POSTPARTUM CARE
Postpartum Psychological Adaptations Reva Rubin
Taking in: Mom wants to talk about her experience of labor & birth, preoccupied with her own needs
Taking hold: More ready to resume control of her body, baby & taking on mothering role. Needs reassurance if inexperienced.
Letting-go: by 5th week, total abandon to NB
Bonding: en face position, engrossement. Encourage through early interaction & breast-feeding (within 1/2 hr of birth is best).
Maternal Responses to NewbornReva Rubin
Touch- progresses from fingertips → palming →cuddling →
Voice- high-pitched & babies respond Odor- mom’s respond to baby’s unique smell Eye contact- en face position delay eye ointment & bright lights Nurse role- be able to answer ? About baby
Blues vs Dpression Postpartum/baby blues: transient depression in first few days: weepiness mood swings anorexia difficulty sleeping feeling of letdown
Postpartum Depression *If persists past 2 weeks, or worsens Symptoms: very sad feelings hopeless worthless anxiety trouble caring for and bonding with your baby Have trouble sleeping. Not be able to concentrate. Not feel hungry and may lose weight. (But some women feel more hungry and gain weight)
Postpartum Psychosis A woman who has postpartum psychosis may feel cut off from her baby.
She may see and hear things that aren't there. Any woman who has postpartum depression can have fleeting thoughts of suicide or of harming her baby. But a woman with postpartum psychosis may feel like she has to act on these thoughts.
Endocrine Adaptations Hormones: drop after delivery of
placenta.– hCG & hPL gone by 24 hours– Estrogen & progesterone drop within 1 wk– FSH remains low for 12 days, then rises
to begin new cycle– Sex is ok once lochia is alba. Menstrual
period in 6-10 wks. – Contraception necessary.
Physiological Adaptations Uterine involution
– @ umbilicus first 24 hours--should feel firm– Decreases 1 finger’s breadth per day– By 10th day, no longer palpable
If high (3 or 4 fingers above U) and/or deviated to right, have pt. void
Risk for delayed involution:– Multiples, hydramnios, exhaustion, grand
multiparity, excessive analgesia Afterpains www.youtube.com/watch?v=EbItF_7KYCc&feature=related
Fundal Assessment
Every 10-15 mins in first hour. Supine position Palpate: one hand at base of uterus & other at
umbilicus. Press inward and downward and feel for firm globular mass.
Assess: – Height (fingers above/below umbilicus)– Position (midline, deviated to right or left)– Consistency: firm, soft, boggy
If not firm, massage & should become firm. If still boggy, notify MD/assess for clots, hemorrhage. Administer oxytocin or other oxytocic (methergine, hemabate).
Lochia
Rubra: Red, day 1-3, blood Serosa: Pinkish or brownish, day 3-10,
blood, mucus, leukocytes Alba: whitish, day 10-14 (may last 6 wks),
largely mucus & leukocytes If flow increases, woman should rest more Warning sign: if lochia returns to previous
type (alba to serosa, or serosa to rubra)
Lochia Assessment
Check q 15 mins in 1st hour. Assessment:
– Color (rubra, serosa, alba), amount, odor, presence of clots.
– Constant trickle of vaginal flow, or soaking pad every 60 minutes is more than average. Can weigh pads--1 gm = 1 ml of blood.
Lochia should not exceed a moderate amount: 4 to 8 partially saturated pads/day
Lochia Assessment Assessing Amounts:
– Scant: peripad has stain less than 1 inch in length after 1 hour
– Small: stain less than 4 inches after 1 hour--10-25 mL
– Moderate: stain less than 6 inches after 1 hour--25-50 mL.
Instruct in perineal care: ∆ pad frequently, hand washing, s/s of infection & hemorrhage, no tampons
Cervix & Vagina
Cervix returns to firm, nongravid consistency by about 7 days, but external os remains slit-like or stellate
Vagina involutes in 6 wk period, with return of rugae. – Kegel exercises for pelvic floor muscles.
Isolate muscles to contract by stopping flow of urine while urinating.
