Transcript Document

POSTPARTUM CARE
Postpartum Psychological Adaptations
Reva Rubin
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Taking in: Mom wants to talk about her
experience of labor & birth, preoccupied with
her own needs
Taking hold: More ready to resume control of
her body, baby & taking on mothering role.
Needs reassurance if inexperienced.
Letting-go: by 5th week, total abandon to NB
Bonding: en face position, engrossement.
Encourage through early interaction & breastfeeding (within 1/2 hr of birth is best).
Maternal Responses to Newborn
Reva Rubin
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Touch- progresses from fingertips →
palming →cuddling →
Voice- high-pitched & babies respond
Odor- mom’s respond to baby’s unique smell
Eye contact- en face position
delay eye ointment & bright lights
Nurse role- be able to answer ? About baby
Blues vs Dpression
 Postpartum/baby blues:
transient depression in first few days:
weepiness
mood swings
anorexia
difficulty sleeping
feeling of letdown
 Postpartum Depression
*If persists past 2 weeks, or worsens
Symptoms: very sad feelings
hopeless
worthless
anxiety
trouble caring for and bonding with your baby
Have trouble sleeping.
Not be able to concentrate.
Not feel hungry and may lose weight. (But some women feel
more hungry and gain weight)
 Postpartum Psychosis
A woman who has postpartum psychosis may feel cut off from her baby.
She may see and hear things that aren't there. Any woman who has
postpartum depression can have fleeting thoughts of suicide or of harming
her baby. But a woman with postpartum psychosis may feel like she has
to act on these thoughts.
Endocrine Adaptations
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Hormones: drop after delivery of
placenta.
– hCG & hPL gone by 24 hours
– Estrogen & progesterone drop within 1 wk
– FSH remains low for 12 days, then rises
to begin new cycle
– Sex is ok once lochia is alba. Menstrual
period in 6-10 wks.
– Contraception necessary.
Physiological Adaptations
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Uterine involution
– @ umbilicus first 24 hours--should feel firm
– Decreases 1 finger’s breadth per day
– By 10th day, no longer palpable
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If high (3 or 4 fingers above U) and/or
deviated to right, have pt. void
Risk for delayed involution:
– Multiples, hydramnios, exhaustion, grand
multiparity, excessive analgesia
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Afterpains
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www.youtube.com/watch?v=EbItF_7KYCc&feature=related
Fundal Assessment
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Every 10-15 mins in first hour. Supine position
Palpate: one hand at base of uterus & other at
umbilicus. Press inward and downward and feel for
firm globular mass.
Assess:
– Height (fingers above/below umbilicus)
– Position (midline, deviated to right or left)
– Consistency: firm, soft, boggy
If not firm, massage & should become firm. If still
boggy, notify MD/assess for clots, hemorrhage.
Administer oxytocin or other oxytocic (methergine,
hemabate).
Lochia
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Rubra: Red, day 1-3, blood
Serosa: Pinkish or brownish, day 3-10,
blood, mucus, leukocytes
Alba: whitish, day 10-14 (may last 6 wks),
largely mucus & leukocytes
If flow increases, woman should rest more
Warning sign: if lochia returns to previous
type (alba to serosa, or serosa to rubra)
Lochia Assessment
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Check q 15 mins in 1st hour.
Assessment:
– Color (rubra, serosa, alba), amount, odor,
presence of clots.
– Constant trickle of vaginal flow, or soaking pad
every 60 minutes is more than average. Can
weigh pads--1 gm = 1 ml of blood.
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Lochia should not exceed a moderate
amount: 4 to 8 partially saturated pads/day
Lochia Assessment
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Assessing Amounts:
– Scant: peripad has stain less than 1 inch
in length after 1 hour
– Small: stain less than 4 inches after 1
hour--10-25 mL
– Moderate: stain less than 6 inches after 1
hour--25-50 mL.
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Instruct in perineal care: ∆ pad
frequently, hand washing, s/s of
infection & hemorrhage, no tampons
Cervix & Vagina
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Cervix returns to firm, nongravid consistency
by about 7 days, but external os remains slitlike or stellate
Vagina involutes in 6 wk period, with return
of rugae.
– Kegel exercises for pelvic floor muscles.
 Isolate muscles to contract by stopping flow of
urine while urinating.
 Contract these muscles in sets of 10 or 20, 3
times per day.
Perineum
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Assessment: turn pt to side in Sim’s
