Postpartum and Newborn

**BUBBLEHEE**

Breasts

Uterus

Bowel

Bladder

Lochia

Episiotomy/Laceration

Hemorrhoids

Emotional Status

Extremities (Edema,DTR)

engorgement care

* Early and frequent feedings
* Proper positioning of infant
* Supportive bra
* Manual expression of milk (or pump)
* Heat to assist milk ejection reflex (let down)
* Ice packs after feeding
* Pain medication

sore nipples care

* proper positioning of areola in infant’s mouth
* change positions, chin away from sore area
* start on unaffected side
* frequent feedings
* expose to air after feeding
* Tea bags/breast milk to nipple
* breast shells

plugged duct care

* ​​Warm compresses/showers
* massaging
* Frequent feedings
* change positions with each feeding
* check clothing - tight, restrictive bras

signs of a good feed

* Lips flanged
* Muscle movement near eyes
* Hear swallowing 
* Sucks in bursts of 15-20 sucks/swallows 

normal involution process

* Autolysis and contractions, end of 3rd stage at umbilicus 
* Every 24 hours descends about 1-2 cm or finger breadth (U/1, U/2)
* Takes 6-8 weeks

what do you assess about uterus

location, position, and tone

where should the uterus be after 24 hours

1 cm below umbilicus (U/1)

where should the uterus be after 48 hours

2cm below umbilicus (U/2)

where should the uterus be after 72 hours

3cm below umbilicus (U/3)

Factors that impede involution

* Prolonged labor
* Anesthesia
* Difficult birth
* Grand multiparity
* Full bladder
* Incomplete expulsion of placenta &/
* Infection

afterpain causes

* Multiparas
* breast feeding
* Oxytocin
* marked distension
* clots or placental fragments retained

how long do afterpains last

2-3 days

How does a full bladder impact the uterus

* displaced uterus 
* stasis leading to infection
* discomfort from bladder distention

how to treat urinary retention

* ​FIRST…assist to normal voiding position
* Warm water on perineum
* Sitz bath
* Elevate knees above pelvis
* Blow through straw
* Catheterization
* Encourage to void every 2 hours

what causes the bowels to slow down

* decreased food during labor
* effects of progesterone
* decreased muscle tone
* loss of fluid from labor
* fear of pain
* Opioids

how to promote bowel movement after birth

* Ingest magnesium and fiber (bread, berries, nuts)
* drink lots of water
* exercise
* lessen perineal pain
* privacy 

rubra

0-3 days, dark red, few small clots

serosa

4-10 days, pink to brown color

alba

10 days to 6 weeks, creamy or yellowish

scant lochia

blood only when wiping or less than 1 inch stain on peripad

light lochia

less than 4 inch stain on peripad

moderate lochia

less than 6 inch stain on peripad

heavy lochia

saturated peripad within 1 hour

lochia odor

earthy, musty

blood clots should be smaller than ______

the size of an egg

what teaching would you give to care for the perineum

* Use peri bottle 
* Shower
* Hot or cold sitz bath 
* Ice to perineum x 24 hours 
* Sit on soft surface 
* Stool softeners
* Topical ointments, sprays, foams

postpartum blues

* Transient during first 1-2 weeks 
* 70-80% or more experience
* Cause unknown
* Signs
* Mood swings
* Anger
* Weepiness
* anorexia
* difficulty sleeping
* feeling of letdown or lack of attention

Postpartum depression

* Severe depression
* 6-12 months 
* Effects family unit
* Is disabling 
* Signs
* Depressed mood for at least 2 weeks 
* Weight loss
* Insomnia or hypersomnia
* Fatigue 
* Decreased ability to concentrate 
* Feeling worthless or guilty 

taking in

* 1 - 2 days
* preoccupied with own needs
* need to review labor & birth
* focus on food and sleep
* Decreased ability to make decisions

taking hold

* 2 days- 6 weeks?
* Beginning to resume control
* Increased care to infant 
* Return home and increased responsibility

letting go

* 6 weeks to remainder of life
* Milestones of letting go/ “firsts”

When would you give RhoGAM?

for Rh negative mom and Rh positive baby **within 72 hours of giving birth** 

* isoimmunization/ hemolytic disease of newborn
* Coomb’s test (on cord blood) 

When would you give Rubella?

