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OB Exam 2

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olanjones's version from 2016-12-16 16:14

NEWBORN ASSESSMENT

Question Answer
Apgar on newbornHR; Respiratory effort; Muscle tone; Reflex response; Color
Apgar scores1-2 = needs resuscitation; 3-6 = gently stimulate by rubbing while administering O2. (did mom get narcotics, may depress infant RR-Have naloxone ready); 7-10 = support infant’s spontaneous efforts, cont observation
Done at 1 & 5 minutes if normal (and 10 mins if abnormal)
Newborn assessment VITALSTemp. 97.7-99.5; HR 120-160 (100 sleeping, 180 crying); RR 30-60 (average 45); BP s65-95/d30-60
Wt. 2500-4000g (5.8-8.13 lbs.); L 48-53cm; HC 32-38cm; CC 30-36cm
Newborn assessment findingsPOSTURE: flexed extremities move freely, return to flexed, hands clenched.
CRY: is lusty & strong.; SKIN: pink or tan with acrocyanosis, TURGOR: good/quick
VERNIX: ↑'s; LANUGO: small amounts on shoulders
HEAD: sutures palpable, small separation b/t each, anterior fontanel is diamond shaped; posterior is triangular/smaller; EARS: well-formed/complete, floppy, bounce back, even with eyes
EYES, NOSE, MOUTH: symmetrical, patent, pink mucus membranes, eyes clear; FEEDING: good suck/swallow
NECK/CLAVICLES: short neck, turns head easily side to side, clavicles intact; CHEST: cylinder shape,symmetric, xiphoid prominent; ABD: rounded, soft, bowel sounds w.in 15min pp
GENITALS: F: labia majora dark & covers clitoris M: testes w/in scrotal sack, rugae on scrotum
EXTREMITIES: equal, bilaterally. upper: Transverse palm creases, lower: gluteal/thigh creases, back no opening observed.
Newborn Priority care in assessmentcardiorespiratory status , thermoregulation, and the presence of anomalies
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NEWBORN CARE

Question Answer
Education to first period of reactivityFirst: 30-60 minutes after birth; quiet alert; good suck; will be breastfeeding, holding baby, assessments-stimulation
Sleep: 2-4 hours; hard to arouse; respiratory and hr slow; temp may be low
Transitioning, may have a stool. environment
Hungry= breastfeed, voiding. another assessment is a good idea. family stimulation
Meconiumfirst stool excreted -Greenish black with a thick, sticky, tarlike consistency; Formed in utero, consists of particles from amniotic fluid & its contents (constituents, intestinal secretions, shed mucosal cells)
Vitamin K educationused as prophylaxis for hemorrhage & tx of deficiency bleeding; promotes liver formation of clotting factors; at birth, newborn does not have bacteria in colon to synthesize fat-soluble vit K for the first 5 days of life
Normal findings circumcision recoverycheck wound frequently, if a plastibell ring used it will fall off in 10-14 days. expect yellow crust/scab to form over site. Scab will fall off w/in 7-10 dy. keep site cleaned. only drops of blood should be present. no bleeding after a few days.
Importance of Newborn heat lossBaby comes in direct contact w/ object cooler than their skin = heat loss by conduction
Signs related to Hypoglycemia in neonatesJitteriness OR hypotonia, Tachypnea, Pallor, Feeding problems, Low temp
Respiratory changes in newbornRR 30-60 mins, first period of reactivity can be as high as 80. Infants may experience 15 sec periods of apnea, neonate is obligatory nose breather. primarily diaphragmatic and abdominal synchronous with chest movements.
Newborn respiration initiationthe infants first breath must force remaining fetal lung fluid out of the alveoli & into the interstitial spaces around to allow air to fill the lungs. This requires a much larger negative pressure than subsequent breathing. a forceful contraction of the diaphragm initiated by chemical factors, & during vag birth fetal chest is compressed and force about 1/3 of fetal fluid out.
PKU understanding-Metabolic screening test: genetic condition in which infant cannot metabolize phenylalanine, a common protein in foods like milk.
-if untreated can result in intellectual disability
-treatment: special low phenylalanine diet within first week of life.
Signs of cephalhematomahemorrhage of blood btwn skull & periosteum of newborn secondary to rupture of blood vessels crossing the periosteum.
*DOES NOT cross suture line
may be associated w/ jaundice bc RBCs are being destroyed
large incident can lead to anemia & hypotension & can be life threatening
Neonate transition priorityAPGAR score; thermoregulation function; cardiomyopathy; GA; exam for obvious abnormalities and birth injuries.
-full neonatal assessment can be delayed for up to 1 hour to allow family bonding and initial feeding.
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HIGH RISK NEWBORN CARE

