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High-Risk Births & Obstetric Emergencies

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1 High-Risk Births & Obstetric Emergencies
Chapter 36

Interference with normal processes & patterns of labor/birth resulting in maternal or fetal jeopardy. Preterm labor; dysfunctional labor patterns; prolonged labor; hemorrhage – uterine ruputure/inversion; amniotic-fluid embolus.

3 Dysfunctional Labor: Possible Causes:
Catecholamines (response to anxiety/fear), increase physical/psychological stress, leads to myometrial dysfunction; painful & ineffective labor. Premature or excessive analgesia, particularly during latent phase. Maternal factors. Fetal factors. Placental factors. Physical restrictions (position in bed). Maternal Factors: Pelvic ctx Uterine tumors (myomas, carcinoma) Congenital uterine anomalies (bicornnate uterus) Pathological contraction ring (Bandl’s ring) Rigid cervix, cervical stenosis/stricture. Hypertonic/hypotonic ctx. Prolonged ROM (intrauterine infection may have caused ROM or may follow rupture). Prolonged 1st or 2nd stage. Medical conditions: diabetes, hypertension. FETAL FACTORS: Macrosomia Malposition/malpresentation Congenital anomaly (hydrocephalus, anencephaly) Multifetal gestation (ex-interlocking twins) Prolapsed cord Posterm PLACENTAL FACTORS: Placenta previa; inadequate placental function with ctx.;abruptio placentae; placenta accreta.

4 ASSESSMENT: Antepartal history. Emotional status. Vital signs, FHR.
Contraction pattern (frequency, duration, intensity). Vaginal discharge. GOAL = to minimize physical / psychological stress during labor/birth. Emotional support. Reinforce relaxation techniques. Support couple’s effective coping techniques / mechanisms. Encourage verbalization of anxiety / fear / concerns. Explain all procedures – to minimize anxiety / fear, encourage cooperation / participation in care. Provide quiet environment conducive to rest. CONTINUOUS MONITORING OF MATERNAL / FETAL STATUS & PROGRESS THROUGH LABOR: To identify early signs of dysfunctional labor, fetal distress. To facilitate prompt, effective treatment of emerging complications. MINIMIZE EFFECTS OF COMPLICATED LABOR ON MOTHER, FETUS: Position change: lateral Sims’ to reduce compression of inferior vena cava. Oxygen per mask, as indicated. Institute interventions appropriate to emerging problems.

5 Preterm Labor: Occurs after 20 weeks gestation and before 38 weeks.
Causes may be from maternal, fetal, or placental factors. Prevention: Primary: close observation and eduction in S&S of labor. Secondary: prompt, effective Rx of associated disorders. Tertiary: suppression of preterm labor. COEXISTING DISORDERS: Infections that may cause PROM. Hypertension (preeclampsia, eclampsia) Uterine overdistention (hydramnios, multifetal gestation) Maternal diabetes, renal or cardiovascular disorder, UTI. Severe maternal illness (ex-pneumonia, acute pylenephritis) Placental abnormalities (previa, abruption) Iatrogenic: miscalculated EDC for repeat C/S. Fetal death. Incompetent cervical os (small percentage). Uterine anomalies (rare): intrauterine septum, bicornate uterus. Positive fetal fibronectin assay (protein found in fetal tissue, membranes, amniotic fluid & decidua) found in cervical / vaginal fluid 1st half of pregnancy & normally absent through mid to late pregnancy).

6 Tertiary: suppression of preterm labor
Bedrest. Position: side-lying – to promote placental perfusion. Hydration. Pharmacological: betaadrenergic agents to reduce sensitivity of uterine myometrium to oxytocic & prostaglandin stimulation; increase bld flow to uterus. Pt may be maintained at home with adequate follow-up & health teaching.

7 CONTRAINDICATIONS: for suppression of labor
Placenta previa or abruptio placenta. Chorioamnionitis. Erythroblastosis fetalis. Severe preeclampsia. Severe diabetes (brittle). Increasing placental insufficiency. Cervical dilation of 4 cm or more. ROM (depends on cause & if sepsis exists).

