Exam #3 NURS230

LAST ONE YAY

Postpartum infection

-Defined as presence of a fever of 38 C or 100.4 F in the first 10 postpartum days (not including the first 24 hours after birth)

Common Types

Endometritis is the most common postpartum infection, occurring in ~2% after vaginal birth and 10-15% after cesarean birth. The highest incidence is associated with cesarean birth after prolonged labor and rupture of membranes.

• Infection of the lining of the uterus

• Fundala tenderness, febrile

• Prolonged rupture of membranes, manual introduction of bacteria

Wound infections are also common, often developing after discharge home. Rates after cesarean birth are 3-5%. Women can also develop infection in perineal lacerations or episiotomy sites.

Key Signs and Symptoms

General indicators:

• Fever and temperature elevation

• Chills

• Localized tenderness or pain

• Discoloration and swelling

Endometritis-specific:

• Fever (usually >38°C)

• Increased pulse

• Anorexia, nausea, fatigue, lethargy

• Pelvic pain and uterine tenderness

• Foul-smelling lochia

Wound infection-specific:

• Erythema, edema, warmth

• Tenderness and pain

• Seropurulent drainage

• Wound separation

Treatment

Endometritis: IV broad-spectrum antibiotics (clindamycin and gentamicin, cephalosporins, or penicillins) with supportive care. Antibiotic therapy is usually discontinued 24 hours after the client is afebrile and asymptomatic.

Wound infections: IV antibiotic therapy. When pus or significant drainage is present, the wound is opened, drained, and irrigated with normal saline; healing occurs by secondary intention.

Prevention

Most effective treatment is prevention:

• Good prenatal nutrition to reduce anemia risk

• Proper maternal perineal hygiene with thorough hand hygiene

• Strict aseptic technique by all healthcare professionals

• Prophylactic antibiotics during labor and cesarean surgery

Critical Nursing Considerations

Early discharge challenge: Women are usually discharged by 48 hours after vaginal birth, often before signs of infection are evident. You must:

• Identify at-risk clients

• Provide anticipatory teaching before discharge

• Teach signs of infection and when to contact the provider

Teaching priorities:

• Hygienic care techniques (changing pads front to back, hand hygiene before/after perineal care)

• Signs of worsening condition

• Adherence to treatment plan

• Need for follow-up care

Endometritis

Endometritis is an infection of the uterine lining that usually begins as a localized infection at the placental site but can spread to the entire endometrium 1.

Incidence

• Most common puerperal infection1

• ~2% after vaginal birth 1

• 10-15% after cesarean birth 1

• Highest incidence: Cesarean birth after prolonged labor and rupture of membranes 1

Signs and Symptoms

• Fever (usually >38°C) 1

• Increased pulse 1

• Chills 1

• Anorexia, nausea 1

• Fatigue and lethargy 1

• Pelvic pain 1

• Uterine tenderness 1

• Foul-smelling lochia1

Laboratory Findings

• Leukocytosis 1

• Markedly increased RBC sedimentation rate 1

• Anemia may be present 1

• Blood cultures or intracervical/intrauterine bacterial cultures are not clinically useful and increase cost of care 1

Treatment

Medical management 12:

• IV broad-spectrum antibiotic therapy: clindamycin and gentamicin, cephalosporins, or penicillins

• Supportive care: hydration, rest, pain relief

• Antibiotics discontinued 24 hours after client is afebrile and asymptomatic12

Comfort measures 2:

• Cool compresses

• Warm blankets

• Perineal care

• Sitz baths

Prevention

Prophylactic antibiotics administered during labor and during cesarean surgery can help reduce incidence and severity 1.

Ongoing Nursing Care

Throughout treatment 12:

• Assess lochia

• Monitor vital signs

• Evaluate changes in client's condition

Patient teaching 2:

• Side effects of therapy

• Prevention of infection spread

• Signs/symptoms of worsening condition

• Adherence to treatment plan

• Need for follow-up care

Additional support 2:

• Maintain mother-infant interactions

• Support breastfeeding continuation

Key Nursing Consideration

Assessments and monitoring continue throughout the entire treatment period, not just until fever resolves

Wound infection

Wound infections are common postpartum infections that often develop after discharge home. Rates after cesarean birth are 3-5%. Women can also develop infection in the perineum at a repaired laceration or episiotomy site.

Risk Factors

Predisposing factors are similar to those for endometritis, including:

• Perineal lacerations and episiotomies (disruption of skin integrity) and cellulitis (abscess of wound)

Signs and Symptoms

• Fever

• Erythema (redness)

• Edema (swelling)

• Warmth

• Tenderness and pain

• Seropurulent drainage

• Wound separation

Diagnosis

Wound exudate may be cultured to identify the causative organism.

Treatment

Medical management:

• IV antibiotic therapy

• When pus or significant serosanguineous effusion is present, the wound is opened and drained

• Wounds are irrigated with normal saline and redressed several times daily

• Healing occurs by secondary intention

• In some cases, a wound vacuum device is used

• Antibiotic treatment continues until the base of the wound appears clear and there are no signs of cellulitis

Nursing Care

In-facility care:

• Frequent assessments of temperature and vital signs

• Wound assessment and care

• Comfort measures: analgesics, sitz baths, warm compresses, perineal care

Patient teaching:

• Hygienic care techniques:

  • Changing perineal pads front to back

  • Cleansing from front to back (urethra to anus)

  • Hand hygiene before and after perineal care

• Self-care measures

• Signs of worsening conditions to report to the provider

Post-discharge care:

• Wound care and assessment continue after discharge

• Woman and family instructed in wound care and dressing changes

• Home visits by nurses may be provided to assess wound, reinforce teaching, and offer support

Prevention

Proper perineal care helps prevent infection and aids healing :

• Wipe front to back after voiding or defecating

• Use squeeze bottle with warm water or antiseptic solution after each voiding

• Change perineal pad front to back with each void or bowel movement

• Wash hands thoroughly before and after

Endometritis

Endometritis is an infection of the uterine lining that usually begins as a localized infection at the placental site but can spread to the entire endometrium.