If not immune: administer rubella vaccine (immediately after birth)

* Can breastfeed
* Do not become pregnant for 4 weeks because it is teratogenic 

common variations with postpartum client

* elevated to 100.4 within 24 hours is due to exhaustion and dehydration
* leukocytosis: 12,000 mm^3 (normal is 16,000 to 30,000) (returns to normal by day 7)
* transient stress incontinence
* blood loss
* 200-500mL (vaginal)
* 600-1000mL (cesarean)
* Hgb and erythrocyte vary until 2-6 weeks
* Hct rises
* Estrogen, progesterone, and prolactin decrease
* sweating (diaphoresis) due to decreased estrogen
* increased sedimentation rate

physiologic changes newborns make to transition to extrauterine life

* Establish and maintain respirations
* Adjust from fetal to adult circulation 
* Temperature regulation
* Ingesting, retaining, and digesting nutrients 
* Waste elimination
* Regulating weight

behavioral changes newborns make to transition to extrauterine life

* Establish a routine
* Processing, storing, and organizing stimuli
* Establishing relationships

normal newborn temp

97\.7-99.5 (36.5-37.5)

normal newborn HR

110-160 bpm

normal newborn RR

30-60 breaths per minute (irregular breathing is normal)

newborn blood glucose should be over

40 mg/dL

convection heat loss

flow of heat from body to cooler air

how to prevent convection heat loss

* Keep environment around 75 degrees
* Wrap newborn to protect from cold 
* Use cap on head
* Don't overexpose during exam

radiation heat loss

loss of heat from body surface to cooler surface nearby

how to prevent radiation heat loss

* Keep bassinets and tables away from windows
* Skin to skin contact with mom

conduction heat loss

loss of heat from body to cooler surface in direct contact 

how to prevent conduction heat loss

* Skin to skin contact with mom 
* Initial assessment: use radiant warmer with pre-warmed bed
* Use protective cover for scales

evaporation heat loss

loss of heat when liquid is converted to a vapor 

how to prevent evaporation heat loss

* Dry newborn directly after bath 
* Don’t overexpose during bath

what babies are at risk of hypoglycemia

* Respiratory distress
* Maternal beta blockers
* Diabetic moms 
* Large for gestational age (LGA >90%)
* Small for gestational age (SGA

how to calculate weight loss

New weight/ Birth weight= %

100-%= % lost

how much should newborns lose in first 3-5 days

5-10%

babies should regain weight lost in _____ days

10-14

intervention for jaundice

Phototherapy: converts indirect to direct bilirubin so that it can be excreted

newborns should pee within

24 hours

newborns should poop within

12-24 hours, definitely within 48 hours

how often should newborns pee before 4th day

2-6 per day

how often should newborns pee after 4th day

6-8 per day

what should newborn urine look like

pale straw color, may see pink from uric acid crystals

meconium

first stool, amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, some blood

transitional

thin, sticky, curds, by third day after first feeding

milk stool

yellow to golden, pasty, by fourth day

Erythromycin ophthalmic

* Within 24 hours 
* To prevent eye infections

Phytonadione (Vit K)-IM

* Within 6 hours
* To promote blood clotting

Hepatitis B vaccine-IM

To vaccinate against hep B

Normal screenings for newborns

* Blood glucose level: as needed
* After 24 hours:Newborn screening “The PKU”
* Congenital heart disease screening-   24 hours
* Hearing screen
* Bilirubin
* ​​Car seat test- before d/c

Newborn screening “The PKU”

* Heel stick after 24 hrs of eating 
* Screens for disorders such as hypothyroidism, sickle cell, and cystic fibrosis
* Screens for phenylketonuria (defect in protein metabolism)

Car seat test

infant in own car seat with pulse ox on foot, watched for 90 minutes to be sure that airway  does not occlude when sitting in seat and perfusion is maintained above 95%,  if not, must retest, if still fails then use car bed – done for SGA and preterm newborns before discharge.

