Postpartum & Newborn PCC Memory Key

8/3/2019 Postpartum & Newborn PCC Memory Key

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Postpartum & NewbornPostpartum & NewbornNursing Theory and PracticeNursing Theory and Practice



MOTHERMOTHER

What is the first thing that comes to mind?What is the first thing that comes to mind?

WordsWords ImagesImages

Day to day life of mothers (and parents) isDay to day life of mothers (and parents) isoften in contrast to our idealized conceptsoften in contrast to our idealized concepts



The ³Fourth´ Trimester The ³Fourth´ Trimester



Defining the Postpartum PeriodDefining the Postpartum Period

Postpartum period is a time of changePostpartum period is a time of change

Medical/Physiologic changeMedical/Physiologic change

Psychosocial (developmental) changePsychosocial (developmental) change Duration of changes is variableDuration of changes is variable

Duration of coping with changes isDuration of coping with changes is

variablevariable



Defining the Postpartum PeriodDefining the Postpartum Period

Physiologically defined as the six weekPhysiologically defined as the six weekperiod of uterine involutionperiod of uterine involution

Begins with the birth of the placentaBegins with the birth of the placenta Includes resolution of anatomic andIncludes resolution of anatomic and

physiologic changes of pregnancyphysiologic changes of pregnancy

return of all systems to (nearly) prereturn of all systems to (nearly) pre--pregnant statepregnant state

Psychosocial tasks of the postpartumPsychosocial tasks of the postpartumperiod take longer than six weeks toperiod take longer than six weeks toaccomplishaccomplish



Physiologic ChangesPhysiologic Changes



Reproductive SystemReproductive System

Uterine InvolutionUterine Involution

Muscle fibers contract with the birth of Muscle fibers contract with the birth of placentaplacenta

Stops bleeding of large uterine vesselsStops bleeding of large uterine vessels

Massage gently to maintain firmnessMassage gently to maintain firmness Can be taught to womanCan be taught to woman

Much more comfortable if woman does herself Much more comfortable if woman does herself

Must be effective or clots can collect in the uterusMust be effective or clots can collect in the uterus




Uterine InvolutionUterine Involution

Uterus progressively smaller Uterus progressively smaller

over ~2 weeksover ~2 weeks 11 ± ± 2 finger breadths below umbilicus immediately2 finger breadths below umbilicus immediately

postpartumpostpartum

At umbilicus on days one and two At umbilicus on days one and two

Progressively smaller until not palpableProgressively smaller until not palpableabdominally by day 10; may take slightly longer abdominally by day 10; may take slightly longer with cesarean sectionwith cesarean section




Uterine InvolutionUterine Involution Afterpains can be intense! Afterpains can be intense!

Especially for multiparaEspecially for multipara

May need narcotic analgesia in addition to NSAIDMay need narcotic analgesia in addition to NSAID Narcotics are constipatingNarcotics are constipating

prevention is importantprevention is important

Void regularlyVoid regularly

Prone position (NOT kneeProne position (NOT knee--chest)chest) HeatHeat

Worse with suckling, preWorse with suckling, pre--medicate prnmedicate prn Education/understanding is criticalEducation/understanding is critical




Oxytotic agents (Oxytotic agents ( afterpains) afterpains)

Pitocin (given almost routinely IV or IM after Pitocin (given almost routinely IV or IM after all births)all births)

Hemabate (PGF2a, not in asthmatics)Hemabate (PGF2a, not in asthmatics)

MethergineMethergine

IM & PO most common, IV if life threateningIM & PO most common, IV if life threatening

Causes sustained uterine contractionCauses sustained uterine contraction Increases BPIncreases BP

Obtain baseline BP before each administrationObtain baseline BP before each administration




Endometrial SloughingEndometrial Sloughing

LochiaLochia

Rubra (Red) 1Rubra (Red) 1 ± ± 5 days5 days

Serosa (Pinkish Tan) 5 daysSerosa (Pinkish Tan) 5 days ± ± 2 weeks2 weeks

Alba (White) 2 to 6 weeks Alba (White) 2 to 6 weeks

Lochia has strong smell, not a foul smellLochia has strong smell, not a foul smell

In the first three daysIn the first three days Small amount of small clots are normalSmall amount of small clots are normal

ONE larger clot after long period supine is normalONE larger clot after long period supine is normal




Placental SitePlacental Site

Heals by exfoliative shedding. Lochia is aHeals by exfoliative shedding. Lochia is acombination of shed tissues.combination of shed tissues.

Lochia is made up of blood, decidua, serous fluid,Lochia is made up of blood, decidua, serous fluid,and leukocytes with the proportion of eachand leukocytes with the proportion of eachchanging as the lochia changeschanging as the lochia changes

Lack of scar tissue important for placentalLack of scar tissue important for placentalimplantation in future pregnanciesimplantation in future pregnancies




CervixCervix

Floppy (patulous) immediately after birthFloppy (patulous) immediately after birth

May be visible at vaginal introitus

May be visible at vaginal introitus

Closes, firms as uterus involutes (~2 weeks)Closes, firms as uterus involutes (~2 weeks)

Os (opening) changes from round to slit likeOs (opening) changes from round to slit likeafter birth of first childafter birth of first child

Cervix not routinely inspected for laceration.Cervix not routinely inspected for laceration.Lacerated cervix can be cause of continuedLacerated cervix can be cause of continuedpostpartum bleeding w/ firm uterus.postpartum bleeding w/ firm uterus.




VaginaVagina

Edematous after delivery (external ice pack)Edematous after delivery (external ice pack)

May have lacerations that may or may not

May have lacerations that may or may notneed repair (hemostasis and approximation)need repair (hemostasis and approximation)

Smooth walled x several weeks, then ruggaeSmooth walled x several weeks, then ruggaereappear reappear

Mucosa thinned and dryer secondary toMucosa thinned and dryer secondary to estrogenestrogen continues until ovulation andcontinues until ovulation andmenstruation resume. Counsel for lubricationmenstruation resume. Counsel for lubrication




PerineumPerineum

May have lacerations or incision (episiotomy*)May have lacerations or incision (episiotomy*)

11stst degree mucosa onlydegree mucosa only

22ndnd degree mucosa and underlying muscle*degree mucosa and underlying muscle*

33rdrd degree mucosa, underlying muscle and partialdegree mucosa, underlying muscle and partialtear of anal sphincter tear of anal sphincter

44thth degree mucosa, underlying muscle, analdegree mucosa, underlying muscle, analsphincter and tear of anal mucosal capsulesphincter and tear of anal mucosal capsule




PerineumPerineum

After 30 years of research there is no After 30 years of research there is noevidence to support routine episiotomyevidence to support routine episiotomy

Episiotomy should be used selectively only if Episiotomy should be used selectively only if

Birth needs to be expeditedBirth needs to be expedited

Access to the baby is essential Access to the baby is essential

Clear evidence of uncontrolled tear (debatable)Clear evidence of uncontrolled tear (debatable) Episiotomy increases the risk of severe tear Episiotomy increases the risk of severe tear

(fabric demo)(fabric demo)




Perineum (continued)Perineum (continued)

All stitches absorb on their own after ~ 2 weeks All stitches absorb on their own after ~ 2 weeks

May see knots on peripad as they dissolveMay see knots on peripad as they dissolve

Nursing care is directed towardNursing care is directed toward Assessment of injured site (visualization, approximation, Assessment of injured site (visualization, approximation,

bruising, bleeding, edema, infection s/sx)bruising, bleeding, edema, infection s/sx)

Decreased edema (ice x 24 hours, then heat prn)Decreased edema (ice x 24 hours, then heat prn)

PainManagement (assessment, positioning, Rx)PainManagement (assessment, positioning, Rx)

Nutrition/Rx support to prevent constipationNutrition/Rx support to prevent constipation

Exercise of injured muscle to improve blood flow andExercise of injured muscle to improve blood flow andstrength (kegel)strength (kegel)




Return to Menstruation/OvulationReturn to Menstruation/Ovulation

Pregnancy can occur prior to first menses!Pregnancy can occur prior to first menses!

