Postpartum & Newborn Nursing

Ana H. Corona, MSN, FNP-C FNPNursing Instructor October 2007 Revised February 2009

The Postpartum Period



 

Puerperium: Term 1st 6 weeks after the birth of an infant Neonate newborn from birth to 28 days. Family adaptation to neonate: Bonding rapid process of attachment during 1st 30 to 60 minutes after birth Mother, father, siblings, grandparents

Factors Affecting Family Adaptation

   

    

Parental fatigue Previous experience with a newborn Parental expectations of newborn Knowledge of and confidence in providing for newborn needs Temperament of the newborn Temperament of parents Age of parents Available support system Unexpected events

Postpartum Assessment


VS, amount of lochia, presence of edema, fundal height and firmness, status of perineum, bladder distension 1 to 2 hrs after delivery: every 15 minutes If no problems every 8 hours

 

KNOW YOUR PATIENT --- DELIVERY HISTORY /ADMISSION/TRANSITION ASSESSMENT:

 

   

Gravida, parity / Time and type of delivery Anesthesia or medications / Risk factors for PPH Medical history / Routine medications / Allergies Infant status / Breast/bottle Rubella immune? Rh Negative? Drug/ETOH Abuse

Body Systems Assessment

         

Vital signs Level of pain Neurological Pulmonary Cardiovascular Musculoskeletal Gastrointestinal Genitourinary Integumentary Psychosocial

Vital Signs
Day 1 Heart Rate Respirations B/P Temperature 50 to 70 bpm Normal Normal 100.4 normal 24 hrs.
Muscular exertion/dehydration

Day 2 and after Bradycardia or normal Normal Normal Normal If 100.4 suspect
infection

Postpartum Physical Assessment

     

B - breast U - uterus B - bowels B - bladder L - lochia E - episiotomy

General Assessment
   

Enter the room quietly, speak quietly. Wash hands and provide for privacy. Inform patient before turning on lights. Note LOC, activity level, position, color, general demeanor. Take note of the total environment:
 

Safety/patient considerations Note equipment and medical devices

Breast Assessment


Breasts: Soft, engorged, filling, swelling, redness, tenderness. Nipples: Inverted, everted, cracked, bleeding, bruised, presence of colostrum or breastmilk. Colostrum yellowish fluid rich in antibodies and high in protein. Engorgement occurs by day 3 or 4. Due to vasoconstriction as milk production begins Lactation ceases within a week if breastfeeding is never begun or is stopped.

Assessing Uterine Fundus



 

 

Location in relation to umbilicus Degree of firmness Is it at Midline or deviated to one side? Bladder Full? A boggy uterus may indicate uterine atony or retained placental fragments. Boggy refers to being inadequately contracted and having a spongy rather than firm feeling.

Massaging the Fundus



 

Every 15 mins during the 1st hr, every 30 mins during the next hr, and then, every hr until the patient is ready for transfer. Document fundal height. Evaluate from the umbilicus using fingerbreadths. This is recorded as 2 fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth. The fundus should remain in the midline. If it deviates from the middlemiddle- distended bladder. bladder.

Uterine Involution


Uterine Involution: return of the uterus to its preprepregnancy size and condition Uterine fundal descent: uterus size of grapefruit immediately after birth Fundus half way between umbilicus and symphysis pubis Fundus rises to the umbilicus stays for 12 hours Descends 1 cm (fingerbreadth) each day for about 10 days

Uterine Atony
   

Lack of muscle tone in the cervix. Uterus feels soft and boggy After delivery: Postpartum diuresis The bladder has increased capacity and decreased muscle tone. This leads to over-distension of the overbladder, incomplete emptying of bladder, retention of residual urine and increased risk of UTI and postpartum hemorrhage.

Bowels & Bladder

   

When was the patients last BM? Is she passing flatus? (gas) Assess for bowel sounds Voiding pattern - without difficulty/pain, urine may be blood tinged from lochia Nursing interventions: Assist to the bathroom. Use measures to encourage voiding (privacy). Encourage use of peri-bottle with warm water, fluids, fiber, frequent ambulation, stool softeners; teach effects of pain medication.

Lochia Assessment
   

Lochia vaginal discharge after childbirth. It takes 6 weeks for the vagina to regain its preprepregnancy contour. Lochia: scant-moderate, rubra, serosa or alba Assessment of lochia includes noting color, presence and size of clots and foul odor. Day 1- 3 - lochia rubra (blood with small pieces 1of decidua and mucus) Day 4-10 lochia serosa (pink or pinkish brown 4serous exudate with cervical mucus, erythrocytes and leukocytes) leukocytes) Day 11- 21 - lochia alba (yellowish white 11discharge)

 

Lochia: Pad Count

1. 2. 3. 4.   

