MATERNITY EXAM 3 BLUEPRINT

Benefits of breastfeeding for the infant

--Reduced risk for: - ◦gastrointestinal infections, bowel disorders, asthma, otitis media, SIDS, obesity, DM, acute lymphocytic and myeloid leukemia -Enhanced neurodevelopmental outcomes, especially in preterm infants

Normal newborn weight range:

2500-4000 g (5lbs. 8 oz. - 8lbs 13 oz.) acceptable weight loss: 10% or less in first 3-5days

UTI care and treatment involves

ABX, pain relief, hydration, hygiene education

Infant skeletal system

Extremities should be symmetric and equal Molding may cause head shape variations üCaput succedaneum üCephlahematoma üSubgaleal hemorrhage Newborn spine appears straight and can be flexed easily Hips should be tested for dysplasia

Cardiovascular System Adaptations

Foramen Ovale Closure Ductus Arteriosus closure Normal Heart Rate: 110-160 Apical pulse Blood volume can increase

Physiologic jaundice

Most cases are physiologic in origin, resulting from increased levels of unconjugated bilirubin. This is normally self limiting and requires no treatment. Shows at about day 3-5 and resolves after 1-2 weeks.

Infant immune system

Passive Immunity and breastfeeding contribute to immunoglobin antibodies

Follow up appointment after delivery

Uncomplicated vaginal deliveries call for follow-up in 6 weeks. C/S patients return within 2 weeks for incision inspection. Infant needs to seen by pediatirician within 3-5 days after birth and at approximately 2 weeks old

Postpartum hemorrhage surgical management

Uterine tamponade, ligation, uterine compression suturing

Superficial venous thrombosis pain management

is treated with pain management (NSAIDS), rest, elevation of leg and compression socks. heat may also be applied locally

When to call for help with postpartum blues, psychosis, and depression

•Baby blues continue for more than 2 weeks •Symptoms of depression get worse •Difficulty performing tasks at home or work •Inability to care for self or baby •Thoughts of harming self or baby

Common Newborn Problems

•Birth Injuries •Jaundice •Hypoglycemia

Immediate newborn care

•Routine care: dry, stimulate, skin to skin, provide warmth •Assess and Assign APGAR score üHeart rate, Respiratory effort, Muscle tone, Reflex irritability and Color •Identification and security bands

Baby blues

•Will go away in a few weeks •Sad, anxious or overwhelmed feelings •Crying spells •Loss of appetite •Difficulty sleeping

vernix

•emollient and has antimicrobial properties

Second stage of newborn transition

•the newborn sleeps or has decrease in motor activity, respirations are rapid and shallow and bowel sounds are audible

Greatest risk for early PPH is

•uterine atony. Bleeding is controlled by contraction of the uterus so lack thereof will allow vessels to bleed. This is associated with an overdistended uterus (macrosomia, polyhydramnios, high parity, multiple gestations).

Abnormal Newborn Breathing

-Bradypnea: <30 respirations -tachypnea: >60 respirations -abnormal breath sounds: coarse or fine crackles, wheezes, expiratory grunt -respiratory distress -seesaw or paradoxical respirations -skin color: cyanosis, mottling -pulse oximetry value: <95%

Self-management teaching for Circumcision

-Check for bleeding (if bleeding occurs, apply gentle pressure with a folded sterile gauze square. If bleeding does not stop with pressure; notify HCP) -Observe for urination -Keep area clean -Check for infection (redness, swelling, discharge, or odor indicated infection; notify HCP) -Provide comfort

Benefits of breastfeeding for the mother

-Decreased postpartum bleeding and more rapid uterine involution -Reduced risk for: ovarian and breast cancer, type 2 diabetes, hypertension, hypercholesterolemia, and cardiovascular disease -Unique bonding experience -Increased maternal role attainment

Newborn Medications Vitamin K

-IM injection -Can also be delayed until after first feeding •Newborn can produce their own Vitamin K by day 7

INFANT signs of effective breastfeeding

-Latches without difficulty -Has bursts of 15 to 20 sucks/swallows at a time -audible swallowing is present -easily releases breast at end of feeding -Infant appears content after feeding -has at least 3 substantive bowel movements and six to eight wet diapers every 24 hours after day 4

Newborn Vital signs: TEMPERATURE

-Normal range: 97.9-99.4 -Axillary: 97.5-99 -Skin: 96.8-97.7 -Rectal: 97.8-99

MOTHER signs of effective breastfeeding

-Onset of copious milk productions (milk is in) by day 3 or 4 -Firm tugging sensation on nipple as infant sucks but no pain -uterine contractions and increased vaginal bleeding while feeding (first week or less) -Feels relaxed and drowsy while feeding -Increased thirst -breasts soften or feel lighter while feeding -With milk ejection (let-down), can feel warm rush or tingling in breasts, leaking of milk from opposite breast

