Family Development Unit 5

postpartum assessment (urinary)

- 2000 to 3000 mL excessive fluid volume accumulates during pregnancy (extra blood volume) - assess for overdistention: can cause hemorrhage - Diuresis is normal - normal for patient to void at least 1500 mL per day from day 2 to 5 after deliver (diaphoreses is also normal)

return of menstrual flow

- A woman who is not breastfeeding can expect her menstrual flow to return in 6 to 10 weeks after birth - if she is breastfeeding, a menstrual flow may not return for 3 or 4 months or in some women for the entire lactation period - The absence of a menstrual flow does not guarantee that a woman will not conceive during this time because she may ovulate well before menstruation returns

promote adequate sucking

- Advise mothers to awaken newborns fully before feeding by handling them, stroking their backs, changing their position, rubbing their arms and chest, or changing their diaper - Gently tickling the bottom of a babys feet will also wake a baby effectively - If an infant is not sucking well, a woman can use manual breast expression after a feeding to empty her breasts manually. This helps ensure good milk production for when the infant is ready to suck again

consulting a physician (before taking any medications while breastfeeding)

- Almost any drug may cross into the acinar cells and be secreted in breast milk -The rule a woman followed during pregnancy (she should take no drug unless prescribed or approved by her primary care provider) continues to apply during lactation

supplemental feeding

- Although you want to recommend a woman breastfeed exclusively, in order to leave her child for a short time in the care of a babysitter or another care provider, she can express breast milk manually and leave it in a bottle in the refrigerator for the other person to use. She could also prepare a single bottle of formula for the time she is away - Once breastfeeding has been established, missing one feeding will not affect milk production enough to make a difference at the next feeding

disappointment

- Another common feeling parents or partners may experience is disappointment in the baby INTERVENTIONS - Handle the child warmly to show you find the infant satisfactory or even special - Comment on the child's good points such as long fingers, lovely eyes and healthy appetite - Be aware, that culturally some groups are fearful for the baby if these types of comments are made because they could draw evil influences toward the child

advantages of applying cold and hot therapy

- Applying an ice or cold pack to the perineum during the first 24 hours reduces perineal edema and the possibility of hematoma formation and also reduces pain and promotes healing and comfort - Be certain not to place ice or plastic directly on the womans perineum - use a commercial cold pack, or wrap an ice bag first in a towel or disposable pad, to decrease the change of a thermal burn (risk of injury increases because the perineum has decreased sensation from edema after birth - Ice to the perineum after the first 24 hours is no longer therapeutic because healing increases best if circulation to the area is encouraged by the use of heat - Dry heat in the form of a perineal hot pack or moist heat with a sitz bath are both effective ways to increase circulation to the perineum, provide comfort, reduce edema, and promote healing

homans sign

- Assess for thrombophlebitis by dorsiflexing a womans ankle and asking her if she notices pain in her calf on that motion - Assess also for redness in the calf area because thrombophlebitis can be present even with a negative Homans sign - Continue to assess for adequate peripheral circulation once every 8 hours during the womans stay in a health care facility - If you suspect thrombophlebitis do not massage the area; doing so could cause the thrombophlebitis to become an embolus

care for the umbilical cord

- Be certain that diapers are folded below the level of the umbilical cord, so when the diaper becomes wet, the cord does not become wet also - Remind parents to continue to keep the cord dry until it falls off after they return home - Discourage the use of creams, lotions, and oils near the cor because these tend to slow drying of the cord as well as invite infection - Remind them to use sponge baths rather than immerse the infant in a tub of water - Some health care agencies recommend that parent apply rubbing alcohol to the cord site once or twice a day to hasten drying - Others prefer that the cord be strictly left alone, becasue manipulation of this type could invite infection

breastfeeding

- Begin immediately after birth - colostrum first 2 to 3 days - milk comes in 3rd to 4th day - proper latch to prevent nipple damage - Break suction before removing the breast - Encourage pumping for mother who are separated fro infant (NICU); stimulates supply - Increase nutrition by 500 calories per day Not Breastfeeding - Snug bra (ace wrap) - avoid nipple stimulation - avoid hot water from shower (stimulate let down) - apply cold compresses - Do not pump breast if engorged (not effective) Discharge Education Breast Care - Good support bra, nursing bra if breastfeeding - Use only water (no soap; it is drying) - Lubrication and air dry - Prevention of crack or fissures

advantages of breastfeeding for infants

- Breast milk contains secretory immunoglobulin A, which binds large molecules of foreign proteins, includes viruses and bacteria, thus keeping them from being absorbed form the GI tract - anti infective properties - Contains the ideal electrolyte and mineral composition for human infant growth - High in lactose, an easily digested sugar that provides ready glucose for rapid brain growth - The protein in breast milk is easily digested and the ratio of cysteine to methionine (2 amino acids) in breast milk favors rapid brain growth in the early months - It contains nitrogen in compounds other than protein so an infant can receive cell building materials from sources other than just protein - Contains linoleic acid, an essential fatty acids for skin intergrity, and less sodium, potassium, calcium, and phosphorus than do many formulas - Better balance of trace elements - Breastfed newborns appear to be able to regulate their calcium/phosphorus levels better than infants who are formula fed - May also help prevent excessive weight gain in infants

nutrition

- Commercial infant formulas are designed to stimulate breast milk and so have the same number of calories per ounce as breast milk - They contain about 9% to 12% of their calories as protein and 45% to 55% of calories as lactose carbohydrate - The balance (34% to 46%) is fat, of which linoleic acid accounts for about 4%

infants nutrition

- During feeding, a parent is close to the infant, and a baby is apt to be particularly sensitive to the parents demonstration of affection or lack of warmth - The feeding experience, therefore, enables an emotional bond between infant and caregiver and helps provide an environment that enhance the psychosocial development of the infant as well as aids physical growth

