Conception & Fetal Development

Chapter 11

Conception and Fetal Movement

Fertilization--union of an ovum and a spermatozoon--upper regions of

the fallopian tube
Fertilization occurs within 24-48 hours of ovulation and within 2 to 3
days of insemination, the average durations of viability for the ovum
and sperm
Zygote: a fertilized ovum and spermatozoon

Critical Thinking
The nurse is preparing a class on reproduction. The cell
division process that results in two identical cells,
each with the same number of chromosomes as the
original cell, should be termed:
A) Mitosis.
B) Meiosis.
C) Gametogenesis.
D) Oogenesis.

Implantation
Zygote propelled toward the uterus
Implantation occurs 7 to 10 days after fertilization
Blastocyst: trophoblast & embryoblast cells
Trophoblast cells (become placenta) allow blastocyst to
burrow into endometrium & establish communication with
maternal blood system
Implantation usually high on posterior uterine wall
Trophoblast secretes human chorionic gonadotropin (hCG)
to ensure that corpus luteum remains viable to secrete
estrogen and progesterone for first 2-3 months of gestation

Fetal Development

Ovum: ovulation to fertilization

Zygote: fertilization to implantation
Embryo: day 15 to 8 weeks
Fetus: 8 weeks to birth
Conceptus: developing embryo or fetus and
placental structures throughout pregnancy

www.youtube.com/watch?v=aRQa_LD2m4&feature=related
www.youtube.com/watch?v=HBBNu_dAGhs&feature=related

Embryonic and Fetal Structures

Decidua: endometrium of uterus that grows thicker
and vascular to support pregnancy
Deciduas basalis: directly under embryo
Deciduas capsulari: surrounds embryonic sac

Chorionic villi- fingers of connective tissue that

contain fetal capillaries at core
Extend into endometrium
Instrumental in production of placental hormones such
as hCG, hPL (human placental lactogen), estrogen and
progesterone

Embryonic and Fetal Structures

Umbilical Cord--made from the amnion and
chorion (inner & outer fetal membranes)

One vein: carries oxygenated blood from the

placental villi to the fetus
Two arteries: carry deoxygenated blood from
the fetus back to the placental villi
Filled with Whartons jelly: protects vessels and
prevents compression

Embryonic and Fetal Structures

Amniotic Fluid

Constantly being made by amniotic membrane--never becomes stagnant. Baby drinks, breathes, and
excretes it.
Functions: cushion embryo, control temperature, permit symmetric growth & development, prevent
adherence of fetus to the amnion & allow freedom of movement, cushion cord
Normal amount at term: 800-1200 mL
Hydramnios: too much fluid (more than 2000 ml)--GI tract problem?
Oligohydramnios: too little fluid----(less than 400 ml)-- disturbance in kidney function?
Complications of: hypoplastic lungs, joint abnormalities

Embryonic and Fetal Structures

Placenta

Serves as the fetal lungs, kidneys and GI tract and as a

separate endocrine organ throughout the pregnancy
Placental circulation established as early as 3rd week of
pregnancy
Grows to 15-20 separate lobes called cotyledons
By wk 20, covers approx. 1/2 surface of internal uterus
No direct exchange of blood between the embryo and
the mother during pregnancy--exchange is through
selective osmosis

Placenta

Placental Circulation
Maternal blood from spiral arteries enters intervillous
space of endometrium
Fetal chorionic villi reach into endometrium
Membrane of chorionic villi is 1 cell thick
Exchange of nutrients/substances across cell
membrane by selective osmosis

Placenta

Placenta

Placental Circulation
Ways nutrients cross placenta:

Diffusion: O2, CO2, Na, Cl

Facilitated diffuson: glucose
Active transport: essential amino acids & water-soluble
vitamins
Pinocytosis: gamma globulin, lipoproteins
phospholipids, large molecules & viruses

Placental osmosis so effective almost all

substances cross from the mother to fetus
Important to carefully screen all medications
expectant mother takes

Endocrine Function of Placenta

Human Chorionic Gonadotropin (hCG)
Maintains production of estrogen and progesterone
from the corpus luteum

Estrogen
Develops mammary glands in for lactation and
stimulates uterine growth

Progesterone
Maintains the endometrial lining of the uterus

Human Placental Lactogen (hPL)

Promotes mammary gland growth and regulates
maternal glucose, protein and fat levels (for adequate
fetal nutrition)

Fetal Circulation
Fetus derives oxygen and excretes carbon
dioxide from oxygen exchange in the placenta,
NOT lungs
Specialized structures in fetus shunt blood flow
away from non-functioning lungs to supply
important organs of the body, especially the brain
Foramen ovale (right to left atrium)
Ductus arteriosus (pulmonary artery to aorta)
Ductus venosus (umbilical vein to inferior vena cava,
bypassing liver)

Critical Thinking
During a prenatal examination, an adolescent client
asks, "How does my baby get air?" The nurse would
give correct information by saying:
A) "The fetus is able to obtain sufficient oxygen due to the
fact that your hemoglobin concentration is 50% greater during
pregnancy."

