Chapter 4

1. Chapter 4 Neonatal Assessment and Resuscitation

2. Labor and Delivery Terms • Departments: L & D, OB, Post Partum, Antepartum, NICU, Nursery • APGAR: A measurement of the newborn's response to birth and life outside the womb. The ratings, APGAR, are based on Appearance (color), Pulse (heartbeat), Grimace (reflex), Activity (muscle tone), and Respiration (breathing). The scores, which are taken at 1 and 5 minutes following birth, range from 10 to 1, with 10 being the highest and 1 being the lowest.

3. Labor and Delivery Terms • Breech: When the fetus is positioned head up to be born buttocks first or with one or both feet first. • Cephalopelvic Disproportion(CPD):The baby is too large to safely pass through the mother's pelvis. • Cervidil: A medication used to ripen the cervix before induction. • Cesarean: An incision through the abdominal and uterine walls for extraction of the fetus; it may be vertical or more commonly, horizontal. Also called abdominal delivery; commonly called C-Section.

4. Labor and Delivery Terms • Colostrum: This is a thin, white fluid discharged from the breasts in the early stage of milk production, and usually noticeable during the last couple weeks of pregnancy • Complete Breech: The baby's buttocks are presenting at the cervix, but the legs are folded “Indian style,” making vaginal delivery difficult or impossible. • Contraction: The regular tightening of the uterus, working to push the baby down the birth canal. • Crowned/Crowning: When the baby's head has passed through the birth canal and the top or “crown” stays visible at the vaginal opening.

5. Labor and Delivery Terms • Dilation: The extent to which the cervix has opened in preparation for childbirth. It is measured in centimeters, with full dilation being 10 centimeters. • Effacement: This refers to the thinning of the cervix in preparation for birth and is expressed in percentages. You will be 100% effaced when you begin pushing. • Epidural: A common method of anesthesia used during labor. It is inserted through a catheter which is threaded through a needle, into the dura space near the spinal cord. • Episiotomy: An incision made to the perineum to widen the vaginal opening for delivery.

6. Labor and Delivery Terms • Fontanelle: Soft spots between the unfused sections of the baby's skull. These allow the baby's head to compress slightly during passage through the birth canal • Forceps: Tong shaped instrument that may be used to help guide the baby's head out of the birth canal during deliver • Frank Breech: The baby's buttocks are presenting at the cervix and the baby's legs are extended straight up to the baby's head. • Induced Labor: Labor is started or accelerated through intervention, such as placing prostaglandin gel on the cervix, using an IV drip of the hormone oxytocin (Pitocin), or by rupturing the membranes.

7. Labor and Delivery Terms • Lightening: When the baby drops in preparation for delivery (Engagement). • Meconium: This is the greenish substance that builds up in the bowels of a growing fetus and is normally discharged shortly after birth • Nubain: Synthetic narcotic pain reliever commonly used in labor and delivery. • Oxytocin: Hormone secreted by the pituitary gland that stimulates contractions and the milk-eject reflex. Pitocin is the synthetic form of this hormone. • Perineum: The muscle and tissue between the vagina and the rectum.

8. Labor and Delivery Terms • Phenergan: A sedative administered that also controls nausea and vomiting. • Placenta Previa: When the placenta partially or completely covers the cervix. • Prostaglandin Cream: Medication used to ripen the cervix before induction. • Ruptured Membranes: Usually refers to the breaking of the fluid filled sac surrounding the baby. The fluid may come as a gush of water or as a slow leak. Slow leaks are sometimes mistaken as incontinence. • Speculum: An instrument used to open the vagina slightly wider so that the cervix can be seen more easily.

9. Labor and Delivery Terms • Timing Contractions: Contractions are measured from the beginning of one contraction until the beginning of the next contraction. • Tocolysis: Inhibition of contractions used to suppress premature labor with medications, Magnesium Sulfate, Terbutaline, Ritodrine • Transverse: Baby's body length is horizontal in the uterus. If the baby cannot be moved, it will have to be delivered by cesarean . • Vacuum Extractor: Instrument that attaches to the baby's head and helps guide it out of the birth canal during delivery. • Betamethasone: glucocorticoid drug which greatly accelerates fetal lung maturity, but takes one to two days to work.