Contract these muscles in sets of 10 or 20, 3 times per day.
Perineum
Assessment: turn pt to side in Sim’s position. Lift upper buttock and assess for:– Ecchymosis, hematoma, erythema,
edema, intactness, approximation, drainage or bleeding from stitches
Assess for hemorrhoids & document number, appearance & size
Episiotomy
Midline or mediolateral Nursing care:
– Assess for approximation, swelling, oozing, infection
– Relief for pain: ice pack in first 24 hours, then heat, local analgesic spray, witch hazel pads (Tucks), sitz bath, peri-bottle for voiding, pain medications
Other Assessments
Constipation: Give stool softeners as ordered, prune juice, encourage ambulation, adequate fluid intake, fiber in diet.
Homan’s sign: assess calves for redness, warmth, pain, swelling.
-↑risk of DVT, thrombophlebitis. -Occur in postpartum because:
– Fibrinogin level is elevated– Dilatation of lower extremity veins– Relative inactivity during labor or prolonged time in
delivery room stirrups leads to pooling, stasis & clotting of blood in lower extremities.
Thrombophlebitis
Superficial leg vein disease:– S/s: tenderness in portion of vein, local heat &
redness, normal temperature or low-grade fever– Tx: local heat, elevate limb, bed rest, analgesia,
elastic support hose
Deep Vein Thrombosis (DVT):– S/s: edema of ankle, leg, initial low-grade fever,
then high temperature & chills, tenderness & pain, changes in limb color & difference in circumference
– Tx: IV heparin, bed rest, elevation of leg, analgesics, warm moist heat, antibiotics
Urinary Retention
Diuresis begins p birth to rid extra fluid (2000-3000 mL)
Trauma to bladder & urethra during birth or anesthesia may cause loss of tone, difficulty sensing need to void
Must assess abdomen frequently to prevent permanent damage to bladder from over distention. Check fundus to see if bladder is full. If unable to void, catheterize. Monitor for UTI.
Vital Signs
May have slight elevation of temp in 1st 24 hours--dehydration. If 100.4 or above, suspect infection.
Rapid or thready pulse--sign of hemorrhage. BP: monitor--still at risk of PIH. Methergine
(oxytocic) can ↑BP. ↓BP could be sign of hemorrhage.– Can have orthostatic hypotension due to blood
loss. Assist pt. with first trip to BR. Instruct pt to dangle legs and sit first, before rising. If dizzy, do not ambulate.
Breast Assessment Breasts
– Soft: Soft on palpation, day 1 & 2– Filling: firmer & warmth, day 3– Engorged: appear large, reddened, taut,
shiny skin, warm, hard, tense & tender/painful on palpation
– Mastitis (infection): only one part of breast is warm/reddened--UNILATERAL
Nipples: look for cracking, fissures, blisters, pain
Lactation
Engorgement: day 3 or 4.– If breastfeeding:
Encourage frequent breastfeeding.Warm compresses or warm shower.
– If not breastfeeding:Cold compresses/ice, snug bra or breast
binder, oral analgesics. Breast care:
– Wash daily with water and air dry –NO SOAP– Advise pt to wear nursing bra--1-2 sizes larger
than bra during pregnancy. Avoid underwires. Use cotton nursing pads for leaking--keep nipples dry.
Discharge Instructions
Avoid/limit heavy lifting, stairs. Good diet, increase fluids if
breastfeeding. Adequate rest, exercise/activity as
tolerated. Report fever, foul smelling discharge,
increased pain or bleeding to MD. Sex/contraception. Follow up in 6 weeks with MD.
Postpartum Complications
Postpartum Hemorrhage– CAUSES: Uterine atony, lacerations, retained
placental fragments Risk factors:
– ↑ uterine distension: multiples, polyhydramnios, macrosomia, fibroids
– Trauma: rapid or operative birth– Placental problems: previa, accreta, abruptio,
retained placental fragments– Atonic uterus: prolonged pitocin, magnesium
sulfate or labor; ↑ maternal age or parity; uterine scar; chorioamnionitis; anemia; prior history
– Inadequate blood coagulation: fetal death or DIC
Hemorrhage
Interventions:– Fundal massage, ensure
bladder emptying. If uterus is firm but bleeding persists, suspect laceration.