8 Nursing Assessment: PTL
Maternal VS. Response to medication: Hypotension Tachycardia, arrhythmia Dyspnea, chest pain Nausea & vomiting Signs of infection: Increased temperature Tachycardia Diaphoresis Malaise

9 Emotional status: denial, guilt, anxiety, exhaustion.
Signs of continuing & progressing labor: Effacement Dilation Station (vaginal exam ONLY if indicated by other signs of continuing labor progress) Status of membranes. FHR, activity (continuous monitoring). Ctx: frequency, duration, strength.

10 Report PROMPTLY to MD: Maternal pulse of 110 or more.
Diastolic pressure of 60 mmHg or less. Increase in maternal temperature. Respirations of 24 or more; crackles (rales). Complaint of dyspnes. Contractions: increasing frequency, strength, duration, or cessation of ctx.

11 Intermittent back and thigh pain. Rupture of membranes.
Vaginal bleeding. Fetal distress. IF LABOR CONTINUES: GOAL = facilitate infant survival; emotional support; support comfort measures; health teaching. NOTE: Analgesics contraindicated – to prevent depression of fetus / neonate. HEALTH TEACHING: Discuss the need for an episiotomy, possibility of outlet forceps-assisted birth (to reduce stress on fetal head). Prepare for c/s: to reduce possibility of fetal intraventricular hemorrhage (usually under 34 weeks). Rationale for avoiding use of medications to reduce contraction pain.

12 Dysfunctional Labor Pattern
Hypertonic labor Hypotonic labor Precipitate labor level Chapter 26

Increased resting tone of uterine myometrium; diminished refractory period; prolonged latent phase. Nullipara: more than 20 hours. Multipara: more than 14 hours. Etiology: unknown. Theory – ectopic initiation of incoordiante uterine ctx. Assessment: Onset (early labor)

14 Signs of fetal distress:
Contractions: Continuous fundal tension, incomplete relaxation. Painful. Ineffectual – no effacement or dilation. Signs of fetal distress: Meconium-stained fluid. FHR irregularities. Maternal VS. Emotional status. Medical evaluation: to rule out CPD. Vaginal examination, x-ray pelvimetry, ultrasonography.

15 Interventions with Hypertonic Dysfunction:
Short-acting barbiturates (to encourage rest, relaxation). IV fluids (to restore / maintain hydration & fluid-electrolyte balance). If CPD – c/s. Provide emotional support. Provide comfort measures. Prevent infection (strict aseptic technique). Prepare patient for c/s if needed.

After normal labor at onset, ctx diminish in frequency, duration, & strength. Lowered uterine resting tone; cervical effacement & dilation slow / cease. Etiology: Premature or excessive analgesia / anesthesia (epidural, spinal block). CPD. Overdistention (hydramnios, fetal macrosomia, multifetal pregnancy). Fetal malposition / malpresentation. Maternal fear / anxiety.

17 Assessment: Onset (latent phase & most common in active phase).
Contractions - normal previously, will demonstrate: Decreased frequency. Shorter duration. Diminished intensity (mild to moderate). Less uncomfortable. Cervical changes – slow or cease. Signs of fetal distress – rare. Usually late in labor d/t infection secondary to prolonged ROM. Tachycardia.

18 Maternal VS (elevated temperature) – may indicate infection.
Medical diagnosis – procedures: vaginal examination, x-ray pelvimetry, ultrasonography. To rule out CPD (most common cause). Management: Amniotomy (artificial ROM). Oxytocin augmentation of labor. If CPD, prepare for c/s. Emotional support, comfort measures, prevent infection.

19 Precipitate Labor Labor that progresses rapidly and ends with the delivery occurring less than 3 hours after the onset of uterine activity. Rapid labor and delivery.

20 Fetal Malpresentation and Malposition
Breech presentation Shoulder presentation Face presentation Malpositions Chapter 26

21 Breech Presentations Fetal descent in which the fetal buttocks, legs, feet, or combination of these parts is found first in the maternal pelvis. Labor tends to be longer and more difficult due to a softer presenting part, that does not fill the birth canal completely. Increase risks for fetal outcome.

22 Shoulder Presentation
Fetal descent in which the shoulder precedes the fetal head in the maternal pelvis alone or along with the ftal arm and hand. Vaginally undeliverable.

23 Face Presentation Fetal descent in which hyperextension of the fetal head and neck allows the fetal face to descend into the maternal pelvis, as opposed to flexion that results in fetal vertex presentation. Brow presentation = occurs when the area between the anterior fontanelle and the fetal eyes descends first.

