Womens health exam 4 - L1

What type of newborn care do most full term and early term (>37 wks gestation) newborns require?

routine

What newborns are at increased risk of needing resuscitation?

Newborns with maternal, fetal, or antepartum/delivery risk factors

Maternal risk factors for neonatal resuscitation

- Extremes of maternal age

- diabetes

- HTN

- substance abuse

- history of stillbirth/fetal loss

Fetal risk factors for neonatal resuscitation

- Congenital anomalies

- IUGR

- multiple gestations

Antepartum/delivery risk factors for neonatal resuscitation

- Placental anomalies

- breech presentation

- chorioamnionitis

- unplanned operative delivery

What are the immediate steps in newborn management?

- Dry newborn

- clear airway secretions if needed

- provide warmth

- quickly assess muscle tone and respiratory effort

When can a newborn be placed skin-to-skin with the mother?

Gestational age ≥35 weeks + good muscle tone + strong respiratory drive with spontaneous breathing/crying

Benefits of skin-to-skin contact

- Promotes bonding

- allows early breastfeeding

- helps stabilize newborn vital signs

When is the umbilical cord commonly clamped?

30-60 seconds after delivery

Benefits of delayed cord clamping

Higher newborn iron stores and reduced mortality in preterm newborns

Contraindications to delayed cord clamping

Mother/newborn unstable and needs timely care OR prenatal Doppler showed abnormal umbilical artery flow

What is the purpose of the Apgar score?

Assess newborn status soon after delivery and identify newborns needing further evaluation/management. Not used to determine need for resuscitation.

When is the Apgar score performed?

1 minute and 5 minutes after birth

What are the 5 Apgar categories?

- Heart rate

- respiratory effort

- muscle tone

- reflex irritability

- color

What should the 5-minute Apgar score be?

≥7

What happens if the 5-minute Apgar score is

Repeat assessment at 10 minutes

What is the third stage of labor?

Interval between delivery of the baby and delivery of the placenta

What are the hallmarks of separation of placenta from the uterus?

- Gush of vaginal blood

- lengthening of umbilical cord

- globular-shaped uterine fundus

How quickly is the placenta normally expelled?

Within 30 minutes

Why is placental delivery >30 minutes concerning?

Increased risk of postpartum hemorrhage and may indicate need for manual removal

What is the fourth stage of labor?

First 1-2 hours after placental expulsion

What occurs during the fourth stage?

- Uterine involution begins

- monitor for abnormal postpartum bleeding

- assess/repair perineal lacerations

What is the neonatal transitional period?

First 4-6 hours after birth

What physiologic changes occur during the transitional period of neonatal care?

- vascular resistance in the lungs decrease after initial breaths

- increased blood flow to lungs and lung expansion

- flap of foramen ovale closes and ductus arteriosus starts to constrict

How often should the newborn be assessed during the transitional period?

Every 30-60 minutes

Normal newborn axillary temperature

97.7-99.5°F

Normal newborn respiratory rate

40-60 breaths/min

Normal newborn heart rate

120-160 bpm

What color is evaluated for in the newborn?

Central cyanosis

What is central cyanosis?

cyanosis involving the lips, tongue, or trunk. may indicate cardiac or respiratory disease

What abnormality of tone should be assessed for in a newborn?

Hypotonia

Why is erythromycin ophthalmic ointment given to newborns?

Prophylaxis against gonococcal conjunctivitis. applied within 2 hours of birth

Why is vitamin K given to newborns?

- Prevents vitamin K deficiency bleeding (VKDB)

- VKDB can cause umbilical/circumcision bleeding or more significant GI/intracranial bleeding.

How is vitamin K given to newborns?

Single IM dose within 6 hours of birth

How should the newborn umbilical cord be cared for?

Keep dry and monitor for omphalitis

What is omphalitis?

Infection/inflammation of the umbilical stump

When is nirsevimab (Beyfortus) recommended?

For those born October-March if maternal RSV vaccine was not given during the 3rd trimester. given as a single IM dose

When is the newborn's first bath typically performed?

6-24 hours after birth

When is the newborn hearing test performed?

Prior to discharge

When is the newborn blood spot screening panel collected?

24-48 hours after birth

What does the newborn blood spot screening panel screen for?

Variety of disorders such as Endocrinopathies, immunodeficiencies, hemoglobinopathies, and cystic fibrosis

When should bilirubin be checked?

Prior to discharge, earlier if high-risk or signs of jaundice. Assess for jaundice every 8-12 hours

How often should a newborn feed?

- Feedings should be frequent (on demand) to avoid hypoglycemia

- 8-12 feeds/day, roughly every 2-3 hours (should exceed 4 hours)

- if BF, should be fed as soon as possible after delivery

- if using formula, should be fortified with iron

- document all feedings (time, duration/volume)

How much birth weight can a newborn normally lose during the first few days?

Up to 10%

When should a newborn regain birth weight?

By approximately 2 weeks of age

When should newborn weight loss be evaluated?

>10% of birth weight

Management of excessive newborn weight loss

Feeding assessment with lactation consultant/dietician, consider expressed breast milk or formula supplementation

Benefits of circumcision

Reduced UTIs, penile cancer, STIs, and retractile disorders such as phimosis/paraphimosis; easier hygiene

Risks of circumcision

procedure complications, sexual dissatisfaction

what procedure complications can occur with circumcision?