Contraceptive options are an essential part of Contraceptive options are an essential part of discharge teachingdischarge teaching

Lactating womenLactating women

Prolactin suppresses ovulation. Return to mensesProlactin suppresses ovulation. Return to mensesunpredictable; from 6 weeks to 1 year or moreunpredictable; from 6 weeks to 1 year or more

NonNon--Lactating womenLactating women

Menses usually resume by 6Menses usually resume by 6 ± ± 8 weeks8 weeks



LactationLactation

Lactating womenLactating women

Sudden drop in estrogen & progesterone withSudden drop in estrogen & progesterone withbirth of placentabirth of placenta

Prolactin Prolactin

milk productionmilk production

mmaternal feelings and wellbeingaternal feelings and wellbeing

supported by frequent contact with babysupported by frequent contact with baby Rooming in with supportRooming in with support

suppresses ovulation, delays menstruationsuppresses ovulation, delays menstruation



LactationLactation

³Let down´ reflex:³Let down´ reflex: sucklingsuckling oxytocinoxytocin Milk ejection, uterine involutionMilk ejection, uterine involution

Afterpains Afterpains ibuprofen 600mg safeibuprofen 600mg safe

Colostrum x 3 daysColostrum x 3 days Baby¶s ³first vaccine´ (high in IgA antibodies)Baby¶s ³first vaccine´ (high in IgA antibodies)

Nutrient denseNutrient dense only small amounts neededonly small amounts needed

Transitional milk days 3Transitional milk days 3 ± ± 66

Mature milk day 6 onMature milk day 6 on Composition of milk changes over timeComposition of milk changes over time



LactationLactation

Breasts immediately postpartumBreasts immediately postpartum

Soft textureSoft texture

May or may not leak small amount of

May or may not leak small amount of colostrumcolostrum

Check nipples if breastfeeding: erect, evertedCheck nipples if breastfeeding: erect, everted



LactationLactation

Breasts on day one and twoBreasts on day one and two

Soft texture, may begin to fill and feel firmer Soft texture, may begin to fill and feel firmer

Check nipples if breastfeeding: erect, everted,Check nipples if breastfeeding: erect, everted,intactintact



LactationLactation

Breasts on day three to fiveBreasts on day three to five

Entire breast feels taut, warm, erythematous,Entire breast feels taut, warm, erythematous,larger larger

Check nipple is erect, everted, intactCheck nipple is erect, everted, intact

Note any nodules (plugged duct, cyst, cancer)Note any nodules (plugged duct, cyst, cancer)



LactationLactation

Breasts day 6 to week 6Breasts day 6 to week 6

Firm when just about time to nurseFirm when just about time to nurse

Softer after baby nurses effectivelySofter after baby nurses effectively May spray milk with let downMay spray milk with let down

Week 6 onwardWeek 6 onward

Breasts much softer, even when fullBreasts much softer, even when full

Softness is not a sign of less milkSoftness is not a sign of less milk



LactationLactation

MastitisMastitis

Wedge shaped areaWedge shaped area

Local painLocal pain RednessRedness

Firm noduleFirm nodule

Fever Fever

ExhaustionExhaustion



LactationLactation

NonNon--Lactating WomenLactating Women

Still have colostrum, may leakStill have colostrum, may leak

M

ilk will still come in on ~ day 3M

ilk will still come in on ~ day 3 Engorgement!Engorgement! Congestion of veins and lymphatic circulationCongestion of veins and lymphatic circulation

Breasts taut, erythematous, painful, hotBreasts taut, erythematous, painful, hot

iibuprofen 600 mg safe;buprofen 600 mg safe; Cold compress; tight braCold compress; tight bra

no breast stimulation or milk expressionno breast stimulation or milk expression

Green Cabbage leavesGreen Cabbage leaves

Prolactin levelsProlactin levels quickly without suckling quickly without suckling



LactationLactation

Breast milk is the best food for humanBreast milk is the best food for humaninfantsinfants

Formula is safe in USFormula is safe in US But does NOT have the benefits of breast milkBut does NOT have the benefits of breast milk

Formula may not be safe developingFormula may not be safe developingcountriescountries

Formula is unsafe in poor countriesFormula is unsafe in poor countries



LactationLactation

Goal is to increase the number of women whoGoal is to increase the number of women whoinitiate and sustain breastfeedinginitiate and sustain breastfeeding

ongoing intense support and education essentialongoing intense support and education essential

³Increased duration of breastfeeding confers³Increased duration of breastfeeding conferssignificant health and developmental benefits for significant health and developmental benefits for the child and the mother...´ (AAP Policythe child and the mother...´ (AAP PolicyStatement 2005)Statement 2005)



LactationLactation

Nursing actions directly affectNursing actions directly affectbreastfeeding initiationbreastfeeding initiation

Encourage rooming inEncourage rooming in

Effective, accurate informationEffective, accurate information

Referral to community resourcesReferral to community resources

Including the mother¶s support systemIncluding the mother¶s support system



Bottle FeedingBottle Feeding

Based on modified cow milk or soyBased on modified cow milk or soy

Cost approx $1200/ year Cost approx $1200/ year Powdered or concentratePowdered or concentrate ± ± mix w/ boiledmix w/ boiled

water water More $ if ³ready to eat´More $ if ³ready to eat´

WIC does not cover the entire cost of formulaWIC does not cover the entire cost of formula

Contains supplemental vitamins and ironContains supplemental vitamins and iron Wash nipples and bottles dailyWash nipples and bottles daily

Discard unused portion of bottleDiscard unused portion of bottle



Cardiovascular SystemCardiovascular System

Normal blood lossNormal blood loss

Vaginal birth = up to 500cc (2 cups)Vaginal birth = up to 500cc (2 cups)

Cesarean birth = up to 1000ccCesarean birth = up to 1000cc

WBC count up to 20,000WBC count up to 20,000

Increased propensity for clotting makesIncreased propensity for clotting makespostpartum women at increased risk for postpartum women at increased risk for thrombithrombi

Varicosities regressVaricosities regress




Blood PressureBlood Pressure

Q 15 minutes x 1 hour postpartum, thenQ 15 minutes x 1 hour postpartum, thenhourly x 4 hours, then q shifthourly x 4 hours, then q shift

>140 systolic or >90 diastolic can suggest>140 systolic or >90 diastolic can suggestpostpartum prepostpartum pre--eclampsia and deserveseclampsia and deservesfurther investigationfurther investigation

