Unit 4 post birth

what baby only require routine newborn care

if born to term at 37 wks and above

what are the maternal risk of needed resuscitation

◦– extremes of maternal age, DM, HTN, substance abuse, hx stillbirth/fetal loss

fetal risk for needing resuscitation

◦congenital anomalies, intrauterine growth restriction, multiple gestations

delivery risk that they will need resuscitation

placental anomalies, breech presentation, chorioamnionitis, unplanned operative delivery

what happens the first few seconds after baby born

◦Dry the newborn

◦Clear airway of secretions if needed

◦Provide warmth

Quick clinical assessment to check muscle tone and respiratory effort

when is it okay to give baby to mom for skin to skin

• gestational age is 35

• good muscle tone

• newborn has strong respiratory drive (spontaneous breathing and crying)

what does skin to skin (kangaroo care) promote

◦Promotes infant-maternal bonding

◦Allows for early initiation of breastfeeding (if that’s the plan)

◦Has been shown to help stabilize newborn vital signs

◦Recommended by the American Academy of Pediatrics

how long to clamp the umbilical cord

• common to clamp 30-60 seconds after delivery (consider delayed)

• has been show to have hematologic benefits for the newborn (higher iron stores)

• reduced mortality rates in preterm newborns

CI for delayed clamping

• if mother or newborn is unstable and requires timely care

• id prenatal doppler studies documented abnormal umbilical artery flow

agar score

method to asses status of newborn soon after delivery and NOT used to determined need for resuscitation

when is agar score preformed

at 1 and 5 min

what does agar check

• HR

• RR

• muscle tone

• reflex irritability

• color

5 min agar acore should be

7 or above

is agar score is not 7 and above at five min

recheck in 10 min

Do not have to know apgar scoring but kow

that catagories and what is normal v not norm

pulse of a newborn should be

over 100pbm

third stage of delivery

time between delivery of the baby and delivery of the placenta

what are the hallmarks of separation of placenta from uterus

• lengthening of the cord

• gush of blood

• globular shaped uterus fundus on palpation

when does the expulsion of the placenta occur time wise

30 min -IF TAKES longer increase risk of hemorrhage

fourth stage is defined

as first 1-3 hours after placental expulsion, uterus begins process of involution, monitor for abnormal postpartum bleeding, asses for perineal lactation

transitional period of neonate care

4-6hrs after birth

when should clinical status of baby be asses

30-60 minutes

what are the parameters for clinical assessment

◦Temperature

◦Normal axillary temperature 97.7 to 99.5° F

◦Respiratory rate

◦Normal respiratory rate 40 to 60 breaths per minute

◦Heart rate

◦Normal HR 120 to 160 bpm

◦Color

◦Evaluate for central cyanosis (lips, tongue, trunk) which can indicate cardiac or respiratory disease

◦Tone

◦Evaluate for hypotonia

prophylaxis given to baby

Erythromycin ointment

• Prophylaxis against gonococcal conjunctivitis – recommended by USPSTF and CDC

• Applied within 2 hours of birth

 Vitamin K

• Prophylaxis against vitamin K deficient bleeding (VKDB)

• Vitamin K deficiency is common in newborns

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

• administered within 6 hours of birth

• Vitamin K1 given as single dose IM

what must you make sure the umbilical cord of baby

kept dry and monitor for signs of infections

hepatitis B vaccine

◦Initial dose previously recommended for all newborns

◦CDC now recommends individualized decision if mom has negative HBsAg

◦Universal vaccination still recommended by AAP/IDSA/WHO

RSV prophylaxis for baby

◦Nirservimab (Beyfortus) recommended for those born October – March if vaccine was not given during 3^rd trimester

◦Given IM as a single dose

when is baby first bath

6-24hrs

what test is given at the hospital

• hearing test- looking at response of inner ear or brain wave response

• blood spot: screening for endocrinopathies, immunodeficiencies, CF, hemoglobinopathies. typically collected 24 to 48hrs after birth

