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prostaglandins could possibly stimulate the
MCHN LECTURE NOTES COMPILATION
COURSE OUTLINE: MIDTERM
1. Intrapartum Care
2. Postpartum Period
3. Neonatal Period
4. Care of Discharge
5. Neonatal Reflexes
INTRAPARTUM CARE
 refers to the period from the commencement of
true labor throughout the first, second, third and
fourth stages of labor, which last from one to two
hours after delivery of the placenta
(Lowdermilk, Perry, Cashion & Alden, 2012).
THEORIES OF LABOR
Labor
 coordinated sequence of involuntary, intermittent
uterine contractions.
 series of events by which uterine contractions
and abdominal pressure expel a fetus and
placenta from the uterus
THEORIES OF WHY LABOR BEGINS
 Labor normally begins between 37 and 42
weeks of pregnancy, when a fetus is sufficiently
mature to adapt to extrauterine life, yet not too
large to cause mechanical difficulty with birth.
 In some instances, labor begins before a
fetus is mature (preterm birth).
 In others, labor is delayed until the fetus
and the placenta have both passed
beyond the optimal point for birth
(postterm birth).
 The uterine muscle stretches from the increasing
size of the fetus, which results in the release of
prostaglandins.
 The fetus presses on the cervix, which stimulates
the release of oxytocin from the posterior
pituitary.
 Oxytocin stimulation works together with
prostaglandins to initiate contractions.
 Changes in the ratio of estrogen to progesterone
occurs, increasing estrogen in relation to
progesterone, which is interpreted as
progesterone withdrawal.
 The placenta reaches a set age, which triggers
contractions.
 Rising fetal cortisol levels reduce progesterone
formation and increase prostaglandin formation.
 The fetal membrane begins to produce
prostaglandins, which stimulate contractions
 Semen does contain prostaglandins, which can
be helpful in softening, also known as “ripening,”
of the cervix; if a cervix is ready to ripen, semen
beginning of contractions.
 Rhythmical contractions brought on by a
woman’s orgasm can conceivably help as well,
although, again, not until a uterus is prepared
and ready for labor.
ASSESSMENT
ASSESSMENT
A woman in labor is keenly aware of both nonverbal
and verbal expressions around her (i.e., not only words
spoken but gestures such as eye rolling or sighing).
Because of this sensitivity, an assessment must be
done quickly yet thoroughly and gently because she
may have difficulty being patient, for example, while
admission information is obtained or relaxing for a
vaginal examination
Remember that pain is a subjective symptom. Only the
woman can evaluate how much she is experiencing or
how much she wants to endure.
Assess how much discomfort she is experiencing and
how she feels about her labor not only by what she
scores on a pain scale but also by subtle signs of pain
such as facial tenseness, flushing or paleness of the
face, hands clenched in a fist, rapid breathing, or
rapid pulse rate.
Appreciate that the fetus as well as the mother is under
stress from the process of labor, so both need vital sign
assessments.
NURSING DIAGNOSIS
Nursing diagnoses in labor generally relate to a woman’s
reaction to labor.
Common nursing diagnoses include:
Pain related to labor contractions
Anxiety related to process of labor and birth
Health-seeking behaviors related to management of
discomfort of labor
Situational low self-esteem related to inability to use
planned childbirth method
Although the discomfort of labor contractions is commonly
referred to as “contractions” rather than “pain,” do not
omit the word “pain” from a nursing diagnosis because the
term strengthens an understanding of the problem as well
as alerts a woman she should feel free to ask for
something for pain at the point she feels she needs
additional help.
OUTCOME IDENTIFICATION AND PLANNING
 be certain they are realistic and that they can be
met.
 (average, 12 hours), it is important not to
project a definite time limit for labor to be
completed because the length of labor can vary
greatly from woman to woman and still be within
normal limits.
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 It is necessary also to appreciate the magnitude

of labor.
COMPONENTS OF LABOR
 It is unlikely all the fear or anxiety experienced
during a woman’s labor can be completely
alleviated. Often, because it is such an unusual
and significant experience, the average couple
may need guidance in order to be able to employ
additional coping measures.

 Be certain to incorporate a support person as

well as the woman in planning so the experience
is a shared one.

 Although a couple may have learned about the

stages of labor and what to expect at each stage
during pregnancy, the reality of labor may seem
very different from what they imagined. Be certain
also that planning is flexible and individualized,
PASSAGE (a woman’s pelvis)
allowing the woman to experience the full
PASSENGER Fetus
significance of the event.
Widest diameter
 Head
IMPLEMENTATION/INTERVENTION
POWER Uterine Contraction
PSYCHE Woman’s psychological
• As much as possible, interventions during labor state that inhibits labor
should always be carried out between
contractions so the woman can use a prepared
childbirth technique to limit the discomfort of STRUCTURE OF FETAL SKULL
contractions.
Cranium
• This calls for good coordination of care among
healthcare providers and the woman and her  Uppermost portion of skull
support person.  Composed of 8 bones
• The person a woman chooses to stay with her 4 superior bones (significant in childbirth)
during childbirth is often culturally determined and
varies from being a husband, a significant other  Frontal (2 fused bones)
or partner, the father of the child, a sister, a  2 parietal
parent, or a close friend.  Occipital

OUTCOME EVALUATION Least significant cranial bones

 Sphenoid
An evaluation during labor should be ongoing to preserve
 Ethmoid
the safety of the woman and her newborn. After birth, an
 2 temporal bones
evaluation helps to determine the woman’s opinion of her
experience with labor and birth. Ideally, the experience
should not only be one she was able to endure but also
one that allowed her self-esteem to grow and the family
bond to intensify through a shared experience. It is
advantageous to talk to women following birth about
their labor experience because doing so serves as a
means of evaluating nursing care during labor. It also
provides a woman the chance to “work through” the
experience and incorporate it into her self-image. Possible
outcome criteria include:

Patient states pain during labor was tolerable because

of her advance preparation.
Patient verbalizes that her need for nonpharmacologic
comfort measures was met.
Patient and family members state the labor and birth
experience was a positive growth experience for them,
both individually and as a family.

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helps a fetus present the smallest

anteroposterior diameter of the skull
to the pelvis and also because it puts
the whole body into an ovoid shape,
occupying the smallest space
possible
Moderate  causes the next widest
Flexion (Military anteroposterior diameter
position)  occipitofrontal diameter
present to the birth canal.
 mechanisms of labor
(descent and flexion) force
the fetal head to fully flex.
Partial Flexion Brow is the presenting part
DIAMETERS OF FETAL SKULL
Face  presenting the
Presentation occipitomental diameter of
Anteroposterior Diameter  wider
the head to the birth canal
Transverse Diameter  oligohydramnios
 reflect a neurologic
 Fetus must present this diameter abnormality in the fetus
causing spasticity.

