Pitocin

Use: Postpartum Hemorrhage

Dosage: 10 IU IM or 10-40 IU in 1000 ml IV fluid

Route: IM or IV infusion, never IV Push

Indication: Postpartum Hemorrhage

Action: Creates a sustained tetanic contraction.

Contraindications: Hypertension, preeclampsia, eclampsia

Dosage: 0.2 mg/mL IM or 0.2 mg tablet

Intramuscular Injection (IM)

(Adult)

Needle Size: 1-1.5" 21-23 guage

Intramuscular Injection (IM)

(Newborn)

5/8 inch, 22-25 gauge needle

Use: local anesthetic for suturing

Dosage: 5-10 cc of 1-2%, with or without epinephrine.

Route: Subcutaneous injection, 10 cc, 23 guage needle

Contraindications: allergy to lidocaine or other caines; causes vasoconstriction and should not be used in people with high blood pressure.  It can cause heart palpitations, tachycardia, tremors, and tissue ischemia

Hypovolemic Shock

(Treatment)

Treatment of shock

• Provide fluids orally
• Position mother flat, legs elevated 12 inches
• Administer oxygen
• Keep mother warm, avoid overheating
• Administer/use non-allopathic remedies
• Encourage deep, calm, centered breathing
• Activate emergency medical services
• Prepare to transport

Hypovolemic Shock

(Symptoms)

Signs & Symptoms of Hypovolemic Shock

• Drop in blood pressure
• Skin becomes pale, cool, moist, clammy
• Pulse increases
• Pupils dilate
• Level of consciousness deteriorates.  As shock progresses, the mother will become increasingly unresponsive.

Oxygen

(Transportation and Usage Precautions)

• Do not allow any open flames (candles, cigarettes/cigars, oil lamps, fireplace fires, cooking fires, etc.) within 10 feet of where the oxygen tank is being stored or used.
• Be careful to also keep things that can spark (heating pads, space heaters, shavers, electric blankets, static electricity, toys that run on friction, etc.) away from where the oxygen will be used or stored.
• Do not use flammable products near oxygen -- rubbing alcohol, petroleum jelly and other oil based products.
• Store oxygen away from direct sunlight and in a well-ventilated space.
• Do not transport oxygen in the trunk of your car.
• Keep the oxygen tank upright and on a stable base.
• Do not use tanks that have fallen or become damaged.

Oxygen

(Drug Risks)

Breathing nothing but pure oxygen may produce coughing and chest pains (often the earliest warning sign of toxicity), paresthesias (burning, prickling, tickling, or tingling in the extremities), nausea and vomiting, malaise and fatigue within 6 to 24 hours.  Concentrations of 60% may produce these symptoms after several days.  Lung damage and enzyme disturbances develop as well, and if the concentration is not reduced, the end result is profound central nervous system disturbance, culminating in coma and death.  Infants given oxygen concentrations of 35 to 40% or above for prolonged periods may suffer permanent visual impairment or blindness.  Retrolental fibroplasias or retinopathy of prematurity, a condition in which light cannot penetrate to the retina, occurs when the withdrawal of long-term oxygen therapy triggers damage to the immature retinal vessels… Premature infants undergoing prolonged hyperoxygenation therapy may also develop bronchopulmonary dysplasia.

Purpose: to prevent hemorrhagic disease of the newborn

Dosage: 1 mg per 0.5 ml

Route: Use a subcutaneous needle for IM injection in thigh

Vitamin K

(Oral)

Given in 3 doses (birth, 2 weeks, 6 weeks)

Dosage: 1 drop (2 mg) of K Quinone orally

Similar rating system to APGAR

(0-2 for each of 5 criteria)

• Fetal Muscle Tone
• Breathing movements
• NST
• Fetal Movement counts
• Amniotic fluid volume

Mnemonic device: The Baby Needs More Attention

• Hemoglobin is the oxygen-carrying capacity of red blood cells.
• Usually 1/3 of the hematocrit.
• Early pregnancy normal range - 12 to 16
• After 28 wk normal range - 10-14

• Hematocrit is the number of red blood cells packed by cetrifuge in a given volume of blood.
• Skewed by blood cells larger or smaller than average

