Chapter 28: Fundamentals of Nursing- Care of the Mother and Newborn

Resumption of Sexual Intercourse

-Can reassume safely when: bleeding stops, episiotomy healed, mom assessed (perineum/cervix exam) for readiness @ 6 wks; vagina doesn't lubricate well 6 wks- 6 mo -Sexual stimulation response slower first 3 mo after birth, less intense, strength of orgasm reduced -Water-soluble gel, cocoa butter, or contraceptive cream used for lubrication; if vaginal tenderness present, have partner relax area w/ 1-2 fingers first, let woman pick position, side-to-side/woman on top may be most comfortable -Sexual response cycle may be disrupted by presence of baby, worrying about noises heard or noises made; may level parents frustrated/unsatisfied, childcare also leads to fatigue -Some women experience sexual stimulation/orgasm while breastfeeding -Teach women to perform Kegel exercises to help voiding control and improved sexual vaginal feeling during intercourse

Urinary System Changes

-Decreased urge to void -Pelvic soreness/edema + trauma of delivery reduce/alter voiding reflex -Woman may bleed excessively if bladder becomes distended, pushes uterus up and to side/prevents uterus from firmly contracting -Over-distention makes bladder more susceptible to infection/delay normal voiding -Usually restored in 5-7 days after childbirth -Output up to 3 L common

Neurologic Changes

-Edema eliminated via diuresis, relieves carpal tunnel syndrome by easing compression of medial nerve -Periodic numbness/tingling of fingers affects 5% of women, usually gone after birth unless lifting/carrying baby -Headache needs careful assessment; may be caused by: gestational HTN, stress, leakage of CSF into extradural space during needle placement of epidural/spinal anesthesia; can last 1-3 days to several weeks

Hygiene

-Excessive sweating normal postpartum, lochia has musty odor but should NOT smell foul -Encourage regular bathing; heat of shower may cause vertigo via vascular shifts few hours after birth, can lead to syncope/injury; 1st shower after should know emergency call signal, length of shower time, chair in shower room -Baths not recommended at least first 6 wks to avoid contamination -Sitz baths recommended for healing/comfort, reduce edema, speeds tissue repair -Assess C-section incisions like any surgical incision; no edema, little exudate, no odor; dressing over it day of surgery, off next day to open air -Staples removed in approx 3 days, adhesive strips applied after, remains on next 5-7 days -Wounds w/ adhesive strips must be protected from direct flow of water during shower

Postpartum Maternal Danger Signs

-Fever with or w/o chills -Malodorous vaginal discharge -Excessisve amount of vaginal discharge -Bright red vaginal bleeding after it has changed to pink or rust -Edema; erythematous or painful area on the legs -Pain or burning sensation with urination or an inability to void -Breast changes such as localized pain, heat, edema, or malodorous drainage -Pain in the perineal or pelvic area

Transfer from Recovery Area

-In traditional setting, woman is moved to postpartum room after recovery -In labor, delivery, recovery, and postpartum (LDRP) setting, woman and infant remain together in room where birth occurred -In some settings, mother/baby stay together, in others baby goes to nursery -Any transfer requires a transfer report, accurate/important info given to nurse accepting pt; include admission, birth, and recovery record -Nurse should know: PCP name, G/P status, age, anesthesia info, meds given, oxytocin induce or augmentation, immunity stat, duration of labor/time of ruptured membranes, type of birth/repair done, blood type, Rh status, IV fluids used, mental status before AND after birth, method of feeding, fetus age/gender, etc. -Most info can be found w/ staff in nursery; find out baby's Apgar score, weight, feeding,voiding and interventions performed (Vit K injection)

Parent-Newborn Relationships

-Include: mom's reaction to sight of newborn, some are excited, laughing, talking, crying, some are apathetic; Look out for: anger/indifference, turning away from baby, thinking of only her pain/needs; regardless of reaction, provide support and consider circumstances such as maternal stage of growth/development and age (teen mothers less mature), unwanted pregnancy, may lead to impaired bonding -Document bonding concerns, note behaviors, verbal and nonverbal; also consider cultural differences w/ birth for behaviors -Chinese families have extended family care for newborn so mom can rest, some cultures don't breastfeed until milk comes in, eye contact varies, etc.