Wake/sleep cycles

* Deep sleep
* Light sleep
* Drowsy
* Alert (quiet alert)
* Eyes open (active alert)
* Crying

newborn bath education

* sponge bath until cord stump falls off,
* after it falls off you may use a couple inches water to bathe
* never leave alone or submerge- sequence

bulb suction newborn education

* squeeze, insert and then release, mouth first
* do not place in center of mouth as will cause the gag reflex

umbilical clamp newborn education

* removed after 24 hours, stump falls off within 2 weeks
* diaper below umbilicus
* if dirty then clean
* contact for bleeding, foul smell, redness

follow up care newborn education

after 48-72 hours of discharge

Plastibell

* no vaseline used
* Rim remains in place for about 1 week 
* Rim and remaining foreskin come off after healing (7-10 days)
* Check for bleeding
* Assess urination (2-6x in 1st 24h)

Gomco clamp

* Small vaseline gauze applied to penis q24h 
* After 24h, apply vaseline to penis to prevent adhering to diaper

circumcision care

* Change diaper at least q4h, assess site
* Wash with warm water (not baby wipes)
* Apply vaseline if Gomco
* Apply diaper so it doesn’t rub 
* Glans will be dark red and then covered with yellow exudate in 24h, lasts 2-3 days (DO NOT REMOVE!)
* Provide comfort, Tylenol

newborn danger signs to report

* Hypothermia or hyperthermia
* Refusal to eat for 2 consecutive feedings
* Vomiting more than once in a 6 hour period
* Diarrhea (green watery, 2 consecutive)
* Decreased bowel movements (less than 3/day)
* Decreased urination (less than 6/day)
* Difficulty breathing
* Cyanosis
* Lethargy (difficulty waking, sleeping more than 6 hours)
* Bleeding
* Inconsolable crying
* Drainage from eyes

NIPS

\-neonatal infant pain score

\-facial expression, cry, breathing pattern, arms, legs, state of arousal, HR, O2 sat

N-PASS

\-neonatal pain, agitation, and sedation scale

\-cry, irritability, behavioral state, facial expression, extremities tone, vital signs

pharmacologic pain management for newborns

sucrose, tylenol, xylocaine (for circumcision)

newborn reflexes

moro

tonic neck

grasp

babinski

rooting

Ortolani maneuver

identifies dislocated hip that can be reduced into the socket (spread legs)

Barlow test

identifies a loose hip that can be pushed out of the socket with gentle pressure (knees to chest)

caput succedaneum

swelling/ edema of the scalp

cephalohematoma

bleeding under periosteum (does not cross suture lines), can lead to jaundice

anterior fontanelle

* diamond shaped
* closes by 18 months

posterior fontanelle

triangle

closes 2-4 months

how much can the stomach hold on day 1?

≤30 mL

how much can the stomach hold on day 3

 >90 mL

vernix

cream cheese like substance that protects baby’s skin from moisture in the womb

laguno

fine, downy hair

milia

distended sebaceous glands

desquamation

peeling

grey slate nevus (formerly known as Mongolian spots)

Blackish patch usually right above buttocks seen more in Asian, African American, Latin Americans, and Mediterranean

Nevi “stork bite”

a vascular lesion appearing as a red patch

erythema toxicum

“newborn rash”

epstein pearls

benign cysts in mouth

jaundice

yellow hue

natal teeth

teeth at birth, need to be pulled

newborns are _________ breathers

nasal and abdominal