetal hgb is highly saturated. - ADULT HGB: Oxygen and 2,3 DPG compete for the globin binding sites and more oxygen is released to the tissues. PO2 is 30 and sat is 50%.

- Neonatal curve is shifted to the left relative to adult curve - Temperature, carbon dioxide and PH affects HGB affinity to oxygen. - What will cause this curve to move--- NCLEX question SHIFT TO LEFT: hypothermia, hypocarbia and alkalinity increases HBG affinity for oxygen, less tissue released to the tissues. SHIFT to RIGHT: hyperthermia, hypercarbia and acidemia decreases hgb affinity to oxygen, more oxygen released to the tissues. Pulmonary Development: Embryonic Fetal Post Natal Embryonic 3-7 weeks Differentiation of airways- bronchioles, terminal broncioles Pulmonary veins return to heart-if this doesnt happen baby can have total anomolous pulmonary venous return- cyanotic heart problem Fetal Psuedo-glandular Period Formation of airway tree Development of diaphragm Canicular Period 17-22 weeks Elongation of lumina of bronchi and bronchioles Proliferation of fetal pulmonary capillaries important!!!

 Differentiation of alveolar cells- 1 is gas exchange cells, type 2 surfactant releasing cells Saccular and Alveolar Period 22-40wks Differentiation of alveolar cells Pulmonary capillaries contact alveolar membrane- until this happens wont have adequate gas exchange. Post natal period Surfactant System Composition of Pulmonary Surfactant

8 % 12 %

10 % 70 %

- Phospholipids 70-80% - Saturated Phosphatidylcholine 60% (lesithin) - Unsaturated Phosphatidylcholine 20% - Phosphatidylglycerol Phosphatidylinositol - Phosphatidylethanolamine Phosphatidylsterine - Sphingomyelin - Neutral Lipids 8% - Protein 6-12% Comments - Pulmonary surfactant that was isolated from bronchoalveolar lavage was found to be similar among mammalian species. This is surfactant is from the extracellular compartment. - The major components of mammalian pulmonary surfactant are 90% lipids with phospholipids (80%). The phospholipid component includes 60% saturated phosphatidylcholine or DPPC dipalmitayl phophatidylcholine; 20% unsaturated phosphatidylcholine (or 20% of the total); - 15% phosphatidylglycerol appears afater 35-36 weeks and phosphatidylinositol increased production after 30 weeks, peak at 35-36 weeks- look for this to see the maturity of the lung; neutral lipids (8%); Cholesterol, triacylglycerol and free fatty acids protein (12%)

SP-D 10%

SP-C 20%
SP-B 20%

SP-A 50%

There are 4 surfactant proteins that have been identified. - SP-A accounts for 50% of the proteins seen in surfactant, is responsible for host defense, down regulation of the inflammatory response in lung - SP-B, 20% of the surfactant proteins plays an important role in stabilizing surfactant - SP-C also 20%, enhances lipid stability and plays a role in reduction of surface tension - SP-D accounts for 10% of surfactant proteins plays a similar role as SP-A,in host defense B and C is what is found in what we can give babies. Biophysical Properties Rapid adsorption- at air liquid interface. Rapid spreadingFormation of stable film Reduces surface tension - The biophysical properties of surfactant include the rapid adsorption to air water interface to facilitate rapid spreading formation of a stable film and the reduction of surface tension. - 90% of the surfactant PC is cleared from the alveoli of developing lungs and recycled, 50% of the surfactant is recycled in adult lungs. - Full term will always have a little bit of liquid left in the lungs even after normal vag birth. - In preterm baby there will be a lot more liquid in the air liquid interface. - Surfactant dec. the tension in the lungs.

Interference with Surfactant Metabolism Acidemia Hypoxia Shock Overinflation too much pressure Under-inflation- to little pressure Pulmonary edema Mechanical ventilation- baby can release inflammatory mediators- want them off asap Hypercapnea Acceleration of Surfactant Production Diabetes- IDM class D,F,R- moms that are having vascular complicationsproduces more surfactant Heroin addiction PROM- over 24 hours Maternal hypertension- stresses the baby Maternal infection Placental insufficiency Antenatal corticosteroids- 2 doses of betamethasone will mature the lungs faster Abruption placenta Tests of Fetal Lung Maturation L/S ratio- lesathin/salphingomiacin Presence of phosphatidylglycerol- either present or not- seen as a better marker than LS ratio in diabetic mother. - L/S RATIO: measures saturated phosphatidylcholine to sphigomyelin - 1.5-2 immature but risk of RDS is low; Mature level of 2 generally seen at 35 weeks. - PG normally seen about 35 weeks. Transient Tachypnea of the Newborn Delayed reabsorption of fetal lung fluid

History C/Section birth- dont have benefit of vag squeeze Neonatal depression Mild asphyxia Precipitous delivery - Any baby who doesnt take a big first breath are at risk for retained fluid. - Generally the fluid that is left will be reabsorbed over 12-24 hours after birth. Pathophysiology Diffusion gradient due to retained fetal lung fluid. Mild immaturity of surfactant system. Clinical Manifestations Cyanosis Tachypnea Grunting Nasal flaring Retractions Increased A-P diameter Breath sounds usually clear Radiographic Findings Patchy infiltrates Peri-hilar streaking Interstitial and pleural fluid-KEY! Fluid in the fissure- diagnostic of TTNBtransient tachypnes of the New Born-retain fluid Patchy infiltrates that clear within 48 hours. Clinical Course Generally benign- Resolution within 12-72 hours - If baby needs O2 early on, you wouldnt use nasal canula (wont know how much O2 baby is requiring). Respiratory Distress Syndrome RDS (HMD) Developmental disorder that affects 50% of infants born between 26 and 30 weeks gestation Increased incidence and severity with decreasing gestational age Maternal DM, male sex, Caucasian, perinatal asphyxia, multiple gestation - Developmental disorder that affects 50% of infants born between 26 and 28 weeks gestation 20-30% of infants born at 30-31 weeks gestation also have RDS. - Increased incidence and severity with decreasing gestational age - Originally known as Hyaline Membrane Disease, this was a diagnosis made at autopsy. Protein rich hyaline membranes were found lining the alveoli and small airways of infants who had died of RDS.

- Hyaline membranes are formed from to damage to the epithelial cells and along with other cellular debris, presents a barrier to oxygen and CO2 exchange at the alveolar capillary interface. - Maternal DM, male sex, caucasian vs black ethnicity, perinatal asphyxia , and multiple gestation, increase the risk for RDS Pathophysiology

- Atalectasis- collapse of alveoli. - Will have VP mismatch - Barotrauma from the inc pressure from ventilator to open the sacs. Want to intervene early on. - The longer the baby is on vent- the higher the risk for inflammartory mediators.

Clinical Manifestations

Surfactant replacement therapy has lead to a decrease in morbidity and mortality of premature infants. - Over the last Last 20 yrs, Surfactant replacement therapy has lead to a decrease in morbidity and mortality of premature infants at 24-29 weeks gestation. - Handicaps secondary to prematurity. Surfactant Preparations

- Administration side port of ETT or through ETT with infant positions - Only B and C are in these. - DOSING - Prophylactic administration - Rescue - Re-Dosing schedules

Clinical Course Early onset If diuresis and lung function does not improve by 1-2 weeks, indication of chronic lung changes. Complications Intraventricular hemorrhage-grade 1,2 minor-outcomes are very good, 3,4-bad Air leak Infection PDA- patent ductus arteriosis Bronchopulmonary Dysplasia Retinopathy of Prematurity- dev. Of retinal vessels is very immature- can cause constriction of vessels and retinal detachment MECONIUM ASPIRATION SYNDROME- Defined as the presence of meconium below the vocal chords. Meconium Viscous, dark green intestinal discharge Composed of intestinal cells, lanugo, mucus and intestinal secretions - Meconium is a viscous, dark green intestinal discharge, which is composed of intestinal cells, lanugo, mucus and intestinal secretions, such as bile. - First appears in the fetus at 10-16 weeks. History Term or post term Maternal hypoxia, anemia Reduced placental or uterine blood flow IUGR Intrauterine asphyxia - Term or post term - Meconium is rarely found prior to 34 weeks gestation, GI tract in term and post term infants more responsive to external stimuli. - Maternal hypoxia, anemia - Reduced placental or uterine blood flow - IUGR - High risk of Mas for infants with thick meconium, fetal tachycardia and /or absence of accelerations. With normal FHR pattersn with Meconium stained amniotic fluid, the outcome is similar to clear amniotic fluid. - Intrauterine asphyxia Incidence - US 8-20% of all births after 34 weeks gestation will have meconium in the amniotic fluid - 30-50% will aspirate meconium - Of those 1-9% may develop MAS

- Mortality is related to severe pulmonary parenchymal disease and pulmonary hypertension and the incidence is as high as 20%. - Color of meconium can give a clue as to when the event happened. IF green, event fairly recent, during labor. If yellow old, occurred in utero.

- Fetal distress and asphyxia, can lead to passage of meconium and subsequent aspiration in utero. - Other factors that can lead to meconium passage in utero include placental insufficiency, maternal hypertension, preeclapmsia, oligohydramnios and maternal drug use, esp tobacco and cocaine. - Meconium can be aspirated in utero or may also be aspirated during labor and delivery.

Acute airway obstruction Decreased lung compliance Ball valve phenomena leading to air leak Parenchymal lung damage Clinical Manifestations Low apgars Post term appearanceYellow staining Respiratory distress Cyanosis Coarse breath sounds Decreased air entry Barrel chest Metabolic and respiratory acidosis - The clinical manifestations are dependent upon the severity of the hypoxic insult and the amount and viscosity of the meconium aspirated. - Low apgars depressed infant, not necessarily ass with mec stained infant. - Post term appearance thin appearance, with decreased sugcutaneous fat, wide eyed alert look. - Yellow staining of the nails, cord, and skin - Respiratory distress tachypnea, nasal flaring and retractions - Cyanosis - Coarse breath sounds scattered, rales - Decreased air entry - Barrel chest due to air trapping or overinflation - Metabolic and respiratory acidosis - The initial clinical appearance is dominated by the neuro and resp depression from hypoxic insult, preceding the passage of the meconium - If baby is younger than 34 weeks gestation with meconium stained--- think listeria--most likely isnt meconium. MAS (see x-ray picture) - The severity of the chest x-ray may not correlate with respiratory distress seen clinically

- 75% had MAS on CXR< though < 50% had respiratory distress - Hyperareation with flattened diaphragms - Atelectasis - Diffuse densities, fluffy, cotton balls - Cardiomegaly generally secondary to perinatal hypoxia - Pleural effusion is seen in 30 % of infants with MAS Blood gas changes Hypoxemia Respiratory alkalosis Respiratory acidosis Metabolic/respiratory acidosis - Arterial blood gas assessment - Hypoxemia from R-L shunting - Respiratory alkalosis seen in mild cases due to hyperventilation - Respiratory acidosis secondary to airway obstruction and pneumonitis - Metabolic/respiratory acidosis is seen in severely asphyxiated infants associated with hypoxia and respiratory failure. Prevention Identification of High Risk Pregnancy Amnioinfusion-thinking it would thin out the meconium- really used for cord compression not for the meconium Delivery room management - Identification of High Risk Pregnancy infant with perinatal asphyxia may have aspirated in utero. - Amnioinfusion injuect NSS into the amniotic sac, done to relieve cord compression, also dilutes meconium. - Delivery room management Combined OB and Pediatric approach - Thorough suctioning of the nose and pharynx after delivery of the head. Before the infant takes the first breath Esp important infants with meconium stained amniotic fluid, who are not depressed - With thinck particulate meconium, infants should be intubaed for direct visualization of the larynx and any residual meconium is suctioned from the trachea. Esp if infant is depressed and/or had evidence of antenatal hypoxia. Respiratory Management Mechanical ventilation Paralysis- usually not used.. Want baby to breath on their own. Surfactant administration- given to babys with mec. Aspiration- like a detergent to help clear it out. Nitric oxide- pulmonary dilator ECMO - Paralysis may be indicated for infants fighting ventilator

