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| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 Module 2Introduction: Please read through the following information for Module 2 "Medical Profile" When you have finished reading about the Module at the bottom of this page you will be directed to Log onto: Online Module Discussion at the Virtual Conference Center . Glossary:
Seminar Facilitators:
Contents
This session will present medical issues around the discharge of a mother with gestational diabetes and infant with neonatal jaundice and a mother with prenatal marijuana use and infant with neurodevelopmental risks. This presentation will include a slide lecture accessed from the Internet, handouts, and a role-playing exercise. The talk and discussion will take 2 hours. As we begin, we will all be working through the virtual case histories of Mrs. A and her baby and Mrs. B and her baby together. This case is a teaching case not just about two mother and babies but also about how this process may work. Objectives for the first cases (At the end of the first part, participants will experience...)
In the next cases, we will be assigning participants to teams. Participants will begin to assume more and more of the facilitative role as they move through the questions and respond to each other. For now, let's begin by getting a sense of who these two families are as they deliver babies at University Hospital and prepare to leave the hospital for their homes in Northern New Mexico. Please click on the link below and read about Mrs. A and Mrs. B You may want to print this out for later reference. Family Profiles Part 1: Labor and DeliveryMrs. A: Mrs. A, a 22 year old pregnant woman, presents to the Testing and Triage area of the Labor and Delivery Unit of the University Hospital at the UNM Health Sciences Center on 29 October 2001. When she presents, the staff of Testing and Triage diagnose her as in active labor. When asked about her prenatal care, she states that she hasn’t gone to any clinics, but she hasn’t had any illnesses nor taken any medications. The nurses begin the usual admission procedures and order the usual laboratory tests anticipating delivery. Mrs. B: Within the hour, a second woman presents the Testing and Triage area on 29 October 2001. When Mrs. B, a 22 year old pregnant woman, presents, the staff of Testing and Triage also diagnose her as in active labor. When asked about her prenatal care, she states that she went to a family planning clinic to confirm her pregnancy in February, but since then she hadn’t seen a medical provider. Mrs. B states that she hasn’t had any illnesses nor taken any medications. The nurses begin the usual admission procedures and order the usual laboratory tests anticipating delivery. History obtained by the medical student admitting Mrs. A to Labor and Delivery: When the medical student interviews Mrs. A, she tells her that she has had 5 pregnancies, delivered 2 children in the past who both live with her, and smoked marijuana daily until yesterday. She then starts with regular frequent contractions. The student and nurses move Mrs. A to the delivery room where she rapidly delivers a baby girl. The Apgar scores for the newborn are 7 at 1 minute and 9 at 5 minutes. The baby weighs 4 pounds and 9 ounces. History obtained by the medical student admitting Mrs. B to Labor and Delivery: A few hours after Mrs. A delivered her baby girl, the same medical student interviews Mrs. B. Mrs. B tells the student that she has had 5 pregnancies, delivered 2 children in the past who both live with her, but with the last baby she had "sugar diabetes." She then has a gush of amnionic fluid that starts regular frequent contractions. The student and nurses quickly move Mrs. B to the delivery room where she rapidly delivers her baby girl. The Apgar scores for the newborn are 7 at 1 minute and 9 at 5 minutes. The baby weighs 9 pounds and 9 ounces. Part 1: Supporting Information Testing and Triage serves as the first stop for women in labor. At that location, women are admitted to the hospital. After filling out admission forms (if they’re able to do so), the nurses draw blood tests, help the patient change to a hospital gown, and start monitoring the progress of labor. To determine if the woman is in active labor, the frequency and strength of contractions are assessed. A member of the medical team interviews the woman to complete an admission history and physical. As part of the physical, the woman may undergo a limited pelvic examination to determine if the amniotic membranes have ruptured, to assess the number of centimeters of cervical dilation, and if possible to feel whether the baby’s head has moved into the cervix as part of a normal head-first delivery. Questions regarding the assessments for the first part of the cases or what history do we want to obtain from these 2 mothers?
