postpartum & newborn nursing theory and practice

Postpartum & NewbornPostpartum & Newborn

Nursing Theory and PracticeNursing Theory and Practice

MOTHERMOTHER

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

WordsWords ImagesImages

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

The “Fourth” TrimesterThe “Fourth” Trimester

Defining the Postpartum PeriodDefining the Postpartum Period

Postpartum period is a time of changePostpartum period is a time of change Medical/Physiologic changeMedical/Physiologic change Psychosocial (developmental) changePsychosocial (developmental) change

Duration of changes is variableDuration of changes is variable Duration of coping with changes is Duration of coping with changes is

variablevariable

Defining the Postpartum PeriodDefining the Postpartum Period

Physiologically defined as the six week Physiologically defined as the six week period of uterine involutionperiod of uterine involution Begins with the birth of the placentaBegins with the birth of the placenta Includes resolution of anatomic and Includes resolution of anatomic and

physiologic changes of pregnancy physiologic changes of pregnancy • return of all systems to (nearly) pre-pregnant statereturn of all systems to (nearly) pre-pregnant state

Psychosocial tasks of the postpartum Psychosocial tasks of the postpartum period take longer than six weeks to period take longer than six weeks to accomplishaccomplish

Physiologic ChangesPhysiologic Changes

Reproductive SystemReproductive System

Uterine InvolutionUterine Involution Muscle fibers contract with the birth of Muscle fibers contract with the birth of

placentaplacenta• Stops bleeding of large uterine vesselsStops bleeding of large uterine vessels• Massage gently to maintain firmnessMassage gently to maintain firmness

Can be taught to womanCan be taught to woman Much more comfortable if woman does herselfMuch more comfortable if woman does herself Must be effective or clots can collect in the uterusMust be effective or clots can collect in the uterus


Uterine InvolutionUterine Involution Uterus progressively smaller Uterus progressively smaller

over ~2 weeksover ~2 weeks• 1 – 2 finger breadths below umbilicus immediately 1 – 2 finger breadths below umbilicus immediately

postpartumpostpartum• At umbilicus on days one and twoAt umbilicus on days one and two• Progressively smaller until not palpable Progressively smaller until not palpable

abdominally by day 10; may take slightly longer abdominally by day 10; may take slightly longer with cesarean sectionwith cesarean section


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

• Especially for multiparaEspecially for multipara• May need narcotic analgesia in addition to NSAIDMay need narcotic analgesia in addition to NSAID• Narcotics are constipating Narcotics are constipating

prevention is importantprevention is important

• Void regularlyVoid regularly• Prone position (NOT knee-chest)Prone position (NOT knee-chest)• HeatHeat• Worse with suckling, pre-medicate prnWorse with suckling, pre-medicate prn

Education/understanding is criticalEducation/understanding is critical


Oxytotic agents (Oxytotic agents (↑ afterpains)↑ afterpains) Pitocin (given almost routinely IV or IM after Pitocin (given almost routinely IV or IM after

all births)all births) Hemabate (PGF2a, not in asthmatics)Hemabate (PGF2a, not in asthmatics) Methergine Methergine

• IM & PO most common, IV if life threateningIM & PO most common, IV if life threatening• Causes sustained uterine contractionCauses sustained uterine contraction• Increases BPIncreases BP• Obtain baseline BP before each administrationObtain baseline BP before each administration


Endometrial SloughingEndometrial Sloughing Lochia Lochia

• Rubra (Red) 1 – 5 days Rubra (Red) 1 – 5 days • Serosa (Pinkish Tan) 5 days – 2 weeks Serosa (Pinkish Tan) 5 days – 2 weeks • Alba (White) 2 to 6 weeksAlba (White) 2 to 6 weeks

Lochia has strong smell, not a foul smellLochia has strong smell, not a foul smell In the first three daysIn the first three days

• Small amount of small clots are normalSmall amount of small clots are normal• ONE larger clot after long period supine is normalONE larger clot after long period supine is normal


Placental SitePlacental Site Heals by exfoliative shedding. Lochia is a Heals by exfoliative shedding. Lochia is a

combination 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 each and leukocytes with the proportion of each changing as the lochia changeschanging as the lochia changes

Lack of scar tissue important for placental Lack of scar tissue important for placental implantation in future pregnanciesimplantation in future pregnancies


CervixCervix Floppy (patulous) immediately after birthFloppy (patulous) immediately after birth May be visible at vaginal introitusMay 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 like Os (opening) changes from round to slit like

after 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 continued Lacerated cervix can be cause of continued postpartum bleeding w/ firm uterus. postpartum bleeding w/ firm uterus.


VaginaVagina Edematous after delivery (external ice pack)Edematous after delivery (external ice pack) May have lacerations that may or may not May have lacerations that may or may not

need repair (hemostasis and approximation)need repair (hemostasis and approximation) Smooth walled x several weeks, then ruggae Smooth walled x several weeks, then ruggae

reappearreappear Mucosa thinned and dryer secondary to Mucosa thinned and dryer secondary to ↓ ↓

estrogen estrogen continues until ovulation and continues until ovulation and menstruation resume. Counsel for lubricationmenstruation resume. Counsel for lubrication


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

• 11stst degree mucosa only degree mucosa only• 22ndnd degree mucosa and underlying muscle* degree mucosa and underlying muscle*• 33rdrd degree mucosa, underlying muscle and partial degree mucosa, underlying muscle and partial

tear of anal sphinctertear of anal sphincter• 44thth degree mucosa, underlying muscle, anal degree mucosa, underlying muscle, anal

sphincter and tear of anal mucosal capsulesphincter and tear of anal mucosal capsule


