Developmental Milestones

Parents are very excited to see their babies and children first smiles, verbalize words, walk and looks at them. The progress of their babys development has been thoroughly documented by some. Normal progress of development has been difficult for some parents to identify. Before discussing the different developmentalmilestones appropriate for a specific age, let us first differentiate growth from development. Growth vs. Development Growth is an increase in the physical size of a child while development is an increase in his or her ability. The former is quantitatively measured through the measurement of weight and height while the latter is qualitative and the progress is determined through direct observation of the childs gross and fine motor, language, socialization and play development. Determining whether the progress of development in a child is normal is not that easy. Thorough observation and knowledge of developmental milestones appropriate for the age is the key factor in qualitatively assessing development. Infancy Period Infancy is the period of time from 1 month to 1 year of age. The growth and development of an infant is rapid in terms of size and the ability to perform specific tasks. 1 month hands fisted; able to follow object to midline; delights in watching the face of the primary caregiver 2 months social smile noted; cooing sounds is differentiated from cry; enjoys bright-colored mobiles 3 months follows object past the midline, laughs out loud, hand regard noted 4 months grasp, tonic neck, step-in-place reflexes fading, needs space to turn 5 months turns from front to back, can handle rattle well 6 months can turn both ways, may be able to verbalize vowel sounds such as oh-oh, bathtub toys are enjoyed at this time, rubber ring for teething are enjoyed, 7 months sits with support, anticipates to being picked up, beginning to fear strangers, prefers and likes to play with objects that are good size for transferring 8 months sits without support, develops the ability to identify known from unknown people thus, peak of stranger anxiety is at this point, enjoys manipulation of toys with different textures 9 months can creep or crawl, needs space for creeping, and says first word (da-da) 10 months pulls self to stand, uses pincer grasp, patty-cake and peek-a-boo are the gamesthat infants of this age enjoy 11 months walks with support cruises 12 months stand alone, pushes arm into sleeve when dressing up, holds spoon and cup, says two words plus mama and da-da, nursery rhymes, loves pulling toys while walking Toddler The toddler period is considered to be from age 1 to 3 years of age and during this time that enormous changes are taking place in a child. 15 months walks alone well, can sit in a chair and can creep upstairs, language: 4-6 words, holds a spoon well but may still turn it upside down on the way to the mouth, exploring the sense of permanence 18 months when using spoon the toddler no longer rotates the spoon to the mouth, able to run and jump in place, can verbalize about 7 to 20 words and the child at this age is able to name one part of a body; parallel play is initiated; loves to imitate household chores such as dusting, sweeping and etc. 24 months the toddler at the period is now able to open doors by turning doorknobs, lids are unscrewed when place near the childs reach, can walk the stairs with both feet on the same step at the same time; evidently by this point the play among these ages is parallel play 30 months using a pencil, a toddler at this point can make simple lines and strokes for crosses, able to jump down from the chair, the development of verbal language is steadily increasing, the toddler at this time already knows his or

her full name and can name one color, when asked about age the toddler holds up his or her fingers to show age; imitating actions is noted at this age, play is either rough housing or active games Preschool 4 years builds a tower of 10 blocks, draw a person with 3 parts, use paragraphs with sentences of 4 or 5 words, distinguishing fantasy from reality, giving first and last name, singing a song 5 years dressing self independently; walking, climbing and running with coordination; drawing a person with details such as with head, body, arms and legs, copying a triangle or square, speaking in shirt paragraphs, recognition of almost all alphabet letters, can give own address and phone number, can follow rules of interactive peer games. School Age The term school age refers to children between the ages 6 and 12 years of age. These years represent the period of slow physical growth. However, cognitive growth and development continue to proceed at rapid rates. 6 years skipping is a new skill learned by the child, authority figure is the first grade teacher, difficulty adjusting to all-day school may be noted during this time that may result to nervous manifestations like fingernail biting and etc, at this time the words are defined by the school age based on their use, eruption of first molar occurs 7 years during play difference between sexes become apparent, conservation is learned, able to tell the time can make simple change, eruption of central incisors 8 years definitely improved coordination is noted during this year, development of best friends, eyes become fully developed, can write and print, able to understand concepts of past, present and future, playing with gang becomes important, 9 years gang age: all activities are done with the gang, has secret codes, gang is all boy or all girl, the gang can disband and reform quickly 10 years improvement in coordination noted, this is the age where the child collects a lot collecting age, the child at this period is now able to camp away from home, ready for participating in competitive games, prefers to have rules. 11 years at this time the child is active but is awkward and ungainly, insecure with the members of the opposite sex, repeats off-color jokes 12 years coordination improves at this point, sense of humor already present at this age, the child is social and cooperative Adolescent: 13 years old 18 years old 1. 2. 3. 4. 5. Self-esteem changes More independent Future plans noted Coordinated body movements noted Sexual maturation

Infancy Period
Definition Infancy period, traditionally, is the time from 1 month to 1 year of age. Because of the growth and learning potential that occurs, the first year of life is a crucial one. Physical development during the infancy period Weight. Most infants double their birth weight at 4 to 6 months and it triples at 1 year. A weight gain of 2 lb per month during the first 6 months is typical among infants. During the second 6 months, the expected weight gain is approximately 1 lb per month. Height. Height like weight is ideally assessed if plotted on a standard growth chart. The average birth length of an infant is about 20 inches. During the first year an infant increases in height by about 50 %. In early months the

growth is apparent in the trunk while it becomes more apparent as lengthening of the legs during the second half

1. 2. 3. 4. 5. 6. 7. 8. 9.

of the first year. Head circumference. Rapid brain growth is reflected by a rapidly increasing head circumference. By the end of the first year of life, the brain has already reached two-thirds of its adult size. Teeth. By 6 months of age, the first baby tooth which is typically ca central incisor erupts. The eruption is followed by a new one monthly. Usual ages of baby tooth eruption by tooth type are as follows: Central lower incisor 6 to 10 months Upper central incisor 8 to 12 months Upper lateral incisor 9 to 13 months Lower lateral incisor 10 to 16 months Upper cuspid 16 to 22 months Lower cuspid 17 to 23 months Upper first molar 13 to 19 months Lower first molar 14 to 18 months Lower second molar 23 to 31 months

10. Upper second molar 25 to 33 months Gross motor development. To assess the development of gross motor skills in infants, four positions should be observed. The positions are as follows: Ventral suspension position This is the appearance of the infant when held in midair on a horizontal plane, supported by a hand under the abdomen. With this position, the infants head is allowed to hang down with little effort on control. 1. 2. 3. One month old infants lift the head momentarily and drop it again. Flexion of elbows, hip extension and knee flexion may be observed. By two months of age, the head is held in the same place as the rest of their body. This signifies a major advancement in muscle control. A month after, the head is lifted and maintained well above the plane of the rest of the body in ventral suspension. It is at this month where a Landau reflex is developed. Landau reflex is the extension of the infants head, legs and spine when held in ventral suspension. Most infants continue to present this reflex until 6 months of age. Inability to perform this reflex would suggest further evaluation for possible motor weakness, cerebral palsy, or 4. other neuromuscular defect. When Landau reflex diminished, the infant then demonstrates a parachute reflex. By 6 to 9 months of age, infants suddenly lower towards the examining table while extending the arms as if protecting themselves when held in a ventral suspension position. An inability to demonstrate this reflex would suggest cerebral palsy because they flex their extremities too tight. Prone position Newborns can turn their heads to move them out of a position where breathing is impaired when placed lying on their abdomen. However, they cannot hold them raised. 1. 2. 3. 4. 5. 6. 7. One month old infants can lift their heads and turn them easily to sides. As what they usually do during the neonatal period, they still tend to keep their knees tucked under their abdomen. A month after, infants can now raise their heads and maintained the position. But they cannot raise their chests and their head is still facing downward. Three month old infants can raise their head and shoulders well. They can now look around when prone. By four months of age, an infants chest can be raised from the bed. Weight is shifted to the forearms when the child is placed on prone by age 5 months. The infant can raise his or her chests and upper parts of the body off the table by 6 months of age. A new skill is advanced by age 9 months when the infant can creep from a prone position. Creeping means that the child has the abdomen off the floor and moves one hand and one leg and then the other hand and leg, using the knees on the floor to move.

Sitting Position By four months of age the infant demonstrates an important milestone by showing no head lag when pulled to a sitting position. An infant can sit without support by 8 months of age. Standing Position A child can stand holding onto furniture when placed in a standing position by about 9 months. A month after they can now pull themselves to a standing position by holding onto something. By 11 months, they start to move around by holding onto something, an event called cruising. At exactly 1 year, the child can stand alone momentarily. Fine Motor Development 1. 2. 3. 4. 5. During the first month of life, the infant has a strong grasp reflex. This is the reason why they have difficulty extending their fingers as they hold their hands in fist. Thumb opposition starts by 4 months of age where the infant brings the thumb and the fingers together. During the first half of the year, infants are now able to hold objects in both hands and they can hold a spoon. The ability to bring the thumb and the fist together in a pincer grasp is a major milestone of 10 month old children. As the skill advances, by 1 year, infants are now able to draw a semi straight line using a crayon. Language Development

1 month: cooing or dovelike sounds made by the infant 2 months: differentiates cry. Certain cry means the infant is hungry while this type of cry would suggest that the child is wet. Increased cooing, gurgling and throaty sounds observed. 3 months: squeals with pleasure 4 months: babbles, gurgles and coos when spoken to. 5 months: verbalizes simple vowel sounds such as goo-goo and gah-gah 6 months: art of imitating is learned. The infant at this time may imitate parents cough or say Oh! to attract attention. 7 months: amount of infant talking increases 9 months: first infant word is verbalized as da-da or ma-ma. It is generally easier for infants to verbalize da-da than ma-ma and infants at this time pronounce these words without knowing its meaning. 10 months: infant masters another words such as bye-bye or no 12 months: infants can generally say two words besides ma-ma and da-da. These words are used knowing that ma-ma is calling his mother and da-da for fathers. Play: Infants enjoy solitary play. Appropriate toys for infants generally depend on their age: 1 month mobiles over a crib or playpen, music box, musical rattle 2 months small rattles, mobiles or cradle gyms strung across the crib 3 months small blocks and small rattles, needs a playpen to practice the skill of rolling over 5 months plastic rings, blocks, squeeze toys, clothespins, rattles and plastic keys 6 months bathtub toys such as rubber ducks or plastic boats, teething rings 7 months blocks, rattles, plastic keys, brightly colored balls 8 months toys that feel differently to infants are enjoyable at this age because of their sensitivity to texture differences. Velvet, fur, fuzzy or smooth items are ideal for these children. 9 months space for creeping, nest of blocks that go inside one another, rings of assorted sizes that fit on a center post 10 months peek-a-boo, patty-cake games 12 months boxes that is inside one another, blocks, cardboard boxes, pull toys (when they can walk), listening to

music Development of Senses Vision 1 month midline vision 2 months focus well and follows objects past midline, binocular vision

4 months recognize familiar objects and follows their parents movements eagerly 6 months organized depth perception 7 months pats their images in a mirror, matured depth of perception 10 months looks under the towel or around a corner for a hidden object Hearing 1 month quiets momentarily at a distinctive sound such as a bell or a squeaky rubber toy 2 months acute hearing awareness, stops an activity at the sound of spoken words 3 months turns head to locate sounds 4 months when distinctive sound is heard they turn and look at that direction 5 months can localize sound downward and to the side by turning their head and looking down 6 months able to locate sounds above them 10 months recognize their name and listen acutely when spoken to 12 months can easily locate a sound in any direction and turn toward it Emotional development 1 month can differentiate between faces and other objects by studying a face or the picture of a face longer than other things, quiet best and eat best for the person who has been their their primary caregiver 2 months social smile 3 months increased social awareness by readily smiling at the sigh of a parents face, laughs out loud at the sight of a funny face 4 months likely cries when the person who entertains the infant leaves, prefers the presence of the primary caregiver than others 5 months show displeasure when an object is taken away 6 months increasingly aware of the difference between people who regularly care for them and strangers, draws back from unfamiliar people 7 months shows obvious fear of strangers, attempts to cling on parents when taken from them and reaches out to be taken back 8 months peak of stranger anxiety 9 months aware of the changes in the voice tone, cries when scolded not because of understanding what is being said but due to sensing a displeasure in their parents 12 months overcome fear of strangers, alert and responsive when approached, plays interactive nursery games, dances with others, likes being at the table for meals and joining family activities Cognitive Development 1 month simple reflex activity 3 months enters the cognitive stage of primary circular reaction, explores objects by grasping them with the hands or mouthing them, unaware of what actions they can cause 6 months enters the cognitive stage of secondary circular reaction, can grasp the idea that their action can initiate pleasurable sensations 10 months coordination of secondary schema stage, object permanence 1 year capable of reproducing interesting events and produce new ones Developmental Task Erikson proposed that the developmental task of the infant is to form a sense trust. Infants learn to trust when their needs are being met. The confidence that their needs are met primarily results to trust development. Hence, rhythm of the care should be familiarized by infants as it gives them the feeling of being able to predict what will happen and gives life some consistency. Aside from that, the one caring for the infant plays an important role. Active interaction with the child promotes trust. Inability to develop the developmental task during the infancy period would result to mistrust which will be brought up until the child meets the sense of trust.

TORCH Infections
Overview Maternal infections can be teratogenic, can cause adverse effects to the fertilized ovum, embryo or fetus. The occurrence of these infections can involve either sexually transmitted or through systemic infection. TORCH infections are diseases identified as causing serious harm to the embryo or fetus. Organisms with these infections can cross the placenta and may be a virus, bacteria or a protozoon. The infected woman will just manifest mild flu-like symptoms. However, a more serious or worst fatal effect on a fetus or newborn is at risk. It is difficult to prevent and predict fetal injury from these infections because the mother may manifest no symptoms and yet internally the infection is injuring the fetus. Definition The umbrella term TORCH is an abbreviation for diseases that are collectively known and tested to cross the placenta and cause fetal harm which includes: Toxoplasmosis, Rubella, Cytomegalovirus and Herpes Simplex Virus. Some sources identify O as other infections which could include syphilis, hepatitis B virus and human immunodeficiency virus (HIV). Generally, TORCH infections are diseases identified to cause serious harm to the embryo or fetus. Toxoplasmosis Toxoplasmosis is caused by the protozoan Toxoplama Gondii. It is spread most commonly through contact or eating poorly cooked or uncooked meat. Handling infected cat stool in soil or cat litter may also contribute to the spread of this disease. The pregnant woman experiences no symptoms (asymptomatic) of the disease. However, few days after body malaise and cervical lymphadenopathy may be observed and experienced. Clinical Manifestations of Toxoplasmosis The clinical manifestations experienced by a pregnant woman with toxoplasmosis are the following: Myalgia

Body malaise Rash Splenomegaly Cervical lymphadenopathy

If the infection crosses the placenta, the infant may be born with the following problems: Central nervous system damage Hydrocephalus Microcephaly

Intracerebral calcification Retinal deformities Nursing Diagnosis for Toxoplasmosis Serum analysis during pregnancy such as the Sabin-Feldman dye test Nursing Management for Toxoplasmosis Therapy with Sulfonamides Sulfadiazine, if the diagnosis is established by serum analysisduring pregnancy. However, the prevention of fetal deformities is uncertain. Taking this medication also leads to increased bilirubin in newborns.

Pyrimethamine, an antiprotozoal agent can also be used. Pregnant women taking this drug must be monitored early in pregnancy as this drug is an antifolic drug that reduces folic acidlevels. Important Information If toxoplasmosis is diagnosed before 20 weeks age of gestation damage to the fetus is more severe than if the disease is acquired later. The incidence of abortion, stillbirths, neonatal deaths and severe congenital anomalies is high. Rubella

Rubella virus only cause mild rash and systemic effects to the mother but a devastating teratogenic effect on the fetus is noted. The period of greatest risk for teratogenic effects of rubella on the fetus is during the first trimester. If the infection occurred during or between the third and seventh week of pregnancy, the damage usually results to fetal death. Permanent hearing impairment is most often the result if the infection occurred in the early second trimester. Fetal damage from maternal infection with rubella or most commonly known as Germanmeasles are the following:

Deafness Mental and motor challenge Cataracts Cardiac defects most commonly patent ductus arteriosus and pulmonary stenosis Restricted uterine growth or small for gestational age Thrombocytopenic purpura

Dental and facial clefts such as cleft lip and palate Nursing Diagnosis for Rubella On the first prenatal check-up, typically, a rubella titer is obtained. If the titer result is greater than 1:8 immunity to rubella is suggested. A titer result of less than 1:8 suggests that a woman is susceptible to viral invasion. A recent infection has occurred if the result of the titer is greatly increased over a previous reading or is initially extremely high. Immunization Immunization to rubella during pregnancy is not allowed because the vaccine causes a live virus that would result to unpleasant effects to the fetus similar to those with a subclinical case. If a woman is immunized with a rubella vaccine she is not advised not to get pregnant for 3 months. By this time, the rubella virus is not longer active and may not cause teratogenic effects to the fetus if pregnancy would occur. Nursing Management for Rubella

Prevention. The best management for rubella is to prevent its occurrence. All pregnant women should avoid contact with children with rashes. Infants who are born to mothers who had rubella during pregnancy should be isolated fro other newborns as the neonate may be capable of transmitting the disease after birth. Live attenuated vaccine should be given to all children. Women of childbearing age should be tested for immunity and vaccinated if susceptible if established that they are not pregnant.

Nurses who care for pregnant women or newborns should receive immunization against rubella to ensure that they neither spread nor contract the disease. Cytomegalovirus The cytomegalovirus (CMV) is a member of the herpes virus family. It is another teratogen that can cause extensive fetal damage while the woman only manifests few symptoms. This virus can cause both congenital and acquired infections referred to as cytomegalic inclusion disease. It is transmitted from person to person by droplet infection. If the woman acquires the infection during pregnancy, the virus has the ability to cross the placenta to the fetus or through the cervical route during delivery. The virus can be found in urine, saliva, cervical mucus, semen and breast milk. Infants with mothers infected to cytomegalovirus during pregnancy may be born with the following conditions:

Severely neurologically challenged hydrocephalus, microcephaly, spasticity Eye damage optic atrophy, chorioretinitis Deafness Chronic Liver disease

Skin covered with large petechiae blueberry-muffin lesions Nursing Diagnosis for Cytomegalovirus Women infected with CMV may not be aware of the disease as they manifest no clinical signs and symptoms. However diagnosis can be established by the isolation of CMV antibodies in the blood serum. Nursing Management for Cytomegalovirus

No treatment for the infection exists even if it presents in the mother with enough symptoms to allow detection. Prevention is the key of not contracting the infection. Exposure to CMV can be prevented by thorough hand washing before eating and avoiding crowds of young children at daycare or nursery settings.

Complications The principal tissues and organs affected with CMV are the blood, brain and the liver. The following are the possible complications of this infectious disease: Hemolysis leads to anemia and hyperbilirubinemia

Thrombocytopenia with subsequent petechiae and ecchymosis Hepatosplenomegaly

Encephalitis lethargy or hyperactivity and convulsions Cerebral palsy Herpes Simplex Virus (Genital Herpes Infection) A substantial risk to the fetus is noted in pregnant women who have a primary first-episode herpes infection. When a woman contracts the genital herpes infection, systemic involvement occurs. After which the virus then spreads to the bloodstream, termed viremia, and crosses the placenta to a fetus. Clinical Manifestations of Herpes Simplex Virus With herpesvirus type 2 the following clinical manifestations will be experienced by the woman:

Genital irritation and itching Vaginal and urethral discharge Copious and foul-smelling vaginal discharges Enlarged tender lymph nodes Dysuria Reddened papules at the start then becomes itchy pustular that break and form painful wet ulcers, which then dry

and develop crusts. The effect of the herpes simplex virus infection varies, depending on the time the infection occurred:

If the infection takes place in the first trimester of pregnancy, severe congenital anomalies or spontaneous miscarriage may occur. There is a 20% to 50% rate of spontaneous abortion if the infection occurred during this time. If the infection occurs during the second or third trimester of pregnancy, there is a high incidence of premature birth, intrauterine growth restriction and continuing infection of the newborn at birth. Infection after the 20 week age of gestation leads to the incidence of premature birth but not to teratogenic defects. The neonate can acquire
th

the infection. Survivors have permanent visual damage and impaired psychomotor and intellectual development. If the woman has genital lesions present at birth the fetus may contract the infection from direct exposure at birth. Nursing Management for Herpes Simplex Virus Women who have history of genital herpes and existing genital lesions is often advised to undergo cesarean section if fetal involvement is not present to reduce the risk of direct neonate exposure to infection at birth. Intravenous or oral Acyclovir (zovirax) can be administered to women during pregnancy. Treatment is towards relieving the womans vulvar pain. Creams containing sulfonamide may be used to treat bacterial infections. During the peak of infection, the client may be advised to stay in bed as it may be most comfortable for him or her. In cases where an infection is suspected to the pregnant woman, an amniocentesis can be performed to determine fetal involvement. If fetal involvement is present, a cesarean section delivery should never be

performed. Other Viral Infections Syphilis Syphilis is a sexually transmitted disease and places a fetus at risk for intrauterine or congenital syphilis. This maternal infection is caused by a spirochete Treponema Pallidum. Suspicion or presence of this infection requires

great concern for the maternal-fetal population despite the availability of accurate screening tests and proven medical treatment. Clinical Manifestations of Syphilis

Newborns born with congenital syphilis may have the following: Congenital anomalies Extreme rhinitis (sniffles) Characteristic syphilitic rash

Oddly shaped primary teeth Nursing Diagnosis for Syphilis Serologic testing either VDRL or rapid plasma regain should be done at the first prenatal visit. The diagnostic th test may be repeated again close to term, about the 8 month age of gestation if the concern is exposure.

Increasing titer means that reinfection has occurred in the woman. Lyme Disease This is a multisystem disease caused by the spirochete Borrelia Burgdorferi. Lyme disease is contracted through the bite of a deer rick and the highest incident of infection is during summer and fall. Clinical manifestations of Lyme Disease The symptoms of Lyme disease is chronic not dramatic. Thus, women may not report them at prenatal visit unless proper education about the importance of reporting a migratory rash and joint pain is known to be related to this infectious illness. The nurse should ask the pregnant woman during prenatal visits for the presence of the following

clinical manifestations: Erythema chronicum migrans large macular lesions with a clear center. This typical rash develops after the tick bite. Pain in large joints (such as the knee) may be present Spontaneous miscarriage can result from the infection during pregnancy Severe congenital anomalies

Prevention To prevent contracting the disease women who are anticipating to be pregnant must avoid wooded or tally grassy areas where they are apt to be bitten by ticks. In case where women are taking nature trips, it is not advisable to take tick repellent lotions as these products contain diethyltoluamide because the ingredient is teratogenic. To prevent exposure to tick the woman should be advised to wear long and light-coloredslacks tucked to the

socks to help prevent the legs from possible exposure. Instruct the woman to inspect her body carefully and immediately remove any ticks found. Nursing Management for Lyme Disease Treatment of Lyme disused for pregnant and non-pregnant women differs. For nonpregnant adults tetracycline and doxycycline may be used. These drugs cannot be used in pregnant women since it causes tooth discoloration and possibly, long-bone formation in fetus. For pregnant women, a course of penicillin will be prescribed to reduce the symptoms.

VATER Syndrome or VACTERL Association

Definition VATER syndrome, presently known as VACTERL association, refers to a pattern of interrelatedbirth defects in an infant. The acronym is used to describe the types of disorders or problems a child may be suffering physically. Some resources prefer to use the VATER association thanVATER syndrome. The main reason of calling it an association is the fact the birth defectspresent are connected or linked with each other. Abnormalities in children with this condition may not follow the same pattern or exact level of severity. Causes

Certain genes or sets of genes that bring about this birth defect are still unknown. Abnormalities in VATER Syndrome Every letter in the acronym VATER represent a certain body part where a birth defect might be present. A short synopsis of what the letters represent is listed below: V Vertebral anomalies. Examples of problems in the vertebrae are an abnormally formed vertebra also termed as hemivertebrae, extra ribs and a bifid vertebra. A Anal anomalies such as imperforate anus, absence of opening in the anal area. Urinogenitary anomalies are also classified under this representation. C Cardiac Anomalies or abnormalities in the heart. Examples of birth defects under this type are missing arterial parts such as the pulmonary artery, or presence of holes in the heart such as in atrial septal defect and ventricular septal defect. T Tracheal anomalies such as the presence of connection between the trachea and esophagus, a condition called tracheoesophageal fistula. E Esophageal anomalies such as the absence of esophageal part or opening called, esophageal atresia or a birth defect where the esophagus connects to the trachea, tracheoesophageal fistula. R Renal or kidney anomalies. Examples of this birth defect are a missing kidney, presence of more than two kidneys or a horse-shoe kidney. L Limb Abnormalities. Missing bone/s in the arm/s, absence of a digit, missing bones in the leg and/or toes or an abnormally formed thumb is an example of birth defects under this category. VATER is presently termed as VACTERL association by some practitioners and researchers in response to the added defects in the heart or cardiac system and limb deformities. Management SURGICAL REPAIR of the Defects If anatomical defects are present, surgical repair would improve the abnormality. The type and timing of surgery performed depends largely on the nature or the extent of birth defects and overall condition of the child.

Healthy Eating Habbits for Infants

Having the first hand experience in taking care of an infant may involve making him comfortable as much as possible like changing the diapers, but whats more important is ensuring that the child is gaining a healthy diet. On the first year of the child, growth spurts and it is really essential for nurses to assist and educate mothers and care givers with the factsabout healthy eating patterns of an infant. Looking forward for a healthy eating pattern may need to start it within the first months such as goo eating habits. Here are pointers to remember: I Initiate one food at a time. Babies would love the new taste of the food and it is fitting to introduce each food one at a time about 5 to 7 days. In this manner, allergic reaction or choice of food can be observed. N No salt or sugar please. Go for natural like mashed potatoes. Avoid using canned foods since they have artificial preservatives that may be harmful in the babys stomach. F First make it a teaspoon up to tablespoon. It is a rule of thumb to introduce solids foods in small amounts so that babys can digest it. A Always use a spoon when feeding. This is the way in order for the baby to get used with the image of the spoon as well as making it easier for him to know that it is feeding time. N No more feeding bottles on the first birthday. Make it a culminating event for feeding bottles onthe first year of the child. In this manner, mothers will be able to remember well when was the time their babies have given up bottle feeding and started on solid foods. T Take the babys diet up a notch. Do not limit the food choice for babies. In this manner, the child may be able to develop good adaptation with a wide variety of food groups. This would also help in preventing the attitude of being picky with foods.

Here are the signs that the infant is ready for solid food: 1. 2. 3. 4. 5. The baby has lost the tongue-thrust reflex wherein the baby can drink and swallow liquids without regurgitating. On the fourth to sixth month, the baby can be introduced with solid foods. The baby can make actions that he or she is full by refusing additional feeding or milk feeding. Sitting up and holding his head with no assistance on the back. Birth weight doubles, this is a sign of growth spurt thus it needs more nourishment. Having an eye on the foods that adults usually eat.

HELLP Syndrome
Definition A life-threatening occurrence that complicates pregnancies is called a HELLP syndrome. The acronym HELLP is variation of PIH named for the common symptoms that occur such as: H Hemolysis E Elevated L Liver Enzymes L Low P Platelet Frequency

The syndrome occurs in 4 to 12 % of women with pregnancy induced hypertension or PIH. Approximately it occurs 1 in every 130 births.

It is a serious condition because it results in maternal mortality rate as high as 24 % and an infant mortality as high as 35 %. Cause HELLP syndrome is believed to occur as a result: Hemolysis Hemolysis occurs due to the fragmentation and distortion of the erythrocytes during passage through small damaged blood vessels. The answer to the question as to why some women with severe preeclampsia also develop HELLP syndrome is unknown. It occurs both in primigravid and multigravid women. Elevated Liver Enzyme When hepatic blood flow is obstructed by fibrin deposits, liver enzymes increase. Low Platelets Vascular damage from vasospasm causes low platelet levels. Signs and Symptoms

Pain pain in the upper right quadrant, the lower right chest or the midepigastric area Nausea and vomiting General malaise

Right upper quadrant tenderness because of liver distention and inflammation Severe edema Laboratory Studies reveal the following: Hemolysis of red blood cells RBCs appear fragmented on a peripheral blood smear Thrombocytopenia a platelet count below 100,000/mm3 Elevated liver enzyme levels such as alanine aminotransferase (ALT) and serum aspartate aminotransferase

(AST) Nursing Management 1. 2. 3. Assist the client to a setting with intensive care facilities available. Administer magnesium sulfate per doctors order to control seizures. To control the blood pressure, give Hydralazine as ordered.

4.

Avoid traumatizing the liver by abdominal palpation. A sudden increase in the intraabdominal pressure, including seizure, could lead to the rupture of a subcapsular hematoma that could result to internal bleeding and hypovolemic shock. Events such as this could result to hepatic rupture leading to maternal and fetal mortality.

5. 6.

Manage prescribed fluid replacement accurately to avoid worsening the womans reduced intravascular tone. Excessive fluid administration could lead to pulmonary edema or ascites. If the gestation is at 34 weeks, cervical ripening with labor induction is usually done. Delivery may be delayed if the gestation is less than 34 weeks and the womans condition is stable to give steroids for stimulating fetal lung maturation. Transfuse fresh-frozen plasma or platelets as ordered to improve the platelet count. Use care when transporting the woman. Give psychosocial support.

7. 8. 9.

Biophysical Profile Procedure

A biophysical profile is a test measures the health of the fetus during the third trimester of pregnancy. It is a simple and painless test that combines an ultrasound evaluation with a non-stress test (NST). The biophysical profile assesses five parameters of fetal status which are the following:

Fetal heart rate (FHR) Fetal breathing movements Gross fetal movements Fetal muscle tone

Amniotic fluid volume Through a biophysical profile (BPP) the condition of the fetus can be most accurately predicted as it involves several parameters to be evaluated. Purpose of Performing Biophysical Profile

1.

To assess acute and chronic markers of fetal well-being. The components of examination in BPP are acute and chronic markers of fetal well-being. The short-term (acute) markers are the FHR reactivity, fetal breathing movements, gross fetal movements and fetal muscle tone. A major chronic or long-term marker is the amount of amniotic fluid.

2.

Check the health status of the fetus if the mother has the following condition: Bleeding problems Lupus Hyperthyroidism Chronic kidney disease Gestational diabetes Oligohydramnios Polyhydramnios Multiple pregnancy Preeclampsia

Pregnancy past the due date Procedure Biophysical profile procedure involves two parts, the Non-stress Test (NST) and the ultrasoundevaluation. Fetal heart rate reactivity is interpreted from a non-stress test (NST). The other four parameters are measured by real-time ultrasonography. With the NST procedure the mother is asked to lie on her left side. Two devices are strapped to her belly the first is used to record the fetal heart beat and the other to measure contractions of the uterus. Fetal movements, heart rate and its reactivity to fetal activity are measured for about 20 to 30 minutes while the technician listens and watches on the electronic screen.

In real-time ultrasonography procedure, fetal body movements, muscle tone and breathing movements are noted and evaluated. Also, the amount of amniotic fluid surrounding the fetus is assessed and recorded. This procedure may take about an hour and the technician will note signs that are important in measuring the health of the fetus. Interpretation of Data A scoring technique is used to interpret the data, with each parameter contributing either 0 or 2 points. These scores are added for a total score range of 0 to 10. A score of 10 is perfect while the score of zero is the worst score. A total score of 8 to 10 is considered normal unless oligohydramnios is present. A score of 6 is considered borderline and a score below it requires further assessment and evaluation.

Amelia
When rare birth defects are the topic, the latest name that can be found is Amelia. In the older medical terminologies, it is sometimes called phocomelia, however recently, Amelia is used to describe a rare birth defect that includes absence of a limb on the arms or legs. The word Amelia can be modified in order to inform the number of limbs absent. For instance, the term called tetra-amelia means that four limbs are [Link] malformation usually happens between 24 to 36 days after fertilization. Amelia is accompanied with other malformation or anomalies in other body parts: 1. 2. 3. 4. 5. 6. 7. 8. Malformations of other organ systems Cleft lip or palate Body wall defects Malformation heaf Defects on the neural tube Defects on the kidneys Defects on the diaphragm Defects on the lungs

9. Defects on the heart 10. Defects on the internal and external genitalia 11. Mental retardation 12. Facial tumors Amelia is also associated with the following syndromes: 1. 2. 3. 4. 5. Baller-Gerold syndrome Holt-Oram syndrome Trisomy 8 (three copies of chromosome 80 Teratogenic causes (such as thalidomide) Other disease process such as diabetes

6. Direct trauma: such as with intented abortion or removal of IUD 7. Alcohol ingestion in the first trimester Signs and Symptoms: Prior to physical examination, signs and symptoms that may suggest Amelia is manifested in the mother: 1. 2. Unusual vaginal bleeding Diabetes mellitus

3. Toxemia (high blood pressure and increased levels of protein in the urine) Diagnostic Evaluation: 1. 2. Ultrasound during the pregnancy, missing limbs can be outlined using this technology. Familial investigation when genetics has something to do with it.

3. Prenatal history medications that are terratogenic or alcohol ingestion can be the cause of the malformation. Medical Management:

1. 2. 3.

Proper education about the prevention of taking thalidomide and other medications that may lead to malformation of the limbs. Prohibiting alcohol intake during pregnancy. Management of the other diseases present during the pregnancy such as high blood pressure and diabetes mellitus

4. Children with Amelia can be given assistance in a form of prosthesis or therapies Nursing Management: As a nurse, you must be able to listen to the point of views of the parents about their child. Assist them to cope with the condition as well as tap community resources and support groups so that they can easily know the ways of taking good care of their child. Remind them that the child needs their love as parents and acceptance to the family.

Pharmacologic Pain Relief during Labor

Labor is a painful process. Pain accompanies labor contractions for a number of different reasons. Uterine contractions, cervical dilatation, fetal descent and perineal stretching are all associated with pain during labor. The level of pain reported by women in labor widely varies. To ensure a smoother birth experience pharmacological pain management may be used. These techniques include the administration of analgesia to reduce or decrease awareness of pain or anesthesia administration that causes partial or complete loss of sensation. To achieve appropriate pain control and maternal satisfaction, it is important to include women in the selection of techniques that is right for them. Women should receive little systemic medication as possible during labor because most medications given during this time cross the placenta and has some effect on the fetus. However, it is important not to test the limit of her endurance since local anesthesia is available. Women should be greatly discouraged in taking acetylsalicylic acid or aspirin for management during labor. This medication interferes with blood coagulation that increases the risk of bleeding in the newborn and/or the mother. Goals of Pharmacologic Pain Relief during Labor 1. 2. 3. Relax a woman Relieve a laboring womans discomfort Medication administration produces minimal systemic effects on the womans uterine contractions, pushing efforts

or the fetus. Medication Administration Preparation P Preferences of medication to be used must be discussed with the woman and the partner. R Remember the topmost criterium in choosing a drug to be used during labor is patient SAFETY. E Educate the woman about the medication to be administered: The type of agent to be given, how it will be administered and what she can expect to happen after administration. P Prompt answers to womans concern regarding drug administration and labor. Analgesic and Anesthetic Agents Used in Labor and Birth Narcotic Analgesics Narcotics are given during labor due to the potency of their analgesic effect. These medications may possibly cause fetal CNS depression. Hence, it is the nurses responsibility to question a physicians order for a narcotic analgesic if a pregnant woman is in preterm labor. The preterm neonate may have extreme difficulty coping due to possible lung immaturity added with respiration depression after narcotic administration. List of Commonly Use Narcotic Analgesics 1. 2. 3. 4. 5. Meperidine Hydrochloride (Demerol) Morphine Sulfate Nalbuphine (Nubain) Fentanyl (Sublimaze) Butorphanol Tartrate (Stadol)

6.

Meperidine Hydrochloride (Demerol)

MECHANISM OF ACTION Meperidine Hydrochloride is ideally used during labor because of the fact that it not only producesanalgesic effect but at the same time it has additional sedative and antispasmodic actions. Thus, it is effective for pain relief, helps in cervical relaxation and provides a feeling of euphoria and well-being. DOSE and ROUTE Demerol can be given either intramuscularly or intravenously; 25 mg IV, 50-100 mg IM every 3 to 54 hours. It can also be given epidurally but this route is used less frequently. IMPORTANT CONSIDERATIONS 1. 2. Demerol once given intramuscularly (IM) begins to act at about 30 minutes and about 5 minutes after intravenous (IV) administration. The drugs duration of action is 2 to 3 hours. This medication crosses the placenta, thus, it can cause respiratory depression in a fetus. However, it takes about 2 to 3 hours after maternal administration, either IM or IV, before the fetal liver activates the drug into the fetal system. Thus, Demerol is given 3 hours away from birth to allow the peak action of the drug to have passed by the time of birth. 3. 4. If Demerol is given early it may slow labor contractions. When a narcotic is given to the mother, a narcotic antagonist should be available for administration of infant at

birth. Naloxone Hydrochloride (Narcan) is a narcotic antagonist that counteracts the effect of narcotic analgesic. Intrathecal Narcotics When narcotics are administered by introducing a catheter into the spinal canal, intrathecal narcotics are used. Drug such as morphine when injected into the spinal canal provides excellent pain relief for labor. It takes effect as early as 15 to 30 minutes but these injections are not as effective in reducing the pain of the actual birth. Thus, they may be supplemented with a pudendal block in late labor. Possible side effects of intrathecal morphine: 1. Intense pruritus can be treated with an IV of dipenhydramine (Benadryl) if it becomes too uncomfortable 2. Nausea and vomiting Regional Anesthesia Regional anesthesia is the administration of a local anesthetic to block specific nerve pathways. This type of pharmacologic relief during labor is not introduced directly into maternal circulation, thus, minimal effects due to the uptake of these drugs by a fetus when compared to those of systemic agents. Aside from that, regional anesthesia administration allows a woman to be completely awake and aware of the labor and birthing process. If an infant is born with toxicity from a regional anesthesia, which seldom happens, an exchange transfusion at birth may be required. This is to remove the anesthetic from the infants bloodstream. Another way of managing this condition is through the performance of a gastric lavage to remove a great deal of anesthetic. Epidural Anesthesia or Peridural Block Anesthetic agents introduced into the spinal canal are epidural anesthetics. They are administered at either the following sites:

L4-5 L3-4

L2-3 These areas contain not only the spinal nerve roots but sympathetic nerve fibers also travel with them. Thus, epidural anesthesia provides pain relief not only during labor but also during actual birth. It is a very effective pain relief during labor because when the woman no longer experiences pain the release of catecholamines with a Bblocking effect from a pain response is also decreased. Epidural blocks are administered by an anesthesiologist or nurse-anesthetist and is suitable for all women. Women with heart disease, pulmonary disease, and diabetes and sometimes those who have pregnancy induced hypertension find epidural blocks advantageous. However, the major concern with this drug is its tendency to produce hypotension. The blocking effects on the sympathetic nerve fibers in the epidural space lead to decreased

peripheral resistance in the womans circulatory system. As a result, blood flows freely into the peripheral vessels and a pseudohypovolemia develops which the body registers as hypotension. Hypotension can be prevented and managed by performing the following: 1. 2. 3. 4. 5. Combined use of fentanyl and bupivacaine can lower the risk of hypotension Making sure that the woman is well hydrated with 500 to 1000 ml of I.V. fluid such as Lactated Ringers solution before the anesthetic is administered Proper positioning of the pregnant woman: be certain that the woman lies on her side after an epidural block to help prevent supine hypotensive syndrome. In cases where hypotension occurred, the nurse should raise the womans legs, administer oxygen and increase IV fluid. To elevate the blood pressure, an agent such as ephedrine may be necessary to stabilize the circulatory status of

the patient. Local Anesthetics Local Infiltration This is the injection of an anesthetic such as Lidocaine (Xylocaine) into the superficial nerves of the perineum. Local infiltration is used when the fetal head is too low to allow pudendal block. The anesthesia is administered along the borders of the vulva and it takes effect for approximately 1 hour. Pudendal Nerve Block Pudendal nerve block is the administration of an anesthetic agent such as chloroprocaine (Nesacaine) or bupicaine (Marcaine) near the right and left pudendal nerves located at the level of the ischial [Link] technique provides perineal pain relief in about 2 to 10 minutes that lasts for approximately 1 hour. Use of low forceps during birth and episiotomy repair has been painless with the use of this method.

