Postpartum & Newborn Nursing Theory and Practice MOTHER What is the first thing that comes to mind? Words Images Day to day life of mothers (and parents) is often in contrast to our idealized concepts The “Fourth” Trimester Defining the Postpartum Period Postpartum period is a time of change Medical/Physiologic change Psychosocial (developmental) change Duration of changes is variable Duration of coping with changes is variable Defining the Postpartum Period Physiologically defined as the six week period of uterine involution Begins with the birth of the placenta Includes resolution of anatomic and physiologic changes of pregnancy • return of all systems to (nearly) pre-pregnant state Psychosocial tasks of the postpartum period take longer than six weeks to accomplish Physiologic Changes Reproductive System Uterine Involution Muscle fibers contract with the birth of placenta • Stops bleeding of large uterine vessels • Massage gently to maintain firmness Can be taught to woman Much more comfortable if woman does herself Must be effective or clots can collect in the uterus Reproductive System Uterine Involution Uterus progressively smaller over ~2 weeks • 1 – 2 finger breadths below umbilicus immediately postpartum • At umbilicus on days one and two • Progressively smaller until not palpable abdominally by day 10; may take slightly longer with cesarean section Reproductive System Uterine Involution Afterpains can be intense! • Especially for multipara • May need narcotic analgesia in addition to NSAID • Narcotics are constipating • • • • prevention is important Void regularly Prone position (NOT knee-chest) Heat Worse with suckling, pre-medicate prn Education/understanding is critical Reproductive System Oxytotic agents (↑ afterpains) Pitocin (given almost routinely IV or IM after all births) Hemabate (PGF2a, not in asthmatics) Methergine • • • • IM & PO most common, IV if life threatening Causes sustained uterine contraction Increases BP Obtain baseline BP before each administration Reproductive System Endometrial Sloughing Lochia • Rubra (Red) 1 – 5 days • Serosa (Pinkish Tan) 5 days – 2 weeks • Alba (White) 2 to 6 weeks Lochia has strong smell, not a foul smell In the first three days • Small amount of small clots are normal • ONE larger clot after long period supine is normal Reproductive System Placental Site Heals by exfoliative shedding. Lochia is a combination of shed tissues. • Lochia is made up of blood, decidua, serous fluid, and leukocytes with the proportion of each changing as the lochia changes Lack of scar tissue important for placental implantation in future pregnancies Reproductive System Cervix Floppy (patulous) immediately after birth May be visible at vaginal introitus Closes, firms as uterus involutes (~2 weeks) Os (opening) changes from round to slit like after birth of first child Cervix not routinely inspected for laceration. Lacerated cervix can be cause of continued postpartum bleeding w/ firm uterus. Reproductive System Vagina Edematous after delivery (external ice pack) May have lacerations that may or may not need repair (hemostasis and approximation) Smooth walled x several weeks, then ruggae reappear Mucosa thinned and dryer secondary to ↓ estrogen continues until ovulation and menstruation resume. Counsel for lubrication Reproductive System Perineum May have lacerations or incision (episiotomy*) • 1st degree mucosa only • 2nd degree mucosa and underlying muscle* • 3rd degree mucosa, underlying muscle and partial tear of anal sphincter • 4th degree mucosa, underlying muscle, anal sphincter and tear of anal mucosal capsule Reproductive System Perineum After 30 years of research there is no evidence to support routine episiotomy Episiotomy should be used selectively only if • Birth needs to be expedited • Access to the baby is essential • Clear evidence of uncontrolled tear (debatable) Episiotomy increases the risk of severe tear (fabric demo) Reproductive System Perineum (continued) All stitches absorb on their own after ~ 2 weeks May see knots on peripad as they dissolve Nursing care is directed toward • Assessment of injured site (visualization, approximation, bruising, bleeding, edema, infection s/sx) • Decreased edema (ice x 24 hours, then heat prn) • Pain Management (assessment, positioning, Rx) • Nutrition/Rx support to prevent constipation • Exercise of injured muscle to improve blood flow and strength (kegel) Reproductive System Return to Menstruation/Ovulation Pregnancy can occur prior to first menses! • Contraceptive options are an