Post-Partum Study Guide
Adaptations CH 15 (4 ?)
Uterus
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Returns to pre-pregnant state (size of fist)
Should lay at the umbilicus 12 hrs PP – any higher may indicate hemorrhage or uterine atony
Descends from the level of the umbilicus at 1 fingerbreadth/day (1cm/day)
No longer palpable by day 10-12 PP – encourage voiding before palpation
Lochia
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Vaginal bleeding & discharge after delivery
Rubra – red, small clots; 1-3 days PP
Serosa – pink-brown, or serosanguinous; 4-10 days PP
Alba – white-yellow, creamy; 11 days – 4-8 weeks PP
Fleshy & non-odorous smell
Note: color, amount, odor, clots, #, type, freq. of soaked pads
Excessive Bleeding:
1. saturation of pad in < 50 mins
2. pooling of blood under the buttocks
Cervix, Vagina, & Perineum
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Cervix
▪ returns to normal & is soft at 2 weeks; has new appearance & like pre-birth at 6
weeks
▪ Cervix opening is closed with a slit after birth
Vagina
▪ edematous, few rugae, 3 weeks, like pre-pregnancy stage at 6 weeks
Perineum
▪ Edematous & bruised for 4-6 weeks
Main concerns for vagina & perineum are injury complications
Cardiovascular System
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Blood volume drops rapidly; CO increased intrapartum then decreased in a few days
HR & BP become normotensive; bradycardia is normal – 40-80 bpm
Elevated coagulation factors for 2-3 weeks
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Diuresis occurs PP around day 2 & 3
Plasma volume decreases
Increased WBCs – may not indicate infection – assess any s/s of infection
Hct & Hgb slightly decrease but rise slowly over 2 weeks
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Decrease indicates hemorrhage
Respiratory System
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Minimally involved, resolves quickly
Diaphragm returns to normal position
Changes in ribcage & thoracic cavity resolve
Relief of SOB & rib aches
Normal respiratory rate
Lung function normalizes by 1-3 weeks
At Risk
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Elevated temperature for 1st 24 hours
Orthostatic BP changes – risk for falls
Risk for DVTs – assess legs
Urinary System
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PP diuresis occurs up to 3000 mL/day - 12 hours after birth
May have an impaired urge to urinate or urinary retention
▪
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d/t anesthesia, prolonged/excessive use of oxytocin, physical injury, perineal lacerations, swelling & bruising, &
hematomas
Assess voiding schedule & VS
Assess for s/s of infection, document I&O
Impaired urge to void, decreased sensation, incomplete emptying, distention, retention,
frequency, burning, anal lacerations, extensions from episiotomies, etc. - leads to risk for
UTIs
Bowels/GI System
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Multifactorial: pelvic floor trauma, pain meds (constipation), lack of fiber & fluids, &
infant care
Low progesterone levels cause relaxation of bowels
Fear factor to have a BM d/t sutures or tears
Normal elimination occurs at 1 week
Assess for normal findings:
▪ Soft, non-distended abdomen
▪ Passing gas
▪ No BM before going home is normal if there’s no straining
Episiotomy, Laceration, & Epidural Sites
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Episiotomies & lacerations
▪ Assess for redness, drainage, edema, & warmth
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Lacerations:
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1st – involves only skin & superficial structures
2nd – extends through perineal muscles
3rd – extends through anal sphincter muscle
4th – continues through anterior rectal wall
▪ Watch for infections & hematomas – bruised, painful, & swollen
Epidural
▪ Inspect site & assess concern for SE of meds – hypotension & itching
▪ Keep site covered after epidural catheter is removed
Endocrine & Sexual Health
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Estrogen & progesterone abruptly decrease – causing breast engorgement & diuresis
Prolactin is produced & oxytocin assists in “let down” of breastfeeding moms
Common sexual problems r/t drive, arousal, orgasmic disorder, & dyspareunia (painful
intercourse) are all associated with the new normal of motherhood
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Normal but not normal if occurring after 6 weeks PP
Anticipatory guidance should be provided including causes & solutions
Ovulation & Menses
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Ovulation may occur 1 month PP even without a menses
Menses can return around 4-6 weeks; up to 8 weeks in non-BF moms;
8 weeks – 6 months in BF moms
Cultural Considerations
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Be mindful of patient preferences & beliefs; address needs ahead of time
Psychological Adaptations
PHASES OF MATERNAL ROLE ATTAINMENT
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Dependent - 1st – “taking it in” - pt is reliant on nurse/caregiver - occurs 24-48 hours PP
Dependent-Independent – 2nd - “taking hold” phase
Interdependent – 3rd - “letting go” phase
PATERNAL ADAPTATION
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Partner goes through bonding (engrossment)
Figure 15.7
SIBLING ADAPTATION
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Some kids developmentally regress
Have siblings see, touch, & hold the baby & establish sibling’s role
Breasts
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Colostrum production is immediate; mature milk is produced 3-5 days later
Assess breasts & nipples; ask & observe a breastfeeding
▪ Assess breaks in skin, red/raw nipples, & appropriate latching & breastfeeding
Engorgement – identify, teach, & provide interventions
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Provide patient-centered care
Encourage on-demand feedings – 8-12 feedings/day
Provide BF positions for mom & infant
LATCH chart
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Should not have a fever, reddened & warm areas, or areas of hardness
Latch
Audible swallowing
Type of nipple
Comfort
Hold
Educate when to report breastfeeding issues
Musculoskeletal System
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Returns to pre-pregnant state by 6-8 weeks after birth ( ligaments, hip, joint pain, abdominal muscles,
& carpal tunnel syndrome)
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Assess the MS system for changes & diastasis recti
Teach PP strengthening exercises – Kegels & pelvic tilt exercises
Post-CS needs to wait 4 weeks or PCP approval
Thermoregulation & Comfort
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Postpartum chills – normal
▪ Nervous system reasons & hormones
▪ Vasomotor changes
▪ Shift in fluids
▪ Work of labor
Comfort
▪ Pain r/t episiotomy, lacerations, incisions, afterpains, sore nipples, & delivery
▪ Assess location, type, & quality to guide interventions
▪ Administer pain meds or non-pharm alternatives
Immune System
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Review status of: Rubella, Hepatitis B, Rh Factor, Varicella, & Tdap Vaccines
IF Rubella titer is less than 1:8, MMR is indicated – no pregnancy for 1 month
Hepatitis B infected mother’s infants need the HBIG & HBV within 12 hours after birth
Rh negative mothers with Rh positive NBs need Rhogam within 72 hours
Varicella is given if not immune, 2nd dose in 4-8 weeks – no pregnancy for 1 month
Tdap is indicated for those not previously receiving
▪
Pregnant people should get a dose of Tdap during every pregnancy, preferably during the early part of the third
trimester to help protect the newborn from pertussis. Infants are most at risk for severe, life-threatening
complications from pertussis.
Nursing Management in the PP Period CH 16
(10 ?)