Comparison between False and True Signs of Labor

Comparison between False and True Signs of Labor Pregnant women who are approaching near their expected date of delivery experience signs of labor. However, these women are not sure if what they are experiencing is either real or false labor. For every woman, every pregnancy is different. But in every pregnancy the same definitive signs of labor will be experienced by women. To figure out if the body is just practicing and preparing for the delivery or actual labor is occurring, pregnant women should be able to classify false from true labor. Labor is a physiologic process during which the products of conception are expelled outside of the uterus. Regular contractions cause progressive dilatation of the cervix and sufficient muscular force to allow the baby to be pushed to the outside. Labor is a time of change, both an ending and a beginning for a woman, a fetus and a family. A false labor also termed as prodromal labor is common because the exact time of the labors onset is rarely known and usually is gradual. This type of labor often causes women to rush to the birth center, thinking that labor has started. Several characteristics distinguish true labor from labor: contractions, discomfort and cervical change. The BEST distinction is that contractions oftrue labor cause a progressive change in the cervix, thus, in false labor there is no dilatation of cervix. Signs of true labor involve uterine and cervical changes. The more a woman knows about the true labor signs, the better. Because it is only in this way that she can better recognize them once she is experiencing contractions. Knowing about the difference between true and false labor is helpful to prevent preterm birth and for the woman to feel secure knowing what is happening during the labor.

Difference between true and false labor Category True Labor Begin irregularly but become regular and Contractions predictable. Usually have a consistent pattern of increasing frequency, duration and intensity. Tends to increase with walking. Begins in the lower back and gradually sweeps around to lower abdomen. Discomfort

False Labor Begin and remain irregular. Do not increase in duration, frequency and intensity. Often disappear with ambulation and sleep. Felt first abdominally and remain confined to the abdomen and groin.

May persist as back pain in some women. Often resembles menstrual cramps during early labor. Includes progressive effacement and dilation (most important characteristic).

Discomfort confined at the abdomen and groin only.

Cervix

No cervical effacement and dilation noted.

Cystic Hygroma
Cystic hygroma was first described in 1843 by Wernher. It is a lesion in the lymphatics that affects the head and neck of the human body. This disease is also similar to cystic lymphangioma or macrocystic lymphatic malformation. Cystic hygroma grows as the child also matures. The intralesional bleeding allows the growth potential of cystic hygromas. Environmental Cause: 1. Maternal viral infections (e.g. Parvovirus Fifths disease) 2. Genetic syndromes Turner syndrome, trisomies (13, 18 and 21) Pathophysiology: Normally, the lympatics would branch out in to the venous system. This failure of branching out will encourage growth of lymphatic tissue in an abnormal way. This unusual growth will penetrate near to the neck or head. The tissues might either be described as capillary, cavernous or cystic. The vascular endothelial growth factor C (VEGF-C) has been found out to have a big role in the abnormal growth of development of lymphatic malformations. Diagnostic Evaluation: As early as 10 weeks of gestation, cystic hygromas can already be detected, however, a transvaginal ultrasound would give a better outline of the cyst. The alpha fetoprotein levels is also increased when the fetus has cystic hygromas. Medical Management:

Administration of sclerosing agents such as OK-432, which is an active strain of group A Streptococcus pyogenes, bleomycin, pure ethanol and doxycycline. The OK-432 encourages inflammatory response leading to fibrosis of the hygroma. Aspiration during the procedure has something to do with the process of effective therapy. Surgical Management: Aside from aspiration, the excision of the hygroma is the only treatment known to be immediate and effective. The goal of surgical intervention is to either remove the lymphangioma. Nursing Management: 1. 2. 3. 4. Proper education of the mother about the condition so that she may be able to cope effectively with the babys condition. Monitor the skin condition of the face and neck area. Provide proper skin care on the areas involved. Evaluate the therapy given as well as the response of the patient. Teach the mother or the care giver proper wound care so that they will be able to take care of the lesion properly when at home.

Phocomelia
When talking about rare conditions, phocomelia is one of it. It is one of the rare birth defects wherein one or more limbs are missing or at least shortened. The limb may appear like a flipper and it is through this manifestation that phocomelia has been formed to describe this. Phoco means seal added to the word that means limb. Phocomelia may have developed within the mother womb by either of the following: 1. 2. Genetic mutation happens when the mother ingests the drug thalidomide. This resulting damage called phocomelia is sometimes called pseudo-thalidomide.

Recessive genes Sometimes, families may have recessive traits that remained dormant for generations until one of the offspring may manifest it. Signs and Symptoms: Absence of lower arm (on the ulnar and radial part) most of the cases The area on the humerus is absent second highest The femoral area is absent with problems on the uterus if females

1. 2. 3.

4. The tibia and fibula is absent or shortened 5. Generally the limbs affected are stiffened and has a limited range of motion Diagnosis: 1. Ultrasound the mainstay diagnostic tool which is used at 12 weeks of pregnancy. At this time, the growth and formation of the arms and legs can already be outlined. 2. An accurate diagnosis can be made through a complete physical examination after birth. Complications: 1. 2. 3. Association with cardiac, renal or gynecologic defects. Skulls abnormalities as well as mental retardation Facial problems such as bells palsy

4. Back problems such as scoliosis Medical Management: At this point, there is no definite medical or surgical management have been discovered. Most of the babies with this rare condition may die within the womb or shortly after birth due to the complications of the shortening of the limbs. Others may survive but with mental retardation as phocomelia may also affect the formation of the skull. Nursing Management: The role of a nurse in this scenario may be as follows: 1. Advocate You must stand on the rights of the client especially during the diagnostic stage. Ensure the privacy of the case as well as the individuals affected by this.

2.

Empathizer As one of the supporting people in the health care team, assist the parents of the child in their grief. Understand them and their reactions about the condition. Provide appropriate information about the case as well as encourage verbalizations of feelings.

Common Concerns during the School-Age Period

Overview The developmental task of school-agers, children between 6 to 12 years old, according to Erik Eriksons psychosocial theory is industry versus inferiority. It is at this time that children learn to deal and socialize with their peers. Cognitive growth and development continue to proceed at rapid rates during this time, although physical growth is slower during these years. During the school-age period, the development is more subtle and most of the time marked by mood swings. These is true in situations where a school-ager enjoys doing something in one occasion but may not accept doing it the next time. For example, a child is interested in joining painting classes. When his parents decided to enroll him in the class, he suddenly losses interest in painting and prefers football instead. Children of this age also love playing in competition with each other. They love playing and spending time with their friends and are more influenced by the attitudes of the peers that they are interested to spend their time with. Some children may prefer not to do something they previously enjoy because no friends are interested in the said activity. This stage is quite frustrating to the parents manifested by unnecessary conflicts with their child as children of this age begin to make truly independent judgments. When parents are not prepared for this, conflict will be the result. Physical Growth of a School-ager During the school-age period, children who did not lose the lordosis and the knock-kneed appearance of toddlers during the preschool period lose these now. The posture becomes erect. The following are important things to know relating the physical growth of school-age children: 1. Malocclusion with teeth malalignment may be present if the eruption of permanent teeth and growth of the jaw do 2. 3. not correlate with the final head growth. An enlarged tonsil in the back of the throat is normal during this period and should not be mistaken for a respiratory illness. Innocent heart murmurs may be present and become apparent due to the extra blood crossing the heart valves of

the school-ager. 4. All school-aged children over 8 years old should be screened for scoliosis. Sexual and Physical Concerns of a School-age Child 1. 2. 3. 4. 5. 6. Sexual maturation is more advanced in girls than in boys at this time. In girls, sexual maturation occurs between 12 and 18 years while it is between 14 and 20 in boys. Effective sex education is noted parents would introduce the material when their children are in grade school and not in middle school or high school. Discuss with children the physical changes that will occur and the sexual responsibility these changes require. Reassure girls that broad bone structure of the hips is part of an adult female profile and she should not misinterpret it as a gain in weight and attempt a crash diet. Girls are very conscious about breast development thats why it is very important that they understand that these changes are normal. An important concept about viewing herself as a woman and for future childbearing is early preparation for menstruation. A girl who is told that menstruation is a normal function and that it occurs every month in all healthy women develops a different attitude towards her body than those who just wake up one morning frightened to find blood in her pajamas. 7. Boys should develop an understanding that testicular development precedes penile growth, thus, they should now worry that their growth is inadequate.

8.

Gynecomastia or the hypertrophy of breast tissue can occur during the prepuberty period and most often it is seen in stocky or heavy boys. He should be assured that this is just a transitory phenomenon and although it makes him self-conscious, this will just fade soon as his male hormones becomes more mature and active.

9.

Nocturnal emissions, the ejaculation that boys notice during sleep, is just normal during the school-age period as seminal fluid is already produced in the male body. Teeth Care During the school-age period, deciduous teeth are lost and permanent teeth erupt. The average child gains 28 teeth during this time. Dental check-ups should be regularly done even without possible dental problem is observed.

1. 2. 3.

Brushing of the teeth without assistance can be started by about 6 years of age. Flossing ones teeth independently can also be done during this period. Play Parents should plan the activities for their child. School-age children spend several hours playing increasingly challenging video games. This activity can foster a healthy sense of competition but may also create isolation from others if the child is involved in too much of this activity.

1.

2. 3. 4. 5.

More props are needed for play in school-age children than when they are younger. For example, a stethoscope and a thermometer are required to become a doctor. Allow the child to be involved in house chores as most girls and boys of this age enjoy helping in kitchens or doing house chores. Collecting, sorting and cataloging are enjoyed by 8 year old children. Set a good reading example and parents should be instructed not to forbid comic-reading. It is beneficial to the

child is the parents would wait out patiently the childs acute interest in comic books. Eventually, the child will seek to read other types of books. Language Development 1. 2. Most 7 year old children have trouble with concepts such as half past and quarter to but they can tell the time in hours. Adults should keep school-agers away from conversations with dirty jokes. Children of this age like to tell their

friends about the jokes they hear. 3. Twelve year olds are able to carry on an adult conversation. Their sense of humor is apparent at this time. Dental Caries When children eat readily fermented carbohydrates the pH of the tooth surface drops to 5.6 or below, as a result, progressive and destructive lesions or decalcification of the tooth enamel and dentin occurs that produces dental caries or cavities. When acid microorganisms found in the dental plaque attack the organic cementing medium of the teeth and destroy it. Areas where plaque is deposited are most susceptible to dental decay. When caries are neglected, poor chewing and digestion takes place. Aside from the mentioned consequences, abscess, pain and even bone infection or osteomyelitis may occur. The following are ways to prevent dental caries: 1. Proper brushing of the teeth. 2. 3. 4. Use of fluoridated water or application of fluoride. Treat caries quickly when they occur. The childs dental hygiene practices must be evaluated and improved if necessary. Children should be taught about the importance of dental hygiene and the possible dental consequences at stake

if they undertake the self-care measures to ensure healthy teeth. 5. Parental support is more important and more effective rather than parental command indental care. Malocclusion 1. 2. Thumb sucking plays a little role in malocclusion as long as the habit does not persist past the time of eruption of the permanent front teeth at about 6 to 7 years. An orthodontist should evaluate children with malocclusion. The time to begin the correction varies with the extent of the malocclusion and the jaw size.

3.

Children with braces develop mild, shallow ulcerations on the buccal membrane from friction of metal wires. To manage this, an oral acetaminophen is administered or an agent such as Ora-Jel may be applied over the ulceration to provide relief.

4. 5.

Dental floss should be used by children with orthondotic braces to remove the plaque around the wires. Retainers are worn when braces are removed to maintain the correction achieved.

Anxiety Related to Beginning School Six year old children have a hard time adjusting to grade school. In grade school, the rules are firmer and it is difficult for a young child to imagine the time span that he or she will be going to the school. The following are important interventions in dealing with anxiety related to beginning school: 1. A health assessment of all school-age children should include an inquiry about the progress in school. Information 2. 3. 4. can be obtained by asking the parents and observing the child in the actual environment. To enhance the ability of a school-ager to read, parents should point to the words and pictures as they go along to help them realize sentence flow which is from the left to the right. Parent should spend more time with the child after school or in the evening. This is to make the child feel secure with his family and does not feel pushed out by being sent to school. For children who develop physical signs of illness such as vomiting, diarrhea, headache or abdominal pain during school days only, fear of attending school or school phobia is noted. With school phobia, the symptoms last after the school bus leaves the house or when the child is allowed to stay home. It is very important that parents should not let the child stay at home when their child shows signs of school phobia. Counseling may help the child manage the situation better. 5. 6. 7. Parents should explore emotions and reasons why their child refuses to go to school. Attempting to transfer a child to another classroom or be excused from a disliked situation may stop the school resistance. The nurse should encourage the parents to allow their child to involve more in school activities. Some cases of school phobia results when the parents are overprotective or is the one having the most difficulty separating.

The nurse should support the parents so they can treat the childs illness symptoms so they can take their child firmly to the classroom. Reading To make reading more enjoyable for children the following are important points to remember: Associate learning to read with adult activities. It is important to set an example to children by reading yourself. Some adults spend most of their time watching television. This practice makes the child think that reading is just for children and think that it is not an important activity. Another way of making reading an enjoyable activity is by asking the child to read car tips and road signs while driving or read aloud the recipe while cooking. Ask the child after reading a book. Let the child express what he feels about the content of the book, if it is good

or bad and if he or she learned something. Reading a book before bedtime is a very good family activity while enhancing the reading skill of the child. Latchkey Children Latchkey children are school-agers who lack adult supervision each weekday after school. In present times, both parents are working and are usually away from home when the child arrives home. Some parents even leave home when their child is still sleeping, leaving the child feeling left out or alone. As a result latchkey children develop an increased tendency to accidents. Delinquent behavior is also noted in these children and beginning of alcohol and drug abuse is usually done to cope up with feelings of loneliness. As lack of parental supervision is observed, children in return will have decreased school performance. The following are suggestions to deal with these situations:

1. 2. 3.

Parents should allot time each day alone with their children before or after school. Determine individual characteristics and changes in working schedule are appropriate to deal with the problem. Arrange with a close relative or neighbor who is usually home late in the afternoon to stay with the child.

4. 5. 6. 7. 8. 9.

Prepare a safety kit and keep it filled. For parents who arrive home at the evening from work, it is very important that they make additional time available for their children and have them describe their day. Before leaving the house or at bedtime, be certain to plan an activity for the next day so that children will be left with something purposeful to do. Consider of having a pet. Animals such as dogs, cats, hamsters and birds offer companionship in a quiet house. Parents should leave messages at the refrigerator or in the bathroom just to say hi. In this way, the child feels loved and remembered even though the parent is not around. It is very frightening for a child to stay home alone unexpectedly when parents are delayed in arriving home. If

cases like this occur, parents should call the children. 10. Increase the childs socialization by exploring and providing opportunities to socialize with friends or join sports programs or activities at school or in the community. Reading To make reading more enjoyable for children the following are important points to remember: Associate learning to read with adult activities. It is important to set an example to children by reading yourself. Some adults spend most of their time watching television. This practice makes the child think that reading is just for children and think that it is not an important activity.

Another way of making reading an enjoyable activity is by asking the child to read car tips and road signs while driving or read aloud the recipe while cooking. Ask the child after reading a book. Let the child express what he feels about the content of the book, if it is good or bad and if he or she learned something. Reading a book before bedtime is a very good family activity while enhancing the reading skill of the child.

Latchkey Children Latchkey children are school-agers who lack adult supervision each weekday after school. In present times, both parents are working and are usually away from home when the child arrives home. Some parents even leave home when their child is still sleeping, leaving the child feeling left out or alone. As a result latchkey children develop an increased tendency to accidents. Delinquent behavior is also noted in these children and beginning of alcohol and drug abuse is usually done to cope up with feelings of loneliness. As lack of parental supervision is observed, children in return will have decreased school performance. The following are suggestions to deal with these situations: 1. 2. 3. 4. 5. 6. 7. 8. 9. Parents should allot time each day alone with their children before or after school. Determine individual characteristics and changes in working schedule are appropriate to deal with the problem. Arrange with a close relative or neighbor who is usually home late in the afternoon to stay with the child. Prepare a safety kit and keep it filled. For parents who arrive home at the evening from work, it is very important that they make additional time available for their children and have them describe their day. Before leaving the house or at bedtime, be certain to plan an activity for the next day so that children will be left with something purposeful to do. Consider of having a pet. Animals such as dogs, cats, hamsters and birds offer companionship in a quiet house. Parents should leave messages at the refrigerator or in the bathroom just to say hi. In this way, the child feels loved and remembered even though the parent is not around. It is very frightening for a child to stay home alone unexpectedly when parents are delayed in arriving home. If

cases like this occur, parents should call the children. 10. Increase the childs socialization by exploring and providing opportunities to socialize with friends or join sports programs or activities at school or in the community.

Tracheoesophageal Atresia and Fistula

Overview The tube that connects the mouth to the stomach is the esophagus. It is this tube also where the food passes. Another tube adjacent to the esophagus directs not the food but the inhaled air to the lungs. This is known as the trachea or the windpipe. By the third and fourth week intrauterine life, the laryngotracheal groove would develop into the larynx, the trachea and this will be the beginning of the development of the lung tissue. Parallel to these structures is the area where the esophageal lumen forms. In cases where the pregnant mother has been taking teratogens, the separation of the trachea and esophagus would be prevented and a certain number of anomalies might occur. Esophageal Atresia Esophageal atresia is present when the upper portion of the esophagus fails to connect with the lower esophagus and the stomach. The word atresia literally means that there is an absent of a normal opening. In this case, the liquid that the baby normally swallows cannot pass through the esophagus and fails to reach the stomach and intestines for digestion and absorption. Tracheoesophageal Fistula The word fistula literally means an abnormal passage from a body organ to the body surface or between two internal organs. In tracheoesophageal fistula there is an abnormal connection between the esophagus and the trachea. This abnormality is tube structure is also known as TE fisutula or TEF. An infant with a tracheosophageal fistula will most likely direct swallowed liquid into the lungs as the fluid passes through the abnormal connection between the esophagus and the trachea. Frequency About one in 3,000 babies is born with one or both of these problems. Clinical Manifestations

Frothy white bubbles in the infants oral cavity Presence of coughing or choking when feeding Regurgitation or vomiting Cyanosis or the bluish color of the skin especially when feeding the infant

Breathing difficulty Full and rounded abdomen Diagnosis passing a catheter through the infants esophagus to the stomach aspiration of stomach contents positive when stomach contents cannot be aspirated flat plate x-ray of the abdomen

barium swallow or bronchial endoscopy Management Emergency surgery to prevent the development of pneumonia from leakage of stomach secretions into the lings or dehydration or an electrolyte imbalance from lack of oral intake Gastrostomy performed under local anesthesia to keep the stomach empty of secretions and prevent reflux into the lungs.

Difference between Epiglottitis and Croup

Comparison of Laryngotracheobronchitis (CROUP) and Epiglotitis

Assessment Causative organism Usual age of child Seasonal occurrence Onset pattern Presence of fever Appearance

Laryngotracheobronchitis Usually viral

Cough Radiographic findings Possible complications

Epiglottitis Usually pneumococci or streptococci 6 months to 3 years 3 years to 6 years Late fall and winter None Preceded by upper respiratory Preceded by upper respiratory infection infection; suddenly very ill Low grade Elevated to about 103 degree F Retractions and stridor; Drooling; very-ill appearing, prolonged inspiratory phase of neck hyperextended to breathe respirations; not very illappearing Sharp, barking Muffled Lateral neck radiograoh Lateral neck radiograph showing subglottal narrowing showing elraged epiglottis Asphyxia due to subglottic Asphyxia due to supraglottic obstruction obstruction
th

Source: Maternal and Child Health Nursing: Care of the Childbearing and Childbreaing Family by Pillitteri , 5 Ed. Detailed Information of Epiglottitis and Croup Epiglottitis The epiglottis is a flap of tissue covering the opening of the larynx to keep out the food and fluid from entering the respiratory tract. Epiglottitis is the inflammation and the infection of the epiglottis. It is a rare case, however, epiglottitis is an emergency condition as the swollen epiglottis cannot rise and allow the airway to open. Frequency

The inflammation of epiglottitis occurs most frequently in children from 2 to about 7 years of age. Signs and Symptoms Severe inspiratory stridor High fever Hoarseness or voice Sore throat Difficulty swallowing or dysphagia Drooling Tongue protrusion to increase free movement in the pharynx Throat seen as a cherry-red structure and edematous

1. 2. 3. 4. 5. 6. 7. 8.

9. Muffled cough 10. Leukocytosis 11. Cyanosis severe cases Management 1. 2. 3. To reduce epiglottal inflammation, moist air is needed. Oxygen if cyanosis is present. Antibiotic therapy such as a second-generation cephalosporin CEFUROXIME may be prescribed until throat culture indicates a specific antibiotic drug. Cefuroxime may be given for a full 7-10 days. After the antibiotic therapy is initiated, the epiglottal inflammation receded rapidly. To maintain hydration in patients with epiglotitis, intravenous fluid therapy is needed since these children cannot swallow.

4.

5.

It is important that the nurse should prepare a tracheostomy or endotracheal intubation set at the bedside. Children with epiglotitis may need a prophylactic tracheostomy or necessitate endotracheal intubation to prevent total airway obstruction.

6. 7.

IMPORTANT REMINDER: Never attempt to visualize the epiglottis directly with a tongue depressor because the gagging procedure causes complete obstruction of the glottis and results to respiratory failure.

Throat culture should NOT be done UNLESS a means of providing an artificial airway such as a tracheostomy or endotracheal intubaton is readily available. Laryngotracheobronchitis or Croup Croup is an infectious illness of the respiratory system which is described as the inflammation of the larynx, trachea and major bronchi. It is one of the most frightening diseases of early childhood for both parents and children. Frequency

The inflammation with laryngotracheobronchitis or croup occurs most frequently in children between 6 months and 3 years of age. Signs and Symptoms The signs and symptoms of croup become worst at night. At nighttime, children are crying and upset making the symptoms worst. The viruses that cause this disease result to the inflammation of the airway and later on affect the bronchi. The following are the clinical manifestations noted in children with croup:

Temperature mildly elevated Only a mild upper respiratory tract infection at bedtime is present but during the night they develop a barking cough (croupy cough), inspiratory stridor, and marked retractions Cyanosis is rarely present

The clinical symptoms often lasts 5 or 6 nights, but the first night or two are usually the most severe. Rarely, croup can last for weeks. The danger of glottal obstruction from the laryngeal inflammation is very real. Pulse oximetry and transcutaneous SO2 monitoring are helpful measures to document whether hypoxemia is occurring. Management 1. 2. 3. 4. 5. 6. Cool moist air helps can provide relief to children. To reduce inflammation and produce effective bronchodilation by opening the airway, a corticosteroid such as dexamethasone or racemic epinephrine may be given through a nebulizer. One emergency method at home in relieving croup symptoms is to run the shower or hot water in a bathroom until steam fills the room. The child is then kept in this warm and moist environment for at least 10 minutes, Cough medications are not recommended to be given to the child unless discussed with the physician. IV fluids are given to keep the patient well hydrated. Never elicit a gag reflex with a croupy cough and provide comfort when crying. Crying and eliciting a gag reflex such as by placing a tongue depressor on the clients mouth results to laryngospasm that causes death in children with croup due to the total occlusion of the airway. 7. 8. Prepare an intubation set at the bedside for possible intubation. When the following clinical manifestations are noted, a need for medical attention or hospitalization is required:

Increasing or persistent breathing difficulty Fatigue Cyanosis or bluish discoloration of the skin Dehydration (poor skin turgor, dry skin)

Antepartum Care
Definition

The antepartum or pre-natal period starts when the womans pregnancy is diagnosed and ends just before the baby is delivered. Antepartum care promotes patient education and provides ongoing risk assessment and development of an individualized patient management plan. The major goal of prenatal care is not only to ensure that a healthy baby is born but also to promote the optimum health for the mother. The following are the goals of antepartum care:

To evaluate the health status of the mother and the fetus To estimate the gestational age To identify the patient at risk for complications To anticipate problems before they occur and prevent them if possible.

To promote patient education and communication Diagnosis of pregnancy Commercial kits are available for the diagnosis of pregnancy, all of which depend on detection of human chorionic gonadotropin (hCG) by an antibody. The various techniques used to detect hCG include agglutination inhibition, radioimmunoassay, enzyme-linked immunosorbent assay, and immunochromatography. Some tests can detect hCG at levels as low as 25 mlU/mL or as early as 1 week after implantation.

Home tests have relatively high positive predictive values. Some of these tests, however, may have high rates of false-negative results. Estimating Gestational Age Age of gestation (AOG) should be estimated to calculate the exact date of delivery and the estimated weight and height of the fetus. The following are some estimates of AOG methods: Nageles Rule McDonalds Method Bartholomews Rule

Haases Rule Johnsons Rule Identifying Patient at Risk for Complications Risk Factors Age < 16 or > 35 2 spontaneous or induced abortions < 8th grade education > 5 deliveries Abnormal presentation Active TB Anemia (Hgb <10, Hct <30%) Chronic pulmonary disease Cigarette smoking Endocrinopathy Epilepsy Heart disease class I or II Infants > 4,000 gm Isoimmunization (ABO) Multiple pregnancy (at term) Poor weight gain Post-term pregnancy Pregnancy without family support Preterm labor (34-37 weeks) Previous hemorrhage Previous pre-eclampsia

Previous preterm or SGA infant Pyelonephritis Rh negative Second pregnancy in 9 months Small pelvis Thrombophlebitis Uterine scar or malformation

Venereal disease Promoting Patient Education Since the goal of antepartum care is to help achieve a maternal and infant outcome as much as possible, this means that psychosocial issues as well as biological issues needs to be addressed. One of the major components of pre-

natal care is HEALTH TEACHING. The following are some important health teaching during the antepartum period. Nutrition. This is the most important aspect of health teaching. Nutritional Risk Factors during pregnancy: Teenagers or adolescent Follow food fads Underweight or overweight Low income women Short interval between pregnancies Drug use (including cigarettes and alcohol) Existence of a chronic illness requiring a special diet Lactose intolerance Multiple pregnancy

1. 2. 3. 4. 5. 6. 7. 8. 9.

10. Anemic at conception Weight gain. The recommended average weight gain in pregnancy is 11.2 to 15.9 kg or 25-35 lbs. Weight gain in pregnancy occurs at approximately 1 lb per month during the first trimester and then 1 lb per week during the last two trimesters. For a more accurate estimation of adequate weight gain, computation of body mass index (BMI) can be

done. To calculate for BMI, refer at the box below. The following are the normal prepregnancy BMI: Underweight under 18.5 Normal weight 18.5 24.9 Overweight 25 29.9 Obese above 30

Calculating the Body Mass Index (BMI) Convert weight into kilograms. (divide weight in pounds by 2.2) Convert height into centimeters. (multiply height in inches by 2.5)

Example: Mrs. White is 54 tall and weighs 130 lbs. To determine her BMI: 130 / 2.2 = 59 kg 5 x 12 = 60 + 4 = 64 inches (foot to inches) 64 inches x 2.5 = 160 cm (inches to cm) 160 / 100 = 1.6 meters

Convert centimeters into meters. (divide result by 100) Square height in meters. 1.6 x 1.6 = 2.56 Divide weight in kilograms by height 59 / 2.56 = 23 BMI in meters squared. Interpretation of Result: 23 BMI = Normal Weight, thus, Mrs. White enters pregnancy at normal weight.

Calorie needs. The easiest way for determining a womans caloric intake is assessing the weight she is gaining. The pattern of weight gain is as important as the total weight gain. Protein needs. The daily recommended intake in women is 44 to 50 grams. During pregnancy, the need for protein increases to 60 g daily. Foods rich in protein are meats, fish, eggs, milk, poultry, cheese, beans and monggo.

1. 2. 3. 4. 5. 6. 7.

Vitamin needs. Vitamin A Vitamin A supplement. Foods rich in Vitamin A are eggs, carrots, squash, and all green and leafy vegetables. Vitamin D Vitamin D supplement. Foods rich in Vitamin D are fish, liver, eggs, milk. Excess Vitamin D during pregnancy can lead to fetal cardiac problem. Vitamin E sources are green leafy vegetables and fish Vitamin B food sources are same as the foods rich in protein Iron the DRI for iron for pregnant women is 30 mg. Sources: liver and other internal organs, camote tops, kangkong, egg yolk, ampalaya Foods to AVOID in pregnancy Foods with caffeine Artificial sweeteners Weight loss diets Smoking. Cigarette smoking causes vasoconstriction which leads to low birth weight infantsand has been a risk factors for some complications during pregnancy. Thus, it is contraindicated during pregnancy. Drugs. Teratogenic drugs can cause congenital defects to the fetus, hence, they are contraindicated unless prescribed by the physician. The following are medications that are contraindicated during pregnancy: Thalidomide can cause Amelia or Phocomelia Steroids can cause cleft palate and abortion Iodides can cause enlargement of the fetal thyroid gland leading to tracheal decompression and dyspnea at birth. Iodides are contained in many OTC cough suppressants. Vitamin K can cause hemolysis and hyperbilirubinemia Aspirin and Phenobarbital can cause bleeding disorders and tendencies th Streptomycin and Quinine can cause damage to the 8 cranial nerve Tetracycline can cause staining of tooth enamel and inhibits growth of long bones. Sexual Activity. During the first trimester, there is a decrease in sexual desire as the woman is more preoccupied with the changes in her body. However, during the second trimester, there is an improvement in the sexual desire as the woman has already adapted to the growing fetus. During the third trimester, a decrease in

1. 2. 3.

sexual desire is noted as the woman is afraid of hurting the fetus. Sex in moderation is permitted during pregnancy. During the last 6 weeks of pregnancy, sexual activity is not advised as it has been noted that there is increased evidence of postpartum infection on women who engage in sex during the last 6 weeks. Sex is contraindicated in the following situations: Spotting or bleeding Incompetent cervical os Ruptured BOW Deeply engaged presenting part Employment. As long as the job does not entail handling toxic substances or lifting heavy objects or excessive physical and emotional strain, there is no contraindication to working. It is important for the nurse to advise the pregnant woman to walk about every few hours of working long periods of standing or sitting to promote circulation.

Traveling. There are no travel restrictions during pregnancy. However, trips should be postponed on the last trimester of pregnancy. On long trips, it is advisable to allot about 15-20 minute of rest period every 2-3 hours to walk about or empty the bladder. Exercises. The goal of prenatal exercises is to strengthen the muscle that will be used in labor and delivery. Exercise should be done in moderation. Recommend that moderate exercise should be done 30 or more minutes daily. Exercises where there is a risk of falling or abdominal trauma should be avoided. Adequate fluid intake before and after exercise should be practiced by the pregnant woman. The pregnant woman should stop the

1. 2. 3. 4. 5.

exercise and seek medical advice if she experiences the following: Chest pain Dizziness Headache Decreased fetal movement Signs of labor

Recommended Exercises during pregnancy: 1. Squatting and tailor sitting 2. 3. 4. 5. 6. Pelvic rock Modified knee-chest position Shoulder circling Walking Kegels exercise Tetanus Immunization. Tetanus Immunization should be given to pregnant women. Bathing. Daily baths protects pregnant women from infections that may develop if bacteria normally present on the skin are allowed to remain and multiply. Advise the pregnant woman to use nonskid pads in the tub or shower especially during the last trimester, when her balance is altered by a changing center of gravity and she is prone to falls. Hot tubs and Sauna. Caution the woman not to be in sauna for more than 15 minutes or a hot tub for more than 10 minutes and to keep her head and chest out of water. Maternal hyperthermia, particularly during the first trimester may be associated with fetal anomalies. Douching. Despite increased vaginal discharge, douching is unnecessary before, during or after pregnancy. Breast care. Instruct the expectant mother to avoid using soap on her nipples because it removes the natural lubricant that forms on the nipples. Advise her to wear bra that fits well and supports her breasts to prevent loss of muscle tone that can occur as the breast becomes heavier during pregnancy. Alcohol. Alcohol is a known teratogen and maternal alcohol use is a leading cause of mental retardation.

Birthmarks

Definition A blemish on the skin noted when a baby is born is called a birthmark. Birthmarks are abnormalities of the skinthat are present at birth. These markings on the skin may be permanent or fade away over time. It is crucial to be able to differentiate the various types of birthmarks so that proper intervention should be implemented with these lesions. The size and location of all birthmarks should also be carefully documented.

The most common birthmarks are caused by a collection of tiny blood vessels just beneath the skin. These small red, mottled spots are sometimes called stork bites or stork marks when theyre on the back of the head or angel kisses when theyre on

cafe-au-lait spot

the forehead or eyelids. Stork bites become obvious when the infant cries. These marks are harmless and they generally disappear in several months or years. Causes of Birthmarks No one knows what causes many types of birthmarks, but some run in families. Most birthmarks are not serious, and some go away on their own. They can be inherited, but usually are not, and typically are unrelated to trauma tothe skin during childbirth. Types of Birthmarks

PIGMENTED BIRTHMARKS Mongolian Spots. These are bluish-black marks that resemble bruises. They usually appear at the sacral area but may appear on the buttocks, arms, shoulders and other areas. Mongolian spots disappear usually after the first few years of life and for some until the school-age period without treatment. Caf-au-lait spots. These are permanent, light-brown marks that may occur anywhere on the body. They can be anywhere on the body and sometimes increase in number as a child gets older. Although they are harmless, the

number and the size are important of

caf-au-lait spots are important to be evaluated. Its wise

to have your child evaluated if there are several (six or more) larger than 0.5 cm marks which are associated with neurofibromastosis(a genetic disorder that causes abnormal cell growth of nerve tissues) . VASCULAR BIRTHMARKS Nevus Simplex. A nevus simplex is also called salmon patch, stork bite or telangiectatic nevus. It is a flat, pink or reddish discoloration from dilated capillaries that occur over the eyelids, just above the bridge of the nose or at the tape of the neck. They may be more noticeable when the baby cries.

port wine stain

Stork bites disappear by 2 years of age, although those at the nape of the nape may persist.

Nevus Flammeus. This is a macular purple or dark-red lesion and is also called a port-wine stain. Typically these lesions appear on the face and are often found in the thigh. These marks do not fade and are not harmful. They occur more often in females than males. Strawberry Hemangioma. These are elevated areas formed by immature capillaries and endothelial cells. Strawberry hemangiomas tend to continue to enlarge from their original size up to 1 year of age. By the time the child is 7 years old, 50-70% of these lesions have disappeared. At 10 years of age, complete absorption may occur. Cavernous Hemangioma. These lesions are dilated vascular spaces. They resemble the appearance of strawberry hemagioma but the only difference is they DO NOT disappear with time. Surgical intervention removes these lesions.

Umbilical Cord Prolapse

Overview of the umbilical cord The umbilical cord is a flexible, tube-like structure that, during pregnancy, connects the fetus to the mother. The umbilical cord is the babys lifeline to the mother. It transports nutrients to the baby and also carries away the babys waste products. It is made up of three blood vessels two arteries and one vein. Definition Umbilical Cord Prolapse is an emergency condition where the umbilical cord drops (prolapses) through the open cervix into the vagina ahead of the baby. It is an obstetric emergency during pregnancy or labor that imminently endangers the life of the fetus. Umbilical cord prolapse is a complication that occurs prior to or during delivery of the baby. The cord can then become trapped against the babys body during delivery. An umbilical cord prolapse presents a great danger to the fetus. During the delivery, the fetus can put stress on the cord. This can result in a loss of oxygen to the fetus, and may even result in a stillbirth. Frequency

Cord prolapse occurs in 0.4 0.6 % of deliveries. It occurs in 1 of 200 pregnancies Risk Factors Fetal malpresentations Premature infants Multiparous women Causes A fetus that remains at a high station A very small fetus Breech presentations. The footling breech is more likely to be complicated because the feet and the legs are small and do not fill well the pelvis. Transverse lie Polyhydramnios Excessive amniotic fluid Premature rupture of the membranes Placenta previa Intrauterine tumors preventing the presenting part from engaging CPD preventing firm engagement Multiple gestation Delivering more than one baby per pregnancy (twins, triplets, etc.)

Premature delivery of the baby An umbilical cord that is longer than usual Signs of Cord Prolapse The umbilical cord seen or felt during a vaginal examination as it pulsates synchronously with fetal heart Fetal bradycardia (sustained) with deceleration (variable) during contraction

Client reports feeling the cord within the vagina

Diagnosis

1. 2. 3.

Use a fetal heart monitor to measure the babys heart rate. If the umbilical cord has prolapsed, the baby may have bradycardia (a heart rate of less than 120 beats per minute).

Conduct a pelvic examination and may see the prolapsed cord, or palpate (feel) the cord with the fingers. Management Assess a laboring client often if the fetus is preterm or small for gestational age, if the fetal presenting part is not engaged, and if the membranes are ruptured. Periodically evaluate FHR, especially after rupture of membranes (spontaneous or surgical), and again in 5 to 10 minutes. If cord prolapsed is identified, notify the physician and prepare for emergency cesarean birth. Assess cord pulsations constantly. PRIORITY: To relieve pressure on the cord to improve blood flow through it until delivery. This is done by any of the following ways: Placing a sterile gloved hand in the vagina and manually elevating the fetal head off the cord. This position is maintained until the physician orders it to stop which is usually before cesarean delivery. Placing the woman in a knee-chest or Trendelenburg position. These positions cause the fetal head to fall back from the cord. Elevate the hips of the woman with pillows and side-lying position maintained. To confirm the presence of fetal heart activity before cesarean delivery, ultrasoundexamination may be used. Administer oxygen at 10 LPM by face mask to the mother to improve oxygenation to the fetus. A tocolytic agent such as terbutaline may be prescribed to reduce uterine activity and pressure on the fetus. Terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure of the fetus against the pelvis and cord.

Birth is always cesarean section unless vaginal delivery can be accomplished more quickly and less traumatically. Warm, saline-moistened towels retard cooling and drying of the cord. If the cord has prolapsed to the extent that it is exposed to room air, drying will begin which leads to atrophy of the umbilical vessels. If the cord is protruding from the vagina, no attempt should be made to replace it because doing so could traumatize and further reduce blood flow through the cord. Cord manipulation can induce umbilical artery spasm, which would reduce blood flow between the fetus and placenta.

In cases where the cervix is fully dilated at the time of prolapsed, the physician may choose to deliver the infant quickly, possibly with forceps, to prevent fetal anoxia. If dilatation is incomplete, the birth method of choice is upward pressure on the presenting part, applied by the practitioners hand in the womans vagina to keep the pressure off the cord until the baby can be born be cesarean birth. The nurse must also consider the womans anxiety. Explanations must be made simple because anxiety interferes with the womans ability to comprehend them.

