Postpartum and Newborn Care Lecture Review

Postpartum and Newborn Nursing: Comprehensive Notes

1) Immediate Postpartum: Uterus, Lochia, and Breast Changes

• Uterus and fundus assessment is central to postpartum assessment; fundus is the top of the uterus.

• Involution: uterus should descend about one centimeter per day back into the pelvis after delivery. Initially, within the first 4–12 hours postpartum, the fundus is at or near the level of the umbilicus. After that, it descends gradually with time.

• If the uterus is not firm (boggy), perform fundal massage and assess for contributing factors.

• If fundus remains boggy and firm massage does not help, consider uterotonic medication (e.g., oxytocics). Typical example referenced: Pitocin; order usually required from a clinician. The process may involve hospital protocols or standing orders depending on the unit.

• Bladder status impacts uterine involution: a full bladder can push the uterus upward and to the side, preventing proper contraction. If the uterus is not midline or boggy, assess bladder distension and perform straight catheterization if retention is suspected.

• Signs of infection or breast problems to monitor: heat, redness, nodules, possible mastitis.

• Postpartum education: encourage mom to breastfeed every 2–3 hours to stimulate milk production and help prevent engorgement; if engorgement occurs and infant cannot latch well, consider small short-term pumping to relieve pressure while supporting latch-back.

• Breast engorgement and lactation education includes: common anticipation of pain when milk comes in; signs of mastitis; evaluation of latch and milk removal.

• Breast milk comes in typically in the first several days postpartum; look for signs of engorgement and support appropriate milk removal to prevent cycle of poor latch and continued engorgement.

2) Lochia: Color and Duration

• Lochia rubra (bright red): typically lasts about 1–3 days (some sources say up to 4 days).

• Lochia serosa: pink to brown discharge occurs after rubra as healing progresses.

• Lochia alba: creamy, yellowish-white discharge; typically lasts up to about 2–3 weeks, sometimes a bit longer.

• Education for red discharge persisting past expected window or heavy clots: notify provider.

3) Perineal Healing and Episiotomy Degrees

• Episiotomy types (ranges given):

  • First-degree: involves only the vaginal mucosa.

  • Second-degree: extends into perineal muscles.

  • Third-degree: extends into anal sphincter.

  • Fourth-degree: extends through perineum to involve the rectal mucosa.

• Episiotomy is sometimes chosen for better control if tearing is anticipated during delivery; physicians decide intra-labor if labor progress/endangerment requires it.

• Post-delivery episiotomy care includes wound management and keeping the area clean and dry; edge approximation is important for healing.

4) Involution, Bleeding, and Thermoregulation

• Postpartum hemorrhage risk is linked to non-firm fundus and improper involution; assessment is continuous.

• Diuresis and temporary gushes: as maternal tissue shifts and pooling occurs, she may feel gushes especially after getting up; reassure that this is expected.

• Uterine massage while considering below-fundus observations (blood loss, clots pooling under mom).

5) Bowel, Bladder, and Bowel Elimination

• Bladder distension prevents the uterus from contracting properly; a full bladder keeps the fundus elevated and to the midline.

• Bladder management: if urinary retention occurs, straight catheterization may be necessary to relieve distension.

• Bowel care: encourage hydration and high-fiber foods to prevent constipation and straining, which can affect perineal healing.

• Hemorrhoids: management with sitz baths and witch hazel pads; some facilities have specialized toilets with integrated bidets to improve comfort.

• Stool softeners or laxatives may be used if constipation occurs after delivery.

6) Medications and Orders

• Pitocin (oxytocin) use: practice varies by facility; typically, provider orders are needed; if fundus isn’t firm with massage, contact the provider promptly.

7) DVT Risk and Lower Extremities Care

• Postpartum period is hypercoagulable, elevating DVT risk.

• Additional risk factors include prolonged labor, immobilization, epidural anesthesia, and venous stasis from prolonged downward leg positioning.

• Preventive measures: encourage ambulation as soon as feasible, use of sequential compression devices (SCDs) or compression stockings as per protocol, and gradual return to activity.