Orthostatic hypotension can occur with acuteOrthostatic hypotension can occur with acuteblood loss or dehydration (pulse bumps 20blood loss or dehydration (pulse bumps 20bpm and BP falls 15bpm and BP falls 15--20 mmHg positionally)20 mmHg positionally)




PulsePulse Increased stroke volume due to increasedIncreased stroke volume due to increased

circulating volume (loss of placental/uterinecirculating volume (loss of placental/uterine

sinuses)sinuses) lower pulse rate (60lower pulse rate (60 ± ± 70)70) DiuresisDiuresis less volumeless volume pulse returns topulse returns to

normal usually by the end of the first weeknormal usually by the end of the first week

Warning! In a postpartum woman, you mayWarning! In a postpartum woman, you maysee ³normal´ vital signs in a patient at risk for see ³normal´ vital signs in a patient at risk for hypovolemiahypovolemia



Temperature RegulationTemperature Regulation

May see slightMay see slight immediately postpartum immediately postpartum

Physical effortPhysical effort

DehydrationDehydration

Temperature >100.4 at any time triggersTemperature >100.4 at any time triggersfurther assessment for infection and reportfurther assessment for infection and reportof the findingsof the findings

Days 3Days 3 ± ± 5 may see slight temperature 5 may see slight temperature due to breast engorgement (<100.4)due to breast engorgement (<100.4)



Weight LossWeight Loss

+/+/-- 12 lbs lost at birth from baby, fluids,12 lbs lost at birth from baby, fluids,placentaplacenta

+/+/-- 5 lbs fluid loss from diuresis from days5 lbs fluid loss from diuresis from days

two to fivetwo to five 22--3 lbs loss from shedding lochia3 lbs loss from shedding lochia

Total by 6 weeks +/Total by 6 weeks +/-- 20 pounds20 pounds

Extra weight remains as fat deposits toExtra weight remains as fat deposits tomake milkmake milk

Lactating women need +500 cal/dayLactating women need +500 cal/day



Integumentary SystemIntegumentary System

Woman may appear about 6 monthsWoman may appear about 6 monthspregnant when standingpregnant when standing

Skin and underlying muscle are stretchedSkin and underlying muscle are stretched

Diastasis recti visible about 2Diastasis recti visible about 2 ± ± 4 cm wide4 cm wide

Abdominal crunches starting about 3 days if Abdominal crunches starting about 3 days if vaginal birthvaginal birth




Stretch marks ³striae´ appear purple to redStretch marks ³striae´ appear purple to red Commonly on abdomen, breasts, hipsCommonly on abdomen, breasts, hips

Over time fade to silvery tanOver time fade to silvery tan--white, do notwhite, do not

disappear disappear Linea nigra and other estrogen mediatedLinea nigra and other estrogen mediated

skin markings gradually fade, may notskin markings gradually fade, may notdisappear disappear

May have new scars and altered bodyMay have new scars and altered bodyimageimage



Striae and Linea NigraStriae and Linea Nigra




ConjunctivaConjunctiva May be pale in anemiaMay be pale in anemia

ScleraSclera

May have hemorrhages due to pushingMay have hemorrhages due to pushing Lacerations of the perineum/vaginaLacerations of the perineum/vagina

May see bruising or hematomaMay see bruising or hematoma

EdemaEdema

Should be well approximated and hemostatic withoutShould be well approximated and hemostatic withoutdischargedischarge

Sitz baths, peri careSitz baths, peri care



Urinary SystemUrinary System

Difficulty voiding immediately postpartumDifficulty voiding immediately postpartum

EdemaEdema

Decreased intraDecreased intra--abdominal pressureabdominal pressure

Residual effects of epidural if usedResidual effects of epidural if used

Running water, stroking lower back, peppermint oilRunning water, stroking lower back, peppermint oil

Catheterization if bleeding uncontrolledCatheterization if bleeding uncontrolled

Uterus deviated to right often indicates full bladder Uterus deviated to right often indicates full bladder



Urinary SystemUrinary System

Marked diuresis of Marked diuresis of ¶d¶d fluid volumefluid volume

Beginning about 12 hours postpartumBeginning about 12 hours postpartum

Urinary lossesUrinary losses

Also diaphoresis profuse Also diaphoresis profuse



Gastrointestinal SystemGastrointestinal System

Usually VERY hungry after birthUsually VERY hungry after birth

Most L&D units keep snack boxesMost L&D units keep snack boxes

birth often occurs outside of regular meal servicebirth often occurs outside of regular meal service

Birth centers often have kitchensBirth centers often have kitchens

Families prepare mealsFamilies prepare meals

Birthday cake!Birthday cake!




At risk for constipation At risk for constipation

Still have poor abdominal and intestinalStill have poor abdominal and intestinalmuscle tonemuscle tone

Fear of passing stool due to laceration(s)Fear of passing stool due to laceration(s)

Fiber, fluid, stool softener, anticipatoryFiber, fluid, stool softener, anticipatoryguidanceguidance




HemorrhoidsHemorrhoids

Pressure from pushingPressure from pushing

CommonCommon

Ice packsIce packs

OintmentOintment

Witch hazel padsWitch hazel pads

Anesthetic spray Anesthetic spray



Psychosocial Aspects of Psychosocial Aspects of PostpartumPostpartum



Adaptation to Parenthood Adaptation to Parenthood

Learning new skillsLearning new skills

Feeding, holding, diapering, bathing, umbilical andFeeding, holding, diapering, bathing, umbilical andpossibly circumcision carepossibly circumcision care

Soothing, interpreting baby¶s communicationSoothing, interpreting baby¶s communication New physical demandsNew physical demands

New skill acquisition occurs just as all of the physicalNew skill acquisition occurs just as all of the physicaladaptations are taking placeadaptations are taking place

Sleep deprivationSleep deprivation

Postpartum changes affect all aspects of lifePostpartum changes affect all aspects of life



Three Phases of PuerperiumThree Phases of Puerperium

Next three slides based on work of:Next three slides based on work of:

Reva Rubin, 1977Reva Rubin, 1977

A classic body of work A classic body of work Describes maternal behavior in threeDescribes maternal behavior in three

phasesphases

Taking InTaking In Taking HoldTaking Hold

Letting GoLetting Go



Three Phases of the PuerperiumThree Phases of the Puerperium

Taking InTaking In

Passive, uncertain, exhaustedPassive, uncertain, exhausted

Reviewing birth experience, baby exploredReviewing birth experience, baby exploredand experienced with wonder, unfamiliar and experienced with wonder, unfamiliar

Often touch baby with only fingertips at first,Often touch baby with only fingertips at first,then move to caress and explore entire babythen move to caress and explore entire baby

Gaze at baby ³en face´Gaze at baby ³en face´ Vulnerable physically and emotionallyVulnerable physically and emotionally




Taking holdTaking hold

Beginning to take tentative action, buildingBeginning to take tentative action, buildingconfidence, gaining familiarityconfidence, gaining familiarity

Strong interest in taking care of her babyStrong interest in taking care of her babyherself herself

Coming to accept birth experienceComing to accept birth experience

Gaining familiarity with baby, still feels unsureGaining familiarity with baby, still feels unsure Praise and positive reinforcement welcomePraise and positive reinforcement welcome