– Administer oxtocics (pitocin, methergine, hemabate, prostaglandins), blood replacement.
– Frequent assessment of bleeding, vital signs. – MD: Bimanual massage,
manual exploration of uterus, uterine packing, D & C, hysterectomy.
Hemorrhage (cont.)
Lacerations: cervical, vaginal, perineal
Retained placental fragments: – can occur well after delivery. Maternal serum test
for hCG or US. Possible D&C.– May see symptoms even after 1 week
Subinvolution: retained placenta, infection, fibroids– PO methergine, antibiotic.
Hematomas Cause:Trauma during the birth process Puerperal hematomas occur in 1:300 to 1:1500 deliveries Most puerperal hematomas arise from bleeding lacerations
related to operative deliveries or episiotomy; however, a hematoma may also result from injury to a blood vessel in the absence of laceration/incision of the surrounding tissue
Most common locations for puerperal hematomas are the vulva, vaginal/paravaginal area, and retroperitoneum
Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams, preeclampsia, prolonged second stage of labor, multifetal pregnancy, vulvar varicosities, or clotting disorders
Assessment: location, size, vital signs, pain, H&H Treatment: evacuation and repair of bleeding source by MD
Postpartum Infection
Puerperal Infection: Endometritis infection of reproductive tract within 6 wks of
childbirth Increased risk with:
– C-section– Prolonged ROM, chorioamnionitis– Retained placental fragments– Preexisting anemia– Prolonged/difficult birth, instrumental birth– Internal fetal monitoring or IUPC– Uterus explored after birth/manual removal of
placenta– Preexisting vaginal infection (BV or chlamydia)
Postpartum Infection
Endometritis: infection of endometrium– Associated with chorioamnionitis & C-
section – S/S: foul-smelling, bloody vaginal
discharge, fever (day 3 or 4), uterine tenderness, tachycardia, chills. (Elevated temp. in 1st 24 hours and elevated WBCs are normal findings.)
– Can progress to pelvic cellulitis or peritonitis.
Endometritis TX: antibiotics as determined by culture of
lochia; oxytocics such as methergine, if necessary, ↑ fluid intake, pain relief
Nursing considerations: Fowler’s position or walking encourages drainage by gravity, gloves, strict handwashing
Usual course is 7-10 days May result in tubal scarring & interfere with
future fertility
Postpartum Infection
Nursing Interventions & Discharge Teaching– Strict handwashing & instruction for pt & family– Instruct re proper perineal care
Wiping front to back, washing after voiding/ defecating, changing peripads frequently
– Well-balanced diet with adequate protein, calories, vitamin C and fluids (2000 mL/day)
– Encourage sitz baths, early ambulation.– Monitor vital signs and report s/s of infection– Assess pain and administer analgesics– Promote rest, relaxation, bonding with infant if
separated.
Post op C/Section Complications
1.Paralytic Ileus
2. Wound Dehiscence
3.Wound infection
1. A mother is experiencing shaking chills during the hour following birth. What is the nurse’s initial action?
A. Take a rectal temperatureB. Notify the physician or nurse-midwifeC. Cover the woman with warmed blanketsD. Review the order sheet for antibiotic orders
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2. The nurse assesses a postpartum client and palpates the fundus at 2 cm above the midline and deviated to the right. What is the appropriate nursing action?
A. Encourage the client to breastfeed B. Assist the client to empty her bladder
C. Assist the client to a prone position and place
a small pillow under her abdomen D. Massage the fundus
3. A nurse is caring for a client who is 2 hours postpartum who complains of severe, unremitting vaginal pain and inability to void. The fundus is firm at the umbilicus with moderate lochia rubra, and the perineum appears edematous with significant bruising. The nurse suspects the client may have
A. A fourth-degree episiotomy. B. Distended bladder.
C. Hematoma. D. Endometritis.
4. A 6-day postoperative C-section client calls the clinic nurse and complains of malaise and increased pain on the right side of her incision with increased drainage. What should be the nurse’s correct initial response?
