Postpartum & Newborn Nursing

Ana H. Corona, MSN, FNP-C Nursing Instructor October 2007 Revised February 2009

The Postpartum Period

Puerperium: Term 1st 6 weeks after the birth of an infant Neonatenewborn from birth to 28 days. Family adaptation to neonate: Bonding rapid process of attachment during 1st 30 to 60 minutes after birth Mother, father, siblings, grandparents

Factors Affecting Family Adaptation

Parental fatigue Previous experience with a newborn Parental expectations of newborn Knowledge of and confidence in providing for newborn needs Temperament of the newborn Temperament of parents Age of parents Available support system Unexpected events

Postpartum Assessment

VS, amount of lochia, presence of edema, fundal height and firmness, status of perineum, bladder distension 1 to 2 hrs after delivery: every 15 minutes If no problems every 8 hours

KNOW YOUR PATIENT --- DELIVERY HISTORY /ADMISSION/TRANSITION ASSESSMENT:

Gravida, parity / Time and type of delivery Anesthesia or medications / Risk factors for PPH Medical history / Routine medications / Allergies Infant status / Breast/bottle Rubella immune? Rh Negative? Drug/ETOH Abuse

Body Systems Assessment

Vital signs Level of pain Neurological Pulmonary Cardiovascular Musculoskeletal Gastrointestinal Genitourinary Integumentary Psychosocial

Vital Signs
Day 1 Heart Rate Respirations B/P Temperature 50 to 70 bpm Normal Normal Day 2 and after Bradycardia or normal Normal Normal

100.4 normal 24 Normal hrs. If 100.4

Muscular exertion/dehydration infection

suspect

Postpartum Physical Assessment

B - breast U - uterus B - bowels B - bladder L - lochia E - episiotomy

General Assessment

Enter the room quietly, speak quietly. Wash hands and provide for privacy. Inform patient before turning on lights. Note LOC, activity level, position, color, general demeanor. Take note of the total environment:

Safety/patient considerations Note equipment and medical devices

B reast Assessment

Breasts: Soft, engorged, filling, swelling, redness, tenderness. Nipples: Inverted, everted, cracked, bleeding, bruised, presence of colostrum or breastmilk. Colostrumyellowish fluid rich in antibodies and high in protein. Engorgement occurs by day 3 or 4. Due to vasoconstriction as milk production begins Lactation ceases within a week if breastfeeding is never begun or is stopped.

Assessing U terine Fundus

Location in relation to umbilicus Degree of firmness Is it at Midline or deviated to one side? Bladder Full? A boggy uterus may indicate uterine atony or retained placental fragments. Boggy refers to being inadequately contracted and having a spongy rather than firm feeling.

Massaging the Fundus

Every 15 mins during the 1st hr, every 30 mins during the next hr, and then, every hr until the patient is ready for transfer. Document fundal height. Evaluate from the umbilicus using fingerbreadths. This is recorded as 2 fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth. The fundus should remain in the midline. If it deviates from the middle- distended bladder.

Uterine Involution

Uterine Involution: return of the uterus to its prepregnancy size and condition Uterine fundal descent: uterus size of grapefruit immediately after birth Fundus half way between umbilicus and symphysis pubis Fundus rises to the umbilicus stays for 12 hours Descends 1 cm (fingerbreadth) each day for about 10 days

Uterine Atony

Lack of muscle tone in the cervix. Uterus feels soft and boggy After delivery: Postpartum diuresis The bladder has increased capacity and decreased muscle tone. This leads to over-distension of the bladder, incomplete emptying of bladder, retention of residual urine and increased risk of UTI and postpartum hemorrhage.

B owels & B ladder

When was the patients last BM? Is she passing flatus? (gas) Assess for bowel sounds Voiding pattern - without difficulty/pain, urine may be blood tinged from lochia Nursing interventions: Assist to the bathroom. Use measures to encourage voiding (privacy). Encourage use of peri-bottle with warm water, fluids, fiber, frequent ambulation, stool softeners; teach effects of pain medication.

L ochia Assessment

Lochiavaginal discharge after childbirth. It takes 6 weeks for the vagina to regain its prepregnancy contour. Lochia: scant-moderate, rubra, serosa or alba Assessment of lochia includes noting color, presence and size of clots and foul odor. Day 1- 3 - lochia rubra (blood with small pieces of decidua and mucus) Day 4-10 lochia serosa (pink or pinkish brown serous exudate with cervical mucus, erythrocytes and leukocytes) Day 11- 21 - lochia alba (yellowish white discharge)

Lochia: Pad Count

1. 2. 3. 4.