newborn weight

- During the first few days after birth, a newborn loses 5 to 10% of birth weight (6 to 10 oz) - This weight loss occurs because a newborn is no longer under the influence of salt and fluid retaining maternal hormones. This causes diuresis to begin to remove a part of the infants high fluid load: in addition, the newborn voids and passes stool - Breastfed newborns have a limited intake until about the third day of life because of the relatively low caloric content and small amount of colostrum they ingest - Formula fed newborns need time to establish effective sucking. This lack of intake also plays a part in weight loss - After this initial loss of weight a newborn has about 1 day of stable weight, then begins to gain weight - The breastfed baby recaptures birth weight within 10 days - The formula fed baby recaptures birth weight within 7 days - After this all infants begin to gain about 2 lb per month (6 to 8 oz per week) for the first 6 months of life

postpartal blues

- During the postpartal period, as many as 50% of women experience some feelings of overwhelming sadness or "baby blues" - may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta - may see crying, mood changes, anorexia, sleep disturbances - 30% go further into postpartal depression INTERVENTIONS - anticipatory guidance and individualized support from health care personnel are important to help the parents understand that this unexpected response is normal - Give the woman a change to verbalize her feelings and make as many decisions as she wants to help her gain a sense of control and move past this strange postpartal emotion - Encouraging women to talk about their postpartal feelings helps to differentiate between problems that can be handled best with discussion and concerned understanding and those that should be referred to a social service department or a community health agency for additional support

interventions to prevent or relieve engorgement

- Empty the breasts of milk by having the infant suck more often or at least continue to suck as much as before - Good breast support from a firm fitting bra also helps prevent a pulling, heavy feeling - If an infant cannot grasp a nipple to suck strongly becasue of engorgement, warm packs applied to both breasts or standing under a warm shower for a few minutes before feeding, combined with massage to begin milk flow, often promotes breast softness so an infant can suck - manual expression or the use of a breast pump to completely empty the breasts after the baby has nursed can help maintain or promote a good milk supply during a period of engorgement

bonding

- En face position - Touch - Rooming in (complete and partial) - Sibling visitation (assess for any contagious diseases prior to visitation), wash hands

postpartum assessment (hormonal changes)

- HCG levels decline rapidly over the first 24 hrs - estrogen and progesterone return to prepregnant state at about 1 week - FSH levels remain low for about 12 days, and rise as normal menstruation returns

erythema toxicum

- In most term newborns, some degree of a rash, called erythema toxicum is present - The rash usually appears in the first to fourth day of life, but may appear as late as 2 weeks of age - It begins with small papules, increases in severity to become erythematous by the second day and then disappears by the third day - sometimes called a flee bite rash because the lesions are so minuscule - One of the chief characteristics of the rash, aside from the pinpoint lesions, is its lack of pattern - It occurs sporadically and unpredictably and may last hours rather than days - Probably caused by the newborns eosinophils reacting to the rough environment of sheets and clothing rather than a smooth liquid against the skin - no treatment - It is important it be differentiated from lesion of herpes simplex (clustered vesicles) because herpes simplex is a serious finding in a newborn

fluid intake

- It is important to maintain a sufficient fluid intake in newborns because their metabolic rate is so high (and metabolism requires water) - Babies lose water by evaporation much more readily than does an adult and because the kidneys of a newborn are not yet capable of fully concentrating urine, a newborn cannot conserve body water by this mechanism to prevent dehydration - If a newborns extracellular fluid store is depleted through loss of fluid or inadequate fluid intake, as much as 35% of a newborns fluid component may be lost - A newborn needs 150 to 200 ml/kg (2.5 to 3 oz/lb) of water intake every 24 hours - Can be supplied completely by breastfeeding or formula feeding - Fruit juice is not recommended for infants younger than 6 months because it supplies no protein and if not pasteurized can carry infectious organisms

abandonment

- Many mothers admit to feeling abandoned and less important after giving birth than they did during pregnancy or labor - You can help a woman move past these feelings by verbalizing the problem: "How things have changed! Everyone's asking about the baby today and not about you, aren't they? - Making infant care a shared responsibility can help allleviate these feelings and make both partners feel equally involved in the babys care - you can help parent or partners move past this competitive stage by pointing out positive parenting behaviors, positive self care behaviors, and the warm infant response to behaviors

advantages of formula

- Modified milk based formulas are used for the average newborn - Lactose free formulas are used for infants with lactose intolerance or galactosemia (inability to use sugar) - Soy formulas were devised for intants who are allergic to cows milk protein, although such infants may be given casein hydrolysate formulas which have protein particles too small to be recognized by the immune system - Elemental formulas are used for infants with protein allergies or fat malnutrition - Modified milk based, soy based, and lactose free formulas are all designed to stimulate the nutritional content of breast milk, so all contain supplemental vitamins as well as 20 calories per ounce - Advise parents to purchase types with added iron to ensure that their newborn receives enough of this element to prevent iron deficiency anemia

purpose of erythromycin ophthalmic ointment

- Most birth settings in the US and Canada still administer prophylactic eye treatment (erythromycin ointment) to help prevent gonorrheal and chlamydia conjunctivits - Such infections are usually acquired from the mother as the infant passes through the birth canal; therefore, if a mother is certain she does not have either of the diseases, she can request eye drops not be given

car safety

- Newborns should always be transported in rear facing car seats placed in the back seat not the front seat - When purchasing a car seat, caution parents to look at the brand and style to be certain the seat meets current federal guidelines - Advise parents not to use a sack sleeper or papoose bunting nor should they wrap the baby in a bulky blanket so the straps will securely fashion the infant into the seat - To support the babys head, parents can use a rolled up receiving blanket, towel or diaper on each side of the head or purchase commercial head supporters - Caution parents that plastic car seats grow extremely hot in the summer, so they should test the temperature of the surface before placing their infant into the seat - Stress also that it is as dangerous to not use a car seat as it is to use a car seat improperly, such as not fastening the harness or not securing the seat belt