A. Instruct the client to take her pain medication as prescribed B. Notify the physician or nurse-midwife C. Instruct the client to increase rest and seek assistance with
household tasks D. Instruct the client to call the physician or nurse-midwife if her
temperature reaches 100.8.
5. A 6-day postpartum client complains of fatigue and episodes of crying during the past two days. Which of the following statements is a correct response by the nurse?
A. “This must be very difficult for you.” B. “This sounds like postpartum blues. It is a normal response to birth.” C. “You sound exhausted. Try and sleep when the baby sleeps.” D. “This sounds like postpartum depression; you should
contact your physician or nurse-midwife for a referral to a counselor.”
6. A nurse is caring for a client with a superficial thrombophlebitis. Which of the following is the most appropriate nursing action?
A. Administer anticoagulants per orderB. Elevate the affected limbC. Apply ice packs to the affected limbD. Administer antibiotics per order
Breastfeeding www.youtube.com/watch?v=CIZ6rVzs4CE&feature=Pl
ayList&p=BD065FA5F03CD81A&index=38 (Breastfeeding Basics)
www.youtube.com/watch?v=RuvJZGFOHU&feature=PlayList&p=1330DE183266B0BC&playnext=1&playnext_from=PL&index=3 (What’s the Big Deal?)
www.youtube.com/watch?v=Ox8ht-EVnQA&feature=PlayList&p=1330DE183266B0BC&index=8 (latch-on 1)
www.youtube.com/watch?v=WOQzEN_dcPc&feature=PlayList&p=1330DE183266B0BC&index=9 (latch-on 2)
The Amazing Newborn
Profile of a Newborn
Vital statisticsWeight: 2.5 to 3.4 kg. Immediately after birth.
Establishes baseline. Baby may lose up to 5-10%.
Length: 18 - 21 inchesHead Circumference: 32 - 35 cmChest Circumference: 32 - 35 cmVital Signs: Heart Rate 120-160 bpm;
Respirations 30-60 breaths/minute; Temperature 97.6- 98.6 axillary
Profile of a Newborn
Temperature: Can be unstable. Guard against loss due to:
Convection Conduction Radiation Evaporation
Dry immediately with warm blankets
Cardiovascular Changes after Birth
Closure of the ductus arteriosus/fetal shunts occurs when a neonate takes in oxygen through the lungs for the first time and when the lungs inflate, pressure in chest decreases (pulmonary artery)
Common to have acrocyanosis, investigate central cyanosis (look at mucous membranes)
Transition from fetal to postnatal circulation: “transitioning”
Critical Thinking During a prenatal examination, an adolescent
client asks, "How does my baby get air?" The nurse would give correct information by saying:
A) "The fetus is able to obtain sufficient oxygen due to the fact that your hemoglobin concentration is 50% greater during pregnancy."
B) "The lungs of the fetus carry out respiratory gas exchange in utero similar to what an adult experiences."
C) "The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into your bloodstream."
