23 Questions Antepartum and Intrapartum

1         23 Questions Antepartum and intrapartum  GTPAL G (Gravida): the number of pregnancies T (Term): number of infants born at ≥ 37 P (Preterm): born after 20 weeks but before the completion of 37 weeks. A (Abortion): pregnancies ending in either spontaneous or therapeutic abortion before the end of 20 weeks. L (Living): number of currently living children. o Due Date: from the month of their last period add nine months, then add seven days to the first day of their last period. o Nägele’s Rule: most common method of determining the EDB, which uses 280 days as the mean length of pregnancy. To use this method, begin with the first day of LMP, subtract 3 months and add 7 days. For  SIGNS OF PREGNANCY Presumptive Changes Subjective symptoms experienced by the woman. Doesn’t confirm pregnancy. o Morning sickness o Excessive fatigue o Urinary frequency o Breast changes o Quickening Probable Changes Objective changes that occur in pregnancy. Doesn’t confirm pregnancy since it could be due to others things o Goodell’s - Softening of the cervix o Chadwick’s - Dark violet coloration of cervix o Hegar’s - Softening of lower part of uterus o Progressive uterine enlargement o Enlargement of the abdomen with amenorrhea (no period) o Braxton-Hicks contractions o Fetal outline Ballottement: passive fetal movement elicited when the examiner inserts two fingers into the vagina and pushes against the cervix. This action pushes the fetal body up and as it falls back down, the examiner feels a rebound o Pregnancy test Positive Changes Diagnostic test that confirm pregnancy o Fetal heartbeat: detectable by doppler ultrasound o Fetal movement: detected by echocardiography or transvaginal sonography o Fetal soufÒé: blowing murmur, synchronous with the fetal heartbeat   TRUE VS FALSE LABOR: Many times the only way to tell between true or false is to asses effacement and dilation. TRUE LABOR: Contractions of TRUE LABOR produce progressive DILATION and EFFACEMENT of the Cervix, occur regularly with increase in frequency, duration and intensity. The discomfort of true labor contractions usually starts in the back and radiates around the abdomen. pain is not relieved by ambulation (walking may actually intensify pain) FALSE LABOR: The contractions of FALSE LABOR DO NOT produce cervical effacement and dilation. They are irregular, and do not increase in frequency, duration, and intensity, perceived as a hardening or “balling up” without discomfort, or discomfort may occur in the lower abd. or groin. Discomfort may be relieved by ambulation, change position.          SIGNS OF ONSET OF LABOR S/S of impending labor Lightening (when the fetus begins to settle into the pelvic inlet (engagement). Braxton Hicks Contractions Cervical Changes: softening of the cervix is called ripening Bloody Show: with softening and effacement of the cervix the mucous plug is often expelled. Rupture of Membranes (ROM) Sudden Burst of energy (nesting) Other signs: weight loss of 1-3 lb resulting from fluid loss, diarrhea, indigestion, or N/V just before the onset of labor.    2  STAGES OF LABOR AND BIRTH First stage begins with the onset of true labor and ends when the cervix is completely dilated to 10 cm, divided into the latent, active, and transition phases. 1. Latent (early) Phase: o beginning of regular contractions, usually mild, woman able to cope with the discomfort, may feel anxious, and able to recognize and express feelings. Woman is often talkative and is eager to talk about herself and answer questions, her partner or other support person is often as elated as she is o They may start as lasting 30 seconds with frequency of 10 to 30 minutes and progress to moderate ones lasting 30-40 seconds with frequency of 5 to 7 minutes. As the cervix begins to dilate and effaces (little or no fetal descent is evident). o For a primipara, latent phase of labor averages 8.6 hours but should not exceed 20 hours, in multipara averages 5.3 hours but should not exceed 14 hours. o Spontaneous Rupture of membranes (SROM) occurs at the height of an intense contraction with a gush of fluid out of the vagina. In many instances ruptured by the certified nurse-midwife (CNM) or physician, using an amnihook, procedure is called an amniotomy, or artificial rupture of membranes (AROM). 