Cultural Considerations
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Understand the client in social and cultural contexts
Continuous cultural self-assessment to prevent stereotyping
▪ Understand their beliefs, experiences, & family environment
▪ Language – use hospital translator programs
▪ Compassionately respect clients & their human rights
Box 16.3 pg. 549 Cultural Influences during the PP Period
Risk Factors for Infection
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Operative procedures, hx of diabetes (including GDM), prolonged labor, indwelling
urinary catheter, anemia, multiple vaginal exams during labor, prolonged ROM (>24
hours), prolonged pushing stage, manual extraction of placenta, & compromised
immune system (HIV +)
Risk Factors for PP Hemorrhage
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Precipitous labor (<3 hours), uterine atony, placenta previa, placental abruption, labor
induction or augmentation, operative procedures, retained placental fragments,
prolonged placental delivery (>30 mins), multiparity, uterine overdistention
Danger Signs
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Fever > 100.4 F
Foul-smelling lochia or unexpected change in color/amount
Large blood clots or pad saturation < 1 hour
Severe headaches, blurred vision, or visual changes – pre-eclampsia
Calf pain with dorsiflexion of the foot – DVT
Swelling, pain, redness, or discharge at episiotomy, epidural, or abdominal sites
Dysuria, burning, or incomplete emptying of the bladder
SOB or difficulty breathing without exertion
Depression or extreme mood swings
Breasts with local redness, pain, & tenderness - mastitis
PP depression
Increased vaginal discharge
Post-Partum Assessment
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VS, physical, psychosocial, & family tolerance
1st hour – every 15 mins
2nd hour – every 30 mins
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1st 24 hours – every 4 hours
After 24 hours – every 8 hours unless more frequently ordered/indicated
Vital Signs
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Use consistent measurement techniques
Slight temperature elevation in 1st 24 hours – normal
▪ Any temps >100.4 anytime or after 1st 24 hours indicates possible infection
Puerperal bradycardia is expected – 40-60 bpm, NOT above 80 bpm
Respiratory system normalizes, SOB & thoracic expansion resolve
BP remains unchanged from labor
Assess pain frequently, provide comfort measures, administer analgesics prn &
encourage non-pharm measures initially
▪ Afterbirth pains, perineal, incisions, swelling & edema, & hematomas
▪ Pre-eclampsia patients will usually have elevated pressures in early PP stage
▪ Low BP is not expected unless there was major blood loss
▪ Good breastfeeding latch can release oxytocin, promoting contractions & pain
PP Assessment
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Breasts
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Uterus
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Assess firmness, midline, at or below umbilicus depending on time after delivery, may
deviate to the side if bladder is full; encourage voiding before assessing uterus
Bowels
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Inspect for symmetry, soft or firm with milk, any colostrum leakage, tingling/tightening
when baby latches, nipples & areolas for redness, warmth, breakdown, & abnormalities
Common issues – constipation, hemorrhoids, & increased hunger; Assess for bowel
sounds, return of BMs, decreased bowel sounds after vaginal or c/s delivery, assess for
abdominal distention & tightness, normal if the patient does not have BM before
discharge if she is not straining; encourage early ambulation, fluids, & fiber; stool
softeners & laxatives available if needed
Bladder
▪
Palpable bladder may indicate urinary retention, note 1 st void after delivery & measure
amount; 1st couple pees after catheter removal may burn or sting but should go away,
assess for distention & tenderness, encourage increased fluids, frequent emptying &
educate to report feeling not totally emptied
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Lochia
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Episiotomy/Laceration/CS Incision
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Assess amount, color, & relation to uterus; weigh pads if bleeding appears heavy
Assess sites for s/s of infection, educate to continue assessing once home, encourage
keeping c-section site clean & dry with clean gauze
EE Extremities/Emotions
▪
Assess for edema in hands & calf pain or redness in legs indicating a DVT; assess how the
patient is responding to the nurse & baby
Emotions, Bonding, & Attachment
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Observe emotional status
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Bonding occurs immediately after birth
Assess that mother is showing behaviors demonstrating attentiveness & affection
Attachment – development of strong reciprocal affection between mom & baby
Assess for bonding behaviors, those that impair or indicate lack of bonding, &
manifestations of mood swings, conflict of role, & personal insecurity
Comfort
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Non-pharm measures
▪ Application of ice packs used in 4th stage & in 1st 24 hours - 20 mins on, 10 mins
off, covered with clean cloth
▪ Application of heated peri bottle with perineal hygiene after 24 hours; sitz bath
(hydrotherapy) after 24 hours – educate safety measures
Topical preparations
▪ Analgesics – hemorrhoid creams, witch hazel wipes, & dermoplast spray
Rest, Activity, & Exercise
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Goals: early ambulation, encourage rest, & promote physical fitness
Encourage sleep when infant sleeps
Reduce outside activities – early PP period
Eat balanced diet for healing & energy
Lift nothing heavier than infant, limit driving, limit stairs, & gradually increase activity
Teach Kegels, pelvic tilt exercises, & pelvic floor therapy (PVT)
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These include stress incontinence prevention
Teaching Guidelines 16.3 pg. 554
Self-Care & Safety
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Frequent peri pad changes
No tampons or douching
Shower with mild soap & water
Sitz baths for hemorrhoid relief
Peri bottle with warm water
Handwashing
Avoid prolonged crossing legs & limit stair climbing – risk of falls
No driving for 2 weeks or if taking narcotics
No sex for 2-4 weeks, use lubricants, awareness of altered sexual response
Use contraception!
Nutrition
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Encourage all food groups & increase protein consumption to aid in tissue repair
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2-3 L of fluid daily
Non-lactating clients – 1800 cals; additional 220 cals/day for recovery; lactating clients
require additional 450-500 cals/day + increased calcium-rich foods
Avoid weight reduction diets & harmful substances
Promotion of Family Adjustment & Well-Being
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Interactions develop parental role, learning cues, & behaviors
Model behaviors by holding & talking to the newborn
Monitor attachment behaviors
Assess support system & presence of stressors
Arrange for home visits or a sooner follow-up
PP: The Woman at Risk CH 22 (15 ?)
Post-Partum Hemorrhage
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Life threatening complication & leading cause of death
14 million or 1:20 births
Blood loss >500 mL = vaginal; blood loss >1000 mL for cesarean birth
Primary = occurring in 1st 24 hours (4-8 hours)
Secondary = occurring 24 hours – 12 weeks PP
Prevention & prompt intervention are critical!
▪ Fundal massage every 15 mins
▪ Provide education & teaching on palpating & massaging fundus within the 1 st 4 hours PP
Risk Factors for PPH
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Uterine rupture
Causing uterine distention – multiparity & multiple gestations
Hydramnios
Placental fragments
Magnesium sulfate
Oxytocin
Precipitous labor & pre-term labor
The 5 Ts
Tone
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Tissue
Overdistention, oxytocin, anesthesia, magnesium sulfate, retention
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Subinvolution (uterus cannot contract down to normal size)
Trauma
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Lacerations & hematomas
Thrombin (usually considered last)
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Idiopathic thrombocytopenic purpura (ITP), Von Willebrand, & DIC
Traction
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Inversion (occurs when umbilical cord is being pulled during delivery of the placenta)
Uterine Atony
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Inability of the uterus to contract adequately after birth
Caused by uterine retention, overdistention of the uterus, prolonged or forceful rapid
labor, infection, anesthesia, or meds causing relaxation – magnesium sulfate or oxytocin
Uterine contraction assistance – oxytocin, methylergonovine, misoprostol, fundal
massage, & breastfeeding
Findings:
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Larger & boggy uterus, lateral, & soft
Irregular or excessive bleeding
Tachycardia & hypotension – late signs
Pale, cool, clammy skin, & loss of skin turgor – Table 22.1 - late signs
▪
Ensure bladder emptying, assess & massage fundus, lochia evaluation, express clots, monitor for VS trends,
maintain IVFs, & administer O2 2-3 lpm
Nursing management:
SUBINVOLUTION
INVERSION
RETAINED
PLACENTA
LACERATIONS &
HEMATOMAS
Risks & Causes
pelvic infection,
endometritis, & retained
placenta
Retained placenta,
fundal pressure, &
excessive cord
traction
Signs &
Symptoms
Prolonged/irregular
vaginal bleeding, higher
uterus than normal, &
boggy uterus
Pain in lower
abdomen, large red
rounded smooth
mass in the dilated
cervix, dizziness,
pallor, & low BP