newborn assessment

- O2 stat, pulse, respirations, and temp - Lung sounds and heart sounds - Fontanelles - Ears (look for pits on earlobe) - Check palate and suck reflex - Back of neck/spine/sacral dimple - Palpate extremities, including the clavicle - Auscultate and Palpate abdomen - Visually inspect genitals - Assess feet (slick or wrinkled)

newborn identification bands

- One traditional form of identification used with newborns is a plastic bracelet with a permanent lock that requires cutting to be removed - A number that corresponds to the mothers hospital number; the mothers name; and the sex, date, and time of the infants birth are printed on the band - A newer form of identification band has a built in sensor unit that sounds an alarm if a baby is transported beyond set hospital boundaries

promote healing of sore nipples

- Painful nipples result from the strong sucking action of a newborn This can be worsened by: - Improper positioning of an infant (e.g., failure to grasp the areola as well as the nipple) - Forcefully pulling an infant from a breast - Allowing an infant to suck too long at a breast after the breast in emptied - Permitting a nipple to remain wet from leaking milk - To help prevent soreness, encourage a mother to position her baby slightly differently for each feeding. This helps prevent the same area of the nipple from receiving the majority of pressure - Adivse her to also expose her nipples to air so the nipple dries by leaving her bra unsnapped for 10 to 15 minutes after feeding - Discourage the use of plastic liners that come with nursing bras as these can prevent air from circulating around the breasts - Applying lanolin to nipples after air exposure is a way to toughen the nipples and prevent further irritation - Applying a few drops of breast milk to the nipples after feeding and gently massaging it into the areola can also be recommended - Advise women with sore nipples not to use hand held breast pumps because the pressure may cause fissures to worsen. An electric or battery operated pump usually can be used

bathing

- Plan to help a mother give a first bath before (not after) a feeding to prevent spitting up or vomiting and possible aspiration. Check to make certain the mothers room is warm to prevent chilling - Supply bath water at 98 to 100 F, a temperature that feels pleasantly warm to the elbow or wrist, plus a washcloth, towel, comb, and clean diaper and shirt - Bathing should proceed from the cleanest parts of the body to the most soiled areas; that is, from the eyes and face to the trunk and extremities and last to the diaper area - Wipe a newborns eyes with clear water from the inner canthus outward using a clean portion of the washcloth for each eye to prevent spread of infection to the other eye - Remind the mother to wash around the cord with care so she doesnt soak the cord and to give particular care to the creases of skin where milk tends to collect if the child spits up after feedings - If mother wants to use soap be sure she rinses well so no soap is left on the skin and also to dry well - Wash infants hair daily

what could slow involution down

- Prolonged labor and difficult delivery - Anesthesia - Grand multiparity - retained placental fragments - full bladder - infection - overdistended uterus - poor nutrition

fluid and calorie intake for breastfeeding mothers

- Remind women a good fluid intake is necessary to maintain an adequate milk supply - Recommend they drink at least four 8 oz glasses of fluid a day; many may need to drink 6 glasses - They also need to increase their calorie intake by about 500 calories per day

perineal care

- Teach a woman to include perineal care as part of her daily bath or shower and after every voiding or bowel movement - Spray the perineum with clear tap water from a spray bottle - A postpartum bathroom should have an area close to the toilet where she can place the equipment she needs for care: a spray bottle, sponges to dry, clean pads - Caution her not to flush the toilet until she is standing upright so the flushing water doesnt spray her perineum and increase the risk of infection - If women are given a clear explanation as to why perineal care is important, they perform it well

newborns stools

- The first stool of a newborn is usually passed within 24 hours after birth. It consists of meconium, a sticky, tarlike blackish green, odorless material formed from mucus, vernix, lanugo, hormones, and carbohydrates that accumulated in the bowel during intrauterine life - About the 2nd or 3rd day of life, newborn stool changes in color and consistency. Termed a transitional stool, bowel contents appear both loose and green; they may resemble diarrhea to the untrained eye - By the 4th day of life, breastfed babies pass three or four light yellow stools per day. They are sweet smelling because breast milk is high in lactic acid, which reduces the amount of putrefactive organisms in the stool - A newborn who receives formula usually passes two or three bright yellow stools a day. These have a slightly more noticeable odor, compared with the stools of breastfed babies - A newborn placed under phototherapy lights as therapy for jaundice will have bright green stools because of increased bilirubin excretion - newborns with bile duct obstruction have clay colored (gray) stools, because bile pigments cannot enter the intestinal tract - Blood flecked stools usually indicate an anal fissure - Occasionally a newborn has swallowed some maternal blood during birth and either vomits fresh blood immediately after birth or passes a black tarry stool after two or more days. Whether bleeding is caused by ingestion of maternal blood at birth or newborn bleeding may be differentiated by a dipstick Apt test. If stools remain black or tarry, this suggests newborn intestinal bleeding rather than swallowed blood - If mucus is mixed with stool or the stool is watery and loose, a milk allergy, lactose intolerance, or some other condition interfering with digestion or absorption should be suspected

molding

- The part of the infants head that engaged the cervix (usually the vertex) molds to fit the cervix contours during labor - After birth, this area appears prominent and asymmetric - you can assure parents the head will restore to its normal shape within a few days after birth

advantages of breastfeeding for the mother

- The release of oxytocin from the posterior pituitary gland aids in uterine involution - Breastfeeding may serve a protective function in preventing breast cancer and possibly ovarian cancer - A woman may return to her prepregnant weight sooner and if menstruation is delayed this may serve as a temporary family planning method - Successful breastfeeding can have an empowering effect because it is a skill only a woman can master - Breastfeeding reduces the cost of feeding and preparation time for infant feeding - A long term effect may include a decreased risk of hip fractures and osteoporosis in the postmenopausal period for the woman - Breastfeeding provides an excellent opportunity to enhance a true symbiotic bond between mother and child. Although this does readily occur with breastfeeding a woman who hold her baby to formula feed can form this bond as well