Prenatal Development
PRE-EMBRYONIC PERIOD

Cell Division Stage The first two weeks after conception is called the preembryonic period. By the fourth day after conception takes place, the fertilized ovum is now called zygote. This structure is the one that enters to the uterus. The zygote undergoes cell division that divides into 2, then 4 then 8 cells and so on. The cells become tightly compacted with each division until the 16-cell stage where they occupy the same amount of space as the original zygote. When 12-16 cells are present, the zygote is then called the morula. The outer cells of the morula (termed as morula because it resembles a mulberry) secrete fluid which forms a balstocyst. A blastocyst is a sac of cells within an inner cell mass placed off within the sac. The inner cell mass develops into the fetus. The outer cell layer develops as the placenta and the fetal membranes.

Zygote Entering the Uterus Period When the blastocyst contains 100 cells it now enters the uterus. However, implantation does not take place immediately as the blastocyst lingers in the uterus for another 2 to 4 days. During this period, the endometrium is now termed as decidua. The endometrial glands are secreting at their maximum at this time. This is to provide rich fluids to nourish the conceptus before placental circulation isestablished. Implantation Implantation, also called nidation, is the gradual process that occurs between the sixth and the tenth day after conception takes place. During this lengthy process, the embryonic structures continue to develop. Maintaining the Decidua Successful implantation and survival of the conceptus would be possible when a continuing supply of estrogen and progesterone is present. To signal the womans body that pregnancy has begun, the zygote secretes human chorionic gonadotropin (hCG). The production of hCG by the conception results to the continuous and persistent secretion of estrogen and progesterone by the corpus luteum until the placenta takes over this function at about 8 weeks age of gestation (AOG). Implantation Location The best area for implantation and placental development is the upper portion of the uterus. Normal implantation occurs in the upper part of the uterus, more often on the posterior wall than the anterior wall. There are three reasons why the site is ideal:

The upper portion of the uterus is supplied with blood for optimal fetal gas exchange and nutrition The uterine lining is thick in this area which is helpful in preventing the placenta from attaching too deeply into the uterine muscle and facilitating easy expulsion of the placenta after full-term birth.

When implantation takes place in this area, blood loss is limited because interlacing muscle fibers in this area compress open endometrial vessels after the placenta detaches.

EMBRYONIC PERIOD Embryonic development begins from the third week age of gestation through the eighth week after conception. During thus period, all major body organs are already completed. Week 3 (CRL = 1.5 mm) By the third week most women miss their first menstrual period. It is also this time that the embryonic disk develops into three layers called germ layers. The following developments take place third week after conception. 1. The three germ layers, ectoderm, mesoderm and endoderm, gives rise to major organ systems of the body. 2. The ectoderm, the outermost germ layer, develops into the: brain and the spinal cord, peripheral nervous system, pituitary gland, sensory epithelium of the eye, ear and nose, epidermis, hair, nails, subcutaneous glands, mammary glands and tooth enamel. The mesoderm, the germ layer situated at the middle area, develops into the: cartilage, bone, connective tissue, muscle tissue, heart, blood vessels, blood cells, lymphatic system, spleen, kidneys, adrenal cortex, ovaries (females), testes (males), reproductive system and the lining membranes of the pericardial, pleural and peritoneal 4. spaces. The endoderm, the innermost germ layer, develops into the lining of the gastrointestinal and respiratory tracts, tonsils, thyroid, parathyroid, thymus, liver, pancreas, lining of the urinary bladder and urethra and lining of the ear canal. 5. 6. 7. 8. 9. CNS: Flat neural plate begins to close to form the neural tube. At this period, the neural tube is still open at each end. CV and RESPI: The heart now consists of two parallel tubes that fuse into a single tube. Contractions of the heart tube begin as early as week 3 (22 to 23 days) and the chorionic villi of early placenta connect with the heart. DIGESTIVE: the endoderm layer will become the digestive tract. MUSCULOSKELETAL: Paired, cube-shaped swellings (somites) appear and will form most of the head and trunk skeleton. The muscle bone, and cartilage develop from the mesoderm. INTEGUMENTARY: The outer layer of the skin, epidermis, will develop from the ectoderm. The dermis and connective tissues will develop from the mesoderm. Week 4 (CRL = 4 mm) By the fourth week after conception the shape of the embryo changes. Laterally, it now resembles a C-shaped cylinder, where it folds at the head and tail. A tail is apparent during the embryonic period because the brain and the spinal cord develop rapidly than other systems. The tail disappears as the rest of the body catches up with growth of the central nervous system. 1. CNS: The neural tube closes at each end. The cranial end of the neural tube will form the brain while the caudal 2. end will form the spinal cord. SENSORY: As an outgrowth of the forebrain, eye development initiates. The nose begins as two pits and the inner ear starts to develop from the hindbrain.

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CARDIO and RESPI: The heart begins partitioning into four chambers and begins beating. Blood is circulating through the embryonic vessels and chorionic villi. The trachea starts to develop as a bud on the upper gut and branches into the two bronchial buds.

4.

DIGESTIVE: Primitive gut development takes place as the embryo folds laterally. The stomach development is initiated as a widening of the tube-shaped primitive gut occurs. The liver, gallbladder and biliary ducts begin as a bud from primitive gut. GENITOURINARY: the primordial germ cells are present on embryonic yolk sac. MUSCULOSKELETAL: The upper limb buds are already present at this time and they look like flippers. The lower limb buds appear at this period. INTEGUMENTARY: The mammary ridges that will develop into mammary glands starts to appear.

5. 6. 7.

Week 6 (CRL = 13 mm) 1. 2. 3. 4. NERVOUS: Pituitary glands and cranial nerves are developed. The head is flexed sharply because of the rapid brain growth. SENSORY: Development of the eyelid is already beginning at this time. The external ear development begins in the neck region as six swellings. CARDIO and RESPI: Formation of blood is primarily on the liver. The partition of the heart into four chambers is completed at this point. Three right and two lung lobes develop as outgrowths of the right and the left bronchi. DIGESTIVE: The liver and the kidney occupy most of the abdominal cavity that results to the containment of most intestines within the umbilical cord. At this period, the stomach is nearing its final form and the development of the upper and lower jaw is observed. 5. GENITOURINARY: The kidneys, which are located near the bladder in the pelvis, are occupying much of the abdominal cavity. Primordial cells are now incorporating to the developing gonads. At this point, the male and female gonads are still undifferentiated and are identical in appearance. MUSCULOSKELETAL: The arms are paddle-shaped and the fingers are webbed. Development of the toes and the feet occurs in a similar pattern however, it occurs a few days later than the hands and the arms. Bones are cartilaginous at this point but the ossification of the skull has already started. 7. INTEGUMENTARY: The development of the mammary glands is initiated. Also starting at this time is the development of the tooth buds for primary or so-called deciduous teeth. Week 8 (CRL= 30 mm) By 8 weeks age of gestation (AOG), the embryo has the definite form of a human. Refinements to all systems are also continuing at this period. 1. NERVOUS: The spinal cord stops at the end of vertebral column. 2. 3. 4. 5. SENSORY: The taste buds are already initiating its development. Eyelids are already fused and the ears already achieve their final form but still are low-set. CARDIO and RESPI: The heart is separated into four chambers and heart is now detected using an ultrasound device. With regards to the respiratory system, additional branching of the bronchi is noted at this time. DIGESTIVE: The final form of the stomach is already observed at 8 weeks AOG. The lips are fused but the intestines are still contained in the umbilical cord. GENITOURINARY: In the presence of a Y chromosome, the testes development is initiated. In cases where the Y chromosome is absent, the ovaries will then develop. The appearance of the external genitalia has its slight differentiations; however, the male and female external reproductive organs still appear quite similar. MUSCULOSKELETAL: By the end of the eighth week, the webbed fingers and the toes are now distinct. Ossification of the bones is initiated and the joints resemble those of adults. INTEGUMENTARY: The auricles of the low-set ears are beginning to assume its final shape.

6.

6. 7.

FETAL PERIOD The fetal period is the longest phase of the prenatal development. This period starts at 9 weeks after conception takes place and ends with the birth of the baby. At this point, all the major systems are already present in their basic form. Structural and functional growth are noted at this time so as the refinements necessary for on all organ systems. Week 10 (CRL= 61 mm) By 10 weeks AOG, the fetus now weighs about 14 g. 1. NERVOUS: Less head flexion is observed. 2. 3. 4. 5. 6. 7. SENSORY: The fused eyelids are still close and the top of the external ear is now situated slightly below the eye level. CARDIO and RESPI: The heartbeat can be possibly detected using a Doppler transducer. The blood is produced in the spleen and lymphatic tissues. DIGESTIVE: The intestines are no longer contained in the umbilical cord. These structures are now situated within the abdominal cavity. The digestive tract is already patent from the mouth (oral cavity) to the anus. GENITOURINARY: The kidneys are already in their adult position by the tenth week. The external male and female genitalia have achieved their different appearances but they are still easily confused. MUSCULOSKELETAL: The toes are already distinct and the soles are now facing each other. INTEGUMENTARY: By the tenth week, the fingernails are now developing and the tooth buds for the permanent

teeth are already forming below the primary teeth. Week 12 (CRL= 87 mm) The most significant development at this period is the determination of the fetal gender at the end of the twelfth week through the appearance of the fetal genitalia. Weight of the fetus is approximately 45 grams. 1. 2. 3. 4. 5. 6. NERVOUS: Brain surface is still smooth without grooves or sulci or gyri, otherwise known as convolutions. SENSORY: The nasal septum and palate development are already completed. CARDIO and RESPI: The heartbeat can now be detected using a Doppler transducer. DIGESTIVE: The sucking reflex is already present. The liver forms the bile at this period. GENITOURINARY: Urine production by the kidney is initiated. The external male and female genitalia can now be distinguished and differentiated by their appearances. MUSCULOSKELETAL: The limbs appear long and thin. At this point, the involuntary muscles of the viscera develop.

7. INTEGUMENTARY: At the end of the twelfth week, the downy lanugo is developing. Week 16 (CRL= 140 mm) By the sixteenth week age of gestation, the fetal face looks human because the eyes are now facing fully forward. Quickening (fetal movements) are felt by pregnant mothers. Approximately, the fetus weighs 200 grams at this time. 1. 2. NERVOUS and SENSORY: The face of the fetus looks like a human because the eyes are facing forward rather than to the side. CARDIO and RESPI: Rapid development of the pulmonary vascular system is taking place.

3. 4. 5. 6.

DIGESTIVE: Amniotic fluid is swallowed by the fetus at this point and meconium is nowproduced. GENITOURINARY: Urine is excreted into the amniotic fluid. MUSCULOSKELETAL: The lower limbs achieve its final relative length which is longer than the upper limbs. A multigravid pregnant woman may now begin to feel the fetal movements. INTEGUMENTARY: Adequate cartilages are present that enable the external ears to stand away from the head.

Visible blood vessels are observed through the delicate fetal skin. At this point, the fingerprints are developing. Week 20 (CRL= 160 mm) At this period, the heart sounds can now be auscultated using a regular fetoscpe. Brown fats, the special heatproducing fat, are deposited at this time. Presence of brown fats enables the newborn to maintain a stable temperature after birth. The fetus weighs about 460 grams by the twentieth week. 1. NERVOUS and SENSORY: The myelination of the nerves initiates. This process continues throughout the first 2. 3. 4. year of life. CARDIO and RESPI: The heart beat can now be detected using a regular fetoscope. DIGESTIVE: The peristalsis is already well developed. GENITOURINARY: 40% of the nephrons are now mature and functioning. The testes is contained in the abdominal area, however, it is starting to descend towards the scrotum. Regarding the ovary, at this point it reaches it peak amount of primordial follicles which is 5 to 7 million and then gradually declines. 5. 6. MUSCULOSKELETAL: Fetal movements are already felt by the mother and may be palpable by an experienced examiner.

INTEGUMENTARY: The thin skin is covered with vernix caseosa. Brown fat production is already completed and the nipple development initiates. Week 24 (CRL= 230 mm) The fetus continues to grow and gain weight at this period. The subcutaneous fat deposition is still minimal thus, the fetus still appears thin. An important event during the twenty-fourth week is the production of surfactant by the lungs. Surfactant is a surface-active lipid substance that facilitates lung expansion. It minimizes surface tension in the alveoli making it easier for the baby to breathe after birth. A fetus born at this gestation has less chance of survival because of the inadequate gas exchange due to the immature body systems. Weight is approximately 820 grams.

1. 2.

NERVOUS and SENSORY: The spinal cord ends at the level of the first sacral vertebra due to the rapid growth of the vertebral canal. CARDIO and RESPI: Capillary network surrounds the developed primitive thin-walled alveoli or air sacs. Surfactant production in the lungs is initiated making respiration possible. However, most fetuses born at this time die because of the immaturity of the body systems. GENITOURINARY: The testes are now descending toward the inguinal rings. MUSCULOSKELETAL: Fetal active movements are noted. These movements are progressively noticeable to the mother and examiner. INTEGUMENTARY: Lean body appearance is notable. The skin appears red and wrinkled because the capillaries are close to its fragile surface. Fingerprints and footprints are already developed. Fingernails are now present and

3. 4. 5.

the eyebrows and eye lashes are also present. Week 28 (CRL= 270 mm) More likely, the fetus will survive if born at this period because of the maturation of the lungs, pulmonary capillaries and central nervous system. Blood formation shifts from the spleen to the bone marrow and more subcutaneous fat is deposited under the skin. At this time, the fetus assumes a head-down position (for normal birth). Weight is approximately, 1300 grams. 1. 2. NERVOUS: Major sulci and gyri are present. th SENSORY: After the 26 week, the eyelids are no longer fused. The fetus now responds to bitter substances in the tongue.

3.

CARDIO and RESPI: Erythrocyte (RBC) formation is shifted completely to the bone marrow from the spleen. Adequate alveoli, surfactant and capillary network allow respiratory function to be possible although respiratory distress syndrome is common. Many infants born at this time survive with an intensive care.

4.

GENITOURINARY: The testes have already descended into the inguinal canal into the scrotum by the end of the th 26 week.

5. INTEGUMENTARY: The skin is slightly wrinkled but is smoothing out as subcutaneous fat is deposited under it. Week 32 (CRL= 300 mm) The fetus weighs about 2100 grams at this period and the chances of survival for fetus born at this time are good. 1. NERVOUS and SENSORY: The maturation of the parasympathetic nervous systems nears that of the sympathetic nervous system. This results to the greater fetal heart rate variability on electronic fetal monitor tracing. 2. 3. CARDIO and RESPI: The surfactant production nears the mature levels. However, respiratory distress is still possible if the fetus is born at 32 weeks age of gestation. INTEGUMENTARY: The skin is now smooth due to more subcutaneous fat deposits. The body contour appears rounded due to the additional fat deposition under the skin. The skin is pigmented according to the race. Larger vessels are visible over the abdomen and beneath the skin. Toenails are present and the fingernails extend to the fingertips. The lanugo is now disappearing. Week 38 (CRL= 360 mm) The rate of growth slows down as full term approaches. At this point, the fetus is mainly gaining weight. Because of the mature pulmonary system efficient and unlabored breathing after birth is enabled. 1. 2. 3. 4. NERVOUS and SENSORY: Sulci and gyri are already developed. The visual acuity after birth is 20/600. CARDIO and RESPI: About one eighth (1/8) to one sixth (1/6) the number of alveoli of an adult is present in a newborn infant. The ability to exchange gases is now well-developed. GENITOURINARY: The testes are both palpable in scrotum at birth. In females, the ovaries contain 1 million follicles at this point. After birth, no new follicles are formed and their numbers continue to decline after birth. INTEGUMENTARY: The fetus appears plump and the skin is smooth. Vernix caseosa is present in the major creases of the body. The lanugo (fine downy hair) is only found in the shoulders and upper back. Ear cartilages are firm at this point and the fingernails are extending beyond the fingertips.

Denver Developmental Screening Test

Definition The Denver developmental screening test (DDST) is a test for screening cognitive and behavioral problems in children 0 to 6 years of age as to their development progress. It is the most widely used tool to assess childhood development. DDST can detect developmental delays during the infancy and preschool years. The name Denver reflects the fact that this screening test was created at the University of Colorado Medical Center in Denver. This test is not a test of intelligence but of the childs level of development. Categories of Development that are rated in DDST are the following: 1. 2. Personal-social Fine motor-adaptive

3. Language 4. Gross motor skills Administration of the Test 1. Ideally, DDST is completed when a child is approximately 3 or 4 month of age. 2. The same test if repeated when the child is 10 months old. 3. Finally, the test is conducted again when the child is 3 years old. Test composition


1. 2. 3. 4.

The test consists of up to 125 items which is divided into four parts: For personal-social category the following aspects are assessed: socialization inside and outside the home; for example smiling of the child For fine motor-adaptive category the following aspects are assessed: hand-eye coordination, handling small objects such as grasping or drawing For the language category the following areas are assessed: production of sounds, ability to recognize, understand and use a language and the ability to combine words

For the gross motor category the following aspects should be assessed: motor control such as sitting, walking, jumping and other movements Materials for the test Skein of red wool A box of raisins A small bottle Bell Rattle with narrow handle Tennis ball Ten 1-inch brightly colored blocks Small plastic baby doll Toy baby bottle

1. 2. 3. 4. 5. 6. 7. 8. 9.

10. Plastic cup 11. Pencil How is the child scored with this test? The child is scored P for passed, R for refused or N.O for no opportunity on each item according to the guidelines in the instruction manual. In interpreting the scores the following is done:

The data are presented as age norms, similar to a growth curve. Draw a vertical line at the childs chronological age on the charts; if the infant was premature, subtract the months premature from chronological age. The more items a child fails to perform (passed by 90% of his/her peers), the more likely the child manifests a significant developmental deviation that warrants further evaluation

Epiglottitis
The epiglottis is a flap of tissue coveringthe opening of the larynx to keep out the food and fluid from entering the respiratory tract. Epiglottitis is the inflammation and the infection of the epiglottis. It is a rare case, however, epiglottitis is an emergency condition as the swollen epiglottis cannot rise and allow the airway to open. Frequency

The inflammation of epiglottitis occurs most frequently in children from 2 to about 7 years of age. Cause Epiglottitis can either be bacterial or viral in origin. The following causes the occurrence of this condition: H. influenzae type B Pneumococci Streptococci

1. 2. 3.

4.

Staphylococci

5. Echovirus 6. Respiratory syncytial virus Signs and Symptoms 1. 2. 3. 4. 5. 6. 7. 8. 9. Severe inspiratory stridor High fever Hoarseness or voice Sore throat Difficulty swallowing or dysphagia Drooling Tongue protrusion to increase free movement in the pharynx Throat seen as a cherry-red structure and edematous Muffled cough

10. Leukocytosis 11. Cyanosis severe cases Management 1. 2. 3. 4. 5. 6. Moist air to reduce the epiglottal inflammation. Oxygen if cyanosis is present. Antibiotic therapy such as a second-generation cephalosporin CEFUROXIME. The antibiotic such as Cefuroxime may be prescribed to the patient for a full 7 to 10 days. After the antibiotic therapy the epiglottal inflammation recedes rapidly. To maintain hydration in patients with epiglotitis, intravenous fluid therapy is needed since these children cannot swallow. It is important that the nurse should prepare a tracheostomy or entracheal intubation set at the bedside. Children with epiglotitis may need a prophylactic tracheostomy or necessitate endotracheal intubation to prevent total airway obstruction. IMPORTANT REMINDER: Never attempt to visualize the epiglottis directly with a tongue depressor because the gagging procedure causes complete obstruction of the glottis and results to respiratory failure. Throat culture should NOT be done UNLESS a means of providing an artificial airway such as a tracheostomy or endotracheal intubaton is readily available.

7. 8.

Difference between Placenta Previa and Abruptio Placenta

Difference Between Placenta Previa and Abruption Placenta Category Placenta Previa Abruptio Placenta Problem Low implantation of the placenta Premature separation of the placenta Incidence It occurs in approximately 5 in every It occurs in about 10% of pregnancies 1000 pregnancies and is the most common cause of perinatal death. Bleeding Always present May or may not be present Color of blood in Bright red Dark red bleeding episodes Pain during Painless Sharp, stabbing pain bleeding Management Bed rest (side lying position) NO vaginal or pelvic examinations


Placenta Previa

Assessment of FHR and bleeding Lateral position No vaginal or pelvic examinations Termination of pregnancy

Placenta previa is the low implantation of the placenta. The types of placenta previa are the following: 1. 2. 3. Low-lying placenta previa the implantation took place in the lower portion rather than the upper portion of the uterus. Marginal placenta previa the placental edges are approaching the cervical os. Partial placenta previa a portion of cerval os is occluded by the placental portion.

4. Total placenta previa implantation that totally obstructs the cervical os. Incidence

It occurs in approximately 5 in every 1000 pregnancies Risk factors Increased parity Advanced maternal age Past cesarean births Past uterine curettage

Multiple gestation Signs and Symptoms Bleeding bright red blood. The lower uterine segment begins to differentiate with the upper segment later in pregnancy. Placenta has the inability to stretch to accommodate the differeing shape of the lower uterine segment or the cervix, thus, abrupt and bright red bleeding occurs. Painless bleeding

Sudden bleeding Therapeutic Management Place the woman immediately on bed rest in a side-lying position. Weight perineal pads.

1. 2.

3. NEVER attempt a pelvic or rectal examination because it may initiate massive blood loss. Abruptio Placenta In this condition, the placenta has been implanted correctly, however the placenta separates prematurely. Incidence

It occurs in about 10% of pregnancies and is the most common cause of perinatal death. Risk factors High parity Advanced maternal age A short umbilical cord Chronic hypertensive disease Pregnancy-induced hypertension Direct trauma Vasoconstriction from cigarette use Thrombophilitic conditions that lead to thrombosis such as autoimmune antibodies

Signs and symptoms Sharp, stabbing pain high in the uterine fundus (during initial separation)

Tenderness felt on uterine palpation

Heavy bleeding (not readily apparent). Blood can either pool under the placenta and be hidden from view. External bleeding is only present if the placenta separates first at the edges and blood escapes freely from the cervix.

Hard, boardlike uterus with no apparent or minimally apparent bleeding Dark red blood (in bleeding episodes)

Management Fluid replacement

Oxygen by mask Monitor FHR Keep the woman in a lateral position DO NOT perform any vaginal or pelvic examinations or give enema Pregnancy must be terminated because the fetus cannot obtain adequate oxygen and nutrients. If birth does not seem imminent, cesarean birth is method of choice for delivery.

Lead Poisoning
Definition Lead poisoning, also called Plumbism or painters colic, is a condition caused by an increased level of heavy metal lead in the body. The heavy metal, lead, is a very strong poison. When an individual swallows a lead object or breathes in lead dust, some of the poison can stay in the body and cause serious health problems. When can you say that a child has been poisoned with lead? Lead poisoning is usually said to be present when the child has two successive blood lead levels greater than 10 ug/dl. Where can lead be found? Lead can be found on various places and in different things especially on old houses. Most commonly lead can be found in the following places: House paints before 1978. Small children often swallow paint chips or dust from lead-based paint that results to

plumbism. Gasoline Storage batteries Pewter pitcher and dinnerware Soil contaminated by decades of car exhaust or years of house paint scrapings. Lead is more common in soil near highways and houses. Old toys and furniture that are painted before 1976 Painted toys and decorations with unknown place of production. Lead bullets, fishing sinkers and curtain weights Plumbing pipes and faucets. Nowadays new building code required a lead-free solder. However, lead is still found

in some modern faucets that may result to the presence of lead in drinking water in homes. Methods of Screening

Serum ferritin. This is the most widely used screening method in determining blood lead levels. However, this test requires the use of atomic absorption spectrophotometry, which is a costly procedure. Erythrocyte protoporphyrin test. This is a free and simple screening method that only involves a fingerstick. Protoporphyrin is elevated in children with lead poisoning as lead blocks protoporphyrin from entering the heme portion of the blood component. Radiograph. A radiograph of the abdomen may reveal paint chips in the intestinal tract. Remove the child from the environemtn containing lead or removal of the source of lead from the childs environment.

1.

Management and Prevention of lead poisoning

2. 3. 4. 5. 6. 7. 8.

The walls must be covered with a paneling or Masonite. For children with lead level greater than 20 ug/dl, an oral chelating agent such as Succimer may be prescribed. Keep the home dust-free as possible. Have everyone wash their hands before eating. Water should be tested for lead. When tested positive, containing high levels of lead, consider installing an effective filtering device or switch to bottled water for drinking and cooking Avoid canned goods from foreign countries. Throw out old painted toys if you do not know whether the paint contains lead.

Nonshivering Thermogenesis
Definition The word thermogenesis means the process of heat production in organisms. When adults are cold, they shiver. Shivering results to increased muscle activity, thus, producing heat. In newborns these mechanisms of heat production do not occur. Newborns rarely shiver except at very low temperatures. Shivering is not an effective way of producing heat in the youngest population. Nonshivering thermogenesis is the primary method of heat production in infants. It is NOT shivering that produces heat but the metabolism of brown fat increases body temperature when the thermal receptors in the skin detect a skin temperature of 35 to 36 degree Celsius (95 to 96.8 degree Fahrenheit). Brown Fat Brown fat, also called adipose tissue or brown adipose tissue (BAT), is a special kind of highly vascular fat found in newborns. It contains an ample supply of blood vessels which cause the brown color. Brown fats are located primarily in the following areas: 1. Back of the neck 2. 3. 4. 5. 6. 7. In the axillae Around the kidneys Adrenals Sternum Between the scapulae Along the abdominal aorta

Some infants have insufficient brown fat stores. Preterm infants may be born before the stores of brown fat have accumulated. Aside from the said case, intrauterine growth restriction also deplete brown fat stores before birth occurs. Newborns that are exposed to prolonged cold stress may have insufficient brown fat stores as large amount brown fat is consumed for heat production in this situation. Thus, these infants will not be able to raise their body temperature if they are subjected to further episodes of cold stress. Without brown fat to be metabolized, no heat production will counteract the cold stress. Hence, the infant is at risk to serious complications. Processes Involved in Nonshivering Thermogenesis 1. 2. 3. 4. 5. 6. Nonshivering thermogenesis begins when the thermal receptors in the skin detect a skintemperature of 35 to 36 degrees Celsius (95 to 96.8 degrees Fahrenheit). The thermal receptors stimulation is then transmitted to the hypothalamus thermal center. In response to the hypothalamic stimulation, norepinephrine is released in brown fat. Presence of norepinephrine in the brown fat initiates its metabolism. As brown fat is metabolized, it generates more heat than other fats. Thus, blood passing through the brown fats is warmed and carries heat to the systemic circulation or to the rest of the body.

Difference between Caput Succedaneum and Cephalhematoma

CAPUT SUCCEDANEUM Definition A caput succedaneum is an edema of the scalp at the neonates presenting part of the head. It often appears over the vertex of the newborns head as a result of pressure against the mothers cervix during labor. The edema in caput succedaneum crosses the suture lines. It may involve wide areas of the head or it may just be a size of a large egg. Causes 1. 2. Mechanical trauma of the initial portion of scalp pushing through a narrowed cervix Prolonged or difficult delivery

3. Vacuum extraction The pressure (at birth) interferes with blood flow from the area causing a localized edema. The edematous area crosses the suture lines and is soft. Caput Succedaneum also occurs when a vacuum extractor is used. In this case, the caput corresponds to the area where the extractor is used to hasten the second stage of labor. Signs and Symptoms 1. 2. 3. Scalp swelling that extends across the midline and over suture lines Soft and puffy swelling of part of a scalp in a newborns head May be associated with increased molding of the head

4. The swelling may or may not have some degree of discoloration or bruising Management 1. Needs no treatment. The edema is gradually absorbed and disappears about the third day of life. Complication 1. Jaundice results as the bruise breaks down into bilirubin. CEPHALHEMATOMA Definition Cephalhematoma is a collection of blood between the periosteum of a skull bone and the bone itself. It occurs in one or both sides of the head. It occasionally forms over the occipital bone. The swelling with cephalhematoma is not present at birth rather it develops within the first 24 to 48 hours after birth. Causes 1. Rupture of a periostal capillary due to the pressure of birth 2. Instrumental delivery Signs and Symptoms 1. 2. Swelling of the infants head 24-48 hours after birth Discoloration of the swollen site due to presence of coagulated blood

3. Has clear edges that end at the suture lines Management

1.

Observation and support of the affected part.

2. Transfusion and phototherapy may be necessary if blood accumulation is significant Complication 1. Jaundice

Difference between a Caput Succedaneum and Cephalhematoma INDICATORS CAPUT SUCCEDANEUM CEPHALHEMATOMA Location Presenting part of the head Periosteum of skull bone and bone Extent of Both hemispheres; Individual bone; DOES Involvement CROSSES the suture lines NOT CROSS the suture lines Period of Absorption 3 to 4 days Few weeks to months Treatment None Support

Common Concerns during the Toddler Period

Promoting Toddler Safety The major cause of accidents of children in all ages is accidents. In toddlers, accidental ingestion or poisoning occur most frequently. In most cases, poisoning occurs from the ingestion of cleaning products. Aside from that accidents can also occur during this age as a result of aspiration or ingestion of small objects such as watch batteries, pencil erasers and crayons. These cases pose a major danger to toddlers. Safety Measure Number 1: Childproof the house and place all poisonous products, drugs, cleaning chemicals and small objects out of childs reach when crawling and the time when the toddler is walking. Examine toys for small parts that could be aspirated and remove toys that appear dangerous. Safety Measure Number 2: Toddlers should not be fed with peanuts and pop corns. Children should NEVER eat while running. The parents should never leave the toddlers alone with balloons. Aside from the accidents from poisonous products and small objects, toddlers frequently experience vehicular accidents, burns, falls and playground injuries. These accidents occur as the toddlers motor ability jumps ahead his or her judgment. They have no judgment concerning the moving cars, thus, toddlers walk across the streets with no concern for incoming cars. Safety Measure Number 3: Direct and constant parental supervision. Educate the parents to know what their toddler is doing at ALL TIMES. Do not allow the child to operate electronic garage doors. Safety Measure Number 4: A toddler-size car seat should be present in automobiles for toddlers until the children weigh 40 to 60 lb. Safety Measure Number 5: Place the child at the back seat of the automobile if airbag is present at the passenger seat. Do not be distracted from safe driving by a child in a car. Safety Measure Number 6: A helmet should be worn by the toddler as soon as they begin riding a tricycle. Supervise a toddler who is too young to be left alone on a tricycle. Teach safety with pedaling toys such as looking before crossing driveways and crossing streets. However, do not expect that the toddler will obey these rules at all times. Hence, the parents should stay close by. Safety Measure Number 7: A safety gate on the door of the room should be built to keep a toddler contained and safe. Keep the house windows closed and keep secure screens in place. Gates should also be placed at the top and bottom of the stairs. Safety Measure Number 8: Move the toddler in a regular bed with side rails to keep the child from falling when climbing out of the crib. Some 15-month old children can climb over the side rails of their cribs and enjoy exploring

the house early in the morning before anyone else is awake. Keep in mind to raise crib rails and check and make sure that they are locked before walking away from it. To prevent the toddler from drowning the parent should keep the next safety measure in mind at all times. Safety Measure Number 9: Do not leave the toddler alone in a bathtub or near water including buckets of cleaning water and washing machines. Poisoning in toddlers can be prevented by doing the next safety measures. Safety Measure Number 10: NEVER present medication as candy. Medications should be bought with childproof caps and should be immediately put away after use. Aside from that,medications should not be taken in front of a child. In putting away medications and poisons, it should be placed in locked cabinets or overhead shelves where a child cannot reach [Link] should never be left in parents purse or pockets where a child can reach it. Safety Measure Number 11: The parents should know the names of the house plants they have and they should be aware if they poisonous or not. Plants should be hanged on high surfaces beyond a toddlers reach. The telephone number of the nearest poison control center should be posted in the telephone. Preventing burns are crucial in toddler. Parents should be aware of the circumstances that might cause burns and ways of preventing them. Safety Measure Number 12: To prevent a toddler from reaching up pots and hot burners cook on the back burners of the stoves if possible and turn the handles of the pots toward back of the stove, thus, preventing the toddler from pulling them down. Safety Measure Number 13: toddlers should be monitored carefully when they are near lit candles and hot water faucets. Screens should be placed in front of a fireplace or heater. Safety Measure Number 14: Coffee and tea pots should never be left in the table where thetoddler can reach them. Do not drink hot beverages when a child is sitting on your lap or playing within reach. Safety Measure Number 15: electrical outlets should be covered with safety plugs. Electrical wires and cords should be kept out of toddlers reach.

Promoting Optimum Nutrition of a Toddler A toddlers appetite becomes smaller compared to that of infants, thus, growth slows abruptly after the first year of life. Feeding problems usually start during the toddler period because parents are unaware that their toddlers appetite has decreased and so as the food consumption. To promote optimum nutrition to toddlers the following should be done: 1. 2. 3. 4. Instruct the parents to place only a small amount of food in the toddlers plate and allow the child to eat it and ask for more rather than serve a large portion the child cannot finish. Educate the parents about the decline in the childs food intake during the toddler period so they will not panic when it happens. To strengthen the independence of the toddler, encourage the parents to allow self-feeding. Most children of this age insist on feeding themselves and in general resists eating if a parent insists on feeding them. Another way of promoting independence is by offering finger foods and allowing the toddler to choose between two types of food. This exposes the children to variety of foods and at the same time promotes independence. Nutritious finger foods that toddlers can enjoy are pieces of chicken, slices of banana, pieces of cheese and crackers. 5. 6. 7. 8. 9. Encourage the parents to prepare foods in bright colors as toddlers prefer brightly colored dishes. Diets high in sugar should be avoided during the toddler period. Milk should be whole milk until age 2 years. After which 2% milk can be introduced. Vegetarian diets are adequate for toddlers if parents are well informed about needed vitamins and minerals.

Toddlers do not usually like foods that are mixed up. These foods include casseroles with the exception of spaghetti. Children of this age prefer foods that do not touch one another on their plate. Promoting Toddler Development: Dressing

Some parents do not allow their toddlers to dress themselves. These parents need help to understand that when toddlers dress themselves, even though they invariably put shoes on the wrong feet, the child is developing his sense of autonomy. The nurse should encourage the parents to give up perfection for the purpose of developing the childs autonomy. Promoting Toddler Development: Sleep As children grow older, the need for sleep gradually decreases. During the toddler period the child may start with a nap time two times a day and sleeping of 12 hours each night. However, the toddler period ends with this sleep pattern: one nap a day and only 8 hours of sleep each night. The parents should be educated about this decline in sleep pattern or they may view their child having disinterest in sleeping as a problem. Bedtime routines are effective in putting a toddler to sleep. A bedtime routine may include bath, tooth brushing, pajamas, a story, being tucked into the bed, having a drink of water, choosing a toy to sleep with and turning out the lights. However, the parents must pay attention and caution of not allowing their child to maneuver them into such long procedure that results to delay in the sleep past the set schedule or time. Promoting Toddler Development: Bathing 1. 2. Parents should make bathing time fun for toddlers by providing toy such as a rubber duck, boat or plastic fish. Toddlers can already sit in the bathtub. However, parents should NEVER leave the toddler unsupervised. The toddler may slip and get their head under water or reach and turn on the hot-water faucet and scald themselves. Promoting Toddler Development: Tooth Care Instruct parents to offer fruits such as bananas, pieces of apple and orange slices and protein foods such as cheese or chicken to their toddler rather than high-carbohydrate snack items such as cookies. Fruits and high protein foods not only promote optimum nutrition but are also important in preventing dental caries by limiting the 2. 3. 4. 5. 6. exposure of the childs teeth to carbohydrate. Calcium should be included in the childs diet which is found in large amounts of milk, yogurt and cheese. This mineral is especially important in the development of strong teeth. Toddlers should be given tooth brush and they need supervision in brushing their teeth until about age of 8 years old. A dental floss can be used after brushing to clean in between the teeth and remove plaque. Fluorinated water should be taken by the child, if available, so that all new teeth are formed with cavity-resistant enamel. By two and a half years of age, the parents should schedule the toddler for his or her first dental visit for assessment of dentition. Most children have fear going to the dentist. To prepare the child for this first visit and the subsequent ones the parents can do the following: Read a story to the child about a dentist Never using the words such as drill and shot and any negative words that might scare the toddler of visiting the dentist

1.

Maintain a positive attitude about the dental visit Answering the childs question honestly without going into much detail Parental Concerns during the Toddler Period Toilet Training Sigmund Freud described the toddler period as a time of achieving anal gratification. Thus, toilet training is one of the highlight of this period. Toilet training is one of the biggest and major tasks a toddler must achieve. Bowel control takes place first at about 15 months followed by daytime bladder control at about 2 to 3 years. Nighttime bladder control is achieved at about 3 to 4 years of age. Most first time parents are asking when is the best time to start toilet training, when it is completed and how to start it. The figures given above can be a guide about the period of starting toilet training. However, toilet training is an individualized task for each child. Thus, it should be started and completed based on the childs ability to accomplish it and NOT MERELY according to a set of schedule.

Before the parents decide to start toilet training, they must see to it that their child has reachedthree developmental levels. Of these developmental levels, one is physiologic and the other two are cognitive: 1. 2. 3. They must have rectal and urethral sphincter control. This task is usually achieved at the time that a child can walk well. (Physiologic) They must have a cognitive understanding of what it means to hold urine and stools until they can release it a certain place and time. (Cognitive) They must a desire to delay immediate gratification for a more socially accepted action. (Cognitive)

Growth and development occurs in a CEPHALOACUDAL manner, thus the physiologic development of having urethral and rectal sphincter control are not mature enough for most children until at least the end of first year of life. By the end of the first year of life, the tracts of the spinal cord are myelinated to the anal level, thus, rectal and urethral sphincter control is achieved. Parents are asking about the exact time of knowing this has occurred, the best way of determining this developmental level is waiting until the child can walk well. Another marker of readiness for toilet training is when the toddler begins to be uncomfortable in wet diapers. This is demonstrated by pulling or tugging at soiled diapers and the toddler bringing a parent a clean diaper after they have soiled so they can be cleaned and changed. Some toddlers are also fond of smearing or playing with feces or stools often at about the same time that toilet training is started. The parents should be educated that this is just normal as the toddlers are becoming aware of their body excretions and have no adult values in them. Stools seem a little different from the modeling clay that they play with. Parents can minimized or avoid this activity by providing toddlers with play substances of similar texture and by changing the diapers immediately after defecation. As a nurse you have to stress out to the parents the importance of toilet training to their toddlers TOILET TRAINING IS AN EXPRESSION OF AUTONOMY. Ritualistic Behavior One of the most common traits of children during the toddler period is enjoying ritualistic patterns and behaviors. These children never leave the house unless his or her mother or father locates his or her favorite cap. Some never goes to sleep without singing their favorite nursery rhyme. Others never eat without their favorite spoons. These behaviors are common to toddlers and it is their way of expressing their autonomy. Negativism One of the characteristics the toddler possesses is showing negativism. Typically, toddlers go through a period of extreme negativism as part of establishing their identities as separate individuals. They refuse to do what their parents want them to do. Being negativistic is demonstrated by a toddler replying a vey definite no to every request ask to them. Here are some points to educate parents about their toddlers extreme negativistic behavior and ways of dealing with it: 1. Parents should never think that the negativism of the toddler is a way of questioning their authority or becoming disrespectful. When parents approach the negativistic behavior this way, they may become frustrated and always irritated. The parents should realize that this is a normal phenomenon of toddlerhood and at the same time a 2. positive stage in development. This change in a childs behavior is an indication that a toddler has learned that he or she is a separate individual with separate needs. It is essential that toddlers do this if they are to grow up to be persons who are independent and able to take care of their own needs and desires. 3. The more parents try to make their negativistic toddlers obey, the more they resist. So how can a parent deal with the uncooperative NO response of their toddler? A parents request can still be

followed with their toddlers negativistic behavior. The following ways are effective in dealing with this behavior. Rephrase the way your request is delivered Make a statement rather than a [Link] or No questions asked from the child would definitely lead to a no response. For instance, a mother asked the toddler Are you ready to sleep? In this case, the mother really means, Its time to sleep. Lets go to your room. If the mother

asks the first question given the toddler would really respond no. However, if the mother makes a statement (the

second request), the negative response is avoided. Offer simple secondary choices. Never offer choices such as Do you want to sleep or not? Because naturally the toddler will answer no to that. So how do we offer simple choices without compromising the main request of asking the toddler to sleep? Always remember that NO is never allowed for the major task which is in this case sleeping. The mother can do this by saying, Its bedtime now but then says Do you want to wear your green or blue pajamas when sleeping? In this case, the No response to the major task (sleeping) is eliminated and the

toddler has been able to decide (green or blue pajamas). Discipline The word discipline means setting rules or road signs so they know what is expected of them. Punishment on the other hand, is the consequence that results from the breakdown in discipline. Parents should begin to instill discipline early in life to promote safety to the child and others. Two general rules are important to follow in disciplining a toddler: 1. Parents need to be CONSISTENT. 2. Rules are leaned best if the correct behavior is praised rather than punishing a wrong behavior. Separation Anxiety Toddlers have the fear of being separated from their parents which is known as the separation anxiety. This anxiety begins as early as 6 months of age and persists throughout the preschool period. Because of this, toddlers have difficulty accepting being away from their parent or primary caregiver when being hospitalized or being enrolled in a

day care center. Separation anxiety is overwhelming to toddlers and the following ways help during these situations: Saying goodbye firmly. Explain to the child that the mother or primary caregiver will be there when the child wakes up in the morning or before the classes end.

