NCM 109- Care of Mother, Child at Risk or with Problem

JPT  Explain the procedure

(doctor/surgeon/obstetrics),
A. CAESAREAN SECTION  assess and administer/prescribe the
medication (anesthesiologist)
Cesarean delivery (C-section) is used to deliver a  Different types of Anesthesia
baby through surgical incisions made in the
abdomen and uterus. Planning for a C-section PREOPERATIVE MANAGEM
INTRA-OPERATIVE MANAGEMENT
might be necessary if there are certain pregnancy
ENTIVE MANAGEM
complications.  Anesthesiologist - monitors the
patient and vital signs
Labor isn't progressing normally. Labor that  Obstetric/surgeon - the one who
isn't progressing (labor dystocia) is one of the perform the operation
most common reasons for a C-section. Issues with  Procedure of CS
 Different types of CS
labor progression include prolonged first stage
 Complications during operation for
(prolonged dilation or opening of the cervix) or mother and child.
prolonged second stage (prolonged time of
pushing after complete cervical dilation). PREOPERATIVE MANAGEM
POST-OPERATIVE MANAGEMENT
The baby is in distress. Concern about changes
For Mother:
in a baby's heartbeat might make a C-section the  Monitor and assess bleeding (color,
safest option. clots, quantity)
 Assess pain
The baby or babies are in an unusual  Monitor vital signs
position. A C-section is the safest way to deliver  Monitor possible indication of
infection
babies whose feet or buttocks enter the birth canal
 Immediate care (1-2 hrs)
first (breech) or babies whose sides or shoulders complications or problems in
come first (transverse). postoperative patient

There's a problem with the placenta. If the For Baby:

 Immediate newborn care
placenta covers the opening of the cervix
assesment
(placenta previa), a C-section is recommended for  Thorough monitoring or provide
delivery. ICU care if needed/necessary

Prolapsed umbilical cord. A C-section might be

recommended if a loop of umbilical cord slips
through the cervix in front of the baby.

PREOPERATIVE MANAGEMENT
 Assessment of the patient
 Secure informed consent
 Lab exams before surgery
 Ultrasound result that determines
the need of CS
 Different preoperative medication
 NCM 109- Care of Mother, Child at Risk or with Problem

JPT RISK
B. HIGH
POSTPARTUM CLIENT
POSTPARTUM HEMORRHAGE
(SPPH)Late postpartum hemorrhage
DEFINITION
-defined as any significant vaginal bleeding that occurs
-Postpartum hemorrhage (also called PPH) is when a woman between 24 hours after placental delivery and during the
has heavy bleeding after giving birth. It's a serious but rare following 6 weeks.
condition. It usually happens within 1 day of giving birth, but it
can happen up to 12 weeks after having a baby. -Common causes of SPPH include retention of the placenta,
-Hemorrhage, one of the primary causes of maternal mortality endometritis, and delayed placental bed involution.
associated with childbearing
-a major threat during pregnancy, throughout labor, and
continuing into the postpartum period. Note!
-defined as blood loss of 500 ml or more following a vaginal What is the difference between primary PPH and
birth; this occurs in as many as 5% to 15% of postpartal secondary PPH?
women Primary postpartum hemorrhage is bleeding that occurs in
-with CS birth, hemorrhage is present when there is a the first 24 hours after delivery, while secondary postpartum
1,000mL blood loss or 10% decrease in the hematocrit level. hemorrhage is characterized as bleeding that occurs 24
ETIOLOGY hours to 12 weeks postpartum.
Four main reasons for postpartum hemorrhage are:

 Uterine atony
 Trauma (lacerations, hematomas, uterine inversion, or
uterine rupture)
 Retained placental fragments Hypovolemic shock
 Development of disseminated intravascular coagulation
(DIC) -a dangerous condition in which your heart can’t get your body
the blood (and oxygen) it needs to function.
Four T’s of postpartum hemorrhage -This happens because you’ve lost a large amount ― more
than 20% ― of your blood volume.
 Tone
-possible complication if PPH is left untreated.
 Trauma
- If the loss of blood is extremely copious, a woman will quickly
 Tissue
begin to exhibit symptoms of hypovolemic shock such as:
 Thrombin
 a falling blood pressure;
-common mnemonic for the etiology of hemorrhage in the
 a rapid, weak, or thready pulse;
puerperium.
 increased and shallow respirations;
SYMPTOMS
 pale, clammy skin;
 Uncontrolled bleeding  and increasing anxiety.
 Decreased blood pressure
 Increased heart rate Replacing lost blood and fluids is important in treating
 Decrease in the red blood cell count (hematocrit) postpartum hemorrhage. You may quickly be given IV
 Swelling and pain in tissues in the vaginal and perineal (intravenous) fluids, blood, and blood products to prevent
area, if bleeding is due to a hematoma shock. Oxygen may also help.

first hour postpartum indicate cardiac decompensation, and

THERAPEUTIC MANAGEMENT treatment should be implemented immediately. From the
diagnosis of PPH, first-line measures should ensure
 Monitor the vital signs such as BP, PR, RR coordinated care actions including the availability of blood
derivatives, the establishment of conditions for volume
 Monitor the amount of bleeding or the lochia
replacement, oxygen therapy, and identification and timely
 Fundal massage to encourage contraction
treatment causes of bleeding. Individualized fluid resuscitation
 Medication that initiates contraction such as oxytocin
should start with warmed crystalloids and be limited to 3.5 L.
 Bimanual compression
 Removal of placental pieces that remain in the uterus
 Blood replacement

Early postpartum hemorrhage

-defined as blood loss of at least 500 mL after vaginal or

1000 mL following cesarean delivery within 24 hours
postpartum.
 NCM 109- Care of Mother, Child at Risk or with Problem

JPT  Clot busters. These medications (also called thrombolytics) are

given to break up blood clots. Because they can cause severe
bleeding, they’re only given in very serious situations.