vitamin K

- Vitamin K is used to prevent and treat hemorrhagic disease in newborns - It is a necessary component for the production of certain coagulation factors and is produced by microorganisms in the intestinal tract - Newborns are at risk for bleeding disorders during the first week of life because their GI tract is sterile at birth and therefor unable to produce vitamin K, a vitamin necessary for blood coagulation - A single dose of 0.5 to 1.0 mg of vitamin K is administered IM within the first hour of life - Vitamin K is also available oral but is not preferred form because newborn absorption may still be immature and vomiting can dilute the dose NURSING IMPLICATION - Anticipate the need for injection within an hour after birth - Administer IM injection into a large muscle, such as the anterolateral muscle of a newborns thigh - Be certain to administer the injection at a time it doesnt interrupt parent child bonding or beginning breastfeeding - If giving vitamin K for treatment, obtain prothrombin time before administration - Assess for signs of bleeding in the infant, such as black tarry stools (different meconium stools which have a greenish shade), hematuria (blood in urine), decreased hemoglobin and hematocrit levels, and bleeding from any open wound or at the base of the cord. (These signs would indicate more vitamin K is necessary because bleeding control has not been achieved)

positions for breastfeeding

- When she is first attempting to breastfeed, lying on her side with a pillow under her head is a good position to use. This relieves fatigue because it allow her infant to rest on the bed, not on her - A sitting position with a pillow under the baby. Using a football hold with the baby supported on a pillow also may be helpful, especially if the mother had a cesarean birth

physiology of breast milk production (prolactin & oxytocin)

- With the delivery of the placenta following birth, the level of progesterone in a womans body falls dramatically, stimulating the production of prolactin, an anterior pituitary hormone - Prolactin acts on the acinar cells of the mammary glands to stimulate the production of milk - When an infant sucks at a breast, nerve impulses travel from the nipple to the hypothalamus to stimulate the production of prolactin releasing factor. This factor stimulates further active production of prolactin - As the infant sucks at the breast, oxytocin, released from the posterior pituitary, causes the collecting sinuses of the mammary glands to contract, forcing milk forward through the nipples, making it available for the baby. This action is called a let down reflex - The release of oxytocin has a second advantage in that by causing smooth muscle contraction, it helps contract the uterus . As a result, a woman may feel a small tugging or cramping in her lower pelvis during the first few days of breastfeeding

APGAR score

- an assessment sclae used as a standard for newborn evaluation - At 1 and 5 minutes after birth, newborns are observed and rated according to an Apgar score Heart rate, respiratory effort, muscle tone, reflex irritability, and color of the infant are each rate 0, 1, or 2 - there is a high correlation between low 5 minute Apgar scores and neurologic illness 0 - 3: critically low 4 - 6: fairly low 7 - 10: generally normal

postpartum assessment (integumentary)

- assess for striae gravidarum (stretch marks) - should fade by 6 months - assess for chloasma, linea nigra, and diastasis recti - abdominal exercises will help strengthen abdominal muscles to return to abdomial support to prepregnant level

postpartum assessment (GI)

- bowel function slower to release of relaxin hormone that relaxes pelvis during labor - assess for hemorrhoids - encourage fluids, fruits, and vegetables - perineum: turn on her side and assess from the back, observe for ecchymosis, hematoma, erythema, edema, intactness, and presence of drainage, assess episiotomy

adequate feeding

- content between feedings - wetting 6 to 8 diapers within 24 hours - losing no more than 10% of birth weight - good skin turgor - 2 to 3 bowel movements - sleeps between feedings

central cyanosis

- cyanosis of the trunk - is always a cause for concern - indicates decreased oxygenation that could be occurring as the result of a temporary respiratory obstruction and also could reflect a serious underlying respiratory or cardiac disease

what could enhance involution

- easy and uncomplicated labor - breastfeeding - early ambulation - complete expulsion of the placenta and membranes

umbilical cord

- for the first hour after birth, the stump of the umbilical cord appears as a white, gelatinous structure marked with the blue and red streaks of the one umbilical vein and the two arteries - after the first hour of life, the cord will begin to dry, shrink, and turn brown as if it were the dead end of a vine - by the end of the second or third day it will have turned black - On day 6 to 10, it breaks free leaving a granulating area a few cm wide that will heal during the following week - There should be no bleeding at the base of the cord because this suggests the cord clamp has become loosened or the cord has been tugged loose by the friction of bedclothes - base of the cord should not appear wet - A moist or odorus cord suggests infection, a situation that requires immediate antibiotic therapy to prevent th einfectious organisms from entering the newborns bloodstream and causing septicemia - Moistness of the base of the cord also may indicate a patent urachus (a narrow opening that connects the bladder and the umbilicus) which will drainurine at the cord site until it is surgically repaired - inspect the base of the cord to be certain no abdominal wall defect such as an umbilical hernia is present - any child with a single umbilical artery needs close observation and assessment until anomalies are ruled out because these are frequently associated with the lack of an umbilical artery

lactation

- formation of breast milk - begins in postpartal woman whether or not she plans to breasfeed - On the 3rd day after birth, breasts become full and feel tense or tender as milk forms within breast ducts and replaces colostrum

components of newborn assessment

- height and weight determinations to establish gestational age and to detect any observable condition such as difficulty breathing, a congenital heart anomaly, or any birthmarks - Always complete assessments quickly to prevent exposing a newborn to chilling - 20 hours after birth, when the babys systems have had time to stabilize, a more thorough and detailed examination is performed