24 Malpositions Persistent occipitoposterior position.
Persistent occipitotransverse position. Result from fetal rotation as the fetus descends through the pelvis. Possible precipitating factors are macrosomia and pelvic abnormalities. Results in increased discomfort (particularly back labor), prolonged, abnormal labor, soft tissue injury, lacerations, or an extensive episiotomy incision.

25 Maternal and Fetal Structural Abnormalities
Cephalopelvic disproportion (CPD) Macrosomia Chapter 26

26 DYSTOCIA: Difficult labor. Causes:
“3 Ps” for mother: Psych, Placenta, Position. “3Ps” for fetus: Power, Passageway, Passenger. POWER: forces of labor (uterine contractions, use of abdominal muscles). Premature analgesia / anesthesia. Uterine overdistension (multifetal pregnancy, fetal macrosomia) Uterine myomas.

27 PASSAGEWAY: Resistance of cervix, pelvic structures.
Rigid cervix. Distended bladder. Distended rectum. Dimensions of the bony pelvis: oelvic contractures. PASSENGER: accommodation of the presenting part to pelvic diameters. Fetal malposition / malpresentation. Fetal anomalies. Fetal size. MALPOSITION / MALPRESENTATION: Transverse lie. Face,brow presentation. Breech presentation. CPD. FETAL ANOMALIES: Hydrocephalus. Conjoined (Siamese) twins. Meningomyelocele.

28 Hazards with Dystocia:
MATERNAL: 1. Fatigue, exhaustion, dehydration. 2. Lowered pain threshold, loss of control. 3. Intrauterine infection. Uterine rupture. Cervical, vaginal, perineal lacerations. Postpartum hemorrhage. FETAL: Hypoxia, anoxia, demise. Intracranial hemorrhage. MATERNAL: d/t prolonged labor. 2. d/t prolonged labor, continued uterine ctx, anxiety, fatigue, lack of sleep. d/t prolonged ROM and frequent vaginal examination. d/t obstructed labor. d/t obstetric interventions. d/t uterine atony or trauma. FETAL: d/t decreased O2 concentration in cord blood. d/t changing intracranial pressure.

29 Placental Abnormalities
Placenta previa Abruptio placentae Other placental abnormalities Chapter 26

30 PLACENTA PREVIA Abnormal placement of placenta so that it partially covers the cervix; dilatation results in bleeding, which can be of hemorrhagic proportions. The placenta is located over or very near the internal cervical os. Severe hemorrhage can result from digital palpation of the internal os. Previa is a serious but uncommon complication, occurring in .3-.5% of pregnancies.

31 Advanced maternal age and multiparity increase the risk.
Painless hemorrhage is symptomatic of previa, often around the end of the 2nd trimester. Clinical diagnosis is reached through ultrasound examination in which the placenta is localized in relationship to the cervix. Manual examination is contraindicated! Management of pregnancy depends on gestational age. If the gestational age is early, an attempt is made to prolong the pregnancy with the intention of optimizing the neonatal outcome. The woman is usually hospitalized to try and avoid preterm labor or hemorrhage, and her mobility is restricted, usually to bed rest at first. Activity will be gradually increased as pregnancy progresses to term. Hemoglobin and hematocrit values are closely monitored, and blood replacement or iron therapy is instituted if anemia is present. Unless an emergency situation arises, delivery is planned for some point after the fetus has reached 36 weeks, and lung maturity. Vaginal delivery would be considered ONLY if the placenta previa were very marginal, the fetal head had descended low enough to act as a tamponade placing pressure against the placenta, active labor had begun, and no other complications were evident. Vag delivery would also be considered if the fetus were dead or had major malformations. In most cases, surgical intervention (C/S) is the delivery method of choice.

32 PLACENTAL ABRUPTION Premature separation of the placenta from the uterine wall; usually results in maternal hemorrhage and fetal compromise. Classified as “partial” or “total”. “Total Abruption” – fetal death is inevitable. “Partial Abruption” – the fetus has a chance of survival. Separation of >50% is incompatible with fetal survival. With an ABRUPTION: There is a hemorrhage into the decidua basalis, which divides, leading to separation of th3e part of the palcenta adjacent to the split. A hematoma may form between the placenta and the uterus. The bleeding then progresses to the edge of the placenta. If the placenta does NOT fully separate from the uterine wall, bleeding can remain concealed.

