N230 Exam #3 Study Guide

Postpartum Infection (also known as Puerperal Infection)

• any clinical infection of the genital tract that occurs within 28 days after miscarriage, induced abortion, or birth

• defined as presence of a fever of 100.4 degrees fahrenheit (38 degrees celsius) in the first 10 postpartum days (not including the first 24 hours after birth)

Endometritis (Endomyometritis) → Postpartum Infection

• most common postpartum infection

• infection of the lining of the uterus which causes fundal tenderness and fever

• caused by prolonged rupture of membranes or manual introduction of bacteria

• Not usually cultured, just treated

• managed with IV broad spectrum antibiotic therapy like gentamicin and clindamycin → treat for 24 hours afebrile

Wound Infections → Postpartum Infection

• develop after mothers are discharged home

• rates of wound infection after cesarean birth are 3-5%

• cellulitis/abscess of wound, laceration

Urinary Tract Infections → Postpartum Infection

• dysuria, burning, frequency, suprapubic pain

• get urinalysis

• foley, straight cath

• occur in 2-4% of postpartum women

Mastitis → Postpartum Infection

• usually staph aureus which is treated with antibiotics such as dicloxacillin or cephalexin

• causes fever, flu-like symptoms

Postpartum Hemorrhage Definition

• cumulative blood loss of greater than or equal to 1,000 mL

• bleeding associated with signs/symptoms of hypovolemia within 24 hours of birth

• leading cause of maternal morbidity and mortality

  • often unrecognized until mother has profound symptoms → early, acute or primary PPH occurs within 24 hours of birth

  • late or secondary PPH occurs more than 24 hours but less than 6 weeks after the birth

PPH Signs and Symptoms

• lightheadedness

• pallor

• diaphoresis

• altered mental status

• tachycardia

• hypotension

• restlessness

• tachypnea

Causes of PPH

• Tone: uterine atony (marked hypotonia of uterus) is most common

  • blood supply to the uterus to supply the placenta is cut off by myometrium contractions

  • risks: high parity, polyhydramnios (excessive amniotic fluid surrounding the fetus), macrosomia (large baby), uterine fatigue due to long labor, tocolytic drugs (used to stop or slow contractions)

• Trauma: lacerations of the genital tract (uterus, cervix, vagina, perineum) and hematomas

• Tissue: retained products of the placenta or a placental anomaly

• Thrombin: when there is no identifiable cause, think coagulopathy.

  • TXA is first line therapy

  • Von Willebrand is the most common inherited bledding disorder due to a missing clotting factor.

  • idiopathic or immune thrombocytopenic purpura (ITP)

• Subinvolution of the Uterus: causes late postpartum bleeding with signs and symptoms of prolonged lochial discharge, irregular or excessive bleeding, and sometimes hemorrhage

• Inversion of the Uterus: potentially life threatening but rare; occurs in 1 in 2000 to 1 in 25000 births.

Management of PPH

• uterine massage → call code and get help → hemorrhage cart → administer IV fluids and uterotonic medications (pitocin, methergine, hemabate, misoprostol) and TXA (antifibrinolytic) → empty bladder → physical pressure (jada) → surgery

Breastfeeding Positions

• football or clutch hold (under the arm) → recommended for early feedings and is particularly helpful for mothers who gave birth by cesarean section and late preterm and early term infants to avoid flexing the head, which can impede breathing and cause positional apnea

• across the lap (cross-cradle or modified cradle)

• cradle: the most common breastfeeding position for infants who have learned to latch easily and feed effectively

• side-lying → allows the mother to rest while breastfeeding and is recommended for women with perineal pain and swelling

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

Engorgement

• condition where the breasts become overfilled with milk, causing them to feel hard, warm, enlarged, shiny, and painful

• normal engorgement is not unusual in the first 24-48 hours after the breasts fill with milk

• occurs around 3 days after birth and with appropriate treatment resolves within 24 hours

