Unit 5 - Postpartum and Newborn

Selected Nursing Diagnoses

-Impaired spontaneous ventilation related to ineffective transition to newborn life. -Risk for injury: Hypoglycemia related to immature metabolism and/or presence of risk factors. -Ineffective thermoregulation related to immature heat-regulating mechanisms. -Risk for infection related to immature immune system, possible exposure to pathogens in the birth canal or in the nursery, and umbilical cord wound. -Risk for imbalanced fluid volume related to immature blood clotting mechanisms. -Risk for injury: Misidentification related to failure of delivery room personnel to adequately identify the newborn before separation from the parents.

How to check for the Ortolani Maneuver and Barlow Sign

1. Wash hands thoroughly 2. Position the newborn flat on his back on a firm surface 3. Position the knees together, and flex the knees and hips 90 degrees 4. Place your middle finger over the greater trochanter of the femur and your thumbs on the inner aspect of the thigh. 5. Apply upward pressure and abduct the hips. A clicking or a clunking sound is a positive Ortolani sign, which is associated with dislocation of the hip. 6. Next apply downward pressure, and adduct the hips. Continue to maintain 90 degrees flexion, if you feel the head of the femur slip out of the acetabulum, the joint is unstable, and Barlow sign is positive.

Chapter 14

Nursing Care of the Normal Newborn Role of the LPN - The LPN's role is to support the newborn as he adapts to these changes, quickly recognize the development of complications, and report changes in condition to the RN to facilitate rapid interventions. Teaching the parents the skills needed for care of their child is another critical role that the LPN plays.

Appearance, body proportions, and posture

A healthy term newborn's appearance is symmetrical and well nourished without cyanosis. Typically the head should be larger in proportion to the body, the neck is short and the chin rests on the chest. The newborn should maintain a flexed position with tightly clenched fists. The abdomen is protuberant (bulging or prominent) and the chest is rounded. Note the newborn's sloping shoulders and rounded hips. The newborn's body should appear long with short extremities.

Becoming a Mother

A woman begins this process during the pregnancy as she anticipates the birth of the baby. After the birth, the woman must take on the role of mother to the baby. The two critical elements of becoming a mother are development of love and attachment to the child and engagement with the child. Engagement includes all the activities of caregiving as the child grows and changes. This transition is a continuously evolving process throughout the woman's life. While everyone woman adapts to motherhood differently and is influenced by her culture, upbringing and role models there are four developmental stages that all women go through. 1. Beginning attachment and preparation for the infant during pregnancy. 2. Increasing attachment, learning to care for the infant, and physical restoration during the early postpartum period. 3. Moving toward a new normal in the first four months. 4. Achieving a maternal identity around four months. These stages can overlap and social/environmental variables influence their lengths. In the early postpartum period the new mother demonstrates dependent behaviors such as difficulty making decisions and the need for assistance with self-care, and tends to be more inwardly focused. This is not the optimum time to teach detailed newborn care as the mother is not readily receptive to instruction. Listen with acceptance and never make a woman feel like the woman is "wrong" for what she is expressing. Most women quickly move from the dependent stage to increasing independence in self- and newborn care. After she has rested and recovered somewhat from the stress of the delivery, the new mother has more energy to concentrate on her infant. At this point she is receptive to infant care instruction, with the first time mother in particular needs reassurance that she is capable for providing care for her newborn. It is important to encourage her to perform care for her newborn while providing gentle guidance and support. This phase lasts from two days to several weeks.

Postpartum Blues

Approximately 40% to 80% of postpartum women experience postpartum blues, sometimes called "baby blues." It is a temporary condition that usually begins on the third day and lasts for two to three days. The woman experiences rapid mood swings, irritability, anxiety, and decreased concentration. She may be tearful, have difficulty sleeping and eating, and feel generally letdown. A combination of factors leads to this condition, but the main factors appear to be psychological adjustment along with a physiologic decrease in estrogen and progesterone. Additional factors include too much activity, fatigue, disturbed sleep patterns, and discomfort. It is important for the woman and her family to know it is a normal reaction; however if the depression lasts for more than several days, or if the symptoms become more severe, the woman should seek a psychological evaluation.

Development of Positive Family Relationships

Attachment is the enduring emotional bond that develops between the parent and infant. However, this process does not happen automatically. Attachment occurs as parents interact with and respond to their infant. In the early postpartum period, disbelief, shock, and ambivalence are normal responses. New parents may be communicate uncertainty of their readiness to care for the newborn. The mother should be encouraged to express her feelings openly and then show acceptance and let her know these feelings are normal, without being dismissive or negative about the feelings. The initial component of healthy attachment is a process called bonding. This is the way the new mother and father become acquainted with their newborn. This process typically begins with the initial inspection of the newborn. The mother explores her newborns extremities, counting fingers and toes, she then advances to using the palms of her hands to touch the newborn and begins exploring larger body parts. Soon she will enfold the baby in her arms and cuddle the baby. As bonding continues she begins to spend more time holding the newborn in the en face position (in which she interacts face to face with the newborn.) She will place the baby's face within direct line of vision and make full eye contact with the newborn. She will laugh, smile and talk to the baby while continuing the en face posture. Access to supportive friends and relatives enhances attachment. When a new mother is isolated without adequate social support, attachment is threatened and it is important to assist the woman in finding sources of support. Discuss the situation with the RN in charge as a referral to social services may be in order. Healthy bonding behaviours include naming the baby and calling the baby by name. Making eye contact and talking to the newborn are other indicators that healthy attachment is occurring. It is important to differentiate between a new parent who is nervous and anxious about her new role and one who is rejecting her parenting role. Warning signals for poor attachment include turning away from the newborn, refusing or neglecting to provide care, and disengagement from the newborn. While early thinking was that the mother was the most important person to bond with but we now know that the baby can form many bonds. The father benefits from early contact with the newborn immediately after delivery and siblings can also bond with the new baby. There are special considerations to consider with older siblings. The birth requires the sibling to change roles and sometimes the new baby does not meet the sibling's expectations such as if the baby is a girl and the sibling wanted a baby brother. It is common for the sibling to regress for a few days after birth.

Breasts

Colostrum, the antibody-rich breast secretion that is the precursor to breast milk is normally excreted by the breasts in the last weeks of pregnancy and continues to be excreted in the first few postpartum days. Prolactin levels rise when estrogen and progesterone levels fall after delivery of the placenta. Suckling at the breast also causes prolactin levels to rise. Prolactin stimulates milk production by the breasts, and the milk normally comes in on the third day.

