Transcript Slide 1

Postpartum & Newborn Nursing
Ana H. Corona, MSN, FNP-C
Nursing Instructor
October 2007
Revised February 2009
The Postpartum Period
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Puerperium: Term 1st 6 weeks after the
birth of an infant
Neonate–newborn from birth to 28 days.
Family adaptation to neonate: Bonding–
rapid process of attachment during 1st 30
to 60 minutes after birth
Mother, father, siblings, grandparents
Factors Affecting Family Adaptation
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Parental fatigue
Previous experience with a newborn
Parental expectations of newborn
Knowledge of and confidence in providing
for newborn needs
Temperament of the newborn
Temperament of parents
Age of parents
Available support system
Unexpected events
Postpartum Assessment
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VS, amount of lochia, presence of edema,
fundal height and firmness, status of
perineum, bladder distension
1 to 2 hrs after delivery: every 15 minutes
If no problems every 8 hours
KNOW YOUR PATIENT --- DELIVERY
HISTORY /ADMISSION/TRANSITION
ASSESSMENT:
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Gravida, parity / Time and type of delivery
Anesthesia or medications / Risk factors for
PPH
Medical history / Routine medications /
Allergies
Infant status / Breast/bottle
Rubella immune?
Rh Negative?
Drug/ETOH Abuse
Body Systems Assessment
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Vital signs
Level of pain
Neurological
Pulmonary
Cardiovascular
Musculoskeletal
Gastrointestinal
Genitourinary
Integumentary
Psychosocial
Vital Signs
Day 1
Day 2 and after
Heart Rate
50 to 70 bpm
Respirations
Normal
Bradycardia or
normal
Normal
B/P
Normal
Normal
Temperature
100.4 normal
24 hrs.
Normal
If 100.4
Muscular
exertion/dehydration
infection
suspect
Postpartum Physical Assessment
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B - breast
U - uterus
B - bowels
B - bladder
L - lochia
E - episiotomy
General Assessment
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Enter the room quietly, speak quietly.
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Wash hands and provide for privacy.
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Inform patient before turning on lights.
Note LOC, activity level, position, color,
general demeanor.
Take note of the total environment:
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Safety/patient considerations
Note equipment and medical devices
Breast Assessment
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Breasts: Soft, engorged, filling, swelling,
redness, tenderness.
Nipples: Inverted, everted, cracked,
bleeding, bruised, presence of colostrum or
breastmilk.
Colostrum–yellowish fluid rich in antibodies
and high in protein.
Engorgement occurs by day 3 or 4. Due to
vasoconstriction as milk production begins
Lactation ceases within a week if
breastfeeding is never begun or is stopped.
Assessing Uterine Fundus
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Location in relation to
umbilicus
Degree of firmness
Is it at Midline or deviated to
one side?
Bladder Full?
A boggy uterus may indicate
uterine atony or retained
placental fragments.
Boggy refers to being
inadequately contracted and
having a spongy rather than
firm feeling.
Massaging the Fundus
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Every 15 mins during the 1st hr,
every 30 mins during the next hr,
and then, every hr until the patient
is ready for transfer.
Document fundal height.
Evaluate from the umbilicus using
fingerbreadths.
This is recorded as 2 fingers
below the umbilicus (U/2), one
finger above the umbilicus (1/U),
and so forth.
The fundus should remain in the
midline. If it deviates from the
middle- distended bladder.
Uterine Involution
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Uterine Involution: return
of the uterus to its prepregnancy size and
condition
Uterine fundal descent:
uterus size of grapefruit
immediately after birth
Fundus half way between
umbilicus and symphysis
pubis
Fundus rises to the
umbilicus stays for 12
hours
Descends 1 cm
(fingerbreadth) each day
for about 10 days
Uterine Atony
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Lack of muscle tone in the cervix.
Uterus feels soft and boggy
After delivery: Postpartum diuresis
The bladder has increased capacity and
decreased muscle tone.