craniotabes

- is a localized softening of the cranial bones probably caused by pressure of the fetal skull against the mothers pelvic bone in utero - more common in first born infants than in infants born later because of the lower position of the fetal head in the pelvis during the last 2 weeks of pregnancy in primaiparous women - the skull is so soft that the pressure of an examining finger can indent it - the condition treats itself without treatment after a few months as the infant takes in calcium from milk

caput succedaneum

- is edema of the scalp that forms on the presenting part of the head - occurs in about 30% of cephalic births and can either involve wide areas of the head or be so confined that its the size of a large egg - The edema, which crosses the suture lines, is gradually absorbed and disappears at about the third day of life with no treatment needed

lanugo

- is the fine, downy hair that covers a term newborns shoulders, back, upper arms, and possibly the forehead and ears - Postterm infants (born after more than 42 weeks of gestation) rarely have lanugo - babies born at 37 to 39 weeks have a generous supply of lanugo - lanugo is rubbed away by the friction of bedding and clothes against the newborns skin - by 2 weeks, it has usually totally disappeared

circumcision

- is the surgical removal of the foreskin of the penis - Contraindications for circumcision include a history of a bleeding tendency in the family or hypospadias or epispadias becasue the prepuce skin may be needed when a plastic surgeon repairs these defects - Complications that can occur from circumcision include hemorrhage, infection , and urethral fistula formation - To keep the risk of these complications to a minimum check the infant for bleeding every 15 minutes for the first hour and observe closely for about 2 more hours - Document that the infant is voiding after the procedure to be certain the urethra is not occluded - Caution parents to keep the area clean from feces and covered with petroleum for about 3 days or until healing is complete - If they notice and redness or tenderness or if the baby cries as if in constant pain, they should report it by telephone to their primary care provider because this suggest and infection

vernix caseosa

- is the white, cream cheese like substance that serves as a skin lubricant in utero - some of it is noticeable on a term newborns skin, at least in the skin folds, at birth - document the color of any vernix present, because it takes on the color of the amniotic fluid was stained from excessive bilirubin or a blood dyscrasia may be present; green vernix suggests meconium was present in the amniotic fluid - Until the first bath, when vernix is washed away, handle newborns with gloves to protect yourself from exposure to this body fluid

en face position

- looking directly at her newborns face, with direct eye contact - a sign a woman in beginning effective attachment

engrossment

- many fathers can be observed staring at a newborn for long intervals in the same way - action alerts caregivers to how actively the father as well as the mother is beginning bonding

witchs milk

- occasionally the breasts of newborn babies secrete a thin, watery fluid - as soon as the hormones are cleared from the infants system (about 1 week), the engorgement and any fluid that is present will subside

technique used to palpate the fundus

- palpate the fundus of the uterus by placing one hand on the base of the uterus just above the symphysis pubis and the other at the umbilicus - press in and downward with the hand at the umbilicus until you "bump" against a firm globular mass in the abdomen: the uterine fundus - To palpate a uterus, be certain to place one hand at the base of the uterus.

involution

- process whereby the reproductive organs return to their nonpregnant state - a woman is in danger of hemorrhage from the denuded surface of the uterus until involution is complete Involution of the uterus involves two processes: - The area where the placenta was implanted is sealed off to prevent bleeding - The organ is reduced to ist approximate pregestational size

hypoglycemia in newborns

- produces few symptoms in newborns, therefore the heel capillary blood sample is necessary to determine if it is present - if the serum glucose reading is less than 40 mg/100 ml of blood, hypoglycemia is said to be present - To correct this condition, the infant is prescribed oral glucose or is breastfed immediately because either of these therapies will increase the infants blood sugar to a safe level - It is important to treat hypoglycemia quickly this way because if brain cells become completely depleted of glucose, brain damage can result - If a newborn exhibits symptoms of hypoglycemia (e.g., jitteriness, lethargy, seizures) in addition to to the low laboratory test results IV glucose will probably be prescribed - A continuous IV infusion of glucose may be necessary if the newborn is unable to maintain glucose levels higher than 40 mg/100 ml

LATCH assessment

- provides a systematic method for gathering information about breastfeeding progress - This system assigns a numerical score of 0, 1, or 2 to five key components of breastfeeding; 10 is a perfect score, meaning the woman is ready to independently breastfeed - useful tool to identify mother infant pairs who might benefit from additional skilled support to encourage them to continue exclusive breastfeeding

signs of hunger in a newborn

- restlessness - tense body posture - smacking lips - tongue thrusting - crying (late sign of hunger)

milia

- sebaceous glands in a newborn are immature, so at least one pinpoint white papule (a plugged or unopened sebaceous gland) is usually found on a cheek or across the bridge of the nose of every newborn - Such lesions, termed milia, disappear by 2 to 4 weeks of age as the sebaceous glands mature and the plugged ones drain - caution parents to avoid scratching or squeezing the papule while they wait for this to clear to prevent secondary infection

postpartum assessment (vital sign changes)

- slight increase in temperature due to dehydration, then in a few days temperature increases from lactation - Pulse: decreased at first then increases - BP: watch for pregnancy induced hypertension; can occur for up to 48 hours postpartum - report BP > 140/90 - assess for orthostatic hypotension - dangle feet at bedside before rising

uterus assessment

- the fundus of the uterus is palpable through the abdominal wall, halfway between the umbilicus and the symphysis pubis, within a few minutes after birth - One hour later, it will rise to the level of the umbilicus, where it remains for approximately the next 24 hours - From then on, it decreases by one fingerbreadth, or 1 cm, per day - Example: on the first postpartal day, it will be palpable 1 cm below the umbilicus - In the average women by the 9th or 10th day the uterus will have contracted so much that is is withdrawn into the pelvis and can no longer be detected by abdominal palpation - Normally midline, if deviated (full bladder or bowel ) will keep the uterus from contracting properly - First hour critical: assess for uterine atony, mulitparas will have afterpains, assess every 15 minutes