Scant: 1-inch stain on pad in 1 hour Light/small: 4 inches in 1 hour Moderate: 6 inches in 1 hour Heavy/large: Pad saturated in 1 hour Excessive: Pad saturated in 15 min Can estimate blood loss by weighing pads: 500 mL = 1 lb. or 454 g

Episiotomy/Perineal Assessment
 

Patient in lateral Sims (side lying) position. Use the acronym REEDA (redness, edema, ecchymosis, discharge, approximation of suture lines edges of episiotomy ) to guide assessment. Even if there is no episiotomy, the perineum should still be assessed. Unusual perineal discomfort may be a symptom of impending infection or hematoma. Hemorrhoids ?

Episiotomy Pain Relief

 

Instruct Mother: Tighten her buttocks and perineum before sitting to prevent pulling on the episiotomy and perineal area and to release tightening after being seated. Rest several times a day with feet elevated. Practice Kegel exercise many times a day to increase circulation to the perineal area and to strengthen the perineal muscles.

Assessment of Edema & Homan s Sign



Assess legs for presence and degree of edema; may have dependent edema in feet and legs. Assess for Homan s sign- thromboembolism should be negative Press down gently on the patient s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)

Homan s Sign

Thromboembolic Conditions


Thrombophlebitis the formation of a clot in an inflamed vein. Risk factors include maternal age over 35, cesarean birth, prolonged time in stirrups, obesity, smoking, and history of varicosities or venous thromboses. Prevention: client needs to ambulate early after delivery.

Postpartum Cesarean
 

 

  

Incision site redness swelling, discharge. Intact? Abdomen soft, distended? Bowel sounds heard all 4 quadrants Flatus? Lochia is less amount than in normal spontaneous vaginal delivery (NSVD) because uterus is wiped with sponges during c/section. If lochia indicates excessive bleeding, combine palpation and pain management measures. Auscultate breath sounds Fluid intake and output Pain?

RhoGAM


It is given to an Rh- mother within 72 Rhhours after delivery of an Rh+ infant or if Rh+ the Rh is unknown. The dose must be repeated after each subsequent delivery. RhoGAM 300 mcg is the standard dose.

Postpartum Disseminated Intravascular Coagulation

 

Abnormal stimulation of clotting mechanism. Normally, the body forms a blood clot in reaction to an injury. Small blood clots throughout the body, depleting the body of clotting factors and platelets. Massive bleeding Causes may include amniotic fluid clots, fetal demise, abruptio placenta. Eclampsia or Retained placenta Symptoms: Sometimes severe bleeding and sudden bruising .

Postpartum Hemorrhage
 

  

Blood loss of more than 500 ml after vaginal birth or 1,000 ml after a cesarean birth. Early hemorrhage Cervical or vaginal tears, uterine atony, retained placental fragments, lacerations, hematomas. Late hemorrhage subinvolution, retained placental fragments. Subinvolution: failure of the uterus to return to normal size. Management may include CBC, sedimentation rate, type and cross, fluid resuscitation with normal saline and blood, vaginal examination, diagnosis, and correction of the underlying cause.

Postpartum Depression


Postpartum depression is a nonpsychotic depressive episode that begins in the postpartum period due to decreased estrogen level Symptoms: changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feeling of worthlessness or guilt; difficulty thinking, concentrating or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts.

Postpartum Psychosis


A very serious type of PPD illness that can affect new mothers. Begin 2-3 weeks post 2delivery Fatigue, restlessness, insomnia, crying liable emotions, inability to move, irrationally statements incoherence confusion and obsessive concerns about the infant s health Psychiatric emergency

Nipple soreness is a portal of entry for bacteria - breast infection (Mastitis). Maternal after pains: may be due to breastfeeding and multiparity Always stay with the client when getting out of bed for the first time hypotension effect and excess bleeding When assessing fundal height, if you notice any discrepancies in fundal height have patient void and then reassess.

Nursing Diagnosis Related to Breasts and Breastfeeding



Pain r/t improper positioning, engorged breasts Ineffective breastfeeding r/t maternal discomfort, improper infant positioning Knowledge deficit r/t normal physiologic changes, breastfeeding Infection r/t improper breastfeeding techniques, improper breast care

The Newborn

Newborn s Immediate Needs

   

Airway Breathing Circulation Warmth

The Newborn


Neonatal transition: 1st few hours after birth newborn stabilizes respiratory and circulatory functions. When the cord is clamped, placental gas exchange ceases. These changes stimulate carotid and aortic chemoreceptors which send impulses to the respiratory center in the medulla. A brief period of asphyxia stimulates respirations.