Leave the area. Prolonging goodbyes only lead to more crying. It is not advisable that parents sneaked out of the room to prevent crying because it can strengthen the fear of abandonment. Temper Tantrums Temper tantrums are very common during the toddler period. To deal with this behavior the following measures should be done:

Check the place for safety. Ignore the temper tantrums. For some leaving the child in a safe place (supervised) cools down the temper tantrums. Never give rewards or bribes to the toddler. Toddlers tend to repeat their temper tantrum the next time when they want something if the parents give in to their request when they are crying and screaming.

Exercises During Pregnancy

Goal of Performing Prenatal Exercises: To strengthen the muscle that will be used in labor and delivery.

squatting

Guidelines in Performing Exercises during pregnancy: 1. 2. 3. 4. 5. Exercise should be done in moderation. Recommend that moderate exercise should be done 30 or more minutes daily. The pregnant woman should avoid strenuous activity or intensifying training. Exercises where there is a risk of falling or abdominal trauma should be avoided. Pre-natal exercises should NOT be done during a hot or humid weather. All exercises in supine position after the first trimester of pregnancy should not be done by the pregnant woman as this position increases the risk of supine hypotensive syndrome.

Tailor-sitting

6. 7. 8. 9.

Should be individualized. Meaning the exercises recommended for each pregnant woman should be according to ones age, physical condition, customary amount of exercise and the stage of pregnancy. Adequate fluid intake before and after exercise should be practiced by the pregnant woman. Exercises that cause fatigue should be stopped. It is important to follow the health care providers advice about taking the pulse rate during the exercise and

keeping it within a certain range. 10. The pregnant woman should stop the exercise and seek medical advice if she experiences the following:

Chest pain Dizziness Headache

Decreased fetal movement

Signs of labor Squatting and tailor sitting Strengthen perineal muscle

1.

2. Increase perineal circulation 3. Make more pelvic joints pliable Pelvic Rock 1. 2. 3. Maintains good posture Relieves abdominal pressure and low backaches Strengthen abdominal muscles following delivery

modified knee-chest position

Modified knee-chest position

1.

Relieves pelvic pressure and cramps in thighs or buttocks

2. Relieves discomfort from hemorrhoids Shoulder circling 1. Strengthens muscles of the chest Walking

shoulder circling

1. Best exercise 2. Promotes circulation Kegels 1. 2. 3. 10 seconds contraction, 10 seconds relaxation (30 times a day) Relieves congestion and discomfort in pelvic region Tones up pelvic floor muscles

Parahemophilia (Factor V Deficiency)

Definition Parahemophilia or Factor V deficiency is a rare coagulation disorder. It is an inherited condition that affects the ability of the blood to clot. It also termed as Owrens disease, proaccelerin deficiency or labile factor deficiency. Frequency

No apparent racial predilection for factor V deficiency exists. Factor V deficiency affects males and females with equal frequency. Factor V deficiency affects all ages. The age at presentation indirectly varies with the severity of disease.

About 1 person in 1 million people is affected with this disease. Causes Parahemophilia is caused by a large number of genetic abnormalities. It follows the inheritancepattern as being autosomal recessive. In this disorder, the plasma protein Factor V is low or missing. Thus, when certain coagulation is needed the chain reaction does not take place normally. Inheriting a defective Factor V gene or acquiring an antibody that interferes with normal Factor V function also contributes to the presence of the deficiency.

Inhibitor of Factor V can be acquired in the following conditions: After giving birth

After being treated with a certain type of fibrin glue After surgery

With an autoimmune diseases and certain cancers Physiology of Blood Clotting Factor V is an essential component in the blood coagulation cascade. It is synthesized by the liver and in megakaryocytes. This plasma protein circulates in an inactive form. When coagulation is taking place, Factor V is converted to an active factor, Factor Va through a limited proteolysis by the presence of the serine protease athrombin. Factor together with the activated factor Xa forms the prothrombinase complex. This complex is the one responsible for the rapid conversion of zymogen prothrombin to the active serine protease a-thrombin. Thrombin cleaves fibrinogen to form fibrin, leading to the ultimate step in coagulation, the formation of a fibrin clot. Signs and Symptoms

Nosebleeds Bleeding of the gums

Easy bruising Excessive menstrual bleeding (menorrhagia) Umbilical stump bleeding Excessive bleeding following injury Excessive bleeding following surgery

Excessive bleeding after giving birth Prolonged bleeding time Diagnosis factor V assay (showing decreased activity) activated partial thromboplastin time (aPTT) test (prolonged) prothrombin time (PT) test (prolonged)

thrombin clotting time (TCT) test Treatment Fresh frozen plasma infusions (FFP). Depending upon availability, solvent-detergent FFP may contain a more reliable level of Factor V than standard FFP. Fresh blood plasma infusions In acute cases of severe bleeding, the addition of platelet concentrates may be helpful. Patients with factor V deficiency can be given oral contraceptives to decrease menorrhagias, thereby improving anemia and decreasing transfusion needs. Tooth extraction in a patient with factor V hereditary deficiency is safely performed with both supplementation of FFP and application of local hemostasis.

Types of Sickle Cell Crisis

Sickle cell anemia is an inherited disorder on the beta chain of the hemoglobin resulting to abnormally shaped red blood cells. RBCs assume a crescent or C-shape that decreases the cells life span and ability to function thereby, producing various complications. In some cases, these sickled cells may block the flow causing pain and organ damage. A severe attack, known as sickle cell crisis, can cause pain because blood vessels can become blocked or the defective red blood cells can damage organs in the body. Most episodes of sickle cell crises last between five and seven days Types of Sickle Cell Crisis A. Vaso-occlusive Crisis This type of sickle cell crisis is due to the presence of sickle shaped red blood cells that impede capillaries and restrict the blood flow to an organ. This results in ischemia, severe pain, necrosis (tissue death) and most of the time it damages an organ. The frequency, severity, and duration of these crises vary considerably. Treatment: Pain crises are managed and treated by the following measures. 1. 2. Hydration Analgesics (Opioid administration at regular intervals until the crisis has settled). For milder crises, NSAIDs such as Diclofenac or Naproxen could be used. For severe crises, intravenous opioids are given such as patientcontrolled analgesia (PCA). Blood transfusion Dipenhydramine. This medication is used for the management of itching associated with the opioid use. To minimize the development of atelectasis a technique that encourages deep breathing, incentive spirometry, is

3. 4. 5.

recommended. B. Splenic Sequestration Crisis This crisis is acute and painful enlargements of the spleen. The spleen is responsible for clearing defective red blood cells. However, because of its narrow vessels, defective RBCs pools down the spleen that leads to its infarction before the end of childhood in individuals suffering from sickle-cell anemia. During a splenic sequestration crisis the abdomen becomes bloated and very hard. Aside from that, the sinusoids

and gates would open at the same time that result to the sudden pooling of the blood into the spleen which leads to a circulatory defects, thus, leading to sudden hypovolemia. Treatment Splenic sequestration crisis is considered an emergency condition and abrupt and prompt treatment is required or the patient may die within 1-2 hours because of the circulatory failure. 1. Blood transfusion 2. Management is supportive C. Aplastic Crisis This crisis stimulated by parvovirus B19. This virus directly affects the production of RBCs through the invasion of the red cell precursors. The resulting condition is the multiplication of the virus and the destruction of the RBCs. The crisis is characterized by acute worsening of the patients baseline anemia which produces pallor, tachycardia and fatigue. Treatment 1. Blood transfusion 2. Supportive management D. Hemolytic Crisis When hemoglobin levels drop, hemolytic crisis is accelerated. Resulting to the speeding up of RBC destruction. Individuals with co-existent G6PD deficiency commonly suffers from this crisis. Treatment: 1. 2. Blood transfusion Supportive management

Impetigo

Definition Impetigo is a superficial infection of the skin. It is an infectious disease transmitted only by direct contact from the affected person. This bacterial skin infection is also known as school sores which is most common among the preschool children. Information on Impetigo Causative agent: Beta-hemolytic streptococcus, group A (nonbullous), Staphylococcus Aureus (bullous) Incubation Period: 2-5 days Period of communicability: from the outbreak of the lesions until the lesions are healed Mode of transmission: direct contact with lesions. Scratching may spread the lesions. Immunity: none Classification 1. Bullous Impetigo this type of impetigo primarily affects infants and children younger than 2 years. Painless and fluid-filled blisters are found on the trunk, arms and legs in children with bullous impetigo. The surrounding akin of the blisters may be red and itchy but not sore. When the blisters break, they scab over with a yellow-colored crust 2. that lasts longer than sores from other type of impetigo. 2. Ecthyma this is the more serious form of impetigo. The infection in ecthyma penetrates deeper into the

second layer of the skin which is the dermis. Clinical Manifestations This infectious disease begins as a single papulovesicular lesion that is surrounded by a localized redness or erythema. Later on, more vesicles will appear and they will become purulent. As the disease progresses, the vesicles

ooze and form a honey-colored crusts. The lesions are found mostly on the extremities and the face. Local adenopathy may occur if an enormous number of lesions will be noted. Management 1. 2. 3. 4. 5. Penicillin or Erythromycin orally administered. Application of mupirocin (Bactroban) ointment for 7 to 10 days. Wash the crusts daily with soap and water for the lesions to heal quickly. Contact precautions should be implemented. Instruct the patient to stay indoors for a few days to stop any bacteria from getting into the blisters and making the infections worse.

6. The infected persons bed linens, towels, and clothing should be separated from those of other family members. 7. The infected person should use separate towels for bathing and hand washing. Prevention 1. 2. 3. Good hygiene. Injured skin areas should be kept clean and covered with clean gauze to prevent infection. Regular and effective hand washing practice.

4. Keep fingernails cut short. Possible Complications 1. 2. Rheumatic fever Acute glumerolunephritis

Congenital Adrenal Hyperplasia

Congenital adrenal hyperplasia (CAH) is a genetic disorder of the adrenal glands which involves a deficiency of an enzyme involved in the synthesis of cortisol, aldosterone, or both. Frequency About 1 in 10,000 to 18,000 children are born with congenital adrenal hyperplasia. Review of Related Anatomy and Physiology The adrenal glands are two bean-shaped glands curved over the top of the kidneys. It has a glandular (cortex) and neural tissue (medulla) parts. The central medulla region is enclosed by the adrenal cortex, which contains three separate layers. The adrenal cortex is responsible for producing three major groups of steroid hormones known as the corticosteroids. The hormones are the following: 1. Mineralocorticoids (aldosterone) important in regulating the mineral or salt content in the blood, particularly the sodium and the potassium ions. The target organ of this hormone is the kidney tubules which is the one responsible for reabsorbing the minerals selectively or allowing them to be excreted out from the body. Increase aldosterone results to increase sodium retention by the kidney tubules and excretion of the potassium. When sodium increases the water also increases or follows. Thus, mineralocorticoids help in the regulation of water and 2. electrolyte levels (equilibrium) in the body. Glucocorticoids (cortisone and cortisol) promotes the normal cell metabolism which helps the body to counteract the stressors (long-term) primarily by elevating glucose levels in the blood. These hormones are also called hyperglycemic hormones as their triggers the breaking down of fats and proteins into glucose. Sex hormones (androgens) produced by the adrenal cortex throughout the life in relatively small amounts. Hypersecretion of the sex hormones leads to masculinization regardless of the sex. Dramatic results are noted in females as they grow beard, a masculine body pattern of hair distribution and other male attributes. Causes

3.

Inherited as an autosomal recessive trait People with congenital adrenal hyperplasia lack an enzyme needed by the adrenal gland to make the hormones cortisol and aldosterone.

Pathophysiology In congenital adrenal hyperplasia (CAH), the affected individuals lack the enzyme needed by the adrenal glands to form and produce the other two hormones cortisol and aldosterone. Absence of these hormones results to the increase production of the third hormone produced by the adrenal cortex which is the SEX HORMONES or the ANDROGENS. This causes males characteristics to early in childhood instead of normally appearing during the puberty period. In females, male characteristics appear inappropriately as early as the fetal life. Signs and Symptoms Elevated androgen production results to masculinization of the female fetus or an increase of the genital organ size in a male fetus. The process of masculinization begins as early as fetal life. FEMALE INFANT 1. 2. 3. 4. 5. 6. Born with a clitoris so enlarged that it appears as penis Sinus between vagina and urethra is present Fused labia (ambiguous genitalia; the enlarged clitoris resembles that of an undescended testes and hypospadias) Precocious appearance of pubic and axillary hair and acne Epiphyseal line of the long bones closes early (prevents the child from reaching adult height unless treatment is initiated) No breast development or menstruation at puberty

MALE INFANT 1. Appear normal at birth 2. 3. 4. 5. 6. Signs of sexual precocity appear by 6 months of age Appearance of pubic hair by 4 years of age Enlargement of the penis, scrotum and prostate by 4 years of age Acne and a deep mature voice during childhood No spermatogenesis thus, the child is infertile

Diagnosis Children with congenital adrenal hyperplasia have increased levels of androgen which is an impartial point for the diagnosis. Determining the levels of other adrenal hormones which is the exact degree of the metabolic defect in production of the cortisol can be measured. 1. 2. 3. 1. 2. 3. 4. 5. 6. 7. A karyotype is essential in the evaluation of an infant with ambiguous genitalia to establish the patients chromosomal sex. The diagnosis of congenital adrenal hyperplasia depends on the demonstration of inadequate production of cortisol, aldosterone, or both in the presence of accumulation of excess concentrations of precursor hormones. Newborn screening programs for 21-hydroxylase deficiency Abnormal salt levels in blood and urine High levels of 17-OH progesterone High levels of serum DHEA sulfate High levels of urinary 17-ketosteroids Low levels of aldosterone and cortisol Normal or low urinary 17-hydroxycorticosteroids X-ray for bone age (shows older bones than normal for the persons age)

8. Chorionic villi sampling at 6-8 weeks of pregnancy to possibly identify the fetus with CAH during pregnancy 9. Amniocentesis at 15 weeks age of gestation to possibly identify the fetus with CAH during pregnancy Treatment

1.

Oral hydrocortisone both male and female infants are given with this corticosteroid agent to replace the hormones that they cannot produce naturally. Administration of corticosteroidsdecreases ACTH stimulation, thus, lowering the androgen level to normal limits and no further masculinization occurs.

2. 3. 4. 5.

Periodic analysis of cortisol levels to evaluate the effectiveness of the therapy. Periodic growth measurement to evaluate the effectiveness of the therapy. Treatment of the mother with Dexamethasone (a corticosteroid), which crosses the placenta, can prevent the masculization of the fetus for the remainder of pregnancy. Girls with male-looking genitals will usually have surgery between ages 1 month 3 months to correct the abnormal appearance.

Hormones in Reproduction
Gonadotropin-Releasing Hormone (GnRH) Gonadotropin-Releasing Hormone is produced by the hypothalamus. The target organ of GnRH is the anterior pituitary gland (APG). In females, GnRH stimulates the release of stimulating hormone (FSH) and luteinizing hormone (LH) from the APG. The release of FSH and LH initiates puberty and sustains female reproductive cycles. However, the release of the hormone is pulsatile. In males, FSH and LH are released from the APG through the work of GnRH initiating puberty. Follicle-Stimulating Hormone (FSH) Follicle-stimulating hormone (FSH) is produced by the anterior pituitary gland (APG). FSH stimulates the ovaries in females and testes in males to produce another hormone. In Females FSH does the following: 1. Stimulates the final maturation of follicle. 2. Stimulates growth and maturation of Graafian follicles before ovulation takes place. In males FSH stimulates the release of testosterone in the Leydig cells of the testes. Luteinizing Hormone (LH) LH is another hormone produced by the Anterior Pituitary Gland that in return stimulates the ovaries in females and testes in males. In males luteinizing hormone stimulates the Leydig cells of the testes to secrete and release testosterone. In females LH does the following: 1. 2. 3. Stimulates final maturation of follicle. Causes ovulation by the surging LH levels 14 days before the next menstrual period. Stimulates the alteration of Graafian follicles to corpus luteum. Corpus luteum continues to secrete estrogen and progesterone for about 12 days if no fertilization occurs. If the ovum is not fertilized, placenta gradually takes over

this function. Estrogen The hormone estrogen is both produced in male and female body. In the early stages of menstrual cycle estrogen is produced by the ovaries. In the latter part of menstrual cycle, when the Graafian follicle is transformed into corpus luteum, estrogen is produced by the corpus luteum. During pregnancy the placenta is responsible for releasing this hormone. In males, it is formed in small quantities from testosterone in Sertoli cells of testes. Also, other tissues such as the liver, produces estrogen in small quantities in males. The target organs of estrogen in females are the internal and external reproductive organs and the breast. In males, estrogen plays a vital role for normal sperm formation in the testes. The actions of estrogen in females are: 1. Development and maturation of the reproductive organs at puberty. 2. 3. 4. 5. 6. Stimulates the endometrium before ovulation. Initiates fat deposition at the breasts during puberty. Induces the growth of ductal and glandular tissues of the breasts. Stimulates the growth of long bones but causes the closure of epiphyses, thus, restricting mature height. Promotes uterine and breast tissue growth during pregnancy.

7.

Inhibits active breast milk production during pregnancy.

8. Relaxes pelvic ligaments during pregnancy. Progesterone This hormone is only found in female body. Progesterone is the second hormone produced by the ovary (in early stage of menstrual cycle) and corpus luteum (latter stage of menstrual cycle). During pregnancy, progesterone is produced by the placenta. Organs stimulated by progesterone are the uterus and the female breasts. The actions of this hormone are the following: 1. 2. Prepares the endometrium for possible embryo implantation by stimulating the secretion of endometrial glands causing the endometrial vessels to become dilated and tortuous.

Decreases uterine contractions. Prepares breast for lactation, however, it inhibits prolactin secretion. Prolactin Prolactin is produced in the posterior pituitary gland (PPG) which is responsible for stimulating the female breasts during lactation. The main function of this hormone is: Stimulates lactinogenesis. (Lactinogenesis is the production and secretion of milk.) Estrogen and progesterone produced by the placenta during pregnancy inhibits effects of active milk production until after placenta is expelled at birth. Prolactin secretion is stimulated by the sucking of a newborn to maintain milk production. Oxytocin Oxytocin like Prolactin is produced by the posterior pituitary gland. This hormone stimulates the female breast and the uterus to contract during and after birth. The presence of this hormone is very important as it does the following: 1. Helps expel the fetus out of the uterus during delivery. Uterine contractions brought about by the presence of 2. oxytocin causes the expulsion of the baby during delivery. Controls bleeding after delivery. Oxytocin stimulates postpartum contractions that compress the

During pregnancy progesterone: Nourishes the implanted embryo by inducing cell growth of the fallopian tubes and uterine lining.

uterine vessels thereby controlling bleeding. 3. During breastfeeding, let-down or milk-ejection reflex is stimulated with the presence of oxytocin. Testosterone Testosterone in males is produced by the testes. In females the adrenal glands and ovaries produce small quantities of this hormone. In women, small amount of androgenic (masculinizing) hormones from the adrenal glands cause growth of pubic and axillary hair at puberty. Most androgens such as testosterone are converted to estrogen in females. The following functions of testosterone are noted in males: 1. Stimulates the development of the male sex organs in fetus. 2. 3. Induces the growth and division of cells that mature sperms. Promotes the development of secondary male sex characteristics.

Cold Stress in Newborns

Thermoregulation is an essential aspect of neonatal care. Newborns that are least able to tolerate hypothermia include the preterm, growth restricted infant and those with asphyxia or respiratory difficulties. Preterm newborns have an impaired ability to preventheat loss and to increase their body heat production in response to low environmental temperatures. The risk of cold stress is greatest during the immediate transitional period after delivery and is caused by the preterm newborns immature skin, the high ratio of surface area to birth weight, and the environmental conditions in the delivery room (large temperature gradients between the newborns body temperature and the ambient temperature of delivery room, air flow through the room, and contact with cold surfaces that lead to significant evaporative, radiant, convective, and conductive heat losses). Consequences of Cold Stress

Decreased body temperature (hypothermia) results to cold stress. Cold stress in response causes many body

changes. The consequences of cols stress are the following: Increased Metabolic Rate Result: Decreased Surfactant Production and hypoxemia leading to respiratory distress When the metabolic rate of a neonate is increased, the need for oxygen also increases. A 2 degree centigrade drop in environmental temperature can double the newborns oxygen need. As cold stress progresses, surfactant production also diminish thereby impeding lung expansion. As a result hypoxemia will be noted and mild respiratory

distress can become severe hypoxia if oxygen must be used for heat production. Increased Metabolic Rate Result: Increase consumption of glucose resulting to hypoglycemia When the metabolic rate rises for the body to produce heat, glucose requirement also increases. As the demand of

glucose surges the body compensates to this need by converting glycogen stores to glucose. When glycogen stores are converted to glucose, they may be quickly used up resulting to hypoglycemia. Increased Metabolic Rate Result: Failure to gain weight Infants who must use glucose for temperature regulation and maintenance have less available supply for growth and development. Metabolism of brown fat Result: Metabolic Acidosis; increases the risk of jaundice When brown fats are metabolized in the presence of insufficient oxygen supply increased acid production will result. Rising amount of acids causes metabolic acidosis, which can be a life-threatening condition. Aside from that, elevated fatty acids in the blood can interfere with the transport of bilirubin to the liver for conjugation, thus, increasing the risk of jaundice in a newborn.

Methods of Heat Loss in Newborns

Overview The maintenance of body temperature at birth or thermoregulation is assumed by infants. Neonates must produce and maintain enough heat to prevent cold stress. Cold stress can have serious and even fatal effects to the neonates. Why are newborns more prone to losing heat? Several features predispose a newborn to lose heat. The following characteristics are: 1. 2. 3. The neonates skin is thin. The newborns blood vessels are close to the surface. Little subcutaneous or white fat is present to serve as a barrier for heat loss. (the percentage of subcutaneous fat in newborns is only half in adults)

4. Newborns have three times more surface area to body mass than adults. Methods of Heat Loss

Evaporation

When wet surfaces are exposed to the air evaporation occurs. Heat is lost when the surface dries. At birth the neonate is bathed with amniotic fluid. As the amniotic fluid dries up on theinfants skin (evaporation), the infant loses heat. The same occurs in bathing an infant. Ways to prevent heat loss by evaporation: 1. Drying the infant as quickly as possible after birth. 2.

Drying the infant immediately after bathing. Conduction

When a neonate comes in direct contact with an object cooler than their skin heat loss by conduction occurs. Heat loss by conduction occurs when an infant is placed on a cooler surface or touching them with a cool object or hands. Ways to prevent heat loss by conduction:

1. 2.

Warming the objects that will touch an infant. Placing an infant against the mothers skin helps prevent conductive heat loss. Convection

When heat is transferred to the air surrounding the infant heat loss by convection takes place. If an air conditioner is kept on or when people move around near the infant increase loss of heat occurs. Ways to prevent heat loss by convection: 1. Keeping the newborn out of drafts. 2. 3. Maintaining warm environmental temperature. Keeping a preterm neonate in an incubator. Radiation

The transfer of heat to cooler objects that are not in direct contact with the neonate is called the heat loss by radiation. When infants are placed near cold windows or walls heat is lost by radiation. Even neonates placed in incubators losses heat to the walls of the incubator if it is cold even if the surrounding air temperature is warm. Ways to prevent heat loss by radiation: 1. Incubators must have double walls. 2. Cribs and incubators should be placed away from the walls and windows.

Implantation Process

Definition Implantation is the penetration of the growing structure to the uterine endothelium. It occurs approximately 8 to 10 days after fertilization. Sequential Events in Implantation 1. 2. 3. 4. 5. 6. Immediately after fertilization, the fertilized ovum or zygote stays in the fallopian tube for 3 days. During this time a rapid cell division (mitosis) or cleavage is taking place. The first cleavage occurs at about 24 hours and it continues to rapidly divide at a rate of one in every 22 hours. The developing cells are now termed as BLASTOMERES. When 16 to 50 blastomeres (developing cells) are present, the cells tend to create a bumpy appearance and it is now called MORULA. Morula comes from a Latin word morus meaning mulberry. In this morula form, it will start to travel by ciliary action and peristaltic contractions of the Fallopian tube to the uterus. It continues to multiply as it floats free in the uterine cavity for 3 or 4 days. Large cells tend to accumulate at the side of the structure. Because of this peripheral accumulation, a fluid space surrounding the inner cell mass is created. When a cavity is formed in the morula the structure is now called a BLASTOCYST.

7.

Blastocyst is the structure that penetrates to the uterine endothelium. Cells form on the outer ring of the blastocyst, which are called trophoblast cells. Trophoblast cells enable the blastocyst to invade the endometrium. These cells will later form the placenta and membranes. The brushing of the blastocyst to the uterine endometrium is a process called APPOSITION. The attachment of the blastocyst to the uterine endometrium is termed as ADHESION.

8. 9.

10. The settling down of the blastocyst down into its soft folds is a process called INVASION. Invasion is made possible because as the growing structure touches the endometrial wall aproteolytic enzyme is produced that dissolve the tissues that they come in contact with. 11. The blastocyst burrows deep into the endometrial wall to receive nourishment from the endometrial glands. 12. Continued invasion establishes an effective communication network with the maternal circulation. 13. Once implanted the zygote is now termed embryo and the uterine endometrium is now termed decidua. 14. Implantation bleeding is characterized by a small amount of vaginal spotting that appears with implantation as capillaries are ruptured by the penetrating trophoblast cells. (This should not be mistaken for the womans last menstrual period or LMP.)

Signs of Pregnancy
Pregnancy Confirmation Women note changes in their bodies that make them aware that they are pregnant when pregnancy occurs. Every pregnant women wish to confirm a pregnancy as soon as possible. Often, confirmation is made by ultrasonography. This test makes it possible to view the fetal outline and observe fetal heartbeat in the early stage of pregnancy. In traditional way, diagnosis is pregnancy is usually made based on the symptoms experienced by the woman and signs observed by the health care provider. These signs and symptoms are classified in three groups: 1. Presumptive signs or indications (subjective signs observed and reported by the woman) 2. 3. Probable signs or indications (objective signs observed by examiner) Positive signs or indications (those than can be caused only by pregnancy).

The diagnosis of pregnancy cannot be solely made on the presumptive or probable signs because they may have other causes. Presumptive signs with other possible causes First trimester: 1. Amenorrhea absence of menstruation. Other possible causes of amenorrhea are: emotional stress, strenuous 2. physical exercise, endocrine problems, chronic disease, early menopause, anovulation, low body weight. Nausea and vomiting (Morning sickness) begins about 6 weeks after the last menstrual period and usually disappears by about 14 weeks. Other possible causes include: gastrointestinal virus, food poisoning, emotional 3. stress. Breast changes begins at about the sixth week of pregnancy. The expectatnt mother experiences breast tenderness, tingling, feelings of fullness, increase in size and pigmentation of the areaolae. Other possible causes are premenstrual changes and the use of oral contraceptives. 4. Fatigue other possible causes are illness, stress and sudden lifestyle changes. Urinary frequency urinary tract infection may also cause urinary frequency.

4. 5.

Second trimester: 1. Quickening other possible causes are intestinal gas, peristalsis or pseudocyesis 2. Increased skin pigmentation: chloasma, linea nigra - Other possible causes are premenstrual changes and the use of oral contraceptives. 3. Striae gravidarum Probable Signs First trimester:

1. 2. 3. 4.

Chadwicks sign can also be possibly caused by hormonal imbalance. Goodells sign can also be possibly caused by hormonal imbalance. Hegars sign can also be possibly caused by hormonal imbalance. Positive HCG Hydatidiform Mole can cause a positive HCG

Second trimester: 1. Enlarged abdomen could also be caused by abdominal or uterine tumors 2. Braxton hicks contractions presence of myomas can cause false and painless contractions 3. Ballottement other possible cause of this occurrence is the presence of uterine or cervical polyps. Positive signs First trimester: 1. Ultrasound evidence Second trimester: 1. Fetal heart tones 2. Fetal movements 3. Fetal outline on x-ray

Hemophilia Symptoms and Treatment

Usually an inherited, congenitalbleeding disorder characterized by lack of blood clotting factors, especially factors VIII and IX An X-linked disorder primarily affecting males; females act as carriers Occurs in 1 in 5000 males No racial predilection; found in all ethnic groups

Pathophysiology and Etiology

Hereditary Spontaneous mutations may cause the condition when the family historyis negative for the disease. The basic defect is in the intrinsic phase of the coagulation cascade. The blood clotting factors are necessary for the formation of prothrombin activator, which acts as a catalyst in theconversion of prothrombin to thrombin. The rate of formation of thrombin from prothrombin is almost directly proportional to the amount of prothrombin activator available. The rapidity of the clotting process is proportional to the amount of thrombin formed. The result is an unstable fibrin clot. Platelet function and number are normal. Therefore, small lacerations and minor hemorrhages are usually not a problem.

Signs and Symptoms

Abnormal bleeding Prolonged bleeding episodes after circumcision Easily bruise Spontaneous soft tissue hematomas Hemarthrosis or hemorrhages on the joints Spontaneous hematuria

GI bleeding Diagnostic Evaluation prothrombin and bleeding time are normal partial thromboplastin time prolonged prothrombin consumption decreased thromboplastin increased

assays for specific clotting factors abnormal gene analysis detects carrier state for prenatal diagnosis Management Prompt, early, appropriate treatment is the key to preventing most complications. Must replace missing coagulation factor (VIII or IX) through the administration of type-specific coagulation concentrates during bleeding episodes.

1. 2.

3. 4. 5. 6.

Factor VIII made from cryoprecipitate that has been viral inactivated, monoclonal or detergent purified. Factor IX made from fresh frozen plasma that has been viral inactivated by solvent detergent.

No viral inactivated concentrate exists for Hemophilia C; fresh frozen plasma is given to supply factor XI. Mild and moderate VIII-deficient hemophiliacs may respond to desmopressin (DDAVP). Antifibrinolytics are given as adjunctive therapy for mucosal bleeding to prevent clot breakdown. Supportive therapies: NSAIDs, physical therapy, orthotics.

7. Synovecty orthopedic surgical intervention. Complications

airway obstruction degenerative joint changes with osteoporosis and muscle atrophy intestinal obstruction compression of nerves by paralysis

intracranial bleeding Nursing Management Provide emergency care for bleeding. Immobilize the affected part and elevate above the level of the heart. Administer recombinant factor VIII or factor IX coagulation concentrate. Apply fibrinolytic agents to wound for oral bleeding. Avoid rectal thermometers. Avoid injections if possible. Maintain a safe environment and teach patients and parent safety measures. Be aware that increased pain usually means that bleeding continues and further replacement therapy may be needed. Enhance family coping.

1. 2. 3. 4. 5. 6. 7. 8. 9.

Pediatric Asthma Management

Pediatric Asthma Management Asthma as defined by National Asthma Education and Prevention Program is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes, neutrophils and epithelial cells. Pathophysiology: When mast cells activate, there is infiltration of inflammatory cells, edema, denudation and disruption of the bronchial epithelium, goblet cell hyperplasia and smooth muscle thickening resulting to asthmatic inflammation. Signs and symptoms: 1. 2. Recurrent episodes of wheezing Breathlessness

3. Chest tightness 4. Cough particularly at night and in the early morning Risk factors: 1. 2. Children before age of 5 hygiene hypothesis (suggests that living in a clean environment may predispose the immune system of the child towards allergic reactivity

3. Heredity Allergic triggers: 1. 2. 3. 4. 5. 6. 7. 8. Allergens Irritants Weather changes Viral or sinus infections Exercise Reflux disease Medications (sensitivity to aspirin, NSAIDs sulphites) Food

9. Emotional anxiety 10. Rhinitis 11. Sinusitis Medical Management: 1. Use of short acting bronchodilator which is inhaled beta2-agonists as needed for symptoms with MDI spacer/holding chamber

2. Bronchodilators should be given every 4 to 6 hours for 24 hours for patient with asthma and viral infection. Nursing Management: 1. 2. 3. 4. Regular monitoring and assessment of the symptoms in the past 2 weeks. Assess for exacerbation, proper compliance to medications. Assess for difficulty with feedings, changes in respiratory rate, altered sleep patterns, presence of retractions, decreased appetite and weight loss. Teach the parents to control or minimize the exposure to allergens.

5. 6. 7. 8.

Emphasize the need for flu vaccine for patients with no restrictions. Limit the exposure to cigarette smoke Eliminate dust mites Encourage to use air conditioners at home and keep doors and windows closed to minimize the exposure to these triggers.

9. Encourage a regular visit to the physician and evaluate the proper usage of equipment. 10. Provide a written instruction for management plans when at home, at school or care givers. 11. Remind the parents or care givers about the medications, its expiry date as well as having a reserve of it in times of exacerbations. 12. Give an easy telephone access when the patient must be taken into the hospital.

Common Concerns During Infancy: Parental Concerns and Problems

Parental Concerns and Problems Related to Normal Infant Development Teething

1. 2. 3. 4.

Instruct the parents that infants may be resistant to chewing for a day because of teething. Educate the parents that the following manifestations are not normal during toot eruption and any of these symptoms signifies an underlying infection or disease process requiringevaluation. High fever Seizures Vomiting Diarrhea Over-the-counter (OTC) medications sold for teething should be discouraged if they contain benzocaine. Benzocaine is a topical anesthetic that once applied in the throat can interfere with the gag reflex. For pain relief of teething, Acetaminophen (Tylenol) 10 to 15 mg/kg every 4 hours can be used. Encourage parents to always check their infants health with a health care provider before administering OTC drugs. To provide soothing coolness against tender gums teething rings can be placed in the refrigerator. Check articles within babys reach to be sure that they are safe to chew or edible as teethinginfants tend to place

almost any object in the mouth. Thumb Sucking

Parents should be educated that thumb sucking is normal and does not cause any jaw malformations on the jaw line as long as it stops by school age period. Thumb sucking peaks at about 18 months where it may begin as early as 3 months of age. Educate the parents that making an out of thumb sucking does not cause a child to stop the habit. It usually

intensifies and prolongs the habit of thumb sucking. The best approach is to be certain an infant has adequate sucking pleasure and then ignore thumb sucking. Head Banging

Educate parents that head banging is a normal mechanism of relief of infants for tension. Head banging begins during the second half of the first year of life and continuing through to the preschool period. It is associated with naptime or bedtime which lasts for about 15 minutes. This habit is normal as children use this measure to relax and fall asleep. Investigate stress factors in the house. Advise parents to pad the crib rails so that infants cannot hurt themselves. Excessive head banging suggests a pathologic condition and children with this condition needs counseling and further evaluation.

Sleep Problems

1. 2.

Educate mother that breast-fed infants tend to wake up more often than formula fed infantsbecause breast milk is easily digested thus, infants fed in breast milk gets hungry sooner. Remaining awake for long periods of time and waking at night is common during the lateinfancy period. To eliminate night waking or cope with this situation the following should be done: Delaying bed time for 1 hour. Shortening the afternoon sleep period.

3. Do not responding immediately to infants so that they can have time to sleep on their own. 4. Providing soft toys and music to allow infant to play quietly alone. Use of pacifiers

1. 2. 3. 4.

Infants who manifest the following need a pacifier: Sucks on clothes ad hands. Those who actively searches for a thing to put in the mouth. Infants who is fed completely but still seems restless and discontented. Babies who have colic (babies interpret the abdominal pain in colic as hunger Parents can offer pacifier to the infant after feeding for more sucking. When sucking needs are met during ones infancy, the individual will not crave as much oral stimulation later in life and will less likely become a pencil chewer, cigarette smoker or nail niter. Instruct the parents to sterilize pacifiers when it falls on the floor before giving back to infants. The major drawback of pacifier use is the problem of cleanliness. Encourage parents to start weaning the infant from pacifier use anytime after 3 months of age and certainly

during 6 to 9 months, when the sucking reflex is fading. Colic (paroxysmal abdominal pain generally occurring in infants under 3 years of age)

1. 2.

Educate the parents of the cause of colic which are: Overfeeding Swallowing air while feeding Instruct parents to burp the infant after feeding.

Hold the infant in an upright position while feeding. Diaper Rash Frequent diaper changing. Exposing the diaper area to air to help relieve rash.

Advise parents to allow the infant to sleep without diaper at night to help control the problem. Application of Desitin ointment on the affected area. Baby Bottle Syndrome

baby bottle syndrome

Baby bottle syndrome is a condition where an infants tooth is decayed because of putting an infant to sleep with a bottle. Tooth decay occur because while an infant is sleeping (with the bottle on the mouth), liquid from the prop bottle continuously soaks the upper front teeth and thelower back teeth. The carbohydrate in milk ferments to organic acid that demineralize the tooth enamel until it is damaged or decayed.


1. 2.

Instruct parents never to put their babies to sleep with a bottle prop in the infants mouth. If the bottle is necessary for infants to fall asleep encourage the parents to do any of the following: Fill the bottle with water not milk and use a nipple with smaller hole. (to prevent the baby from receiving too much fluid) In case where the infant refuses to drink water, instruct the mother to dilute the milk with more and more water each night.

Milliaria Milliaria is also called a prickly heat rash which is commonly occurring during hot seasons. It also occurs when the infants are overdressed or sleep in over-heated rooms. Bath the infant twice a day during hot seasons. To help relieve rash mix a small amount of baking soda into the bath water. Lower room temperature.

Common Concerns During Infancy: Safety

Promoting Infant Safety Safety is one of the most crucial things a parent or nurse should consider when caring for infants. The leading cause of infant death is accident. Most accidents in infancy occur because of the parents carelessness. Nurses should provide parents teachings on the ways on becoming sensitive to their infants developmental progress and

anticipatory guidance for a childs safety. The following measures are important to promote safety to children infants. Aspiration Prevention Infants place anything they touch to their mouth. This is the main reason why aspiration is the most commoninfant cause of infant accidents. Aside from that parents usually prop bottles when feeding preventing the infant to push the bottle away if the milk flows rapidly into the mouth thus causing the infant to aspirate. The following ways should be instructed to parents to prevent aspiration:

1. 2. 3. 4. 5. 6.