Continuing assessment throughout Newborn Transition

Continue to observe for signs of respiratory distress. Observe for excess mucus, which could obstruct the airway. Measure the heart and respiratory rates at least every 30 minutes during the first two hours of transition. Observe the newborn closely for cold stress, using a thermal skin probe for continuous temperature assessment while the newborn is under the radiant warmer. Measure the axillary temperature at least every 30 minutes until the temperature stabilizes above 97.6F (36.5C). Hypoglycemia is a potential problem that can, if prolonged, have devastating effects on the newborn. Therefore it is critical for you to be able to recognize the signs of neonatal hypoglycemia. These signs include jitteriness or tremors, exaggerated Moro reflex, irritability, lethargy, poor feeding, listlessness, apnea or respiratory distress including tachypnea, or a high pitch cry. Never mistake jitteriness in the newborn for shivering. If the newborn has shaking movements or startles easily immediately check the blood sugar. Remember newborns can develop hypoglycemia even when there are no recognizable risk factors for its development. The main sign of hypoglycemia is jitteriness, which is often exhibited in the newborn as an exaggerated Moro reflex. If hypoglycemia is prolonged without treatment, the newborn may have seizures or lapse into a coma. Permanent brain damage can result, leading to lifelong disability or death. If the newborn is exhibiting signs of or is at risk for hypoglycemia, check the bgl using a heel stick to obtain a blood sample for testing. Bgl between 50 and 60mg/dL during the first 24 hours of life are considered normal. Less than 50mg/dL are indicative of hypoglycemia in the newborn.

Integumentary System

Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The woman waking up drenched in sweat is a normal finding and not cause for concern. The woman will likely have striae (stretch marks) on the abdomen and sometimes on the breasts. Immediately after birth, striae appear red or purplish. Overtime they fade to a light silvery color and remain faintly visible.

Cervix

During Labor, the cervix thins and dilates. This process does not occur without some trauma. directly after delivery, the cervix is still partially open and contains soft, small tears. It may also appear bruised. The internal os closes after a few days. Gradually, the muscle cells regenerate, and the cervix recovers by the end of the six-week puerperium. The external os, however, remains slightly open and has a slit-like appearance in comparison with the dimple-like appearance of the cervix of a nulliparous woman.

Cardiovascular Adaptation

Fetal circulation differs greatly from newborn circulation and requires the newborn's cardiovascular system to make drastic changes upon birth for the survival of the newborn. (Fetal circulation learned in chapter 5) Newborn circulation is similar to adults. After birth, deoxygenated blood that enters the heart must go to the lungs for gas exchange; therefore, the shunts must close. Several factors that contribute to their closing include the following: > As the lungs fill with air, the pressure in the chest drops causing a reversal in pressures between the right and left atria, forcing the foramen ovale to close and redirecting blood to the lungs. > The first few breaths greatly increase oxygen content of the circulating blood, this chemical change contributes to the closing of the ductus arteriosus, which eventually becomes a ligament. The ductus venosus also closes, allowing nutrient-rich blood from the gut to circulate through the newborns liver.

Respiratory Adaptation

Fetal lungs are uninflated and full of amniotic fluid because they are not needed for oxygen exchange. Immediately after birth the newborn's lungs must inflate, the remaining fluid must be absorbed, and oxygen exchange must begin. One factor that helps the newborn clear fluid from the lungs and take his or her first breath begins during labor. Much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. This "vaginal squeeze" also plays a role in stimulating lung expansion because as the baby is born, the pressure being exerted on its chest is removed and the lowered pressure causes the chest to expand, drawing air into the lungs. [[ A newborn delivered by cesarean does not always have the benefit of the vaginal squeeze and often has more fluid in his or her lungs making respiratory adaptation more challenging. These newborns should be monitored closely for signs of respiratory distress]] When the umbilical cord is clamped, oxygen levels fall, and CO2 levels rise causing the newborn's pH to fall with the resulting acidosis and falling oxygen level stimulating the respiratory centers of the brain to begin their lifelong function of regulating respiration. The newborn must make a strong respiratory efforts in the first few moments of life and this is best demonstrated and stimulated by a vigorous cry as crying opens up the small air sacs (alveoli) in the lungs. This cry is stimulated by the immediate sensory and thermal changes that they experience upon leaving the womb and entering the world. Another important factor in the newborn's respiratory adaptation is surfactant. Surfactant (a substance found in the lungs of a mature fetus) keeps the alveoli from collapsing after they first expand. The effort needed to breath increases dramatically without enough surfactant and the newborn will quickly become exhausted without medical intervention. Usually by 35 weeks gestation the fetus has enough surfactant.

Postpartum Assessment

Focuses on 11 areas: breasts, uterus, lochia, bladder, bowel, perineum, lower extremities, pain, laboratory studies, maternal-newborn bonding, and maternal emotional status.

Nursing interventions in Early postpartum period

Focuses on preventing and detecting hemorrhage, treating pain, preventing infection, preventing falls, detecting and treating urinary retention, preventing constipation, preventing and detecting thrombus formation, promoting sleep, and promoting healthy parental-newborn attachment. A woman who has a cesarean birth requires additional considerations because she has undergone surgery. Complications include respiratory compromise and pain, infection and hemorrhage from the abdominal incision. Helping the woman turn, cough and deep breathe and encouraging early and frequent ambulation after cesarean delivery are necessary measures to help prevent respiratory compromise and thrombus formation. Prepare the woman for discharge by teaching her to perform self- and infant care. Self-care includes breast care, fundal massage, assessment, prevention of constipation, and prevention of fatigue.

Preventing Misidentification of a Newborn

Fortunately, it is a rare occurrence for newborns to be switched in the hospital and go home with the wrong parents, but it has happened. When the mistake is uncovered years later the situation often results in heartache and heart-wrenching choices for all parties involved. Many facilities footprint the infant and fingerprint the mother but this practice has declined as footprints are not an accurate way to identify an infant. Most hospitals use some form of bracelet system. Three to four bracelets are prepared immediately after delivery and before the newborn is separated from the parents. Information included on the band is the mother's name, hospital number, physician, and the newborn's date and time of birth and sex. Two bands are placed on the newborn, one on the arm and one on the leg. A matching band is placed on the mother and another band may be placed on the father or another designated adult. Instruct parents to always check the band when the newborn is brought to them to ensure they have their infant.

Neurologic Assessment

General Appearance and Behavior The first part of a neurologic exam involves quiet observation of the general appearance and behavior of the newborn. Hypotonus (decreased tone) is an abnormal finding, as is hypertonus, distinct tremors, jitteriness, or seizure activity. Any of these states may be associated with neurologic dysfunction, hypoglycemia, hypocalcemia, or neonatal drug withdrawal. A high-pitched, shrill cry is associated with neurologic dysfunction. Reflexes Normal newborn reflexes are assessed at the end of the examination. The most commonly assessed reflexes are the following: Rooting, sucking, and swallowing reflexes are important to the newborn's nutritional intake. By gently stroking the newborn's cheek, the newborn should demonstrate the rooting reflex by turning toward the touch with an open mouth. By placing a gloved finger in the newborn's mouth you can test the sucking reflex, which should be strong. Swallowing is evaluated when the infant eats. Look and listen for coordinated swallowing efforts. Evaluate the palmar and plantar grasp reflexes by placing a finger in the palm or parallel to the toes. The digits will wrap around the finger and hold on. The grasp should be bilaterally equal and strong. Check the stepping reflex by supporting the newborn in a standing position on a hard surface. He or she will lift the legs up and down in a stepping motion. Babinski sign is positive (normal) if the newborn's toes fan out and hyperextend and the foot dorsiflexes when a firm object(such as the blunt end of a pen) is traced from the heal along the lateral aspect of the foot up and across the ball of the foot. After the infant starts walking this reflex should disappear and the toes should curl inward (negative Babinski), rather than fanning outward. The Moro reflex is also known as the startle reflex. When the newborn is startled, he or she extends the arms and legs away from the body and to the side. Then the arms come back toward each other with the fingers spread in a "C" shape. The arms look as if the newborn is trying to embrace something. The Moro reflex should be symmetrical. This reflex disappears approximately 6 months of age. The tonic neck reflex is another total body reflex. With the newborn lying quietly on his or her back, turn the head to one side without moving the rest of the body. The newborn responds by extending the arm and leg on the side he or she is facing and flexing the opposite arm and leg. This position is called the "fencer's position" because it looks as if the newborn is poised to begin fencing.

