NCM 109 RLE – MIDTERMS
*NO Newborn Screening, Preterm Labor & Delivery, Premature
Rupture of Membranes (PROM), Gestational Size Variations*
HYPERTENSIVE DISORDERS IN PREGNANCY
Preeclampsia
• is a pregnancy-related disease process
evidenced by increased blood pressure
andproteinuria.
• An older term for preeclampsia was
toxemia of pregnancy
• The symptoms of preeclampsia affect
almost all organs.
• The vascular spasm that occurs may be
caused by the increased cardiac output
required by pregnancy, which injures the
endothelial cells of the arteries and
reduces the action of prostacyclin—a
prostaglandin vasodilator—and excess
production of thromboxane—a
prostaglandin vasoconstrictor and stimulant
of platelet aggregation.
• Usually during pregnancy, blood vessels
are resistant to the effects of pressor
substances such as angiotensin and
norepinephrine, so even with the increased
blood supply, blood pressure remains
normal during pregnancy.
• With gestational hypertension, this reduced
responsiveness to blood pressure changes
appears to be lost because of the
prostaglandin release.
• Vasoconstriction occurs, and blood
pressure increases dramatically.
• Beginning about the 20th week of • Edema is further increased
pregnancy, almost all body systems begin
to be affected.
• The cardiac system, for example, can
easily become overwhelmed because the
heart is forced to pump against rising
peripheral resistance. This causes a
reduced blood supply to organs, most
markedly the kidney, pancreas, liver, brain,
and placenta.
• Poor placental perfusion reduces the fetal
nutrient and oxygen supply. Ischemia in the
pancreas can result in epigastric pain and
an elevated amylase–creatinine ratio. If
spasm occurs in the arteries of the retina,
vision changes can occur.
• If this results in retinal hemorrhage,
blindness can result. Vasospasm in the
kidney increases blood flow resistance.
• Degenerative changes then develop in the
kidney glomeruli because of back
pressure. This leads to increased
permeability of the glomerular membrane,
allowing the serum proteins albumin and
globulin to escape into the urine (i.e.,
proteinuria).
• The degenerative changes also result in
decreased glomerular filtration, so there is
lowered urine output and clearance of
creatinine. If increased kidney tubular
reabsorption occurs, retention of sodium
begins. As sodium retains fluid, edema
results.
because, as more protein is
lost, the osmotic pressure of
the circulating blood falls and
fluid diffuses from the
circulatory system into the
denser interstitial spaces to
equalize the pressure
• Extreme edema can lead to maternal
cerebral and pulmonary edema and
seizures (eclampsia).
Gestational hypertension
• Blood pressure is 140/90 mmHg or systolic
pressure elevated 30 mmHg or diastolic
pressure elevated 15 mmHg above
prepregnancy level; no proteinuria or
edema; blood pressure returns to normal
after birth
Preeclampsia without severe features
• Blood pressure is 140/90 mmHg or systolic
pressure elevated 30 mmHg or diastolic
pressure elevated 15 mmHg above
prepregnancy level; proteinuria of 1+ to
2+ on a random sample; weight gain over
2 lb/week in second trimester and 1
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 lb/week in third trimester; mild edema in
upper extremities or face
Preeclampsia with severe features
• Blood pressure is 160/110 mmHg;
proteinuria 3+ to 4+ on a random sample
and 5 g on a 24-hour sample; oliguria
(500 ml or less in 24 hours or altered renal
function tests; elevated serum creatinine
more than 1.2 mg/dl); cerebral or visual
disturbances (headache, blurred vision);
pulmonary or cardiac involvement;
extensive peripheral edema; hepatic
dysfunction; thrombocytopenia; epigastric
pain
Eclampsia
• Either seizure or coma accompanied by
signs and symptoms of preeclampsia are
present.
MULTIPLE PREGNANCY
• Multiple gestation is considered a
complication of pregnancy because a
woman’s body must adjust to the effects
of more than one fetus. The incidence of
multiple births has increased dramatically
because of the use of in vitro fertilization,
but still only occurs in 2% to 3% of all
births
IDENTICAL (I.E., MONOZYGOTIC) TWINS
• begin with a single ovum and
spermatozoon. In the process of fusion, or
in one of the first cell divisions, the zygote
divides into two identical individuals.
Single-ovum twins usually have one
placenta, one chorion, two amnions, and
two umbilical cords. The twins are always
of the same sex; they account for one third
of twin births
FRATERNAL (I.E., DIZYGOTIC,
NONIDENTICAL) TWINS
• the result of the fertilization of two
separate ova by two separate
spermatozoa (possibly not from the same
sexual partner). Double-ova twins have two
placentas, two chorions, two amnions, and
two umbilical cords. The twins may be of
the same or a different sex
• Multiple pregnancies of two to eight
children may be single-ovum conceptions,
multiple-ova conceptions, or a combination
of the two types.