Acrocynanosis
Cyanosis
Respiratory
Breathing is a result of replacement of air for fluid
Takes longer for a c-section baby to initially establish effective respirations because excessive fluid blocks air exchange space (baby’s chest not compressed and squeezed in birth canal)
Factors predisposing respiration problems
Maternal history of diabetes
Premature rupture of membranes
Maternal use of barbiturates or narcotics close to birth
Non-reassuring fetal monitoring strip
C-section birth
Cord prolapse Low APGAR Meconium staining Prematurity Postmaturity Small for gestational
age Breech birth Chest, heart or
respiratory tract anomalies
Newborn Assessment: Respiratory Distress
5 symptoms of respiratory distress– Tachypnea– Cyanosis – Nasal flaring– Expiratory grunting– Retractions
Transition period (1-2 hrs post birth) vs signs of respiratory distress that persist
Sleep Wake Cycle
Supine position decreases risk for SIDS
Sleep 16 out of 24 hours, avg. of 3-4 hours at a time (wake q 2-3 for feeding)
Don’t add cereal to diet till 4-6 months of age
Infants should never sleep in parents’ bed
Gastrointestinal
Accumulation of bacteria in GI tract necessary for digestion and synthesis of vitamin K
Uncoordinated peristalsis Limited ability to digest fats & starch (deficient
enzymes) Immature cardiac sphincter-regurgitates easily Stools-
– 1st meconium, sticky tarlike– 2nd-3rd day- transitional (diarrhea like)– BF: 3-4 light yellow/day. Formula: 2-3 bright
yellow/day– Infants receiving phototherapy have bright green
stools as a result of increased bilirubin excretion
Urinary
Very important to observe for first void Urine light colored and odorless--kidneys do not
concentrate urine well
Immune System
Prone to infection Inability to form antibodies until 2 months of
age: most immunizations delayed until then Born with passive antibodies (protect against
diseases such as polio, measles, diphtheria, pertusis, chickenpox, rubella & tetanus)
Hepatitis B vaccine: babies exposed early in life have ↑risk of chronic liver problems– Positive mom: HBIG (Hep B immune globulin)
and vaccine for baby
Profile of a NewbornReflexes
• Neuromuscular function– Rooting reflex– Sucking reflex– Swallowing reflex– Palmar grasp
reflex
Profile of a Newborn
Neuromuscular functionMoro reflexBabinski reflexCrossed extension
reflex
Moro or “startle” reflex
Senses
Hearing- yes Vision- “light” and “dark” in the first
months. Approx 18” range. Touch- well-developed Taste- can discriminate Smell- well-developed
Appearance of a Newborn
Skin: Color should be pinkCyanosis: mottling, acrocyanosis normal.
Investigate central cyanosis. Look at mucus membranes
Hyperbilirubinemia: yellow tone to skin, sclera
Pallor: usually caused by anemia: blood loss?, blood incompatibility?, internal bleeding?
Harlequin sign: normal, immature circulatory system. Dependent side red, upper side pale.
Appearance of a Newborn
Skin Birthmarks
– Hemangiomas: vascular tumors of skin
– Erythema toxicum: innocuous, pink, papular neonatal rash
– Milia: unopened sebaceous glands--tiny, white, pinpoint papules on nose, etc.
Erythema toxicum-newborn rash
Birthmarks Mongolian Spots: hyperpigmentation (usually
disappear by school age)
Appearance of Newborn
Skin•Vernix caseosa: white, cream cheese-like
substance, natural lubricant
•Lanugo: fine downy hair on body
•Desquamation: dry, peeling
Appearance of a Newborn
Head: large-1/4 body length
• Fontanelles• Sutures•Molding•Caput succedaneum•Cephalhematoma
Head Fontanelles: Anterior closes at 12 to 18 mos.
Posterior closes at 2 mos. Sutures: separation indicates ↑ intracranial pressure.
Fused sutures abnormal--evaluate Molding: common in vaginal births. Resolves in first
few days of life Caput succedaneum: edema of the scalp-- crosses
suture lines. Disappears by day 3-4. Cephalhematoma: blood between periosteum of skull
bone and bone itself. Does not cross suture line. Appears 24 hours after birth. May take weeks to disappear. May ↑ jaundice.
Appearance of a Newborn
Eyes: gray/blue. Permanent color after 3 mos. Erythromycin (gonorrhea/chlamydia infection)
Ears: level, recoil, newborn testing
Nose: patency, choanal atresia?
Mouth: symmetrical opening, inspect/palpate palate
Neck: short, free rotation?, rigidity?, masses?
Chest: symmetrical, no masses, retractions
Appearance of a Newborn
Abdomen: appears slightly protuberant, bowel sounds, bulges/masses?, 3 vessels in cord stump?