2. Active Phase: o Anxiety increases as the contractions and pain increases. Shows decreased ability to cope and a sense of helplessness. Women who have support may feel greater satisfaction and less anxiety than those without support. o Cervix dilates from about 4 cm to 7 cm. Fetal descent is progressive. o Cervical/dilation averages 1.2cm/her in primiparas and 1.5cm/hr in multiparas 3. Transition Phase o Last part of the first stage of labor, woman shows significant anxiety. Becomes acutely aware of the increasing force and intensity of contractions, may become restless, and changes position frequently. o Often already tired. Fears to be left alone, the nurse should reassure her that she will not be left alone. o Contractions have a frequency of 1.5 to 2 minutes, a duration of 60-90 seconds, and strong in intensity. o Cervical dilation slows down and progresses from 8 to 10 cm and the rate of fetal descent dramatically increases. o This phase does not last > 3 hours for primiparas or > 1 hour for multiparas. o Other characteristics of this phase may include: Increasing bloody show – Hyperventilation - Generalized discomfort, low backache, shaking, cramping in legs - Increased need for partners’ or nurse’s support – Restlessness - Increased apprehension and irritability - A sense of bewilderment, frustration, and anger at the contraction - Request for medication - Hiccupping, belching, N/V - Beads of perspiration on the upper lip or brow - Increasing rectal pressure and an urge to bear down.  Second stage begins with complete dilation and ends with the birth of the baby, usually completed within 3 hours after fully dilation for primiparas; the stage averages 15 minutes for multiparas. o Contractions frequency 11/2 to 2 minutes, duration 60-90 seconds and strong intensity. Descent of fetal presenting part continues until it reaches the perineal floor. o During this time, the “first phase”, passive fetal descent occurs in response to uterine contractions. Nursing tasks during this phase include: 1. Assessing the woman’s perception of the need or urge to push 2. Evaluating the maternal-fetal oxygenation status 3. Assessing fetal status through recommended monitoring protocols. o Second phase is known as the pushing phase, occur with the urge to push, and the woman starts to push with her contractions. 1. Assessing the effectiveness of the maternal pushing efforts 2. Providing encouragement and direction to obtain a more adequate pushing effort 3. Assessing fetal response that occurs as maternal pushing is performed including continued fetal assessment measures. o Crowning: fetal head is encircled by the external opening of the vagina (inroitus)  MECHANISM OF LABOR/ CARDINAL MOVEMENTS OF LABOR 1. Descent: four forces: (1) pressure of the amniotic fluid, (2) direct pressure of the uterine fundus on the breech, (3) contraction of the abdominal muscles, and (4) extension and straightening of the fetal body. 2. Flexion: fetal head descend and meets resistance. As a result of the resistance the fetal chin flexes downward onto the chest. 3. Internal rotation: fetal head must rotate to fit the diameter of the pelvic cavity. 4. Extension: resistance of the pelvic floor assist with extension of the fetal head as it passes under the symphysis pubis. 5. Restitution: once the head is out and is free of pelvic resistance, the neck untwists, turning the head to one side (restitution) and aligns with position of the back in the birth canal. 6. External rotation: as shoulders rotate to the antereoposterior position in the pelvis the head turns farther to one side 7. Expulsion: as lateral flexion of the shoulder and head occurs the anterior shoulder is born before the posterior  3           shoulder, the body follows quickly. Third stage begins with the birth of the baby and ends with expulsion of the placenta. o After birth the uterus contracts firmly, decreasing the surface area of the placental attachment. The placenta begins to separate due to this o When the signs of placental separation appear, the woman may bear down to aid in expulsion. A placenta is considered retained if 30 minutes have elapsed from completion of the second stage of labor. Fourth stage, last 1 to 4 hours after expulsion of the placenta, the uterus contracts to control bleeding at the placental site. With the birth, hemodynamic changes occur. Blood loss ranges from 250 to 500 mL, results in a drop in BP, increased pulse pressure, and moderate tachycardia. o Woman may feel thirsty or hungry. She may experience shaking chill. o Bladder is often hypotonic due to anesthetics that decrease sensations. Hyptonic bladder can lead to urinary retention. o women should be assisted during their initial attempt to ambulate since dizziness and syncope can lead to falls.  