acrocyanosis

- the lips, hands, and feet are likely to appear blue from immature peripheral circulation - normal finding at birth through the first 24 to 48 hours

sutures

- the separating lines of the skull - may override at birth because of the extreme pressure exerted on the head during passage through the birth canal - should never appear widely separated in newborns - wide separation suggests increased intracranial pressure because of abnormal brain formation, abnormal accumulation of cerebrospinal fluid in the cranium or an accumulation of blood from a birth injury such as subdural hemorrhage - fused suture lines are also abnormal; they require xray confirmation and further evaluation because this will prevent the head from expanding with brain growth

colostrum

- thin, ,watery, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies - secreted by the acinar breast cells starting in the fourth month of pregnancy - Because it is high in protein and fairly low in sugar and fat, colostrum is easy to digest and capable of providing adequate nutrition for a newborn until it is replaced by transitional breast milk on the second to fourth day

postpartum assessment (Circulatory)

- vaginal blood loss 300 to 500 mL normal to help the body return to prepregnant blood volume levels - initially drop in hemoglobin and hematocrit - plasma fibrinogen and WBC levels will remain high for the first few weeks postpartum - WBCs can be as high as 30,000 Normal blood loss - 300 to 500 mL vaginal delivery - 500 to 1000 C section - Blood loss > 500 mL indicates hemorrhage - absence of bleeding during early postpartum may indicate infection

postpartum assessment (vagina)

- very soft after birth, thin - Kegel exercises help strengthen overstreched vaginal muscles

profile of a newborn kidnapper

- woman who has recently lost a pregnancy or had an infant stillborn and therefore desires an infant very much - she often is someone familiar with hospitals - she may pretend to be a volunteer or an unlicensed health care worker and says she needs to take a baby out of the nursery or the mothers room for a procedure

reasons women lost the sensation of knowing she needs to void

- women who have had epidural anesthesia are particularly prone to inability to sense a full bladder and can develop urinary retention

jaundice

- yellowing of the skin - occurs in as many as 15% of breastfed infants because pregnanediol (a breakdown product of progesterone) in breast milk depresses the action of glucuronyl transferase, the enzyme that converts indirect bilirubin (which cannot be excreted) to the direct form, which is then readily excreted in bile - To prevent excess buildup of bilirubin in their infant, women should feed frequently in the immediate postbirth period because colostrum is a natural laxative and helps promote passage of both meconium and bile - Newborns who are discharged early from their birth setting or born at home need to be observed carefully for jaundice

proportion of head to body length for infants vs adults

A newborns head usually appears disproportionately large because it is about 1/4 of the total body length compared with an adult, whose head is 1/8 of total heigh

evaluating lochia flow

Amount - lochia amount varies greatly from woman to woman. Mothers who breastfeed tend to have less lochial discharge than those who do not, because the natural release of the hormone oxytocin during breastfeeding strengthens uterine contractions. Lochial flow increases on exertion, especially the first few times a woman is out of bed, but decreases again with rest. Saturating a perineal pad in less than 1 hour is considered an abnormally heavy flow and should be reported. Dont use tampons to halt the flow or this could lead to infection Consistency - Lochiashould contain no exceedingly large clots as these may indicate a portion of the placenta has been retained and is preventing closure of the maternal uterine blood sinuses. In any event, large clots denote poor uterine contraction, which needs to be corrected Pattern - lochia is red for the first 1 to 3 days (lochia rubra), pinkish brown from days 4 to 10 (lochia serosa), and then white (lochia alba) for as long as 6 weeks after birth. The pattern of lochia (rubra to serosa to alba) should not reverse as this suggests a placental fragment has been retained or uterine contraction is decreasing and new bleeding is beginning Odor - Lochia should not have an offensive odor as this suggests the uterus has become infected. Immediate intervention is needed to halt postpartal infection Absence - Lochia should never be absent during the first 1 to 3 weeks as absence of lochia, like presence of an offensive odor, may indicate postpartal infection. Lochia may be scant in amount after cesarean birth, but it is never altogether absent

fontanelles

Anterior Fontanelle - located at the junction of the two parietal bones and the two fused frontal bones - diamond shaped and measure 2 to 3 cm in width and 3 to 4 cm in length - can be felt as a soft spot - It should not appear indented (sign of dehydration) or bulging (sign of increased intracranial pressure) - normally closes at 12 to 18 months Posterior Fontanelle - located at the junction of the parietal bones and the occipital bone - triangular and measure about 1 to 2 cm in length - In some newborns, the posterior fontanelle is so small that it cannot be palpated readily - closes by the end of the 2nd month

reflexes

BLINK REFLEX - Serves the same purpose as it does in an adult; to protect the eye from any object coming near it by rapid eyelid closure - may be elicited by shining a strong light such as a flashlight or otoscope light into an eye ROOTING REFLEX - If a newborns cheek is brushed or stoked near the corner of the mouth the infant will turn the head in that direction - This reflex serves to help a newborn find food - Disappears at about the 6th week of life SUCKING REFLEX - When a newborns lips are touched, the baby makes a sucking motion - also helps a newborn find food - begins to diminish about 6 months SWALLOWING REFLEX - same as in the adult - food that reaches the posterior portion of the tongue is automatically swallowed EXTRUSION REFLEX - In order to prevent the swallowing of inedible substances, a newborn extrudes any substance that is placed on the anterior portion of the tongue - Disappears at 4 months PALMAR GRASP REFLEX - newborns grasp an object placed in their palm by quickly closing their fingers on it - Mature newborns grasp so strongly they can be raised from a supine position and suspended momentarily from an examiners fingers - Disappears from 6 weeks to 3 months STEP IN PLACE REFLEX - newborns who are held in a vertical position with their feet touching a hard surface will take a few quick alternating steps - disappears by 3 months PLACING REFLEX - similar to the step in place reflex, except it is elicited by touching the anterior surface of the lower part of a newborns leg against a hard surface such as the edge of a bassinet or table - the newborn makes a few quick lifting motions as if to step onto the table