essential part of discharge teaching Lactating women • Prolactin suppresses ovulation. Return to menses unpredictable; from 6 weeks to 1 year or more Non-Lactating women • Menses usually resume by 6 – 8 weeks Lactation Lactating women Sudden drop in estrogen & progesterone with birth of placenta ↑ Prolactin • milk production • maternal feelings and wellbeing • supported by frequent contact with baby Rooming in with support • suppresses ovulation, delays menstruation Lactation “Let down” reflex: suckling oxytocin • Milk ejection, uterine involution • Afterpains ibuprofen 600mg safe Colostrum x 3 days • Baby’s “first vaccine” (high in IgA antibodies) • Nutrient dense only small amounts needed milk days 3 – 6 Mature milk day 6 on Transitional Composition of milk changes over time Lactation Breasts immediately postpartum Soft texture May or may not leak small amount of colostrum Check nipples if breastfeeding: erect, everted Lactation Breasts on day one and two Soft texture, may begin to fill and feel firmer Check nipples if breastfeeding: erect, everted, intact Lactation Breasts on day three to five Entire breast feels taut, warm, erythematous, larger Check nipple is erect, everted, intact Note any nodules (plugged duct, cyst, cancer) Lactation Breasts Firm when just about time to nurse Softer after baby nurses effectively May spray milk with let down Week day 6 to week 6 6 onward Breasts much softer, even when full Softness is not a sign of less milk Lactation Mastitis Wedge shaped area Local pain Redness Firm nodule Fever Exhaustion Lactation Non-Lactating Women Still have colostrum, may leak Milk will still come in on ~ day 3 • Engorgement! Congestion of veins and lymphatic circulation Breasts taut, erythematous, painful, hot • ibuprofen 600 mg safe; Cold compress; tight bra • no breast stimulation or milk expression • Green Cabbage leaves Prolactin levels ↓ quickly without suckling Lactation Breast milk is the best food for human infants Formula is safe in US But does NOT have the benefits of breast milk Formula may not be safe developing countries Formula is unsafe in poor countries Lactation Goal is to increase the number of women who initiate and sustain breastfeeding ongoing intense support and education essential “Increased duration of breastfeeding confers significant health and developmental benefits for the child and the mother...” (AAP Policy Statement 2005) Lactation Nursing actions directly affect breastfeeding initiation Encourage rooming in Effective, accurate information Referral to community resources Including the mother’s support system Bottle Feeding Based on modified cow milk or soy Cost approx $1200/ year Powdered or concentrate – mix w/ boiled water More $ if “ready to eat” WIC does not cover the entire cost of formula Contains supplemental vitamins and iron Wash nipples and bottles daily Discard unused portion of bottle Cardiovascular System Normal blood loss Vaginal birth = up to 500cc (2 cups) Cesarean birth = up to 1000cc WBC count up to 20,000 Increased propensity for clotting makes postpartum women at increased risk for thrombi Varicosities regress Cardiovascular System Blood Pressure Q 15 minutes x 1 hour postpartum, then hourly x 4 hours, then q shift >140 systolic or >90 diastolic can suggest postpartum pre-eclampsia and deserves further investigation Orthostatic hypotension can occur with acute blood loss or dehydration (pulse bumps 20 bpm and BP falls 15-20 mmHg positionally) Cardiovascular System Pulse Increased stroke volume due to increased circulating volume (loss of placental/uterine sinuses) lower pulse rate (60 – 70) Diuresis less volume pulse returns to normal usually by the end of the first week Warning! In a postpartum woman, you may see “normal” vital signs in a patient at risk for hypovolemia Temperature Regulation May see slight ↑ immediately postpartum Physical effort Dehydration Temperature >100.4 at any time triggers further assessment for infection and report of the findings Days 3 – 5 may see slight temperature ↑ due to breast engorgement (<100.4) Weight Loss +/- 12 lbs lost at birth from baby, fluids, placenta +/- 5 lbs fluid loss from diuresis from days two to five 2-3 lbs loss from shedding lochia Total by 6 weeks +/- 20 pounds Extra weight remains as fat deposits to make milk Lactating women need +500 cal/day Integumentary System Woman may appear about 6 months pregnant when standing Skin and underlying muscle are stretched Diastasis recti visible about 2 – 4 cm wide • Abdominal crunches starting about 3 days if