PerineumPerineum After 30 years of research there is no After 30 years of research there is no

evidence to support routine episiotomyevidence to support routine episiotomy Episiotomy should be used selectively only ifEpisiotomy should be used selectively only if

• Birth needs to be expeditedBirth needs to be expedited• Access to the baby is essential Access to the baby is essential • Clear evidence of uncontrolled tear (debatable)Clear evidence of uncontrolled tear (debatable)

Episiotomy increases the risk of severe tear Episiotomy increases the risk of severe tear (fabric demo)(fabric demo)


Perineum (continued)Perineum (continued) All stitches absorb on their own after ~ 2 weeksAll 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)• Pain Management (assessment, positioning, Rx)Pain Management (assessment, positioning, Rx)• Nutrition/Rx support to prevent constipationNutrition/Rx support to prevent constipation• Exercise of injured muscle to improve blood flow and Exercise of injured muscle to improve blood flow and

strength (kegel)strength (kegel)


Return to Menstruation/OvulationReturn to Menstruation/Ovulation Pregnancy can occur prior to first menses! Pregnancy can occur prior to first menses!

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

Lactating womenLactating women• Prolactin suppresses ovulation. Return to menses Prolactin suppresses ovulation. Return to menses

unpredictable; from 6 weeks to 1 year or moreunpredictable; from 6 weeks to 1 year or more Non-Lactating womenNon-Lactating women

• Menses usually resume by 6 – 8 weeksMenses usually resume by 6 – 8 weeks

LactationLactation

Lactating womenLactating women Sudden drop in estrogen & progesterone with Sudden drop in estrogen & progesterone with

birth of placentabirth of placenta ↑ ↑ Prolactin Prolactin

• milk production milk production • maternal feelings and wellbeingmaternal feelings and wellbeing• supported by frequent contact with babysupported by frequent contact with baby

Rooming in with supportRooming in with support

• suppresses ovulation, delays menstruationsuppresses ovulation, delays menstruation

LactationLactation

““Let down” reflex: suckling Let down” reflex: suckling oxytocin oxytocin• Milk ejection, uterine involutionMilk ejection, uterine involution• Afterpains Afterpains ibuprofen 600mg safe ibuprofen 600mg safe

Colostrum x 3 daysColostrum x 3 days• Baby’s “first vaccine” (high in IgA antibodies)Baby’s “first vaccine” (high in IgA antibodies)• Nutrient dense Nutrient dense only small amounts needed only small amounts needed

Transitional milk days 3 – 6Transitional milk days 3 – 6 Mature milk day 6 onMature milk day 6 on

Composition of milk changes over timeComposition of milk changes over time

LactationLactation

Breasts immediately postpartumBreasts immediately postpartum Soft textureSoft texture May or may not leak small amount of May or may not leak small amount of

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

LactationLactation

Breasts on day one and twoBreasts on day one and two Soft texture, may begin to fill and feel firmerSoft texture, may begin to fill and feel firmer Check nipples if breastfeeding: erect, everted, Check nipples if breastfeeding: erect, everted,

intactintact

LactationLactation

Breasts on day three to fiveBreasts on day three to five Entire breast feels taut, warm, erythematous, Entire breast feels taut, warm, erythematous,

largerlarger Check nipple is erect, everted, intactCheck nipple is erect, everted, intact Note any nodules (plugged duct, cyst, cancer)Note any nodules (plugged duct, cyst, cancer)

LactationLactation

Breasts day 6 to week 6Breasts day 6 to week 6 Firm when just about time to nurseFirm when just about time to nurse Softer after baby nurses effectivelySofter after baby nurses effectively May spray milk with let downMay spray milk with let down

Week 6 onwardWeek 6 onward Breasts much softer, even when fullBreasts much softer, even when full Softness is not a sign of less milkSoftness is not a sign of less milk

LactationLactation

MastitisMastitis Wedge shaped areaWedge shaped area Local painLocal pain RednessRedness Firm noduleFirm nodule FeverFever ExhaustionExhaustion

LactationLactation

Non-Lactating WomenNon-Lactating Women Still have colostrum, may leakStill have colostrum, may leak Milk will still come in on ~ day 3Milk 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

• ibuprofen 600 mg safe; Cold compress; tight braibuprofen 600 mg safe; Cold compress; tight bra• no breast stimulation or milk expressionno breast stimulation or milk expression• Green Cabbage leaves Green Cabbage leaves

Prolactin levels Prolactin levels ↓ quickly without suckling↓ quickly without suckling

LactationLactation

Breast milk is the best food for human Breast milk is the best food for human infants infants

Formula is safe in US Formula 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 developing countriesFormula may not be safe developing countries Formula is unsafe in poor countriesFormula is unsafe in poor countries

LactationLactation

Goal is to increase the number of women who Goal is to increase the number of women who initiate and sustain breastfeeding initiate and sustain breastfeeding ongoing intense support and education essentialongoing intense support and education essential

““Increased duration of breastfeeding confers Increased duration of breastfeeding confers significant health and developmental benefits for significant health and developmental benefits for the child and the mother...” (AAP Policy the child and the mother...” (AAP Policy Statement 2005)Statement 2005)

LactationLactation

Nursing actions directly affect Nursing actions directly affect breastfeeding initiationbreastfeeding initiation Encourage rooming inEncourage rooming in Effective, accurate informationEffective, accurate information Referral to community resourcesReferral to community resources Including the mother’s support systemIncluding the mother’s support system