- inadequate/excessive skin removal

- bleeding

- infection

- urethral complications

- adhesions

How often are postpartum fundal and perineal checks performed?

Every hour for first 2 hours, then every 4 hours for first 24 hours

What is included in postpartum perineal care?

Cold packs; peri bottle; sitz baths; acetaminophen/NSAIDs; stool softeners/laxatives

What vaccines can be given postpartum?

Both inactivated and live vaccines

What vaccines should be given before discharge if the patient is not immune?

MMR and varicella

When should Tdap be given postpartum?

If it was not given during pregnancy

Infant discharge criteria

No abnormality requiring hospitalization; stable normal vital signs ≥12 hours; urinated and passed ≥1 stool; ≥2 successful feedings; routine screenings/care completed

Maternal discharge criteria

Labs reviewed/follow-up arranged; competent in newborn care; social/environmental risks addressed; proper car-seat use confirmed

How long is exclusive breastfeeding recommended?

Until 6 months of age

What does breast milk contain?

Macro- and micronutrients, growth factors, and immunoprotective substances

What is colostrum?

Early yellowish breast milk with high protein content

When is colostrum present?

Approximately first 2-5 days after delivery

Benefits of breastfeeding for infant GI function

Helps develop microbiota; decreases gastroenteritis/diarrheal disease; stimulates GI growth and motility

What infections/conditions are reduced in breastfed infants?

Serious infections, respiratory disease, otitis media, and SIDS

Other potential infant benefits of breastfeeding

Lower dental caries; associations with reduced type 1 DM, IBD, wheezing, and ADHD

Maternal benefits of breastfeeding

Reduced postpartum blood loss; faster uterine involution; delayed ovulation; reduced breast/ovarian/endometrial cancer risk

Additional maternal benefits of breastfeeding

Reduced HTN, coronary heart disease and stroke; improved glucose control; associated with lower type 2 DM risk

Absolute infant contraindication to breastfeeding in the lecture

Galactosemia

Why is breastfeeding contraindicated in infant galactosemia?

Infant cannot process galactose found in breast milk

Maternal contraindications to breastfeeding

HIV without ART/confirmed viral suppression; illicit drug use; suspected/confirmed Ebola; active varicella; untreated active TB; monkeypox; active HSV lesion on breast

What causes primary breast engorgement?

Interstitial edema associated with onset of lactation after birth

What causes secondary breast engorgement?

Excess milk accumulation due to mismatch between milk production and removal

Presentation of breast engorgement

Breast fullness and firmness causing pain/tenderness

When does primary breast engorgement usually occur?

3-5 days after birth

Management of breast engorgement

Good latch/position and milk removal; express small amount before feeding if needed; warm compresses; acetaminophen or NSAIDs

What is a galactocele?

Milk retention cyst caused by inflammation/edema blocking a duct

Presentation of galactocele

Large cystic breast mass; usually painless unless infected

How is a galactocele evaluated?

Ultrasound can distinguish it from other masses; aspiration can confirm diagnosis

Management of bothersome galactocele

Needle aspiration or surgical excision

What is lactational mastitis?

Localized breast inflammation associated with breastfeeding

Pathophysiology of lactational mastitis

Ductal narrowing → poor drainage/incomplete emptying → organisms proliferate → possible infection

Most common organisms associated with lactational mastitis

S. aureus or Streptococcus

Presentation of lactational mastitis

Usually unilateral swollen, red, tender breast region; may have myalgias, chills, and flu-like symptoms

How is lactational mastitis usually diagnosed?

Clinically

When might culture or ultrasound be used for mastitis?

If there is no response to initial treatment

Management of mild/focal mastitis

NSAIDs, cold compresses, and continued breast emptying

Antibiotics for mild lactational mastitis

Dicloxacillin or cephalexin for 5-7 days

Treatment of severe mastitis with fever/hypotension

May require IV vancomycin and ceftriaxone

What is a breast abscess?

Localized collection of pus within breast tissue, often following mastitis

Most common organism associated with breast abscess

S. aureus

Presentation of breast abscess

Mastitis-like symptoms plus a fluctuant, tender, palpable mass

Management of breast abscess

Ultrasound-guided needle aspiration plus antibiotics for 10-14 days; tailor antibiotics to culture if available

Can breastfeeding usually continue with a breast abscess?

Yes, if there is no direct contact with purulent drainage or open infection

What is the puerperium?

Postpartum period/fourth trimester during which pregnancy-related physiologic changes return toward the prepregnant state

When does the puerperium begin?

At birth of the newborn

How long does the postpartum period last according to most literature?

Approximately 6-8 weeks; ACOG describes 12 weeks

When is the usual postpartum OB check?

4-6 weeks after delivery

Is postpartum shivering usually abnormal?

No; affects 25-50% and usually begins/resolves within the first 1-2 hours after birth

Management of normal postpartum shivering

Supportive care such as warm blankets

What is uterine involution?

Process of the uterus returning to its nonpregnant state

When does uterine involution begin?

Immediately after delivery of the placenta