vaginal birth Integumentary System Stretch marks “striae” appear purple to red Commonly on abdomen, breasts, hips Over time fade to silvery tan-white, do not disappear Linea nigra and other estrogen mediated skin markings gradually fade, may not disappear May have new scars and altered body image Striae and Linea Nigra Integumentary System Conjunctiva Sclera May be pale in anemia May have hemorrhages due to pushing Lacerations of the perineum/vagina May see bruising or hematoma Edema Should be well approximated and hemostatic without discharge Sitz baths, peri care Urinary System Difficulty voiding immediately postpartum Edema Decreased intra-abdominal pressure Residual effects of epidural if used • Running water, stroking lower back, peppermint oil • Catheterization if bleeding uncontrolled • Uterus deviated to right often indicates full bladder Urinary System Marked diuresis of ↑’d fluid volume Beginning about 12 hours postpartum Urinary losses Also diaphoresis profuse Gastrointestinal System Usually VERY hungry after birth Most L&D units keep snack boxes • birth often occurs outside of regular meal service Birth centers often have kitchens • Families prepare meals • Birthday cake! Gastrointestinal System At risk for constipation Still have poor abdominal and intestinal muscle tone Fear of passing stool due to laceration(s) Fiber, fluid, stool softener, anticipatory guidance Gastrointestinal System Hemorrhoids Pressure from pushing Common • • • • Ice packs Ointment Witch hazel pads Anesthetic spray Psychosocial Aspects of Postpartum Adaptation to Parenthood Learning new skills New physical demands Feeding, holding, diapering, bathing, umbilical and possibly circumcision care Soothing, interpreting baby’s communication New skill acquisition occurs just as all of the physical adaptations are taking place Sleep deprivation Postpartum changes affect all aspects of life Three Phases of Puerperium Next three slides based on work of: Reva Rubin, 1977 A classic body of work Describes maternal behavior in three phases Taking In Taking Hold Letting Go Three Phases of the Puerperium Taking In Passive, uncertain, exhausted Reviewing birth experience, baby explored and experienced with wonder, unfamiliar Often touch baby with only fingertips at first, then move to caress and explore entire baby Gaze at baby “en face” Vulnerable physically and emotionally Three Phases of the Puerperium Taking hold Beginning to take tentative action, building confidence, gaining familiarity Strong interest in taking care of her baby herself Coming to accept birth experience Gaining familiarity with baby, still feels unsure Praise and positive reinforcement welcome Three Phases of the Puerperium Letting go Acceptance of fantasy and reality in • birth experience • baby • new roles (mother, lover, worker, etc) Grief work Confident, independent action Forms own opinions Ongoing . . . duration measured in years Postpartum Blues Normal reaction (70% in some sources) to Sleep deprivation Grief work Life change Conflict between expectation and reality Physiologic changes, including endocrine changes Usually worst around days 3 - 5 Characterized by labile mood, tearfulness, and reality based passing feelings of inadequacy Early onset and resolution Bonding Behaviors En face positioning Baby talking (high pitched, sing song) Fingertips open palm enfolding Eye gazing Entrainment (baby moves in rhythm with adult speech) Encouraging rooming in with support is essential Postpartum Nursing Care Is based on an understanding of the physiology and psychology of the postpartum period Nursing interventions include: Nurse’s Role in Postpartum Care Change agent Skilled observer Thoughtful teacher Expert time manager Coach Scientist Care taker Nursing Activities Birth – 2 hours obtaining/assessing frequent vital signs on two patients supporting and assessing the baby’s transition to the extra-uterine environment assessing the mother for bleeding, pain, uterine tone supporting breastfeeding initiation supporting initial bonding helping the provider prepare for any suturing planning for vitamin K and erythromycin for the baby facilitating formation of the new family unit completing paperwork, often needed by clerk, OB provider and pediatrician preparing to give report and arranging for transport to new unit(s) disposing of the placenta accounting for all instruments, sharps and sponges used during the birth ensuring that the nurse’s other laboring patient is under RN care Nursing Care from 2 – 48 hours Directed by a knowledge