 Filters. If you cannot take medications, you may have a small

filter inserted into a large vein in the abdomen called the vena
THROMBOEMBOLIC DISORDERS cava. If a blood clot breaks off, this will reduce the chance of it
traveling to the lungs.
Superficial Venous Thrombosis  Compression stockings. These can reduce the swelling that
is thrombosis and inflammation of the superficial vein, characterized happens after a blood clot forms in your leg. The stockings are
by painful, warm, erythematous, tender, and palpable cord-like tighter near the ankle and looser near the top. This helps keep
structure along the course of a superficial vein, usually in the lower your blood from pooling and clotting.
extremities, but potentially affecting any superficial vein in the  Self-care. Your doctor may recommend that you: – Elevate
body. your leg. – Apply a heating pad for 20 minutes every 2 hours.
– Keep walking, physical work, and lifting to a minimum.
Symptoms
Pain and swelling develop rapidly in the area of inflammation. The
skin over the vein becomes red, and the area feels warm and is very
tender. Because blood in the vein is clotted, the vein feels like a hard
cord under the skin, not soft like a normal or varicose vein. The vein
may feel hard along its entire length.

Causes
Blood clots can be caused by anything that slows or stops blood
circulation. This can include inactivity, surgery, injury, or inherited
factors. Risk factors are similar to those of DVT, including:
 Sitting for a long time, as when you’re driving, flying, or on
bedrest
 Injury to a vein from surgery or IV line
 Pregnancy and the first 6 weeks after giving birth
 Birth control pills or hormone replacement therapy
 Cancer and some of its treatments
 Heart failure
 Overweight or obesity
 Smoking
 Personal or family history of DVT or embolism

Diagnosis and Tests

If your doctor suspects you have a superficial blood clot, you may
be given one or more of these tests:
 Ultrasound. Sound waves are used to measure the blood flow
through your veins and to identify any blood clots.
 Venogram. An x-ray is taken to produce an image of your veins
and to identify blood clots.
 CT or MRI scans. Computerized tomography (CT) and
magnetic resonance imaging (MRI) provide images of the
inside of the body, including the veins.
 Blood tests. Your blood may be tested for an inherited blood
clotting disorder. It may also be tested for a substance called D-
dimer, which is usually present in patients with blood clots. If
you don’t have it, your symptoms are probably not caused by a
blood clot.

Treatments
Superficial venous thrombosis should be treated right away. The
goal of treatment is to prevent the blood clot from getting bigger, or
forming a DVT and becoming an embolism (breaking off and
traveling toward the lungs).
Treatment also aims to keep you from getting more blood clots. Your
treatment may include one or more of the following:
 Blood thinner medications. These medications (also called
anticoagulants) reduce your blood’s ability to clot. They can’t
break up clots you already have, but they can prevent them from
getting bigger. They can also prevent new clots from forming.
They’re usually taken for at least three months.
 NCM 109- Care of Mother, Child at Risk or with Problem

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Complications
Deep Vein Thrombosis  Pulmonary embolism (PE). PE is a potentially life-threatening
occurs when a blood clot (thrombus) forms in one or more of the complication associated with DVT. It occurs when a blood clot
deep veins in the body, usually in the legs. Deep vein thrombosis can (thrombus) in a leg or other body area breaks free and gets stuck
cause leg pain or swelling. Sometimes there are no noticeable in a blood vessel in a lung. Get immediate medical help if you
symptoms. have symptoms of PE. They include sudden shortness of
breath, chest pain while breathing in or coughing, rapid
Symptoms breathing, rapid pulse, feeling faint or fainting, and coughing
 Leg swelling up blood.
 Leg pain, cramping or soreness that often starts in the calf  Postphlebitic syndrome. Damage to the veins from the blood
 Change in skin color on the leg — such as red or purple, clot reduces blood flow in the affected areas. Symptoms include
depending on the color of your skin leg pain, leg swelling, skin color changes and skin sores.
 A feeling of warmth on the affected leg  Treatment complications. Blood thinners are often used to
treat DVT. Bleeding (hemorrhage) is a worrisome side effect of
Causes blood thinners. It's important to have regular blood tests while
Anything that prevents the blood from flowing or properly clotting taking blood-thinning drugs.
can cause a blood clot. The main causes of deep vein thrombosis
(DVT) are damage to a vein from surgery or inflammation and Prevention
damage due to infection or injury.  Move your legs. If you've had surgery or have been on bed rest,
try to move as soon as possible.
Risk factors  Don't smoke. Smoking increases the risk of DVT.
 Age. Being older than 60 increases the risk of DVT.  Manage weight. Obesity is a risk factor for DVT. Regular
But DVT can occur at any age. exercise lowers the risk of blood clots. As a general goal, aim
 Lack of movement. When the legs don't move for a long time, for at least 30 minutes of moderate physical activity every day.
the calf muscles don't squeeze (contract). Muscle contractions If you want to lose weight, maintain weight loss or meet
help blood flow. Sitting for a long time, such as when driving specific fitness goals, you may need to exercise more.
or flying, increases the risk of DVT. So does long-term bed rest,
which may result from a lengthy hospital stay or a medical
condition such as paralysis.
 Injury or surgery. Injury to the veins or surgery can increase the
risk of blood clots.
 Pregnancy. Pregnancy increases the pressure in the veins in the
pelvis and legs. The risk of blood clots from pregnancy can
continue for up to six weeks after a baby is born. People with
an inherited clotting disorder are especially at risk.
 Birth control pills (oral contraceptives) or hormone
replacement therapy. Both can increase the blood's ability to
clot.
 Being overweight or obese. Being overweight increases the
pressure in the veins in the pelvis and legs.
 Smoking. Smoking affects how blood flows and clots, which
can increase the risk of DVT.
 Cancer. Some cancers increase substances in the blood that
cause the blood to clot. Some types of cancer treatment also
increase the risk of blood clots.
 Heart failure. Heart failure increases the risk of DVT and
pulmonary embolism. Because the heart and lungs don't work
well in people with heart failure, the symptoms caused by even
a small pulmonary embolism are more noticeable.
 Inflammatory bowel disease. Crohn's disease or ulcerative
colitis increase the risk of DVT.
 A personal or family history of DVT or PE. If you or someone
in your family has had one or both of these conditions, you
might be at greater risk of developing DVT.
 Genetics. Some people have DNA changes that cause the blood
to clot more easily. One example is factor V Leiden. This
inherited disorder changes one of the clotting factors in the
blood. An inherited disorder on its own might not cause blood
clots unless combined with other risk factors.
 NCM 109- Care of Mother, Child at Risk or with Problem