10. Labor and Delivery Terms • Chorioamnionitis: an inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection. • Prelabor Rupture of Membranes (PROM) or Premature Rupture of Membranes as it is sometimes known, is a condition that occurs in pregnancy when there is rupture of the membrane of the amniotic sac and chorion more than one hour before the onset of labor • Umbilical cord prolapse happens when the umbilical cord precedes the fetus' exit from the uterus. It is an obstetric emergency during pregnancy or labor that imminently endangers the life of the fetus. Cord prolapse is rare

11. Labor and Delivery Terms • Para – the number of births (alive or not) with a viable infant > 22 weeks and at least 500 grams • Gravida – the number of pregnancies • Pre-eclampsia (toxemia)-Usually occurs at > 24 weeks gestation, Acute hypertension, edema, renal impairment (proteinuria), sudden weight gain, Occurs in 7% of pregnancies, More common in low socioeconomic groups • Eclampsia; Toxemia, seizures, coma, convulsions, hemolysis, renal failure, 5% of women with pre-eclampsia develop eclampsia, 15% die from complications; Associated with high fetal mortality due to premature delivery • Dystocia: Difficult birth

12. Neonatal Resuscitation • Newly born – infant at time of birth • Newborn – within first few hours of birth • Neonate – within first 30 days of delivery • Pre-term – less than 37 weeks of gestation • Term – 38 to 42 weeks of gestation • Post-term (post-date) – greater than 42 weeks of gestation • http://vimeo.com/31423498

13. General Pathophysiology and Assessment • Approximately 10% of newborns require assistance to begin breathing • Extensive resuscitation needed in less than 1% of newborns • Rate of complication increases as the newborn weight and gestational agedecrease • 80% of 30,000 babies born each year weighing less than 3 lbs. (1,500 grams) require resuscitation

14. Factors that indicate high risk delivery • Factors can be divided into maternal and fetal. • Maternal factors include age (younger than age 15, older than age 35) • weight (pre-pregnancy weight under 100 lb or obesity) • height (under five feet) • history of complications during previous pregnancies (including stillbirth, fetal loss, preterm labor and/or delivery, small-for-gestational age baby, large baby, pre-eclampsia or eclampsia) • more than five previous pregnancies • bleeding during the third trimester • abnormalities of the reproductive tract • uterine fibroids • Hypertension • Rh incompatability • gestational diabetes • infections of the vagina and/or cervix • kidney infection • Fever • acute surgical emergency (appendicitis, gallbladder disease, bowel obstruction) • post-term pregnancy • pre-existing chronic illness (such as asthma, autoimmune disease, cancer, sickle cell anemia, tuberculosis, herpes, AIDS, heart disease, kidney disease, Crohn's disease, ulcerative colitis, diabetes)

15. Factors that indicate high risk delivery • Fetal factors include • exposure to infection (especially herpes simplex, viral hepatitis, mumps, rubella, varicella, syphilis, toxoplasmosis, and infections caused by coxsackievirus) • exposure to damaging medications (especially phenytoin, folic acid antagonists, lithium, streptomycin, tetracycline, thalidomide, and warfarin) • exposure to addictive substances (cigarette smoking, alcohol intake, and illicit or abused drugs) • A pregnancy is also considered high-risk when prenatal tests indicate that the baby has a serious health problem (for example, a heart defect). In such cases, the mother will need special tests, and possibly medication, to carry the baby safely through to delivery. Furthermore, certain maternal or fetal problems may prompt a physician to deliver a baby early, or to choose a surgical delivery (cesarean section) rather than a vaginal delivery.

16. The Birth Process • At the onset of true labor, the contractions will feel like a tightening of abdominal muscles, a dull ache or a pressure on the lower pelvis or back. • At about this time the baby drops down into the pelvis; this is known as engagement because the baby has settled into its position for birth. Another term aptly used is lightening because the baby's new position means the mother has now more space to breathe and digest food. • With time the contractions start to come at a more regular pace and the pain intensifies. The sensation is like a belt tightening around your back which spreads round underneath the baby. As the labor progresses the contractions last longer and occur at decreasing intervals.