Please post your responses to these questions to the Assessment and Intervention Room for the cases. We’re following the model of Profile, Assessment, Questions, and Learning Issues. After this first part of the profile, through the virtual classroom, we’ll discuss how all of us as providers and learners responded to the first questions. Family Profiles Part 2: The Mother and Baby UnitBaby A has done very well after delivery. She appears very stable and after spending 30 minutes with Mrs. A, the labor and delivery nurse takes Mrs. A and her baby girl to the Mother and Baby Unit for postpartum care. The next morning, the team members responsible for the care of newborns assign a medical student to do the admission history and physical exam for Baby A. As they end their meeting, one of the nurses mentions that the Labor and Delivery team thought Mrs. A appeared "high" at the time of the delivery. However, the baby did well in the transition period with stable breathing and heart rates and normal blood glucose and hematocrit levels. She was taken to the mom’s room during the evening and did well with feedings. The student goes to interview Mrs. A and examine her baby. The student reports to the attending physician after obtaining more information from Mrs. A. The medical team learns that Mrs. A is single and that the baby’s father will not be involved with the new baby or her other 2 children at home. Mrs. A has insurance, but she found herself "too busy" with her part-time work and caring for her other children to make prenatal care visits. At the same team meeting, a second medical student is assigned to do the admission history and physical for Baby B. The nurses reported that Baby B came into the nursery without problems. Her vital signs were stable. With the routine check of the baby’s blood glucose level, the nurses found that Baby B had a lower than normal glucose. Per protocol, they fed the baby an ounce of milk formula by syringe before they repeated the test. Over the first several times the blood glucose was repeated, lower than normal levels required additional supportive feeding with milk formula. After 6 hours, the blood glucose level stabilized and the baby went to Mrs. B’s room. The student goes to interview Mrs. B and examine her baby. The student reports to the attending physician after obtaining more information from Mrs. B. The medical team learns that Mrs. B is single and that the baby’s father will not be involved with the new baby or her other 2 children at home. Mrs. B has insurance, but she found herself "too busy" with her part-time work and caring for her other children to make prenatal care visits. She reports that she weighs 250 pounds and that she gained 35 pounds during her pregnancy.
Please post your responses to these questions to the Assessment and Intervention Room for the cases. Also post any suggested learning issues for us to consider. Part 2: Supporting Information (A) Management of hypoglycemia for newborn infants of diabetic mothers Infants of diabetic mothers may experience acute hypoglycemia when the umbilical cord is cut. In the intrauterine environment, infants of diabetic mothers may express elevated levels of their self-produced insulin to counteract higher than normal levels of glucose carried across placental circulation. At the time the umbilical cord is cut, the infants’ pancreas continues to excrete insulin causing glucose in the blood to move rapidly into storage in cells. This movement of glucose out of circulation may cause the set of symptoms associated with hypoglycemia. In addition, other hormonal systems, particularly glucagon, may not respond to the level that opposes the insulin effect. Newborns have fewer glucagon receptors at birth than later in infancy. This creates the condition for falling serum glucose levels that eventually may decrease available glucose to the brain with resulting CNS problems. The symptoms that suggest hypoglycemia include:
These symptoms also occur with other problems, that is they are nonspecific. Therefore, clinicians have to pay specific attention to the infants’ blood glucose level. Those infants born to diabetic mothers as well as though born smaller than normal for weight or prematurely need routine screening before they develop symptoms. Usually in our hospital, the first testing happens at 2 hours of age repeated every 2 hours until the glucose levels stabilize. However, it is important to screen for hypoglycemia in any infant that shows symptoms like those of hypoglycemia. The testing should be done with a quantitative method if possible. In the immediate newborn transition period, we consider a glucose level below 35 mg/dl a level that needs intervention. Other experts define hypoglycemia as a level below 40 mg/dl. Blood can be obtained from a finger or heelstick or from a venous site. The treatment depends on whether the baby with hypoglycemia seems vigorous and able to eat. For a vigorous infant, the mother can put the baby to breast as soon as possible. Even though the mother may have small amounts of colostrum, the baby may receive enough glucose and fluid to stabilize glucose levels. After feeding, the baby’s nurse will check another quantitative glucose level. If the baby continues to have a low glucose level, the nursing staff will feed the baby formula by cup to protect breastfeeding. If the baby takes bottle feedings, the mother is encouraged to feed the baby frequently. After feeding, the baby’s nurse will check another quantitative glucose level. If the baby continues to have a low glucose level, the nursing staff will feed the baby formula. It is key to continue checking the baby’s serum glucose before feedings at