pudendal nerve block
- Administered during the 2nd stage to anesthetize the vagina, vulva and perineum (somatic pain).
- 10-20ml of local anesthetic is injected into the pudendal canals unilaterally or bilaterally.
- Provides pain relief within 2-10 minutes and lasts up top 1 hour (Fall risk immediately after birth)
- Often used in conjunction with epidrual since the strecthing burning sensation is not blocked by the epidural
- Often used for instrumental birth (vacuum or forceps) or for extensive perineal and vagina repair when no epidural is in place.
- Pt must be in a lithotomy position for administration.
Epidural
what, types, diffusion
- The most effective pain relief for labour.
- Relieves pain of contractions, but not the pressure of fetal descent in the pelvis.
Types of infusions
Intermittent
- Catheter and you will have intermittend injections (not common)
Continuous (Most common)
- Initial dose and then a continuous baseline infusion → then you can give boots of another infusion
PCEA (recommended)
- Increased sense of control over labour
Decreased amount of medication used
regional analgesia/ anesthesia
epidural, spinal, combined
Epidural:
- A catheter is placed in the epidural space between the 4th and 5th lumbar vertebrae
Spinal:
- A catheter (smaller needle than for epidural) is placed in the subarachnoid space.
Combined Epidural-Spinal:
- An epidural needle is used to reach the epidural space then a smaller needle is threaded through to reach the subarachnoid space to inject the anesthetic followed by usual placement of the epidural catheter.
- Medications used: opioid (ex. Fentanyl) and local anesthetic (ex. bupivacaine)
epidural nurisng care before, during and after
before
- Assess maternal VS, hydration status, labour progress, and FHR pattern
- Review lab results (special attention to platelets)
- Insert IV line and give 500-1000ml bolus 15-30 min. prior to epidural initiation.
- Assist client to void
during
- Monitor maternal VS and FHR as per protocol (typically q5-10 min x 30 min)
- Have oxygen and suction available.
- Have Ephedrine or phenylphrine available (To bring the blood pressure back up)
- Assist client to change position minimum q1hour. Ideally q30min.
- Monitor bladder distension. Assist with voiding in the toilet or bedpan (if they have a walking epidural). Perform “in & out” urinary catheterization as needed → decreases risk of UTI.
5 keeps of epidural and positioning
5 keeps for epidurals
- Keep her moving.
- Keep her cool.
- Keep her company.
- Keep from pushing too early.
- Keep her skin to skin with her baby.
positioning
- Help your patient change position every 30-60 minutes.
- Be mindful of where the fetal back is, in order to select positions that will facilitate OA orientation.
peanut ball for labour
Peanut ball
- Stage 1 reduced by > 90 minutes
- Stage 2 reduced by average 22.3 minutes
- C-section rate decreased by 12%
- Increased patient satisfaction
- No adverse neonatal effects noted
APGAR
appearance
pulse
grimace
activity
respirations
If apgar is less than 7 at 5 mins → reasses at 10 mins
adaptations at birth
resp and cardio
Adaptations at Birth - Respiratory
- The first breath is triggered by light, cold, noise, decreased pO2, increased pCO2
- Surfactant is required to decrease surface tension and maintain alveolar stability
- Patent nares are necessary as newborns are by preference nose breathers
Adaptations at Birth - Cardiovascular
- Adaptation begins with cord clamping and the first breath
- Increased blood flow to lungs and liver
- Increased O2 to periphery
The following anatomical structures close:
- Ductus arteriosus
- Ductus venosus
- Foramen ovale
sleep wake state
Variations in the state of consciousness of infants
- Six states form a continuum from deep sleep to crying
- Two sleep states: deep sleep, light sleep
- Four wake states: drowsy, quiet alert, active alert, crying
erythromycin
- Administered to the eyes to prevent opthalmia neonatorum
- Inflammation of the eyes caused by a gonorrhea and chlamydia infection
- Contracted by the newborn during the passage through the mother’s birth canal
- Legally required to prescribe for all newborns in Ontario
- Canadian Pediatric Society no longer recommends routine administration as long as STI screening has been performed in pregnancy and there is a negative chlamydia and gonorrhea result on file + there are no risk factors for these infections post screening.