FETAL POSITION AND ENGAGEMENT Bones are not fused, head can adjust in shape as it passes through the narrow portions of the pelvis. The cranial bones overlap under pressure, called molding, sutures allow for molding, allows clinician to identify position of the head Fetal atÝtude: relationship of baby’s limbs to body, normal atÝtude: moderate flexion of head, flexion of the arms to chest, and flexion of the legs onto the abdomen. Fetal lie: fetal spine as it relates to the mother’s spine (oblique, longitudinal, transverse) Fetal presentation: determined by fetal lie and presenting part in the pelvic passage (cephalic, breech (buttocks), or shoulder) Engagement: occurs when the largest diameter of the presenting part reaches or passes through the pelvic inlet, at the ischial spines. Station: relationship of presenting part to the ischial spines and the maternal pelvis. if the presenting part fails to descend with contractions there may be disproportion between maternal pelvis and presenting part.  Ischial spines: 0 station; when engagement occurs  Above ischial spines: (–) minus station; presenting part at pelvic inlet  Below ischial spines: (+) plus station; presenting part descended past ischial spines Fetal Position: refers to a designated landmark on the presenting fetal part to the front, sides, or back of the maternal pelvis. o vertex presentation is the occiput o face presentation is the mentum o breech presentation the sacrum o Should presentations the acromion process 4     DECELERATIONS Early Deceleration: before onset of uterine contraction, is uniform shape, usually considered benign, and does not require intervention. Late Deceleration: onset after the onset of a uterine contraction caused by uteroplacental insufÏciency results from decreased blood flow and O2 to the fetus through the intervillous spaces during uterine contractions; most common cause: maternal hypotension resulting from epidural anesthesia and uterine hyperstimulation associated with oxytocin infusion. Considered a nonreasseuring sign but does not necessarily require immediate childbirth. However id they continue caesarean birth may be indicated. Variable Deceleration: onset varies in timing with the onset of the contraction. Occurs if umbilical cord becomes compressed, reducing blood flow between the placenta and fetus. This pattern requires further assessment. Variable decelerations Early decelerations Accelerations Late decelerations   •      Cord compression Head compression Oxygenation and perfusion is good! Poor oxygenation, uteroplacental insufÏciency, NEVER REASSURING Managing Decelerations: Early decelerations: No intervention necessary; however, the nurse may choose to reposition the patient Late and variable decelerations: o Reposition to left lateral o Administer oxygen via face mask o Give IV fluids (bolus) o Turn off Pitocin, if applicable o Notify physician as needed  DRUGS DURING LABOR Opioid analgesics o Morphine sulfate o Demerol (Meperidine); can be given up to the second phase of first stage. Fetal Effects: Liver/kidney clears drug slowly (immature liver); Respiratory depression @ birth Reversal agent (Narcan) o Sublimaze (fentanyl); Narcotic angonist-anatagonist compound: Stadol; Nubain  FHR needs to be between 120-160, SVT needs to be present and LTV is average, accels are noted with normal fetal movement  Contraction pattern needs to be well established, cervix is dilate 4 cm (varies a little in first time versus multiparas)  Never given within 1 hour of birth - minimal use to the mother at this point and can cause fetal respiratory depression  IF MOTHER GETS DEMEROL TOO LATE BABY CAN COME OUT W/ RESPIRATORY DEPRESSION.  