● She prefers to get her own washcloth and to make her
Mcn CHAPTER 17
postpartal period/ puerperium
● refers to the 6-week period after childbirth.
● It is a time of maternal changes that are both
retrogressive (involution of the uterus and vagina) and
progressive (production of milk for lactation, restoration
of the normal menstrual cycle, and beginning of a
parenting role).
● The period is popularly termed the fourth trimester of
pregnancy
PSYCHOLOGICAL CHANGES IN PREGNANCY
Transition
● is a movement or passage from one position or concept
to another or a pause between what was and what is to
be.
● It represents the internal process experienced by people
when change occurs. In a classic presentation of what
transition entails
● transition is how they respond to that change.
People move through several predictable stages during Transition:
1st
letting go
● is the act of ending old ways of thinking or believing; next,
there is a neutral zone, during which the old way is gone
but the new way is not yet comfortable;
2nd
● there is a new beginning, during which new ideas and
concepts are put into action
The postpartum period is a time of transition, during which a couple
gives up concepts such as “childless” or “parents of one” and
moves to the beginning of new parenthood.
PHASES OF PUERPERIUM
taking-in phase
● a time when the new parents review their pregnancy and
the labor and birth.
subsequent phases,
● taking-hold phase and the letting-go phase,
● are times of renewed action and forward movement.
● At the time these phases of the puerperium were
identified, women were hospitalized for 5 to 7 days after
childbirth and moved in a paced manner from one step
to the next.
Taking-In Phase
● the first phase experienced is a time of reflection.
● During this 2- to 3-day period, a woman is largely
passive.
● She prefers having a nurse minister to her (such as
bringing her a bath towel or a clean nightgown) and make
decisions for her, rather than do these things herself.
● This dependence results partly from her physical discomfort
because of afterpains or hemorrhoids; partly from her uncertainty
in caring for her newborn; and partly from the extreme exhaustion
that follows childbirth.
● the woman usually wants to talk about her pregnancy, especially
about her labor and birth
Taking-Hold Phase
● After a time of passive dependence, a woman begins to
initiate action.
own decisions.
● Women who give birth without any anesthesia may
reach this second phase in a matter of hours after
birth.
● a woman may have expressed little interest in caring for her child.
● Now, she begins to take a strong interest.
● it is always best to give a woman brief demonstrations of baby care
and then allow her to care for her child herself—with watchful
guidance.
● she often still feels insecure about her ability
Letting-Go Phase
● In the third phase, called letting-go, a woman finally
redefines her new role.
● She gives up the fantasized image of her child and
accepts the real one;
● she gives up her old role of being childless or the mother
of only one or two (or however many children she had
before this birth).
● This process requires some grief work and readjustment of
relationships, similar to what occurred during pregnancy
● It is extended and continues during the child’s growing years. A
woman who has reached this phase is well into her new role
Development of Parental Love and Positive Family Relationships
During pregnancy, almost every woman worries about her ability to be a “good”
mother, and this concern does not evaporate as soon as the baby is born
. Some fathers admit they have difficulty “claiming” or bonding with an infant
(feeling fatherly toward the new child) until as late as 3 months after the birth,
● Soon, she feels comfortable enough to press her cheek
against the baby’s or kiss the infant’s nose or mouth/ she
has become a mother tending to her child.
● This identification process is termed claiming or
bonding.
Looking directly at her newborn’s face, with direct eye contact
(termed an en face position), is a sign a woman is beginning
effective interaction.
● Many fathers can be observed staring at a newborn for
long intervals in this same way.
● Often termed engrossment, this action alerts caregivers
to how actively the father, as well as the mother, is
beginning bonding.
Rooming-In
● The more time a woman has to spend with her baby, the
sooner she may feel competent in child care, and the
more likely she may be to form a sound mother–child
relationship
● . If her infant stays in the birthing room with her (called
rooming-in) rather than in a central nursery,
2 types of rooming in:
complete,
● in which the mother and child are together 24 hours a day
Partial
● in which the infant remains in the woman’s room for most
of the time, perhaps from 8:00 AM to 9:00 PM, but then
the infant is taken to a small nursery near the woman’s
room or returned to a central nursery for the night
Sibling Visitation
● Separation from children is often as painful for a mother
as it is for her children. Waiting at home, separated from
their mother and listening only to telephone reports of
what a new brother or sister looks like, can be very
difficult for older children
Maternal Concerns and Feelings in the Postpartal Period

Typical issues identified by postpartal women include breast

soreness; regaining their figure; regulating the demands of
housework, their partner, and their children; coping with emotional
tension and sibling jealousy; and fatigue.

Overlooked/forgotten
● Many mothers, if given the opportunity, admit to feeling
abandoned and less important after giving birth than they
did during pregnancy or labor.
● Only hours before, they were the center of attention, with
everyone asking about their health and well-being.
Disappointment/disillusionment
● . Handle the child warmly, to show that you find the infant
satisfactory or even special. Comment on the child’s good
The Uterus
points, such as long fingers, lovely eyes, and good
● Involution of the uterus involves two main processes.
appetite
Postpartal Blues
First,
● During the postpartal period, as many as 50% of women
● the area where the placenta was implanted is sealed off
experience some feelings of overwhelming sadness
to prevent bleeding.
● They may burst into tears easily or feel let down or
Second,
irritable.
● the organ is reduced to its approximate pregestational
● This temporary feeling after birth has long been known as
size.
the “baby blues.”
● This phenomenon may be caused by hormonal changes,
The sealing of the placenta site is accomplished by rapid
particularly the decrease in estrogen and progesterone
contraction of the uterus immediately after delivery of the placenta.
that occurs with delivery of the placenta.
This contraction pinches the blood vessels entering the 7-cm-wide
● For some women, it may be a response to dependence
area left denuded by the placenta and stops bleeding.
and low self-esteem caused by exhaustion, being away
from home With time, thrombi form within the uterine sinuses and permanently seal the
● . The syndrome is evidenced by tearfulness, feelings of area. Eventually, endometrial tissue undermines the site and obliterates the
inadequacy, mood lability, anorexia, and sleep organized thrombi, covering and healing the area so completely that the process
disturbance leaves no scar tissue within the uterus and does not compromise future
implantation sites.
30% of women experience a more serious level of sadness after birth
the fundus of the uterus may be palpated through the abdominal wall,
or postpartal depression
halfway between the umbilicus and the symphysis pubis, within a
few minutes after birth.
PHYSIOLOGIC CHANGES IN POSTPARTAL PERIOD

Retrogressive physiologic changes that occur during the
postpartal period include those related specifically to the reproductive
system as well as other systemic changes
Reproductive System
Involution
● is the process whereby the reproductive organs return to
their nonpregnant state.
● A woman is in danger of hemorrhage from the denuded
surface of the uterus until involution is complete
One hour later, it will have risen to the level of the umbilicus, where
it remains for approximately the next 24 hours
● . From then on, it decreases one fingerbreadth per day—on the
first postpartal day, it will be palpable one fingerbreadth below the
umbilicus;
● on the second day, two fingerbreadths below the umbilicus; and
so on.
Because a fingerbreadth is about 1 cm, this can be recorded as 1 cm below the
umbilicus, 2 cm below it, and so forth. In the average woman, by the ninth or
tenth day, the uterus will have contracted so much that it is withdrawn into the
pelvis and can no longer be detected by abdominal palpation

Uterine involution may be delayed by a condition such as the birth of multiple

fetuses, hydramnios, exhaustion from prolonged labor or a difficult birth, grand
multiparity, or physiologic effects of excessive analgesia.