Apgar Score


Assesses the infants cardiopulmonary adaptations to extrauterine life Provides a quick evaluation on how the heart and lungs are adapting 5 items to be assessed 1 and 5 minutes after birth.

Apgar Score
    

Heart rate, respiratory rate, muscle tone, reflex irritability and color Score of 0 2 for each item, then totaled. Apgar Score 8 or higher no intervention Apgar Score 4 8 gentle rubbing, oxygen Apgar Score 0 4 resuscitation Points Given 0 1 2 Some Active motion/well motion/flexion flexed <100 bts/min Grimace Body pink, extremities blue >100 bts/min Cry, cough, sneeze Pink all over Absence of cyanosis

A Activity/muscle Limp/flaccid tone P Pulse Rate Absent

G Grimace/Reflex No Response Irritability A Appearance/ Skin Color Blue, Pale

R Respiration

Absent

Slow weak cry Good Cry

Prophylactic Care


Vitamin K to prevent hemorrhagic disorders vit k (clotting process) is synthesized in intestine requires food for this process. Newborn s stomach is sterile has no food. aquaMEPHYTON Hepatitis B vaccination within the first 12 hours Eye prophylaxis (Erythromycin Ointment) to prevent ophthalmia neonatorum gonorrhea/chlamydia

Newborn: Intramuscular injection

  

aquaMEPHYTON (Vit.K) 1 mg/0.5 ml IM lateral thigh Vastus lateralis

Vital Signs
 

Temperature - range 36.5 to 37 axillary (97.7-98.6) (97.7Axillary vs Rectal about 0.2 to 0.5 difference Common variations  Crying may elevate temperature  Stabilizes in 8 to 10 hours after delivery Heart rate - range 120 to 160 beats per minute


Apical pulse for one minute Heart rate range to 100 when sleeping to 180 when crying Color pink with acrocyanosis Heart rate may be irregular with crying

Common variations
  

 

Respiration - range 30 to 60 breaths per minute Blood pressure - not done routinely


Ranges between 60-80 mm systolic and 40-45 mm diastolic. 6040diastolic.

Reflexes: indicate neurological integrity

     

Rooting Sucking Extrusion Palmar grasp Plantar grasp Tonic neck

    

Moro Gallant Stepping Babinski s Crossed extension reflex Placing

Reflexes
 

 

Tonic Neck Reflex (FENCING) EXTENDS arm & leg on the side that the face points. Flexes opposite arm & leg 6-8 wks to 6 months

 

Moro Reflex Birth to 4-6 months 4-

Rooting and Sucking Reflexes



Birth to 3-4months 3-

Birth to 10 months

Babinski and Palmer Grasping Reflex

   

Babinski Reflex is (+) This is Normal Birth to after walking 1212-18 months age

Birth to 4 months

Skin
 

    

Expected findings Skin reddish in color, smooth and puffy at birth At 24 - 36 hours of age, skin flaky, dry and pink in color Edema around eyes, feet, and genitals Vernix caceosa Lanugo (baby hair) Turgor good with quick recoil Hair silky and soft with individual strands

Common Normal Variations

 

Acrocyanosis - result of sluggish peripheral circulation. Mongolian Spots: Patch of purple-black or Spots: purpleblueblue-black color distributed over coccygeal and sacral regions of infants of AfricanAfricanAmerican or Asian descent. Milia: Milia: Tiny white bumps papules (plugged sebaceous glands) located over nose, cheek, and chin. Erythema toxicum: Most common newborn rash. toxicum:
Variable, irregular macular patches. Lasts a few days.

Erythema toxicum, acrocyanosis, milia and mongolian spots

Hyperbilirubinemia
 

 

Physiologic Jaundice =Appears 24 hours after birth peaks at 72 hrs. Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days. Due to Unconjugated bilirubin circulating in the blood stream that is deposited in the skin. Immature liver unable to conjugate bilirubin released by destroyed RBC. Pathologic Jaundice =Not appear until after 24 hrs leads to Kernicterus (deposits of bili in brain). Bilirubin >20mg/dl The most common cause is Rh incompatibility.