• all postpartum women are at risk, not just those who are breastfeeding

• management for all women: icepacks and cabbage leaves, well-fitted support bra, anti-inflammatory medications

• management for breastfeeding women: feed frequently, hand expression or breast pump to reduce engorgement and promote comfort

• management for formula feeding women: do NOT express breast milk as it can stimulate milk production and worsen engorgement

Newborn Jaundice

• jaundice in newborns differs from adults because newborns produce bilirubin 2-2.5 times that of an adult. it occurs when bilirubin levels exceed 5mg/dL and is observed in 60% of term infants and 80% of preterm infants in the first week after birth

Physiologic Jaundice

• the most common type and is not associated with any pathologic process

• occurs due to the newborn’s immature liver function

• appears after 24 hours of age and peaks between 2-4 days and gradually decreases between days 5-7

Breastfeeding Related-Jaundice

Early Onset

• begins at 2-4 days of age

• related to poor latch or inadequate milk supply resulting in decreased caloric and fluid intake

• Increased enterohepatic circulation from delayed meconium passage

Late Onset

• occurs in up to 30% of breastfed infants

• bilirubin continues to rise while formula-fed infants’ levels around day 5

• peaks between 5-15 and may persist beyond 1 month, lasting up to 3 months

• safe condition - breastfeeding should NOT be discontinued

Pathologic Jaundice

• warning signs requiring investigation

  • jaundice appearing within 24 hours after birth

  • total serum bilirubin >15-17mg/dL in newborns

  • TSB increasing >5mg/dL during the newborn period

• risk factors include preeclampsia, maternal diabetes, ABO/Rh incompatibility, prematurity, delayed meconium passage, G6PD deficiency, infections, and birth trauma

Jaundice Treatment

• phototherapy (UVB light)

• absorbed through skin, causes photochemical reaction with bilirubin facilitating dissolution of it of excretion

• overhead lights, blanket

Fetal Loss Communication

Communicating With Bereaved Parents After Fetal Loss

Effective communication with families experiencing perinatal loss requires intentional presence, active listening, and avoiding common pitfalls.

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Core Principles

Validate and Listen:

• Acknowledge the loss with a simple but sincere "I am sorry"

• Encourage parents to tell their stories and listen with care

• Women who had a stillbirth or whose baby died may have a particularly strong need to share details about the birth

• Ask the father or partner directly about their views and feelings, as nurses often focus primarily on the mother

Therapeutic Presence:

• Have a presence of self and willingness to be alongside, quietly supporting the bereaved person

• Lean forward, nod, and use phrases like "Tell me more" to encourage sharing

• Sitting through silence can be therapeutic - it gives parents time to collect thoughts and process emotions

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What to Avoid

Resist unhelpful responses:

• Don't give advice or use clichés

• Don't try to reduce their pain with quick fixes - the initial impulse to say or do something to stop crying can actually stifle further expression of emotion

Be cautious with touch:

• Assess before using touch as a therapeutic technique

• For some it's meaningful; for others it's an invasion of privacy or contrary to cultural/religious beliefs

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Practical Considerations

Time allocation:

• Providing adequate care for grieving families is time-consuming

• Nurses may need adjusted shift assignments to give adequate attention without being rushed

Empowering decisions:

• Parents should make decisions about when and by whom nursery items are stored or given away

• Well-meaning relatives who rush to dismantle the nursery without involving parents can compound their grief

Address guilt:

• Women are particularly vulnerable to feelings of guilt and may wonder what they did to cause the loss

Neonatal Heat Loss

Newborns, especially preterm and low birth weight (LBW) infants, are highly vulnerable to heat loss due to several physiological factors.

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Why Newborns Lose Heat

Preterm infants face additional challenges:

• Smaller muscle mass and fewer brown fat deposits for heat production

• Lack of insulating subcutaneous fat

• Poor reflex control of skin capillaries

• Thin skin in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants

In VLBW and ELBW infants, heat loss from radiation, evaporation, and transepidermal water loss is three to five times greater than in larger infants.