Incidence

• Most common puerperal infection

• ~2% after vaginal birth

• 10-15% after cesarean birth

• Highest incidence: Cesarean birth after prolonged labor and prolonged rupture of membranes and manual introduction of bacteria

Signs and Symptoms

• Fever (usually >38°C)

• Increased pulse

• Fundal tenderness, febrile

• Chills

• Anorexia, nausea

• Fatigue and lethargy

• Pelvic pain

• Uterine tenderness

• Foul-smelling lochia

Laboratory Findings

• Leukocytosis

• Markedly increased RBC sedimentation rate

• Anemia may be present

• Blood cultures or intracervical/intrauterine bacterial cultures are not clinically useful and increase cost of care

  • Don’t usually culture, just treat

Treatment

Medical management:

• IV broad-spectrum antibiotic therapy: clindamycin and gentamicin, cephalosporins, or penicillins

• Supportive care: hydration, rest, pain relief

• Antibiotics discontinued 24 hours after client is afebrile and asymptomatic

Comfort measures:

• Cool compresses

• Warm blankets

• Perineal care

• Sitz baths

Prevention

Prophylactic antibiotics administered during labor and during cesarean surgery can help reduce incidence and severity.

Ongoing Nursing Care

Throughout treatment:

• Assess lochia

• Monitor vital signs

• Evaluate changes in client's condition

Patient teaching:

• Side effects of therapy

• Prevention of infection spread

• Signs/symptoms of worsening condition

• Adherence to treatment plan

• Need for follow-up care

Additional support:

• Maintain mother-infant interactions

• Support breastfeeding continuation

Key Nursing Consideration

Assessments and monitoring continue throughout the entire treatment period, not just until fever resolves

Urinary Tract Infections (UTIs)

-Important to note:

• Get UA

• Foley increases risk of UTI

UTIs are a common medical complication of pregnancy, occurring in up to 20% of all pregnant women and responsible for 10% of all hospitalizations during pregnancy .

Most common causative organisms :

• Escherichia coli: Responsible for at least 80% of initial cases and ~70% of recurrent cases

• Klebsiella pneumoniae and Proteus species (especially in women with recurrent infections)

• Gram-positive organisms (group B streptococci, enterococci, staphylococci): Up to 10% of infections

Signs and Symptoms

Although UTIs can be asymptomatic, typical symptoms include:

• Frequency

• Urgency

• Dysuria

• Burning

• Suprapubic pain

• Dribbling

• Hesitancy

• Gross hematuria (can occur)

Women should be instructed to inform their healthcare provider promptly if they experience these symptoms.

Complications

Pyelonephritis (renal infection) is the most frequent serious nonobstetric medical complication of pregnancy and a leading cause of septic shock during pregnancy. Maternal complications include sepsis, acute respiratory distress syndrome, and preterm labor.

Prevention Strategies

Hygiene practices:

• Proper hand hygiene before and after urinating

• Wipe perineum front to back

• Use soft, absorbent, white, unscented toilet tissue (harsh/scented paper can cause irritation)

• Avoid bubble bath or bath oils (can irritate urethra)

Clothing choices:

• Wear all-cotton undergarments and cotton-lined pantyhose

• Avoid tight-fitting slacks or jeans for long periods

• Prevent heat and moisture buildup in genital area

Fluid intake and urination habits:

• Drink at least 2.5 L daily (8-10 glasses of 8 oz each), preferably water

• Do not limit fluids to reduce urination frequency

• Increase fluids if urine appears dark/concentrated

• Do not ignore the urge to urinate (holding urine allows bacteria to multiply)

• Urinate before bed at night

• Urinate before and after sexual activity, then drink a large glass of water

Treatment

Oral antibiotics are commonly prescribed. Complete the entire course rather than stopping when feeling better to prevent drug-resistant organisms

What are other reasons for fever/infection symptoms?

-Pneumonia, flu or other virus, DVT/PE, mastitis

• Mastitis will be febrile, flu-like symptoms, true infection

-Misoprostol can cause transient fever, not too high and no other symptoms

Postpartum bleeding and hemorrhage

All women who have given birth are at risk for excessive bleeding that can progress to postpartum hemorrhage (PPH). Excessive blood loss can occur during different time periods and from various causes.

Primary Causes

Uterine atony (failure of the uterine muscle to contract firmly) is the most frequent cause of excessive bleeding after birth. When atony occurs:

• The relaxed uterus distends with blood and clots

• Blood vessels in the placental site are not clamped off

• Excessive bleeding results

Though the cause isn't always clear, uterine atony often results from retained placental fragments.

High Risks

• High parity

• Polyhydramnios

• Macrosomia

• Uterine fatigue/long labor

• Tocolytic drugs

Other causes:

• Vaginal or vulvar hematomas

• Trauma (lacerations or genital tract or hematomas)

• Unrepaired lacerations of the vagina or cervix

• Incomplete placental separation

• Excessive fundal manipulation or cord traction

• Uterine prolapse

• Late PPH: subinvolution, infection, retained placental fragments, or coagulopathy

• Inversion of the uterus (potentially life threatening but rare)

Key Assessment Finding

Suspect lacerations or hematomas if excessive vaginal bleeding occurs with a firmly contracted uterine fundus.