position. Lift upper buttock and assess
for:
– Ecchymosis, hematoma, erythema,
edema, intactness, approximation,
drainage or bleeding from stitches
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Assess for hemorrhoids & document
number, appearance & size
Episiotomy
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Midline or mediolateral
Nursing care:
– Assess for
approximation,
swelling, oozing,
infection
– Relief for pain: ice
pack in first 24
hours, then heat,
local analgesic
spray, witch hazel
pads (Tucks), sitz
bath, peri-bottle for
voiding, pain
medications
Other Assessments
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Constipation: Give stool softeners as
ordered, prune juice, encourage ambulation,
adequate fluid intake, fiber in diet.
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Homan’s sign: assess calves for redness,
warmth, pain, swelling.
-↑risk of DVT, thrombophlebitis.
-Occur in postpartum because:
– Fibrinogin level is elevated
– Dilatation of lower extremity veins
– Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling, stasis &
clotting of blood in lower extremities.
Thrombophlebitis
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Superficial leg vein disease:
– S/s: tenderness in portion of vein, local heat &
redness, normal temperature or low-grade fever
– Tx: local heat, elevate limb, bed rest, analgesia,
elastic support hose
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Deep Vein Thrombosis (DVT):
– S/s: edema of ankle, leg, initial low-grade fever,
then high temperature & chills, tenderness & pain,
changes in limb color & difference in
circumference
– Tx: IV heparin, bed rest, elevation of leg,
analgesics, warm moist heat, antibiotics
Urinary Retention
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Diuresis begins p birth to rid extra fluid
(2000-3000 mL)
Trauma to bladder & urethra during
birth or anesthesia may cause loss of
tone, difficulty sensing need to void
Must assess abdomen frequently to
prevent permanent damage to bladder
from over distention. Check fundus to
see if bladder is full. If unable to void,
catheterize. Monitor for UTI.
Vital Signs
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May have slight elevation of temp in 1st 24
hours--dehydration. If 100.4 or above,
suspect infection.
Rapid or thready pulse--sign of hemorrhage.
BP: monitor--still at risk of PIH. Methergine
(oxytocic) can ↑BP. ↓BP could be sign of
hemorrhage.
– Can have orthostatic hypotension due to blood
loss. Assist pt. with first trip to BR. Instruct pt to
dangle legs and sit first, before rising. If dizzy, do
not ambulate.
Breast Assessment
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Breasts
– Soft: Soft on palpation, day 1 & 2
– Filling: firmer & warmth, day 3
– Engorged: appear large, reddened, taut,
shiny skin, warm, hard, tense &
tender/painful on palpation
– Mastitis (infection): only one part of
breast is warm/reddened--UNILATERAL
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Nipples: look for cracking, fissures,
blisters, pain
Lactation
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Engorgement: day 3 or 4.
– If breastfeeding:
 Encourage frequent breastfeeding.
 Warm compresses or warm shower.
– If not breastfeeding:
 Cold compresses/ice, snug bra or breast
binder, oral analgesics.
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Breast care:
– Wash daily with water and air dry –NO SOAP
– Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy. Avoid underwires.
Use cotton nursing pads for leaking--keep
nipples dry.
Discharge Instructions
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Avoid/limit heavy lifting, stairs.
Good diet, increase fluids if
breastfeeding.
Adequate rest, exercise/activity as
tolerated.
Report fever, foul smelling discharge,
increased pain or bleeding to MD.
Sex/contraception.
Follow up in 6 weeks with MD.
Postpartum Complications
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Postpartum Hemorrhage
– CAUSES: Uterine atony, lacerations, retained
placental fragments
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Risk factors:
– ↑ uterine distension: multiples, polyhydramnios,
macrosomia, fibroids
– Trauma: rapid or operative birth
– Placental problems: previa, accreta, abruptio,
retained placental fragments
– Atonic uterus: prolonged pitocin, magnesium
sulfate or labor; ↑ maternal age or parity; uterine
scar; chorioamnionitis; anemia; prior history
– Inadequate blood coagulation: fetal death or DIC
Hemorrhage
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Interventions:
– Fundal massage, ensure
bladder emptying. If
uterus is firm but bleeding
persists, suspect
laceration.
– Administer oxtocics
(pitocin, methergine,
hemabate,
prostaglandins), blood
replacement.
– Frequent assessment of
bleeding, vital signs.
– MD: Bimanual massage,
manual exploration of