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Four Mechanisms of Heat Loss

1. Radiation:

• Heat loss to cooler objects not in direct contact with the infant

• Example: Crib placed near a cold window or air conditioning unit cools the crib walls, which then cools the baby's body

• Prevention: Place cribs away from exterior walls, windows, and ventilating units

2. Conduction:

• Heat loss through direct contact with a cooler solid object

• Prevention: Place infant on padded, covered surfaces; use clothes and blankets for insulation

3. Convection:

• Heat loss aided by surrounding air currents

• Example: Placing infant in direct airflow from a fan or air conditioning vent

• Prevention: Transport in cribs with solid sides to reduce airflow

4. Evaporation:

• Heat loss through moisture evaporating from skin

• Particularly significant in preterm infants with increased transepidermal water loss 2

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Consequences of Cold Stress

For every 1°C temperature decrease from normal, mortality risk increases by 28%.

Cold stress produces 2:

1. Hypoxia

2. Pulmonary vasoconstriction

3. Metabolic acidosis

4. Hypoglycemia

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Prevention Strategies

• Skin-to-skin contact with parent immediately after birth if medically stable

• Prewarmed incubator

• Head coverings (fabric-insulated or wool caps)

• Heated gel mattress with radiant heat in delivery room

• Plastic wrap or heated humidified gas in delivery room

APGAR

Neonatal Head to Toe Assessment Findings

General Appearance

Posture: Term newborns exhibit complete flexion - head flexed with chin on chest, arms flexed with hands clenched, legs flexed at knees and hips with thighs on abdomen, and feet dorsiflexed. The vertebral column is also flexed.

Behavior: Assess alertness, drowsiness, and irritability, which may reflect neurologic problems.

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Neurologic System

Reflexes to assess:

• Grasp reflex: Touching palms or soles near digit base causes flexion/grasping

• Babinski reflex: Stroking outer sole upward causes big toe dorsiflex and other toes hyperextend

• Mass reflexes should be tested at exam end as they may disturb the infant

Document: Absence, asymmetry, persistence, or weakness of reflexes.

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Extremities

Digits:

• Count fingers and toes

• Note polydactyly (extra digits) or syndactyly (fused digits)

• Partial syndactyly between 2nd and 3rd toes is a common normal variation

Nails:

• Should be pink (slight blueness in acrocyanosis is normal)

• Yellowing may indicate intrauterine distress, postterm birth, or hemolytic disease

• Short/absent nails: preterm; Long nails: postterm

Palmar creases:

• Should have usual creases

• Transverse palmar crease (simian crease) suggests Down syndrome but may be normal

Sole creases:

• Full-term: creases cover entire sole

• Postterm: deep creases

• Preterm: partial or absent creases

• Soles are flat with prominent fat pads

Range of motion:

• Should demonstrate full ROM in elbow, hip, shoulder, and knee joints

• Movements should be symmetric, smooth, and unrestricted

• Absence of arm movement signals potential birth injury (Klumpke or Erb-Duchenne palsy)

• Asymmetric Moro reflex warrants upper extremity evaluation

Muscle tone:

• Extension of flexed extremity meets resistance and returns to flexed position when released

• Hypotonia suggests hypoxia, neurologic abnormalities, or Down syndrome

• Asymmetry may indicate paralysis from CNS damage

• Failure to move lower limbs suggests spinal cord lesion

Neonatal Hypoglycemia

Hypoglycemia is a blood glucose concentration inadequate to support neurologic, organ, and tissue function . It's particularly common in infants of diabetic mothers (IDMs), especially those who are macrosomic or large-for-gestational-age.

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Diagnostic Thresholds

Symptomatic infants - treat when glucose is <40 mg/dL with a goal to maintain prefeeding levels ≥45 mg/dL.

Asymptomatic infants - treat when glucose is:

• <25 mg/dL if <4 hours of life

• <35 mg/dL between 4-24 hours of life

General guidelines: Hypoglycemia is defined as glucose <40 mg/dL in the first 4 hours and <45 mg/dL once 4-24 hours of life.