• Education about signs of DVT (calf swelling, redness, warmth, sudden chest pain, shortness of breath) and when to seek care.

8) Postpartum Safety and Baby in Room

• In some units, when mom is at risk of exhaustion, baby safety may require temporary nursery care; otherwise, rooming-in with mom is common.

• If mom is fatigued, staff may move baby to the nursery to prevent safety risks such as dropping the baby during sleep.

9) Postpartum Mood and Mental Health

• Postpartum blues vs. depression vs. postpartum psychosis:

  • Baby blues: typically within the first two weeks postpartum; mild mood changes that resolve without intervention and should not significantly impair bonding or daily functioning.

  • Postpartum depression: longer-lasting mood changes, sleep disturbance, irritability, anhedonia, impairment in daily living; requires evaluation and care with a provider.

  • Postpartum psychosis: more severe, including potential thoughts of harming self or baby; urgent medical attention is required.

• Routine depression screening often occurs during follow-up visits (OB/GYN at ~6 weeks) and in pediatric settings during newborn visits.

• Education emphasizes seeking help early; providers, lactation consultants, and nurses should connect families with appropriate resources.

10) Breastfeeding Decision-Making and Lactation Support

• If mom decides not to breastfeed, involve lactation to explore reasons and provide education on options, while respecting her choice.

• Lactation support is also valuable to help plan how to manage breastfeeding if the decision may change later.

• Donor human milk: available at some hospitals as an option when maternal milk is delayed or insufficient; donor milk is screened and used to support glucose needs and nutrition.

11) Newborn Assessment: Quick Screen (FBAR) and Gestational Age

• FBAR-style quick assessment is used in the delivery room to determine immediate newborn status; not a substitute for full assessments later.

• Gestational age assessment uses standardized charts that compare posture, flexion, reflexes, and muscular tone to gestational age; also assess intrauterine growth for Small for Gestational Age (SGA) vs Large for Gestational Age (LGA).

• Weight, length, head circumference (HC), and chest circumference measurements are recorded; HC is typically about one-fourth of newborn length, and chest circumference is usually close to or equal to HC.

• A detailed head-to-toe examination is performed in the postpartum unit; focal points include skin color, respiratory status, congenital anomalies, nasal patency, and reflexes.

• Respiratory status: count respirations and assess for grunting, flaring, or retractions; look for even chest movement; observe belly breathing.

• Skin assessment: visible changes such as erythema toxicum (newborn rash), capillary malformations (nevus vasculosus/hemangioma), caput vs cephalohematoma, Mongolian spots, milia, Lanugo, vernix.

• Posture and movement: neonatal posture (flexed vs extended), molding of skull, fontanelles (anterior and posterior); palpate sutures.

• Caput vs cephalohematoma: caput is diffuse scalp swelling across suture lines, cephalohematoma is a subperiosteal hemorrhage limited to one cranial bone; both may affect bilirubin handling and require monitoring.

• Neonatal jaundice risk: monitor bilirubin; bilirubin rises due to immaturity of the liver and rapid breakdown of fetal red blood cells.

12) Skin, Hair, and Vernix at Birth

• Lanugo: fine fetal hair, common in preterm infants.

• Vernix caseosa: waxy coating on the skin that serves as a protective barrier; it helps with thermoregulation and moisture; typically not bathed off immediately to allow natural temperature regulation.

• Milia: small white bumps on the nose and face due to blocked oil glands.

• Mongolian spots: bluish-gray skin patches more common in darker-skinned infants; benign and usually fade with time.

• Nevus simplex (stork bite): pink/red patches on the eyelids, forehead, or neck; usually fade over time.

13) Newborn Physical Exam Details

• Fontanelles: anterior fontanelle and posterior fontanelle should be soft, flat, and open; not sunken or bulging.

• Cephalohematoma and caput: monitor as they may affect bilirubin levels and risk of jaundice.

• Skull sutures: palpation to assess for molding and fontanelle status; molding is normal as the skull bones overlap to facilitate passage through birth canal and typically resolves.

• Caput cephalohematum considerations: monitor for signs of jaundice; cephalohematoma may increase bilirubin production as blood breaks down.