❖ Whenever the fundus feels boggy (soft or flabby), it is not as

contracted as it should be, despite its position in the abdomen

The first hour after birth is potentially the most dangerous time for a
woman.

If her uterus should become relaxed during this time (uterine atony),
she will lose blood very rapidly, because no permanent thrombi have
yet formed at the placental site
.
In some women, contraction of the uterus after birth causes
intermittent cramping termed afterpains, similar to that
accompanying a menstrual period.

Afterpains tend to be noticed most by multiparas rather than primiparas and by

women who have given birth to large babies or multiple births.
Lochia
● The separation of the placenta and membranes occurs in
the spongy layer or outer portion of the decidua basalis of
the uterus.
● By the second day after birth, the layer of decidua
remaining under the placental site (an area 7 cm wide)
and throughout the uterus differentiates into two distinct
layers.
● This uterine flow, consisting of blood, fragments of
decidua, white blood cells, mucus, and some bacteria
The portion of the uterus where the placenta was not attached is so
fully cleansed by this sloughing process that it will be in a
reproductive state in about 3 weeks’ time
. It takes approximately 6 weeks (the entire postpartal period) for the
placental implantation site to be healed.
lochia rubra.
● For the first 3 days after birth, a lochia discharge
consists almost entirely of blood, with only small particles
of decidua and mucus.
lochia serosa
● As the amount of blood involved in the cast-off tissue
decreases (about the fourth day) and leukocytes begin to
invade the area, as they do with any healing surface, the
flow becomes pink or brownish
lochia alba
● On about the 10th day, the amount of the flow decreases
and becomes colorless or white .
● Lochia alba is present in most women until the third week
after birth, although it is not unusual for a lochia flow to
last the entire 6 weeks of the puerperium
The Cervix
● Immediately after birth, a uterine cervix is soft and
malleable.
● Both the internal and external os are open. Like
contraction of the uterus, contraction of the cervix toward
its prepregnant state begins at once.
● By the end of 7 days, the external os has narrowed to
the size of a pencil opening; the cervix feels firm and
nongravid again.
The Vagina
● After a vaginal birth, the vagina is soft, with few rugae,
and its diameter is considerably greater than normal. The
hymen is permanently torn and heals with small, separate
tags of tissue.
● It takes the entire postpartal period for the vagina to
involute (by contraction, as with the uterus) until it
gradually returns to its approximate prepregnancy state.
Thickening of the walls also appears to depend on renewed
estrogen stimulation from the ovaries.
● Because a woman who is breastfeeding may have delayed
ovulation,
● continue to have thin-walled or fragile vaginal cells that cause
slight vaginal bleeding during sexual intercourse until about 6
weeks’ time.
The Perineum
● Because of the great amount of pressure experienced
during birth, the perineum feels edematous and tender
immediately after birth.
● Ecchymosis from ruptured capillaries may show on the
surface.
● The labia majora and labia minora typically remain atrophic and
softened after birth, never returning to their prepregnancy state.
The Hormonal System
● Pregnancy hormones begin to decrease as soon as the
placenta is no longer present.
● Levels of human chorionic gonadotropin (hCG) and
human placental lactogen (hPL) are almost negligible by
24 hours. By week 1, progestin, estrone, and estradiol are
all at prepregnancy levels.
● Estrol may be elevated for an additional week before it
reaches prepregnancy levels.
● Follicle-stimulating hormone (FSH) remains low for
about 12 days and then begins to rise as a new menstrual
cycle is initiated.
The Urinary System
● During pregnancy, as much as 2000 to 3000 mL excess
fluid accumulates in the body.
● An extensive diuresis begins to take place almost
immediately after birth to rid the body of this fluid.
● This easily increases the daily output of a postpartal
woman from a normal level of 1500 mL to as much as
3000 mL/day during the second to fifth day after birth
The hydronephrosis or increased size of ureters that occurred
during pregnancy remains present for about 4 weeks after birth.
The increased size of these structures, in conjunction with reduced bladder
sensitivity, increases the possibility of urinary stasis and urinary tract infection in
the postpartal period.
During the entire postpartal period, urine tends to contain more
nitrogen than normal.
❖ This is probably due in part to a woman’s increased
muscle activity during labor and in part to the breakdown
of protein in a portion of the uterine muscle that occurs
during involution.
❖ Lactose levels in the urine are slightly elevated the same as during
pregnancy, as the body prepares for breastfeeding.
❖ Diaphoresis (excessive sweating) is another way by
which the body rids itself of excess fluid. This is
noticeable in women soon after birth.
The Circulatory System
The diuresis that is evident between the 2nd and 5th days after birth, as well as
the blood loss at birth, acts to reduce the added blood volume a woman
accumulated during pregnancy.
● The usual blood loss with a vaginal birth is 300 to 500
mL.
● With a cesarean birth, it is 500 to 1000 mL.
● A 4-point decrease in hematocrit (proportion of red blood cells to
circulating plasma) and a 1-g decrease in hemoglobin value occur
with each 250 mL of blood lost.
 ● Women usually continue to have the same high level of
plasma fibrinogen during the first postpartal weeks as
they did during pregnancy.
● This is a protective measure against hemorrhage.
● this high level also increases the risk of thrombus
formation.
● There is also an increase in the number of leukocytes in the
blood. The white blood cell count may be as high as 30,000
cells/mm3 (granulocytes) compared to a normal level of 5000 to
10,000 cells/mm3 , particularly if labor was long or difficult.
The Gastrointestinal System
● Digestion and absorption begin to be active again soon after birth
unless a woman has had a cesarean birth.
● Almost immediately, the woman feels hungry and thirsty and she
can eat without difficulty from nausea or vomiting during this time.
● Hemorrhoids (distended rectal veins) that have been
pushed out of the rectum because of the effort of
pelvic-stage pushing often are present.
● Bowel sounds are active, but passage of stool through
the bowel may be slow because of the still-present effect
of relaxin on the bowel
The Integumentary System
After birth, the stretch marks on a woman’s abdomen (striae
gravidarum) still appear reddened and may be even more prominent
than during pregnancy.
● in a Caucasian woman, these will fade to a pale white
over the next 3 to 6 months;
● in an African American woman, they may remain as
areas of slightly darker pigment. Excessive pigment on
the face and neck (chloasma) and on the abdomen (linea
nigra) will become barely detectable in 6 weeks’ time.
● If diastasis recti (overstretching and separation of the
abdominal musculature) is present, the area will appear
slightly indented
● . If the separation is large, it will appear as a bluish area
in the abdominal midline.
● Modified sit-ups help to strengthen abdominal muscles
and return abdominal support to its prepregnant level
Effects of Retrogressive Changes
The overall effects of postpartal retrogressive changes are
exhaustion and weight loss.
Exhaustion
As soon as birth is completed, a woman experiences total exhaustion. For the
last several months of pregnancy, she probably has experienced some difficulty
sleeping.
Now she has “sleep hunger,” which may make it difficult for her to cope with new
experiences and stressful situations until she has enjoyed a sustained period of
sleep.
Weight Loss
The rapid diuresis and diaphoresis during the second to fifth days
after birth usually result in a weight loss of 5 lb (2 to 4 kg)
● ,12 lb (5.8 kg) lost at birth.
● Lochia flow causes an additional 2- to 3-lb (1-kg) loss,
for a total weight loss of about 19 lb
Vital Sign Changes
Vital sign changes in the postpartum period reflect the internal
adjustments that occur as a woman’s body returns to its prepregnant
state.
Temperature
● Temperature is always taken orally or tympanically
(never rectally) during the puerperium, bc danger of
vaginal contamination and the discomfort involved in
rectal intrusion.
● a slight increase in temperature during the first 24 hours after birth
bc of dehydration during labor.
● If she receives adequate fluid during the first 24 hours, this
temperature elevation will return to normal.
● Most women are thirsty after birth
● . Any woman whose oral temperature rises above 100.4°
F (38° C), excluding the first 24-hour period, is considered
by criteria of the Joint Commission on Maternal Welfare to
be febrile.
● In such women, a postpartal infection may be present
Occasionally, when a woman’s breasts fill with milk on the
3rd or 4th postpartum day, her temperature rises for a
period of hours because of the increased vascular activity
involved.
Pulse
● A woman’s pulse rate during the postpartal period is
usually slightly slower than normal.
● During pregnancy, the distended uterus obstructed the amount of
venous blood returning to the heart; after birth, to accommodate the
increased blood volume returning to the heart, stroke volume
increases.
● This increased stroke volume reduces the pulse rate to
between 60 and 70 beats per minute.
● As diuresis diminishes the blood volume and causes
blood pressure to fall, the pulse rate increases
accordingly.
● By the end of the first week, the pulse rate will have
returned to normal.
● Evaluate pulse rate conscientiously in the postpartal period,
because a rapid and thready pulse during this time could be a sign
of hemorrhage
Blood Pressure
● BP monitored in the postpartal period, because a
decrease in this can indicate bleeding.
● elevation above 140 mm Hg systolic or 90 mm Hg
diastolic may indicate the development of postpartal
pregnancy-induced hypertension, an unusual but serious
complication of the puerperium
● Oxytocics, (up BP) drugs frequently administered during
the postpartal period to achieve uterine contraction, cause
contraction of all smooth muscle, including blood vessels
● If the blood pressure is greater than 140/90 mm Hg, tell prevent
hypertension and, possibly, a cerebrovascular accident.
A major complication in women who have lost an appreciable amount
of blood with birth is orthostatic hypotension, or dizziness that
occurs on standing because of the lack of adequate blood volume to
maintain nourishment of brain cells.
● To test whether a woman will be susceptible to orthostatic
hypotension, assess her blood pressure and pulse while she is
lying supine.
● Next, raise the head of the bed fully upright, wait 2 or 3 minutes,
and reassess these values.
● If the pulse rate is increased by more than 20 beats per minute and
blood pressure is 15 to 20 mm Hg lower than formerly, the woman
might be susceptible to dizziness and fainting when she ambulates
Progressive Changes
Two physiologic changes that occur during the puerperium involve
progressive changes, or the building of new tissue. Because building
new tissue requires good nutrition, caution women against strict
dieting that would limit cell-building ability during the first 6 weeks
after childbirth
Lactation
The formation of breast milk (lactation) begins in a postpartal woman
whether or not she plans to breastfeed
After this initial hour, teach perineal care and encourage a woman to shower.
She then remains in the room as a postpartal patient or is transferred to a
separate postpartal room. The most dangerous hour in childbearing—the first
hour after birth—has passed.
Hemorrhage is still a possibility for the first 2 or 3 days after birth,
until the myometrial vessels have sclerosed. One of the worries for a
woman giving birth at home is that she will not appreciate how
dangerous a time this is. With attention focused more on the newborn
than on her, postpartal hemorrhage could occur.