Nursing Assessment of and Interventions for Mother

-Insurance companies began shrinking hospital stay durations via childbirth (vaginal or C-section) in 1990s, legislation placed to restrict from discharging less than 48 hrs after vaginal birth, 96 hrs after C-section; moms can leave voluntarily before if well enough -64% women after vaginal birth have 2-3 day hospital stay, uncomplicated birth can do 24 hrs or less; C-section hospital stay 2-4 days -Assess mental/physical ability to care for infant before discharge; consult w/ social worker if concerned -Emphasize importance of follow up, infant care, family planning

Cultural Considerations- Postpartum Period

-Many cultures have postpartum ritual w/ mom and baby; including Chinese, Mexican, Korean, and Southeast Asian, may have bathing/activity/dietary restrictions designed to restore hot-cold (yin-yang) balance: -Mom may have long period of seclusion/rest w/ avoidance of activity, household chores/newborn care provided by other females in family from 2 wks to 40 days -Avoid cold/maintain increased body heat; avoid bathing, hair washing, exercise, exposure to win 7-30 days after -Avoid cold/raw foods/water, eat only warm foods, drink only hot beverages to replace blood lost/rest balance of hot and cold in body -May wear abdominal binder, may prefer not to give baby colostrum (some cultures think it's bad for baby), may not breast feed until milk comes in -Low-income mom may need content w/ stressors that distract from relationship w/ baby; inability to pay for child's needs, chaotic home life, worry over eligibility for medical/social services depletes mom's energy -Arabic women may eat special meals designed to restore energy; expected to stay home for 40 after birth to avoid illness from exposure to outside air -Haitian women may request to take placenta home to burn or bury

Assessment of Attachment Behaviors

-Observe bonding behaviors such as calling name or reaching for baby, consider culture however (some don't name baby right away) -Do parents look for physical traits or note special characteristics? -Do parents seem comfortable holding baby? Do they avoid touching some parts or study them? -Do they talk to the child when awake or provide stimulation through talking to them, visual contact, or do they look away at other things? -Do they seem okay caring for baby? Do they seem concerned/unwilling to change diapers? -Are they affectionate towards baby and do they comfort the baby when they're fussy?

Promoting Parenting Skills

-Parents respond to praise of baby, reassure cyanosis temporary and color will improve -Review molding of baby's head, relay info to future parent-child contacts, encourage siblings to meet/bond with new family member -Educate new parents on baby's needs, reassure them, nurses are role model for care as parents observe care given during exam

Postpartum danger signs for Parent-Newborn Relationships

-Passive reaction, verbal or nonverbal -Hostile reaction, verbal or nonverbal (disparaging remarks about child) -Disappointment of gender -Lack of eye contact (consider culture) -Nonsupportive interaction between parents, talk to MD/nurse present for delivery if concerned for further info

Breasts

-^ estrogen stimulates breast enlargement, ^ adipose tissue and fluid retention, stimulates growth of milk ducts for lactation -1st secretion is colostrum, precursor of breast milk; thin, watery, slightly yellow, rich in proteins, calories, antibodies, lymphocytes; begins in 2nd trimester then later weeks of 3rd till 2 days after delivery then true milk produces -Lactation combo of hormonal, neurologic, psychological responses; estrogen/progesterone levels diminish after delivery, prolactin increases -Prolactin responsible for stimulating milk production in mammary alveolar cells; stimulating nipples, esp from infant, causes a release of oxytocin, stimulates contraction of mammary glands, milk ejected from breast (let-down refex)

Advantages of Breastfeeding

1. Antiinfective properties: immunoglobulins, lymphocytes, other immune components present in milk, protects against infection, bifidus factor encourages growth of normal bacterial flora in GI tract 2. Nutrition: Has protein, carbohydrates, fat ratio thought ideal for growth/development; well digested, easily absorbed 3. Growth & Development: Promotes better tooth/jaw alignment; less likely to produce obesity; optimal bonding between mom and baby 4. Allergy- May reduce rate of allergies in infants at high risk for allergic conditions 5. Maternal benefits- Hormones triggered help shrink uterus; requires no formula prep or bottle sterilization, no purchase needed