Scant: 1-inch stain on pad in 1 hour Light/small: 4 inches in 1 hour Moderate: 6 inches in 1 hour Heavy/large: Pad saturated in 1 hour Excessive: Pad saturated in 15 min Can estimate blood loss by weighing pads: 500 mL = 1 lb. or 454 g

E pisiotomy/Perineal Assessment

Patient in lateral Sims (side lying) position. Use the acronym REEDA (redness, edema, ecchymosis, discharge, approximation of suture lines edges of episiotomy) to guide assessment. Even if there is no episiotomy, the perineum should still be assessed. Unusual perineal discomfort may be a symptom of impending infection or hematoma. Hemorrhoids ?

Episiotomy Pain Relief

Instruct Mother: Tighten her buttocks and perineum before sitting to prevent pulling on the episiotomy and perineal area and to release tightening after being seated. Rest several times a day with feet elevated. Practice Kegel exercise many times a day to increase circulation to the perineal area and to strengthen the perineal muscles.

Assessment of Edema & Homans Sign

Assess legs for presence and degree of edema; may have dependent edema in feet and legs. Assess for Homans sign- thromboembolism should be negative Press down gently on the patients knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)

Homans Sign

Thromboembolic Conditions

Thrombophlebitisthe formation of a clot in an inflamed vein. Risk factors include maternal age over 35, cesarean birth, prolonged time in stirrups, obesity, smoking, and history of varicosities or venous thromboses. Prevention: client needs to ambulate early after delivery.

Postpartum Cesarean

Incision siteredness swelling, discharge. Intact? Abdomen soft, distended? Bowel sounds heard all 4 quadrants Flatus? Lochia is less amount than in normal spontaneous vaginal delivery (NSVD) because uterus is wiped with sponges during c/section. If lochia indicates excessive bleeding, combine palpation and pain management measures. Auscultate breath sounds Fluid intake and output Pain?

RhoGAM

It is given to an Rh- mother within 72 hours after delivery of an Rh+ infant or if the Rh is unknown. The dose must be repeated after each subsequent delivery. RhoGAM 300 mcg is the standard dose.

Postpartum Disseminated Intravascular Coagulation

Abnormal stimulation of clotting mechanism. Normally, the body forms a blood clot in reaction to an injury. Small blood clots throughout the body, depleting the body of clotting factors and platelets. Massive bleeding Causes may include amniotic fluid clots, fetal demise, abruptio placenta. Eclampsia or Retained placenta Symptoms: Sometimes severe bleeding and sudden bruising .

Postpartum Hemorrhage

Blood loss of more than 500 ml after vaginal birth or 1,000 ml after a cesarean birth. Early hemorrhage Cervical or vaginal tears, uterine atony, retained placental fragments, lacerations, hematomas. Late hemorrhage subinvolution, retained placental fragments. Subinvolution: failure of the uterus to return to normal size. Management may include CBC, sedimentation rate, type and cross, fluid resuscitation with normal saline and blood, vaginal examination, diagnosis, and correction of the underlying cause.

Postpartum Depression

Postpartum depression is a nonpsychotic depressive episode that begins in the postpartum period due to decreased estrogen level Symptoms: changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feeling of worthlessness or guilt; difficulty thinking, concentrating or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts.

Postpartum Psychosis

A very serious type of PPD illness that can affect new mothers. Begin 2-3 weeks post delivery Fatigue, restlessness, insomnia, crying liable emotions, inability to move, irrationally statements incoherence confusion and obsessive concerns about the infants health Psychiatric emergency

Nipple soreness is a portal of entry for bacteria - breast infection (Mastitis). Maternal after pains: may be due to breastfeeding and multiparity Always stay with the client when getting out of bed for the first time hypotension effect and excess bleeding When assessing fundal height, if you notice any discrepancies in fundal height have patient void and then reassess.