Anogenital area: imperforate anus• Male genitalia: meatus at tip, (hypo- or epi-spadias), testes
descended• Female genitalia: pseudomenstruation
Back: appears flat, for completion (no pinpoint ✓opening, sinus or dimpling)
Extremities: all moving and symmetrical, legs bowed, clubfoot (talipes equinovarus), subluxated hip/hip dysplagia: check thigh & gluteal creases
Assessment for Well-Being Apgar scoring--10 is perfect score
Done at 1, 5 & 10 minutes• Heart rate• Respiratory effort• Muscle tone• Reflex irritability• Color
• Normal Apgars at 1 minute: 7 to 10
Immediate Care at Birth Keep the newborn warm Promote adequate
breathing pattern Inspection and care of
umbilical cord Eye care Infection precautions
Critical Thinking
The nurse is planning care for a newborn. Which of the following nursing interventions would best protect the newborn from the most common form of heat loss?
A) Pre-warming the examination table
B) Placing the newborn away from air currents
C) Drying the newborn thoroughly
D) Removing wet linens from the isolette
Care of Newborn At Birth Identification and
Registration Identification Band Birth Registration Birth Record
Documentation (vitals, meds,labs)
Continuing Assessment for Well-Being
Respiratory evaluation Physical examination
• Height and weight Laboratory studies: cord blood collected
– CBC, – ABO type & Rh, – Direct Coombs if mom Rh - or Type O– C reactive protein if risk for infection
Assessment for Well-Being
Gestational age – neuromuscular & physical maturity– Ballard Scale• Dubowitz Maturity Scale
Useful in determining large for gestational (LGA) and small for gestational age (SGA)
LGA/SGA: at risk for hypoglycemia BS < 40 mg/dL → feed immediately s/s: jitteriness, lethargy, seizures
SGA (IUGR) vs LGA babies
Periods of Reactivity (P. 690, Pilleterri)
First Period 15-30 minutesAlert, acrocyanosis, body temp falls, irregular
respirations, vigorous reaction to stimuli Resting Period 30-120 minutes
– Color, temperature stabilizing; respirations, HR slowing; sleeping (hard to wake up)
Second Period 2-6 hours– Quick color changes with crying/movement;
temperature increases; irregular respirations, HR; awake and responsive; first meconium passed
Nursing Care: Newborn and Family
Initial feeding Bathing Sleeping pattern Diaper area care Newborn Screening Test
(PKU)– Test for metabolic disorders
(inborn errors of metabolism)
– Done 24 hrs after first feeding
Nursing Care: Newborn and FamilyMedications
Erythromycin opthalmic ointment Vitamin K administration
– GI tract unable to produce Vitamin K (needed for blood coagulation)
– O.5 mg to 1mg IM in thigh– Side effects- local irritation
Hepatitis B vaccination prior to discharge HBIG if needed (first 12 hours) Circumcision- per parent’s consent
Nutritional Allowances
Calories: 110 calories x kg/24 hours
Protein: 2.2 g x kg/24 hours
Fat: need linoleic acid
Carbohydrates: lactose intolerance rarely present in newborn--switch to soy-based formula
Fluid: supplied by breast milk or formula, **do not supplement with water
Nutritional Allowances
Minerals•Calcium• Iron: supplement formula-fed babies
•Fluoride: breastfeeding mom should drink fluoridated H2O. Make formulas with fluoridated H2O. Can supplement.
Vitamins: No supplementation needed until 6 mos.
Breastfeeding Promotion
WHO promotes Breastfeeding around the world
APA advocates breastfeeding for 12 months
Baby Friendly initiatives in hospitals ↑breastfeeding rates and duration
Breastfeeding
Prolactin produced (stimulates milk production) when progesterone levels fall after placenta is delivered
Colostrum- First milk produced: thick, creamy, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins and maternal antibodies--digestible. Has laxative effect to aid baby to excrete meconium.
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Breastfeeding Milk flows from lactiferous
sinuses Fore milk- constantly formed
milk. Low in fat. As infant sucks, oxytocin is
released from the posterior pituitary. Produces let-down reflex
Let-down reflex- stimulation of baby at breast, sound of baby. Hind milk ejected.