FETAL LIE

 relationship between long axis of mother to long

axis of fetus
 horizontal, vertical, transverse
 96% of fetus assumes horizontal or longitudinal
position

FETAL PRESENTATION

 Body part in contact with cervix

 Determined by both fetal lie and degree of flexion

Molding

 overlapping of skull bones along the suture lines,

which causes a change in the shape of the fetal
skull to one long and narrow, a shape that
facilitates passage through the rigid pelvis.
 caused by the force of uterine contractions as the
vertex of the head is pressed against the not yet
dilated cervix.
 The overlapping that occurs in the sagittal suture
line and, generally, the coronal suture line can be
easily palpated on the newborn skull. TYPES OF CEPHALIC PRESENTATION
TYPE LIE ATTITUDE DESCRIPTION
FETAL ALIGNMENT Vertex Longitudina Full flexion Head is
l flexed.
FETAL ATTITUDE Most common
presentation
Complete  spinal column is bowed Brow Longitudina Moderate Brow becomes
Flexion (Good forward l presenting
Attitude)  head is flexed forward so Face Longitudina Poor Face is
much that the chin touches l presenting part
the sternum Extreme
 the arms are flexed and edema and
folded on the chest distortion of
 thighs are flexed onto the face may occur
abdomen Mentum Longitudina Very poor Hyperextended
 calves are pressed against l head to
the posterior aspect of the present the
thighs chin.
Vaginal birth
advantageous for birth because it not possible

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because of Engagement
wide diameter.
 Settling of presenting part of a fetus far enough
into pelvis that it rests at the level of ischial
Caput Succedaneum spines(midpoint of pelvis)

 During labor, the area of the fetal skull that Descent to the point
contacts the cervix often becomes edematous
from the continued pressure against it. This  Widest part of the fetus of presenting part has
edema is called a caput succedaneum. passed through the pelvis or pelvis inlet has been
 In the newborn, what was the point of proven adequate for birth
presentation can be analyzed from the location of
Floating
the caput.
 Presenting part is not engaged
FETAL POSITION
Dipping
 Relationship of presenting part to a specific
quadrant of a woman’s pelvis  Descending but has not yet reached the ischial
 Four quadrants: (also known as landmarks) spine
a. Right anterior
Station
b. Left anterior
c. Right posterior  Relationship of presenting part to level of ischial
d. Left posterior spine
 Vertex presentation = Occiput
 Face presentation = mentum(M)
 Breech presentation = sacrum (Sa)
 Shoulder presentation = acromion process or
scapula

FETAL ENGAGEMENT

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Flexion
 When the presenting fetal part is at the level of
the ischial spines,
 it is at a 0 station (synonymous with
engagement). Engaged
 If the presenting part is above the spines, the
distance is measured and
 described as minus stations, which
range from −1 to −4 cm. Floating
 If the presenting part is below the ischial
spines,
 the distance is stated as plus stations
(+1 to +4 cm).
 At a +3 or +4 station, the presenting part is at the
perineum and can be seen if the vulva is
separated (i.e., it is crowning).
MECHANISMS (CARDINAL MOVEMENTS)
OF LABOR
DESCENT
Descent
 Downward movement of biparietal diameter of
fetal head within pelvic inlet
 Occurs because of the pressure of the fetus by
the uterine fundus
 Mother experiences “pushing sensation” within
labor because of the pressure of fetal head on
sacral nerves
 As a woman contracts her abdominal muscles
with pushing, it aids descent
a. Full descent  fetal head protrudes beyond
dilated cervix and touches posterior vaginal floor
FLEXION
 Head bends forward onto chest, causing
smallest anteroposterior diameter
(suboccipitobregmatic) to present in birth canal
 Aided by abdominal muscle contraction during
pushing.
INTERNAL ROTATION
 . As the head flexes at the end of descent, the
occiput rotates so the head is brought into the
best relationship to the outlet of the pelvis, or the
anteroposterior diameter is now in the
anteroposterior plane of the pelvis
 This movement brings the shoulders, coming
next, into the optimal position to enter the inlet, or
puts the widest diameter of the shoulders (a
transverse one) in line with the wide transverse
diameter of the inlet.
EXTENSION
 As the occiput of the fetal head is born, the back
of the neck stops beneath the pubic arch and acts
as a pivot for the rest of the head. The head
extends, and the foremost parts of the head, the
face and chin, are born.
EXTERNAL ROTATION
 In external rotation, almost immediately after the
head of the infant is born, the head rotates a final
time (from the anteroposterior position it assumed
to enter the outlet) back to the diagonal or
transverse position of the early part of labor.
 This brings the after coming shoulders into an
anteroposterior position, which is best for entering
the outlet. The anterior shoulder is born first,
assisted perhaps by downward flexion of the
infant’s head.
EXPULSION
 Once the shoulders are born, the rest of the baby
is born easily and smoothly because of its smaller
size.
 This movement, called expulsion, is the end of
the pelvic division of labor.
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POSTPARTUM PERIOD

postpartal period, or puerperium

 (from the Latin puer, for “child,” and parere, for “to
bring forth”)
 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 often termed the fourth trimester of
pregnancy.
NURSING PROCESS OVERVIEW
ASSESSMENT health interview; awareness of her
prenatal, natal, and medical history;
physical examination; and analysis
of laboratory data

ensure that physical changes,

such as uterine involution, are
occurring by evaluating uterine size
and consistency and the amount of
lochia flow.
NURSING postpartal period are often “risk
DIAGNOSIS for” diagnoses and concerned with
a family’s ability to accept and
bond with a new child or with
physiologic considerations.

Examples include:
 Health-seeking behaviors
related to care of newborn
 Fear related to lack of
preparation for child care
 Risk for deficient fluid
volume related to
ESSENTIAL INTRAPARTUM AND NEWBORN postpartal hemorrhage
 Risk for altered family
CARE coping related to an
additional family member
 Risk for complications in

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human
lactation/breastfeeding
Uncertainty regarding the
infant’s well-being if there
are congenital anomalies
OUTCOME realistic in light of a woman’s
IDENTIFICATION changed life pattern, support from
AND PLANNING family, and cultural preferences.
outcomes must be devised that can
be accomplished and evaluated
during this short period of
patient contact. If an outcome
cannot be evaluated within this
short time frame, follow-up home
care, ambulatory visits, or phone
calls may be necessary
try to arrange procedures to
allow optimal time for family–
infant interaction and yet provide
adequate time for a woman to rest
to prevent exhaustion because this
can improve her coping ability and
plans for self-care.
Planning should also include
ample time for health teaching
such as care of the newborn and
the need for flexibility in care
because the parents do not yet
know what their new life will be like
or how tired they will become after
being awakened frequently during
the night.
Brainstorming with the parents—
practicing to produce at least three
different methods of reaching a
particular goal—is excellent
practice for parenting because
giving advice only solves an
immediate problem; helping
parents learn good problem-solving
techniques improves their ability to
handle the many challenges that
will arise with childrearing.
IMPLEMENTATION All interventions in the postpartal
period should be family-centered,
to enhance family functioning and
bonding, and geared toward
increasing a woman’s selfesteem,
allowing her to view herself as a
new mother and helping her view
her new infant as part of her family.
OUTCOME involves not only being certain a
EVALUATION woman and her baby are safe but
also that the woman knows how to
maintain her own and her infant’s
health. Such follow-up evaluation
can be done by telephone, during
home visits, or during postpartal
and well-child assessments.
Examples of expected outcomes
include:
The parents spontaneously
verbalize at least one positive
comment about their child’s
characteristics before hospital
discharge. T
he patient states she believes she
will be able to manage newborn
care with the support of her
significant other. The patient’s
lochial flow is no more than one
saturated perineal pad (50 ml)
every 3 hours.
The patient states she is tired but
feels able to manage her newborn
and family care. Physical
interaction and holding of the infant
appears appropriate and
responsive to the infant’s needs.
PSYCHOLOGICAL CHANGES
BEHAVIORAL ADJUSTMENT
A. Taking-In Phase
Time when new parents review pregnancy and labor
and birth.
 During this 1 to 3 day period, woman is largely
passive. She prefers having a nurse attend to
her needs and make decisions for her rather than
to do things herself.
 Dependence results partly from physical
discomfort because of afterpains, uncertainty in
caring for newborn, exhaustion that follows
childbirth.
B. Taking-Hold Phase
Woman begins to initiate action. She prefers to get her
own things and decisions
 Women without anesthesia may reach this phase
in a matter of hours after childbirth.
 Time of initiation of action and greater
independence as evidenced by performing self-
care
 Woman may be too tired to care for her own
child.
 Begins a stronger interest in infant and begin
maternal role behavior. Give woman a brief
demonstration of baby care and allow her to care
for her child herself.
C. Letting-Go Phase
Finally redefines new role
 Gives up fantasized image of the child and
accepts the real one
 Give sup old role of being childless
 This process requires some grief work and
readjustment of relationship
 Extended and continues during child’s growing
years
PHYSIOLOGICAL CHANGES
REPRODUCTIVE SYSTEM CHANGES
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Involution  Amount of blood in the cast off tissue has

decreased.
 Reproductive organs return to non-pregnant state  Leukocytes begin to invade the area
 Woman is in danger of hemorrhage from
 Flow becomes pink or brownish (Lochia Serosa)
denuded surface of uterus until involution is
incomplete. 10th day

