Module 3 Postpartum-Newborn

reproductive system

Uterus

•Involution - shrink to umbilicus

•Lochia: (bleeding after delivery)

•Rubra (stage 1): deep-red mixture of mucus, tissue debris, and blood

•Serosa (stage 2): pinkish brown containing leukocytes, decidual tissue, RBCs, and serous fluid

•Alba (stage 3): creamy white or light brown

•Afterpains : uterine contractions

Cervix - returns to pre pregnant state but never completely like pre pregnancy

•Vagina - will return to normal but will be slightly larger

•Perineum: encourage pelvic floor muscle training

cardiovascular system

•Blood volume and cardiac output

•Hematocrit level rises slightly within the next 2 weeks after birth

•Pulse rate and blood pressure

•Coagulation factors elevated up to 2-3 weeks postpartum

•Red blood cell production: Ceases in early postpartum in the first 24 hours postpartum

urinary system

•Glomerular filtration rate and renal flow: Usually returns to normal in 6 wks PP

•Voiding sensation affected by:

•Perineal lacerations

•Generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus

•Hematomas

•Decreased bladder tone due to regional anesthesia

•Diminished sensation of bladder pressure due to swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor

GI system

•The GI system quickly returns to normal

•Relief of pressure on organs

•Decreased bowel tones for several days

•Decreased peristalsis occurs: Response to pain meds, surgery, insufficient fluid intake

•Constipation is common due to fear of straining affecting the perineum

•Hunger and thirst occur due to NPO status prior to delivery

musculoskeletal system

•Joints return to prepregnant state except for feet

•Women commonly experience fatigue and activity intolerance for weeks after giving birth

•Abdominal muscle tone is diminished after birth and special exercises are needed to return to normal

integumentary system

•Pigmentation fades

•Stretch marks fade to silvery lines

•Diaphoresis is common for about a week postpartum

respiratory system

•Tidal volume, minute volume, vital capacity, and functional residual capacity return to prepregnant values within 1 to 3 weeks of birth

•Anatomic changes reside quickly

endocrine system

•Estrogen and progesterone levels drop quickly

•Placental hormones decline rapidly

•Prolactin levels decline within 2 weeks if not breast-feeding

lactation

•Secretion of milk by the breasts

•Result of interaction of progesterone, estrogen, prolactin, and oxytocin

•Typically appearing 4 to 5 days after childbirth

engorgement

•Process of swelling of the breast tissue due to an increase in blood and lymph supply as a precursor to lactation

ovulation and return of menstruation

•Interplay of hormones: estrogen, progesterone, prolactin, and oxytocin

•Nonlactating women: return of menstruation 7 to 9 weeks after birth

•Lactating women: return dependent on breast-feeding frequency and duration; anywhere from 2 to 18 months

typical assessments in postpartum period

•During the first hour: every 15 minutes

•During the second hour: every 30 minutes

•During the first 24 hours: every 4 hours

•After 24 hours: every 8 hours

physical assessment postpartum period

•Breasts (size, contour, engorgement)

•Uterus (height of fundus, firmness)

•Bladder (voiding, bladder emptying)

•Bowels (bowel sounds, distention)

•Lochia (amount, color, odor)

•Episiotomy and perineum (lacerations, hematoma)

•Extremities

•Emotional status

teach for feeding: breast

•Frequency 2-3 hours

•Volume (10-20 minutes on each breast)

•Colostrum

•Positioning

•LATCH

•Let down

•"Nipple confusion"

•Pumping and storage

teach for feeding: bottle

•Frequency 3-4 hours (6 feedings daily)

•Volume - 2 to 4 oz

•Preparation of equipment

•Preparation of formula

•Positioning

•Don't prop

•Discard unused after 1 hour

discharge

•Afebrile

•Lochia appropriate

•Uterus fundus firm

•Mother can ambulate w/o difficulty

•Teaching

•Providing immunizations: Rubella, Flu

•Ensuring follow-up care: Telephone follow-up: during the first week after discharge, Outpatient follow-up, Home visit follow-up: within the first week after discharge

bonding

•Close emotional attraction to a newborn by the parents that develops the first 30 to 60 minutes after birth