Educate parents not to prop bottles when feeding the infant with a formula. Instruct parents to offer large toys only. Caution them to be certain that all small objects are put away from the infants reach. Check rattles and toys to ensure that they have no small parts that could snap or fall out. Infant clothing should contain no small decorative buttons. Solid foods should be introduced in small pieces not large chunks. Popcorns and peanuts should not be offered to children below 5 years old because of the danger of aspiration. Fall Prevention Direct and constant supervision of infants. Crib side rails should be raised and secured. Educate the parents that two months is the maximum time where infants can safely sleep in a bassinet. Cribs should have high side rails to prevent infants from falling. Car Safety Infants up to 20 lb should be placed in rear-facing seats in the back seat because an inflating front-seat airbag could suffocate aninfant. Do not leave an infant unattended in a parked car. Do not be distracted by an infant while driving. Bathing and Swimming Safety Constant and direct supervision of infants while bathing or swimming or in bathtubs. Infantsshould NEVER be left unattended near water even buckets of cleaning water. Poisoning precautions

1. 2. 3. 4.

1. 2. 3.

1.

1. 2. 3. 4. 5. 6.

Place medications in containers with safety caps and should be placed on areas whereinfants cant reach. Medication should never be presented as candy. Medications should never be taken in front of an infant and should be put away immediately after use in a locked cabinet or overhead shelves. Paints should be thoroughly assessed for lead content. All paints used should be free from lead. Medications should never be left in pockets or handbags. Plants should be hanged or placed in high surfaces. Burn Prevention Formula and food warmth should be tested before feeding. Avoid smoking or drinking hot liquids when holding an infant. Do not leave infants unattended. Cover electrical outlets with safety plugs. Electric wires and cords should be kept out of reach.

1. 2. 3. 4.

Fertilization

Definition Fertilization is the union of an ovum and a spermatozoon. It is also called conception, impregnation or fecundation and usually occurs in the outer third of the fallopian tube, the ampullar portion. Important facts about fertilization 1. 2. 3. 4. An ovum is capable of fertilization for 24 to 48 hours. After this time, the ovum atrophies and becomes nonfunctional. The functional life of a spermatozoon is about 48-72 hours. The normal amount of semen in an ejaculation is about 3-5 cc (average: 2.5 ml). The number of sperms in an ejaculate is 50-200 million per milliliter or an average of 400 million sperm per ejaculation.

5. Spermatozoon reaches the cervix within 80 seconds and the outer end of the fallopian tubewithin 5 minutes. Sequential Events of Fertilization 1. An ovum is surrounded by a ring of polysaccharide called the zona pellucida and a circle of cells called corona radiate as it is forced out of the graafian follicle of the ovary during ovulation. These surrounding cells serve as a protective buffer of the ovum against injury. The fimbrae, fine, hair-like structures that line the openings of the fallopian tubes initiate currents that propel the ovum and surrounding cells into the nearby fallopian tube. The ovum is propelled along the length of the tube through the peristaltic action of thefallopian tube and the movements of cilia. It is easier for spermatozoon to penetrate the vagina as the viscosity of cervical mucus is decreased.

2. 3. 4.

5. 6. 7. 8. 9.

Spermatozoon moves through the cervix and the body of the uterus and into the fallopian tubes to the ovum by means of their tails (flagella) and uterine contractions. Capacitation, a process where sperm-binding receptor sites are revealed, takes place right before fertilization. As the sperms move toward the ovum and cluster around the ovums protective layer of cells HYALURONIDASE is released and dissolves the layer of cells that protects the ovum. Right after penetration, the chromosomal material of the ovum and sperm combine. The resulting structure is termed zygote (fertilized ovum). The ovum always contains the X-chromosome. A sperm contains either an x or Y chromosome. If an X-carrying sperm fertilizes an ovum the resulting structure will have two X chromosomes and the child will be female (XX). If a Y-carrying chromosome fuses with an ovum, the resulting structure will have an X and Y chromosome and the child will be male (XY).

Bilirubin Conjugation

Definition of terms Bilirubin a product of hemoglobin degradation and is toxic once it accumulates in the body. Unconjugated bilirubin also termed as indirect bilirubin. This type of bilirubin is soluble in fat but not in water. Because it is fat soluble it may be absorbed by the subcutaneous fat, causing the yellowish discoloration of skin or jaundice. Conjugated bilirubin also termed as direct bilirubin. This type of bilirubin is water soluble. It is in this form that bilirubin is excreted out of the body. Conjugated bilirubin is less toxic that the other type. Factors Contributing to Bilirubin Production

Excess production Approximately 6-8 mg/kg of bilirubin is produced in infants each day during the first 2 weeks of life and adults have a rate of 2.5 times than that of neonates. Red Blood Cell Life In adults RBCs life span is 120 days. In preterm infants the RBCs last only for 60-70 days and 80-100 days in term infants. Neonates erythrocytes are more fragile and susceptible to damage and injury than those of adults. Red

blood cells break down faster in neonates and thereby producing more amount of bilirubin than adults. Liver immaturity

The liver normally produces adequate amounts of the enzyme glucoronyl transferase to conjugate bilirubin and be excreted out of the body. The newborns immature liver may not be able to produce adequate amounts of this enzyme resulting to the limited amount of bilirubin that can be conjugated.

Intestinal factors Two factors may result to high levels of unconjugated bilirubin: Sterile intestines of newborns at birth conjugated bilirubin cannot be reduced to urobilirubin or stercobilin to be excreted out of the body without the intervention of intestinal flora. Large amount of beta-glucuronidase enzyme in the newborns intestines beta-gucuronidase changes bilirubin back to the unconjugated state.

1. 2.

Delayed Feeding Feeding the newborn helps to establish a normal intestinal flora and promotes the passage of meconium. Meconium contains high amounts of bilirubin. In cases where feeding is delayed or meconium is not excreted the betaglucuronidase exposure in the intestine is prolonged thus increasing the chance of converting the unconjugated

bilirubin to the conjugated state. Trauma Trauma at birth (e.g. bruising) results to the increased hemolysis of RBC. Hemolysis of RBC results to the production of additional bilirubin. Bilirubin conjugation 1. 2. 3. 4. 5. Unconjugated bilirubin (UCB) is released into the bloodstream and attaches to the albumin binding sites in the plasma to be carried to the liver. Once unconjugated bilirubin is already at the liver, the enzyme glucuronyl transferase in the smooth endoplasmic reticulum of liver cells binds the UCB to ligandin and other proteins to become a conjugated bilirubin. Conjugated bilirubin (CB) is then excreted into the bile and into the duodenum. As CB reaches the intestines, the normal intervenes on conjugated bilirubin and converts it to urobilinogen and stercobilin. Urobilinogen and stercobilin are excreted in the stools and some urobilinogen are excreted by the kidneys.

Neural Tube Defects

Definition

anencephaly

Neural tube defects (NTDs) are birth defects of either the brain or spinal cord. This group of disorders is characterized by an opening in the brain or spinal cord occurring at an early stage of human development. Incidence

NTDs are one of the most common birth defects. Female predominance is observed. About 60-70% of all cases are females. The incidence of neural tube disorders have fallen dramatically in recent years from 3 cases in every 1000 births to only 0.6 cases in every 1000 births. Risk Factors Cigarette smoking and maternal exposure to cigarette smoke

Maternal diabetes Maternal obesity

Causes

Polygenic inheritance pattern Poor maternal nutrition Maternal diet deficient in folic acid Intake of folate antimetabolites (methotrexate)

Use of teratogens Review of the related anatomy andphysiology The central nervous system is the first observable structure in a human embryo. This embryo passes through 23 stages of development after conception. Two processes work in order to form the CNS:

1.

Primary neurolation

2. Secondary neurolation Primary neurolation is the formation of the neural structures into a tube. This forms the brain and the spinal cord. Secondary neurolation is the formation of the lower spinal cord. This gives rise to the lumbar and sacral elements. Types of Neural Tube disorders

Anencephaly absence of the cerebral hemispheres. Closure of the anterior neuropore occurs at stage 11 at about 23-26 days age of gestation. Failure of this point to close results to anencephaly. Children with this disorder cannot survive because of the absence of cerebral function. These children may only survive for a number days because the respiratory and cardiac centers are located in the intact medulla. Microcephaly characterized by a slow brain growth. Generally, infants with this disorder are cognitively challenged because of the lack of functioning brain tissue. The head circumference of affected neonates is decreased. Spina Bifida Occulta occurs when the posterior laminae of the vertebra fail to fuse at 26-28 days age of gestation. The most common site is the fifth lumbar or sacral level though it may occur at any point along the spinal canal. Meningocele herniation of the meninges through the unformed vertebrae of the spinal cord. Generally, it occurs at the lumbar area but it can be present anywhere along the spinal canal. It is characterized by an appearance of an orange-shaped mass at the center of the back. Myelomeningocele herniation of the spinal cord and meninges through the unformed vertebrae. The spinal cord ends at the pint of protrusion, thus, motor and sensory function beyond the point of herniation is absent.

Pediatric Nephrotic Syndrome

Pediatric Nephrotic Syndrome

Nephrotic syndrome is characterized by heavy proteinuria, hypoalbuminemia, and edema. Pediatric nephrotic syndrome are usually the primary type. Approximately 85% to 95% of primary cases in preadolescents are minimal change nephroticsyndrome and are associated with minimal histologic changes in the glomeruli. Nephrotic syndrome annually inflicts about 16 children per 100,000 younger than age 16 in the United States.

It is slightly more common in males than females in younger children, but this disappears in teenagers and adults. Mean age of onset is 2 and a half years. Pathophysiology: Underlying defect is thought to be caused by the loss of charge selectivity of the glomerular basement membrane, which permits negatively charged proteins, primarily albumin, to pass easily through the capillary walls into the urine.

Excessive urinary loss of protein and catabolization by the kidney of circulating albumin leads to a decrease in serum protein. The colloidal osmotic pressure that holds water in the vascular compartments is reduced because of the decrease in the amount of serum albumin. This allows fluid to flow from the capillaries into the interstitial spaces, thus producing edema. The shift of fluid from the plasma to the interstitial spaces reduces the vascular fluid volume, which in turn stimulates the renin-angiotensin system and the secretion of the the antidiuretic hormone and aldosterone. Tubular resorption of sodium and water is increased to increase intravascular volume.

1. 2. 3. 4.

The loss of proteins, particularly immunoglobulins, predisposes the child to infection. Clinical Manifestations: Edema Periorbital edema usually becomes apparent first Dependent edema in the hands, ankles, feet, genitalia Ascites and pleural effusions Striae due to overstretching Profound weight gain Decreased urine output Pallor, irritability, lethargy, fatigue

GI disturbances such as vomiting, diarrhea and anorexia Diagnostic Evaluation: Urinalysis, usually with protein of 2+ or greater 24-hour urine protein, frequently greater than 2 g/m2 per day Total protein and albumin reduced

Cholesterol, greater than 200 mg/dL Complications: Peritonitis Septicemia Cellulitis

Thrombosis Acute renal failure Management: Steroid therapy Immunosuppressants: Cyclophosphamide Cyclosporin A Tacrolimus

1. 2. 3.

IV Albumin 25% Nursing Management: Relieve excess fluid by administering steroids or alternative drugs as prescribed. Offer foods high in potassium, low in sodium, fat and sugar. Encourage activity as tolerated. Restrict fluids as ordered. Strictly monitor intake and output. Weigh patient daily. Provide meticulous skin care to the edematous parts of the body. Give emotional support to the child and his parents. Help child adjust to body image changes by explaining changes ahead of time.

Difference between a Cows Milk and Human Breast Milk

Newborns and infants need sufficient nutrition to be sued for their growth and development. To meet energy needs, prevent the use of body stores and to provide for growth the infant must consume adequate calories. Nutrients needed by neonates such as carbohydrates, proteins, and fat are contained in breast or formula milk. Full-term neonates digest simple carbohydrates and protein well. Fats are less digested because of the lack of pancreatic enzyme in the newborn. Aside from nutrients and calories, newborns also need larger amount of fluid. Water is unnecessary to be given as breast milk or formula already supplies the infants fluids needs. Daily Calorie and Fluid Needs of the Newborn (Source: Saunders Foundations of Maternal-Newborn Nursing by Murray and McKinney) Calories

110-120 kcal/kg (50-55 kcal/lb) Fluid 40 to 60 ml/kg (18-27 ml/lb) for the first two days of life 100 to 150 ml/kg (45-68 ml/lb) by the end of the first week Breast Milk Breast milk offers many advantages compared to that of formula. Not only that nutrients are proportioned appropriately in breast milk to meet the neonates changing needs but it also provides protection against infection. Composition of breast milk changes in three phases which are the following:

Colostrum secreted during the first week of lactation. It is a yellowish and thick substance. This type of breast milk contains higher protein, fat-soluble vitamins and minerals than the mature milk. However, it contains lower calories, fat and lactose. It is also rich in immunoglobulin that helps in the protection of the GI tract from infection. Transitional Milk contains lesser immunoglobulin and proteins. Lactose, fat and calories are increased in this type of breast milk.

Mature milk replaces transitional milk after 2 weeks of lactation. Contains 20 kcal/oz and nutrients essential

for infants growth and development. Cows Milk Modified cows milk is the source of most commercial formulas. It is specifically formulated forinfants. The protein component is reduced to decrease the renal solute load. Vegetable fat replaces the saturated fat of an unmodified cows milk. To simulate the contents of breast milk, vitamins and other nutrients are added to the preparation.

Content Protein: Casein Whey Carbohydrate: Lactose Vitamin C Iron

Breast Milk High ratio of whey to casein (that makes it more easily digested) 6.8 g/dl 43 mg 0.5 mg

Cows Milk Contains high casein (not easily digested) 4.9 g/dl 11 mg 0.5 mg (High casein and low Vitamin C concentration of cows milk level interferes with iron absorption.) 14 iu

Vitamin D

22 iu

Congenital Heart Disorders Disorders with Obstruction to Blood Flow

Disorders with Obstruction to Blood Flow Obstruction to the blood flow in the heart may be caused by narrowing of vessels or valves. As a result, the pressure before the narrowed part increased while it decreases after the narrowed area. This prevents the heart from reaching the lungs for oxygenation or the rest of the body. Disorders under this category include pulmonary stenosis, aortic stenosis and coarction of aorta. These heart diseases can cause back-pressure of the heart thereby overwhelming it.

Pulmonary Stenosis The word stenosis means narrowing of a specific part. Pulmonary stenosis is the narrowing of the pulmonary valve or the pulmonary artery itself distal to the valve. The pulmonary artery carries deoxygenated blood from the right ventricle to the lungs. A pulmonary valve is a flap of tissue that opens with pressure to allow blood to enter the

pulmonary circulation. Inability of the right ventricle to evacuate blood to the pulmonary artery would result to right ventricular hypertrophy. Clinical Manifestations Some infants with pulmonary stenosis may be asymptomatic or have mild signs of right sided heart failure. Severe narrowing of the pulmonary artery may cause the following manifestations:

Cyanosis Typical systolic ejection murmur (grade IV or V crescendo-decrescendo quality) loudest at the upper left sternal border Thrill at the upper left sternal border

Aortic Stenosis Oxygenated blood is pumped from the left ventricle to the aorta. Presence of a stricture or stenosed aortic valve prevents blood from flowing to the systemic circulation. The hearts inability to evacuate blood in the left ventricle results to increased pressure and hypertrophy of the left ventricle. If the left ventricles pressure becomes acute, pressure in the left atrium increases that would result to back-pressure in the pulmonary veins and possible pulmonary edema. Clinical Manifestations Most infants are asymptomatic however generally they present the following physical manifestation: Typical murmur (rough systolic sound at the second right interspace)

Thrill at the suprasternal notch For severe cases Decreased cardiac output Hypotension Tachycardia Poor sucking ability

Chest pain similar to angina (when the child is active) Disorders with Obstruction to Blood Flow Obstruction to the blood flow in the heart may be caused by narrowing of vessels or valves. As a result, the pressure before the narrowed part increased while it decreases after the narrowed area. This prevents the heart from reaching the lungs for oxygenation or the rest of the body. Disorders under this category include pulmonary stenosis, aortic stenosis and coarction of aorta. These heart diseases can cause back-pressure of the heart thereby overwhelming it. Pulmonary StenosisChest pain similar to angina (when the child is active)

Coarction of Aorta The narrowing of the lumen of aorta is a congenital heart failure called coarction of aorta. There are two types of this disorder:

Preductal coarction is present between the subclavian artery and the ductus arteriosus Postductal coarction is present distal to the ductus arteriosus

Difficulty of the blood to enter the systemic circulation through narrowed aorta result to increase the blood pressure before (proximal) the coarction and decreased distal to it. Clinical Manifestations

Absence of palpable femoral pulses Elevated blood pressure in the upper part of the body and decreased BP in the lower extremities. Leg pain on exertion Exceptional irritability Epistaxis Headache Vertigo

Congenital Heart Disorders Disorders with Mixed Blood Flow

Disorders with Mixed Blood Flow Mixing of the blood from the pulmonary and systemic circulation in the chambers of the heart results in a relative deoxygenation of the blood flowing. The defects under this include transposition of the great arteries, total anomalous pulmonary venous return, truncus arteriosus and hypoplastic left heart syndrome.

Transposition of the Great Arteries

Normally, the pulmonary artery arises from the right ventricle and the aorta from the left ventricle. With transposition of the great arteries, the pulmonary artery arises from the left ventricle while the aorta from the right ventricle. As blood (unoxygenated) enters the right atrium it flows to the right ventricle. Because the aorta is connected to the right ventricular portion of the heart completely deoxygenated blood goes out into the aorta to the different parts of the body. On the other side of the heart oxygenated blood enters the left atrium via the pulmonary veins. It flows to the left ventricle then back to the pulmonary artery then to the lungs and returns to the left atrium. Two closed circulatory systems are present. In most cases, ASD and VSD are present with transposition of the great arteries. This makes the entire heart have a single yet mixed circulation. Clinical Manifestations

Cyanosis at birth There may be murmur or there may be various murmurs (depending on the shunting of blood through atrial or ventricular septal defects)

Total Anomalous Pulmonary Venous Return Normally, the pulmonary vein drains oxygenated blood to the left atrium. In total anomalous pulmonary venous return, the pulmonary veins drain the blood to the right atrium or the superior vena cava. Blood from the right atrium enters the right ventricle to the pulmonary artery, lungs, pulmonary veins and back to the right atrium. Often, an absent spleen is associated with this disorder. Truncus Arteriosus Normally aorta and pulmonary artery are separate vessels. In Truncus Arteriosus, one major artery or trunk serves as the common pathway for the pulmonary artery and aorta. This trunk or major artery arises from the right and the left

ventricles. Thus, oxygenated blood (in the aorta) mixes in one major trunk. Hypoplastic Left Heart Syndrome

deoxygenated blood (from the pulmonary artery) and

In Hypoplastic left heart syndrome, the left side of the heart is non-functional. The left ventricle, which pumps blood to the systemic circulation, lacks sufficient strength to pump the blood into the systemic circulation. This results to the hypertrophy of the right ventricle as it tries to maintain the adequate heart function and action.

Congenital Heart Disorders Disorders with Increase Pulmonary Blood Flow

Classification of Congenital Heart Diseases Congenital Heart disorders were formerly classified as either cyanotic and acyanotic heart diseases. Cyanotic heart diseases occur when deoxygenated blood is shunted from the venous circulation to the arterial circulation, resulting to the bluish discoloration of the skin (cyanosis) due to decreased oxygen levels in the systemic circulation. With this classification, blood is shunted directly from the right to the left part of the heart. Acyanotic heart diseases involve narrowing or stricture of the blood that moves the blood from the arterial to the venous circulation (left to right shunt). However, some patients with heart diseases under the cyanotic type do not show cyanosis until they are seriously ill. And those with cyanotic heart diseases can also exhibit cyanosis. Because of the confusion the former system created a second classification system has been established. This classification system identifies four types of disorders which is classified according to the blood flow patterns of the disease not their signs and symptoms. The following are: 1. 2. 3. 4. Increased pulmonary blood flow Obstruction to blood flow Mixed blood flow Decreased pulmonary blood flow

Disorders with Increased Pulmonary Blood Flow Congenital heart disorders classified with increased pulmonary blood flow follows the movement pattern of the blood from the left side of the heart (greater pressure) to the right side of the heart (lower pressure). This abnormal blood movement is due to an opening between two systems or arteries. Disorders of this type include the following: Ventricular Septal Defect (VSD) With this cardiovascular defect, an opening between the two ventricles is present. Because pressure in the left side of the heart is greater than the right side, blood will be shunted from the left to the right. Thus, more blood enters the

pulmonary circulation (from the right side) and less to the aorta.

Clinical Manifestations: 1. 2. Easy fatigability Loud harsh pansystolic murmur at the left sterna border Atrial Septal Defect (ASD)

Presence of an opening in between the two atria resulting to the shunt of the oxygenated blood from the left side of the heart to the right side is noted with ASD. This congenital heart disease is more common in girls than boys. Clinical Manifestations:

1. 2.

Harsh systolic murmur (at 2

nd

or 3 interspace)

rd

Second heart sound auscultated as split (fixed splitting) Atrioventricular Canal Defect (AVC) or Endocardial Cushion Defect

Endocardial cushion is the septum of the heart at the junction of the atrium and ventricle. When this endocardial cushion fails to fuse the disorder is called AVC or Endocardial Cushion Defect. Patent Ductus Arteriosus (PDA) Ductus arteriosus is a fetal accessory that links the pulmonary artery to the aorta. Failure of this accessory structure to close at birth (Patent Ductus Arteriosus) will result to the shunting of the oxygenated blood from the aorta

to the pulmonary artery. artery because of the increase pressure in the aorta. Clinical Manifestations: 1. 2. Wide pulse pressure Continuous machinery murmur on auscultation

Blood is shunted from the aorta to the pulmonary

Encephalocele
Encephalocele, sometimes known by the Latin namecranium bifidum, is a neural tube defect characterized by saclike protrusions of the brain and the membranes that cover it through openings in the skull. It is a rare birth defect. Types of encephalocele 1. Meningocele the bulging portion contains onlycerebrospinal fluid and the overlaying membrane 2. Encephalomeningocele brain tissue is present. Causative Factor 1. 2. Failure of the neural tube to close completely during fetal development Encephaloceles occur rarely, at a rate of one per 5,000 live births worldwide. Ethnic, genetic, and environmental factors, as well as parental age, can all affect the likelihood of encephaloceles. The condition can also occur in families with a family history of spina bifida. 3. Although the exact cause is unknown, encephaloceles are caused by failure of the neural tube to close completely during fetal development. Research has indicated that teratogens (substances known to cause

birth defects), trypan blue (a stain used to color dead tissues or cells blue), and arsenic may damage the developing fetus and cause encephaloceles. Symptoms 1. 2. 3. 4. 5. 6. 7. Neurologic problems Hydrocephalus Spastic quadriplegia (paralysis of the limbs) Microcephaly (an abnormally small head) Ataxia (uncoordinated muscle movement) Developmental delay Vision problems

8. Mental and growth retardation 9. Seizures. Process of diagnosing the case Usually encephaloceles are noticeable deformities and are diagnosed immediately after birth, but a small encephalocele in the nasal or forehead region can go undetected. Various physical and mental developmental delays can indicate the presence of encephaloceles. Treatment

Surgery is currently the only effective treatment, generally performed during infancy. Occasionally, shunts are placed to drain excess cerebrospinal fluid from the brain. Nursing Considerations 1. 2. 3. Teach the mothers that the role of Folic Acid is very important in every neural tube defects therefore emphasizing this to pregnant woman and those who are planning to get pregnant is very crucial. Encourage them to take foods rich in folic acid. An adequate prenatal check-up must be complied to provide proper evaluation of the growth and development of the fetus.

Anencephaly
Anencephaly is the absence of a large part of the brain and the skull. It is also called Aprosencephaly with open cranium. It is one of the most common neural tube defects and occurs early in the development of an unborn baby, usually in the 23 and 26 day of pregnancy. It happens when the upper part of the neural tube fails to close. Cause: 1. 2. environmental toxins (such as lead, chromium, mercury, and nickel) lack of folic acid intake of the mother.
rd th

It is also can be inherited as evidence show that a woman who has had one child with a neural tube defect such as anencephaly has about a 3% risk of having another child with a neural tube defect. Woman who are taking certain medications for epilepsy and women with insulin-dependent diabetes have also a higher risk of having a child with a neural tube defect. It is characterized by absence of the skull, absence of the brain (cerebral hemispheres and cerebellum), facial feature abnormalities, heart defects, blindness, deafness, unconscious, and unable to feel pain. Diagnostic evaluation: 1. 2. A pregnancy ultrasound may be done to confirm the diagnosis. It may reveal too much fluid in the uterus. Other tests includes Amniocentesis (to look for increased levels of alpha-fetoprotein), and Alpha-fetoprotein level (increased levels suggest a neural tube defect).

3. pre-pregnancy serum folic acid test may also be done. Prognosis: The prognosis for this condition is usually poor, in which death usually occurs after a few days. Therefore Proper Prenatal Check is very important and that pregnant mothers should get enough folic acid as according to some research, Folic acid can reduce the chance of neural tube defectsby 50 percent. Nursing Considerations: 1. 2. 3. 4. Encourage compliance to pre-natal check-ups. Include in the diet foods that are rich in folic acid (cereal, white bread, cooked okra, juice and etc). Have a regular ultrasound check-up. Listen to the concerns of the pregnant woman about what she is undergoing.

Muscular Dystrophy (MD)

Definition Muscular dystrophy is a collective term denoting a group of genetic disorders that results to the progressive degeneration of the skeletal muscles. Individuals affected with this disorder apparently lack information on their genes that prevents their body from making a protein (merosin) which is necessary for muscle contractions. Types Congenital Myotonic Dystrophy (CMD) This type of muscular dystrophy is inherited through an autosomal dominant trait pattern. The disease begins in the utero and the newborn may have severe muscle weakness (myotonia) at birth. The degeneration of the muscle progresses until respiratory movement becomes very hard and difficult. Many of these infants die before 1 year of age because they cannot sustain respiratory function. In rare cases, congenital myotonic muscular dystrophy can cause learning and intellectual disabilities in affected children. Fascioscapulohumeral Muscular Dystrophy (FSMD)f

fascioscapulohumeral muscular dystrophy

Fascioscapulohumeral muscular dystrophy is inherited asdominant trait, where the defect is carried in the chromosome 4. Symptoms are apparent during late school-age or adolescent period, about 10 years of age. It affects both sexes and this type of muscular dystrophy usually affects the muscles of the face and shoulder, giving its name. The predominant manifestation of FSMD is facial weakness making a child unable to whistle and wrinkle his or her forehead, close eyes tightly and raise arms. The progression of the disorder is slow, hence allowing a normal-life

span. Pseudohypertrophic Muscular Dystrophy (Duchennes Muscular Dystrophy) This is the most common form of muscular dystrophy and is inherited as a sex-linked recessive trait. Duchennes muscular dystrophy affects only boys where the symptoms usually becomeapparent by 3 years of age. A problem with the gene that makes a protein called dystrophin causes this type of MD. Without dystrophin muscles cannot keep their shpe and strength. At about 10-12 years of age children with this disease needs a wheelchair. Later on, respiratory muscles become weak necessitating the help of a ventilator to breathe. Affected individuals usually die in their late teens or early adulthood.

Clinical Manifestations

Progressivemuscular weakness Delayed meeting of motor milestones Waddling gait Walking on toes Frequent falls Gowers sign (to stand, affected children press their hands against their ankles, knees and thighs) Hyperthrophied calf muscles Poor balance Scoliosis of the spine

Fracture of long bones Inability to walk (late stages) Diagnostic tests Muscle biopsy History and physical findings Electromyography

Enzyme analysis (increased concentration of serum creatine phosphokinase) Management There is no cure for muscular dystrophy. Treatments include physical and speech therapy, orthopedic devices, surgery and medications.

Encourage to remain ambulatory for as long as possible.

gower's sign

Active and passive daily ROM exercise program. Splinting and bracing ( to maintain lower extremity stability and avoid contractures)

Low-calorie, high-protein diet to avoid excessive weight gain (ambulation becomes more difficult if the child is overweight) Increase fiber and fluids in diet (to prevent constipation.) Stool softeners if needed. Support groups for parents to assist them with coping (Muscular Dystrophy Association)

Estimates in Pregnancy
Estimates in Pregnancy A good preparation for the upcoming labor and delivery prevents life threatening risks to the mother and the baby. To have an idea when the estimated date of delivery (EDD) is, the nurse should have knowledge on the different estimates used for pregnant women. These techniques may or may not exactly point out the EDD or age of gestation, but it tries to estimate the age of pregnancy and possible date of delivery for the mother to be prepared. Nageles Rule Nageles rule is used to determine the EDD on the basis of the first day of the last menstrual period or LMP. To calculate the date of birth in this rule, subtract 3 months from the first day of LMP then add 7 days and change the year. For example the last menstrual period (LMP) began July 30, 2010. To determine the EDD follow the following steps: 1. Subtract 3 months (June 30, May 30, April 30) = April 30, 2010 2. Add 7 days then change the year = April 30 + 7 (April has 30 days only, thus, adding 7 days would make the EDD May 7) = May 7 (change the year) = May 7, 2011 Modified McDonalds Rule

measuring the fundic height in mcdonald's rule

McDonalds Rule or method is used to determine the age of gestation by measuring from the fundus (obtaining the fundal height) to the symphysis pubis. The distance in centimeters will determine the age of gestation from 16-38 weeks. (From Benson and Pernolls handbook of obstetrics and gynecology) Johnsons Rule Johnsons rule is used to estimate the weight of the fetus in grams. To determine this, a standard formula is used. Formula: fundic height in cm n x k k is constant, it is always 155 n is 12 if the fetus is engaged. It is 11 if the fetus is not yet engaged. Example: A fundic height of 28 cm, and the fetus is not engaged. 28 cm 11 x 155 = 17 x 155 = 2635 grams Bartholomews Rule of fourths

This method estimates the age of gestation relative to the height of the fundus of the uterus above the symphysis pubis. rd By 3 lunar month (12 weeks), the fundus is slightly palpated above the above the symphysis pubis. By the 5 lunar month (20 weeks), the fundus is palpable at the level of the umbilicus. th On the 9 lunar month, the fundus is at the level of the xiphoid process.
th

Neonatal Immune System Adaptation Processes

Neonatal Immune System Adaptation Processes Neonates WBC responds slowly and inefficiently when the body is invaded with microorganisms. This is due to the immaturity of the hypothalamus and inflammatory responses. Because of the immaturity of the immune system, neonates are susceptible to pathogens which do not generally affect older children. Full-term neonates receive antibodies from the mother during the last trimester of pregnancy. When an infant is breastfed, the mother continues to give antibodies to the infant. This is called passive immunity. These immunoglobulin help protect the newborn from infection. At birth there are about 55-80% of antibodies present in the newborns body. Immunoglobulin G (IgG) There is only one immunoglobulin that passes or crosses that placenta, the IgG. IgG starts to cross the placenta at the first trimester of pregnancy. However, the largest amount of IgG transfer is noted during the third trimester of pregnancy. Thus, a preterm neonate is more susceptible to infection that a full-term infant. This type of immunoglobulin provides the fetus a passive immunity to possible bacterial and viral infections. However, the passive immunity it provides is only temporary. The immunity gradually disappears at about 6 to 8 months of life. The gradual disappearance of passive immunity, leads to the gradual production of larger quantities of immunoglobulin to replace the IgG from the mother. Immunoglobulin M (IgM) IgM is the first immunoglobulin produced by the body when the neonate is distressed, has acquired an infection or is challenged. When a newborn is exposed to environmental antigens, production of IgM rapidly increases. This type of immunoglobulin provides protection from gram-negative bacteria. IgM cannot cross the placental barrier. In cases where large amount of IgM is found in the placenta, possible exposure to infection in the utero is probable. Immunoglobulin A (IgA) Another immunoglobulin produced by the infants body is called the Immunoglobulin A (IgA). Neonates are susceptible to infections in the gastrointestinal (GI) and respiratory systems. IgA is vital in providing protecting of those systems. Another important function of IgA is limiting the absorption of antigenic protein the diet of an infant. A particular form of IgA is present in the colostrum and breast milk. This is the main reason why breastfed infants have more immune protection than the formula fed babies.

Torticollis (Wry Neck)

Torticollis Definition Torticollis literally means wry neck. It comes from the term tortus meaning twisted andcollum denoting to neck. Infants born with this deformity has a twisted neck (congenital torticollis) has a head tipped to one side while the chin is rotated to one side. Types

Torticollis is classified into: Congenital Muscular Torticollis present at birth and the most common form. Acquired Torticollis acquired later in life Incidence 1 in every 250 neonates is born with congenital torticollis. Ten to twenty percent of infants with torticollis have also a congenital hip dysplasia (improper formation and function of the hip socket.) Risk Factors Fetuses with wide shoulders are at high risk of injuring the sternocleidomastoid muscle during delivery due to the pressure exerted on the head to deliver the shoulder. Causes Congenital Torticollis causes

Injury of sternocleidomastoid muscle during birth Injured blood supply of the fetus neck at birth Wrong position of fetus while inside the womb resulting to tightness of the sternocleidomastod muscle (muscle that connects the breastbone and the collarbone to the skull)

Klippel-Fiel Syndrome (less common cause) This is characterized by abnormalities in the bones of the neck (cervical vertebrae) where the bone is abnormally formed and/or fused. Inherited (rare cases only) Result of underlying condition that damages the nervous system or muscles (e.g. spinal or brain tumor) Acquired Torticollis causes Damage of the nervous system Damage of the muscles around the neck Tumors of the skull base (posterior fossa tumor) Pharyngitis (can irritate the nerves supplying the neck muscles and cause a wry neck) Use of antipsychotics (acute dystonia)

Assessment

Positional plagiocephaly (asymmetrical head shape) X-ray

Electromyogram (EMG) Clinical Manifestations Congenital Torticollis Painless

Head posture abnormality: If the right sternocleidomastoid is injured: the infants head is rotated to the right and chin rotated to the left.

If the left sternoceidomastoid muscle is affected: the infants head is rotated to the left and chin turned to the right. Lump in the affected muscle (can be palpated or noticeable at about 1-2 months of age)

Limited range of motion of the head Swelling of the neck muscles (possibly present at birth)

Shoulder is higher on one side of the body Stiff neck muscles Acquired Torticollis Painful neck Shoulder is higher on one side of the bosy Stiff neck muscles Head posture abnormality Head tremor

Headache Shoulder is higher on one side of the body Management Congenital Torticollis Passive stretching exercises and encouraging the infant to look at the affected muscle (by feeding at the direction of the affected area and positioning mobiles on the injured part).

If simple exercises are not effective, a surgical correction is done. This is followed by usage of neck immobilizer to further correct the deformity. Acquired Torticollis Identification of underlying cause of the disorder. Heat application for head and neck pain Cervical spine traction Neck massage Anticholihergic drugs Use of Botulism (Botox)

Difference Between Adult and Fetal Circulation

Difference between Adult and Fetal Circulation

Criteria Artery Veins Exchange of Gases Pressure

Adult circulation sequence 1. 2. 3. 4. 5. 6.

Adult Circulation Carries oxygenated blood awayfrom the heart Carries non-oxygenated blood towards the heart Takes places in the lungs Increase pressure on the left side of the heart

Fetal Circulation Carries Non-oxygenated blood away from the fetal heart Carries oxygenated blood back to the heart Takes place in the placenta Increase pressure on the right side of the heart

Non-oxygenated blood enters the right atrium via the inferior and superior vena cava. Increase level of blood in the right atrium causes the tricuspid valve to open and drain the blood to the right ventricle. Pressure of blood in the right ventricle causes the pulmonic valve to open and non-oxygenated blood is directed to the pulmonary artery then to the lungs. Exchange of gases occurs in the lungs. Highly oxygenated blood is returned to the heart via the pulmonary vein to the left atrium. From the left atrium the pressure of the oxygenated blood causes the mitral valve to open and drain the oxygenated blood to the left ventricle. Left ventricle then pumps the oxygenated blood that opens the aortic valve. Blood is then directed to the ascending and descending aorta to be distributed in the systemic circulation.

Fetal Circulation Sequence 1. 2. 3. 4. Exchange of gases occurs in the placenta. Oxygenated blood is carried by the umbilical vein towards the fetal heart. The ductus venosus directs part of the blood flow from the umbilical vein away from the fetal liver (filtration of the blood by the liver is unnecessary during the fetal life) and directly to the inferior vena cava. Blood from the ductus venosus enters to the inferior vena cava. Increase levels of oxygenated blood flows into the right atrium. In adults, the increase pressure of the right atrium causes the tricuspid valve to open thus, draining the blood into the right ventricle. However, in fetal circulation most of the blood in the right atrium is directed by the foramen ovale (opening between the two atria) to the left atrium. 5. 6. The blood then flows to the left atrium to the left ventricle going to the aorta. Majority of the blood in the ascending aorta goes to the brain, heart, head and upper body. The portion of the blood that drained into the right ventricle passes to the pulmonary artery.

7.

As blood enters the pulmonary artery (carries blood to the lungs), an opening called ductus arteriosus connects the pulmonary artery and the descending aorta. Hence, most of the blood will bypass the non-functioning fetal lungs and will be distributed to the different parts of the body. A small portion of the oxygenated blood that enters

8.

the lungs remains there for fetal lung maturity. The umbilical arteries then carry the non-oxygenated blood away from the heart to the placenta for oxygenation.

Maple Syrup Urine Disease (MSUD)

Maple Syrup Urine Disease Definition Maple syrup urine disease (MSUD) is a rare inherited disorder where the body cannot break down certain parts of protein. The urine of the child smells like a maple syrup. Incidence This disorder occurs in about 1 case per 180,000 newborns. Causes Maple Syrup Urine Disease is an inherited disorder which follows an autosomal recessive pattern. In this disease the branched-chain alpha-keto acid dehydrogenase complex (BCKDH) responsible for metabolizing some amino acids is absent or deficient. In some cases, MSUD can damage the brain during infection, fever, fasting or any physical stress experienced by the child. Repeated periods of physical stress result to catabolism of cells releasing amino acids (including leucine, isoleucine and valine) into the bloodstream thereby, leading to mental retardation. Pathophysiology Branched-chain alpha-keto acid dehydrogenase complex (BCKDH) is combination of enzymes that is responsible for the breakdown of the branched chain amino acid. These branched chain amino acids include leucine, isoleucine and valine. In maple syrup urine disease, the branched chain alpha-keto acid dehydrogenase complex (BCKDH) is absent or deficient resulting to the accumulation of the branched chain amino acids (leucine, isoleucine, and valine) into the urine and blood. Elevated components of leucine, isoleucine and valine that are not metabolized spill out in the urine giving the waste product a distinctive sweet-smelling odor similar to that of maple syrup, hence, the name of the disease. The buildup of the toxic by-products of these amino acids leads to the cerebral degeneration (brain damage) similar to that observed in children diagnosed with Phenylketonuria (PKU) and death, if left untreated. Clinical Manifestations Infants with the disorder tend to appear well at birth; however, they quickly show abnormal signs in about 2-7 days depending on the feeding regimen.