Nursing Diagnosis Related to Breasts and Breastfeeding

Pain r/t improper positioning, engorged breasts Ineffective breastfeeding r/t maternal discomfort, improper infant positioning Knowledge deficit r/t normal physiologic changes, breastfeeding Infection r/t improper breastfeeding techniques, improper breast care

The Newborn

Newborns Immediate Needs

Airway Breathing Circulation Warmth

The Newborn

Neonatal transition: 1st few hours after birth newborn stabilizes respiratory and circulatory functions. When the cord is clamped, placental gas exchange ceases. These changes stimulate carotid and aortic chemoreceptors which send impulses to the respiratory center in the medulla. A brief period of asphyxia stimulates respirations.

Apgar Score

Assesses the infants cardiopulmonary adaptations to extrauterine life Provides a quick evaluation on how the heart and lungs are adapting 5 items to be assessed 1 and 5 minutes after birth.

Apgar Score

Heart rate, respiratory rate, muscle tone, reflex irritability and color Score of 0 2 for each item, then totaled. Apgar Score 8 or higher no intervention Apgar Score 4 8 gentle rubbing, oxygen Apgar Score 0 4 resuscitation Points Given 0 1 2 Some Active motion/well motion/flexion flexed <100 bts/min Grimace >100 bts/min Cry, cough, sneeze

A Activity/muscle Limp/flaccid tone P Pulse Rate Absent G Grimace/Reflex No Response Irritability A Appearance/ Skin Color R Respiration Blue, Pale

Body pink, Pink all over extremities blue Absence of cyanosis Slow weak cry Good Cry

Absent

Prophylactic Care

Vitamin K to prevent hemorrhagic disorders vit k (clotting process) is synthesized in intestine requires food for this process. Newborns stomach is sterile has no food. aquaMEPHYTON Hepatitis B vaccination within the first 12 hours Eye prophylaxis (Erythromycin Ointment) to prevent ophthalmia neonatorum gonorrhea/chlamydia

Newborn: Intramuscular injection

aquaMEPHYTON (Vit.K) 1 mg/0.5 ml IM lateral thigh Vastus lateralis

Vital Signs

Temperature - range 36.5 to 37 axillary (97.7-98.6) Axillary vs Rectal about 0.2 to 0.5 difference Common variations Crying may elevate temperature Stabilizes in 8 to 10 hours after delivery Heart rate - range 120 to 160 beats per minute

Apical pulse for one minute Heart rate range to 100 when sleeping to 180 when crying Color pink with acrocyanosis Heart rate may be irregular with crying

Common variations

Respiration - range 30 to 60 breaths per minute Blood pressure - not done routinely

Ranges between 60-80 mm systolic and 40-45 mm diastolic.

Reflexes: indicate neurological integrity

Rooting Sucking Extrusion Palmar grasp Plantar grasp Tonic neck

Moro Gallant Stepping Babinskis Crossed extension reflex Placing

Reflexes

Tonic Neck Reflex (FENCING) EXTENDS arm & leg on the side that the face points. Flexes opposite arm & leg 6-8 wks to 6 months

Moro Reflex Birth to 4-6 months

Rooting and Sucking Reflexes

Birth to 3-4months

Birth to 10 months

Babinski and Palmer Grasping Reflex

Babinski Reflex is (+) This is Normal Birth to after walking 12-18 months age

Birth to 4 months

Skin

Expected findings Skin reddish in color, smooth and puffy at birth At 24 - 36 hours of age, skin flaky, dry and pink in color Edema around eyes, feet, and genitals Vernix caceosa Lanugo (baby hair) Turgor good with quick recoil Hair silky and soft with individual strands

Common Normal Variations

Acrocyanosis - result of sluggish peripheral circulation. Mongolian Spots: Patch of purple-black or blue-black color distributed over coccygeal and sacral regions of infants of AfricanAmerican or Asian descent. Milia: Tiny white bumps papules (plugged sebaceous glands) located over nose, cheek, and chin. Erythema toxicum: Most common newborn rash.
Variable, irregular macular patches. Lasts a few days.

Erythema toxicum, acrocyanosis, milia and mongolian spots

Hyperbilirubinemia

Physiologic Jaundice =Appears 24 hours after birth peaks at 72 hrs. Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days. Due to Unconjugated bilirubin circulating in the blood stream that is deposited in the skin. Immature liver unable to conjugate bilirubin released by destroyed RBC. Pathologic Jaundice =Not appear until after 24 hrs leads to Kernicterus (deposits of bili in brain). Bilirubin >20mg/dl The most common cause is Rh incompatibility.

