N230 - Exam #3 Study Guide

Postpartum Complications

Postpartum infection

• Also called a puerperal infection

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

• Defined as the presence of a fever of 100.4 degrees F or 38 degrees C in the first 24 hours after birth

Endometritis (endomyometritis):

• Infection of the lining of the uterus

• Not endometriosis

• Most common puerperal infection

• Occurs in ~2% after vaginal birth, 10-15% after cesarean birth

• Highest incidence with cesarean birth after prolonged labor and membrane rupture

Signs & Symptoms:

• Fever (usually >38°C), increased pulse, chills

• Anorexia, nausea, fatigue, lethargy

• Pelvic pain, uterine tenderness

• Foul-smelling lochia

• Leukocytosis, elevated RBC sedimentation rate, possible anemia

Wound Infections:

• Common after cesarean birth (3-5% rate)

• Can develop in perineal lacerations or episiotomy sites

Signs & Symptoms:

• Fever, erythema, edema, warmth

• Tenderness, pain, seropurulent drainage

• Wound separation

Treatment

Endometritis:

• IV broad-spectrum antibiotics (clindamycin and gentamicin, cephalosporins, penicillins)

• Supportive care: hydration, rest, pain relief

• Antibiotics discontinued 24 hours after afebrile and asymptomatic

• Comfort measures: cool compresses, warm blankets, perineal care, sitz baths

Wound Infections:

• IV antibiotic therapy

• Wound opened and drained if pus or significant effusion present

• Irrigated with normal saline, redressed several times daily

• Wound vacuum device may be used

• Continued until wound base is clear without cellulitis signs

Nursing Care

Assessment:

• Frequent vital signs and temperature monitoring

• Lochia assessment

• Wound assessment and care

Patient Teaching:

• Hygienic care techniques: changing perineal pads, cleansing front to back, hand hygiene before/after perineal care

• Signs of infection and when to contact provider

• Side effects of therapy, prevention of infection spread

• Wound care and dressing changes for home

Support:

• Maintain mother-infant interactions and breastfeeding

• Home visits for wound assessment and teaching reinforcement

• Telephone follow-up and access to support resources

• S/S → fundal tenderness, febrile

• Causes → Prolonged rupture of membranes, manual introduction of bacteria

• Other reasons for fever/infection symptoms:

  • PE, DVT, pneumonia, flu/virus

  • Mastitis (treated w/ dicloxacillin, cephalexin)

  • Misoprostol can cause a transient fever, not too high and no other symptoms

Postpartum bleeding and hemorrhage

Definition

Postpartum hemorrhage (PPH) is an obstetric emergency and a leading cause of maternal morbidity and mortality.

Current Definition (ACOG):

• Cumulative blood loss ≥1000 mL, OR

• Bleeding with signs/symptoms of hypovolemia within 24 hours of birth, regardless of delivery type

Classification:

• Early/Primary PPH: Within 24 hours of birth

• Late/Secondary PPH: More than 24 hours up to 12 weeks after birth

Causes

Most Common: Uterine Atony

• Failure of uterine muscle to contract firmly

• Relaxed uterus distends with blood and clots

• Blood vessels at placental site not clamped off

• Often results from retained placental fragments

Other Causes:

• Vaginal or vulvar hematomas

• Unrepaired lacerations of vagina or cervix

• Lacerations of birth canal during placental separation

• Incomplete placental separation

• Undue fundal manipulation or excessive cord traction

• Uterine prolapse

• Late PPH: subinvolution, infection, retained placental fragments, coagulopathy

Assessment

Blood Loss Estimation:

• Quantification by weighing (1 mL = 1 g) is the most accurate method

• Visual estimation: scant, light, moderate, or heavy

• Time factor is critical: saturating pad in 1 hour vs. hours indicates very different bleeding rates

First Step When Bleeding Appears Excessive:

• Evaluate uterine contractility

• If uterus is firmly contracted and bleeding continues, identify other sources

• Assessment may include visual/manual inspection of perineum, vagina, uterus, cervix, rectum

• Laboratory studies: hemoglobin, hematocrit, coagulation studies, platelet count

Prevention

Two Most Important Interventions:

1. Maintaining good uterine tone

2. Preventing bladder distention

Management

• If uterus is hypotonic or boggy, management focuses on increasing contractility and minimizing blood loss

• Treatment depends on bleeding source

• Treated even if blood loss doesn’t meet parameters

• Boggy fundus, tachycardia, hypotension, postural hypotension, sweating, anxiety, pallor, tachypnea, restlessness, lightheaded, altered mental status.