B) "The lungs of the fetus carry out respiratory gas exchange

in utero similar to what an adult experiences."
C) "The placenta assumes the function of the fetal lungs by
supplying oxygen and allowing the excretion of carbon
dioxide into your bloodstream."

Zygote Growth & Development

Cephalocaudal
3 germ layers:
Ectoderm: CNS, & peripheral nervous system
Entoderm: lungs, GI tract, bladder & urethra
Mesoderm: heart, kidneys, reproductive system

Organogenesis complete by 8 wks

Fetus vulnerable to teratogens during organ
formation

Fetal Development

Respiratory System

Alveoli & capillaries begin to form between the

24th and 28th weeks.
Surfactant, a phospholipid, is formed about the 24th
week of pregnancy.

Prevents alveolar collapse and improves infants ability

to maintain respirations
Made up of lecithin (L) & sphingomyelin (S) which is
detected in amniotic fluid.
Surge of L at 35 wks signals lung maturity. L/S ratio
analysis then (by amniocentesis) tests fetal maturity (2:1
is maturity)

Steroids given to mom (GA 24-34 wks) at risk of

preterm delivery to help mature lungs

Fact
1 in 20 newborns has an inherited
genetic disorder
Over 30% of pediatric admissions are
for genetic-influenced disorders

Genetic Counseling Outline

Genetic Counseling and considerations
Assessment of genetic disorders: history, maternal
serum screening, amniocentesis, ultrasound
Ethical and legal considerations of genetic counseling

Genetic Disorders
Inherited or genetic disorders
Genetics
Study of why disorders occur

Diploid: 46 chromosomes--body cells

Haploid: 23 chromosomes--sperm & egg
Autosomes: 22 pairs of homologous chromosomes
(matched pairs, one from each mom & dad)
Sex Chromosome: last pair of XX or XY that
determines sex
Karyotype: photo/pictorial analysis of persons
chromosomes

Karyotypes

Genetic Disorders
Problems with Number
Trisomies, monosomies, mosaicism
Most often caused by nondisjunction (failure of
paired chromosomes to separate during cell
division) in egg or sperm
Trisomy 21 (Downs), Trisomy 18, Trisomy 13
Defect in sex chromosomes: Turner (girls, X),
Klinefelter (boys, XXY)

Problems with Structure

Translocations, deletions, additions

Modes of Inheritance
Mendelian (single-gene) inheritance
Phenotype: persons outward appearance/expression of genes
Genotype: persons actual gene composition
Homozygous/Heterozygous
Dominant/Recessive

Phenotype vs Genotype
Homozygous vs Heterozygous
Dominant vs Recessive

Mendelian Inheritance
Autosomal Dominant
Affected person has
affected parent
50% chance of passing
the trait
Males & females
equally affected--dad
can pass to son

Autosomal Recessive
Can have clinically normal
parents, but both parents
must be carriers
25% chance of affected child
50% chance child is carrier
Males & females affected
equally

What is the chance of my baby having the disease?

X Linked Inheritance
X-Linked Recessive
No male to male
transmission
50% chance carrier mom
passes to son who will be
affected
50% chance carrier mom
passes to daughters who
become carriers
Affected dads cannot pass
to sons, but all daughters
are carriers

X-Linked Dominant (Extremely

rare)
Fragile X syndrome
Heterozygous females
may be affected
No male to male
transmission
Affected fathers will
have affected daughters,
but no affected sons

Genetic Counseling
Purpose
Provide accurate information
Provide reassurance
Make informed choices
Educate people about disorders

Nursing Responsibilities
Assess for signs and
symptoms of genetic
disorders
Offer support
Assist in value
clarification
Educate on procedures
and tests

Prenatal Diagnostic Testing

Prescreening
counseling:

Conditions detectable
by the screen
Diagnostic test
available if screen is
positive
Risk to mother & child
of the test
Accuracy & limitations
of the test

Assessing for Genetic Disorders

Ultrasound--best between 18-20 weeks
Detect head and craniospinal defects: anencephaly,
microcephaly, hydrocephalus

GI malformations: omphalocele, gastroschisis

Renal malformations: dysplasia or obstruction
Skeletal malformations: caudal regression, conjoined
twins

Fetal nuchal translucency: 10-13 weeks

Assessing for Genetic Disorders

Amniocentesis: 15 - 20 wks

Risks: miscarriage, bleeding, infection

Maternal age 35
Hx of child with chromosomal abnormality
Parent carrying chromosomal abnormality
Mother carrying x-linked disease
Parent with in-born error of metabolism
Both parents carrying autosomal recessive
disease
Family hx of neural tube defects