Letting goLetting go

Acceptance of fantasy and reality in Acceptance of fantasy and reality in

birth experiencebirth experience

babybaby

new roles (mother, lover, worker, etc)new roles (mother, lover, worker, etc)

Grief workGrief work

Confident, independent actionConfident, independent action Forms own opinionsForms own opinions

Ongoing . . . duration measured in yearsOngoing . . . duration measured in years



Postpartum BluesPostpartum Blues

Normal reaction (70% in some sources) toNormal reaction (70% in some sources) to Sleep deprivationSleep deprivation

Grief workGrief work

Life changeLife change Conflict between expectation and realityConflict between expectation and reality

Physiologic changes, including endocrine changesPhysiologic changes, including endocrine changes

Usually worst around days 3Usually worst around days 3 -- 55

Characterized by labile mood, tearfulness, andCharacterized by labile mood, tearfulness, andreality based passing feelings of inadequacyreality based passing feelings of inadequacy

Early onset and resolutionEarly onset and resolution



Bonding BehaviorsBonding Behaviors

En face positioningEn face positioning

Baby talking (high pitched, sing song)Baby talking (high pitched, sing song)

FingertipsFingertips open palmopen palm enfoldingenfolding Eye gazingEye gazing

Entrainment (baby moves in rhythm withEntrainment (baby moves in rhythm with

adult speech)adult speech) Encouraging rooming in with support isEncouraging rooming in with support is

essentialessential



Postpartum Nursing CarePostpartum Nursing Care

Is based on an understanding of theIs based on an understanding of thephysiology and psychology of thephysiology and psychology of thepostpartum periodpostpartum period

Nursing interventions include:Nursing interventions include:



Nurse¶s Role in Postpartum CareNurse¶s Role in Postpartum Care

Change agentChange agent

Skilled observer Skilled observer

Thoughtful teacher Thoughtful teacher Expert time manager Expert time manager

CoachCoach

ScientistScientist Care taker Care taker



Nursing ActivitiesNursing ActivitiesBirthBirth ± ± 2 hours2 hours

obtaining/assessing frequent vital signs on two patientsobtaining/assessing frequent vital signs on two patients supporting and assessing the baby¶s transition to the extrasupporting and assessing the baby¶s transition to the extra--uterineuterine

environmentenvironment assessing the mother for bleeding, pain, uterine toneassessing the mother for bleeding, pain, uterine tone supporting breastfeeding initiationsupporting breastfeeding initiation supporting initial bondingsupporting initial bonding helping the provider prepare for any suturinghelping the provider prepare for any suturing planning for vitamin K and erythromycin for the babyplanning for vitamin K and erythromycin for the baby facilitating formation of the new family unitfacilitating formation of the new family unit completing paperwork, often needed by clerk, OB provider andcompleting paperwork, often needed by clerk, OB provider and

pediatricianpediatrician

preparing to give report and arranging for transport to new unit(s)preparing to give report and arranging for transport to new unit(s) disposing of the placentadisposing of the placenta accounting for all instruments, sharps and sponges used during the birthaccounting for all instruments, sharps and sponges used during the birth ensuring that the nurse¶s other laboring patient is under RN careensuring that the nurse¶s other laboring patient is under RN care





Nursing Care from 2Nursing Care from 2 ± ± 48 hours48 hours

Directed by a knowledge of the stages of Directed by a knowledge of the stages of the puerperiumthe puerperium

Monitoring safetyMonitoring safety

Intensive discharge planningIntensive discharge planning

Repetitive anticipatory guidanceRepetitive anticipatory guidance

Increasing self care and self confidenceIncreasing self care and self confidence

Increasing independence with baby careIncreasing independence with baby care Closing knowledge deficitsClosing knowledge deficits



Nursing Care from 2Nursing Care from 2 ± ± 48 hours48 hours

Group ClassesGroup Classes

Nurses lead group classes on postpartumNurses lead group classes on postpartumunitsunits

Baby careBaby care

BreastfeedingBreastfeeding

Group classes are not a substitute for Group classes are not a substitute for

individualized care planningindividualized care planning



Special SituationsSpecial Situations

StillbirthStillbirth Woman may choose to be on a gyn floor Woman may choose to be on a gyn floor

Still needs discharge teachingStill needs discharge teaching

Rewrite the form if you need to!Rewrite the form if you need to! Often special door markers to ID to all staff Often special door markers to ID to all staff

Baby kept available for several hoursBaby kept available for several hours Some autopsy tissue obtained quicklySome autopsy tissue obtained quickly

Dress baby as attractively as possibleDress baby as attractively as possible Exploration follows fingertipExploration follows fingertip enfolding order enfolding order

Mementos kept on fileMementos kept on file




Surrendering infant for adoptionSurrendering infant for adoption Immediate postpartum not a time to reImmediate postpartum not a time to re--evaluateevaluate

Examine/clarify your own valuesExamine/clarify your own values

Private room, may or may not be on maternity unitPrivate room, may or may not be on maternity unit Adoptive parenting Adoptive parenting

Many of the same stages Rubin describesMany of the same stages Rubin describes

The ill infantThe ill infant

Encourage bondingEncourage bonding Private room appreciatedPrivate room appreciated

Breast pumpBreast pump




The ill mother The ill mother

Private roomPrivate room

SnapshotsSnapshots

TelephoneTelephone

Family supportFamily support

EducationEducation

Nursery staff and volunteersNursery staff and volunteers

Breast pumpBreast pump



Newborn NursingNewborn Nursing



Audrey Gives Birth! Audrey Gives Birth!

The nurse dries the baby immediatelyThe nurse dries the baby immediately

Places the baby on Audrey¶s belly skin to skin or Places the baby on Audrey¶s belly skin to skin or on a preon a pre--warmed infant warmer prnwarmed infant warmer prn

To prevent heat loss byTo prevent heat loss by EvaporationEvaporation

ConvectionConvection

ConductionConduction

To stimulate respirationsTo stimulate respirations

Removes wet towelsRemoves wet towels Covers with dry towel and warmed hatCovers with dry towel and warmed hat

Rapid evaluation of infant¶s transitionRapid evaluation of infant¶s transition



Rapid Initial EvaluationRapid Initial Evaluation

Color Color

ToneTone

RespirationsRespirations Heart rate (often by palpation of cord)Heart rate (often by palpation of cord)

Counted for six seconds and multiplied by tenCounted for six seconds and multiplied by ten

General survey for major anomaliesGeneral survey for major anomalies General sense of presence in the bodyGeneral sense of presence in the body



Apgar Scoring Apgar Scoring

Score to assess neonatal wellbeing atScore to assess neonatal wellbeing atbirthbirth

Obtained at 1 and 5 minutes of lifeObtained at 1 and 5 minutes of life

May be obtained at 10 minutes if still under 7May be obtained at 10 minutes if still under 7

A maximum ten point scale A maximum ten point scale

Five items worth 0, 1 or 2 points eachFive items worth 0, 1 or 2 points each

High correlation with low 5 minute apgar High correlation with low 5 minute apgar score and morbidity/mortalityscore and morbidity/mortality



Apgar Scoring Apgar Scoring

Points are 0, 1, 2 for a total of 10Points are 0, 1, 2 for a total of 10 Heart RateHeart Rate

Absent, slow (<100), good (>100) Absent, slow (<100), good (>100)