Caused by excessive
cord traction, partial
separation of
placenta, &
entrapment by
uterine ring
Excessive bleeding,
atony, return of
lochia progression,
foul-smelling
discharge, & an
elevated temp
Treatment
D&C, oxytocin,
methylergonovine, &
antibiotics
Replace the uterus,
terbutaline
(tocolytic), &
antibiotics
Operative
procedures, birth,
CPD/macrosomia,
previous scarring, &
prolonged pressure
of fetal head
Laceration: vaginal
bleeding, firm
uterus, continuous
slow trickle of bright
blood
Hematoma: bulging
bluish mass, redpurple
discoloration, &
difficulty voiding
Repair of laceration/
hematoma, ice
packs, & pain meds
Thrombin
ITP – idiopathic thrombocytopenia purpura
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Autoimmune
Low # of circulating platelets due to antibodies
Manual removal,
D&C, oxytocin, &
terbutaline
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Low platelets & low fibrinogen causing increased bleeding time
Treatment: glucocorticoids, platelet infusion, & splenectomy if needed
Von Willebrand Disease
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Congenital bleeding disorder with prolonged bleeding time, deficiency of Von Willebrand
factor, & impairment of platelet adhesion
S/S: bleeding gums, bruising easily, menorrhagia (heavy period), blood in urine & stool,
& hematomas
Von Willebrand factor increases in pregnancy
DIC Disseminated Intravascular Coagulation
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Clotting & anticlotting occurs simultaneously, resulting in organ damage + death
Identifying initiating cause is most important; Tx focuses on tissue perfusion through
fluid therapy, heparin, blood & blood products, oxygen, vasoactive meds, antibiotics,
uterotonic meds
Nursing Assessment & Management
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Identify risk factors
PALPATE the uterus, MASSAGE if boggy, & make sure bladder is empty if displaced
Assess QUANTITATIVE amount of bleeding
Assess for 5 Ts:
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Boggy uterus – massage & consider bladder distention
Large uterus with dark, red bleeding – retained placenta (tissue)
Firm uterus with steady bright red trickle – laceration (trauma)
Firm uterus with bright red trickle & bluish bulging area – hematoma (trauma)
Gingival bleeding, petechiae, ecchymosis, oozing at puncture sites (DIC), heavy lochia
(thrombin)
▪ Signs of shock: < output, tachycardia, & < LOC
Uterotonic drugs
Maintain primary IV infusion & start 2nd infusion if needed
Foley catheter
Provide O2 via NC 2-3 Lpm & monitor O2 sats
Elevate legs 20-30 degrees
Continually monitor VS, LOC, & lochia
Prepare for use of uterine tamponade & bimanual compression
DRUG
ACTION/INDICATION
oxytocin
Stimulates uterine contraction &
controls bleeding
misoprostol
Stimulates uterine contraction &
reduces bleeding
dinoprostol
---
Methylergonovine maleate
carboprost
Tranexamic acid
Stimulates uterus to prevent &
treat PPH due to atony or
subinvolution
Prostaglandin; stimulates
uterine contractions to treat
PPH; second-line therapy
1 gram IV over 10 mins
Antifibrinolytic
(New, inexpensive, & IVP)
NURSING IMPLICATIONS
& CONTRAINDICATIONS
Monitor for urinary retention
CI: never give undiluted as an IV
bolus injection
CI: never give undiluted as an IV
bolus injection
Off-label use
Monitor BP since hypotension is
a frequent SE
CI: HTN
CI: asthma & active CV disease
(also pulmonary, renal, &
hepatic disease)
CI: any woman with a hx of
thromboembolic events or
clotting issues, hx of
coagulopathy, & known
hypersensitivity
Preparation
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Prepare for removal of placental fragments
▪ Manually – assist with suturing
▪ Surgery if tamponade fails – maybe hysterectomy
Assess for S/S of hemorrhagic shock
▪ Goals: control the source of bleeding, fluid resuscitation, correct imbalance of O2
delivery & consumption
▪ Monitor VS, mental status, & output
ITP
▪ Administer glucocorticoids, IV platelet transfusions, & possible splenectomy
▪ Teach clients to find & massage uterus, track # of peri pads, & avoid NSAIDS,
ASA, antihistamines
Uterine Inversion
Prevention
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Avoid episiotomy
Experienced L&D nurse present
Active management in 3rd stage
Staff education & PPH drills
Ensure hemorrhage cart is stocked
Know policies/PPH protocols
▪ Establish emergency release transfusion protocols
Venous Thromboembolic Conditions
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Thrombophlebitis caused by thrombus can become embolus (thromboembolism)
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Superficial & deep vein thrombosis can lead to pulmonary embolus
▪ Popliteal, femoral, & saphenous
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S/S: calf pain, hardened area, redness, warmth, & edema
Dx: doppler, CT, MRI
Prevention & management
Thromboembolic Care
Prevention
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SCDs, TE hose
If BR > 8 hours, perform ROM
Early ambulation
Avoid prolonged sitting, standing, & immobility
Elevate legs & avoid crossing legs
Promote hydration & discontinue smoking
Management
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Encourage rest
BR & elevate legs
Intermittent warm compresses
Do NOT massage
Leg circumference measurements
Thigh-high anti-embolism stockings
Analgesics (NSAIDS – no ASA)
Anticoagulants
Treatments
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HEPARIN
▪ Prevents clot formation & growth
▪ IV 3-5 days, adjusted by coagulation studies
▪ APTT 1.5-2.5 times the control of 30-40 seconds
▪ Antidote on hand – protamine sulfate
WARFARIN
▪ Oral treatment for clots
▪ Taken for 3 months
▪ Monitor PT 1.5-2.5 times control 11-12.5 seconds & INR 2-3
▪ Antidote on hand – vitamin K
▪ Is teratogenic, no OC – discourage pregnancy
Pulmonary Embolism
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S/S: apprehension (anxiety), chest pain, dyspnea, tachycardia, hemoptysis, hypotension,
& hypoxia
Dx: ventilation & perfusion lung scan & chest x-ray
Semi-fowler's position & oxygen by face mask
Same meds as DVT & thrombolytics to break up clots – alteplase & streptokinase
Post-Partum Infections
Endometritis, surgical sites, UTI, & mastitis
•
Common risk factors:
▪ 18–24 hour PROM
▪ Prolonged labor/c-section
▪ Invasive procedures & birth (before, during, or after birth)
▪ Chronic conditions & pre-existing infections
▪ Break in aseptic technique & ill healthcare providers
Endometritis
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Lining of uterus infection
Can involve endometrium ( & decuda & myometrium)
Organisms – normal flora – E. Coli, Klebsiella, & G Vaginalis
25x more common in c-section deliveries
S/S: pelvic pain, loss of appetite, fever >100.4 F after the 1st 24 hours after birth, foul
odor, purulent & dark lochia, & flu-like symptoms
Surgical Site Infections
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c-section incision, episiotomy, & genital lacerations
Usually noted after discharge
S/S: fever after 1st 24 hours after birth, redness, swelling, new or foul drainage, new or
increased tenderness, not approximated & dehiscence or evisceration, & elevated WBCs
UTI
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Organisms – E. Coli, Klebsiella, Proteus, & Enterobacter species
Causes: frequent vaginal exams, catheterization, & genital trauma
S/S: frequency, urgency, painful urination, lower abd pain, flank pain, & fever
Dx: clean catch urine sample
Teaching: perineal hygiene, fluid intake, & cranberry/prune juice
Mastitis
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Inflammation of the mammary gland
Risk factors: milk stasis, nipple trauma, previous episodes, & poor hygiene
S/S: red, hot, painful, tender area on breast, fever, malaise, & pain most often in outer
edge of breast to axillary
Take note, regardless of the cause
Goals: reverse, encourage hydration, maintain milk supply, breastfeed, prevention,
provide comfort, & administer antibiotics
Nursing Assessment & Management
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Risk factors for PP infection: prolonged PROM, c-section, urinary catheterization,
regional anesthesia, ill staff, compromised health status, pre-existing lower genital tract
infections, retained placental fragments, manual removal of retained placenta, insertion
of fetal scalp electrode or IU pressure catheters, forceps or vacuum extraction,
episiotomy or lacerations, prolonged labor with frequent vaginal exams, poor nutrition,
gestational diabetes, & break in aseptic technique during surgery or birthing process
REEDA – redness, edema, ecchymosis, drainage, & approximation
Dx: labs – CBC & cultures
Infection prevention: aseptic technique, HANDWASHING, perineal hygiene, screening
visitors, MASKS, & self-care
Tx: antibiotics, analgesics, & compresses
Teaching guidelines 22.2 - pg. 826
Post-Partum Mood Disorders
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PP “baby blues”
▪ S/S: mild depressive behaviors, anxiety, irritability, mood swings, tearfulness,
increased sensitivity, & fatigue
▪ Usually peaks at days 4 & 5 & resolves by day 10 – if >10 days, seek treatment!
PP depression
▪ Symptoms last longer, are more severe, & require treatment
▪ May lead to poor bonding, alienation from loved ones, daily dysfunction, &
violent thoughts/actions
▪ S/S: restlessness, worthlessness, guilt, hopelessness, moodiness, sadness,
feelings of being overwhelmed, loss of enjoyment, low energy levels, loss of libido,
shows lack of concern for herself & lack of interest in her baby, worry about
hurting the baby, or withdrawn from family & friends
Psychosis
▪ Onset can be abrupt, around 3 months PP, & with previous hx of mental illness
▪ Emergency condition
▪ S/S: extreme mood swings, delusional beliefs, hallucinations, disorganized
thinking, & anger; early symptoms mimic depression, sleep disturbance, &
fatigue
▪ Do NOT leave the mother alone with the infant!