Lacerations of the genital tract

A steady trickle of bright red blood from the vagina in the presence of a firm fundus; types of tears include: perineal, vaginal/urethral, and cervical; bleeding can be: slow trickle, oozing, or frank hemorrhage Factors that lead to lacerations: operative birth, precipitous birth, congenital abnormalities of maternal soft parts (vulva perineum), contracted pelvis, size, abnormal presentation, position of fetus, relative size of presenting part to size of birth canal, etc. Injury should be repaired at time of delivery; facilitates healing, limits residual damage, reduces infection rate

Gynecomastia

Abnormal development of breast tissue, may enlarge for females but develop breast tissue in males

Causes of postpartum hemorrhage:

Abruptio placentae, placenta previa and uterine atony (failure of the uterus to contract), lacerations of the genital tract

How long does the body take to return to "normal" after pregnancy?

Approximately 6 weeks

Perineal Lacerations

Are the most common of injuries in the lower genital tract. They usually occur when the fetal head is being born. The extent of the laceration is defined in terms of its depth. 1st-degree: Extends through skin and structures superficial to muscles 2nd-degree: Extends through muscles of perineal body 3rd-degree: Continues through sphincter muscle 4th-degree: Involves anterior rectal wall Assess BM habits of women w/ 3rd or 4th degree lacerations, may need stool softeners, promote fluid intake, encourage more dietary fiber or activity like walking; enemas/suppositories contraindicated

Latch-on

Attachment of the infant to the breast while feeding

What carries out the process of involution?

Autolysis

Cardiovascular Changes

Blood volume reduced to nonpregnant levels by 2-4 wks after delivery; diuresis/diaphoresis results in most fluid loss, blood lost in delivery +300-500 (600-800 for C-section) Cardiac output rapidly declines; @ risk for thrombus formation via elevation of platelets

BUBBLE HE assessment

Breasts- Have pt lie down and remove bra, palpate breasts for engorgement/nodules; inspect nipples for pressure, soreness, cracks, fissures Uterus- Top of uterus (fundus) remains firm, if not may have placental fragments, can lead to hemorrhage, gently massage to help muscles contract Bladder- Polyuria during first few days after delivery, watch for s/s of infection, note dysuria/retention Bowels- Assess for bowel sounds, encourage activity w/ rest periods, and adequate fluid intake Lochia- Fleshy scent, a fetid odor may mean infection Episiotomy- Midline sight of choice, for lateral position patient on affected side, instruct to flex top leg at knee and draw it up toward waist; use penlight, wear gloves, gently lift top buttock to expose area, assess for hemorrhoids Homan's Sign- Position legs flat on bed w/ she's in supine position; dorsiflex the foot toward ankle, once on each leg; if she reports calf pain, must assess for blood clot in leg Emotional Status- Consider 3 new mom phases 1. "Taking in", often sleeps, relives events surrounding birth 2. "Taking hold", preoccupied w/ present, concerned for herself and baby's condition, want to learn to care for baby 3. "Letting go", later in postpartum period, reestablishes relationships w/ others

Fontanelles

Broad area or soft spot consisting of a strong bond of connective tissue between an infant's cranial bones

Interventions for Episiotomy, Lacerations, & Hemorrhoids

Cleanse -Wash hands before/after cleaning perineum/changing pads, apply pad front to back to avoid contamination -Wash area w/ milk soap/warm water minimum once daily from symphysis pubis to anal area -Wrap soiled pad, place in covered container -Change pad w/ each voiding/defecation or min 4x daily; assess amount/character of lochia w/ pad change Ice -Use covered ice pack from front to back first 2 hrs after birth, decreases edema formation, increases comfort; after first 2 hrs, provide anesthetic effect Squeeze Bottle -Demonstrate use, assist women, explain rationale -Fill w/ tap water warmed to 100.4, use WHOLE bottle -Teach to place nozzle between legs so squirts of water reach perineum as she sits on toilet -Blot dry w/ TP or clean wipes; avoid contamination, apply clean pads. Sitz Bath Built in: -Clean/scrub thoroughly first, rinse; paid w/ towel before filling -Fill 1/2 to 1/3 w/ water at 100.4-105 temp; add ice if preferred colder -Encourage to do 2x daily for 20 min -Check on them q 15 min assess pulse PRN Disposable: -Clamp tubing/fillbag w/ warm water -Raise toilet seat, place bath in bowl w/ overflow opening directed @ back of toilet -Place container above toiler, attach tube into groove @ front of bath; loosen tube clamp regulate flow rate Dry Heat -Inspect lamps for defects, cover w/ towels, position 50 cm from perineum, use 3x daily for 20 min periods -Provide draping over women, clean between uses -Teach women about use of 40 watt bulb @ home Topical Applications -Apply anesthetic cream/spray; use sparingly 3-4 x daily -Offer witch hazel pads (Tuckes) after voiding/defecating, pat perineum dry from front to back

