Lecture day 3:

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					Lecture day 3:

How can moms lose so much blood in labor, but then their crit and hemglobin go
way up? B/c of loss of fluid volume: they lose most water by sweating.

Questions from the study guide:
how often baby voids on day 1: 1X
Day 2: 1-6x
Day 3 and 4: 6-8 wet diapers

RH: moms who are negative are likely to have Rh+. Mom and baby blood don't
mix but they can during labor and delivery.
We usually give Rh- moms a shot of rhogam in the middle of their pregnancy

Physiologic Jaundice: doesn't show up til about day 3, gone by 7-10 days, peaks
on day 3-5 and drops off.

10. How can you distinguish between acrocyanosis and true cyanosis?
acro= blue around extremities-- hands and feet. The issue is that they aren't as many
oxygenated RBC's in this area, it's a circulation thing.
cyanosis: 'dusky' all over, not just extremities.
also 'periorbital' and perioral cyanosis around eyes and mouth-- that's different. Might
see circumoral cyanosis during crying; it's not a time to worry about O2, they are
screaming.

Babie's hemoglobin and crit is bloody high. By adult standard they have polycythemia.
Why do they have so many RBC's? B/c the placenta gives them blood, and they don't get
as much O2 as a mommy.

Ductus venosus closes right away, the ductus arterious takes its time, and the foramen
ovale takes a while too.

Best time to gather genetic tests: right before discharge is best. PKU won't show up until
after feedings, so it's best to wait. Babies that go home w/i 12 hrs of delivery really need
those tests done again.
Most common inborn error that we screen for is: hypothyroidism. This is easily treated
but untreated can cause brain damage.

Vegan moms need vit D and B12.

APGAR score: how's the baby adjusting to extra uterine life.

fetal circulation: fetus doesn't need his lungs or liver-- mom's doing all that for them. the
ductus V takes just a little blood to the liver, and the ductus A shunts away from lungs.
Term babies' bodies O2 drops from 80 to 20%, CO2 from 40 to 70%, chemoreceptors in
the carotid arteries trigger breathing, and shutting the valves of the foramen ovale and
ducti. We also think there's something with the change in temp b/c water birth babies
don't come up screaming either-- and that's good.


Normal Newborn: General Appearance
head is 1/4 of their size
cord should be clamped w/ 2 arteries, 1 vein.
eyes aren't quite open all the way, most of the time
periods of reactivity: 1/2 hour post deliv and 10 hrs later.

Head
Caput: swelling between periosteum and scalp:Swelling of the soft tissue of the scalp
caused by pressure of the fetal head on a cervix that is not fully dilated. Swelling crosses
suture line and decreases rapidly in a few days after birth. These 'cross suture lines' and
feel mushy to the touch.
A hematoma: bruise that is under the periosteum, red, and solid: due to birth canal
trauma, instrumental birth. Could be damage to ventricles in the brain, watch these kids
for neuro, and be sure that the hematoma will go down rather than getting worse. These
kids are also more likely to get jaundice from the lysis of rbc's in that area.
"Cephalhematoma:" Subperiosteal extravasation of blood due rupture of vessels.
Swelling increases in size on second and third day after delivery. Often associated with
delivery by forceps. Swelling does not cross suture line and may take several weeks after
birth. Jaundice may occur as blood cells are broken down as the swelling resolves.
Why do we give kids Vit K? b/c babies don't have any, b/c they guts are sterile. They
need Vit K for clotting.

Eppstein pearls: normal
Make sure that the kid doesn't have teeth.

Witches' milk and newborn menses: due to mom's high estrogen levels.

Some babies just get suckling. But some moms are anal and some babies are anal.
Common mistakes on JK's list; the bottom lip is tucked in and won't get good suction.
Also, it's only on the little nip part and not the areola. Bring the baby to boob, not vice
versa-- you'll kill your back.

L: Latch on: 0-2
A: Audible swallowing 0-2
T: nipple Type (inverted (0), flat (1), nl (2)
C: mother’s Comfort level: 0-2
H: Hold (how much help mom needs (0-2)
Total: 7-10 is good!

Mom's nipples can be cracked and sore within a minute.

Lactation Physiology: Warning!! Doesn’t come with ounce marks!
Baby has to work for it, which is why preemies can't always feed. baby has to get to the
areola b/c that's where the ducts are...something...

Lying down: advanced breastfeeding position.

Contents of Breast Milk
-Has 200 constituents
-Whey protein, lactose, easy to digest fat (esp. hindmilk), vitamins, enough Fe for 1st six
      months, antibodies, IgA
-But also: HIV, drugs, alcohol, tobacco or other teratogens the mother ingests

Some HIV- babies can become HIV+ thru breast milk

Drinking beer: somehow it helps let down milk. We don't know why. We didn't hear it
      from JK.