• Most multiple pregnancies today occur
from multiple ova being implanted as an in
vitro fertility process.
• Naturally occurring multiple pregnancies
are more frequent in Blacks and Hispanics
than Whites. The higher a woman’s parity
and age, the more likely she is to have a
multiple gestation.
• Inheritance appears to play a role in
natural dizygotic twinning; this has a
familial maternal pattern of occurrence
ASSESSMENT
• Multiple gestation is suspected early in
pregnancy when the uterus begins to
increase in size at a rate faster than usual.
AFP levels will also be elevated
• On auscultation of the abdomen, multiple
sets of fetal heart sounds can be heard
• An ultrasound can reveal multiple gestation
sacs early in pregnancy. In some instances,
early ultrasound examinations reveal
multiple amniotic sacs but then later in
pregnancy, in as many as 30% of women,
only one fetus remains (i.e., vanishing twin
syndrome)
THERAPEUTIC MANAGEMENT
• Women with a multiple gestation are more
susceptible to complications of pregnancy
such as gestational hypertension,
polyhydramnios, placenta previa, preterm
labor, and anemia than are women
carrying one fetus
• If monozygotic twins share a common
vascular communication, it can lead to
overgrowth of one fetus and undergrowth
of the second (a twin-to-twin transfusion),
resulting in discordant infants
GESTATIONAL DIABETES
• A condition of abnormal glucose
metabolism that arises during pregnancy.
• Possible signal of an increased risk for
type 2 diabetes later in life.
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• Approximately 2% to 3% of all women
who do not begin a pregnancy with
diabetes develop the condition during
pregnancy, usually at themidpoint of
pregnancy when insulin resistance becomes
most noticeable. This is termed gestational
diabetes mellitus
• The symptoms fade again at the
completion of pregnancy, but the risk of
developing type 2 diabetes later in life
may be as high as 50% to 60%.
• It is unknown whether gestational diabetes
results from inadequate insulin response to
carbohydrate, from excessive resistance to
insulin, or from a combination of both. Risk
factors for developing gestational
diabetes include:
→ Obesity
→ Age over 25 years
→ History of large babies (10 lb or more)
→ History of unexplained fetal or perinatal
loss
→ History of congenital anomalies in
previous pregnancies
→ History of polycystic ovary syndrome
→ Family history of diabetes (one close
relative or two distant ones)
→ Member of a population with a high risk
for diabetes (Native American, Hispanic,
Asian)
ASSESSMENT
• A fasting plasma glucose greater than or
equal to 126 mg/dl or a nonfasting
plasma glucose greater than or equal to
200 mg/dl meets the threshold for the
diagnosis of diabetes and does not need
confirmation.
• It is recommended that all pregnant women
receive a 50-g glucose challenge test
between 24 and 28 weeks gestation to
determine if they are at risk for gestational
diabetes.
• If the result of that test is 140 mg/dl (some
providers use 130 mg/dl as the cutoff),
then the woman will need to do a three
hour glucose tolerance test.
• For this, after a fasting glucose sample is
obtained, the woman drinks an oral 100-g
glucose solution; a venous blood sample is
then taken for glucose determination at 1,
2, and 3 hours later. If two of the four
blood samples collected for this test are
abnormal or the fasting value is above 95
mg/dl, a diagnosis of diabetes is made.
HYPEREMESIS GRAVIDARUM
• (sometimes called pernicious or persistent
vomiting)
• is nausea and vomiting of pregnancy
prolonged past week 16 of pregnancy or
that is so severe that dehydration,
ketonuria, and significant weight loss occur
within the first 12 weeks of pregnancy
• The cause is unknown, but women with the
disorder may have increased thyroid
function because of the thyroid-stimulating
properties of human chorionic
gonadotropin.
• With hyperemesis gravidarum, weight loss
can be severe because, with so much
nausea and vomiting, a woman cannot
maintain her usual nutrition.
• Urine may test positive for ketones,
evidence the woman’s body is breaking
down stored fat and protein for cell
growth.
• An elevated hematocrit concentration may
be detected at a monthly prenatal visit
because the inability to retain fluid has
resulted in hemoconcentration (which is
dangerous because it can lead to
thromboembolism).
• In contrast, concentrations of sodium,
potassium, and chloride may be reduced
because of a woman’s low intake;
hypokalemic alkalosis may develop from
loss of hydrochloric acid from the stomach.
In some women, ataxia and confusion,
caused by deficiency of vitamin B1
(thiamine), develops.
• If left untreated, a woman with
hyperemesis may become so dehydrated
she can no longer provide a fetus with
essential nutrients for growth, and
intrauterine growth restriction or preterm
birth can result
ASSESSMENT
• Always try to determine exactly how much
nausea and vomiting women are having
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 during pregnancy. Ask the patient to
describe the events of the day before:
→ How late into the day did the nausea
last?