Assessing for Genetic Disorders

Pg. 174, Table 7.2--Disorders diagnosed by amnio/cvs

Chorionic villi sampling (CVS)

Biopsy & chromosomal analysis of chorionic villi

of placenta (transvaginal or abdominally)
8-12 weeks (earlier than amnio)
Risks

Limb reduction syndrome

Excessive bleeding & pregnancy loss
Infection
Rh-Negative mom needs RhoGAM
Advantages: 1st trimester,highly accurate, quicker results
than amnio

Assessing for Genetic Disorders

Maternal Serum Screening
AFP (alpha-fetoprotein): done at 15-18 wks of
pregnancy

Abnormal value:
HIGH: suspect open neural tube defect, anencephaly,
omphalocele or gastroschisis
LOW: suspect Down syndrome

Detects 85-90% neural tube defects & 80% Downs

Inaccurate dating of pregnancy is common cause of
false positive
If positive:
Ultrasound and amniocentesis

Physiological Changes of Pregnancy

(Chapter 14)
Causes: hormonal changes,
growth of the fetus, or
moms physical adaptation
Affect all organ systems
Allow oxygen & nutrients
for fetus and mom
Ready body for labor, birth
& lactation

Reproductive System
Amenorrhea: FSH suppressed by estrogen--no ovulation
Uterus: growth (hypertrophy & hyperplasia), increased
blood flow (1/6 of total maternal blood volume), Braxton
Hicks
Cervix: Goodells sign (softening), Chadwicks sign (blue
color), mucous plug seals endo cervical canal, discharge
(mucorrhea)
Vagina: hypertrophy, vascularization & hyperplasia,
secretions & acidity, Chadwicks sign
Breast changes: growth,veins, darkening & increase in
size of areola, colostrum ay 12th wk

Systemic Changes
Respiratory-tidal volume, RR, SOB, nasal congestion,
epistaxis

Gastrointestinal- N/V, saliva, smooth muscle relaxtion

causes peristalsis to slow, displacement of intestines &

stomach heartburn, bloating, constipation
Urinary-glomerular filtration rate & renal plasma flow,
frequency, nocturia, UTIs common (can cause PTL)
Integumentary- striae gravidarum, linea nigra, melasma,
spider veins, sweat & sebaceous gland hyperactivity

Cardiovascular
Blood volume 30-50% for a single baby
Hemodilution pseudoanemia

Anemia in pgncy: Hgb < 11. Hematcrit < 30%

fibrinogen & clotting fx: hypercoaguable state (DVT)
Cardiac output 30-50%, HR 15-20 BPM, palpitations

Blood pressure 2nd trimester, then returns to normal baseline

Gravid uterus causes vena cava compression (supine
hypotension syndrome), Orthostatic hypotension
Venous pressure increases in legs--edema, varicosities,
hemorrhoids

MATERNAL POSITION
& BLOOD FLOW
side lying

supine

Systemic Changes
Musculoskeletal: sacroiliac, sacrococcygeal & pubic joints
relax, increased lordosis (low backache), possible diastasis
recti (separation of rectus abdominis)

Metabolism increases: water retention;absorption of

protein, fats;insulin production; body temperature increases

Endocrine:thyroid/BMR; pancreas: insulin;

Hormones of Pregnancy (corpus luteum, then placenta):
human chorionic gonadotropin (hCG), human placental
lactogen (hPL), estrogen, progesterone relaxin

Critical Thinkng
Which of the following are diagnostic (positive) signs
of pregnancy?
A) morning sickness, enlargement of the abdomen, fetal movement
B) an auscultated fetal heart rate, fetal movement, and a visualized fetal
by ultrasound
C) positive pregnancy test, enlargement of the abdomen, nausea &
vomiting
D) amenorrhea, nausea & vomiting, fetal movement

Signs of Pregnancy
Presumptive signs: N/V, fatigue, breast tenderness,
amenorrhea, urinary freq.

Probable signs: Lab tests, Changes in pelvic organs:

Chadwicks, Goodells & Hegars signs, enlargement of
abd,

Positive signs: US evidence of fetal outline, fetal heart

audible, fetal movement felt by examiner

Psychological Response to Pregnancy

Role changes: partner?,
parenting role, social roles
Developmental stage with its
own tasks
Family dynamics very important
Can be a crisis stage
-may be cause of abuse

Psychological Responses of Mother

Intendedness
Ambivalence: normal response
Acceptance: quickening (20 wks)--baby is real

Psychological Tasks of Mother

Tasks to develop self-concept as mother
Ensuring safe passage
Seeking acceptance of child by others
Seeking commitment and acceptance of self as mother
(binding-in)--attachment formed
Learning to give of oneself on behalf of ones child