Storage:
Room temperature (66-72°F, 19-22°C) for up to 10 hours in a refrigerator (32-
39°F, 0-4°C) for up to 8 days
Freezer compartment inside a refrigerator (variable temperature due to the
door opening frequently) for up to 2 weeks
Freezer compartment with a separate door (variable temperature due to the
door opening frequently) for up to 3 to 4 months.
Separate deep freezer (0°F, -19°C) for up to 6 months or longer.
Can't thaw milk in the microwave

Good bottle feeding: bonding and stuff happens if you do it in a good way.

Bottle in the diaper bag-- a great way to pick up bacteria.

Sometimes moms have a tough time w/ feeding, and need support to get past
the first few days.
There are lots of ways to be a “good” parent; breast feeding is not the be
    all end all.

Newborns: pretty cool, given that their brains aren't fully cooked. They have to
    eat and make waste and signal attention all on their own now.
As RN's we need to know what it looks like when babies aren't doing so hot.

Babies are: flexed usually, keep hands clenched, they're reddish from high crit
    and globin, they can have funky skin from living in water. Irregular RR and
    HR, breathe w/ their noses, that's why they sneeze. HR range: 120-160,
    180 if they're crying, 110 if sleeping. Normal RR: 30-60, w/ periods of
    apnea up to 15 or 20 seconds.

Acrocyanosis is not about cold: it's about O2. Babies are more like lizards: their
    temp comes from their environment.
Periods of reactivity: 1/2 hour, then they conk out for 10 hours, then reactivity,
etc.

Sometimes they are ugly. Ugly as hell even.

APGAR: 7 to 10. What do they usually miss? Most babies don't get a 10 1 min
apgar, usually they lose points for being bluish. HR might be off too. We want
them to be flexed and we want them to get mad at us if we poke them [reflex]. If
the 5 minute apgar is going down but WNL, do be concerned. APGAR is pretty
subjective.
One great thing: it makes us pay attention to the kid at 1 and 5 minutes

Cross their eyes: it's normal. Sometimes the epicanthal fold is big and
     makes them look pretty cross eyed too
Holes in their heads: soft spots: you won't destroy a kid by touching
     fontanels. posterior closes first, anterior last. For rapid brain growth.
     Rarely kids' skulls are too mature and there's not enough room for
     brain growth and we have to surgically make room. Also look at the
     fetal scalp electrode site and make sure its healing
Have dry skin (after the vernix absorbs)
They sneeze
Like being wrapped up tightly
Don’t get spoiled
Cord: keep clean and dry, no alcohol, no diaper friction, never pull off the
     cord even if its on by just a little thread gone by 1-2 weeks. Cords
     smell funky b/c they are decaying.

if you work w/ neonates you've gotta know whats up with their mom's
     Hx and the L&D Hx.
Prenatal: IDM?, DM babies are more likely to get high sugars: some hosps
     to BS on them routinely.
GBS+ culture: most moms get IV antibiotix in L&D, b/c we don't want
     exposure to fetus post ROM. Babies get pneumonia if they are
     exposed.
Mother’s bld type: rhogam which protects the second baby. ABO is
     another incompatibility: if mom is O, and baby is something else, mom
     can be senstitized to that, and mom's antibodies create more jaundice
     in the kiddo. We don't do routine blood types on babies. If mom is O,
     we just remember that the baby is more at risk for jaundice.
Mom's significant labs or tests, gen. history: Need to know about home
     status, syphillis, how many other kids are at home, if mom eats or not.
Intrapartum: length of labor [b/c this kid has been stressed over time, so
     may have risk for hypoglycemia, trouble breathing, etc.,] PROM
     [infection risk], medications received, anoxia, assisted birth [vaccum
     or shoulder dystocia; baby might be in pain, may have bruising, and
     vacuums sometimes do neural damage--shoulder: sometimes the
     clavicle breaks and we don't know about it, we need to watch for a
     baby who isn't moving an arm], FSE,

Determining Gestational Age: good to know b/c our conception dates
are usually off-- and we may think it's a term baby, but it might be
young. Don't base term on weight-- that's not true. Check out the
Ballard scale too.




There's also a physical scale:
      skin
      lanugo= lots equals preterm
      Vernix: less mean posterm
      plantar surface: Feet creases: term babies have plantar creases to the
           heel. Preterm may have no creases
      breast: term have breast tissue
      eye/Ear: cartilage is floppy on preterm kids
      Genitals: on males you’re looking at the scrotum—at term its crinkly, pre
           its’ smooth. Preterm girls may have equal sized inner and outer labia,
           term have larger outer labia.

      Scarf Sign: wrap the kids arm across their body [see stick figures.]
You do not have to weigh kids right away. Growth rates are normed on white
people at sea level. Are they AGA
SGA: risk for breathing problems, infection etc, risk for hypoglycemia
LGA: risk for hypoglycemia

Erythromycin ointment to eyes: for gohnorrhea and clamydia. You really gotta
get it in the eye. Parents can sign to refuse this tx. We usually don’t ask if the
parents want it b/c it’s such a risk for the baby to go blind. If a C/S baby, w/o
ROM, there’s no real reason to do it but we probably do it.