Bottle FeedingBottle Feeding

Based on modified cow milk or soyBased on modified cow milk or soy Cost approx $1200/ year Cost approx $1200/ year

Powdered or concentrate – mix w/ boiled Powdered or concentrate – mix w/ boiled waterwater

More $ if “ready to eat”More $ if “ready to eat” WIC does not cover the entire cost of formulaWIC does not cover the entire cost of formula

Contains supplemental vitamins and ironContains supplemental vitamins and iron Wash nipples and bottles dailyWash nipples and bottles daily Discard unused portion of bottleDiscard unused portion of bottle

Cardiovascular SystemCardiovascular System

Normal blood lossNormal blood loss Vaginal birth = up to 500cc (2 cups)Vaginal birth = up to 500cc (2 cups) Cesarean birth = up to 1000ccCesarean birth = up to 1000cc

WBC count up to 20,000WBC count up to 20,000 Increased propensity for clotting makes Increased propensity for clotting makes

postpartum women at increased risk for postpartum women at increased risk for thrombi thrombi

Varicosities regressVaricosities regress


Blood PressureBlood Pressure Q 15 minutes x 1 hour postpartum, then Q 15 minutes x 1 hour postpartum, then

hourly 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 suggest

postpartum pre-eclampsia and deserves postpartum pre-eclampsia and deserves further investigationfurther investigation

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


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

circulating volume (loss of placental/uterine circulating volume (loss of placental/uterine sinuses) sinuses) lower pulse rate (60 – 70) lower pulse rate (60 – 70)

Diuresis Diuresis less volume less volume pulse returns to pulse 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 may Warning! In a postpartum woman, you may see “normal” vital signs in a patient at risk for see “normal” vital signs in a patient at risk for hypovolemiahypovolemia

Temperature RegulationTemperature Regulation

May see slight May see slight ↑ immediately postpartum↑ immediately postpartum Physical effortPhysical effort DehydrationDehydration

Temperature >100.4 at any time triggers Temperature >100.4 at any time triggers further assessment for infection and report further assessment for infection and report of the findingsof the findings

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

Weight LossWeight Loss

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

+/- 5 lbs fluid loss from diuresis from days +/- 5 lbs fluid loss from diuresis from days two to fivetwo to five

2-3 lbs loss from shedding lochia2-3 lbs loss from shedding lochia Total by 6 weeks +/- 20 poundsTotal by 6 weeks +/- 20 pounds Extra weight remains as fat deposits to Extra weight remains as fat deposits to

make milkmake milk Lactating women need +500 cal/dayLactating women need +500 cal/day

Integumentary SystemIntegumentary System

Woman may appear about 6 months Woman may appear about 6 months pregnant when standingpregnant when standing Skin and underlying muscle are stretchedSkin and underlying muscle are stretched Diastasis recti visible about 2 – 4 cm wideDiastasis recti visible about 2 – 4 cm wide

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


Stretch marks “striae” appear purple to redStretch marks “striae” appear purple to red Commonly on abdomen, breasts, hipsCommonly on abdomen, breasts, hips Over time fade to silvery tan-white, do not Over time fade to silvery tan-white, do not

disappeardisappear Linea nigra and other estrogen mediated Linea nigra and other estrogen mediated

skin markings gradually fade, may not skin markings gradually fade, may not disappeardisappear

May have new scars and altered body May have new scars and altered body imageimage

Striae and Linea NigraStriae and Linea Nigra


ConjunctivaConjunctiva May be pale in anemiaMay be pale in anemia

ScleraSclera May have hemorrhages due to pushingMay have hemorrhages due to pushing

Lacerations of the perineum/vaginaLacerations of the perineum/vagina May see bruising or hematomaMay see bruising or hematoma EdemaEdema Should be well approximated and hemostatic without Should be well approximated and hemostatic without

dischargedischarge Sitz baths, peri careSitz baths, peri care

Urinary SystemUrinary System

Difficulty voiding immediately postpartumDifficulty voiding immediately postpartum EdemaEdema Decreased intra-abdominal pressureDecreased intra-abdominal pressure Residual effects of epidural if usedResidual effects of epidural if used

• Running water, stroking lower back, peppermint oil Running water, stroking lower back, peppermint oil • Catheterization if bleeding uncontrolledCatheterization if bleeding uncontrolled• Uterus deviated to right often indicates full bladderUterus deviated to right often indicates full bladder

Urinary SystemUrinary System

Marked diuresis of Marked diuresis of ↑’d ↑’d fluid volumefluid volume Beginning about 12 hours postpartumBeginning about 12 hours postpartum Urinary lossesUrinary losses Also diaphoresis profuseAlso diaphoresis profuse

Gastrointestinal SystemGastrointestinal System

Usually VERY hungry after birthUsually VERY hungry after birth Most L&D units keep snack boxesMost L&D units keep snack boxes

• birth often occurs outside of regular meal servicebirth often occurs outside of regular meal service Birth centers often have kitchensBirth centers often have kitchens

• Families prepare mealsFamilies prepare meals• Birthday cake!Birthday cake!