Feeding difficulty Vomiting Loss of Moro reflex Irregular respirations Opisthotonos Generalized muscular rigidity Generalized seizures Sweet-smelling odor of urine similar to that of maple syrup by the first or second day Poor weight gain Increasing lethargy

If the condition remains untreated, the infant may die as early as 2 to 4 weeks of age. Diagnosis

Prenatal diagnostic tests

Amniocentesis Chrorionic villus sampling Extrauterine diagnostic tests Plasma amino acid test Urine amino acid test Management Dietary therapy Low amino acids (leucine, isoleucine and valine) and high thiamine (Vitamin B1) diet is prescribed to the

affected infant. Thiamine, also called Vitamin B1, is responsible for muscle nerve function and a coenzyme for energy metabolism. The child has to comply with the dietary therapy lifelong and must restrict intake of branched chain amino acids without impairing growth and development. This is the main reason why infants are given thiamine. Activity

No activity restrictions. Hemodialysis or peritoneal dialysis This measure can be used to temporarily reduce abnormal serum levels at birth or during a childhood infection, when catabolism of cells releases increased amino acid into the blood stream. Medication

Thiamine Thiamine is a necessary coenzyme in carbohydrate and amino acid metabolism. The oral absorption is poor however, the parenteral route is associated with sever adverse reactions.

Anomalies of the Placenta

Anomalies of the Placenta The placenta is a thick, disk-shaped organ. This organ approximately weighs 500 g and is 15 to 20 cm in diameter and about 1.5 to 3.0 cm thick. Normally, its weight is approximately one sixth of the fetus. Placenta is a very important structure for the fetus as it is involved in metabolic, circulatory, respiratory and endocrine functions. It has two components, the maternal and fetal side. The maternal side is rough and it attaches to the uterine wall whilst the fetal portion is smooth with branching vessels covering the membrane-covered surface. This fetal structure is always examined for the presence of anomaly. Injury of placental portions can lead to serious fetal demise if left untreated.

(top) placenta succenturiata (middle) battledore placenta (bottom) velamentous insertion of the cord

Placenta succenturiata is a condition where one or more accessory lobes are connected to the main placenta by blood vessels. A succenturiate (accessory) lobe is either a second or third lobe that is quite smaller than the main

lobe. This smaller succenturiate portion often has areas of disorder or atrophy. Such accessory lobes by themselves are of no major consequence to the fetus. However, they could produce problems on delivery. Membranes in between the lobes of a succenturiate placenta can be torn during delivery resulting to massive blood loss. The small lobes can be retained in the uterus after delivery that could lead to severe maternal hemorrhage. This can be detected on inspection of the placenta at birth, where it appears torn at the edge. The remaining lobes must be removed from the uterus manually to prevent bleeding. Placenta Circumvallata Normally, the chorionic membranes are not covering the fetal side of the placenta. With placenta circumvallata, the fetal side (smooth portion) is covered to some extent with chorion. The placenta has a central depression on its fetal surface to the edge where fetal membranes are attached. The umbilical cord enters the placenta at the normal site, however, the blood vessels end abruptly at the point where the chorion folds back to the surface. No fetal abnormalities are associated with this type of placenta but it is necessary to note its presence. Battledore Placenta Naturally, the umbilical cord is inserted at the central portion of the placenta. Battledore placenta presents with a marginal cord insertion.

velamentous insertion of the cord

In this anomaly, the umbilical cord is inserted directly to the fetal membranes instead of inserting to the middle of the placenta. The cord then travels to the membranes of the placenta where the exposed vessels are not protected by Whartons jelly which poses a high risk of rupture. This condition may be associated with fetal anomalies. Vasa Previa If the umbilical vessels of a velamentous cord insertion cross the cervical os that causes it to be delivered first before the fetus is a condition called vasa previa. Cervical dilatation may tear the blood vessels that would result to fetal blood loss. If vasa previa is identified a cesarean section is done to deliver the fetus.

Theories of Labor Onset

Theories of Labor Onset Labor is a coordinated sequence of involuntary, intermittent uterine contractions. It is the series of events that expels the fetus and placenta out of the mothers body. This is made possible by the presence of uterine contractions and abdominal pressure that push the fetus out during the expulsion period of delivery. Regular contractions result to gradual cervical effacement and dilatation. Adequate pressure from abdominal muscles allows the baby to be pushed outside the mothers womb. Labor and delivery require a woman to utilize her coping methods psychologically and physiologically. Normally, labor begins when the fetus reaches a mature age (38-42 weeks age of gestation). This is to ensure survival of the fetus with the extrauterine life. The mechanism that converts Braxton Hicks Contractions (painless contractions) to strong and coordinated uterine contractions is unknown. In some cases, labor occurs before the fetus reaches the mature age (preterm birth) while in others it is delayed (postterm birth). Although the exact mechanism that initiates labor is unknown. Theories have been proposed to explain how and why labor occurs.

Uterine Stretch theory

The idea is based on the concept that any hollow body organ when stretched to its capacity will inevitably contract to expel its contents. The uterus, which is a hollow muscular organ, becomes stretched due to the growing fetal

structures. In return, the pressure increases causing physiologic changes (uterine contractions) that initiate labor. Oxytocin theory Pressure on the cervix stimulates the hypophysis to release oxytocin from the maternal posteriorpituitary gland. As pregnancy advances, the uterus becomes more sensitive to oxytocin. Presence of this hormone causes the initiation

of contraction of the smooth muscles of the body (uterus is composed of smooth muscles). Progesterone deprivation theory Progesterone is the hormone designed to promote pregnancy. It is believed that presence of this hormone inhibits uterine motility. As pregnancy advances, changes in the relative effects estrogen and progesterone encourage the onset of labor. A marked increase in estrogen level is noted in relation to progesterone, making the latter hormone less effective in controlling rhythmic uterine contractions. Also, in later pregnancy, rising fetal cortisol levels inhibit

progesterone production from the placenta. Reduce progesterone formation initiates labor. Prostaglandin theory In the latter part of pregnancy, fetal membranes and uterine decidua increase prostaglandin levels. This hormone is secreted from the lower area of the fetal membrane (forebag). A decrease in progesterone amount also elevates the

prostaglandin level. Synthesis of prostaglandin, in return, causes uterine contraction thus, labor is initiated. Theory of Aging Placenta Advance placental age decreases blood supply to the uterus. This event triggers uterine contractions, thereby, starting the labor.

Neonatal Gastrointestinal Adaptation Processes

Neonatal Gastrointestinal Adaptation Processes In fetal life the placenta is performing the function of the gastrointestinal system. After delivery, newborns must take in, digest and absorb food as placenta no longer performs these functions. Stomach Gastric emptying may be delayed at first in neonates. A neonates gastric capacity is about 6 ml/kg at birth. However, it may expand to approximately 90 ml in the first week. Gastric emptying in breastfed newborns is more rapid than the formula fed babies. When milk hits the stomach and fills it, gastrocolic reflex is triggered. The gastrocolic reflex or gastrocolic response is a physiological reflex that contributes in controlling gastrointestinal motility and peristalsis. This is the one that signals the colon to empty when food hits the stomach. The reason why infants usually pass a stool after feeding is because of the said mechanism. Intestines The newborns intestines are quite long in relation to the infants size. This length allows for extra surface area of absorption. However, the longer intestines make infants more prone to water loss. Thats why diarrhea is usually observed in infants. At birth the intestines are sterile. When a neonate is exposed to the extrauterine environment and starts taking in fluids (feeding), entry of bacteria to the intestinal tract occurs. Normal intestinal flora is established within the first few days of life. Bowel sounds, on the other hand, are present within the first few hours. Digestive Enzymes Pancreatic amylase, the enzyme responsible for digesting complex carbohydrates, has inadequate levels for the first 4 to 6 months of life. This enzyme can also be produced in the salivary glands but only in low amounts until the third month. Thus, an infant can start taking in complex carbohydrates (such as cereals) by about 4 to 6 months of age due to the said reason. Amylase is also found in breast milk.

Pancreatic lipase is also deficient in newborns. This enzyme is responsible for fat digestion and absorption. Lipase is also found in breast milk making it more digestible than the formula milk. Stools Meconium the first stool excreted by the neonate. It consists of particles from the fetal structure such as vernix, skin cells, cells shed from the fetal intestinal tract, bile and other intestinal secretions. The color of this defecated material is greenish black with a thick, tarlike and sticky consistency. This stool accumulates into the fetal GI tract throughout gestation. Neonates usually pass meconium within the first 12 to 48 hours. Transitional Stool mixture of meconium and milk stools. Color is greenish-brown and consistency is looser than the meconium. This is the second stool that is excreted by the neonates. Milk Stools stools of infants that vary with the type of milk ingested:

Breastfed Infants

Breast milk stools are seedy with the color and consistency resembling to that of mustard with a sweet-sour smell. Babies who are breast-fed pass stools more frequently than formula-fed. Normal breastfed newborn passes at least three stools daily. Formula-fed Infants A formula-fed infant has a pale yellow to light brown stools. The consistency is firmer than the breastfed infants and has a characteristic odor of feces. The infant may excrete only one or two stools daily.

Neonatal Cardiovascular Adaptation Process

Neonatal Cardiovascular Adaptation Process During fetal life three accessories ductus venosus, foramen ovale, ductus arteriosus areplaying a major role in circulation (see section on fetal circulation). After delivery, changes in the circulatory pattern are occurring in a neonates body. Alterations in the blood oxygen level, shifting of pressure in the left side of the heart and clamping of the cord all contributes to the cardiovascular adaptation of a neonate. These events occur within few minutes after birth. Ductus Venosus Ductus venosus (DV) is an opening between the umbilical vein and the liver shunting blood directly to the inferior vena cava. At birth, when the umbilical cord is clamped blood supply in DV is halted thus, closing the structure. Fibrosis of ductus venosus forms ligamentum venosum. Foramen Ovale Foramen Ovale (FO) is a flap in the septum between the right and the left atrium. This fetal accessory opens only from the right side to the left side of the heart. It remains to be open in the intrauterine life because of the difference of the pressure in the left and the right side of the heart (right side has higher pressure in fetus). Thus, increased left side of the heart pressure at birth contributes to the closure of the foramen ovale. Once it is permanently close, it is called fossa ovale. Ductus Arteriosus The dilated portion in the pulmonary artery and aorta in fetal life is called a ductus arteriosus (DA). Blood no longer needs to enter the immature fetal lungs for oxygenation since exchange of gases already occurred in the placenta. Increase prostaglandin also contributes to the opening of this structure. Hence, decrease prostaglandin levels once the neonate is no longer influenced by the maternal hormones can contribute to its closure. Elevated oxygen levels also after the initiation of respiration constrict the ductus arteriosus. Once closed, it is then called ligamentum arteriosum. Summary of fetal structures and mechanisms of its changes at birth

Fetal structure Ductus

Purpose of presence in fetal life Shunts blood

Causes of Mechanisms of closure closure at birth Clamping of Blood flow stops from the

Venosus (DV)

Foramen Ovale

1. As the cord is clamped systemic resistance is elevated which results to increase pressure of the left side of the heart. 2. Decreased pulmonary resistance also allows free blood to enter the lungs thus, decreasing the pressure of the right side of the heart and increasing the left sides pressure. Pulmonary Narrowed to Initiation of 1. Initiating respirations bloodvessels increase the respirations elevates the blood oxygen resistance of (first breath) level and relives the fetal blood flow to lung fluid. the lungs 2. Presence of oxygen dilates the bloodvessels in the lungs. 3. Dilation of lung blood vesselsdecreases the pulmonary resistance allowing blood to enter freely in the lungs to be oxygenated. Ductus Dilated portion Increase 1. Elevated oxygen levels Arteriosus between the oxygen level constrict the ductus (DA) pulmonary in the blood. arteriosus. artery and the Decrease 2. As the neonate is no longer aorta to bypass prostaglandin influenced by the maternal blood from the levels. hormones prostaglandin nonfunctioning level in the newborns body fetal lungs decreases causing the DA to close.

away from the the cord immature liver to the inferior vena cava Opening Increase between right pressure of atrium and left the left side atrium to of the heart bypass the blood from the nonfunctioning lungs

placenta via the umbilical vein to the ductus venosus

Neonatal Respiratory Adaptation Processes

Neonatal Respiratory Adaptation Processes The major and first essential task of a neonate at birth is completing the initiation of respiration. If respiration is halted at birth it can lead to severe and fatal conditions to the neonate. Before proceeding to the mechanisms on how a neonates respiration is accomplished let us first take a look on the physiology of the fetal lung. Fetal Lungs During the intrauterine life, fetal lung fluid is produced by the alveoli to expand it and to promote normal lung development. Some of this fluid empties into the amniotic fluid. This fluid is continuously produced at a rate of 4-6 ml/hg/hr with an overall volume of 20-30 ml/kg (the approximate amount of residual capacity after delivery). Another purpose of the fluid is to increase the pulmonary resistance to prevent a large amount of blood from the entering the lungs, since exchange of gases takes place in the placenta not the fetal lung. Surfactant, a slippery, detergent-like lipoprotein is produced by the fetal lungs at about 22 weeks age of gestation. The main purpose of surfactant is to reduce the surface tension within the alveoli which allows the alveoli to remain partially open when the neonate begins to breathe after birth. At 34-36 weeks age of gestation adequate surfactant is already present in the fetal lungs to allow a neonate born at that time to breathe without difficulty. Respirations at birth As the pregnancy advances, the fetal lung fluid production decreases leaving only about 35% of the original amount. During labor the fetal lung fluid moves to the interstitial spaces around the alveoli, where it is absorbed, so that air can enter the respiratory tract. The process of absorption is escalated by the presence of fetal epinephrine secreted. Removal of fluid in the alveoli decreases pulmonary resistance that allows flow of air in the lungs. Throughout labor, delivery and after birth the production of surfactant increases to adjust to the indifferent extrauterine life. The first breath forces the fetal lung fluid into the interstitial spaces to enhance the advent of breathing in air. To push more fetal lung fluid on the interstitial spaces a much larger negative pressure is done by suctioning. There are several factors that contribute to the initiation of respiration in neonates. These factors are triggered by both external and internal stimuli. Chemical Factors (internal stimuli) Stimuli: Changes in blood chemistry (decrease O2, increase CO2, decrease pH) At birth, a decrease oxygen level is circulating in a neonates body. The carbon dioxide then increases leading to an acidic pH. These events cause impulses of the chemoreceptors of carotid artery and aorta to stimulate the respiratory center in the medulla. In response to this, the diaphragm is triggered to contract causing the air to enter the lungs. Mechanical Factor (external stimuli) During vaginal delivery the compression of the fetal chest by the narrow birth canal forces small amount of fetal lung fluid to be pushed out of the lungs to the upper airway channels. This fluid is then suctioned in the mouth and nose of a neonate as the head emerges from the vagina. When the pressure from the chest is released the chest draws in air into the lungs. Thermal Factor (external stimuli)

Intrauterine temperature is warm. At birth, when the neonate moves into a cooler environment, sensors of the skin transmit impulses to the brain to stimulate the respiratory center, thus, breathing is initiated. Sensory Factor (external stimuli) This pertains to the tactile stimulation on the neonate at birth. Holding, drying, wrapping of neonates in blankets further stimulates the skin sensors to transmit impulses to the brain to stimulate the respiratory center and breathing. Sustaining of Respirations Because the alveoli remain partially expanded (work of surfactant), following breaths of the neonate is already done with less effort than the firth one. As newborn cries, more fetal lung fluid is forced out into the interstitial spaces where it is absorbed by the pulmonary and lymphatic circulation.

Lamaze Childbirth Method

Lamaze Childbirth Method Definition Lamaze method is a prepared labor and delivery technique. It is often called psychoprophylactic method as it uses the mind (psyche) to prevent labor pains (prophylaxis). History Lamaze childbirth method is an alternative to the use of medical intervention during childbirth. The method was originally developed in Russia (based on Pavlovs conditioning studies) but was popularized by a French obstetrician Dr. Ferdinand Lamaze. After watching a woman gave birth in Russia Dr. Lamaze developed his own system of painless childbirth. Theory The Lamaze method of prepared childbirth is based on the gating control theory of pain relief. It involves concentration and conditioning to help the woman respond to contractions with relaxation from techniques thereby alleviating pain. This is based on the theory that through stimulus-response conditioning, women can learn to use controlled breathing to reduce the painin the labor. Lamaze method is the most popular approach used to today. Techniques and Methods Gating Control Theory of Pain The gating theory of pain refers to gate control mechanisms in the substantia gelatinosa that has the ability to stop an impulse at the level of the spinal cord so the never would not reach the brain as pain. This process is similar to that of closing a gate. The following techniques are used to assist gating mechanism: Cutaneous stimulation This technique involves: 1. Effleurage slow massage of the abdomen during contractions. The massage is done with just enough pressure to avoid tickling. The woman can perform effleurage using her fingertips and tracing a pattern on her abdomen. Massage and pressure on the palms and fingertips stimulate the large diameter nerves to decrease the ability of 2. 3. the small nerve fibers at the site of pain to transmit impulses. Sacral Pressure firm pressure against the sacral area may help relieve strain on thesacroiliac joint. The partner (husband) can increase the pressure on the sacrum as soon as the contraction begins. Thermal stimulation application of heat and cold stimulates the thermoreceptors thereby decreasing pain felt by the woman. This is done by wiping the womans face with cool cloths and ice chips offered to the woman for eating. In early labor a warm shower directed against the back may be soothing. Positioning position changes during labor also provides cutaneous stimulation. Ambulation and fowlers position makes contractions less painful. Changing position can be done every 30-60 minutes to increase comfort. Distraction

4.

An impulse cannot register in the brain if it is distracted. Techniques of distraction are as follows:

1. 2. 3. 4.

Breathing techniques Focal point a focal point is an object in which the woman focuses during contractions to help her direct her thoughts away from the contractions. Imagery Music Reduction of anxiety Giving the woman idea of what to expect during labor

1.

2. Presence of a support person (husband) Concepts stressed in Lamaze method 1. 2. 3. 4. 5. 6. Labor should not be induced Women should move freely during labor A continuous support should be available for the woman No routine interventions should be done (IV fluids) Woman should change position during labor The newborn and mother should stay in the same room after birth and breastfeedingopportunity should be unlimited

Grantly Dick-Read Childbirth Method

Grantly Dick-Read Childbirth Method Overview Childbirth education classes allow expectant mothers to spend time with other pregnant women who are experiencing the same fears and discomforts for the upcoming labor and delivery. Nowadays, couples are attending specific types of childbirth education classes for several reasons. One of these is to prepare themselves for labor and delivery. Others are just tagged by friends and there are some who are just joining the sessions because they know they have to. To sum it up, people are joining childbirth education classes because they want become oriented about the upcoming event in their lives (labor and delivery) and they want to make the moment as a much as possible comfortable and valuable both for the newborn and the mother herself. There are different theories governing the childbirth methods. All of these techniques help expectant couples to anticipate and prepare for what to expect during labor and delivery. Though the theories are different all the childbirth methods are promoting comfort and relaxation to the mothers and newborns making the event a less stressful and fulfilling experience. Definition Grantly Dick-read Method is a psychophysiological preparation for childbirth. This technique alleviates pain during childbirth by blocking feelings of fear and tension. History Dr. Grantly Dick-Read is an English obstetrician who was practicing medicine in 1900s. To alleviate pain during childbirth Dr. Dick-Read was administering chloroform (generally given routine in those times during the last stage of labor) to women. One woman whom Dr. Dick-Read handled refused chloroform for pain relief. After this woman gave birth, the gynecologists curiosity led him to ask why she had not accepted the drug. The woman responded that it did not hurt since delivery was not meant to injure and hurt women. The womans experience of a painless delivery without taking chloroform led Dr. Grantly Dick-Read to study and observe about childbirth in natural process. He wrote these observations and data in a manuscript entitled, Natural childbirth. His work brought personal and professional ridicule, but that did not stop him from sharing his thoughts and beliefs.

On 1933 his book, Childbirth without Fear, was published. He explained in this publication that no physiological function in a persons body can give rise to pain under the condition that it is of normal course of health. Unless a disease process is taking place, pain or agony would associate delivery. Theory Women who had been prepared for childbirth still experience pain because of fears associated with the event. Dr. Dick-Read postulated that this fear felt by women during delivery causes the blood to be carried away from the uterus to be used by the muscles needing it due to perceivedpain. This results to an unoxygenated uterus which would be unable to perform its function well leading to pain, a phenomenon called the fear-tension-pain syndrome. Dick-Read believed that presence of fear and tension result to labor pains. Thus, eliminating fear would increase blood supply to the uterus and alleviating labor pains. He also identified that laboring women needed constant emotional support to help them cope. Technique To prevent the fear-tension-pain cycle Dick-Read developed a method of slow abdominal breathing in the early stage of labor and rapid chest breathing in the latter stage. A woman should break the chain of events occurring (between fear and tension or tension and pain) to reduce thepain during contractions. Relaxation, comfort and minimal pain are achieved only if the woman focuses on abdominal breathing during contractions.

Leboyer Childbirth Method

LeBoyer Childbirth Method Childbirth education is an essential part of a successful, safe and comfortable delivery. Although all methods of childbirth education utilize different techniques they all contribute to promoting comfort during childbirth. Definition Leboyer childbirth method sometimes termed as birth without violence, views birth as a stressful experience for the newborn. The focus of this method is to primarily improve the quality of the birth experience for the baby. History Leboyer childbirth method was introduced by Frederick Leboyer. He is a French obstetrician who believed that the traditional hospital births of the time (1975) were traumatic for the infant. In 1975, he published a book entitled Birth without Violence, where depth of a newborns sensitivity and the importance of how the baby is handled by the people around him were emphasized. He pointed out that babies born in a less stressful environment were more content. Leboyer postulated that moving from a warm, fluid-filled intrauterine environment to a noisy, air-filled, brightly lit extrauterine environment creates a major distress to the newborn. He believed that holding a newborn upside down at birth and cutting his/her cord immediately from the mother is not beneficial to the baby. In his view, the newborns senses are intact at birth and intense sensations at birth such as by slapping the babys buttocks are vividly perceived. He emphasized that a sensitive, unobtrusive technique of care, respecting the natural process and promoting a peaceful atmosphere at birth will help the baby to be born with a minimum stress. Leboyer Method or Technique Leboyer childhood method or birth without violence, creates an environment of serenity and peacefulness. To decrease the trauma at birth this technique is an advocate of the following:

The birthing room is darkened or dimmed. Doing so prevents sudden contrast of light that might distress the newborn. Leboyer thought that this is less shocking for the neonates eyes that have been in semi-darkness for several months. A soft music is played or at least harsh noises are kept to a minimum. All the talking inside the delivery room is done by whispering.

The room is kept pleasantly warm, not chilled, to help the newborn be comfortable with the new environment and adapt to extrauterine life more easily. Newborns are handled gently and carefully. Leboyer recommends not pulling the babys head to completely allow a natural childbirth. The umbilical cord is cut late (It is cut after it has stopped pulsating). According to Leboyer, this allows the newborn to continue receiving the maternal hormones and oxygen carrying red blood cells. This is also done to allow the baby to breathe when he is ready and not have to be rushed.

The infant receives a warm bath immediately after birth for relaxation. Before maternal and newborn bonding is done, the infant is massage to ease crying. Nowadays, mothers do this massaging to encourage immediate bonding. Placing the infant in the mothers abdomen is done for maternal-neonate bonding.

Since fewer drugs are given to the mother during delivery with this method babies are typically more alert and need less invasive measures to help them breathe. Opponents to Leboyer Method Some neonatologists are questioning the principle of warm bath because doing so can reduce spontaneous respiration and allows a high level of acidosis can occur. Cutting of the cod until it stops pulsating can lead to excess RBC in the neonates circulatory system that could lead to extra blood viscosity and increased risk of jaundice.

Bradley Childbirth Method

Bradley Childbirth Method Definition Bradley childbirth method was the first technique to include the father as a support person during delivery. This method embraces the belief that childbirth is a natural event and with the right preparation most women can have spontaneous and unmedicated vaginal births. History Bradley Method was named after an American obstetrician Dr. Robert Bradley. Husband Coached Childbirth, was written by Dr. Bradley and his principles and theories paved the way for fathers to be present in the delivery room. This changed the face of childbirth around the globe. Theory Dr. Robert Bradley believed that birth is a joyful natural process and women can handle it without drugs or medical interventions. He is also an advocate to the idea that husbands are vital factors in the birthing process and early newborn period. Aside from avoiding all medications and other interventions, relaxation techniques such as abdominal breathing and breath control is taught usually for 12 weeks. Techniques and Methods During pregnancy, a woman performs exercises to tone the muscles and omit if not minimize foods that contains preservatives, fats and salt. She should also takes early birth classesfollowed by weekly sessions on the sixth month until birth. The husband should actively participate during these sessions and in delivery. Throughout labor, the woman is advised to walk and use an internal focus point as a dissociation technique. Relaxation and natural breathing techniques are also employed at this point. However, there is no patterned breathing with this method. The women are just taught to breathe deeply within their abdomen. After delivery, immediate maternal-newborn bonding is promoted and breastfeeding is encouraged. Still the husband is actively participating up to this time. Bradley Method Class

The Bradley program lasts for about 12 weeks. The philosophy of this method believes that it takes months to prepare the couple not only for childbirth but also for parenting. It takes pride in addressing all aspects of natural childbirth (mentally, physically and emotionally). The course is an advocate on educating the husbands to be an effective coach to their wives. The following concepts are taught in Bradley Classes:

Natural birth process Active involvement of the husband as a coach Proper nutrition during pregnancy Avoidance of drugs throughout the pregnancy Natural breathing methods (without patterns) Coaching techniques Natural pain coping methods Maternal-newborn bonding Breastfeeding Education on emergent situations throughout pregnancy and delivery (CS) Postpartum and newborn care Responsible parenthood

The physiology of labor and delivery is discussed in one of the sessions with emphasis on making the expectant mothers to believe that birth can be a joyful and natural process without drug administration and medical interventions.

Bradley Childbirth Method

Bradley Childbirth Method Definition Bradley childbirth method was the first technique to include the father as a support person during delivery. This method embraces the belief that childbirth is a natural event and with the right preparation most women can have spontaneous and unmedicated vaginal births. History Bradley Method was named after an American obstetrician Dr. Robert Bradley. Husband Coached Childbirth, was written by Dr. Bradley and his principles and theories paved the way for fathers to be present in the delivery room. This changed the face of childbirth around the globe. Theory Dr. Robert Bradley believed that birth is a joyful natural process and women can handle it without drugs or medical interventions. He is also an advocate to the idea that husbands are vital factors in the birthing process and early newborn period. Aside from avoiding all medications and other interventions, relaxation techniques such as abdominal breathing and breath control is taught usually for 12 weeks. Techniques and Methods During pregnancy, a woman performs exercises to tone the muscles and omit if not minimize foods that contains preservatives, fats and salt. She should also takes early birth classesfollowed by weekly sessions on the sixth month until birth. The husband should actively participate during these sessions and in delivery. Throughout labor, the woman is advised to walk and use an internal focus point as a dissociation technique. Relaxation and natural breathing techniques are also employed at this point. However, there is no patterned breathing with this method. The women are just taught to breathe deeply within their abdomen. After delivery, immediate maternal-newborn bonding is promoted and breastfeeding is encouraged. Still the husband is actively participating up to this time. Bradley Method Class

The Bradley program lasts for about 12 weeks. The philosophy of this method believes that it takes months to prepare the couple not only for childbirth but also for parenting. It takes pride in addressing all aspects of natural childbirth (mentally, physically and emotionally). The course is an advocate on educating the husbands to be an effective coach to their wives. The following concepts are taught in Bradley Classes:

Natural birth process Active involvement of the husband as a coach Proper nutrition during pregnancy Avoidance of drugs throughout the pregnancy Natural breathing methods (without patterns) Coaching techniques Natural pain coping methods Maternal-newborn bonding Breastfeeding Education on emergent situations throughout pregnancy and delivery (CS) Postpartum and newborn care Responsible parenthood

The physiology of labor and delivery is discussed in one of the sessions with emphasis on making the expectant mothers to believe that birth can be a joyful and natural process without drug administration and medical interventions.

Tay-Sachs Disease
Tay-Sachs Disease Definition Tay-Sachs disease (TSD), also known as Hexosaminidase A Deficiency or GM2 gangliosidosis, is a rare inherited metabolic disorder. In this disorder the affected persons body is unable to metabolize lipids that results to its accumulation in the tissues and nerve cells of the brain. Incidence This inborn error of metabolism is primarily found in Ashkenazi Jewish population (Eastern European Jewish ancestry). Cause Tay-Sachs disease (TSD) is an inherited disorder that follows an autosomal recessive pattern. If both parents are carriers (mother and father), the following probability of disorder incidence will occur: 25% chance of having a child with the disease

25% chance of having a normal child 50% chance of having a carrier child

If either the mother or the father is the carrier, any of their children will not have the Tay-Sachs disease but will be carrier.

50% chance of having a carrier child 50% chance of having a normal child Pathophysiology Hexosaminidase A is an enzyme necessary for lipid metabolism. This enzyme catalyzes the biodegradation of acidic fatty materials known as gangliosides. Absence of Hexosaminidase A results to accumulation of ganglioside GM2 into the tissues and nerve cells leading to cognitive challenge due to buildup on brain cells and blindness due to deposits on optic nerve cells. Types Infantile TSD

Neonates with Tay-Sachs disease develop normally for the first 3 to 6 months of life. As nerve cells swell up with buildup of gangliosides, a persistent mental and physical deterioration occurs. Progressively, the baby will lose the ability to see, hear and move. Muscle atrophy will begin leading to inability to swallow and later paralysis. A red spot at the back of the childs eye will develop. Most children die of pneumonia and cachexia (malnutrition) by age 3 to 5 years. Juvenile TSD This is an extremely rare type of TSD. In Juvenile TSD, the signs and symptoms are observed between 2 to 10 years. Cognitive, motor, speech difficulties (dysarthria), difficulty swallowing (Dysphagia), unsteady gait (ataxia) and spasticity are observed in affected children. The disease progresses more slowly but death usually occurs by the time the child is 5 to 15 years of age. Adult or Late Onset TSD (LOTS) Late Onset TSD (LOTS) occurs in patients between 20 to 30 years of age. This is a rare form of TSD that is frequently misdiagnosed and more often non-fatal. It is characterized by an unsteady gait (ataxia) and a progressive neurological deterioration. Diagnosis

Simple blood test Chorionic Villus Sampling (prenatal)

Amniocentesis (prenatal) Clinical Manifestations Before 6 months Extreme Moro Reflex

Mild hypotonia At about 6 months

cherry red macula at the eye of a child with TSD

Loses head control Inability to sit up and roll over

Cherry red macula noticeable during ophthalmic examination By 1 year Spasticity Inability to perform simple motor tasks

Dysphagia By 2 years or more Generalized seizures Blindness Hearing difficulties

Paralysis Malnutrition (cachexia) Cognitive deterioration

Dysarthria Ataxia Management There is no cure for Tay-Sachs disease, however physicians may prescribe medications to relieve pain, manage seizures, and control muscle spasticity.

Galactosemia
Galactosemia Definition Galactosemia is an inherited carbohydrate metabolism disorder. This metabolic disorder is characterized by the abnormal levels of galactose in the blood (galactosemia) and in the urine (galactosuria). People with this disorder are unable to breakdown the simple sugar galactose to glucose. Incidence This inborn error of metabolism occurs 1 in every 60,000 births. Higher incidence rate is noted in Ireland with about 1 case in every 20,000 population. It is less common in Asian people. Causes Galactosemia follows an autosomal recessive mode of inheritance that is typified by the absence or deficiency of any of the three enzymes that are involved in galactose to glucose conversion which are: Galactokinase uncommon Galactose 1-phosphate uridyltransferase or GALT most common deficiency Uridine diphosphate (UDP)-galactose4-epimerase or GALE uncommon

Physiology Galactose, a type of sugar, has to be converted to glucose before it can be used by the body. Lactose, the sugar found in milk, is normally broken down into galactose and glucose. 1. Galactokinase (GALK) converts galactose to galactose 1-phosphate. 2. Galactose 1-phosphate uridyltransferase (or GALT) converts galactose 1-phosphate to UDP galactose. It also converts UDP glucose to glucose 1-phosphate. 3. Finally, Uridine diphosphate (UDP)-galactose 4-epimerase (or GALE) converts UDP galactose to UDP glucose to be used by the body.

To summarize, the order of galactose conversion in its metabolic pathway in relation to the enzymes it encounters starts with GALK then GALT and finally GALE. Types of Galactosemia Type 1 characterized by absence of the liver enzyme GALT. It is termed as the classic galactosemia. This is the most common type. People with absent or deficient GALT have intolerance to galactose. Type 2 characterized by the absence of the enzyme Galactokinase (GALK). It is called as galactokinase deficiency. Type 3 characterized by absence of the enzyme GALE. This form of galactosemia is termed as UDP-Galactose-4epimerase deficiency. Pathophysiology Absence or deficiency of galactose 1-phosphate uridyltransferase (GALT) prevents the conversion of galactose into glucose. When an infant or neonate is given milk (formula milk or breast milk), the substances made from galactose builds up in the bloodstream (galactosemia) and spills into the urine (galactosuria). These can cause severe damage to the eyes, kidneys, liver and brain. Diagnosis Beutlers test a screening test used to analyzed the cord blood if a child is known to be at risk for the disorder. Newborn Screening Test a heel puncture test done in newborns.

Clinical Manifestations

The symptoms begin to appear when the neonate is started on formula feeding or breastfeeding. Lethargy Hypotonia Diarrhea

Vomiting The symptoms start abruptly and develop rapidly leading to further manifestations: Hepatomegaly liver enlarges Persistent jaundice Bilateral cataracts Brain damage Ascites fluid in the abdomen Galactosuria galactose in urine

Untreated neonates may die by 3 days of age. Those who survived beyond the untreated 3 days may have bilateral cataracts and will be cognitively challenged. Management Early detection prevents fatal complications. Timely identification and management of galactosemia prevents brain damage. Any neurologic or cataract damage present before the treatment will persist.

Galactose-free diet for life Milk substitute such as casein hydrolysates (Nutraminogen)

Accutane (Isotretinion) on Birth Defects

Accutane is a form of vitamin A or of Isotrenition. It is marketed since 1982 to reduce the amount of oil released by oil glands in the skin, and helps the skinrenew itself more [Link] is used to treat severenodular acne. It is usually given after other acne medicines or antibiotics have been tried without successful treatment of symptoms. However, it is well document on researches that excessive intake of Vitamin A has something to do with miscarriage and congenital anomalies. Women at any time of conception or during pregnancy, regardless of the length of exposure to this substance is in great risk of experiencing fetal abnormal development. Congenital anomalies include: 1. Crainofacial anomalies like lacking of ears, abnormally smaller jaw, cleft palate, misshapen skull, small eyes 2. 3. (micropthalmia), Cardiac anomalies like congestive heart failure Central Nervous System anomalies like facial and muscle paralysis, hydrocephalus, small head (microcephaly) These are severe, life-threatening birth defects. That is why it is our role as nurses to help doctors in the assessment stage to have a thorough drug history for clients having signs of pregnancy. Accutane is strictly prohibit during pregnancy. Nursing Considerations: 1. 2. 3. 4. Assess properly during the drug history to enable to know if the client uses Isotrenition or taking vitamin A supplements. Teach the client to refrain from using such substances during pregnancy due to harmful severe effects to the fetus and fetal development. Apply comforting measures and non-teratogenic measures for mothers experiencing acne as well as relief from oily skin caused by hormonal changes during pregnancy. Give more importance to incorporate knowledge about the harmful effects of this chemical to pregnancy and would-be mothers.

Intrauterine Reproductive Development

Physiology of Intrauterine Reproductive Development The genetic sex of an individual is determined at conception. The sperm contains either an X or Y chromosome while the ovum always carries an X [Link] is the process where the union ofegg and sperm cell occur. If a sperm containing an X chromosome fertilizes the ovum (X), the resulting zygote will become achromosomal female (XX). But if the inherited chromosome from the father is Y combined with X from the mother the result will be agenetic male (XY). Thus, it is the father that determines the sex of the baby.

Gonads are body organs that produce sex cells in an individual. It is ovaries in females and testes in males. Several processes take place in the utero before gonads are formed and fetal external genitalia are differentiated to male and female. 1. Primitive gonadal tissue is the first component of gonads formed at about 5 weeks of intrauterine life. During this time male and female reproductive system still looks similar or sexually undifferentiated. 2. In both sexes, still at 5 weeks I.U. life, two indistinguishable ducts are formed and present. The first is called

3. 4. 5.

a mesonephric and the other is paramesonephric duct. Mesonephric or also called a Wolffian duct is a pair of organ found during intrauterine period that connects the primitive kidney to cloaca (opening of reproductive tracts) and will develop into male reproductive organ. Paramesonephric or mullerian ductsare paired ducts present during the prenatal period that develops into female reproductive organs. At about 7-8 weeks, internal reproductive structures starts to develop. Primitive testes begin to differentiate in genetic males. Testes (testis is the singular form) are responsible for producing testosterone. In response to the presence of testosterone, themesonephric or Wolffian duct starts to develop into the male reproductive organs. Paramesonephric or mullerian duct on the other hand, undergoes degeneration. To easily remember because mesonephric duct starts with letter M, it is the structure that develops into male reproductive organs.

6. 7.

The external genitals continue to look similar until the ninth week. Around 10 weeks, if no testosterone would cause the differentiation of mesonephric duct, the primitive gonadal tissues will develop into ovaries. The paramesonephric or mullerian duct then progresses to become the female reproductive organs. It is during this time that alloocytes (immature female reproductive cells) are formed inside

8. 9.

the ovaries. Differentiation of external genitalia in both sexes is complete at approximately 12 weeks. The noticeable difference is noted because the influence of testosterone in male causes the penile tissue to elongate and the urogenital fold situated at the ventral portion of the peniscloses to form the urethra.

10. If no testosterone is detected in the system, the urogenital folds remains wide and apart (open) which forms the labia minora in females. The scrotal tissue in males is the one that develops as labia majora in females. 11. Though the external reproductive organs are already different at 12 weeks, to avoid false interpretation during ultrasonography, it is recommended to undergo the test in determining the sex of the fetus at the midpoint of pregnancy where further external sexual development takes place. However, some are assessing the gender of the baby at about 18-22 weeks age of gestation. More inaccurate results are reported with an ultrasound done before 18 weeks.

Ambiguous Genetalia

Ambiguous genitalia An ambiguous genital is a form of birth defect where the external genitalia do not normally present as either male or female. Sex of an individual is genetically determined during conception. However, external reproductive structures are not differentiated at this point. It is the sperm or the father that determines that sex of a baby. The sperm contains either an X or Y chromosome while the ovum always carries an X chromosome. An ovum (X) fertilized by a sperm with an X chromosome will result to a genetic female (XX). On the other hand, an ovum (X) fertilized by a sperm with Y chromosome will bring about a chromosomal male (XY). The reproductive system of both sexes is similar for the first six weeks of intrauterine life. Internal differences in male and female reproductive structures are occurring during the seventh week. External genitals look the same until 9 weeks, when external changes start to occur with either the presence or absence of testosterone. The differentiations of male and female external reproductive organs are completed by about 12 weeks age of gestation.