Respiratory EffortRespiratory Effort Absent, slow Absent, slow--irregular irregular--weak, goodweak, good--strongstrong

Muscle ToneMuscle Tone Flaccid, some flexion, well flexedFlaccid, some flexion, well flexed

Reflex IrritabilityReflex Irritability No response, grimace, cry and responseNo response, grimace, cry and response

Color Color Blue/pale, extremities only blue, all good color Blue/pale, extremities only blue, all good color



Newborn IdentificationNewborn Identification

IdentibandIdentiband

Locks and must be cut be removedLocks and must be cut be removed

May have a chip in it for further securityMay have a chip in it for further security

# corresponds to mother¶s ## corresponds to mother¶s #

Other identifying demographic informationOther identifying demographic information

Two bands are used (wrist and ankle)Two bands are used (wrist and ankle)

Footprints obtainedFootprints obtained Unique like fingerprintsUnique like fingerprints



Giving ReportGiving Report

Time of birthTime of birth

Brief synopsis of labor and birthBrief synopsis of labor and birth

Respirations spontaneous or assistedRespirations spontaneous or assisted If assisted in what way and for how longIf assisted in what way and for how long

Apgar scores (include why points taken off) Apgar scores (include why points taken off) Any medications administered Any medications administered

Including Vitamin K and erythromycinIncluding Vitamin K and erythromycin

General condition of the neonateGeneral condition of the neonate

Number of vesselsNumber of vessels Relevant lab tests (cord bloods, maternal labs, cultures)Relevant lab tests (cord bloods, maternal labs, cultures)

Notation of void or meconium passage that occurredNotation of void or meconium passage that occurred



Understanding the PhysiologicUnderstanding the PhysiologicTransition from Fetus to NewbornTransition from Fetus to Newborn



Physiologic TransitionPhysiologic Transition

Circulatory changesCirculatory changes

In utero, lungs are like wet plastic bags stuckIn utero, lungs are like wet plastic bags stucktogether with minimal blood flowtogether with minimal blood flow

With the first few breaths lungs expand andWith the first few breaths lungs expand andblood flow for gas exchange beginsblood flow for gas exchange begins

Circulatory changes occur that allow bloodCirculatory changes occur that allow blood

flow to change from fetal to neonatal flowflow to change from fetal to neonatal flow




Umbilical vein and ductus venosisUmbilical vein and ductus venosis

(connection to vena cava)(connection to vena cava)

constricts after cord clamped; becomeconstricts after cord clamped; becomeligaments (takes months)ligaments (takes months)

Some babies don¶t cry until the cord isSome babies don¶t cry until the cord isclampedclamped




Circulatory ChangesCirculatory Changes

Foramen ovale (rt atriumForamen ovale (rt atrium aorta) closesaorta) closesfunctionally with onset of respirationsfunctionally with onset of respirations

Permanent closure takes several monthsPermanent closure takes several months

Ductus Arteriosis (pulm arteryDuctus Arteriosis (pulm artery aorta)aorta)constricts with onset of respirationsconstricts with onset of respirations

Becomes a ligament (takes months)Becomes a ligament (takes months)




Heart murmurs are understandablyHeart murmurs are understandablycommoncommon

usually clinically insignificantusually clinically insignificant

should be reportedshould be reported

Heart rate remains 120Heart rate remains 120--160 bpm160 bpm

sleep (slower)sleep (slower)

activity (higher)activity (higher)




Circulatory ChangesCirculatory Changes

Peripheral circulation established slowly over Peripheral circulation established slowly over the first 24 hoursthe first 24 hours

Acrocyanosis normal (blueish hands and feet) Acrocyanosis normal (blueish hands and feet)

BP averages 78/42BP averages 78/42

not usually checked in L&Dnot usually checked in L&D

RBC count high initiallyRBC count high initially Falls over the first weekFalls over the first week

Breakdown of RBC related to neonatal jaundiceBreakdown of RBC related to neonatal jaundice






Establishing respirationsEstablishing respirations

Thoracic squeeze with vaginal birth pushesThoracic squeeze with vaginal birth pushesexcess fluids out of lungsexcess fluids out of lungs

Birth by cesarean sectionBirth by cesarean section risk for transient risk for transienttachypnea of the newborn (TTN)tachypnea of the newborn (TTN)

Surfactants present in full term babiesSurfactants present in full term babies

Allow lungs and alveoli to expand with first few Allow lungs and alveoli to expand with first few

breathsbreaths

Prevent alveolar collapse and RDSPrevent alveolar collapse and RDS




Normal respiratory rate is 30Normal respiratory rate is 30 ± ± 6060breaths/minbreaths/min

Short periods of apnea are normalShort periods of apnea are normal

<15 seconds duration<15 seconds duration

must count for a full minute to assess accuratelymust count for a full minute to assess accurately

Obligate nose breather Obligate nose breather

Chest & abdomen rise simultaneouslyChest & abdomen rise simultaneously




Renal SystemRenal System

Urine present in bladder at birthUrine present in bladder at birth

11stst void within 24 hoursvoid within 24 hours

In breastfed baby one void for each day of life untilIn breastfed baby one void for each day of life untilmilk in (usually day 3milk in (usually day 3--5), then 65), then 6--10 voids/day10 voids/day

In bottlefed baby, one void per day for first 48In bottlefed baby, one void per day for first 48hours, then 6hours, then 6--10 voids/day10 voids/day




Renal SystemRenal System

Kidneys do not concentrate urine for firstKidneys do not concentrate urine for firstthree monthsthree months

Attention to adequate hydration essential Attention to adequate hydration essential

Urine pale and straw coloredUrine pale and straw colored

Uric acid crystals common initiallyUric acid crystals common initially

M

ay leave brick red spots in diaper M

ay leave brick red spots in diaper





Newborns can establish suckling instinctivelyNewborns can establish suckling instinctively

Help with this is still appreciated!Help with this is still appreciated!

³Baby cheeks´ (fullness) d/t sucking pads³Baby cheeks´ (fullness) d/t sucking pads

May develop sucking blister on upper lipMay develop sucking blister on upper lip

Minimal salivaMinimal saliva

Cannot move food from lips to pharynx, nippleCannot move food from lips to pharynx, nipplemust be far into mouthmust be far into mouth





Variable feeding patternsVariable feeding patterns Usually active in the first hour after birthUsually active in the first hour after birth

Then ~ 4 hours sleep timeThen ~ 4 hours sleep time

Then active againThen active again

Feeding is a learned skillFeeding is a learned skill May take a few days to learn how to nurseMay take a few days to learn how to nurse

Walking is natural too, and that also takes timeWalking is natural too, and that also takes time

Feeding is emotional area for many momsFeeding is emotional area for many moms May be interpreted as rejection by her infant if difficultMay be interpreted as rejection by her infant if difficult

Nursing support and knowledge is essentialNursing support and knowledge is essential





Circumoral pallor while sucking normalCircumoral pallor while sucking normal

Stomach capacity small (15Stomach capacity small (15± ±30cc)30cc)

Frequent feedings essentialFrequent feedings essential

Learn early hunger behaviorsLearn early hunger behaviors

Waiting for late feeding cues interferes withWaiting for late feeding cues interferes withestablishing breastfeedingestablishing breastfeeding

Breastfed babies usually feed every 2 hoursBreastfed babies usually feed every 2 hours

Bottlefed babies usually feed every 3Bottlefed babies usually feed every 3--4 hours4 hours

Watch baby, not clock!Watch baby, not clock!