. Early in pregnancy, the increased estrogen level produced by the In the hospital, various health care personnel may be involved in caring for a
placenta stimulates the growth of milk glands; breasts increase in woman: be sure all members of the health care team are knowledgeable about
size because of the larger glands, accumulated fluid, and some extra this danger.
adipose tissue.
ASSESSMENT
For the first 2 days after birth, an average woman notices little
change in her breasts from the way they were during pregnancy. Health History
Since midway through pregnancy, she has been secreting colostrum, ● The technical aspects of a woman’s pregnancy, labor, and birth can
a thin, watery, prelactation secretion. She continues to excrete this be learned from her pregnancy, labor, and birth charts.
fluid the first 2 postpartum days. Family Profile.
Pregnancy History
● Information for a pregnancy history includes para and gravida
On the third day status
● , her breasts become full and feel tense or tender as milk Labor and Birth History
forms within breast ducts. Infant Data.
● Breast milk forms in response to the decrease in Postpartal Course.
estrogen and progesterone levels that follows delivery Laboratory Data
● Women routinely have their hemoglobin and hematocrit levels
of the placenta (which stimulates prolactin production
measured 12 to 24 hours after birth.. If the hemoglobin finding is
and, consequently, milk production). lower than 10 g/100 mL, supplementary iron is usually prescribed
● When breast milk first begins to form, the milk ducts
become distended.
● The nipple secretion changes from the clear colostrum
to bluish white, the typical color of breast milk.
● A woman’s breasts become fuller, larger, and firmer.
● In many women, breast distention becomes marked, and this often
is accompanied by a feeling of heat or throbbing pain. Breast tissue
may appear reddened, simulating an acute inflammatory or
infectious process.

● The distention is not limited to the milk ducts but occurs in

the surrounding tissue as well, because blood and lymph
enter the area to contribute fluid to the formation of milk.
This feeling of tension in the breasts on the third or fourth
day after birth is termed primary engorgement.
- It fades as the infant begins effective sucking
and empties the breasts of milk. Whether milk
production continues depends on the sucking
of the infant at the breasts as this releases
oxytocin and causes new milk to form.