33 Grading of Placental Abruptions:
Grade I: Slight vag.bleeding & some uterine irritability. Maternal BP is unaffected & there are normal fibrinogen levels. FHR has a normal pattern. Grade II: External bleeding is mild to moderate. The uterus is irritable. Tetanic ctx may be present. Maternal BP is maintained. FHR shows signs of distress. Maternal fibrinogen level is decreased.

34 Grade III: The bleeding may be severe & may be concealed in some instances. Uterine ctx are tetanic and painful. Maternal hypotension may be present. The fibrinogen level is greatly decreased & there are coagulation problems. Diagnosis: may be made by ultrasound, but frequently the diagnosis is made and confirmed at delivery, by inspection of the placenta.

35 Umbilical Cord Abnormalities
Velamentous insertion of the cord Umbilical cord compression Umbilical cord prolapse Chapter 26

36 Velamentous Insertion of the Cord
Condition where the umbilical cord joins the placenta at the edge, rather than the typical insertion in the center. Can result in chronic altered fetal perfusion. Can lead to trauma and compression during L&D, resulting in rupture and hemorrhage.

Cord descent in advance of presenting part; compression interrupts blood flow, exchange of fetal / maternal gases. Leads to fetal hypoxia, anoxia, death (if unrelieved). Etiology: SROM or AROM. Excessive force of escaping fluid (hydramnios). Malposition (breech, compound presentation, transverse lie). Preterm or SGA fetus – allows space for cord descent.

38 Nursing interventions:
Assessment: Visualization of cord outside (or inside) vagina. Palpation of pulsating mass on vaginal exam. Fetal distress – variable deceleration and persistent bradycardia. Nursing interventions: Reduce pressure on cord. Increase maternal / fetal oxygenation (O2 per 8-10 liters). Protect exposed cord (continuous pressure on presenting part to keep pressure off cord). REDUCE PRESSURE ON CORD: Position = knee to chest; lateral modified Sims’ with hips elevated; modified Trendelenburg. With gloved hand, support fetal presenting part.

39 Identify fetal response to these measures, reduce threat to fetal survival: moniotr FHR continuously. Expedite termination of threat to fetus (prepare for immediate vaginal or c/s). Support mother and significant other (try to explain things while mobilizing delivery team).

40 Amniotic Fluid Abnormalities
Polyhydramnios Oligohydramnios Amniotic fluid embolism Chapter 26

41 Summary of Danger Signs During Labor:
Contractions: strong, every 2 min. or less, lasting 90 sec. or more; poor relaxation between ctx. Sudden sharp abdominal pain followed by boardlike abdomen and shock (abruptio placenta or uterine rupture). Marked vaginal bleeding. FHR periodic pattern decelerations – late; variable; absent.

42 Baseline FHR: Amniotic fluid: Maternal hypotension.
Bradycardia (<100 bpm) Tachycardia (>160 bpm) Amniotic fluid: Amount: excessive; diminished. Odor Color: meconium stained or particulate; port-wine; yellow. 24 hr or more since ROM. Maternal hypotension.

Chapter 37

44 Postpartum Hemorrhage:
Definition: More than 500cc of blood loss after vaginal birth. More than 1000cc of blood loss after C/S. Blood loss is often underestimated by up to 50% (ACOG, 1998). Subjective. #1 cause of PP Hemorrhage = Uterine Atony.

45 Risk Factors for PP Hemorrhage:
Uterine Atony: Marked hypotonia of the uterus Overdistended uterus Anesthesia and analgesia Previous history of uterine atony High parity Prolonged labor, oxytocin-induced labor Trauma during labor and birth Overdistended Uterus: Large fetus’ Multiple fetuses Hydramnios Distention with clots Anesthesia and analgesia: Conduction anesthesia Trauma during labor and birth: Forceps-assisted birth Vacuum-assisted birth Cesarean birth

46 Risk Factors for PP Hemorrhage:
Lacerations of the birth canal Retained placental fragments Ruptured uterus Inversion of the uterus Placenta accreta Coagulation disorders Placental abruption

47 Risk Factors for PP Hemorrhage:
Placenta previa Manual removal of a retained placenta Magnesium sulfate administration during labor or postpartum period Endometritis Uterine subinvolution

