Newborn Care and Postpartum Management

Symptoms of Hypoglycemia in Newborns

  • Definition: Brain is totally dependent on a steady supply of glucose for metabolism.

  • Normal Blood Sugar Levels:
      - Healthy newborns' glucose levels fall after birth, stabilize at 40 mg/dL by 1-2 hours after birth, and then rise to 50-80 mg/dL by 3 hours of age.
      - Blood glucose lower than 45 mg/dL at 2 hours after birth indicates hypoglycemia.
      - Infants with prolonged low blood glucose (for 3-4 days) require evaluation for endocrine disorders.

  • Symptoms of Hypoglycemia:
      - Jitteriness
      - Poor muscle tone
      - Sweating
      - Respiratory difficulty
      - Low temperature (which can cause hypoglycemia)
      - Poor suck
      - High-pitched cry
      - Lethargy
      - Seizures

Location of the Fundus Post Delivery

  • Initial Position: Midline at or below umbilicus, firm mass about size of grapefruit.

  • Postpartum Changes:
      - Begins to descend about 1 cm (one finger width) each day after 24 hours.
      - By 10 days postpartum, it should be non-palpable.

Teaching Breastfeeding Techniques

  • Hand Hygiene: Wash hands before feeding and nipples with warm water (no soap) to prevent infection and irritation.

  • Positioning:
      - Sit in a comfortable position with back support; hold the newborn using cradle or football hold.
      - Alternating positions helps in proper milk flow and reduces nipple trauma.

  • Latching:
      - Turn the newborn to face the mother’s breast, stroke cheek with nipple to elicit rooting reflex.
      - Newborn's mouth should encompass the entire areola.

  • Feeding Practices:
      - Avoid strict time limits; at least 10 minutes before switching breasts.
      - Use a safety pin on bra to track which breast to start with next.
      - Break suction by placing finger in corner of newborn’s mouth if necessary.
      - Burp newborn every halfway through feeding and after.

Assessment of Fundus to Control Postpartum Hemorrhage

  • Technique:
      - Massage fundus if soft and above umbilicus; firm fundus does not require massage.
      - Position mother supine with knees flexed; observe lochia during palpation.
      - Support the lower uterus while palpating fundus with fingers in circular motion.
      - Gently push fundus downward to expel blood/clots accumulated in the uterus.
      - Encourage mother to void to prevent bladder overdistension.

  • Documentation:
      - Consistency and location of fundus before and after massage.
      - Administer prescribed medications, like oxytocin, for maintaining contraction.
      - Report if fundus does not remain firm.

Characteristics of Postpartum Bleeding (Lochia)

  • Lochia Rubra:
      - Characteristics: Red; composed mainly of blood; lasts about 3 days post-birth.

  • Lochia Serosa:
      - Characteristics: Pinkish; lasting from 3rd to 10th day post-birth.

  • Lochia Alba:
      - Characteristics: Clear/white; composed mostly of mucus; lasts from 10th to 21st day post-birth.

  • When to Report Abnormalities:
      - Absence of lochia
      - Foul-smelling lochia (with or without fever)
      - Lochia rubra persisting beyond 3 days
      - Heavy flow or sudden bright red color reappearing after changes
      - Presence of large clots

Perineal Care Post Delivery

  • Purpose: To teach proper perineal care to promote healing and prevent infection.

  • Technique:
      1. Wash hands before and after care.
      2. Use peribottle filled with warm water to cleanse perineum in front-to-back direction.
      3. Blot perineum dry with clean tissue (one-time use).
      4. Apply medicated ointments as directed without covering immediately.
      5. Change perineal pad in front-to-back direction.
      6. Wait to flush toilet until standing to prevent flushing water from spraying perineum.

  • Frequency: After each voiding, bowel movement, or every 4 hours during puerperium.

  • Report: Clots, increased lochia flow, or severe cramping.