This leads to over-distension of the
bladder, incomplete emptying of bladder,
retention of residual urine and increased
risk of UTI and postpartum hemorrhage.
Bowels & Bladder
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When was the patients last BM?
Is she passing flatus? (gas)
Assess for bowel sounds
Voiding pattern - without difficulty/pain, urine may
be blood tinged from lochia
Nursing interventions: Assist to the bathroom. Use
measures to encourage voiding (privacy).
Encourage use of peri-bottle with warm water,
fluids, fiber, frequent ambulation, stool softeners;
teach effects of pain medication.
Lochia Assessment
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Lochia–vaginal discharge after childbirth.
It takes 6 weeks for the vagina to regain its prepregnancy contour.
Lochia: scant-moderate, rubra, serosa or alba
Assessment of lochia includes noting color,
presence and size of clots and foul odor.
Day 1- 3 - lochia rubra (blood with small pieces
of decidua and mucus)
Day 4-10 – lochia serosa (pink or pinkish brown
serous exudate with cervical mucus, erythrocytes
and leukocytes)
Day 11- 21 - lochia alba (yellowish white
discharge)
Lochia: Pad Count
1.
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3.
4.
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Scant: 1-inch stain on pad in 1 hour
Light/small: 4 inches in 1 hour
Moderate: 6 inches in 1 hour
Heavy/large: Pad saturated in 1 hour
Excessive: Pad saturated in 15 min
Can estimate blood loss by weighing pads:
500 mL = 1 lb. or 454 g
Episiotomy/Perineal Assessment
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Patient in lateral Sims (side lying) position.
Use the acronym REEDA (redness, edema,
ecchymosis, discharge, approximation of
suture lines “edges of episiotomy”) to guide
assessment.
Even if there is no episiotomy, the perineum
should still be assessed.
Unusual perineal discomfort may be a
symptom of impending infection or
hematoma.
Hemorrhoids ?
Episiotomy Pain Relief
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Instruct Mother:
Tighten her buttocks and perineum before
sitting to prevent pulling on the
episiotomy and perineal area and to
release tightening after being seated.
Rest several times a day with feet
elevated.
Practice Kegel exercise many times a day
to increase circulation to the perineal area
and to strengthen the perineal muscles.
Assessment of Edema & Homan’s Sign
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Assess legs for presence and degree of
edema; may have dependent edema in feet
and legs.
Assess for Homan’s sign- thromboembolism
should be negative
Press down gently on the patient’s knee
(legs extended flat on bed) ask her to flex
her foot (dorsiflex)
Homan’s Sign
Thromboembolic Conditions
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Thrombophlebitis–the formation of a clot
in an inflamed vein.
Risk factors include maternal age over 35,
cesarean birth, prolonged time in stirrups,
obesity, smoking, and history of
varicosities or venous thromboses.
Prevention: client needs to ambulate early
after delivery.
Postpartum Cesarean
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Incision site…redness swelling, discharge. Intact?
Abdomen soft, distended? Bowel sounds heard all
4 quadrants
Flatus?
Lochia is less amount than in normal spontaneous
vaginal delivery (NSVD) because uterus is wiped
with sponges during c/section.
If lochia indicates excessive bleeding, combine
palpation and pain management measures.
Auscultate breath sounds
Fluid intake and output
Pain?
RhoGAM
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It is given to an Rh- mother within 72
hours after delivery of an Rh+ infant or if
the Rh is unknown.
The dose must be repeated after each
subsequent delivery. RhoGAM 300 mcg is
the standard dose.
Postpartum Disseminated Intravascular Coagulation
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Abnormal stimulation of clotting mechanism.
Normally, the body forms a blood clot in
reaction to an injury.
Small blood clots throughout the body,
depleting the body of clotting factors and
platelets. –Massive bleeding
Causes may include amniotic fluid clots, fetal
demise, abruptio placenta. Eclampsia or
Retained placenta
Symptoms: Sometimes severe bleeding and
sudden bruising .