Schedule of Prenatal Visits

Every 4 weeks for first 28 weeks of gestation
Every 2 weeks until 36 weeks of gestation
Every week from 36 weeks until birth

Prenatal Care
Essential for ensuring
overall health of newborns
& moms
Low birthweight babies
Complications
Should be begun early
Preconception visit
As soon as woman learns
of pregnancy

Purposes of Prenatal Care

Establish baseline of present health

Determine gestational age of fetus
Monitor fetal development
ID women at risk for complications
Minimize risk of possible complications
Provide time for education

First Prenatal Visit

Extensive health history (pg 339)
Screening tool that IDs factors that may adversely
affect the pregnancy
Family/social profile
Hx of past illness, family illnesses, current medical
history
Gynecologic history
Obstetric history
Identify high risk factors (Table 15-2, pg 342)
Establish rapport & trust

Obstetrical History--G/P
Gravida: any pregnancy, including present
Nulligravida: never been pregnant
Primigravida: in first pregnancy
Multigravida: 2nd or more pregnancy

Para: birth after 20 wks gestation (before 20 wks:

spontaneous abortion (SAB)

Nullipara: never given birth at > 20 wks

Primipara: has had 1 birth > 20 wks
Multipara: 2 or more births > 20 wks
Multiples such as twins are counted as ONE birth

G/P
Susie Smart is pregnant.
She has four sons at home:
twins born in 1996 at 34 weeks,
then singletons born in 1998, and 2001.
She had 1 miscarriage in 2000.
What is her Gravida/Para?

G
=5
P
=3

Obstetrical History--G/P
P =TPAL

G = gravida, # of pregnancies
P is further broken down & multiples are counted:

T = # of term infants born (37 wks+)

P = # of preterm infants (> 20, < 37 wks)
A = # pregnancies ending in spontaneous or therapeutic
abortion (SAB/TAB)
L = # of currently living children

G/P vs GTPAL
Susie Smart is pregnant. She has four sons at home: twins born in 1996 at 34
wks, then singletons born in 1998, and 2001. She had 1 miscarriage in 2000.

What is her G/P?

G=5
P=3

What is her GTPAL?

G=5
T (term) = 2
P (preterm) = 1
A (abortions) = 1
L (living) = 4

Example
Nancy Tam is seeing the MD for her first PN
visit. She has 4 kids at home, two of whom
are twins and were born at 33 wks. She has
had 1 miscarriage and 1 abortion.
What is her gravida/para?

G6 P3 AB 2 (SAB 1 & TAB 1)

What is her GTPAL?

G6 T2 P1 A2 L4 or (G 6 P 2224)

????
Tracy H. is pregnant. She has one son at home born
at 38 wks. Her 2nd pregnancy ended at 10 wks
gestation. She then had twins at 30 wks. One twin
died soon after birth.
What is her G/P?
G 4 P 2 AB 1
What is her GTPAL?
G 4 P 1112

Estimated Birth Date (EDC/EDD/EDB)

Use LMP (last menstrual period)

First Prenatal Visit

(Assessment Guide, Pg. 345)

Complete Physical Exam

Pelvic exam: external genitals, vagina, cervix

Signs of pregnancy (Goodells, Hegars, Chadwicks)

Pelvic measurements: diagonal conjugate, obstetric
conjugate, ischial tuberosity diameter

Sterile speculum, pap smear

(infection, discharge, growths?)

GC, Clamydia cultures

Laboratory Work
Pg. 349

CBC
ABO & Rh type
Antibody screen
Rubella titer
VDRL or RPR (syphillis)
Hepatitis B surface antigen
Gonorrhea culture
Chlamydia culture
Alpha-fetoprotein @ 14 wks

HIV screen
Urine: glucose, protein &
ketones by dipstick.
Urinalysis: RBCs, leukocytes,
bacteria
Hereditary disease screening
Sickle cell
Tay-sachs
Cystic fibrosis

Assessment of Growth & Development

(Confirm dating of pregnancy)
Estimating fetal growth:
Fundal height: symphysis to top of fundus
McDonalds Rule: Between wks 22-34 fundal height in
cms should match no. of weeks gestation ( 2 cm)
Milestones:
12 weeks: fundus clears symphysis
20 weeks: fundus at umbilicus
36 weeks, fundus at xyphoid

Assessing Fetal Development

Fetal

Movement/Heartbeat/Ultrasound
Quickening: fetal movement felt by mom between 18-20
weeks (fetal movement record- pg 385)

Fetal heart tones by doppler (intermittent) or ultrasound

transducer (continuous)
Can be heard as early as 10th or 11th week of pregnancy
by Doppler
Normal: 110-160 BPM

Ultrasound: gestational sac by 5-6 wks

Crown-to-rump, biparietal measurements

Danger signs of Pregnancy

(Table 15-3, pg 359)

Gush of fluid from vagina

Vaginal bleeding
Abdominal pain
Temperature > 101/chills
Dizziness, blurry vision, double vision, severe headache,
epigastric pain, edema of hands/face, convulsions
Persistent vomiting
Oliguria, dysuria
Absence of fetal movement

The Amazing Newborn

Profile of a Newborn
Vital statistics

Weight: 2.5 to 3.4 kg. Immediately after birth.