•Unidirectional, from parent to infant

attachment

•Development of a strong affection between an infant and a significant other (mother, father, sibling, caretaker)

Reva Rubin's 3 phases

•Taking-in phase: time immediately after birth; they feel they need others to help relieve them; reliving birthing process; needy; 24-28 hr after birth

•Taking-hold phase: independent; 2-3 day after

•Letting-go phase: reestablishes herself; moves forward with parenteral role

4 stages of becoming a mother

•Commitment, attachment to unborn baby, preparation for delivery and motherhood during pregnancy

•Acquaintance/attachment to infant, learning to care for infant, and physical restoration 2 to 6 weeks post birth

•Moving toward a new normal

•Achievement of a maternal identity through redefining self to incorporate motherhood (around 4 months)

partner psychological adaptation

Engrossment behaviors

•Visual awareness of the newborn

•Tactile awareness of the newborn

•Perception of the newborn as perfect

•Strong attraction to the newborn

•Awareness of distinct features of the newborn

•Extreme elation by the father

•Increased sense of self-esteem

Three-Stage Role Development Process

•Expectations

•Reality

•Transition to mastery

contraception: behavioral methods

•Abstinence

•Fertility awareness

•Cervical mucus ovulation method

•Basal body temperature

•Symptothermal method

•Standard days method

•Withdrawal (coitus interruptus)

•Lactational amenorrhea method

contraception: barrier methods

•Condoms

•Diaphragm

•Cervical cap

•Contraceptive sponge

contraception: hormonal methods

•Oral contraceptives

•Injectable contraceptives

•Transdermal patches

•Vaginal rings

•Implantable contraceptives

•Intrauterine contraceptives

•Emergency contraception

contraception: sterilization

Tubal ligation

•Sterilization for women

•A laprascope is inserted; fallopian tubes are grasped and sealed

Vasectomy

•Sterilization for men

•Usually performed under local anesthesia

•Involves cutting the vas deferens, which carries the sperm

postpartum hemorrhage

Patho

•Tone: uterine atony, distended bladder

•Tissue: retained placenta and clots

•Trauma: vaginal, cervical, or uterine injury

•Thrombin: coagulopathy (pre-existing or acquired)

•Traction: uterine inversion

Assess

•Risk factors: Overdistention (multiple gestation, macrosomia), Hydramnios, Fetal abnormality, Placenta previa, Precipitous birth, Retained placental fragments

•Uterine tone

•Vaginal bleeding

Management

•Uterine massage

•Pad count

•Removal of retained placental fragments

•Administration of uterotonic

•Fluid administration

•Antibiotics for infection

•Repair of lacerations

•Monitoring for s/s of shock

•Emergency measures if DIC occurs

subinvolution

•Incomplete involution of uterus after birth (failure to return to its normal size)

•Causes: Retained placental fragments, distended bladder, uterine myoma, infection

•Complications: Hemorrhage, pelvic peritonitis, salpingitis, abscess formation

•Presentation: Fundal height will be higher than expected with boggy uterus, Lochia fails to change within a few weeks

thromboembolic conditions

•Inflammation of blood vessel lining

•Usually highest risk during 1st 3 weeks after birth

•Three most common types

•Superficial thrombosis: Usually confined to the saphenous vein in lower leg

•Deep vein thrombosis: Most common, May cause pulmonary embolism

•PE: Leading cause of pregnancy related deaths, Chest pain, Breathlessness, Sudden death

•Pathophysiology: Venous stasis (Injury to innermost layer of blood vessel), Hypercoagulation (Related to pregnancy)