• bilirubin check: prior to discharge and asses for jaundice every 8-12 hrs

when should feedings be started

soon after birth

how frequent should feedings be done

frequent (on demand) to aviod hypoglycemia h

how many time to feed baby

8-12 feeds per day

is using formula

make sure it is fortified with iron and document all findings like volume wise

newborns - weight change

lose up to 10% of birth weight in the first few days any more weight loss should be evaluated

when does weight gain happen in new borns

regain weight by 2 wks of age

circumcision

◦Surgical removal of the foreskin of the penis

◦May be performed for religious, cultural, or medical reasons

◦Parents/caregivers must be properly educated and provide consent

◦Can be performed in the hospital or at pediatrician’s office

benefits of circumcision

◦UTIs

◦Penile cancer

◦STIs

◦Retractile disorders (phimosis/paraphimosis)

risk of circumcision

◦Inadequate/excessive skin removal

◦Bleeding

◦Infection

◦Urethral complications

◦Adhesions, increase sexual dissatisfaction

fundal checks

asses uterine tone and perineal checks to assess bleeding, performed every hour for the first 2 hrs and then every 4 hrs for first 24hrs

perineal care

◦Cold packs, Peri bottle, sitz baths, oral analgesics (acetaminophen, NSAIDs)

◦Stool softener and laxatives

when should CBC for mom be done

case by case based on blood loss and prenatal labs

vaccines for mother post birth

◦Can receive inactivated and live vaccines postpartum (during preg aviod live)

◦Depends on patient’s vaccination history

◦MMR and varicella should be given prior to discharge if patient is not immune

◦HPV for those 26 years of age or younger who have not completed series

◦Tdap if not given during pregnancy

infant criteria for discharge

◦Vital signs are in normal range and stable for at least 12 hours before discharge

◦Urinated and passed at least one stool

◦Completed at least two successful feedings

◦Screenings and other routine newborn care completed

mother criteria for discharge

◦Has demonstrated competency in care of the newborn (like they know how to hold baby)

◦Family/environmental/social risk factors have been assessed and addressed

◦Confirmation of proper use of car seat

what is the optimal source of nutrition

breast milk

what is the recommendation for breastfeeding

exclusive breastfeeding until 6 months of age

what can cause trouble with breastfeeding

• trouble with latching

• low milk supply

• pain and exhaustion

colostrum

milk produced first five days more nutritional due to baby small stomach

neurobehavioral benefits of breastfeeding

◦Appears to reduce crying and have an analgesic effect

◦Unclear if due to breastmilk vs. skin-to-skin contact

GI benefits of breastfeeding

◦Influences development of microbiota, decreases risk of gastroenteritis/diarrheal diseases

◦Stimulates GI growth and motility

prevention of illness benefits of breastmilk

◦Associated with fewer serious infections during first year of life

◦Lowers risk of respiratory disease, otitis media, and SIDS

dental benifits

◦Lower risk of developing dental caries

breast feeding decreases

◦Type 1 diabetes mellitus

◦Inflammatory bowel disease

◦Wheezing

lower rates of ADHD

postpartum bleeding and breastfeeding

◦If initiated soon after delivery helps uterus return to normal size more quickly

breastfeeding cause delay in

return of ovulation

what is breastfeeding a protective factor for

certain cancers: brest, ovarian, endomertrial

cardioprotective effects of breastfeeding

◦Reduced risk of hypertension, coronary heart disease, and stroke

how many calories does breastfeeding burn

500 per day

galactosemia

unable to process galactose (sugar found in breast milk) can cause vomiting diarrhea jaundice and failure to thrive

breast engorgement

◦Primary - from interstitial edema with onset of lactation after birth

◦Secondary - any accumulation of excess milk (mismatch between production and removal)

breast engorgement presentation

◦Breast fullness and firmness leading to pain and tenderness

◦May involve areolar or peripheral region or both

◦In primary cases tends to occur 3 to 5 days after birth – secondary can be anytime during lactation

management of breast engorgement

◦Ensure good feeding techniques (latch, position) for adequate milk removal

◦Can express small amount of milk immediately prior to feeding if latching is a problem