Newborn Teaching Summary (2/2)

Diaper Care -Change diaper promptly, wash from front to back esp for girls to avoid UTIs -Cleanse w/ warm water/mild soap; dry well -Air dry when able, avoid powder! Contact PCP if rash persists Feeding Methods (Breast/Bottle) Breast -Feed in proper position (body facing breast), feed before baby fussy/upset -Lightly brush infant to start rooting reflex, direct nipple to infant's mouth/tongue, hold breast away from nose for breathing -Break by placing finger between baby and breast, don't pull -If mom had c-section, don't rest baby on abdomen too long -Burp: between breasts, over shoulder, sitting up supported, lying across lap -Feed 10-15 min on each breast, empty both breasts to signal more milk production -Pump breasts when away from baby, keep milk cold during transport, can be in fridge 24-48 hrs; 2 wks in freezer; thaw in warm tap water, use ASAP, don't refreeze, do NOT heat in microwave -Occasional bottle feeding not bad, won't affect lactation/breastfeeding -Stool should be loose, may have some w/ each meal Bottle -Never prop bottle, hold so fluid fills nipple, no air enters nipple -Avoid overheating, be alert to baby's cues (asleep, turns head) -Burp baby q 0.5-1 oz of milk, burp pattern same -Prepare formula w/ cleanliness, boil water for 15 min if supply questionable -Give formula @ room temp, test temp on inner wrist -Opened container of ready-to-feed should be discarded 24 hrs after open date -Position baby on R side after feeding Clothing -Dress baby right for season in soft, comfy clothes, similar to your clothes Vaginal/Breast Secretions -Baby girl may have mucus-like bloody vaginal discharge; boys or girls may have swelling of breast tissue Bulb Syringe -Squeeze out air to establish suction, compress bulb and hold it in -Gently insert tip into side of infant's mouth, release, suction nares; clean well after each use Infant CPR -Show video to educate -Fingertip compressions (5 to 1), puffs for breaths (1 to 5), cover baby's nose w/ cheek as you cover mouth -Careful stretching head back too far w/ head/chin tilt Phenylketonuria, Biotinidase, & Thyroid Testing -Performed on all newborns -Undetected issues can lead to brain damage or death, preventable w/ early detection and proper treatment After Discharge -Keep, read, refer to pamphlets w/ questions -Use meds only prescribed by MD When to Call MD -If baby has fever, rash, excessive vomiting, diarrhea, distended abdomen, bleeding from circumcision, call -Normal temp 97.6-99 taken via axillary route, recommended up to 6 yo

Lochia

Discharge from the vagina of mucus, blood, and tissue debris following childbirth; may last 2-4 months after childbirth Lochia Rubra- Bright red drainage mostly blood day 1-2 after childbirth Lochia Serosa- Pink to brown discharge that thins as placental site heals, days 3-6 Lochia Alba- Starts around 7th day, drainage slightly yellow to white, continues for +10-14 days

Pseudomenstruation

Discharge of blood-tinged mucus from the vagina of the newborn, which occurs in response to maternal hormones

Lanugo

Downy, fine hair characteristic of the fetus between 20 weeks of gestation and birth that is most noticeable over the shoulder, forehead, and cheeks but is found on nearly all parts of the body except the palms of the hands, soles of the feet, and the scalp

How does the placental site heal?