•Nursing assessment

•Risk factors: Oral contraceptive usage before pregnancy, Smoking, Prolonged standing, Hx of thrombosis, Evidence of current varicosities

•Signs and symptoms: Pain or tenderness in lower extremities

•Nursing management: Prevention, Adequate circulation: NSAIDs, bed rest, antiembolism stockings, anticoagulant therapy(heparin); emergency measures for pulmonary embolism, Education

postpartum infections

•Fever >38°C or 100.4°F after first 24 hours of birth

•Higher occurrence in c/s than vaginal births

•Organisms usually those of normal vaginal flora (aerobic and anaerobic): Staphylococcus aureus, E. coli, Klebsiella, Chlamydia

•Metritis: infection of endometrium, decidua, and adjacent myometrium

•Wound infections: Episiotomy, c/s incision

•Urinary tract infections

•Mastitis: inflammation of the breast: May occur 2 days to 2 weeks postpartum

Therapeutic management:

•Broad-spectrum antibiotics for "metritis"

•Wound care for wound infections

•Fluids and antibiotics for UTIs

•Breast emptying and antibiotics for mastitis

Assess: REEDA (redness, edema, ecchymosis, discharge, approximation)

postpartum blues

•Emotional lability

•Irritability

•Insomnia

•Tearfulness

•Increase sensitivity

•Typically peaks day 4-5 and resolves within 2 weeks (by postpartum day 10)

•Usually self-limiting

postpartum depression

•Major depressive episode associated with childbirth

•Early detection is crucial

•Symptoms lasting beyond 6 weeks and worsening

•Guilt

•Overwhelm

•Sadness

•Cry a lot

•Feel negatively toward baby

•Lack interest in her baby

•Worry about hurting the baby

postpartum psychosis

•Surfaces within 3 weeks of giving birth, but can occur any time in the 1st year postpartum

Severe end of postpartum emotion disorders:

•Can be hospitalized for several months

•Psychotrophic drugs

•psychotherapy

Emergency psychiatric condition:

•Risk for suicide

•Sleep disturbances

•Fatigue

•Depression

•Hypomania

newborn: cardiovascular

•Switch from fetal to newborn circulation

•Change from placental to pulmonary gas exchange

•Physical forces leading to increased release of catecholamines critical for changes involved in transition to extrauterine life

•Changes in fetal structures: foramen ovale, ductus arteriosus, ductus venosus, umbilical arteries and vein

•Heart rate

•Blood volume

•Blood components

newborn: respiratory

•Initiation of respirations: adjusting from a fluid-filled intrauterine environment to gaseous extrauterine environment

•Role of surfactant: surface tension reducing lipoprotein that prevents alveolar collapse

•Respirations: 30-60 breaths/minute; irregular, shallow, unlabored; short periods of apnea (<15 sec); symmetrical chest movements

thermoregulation

Characteristics Predisposing Newborn to Heat Loss

•Thin skin; blood vessels close to the surface

•Lack of shivering ability; limited stores of metabolic substrates (glucose, glycogen, fat)

•Limited use of voluntary muscle activity

•Large body surface area relative to body weight

•Lack of subcutaneous fat; little ability to conserve heat by changing posture

•No ability to adjust own clothing or blankets to achieve warmth

•Infants cannot communicate that they are too cold or too warm

newborn: hepatic

•Iron storage

•Carbohydrate metabolism

•Bilirubin conjugation

•Three groups of jaundice based on mechanism of accumulation of bilirubin

•Overproduction (ABO incompatibility, trauma at birth, delayed cord clamping)

•Decreased conjugation (hypothyroidism, physiologic jaundice, breast feeding)

•Impaired excretion (hepatitis, Turner syndrome, biliary obstruction)

newborn: GI

intestine/gut still immature, meconial has amniotic fluid (greenish/black color; passes 24 hr)

newborn: renal

should have 6-8 voids

newborn: immune

protected from certain infections due to mom's antibodies, protected up to 6 months, develop their own 2-3 months

newborn: neurologic

•Hearing - well developed at birth, responds to noise by turning to sound

•Taste - ability to distinguish between sweet and sour by 72 hours old

•Smell - ability to distinguish between mother's breast milk and breast milk from others