Can digest simple carbohydrates andCan digest simple carbohydrates andproteins, may have difficulty with fat inproteins, may have difficulty with fat in

formulasformulas Immature cardiac sphincter Immature cardiac sphincter

Reflux of food when burpedReflux of food when burped

Projectile vomiting needs to reportedProjectile vomiting needs to reported May signal pyloric stenosisMay signal pyloric stenosis





MeconiumMeconium

First stoolFirst stool²²black, tarry, stickyblack, tarry, sticky Usually passed within the first 24 hoursUsually passed within the first 24 hours

Sterile gutSterile gut± ± needs Vitamin K injectionneeds Vitamin K injection Given within hours of birthGiven within hours of birth

Prevents Hemolytic Disease of the NewbornPrevents Hemolytic Disease of the Newborn

Transitional stool is thin, brownishTransitional stool is thin, brownish--greengreen




Normal newborn stoolNormal newborn stool

BreastfedBreastfed

When milk established (days 3When milk established (days 3--5)5)

Loose, golden yellow, seedy, unformed, minimalLoose, golden yellow, seedy, unformed, minimalodor odor

May occur after each nursingMay occur after each nursing

Formula fedFormula fed

Formed, pale yellowFormed, pale yellow

May vary from 1/day to after each feedingMay vary from 1/day to after each feeding




HepaticHepatic

Liver metabolizes excess hemoglobinLiver metabolizes excess hemoglobin

From breakdown of unneeded fetal RBCFrom breakdown of unneeded fetal RBC

Unconjugated bilirubinUnconjugated bilirubin

Conjugated bilirubinConjugated bilirubin

(H2O soluable)(H2O soluable)

ExcretedExcreted




Immature liver functionImmature liver function

Unconjugated bilirubin accumulatesUnconjugated bilirubin accumulates

JaundiceJaundice

Lab assessmentLab assessment Normal <12mg/dlNormal <12mg/dl

Heel stick or transdermal assessment on babyHeel stick or transdermal assessment on baby

Clinical AssessmentClinical Assessment

Physiologic (normal) begins at >24 hrs of lifePhysiologic (normal) begins at >24 hrs of life

Proceeds head to toeProceeds head to toe




Pathophysiologic jaundicePathophysiologic jaundice

Multiple etiologiesMultiple etiologies Blood incompatibilityBlood incompatibility

InfectionInfection

TraumaTrauma

HypothermiaHypothermia

medicationsmedications

Indirect coombs test for maternal antibodies (done onIndirect coombs test for maternal antibodies (done on

cord blood)cord blood) Risk for Kernicterus if severe/sustainedRisk for Kernicterus if severe/sustained

Intervention (light therapy)Intervention (light therapy)





Newborn cannot shiver to produce heatNewborn cannot shiver to produce heat

Heat productionHeat production Metabolism of brown fatMetabolism of brown fat Increased metabolic rateIncreased metabolic rate

Increased activityIncreased activity





Newborn has large surface area and largeNewborn has large surface area and largeheadhead ± ± significant source of heat losssignificant source of heat loss

Rapid temperature drop with birthRapid temperature drop with birth Cold stress occurs easilyCold stress occurs easily

O2 consumptionO2 consumption

can lead to metabolic acidosiscan lead to metabolic acidosis

respiratory distressrespiratory distress

Body temperature stabilizes about 10 hours of Body temperature stabilizes about 10 hours of life (if unstressed)life (if unstressed)




ImmunologicImmunologic

IgG transplacentallyIgG transplacentally

IgA in colostrum and breast milkIgA in colostrum and breast milk

Greatest risk of infection in first six weeksGreatest risk of infection in first six weeks

s/sx may not be same as in adults/sx may not be same as in adult

Immunity acquired sequentiallyImmunity acquired sequentially

Vaccinations may start in hospital and areVaccinations may start in hospital and areongoingongoing

http://www.cispimmunize.orghttp://www.cispimmunize.org



Neurologic/SensoryNeurologic/Sensory

States of ConsciousnessStates of Consciousness

Deep sleep: no body movements, palms openDeep sleep: no body movements, palms open

Light sleep: some body movementsLight sleep: some body movements

Drowsy: startle, eyes open, ³no one home´Drowsy: startle, eyes open, ³no one home´

Quiet alert: few movements, intent, focusedQuiet alert: few movements, intent, focused

Active alert: body movements, facial Active alert: body movements, facial

movements, fussy periodsmovements, fussy periods Crying: active body movements, eyes open or Crying: active body movements, eyes open or

closedclosed




Periods of ReactivityPeriods of Reactivity FirstFirst

Begins at birthBegins at birth

Continues for 1Continues for 1 ± ± 2 hours2 hours

Alert, good suck reflex, irregular heart rate and respirations Alert, good suck reflex, irregular heart rate and respirations SecondSecond

Begins around 4 hoursBegins around 4 hours May spit up mucusMay spit up mucus

Pass meconiumPass meconium

Suck wellSuck well Equilibrates by 8 hours of ageEquilibrates by 8 hours of age

Newborns typically sleep ~17/day in short burstsNewborns typically sleep ~17/day in short bursts




Impact on Nursing InterventionsImpact on Nursing Interventions

Early discharge timingEarly discharge timing

Accommodate periods of reactivity Accommodate periods of reactivity

Accommodate mother¶s level of energy Accommodate mother¶s level of energy

TeachingTeaching

Consideration of periods of reactivityConsideration of periods of reactivity

Consideration of newborn¶s stateConsideration of newborn¶s state




SightSight

Newborns can seeNewborns can see

Best at about 18 inchesBest at about 18 inches

³en face´ is perfect³en face´ is perfect Love facesLove faces

Enjoy high contrast (black & white)Enjoy high contrast (black & white)

Will gaze or fix on objectsWill gaze or fix on objects

Uncoordinated eye movementsUncoordinated eye movements

May mimic slow, repeating facial movementsMay mimic slow, repeating facial movements




HearingHearing

Begins in utero (24 weeks)Begins in utero (24 weeks)

Enjoys speech cadenceEnjoys speech cadence

EntrainmentEntrainment

³baby talk´ singsong³baby talk´ singsong

TeachingTeaching

Talk to the baby!Talk to the baby! Watch baby for ³I need a break´ cuesWatch baby for ³I need a break´ cues




TasteTaste Amniotic fluid has taste and baby has been Amniotic fluid has taste and baby has been

tasting in uterotasting in utero

Prefers sweetPrefers sweet Sucking is essentialSucking is essential

Reduces pain and stressReduces pain and stress

SatisfyingSatisfying

NourishmentNourishment May improve brain developmentMay improve brain development

May decrease SIDSMay decrease SIDS




SmellSmell

Sense present at birthSense present at birth

Newborns can identify their own mother¶sNewborns can identify their own mother¶s

breast pads by smell alonebreast pads by smell alone

Newborns may use smell to help establishNewborns may use smell to help establishnursingnursing