A. Uterus  Amount of flow decreases and becomes colorless

or white with streaks of brownish mucus (Lochia
Involution of uterus has 2 processes: Alba)
1. Area where placenta was implanted is sealed off Lochia Alba
to prevent bleeding
2. Organ is reduced to its approximate  Present in women until 3rd week after birth.
pregestational state.  Unusual for a lochia flow to last entire 6
 Uterus of a breastfeeding mother may contract weeks of puerperium
even more quickly because oxytocin stimulates
uterine contractions. CHARACTERISTICS OF LOCHIA
TYPE COLOR DAY COMPOSITION
 Breastfeeding is not sufficient to prevent
Lochia red 1-3 Blood,
hemorrhage.
Rubra fragments of
Uterine involution decidua
Lochia pink 3-10 Blood, mucus,
Day of birth at umbilicus Serosa invading
2 days postpartum decrease at 1 – 2 cm leukocytes
4 days PP between symphysis pubis Lochia Alba White 10-14 Largely mucus,
and umbilicus (may last leukocyte count
6 days PP above pubic symphysis 6weeks) high
8 days PP at pubic symphysis
C. Cervix
 st
1 hour of birth is most dangerous for a After birth, uterine cervix feels soft and malleable to
woman palpation
 Uterine decreases at rate 1cm a day.
 After 10 days it recedes and should not be  Contraction towards pre-pregnant state begins at
palpable. once
 If the uterus had become relaxed during this time
By end of 7 days
(uterine atony), she will lose blood very rapidly
because there are no permanent thrombi have  external os has narrowed down to a size of a
yet formed at placental site. pencil opening. Cervix feels firm and nongravid
B. Lochia again.
Separation of placenta and membranes occurs in spongy Process in cervix does not involve formation of new
layer or outer portion of decidua basalis of uterus muscles, cervix does not return exactly to its pre-
 2nd day after birth, layer of decidua remaining pregnant state.
under placental site differentiates into 2 distinct Pelvic examination normal finding:
layer:
I. Inner layer Internal OS:  closes as before
 is attached to muscular wall of uterus remains, External OS:  remains slightly
serving as the foundation from which a new layer open and
of endometrium can be found. appears stellate
II. Layer adjacent to uterine cavity or slit like (star
 becomes necrotic and is cast off as a vaginal shaped)
discharge similar to a menstrual flow. previously it was
round.
Lochia

 Flow consisting of blood, fragments of decidua,

WBC, mucus, and some bacteria D. Vagina
 Feels soft, with few rugae, its diameter is greater
First 3 days after birth
than normal
 Lochia discharge is entirely blood, with small  Hymen is permanently torn and heals with small,
particles of decidua and mucus. (Lochia Rubra) separate tags of tissue.
 Takes entire postpartal period for vagina to
4th day involute

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 Thickening of walls depend on renewed estrogen  Assess woman’s abdomen frequently in

stimulation from ovaries.
 A woman who is breastfeeding may have
delayed involution, she may continue to have
thin-walled or fragile vaginal cells that cause
slight vaginal bleeding during coitus until about 6
weeks’ time.
 If a woman practices Kegel exercises, strength
and tone of vagina will increase more rapidly.
E. Perineum
 Edematous and tender
 Ecchymosis patches from ruptured capillaries
Hydronephrosis or increased size of uterus
may show on surface.
Labia Minora and Majora:
 Remain atrophic and softened after birth
 Never returning to pre-pregnancy state.
immediate postpartum period to prevent
permanent damage to bladder from
overdistention
 on palpation, full bladder is felt as hard or firm
area just above pubis symphysis.
 on percussion, a full bladder sounds resonant
 pressure may make woman feel as if she has to
void, but then unable to do so. As bladder fills
displaces the uterus; uterine position and lack of
contraction are good gauge of a bladder whether
if it is full or empty.
 occurs during pregnancy is present for about 4
weeks after birth.
 Increases possibility of urinary stasis and UTI in
postpartal period.

Mothers may experience various level of tenderness in

perineum area, suggesting nonpharmacologic measures. c. Circulatory system
Nurses should also discuss mother’s provider the Usual blood loss at NSD = 300 to 500ml
pharmacologic pain relievers
Usual blood loss at CSD = 500 to 1,00ml
SYSTEMIC CHANGES
 4 point decrease in hematocrit(proportion of RBC
a. Hormonal system to circulating plasma)
 1g decrease in hemoglobin value which occur
Pregnancy hormones decreases as soon as placenta is no every 250ml of blood loss.
longer present.
If woman was anemic during pregnancy:
 Levels of HCG and hPL (human placental
lactogen) are almost negotiable by 24 hours.  Expect to be anemic afterwards.
 Excess fluid is excreted, hematocrit gradually
Week1 rises
 Reaching prepregnancy state at 6weeks after
 Progestin, estrogen, estradio are all at
birth
prepregnancy state
High level of plasma fibrinogen during 1 st post partal week,
FSH remains low for 12 days and begins to rise as new
as it is the protective measure against hemorrhage. This
menstrual cycle is initiated.
high level also increases risk of thrombus formation.

 WBC may be high as 30,000 cells/mm3 (mainly

b. Urinary system
Pregnancy
 2000 to 3000 ml of excess fluid, so extensive
diaphoresis (excessive sweating) and diuresis
(excess urine production) begin after birth to get
rif of excess fluid.
Postpartal
 Increased urine output from 1,500 to 3,000
ml/day during 2nd to 5th day after birth.
 Reassure mother that increased urine production
is normal and she still needs to continue drinking
fluids.
Epidural Anesthesia
 This can make woman feel no sensation in the
bladder area until anesthetic has worn off.
ASSESSMENT
granulocytes) (normal level = 5,000 to 10,000
cells/mm3)
 Any varicosities will recede, but rarely return to
complete prepregnant state.
Spider angiomas  fade slightly, may not disappear
completely
 should not progress above the knees. Decreases
over time as fluid shifts and returns to system.
d. Gastrointestinal system
Digestion and absorption begin to be active again
 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,

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 but passage of stool through the bowel may be
slow because of the stillpresent effect of relaxin
 relaxin - a hormone which softens and
lengthens the cervix and pubic
symphysis for preparation of the infant’s
birth during pregnancy) on the bowel.
 Bowel evacuation may be difficult because of
pain if a woman has episiotomy sutures or from
hemorrhoids.
 Encouraging the mother to eat produce and
soluble fiber foods, especially fruits, will help keep
her stools naturally soft and ease in her bowel
movements.
women, this baseline is higher than their prepregnancy
weight and one of the reasons that obesity has become
a national health concern
Balancing a newborn, eating healthy foods, and finding
the time to exercise becomes a challenge to many
mothers.
Discussing strategies with her will help to organize her
efforts to find balance, such as helpful babysitters,
family members, and/or her partner to come and give
her needed breaks.
VITAL SIGNS