STEROIDS ARE USED TO MATURE LUNGS OF PRETERM BABIES GIVEN BEFORE THE DELIVERY. (DEXAMETHASONE) Prepidil: softens the cervix, rippening (also used Cervidil, Cytotec) Terbutaline: tocolitic for version Oxytocin (petocin): used for augmentation or induction of labor. Produces contractions; if contractions are 1-2 minutes lasting >90 sec discontinue. If uterus tone >20 at rest stop petocin. Normal Tone 5-15 mmHg at rest. EPIDURAL BLOCK: o Most commonly used and controversial in the United States, most effective and flexible method of pain management o Used for vaginal births; Given in the active phase of the first stage of labor; cervical dilation 4-5 cm between L2 and L3 o Fetal head engaged at zero station; Reassuring FHR pattern o Advantages: Fully awake; good relaxation; Airway reflexes remain intact; Gastric emptying not delayed; Minimal blood loss o Disadvantage: Hypotension; N/V; Pruritis; Urinary Retention; Temperature o NURSING MANAGEMENT: Epidural anesthesia  Monitoring maternal and FHR  NPO  Insertion of foley catheter  IV access established; Loading dose (500ml-1000ml) to prevent HYPOTENSION (most common side effect) EPHEDRINE used when BP is still low after fluids.  Monitor VS (specially BP) according to agency policy, Adverse reactions and complications  Positioning PUDENDAL ANESTHESIA: o Administered during the second stage of labor transvaginally into the pudendal nerve provides pain relief within 2-10 min, last for approx. one hour. Provides anesthesia for vaginal births, forceps or vacuum extraction, perineal repair 5  • • • • • • • • • • • • •    o Monitoring: Assess maternal FHR and maternal BP o Advantage: easy to administer, no risk of maternal hypotension, doesn’t affect maternal HR or FHR o Disadvantages - include risk for ligament hematoma, perforation of rectum and trauma to sciatic nerve SPINAL ANESTHESIA: o Advantages: Immediate onset; Ease of administration; Smaller dose; Excellent muscle relaxant; Does not pass through placenta o Disadvantages; Cannot sense urge to push, might need forceps or vacuum extraction; Bladder and uterine atony; Spinal headaches, Headache is normal a few days after o NURSING MANAGEMENT: pt. must lie flat 6-12 hours after injection; monitor for adverse reactions and complications, Postdural spinal headache; Epidural blood patch 20 Questions: Assessment of the Postpartum (woman (6 WKS)  MATERNAL AND PATERNAL ADJUSTMENT Taking-in First PP day or 2, mother preoccupied with own needs Tells her story Passive, independent Touches and explores infant Taking-hold Second or third PP day ready to resume control Obsessed with body functions Anticipatory guidance most effective Rapid mood swings Mothering functioning established; sees infant as unique person Engrossment Father’s absorption, preoccupation, and interest in infant; stimulated by active participation in the birth  FUNDAL HEIGHT At delivery fundus is at the umbilicus 1-2 hours: midway between umbilicus and symphysis pubis 12 hours: rises back to 1 cm above or at umbilicus. After that the height of the uterine fundus decreases (involutes) by approximately 1 cm per day. Involution of the uterus-rapid reduction in size of the uterus to a non-pregnant state following birth. Should remain firm at all times o Boggy-soft; bad need to massage o Blood and clots formation o Failure of uterus to contract o If off to the side; suspect full bladder Subinvolution is the failure of the uterus to return to a nonpregnant state o Common causes- retained placental fragments and infection o Methergine – provides sustained contractions for subinvolution  POSTPARTUM HEMORRHAGE Early (Primary) postpartal hemorrhage occurs in the first 24 hours after childbirth. Uterine Atony o Contributing factors: Over distension caused by multigravida; hydramnios; or large infant (Macrosomia); Twins; Dysfunctional or prolonged labor. Oxytocin augmentation or induction of labor. Use of anesthesia, magnesium sulfate, CCBs, or tocolytics; use vacuums or forceps. Retained placental fragments. Preeclampsia. Asian and Hispanic heritage. Placenta Previa. o If not contracted after birth, fundal massage performed until fundus contracts, fundal massage is painful. If bleeding persist, HCP may order IV oxytocin. IV fluids may be required as well as blood transfusions; depends on the H&H and coagulation 6                                 studies. Surgical interventions may be required if