- Surfactant administration study published use of survanta 6cc/kg every 6 hours. Surfactant acts as a detergent and loosens up and allows for suctioning of the meconium. Further studies underway. - Nitric oxide for infants with concurrent PPHN to improve pulmonary vascular tone. - ECMO for those infants who dont respond to ventilatory management and NO Systemic effects Decreased renal function Decreased liver function Central nervous system - Respiratory distress and the prognosis is dependent upon the degree of asphyxia and aspiration - Death results from profound acidosis and progressive hypoxia leading to pulmonary hypertension and PPHN - Some other systemic effects that are seen in infants with MAS are secondary to the initial asphyxial insult - Decreased renal function close monitoring of urine output, creatinine levels, renal fx studies, coags, - Decreased liver function decreased clotting factors and albumin - Central nervous system- cerebral edema Complications Air leak-pneumo mediastinum, pneumothorax Persistent Pulmonary Hypertension Hypoxic/ischemic damage Pulmonary sequelae-higher risk of asthma - Complications associated with MAS - 10-25% incidence of airleak pneumothorax, pneumonmdiastium - Persistent Pulmonary Hypertension - Hypoxic/ischemic damage- CNS, kidney and liver - Pulmonary sequelae- cough, wheezing, abnormal pulmonary function test and asthma

Neonatal Sepsis Cheryl A. Carlson PhD, APRN, NNP-BC Incidence Early onset Occurs 1st 7 days Vertical transmission Fulminant onset Late onset Insidious or acute onset Late, late onset After 3 months of life

 Premature infants, VLBW Multisystem involvement Chorioamnionitis= increased incidence of sepsis 1-5 cases per 1000 live births Case fatality rate 5-10% Sequelae Due to CNS infection Hypoxemia PPHN Severe lung disease - If meningitis and have a CNS infection, sequelae will be much more significant. Mortality Rate 13-45% of neonatal deaths are from sepsis Of affected newborns, about 30% will spread to meningitis with increased complications and long-term effects - Do a full scrub before entering the NICU and wash hands frequently once inside. - Early onset- generally do a blood culture, bp, cbc and start on a broad spectrum antibiotic and an aminoglycoside. Routes of Infection Ascending Descending Transplacentally Nosocomial / Environmental- we really need to work on preventing this!! Ascending = Most common route Entry of pathogenic organisms into the uterine cavity through the cervix If membranes are ruptured invasion directly into the amniotic space. If membranes are intact, can spread along the uterine wall through the maternalfetal vascular system. Suspect in cases of foul-smelling or discolored amniotic fluid. Suspect when history of maternal fever. Prolonged 2nd stage of labor (> 1 hours) predisposes to ascending infections Can aspirate fluid in utero Descending = acquired during passage through the birth canal (at time of birth), can occur with normal flora of the GI tract Eg. Herpes, GBS, Listeria, Monilia Transplacentally (GBS can be transplacentally transferred) Viruses are capable of crossing the placenta (TORCH) Exposure to viral infections within the 1st 12 weeks of gestation may cause developmental anomalies. Exposure to viral illness in the 2nd or 3rd trimester may lead to IUGR or serious neonatal viral syndrome.

Risk Factors Maternal Intrapartum fever Chorioamnionitis PROM ( > 18 hours) Maternal Malnutrition Sexually transmitted diseases Maternal colonization with GBS Neonatal Prematurity Low birth weight Male infants Metabolic disturbances Late onset Mechanical ventilation TPN UAC/UVC Duration of hospitalization - Most units have a protocol for babies born >35 weeks and whos mom is GBS positive. - 42 hour rule-out antibiotic therapy started immediately if there is suspicion of BGS (was cut from 72 hours so they do not build up resistance to the antibiotics). - Hyperglycemia- red flag for late onset septicemia Clinical Manifestations Often non-specific Temperature- normal, elevated or depressed Respiratory symptoms Apnea, cyanosis Feeding difficulties, abdominal distension, vomiting, guiac positive stools, Lethargy, seizures - Temperature is not very helpful- can be normal Diagnostic Tests Cultures Blood, urine and CSF Immunoassays Detect bacterial cell wall or capsule carbohydrate antigens Serum and CSF Leukocyte counts Leukocytosis (20,000/mm) Leukopenia (<5000/mm) - If mom has been on antibiotics, we cannot trust the culture. - Blood, urine, and CSF tests are done with late onsets. - We often see leukopenia in preterm infants before seeing leukocytosis.

 Absolute total neutrophil count I:T ratio 0.16 in 1st 24 hours High likelihood that infection is absent if the I:T ratio is normal Acute phase reactants (C-reactive proteins) Response of the body to infection or trauma Proteins produced by liver in response to inflammation Infection, trauma, or other processes of cellular destruction - I:T= immature to total ratio - .16 used as cut off (some units will use .2) - Higher than .7 (C-reactive proteins) is suspicious of infection but can also be due to other causes. C-reactant protein Low positive predictive value Not used alone to diagnose sepsis Increasing CRP within 6-18 hours Peak CRP is seen at 8-60 hours after onset of an inflammatory process - It by itself is not very helpful. Treatment Empirical antimicrobial therapy Instituted immediately if sepsis suspected Early Onset sepsis GBS, E coli and other gram negative enteric bacilli and Listeria monocytogenes Ampicillin and an aminoglycoside - coverage for potential community acquired infection. - Meningitis frequent component of late onset use of antibiotic with good CSF penetration - GBS and E. Coli are the most common seen in first 7 days of life!! Know what the most common ones in your unit are! Heath care associated late onset Coagulase negative staphyloccus (CONS) Enterococci Gran negative enteric bacilli Fungi Late onset sepsis Nafcillin and gentamicin Vancomycin and Zosyn - Mostly associated w/ just being in the hospital/neonatal unit. Dosage and frequency depends on Gestational age Birthweight or current weight Hepatic function

 Renal function Postnatal age - Dry weight - Renal function- vanc and gentamicin are excreted in kidneys - Get a trough level right before dose to decide if need to increase dose or change the interval. - <34 weeks gestation have immature kidneys Other therapy Supportive therapy Ventilatory support (if baby is apneic) IV hydration (almost always used), TPN (almost always made NPO) Electrolyte monitoring Blood pressure support Immunotherapy Intravenous Immune globulin (IVIG) More research needed - Maternal IgG transferred to fetus at 32-34 weeks gestation and even term infant can lack specific antibodies. Prevention Intrapartum antibiotic prophylaxis for prevention of early onset GBS Initial guidelines in 1996 2002 guidelines from CDC All pregnant women be screened for GBS Lower vaginal and rectal cultures at 35-37 weeks gestation All GBS carriers should receive Penicillin, Ampicillin or Vancomycin, Cefaxolin (PCN allergic) Neonatal Management for GBS Adequate treatment (of mom) 2 doses of antibiotic prior to vaginal delivery 1 dose prior to C/S delivery Inadequate treatment Infant less than 35 weeks Symptomatic infants Blood culture, CBC diff and plts, Ampicillin and gentamicin depending on CBC and clinical status - If you have a mom with PIH (pregnancy induced hypertension), the baby will often have neutropenia and thrombocytopenia and present w/ symptoms of sepsis. It is very important to know what is going on with the mom so that you can tell the difference between that and sepsis.

Congenital Viral Infection Influences on extent of illness Primary versus recurrent maternal infection Stage of gestation Severity of systemic illness in mother If mom has a primary infection, the baby is more likely to get infected (as opposed to a recurrent infection). TORCH T- Toxoplasmosis O- other such as syphilis, Hepatitis B, coxsackie virus, Epstein-Barr, Varicellazoster, Parvovirus R- Rubella C- Cytomegalovirus H- Herpes - First insult of herpes (primary infection)- if it occurs closer to term, it is MORE lethal!!!!! With herpes, the baby will often present with hyperthermia!! Clinical Manifestations Some are disease specific Hepatosplenomegaly SGA Early jaundice Thrombocytopenia Anemia CNS manifestations (cerebral calcifications) - Rubella- cataract symptoms Treatment Generally supportive Depends on infectious agent Prognosis varies Duration of Treatment Meningitis 14-21 days Sepsis 10-14 days ? Sepsis 3-7 days - High protein, low glucose usually means there is an infection. Cell count is the number one indicator- up to 20 WBCs is normal.

Labor and Delivery complication Intraamniotic infection (IAI) refers to infection of the amniotic fluid, membranes, placenta Chorioamnionitis is a condition that can affect pregnant women in which the chorion and amnion (the membranes that surround the fetus) and the amniotic

fluid (in which the fetus floats) are infected by bacteria. This can lead to infection in both the mother and fetus - This is a problem b/c even after delivery of the baby you still have an infected uterus to deal with. You have to watch her and baby for sepsis. LD problem for PP What are the symptoms? fever, an increased heart rate in both mother and baby, a tender, painful uterus, and leaking, foul-smelling amniotic fluid Fetal tachycardia seen on EFM Treatment consists of: antibiotics for the mother, and quickly delivering the baby. - Some of these will start while in L&D. - First thing you will see (even before temp. in the mother) is an increase in babys baseline (will become tachycardic). This increase is due to the mothers temperature. - Septic babies are not initially cyanotic. Third Stage of Labor Birth of baby until placenta is delivered Placenta attached to decidual layer of endometrium (uterine wall) After birth strong uterine contractions cause the placenta site to shrink Causes placenta to separate from uterine wall Placenta can not be separated from flaccid uterine wall because site would not have shrunk Major bleeding - If the uterus will not contract (ex. if they have had a intrauterine infection or if they are preterm), the placenta cannot separate. If they cant deliver the placenta spontaneously, they will medicate her (ex. morphine IV push) and will go in with their arm and scrape it off. - Maternal factors to consider: - Gravidity of the mother grand multip may bleed more - Mother with fibroids may bleed more, uterus may not contract as well - Preterm delivery may take longer for the placenta to release Placental Separation Assessment Contracting firm fundus Sudden gush of dark blood from introitus Lengthening of umbilical cord Maternal report of sensation of vaginal fullness or rectal pressure Examination of the placenta - Is the placenta intact, retained placenta causes uterine hemorrhage. - The blood has been trapped behind the placenta so it is not cherry red but more dark red. - Never pull the umbilical cord (it can invert the uterus and pull it outside the body- an emergency situation!)