→ How many times did she vomit and how
much?
→ What was the total amount of food she
was able to eat?
THERAPEUTIC MANAGEMENT
• Women with hyperemesis gravidarum may
need to be hospitalized for about 24 hours
to document and monitor their intake,
output, and blood chemistries and to
restore hydration.
• All oral food and fluids are usually
withheld for the first 24 hours. Intravenous
fluid (e.g., 3,000 ml Ringer’s lactate with
added vitamin B1) may be administered to
increase hydration.
• An antiemetic, such as metoclopramide
(Reglan, pregnancy class B), may be
prescribed to control vomiting.
• Throughout this period, carefully measure
intake and output, including the amount of
vomitus, so the degree of hydration can
best be evaluated.
• If there is no vomiting after the first 24
hours of oral restriction, small amounts of
clear fluid can be started and the woman
discharged home, usually with a referral
for home care.
• If she can continue to take clear fluid
without vomiting, small quantities of dry
toast, crackers, or cereal can be added
every 2 or 3 hours, after which the woman
may be gradually advanced to a soft diet
and then to a regular diet. If vomiting
returns at any point, enteral or total
parenteral nutrition may be prescribed to
ensure she receives adequate nutrition
ASTHMA
• Asthma is a chronic inflammatory disorder
of the respiratory track and is the most
common chronic illness in children
• Typically, asthma presents before 5 years
of age, although it may be difficult to
make a definitive diagnosis in these early
years.
• Many viral illnesses can present with
symptoms that are similar and asthma and
viral illnesses can trigger asthma symptoms,
adding to the complexity of diagnosis.
• The severity of asthma in a child is
dependent on risk factors, which include
genetics as well as environmental
exposures, such as allergens, stress,
pollution, etc., that affect the body’s
immune responses
• When an allergen invades, mast cells
release histamine and leukotrienes that
result in diffuse obstructive and restrictive
changes in the airway because of a triad
of inflammation, bronchoconstriction, and
increased mucus production. Most children
with asthma can be shown to have allergy
triggers. A primary irritant is environmental
tobacco smoke. Other indoor allergens,
such as mice and cockroaches, are common
irritants. Outdoor irritants can include
pollens, grasses, and pollution, among
others. Viral respiratory illnesses are a
common trigger for asthma exacerbations
in children.
MECHANISM OF DISEASE
• Asthma primarily affects the small airways.
The relationship of inflammation to airway
hyperresponsiveness and airway
obstruction contributes to clinical symptoms.
This complex interplay of factors presents
as recurrent wheezing, breathlessness, chest
tightness, and coughing
ASSESSMENT
• The word asthma is derived from the
Greek word for “panting,” a description of
the child’s distress.
• Typically, an episode begins with a dry
cough. Children then develop increasing
difficulty exhaling as it becomes more and
more difficult for them to force air through
the narrowed lumen of the bronchioles that
are not only inflamed and swollen but also
filled with mucus.
• Typical dyspnea and wheezing (the sound
caused by air being pushed forcibly past
obstructed bronchioles) associated with the
disorder begin.
• Wheezing is heard primarily upon
expiration because the lumen of
bronchioles are narrower during exhalation
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 than inhalation, but it may be absent with
severe asthma exacerbations.
HISTORY
• An assessment should include a thorough
history of the development of a child’s
symptoms; for example, what the child was
doing at the time symptoms began, the
child’s known asthma triggers, and what
treatments were given.
• After the acute attack has passed, take
time to ask a parent or the child to
describe the home environment, including
any pets, the child’s bedroom, outdoor
play space, classroom environment, and
type of heating in the house, to see
whether more environmental control could
reduce allergen triggers and future
occurrences.
PHYSICAL ASSESSMENT
• In some children, the initial wheezing is
evident only by stethoscope auscultation; in
others, it is so loud it can be heard by
simply listening.
• Air-filled lungs are hyperresonant to
percussion or they make a louder, more
hollow noise on percussion than usual. With
normal respiration, the inspiration phase of
breathing is longer than the expiration
phase.
• During an asthma attack, however, a child
must work so hard to exhale due to air
trapping that the expiration phase
becomes longer than the inspiration phase.
• Time the two phases to demonstrate this.
Also, observe for retractions (the chest wall
is drawn inward with breaths) because
children have to use intercostal accessory
muscles to achieve full breaths.
• As constriction becomes acute, the sound of
wheezing may decrease because so little
air can leave the alveoli.
• During attacks, children with asthma are
generally more comfortable in a sitting or
standing position rather than lying down
and should be allowed to be in a position
of comfort.
• If seated in a chair, they lean forward and
raise their shoulders to give themselves
more breathing space.
• Children who do agree to lie down are
either at the end of an attack and
beginning to feel less threatened by the
dyspnea or are so exhausted by the
paroxysms of coughing that they no longer
have the strength to sit upright.