Early Postpartum Hemorrhage Causes: 4 T’s

1. Tone

2. Trauma

3. Tissue

4. Thrombin

Tone

• Uterine atony (Marked hypotonia of uterus)

• Most common

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

  • Lattice muscle fibers surround large blood vessels

  • Contractions cause pressure on those vessels, which activate coagulation pathways

  • Initiated after delivery of placenta

• Risk factors:

  • High parity

  • Polyhydramnios

  • Macrosomia

  • Multiple gestation

  • Uterine fatigue/long labor

  • Tocolytic drugs

• The greatest risk for early PPH is during the first hour after birth. The body of the uterus is like a basket-weave of strong, interlacing smooth muscle bundles through which many large maternal blood vessels pass. After the expulsion or removal of the placenta, bleeding is controlled when these smooth muscle fibers in the uterus are well contracted. If inadequate uterine contraction occurs, the uterus remains flaccid, and rapid blood loss can follow. This hypotonia of the uterus is called uterine atony.

  Uterine atony is the leading cause of early PPH. It is associated with high parity, polyhydramnios, fetal macrosomia, obesity, and multiple gestation. In such conditions the uterus is more distended and therefore may not contract as well after birth.

Trauma

• Lacerations of the genital tract

  • Uterus, cervix, vagina, perineum

  • Hematomas

• Lacerations of the cervix, vagina, and perineum are also causes of PPH. Hemorrhage related to lacerations should be suspected if bleeding continues despite a firm, contracted uterine fundus. This bleeding can be a slow trickle, an oozing, or frank hemorrhage. Factors that influence the causes and incidence of obstetric lacerations of the lower genital tract include operative birth, precipitous or rapid birth, congenital abnormalities of the maternal soft tissue, and contracted pelvis. Other possible causes of lacerations are increased size, abnormal presentation, and position of the fetus; relative size of the presenting part and the birth canal; previous scarring from infection, injury, or surgery; and vulvar, perineal, and vaginal varicosities.

Tissue

• Retained products of the placenta

• Placental anomaly → sometimes connects further into the abdominal wall

• When the placenta has not been expelled within 30 minutes after birth despite an upright posture of the woman, gentle traction on the umbilical cord, and uterine massage, it is described as a retained placenta. Initial management of a retained placenta consists of manual separation and removal by the midwife or physician. This involves the provider reaching into the uterus and gently separating the placenta from the uterine wall and removing it manually. When the client has regional anesthesia for labor, supplementary anesthesia is usually not needed. For other women, administration of light nitrous oxide and oxygen inhalation anesthesia or intravenous (IV) pain medications should be considered. After removal of a retained placenta, the woman has an increased risk for PPH and infection.

  Fragments of the placenta and/or amniotic membranes can remain in the uterus after spontaneous separation of the placenta during the third stage of labor. In this case the client may have excessive bleeding and the uterus feels boggy (soft) due to uterine atony. The midwife or physician may attempt manual exploration to remove the fragments; uterine curettage (removal of uterine contents using a curette or vacuum suction) may be necessary

• PPH can also be due to an abnormally implanted, invasive, or adherent placenta; this is known as placenta accreta syndrome. Abnormal placental adherence can be total, partial, or focal, depending on how much placental tissue is involved. The following degrees of abnormal placental attachment are recognized:

  • Placenta accreta—slight penetration of myometrium

  • Placenta increta—deep penetration of myometrium

  • Placenta percreta—perforation of myometrium and uterine serosa, possibly involving adjacent organs

Thrombin (Coagulation)

• When no identifiable cause, think coagulopathy

• TXA first-line therapy

• Von Willebrand

  • Most common inherited bleeding disorder. Missing clotting factor

  • Idiopathic or immune thrombocytopenic purpura (ITP)

• Taking anticoagulants

  • Coumadin is generally contraindicated; should be avoided in the first trimester due to tetragenicity

Mastitis 

Definition

Mastitis is an infectious process of the breast characterized by inflammation that may be accompanied by infection and pain. While most commonly associated with lactating and breastfeeding women, it can occur in non-lactating women as well.