Exfoliation (necrotic tissue sloughed from the uterine lining, leaving a fresh layer of endometrial tissue free from scars, necessary for future pregnancies)

Meconium

First bowel movement of a newborn. It is greenish-black in color and consists of mucus and bile

Lactation

Function of secreting milk or period during which milk is secreted

Postpartum Maternal Teaching Summary

Fundus (Height, Massage) -Height shrinks 1 fingerbreadth/day, back into pelvis by day 10; feels firm like a softball, report bogginess to PCP ASAP; Cramping common w/ nursing Lochia -Day 2-3, dark red color like menstrual flow, after pinkish brown -Moderate flow consists of 4-8 lightly saturated pads/day; flow lasts 3-4 wks; flow is yellowish color w/ musty odor last few weeks -Report foul-smelling/bright red discharge or large clots; flow may ^ w/ activity, rest, contact MD if not slowed Perineum Care (Episiotomy) -Sitz bath 2-3x/day w/ vaginal delivery -Cleanse front to back, use spray water bottle after voiding -Change pad often, after each voiding/when soiled -Do NOT douche/use tampons until PCP says okay -Use witch hazel (Tucks pads) for discomfort/healing -Episiotomy heals in approx 3 wks (lochia stops) Breasts Feeding -Wear supportive bra, air dry, ease infant off nipple in right way -Use B/C while nursing, can get pregnant -Apply heat to engorgement, warm shower -Educate proper feeding techniques, where to buy formula/supplies, express milk, freeze up to 2 wks -Can take mild analgesic 1 hr prior to nursing Dry -Supportive, well-fitting bra -Avoid breast stimulation, apply ice 20 min 4x/day -Suppression of lactation about 5 days, no excessive fluids Nutrition -Finish prenatal vitamins, nursing diet 500+ cal than pre-pregnancy, 400 mg Ca/Day, 8-10 glasses of fluid, avoid onions, cabbage, chocolate, spices, foods that can distress infant (Do not diet during) Sexuality -45% non-nursing moms resume menses by 6th wk -Can get pregnant while breastfeeding -Avoid sexual activity until 1st post-delivery appt w/ PCP -Resuming sex when episiotomy not fully healed can cause ^ discomfort and possible infection Exercise -^ lochia/pain means reevaluate activity, do not resume until PCP approves; gradually increase when resuming Emotions (Bonding, Baby blues) -Schedule time to bond, enjoy feeding, cuddle and use eye contact -PPD, usually within 4 wks, can last months; mom may be tearful, anorexic or have difficulty sleeping -Hormonal factors/fatigue responsible for moods -Notify PCP if PPD lasts more than few months C-Section (Incision, Activity) -Notify PCP of any redness, drainage, separation of incision, temp > 100.4 -Do not lift anything heavier than baby, gradually increase weight -Take pain meds PRN Report to PCP/Caregiver -Temp > 100.4, chills, change in lochia (foul odor, return to bright red type), calf pain/tenderness/swelling, evidence of mastitis: breast tenderness, cracking, redness, feeling of discomfort/unease, urinary urgency/burning/frequency, and severe/incapacitating depression Safety (Carseat Safety, Demo) -Review safety info from discharge sheet, review video if able -Volunteers have car seats to rent, demo proper use/install

GI & ENDO Changes

GI: -Appetite returns -Gastric motility may decline, may lead to constipation -Normal BM should happen 2-3 days after delivery -Decreased abdominal tone/tenderness/hemorrhoids may make pt reluctant to strain for BM ENDO: -Hormones drop to nonpregnancy values -Estrogen/progesterone drop @ expulsion of placenta, lowest level 1 wk after delivery -Estrogen levels in nonlactating women rise by 2 wks, higher by day 17 -Anterior pituitary gland secretes prolactin ONLY w/ nipple stimulation, other glands return to pre-pregnancy size/function

What else does mother's milk contain?

Growth factors, digestive enzymes, proteins that foster maturation process

Harlequin Sign

Harmless color change in a newborn in which the dependent side of the body is a deep color while the other side is pale results from a vasomotor disturbance; may last up to 20 min but is not harmful

Standard Labs for Full-Term Infant

Hematocrit- 14-24 g/dL Glucose- 40-60 mg/dL Billirubin, direct 0-1 mg/dL Hemoglobin- 14-24 g/dL

Dance or Stepping Reflex

If infant is held so that sole of foot touches a hard surface, there will be a reciprocal flexion and extension of the leg, stimulating walking.

Signs of Potential Psychosocial Problems

Inability or refusal to discuss labor and birth experience. Refusal to interact with or care for baby (Ex: does not name baby, does not want to hold or feed baby). Refusal to attend infant care (including breastfeeding) classes. Refusal to discuss contraception. References to self as ugly and useless. excessive preoccupation with self (Body image). Marked depression. Lack of support. Partner or family member acting negatively to baby. Expression of disappointment over babies sex. View of baby as messy or unattractive. Baby reminding mother of family member or friend she does not like.