- Look for s/s that placenta is separating. The un-medicated mother will report some contractions (not as painful as labor contractions) and pressure in the rectal area (can have her push to help deliver the placenta). Immediate Care Pitocin Fluids Uterine Massage Baby to breast Apply peri pad/ice pad to reduce swelling Clean gown Assessment q 15 minutes x 4,q30x 2 Fundal Lochia VS Perineum Bladder Mobility Pain - This is somewhat provider dependent. Usually ever patient will get Pitocin IV versus a second line drip (on a pump). When you are going to get close to delivery be sure to have Pitocin ready for after the delivery (and switch out w/ bag of fluids). - The can have PO fluids. Dont want them to eat a lot if they havent been eating b/c it can make them sick. Check uterus/massage every 15 minutes. VS and lochia checks every 15 minutes. Turn over on a lateral Sims position and look from the rear (more comfortable). A cheaper way is to fill up glove with ice and use to reduce swelling. Getting the baby to breast will help the uterus contract. - Epidural patients may need to empty bladder (every 15 minutes) b/c they get the 2 liter preload. Full bladders can cause problems with uterine contractions (hemorrhage). If the epidural patient cannot push against your hand, do not try to get her up to go to the bathroom. Possible Alteration Assessment Position deviated to side or fundus rising Boggy Distended bladder, non-contracted uterus Large baby, multiple gestation Sub involution infected uterus, fatigued uterus, retained placenta - Your biggest one is when the uterus is to the left/right of midline. This usually means the bladder is full. If she hasnt had an epidural, try to get her up to go to the bathroom. - Mothers with a really stretched uterus (ex. if had triplets, 10-11 lb. baby, having 5th-6th child) will not tone up as fast (may be boggy).

Uterus Oxytocin natural levels help uterus remain contracted Position 2 hours after delivery After pains More common in multiparous, periodic relaxation and contractions Breast feeding increase release oxytocin, causes milk ejection, increases uterine contraction - Two-handed procedure (see pictures in powerpoint). Bottom hand right over the public arch. Initially after delivery, always support lower uterine segment. Dont have patient sitting up in a high Fowlers position. Immediately after delivery, the fundus rises up w/in the first 12 hours to about the level of the umbilicus. The highest it should be immediately the first day is at the umbilicus and it should continue to go down. - Multiparous uterus will need more contractions to firm up (so they will have more after pains). Sucking on breast promotes oxytocin to let the milk out as well as uterus contraction. - Prolactin- what makes the milk - Oxytocin- what makes the milk come out of the body.

Lochia Sloughing of endometrial tissue, blood and fetal debris Expected findings-decreasing amount, non-malodorous, without clots Possible Alteration Hemorrhage, undetected laceration, retained placenta, infection - Composition of both blood and products of conception. It should be a dark red and no foul smell. It shouldnt have any clots in it. - When you turn pt on side to assess the peritoneum, look at pads underneath her b/c often the blood will run to the back. - The bleeding r/t a laceration is usually arterial type bright red blood. It needs to be followed up by the health care provider b/c she may need a repair (it is not self-limiting).

- Retained placenta- the placenta should not have any chunks out of it. It could mean that some chunks are still inside of the patient and they can cause hemorrhage. LOCHIA FLOW

1 pad= holds 100 ml - With a vaginal delivery, a total of 500 ml should be lost at the time of the delivery. - If someone is saturating their pad, there is a problem. She may need a different medication. **Methagen cannot be given to any patient with hypertension. Reproductive Cervix Soft and bruised 18 hours shortened and firm 4-6 days can insert up to 2 fingers Allows for Lochia drainage Perineum S/S of infection Pain Redness Warmth Swelling Discharge REEDA - Introitus edematous. - Should not see any bulging of red when examining the perineum. Vagina Swelling

visualize, Sims position, good light, elevate buttocks Estrogen deprivation responsible for thinness Distended smooth walled vagina returns to pre-pregnant size by 4-6 weeks Mucosa atrophic in lactating woman until resumption of menstruation Reduced estrogen responsible for decreased vaginal lubrication =dyspareunia They will have lochia discharge for the first 3 days. First 12 hours, with a moderate pad you would change every 2 to 3 hours. After that, probably light to moderate and changing once or twice a shift. Recommend waiting 4-6 weeks for sexual intercourse following birth.

After Pains Oxytocin released from pituitary gland makes the uterus contract which causes uterus to contract compressing vessels and placenta site Multiparous women may have more problems Uterus a muscle that has been stretched repeatedly will take more post delivery contractions to restore to non pregnant size Breastfeeding women will experience contraction related to baby suckling Urinary System Urine components Renal glycosuria disappears by 1 week postpartum Postpartal diuresis Diuresis of extracellular fluid Urethra and bladder Immediately after birth excessive bleeding can occur if bladder becomes distended Hemorrhoids Anal varicosities Painful BM Tucks Sitz bath Stool soften Fiber diet Pre-labor diarrhea, not eating during labor, may not have a BM for 2 to 3 days - If they have had hemorrhoids during the pregnancy, they will get more irritated during delivery. - Any patient with a 3rd or 4th degree laceration or hemorrhoids, send them home with a sitz bath. - Tucks= witch hazel pad; line kotex pads with tucks - High fiber diet to prevent constipation. - Pain meds (ex. Percocet) often make postpartum women constipated. - Give 1 motrin and 1 percocet. Motrin reduces inflammation so it treats the pain and the initial problem.

Bonding With Baby Touch is an essential part of bonding even when there are complications - Oxytocin= love hormone (released during orgasm and when baby is put to breast). - You want to see mother looking at, talking to, smiling at, and touching the baby. Breasts Breastfeeding mothers First 24 hours colostrum Transitions to milk in 72 to 96 hours Breast Soft Colostrum Warm to touch Tenderness True milk Nipples Erectile, cracks, blisters Teach about proper positioning Non breast feeding Colostrum disappears by 2-3 days Tenderness Engorgement-vasocongestion Decrease in tenderness in 24 to 36 hours Breast binder, ice packs, mild analgesic Avoid stimulation - If mom is breastfeeding, the first 24 hours all you will get is colostrum. - 1 ounce of colostrum= 65 calories; formula= 20 calories - 72 hours before true mil comes in. - Breasts should be soft (warm but not hot to touch; any tenderness may indicate a blocked duct or beginning of mastitis). The nipple will break down if it is treated like a pacifier. - If a breastfeeding mom is going to get up and take a shower: she wants to face the hot water (it increases circulation to the breast). However, for non-breast feeding mom needs to face away from the water (to avoid stimulation). - Breast feeding woman should shower and put on good support bra (w/o underwire). A non-breast feeding mom needs a tight bra or breast binder to suppress the milk. If her breasts are tender, tell her NOT to stimulate the breast to make it feel better b/c it will only produce more milk. Lactogenesis Estrogen and progesterone levels fall Prolactin triggers milk production Oxytocin elicits the let-down reflex milk ejection Milk production depends on supply and demand

 Feed often (every two to three hours) Avoid supplements Encourage night feedings - Baby should always be facing the breast. - Make sure to talk to moms about the fact that babies need to eat every 3-4 hours (stomach is size of walnut). Breast milk gets metabolized every 2 hours. Newborns (1st week to 10 days) should NEVER go more than 4 hours w/o eating. It can result in hypoglycemia ( a baby with low blood sugar acts lethargic). Interferences with Lactation Poor nutrition, inadequate fluid intake Maternal anxiety Medical conditions Pendulous breasts Flat or inverted nipples Postoperative pain Deficient knowledge - She needs to drink lots of water. - How many calories does a breastfeeding mom need? An extra 500 (and 300 if just pregnant). - Teach mom that if baby is crying not to put them straight to breast. Teach them other comforting measures. Baby needs to be calm before going to the breast. - If you are taking a baby to breast, bring the mom a glass of water. Educate her that every time she feeds the baby, she should have a glass of water. - Teach mom to hold breast tissue away from the babys nose (if big breasts; after 2- 3 weeks the babys adjust on their own). - If you have a c-section baby, put a pillow over moms abdomen and place baby on pillow. Techniques for Successful Breastfeeding (see pics in powerpoint) Proper latching-on technique Breaking suction Rooting reflex - Dont stroke the other side of the baby when trying to get them to latch on. Do not break suction or will result in cracked nipples. Preventing and Treating Engorgement 1. Nurse (put baby to breas) 2 Take a warm shower 3. Pump (teach the mom how to use the breast pump) 4. Keep nursing pads in the freezer. 5. Wear wireless bras 6. Try putting cold cabbage leaves in the bra - It drains milk from breasts and sets your milk production on the right schedule. - Breastfeed a newborn about every two hours around the clock, but sometimes infants need more frequent feedings.

- If newborn sleeps longer than 4 hours assess for lethargy. - Engorgement: - Popcorn kernels in a plastic bag (that has been inside the freezer) can help - Cabbage leaves help with engorgement (take the whole leaf kept in refrigerator and put on breast to reduce swelling..an enzyme in the cabbage does this) Nursing Implications: Barriers to Successful Breastfeeding Maternal barriers Diet, medications, smoking, fatigue Prior breast surgery Nipple abnormalities Contraceptives Psychological issues, modesty Infant barriers Prematurity Illness and disability Hypoglycemia Jaundice - Try to give pain meds as mom is finishing up feeding the baby so that it is out by the next time she has to feed. - If they have had breast implants, some can still successfully breast feed (depending on where the implants are). - Depo Provera- If a woman is going to use this as birth control and breast feed, it will take more stimulation to keep her milk established. If she is going to use pills, the progestin only mini-pills are best. Remind her if she misses one pill, to use an alternative protective method. - If baby is in NICU, make sure to get the mom a pump. - Babies who have Rh incompatibility, ABO incompatibility, or premature sometimes get jaundice. Have the mom feed in the nursery and pump milk. Nursing Interventions and Education Anticipatory guidance Rest and prevent infection Observe changes in body Weight loss and diet Fatigue Breast and peri care Constipation Postpartum Check-Up History since discharge Illnesses, readmissions, etc.. Discomfort and headache Maternal adaptation & infant status Maternal self image assessment Rest/Sleep

 Activity/Exercise Nutrition Individual/family adaptation Sexual activity & family planning Violence/substance use - Most women return to see her provider about 6 weeks postpartum. - At this point there should be no more delivery related vaginal delivery. - Mom should be up and walking around. - Have they resumed sexual activity? Any pain during sex? Encourage use of KY jelly if needed (never use Vaseline). Six Week Check- Up Physical Assessment Pelvic Exam Pap smear Cystocele/Rectocele evaluation Bladder Bowel (hemorrhoids) Lochia & vaginal discharge Breast Exam Lactating Non-lactating CBC if indicated Abdomen tone Incision if C/S - If not having any bloody discharge, they may go ahead and do their annual pap smear. - May or may not do a CBC and H&H (if she complains that she is not feeling well or really tired). - C-section scar should be pretty well healed (some providers take out staples prior to discharge, others may wait a few days). Assessment Sleep/Wake Lactation/ suppression of milk Incisional status Maternal infant interaction Family planning Possible referrals social services child protective services substance abuse counseling Postpartum Infections - Puerperal Infection (Childbed Fever) - Any infection of the genital canal that begins within 28 days after abortion, miscarriage or childbirth.