Question Answer
RF in late-preterm infantRDS, respiratory disorders, tachypnea/apnea, temp maintenence, hypoglycemia, hyperbilirubinemia, kernicterus, seizures, feeding difficulties, and suspected sepsis because of their immaturity, long term neuro development disorders
SIDSsudden death of an infant - primary cause is unknown but associated with: sleeping prone; overheating; maternal smoking/drug use during pregnancy; young maternal age; low socioeconomic status; late/no prenatal care; low birth wt.; prenatal exposure
Risks ↑ co-sleeping; loose bedding
Neonatal abstinence syndrome-infant withdrawal from maternal OPIATES use. Appears w/in 24-72hrs.
-s/s low birth wt., neurologic (sneezing, excessive crying/sucking, increased muscle tone/hyperactive reflexes), sleep problems, & GI symptoms
High risk Hypoglycemia in neonatespre/post maturity; late preterm infant; intrauterine growth restriction; LGA/SGA; Asphyxia; problems; cold stress; maternal diabetes; maternal intake of terbutaline
Pathologic & non-physiologic jaundice-pathologic= transient hyperbilirubinemia (normal); jaundice appears 2-3rd day of life (bilirubin is >5mg/dL)
-non-physiologic (hemolytic anemia)= biggest difference is the TIME at which jaundice appears (usu w/in 24 hours)
→the result of abnormalities causing excessive destruction of RBCs or problems in bilirubin & incompatibilities b/t mother & infant's blood types
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PP CARE

Question Answer
Use of misoprostol in OB patientUsed for cervical ripening & induction of labor (unlabeled use for ripening). Should not be given to women w/ previous c-sect. Major AE uterine hyperstimulation
PP AssessmentVitals, fundus check, lochia, perineum, bladder elimination, breasts, lower extremities, edema, DTRs
LochiaRubra: red, clots, blood - 1-3 dys
Serosa: mucous, pink tinged, invading leukocytes - 3-10 dys
Alba: white, mostly mucus and high leukocyte count - 10-14 dys (may last longer)
Lochia pooledSign of hemorrhage! (Scant: <2.5cm; Light: 2.5-10cm; Moderate: 10-15cm; Heavy: saturated in 1 hr.) Smell: Fleshy
PP careIce packs, sitz bath, perineal care, topical meds, fundus checks, sitting measures, analgesics, s/s hemorrhage, bladder elimination; providing fluids/food
Calf pain Interventionspromote fluids & early ambulation; analgesics, compression socks, rest, antibiotics, anticoagulant therapy
S/S thrombophlebitistenderness, heat, redness, & low grade fever, decreased peripheral pulses
Perineal discomfortMarked distention of perineum in second stage of fetal decent, may describe as burning, tearing, spliting pain. May be swollen & edematous after birth (laceration/episiotomy); Use ice to numb/decrease edema- 20 min on, 10 min off for first 24 hours; analgesics; pericare
Prevent abdominal distentionEarly, frequent ambulation, tightening/relaxing abd muscles, pelvic lifts, avoid carbonated drinks/use of straws (increase intestinal gas), use simethicone (gas-x), rectal suppositories (promote peristalsis and flatus)
C-Section InterventionsPain relief: S/S of Pain (diaphoresis, chills, intense tremors), can use PCA pump (watch RR, itching, n/v, urinary retention, pulse ox). Ambulate early to prevent abd distension, splint when moving or TCDB, pre-med before activity, Prevent DVTs by ambulating ASAP. Carefully assess headaches (especially if using Duramorph)
C-section assmntRespiratory status (if epidural), I&O, HA, Temp (infection), Blood clots
Normal PPFUNDUS midline, firm, at the umbilicus for first 12 hours, descends by one finger breadth per day. By day 10 cannot find, has retracted to pelvis. LOCHIA: see stages. PERINEUM: (REEDA) topical anesthetics 12-24hrs. Normal vitals, RF orthostatic, bradycardia WNL 50-70, temp to 100.4 still normal, afebrile after 24 hrs. BREASTS: soft to filling with potential for engorgement. URINARY: increased output. GI: sluggish bowel. afterpains last 2-3 days.
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Fundus & PP Hemorrhage

Question Answer
Fundal assmntassess height (in relation to umbilicus), tone (firm), location (midline); always assess post voiding to avoid uterine deviation from full bladder
Fundal interventionSupport uterus when expelling clots to prevent inversion, drugs may be needed to increase contractions (Non-contracted uterus increases risk of postpartum hemorrhage)
PPHRF: Asian/Hispanic, Nullipara/Grand multipara, HTN, Anemia, Infection, Traumatic birth/manual removal of placenta, LGA infant
Early (within 24 hr): Uterine atony/trauma
Late (>24 hrs-6 wks): Retained placenta, Subinvolution
PPH signsVaginal birth: > 500ml in first 24 hours; Cesarean Birth: >1000ml in first 24 hours; Saturated pad in <15 minutes, (s/s: boggy fundus, large clots, backache, elevated temp, low BP)
PPH teachingvoid 1-2 hrs post deliver, fundal massage, breastfeeding, report clots/excessive bleeding
PPH interventionsFundal massage, bimanual compression, D&C, Last resort: hysterectomy
PPH MedsMethergine, Oxytocin, Prostin (Carboprost, Hemabate)
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Breastfeeding & Breast Care