JPT
Pulmonary Embolism
Prolonged immobility
Blood clots are more likely to form during periods of inactivity,
is a blockage in one of the pulmonary arteries in your lungs. In most such as:
cases, pulmonary embolism is caused by blood clots that travel to  Bed rest. Being confined to bed for an extended period after
the lungs from deep veins in the legs or, rarely, from veins in other surgery, a heart attack, leg fracture, trauma or any serious
parts of the body (deep vein thrombosis). illness makes you more vulnerable to blood clots. When the
lower extremities are horizontal for long periods, the flow of
Symptoms venous blood slows and blood can pool in the legs, sometimes
Common signs and symptoms include: resulting in blood clots.
 Shortness of breath. This symptom typically appears suddenly  Long trips. Sitting in a cramped position during lengthy plane
and always gets worse with exertion. or car trips slows blood flow in the legs, which contributes to
 Chest pain. You may feel like you're having a heart attack. The the formation of clots.
pain is often sharp and felt when you breathe in deeply, often Other risk factors
stopping you from being able to take a deep breath. It can also  Smoking. For reasons that aren't well understood, tobacco use
be felt when you cough, bend or stoop. predisposes some people to blood clot formation, especially
 Cough. The cough may produce bloody or blood-streaked when combined with other risk factors.
sputum.  Being overweight. Excess weight increases the risk of blood
Other signs and symptoms clots — particularly in people with other risk factors.
 Rapid or irregular heartbeat  Supplemental estrogen. The estrogen in birth control pills and
 Lightheadedness or dizziness in hormone replacement therapy can increase clotting factors in
 Excessive sweating your blood, especially if you smoke or are overweight.
 Fever  Pregnancy. The weight of the baby pressing on veins in the
 Leg pain or swelling, or both, usually in the calf caused by a pelvis can slow blood return from the legs. Clots are more likely
deep vein thrombosis to form when blood slows or pools.
 Clammy or discolored skin (cyanosis)
Complications
Causes Pulmonary embolism can be life-threatening. It can also lead to
Pulmonary embolism occurs when a clump of material, most often pulmonary hypertension, a condition in which the blood pressure in
a blood clot, gets wedged into an artery in your lungs. These blood your lungs and in the right side of the heart is too high. When you
clots most commonly come from the deep veins of your legs, a have obstructions in the arteries inside your lungs, your heart must
condition known as deep vein thrombosis (DVT). work harder to push blood through those vessels, which increases
In many cases, multiple clots are involved in pulmonary embolism. blood pressure and eventually weakens your heart. In rare cases,
The portions of lung served by each blocked artery are robbed of small emboli occur frequently and develop over time, resulting in
blood and may die. This is known as pulmonary infarction. This chronic pulmonary hypertension, also known as chronic
makes it more difficult for your lungs to provide oxygen to the rest thromboembolic pulmonary hypertension.
of your body.
Occasionally, blockages in the blood vessels are caused by Prevention
substances other than blood clots, such as:  Blood thinners (anticoagulants). These medications are often
 Fat from the marrow of a broken long bone given to people at risk of clots before and after an operation —
 Part of a tumor as well as to people admitted to the hospital with medical
 Air bubbles conditions, such as heart attack, stroke or complications of
cancer.
Risk factors  Compression stockings. Compression stockings steadily
Although anyone can develop blood clots and subsequent pulmonary squeeze your legs, helping your veins and leg muscles move
embolism, certain factors can increase your risk. blood more efficiently. They offer a safe, simple and
inexpensive way to keep blood from stagnating during and after
Medical conditions and treatments general surgery.
 Heart disease. Cardiovascular disease, specifically heart  Leg elevation. Elevating your legs when possible and during
failure, makes clot formation more likely. the night also can be very effective. Raise the bottom of your
 Cancer. Certain cancers — especially brain, ovary, pancreas, bed 4 to 6 inches (10 to 15 cm) with blocks or books.
colon, stomach, lung and kidney cancers, and cancers that have  Physical activity. Moving as soon as possible after surgery can
spread — can increase the risk of blood clots, and help prevent pulmonary embolism and hasten recovery overall.
chemotherapy further increases the risk. Women with a This is one of the main reasons your nurse may push you to get
personal or family history of breast cancer who are taking up, even on your day of surgery, and walk despite pain at the
tamoxifen or raloxifene also are at higher risk of blood clots. site of your surgical incision.
 Surgery. Surgery is one of the leading causes of problem blood  Pneumatic compression. This treatment uses thigh-high or calf-
clots. For this reason, medication to prevent clots may be given high cuffs that automatically inflate with air and deflate every
before and after major surgery, such as joint replacement. few minutes to massage and squeeze the veins in your legs and
 Disorders that affect clotting. Some inherited disorders affect improve blood flow.
blood, making it more prone to clot. Other medical disorders
such as kidney disease can also increase your risk of blood
clots.
 Coronavirus disease 2019 (COVID-19). People who have
severe symptoms of COVID-19have an increased risk of
pulmonary embolism.
 NCM 109- Care of Mother, Child at Risk or with Problem