▪ Tx: psychotropic drugs, psychotherapy, & support groups
Assessment & Management
▪ Recognize risk factors & assessment findings – Box 22.2 pg. 832
▪ Nursing assessment & management
▪ Monitor interactions between mom & infant
▪ Monitor mood & affect, reinforce normal vs reportable
▪ Encourage communication of feelings & reinforce compliance with meds
▪ Ask about thoughts of self-harm, suicide, & harming infant
▪ Assist with coping & adjustment
▪ Education (before & during depressive episodes)
▪ Referral for support
Newborn Study Guide
Newborn Transitioning CH 17
(4 ?)
Physiological Response to Birth
Table 17.1 pg. 577 – Anatomic & Physiologic Comparison between the Fetus & Newborn
Respiratory
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•
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Fetus
Fluid-filled
High-pressure system
Blood is shunted through the ductus arteriosus
to the rest of the body
Circulation
•
R atrium pressure > than L atrium; blood
flows through foramen ovale
Hepatic
•
Bypass ductus venosus; maternal liver
performs filtering functions
Thermoregulation
•
Temp is maintained by maternal temp &
intrauterine environment
Respiratory
•
•
•
•
Newborn
Air-filled
Low-pressure system
Blood flows through lungs
Increased O2 content – closes ductus
arteriosus
Circulation
•
L atrium pressure > R atrium; foramen ovale
closes
Hepatic
•
•
Ductus venosus closes
Circulation to infant’s liver to function
Thermoregulation
•
Temp is maintained through a flexed posture &
brown fat
Cardiovascular System
Box 17.1 pg 581 – Summary of Fetal to Neonatal Circulation
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•
•
•
Fetus
▪ Gas exchange = placenta
▪ Umbilical vein carries O2 from placenta to the fetus
▪ O2 blood bypasses the liver through the vena cava & brings it to the heart quicker
▪ Placenta = perfusion, nutrients, & waste removal
Newborn
▪ Gas exchange = lungs
▪ Umbilical cord clamping + 1st breath = beginning of lung function
▪ Closure of:
▪ Foramen ovale
▪ Ductus venosus & ductus arteriosus
Heart Rate
▪ Begins to decrease after a few hours of life
▪ Increases with activity
▪ Helps determine defects & early ID
▪ Tachycardia – volume depletion, cardiorespiratory disease, drug withdrawal,
hyperthyroidism, & infection
▪ Bradycardia – hypoxia, hypothermia, & apnea
Blood Volume
▪ Varies – depending on cord clamping (delayed)
▪ Benefits: anemia prevention, improved BP, volume, iron stores, RBC count
•
▪ 30-60 secs after birth
Blood Components
▪ RBC – 4.5-7.0
▪ Hgb – 16-18
▪ WBC – 10-30,000
Respiratory System
•
•
Initial breath – converts from fluid-filled environment to a gaseous environment
Surfactant
▪
▪
▪
▪
•
Lipoprotein – reduces tension on lung surface
Prevents alveolar collapse
Peaks at 35 weeks
Infants born <35 weeks + c/s have greater risk of respiratory problems
Respirations
▪
▪
▪
▪
30-60 bpm
Irregular & shallow
Short periods of apnea (<15 secs)
Symmetrical chest movements
Essential for newborns to maintain respiratory function:
Respiratory Distress in the Newborn
•
•
•
Can occur at any time, usually during the transitional period
50% of premature infants < 30 weeks will have RD
S/S:
1. Nasal flaring
2. Grunting
3. Retractions
4. Tachypnea (>60 breaths/min)
5. Cyanosis
Thermoregulation
•
•
•
Characteristics that predispose infants to heat loss:
▪ Thin skin – superficial blood vessels
▪ Inability to shiver, limited fat stores, glucose, & glycogen
▪ Limited use of voluntary muscles
▪ Body surface area > body weight
▪ Non-existent subcutaneous fat
▪ Inability to adjust clothing & blankets for warmth
▪ No communication
Infants can overheat d/t:
▪ Large body surface area
▪ Limited insulation
▪ Limited sweating ability
Need for a neutral thermal environment!
Conduction
•
•
•
Heat transfer from one object to another – direct contact
Ex: cold surface, stethoscope, & cold hands
Skin-to-skin with mom helps
Convection
•
•
•
Heat loss through cooler air
Ex: cool air coming from another room
Keep AC between 68-72 degrees; use blankets, clothing, & hat
Evaporation
•
•
Liquid coverts to vapor
Dry at delivery, wash over a warmer, cover with warm blankets & hat after baths
Radiation
•
•
Heat loss via cooler surfaces being within close proximity; not direct contact
Do not place the infant next to a window, AC unit or vent, or outside walls
Higher risk for cold stress within 1st 12 hours of life – leads to increased O2 + glucose consumption!
Hepatic System
•
•
Usually fully functioning by 3 months
Iron Storage
▪
•
Carbohydrate Metabolism
▪
▪
•
If mom’s stores were adequate, baby should have sufficient stores for the 1 st 6 months
Loss of maternal glucose at birth
Declines initially; liver releases stores of glycogen for the 1 st 24 hours
Bilirubin Conjugation
▪
•
•
3 groups of jaundice
1. Overproduction – blood incompatibility, trauma, delayed cord clamping, & breast milk
2. Pathologic – within the 1 st 24 hours
•
Impaired excretion
•
Biliary obstruction, sepsis, hepatitis, chromosomal abnormality, & drugs
3. Physiologic – 3rd – 4th day – normal finding & most common
•
Decreased conjugation
•
Hypothyroidism & breastfeeding
Bilirubin is the breakdown of RBCs, resulting in a yellow-orange color
Increased levels of bilirubin or jaundice can cause encephalopathy, leading to permanent brain damage
Gastrointestinal System
•
•
•
•
•
Gut health is huge in infants!
▪ Breastfeeding = antibody protection
▪ Develops a mucosal barrier to prevent penetration of harmful substances
Small frequent feedings – NB’s stomachs do not “stretch” immediately
Immature cardiac sphincter & nervous control – acid reflux
Need 108 cals/kg/day to gain weight (birth – 6 months)
Infants can lose up to 5-10% of birth weight in the 1st week
▪ Weigh daily & ensure toleration with feedings
Bowel Elimination
•
•
•
1st stool = meconium
▪ Black & tarry
▪ Begins to change after 1st feeding to “transitional” stools
Formula fed:
▪ Yellow or yellow-green, loose, pasty, formed, & has unpleasant odor
Breastfed:
▪ Bright yellow-gold, stringy to pasty, & has sour-smelling odor
Renal System
•
•
•
•
Increased risk for dehydration & fluid overload
Usually void immediately after birth
▪ Need 1 void in 1st 24 hours & prior to circumcision
6-8 voids per day = normal (expected within 1 week of life)
Low GFR & limited excretion affect NB’s ability to excrete salt, water loads, & drugs
Immune System
• Immature = increased risk for infections
1. Natural immunity
▪ Made up of physical & chemical barriers & resident nonpathological organisms
2. Acquired immunity
•
•
▪ Developed through circulating immunoglobulins
▪ Formation of activated lymphocytes
▪ Absent until 1st invasion by foreign organism/toxin
Some form of protection through maternal antibodies
Breastfed babies have increased antibodies through breastmilk
Integumentary System
•
•
•
Protective barrier between the body & environment
Functions:
▪ Limits loss of water
▪ Prevents absorption of harmful agents
▪ Thermoregulation & fat storage
▪ Protection from physical trauma
Accelerated epidermal development with exposure to air
Neurologic System
Acute Senses: hearing, smell, & taste
•
Hearing – well developed at birth & turns to sound
•
•
•
Smell – can ID mother’s breastmilk from others
Taste – distinguish between sweet/sour at 72 hours
Touch – sensitive to pain & respond to tactile stimuli
▪ Most sensitive – mouth, hands, & feet
Vision – least mature sense at birth
▪ Can only see about 8-10 inches away
▪
•
Not passing initial hearing screen is okay, may just be a build-up of amniotic fluid in the ears
Brain increases size threefold within the 1st year
Development typically follows a cephalocaudal proximal-distal pattern (head-to-toe & center-to-outwards)
Congenital Reflexes
•
•
Congenital reflexes = CNS intact, mature viability, & adaptation to extrauterine life
Involuntary muscular response to sensory stimuli
▪
▪
▪
▪
▪
•
•
Resting posture
Cry
Muscle tone
Motor activity
State of alertness
Trauma from birth & hypoxia can cause delays in growth, development, & functions
Common reflexes: gag, Babinski, Moro, finger/toe grasp, rooting, sucking, stepping,
tonic neck, & head righting
Behavioral Patterns
•
•
•
1st period of reactivity (golden hour)
▪ Birth – 30 mins, up to 2 hours
▪ Alert, moving, may appear hungry – breastfeed initiated within the 1st hour
Period of decreased responsiveness
▪ 30 – 120 mins
▪ Period of sleep or decreased activity
▪ “crash” after adrenaline rush
▪ Difficult to arouse infant & may not want to wake for feedings
nd
2 period of reactivity
▪ 2 – 8 hours
▪ Newborn awakens & shows interest in stimuli
▪ More interest in feedings & may pass 1st stool
Behavioral Responses
•
•
•
•
•
•
Predictable responses from the NB in response to its environment
Orientation – response to stimuli
Habituation – NB's ability to process & respond to visual/auditory stimuli & ability to
block out external stimuli (during sleep) after becoming used to stimuli
Motor maturity – ability to control movements
Self-quieting ability – being able to comfort itself
▪ the 5 S’s
▪ Swaddling, swinging, shushing, sucking, & side/stomach position
Social behaviors – cuddling & snuggling
Nursing Management of the Newborn CH 18
Newborn Assessment
•
•
Initial – at birth
▪ APGAR
▪ Length & weight
▪ VS
▪ Gestational age assessment
▪ Physical maturity
▪ Neuromuscular maturity
▪ Place ID bands before leaving the room!