Ambiguity in external genitals can also be due to the following instances: Congenital adrenal hyperplasia In congenital adrenal hyperplasia (CAH), the adrenal gland is not producing enough cortisol and aldosterone but extremely supplies androgen (masculinizing hormone) in the body. This is an autosomal recessive inherited gene can cause a large clitoris in females, closed labial folds, no menses and breast development. The female baby at birth appears to have a penis with undescended testes. In males, the genitals appear normal at birth but sexual precocity

starts to occur by about 6 months where the penis is enlarged and pubic hair grows early. Sterility also is a complication in boys as absence of spermatogenesis is noted. Chromosomal abnormalities (Klinefelters syndrome and Turners syndrome) In Turners syndrome, only one chromosome X is present. Normally, there are 46 chromosomes in the body; however, with this chromosomal abnormality only 45 chromosomes are present. This leads to gonadal streak (underdeveloped gonadal structures) and sterility. Klinefelters syndrome presents with an extra X chromosome. A female is represented by an XXX chromosome while XXY for males. Occurrence of this abnormality results to small testes, gynecomastia and infertility. Mixed gonadal dysgenesis (MGD) MGD is the development of both male and female reproductive structures. The visible characteristic of reproductive

expression in an individual is unclear. Maternal intake of androgenic hormones If a woman has been taking a form of testosterone during pregnancy, a chromosomal female will present with a maleappearing genitalia. It is the influence of testosterone that causes the development of Mesonephric duct to form into

the internal male reproductive organs and the elongation of penile tissue externally forms the penis. Absent testosterone cellular receptors or Inappropriate testosterone production Without testosterone, the urogenital folds remain open forming the labia minora and the paramesonephric duct develops to form the internal female reproductive structures even if the baby is genetically determined as male. Therefore, formation of external reproductive structures is relatively dependent on the presence of testosterone even if the genetic composition is already established. Hermaphroditism If faulty cell division occurs after conception, mosaicism (presence of two cells) may occur. The baby may have both 46 XX and 46 XY chromosomes. This leads to the development of both male and female structures.

Sequential Pattern in Female Reproductive Cycle

Menstruation is the actual blood flow from the sloughing off of the uterine endothelium. The actual blood loss is due to progesterone withdrawal that occurs in the latter part of menstruation. The female reproductive cycle involves a sequential pattern of changes in the tropic hormones(hormones that stimulates an organ) which will cause a cyclic change in the female gonads (ovaries). Average cycle varies from woman to woman but it usually is 28, ranging from 20-45 days. The female reproductive cycle is further divided into two cycles that considers the changes in the uterus and ovaries. In obstetric nursing it is important to fully understand and if possible, memorize the menstrual cycle as it is the backbone of OB learning. However, before proceeding to the cycle stages, it is important to note that all the phases in a reproductive cycle is influenced by the functioning of four organs, namely:

Hypothalamus Anterior pituitary gland Ovaries Uterus

It is very essential to chronologically memorize these body organs to easily remember the sequence of changes that occurs recurrently in a womans body each month. Again, remembering these body parts in order would help one to fully understand the processes involve in a menstrual cycle. Now lets start. 1. Approximately three days after menstruation (actual blood flow), a dramatic decrease estrogen level would be noted. Extreme reduction of its level will stimulate the hypothalamusto produce Follicle Stimulating Hormone Releasing Factor (FSHRF), a tropic hormone indirectly related in estrogen production. 2. 3. 4. 5. FSHRF then triggers the Anterior Pituitary Gland to produce Follicle Stimulating Hormone (FSH). In response FSH goes to the ovaries and would cause release of the first ovarian hormone,estrogen. With the influence of estrogen, primordial follicles (immature cells incapable of fertilizationlocated at the cortex of the ovaries) are now called Graafian follicles. Estrogen in higher amount would cause rapid growth of the uterine lining (proliferation). Therefore, this phase is called a Proliferative phase because of the rapid growth of uterine lining. It is also termed as Estrogenic phase due to increase estrogen production andFollicular phase because of the presence of graafian follicle. Because this event occurs after the actual menstruation it is also called a Postmenstrual Phase and since ovulation has not occurred yet it can also be termed as Preovulatory phase (before ovulation). 6. 7. 8. 9. Estrogen increases fat deposition causing a woman to feel bloated. A significant decline of progesterone will stimulate the hypothalamus to stimulate to release of Luteinizing Hormone Releasing Factor. LHRF sets off the production of luteinizing hormone (LH) in the anterior pituitary gland. LH makes it way to the ovaries which in turn produces the second ovarian hormone,progesterone.

10. High levels of estrogen and progesterone would then cause the release of the mature ovum. This phenomenon known as ovulation exactly occurs 14 days before the next menstrual period. Meaning to say, in a 30 day cycle, ovulation occurs on the 16 day. In a 28 day cycle it is on the 14 day. The technique here is just to subtract 14 th from the number of cycle the woman has. (E.g. 30 days 14 = 16 day) 11. During ovulation the woman may feel pain in either right or left lower abdominal quadrant due to the pressure in the release of the ovum. This is called mittelschmerz. 12. Right after ovulation, Graafian follicle (a body containing high amounts of estrogen) with the influence of the escalating progesterone level will change its color to yellow and is now calledcorpus luteum. 13. Corpus luteum has a life span of about 8-10. Because follicles develop to corpus luteum (a body containing high amounts of progesterone), this stage is termed Luteal Phase and as the changes occurred after ovulation it is also called Postovulatory phase. Menses is expected in a fixed date (if no fertilization will occur) therefore it is also a premenstrual phase. 14. Progesterone causes increase blood supply, thickening and vascularity of the uterus. Capillaries are pooling down the uterine portions in preparation for possible implantation of zygote (the result of the fusion of DNA from
th th

sperm and egg). This is the reason why progesterone is called the hormone of pregnancy. However, if no fertilization would occur on the 8 to the 10 of corpus luteums lifespan, progesterone level starts to drop. 15. Progesterone diminution will cause alteration in corpus luteums color. Thus, it will turn white for the succeeding 3-4 days and is called corpus albicans. 16. Withdrawal of the progesterone hormone (on the 4 day of corpus albicans) would cause the sloughing off and rupture of capillaries in the uterus. Thus, actual blood flow then takes place.
th th th

Atopic Dermatitis (Infantile Eczema)

Atopic dermatitis or eczema is a common disease ofinfants, occurring as early as the second or six months of life. It is of unknown origin but speculations are noted that it may be related to food allergies and genetic factors. Heat and humidity (sweating), tight clothing, soap and other skin irritants may also trigger the onset of the illness. Eczema is a chronic disease, possibly lasting until one (1) to two (2) years of age. It is neither a contagious nor an infectious disease but infection may occur as a complication due to prolonged scratching that allows the bacteria to get through the skin. The word atopic denotes to a condition when an individual is highly sensitive to a particular thing (allergen) such as food, pollen, dust and molds. Dermatitis refers to skin inflammation. Incidence Prevalence appears to be high among: 1. Formula fed infants 2. Infants fed with solid food before 6 months 3. Family history with asthma and allergies Signs and symptoms With infantile eczema, an increase in capillary permeability occurs allowing more serous fluid to be extravasated out into the tissues. As a result, the baby will develop pink to red bumps orpapules that may contain fluid (vesicles). The vesicular eruptions may rupture and releases sticky and yellowish secretions. As the exudates dry, they form crusts on the infants skin. Extreme pruritus is one major characteristic of the eruptions that causes the child to scratch the lesion, thereby, further irritating and tearing the skin. Infection may occur due to uncontrolled scratching that forms open lesions. The child may have a fever (first sign of infection) and swollen wound. Aside from secondary infection, the child may exhibit irritability and may be overly noisy and restless. Generalized discomfort causes infant not to eat leading to poor nutritional intake. As the papulovesicular lesions are healing, the childs skin may become shiny (lichenified), dry and flaky. The common eruption sites are the following:

Scalp and forehead Cheeks Neck Behind the ears

Extensor surfaces of extremities (outer part of arms and skin) In most infants, the fist location of lesions is the cheek area. The palms of the hands and soles of the feet are not affected by the eruptions. Treatment Conservative Management

Preventing allergen exposure, if allergens can be identified.

Studies reveal that the most allergenic foods to infants are milk, eggs, wheat, chocolate, fish, tomatoes, and peanuts.

One to two weeks (1-2) weeks interval when introducing solid foods is one way to determine the food that may cause

eczema. Reducing pruritus to prevent secondary infections. Skin hydration is done by bathing the infant or applying wet dressing with tap water or Burrows solution for 15-20 minutes. Hydrating emollient application can be used like petroleum jelly (Vaseline) or vegetableshortening. Select cotton fabrics for the infants clothing. Tight clothing increases pruritus.

Preventing secondary infection Keep the infants fingernails short and clean. Use infant mittens. Monitor for signs of infection (e.g. fever) to promote prompt treatment. Medical Management

1. 2. 3. 4. 5.

Antihistamines (reduces itching) Topical steroids 1% hydrocortisone cream to reduce inflammation and pruritus. For dry lesions use a corticosteroid ointment with an occlusive dressing overnight. For moist lesions use a lotion with an occlusive dressing overnight. For infected lesions hydrocortisone mixed with antibiotic (Neomycin)

Roles of a Pediatric Nurse

Pediatric nurses nowadays serves a variety of roles, fromteaching in various setting to rendering hands-on care inhospitals or clinic. Taking care of children involves self-awareness that one must be patient enough about kids as well as consider the fundamentals of child psychology especially the developmental stages. Since children could not sometimes utter what they really felt whenever they are sick, careful assessment and an experienced clinical eye must be employed. It may sound too complex, but beyond the grimaces and cries of children comes their angelic faces smiling at you when you will be able to talk their language. Their parents and caregivers are the next people who must be well taken cared of in terms of proper health teaching since they will be the primary caregivers once children will return to thier community. Here are some of the important roles of a pediatric nurse: A. Family Advocate Nurses are expected to be sensible enough in voicing out the needs of their patients and folks in behalf of them when it is impossible for them to readily address their needs. B. Health Promoter Nurses prefer measures to prevent diseases rather than waiting for it to be complicated. They are the ones responsible enough to guide the parents to promote proper nutrition, updated immunizations, and early detection of health problems. It is their primary responsibility to ensure the normal growth and development of children so that they can perform daily activities to its optimum level. C. Health teacher Health teaching is very basic for nurses since they are the ones responsible for monitoring the patients as well as carry out the physicians discharge orders. It is then a must to anticipate parents to ask for ways to improve their childrens health such as parenting and disease process so as to prevent future hospital admission as much as possible. D. Counselor Nurses must be active listeners in order to establish a therapeutic relationshipbetween parents and the child, making health care plans easier. E. Researcher- Change is constant in the health care setting, so it is a must to practice evidenced-based practice. This means that pediatric nurses should have the ability to improve themselves in order to give updated care. F. Coordinator / Collaborator Pediatric nurses are sometimes or most of the member of the health team, so he or she might be in a position wherein he or she is the avenue of important information that other health team members need in delivering competent care. So it is a must that pediatric nurses need to be a good information giver and communicator among health team members to promote a harmonious working environment.

There are many roles that a pediatric nurse could perform as health care settings evolved from one stage to another. The challenge lies behind the application of evidenced-based practice to provide competent care to children. Last but not the least, having a heart for children matters a lot when the work load at the area seems to be heavy children could make you smile no matter how harsh the world could be.

Phenylketonuria (PKU)
Phenylketonuria (PKU) is an inborn error of metabolism that results from the absence of a liver enzyme, phenylalanine hydroxylase. It is an inherited autosomal recessive trait that causes negative impact on development and mental retardation. Phenylalanine hydroxylase enzyme is responsible for the conversion of phenylalanine (an essential amino acid) to tyrosine. The nonessential amino acid, tyrosine, is a significant element for some neurotransmitters such as dopamine, norepinephrine, epinephrine and serotonin. It is also essential in the production of melanin and function of the hormone regulating organs such as thyroid, pituitary, and adrenal glands. Consequences of absent liver enzyme in children with PKU would result to deficient tyrosine leading to the following conditions: Absence of serotonin, dopamine and epinephrine Result: Faulty nerve (Nervous System) transmission Neurotransmitters communicate impulses to the nerve cells. Lack of tyrosine would lead to deterioration of this function. Mood regulation is also connected to the presence of these chemicals (dopamine, serotonin, and epinephrine); therefore, alteration of ones disposition and temperament will be expected. Deficient Melanin levels Result: Unusual skin color Melanin is responsible for skin pigmentation. Deficient levels of melanin lead to a very fair complexion, a light blond hair and blue eyes. Hyposecretion of thyroid hormones Result: Permanent brain damage (Mental Retardation) and developmental delay Thyroid glands are located at the throat that comprises the two lateral masses on each side of the trachea. Before the two active thyroid hormones are produced, a process known as iodide trapping (iodide ion is concentrated within the thyroid) occurs. Then iodide is dissolved inside the follicular cells of the thyroid to become iodine and later released as a colloid. Colloids contain thyroglobulins which are made up of the amino acid tyrosine. Iodide when combined with tyrosine produces Monoiodotyrosine (MIT) and Diiodotyrosine (DIT). Conversion of MIT and DIT would form the two active thyroid hormone, triiodothyronine (T3) and Thyroxine (T4). These hormones are stored in the follicular cells until needed. T3 and T4 are primarily responsible for cellular metabolism affects nearly all cells in the body. They play a vital role for normal development to occur. In PKU, no Monoiodotyrosine (MIT) and Diiodotyrosine (DIT) is formed due to absence of tyrosine. Production of T3 and T4 would be inevitable causing decrease basal metabolism, cessation of cognitive and physical development. Most children with PKU are cognitively challenged having an IQ of less than 20.

Increase Phenylalanine levels

Result: Mousy urine odor Phenylalanine levels increase due to the absence of the liver enzyme. The end product of phenylalanine metabolism is phenylpyruvic acid (a keto acid). The by-product spills into the urine that gives it a strong mousy or musty odor that often spreads through the entire body of theinfant or child. This is the reason why the disorder is called phenylketonuria (meaning there isphenylpruvic or keto acid in the urine)

Iron-deficiency Anemia
Definition: Iron deficiency anemia (IDA)is an ailment when there is not enough hemoglobin produced by the body to meet its requirement. The benchmark for its diagnosis is marked by below-normal total body iron Etiology:

It is caused by inadequate intake of iron-rich foods or inadequate absorption of iron. Some of the known could be due to: a.) chronic diarrhea

b.) malabsorption syndromes c.) high cereal intake with low animal protein ingestion partial or complete gastrectomy Prevalence: It is more common in developing countries and tropical zones. According to the Food and Nutrition Research Institute (FNRI) as of 2003, in the Philippines iron deficiency anemia is common among children 6 months to one year old, pregnant and lactating women. Government efforts are still being implemented since it poses a public concern. Women between 15 45 years old are the ones being mostly affected. Pathophysiology: In IDA, when iron levels in the body decreases, transferrin which binds with and transport iron is also depleted. As a result, red blood cells (RBCs) the oxygen carryingcomponent of the blood is likewise depleted leading to decreased levels of hemoglobin in the body. Physical Findings:

Asymptomatic if in mild cases palpitations, dizziness and cold sensitivity brittleness of hair, nails and pallor dysphagia, stomatis, atrophic glossitis

dyspnea and weakness Diagnosttic Examinations: Complete Blood count first test to check the levels of the parts of the blood (red blood cells, white blood cells, platelets) Reticulocyte count - The test shows whether your bone marrow is making red blood cells at the correct rate. Peripheral smear To check whether the red blood cells look (microcytic) smaller and (hypochromic) paler than normal Serum iron markedly decreased

Serum ferritin decreased *Ferritin a protein that binds with iron in the body making it easier to be transported. Medical Management: Oral supplements of iron (Ferrous Sulphate)

1.

2. Parenteral Iron for children with iron malabsorption or chronic hemoglobinuria 3. Transfusion indicated for severe anemia cases of severe infection, cardiac dysfunction Nursing Management: 1. 2. 3. 4. 5. Asses for fatigue, activity intolerance, and other sings of impaired tissue oxygenation Promote an adequate intake of iron-rich foods (iron fortified formula and cereals, liver, egg yolk, and organ meats Emphasize to family members or care givers proper administration of oral iron supplements. Give supplements in two or three divided doses in small amount of Vitamin C-containing liquid. (This enhances absorption) Explain the potential adverse effects of iron which includes nausea and vomiting, diarrhea or constipation or black stools and tooth discoloration. Instruct care givers to keep iron supplements out of reach of children since it is toxic when overdosed.

Comparison of Pediatric Cancers and Adult Cancers

Pediatric Cancers: Incidence: Pediatric cancers are rare, covers less than one percent of all cancers. Sites : t involves tissues such as mononuclear phagocyte system, Central Nervous System , muscles and bones.

Histology : Most common type could be found are nonepithelial, sarcomas, embryonal, leukemia, lymphoma. Latency (from iniationa to diagnosis): It occurs relatively in shorter periods of time. Environmental factors: Most pediatric cancers occur as a combination of environmental factors and hereditary factors called ecogenetics. Prevention: As of the present, there minimal strategies known. Early Detection: These are generally accidental findings. State of diagnosis: 80% of the cases are metastasized when found out. Response to treatment: Pediatric cancers are very responsive to chemotherapy and tolerance to higher doses could be noted. Treatment of side effects: There is less difficulty in treating the side effects, however there are long term consequences. Prognosis: Greater than 60% are cured.

Adult Cancers Incidence: Adults cancers are common which covers more then 99% of all cancers. Sites : It involves organs such as the lungs, breast, colon prostate. Histology : Most common types are epithelial and carcinomas. Latency (from initiation to diagnosis): It occurs in a long period of time like a patient could be well over 20 years Environmental factors: It has a strong relationship to environmental and lifestyle factors Prevention: Adult cancers today are 80% preventable. Early Detection: It is possible to detect early when early detection and screening practices are done such as Breast Self Examination. State of diagnosis: It could either be local or regional. Response to treatment: It is less responsive to chemotherapy. Treatment of side effects:More difficulty with acute toxicity but fewer long-term consequences. Prognosis: Less than 60% could be cured.

From Fetal Circulation to Pulmonary Circulation

The development of the cardiovascular system begins to develop toward the end of the third week of pregnancy. On the Fetal Circulation ,shunts for the blood in the developing heart serve a very practical need. Initially all of the blood returns to the right atrium. However, because the lungs develop very late, the pulmonary vessels are limited in their capacity and the resulting resistance is high. Thus, the pulmonary circulation system cannot deal with all the blood. For the circulation system to remain balanced nonetheless, there are two shunts that provide shortcuts for most pulmonary circulation system. The Fetal Circulation: 1. 2. 3. 4. 5. 6. 7. 8. Oxygen from the placenta travels to the umbilical vein bringing oxygen and nutrients. Some of the blood flows to the hepatic circulation, others bypass the liver and pass through the ductus venosus. The blood from the lower parts of the lower parts of the body together with the blood in the ductus venosus flows toward the inferior vena cava. Some of the blood goes from the right atrium goes to the right ventricle via the tricuspid valve while others pass the foramen ovale leading to the left atrium. From the left atrium, it goes towards the left ventricle, mixing with the poorly oxygenated blood from the lungs and then pumped towards the ascending aorta. From th ascending aorta, the blood is pumped to the upper parts of the body like the heart, neck, head and upper limbs. Then perfuse to the placenta via the two umbilical arteries. Meanwhile the blood that enters the right ventricle together with the poorly oxygenated blood from the head and upper extremities returns to the right side of the heart by the way of the superior vena cave then, passes through the pulmonary artery wherein 10% enters the lungs, most of the blood bypasses the lungs which is then pumped to the ductus arteriosus going to the descending aorta. 9. The blood is the pumped and perfused to other parts of the fetus. 10. The blood then returns to the placenta via the two umbilical arteries. Transition after Birth The infant takes his first breath causing the mechanical expansion of the lungs. In this way the ductus venosus and ductus arteriosus constrict as large amount of oxygen enters the young lungs. With lung inflation, the alveolar oxygen tension increases, causing reversal of the hypoxemia-induced pulmonary vasoconstriction of the fetal circulation. Clamping of the umbilical cord also increases systemic vasucalr resistance and left ventricle pressure, which further closes the ductus venosus. A decrease in pulmonary vascular resistance and an increase in systemic vasuclar resistance causes a left to right shunting and increasing PO2 which further closes the ductus arteriosus. Pulmonary Circulation

1.

Oxygen-depleted blood from the body leaves the systemic circulation when it enters the right heart, more specifically the right atrium through the superior (upper) vena cava and inferior (lower) vena cava.

2. 3. 4. 5. 6. 7.

The blood is then pumped through the tricuspid valve (or right atrioventricular valve) into the right ventricle Blood is then pumped through the semilunar valve and i nto the left and right pulmonary arteries (one for each lung) and travels through the lungs. The pulmonary arteries carry out deoxgenated blood to the lungs while the pulmonary veins carry oxygenated blood to the red blood cells where they release carbon dioxide and pick up oxygen during respiration. The oxygenated blood then leaves the lungs through pulmonary veins, which return it to the left heart, completing the pulmonary cycle. This blood then enters the left atrium, which pumps it through the bicuspid valve, also called the mitral or left atrioventricular valve, into the left ventricle. The blood is then distributed to the body through the systemic circulation before returning to the pulmonary circulation.

As changes in the cardiovascualr system at birth happens, there are some structure of the system do not function as it used to be and there are adult structures are derived from these:

Foramen Ovale turns into Foramen Ovalis Umbilical Vein turns into Ligamentum teres Ductus Venosus turns into medial umbilical ligaments Umbilical arteries and abdominal ligaments turns into superior vesicular artery (which supplies the bladder) Ductus Arteriosum turns into Ligamentum arteriosum

Hirschsprungs Disease (Aganglionic Megacolon)

Definition: It involves an enlargement of the colon, caused by the bowel obstruction resulting from an aganglionic section of bowel or absence of ganglion cells nerve do not function correctly and normal relaxation of bowel cannot occur. The length of the bowel that is affected varies but seldom stretches for more than about 30 cm. Clinical Manifestations: 1. Newborn period: a. abdominal distention b. failure of passage of meconium within the first 48 hours of life c. develops disinterest in feeding d. repeated vomiting 2. Older infants and children a. suffers from chronic constipation b. tympanic abdominal distention c. poor feeding d. failure to thrive e. irritable and fretful f. Diarrheal enterocolitis common complication below 3 months g. fever i. passage of ribbon like stools Diagnostic examinations:

Barium enema may reveal megacolon

Rectal biopsy Anorectal Manometry it shows that the external sphincter contracts normally but does not relax Etiology: Heredity The incidence is sporadic, however there is an increasing incidence in the family Associated conditions -strongly associated with Down syndrome ( 5-15% of patients with Hirschsprung disease also have trisomy21) Waardenburg syndrome, congenital deafness, malrotation, gastric diverticulum and intestinal atresia

Medical Management:

Initial intravenous hydration, NPO (nothing per orem) status, intestinal and gastric decompression Decompression Nasogastric tube insertion or either digital rectal examination or normal saline rectal irrigations 3 to 4 times daily. Surgical options: Colostomy at the level of normal bowel

*Surgery done in a 3 stage approach: 1. Temporary colostomy 2. Definitive Repair / Diversion Procedure a. Abdomino-Perineal Procedure b. Duhamel c. Scaves Approach- Endorectal Pulithru c.1. done 8 months to 1 year c.2. Infants has weight of 20 pounds 3. Closure of colostomy Nursing Management:

Asses immediately for enterocolitis. Avoid taking body temperature rectally because it may damage the mucosal lining Prevention of constipation small frequent feeding with low residue diet Administration of oral and systemic antibiotics Use of stool softeners Provide a comfortable position- Semi-fowlers to relieve dyspnea of abdominal distention Encourage the family members to have a diet which includes corn and rice Encourage parents to verbalize their anxieties as well as teach them the proper care of colostomy.

Ovarian Cancer

Is a common gynecologic malignancy that carries a high mortality because it is not usually diagnosed until well advanced. Its exact cause is unknown, about 10% of cases are associated with family history of breast, endometrial, colon, or ovarian cancer. High fat diet, smoking, alcohol, environmental toxins; patient history of breast, colon, or endometrial cancer, and low parity are additional risk factors. Ninety percent of ovarian tumors arise in epithelial tissue, with germ cell and stromal tissue making up the rest.

Incidence peaks in women age 50 or older. Ovarian tumors spread intra-abdominally and through the lymph system. Assessment First manifestation includes vague abdominal discomfort, indigestion, flatulence, anorexia, pelvic pressure, weight

1.

loss or gain, and palpable ovarian enlargement. 2. Late manifestations include abdominal pain, ascites, pleural effusion, and instestinal obstruction. Diagnostic Evaluation 1. 2. 3. 4. 5. Pelvic sonography (with transvaginal probe) and CT scan may be done. Unfortunately, these are not sensitive to early detection of ovarian cancer. Color Doppler imaging may be used to detect vascular changes within the ovaries. Paracentesis or thoracentesis are done if ascites or pleural effusion is present. Laparotomy is necessary to stage the disease and determine effectiveness of the treatment.

CA 125 is a serum tumor marker that is not reliable for screening because its level may be elevated due to inflammation; however, an increase signifies progression of disease. Therapeutic and Pharmacologic Interventions

1.

Chemotherapy is more effective if tumor is optimally bulked; usually follows surgery because of frequency of

advanced disease; may be given I.V. or intraperitoneally. 2. Immunotherapy with interferon or hormonal therapy with tamoxifen, an antiestrogen agent may be used. Surgical Interventions 1. 2. Total abdominal hysterectomy with bilateral salpingooophorectomy and omentectomy is usual treatment because of delayed diagnosis. Second-look laparotomy may be done after adjunct therapies to take multiple biopsy specimens and determine

effectiveness of therapy. Nursing Interventions 1. 2. 3. 4. 5. 6. 7. 8. Administer anxiolytic and analgesic medications as prescribed and provide support throughout the diagnostic process. Administer or teach the patient or caregiver to administer antiemetics as needed for nausea and vomiting due to chemotherapy. Encourage small, frequent, bland meals or liquid nutritional supplements as able. Assess the need for I.V. fluids if patient is vomiting. Prepare the patient for body image changes resulting from chemotherapy. Encourage the patient to prepare ahead of time with turbans, wig, hats, and so forth. Stress the positive effects of the patients treatment plan. Prepare the patient for surgery as indicated. Postoperatively, reposition frequently and encourage early ambulation to promote comfort and prevent adverse effects.

9. Explain to the patient that ovary removal will cause menopausal symptoms. 10. Tell the patient that disease progression will be monitored closely by laboratory tests and that a second-look laparoscopy may be necessary.

Cervical Cancer

Is a common gynecologic malignancy. Most commonly occurs in women age 35 to 55. Major risk factors include early sexual activity, multiple sexual partners, and history of sexually transmitted diseases especially human papilloma virus and herpes simplex virus. Cervical cancer may involve the bladder, rectum, and may metastasize to the lungs, mediastinum, bones, and liver.

Invasive cancer spreads by local invasion and lymphatics to the vagina and beyond. Assessment 1. 2. 3. Early disease is usually asymptomatic. Initial symptoms are postcoital bleeding, irregular vaginal bleeding or spotting between periods or after menopause, and malodorous discharge. As disease progresses, bleeding becomes more constant and is accompanied by pain that radiates to buttocks

Types of cervical cancer includes: Dysplasia atypical cells with some degree of surface maturation. Carcinoma in Situ (CIS) which is confined to the cervical epithelium. Invasive carcinomas the stroma is involved, 90% are of the squamous cell type.

and legs. 4. Weight loss, anemia, and fever signal advance disease. Diagnostic Evaluation

1. 2. 3.

Papanicolaou (Pap) smear for cervical cytology is usual screening test. A computerizedscreening program may increase the accuracy of manual laboratory Pap screening by as much as 30%. If Pap test is abnormal, colposcopy, and biopsy or conization may be done.

Additional testing includes metastatic workup (chest x-ray, I.V. urogram, cystoscopy, barium studies of colon and rectum, sigmoidoscopy) Therapeutic Interventions Intracavitary radiation for earlier localized stages radium by way of applicator in endocervical canal. External radiation for generalized pelvis effect in later stages. Laser therapy may be used to treat dysplasia.

1. 2. 3.

4. Chemotherapy may be used as adjuvant to surgery or radiation treatments. Surgical Interventions 1. 2. Conization is performed for microinvasize stage if child-bearing is desired. Cryosurgery, laser ablation, and loop electrosurgical excision procedure may be done for dysplasia or CIS.

3. Hysterectomy, simple or radical depending on stage. 4. Pelvic exenteration for very advanced disease if radiation therapy cannot be used; also for recurrent cancer. Nursing Interventions 1. 2. 3. 4. 5. 6. 7. During intracavitary radiation, check radioisotope applicator position every 8 hours, and monitor amount of bleeding and drainage (a small amount is normal). Observe for signs and symptoms of radiation sickness such as nausea, vomiting, fever, diarrhea, abdominal cramping. Monitor for complications of surgery bleeding, infection. Help the patient seek information on stage of cancer, treatment options. Provide emotional support during treatment. Advise patient to discharge after surgical procedures and need to report excessive, foul-smelling, discharge or bleeding. Explain the importance of life-long follow up regardless of treatments to determine the response to treatment and to detect spread of cancer.

8. Encourage all women to receive regular cervical cancer screening. The HPV Vaccine The human papilloma virus (HPV) vaccine prevents infection with certain serotypes of human papilloma virus associated with the development of cervical cancer, genital warts, and some less common cancers. The HPV vaccine is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series. Note: The vaccine is not recommended for pregnant women.

Oligohydramnios

Severe reduction of amniotic fluid volume (typically less than 500 ml at term); highly concentrated urine. Possibility of prolonged, dysfunctional labor (usually beginning before term). Fetal risk: renal anomalies, pulmonary hyperplasia, hypoxia, increased skeletal deformities, and wrinkled, leathery skin. Causes Exact cause is unknown. Any condition that prevents the fetus from making urine or that blocks urine from going into the amniotic sac. Contributing factors: uteroplacental insufficiency, premature rupture of membranes prior to labor onset,

maternal hypertension, maternal diabetes, intrauterine growth restriction, postterm pregnancy, fetal renal genesis, polycystic kidneys, and urinary tract obstructions. Assessment

Asymptomatic

Lagging fundal height growth. Test result Ultrasonography reveals no pockets of amniotic fluid larger than 1 cm. Treatment Close medical supervision of the mother and fetus. Fetal monitoring

Amnioinfusion (infusion of warmed sterile normal saline or lactated Ringers solution) to treat or prevent variable decelerations during labor. Nursing Interventions Monitor maternal and fetal status closely, including vital signs and fetal heart rate patterns. Monitor maternal weight gain pattern, notifying the health care provider if weight loss occurs. Provide emotional support before, during, and after ultrasonography. Inform the patient about coping measures if fetal anomalies are suspected. Instruct her about signs and symptoms of labor, including those shell need to report immediately. Reinforce the need for close supervision and follow up. Assist with amnioinfusion as indicated. Encourage the patient to lie on her left side. Ensure that amnioinfusion solution is warmed to body temperature.

1. 2. 3. 4. 5. 6. 7. 8. 9.

10. Continuously monitor maternal vital signs and fetal heart rate during the amnioinfusion procedure. 11. Note the development of any uterine contractions, notify the health care provider, and continue to monitor closely. 12. Maintain strict sterile technique during amnioinfusion.

Pregnancy Complications
Complications of pregnancy are the symptoms and problems that are associated with pregnancy. There are both routine problems and serious, even potentially fatal problems. The routine problems are normal complications, and pose no significant danger to either the woman or the fetus. Serious problems can cause both maternal death and fetal death if untreated. A. Abortion

1. 2.

expulsion of the fetus before it is viable; may be spontaneous or induced the most common bleeding disorder of early pregnancy Occur in 15-20% of recognized pregnancy Causes of Spontaneous Abortion: Fetal abnormalities or abnormal development of the zygote, embryo or fetus Maternal Factors these are congenital or acquired conditions of the mother and environmental factors that had

adversely affected pregnancy outcome and led to abortion. These includes diabetes mellitus, problems of the reproductive tract, exposure to radiation and infection and endocrine disturbances. Types of Abortion B. Ectopic Pregnancy

1. 2.

a pregnancy that develops outside of the uterus; 90 percent are tubal the second leading cause of bleeding in early pregnancy Types of Ectopic Pregnancy Tubal Ovarian

3. 4. 5. 6. 7.

Cervical Abdominal Broad Ligaments Tubo-uterine Tubo-abdominal

8. Tubo-ovarian 9. Heterotypic pregnancy C. Hyperemesis Gravidarum

severe, persistent vomiting during pregnancy or excessive nausea and vomiting which leads to electrolyte, metabolic and nutritional imbalances in the absence of other medical problems Causative Factors: High levels of hCG in early pregnancy Metabolic or nutritional deficiencies More common in unmarried white women and first pregnancies

1. 2. 3.

4. Ambivalence toward the pregnancy of family-related stress 5. Thyroid dysfunction D. Placenta Previa

the placenta partially or completely covers the internal os of the

cervix the most common bleeding disorder of the third trimester Types of Placenta Previa: 1. Complete or Total Placenta Previa the placenta completely 2. 3. 4. covers the internal os when the cervix is fully dilated. Partial Placenta Previa the placenta partially covers the internal os. Marginal Placenta Previa the edge of the placenta is lying at the margin of the internal os. Low lying Placenta Previa the placenta implants near the internal os, its edges can be felt by the examining finger on IE. Causes of Placenta Previa 1. 2. 3. 4. 5. 6. Multiparity Multiple pregnancy Advance of maternal age over 35 years old Smoking Previous cesarean section and abortion Uterine incisions

7. Prior placenta previa 8. Abnormal placentas placenta increta and accreta E. Abruptio Placentae

1. 2. 3. 4. 5.

separation of the placenta from the uterus before the babys birth also called placental abruption and accidental hemorrhage Causes of Abruptio Placentae: Uterine anomalies Multiparity Preeclampsia Previous cesarean delivery Renal or vascular disease

6. 7. 8. 9. 1. 2.

Trauma to the abdomen Previous third trimester bleeding Abnormally large placenta Short umbilical cord Types of Abruptio Placentae: Covert/Central Abruptio Placentae Separation begins at the center of placenta attachment resulting in blood being trapped behind the placenta, bleeding, then, is internal and not obvious. Overt or Marginal Abruptio Placentae Separation begins at the edges of the placenta allowing blood to escape from the uterus cavity. Bleeding is external. Classification of abruptio placentae is based on extent of separation (ie, partial vs complete) and location of Grade 0: asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta. Grade 1: mild and represents approximately 48% of all cases. No vaginal bleeding to mild vaginal bleeding Slightly tender uterus Normal maternal BP and heart rate No coagulopathy No fetal distress Grade 2: moderate and represents approximately 27% of all cases. Characteristics include the following: No vaginal bleeding to moderate vaginal bleeding Moderate-to-severe uterine tenderness with possible tetanic contractions Maternal tachycardia with orthostatic changes in BP and heart rate Fetal distress Hypofibrinogenemia (ie, 50-250 mg/dL) Grade 3: severe and represents approximately 24% of all cases. Characteristics include the following: No vaginal bleeding to heavy vaginal bleeding Very painful tetanic uterus Maternal shock Hypofibrinogenemia (ie, <150 mg/dL) Coagulopathy

separation (ie, marginal vs central). 1. 2.

3.

4.

Fetal death F. Pregnancy Induced Hypertension preeclampsia is a hypertensive disorder of pregnancy developing after 20 weeks gestation and characterized by edema, hypertension and proteinuria eclampsia is an extension of preeclampsia and is characterized by the client experiencing seizures Predisposing Factors of PIH:

1. 2. 3. 4.

Primigravida status higher incidence in primiparas below 20 and above 35 years old. Low socioeconomic status Previous hypertension of pregnancy, hydatidiform mole, diabetes mellitus, multiple pregnancy, polyhydramnios, renal disease, heart disease Genetic or immunologic

Mild Preeclampsia

Severe Preeclampsia

Eclampsia

Increased BP (systolic increase 30 mm hg convulsions over baseline; diastolic 15 1+ Proteinuria Edema especially of hands and face

BP 160/110 Tonic-clonic Proteinuria 3-4+ Possible coma Very edematous Renal shutdown Elevated BUN, serum creatinine, uric acid Oliguria (. 400cc/24 hrs) Cerebral or visual disturbances Epigastric pain, vomiting

G. Gestational Diabetes

diabetes diagnosed during pregnancy it is a disorder of late pregnancy (typically) caused by the increased pancreatic stimulation associated with pregnancy. babies born to mothers with gestational diabetes are at increased risk of problems typically such as being large for gestastional age

(which may lead to delivery complications), low blood sugar, and jaundice 2 Subtypes of Gestational Diabetes (diabetes which began during pregnancy):

Type A1: abnormal oral glucose tolerance test (OGTT) but normal blood glucose levels during fasting and 2 hours after meals; diet modification is sufficient to control glucose levels Type A2: abnormal OGTT compounded by abnormal glucose levels during fasting and/or after meals; additional therapy with insulin or other medications is required Predisposing Factors of Gestational Diabetes: A previous diagnosis of gestational diabetes or prediabetes, impaired glucose tolerance, or impaired fasting glycaemia A family history revealing a first degree relative with type 2 diabetes Maternal age a womans risk factor increases as she gets older (especially for women over 35 years of age) Ethnic background (those with higher risk factors include African-Americans, Afro-Caribbeans, Native Americans, Hispanics, Pacific Islanders, and people originating from the Indian subcontinent) [7] Being overweight, obese or severely obese increases the risk by a factor 2.1, 3.6 and 8.6, respectively.

1. 2. 3. 4. 5.

6. A previous pregnancy which resulted in a child with a high birth weight (>90th centile, or >4000 g (8 lbs 12.8 oz)) 7. Previous poor obstetric history H. Anemia (Iron deficiency)

iron deficiency anemia is the most common anemia of pregnancy affecting 15-50% of pregnant women. also called the physiologic anemia of pregnancy hemoglobin value of less than 11 mg/dL or hematocrit value less than 33% during the 2nd and 3rd trimester. Predisposing factors of Anemia: Poor diet and poor nutrition Heavy menses Pregnancies at close intervals; successive pregnancies Unwise reducing programs

1. 2. 3. 4.

I. Hydatidiform Mole

1.

a benign disorder characterized by degeneration of the chorion and death of the embryo the chorionic villi rapidly proliferate and become grape like vesicles that produce large amount of hCG Predisposing Factors of Hydatidiform Mole: Higher incidence in asian women

2. Low socioeconomic status 3. Below 18 years old and above 40 years old. J. Incompetent cervix

1. 2. 3. 4.

characterized by a painless dilation of the cervical os without contractions of the uterus commonly occurs at about the 20th week of pregnancy Predisposing Factors of Incompetent Cervix: History of traumatic birth Repeated dilatation and curettage Clients mother treated with diethylstilllbestrol (DES) when pregnant with the client Congenitally short cervix

5. Uterine anomalies 6. Unknown etiology K. Polyhydramnios

characterized by excessive amount of amniotic fluid, more than 2000 ml Predisposing Factors of Polyhydramnios:

1. 2.

Multiple pregnancy Fetal abnormalities-esophageal atresia, anencephaly, spina bifida

3. Diabetes mellitus L. Oligohydramnios

amniotic fluid is less than 300 ml or amniotic fluid index less than 5 cm Causes of Oligohydramnios: Fetal renal anomalities that results in anuria

1.