Return of Menstrual Flow

● With the delivery of the placenta, the production of

placental estrogen and progesterone ends.
● The resulting decrease in hormone concentrations causes
a rise in production of FSH by the pituitary, which leads,
with only a slight delay, to the return of ovulation.
● This initiates the return of normal menstrual cycles.
● A woman who is not breastfeeding can expect her
menstrual flow to return in 6 to 10 weeks after birth.
● If she is breastfeeding, a menstrual flow may not return
for 3 or 4 months (lactational amenorrhea) or, in some
women, for the entire lactation period. H
NURSING CARE OF WOMEN AND FAMILY 24 HOURS AFTER
BIRTH
A woman remains in a birthing room for at least the first hour after
birth so she has time to become acquainted with her newborn and to
provide for careful health care team observation.
NURSING CARE OF A WOMAN AND FAMILY IN PREPARATION
FOR DISCHARGE
Group Classes
● Providing group classes on bathing infants, breastfeeding
techniques, minimizing jealousy in older children, and
maintaining health in the newborn can be helpful to
mothers and fathers, because in these settings they can
learn not only from the instructor but also from other
parents.
● Brain-storming this way is helpful to women who envision
jealousy problems with older children or who plan to
return to a full-time job and also breastfeed
 ● Be certain that a time for questions and answers is
planned at these sessions, so parents can apply what is
being taught to their individual circumstances
Individual Instruction
● Every family needs some individual instruction in how to
care for their infant and how the woman can care for
herself after discharge.
● How to bathe and feed the baby, how to care for the
infant’s cord and circumcision if the infant has this, a
review of how much infants sleep during 24 hours, and
how to fit a newborn into the family’s pattern of living are
topics parents like to discuss
● This kind of instruction saves parents many anxious
moments when they are at home.
Discharge Planning
● Before a postpartal family is discharged from the health care
agency, a woman will be given instructions by her physician or
nurse-midwife concerning her care at home.
● . Before discharge, make sure a woman is aware that she
must return for an examination 4 to 6 weeks after birth,
and that she should make an appointment to take her
baby to a primary care provider for an examination at 2 to
4 weeks of age.
● If a woman does not have an adequate rubella antibody
titer and anticipates further pregnancies, she may receive
a rubella immunization before discharge.
● Women who are Rh negative and who have had an
Rh-positive infant will receive RhiG or Rh antibodies to
prevent problems in a future pregnanc
NURSING CARE AFTER DISCHARGE
Postpartal Examination
● Every newborn should have a health maintenance visit 2
to 4 weeks after birth
● Every woman should have a checkup by her physician or
nurse-midwife at 4 to 6 weeks after birth (the end of the
postpartal period), to assure herself and her health care
provider that she is in good health and has no residual
problems from childbearing
PPT
Pathophysiology of Postpartum
Involution
● rapid reduction in size of uterus and return to prepregnant
state
Subinvolution
● failure to descent
✓ Uterus is at level of umbilicus within 6 to 12 hours after childbirth
-decreases by one finger breadth per day
Exfoliation
● - allows for healing of placenta site and is important part
of involution – may take up to 6 weeks
Enhanced by
● uncomplicated labor and birth
● complete expulsion of placenta or membranes
● breastfeeding
● early ambulation
Involution of the uterus.
A) Immediately after expulsion of the placenta, the top of the fundus
is in the midline and approximately halfway between the symphysis
pubis and the umbilicus.
B) About 6 to 12 hours after birth, the fundus is at umbilicus. The
height of the fundus then decreases about one finger breadth
● (approximately the level of the 1cm) each day.
Uterus rids itself of debris remaining after birth through
discharge called lochia
Lochia changes:
● Bright red at birth
● Rubra - dark red (2 – 3 days after delivery)
● Serosa – pink (day 3 to 10 after delivery)
● Alba – white
● Clear
If blood collects and forms clots within uterus, fundus rises
and becomes boggy (uterine atony)
Ovulation and Menstruation/Lactation
Return of ovulation and menstruation varies for each postpartal
woman
● Menstruation returns between 6 and 10 weeks after
birth in non lactating mother - Ovulation returns within 6
months
● Return of ovulation and menstruation in breastfeeding
mother is prolonged related to length of time
breastfeeding continues
● Breasts begin milk production
- a result of interplay of maternal hormones
BOWEL ELIMINATION
● Intestines sluggish because of lingering effects of
progesterone and decreased muscle tone
- Spontaneous bowel movement may not occur
for 2 to 4 days after childbirth
- Mother may anticipate discomfort because of
perineal tenderness or fear of episiotomy
tearing
● Elimination returns to normal within one week
● After cesarean section, bowel tone return in few days and
flatulence causes abdominal discomfort
URINARY TRACT
● Increased bladder capacity, decreased bladder tone,
swelling and bruising of tissue.
● Puerperal diuresis leads to rapid filling of bladder -
urinary stasis increases chance of urinary tract infection.
● If fundus is higher than expected on palpation and is not
in midline, nurse should suspect bladder distension
LABORATORY VALUES
● White blood cell count often elevated after delivery
- Leukocytosis
- Elevated WBC to 30,000/mm3
● Physiologic Anemia
- Blood loss – 200 – 500 Vaginal delivery
- Blood loss 700 – 1000 ml C/S
- RBC should return to normal w/in 2 - 6 weeks
Hgb – 12 – 16, Hct – 37% - 47%
● Activation of clotting factors (PT, PTT, INR) predispose
to thrombus formation - hemostatic system reaches
non-pregnant state in 3 to 4 weeks
● Risk of thromboembolism lasts 6 weeks
WEIGHT LOSS
● 10 –12 pounds w/ delivery
● 5 pounds with diuresis
● Return to normal weight by 6 – 8 weeks if gained 25 - 30
pounds Breastfeeding will assist with weight loss even
with extra calorie intake
PSYCHOSOCIAL CHANGES
Taking in - 1 to 2 days after delivery
● Mother is passive and somewhat dependent as she sorts
reality from fantasy in birth experience
● Food and sleep are major needs
Taking hold - 2 to 3 days after delivery
● Mother ready to resume control over her life
● She is focused on baby and may need reassurance
Maternal Role Attachment
● Woman learns mothering behaviors and becomes
comfortable in her new role
Four stages to maternal role attainment
● Anticipatory stage - During pregnancy
● Formal stage - When baby is born
● Informal stage - 3 to 10 months after delivery
● Personal stage - 3 to 10 months after delivery
Father-Infant Interaction
● Engrossment
● Sense of absorption
● Preoccupation - Interest in infant
POSTPARTUM ASSESSMENT
● Vital signs: Temperature elevations should last for only
24 hours –should not be greater than 100.4°F
● Bradycardia rates of 60 to 70 beats per minute occur
during first 6 to days due to decreased blood volume
● Assess for BP within normal limits: Notify MD for
tachycardia, hypotension, hypertension
● Respirations stable
● Breath sounds should be clear
● Complete systems assessment
● BUBBLEHE assessment
● Postpartum chills or shivers are common
BREAST ASSESSMENT
● Assess if mother is breast- or bottle-feeding - inspect
nipples and palpate for engorgement or tenderness –
should not observe redness, blisters, cracking
● Breasts should be soft, warm, non-tender upon palpation
● Secrete colostrum for 1st 2-3 days –yellowish fluid -
protein and antibody enriched to offer passive immunity
and nutrition
● Milk comes in around 3 – 4 days – feel firm, full, tingly to
client
UTERUS ASSESSMENT
● Monitor uterus and vaginal bleeding, every 30 minutes x
2 for first PP hour, then hourly for 2 more hours, every 4
hours x 2,
● then every 8 hours or more frequently if there is
bogginess, position out of midline, heavy lochia flow.
● Determine firmness of fundus and ascertain position
approximate descent of 1 cm or 1 fingerbreadth per day
● If boggy (soft), gently massage top of uterus until firm –
notify health care provider if does not firm
● Displaced to the right or left indicates full bladder – have
client void and recheck fundus
➔ Measurement of descent of fundus for the woman with vaginal
birth. The fundus is located two finger-breadths below the
umbilicus.
➔ Always support the bottom of the uterus during any assessment of
the fundus
BLADDER AND BOWEL ASSESSMENT
● Anesthesia or edema may interfere with ability to void –
palpate for bladder distention - may need to catheterize –
measure voided urine
● Assess frequency, burning, or urgency
● Diuresis will occur 12 – 24 hours after delivery –
eliminate 2000 – 3000 ml fluid, may experience night
sweats and nocturia
LOCHIA-RUBRA ASSESSMENT
● Lochia = blood mucus, tissue vaginal discharge
● Assess amount, color, odor, clots
● If soaking 1 or > pads /hour, assess uterus, notify health
care provider
● Total volume – 240 – 270 ml
● Resume menstrual cycle within 6 – 8 weeks, breast
feeding may be 3 months
EPISIOTOMY/LACERATIONS/ CS INCISIONS
● Inspect the perineum for episiotomy/lacerations with
REEDA assessment
● Inspect C/S abdominal incisions for REEDA
R = redness (erythema)
E = edema
E = ecchymosis
D = drainage, discharge
A = approximation
POSTPARTUM NURSING INTERVENTION
● Relief of Perineal Discomfort
- Ice packs for 24 hours, then warm sitz bath
- Topical agents - Epifoam
- Perineal care – warm water, gently wipe dry
front to back
COMPOSITION OF BREASTMILK
● Breast milk is 90% water; 10% solids consisting of
carbohydrates, proteins, fats, minerals and vitamins
● Composition can vary according to gestational age and
stage of lactation
● Helps meet changing needs of baby