Postpartum Hemorrhage
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Blood loss of more than 500 ml after vaginal birth
or 1,000 ml after a cesarean birth.
Early hemorrhage –Cervical or vaginal tears,
uterine atony, retained placental fragments,
lacerations, hematomas.
Late hemorrhage –subinvolution, retained placental
fragments.
Subinvolution: failure of the uterus to return to
normal size.
Management may include CBC, sedimentation rate,
type and cross, fluid resuscitation with normal
saline and blood, vaginal examination, diagnosis,
and correction of the underlying cause.
Postpartum Depression
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Postpartum depression is a nonpsychotic
depressive episode that begins in the
postpartum period due to decreased
estrogen level
Symptoms: changes in appetite or weight,
sleep, and psychomotor activity; decreased
energy; feeling of worthlessness or guilt;
difficulty thinking, concentrating or making
decisions; or recurrent thoughts of death or
suicidal ideation, plans, or attempts.
Postpartum Psychosis
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A very serious type of PPD
illness that can affect new
mothers.
Begin 2-3 weeks post
delivery
Fatigue, restlessness,
insomnia, crying liable
emotions, inability to move,
irrationally statements
incoherence confusion and
obsessive concerns about
the infant’s health
Psychiatric emergency
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Nipple soreness is a portal of entry for
bacteria - breast infection (Mastitis).
Maternal after pains: may be due to
breastfeeding and multiparity
Always stay with the client when getting
out of bed for the first time – hypotension
effect and excess bleeding
When assessing fundal height, if you
notice any discrepancies in fundal height
have patient void and then reassess.
Nursing Diagnosis Related to Breasts and
Breastfeeding
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Pain r/t improper positioning, engorged
breasts
Ineffective breastfeeding r/t maternal
discomfort, improper infant positioning
Knowledge deficit r/t normal physiologic
changes, breastfeeding
Infection r/t improper breastfeeding
techniques, improper breast care
The Newborn
Newborn’s Immediate Needs
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Airway
Breathing
Circulation
Warmth
The Newborn
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Neonatal transition: 1st few hours after
birth newborn stabilizes respiratory and
circulatory functions.
When the cord is clamped, placental gas
exchange ceases.
These changes stimulate carotid and aortic
chemoreceptors which send impulses to
the respiratory center in the medulla.
A brief period of asphyxia stimulates
respirations.
Apgar Score
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Assesses the infants cardiopulmonary
adaptations to extrauterine life
Provides a quick evaluation on how the
heart and lungs are adapting
5 items to be assessed 1 and 5 minutes
after birth.
Apgar Score
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Heart rate, respiratory rate, muscle tone, reflex irritability and color
Score of 0 – 2 for each item, then totaled.
Apgar Score 8 or higher no intervention
Apgar Score 4 – 8 gentle rubbing, oxygen
Apgar Score 0 – 4 resuscitation
Points Given
0
1
2
A Activity/muscle Limp/flaccid
tone
Some
Active motion/well
motion/flexion flexed
P Pulse Rate
<100 bts/min
>100 bts/min
G Grimace/Reflex No Response
Irritability
Grimace
Cry, cough,
sneeze
A Appearance/
Skin Color
Blue, Pale
Body pink,
extremities
blue
Pink all over
Absence of
cyanosis
R Respiration
Absent
Slow weak cry Good Cry
Absent
Prophylactic Care
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Vitamin K –to prevent hemorrhagic
disorders – vit k (clotting process) is
synthesized in intestine requires food for
this process. Newborn’s stomach is sterile
has no food. aquaMEPHYTON
Hepatitis B vaccination –within the first 12
hours
Eye prophylaxis –(Erythromycin Ointment)
to prevent ophthalmia neonatorum –
gonorrhea/chlamydia
Newborn: Intramuscular injection
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aquaMEPHYTON (Vit.K)
1 mg/0.5 ml IM lateral thigh
Vastus lateralis
Vital Signs
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Temperature - range 36.5 to 37 axillary (97.7-98.6)
Axillary vs Rectal about 0.2 to 0.5 difference
Common variations
 Crying may elevate temperature
 Stabilizes in 8 to 10 hours after delivery
Heart rate - range 120 to 160 beats per minute
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Apical pulse for one minute
Common variations
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Heart rate range to 100 when sleeping to 180 when crying
Color pink with acrocyanosis
Heart rate may be irregular with crying
Respiration - range 30 to 60 breaths per minute
Blood pressure - not done routinely
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Ranges between 60-80 mm systolic and 40-45 mm diastolic.