Superficial venous thrombosis signs

-Superficial pain and tenderness, warmth, redness, enlargement, firmness

Frequency of breastfeeding

-at least 8-12times in 24 hours -every 2 to 3 hours throughout a 24 hour period

Benefits of breastfeeding for families and socities

-convenient: ready to feed -no bottles or other necessary equipment -less expensive -reduced annual health care costs -less parental absence from work because of ill infant -reduced environment burden related to disposal of formula packaging and equipment

Newborn medications Eye prophylaxis: Erythromycin

-helps prevent ophthalmia neonatorum (neonatal conjunctivitis) -Mandated by law in KY -Normally given within 1-2 hours of birth •Neonatal conjunctivitis is caused by sexually transmitted bacteria acquired by passing through the birth canal; primarily for neissera gonorrhea which can lead to blindness •For eye prophylaxis, can also give tetracycline or Silver nitrate

Von Willebrand Disease

-is a type of hemophilia resulting from deficiency of von Willebrand clotting factor. Desmopressin releases VW factor and factor vIII -Signs of recurrent bleeding episodes, bruising easily, prolonged bleeding time and bleeding from mucus membranes -Treatment: Desmopressin

Different newborn gestational ages

-premature: before 37 wks -late preterm: 34 0/7 - 36 6/7 wks -Early term: 37 0/7 - 38 6/7 wks - Full term: 39 0/7 -40 6/7 -Late term: 41 0/7 - 41 6/7 - Postterm: 42 0/7 and beyond -Postmature: born after completion of 42 weeks

Jaundice frequent assessment and what to monitor

-q8-12 hours -monitor temperature, hydration, UO, stools, skin integrity

Circumcision Benefits and Pain management

-•prevention of UTIs, reduced risk of penile cancer, reduced risk of acquiring heterosexual acquired STIs (HIV) •Anesthesia and analgesia available as well as nonnutritive sucking and swaddling can assist with pain management. fussiness and disturbed sleep patterns after are normal

Newborn vital signs: PULSE

120-160BPM -during sleep as low as 80bpm -if crying up to 180bpm -apical pulse counted for 1 full min

Postpartum caloric intake

1800-200 kcal/day with an additional 450-500 for lactating women A well balanced diet promotes healing and health

Newborn vital signs: RESPIRATIONS

30-60 respirations -predominantly diaphragmatic but synchronous with abdominal movements

How much blood does a mom lose during a vaginal delivery?

300-500ml of blood

HEPATIC SYSTEM: at birth, infants have iron storage sufficient to last

4-6 months

Average blood loss during a c/section

500-1000ml of blood

Exclusive breastfeeding for first

6 months of life and continues as foods are introduced

Mothers should void how many hours after delivery?

6-8hours •Stool softeners are available. Educate mom on the importance of hydration and movement to help with constipation

Newborn vital signs: BLOOD PRESSURE

80-60/45-40mmHG at birth 100/50mmHg at day 10

Apgar scale measures the

A. appearance P. pulse G. grimace A activity R. respiratory

Nursing interventions for Hemorrhagic (Hypovolemic) Shock

ASSESS, monitor for fluid overload, transfusion reactions, Vital signs, skin, lungs, administer O2, ECG, F/C -start intravenous infusion per standing orders, ensure patient airway

infant integumentary system

All skin structures are present Vernix may be present as well as: üLanugo, milia, desquamation, Mongolian spots, nevi Female genitalia are edematous and may have discharge and spotting due to hormones Male genitalia should have rugae covered scrotal sacs and urethra at the tip of the penis Swollen breast tissue may be present with both sexes

Newborn Behavior

Alternate periods of sleep an wakefulness Six states on continuum from deep sleep to extreme irritability üTwo sleep states (deep and light) üFour wake states (drowsy, quiet alert, active alert, crying) Sleep approximately 16-19 hours a day Influencing factors: gestational age, time from birth, stimuli, medication •Optimal state is quiet and alert, where infant can smile, vocalize and move in synchrony with speech provided to them •Gestational age and level of CNS development affect behavior

Acute pulmonary embolism is treated with

Anticoagulants (IV)

When to assess with Circumcision

Assess every 15-30mins for 1st hour, and then hourly for 4-6 hours; look for bleeding or infection

Signs of a correct latch

Baby's lips are around the nipple AND the areola, top lip will be closer to the nipple, and some areola shows above top lip, more areola is taken in with the lower lip than the top lip, baby's chin is close against breast. Baby's lips are "flanged," not tucked in, you hear baby swallow after every 1 or 2 sucks, listen for a slight pause in baby's breathing which shows he/she is swallowing,

infant neuromuscular system

Brain growth and development is gradual Transient tremors may be present General flexion Muscle tone and strength Limited head control Primitive reflexes