JPT
Puerperal Infection
occurs when bacteria infect the uterus and surrounding areas after a
How is a puerperal infection diagnosed?
Your doctor can diagnose postpartum infections primarily through a
female gives birth. It’s also known as a postpartum infection. physical exam. The doctor will review your risk factors and check
for fever over 100.4°F (38°C), pain, bleeding, and foul-smelling
What are the types of puerperal infections? vaginal discharge. If needed, the doctor may check a white blood
Postpartum infections are described by the three distinct areas where cell count to see if your body is fighting an infection. Your doctor
they may occur, including: will then move quickly to diagnose an infection to decrease the
 Endometritis: uterine lining chance it will enter your bloodstream.
 Myometritis: uterine muscle
 Parametritis (also called pelvic cellulitis): supporting tissue Can puerperal infections cause complications?
around the uterus  abscesses, or pockets of pus
 peritonitis, or an inflammation of the abdominal lining
Symptoms  pelvic thrombophlebitis, or blood clots in the pelvic veins
 fever  pulmonary embolism, a blood clot that blocks an artery in the
 Chills lungs.
 body aches  septic shock, bacteria get into the bloodstream and cause
 loss of appetite dangerously low blood pressure
 overall discomfort
More severe symptoms specific to a postpartum infection How are puerperal infections treated?
include: Postpartum infections are primarily treated with broad-spectrum
 pain below the waist or in the pelvic bone area caused by an antibiotics given intravenously (IV) if you are still in the hospital.
inflamed uterus Broad-spectrum antibiotics cover a variety of bacteria and are used
 pale, clammy skin related to a large amount of blood loss when the type of bacteria is unknown.
 foul-smelling vaginal drainage revealing an infection Oral antibiotics may include:
increased heart rate from blood loss  Augmentin (amoxicillin and clavulanate)
 Vibramycin (doxycycline) plus Flagyl (metronidazole)
How are puerperal infections caused?  Levaquin (levofloxacin) plus Flagyl (metronidazole)
An intact uterus is considered sterile. However, bacteria that live
on the skin, such as Streptococcus or Staphylococcus, and other Can puerperal infections be prevented?
bacteria can still cause infections by invading damaged skin or  removing pubic hair with clippers rather than a razor
tissue. These bacteria thrive in the moist and warm environment of  taking a shower with chlorhexidine soap at least the night
the lower abdomen. Postpartum infections can start in the uterus before surgery
after the mother’s water breaks. Additionally, the uterus can become  keeping blood sugar under 200 mg/dL throughout pregnancy
infected if the amniotic sac and its fluid become infected. The Your doctor may use the following prevention practices before
amniotic sac is the membrane that contains the fetus and fluids. surgery:
 preparing the incision area with an alcohol-based preparation
Risk factors  administration of a one-dose antibiotic 1 hour before incision
Your risk of developing an infection after you deliver differs  administration of an entire course of antibiotics for GBS or
depending on the method used to deliver your baby. Your chance of bacterial vaginosis
contracting an infection is:

 1-3% of standard vaginal deliveries

 5-15% of scheduled cesarean deliveries performed before labor
begins
 15-20% of non-scheduled cesarean deliveries performed after
labor begins
An added risk may include females with no previous pregnancy
and extremes in age, such as very young or older.
Furthermore, prior medical condition such as
obesity, diabetes, high blood pressure, anemia, and immune
system problems may add to the chance of infection.
Additional factors
 multiple vaginal exams during labor
 monitoring the fetus inside the uterus
 delay between amniotic sac rupture and delivery or prolonged
labor
 manual removal of the placenta
 having remains of the placenta in the uterus after delivery
 excessive bleeding after delivery
 baby’s stool found in amniotic fluid
 use of a catheter to soften the opening of the uterus for birth
Other infectious conditions that may contribute to postpartum
infections, namely:
 overgrowth of “bad” bacteria in the vagina
 group B Streptococcus (GBS) bacteria naturally living in the
vaginal tract
 sexually transmitted infections
 NCM 109- Care of Mother, Child at Risk or with Problem

JPT ✓ Temp-controlled bed

C. NEWBORN ✓ Monitoring of vital signs
COMPLICATIONS ✓ Mechanical ventilators
✓ Radiologic studies
✓ Feeding care

A. A PROBLEMS RELATED TO
APNEA OF PREMATURITY
MATURITY

Term for absence of breathing for more than 20 seconds.

1. PREMATURITY - Occur in full-term babies but is more common in premature
babies.
DEFINITION
- Followed by bradycardia, a decrease heart rate.

- AKA preterm birth is when a baby is born too early,

before 37 weeks of pregnancy have been completed. CAUSES OF APNEA
The earlier a baby is born, the higher the risk of death - Disturbance in the brains breath control center
or serious disability.
- Problems in other organs
CLASSIFICATION =by gestational age
- Breathing stops because something is blocking
Preterm- less than 37 completed weeks
airway.
Late preterm-
- Respiratory disease

- Infection
ETIOLOGY
Multifactorial and involves complex interaction
- Very low or very high levels of chemicals in the
between fetal, placental, uterine and maternal
factors. body such as glucose and calcium
o Fetal
- Unstable temperature
 Fetal distress
 Multiple gestation
 Non immune hydrops
o Placental SYMPTOMS OF APNEA
 Placental dysfunction Periods of absence of breathing for 20 secs or more
 Placenta previa and abruptio - Blue coloring
o Uterine - Severe decrease in heart rate
 Trauma
 Incompetent cervix TREATMENT OF APNEA

o Maternal
 Preeclampsia  - Monitor breathing and HR
 Woman younger than 16 and older  - Medications caffein or theophylline to
than 35 stimulate CNS
 Chronic medical illness  - Continuous positive airway CPAP

CHARACTERISTICS
1. Small baby, usually weight less than 5 pounds
2. Thin, shiny, red skin
3. Little scalp hair
4. Weak cry
Care of premature baby:
 NCM 109- Care of Mother, Child at Risk or with Problem

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2. POST MATURITY  - Large amount of hair on head
 - Green-yellowish/brownish coloring of skin

DEFINITION PREVENTION
- Continuing beyond 2 weeks of expected  More alert/ wide eye.
date of delivery
- Average incidence is about 3-12% -  - Woman should keep track of their
Determining Gestational Age menstrual cycles
= Naegele’s rule  - Ultrasonography in the 1st 12 weeks most
= Quickening -around 16-18 weeks GA important
= Uterine size -increase with GA
= Ultrasound -examination in 1st trimester B. PROBLEMS RELATED TO
provide the most accurate dating GESTATIONAL AGE
= Doppler- detect fetal heart tone as early
as 10-11 weeks GA 1. SMALL GESTATIONAL AGE