Reflexes: indicate neurological integrity
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Rooting
Sucking
Extrusion
Palmar grasp
Plantar grasp
Tonic neck
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Moro
Gallant
Stepping
Babinski’s
Crossed extension
reflex
Placing
Reflexes
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Tonic Neck Reflex (FENCING)
EXTENDS arm & leg on the side
that the face points.
Flexes opposite arm & leg
6-8 wks to 6 months
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Moro Reflex
Birth to 4-6 months
Rooting and Sucking Reflexes
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Birth to 3-4months
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Birth to 10 months
Babinski and Palmer Grasping Reflex
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Babinski Reflex is (+)
This is Normal
Birth to after walking
12-18 months age
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Birth to 4 months
Skin
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Expected findings
Skin reddish in color, smooth and puffy at
birth
At 24 - 36 hours of age, skin flaky, dry and
pink in color
Edema around eyes, feet, and genitals
Vernix caceosa
Lanugo (baby hair)
Turgor good with quick recoil
Hair silky and soft with individual strands
Common Normal Variations
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Acrocyanosis - result of sluggish peripheral
circulation.
Mongolian Spots: Patch of purple-black or
blue-black color distributed over coccygeal
and sacral regions of infants of AfricanAmerican or Asian descent.
Milia: Tiny white bumps papules (plugged
sebaceous glands) located over nose, cheek,
and chin.
Erythema toxicum: Most common newborn rash.
Variable, irregular macular patches. Lasts a few
days.
Erythema toxicum, acrocyanosis, milia and
mongolian spots
Hyperbilirubinemia
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Physiologic Jaundice =Appears 24 hours after
birth peaks at 72 hrs.
Bilirubin may reach 6 to 10 mg/dl and resolve in 5
to 7 days.
Due to Unconjugated bilirubin circulating in the
blood stream that is deposited in the skin.
Immature liver unable to conjugate bilirubin
released by destroyed RBC.
Pathologic Jaundice =Not appear until after 24
hrs leads to Kernicterus (deposits of bili in brain).
Bilirubin >20mg/dl
The most common cause is Rh incompatibility.
The Head and Chest
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The Head: Anterior
fontanel diamond shaped
2-3 - 3-4 cms
Posterior fontanel
triangular 0.5 - 1 cm
Fontanels soft, firm and flat
head circumference is 33 –
35 cm
The head is a few
centimeters larger than the
chest!!!!
The Chest: circumference
is 30.5 – 33 cm
Anterior and Posterior
Fontanelles
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Anterior diamond shaped 2-3 3-4 cms
Posterior triangular 0.5 - 1 cm
Fontanels soft, firm and flat
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Molding is shaping of
fetal head to adapt to
the mothers pelvis
during labor.
Caput succedaneum
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Swelling of the soft tissue
of the scalp caused by
pressure of the fetal head
on a cervix that is not
fully dilated.
Swelling is generalized.
may cross suture line and
decreases rapidly in a few
days after birth. Requires
no treatment
2 – 3 days disappears
Cephalohematoma
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Collection of blood
between the periosteum
and skull of newborn.
Does not cross suture
lines
Caused by rupturing of
the periosteal bridging
veins due to friction and
pressure during labor.