Measuring Blood Loss

Quantification by weighing (1 mL = 1 g) is the most accurate method for objectively determining blood loss. Visual estimation alone is inaccurate.

Time factor is critical: A woman saturating a pad in 1 hour is bleeding much more heavily than one saturating a pad in 8 hours. Always ask when the pad was last changed.

Prevention - Two Most Important Interventions

1. Maintaining good uterine tone

2. Preventing bladder distention

Initial Management of Uterine Atony

• Firm massage of the uterine fundus (FIRST THING)

• Expression of clots

• Get help, call code hemorrhage

• Elimination of bladder distention

• Continuous IV infusion of 10-40 units oxytocin in 1000 mL lactated Ringer's or normal saline

Additional Medications if Oxytocin Fails

• Misoprostol (Cytotec): Can be given rectally, sublingually, or orally

• Methylergonovine: IM for sustained contractions. Contraindicated with hypertension

• Hemabate: 0.25 mg IM, every 15 minutes maximum 2 mg or 8 doses. Contraindicated with asthma

• Tranexamic acid (TXA): Antifibrinolytic agent if initial therapy ineffective

Mastitis

-Important note from slides:

• Usually stap aureus can be treated with antibiotics (ex. dicloxacillin, cephalexin)

• Mastitis will be febrile, flu-like symptoms, true infection

Mastitis is an infectious process of the breast characterized by sudden onset of influenza-like symptoms.

Signs and Symptoms

• Fever

• Chills

• Malaise

• Body aches

• Headache

• Nausea and vomiting

• Localized breast pain and tenderness

• Hot, reddened area on the breast

Location and Timing

• Most commonly occurs in the upper outer quadrant of the breast

• One or both breasts can be affected

• Most cases occur during the first 2 to 4 weeks postpartum, although mastitis can occur at any time

Causative Organisms

The most common pathogens are:

• Staphylococcus

• Streptococcus

• Escherichia coli

Risk Factors

Inadequate emptying of the breasts is common and can be related to:

• Engorgement

• Plugged ducts

• Sudden decrease in number of feedings

• Abrupt weaning

• Wearing underwire bras

Other predisposing factors:

• Sore, cracked nipples (provide portal of entry for organisms)

• Stress and fatigue

• Maternal illness

• Ill family members

• Breast trauma

• Poor maternal nutrition

Treatment

• Bedrest

• Antibiotics: dicloxacillin, cephalexin, or clindamycin

• Pain and swelling reduction: anti-inflammatory medications and cold compresses

• Continued lactation

• Complete emptying of the breasts through breastfeeding, hand expression, or pumping

• Adequate fluid intake and balanced diet

Important Points

• The infection cannot be transmitted to the infant

• Breastfeeding should continue during treatment

• Mothers should be taught signs of mastitis before discharge from the birth facility

• Women need to know to call their healthcare provider promptly if symptoms occur

Complications

If not treated early, complications can include:

• Breast abscess

• Chronic mastitis

• Fungal infections of the breast

Most complications can be prevented by early recognition and treatment

Breastfeeding positions

Traditional Breastfeeding Positions

Four traditional positions:

1. Football or clutch hold (under the arm)

2. Across the lap (cross-cradle or modified cradle)

3. Cradle

4. Side-lying

Semireclining Position

For initial feedings, a semireclining position can be advantageous:

• Mother is in a semireclining position

• Newborn lies prone, skin-to-skin on mother's bare chest

• Mother's body supports the baby

• Benefits: Mother is more relaxed, nipple pain is reduced or eliminated, more freedom of movement, baby can use inborn reflexes to latch and feed effectively

• Some mothers prefer this position even after early days

Football or Clutch Hold

Often recommended for early feedings because the mother can see the baby's mouth easily as she guides the infant onto the nipple

Especially helpful for:

• Mothers who gave birth by cesarean (often prefer this position)

• Late preterm and early term infants (helps avoid flexing the head, which can impede breathing and cause positional apnea)

Modified Cradle or Across-the-Lap Hold

Works well for early feedings, especially with smaller babies

Side-Lying Position

Allows the mother to rest while breastfeeding

Preferred by women with:

• Perineal pain and swelling

Cradle Position

The most common breastfeeding position for infants who have learned to latch easily and feed effectively

Key Positioning Principles

Regardless of position:

• Mother holds infant securely at the level of the breast

• Supported by firm pillows or folded blankets

• Baby facing toward mother

• Baby's mouth is directly in front of the nipple

• Mother supports baby's neck and shoulders with her hand (not pushing on the occiput)

• Baby's body held in alignment (ears, shoulders, and hips in a straight line)

Recommendation

The mother should be encouraged to use the position that most easily facilitates latch while allowing maximal comfort. Before discharge, nurses can help mothers try all positions so they feel confident at home

Engorgement

Engorgement is a common response of the breasts to the sudden change in hormones and the onset of significantly increased milk volume during lactogenesis stage II. It usually occurs 3 to 5 days after birth as milk transitions from colostrum to mature milk.