PNEUMONIA
• Pneumonia is an infection and inflammation
of alveoli.
• It often has a bacterial or viral origin and
is categorized as hospital- or community-
acquired.
• Pneumonia occurs most often in late winter
and early spring.
PNEUMOCOCCAL PNEUMONIA
• The onset of pneumococcal pneumonia is
generally abrupt and follows an upper
respiratory tract infection. In infants, the
infection tends to be bronchopneumonia
with poor consolidation. In older children,
pneumonia often localizes in a single lobe
with full consolidation.
• During the initial 24 to 48 hours of
infection, children may have blood-tinged
sputum that transitions to a thick, purulent
sputum
ASSESSMENT
• Children may often appear acutely ill, with
high fever, tachycardia, chest or abdominal
pain, chills, and signs of respiratory
distress. Breath sounds are often
diminished, and crackles (rales) may be
present. Dullness on percussion indicates
total consolidation. Chest radiography will
often reveal consolidation, and laboratory
studies will indicate leukocytosis.
THERAPEUTIC MANAGEMENT
• Pharmacologic management may include
IV fluid therapy, antibiotics, and
antipyretics
• Oxygen saturation levels should be
assessed frequently. Humidified oxygen
may help labored breathing and prevent
hypoxemia. CPT may be used to
encourage the movement of mucus and
prevent obstruction. Repositioning the child
will prevent pooling of secretions.
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CHLAMYDIAL PNEUMONIA
• Chlamydia trachomatis pneumonia,
typically seen in newborns up to 12 weeks
of age, is often contracted from contact
with the mother’s vagina during birth.
Symptoms begin gradually with nasal
congestion, a sharp cough, and poor
weight gain. These progress to tachypnea
and wheezing and rales on auscultation. A
laboratory assessment will show elevated
levels of IgG and IgM antibodies,
peripheral eosinophilia, and antibodies to
C. trachomatis. Antibiotics are often used
for pharmacologic treatment.
VIRAL PNEUMONIA
• Viral pneumonia is generally caused by
viral infections of the upper respiratory
tract. Symptoms begin as an upper
respiratory tract infection and may
progress to diminished breath sounds and
fine rales on auscultation. Antibiotic
therapy is not effective against viral
infections. Rest and antipyretics are used
for treatment. Similar to bacterial
pneumonia, fatigue often occurs following
the acute phase of illness.
MYCOPLASMAL PNEUMONIA
• Mycoplasmal pneumonia occurs more
frequently in children over 5 years of age
during winter months. Fever, cough, cervical
lymphadenopathy, and rhinitis are common
symptoms. Mycoplasmal organisms are
generally sensitive to erythromycin or
tetracycline.
TETRALOGY OF FALLOT
• This typically cyanotic defect is defined by
four components: pulmonary artery
stenosis, VSD, overriding aorta, and right
ventricular hypertrophy
• The right ventricular hypertrophy is not an
isolated problem but occurs secondary to
the pulmonary stenosis.
• The degree of cyanosis is directly
proportional to the degree of pulmonary
stenosis.
• Pulmonary stenosis can be noted at
several sites along this right ventricular
outflow tract; most typical is subpulmonary
valve stenosis with anomalies of the actual
pulmonary valve also seen.
• Significant narrowing produces increased
resistance to blood flowing through the
pulmonary valve and out to the lungs.
• Because of this increased resistance, the
blood will shunt right to left through the
VSD because the VSD provides less
resistance, and this deoxygenated blood
travels directly out through the aorta into
the systemic circulation.
• Children with minimal obstruction through
right ventricular outflow tract may have
normal systemic arterial oxygen saturations
and are termed “pink” tetralogy patients.
ASSESSMENT
• These children will have a systolic murmur
noted at the left upper sternal border; this
murmur is due to the turbulent flow out the
right ventricular outflow tract.
• The VSD murmur may not be noticed if the
defect is large. Echocardiography will
confirm the diagnosis.
• A cardiac catheterization may be
necessary if the coronary arteries are not
well visualized. There have been instances
where one of the coronary arteries crosses
directly over the pulmonary artery.
• If this occurs, the surgical plan will be
altered so as not to damage the coronary
artery.
• Occasionally, the area below the
pulmonary valve may spasm, thereby
increasing the resistance to flow through
this area even more. This will cause a
greater than usual amount of blood to
shunt from right to left across the VSD, and
the child will be more deoxygenated. This
is termed a hypercyanotic spell, or a “tet
spell.”
• The exact etiology of these episodes is
unclear, although a number of mechanisms
have been proposed, including increased
infundibular contractility, peripheral
vasodilatation, hyperventilation, and
stimulation of right ventricular
mechanoreceptors.
• During a spell, the child becomes distressed
and irritable, possibly without reason.