• Fasting glucose - should be below 105
• Glucose Screen (50 gram, non-fasting, 1 hour venous draw) - should be below 140
• OGTT (100 gram, fasting, 1 hour, 2 hour, 3 hour venous draws) - should be below 190 @ 1 hour, below 160 @ 2 hours, and below 145 @ 3 hours

• Transmitted by blood and sexual contact
• Symptoms: may be asymptomatic or may be acute, flu-like symptoms, dark urine, light stools, liver tenderness, jaundice
• Resolves spontaneously 90% of the time
• Acute infection associated with early SAB
• Acute 3rd trimester infection risk of preterm labor

Same symptoms as Hep B

Spread mainly by infected needles. Blood borne

• Titer above 1:8 is evidence of immunity
• Risk to fetus: deafness, heart defects, eye disorders, CNS anomalies, mental retardation, insulin dependent diabetes,  becomes a chronic condition

CBC

(Complete Blood Count)

Includes a Hemogram (red blood cell count, total white blood cell count, hemoglobin, hematocrit, red blood cell indices, and a platelet count) and a differential white blood cell count

Used:

• to establish baseline
• to determine anemia
• to determine whether there is an infection (PROM, illness)
• when monitoring a woman's response to a therapy

PAP Smear

(Interpreting Results)

Evaluates for:

• Organisms - yeast, BV, trichomonas, actinomyces, HSV
• Squamous cell changes:
  • ASCUS - likely benign, usually due to inflammation
  • ASCH - considered an intermediate between ASCUS and HSIL. Risk of higher grade lesions on biopsy.
  • LSIL - usually due to transient HPV infections, may be a precursor to cancer
  • HSIL - often due to HPV, higher risk of progression to cancer
• Glandular cell findings:
  • AGC - tells whether the cells are endometrial, endocervical, or not otherwise specified (NOS), guides treatment plan
  • Atypical glandular cells that favor neoplastic changes - some features suggestive of cancer
  • Endocervical adenocarcinoma in situ (AIS)
  • Adenocarcinoma

Adult Vital Signs

(Normal Ranges)

• Pulse: 60-90 BPM
• Blood Pressure: 90-130/60-90
• Respirations: 14-20 breaths per minute
• Temperature: 97.6-99.6

Assessment of Edema:

• Edema present without pitting - Slight (+1)
• Pitting 0-0.25" - Mild (+2)
• Pitting 0.25-0.5" - Moderate (+3)
• Pitting 0.5-1" - Severe (+4)

Grading of Reflexes

• 5+ : Ankle clonus is sometimes graded as 5+, associated with disease
• 4+ : Very brisk, often indicative of anxiety or disease
• 3+ : Brisker than average, possibly but not necessarily indicative of disease
• 2+ : Average, normal response
• 1+ : Somewhat diminished, may be associated with disease
• 0 : No response, may be associated with disease

Gestational Diabetes

Screening

• At risk moms: Hemoglobin A1C at first prenatal if before 13 weeks.
• Suspect preexisting diabetes if ketones and glucose are present in urine.
• Normal fasting glucose should be below 95
• 1 hour 50 gram glucose screen should be below 140
• OGTT (100 grams of glucose)
  
  • Fasting below 105
  • 1 hour below 190
  • 2 hour below 160
  • 3 hour below 145
• Diagnosis of GDM made if
  • Fasting glucose is above 125
  • 2 hour postprandial above 219
  • 2 or more abnormal OGTTs

Pyelonephritis

Signs/Symptoms

• Fever
• Chills
• Flank pain and tenderness
• CVAT
• Nausea
• Vomiting
• Cystitis symptoms
• Tachycardia
• Fetal tachycardia
• Dehydration
• Preterm labor

Thrombophlebitis

Symptoms and Treatment

Superficial Thrombophlebitis Symptoms:

• Leg pain
• Localized heat
• Tenderness
• Inflammation of the site
• Palpation of a knot or cord

Deep Thrombophlebitis Symptoms:

• Elevated temperature
• Sudden onset
• Severe pain that worsens upon moving or standing
• Lower extremity edema
• Positive Homan's sign
• Pain with calf pressure
• Tenderness of the involved vessels with palpable cord

Treatment: Immediate transport

Definition: Lower than normal amount of amniotic fluid

Causes:

• IUGR
• Postmaturity syndrome
• Fetal anomalies

Risk: Cord compression, fetal distress, hypoxia

Definition: Greater than normal amount of amniotic fluid

Found more often in: Multiple gestation, Rh incompatibility, diabetes, fetal anomalies associated with atresia of the esophagus, hydrocephaly, anecephaly, spina bifida

Treatment: None, evaluate via ultrasound for possible cause

Risks: preterm birth, uterine dysfunction, placental abruption, postpartum hemorrhage, cord prolapse, malpresentation

Breech Presentation

Types

• Frank - butt first, legs extended upwards, least likely breech presentation for cord prolapse (0-2%)
• Complete - butt first, legs crossed, more likely breech presentation for cord prolapse (5-10%)
• Footling - feet first, most likely breech presentation for cord prolapse (10-25%)

Breech Presentation

Management of Second Stage

• Descent - breech should be at zero station by 6cm dilation, and should be at the pelvic floor at full dilation.
• No pushing until completely dilated.  Some midwives recommend an hour of patience.
• Loop of cord - most books recommend bringin out a loop of cord to reduce tension on the cord, but studies do not support this.
• Position of mother - upright, supported squat, or semi-sit at the edge of the bed.
• Make sure the room is warm
  
• If legs don't come out on their own, reach along side and push out towards the hips to extract the foot and leg one at a time.
• Cover the body with a warmed towel
• Arms - if extended, reach in and slide them out.  If behind baby's head, grab the hips and rotate the baby 180 degrees to free them.
• When hairline appears, lift baby up and have assistant provide suprapubic pressure.
• If head is not born spontaneously, drape baby on your arm, and use your fingers alongside the nose and pull down on the maxilla, while using other hand on the occiput to assist flexion

Twins

Management of Second Stage

• Setup - 4 cord clamps marked with two each Baby A and Baby B, 2 resuscitation units, warmed blankets
• FHT Ausculation - 2 Dopplers or fetoscopes, listen simultaneously, can mark the belly with different color waterproof markers
• Nuchal cord - leave intact
• Cord after Baby A - clamp both ends and do not drain the placental end of the cord.
• Position of Baby B - assist the baby to get into a longitudinal lie
• Cord after Baby B - allow to remain unclamped unless the baby is small and weak (could be TTTS), if so, clamp soon but not immediately.
• Placenta(s) - work on placenta A first, remove cord clamp A to drain the placenta

Twins

Complications

• Obstruction due to positioning
  • Collision - parts of each twin come into contact with each other and prevent engagement of the presenting part
  • Impaction - indentation of  part of one baby against the other, permitting partial engagement of both
  • Compaction - presenting parts of both babies become fully engaged, preventing descent of either
  • Interlocking - descent of one baby is arrested because part of his body is caught on that of the second baby.
• Monoamniotic gestation - cord entanglement, anastomoses (vascular communications) between two fetuses
• TTS
• Conjoined twins
• Fetus papyraceus

Ectopic Pregnancy

Signs/Symptoms

All of the signs and symptoms of early pregnancy; false negative result on pregnancy test (in 33% of cases); lower abdominal pain and tenderness; symptoms occurring between 5 and 10 weeks of pregnancy; referred pain in shoulder, back, chest; dizziness; signs of shock.  Tubal pregnancies may have crampy lower abdominal pain (often on one side) and slight brownish vaginal bleeding. (Holistic Midwifery, Volume I, p. 724-727)

Hydatidiform Mole

Definition

Hydatidiform mole “results from the abnormal development of the chorionic villi, which ordinarily form the membranes and placenta, but in this case, become a mass of clear, grape-like vesicles filling the uterus.”   It is caused from the fertilization of one ovum by one or two sperm where the nucleus of the ovum is absent or inactive.

Hydatidiform Mole

Symptoms

Symptoms of hydatidiform mole include vaginal bleeding starting around the 12th week of pregnancy (watery red and profuse, or brownish due to the presence of old blood) and excessive vomiting and nausea.  If the mole is still attached to the uterine wall, the uterus will be large for gestational dates (reaching the navel by 12 weeks of pregnancy).  If the mole has detached from the uterine wall, the uterus may be normally sized or even smaller than expected.  Multiple lutein cysts cause the ovaries to enlarge, becoming almost as big as the uterus.  No fetal movement or fetal heart tones will be present, and no fetal parts may be palpated.  The uterus will feel doughy to the touch, with pain and tenderness due to distension from the mole.  Hypertension and proteinuria may be present.  hCG levels will be exceptionally high for dates.