of the stages of the puerperium Monitoring safety Intensive discharge planning Repetitive anticipatory guidance Increasing self care and self confidence Increasing independence with baby care Closing knowledge deficits Nursing Care from 2 – 48 hours Group Classes Nurses lead group classes on postpartum units • Baby care • Breastfeeding Group classes are not a substitute for individualized care planning Special Situations Stillbirth Woman may choose to be on a gyn floor Still needs discharge teaching • Rewrite the form if you need to! Often special door markers to ID to all staff Baby kept available for several hours • • • • Some autopsy tissue obtained quickly Dress baby as attractively as possible Exploration follows fingertip enfolding order Mementos kept on file Special Situations Surrendering infant for adoption Adoptive parenting Immediate postpartum not a time to re-evaluate Examine/clarify your own values Private room, may or may not be on maternity unit Many of the same stages Rubin describes The ill infant Encourage bonding Private room appreciated Breast pump Special Situations The ill mother Private room Snapshots Telephone Family support Education Nursery staff and volunteers Breast pump Newborn Nursing Audrey Gives Birth! The nurse dries the baby immediately Places the baby on Audrey’s belly skin to skin or on a pre-warmed infant warmer prn • To prevent heat loss by Evaporation Convection Conduction • To stimulate respirations Removes wet towels Covers with dry towel and warmed hat Rapid evaluation of infant’s transition Rapid Initial Evaluation Color Tone Respirations Heart rate (often by palpation of cord) Counted for six seconds and multiplied by ten General survey for major anomalies General sense of presence in the body Apgar Scoring Score to assess neonatal wellbeing at birth Obtained at 1 and 5 minutes of life May be obtained at 10 minutes if still under 7 A maximum ten point scale Five items worth 0, 1 or 2 points each High correlation with low 5 minute apgar score and morbidity/mortality Apgar Scoring Points are 0, 1, 2 for a total of 10 Heart Rate Respiratory Effort Flaccid, some flexion, well flexed Reflex Irritability Absent, slow-irregular-weak, good-strong Muscle Tone Absent, slow (<100), good (>100) No response, grimace, cry and response Color Blue/pale, extremities only blue, all good color Newborn Identification Identiband Locks and must be cut be removed May have a chip in it for further security # corresponds to mother’s # Other identifying demographic information Two bands are used (wrist and ankle) Footprints obtained Unique like fingerprints Giving Report Time of birth Brief synopsis of labor and birth Respirations spontaneous or assisted Apgar scores (include why points taken off) Any medications administered If assisted in what way and for how long Including Vitamin K and erythromycin General condition of the neonate Number of vessels Relevant lab tests (cord bloods, maternal labs, cultures) Notation of void or meconium passage that occurred Understanding the Physiologic Transition from Fetus to Newborn Physiologic Transition Circulatory changes In utero, lungs are like wet plastic bags stuck together with minimal blood flow With the first few breaths lungs expand and blood flow for gas exchange begins Circulatory changes occur that allow blood flow to change from fetal to neonatal flow Physiologic Transition Umbilical vein and ductus venosis (connection to vena cava) constricts after cord clamped; become ligaments (takes months) Some babies don’t cry until the cord is clamped Physiologic Transition Circulatory Changes Foramen ovale (rt atrium aorta) closes functionally with onset of respirations • Permanent closure takes several months Ductus Arteriosis (pulm artery aorta) constricts with onset of respirations • Becomes a ligament (takes months) Physiologic Transition Heart murmurs are understandably common usually clinically insignificant should be reported Heart rate remains 120-160 bpm sleep (slower) activity (higher) Physiologic Transition Circulatory Changes Peripheral circulation established slowly over the first 24 hours • Acrocyanosis normal (blueish hands and feet) BP averages 78/42 • not usually checked in L&D RBC count high initially • Falls over the first week • Breakdown of RBC related to neonatal jaundice Physiologic Transition Establishing respirations Thoracic squeeze with vaginal birth pushes excess fluids out of lungs • Birth by cesarean section ↑ risk for transient tachypnea of the newborn (TTN) Surfactants present