Signs & Symptoms

• Sudden onset of influenza-like symptoms: fever, chills, malaise, body aches, headache, nausea, vomiting

• Localized breast pain and tenderness

• Hot, reddened area on the breast

• Most commonly occurs in the upper outer quadrant of the breast

• One or both breasts can be affected

Timing

Most cases occur during the first 2 to 4 weeks postpartum, although mastitis can occur at any time.

Risk Factors

Breastfeeding-Related:

• Inadequate emptying of breasts (engorgement, plugged ducts)

• Sudden decrease in number of feedings or abrupt weaning

• Wearing underwire bras

• Sore, cracked nipples (provide portal of entry for bacteria)

Other Factors:

• Stress, fatigue, maternal illness, ill family members

• Breast trauma, poor maternal nutrition

• Smoking and nipple piercings (bacteria can enter through milk duct)

Common Causative Organisms: Staphylococcus, Streptococcus, and Escherichia coli

Treatment

• Bedrest

• Antibiotics: dicloxacillin, cephalexin, or clindamycin

• Pain and swelling reduction: anti-inflammatory medications and cold compresses

• Continued lactation with complete emptying of breasts through breastfeeding, hand expression, or pumping

• Adequate fluid intake and balanced diet

Important: The infection cannot be transmitted to the infant

Complications

• Breast abscess

• Chronic mastitis

• Fungal infections of the breast

Most complications can be prevented by early recognition and treatment.

Patient Education

Breastfeeding mothers should be taught the signs of mastitis before discharge from the birth facility and instructed to call the healthcare provider promptly if symptoms occur.

Important Note: Mastitis does not increase the risk for developing breast cancer in the future

Newborn Nutrition/Breastfeeding

Breastfeeding positions

Initial Feeding Position

Semireclining Position (Laid-Back Breastfeeding):

• Recommended for initial feedings

• Mother in semireclining position with newborn prone, skin-to-skin on her bare chest

• Mother's body supports the baby

• Benefits: reduces/eliminates nipple pain, mother more relaxed with freedom of movement, baby uses inborn reflexes to latch and feed effectively

• Some mothers prefer this position even after early days

Four Traditional Positions

Football or Clutch Hold (Under the Arm):

• Often recommended for early feedings

• Mother can easily see baby's mouth as she guides infant onto nipple

• Preferred by mothers after cesarean birth

• Works well for mothers with large breasts or small babies

Modified Cradle or Across-the-Lap (Cross-Cradle):

• Works well for early feedings, especially with smaller babies

• Mother has more control over baby's head positioning

Cradle Hold:

• Most common position for infants who have learned to latch easily and feed effectively

• Used once breastfeeding is well established

Side-Lying Position:

• Allows mother to rest while breastfeeding

• Preferred by women with perineal pain and swelling

• Good for nighttime feedings

General Positioning Guidelines

Key Principles:

• Mother should use position that most easily facilitates latch while allowing maximal comfort

• Infant held securely at level of breast, supported by firm pillows or folded blankets

• Baby facing toward mother

• Baby's mouth directly in front of nipple

• Mother supports baby's neck and shoulders with her hand (not pushing on occiput)

• Baby's body held in alignment: ears, shoulders, and hips in straight line

Comfort Measures:

• Mother should be as comfortable as possible

• Empty bladder before feeding

• Nurse/lactation consultant at mother's eye level when assisting

Before Discharge:

• Help mother try all positions so she's confident using them at home

Engorgement

Definition

Engorgement is a common response of the breasts to sudden hormonal changes and the onset of significantly increased milk volume during lactogenesis stage II. It usually occurs 3 to 5 days after birth as milk transitions from colostrum to mature milk.