e. The Integumentary System a. Temperature

striae gravidarum  Taken orally or tympanic
 stretch marks on a woman’s abdomen still
 Woman may show slight increase in temperature
appear reddened and may be even more
during first 24 hours after labor
prominent than during pregnancy, when they
were tightly stretched.  Any woman whose oral temperature rises above
 Typically, in a White woman, these will fade to a 100.4°F (38°C), excluding the first 24-hour
pale white over the next 3 to 6 months; in a Black period, is considered by criteria to be febrile, and
woman, they may remain as areas of slightly such a high temperature may indicate that a
darker pigment. postpartal infection is present
Chloasma
 Excessive pigment on face and neck  Occasionally, when a woman’s breasts fill with
 will become barely detectable by 6 weeks’ time. milk on the third or fourth postpartum day during
lactogenesis II, her temperature will rise for a
Linea Nigra period of hours because of the increased
 Excessive pigment on abdomen vascular activity involved; this process is termed
 will become barely detectable by 6 weeks’ time. engorgement
 An infection of the breast during lactation is
diastasis recti termed mastitis.
 overstretching and separation of the abdominal  Mastitis can interfere with lactation, and
musculature sometimes, an infant will refuse to nurse
 area will appear as a slightly indented bluish on the affected side
streak in the abdominal midline.
b. Pulse
The women’s medical provider must be notified to initiate antibiotic
 Modified sit-ups help to strengthen abdominal treatment (congruent with breastfeeding). Mothers should be
muscles and return abdominal support to its  A woman’s pulse rate during the postpartal period
instructed to continue breastfeeding if the infant will breastfeed from
prepregnant level. Diastasis recti, however, may is usually
the affected slightly
side. If the infantslower
refuses,than usual.
instruct the mother to pump
require surgery to correct (Hickey, Finch, & 
her breastsDuring
to maintainpregnancy, the clogged
flow (and to avoid distended uterus
ducts) and then
Khanna, 2011). obstructed
offer the affected breasttheafter
amount of venous
12 to 24 hours. Once blood
thereturning
mastitis is
treated, infants
to theoften will resume
heart; after breastfeeding after 12 to 24 hours.
birth, to accommodate the
Unless specifically
increased directed
bloodotherwise,
volume infants
returningare to
safethe
to continue
heart,
RETROGRESSIVE CHANGES to breastfeed while a mother is being treated for mastitis; there is
stroke volume increases
no reason to provide alternative feeding methods or to wean
EXHAUSTION  ofThis
because increased
maternal mastitis.stroke
Becausevolume reduces
infection the cause
is a major pulseof
postpartal rate to between
mortality 60 and
and morbidity, 70 beats/min.
nurses have the important role of
Woman experiences total exhaustion, difficulty sleeping beingthe healthcare
As diuresis diminishes
providers who maythe firstblood volume
detect the and
problem.
causes blood pressure to fall, the pulse rate
Has sleep hunger increases accordingly.
 By the end of the first week, the pulse rate will
WEIGHT LOSS have returned to normal.
 Evaluate pulse rate conscientiously in the
The rapid diuresis and diaphoresis during the second to postpartal period because a rapid and thready
fifth days after birth usually result in a weight loss of 5 lb pulse during this time could be a sign of
(2 to 4 kg), in addition to the approximately 12 lb (5.8 hemorrhage.
kg) lost at birth.
Lochia flow causes an additional 2- to 3-lb (1-kg) loss, PROGRESSIVE CHANGES
for a total weight loss of about 19 lb.
Additional weight loss is dependent on the amount of Nursing Care of a Woman and Family During the First 24
pregnancy weight gain and on whether a woman Hours After Birth
continues active measures to lose weight (Cahill, A. ASSESSMENT
Freeland-Graves, Shah, et al., 2012). It is also 1. Health History
influenced by nutrition, exercise, and breastfeeding. 2. Family Profile
The weight a woman reaches at 6 weeks after birth 3. Pregnancy History
becomes her baseline postpartal weight unless she 4. Labor and Birth History
continues active measures to lose the weight. In many 5. Infant Data

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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS

Depend on other family

MUSCLE STRENGTHENING EXERCISES member, explore other
EXERCISE DESCRIPTION people that can help so she
Abdominal May be started on first day after birth can rest
Breathing Lying flat on her back or sitting, woman Exercise Limit number of stairs she
should breathe slowly and deeply in and out climbs to one day of first
five times using abdominal muscles. week at home
Check by watching her abdominal wall rise Help plan for a place for the
that she is actually using these muscles baby to sleep downstairs to
Chin-to- Excellent to use for second day alleviate second concern.
chest Lying in back with no pillow, a woman raises Should continue muscle
her head and bends her chin forward on her strengthening exercises
chest without moving any part of the body Hygiene Either take tub bath or
while exhaling. She should start this shower. Should continue to
gradually repeating it no more than 5 times apply perineal cream or
the first time and then increasing it to 10-15 ointment.
times in succession. Remind her to cleanse her
This can be done 3 or 4 times a day. She will perineum from front to back
feel her abdominal muscles pull and tighten after voiding to prevent fecal
is she is doing it correctly. contamination. Any perineal
Perineal Good to add on third day stitches will be absorbed
Contraction She should tighten and relax her perineal within 10 days
muscles 10-25 times in succession as if she Coitus Coitus is safe as soon as a
were trying to stop voiding (kegel exercises) woman’s lochia turned to
She will fell her perineal muscles as if she is alba. If present, episiotomy is
doing it correctly. healed. Vaginal cells may not
Arm raising Helps both breast and abdomen return to be as thick as formerly
good tone and is a good exercise to add on because pre-pregnancy
fourth day hormone balance has not yet
Lying on back with arms at sides, a woman completely returned to
moves her arms out from her sides until they supply lubrication. Use of a
are perpendicular to her ody. She then raises contraceptive form or
them over her body until her hands touch lubricating jelly will aid
and lowers them slowly to her sides. comfort. Be certain she
She should ret a moment and then repeat knows safer sex precautions
the exercise five times. Contraception If desired, woman should
Abdominal Advisable to wait until the 10th day or 12th begin contraception measure
crunches day after birth before attempting abdominal with the initiation of coitus. If
crunches. Lying flat on back with knees bent, she wants an intrauterine
a woman folds her arms across the chest and device, this may be fitted
raises herself to a sitting position. immediately after birth or at
This exercise expends a great deal of effort her post-partal checkup.
and tires a postpartal woman easily. Caution Combination of oral
her to begin very gradually and work up contraceptives are begun
slowly to doing it 10 times in a row about 2-3weeks after birth
NURSING CARE OF A WOMAN AND FAMILY IN due to clotting factor risk and
PREPARATION FOR HEALTH AGENCY DISCHARGE interference with milk
production for women who
POSTPARTAL DISCHARGE INSTRUCTIONS are breastfeeding.
Work Avoid heavy work for at least Follow-up Should notify health provider
3 weeks after birth If she notices increase, not a
Modify plan if she plan to do decrease in lochia discharge,
work or if lochia serosa or alba
Woman must not return to becomes rubra; if lochia has
an outside job for at least 3 foul odor; if she has a
weeks or better for 6 weeks temperature greater than
not only for her own health 101F; or if symptoms of
but also for enjoyment of the sadness last longer than 2
early weeks with her weeks.
newborn A woman should schedule a
Rest Plan at least one rest period 4 to 6 week checkup so she
each day while baby is asleep can be assured involution is
and try to get a good night complete and immunization
sleep if not previously immunized
against the virus associated