Not washing their hands right awayNot washing their hands right away




TouchTouch

Infants are highly sensitive to touchInfants are highly sensitive to touch

Startle easilyStartle easily

Treat with respectTreat with respect

BondingBonding

Touch progressionTouch progression

SwaddlingSwaddling Seems to calm some babiesSeems to calm some babies



Physical AssessmentPhysical Assessment

WeightWeight

Obtained initially soon after birthObtained initially soon after birth

Obtained dailyObtained daily

Initial loss of up to 10% body weight normalInitial loss of up to 10% body weight normal Should be regained by 2 weeks of ageShould be regained by 2 weeks of age

LengthLength

Babies are curled up in uteroBabies are curled up in utero

Need some time to stretch out, not measured immediatelyNeed some time to stretch out, not measured immediately Make sure leg is completely extended when measuringMake sure leg is completely extended when measuring

Average is 45.7 Average is 45.7 ± ± 60 cm (1860 cm (18--22 inches)22 inches)




Head CircumferenceHead Circumference Measure biparietal diameter Measure biparietal diameter

3333 ± ± 33.5 cm (1333.5 cm (13--14 inches)14 inches)

May need to reMay need to re--measure in a few days if measure in a few days if Significant molding and caputSignificant molding and caput

Head circumference should be 2 cm> chestHead circumference should be 2 cm> chestcircumferencecircumference

Report findings > or < the 2cm differenceReport findings > or < the 2cm difference

Chest CircumferenceChest Circumference 2 cm less than head circumference (3/4 inch)2 cm less than head circumference (3/4 inch)

Measure at level of the nipplesMeasure at level of the nipples

Ph i l APh i l A




SkinSkin Skin color varies with ethnicity, pigmentSkin color varies with ethnicity, pigment after birth after birth

Lanugo and vernix present (Lanugo and vernix present ( with younger GA) with younger GA)

Skin may be dry/peeling in term/postSkin may be dry/peeling in term/post--termterm Palms, soles, possibly cracks/crevicesPalms, soles, possibly cracks/crevices

Acrocyanosis normal x 24 hours Acrocyanosis normal x 24 hours

Erythema toxicum neonatorum (³flea bites´)Erythema toxicum neonatorum (³flea bites´)

Mongolian spots (common in African, Asian ancestry)Mongolian spots (common in African, Asian ancestry)

Harlequin signHarlequin sign Nevus flammeus ³Stork bite´Nevus flammeus ³Stork bite´

MiliaMilia

Ph i l A tPh i l A t




HeadHead Caput succedaneumCaput succedaneum

Edema of the scalp (presenting part)Edema of the scalp (presenting part)

Present at birthPresent at birth

Crosses suture linesCrosses suture lines Resolves in a few daysResolves in a few days

CephalohematomaCephalohematoma Blood collection between periosteum and the skullBlood collection between periosteum and the skull

Often appears by 24 hours of lifeOften appears by 24 hours of life

Does not cross suture linesDoes not cross suture lines Resolves slowly over several weeksResolves slowly over several weeks

Increased risk of jaundice from additional blood breakdownIncreased risk of jaundice from additional blood breakdown





FontanelsFontanels Should be flat (not sunken or bulging)Should be flat (not sunken or bulging) OpenOpen

EarsEars Even with canthi of eyesEven with canthi of eyes Cartilage present and springy at termCartilage present and springy at term Look at the parents!Look at the parents!

EyesEyes

Slate blueSlate blue Some edema/irritation from medicationSome edema/irritation from medication

Less common with erythromycin than silver nitrateLess common with erythromycin than silver nitrate





MouthMouth

Inspect gums and lipsInspect gums and lips

IntactIntact

No teethNo teeth

Inspect hard palateInspect hard palate

IntactIntact

Small white bumps normal (Epstein¶s pearls)Small white bumps normal (Epstein¶s pearls)





NeckNeck

ShortShort

Skin foldsSkin folds

Muscles not strong enough to support headMuscles not strong enough to support head

Abnormalities Abnormalities

Toriticollis (injury to sternocleidomastoid muscle)Toriticollis (injury to sternocleidomastoid muscle)

WebbingWebbing MassesMasses





ChestChest

Rounded (transverse and AP diameter =)Rounded (transverse and AP diameter =)

Areola edema ³breast buds´ Areola edema ³breast buds´

³witches milk´³witches milk´

Circumference 2 cm less than headCircumference 2 cm less than head

Abnormalities Abnormalities

Clavicle separation/crepitusClavicle separation/crepitus retractionsretractions





Abdomen Abdomen

Rounded, protuberantRounded, protuberant

If sunken report immediatelyIf sunken report immediatelydiaphramatic herniadiaphramatic hernia

UmbilicusUmbilicus One vein, Two arteriesOne vein, Two arteries

Air dry, alcohol swaps, triple dye Air dry, alcohol swaps, triple dye

No bleeding, cord clamp secure, base dryNo bleeding, cord clamp secure, base dry

Cord dries, turns black and falls off Cord dries, turns black and falls off Usually by 2 weeksUsually by 2 weeks





GenitaliaGenitalia MaleMale

Scrotum edematous, ruggae presentScrotum edematous, ruggae present

M

ay be darkly pigmentedM

ay be darkly pigmented Palpate that both testes are descendedPalpate that both testes are descended

Penis small (2 cm), meatus at tipPenis small (2 cm), meatus at tip

Do not attempt to retract foreskinDo not attempt to retract foreskin

CircumcisionCircumcision Elective surgery, pain relief necessaryElective surgery, pain relief necessary

May be part of religious ritualMay be part of religious ritual

Should not be done if hypospadias/epispadiasShould not be done if hypospadias/epispadias





GenitaliaGenitalia

FemaleFemale

Maternal hormones may affect genitaliaMaternal hormones may affect genitalia

Vulva edematousVulva edematous May see vaginal dischargeMay see vaginal discharge

MucusMucus

Blood tinged (pseudo menstruation)Blood tinged (pseudo menstruation)

Labia majora cover labia minora and clitorisLabia majora cover labia minora and clitoris





ExtremitiesExtremities Short arms and legsShort arms and legs

Fingers reach over proximal thighFingers reach over proximal thigh

Flexed tone, springs back when extendedFlexed tone, springs back when extended

Bowed legsBowed legs Fat, clenched handsFat, clenched hands

Holds grip securely (able to raise up)Holds grip securely (able to raise up)

Fingernails at least to the tips of the fingersFingernails at least to the tips of the fingers

Hip abduction testsHip abduction tests Ortolani sign ³clunk´ of femur head in socketOrtolani sign ³clunk´ of femur head in socket

Barlows sign ³feeling the hip slip out of socket´Barlows sign ³feeling the hip slip out of socket´





FeetFeet

Able to be manipulated into midline easily Able to be manipulated into midline easily

Creased over twoCreased over two--thirds of solethirds of sole

Fat pads make feet appear chubby and flatFat pads make feet appear chubby and flat

Fingers and ToesFingers and Toes

SyndactalySyndactaly± ± fused digitsfused digits

PolydactlyPolydactly± ± extra digit (often like a skin tag)extra digit (often like a skin tag)

Ph sical AssessmentPh sical Assessment




Spine/BackSpine/Back

Spine has ³C´ curve not ³S´ like in adultsSpine has ³C´ curve not ³S´ like in adults