Establishes baseline. Baby may lose up to 5-10%.

Length: 18 - 21 inches
Head Circumference: 32 - 35 cm
Chest Circumference: 32 - 35 cm
Vital Signs: Heart Rate 120-160 bpm; Respirations 3060 breaths/minute;
Temperature 97.6- 98.6 axillary

Profile of a Newborn
Temperature:

Can be
unstable. Guard against loss
due to:
Convection
Conduction
Radiation
Evaporation

Dry immediately with

warm blankets

Cardiovascular Changes after Birth

Closure of the ductus arteriosus/fetal shunts occurs
when a neonate takes in oxygen through the lungs for
the first time and when the lungs inflate, pressure in
chest decreases (pulmonary artery)
Common to have acrocyanosis, investigate central
cyanosis (look at mucous membranes)
Transition from fetal to postnatal circulation:
transitioning

Critical Thinking
During a prenatal examination, an adolescent client
asks, "How does my baby get air?" The nurse would
give correct information by saying:
A) "The fetus is able to obtain sufficient oxygen due to the fact
that your hemoglobin concentration is 50% greater during
pregnancy."

B) "The lungs of the fetus carry out respiratory gas exchange in

utero similar to what an adult experiences."
C) "The placenta assumes the function of the fetal lungs by
supplying oxygen and allowing the excretion of carbon dioxide
into your bloodstream."

Acrocynanosis

Cyanosis

Respiratory
Breathing is a result of replacement of air for fluid
Takes longer for a c-section baby to initially establish
effective respirations because excessive fluid blocks
air exchange space (babys chest not compressed and
squeezed in birth canal)

Factors predisposing respiration problems

Maternal history of
diabetes
Premature rupture of
membranes
Maternal use of
barbiturates or narcotics
close to birth
Non-reassuring fetal
monitoring strip
C-section birth

Cord prolapse
Low APGAR
Meconium staining
Prematurity
Postmaturity
Small for gestational age
Breech birth
Chest, heart or respiratory
tract anomalies

Newborn Assessment: Respiratory Distress

5 symptoms of respiratory distress

Tachypnea
Cyanosis
Nasal flaring
Expiratory grunting
Retractions

Transition period (1-2 hrs post birth) vs signs

of respiratory distress that persist

Sleep Wake Cycle

Supine position decreases risk for SIDS
Sleep 16 out of 24 hours, avg. of 3-4 hours at
a time (wake q 2-3 for feeding)
Dont add cereal to diet till 4-6 months of age
Infants should never sleep in parents bed

Gastrointestinal
Accumulation of bacteria in GI tract necessary for digestion
and synthesis of vitamin K
Uncoordinated peristalsis
Limited ability to digest fats & starch (deficient enzymes)
Immature cardiac sphincter-regurgitates easily
Stools 1st meconium, sticky tarlike
2nd-3rd day- transitional (diarrhea like)
BF: 3-4 light yellow/day. Formula: 2-3 bright
yellow/day
Infants receiving phototherapy have bright green stools
as a result of increased bilirubin excretion

Urinary
Very important to observe for first void
Urine light colored and odorless--kidneys do not
concentrate urine well

Immune System
Prone to infection
Inability to form antibodies until 2 months of age:
most immunizations delayed until then
Born with passive antibodies (protect against diseases
such as polio, measles, diphtheria, pertusis, chickenpox,
rubella & tetanus)

Hepatitis B vaccine: babies exposed early in life have

risk of chronic liver problems
Positive mom: HBIG (Hep B immune globulin) and
vaccine for baby

Profile of a Newborn
Reflexes
Neuromuscular
function

Rooting reflex
Sucking reflex
Swallowing reflex
Palmar grasp reflex

Profile of a Newborn
Neuromuscular
function
Moro reflex
Babinski reflex
Crossed extension
reflex

Moro or startle reflex

Senses
Hearing- yes
Vision- light and dark in the first months.
Approx 18 range.
Touch- well-developed
Taste- can discriminate
Smell- well-developed

Appearance of a Newborn
Skin: Color should be pink

Cyanosis: mottling, acrocyanosis normal. Investigate

central cyanosis. Look at mucus membranes

Hyperbilirubinemia: yellow tone to skin, sclera
Pallor: usually caused by anemia: blood loss?, blood
incompatibility?, internal bleeding?
Harlequin sign: normal, immature circulatory
system. Dependent side red, upper side pale.