postpartum assessment

BUBBLEHEEN B : Breast - Breast vs Bottle feeding: assess for latching on. If formula feeding, teach about engorgement of breast, mother binds breast 24/7 and no nipple stimulation U : Uterus - Firm and Midline; 12 hours after delivery uterus is 1 fingerbreadth above naval, decreases approximately 1 fingerbreadth each day. If uterus is not midline, have patient void B : Bladder - Patients have decreased sensation to void, especially with spinal, patients need to void every 3 hours. Number 1 cause of hemorrhage is a full bladder B : Bowel - Flatus? bowel sounds x 4 quadrants? Use stool softener, as needed. Should take stool softener if second degree tear or higher and all C sections. If C section, patient should walk at least 3 times per day (breakfast, lunch, and dinner) L : Lochia - Assess flow and ask how many hours since last changed pad, if using one pad per hour, suspect hemorrhage. Lochia flow should progress in color: red, pink, brownish, white, none E : Epistiotomy - Check incision for REEDA (redness, edema, ecchymosis, drainage, and approximation) Look for signs and symptoms of infection H : Homan's Sign - Must assess Homan's Sign (support leg with dorsiflexion) Teach patient about ambulation and hydration to prevent DVT E : Edema - Swelling in lower legs? Pitting? E : Emotions - Is the mother bonding with newborn? Changing diapers? N : Nutrition - Mothers need 500 calories more when breastfeeding. C sections cannot have a straw due to intake of air. Also, no cabbage or broccoli due to causing gas

complications

Bleeding Complications - One of the leading causes of mortality/morbidity - Normal blood loss is 300 to 500 mLs with vaginal delivery - More than 500 mLs in 24 hours is excessive - Greatest danger is within the first 24 hours - Soaking more than one vaginal pad per hour may indicator hemorrhage - uterine atony (boggy uterus) - retained placental fragments - cervical lacerations Infections - endometritis - mastitis - cystitis Other Complications Thrombophlebitits - S/S: heat, redness, swelling - positive Homans sign - encourage ambulation - pulmonary embolus - DIC

heat loss in newborns

Convection - is the flow of heat from the newborns body surface to cooler surrounding air. - Eliminating drafts, such as from air conditioners, is an important way to reduce convection heat loss Radiation - is the transfer of body heat to a cooler solid object not in contact with the baby, such as a cold window or air conditioner - Moving an infant as far from the cold surface as possible helps reduce this type of heat loss Conduction - is the transfer of body heat to a cooler solid object in contact with a baby - For example, a baby placed on the cold base of a warming unit quickly loses heat to the colder metal surface - Covering surfaces with a warmed blanket or towel is necessary to help minimize conduction heat loss Evaporation - is loss of heat through conversion of a liquid to a vapor - newborns are wet when born so they can lose a great deal of heat as the amniotic fluid on their skin evaporates - to prevent this type of heat loss, lay a newborn on the mothers abdomen immediately after birth and cover with a warm blanket for skin to skin contact - In addition, drying the infant, especially the face and hair, also effectively reduces evaporation because the head, which is a large surface area in a newborn, can be responsible for a great amount of heat loss - Covering the hair with a cap after drying further reduces the possibility of evaporation cooling

newborn care in the delivery room

Following steps are necessary for every delivery - Prevent heat loss - Open airway - Initiate Breathing - Evaluate infant Prevent Heat Loss - Provide warmth - Dry thoroughly and remove wet towels Open Airway - Positioning (small towel under shoulders); Sniffling position - Suctioning (mouth first then nose) Initiate Breathing - tacticle stimulation Evaluate Infant - Breathing - Heart rate > 100 - Supplemental oxygen Color - Cyanosis: entire body blue - Acrocyanosis: only hands and feet blue

discharge education (cont)

Hormonal Changes - Diuresis, including extreme perspiration, begins after childbirth to rid the body of excess fluid - Encourage fluid intake Postpartum Shaking Chills: - occurs within 30 minutes of delivery - provide a warm blanket and warm drink - Etiology: abdominal pressure changes and emotions (exhilation/exhaustion) Bowel Care - Increase fluids, fiber, and activity - stool softeners - Hemorrhoids: SIMS positioning, gentle replacement Rest and Activity - No heavy lifting - Rest when infant sleeps - No sleeping with the infant in bed Exercise - start slowly - first couple of days: no abdominal exercises; may resume 4 to 6 weeks normal prepregnant exercise - Kegel exercises to stengthen pelvic floor muscles Rooming In - Mother and infant are not separated after birth - Promotes bonding and makes breast feeding easier - Encourage bonding - Holding infant, gazing at infant, normal (enface position) GOOD HANDWASHING OF ALL FAMILY AND VISITORS

characteristics of lochia

Lochia Rubra - red - 1 to 3 days postpartal - blood, fragments of decidua, and mucus Lochia Serosa - pink - 3 to 10 days postpartal - blood, mucus, and invading leukocytes Lochia Alba - white - 10 to 14 days postpartal (may last 6 weeks) - largely mucus, leukocyte count high

discharge education

Locial Flow - Moderate bright red flow first few days is normal - Absence may indicate infection - Should not have an offensive odor - Should not contain large clots - encourage breastfeeding Soaking 1 pad per hour; not good - need to check fundus - Meds: oxytocin, hembate, methergine, cytotec Perineal Care - Cleanse after each elimination (shower daily) - Peri bottle, no wiping - Change peri pads often; remove front to back - Good handwashing - Episiotomy care: anesthetic sprays/creams, cortisone based creams, witch hazel preparations (Tucks pads), oral pain pills - Sitz bath: increase blood flow, speed healing Bladder Care - Increase fluids - Encourage ambulation to the bathroom and void frequently Avoid a distended bladder - may have to run water - offer drinks - pouring water over the perineum to encourage voiding - If unable to void after 4 to 8 hours, catheterize - If residual is > 150 mL, leave catheter in place for 12 to 24 hours

differences between nipple rolling and breast massage

Nipple Rolling - physical preparation which was advised in the past as a way of making a womans nipples more protuberant, is not necessary because few women have inverted or nonprotuberant nipples - Oxytocin, which is released by this maneuver could lead to preterm labor (nipple rolling is used to create uterine contractions for stress tests) Breast Massage -

reflexes (cont)