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Pathophysiology in IDMs

In utero: High maternal glucose crosses the placenta, stimulating fetal pancreatic islet cell hypertrophy and hyperplasia, leading to hyperinsulinism. This causes excessive fetal growth and fat deposition (macrosomia).

At birth: Umbilical cord clamping abruptly removes the maternal glucose supply. The infant's continued high insulin production rapidly depletes circulating glucose, creating hypoglycemia within 0.5-4 hours (most commonly 1-6 hours) after birth.

High insulin levels also inhibit gluconeogenesis and glycogenolysis, further contributing to hypoglycemia.

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Clinical Presentation

Signs include:

• Jitteriness

• Apnea

• Tachypnea

• Hypotonia

• Decreased activity

• Cyanosis

• Seizures (in severe cases)

Many infants remain asymptomatic. Asymptomatic hypoglycemia is concerning and associated with increased risk of poor executive function and visual motor function.

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Management

Feeding:

• Begin breast milk or formula within the first hour if cardiorespiratory status is stable

• Avoid oral glucose - it can trigger massive insulin release causing rebound hypoglycemia

IV therapy:

• 10% dextrose and water (IV) for IDMs with poorly controlled maternal diabetes

• Goal: maintain serum glucose >45 mg/dL

Monitoring:

• Frequent blood glucose checks for first 2-4 days

• Use heel-stick glucometers for screening, confirm with laboratory testing

Neonatal Infections

Sepsis (septicemia) is a generalized bacterial infection in the bloodstream. Neonates are highly susceptible due to diminished immune function - impaired phagocytosis, delayed chemotactic response, minimal/absent IgA and IgM, and decreased complement levels.

Key challenge: Infants show no local inflammatory reaction at the infection portal, and symptoms are vague and nonspecific, delaying diagnosis and treatment. Therefore, maintain high suspicion for infection and begin antibiotics promptly when concerned.

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Early-Onset Sepsis (EOS)

Timing: Less than 3 days after birth

Acquisition: Perinatal period through:

• Direct contact with maternal GI/GU tract organisms

• Aspiration of infected amniotic fluid

• Transplacental transfer from maternal bloodstream

Common pathogens:

• Term infants: Group B streptococcus (GBS) - most common

• Preterm infants: Escherichia coli

• Others: Viridans streptococci, Listeria monocytogenes, enteroviruses, coagulase-negative Staphylococcus

• Vaginal pathogens: Syphilis, gonococci, Candida albicans, HSV type II, Chlamydia

Risk factors:

• Prolonged rupture of membranes

• Preterm labor (<37 weeks)

• Maternal intrauterine infection

• Maternal GBS colonization

Current rates: Despite maternal screening/prophylaxis, early-onset GBS infection remains at approximately 0.25 per 1000 live births.

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Late-Onset Sepsis (LOS)

Timing: After 72 hours up to 30 days of life

Sources: Maternally derived or health care-acquired infection

Common pathogens: Coagulase-negative staphylococci, Klebsiella, Enterobacter, E. coli, Candida species

Risk factors:

• Prematurity (most significant)

• Invasive procedures (intubation, catheterization, surgery)

• Infection entry through umbilical stump, skin, mucous membranes, or internal systems

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Treatment

Empiric antibiotic therapy initiated before lab confirmation:

• Early-onset sepsis: Ampicillin + aminoglycoside

• Late-onset sepsis: Vancomycin + aminoglycoside

• Narrow therapy to confirmed pathogen ASAP due to antibiotic-resistance concerns

Supportive care:

• Oxygen administration (if respiratory distress/hypoxia)

• Fluid regulation and electrolyte/acid-base correction

• Temporary NPO status (if septic ileus/NEC concern)

• Blood product transfusions (RBCs, platelets, FFP, cryoprecipitate)

• Vital sign monitoring and thermal regulation

Neonatal Skin Findings

Normal Skin Findings

Color changes:

• At birth: Skin may appear grayish-white with vernix caseosa (cheeselike mixture of sebum and desquamating cells) absorbed within 24-28 hours

• By day 2-3: Skin turns to natural tone, becomes drier and flakier

• Lanugo: Fine, downy hair on forehead, cheeks, shoulders, and back

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Benign Birthmarks

Slate grey nevi (previously called Mongolian spots/congenital dermal melanocytosis) and telangiectatic nevi require no therapy, only parental reassurance

Café-au-lait spots: Multiple light brown spots may indicate:

• Neurofibromatosis (autosomal dominant)

• McCune-Albright syndrome

• Warrants further examination of child and family members

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Erythema Toxicum Neonatorum

Description: Benign, self-limiting rash also called "flea-bite dermatitis" or "newborn rash"

Timing: Appears within first 2 days (up to day 10)

Appearance:

• Firm, 1-3 mm pale yellow or white papules/pustules on erythematous base

• Resembles flea bites

• May progress from discrete macular erythematous rash to papules/vesicles/pustules

Distribution: Face, proximal extremities, trunk, buttocks - anywhere except palms and soles (no pilosebaceous follicles there)

Characteristics:

• More obvious during crying

• No systemic manifestations

• Heals without pigmentation changes

• Lasts 5-7 days (resolves within weeks)

Diagnosis: Pustule smear shows numerous eosinophils, relative absence of neutrophils

Management:

• No treatment necessary

• Reassure parents of benign, transient nature

• Avoid topical treatments - may exacerbate condition

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Birth Trauma-Related Findings

Soft tissue injuries from delivery:

• Erythema, ecchymoses, petechiae

• Abrasions, lacerations, edema

• Localized discoloration over presenting/dependent parts

• Face presentation: bruising over face

• Breech presentation: bruising/swelling over buttocks and genitalia

• Tight nuchal cord: ecchymosis and petechiae over head/upper trunk/face

Benign if: Petechiae disappear within 2 days with no new lesions

Forceps injury: Linear configuration across both sides of face

Newborn Vital Signs

Heart Rate

Normal range: 120-160 beats/min

Variations:

• During deep sleep: 80-100 beats/min

• During crying: Up to 180 beats/min or higher

• At birth: Rates close to 200 beats/min may occur in neonates, decreasing rapidly to ~120 beats/min within hours

Assessment:

• Point of maximal impulse (PMI): Fourth to fifth intercostal space, medial to left midclavicular line

• Often visible and easily palpable due to thin chest wall

• Reevaluate if heart rate is >160 or <100 beats/min within 30 minutes to 1 hour

Abnormal findings:

• Sustained tachycardia: May indicate infection or cardiac rhythm disturbance (e.g., paroxysmal atrial contractions)

• Irregular heart rate/sinus dysrhythmia: Common in first few hours but may need evaluation thereafter

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Respiratory Rate

Normal range: 40-60 breaths/min

• Rate up to 80 breaths/min may be noted

Assessment: Count for 1 full minute

Variations:

• Infants delivered by cesarean section may have more rapid respiratory rate than vaginal deliveries

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Blood Pressure

Normal ranges:

• Systolic: 60-96 mm Hg

• Diastolic: 30-62 mm Hg

Alternative reference:

• Day 1: Average 65/45 mm Hg

• Day 4: Average 70/46 mm Hg

Assessment method:

• Electronic sphygmomanometer with Doppler or oscillometric technique (e.g., Dinamap)

• Cuff width-to-arm ratio: 0.45-0.70 (approximately half to three-quarters)

• Best measured when infant is quiet or sleeping

• Compare upper and lower extremities - should be equal

Abnormal findings:

• Sustained hypertension: May indicate thrombosis (umbilical artery catheter), coarctation of aorta, renal disorders, congenital adrenal hyperplasia, or CNS disease

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Additional Screening

Pulse oximetry: Recommended for all newborns after 24 hours of age to screen for critical congenital heart disease (CCHD)