48 Lacerations: Cervix, vagina, perineum.
Suspected when bleeding continues despite a firm, contracted uterine fundus. Characteristics: bleeding can be a slow trickle, an oozing, or frank hemorrhage. Influencing factors: structural, maternal, fetal Lacerations = the most common cause of injuries in the lower portion of the genital tract. Influencing factors having to do with the Mom: Operative birth Precipitate birth Congenital abnormalities of the maternal soft parts Contracted pelvis Previous scarring from infection, injury or operation Vulvar, perineal, and vaginal varicosities also can cause lacerations Pelvic hematomas can be vulvar, vagtinal or retroperitoneal in origin. Vulvar hematomas are the most common, and generally the most visible. Cervical lacerations usually occur at the lateral angles of the external os. Most are shallow, and bleeding is minimal. More extensive lacerations may extend into the vaginal vault or into the lower uterine segment. Influencing factors having to do with the baby: Size Abnormal presentation Position of the fetus

49 Retained Placenta: Causes: Types:
Partial separation of normal placenta Entrapment of the partially or completely separated placenta by uterine constriction ring Mismanagement of the 3rd stage of labor Abnormal adherence of the entire placenta or a portion of placenta to the uterine wall Types: Nonadherent retained placenta Adherent retained placenta Placental retention because of poor separation is common in very preterm births (20 to 24 weeks gestation). NONADHERENT RETAINED PLACENTA Management: manual separation and removal of placenta Don’t usually need supplemental anesthesia if woman has had regional anesthesia After removal woman is still at risk for severe PPH and infection ADHERENT RETAINED PLACENTA Abnormal adherence of the placenta Cause unknown. Placenta adheres to an area of defective endometrium so that there is no separation between placenta and the decidua. Attempts to remove are usually unsuccessful. Laceration or perforation of the uterine wall may result. Risk for severe PPH and infection. Can be partal or complete. Treatment may include blood replacement and hysterectomy. Degrees of attachement: Placenta accreta = slight penetration of myometrium by placental trophoblast Placenta increta = deep penetration of myometrium by placenta Placenta percreta = perforation of uterus by placenta.

50 Inversion of the Uterus
Rare, but life threatening. (1 in births). May recur with additional births. Contributing factors: Fundal implantation of placenta Vigorous fundal pressure Excessive traction applied to cord Uterine atony Leiomyomas Abnormally adherent placental tissue Most often occurs in multiparous women and with placenta accreta or increta. Presenting signs: Hemorrhage Shock pain

51 Uterine Subinvolution
Causes: Retained placental fragments Pelvic infection Signs and symptoms: Prolonged lochial discharge Irregular or excessive bleeding Hemorrhage Pelvic exam reveals a uterus that is larger than normal and may be boggy

52 Assessing Cardiac Output: PPH
NURSING ASSESSMENTS: Palpation of pulses (rate,quality, equality) Auscultation Inspection Observation Palpation of pulses: Arterial Blood pressure Auscultation: Heart sounds and murmurs Breath sounds Inspection: Skin color, temperature, turgor Level of consciousness Capillary refill Urinary output Neck veins Pulse oximetry Mucous membranes Observation Presence or absence of anxiety, apprehension, restlessness, disorientation

53 Meds used to Rx PP Hemorrhage
Oxytocin (Pitocin) Methylergonovine (Methergine; Ergotrate) Prostaglandin F2 (Prostin / 15M; Hemabate) Pitocin: action – contraction of uterus Side effects = infrewuent; water intoxication; nausea and vomiting Contraindications = none for PPH Nsg considerations = continue to monitor vaginal bleeding and uterine tone Methergine / Ergotrate: Action = contraction of the uterus Side effects = hypertension, nausea, vomiting, h/a Contraindications = hypertension, cardiac disease Nsg consideration = check BP before giving and don’t give if >140/90; continue monitoring vaginal bleeding and uterine tone Prostin / Hemabate: Action = contraction of uterus Side effects = headache, nausea, vomiting, feber Contraindications = asthma, hypersensitivity Nsg consideration = continue to monitor vaginal bleeding and uterine tone