Testing on baby: Heel Stick: don’t hit the bone, it’s painful, etc
Hypothyroidism (most common)
PKU
Galactocemia
Sickle cell
CF
Congenital adrenal hyperplasia (CAH)

“Sweeties” are good when we’re about to do something mean to babies. Also use
numbing cream.

Algo: Hearing tests [1/1000 kids have hearing loss]. Gotta get the kids quiet and calm
before they go home. It’s state mandated and state paid for.

Pain and babies:
Obvious
Subtle
    Grimace, eye squeeze [closed tightly], get indents of the nasolabial line, brow
       contraction, nasolabial furrows
    Flexed and rigid
    Really quiet or restless
Pain scales for Infants: CRIES or NIPS

Stools:
Breast fed babies have smaller stools more often, bottle babies stool less frequently.

Jaundice: starts at the head and works its way down the body
Physiologic (just on face)—50% of kids are jaundiced
Pathophysiologic (all over the kid)
Breast milk: controversial- we don’t know if it really exists.

Physiologic:
> RBCs
> breakdown (60-90 days)
Liver immature
Direct bili binds with globulin & is excreted: Good!
Indirect: Unbound so absorbs into skin: Bad!!
Day 3-7
< 5/mg/dl/day
< peaks < 13 mg/dl. Rarely gets above 13
Appears healthy: eating, eliminating
Jd to nipple line

Pathophysiologic Jaundice
Risk factors:
Premature
Sepsis
Cold stress
ABO incompatibility
Excessive RBCs or release (i.e. hematoma)
Problem with liver
Native American or Asian

Major clinical markers:
Occurs within 24 hrs
> 15 mg/dl (10 in premies), > 5 mg/dl/day or > 0.5 in 4 hrs [the book was confused]
Visible jd > 10 days
Lethargic, irritable, poor feeding

We do bili tests on these kids every few hours to confirm if it’s patho-jaundice.

Breast Milk Jaundice???
Early
Day 2-4
< fluid and protein intake
< hepatic clearance
Some of the bilirubin in the intestine can get back into the body…maybe?
Rx: take off Br for 24-48 hrs??

Late
Peaks at 2 weeks
Can last up to 12 weeks
BrM interferes with conjugation or excretion of bili: mystery enzyme that intereferes with
conjugation.
Less stools
Acts normal: Thriving, gaining weight, etc. Then why do we need to treat them?
Recommend that baby stops breast feeding for 24 hrs, and if the bili goes down, it’s
probably Breast milk jaundice and not a problem.

Some hosps do this weird scan to check bili—
Bili lights: sunlight to help break down bili and get it into the intestines. You gotta cover
up their eyes, make sure they don’t get too hot, and make sure they’re getting enough
protein so that they can flush it out.

Why do we care if babies are yellow? We want to prevent kernicterous—which comes
from high sustained jaundice, kernicterious causes brain damage.

Hypothermia
Normal temp= 36.5 to 37.2
If too low: what do you do? Check their baseline, make sure they’re bundled enough.
Remember 4 ways to lose heat: convection, etc.
Wrap the kid up and check their temp again in a ½ hour or so. If they are still too cold,
throw them in an incubator. If their temp stays down, we need to look at other problems.

Hypothermia: signs: cyanosis, low RR, temp under normal limits. Don’t bathe a cold
baby ever never ever.

Cold stress: babies don’t shiver. They start burning their brown fat, increase metabolic
rate. So their o2 demands go up…but they don’t breath any more to supplement it, and
so they become hypoxic really fast. Kids’ temps can drop like a rock.

Hypoglycemia: if less than 35 mg/dl or less than 40.
At risk kids: Risks: LGA, IDM, preterm, cold stress, asphyxia
Signs: poor feeding, jittery, hypothermia, lethargic, flaccid, shrill cry, diaphoretic…we
want to avoid: seizures, coma
What to do??? Know risk factors!,Stabilize them: monitor VS, keep warm, monitor
glucose, feed them glucose, formula, etc.

Circumsicion:
Informed consent from parents: make sure you really do get informed consent.
Pain medication for patient Before and after: local block, sweeties, topical, etc.
Post op care
Check for bleeding, ability to void
Yes is does hurt.

Reasons for Circ:
Religious: bris babies are chill b/c they get sweet wine
Cultural
HIV Prevention? More and more research around this; it might be because of more
langerhaan’s cells in the foreskin?
Cleanliness?

Newborn Reflexes: we care a lot about rooting reflex, and also the startle reflex [arms
and legs out wide] [moro reflex?]
Babinski: the footprint reflex
Café au lait spots are abnormal: can be normal but if there’s more than 6 kid might have
fibromatosis or allbrights

				
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