HEMORRHOIDS/ HOMANS SIGN Foremilk – high water content, vitamins, protein

● Assess for hemorrhoids Hindmilk - higher fat content

● Relief of hemorrhoidal discomfort may include
Sitz baths IMMUNOLOGIC AND NUTRITIONAL PROPERTIES
Topical anesthetic ointments
Rectal suppositories Secretory IgA, immunoglobulin found in colostrum and breast
Witch hazel pads - Tucks milk, has antiviral, antibacterial, antigenic-inhibiting properties
● Contains enzymes and leukocytes that protect against pathogens
Extremities ● Composed of lactose, lipids, polyunsaturated fatty acids, amino
acids,especially taurine
● Assess for pedal edema, redness, and warmth
● Cholesterol, long-chain polyunsaturated fatty acids, and balance of
● Check Homan's sign – dorsiflex foot with knee slightly amino acids in breast milk help with myelination and neurologic
bent development

EMOTIONAL STATUS ASSESSMENT ADVANTAGES OF BREASTFEEDING

● Describe level of attachment to infant
● Determine mother's phase of adjustment to parenting ● Provides immunologic protection
● Postpartum Blues ● Infants digest and absorb component of breast milk easier
- Transient period of depression ● Provides more vitamins to infant if mother's diet is
- Occurs first few days after delivery adequate
- Mother may experience tearfulness, anorexia, ● Strengthens mother-infant attachment
difficulty sleeping, feeling of letdown ● No additional cost
Usually resolves in 10 to 14 days ● Breast milk requires no preparation
Causes: ● AAP= Only food for 6 months, w/ foods for 12 months
● Changing hormone levels, fatigue, discomfort,
overstimulation DISADVANTAGES OF BREASTFEEDING
● Psychologic adjustments ● Many medications pass through to breast milk
● Unsupportive environment, insecurity ● Father unable to equally participate in actual feeding of
infant
Postpartum NURSING INTERVENTION ● Mother may have difficulty being separated from infant
After pains
- Uterine contractions as uterus involutes
Relief of after pains
- Positioning (prone position)
- Analgesia administered an hour before breastfeeding
- Encourage early ambulation - monitor for dizziness and
weakness

MEDICATIONS
Bleeding
oxytocin (Pitocin) – watch for fluid overload and hypertension
methylergonovine (Methergine) – causes hypertension
prostaglandin F (Hemabate, carboprost) – n/v, diarrhea

Pain Medications
NSAIDS – GI upset
Oxycodone/acetaminophen (Percocet) – dizziness, sleepiness
PCA – Morphine for C/S – respiratory distress
Docusate (Senna) – causes diarrhea
Rubella Vaccine – titer 1:10, do NOT get pregnant for 3 months
Rh Immune Globulin (RhoGAM) – Rh negative mother – do not
administer rubella vaccine for 3 months
FORMULA PREPARATIONS
● Three categories of formulas based on cow milk proteins,
soy protein-based formulas, specialized or therapeutic
formulas - all are enriched with vitamins, particularly
vitamin D

BREASTFEEDING PATHO Bottle-Feeding Advantages

● Provides good nutrition to infant.
Before delivery, increased estrogen stimulates duct formation, ● Father can participate in infant feeding patterns.
progesterone promotes development of lobules and alveoli
Bottle-Feeding Disadvantages
After delivery, estrogen and progesterone decrease, prolactin ● May need to try different
increases to promote milk production by stimulating alveoli ● formulas before finding one
● that is well-tolerated by infant.
Newborn suck releases oxytocin to stimulate let-down reflex ● Proper preparation necessary
● for nutrition adequacy.
Bottle Feeding Mother
● Teach to wear a binder or tight-fitting sports bra day and night
● for two weeks.
● Do not allow hot water from shower to run over breasts
● Avoid manual stimulation
● Apply cabbage leaves (dries up breast)
● Use acetaminophen for discomfort

Cesarean Section Needs

● Assess vital signs
● Assess breasts
● Assess location and firmness of uterine fundus
● Assess lochia
● Assess incision site – REEDA
● Assess breath sounds
● Assess indwelling urinary catheter - color and amount of urine
noted
● Assess bowel sounds: present, hypoactive or hyperactive

Cesarean birth is major abdominal surgery - if general anesthesia

used, abdominal distension may cause discomfort, assess for bowel
obstruction
● Position client on left side, include exercises, early
ambulation, increase po intake, avoid carbonated
beverages, avoid straws - may need enemas, stool
softeners, antiflatulent meds
Pulmonary infections may occur related to immobility and use of
narcotics because of altered immune response
● TCDB, use incentive spirometer q 2 hours

Administer analgesics within the first 24 to 72 hours - allows woman

to become more mobile and active

By second or third day, cesarean birth mother moves into "taking-hold

period“

Discharge Instructions
● New mother should gradually increase activities and
ambulation after birth
● Avoid heavy lifting, excessive stair climbing, strenuous
activity, vacuuming
● Resume light housekeeping by second week at home
● Delay returning to work until after 6-week postpartum
examination
● Usually sexual intercourse is resumed once episiotomy
has healed and lochia has stopped (about 3 – 6 weeks)
● Breastfeeding mothers concerned that contraceptive
method will interfere with ability to breastfeed - they
should be given available options – progesterone only

Types of Follow-Up Care

● Telephone calls - nurses must listen carefully and ask open ended
questions
● Return visits - Within one week after first visit
● Telephone follow-up - Within 3 days of discharge
● Baby care/postpartum classes
● New mother support groups
● Need to have a caring attitude in these activities