54 Emergency: Hemorrhagic Shock
Assessments: Respirations = rapid and shallow Pulse = rapid, weak, irregular BP = decreasing (late sign) Skin = cool, pale, clammy Urinary Output = decreasing Level of Consciousness = lethargy to coma Mental status = anxiety to coma Central venous pressure = decreased

55 Emergency: Hemorrhagic Shock
Intervention: Summon assistance and equipment Start IV per standing orders (large bore preferable) Ensure patent airway; administer oxygen Continue to monitor status

56 Coagulopathies Idiopathic Thrombocytopenic Purpura: (ITP)
von Willebrand Disease: a type of hemophilia, factor VIII deficiency, most common congenital clotting defect of women in childbearing years. Disseminated Intravascular Coagulation: (DIC) a pathologic form of clotting, diffuse. Includes platelets, fibrinogen, prothrombin, and factors V and VII. Thromboembolic Disease: formation of clot(s) in blood vessels caused by inflammation or partial obstruction of the vessel. DIC: Renal failure is a consequence of DIC, output must be maintained at more than 30 cc/hr. Thromboembolic conditions in PP period: Superficial venous thrombosis = involvement of the superficial saphenous venous system. Deep venous thrombosis = involvement varies but can extend from the foot to the iliofemoral region. Pulmonary embolism = complication of deep venous thrombosis occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs.

57 Postpartum Infection Antepartal factors:
Hx of previous venous trhombosis, UTI, mastitis, pneumonia Diabetes mellitus Alcoholism Drug abuse Immunosuppression Anemia Malnutrition

58 Intrapartal Factors Cesarean birth PROM Chorioamnionitis
Prolonged labor Bladder catheterization Internal fetal or uterine pressure monitor Multiple vaginal exams after ROM

59 Intrapartal Factors (continued)
Epidural anesthesia Retained placental fragments PP hemorrhage Episiotomy or lacerations Hematomas

60 Types of PP Infection Endometritis (most common – usually begins as a localized infection at the placental site, but can involve entire endometrium) Wound infections (c/s incision, episiotomy, repaired laceration site) UTIs (2-4 % of PP women) Mastitis (1% of BF moms, usually 1st)

61 Sequelae of Childbirth Trauma
Uterine Displacement & prolapse Cystocele and Rectocele Urinary Incontinence Genital Fistulas Uterine Displacement & prolapse: Normally: the round ligaments hold the uterus in anteversion, and the uterosacral ligaments pull the cervix backward and upward. Displacement: is a variation of this normal placement. Most common = posterior displacement or retroversion, in which the uterus is tilted posteriorly and the cervix rotates anteriorly. May also be retroflexion and anteflexion. Cystocele and Rectocele: often asymptomatic Usually accompany uterine prolapse, causing the uterus to sag even further backward and downward into the vagina. Cystocele = protrusion of the bladder downward into the vagina that develops when supporting structures in the vesicovaginal septum are injured. Rectocele = the herniation of the anterior rectal wall through the relaxed or ruptured vaginal fascia and rectovaginal septum. It appears as a large bulge that may be seen through the relaxed introitus. Urinary Incontinence: Incidence increases as women age. Stress incontinence can follow injury to bladder neck structures. Urine leaks or spurts out when women laugh, sneeze, cough, or bear down. Genital fistulas: perforations between genital tract organs. Most occur between the bladder and the genital tract; the urethra and the vagina; the rectum or sigmoid colon and the vagina.

62 PP Psychologic Complications
Mood Disorders: with or without psychotic features, if the onset occurs within 4 weeks of childbirth. “Baby Blues” – occurs in up to 70% of PP moms Postpartum Depression Postpartum Psychosis

63 High-Risk Newborn & Family
Chapter 26

64 Infants With Special Needs
Priorities Initiation & maintenance of respirations Establishment of extrauterine circulation Control of body temperature Intake of adequate nourishment Establishment of waste elimination Establishment of an infant-parent relationship Prevention of infection Provision of developmental care for mental & social development Priorities for preterm or posterm infants are the same as for term infants.

65 High-Risk Infants May need resuscitation at birth.
Most institutions require AHA Certification in Neonatal Resuscitation of all personnel at deliveries Requirements may include: Warmth Oxygen Intubation Suctioning

66 Small for Gestational Age (SGA)
Definition: birth weight is below the 10th percentile on an intrauterine growth curve for that age infant. Infant could be preterm, term, or postterm. Have difficulty maintaining body warmth d/t low fat stores; may develop hypoglycemia from low glucose stores.