What Happens Physiologically

• Increased blood flow to the breasts

• Increased uptake of glucose and oxygen

• Milk production rapidly increases, potentially exceeding storage capacity of the alveoli

• If milk is not removed, alveoli become distended, impairing capillary blood flow

• Blood vessels become congested, fluid leaks into surrounding tissue causing edema

• Milk ducts become compressed by tissue edema, preventing easy milk flow

Signs and Symptoms

• Breasts become firm, tender, and hot

• Appear shiny and taut

• Areolae become edematous

• Nipples can flatten, making it difficult for infant to latch

Risk Factors

• Primiparas (first-time mothers)

• Women who received large amounts of IV fluids during labor and birth

• Women who had previous breast surgery

• Infrequent or ineffective feedings during first 2-3 days after birth

Prevention

• Early and frequent feedings (8-12 times in 24 hours)

• Keeping mother and infant together to recognize and respond to feeding cues

Management for Breastfeeding Mothers

• Feed frequently without limiting time on first breast

• Use hand expression or breast pump to reduce engorgement

• Apply ice packs to breasts

• Apply cabbage leaves (replace when wilted)

• Wear well-fitted support bra

• Take antiinflammatory medications (e.g., ibuprofen) for discomfort

Management for Formula-Feeding Mothers

• Wear well-fitted support bra continuously for at least 72 hours

• Avoid breast stimulation (warm water, expressing milk)

• Apply ice packs periodically

• Use cabbage leaves

• Take mild analgesic or antiinflammatory medication

• Do NOT express breast milk (stimulates production and worsens engorgement)

Important Points

• Engorgement is temporary, usually resolving within 24 hours

• Back pressure on full milk glands inhibits milk production - if milk isn't removed, supply can diminish

Jaundice

-Important to note from slides:

• RBCs have a shorter lifespan

• Bili metabolism is initiated in the reticuloendothelial system, primarily liver and spleen

• Bili binds tightly to albumin, its carrier protein enters the liver for conjugation and excretion

• Can be treated with Phototherapy: UVB light, an overhead lights and blanket

  • Absorbed through skin, causes photochemical reaction with Bilirubin, facilitating dissolution of it for excretion

Types of Neonatal Jaundice

Physiologic jaundice occurs in approximately 60% of term newborns, appears after 24 hours of age, and usually resolves without treatment 3. Total serum bilirubin (TSB) levels peak at 5-6 mg/dL by 72-96 hours of life, then gradually decrease.

Two types related to breastfeeding:

1. Breastfeeding-associated jaundice (early-onset)

   • Occurs during the first week of life

   • Related to insufficient feeding and infrequent stooling

   • NOT caused by breastfeeding itself, but by lack of effective breastfeeding

2. Breast milk jaundice (late-onset)

   • Develops between 5-10 days of age

   • Infants typically thrive, gain weight, and stool normally

   • Bilirubin can remain elevated for 3-12 weeks

   • Etiology uncertain, possibly related to factors in breast milk that inhibit bilirubin conjugation

Why Jaundice Occurs

Bilirubin is excreted primarily through the intestines. When stooling is infrequent, bilirubin in stool is reabsorbed back into the infant's system, increasing bilirubin levels.

Prevention of Early-Onset Jaundice

• Frequent breastfeeding: at least 8-12 times or more in 24 hours during first several days

• Colostrum has a natural laxative effect and promotes early passage of meconium

• Increased feeding frequency is associated with decreased bilirubin levels

Assessment

Any breastfeeding infant with jaundice should be evaluated for:

• Weight loss greater than 7%

• Decreased milk intake

• Infrequent stooling or delayed stool transition

• Decreased urine output (fewer than 4-6 wet diapers per day)

Bilirubin levels should be assessed by serum testing or transcutaneous monitoring.

Treatment of Early-Onset Jaundice

• Evaluate breastfeeding: frequency, length, positioning, latch, milk transfer

• Address factors interfering with effective feeding (sleepy infant, breast engorgement)

• If infant not feeding effectively: mother can pump and feed expressed milk

• Some cases may need formula supplementation

• In presence of other risk factors, phototherapy may be required

Key Point

For breast milk jaundice, no intervention is usually necessary. These infants have no signs of hemolysis or liver dysfunction despite elevated bilirubin

Fetal Loss Communication

Caring Theory Framework

Swanson's caring theory provides a model for nursing practice with five key concepts:

1. Knowing: Assess how the woman, partner, and family perceive the loss and what it means to them

2. Being with: Provide caring presence that conveys acceptance of various feelings and perceptions

3. Doing for: Perform activities that provide physical care, comfort, and safety

4. Enabling: Offer options for care, provide information, articulate choices, and give support to help family feel more in control 5

Time and Presence

Create adequate time to engage with bereaved families without being rushed 1. Nurses may need adjusted assignments to provide sufficient attention to newly bereaved individuals.

Active Listening

Women who experienced stillbirth or infant death have a particularly strong need to share details about the birth 3. Actively listen and allow women to work through their birth and loss stories as they try to make sense of the experience.

Helping Parents See and Hold Their Baby

Prepare the baby with special care:

• Bathe, apply lotion, comb hair

• Place identification bracelets

• Dress in diaper and special outfit

• Wrap in soft blanket

Model appropriate behavior: Hold the baby close, touch a hand or cheek, use the baby's name, and talk about the infant's special features—this conveys it's okay for parents to do likewise.

If the baby has a congenital anomaly, help explain what they are seeing.

Respect Family Decisions

Nursery and baby items: Bereaved parents should make decisions about when and by whom these items are stored or given away 3. Well-meaning relatives who rush to disassemble the nursery may compound grief if parents weren't involved in the decision.