2. Premature rupture of membranes 3. Exposure to angiotensin converting enzyme inhibitors M. Premature Labor

1. 2. 3. 4. 5. 6. 7. 8. 9.

labor that begins after 20 weeks gestation and before 37 weeks gestation. Causes of Preterm Labor: PROM Preeclampsia Hydramnios Placenta previa Abruptio placentae Incompetent cervix Trauma Uterine structural anomalies Multiple gestation

10. Intrauterine infection (chorioamnionitis) 11. Congenital adrenal hyperplasia 12. Fetal death

13. Maternal factors, such as stress (physical and emotional) 14. Urinary tract Infection 15. Dehydration

Placenta Previa
Placenta Previa is the development of the placenta in the lower uterine segment, partially or completely covering the internal cervical os. Types of Placenta Previa: 1. 2. 3. 4. Complete or Total Placenta Previa the placenta completely covers the internal os when the cervix is fully dilated. Partial Placenta Previa the placenta partially covers the internal os. Marginal Placenta Previa the edge of the placenta is lying at the margin of the internal os. Low lying Placenta Previa the placenta implants near the internal os, its edges can be felt by the examining finger on IE.

Predisposing Factors: 1. 2. 3. 4. Multiparity (80% of affected clients are multiparous) Multiple Pregnancy Advanced maternal age (older than 35 years old in 33% of cases) Previous cesarean section and abortion

5. Uterine incisions 6. Prior placenta previa Clinical Manifestations: 1. 2. 3. Bleeding that is painless, sudden and profuse during the end of second trimester, or during third trimester. Soft, nontender abdomen; relaxes between contractions, if present. FHR stable and within normal limits.

4. Normal uterine tone 5. Leopolds maneuver: the fetus is in breech, oblique or transverse position. Laboratory and Diagnostic Study Findings: 1. Transabdominal ultrasonography confirms suspicion of placenta previa. 2. CBC: decreased Hb and HCT levels if bleeding is present. Nursing Management: 1. 2. 3. 4. Take and record vital signs, assess bleeding, and maintain a perineal pad count. Weigh saturated perineal pads to assess maternal blood loss. Maintain bedrest and elevate the head of the bed. Provide fluid administration, usually with lactated Ringers solution, through a large-bore IV line to maintain fluid balance. Consider cesarean delivery if the placenta previa is more than 30% or if excessive bleeding occurs.

5. 6. 7. 8. 9.

Measure fundal height to assess for rising fundus, which may reveal concealed bleeding. Disallow rectal or vaginal examinations, to minimize the danger of bleeding. Prepare the patient and family emotionally and physically for delivery. Observe for meconium in the amniotic fluid; may indicate fetal distress. Provide emotional support to the patient and family.

Types of Abortion
An abortion is the termination of a pregnancy by the removal or expulsion from the uterus of a fetus or embryo, resulting in or caused by its death. Causes of Abortion Abortion may be occur due to various factors such as fetal, placental, or maternal. 1. Fetal Causes The most common cause of early spontaneous abortion is abnormal development of the zygote, embryo or fetus. These abnormalities are incompatible with life and would have resulted in severe congenital 2. anomalies had pregnancy not been aborted spontaneously. Maternal Factors These are congenital or acquired conditions of the mother and environmental factors that had adversely affected pregnancy outcome and led to abortion. Such conditions include diabetes mellitus, incomplete cervix, exposure to radiation and infection. Placental Factors Placental factors usually cause abortion around the 14th week of gestation. These factors includes premature separation of the normally implanted placenta and abnormal placental implantation.

3.

Abortion Types

Threatened Abortion

Characteristics Management occurring before the 1. Bedrest 20th week of gestation 2. No coitus up to 2 characterized by weeks after bleeding cramping and vaginal stopped bleeding with no cervical dilation. it may subside or an incomplete abortion may follow. membranes rupture and the cervix dilates characterized by lower abdominal cramping and bleeding. 1. 2. 3. 4. 5. Hospitalization D and C Oxytocin after D and C Sympathetic Understanding and emotional support D and C Oxytocin after D and C Sympathetic Understanding and emotional support

Imminent or Inevitable Abortion

Incomplete Abortion

is characterized by 1. expulsion of only part 2. of the products of 3. conception (usually the 4. fetus). severe uterine cramping bleeding occur with

cervical dilation.

Complete Abortion

characterized 1. There is no treatment by completeexpulsion other than rest is of all products of usually needed. conception 2. All of the tissues that light bleeding came out should be mild uterine cramping saved passage of tissue forexamination by a closed cervix doctor to make sure that the abortion is complete. 3. The laboratory examination of the saved tissue may determine the cause of abortion. intrauterine pregnancy 1. is present but is no longer developing normally the cervix is closed, and the client may report dark brown vaginal discharge. pregnancy test findings are negative. Usually treated by induction of labor by dilation (or dilatation) and curettage (D & C).

Missed Abortion

Recurrent orHabitual Abortion

characterized by 1. Trace the cause of spontaneous abortion recurrent abortion of three or more consecutivepregnancie s abortion complicated by infection foul smelling vaginal discharge uterine cramping fever 1. Antibiotics as prescribed by your Obstetrician

Septic Abortion

Breast self-examination (BSE) is a method of finding abnormalities of the breast, for early detection of breast cancer. The method involves the woman herself looking at and feeling each breast for possible lumps, distortions or swelling. BSE was once promoted heavily as a means of finding cancer at a more curable stage, but randomized controlled studies found that it was not effective in preventing death, and actually caused harm through needless biopsies and surgery. 1. The self-exam is performed by standing in front of a mirror with the torso exposed to view. 2. The woman looks in the mirror for visual signs of dimpling, swelling, or redness on or near the breasts. This is usually repeated in several positions, such as while having hands on the hips, and then again with arms held overhead. The woman then palpates her breasts with the pads of her fingers to feel for lumps (either superficial or deeper in tissue) or soreness. To be effective, this process needs to cover the entire breast, including the axillary tail of

3.

each breast that extends toward the axilla (armpit). This is usually done once while standing in front of 4. the mirror and again while lying down. Some guidelines suggest mentally dividing the breast into four quadrants and checking each quadrant separately.

Finally, women that are not breastfeeding gently squeeze each nipple to check for any discharge. The 7 Ps of Breast Self Examination (BSE) 1. Position: Inspect breasts visually and palpate in the mirror with arms at various positions. Then perform the examination lying down, first with a pillow under one shoulder, then with a pillow under the other shoulder, 2. 3. 4. 5. and finally lying flat. Perimeter: Examine the entire breast, including the nipple, the axillary tail that extends into the armpit, and nearby lymph nodes. Palpation: Palpate with the pads of the fingers, without lifting the fingers as they move across the breast. Pressure: First palpate with light pressure, then palpate with moderate pressure, and finally palpate with firm pressure. Pattern: There are several examination patterns, and each woman should use the one which is most comfortable for her. The vertical strip pattern involves moving the fingers up and down over the breast. The pie-wedge pattern starts at the nipple and moves outward. The circular pattern involves moving the fingers in concentric circles from the nipple outward. Dont forget to palpate into the axilla. Practice: Practice the breast self-exam and become familiar with the feel of the breast tissue, so you can recognize changes. A health care practitioner can provide feedback on your method. Plan: Know what to do if you suspect a change in your breast tissue. Know your family historyof breast cancer. Have mammography done as often as your health care provider recommends. For premenopausal women, BSE is best done at the same stage of their period every month to minimize changes due to the menstrual cycle. The recommended time is just after the end of the last period when the breasts are least likely to be swollen and tender. Older, menopausal women should do BSE once a month, perhaps on the first or last day of every month.

6. 7.

Polyhydramnios

Abnormally large amount of amniotic fluid in the uterus. Normal range from 500 to 1,000 ml at term; typically greater than 2,000 ml in polyhydramnios at 40 weeks gestation. Also called hydramnios. Possible complications: prolapsed umbilical cord when membranes rupture, increased incidence of malpresentations, increased perinatal mortality from fetal malformations and premature deliveries, and increased incidence of postpartum maternal hemorrhage. Kinds/Degrees of Polyhydramnios 1. Mild Polyhydramnios when amniotic fluid pockets is between 8 to 11 cm in vertical dimensions. (85%) 2. Moderate Polyhydramnios when amniotic fluid pockets is between 12 to 15 cm in vertical dimensions. (17%) Predisposing Factors Multiple pregnancy Fetal abnormalities esophageal atresia, anencephaly, spina bifida Diabetes Mellitus Pathophysiology Normally, amniotic volume is maintained by a balance of fetal fluid production (lung liquid and urine) and fluid resorption (fetal swallowing and flow across the membrane to the fetus or the maternal uterus).

Fetal urine is the primary source of amniotic fluid with output at term ranging from 400 to 1,200 ml/day. Fetal swallowing is believed to be the major route of amniotic fluid resorption. With polyhydramnios, fluid accumulates because of a problem with the fetuss ability to swallow or absorb the fluid or as a result of over production of urine. Fluid may have increased gradually (chronic type) by the third trimester or rapidly (acute type) between 20 and 24 weeks gestation. Causes Exact cause is unknown in about 35% of all cases. May be associated with diabetes mellitus (about 25%), erythroblastosis ( about 10%), multiple gestations (about 10%), anomalies of the central nervous system (such as neural tube defects), or GI anomalies such as tracheoesophageal fistula that prevent ingestion of the amniotic fluid (about 20%). Assessment Findings Depend on the length of gestation, the amount of amniotic fluid, and whether the disorder is chronic or acute. Mild signs and symptoms; maternal abdominal discomfort, slight dyspnea, and edema of feet and ankles. Severe signs and symptoms; severe dyspnea, orthopnea, and significant edema of the vulva, legs, and abdomen. Symptoms common to mild and severe cases: uterine enlargement greater than expected for the length of gestation, and difficulty in outlining the fetal parts and in detecting fetal heart sounds. Test Results Ultrasonography shows evidence of excess amniotic fluid as well as underlying conditions. Amniotic fluid index is 20 cm or greater. Treatment High protein, low sodium diet Mild sedation Indomethacin therapy a drug that decreases the fetal urine formation. The side effect of indomethacin, as with other prostaglandin synthase inhibitors, is the potential premature closure of the ductus arteriosus. Amniotomy The fluid is removed by a needle inserted through the cervix. The danger of this procedure is cord proplapse and abruptio placenta. to prevent these complications, amniotic fluid must be removed [Link] closely for hemorrhage after delivery, prevent uterine relaxation by massaging the uterus and administering oxytoxin as ordered. Induction of labor if the fetus is mature and symptoms are severe. Nursing Interventions Mild to moderate degrees usually does not require treatment. Hospitalization if symptoms are severe dyspnea, abdominal pain and difficult ambulation. Maintain bed rest with sedation to make the situation endurable. Monitor the patient for signs and symptoms of premature labor. Monitor maternal vital signs and fetal heart rate frequently; report changes immediately. Prepare the patient for amniocentesis and possible labor induction, as appropriate; keep in mind that amniocentesis for fluid removals is only temporary and may need to be done repeatedly.

Gestational Trophoblastic Disease

Developmental anomaly of the placenta that converts the chorionic villi into a mass of clear fluid-filled vesicles. Two types of moles: a. Complete moles neither an embryo nor an amniotic sac. It is characterized by swelling and cystic formation of all trophoblastic cells. No fetal blood is present. If an embryo did develop, it was most likely only 1 to 2 mm in size and died early on. A complete mole is highly associated with the development of choriocarcinoma. b. Partial mole embryo (usually with multiple anomalies) and amniotic sac. It is characterized by edema of a layer of the trophoblastic villi with some of the villi forming normally. Fetal blood may be present in the villi, and an embryo up to the size of 9 weeks gestation may be present. Typically, a partial mole has 69 chromosomes in which there are three chromosomes for every one pair. Major cause of second trimester bleeding. Also called molar pregnancy or hydatidiform mole. Pathophysiology Trophoblastic villi cells located in the outer ring of the blastocyst (the structure that develops via cell division around 3 to 4 days after fertilization) rapidly increase in size, begin to deteriorate, and fill with fluid. The cells become edematous, appearing a grapelike clusters of vesicles. As a result, the embryo falls to develop past the early stages. Causes Exact cause is unknown May be associated with poor maternal nutritional (specifically, an insufficient intake of protein and folic acid), a defective ovum, chromosomal abnormalities, or hormonal imbalances. Preceding molar pregnancy in about 50% of patients with choriocarcinoma. Preceding spontaneous or induced abortion, ectopic pregnancy, or normal pregnancy in the remaining 50% of patients. Assessment findings Disproportionate enlargement of the uterus; possible grapelike clusters noted in the vagina on pelvic examination. Excessive nausea and vomiting, abdominal cramping. Intermittent or continuous bright red or brownish vaginal bleeding Passage of tissue resembling grapelike clusters. Symptoms of gestational hypertension before 20 weeks gestation. Absence of fetal heart tones. Test Results: Radioimmunoassay of human chorionic gonadotropin (hCG) levels reveals extremely elevated levels of early pregnancy. Histologic examination may reveal the presence of vesicles. Ultrasonography performed after 3 months gestation reveals grapelike clusters rather than a fetus, an absence of fetal skeleton, and evidence of a snowstorm-like pattern. Hemoglobin level, hematocrit, red blood cells (RBC) count, prothrombin time, partial thromboplastin time, fibrinogen levels, and hepatic and renal function findings are all abnormal.

White blood cells count and erythrocyte sedimentation rate are increased. Treatment: Suction and curettage; if indicated. Weekly monitoring of beta-hCG levels until normal 3 consecutive weeks. Periodic follow-up for 1 to 2 years. Pelvic examinations and chest X-rays at regular intervals. Emotional support. Avoidance of pregnancy until hCG levels are normal (may take up to 1 year). Nursing Interventions: Obtain baseline vital signs. Preoperatively observe the patient for signs of complications, such as hemorrhage, uterine infection, and vaginal passage of vesicles. Save any expelled tissue for laboratory analysis. Prepare the patient physically and emotionally for surgery, if indicated. Postoperatively, monitor vital signs and fluid intake and output, and assess for signs of hemorrhage. Encourage the patient and her family to express their feelings. Offer emotional support, and help them through the grieving process. Help the patient and her family develops effective coping strategies, referring them to a mental health professional, if needed.

Toxic Shock Syndrome (TSS)

Is a rare, potentially life threatening condition caused by a bacterial toxin secreted by Staphylococcus aureus in the blood stream. The cause is uncertain, but 70% of cases are associated with menstruation and tampon use. Research suggests that magnesium-absorbing fibers in tampons may lower magnesium levels in the body, thereby providing ideal conditions for toxic formations. It also occurred in non-menstruating people with conditions such as cellulitis, surgical wound infection, vaginal infections, and subcutaneous abscesses, and with the use of contraceptive sponges, diaphragms, and tubal ligation. Death may result from cardiovascular collapse and renal failure caused by shock. Assessment 1. Sudden onset of high fever greater than 102F (39C). 2. Vomiting and profuse, watery diarrhea. 3. Rapid progression to hypotension and shock within 72 hours of onset. 4. Mucous membrane hyperemia. 5. Sometimes, sore throat, headache, and myalgia. 6. Rash (similar to sunburn) that develops 1 to 2 weeks after onset of illness as followed by desquamation particularly of the palms and soles. Diagnostic Evaluation 1. Blood urine, throat, and vaginal or cervical cultures, and possibly cerebrospinal fluid culture, detect or rule out infectious organism. 2. Additional tests may be required to rule out other febrile illnesses: Rocky Mountain spotted fever, Lyme disease, meningitis, Epstein-Barr, or Coxsackie viruses. 3. Complete blood count, electrolytes, and renal function tests monitor condition. Therapeutic Intervention

Fluid and electrolyte replacement to increase blood pressure and prevent renal failure. 2. Supportive care to maintain cardio-respiratory functions. Pharmacologic Interventions 1. Vasopressors, such as dopamine, to treat shock. 2. Antibiotics, such as penicillin-resistant penicillin, or cephalosporins to decrease the rate of relapse. 3. Antipyretics to treat fever. 4. Use of corticosteroids and immunoglobulins is controversial. Nursing Interventions 1. Monitor core body temperature. 2. Perform hemodynamic monitoring as indicated (ie, arterial line, central venous pressure, or pulmonary artery pressure). 3. Maintain strict intake and output measurement. 4. Insert indwelling catheter to monitor hourly urine output. 5. Monitor respiratory status for pulmonary edema and respiratory distress syndrome caused by fluid overload from increased fluid replacement, diuretics may be necessary. 6. Use cooling measures, such as sponge baths and hypothermia blanket, if indicated. 7. Tell patient to expect desquamation of skin, as in peeling sunburn. 8. Protect skin and avoid using harsh soaps and alcohol which cause drying. 9. Tell patient to apply mild moisturizer and avoid direct sunlight until healed. 10. Advise patient that reversible hair loss may occur 1 or 2 months after TSS. 11. Tell patient to expect fatigue for several weeks to months after TSS. 12. Tell patient to avoid using tampons to reduce risk of recurrence. 13. Encourage follow-up visits for examination and cultures. 14. Alternate use of pads with tampons; avoid super-absorbent tampons. 15. Change pads or tampons frequently and do not wear one longer than 4 hours. 16. Recognize and report symptoms of TSS.
1.

Encephalitis

Is an inflammation of cerebral tissue typically accompanied by meningeal inflammation, caused by an infection or other source. It can present as acute viral encephalitis, most frequently caused by herpes virus and most commonly occurring in children. Cytomegalovirus (CMV) and toxoplasma are common causes in patients with acquired immunodeficiency syndrome. It may also present as post-infectious encephalitis, which follows a viral or bacterial infection, usually of the respiratory or GI tract. It may also present as an anthropod-borne infection such as West Nile Virus. The disease, which is commonly fatal, causes lymphocytic infiltration of the brain, which leads to cerebral edema, basal ganglia degeneration, and diffuse nerve cell destruction. Complications include motor and sensory deficits, amnesia syndrome, syndrome of inappropriate antidiuretic hormone (SIADH), coma, and death.

Assessment 1. Fever, headache, nausea and vomiting, mental status changes. 2. Meningeal signs nuchal rigidity (stiff neck), photophobia. 3. Seizures, motor deficits, personality changes. 4. Signs of brain stem involvement, such as nystagmus, extraocular nerve palsies, hearing loss, dysphagia, and respiratory dysfunction. 5. Patients with hypothalamic-pituitary involvement may develop diabetes insipidus, hypothermia, or SIADH. Diagnostic Evaluation 1. Lumbar puncture evaluates cerebrospinal fluid (CSF) for increased cell count; polymerase chain reaction analysis of CSF for viral antibodies. 2. Electroencephalogram may reveal abnormalities. 3. Gadolinium-enhanced magnetic resonance imaging can detect different patterns of inflammation to differentiate type of encephalitis. 4. Blood cultures rarely identify causative organism, but brain-tissue biopsy may indicate presence of microorganism. 5. West Nile virus serologic testing on blood or CSF. Pharmacologic Interventions 1. Antiviral agent acyclovir given I.V. for 10 days to 3 weeks for herpes simplex virus. 2. Blood cultures and foscarnet I.V. for CMV encephalitis. 3. Anticonvulsants to treat seizures, corticosteroids to reduce cerebral edema, and sedatives and analgesics as supportive therapy. Nursing Interventions 1. Monitoring pupils and vital signs frequently for increased intracranial pressure(ICP; irregular pupils, widening pulse pressure, tachycardia, irregular breathing hyperthermia). 2. Monitor the patients response to medications and observe for adverse reactions. 3. Monitor neurologic status closely. Watch for subtle changes, such as behavior or personality changes, weakness, or cranial nerve involvement. 4. Monitor fluid intake and output to ensure adequate hydration. 5. Maintain quiet environment and provide care gently, to avoid excessive stimulation and agitation, which may cause increase ICP.

6. 7. 8. 9. 10. 11. 12.

Maintain seizure precautions; pad side rails of bed and have airway and suction equipment available at bedside. Maintain standard precautions and additional isolation according to hospital policy to prevent transmission. Administer antipyretics and other cooling measures as indicated. Provide fluid replacement through I.V. lines as needed. Reorient patient frequently. Provide supportive care if coma develops; may last several weeks. Encourage significant others to interact with patient with even while in coma and to participate in care to promote rehabilitation.

Cleft Lip and Palate

A. Description 1. Cleft lip (cheiloschisis) is a congenital anomaly that occurs at a rate of 1 in 800 births. a. If the cleft does not affect the palate structure of the mouth it is referred to as cleft lip. b. Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or it continues into the nose (complete cleft) c. Cleft lip can be unilateral or bilateral. d. It is due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate). 2. Cleft palate (palatoschisis) is a congenital anomaly that occurs in approximately 1 of every 2000 births, and it is more common in boys than girls. a. It is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined. b. It ranges in severity from soft palate involvement alone to a defect including the hard palate and portions of the maxilla. c. Cleft palate may or may not be associated with cleft lip. 3. Children with these structural disorders may have associated dental malformations, speech problems, and frequent otitis media, the latter resulting from improper functioning of the Eustachian tubes.

B. Etiology 1. Many factors are associated with the development of cleft lip and cleft palate, andcleft lip with or without cleft palate is developmentally and genetically different from isolated cleft palate. 2. Most cases appear to be consistent with the concept of multifactorial inheritance as evidenced by an increase incidence in relatives and monozygotic twins. C. Pathophysiology 1. During embryonic development the lateral and medial tissues forming the upper lip palates fuse between weeks 7 and 8 of gestation; the palatal tissues forming the hard and soft palates fuse between weeks 7 and 12 gestation. 2. Cleft lip and cleft palate result when these tissues fail to fuse. D. Assessment findings 1. Clinical manifestations a. Cleft lip and cleft palate are readily apparent at birth. Careful physical assessment should be performed to rule out other midline birth defects. b. Cleft lip and cleft palate appear as incomplete or complete defects, and may be unilateral or bilateral. 2. Laboratory and diagnostic study findings. Obstetric ultrasound will reveal cleft lipwhile the infant is in utero. E. Nursing management 1. Assess for problems with feeding, breathing parental bonding, and speech. 2. Ensure adequate nutrition and prevent aspiration. a. Provide special nipples or feeding devices (eg, soft pliable bottle with soft nipple with enlarged opening) for a child unable to suck adequately on standard nipples.

b. Hold the child in a semiupright position; direct the formula away from the cleft and toward the side and back of the mouth to prevent aspiration. c. Feed the infant slowly and burp frequently to prevent excessive swallowing of air and regurgitation. d. Stimulate sucking by gently rubbing the nipple against the lower lip. 3. Support the infants and parents emotional and social adjustment. a. Help facilitate the familys acceptance of the infant by encouraging the parents to express their feelings and concerns and by conveying an attitude of acceptance toward the infant. b. Emphasize the infants positive aspects and express optimism regarding surgical correction. 4. Provide preoperative care. a. Depending in the defect and the childs general condition, surgical correction of the cleft lipusually occurs at 1 to 3 months of age; repair of the cleft palate is usually performed between 6 and 18 months of age. Repair of the cleft palate may require several stages of surgery as the child grows. b. Early correction of cleft lip enables more normal sucking patterns and facilitates bonding. Early correction of cleft palate enables development of more normal speech patterns. c. Delayed closure or large defects may require the use of orthodontic appliances. d. The responsibilities of the nurse are to: 1. Reinforce the physicians explanation of surgical procedures. 2. Provide mouth care to prevent infection. 5. Provide postoperative care. a. Assess airway patency and vital signs; observe for edema and respiratory distress. b. Use a mist tent, if prescribed, to minimize edema, liquefy secretions, and minimize distress. c. Position the child with cleft lip on her back, in an infant seat, or propped on a side to avoid injury to the operative site; position the child with a cleft palate on the abdomen to facilities drainage. d. Clean the suture line and apply an antibacterial ointment as prescribed to prevent infection and scarring. Monitor the site for signs of infection. e. Use elbow restraints to maintain suture line integrity. Remove them every 2 hours for skin care and range-of-motion exercises. f. Feed the infant with a rubber-tipped medicine dropper, bulb syringe, Breck feeder, or soft bottle-nipples, as prescribed, to help preserve suture integrity. For older children, diet progresses from clear fluids; they should not use straws or sharp objects. g. Attempt to keep the child from putting tongue up to palate sutures.

h. Manage pain by administering analgesic as prescribed. 6. Provide child and family teaching.

Demonstrate surgical wound care. Show proper feeding techniques and positions. Explain that temperature of feeding formulas should be monitored closely because new palate has no nerve endings; therefore; the child can suffer a burn to the palate easily and without knowing it. Explain handling of prosthesis if indicated. Stress the importance of long-term follow up, includingspeech therapy, and preventing or correcting dental abnormalities. Discuss the need for, at least, annual hearing evaluations because of the increased susceptibility to recurrent otitis. The child may require myringotomy and surgical placement of drainage tubes. Teach infection control measures.

Family Planning and Contraception

Family Planning is the conscious process by which a couple decides on the number and spacing of children and the timing of births. Specific Objectives of Family Planning: 1. 2. 3. 4. 5. 6. Avoiding unwanted pregnancies through contraception Regulating intervals between pregnancies Deciding on the number of children that will be in the family Controlling the time at which births occur Preventing pregnancy for women with serious illness in whom pregnancy would pose a health risk Providing the option of avoiding pregnancy to women who are carrier of genetic disease

The overall goal of nursing intervention in family planning is to improve general maternal, neonatal and family health. Preconception Planning an ideal that is not always realized offers couple an opportunity to enhance the probability of having a healthy newborn. It involves examining the health history and physical health of both partners and providing appropriate instruction relative to physical, psychological an financial preparation for pregnancy and childbirth. Contraception is the voluntary prevention of pregnancy. The decision to practice contraception has individual and social implications. Factors to consider when choosing the appropriate contraceptive method: 1. 2. 3. 4. 5. 6. 7. 8. 9. Religious orientation Social and cultural values Medical contraindications Psychological contraindications Individual sexual expression Cost Availability of bathroom facilities and privacy Partners support and willingness to cooperate Personal lifestyle

Abstinence the most effective way to protect against conception. This has 0% failure rate. Also, this is the most effective way to prevent STDs. I. Natural Family Planning Method this involve no chemical or foreign material being introduced into the body. The effectiveness of these methods varies greatly, depending mainly on the couples ability to retain from having sex on fertile days. Failure rates usually

range from 10% to 20%, although theoretical failure rate is as low as 1% or 2%. If pregnancy should occur, the continued use of these methods poses no risk to the fetus. A. Calendar (Rhythm) Method This requires a couple to abstain from coitus on the days of amenstrual cycle when the woman is most likely to conceive (3 or 4 days before until 3 or 4 days after ovulation). B. Basal Body Temperature Method (BBT) The basis of this method is that just before the day of ovulation, a womans BBT falls about half a degree. At the time of ovulation, her BBT rises a full degree because of the influence of progesterone. This higher level is then maintained for the rest of the menstrual cycle. C. Cervical Mucus (Billings) Method Before ovulation each month, the cervical mucus is thick and does not stretch when pulled between the thumb and finger (known as spinnbarkeit). Just before ovulation, mucus secretion increases. With ovulation (the peak day), cervical mucus becomes copious, thin, watery and transparent. It feels slippery and stretches at least 1 inch before the strand beaks. In addition, breast tenderness and an anterior tilt to the cervix occur. All the days the mucus is copious and the 3 days after the peak day are considered to be fertile days, or days the woman should abstain from sex to avoid conception. D. Symptothermal Method The symptothermal method of birth control combines the cervical mucus and BBT methods. The woman takes her temperature daily, watching for the rise is temperature that marks ovulation. She also analyzes her cervical mucus daily. The couple must abstain from intercourse until 3 days after the rise in temperature or the fourth day after the peak of mucus change because these are the womans fertile days. The symptothermal method is more effective than either the BBT or cervical mucus method alone. E. Ovulation Awareness This is another method to predict ovulation with the use of overthe-counter ovulation detection kit. These kits detect the midcycle surge of luteinizing hormone that can be detected in urine 12 to 24 hours before ovulation. Such kits are about 98% to 100% accurate in predicting ovulation. Although fairly expensive, using such kit in place of cervical mucus testing makes this form of natural family planning more attractive to many women. F. Lactation Amenorrhea Method (LAM) As long as a woman is breast-feeding an infant, there is some natural suppression of ovulation. However, the use of lactation as a birth control method is not dependable. Because women may ovulate but not menstruate while breastfeeding, the woman may still be fertile even if she has not had a period since childbirth. After 6 months of breast feeding, the woman should be advised to choose another method of contraception. G. Coitus Interruptus It is one of the oldest known methods of contraception. The couple proceeds with coitus until the moment of ejaculation. The man withdraws and spermatozoa are emitted outside the vagina. Unfortunately, ejaculation may occur before withdrawal is complete and, despite the care used, some spermatozoa may be deposited in the vagina. Because there maybe a few spermatozoa in pre-ejaculation fluid, even though withdrawal seems controlled, fertilization may occur. For these reason, coitus interruptus offers little protection against conception. II. Barrier Methods are forms of birth control that works by the placement of a chemical or another barrier between the cervix and advancing sperm so sperm cannot enter the uterus or fallopian tubes and fertilize the ovum.

A. Spermicides Spermicidal agents cause the death of spermatozoa before they can enter the cervix. Vaginal jelly, cream, suppository, or foam preparations interfere with sperm viability and prevent sperm from entering the cervix. Nonoxynol-9, the active chemical ingredient, destroys the sperm cell membrane. Pregnancy rates among typical users range from 5% to 50%. Advantages are that they are available without prescription, are useful when other methods are inappropriate or contraindicated, and have few or no side effects. They also may provide moderate protection (up to 25%) against some STDs, including gonorrhea and Chlamydia. Disadvantages are that they have a lower effectiveness than other methods, may irritate tissues (most products contain alum), and are esthetically unpleasant. One dose of most spermicides is effective for 1 hour. If a longer time has passed, a new application of spermicide is required. B. Female condom (vaginal pouch) This is a long polyurethane sheath that inserts manually into the vagina with a flexible internal ring forming the cervical barrier and a wide outer ring extending to cover the perineum; it is lubricated with spermicide (nonoxynol-9). It can be inserted up to 8 hours before intercourse and is available over counter (OTC). It is about 80% effective. Advantages are that it protects against STDs and conception, allows the woman to control protection, is inexpensive for single use, and is disposable. Disadvantages are that it is esthetically unappealing, requires dexterity, is expensive for frequent use, may cause sensitivity to sheath material, and decreases spontaneity. C. Male condom This is a rubber sheath that fits over the erect penis and prevents sperm from entering the vagina. The condom is about 86% effective. Advantages are that it helps prevent conception and transmission of STDs (thereby preserving fertility), is available OTC, and has no side effects. In addition, the condom helps men maintain erections longer, prevents premature ejaculation, prevents sperm allergies, and is easily and discreetly carried by men and women. Disadvantages are that it may decrease spontaneity and sensation, and should be used with vaginal jelly if the condom or vagina is dry. Male condoms cannot be used in cases of latex allergy in the man or the woman. There are natural (animal skin) condoms available, but they are expensive and do not protect against most STDs. D. Cervical cap This is a small rubber or plastic dome that fits snugly over the cervix. Effectiveness depends on parity. In parous women, effectiveness is about 60%; in nulliparous women, effectiveness is about 80%. The advantage is that it provides continuous protection for 48 hours, no matter how many times intercourse occurs. Additional spermicide is not necessary for repeated acts of intercourse. Disadvantages are that it may dislodge, must be filled with spermicide, must be fitted individually by a health care provider, and may not be used if the woman has anatomic abnormalities or an allergy to plastic, rubber, or spermicide. Wear for longer than 48 hours is not recommended because of the risk of toxic shock syndrome. Side effects include trauma to the cervix or vagina, pelvic infection, cervicitis, and abnormal Pap test results. Odor problems may occur with prolonged use. E. Diaphragm This is a flexible ring covered with a dome-shaped rubber cap that inserts into the vagina and covers the cervix. The posterior rim rests on the posterior fornix and the anterior rims fits snugly behind the pubic bone. It is used with spermicide in the dome and around the rim, is applied no more than 2 hours before intercourse, and is left in place for 6 hours after coitus, but no longer than 12 ( and never more than 24). Additional

spermicide must be applied for repeated intercourse. Effectiveness is about 80% with typical use. Advantages are that it is reusable and inexpensive with use over several years. Disadvantages are that it requires dexterity to insert, it must be fitted individually, it must be refitted after childbirth or after a weight loss of 15 lb or more. Wear for longer than 24 hours is not recommended because of the risk of toxic shock syndrome. Side effects include toxic shock syndrome, cystitis, cramps or rectal pressure, and allergy to spermicide or rubber. F. Intrauterine device (IUD) This is a flexible device inserted into the uterine cavity. It alters tubal and uterine transport of sperm so that fertilization does not occur. Estimates of effectiveness vary between 93% (typical effectiveness) and 97% (maximal effectiveness). Advantages are that it is inexpensive for long-term use, is reversible, has no systemic side effects, may be used in lactating women, and requires no attention other than checking that it is in place (by feeling for the attached string in the vaginal canal). An ideal candidate for an IUD is a parous woman in a mutually monogamous relationship. Disadvantages are that there are possibly serious side effects. The device is available only through a health care provider and cannot be used if the woman has an active or chronic pelvic infection, postpartum infection, endometrial hyperplasia or carcinoma, or uterine abnormalities. It should not be used by women who have an increased risk of STDs and women with multiple sexual partners. Side effects include dysmenorrheal, increased menstrual flow, spotting between periods, uterine infection or perforation, and ectopic pregnancy. Danger signs to report to the health care provider include late or missed menstrual period, severe abdominal pain, fever and chills, foul vaginal discharge, and spotting, bleeding, or heavy menstrual periods. Spontaneous expulsions occur in 2% to 10% of users in the first year. III. Pharmacologic methods are reversible and contraceptive steroids are now formulated in pills, patches, intravaginal rings, subdermal implants and injections. A. Oral contraceptives Combined estrogen and progesterone preparation in tablet form inhibits the release of FSH, LH, and an ovum. The tablets are taken daily and are available in numerous hormone combinations (and as a progesterone-only preparation. Biphasic and triphasic contraceptives closely mirror normal hormonal fluctuations of the menstrual cycle. They are about 97% effective. Advantages are that they are among the most reliable contraceptive methods and are convenient to use. In addition, they are protective against ovarian and endometrial cancer, benign breast disease, ovarian cysts, ectopic pregnancy, pelvic inflammatory disease (PID), and anemia. Oral contraceptives also tend to decrease menstrual cramps and pain. Disadvantages are that they should not be used by women who smoke; women with a history of thrombophlebitis, circulatory disease, varicosities, diabetes, estrogendependent carcinomas, and liver disease; or by women who are older than 35 years of [Link] and reevaluation are essential every 6 months. No protection is conferred against STDs. Side effects include breakthrough bleeding, nausea, vomiting, susceptibility to vaginal infections, thrombus formation, edema, weight gain, irritability, and missed [Link] signs indicating complications include abdominal pain, chest pain or shortness of breath, headaches, blurred or loss of vision, or leg pain in the calf or thigh. B. Minipills These contraceptive pills contain progestin but no estrogen. A pill must be taken each day and preferably at the same time each day to achieve maximal

effectiveness. The use of minipills results in a thin atrophic endometrium and a thick cervical mucous, which inhibits permeability of sperm. Minipills do not suppress ovulation consistently; 40% of women will ovulate normally. Typical user failure rate is 3%. Advantages are that it may be used immediately postpartum if the client is not breast feeding and 6 weeks postpartum if she exclusively breastfeeding; it is highly effective when combined with breast feeding; it has no estrogen side effects; there is an immediate return to fertility when discontinued; and there is a decreased risk of PID and irondeficiency anemia. Disadvantages include irregular bleeding, increased risk of functional ovarian cysts, increased risk of ectopic pregnancy (if pregnancy does occur), and it must be taken at the same time each day. There is no data to suggest that minipills increase the risk of cardiovascular disease or malignancy. C. Subdermal implants Six, soft, Silastic rods filled with synthetic progesterone are implanted into the womans arm. The progesterone leaks into the bloodstream, inhibiting ovulation, making cervical mucus hostile to sperm and inhibiting implantation in the endometrium. The implants are known as Norplant. Estimates of effectiveness vary from 0.04% failure to 99% effective within 24 hours (dropping to 96% effective after 5 years). Advantages are that they are long acting (effective for up to 5 years), not coitus dependent, reversible, inexpensive over the life of the drug, and require little attention other than health care visits for problems or scheduled health maintenance. Production of thick cervical mucous confers a protective effect against PID. Disadvantages are that they require surgical insertion through a half-inch incision on the inside surface of the nondominant arm. They may be difficult to remove and should not be used by a woman who has active thrombophlebitis, unexplained bleeding, active liver disease or tumor, or known or suspected breast cancer. Side effects include tenderness and bruising at the insertion site, irregular bleeding, headaches, acne, weight change, and breast [Link] of reportable complications include infection, bleeding, or pain at the insertion site; subdermal rod breaking through the skin; heavy vaginal bleeding; severe abdominal pain; and sudden menstrual irregularity after a regular cycle has been established. Any pregnancy that does occur is likely to be ectopic. D. Subcutaneous injections Medroxyprogesterone (DMPA or Depo-Provera) is an intramuscular injection given every 3 months that works like subdermal implants. Effectiveness is similar to subdermal implants. Advantages are that it is highly effective and requires little attention except for returning to the health care provider for injection every 3 months. Also, it may be used by breast-feeding women. Disadvantages are similar to those for subdermal implants. In addition, the risk for breast cancer and osteoporosis may be increased, and there may be a delayed return to fertility (up to 18 months) and a decrease in bone density (reversible). Side effects are similar to those for subdermal implants, primarily spotting, headache, and weight gain. DMPA is likely cause amenorrhea, particularly after the first year. IV. Sterilization is considered a permanent method of contraception. In certain cases, sterilization can be reversed, but this is not guaranteed. For this reason, sterilization is meant for men and women who do not intend to have children in the future. A. Vasectomy Surgical ligation of the vas deferens terminates sperm passage through the vas completely after residual sperm clear the male reproductive tract. It is almost 100% effective (nurses should point out the finality of the procedure). Advantages are that it is highly effective and usually permanent. Disadvantages are that it requires surgery and

may be [Link] success rates vary; anatomic success is 40% to 90%; clinical success is 18% to 60%.There is no protection against STDs. B. Tubal ligation The fallopian tubes are surgically ligated or cauterized either through minilaparotomy or laparoscopy. It is almost 100% effective (nurses should stress the finality of the procedure). Advantages are that it is highly effective and usually permanent. May be performed immediately postpartum. Disadvantages are that it is an invasive procedure and may be irreversible. Tubal reconstruction has a 50% to 70% successful reversal rate; however, there is a high risk of ectopic pregnancy after reversal. In addition, no protection is conferred against STDs. CONTRACEPTIVE FAILURE RATES: Type of Failure Advantages Disadvantages Contraceptive Rate (%) None 85 No motivation necessary Highly unreliable No major health risk; no Unaesthetic to some; Spermicides 21 prescription necessary must be properly inserted Periodic No costs; acceptable to Requires high motivation 20 Abstinence Roman Catholic Church and periods of abstinence Withdrawal 18 No cost Requires Motivation Can use for several days May be difficult to insert; Cervical Cap 18 if desired can irritate cervix No major health risks; Insertion may be difficult Diaphragm 18 easy to use Female Condom 15 Protection against STDs Insertion may be difficult Protects against STDs; Requires interruption of Male Condom 12 male responsibility; no sexual activity prescription necessary No memory or Cramping, bleeding; IUD 3 motivation needed expulsion possible; possible risk of PID Coitus independent Continual cost; possible Pill 3 side effects Coitus independent; Continual cost; continual Injectable 0.3 dependable for 4 to 12 injections progesterone weeks Implanted Coitus independent; Initial cost; appearance 0.04 progesterone dependable for 5 years on arm Female Permanent and highly Initial cost; irreversible 0.4 sterilization reliable Permanent and highly Initial cost; irreversible Male sterilization 0.1 reliable