Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Chapter 15
Caring for the Postpartum Woman
and Her Family
Fourth Trimester
 Begins immediately after childbirth
 Puerperium—first 6 weeks after birth
 Close observation—identify hemorrhage and
complications during first critical hour
 Ongoing education and support
Safety for Mother
and Infant
Key Patient Safety Concerns:
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Prevent infant abductions
Check ID bands
Educate mother about safety measures
#1 risk on postpartum is Falls
Postpartum Psychological
Adaptation
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 & breastfeeding (within 1/2 hr of birth is best).
Maternal Responses
to Newborn
Reva 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
 Postpartum/baby blues:
Blues vs
Depression
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
 Onset within first 8 weeks after childbirth
 Distinguishing signs: hallucinations,
agitation, confusion, suicidal/homicidal
thoughts, delusions, sleep disturbances,
loss of touch with reality
 Requires hospitalization & treatment
Postpartum Nursing
for Vulnerable Populations
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Victims of abuse
History of depression/ mental illness
Special needs population- support
Adolescents- Teen support groups
Undocumented immigrants
Limited Access to care/homelessness
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.
Early Maternal
Assessment
 Vital signs
 Fundus
 Immediate postpartum—halfway between the symphysis pubis
and the umbilicus
 1 hour postpartum—level of the umbilicus or one fingerbreadth
above
 Then, descends one fingerbreadth each day
 Lochia
 Rubra, serosa, alba
Postpartum Assessment
Guide
BUBBLE-HE
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Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy
Homan’s sign
Emotions & bonding
Afterpains
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Occur during process of involution
Assess pain
More pronounced in multipara
Nursing care
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Explain cause
Prone position with abdominal pillow
Sitz baths
Encourage ambulation
Administer mild analgesics
Cardiovascular
System
 Delivery of the baby, expulsion of the
placenta, and loss of amniotic fluid can
create cardiovascular instability
 Cardiac output remains elevated
 Physiological diuresis
Hematological
System
 Decrease in blood volume
 Blood loss
 Diuresis
 White blood count increased x 5 to 6 days
 Fibrinogen increased
 Returns to normal by third to fourth week
Deep Vein
Thrombosis
 Homans’ sign
 Clinical assessment
 Erythema, unequal calf circumference, heat
 Clinical signs are NOT reliable
Hormonal Levels
 Estrogen and progesterone decrease
 Anterior pituitary—prolactin
 Placental lactogen, cortisol, growth
hormone, and insulinase levels decrease
 Insulin needs decrease—“Honeymoon phase”
Neurological
System
 Altered sleep patterns—maternal fatigue
 Numbness in legs, dizziness
 Safety for infant and mother
 Headaches
 Assess quality and location, and carefully
monitor vital signs
 Implement environmental interventions
Immune System
 Rho (D) immune globulin (RhoGAM)
 Rubella vaccination
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Nonimmune status
Signed consent form
Avoid pregnancy for 1 month
Flu-type symptoms may occur
Menstruation
& Ovulation
 Nonlactating women
 Menstruation returns in 6 to 8 weeks
 First cycle may be anovulatory
 Lactating women
 Delayed ovulation and menstruation
 Educate—ovulation can precede
menstruation, need contraception
Gastrointestinal
System
 Decreased gastric motility
 Decreased muscle tone in abdominal wall
 Constipation
 Stool softeners
Musculoskeletal
System
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Laxity of pelvic joints and ligaments
Relaxation of soft tissues
Muscle fatigue
Body aches
Rectus abdominis diastasis
 Correct posture
 Modified sit-ups
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.
Postpartum
Hemorrhage
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Definition
Accurately estimating blood loss
Hypovolemic shock
DIC
Early vs. late
 LARRY
 4 “T’s”
Postpartum
Hemorrhage
 Uterine atony
 Hallmark—soft uterus filled with clots and
blood
 Genital tract trauma- lacerations
 Uterus firm
 Tissue trauma- hematoma
 Thrombin
Postpartum
Hemorrhage
 Late postpartum hemorrhage
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Retained placental fragments
Ergonovine medication- Methergine
antibiotics
possible D&C
Collaborative
Management
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Frequent vital signs and fundal massage
Note patient’s behavior- PTSD noted
Medical management depends on cause
Administer oxygen
Obtain laboratory tests
Accurate I/O
Hematomas
Cause: Trauma
 Puerperal hematomas occur in 1:300 to 1:1500
deliveries
 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
 Definition
Puerperal
Infections
 Types of puerperal infections
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Endometritis
Mastitis
Operative wound
Urinary tract
 Careful and thorough assessment
Postpartum
Infection
 Puerperal Infection: Endometritis
 infection of reproductive tract within 6 wks of
childbirth
 Increased risk with:
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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 & Csection
 Signs & Symptoms
 Can progress to pelvic cellulitis or
peritonitis.
