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Postpartum & NewbornPostpartum & NewbornNursing Theory and PracticeNursing Theory and Practice
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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
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The ³Fourth´ Trimester The ³Fourth´ Trimester
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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
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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
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Physiologic ChangesPhysiologic Changes
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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
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Reproductive SystemReproductive System
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
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Reproductive SystemReproductive System
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
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Reproductive SystemReproductive System
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
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Reproductive SystemReproductive System
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
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Reproductive SystemReproductive System
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
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Reproductive SystemReproductive System
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.
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Reproductive SystemReproductive System
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
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Reproductive SystemReproductive System
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
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Reproductive SystemReproductive System
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)
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Reproductive SystemReproductive System
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)
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Reproductive SystemReproductive System
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
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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
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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
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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
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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
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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)
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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
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LactationLactation
MastitisMastitis
Wedge shaped areaWedge shaped area
Local painLocal pain RednessRedness
Firm noduleFirm nodule
Fever Fever
ExhaustionExhaustion
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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
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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
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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)
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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
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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
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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
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Cardiovascular SystemCardiovascular System
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)
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Cardiovascular SystemCardiovascular System
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
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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)
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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
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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
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Integumentary SystemIntegumentary System
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
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Striae and Linea NigraStriae and Linea Nigra
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Integumentary SystemIntegumentary System
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
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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
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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
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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!
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Gastrointestinal SystemGastrointestinal System
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
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Gastrointestinal SystemGastrointestinal System
HemorrhoidsHemorrhoids
Pressure from pushingPressure from pushing
CommonCommon
Ice packsIce packs
OintmentOintment
Witch hazel padsWitch hazel pads
Anesthetic spray Anesthetic spray
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Psychosocial Aspects of Psychosocial Aspects of PostpartumPostpartum
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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
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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
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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
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Three Phases of the PuerperiumThree Phases of the Puerperium
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
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Three Phases of the PuerperiumThree Phases of the Puerperium
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
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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
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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
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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:
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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
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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
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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
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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
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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
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Special SituationsSpecial Situations
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
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Special SituationsSpecial Situations
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
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Newborn NursingNewborn Nursing
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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
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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
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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
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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
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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
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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
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Understanding the PhysiologicUnderstanding the PhysiologicTransition from Fetus to NewbornTransition from Fetus to Newborn
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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
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Physiologic TransitionPhysiologic Transition
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
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Physiologic TransitionPhysiologic Transition
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)
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Physiologic TransitionPhysiologic Transition
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)
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Physiologic TransitionPhysiologic Transition
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
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Physiologic TransitionPhysiologic Transition
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
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Physiologic TransitionPhysiologic Transition
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
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Physiologic TransitionPhysiologic Transition
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
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Physiologic TransitionPhysiologic Transition
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
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Physiologic TransitionPhysiologic Transition
Gastrointestinal SystemGastrointestinal System
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
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Physiologic TransitionPhysiologic Transition
Gastrointestinal SystemGastrointestinal System
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
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Physiologic TransitionPhysiologic Transition
Gastrointestinal SystemGastrointestinal System
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!
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Physiologic TransitionPhysiologic Transition
Gastrointestinal SystemGastrointestinal System
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
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Physiologic TransitionPhysiologic Transition
Gastrointestinal SystemGastrointestinal System
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
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Physiologic TransitionPhysiologic Transition
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
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Physiologic TransitionPhysiologic Transition
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
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Physiologic TransitionPhysiologic Transition
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
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Physiologic TransitionPhysiologic Transition
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)
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Physiologic TransitionPhysiologic Transition
Temperature RegulationTemperature Regulation
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
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Physiologic TransitionPhysiologic Transition
Temperature RegulationTemperature Regulation
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)
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Physiologic TransitionPhysiologic Transition
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
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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
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Neurologic/SensoryNeurologic/Sensory
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
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Neurologic/SensoryNeurologic/Sensory
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
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Neurologic/SensoryNeurologic/Sensory
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
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Neurologic/SensoryNeurologic/Sensory
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
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Neurologic/SensoryNeurologic/Sensory
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
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Neurologic/SensoryNeurologic/Sensory
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
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Neurologic/SensoryNeurologic/Sensory
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
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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)
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Physical AssessmentPhysical Assessment
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
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Physical AssessmentPhysical Assessment
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
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Physical AssessmentPhysical Assessment
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
Ph i l A tPh i l A t
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Physical AssessmentPhysical Assessment
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
Ph i l A tPh i l A t
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Physical AssessmentPhysical Assessment
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)
Ph i l A tPh i l A t
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Physical AssessmentPhysical Assessment
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
Ph i l A tPh i l A t
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Physical AssessmentPhysical Assessment
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
Ph i l A tPh i l A t
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Physical AssessmentPhysical Assessment
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
Ph i l A tPh i l A t
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Physical AssessmentPhysical Assessment
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
Ph i l A tPh i l A t
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Physical AssessmentPhysical Assessment
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
Ph i l A tPh i l A t
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Physical AssessmentPhysical Assessment
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´
Ph i l A tPh i l A t
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Physical AssessmentPhysical Assessment
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
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Physical AssessmentPhysical 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
Physical AssessmentPhysical Assessment
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Physical AssessmentPhysical Assessment
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
Physical AssessmentPhysical Assessment
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Physical AssessmentPhysical Assessment
ReflexesReflexes BlinkBlink
ExtrusionExtrusion
SwallowingSwallowing RootingRooting
SuckingSucking
Tonic Neck (Fencing)Tonic Neck (Fencing)
MoroMoro
Landeau (U)Landeau (U)
Physical AssessmentPhysical Assessment
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Physical AssessmentPhysical Assessment
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
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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 AssessmentGestational Age Assessment
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Gestational Age AssessmentGestational Age Assessment
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
4mm4mmdiameter diameter
7mm7mmdiameter 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
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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
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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
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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
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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
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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
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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
SIDS FactsSIDS Facts
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SIDS FactsSIDS Facts
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
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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
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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
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Finally HomeFinally Home