Diuresis

Increased formation and secretion of urine

Parent-child Attachment (Bonding)

Initial phase in a relationship characterized by strong attraction and a desire to interact

Lochia and Nonlochia Bleeding

Lochia- Trickles from vaginal opening, steady flow greater as uterus contracts; may result when uterus massaged (if color dark, pooling in relaxed vagina, amount lessens to trickle of bright red) Non-Lochia- Blood discharge from vagina, cervical/vaginal tears in addition to lochia; if amount continues to be excessive/bright red, tear may be source

Muscoskeletal, Integumentary, & Immune Changes

MUSCO: -Abdominal muscle tone return/joint stabilization occurs over 6-8 wk period post delivery (depends on prev muscle, exercise routine, % of adipose tissue -May feel joint discomfort post delivery via secretion of relaxin -Most body parts return to size but feet do not, mom has new increase in shoe size SKIN: -Chloasma usually gone @ pregnancy end, darkened nipples and linea nigra line may not disappear after, some permanent; same applies to stretch marks (striae gravidarum) -Vascular abnormalities (spider angiomas (nevi), palmar erythema, epulis regress when estrogen declines @ pregnancy end -Abundance of fine hair usually gone after birth, course/bristly hair usually remains, fingernails return to normal -Profuse sweating common after birth, esp @ night, during 1st wk after (most noticed change) IMMUNE: -Determine if mom needs rubella vaccine or Rh (D) immune globulin (RhoGAM), immunize before discharge; if moms not sensitized and give birth to Rh positive infants, must receive RhoGAM within 72 hrs of delivery

Syndactyly

Malformation of digits, commonly seen as webbing or fusion of two or more digits to form one structure

Polydactyly

Malformation of extra digits

Where is the fundus located after delivery?

Midway between umbilicus at midline gradually descends 24-48 hrs following delivery moves approximately 1 fingerbreadth per day

Common Skin Observations in Newborn

Milia- small, white spots usually on nose/chin; result of occluded sebaceous glands, disappear within a few weeks Newborn rash (erythema toxicum neonatum)- elevated, hivelike rash may result in small, white vesicles; not contagious, disappears w/o treatment Telangiectatic Nevi (Stork bites)- Flat pink/red marks often on eyelids, nose, nape of neck; dilated capillaries becomes more vivid when baby cries; not significant, gone by 1-2 yo Mongolian spots- Most common on lumbar dorsal area, appears bluish black, more often seen in dark-skinned babies Nevus Flammeus- Port-wine stain, reddish purple discoloration often seen on face; capillary angioma below epidermis; does not disappear spontaneously, medical techniques available Stawberry birthmarks- Shrink spontaneously and disappear in early childhood

The Newborns' and Mothers' Health Protection Act of 1996

Minimal federal standards for health plan coverage for moms and newborns; allows mom and newborn to stay in hospital minimum of 48 hr after vaginal birth, 96 hr after C-section birth unless attending MD w/ consult of mother, decides on early discharge

Cervical Injuries

Occur when the cervix retracts over the advancing fetal head. These lacerations occur at the lateral angles of the external os; most are shallow, and bleeding is minimal. Larger lacerations extend to the vaginal vault or beyond the vault into the lower uterine segment; serious bleeding may occur. Extensive damage can occur if allowed to push before full cervical dilation achieved, can affect future pregnancies/childbirth

Vaginal and Urethral Lacerations

Often occur in conjunction with perineal lacerations. They tend to extend up the lateral walls (sulci) and, if deep enough, involve the levator ani muscle near ischial spines May be circular, may result from forceps rotation, esp w/ cephalopelvic disproportion, rapid fetal descent, precipitous birth; can occur around urethra and in area of clitoris

After birth of the baby and delivery of the placenta, what does the uterus contract in response to?

Oxytocin, stimulated by posterior pituitary gland, stimulates uterine contractions/release of milk in mammary glands (let-down reflex)

Grasp (Palmar and Plantar) Reflex

Palmar: Occurs when the palm is stroked. The fingers close firmly around the object Plantar: Place fingers at base of toes, toes curl downward

Diaphoresis

Profuse sweating

Pull to Sit (Traction) Reflex

Pull infant up by the wrist from supine position with head in midline. Head lags until infant is in upright position, then head is held in the same place with chest and shoulder momentarily before falling forward; infant will attempt to right head.