- Definition is a fever of 38o C (100.4o F) on 2 successive days of the first 10 days postpartum (not counting 1st 24 hours after birth). Not uncommon for postpartum woman to have a little bit of low grade fever (< 100.4). It is often the result of inflammation and the stress to the body (caused by labor). Anything greater than 100.4 needs to be reported! Postpartum Complications - Also increased risk with history of STD * A Cesarean or other operative birth * Prolonged labor (more vaginal exams) * Prolonged rupture of membranes * Internal fetal or uterine monitoring (IUPC or fetal scalp monitoring) - Signs/symptoms * Endometritis - Pelvic pain - Uterine tenderness - Foul-smelling, profuse lochia Endometritis is an inflammation or irritation of the lining of the uterus (the endometrium). Endometritis- infection of endometrial lining after delivery. General discomfort, uneasiness, or ill feeling Chills ,fever (ranging from 100.4 to 104 degrees Fahrenheit) usually after 24 hours after delivery Lower abdominal or pelvic pain (uterine pain) Pain when palpating for fundal location Abnormal vaginal bleeding or discharge Increased amount of discharge Unusual color, consistency, or odor Treatment is a broad-spectrum antibiotic regimen given IV Clindamycin (Cleocin) Gentamicin (Garamycin) Ampicillin Check mothers labor record did she spike a fever during labor What else would predispose a woman to postpartum infection? - Treated the same way as chorioamnionitis.

Complications Pelvic peritonitis (generalized pelvic infection) Pelvic or uterine abscess formation Septicemia Septic shock Infertility - The uterus has an opening in the top that goes to the fallopian tubes. Infections can be ascending and go through fallopian tubes and into the peritoneum. - Infection= increased risk of infertility (secondary scarring in the fallopian tubes). Postpartum Complications * Wound infection - Erythema, edema, warmth, tenderness, sero-purulent drainage * Mastitis - Almost always unilateral - Develops well after milk flow established Assess lacerations, sutures, etc. The breast are normally going to swell (bilaterally, equally= engorgement). If it is unilateral it may be Mastitis. Teach mom to always wash hands before putting baby to breast. MASTITIS Description Inflammation of the breast as a result of infection Primarily seen in breast-feeding mothers 2 to 4 weeks after delivery Cause Staph aureus Hemolytic strep How it is transmitted: Babys nose and throat Mothers or health care providers hands Cracked nipples - Can be a staph infection or hemolytic strep. Can be transmitted by not using good hygiene. - Moms with cracked, bleeding nipples are more susceptible. She should not use plastic linings (anything warm, dark, and moist will promote infection). Assessment Localized heat and swelling Pain: redness, warmth and firm to touch with areas of lumpiness Elevated temperature and chills Tachycardia Headache Complaints of flu-like symptoms - This patient may call from home and report flu-like symptoms, as well as unilateral breast tenderness. The only way to treat is with antibiotics. Most of these infections do not spread to the baby.

Postpartum Complications - Infected nipple fissure usually the initial lesion - Accompanied by inflammatory edema and engorgement that obstruct milk flow in the region and generalized mastitis follows - Chills, fever, malaise, pain - Treated by antibiotics and emptying breasts q 2-4 hours by feeding, manual expression or pump. Try a warm compress before nursing and a cold compress afterwards. placing chilled cabbage leaves on each breast (make an opening for your nipple first) will prove surprisingly soothing. Change positions and check latch on Warm line

Postpartum Complications * Use of magnesium sulfate * Use of oxytocin * Multiple pregnancy - Management of uterine atony. * Manual massage of the uterus * Expression of clots * Eliminate bladder distention - Magnesium sulfate- given for pregnancy related hypertensive disorders, also for preterm labor (a strong CNS depressant that causes uterine relaxation). - Multiple pregnancy= over stretching of uterus - These pts are all at more risk for poor contractility of uterine muscles. Hemorrhage is the underlying causative factor in at least 25% of maternal deaths in industrialized and underdeveloped countries. HEMORRHAGE - An uncontracted uterus fills up with blood (you not only have to massage it but also squeeze out the blood). Description: (overall category of hemorrhage) Bleeding of 500 mL or more following delivery Traditional definition vs. new definition: Traditional: NVD => 500cc C-section => 1000cc New criteria: Decreased Hct of 10 points OR The need for fluid replacement after birth - In a woman who is hemorrhaging will not have bp changes but will become TACHYCARDIC. - 1st vital sign of PP patient= fundal assessment - If fundus is firm, she must have a laceration.

Maternal physiology is well prepared for hemorrhage: increase in blood volume . Although concern is for blood loss remember mom has extra volume on board thus blood pressure is not always your best vital sign to evaluate first Etiology of PPH The causes of postpartum hemorrhage can be thought of as the Ts: Tone Tissue Trauma Thrombosis Causes of Postpartum Hemorrhage Tone- cause is Atonic uterus (70% incidence) Tissue- cause is Lacerations, hematomas, inversion, rupture (20% incidence) Trauma- cause is Retained tissue, invasive placenta (10% incidence) Thrombosis- cause is Coagulopathies (1% incidence) - Tone: a boggy, atonic uterus is most common cause of postpartum hemorrhage. TONE Uterine atony Multiple gestation, Cesarean delivery Grand multiparity high parity, Precipitous labor prolonged labor, Endometritis chorioamnionitis, Magnesium sulfate augmented labor, tocolytic agents - May have lacerations with a precipitous delivery. - Augmented labor- a lot of times they use up their Pitocin receptor sites. - Tocolytic agents- meant to relax the uterus STOP THE BLEEDING Exclude causes of bleeding other than uterine atony Cervical laceration Hematoma Ensure bladder empty Uterine compression Methergine 0.2 mg Check maternal history!!!!!! No history of hypertension Pitocin infusion (30 units in 500 ml) IM Hemabate (Carboprost 500 mg) Rectal 800mcg. Misoprostol (cytotec)is beneficial D&C Hysterctomy early rather than late - If you have good uterine tone, look for lacerations.

- Hematoma- feel a lot of pressure in their bottom; bulging, swelling, blue area in the vaginal area; report to provider immediately; may have to go to surgery. - Cytotec is given rectally. It causes a strong contraction. It is rapidly absorbed rectally. - Carboprost- side effect is a frosty, foul smelling diarrhea Uterotonic Agents for PPH Drug Dose Route Freq Oxytocin (Pitocin) 10 units/ml Dilut e 2040 units in 1 L NS 10 IU IM 0.25 mg IV IM Continuo us Infusion, 250 ml/hr

Side Effects Nausea, vomiting Water intox with prolonged IV use

Contraind. Hypersensiti vity to the drug

Store Room temp

Carbopros t (Hemabate ) 15-methyl PG F2a 0.25 mg/ml Methylerg on-ovine (Methergin e) 0.2 mg/ml

IM IM M

Q 15-90 min not to exceed 8 doses

Nausea, vomiting Diarrhea Fever/Chills HA Hypertension Bronchoconstric tion Nausea, vomiting Hypertension, esp in pts with PIH or chronic HTN Hypotension Nausea, vomiting Shivering Fever Diarrhea

Hypersensiti vity to the drug Use with caution in patients with HTN or asthma Hypertension Preeclampsia Hypersensiti vity to the drug

Refri g

0.2 mg

IM

Q 10 min x2 Q24 hrs

Refri g Prote ct from light Room temp

Misoprosto l (Cytotec) 100 and 200 mcg tabs

6001000 mcg

PR

Single dose

Hypersensiti vity to the drug

- Will never ask the dosages. - Know side effects and contraindications. - Know hemorrhage drugs for test 2!!!

Tissue Fibroids Retained placenta Placenta accreta the placental roots grow too deeply into the muscular wall of the womb. The most important risk factor for placenta accreta is previous uterine surgery and the most common setting is placenta previa after a prior pregnancy delivered by cesarean. - Retained placenta will cause postpartum hemorrhage. That area will not contract and continue to bleed. - Fibroids- benign masses growing in uterine muscles (tend to grow a lot with pregnancy due to hormones). They prevent contraction of uterus. - Placenta accreta- grows into the uterine muscle (probably requires a D&C). Likely to see in someone with a previous c-section (if implants near the previous scar). Tissue: Dilitation & Curettage

- Retained placenta - The placenta is more likely to be retained at extreme preterm gestations (especially < 24 wk). - Will have after an incomplete abortion. trauma PP hemorrhage Laceration of the birth canal If there is post-partum hemorrhage and the fundus is firm, suspect laceration

 Vaginal lacerations: Cervical laceration: Surgical repair - Trauma may occur following very prolonged or vigorous labor, especially if the patient has relative or absolute cephalopelvic disproportion and the uterus has been stimulated with oxytocin or prostaglandins. - 3rd and 4th degree lacerations require repairs (sometimes 2nd degree also)- these stitches do not come out Trauma Rapid Delivery Lacerations VULVAR HEMATOMA Description The formation of a hematoma following the escape of blood into the tissues after the delivery Predisposing conditions include operative delivery with forceps or injury to a blood vessel A life-threatening condition - Hematomas may developed in patients who had to have forceps used. Doesnt happen as much as with vacuum extraction. - It needs to be reported. It will be extremely painful (ice will help). HEMATOMA- The bleeding may go into the tissues. May have to have surgery to go in and drain the blood. Monitor any hematoma patient for infection. Trauma during Pregnancy Inadequate hemostasis at episiotomy Difficult or prolonged second stage Notify health care provider Signs and symptoms Extreme pain Appearance of tense discolored mass Sensation for a bowel movement Treatment Incision and evacuation of blood, ligation of bleeding points Antibiotics Analgesics Blood products if loss is excessive Signs and Symptoms of Shock Hypotension Tachycardia, weak, thready pulse Cool, pale, clammy skin Reddish or blue discoloration of the skin Decreased hemoglobin and hematocrit (H&H)

Cyanosis Oliguria, Thirst Hypothermia Behavioral changes (lethargy, confusion, anxiety) Signs of shock such as pallor, tachycardia, and hypotension if significant blood loss has occurred - Shock can occur due to postpartum hemorrhage. Blood pressure will NOT be the number one indicator. - 1st sign= tachycardia - Urine output indicates whether or not circulatory system is intact!! HEMATOMA Implementation Prepare for urinary catheterization if client is unable to void Administer blood replacements as prescribed Monitor for signs of infection such as increased temperature, pulse rate, and WBC count Administer antibiotics as prescribed as infection is common following hematoma formation Prepare for incision and evacuation of hematoma if necessary Superficial Thrombophlebitis More common PP than during pregnancy Clot often involves the smaller saphenous veins Common in women with pre-existing varicose veins S/S: Usually present after 3-4 days PP Tenderness and pain in the affected lower extremity Positive Homan sign Warm and pinkish-red color over thrombus area Palpable thrombus that feels bumpy and hard Slightly elevated pulse rate Temperature normal to low grade fever - Coagulopathy is a compensatory mechanism. - The longer they stay in bed, the less effective their circulatory system works. - Tell the mom to stop rubbing the leg if there is pain (even if it makes it feel better) b/c if it is a clot you dont want to dislodge it. Thrombophlebitis Clot in leg vein, may effect ovarian or uterine veins Appears about 10-20 days post partum Pain; redness and swelling or pale skin denoting impaired circulation Malaise, fever and chills Acute symptoms last for a few days but resolution takes 4-6 weeks Vital signs and I&O Anticoagulants; antibiotics Bedrest without pressure on leg

 No pressure or massage to leg - Pelvic Thrombophlebitis more serious and difficult to treat! - Those that effect ovarian and uterine veins are very hard to diagnose. Femoral Thrombophlebitis Provide bed rest Elevate affected leg Apply moist heat continuously to affected area if prescribed to alleviate discomfort Administer analgesics as prescribed Administer antibiotics if prescribed Prepare to administer intravenous heparin to prevent further thrombus formation if prescribed

Urinary Tract Infections Description An infection of the urinary tract / bladder Caused by: Decreased bladder sensitivity Increased bladder capacity to accommodate increased blood volume Inhibitory neural control of bladder after epidural or spinal anesthesia Poor sterile technique with catheterization Residual problems = stasis - Wipe front to back, dont wear a lot of pads with discharge, peri-care prior to catheterization. - B/c the bladder has been anesthetized, she may not be completely emptying it (increases chance of bladder infection). Teach mom to completely empty her bladder. - For postpartum patients, put a hat in commode and have her void in the hat (for the first 2 voidings). Predisposed by changes of pregnancy; Stasis, reflux, dilatation of ureters; Changes persistent for post partum period; E coli major causative organism; effect 5% of pregnancies.