Follow-Up Care

A grief conference typically occurs as follow-up, where:

• The loss is discussed in detail

• Autopsy and genetic study results are shared

• Parents can ask questions

• Events of hospitalization are reviewed

• Assessment of family coping occurs

• Information about grief support groups is provided

This helps parents understand the cause of loss or accept that the cause may never be known

Neonatal Heat Loss

Four Mechanisms of Heat Loss

1. Convection Heat loss from warm body surface to cooler surrounding air 2. Air flow and velocity affect the rate of loss.

• Occurs when drafts come from open doors, air conditioning, or even air currents created by people moving about

2. Conduction Heat loss from direct contact between the infant's skin and cooler surfaces.

• Conduction occurs when the infant comes in contact with cold objects or surfaces such as a scale, a circumcision restraint board, cold hands, or a stethoscope

3. Radiation Heat loss to cooler surfaces not in direct contact with the infant.

• Heat is loss by radiation when the infant is near cold surfaces. Thus, heat is lost from the infant’s body to the sides of the crib or incubator and to the outside walls and windows

4. Evaporation Heat loss when water on the skin surface converts to vapor.

• Can occur during birth or bathing from moisture on skin, as a result of wet linens or clothes, and from insensible water loss

Why Newborns Are at Risk

• Large body surface area in relation to weight

• Limited fat stores and calorie reserves

• Immature skin (especially preterm infants <28 weeks) causes greater transepidermal water loss

Goal: Neutral Thermal Environment (NTE)

The ideal environmental temperature that allows the newborn to maintain normal body temperature (36.5°C-37°C or 97.9°F-99°F) while minimizing oxygen and glucose consumption.

Prevention Strategies

• Dry the infant quickly after birth

• Skin-to-skin contact with mother reduces conductive and radiant heat loss

• Place naked newborn on mother's bare chest, cover with warm blanket

• Cap on infant's head helps conserve heat

• For preterm infants: use prewarmed incubator or radiant warmer

• For extremely low birth weight infants: place in polyethylene bag to decrease heat and water loss

Consequences of Hypothermia and Cold Stress

Early signs:

• Pale, mottled skin

• Cool extremities

• Acrocyanosis

Physiologic effects:

• Increased oxygen consumption and respiratory rate

• Increased glucose consumption → risk of hypoglycemia

• Vasoconstriction to conserve heat

• Metabolic acidosis (if prolonged)

• Apnea, bradycardia, central cyanosis (severe cases)

• Diverts energy from normal brain/cardiac function and growth to heat production

Rewarming

If hypothermia occurs, slow rewarming is recommended:

• External heat sources slightly warmer than skin temperature

• Increase gradually to avoid apnea and acidosis

• Use radiant heaters or heated mattresses

Cold Stress - Condensed

Definition: Metabolic and physiologic demands from uncorrected hypothermia.

Pathophysiology:

• Norepinephrine → vasoconstriction → pale, mottled, cool skin

• Increased O₂ consumption and metabolic rate → energy diverted from growth/normal function to heat production

Respiratory Effects:

• ↓ O₂ tension → pulmonary vasoconstriction → ↓ perfusion

• ↓ PO₂, ↓ pH, altered surfactant

• Can cause/worsen respiratory distress

Metabolic Complications:

• Metabolic acidosis: Anaerobic glycolysis → ↑ acid production

• Hypoglycemia: Depleted glucose stores

• Hyperbilirubinemia: Fatty acids displace bilirubin from albumin

Clinical Signs:

• Pale, mottled, cool extremities

• Acrocyanosis, respiratory distress

• Apnea, bradycardia, central cyanosis (severe)

Key Point: Prevention is critical nursing role.

APGAR Score

What the Apgar Score Measures

The Apgar score is a routine rapid assessment of the newborn's overall status and response to resuscitation. It evaluates five signs indicating the physiologic state of the neonate:

1. Heart rate - auscultated with stethoscope or by palpating umbilical cord

2. Respiratory effort - observed chest wall movement

3. Muscle tone - degree of flexion and movement of extremities

4. Reflex irritability - presence of grimace, crying, or active withdrawal

5. Generalized skin color - described as pallid, cyanotic, or pink

Scoring and Interpretation

Score ranges:

• 0-3: Severe distress

• 4-6: Moderate difficulty

• 7-10: Minimal or no difficulty adjusting to extrauterine life

Timing of Assessment

• Assigned at 1 and 5 minutes after birth

• For scores less than 7 at 5 minutes, repeat assessment every 5 minutes for up to 20 minutes

Important Considerations

Who performs it: Nurse or birth attendant, depending on facility policy

What it does NOT do: Apgar scores do not predict future neurologic outcome for the newborn

What it DOES do: Useful in describing the newborn's transition to extrauterine environment and response to resuscitative efforts

Critical timing note: If resuscitation is required, it should be initiated before the 1-minute Apgar score is determined

Adjunct Assessment

When there has been an abnormal or confusing fetal heart rate tracing during labor or neonatal depression at birth, umbilical cord blood acid-base determination is a useful adjunct to the Apgar score 3. Cord blood values should be obtained when a newborn has an Apgar score of 5 or less at 5 minutes of age

Head to Toe Assessment Findings

Head and Skull

Proportions: Head is approximately one-fourth of total body length at term; appears large and heavy with face appearing small in relation to skull.

Molding: Shaping of fetal head by overlapping cranial bones during labor to facilitate birth canal passage.

Caput succedaneum: Generalized edematous area of scalp (usually occiput), present at birth, crosses suture lines, resolves spontaneously in 3-4 days. Results from sustained pressure against cervix causing venous congestion.

