Postpartum & Newborn NursingPostpartum & Newborn Nursing

Ana H. Corona, MSN, FNP-CAna H. Corona, MSN, FNP-CNursing InstructorNursing Instructor

October 2007October 2007Revised February 2009Revised February 2009

The Postpartum PeriodThe Postpartum Period

Puerperium: Term 1st 6 weeks after Puerperium: Term 1st 6 weeks after the birth of an infant the birth of an infant

Neonate–newborn from birth to 28 Neonate–newborn from birth to 28 days.days.

Family adaptation to neonate: Family adaptation to neonate: Bonding–rapid process of attachment Bonding–rapid process of attachment during 1during 1stst 30 to 60 minutes after birth 30 to 60 minutes after birth

Mother, father, siblings, grandparentsMother, father, siblings, grandparents

Factors Affecting Family Factors Affecting Family AdaptationAdaptation

Parental fatigueParental fatigue Previous experience with a newbornPrevious experience with a newborn Parental expectations of newbornParental expectations of newborn Knowledge of and confidence in Knowledge of and confidence in

providing for newborn needsproviding for newborn needs Temperament of the newbornTemperament of the newborn Temperament of parentsTemperament of parents Age of parentsAge of parents Available support systemAvailable support system Unexpected eventsUnexpected events

Postpartum AssessmentPostpartum Assessment VS, amount of lochia, presence of VS, amount of lochia, presence of

edema, fundal height and firmness, edema, fundal height and firmness, status of perineum, bladder status of perineum, bladder distension distension

1 to 2 hrs after delivery: every 15 1 to 2 hrs after delivery: every 15 minutesminutes

If no problems every 8 hoursIf no problems every 8 hours

KNOW YOUR PATIENT --- DELIVERY KNOW YOUR PATIENT --- DELIVERY HISTORY /ADMISSION/TRANSITION HISTORY /ADMISSION/TRANSITION

ASSESSMENT:ASSESSMENT:

Gravida, parity / Time and type of Gravida, parity / Time and type of deliverydelivery

Anesthesia or medications / Risk factors Anesthesia or medications / Risk factors for PPHfor PPH

Medical history / Routine medications / Medical history / Routine medications / AllergiesAllergies

Infant status / Breast/bottleInfant status / Breast/bottle Rubella immune?Rubella immune? Rh Negative?Rh Negative? Drug/ETOH Abuse Drug/ETOH Abuse

Body Systems AssessmentBody Systems Assessment Vital signs Level of pain Neurological Pulmonary Cardiovascular Musculoskeletal Gastrointestinal Genitourinary Integumentary Psychosocial

Vital SignsVital SignsDay 1Day 1 Day 2 and Day 2 and

afterafter

Heart RateHeart Rate 50 to 70 bpm50 to 70 bpm Bradycardia Bradycardia or normalor normal

Respirations Respirations NormalNormal NormalNormal

B/PB/P NormalNormal NormalNormal

TemperatureTemperature 100.4 normal 100.4 normal 24 hrs.24 hrs.Muscular Muscular exertion/dehydratiexertion/dehydrationon

Normal Normal If 100.4 If 100.4 suspect suspect infectioninfection

Postpartum Physical Postpartum Physical AssessmentAssessment

B B - breast- breast U U - uterus- uterus BB - bowels - bowels B B - bladder- bladder L L - lochia- lochia E E - episiotomy - episiotomy

General AssessmentGeneral Assessment

Enter the room quietly, speak quietly.

Wash hands and provide for privacy. Inform patient before turning on

lights. Note LOC, activity level, position,

color, general demeanor. Take note of the total environment:

Safety/patient considerations Note equipment and medical devices

BBreast Assessmentreast Assessment Breasts: Soft, engorged, filling, swelling, Breasts: Soft, engorged, filling, swelling,

redness, tenderness.redness, tenderness. Nipples: Inverted, everted, cracked, Nipples: Inverted, everted, cracked,

bleeding, bruised, presence of colostrum bleeding, bruised, presence of colostrum or breastmilk.or breastmilk.

Colostrum–yellowish fluid rich in antibodies Colostrum–yellowish fluid rich in antibodies and high in protein.and high in protein.

