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OB Exam 2 Study Guide COMPLICATIONS DURING PREGNANCY: Pre-Eclampsia: condition in which HTN develops (>140/90 mmHg) during the last half of pregnancy in a woman who previously had normal blood pressure; renal involvement may also cause proteinuria (> 0.3 g in 24-hour urine collection) and generalized edema o ONLY CURE IS BIRTH OF FETUS o Maternal and fetal morbidity can be minimized if detected early and managed carefully Major cause of perinatal death and often associated with intrauterine fetal growth restriction o Caused by generalized vasospasm possible that preeclampic women develop sensitivity to effects of vasoconstrictors like angiotensin II; peripheral vascular resistance increases and decreased vasodilators This ultimately causes vasoconstriction, reducing the flow of blood to kidneys, liver, brain, and placenta o Risk Factors First pregnancy First pregnancy for father/man who has fathered one preeclamptic pregnancy Age > 35 years Anemia Family/personal history of pregnancy-induced HTN Chronic HTN Preexisting valvular/renal disease Obesity Diabetes mellitus Antiphospholipid syndrome Multifetal pregnancy o Prenatal Care Monitor weight gain and blood pressure Assess and monitor urinary protein levels Home Care Lateral position for at least 1.5 hours to decrease pressure on vena cava (increases cardiac return and circulatory volume to improve perfusion) BP checks 2-4 times/day check in same arm, same position Daily weights same scale, same clothing Daily urine dipstick checking for protein No salt diet/Fluid restriction Fetal Assessments monitor for reduced fetal compromise (reduced fetal movement) o Appointments for ultrasounds to monitor fetal growth and quantity of amniotic fluid o Signs & Symptoms Classic Signs: First indication = HTN BP should be measured at same position, same extremity with each visit (should be seated, arm supported, appropriate cuff size)
Proteinuria Additional Signs: Vascular constriction and narrowing of small arteries in retina Hyperreflexia of DTRs due to decreased brain circulation and edema Generalized edema first may manifest as rapid weight gain due to fluid retention, but is usually a nonspecific sign Symptoms: Continuous headache, drowsiness, mental confusion indicates poor cerebral perfusion and are often a precursor to seizures Visual disturbances blurred/double vision/spots indicate arterial spasms and retinal edema Numbness/tingling of hand/.feet compression of nerves by extra fluid Epigastric pain indicate distension of hepatic capsule and may indicate seizure is about to occur Decreased urinary output poor perfusion of kidneys and may precede acute renal failure Management Only cure is delivery MUST OCCUR if any deterioration occurs, either maternal or fetal o Vaginal birth is preferred If < 34 weeks steroids (betamethasone) can be given to accelerate fetal lung maturity and attempt to delay birth for 48 hours o Severe Preeclampsia >160/110 mmHg and immediate delivery is required Management BR in lateral position Quiet, calm environment to reduce incidence of seizures Antihypertensives with severe preeclampsia, at higher risk for stroke/CHF o Hydralazine vasodilator, so increases cardiac output and blood flow to placenta o Nifedipine, Labetalol can also be used o Antihypertensives often contraindication with magnesium sulfate because hypotension can occur, reducing placental perfusion Anticonvulsants o Magnesium sulfate CNS depressant because blocks neuromuscular transmission and decreases amount of acetylcholine Relaxes smooth muscle, including uterus and reduces vasoconstriction, resulting in moderate BP decrease and promotes circulation Administered via IV infusion (piggyback) immediate onset Two RNs to check May show decreased fetal HR variability but not a cause for concern
Nausea and vomiting Severe edema Avoid abdominal palpation and use care in transporting to avoid traumatizing the liver Hepatic rupture can lead to fetal and maternal mortality Sudden increase in intrabdominal pressure leads to rupture of subscapular hematoma, resulting in internal bleeding and hypovolemic shock o Management Magnesium sulfate to control seizures Hydralazine to control BP IV Fluids to avoid worsening of reduced intravascular volume, but do not give to much which could cause pulmonary edema Cervical ripening and labor induction if > 34 weeks Induction is preferred to avoid bleeding and clotting complications that accompany C-sections and anesthesia is often difficult due to edema; low platelets may reduce safety of epidurals/spinals C-section preferred if unfavorable cervix or far from term Labor is delayed if < 34 weeks if mother is stable Can give antenatal steroids (betamethasone) to accelerate fetal lung maturity Hypertension Disorders in Pregnancy: o Gestational Hypertension: > 140/90 mmHg that develops after 20 weeks of pregnancy, but return to normal within 6 weeks postpartum; Proteinuria is not present o Chronic Hypertension: >140/90 mmHg that existed before pregnancy or develops before 20 weeks gestation; Also diagnosed if HTN does not resolve during postpartum period Risk Factors Older women (> 35 years/late childbearing age) Obese Diabetes African-American women Secondary to another disease process (renal disease/autoimmune disorder) Management Monitor BP, proteinuria to due increased risk of development of preeclampsia Consult dietician increase protein, reduce salt Frequent prenatal visits regular fetal surveillance Antihypertensive either continue current meds or Methyldopa o ACE inhibitors not recommended during pregnancy, but ok during postpartum o Avoid diuretics because may decrease blood volume, which may already be reduced if preeclamptic Thiazides are safe during pregnancy Rh Incompatibility o Possible if: Mother is Rh-negative
Fetus is Rh-positive (thus father is Rh-positive) o Pathophysiology When Rh-positive blood enters Rh-negative bloodstream, blood reacts as if it is a foreign substance and develops antibodies against “invading” antigen to destroy the Rh antigen, the whole RBC must be destroyed Most exposure of maternal blood to fetal blood occurs during third stage of labor, when active exchange of fetal and maternal blood may occur from damaged placental vessels First child is not usually affected because antibodies are formed after birth of infant and subsequent fetuses may be affected unless mother receives RhoGAM to prevent antibody formation Antibodies to Rh factor cross placental and destroy fetal RBCs and thus fetus becomes deficient, which are needed to transport O2 to fetal tissues ERYTHROBLASTOSIS FETALIS Fetal bilirubin increases, leading to neurological disease like staining of brain tissue (kernicterus) and bilirubin encephalopathy) Results in rapid production of erythroblasts (immature RBCs) which can’t carry O Fetus becomes so anemic that generalized edema results and can end in fetal CHF o Prenatal Assessment and Management Initial prenatal visit blood test Rh-negative indirect Coombs test to determine whether they are sensitized (have developed antibodies) as a result of previously exposed Rh-positive blood o If Coombs is negative = test repeated at 28 weeks to detect for subsequent sensitization o If Coombs is positive = repeated at frequent intervals throughout pregnancy to determine whether the antibody titer is increasing Increased titer fetal compromise will occur o RhoGAM Administered to unsensitized Rh-negative mother at 28 weeks, IM, to prevent sensitization Effectively prevents formation of active antibodies against Rh-positive erythrocytes if small amount of Rh-positive fetal blood enters maternal circulation Repeated IM administration after birth if newborn is determined to be Rh- positive (within 72 hours of delivery) Umbilical cord is taken at delivery to determine newborn blood type, Rh factor, and antibody titer (Coombs) Gestational Diabetes o Risk Factors women with any of these risk factors should be screened for type 2/gestational diabetes at first prenatal visit Overweight or obese Maternal age > 25 years
If fasting is > 95 mg/dL or postprandial is > 120 mg/dL, insulin therapy is started Fetal Surveillance may begin as early as 28 weeks if poor glycemic control/ 34 weeks in low-risk “Kick counts” fetal movements felt by mother Ultrasound for fetal growth and amniotic fluid volume Non-Stress Test, Contraction stress test Amniocentesis for fetal lung maturity Cardiac Disease in Pregnancy affects about 1% of pregnancies o Alterations in cardiovascular function are necessary in pregnancy to meet additional maternal demands and needs of fetus Plasma volume, venous return, cardiac output, heart rate, stroke volume all increase o For women with preexisting conditions/underlying heart disease, these changes can cause an additional burden on an already compromised heart resulting in cardiac decompensation of CHF o Rheumatic Heart Disease complication that often occurs after streptococcal pharyngitis, causing scarring of heart valves, resulting in stenosis (narrowing) Mitral stenosis = most common Obstructs blood from left atrium to left ventricle, causing left atrium to become dilated Dilation causes pressure in left atrium, pulmonary veins, and pulmonary capillaries, leading to pulmonary HTN, edema or CHF Warning signs persistent rales at lung bases, dyspnea on exertion, cough, hemoptysis, progressive edema, tachycardia o Congenital Heart Disease fetus is more likely