Maternal Assessment

Lochia
● Should progress from lochia rubra to lochia alba
● If not breastfeeding, menstrual pattern should return
about 6 weeks postpartum
Fundus
● Uterus should return to normal size by 6 weeks
postpartum
Perineum: Episiotomy and lacerations should show signs of
healing
MCN CH 18
PROFILE OF A NEWBORN
Vital Statistics
WEIGHT
The birth weight of newborns varies depending on the racial,
nutritional, intrauterine, and genetic factors that were present during
conception and pregnancy. The weight in relation to the gestational
age should be plotted on a standard neonatal graph
The arbitrary lower limit of normal for all races is
● 2.5 kg (5.5 lb)
Birth weight exceeding 4.7 kg (10 lb) is unusual, but weights as high
as 7.7 kg (17 lb) have been documented.
If a newborn weighs more than 4.7 kg, the baby is said to be
macrosomic and a maternal illness, such as diabetes mellitus, must
be suspected.
During the first few days after birth, a newborn loses 5% to 10% of
birth weight (6 to 10 oz). This weight loss occurs because a newborn
is no longer under the influence of salt and fluid-retaining maternal
hormones.
● Diuresis begins to remove a part of the infant’s high fluid
load.
● A newborn also voids and passes stool.
● Because approximately 75% to 90% of a newborn’s
weight is fluid, all three of these measures reduce weight
● breastfed newborns have a limited intake until about the
third day of life because of the relatively low caloric
content and amount of colostrum they ingest.
● . The breastfed newborn recaptures birth weight within 10
days;
● a formula-fed infant accomplishes this gain within 7 days.
● After this, a newborn begins to gain about 2 lb per month
(6 to 8 oz per week) for the first 6 months of life.
LENGTH
● The average birth length (50th percentile) of a mature
female neonate is 53 cm (20.9 in).
● For mature males, the average birth length is 54 cm (21.3
in).
● The lower limit of normal length is arbitrarily set at 46 cm
(18 in).
HEAD CIRCUMFERENCE
In a mature newborn, the head circumference is usually 34 to 35 cm
(13.5 to 14 in).
● A mature newborn with a head circumference greater than >37 cm
(14.8 in) or less than <|33 cm (13.2 in) should be carefully
assessed for neurologic involvement,
CHEST CIRCUMFERENCE
● The chest circumference in a term newborn is about 2 cm
(0.75 to 1 in) less than the head circumference.
VITAL SIGNS
TEMPERATURE
● Newborn temp 99° F (37.2° C)
Convection
● is the flow of heat from the newborn’s body surface to
cooler surrounding air.
● The effectiveness of convection depends on the velocity
of the flow (a current of air cools faster than nonmoving
air).
● Eliminating drafts from windows or air conditioners
reduces convection heat loss.
Conduction
● is the transfer of body heat to a cooler solid object in
contact with a baby. For example, a baby placed on a cold
counter or on the cold base of a warming unit quickly
loses heat to the colder metal surface.
● Covering surfaces with a warmed blanket or towel helps
to minimize conduction heat loss.
Radiation
● is the transfer of body heat to a cooler solid object not in
contact with the baby, such as a cold window or air
conditioner.
● Moving an infant as far from the cold surface as possible
helps reduce this type of heat loss.
Evaporation
● is loss of heat through conversion of a liquid to a vapor.
Newborns are wet, so they lose a great deal of heat as
the amniotic fluid on their skin evaporates.
Brown fat,
● a special tissue found in mature newborns, apparently
helps to conserve or produce body heat by increasing
metabolism.
● The greatest amounts of brown fat are found in the
interscapular region, thorax, and perirenal area.
● Brown fat is thought to aid in controlling newborn
temperature similar to temperature control in a
hibernating animal
PULSE
● fetus in utero averages 120 to 160 bpm
● Stabilized and sleep = 120-140
● Transient murmurs may result from the incomplete
closure of fetal circulation shunts.
RESPIRATION
● First minutes of life = 80 breaths per minute.
● At rest = 30 to 60 breaths
● periodic respirations -irregular, apnea 15 sec
BLOOD PRESSURE ● This inability to form antibodies is the reason that most
immunizations against childhood diseases are not given
● 80/46 mm Hg at birth. to infants younger than 2 months of age.
● 10th day- 100/50 mm H ● (immunoglobulin G) from their mother
● Newborns are routinely administered hepatitis B vaccine
during the first 12 hours after birth to protect against this
PHYSIOLOGIC FUNCTIONS disease

CARDIOVASCULAR SYSTEM
When the cord is clamped, a neonate is forced to take in oxygen through the NEUROMUSCULAR SYSTEM
lungs. As the lungs inflate for the first time, pressure decreases in the pulmonary
artery (the artery leading from the heart to the lungs).

The peripheral circulation of a newborn remains sluggish for at least

the first 24 hours. It is common to observe cyanosis in the infant’s
feet and hands (acrocyanosis) and for the feet to feel cold to the
touch at this time.

Blood Values
● newborn’s blood volume is 80 to 110 mL/kg or 300 ml
total
● Hemoglobin level averages 17 to 18 g/100 mL of blood.
● The hematocrit is between 45% and 50%
● indirect bilirubin level at birth is 1 to 4 mg/100 mL

Blood Coagulation

● Because most newborns are born with a lower than normal level of
vitamin K, they have a prolonged coagulation or prothrombin Blink Reflex.
time.
● A blink reflex in a newborn serves the same purpose as it
● Vitamin K, synthesized through the action of intestinal flora, is
necessary for the formation of factor II (prothrombin), factor VII
does in an adult—to protect the eye from any object
(proconvertin), factor IX (plasma thromboplastin component), and coming near it by rapid eyelid closure.
factor X (Stuart-Prower factor Rooting Reflex.
● vitamin K (AquaMEPHYTON) IM in birth ● If the cheek is brushed or stroked near the corner of the
mouth, a newborn infant will turn the head in that
RESPIRATORY SYSTEM direction.
It is initiated by a combination of cold receptors; a lowered partial pressure of ● This reflex serves to help a newborn find food
oxygen (PO2), which falls from 80 to as low as 15 mm Hg before a first breath; Sucking Reflex.
and an increased partial carbon dioxide pressure (PCO2), which rises as high as
● The sucking reflex begins to diminish at about 6 months
70 mm Hg before a first breath.
of age.
Swallowing Reflex.
GASTROINTESTINAL SYSTEM
● The swallowing reflex in a newborn is the same as in the
● a newborn’s stomach holds about 60 to 90 mL,
adult
Stools
Extrusion Reflex.
● A newborn extrudes any substance that is placed on the
● Meconium - a sticky, tarlike, blackish-green, odorless
anterior portion of the tongue.
material formed from mucus, vernix, lanugo, hormones,
● This protective reflex prevents the swallowing of inedible
and carbohydrates that accumulated during intrauterine
substances
life.
● . It disappears at about 4 months of age.
● Not passed by 24 to 48 hours after birth (ileus,
Palmar Grasp Reflex.
imperforate anus, or volvulus)
● This reflex disappears at about 6 weeks to 3 months of
age. A baby begins to grasp meaningfully at about 3
● transitional stool - About the second or third day of life,
months of age
newborn stool changes in color and consistency,
Step (Walk)-in-Place Reflex.
becoming green and loose.
● Newborns who are held in a vertical position with their
● may resemble diarrhea to the untrained eye
feet touching a hard surface will take a few quick,
● By the fourth day of life, breastfed babies pass three or
alternating steps
four light yellow stools per day.
● This reflex disappears by 3 months of age.
● Newborns with bile duct obstruction have clay-colored
Placing Reflex.
(gray) stools,
● The placing reflex is similar to the step-inplace reflex,
except that it is elicited by touching the anterior surface of
URINARY SYSTEM
the lower part of a newborn’s leg against a hard surface
such as the edge of a bassinet or table
● The kidneys of newborns do not concentrate urine well,
making newborn urine usually light-colored and odorless.
Plantar Grasp Reflex.
● A single voiding in a newborn is only about 15 mL
● This reflex disappears at about 8 to 9 months of age
● . The daily urinary output for the first 1 or 2 days is about
Tonic Neck Reflex.
30 to 60 mL total. By week 1, total daily volume rises to
● When newborns lie on their backs, their heads usually
about 300 mL.
turn to one side or the other
● stimulate eye coordination,
IMMUNE SYSTEM
Moro Reflex.
● A Moro (startle) reflex can be initiated by startling a
newborn with a loud noise or by jarring the bassinet
● . The most accurate method of eliciting the reflex is to
hold newborns in a supine position and allow their heads
to drop backward about 1 inch.
● C fingers
Babinski Reflex.
● When the sole of the foot is stroked in an inverted “J”
curve from the heel upward, a newborn fans the toes
● This reaction occurs because nervous system
development is immature.