At risk for constipationAt risk for constipation Still have poor abdominal and intestinal Still have poor abdominal and intestinal

muscle tonemuscle tone Fear of passing stool due to laceration(s)Fear of passing stool due to laceration(s) Fiber, fluid, stool softener, anticipatory Fiber, fluid, stool softener, anticipatory

guidanceguidance


Hemorrhoids Hemorrhoids Pressure from pushing Pressure from pushing CommonCommon

• Ice packsIce packs• OintmentOintment• Witch hazel padsWitch hazel pads• Anesthetic sprayAnesthetic spray

Psychosocial Aspects of Psychosocial Aspects of PostpartumPostpartum

Adaptation to ParenthoodAdaptation to Parenthood

Learning new skillsLearning new skills Feeding, holding, diapering, bathing, umbilical and Feeding, holding, diapering, bathing, umbilical and

possibly circumcision care possibly 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 physical New skill acquisition occurs just as all of the physical

adaptations are taking placeadaptations are taking place Sleep deprivationSleep deprivation

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

Three Phases of PuerperiumThree Phases of Puerperium

Next three slides based on work of:Next three slides based on work of: Reva Rubin, 1977Reva Rubin, 1977 A classic body of work A classic body of work Describes maternal behavior in three Describes maternal behavior in three

phasesphases Taking InTaking In Taking HoldTaking Hold Letting GoLetting Go

Three Phases of the PuerperiumThree Phases of the Puerperium

Taking InTaking In Passive, uncertain, exhaustedPassive, uncertain, exhausted Reviewing birth experience, baby explored Reviewing birth experience, baby explored

and experienced with wonder, unfamiliarand 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 “en face”Gaze at baby “en face” Vulnerable physically and emotionallyVulnerable physically and emotionally


Taking holdTaking hold Beginning to take tentative action, building Beginning to take tentative action, building

confidence, gaining familiarityconfidence, gaining familiarity Strong interest in taking care of her baby Strong interest in taking care of her baby

herselfherself Coming to accept birth experienceComing to accept birth experience Gaining familiarity with baby, still feels unsureGaining familiarity with baby, still feels unsure Praise and positive reinforcement welcomePraise and positive reinforcement welcome


Letting goLetting go Acceptance of fantasy and reality inAcceptance of fantasy and reality in

• birth experiencebirth experience• baby baby • new roles (mother, lover, worker, etc)new roles (mother, lover, worker, etc)

Grief workGrief work Confident, independent actionConfident, independent action Forms own opinionsForms own opinions Ongoing . . . duration measured in yearsOngoing . . . duration measured in years

Postpartum BluesPostpartum Blues

Normal reaction (70% in some sources) toNormal reaction (70% in some sources) to Sleep deprivationSleep deprivation Grief workGrief work Life changeLife change Conflict between expectation and realityConflict between expectation and reality Physiologic changes, including endocrine changesPhysiologic changes, including endocrine changes

Usually worst around days 3 - 5Usually worst around days 3 - 5 Characterized by labile mood, tearfulness, and Characterized by labile mood, tearfulness, and

reality based passing feelings of inadequacyreality based passing feelings of inadequacy Early onset and resolutionEarly onset and resolution

Bonding BehaviorsBonding Behaviors

En face positioningEn face positioning Baby talking (high pitched, sing song)Baby talking (high pitched, sing song) Fingertips Fingertips open palm open palm enfolding enfolding Eye gazingEye gazing Entrainment (baby moves in rhythm with Entrainment (baby moves in rhythm with

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

essentialessential

Postpartum Nursing CarePostpartum Nursing Care

Is based on an understanding of the Is based on an understanding of the physiology and psychology of the physiology and psychology of the postpartum periodpostpartum period

Nursing interventions include:Nursing interventions include:

Nurse’s Role in Postpartum CareNurse’s Role in Postpartum Care

Change agentChange agent Skilled observerSkilled observer Thoughtful teacherThoughtful teacher Expert time managerExpert time manager CoachCoach ScientistScientist Care takerCare taker

Nursing ActivitiesNursing ActivitiesBirth – 2 hoursBirth – 2 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 extra-uterine supporting and assessing the baby’s transition to the extra-uterine

environmentenvironment assessing the mother for bleeding, pain, uterine toneassessing the mother for bleeding, pain, uterine tone supporting breastfeeding initiationsupporting breastfeeding initiation supporting initial bonding supporting initial bonding helping the provider prepare for any suturing helping 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 and completing 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 care ensuring that the nurse’s other laboring patient is under RN care

Nursing Care from 2 – 48 hoursNursing Care from 2 – 48 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 planning Intensive discharge planning Repetitive anticipatory guidanceRepetitive anticipatory guidance Increasing self care and self confidenceIncreasing self care and self confidence Increasing independence with baby careIncreasing independence with baby care Closing knowledge deficitsClosing knowledge deficits

Nursing Care from 2 – 48 hoursNursing Care from 2 – 48 hours

Group ClassesGroup Classes Nurses lead group classes on postpartum Nurses lead group classes on postpartum

unitsunits• Baby careBaby care• BreastfeedingBreastfeeding

Group classes are not a substitute for Group classes are not a substitute for individualized care planningindividualized care planning

Special SituationsSpecial Situations

StillbirthStillbirth Woman may choose to be on a gyn floorWoman 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 staffOften 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 fingertip Exploration follows fingertip enfolding order enfolding order• Mementos kept on fileMementos kept on file


Surrendering infant for adoptionSurrendering infant for adoption Immediate postpartum not a time to re-evaluateImmediate postpartum not a time to re-evaluate 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 parentingAdoptive parenting Many of the same stages Rubin describesMany of the same stages Rubin describes

The ill infantThe ill infant Encourage bondingEncourage bonding Private room appreciatedPrivate room appreciated Breast pumpBreast pump


The ill motherThe ill mother Private roomPrivate room SnapshotsSnapshots TelephoneTelephone Family support Family support EducationEducation Nursery staff and volunteersNursery staff and volunteers Breast pumpBreast pump

Newborn NursingNewborn Nursing

Audrey Gives Birth!Audrey Gives Birth!