Placenta Abruption

Symptoms

Bleeding (unless it is a concealed abruption) and abdominal pain are common signs.  Varney says that placental abruption is often mistaken for false labor since back pain and discoordinate uterine activity are sometimes present.  The uterus is very hard, board-like.  If the abruption is concealed, the mother will have all the signs of hypovolemic shock and the uterus will enlarge and be extremely painful.  Myles says the most severe hemorrhages from abruptions are from concealed abruptions, which I imagine is because since there is no visible bleeding, more blood might be lost before action is taken to stop it.

Placenta Abruption

Risk Factors

Blunt trauma to the abdomen, preeclampsia, placenta previa, advanced maternal age, high parity, maternal smoking, poor nutrition, chorioamnionitis, history of previous placental abruption, external cephalic version, sudden decrease in uterine volume or size, and crack cocaine usage (Varney, p. 703-704).

Placenta Previa

Risk Factors

Multiparous, advanced maternal age, previous placenta previa, previous uterine surgery, multiple pregnancy, smoking (Varney, p. 703).

Placenta Previa

Symptoms

Painless vaginal bleeding with sudden onset, especially during the third trimester.

FHT

Beat to Beat Variability

FHT

Long-term Variability

FHT

Variable Decelerations

FHT

Early Decelerations

FHT

Late Decelerations

FHT

Sinusoidal Pattern

LOT

Presentation

• FHT heard loudest to the left of midline, below umbilicus
• Sagittal suture goes side to side and is central if the presentation is synclitic, off-center if asynclitic
• Anterior fontanel on right side during VE

ROT

Presentation

• FHT heard loudest to the right of midline, below umbilicus
• Sagittal suture goes side to side and is central if the presentation is synclitic, off-center if asynclitic
• Anterior fontanel on left side during VE

LOP

Presentation

• FHT heard loudest on the far left side, below umbilicus
• Sagittal suture goes at a slant from 4:00 to  10:00, and is central if the presentation is synclitic, off-center if asynclitic
• Anterior fontanel on right side at 10:00 during VE

Cervix

Anatomy and Physiology

Length before effacement - 2 to 3 cms

Very few oxytocin receptors

Mostly connective tissue

Rates 5 factors to evaluate the cervix readiness or need for pre-induction ripening.  Max score is 13:

Position: Posterior (0), Midposition (1), Anterior (2)

Dilation:  0cms (0), 1-2cms (1), 3-4 cms (2), 5+cms (3)

Effacement: 0-30% (0), 40-50% (1), 60-70% (2), 80%+(3)

Station: -3 (0), -2 (1), -1/0 (2), +1/+2 (3)

Consistency: Firm (0), Medium (1). Soft (2)

Mnemonic: Please Don't Even Start Contracting

• Evening primrose oil
• Bellis Perennis 30C
• L Side, H&K, R Side, Supine, repeat
• Ice
• Pushing the lip back while she bears down

• Denominator is the mentum
• Impossible for RMP and LMP to be born vaginally
• Molding is front and back, with the top of the head being flat

OP

Presentation

• H&K helps to relieve back pain with OP, and can help baby rotate to anterior
  
• Lying on left side with knees below her bottom can help baby rotate to anterior
• Deep knee-chest (shoulders to floor, butt in the air)
• Exaggerated Sims (L side Bradley pose, upper leg supported by pillows
• Stroking the baby over
• Belly lifting
• Manual rotation

Shoulder Dystocia

Sequence of Maneuvers

• McRoberts Maneuver
• Suprapubic Pressure
• Gaskin Maneuver
• Rotational Maneuvers (Woods’ and Rubin)
• Posterior Arm Release
• Zavanelli Maneuver

Meconium Aspiration Syndrome

Defined

Meconium aspiration syndrome is an irritation and blockage of the lungs caused by the inhalation of meconium and amniotic fluid at birth.  Meconium aspiration syndrome includes airway obstruction, chemical pneumonitis, and surfactant dysfunction.