Pathophysiology

• Increased blood flow to the breasts

• Increased uptake of glucose and oxygen by the breasts

• Milk production rapidly increases, volume can exceed storage capacity of the alveoli

• If milk is not removed, alveoli become distended, causing impaired capillary blood flow

• Blood vessels become congested, fluid leaks into surrounding tissue causing edema

• Milk ducts compressed by tissue edema, preventing easy milk flow

Signs & Symptoms

• Breasts become firm, tender, and hot

• Appear shiny and taut

• Areolae become edematous

• Nipples can flatten, making it difficult for infant to latch

• May feel hard and warm, enlarged and painful

Timing

• Not unusual in first 24 to 48 hours after breasts fill with milk

• Later development may signal onset of mastitis

Consequences

Back pressure on full milk glands inhibits milk production - if milk is not removed from breasts, milk supply can diminish.

Note: Engorgement does not occur in all breastfeeding mothers.

Management

Key Intervention: Remove milk from the breasts through frequent breastfeeding and/or milk expression

Assessment:

• Determine if breasts are adequately supported with a properly fitting bra

• Palpate breasts to determine degree of softness

• Distinguish between full breasts (firm, dense, slightly enlarged) and engorged breasts (hard, warm, enlarged, shiny, painful)

Prevention:

• Frequent, effective breastfeeding

• Proper breast support without overly tight bras

Neonates

Jaundice

Jaundice (icterus) occurs when bilirubin levels exceed 5 mg/dL and becomes visible in the skin 2. It's observed in approximately 60% of term infants and 80% of preterm infants during the first week after birth.

Physiologic Jaundice (Normal)

Timing & Pattern:

• Appears after 24 hours of age

• Peaks between days 2-4 at 5-6 mg/dL

• Gradually decreases between days 5-71

• Resolves by 2 weeks of age in term infants

• Usually mild (total bilirubin <15 mg/dL) and self-limiting

Causes:

• Immature liver uptake and conjugation of bilirubin

• Higher hemoglobin levels and shorter RBC lifespan in newborns

• Not associated with any pathologic process

Breastfeeding-Related Jaundice

Early-Onset (Breastfeeding-Associated):

• Begins at 2-4 days of age

• Related to poor latch or inadequate milk supply

• Caused by decreased caloric/fluid intake and increased enterohepatic circulation

Late-Onset (Breast Milk Jaundice):

• Occurs in up to 30% of breastfed infants

• Peaks between days 5-15

• May persist beyond 1 month, lasting up to 3 months

• Safe—do not discontinue breastfeeding

Pathologic Jaundice (Abnormal)

Warning Signs:

• Jaundice appearing within first 24 hours

• Total bilirubin >15-17 mg/dL

• Bilirubin increasing >5 mg/dL per day

• Jaundice persisting beyond 2 weeks in term infants

Risk Factors:

• Prematurity

• Blood group incompatibility (ABO, Rh)

• G6PD deficiency

• Cephalhematoma or significant bruising

• Asian or Asian American race

• Exclusive breastfeeding with poor intake

• Family history of hyperbilirubinemia

• Maternal diabetes

Evaluation

Visual Assessment: Jaundice progresses head to toe, but visual determination can be erroneous. Diagnosis requires serum bilirubin measurement or transcutaneous monitoring.

Important: Evaluation considers timing, gestational age, feeding method, family history, and serial bilirubin trends—not just a single value

• Yellow skin

• Immature liver (Not usually the liver’s fault); liver can’t keep up (physiologic)

• Usually isn’t a problem if it occurs 24 hours after birth; still needs treatment → UVB light therapy

• As it gets worse, it heads down the body, starts at face, goes down the body

• If jaundice occurs in the first 24 hours, it can be a pathologic problem! Like a blood incompatibility with mom

• Newborns produce bilirubin 2-2.5 times that of an adult

Fetal loss communication

Core Principles of Communication After Fetal Loss

Validate the Experience: One of the most important goals is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. Help parents talk about their loss, the meaning it has for their lives, and share their emotional pain.

Simple Acknowledgment: At the very least, acknowledge the loss with a simple but sincere, "I am sorry".