Administration of Rubella Vaccine

  • Administration: Given subcutaneously in the upper arm.

  • Contraindications:
      - Do not administer to those sensitive to neomycin.

  • Pregnancy Precautions: Avoid conception for 1 month post-vaccination.

  • Breastfeeding: Safe; no adverse effects on the newborn.

Timeline for Resumption of Menstruation Post Delivery

  • Not Breastfeeding: Menstrual cycles resume about 5 weeks post-delivery.

  • Breastfeeding: Menstruation resumes around 8 weeks post-delivery.

Administration of Rhogam (Rho(D) Immune Globulin)

  • Indications: Administer to Rh-negative mothers within 72 hours of delivery of an Rh-positive newborn to prevent Rh sensitization.

  • Route: Intramuscular injection into the deltoid muscle.

Mechanisms of Heat Loss in Newborns

  • Evaporation: Loss of heat via fluid drying on skin (e.g., wet hair, linens, or diaper).

  • Conduction: Direct contact with cold surfaces (e.g., cold hands, stethoscope, bed).

  • Convection: Heat loss from air currents (e.g., air conditioning).

  • Radiation: Heat loss to nearby cold objects (e.g., windows, exterior walls).

Umbilical Cord Care

  • Instructions:
      - Sponge baths until cord stump falls off.
      - Keep cord dry and above the diaper line.
      - Report if signs of foul odor, redness, or moisture develop.

Milk Supply Suppression for Bottle-Feeding Mothers

  • Recommendations:
      - Use a supportive bra, apply ice packs, pain relief medications, or cabbage leaves to alleviate discomfort.
      - Avoid breast pumping to prevent stimulation that could sustain milk production.

Causes of Afterpains

  • Definitions: Intermittent uterine contractions leading to afterpains.

  • Occurrence: More frequent and intense in multiparas or those with overly distended uteri.

  • Influence of Breastfeeding: Increased afterpains due to suckling stimulating oxytocin release from the posterior pituitary, leading to uterine contractions.

Teaching for Bottle-Feeding Mothers

  • Bottle Feeding Frequency: Every 3-4 hours.

  • Bottle Positioning: Hold bottle at 45-degree angle; burp newborn every ounce.

  • Heating Formula: Prefer warming in hot water but never in microwave to prevent uneven heating (hot spots).

  • Avoid Propping: Risks of aspiration, dental caries, and ear infections.

  • Involvement: Encourage fathers/partners to assist with feedings for support.

Assessing the Fundus After Delivery

  • Technique (Post Vaginal Delivery):
      1. Place one gloved hand on fundus and one on symphysis pubis for support.
      2. Gently massage fundus in a circular motion.
      3. Assess firmness and location.
      4. Firm fundus should not be massaged unless soft.

  • Technique (Post Cesarean Delivery):
      1. Gently palpate the fundus with careful support.
      2. Assess the incision site while checking the fundus.

Storing Breast Milk

  • Time Frames for Storage:
      - Room Temperature: 4-6 hours in a tightly capped container.
      - Refrigerator (4°C [39°F]): up to 96 hours (4 days).
      - Freezer section: up to 2 weeks.
      - Deep freezer (−4°C [−18°C]): up to 6 months.
      - Thawed milk should not be refrigerated for longer than 24 hours.

Routine Practices for Infant Identification

  • Identification Method: Use wristbands for mother, newborn, and support person with preprinted details.

  • Matching Number Check: Verify matching wristband numbers upon separation/reunion.

  • Security Measures: Some bands/clamps contain microchips for alerts if the infant is removed from the unit.

Teaching Infant Bathing

  • Method of Teaching: Use teach-back method to ensure understanding; have family demonstrate.

  • Bathing Steps:
      1. Keep infant wrapped while washing hair.
      2. Wash face with clear water; ensure water temperature of 99-100.4°F.