17. The Birth Process • Bloody Show: A plug of mucous which seals the top of the vagina acts as a barrier against infection from invading the uterus. Sometimes this plug dislodges itself before the contractions commence and you will notice a 'show' i.e. thick vaginal discharge mixed with blood in the patient’s underwear. • This however is no indication that you are into proper labor; it may be several days before the action commences. In other instances, the contractions begin well before the expulsion of the mucous plug.

18. The Birth Process • Water Break: In about 20% of women, the pressure of the baby's head can puncture the amniotic bag causing the fluids to leak out before labor. Often it occurs in later part of labor. There is no mistaking a rupture; the leakage is clear and watery from the vagina and you can lose as much as 2 pints of fluid. The water can gush out or come in a slow trickle. • The baby is in risk of infection and chance of umbilical cord's descent into the birth canal. Water breaking can pose a risk in the form of infection or the oxygen supply being affected.

19. The Birth Process • other symptoms; nausea, diarrhea and backache. Sometimes tightening the whole day before labor begins; this is indicative of the cervix ripening and shortening at a gradual pace or your baby could be probably lying with its back to your back. In the case of the latter the tightening occurs as the baby rotates round to assume the right position before making its entry into the world.

20. Stages of Birth • The first stage begins with the first contraction and ends when the cervix is fully dilated. The cervix undergoes many changes: it becomes softer, spongier, the cells thin out and the cervix shortens. This shortening and thinning is termed effacement. Before effacement the cervix is 1.5 inches in length and after effacement it somewhat disappears.

22. Stages of Birth • Force from the contractions combined with the pressure from baby's head slowly compels the now 'thin' cervix opening to widen. This is termed as dilation, which basically means the widening of the opening. Full dilation is at 10cm, about the width of a hand. When the cervix is beginning to dilate most mothers will feel the contractions in the back. You will be conscious of this ache but you can still go about with your normal activities. If you do not experience this, the mucous plug will soon dislodge instead.

23. Stages of Birth • The rate of dilation varies; tends to be slower in first time mothers. • On average it will take about 9 hours for the cervix to dilate 2.5 cm (the latent phase). The time varies; some women take longer, some with lesser time. • Next comes the active phase which causes the cervix to dilate from 3 - 10 cm; this phase lasts between 2 - 4 hours. Again the time varies. The pain is intense and the urge to bear down and push the baby out starts now. • On average one hour is taken up for every centimeter that the cervix dilates

24. Stages of Birth • The second stage begins at full dilation and ends when the baby makes an entry into the world. • Uterine contractions are now even more pronounced; they help in the dilation and force the baby down and out. The contractions now occur every 2-3 minutes, lasting between 1 to 1.5 minutes. • As the baby makes its descent, the mother works hard on the pushing. In a typical, normal situation, first the head descends followed by the rest of the body through the vagina.

25. Stages of Birth • It takes a first baby close to an hour to make its way down the birth canal, through the vagina to the vulva • The appearance of the baby's head at the mouth of the vagina is called crowning. • http://www.youtube.com/watch?v=vpeggjIiE9k • Following the crowning, the doctor may make a small cut into the area between the vagina and the rectum; this is called episiotomy.

26. Episiotomy

27. Stages of Birth • In the final stage, the placenta dislodges from the uterus and is expelled. • After the baby is delivered, the uterus sheds the placenta • Contractions continue even after baby is born. The uterus begins to get smaller and its walls thicker. This reduces the surface the placenta was attached. The placenta then separates and is pushed down and out of the vagina. Blood clots form immediately at the site of separation preventing any excessive bleeding. Bleeding is also controlled by the uterus contracting and closing the blood vessels that previously supported the placenta.