bleeding does not stop. Manual compressions (PutÝng pressure on the uterus internally). Uterine balloon tamponade is a successful technique to stop bleeding. Lacerations of the genital tract; Retained placental fragments; Vulvar, vaginal, and pelvic hematomas- result from injury to a blood vessel from birth trauma. Uterine inversion- Prolapse of the fundus to or through the cervix so that the uterus is, in effect, turned inside out after birth. Late (Secondary) postpartal hemorrhage occurs from 24 hours to 6 weeks after birth. Usually caused by subinvolution (failure to return to normal size). Subinvolution commonly diagnose during the routine postpartal examination at 4 to 6 weeks.  POSTPARTUM BLUES Usually resolves in 10-14 days but can last up to 6 weeks. Precipitated by decrese in estrogen and progesterone level Adjustment reaction with depressed mood is known as the postpartum blues Postpartum mood episodes with psychotic features is worse Contributing factors: emotional letdown (failure to be the “perfect mother”), physical discomfort, and fatigue, anxiety to care for newborn, severe pms, depression during pregnancy or hx of depression. S/S: tearfullness, anorexia, difÏculty sleeping.  BREASTFEEDING AND CARE Engorgement: Nipples are hard and distended with congestion and accumulation of milk Causes can be not fully emptying Mastitis-infection of the breast tissue causative organisms=staph, e-coli, or strep Can cause difÏculty in latching on, bc nipple becomes less pliable Cold compress if mother doesn’t want to breastfeed, and tight bra. If breastfeeding can put warm compresses Encourage feeding every 2 -3 hrs. Express small amount of breast to help soften breast and to latch successfully. Assess symmetry, redness, drainage, bruising, consistency, lumps , cracked nipples Milk production: Colostrum- secreted mid pregnancy, 1st milk baby receives, lasts 3 days (immunoglobulins, antibodies, bacteria for babys gut-helps prevent hyperbilli, antioxidants, laxative effects to help release meconium) does not contain high fat, takes place after day 3. Yellowish and is a creamy fluid, thicker than milk Transition milk- intermediate colostrum and mature milk, contains more fat Mature milk - white or blue tinged (starts in 2 weeks) Let down reflex = release of oxytocin and prolactin. Oxytocin Contracts and ejects milk. Successdul lactation depends on infant sucking production and delivery of milk  LOCHIA Assess character, amount, odor, and the presence of clots. Wear gloves to assess fundus or to assess perineum. Has fleshy odor but not foul. Consist of blood from vessels at the placental and decidual debris. Suggests the stage of healing. Pooling of blood in vagina may cause a gush of blood upon standing. Clots should not be larger than quarter size. The pads should never be fully saturated. If having a hard time assessing volume, instruct patient to put on clean pad and recheck in one hour, weigh pad, 1g = 1 mL. Rubra - Red and lasts 3 days. Serosa - brownish, contains WBCs from 3-10 days. Alba - Whitish, from day 10 up to 6 weeks OVULATION: precedes menstruation; non-nursing mothers will resume menstruation by 12 wks; nursing mothers by 6 months  EPISIOTOMY CARE Ice packs generally applied to the perineum to reduce edema and provide numbing of the tissues, which promotes comfort. To attain maximum effect of this cold treatment, a pattern of applying the ice pack for approximately 20 minutes and then removing it for about 10 minutes should be followed during the first 2 hours to reduce edema. Usually ice packs are needed for the first 24 hours to reduce pain. Sitz baths provide comfort, decrease pain, promote circulation, and reduces the incidence of infection. Topical agents Tighten buttocks before sitÝng. Signs of infection are: redness, edema, drainage, incomplete approximation of the edges.  