Listen Patiently: Listen patiently during the story of loss or grief, even though it can be difficult and sometimes painful. Use therapeutic communication techniques like:

• Leaning forward

• Nodding the head

• Using words such as "Tell me more" to encourage the bereaved person to tell their story

• Sitting through the silence—this gives the bereaved person an opportunity to collect thoughts and process what they are sharing

Include Both Parents

Don't forget the partner: Because nurses tend to focus on the physical and emotional needs of the mother, it's especially important to ask the father or partner directly about their views of what happened and the associated feelings of loss.

What to Avoid

Resist unhelpful responses:

• Don't give advice or use clichés

• Don't try to reduce their pain with quick fixes—although the impulse to say or do something to reduce helplessness is natural, such responses can stifle the further expression of emotion

Be cautious with touch: Careful assessment is important before using touch as a therapeutic technique. For some, touch is meaningful; for others, it's an invasion of privacy or contrary to their cultural or religious beliefs.

Create Adequate Time

Don't rush: The nurse must create enough time to engage with bereaved families without being rushed. Nurses caring for families whose baby has died may need assignments that allow time to give adequate attention to newly bereaved individuals.

Professional Self-Awareness

Nurses need to be comfortable with their own feelings of loss and grief to support and care for bereaved individuals effectively. Have a presence of self and willingness to be alongside, quietly supporting the bereaved person in whatever expressions of feelings or emotions are appropriate for them.

Neonatal heat loss 

Four Modes of Heat Loss

Newborns lose heat through four distinct mechanisms:

1. Convection - Heat loss to cooler air currents flowing over the infant's skin

2. Conduction - Heat transfer to cooler surfaces in direct contact with the infant

3. Radiation - Heat loss to cooler solid objects not in direct contact (e.g., cold walls, windows)

4. Evaporation - Heat loss through moisture on the skin converting to vapor

Why Newborns Are Vulnerable

Anatomic & Physiologic Factors:

• Large surface area relative to weight facilitates environmental heat loss

• Thin subcutaneous fat layer provides minimal insulation

• Temperature gradient between core (higher) and surface (lower) body temperature drives heat transfer

• Cannot shiver - instead produce heat through nonshivering thermogenesis (NST)

High-Risk Infants Face Additional Challenges:

• Smaller muscle mass

• Fewer brown fat deposits

• Lack of insulating subcutaneous fat

• Poor reflex control of skin capillaries

Consequences of Cold Stress

Cold stress produces serious complications:

1. Hypoxia

2. Pulmonary vasoconstriction

3. Metabolic acidosis

4. Hypoglycemia

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

Prevention Strategies

Immediate Interventions:

• Dry the infant quickly after birth

• Skin-to-skin contact with mother reduces conductive and radiant heat loss

• Cover with warm blanket

• Place cap on head to conserve heat

For High-Risk Infants:

• Plastic wrap or heated humidified gas in delivery room

• Prewarmed incubators

• Heated gel mattress with radiant heat

• Head coverings (fabric-insulated or wool caps)

• Double-walled incubators

Goal: Neutral Thermal Environment

A neutral thermal environment (NTE) allows the newborn to maintain normal core temperature with minimum oxygen consumption and calorie expenditure.

Target temperatures:

• Term infants: 36.5°C to 37.5°C (97.7°F–99.5°F) axillary

• Preterm infants: 36.5°C to 37.2°C (97.7°F–98.9°F)

Apgar score

The Apgar score is a rapid assessment of the newborn's overall status and immediate adjustment to extrauterine life. It evaluates five physiologic signs, each scored 0, 1, or 2 1:

1. Heart rate - Auscultation with stethoscope or palpation of umbilical cord

2. Respiratory effort - Observed chest wall movement

3. Muscle tone - Degree of flexion and movement of extremities

4. Reflex irritability - Grimace, crying, or active withdrawal

5. Generalized skin color - Pallid, cyanotic, or pink

Timing & Interpretation

When assessed:

• At 1 and 5 minutes after birth

• Repeated every 5 minutes for up to 20 minutes if score <7 at 5 minutes

Score interpretation:

• 0-3 = Severe distress

• 4-6 = Moderate difficulty

• 7-10 = Minimal or no difficulty adjusting to extrauterine life

Important Limitations

The Apgar score does NOT:

• Predict future neurologic outcome or physical status

• Stand alone to interpret past events

• Determine need for resuscitation (resuscitation should begin before the 1-minute score if needed)

Factors affecting accuracy:

• Physiologic immaturity

• Infection or congenital anomalies

• Maternal sedation/analgesia

• Hypovolemia

• Neuromuscular disorders

• Assessment of skin color in darker skin tones may lead to under-recognition of cyanosis

Clinical Use

The Apgar score is useful for describing the newborn's transition to extrauterine environment and response to resuscitative efforts. It represents an assessment of physiologic condition at one specific timepoint.

Remember: A score of 8-10 indicates the baby is adapting well, but the score should be interpreted alongside other clinical findings and the infant's overall condition.

Head-to-toe assessment findings

General Appearance & Posture

Term newborn position: Complete flexion with head flexed, chin on chest, arms flexed with clenched hands, legs flexed at knees and hips with thighs on abdomen, and feet dorsiflexed. The vertebral column is also flexed. Any deviation from this characteristic fetal position should be noted.

Behavior assessment: Observe degree of alertness, drowsiness, and irritability, which may reflect neurologic problems.

Vital Signs & Measurements

Gestational age indicators:

• Full-term (40 weeks): Many sole creases, 4-mm breast nodule, ear cartilage present, descended testes with scrotal rugae

• Increasing muscle tone with predominantly flexed extremities indicates maturity

Skin

Nail beds: Should be pink, though slight blueness in acrocyanosis is normal. Persistent cyanosis may indicate hypoxia; yellowing suggests intrauterine distress, postterm birth, or hemolytic disease.

Nail length: Short/absent in preterm; long nails extending over fingertips in postterm infants.

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.

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 covering sole

• Preterm: Partial or absent creases

Neurologic Assessment

Reflexes to elicit:

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

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

Important: Test mass (total body) reflexes at examination end as they may disturb the infant. Record and report absence, asymmetry, persistence, or weakness of reflexes.

Key Principle

Physical assessment should establish baseline data and identify normal characteristics versus abnormalities requiring intervention. Ongoing assessments are critical nursing priorities

Neonatal hypoglycemia

Definition & Thresholds

Hypoglycemia is defined as blood glucose <40 mg/dL in the first 4 hours of life and <45 mg/dL between 4-24 hours. For asymptomatic infants, treatment is recommended when glucose is <25 mg/dL if <4 hours old and <35 mg/dL between 4-24 hours. When symptoms are present, begin treatment at <40 mg/dL with a goal to maintain prefeeding glucose of 45 mg/dL.

Some sources cite the lower limit for normal plasma glucose during the first 72 hours as 40-45 mg/dL.

At-Risk Populations

Infants of Diabetic Mothers (IDM):

• Most common in macrosomic or large-for-gestational-age infants

• Caused by fetal pancreatic hypertrophy and hyperplasia from chronic maternal hyperglycemia

• High maternal glucose stimulates fetal insulin production; at birth, abrupt loss of maternal glucose supply causes hyperinsulinism and hypoglycemia within 0.5-4 hours

Growth-Restricted & Preterm Infants:

• Decreased glycogen stores

• Inadequate gluconeogenesis

• Increased metabolic demands from illness

Clinical Presentation

Symptoms include:

• Jitteriness

• Apnea and tachypnea

• Hypotonia and decreased activity

• Cyanosis

• Poor feeding and hypothermia

• Weak cry, lethargy, floppy posture

• Seizures with profound hypoglycemia

Critical concern: Many infants remain asymptomatic. Asymptomatic hypoglycemia is associated with dose-dependent increased risk of poor executive function and visual motor function.