28. Antepartum Risk Factors • Multiple gestation • Pregnant patient <16 or >35 years of age • Post-term >42 weeks • Preeclampsia, HTN, DM • Polyhydraminos • Premature rupture of amniotic sac (PROM) • Fetal malformation (CDH, Gastroscesis…) • Inadequate prenatal care • History of prenatal morbidity or mortality • Maternal use of drugs or alcohol • Fetal anemia • Oligohydraminos

29. Risks of Multiple gestation • Preterm labor and birthAbout half of twins and nearly all higher-order multiples are premature (born before 37 weeks). The higher the number of fetuses in the pregnancy, the greater the risk for early birth. • pregnancy-induced hypertensionWomen with multiple fetuses are more than three times as likely to develop high blood pressure of pregnancy. This condition often develops earlier and is more severe than pregnancy with one baby. It can also increase the chance of placental abruption (early detachment of the placenta).

30. Risks of Multiple gestation • Anemia is more than twice as common in multiple pregnancies as in a single birth. birth defects • Multiple birth babies have about twice the risk of congenital (present at birth) abnormalities including neural tube defects (such as spina bifida), gastrointestinal, and heart abnormalities.

31. Risks of Multiple gestation • A phenomenon called the vanishing twin syndrome in which more than one fetus is diagnosed, but vanishes (or is miscarried), usually in the first trimester, is more likely in multiple pregnancies. This may or may not be accompanied by bleeding. The risk of pregnancy loss is increased in later trimesters as well. • twin-to-twin transfusion syndromeTwin-to-twin syndrome is a condition of the placenta that develops only with identical twins that share a placenta. Blood vessels connect within the placenta and divert blood from one fetus to the other. It occurs in about 15 percent of twins with a shared placenta.

32. Age Related Complications • >35 years more likely to have a multiple pregnancy. The chance of having twins increases with age. The use of assisted reproductive technologies — such as in vitro fertilization — also can play a role. • You're more likely to develop gestational diabetes. This type of diabetes occurs only during pregnancy, and it's more common as women get older. Tight control of blood sugar through diet, physical activity and other lifestyle measures is essential.

33. Age Related Complications • You're more likely to develop high blood pressure during pregnancy. Some studies suggest that high blood pressure that develops during pregnancy — before 20 weeks (chronic hypertension), after 20 weeks (gestational hypertension) or after 20 weeks and accompanied by protein in the urine (preeclampsia) — might be more common in older women. • The risk of chromosome abnormalities is higher. Babies born to older mothers have a higher risk of certain chromosome problems, such as Down syndrome.

34. Preeclampsia, HTN, DM • Preeclampsia is a condition that occurs only during pregnancy. Diagnoses is made by the combination of high blood pressure and protein in the urine, occurring after week 20 of pregnancy. Preeclampsia may also be called toxemia; who is at risk: • A first-time mom • Previous experience with gestational hypertension or preeclampsia • Women whose sisters and mothers had preeclampsia • Women carrying multiple babies; women younger than 20 years and older than age 40 • Women who had high blood pressure or kidney disease prior to pregnancy • Women who are obese or have a BMI of 30 or greater

35. Preeclampsia • Mild preeclampsia: high blood pressure, water retention, and protein in the urine. • Severe preeclampsia/leading to eclampsia: headaches, blurred vision, inability to tolerate bright light, fatigue, nausea/vomiting, urinating small amounts, pain in the upper right abdomen, shortness of breath, and tendency to bruise easily. Seizures and associated symptoms

36. Placenta Previa • Placenta Previa is a condition where the placenta lies low in the uterus and partially or completely covers the cervix. The placenta may separate from the uterine wall as the cervix begins to dilate (open) during labor. • Requires C-section Delivery • Signs and symptoms of placenta previa vary, but the most common symptom is painless bleeding during the third trimester. Other reasons to suspect placenta previa would be: • Premature contractions • Baby is breech, or in transverse position • Uterus measures larger than it should according to gestational age

38. HELLP Syndrome • HELLP Syndrome is a series of symptoms that make up a syndrome • HELLP syndrome is thought to be a variant of preeclampsia, but it may be an entity all on its own. There are still many questions about the serious condition of HELLP syndrome. The cause is still unclear to many doctors and often HELLP syndrome is misdiagnosed. It is believed that HELLP syndrome affects about 0.2 to 0.6 percent of all pregnancies.