AFTERPAINS 7 • • • • Intermittent uterine contractions Common in multiparas than primiparas May cause the mother severe discomfort for 2-3 days after birth Breastfeeding also increases the frequency and severity of afterpains 20 Questions Newborn Care and Assessment  APGAR SCORE Sign A Appearance/Color P G A R Pulse Grimace/reaction Activity/Muscle tone Respiratory effort 0 Blue/pale Absent Absent Limp Absent 1 Pink body with blue extremities <100/min Grimace/whimper Some flexion Slow, weak cry 2 Pink >100/min Cough/sneeze/cry Active/spontaneous Regular, good cry  Apgar Score is recorded at 1 minute and at 5 minutes after birth, and at 10 minutes if needed  Heart Rate = Absent (0) - < 100 (1) - >100 (2)  Respiratory effort = Absent (0) - Slow Irregular (1) - Good crying (2)  Muscle tone = Flaccid (0) - Some flexion of extremities (1) - Active motion (2)  Reflex Irritability = None (0) – Grimace (1) - Vigorous cry (2)  Skin Color = Pale Blue (0) - Body pink, blue extremities (1) - Completely Pink (2) Interventions:  8-10: no intervention except to support newborns spontaneous efforts, nasopharyngeal suctioning  4-7: Stimulate; rub newborn’s back; administer oxygen to newborn; rescore at specific intervals  0-3: Newborn requires full resuscitation; score at specific intervals  Apgar scores of less than 3 at 5 minutes postbirth may correlate with neonatal mortality.  Establish airway suction mouth first then nose      Vital sign – normal findings Respirations = Rate 30-60 (nares shouldnt flare, indicator of respiratory distress) Apical Pulse = Rate 120-160 (80-100 asleep – up to 180 crying) Temperature = Skin Temp above 36.5C – 37C (96.8-99F) Skin Color = Body pink with bluish extremities Umbilical Cord = 2 Arteries and 1 Vein  Gestational Age = Should be 38-42 wks to remain with parents for extended time.  Sole creases= Sole creases that involve the heel.  BP: 80/46 Basic Measurements o Weight: Average 2500-4000g (7lb 8oz) o Length: 45-55 cm (18-22 in) o Head: 32-37 cm (12.5-14.5 in) o Chest: 30-33cm (12.5 in) o Abdomen: 30-33cm Fetal Development 4 wks: heart begins to beat 8 wks: body organs are formed 8-12 wks: heart can be heard 16 wks: you can know the sex of the baby 20 wks: heart can be heard with a fetoscope, feels movemnt Phytonadine (vit K)    THERMOREGULATION Maintenance of thermal balance by the loss of heat to the environment at a rate equal to the production of heat; the newborn responds with increased oxygen consumption and metabolism. Prolonged exposure to the cold may result in depleted glycogen stores and acidosis. Convection - loss of heat from warm body surface to the cooler air currents. (Having a cooler environment than that of the babies temperature) 8     • • • • • • • • • • •                    Radiation (Indirect) - loss of heat transfer from the heated body surface to cooler surfaces and objects not in direct contact with the body. (Giving of heat just like radiating) Evaporation - loss of heat when water is converted to a vapor. The newborn is prone to heat loss immediately after birth when the baby is wet with amniotic fluid, as well as during baths; therefore drying the newborn is critical. Conduction (Direct) - loss of heat to cooler surfaces by direct skin contact. Chilled hands, cold scales, cold stethoscopes.  JAUNDICE Physiological Jaundice: Accumulation of bilirubin, results in yellowish coloring of skin and mucous membranes. Formed when body breaks down old RBC. Liver usually processes and removes the bilirubin but immature liver cant. Predisposing factors: Prenatal DM, Torch, Rh and ABO incompatibilities. Prematurity, Polycythemia, baby’s bowel obstruction Occurs at 24 hours, peaks at 72 hours, last about 5-7 days in full term, 9-10 days in preterm. Pathologic jaundice Bilirubin > 4mg/dl in cord blood; Total serum bilirubin increasing by > 5mg/dl over 24 hours or 0.5mg/dl or more over 4-8 hours Clinical jaundice with 24 hours of birth In preterm newborn: over 10mg/dl at any time In term newborn: > 15mg/dl that persist over 10 days Visible jaundice > 21 days in a preterm or >10 days in a term infant; unless breastfeeding Normal physiological changes PKU screening Effects: Can cause kernicterus; Permanent brain damage; Motor abnormalities; Deafness; Mental retardation; Seizures; Death Interventions o Laboratory monitoring o Fluids o Monitoring intake and output o Phototherapy o Exchange transfusion o Parental education  TERMS Acrocyanosis - Bluish discoloration of hands and feet, normal in first 2-6 hrs after birth, may be intermittently 7-10 days; caused by poor peripheral circulation, results in vasomotor instability and capillary stasis, especially when the baby is exposed to cold. Mottling - lacy pattern of dilated blood vessels under