uterus, uterine packing,
D & C, hysterectomy.
Hemorrhage (cont.)
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Lacerations: cervical, vaginal, perineal
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Retained placental fragments:
– can occur well after delivery. Maternal serum
test for hCG or US. Possible D&C.
– May see symptoms even after 1 week
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Subinvolution: retained placenta, infection,
fibroids
– PO methergine, antibiotic.
Hematomas
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Cause:Trauma during the birth process
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Puerperal hematomas occur in 1:300 to 1:1500 deliveries
Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy; however, a
hematoma may also result from injury to a blood vessel in the
absence of laceration/incision of the surrounding tissue
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Most common locations for puerperal hematomas are the
vulva, vaginal/paravaginal area, and retroperitoneum
Women at increased risk of developing puerperal hematomas
include those who are nulliparous or who have an infant over
4000 grams, preeclampsia, prolonged second stage of labor,
multifetal pregnancy, vulvar varicosities, or clotting disorders
Assessment: location, size, vital signs, pain, H&H
Treatment: evacuation and repair of bleeding source by MD
Postpartum Infection
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Puerperal Infection: Endometritis
infection of reproductive tract within 6 wks of
childbirth
Increased risk with:
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C-section
Prolonged ROM, chorioamnionitis
Retained placental fragments
Preexisting anemia
Prolonged/difficult birth, instrumental birth
Internal fetal monitoring or IUPC
Uterus explored after birth/manual removal of
placenta
– Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
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Endometritis: infection of endometrium
– Associated with chorioamnionitis & Csection
– S/S: foul-smelling, bloody vaginal
discharge, fever (day 3 or 4), uterine
tenderness, tachycardia, chills. (Elevated
temp. in 1st 24 hours and elevated WBCs
are normal findings.)
– Can progress to pelvic cellulitis or
peritonitis.
Endometritis
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TX: antibiotics as determined by culture of
lochia; oxytocics such as methergine, if
necessary, ↑ fluid intake, pain relief
Nursing considerations: Fowler’s position or
walking encourages drainage by gravity,
gloves, strict handwashing
Usual course is 7-10 days
May result in tubal scarring & interfere with
future fertility
Postpartum Infection
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Nursing Interventions & Discharge Teaching
– Strict handwashing & instruction for pt & family
– Instruct re proper perineal care
 Wiping front to back, washing after voiding/
defecating, changing peripads frequently
– Well-balanced diet with adequate protein,
calories, vitamin C and fluids (2000 mL/day)
– Encourage sitz baths, early ambulation.
– Monitor vital signs and report s/s of infection
– Assess pain and administer analgesics
– Promote rest, relaxation, bonding with infant if
separated.
Post op C/Section Complications
1.Paralytic Ileus
2. Wound Dehiscence
3.Wound infection
1. A mother is experiencing shaking chills during
the hour following birth. What is the nurse’s
initial action?
A.
B.
C.
D.
Take a rectal temperature
Notify the physician or nurse-midwife
Cover the woman with warmed blankets
Review the order sheet for antibiotic orders
\
2.
The nurse assesses a postpartum client
and palpates the fundus at 2 cm above the
midline and deviated to the right. What is
the appropriate nursing action?
A. Encourage the client to breastfeed
B. Assist the client to empty her bladder
C. Assist the client to a prone position and
place
a small pillow under her abdomen
D. Massage the fundus
3.
A nurse is caring for a client who is 2 hours
postpartum who complains of severe, unremitting
vaginal pain and inability to void. The fundus is
firm at the umbilicus with moderate lochia rubra,
and the perineum appears edematous with
significant bruising. The nurse suspects the client
may have
A. A fourth-degree episiotomy.
B. Distended bladder.
C. Hematoma.
D. Endometritis.
4. A 6-day postoperative C-section client calls the clinic nurse
and complains of malaise and increased pain on the right side
of her incision with increased drainage. What should be the
nurse’s correct initial response?
A. Instruct the client to take her pain medication as prescribed
B. Notify the physician or nurse-midwife
C. Instruct the client to increase rest and seek assistance with
household tasks
D. Instruct the client to call the physician or nurse-midwife if her
temperature reaches 100.8.
