OB trans 10
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Page 1 of 4 S2 Lec 3(2 of 2): Breastfeeding, Home Delivery, Newborn by Dra. Teresita Cadiz-Brion A A A u uu g g g u uu s s s t t t 2 2 2 3 3 3 , , , 2 2 2 0 0 0 1 1 1 0 0 0 ASSESSMENT OF THE NEWBORN Neonatal period -1 st 4 wks of life (28 days) - Infant mortality rate - 1985: 45/1000 live births - 1990: 24.3/1000 live births -neonatal deaths – 48% of total infant deaths & majority took place in the 1 st week of life Leading Causes of Infant Mortality 1. Respiratory conditions of the fetus and newborn 2. Congenital anomalies 3. Birth injury 4. Difficult labor General Management of the Newborn o The outcome of the neonatal depends on his/her ability to adapt to extrauterine environmen t o He will need to take over the function of breathing, maintaining circulation, nutrition & excretion. o The newborn needs immediate assistance at birth, primarily for establishme nt of respiration, maintenance of body temperature, provision for adequate nutrition & prevention of infection. Manageme nt After Delivery 1. wipe face 2. suction nares & oral cavity during restitution 3. dry baby 4. rub body stimulati on 5. tap soles 6. get APGAR sore o Immediately after birth, the neonate’s head is held downward in order to clear the mouth, nose & pharynx of fluid, mucus, blood & amniotic debris. o The upper airway may be cleared w/ a rubber bulb syringe or a catheter. o Once meconium is detected in the amniotic fluid, the larynx should be visualized & any meconium removed promptly o If infant is depressed , tracheal intubation & suctioning should be done to clear any aspirated material from beneath the glottis o If the baby is vigorous & spontaneou sly breathing, the indication for aggressive remova l is less clear. ESSENTIAL NEWBORN CARE o After delivery, cord is not clamped at once o May wipe the face but the nares are not suctioned o Put baby face down on body of the mother (skin to skin contact) o When there are no more pulsations, clamp then cut the cord (to avoid fetal anemia) o Mother and baby are not separated for 30mins-1hr (baby should be colonized by the bacteria of the mother) o After first full feed, baby is bathed, immunizations are given and the rest of the newborn care are routinely done APGAR SCORING SYSTEM -reflective for need of resuscitation Appearance Pulse Grimace Activity Respiration Sign 0 1 2 Heart rate (pulse) Absent <100 >100 Respiratory effort Absent Slow, irregular Good, regular, crying Muscle tone Flaccid Some flexion of extremities Active recoil Reflex irritability (grimace) No response Grimace Vigorous Color (appearance) Blue, pale Body pink, extremities blue Completely pink Done during the 1 st minute and at 5 minutes If score at 5 minutes is <7, additional score every 5 minutes is taken until the 20 th minute unless 2 successive scores 8 APGAR score is not indicative of the newborn’s ability to survive Interpretation: 7-10 = good 4-6 = mild to moderate asphyxia 0-3 = severe asphyxia Lack of Effective Respiration (causes) 1. Fetal hypoxemia or acidosis from any cause 2. Drugs given to mother 3. fetal immaturity 4. upper airway obstruction 5. pneumothorax 6. lung abnormalities – hypoplasia 7. MAS 8. CNS abnormality 9. Septicemia Principles of Resuscitation ABC o open Airway o initiate Breatihng o assure Circulation I J I J J J J l i ň l l . . J i
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3 Signs to be Evaluated
o respiratory effort
o heart rate
o color
LATCHING ON
o the stable newborn is wiped dry & placed on the mother’s chest for
immediate bonding (w/in 30 mins – 1 hr after birth)
o the mother is encouraged to initiate breastfeeding during this time
o Suckling: oxytocin release, uterine contractions, less bleeding
TEMPERATURE REGULATION
To minimize heat loss
o Dry skin
o Provide adequate dry covering for the baby including the head
o Avoid exposure to air conditional vents & electric fans as well as contact w/
cold surfaces
o Droplight (25-30 W) over the basinet
Maintain temp: 36.4 – 37.2o C
Failure to maintain temperature range can lead to cold stress:
o Peripheral vasoconstriction
o Hypoxia
o Anaerobic metabolism
o Acidosis (treatment: bicarbonate, intubation, naloxone if due to anesthetic
depression)
o Death
ROUTINE NEWBORN CARE
A. Estimation of Gestational Age
1. sole creases
2. breast nodules
3. scalp hair
4. ear lobes5. testes & scrotum
B. Care of the Eyes
o Gonococcal/ Chlamydia conjunctivitis/Ophthalmia neonatorum
o Silver nitrate (Crede’s prophylaxis) – may cause chemical conjunctivitis ;
no longer used
o Give penicillin, tetracycline, erythromycin
o Other causes of Neonatal Conjunctivitis
Staphylococcus aureus
Streptococcus pneumoniae
Neisseria meningitides
Pseudomonas aeruginosa
Haemophilus influenzaeEscherichia coli
Herpes virus
C. Permanent Infant Identification
o Identification band
o Footprints (not preferred)
D. Vitamin K
o Prevent hemorrhagic disease of the newborn
-Vitamin K-dependent factors: II, VII, IX, X
-Vitamin K (phytonadione)
o 1mg IM term
o 0.5mg for preterm
E. Cord care
o strict aseptic precautions
o apply povidone-iodine daily
o separation in 3-45 days; faster if exposed to air
o neonatal tetanus
F. Observe passage of urine & meconium shortly after birth
o indicates patency of the GIT & urinary tracts
UNIVERSAL NEWBORN SCREENING
Routine newborn screening for 5 conditions (1996)
1. congenital hypothyroidism
2. congenital adrenal hyperplasia
3. phenylketonuria
4.