Appearance of a Newborn
Skin
Birthmarks
Hemangiomas: vascular tumors
of skin
Erythema toxicum: innocuous,
pink, papular neonatal rash
Milia: unopened sebaceous
glands--tiny, white, pinpoint
papules on nose, etc.

Erythema toxicum-newborn rash

Birthmarks
Mongolian Spots: hyperpigmentation (usually
disappear by school age)

Appearance of Newborn
Skin

Vernix caseosa: white, cream cheese-like

substance, natural lubricant

Lanugo: fine downy hair on body
Desquamation: dry, peeling

Appearance of a Newborn
Head: large-1/4 body length

Fontanelles
Sutures
Molding
Caput succedaneum
Cephalhematoma

Head
Fontanelles: Anterior closes at 12 to 18 mos. Posterior closes
at 2 mos.
Sutures: separation indicates intracranial pressure. Fused
sutures abnormal--evaluate
Molding: common in vaginal births. Resolves in first few
days of life
Caput succedaneum: edema of the scalp-- crosses suture
lines. Disappears by day 3-4.
Cephalhematoma: blood between periosteum of skull bone
and bone itself. Does not cross suture line. Appears 24 hours
after birth. May take weeks to disappear. May jaundice.

Appearance of a Newborn
Eyes: gray/blue.

Permanent color after 3 mos.

Erythromycin (gonorrhea/chlamydia infection)

Ears: level, recoil, newborn testing

Nose: patency, choanal atresia?
Mouth: symmetrical opening, inspect/palpate palate
Neck: short, free rotation?, rigidity?, masses?
Chest: symmetrical, no masses, retractions

Appearance of a Newborn
Abdomen: appears slightly protuberant, bowel sounds,
bulges/masses?, 3 vessels in cord stump?

Anogenital area: imperforate anus

Male genitalia: meatus at tip, (hypo- or epi-spadias), testes descended

Female genitalia: pseudomenstruation

Back: appears flat, for completion (no pinpoint opening,

sinus or dimpling)

Extremities: all moving and symmetrical, legs bowed, clubfoot

(talipes equinovarus), subluxated hip/hip dysplagia: check thigh & gluteal

creases

Assessment for Well-Being

Apgar scoring--10 is perfect score
Done at 1, 5 & 10 minutes

Heart rate
Respiratory effort
Muscle tone
Reflex irritability
Color

Normal Apgars at 1 minute: 7 to 10

Immediate Care at Birth

Keep the newborn warm
Promote adequate breathing
pattern
Inspection and care of
umbilical cord
Eye care
Infection precautions

Critical Thinking

The nurse is planning care for a newborn. Which of the

following nursing interventions would best protect the
newborn from the most common form of heat loss?
A) Pre-warming the examination table
B) Placing the newborn away from air currents
C) Drying the newborn thoroughly
D) Removing wet linens from the isolette

Care of Newborn At Birth

Identification and
Registration
Identification Band
Birth Registration
Birth Record
Documentation (vitals,
meds,labs)

Continuing Assessment for

Well-Being

Respiratory evaluation
Physical examination
Height and weight

Laboratory studies: cord blood collected

CBC,
ABO type & Rh,
Direct Coombs if mom Rh - or Type O
C reactive protein if risk for infection

Assessment for Well-Being

Gestational age neuromuscular & physical maturity
Ballard Scale
Dubowitz Maturity Scale

Useful in determining large for gestational (LGA) and

small for gestational age (SGA)
LGA/SGA: at risk for hypoglycemia
BS < 40 mg/dL feed immediately
s/s: jitteriness, lethargy, seizures

SGA (IUGR) vs LGA babies

Periods of Reactivity (P. 690, Pilleterri)

First Period 15-30 minutes
Alert, acrocyanosis, body temp falls, irregular respirations,
vigorous reaction to stimuli

Resting Period 30-120 minutes

Color, temperature stabilizing; respirations, HR slowing;

sleeping (hard to wake up)

Second Period 2-6 hours

Quick color changes with crying/movement; temperature

increases; irregular respirations, HR; awake and
responsive; first meconium passed

Nursing Care: Newborn and Family

Initial feeding
Bathing
Sleeping pattern
Diaper area care
Newborn Screening Test
(PKU)
Test for metabolic disorders
(inborn errors of metabolism)
Done 24 hrs after first feeding

Nursing Care: Newborn and Family

Medications

Erythromycin opthalmic ointment

Vitamin K administration

GI tract unable to produce Vitamin K (needed for blood

coagulation)
O.5 mg to 1mg IM in thigh
Side effects- local irritation

Hepatitis B vaccination prior to discharge

HBIG if needed (first 12 hours)
Circumcision- per parents consent

Nutritional Allowances

Calories: 110 calories x kg/24 hours

Protein: 2.2 g x kg/24 hours
Fat: need linoleic acid
Carbohydrates: lactose intolerance rarely present in
newborn--switch to soy-based formula

Fluid: supplied by breast milk or formula,

**do not supplement with water

Nutritional Allowances
Minerals

Calcium
Iron: supplement formula-fed babies
Fluoride: breastfeeding mom should drink fluoridated H2O. Make
formulas with fluoridated H2O. Can supplement.