2nd assessment – 2-4 hours
(14 ?)
Newborn Distress
1. Nasal flaring
2. Chest retractions
3. Grunting – exhalation
4. Labored breathing
5. Cyanosis
6. Flaccid tone
7. Abnormal breath sounds
8. Tachypnea/bradypnea
9. Tachycardia/bradycardia
10. Abnormal size: LGA & SGA
APGAR Scoring
•
•
•
•
•
A – appearance (color)
P – pulse (heart rate)
G – grimace (reflex)
A – activity (muscle tone)
R – respiratory (respiratory effort)
Newborn Vital Signs
•
•
•
•
HR: 110-160 bpm
RR: 30-60 breaths/min
Temp: 97.7-99.5 F
BP: systolic 50-75 mmHg / diastolic 30-45 mmHg
Gestational Age: Size
•
•
•
AGA
▪
▪
SGA
▪
▪
▪
LGA
▪
▪
▪
Appropriate for gestational age
Weight between 10th – 90th percentile
Small for gestational age
Weight < 10th percentile
Malnutrition, vascular complications, IUGR, maternal smoking, poor weight
gain, & HTN
Large for gestational age
Weight > 90th percentile
Maternal DM & maternal obesity
Gestational Age Assessment: Physical Maturity
•
•
Skin texture: ranges from sticky/transparent, smooth, & peeling
Lanugo: soft downy hair
▪
▪
•
Plantar creases: sole of feet
▪
▪
•
•
More creases = more mature
Slick feet = premature
Breast tissue: thickness & size of breast & areola increase with maturity
Eyes & ears
▪
▪
•
Covers entire body
May or may not be absent in preterm, appears with maturity, then disappears again with post
maturity
Eyelids can be fused or open
Ear cartilage stiffness increases with maturity
Genitals
▪
▪
Males – evidence of testicular descent & appearance of scrotum
Females - prominent clitoris = premature; prominent labia = mature
Nursing Interventions
Immediate Newborn Period
•
•
•
•
•
Maintaining airway patency
Mouth BEFORE nose!
Ensuring proper identification
Thermoregulation
Administering prescribed medications
▪ Phytonadione – vitamin K – IM 1-2 hours after birth – clotting
▪ Erythromycin Ointment – prophylactic for eyes – 1-2 hours after – blindness
▪ Hepatitis B Vaccine – IM – requires parental consent – series of 3 injections
Thermoregulation
•
•
•
•
•
•
•
•
•
•
Dry immediately after delivery
Skin-to-skin – best way for thermoregulation
Warmed blankets & hat
Weigh on warmer & place warmed blanket over scale
Warm stethoscopes & hands before examining
Avoid placing newborns in drafts or near air vents
Delay the initial bath – hospital policies differ
Avoid placing cribs near cold outer walls & windows
Place under radiant warmer: bath, procedures, & if temp is unstable
Prevent cold stress!
Newborn Physical Exam
•
•
Prenatal history
Newborn physical examination
▪ Table 18.3 NB Assessment Summary – pg 622
▪ Do not perform while crying/upset
▪ Begin with least invasive 1st
▪ Anthropometric measurements: length, weight, head & chest circumference
▪ Vital signs: full minute for HR & RR
▪ Skin: color, condition, & common skin variations
▪ Acrocyanosis may be a normal finding in 1 st 24 hours – baby may just be cold
NB PE: Common Skin Variations
•
•
•
•
•
•
•
•
Vernix caseosa
▪ Thick, white, & cheesy substance
▪ Protects the infant – do not remove, absorbs into the skin
Telangiectatic nevi
▪ “Stork bites”
▪ Appears on back of the neck, eyelids, between eyes, & upper lip
▪ Fade within 1 year, blanches when pressed
Milia
▪ Unopened sebaceous glands
▪ Small white spots – nose, chin, & forehead
▪ Disappear in 2-4 weeks
Mongolian spots
▪ Mimic bruising
▪ Dark blue, gray, brown, or black spots – back or buttocks
▪ More common in darker ethnicities
▪ Disappears within 4 years
Erythema toxicum
▪ “Newborn rash”
▪ Pink/red rash – generalized location
▪ No Tx needed = normal
▪ Appears around 24 hours, affects all ethnicities
Harlequin sign
▪ Dilation of blood vessels on one side of the body
▪ Transient, lasts up to 20 mins, no intervention needed
Nevus flammeus – lifelong
▪ “Port-wine stain”
▪ Capillary angioma – purple or red
▪ Does not grow
Nevus vasculosus
▪ Strawberry hemangioma
▪ Resolves by 3 years
NB PE: Head
•
•
•
•
Head Size & Shape Variations
Size, fontanelles – separated, approximated, or overriding?
Variations – figure 18.14 pg 616
▪ Molding – sutures override
▪ Caput succedaneum – scalp edema
▪ Cephalohematoma – does not cross suture line, red-purple, & increased risk of
developing jaundice
Abnormalities
▪
Microcephaly – may be associated with CMV, rubella, toxoplasmosis, zika virus, trisomy 13, 18,
▪
▪
or 21, & exposure to alcohol or certain drugs in utero
Macrocephaly – familial, hydrocephalus, & skeletal disorders
Large, small, or closed fontanelles
NB PE:
•
•
•
•
•
•
•
•
•
•
•
Nose – patent, symmetrical nares, drainage, & sneezing
Mouth
▪ Lips – moist, cracked, pink/pale, cleft lip
▪ Mucous membranes – moist/pink, pale, Epstein pearls (small bumps on
gumline), cleft palate
▪ Reflexes – gag, suck, & swallow
Eyes – pupils, sclera, & conjunctiva
Ears – symmetrical, drainage/discharge, low set – indicates down syndrome
Neck & chest
▪ Clavicle – intact, fractured, or crepitus
▪ Chest shape, nipples, & breasts
Respiratory – irregular, unlabored, s/s resp distress, adventitious breath sounds
Cardiovascular – auscultate, palpate cord at delivery, murmur (common in 1st 24 hours)
▪ Pulses: regular/irregular, strong/weak, palpate bilaterally
Gastrointestinal
▪ Umbilical cord – how many vessels, moist/drying/dry, clamped, s/s of infection
▪ Abdomen – soft/distended, visible bowel loops, hernia, BS x 4?
▪ Bowel movement – present? Describe BM
▪ Feedings – what type? Tolerating? Spit up or regurgitation?