- Ontario law allows parents to refuse
vitamin K prophylaxis
- Administration of vitamin K (IM) is routine to prevent hemorrhagic disease of the newborn
- Administration is important as the newborn does not have intestinal flora to produce vitamin K in the first week after birth and it promotes the formation of clotting factors in the liver
- 1.0mg of vitamin K for babies >1500 g
- 0.5mg of vitamin K for babies <1500g
- Administered within 6 hours after birth
- Skin to skin when administering in order to decrease the perception of pain in the newborn
Thermogenesis and thermoregulation
cold stress? why are newborns at risk?
Thermogenesis (generation of heat) in infants:
- Heat loss occurs via convection, radiation, evaporation, and conduction
Thermoregulation – Cold stress
- Hypoglycemia d/t increased energy expenditure
- Decreased 02 consumption
- Decreased pulmonary perfusion
- Respiratory distress
- Hyperbilirubinemia d/t an increased metabolic rate which results in glycolysis and acidosis
Why are newborns at risk of getting cold?
- Unable to shiver
- Large surface area in comparison to weight
- Blood vessels are superficial
- Low energy stores
weight in new borns
Birth weight of term newborns ~2500 - 4000 grams
loss of less than 10% is normal will regain as they feed
Caput Succedaneum:
- Generalized, easily identifiable edematous area of the scalp
- D/t compression of local vessels resulting in slowed venous return which causes an increase in tissue fluids within the skin of the scalp
- Edematous swelling is present at birth
- Extends across the suture lines of the skull
- Disappears spontaneously within 3 to 4 days
- Common in infants born via vacuum-assisted delivery
Cephalohematoma:
- Collection of blood between a skull bone and its periosteum
- Does NOT cross cranial suture lines
- Often occurs with caput succedaneum
- May be d/t pressure against the maternal bony pelvis or forceps extraction
- Does not bulge when the newborn cries
- Resolves in 3 to 6 weeks
subgaleal hemorrhage
- Bleeding into the subgaleal compartment
- Associated with difficult operative vaginal birth especially vacuum extraction
- Blood loss can be severe and result in hypovolemic shock, DIC, and death
- Early detection of hemorrhage is vital
- Can cross suture lines
Early signs of a subgaleal hemorrhage include
- a boggy scalp
- tachycardia
- increasing head circumference
- CT or MRI confirms the diagnosis and the replacement of lost blood and clotting factors may be needed
respiratory distress s/s
Signs:
- Nasal flaring
- Head bobbing
- Tracheal tug// intercostal or subcostal retractions
- Grunting/ Stridor
- Tachypnea
- Centralized cyanosis and duskiness
- Mild TTN (Transient Tachypnea of the Newborn)
- hypotension
- temperature instability
- hypoglycemia
- acidosis
- signs of cardiac problems
- RR may exceed 120
feeding in newborns, 6 months/why
- Exclusive breastfeeding (BF) for the first 6 months of life for healthy, term infants
- introduction of nutrient rich complementary food at 6 months, and continued partial BF up to 2 years or beyond.
- Daily Vitamin D supplement (until 1 year) 400 IU/day “D-drops”
- Focus on introducing Iron rich foods at 6 months
why 6 months
- By 6 months, babies reach several growth and developmental milestones indicating that they are ready to begin eating complementary foods:
- Gut closure – maturation of the gut → Able to absorb nutrients
- Ability to sit up on their own
- Tongue protrusion reflex has subsided → if they still have it it tells us they are not ready yet
What is in human breast milk
actual composition and protective factors
- Composition of milk changes over time to meet the nutritional and immunological needs of the infant
- Enhances the maturation of the GI tract/gut microbiome
- Major immunoglobulin (Ig) in human milk is secretory IgA (sIgA).
- Human milk also contains IgG, IgM, IgD, and IgE
- Also contains T and B lymphocytes,
mature mlk is:
- 87-88% water
- 7% carbs
- 1% protein
- 3.8% fat
- Some variation with factors, such as gestational age of infant, timing of feedings, maternal health, etc.
advantages of BF for baby
- Reduced infant morbidity and mortality (also SIDS)
- Decreases risk of GI disorders
- Decreases risk of type 1 and 2 diabetes & certain childhood cancers (leukemia and lymphoma)
- protects against infections/ resp ilnesses
- Meets the nutritional requirements for every stage of development
- Enhances cognitive and physical development
- Baby controls how much they drink at each feeding
- No risk of contaminated formula and optimal food available even in disasters.