Hind milk is formed after the let-down reflex. Higher in fat and calories.
Infant Advantages in Breastfeeding
Less infection: mom’s antibodies passed, breast milk has elements that prevent absorption of viruses & bacteria from GI tract and that kill/inhibit bacteria & viruses
- ↓ gastroenteritis and ↓ ear infections Ideal composition for human baby:
electrolytes, minerals, linoleic acid, trace elements, hypoallergenic--reduces allergies
Easy to digest Reduces obesity, diabetes later in life
Maternal Advantages of Breastfeeding
Protective function in breast cancer prevention
Release of oxytocin from the posterior pituitary gland aids in uterine involution
Empowerment effect Reduces economic costs Bonding Breast milk contains lysozymes that are
involved in destroying bad bacteria
Breast Feeding and Jaundice
Jaundice occurs in 15% of breast fed babies Pregnanediol (breakdown product of
progesterone) depresses an enzyme that converts indirect bilirubin to direct bilirubin (accumulation of indirect bilirubin)
Encourage frequent feedings because colostrum is a natural laxative and helps promote passage of meconium and bile
Baby who is feeding well--”getting enough”
Breastfeeding
Every 2-3 hours in first weeks Promote adequate sucking Provide support Techniques for burping Multiple infants Engorgement
Problems in Breastfeeding
Sore nipples Supplemental feedings Working outside of the home Weaning Engorgement Mastitis
Formula Feeding Preparation
Commercial formulasFormula adequacySupplies neededFormula preparationFeeding techniques– 75 to 90 ml of fluid per
pound of body weight per day
Circumcision CareSurgical Removal of Foreskin
Site covered with sterile petroleum Assess bleeding q 15 mins. for 1st hour, then q hour for
24 hr Note first voiding Apply diapers loosely to prevent irritation Teach parents to keep area clean & check diaper q 4
hours Notify provider for redness, discharge, swelling, strong
odor, tenderness, decrease in urination or excessive crying of infant.
Yellowish mucus “crust” may form over glans--normal, don’t wash off
Avoid premoistened towlettes--use only water to wash
Circumcision Care
Heals in a couple of weeks Monitor for complications: hemorrhage, cold
stress/hypoglycemia, infection, urethral fistula, delayed healing and scarring, fibrous bands.
Provide discharge instructions to parents about sign & symptoms to report to provider.
Discharge Teaching
When to call healthcare provider:– Baby’s axillary temp > 100.4– > 1 episode of forceful (projectile) vomiting or
frequent vomiting over 6-hr period– Refusal of 2 feedings in a row– Lethargy, difficulty awakening baby– Cyanosis with or without feeding– Absence of breathing > 20 secs– Inconsolable crying or continuous high-pitched cry– Discharge/bleeding from umbilical cord,
circumcision– No wet diapers for 18-24 hrs or < than 6-8 wet
diapers/day– Eye drainage
Hyperbilirubinemia Hyperbilirubinemia: results from
destruction of red blood cells – Physiologic jaundice
Normal physiologic processDoes not occur in first 24 hours of lifeHome care
– Pathologic jaundiceAbnormal destruction of RBCsOccurs in first 24 hours of life or persists after 1
weekCauses: hemolytic disease of newborn: Rh or
ABO blood incompatibility (mom Rh - or type O)
Hyperbilirubinemia
Physiological Jaundice (p. 690)
2nd or 3rd day of life. Breakdown of fetal red
blood cells. Heme and globin
realeased. Heme breaks down into protoporphyrin which breaks down into indirect bilirubin & is excreted by liver in feces
Baby’s liver is immature
Pathologic Jaundice
Before 24 hours or persistent after day 7 Bilirubin increases more than 0.5 mg/dl/hr, peaks
at greater than 13 mg/dl or associated with anemia and hepatosplenomegaly
Rh incompatibility/isoimmunization, infection, RBC disorder. ABO incompatibility: positive coombs test (test babies when mom O−/O+)