Metabolic Adaptation

Glucose is not only necessary to carry out metabolic processes and produce energy, but is also an essential nutrient for brain tissue. Neonatal hypoglycemia occurs when bgl drops below 50mg/dL or lower. Risk factors from the pregnancy include gestational hypertension, maternal diabetes (either pre-existing or gestational), prolonged labor, fetal distress during labor and/or ritodrine or terbutaline administered to mother. Risk factors present in newborn characteristics include intrauterine growth restriction, macrosomia (very large baby), large for gestational age, small for gestational age, prematurity, postmaturity, hypothermia and/or respiratory or cardiovascular depression requiring resuscitation. Early signs of hypoglycemia in the newborn include jitteriness, poor feeding, listlessness, irritability, low temperature, weak or high-pitched cry, and hypotonia. Respiratory distress, apnea, seizures, and coma are late signs.

Assessment of Normal Newborn

Immediate concerns are with the success of cardiopulmonary adaptation. A vigorous or lusty cry, heart rate greater than 100 bpm and pink color are associated with effective cardiopulmonary adaptation. These assessments are made rapidly during the first seconds of birth. A traditional immediate assessment of newborn adaptation is the Apgar score. This score is not used to guide newborn resuscitation; but it is useful to evaluate the effectiveness of resuscitation efforts and to help determine the intensity of care the newborn will require in the first few days of life. The five parameters that determine the total Apgar score are heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each factor receives a score of 0 to 2 points for a maximum total of 10. The RN will assign the Apgar score at one to five minutes after birth. If the newborn receives a score less than 7 at five minutes the RN continues to assign a score every five minutes until the score is 7 or above, the newborn is intubated, or the newborn is transferred to the nursery. Scores of 7 to 10 at five minutes are indicative of a healthy baby who is adapting well to the extrauterine environment. Scores between 4 to 6 at five minutes indicate the newborn is having some difficulty adjusting to life outside the womb and requires close observation. These will usually go to a special nursery where they may receive oxygen and other special monitoring until their condition improves. Newborns who score a 0 to 3 are having severe difficulty transitioning to the extrauterine environment and require observation and care in a NICU. If the heart rate is >100 bpm they are given a score of 2. If it is present but <100 bpm they are given a score of 1. If it not present they are given a score of 0. If the respiratory effort is strong and they present with a vigorous cry they are given a 2. If they have a weak cry, and or have slow or difficult respirations they are given a 1. If there is no respiratory effort they are given a 0. When muscle tone maintains a position of flexion with brisk movements it is give a 2. When there is minimal flexion in the extremities it is given a 1 and when the newborn extremities are limp and flaccid they are given a 0. When the newborn cries or sneezes when stimulated (usually by suctioning the infant or gently flicking the sole of the foot), the reflex irritability is given a 2. When it grimaces upon stimulation with no crying or sneezing, it is given a 1 and if there is no response it is given a 0. Finally, if the color of the body and extremities is pink it is given a 2. If the body is pink but the extremities are blue (acrocyanosis) it is given a 1 and if the body and extremities are blue (cyanosis) or completely pale (pallor) it is given a 0.

Gastrointestinal System

Immediately after delivery the postpartum woman is often very hungry. The energy expended during labor uses up glucose stores, and food has generally been restricted. Restriction of fluids and loss of fluids in labor, in the urine, and via diaphoresis often lead to increased thirst. Constipation can be a problem as intra-abdominal pressure decreases rapidly after childbirth, and peristalsis is diminished. These factors make it more difficult to travel down the GI tract. The woman may be afraid to defecate in the early postpartum period because of the hemorrhoidal discomfort and perineal pain. Suppressing the urge to defecate complicates the problem of constipation and may actually cause increased pain when defecation finally occurs. Iron supplementation adds to the problem, however by the end of the first week of postpartum, bowel function has usually returned to normal.

Weight Loss

Immediately after delivery, approximately 12 to 14 lb are lost with the delivery of the fetus, placenta, and amniotic fluid. The woman loses an additional 5 to 15 lb in the early postpartum period because of fluid loss from diaphoresis and urinary excretion. The average woman will have returned to her pre-pregnant weight six months after child birth if she is within the 25 to 30 lb of weight gain during pregnancy. Some women take longer to lose the additional pounds. In general breast-feeding women tend to lose weight faster than women who do not breast-feed because of increased caloric demand.

Cardiovascular system

In the early postpartum period the woman eliminates the additional fluid volume that is present during the pregnancy via the skin, urinary tract and through blood loss. The woman who experiences a normal vaginal delivery loses approximately 300 to 500mL of blood during delivery, while a woman who has a cesarean section will experience a normal blood loss of 500 to 1000 mL. As blood volume returns to normal, some hemoconcentration occurs that causes an increase in the hematocrit. [[For every 250 mL of blood loss, the hemoglobin and hematocrit (H&H) falls by one and two points respectively. So if a woman starts with an H&H of 12/34 and loses approximately 500mL of blood it will show up as 10/30.]] High plasma fibrinogen levels and other coagulation factors mark the postpartum period. This is protective against hemorrhage, but it also predisposes to the development of deep vein thrombosis (DVT), formation of blood clots in the deep veins of the legs. Dehydration, immobility, and trauma can add to the risk for DVT. White blood cell count is elevated to approximately 15,000 to 20,000/mL and may reach as high as 30,000/mL. Leukocytosis, high white blood cell count, helps protect the woman from infection as there are multiple routes for infection to occur in the early postpartum period. Immediately after birth or soon afterwards the woman may suffer a shaking postpartum chill which is likely due to hormonal and physiologic changes. The chill is not harmful unless accompanied by a fever greater than 100.4F or other signs of infection. The shivering normally resolves within minutes, especially if a prewarmed blanket is placed over the woman.

Eyes

It is normal for eyelids to be swollen from pressure during birth. A chemical conjunctivitis may develop after instillation of eye prophylaxis in the delivery room. The sclera should be clear and white, not blue. The pupils should be equal and reactive to light. A red reflex should be present (elicited by shining an ophthalmoscope onto the retina of the eye with the normal response being a red reflection from the retina). Absence of the red reflex is associated with congenital cataracts. Small subconjunctival hemorrhages may be present and these usually disappear within a week or two and are not harmful. Eye movements are usually uncoordinated and some strabismus (crossed eye) is expected. A "Doll's eye" reflex is normal for the first few days (when the newborn's head is turned the eyes travel to the opposite side). Persistence of this reflex into the second week requires evaluation. The newborn can perceive light and can track objects held close to the face. The newborn's vision is sharp at about 8 to 15in from the face. He or she will like shapes and colors and shows a preference for the human face. Crying is usually tearless because the lacrimal apparatus is underdeveloped.