Vitamins: No supplementation needed until 6 mos.

Breastfeeding Promotion
WHO promotes Breastfeeding around the
world
APA advocates breastfeeding for 12 months
Baby Friendly initiatives in hospitals
breastfeeding rates and duration

Breastfeeding
Prolactin produced (stimulates milk production)
when progesterone levels fall after placenta is
delivered
Colostrum- First milk produced: thick, creamy,
yellow fluid composed of protein, sugar, fat, water,
minerals, vitamins and maternal antibodies-digestible. Has laxative effect to aid baby to excrete
meconium.

Breastfeeding
Milk flows from lactiferous
sinuses
Fore milk- constantly formed milk.
Low in fat.
As infant sucks, oxytocin is
released from the posterior
pituitary. Produces let-down
reflex
Let-down reflex- stimulation of
baby at breast, sound of baby.
Hind milk ejected.
Hind milk is formed after the letdown reflex. Higher in fat and
calories.

Infant Advantages in Breastfeeding

Less infection: moms antibodies passed, breast milk has

elements that prevent absorption of viruses & bacteria from GI

tract and that kill/inhibit bacteria & viruses
- gastroenteritis and ear infections
Ideal composition for human baby: electrolytes,
minerals, linoleic acid, trace elements, hypoallergenic-reduces allergies

Easy to digest
Reduces obesity, diabetes later in life

Maternal Advantages of Breastfeeding

Protective function in breast cancer prevention
Release of oxytocin from the posterior pituitary gland
aids in uterine involution
Empowerment effect
Reduces economic costs
Bonding
Breast milk contains lysozymes that are involved in
destroying bad bacteria

Breast Feeding and Jaundice

Jaundice occurs in 15% of breast fed babies
Pregnanediol (breakdown product of progesterone)
depresses an enzyme that converts indirect bilirubin
to direct bilirubin (accumulation of indirect bilirubin)
Encourage frequent feedings because colostrum is a
natural laxative and helps promote passage of
meconium and bile

Baby who is feeding well--getting enough

Breastfeeding

Every 2-3 hours in first weeks

Promote adequate sucking
Provide support
Techniques for burping
Multiple infants
Engorgement

Problems in Breastfeeding

Sore nipples
Supplemental feedings
Working outside of the home
Weaning
Engorgement
Mastitis

Formula Feeding
Preparation

Commercial formulas
Formula adequacy
Supplies needed
Formula preparation
Feeding techniques
75 to 90 ml of fluid per
pound of body weight
per day

rcumcision Care

rgical Removal of Foreskin

Site covered with sterile petroleum

Assess bleeding q 15 mins. for 1st hour, then q hour for 24 hr
Note first voiding
Apply diapers loosely to prevent irritation
Teach parents to keep area clean & check diaper q 4 hours
Notify provider for redness, discharge, swelling, strong odor,
tenderness, decrease in urination or excessive crying of infant.
Yellowish mucus crust may form over glans--normal, dont
wash off
Avoid premoistened towlettes--use only water to wash

Circumcision Care
Heals in a couple of weeks
Monitor for complications: hemorrhage, cold
stress/hypoglycemia, infection, urethral fistula, delayed
healing and scarring, fibrous bands.
Provide discharge instructions to parents about sign &
symptoms to report to provider.

Discharge Teaching
When to call healthcare provider:

Babys axillary temp > 100.4

> 1 episode of forceful (projectile) vomiting or frequent
vomiting over 6-hr period
Refusal of 2 feedings in a row
Lethargy, difficulty awakening baby
Cyanosis with or without feeding
Absence of breathing > 20 secs
Inconsolable crying or continuous high-pitched cry
Discharge/bleeding from umbilical cord, circumcision
No wet diapers for 18-24 hrs or < than 6-8 wet
diapers/day
Eye drainage

Hyperbilirubinemia
Hyperbilirubinemia: results from destruction
of red blood cells
Physiologic jaundice

Normal physiologic process

Does not occur in first 24 hours of life
Home care

Pathologic jaundice

Abnormal destruction of RBCs

Occurs in first 24 hours of life or persists after 1 week
Causes: hemolytic disease of newborn: Rh or ABO
blood incompatibility (mom Rh - or type O)