Cystitis Infection of the bladder S/S: Dysuria at end of urination Urgency and frequency Low grade fever Hematuria CBC: abnormal number of leukocytes and bacteria

Treatment: Sulfa drugs: trimethoprim/trimethoprim, sulfamethoxazole/sulfisoxazole (Bactrim) Ciprofloxacin is commonly used today Nursing: Teach good hygiene: Wipe front to back Increase fluid Acid fluids such as Cranberry juice and Vitamin C Antibiotic therapy If you really think you have a problem, may want to get a catheterized specimen (b/c hematuria is hard to see). PP Emotional Disturbances Teach about prenatally Discuss resources for support prior to discharge Discuss what is normal and when emotions are out of control Express to patient what is normal after delivery (ex. fatigue). Depression screens at pre-natal clinics. Teach them about emotion changes prior to delivery. May feel weepy in first 2- 3 days but should be gone by about 10 days. Postpartum Complications Perinatal depression * Prevalence of major and minor depression begins to rise after delivery and peaks in the 3rd month * Postpartum Blues - 50% of women have symptoms - Peak on 5th postpartum day - considered a normal part of early motherhood - Go away within 10 days Fatigue is the number 1 clue! What are the "baby blues?" feelings of disappointment crying with no known reason irritability Loneliness Decreased self esteem Impatience Anxiety Fear of loss of control Restlessness These are normal. Hormone related.

Postpartum Complications * Postpartum Depression - May occur in 10% - 23% of women - A true, major depression - Can last into the 2nd year after delivery - Risk factors * Past history of depression (often bipolar) * Depression during pregnancy * Previous history of postpartum depression * Life stress (unemployment) * Poor social support * History baby blues * History of severe PMS * Poor marital relationship * Family history of postpartum depression - Symptoms * Feeling of sadness, extreme fatigue, inability to stop crying, anxiety about her own or the babys health, insecurity and psychosomatic symptoms PP Depression Treatment SSRIs are first-line drugs Initiate at half the usual starting dose Treat for at least 6 12 months after full remission to prevent relapse Sertraline or paroxetine for breast-feeding mothers May also respond to psychotherapy Hormonal therapy?? Patient resources National Womens Health Info Center (www.4woman.gov) www.depressionafterdelivery.com Physiologic vs Nonphysiologic Jaundice Physiologic Jaundice- Normal defects in bilirubin metabolism. - Normal newborns have one or more defects in bilirubin metabolism. - Bilirubin Levels in 97 % of infants did not exceed 12.9% before the use of phototherapy. - Maisels in 1986- 97% tile bottle fed infants 12.4 mg/kd breast fed infants 14.8 mg/dl

Criteria Infant otherwise well Clinical presentation Term: jaundice after 24 hours Preterm: jaundice after 48 hours Serum levels not > 12-13 mg/100ml Direct levels <1.5 -2mg/dl Increments < 5/day Clinical jaundice - Average cord blood bili 1.5 mg/dl - Term infant peaks day of life 3 or 4 12.9 mg.dl possible 15 - Preterm infant peak 5-7 days Peak 10-12, depends on gestational age 15 mg/dl peak - Increments of > 0.5 mg/kg/hour - Clinical jaundice, if persists for greater than 1 week in a full term infant or 2 weeks in a preterm infant. Rules out physiologic jaundice. Non Physiologic Jaundice- Unconjugated Hyperbilrubinemia - Unconjugate bilirubin is fat soluble also know as indirect bilirubin. - When obtaining bilirubin levels, a total bilirubin is generally reported. It is important to obtain a direct bilirubin level at some point to evaluate whether there is a direct hyperbilirubinemia or strictly an indirect hyperbilirubinemia . Treatment will vary. - We will briefly discuss direct hyperbilirubinemia later. Non-physiologic Causes of Indirect Hyperbilirubinemia Increased bilirubin production Decreased bilirubin clearance - The Pathologic causes of hyperbilirubinemia is caused by either an increase in the production of bilirubin or a decreased ability for bilirubin clearance.

Nonphysiologic Jaundice: Hemolytic Disease Isoimmunization Rh incompatability ABO incompatibility Minor blood group incompatibility Kell, Duffy, Kidd Congenital Erythrocyte defects Hemoglobin defects - One of the causes of non physiologic jaundice from overproduction of bilirubin is hemolytic disease. Isoimmunization is caused by antigen/antibody reactions. - Just as a review. There 6 RH antigens identified. A a C c D d E e. (95% of the population that is RH+, has the D antigen. Rhogam is AntiD gamma globulin. - ABO incompatibility can also cause hyperbilirubinemia. - There are also other RBC antigens that have been identified for example, Kell, Duffy and Kidd. They rarely cause significant problems with hyperbilirubinemia. - Maternal Disease lupus

Non physiologic Jaundice: Increased bilirubin production Polycythemia Extravascular Blood Metabolic Hypothyroidism, Galactosemia, Maternal Diabetes Mellitus Enzyme defects Infection - With the increase in circulating red cell volume, there will be an increased load on the liver to conjugate and excrete bilirubin. - There are also some endocrine or metabolic disorders that can present with hyperbilirubinemia. Eg. Adrenal hyperplasia, Beckwith Wiedeman syndrome. Etiology Infections

 TORCH Sepsis,UTI Inborn errors of metabolism Criggler-Najjar Type I and II Gilbert Tyrosenemia, galactosemia ECMO - Reduction in glucuronyl transferase enzyme important in the conjugation of bilirubin in the liver. - Crigglar Najjar syndromes Type I severe disorder enzyme totally absent Type II decrease amount or activity of the enzyme Also known as Arias Syndrome Gilbert Syndrome mildest form of disease with decreased enzyme activity - Inhibition of glucuronyl transferase - Tyrosenemia, galactosemia Decreased bilirubin clearance Inborn errors of metabolism Drugs Hormones Hypothyroidism, hypopituitarism Exaggerated Enterohepatic Circulation - Decreased in bilirubin clearance is seen in infants with inborn errors of metabolism - Drugs: Glucuronyl transferase activity can be inhibited by drugs - Hormones (Hypothyroidism, hypopituitarism) - Delayed passage of meconium Mechanical obstruction, underfeeding, decreased peristalsis. Non physiologic JaundiceIdiopathic Indirect Hyperbilirubinemia - Breast feeding jaundice thought to be related to decreased caloric intake and low UDPGA; early onset - Breast milk jaundice late onset, peak by day 14 possible presence of inhibits in breast milk such as free fatty acid,which will inhibit bilirubin conjugation. Diagnosis- Review of maternal and perinatal history Examination of Infant- Physical examination - Physical exam - Pallor, associated with anemia or extravascular blood loss - Petechiae, associated with congenital infection, sepsis, or erythroblastosis - Hepatosplenomegaly associated with hemolytic anemia, congenital infection or liver disease

- Omphalitis - Chorioretinitis associated with congenital infection, delayed or infrequent stooling, vomiting may be from pyloric stenosis, sepsis or galactosemia Diagnosis Laboratory data Hematocrit, reticulocyte count, CBC, Peripheral smear Mother and infant blood typing Coombs Bilirubin level Cord level, rate of rise - If at risk, bili levels initially at 12 hours of age - Rate of rise should be less than 0.5 mg/hr within the first 24 hours Management- Prevention of bilirubin encephalopathy - The goal of management for an infant with an indirect or unconjugated hyperbilirubinemia is prevention of bilirubin encephalopathy - The treatment will depend on the underlying cause of the hyperbilirubinemia - Utilization of alternate pathway - Mechanical removal - Acceleration of normal pathway - Inhibition of bilirubin production - Inhibition of hemolysis Phototherapy Utilization of alternate pathway of bilirubin excretion Photo oxidation Configurational Isomerization Structural Isomerization - With phototherapy there is utilization of an alternate pathway of bilirubin conjugation and excretion. - There are 3 photo chemical reactions, which convert bilirubin to water soluble isomers that are not able to cross the blood brain barrier. - Photo oxidation, which is the least important, - Configurational isomerization very rapid process that changes the bili to a water soluble isomer - Structural isomerization results in the formation of lumirubin. Can be enhanced by the intensity of the light. Spectral band Irradiance meter Types of phototherapy units Daylight white fluorescent Special blue bulbs Quartz halogen

 Fiberoptic light - The spectral band of effective light is between 425-475 Nanometers of light. Blue/green spectrum of light - Irradiance measurements most units deliver around 6 microwatts/cm squared. There is a dose response relationship and reduction in serum bilirubin occurs up to a irradiance of 25-40 - Types of phototherapy units daylight white fluorescent less efficient than blue bulbs special blue bulbs are narrow spectrum blue lamps. Generally mixed with white fluorescent bulbs and are most effective Green light has a theoretical advantage of better skin penetration, not been shown to work better in clinical situations. Unpleasant to work with for staff. quartz halogen significant blue component , spotlights focus energy in center Fiberoptic light deliver high energy levels but to a limited surface area. Bili blankets Increase surface area exposure Distance from light Use of reflecting material - Increase surface area exposure will enhance the efficiency of the phototherapy. Remove clothes, uses small diapers. Turn infant frequently to allow exposure of all sides - Distance from light should not be greater than 20 inches. The closer the source of light to the infant, the more energy delivered to the skin. Close monitoring of infants temperature if placing light source closer to the baby - Use of reflecting material, such as foil or white sheets to reflect light back onto the baby. Indications: Clinical characteristics of infant indirect bilirubin levels - Clinical characteristics of infant Infants with hemolytic disease or in some cases premature infants will have phototherapy initiated sooner. - Indirect bilirubin levels - Guidelines based on biliirubin level, gestational age of infant or birthweight, post natal age and rate of rise. Side Effects Gastrointestinal Fluid & Electrolyte Respiratory Integumentary Growth & Development - Gastrointestinal loose stools, increased fecal water loss, - Fluid & Electrolyte due to water loss, dehydration, - Hypocalcemia is more common in premature infants under phototherapy, maybe mediated by altered melatonin metabolism. - Respiratory risk of apnea from patches, tachypnea - Integumentary rashes may be seen