Thermogenic system is

Critical regulation secondary to only respirations and circulation Goal is to provide neutral thermal environment

Causes of Postpartum hemorrhage

Incomplete separation of placenta, uterine atony, uterine prolapse, subinvolution ,retained products •Other causes include traumatic birth, Magnesium, rapid or prolonged labor, chorioamnionitis and use of Oxytocin for IOL or AOL

Babinski Reflex

Infant reflex where if its foot is stroked, the baby's toes fan out

Neonatal Respiratory System Adjustments

Lungs are the site of gas exchange instead of the placenta Multiple triggers for respiratory function Surfactant importance Breaths are shallow and irregular with brief pauses Preferential nose breathers Abdominal breathing Acrocyanosis vs Central Cyanosis Neonatal respiratory function is due largely to diaphragmatic contractions

Newborn transition to extrauterine life

Major adjustments in first 6-8 hours after birth Three stages of transition: üFirst period of reactivity üPeriod of decreased responsiveness üSecond period of reactivity

Stepping reflex

Reflex that causes newborn babies to make little stepping motions if they are held upright with their feet just touching a surface

Newborn neuromuscular system tremors

Transient tremors may be present •Must differentiate tremors; they should not be present when infant is quiet and shouldn't persist past a month of age. Can indicate hypoglycemia, withdrawal, seizure activity

Afterpains are more prominent with which mothers and why?

With woman who have been pregnant more than once. First time mothers generally have a firm uterus and perceive mild cramping whereas more vigorous contractions are common with subsequent pregnancies (afterpains) that resolve in about t 3-7 days. •Afterpains are more prominent when the uterus is overdistended. Combined with Oxytocin and breastfeeding, the pain intensifies because of combined stimulation for contractions.

Rooting reflex

a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple

Deep Venous Thromboembolism(DVT) is treated with

anticoagulant therapy (IV then oral, heparin then warfarin), rest until cleared to ambulate with compressions sock

Medications containing aspirin are not given to women on anticoagulant therapy because

aspirin inhibits synthesis of clotting factors and can lead to prolonged clotting time and increased risk for bleeding

Thermoregulation refers to

balance between heat loss and production. Neutral thermal environment allows the neonate to maintain a normal body temperature to minimize oxygen and glucose consumption

Postpartum UTI's

can result from catherization, pelvic exams, injury. Signs include dysuria, frequency, urgency, low grade fever, CVA tenderness, flank pain. Care involves ABX, pain relief, hydration, hygiene educaition

Thermogenesis is the neonates response to

cold as it attempts to generate heat by increasing muscle activity. Infants assume a position of flexion in an effort to guard against heat loss. They also rely on brown fat deposits, which reserves increase with weeks of gestation

Regurgitation is

common due to immature GI system

MOTHER: normal temperature after birth

during first 24 hours temp can increase to 100.4 as a result of dehydrating effects of labor. after 24 hours the women should be afebrile deviations from this a diagnosis of puerperal sepsis is suggested as well as other infections

Pulmonary embolism signs

dyspnea, tachypnea, tachycardia, apprehension, cough, syncope

The weight loss experienced by most newborns during the first few days is caused primarily by

extracellular water loss

Medical Management of post partum hemorrhage

firm massage of fundus, expression of clots, eliminate bladder distention, F/C placement, -IV infusion of Oxytocin, other medications (Misoprostol, Methylergonovine, Carboprost), ---Continue to monitor vaginal bleeding and uterine tone with medication use -Oxygen placement, -bimanual compression

Postpartum first menstrual flow is the

heaviest and will return to pre-pregnancy flow within 3-4 cycles

Jaundice feedings are essential and to be provided early and often because they can help prevent

hyperbilirubinemia. Newborns should breastfeed within 1-2 hours and should eat 8-12 times in 24 hours. Colostrum acts as a laxative and helps with removal of bilirubin. Bottlefed babies should be fed when stable and should feed every 2-3 hours

Hyperthermia can result from

inappropriate use of external heat sources, increased environmental temps and use of excessive clothes or blankets, or infection. Hyperthermia develops more quickly in an infant due to larger surface area and poor functioning sweat glands. It can result in seizures and neurologic damage

Postpartum hemorrhage discharge instructions

include limit activity to conserve strength, increase dietary iron and protein intake, ask for assistance