Engorgement occurs by day 3 or 4. Due to Engorgement occurs by day 3 or 4. Due to vasoconstriction as milk production beginsvasoconstriction as milk production begins

Lactation ceases within a week if Lactation ceases within a week if breastfeeding is never begun or is breastfeeding is never begun or is stopped.stopped.

Assessing Assessing UUterine Fundusterine Fundus Location in relation to Location in relation to

umbilicusumbilicus Degree of firmnessDegree of firmness Is it at Midline or Is it at Midline or

deviated to one side?deviated to one side? Bladder Full?Bladder Full? A boggy uterus may

indicate uterine atony or retained placental fragments.

Boggy refers to being inadequately contracted and having a spongy rather than firm feeling.

Massaging the FundusMassaging the Fundus Every 15 mins during the 1Every 15 mins during the 1stst hr, hr,

every 30 mins during the next hr, every 30 mins during the next hr, and then, every hr until the patient and then, every hr until the patient is ready for transfer. is ready for transfer.

Document fundal height. Document fundal height. Evaluate from the umbilicus Evaluate from the umbilicus

using fingerbreadths. using fingerbreadths. This is recorded as 2 fingers This is recorded as 2 fingers

below the umbilicus (U/2), one below the umbilicus (U/2), one finger above the umbilicus (1/U), finger above the umbilicus (1/U), and so forth. and so forth.

The fundus should remain in the The fundus should remain in the midline. If it deviates from the midline. If it deviates from the middle- distended bladdermiddle- distended bladder. .

Uterine InvolutionUterine Involution Uterine Involution: Uterine Involution:

return of the uterus to return of the uterus to its pre-pregnancy size its pre-pregnancy size and conditionand condition

Uterine fundal descent: Uterine fundal descent: uterus size of uterus size of grapefruit immediately grapefruit immediately after birthafter birth

Fundus half way Fundus half way between umbilicus and between umbilicus and symphysis pubissymphysis pubis

Fundus rises to the Fundus rises to the umbilicus stays for 12 umbilicus stays for 12 hourshours

Descends 1 cm Descends 1 cm (fingerbreadth) each (fingerbreadth) each day for about 10 daysday for about 10 days

Uterine AtonyUterine Atony Lack of muscle tone in the cervix.Lack of muscle tone in the cervix. Uterus feels soft and boggyUterus feels soft and boggy After delivery: Postpartum diuresisAfter delivery: Postpartum diuresis The bladder has increased capacity The bladder has increased capacity

and decreased muscle tone.  and decreased muscle tone.  This leads to over-distension of the This leads to over-distension of the

bladder, incomplete emptying of bladder, incomplete emptying of bladder, retention of residual urine bladder, retention of residual urine and increased risk of UTI and and increased risk of UTI and postpartum hemorrhage. postpartum hemorrhage.

BBowels & owels & BBladderladder When was the patients last BM?When was the patients last BM? Is she passing flatus? (gas)Is she passing flatus? (gas) Assess for bowel soundsAssess for bowel sounds Voiding pattern - without difficulty/pain, urine

may be blood tinged from lochia Nursing interventions: Assist to the

bathroom. Use measures to encourage voiding (privacy). Encourage use of peri-bottle with warm water, fluids, fiber, frequent ambulation, stool softeners; teach effects of pain medication.

LLochia Assessmentochia Assessment Lochia–vaginal discharge after childbirth.Lochia–vaginal discharge after childbirth. It takes 6 weeks for the vagina to regain its It takes 6 weeks for the vagina to regain its

pre-pregnancy contour.pre-pregnancy contour. Lochia: scant-moderate, rubra, serosa or alba Assessment of lochia includes noting color, Assessment of lochia includes noting color,

presence and size of clots and foul odor.presence and size of clots and foul odor.

Day 1- 3 - lochia rubra Day 1- 3 - lochia rubra (blood with small (blood with small pieces of decidua and pieces of decidua and mucus)  mucus)                                                             

Day 4-10 – lochia serosa Day 4-10 – lochia serosa (pink or pinkish (pink or pinkish brown serous exudate with cervical mucus, brown serous exudate with cervical mucus, erythrocytes and leukocyteserythrocytes and leukocytes))

Day 11- 21 - lochia alba Day 11- 21 - lochia alba ((yellowish white yellowish white discharge)discharge)

Lochia: Pad Lochia: Pad

CountCount 1. Scant: 1-inch stain on pad in 1 hour2. Light/small: 4 inches in 1 hour3. Moderate: 6 inches in 1 hour4. Heavy/large: Pad saturated in 1 hour Excessive: Pad saturated in 15 min Can estimate blood loss by weighing pads: 500 mL = 1 lb. or 454 g

EEpisiotomy/Perineal pisiotomy/Perineal AssessmentAssessment

Patient in lateral Sims (side lying) Patient in lateral Sims (side lying) position.position.