• This period of lower saturations is
temporary and can be managed by the
family by soothing the child if he or she is
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 upset and bringing the child’s knees tightly
to the chest in an effort to increase systemic
vascular resistance.
• This increase in the pressure on the left side
of the heart (the systemic side) will help
force blood back through the pulmonic
valve, thereby oxygenating more blood. In
a hospital setting, along with knee-to-chest
positioning, blow-by oxygen can be
beneficial to enhance circulating oxygen
and possibly dilate the distal pulmonary
bed.
• It will have no effect on subpulmonary
spasm. The use of sedatives is controversial
because they will dilate the systemic
circulation, which may enhance right-to-left
shunting, worsening the cyanosis. If needed,
the use of alpha adrenergic agonists such
as phenylephrine causes vasoconstriction
and may facilitate more flow out the
pulmonary artery.
• If a child experiences a true hypercyanotic
spell, the parents must notify their
cardiologist, as this may be an indication
that the child requires corrective surgery
soon. It is possible for children with a “pink”
tetralogy anatomy to experience
pulmonary overcirculation due to the VSD
and have clinical symptoms similar to those
previously discussed.
MANAGEMENT
• Children with TOF are generally medically
managed and followed by a pediatric
cardiologist. If they have trouble gaining
weight or experience hypercyanotic spells,
they will be referred for surgery. Repair is
usually performed by approximately 3 to
6 months of age, regardless of the
occurrence of spells.
• Surgical repair of this defect includes
closure of the VSD and repair of the
stenotic pulmonary valve and any
associated right ventricular outflow tract
anomalies.
• Postoperative concerns center on right
ventricular function, adequacy of the
pulmonary valve, and flow through the
pulmonary artery.
• In some instances, the pulmonary valve
cannot be saved and is completely
removed. This creates a continuous, to-and-
fro murmur noted at the left upper sternal
border, with radiation throughout the chest.
• The valve will have to be replaced,
typically during the child’s school-age
years. If the right ventricular outflow tract
narrowing was extremely severe at birth, a
child may be referred for a palliative
procedure, which will allow for adequate
pulmonary blood flow until the complete
surgical repair can be performed.
• This palliative procedure is typically a
modified Blalock-Taussig (BT) shunt, which is
placement of a conduit (synthetic tube)
between the subclavian artery and the
pulmonary artery
• This allows for a stable source of
pulmonary blood flow as blood flowing out
of the aorta travels through the shunt and
into the lower pressure pulmonary system
to become oxygenated. This ultimately
increases the amount of oxygenated blood
mixing with the deoxygenated blood and
increases saturation. These conduits are not
made of viable human tissue, however, and
will not grow with the child. This is a
temporary measure until it is safe for the
child to undergo open heart surgery.
BALLARD’S SCORING
• The Ballard or Dubowitz test may be
performed if the mother did not have
prenatal care or if there is another
question regarding maturity of the
newborn.
• Gestational rating scales such as the
Ballard or Dubowitz use extensive criteria
to assess gestational age.
• The process of rating the infant, completed
shortly after birth, includes physical
maturity and neuromuscular maturity
• The newborn’s skin, lanugo, foot creases,
breast maturity, eyes and ears, and
genitalia are observed and given a score
of -1 to +5.
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• For the second half of the examination,
observe or position a newborn
• Again, score the child’s response
numerically from -1 to +5. Then, the total
score obtained (on both sections) is
compared with the rating scale
• Using this standard method to rate maturity
helps detect infants who were thought to
be term but instead are actually preterm
because of a miscalculated due date and
who need additional observation and
perhaps high-risk care
A. Physical maturity assessment criteria.
B. Neuromuscular maturity assessment criteria.
• Posture: With infant supine and quiet,
score as follows: arms and legs extended
= 0; slight or moderate flexion of hips
and knees = 2; legs flexed and
abducted, arms slightly flexed = 3; full
flexion of arms and legs = 4.
• Square window: Flex hand at the wrist.
Exert pressure sufficient to get as much
flexion as possible. The angle between
hypothenar eminence and anterior
aspect of forearm is measured and
scored. Do not rotate wrist.
• Arm recoil: With infant supine, fully flex
forearm for 5 seconds and then fully
extend by random movements = 0;
incomplete or partial flexion = 2; brisk
return to full flexion = 4.
• Popliteal angle: With infant supine and
pelvis flat on examining surface, flex leg
on thigh and fully flex thigh with one
hand. With the other hand, extend leg
and score the angle attained according
to the chart.
• Scarf sign: With infant supine, draw
infant’s hand across the neck and as far
across the opposite shoulder as possible.
Assistance to elbow is permissible by
lifting it across the body.
• Score according to location of the elbow:
elbow reaches opposite anterior axillary
line = 0; elbow between opposite
anterior axillary line and midline of the
thorax = 1; elbow at midline of thorax =
2; elbow does not reach midline of
thorax = 3; elbow at proximal axillary
line = 4.