Elimination- Recovery & Later Stages

Recovery -Diuresis/diaphoresis common after delivery; if woman received fluids, output may increase -Support bladder above symphysis pubis, palpate it to check fullness, encourage voiding full bladder interferes w/ complete contraction -Initial voiding within 4-6 hrs; tissue edema may cause difficulty (reduced sensitivity, may not know bladder is full) -Some have policy of 3x in 300 mL or more amount after delivery, may need catheter if consistently less, foley cath if repetition needed -Indwelling inserted before c-section, may remain in place 1-2 days after delivery Later -Less strong urgency when bladder full, soreness makes mom reluctant to void -Encourage regular voiding q 2-4 hrs; retention if voiding less than 100 mL -Assessment should include urgency, frequency, dysuria; incomplete emptying can lead to UTIs -Cleanse are gently, pat dry front to back; peri bottle maybe used after each urination/bm -Promote increased fluid/fiber intake and activity to prevent ^ constipation -Occasional enemas used, contraindicated in women w/ 3rd and 4th degree lacerations -C-section esp w/ general anesthesia likely to develop issues w/ bowel function -Encourage pt to ambulate periodically throughout day -Pads should be changed after each void/bm, place front to back and secure to keep area clean, decrease chance of infection; stress cleanliness

Diet/Metabolic Issues- Recovery & Later Stages

Recovery -Mom often hungry after delivery, no diet after vaginal birth, limit oral intake to ice/liquids 1st day after C-section -Fluids CRUCIAL to replace any fluid loss in delivery, offer variety; administer IV promptly if ordered -If anesthetic used, verify bowel sounds before food -Perform oral hygiene if mom's mucous membranes/lips dry from breathing techniques, give complete sponge bath or shower w/ assist to enhance well-being Later Stage -Diet can't deprive necessary nutrition, mom should return (almost) to prepregnant weight in 6-8 wks w/o dietary restrictions -Body still needs extra calories if breastfeeding (300-500+ kcal/day of normal, fluid intake 2-3 L/day

Activity and Energy- Recovery & Later Stages

Recovery -Monitor VS q 15 min 1st hr, then q 1 hr next 4 hrs -Make sure mom comfortable, mom should need to remain in bed to allow body to adjust to fluid volume changes -Early ambulation key in preventing complications -Consider baseline B/P, amount of blood lost, type/amount of anesthesia, pain level, mom may need help ambulating -Slow position changes needed to prevent orthostatic hypertension, mom may be faint/lightheaded; teach mom to use call light for assist; assess pulse, color, LOC -Assist to bathroom, check on her during use, have wheelchair outside in case she's too weak to walk back -Keep mom on conduction anesthesia (epidural block) until she can fully move, feels sensation in legs, has B/P and pulse within limits; assess speaking, LOC, vitals, wear slippers when walking to avoid slipping -Temp may ^ first 24 hrs after birth if dehydrated, after may indicate infection

Involution

Return of the uterus to a non-pregnant state after birth, decreasing in size and no longer palpable

Hypovolemic Shock

S/S: -Women persistent bleeding (soaks pad in 15 min); may/may not accompany change in VS or color/behavior -Woman feels weak, lightheaded, "funny" or "sick to stomach" -Becomes anxious, exhibits "air hunger" -Skin turns ashen/grayish, cool/clammy to touch -Pulse ^, B/P goes down Interventions -Notify MD ASAP -If uterus atonic, massage gently/expel clots to make uterine contract, compress manually if needed, add oxytocic agent to IV drip -Give 02 via face mask/nasal prongs at 8-10 L/min -Tilt on her side or elevate right hip, elevate legs to at least 30 degree angle -Provide/maintain IV infusing of Lactated Ringer's solution or normal saline to restore circulatory volume -Administer blood/blood products as ordered -Administer ER meds as ordered -Prepare for possible sx procedure or ER treatment -Chart incident, medical/nursing interventions done, results

Prolactin (PRL)

Secreted by the anterior lobe of the pituitary gland; promotes milk secretion

Newborn Teaching Summary (1/2)

