MIDTERMS NOTE FOR MATERNAL 1.

Rh Incompatibility
CHILD HEALTH CARE NURISNG
MECONIUM ASPIRATION SYNDROME
 refers to breathing problems that a newborn
baby may have when the baby has passed
meconium (stool) into the amniotic fluid
 this may happen while the baby is still in the
uterus during delivery or immediately after
birth
 meconium irritates lungs leading to
inflammation and infection
 Mother is Rh negative and fetus is Rh positive
---> mother begins to form few antibodies
against Rh positive (antigen D) ---> anemia and
hyperbilirubinemia
 Most antibodies are formed within 72 hours
after birth (there is an active exchange of fetal-
maternal blood as placental villi loosen and the
placenta is delivered) ---> antibodies will
destroy the fetal red blood cells early in the
next pregnancy if the fetus is Rh positive --->
fetus is severely compromised

Causes: Note: Woman should receive Rho immune globulin

A. hypoxia - stimulation of vagus reflex ---> relaxes (RhoGAM – passive Rh antibodies) within 72 hours after
rectal sphincter ---> releases meconium into the birth
amniotic fluid
a. aging placenta, prolonged/difficult labor 2. ABO Incompatibility
B. breech presentation – pressure on the buttocks  Maternal blood type is O and fetal blood type
expels meconium into the amniotic fluid is either A or B ---> antibodies IgM are formed
C. infection (large, does not cross the placenta) ---> no
anemia
Common signs:
a. tachypnea  Hemolysis of the blood begins with birth
b. grunting (when maternal and fetal blood are mixed as
c. retractions the placenta is loosened) ---> RBC destruction
d. cyanosis until 2 weeks
e. yellow skin and nails Assessment:
f. low APGAR score 1. Indirect Coombs Test – increased anti-Rh titer
or increased antibodies
Therapeutic Management: a. determines the level of antibodies in a
1. Place infant on a warmer – to help maintain woman during pregnancy
body temperature 2. Direct Coombs Test
2. Oxygen therapy – to provide enough oxygen in a. confirms Rh incompatibility by
the blood detecting antibodies on the fetal
3. Antibiotics – to prevent or treat infection erythrocytes in cord blood
4. Maintain a neutral thermal environment – to 3. increased reticulocyte count (immature RBC) –
prevent increase in metabolic oxygen demands because infant attempts to replace destroyed
5. Chest physiotherapy – to remove remnants of cells
meconium from the lungs 4. anemia due to RBC destruction (decreased
A. 4. Amnioinfusion – to dilute meconium in the hemoglobin)
amniotic fluid 5. heart failure due to anemia
6. Cesarean section – for deeply stained amniotic 6. extreme edema – fluids shift to interstitial space
fluid during labor 7. Hydrops fetalis
7. ventilator 8. progressive jaundice within 24 hours of life
(indicates Rh and ABO incompatibility)
Complications: Destruction of RBC ---> indirect bilirubin is released --->
1. Pneumonia jaundice
2. Respiratory distress syndrome Conditions:
3. Barrel chest Normal Total serum Bilirubin (TsB): 0 to 3 mg/100 mL
 Dangerous level: for term infants: above 20
mg/dL
 For preterm infants: 12 mg/dL and above
HYPERBILIRUBINEMIA
(HEMOLYTIC DISEASE OF THE NEWBORN) 9. hypoglycemia – stored glucose is used to
maintain metabolism in the presence of anemia
 results from the excessive destruction of red
Therapeutic Management:
blood cells by a normal physiologic process as
1. Early breastfeeding
the newborn breaks down excess red blood
2. Phototherapy
cells formed in utero
3. Exchange transfusion
Causes:
Early breastfeeding
 Stimulates peristalsis ---> bilirubin is removed
by being excreted through the feces
Phototherapy
 matures liver enzymes ---> liver converts
indirect bilirubin to direct bilirubin --->
combines with bile and excreted from the body
through feces
 infants are for phototherapy if the TsB is 10 to
12 mg/dL at 24 hours of age
Considerations:
a. lights are placed 12 to 30 inches above the
newborn’s bassinet or incubator
b. eyes should be covered (it can damage the
retina)
c. monitor temperature to prevent from
overheating SMALL FOR GESTATIONAL AGE
d. assess skin turgor and intake and output to
prevent dehydration
e. continue breastfeeding (remove infant from
the lights when feeding)
f. infant should be undressed , but with
diaper to protect ovaries/testes and to
expose much skin surface Etiology
Normal during phototherapy:
 loose bright green stools
 dark-colored urine
Exchange Transfusion
 small amounts (2 to 10 mL) of the infant’s
blood are drawn from the infant’s umbilical vein