Genitourinary
▪ Voided in life? Describe color, smell, & amount
▪ Keep I&O
Genitalia
▪ Male – urethra location & testes
▪ Circumcision – s/s of infection, healing, & interventions
▪ Female – urethra location, mons, labia, & discharge
▪ Pseudomenstruation – normal & temporary, response to mom’s
hormones
Buttocks/Spine
▪
▪
•
Rectum – patent
Spine – straight, curved, sacral dimple (let ped MD know to test for spina bifida),
& myelomeningocele
Extremities
▪ Symmetrical, ROM bilateral, flexed/extended, cap refill
▪ Extra digits, club foot, “hip click”
▪ Ortolani & Barlow – detects congenital developmental hip dysplasia
▪ Clicking or clucking sound indicates hip dysplasia
▪ Ortolani maneuver – supine, flex hips & knees, abduct the hips while
applying upward pressure
▪ Barlow maneuver – supine, flex hips & knees, adduct the hips towards the
center & apply outward & downward pressure
Neurologic Status
•
•
Alertness, posture, & muscle tone
▪ Alert – not persistently lethargic
▪ Hips & knees partially flexed, arms abducted, fists clenched, & fingers covering
thumbs
▪ Only slight head lag when pulling NB from supine to sitting position
Reflexes – pg 620-624
▪ Sucking
▪ Sucking & rooting – stroking the cheek or mouth – infant should turn to the side/sucks
▪ Palmar grasp
▪ Infant curls fingers around examiner’s finger
▪ Plantar grasp
▪ Infant curls toes downward when examiner’s finger touches
▪ Moro
▪ Infant should stretch out arms & then abduct at elbows when “falling” backwards
▪ Tonic neck
▪
▪
▪
“Fencer” position – turn NB’s head to the side, the NB will then extend arm & leg to the side the head
is facing with opposite arm & leg flexed
Babinski
▪ Stroke the outer sole of the foot (upwards to toes) - infant should fan toes outward
Stepping
▪ Hold infant upright with feet touching surface, infant should begin “stepping”
Nursing Management: Early Newborn Period
General Newborn Care:
•
•
Bathing & hygiene – pg 625 – teaching guidelines 18.1
▪ Plain water on face & eyes, mild soap for body
▪ Wear gloves – 1st bath
▪ Do not submerge until umbilical cord has fallen off! – 10 days
Cord care – pg 627 – teaching guidelines 18.2
▪ s/s of infection
▪ Air exposure
▪ Stump will dry & darken in color
•
▪ Never pull the cord – let it fall off on its own
Elimination & diaper area care
▪ Urine characteristics
▪ Stool pattern
▪ Diaper area care
Circumcision Care: pg 627
•
•
•
•
Risks: infection, hemorrhage, skin dehiscence, adhesions, ureteral fistula, & pain
Benefits: easier hygiene, less UTIs, less STIs, lower rate of penile cancer
Criteria:
▪ Infant is at least 12 hours old or older
▪ Infant has received standard vitamin K prophylaxis
▪ Infant has voided normally at least once since birth
▪ Infant has not eaten for at least an hour prior to the procedure
▪ Written parental consent has been obtained
▪ Correct identification of the infant is brought to the procedure room
Nursing Management:
▪
▪
▪
▪
▪
▪
Immediately cover with petroleum jelly
Assess for bleeding & s/s of infection
Diaper changes – educate parents on normal vs abnormal findings
Educate the parents
Pay attention to 1 st void after procedure
Sponge baths until fully healed
Safety: teaching guidelines 18.3 pg 629
•
•
•
Prevention of abduction
▪ Wear badge
▪ Transport in the crib
▪ Check arm bands
▪ Be aware of surroundings!
▪ Code Pink
Car safety – pg. 630
▪ Should be secured before leaving the room
▪ Rear-facing
▪ Appropriate for size
Safe sleep – pg. 631
▪ Room sharing, no smoking
▪ No objects in crib – can smother; firm mattress
▪ One layer of clothing
▪ Room temp
▪ Back for sleeping
Nutrition:
•
•
•
•
Physiologic changes
Nutritional needs: calories = 110-120/kg body weight (not for exam)
Fluid requirements: 100-150 mL/kg daily (not for exam)
Feeding Methods – breast or formula
▪ Frequency
▪ Breast – Q2-3 hours, 8-12 feedings/day
▪
▪ Formula – Q3-4 hours
Decrease air swallowing
▪ Upright position
▪ Head/neck support
▪ Burping
Breastfeeding
•
Changes from colostrum > transitional milk > mature milk
1. Colostrum – thick, yellow, “syrup” - first few days
2. Transitional – thinner, less yellow, 3-10 days
3. Mature milk – approx. Day 10, appears more like cow’s milk, even thinner
•
Benefits: reduces the risk of SIDS, decreases risk of infections, easily digested, allergies,
& childhood obesity – promotes bonding & attachment
Assistance – positions & latch
Education – teaching guidelines 18.4 - pg. 644
Concerns – sore nipples, engorgement, & mastitis
▪
•
•
•
Contains: carbs, protein, fat, water, minerals, enzymes, vitamins, & mom’s immunities
Bottle-Feeding: teaching guidelines 18.5 pg. 647
•
•
•
•
Types of formula
Provide assistance – how to prep & decrease air during feedings
Positioning – 45-degree angle & upright
Education
▪ Never prop a bottle! RISK FOR ASPIRATION!
▪ Burp often
▪ Always keep bulb syringe close by!
▪ Throw away previous feedings
▪ Test temperature on the back of your hand, do not microwave formula – place in warm water
Discharge Preparation
•
•
Education & cultural considerations
Follow-up care
▪ Return visit – 72 hours
▪ Immunization information
▪ Warning signs & symptoms & when to call the MD!
▪ Temp above 100.4 F OR below 97.8 F axillary
▪ Continual rise in temperature
▪ Forceful, projectile vomiting – not spit up
▪ Refusal of 2 feedings in a row
▪ Cyanosis with or without feedings
▪ No wet diapers for 18-24 hours or fewer than 6-8 wet per day after 4 days
of age
▪ 2 or more consecutive green, watery diarrheal stools
▪ Lethargy
▪ Abdominal distention
▪ Difficult or labored breathing
▪ Color – pale, dusky, or cyanotic
▪ Circumcision – s/s of infection
Newborn Screenings
•
•
Phenylketonuria (PKU)
▪ “Newborn Screen”
▪ 24-48 hours
▪ Can the infant break down phenylalanine?
▪ Can diagnose sickle cell anemia & CF
Hearing Screen
▪ Most common birth disorder
▪ 3-5: 1,000 births
▪ Assess for risk factors associated with hearing loss
▪ Ex: family hx, CMV, rubella, herpes, head trauma, hyperbilirubinemia, ototoxic drugs
Common Concerns: Transient Tachypnea of the Newborn
“TTN”
•
•
•
•
•
•
•
Slow or incomplete removal of fluid in lungs
Resp distress present at birth or within 1st 6 hours of life
Usually resolves around 24-72 hours
Assessment: resp distress, RR = 100-140, & decreased breath sounds
Risk factors: prolonged labor, < 39 weeks, c-section delivery, macrosomia, GDM,
maternal asthma, fetal distress in labor, male sex
“Wimpy white boy”
Nursing interventions:
▪ Supportive care
▪ O2 – if O2 sat is low
▪ Warmth – prevent cold stress – causes resp distress
▪ Observing respiratory status frequently
▪ Allowing time for pulmonary capillaries & the lymphatics to remove the
remaining fluid
Common Concerns: Hyperbilirubinemia
•
•
•
Imbalance in rate of bilirubin production & elimination; total serum bilirubin level
>5mg/dL
Pathologic jaundice
▪ Within the 1st 24 hours of life
▪ Kernicterus
▪ Rh isoimmunization; ABO incompatibility
Physiologic jaundice
▪ Normal – 65% of newborns
▪ Occurs after 24 hours of life – usually 3rd to 4th day
▪ More common in preterm (80%) than term (50%)
▪ Bilirubin levels peak on days 3-5
▪ Good feedings are essential!