• Facial and cranial symmetry: assess for symmetry, cleft palate, and other craniofacial anomalies.

• Genitalia: for males, check that both testes are descended; assess meatus position; for females, note potential edema or discharge due to maternal hormones; ambiguous genitalia should prompt further genetic testing workup.

• Reflexes and neonatal neurological checks: reflexes include rooting, sucking, Babinski, grasp, Moro, stepping, tonic neck (fencing), and doll’s eye responses (brainstem integrity) as educational examples discussed.

• The importance of engaging with parents about newborn behavior: first period of reactivity (awake and feeding ready), a sleep period, then a second reactivity period; if feeding was not optimal initially, reattempt feeding during the second reactivity phase.

14) Feeding, Diapers, and Stool Patterns

• Early feeding: breastfeeding infant with milk coming in typically feeds every 2–3 hours; encourage on-demand feeding; initially wake the baby for feeds if needed.

• Formula-fed infants may tolerate longer intervals, but generally not more than every 4 hours.

• Diaper outputs after milk comes in:

  • For breastfeeding babies: aim for roughly six to twelve wet diapers per day and about one to three stools daily as feeding becomes established.

  • For formula-fed babies: output tends to be steadier and may appear sooner as digestion of formula takes longer; monitor for adequate stooling as you monitor hydration.

• Meconium to transitional stools: meconium is thick, tar-like stool that usually passes by day 3; breastfed stools tend to be yellow and seedy; formula stools may be more formed and yellow to brownish.

• Cord care: keep the cord clean and dry; avoid immersion in water until the cord stump has fallen off; petroleum jelly around the diaper area to prevent diaper friction and seal.

• Bathing: newborns do not need daily baths; on radiant warmer if not skin-to-skin; delay bath to support thermoregulation and skin barrier; bath water should be warm but not hot.

• Circumcision and post-procedure care: circumcised babies may nap after procedure; monitor for comfort and healing; keep the diaper area clean to prevent infection.

• Safety with car seats: babies must be in a car seat for discharge; hospital staff will verify proper car seat use before discharge.

15) Newborn Screening, Immunizations, and Eye Care

• Newborn screen (heel prick): essential metabolic and genetic screening performed before leaving the hospital; results are tracked and reviewed.

• Hearing screen: performed before discharge by a technician; devices measure newborn hearing ability and identify potential hearing loss early.

• Erythromycin ophthalmic ointment: historically used to prevent ophthalmia neonatorum due to gonorrhea and chlamydia exposure; risk-benefit discussions with parents and consent are part of newborn care, and practices may vary by state.

• Vitamin K prophylaxis: given to prevent bleeding; newborns are not fully equipped with all clotting factors at birth; vitamin K kick-starts the coagulation cascade. It is not a vaccine; its purpose is to reduce bleeding risk.

• Hepatitis B vaccine: provides immunity against hepatitis B; rationale includes protection if the mother is a carrier and evidence for early immunization; parents may choose to defer in consultation with the pediatrician and consider timing for future vaccines; hospital staff will respect parental choice and coordinate with the pediatrician for follow-up.

• Eye prophylaxis, Vitamin K, and Hep B are routine newborn procedures; some states have mandates for certain interventions; providers should inform parents and obtain consent where required.

16) Immediate Respiratory and Circulatory Considerations in the Newborn

• Apgar-like quick checks in the delivery room include observing breathing, color, heart rate, muscle tone, and reflex irritability; neonates typically exhibit rapid adaptation in the first minutes and hours after birth.

• Signs of respiratory distress in newborns: grunting, nasal flaring, retractions, cyanosis, and low oxygen saturation; term infants may require observation, supplemental oxygen, or NICU transfer if persistent.

• Common immediate causes of respiratory distress: transient tachypnea of the newborn, infection, or delayed mechanism closure; C-section babies may experience more fluid in the lungs due to less squeezing during delivery.

• Circulation changes after birth: with first breath, the foramen ovale closes; ductus arteriosus and ductus venosus also close and become ligaments; most closures occur within the first hours to weeks, though some may take longer; persistent shunts can require cardiology evaluation.