Cephalhematoma: Blood collection between skull bone and periosteum, does not cross suture lines, firmer and better defined than caput, resolves in 2-8 weeks. Can cause hyperbilirubinemia as it resolves. May be present in up to 25% of newborns with linear skull fractures.

Subgaleal hemorrhage: Bleeding beneath galea aponeurosis, associated with difficult operative vaginal birth (especially vacuum extraction). Results from traction/shearing forces pulling scalp away from bony calvaria.

Extremities

Symmetry: Should be symmetric and equal length.

Digits: Five fingers on each hand, five toes on each foot with nails present.

• Oligodactyly: Missing digits

• Polydactyly: Extra digits

• Syndactyly: Fused digits

Hip assessment for Developmental Dysplasia of Hip (DDH):

• More common in: breech presentations, firstborn infants, female infants, family history of DDH

• Signs: Asymmetric gluteal/thigh skinfolds, uneven knee levels, positive Ortolani test, positive Barlow test

• Gluteal and thigh skinfolds should be equal and symmetric

• Legs should be equal length

• Knee levels in flexion should be equal

Skeletal Injuries

Skull fractures:

• Linear fractures: Most common, from compression during birth, usually no treatment needed

• Depressed fractures: "Ping-pong ball" indentations from pressure on bony pelvis or forceps

• Occipital osteodiastasis: Separation of occipital bone cartilaginous joint from traumatic breech births

Clavicle: Most commonly fractured bone during birth, typically in middle third

Cardiovascular System

Heart rate: Normal is 110-160 beats/min when awake; can range from 85-100 during deep sleep to up to 180 during crying 1.

Heart sounds: Should be clear and regular; murmurs are common in first few hours and usually benign 1.

Blood pressure: Average is 60-80 mmHg systolic and 40-50 mmHg diastolic at birth.

Peripheral pulses: Should be palpable and equal bilaterally (brachial, radial, femoral).

Respiratory System

Respiratory rate: Normal is 30-60 breaths/min; counted for full minute.

Breathing pattern: Primarily diaphragmatic and abdominal; may be shallow and irregular with brief pauses (less than 20 seconds).

Chest: Should be symmetric with equal bilateral breath sounds.

Signs requiring attention: Nasal flaring, grunting, retractions, tachypnea (>60 breaths/min), or apnea (pauses >20 seconds).

Integumentary System

Color: Pink or ruddy; acrocyanosis (bluish hands/feet) is normal in first 24 hours.

Vernix caseosa: Protective white cheesy substance, more abundant in term infants.

Lanugo: Fine downy hair, especially on shoulders, back, and forehead.

Milia: Small white papules on nose, chin, forehead from sebaceous gland retention.

Erythema toxicum: Pink papular rash with vesicles on trunk/extremities, appears 24-48 hours after birth, resolves spontaneously.

Neurologic Assessment

Muscle tone: Should have flexed posture with resistance to extension.

Key reflexes:

• Moro (startle): Arms extend then flex with crying when startled

• Rooting: Turns toward touch on cheek

• Sucking: Strong coordinated suck

• Grasp: Fingers curl around object placed in palm

• Babinski: Toes fan outward when sole stroked

Abdomen

Shape: Rounded, soft, moves with respirations.

Umbilical cord: Should have three vessels (two arteries, one vein); clamp should be secure.

Bowel sounds: Present within first hour after birth

Genitourinary System

Female genitalia:

• Labia majora may be swollen from maternal hormones

• Vernix caseosa between labia folds is normal

• Pseudomenstruation: Small amount of blood-tinged mucus discharge from maternal hormone withdrawal (normal finding)

• Hymenal tag may be visible

Male genitalia:

• Testes should be descended into scrotum (palpate if not visible)

• Scrotum may appear large and edematous

• Urethral opening should be at tip of glans penis

• Hypospadias: Urethral opening on ventral (underside) surface

• Epispadias: Urethral opening on dorsal (top) surface

• Foreskin adheres to glans (if uncircumcised)

Voiding: First void should occur within 24 hours of birth; document timing.

Eyes, Ears, Nose, Mouth

Eyes:

• Eyelids may be edematous

• Subconjunctival hemorrhages common from birth pressure

• Eye color typically slate gray, blue, or brown

• Red reflex should be present bilaterally

• Blink reflex present

Ears:

• Top of ear should align with outer canthus of eye

• Cartilage should be present and firm

• Startle response to loud sounds

Nose:

• Obligate nose breathers

• Nares patent bilaterally (check for choanal atresia)

Mouth:

• Palate intact (hard and soft)

• Epstein pearls (small white cysts on palate) are normal

• Tongue moves freely

• Coordinated suck and swallow

Spine

Curvatures: Two primary forward concave curvatures in thoracic and sacral regions.

Appearance: Should appear straight and flat; can flex easily.

Mobility: Newborn can lift head and turn side to side when prone.

Pilonidal dimple: If noted, inspect for sinus; especially with hairy nevus can indicate spina bifida.

Skin Assessment for Problems

Concerning findings:

• Pallor, plethora (deep purplish from increased RBCs)

• Petechiae: Can indicate low platelets or infection if scattered over body

• Central cyanosis

• Jaundice

• Birth injuries: forceps marks, fetal monitoring lesions

• Bruising on head/neck/face with nuchal cord or face presentation

Neonatal Hypoglycemia

Definition and Thresholds

Hypoglycemia is defined as blood glucose concentration inadequate to support neurologic, organ, and tissue function. The lower limit for normal plasma glucose during the first 72 hours after birth is often cited as 40-45 mg/dL.