and then replaced with equal amounts of donor
blood
 should be done under a radiant heat warmer to
keep the infant warm
 donor blood must be maintained at room
temperature Assessment
 use only commercial blood warmers to avoid
destroying red cells
After:
a. a. closely observe infant, especially vital
signs and the cord for signs of bleeding and
infection
b. monitor bilirubin levels for 2 to 3 days
THE NEWBORN AT RISK BECAUSE OF
ALTERED GESTATIONAL AGE/BIRTH
WEIGHT
 Infants need to be evaluated as soon as possible
after birth to determine their weight and Laboratory Findings
gestational age
 Birth weight is normally plotted on a growth
chart such as the Colorado (Lubchenco)
Intrauterine Growth Chart Common Problems
Terminology:
1. Term infants - born after the beginning of week
38 and before week 42 of pregnancy
2. Preterm infants- born before term (less than
the full 37th week of pregnancy) account for
approximately 7% to 19% of all births regardless
of their birth weight Therapeutic Management
3. Postterm, dysmature, or postmature- Infants
born after the onset of week 43 of pregnancy
4. Appropriate for gestational age (AGA) - Infants
who fall between the 10th and 90th percentiles
of weight for their age regardless of gestational
age
5. Small for gestational age (SGA)- Infants who
fall below the 10th percentile of weight for their
age are considered
6. Large for gestational age (LGA)- those who fall
above the 90th percentile in weight
7. Low-birth-weight infants - Infants weighing
under 2500 g
8. Very-low-birth-weight infants (VLB) - weighing
1000 to 1500 g.
9. Extremely very-low-birth-weight infants
(EVLB)- those born weighing 500 to 1000 g
 weight is below the 10th percentile expected
at term
 maybe born preterm, term, or post term
 experienced intrauterine growth restrictions
(IUGR)
a. Lack of adequate nutrition – major contributor
to IUGR
b. Placental anomaly – most common cause of
IUGR
c. Intrauterine infections (rubella, toxoplasmosis)
d. Chromosomal abnormality
e. Teratogens
f. DM
g. PIH
h. Smoking
i. Use of narcotics
10. Sonogram – demonstrates the decreased size
11. Appearance:
a) deprivation early pregnancy - below
average weight, length, and head
circumference
b) deprivation late pregnancy- reduction in
weight
c) In general: wasted appearance, small
liver, poor skin turgor, large head and
small body, widely separated skull
sutures, lusterless and dull hair, sunken
abdomen, dry umbilical cord and stained
yellow
a. CBC (increased hematocrit, increased RBC
(polycythemia)
b. Hypoglycemia – below 45 mg/dl
1. Perinatal Asphyxia
2. Hypoglycemia
3. Meconium aspiration
4. Immunodeficiency
5. Polycythemia
6. Heat loss
1. For gas exchange:
 a. clearing the airway  Infant born before the end of 37 weeks
b. preventing cold stress gestation
c. resuscitation  Weight of less than 2500 g
2. For hypoglycemia: oral feedings or IV glucose
3. For heat loss: radiant warmer or incubator Etiology: exact cause is unknown
4. Prevent infection a. Inadequate nutrition
b. Multiple pregnancies
NURSING DIAGNOSES c. Lack of prenatal care
1. Ineffective Breathing Pattern r/t underdeveloped d. Reproductive organ anomaly
chest muscles e. Early induction of labor
2. Ineffective thermoregulation r/t Lack of f. Elective CS
subcutaneous fats g. Closely spaced pregnancies
3. Risk for infection r/t immunodeficiency h. Infections
4. Impaired cognitive level r/t lack of oxygen and i. Cigarette smoking
nourishment in utero Prevention Measures:
a. Adequate prenatal care
LARGE FOR GESTATIONAL AGE b. Amniocentesis/ultrasound
 Also termed as macrosomia Assessment:
 Birth weight is above the 90th percentile on an 1. Head: larger than the chest (>3cm)
intrauterine growth chart 2. Skin: ruddy, visible veins
 An infant weighing 4000 g or more 3. Vernix Caseosa: few or absent
 Maybe preterm, term, or post term 4. Lanugo: extensive
5. Fontanelles: small
Etiology: Mothers who have/are 6. Eyes small: (+) pupillary reaction
 DM 7. Ears: large: pinna is flat and with little cartilage
 Obese 8. Extremities: limp and with no resistance when
 Multiparous moved
9. Nipples and areola: barely visible
Assessment 10. Clitoris and labia majora: large
11. Testes: undescended with small smooth scrotal
1. Sonogram – confirms LGA
sac, few rugae
2. Appearance: 12. Sucking/swallowing: absent if below 33 weeks
13. DTR/Deep Tendon Reflex: diminished
a.
immature reflexes 14. Cry: weak high-pitched
b.
extensive bruising 15. Soles of the foot: few/no creases
c.
clavicle injury Potential Complications:
d.