Maintaining Thermoregulation

Most info covered in previous section. New Info: Cold Stress increases the amount of oxygen and glucose needed by the newborn and the newborn can quickly deplete glucose stores and develop hypoglycemia. A way you can prevent heat loss and promote early bonding is to dry the newborn quickly, place a diaper or blanket over the genital area and a cap on the head, then place the newborn skin to skin with the mother or father and cover them both with blankets. This method of keeping the newborn warm is called kangaroo care and is an excellent way to meet the needs of the newborn and provide family centered cared. The environmental temperature necessary to maintain a thermoneutral environment (an environment in which heat is neither lost nor gained) is slightly higher for the newborn than that required for an older child or adult. Do not allow the newborn to become overheated. Hyperthermia can be just as harmful as hypothermia. Hyperthermia causes the infant to increase his or her metabolic rate, and this causes an increase in oxygen consumption. Hyperthermia can lead to vasodilation which can cause hypotension or could lead to dehydration. Avoid placing temperature sensors over a bony prominence or areas of brown fat as to prevent false temperature readings as these areas tend to be warmer than the rest of the infants body.

Supporting Cardiovascular and Respiratory Transition

Most of this section is covered in the last chapter. New information is the following: If the newborn does not cry immediately, transport him to a preheated radiant warmer for prompt resuscitation. If the newborn still does not make adequate breathing efforts, a bag and mask connected to 100% oxygen are used to provide respiratory support until spontaneous breathing occurs. Most newborns do not require resuscitation, and the ones who do generally respond well to a short period of positive pressure ventilation with a bag and mask. However, a small number of infants also require chest compression, intubation, and medications. Give constant attention to the airway. Newborns often have abundant secretions and as such the initial intervention is to position the newborn on the side or with the head in a slightly lower position than the body to help prevent aspiration of secretions. Use a bulb syringe to suction the mouth first and then the nose (this is done because if the nose is suctioned before the mouth the newborn may gasp or cry and aspirate secretions in the mouth) and keep the bulb syringe with the newborn and teach the parents how and when to suction the baby. If copious secretions are present that do not resolve with a bulb syringe, a small suction catheter connected to a suction source may be used. Be careful not to apply suction for longer than five seconds at a time and to minimize suction pressures to avoid damaging the delicate respiratory structures.

Urinary System

Must handle an increased load in the early postpartum period as the body excretes excess plasma volume. Healthy kidneys are able to adjust to the increased demands and urinary output exceeds intake with transient glycosuria, proteinuria, and ketonuria are normal in the immediate postpartum period. During the process of labor and delivery, trauma can occur to the lower urinary system. Pressure of the descending fetal head on the ureters, bladder, and urethra can lead to transient loss of bladder tone and urethral edema. Trauma, certain medications, and anesthesia given during labor can also lead to a temporary loss of bladder sensation. The result can be urinary retention where the woman either voids small amounts but does not completely void or does not void at all. Voiding may also be painful if the urethra was traumatized. The urinary system is more susceptible to infection during the postpartum period. Hydronephrosis (Dilation of the renal pelves and ureters) is a normal change that occurs during pregnancy because of hormonal influences. This condition persists for approximately four weeks after delivery. Hydronephrosis and urinary stasis predispose the woman to urinary tract infection. [[If you palpate the fundus and find it above the umbilicus, deviated to the right side, and boggy, the most likely cause is a fully bladder. Assist the woman to void and then reevaluate the fundus.]]

Preventing Injury from Hypoglycemia

New Info: The best way to prevent injury from hypoglycemia is to prevent the condition altogether. If the mother is breast-feeding, encourage early and frequent feedings and if necessary have a lactation consultant assist the mother. If the newborn is bottle-fed, initiate early feedings. When a newborn displays signs of this condition perform a heel stick and use a bedside glucose analyzer to check the blood sugar level. If the heel stick specimen reveals a bgl <50 mg/dL, draw a venous blood sample and send it to the laboratory for confirmation. It is critical however to immediately notify the RN and initiate treatment. In the past, glucose water was used to treat low bgl, but most authorities now recommend feeding breast milk or formula to the alert newborn. If the infant's symptoms are severe enough to interfere with regular feeding, intravenous dextrose solutions are usually administered.

Genitourinary

Newborn should void within the first 24 hours of life, and some newborns may urinate for the first time in the delivery room within minutes of birth. The stream of a male newborn should be strong enough to cause a steady arch during voiding and the female should be able to produce a steady stream. The kidneys are not able to concentrate urine well during the first few days and as such will be light in color and there is no odor. Excess uric acid in the urine causes a temporary condition where there is a small amount of pink or light orange color in the diaper and this is normal to find the first few times the newborn voids. Both male and female genitalia may be swollen. Smegma, a cheesy white sebaceous gland secretion, is often found within the folds of the labia of the female and under the foreskin of the male. It is best to allow the secretion to gradually wear away because vigorous attempts at removal can irritate the tender mucosa. Immediately report the presence of ambiguous genitalia (difficult to tell if the gender is male or female). Female - The labia and clitoris may be edematous. In the term newborn, the labia majora cover the labia minora. A hymenal tag may be present. An imperforate hymen (a hymen that completely covers the vaginal opening) should be reported. A blood-tinged mucous discharge from the vagina, pseudomenstruation, results from sudden withdrawal of maternal hormones. Reassure the parents that this condition is not cause for alarm and will resolve on its own within a few days. Male - The urinary meatus should be positioned at the tip of the penis. If the opening is located abnormally on the dorsal (upper) surface of the glans penis, the condition is called epispadias. Hypospadias occurs when the opening to the urethra is on the ventral (under) surface of the glans. If either of these is noted, circumcision is contraindicated as the foreskin is used during the reconstruction process. Phimosis, tightly adherent foreskin, is a normal condition in the term newborn. The tissue should not be forced over the glans penis. Monitor the urinary stream for adequacy. If phimosis interferes with urination, intervention will be needed. Spontaneous erections are a common finding. The male scrotum is pendulous, edematous, and covered with rugae (deep creases). Dark-skinned newborns have deeply pigmented scrotum. Both testes should be descended. Using a thumb and forefinger, the nurse gently palpates the scrotal sac while pressing down on the inguinal canal with the opposite hand. The procedure is repeated on the opposite side. Cryptorchidism results when the testes do not descend into the scrotal sac during fetal life. This condition requires medical evaluation. A hydrocele, fluid within the scrotal sac, may be present and should be noted. [[You can easily identify a hydrocele by taking a penlight and holding it against the scrotal sac. If fluid is present (hydrocele), the light will transilluminate the scrotum. If there is no hydrocele, the light will not shine through solid structures.]]