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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
with cervical cancer.
SIX WEEK PHYSICAL ASSESSMENT
AREA OF DATA COLLECTION
ASSESSMENT
History Assess CC, family profile, interval
history, review of systems.
Assess maternal intake because some
new mothers are too fatigued to eat
well
PHYSICAL EXAMINATION
General Alert; positive mood. If not it may be
Appearance they are still fatigued
Weight Achievement of prepregnant weight; if
not this will be her baseline
postpregnant weight
Hair Healthy, firm hair; excess loss of hair
from early postpartal has halted
Eyes Pink and moist conjunctiva; if pallor
persists, diet may be inadequate to
iron
BREASTS
Breastfeeding Full and firm to palpation; blue veins
woman prominent under skin. Areola darkens
and nipples elongates. No palpable
nodules or lumps. If erythematous or
extremely tender, mastitis or nipple
fissure may be present. An occasional
fille dmilk gland may present as lump;
reexamine after breastfeeding.
Nonbreastfeeding Return to pre-pregnant size; no
woman palpable nodules or lumps
Abdomen Striae less prominent; linea Negra
fading; muscle tone improving, no
distended bowel from constipation. No
distended bladder from retention. No
history of pain, frequency, or blood on
urination. Urinary symptoms probably
reflect urinary infection that needs
specific treatment
Perineum and Lochia no longer present; cervix closed;
uterus uterus has returned to pre-pregnant
size. Pap test is normal. Ask woman to
bear down during pelvic examination
to observe for uterine prolapse,
rectocele or cystocele. If involution is
not complete, reason for subinvolution
must be investigated.
Lower extremities Varicosities barely noticeable
Rectum Hemorrhoids receeded to pre-pregnant
size or are no longer observable.
Mental Positive interaction with infant,
appropriate personal hygiene. No
indication of postpartal depression or
psychosis is present.
LABORATORY REPORTS
Laboratory Hct: 37%; Hgb: 11-12g/100mL. If
Values these are low, reassess diet; possibly
iron supplement may be needed
Rubella antibody tier: 1:8; if low,
additional immunization is
recommended before a second
pregnancy
Immunization Assess need for human
status papillomavirus (HPV) (Gardasil) or
rubella vaccine
KEY POINTS TO REVIEW
postpartal period (puerperium) is the
 6-week period after childbirth.
 Women move through an initial “taking-
in” phase, in which they are dependent;
 a “takinghold” phase, in which they
manifest independence;
 and a “letting-go” phase, in which the
mother role is finally defined.
Rooming-in
 is the preferred healthcare agency arrangement
for postpartal families because it allows a new
family the best chance for quality interaction and
promote breastfeeding
 The more time new parents spend with a
newborn, the more likely it is that effective
bonding will occur.
 Help parents to feel comfortable with their
newborn by offering anticipatory guidance and
role modeling infant care as this not only helps in
planning nursing care that meets QSEN
competencies but also best meets the family’s
total needs.
“Postpartal blues”
 are a normal accompaniment to childbirth.
 You can assure a woman that such feelings are
normal and offer supportive care until the emotion
passes.
Uterine involution
 is the process whereby the uterus returns to its
prepregnant state.
 A uterus decreases in size one fingerbreadth (1
cm) a day until it disappears under the pubic
bone at about day 10.
Lochia
 is the name of the vaginal flow after childbirth:
 The flow is lochia rubra (red) for the
first 1 to 3 days,
 lochia serosa (pink to brown) on days
4 through 10,
 and lochia alba (white) until 2 to 6
weeks after the birth.
 A woman is at great risk for hemorrhage in the
postpartal period, so assessments done to reveal
this are some of the most critical assessments
made in nursing. Do not discount the importance
of these assessments because the overall
content of the postpartal period is so focused on
wellness.
Lactation
 is the production of breast milk.
 Colostrum is present immediately after
birth; milk forms on the third to fourth
postpartal day.
 A feeling of fullness and firmness on this day is
termed filling; if warmth and discomfort occur, it is
termed engorgement.
 Assessing the mother’s milk production, infant’s
latch, painful nipples, and ability to transfer milk is
crucial in the early postpartum period.
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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
 Women may need various comfort measures to
alleviate pain from uterine pain (afterpains) and
breast tenderness. Application of cold or heat and
administration of analgesics are important nursing
interventions.
 Women need to learn about self-care before
healthcare agency discharge, so they can
maintain self-care at home. A follow-up telephone
call or home visit can be helpful to answer
questions.
 All women should conscientiously return for a
health assessment visit at 6 weeks after childbirth
to be certain their reproductive organs have
returned to their nonpregnant state.
 Menstrual flow should return within 6 to 10
weeks in the nonbreastfeeding mother or after
3 to 4 months in the breastfeeding mother.
NEONATAL PERIOD
ASSESSMENT
 a review of the mother’s pregnancy history;
 a physical examination of the infant;
 an analysis of laboratory reports such as
hematocrit, bilirubin, and blood type;
 and an assessment of parent–child interactions to
be certain bonding is beginning.
This assessment
 begins immediately after birth and is continued
at every contact during a newborn’s birthing
center stay, at early home visits, and at well-baby
and sick baby visits.
 Teaching new mothers and their partners to make
assessments concerning their infant’s
temperature, respiratory rate, and overall health
is crucial so they can continue to monitor their
infant’s health at home
NURSING DIAGNOSIS
 Nursing diagnoses associated with newborns
center on the difficulty of establishing
respirations, beginning nutrition, and assisting
with parent–newborn bonding.
Examples include:
Ineffective airway clearance related to mucus in the
airway
Ineffective thermoregulation related to heat loss from
exposure in the birthing room
Imbalanced nutrition, less than body requirements,
related to poor sucking reflex
Readiness for enhanced family coping related to birth of
infant
Health-seeking behaviors related to newborn needs If a
minor deviation from the normal is present, such as a
birthmark, a diagnosis such as “Parental fear related to
hemangioma on left thigh of newborn” might be
relevant.
OUTCOME IDENTIFICATION AND PLANNING
 Nursing care planning should take into account
the newborn’s needs during this transition
period, a mother’s need for adequate rest during
the postpartum period, and the parents’ need to
become acquainted with their new child.
 Try to adapt teaching time to the schedules of
the mother, her partner, and the newborn.
Although the woman must learn as much as
possible about newborn care, she also must go
home from the healthcare setting with enough
energy to practice what she has learned.
 Important planning measures for newborns
include helping them regulate their temperature
and helping them grow accustomed to feeding.
 Refer parents to helpful websites and other
resources when appropriate.
IMPLEMENTATION
 Role modeling by the nurse during the newborn
period is an effective way to help new parents
grow confident with their newborn. Parents will be
observing you closely.
 Conserving newborn warmth and energy, to help
prevent hypoglycemia and respiratory distress,
should be an important consideration during all
interventions.
OUTCOME EVALUATION
 An evaluation of expected outcomes should
reveal that a baby’s primary caregiver is able to
give beginning newborn care with confidence.
 Be certain a woman and her partner make
arrangements for continued health supervision for
their newborn, so the infant’s long-term health
needs are met.
Examples indicating achievement of outcomes concerning
newborns include:
 Infant establishes respirations of 30 to 60
breaths/min.
 Infant maintains temperature at 97.8° to 98.6°F
(36.5° to 37°C).
 Mother demonstrates competence in caring for
newborn.
 Infant breastfeeds well with a strong sucking
reflex.
VITAL STATISTICS
AVERAGE NEWBORN
Head Circumference Temperature (Axillary)
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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS

 34 to 35 cm 97.6 to 98.6 F  If a large amount of breast tissue or edema of the

breasts is present, this measurement will not be
Chest Circumference Heart Rate
accurate until the edema has subsided.
 32 to 33 cm 120 to 140bpm  The chest circumference in a term newborn is
about 2 cm (0.75 to 1 in.) less than head
Respirations Weight circumference.
 30 to 60 breaths/min 2.5 to 3.4 kg

Length APGAR SCORING

 46 to 54cm At 1 minute and 5 minutes after birth, newborns are

WEIGHT
 A newborn’s weight is important because it helps
to determine maturity as well as establish a
baseline against which all other weights can be
compared.
 Following this initial weight, an infant is weighed
nude once a day, at approximately the same time
every day, during a hospital or birthing center
stay.
Length
 A newborn’s length at birth in relation to weight is
a second important determinant used to confirm
that a newborn is healthy.
 The average birth length (50th percentile) of a
mature female newborn is 49 cm (19.2 in.).
 For mature males, the average birth length is
50 cm (19.6 in.).
 The lower limit of expected birth length is
arbitrarily set at 46 cm (18 in.).
 Although rare, babies with lengths as great as
57.5 cm (24 in.) have been reported
observed and rated according to an
Apgar score
 an assessment scale used as a standard for
newborn evaluation since 1958
 heart rate, respiratory effort, muscle tone, reflex
irritability, and color of the infant are each rated 0,
1, or 2.
 There is a high correlation between low 5-minute
Apgar scores and neurologic illness (American
Academy of Pediatrics [AAP], 2015b). The
following points are considered in obtaining the
rating:
 done at one and five minutes after birth. The
newborn is considered to be “vigorous” if the
initial scores are 7 and above.
 If the five-minute score is less than 7, scoring is
done every five minutes thereafter until the score
reaches 7.
 The numbers in the left-hand column represent
the number of points that are assigned to each
parameter when the criteria in the corresponding
column are met.