Kernicterus (bilirubin encephalopathy) can result from untreated hypergbilirubinemia with bilirubin levels at or higher than 20 mg/dl → mental retardation
Risk Factors for Hyperbilirubinemia
↑ RBC production or breakdown (cephalohematoma, extensive bruising from birth trauma)
Rh or ABO incompatibility Ineffective breastfeeding & dehydration Certain medications (aspirin, tranquilizers, and
sulfonamides) Maternal enzymes in breast milk- fairly
uncommon Hypoglycemia Hypothermia Decreased liver function Anoxia
Lab Testing Elevated serum bilirubin (direct and indirect) Blood group incapability between the mother
and newborn Hemoglobin and hematocrit Direct Coomb’s test--reveals presence of
antibody-coated (sensitized) Rh-positive RBCs in the newborn
Electrolyte levels for dehydration from phototherapy (treatment of hyperbilirubinemia)
Nursing Assessments ofHyperbilirubinemia
Yellowish tint to skin, sclera and mucus membranes--observe by window
Press infant’s skin lightly and release and notice yellowish tint
Note time of jaundice (integral in differentiating between physiologic and pathologic jaundice)
Treatments: early feedings, phototherapy, exchange transfusion
Neonatal ComplicationsRDS (Respiratory Distress Syndrome)
Pathophysiology: – Low-level or absent surfactant – Inspiratory effort to inflate alveoli remains
high– Pulmonary resistance prevents fetal shunts
from closing – Lungs are poorly perfused and tissue
hypoxia occurs with resultant acidosis
Surfactant not formed until week 34
Neonates at Risk for Respiratory Distress Syndrome (RDS)
Preterm infants Infants of diabetic mothers Infants born by cesarean Perinatal asphyxia Decreased O2 tension in the lungs (one
cause is meconium aspiration) Maternal factors: PROM,
barbiturate/narcotic use, hypotension, bleeding
Assessment of Infants with RDS
S/S usually don’t develop immediately post birth. First S/S are subtle:– Low body temperature– Nasal flaring – Expiratory grunting– Sternal and subcostal retractions– Tachypnea (> 60 respirations per minute)– Cyanotic mucous membranes
Assessment of Infants with RDS
As distress continues:– Seesaw respirations– Heart failure– Pale, gray skin– Periods of apnea– Bradycardia– Pneumothorax
Therapeutic Management
Administer surfactant through ET tube Oxygen administration (CPAP or
assisted ventilation with PEEP) Ventilation Indomethacin or ibuprofen to close
patent ductus arteriosus
Prevention of RDS
Tocolytics (Magnesium Sulfate, Terbutaline, Procardia), corticosteroids (Betamethasone) usually given between 24-34 weeks
L:S (lecithin:sphingomyelin) ratio is 2:1 in amniotic fluid (indicates fetal maturity)
Transient Tachypnea of Newborn
When respiratory rate continues to remain high (between 80-120 breaths/min) after 1 hour mark
Usually infant doesn’t appear distressed but instead tired from breathing too fast
Usually mild retractions but no cyanosis Feeding difficulties Usually occurs from a slow absorption of lung fluid More common in C-section babies & preterm infants Peaks at 36 hours and usually resolves at 72 hours TX: close observation, O2
Critical Thinking The mother of a three-day-old infant calls the clinic
and reports that her baby's skin is turning slightly yellow. The nurse should explain to the mother that:
A) The baby is yellow because the bowels are not excreting bilirubin.
B) The newborn's liver is not working as well as it should.
C) The yellow color indicates that brain damage may be occurring.
D) Physiologic jaundice is normal and peaks at this age.
Critical Thinking The nurse is caring for a newborn with jaundice. The parents
question why the newborn is not under the phototherapy lights. The nurse explains that the fiber optic blanket is beneficial because: (Select all that apply.)
A) The lights can be turned off intermittently.
B) The eyes do not need to be covered.
C) The lights will need to be removed for feedings.
D) Newborns do not get overheated.
E) Weight loss is not a complication of this system.