•Touch - sensitivity to pain, responds to tactile stimuli

•Vision - incomplete at birth

behavioral patterns of newborns

First period of reactivity

•Birth to 30 minutes to 2 hours after birth

•Newborn is alert, moving, may appear hungry

Period of decreased responsiveness

•30 minutes to 120 minutes old

•Period of sleep or decreased activity

Second period of reactivity

•2 to 8 hours

•Newborn awakens and shows an interest in stimuli

newborn behavioral responses

•Orientation: response to stimuli, more alert

•Habituation: ability to process and respond to auditory and visual stimuli; ability to block out external stimuli after newborn has become used to activity

•Motor maturity: ability to control movements

•Self-quieting ability: consolability

•Social behaviors: cuddling and snuggling

caput succedaneum

involves the collection of serous fluid and often crosses the suture line

cephalhematoma

involves the collection of blood and does not cross the suture line

vermix caseosa

thick white substance that protects the skin of the fetus

stork bites/salmon patches

red patch on skin; caused by concentration of blood vessels (considered normal; disappears within first yr)

milia

multiple pearly white or pale yellow unopened sebaceous glands

mongolian spots

benign blue or purple splotches

erythema toxicum

generalized rash

harlequin sign

dilation of blood vessels on one side of body; lasts 20 min

nevus flammeus, port wine stain

Reddish usually flat discoloration; associated with childhood cancer

nevus vasculosus

Rough, red collection of capillaries with a raised surface

selected screening for newborns

•PKU

•Congenital hypothyroidism: Deficiency of thyroid hormone necessary for brain growth, 4-6 days of life

•Galactosemia: Absence of enzyme to convert milk sugar galactose to glucose, Discharge and follow up within 1 week

•Sickle cell anemia: Anemia develops shortly after birth

nursing interventions for transient tachypnea

•Providing oxygen

•Ensuring warmth

•Observing respiratory status frequently

•Allowing time for pulmonary capillaries and the lymphatics to remove the remaining fluid

LGA

•weight >4,000 grams (8 lb 13 oz) or >90th %

SGA

•weight <2,500 grams (5 lb 8 oz) or <10th %

•Low birth weight (LBW): weighing <2,500 grams or 5.5 lb

•Very low birth weight (VLBW): weighing <1,500 grams or 3 lb 5 oz

•Extremely low birth weight (ELBW): weighing <1,000 grams or 2 lb 3 oz

SGA

Contributing factors

•Maternal

•Nutrition (extreme stress, low socioeconomic status, <20yo or >34yo)

•Disease (autoimmune diseases, sickle cell anemia)

•Environmental factors - exposure (smoking, substance abuse)

•Placental function

•Placenta previa

•Placental insufficiency

•Fetal factors

•Genetic (Turner syndrome, trisomies 13, 18, 21)

•multiples

SGA

•Head disproportionately large compared to rest of body

•Wasted appearance of extremities; loose dry skin

•Reduced subcutaneous fat stores

•Decreased amount of breast tissue

•Scaphoid abdomen (sunken appearance)

•Wide skull sutures

•Poor muscle tone over buttocks and cheeks

•Thin umbilical cord

SGA

common problems

•Perinatal asphyxia

•Difficulty with thermoregulation

•Hypoglycemia

•Polycythemia

•not uncommon and is a potentially serious disorder of newborns

•Meconium aspiration

•Hyperbilirubinemia

•Birth trauma

LGA

risk factors

•Maternal diabetes mellitus or glucose intolerance

•Multiparity

•Prior history of a macrosomic infant

•Post-dates gestation

•Maternal obesity

•Male fetus

•Genetics

LGA

characteristics

•Large body, plump, full-faced

•Proportional increase in body size

•Poor motor skills

•Difficulty regulating behavioral states

LGA

common problems

•Birth trauma

•fractured clavicles, brachial palsy, facial paralysis, phrenic nerve palsy, skull fractures, or hematomas