• Heel to ear: With infant supine, hold
infant’s foot with one hand and move it
as near to the head as possible without
forcing it. Keep pelvis flat on examining
surface.
C. Scoring for the Ballard assessment scale.
The point total from assessment is
compared to the left column. The matching
number in the right column reveals the
infant’s age in gestation weeks.
RESPIRATORY DISTRESS SYNDROME
Respiratory distress syndrome (RDS) of the
newborn, formerly termed hyaline membrane
disease, is most often seen in newborns born
prematurely. Other causes of RDS include
newborns with meconium aspiration syndrome,
sepsis, a newborn who is slow to transition to
extrauterine life, and pneumonia (Hermansen &
Mahajan, 2015). The pathologic feature of
RDS is a hyalinelike (fibrous) membrane formed
from an exudate of an infant’s blood that
begins to line the terminal bronchioles, alveolar
ducts, and alveoli. This membrane prevents the
exchange of oxygen and carbon dioxide at
the alveolar–capillary membrane, interfering
with effective oxygenation. The cause of RDS is
a low level or absence of surfactant, the
phospholipid that normally lines the alveoli and
reduces surface tension to keep the alveoli
from collapsing on expiration. Because
surfactant does not form until the 34th week of
gestation, as many as 30% of LBW infants and
as many as 50% of VLBW premature infants
are susceptible to this
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MECONIUM ASPIRATION SYNDROME
• Meconium is present in the fetal bowel as
early as 10 weeks of gestation. If hypoxia
occurs, a vagus reflex is stimulated,
resulting in relaxation of the rectal
sphincter. This releases meconium into the
amniotic fluid.
• Babies born breech may expel meconium
into the amniotic fluid from pressure on the
buttocks. In both instances, the appearance
of the fluid at birth is green to greenish
black from the staining.
• Meconium staining occurs in approximately
10% to 20% of all births; in 2% to 4% of
these births, infants will aspirate enough
meconium to cause meconium aspiration
syndrome (MAS)
• Meconium aspiration does not tend to occur
in ELBW infants because the substance has
not passed far enough in the bowel for it
to be at the rectum in these infants.
• An infant may aspirate meconium either in
utero or with the first breath at birth.
• Meconium can cause severe respiratory
distress (tachypnea, retractions, and
grunting).
• The infant may also require increased
oxygen to maintain saturations in the mid
to upper 90s.
• This oxygen requirement usually starts in
the first couple hours after birth without
any congenital anomalies that may cause
the low oxygen saturations
THERAPEUTIC MANAGEMENT
• Amnioinfusion can be used to dilute the
amount of meconium in the amniotic fluid
and has shown to improve the outcomes for
the newborn with meconium in situations
where perinatal observation is limited. The
benefits may be related to dilution of the
meconium or having an effect on the
oligohydramnios (
• If deeply stained amniotic fluid is identified
during labor, the infant may be scheduled
for a cesarean birth. After birth, infants
may need to be treated with oxygen
administration and assisted ventilation.
Antibiotic therapy may be prescribed to
forestall the development of pneumonia as
a secondary problem. If lung compliance is
poor, surfactant may be administered
• If lung noncompliance continues, this may
necessitate high inspiratory pressure.
Unfortunately, this can cause a
pneumothorax or pneumomediastinum (air
in the chest cavity).
• Observe the infant closely, therefore, for
signs of trapping air in the alveoli because
the alveoli can expand only so far and
then will rupture, sending air into the
pleural space (pneumothorax).
• Yet, a further complication that can occur
because of increased pulmonary resistance
is the ductus arteriosus remaining open,
causing blood to shunt from the pulmonary
artery into the aorta and compromising
cardiac efficiency and increasing hypoxia.
• To detect this, observe an infant closely for
signs of heart failure such as increased
heart rate or respiratory distress. Maintain
a temperature-neutral environment to
prevent the infant from having to increase
metabolic oxygen demands. A chest
physiotherapy with percussion and
vibration may be helpful to encourage the
removal of remnants of meconium from the
lungs
• Some infants may need to be administered
nitric oxide or maintained on ECMO to
ensure adequate oxygenation
PHARMACOLOGIC MEASURES FOR PAIN
RELIEF DURING LABOR
TOPICAL ANESTHETIC CREAM
• To reduce the pain of procedures such as
venipuncture, lumbar puncture, and bone
marrow aspiration, a local anesthetic
cream that contains 4% lidocaine can be
used
• The cream is applied to the skin, and the
site is then covered with an occlusive
dressing or plastic wrap to keep young
children from wiping away or tasting the
cream. The time needed for effect between
different brands varies from 30 minutes to
1 hour and so must be applied within that
time frame before an expected procedure
• Parents can apply anesthetic cream at
home before bringing a child to a clinic
visit for a procedure such as bone marrow
aspiration to avoid a long waiting time
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• Caution them not to allow their child to
remove the dressing because the cream
could anesthetize the gag reflex if eaten
or cause eye damage if rubbed into the
eyes.