ETIOLOGY DEFINITION

 Wrong dates: inaccurate LMP  - Birth Weight <10th percentile

 Biological variability: Familial/Hereditary  - <2SD from mean weight for the period
 Maternal Factors: Primiparity, Previous of gestation
prolonged pregnancy TYPES
 Fetal factors: Congenital anomalies
anencephaly  Malnourished SGA
 Placental factors: Sulphatase deficiency—  - Commonest type of SGA
 - Asymmetric IUGR
Low estrogen—male baby  - Long, thin and marasmic
 - 2/3 of IUGR
 - Malnourishment during latter part of
DIAGNOSIS gestation -Placental dysfunction
 Menstrual History: useful if the px is sure  - Loose skin folds
about her date  Hypoplastic SGA
 - Clinical findings: weight record, girth of the  - Symmetric IUGR
abdomen and history of false pain, obstetric  - 1/3 of IUGR
 - Growth retardation in Early Pregnancy
palpitation and internal examination.
 - Incidence anomalies 10-20 times higher
Features:
INVESTIGSTIONS: Aim to confirm fetal  - Decrease in cell number
maturity and detect placental insufficiency.  - All organs affected including brain
 - Poor prognosis
COMPLICATIONS  - Permanent physical and mental retardation
Big baby, AKA Macrosomia  Mixed SGA
- Meconium aspiration  Adverse factors during both early and mid-
pregnancy
- Hypoglycemia  Neither obvious malnourished nor grossly
- Placental insufficiency which might cause poor hypoplastic
oxygen supply.  Decrease in both cell size and count.

SYMPTOMS
Maternal COMPLICATIONS

 - Increase severe perineal injury

 - Increase labor dystocia

 Dry loose peeling skin

NCM 109- Care of Mother, Child at Risk or with Problem

CAUSES COMMON PROBLEMS OF SGA

JPT
✓IUD
✓Hypothermia
✓Hypoglycemia
✓Infections
✓ Poor growth potential
SGA MANAGEMENT:
 Emergency CS- Fetal distress
 Control infections, temperature regulation
 Screening for cong. Malformations

2. LARGE GESTATIONAL AGE

DEFINITION

 - Birth wt of >90 percentile

 - Birth weight >2SD from the mean
weight for gestation.

CAUSES OF LGA
 NCM 109- Care of Mother, Child at Risk or with Problem

Why is LGA aJPT

concern? Pathophysiology
 Prolonged vaginal delivery time Inflammatory triggers initiate the release of
 Difficult birth cellular and chemical mediators, causing injury to
 Birth injury the alveolar capillary membrane in addition to
 Increased risk of cesarean delivery other structural damage to the lungs. Severe V./Q.
mismatching occurs. Alveoli collapse because of
How is LGA diagnosed? the inflammatory infiltrate, blood, fluid, and
surfactant dysfunction. Small airways are
- Ultrasound narrowed because of interstitial fluid and
- A mothers weight gain bronchial obstruction. Lung compliance may
markedly decrease, resulting in decreased
Prevention of LGA functional residual capacity and severe
hypoxemia. The blood returning to the lung for
 - Prenatal gas exchange is pumped through the
 - Careful management of diabetes nonventilated, nonfunctioning areas of the lung,
causing shunting. This means that blood is
 - Proper weight gain
interfacing with nonfunctioning alveoli and gas
exchange is markedly impaired, resulting in
C. ACUTE CONDIITON OF NEONATES
severe, refractory hypoxemia.
1. ACUTE RESPIRATORY
DISTRESS
nonspecific pulmonary response to a variety of
pulmonary and non-pulmonary insults to the lung;
characterized by interstitial infiltrates, alveolar
hemorrhage, atelectasis, decreased compliance,
and refractory hypoxemia

RISK FACTORS

 Acute Respiratory Distress Syndrome

 Aspiration (gastric secretions, drowning,
hydrocarbons)
 Drug ingestion and overdose
 Hematologic disorders (disseminated
intravascular coagulopathy, massive
transfusions, cardiopulmonary bypass)
 Prolonged inhalation of high
concentrations of oxygen, smoke, or
corrosive substances
 Localized infection (bacterial, fungal, viral
pneumonia)
 Metabolic disorders (pancreatitis, uremia) CLINICAL MANIFESTATIONS
 Shock (any cause)
 Trauma (pulmonary contusion, multiple  ARDS closely resembles severe
fractures, head injury) Major surgery pulmonary edema.
 Fat or air embolism  The acute phase of ARDS is marked by a
 Sepsis rapid onset of severe dyspnea that usually
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occursJPT
less than 72 hours after the V./Q. imbalance. By using PEEP, a lower FiO2
precipitating event (Siegel, 2015a). may be
 Arterial hypoxemia that does not respond required. The goal is a PaO2 greater than 60 mm
to supplemental oxygen is characteristic. Hg or an oxygen
 Findings on chest x-ray are similar to those saturation level of greater than 90% at the lowest
seen with cardiogenic pulmonary edema possible FiO2.
and are visible as bilateral infiltrates that
quickly worsen. 2. MECONIUM ASPIRATION
 The acute lung injury then progresses to SYNDROME
fibrosing alveolitis with persistent, severe
hypoxemia.
 The patient also has increased alveolar Meconium aspiration syndrome (MAS) refers to
dead space (ventilation to alveoli but poor breathing problems that a newborn baby may have
perfusion) and decreased pulmonary when:
compliance (“stiff lungs,” which are  There are no other causes, and
difficult to ventilate).  The baby has passed meconium (stool)
 Clinically, the patient is thought to be in into the amniotic fluid during labor or
the recovery phase if the hypoxemia delivery
gradually resolves, the chest x-ray CAUSES
improves, and the lungs become more
compliant. Meconium is the early stool passed by a newborn
soon after birth, before the baby starts to feed and
MEDICAL MANAGEMENT
digest milk or formula.