Use the acronym Use the acronym REEDAREEDA (redness, (redness, edema, ecchymosis, discharge, edema, ecchymosis, discharge, approximation of suture lines “edges of approximation of suture lines “edges of episiotomy”) to guide assessment.episiotomy”) to guide assessment.

Even if there is no episiotomy, the Even if there is no episiotomy, the perineum should still be assessed. perineum should still be assessed.

Unusual perineal discomfort may be a Unusual perineal discomfort may be a symptom of impending infection or symptom of impending infection or hematoma.hematoma.Hemorrhoids ?Hemorrhoids ?

Episiotomy Pain Relief Episiotomy Pain Relief Instruct Mother:Instruct Mother: Tighten her buttocks and perineum Tighten her buttocks and perineum

before sitting to prevent pulling on the before sitting to prevent pulling on the episiotomy and perineal area and to episiotomy and perineal area and to release tightening after being seated.release tightening after being seated.

Rest several times a day with feet Rest several times a day with feet elevated.elevated.

Practice Kegel exercise many times a Practice Kegel exercise many times a day to increase circulation to the day to increase circulation to the perineal area and to strengthen the perineal area and to strengthen the perineal muscles.perineal muscles.

Assessment of Edema & Homan’s Assessment of Edema & Homan’s SignSign

Assess legs for presence and degree of edema; may have dependent edema in feet and legs.

Assess for Homan’s sign- thromboembolism should be negative

Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)

Homan’s SignHoman’s Sign

Thromboembolic ConditionsThromboembolic Conditions

Thrombophlebitis–the formation of a Thrombophlebitis–the formation of a clot in an inflamed vein.clot in an inflamed vein.

Risk factors include maternal age Risk factors include maternal age over 35, cesarean birth, prolonged over 35, cesarean birth, prolonged time in stirrups, obesity, smoking, time in stirrups, obesity, smoking, and history of varicosities or venous and history of varicosities or venous thromboses.thromboses.

Prevention: client needs to ambulate Prevention: client needs to ambulate early after delivery.early after delivery.

Postpartum Cesarean Postpartum Cesarean Incision site…redness swelling, discharge. Incision site…redness swelling, discharge.

Intact?Intact? Abdomen soft, distended? Bowel sounds heard Abdomen soft, distended? Bowel sounds heard

all 4 quadrantsall 4 quadrants Flatus? Flatus? Lochia is less amount than in normal Lochia is less amount than in normal

spontaneous vaginal delivery (NSVD) because spontaneous vaginal delivery (NSVD) because uterus is wiped with sponges during c/section.uterus is wiped with sponges during c/section.

If lochia indicates excessive bleeding, combine If lochia indicates excessive bleeding, combine palpation and pain management measures. palpation and pain management measures.

Auscultate breath soundsAuscultate breath sounds Fluid intake and outputFluid intake and output Pain?Pain?

RhoGAM RhoGAM

It is given to an RhIt is given to an Rh-- mother within 72 mother within 72 hours after delivery of an Rhhours after delivery of an Rh++ infant infant or if the Rh is unknown. or if the Rh is unknown.

The dose must be repeated after The dose must be repeated after each subsequent delivery. RhoGAM each subsequent delivery. RhoGAM 300 mcg is the standard dose.300 mcg is the standard dose.

Postpartum Disseminated Intravascular Postpartum Disseminated Intravascular CoagulationCoagulation

Abnormal stimulation of clotting Abnormal stimulation of clotting mechanism.mechanism.

Normally, the body forms a blood clot Normally, the body forms a blood clot in reaction to an injury. in reaction to an injury.

Small blood clots throughout the body, Small blood clots throughout the body, depleting the body of clotting factors depleting the body of clotting factors and platelets. –Massive bleedingand platelets. –Massive bleeding

Causes may include amniotic fluid Causes may include amniotic fluid clots, fetal demise, abruptio placenta. clots, fetal demise, abruptio placenta. Eclampsia or Retained placenta Eclampsia or Retained placenta

Symptoms: Sometimes severe Symptoms: Sometimes severe bleeding and sudden bruising .bleeding and sudden bruising .