Prominent caput succedaneum, 1. Anemia
cephalohematoma, or molding 2. Kernicterus
Common Problems 3. PDA (patent ductus ateriosus)
1. Cephalopelvic disproportion (CPD) CS is advised 4. Periventricular/Intraventricular Hemorrhage
2. Shoulder dystocia 5. RDS
3. Birth trauma/injury 6. Retinopathy of prematurity (retrolental
4. Hypoglycemia fibroplasia)
5. Diaphragmatic paralysis 7. Necrotizing interocolitis
6. Asphyxia 8. Hypoglycemia
7. CNS injury 9. Hypothermia
10. Apnea
11. Jaundice
12. Electrolyte imbalance
13. Infection
NURSING DIAGNOSES
1. Impaired Gas Exchange r/t immature
pulmonary function
 oxygen
 side-lying/prone position
 frequent position changes
 suction secretions
2. Ineffective Thermoregulation r/t immaturity
Due to:
 greater body surface
 less flexion
PREMATURE INFANTS  little subcutaneous fats
 less active movement
  less brown fat
 unable to shiver
 immature CNS and hypothalamic control
Interventions:
Keep the environment warm
a. radiant warmer:
 close door near warmer
 transparent plastic blanket over infant
b. incubator
 warmed air is circulated inside
incubator
 close doors
 when removed from incubator: wrap
infant in heated blankets with head
covering or on a surface padded with
warm blankets
3. Risk for fluid volume deficit r/t insensible
water loss
a. IVF within hours of birth
b. monitor intake and output (40-
100ml/kg/24H or 1ml/kg/H)
c. monitor specific gravity (1.002-1.010)
d. monitor weight
e. monitor blood glucose (40-60mg/dl)
4. Risk for imbalanced nutrition: less than body
requirements r/t sucking difficulty and small
stomach capacity
a. SFF: 1-2 ml every 2-3H
b. gavage feeding (OGT/NGT)
 provide pacifier
5. Risk for Infection r/t immature immune system
a. hand washing
b. meticulous skin care
c. staff/family members should be
free of infection
d. linen and equipment should not
be shared with other infant
e. proper gowning
POSTMATURE INFANTS
 Born after 42 weeks of gestation
 Placenta is able to function for only
40 weeks
Post-mature Syndrome:
a. small for gestational age
b. wrinkled, cracked, and peeling of skin
c. thin with loose skin and little subcutaneous
fats
d. abundant hair
e. fingernails beyond fingertips and stained with
meconium
f. little/no lanugo and vernix Caseosa
g. unusually alert, wide-eyed, and worried
looking
Common Problems
a. Hypoglycemia
b. Respiratory difficulty
c. Meconium aspiration
d. Polycythemia
e. Cord compression
Management
1. Induction of labor if signs of placental
deterioration is discovered
2. CS may be advised
AN INFANTS OF A WOMAN WHO HAS DIABETES
MELLITUS
 An infant of a woman who has diabetes mellitus
whose illness was poorly controlled during
pregnancy has:
1. Macrosomia (results from
overstimulation of pituitary growth
hormone and extra fat deposits created
by high levels of insulin during
pregnancy)
Note: The infant’s large size is deceptive, however: such
babies are often immature
2. greater chance of having a congenital
anomaly such as a cardiac anomaly
3. hyperglycemia is teratogenic to a
rapidly growing fetus
4. Caudal regression syndrome
(hypoplasia of the lower extremities)
Assessment:
1. Cushingoid (fat and puffy)
2. lethargic or limp in the first days of life as a
result of hyperglycemia
3. RDS occurs frequently in these infants because
they may be born preterm or, even at term,
lecithin pathways may not mature
Note: High fetal insulin secretion during pregnancy to
counteract the hyperglycemia may interfere with
cortisol release
4. loses a greater proportion of weight in the first
few days of life than does the average newborn
Complications:
1. birth injury, especially shoulder and neck injury
2. Immediately, after birth the infant tends to be
hyperglycemic
3. severe hypoglycemia
4. Hyperbilirubinemia
5. Hypocalcemia
6. Hypomagnesemia
7. May be SGA
Some infants of diabetic women have a smaller-than-
usual left colon
 Signs of an inadequate colon: vomiting or
abdominal distention after the first few
feedings
Therapeutic Management
1. Fed early with formula or administered a
continuous infusion of glucose.