Endometritis
 Ttreatments:
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antibiotics
oxytocics such as methergine,
↑ fluid intake
pain relief
diet
 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
Post op C/Section
Complications
1. Paralytic Ileus
2. Wound Dehiscence
3. Wound infection
Cultural Sensitivity
 Conduct cultural assessments
 Expand knowledge and understanding
 Culturally influenced beliefs
 Common health care practices
 Customs and rituals
Discharge Planning
and Teaching
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Fundus and lochia
Hygiene
Abdominal incision
Body temperature
Elimination
Nutrition
Discharge Planning
and Teaching
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Fatigue
Weight loss
Exercise
Pain management
Mood
Sexual activity and contraception
Community
Resources
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Support groups
Home visits
Telephone follow-up
Outpatient clinics
Critical Thinking
1. A mother is experiencing shaking
chills during the hour following birth.
What is the nurse’s initial action?
A.
B.
C.
D.
Take a rectal temperature
Notify the physician or nurse-midwife
Cover the woman with warmed blankets
Review the order sheet for antibiotic
orders
Critical Thinking
\
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. Massage the fundus
D. Assist the client to a prone position
and place a small pillow under her
abdomen
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 health care provider for 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 order
B. Elevate the affected limb
C. Apply ice packs to the affected limb
D. Administer antibiotics per order
Infant Feeding
Choices
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Breastfeeding
Bottle feeding
Educate
Support
Breastfeeding
Promotion
 WHO promotes Breastfeeding around the
world
 Healthy People 2020
 APA advocates breastfeeding for 12
months
 Baby Friendly initiatives in hospitals
↑breastfeeding rates and duration
11753398
Breastfeeding
Initiation
 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.
 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
 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
 Don’t need to bottlefeed- although frequently done
Baby who is feeding well--”getting enough”
Breastfeeding
Teaching
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Every 2-3 hours in first weeks
Promote adequate sucking
Provide support
Techniques for burping
Multiple infants
Engorgement
Breastfeeding
Problems
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Sore nipples– poor latch-on
Supplemental feedings
Working outside of the home
Weaning
Engorgement
Mastitis
-Signs & symptoms
-Interventions
-Collaborative Treatment
The Amazing Newborn
The First Breath
 Internal stimuli
 Chemical factors
 External stimuli
 Sensory factors
 Thermal factors
 Mechanical factors
Respiratory
 Breathing is a result of replacement of air for
fluid
 Big Squeeze with vaginal birth
Cardiopulmonary
Adaptation
 Increased aortic pressure
and decreased venous
pressure
 Increased systemic
pressure and decreased
pulmonary pressure
 Closure of foramen ovale,
ductus arteriosus, and
ductus venosus
Cardiopulmonary
Transitions
 Increased pulmonary blood volume
 Conversion from fetal to neonatal circulation
 Immediate assessment necessary
 Skin color
 Respiratory rate; breathing pattern
 Common to have acrocyanosis, investigate
central cyanosis (look at mucous membranes)
Cyanosis in the
Newborn
Acrocynanosis
Cyanosis
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Respiration problems:
Predisposing
Factors
Cord prolapse
Low APGAR
Meconium staining
Prematurity
Postmaturity
Small for gestational
age
 Breech birth
 Chest, heart or
respiratory tract
anomalies
 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
Respiratory Distress:
Newborn
Assessment
 5 symptoms of respiratory distress
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Tachypnea
Cyanosis
Nasal flaring
Expiratory grunting
Retractions
 Transition period (1-2 hrs post birth) vs
signs of respiratory distress that persist
Thermogenic
Adaptation
 Newborns are homeothermic
 Neutral thermal environment
 Cold stress
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Large body area
Limited subcutaneous fat
Limited ability to shiver
Thin skin and blood vessels close to surface
Mechanisms of
Heat Loss
 Can be unstable. Guard
against loss due to:
Convection
Conduction
Radiation
Evaporation
 Dry immediately with
warm blankets
Adaptations: Increase
Heat Production
 Increased BMR and muscle activity
 Peripheral vasoconstriction
 Nonshivering thermogenesis
 Brown adipose tissue
Hematopoietic
Adaptation
 Blood volume
 Blood components
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Erythrocytes and hemoglobin
Hematocrit
Leukocytes
Platelets
Hepatic
Adaptation
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Glycogen and blood glucose maintenance
Iron storage
Conjugation of bilirubin