Question Answer
Education for Breast feedinginform them about engorgement; what to do (position of mother, infant, hands; latch-on techniques; frequency; etc); if not breast feeding still need to empty to avoid milk stasis in ducts --> engorgement/mastitis
Mastitis causesstasis of milk & engorgement previously occurred; by bacteria carried on skin of mother & can have portal of entry
Tx of mastitis-emptying of breasts (feeding/pumping) help prevent abscess formation
-ice/heat packs, breast support, fluids, analgesics
-antibiotics
Complications affecting mastitis-Flu-like symptoms w/ fatigue & aching muscles
-temperature of 102.2<
-malaise, headache
-hard/hot/painful breasts, red streaks
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PP Education & Bonding

Question Answer
Parental educationTEACH: newborn characteristics & behavior; use of bulb syringe; breastfeeding; formula feeding; burping; cord care; care of penis; holding & positioning; sleep pattern & position; elimination patterns; bathing & skin care; clothing; signs of problems; taking a temp.; infant safety; abusive head trauma; car seat use.
Family involvement in newborn carePaternal: Develops bond to newborn. “engrossment” = desire to touch/hold baby.Strong attachment to infant & looks forward to parenting but lack confidence.
Siblings: response to new baby depends on developmental level; may view the infant as competition and that they will be replaced
Grandparents: Unconditional love, sense of security to the grandchild.
Maternal adj: taking instart of attachment 1-2 dy, focuses on own needs of fluid/food/sleep. Behaviors are introspective, passive, reviews L&D birth with reality, worries about self and infant
Maternal adj: taking hold3-7 dy, attachment continues & mom becomes more independent; assumes responsibility for own care. Begins to shift attention to infant, welcomes info about newborn behaviors, may verbalize anxiety about competence as a mother. Ideal time to provide instructions and demonstrations.
Maternal adj: letting go7 dy-?. independence: assuming new role responsibility, may be grief for relinquished roles, adjustment to accommodate for infant in family.
Healthy bondingRapid initial attraction felt by parents for their infant; enhanced with touching & interaction during the first 20- 60 minutes after birth; esp when infant is in quiet alert state & seems to gaze directly at the parents. Skin-to-skin directly after delivery, nurse can delay procedures (measurements/meds) that would interfere with this time
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GRIEF & Beyond Baby Blues

Question Answer
Postpartum grief/significanceEmotional response to loss. Birth of infant w/ anomaly evokes grief response; must detach from/mourn fantasy baby to be able to attach to actual infant. Early emotions inc: anger/denial/guilt
Health grievingFetal death: Parents often feel alone in their grief, perinatal loss may not be considered at the same level as an older child/adult. May be hard for others to discuss the loss/fear of saying wrong thing/uncomfortable with subject
Postpartum psychosis*Onset: Usually w/in 48-72 hours or <six weeks following childbirth>
*Symptoms: Early symptoms may resemble depression & then suddenly escalate to delirium, hallucinations, anger towards self & baby, bizarre behavior, manifestations of mania & thoughts of hurting self/baby
*Contact with reality: Loss of touch w/ reality, severe regressive breakdown, associated with high risk of suicide and/or infanticide
Postpartum depression* W/in 12 mths after childbirth/with weaning from breastfeeding (May occur during purpuerium, after abortion, SAB/miscarriage, stillbirth or interrupted pregnancy)
* Sx: anorexia, wt loss, insomnia, fear of harming the baby, neglect of personal care, self-destructiveness, feedings of worthlessness, guilt, fatigue, hypochondria & low self-esteem
* pt is in contact with reality but can be disoriented; report a sense of depersonalization, suicidal thoughts when severe Et: theories re: abrupt hormonal shifts
Treatment for Postpartum bluesencourage mom to hold baby, rest, educate that it only usually lasts a few days, educating both parents is also important
Patient at risk for PPD* 14.5% of moms, increased in: <19 y/o, Hispanic, black
*RF: Hx of ppd, mood disorder or PMDD, Family hx of depression, bipolar, anxiety, Marital dissatisfaction, Anxiety/depression during pregnancy, postpartum blues (stressors r/t infant, such as problematic temperament), adverse life events, lack of support from family, friends, spouses
***SES, culture and educational level do not significantly contribute--->EACH mom must be assessed during pg and postpartum
PPD treatments effects- combination of antidepressant medication, antianxiety medication & psychotherapy in outpatient/inpatient behavioral health setting
- TX should be continued for 9-12 months after symptom remission
- Women with PPD more likely to experience future episodes of depression, especially following childbirth.
Benefits of support groups for PPD* Group therapy is helpful after the mother has begun to recover from the severe depression
* During the acute phase, a group of strangers can seem threatening
* Participation in a support group can help reduce feelings of isolation, anger and guilt
* Contact with other moms reinforces the belief that the depression will eventually dissipate, validates feelings.
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