5. A 6-day postpartum client complains of fatigue and
episodes of crying during the past two days. Which of
the following statements is a correct response by the
nurse?
A. “This must be very difficult for you.”
B. “This sounds like postpartum blues. It is a normal
response to birth.”
C. “You sound exhausted. Try and sleep when the baby
sleeps.”
D. “This sounds like postpartum depression; you should
contact your physician or nurse-midwife for a
referral to a counselor.”
6. A nurse is caring for a client with a
superficial thrombophlebitis. Which of the
following is the most appropriate nursing
action?
A. Administer anticoagulants per order
B. Elevate the affected limb
C. Apply ice packs to the affected limb
D. Administer antibiotics per order
Breastfeeding
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www.youtube.com/watch?v=CIZ6rVzs4CE&feature=Pl
ayList&p=BD065FA5F03CD81A&index=38
(Breastfeeding Basics)
www.youtube.com/watch?v=RuvJZGFOHU&feature=P
layList&p=1330DE183266B0BC&playnext=1&playnext
_from=PL&index=3 (What’s the Big Deal?)
www.youtube.com/watch?v=Ox8htEVnQA&feature=PlayList&p=1330DE183266B0BC&in
dex=8 (latch-on 1)
www.youtube.com/watch?v=WOQzEN_dcPc&feature=
PlayList&p=1330DE183266B0BC&index=9 (latch-on
2)
The Amazing Newborn
Profile of a Newborn
 Vital
statistics
Weight: 2.5 to 3.4 kg. Immediately after birth.
Establishes baseline. Baby may lose up to 510%.
Length: 18 - 21 inches
Head Circumference: 32 - 35 cm
Chest Circumference: 32 - 35 cm
Vital Signs: Heart Rate 120-160 bpm;
Respirations 30-60 breaths/minute;
 Temperature 97.6- 98.6 axillary
Profile of a Newborn
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Temperature:
Can
be unstable. Guard
against loss due to:
 Convection
 Conduction
 Radiation
 Evaporation
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Dry immediately with
warm blankets
Cardiovascular Changes after
Birth
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Closure of the ductus arteriosus/fetal shunts
occurs when a neonate takes in oxygen
through the lungs for the first time and when
the lungs inflate, pressure in chest
decreases (pulmonary artery)
Common to have acrocyanosis, investigate
central cyanosis (look at mucous
membranes)
Transition from fetal to postnatal circulation:
“transitioning”
Critical Thinking
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During a prenatal examination, an adolescent
client asks, "How does my baby get air?" The
nurse would give correct information by saying:
A) "The fetus is able to obtain sufficient oxygen due to
the fact that your hemoglobin concentration is 50%
greater during pregnancy."
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B) "The lungs of the fetus carry out respiratory gas
exchange in utero similar to what an adult experiences."
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C) "The placenta assumes the function of the fetal lungs
by supplying oxygen and allowing the excretion of
carbon dioxide into your bloodstream."
Acrocynanosis
Cyanosis
Respiratory
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Breathing is a result of replacement of air for
fluid
Takes longer for a c-section baby to initially
establish effective respirations because
excessive fluid blocks air exchange space
(baby’s chest not compressed and squeezed
in birth canal)
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Factors predisposing respiration
problems
Maternal history of
diabetes
Premature rupture of
membranes
Maternal use of
barbiturates or
narcotics close to birth
Non-reassuring fetal
monitoring strip
C-section birth
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Cord prolapse
Low APGAR
Meconium staining
Prematurity
Postmaturity
Small for gestational
age
Breech birth
Chest, heart or
respiratory tract
anomalies
Newborn Assessment:
Respiratory Distress
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5 symptoms of respiratory distress
– Tachypnea
– Cyanosis
– Nasal flaring
– Expiratory grunting
– Retractions
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Transition period (1-2 hrs post birth) vs
signs of respiratory distress that persist
Sleep Wake Cycle
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Supine position decreases risk for
SIDS
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Sleep 16 out of 24 hours, avg. of 3-4
hours at a time (wake q 2-3 for feeding)
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Don’t add cereal to diet till 4-6 months
of age
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Infants should never sleep in parents’
Gastrointestinal
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Accumulation of bacteria in GI tract necessary for
digestion and synthesis of vitamin K
Uncoordinated peristalsis
Limited ability to digest fats & starch (deficient
enzymes)
Immature cardiac sphincter-regurgitates easily
Stools– 1st meconium, sticky tarlike