- Growth & Development weight loss, lethargy while under phototherapy, - Redistribution of blood flow may occur in small premature infants and an increased incidence of PDA has been reported in these circumstances. Nursing Care Shield eyes Assess thermoregulatory needs Monitor fluid balance Assess nutritional needs Monitor skin condition - Shield eyes - Assess thermoregulatory needs - Monitor fluid balance - Assess nutritional needs - Monitor skin condition Inhibition of Bilirubin Production Heme oxygenase inhibitors Metal meso/protoporphyrins Treatment of Coombs positive ABO incompatibility Not widely used - Metalloporphyrins inhibit heme oxygenase blocking the enzymatic process for the formation of bilirubin from heme. - Initial studies with tin or Zinc protoporphyrin, concerns about photosensitization, iron deficiency - Must be given IM and effectiveness is dose related - Further evaluations being done with zinc, manganese and chromium especially for infant with hemolytic disease. Inhibition of Hemolysis IVIG for isoimmune hemolytic disease Mechanism related to blockage of receptors in the neonatal reticuloendothelial system - IVIG for isoimmune hemolytic disease - Shown to limit red cell destruction and limit the rate of rise in serum bilirubin Acceleration of Pathway Phenobarbital Increases the concentration of ligandin Induces glucuronyl transferase 5-7 days for effect Criggler-Najjar Type II cholestasis - Acceleration of Pathway with Phenobarbital - Increases the concentration of ligandin, which Induces glucuronyl transferase invreasing the conjugation and excretion of bilirubin by raising uptake and enhancing bile flow - 5-7 days for effect - Criggler-Najjar Type II

- Cholestasis associated with hyperalimentation Exchange Transfusion- Mechanical Removal Criteria - Indicated to avoid bilirubin neurotoxicity when other treatment modalities have not worked. - Indicated in infants with erythroblastosis presenting with severe anema and or hydrops. - Controversial level for exchange. For full term infants, generally a level of 20 is used, however with non hemolytic disease there are newer recommendations that exchange levels are higher. - Premature infants a general rule of thumb is 10 times the weight in kilos. So a 1200 gm infant would have an exchange level of 12. - Other uses for exchange transfusion Sepsis DIC Severe anemia HB <10g/dl Rate of bilirubin rise > in spite of phototherapy Procedure Double volume exchange for complete exchange transfusion Calculations for partial exchange Blood type, replacement fluids Blood warmer - Double volume exchange will remove approximately 75-80% of the infants circulating ed blood cells. 25 % Bili is removed from the plasma, and extravascular bili will then move into the plasma Recommended time is at least 1 hour - Correction of asphyxia. Low albumin levels, acidosis, hypoxia or shock prior to the exchange transfusion - Blood type depends on the underlying cause RH disease RH negative blood AB compatible ABO disease O blood RH specific or O negative - Preservatives CPD is a commonly used preservative, increased dextrose load citrate binds with calcium and there may be a need for calcium bolus midway through transfusion. - Blood warmer blood warmed to 37 degrees Centigrade - UVC Push pull method aliquats of 5-20 cc depending on the infants weight and cardiovascular status - isovolumetric, Out of uac and into uvc simultaneously or out of UVC and run on pump through PIV Nursing Role Vital sign monitoring including blood pressure Accurate recording of blood in and blood out. - Vital sign monitoring including blood pressure every 5 minutes - Accurate recording of blood in and blood out.

Complications Vascular Cardiac Metabolic Infection Other - Vascular emboli with air or clots thrombosis hemorrhagic infarction - Cardiac Arrhythmias calcium infusion volume overload/or volume depletion inaccurate recording Hydropic infant with low serum proteins after the exchange and a increase in plasm proteins, there will be a shift of extravascular fluid back into the intravascular space. Arrest calcium infusion hyperkalemia hypernatremia hypocalcemia Hypomagnesemia citrate binds with mag and calcium acidosis Hypoglycemia increased glucose levels in preservative that may stimulate insulin secretion and can cause a rebound hypoglycemia once the exchange is done. Seen in infants with Rh incompatability - Infection bacteremia serum hepatitis CMV, HIV, and malaria Hypothermia or hyperthermia inadequately warmed blood perforation mechanical injury to donor cells

Hypertensive disorders

CHT- chronic hypertension GST- gestational hypertension If elevated bp and protein in the urine= preeclampsia 5 gm protein in the urine Eclampsia- where a seizure has actually occurred

Hypertensive Disorders in Pregnancy Case Study- Pregnant Woman with Preeclampsia Terms to Know Gestational Hypertension Chronic Hypertension Preeclampsia Eclampsia HELLP Syndrome DIC (disseminated intravascular coagulation) Gestational hypertension- occurs after 20 weeks of pregnancy Chronic hypertension- occurs before 20 weeks or pre-pregnancy Preeclampsia- before a seizure Eclampsia- aftetr a seizure

Case Study Sarah is an 18 year old primigravida at 29 weeks gestation. She is African American. She weighs 210 pounds with a BMI of 31. She has a negative health history for chronic conditions. She is in her senior year of high school. Her mother is a single parent and Sarah helps care for her 3 younger siblings at home. The father of the baby is involved and supportive. Her glucose tolerance test was borderline at 118. She presents for her routine prenatal care visit. Assessment includes a blood pressure of 148/95 while sitting and urine dipstick for 1+ protein. Questions: What further testing should be performed on Sarah at this time? What risk factors does Sarah have for hypertensive disorders of pregnancy? How would the nurse explain preeclampsia to Sarah? When assessing Sarah in future visits, what signs must her nurse be alert for that her mild preeclampsia may be progressing to a more advanced stage? What clinical manifestations would indicate a worsening condition? High Risk Pregnancy Hypertension concerns Hypertension during pregnancy is considered high risk. Pathophysiology Definition: A hypertensive d/o of pregnancy characterized by HTN A systolic bp of greater than or equal to 140 mm Hg, or a diastolic bp of greater than or equal to 90 mm Hg occurring after 20 weeks of pregnancy A condition in which HTN develops during the last half of pregnancy in a woman who previously had normal bp Relatively common, affecting 5% to 10% of all pregnancies Many risk factors may be inter-related, such as obesity & pre-pregnancy diabetes Gestational Hypertension Systolic Blood Pressure >140, Diastolic Blood Pressure >90, Mean Arterial Pressure >105 in 2 separate measurements at least 4-6 hours apart. Onset of hypertension after 20 weeks gestation without proteinuria. Transient Hypertension occurs when Blood Pressure is elevated without other signs of preeclampsia and returns to normal within 12 weeks after birth. Chronic Hypertension develops before pregnancy, or before week 20 of gestation. Usually doesn't resolve within 12 weeks after birth. Benign condition with good pregnancy outcomes.

Chronic Hypertension Hypertension with onset at <20 week gestation or before pregnancy. Increased risk of poor fetal growth or fetal demise Effects 5% of pregnant women

Increased incidence of placental abruption (due to increased pressure) Superimposed preeclampsia Increased perinatal mortality Fetal growth restriction Small for gestational age fetus (SGA)

Treatment for Chronic Hypertension Methyldopa (Aldomet) is drug of choice Maintain blood pressure below 150 - 160 SBP and 100 - 110 DBP Bed rest Postpartum monitoring should include assessment for: Pulmonary edema Renal failure Heart failure Encephalopathy Methyldopa or hydralazine are drugs of choice for breastfeeding moms Counseling of woman and family related to lifestyle changes that include: Decreased sodium intake Exercise as appropriate Consumption of well-balanced diet Limiting caffeine intake Avoiding alcohol and tobacco Losing weight in preconception period Blood pressure monitoring Fetal kick counts Weight gain can increase HTN so you want them to lose weight before getting pregnant. Chronic Hypertension with superimposed preeclampsia Twenty-five percent of women with chronic hypertension will develop preeclampsia or eclampsia Hypertension at <20 week gestation with new onset proteinuria Hypertension and proteinuria at <20 week gestation. Sudden increase in proteinuria Sudden increase in blood pressure after previously well-controlled Thrombocytopenia (platelet count <100,000) Increased Liver Function tests (LDH, AST, ALT, uric acid)

Changes in Normal Pregnancy Vascular volume & CO increase significantly Peripheral vascular resistance decreases because of the effects of certain vasodilators, such as prostacyclin (PGI2), PGE, & endothelium-derived relaxing factor (EDRF) Bp does not rise

Changes in Preeclampsia Pregnancy Peripheral vascular resistance increases because some women are sensitive to angiotensin II May also have a decrease in vasodilators: The ratio of thromboxane (TXA2) to PGI2 (prostacyclin) increases TXA2 TXA2, produced by the kidney & trophoblastic tissue, causes vasoconstriction & platelet aggregation (clumping) PGI2, produced by placental tissue & endothelial cells, causes vasodilation & inhibits platelet aggregation Vasospasm decreases the diameter of blood vessels, which results in endothelial cell damage & decreased EDRF Vasoconstriction also results in impeded blood flow & elevated bp As a result, circulation to all body organs, including the kidneys, liver, brain, & placenta is decreased S/S of preeclampsia: Blurred vision (or double vision), decreased urine output (oliguria), protein in urine, bruising on the liver causing epigastric pain Preeclampsia Pregnancy specific syndrome Hypertension develops after 20 weeks gestation in a previously normotensive woman and is accompanied by proteinuria. Vasospastic, systemic disorder with a clinical continuum from mild to severe. - HELP syndrome- will experience nausea and vomiting (due to the liver involvement) - It makes the vessels spasm and is systemic. Can be mild to severe. Proteinuria is defined as >30mg/dl (>1+ on urine dipstick) in at least 2 random urine samples collected at least 6 hours apart. Hyperuricemia is a uric acid level of >6mg/dl. Both of these are indicators of glomerular damage in the kidneys Mild preeclampsia is hypertension with proteinuria but without organ dysfunction. Severe preeclampsia is defined as systolic blood pressure >160, diastolic blood pressure >110, and proteinuria >2g/24hr or >2+ on dipstick and multiorgan involvement.

Symptoms of preeclampsia include: o oliguria (pregnant women normally pee a lot) o cerebral disturbances (i.e. altered level of consciousness, confusion, headache) o visual disturbances (i.e. blurred vision, diplopia) o hepatic involvement (epigastric pain, RUQ pain,impaired Liver Function Tests/elevated liver enzymes) o thrombocytopenia (Platelet count <100,000) o pulmonary edema due to increased edema and increased capillary permeability o intrauterine growth retardation (IUGR) due to decreased placental perfusion.

Risk factors for developing preeclampsia There are currently no reliable tests available for routine screening for the prediction of developing preeclampsia. Primigravida Less than 20 years or greater than 40 years of age Multiple gestation (twins) Hydatiform moles (molar pregnancy- abnormal cells proliferate quickly; never form into a fetus) History of infertility treatments - They just treat the symptoms b/c we really dont know exactly what causes it. - These are at higher risk of development. Possibly change in partners in multiparous women. Family history of preeclampsia Rh incompatibility Obesity

African American ethnicity Insulin resistance Limited sperm exposure with the same partner Preeclampsia in previous pregnancy Pregnancy after donor insemination, oocyte donation, embryo donation Maternal infections - New partners increase risk (you start over with the risk of a first pregnancy). Clinical tests for preeclampsia: Nonstress test (NST) Biophysical profile (BPP) Ultrasonography for fetal well-being and uteroplacental perfusion Complete Blood Count (CBC) including platelet count Clotting studies (bleeding time, PT, PTT, and fibrinogen) - 20 min. is usually the minimum amount of time they will monitor for a NST. - BPP- done via ultrasound - Look at placenta over ultrasound to see if blood is perfusing the placenta. - Clotting time- looking for DIC Liver enzymes (lactate dehydrogenase (LDH), AST, ALT) Chemistry panel (BUN, creatinine, glucose, uric acid)- looks at renal function Type and screen Urine dipstick with 24 hour urine collection for protein if protein >2-3+ on dipstick - Type and screen- need to know moms blood and Rh type to make sure there are no antibodies. Case Study (cont)

Because Sarahs preeclampsia is mild at this point, her health problem will be managed as an outpatient-home care basis. She is instructed to record her daily health status in a diary.