Magnet Reflex.
● If pressure is applied to the soles of the feet of a newborn
lying in a supine position, he or she pushes back against
the pressure
● Spinal cord integ
Crossed Extension Reflex.
● If one leg of a newborn lying supine is extended and the
sole of that foot is irritated by being rubbed with a sharp
object,
Trunk Incurvation Reflex.
● When newborns lie in a prone position and are touched
along the paravertebral area
Landau Reflex.
● A newborn who is held in a prone position with a hand
underneath, supporting the trunk, should demonstrate
some muscle tone.
● inverted “U” position.
Deep Tendon Reflexes.
● A patellar reflex can be elicited in a newborn by tapping the
patellar tendon with the tip of the finger. The lower leg moves
perceptibly if the infant has an intact reflex.
● . A biceps reflex is a test for spinal nerves C5 and C6; a patellar
reflex is a test for spinal nerves L2–L4
Physiologic Adjustment to Extrauterine Life
All newborns seem to move through periods of irregular adjustment in
the first 6 hours of life, before their body systems stabilize.
first period of reactivity
● The first phase lasts about half an hour.
● During this time, the baby is alert and exhibits exploring,
searching activity, often making sucking sounds.
● Heart beat and respiratory rate are rapid.
quiet resting period
● Heartbeat and respiratory rates slow, and the newborn
typically sleeps for about 90 minutes
● The second period of reactivity, between 2 and 6 hours
of life, occurs when the baby wakes again, often gagging
and choking on mucus that has accumulated in the
mouth.
● He or she is again alert and responsive and interested in
surroundings
APPEARANCE OF A NEWBORN
SKIN
COLOR
Cyanosis
● Acrocyanosis (blueness of hands and feet) is so
prominent in some newborns that it appears as if some
stricture were cutting off circulation,
central cyanosis, or cyanosis of the trunk, is always a cause for
concern.
● Central cyanosis indicates decreased oxygenation.
● It may be the result of a temporary respiratory obstruction
or an underlying disease state
Hyperbilirubinemia.
● leads to jaundice,
● . This occurs on the second or third day of life in about
50% of all newborns, as a result of a breakdown of fetal
red blood cells (physiologic jaundice)
● Observe infants who are prone to extensive bruising (large, breech,
or immature babies) carefully for jaundice, because bruising leads
to hemorrhage of blood into the subcutaneous tissue or skin
Cephalhematoma
● is a collection of blood under the periosteum of the skull
bone.
● As the bruising in these locations heals and the red blood
cells are hemolyzed, additional indirect bilirubin is
released and can be another cause of jaundice
Above-normal indirect bilirubin levels are potentially dangerous
because, if enough indirect bilirubin (about 20 mg/100 mL) leaves the
bloodstream, it can interfere with the chemical synthesis of brain
cells, resulting in permanent cell damage, a condition termed
kernicterus.
Pallor.
Pallor in newborns is usually the result of anemia.
This may be caused by
(a) excessive blood loss when the cord was cut,
(b) inadequate flow of blood from the cord into the infant at birth,
(c) fetal–maternal transfusion,
(d) low iron stores caused by poor maternal nutrition during pregnancy
(e) blood incompatibility
Harlequin Sign.
● because of immature circulation, a newborn who has
been lying on his or her side appears red on the
dependent side of the body and pale on the upper side,
as if a line had been drawn down the center of the body.
● This is a transient phenomenon
BIRTHMARKS Molding
● fit the cervix contours during labor. After birth, this area appears
prominent and asymmetric
Hemangiomas
● Extreme primiparus
● are vascular tumors of the skin.
Caput Succedaneum
Nevus flammeus
● is edema of the scalp at the presenting part of the head. It
● is a macular purple or dark-red lesion (sometimes called
may involve wide areas of the head
a portwine stain because of its deep color) that is present
at birth.
Cephalhematoma
● Nevus flammeus lesions also occur as lighter, pink
● a collection of blood between the periosteum of a skull
patches at the nape of the neck, known as stork’s beak
bone and the bone itself, is caused by rupture of a
marks or telangiectasis
periosteal capillary because of the pressure of birth
● w/ coagulated blood.
Strawberry hemangioma
● a type of birthmark identified as an elevated area formed
Craniotabes
by immature capillaries and endothelial cells
● is a localized softening of the cranial bones that is
● high estrogen levels
probably caused by pressure of the fetal skull against the
Cavernous hemangiomas
mother’s pelvic bone in utero
● are dilated vascular spaces
EYES
● Permanent color 3 and 12 months of age
Mongolian Spots.
● Chlamydia infection and ophthalmia neonatorum
● are collections of pigment cells (melanocytes) that appear
(gonorrheal conjunctivitis), has caused a discharge
as slate-gray patches across the sacrum or buttocks and
● Pressure during birth sometimes ruptures a conjunctival
possibly on the arms and legs.
capillary of the eye, resulting in a small subconjunctival
hemorrhage. (red spot sclera)
VERNIX CASEOSA
● is a white, cream cheese–like substance that serves as a
EARS
skin lubricant in utero.
● trisomy 18 and 13, syndromes in which low-set ears
LANUGO
● is the fine, downy hair that covers a newborn’s shoulders,
NOSE
back, and upper arms.
● Test for choanal atresia (blockage at the rear of the
● 37 to 39 weeks more lanugo
nose) by closing the newborn’s mouth and compressing
● 2 weeks disappear
one naris at a time with your fingers

DESQUAMATION
● Within 24 hours after birth, the skin of most newborns has
become extremely dry. The dryness is particularly evident
on the palms of the hands and soles of the feet.
MILIA
● pinpoint white papule that can be found on the cheek or
across the bridge of the nose of newborns
● are unopened sebaceous glands
MOUTH
● thrush, a Candida infection, which usually appears on the tongue
and sides of the cheeks as white or gray patches and needs
therapy with an antifungal drug
● It is unusual for a newborn to have teeth, but sometimes one or two
(called natal teeth)
NECK
● . If there is rigidity of the neck, congenital torticollis, caused by
injury to the sternocleidomastoid muscle during birth, might be
present

ERYTHEMA TOXICUM CHEST

● newborn rash ● , the breasts of newborn babies secrete a thin, watery
● From papule fluid popularly termed witch’s milk.
● Unpredictable
● flea-bite rash because the lesions are so minuscule ABDOMEN
● scaphoid or sunken appearance may indicate missing
FORCEPS MARKS abdominal contents or a diaphragmatic hernia
● mark disappears in 1 to 2 days
MALE GENITALIA
SKIN TURGOR ● (cryptorchidism)
● If a fold of the skin is grasped between the thumb and ● Inspect the tip of the penis to see that the urethral opening is at the
tip of the glans, not on the dorsal surface (epispadias) or on the
fingers, it should feel elastic ventral surface (hypospadias).
● undescended testis hydrocele, inguinal hernia hypospadias
HEAD
● disproportionately large because it is about one fourth of the total FEMALE GENITALIA
body length; ● Some female newborns have a mucus vaginal secretion, which is
Fontanelles sometimes blood-tinged (pseudomenstruation).
● are the spaces or openings where the skull bones join
● Anterior close 12-18 months
● Posterior close 2-3 months
Sutures
● the separating lines of the skull, may override at birth because of
the extreme pressure exerted on the head during passage through
the birth canal
 7-10
ASSESSMENT FOR WELLBEING ● severe distress.