– 2nd-3rd day- transitional (diarrhea like)
– BF: 3-4 light yellow/day. Formula: 2-3 bright
yellow/day
– Infants receiving phototherapy have bright green
stools as a result of increased bilirubin excretion
Urinary
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Very important to observe for first void
Urine light colored and odorless--kidneys do not
concentrate urine well
Immune System
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Prone to infection
Inability to form antibodies until 2 months of
age: most immunizations delayed until then
Born with passive antibodies (protect against
diseases such as polio, measles, diphtheria,
pertusis, chickenpox, rubella & tetanus)
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Hepatitis B vaccine: babies exposed early in
life have ↑risk of chronic liver problems
– Positive mom: HBIG (Hep B immune globulin)
and vaccine for baby
Profile of a Newborn
Reflexes
•
Neuromuscular
function
– Rooting reflex
– Sucking reflex
– Swallowing reflex
– Palmar grasp
reflex
Profile of a Newborn
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Neuromuscular
function
 Moro reflex
 Babinski reflex
 Crossed extension
reflex
Moro or “startle” reflex
Senses
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Hearing- yes
Vision- “light” and “dark” in the first
months. Approx 18” range.
Touch- well-developed
Taste- can discriminate
Smell- well-developed
Appearance of a Newborn
 Skin: Color should be pink
 Cyanosis: mottling, acrocyanosis normal.
Investigate central cyanosis. Look at mucus
membranes
 Hyperbilirubinemia: yellow tone to skin,
sclera
 Pallor: usually caused by anemia: blood loss?,
blood incompatibility?, internal bleeding?
 Harlequin
sign: normal, immature circulatory
system. Dependent side red, upper side pale.
Appearance of a Newborn
Skin
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Birthmarks
– Hemangiomas: vascular
tumors of skin
– Erythema toxicum:
innocuous, pink, papular
neonatal rash
– Milia: unopened sebaceous
glands--tiny, white, pinpoint
papules on nose, etc.
Erythema toxicum-newborn rash
Birthmarks
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Mongolian Spots: hyperpigmentation (usually
disappear by school age)
Appearance of Newborn
 Skin
• Vernix caseosa: white, cream cheese-like
substance, natural lubricant
• Lanugo: fine downy hair on body
• Desquamation: dry, peeling
Appearance of a Newborn
Head: large-1/4 body length
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Fontanelles
Sutures
Molding
Caput succedaneum
Cephalhematoma
Head
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Fontanelles: Anterior closes at 12 to 18 mos.
Posterior closes at 2 mos.
Sutures: separation indicates ↑ intracranial pressure.
Fused sutures abnormal--evaluate
Molding: common in vaginal births. Resolves in first
few days of life
Caput succedaneum: edema of the scalp-- crosses
suture lines. Disappears by day 3-4.
Cephalhematoma: blood between periosteum of skull
bone and bone itself. Does not cross suture line.
Appears 24 hours after birth. May take weeks to
disappear. May ↑ jaundice.
Appearance of a Newborn
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Eyes: gray/blue.
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Ears: level, recoil, newborn testing
Nose: patency, choanal atresia?
Mouth: symmetrical opening, inspect/palpate
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Permanent color after 3 mos.
Erythromycin (gonorrhea/chlamydia infection)
palate
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Neck: short, free rotation?, rigidity?, masses?
Chest: symmetrical, no masses, retractions
Appearance of a Newborn
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Abdomen: appears slightly protuberant, bowel
sounds, bulges/masses?, 3 vessels in cord stump?
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Anogenital area: imperforate anus
• Male genitalia: meatus at tip, (hypo- or epi-spadias), testes
descended
• Female genitalia: pseudomenstruation
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Back: appears flat, ✓ for completion (no pinpoint
opening, sinus or dimpling)
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Extremities: all moving and symmetrical, legs bowed,
clubfoot (talipes equinovarus), subluxated hip/hip dysplagia:
check thigh & gluteal creases
Assessment for Well-Being
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Apgar scoring--10 is perfect score
Done at 1, 5 & 10 minutes
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Heart rate
Respiratory effort
Muscle tone
Reflex irritability
Color
Normal Apgars at 1 minute: 7 to 10
Immediate Care at Birth
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Keep the newborn warm
Promote adequate
breathing pattern
Inspection and care of
umbilical cord
Eye care
Infection precautions
Critical Thinking