in full term babies • Allow lungs and alveoli to expand with first few breaths • Prevent alveolar collapse and RDS Physiologic Transition respiratory rate is 30 – 60 breaths/min Normal Short periods of apnea are normal • <15 seconds duration • must count for a full minute to assess accurately Obligate nose breather Chest & abdomen rise simultaneously Physiologic Transition Renal System Urine present in bladder at birth • 1st void within 24 hours • In breastfed baby one void for each day of life until milk in (usually day 3-5), then 6-10 voids/day • In bottlefed baby, one void per day for first 48 hours, then 6-10 voids/day Physiologic Transition Renal System Kidneys do not concentrate urine for first three months • Attention to adequate hydration essential Urine pale and straw colored Uric acid crystals common initially • May leave brick red spots in diaper Physiologic Transition Gastrointestinal System Newborns can establish suckling instinctively • Help with this is still appreciated! “Baby cheeks” (fullness) d/t sucking pads May develop sucking blister on upper lip Minimal saliva Cannot move food from lips to pharynx, nipple must be far into mouth Physiologic Transition Gastrointestinal System Variable feeding patterns • Usually active in the first hour after birth • Then ~ 4 hours sleep time • Then active again Feeding is a learned skill • May take a few days to learn how to nurse • Walking is natural too, and that also takes time Feeding is emotional area for many moms • May be interpreted as rejection by her infant if difficult • Nursing support and knowledge is essential Physiologic Transition Gastrointestinal System Circumoral pallor while sucking normal Stomach capacity small (15–30cc) • Frequent feedings essential • Learn early hunger behaviors • Waiting for late feeding cues interferes with establishing breastfeeding Breastfed babies usually feed every 2 hours Bottlefed babies usually feed every 3-4 hours • Watch baby, not clock! Physiologic Transition Gastrointestinal System Can digest simple carbohydrates and proteins, may have difficulty with fat in formulas Immature cardiac sphincter • Reflux of food when burped • Projectile vomiting needs to reported May signal pyloric stenosis Physiologic Transition Gastrointestinal System Meconium • First stool—black, tarry, sticky Usually passed within the first 24 hours • Sterile gut– needs Vitamin K injection Given within hours of birth Prevents Hemolytic Disease of the Newborn Transitional stool is thin, brownish-green Physiologic Transition Normal newborn stool Breastfed • When milk established (days 3-5) • Loose, golden yellow, seedy, unformed, minimal odor • May occur after each nursing Formula fed • Formed, pale yellow • May vary from 1/day to after each feeding Physiologic Transition Hepatic Liver metabolizes excess hemoglobin • From breakdown of unneeded fetal RBC • Unconjugated bilirubin • Conjugated bilirubin (H2O soluable) • Excreted Physiologic Transition Immature liver function Unconjugated bilirubin accumulates • Jaundice Lab assessment • Normal <12mg/dl Heel stick or transdermal assessment on baby Clinical Assessment • Physiologic (normal) begins at >24 hrs of life • Proceeds head to toe Physiologic Transition Pathophysiologic jaundice Multiple etiologies • • • • • Blood incompatibility Infection Trauma Hypothermia medications Indirect coombs test for maternal antibodies (done on cord blood) Risk for Kernicterus if severe/sustained Intervention (light therapy) Physiologic Transition Temperature Regulation Newborn cannot shiver to produce heat • Heat production Metabolism of brown fat Increased metabolic rate Increased activity Physiologic Transition Temperature Regulation Newborn has large surface area and large head – significant source of heat loss Rapid temperature drop with birth • Cold stress occurs easily ↑ O2 consumption can lead to metabolic acidosis respiratory distress Body temperature stabilizes about 10 hours of life (if unstressed) Physiologic Transition Immunologic IgG transplacentally IgA in colostrum and breast milk Greatest risk of infection in first six weeks • s/sx may not be same as in adult Immunity acquired sequentially Vaccinations may start in hospital and are ongoing http://www.cispimmunize.org Neurologic/Sensory States of Consciousness Deep sleep: no body movements, palms open Light sleep: some body movements Drowsy: startle, eyes open, “no one home” Quiet alert: few movements, intent, focused Active alert: body movements, facial movements, fussy periods Crying: active body