Lasts 3 – 6 weeks
Bathing the Newborn
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No tub bath until after
the cord has fallen off
and healing is complete.
Newborn’s first bath- the
nurse needs to wear
gloves to prevent
infection.
Newborn temperature
needs to be >98. F
No soap applied on the
face.
Baby shampoo may be
applied on scalp
Start from face down.
Gestational Age Relationship to Intrauterine Growth
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Normal range of birth weight for each week
of gestation.
Birth weight is classified as follows:
Large for gestational age (LGA): weight falls
above the 90th percentile for gestational age
Appropriate for gestational age (AGA):
weight falls between the 90th and 10th
percentile for gestational age
Small for gestational age (SGA): weight falls
below the 10th percentile for gestational age
Intrauterine Growth Grid
Circumcision
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Circumcision is considered an elective procedure
Anesthesia should be provided.
Parents must give written consent
Full term health infants
Aftercare: Check hourly for 12 hours
Check for bleeding and voiding
Before discharge:
Newborn goes home within the first 12 hours
after procedure
Bleeding should be minimal and infant must void
Ensure that parents know how to care for the
circumcision.
Breastfeeding
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Colostrum is rich in immunoglobulins to protect
newborn GI tract from infection; laxative effect.
Breast milk in 2 weeks sufficient nutrients 20
kcal/oz (infant’s nutritional needs)
To support Breastfeeding: Mother needs to
consume extra 500 calories per day.
Feeding length: should be long enough to
remove all the foremilk (watery 1st milk from
breast high in lactose - skim milk & effective in
quenching thirst)
Hindmilk: higher in fat content leads to weight
gain and more satisfying.
Breastfeeding time approximately 30 minutes
Infant Formula
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Formula 7.5 ml to 15 ml at feeding
gradually increase to 90 ml to 120 ml at
each feeding in 2 weeks.
Formula preparation: mixing must be
accurate to provide the 20 kcal/oz.
(newborn nutritional need)
Burping: is needed to expel air swallowed
when infant sucks.
Should be done about ½ way through
feeding for bottle feeders and when
changing breasts for breast feeders.
Respiratory Distress
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2 types: Respiratory Distress Syndrome (RDS) and
Transient Tachypnea of the Newborn (TTN)
RDS: preterm infants/surfactant deficiency
Hypoxia, respiratory acidosis and metabolic acidosis
Surfactant is produced by alveoli - lung maturity
L/S ratio 2:1 is a test done before birth to determine
fetal lung maturity
TTN: AGA, near term infants
Intrauterine or intrapartum asphyxia
Newborn unable to clear airway of lung fluid, mucous or
amniotic fluid aspiration.
Expiratory grunting nasal flaring, tachypnea with
respirations as high as 100 to 140 breaths/minute.
Neural Tube Defects
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3 types:
Spina Bifida Occulta: failure of the vertebral
arch to close. Has dimple on the back with a tuft of
hair. No treatment required.
Meningocele: saclike protrusion along the
vertebral column filled with cerebrospinal fluid and
meninges. Surgery required.
Myelomeningocele: saclike protrusion along the
vertebral column filled with spinal fluid meninges,
nerve roots, and spinal cord = paralysis. Surgical
repair required.
Sterile saline dressing.
hydrocepalus
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Spina bifida occulta
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Spina bifida Occulta
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meningocele
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myelomeningocele
Infants of DM mothers (IDM) Complications
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Hypoglycemia: maternal glucose declines at
birth. Infant has high level of insulin
production= decreases infant’s blood glucose
within hours after birth.
Respiratory Distress: less mature lungs due
to insulin
Hyperbilirubinemia: hepatic immaturity,
increased hematocrit, bruising due to difficult
delivery.
Birth trauma: large size of infant
Congenital birth defects: birth defects –
Patent Ductus Arteriosus, Ventricular Septal
Defect and more.