• They are effective with procedures such as
venipuncture, intramuscular (IM), or
subcutaneous injections. They also can be
used effectively for pain relief with
circumcision
• EMLA cream, a combination of local
anesthetics, is a popular cream used but
has to be applied at least 1 hour before
the procedure; however, it can be applied
up to 3 hours before a procedure and still
be effective. A newer compound, ELA-MAX
(LMX), containing only lidocaine, takes
effect in 30 minutes or less
ORAL ANALGESIA
• Many analgesics are supplied in liquid
form and flavored with cherry or grape
syrup to disguise unpleasant tastes.
• Caution parents that even though such
drugs taste sweet, they should never refer
to them as “candy.”
• Toxicity from too frequent or overly large
doses of acetaminophen is the number one
reason for poisoning in small children and
can lead to severe liver damage in
children
• If swallowing pills or large volume of
liquids is not an option, enterally dosed
opioids can also be given sublingually or
rectally, if appropriate.
• Nonsteroidal anti-inflammatory drugs
(NSAIDs) such as ibuprofen or naproxen
are excellent for reducing pain because, as
their name implies, they reduce
inflammation as well as pain in conditions
such as sprained ankles or rheumatic
conditions. Long-term administration of any
NSAID can lead to severe gastric irritation,
so this category of analgesics should not be
used longer than prescribed. Help parents
giving any analgesia around the clock for
several days to make out a medication
sheet to hang on their refrigerator door or
some other method to remind them when
the next dose will be due and alert them
not to give drug doses too close together.
• Children should not receive acetylsalicylic
acid (aspirin) for pain relief, especially in
the presence of flulike symptoms, because
there is an association between aspirin
administration and the development of
Reye syndrome, a severe neurologic
disorder
• For managing severe or acute pain, such as
postoperative pain or the pain of a sickle-
cell crisis, opioids, such as morphine,
oxycodone, and hydromorphone
(Dilaudid), are frequently prescribed.
Because this class of drugs is also referred
to as narcotics or opioids, parents may be
reluctant to give their children these
medications out of concern that their child
will become addicted.
INTRAMUSCULAR INJECTION
• Although opiates are available as IM
injections, analgesia for children is rarely
given by this route because the number of
suitable injection sites in children is limited,
injections are associated with pain on
administration, and such an injection can
produce great fear in children. An IM
injection also can lead to several risks,
including uneven absorption, unpredictable
onset of action, and nerve and tissue
damage. As a rule, other routes are used
whenever possible.
INTRAVENOUS ADMINISTRATION
• IV administration of analgesia, the most
rapid-acting route, is the method of choice
in emergency situations, in the child with
acute pain, and in a child requiring
frequent doses of analgesia but in whom
the gastrointestinal tract cannot be used.
• Common opioids given by this route include
morphine (no common brand name),
fentanyl (Sublimaze), hydromorphone
(Dilaudid), and methadone (no common
brand name).
• In equianalgesic doses, they act very
similarly.
• Fentanyl has a shorter duration of action
than the others but works quickly and
produces less side effects such as pruritus
and vasodilatation. These features make it
an ideal drug to use for short, painful
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 procedures, such as debriding a burn or
inserting a chest tube to relieve a
pneumothorax.
• Opiate analgesics can be given by bolus
injection or by continuous infusion. If doses
will be given periodically by an IV line,
advocate for the use of an intermittent
infusion device to avoid repeated
venipunctures with each dose or the need
for a confining IV line to be in place.
• If a child’s pain is frequent or constant so a
continuous IV line is necessary, advocate
for a patient-controlled pump to offer the
child a sense of control and rapid
analgesia.
• As the child becomes able to take
medications by mouth, oral forms of
analgesics will then be administered.
• When switching from IV to oral
medications, be certain the oral medication
is supplied in an equianalgesic dose. All
opioids have the potential to decrease
respiratory rate.
• Other side effects include nausea, pruritus,
vasodilatation, cough suppression, urinary
retention, and constipation.
• If toxicity with opioids should occur, low-
dose naloxone (Narcan), an opiate
antagonist, can be administered to
counteract the effects. This low dose for
side effect management is a different dose
than the rescue dose needed for
respiratory complications.
PATIENT-CONTROLLED ANALGESIA
• Patient-controlled analgesia (PCA) allows a
child or a parent to self-administer boluses
of medication, usually opioids, with an IV
medication pump
• Children as young as 5 or 6 years of age
are able to assess when they need a bolus
of medicine and press the button on the
pump to deliver the new dose through an
established IV line.