Head Circumference

 Head circumference is measured with a tape

measure drawn across the center of the forehead
and then around the most prominent portion of
the posterior head (the occiput) (see Chapter 34,
Fig. 34.5).
 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, although some well
newborns have these measurements.

Chest Circumference

 Chest circumference is measured at the level of

the nipples.

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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS

Heart Rate

 Auscultating a newborn heart with a stethoscope

is the best way to determine heart rate; however,
heart rate also may be obtained by observing and
counting the pulsations of the umbilical cord at
the abdomen if the cord is still uncut.
Respiratory Effort

 Respirations are counted by observing chest

movements. A mature newborn usually cries and
aerates the lungs spontaneously at about 30
seconds after birth.
 By 1 minute, he or she is maintaining regular,
although rapid, respirations.
 Difficulty with breathing might be anticipated in a
newborn whose mother received large amounts
THE ASSESSMENT OF GESTATIONAL AGE
of analgesia or general anesthetic during labor or
birth.  Newborns are said to be term if they are born
Muscle Tone between 37 and 42 weeks of gestation or within
2 weeks of their due date.
 Term newborns hold their extremities tightly  Gestational age for an infant born 5 days after the
flexed, simulating their intrauterine position. due date would be recorded as 40 + 5; an infant
Muscle tone is tested by observing their born 3 days before the due date would be
resistance to any effort to extend their extremities recorded as 40 − 3.
 Specific findings from physical assessment also
provide clues to a newborn’s gestational age.
Reflex Irritability
 These quick criteria can be used for an
 One of two possible cues is used to evaluate assessment of all newborns in a birthing room.
reflex irritability:
1. response to a suction catheter in the nostrils
2. response to having the soles of the feet
slapped.
 A baby whose mother was heavily sedated for
birth will probably demonstrate a low score in this
category.
Color

 All infants appear cyanotic at the moment of

birth. They grow pink with or shortly after the first
breath, which makes the color of newborns
correspond to how well they are breathing.
 Acrocyanosis (cyanosis of the hands and feet) is
so common in newborns that a score of 1 in this
category can be thought of as normal.
The Respiratory Evaluation

 Good respiratory function has the highest priority

in newborn care, so the assessment for it is
ongoing at every newborn contact.
 Silverman-Andersen index,
 is a standard method, which can be
used to estimate degrees of respiratory
distress in newborns. For this
assessment, a newborn is observed and
then scored on each of five criteria (Fig.
18.11).

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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS

POSTURE  arms and legs  elbow at proximal

extended = 0; axillary line = 4
 slight or moderate HEEL TO EAR With infant supine, hold
flexion of hips and infant’s foot with one hand
knees = 2; and move it as near to the
 legs flexed and head as possible without
abducted, arms forcing it. Keep pelvis flat on
slightly flexed = 3; examining surface
 full flexion of arms
and legs = 4.

SQUARE WINDOW Flex hand at the wrist. Exert

pressure sufficient to get as
THE BRAZELTON NEONATAL BEHAVIORAL
much flexion as possible. The ASSESSMENT SCALE
angle between hypothenar
eminence and anterior Term newborns are physically active and emotionally
aspect of forearm is prepared to interact with the people around them. They are
measured and scored. Do people oriented from the beginning, and how much so can
not rotate wrist be demonstrated by the way they immediately attune to
human voices or concentrate on their mother’s face
ARM RECOIL  With infant supine,
fully flex forearm for  is a rating scale of six different categories of
5 seconds and then behavior: habituation, orientation, motor maturity,
fully extend by variation, selfquieting ability, and social behavior
pulling the hands and was devised by Brazelton in the early 1970s
and release. (Brazelton, 1973) to evaluate a newborn’s
 Score as follows: behavioral capacity or ability to respond to set
 remain stimuli.
extended  A total evaluation takes 20 to 30 minutes to
or random complete.
movements
 To perform an assessment using the scale
= 0;
 incomplete requires training to ensure it is used consistently.
or partial  Unlike many assessment scales, the infant is
flexion = 2; scored on best performance rather than on
 brisk return average performance.
to full  Although not used routinely, many of the items
flexion = 4 tested on the scale, such as how infants alert to a
voice (e.g., eyes widen, head held as if listening)
POPLITEAL ANGLE With infant supine and pelvis or how they naturally cuddle when held next to
flat on examining surface, their parent, are excellent examples of newborn
flex leg on thigh and fully flex behavior to point out to parents to help them
thigh with one hand. With the interact with their newborn.
other hand, extend leg and
score the angle attained
according to the chart
SCARF SIGN With infant supine, draw THE HEALTH HISTORY
infant’s hand across the neck
and as far across the  The history of a newborn is obtained from
opposite shoulder as examination of the mother’s pregnancy record if
possible. Assistance to elbow this is available, her labor and birth record, and
is permissible by lifting it
an interview with the mother.
across the body.
 Important information to gather includes:
Score according to location  Any complications of pregnancy such as
of the elbow: gestational diabetes, hypertension,
 elbow reaches premature rupture of membranes,
opposite anterior serious falls, or other injuries
axillary line = 0;  Length of pregnancy and length of labor
 elbow between  Type of birth (vaginal or cesarean) and
opposite anterior whether the infant breathed
axillary line and spontaneously or needed assistance at
midline of the thorax birth
= 1;
 elbow at midline of The Physical Examination
thorax = 2;
 elbow does not
reach midline of
thorax = 3;

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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS

A newborn is given a preliminary physical examination as
soon as parents have had an initial time to spend with their
new child in addition to height and weight determinations,
 to establish gestational age and
 to detect any observable condition such as
difficulty breathing, a congenital heart anomaly, or
any birthmarks (Table 18.4).
This assessment may be the responsibility of the primary
care provider or a nurse depending on the facility and
circumstances of birth. Always complete such
assessments quickly to prevent exposing a newborn to
chilling, yet not so swiftly that important findings are
overlooked (Gooding & McClead, 2015).
 This occurs because, as the high red blood cell
count built up in utero is being reduced, heme
and globin are released.
 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 acute bilirubin
encephalopathy or kernicterus.
Pallor
in newborns is potentially serious because it usually
occurs as the result of anemia, which may be caused by
a number of circumstances such as:

 Low iron stores caused by poor maternal nutrition

THE APPEARANCE OF A NEWBORN during pregnancy.
 Blood incompatibility in which a large number of
The Skin red blood cells were hemolyzed in utero.
 Fetal–maternal transfusion.
General inspection of a newborn’s skin includes color, any  Inadequate flow of blood from the cord into the
birthmarks, and general appearance infant before the cord was cut.
 Excessive blood loss when the cord was cut.
A. The Color  Internal bleeding.