Lochia smell should not be offensive in odor, if it is it can be a sign of

infection. Not all VB is lochia; can be from unrepaired lacerations

Central cyanosis

is a late sign of distress and is not normal, indicates hypoxemia; it include discoloration of lips and mucus membranes

Newborn Medications Hepatitis B vaccine

is an IM injection normally given in vastus lateralis of the leg; induces anti Hep B antibodies. Series of 3 shots that can be initiated at birth or at first visit. Must obtain consent. HBIG and Hep B vaccine are given to mother positive for Hep B

Subgaleal Hemorrhage

is bleeding into the subgaleal compartment as a result of traction and shearing forces on the scalp. Blood loss can result in shock so early detection is vital

Mastitis

is inflammation of the breast; characterized by sudden onset flu-like symptoms (fever, chills, body aches), localized pain, hot reddened area. Commonly in upper outer quadrant of breast. Treatment includes Abx, analgesics and antipyretics, rest, hydration

Newborn Hypoglycemia signs

jitteriness, lethargy, poor feeding, temperature instability, respiratory distress, apnea, seizures

First stage of newborn transition

lasts up to 30 minutes after birth. Newborn experiences rises in heart rate than gradually decreases, respirations are irregular and audible crackles can be normal to hear. Grunting, nasal flaring and retractions can also be present but should not persists. The infant is alert and moves spontaneously. Bowel sounds are audible and meconium may be passed

Signs of respiratory distress

nasal flaring, retractions, grunting, bradypnea

If increased levels of unconjugated bilirubin are left untreated...

neurotoxicity can result as bilirubin is transferred into the brain cells

Third stage of newborn transition

occurs between 2-8 hours after birth. There may be brief periods of tachycardia and tachypnea, increased muscle tone and passing of meconium

Type of jaundice depends on

on time of appearance and serum bilirubin levels. Physiologic jaundice appears after 24 hours

Venous Thromboembolic Disorders Nursing care

ongoing assessment, laboratory reports, explain and educate, pain management

Lochia

postpartum uterine discharge. Initially it is bright red and may contain clots and should equate to ½ of a heavy menstrual period. After 3-4 days, it becomes pink or brown and contains old blood, serum, leukocytes and tissue (serosa). At about day 10-14, drainage becomes yellow to white (alba) and lochia can last from 4-8 weeks postpartum. There is usually scant lochia as long as Oxytocin is on board. Also less after C/S due to suctioning during the procedure. Flow will increase with breastfeeding and ambulation. Pooling happens while lying and is not hemorrhage.

With newborn the greatest risk for infection is

prematurity -other risk factors include premature rupture of membranes, chorioamnionitis, maternal fever, antenatal and intrapartal asphyxia, invasive procedures, stress, and congenital anomalies

MOTHER: normal pulse after birth

pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after birth. it gradually decreased over the first 48 hours postpartum. puerperal bradycardia (40-50bpm) is common deviations from this indicates hypovolemia as a result of hemorrhage

Cutaneous Jaundice will turn

skin yellow when blanched. Transcutaneous bilirubinometry can be used to screen and decrease the need for serum bilirubin measurements

Moro reflex

startle reflex

MOTHER: normal respirations after birth

the respiratory rate, which was unchanged or slightly increased during pregnancy, should be within the woman's normal pre-pregnancy range soon after birth

Causes of heat lass:

thin layer of subcutaneous fat, superficial blood vessels, environmental changes, convection, radiation, evaporation and conduction

Immature intestinal mucosa allows

transport of bacteria across the intestinal wall into systemic circulation; can cause allergies or infection. In intestines are sterile at birth; oral and anal orifices change sterile environment

DVT signs

unilateral leg pain, calf tenderness, swelling, + Homan sign

What is retained placenta?

when the placenta hasn't been delivered in 30 minutes despite traction on the umbilical cord and uterine massage

Wound infections treated with

•Abx and debridement. Important to teach good hygiene, providing pain management

newborn Acrocyanosis and cyanosis

•Acrocyanosis is normal for first 24 hours. It's bluish discoloration of the hands and feet. Central cyanosis is a late sign of distress and is not normal, indicates hypoxemia; it include discoloration of lips and mucus membranes

Post partum hemorrhage management

•Assess uterus: firm or boggy? ---If boggy, management is geared towards increasing contractility •Visual or Manual inspection ---•If still bleeding, identify and treat source •Nursing Interventions: Recognize signs, calmly explain interventions •Laboratory studies (H&H, coagulation, platelets) -Surgical management

Discharge topics for mom

•Be able to provide basic care for self and infant •Signs of Potential Complications •Nutrition •Exercise •Family Planning •Resumption of sexual activity •Prescribed medications •Follow-up instructions

Care for Lacerations of the Genital Tract

•Care includes suturing, providing pain medication and hot/cold applications as desired -Increased fiber diet and stool softeners are recommended

Hematomas

•Collections of blood in connective tissue •Vulvar, vaginal and retroperitoneal •Painful •Surgically evacuated -Pain relief, monitor bleeding, replace fluids and review H&H •Vulvar is most common. Retroperitoneal are life threatening due to association with rupture of a C/S scar during labor

With postpartum hemorrhage why is character of blood noted is important?