The nurse dries the baby immediatelyThe nurse dries the baby immediately Places the baby on Audrey’s belly skin to skin or Places the baby on Audrey’s belly skin to skin or

on a pre-warmed infant warmer prnon a pre-warmed infant warmer prn• To prevent heat loss by To prevent heat loss by

EvaporationEvaporation ConvectionConvection ConductionConduction

• To stimulate respirationsTo stimulate respirations

Removes wet towelsRemoves wet towels Covers with dry towel and warmed hatCovers with dry towel and warmed hat Rapid evaluation of infant’s transitionRapid evaluation of infant’s transition

Rapid Initial EvaluationRapid Initial Evaluation

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

Counted for six seconds and multiplied by tenCounted for six seconds and multiplied by ten General survey for major anomaliesGeneral survey for major anomalies General sense of presence in the bodyGeneral sense of presence in the body

Apgar ScoringApgar Scoring

Score to assess neonatal wellbeing at Score to assess neonatal wellbeing at birthbirth

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 scaleA maximum ten point scale Five items worth 0, 1 or 2 points eachFive items worth 0, 1 or 2 points each

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

Apgar ScoringApgar 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-irregular-weak, good-strongAbsent, slow-irregular-weak, good-strong 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 ColorColor

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

Newborn IdentificationNewborn Identification

IdentibandIdentiband Locks and must be cut be removedLocks and must be cut be removed May have a chip in it for further securityMay have a chip in it for further security # corresponds to mother’s ## corresponds to mother’s # Other identifying demographic informationOther identifying demographic information Two bands are used (wrist and ankle)Two bands are used (wrist and ankle)

Footprints obtainedFootprints obtained Unique like fingerprintsUnique like fingerprints

Giving ReportGiving Report

Time of birthTime of birth Brief synopsis of labor and birthBrief synopsis of labor and birth Respirations spontaneous or assistedRespirations spontaneous or assisted

If assisted in what way and for how longIf assisted in what way and for how long Apgar scores (include why points taken off)Apgar scores (include why points taken off) Any medications administeredAny medications administered

Including Vitamin K and erythromycinIncluding Vitamin K and erythromycin General condition of the neonateGeneral condition of the neonate Number of vesselsNumber of vessels Relevant lab tests (cord bloods, maternal labs, cultures)Relevant lab tests (cord bloods, maternal labs, cultures) Notation of void or meconium passage that occurredNotation of void or meconium passage that occurred

Understanding the Physiologic Understanding the Physiologic Transition from Fetus to NewbornTransition from Fetus to Newborn

Physiologic TransitionPhysiologic Transition

Circulatory changesCirculatory changes In utero, lungs are like wet plastic bags stuck In utero, lungs are like wet plastic bags stuck

together with minimal blood flowtogether with minimal blood flow With the first few breaths lungs expand and With the first few breaths lungs expand and

blood flow for gas exchange beginsblood flow for gas exchange begins Circulatory changes occur that allow blood Circulatory changes occur that allow blood

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


Umbilical vein and ductus venosisUmbilical vein and ductus venosis (connection to vena cava) (connection to vena cava) constricts after cord clamped; become constricts after cord clamped; become

ligaments (takes months)ligaments (takes months) Some babies don’t cry until the cord is Some babies don’t cry until the cord is

clampedclamped


Circulatory ChangesCirculatory Changes Foramen ovale (rt atrium Foramen ovale (rt atrium aorta) closes aorta) closes

functionally with onset of respirationsfunctionally with onset of respirations• Permanent closure takes several monthsPermanent closure takes several months

Ductus Arteriosis (pulm artery Ductus Arteriosis (pulm artery aorta) aorta) constricts with onset of respirationsconstricts with onset of respirations• Becomes a ligament (takes months)Becomes a ligament (takes months)


Heart murmurs are understandably Heart murmurs are understandably common common usually clinically insignificant usually clinically insignificant should be reportedshould be reported

Heart rate remains 120-160 bpm Heart rate remains 120-160 bpm sleep (slower) sleep (slower) activity (higher)activity (higher)


Circulatory ChangesCirculatory Changes Peripheral circulation established slowly over Peripheral circulation established slowly over

the first 24 hoursthe first 24 hours• Acrocyanosis normal (blueish hands and feet)Acrocyanosis normal (blueish hands and feet)

BP averages 78/42 BP averages 78/42 • not usually checked in L&Dnot usually checked in L&D

RBC count high initiallyRBC count high initially• Falls over the first weekFalls over the first week• Breakdown of RBC related to neonatal jaundiceBreakdown of RBC related to neonatal jaundice


Establishing respirationsEstablishing respirations Thoracic squeeze with vaginal birth pushes Thoracic squeeze with vaginal birth pushes

excess fluids out of lungsexcess fluids out of lungs• Birth by cesarean section Birth by cesarean section ↑ risk for transient ↑ risk for transient

tachypnea of the newborn (TTN)tachypnea of the newborn (TTN) Surfactants present in full term babiesSurfactants present in full term babies

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

• Prevent alveolar collapse and RDSPrevent alveolar collapse and RDS


Normal respiratory rate is 30 – 60 Normal respiratory rate is 30 – 60 breaths/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 breatherObligate nose breather Chest & abdomen rise simultaneouslyChest & abdomen rise simultaneously