Postpartum HemorrhagePostpartum Hemorrhage Blood loss of more than 500 ml after vaginal Blood loss of more than 500 ml after vaginal

birth or 1,000 ml after a cesarean birth. birth or 1,000 ml after a cesarean birth. Early hemorrhage –Cervical or vaginal tears, Early hemorrhage –Cervical or vaginal tears,

uterine atony, retained placental fragments, uterine atony, retained placental fragments, lacerations, hematomas.lacerations, hematomas.

Late hemorrhage –subinvolution, retained Late hemorrhage –subinvolution, retained placental fragments.placental fragments.

Subinvolution: failure of the uterus to return Subinvolution: failure of the uterus to return to normal size.to normal size.

Management may include CBC, Management may include CBC, sedimentation rate, type and cross, fluid sedimentation rate, type and cross, fluid resuscitation with normal saline and blood, resuscitation with normal saline and blood, vaginal examination, diagnosis, and vaginal examination, diagnosis, and correction of the underlying cause. correction of the underlying cause.

Postpartum DepressionPostpartum Depression Postpartum depression is a nonpsychotic Postpartum depression is a nonpsychotic

depressive episode that begins in the depressive episode that begins in the postpartum period due to decreased postpartum period due to decreased estrogen levelestrogen level

Symptoms: changes in appetite or Symptoms: changes in appetite or weight, sleep, and psychomotor activity; weight, sleep, and psychomotor activity; decreased energy; feeling of decreased energy; feeling of worthlessness or guilt; difficulty thinking, worthlessness or guilt; difficulty thinking, concentrating or making decisions; or concentrating or making decisions; or recurrent thoughts of death or suicidal recurrent thoughts of death or suicidal ideation, plans, or attempts. ideation, plans, or attempts.

Postpartum Postpartum PsychosisPsychosis

A very serious type of A very serious type of PPD illness that can PPD illness that can affect new mothers. affect new mothers.

Begin 2-3 weeks post Begin 2-3 weeks post deliverydelivery

Fatigue, restlessness, Fatigue, restlessness, insomnia, crying liable insomnia, crying liable emotions, inability to emotions, inability to move, irrationally move, irrationally statements incoherence statements incoherence confusion and obsessive confusion and obsessive concerns about the concerns about the infant’s healthinfant’s health

Psychiatric emergencyPsychiatric emergency

Nipple soreness is a portal of entry for Nipple soreness is a portal of entry for bacteria - breast infection (Mastitis).bacteria - breast infection (Mastitis).

Maternal after pains: may be due to Maternal after pains: may be due to breastfeeding and multiparitybreastfeeding and multiparity

Always stay with the client when getting Always stay with the client when getting out of bed for the first time – out of bed for the first time – hypotension effect and excess bleedinghypotension effect and excess bleeding

When assessing fundal height, if you When assessing fundal height, if you notice any discrepancies in fundal notice any discrepancies in fundal height have patient void and then height have patient void and then reassess.reassess.

Nursing Diagnosis Related to Breasts and Nursing Diagnosis Related to Breasts and BreastfeedingBreastfeeding

Pain r/t improper positioning, engorged breasts

Ineffective breastfeeding r/t maternal discomfort, improper infant positioning

Knowledge deficit r/t normal physiologic changes, breastfeeding

Infection r/t improper breastfeeding techniques, improper breast care

The NewbornThe Newborn

Newborn’s Immediate Newborn’s Immediate NeedsNeeds

AirwayAirway BreathingBreathing CirculationCirculation WarmthWarmth

The NewbornThe Newborn Neonatal transition: 1Neonatal transition: 1stst few hours few hours

after birth newborn stabilizes after birth newborn stabilizes respiratory and circulatory functions.respiratory and circulatory functions.

When the cord is clamped, placental When the cord is clamped, placental gas exchange ceases.gas exchange ceases.

These changes stimulate carotid and These changes stimulate carotid and aortic chemoreceptors which send aortic chemoreceptors which send impulses to the respiratory center in impulses to the respiratory center in the medulla.the medulla.

A brief period of asphyxia stimulates A brief period of asphyxia stimulates respirations.respirations.