The Head and Chest



 

The Head: Anterior Head: fontanel diamond shaped 2-3 - 3-4 cms Posterior fontanel triangular 0.5 - 1 cm Fontanels soft, firm and flat head circumference is 33 35 cm The head is a few centimeters larger than the chest!!!! The Chest: circumference is 30.5 33 cm

Anterior and Posterior Fontanelles



 

Anterior diamond shaped 2-3 23-4 cms Posterior triangular 0.5 - 1 cm Fontanels soft, firm and flat

Molding is shaping of fetal head to adapt to the mothers pelvis during labor.

Caput succedaneum


Swelling of the soft tissue of the scalp caused by pressure of the fetal head on a cervix that is not fully dilated. Swelling is generalized. may cross suture line and decreases rapidly in a few days after birth. Requires no treatment 2 3 days disappears

Cephalohematoma


Collection of blood between the periosteum and skull of newborn. Does not cross suture lines Caused by rupturing of the periosteal bridging veins due to friction and pressure during labor. Lasts 3 6 weeks

Bathing the Newborn



No tub bath until after the cord has fallen off and healing is complete. Newborn s first bathbaththe nurse needs to wear gloves to prevent infection. What is wrong with this nursing action?

Gestational Age Relationship to Intrauterine Growth



 

Normal range of birth weight for each week of gestation. Birth weight is classified as follows: Large for gestational age (LGA): weight falls above the 90th percentile for gestational age Appropriate for gestational age (AGA): weight falls between the 90th and 10th percentile for gestational age Small for gestational age (SGA): weight falls below the 10th percentile for gestational age

Intrauterine Growth Grid

Circumcision
         

Circumcision is considered an elective procedure Anesthesia should be provided. Parents must give written consent Full term health infants Aftercare: Check hourly for 12 hours Check for bleeding and voiding Before discharge: discharge: Newborn goes home within the first 12 hours after procedure Bleeding should be minimal and infant must void Ensure that parents know how to care for the circumcision.

Breastfeeding
   

 

Colostrum is rich in immunoglobulins to protect newborn GI tract from infection; laxative effect. Breast milk in 2 weeks sufficient nutrients 20 kcal/oz (infant s nutritional needs) To support Breastfeeding: Mother needs to consume extra 500 calories per day. Feeding length: should be long enough to remove all the foremilk (watery 1st milk from breast high in lactose - skim milk & effective in quenching thirst) Hindmilk: higher in fat content leads to weight gain and more satisfying. Breastfeeding time approximately 30 minutes

Infant Formula


Formula 7.5 ml to 15 ml at feeding gradually increase to 90 ml to 120 ml at each feeding in 2 weeks. Formula preparation: mixing must be accurate to provide the 20 kcal/oz. kcal/oz. (newborn nutritional need) Burping: is needed to expel air swallowed when infant sucks. Should be done about way through feeding for bottle feeders and when changing breasts for breast feeders.

Respiratory Distress


   

  

2 types: Respiratory Distress Syndrome (RDS) and Transient Tachypnea of the Newborn (TTN) RDS: preterm infants/surfactant deficiency Hypoxia, respiratory acidosis and metabolic acidosis Surfactant is produced by alveoli - lung maturity L/S ratio 2:1 is a test done before birth to determine fetal lung maturity TTN: AGA, near term infants Intrauterine or intrapartum asphyxia Newborn unable to clear airway of lung fluid, mucous or amniotic fluid aspiration. Expiratory grunting nasal flaring, tachypnea with respirations as high as 100 to 140 breaths/minute.

Neural Tube Defects

 

 

3 types: Spina Bifida Occulta: failure of the vertebral Occulta: arch to close. Has dimple on the back with a tuft of hair. No treatment required. Meningocele: Meningocele: saclike protrusion along the vertebral column filled with cerebrospinal fluid and meninges. Surgery required. Myelomeningocele: Myelomeningocele: saclike protrusion along the vertebral column filled with spinal fluid meninges, nerve roots, and spinal cord = paralysis. Surgical repair required. Sterile saline dressing. hydrocepalus

 

meningocele

Spina bifida occulta

Spina bifida Occulta

myelomeningocele

Infants of DM mothers (IDM) Complications



 

 

Hypoglycemia: maternal glucose declines at birth. Infant has high level of insulin production= decreases infant s blood glucose within hours after birth. Respiratory Distress: less mature lungs due to insulin Hyperbilirubinemia: Hyperbilirubinemia: hepatic immaturity, increased hematocrit, bruising due to difficult delivery. Birth trauma: large size of infant trauma: Congenital birth defects: birth defects defects: Patent Ductus Arteriosus, Ventricular Septal Defect and more.