•Hypoglycemia

•blood glucose value below 40 mg/dL

•Polycythemia

•Hyperbilirubinemia

LGA

management

•Vital sign monitoring

•Blood glucose level monitoring

•Initiation of oral feedings with IV glucose supplementation as needed

•Continued monitoring for signs and symptoms of polycythemia and hypoglycemia

•Hydration

•Phototherapy for increased bilirubin levels

preterm

etiology

•Infections/inflammation: genital and urinary tracts and fetal membranes

•Maternal or fetal distress: insufficient blood flow from the placenta

•Bleeding: problems such as placental abruption

•Stretching: Multiple fetuses, excessive amniotic fluid, uterine or placental abnormalities

preterm

body systems

•Respiratory system: one of the last body systems to mature

•Cardiovascular system: Difficulty of fetal to newborn circulation pattern

•GI system: lack the neuromuscular coordination required to maintain the sucking, swallowing

•Renal system: immature, reducing the baby's ability to concentrate urine and slowing the glomerular filtration rate

•Immune system: immune system is immature, increasing their susceptibility to infections

•Central nervous system: susceptible to injury and insult to the CNS

preterm

characteristics

•Weight <5.5 lb

•Scrawny appearance

•Poor muscle tone

•Minimal subcutaneous fat

•Undescended testes

•Plentiful lanugo

•Poorly formed ear pinna

•Fused eyelids

•Soft spongy skull bones

•Matted scalp hair

•Absent to few creases in soles and palms

•Minimal scrotal rugae; prominent labia and clitoris

•Thin transparent skin

•Abundant vernix

preterm

common problems

•Hypothermia

•Hypoglycemia

•Hyperbilirubinemia

•Problems related to immaturity of body systems

preterm

management

•Oxygenation

•Thermal regulation

•Nutrition and fluid balance

•Infection prevention: Monitor for changes in vital signs such as temperature instability, tachycardia, or tachypnea

•Stimulation: Touch, singing

•Pain management

•Growth and development

•Parental support: high-risk status; possible perinatal loss

•Discharge preparation

postterm

•Inability of placenta to provide adequate oxygen and nutrients to fetus after 42 weeks

•Nursing Assessment: Typical characteristics

•Dry, cracked, wrinkled skin; possibly meconium-stained

•Long, thin extremities; long nails; creases cover entire soles of feet

•Wide-eyed, alert expression

•Abundant hair on scalp

•Thin umbilical cord

•Limited vernix and lanugo

postterm

common problems

•Perinatal asphyxia

•Hypoglycemia

•Hypothermia

•Polycythemia

•Meconium aspiration

postterm

management

•Resuscitation

•Blood glucose level monitoring

•Initiation of feedings; IV dextrose 10%

•Prevention of heat loss

•Evaluation for polycythemia

•Parental support

acquired d/o

•Typically occur at, or soon after, birth

•Problems or conditions experienced by the woman during her pregnancy or at birth

•Possibly no identifiable cause for the disorder

congenital d/o

•Present at birth; usually due to some type of malformation occurring during the antepartal period; typically some problem with inheritance

•Majority with a complex etiology

neonatal asphyxia

•Failure to establish adequate, sustained respirations after birth

•Pathophysiology: insufficient oxygen delivery to meet metabolic demands

•Nursing Assessment: risk factors, newborn's color, work of breathing, heart rate, temperature, Apgar scores

•Nursing Management: immediate resuscitation, continued observation, neutral thermal environment, blood glucose levels, parental support and education

transient tachpnea

•Mild respiratory distress; pulmonary liquid removed slowly or incompletely; resolution by 72 hours of age