 Most term newborns have a ruddier complexion To detect this, a baby who appears pale should be
for their first month than they will have later in life watched closely for signs of blood in the stool or vomitus.
because of the increased concentration of red Newborns identified as having anemia need therapy such
blood cells in their blood vessels and a decrease as supplemental iron or a packed red cell transfusion to
in the amount of subcutaneous fat, which makes restore their blood volume.
blood vessels more visible.
The Harlequin Sign
Cyanosis
 Occasionally, because of immature blood
 Generalized mottling of the skin is a common circulation, a newborn who has been lying on his
finding in newborns. or her side appears red on the dependent side
 The lips, hands, and feet are likely to appear blue of the body and pale on the upper side, as if a
from immature peripheral circulation (termed line had been drawn down the center of the body.
acrocyanosis). This is a transient phenomenon and, although
 Acrocyanosis is a normal finding at birth through startling, is of no clinical significance.
the first 24 to 48 hours after birth.  The odd coloring fades immediately if the infant’s
 In contrast, central cyanosis, or cyanosis of the position is changed or the baby kicks or cries
trunk, is always a cause for concern.
VASCULAR DISORDERS OF NEWBORN
 Central cyanosis indicates decreased
TYPE DESCRIPTIO LOCATI TREATM
oxygenation that could be occurring as
N ON ENT
the result of a temporary respiratory
Nervus Types:
obstruction and also could reflect a flammeus
serious underlying respiratory or cardiac Benign Face Spontane
disease. macular and ously fade
purple or dark thighs Cosmetica
A cephalohematoma red lesion lly cover
(port-wine Laser in
 is a collection of blood under the periosteum of
stain) life
the skull bone caused by pressure at birth.

Hyperbilirubinemia Light pink

patches, Nape of Do not
 caused by the accumulation of excess bilirubin stork bites or neck face and
in blood serum. telangiectasi no
 In the average newborn, the skin and sclera of a treatment
the eyes begin to appear noticeably yellow on Infantile Elevated Common Educate parent
hemangio areas on scalp, about expected
the second or third day of life as a result of a
mas also formed face, and increase in size
breakdown of fetal red blood cells (called
called as immature neck for up to one
physiologic jaundice). Strawberr capillaries year and that

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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS

y and they are likely to

hemangio endotheli resolve with
mas al cells. time

Appear at Propranolol and

birth or corticosteroids
within 2 can be used to
weeks reduce size.
after
birth. Surgical
excision is
Size may rarely done due Mongolian Spots
enlarge to complication
up to 1  collections of pigment cells (melanocytes) that
year of appear as slate gray patches across the sacrum
age. or buttocks and possibly on the arms and legs of
newborns.
After 1 yr  They tend to occur most often in children of
of age, it Asian, Southern European, or African ethnicity
tends to and disappear by school age without treatment
be
(Smith & Grover, 2016).
absorbed
 Be sure to educate parents that these are not
and
shrink in bruises.
size. By
Vernix caseosa
the time
the child  white, cream cheese–like substance that
is 7 year serves as a skin lubricant in utero.
old of
 It is typically noticeable on a term newbon’s skin,
above,
at least in the skin folds, at birth.
70% have
involuted  Handle newborns with gloves to protect yourself
to a from exposure to vernix.
reasonabl  Remove only the vernix that is contaminated by
e level. meconium or blood (Lovejoy-Bleum, 2014).
Most  Never rub it away harshly because newborn skin
involution is tender and breaks in the skin caused by too
takes 10 vigorous attempts at removal could open portals
years of entry for bacteria.
Cavernou Caused Face, Surgical
s by dilated behind removal if it Lanugo
hemangio vascular ears, neck interferes with
ma spaces. breathing  fine, downy hair that covers a term newborn’s
shoulders, back, upper arms, and possibly also
Raised Steroid, the forehead and ears.
and interferons or  Postterm infants (born after more than 42
irregular radiation may weeks of gestation) rarely have lanugo.
shape; reduce size of  Babies born at 37 to 39 weeks, in contrast, have
resemble lesions a generous supply of lanugo.
strawberr  Following birth, lanugo is rubbed away by the
y Hematocrit level friction of bedding and clothes against the
hemangio to assess blood
newborn’s skin. By 2 weeks of age, it has usually
ma if lesions on
internal organs totally disappeared.
Do not occured. Desquamation
disappear
on time  Within 24 hours after birth, the skin of most
newborns begins to dry.
Some  The dryness is particularly evident on the palms
may have
of the hands and soles of the feet and results in
additional
lesions areas of peeling similar to those caused by
on sunburn.
internal  This is a reaction to suddenly living in an air-filled
organs rather than a liquid-filled environment. No
treatment is needed.
 Parents may apply mild lotion to prevent
excessive dryness if they wish.