Apgar Score Apgar Score Assesses the infants Assesses the infants

cardiopulmonary adaptations to cardiopulmonary adaptations to extrauterine lifeextrauterine life

Provides a quick evaluation on how Provides a quick evaluation on how the heart and lungs are adaptingthe heart and lungs are adapting

5 items to be assessed 1 and 5 5 items to be assessed 1 and 5 minutes after birth.minutes after birth.

Apgar ScoreApgar Score Heart rate, respiratory rate, muscle tone, reflex irritability and Heart rate, respiratory rate, muscle tone, reflex irritability and

colorcolor Score of 0 – 2 for each item, then totaled. Score of 0 – 2 for each item, then totaled. Apgar Score 8 or higher no interventionApgar Score 8 or higher no intervention Apgar Score 4 – 8 gentle rubbing, oxygenApgar Score 4 – 8 gentle rubbing, oxygen Apgar Score 0 – 4 resuscitation Apgar Score 0 – 4 resuscitation

Points GivenPoints Given 00 11 22

AA Activity/Activity/muscle tonemuscle tone

Limp/flaccidLimp/flaccid Some Some motion/fleximotion/flexionon

Active Active motion/well motion/well flexedflexed

PP Pulse RatePulse Rate Absent Absent <100 <100 bts/minbts/min

>100 bts/min>100 bts/min

GG Grimace/Grimace/Reflex Reflex IrritabilityIrritability

No No ResponseResponse

GrimaceGrimace Cry, cough, Cry, cough, sneezesneeze

AA Appearance/ Appearance/ Skin ColorSkin Color

Blue, PaleBlue, Pale Body pink, Body pink, extremities extremities blueblue

Pink all overPink all over

Absence of Absence of cyanosiscyanosis

RR Respiration Respiration Absent Absent Slow weak Slow weak crycry

Good CryGood Cry

Prophylactic CareProphylactic Care Vitamin K –to prevent hemorrhagic Vitamin K –to prevent hemorrhagic

disorders – vit k (clotting process) is disorders – vit k (clotting process) is synthesized in intestine requires food synthesized in intestine requires food for this process. Newborn’s stomach for this process. Newborn’s stomach is sterile has no food. aquaMEPHYTONis sterile has no food. aquaMEPHYTON

Hepatitis B vaccination –within the Hepatitis B vaccination –within the first 12 hoursfirst 12 hours

Eye prophylaxis –(Erythromycin Eye prophylaxis –(Erythromycin Ointment) to prevent ophthalmia Ointment) to prevent ophthalmia neonatorum – gonorrhea/chlamydianeonatorum – gonorrhea/chlamydia

Newborn: Intramuscular Newborn: Intramuscular injectioninjection

aquaMEPHYTON (Vit.K)aquaMEPHYTON (Vit.K) 1 mg/0.5 ml IM lateral thigh1 mg/0.5 ml IM lateral thigh Vastus lateralisVastus lateralis

Vital SignsVital Signs Temperature - range 36.5 to 37 axillary (97.7-98.6)Temperature - range 36.5 to 37 axillary (97.7-98.6) Axillary vs Rectal about 0.2 to 0.5 differenceAxillary vs Rectal about 0.2 to 0.5 difference

Common variationsCommon variations Crying may elevate temperatureCrying may elevate temperature Stabilizes in 8 to 10 hours after deliveryStabilizes in 8 to 10 hours after delivery

Heart rate - range 120 to 160 beats per minute Heart rate - range 120 to 160 beats per minute Apical pulse for one minuteApical pulse for one minute

Common variationsCommon variations Heart rate range to 100 when sleeping to 180 when cryingHeart rate range to 100 when sleeping to 180 when crying Color pink with acrocyanosisColor pink with acrocyanosis Heart rate may be irregular with cryingHeart rate may be irregular with crying

Respiration - range 30 to 60 breaths per minuteRespiration - range 30 to 60 breaths per minute Blood pressure - not done routinely Blood pressure - not done routinely

Ranges between 60-80 mm systolic and 40-45 mm Ranges between 60-80 mm systolic and 40-45 mm diastolicdiastolic..