The primary focus in the management of ARDS In some cases, the baby passes meconium while
includes identification and treatment of the still inside the uterus. This can happen when
underlying condition. Aggressive, supportive care babies are "under stress" due to a decrease in
must be provided to compensate for the severe blood and oxygen supply. This is often due to
respiratory dysfunction. This supportive therapy problems with the placenta or the umbilical cord.
almost always includes endotracheal intubation
and mechanical ventilation. In addition,
circulatory support, adequate fluid volume, and Once the baby passes the meconium into the
nutritional support are important. Supplemental surrounding amniotic fluid, they may breathe it
oxygen is used as the patient begins the initial into the lungs. This may happen:
spiral of hypoxemia. As the hypoxemia
progresses, intubation and mechanical ventilation  While the baby is still in the uterus
are instituted. The concentration of oxygen and
ventilator settings and modes are determined by  During delivery
the patient’s status. This is monitored by arterial
blood gas analysis, pulse oximetry, and bedside  Immediately after birth
pulmonary function testing.
The meconium can also block the infant's airways
Providing ventilatory PEEP support is a critical
right after birth. It can cause breathing problems
part of the treatment of ARDS. PEEP usually
due to swelling (inflammation) in the baby's lungs
improves oxygenation, but it does not influence
after birth.
the natural history of the syndrome. The use of
PEEP helps increase functional residual capacity
and reverse alveolar collapse by keeping the
alveoli open, resulting in improved arterial
oxygenation and a reduction in the severity of the
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• Sleeping prone rather than supine
RISK FACTORS THAT MAY CAUSE STRESS ON THE
BABY BEFORE BIRTH • Viral respiratory or botulism infection
 "Aging" of the placenta if the pregnancy goes far • Exposure to secondary smoke
• Pulmonary edema
past the due date
• Brainstem abnormalities
 Decreased oxygen to the infant while in the uterus • Neurotransmitter deficiencies
• Heart rate abnormalities
 Diabetes in the pregnant mother • Distorted familial breathing patterns
• Decreased arousal responses
 Difficult delivery or long labor • Possible lack of surfactant in alveoli
• Sleeping in a room without moving air currents
 High blood pressure in the pregnant mother (the infant rebreathes expired carbon dioxide)
Typically, affected infants are well nourished.
 Infection in the placenta affecting the baby
SIGNS AND SYMPTOMS Parents may report an infant had a slight head
cold. After being put to bed at night or for a nap,
 Before or at a baby's birth, doctors will the infant is then found dead a few hours later.
notice one or more of these signs: Infants who die this way do not appear to make
any sound as they die, which indicates they die
 The amniotic fluid is meconium-stained with laryngospasm. Although many infants are
(green). found with blood-flecked sputum or vomitus in
their mouths or on the bedclothes, this seems to
 The baby has meconium stains occur as the result of death, not as its cause. An
autopsy often reveals petechiae in the lungs and
mild inflammation and congestion in the
 The baby has breathing problems or a slow respiratory tract. However, these symptoms are
heart rate. not severe enough to cause sudden death. It is
clear these infants do not suffocate from
 The baby is limp. bedclothes or choke from overfeeding,
underfeeding, or crying.