Coagulation of blood
Gastrointestinal
Adaptation
 Stomach and digestive enzymes
 Bacterial colonization once starts eating
• Vitamin K produced
 Intestinal peristalsis
• Meconium
 Meconium Ileus- Cystitic Fibrosis
Genitourinary
Adaptation
 Kidney function
 Bladder capacity 6 to 44 mL
 Fluid requirements—60 to 80 mL/kg
 Urine output 1 to 3 mL/kg/hour
 Nursing assessments
 Careful monitoring of I/O
 Assess appearance of urine
 Signs dehydration or ↑ ICP
Immunological
Adaptation
 Active acquired immunity
 Passive acquired immunity
 Immunoglobulins
Psychosocial
Adaptation
 Early stages of activity
 First period of reactivity
 Period of inactivity and sleep
 Second period of reactivity
Behavioral
States
 Sleep
 Deep, quiet; REM
 Alert
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Drowsy/semidozing
Wide awake
Active awake
Crying
The 5
Senses
 Hearing- yes
 Vision- “light” and “dark” in the first
months. Approx 18” range.
 Touch- well-developed
 Taste- can discriminate
 Smell- well-developed
Integumentary
System
 Smooth and soft
 Postterm infants—tough, leathery skin
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Pustular melanosis
Milia
Erythema toxicum
Pigmentation—Mongolian spots, café-aulait marks
Integumentary
System
 Skin: Color should be pink
 Cyanosis: 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)
Assessment
Infant’s Head
 Symmetry
 Eye shape, size, placement, and
coordinated lid movement, red reflex,
gross vision
 Ears: shape, size, placement, hearing
 Movement, color of the lips
 Chin—appropriate size
Head
Fontanels
 Estimate size
 Fullness without bulging—normal
 Bulging and tense with large head
circumference—increased intracranial
pressure
 Sunken—dehydration
Head
 Caput Succedaneum
 Diffuse edema, crosses suture lines,
disappears in few days
 Cephalhematoma
 Subperiosteal hemorrhage
 Does not cross suture lines
 Persists for weeks
Respiratory System
Assessment
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Symmetry in chest movement
Auscultate lungs anterior and posterior
Nasal patency
Respiration rate, pattern, and use of
accessory muscles
 Abnormal: Sx RDS
 Asymmetry: Pneumothorax, Diaphragmatic hernia
Cardiovascular System
Assessment
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Inspection and auscultation
Point of maximum impulse
Heart rate
Capillary refill
Peripheral pulses
Auscultate all areas—murmurs
Gastrointestinal System
Assessment
 Abdominal inspection, including umbilical
cord
 Auscultate bowel sounds, upper abdomen
for gastric bubble, and heart sounds of the
abdominal aorta
 Palpation
Conditions That Warrant Further
Assessment
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Abdominal distention
Absence of bowel sounds
Discharge from umbilical cord/site
Abdominal mass
Genitourinary System
Assessment
 Hips abducted
 Palpate and inspect scrotum, testes, and
penis
 Male—check meatus location
 Palpate and inspect female genitalia
 Anus and anal wink reflex
Common Findings
Male Infants
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Scrotal swelling
Smegma
Hypospadius
Epispadius
Common Findings
Female Infants
 Hymenal tags
 Vernix caseosa on labia
 Pseudomenstruation
Conditions That Warrant Further
Assessment
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Undescended testicles
Micropenis
Ambiguous genitalia
Imperforate hymen
Imperforate anus
Musculoskeletal System
Assessment
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Observe infant’s movements in crib
Inspect for differences in extremity length and size
Assess muscle tone and symmetry
Gentle passive ROM to assess joint rotation
Assess head lag
Skin folds on thighs
ASSESS change in tone & movement
Musculoskeletal System
Assessment
Common Findings
 Torticollis
 Developmental dysplasia of the hip
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Asymmetry of hip folds
Barlow maneuver
Ortolani maneuver
Crepitus
Unusual positions of foot
Musculoskeletal System
Assessment
Conditions That May
Warrant Further Assessment
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Fractured clavicle
Sacral dimple, spinal bifida, or scoliosis
Polydactyly
Syndactyly
Simian crease
Newborn and Family:
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Initial feeding
Bathing
Sleeping pattern
Diaper area care
Hearing Screen
Newborn Screening Test
(PKU)
 Test for metabolic disorders
(inborn errors of
metabolism)
 Done 24 hrs after first
feeding
Discharge Teaching:
Newborn Care
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Temperature assessment
Bathing
Nail Care and umbilical cord care
Clothing & Diapering
Attachment
Boys- Circumcision
Girls- Vaginal bleeding
Feeding frequency & duration
Child care
Circumcision Care
Surgical 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
Circumcision Care
 Heals in a couple of weeks
 Monitor for complications: hemorrhage, cold
stress/hypoglycemia, infection, urethral fistula,
delayed healing and scarring, fibrous bands.