Management

Monitoring:

• Begin screening soon after birth in all high-risk infants

• Use point-of-care testing (glucometers) confirmed by laboratory

• Frequent determinations for first 2-4 days

Treatment:

• Initiate feeding within first hour if cardiorespiratory status stable (breast milk or formula preferred)

• Avoid oral glucose - triggers massive insulin release causing rebound hypoglycemia

• IV dextrose (10%) for poorly controlled IDM or symptomatic infants

• Goal: maintain glucose >45 mg/dL

Physiologic correlation: Direct relationship exists between temperature regulation, glucose homeostasis, and respiratory distress

Skin-to-skin care

Skin-to-skin contact (also called kangaroo care) involves placing the undressed infant (wearing only a diaper) in a vertical position on the parent's bare chest, which permits direct eye contact, skin-to-skin contact, and close proximity. The parent is bare-chested or wears a loose-fitting, open-front top with a modified marsupial-like pocket carrier.

Benefits for Preterm & High-Risk Infants

Physiologic stability:

• Maintains thermal stability and oxygen saturation

• Promotes stability of heart and respiratory function

• Reduces risk of mortality and nosocomial infections

• Decreases length of hospital stay

Developmental benefits:

• Fosters appropriate neurobehavioral development

• Minimizes purposeless movements

• Improves infant's behavioral state

• Permits self-regulating behaviors

• Maintains organized state

Feeding & growth:

• Increased feeding vigor and enhanced breastfeeding

• Improved growth outcomes

• Mothers more likely to continue breastfeeding

Pain management:

• Strong analgesic effect during procedures like heel lance in full-term newborns

• Decreased pain perception during painful heelsticks in preterm infants

Benefits for Parents

Maternal healing:

• Positive healing effect for mothers who had high-risk pregnancies

• Psychologic healing related to preterm delivery

• Helps mothers regain the mothering role through early contact

• Permits early contact even with mechanically ventilated infants

Safety & Appropriateness

Skin-to-skin contact is appropriate for stable preterm infants because of the maintenance of appropriate body temperature. This practice has minimal untoward effects of being held.

Temperature Regulation

Skin-to-skin contact is an effective method for conserving newborn body heat. At birth, rapidly drying the skin and hair with a warmed towel and placing the infant in skin-to-skin contact with mother, covered by a blanket, minimizes heat loss through evaporation

Neonatal infection

Definition & Susceptibility

Sepsis (septicemia) refers to a generalized bacterial infection in the bloodstream. Neonates are highly susceptible due to diminished immune function:

• Impaired phagocytosis

• Delayed chemotactic response

• Minimal or absent IgA and IgM

• Decreased complement levels

Critical challenge: Infants show no local inflammatory reaction at the portal of entry, and symptoms are vague and nonspecific, delaying diagnosis and treatment. Maintain a high suspicion for infection.

Early-Onset Sepsis (EOS)

Timing: Less than 3 days after birth

Acquisition routes:

• Direct contact with maternal GI/GU tract organisms

• Transplacental transfer from maternal bloodstream

• Aspiration of infected amniotic fluid during labor

• Contact with mother with active infection during delivery

Common pathogens:

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

• Preterm infants: Escherichia coli - most common

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

• Vaginal pathogens: Syphilis, gonococci, C. 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 and prophylaxis, early-onset GBS infection remains at approximately 0.25 per 1000 live births.

Treatment

Empiric antibiotic therapy:

• Early-onset sepsis: Ampicillin + aminoglycoside

• Late-onset sepsis: Vancomycin + aminoglycoside

• Initiated before laboratory confirmation

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

Supportive care:

• Circulatory and respiratory support

• Oxygen administration if needed

• Fluid regulation and electrolyte correction

• Temporary discontinuation of oral feedings

• Blood product transfusions as needed

Nursing Priorities

Recognition is paramount - nurses typically identify that "something is wrong.” Obtain a minimum 1 mL blood for culture to detect low-level bacteremia 2. Monitor for superinfection from prolonged antibiotic therapy (C. albicans) 2, though prophylactic antifungal therapy is not standard

• The newborn infant is susceptible to infection because of the immature immune system

Sepsis

• One of the most significant causes of neonatal morbidity and

mortality: Systemic Inflammatory Response Syndrome (SIRS)

• 2 Types of Neonatal Sepsis

  • Early-onset sepsis

  • Late-onset sepsis

• S/S: Respiratory distress, apnea, decreased tone, difficulty with thermoregulation

