Postpartum & Newborn Nursing

1. Postpartum & Newborn Nursing Ana H. Corona, MSN, FNP-C Nursing Instructor October 2007 Revised February 2009

2. 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

3. 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

4. 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

5. 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

6. Body Systems Assessment • Vital signs • Level of pain • Neurological • Pulmonary • Cardiovascular • Musculoskeletal • Gastrointestinal • Genitourinary • Integumentary • Psychosocial

7. Vital Signs

8. Postpartum Physical Assessment • B - breast • U - uterus • B - bowels • B - bladder • L - lochia • E - episiotomy

9. 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

10. 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.

11. 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.

12. 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 middle- distended bladder.

13. Uterine Involution • Uterine Involution: return of the uterus to its pre-pregnancy 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

14. 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 bladder, incomplete emptying of bladder, retention of residual urine and increased risk of UTI and postpartum hemorrhage.

15. 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.

16. Lochia Assessment • Lochia–vaginal discharge after childbirth. • It takes 6 weeks for the vagina to regain its pre-pregnancy 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 of decidua and mucus)   • Day 4-10 – lochia serosa (pink or pinkish brown serous exudate with cervical mucus, erythrocytes and leukocytes) • Day 11- 21 - lochia alba (yellowish white discharge)

17. Lochia: Pad Count • 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

18. 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 ?

19. 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.

20. 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)

21. Homan’s Sign

22. 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.

23. 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?

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

25. 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 .

26. 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.

27. 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.

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

29. 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.

30. 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

31. The Newborn

32. Newborn’s Immediate Needs • Airway • Breathing • Circulation • Warmth

33. 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.

34. 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.

35. 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

36. 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

37. Newborn: Intramuscular injection • aquaMEPHYTON (Vit.K) • 1 mg/0.5 ml IM lateral thigh • Vastus lateralis

38. Vital Signs • Temperature - range 36.5 to 37 axillary (97.7-98.6) • Axillary 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 Common variations • Heart rate range to 100 when sleeping to 180 when crying • Color pink with acrocyanosis • Heart rate may be irregular with crying • Respiration - range 30 to 60 breaths per minute • Blood pressure - not done routinely • Ranges between 60-80 mm systolic and 40-45 mm diastolic.

39. Rooting Sucking Extrusion Palmar grasp Plantar grasp Tonic neck Moro Gallant Stepping Babinski’s Crossed extension reflex Placing Reflexes: indicate neurological integrity

40. Reflexes • Moro Reflex • Birth to 4-6 months • Tonic Neck Reflex (FENCING) • EXTENDS arm & leg on the side that the face points. • Flexes opposite arm & leg • 6-8 wks to 6 months

41. Rooting and Sucking Reflexes • Birth to 3-4months • Birth to 10 months

42. Babinski and Palmer Grasping Reflex • Babinski Reflex is (+) • This is Normal • Birth to after walking • 12-18 months age • Birth to 4 months

43. Skin • Expected findings • Skin reddish in color, smooth and puffy at birthAt 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

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

45. Erythema toxicum, acrocyanosis, milia and mongolian spots

46. 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.

47. The Head and Chest • The Head: Anterior 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

48. Anterior and Posterior Fontanelles • Anterior diamond shaped 2-3 - 3-4 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.

49. 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

50. 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