Reflexes: indicate neurological Reflexes: indicate neurological integrityintegrity

RootingRooting SuckingSucking ExtrusionExtrusion Palmar graspPalmar grasp Plantar graspPlantar grasp Tonic neckTonic neck

MoroMoro GallantGallant SteppingStepping Babinski’sBabinski’s Crossed Crossed

extension reflexextension reflex PlacingPlacing

ReflexesReflexes Moro ReflexMoro Reflex Birth to 4-6 monthsBirth to 4-6 months

Tonic Neck Reflex (FENCING)Tonic Neck Reflex (FENCING) EXTENDS arm & leg on the EXTENDS arm & leg on the

side that the face points.side that the face points. Flexes opposite arm & legFlexes opposite arm & leg 6-8 wks to 6 months6-8 wks to 6 months

Rooting and Sucking ReflexesRooting and Sucking Reflexes

Birth to 3-4monthsBirth to 3-4months Birth to 10 monthsBirth to 10 months

Babinski and Palmer Grasping Babinski and Palmer Grasping ReflexReflex

Babinski Reflex is (+)Babinski Reflex is (+) This is Normal This is Normal Birth to after walkingBirth to after walking 12-18 months age12-18 months age

Birth to 4 monthsBirth to 4 months

Skin Skin Expected findingsExpected findings Skin reddish in color, smooth and Skin reddish in color, smooth and

puffy at birthpuffy at birthAt 24 - 36 hours of age, skin flaky, dry At 24 - 36 hours of age, skin flaky, dry and pink in colorand pink in color

Edema around eyes, feet, and genitalsEdema around eyes, feet, and genitals Vernix caceosaVernix caceosa Lanugo (baby hair)Lanugo (baby hair) Turgor good with quick recoilTurgor good with quick recoil Hair silky and soft with individual Hair silky and soft with individual

strandsstrands

Common Normal Variations Common Normal Variations Acrocyanosis - result of sluggish Acrocyanosis - result of sluggish

peripheral circulation.peripheral circulation. Mongolian Spots: Patch of purple-black Mongolian Spots: Patch of purple-black

or blue-black color distributed over or blue-black color distributed over coccygeal and sacral regions of infants coccygeal and sacral regions of infants of African-American or Asian descent. of African-American or Asian descent.

Milia: Tiny white bumps papules Milia: Tiny white bumps papules (plugged sebaceous glands) located (plugged sebaceous glands) located over nose, cheek, and chin. over nose, cheek, and chin.

Erythema toxicum: Erythema toxicum: Most common newborn Most common newborn rash. Variable, irregular macular patches. rash. Variable, irregular macular patches. Lasts a few days.Lasts a few days.

Erythema toxicum, acrocyanosis, milia Erythema toxicum, acrocyanosis, milia and mongolian spotsand mongolian spots

Hyperbilirubinemia Hyperbilirubinemia Physiologic JaundicePhysiologic Jaundice =Appears 24 hours =Appears 24 hours

after birth peaks at 72 hrs.after birth peaks at 72 hrs. Bilirubin may reach 6 to 10 mg/dl and resolve Bilirubin may reach 6 to 10 mg/dl and resolve

in 5 to 7 days. in 5 to 7 days. Due to Unconjugated bilirubin circulating in Due to Unconjugated bilirubin circulating in

the blood stream that is deposited in the skin. the blood stream that is deposited in the skin. Immature liver unable to conjugate bilirubin Immature liver unable to conjugate bilirubin

released by destroyed RBC.released by destroyed RBC. Pathologic JaundicePathologic Jaundice =Not appear until after =Not appear until after

24 hrs leads to Kernicterus (deposits of bili in 24 hrs leads to Kernicterus (deposits of bili in brain).brain).

Bilirubin >20mg/dlBilirubin >20mg/dl The most common cause is The most common cause is RhRh incompatibility. incompatibility.

The Head and The Head and ChestChest

The HeadThe Head:: Anterior Anterior fontanel diamond shaped fontanel diamond shaped 2-3 - 3-4 cms2-3 - 3-4 cms

Posterior fontanel Posterior fontanel triangular 0.5 - 1 cmtriangular 0.5 - 1 cm

Fontanels soft, firm and Fontanels soft, firm and flatflat

head circumference is 33 head circumference is 33 – 35 cm– 35 cm

The head is a few The head is a few centimeters larger than centimeters larger than the chest!!!!the chest!!!!