The nurse is planning care for a newborn. Which of
the following nursing interventions would best
protect the newborn from the most common form of
heat loss?
A) Pre-warming the examination table
B) Placing the newborn away from air currents
C) Drying the newborn thoroughly
D) Removing wet linens from the isolette
Care of Newborn At Birth
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Identification and
Registration
Identification Band
Birth Registration
Birth Record
Documentation
(vitals, meds,labs)
Continuing Assessment for
Well-Being
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Respiratory evaluation
Physical examination
• Height and weight
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Laboratory studies: cord blood collected
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CBC,
ABO type & Rh,
Direct Coombs if mom Rh - or Type O
C reactive protein if risk for infection
Assessment for Well-Being
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Gestational age – neuromuscular & physical
maturity
– Ballard Scale
• Dubowitz Maturity Scale
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Useful in determining large for gestational (LGA)
and small for gestational age (SGA)
LGA/SGA: at risk for hypoglycemia
BS < 40 mg/dL → feed immediately
s/s: jitteriness, lethargy, seizures
SGA (IUGR) vs LGA babies
Periods of Reactivity (P. 690, Pilleterri)
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First Period 15-30 minutes
Alert, acrocyanosis, body temp falls, irregular
respirations, vigorous reaction to stimuli
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Resting Period 30-120 minutes
– Color, temperature stabilizing; respirations, HR
slowing; sleeping (hard to wake up)
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Second Period 2-6 hours
– Quick color changes with crying/movement;
temperature increases; irregular respirations, HR;
awake and responsive; first meconium passed
Nursing Care: Newborn and Family
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Initial feeding
Bathing
Sleeping pattern
Diaper area care
Newborn Screening Test
(PKU)
– Test for metabolic disorders
(inborn errors of
metabolism)
– Done 24 hrs after first
feeding
Nursing Care: Newborn and Family
Medications
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Erythromycin opthalmic ointment
Vitamin K administration
– GI tract unable to produce Vitamin K (needed for
blood coagulation)
– O.5 mg to 1mg IM in thigh
– Side effects- local irritation
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Hepatitis B vaccination prior to discharge
HBIG if needed (first 12 hours)
Circumcision- per parent’s consent
Nutritional Allowances
Calories: 110 calories x kg/24 hours
 Protein: 2.2 g x kg/24 hours
 Fat: need linoleic acid
 Carbohydrates: lactose intolerance rarely

