Women's Health L20 - Normal Newborn Assessment and Puerperium

most full term and early term (≥ 37 weeks of gestation) newborns successfully transition to extrauterine life AND will only require only routine newborn care

true

2 multiple choice options

newborns at an increased risk of requiring resuscitation should have a skilled provider present at the time of delivery

true

2 multiple choice options

what are some risks that might increase the risk of resuscitation?

1. maternal

2. fetal

3. antepartum/delivery

what are some maternal risks associated with an increased risk of resuscitation?

1. extremes of maternal age

2. diabetes or hypertension

3. substance abuse

4. history of stillbirth or fetal loss

what are some fetal risks associated with an increased risk of resuscitation?

1. congenital anomalies

2. intrauterine growth restriction

3. multiple gestations

what are some antepartum/delivery risks associated with an increased risk of resuscitation?

1. placental anomalies

2. breech presentation

3. chorioamnionitis

4. unplanned operative delivery

how soon does immediate management of a neonate begin?

started within a few seconds of birth

what occurs with immediate management of a neonate?

1. dry the newborn

2. clamping the umbilical cord

3. clear secretions from the airway if needed

4. provide warmth

5. quick clinical assessment to check muscle tone and respiratory effort

when is it okay for a mother to give skin-to-skin contact?

1. if the gestational age is ≥ 35 weeks

2. good muscle tone is present

3. the newborn has a strong respiratory drive

how is skin-to-skin contact beneficial?

1. promotes infant-maternal bonding

2. allows for early initiation of breastfeeding

3. has been shown to help stabilize newborn vital signs

when is the umbilical cord commonly clamped?

30-60 seconds after delivery

what are the benefits of clamping the umbilical cord?

1. hematologic benefits for the newborn -- has higher iron stores

2. reduces mortality in preterm newborns

what are the contraindications to delayed clamping?

1. if the mother or newborn is unstable and requires timely care

2. if prenatal Doppler studies documented abnormal umbilical artery flow

what is the Apgar Score?

1. a method to assess status of the newborn immediately after delivery

2. performed 1 minute and 5 minutes after birth

what does the Apgar Score assess?

1. heart rate

2. respiratory effort

3. activity (muscle tone)

4. reflex irritability

5. color

the Apgar Score is used to determine the need for resuscitation

false

2 multiple choice options

an Apgar Score at 5 minutes should be ≥ 7

true

2 multiple choice options

an Apgar Score is < 7 requires a repeat assessment at 10 minutes

true

2 multiple choice options

how is activity (muscle tone) in the Apgar Scoring scored?

- 0 points = absent

- 1 point = flexed arms and legs

- 2 points = active

how is pulse in the Apgar Scoring scored?

- 0 points = absent

- 1 point = < 100 bpm

- 2 points = > 100 bpm

how is grimace (reflex irritability) in the Apgar Scoring scored?

- 0 points = floppy

- 1 point = minimal response to stimulation

- 2 points = prompt response to stimulation

how is appearance in the Apgar Scoring scored?

- 0 points = blue/pale

- 1 point = pink body/blue extremities

- 2 points = pink

how is respiration in the Apgar Scoring scored?

- 0 points = absent

- 1 point = slow and irregular

- 2 points = vigorous cry

what is the transitional period of neonate care?

the first 4-6 hours after birth

what physiologic changes take place during the transitional period of neonate care?

1. vascular resistance in the lungs decreases after initial breaths

2. increased blood flow to lungs and lung expansion

3. flap of foramen ovale closes and ductus arteriosus starts to constrict

how often should the clinical status of a newborn be assessed during the transitional period of neonate care?

30-60 minutes

what are the parameters for clinical assessment?

1. temperature

2. respiratory rate

3. heart rate

4. color

5. tone

what is the normal respiratory rate of a neonate?

40-60 breaths per minutes

what is the normal heart rate of a neonate?

120-160 bpm

what all is involved in routine newborn care?

1. ophthalmic antibiotics

2. vitamin K

3. keep the umbilical cord dry

4. hepatitis B vaccine

5. RSV prophylaxis

6. bath

7. hearing test

8. "blood spot" screening panel

9. bilirubin check

10. feeding

11. monitor weight

12. +/- circumcision

what ophthalmic antibiotics are administered to a newborn?