•Color and consistency of blood can tell information of origin. Dark red blood can be venous in origin from varices or superficial lacerations. Bright red bleeding can indicate cervical lacerations. Blood with clots can be from placental separation. Failure to clot can indicate DIC

Subinvolution of the uterus

•Delayed return of uterus to normal size and function •Due to retained placenta fragments and infection •Signs: prolonged lochia, irregular or excessive bleeding, large or boggy uterus •Can treat with medication or D&C; Abx if needed -Causes late postpartum bleeding

Postpartum interventions for promoting ambulation and exercise

•Early ambulation correlates with decreases VTE risk and promotes return of strength •TED hose and/or SCDs for those in bed for 8 hours or more •Kegel exercises •Bed exercises include flexing and rotating ankle, flexion and extension of knee

Hemorrhagic (Hypovolemic) Shock

•Emergent complication of hemorrhage •Perfusion to organs is compromised and can become necrotic •Shunting to vital organs takes place, leaving organs such as the uterus to accumulate lactic acid and acidosis (causes arteriole dilation). Circular pattern is established: decreased perfusion, increased tissue anoxia and acidosis, edema formation and pooling of blood further decreases perfusion)

Postpartum endocrine changes include

•Estrogen and Progesterone decrease •HCG remains detectable •Reversal of diabetogenic effects •Thyroid volume gradually returns at 3 months •Basal metabolic rate gradually returns •Prolactin increases •Return of ovulation and menstruation

Newborn tests and screening

•Heel puncture, Venipuncture, Urine, Stool (Tests include CBC, glucose as needed, arterial blood gases. Warm heel to help with blood flow. Understand it is painful to infant so allow support system to help calm and comfort infant. ) •Genetic Screening (collected within 24hrs and before discharge) •Newborn Hearing Screen (done before hospital discharge and no later than 1 month of age) üNon-invasive, measures response to sound •Critical Congenital Heart Disease(screen between 24-48hrs) üNon-invasive, goal to detect hypoxemia

Coagulopathies

•Idiopathic Thrombocytopenic Purpura •Von Willebrand Disease •Suspect when bleeding is continuous and there is no identifiable source

Venous Thromboembolic Disorders

•Includes Superficial venous thrombosis, DVT and PE -DVT most common in pregnancy and PE most common postpartum -Cause by venous stasis and hypercoagulation •Caused by formation of blood clot inside a blood vessel or by inflammation or partial obstruction of thee vessel •C/S nearly doubles risk for VTE; rationale for compression socks

Uterine changes

•Involution •Contractions •Placental Site •Lochia üRubra, serosa, alba •Cervix •Vagina and Perineum •Hemorrhoids

Formula preparation

•Iron-fortified •Cow's milk based, soy milk based, casein-whey hydrolysate formula and amino acid formula •Powder, concentrate and ready to feed forms •Mix with sterile water •Never microwave bottle •Commercial formula resembles human milk as closely as possible; content varies amongst manufacturers •Mix with boiled water

Guidelines with formula feeding

•It's ok to wake infant to feed. An infant showing signs of adequate weight gain can be allowed to sleep at night and fed only when awakening •Never prop a bottle due to aspiration risk and risk of caries development •Newborns must learn to coordinate suck, swallow and breathing; fast flowing milk can create difficulty so start with a slow flowing nipple •Falling asleep or ceasing to suck indicates adequate consumption. To minimize spit up, Burp during feeds and after, hold upright for 30 mins after feeds, avoiding bouncing •Be sure to wash bottles and nipples with warm soapy water, boil for 5 mins and air dry. Boil before first use

What is Postpartum Hemorrhage

•Leading cause of maternal morbidity and mortality •Greater than 500 ml (vaginal) or 1000 ml (cesarean) •Can be acute onset or delayed •Also based on Hematocrit changes, the need for transfusion and subjective observations

Nursing intervention for Vaccinations for Future Pregnancies

•MMR (given before discharge) •Varicella (given before discharge and 2nd dose at PP follow up) •Tdap •Rh immune globin (Rhogam) (given within 72 hours)

Hypoglycemia in Newborn

•Maternal glucose source is cut off at birth •Protocols for monitoring vary amongst facilities •Risk factors: prematurity, mothers with DM, SGA or LGA •Feed within an hour and test 30 mins after feed •Infant depends on intake, glycogen, fatty acids and ketones to maintain glucose levels •Glucose less than 40 warrants treatment

Postpartum intervention for promoting comfort

•Non-pharmacologic methods: üDistraction, imagery, therapeutic touch, relaxation, acupressure, aromatherapy, hydrotherapy, massage, music, TENS üWarmth, ice, position changes, sitz bath üLanolin •Pharmacologic methods: üOpioids and non-opioids üScheduled NSAIDS •Afterpains are more severe during and after breastfeeding

Postpartum nursing interventions for adaptations to parenthood?