 Discharge instructions & signs of danger
 Avoid premoistened towlettes--use only water to
wash
Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Susan Ward
Shelton Hisley
Chapter 19
Caring for the Newborn at Risk
Risk Factors
for Newborns
 Intrauterine development
-prematurity, IUGR, hypoxia
 Intrapartum development
-birth injury, hypoxia
 Extrauterine development
-cold stress, infection, jaundice
Classification of High-Risk
Newborns
Gestational Age (GA)
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Preterm (born before 37 weeks)
Late Preterm (born 37-39 weeks)
Term (born between 38 and 42 weeks)
Postterm (born after 42 weeks)
Birth Weight
 Low birth weight (LBW) (<2500 g)
 Very low birth weight (VLBW) (<1500 g)
 Extremely low birth weight (ELBW) (<1000 g)
Intrauterine Growth Restriction
(IGUR)
 A term used to denote a lack of
intrauterine fetal growth that usually
results in an SGA newborn
 At risk for hypoglycemia
Small-for-Gestational-Age Infants
(SGA)
 Infants born at any gestational age who
have a birth weight that falls below the
10th percentile on the growth charts
 Hypothermia
 Pain
 Hypoglycemia
 Polycythemia
Large-for-Gestational- Age Infants
(LGA)
 Infants born who are over the
90th percentile on the growth chart
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Chronic hyperglycemic state
Transient tachypnea of the newborn
Hypoglycemia
Hypocalcemia
Hypomagnesemia
Birth injuries
Brachial plexus injuries
Fractures
Hyperbilirubinemia
Physiologic jaundice
appears 24 to 48
hours after birth; transient
Pathologic jaundice
present at birth or
within 24 hours
Breastfeeding jaundice—2 to 4 days
Breast milk jaundice—7 days; peaks at 10
days
Hyperbilirubinemia
 Hyperbilirubinemia: results from
destruction of red blood cells
 Physiologic jaundice
 Normal physiologic process Peaks ≤ 12 mg/dl
 Does not occur in first 24 hours of life
 Home care
 Pathologic jaundice
 Abnormal destruction of RBCs
 Occurs in first 24 hours of life or persists after 1
week
 Causes: hemolytic disease of newborn: Rh or
ABO blood incompatibility (mom Rh - or type O)
Physiological
Jaundice
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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
Before 24 hours or
persistent after day 7
Pathologic
Jaundice
 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
Hyperbilirubinemia:
Risk Factors
 ↑ RBC 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
Hyperbilirubinemia:
Nursing
Assessments
 Yellowish tint to skin, sclera and mucus
membranes--observe by window
 Note time of jaundice
physiologic > 24 hours
pathologic ≤ 24 hours
 Treatments: early feedings, phototherapy,
exchange transfusion if very high levels
Hyperbilirubinemia:
Lab Testing
 Elevated serum bilirubin (direct and indirect)
 Blood type
 H&H
 Direct Coomb’s test--reveals presence of antibodycoated (sensitized) Rh-positive RBCs in the
newborn
 Electrolyte levels for dehydration from phototherapy
(treatment of hyperbilirubinemia)
Hyperbilirubinemia Graph
Well Baby > 36 weeks gestation
The Premature
Newborn
 Severe prematurity
 23 to 26 weeks
 Moderate prematurity
 26 to 30 weeks
 Long-term health problems
Neonatal Complications
 Pathophysiology:
RDS
 Atelectasis with congestion and edema in lung
spaces
 Underdeveloped alveoli
 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)
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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
Collaborative Management
RDS
 Assist with endotracheal intubation (ET)
 Administer surfactant through ET tube
 Oxygen administration (CPAP or assisted
ventilation with PEEP)
 Maintain mechanical ventilation