Behavioral Assessment

Newborns who demonstrate self-quieting behaviors may be considered "good" babies. Parents usually respond positively to cuddly and sociable newborns. When a newborn resists cuddling or is difficult to console, the parents may feel rejected, and bonding can be adversely affected. Teach the parents to watch for cues as to when he or she wants to interact. The quiet alert state is a good time for focused interaction with the newborn. When the newborn is in the active alert stage, he or she likes to play. The drowsy state lets the parents know the newborn needs rest. Crying signals that the newborn has a need. Teach the parents to check for physical problems first such as a soiled diaper, hunger, or need to burp. If the newborn is still crying, the parents can try soothing actions, such as walking, rocking, or riding in the car. Reassure the parents that contrary to popular opinion, you cannot spoil a newborn by picking him up when he is crying. Holding reassures and comforts the newborn. [[It is vital to teach the parents NEVER to shake an infant. Shaking can cause permanent brain damage. If the parent is frustrated because a crying infant is inconsolable, encourage the parent to take a minute to stop and count to 10 or ask a friend for help.]]

Chapter 13

Nursing Assessment of Newborn Transition

Preventing Imbalanced Fluid Volume

One possible cause of hemorrhage and fluid volume loss is an immature clotting mechanism which is due to the newborn GI tract not having the flora to produce vitamin K and is avoided by an IM injection of 0.5 to 1 mg to vitamin K (AquaMEPHYTON) within the first hour of birth. One potential source of hemorrhage is the clamped umbilical cord. An unusually large cord may have large amounts of Wharton jelly, which may disintegrate faster than the cord vessels and cause the clamp to become loose, leading to blood loss from the cord. Another cause could be an improperly applied or defective cord clamp. Inspect the umbilical cord for signs of bleeding.

Puerperium

Otherwise known as the postpartum period, it encompasses the six weeks after birth. It is divided into three categories: the immediate postpartum period, which covers the first 24 hours; the early postpartum period, which covers the first week; and late postpartum period, which refers to weeks two through six. During the postpartum period, the body recovers from the stress of pregnancy and returns to its normal pre-pregnancy state.

Ovaries

Ovulation can occur as soon as three weeks after delivery. Menstrual periods usually begin within six to eight weeks for a woman who is not breast-feeding. However, the lactating woman may not resume menses for as long as 18 months after giving birth. Although lactation may suppress ovulation, it is not a dependable form of birth control. It is wise for the woman to use some type of birth control to prevent an unplanned pregnancy when she resumes sexual activity.

Vital Signs

Respirations are activity-dependent and should be counted when the baby is not crying or feeding (best to be done before the baby is disturbed for examination.) The respiratory rhythm is often irregular, a characteristic known as episodic breathing. Momentary cessation of breathing interspersed with rapid breathing movements is typical of an episodic breathing pattern. Extended periods of apnea are not normal. The abdomen and chest rise and fall together with breathing movements. The normal respiratory rate is 30 to 60 breaths per minutes and should be counted for the full minute when the infant is quiet. Then you auscultate breath sounds. Auscultate the heart rate apically for a full minute, the normal heart rate is the same for a newborn as it is for a fetus (ranging from 110-160 bpm depending on activity level). When the newborn is sleeping it is normal for it to be on the lower level so long as it stays above 100 bpm. The heart rate increases with activity and may be in the 180s for a short period of time, usually occurring during vigorous activity and/or crying. The rhythm should be regular, listen for any abnormal sounds or murmurs. Although most newborn murmurs are benign, always report a murmur for further evaluation. [[Remember the newborn starts with a low blood pressure (60-80/40-45 mm Hg) and a high pulse (110-160 bpm)]] The axilla is the preferred site for newborn temperature measurement. Normal temperature range is between 97.7F (36.5C) and 99.5F (37.5C). Blood pressures are not taken routinely and if they are measured the cuff should be the appropriate size and the pressure may be measured on the arm or leg.

Psychological Adaptation

Role change is the most significant psychological adaptation the woman must make. This process occurs with each new addition to the family but tends to be most pronounced for the first-time mother. Because every child is different the whole family must adapt the the addition of a new member.

Head to toe assessment

Skin, Hair, and Nails Normal newborn skin is supple with good turgor, reddish at birth (turning pink within a few hours), and flaky and dry. Vernix caseosa (or vernix), a white cheese-like substance that covers the body of the fetus during the second trimester, is normally only found in creases of the term baby. Vernix protects fetal skin from the drying effects of amniotic fluid. Lanugo is fine downy hair that is present in abundance on the preterm infant but is found in thinning patches on the shoulders, arms, and back of the term newborn. The scalp hair should be silk and soft. Fingernails are present and extend to the end of the fingertips or slightly beyond. Common newborn skin manifestations include milia, erythema toxicum or newborn rash, mongolian spot(s), telangiectatic nevi or "stork bites," and nevus flammeus or port-wine stain. Milia on the face is a frequent finding and are tiny white papules that resemble pimples. Parents should be reassured that these are harmless and will subside spontaneously. Instruct them not to pick or squeeze them. Erythema Toxicum or newborn rash commonly appears on the chest, abdomen, back and buttocks of the newborn. The rash is harmless and will disappear without treatment. Mongolian Spots are bluish black areas of discoloration that commonly appear on the back, buttocks, or extremities of dark-skinned newborns. These spots should not be mistaken for bruises or mistreatment and gradually fade during the first year or two of life. Telangiectatic Nevi or "stork bites" are pale pink or red marks that sometimes occur at the nape of the neck, eyelids, or nose of fair-skinned newborns. Stork bites blanch when pressed and generally fade as the child grows. Nevus Flammeus or Port-Wine Stain is a dark reddish purple birthmark most common appearing on the face. A group of dilated blood vessels cause the mark. It does not blanch with pressure or fade with time. Cosmetics are available to help cover the stain if it is disfiguring. Physicians have had success fading port-wine stains with laser therapy. Acrocyanosis (blue hands and feet with a pink trunk) results from poor peripheral circulation and is not a good indicator of oxygenation status. Usually this resolves itself within 24-48 hours after birth. The mucous membranes should be pink and there should be no central cyanosis. Mottling is a red and white lacy pattern sometimes seen on the skin of newborns who have fair complexions. It is variable in occurrence and length, lasting from several hours to several weeks. Mottling sometimes occurs with exposure to cool temperatures. Harlequin sign is characterized by a clown suit-like appearance of the newborn. The newborn's skin is dark red on one side of the body while the other side is pale. Dilation of blood vessels causes the dark red color, while constriction of the blood vessels causes the pallor. This harmless condition occurs frequently with vigorous crying or with the infant lying on his or her side. It is important to evaluate the newborn's skin for jaundice and natural sunlight is the best environment in which to assess for jaundice. If natural light is not available use indirect lighting. Press the newborn's skin over the forehead or nose with your finger and note if the blanched area appears yellow. It is also helpful to evaluate the sclera of the eyes, particularly in dark-skinned newborns. A yellow tinge to the sclera indicates the presence of jaundice. Bruising can occur to the presenting part or face if labor is unusually short or long. Swelling may form on the newborn's head from vacuum extraction. Look for forceps mark on the face or cheek after forcep-assisted delivery. Occasionally there will be a nick or cut on the infant born by cesarean, particularly if the surgery was done rapidly under emergency conditions. [[Nursing assessment plays an important role in detecting early (pathologic) jaundice. If you notice jaundice report it immediately, however assessing for jaundice with the naked eye is not a reliable way to screen for hyperbilirubinemia and most facilities will use transcutaneous bilirubinometers or blood samples to screen for this purpose.]]