APGAR SCORING Notice that the scores of this index run opposite to those of the
Apgar: an Apgar score of 7 to 10 would indicate a well infant

<4
● Is in serious danger of respiratory or cardiovascular
failure and needs resuscitation.
4-6
● the infant’s condition is guarded and the baby may need
clearing of the airway and supplementary oxygen.

7 - 10 indicates that the infant scored as high as 70% to 90% of all

infants at 1 to 5 minutes after birth or is adjusting well to extrauterine
life (10 is the highest score possible).

The Apgar score is repeated every additional 5 minutes, until a

minimum score of 7 is reached. PHYSICAL EXAMINATION

Height and Weight

● Abnormal loss of weight may be the first indication that a
newborn has an inborn error of metabolism, such as
adrenocortical insufficiency (salt-dumping type), or is
becoming dehydrated

Laboratory Studies
● excess of red blood cells (polycythemia), probably
caused by excessive flow of blood into an infant from the
umbilical cord.
● A heel-stick hematocrit reveals this also so treatment
then can be instituted. A normal hematocrit at 1 hour of
life is about 50% to 55%

Heart rate – above 100 Assessment of Gestational Age

Respiratory Effort – spontaneous with cry
Muscle tone – flexed with movement ● Thorough assessment with Ballard Scale done later
Reflex response – active, prompt cry
Color – pink or acrocyanosis
0-3 infant needs resuscitation
4-7 Gentle stimulation – Narcan
8-10 – no action needed

Respiratory Effort
● A mature newborn usually cries and aerates the lungs
spontaneously at about 30 seconds after birth.

Muscle Tone
● Muscle tone is tested by observing their resistance to any effort to
extend their extremities
● . Poor muscle tone is no flexion of the arms and legs
Dubowitz Maturity Scale
Reflex Irritability
One of two possible cues is used to evaluate reflex irritability in a newborn
● devised a gestational rating scale that uses more
● : response to a suction catheter in the nostrils o
● r response to having the soles of the feet slapped. extensive criteria.
Color ● The assessment consists of two portions
● All infants appear cyanotic at the moment of birth. They ● : physical maturity
grow pink with or shortly after the first breath, ● neuromuscular maturity

RESPIRATORY EVALUATION ● An infant with a total score of 5 is at 26 weeks’ gestational

0 age
● indicates no respiratory distress. ● ; a total score of 10 reveals a gestational age of about 28
4-6 weeks
● moderate distress. ● ; a total score of 40 points is found in infants at term or 40
weeks’ gestation
Brazelton Neonatal Behavioral Assessment Scale Heart Sounds
● Test ability to respond to set stimuli - Position: 3rd and 4th intercostal space
● Six major categories of behavior— habituation, - Rhythm and Murmurs
orientation, motor maturity, variation, selfquieting ability, ● Brachial and Femoral Pulses
and social behavior—are assessed ● Blood Pressure
● Capillary Refil
CARE OF NEWBORN AT BIRTH
Vital Sign Normals
Initial Feeding ● 97.7-98.6 F (36.5-37 C)
● A term newborn who is to be breastfed may be fed ● 110-160
immediately after birth. - A soundly sleeping baby can go to 80 bpm
● A baby who is to be formula-fed may receive a first - A crying baby may be as high as 180
feeding at about 2 to 4 hours of age. ● 30-60
● Both formula-fed and breastfed infants do best on a
demand schedule; many need to be fed as often as every Maintaining thermoregulation
2 hours in the first few days of life. Referred to as maintaining a neutral thermal environment
- Heat loss is minimal
Metabolic Screening Tests - Oxygen consumption needs are at their lowest
● By state law, every infant must be screened for Hypothermia can cause
phenylketonuria (PKU; a disease of defective protein ● Hypoglycemia
metabolism), hypothyroidism, and cystic fibrosis. ● Increased oxygen needs

Hepatitis B Vaccination Four mechanisms of heat loss and corresponding interventions

● All newborns receive a first vaccination against hepatitis B Evaporation
within 12 hours after birth; a second dose is administered - Dry infant immediately
at 1 month and a third at 6 months. Conduction
- Place on mothers body skin to skin
Vitamin K Administration Convection
● Newborns are at risk for bleeding disorders during the first - Cover with a blanket, wear a cap
week of life because their gastrointestinal tract is sterile at Radiation
birth and unable to produce vitamin K, which is necessary - Keep away from cold windows and cold objects
for blood coagulation.
● A single dose of 0.5 to 1.0 mg Thermoregulation Assessment
● Check soon after birth
● Set warmer controls
Circumcision
● Take temp q 30 min until stable
● Rectal for first temp
● Circumcision is the surgical removal of the foreskin of the ● Insert only 0.5 inch
penis. ● Axillary route rest of time
● In only a few babies, constriction (phimosis) of the
foreskin is so severe that it obstructs the urinary meatal Hypoglycemia
opening; otherwise, there are few medical indications for ● Criteria vary from source to source
● LPN book says <40
circumcision of a male newborn.
● RN book says <36 but a threapuetic objective of 45
● mg/dl or greater
● Circumcision is performed on Jewish boys on the eighth ● The brain is dependent on a steady supply of glucose
day of life as part of a religious rite, in a ceremony called ● for its metabolism
a bris Infants at Increased Risk for Hypoglycemia
● Preterm/postterm
● Infants of diabetic mothers
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● Large for gestational age
● Small for gestational age
Three transition phases ● Infants with Intrauterine growth retardation
● Phase One: the first hour ● Asphyxiated infants
● Phase Two: from one to three hours
● Phase Three: from two to 12 hours Symptoms of Hypoglycemia
Priorities in first hour
1. Cardiovascular assessment and support ● Jitteriness
● Poor muscle tone
2. Thermoregulation
● Sweating
3. Assessment and support of blood glucose
Hepatic System
4. Identification
5. Observing urinary/meconium passage
Blood Glucose
6. Observing for major anomalies and for apparent ● Normal blood glucose: 40-6omg/dl first day of life 50-90
gestational age concerns ● mg/dl, thereafter
● Rechecked 30-60 minutes after feeding
1. Cardiovascular assessment and support Signs of Neonatal Hypoglycemia
Airway Breathsounds Tachnypnea Retractions Flaring of Nose ● Jitteriness or tremor
Cyanosis Grunting Seasaw or Paradoxical Respirationss Asymety
Physiologic Jaundice
Color RBC/Hgb level is higher than required
● Pallor ● Neonatal RBC: 4.8-7.1 Infant: 4.2-5.2
● Ruddy Color ● Neonatal Hbg 14-24 Infant 11-17