skin, results of general circulation fluctuations; may be r/t chilling or prolonged apnea, sepsis, or hypothyroidism. Harlequin Sign (clown) - deep red color develops over one side of the newborns body while other side remains pale. May indicate shunting of the blood occurs w/ cardiac problems or sepsis. Last 1 to 20 mints, may occur in episodes; document every occurrence. Erythema Toxicum- common rash that does not require any treatment, spontaneously goes away in 5–7 days. Cause unknown Milia - exposed sebaceous glands, raised white spots on the face, especially across the nose. No treatment necessary. Skin Turgor - determine hydration status, the need to initiate early feedings, and presence of any infectious process; place to assess skin turgor: over abdomen, forearm, and thigh. Skin should be elastic and return rapidly to original shape. Vernix caseosa - whitish, cheese-like substance that covers fetus. Term/postterm babies have less Vernix than preterm. Stork Bites (telangiectatic nevi) - Appear as pale pink or red spots, frequently found on the eyelids, nose, lower occipital bone, and nape of the neck. More noticeable during periods of crying. No clinical significant, usually fade by the second birthdate. Mongolian spots - macular areas of bluish black or grey-blue pigmentation on the dorsal area of buttocks. Commonly found in Hispanics, Asian, and African American race. Strawberry Mark (Nevus vasculosus) - capillary hemangioma, raised. Newly formed and enlarged capillaries in dermal and subdermal. Found in the head and it subsides on its own by 7-9 y/o. Port-wine stain (Nevus flammeus) – capillary angioma below the epidermis, nonelevated, sharply demarcated. Red to purple, common in face, doesnt fade with time, may need surgery. Meconium - dark, sticky first stools of the neonate. Has to pass within the first 24 hours of life. Lanugo - fine, soft, downy hair found on the neonate. Hypoglycemia - low blood sugar in a neonate, mostly defined at glucose < 40mg/dL. IDM- Infant of diabetic mother. Physiologic jaundice - caused by excessive breakdown of red blood cells. Pseudomenstruation - blood-tinged vaginal discharge noted after birth related to maternal hormones. Kernicterus - excessive accumulation of unbound, unconjugated bilirubin that is distributed to brain tissues. Caput succedaneum - occurs due to trauma during birth or due to the use of a vacuum during delivery. Localized edema that usually is reabsorbed within 12 hours to a few days after birth (Overrides suture lines) Cephalohematoma (Does not override suture lines) - collection of blood resulting from ruptured vessels between surface of cranial bone and the periosteal membrane. May be unilateral or bilateral without crossing suture lines. Relatively common in vertex birth, 9               may disappear within 2 wks to 3 months. May be associated with physiologic jaundice, extra RBC being destroyed within the Cephalohematoma. Moro - involuntary response to stimulation seen at birth. Disappears after 3-4 months. Absence on both sides suggests damage to the brain or spinal cord. Absence on one side suggests either broken shoulder bone or injury to the group of nerves Babinski reflex - Toes fan outward when sole of foot is stroked. Palmar grasp - Infant closes hand and "grips" your finger. Plantar grasp - Infant flexes the toes and forefoot. Placing - Leg extends when sole of foot is touched. Glabellar - blinking response due to a tap on the bridge of the nose. Stepping - Takes brisk steps when both feet are placed on a surface, with body supported. Tonic Neck - Left arm extends when infant gazes to the left, while right arm and leg flex inward, and vice versa. Magnet – apply pressure to feet with fingers when the lower limbs are semiflexed, legs extend against examiners pressure Cremastric – testes retract when infant is chill Galant (truncal incurvation) – place infant prone on flat surface, run finger down side of back first on one side then down the other 4 to 5 cm lateral to spine, body flexes and pelvis swings towards stimulated side Wink Reflex – anal sphincter responds to touch, open and close Extrusion – touch or depress tip of tongue, tongue is forced outward Rooting – touch infant’s lip, cheek, or corner of mouth with nipple, turns head towards stimulus, opens mouth.