Renal SystemRenal System Urine present in bladder at birth Urine present in bladder at birth

• 11stst void within 24 hours void within 24 hours• In breastfed baby one void for each day of life until In breastfed baby one void for each day of life until

milk in (usually day 3-5), then 6-10 voids/daymilk in (usually day 3-5), then 6-10 voids/day• In bottlefed baby, one void per day for first 48 In bottlefed baby, one void per day for first 48

hours, then 6-10 voids/dayhours, then 6-10 voids/day


Renal System Renal System Kidneys do not concentrate urine for first Kidneys do not concentrate urine for first

three monthsthree months• Attention to adequate hydration essentialAttention to adequate hydration essential

Urine pale and straw coloredUrine pale and straw colored Uric acid crystals common initiallyUric acid crystals common initially

• May leave brick red spots in diaperMay leave brick red spots in diaper


Gastrointestinal SystemGastrointestinal System Newborns can establish suckling instinctivelyNewborns can establish suckling instinctively

• Help with this is still appreciated!Help with this is still appreciated! ““Baby cheeks” (fullness) d/t sucking padsBaby 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, nipple Cannot move food from lips to pharynx, nipple

must be far into mouthmust be far into mouth


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


Gastrointestinal SystemGastrointestinal System Circumoral pallor while sucking normalCircumoral pallor while sucking normal Stomach capacity small (15–30cc)Stomach capacity small (15–30cc)

• Frequent feedings essentialFrequent feedings essential• Learn early hunger behaviorsLearn early hunger behaviors• Waiting for late feeding cues interferes with Waiting for late feeding cues interferes with

establishing breastfeedingestablishing breastfeeding Breastfed babies usually feed every 2 hoursBreastfed babies usually feed every 2 hours Bottlefed babies usually feed every 3-4 hoursBottlefed babies usually feed every 3-4 hours

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


Gastrointestinal SystemGastrointestinal System Can digest simple carbohydrates and Can digest simple carbohydrates and

proteins, may have difficulty with fat in proteins, may have difficulty with fat in formulasformulas

Immature cardiac sphincterImmature 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


Gastrointestinal SystemGastrointestinal System MeconiumMeconium

• First stool—black, tarry, stickyFirst stool—black, tarry, sticky Usually passed within the first 24 hoursUsually passed within the first 24 hours

• Sterile gut– needs Vitamin K injection Sterile gut– needs 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, brownish-greenTransitional stool is thin, brownish-green


Normal newborn stoolNormal newborn stool BreastfedBreastfed

• When milk established (days 3-5)When milk established (days 3-5)• Loose, golden yellow, seedy, unformed, minimal Loose, golden yellow, seedy, unformed, minimal

odorodor• May occur after each nursing May occur after each nursing

Formula fedFormula fed• Formed, pale yellowFormed, pale yellow• May vary from 1/day to after each feedingMay vary from 1/day to after each feeding


HepaticHepatic Liver metabolizes excess hemoglobin Liver metabolizes excess hemoglobin

• From breakdown of unneeded fetal RBCFrom breakdown of unneeded fetal RBC• Unconjugated bilirubinUnconjugated bilirubin • Conjugated bilirubin Conjugated bilirubin

(H2O soluable) (H2O soluable)

• ExcretedExcreted


Immature liver functionImmature liver function Unconjugated bilirubin accumulatesUnconjugated bilirubin accumulates

• JaundiceJaundice Lab assessmentLab assessment

• Normal <12mg/dlNormal <12mg/dl Heel stick or transdermal assessment on babyHeel stick or transdermal assessment on baby

Clinical AssessmentClinical Assessment• Physiologic (normal) begins at >24 hrs of lifePhysiologic (normal) begins at >24 hrs of life• Proceeds head to toeProceeds head to toe


Pathophysiologic jaundice Pathophysiologic jaundice Multiple etiologiesMultiple etiologies

• Blood incompatibilityBlood incompatibility• InfectionInfection• TraumaTrauma• HypothermiaHypothermia• medicationsmedications

Indirect coombs test for maternal antibodies (done on Indirect 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)


Temperature RegulationTemperature Regulation Newborn cannot shiver to produce heatNewborn cannot shiver to produce heat

• Heat productionHeat production Metabolism of brown fat Metabolism of brown fat Increased metabolic rateIncreased metabolic rate Increased activityIncreased activity


Temperature RegulationTemperature Regulation Newborn has large surface area and large Newborn has large surface area and large

head – significant source of heat losshead – significant source of heat loss Rapid temperature drop with birthRapid temperature drop with birth

• Cold stress occurs easily Cold stress occurs easily ↑↑ O2 consumption O2 consumption can lead to metabolic acidosis can lead to metabolic acidosis respiratory distressrespiratory distress

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


ImmunologicImmunologic IgG transplacentallyIgG transplacentally IgA in colostrum and breast milkIgA in colostrum and breast milk Greatest risk of infection in first six weeksGreatest risk of infection in first six weeks

• s/sx may not be same as in adults/sx may not be same as in adult Immunity acquired sequentiallyImmunity acquired sequentially Vaccinations may start in hospital and are Vaccinations may start in hospital and are

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

Neurologic/SensoryNeurologic/Sensory

States of ConsciousnessStates of Consciousness Deep sleep: no body movements, palms openDeep sleep: no body movements, palms open Light sleep: some body movementsLight sleep: some body movements Drowsy: startle, eyes open, “no one home”Drowsy: startle, eyes open, “no one home” Quiet alert: few movements, intent, focusedQuiet alert: few movements, intent, focused Active alert: body movements, facial Active alert: body movements, facial