Timing

Most commonly occurs within the first 1-6 hours after birth.

At-Risk Populations

• Infants of diabetic mothers (IDM) - especially macrosomic or large-for-gestational-age (LGA) infants

• Intrauterine growth restriction (IUGR) infants

• Preterm infants

• Late preterm infants (LPIs)

• All high-risk infants

Pathophysiology in Infants of Diabetic Mothers

When the umbilical cord is clamped, the maternal glucose supply stops abruptly, but the infant's fetal hyperinsulinism persists. High insulin levels cause:

• Inhibition of gluconeogenesis and glycogenolysis → hypoglycemia

• Can take several days for the newborn to regulate insulin secretion

Pathophysiology in IUGR/Preterm Infants

• Decreased glycogen stores

• Decreased rate of gluconeogenesis

• Inadequate intake and increased metabolic demands from illness

Clinical Signs and Symptoms

Common signs:

• Jitteriness

• Tremors

• Apnea

• Tachypnea

• Hypotonia

• Decreased activity/lethargy

• Cyanosis

• Poor feeding

• Hypothermia

• Diaphoresis

• Weak cry

• Floppy posture

Severe hypoglycemia: Seizures or coma

Critical concern: Many infants remain asymptomatic. Asymptomatic hypoglycemia is just as concerning as symptomatic and has been associated with increased risk of poor executive function and visual motor function.

Physiologic Relationships

Direct correlation exists between temperature regulation, glucose homeostasis, and respiratory distress.

Screening and Monitoring

• Point-of-care testing (Accu-Chek, One-Touch) or laboratory confirmation

• Screen all high-risk infants soon after birth, preferably after feeding

• Monitor frequently during first few hours until glucose levels stabilize

• Most nurseries have protocols for frequency of monitoring in at-risk infants

Treatment Threshold

Blood glucose values less than 40 or 45 mg/dL or presence of symptoms should be treated

Skin to skin care in Neonate

Skin-to-Skin Care (Kangaroo Care)

Definition: Parent is bare-chested or wears loose-fitting, open-front top. Undressed infant (diaper only) is placed vertically on parent's bare chest, allowing direct eye contact, skin-to-skin contact, and close proximity.

Who Can Provide: Mothers, fathers, or co-parents.

When to Initiate:

• Immediately after birth during first hour (recommended standard of care)

• Stable preterm infants

• Even with mechanically ventilated infants

Benefits for Infant:

• Maintains thermal stability and oxygen saturation

• Reduces conductive and radiant heat loss

• Decreases stress in preterm infants

• Increased feeding vigor and enhanced breastfeeding

• Maintains organized behavioral state

• Decreased pain perception during painful procedures (heelsticks)

• Improved transitional circulation in preterm infants

Benefits for Parents:

• Facilitates bonding and affectionate behaviors

• Positive healing effect for mothers with high-risk pregnancies

• Promotes maternal behavior through oxytocin release with breastfeeding

Standard of Care: Recommended as standard practice due to many benefits and no adverse effects.

Clinical Application:

• Routine assessments and procedures can be completed with newborn on mother's abdomen or chest

• Initial newborn bath often delayed to allow skin-to-skin time

• Viable option for high-risk/preterm infants due to maintenance of appropriate body temperature

• Infant may wear cap to conserve additional heat

Reassurance for Delayed Contact: Parents who cannot have early contact (e.g., infant in NICU) can be reassured that immediate contact is not essential for optimal parent-infant interactions. The parent-infant relationship is a process that develops over time

Neonatal infection

-Important to note from slides:

• Birth of baby exposed to TORCH infections (ex. Hepatitis B, HIV, and Herpes)

• S/S: Respiratory distress, apnea, decreased tone, difficulty with thermoregulation

Neonatal Sepsis

Definition: Systemic inflammatory response syndrome (SIRS) secondary to infection. Diagnosed by ≥2 signs: hypothermia/fever, tachypnea/hyperventilation, tachycardia, bradycardia, proven/suspected sepsis, or high/low WBC count.

Classification by Timing:

Early-Onset Sepsis (within first 72 hours):

• Common organisms: Group B streptococci (GBS), E. coli, coagulase-negative staphylococci

• Risk factors: Prematurity, low birth weight (<2500 g), preterm labor, ROM >18 hours, maternal fever >38°C (100.4°F), chorioamnionitis

• Note: Intrapartum antibiotics for GBS+ mothers have significantly reduced early-onset GBS infections

Late-Onset Sepsis (after 72 hours up to 30 days):

• Common organisms: Coagulase-negative staphylococci, Klebsiella, enterobacter, E. coli, Candida

• Risk factors: Prematurity (most significant), invasive procedures (intubation, catheterization, surgery)

• Entry sites: Umbilical stump, skin, mucous membranes, respiratory/nervous/urinary/GI systems

Clinical Presentation

Signs are nonspecific and nonlocalizing:

• Temperature instability (usually hypothermia)

• Respiratory distress

• Lethargy

• Feeding difficulties

• Abdominal distention

• Purpura

• Seizures

Challenge: Signs mimic noninfectious problems (anemia, hypoglycemia).