Gestational Age Assessment

The Gestational age assessment is a critical part of the newborn assessment. While the RN is ultimately responsible for performing the gestational age assessment, however the LPN should be familiar with the instruments used and be able to differentiate the characteristics of the full-term newborn from those of a premature newborn.

Behavioral and Social Adaptation

The Neonatal Behavioral Assessment Scale (developed by Dr. T Berry Brazelton in 1973 based on research he had done on a newborn's personality, individuality, and ability to communicate) identifies six sleep and activity patterns that are characteristic of newborns. 1. Deep sleep: quiet, non-restless sleep state; newborn is hard to awaken 2. Light sleep: eyes are closed, but more activity is noted; newborn moves actively and may show sucking behavior 3. Drowsy: eyes open and close, and the eyelids look heavy; body activity is present with intermittent periods of fussiness 4. Quiet alert: quiet state with little body movement, but the newborn's eyes are open and he or she is attentive to people and things that are in close proximity; this is a good time for the parents to interact with their newborn 5. Active alert: eyes are open and active body movements are present; newborn responds to stimuli with activity 6. Crying: eyes may be tightly closed, thrashing movements are made in conjunction with active crying

Initial Admitting Assessment

The RN completes the initial nursing assessment (sometimes called the admissions assessment) within the first two hours after birth. While the RN, NP, or Pediatrician is responsible for the full assessment, the LPN may assist with portions of the exam. Review the woman's history looking for clues to neonatal conditions in her family, medical/surgical, prenatal, and obstetric histories. Exams should be conducted in a warm area without drafts to protect the newborn from chilling. There should be plenty of lighting (indirect lighting works best). Examinations should be completed as quickly as possible while still maintaining accuracy as newborns become easily fatigued when overstimulated. Generally the least disturbing aspects of the exam, such as observation and auscultation are completed before more intrusive techniques, such as deep palpation and examination of the hips. The overall physical appearance of the newborn is evaluated first, followed by measurement of vital signs, weight, and length. Then a thorough head-to-toe assessment follows ending with assessment of neurologic reflexes and gestational age assessment. The behavioral assessment is done throughout the exam by noting how the newborn reacts to sensory stimuli.

Head and Face

The head may be misshapen because of molding or caput succedaneum. Molding is an elongated head shaped caused by overlapping of the cranial bones as the fetus moves through the birth canal. Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. While these conditions are of concern to new parents, they should be reassured that molding and/or caput will decrease in a few days without treatment. [[These are more likely to occur in the first born baby as oppose to the newborn of a multipara. Cesarean deliveries do not experience either of these unless the fetus is in the birth canal for a prolonged period of time before delivery.]] A cephalhematoma is swelling that occurs from bleeding under the periosteum of the skull, usually over one of the parietal bones. This is caused by birth trauma, usually requires no treatment, and will spontaneously resolve. However the practitioner should evaluate the newborn for signs of anemia (pallor) or shock from acute blood loss. Infants with cephalhematoma need to be observed for jaundice as bilirubin will be produced when the infant's body breaks down the blood cells from the site. It is also important to make certain the cephalhematoma does not cross over the suture lines. If it does, it suggests a skull fracture. Sometimes it is difficult for an inexperienced practitioner to tell the difference between a cephalhematoma and caput. Sutures occur in the place where two cranial bones meet. Normal newborn sutures are palpable with a small space between them. It may be difficult to palpate sutures in the first 24 hours if significant molding is present. However it is important to determine the presence of sutures as sutures will rarely fuse prematurely (craniosynostosis). It is important to detect this condition as it will require surgery to allow the brain to grow. Fontanels occur at the junction of cranial bones where two or more sutures meet. The anterior and posterior fontanels are palpable. The anterior fontanel is diamond-shaped and larger than the posterior fontanel, which has a triangular shape. The posterior fontanel closes in the first 3 months of life while the anterior fontanel does not close until 12 to 18 months of life. Fontanels should be flat, neither depressed nor bulging and it is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel. Bulging fontanels may indicate hydrocephalus or increased intracranial pressure, and sunken fontanels are a sign of severe dehydration. Facial movements should be symmetrical, facial paralysis can occur from a forceps delivery or from pressure on the facial nerve as the fetus travels down the birth canal. It is easiest to assess for facial paralysis when the newborn is crying. The affected side will not move and the space between the eyelids will widen. Facial paralysis is usually temporary but on occasion can be permanent.

Musculoskeletal System

The most pronounced changes are evident in the abdominal muscles, although other muscles may be weak because of the exertion of labor. The abdomen is soft and sagging in the immediate postpartum period. Often the woman has to wear loose clothing for the first few weeks. However, in some women, the abdomen remains slack. In this situation, if another pregnancy occurs, the abdomen will be pendulous, and the woman will have more problems with backache. Diastasis recti abdominis is a condition in which the abdominal muscles separate during the pregnancy, leaving part of the abdominal wall without muscular support. Exercise can improve muscle tone when this condition occurs. A woman is predisposed to poor muscle tone and diastasis if she has weak muscles or is bese before the pregnancy, her abdomen is overdistended during pregnancy, or she is a grand multipara.

Mouth

The mucous membranes should be moist and pink. Sucking calluses may appear on the central part of the lips shortly after birth. Place a gloved finger in the newborns mouth to evaluate the suck and gag reflexes and check the palate for intactness. The suck reflex should be strong, the gag reflex present, and both hard and soft palates should be intact. Well-developed fat pads are bilaterally present on the cheeks. [[A cleft palate can be present even with the absence of a cleft lip. Check the roof of the mouth carefully to be sure it is intact.]] Epstein pearls are small white cysts found on the midline portion of the hard palate of some newborns. They feel hard to the touch and are harmless. Precocious teeth may be present on the lower central portion of the gum. If the teeth are loose, removal is recommended to prevent the infant from aspirating them. A fungal infection (caused by candida albicans) in the oral cavity, called thrush, may be present. This infection can be contracted while passing through the birth canal. The fungus causes white patches that resemble milk curds on the oral mucosa, particularly the tongue. It is important not to remove the patches because doing so will cause bleeding in the underlying tissue. The oral solution of nystatin (mycostatin, nilstat) is the treatment of choice for thrush.

Neck and Chest

The neck is short and thick and should allow the head to move freely and have full range of motion. There should be no masses or webbing. Significant head lag is present when the newborn is pulled from a supine to a sitting position. Newborns can hold up their heads slightly when placed on their abdomens. Clavicles should be intact though occasionally there may be a clavicle fracture during a difficult delivery. Signs of a fractured clavicle include a lump along one clavicle accompanied by crepitus (a popping sensation) at the site. An asymmetrical Moro reflex is another indicator. The anteroposterior and lateral diameters of the chest should be equal making the chest appear barrel-shaped. the xiphoid process is prominent. Chest movements should be equal bilaterally and synchronous with the abdomen. Breast enlargement and breast engorgement is normal for both sexes and is temporary/caused by maternal hormones. Assess for supernumerary (accessory) nipples below and medial to the true nipples.