The Chest:The Chest: circumference circumference is 30.5 – 33 cmis 30.5 – 33 cm

Anterior and Posterior Anterior and Posterior FontanellesFontanelles

Anterior diamond shaped Anterior diamond shaped 2-3 - 3-4 cms2-3 - 3-4 cms

Posterior triangular 0.5 - 1 Posterior triangular 0.5 - 1 cmcm

Fontanels soft, firm and Fontanels soft, firm and flatflat

Molding is shaping Molding is shaping of fetal head to of fetal head to adapt to the adapt to the mothers pelvis mothers pelvis during labor.during labor.

Caput succedaneumCaput succedaneum

Swelling of the soft Swelling of the soft tissue of the scalp tissue of the scalp caused by pressure of caused by pressure of the fetal head on a the fetal head on a cervix that is not fully cervix that is not fully dilated. dilated.

Swelling is generalized. Swelling is generalized. may cross suture line may cross suture line and decreases rapidly and decreases rapidly in a few days after in a few days after birth. Requires no birth. Requires no treatmenttreatment

2 – 3 days disappears 2 – 3 days disappears

Cephalohematoma Cephalohematoma

Collection of blood Collection of blood between the between the periosteum and skull periosteum and skull of newborn.of newborn.

Does not cross suture Does not cross suture lineslines

Caused by rupturing of Caused by rupturing of the periosteal bridging the periosteal bridging veins due to friction veins due to friction and pressure during and pressure during labor.labor.

Lasts 3 – 6 weeksLasts 3 – 6 weeks

Bathing the NewbornBathing the Newborn No tub bath until after No tub bath until after

the cord has fallen off the cord has fallen off and healing is and healing is complete.complete.

Newborn’s first bath- Newborn’s first bath- the nurse needs to the nurse needs to wear gloves to wear gloves to prevent infection.prevent infection.

Newborn temperature Newborn temperature needs to be >98. F needs to be >98. F

No soap applied on No soap applied on the face.the face.

Baby shampoo may be Baby shampoo may be applied on scalpapplied on scalp

Start from face down.Start from face down.

Gestational Age Relationship to Intrauterine Gestational Age Relationship to Intrauterine GrowthGrowth

Normal range of birth weight for each week Normal range of birth weight for each week of gestation.of gestation.

Birth weight is classified as follows:Birth weight is classified as follows: Large for gestational age (LGA): weight falls Large for gestational age (LGA): weight falls

above the 90above the 90thth percentile for gestational percentile for gestational ageage

Appropriate for gestational age (AGA): Appropriate for gestational age (AGA): weight falls between the 90weight falls between the 90thth and 10 and 10thth percentile for gestational agepercentile for gestational age

Small for gestational age (SGA): weight Small for gestational age (SGA): weight falls below the 10falls below the 10thth percentile for percentile for gestational agegestational age

Intrauterine Growth GridIntrauterine Growth Grid

Circumcision Circumcision Circumcision is considered an elective Circumcision is considered an elective

procedureprocedure Anesthesia should be provided.Anesthesia should be provided. Parents must give written consentParents must give written consent Full term health infantsFull term health infants Aftercare: Check hourly for 12 hoursAftercare: Check hourly for 12 hours Check for bleeding and voidingCheck for bleeding and voiding Before dischargeBefore discharge:: Newborn goes home within the first 12 hours Newborn goes home within the first 12 hours

after procedureafter procedure Bleeding should be minimal and infant must Bleeding should be minimal and infant must

voidvoid Ensure that parents know how to care for the Ensure that parents know how to care for the

circumcision.circumcision.

Breastfeeding Breastfeeding Colostrum is rich in immunoglobulins to Colostrum is rich in immunoglobulins to

protect newborn GI tract from infection; protect newborn GI tract from infection; laxative effect.laxative effect.

Breast milk in 2 weeks sufficient nutrients Breast milk in 2 weeks sufficient nutrients 20 kcal/oz (infant’s nutritional needs)20 kcal/oz (infant’s nutritional needs)

To support Breastfeeding: Mother needs to To support Breastfeeding: Mother needs to consume extra 500 calories per day.consume extra 500 calories per day.

Feeding length: should be long enough to Feeding length: should be long enough to remove all the foremilk (watery 1remove all the foremilk (watery 1stst milk from milk from breast high in lactose - skim milk & effective breast high in lactose - skim milk & effective in quenching thirst)in quenching thirst)

Hindmilk: higher in fat content leads to Hindmilk: higher in fat content leads to weight gain and more satisfying.weight gain and more satisfying.