movements, eyes open or closed Neurologic/Sensory Periods of Reactivity First • Begins at birth • Continues for 1 – 2 hours Alert, good suck reflex, irregular heart rate and respirations Second • Begins around 4 hours May spit up mucus Pass meconium Suck well Equilibrates by 8 hours of age Newborns typically sleep ~17/day in short bursts Neurologic/Sensory Impact on Nursing Interventions Early discharge timing • Accommodate periods of reactivity • Accommodate mother’s level of energy Teaching • Consideration of periods of reactivity • Consideration of newborn’s state Neurologic/Sensory Sight Newborns can see • • • • • • • Best at about 18 inches “en face” is perfect Love faces Enjoy high contrast (black & white) Will gaze or fix on objects Uncoordinated eye movements May mimic slow, repeating facial movements Neurologic/Sensory Hearing Begins in utero (24 weeks) Enjoys speech cadence • Entrainment • “baby talk” singsong Teaching • Talk to the baby! • Watch baby for “I need a break” cues Neurologic/Sensory Taste Amniotic fluid has taste and baby has been tasting in utero Prefers sweet Sucking is essential • • • • • Reduces pain and stress Satisfying Nourishment May improve brain development May decrease SIDS Neurologic/Sensory Smell Sense present at birth Newborns can identify their own mother’s breast pads by smell alone Newborns may use smell to help establish nursing • Not washing their hands right away Neurologic/Sensory Touch Infants are highly sensitive to touch Startle easily Treat with respect Bonding Touch progression Swaddling Seems to calm some babies Physical Assessment Weight Obtained initially soon after birth Obtained daily Initial loss of up to 10% body weight normal • Should be regained by 2 weeks of age Length Babies are curled up in utero • Need some time to stretch out, not measured immediately • Make sure leg is completely extended when measuring Average is 45.7 – 60 cm (18-22 inches) Physical Assessment Head Circumference Measure biparietal diameter 33 – 33.5 cm (13-14 inches) May need to re-measure in a few days if • Significant molding and caput Head circumference should be 2 cm> chest circumference Report findings > or < the 2cm difference Chest Circumference 2 cm less than head circumference (3/4 inch) Measure at level of the nipples Physical Assessment Skin Skin color varies with ethnicity, pigment ↑ after birth Lanugo and vernix present (↑ with younger GA) Skin may be dry/peeling in term/post-term • Palms, soles, possibly cracks/crevices Acrocyanosis normal x 24 hours Erythema toxicum neonatorum (“flea bites”) Mongolian spots (common in African, Asian ancestry) Harlequin sign Nevus flammeus “Stork bite” Milia Physical Assessment Head Caput succedaneum • • • • Edema of the scalp (presenting part) Present at birth Crosses suture lines Resolves in a few days Cephalohematoma • • • • • Blood collection between periosteum and the skull Often appears by 24 hours of life Does not cross suture lines Resolves slowly over several weeks Increased risk of jaundice from additional blood breakdown Physical Assessment Fontanels Ears Should be flat (not sunken or bulging) Open Even with canthi of eyes Cartilage present and springy at term Look at the parents! Eyes Slate blue Some edema/irritation from medication • Less common with erythromycin than silver nitrate Physical Assessment Mouth Inspect gums and lips • Intact • No teeth Inspect hard palate • Intact • Small white bumps normal (Epstein’s pearls) Physical Assessment Neck Short Skin folds Muscles not strong enough to support head Abnormalities • Toriticollis (injury to sternocleidomastoid muscle) • Webbing • Masses Physical Assessment Chest Rounded (transverse and AP diameter =) Areola edema “breast buds” • “witches milk” Circumference 2 cm less than head Abnormalities • Clavicle separation/crepitus • retractions Physical Assessment Abdomen Rounded, protuberant • If sunken report immediatelydiaphramatic hernia Umbilicus • • • • One vein, Two arteries Air dry, alcohol swaps, triple dye No bleeding, cord clamp secure, base dry Cord dries, turns black and falls off Usually by 2 weeks Physical Assessment Genitalia Male • • • • • • Scrotum edematous, ruggae present May be darkly pigmented Palpate that both testes are descended Penis small (2 cm), meatus at tip Do not attempt to retract foreskin Circumcision Elective surgery, pain relief necessary May be part of religious ritual Should not be done if hypospadias/epispadias Physical Assessment Genitalia Female • Maternal hormones may affect genitalia Vulva edematous