Hepatic Adaptation

The newborn has a hematocrit of about 45% to 65% due to the large amount of red blood cells circulating that are present to make use of all available oxygen in a low oxygen environment. After birth the extra blood cells gradually die and circulate to the liver to be broken down. Bilirubin (yellow colored pigment) is released as the blood cells are broken down. Normally the liver conjugates bilirubin (makes it water-soluble), and then it is excreted in the feces. However the newborn's liver is immature and easily overwhelmed by the large volume of RBCs. When this happens, unconjugated bilirubin, which is fat-soluble, builds up in the blood stream, crossing into the cells and staining them yellow. Hyperbilirubinemia (high levels of unconjugated bilirubin in the blood stream [serum levels of 4 to 6 mg/dL and greater]) can lead to jaundice (yellow staining of the skin) which will first appear on the head and face and then, as the bilirubin levels rise, jaundice will progress to the trunk and then the extremities. In approximately 50% of all term newborns, a condition known as physiologic jaundice occurs. This condition is characterized by jaundice that occurs after the first 24 hours of life, usually 2 to 3 days after birth; bilirubin that peaked on days 3 and 5; and bilirubin levels that do not rise rapidly (no greater than 5mg/dL/day). Jaundice that occurs within the first 24 hours is considered pathologic. However, anytime jaundice is present, document and report it. The liver manufactures clotting factors necessary for normal blood coagulation, but several of the factors require vitamin K in their production. Because the newborn's gut is sterile upon birth and not been introduced and colonized by the bacteria that produce Vitamin K, a newborn is unable to produce vitamin K and in turn the liver cannot produce some clotting factors which can lead to bleeding problems. Because of this, newborns receive vitamin K (AquaMEPHYTON) IM shortly after birth to prevent hemorrhage.

Nose

The newborn's nose is flat and the bridge may appear to be absent. The nostrils should be bilaterally patent as the newborn is an obligate nose breather. Newborns clear obstructions from the nose by sneezing. There should be no nasal flaring, which is a sign of respiratory distress. The sense of smell is present as evidenced by the newborn's turning towards milk and by turning away or blinking at the presence of strong odors. [[To assess for bilateral nostril patency, use your finger to occlude one naris. If the naris on the other side is patent the newborn can breath easily. Repeat test on the other side.]]

Back and Rectum

The newborn's spine is straight and flat. The lumbar and sacral curves do not appear until the infant begins to use his back to sit and stand upright. Feel along the length of the spine, there should be no masses, openings, dimples, or tufts of hair. Any of these findings may be associated with spina bifida (an opening in the spinal column) and should be reported. The anus should be patent. Meconium, the first stool of the newborn, is a thick black tarry substance composed of dead cells, mucus, and bile that collects in the rectum of the fetus. Passage of meconium should occur within the first 24 to 48 hours and confirms the presence of a patent anus. [[Do not take a rectal temperature in an attempt to make the infant pass the first meconium. A delay in passing the first meconium may indicate Hirschsprung disease or cystic fibrosis.]]

Physical Measurements

The normal weight range for a full-term newborn is between 5lb 8oz and 8lb 13oz (2500-4000g). The average length is 20in wit the range between 19 and 21in (48-53 cm). It is normal for the newborn to lose 5-10% of his or her birth weight in the first few days. For most newborns this equates to a weight loss of 6-10oz and the cause is the loss of excess fluid combined with a low fluid intake during the first few days of life. The newborn will regain this weight during the seven to ten days, after which he or she begins to gain approximately 2lb every month until 6 months of age. Head and chest circumference are two additional important measurements in a newborn. Obtain the frontal-occipital circumference (FOC) by placing a paper tape measure around the widest circumference of the head (i.e. from the occipital prominence around to just above the eyebrows). To measure chest circumference, place the infant on his or her back with the tape measure under the lower edge of the scapulae posteriorly, and then bring the tape forward over the nipple line. The average head circumference is 13-14in (33-35.5cm) while the chest is usually 12-13in (30.5-33cm).

Ears

The pinna should be flexible with quick recoil, indicating the presence of cartilage. the top of the pinna should be even with or above an imaginary horizontal line drawn from the inner to outer canthus of the eye and continuing past the ear. Low-set ears are associated with congenital defects, including those that cause cognitive impairment and internal organ defects. There are two main ways to test a newborn's hearing: evoked otoacoustic emissions and auditory brainstem response. Both methods are noninvasive, take less than five minutes, and are easy to perform. It is important that the nursery nurse ensures the newborn receives a hearing test before discharge.

Involution

The process by which the uterus, cervix, and vagina return to the non-pregnant size and function.

Vital Signs

The temperature is can be elevated during the first 24 hours due to exertion and dehydration from labor. After the first 24 hours, a temperature of 100.4F or greater is abnormal and may indicate infection. The blood pressure should remain at the woman's baseline level as an elevated blood pressure could be a sign of developing preeclampsia and should be promptly reported. A falling blood pressure, particularly in the presence of a rising pulse, is suggestive of hemorrhage. Assess the woman carefully for a source of blood loss if her blood pressure drops. It is normal for the pulse to be slow in the first week after delivery. The heart rate may be as low as 50 beats per minute. Occasionally the woman may experience tachycardia. This is more likely to occur after a difficult labor and delivery, or it may indicate excessive blood loss.

Extremities

The term newborn maintains a posture of flexion. He or she has good muscle tone, and his extremities return quickly to an attitude of flexion after they are extended. They are short in relation to the body without deformities. Full range of motion is present in all joints and movements are equal and bilateral. A full complement of fingers and toes should be present without webbing between the digits and without extra digits. Syndactyly refers to fusion or webbing of the toes or fingers, while polydactyly is the medical term for extra digits. The palms of the hands should have creases. A single straight palmar crease, a simian crease, is a finding that is associated with Down's syndrome. Brachial pulses should be present and equal. The legs are bowed and the feet flat due to fatty pads in the arch of each foot. Creases should cover at least two thirds of the bottom of the feet. The femoral pulses should be equal and strong bilaterally. A strong brachial pulse with a weak femoral pulse is abnormal and should be reported. When testing to elicit the ortolani maneuver, you are looking to hear for a clicking or clunking sound which is a positive sign for a dislocated hip. If you find a positive Barlow sign (feel the head of the femur slip out of the acetabulum) that means the joint is unstable and could be a sign of subluxation (partial dislocation). Other signs of a dislocated hip include uneven gluteal folds or one knee that is lower than the other when the newborn is supine with both knees flexed. The feet may appear inward because of the way the fetus was positioned in the womb or birth canal. If the feet are easily reducible, that is they can be easily moved to a normal position, the "deformity" is positional and will resolve spontaneously. If they do not move to a normal position, true clubfoot may be present. A specialist should evaluate this condition.