◦Warm compresses to increase milk let-down

◦Acetaminophen or NSAIDs for discomfort

galactocele

milk retention cyst from inflammation blocking ducts via external pressure

presentation of galactocele

◦Cystic, large masses but usually painless unless infected

◦US can be used to distinguish from other breast masses

◦Aspiration can confirm diagnosis

if galactocele painful

◦Needle aspiration or surgical excision can be pursued if bothersome

lactational mastitis

◦Localized inflammation of the breast associated with breastfeeding

◦Ductal narrowing leads to poor drainage and incomplete emptying, allows organisms to proliferate and can lead to infection (S. aureus or Streptococcus most common)

presentation of lactational mastitis

◦Swollen, red, and tender region of the breast (typically unilateral)

◦May develop systemic sx including myalgias, chills, and flu-like sx

◦Typically a clinical diagnosis – can obtain culture and/or US if no response to initial tx

management of lactational mastitis

◦If focal/mild inflammation – NSAIDs, cold compresses, continued emptying of the breast

◦Antibiotics – dicloxacillin or cephalexin x 5-7 days in mild cases, if severe (fever, hypotension) may need IV vancomycin and ceftriaxone

breast abscess

◦Localized collection of pus within breast tissue (rare)

◦Often preceded by mastitis (S. aureus most common)

presentation of breast abscess

◦a fluctuant, tender, palpable mass

management of breast abscess

◦US-guided needle aspiration for drainage

◦Antibiotics same as those given for mastitis (but x 10-14 days) – tailor to culture results if available

◦Can usually continue to breastfeed as long as there is no direct contact with purulent drainage or open infection

postpartum

starts at birth until the 6-8 wks

when is postpartum check

4-6 wks after delivery

shivering post partum

◦Typically starts and resolves within the first hour or two after giving birth

◦Cause is unknown and care is supportive (warm blankets)

uterine involution

◦Process of uterus returning to non-pregnant state – starts immediately after delivering placenta

◦Myometrial muscle constricts

◦Fundus recedes by ~1 cm/day for the first week

◦Should not be palpable on abdominal exam by 2 weeks postpartum

◦Returns to prepregnancy size by 6 to 8 weeks postpartum

lochia

◦Vaginal discharge after giving birth

◦Contains blood, mucus, and uterine tissue

◦Heavy at first and gradually lightens – should resolve around 4 to 6 weeks postpartum

cervix post-partum

• transverse cervical os- never resumes pregravid shape

• remains dilated 2 to 3 cm after a few days after birth

when should cervix be less than 1 cm '

by 1 wk postpartum

when should the uterus no longer be palpable

by 2 wks postpartum

vaginal and pelvic muscle changes

◦Vagina slowly contracts and rugae are restored as edema subsides by ~3 weeks postpartum

◦Relaxation of pelvic muscles may not return to prepregnancy state depending on trauma

abdominal wall postpartum

◦Regains muscular tone over several week period

◦Diastasis recti (separation of rectus abdominis muscles) may persist

hot flashes

◦Cause is unknown but estrogen withdrawal after delivery may alter thermoregulation

◦Resolves over time

when should ovulation resume is not breastfeeding

12 wks

when should ovulation resume is breastfeeding

can be amenorrheic at 6 months postpartum

skin and hair postpartum

◦Striae (stretch marks) start to fade

◦Hair loss (telogen effluvium) typically starts 1 to 5 months postpartum and resolves by a year

postpartum weight loss

◦Approximately half of the weight gained during pregnancy is lost in first 6 weeks postpartum

◦Slower rate of loss after that

cardiovascular system postpartum changes

◦Cardiac output rises soon after giving birth then gradually decreases

◦HTN can present after hospital discharge – BP should be monitored first week at home

hematological system

◦Labor-related leukocytosis can take several days to resolve

◦Other pregnancy-related changes return to baseline around 6 to 12 weeks

◦Prothrombotic state takes weeks to resolve

sexual activy postpartum

• wait 6 wks

• contraception should occur in 3rd trimester and again in the hospital

• if not breastfeeding can occur early as 3-4 wks

• if breastfeeding return of ovulation is less predictable

review the postpartum contraception options

when can IUD be placed

any time but may have higher expulsion

progestin only pills must

be taken at the EXACT same time every day

COPS may

increase VTE risk and decrease milk supply