•Positive interactions include: üTaking pleasure in providing infant care üRespond to feeding cues üProvide comfort •Signs of concern: Negative talk toward self or baby, lack of support, difficulty sleeping or eating, unwillingness to discuss birth experience

Nursing interventions for postpartum care

•Prevent Excessive bleeding •Maintain uterine tone •Prevent bladder distention and promote elimination •Prevent Infection •Promote comfort and rest •Promote ambulation and exercise •Promote nutrition and lactation

Birth Injuries

•Retinal and subconjunctival hemorrhages •Erythema, ecchymoses, petechiae, abrasions, lacerations, edema •Injuries may be present at presenting part or throughout entire body; must note because petechiae can be from more serious conditions (differentiate by blanching skin) •Lacerations may also result from accident during C/S; normally superficial

Postpartum urinary system

•Return to normal function within 1 month •Loss of excess fluid (12 hours of birth. UO of 3000 ml or more during first 2-3 days are common.) •Bladder tone (normally restored 5-7 days after birth) •Stress incontinence

Postpartum Psychosis

•Seeing things and hearing things that aren't there •Feelings of confusion •Rapid mood swings •Trying to hurt self or baby

Birth injuries: Retinal and subconjunctival hemorrhages

•Subconjunctival and retinal hemorrhages: Harmless injuries due to rupture of capillaries caused by increased pressure during birth; usually resolve in 5 days

Lacerations of the Genital Tract

•Suspect if uterus is firm and contracted but bleeding persists -Slow, oozing trickle or frank •Due to operative birth, precipitous delivery, abnormal presentation of fetus •Includes 1-4th degree as well as episiotomies •Involves tears to the cervix, vagina and perineum •Prolonged pressure of the head on the vaginal mucosa makes it necrotic and cause tears and lead to hematomas

Correct bathing techniques with baby

•Swaddled bathing helps prevent heat loss (one part removed at a time), daily bath is not necessary (every other day), clean the cord with water. Stump dries in 24-48 hours; assess for redness, edema, drainage; keep clean, dry and open to air. Cord hardens, shrivels and blackens by day 2 or 3. Average separationtime is 10-14 days but can take 3 weeks

Discharge planning regarding newborn needs to involve education throughout stay on these topics

•Thermoregulation •Respiratory measures •Feeding patterns •Elimination •Safe Sleep •Skin care •Clothing •Car seat safety •Nonnutritive suck and pacifiers •Bathing •Provider Follow-up (within 72 hours of discharge) •Soothing techniques

Postpartum nursing interventions for Preventing Excessive Bleeding and maintaining tone

•Uterine Atony üProvide fundal massage •Subjective and objective assessment of blood loss •Empty bladder •Always assess both pad and underneath buttocks where blood may pool

Inversion of the uterus

•Uterus turns (inside out) •Rare but life threatening emergency •Incomplete, complete, prolapsed •Signs: sudden hemorrhage, shock and pain, unable to palpate uterus abdominally •Prevention is key •intervention: Fluid resuscitation, replacement of uterus •Incomplete cant be seen but is more palpated. With complete, the fundus crossed through the cervical os and forms a mass in the vagina. Prolapsed is obvious, where a large, red rounded mass protrudes out the introitus •Don't pull umbilical cord unless there are signs of placental separation, avoid aggressive fundal massage

Newborn urine output

•Voids: 2-6/day in first several days of life. Increases to 6-8/day •An infant who hasn't voided in first 24 hours should be assessed for adequacy of fluid intake, bladder distention restlessness and symptoms of pain

Postpartum infections

•Wound Infections •Mastitis •Endometritis •Urinary Tract infections •Postpartum or puerperal infections are any clinical sign of infection in the genital tract that occurs with 2 days after miscarriage, birth or abortion •Common in women with concurrent medical or immunosuppressive conditions; Also with C/S or operative delivery

Human milk is the gold standard for infant nutrition. The composition changes to meet the needs of a growing infant; contains