•Nursing Assessment

•Maternal sedation or birth by cesarean; tachypnea, expiratory grunting, retractions, labored breathing, nasal flaring and mild cyanosis; respiratory rates possibly 100 to 140; barrel-shaped chest; slightly ↓ breath sounds

•Chest x-ray: mild symmetric lung overaeration; prominent perihilar interstitial marks and streaks

•Nursing Management

•Oxygenation

•Supportive care

•IV fluids or gavage feedings

•Supplemental oxygen

•Neutral thermal environment

respiratory distress syndrome (RDS)

•Lung immaturity and lack of alveolar surfactant

•Nursing Assessment

•Respirations

•HR

•Nursing Management

•Monitoring

meconium aspiration syndrome

•Inhalation of particulate meconium with amniotic fluid into lungs; secondary to hypoxic stress

•Nursing Assessment

•Risk factors

•Nursing Management

•Adequate tissue perfusion

•Parental support and education

necrotizing enterocolitis (NEC)

•3 pathologic mechanisms: bowel ischemia, bacterial flora, and effect of feeding

•Nursing Assessment

•Risk factors

•Nursing Management

•Maintenance of fluid and nutritional status

•Bowel rest and antibiotic therapy; IV fluids

•Surgery with proximal enterostomy

•Supportive care

•Family education

infants of diabetic mothers

•High levels of maternal glucose crossing placenta, stimulating increased fetal insulin production leading to somatic fetal growth

•Nursing Assessment

•Mother with diabetes

•Full rosy cheeks, ruddy skin color, short neck, buffalo hump, massive shoulders, distended upper abdomen, excessive subcutaneous fat tissue hypoglycemia, birth trauma

•Hypocalcemia, hypomagnesemia, polycythemia, hyperbilirubinemia

•Nursing Management

•Prevention of hypoglycemia (oral feedings, neutral thermal environment, rest periods)

•Maintenance of fluid and electrolyte balance (calcium level monitoring, fluid therapy, bilirubin level monitoring)

•Parental support and education

newborns of substance abusing mothers

•Most common substances: tobacco, alcohol, and marijuana

•Fetal alcohol syndrome: physical and mental disorders appearing at birth and remaining problematic throughout the child's life

•Fetal alcohol spectrum disorders

•Alcohol-related birth defects

•Neonatal abstinence syndrome: drug dependency acquired in utero manifested by neurologic and physical behaviors

•Nursing Assessment

•Maternal history; risk behaviors, toxicology

•Newborn behaviors; WITHDRAWAL assessment

•Nursing Management

•Comfort promotion; stimuli reduction

•Nutrition

•Prevention of complications

•Decrease environmental stimulation

•Parent-newborn interaction

birth trauma

•Injuries due to the forces of labor and birth

•Types: fractures, brachial plexus injury, cranial nerve trauma, head trauma (cephalhematoma, caput succedaneum)

•Nursing Assessment

•Risk factors

•Physical and neurologic assessment: bruising, bumps, swelling, paralysis, symmetry of structure and function

•Nursing Management

•Supportive

•Assessment for resolution or complications

•Support and education

•Realistic appraisal of situation

•Community referral for ongoing follow-up and care

hyperbilirubinemia

•Imbalance in rate of bilirubin production and elimination; total serum bilirubin level >5 mg/dL

•Physiologic jaundice (3rd to 4th day of life)

•Early-onset breast-feeding jaundice

•Late-onset breast-feeding jaundice

•Pathologic jaundice (within first 24 hours of life)

•Kernicterus

•Rh isoimmunization

•ABO incompatibility

•Nursing Assessment

•Risk factors

•Jaundice

•Signs of Rh incompatibility

•Bilirubin levels

•Nursing Management

•Reduction of bilirubin levels: early feeding, phototherapy, exchange transfusions

Educationandsupport;homephototherapy