• Viral infections:

  • Birth of baby exposed to TORCH infections

  • Hep B

  • HIV

  • Herpes simplex

• Bacterial infections:

  • GBS

  • E. coli

  • Staphylococcus aureus

  • Chlamydia

  • Gonorrhea

  • Syphilis

  • Listeriosis

• Protozoal infections → Toxoplasmosis

• Fungal infection → Candidiasis

Neonatal skin findings

Normal Skin Characteristics

Texture & appearance: Velvety smooth and puffy, especially around eyes, legs, dorsal hands/feet, and scrotum or labia. By the second or third day, skin becomes drier and flakier.

Color variations:

• Depends on racial and familial background

• White infants have light pigment at birth

• Black, Indigenous, Hispanic, Latino, Asian, and other children of color may have partial pigmentation that may change with development

• Hyperpigmentation may appear shortly after birth in lips, axillae, genitalia, umbilicus, and fingertips in darker-skinned infants

Important: In darker skin tones, visual inspection alone may not reliably identify jaundice - rely on laboratory bilirubin testing.

Preterm Infant Skin

Characteristics:

• Bright pink (often translucent depending on immaturity)

• Smooth and shiny

• Small blood vessels clearly visible under thin epidermis

• Fine lanugo hair abundant over body (sparse on head)

• Soft, pliable ear cartilage

• Minimal sole/palm creases

Fragility concerns:

• Thinner than full-term skin, lacks rete pegs (anchoring appendages)

• Less cohesion between skin layers

• Easily excoriated and denuded

• Adhesive tape may separate epidermis from dermis

• Use pectin barriers and hydrocolloid adhesives instead

Care precautions:

• Avoid alkaline-based soaps

• Use alcohol, chlorhexidine, and povidone-iodine with caution

• Rinse skin with water after product use to prevent severe irritation and chemical burns in VLBW/ELBW infants

• Increased permeability facilitates absorption of topical products

Benign Skin Findings

Erythema toxicum neonatorum:

• Benign accumulation of macules, papules, or pustules

• Appears 24-48 hours after birth (may develop until day 10)

• Discrete, blotchy, macular erythematous rash

• Light yellow/white papules/pustules (1-3 mm)

• Affects any body surface except palms and soles

• Self-limiting, resolves within weeks

• No treatment required

Periauricular papillomas (skin tags): Fairly frequent, usually familial trait, no consequence

Concerning Findings

Report immediately:

• Pallor, plethora (deep purplish color), central cyanosis, jaundice

• Petechiae scattered over body (may indicate low platelets or infection)

• Birth injuries: forceps marks, fetal monitoring lesions

• Bruising (increases hyperbilirubinemia risk)

Neonatal vital signs

Heart Rate

Normal range: 120-160 beats/min

Variations:

• During deep sleep: 80-100 beats/min

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

• Shortly after birth: May range 100-180 beats/min

• After stabilization: 120-140 beats/min

Reevaluation needed: Heart rate >160 beats/min or <100 beats/min should be reassessed within 30 minutes to 1 hour or when infant's activity changes.

Location: Point of maximal impulse (PMI) at fourth to fifth intercostal space, medial to left midclavicular line. Often visible and easily palpable due to thin chest wall.

Respiratory Rate

Normal range: 40-60 breaths/min

Variations:

• Rate up to 80 breaths/min may be noted

• During first reactive period: May reach 80 breaths/min

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

Assessment: Count for 1 full minute

Blood Pressure

Normal ranges:

• Systolic: 60-96 mm Hg

• Diastolic: 30-62 mm Hg

Measurement: Often determined using electronic sphygmomanometer with Doppler or oscillometric technique

Clinical significance: Sustained increase in blood pressure is almost always significant. Hypertension may indicate thrombosis (from umbilical artery catheter), coarctation of aorta, renal disorders, congenital adrenal hyperplasia, or CNS disease.

Temperature

Maintaining appropriate temperature is best accomplished through skin-to-skin care with mother. Temperature may decrease during the first reactive period.

Key Assessment Points

Pulse variability: Greatest around time of birth and more marked in premature infants. 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