Since the AAP made the recommendation to put

3. SUDDEN INFANT DEATH newborns to sleep on their back, the incidence of
SYNDROME SIDS has declined almost 50% to 60%. Other
recommendations include the use of a firm sleep
Sudden infant death syndrome (SIDS) is a surface; breastfeeding; room sharing without bed
sudden unexplained death in infancy. It tends to sharing; routine immunizations; consideration of
occur at a higher than usual rate in infants of using a pacifier; and avoidance of soft bedding,
adolescent mothers, infants of closely spaced overheating, and exposure to tobacco smoke,
pregnancies, and underweight and preterm infants. alcohol, and illicit drugs (Byars & Simon, 2017).
Also prone to SIDS are infants with BPD, twins, Although it was once thought having infants sleep
Native American infants, Alaskan Native infants, with a fan in their room to keep air moving might
economically disadvantaged Black infants, and decrease the incidence of SIDS, the AAP has
infants of narcotic-dependent mothers. The peak noted that, currently, there is insufficient evidence
age of incidence is 2 to 4 months of age (AAP, to recommend the use of a fan as a SIDS risk1533
2011b). reduction strategy (AAP, 2011b). Parents have a
Although the cause of SIDS is unknown, in difficult time accepting the death of any child.
addition to prolonged but unexplained apnea, This can be especially difficult when it happens so
other possible contributing factors include: suddenly and to an infant. In discussing the child,
they often use both the past and present tense as if
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yet aware of the death. Many parents SEPSIS (NEONATAL SEPTICEMIA OR
experience a period of somatic symptoms that SEPSIS NEONATORUM)
occur with acute grief, such as nausea, stomach
 systemic condition that arises from a bacterial, viral, or
pain, or vertigo. fungal origin, is associated with hemodynamic changes
and clinical findings, and causes severe morbidity and
Parents should be counseled by someone who is mortality (Bulbul, 2020)
trained in counseling at the time of the infant’s  serious medical condition caused by the body's response
to an infection
death; it helps if they can talk to this same person  blood infection that occurs in an infant younger than 90
periodically for however long it takes to resolve days old
their grief. The American Sudden Infant Death
Neonatal sepsis may be categorized into three:
Syndrome Institute, listed at the beginning of the 1. Early-onset Sepsis
chapter, offers suggestions for counseling.  clinical manifestations occur in the first three days of life
Autopsy reports should be given to parents as (<72 hours)
 85% are present within 24 hours.
soon as they are available (if toxicology tests are  associated with vertical transmission or acquisition of
included in the autopsy, results will not be microorganisms from the mother
available for weeks). Reading that their child’s  occur via hematogenous, transplacental spread from an
infected mother
death was unexplained can help to reassure  baby gets the infection from the mother before or during
parents the death was not their fault. They need delivery
this assurance if they are to plan for other
children. If there are older children in the family, 2. Late-onset Sepsis
 babies are infected after delivery
they also need assurance SIDS is a disease of  occurs at 4-90 days of life
infants and the strange phenomenon that invaded  acquired from the environment for staying in the hospital
their home and killed a younger brother or sister for an extended period of time
 having a catheter in a blood vessel for a long time
will not also kill them. If they wished the infant  infant’s skin, respiratory tract, conjunctivae,
dead, as some children wish siblings were dead gastrointestinal tract, and umbilicus may become
occasionally, they need reassurance their wishes colonized via contact with the environment or caregivers
did not cause the baby’s death.
3. Very Late-onset Sepsis
 diagnosed in infants who are hospitalized in the neonatal
When another child is born, parents can be intensive care unit from the first 30 days of life until
expected to become extremely frightened at any discharge (Bulbul, 2020)
sign of illness in their child. They need support to CAUSES
see them through the first few months of the
second child’s life, particularly until past the point  bacterial infections are the most common cause such as
at which the first child died. Some parents may Escherichia coli (E coli), Listeria, and some strains of
need support to view a second child as an streptococcus
 group B streptococcus (GBS) has been a major cause of
individual child and not as a replacement for the neonatal sepsis
first child. A new baby born to a family in which a  sepsis can also be caused by fungi, parasites or viruses
SIDS infant died can be screened using a sleep  herpes simplex virus (HSV) can also cause a severe
assessment as a precaution within the first 2 weeks infection in a newborn baby. This happens most often
when the mother is newly infected.
of life or, if the parents’ level of anxiety is acute,
before hospital discharge. The baby may then be Newborns can get sepsis in several different ways:
placed on continuous apnea monitoring pending  If the mother has an infection of the amniotic fluid (a
condition known as chorioamnionitis)
the results of the sleep assessment.  If the mother’s water breaks early (more than 18 hours
before the baby is born)
INTRA-OPERATIVE MANAGEMENT  If the baby is being treated for another condition while still
in the hospital
 If the mother’s birth canal is colonized with bacteria
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JPTRISK FACTORS  happens when there is too much bilirubin in your baby’s
blood
 Premature babies with low birth weight have a risk of
 elevation of serum bilirubin levels that is related to the
developing sepsis three to ten times higher than full-term
hemolysis of RBCs and subsequent reabsorption of
babies with normal birth weight
unconjugated bilirubin from the small intestines. The
condition may be benign or place the neonate at risk for
multiple complications/untoward effects
CLINICAL MANIFESTATION
*Bilirubin is made by the breakdown of red blood cells.
Symptoms of infections in newborns include: It’s hard for babies to get rid of bilirubin at first. It can
 Not feeding well build up in their blood, tissues, and fluids.
 Being very sleepy *Bilirubin has a color. It makes a baby’s skin, eyes, and
 Being very irritable other tissues turn yellow (jaundice). Jaundice may first
 Rapid breathing or breathing pauses (apnea) appear when your baby is born. Or it may also show
 Vomiting or diarrhea up any time after birth.
 Fever (temperature over 100.4 degrees F or over 38.1
degrees C) CAUSES
 Inability to stay warm -- having a low body temperature
despite being clothed and wrapped in blankets What causes hyperbilirubinemia in a newborn?
 Pale appearance During pregnancy, the placenta removes bilirubin from your baby’s
blood. When a baby is born, the baby's liver takes over this job. Your
baby may have too much bilirubin for many reasons.

DIAGNOSTIC TOOL Physiological jaundice

 normal, typical pattern
Tests for sepsis in newborns can include:  most common type of newborn hyperbilirubinemia
 blood tests (blood cell counts, blood cultures)  this unconjugated hyperbilirubinemia presents in
 urine tests (urinalysis and culture) newborns after 24 hours of life and can last up to the first
 skin swabs week
 spinal tap (also known as lumbar puncture) to test for  increased bilirubin load because of relative polycythemia
meningitis (Spinal tap is a procedure in which a very  shortened erythrocyte life span (80 days compared with
small needle is inserted into the space around your child’s the adult 120 days)
spine to withdraw spinal fluid to test for infections)  immature hepatic uptake and conjugation processes
 increased enterohepatic circulation

TREATMENT BREASTFEEDING FAILURE JAUNDICE

Some babies don’t breastfeed well at first. This causes breastfeeding
How is sepsis in newborns treated? failure jaundice. Not feeding well makes your baby dehydrated. It
 babies who have sepsis are admitted to an intensive care also causes your baby to urinate less. This makes bilirubin build up
unit. Treatments may include the following: in your baby’s body. Babies born between 34 to 36 weeks of
 intravenous (IV, directly into a vein) fluids pregnancy are more likely to get this problem. These babies often
 IV antibiotics don’t have the coordination and strength to breastfeed well. But this
 medications for fever (rarely used in newborns) condition is also common in early-term newborns (37 to 38 weeks).
 extra oxygen and other forms of respiratory support, if It can also happen in any newborns who have had a difficult start,
needed especially if they were separated from their mother and unable to
feed often. It usually gets better once a baby learns how to breastfeed
 occasionally, babies may need blood transfusions
well.