• Parents or a nurse are able to administer a
new dose to children younger than this as
long as the child is awake. Morphine is a
common analgesic used for PCA
administration
• The pump is set with a lockout time so that
after each dose, the pump will not release
further medication even if the button is
pushed again; because of this, children
cannot overmedicate themselves.
• If pain is constant, a continuous infusion
should be used so that pain relief continues
even while the child sleeps. The pump can
still be programmed for bolus dosing to
cover episodes of increased pain.
CONSCIOUS SEDATION
• Conscious sedation refers to a state of
depressed consciousness usually obtained
through IV analgesia therapy (
• The technique allows a child to be both
pain free and sedated for a procedure.
• Unlike the use of general anesthesia,
protective reflexes are left intact and a
child can respond to instructions during the
procedure. The technique is used for
painful procedures such as dental
extractions, wound care, and bone marrow
aspiration, as well as for magnetic
resonance imaging and endoscopy, both of
which require a child to lie still for a long
period of time and can be potentially
frightening.
• Drugs used for conscious sedation can be
something as common as chloral hydrate or
as involved as a sedative-hypnotic-
analgesic combination, which relieves both
anxiety and pain and depresses the child’s
memory of the event. In many healthcare
settings, conscious sedation is administered
and monitored by nurses specially
prepared in the technique
INTRANASAL ADMINISTRATION
• Intranasal administration is becoming an
attractive way to dispense medicine for
children because it’s easy for parents to
administer and the medicine absorbs well
from the nasal mucous membrane. Influenza
vaccine, for example, is now available in
an intranasal form
• Midazolam (Versed) is a short-acting
adjuvant sedative that can be administered
intranasally by nasal drops or nasal spray
before surgery or procedures such as
nuclear medicine scanning
• Because it has a very short duration of
action, it may require repeat
administration. Because it has no analgesic
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 action, an analgesic should be
administered concurrently if the procedure
will be painful.
LOCAL ANESTHESIA INJECTION
• Local anesthetics stop pain transmission by
blocking nerve conduction of the impulse at
the site of pain. Children receive local
anesthetic injections, such as lidocaine,
before procedures such as bone marrow
aspiration, peritoneal dialysis, or suturing
of lacerations.
• For many children, the sight of the
anesthetic needle is so frightening that they
cannot listen to the assurance that the
momentary needlestick will actually
prevent further pain. The use of an
anesthetic cream before the injection can
be helpful to relieve the needlestick pain
and allow the anesthetic to numb the tissues
to prevent pain
EPIDURAL ANALGESIA
• Epidural analgesia, an injection of an
analgesic agent into the epidural space just
outside the spinal canal, can be used to
provide analgesia to the lower chest,
abdomen, and lower body for 12 to 24
hours or longer if needed. An opioid, often
combined with a long-acting anesthetic, is
instilled continuously or administered
intermittently by a catheter into the
epidural space. Children who have
orthopedic or chest surgery, for example,
may have an epidural catheter inserted in
the operating room and then continue to
receive analgesia by this method to relieve
postsurgical
INDUCTION AND AUGMENTATION OF
LABOR
• When labor contractions are ineffective,
several interventions, such as induction and
augmentation of labor with oxytocin or
amniotomy (artificial rupture of the
membranes), may be initiated to strengthen
them
• Induction of labor means labor is started
artificially.
• Augmentation of labor refers to assisting
labor that has started spontaneously but is
not effective.
• Although induction may be necessary to
initiate labor before the time when it would
have occurred spontaneously because a
fetus is in danger, it is not used as an
elective procedure until the fetus is at term
(over 39 weeks).
• At one time, induction could be completed
if a fetus was proven to have adequate
lung surfactant by amniocentesis at term
but less than 39 weeks.
• However, indicating that fetal lung maturity
should not be used and inductions should
be avoided until 39 weeks unless medically
indicated.
• Conditions that might make induction
necessary before that time include
preeclampsia, eclampsia, severe
hypertension, diabetes, Rh sensitization,
prolonged rupture of the membranes, and
intrauterine growth restriction.
• Postmaturity (a pregnancy lasting beyond
42 weeks) is yet another situation that
makes it more potentially dangerous for a
fetus to remain in utero than to be born.
• Because either augmentation or initiation of
labor carries a risk of uterine rupture or
premature separation of the placenta, it
must be used cautiously in women with
multiple gestation, polyhydramnios, grand
parity, who are older than 40 years, or
have previous uterine scars
• Oxytocin is an effective uterine stimulant,
but there is a thin line between adequate
stimulation and hyperstimulation,
• Before induction of labor is begun in term
and postterm pregnancies, the following
conditions should be present:
→ The fetus is in a longitudinal lie.
→ The cervix is ripe, or ready for birth
→ The presenting part is the fetal head
(vertex) and is engaged.
→ There is no CPD.
→ The fetus is estimated to be mature by
date (over 39 weeks).
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