present in newborn--switch to soy-based formula

Fluid: supplied by breast milk or formula,
**do not supplement with water
Nutritional Allowances

Minerals
• Calcium
• Iron: supplement formula-fed babies
• Fluoride: breastfeeding mom should drink fluoridated
H2O. Make formulas with fluoridated H2O. Can
supplement.

Vitamins: No supplementation needed until 6
mos.
Breastfeeding Promotion



WHO promotes Breastfeeding around
the world
APA advocates breastfeeding for 12
months
Baby Friendly initiatives in hospitals
↑breastfeeding rates and duration
11753398
Breastfeeding


Prolactin produced (stimulates milk
production) when progesterone levels fall
after placenta is delivered
Colostrum- First milk produced: thick,
creamy, yellow fluid composed of protein,
sugar, fat, water, minerals, vitamins and
maternal antibodies--digestible. Has laxative
effect to aid baby to excrete meconium.
Breastfeeding





Milk flows from lactiferous
sinuses
Fore milk- constantly formed
milk. Low in fat.
As infant sucks, oxytocin is
released from the posterior
pituitary. Produces let-down
reflex
Let-down reflex- stimulation of
baby at breast, sound of baby.
Hind milk ejected.
Hind milk is formed after the
let-down reflex. Higher in fat
and calories.
Infant Advantages in
Breastfeeding

Less infection: mom’s antibodies passed, breast
milk has elements that prevent absorption of viruses
& bacteria from GI tract and that kill/inhibit bacteria
& viruses
- ↓ gastroenteritis and ↓ ear infections

Ideal composition for human baby:
electrolytes, minerals, linoleic acid, trace elements,
hypoallergenic--reduces allergies


Easy to digest
Reduces obesity, diabetes later in life
Maternal Advantages of
Breastfeeding






Protective function in breast cancer
prevention
Release of oxytocin from the posterior
pituitary gland aids in uterine involution
Empowerment effect
Reduces economic costs
Bonding
Breast milk contains lysozymes that are
involved in destroying bad bacteria
Breast Feeding and Jaundice



Jaundice occurs in 15% of breast fed babies
Pregnanediol (breakdown product of
progesterone) depresses an enzyme that
converts indirect bilirubin to direct bilirubin
(accumulation of indirect bilirubin)
Encourage frequent feedings because
colostrum is a natural laxative and helps
promote passage of meconium and bile
Baby who is feeding well--”getting enough”
Breastfeeding






Every 2-3 hours in first weeks
Promote adequate sucking
Provide support
Techniques for burping
Multiple infants
Engorgement
Problems in Breastfeeding






Sore nipples
Supplemental feedings
Working outside of the home
Weaning
Engorgement
Mastitis
Formula Feeding

Preparation
 Commercial formulas
 Formula adequacy
 Supplies needed
 Formula preparation
 Feeding techniques
– 75 to 90 ml of fluid per
pound of body weight
per day
Circumcision Care
Surgical Removal of Foreskin







Site covered with sterile petroleum
Assess bleeding q 15 mins. for 1st hour, then q hour for
24 hr
Note first voiding
Apply diapers loosely to prevent irritation
Teach parents to keep area clean & check diaper q 4
hours
Notify provider for redness, discharge, swelling, strong
odor, tenderness, decrease in urination or excessive
crying of infant.
Yellowish mucus “crust” may form over glans--normal,
don’t wash off
Circumcision Care



Heals in a couple of weeks
Monitor for complications: hemorrhage, cold
stress/hypoglycemia, infection, urethral fistula,
delayed healing and scarring, fibrous bands.
Provide discharge instructions to parents about sign
& symptoms to report to provider.
Discharge Teaching

When to call healthcare provider:
– Baby’s axillary temp > 100.4
– > 1 episode of forceful (projectile) vomiting or
frequent vomiting over 6-hr period
– Refusal of 2 feedings in a row
– Lethargy, difficulty awakening baby
– Cyanosis with or without feeding
– Absence of breathing > 20 secs
– Inconsolable crying or continuous high-pitched cry
– Discharge/bleeding from umbilical cord,
circumcision
– No wet diapers for 18-24 hrs or < than 6-8 wet
diapers/day
– Eye drainage
Hyperbilirubinemia

Hyperbilirubinemia: results from
destruction of red blood cells
– Physiologic jaundice
Normal physiologic process
 Does not occur in first 24 hours of life
 Home care

– Pathologic jaundice
Abnormal destruction of RBCs
 Occurs in first 24 hours of life or persists after 1
week
 Causes: hemolytic disease of newborn: Rh or
ABO blood incompatibility (mom Rh - or type O)

Hyperbilirubinemia
Physiological Jaundice (p.
690)
 2nd or 3rd day of life.
 Breakdown of fetal red
blood cells.
 Heme and globin
realeased. Heme breaks
down into protoporphyrin
which breaks down into
indirect bilirubin & is
excreted by liver in feces
 Baby’s liver is immature
Pathologic Jaundice




Before 24 hours or persistent after day 7
Bilirubin increases more than 0.5 mg/dl/hr, peaks
at greater than 13 mg/dl or associated with
anemia and hepatosplenomegaly
Rh incompatibility/isoimmunization, infection,
RBC disorder. ABO incompatibility: positive
coombs test (test babies when mom O−/O+)
Kernicterus (bilirubin encephalopathy) can result
from untreated hypergbilirubinemia with bilirubin
levels at or higher than 20 mg/dl → mental
retardation
Risk Factors for Hyperbilirubinemia