1. erythromycin ointment

2. prophylaxis against gonococcal conjunctivitis

how and why is vitamin K given to a newborn?

1. vitamin K1 as a single IM dose

2. prophylaxis against vitamin K deficient bleeding (VKDB) because vitamin K deficiencies are common in newborns

why must the umbilical cord be kept dry?

due to risk of omphalitis (infection of the umbilical stump)

for which newborns is RSV prophylaxis recommended?

for those born between october and march

when is the first bath given to newborns?

typically 6-24 hours after birth

what does a "blood spot" screening panel screen for?

1. endocrinopathies

2. immunodeficiencies

3. hemoglobinopathies

4. cystic fibrosis

how often should you assess for jaundice in a newborn?

every 8-12 hours

how often should a newborn be fed?

1. frequent/on demand to avoid hypoglycemia

2. every 2-3 hours = 8-12 feeds per day

if a patient decides to breastfeed, how early should a newborn be fed?

as soon as possible after delivery

what should formula be fortified with if a mother chooses to formula-feed the newborn?

iron

3 multiple choice options

how much weight do newborns commonly lose in the first few days of life?

up to 10%

you should evaluate a newborn if their weight loss exceeds 10%

true

2 multiple choice options

what is circumcision?

surgical removal of the foreskin of the penis

what are the benefits of circumcision?

1. reduction in UTIs

2. reduction in penile cancer

3. reduction in STIs

4. reduction in retractile disorders -- phimosis/paraphimosis

5. easier hygiene

what are the risks of circumcision?

1. inadequate/excessive skin removal during the procedure

2. bleeding during the procedure

3. infection following the procedure

4. urethral complications following the procedure

5. adhesions following the procedure

6. sexual dissatisfaction

what all is involved in routine maternal care in the hospital?

1. monitor vitals

2. fundal checks

3. perineal checks and care

4. draw labs -- CBC

5. assess the need for vaccines

what do fundal checks assess?

uterine tone

2 multiple choice options

what do perineal checks assess?

bleeding

what is involved in perineal care?

1. cold packs

2. Peri bottles and Sitz baths

3. oral analgesics

4. stool softeners/laxatives

assessing a CBC for WBCs and Hgb/Hct is done on a case-by-case basis

true

1 multiple choice option

what criteria is used to determine if a newborn can be discharged from the hospital?

1. no abnormality requiring continued hospitalization

2. vital signs are within normal range and stable for at least 12 hours

3. urinated and passed at least one stool

4. completed at least two successful feedings

5. screenings and hepatitis B vaccine completed

what criteria is used to determine if a mother can be discharged from the hospital?

1. lab results have been reviewed and a follow-up has been scheduled if needed

2. has demonstrated competency in care of the newborn

3. family/environmental/social risk factors have been assessed and addressed

4. confirmation that mother and father can properly use a car seat

what is the optimal source of nutrition for infants?

breastfeeding

what is the recommended duration for breastfeeding?

infants should be exclusively breastfed until 6 months of age

what does breast milk contain that make breastfeeding the optimal source of nutrition?

1. macro/micronutrients

2. growth factors

3. immunoprotective substances

why might breastfeeding be challenging for some mothers?

1. trouble with latching

2. low milk supply

3. pain and exhaustion

what are the benefits of breastfeeding for the infant?

1. neurobehavioral benefits

2. GI function

3. prevents illnesses

4. dental health

5. reduced risk of type I diabetes, IBD, and wheezing

what neurobehavioral benefits does breastfeeding have?

1. reduces crying

2. analgesic effect

how is GI function affected by breastfeeding?

1. influences the development of microbiota

2. decreases the risk of gastroenteritis/diarrheal disorders

3. stimulates GI growth and motility

how does breastfeeding prevent illnesses in infants?

1. associated with fewer serious infections during the first year of life

2. lower risk of SIDS

what are the benefits of breastfeeding for the mother?

1. reduced risk of postpartum blood loss

2. delay in return of ovulation

3. protective factors against certain cancers

4. cardioprotective effects

5. improved glucose control

6. financial benefit

how does breastfeeding reduce the risk of postpartum blood loss?

helps the uterus return to normal size quicker if initiated soon after delivery

which cancers does breastfeeding protect against?