galactosemia5. G6PD deficiency
Hearing Screening
ROOMING-IN
o Trend to make childbearing as natural as possible
o Foster mother-child relationship
o Mother’s increased ability to assume full care of the baby when she arrives
home
PLACE OF DELIVERY
o majority of deliveries take place at home (next common are gov’t
hospitals then private hospitals)
o attendants at birth (in descending order) midwife, hilot, physician
CONCLUSIONS
o 7/10 of women deliver at home
o Strengthen the support system
o Virtually all births were delivered w/ some assistance
o Prenatal care was most often given by a nurse or midwife
HOME DELIVERY
-Commonly practiced
-Danger of being managed by untrained personnel
-Inability of caretaker to identify high r isk pregnancies needing more care-Resources for transfer may be inadequate or unavailable
Role of the Midwives & Primary care
1. Rendering services in the supervision and care of women during
pregnancy, labor and puerperium
2. Management of normal deliveries including IE during labor
3. Health education of patient, family and community
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4. Primary health care services in the community including nutrition and
family planning
5. Giving immunizations
6. Oral or parenteral dispensing of oxytocic drug after delivery of the
placenta
7. Suturing perineal lacerations to control bleeding
8. Giving IVF during obstetric emergencies
9. Injecting Vit. K to the newborn
When Do You Refer? High Risk Pregnancies Maternal Conditions
1. Abnormal OB history
a. CPD
b. Pre-eclampsia
c. Antepartum h’ge
d. Polyhydramnios
e. Previous CS
f. Forceps delivery
g. Post-partum h’ge
h. Adherent placenta
i. Elderly primigravida
2. Abnormal medical history
a. Cardiac diseaseb. TB
c. DM
d. serious anemia
e. venereal disease
Fetal Conditions
1. History of repeated stillbirths
2. Neonatal death or no living child
3. Malpresentation
4. <34 weeks AOG
5. Rh incompatibility
6. Fetal monstrosities
Home Delivery (again)
A. Advantages of Home Delivery
Emotional support by husband/family
Less danger of nosocomial infections
Less expensive
B. Conditions not favorable to home delivery
Presence of infectious diseases
Overcrowding
Destitution or poverty
Unsanitary conditions
C. Disadvantages of Home Delivery Lack of services
Lack of sophisticated equipment
Lack of trained personnel
GENERAL PRINCIPLES IN THE MANAGEMENT OF LABOR
First Stage of Labor
o careful observation of the progress of labor (Partograph or the
Friedman’s curve)
o vital signs and FHT
o prevention of infection
o reduction of anxiety
o empty bladder
Second Stage of Labor
o Cleanse vulva with betadine cleanser and antiseptic
o Scrub hands and wear sterile gloves
o Patient prepared – semi Fowler, dorsal lithotomy position
o Set up sterile equipment
o Advice mother to bear down
Third Stage of Labor
o Observe for signs of placental separation
uterus becomes round and globular
lengthening of the cord
sudden gush of blood
the uterus rises up in the abdomen
o Placenta delivered
Modified Crede’s Maneuver - separated placenta pushed
downward on the fundus
Brandt-Andrews Maneuver- put pressure on suprapubic
areao Examine placenta
o Check birth canal for lacerations
o Oxytocics – methylergometrine
o Mother’s vital signs
PUERPERAL CARE
O Encourage to move around
O Balanced diet
O Pain control as needed
O Daily routine check-up
TPR, BP,fundus, lochia, perineum
Breast and perineal care
o Encourage breastfeedingo Teach family care of mother and baby
Home Delivery(Yet Again)o REGISTER!
Responsibility of the MD, nurse, midwife and parent
Ensure that the certificate is accurately and completely
filled up
BREASTFEEDING
In Utero
Secretory buds
Inner layer- secretory epithelium
Outer layer- myoepithelium (mechanism for milk ejection)
Endocrinology of Lactation
Progesterone withdrawal during delivery removes inhibitory effect onproduction of α- lactalbumin
Allows prolactin to act unopposed in production of α- lactalbumin
Increased α- lactalbumin stimulate lactose synthase activity
Each act of suckling triggers rise in prolactin and oxytocin levels
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