Common Concerns: Hypoglycemia
•
•
•
•
•
Plasma glucose concentration < 45 mg/dL in the 1st 72 hours of life
Higher risk – DM mothers, SGA, & LGA
S/S: most are asymptomatic, jitteriness, lethargy, cyanosis, apnea, seizures, high-pitched
or weak cry, hypothermia, & poor feeding
Assess for birth trauma, O2, & temp instability
Nursing Interventions:
▪ Rapid acting glucose source
▪
▪
▪
▪
▪
▪
Dextrose gel
Breastfeeding
Formula feeding – may need to be gavage fed
IV glucose – severe cases
Provide warmth & prevent cold stress
Continue to reassess BG levels & monitor for symptoms
Nursing Care of the Newborn with Special Needs CH 23
(4 ?)
Newborns at Risk
•
•
•
•
•
•
•
Low socioeconomic status & no prenatal care
Maternal age extremes – adolescent/AMA
Maternal nutritional extremes – malnutrition, overweight, obesity
Infection – chorioamnionitis, STI, BV, or UTI
Maternal history of:
▪ Cervical surgery, uterine anomaly, placental abnormality
▪ Previous pre-term birth
▪ Smoking, ETOH, drug use
▪ Multiple gestation
▪ PPROM
Maternal disease – HTN, DM, HIV, autoimmune disease, iron deficiency anemia
Maternal psychological stress
Small for Gestational Age (SGA)
Box 23.1 pg. 841 - contributing factors
•
Maternal malnutrition, HTN, smoking, pre-eclampsia, infections, chromosomal
abnormalities, congenital malformations, etc.
ATI pg. 193
•
Some SGA infants can have growth restriction
▪ Placental insufficiency – decreased O2 & nutrients chronically
▪ IUGR = asymmetric or symmetric (everything is proportionately small)
SGA Newborn
Table 23.1 - common problems associated with SGA
Assessment:
•
•
•
•
•
•
•
•
•
•
< 2500 grams (5lb. 8 oz.)
Head = larger than the body
Wasted/sunken appearance
Decreased subcutaneous fat stores
Loose & dry skin
Scaphoid abdomen
Thin umbilical cord
Jittery (hypoglycemia)
Poor muscle tone over buttocks/cheeks
Unstable thermoregulation
Nursing Management:
•
•
•
•
Weight, length, & head circumference measurements
Monitor VS
Hypoglycemia management:
▪ Observe for s/s & obtain labs
▪ Serial blood glucose checks
▪ Early & frequent oral feedings
▪ Provide a neutral thermal environment
Risk for: hypoglycemia, polycythemia, temperature instability, & asphyxia
Large for Gestational Age (LGA)
Table 23.1 - common problems associated with LGA – ATI pg. 194
•
Risk Factors:
1. Maternal diabetes
2. Multiparity
3. Previous macrosomia infant
4. Post-term gestation
5. Maternal obesity
6. Paternal height
7. Gestational weight gain
8. Male fetus
9. Genetics
LGA Newborn
Assessment:
•
•
•
> 4000 grams (8lbs 13 oz)
Large & plump body
Proportionate increase in body size
•
•
Poor motor skills
Difficulty regulating behavioral state
Nursing Management:
•
•
•
•
•
•
Assess for any birth trauma; neuro exam
Monitor VS & BS levels
Initiate oral feedings & IV supplementation as needed
Monitor for s/s of polycythemia & hypoglycemia
Promote hydration
Risk for: birth injuries, c/s birth, & hypoglycemia
Hypoglycemia
ATI pg. 190
•
•
•
•
•
Blood glucose < 45 mg/dL
ACA recommends interventions for any BS < 40 within the 1st 4 hours of life;
<45 from 4-24 hours
Can be asymptomatic in some newborns
S/S: lethargy, apathy, drowsiness, irritability, tachypnea, weak cry, temperature
instability, jitteriness, seizures, apnea, bradycardia, cyanosis or pallor, feeble suck & poor
feeding, hypotonia, & coma
Obtain BS within 30 mins from birth
Nursing Management:
•
•
•
•
•
•
•
Observe for s/s & obtain labs
Serial blood glucose checks
Early & frequent oral feedings
Provide a neutral thermal environment
Reassess prior to feedings, 1 hour after feedings, or for any s/s
At risk: SGA, LGA, infants of diabetic moms
Heel sticks: ONLY on medial & lateral curve of the heel (right & left sides)
Polycythemia
•
•
•
•
Hct > 65% peaks between 6-12 hours
S/S: respiratory distress, cyanosis, feeding difficulties, hypoglycemia, jitteriness,
jaundice, ruddy skin color, seizures, & lethargy
Increase fluid volume – oral or IV
Monitor Hct levels
Post-term Newborn
•
•
> 42 weeks gestation
Morbidity & mortality rates SIGNIFICANTLY increase
•
•
•
Placenta becomes “old” & compromised & aging begins
▪ Loses ability to nourish the fetus, can become wasted, & lose muscle mass/fat
▪ Increases fetal complications at birth
Poor nutrition = poor oxygenation
Risk for asphyxia, hypoglycemia, & respiratory distress
Assessment:
•
•
•
•
•
•
•
•
•
•
•
Dry, cracked, peeling, & wrinkled skin
Vernix caseosa & lanugo = absent
Long, thin extremities, & fingernails
Minimal fat
Creases that cover the entire soles of the feet
Wide-eyed & alert expression
Abundant hair on scalp
Loose skin around thighs & buttocks
Thin umbilical cord
Meconium-stained skin & fingernails
Macrosomia
Nursing Management:
•
•
•
•
•
•
•
•
Anticipate the need for resuscitation = priority!
Have RT & NICU team at delivery
Continuous assessment, monitoring, & Tx depends on the status of the infant
Monitor BS levels
Early feedings if needed
Monitor VS, respiratory characteristics, ABGs, serum bilirubin levels, & neuro status
Provide neutral thermal environment
Monitor for polycythemia, hyperbilirubinemia, & hypoglycemia
Pre-term Newborn
•
•
Different variations of pre-term
Risk Factors:
▪ Often unknown
▪ Infection/inflammation
▪ Maternal or fetal distress
▪ Bleeding
▪ Stretching
Pre-term: Nursing Assessment
Common characteristics – pg. 850
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Birth weight < 5.5 lbs
Appearance:
▪ Scrawny
▪ Head disproportionately larger than chest circumference
▪ Plentiful lanugo & vernix caseosa
▪ Poor muscle tone & flexion, limited subcutaneous fat stores
▪ Absent – few creases in the soles & palms
▪ Wide & soft fontanelles with overriding sutures
▪ Fused eyelids
▪ Thin, transparent skin with visible veins
Genitals:
▪ Males – undescended testes
▪ Females - prominent clitoris & labia minora
Pre-term: Nursing Management
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Promote O2 & monitor VS – watch for trends
Thermal regulation – PREVENT COLD STRESS
Nutrition & fluid balance
Prevent infection & injury
Limit stimulation
Pain management – Box 23.4 & 23.5 pg. 858 & 859
Parental support – promote positive coping skills – potential for perinatal loss
Discharge planning – pg. 861
Effects of Prematurity
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Body system immaturity impacts transition & survival to extrauterine life
Depends on the degree of pre-term
Pg. 848 & 849
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Respiratory System
▪ Little to no surfactant, apnea, smaller resp passageways, TTN
CV System
▪ Circulation pattern is changing, PDA, impaired regularity of BP – risk for hematoma & intracranial
hemorrhage
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GI System
▪ Hypoxia shunts blood away from the gut – risk for malnutrition & weight loss – breast milk is best
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Hepatic System
▪ At risk for hyperbilirubinemia – need for phototherapy
Renal System
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Immune System
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CNS
(lowers risk of NEC)
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Immature GFR, fluid retention/imbalances
Increased risk for infection, immunities, fragile & thin skin – limited protection
▪
Increased risk for insult to CNS – cannot regulate temp – PREVENT COLD STRESS
Dealing with Perinatal Loss
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Any pregnancy loss and/or neonatal loss death up to 1 month of age
Profound experience for the family
Provide memory items, time with the infant, & remove lines
▪ Memories made can help with the grieving process for the family
Avoidance is a common reaction - including nurses
▪ Communicate with empathy
▪ Practice active listening
▪ Be aware of personal feelings, facial expressions, & tone of voice
▪ Table 23.2 pg. 864 - assisting parents to cope with perinatal loss
Child-life specialist
Nursing Management. of the NB at Risk: Acquired & Congenital Conditions
CH 24 (8 ?)