to inherit these, as well as affecting the mother with complications occurring throughout pregnancy Left-to-Right Shunts (Acyanotic) Atrial Septal Defectoften first discovered because symptoms are absent/vague o Pressure on left side of heart is higher than right side o Pregnancy is well tolerated and no specific treatment is recommended o Pulmonary HTN occasionally develops in untreated ASD because additional blood moves to right side of heart and is transported to lungs Ventricular Septal Defect more common; usually detected by auscultation and often close with no surgical intervention o Most women are asymptomatic, but fatigue or symptoms of pulmonary congestion may occur o Pregnancy is well-tolerated in small to moderate shunts o Pregnancy occasionally precipitates heart failure/dysrhythmia o Bacterial endocarditis is common in unrepaired defects and antibacterial prophylaxis is recommended Patent Ductus Arteriosus physiological effects are related to size
o Small may be well tolerated during pregnancy, unless complicated by pulmonary HTN o Tends to become infected antibacterial prophylaxis is recommended before labor Right-to-Left Shunts (Cyanotic) Tetralogy of Fallot combination of 4 defects (VSD, pulm. Valve stenosis, right ventr. Hypertrophy, and displacement of aorta towards right ventricle) o Women who have undergone repair and have no cyanosis tolerate pregnancy well o Untreated high maternal and fetal mortality Eisenmenger’s Syndrome develops when pulmonary resistance equals or exceeds systemic resistance to blood flow and a right to left shunt develops o Late surgical correction often results in woman’s death o If survive, pregnancy may carry 50% maternal risk, usually from ventricular failure o Most newborns are preterm and small for gestational age o Mitral Valve Prolapse may be inherited, or accompany other conditions, such as atrial septal defects and Marfan syndrome – leaflets of mitral valve prolapse into left atrium during ventricular contraction Considered benign and most women are asymptomatic and tolerate pregnancy well Some may experience chest pain and dysrhythmias give beta-blockers, like atenolol and metoprolol Some MDs may consider it a significant risk for bacterial endocarditis and administer prophylactic antibiotics before and during labor o Peripartum/Postpartum Cardiomyopathy rare condition exclusively associated with pregnancy after exclusion of other causes; have no underlying heart disease, but symptoms are cardiac decompensation appear during last weeks of pregnancy/2- weeks postpartum Symptoms of CHF dyspnea, edema, weakness, chest pain, palpitations Anticoagulation with low-molecular weight heparins is usually therapy to prevent clot formation during pregnancy when coagulations factors are higher Fluid restriction to reduce pulmonary edema and treatment of CHF are usually required Sudden appearance/Abrupt downhill course = occurs in 20% of women and only transplant can save the woman Often occurs with subsequent pregnancies, often in women who do not have complete recovery of left ventricle o Therapeutic Management Mild to Moderate Heart Disease: Limit physical activity to remain free of dyspnea, chest pain, tachycardia Avoid excessive weight gain to decrease demands on heart; low sodium diet may be advised
Careful management of IV fluid administration is essential to prevent fluid overload Position woman on side, with head and shoulders elevated O2 can be administered to increase O2 saturation and is monitored with POX Keep a calm, quiet environment to decrease anxiety and tachycardia Epidural block may be contraindicated because of potential hemodynamic effects Fetal compromise/maternal decompensation should be reported immediately Vaginal birth is often recommended Vacuum extraction/forceps are often used to minimize maternal pushing, avoid use of Valsalva maneuver, and to limit prolonged labor C-section may be chosen for obstetric indications Must discuss added stress of major surgery on heart Expected blood loss is higher than in vaginal birth General anesthesia may be required over epidural, leading to airway management by anesthesiologist Fourth stage of labor proposes special risks After placental delivery, about 500 mL of blood is returned to intravascular volume To minimize overloading the heart, positional changes should be avoided Uterus should not be massaged to expedite separation of placenta Careful assessment of signs of fluid overload, such as bounding pulse, distended neck and peripheral veins, and moist rales in lungs should be done throughout labor and postpartum periods POSTPARTUM: Postpartum Hemorrhage major cause of maternal death and morbidity in the US and world; in US, complicates 1-5% of births o Blood loss > 500 mL after vaginal birth or 1000 mL after C-section, a decrease in hematocrit > 10% since admission, or the need for a blood transfusion o Early Postpartum Hemorrhage occurs in first 24 hours after delivery Usually occurs during 1st^ hour after delivery and most often caused by uterine atony Risk Factors/Causes Overdistension of uterus (multiple gestation, large infant, hydramnios) Multiparity (five or more) Precipitate labor/delivery Prolonged labor Use of forceps/vacuum extraction C-section Manual removal of placenta Uterine Inversion Placenta Previa, placenta accrete (adherence to uterine wall), low implantation General anesthesia