↑ RBC production or breakdown
(cephalohematoma, extensive bruising from
birth trauma)
Rh or ABO incompatibility
Ineffective breastfeeding & dehydration
Certain medications (aspirin, tranquilizers, and
sulfonamides)
Maternal enzymes in breast milk- fairly
uncommon
Hypoglycemia
Hypothermia
Decreased liver function
Anoxia
Lab Testing





Elevated serum bilirubin (direct and indirect)
Blood group incapability between the mother
and newborn
Hemoglobin and hematocrit
Direct Coomb’s test--reveals presence of
antibody-coated (sensitized) Rh-positive
RBCs in the newborn
Electrolyte levels for dehydration from
phototherapy (treatment of
hyperbilirubinemia)
Nursing Assessments of
Hyperbilirubinemia




Yellowish tint to skin, sclera and mucus
membranes--observe by window
Press infant’s skin lightly and release and
notice yellowish tint
Note time of jaundice (integral in differentiating
between physiologic and pathologic jaundice)
Treatments: early feedings, phototherapy,
exchange transfusion
Neonatal Complications
RDS (Respiratory Distress Syndrome)

Pathophysiology:
– Low-level or absent surfactant
– Inspiratory effort to inflate alveoli remains
high
– Pulmonary resistance prevents fetal shunts
from closing
– Lungs are poorly perfused and tissue
hypoxia occurs with resultant acidosis

Surfactant not formed until week 34
Neonates at Risk for Respiratory
Distress Syndrome (RDS)






Preterm infants
Infants of diabetic mothers
Infants born by cesarean
Perinatal asphyxia
Decreased O2 tension in the lungs (one cause
is meconium aspiration)
Maternal factors: PROM, barbiturate/narcotic
use, hypotension, bleeding
Assessment of Infants with RDS

S/S usually don’t develop immediately post
birth. First S/S are subtle:
– Low body temperature
– Nasal flaring
– Expiratory grunting
– Sternal and subcostal retractions
– Tachypnea (> 60 respirations per minute)
– Cyanotic mucous membranes
Assessment of Infants with RDS

As distress continues:
– Seesaw respirations
– Heart failure
– Pale, gray skin
– Periods of apnea
– Bradycardia
– Pneumothorax
Therapeutic Management




Administer surfactant through ET tube
Oxygen administration (CPAP or
assisted ventilation with PEEP)
Ventilation
Indomethacin or ibuprofen to close
patent ductus arteriosus
Prevention of RDS


Tocolytics (Magnesium Sulfate,
Terbutaline, Procardia), corticosteroids
(Betamethasone) usually given between
24-34 weeks
L:S (lecithin:sphingomyelin) ratio is 2:1 in
amniotic fluid (indicates fetal maturity)
Transient Tachypnea of Newborn








When respiratory rate continues to remain high
(between 80-120 breaths/min) after 1 hour mark
Usually infant doesn’t appear distressed but instead
tired from breathing too fast
Usually mild retractions but no cyanosis
Feeding difficulties
Usually occurs from a slow absorption of lung fluid
More common in C-section babies & preterm infants
Peaks at 36 hours and usually resolves at 72 hours
TX: close observation, O2
Critical Thinking

The mother of a three-day-old infant calls the clinic
and reports that her baby's skin is turning slightly
yellow. The nurse should explain to the mother that:
A) The baby is yellow because the bowels are not excreting
bilirubin.
B) The newborn's liver is not working as well as it should.
C) The yellow color indicates that brain damage may be
occurring.
D) Physiologic jaundice is normal and peaks at this age.
Critical Thinking

The nurse is caring for a newborn with jaundice. The parents
question why the newborn is not under the phototherapy
lights. The nurse explains that the fiber optic blanket is
beneficial because: (Select all that apply.)
A) The lights can be turned off intermittently.
B) The eyes do not need to be covered.
C) The lights will need to be removed for feedings.
D) Newborns do not get overheated.
E) Weight loss is not a complication of this system.