Blood Stain Assessment on Postpartum Pads

  • Measurement Definitions:
      - Scant: <5 cm (2-inch) stain.   - **Light:** <10 cm (4-inch) stain.   - **Moderate:** <15 cm (6-inch) stain.   - **Large/Heavy:** >15 cm stain or saturated pad within 2 hours.
      - Excessive: Saturation of pad within 15 minutes.

Causes and Symptoms of Postpartum Hypovolemic Shock

  • Definition: Hipovolemic shock due to postpartum hemorrhage/clotting disorders.

  • Signs/Symptoms:
      - Tachycardia
      - Narrow pulse pressure (falling systolic, rising diastolic)
      - Pale, cold, clammy skin
      - Changes in mental state (anxiety, confusion, lethargy)
      - Decreased kidney perfusion leading to reduced urine output.

Care of Patient with Uterine Atony

  • Nursing Actions:
      - Massage fundus until firm.
      - Encourage urination (empty bladder).
      - Expel clots.
      - Support breastfeeding to stimulate uterine contraction.

Initial Management of Uterine Atony

  • If Boggy Fundus:
      - Massage fundus and facilitate breastfeeding.
      - Check for full bladder and encourage restroom use or catheterization.

  • Medications:
      - Common drugs include dilute oxytocin (Pitocin), Methylergonovine, Prostaglandins (e.g., Hemabate or Cytotec).
      - Methylergonovine contraindicated in hypertension.

Causes of Uterine Atony

  • Factors:
      - Uterine overdistention
      - Retained placental fragments
      - Prolonged labor
      - Medications during labor that relax the uterus (tocolytics)
      - Chorioamnionitis

Benefits of Breastfeeding for Uterine Tone and Maternal Health

  • Oxytocin Release: Infant suckling stimulates oxytocin secretion, promoting uterine contractions.

  • Nutritional Benefits of Breastmilk:
      - Ideal nutrient composition
      - Easily digestible
      - Reduces allergies and promotes immunity
      - Facilitates meconium elimination
      - Cost-effective and reduces contamination risks.

  • Maternal Advantages:
      - Aids in weight loss post-pregnancy, enhances bonding, and adjusts fluid needs based on infant requirements.

Mastitis: Overview and Management

  • Definition: Mastitis is breast infection typically occurring 2-3 weeks post-delivery.

  • Causes: Bacteria enter via cracks in nipples; often associated with engorgement.

  • Symptoms:
      - Redness, warmth, and tenderness in the affected breast
      - Possible purulent drainage.

  • Management: Antibiotics, milk removal, possible incision/drainage if an abscess develops.

  • Patient Teaching:
      - Practice hand hygiene before breastfeeding.
      - Keep the breast clean; expose nipple to air.
      - Ensure proper latch and encourage frequent breastfeeding to minimize infection risks.

Postpartum Complications

  • Common Complications:
      - Shock
      - Hemorrhage
      - Thromboembolic disorders
      - Puerperal infections
      - Subinvolution of the uterus
      - Mood disorders.

Clinical Manifestations of Phlebitis

  • Signs:
      - Local tenderness, redness, warmth
      - Slight edema at the vein above insertion site.

Preventative Care for Embolism

  • Methods:
      - Sequential compression devices (PCD)
      - Early ambulation
      - Anticoagulant therapy.

Do's and Don'ts for Phlebitis and Thrombus

  • Do's:
      - Elevate the leg
      - Use thrombolytic agents, encourage fluids
      - Apply warm, moist compresses; provide pain relief

  • Don'ts:
      - Massage affected area
      - Cross legs, prolonged sitting
      - Apply pressure or rub the site
      - Engage in vigorous movement.

Symptoms and Implications of Endometriosis

  • Signs/Symptoms:
      - Abdominal/pelvic pain, dysmenorrhea, dyspareunia
      - Painful BMs or urination, infertility
      - Chronic pain, heavy/irregular bleeding.