Diagnosis

Laboratory studies:

• Cultures: Blood, CSF, urine

• CBC with differential

• Total neutrophil count, immature-to-total neutrophil ratio, absolute neutrophil count, platelet count, procalcitonin, C-reactive protein

• Note: Tests are adjuncts; combination of labs + clinical signs + history guide treatment

Treatment

Early-onset: Ampicillin + aminoglycoside
Late-onset: Vancomycin + aminoglycoside
Duration: Depends on organism, infection site, clinical response
Antivirals: Acyclovir, ganciclovir for viral infections

Breastfeeding Benefits

Encouraged for protective mechanisms:

• IgA in colostrum protects GI tract

• Iron-binding protein has bacteriostatic effect on E. coli

• Contains macrophages and lymphocytes

• Passive immunity transfer reduces vulnerability to respiratory pathogens

Differences of Early-onset and Late-onset Sepsis

Quick Differentiation: Early vs. Late-Onset Sepsis

Feature	Early-Onset Sepsis	Late-Onset Sepsis
Timing	Within first 72 hours of life	After 72 hours up to 30 days of life
Source	Maternal/perinatal transmission	Maternally derived OR health care-acquired
Common Organisms	• Group B streptococci (GBS) • E. coli • Coagulase-negative staphylococci	• Coagulase-negative staphylococci • Klebsiella • Enterobacter • E. coli • Candida
Risk Factors	• Prematurity • Low birth weight (<2500 g) • Preterm labor • ROM >18 hours • Maternal fever >38°C • Chorioamnionitis	• Prematurity (most significant) • Invasive procedures (intubation, catheterization, surgery)
Entry Sites	Vertical transmission during labor/delivery	Umbilical stump, skin, mucous membranes, respiratory/nervous/urinary/GI systems
Antibiotic Treatment	Ampicillin + aminoglycoside	Vancomycin + aminoglycoside

Key Clinical Point

Signs and symptoms are nonspecific and similar for both types:

• Temperature instability (usually hypothermia)

• Respiratory distress

• Lethargy

• Feeding difficulties

• Abdominal distention

• Purpura

• Seizures

Memory Tip

Early = "E" for External/Environmental exposure during birth
Think: maternal/labor factors (ROM, fever, chorioamnionitis)

Late = "L" for Life-sustaining procedures
Think: hospital-acquired from invasive interventions

Neonatal Skin Findings

Normal Skin Findings

At Birth:

• Erythematous (red) for first few hours, then fades to normal color

• Blotchy or mottled appearance, especially over extremities

• Acrocyanosis: Slight cyanosis of hands and feet from vasomotor instability; common first 48 hours, intermittent for 7-10 days, especially with cold exposure

• Vernix caseosa: Cheeselike, whitish protective covering with emollient, antimicrobial, antioxidant properties; prevents fluid loss; present after 35 weeks gestation

Skin Structure:

• All structures present at birth but epidermis and dermis are loosely bound and extremely thin

• Desquamation (peeling) follows vernix removal in most infants

Benign Variations

Periauricular papillomas (skin tags): Unilateral or bilateral; usually familial trait with no consequence

Signs Requiring Assessment

Birth-Related Trauma:

• Erythema, ecchymoses, petechiae, abrasions, lacerations, edema on face, head, buttocks, extremities

• Localized discoloration over presenting/dependent parts

• Forceps marks: Linear configuration across both sides of face

• Nuchal cord: Bruises/petechiae on head, neck, face; skin over entire head can be ecchymotic

• Face presentation: Bruising over face

• Breech presentation: Bruising and swelling over buttocks and genitalia

Petechiae:

• Benign if: Disappear within 2 days, no new lesions appear

• Report to provider if: Scattered over body (may indicate low platelet count or infection)

Concerning Findings to Document:

• Pallor

• Plethora (deep purplish color from increased RBCs)

• Central cyanosis

• Jaundice

Note: Bruising increases risk for hyperbilirubinemia

Newborn Vital Signs

-Important note from slides:

• Pulse oximetry: 95%+

• Blood sugar: 42-50 minimum

• Weight: 2700-4100 G (6-9 lbs)

• Length: 46-56 cm (18-21 in)

• Head circumference: 32-36 cm (12.6-14.2 in)

Newborn Vital Signs

Parameter	Normal Range	Key Points
Heart Rate	100-160 beats/min	• 80-100 beats/min during deep sleep • Up to 180 beats/min when crying • Reevaluate if >160 or <100 beats/min within 30 min to 1 hour
Respiratory Rate	30-60 breaths/minute	• Count for full minute due to irregular pattern • Assess chest movement
Temperature	97.7 F - 99.5 F 36.5 C - 37.5 C	• Hypothermia is common concern • Monitor closely for cold stress
Blood Pressure	60-80/40-50	• MAP should equal weeks of gestation (e.g., 40 weeks = MAP 40 mmHg) • Systolic BP drops ~15 mmHg in first hour • Increases over first 5 days, then levels off

Heart Rate Assessment Details

Location: Apical impulse at 4th intercostal space, left of midclavicular line

Characteristics:

• Often visible and easily palpable (thin chest wall)

• Higher pitch, shorter duration, greater intensity than adult

• S₁ louder and duller than S₂ (which is sharp)

• Irregular heart rate/sinus dysrhythmia common in first few hours

Emergency Assessment: During resuscitation, count for 6 seconds and multiply by 10; heart rate should be >100 beats/min

Blood Pressure Factors

Affected by:

• Gestational age

• Postconceptional age

• Birth weight

• Cuff size

• State of alertness

• Movement

Assessment Tips

When to Reassess Heart Rate:

• If outside normal range (>160 or <100 beats/min)

• When infant's activity state changes

• After 30 minutes to 1 hour

Apgar Score Components 4: Heart rate is one of five signs assessed at 1 and 5 minutes after birth based on auscultation or umbilical cord palpation