May see vaginal discharge • Mucus • Blood tinged (pseudo menstruation) Labia majora cover labia minora and clitoris Physical Assessment Extremities Short arms and legs • Fingers reach over proximal thigh Flexed tone, springs back when extended Bowed legs Fat, clenched hands • Holds grip securely (able to raise up) Fingernails at least to the tips of the fingers Hip abduction tests • Ortolani sign “clunk” of femur head in socket • Barlows sign “feeling the hip slip out of socket” Physical Assessment Feet Able to be manipulated into midline easily Creased over two-thirds of sole Fat pads make feet appear chubby and flat Fingers and Toes Syndactaly– fused digits Polydactly– extra digit (often like a skin tag) Physical Assessment Spine/Back Spine has “C” curve not “S” like in adults Posture is affected by fetal position Inspect the base of the spine • Hairy tuft • Dimple • Pinpoint opening Gluteal folds even Physical Assessment Anus Inspect to confirm • Present • Patent Insert gloved, lubricated pinkie finger Meconium should pass by 24 hours Physical Assessment Reflexes Blink Extrusion Swallowing Rooting Sucking Tonic Neck (Fencing) Moro Landeau (U) Physical Assessment Reflexes Stepping/Placing (Foot/Shin) Palmar/Plantar grasp Crossed Extension (Pushing away) Magnet (pressure against pressure) Trunk Incurvation Babinski Assessing neurologic integrity Understanding newborn behavior Gestational Age Assessment Standardized forms for assessing gestational age. Most common: Dubowitz Ballard Help to identify infants who are small for gestational age versus those who are of young gestational age Guides clinical care and expectations Gestational Age Assessment Gestational Age (weeks) FINDING 0-36 37-38 39+ Sole Creases Ant trans only Ant 2/3 Entire sole Breast nodule Scalp Hair 2mm diameter Fine, fuzzy 4mm diameter Fine, fuzzy 7mm diameter Silky, coarse Ear Lobe Pliable, no cartilage Some cartilage Cartilage stiff and shaped Testes & scrotum Testes in canal, few rugae intermediate Scrotum full, rugae covers Crying Infants tend to cry a lot Infant cry is supposed to be distressing About 2 hours of each day “Fussy” time of day Peaks around 6 weeks Purpose is to get your attention Infant can’t talk to express needs Parents learn specific cries for specific needs Pacifiers Individual decision Not to be used as a plug Bathing Initial bath Wear gloves until after first bath Usually within 1–2 hours of birth • Important in newborns of HIV+ mothers Bath should be delayed until after first nursing Initial bath is complete Subsequent daily baths may be just face, neck, hands, diaper area Bathing Always proceed from cleanest to most soiled areas of the body Gather all equipment ahead of time NEVER leave an infant unattended Protect neonate from excessive heat loss Prewarm the room if possible Expose only one part at a time Dry well Hat if cool temperature Diapering Nurses wear gloves Modern disposable diapers Very absorbant Difficult to determine if wet • Feel for gel to form: “pinch” • Weigh if uncertain Urine is very irritating (ammonia) Wash with clear water and dry well • Many infants irritated by wipes Mild barrier ointment (A&D, Vaseline) • Also helps get sticky meconium off their bottoms! Sleeping “Back to Sleep” Always place infant on back to sleep • Rare syndromes require prone position Side lying is NOT as safe as supine Protecting the airway is not a concern Nurses’ attitudes and teaching directly affect parents behavior 50% decrease in SIDS deaths SIDS Facts SIDS is leading cause of death in infants from 1 month to 1 year Most SIDS deaths occur between 2 months and 4 months of age African American risk is 2 times that of white babies American Indian/Alaskan Native almost 3 times higher than white babies SIDS Facts www.nichd.nih.gov/sids Always on back Firm surface Keep soft objects out No smoking Sleep close, but separate Pacifier Temperature Smart shopper, big $ for untested products Home monitors not necessary to prevent SIDS Tummy time while awake and adult present Car Seat Safety Usually required for discharge home CHOP has car seat subsidy program Requires a prescription Watch video Pay nominal fee Can trade up as baby grows when return seat Many fire/police departments have car seat installation days Discharge Assess Social worker to assist with issues Assess home environment support systems Know community resources Use the hospital social worker prn Assess knowledge of newborn care Parent to schedule f/u visit (2 weeks) Sooner if concerns or early discharge Finally Home