 Indomethacin or ibuprofen to close patent
ductus arteriosus
 Wean ASAP to prevent complications
Retinopathy
of Prematurity
Pathology:
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Result of immature retinal vasculature followed by hypoxia
Inversely related to gestational age
Risk factors
Diagnosis –– 5 stages
Nursing Care:
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Maintain lowest O2 levels possible
Fluctuations in concentrations of oxygen must be prevented
Wean off oxygen ASAP
Decrease constant bright lights
Encourage routine examinations
Anemia
of Prematurity
 Hemoglobin below 35% and 45%
Nursing Care:
 Administer recombinant human
erythropoieten SC
 Sudden Infant Death Syndrome (SIDS)
 “Back to Sleep”
 Educate parents about prevention
Gastrointestinal Conditions
of Prematurity
Necrotizing Enterocolitis
 Ischemic episode of the bowel; can produce
septicemia
Nursing Care:
 Ensure that oral feedings are stopped
 Discuss possible surgery
 Colon resection
Short gut syndrome
Neurological Conditions
of Prematurity
Intraventricular and Periventricular Hemorrhage
[categorized by extent and involvement (grades)]
Nursing Care:
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Recognize seizures
Administer antiseizure medications
Prevent cerebral damage
Maintain adequate oxygenation
Educate parents
The Postterm
Newborn
 Newborns in utero after the optimal
growth time (42 weeks)
 Skin is parchment-like
 Fingers are long and peeling
 Muscle wasting is present
Conditions Affecting the
Postterm Newborn
Meconium Aspiration Pneumonia
— meconium aspirated at birth
 Meconium-stained skin, nails, and umbilical cord
 Initial respiratory distress
 Rales and rhonchi on auscultation
Nursing Care:
 Give chest physiotherapy (CPT)
 Monitor mechanical ventilation
 Administer medications
Persistent Pulmonary Hypertension
of the Newborn
Vascular resistance in pulmonary system
 Meconium-stained amniotic fluid
 Brief respiratory distress at birth, then resolves and
returns about 12 hours later
 Centrally cyanotic and tachypenic
 Audible murmur
Nursing Care:
 Extracorporeal membrane oxygenation (ECMO)
 See Chapter 19 Nursing Care Plan
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Neonatal Abstinence
Syndrome
Drug-abusing mother
Irritability
Withdrawal process
Refer to Table 19-6 for drugs that cause withdrawal
symptoms
Nursing Care:
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Do Not administer Narcan
Toxicology screen
Use neonatal abstinence scoring tool every 3 hours
Social Services referral
CASE STUDY: BABY BOY QUINCY
Baby boy Quincy is a neonate who was born at 37 weeks of
gestation via a normal spontaneous vaginal birth 4 hours ago.
Baby Quincy’s mother is a 17-year-old G1 P1, whose prenatal
course was complicated by pregnancy-induced hypertension.
Baby Quincy’s weight is 2400 g (5 lbs 4.6 oz); his length is 18
inches (45.72 cm).
He has just returned from a rooming-in session with his mother.
The infant’s vital signs are axillary temperature 97.2°F (36.2°C);
apical pulse 172 beats/minute; respiratory rate 62
breaths/minute with occasional periods of apnea lasting 15 to
20 seconds; BP 60/40 mm Hg. Baby Quincy’s skin has a mottled
appearance; his hands and feet have a bluish tinge and are cool
to the touch.
Critical Thinking Questions
1. What is the priority nursing diagnosis at this time?
2. What is the expected outcome associated with this diagnosis?
3. Describe the teaching/learning needs related to the scenario
that corresponds to the priority nursing diagnosis.
4. List nursing interventions with rationales that correspond to the
priority nursing diagnosis.