Security -Know caregiver, check references -Asks others who they trust to babysit -DO NOT leave baby alone on flat surface, could roll over/fall off -Do not place on abdomen, lay on side or back to prevent SIDS -Carseat (use until 4 yo or 40 lb); seat in back, facing rear of car; can be fined w/o one Bath Demo/Skin Conditions -Skin should be pinkish, soft, dry, use hypoallergenic soap when bathing q other day -Clean perineum front to back to prevent UTIs, keep diaper area clean as possible (NO TALC POWDER) -Keep head clean, rinse well after each shampoo to prevent cradle cap Umbilical Cord Care -Use alcohol on cord stump daily, don't let drip to perineal area; report redness, drainage -Keep area dry, fold diaper down w/ plastic side outside; sponge bath 7-10 days or until cord falls off (10-14 days) Circumcision Care -If Gomco/Mogen clamp used, apply petroleum-jelly covered gauze after q diaper change, keep area clean/dry, wash q 4 hr w/ warm water -If Plastibell used, plastic remains in place 1 wk while healing, will fall off, no gauze needed -Avoid pressure, apply diaper loosely; yellowish-crust normal do not remove, fanfold diaper Eye care -Wash w/ water inner to outer eye, use different part of towel on each eye -Swelling/redness of eyes via special treatment @ birth normal, no alarm

Well Baby Follow-Up Care

Seen by MD @ 3-5 days after discharge, 2 wks old, and q 2-3 mo until 18 mo old Milestone visits @ 2 yrs, 3 yrs then q 2 yrs

Epstein's Pearls

Small,white epithelial cysts on baby's gums

Transition to Fatherhood: A Three-Stage Process

Stage 1: Expectations- preconceptions about life w/ baby Stage 2: Reality-Expectations not always met, commonly feels sadness, jealousy, frustration; overwhelming desire to be more involved, some pleasantly surprised at ease/fun of parenting Stage 3: Transition to mastery- Conscious decision to take control, become more actively involved w/ baby

What is the cause of autolysis?

Sudden withdrawal of estrogen and progesterone, releasing poteolytic enzymes into endometrium; cells lose protein material and shrink

Newborn Vital Signs

Temperature: Axillary, 97.6 ° to 98.6 ° F Apical heart rate: 120 to 160 beats/ min Respirations: 30 to 60 (average 40) breaths/ min Blood pressure: 60-80/40-50 mm Hg

Acrocyanosis

Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming

What is sometimes known as the fourth stage of labor?

The "immediate postpartum periods" lasts up to 6 hrs after delivery, AKA recovery stage

Puerperium

The postpartum period, lasts from delivery of placenta until reproductive organs return to non-pregnancy size and position

Autolysis

The self-dissolution or self-digestion that occurs in tissues or cells by enzymes in cells

Circumcision

The surgical removal of the male foreskin

Engorgement

Uncomfortable fullness of the breasts that occurs when the milk supply initially comes in

Engorgment

Uncomfortable fullness of the breasts when milk supply comes in Consider 3 factors: congestion, increased vascularity, and accumulation of milk Filling of breast begins at axillary region; usually observed around 3rd day, resolves in 48 hrs or up to 1 wk If breastfeeding: manual expression of milk, application of warm, moist heat If not: compress breasts w/ firm bra, wrapped ice packs, analgesics, placement of clean cabbage leaves inside bra

Cryptochidism

Undescended testes; the condition in which the testes do not descend to the scrotum as they should during prenatal development; can happen in preterm birth

Vernix Caseosa

Waxy or "cheesy" white substance found coating the skin of newborn humans

opthalmia neonatorum

a severe eye infection contracted in the birth canal of a woman with gonorrhea or chlamydia

Moro (Startle) Reflex

stimulus: loud noises or sudden movement response: extend arms and legs; throw head and neck back

Babinski's Reflex

the dorsiflexion of the great toe when the heel is stroked (babies have a negative Babinski sign where their toes curl in, this is abnormal for children and adults)

Colostrum

thin, milky fluid secreted by the breast during pregnancy and during the first days after birth before lactation begins; rich in protein, calories, antibodies and lymphocytes

Tonic Neck Reflex

turning the head to one side, extending the arm and leg on that side, and flexing the limbs on the opposite side