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

closedclosed


Periods of ReactivityPeriods of Reactivity FirstFirst

• Begins at birthBegins at birth• Continues for 1 – 2 hoursContinues for 1 – 2 hours

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

• Begins around 4 hoursBegins around 4 hours May spit up mucusMay spit up mucus Pass meconiumPass meconium Suck wellSuck well

Equilibrates by 8 hours of ageEquilibrates by 8 hours of age Newborns typically sleep ~17/day in short burstsNewborns typically sleep ~17/day in short bursts


Impact on Nursing Interventions Impact on Nursing Interventions Early discharge timingEarly discharge timing

• Accommodate periods of reactivityAccommodate periods of reactivity• Accommodate mother’s level of energyAccommodate mother’s level of energy

Teaching Teaching • Consideration of periods of reactivity Consideration of periods of reactivity • Consideration of newborn’s stateConsideration of newborn’s state


SightSight Newborns can seeNewborns can see

• Best at about 18 inches Best at about 18 inches • ““en face” is perfecten face” is perfect• Love facesLove faces• Enjoy high contrast (black & white)Enjoy high contrast (black & white)• Will gaze or fix on objectsWill gaze or fix on objects• Uncoordinated eye movementsUncoordinated eye movements• May mimic slow, repeating facial movementsMay mimic slow, repeating facial movements


HearingHearing Begins in utero (24 weeks)Begins in utero (24 weeks) Enjoys speech cadenceEnjoys speech cadence

• EntrainmentEntrainment• ““baby talk” singsongbaby talk” singsong

TeachingTeaching• Talk to the baby!Talk to the baby!• Watch baby for “I need a break” cuesWatch baby for “I need a break” cues


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

tasting in uterotasting in utero Prefers sweetPrefers sweet Sucking is essentialSucking is essential

• Reduces pain and stressReduces pain and stress• SatisfyingSatisfying• NourishmentNourishment• May improve brain developmentMay improve brain development• May decrease SIDSMay decrease SIDS


SmellSmell Sense present at birthSense present at birth Newborns can identify their own mother’s Newborns can identify their own mother’s

breast pads by smell alonebreast pads by smell alone Newborns may use smell to help establish Newborns may use smell to help establish

nursingnursing• Not washing their hands right awayNot washing their hands right away


TouchTouch Infants are highly sensitive to touchInfants are highly sensitive to touch Startle easilyStartle easily Treat with respectTreat with respect

BondingBonding Touch progressionTouch progression

SwaddlingSwaddling Seems to calm some babiesSeems to calm some babies

Physical AssessmentPhysical Assessment

WeightWeight Obtained initially soon after birthObtained initially soon after birth Obtained dailyObtained daily Initial loss of up to 10% body weight normalInitial loss of up to 10% body weight normal

• Should be regained by 2 weeks of ageShould be regained by 2 weeks of age

LengthLength Babies are curled up in uteroBabies are curled up in utero

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

Average is 45.7 – 60 cm (18-22 inches)Average is 45.7 – 60 cm (18-22 inches)


Head CircumferenceHead Circumference Measure biparietal diameterMeasure biparietal diameter 33 – 33.5 cm (13-14 inches)33 – 33.5 cm (13-14 inches) May need to re-measure in a few days ifMay need to re-measure in a few days if

• Significant molding and caputSignificant molding and caput Head circumference should be 2 cm> chest Head circumference should be 2 cm> chest

circumferencecircumference 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


SkinSkin Skin color varies with ethnicity, pigment Skin 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/post-termSkin may be dry/peeling in term/post-term

• Palms, soles, possibly cracks/crevicesPalms, soles, possibly cracks/crevices Acrocyanosis normal x 24 hoursAcrocyanosis normal x 24 hours Erythema toxicum neonatorum (“flea bites”)Erythema toxicum neonatorum (“flea bites”) Mongolian spots (common in African, Asian ancestry)Mongolian spots (common in African, Asian ancestry) Harlequin signHarlequin sign Nevus flammeus “Stork bite”Nevus flammeus “Stork bite” MiliaMilia


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

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


MouthMouth Inspect gums and lipsInspect gums and lips

• IntactIntact• No teethNo teeth

Inspect hard palateInspect hard palate• IntactIntact• Small white bumps normal (Epstein’s pearls)Small white bumps normal (Epstein’s pearls)


NeckNeck ShortShort Skin foldsSkin folds Muscles not strong enough to support headMuscles not strong enough to support head AbnormalitiesAbnormalities

• Toriticollis (injury to sternocleidomastoid muscle)Toriticollis (injury to sternocleidomastoid muscle)• Webbing Webbing • MassesMasses


ChestChest Rounded (transverse and AP diameter =)Rounded (transverse and AP diameter =) Areola edema “breast buds”Areola edema “breast buds”

• ““witches milk”witches milk” Circumference 2 cm less than headCircumference 2 cm less than head AbnormalitiesAbnormalities

• Clavicle separation/crepitusClavicle separation/crepitus• retractionsretractions


AbdomenAbdomen 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 dyeAir dry, alcohol swaps, triple dye• No bleeding, cord clamp secure, base dryNo bleeding, cord clamp secure, base dry• Cord dries, turns black and falls offCord dries, turns black and falls off