Vagina and Perineum

The vagina may have small tears that will heal without intervention. Immediately after delivery, the walls of the vagina are smooth. Rugae begin to return to the vaginal walls after approximately three weeks. The diameter of the introitus gradually becomes smaller by contraction, but rarely returns to pre-pregnant size. Muscle tone in the perineum never fully returns to the pregravid state; however kegel exercises may help increase the tone and enhance sexual enjoyment. Because breast-feeding suppresses ovulation, estrogen levels remain lower in the lactating woman, which can lead to vaginal dryness and dyspareunia (painful intercourse). The labia and perineum may be edematous after delivery and may appear bruised, particularly after a difficult delivery. If an episiotomy was done or perineal tears repaired, absorbable stitches will be in place. The edges of the episiotomy or repair should be approximated (intact). the episiotomy takes several weeks to heal fully. The labia tend to be flaccid after child birth

Thermoregulatory Adaptation

Thermoregulation is the process by which the body balances heat production with heat loss to maintain adequate body temperature. The newborn has difficulty performing this vital function because it is one prone to heat loss due to the amount of heat producing tissue such as muscle and adipose tissue being smaller in relation to the amount of skin exposed to the environment. The newborn is also not readily able to produce heat by muscle movement and shivering. These factors make the newborn vulnerable to cold stress (exposure to temperatures cooler than normal body temperature) so that the newborn must use energy to maintain heat. The four main ways the newborn loses heat are conduction, convection, evaporation, and radiation. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing the body heat to transfer to the colder object. Heat loss by convection occurs when air currents blow over the newborn's body. Evaporative heat loss happens when the newborn's skin is wet. (works in the same way as sweat for adults) Heat loss also occurs through radiation to a cold object that is close but not touching the newborn, such as if the baby is close to a cold windowpane but not touching it and their body heat moves towards it. The newborn naturally assumes a flexed fetal position that conserves body heat by reducing the amount of skin exposed and conserving core heat. The newborn can also produce heat by burning brown fat (a specialized form of heat-producing tissue found only in fetus and newborns). Deposits are located at the nape of the neck, in the armpits, between the shoulder blades, and along the abdominal aorta, and around the kidneys and sternum. Unfortunately brown fat is not renewable and once it is gone the newborn cannot use the form of heat production. Brown fat also maintains blood glucose levels in the first few days of life. [[It takes oxygen to produce heat. If the newborn becomes cold stressed he or she will eventually develop respiratory distress. This is why it is important to protect newborns from heat loss.]]

Abdomen

Typically dome-shaped and protuberant. Respirations are typically diaphragmatic, which make them appear abdominal in nature. Peristaltic waves should not be visible. Bowel sounds should be audible within two hours after birth. The abdomen should be soft to palpation without palpable masses. A normal umbilical cord is well formed and has three vessels. The base of the cord should be without redness or drainage, and the umbilical clamp should be fastened securely.

Uterus

Uterine contraction and involution: Immediately after the placenta delivers, the uterus contracts inward, a process that seals off the open blood vessels at the former site of the placenta. If the uterus does not contract effectively, the woman will hemorrhage. Gradually, the decidua sloughs off, new endometrial tissue forms, and the placental area heals without leaving fibrous scar tissue. Uterine contraction also leads to uterine involution, which normally occurs at a predictable rate. It is measured by measuring the fundal height. Immediately after delivery the fundus is firm and located at the midline halfway between the umbilicus and symphysis pubis. One hour after deliver, the uterus should contrat firmly with the fundus midline at level of the umbilicus. Each day after delivery the fundus should recede 1 cm towards the pelvis and by the 10th to 14th day should not be palpable. Breastfeeding stimulates oxytocin release from the woman's posterior pituitary gland which stimulates the uterus to contract, or Pitocin (Synthetic oxytocin) given via IV or IM route can help the uterus contract. Early ambulation and nourishment also assist with normal involution. Factors that delay or inhibit uterine involution include a full bladder (pushes upward on the uterus and displacing it from the midline), any condition that over distends the uterus during pregnancy can lead to ineffective uterine contraction after delivery (multifetal pregnancy, hydramnios, maternal exhaustion, excessive analgesia, and oxytocin used during labor and delivery), and other factors that can hinder effective contraction of the uterus include retained placental fragments, infection, and grand multiparity (five or more pregnancies). When the uterus does not contract effectively, blood clots collect in the uterus, which makes it even more difficult for the uterus to contract. This leads to a boggy uterus and hemorrhage if the condition is not corrected. A boggy uterus feels soft and spongy, rather than firm and well contracted. Afterpains: After a multipara delivers, the uterus contracts and relaxes at intervals, which leads to afterpains which can be quite severe. For the primipara, the uterus normally remains contracted and the after pains are less severe than the multipara. However, because breast-feeding releases oxytocin, it can increase the duration and intensity of afterpains for both primipara and multipara women. Lochia: The uterus must shed its lining that helped nourish the pregnancy. Blood mucus, tissue, and white blood cells compose the uterine discharge known as lochia during the postpartum period. Lochia progresses through three stages. Lochia rubra - Occurs during the first three to four days; is of small to moderate amount; is composed mostly of blood; is dark red in color; has a fleshy odor. Lochia serosa - Occurs during days 4 to 10; decreases to a small amount; takes on a brownish or pinkish color Lochia alba - Occurs after day 10; becomes white or pale yellow because the bleeding has stopped, and the discharge is now composed mostly of white blood cells. Lochia can persist for the entire six weeks after delivery but usually subsides by the end of the second or third week. It should never contain large clots. Other abnormal findings are reversal of the pattern, Lochia that fails to decrease in amount or increases versus gradually decreasing, or a malodorous (bad smelling) lochia. [[Normal lochia has a fleshy, but not offensive, odor. If the lochia is malodorous or smells rotten, suspect infection. Report this immediately to the RN or physician.]]

Physiological Adaptation

While a fetus is fully dependant on the mother for all vital needs including oxygen, nutrients, and waste removal, at birth the body systems must immediately undergo tremendous changes so that the newborn can exist outside the womb.

Newborn Stabilization and Transition

While the LPN is not responsible for complete resuscitation; they must be able to initiate resuscitation and assist throughout the process. The first 6 to 12 hours after birth are a critical transition period for the newborn. During this period you must be alert to early signs of distress and be ready to intervene quickly to prevent complications and poor outcomes. Assessments are discussed in the previous chapter.

Preventing Infection

Within the first hour after birth, an antibiotic must be placed in the newborn's eyes to prevent ophthalmia neonatorum (a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia). There are three ophthalmic agents approved for eye prophylaxis: 1% silver nitrate, 0.5% erythromycin, and 1% tetracycline. Silver nitrate is used infrequently because it is irritating to the eyes. While some facilities may instill eye prophylaxis in the delivery area immediately after birth, it is recommended that the instillation be delayed up to one hour to allow the newborn and parents to bond while the infant is in a quiet alert state. Another possible infection site is the umbilical cord stump. Practice careful hand washing and use strict aseptic technique when caring for the cord. Often an antiseptic solution such as triple dye, bacitracin ointment, or providone-iodine is used initially to paint the cord to help prevent the development of infection.