Note: It is important the infant not be given only a
bolus of glucose; otherwise, rebound hypoglycemia
may occur
2. Careful monitoring for normal bowel
movements is important in relation to the
smaller than usual left colon.
AN INFANT OF A DRUG DEPENDENT MOTHER
 tend to be SGA
 infant will show withdrawal symptoms
(neonatal abstinence syndrome) shortly after
birth
Withdrawal symptoms include:
 irritability
 disturbed sleep pattern
 constant movement, possibly leading to
abrasion on the elbows, knees and nose
 tremors
 frequent sneezing
 shrill, high pitched cry
 possible Hyperreflexia and clonus s
(neuromuscular irritability)
 convulsions
 tachypnea (rapid respirations), possibly so
severe that it leads to hyperventilation and
alkalosis
 vomiting and diarrhea
Additional information
 In newborns experiencing opiate withdrawal,
signs usually begin 24 to 48 hours after birth,
but in some infants they may not appear for up
to 10 day
 Generally signs last approximately 2 weeks, but
mild signs may appear for up to 6 months.
In heroin-addicted neonates
 Signs begin within the first 2 weeks of life, with
an average onset of approximately 72 hours.
 The signs may last 8 to 16 weeks or longer.
In methadone-addicted newborns:
 Withdrawal begins later and lasts longer than
heroin withdrawal. The onset varies.
 A newborn may exhibit signs beginning at 24 to
28 hours, or these early signs may improve,
then reappear at 2 to 4 weeks of age.
 Other newborns exhibit no signs until they are
2 to 3 weeks old
In cocaine-addicted newborns
 no predictable withdrawal sequence noted for
the cocaine-addicted neonate
 causes long-term effects varies with different
studies
 maladaptive coping behaviors may be present
in such newborns
Assessment:
1. Narcotic metabolites or quinine may be
obtained from an infant’s urine or meconium in
the first hour after birth.
2. Cocaine may be detected in infants’ hair
samples for an extended time
3. Infants of heroin-addicted women suck
vigorously and continuously and seem to find
comfort and quiet if given a pacifier
4. Infants of methadone- and cocaine-addicted
women may have extremely poor sucking ability
and may have difficulty achieving sufficient fluid
intake unless gavage fed.
Management:
1. usually seem most comfortable when firmly
swaddled
2. Keep them in an environment free from
excessive stimuli (quiet and darkened)
Specific therapy for an infant is individualized according
to the nature and severity of the signs.
3. Maintenance of electrolyte and fluid balance
is essential.
4. If an infant has vomiting or diarrhea,
intravenous administration of fluid may be
indicated.
5. drugs used to counteract withdrawal
symptoms include:
 paregoric
 phenobarbital
 methadone
 chlorpromazine (Thorazine)
 diazepam (Valium)
6. An infant should not be breastfed to avoid
passing narcotics in breast milk to the child.
7. Mother needs treatment for withdrawal
symptoms and follow-up care as much as the
infant.
Note: Infants who are exposed to drugs in utero may
have long-term neurologic problems
INFANTS WITH FETAL ALCOHOL EXPOSURE
 Alcohol crosses the placenta in the same
concentration as is present in the maternal
bloodstream ---- results in fetal alcohol
exposure and fetal alcohol syndrome
 appears in about 2 per 1000 newborns
 is often more difficult to document than
recreational drug exposure
Note: Alcohol has deteriorating effects on the placenta
 all pregnant women are advised to avoid
alcohol intake to prevent any teratogenic
effects on their newborn
Characteristics:
1. prenatal and postnatal growth restriction
2. CNS involvement such as cognitive challenge,
microcephaly, and cerebral palsy
3. a distinctive facial feature of a short palpebral
fissure
4. thin upper lip
Assessment:
1. Tremulous
2. Fidgety
3. Irritable
4. demonstrate a weak sucking reflex
5. Sleep disturbances
Long Term Effects:
 cognitive challenge (most serious)
 Behavior problems such as hyperactivity
 Growth deficiencies may