Chorioamnionitis Clotting disorders Previous postpartum hemorrhage or uterine surgery Disseminated intravascular coagulation Uterine leiomyomas (fibroids) Uterine Atony refers to lack of muscle tone that results in failure of uterine muscle fibers to contract firmly around blood vessels when the placenta separates Relaxed muscles allow rapid bleeding from endometrial arteries at the placental site and bleeding continues until uterine muscle fibers stop flow of blood Risk Factors o Overdistension o Multiparity o Obesity o Ineffective contractions/prolonged labor o Vigorous contractions/precipitate labor o Labor augmented/induced with oxytocin o Retention of part of placenta Manifestations o Fundus that is difficult to locate o Soft/” boggy” fundus o Uterus that becomes firm as its massaged but loses tone when massage is stopped o Fundus that is located above expected level o Excessive lochia, especially if bright red (soaking pad in 15 mins) o Excessive clots in lochia with/without uterine massage Management o 1 st^ = massage the fundus! to contract uterine muscle fibers/express clots DO NOT MASSAGE IS FUNDUS IS FIRM AND CONTINUED BLEEDING o If fundus is displacement encourage mother to void/catheterize if necessary and note urine output o Pharmacologic Measures: IV Pitocin rapid infusion will increase uterine tone and control bleeding Methylergonovine (Methergine) can be given IM but elevates BP and should not be given if woman is hypertensive Prostaglandin 2a analogs effective when given IM or into uterine muscle if oxytocin is ineffective Prostin (dinoprostone) or misoprostol (Cytotec) can be given rectally to control bleeding o If massage/pharmacologic measures are ineffective = MD/midwife will use bimanual compression of uterus
Uterine leiomyomas (fibroids) Management Initial treatment CONTROL BLEEDING Oxytocin, Methylergonovine, and prostaglandins are most commonly used Ultrasound can be used to identify location of retained placental fragments Dilation and Curettage – stretching of cervical os to permit suctioning/scraping of wall of uterus may be necessary to remove fragments Broad-spectrum antibiotics can be given if postpartum infection is suspected because of uterine tenderness, foul-smelling lochia, or fever Hypovolemic Shock Normally, woman can tolerate blood loss that is similar to amount of blood added during pregnancy (1500-2000 mL) o If anemic before birth = less reserve Amount of blood lost can be estimated by comparing pre and post hematocrit o If lower after delivery, woman lost amount of blood added during pregnancy and an additional 500 mL for each 3% drop in hematocrit value Signs and Symptoms o Early sign tachycardia o Late signs hypotension – usually does not occur until 20-25% of blood volume has been lost; CNS changes, confusion, lethargic, decreased urine output Narrowing pulse pressure should also be noted Increased respirations due to anxiety and increased oxygen demands Vasoconstriction causes pallor, cold, clammy Management o CONTROL BLEEDING AND PREVENT FROM BECOMING IRREVERSIBLE o Insert secondary large bore IV if need to transfuse and monitor I/Os o Vasopressors for low BP o Hemorrhage Medications Oxytocin (Pitocin) stimulates uterine contractions; given IV Action: stimulates uterine smooth muscle, resulting in increased strength, duration, and frequency of contractions o Sensitivity will increase with continued use makes it less effective! Indications: tachysystole; controls postpartum bleeding Contraindications: Placenta Previa, vasa Previa, nonreassuring FHR, abnormal fetal presentation, prolapsed cord, presentation above pelvis,