Meconium Aspiration Syndrome

Signs/Symptoms

• Meconium in the amniotic fluid
• Signs of respiratory distress, including rapid breathing and cyanosis.
• When listening to the lungs, there might be a crackling sound.
• Barrel shaped chest, which would indicate an overinflation of the lungs.
• Pneumothorax (occurs in 20% of babies with MAS) could also be present because of the overinflation of the lungs.

Persistent Pulmonary Hypertension of the Newborn

(PPHN)

Definition

PPHN is caused by inadequate lung inflation that results in a fall in pulmonary vascular resistence.  Because of this, some of the newborn physiological changes in the cardiopulmonary system do not completely change over from the fetal state.  The fetal cardiovascular pathways become reactivated.  Blood flows through the foramen ovale and ductus arteriosis, resulting in poor oxygenation of the baby.

Meconium Ileus

Defined

Meconium ileus is obstruction of the terminal ileum by abnormally tenacious meconium; it almost universally occurs in neonates with cystic fibrosis. Meconium ileus accounts for up to 33% of neonatal small-bowel obstructions.

Uterine Rupture

Signs/Symptoms

Abdominal pain, sensations of uterine contractions without having cervical changes, uterine tenderness when palpated, vaginal bleeding, vomiting, absence of FHT and symptoms of shock (rising pulse, pallor, faintness).

Amniotic Fluid Embolism

Signs/Symptoms

• Abrupt onset of hypotension, hypoxia, and disruption of coagulation
• Woman suddenly gasps for air, develops seizures, and goes into cardiorespiratory arrest and has DIC
• Knife-like chest pain

Missed Abortion

Definition

Miscarriage where the baby dies but the products of conception are not expelled from the uterus for two months or longer

Spontaneous Abortion

Definition

Incomplete Abortion

Definition

Intrauterine Fetal Death

Definition

Fetal Demise

Definition

Missed Abortion

Signs/Symptoms

Miscarriage

Signs/Symptoms

• Appearance (color)
• Pulse (heart rate)
• Grimace response (reflex irritability)
• Activity (muscle tone)
• Respiratory effort

• keep baby warm
• make initial newborn assessment
• determine APGAR score at 1 minute, 5 minutes, 10 minutes (as appropriate)
• keep baby and mother together
• monitor respiratory and cardiac function

Respiratory Distress Symptoms

(Newborn)

• asymmetry of the chest
• nasal flaring
• grunting
• retractions
• circumoral cyanosis
• central cyanosis

• Rub up the baby’s spine
• Encourage parental touch, and call newborn’s name
• Flick or rub the soles of the baby’s feet
• Keep baby warm
• Rub skin with blanket

• Provide Warmth
• Position, clear airway as necessary
• Dry, stimulate, reposition
• (At 30 seconds) Evaluate respirations, heart rate, color
• If apneic or heart rate below 100 bpm, start PPV
• If cyanotic, breathing, HR>100, give blow by O2
• Chest compressions if HR<60

Assessment of

Perineal Lacerations

• 1st Degree – fourchette only
• 2nd Degree – fourchette and superficial perineal muscles (bulbocavernosus, transverse perineal, and pubococcygeus)
• 3rd Degree – involves the same structures of 2nd degree plus damage to the anal sphincter
• 4th Degree – laceration extends into the rectal mucosa

• Well-rounded
• Sacrum and symphysis pubis are parallel
• Sidewalls straight
• Ischial spines blunt
• Pubic arch >90 degrees

• Heart-shaped inlet
• Sacrum is anteriorly inclined and flat
• Sidewalls are convergent
• Ischial spines are prominent
• Pubic arch is narrow, <90 degrees

• Favors posterior position of baby
• Deep and oval, with large antero-posterior diameter
• Sacrum is posteriorly inclined and long
• Sidewalls somewhat convergent
• Ischial spines prominent but not encroaching
• Pubic arch is somewhat narrow

• Like a flat gynecoid pelvis
• Opposite of the anthropoid pelvis
• Sacrum inclined posteriorly, hollow, short
• Pelvis is shallow
• Sidewalls slightly convergent
• Ishial spines are somewhat prominent
• Pubic arch is quite wide
• Pelvis is wide from hip to hip, narrow from front to back

1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. Restitution
7. Expulsion

Mnemonic device: Even Dumb Fools Instinctively Evade Rectal Exams

• Calculated by adding the systolic to twice the diastolic pressure and dividing by 3.
• Example: BP= 130/70, MAP = (130+ 2(70))/3, which is 270/3 or 90.