PLANTAR GRASP REFLEX - When an object touches the sole of the foot at the base of the toes, the toes grasp in the same manner as the fingers - Disappears at about 8 to 9 months TONIC NECK REFLEX - When newborns lie on their backs, their head usually turn to one side or the other - The arm and leg on the side toward which the head turns extend, and the opposite arm and leg contract - disappears between the 2nd and 3rd month MORO REFLEX - startle reflex - can be initiated by startling a newborn with a loud noise or by jarring the bassinet - fades by the end of the 4th or 5th month BABINSKI REFLEX - When the sole of a newborns foot is stroked in an inverted "J" curve from the heel upward, a newborn fans the toes (positive Babinski sign) - The reflex remains positive until at least 3 month MAGNET REFLEX - If pressure is applied to the soles of the feet a newborn lying in a supine position, he or she pushes back against the pressure - tests of spinal cord integrity CROSSED EXTENSION REFLEX - When a newborn is lying supine, if one leg is extended and the sole of that foot is irritated by being rubbed with a sharp object, such as a thumbnail, the infant raises the other leg and extends it as if trying to push away the hand irritating the first leg TRUNK INCURVATION REFLEX - When a newborn lies in a prone positon and is touched along the paravertebral area on the back by a probing finger, the newborn flexes the trunk and swings the pelvis toward the touch LANDAU REFLEX - When a newborn is supported in a prone position by a hand, the newborn should demonstrate some muscle tone DEEP TENDON REFLEXES - both a patellar and a biceps reflex are intact in a newborn - a biceps reflex is a test for spinal nerves C5 and C6 - a patellar reflex is a test for spinal nerves L2 through L4

sleeping position

Prevention of SIDS - Place infants on their backs to sleep - Use a firm sleep surface - Breastfeeding - Room sharing without bed sharing - routine immunizations - consideration of using a pacifier - avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs

clinical criteria for gestational assessment

Sole Creases 0 - 36 weeks: anterior transverse crease only 37 - 38 weeks: occasional creases in anterior 2/3 39 and over: sole covered with creases Breast nodule diameter (mm) 0 - 36 weeks: 2 mm 37 - 38 weeks: 4 mm 39 and over: 7 mm Scalp Hair 0 - 36 weeks: fine and fuzzy 37 - 38 weeks: fine and fuzzy 39 and over: coarse and silky Ear lobe 0 - 36 weeks: pliable; no cartilage 37 - 38 weeks: some cartilage 39 and over: stiffened by thick cartilage Testes and scrotum 0 - 36 weeks: testes in lower canal; scrotum small; few rugae 37 - 38 weeks: intermediate 39 and over: testes pendulous, scrotum full; extensive rugae

three phase of the puerperium

TAKING IN PHASE - the time when the new parents review their pregnancy and the labor and birth - time of reflection - 1 to 3 day period - spends time holding infant - woman rests and physically revoers and discusses birth of infant - woman is largely passive, she prefers to have nurse attend to her needs and make decisions for her rather than do things herself - Encourage her to talk about the birth is an important way to help her integrate the experience into her total life experiences TAKING HOLD - woman becomes more interactive with self care and care of infant - more independent in self care - excellent time for teaching - positive reinforcement - woman begins to initiate action - she prefers to make own decisions - women who give birth without any anesthesia may reach this second phase in a matter of hours after birth - stronger interest in infant and begins maternal role behaviors - she needs praise for the things she does well - Do not rush a woman through the phase of taking in or prevent her from taking hold when she reaches this point LETTING GO - recognizes new role as parent - gives up old role of being childless - A woman finally redefines her new role - she gives up the fantasized image of her child and accepts the real one - requires some grief work and readjustment of relationships - It is extended and continues during the childs growing years - A woman who has reached this phase is well into her new role

normal range of vital signs for a newborn

Temperature - 97.6 to 98.6 axillary Heart rate - 120 to 140 beats per minute Respirations - 30 to 60 breaths/min Length - 46 to 54 cm Head circumference - 34 to 35 cm Chest circumference - 32 to 33 cm Weight - 2.5 to 3.4 kg - 5.5 to 7.4 lbs

postpartum assessment (weight)

Weight loss - The rapid diuresis and diaphoresis during the 2 to 5th day after birth usually result in a weight loss of 5 lb in addition to approximately 12 lb lost at birth - Lochia flow causes an additional 2 to 3 lb loss for a total weight loss of 19 lbs - additional weight loss is dependent on the amount of pregnancy weight gain and on whether a woman continues active measure to lose weight - Also influenced by nutrition, exercise, and breastfeeding Ways to lose extra weight - breast feeding - well balanced diet - exercise will help with weight loss. Start slow - 1 full year to return to prepregnant weight

cephalohematoma

a collection of blood between the periosteum of a skull bone and the bone itself, is caused by rupture of a periosteal capillary because of the pressure of birth

what can nurses assess to know if the postpartum woman has a full bladder

assess a womans abdomen frequently in the immediate postpartal period

postpartum assessment (cervix)

by the end of 1 week the cervical os has narrowed to the size of a pencil size opening, feels firm and nongravid

engorgement

feeling of tension is the breasts on the 3rd or 4th day after birth

lochia

flow, consisting of blood, fragments of decidua, white blood cells, mucus, and some bacteria