•anti-infective components, enzymes, growth factors and fatty acids. Infant formula provides adequate nutrition to maintain growth an development but is not equivalent •During each feeding, fat gradually increases from lower foremilk to richer hindmilk that contains calories needed for growth •Pasteurized donor milk from a milk bank is available for mother's who may want to breastfeed but aren't able to

Postpartum Wound infections

•are common after mom is discharged home; commonly at incisional or laceration/episiotomy sites. Involves Abx and debridement. Important to teach good hygiene, providing pain management

Engorgement or engorged breasts

•are hard and uncomfortable. Can be relieved and typically lasts 24—48 hours •Day 3 or 4, women may have engorgement. Tenderness is due to congestion of veins and accumulation of milk. Milk should not be expressed. Engorgement will resolve on its own or can be assisted with binders, tight bras, ice packs, cabbage leaves. If sucking or milk expression is never begun, lactation ceases with a few days to a week.

Correct elimination with newborn

•at least 2-6 for first 1-3 days, then 6-8 voids per day, pale yellow urine, stool changes (mec to yellow and seedy), odor differences with breast or bottlefed, loose stools for breastfed and should be atleast 3 q24 hours, bottlefed may have 1 every other day

(formula feeding) Paced feeding:

•baby sits upright, hold bottle at a horizontal angle and withdraw the nipple as the infant pauses and allow rest until infant is ready to suck again

Postpartum Mastitis

•breast infection) happens amongst breastfeeding women; symptoms include fever, malaise flulike symptoms and sore breast

Prolactin during pregnancy prepares the

•breast to secrete milk and during lactation to synthesize and secrete milk. Oxytocin is responsible for let down reflex (also known as milk ejection reflex (MER)), which can be triggered from sights, sounds, warmth, sexual excitement •As milk is removed from breast, more is produced. Incomplete removal can lead to decreased supply

Endometritis is treated with

•broad spectrum ABX and supportive care (hydration, rest, pain relief)

Pacifiers education

•can be offered for naps but not forced; delay use for 3-4 weeks to ensure breastfeeding is established. Thumb sucking is ok until age 4

Postpartum Depression

•can begin anytime within 1st year •Same signs as baby blues but they last longer and are more severe •Thoughts of harming self or baby •Not having interest in the baby

Plugged ducts

•can cause swollen and tender breasts due to decreased emptying (may see visible clog at the nipple). Can be caused by tight clothing, poor fitting bra, and using the same position with feeds. Providing warmth and massaging prior to feeds can help promote emptying.

Sore nipples with breastfeeding is

•common! However, severe pain or soreness, abraded, cracked or bleeding nipples are not normal; result from poor positioning, latch, improper suck or infection. Key to prevention is correct breastfeeding technique; intervene early and correct the problem. To assist; colostrum can be applied to nipple as moisturizer; break suction and reposition if pain when latching

Colostrum

•early milk, yellow may be expressed. Breasts get heavier and fuller as more mature milk develops by 72-96 hours after birth. Blueish, white milk is true milk can then be expressed. Nodules develop as milk glands and ducts fill.

Caput succedaneum

•edematous area of the scalp due to sustained pressure on presenting vertex. It extends across suture lines and usually disappears over 3-4 days

Cephlahematoma

•is a collection of blood between the skull bone and periosteum; does not cross suture lines. Its more firm and more defined; resolves in 2-8 weeks

Breastfeeding LACK OF SUPPLY

•is a major reason women stop breastfeeding. Interventions include trying KC prior to feeds, increase feeding frequency, express milk via pump and reduce stress. Galactogogues (meds) and herbs can help increase supply

Idiopathic Thrombocytopenic Purpura

•is an autoimmune disorder in which platelet antibodies decrease the life span of platelets -Signs: Thrombocytopenia, capillary fragility and increased bleeding time -Treatment: platelet stability, treat with corticosteroids or IV immunoglobin, transfusion

Postpartum Endometritis

•is an infection of the lining of the uterus; most common postpartum infection; signs include fever, increased pulse, chills, anorexia, uterine tenderness, foul smelling lochia, leukocytosis. Treat with broad spectrum ABX and supportive care (hydration, rest, pain relief)

Pathologic jaundice

•is increased with higher levels of unconjugated bilirubin and require phototherapy to resolve; can be present in the first 24 hours.