Bacterial Vaginosis

Signs/Symptoms

Trichomoniasis

Signs/Symptoms

Chlamydia

Signs/Symptoms

Uterine Infection

Signs/Symptoms

• Elevated temperature
• Not feeling well
• Pain
• Foul-smelling lochia
• Elevated pulse could be present if the infection is severe

Urinary Tract Infection

Signs/Symptoms

• Urinalysis shows nitrites
• Pain during urination
• Urgent need to urinate
• Increased urinary frequency

Infection of

Vaginal Tear or Incision

Signs/Symptoms

• Inflammation
• Pain
• Discharge

Postpartum Depression

Signs/Symptoms

• Feelings of inadequacy, worthlessness, or guilt, especially failure at motherhood
• Loss of interest or pleasure in activities that used to bring pleasure
• Excessive anxiety over the baby’s health or, the opposite, lack of interest in the baby
• Inability to care for yourself or your baby
• Restlessness, irritability, or excessive crying
• Changes in appetite, such as forgetting to eat or overeating
• Changes in sleep, such as waking in the night, having racing thoughts, and not being able to go back to sleep
• Difficulty concentrating, remembering, or making decisions
• Hopelessness and profound sadness
• Uncontrollable mood swings, including feelings of rage or anger
• Feeling overwhelmed or unable to cope
• Fear of being alone

Postpartum Psychosis

Signs/Symptoms

• Rapid speech
• Visual or auditory hallucinations
• Delusions
• Delirium
• Mania
• Extreme agitation
• Inability to sleep
• Irrational speech or behavior
• Paranoia

Late Postpartum Hemorrhage

Causes

• Subinvolution of the placental site
• Retained placental fragments or membranes
• Previously undiagnosed reproductive tract laceration
• Hematoma

Late Postpartum Hemorrhage

Signs and Management

• Obvious external bleeding
• Signs and symptoms of shock and anemia
• Consult/Transport

• Gauze and vaseline/A&D ointment for 24 hours left undisturbed.  If it falls off, replace it.
• Dressing removed after 24 hours
• Gauze 2x2 with a teaspoon or so of vaseline/A&D ointment should be put over the penis at every diaper change for one week.
• Signs of infection should be referred to the person who performed the circumcision.

Thrush

Signs/Symptoms

• Persistent nipple pain in the early weeks of breastfeeding, or nipple pain that appears after several weeks or months of pain-free nursing, may be caused by thrush which is a yeast infection of the nipples
• Itchy or burning nipples that appear pink or red, shiny, flaky, and/or have a rash with tiny blisters
• Cracked nipples
• Shooting pains in the breast during or after feedings
• Intense nipple or breast pain that is not improved with better latch-on and positioning
• Deep breast pain

Thrush

Treatment

• Nystatin (prescription)
  
• OTC Miconazole
• Gentian Violet
• Rinse nipples with a solution of 1 tablespoon of vinegar to 1 cup of water, and air dry after feedings
• Boil bottles, bottle nipples, pacifiers, and cloth nursing pads, breast pump parts, anything that has come into contact with your baby's mouth or your breasts
• Probiotics
• Reduce dietary sugar and yeast

Sore Nipples

Treatment

• Apply topical agents (Lansinoh)
• Expose to air
• Suggest alternate nursing positions
• Evaluate baby’s sucking method
• Apply expressed milk

Mastitis

Signs/Symptoms

• Localized tenderness, redness, heat
• Systemic reactions of fever, malaise, and sometimes nausea and vomiting

Mastitis

Treatment

• Bedrest
• Frequent nursing, starting on the less sore side first
• Alternate heat before feedings, and cold compresses to reduce swelling afterwards
  
• Massaging from above the lump towards the nipple
• Homeopathics - Bryonia, Arnica, Phytolaca, Belladonna
• Echinacea tincture
  
• Antibiotics if the fever goes above 103

Physiologic Jaundice

Cause

HbF (fetal hemoglobin) has a greater affinity for oxygen than HbA(adult hemoglobin), and it is found in greater concentration in fetal blood than HbA would be in adult blood.  This allows oxygen transfer from the maternal blood at the placental site to happen more easily.  When the baby is born, it no longer needs HbF due to the higher oxygen content of room air.  The baby’s bone marrow, in response to this, starts to make HbA.  The fetal red blood cells containing extra hemoglobin are destroyed over the first few days after birth (hemolysis).