  • When to Report:
      - Severe pelvic pain not relieved by medication
      - Excessive or abnormal menstrual bleeding
      - Pain during intercourse affecting daily life

Clinical Manifestations of Postpartum Depression and Psychosis

  • Postpartum Depression Symptoms:
      - Lack of enjoyment in life, disinterest in relationships,
      - Feelings of inadequacy, guilt, difficulty concentrating,
      - Sleep/appetite disturbances, fatigue.

  • Postpartum Psychosis Symptoms:
      - Hallucinations, delusions, confusion,
      - Rapid mood swings, bizarre behavior, thoughts of self-harm.

Maternal Complications of Macrocosmic Infant Delivery

  • Complications Resulting From Delivery:
      - Hypotonic labor dysfunction, uterine atony
      - Trauma (tears, episiotomy)
      - Prolonged labor, uterine rupture, infection risk.

Pulmonary Embolism Symptoms and Assessment

  • Signs of Pulmonary Embolism:
      - Sudden chest pain, cough, dyspnea
      - Decreased consciousness, signs of heart failure
      - Small PE: shortness of breath, palpitations, hemoptysis, faintness.

Lochia Rubra Characteristics and Assessment

  • Normal Lochia Rubra:
      - Red, primarily blood, lasting up to 3 days; normal flow should not exceed one saturated pad/hour; small clots may be present but large clots are not.

  • Concerns: Constant bright red trickle may indicate hemorrhage or laceration.

Positive Homan’s Sign

  • Definition: Pain in calf upon dorsiflexion has implications for thrombophlebitis/DVT.

  • Symptoms of DVT:
      - Calf pain, tenderness, swelling, redness, warmth, color change, pallor (in deep veins).

Changes in Lab Values Post Delivery

  • WBCs: Elevated for 1 week, levels of 20,000-30,000 cells/mm³.

  • HgB/Hct Postpartum: Lowered, typically around 107-140 g/L.

Nursing Care for Anaphylactic Shock

  • Definition: Caused by allergic responses to medication.

  • Actions: Immediate removal of the cause, start resuscitation measures.
      - Continual monitoring of airway, breathing, and circulation is crucial; administer oxygen and prepare for epinephrine.
      - Position the patient to support circulation, monitor for recurrent reactions, and educate on avoidance of triggers.

Antidotes for Common Anticoagulants

  • Warfarin Antidote: Vitamin K

  • Heparin Antidote: Protamine Sulfate

Breast Self Examination (BSE) Instructions

  • Recommendation: Women >20 years should perform BSE to familiarize with breast tissue.

  • Ideal Timing: 1 week after menstrual period.

  • Inspection Steps:
      1. Inspect breasts from various angles and positions (arms at sides, over head).
      2. Squeeze nipples for discharge.

  • Lying Down Method:
      1. Use pillows for support and systematic checking.

  • Shower Method:
      1. Use soapy hands in systematic pattern to check breasts.

Cervical Mucus and Fertility

  • Function and Characteristics of Mucus:

  • Pre-ovulation: thick and sticky

  • Ovulation: becomes slippery, elastic, resembling raw egg whites, indicating peak fertility.

Preterm Infant Physical Characteristics

  • Skin: Transparent and loose; superficial veins visible.

  • Fat: Lack of subcutaneous fat; presence of fine lanugo on forehead, shoulders, and arms.

  • Vernix: Abundant cheese-like vernix caseosa.

  • Body Features: Short extremities, protruding abdomen, few creases on soles of feet, small genitalia, open labia majora in girls, poor ear cartilage development, disproportionally large head, weak reflexes, and poor muscle tone.

Contraindications for Hormone Replacement Therapy (HRT)

  • Risks Include:
      - History of endometrial or breast cancer
      - History of thromboembolic disorders
      - Acute or chronic liver disease
      - Coronary artery disease
      - Elevated triglycerides
      - Undiagnosed vaginal bleeding.