39. HELLP Syndrome • What is HELLP Syndrome? • The name HELLP stands for: • H- hemolysis ( breakdown of red blood cells) • EL- elevated liver enzymes (liver function) • LP- low platelets counts (platelets help the blood clot)

40. HELLP Syndrome • The most common symptoms of HELLP syndrome include: • Headaches • Nausea and vomiting that continue to get worse (this may also feel like a serious case of the flu.) • Upper right abdominal pain or tenderness • Fatigue or malaise • A woman with HELLP may experience other symptoms that often can be attributed to other things such as normal pregnancy concerns or other pregnancy conditions. These symptoms may include: • Visual disturbances • High blood pressure • Protein in urine • Edema (swelling) • Severe headaches • Bleeding

41. HELLP Syndrome • Hemolysis -Red blood bells • Abnormal peripheral smear • Lacatate dehydrogenase >600 U/L • Bilirubin > 1.2 mg/dl • Elevated liver Enzyme levels • Serum aspartate amniotransferase >70 U/L • Lacatate dehydrogenase >600 U/L • Low Platelets • Platelet count • How is HELLP Syndrome Treated? • The treatment of HELLP Syndrome is primarily based on the gestation of the pregnancy, but delivery of the baby is the best way to stop this condition from causing any serious complications for mom and baby. Most symptoms and side effects of HELLP will subside within 2-3 days of delivery. • http://www.youtube.com/watch?v=LRWLB2T96MQ

42. Placental Abruption • http://www.youtube.com/watch?v=CLI43qRqcjw • Requires C-sec delivery, fluid replacement • Complications • PROM, Premature birth, amniotic embolism, • Hypovolemic shock • Risk factors • HTN, preclampsia, trauma, smoking

43. Fetal Alcohol Spectrum Disorders (FASD);Fetal Alcohol Syndrome (FAS) • Drinking alcohol during pregnancy can result in a number of different physical, neurological and mental effects that range in severity. These effects fall under the term “Fetal Alcohol Spectrum Disorders (FASD)”, which encompasses all the problems that result from prenatal alcohol exposure. The most known of these effects is Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE). Fetal Alcohol Effects can also be separated into two different categories: Alcohol-Related Neurodevelopmental Disorder (ARND) and Alcohol-Related Birth Defects (ARBD).

44. FAS • The effects of FAS include: mental retardation, malformations of the skeletal system and major organ systems (specifically the heart and brain), growth deficiencies, central nervous system problems, poor motor skills, mortality, and problems with learning, memory, social interaction, attention span, problem solving, speech and/or hearing. • There are also facial features that are characteristic of babies with FAS. These features include: small eyes, short or upturned nose, flat cheeks, and thin lips. These features fade as the child grows up, but the child is left with a lifetime of difficulties trying to cope with other effects.

45. http://www.youtube.com/watch?v=o-xGBjpGLdI

46. Other Antepartum risk factors • Ectopic pregnancy • Fetal growth restriction • HIV/AIDS • Listeria • Placenta Accreta • RH Factor • Tipped Uterus • UTI • Yeast Infection • Fetal position • Chicken Pox • Cytomegalovirus (CMV) infection • Gestational Diabetes • Group B Strep Infection • Intrauterine Growth Retardation (IUGR) • STD’s/STI’s • Toxoplasmosis • Hyperemesis Gravidarum

47. Intrapartum Risk Factors • Premature labor • PROM >24 hours • Abnormal presentation • Prolapsed cord • Chorioamnionitis • Meconium-stained amniotic fluid • Use of narcotics within 4 hours of delivery • Prolonged labor • Precipitous delivery • Bleeding • Placenta previa

48. Pain Control during child birth • Two options, natural child birth (deep breathing, laboring in water, massage…) or pain controlled with opiates • Opiates do not interfere with the ability to push during delivery, does not numb the pain like a epidural, can reduce anxiety • Side effects of opiates: nausea, vomiting, sedation, loss of protective airway reflexes

49. Fetal Transition • Rapid process that allows baby to breathe • Fetal lung is collapsed and filled with fluid • Reduction in pulmonary resistance

50. Causes of Delayed Fetal Transition • Hypoxia • Meconuium aspiration • Blood aspiration • Acidosis • Hypothermia • Pneumonia • Hypotension