Bilirubin comes from the catabolism of hemoglobin.  Heme is broken down into biliverdin, iron, and carbon monoxide.  Iron gets recycled to create more heme, carbon monoxide is excreted by the lungs, and biliverdin is transformed into unconjugated bilirubin (Understanding Diagnostic Tests, p. 1092-1093).

Unconjugated bilirubin binds to albumin and is transferred to the liver.  The liver processes the bilirubin with the help of liver enzymes, making it into conjugated bilirubin.  Conjugated bilirubin is water soluble.  98% of conjugated bilirubin is excreted via bile into the intestines.  Intestinal flora breaks the bilirubin down into urobilinogen and is excreted in the feces.  The other 2% is excreted in urine (Understanding Diagnostic Tests, p. 1093).

The newborn GI tract is sterile at birth and needs to be colonized by intestinal flora before it can break the conjugated bilirubin down into urobilinogen and excrete it into the feces.  This process can take a few days to be established.  Also, for the first few days after birth, the mother is producing colostrum in small amounts, which decreases the amount of bilirubin excreted.  Because of this, bilirubin builds up in the baby’s body, creating jaundice.

ABO Jaundice

Cause

When the mother has one blood type and the baby has another, she may produce antibodies against her baby's blood type (similar to Rh negative moms).  The antibodies attack the baby's red blood cells and cause hemolytic jaundice.

Jaundice

Warning Signs

Vomiting, lethargy, poor feeding, hepatosplenomegaly, excessive weight loss, apnea, temperature instability, tachypnea, dark urine, urine positive for bilirubin, light colored stools, persistent jaundice for more than three weeks (Varney, p. 1027).  Anne Frye also lists unusual or high-pitched cry, fever, onset in first 24 hours, extreme jaundice at any time, and onset of 2nd rise after peak occurred (Understanding Diagnostic Tests, p. 1103).

Jaundice

Visual Progression

1. Head and neck
2. Trunk to umbilicus
3. Groin and thighs; upper arms
4. Knees to ankles; elbows to wrists
5. Hands and palms; feet and soles

Excessive red blood cells. Infant with polycythemia will appear ruddy at birth.  "True polycythemia is the result of chronic intrauterine hypoxia.  The baby compensates for this hypoxia by producing an excessive amount of red blood cells" (Anne Frye, regarding the controversy of delayed cord clamping causing polycythemia)

Infection in Newborn

Signs/Symptoms

• Apnea
• Diminished Activity
• Poor Feeding
• Temperature Instability
• Respiratory Distress
• Poor Color

HSV Infection in Newborn

Signs/Symptoms

Irritability, seizures, respiratory distress, and shock (Maternal and Newborn Care, p. 19-11).  Neonatal herpes infection manifests in three ways: disseminated (20% of cases), SEM (skin, eyes, mouth – 1/3 of cases) lesions, or CNS disease (40-45% of cases).  In disseminated disease, about 20% of the babies have skin lesions. (AAP Red Book, http://aapredbook.aappublications.org/cgi/content/extract/2009/1/3.57)

It can be hard to diagnose neonatal herpes if lesions aren’t present.  This is because you wouldn’t necessarily suspect herpes unless you saw lesions.  The AAP suggests suspecting herpes if there are signs of sepsis, negative bacteriological cultures, also severe liver dysfunction.

Glucose Disorders in Newborn

Screening/Signs/Symptoms

• Birthweight >4000 grams
• Tremors
• Early jaundice
• Unexplained respiratory distress
• Polycythemia (hematocrit >65%)
• Screen for hypoglycemia by doing a glucose test.  If below 36 (if asymptomatic) or 45 (if symptomatic), baby will need IV fluids with dextrose. TRANSPORT

Failure to Thrive

Definition

“Failure to thrive is a description applied to children whose current weight or rate of weight gain is significantly below that of other children of similar age and sex” (Medline Plus).