Breastfeeding time approximately 30 Breastfeeding time approximately 30 minutesminutes

Infant FormulaInfant Formula Formula 7.5 ml to 15 ml at feeding Formula 7.5 ml to 15 ml at feeding

gradually increase to 90 ml to 120 ml gradually increase to 90 ml to 120 ml at each feeding in 2 weeks.at each feeding in 2 weeks.

Formula preparation: mixing must be Formula preparation: mixing must be accurate to provide the 20 kcal/ozaccurate to provide the 20 kcal/oz.. (newborn nutritional need)(newborn nutritional need)

Burping: is needed to expel air Burping: is needed to expel air swallowed when infant sucks.swallowed when infant sucks.

Should be done about ½ way through Should be done about ½ way through feeding for bottle feeders and when feeding for bottle feeders and when changing breasts for breast feeders.changing breasts for breast feeders.

Respiratory DistressRespiratory Distress 2 types: Respiratory Distress Syndrome (RDS) and 2 types: Respiratory Distress Syndrome (RDS) and

Transient Tachypnea of the Newborn (TTN)Transient Tachypnea of the Newborn (TTN) RDS: preterm infants/surfactant deficiencyRDS: preterm infants/surfactant deficiency Hypoxia, respiratory acidosis and metabolic Hypoxia, respiratory acidosis and metabolic

acidosisacidosis Surfactant is produced by alveoli - lung maturity Surfactant is produced by alveoli - lung maturity L/S ratio 2:1 is a test done before birth to L/S ratio 2:1 is a test done before birth to

determine fetal lung maturitydetermine fetal lung maturity TTN: AGA, near term infantsTTN: AGA, near term infants Intrauterine or intrapartum asphyxia Intrauterine or intrapartum asphyxia Newborn unable to clear airway of lung fluid, Newborn unable to clear airway of lung fluid,

mucous or amniotic fluid aspiration.mucous or amniotic fluid aspiration. Expiratory grunting nasal flaring, tachypnea with Expiratory grunting nasal flaring, tachypnea with

respirations as high as 100 to 140 breaths/minute.respirations as high as 100 to 140 breaths/minute.

Neural Tube DefectsNeural Tube Defects 3 types: 3 types: Spina Bifida OccultaSpina Bifida Occulta: failure of the : failure of the

vertebral arch to close. Has vertebral arch to close. Has dimpledimple on the on the back with a tuft of hair. No treatment back with a tuft of hair. No treatment required.required.

MeningoceleMeningocele: saclike protrusion along the : saclike protrusion along the vertebral column filled with cerebrospinal vertebral column filled with cerebrospinal fluid and meninges. Surgery required.fluid and meninges. Surgery required.

MyelomeningoceleMyelomeningocele: saclike protrusion : saclike protrusion along the vertebral column filled with spinal along the vertebral column filled with spinal fluid meninges, nerve roots, and spinal cord fluid meninges, nerve roots, and spinal cord = paralysis. Surgical repair required.= paralysis. Surgical repair required.

Sterile saline dressing. Sterile saline dressing. hydrocepalushydrocepalus

Spina bifida occultaSpina bifida occulta meningocelemeningocele

Spina bifida OccultaSpina bifida Occulta myelomeningocelemyelomeningocele

Infants of DM mothers (IDM) Infants of DM mothers (IDM) ComplicationsComplications

Hypoglycemia:Hypoglycemia: maternal glucose maternal glucose declines at birth. Infant has high level of declines at birth. Infant has high level of insulin production= decreases infant’s insulin production= decreases infant’s blood glucose within hours after birth.blood glucose within hours after birth.

Respiratory Distress: Respiratory Distress: less mature lungs less mature lungs due to insulin due to insulin

HyperbilirubinemiaHyperbilirubinemia: hepatic immaturity, : hepatic immaturity, increased hematocrit, bruising due to increased hematocrit, bruising due to difficult delivery.difficult delivery.

Birth traumaBirth trauma: large size of infant: large size of infant Congenital birth defectsCongenital birth defects: birth defects – : birth defects –

Patent Ductus Arteriosus, Ventricular Patent Ductus Arteriosus, Ventricular Septal Defect and more.Septal Defect and more.