previous classic/fundal incision, active genital herpes, pelvic deformities, cervical carcinoma Side Effects: tachysystole (fetal bradycardia/tachycardia, reduced variability, late decelerations), impaired uterine blood flow, uterine rupture, abruption placentas Assess uterus for firmness and height Assess lochia Assess VS Q15 minutes Hemabate (carboprost tromethamine) stimulates uterine contractions and causes arterial vasoconstriction; given IV or oral Action: stimulates contraction of uterus vasoconstrictor Indication: treatment of postpartum hemorrhage caused by uterine atony Contraindications: PID; cardiac, pulmonary, renal, or hepatic disease; Caution in history of asthma (causes vasoconstriction), hypo/hypertension, anemia, jaundice, diabetes, epilepsy, previous uterine surgery Methergine (methylergonovine) Action: stimulates sustained contraction of uterus and causes arterial vasoconstriction Indication: used for the prevention and treatment of postpartum/postabortion hemorrhage caused by uterine atony/subinvolution Contraindications: HTN, severe hepatic/renal disease, thrombophlebitis, CAD, PVD, hypocalcemia, sepsis, before 4th^ stage of labor Side Effects: N&V, uterine cramping, hypertension, dizziness, headache, chest pain Assess BP before administration Cytotec Action: stimulates uterine contractions; given vaginally or rectally Subinvolution slower-than-expected return of uterus to its nonpregnant size after childbirth o Causes Retained placental fragments Pelvic Infection o Signs and Symptoms Prolonged discharge of lochia Irregular/excessive uterine bleeding Profuse Hemorrhage Pelvic pain/feelings of heaviness Backache Fatigue/Persistent malaise Uterus feels larger and softer than normal than expected o Management correct cause of subinvolution Methergine may be given rally to provide long, sustained contractions of uterus Infection responds to antimicrobial therapy EDUCATION usually does not occur until other has been discharged
Management o Antibiotic therapy o Continued emptying of breast through breastfeeding/pumping Q2 hours o Moist heat o Breast support (nursing bra) o Bed rest o Fluids o Analgesics Septic Pelvic Thrombophlebitis often occurs 2-4 days postpartum occurs when infection spreads along venous system and thrombophlebitis develops Develops more often in women with wound infection and usually involves one or both ovarian veins Primary symptom pain in groin, abdomen, flank o Fever, tachycardia, N&V, bloating, GI distress, decreased bowel sounds o Spiking fever that does not respond to antibiotics and tachycardia in a woman who was treated for endometritis previously CBC with differential, blood chemistries, coagulation studies, and cultured can be used to confirm diagnosis o CT, MRI, pelvic ultrasound also helpful Management o Readmission is usually necessary o Primary treatment anticoagulation with IV heparin and IV antibiotics o Warfarin can be given when heparin is discontinued o Improvement usually occurs within 2-3days of therapy Postpartum Mood Disorders: o Postpartum Depression period of depression with onset during pregnancy or within 4 weeks after childbirth that lasts at least 2 weeks; affects 10-15% of postpartum women Includes persistent depressed mood/loss of interest in almost all activities, changes in appetite/weight, sleep, and psychomotor activity; decreased energy; feeling of worthlessness/guilt; difficulty thinking, concentrating, or making decisions; recurrent thoughts of death/suicide; death/suicide plans/attempts Symptoms last for at least a 2-week period and tend to become worse over time Creates strain on family and support system communication is impaired and gradually withdraws Appear tense, irritable, feel less competent mothers, less likely to provide health sleep and eating practices Management Combination of psychotherapy, social support, and medication If combination is not solely effective medication should be considered (SSRIs, tricyclic antidepressant)
o May take up to 4 weeks to become effective and may be continued for 9-12 months o Must considered if woman is pregnant/breastfeeding o Baby Blues transient, self-limit mood disorder; mild depression Affects 60-80% of postpartum women Begins in 1st^ week, peaks around day 5, and ends within 2 weeks Characterized by insomnia, fatigue, tearfulness, mood instability, and anxiety and do not affect mother’s ability to care for infant Benefit greatly when empathy and support are freely given by family and health acre team Encouraged to rest, take time for herself, and discuss feelings o Postpartum Psychosis mental state in which person’s ability to recognize reality, communication, and relationship to others is impaired Can either be depressed psychosis or manic psychosis Can occur as early as 2 days after delivery and is a psychiatric emergency, requiring hospitalization S/S agitation, irritability, rapidly shifting moods, disorientations, disorganized behavior, delusions/hallucinations Women who have had one episode of psychosis are at increased risk for having another episode Management requires hospitalization, pharmacologic treatment, and psychiatric care Breastfeeding o Composition