Questions What should the nurse instruct Sarah to include in her diary? What are Sarahs learning needs with regard to the recommendation that she maintain a daily diary of her health and well-being? Describe the major components of Sarahs care management at home. State three priority nursing diagnoses related to Sarahs health problem and their impact on her pregnancy and lifestyle. Management of Mild Preeclampsia Stable BP, urine protein <300mg in a 24 hour collection and no subjective complaints Fetal/maternal well-being assessment 2-3 times per week to include weight, urine dipstick protein, BP measurement, and fetal kick counts. NST 1-2 times/week, BioPhysical Profile prn, Ultrasound q3 weeks to assess for fetal growth. Maternal bedrest in lateral recumbent position to facilitate uteroplacental perfusion - Subjective complaints- double vision, epigastric pain. - The used to recommend specifically left side but really they just want you on your side (left or right). Diet recommendations are the same as for pregnancy with emphasis on maintaining optimum fluid volume. Bathroom privileges recommended to prevent complications of bedrest that include cardiovascular deconditioning, diuresis with fluid, electrolyte, and weight loss, muscle atrophy, and psychologic stress. - Drink a lot of water. - Bathroom privileges helps reduce some of the complications of bedrest. Case Study (cont) At her 33 week visit, Sarahs blood pressure is 160/105. Her urine dipstick is positive for 3+ protein. Sarah complains of headache that is unrelieved by Tylenol and rest. She complains of blurred vision, and epigastric pain. She has had a weight gain of 8 pounds in 1 week and 2+ edema is noted to bilateral lower extremities. Sarah is sent to Labor and Delivery for evaluation for preeclampsia. Questions What assessments will be performed on the labor and delivery unit for Sarah? What nursing diagnoses are appropriate at this time? What lab tests might be ordered?

Case Study (cont) Sarah is admitted to the hospital for collection of 24 hour urine specimen, continuous fetal monitoring, and serial blood pressures. - CBC with platelets, renal studies, liver function tests, and clotting studies Questions What nursing interventions should be instituted at this time? What are the risks to Sarah and to her baby? What medical interventions are likely to be ordered? 1) Laying on side in the bed, hourly bp check (at least), keep lights low, decrease noise and visitors, decrease stimulation to prevent seizures Case Study (cont) Sarahs 24 hour urine shows 2400mg of protein. Her uric acid level is 6.5. Her platelet count is 92,000. She is complaining of new onset of nausea and vomiting with epigastric pain. Questions What is the most likely diagnosis for Sarah at this time? What medical management is most appropriate for Sarah at this time? What nursing interventions are appropriate? What nursing diagnoses should be incorporated into her care plan? 1) HELLP syndrome (b/c of the 92,000 platelets) 2) 33 weeks is viable; will probably start an induction of labor HELLP syndrome H - hemolysis EL - Elevated Liver Enzymes LP - Low Platelets (<100,000) Without hemolysis (normal PT/PTT and Bleeding Time), the syndrome is termed ELLP. - H- why we look at clotting studies (PT/PTT and bleeding times). Management of Preeclampsia A pregnant woman at 36 weeks of gestation is admitted to the high risk pregnancy unit with preelampsia. Assessment findings indicate severe preeclampsia. The nurse should: A. expect a maintenance dose of intravenous magnesium sulfate to be between 1 and 2 g per hour. B. assign the woman to a semiprivate room next to the nurses station. C. offer her a diet that is high in complex carbohydrates and low in salt and protein. D. encourage the woman to maintain a semi-Fowler position when in bed B. Too much stimulus C. dont lower salt intake with preeclampsia D. Lateral recumbent position

HELLP Syndrome (cont) Occurs in 20% of women with severe preeclampsia More common in older, Caucasian, multiparous women. 90% report malaise, 65% report epigastric/RUQ pain, 50% report N/V. May or may not have signs and symptoms of severe preeclampsia. Complications include: Renal failure Pulmonary edema Ruptured liver hematoma DIC Placental abruption Preterm birth

Complications of Severe Abruption

The only cure for HELLP syndrome is delivery. Case Study Sarahs diagnosis has been advanced to HELLP syndrome. Magnesium Sulfate is initiated with a 4gm bolus followed by 2gm/hr continuous infusion. Questions State the primary expected outcome associated with Magnesium Sulfate infusion. What nursing interventions should be incorporated into Sarahs plan of care?

What nursing assessments must be completed for Magnesium Sulfate infusion? Identify the signs Sarah would exhibit for Magnesium toxicity. What emergency readiness measures should be implemented and available related to Sarahs current health status? Is delivery recommended at this time? - Magnesium sulfate decreases the seizure threshold (by quieting the nerve endings; it does NOT lower the blood pressure)!!!!!!! KNOW THIS - Interventions: decrease stimulus, seizure precautions (head and bed rails, have an oral airway), Calcium gluconate is the antidote - Assessments done when patient is on magnesium (it relaxes everything): on a 30 minute basis assess respiratory rate and pulse ox!!! O2 sat should be greater than 92% (if not, the patient may be magnesium toxicity), assess for Clonus (hyperflex the foot and let go, as it moves back you will feel it beating) - To assess for mag toxicity ask: Is she n/v? Confusion? Shortness of breath? - We are recommending delivery at this time!!! 2. The nurse performs an assessment of a client at 34 weeks of gestation who is being treated with magnesium sulfate for severe preeclampsia. Which of the following signs and symptoms would cause the nurse to discontinue the magnesium sulfate infusion? a. The client is complaining of nausea. b. The fetal heart rate is 120 beats per minute. c. The clients respiratory rate is 8 breaths per minute. d. The clients hourly urine output is 35 ml/hour. Correct answer: C Nausea- a side effect of magnesium that we treat Fetal heart rate of 120 is normal 35 ml/hour is an adequate urine output. Management of Severe Preeclampsia and HELLP syndrome Hospital or tertiary care center placement <32 weeks gestation - initial observation period and conservative management if possible 32-36 weeks gestation - labor induction is usually performed. Vaginal birth if possible. <34 weeks gestation - antenatal corticosteroids to promote fetal lung maturity if delivery can be delayed 48 hours - If you have started magnesium, it is hard to get a person in labor so vaginal birth is difficult. Severe preeclampsia and HELLP syndrome (cont) Control of blood pressure with antihypertensive medication Hydralazine remains drug of choice Other options include: Labetalol, nifedipine, verapamil, and oral methyldopa Magnesium sulfate: 4-6 gram bolus, then 2 grams per hour.

Therapeutic magnesium levels are 4-7meq/L Toxicity signs: nausea, feeling of warmth, flushing, muscle weakness, decreased reflexes, slurred speech. Calcium gluconate is the antidote for magnesium toxicity (1g slow IVP over 3 minutes Eclampsia Onset of seizure activity or coma with a diagnosis of preeclampsia. May develop during pregnancy, labor, or 72 hours postpartum Premonitory symptoms and signs include headache, severe epigastric pain, and hyperreflexia. Convulsions may occur in stable woman without warning with only minimal blood pressure elevations. Increased hypertension and tonic contraction of all body muscles precede tonicclonic convulsions followed by hypotension and coma - Hyperreflexia= 3+ or 4+ deep tendon reflex Immediate goal of care is ensuring a patent airway Turn woman onto side to prevent aspiration of vomitus and supine hypotension syndrome Note time and duration of convulsion Suction food/fluid from glottis past convulsion Provide 10 L of oxygen via facemask - Have suction at bedside (only suction food/fluid AFTER the convulsion has completed; NEVER while she is seizing) - Baby does not get blood flow during a seizure. Magnesium bolus up to 6 grams if magnesium not already infusing Valium (diazepam) or Ativan (lorazepam) may be administered if magnesium limit reached Chest x-ray and possibly ABG to rule out aspiration Assessment of fetus, uterine activity, and cervical status to check for imminent delivery - Valium is faster. Ativan works longer. - The cervix may be fully dilated following the seizure. Assistance with change of gown and hygiene for spontaneous bowel movement, void, or rupture of membranes during seizure Lab work for renal and liver function, coagulation system, and drug levels Support woman and family. Keep them informed

Anticonvulsant Medications Magnesium Sulfate IV is given as a continuous drip to prevent eclampsia in patients with severe disease. It is not an antihypertensive. Also given during eclampsia to stop the seizure. Valium or Ativan can be used to stop a seizure.

DIC

Definition: Disseminated Intravascular Coagulation (DIC) is the overactivation of the clotting cascade and fibrinolytic system resulting in depletion of platelets and clotting factors. It is a diffuse pathologic form of clotting. It is always a secondary diagnosis. - If you find a patient with DIC, look for the underlying cause. It is a symptom NOT a disease. Conditions that may lead to DIC in pregnant women: Abruptio placentae Retained dead fetus Amniotic fluid embolus Severe preeclampsia HELLP syndrome Gram-negative sepsis - Amniotic fluid embolus- rare; when membranes rupture, you get a bolus of amniotic fluid that is an embolus Physical exam findings: Spontaneous bleeding from gums, nose Oozing, excessive bleeding from venipuncture site, intravenous access site, or insertion site of urinary catheter Petechiae Other signs of bruising Hematuria GI bleeding Diaphoresis - Spontaneous bleeding from nose can also be due to low platelets (depends of severity and if there are other areas bleeding as well). - GI bleed- vomiting blood or bloody stools Laboratory screening results: Platelets - decreased Fibrinogen - decreased Factor V (proaccelerin) - decreased Factor VIII (antihemolytic factor) - decreased - Fibrinogen in pregnancy is usually increased. You are gonna see levels over 400!! 350 is normal in non-pregnant women. Prothrombin time - prolonged Partial Prothrombin time - prolonged Fibrin degradation products (FSP) - increased D-Dimer test (specific Fibrin degradation fragment) - increased Red blood smear - fragmented red blood cells

Medical Management: Treat the underlying cause Replace essential clotting factors (often end up needing cryoprecipitous???) Replace fluid volume

DIC Nursing interventions Awareness of risk factors Careful and thorough assessment for signs of bleeding (petechiae, bleeding from injection sites, hematuria) Strict monitoring of urine output (Foley catheter recommended) Frequent VS assessment (can alert you to internal bleeding; ex. elevated pulse and decreased bp) Position pregnant women in side-lying tilt to maximize uterine blood flow Oxygen via FM at 8-10 L per minute or per hospital protocol/order Safe administration of blood/blood products Fetal monitoring (if she hasnt delivered yet) Meet educational and emotional needs of patient and family

Nursing Assessment and Management of Hypertensive Disorders of Pregnancy Initial nursing assessment should include: complete medical history that includes history of diabetes, renal disease, hypertension, family history of hypertensive disorders, diabetes, and other chronic conditions social history including marital status, nutritional status, cultural beliefs, activity level lifestyle behaviors such as smoking and drug or alcohol use. Complete baseline examination to include blood pressure, edema, deep tendon reflexes, and ankle clonus If patient has a hx of metadone use, do not give the patient Nubain (it will cause severe pain). Variable influences on BPs Cuff size Repeated inflations of cuff Maternal position Pain and anxiety Medications Poor technique Cuff variances - If sitting up or laying flat, it will be increased. Lay them on their side. - Meds can decrease or increase bp.