Usually by 2 weeksUsually by 2 weeks


GenitaliaGenitalia MaleMale

• Scrotum edematous, ruggae presentScrotum edematous, ruggae present• May be darkly pigmentedMay be darkly pigmented• Palpate that both testes are descendedPalpate that both testes are descended• Penis small (2 cm), meatus at tipPenis small (2 cm), meatus at tip• Do not attempt to retract foreskinDo not attempt to retract foreskin• CircumcisionCircumcision

Elective surgery, pain relief necessaryElective surgery, pain relief necessary May be part of religious ritualMay be part of religious ritual Should not be done if hypospadias/epispadiasShould not be done if hypospadias/epispadias


GenitaliaGenitalia FemaleFemale

• Maternal hormones may affect genitaliaMaternal hormones may affect genitalia Vulva edematousVulva edematous May see vaginal dischargeMay see vaginal discharge

• MucusMucus• Blood tinged (pseudo menstruation)Blood tinged (pseudo menstruation)

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


ExtremitiesExtremities Short arms and legsShort arms and legs

• Fingers reach over proximal thighFingers reach over proximal thigh Flexed tone, springs back when extendedFlexed tone, springs back when extended Bowed legsBowed legs Fat, clenched handsFat, clenched hands

• Holds grip securely (able to raise up)Holds grip securely (able to raise up) Fingernails at least to the tips of the fingersFingernails at least to the tips of the fingers Hip abduction testsHip abduction tests

• Ortolani sign “clunk” of femur head in socketOrtolani sign “clunk” of femur head in socket• Barlows sign “feeling the hip slip out of socket”Barlows sign “feeling the hip slip out of socket”


FeetFeet Able to be manipulated into midline easilyAble to be manipulated into midline easily Creased over two-thirds of soleCreased over two-thirds of sole Fat pads make feet appear chubby and flatFat pads make feet appear chubby and flat

Fingers and ToesFingers and Toes Syndactaly– fused digitsSyndactaly– fused digits Polydactly– extra digit (often like a skin tag)Polydactly– extra digit (often like a skin tag)


Spine/BackSpine/Back Spine has “C” curve not “S” like in adultsSpine has “C” curve not “S” 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


AnusAnus Inspect to confirmInspect to confirm

• PresentPresent• PatentPatent

Insert gloved, lubricated pinkie fingerInsert gloved, lubricated pinkie finger

Meconium should pass by 24 hoursMeconium should pass by 24 hours


ReflexesReflexes BlinkBlink ExtrusionExtrusion SwallowingSwallowing RootingRooting SuckingSucking Tonic Neck (Fencing)Tonic Neck (Fencing) Moro Moro Landeau (U)Landeau (U)


ReflexesReflexes Stepping/Placing (Foot/Shin)Stepping/Placing (Foot/Shin) Palmar/Plantar graspPalmar/Plantar grasp Crossed Extension (Pushing away)Crossed Extension (Pushing away) Magnet (pressure against pressure)Magnet (pressure against pressure) Trunk IncurvationTrunk Incurvation BabinskiBabinski

Assessing neurologic integrityAssessing neurologic integrity Understanding newborn behaviorUnderstanding newborn behavior

Gestational Age AssessmentGestational Age Assessment

Standardized forms for assessing Standardized forms for assessing gestational 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 Gestational Age (weeks)Gestational Age (weeks)

FINDINGFINDING 0-360-36 37-3837-38 39+39+

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

Breast Breast nodule nodule

2mm 2mm diameterdiameter



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

Ear LobeEar Lobe Pliable, no Pliable, no cartilagecartilage

Some Some cartilagecartilage

Cartilage stiff Cartilage stiff and shapedand shaped

Testes & Testes & scrotumscrotum

Testes in Testes in canal, few canal, few rugaerugae

intermediateintermediate Scrotum full, Scrotum full, rugae coversrugae covers

CryingCrying Infants tend to cry a lotInfants tend to cry a lot

About 2 hours of each dayAbout 2 hours of each day ““Fussy” time of dayFussy” time of day Peaks around 6 weeksPeaks around 6 weeks

Infant cry is supposed to be distressing Infant 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

Initial bathInitial bath Wear gloves until after first bathWear gloves until after first bath Usually within 1–2 hours of birthUsually within 1–2 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

Always proceed from cleanest to most Always proceed from cleanest to most soiled 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

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: “pinch” Feel for gel to form: “pinch” • 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

““Back to Sleep”Back to Sleep” Always place infant on back to sleepAlways place infant on back to sleep

• RareRare syndromes require prone position syndromes 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 affect Nurses’ attitudes and teaching directly affect

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

SIDS FactsSIDS Facts

SIDS is leading cause of death in infants SIDS is leading cause of death in infants from 1 month to 1 yearfrom 1 month to 1 year

Most SIDS deaths occur between 2 Most 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 3 times higher than white babiestimes higher than white babies

SIDS FactsSIDS Facts

www.nichd.nih.gov/sidswww.nichd.nih.gov/sids Always on backAlways on back Firm surfaceFirm surface Keep soft objects outKeep soft objects out No smokingNo smoking Sleep close, but separateSleep close, but separate PacifierPacifier 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

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

Assess home environmentAssess home environment Social worker to assist with issuesSocial worker to assist with issues

Assess support systemsAssess support systems Know community resourcesKnow community resources Use the hospital social worker prnUse the hospital social worker prn

Assess knowledge of newborn careAssess 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

postpartum & newborn nursing theory and practice

Documents

uterus slide

physiologic changes

critical slide

variable slide

practice slide

trimester slide

uterine contractioncauses

day life of mothers