67 Large for Gestational Age (LGA)
Definition: birthweight is above the 90th percentile on an intrauterine growth chart for that gestational age. Infant could be preterm, term, or postterm. Often are IDM (infants of diabetic mothers), and particularly prone to hypoglycemia or birth trauma.

68 Preterm Infants Definition: born before 37 weeks of gestation.
Particular problems: respiratory function, anemia, jaundice, persistent patent ductus arteriosus, & intracranial hemorrhage. Low-birthweight infants = those weighting grams.

69 Very-low-birthweight infants = those weighing 1000-1500 grams.
Extremely-very-low-birthweight infants = those weighing between grams. All such infants need intensive care from the moment of birth. Risks: neurologic after-effects caused by being so critically close to the age of viability.

70 Postterm Infants Definition: born after 42 weeks gestation.
Particular problems: establishing respirations, meconium aspiration, hypoglycemia, temperature regulation, and polycythemia.

71 Respiratory Distress Syndrome
Commonly occurs in preterm infants from a deficiency or lack of surfactant in the alveoli. Without surfactant the alveoli collapse on expiration & require extreme force for reinflation. Primary Rx: synthetic surfactant replacement at birth by ET tube insufflation, followed by oxygen and ventilatory support.

72 Transient Tachypnea A temporary condition caused by slow absorption of lung fluid at birth. Close observation of the infant is necessary until the fluid is absorbed and respirations slow to a normal rate. C/S infants may be more prone to this because of the excess fluid in their lungs at birth.

73 Meconium Aspiration Syndrome
Occurs when infant inhales meconium-stained amniotic fluid during birth. Results in irritation to the airway (from meconium) & may lead to both airway spasm and pneumonia. Infant needs: oxygen, ventilatory support, & possibly antibiotic until the effects of the airway subside. It is important that they are suctioned before oxygen administration undeer pressure to prevent meconium being forced further into their lungs.

74 Apnea: Definition: a pause in respirations longer than 20 seconds, with accompanying bradycardia. Occurs in preterm infants who have secondary stresses such as: infection, hyperbilirubinemia, hypoglycemia, or hypothermia. Apnea monitors are used to detect this, and infants who are high risk for this are discharged home on a home monitoring program. At birth, infants can suffer from primary apnea and secondary apnea. Primary = a period of halted respirations during the first few seconds of life. Secondary = a weakening of a newborn’s respiratory effort after attempts to initiate respirations with a few strong gasps after 1-2 minutes of apnea.

75 Sudden Infant Death Syndrome
Definition: the sudden, unexplained death of an infant. Associated with infants sleeping on their stomachs (prone) and infants who were born premature. Nursing prevention: advising parents to position their infant on the back for sleeping.

76 Hyperbilirubinemia Results from: destruction of RBCs, due either to a normal physiologic response or an abnormal destruction of the RBCs. Hemolytic disease of the newborn is destruction of RBCs from Rh or ABO incompatibility. Phototherapy or exchange transfusion is used to prevent kernicterus. The administration of Rhogam (RHIG) (Rh antibodies) to Rh-negative mothers during pregnancy and after the birth of an Rh-positive infant to an Rh-negative mother has greatly reduced the incidence of the condition. Affected infants are jaundiced from release of bilirubin from injured RBCs. Kernicterus = deposition of bilirubin in brain cells, causing destruction of the cells.

77 Neonatal Hemorrhagic Disease
Definition: a lack of clotting ability resulting from a deficiency of vitamin K at birth. Prevention is by injection of vitamin K to all infants at birth.

78 Retinopathy of Prematurity
Definition: destruction of the retina due to exposure of immature retinal capillaries to oxygen. Monitoring oxygen saturation via arterial blood gases is an important prevention measure.

79 Infections of the Newborn
Streptococcal Group B pneumonia: from maternal GBBS. Hepatitis B infection Ophthalmia neonatorum: from gonococcal and chlamydial conjunctivitis. Herpes Virus infection.

80 Other Neonatal Risks: Infants of diabetic mothers (IDM)
Infants of drug abusing women NOTE: respiratory distress, hypoglycemia, hypo/hyperthermia are common S&S of neonatal infection.

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