Colostrum – forms during pregnancy (can occur at 16 weeks) and for use immediately after birth Low quantity, high quality Baby only needs 2-3 teaspoons Transitional Milk – occurs 2-3 days after birth and can continue for up to 10 days; like 2% milk; pale yellow Mature milk – replaces transitional milk – bluish in color, thinner; 20 kcal/oz.; sufficient to meet infant’s nutritional needs o Benefits Infant Less likely to develop allergies Infection prevention/decreased incidence Lower incidence of obesity, diabetes, SIDS Composition meets specific nutritional needs and will change accordingly Easily digested Protein, fat, and carbs in appropriate proportions Unlikely to be contaminated Less likely to overfeeding Constipation less likely Decreases incidence of jaundice Mother
0 = absent 1 = <100 bpm 2 = > 100 bpm or higher o Respiratory Effort 0 = no spontaneous respirations 1 = Slow respirations/weak cry 2 = Spontaneous respirations/Strong, lusty cry o Muscle Tone 0 = Limp 1 = Minimal flexion of extremities; Sluggish movement 2 = Flexed body posture; Spontaneous and vigorous movement o Reflex Response 0 = No response to suction/gentle slap on soles 1 = Minimal response (grimace) to suction or gentle slap on soles 2 = Responds promptly to suction or gentle slap to sole with cry/active movement o Color 0 = Pallor/cyanosis 1 = Bluish hands and feet only 2 = Pink (light skinned) or absence of cyanosis (dark skinned); Pink mucous membranes Initiation of Infant Breathing o Development of Lungs Fetal life fetal lung fluid expands alveoli and is essential for normal development of lungs and is continuously produced until fetus nears term When nears term, fetal lung fluid decreases in preparation for birth, when fluid must be cleared for infant to take in air Absorption of this fluid begins in early labor (moves into interstitial spaces) and is accelerated by secretion of fetal epinephrine and corticosteroids Surfactant combination of lipoproteins – is detectable around 24-25 weeks Lines inside of alveoli and reduces surface tension within alveoli, allowing alveoli to remain partially open when infant begins to breathe in air at birth 34-36 weeks enough surfactant is present to prevent respiratory distress/lung collapse Secretion increases during labor and immediately after birth to allow spontaneous respirations to occur Can give steroids, like betamethasone/dexamethasone to help speed up fetal lung maturation/surfactant production Example in cases such as intrauterine growth restriction, maternal HTN, heroin addiction, preeclampsia, infection, placental insufficiency, premature rupture of membranes o Causes of Respirations
First breath must force remaining fluid out of alveoli and into interstitial spaces around alveoli so air can enter lungs why suctioning is often done at birth, since higher pressure is required Chemical Factors Chemoreceptors in carotid arteries and aorta respond to changes in blood caused by hypoxia that occurs with birth Decreased PO2 and pH/Increased PCO2 in blood causes receptors to stimulate respiratory center in medulla Occlusion of cord vessels halts respirations and causes diaphragm to contract to bring air into lungs Mechanical Factors Fetal chest is compressed during delivery 1/3 of lung fluid is forced out into upper passages and is suctioned out during birth When pressure from delivery is released, chest recoils to draw air into lungs and helps removes viscous fluid Thermal Factors Infant moves from warm, fluid-filled environment into cooler environment Sensors on skin respond to sudden change in temperature by sending impulses to medulla that stimulate respiratory center and breathing Sensory Factors drying infants and swaddling t increase thermal factors; skin to skin contact o Continuation of Respirations As alveoli expand, surfactant allows them to stay partially open between respirations Because alveoli remain open, subsequent breaths require much less effort As infant cries, pressure in lungs increases, causing remaining fluid to move into interstitial spaces, where it is absorbed by the cardiopulmonary/lymphatic systems Often why lungs sound moist when first auscultated but become clear short time afterward o Order of Events in Cardiopulmonary Adaptation:
- Increased blood CO2 level
- Respirations started
- Surfactant keeps alveoli open
- Increased blood oxygen level
- Ductus arteriosus constricts
- Increased pressure on left side of heart
- Foramen ovale closes
- Fibrosis of ductus venosus Methods of Heat Loss o Evaporation air-drying of skin that resulting in cooling Drying the infant, especially head, ASAP helps prevent heat loss this way Insensible water loss from skin and respiratory tract increases heat loss from evaporation