1. breast

2. ovarian

3. endometrial

which cardiac issues does breastfeeding reduce the risk of?

1. hypertension

2. coronary heart disease

3. stroke

why might breastfeeding be contraindicated in an infant?

the infant has galactosemia (unable to process galactose)

what are the maternal contraindications to breastfeeding?

1. HIV infection and not on an ART

2. use of illicit drugs

3. suspected or confirmed Ebola virus

4. active varicella virus

5. monkeypox infection

6. untreated active TB

7. active HSV infection with lesion present on the breast

what is the etiology of breast engorgement?

1. primary -- interstitial edema with the onset of lactation after birth

2. secondary -- accumulation of excess milk

what is the clinical presentation of breast engorgement?

1. breast fullness and firmness leading to pain and tenderness

2. +/- areolar or peripheral involvement or both

how do you manage breast engorgement?

1. ensure good feeding techniques for adequate milk removal

2. warm compresses to increase milk let-down

3. NSAIDs or APAP for discomfort

what is the etiology of galactocele?

milk-retention cysts from inflammation/edema blocking th ducts via external pressure

what is the clinical presentation of galactocele?

1. cystic, large masses

2. usually painless unless infected

how can galactocele be distinguished from other breast masses?

US

3 multiple choice options

how can galactocele be confirmed?

aspiration

3 multiple choice options

how is galactocele managed?

1. needle aspiration

2. surgical excision if bothersome

what is the etiology of mastitis?

1. localized inflammation of the breast associated with breastfeeding

2. ductal narrowing leads to poor drainage and incomplete emptying, and organism proliferation and infection (S. aureus or Streptococcus)

what is the clinical presentation of mastitis?

1. swollen and tender region of the breast -- typically unilateral

2. +/- myalgias, chills, and flu-like symptoms

how is mastitis managed?

1. NSAIDs, cold compresses, and continued emptying of the breast

2. antibiotics x 5-7 days -- dicloxacillin or cephalexin if mild or IV vancomycin and ceftriaxone if severe

what can you obtain if a patient with mastitis does not respond to initial treatment?

1. culture

2. US

what is the etiology of a breast abscess?

1. often preceded by mastitis (S. aureus)

2. localized collection of pus within the breast tissue -- rare

what is the clinical presentation of a breast abscess?

1. similar to mastitis

2. mass is palpable, fluctuant, and tender

how is a breast abscess managed?

1. US-guided needle aspiration for drainage

2. antibiotics x 10-14 days -- dicloxacillin or cephalexin if mild or IV vancomycin and ceftriaxone if severe

can a patient with mastitis continue to breastfeed?

yes, as long as there is no direct contact with purulent drainage or an open infection

what is the postpartum period?

1. the "fourth trimester"

2. the time when physiologic changes from pregnancy return to a pre-pregnant state

what is the duration of the postpartum period?

1. there is no consensus on how long this period lasts

2. starts at the birth of the newborn

3. ends after 6-8 weeks of delivery, but ACOG says 12 weeks

when will most patients have a postpartum check with their OB?

4-6 weeks after delivery

when does shivering start postpartum?

within the first hour after giving birth

when does the process of uterus return to a non-pregnant state?

starts immediately after delivering placenta

the fundus should not be palpable on an abdominal exam by how many weeks postpartum?

2 weeks

what is lochia?

vaginal discharge after giving birth

what is diastasis recti and does it persist postpartum?

1. separation of the rectus abdominis muscles

2. +/- persist

why might hot flashes begin postpartum?

estrogen withdrawal after delivery may alter thermoregulation

if a patient is not breastfeeding, when will ovulation resume?

70% will resume by 12 weeks postpartum

if a patient is breastfeeding, when will ovulation resume?

40% will remain amenorrheic at 6 months postpartum

when does hair loss start postpartum?

1-5 months postpartum

when might hypertension present postpartum?

after hospital discharge

if a patient presents with hypertension after hospital discharge, when should blood pressure be monitored?

first week at home

how long does it take for a postpartum patient to return to a prothrombotic state?

weeks

when should a postpartum patient resume sexual activity?

wait until 6 weeks postpartum

when should contraception be discussed with a postpartum patient?

1. 3rd trimester

2. in the hospital

what is a permanent option for contraception?

bilateral salpingectomy (tubal ligation)