The Head and Chest

The Head: Anterior fontanel diamond shaped 2-3 - 3-4 cms Posterior fontanel triangular 0.5 - 1 cm Fontanels soft, firm and flat head circumference is 33 35 cm The head is a few centimeters larger than the chest!!!! The Chest: circumference is 30.5 33 cm

Anterior and Posterior Fontanelles

Anterior diamond shaped 2-3 3-4 cms Posterior triangular 0.5 - 1 cm Fontanels soft, firm and flat

Molding is shaping of fetal head to adapt to the mothers pelvis during labor.

Caput succedaneum

Swelling of the soft tissue of the scalp caused by pressure of the fetal head on a cervix that is not fully dilated. Swelling is generalized. may cross suture line and decreases rapidly in a few days after birth. Requires no treatment 2 3 days disappears

Cephalohematoma

Collection of blood between the periosteum and skull of newborn. Does not cross suture lines Caused by rupturing of the periosteal bridging veins due to friction and pressure during labor. Lasts 3 6 weeks

Bathing the Newborn

No tub bath until after the cord has fallen off and healing is complete. Newborns first baththe nurse needs to wear gloves to prevent infection. What is wrong with this nursing action?

Gestational Age Relationship to Intrauterine Growth

Normal range of birth weight for each week of gestation. Birth weight is classified as follows: Large for gestational age (LGA): weight falls above the 90th percentile for gestational age Appropriate for gestational age (AGA): weight falls between the 90th and 10th percentile for gestational age Small for gestational age (SGA): weight falls below the 10th percentile for gestational age

Intrauterine Growth Grid

Circumcision

Circumcision is considered an elective procedure Anesthesia should be provided. Parents must give written consent Full term health infants Aftercare: Check hourly for 12 hours Check for bleeding and voiding Before discharge: Newborn goes home within the first 12 hours after procedure Bleeding should be minimal and infant must void Ensure that parents know how to care for the circumcision.

Breastfeeding

Colostrum is rich in immunoglobulins to protect newborn GI tract from infection; laxative effect. Breast milk in 2 weeks sufficient nutrients 20 kcal/oz (infants nutritional needs) To support Breastfeeding: Mother needs to consume extra 500 calories per day. Feeding length: should be long enough to remove all the foremilk (watery 1st milk from breast high in lactose - skim milk & effective in quenching thirst) Hindmilk: higher in fat content leads to weight gain and more satisfying. Breastfeeding time approximately 30 minutes

Infant Formula

Formula 7.5 ml to 15 ml at feeding gradually increase to 90 ml to 120 ml at each feeding in 2 weeks. Formula preparation: mixing must be accurate to provide the 20 kcal/oz. (newborn nutritional need) Burping: is needed to expel air swallowed when infant sucks. Should be done about way through feeding for bottle feeders and when changing breasts for breast feeders.

Respiratory Distress

2 types: Respiratory Distress Syndrome (RDS) and Transient Tachypnea of the Newborn (TTN) RDS: preterm infants/surfactant deficiency Hypoxia, respiratory acidosis and metabolic acidosis Surfactant is produced by alveoli - lung maturity L/S ratio 2:1 is a test done before birth to determine fetal lung maturity TTN: AGA, near term infants Intrauterine or intrapartum asphyxia Newborn unable to clear airway of lung fluid, mucous or amniotic fluid aspiration. Expiratory grunting nasal flaring, tachypnea with respirations as high as 100 to 140 breaths/minute.

Neural Tube Defects

3 types: Spina Bifida Occulta : failure of the vertebral arch to close. Has dimple on the back with a tuft of hair. No treatment required. Meningocele : saclike protrusion along the vertebral column filled with cerebrospinal fluid and meninges. Surgery required. Myelomeningocele : saclike protrusion along the vertebral column filled with spinal fluid meninges, nerve roots, and spinal cord = paralysis. Surgical repair required. Sterile saline dressing. hydrocepalus

Spina bifida occulta

meningocele

Spina bifida Occulta

myelomeningocele

Infants of DM mothers (IDM) Complications

Hypoglycemia: maternal glucose declines at birth. Infant has high level of insulin production= decreases infants blood glucose within hours after birth. Respiratory Distress: less mature lungs due to insulin Hyperbilirubinemia : hepatic immaturity, increased hematocrit, bruising due to difficult delivery. Birth trauma : large size of infant Congenital birth defects : birth defects Patent Ductus Arteriosus, Ventricular Septal Defect and more.