least twice. If the baby seems lethargic or appears ill, the nurses will attempt feeding with glucose water or formula. If the baby will not feed, an intravenous line should be started. Using 10% glucose IV fluid, the baby should get a bolus of 2 mL/kg (6 mL in a 3 kg baby) followed by an infusion of 10% glucose to deliver 6-8 mg/kg/min (10% glucose solution is 10 grams in 100 mL or 10,000 mg in 100 mL or 100 mg in 1 mL. For a 3 kg baby, the rate per hour would be about 10 to 15 mL per hour infusion.) for the next 24 hours.. Continued monitoring of the blood glucose should be done to ensure that the baby’s glucose level stays > 50 mg/kg. In answer to the question of effects on a baby’s brain from hypoglycemia, there is controversy. There is an association between symptomatic hypoglycemia and "risk of long term neurodevelopmental sequelae but the evidence for a causative link is weak." (Williams AF. World Health Organization, 1997. http://www.who.int/child-adolescent/). The major controversy concerns the risk of brain injury for infants with asymptomatic hypoglycemia. Current management recommendations attempt to differentiate between the 2 conditions based on quantitative measures of blood glucose. Part 2: Supporting Information (B) Effects of drugs on the development of infants and children Different drugs cause somewhat different consequences on the developing brains of fetuses. Early in fetal development, exposure to large quantities of drugs such as alcohol or cocaine has the greatest effects on brain structure. Very heavy alcohol may cause the brain to stop developing and growing leading to loss of the pregnancy. Similarly, the effects of heavy cocaine and methamphetamine use on decreasing the blood supply to the fetal brain may result in inadequate blood circulation to the brain and other organs leading to fetal death. Marijuana is unlikely to have such severe effects on the developing brain. Instead, marijuana exerts its effects on the neuroreceptor systems of the developing brain. When the pregnant woman uses it, marijuana metabolites pass through her circulation to the placenta, cross into the circulation of the fetus, and travel across the blood-brain barrier to bind to specific neuroreceptors on the surface of brain cells. The other drugs of abuse follow the same pathways into the fetal brain and also bind to specific receptors on brain cells. Most of the drugs bind brain cells located in areas of the brain that control memory, sensation of pleasure, and sensation of pain. From repeated binding of the neuroreceptor systems, nerve cells are stimulated to generate signals to the rest of the brain and the body. With recurrent use, the neuroreceptor systems begin to alter responsivity to the effects of the drugs. Some receptor systems such as those related to opiate type drugs develop tolerance leading to physical addiction. Other systems lose normal regulation of nerve signals and probably create the loss of inhibitory activity seen clinically. After marijuana exposure prenatally, infants have less quiet-alert time (the time period of the newborn’s cycle that allows the best attention to stimuli). They also manifest more jitteriness of arms and legs. The best studies of longer term effects of marijuana on infant and child development have shown some decrease in abilities to learn. The main effect appears to be on the development of language. However, the studies reported in the literature have to overcome many methodological challenges, and many experts debate the significance of their findings. No study has shown that marijuana or other drugs improve the cognitive and language development of infants and young children. Part 2: Supporting Information (C) Legal issues regarding urine drug testing of newborns Ethical and legal issues Ethical issues drug testing pregnant women Test for medical indications and care Societal interests in identifying drug use Increased safety in home for children Societal interests in infants with exposure Developmental consequences Dyadic implications Engagement in healthier family life Medical Care and Ethics Past policy for urine drug tests Past history of illicit drug use, intoxication Suspected abruption of placenta Premature onset of contractions No prenatal care 5 to 6% infants with prenatal exposure 10% referred to CYFD, notifies police 1 to 2 per year placed in foster care Application in Health Care Poor women with less prenatal care Medicaid clients tested more often Providers reluctant to discuss drug use Use viewed as normal behavior Mothers afraid to disclose use Non-exposed infants have some symptoms Foster care outcomes variable Legal Response and Ethics
Family Profiles Part 3: Day of Discharge from the Mother and Baby UnitAfter Mrs. A and her baby have been patients overnight on the unit, the nursing and medical teams begin preparations for sending them home. The nurses report that Mrs. A has appeared anxious through the night especially when trying to feed her baby. She’d tried to nurse the baby, but the baby seemed sleepy. Most of the previous day and night, Mrs. A put the baby to breast briefly and then gave the baby formula despite reassurances from her nurses. When the urine drug screen results showed a positive test from marijuana, the nurses called the midwife on call to inform her of the results. The midwife stated that the positive drug screen probably came from Mrs. A having spent several days at a home where a lot of people smoked marijuana. The midwife didn’t seem overly concerned that Mrs. A had a past history of using marijuana. Part 3: Supporting Information Child development after severe hyperbilirubinemia
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