Infants of Diabetic Mothers
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Patho: high levels of maternal glucose crossing placenta, stimulating increased fetal
insulin production, leading to somatic fetal growth
Nursing Assessment:
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Diabetic mother
Baby - full rosy cheeks, ruddy skin color, short neck, buffalo hump, massive shoulders,
distended upper abdomen, excessive subcutaneous fat tissue, & birth trauma
Hypoglycemia, hypocalcemia, hypomagnesemia, polycythemia, & hyperbilirubinemia –
table 24.1 pg. 887
Nursing Management:
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Prevention of hypoglycemia – frequent oral feedings, neutral thermal environment, &
rest periods
Maintenance of fluid & electrolyte balance – calcium level monitoring, fluid therapy, &
bilirubin level monitoring
Parental support & education
Hypoglycemia - < 40 mg/dL
Hypocalcemia - < 7 mg/dL
Hypomagnesemia - < 1.5 mg/dL
Hyperbilirubinemia - > 12 mg/dL (term infant)
Polycythemia - > 65%
Hyperbilirubinemia
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Risk Factors – pg. 902
▪ Polycythemia
▪ Significant bruising or cephalohematoma
▪ Birth trauma
▪ Prematurity
▪ ABO incompatibility
▪ Rh isoimmunization
▪ Macrosomia
▪ Delayed cord clamping – increases erythrocyte volume
▪ Siblings with hx of jaundice
▪ Inadequate breastfeeding
▪ Male
Nursing Assessment
▪ Risk factors
▪ Skin, mucous membranes, sclera, & bodily fluids
▪ Signs of Rh incompatibility
▪ Bilirubin levels – pg. 902
▪ TC Bili – transcutaneous & non-invasive
▪ Total serum – invasive, more accurate, & a blood draw
▪ COOMBs/DAT (identifies hemolytic disease of the NB) - + result indicates that NB’s
RBCs have been coated with antibodies & are sensitized
Nursing Management
▪ Prevention – early detection – pg. 903
▪ Reduction of bilirubin levels
▪ Early feedings, exposure to natural sunlight, & phototherapy
▪ Monitor hydration status, stools, skin color, & reassess bilirubin levels –
assess based on baby’s birth & last bilirubin check
▪ Education & support
Phototherapy – Nursing Management
▪ Monitor temp every 3-4 hours & I&Os
▪ Monitor hydration status & elimination characteristics
▪ Position changes every 2 hours – ensure bilirubin is being broken down all over
the body
▪ Monitor skin integrity
▪ Eye & genital protection!
▪ Encourage parents to participate in care
▪ Only remove infant for feedings
▪ Maintain neutral thermal environment
Respiratory Distress Syndrome – ATI pg. 191
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Lung immaturity & lack of alveolar surfactant – pre-term baby
Risk factors: pre-term birth, c/s delivery, male, cold stress, maternal diabetes, &
perinatal asphyxia
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Occurs at birth or within a few hours of birth; will worsen after 72 hours
(different from TTN, TTN improves after 72 hours)
Assessment: S/S - respiratory distress, tachycardia (>150-180), generalized cyanosis,
& tachypnea (>60)
Tx: supportive O2 (mechanical ventilation, CPAP, or PEEP), surfactant,
thermoregulation, cardiovascular & nutritional support, & glucose maintenance
Meconium Aspiration Syndrome
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Inhalation of particulate meconium with amniotic fluid into the lungs
– secondary to hypoxic stress
Nursing Assessment:
▪ Risk factors
▪ Staining of amniotic fluid, nails, skin, or umbilical cord
▪ Prolonged or increasing respiratory distress
▪ Chest x-ray & ABGs – metabolic acidosis
Nursing Management:
▪ Suctioning at birth
▪ Ensure adequate tissue perfusion
▪ Decrease in oxygen demand & energy expenditure
▪ Neutral thermal environment
▪ Parental support & education
Necrotizing Enterocolitis (NEC)
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Pre-term NBs – especially with enteral feedings
Predisposing factors – box 24.1 pg. 884
Assessment:
▪ S/S of respiratory distress, feeding intolerance, diarrhea, bloody stools, &
increased abdominal circumference
▪ Determine residual gastric volume prior to next feeding
– when high, suspect NEC
Management:
▪ Immediately stop feedings – encourages bowel rest
▪ IVF
▪ Measure abdominal circumference
▪ Monitor stools & gastric contents
▪ Antibiotic therapy
▪ May need surgery
Neonatal Sepsis
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Congenital – intrauterine - “vertical transmission” - onset is before birth
▪ CMV, Rubella, Toxoplasmosis, Herpes, HIV, & Syphilis
Early Onset – perinatal - < 72 hours – from mom’s genitourinary system
▪ GBS, E. Coli, Staph, & Listeria
Late Onset - “horizontal transmission” - > 72 hours – hospital/caregiver acquired
through environmental exposures - preventable – more common with invasive
procedures, ET intubation, catheter insertion, & loss of protective barrier
▪ Staph, E. Coli, Klebsiella, Pseudomonas, Enterobacter, Candida, Anaerobes
▪ HIV & CMV – no breastfeeding or direct contact
▪ Higher chance for pre-term infants with prolonged hospital stays – NICU
Comparison chart 24.2 pg. 907
Nursing Assessment:
▪ Risk factors: prolonged labor, antepartum/intrapartum infections, pre-term
birth, maternal substance abuse, meconium aspiration, chorioamnionitis, low
birth weight, & prolonged hospital stay (NICU)
▪ S/S: poor feedings, resp distress, bradycardia, GI problems, increased O2
demands, lethargy, hypotension, decreased or elevated temp, & irritability
▪ Labs: CBC – anemia, leukocytosis, or leukopenia – elevated C-reactive protein
indicates inflammation
▪ Chest x-ray & blood cultures (blood, spinal fluid, & urine)
Nursing Management:
▪ Early recognition is essential!
▪ Broad spectrum Abx – ampicillin & gentamycin/cefotaxime initially, then
organism-specific once cultures return – Abx Tx for 7-21 days if positive, or
discontinue after 72 hours if cultures are negative
▪ ALWAYS maintain medical & surgical asepsis
▪ Monitor VS, comfort/pain, nutritional needs, proper positioning, oral care,
monitoring of invasive sites for s/s of infection
▪ Watch for organ system dysfunction
▪ Assess parents’ educational needs & provide instructions as needed
▪ ATI pg. 196
Newborns of Substance-Abusing Mothers
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Table 24.4 pg. 892 – commonly used substances & their effects on the fetus/NB
Most common substances = tobacco, alcohol, & marijuana
Fetal alcohol spectrum disorders – fetal alcohol syndrome & alcohol-related birth defects
Neonatal abstinence syndrome – drug dependency acquired in utero, manifested by
neurologic & physical behaviors
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Nursing Assessment:
▪ Maternal history; risky behaviors & toxicology
▪ Newborn behaviors - “super irritated baby” - box 24.3 pg. 893
▪ WITHDRAWAL assessment – box 24.4 pg. 898
▪ Wakefulness
▪ Irritability
▪ Temperature variation, tachycardia, & tremors
▪ Hyperactivity, high-pitched persistent cry, hyperreflexia, & hypertonus
▪ Diarrhea, diaphoresis, & disorganized suck
▪ Respiratory distress, rub marks, & rhinorrhea
▪ Apneic attacks & autonomic dysfunction
▪ Weight loss or failure to gain weight
▪ Alkalosis – respiratory
▪ Lacrimation
Nursing Management:
▪ Promote comfort & reduce stimuli
▪ Nutrition
▪ Complication prevention
▪ Parent-newborn interaction – teaching guidelines 24.1
▪ Goals: comfort, improve feedings & weight gain, & prevent seizures
▪ May have to receive IV morphine or methadone
▪ Encourage breastfeeding – situational – baby gets some substance & this can
help with withdrawal symptoms
Fetal Alcohol Spectrum Disorders
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Fetal alcohol syndrome = most common
Physical & mental disorders appearing at birth & remaining problematic throughout the
child’s life – Box 24.2 pg. 895
3 main findings:
▪ Fetal growth restriction
▪
Craniofacial structure abnormalities – microcephaly, flat midface, short palpebral fissure length,
thin upper lip, smooth gap between nose & lips, etc.
CNS dysfunction
Effect of alcohol amount – unknown – CDC reports increased risk if alcohol is consumed
in the 1st trimester
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