Posture is affected by fetal positionPosture is affected by fetal position

Inspect the base of the spineInspect the base of the spine Hairy tuftHairy tuft

DimpleDimple

Pinpoint openingPinpoint opening

Gluteal folds evenGluteal folds even





Anus Anus

Inspect to confirmInspect to confirm

PresentPresent

PatentPatent Insert gloved, lubricated pinkie finger Insert gloved, lubricated pinkie finger

Meconium should pass by 24 hoursMeconium should pass by 24 hours





ReflexesReflexes BlinkBlink

ExtrusionExtrusion

SwallowingSwallowing RootingRooting

SuckingSucking

Tonic Neck (Fencing)Tonic Neck (Fencing)

MoroMoro

Landeau (U)Landeau (U)





ReflexesReflexes Stepping/Placing (Foot/Shin)Stepping/Placing (Foot/Shin)

Palmar/Plantar graspPalmar/Plantar grasp

Crossed Extension (Pushing away)Crossed Extension (Pushing away) Magnet (pressure against pressure)Magnet (pressure against pressure)

Trunk IncurvationTrunk Incurvation

BabinskiBabinski

Assessing neurologic integrity Assessing neurologic integrity

Understanding newborn behavior Understanding newborn behavior

Gestational Age AssessmentGestational Age Assessment




Standardized forms for assessingStandardized forms for assessinggestational age. Most common:gestational age. Most common:

DubowitzDubowitz

BallardBallard

Help to identify infants who are small for Help to identify infants who are small for gestational age versus those who are of gestational age versus those who are of

young gestational ageyoung gestational age Guides clinical care and expectationsGuides clinical care and expectations





Gestational Age (weeks)Gestational Age (weeks)

FINDINGFINDING 00--3636 3737--3838 39+39+

Sole CreasesSole Creases Ant trans only Ant trans only Ant 2/3 Ant 2/3 Entire soleEntire sole

BreastBreastnodulenodule

2mm2mmdiameter diameter



Scalp Hair Scalp Hair Fine, fuzzyFine, fuzzy Fine, fuzzyFine, fuzzy Silky, coarseSilky, coarse

Ear LobeEar Lobe Pliable, noPliable, nocartilagecartilage

SomeSomecartilagecartilage

Cartilage stiff Cartilage stiff and shapedand shaped

Testes &Testes &scrotumscrotum

Testes inTestes incanal, fewcanal, few

rugaerugae

intermediateintermediate Scrotum full,Scrotum full,rugae coversrugae covers

CryingCrying



CryingCrying

Infants tend to cry a lotInfants tend to cry a lot About 2 hours of each day About 2 hours of each day ³Fussy´ time of day³Fussy´ time of day Peaks around 6 weeksPeaks around 6 weeks

Infant cry is supposed to be distressingInfant cry is supposed to be distressing Purpose is to get your attentionPurpose is to get your attention Infant can¶t talk to express needsInfant can¶t talk to express needs Parents learn specific cries for specific needsParents learn specific cries for specific needs

PacifiersPacifiers Individual decisionIndividual decision Not to be used as a plugNot to be used as a plug

BathingBathing



BathingBathing

Initial bathInitial bath

Wear gloves until after first bathWear gloves until after first bath

Usually within 1Usually within 1± ±2 hours of birth2 hours of birth

Important in newborns of HIV+ mothersImportant in newborns of HIV+ mothers

Bath should be delayed until after first nursingBath should be delayed until after first nursing

Initial bath is completeInitial bath is complete

Subsequent daily baths may be just face,Subsequent daily baths may be just face,neck, hands, diaper areaneck, hands, diaper area

BathingBathing



BathingBathing

Always proceed from cleanest to most Always proceed from cleanest to mostsoiled areas of the bodysoiled areas of the body

Gather all equipment ahead of timeGather all equipment ahead of time

NEVER leave an infant unattendedNEVER leave an infant unattended Protect neonate from excessive heat lossProtect neonate from excessive heat loss

Prewarm the room if possiblePrewarm the room if possible

Expose only one part at a timeExpose only one part at a time

Dry wellDry well

Hat if cool temperatureHat if cool temperature

DiaperingDiapering



DiaperingDiapering

Nurses wear glovesNurses wear gloves

Modern disposable diapersModern disposable diapers Very absorbantVery absorbant

Difficult to determine if wetDifficult to determine if wet Feel for gel to form: ³pinch´Feel for gel to form: ³pinch´

Weigh if uncertainWeigh if uncertain

Urine is very irritating (ammonia)Urine is very irritating (ammonia) Wash with clear water and dry wellWash with clear water and dry well

Many infants irritated by wipesMany infants irritated by wipes Mild barrier ointment (A&D, Vaseline)Mild barrier ointment (A&D, Vaseline)

Also helps get sticky meconium off their bottoms! Also helps get sticky meconium off their bottoms!

SleepingSleeping



SleepingSleeping

³Back to Sleep´³Back to Sleep´

Always place infant on back to sleep Always place infant on back to sleep

RareRare syndromes require prone positionsyndromes require prone position

Side lying is NOT as safe as supineSide lying is NOT as safe as supine Protecting the airway is not a concernProtecting the airway is not a concern

Nurses¶ attitudes and teaching directly affectNurses¶ attitudes and teaching directly affect

parents behavior parents behavior 50% decrease in SIDS deaths50% decrease in SIDS deaths

SIDS FactsSIDS Facts




SIDS is leading cause of death in infantsSIDS is leading cause of death in infantsfrom 1 month to 1 year from 1 month to 1 year

Most SIDS deaths occur between 2Most SIDS deaths occur between 2

months and 4 months of agemonths and 4 months of age

African American risk is 2 times that of African American risk is 2 times that of white babieswhite babies

American Indian/Alaskan Native almost 3 American Indian/Alaskan Native almost 3times higher than white babiestimes higher than white babies





www.nichd.nih.gov/sidswww.nichd.nih.gov/sids

Always on back Always on back

Firm surfaceFirm surface

Keep soft objects outKeep soft objects out

No smokingNo smoking Sleep close, but separateSleep close, but separate

Pacifier Pacifier

TemperatureTemperature

Smart shopper, big $ for untested productsSmart shopper, big $ for untested products Home monitors not necessary to prevent SIDSHome monitors not necessary to prevent SIDS

Tummy time while awake and adult presentTummy time while awake and adult present

Car Seat SafetyCar Seat Safety



Car Seat SafetyCar Seat Safety

Usually required for discharge homeUsually required for discharge home

CHOP has car seat subsidy programCHOP has car seat subsidy program

Requires a prescriptionRequires a prescription

Watch videoWatch video

Pay nominal feePay nominal fee

Can trade up as baby grows when return seatCan trade up as baby grows when return seat

Many fire/police departments have car Many fire/police departments have car seat installation daysseat installation days

DischargeDischarge



DischargeDischarge

Assess home environment Assess home environment

Social worker to assist with issuesSocial worker to assist with issues

Assess support systems Assess support systems

Know community resourcesKnow community resources

Use the hospital social worker prnUse the hospital social worker prn

Assess knowledge of newborn care Assess knowledge of newborn care

Parent to schedule f/u visit (2 weeks)Parent to schedule f/u visit (2 weeks) Sooner if concerns or early dischargeSooner if concerns or early discharge

Finally HomeFinally Home



Finally HomeFinally Home

Documents

Postpartum & Newborn PCC Memory Key