BREASTMILK JAUNDICE
PREVENTION About 2% of breastfed babies get jaundice. This happens later in
their first week of life. It peaks at about 2 weeks of age. It can last 3
Can sepsis be prevented in newborns? to 12 weeks. It is not dangerous, but tests may need to be done for
 To prevent infection in the baby, expectant women can be other problems that are dangerous. This issue may be caused by a
treated with IV antibiotics for several hours before substance in breastmilk. This substance may increase how much
delivery bilirubin the baby's body can reabsorb.
 If indicated by prenatal screens or clinical signs such as
maternal fever or uterine tenderness, your obstetrician will JAUNDICE FROM HEMOLYSIS
If your baby has Rh disease of ABO incompatibility, they may get
decide if you should be given antibiotics before delivery
this type of jaundice. This condition refers to hemolytic diseases of
HYPERBILIRUBINEMIA (NEONATAL the newborn caused by a baby having a different blood type from the
HYPERBILIRUBINEMIA) mother. This issue can also be from having too many red blood cells.
Or it may be caused by rare problems where the red blood cells are
more fragile than normal. Hemolysis is the word for the process in
 accumulation of the unconjugated bilirubin in the which the red blood cells break down and release bilirubin.
circulation (less than 15 ml/dl) that occurs after 24 hours
of life JAUNDICE CAUSED BY POOR LIVER FUNCTION
 most common problems encountered in term newborns
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Jaundice can happen if your baby’s liver doesn’t work well. This  First 24 hours. This type of jaundice is often serious. Your
may be because of an infection or other factors. The liver is the part child will likely need treatment right away.
of the body most responsible for getting rid of bilirubin. A problem  Second or third day. This is often physiologic jaundice.
with the liver can cause higher levels of bilirubin. Sometimes it can be a more serious type of jaundice. It's
important to be sure the baby is getting enough milk at this
Pathological jaundice point.
 more serious  Toward the end of the first week. This type of jaundice
 the appearance of jaundice in the first 24 hours of life due may be from breastmilk jaundice but may be due to an
to an increase in serum bilirubin levels greater than 5 infection or other rare, serious problems.
mg/dl/day, conjugated bilirubin levels ≥ 20% of total  In the second week. This is often caused by breastmilk
serum bilirubin, peak levels higher than the normal range, jaundice but may be caused by rare liver problems.
and the presence of clinical jaundice greater than two
weeks Your child’s healthcare provider may do these tests to confirm the
 breast milk jaundice occurs in breast-fed newborns diagnosis:
between the first and third day of life but peaks by day 5  Direct and indirect bilirubin levels. These levels show if
to 15, with a decline occurring by the third week of life bilirubin is bound with other substances by your child’s
(Morrison, 2021) liver. Normal physiologic jaundice has indirect bilirubin.
 prolonged jaundice, evidence of underlying illness, and Jaundice due to more serious problems can have high
elevation of the serum conjugated bilirubin level to greater levels of either type of bilirubin.
than 2 mg per dL or more than 20 percent of the total  Red blood cell counts
serum bilirubin concentration  Blood type and testing for Rh incompatibility (Coombs
 pathologic causes include disorders such as sepsis, rubella, test)
toxoplasmosis, occult hemorrhage, and erythroblastosis
fetalis
TREATMENT

RISK FACTORS Treatment will depend on your child’s symptoms, age, and general
health. It will also depend on how severe the condition is.
Maternal factors:  Phototherapy
 Blood type ABO or Rh incompatibility Bilirubin absorbs light. High bilirubin levels often
 Breastfeeding decrease when a baby is put under special blue spectrum lights. This
 Drugs: diazepam (Valium), oxytocin (Pitocin) is called phototherapy. Your child may get this treatment
 Ethnicity: Asian, Native American in the day and night. It may take several hours for it to start
 Maternal illness: gestational diabetes working. During light treatment, your baby’s eye will be
protected. Your baby’s healthcare provider will check your baby’s
Neonatal factors: temperature. He or she will also test your baby’s bilirubin levels.
 Birth trauma: cephalohematoma, cutaneous bruising, This will tell if phototherapy is working.
instrumented delivery  Fiber optic blanket
 Drugs: sulfisoxazole acetyl with erythromycin A fiber optic blanket is another form of phototherapy. The
ethylsuccinate (Pediazole), chloramphenicol blanket is usually put under your baby. It may be used alone
(Chloromycetin) or with regular phototherapy.
 Excessive weight loss after birth  Exchange transfusion
This treatment removes your baby’s blood that has a high
 Infections: TORCH
bilirubin level. It replaces it with fresh blood that has a normal
 Infrequent feedings
bilirubin level. This raises your baby’s red blood cell count. It also
 Male gender lowers their bilirubin level. During the procedure, your baby will
 Polycythemia switch between giving and getting small amounts of blood. This will
 Prematurity be done through a vein or artery in the baby's umbilical cord.
 Previous sibling with hyperbilirubinemia It is only done in an intensive care nursery when bilirubin levels are
extremely high. Your baby may need to have this
procedure again if their bilirubin levels stay high.
CLINICAL MANIFESTATIONS  Feeding with breastmilk
The American Academy of Pediatrics says that you should
Symptoms can occur a bit differently in each child. They can include: keep breastfeeding a baby with jaundice. If your baby has not
 Yellowing of your baby’s skin and the whites of their eyes. been getting enough milk at the breast, you may need to supplement
This often starts on a baby’s face and moves down their with pumped breastmilk or formula.
body.  Treating any underlying cause of the condition
 Poor feeding This may include treating an infection. In very rare
 Lack of energy conditions, a liver transplant may be needed.

COMPLICATIONS
DIAGNOSTIC TOOL
What are possible complications of hyperbilirubinemia in a
The timing of when your child’s jaundice first starts matters. It may newborn?
help their healthcare provider make a diagnosis.
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High levels of bilirubin can travel to your baby’s brain. This can
cause seizures and brain damage. This is called kernicterus.

PREVENTION

What can I do to prevent hyperbilirubinemia in my newborn?

This condition can’t really be prevented except in the case of
breastfeeding failure jaundice. Feedings should start within the first
hour of life and continue at least every 2 or 3 hours, or sooner if the
baby shows signs of wanting to eat. The more premature the baby,
the more likely they are to need supplements of expressed milk or
formula at first. For all babies, diagnosing jaundice early and getting
treatment right away are key. This can stop your baby’s bilirubin
levels from rising to dangerous levels.

*Key points
 Hyperbilirubinemia happens when there is too much
bilirubin in your baby’s blood.
 About 60% of full-term newborns and 80% of premature
babies get jaundice.
 The most common symptom is yellowing of your baby’s
skin and the whites of their eyes.
 The timing of when your child’s jaundice first starts
matters. It can help their healthcare provider make a
diagnosis.
 Make sure you feed your baby early and often.
 Diagnosing jaundice early and getting treatment right
away are key. This can stop your child’s bilirubin from
rising to dangerous levels.