• Normal circulatory adaptation supports the newborn transitioning from fetal to neonatal circulation; persistent issues may warrant cardiology involvement.

17) Common Conditions and Concepts Mentioned

• Kernicterus: bilirubin-induced neurologic dysfunction; risk increases with high bilirubin levels and is a concern if jaundice is untreated or worsens.

• Kernicterus risk emphasizes the importance of monitoring bilirubin, initiating feeding to promote bilirubin elimination via stool, and using phototherapy when indicated.

• Hypoglycemia in newborns: defined as glucose levels below a safe threshold; a common concern in infants of diabetic mothers, preterm infants, or those with poor feeding; normal neonatal glucose ranges are typically around 30 ext{ to }100 ext{ mg/dL}; hypoglycemia concerns occur when glucose is below 30 ext{ mg/dL} in the first 72 hours.

• Donor milk and formula supplementation options: donor milk can be used when maternal supply is insufficient or delayed; formula feeding is an option when breast milk is not feasible; glucose and caloric needs guide decisions.

• Special neonatal conditions mentioned: Down syndrome (trisomy 21) with associated features and potential cardiac defects; spina bifida with possible sacral tuft of hair; assessment for symmetry, symmetry of limbs, and presence of a meatus location and genital normalcy.

• Neonatal safety: avoid cushions or unsafe sleeping positions; promote back-to-sleep, separate sleep spaces; promote bonding during awake times.

18) Practical Scenarios and Application Points

• Scenario-based questions may ask you to compute or interpret a newborn's status using a rubric similar to FBAR/ABAR—understand general categories and what constitutes normal vs concerning findings rather than memorizing a strict numeric checklist.

• When a scenario involves respiratory distress or poor feeding, focus on immediate actions: check airway, ensure breathing, assess circulation, start or optimize supportive care, and escalate to NICU as needed.

• When a newborn's bilirubin level indicates phototherapy, use the provided thresholds to determine the risk level and treatment initiation point; remember bilirubin is excreted in stool following feeding and hydration improvements.

19) Quick References and Common Numbers (LaTeX-formatted)

• Fundal involution: descend about 1 ext{ cm/day} after delivery.

• Uterus location: within the first 4–12 hours postpartum, fundus at the level of the umbilicus; then descends gradually.

• Postpartum pulse rate thresholds for action: consider intervention if pulse is below 100 ext{ bpm} under specific clinical contexts.

• Neonatal respiration: usually 30 ext{ to } 60 ext{ breaths/min}.

• Neonatal heart rate: typically 120 ext{ to } 160 ext{ bpm}.

• First newborn temperature checks: rectal temperature is most accurate for initial assessment; then axial temperature measurements may be used if rectal is not feasible.

• Glucose thresholds for hypoglycemia concern: if glucose is below 30 ext{ mg/dL} in the first 72 hours, intervention is considered.

• Bilirubin thresholds for phototherapy (approximate):

  • Day 0–1: < 6 ext{ mg/dL}

  • Day 1–2: < 8 ext{ mg/dL}

  • Day 2–5: < 12 ext{ mg/dL}

• Head circumference relation: ext{HC}
  oughly rac{1}{4} ext{ of length}; chest circumference close to HC.

• Lochia durations: rubra (1–3 days), serosa follows, alba last up to several weeks.

• Bathing: daily baths are not required; delay first bath to aid thermoregulation; cord care and avoidance of submersion until cord detaches.

20) Summary of Core Concepts

• The postpartum period requires close monitoring of the uterus, lochia, perineal healing, bladder function, and potential thrombotic risks; early mobilization and monitoring are essential.

• Newborn health hinges on early assessment of respiration, circulation, temperature stability, feeding readiness, and safety practices (skin-to-skin, sleep position, car seat use).

• Preventive care (Vitamin K, eye prophylaxis, Hep B vaccination) and newborn screening are standard, with parental education and consent considerations.

• Mental health support for the mother is essential, including recognizing baby blues and seeking help for depression or psychosis.

• Clear communication with families about feeding choices, safety practices, follow-up appointments, and red-flag signs ensures better transition from hospital to home.