Involution

•is the return of the uterus to a nonpregnant state after birth. It begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle

Jaundice and types of jaundice

•is the yellow color of the skin and sclera caused by elevated levels of unconjugated (indirect) bilirubin. -Physiologic jaundice, pathologic jaundice, Jaundice related to breastfeeding

Jaundice risk factors

•less than 38 weeks, exclusive breastfeeding, jaundice in a sibling, hemolytic disease, significant bruising, east Indian race

At the end of the third stage, the uterus is normally

•midline and approx. 2 cm below the umbilicus, Within 12 hours the fundus can rise to 1 cm above the umbilicus. By 24 hours after birth, the uterus is about the same size it was at 20 weeks gestation. The fundus descends 1-2 cm every 24 hours. By day 6 PP, the fundus is normally located halfway between the umbilicus and symphysis pubis. The uterus should not be palpable after 2 weeks and should return to pre-pregnancy state by 6 weeks. Subinvolution is the failure to return to non-pregnant state.

With postpartum hemorrhage rare adherence of the placenta to the

•myometrium can make removal difficult, causing lacerations or perforation of the uterine wall. This will increase PPH and infection risk. Slight penetration of the myometrium is an accrete. Deep penetration of the myometrium is an increta. Perforation of the uterus is a percreta. These can be recognized via MRI but are often noticed after birth when there is excessive bleeding. May call for blood transfusions and hysterectomy if bleeding is uncontrolled but is best managed if discovered early and there is no manual attempt to removed placenta

Jaundice treatment

•phototherapy, exchange blood transfusion •is based on levels present, gestational age and presence of risk factors. The goal is to reduce levels of unconjugated bilirubin. Phototherapy uses light energy to change shape and structure of unconjugated bilirubin, converting it to conjugated so that it can be excreted in urine and stool; effectiveness is based on distance between the lights neonate and the surface of skin exposed. The neonates eyes are covered to prevent damage. Levels should decrease within 4-6hours -Infant is often wearing just a diaper and lights can cause perspiration

Persistence of lochia rubra is due to retained fragments of the

•placenta or membranes. There may be an increase in bleeding from days 7-14 due to the placenta site sloughing but if it's persistent, pt should be evaluate for retained products.

Medical Management for Hemorrhagic (Hypovolemic) shock

•restore circulation, eliminate the cause of hemorrhage, two large bore IVs for fluid resuscitation, PRBCs (Packed red blood cells) and FFP(fresh frozen plasma) if needed

Engorgement

•results from hormone changes and the onset of increased milk volume; normally occurs 3-5 days after birth. Volume exceeds alveoli storage capacity and if milk is not removed, alveoli become distended (and impairs blood flow).Fluid then leaks into surrounding tissue (edema), which can compress milk ducts. The breasts will be firm, tender and taut. Relieve by feeding or pumping q 2 hours, cold packs, chilled cabbage leaves, anti-inflammatory meds, breast massage. Warmth can help with expression and let down reflex

Respiratory measures for newborn that parents must be educated on

•signs of distress, use of bulb suction, ways to avoid suffocation, avoid powders due to lung irritation, smoke exposure, limitation of visitors, feed smaller meals if sick

If infant appears jaundiced in first 24 hours..

•tcB or total serum bilirubin level should be measure and results interpreted based on newborn's age. If greater than 12 mg/dl, a serum bili is checked. To prevent more serious complications, routine screening of all newborns should be done before hospital discharge

Postpartum hemostasis is achieved by

•uterine contractions instead of platelet aggregation and clot formation. Oxytocin from the pituitary gland strengthen and coordinates contractions. These contractions peter out within 1-2 hours so exogenous oxytocin may be needed to keep the uterus firm and contracted. This can be given IV or IM after placental expulsion. Breastfeeding can also increase endogenous release and decrease bleeding.

When the neonates temperature drops,

•vasoconstriction occurs to conserve heat. If it persists, cold stress will impose metabolic and physiologic demands on infants: increasing need for oxygen as RR increases, metabolic acidosis can develop, hypoglycemia

Thermoregulation education for newborn that parent must be educated on

•ways to promote normal temp, use of wraps/blankets in cold, methods for obtaining temps, signs of abnormal temps

Common Concerns with Breastfeeding

◦Engorgement ◦Sore Nipples ◦Insufficient supply ◦Plugged Ducts ◦Mastitis

Newborn Feeding Cues

◦Hand to mouth movements ◦Sucking motions ◦Rooting reflex ◦Mouthing •Instead of waiting to feed when the infant is crying and distraught, feed when cues are exhibited

Contraindications for breastfeeding

◦Newborns with galactosemia --•Galactosemia: Group of inherited disorders that impairs the body's ability to process and produce energy from a sugar called galactose. ◦Mothers with human T-cell lymphotrophic virus ◦Active TB ◦Active Herpes lesions on breast ◦Maternal HIV infection (in US)

Formula feeding

◦Normal intake: 15-30 ml/feed in first 24-48 hours ü90-150 ml by end of second week ◦Feed every 3-4 hours (6-8 feeds in 24 hours) ◦Always hold during feedings ◦Paced Bottle feeding