Hyperbilirubinemia
Physiological Jaundice (p. 690)
2nd or 3rd day of life.
Breakdown of fetal red blood
cells.
Heme and globin realeased.
Heme breaks down into
protoporphyrin which breaks
down into indirect bilirubin &
is excreted by liver in feces
Babys liver is immature

Pathologic Jaundice
Before 24 hours or persistent after day 7
Bilirubin increases more than 0.5 mg/dl/hr, peaks at
greater than 13 mg/dl or associated with anemia and
hepatosplenomegaly
Rh incompatibility/isoimmunization, infection, RBC
disorder. ABO incompatibility: positive coombs test
(test babies when mom O/O+)
Kernicterus (bilirubin encephalopathy) can result from
untreated hypergbilirubinemia with bilirubin levels at
or higher than 20 mg/dl mental retardation

Risk Factors for Hyperbilirubinemia

RBC production or breakdown (cephalohematoma,

extensive bruising from birth trauma)

Rh or ABO incompatibility
Ineffective breastfeeding & dehydration
Certain medications (aspirin, tranquilizers, and
sulfonamides)
Maternal enzymes in breast milk- fairly uncommon
Hypoglycemia
Hypothermia
Decreased liver function
Anoxia

Lab Testing
Elevated serum bilirubin (direct and indirect)
Blood group incapability between the mother and
newborn
Hemoglobin and hematocrit
Direct Coombs test--reveals presence of antibodycoated (sensitized) Rh-positive RBCs in the newborn
Electrolyte levels for dehydration from phototherapy
(treatment of hyperbilirubinemia)

Nursing Assessments of
Hyperbilirubinemia
Yellowish tint to skin, sclera and mucus membranes-observe by window
Press infants skin lightly and release and notice
yellowish tint
Note time of jaundice (integral in differentiating
between physiologic and pathologic jaundice)
Treatments: early feedings, phototherapy, exchange
transfusion

Neonatal Complications
RDS (Respiratory Distress Syndrome)
Pathophysiology:

Low-level or absent surfactant

Inspiratory effort to inflate alveoli remains high
Pulmonary resistance prevents fetal shunts from
closing
Lungs are poorly perfused and tissue hypoxia
occurs with resultant acidosis

Surfactant not formed until week 34

Neonates at Risk for Respiratory Distress

Syndrome (RDS)

Preterm infants
Infants of diabetic mothers
Infants born by cesarean
Perinatal asphyxia
Decreased O2 tension in the lungs (one cause is
meconium aspiration)
Maternal factors: PROM, barbiturate/narcotic use,
hypotension, bleeding

Assessment of Infants with RDS

S/S usually dont develop immediately post birth.
First S/S are subtle:
Low body temperature
Nasal flaring
Expiratory grunting
Sternal and subcostal retractions
Tachypnea (> 60 respirations per minute)
Cyanotic mucous membranes

Assessment of Infants with RDS

As distress continues:

Seesaw respirations
Heart failure
Pale, gray skin
Periods of apnea
Bradycardia
Pneumothorax

Therapeutic Management
Administer surfactant through ET tube
Oxygen administration (CPAP or assisted
ventilation with PEEP)
Ventilation
Indomethacin or ibuprofen to close patent
ductus arteriosus

Prevention of RDS
Tocolytics (Magnesium Sulfate, Terbutaline,
Procardia), corticosteroids (Betamethasone)
usually given between 24-34 weeks
L:S (lecithin:sphingomyelin) ratio is 2:1 in
amniotic fluid (indicates fetal maturity)

Transient Tachypnea of Newborn

When respiratory rate continues to remain high (between 80120 breaths/min) after 1 hour mark
Usually infant doesnt appear distressed but instead tired from
breathing too fast
Usually mild retractions but no cyanosis
Feeding difficulties
Usually occurs from a slow absorption of lung fluid
More common in C-section babies & preterm infants
Peaks at 36 hours and usually resolves at 72 hours
TX: close observation, O2

Critical Thinking
The mother of a three-day-old infant calls the clinic and
reports that her baby's skin is turning slightly yellow. The
nurse should explain to the mother that:
A) The baby is yellow because the bowels are not excreting bilirubin.
B) The newborn's liver is not working as well as it should.
C) The yellow color indicates that brain damage may be occurring.
D) Physiologic jaundice is normal and peaks at this age.

Critical Thinking

The nurse is caring for a newborn with jaundice. The parents question wh
the newborn is not under the phototherapy lights. The nurse explains that
the fiber optic blanket is beneficial because: (Select all that apply.)
A) The lights can be turned off intermittently.
B) The eyes do not need to be covered.
C) The lights will need to be removed for feedings.
D) Newborns do not get overheated.
E) Weight loss is not a complication of this system.