Nursing Assessment, and Management of Hypertensive Disorders of Pregnancy (cont) Ongoing nursing assessment should include: Blood pressures, edema, deep tendon reflexes and ankle clonus Presence of headache, epigastric pain, and visual disturbances Uterine tenderness and tone, presence of vaginal bleeding (earliest signs of placental abruption) - Put your hands on their belly. Feel through a contraction to be sure that it is relaxing between contractions.

Nursing Diagnoses: Anxiety, related to preeclampsia and its effect on woman and infant Deficient knowledge related to management of preeclampsia Ineffective family coping related to restricted activity and concern over a complicated pregnancy, financial concerns, transfer of the woman to a tertiary care center for more intensive management. Powerlessness related to inability to prevent or control condition and outcomes Ineffective tissue perfusion related to hypertension, cyclic vasospasms, cerebral edema, hemorrhage Risk for injury to fetus related to uteroplacental insufficiency, preterm birth, abruption placentae

Risk for injury to mother related to CNS irritability secondary to cerebral edema, vasospasm, decreased renal perfusion, magnesium sulfate and antihypertensive therapies.

Case Study (cont) Forty-eight hours after admission to the hospital, Sarahs baby girl is delivered via C-section. Questions What potential postpartum complications should the nurse be aware of? What nursing assessments should continue postpartum? How long should Sarah expect to remain in the hospital postpartum? What nursing diagnoses should be incorporated into Sarahs plan of care at this time? What medical interventions should Sarahs nurse expect to be ordered on Sarah postpartum? - hemorrhage, seizures, magnesium effects - Blood pressure, neuro assessment, DTRs, clonus, lungs to check for pulmonary edema, vital signs including pain - Normally from a c-section is 3-5 dayswith magnesium you can add 1 day b/c they are on L&D longer. They will be monitored until bp returns to pre-pregnant state. - Magnesium for 24 hours; foley catheter (at least 30 cc/hour); watch fluid intake and limit to about 125 cc/hr (prevent pulmonary edema). Postpartum care Symptoms of preeclampsia and eclampsia usually resolve within 48 hours Resolution is manifested by diuresis, usually within 24 hours HELLP syndrome usually resolves within 72-96 hours (watch platelet counts to assure they come back up to normal) Nursing care in immediate postpartum period includes: Careful assessment of vital signs, intake and output, DTRs, level of consciousness, uterine tone, and lochia flow Continued Magnesium infusion for 12 - 24 hours postpartum Seizure precautions Assessment and documentation of Preeclamptic symptoms such as headache, visual disturbances, or epigastric pain. Postpartum hemorrhage Oxytocin (pitocin), hemabate, or cytotec Methergine and ergotrate are contraindicated due to side effect of increased blood pressure. Emotional support to woman and family. Inclusion of family in discharge planning and teaching - 1st drug of choice for hemorrhage is Pitocin! - Do NOT use Methergine or ergotrate with postpartum hemorrhage!!!!!

Maternal and fetal morbidity and mortality Hypertensive disorders of pregnancy are the second leading cause of maternal and prenatal morbidity and mortality. Fifteen percent of pregnancy related deaths are from hypertensive disorders of pregnancy. There is a higher incidence of death in African American women. - 15% of deaths that occur during pregnancy are r/t hypertensive disorders. Risks to Mother Placental abruption Thrombocytopenia DIC Pulmonary edema Adult Respiratory Distress Syndrome (ARDS) Aspiration Pneumonia Cerebral hemorrhage Increased risk for C-section Mortality in Mothers Placental abruption (bleeding that cannot get under control) Eclampsia Liver rupture can be due to a hematoma If someone is complaining of epigastric pain, do not rub that area! Risks to Fetus Preterm birth Respiratory distress syndrome Chronic lung disease Intraventricular hemorrhage Sepsis Necrotizing enterocolitis Failure to Thrive Blindness Neurologic disabilities: Cerebral Palsy Asthma Vision/hearing loss Behavior problems Attention Deficit Hyperactivity Disorders Decreased levels of academic achievement Death Increased incidence with HELLP syndrome

Significance of Trauma Special considerations for mother and fetus

Physiologic alterations of pregnancy Presence of fetus Fetal survival depends on maternal survival Pregnant woman must receive immediate stabilization and care for optimal fetal outcome Effect of trauma on pregnancy influenced by: Length of gestation Type and severity of trauma Degree of disruption of uterine and fetal physiologic features

Management of Trauma in Pregnancy Trauma caused by accidents and violence is a common and important complication of pregnancy, involving 5-20% of pregnancies. Recent studies demonstrate that trauma is more likely to cause maternal death than any other medical complication of pregnancy. - Violence is common during pregnancy (often even increases). - Trauma is first cause of death in pregnant women (hypertensive disorders is 2nd common cause). Incidence According to the Committee on Trauma of the American College of Surgeons, accidental injury occurs in 6% to 7% of all pregnancies and is the most common cause of death in the gravid patient. The causes of maternal injury are as follows: - 42% MVAs - 34% falls - 18% assaults - < 1% burns. Factoids - One in twelve inner-city women are battered during pregnancy - Closed head injury and hemorrhage are the most common causes of traumatic maternal death (85%). - 8 of 10 pregnancies complicated by maternal traumatic shock result in fetal death. - Placental abruption is the most common cause of traumatic fetal death with maternal survival Patient Management Most common cause of fetal death is maternal shock When maternal shock is present, fetal mortality is 80% Resuscitate the mother you resuscitate the baby! Assessment Primary Survey A irway with Spinal Precautions B reathing C irculation

D isability E xposure and Examine

Airway and Breathing Supplemental Oxygen All pregnant trauma patients should receive supplemental oxygen Fetus is extremely sensitive to hypoxia Oxygen reserve is significantly diminished in the pregnant patient Pregnancy does NOT affect the decision to intubate risk of aspiration RSI medications in pregnancy is not well studied, but no absolute contraindications exist. Circulation WARMED crytalloids through large bore IVs Rule out occult sources of bleeding, maternal bleeding is maintained at the expense of fetal blood flow RH Negative blood only! Fetal assessment done ASAP in secondary survey of mother. Assessment Secondary Treat early! Highflow Oxygen Left tilt if possible (vena cava syndrome) if greater than 24 weeks. Aggressive Fluid Replacement History Mechanism Direct Abdominal Trauma Weapons Seat Belt Usage? Proper Placement? Did airbag deploy? LMP / EDC Uterine contractions Fetal Movement Premature Rupture of Membranes Vaginal Bleeding - If mom is not available to give her history, ask a family member or witness. Physical Abdominal Exam Inspect for ecchymoses, especially across lower abdomen Palpate for uterine contractions Gestational age can be estimated by fundal height At umbilicus 20 weeks

 After 20 weeks, fundal height measured in centimeters equals gestational age in weeks Fetal Heart Tones Doppler or Ultrasound 120 -160bpm Should be able to auscultate by 20 weeks gestation Variability may not be present until as late as 28 weeks (neurological system may not yet be intact) Abdomen Abdominal exam is relatively unreliable because of peritoneal stretching in third trimester decreases the density of afferent nerve fibers. Pelvic Sterile Speculum Only in absence of vaginal bleeding Test fluid for pH pH 7 indicates amniotic fluid pH 5 indicates vaginal secretions If it turns blue, they are ruptured. Lateral tilt

Pelvic Vaginal lacerations may signify an open pelvic fracture Bone fragments in vagina signify open pelvic fracture Bimanual Exam In general, should be done by OB Performed in setting where emergency C-Section can be performed (not in the ER; should be on L&D)

 You will treat someone different if fetus is more than 24 weeks (viable) as opposed to non-viable. (SEE FLOW CHART IN PPT) Lab Testing Trauma Panel Rh type PT/PTT Kleihaure-Betke Used to detect fetal to maternal hemorrhage Determine dose of RhoGAM Only used in major trauma should not be a routine test Toxicology screening any drugs in the system? D-dimer - K-B test: to see if fetal and maternal cells are mixing; only significant in a Rh negative mom - D-dimer: looking at DIC stuff Imaging Do not delay radiological examination due to pregnancy!!! Ultrasonography Fetal viability FAST MRI No adverse effects reported, but very little data exists Usually they will order an ultrasound to determine fetal viability. Cardiotocographic Monitoring (Fetal Monitor) Efficacy of monitoring begins at 20-24 weeks gestation Fetal distress may be the first sign of maternal hemodynamic compromise because the mother will maintain her vital signs by shunting blood away for the relatively low-resistance uterus. - Will see fetal distress BEFORE you see moms distress. Minimum of 4 hours of monitoring is suggested, even after minor abdominal trauma Monitoring for 24 hours is suggested with major trauma or signs of obstetric compromise Procedures Perimortem cesarean delivery Must be performed within 4-5 minutes of maternal cardiac arrest Rapid delivery large incisions Midline incision from xiphoid to pubis Remove neonate, perform suctioning, clamp and cut cord, and resuscitate neonate. Continue maternal resuscitation

Complications Rupture of amniotic membranes Chorioamnionitis Preterm labor Cord prolapse Retroperitoneal Hemorrhage (not as noticeable; bleeding in to the back of the abdomen) Uterine Rupture Fetal mortality close to 100% Maternal mortality of 10% is usually a result of associated injuries Placenta Abruption 38-66% of major injuries, 2-4% in minor injuries Most common cause of fetal death when the mother survives the trauma. May be delayed as long as 24-48 hours Fetal distress is the most reliable indicator of active or impending abruption Ultrasound is insensitive and causes more than 50% of abruptions to be missed Abruption can lead to consumptive coagulopathy Mechanism of Abruption Uterus thrown forward against anterior abdominal wall + body pushed down into seat Increase IUP to 550 mm Hg! Torso thrown forward crushing uterus - Even with Pitocin you dont usually get over 100 mm Hg of pressure. With trauma it can increase up to 550 mm Hg!! Shear Effect Enough negative pressure in posterior uterus to pull the placenta off the uterine wall (contrecoup injury) Very high positive pressure noted in anterior parts of the uterus Prognosis Penetrating injury has a perinatal mortality of 40-70% Maternal mortality is less than the non pregnant patient due to protective effect of the uterus In one urban study, violence accounted for 57% of maternal deaths (48% homicides, 9% suicides) Another study reported 7% maternal mortality rate in serious MVCs Seat Belt Recommendations Always wear both the lap and shoulder safety belts. Place the lap belt under your abdomen, as low on your hips as possible and across your upper thighs. Never place the belt above your abdomen. Place the shoulder belt between your breasts.

 If your vehicle is equipped with an air bag, it is very important to wear your shoulder and lap belts. In addition, always sit back at least 10 inches away from the site where the air bag is stored. On the driver's side, the air bag is located in the steering wheel. When driving, pregnant women should adjust the steering wheel so that it is tilted toward the chest and away from the head and abdomen