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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
Milia
 Sebaceous glands in a newborn are immature, so
at least one pinpoint white papule (a plugged or
unopened sebaceous gland)
 is usually found on a cheek or across the bridge
of the nose of every newborn.
 disappear by 3 to 4 weeks of age as the
sebaceous glands mature and the plugged ones
drain.
 Advise parents to wait for the milia to resolve
spontaneously; recommend that they avoid
scratching or squeezing the papule, which could
lead to secondary infection.
Erythema Toxicum “flea-bite rash’’
 commonly presents on the skin of most term
newborns (Fig. 18.16).
 The rash usually appears in the first to fourth day
of life but may appear as late as 2 weeks of age.
 It begins with small papules, increases in severity
to become erythematous by the second day and
then disappears by the third day.
Forceps Marks
 Forceps are rarely used for birth today, but if they
are used, they may leave a circular or linear
contusion matching the rim of the forceps blade
on the infant’s cheek
 The mark occurs with normal forceps use and
does not denote unskilled or overly vigorous
application of forceps.
 The mark disappears in 1 to 2 days, along with
the edema that accompanies it.
 Closely assess the face of a newborn with a
forceps mark especially during a crying episode
to be certain the infant’s mouth is symmetrical, to
detect any potential facial nerve injury requiring
further evaluation.
THE HEAD
A newborn’s head usually appears disproportionately large
because it is about one fourth of the total body length
compared with an adult, whose head is one eighth of total
height.
Other features include:
 The forehead appears large and prominent.
 The chin appears to be receding, and it quivers
easily if the infant is startled or cries.
 If a newborn has hair, the hair should look full
bodied; both poorly nourished and preterm infants
have thin, lifeless hair.
 If internal fetal monitoring was used during labor,
a newborn may have a pinpoint ulcer at the point
where the monitor was attached
Fontanelles
The fontanelles are the spaces or openings where the
skull bones join.
The anterior fontanelle
 is located at the junction of the two parietal bones
and the two fused frontal bones.
 It is diamond-shaped and measures 2 to 3 cm
(0.8 to 1.2 in.) in width and 3 to 4 cm (1.2 to 1.6
in.) in length.
 can be felt as a soft spot.
 It should not appear indented (a sign of
dehydration) or bulging (a sign of increased
intracranial pressure) when the infant is held
upright.
 normally closes at 12 to 18 months of age
The posterior fontanelle
 located at the junction of the parietal bones and
the occipital bone.
 It is triangular and measures about 1 to 2 cm (0.4
to 0.7 in.) in length.
 . In some newborns, the posterior fontanelle is so
small that it cannot be palpated readily.
 It closes by the end of the second month
Sutures
The skull 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.
If the sagittal suture between the parietal bones overrides,
the fontanelles are less perceptible than usual.
 The overriding subsides in 24 to 48 hours.
Suture lines
 should never appear widely separated in
newborns.
 Wide separation suggests increased
intracranial pressure because of abnormal brain
formation, abnormal accumulation of
cerebrospinal fluid in the cranium
(hydrocephalus), or an accumulation of blood
from a birth injury such as subdural hemorrhage.
 Fused suture lines also are abnormal; they
require X-ray confirmation and further evaluation
because this will prevent the head from
expanding with brain growth
Molding
 The part of the infant’s head that engaged the
cervix (usually the vertex) molds to fit the cervix
contours during labor
 After birth, this area appears prominent and
asymmetric
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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
You can assure parents the head will evolve to a more
rounded shape within a few days after birth.
Caput Succedaneum
 edema of the scalp that forms on the presenting
part of the head.
 It occurs in cephalic births and can either involve
wide areas of the head or be so confined that it’s
the size of a large egg.
 The edema, which crosses the suture lines, is
gradually absorbed and disappears within several
days.
 No treatment is needed
Cephalohematoma
 a collection of blood between the periosteum of a
skull bone and the bone itself,
 is caused by rupture of a periosteal capillary
because of the pressure of birth
 Cephalohematomas will subside without
treatment.
 It may take weeks for the blood under the
periosteum to be absorbed.
 As the blood breaks down, the infant needs to be
observed for jaundice that can occur from the
large amount of indirect bilirubin that may be
released
Craniotabes
 localized softening of the cranial bones probably
caused by pressure of the fetal skull against the
mother’s pelvic bone in utero.
 It is more common in first-born infants than in
infants born later because of the lower position of
the fetal head in the pelvis during the last 2
weeks of pregnancy in primiparous women.
 Craniotabes is an example of a condition that is
normal if seen in a newborn but would be
pathologic in an older child or adult (because then
it probably would be the result of faulty calcium
metabolism or kidney dysfunction).
THE ANOGENITAL AREA
Examine the anus to ascertain its presence and patency.
 Test for anal patency and that the anus is not
covered by a membrane (imperforate anus) by
gently inserting the tip of your gloved and
lubricated little finger.
 Note the time after birth when the infant first
passes meconium. If a newborn does not do so in
the first 24 hours, there may be an anatomical or
physiologic problem that needs to be assessed
The Male Genitalia
The scrotum
 most male newborns is edematous and has
rough rugae on the surface.
 It may be deeply pigmented in dark-skinned
newborns.
 Both testes should be palpable in the scrotum. If
one or both testicles are not present
(cryptorchidism), referral is needed to further
investigate the problem.
Always elicit a cremasteric reflex by stroking the internal
side of the thigh while inspecting testes (as the skin on the
thigh is stroked, the testis on that side moves perceptibly
upward).
The response is indication that spinal nerves T8 through
T10 are intact, although it may be absent before 10 days
of age when nerve stabilization is complete.
The Female Genitalia
The vulva
 female newborns may appear swollen because of
the effect of maternal hormones during
intrauterine life.
Some female newborns also have a mucus vaginal
secretion, sometimes blood tinged
(pseudomenstruation), which is also caused by maternal
hormones.
 The discharge does not indicate an infection or
trauma and disappears in 1 or 2 days.
The Back
The spine of a newborn typically appears flat in the
lumbar and sacral areas; these curves appear after a
child is able to sit and walk. Inspect the base of a
newborn’s spine carefully to be certain there is no pinpoint
opening, dimpling, or sinus tract in the skin, which suggest
a dermal sinus or spina bifida occulta
THE EXTREMITIES
 The arms and legs of a newborn appear short in
proportion to the trunk.
 The hands seem plump and are typically
clenched.
 Newborn fingernails feel soft and smooth and
extend over the fingertips.
Test the upper extremities for muscle tone by unflexing
the arms for approximately 5 seconds then letting them
return to their flexed position (which typically occurs
immediately if muscle tone is good).
Next, hold the arms down by the sides and note their
length.
The fingertips on both sides should reach as far as the
midthigh. Unusually short arms may signify
achondroplasia (dwarfism) and would require further
evaluation.
LABORATORY STUDIES
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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
After the first hour of undisturbed rest, depending on
health agency policy, newborns may have a heel-stick
test for hematocrit, hemoglobin, and hypoglycemia
determinations.
 Another condition as dangerous as anemia is the
presence of excess red blood cells
(polycythemia), probably caused by excessive
flow of blood into an infant from the umbilical
cord.
THE CARE OF A NEWBORN AT BIRTH
Birthing rooms provide an island for newborn care
separate from the supplies needed for the mother’s care.
Necessary equipment includes a radiant heat table or
warmed bassinet; a warm, soft blanket; and equipment for
oxygen administration, resuscitation, suction, eye care,
identification, and weighing of a newborn.
NEWBORN IDENTIFICATION AND REGISTRATION
•Newborn identification is an important nursing
responsibility.
Nurses must be certain the infant has an identification
band in place, so medicine administration or performing
procedures can be done safely.
Identification Banding
 One traditional form of identification used with
newborns is a plastic bracelet with a permanent
lock that requires cutting to be removed.
 A number that corresponds to the mother’s
hospital number; the mother’s name; and the sex,
date, and time of the infant’s birth are printed on
the band. If an identification band is attached to a
newborn’s arm or leg, two bands should be used
because bands can slide off easily.
 A newer form of identification band has a built-in
sensor unit that sounds an alarm—similar to
those attached to clothing in department stores to
stop shoplifting—if a baby is transported beyond
set hospital boundaries
THE INITIAL FEEDING
The Baby-Friendly Hospital Initiative (BFHI) is a global
program sponsored by the WHO and the United Nations
Children’s Fund (UNICEF) to encourage and recognize
hospitals and birthing centers that offer an optimal level of
care for infants that promotes breastfeeding.
To qualify as a Baby-Friendly–designated facility, a setting
must:
QUALIFICATION FOR A BABY-FRIENDLY
DESIGNED FACILITIES
1. Maintain a written breastfeeding policy that is
routinely communicated to all healthcare staff.
2. Educate all healthcare staff in skills necessary to
implement the written policy.
3. Inform all pregnant women about the benefits
and management of breastfeeding.
4. Help mothers initiate breastfeeding within 1 hour
of birth.
5. Show mothers how to breastfeed and how to
maintain their milk supply, even if they are
separated from their infants.
6. Offer breastfed newborns no food or drink other
than breast milk unless medically indicated.
7. Practice “roo6ming in” or allow mothers and
infants to remain together 24 hours a day.
8. Encourage unrestricted or “on-demand”
breastfeeding.
9. Give breastfeeding infants no pacifiers or
artificial nipples.
10. Foster the establishment of breastfeeding
support groups and refer mothers to them on
discharge from the birth setting
After a first feeding in the birthing room, both formula-fed
and breastfed infants do best with an “on-demand”
schedule (i.e., are fed when they are hungry).
Many need to be fed as often as every 1.5 to 2 hours in
the first few days and weeks of life. Nurses can play an
important role in helping new mothers establish
breastfeeding during the infant’s first weeks of life.
BATHING
The Association of Women’s Health, Obstetric and
Neonatal Nurses recommends that most newborns receive
a complete
 sponge bath in 2 to 4 hours after birth when
their temperature and vital signs are stable.
 There is no need to use antibiotic cleansers and
no need to remove all vernix
Plan to help a mother give a first bath before (not after) a
feeding to prevent spitting up or vomiting and possible
aspiration.
 Check to be certain the mother’s room is warm
(about 75°F [24°C]) to prevent chilling.
 Supply bath water at 98° to 100°F (37° to 38°C),
a temperature that feels pleasantly warm to the
elbow or wrist, plus a washcloth, towel, comb,
and clean diaper and shirt
SLEEPING POSITION
Sudden infant death syndrome (SIDS)
 sudden, unexplained death of an infant younger
than 1 year of age.
Although the specific cause of SIDS cannot be explained,
these interventions have been shown to decrease the
incidence of the syndrome:
1. place infant on the back to sleep; use a firm sleep
surface;
2. breastfeeding;
3. room sharing without bed sharing;
4. routine immunizations;
5. consideration of using a pacifier;
6. avoidance of soft bedding, overheating;
7. exposure to tobacco smoke, alcohol, and illicit
drugs
DIAPER AREA CARE
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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
Preventing diaper dermatitis, or diaper rash,
 practice parents need to start from the very
beginning with their newborns
Advise parents to change diapers frequently and, with
each diaper change, wash the area with clear water and
dry well. For yourself, wear gloves for diaper care as part
of standard precautions.
METABOLIC SCREENING TESTS
Newborns born in a hospital or birthing center are routinely
screened for more than 30 metabolic or inherited disorders
by a screening technique that requires a small blood
sample obtained by a heel stick and then dropped onto
special filter paper
 Ideally, a baby should have received formula or
breast milk for 24 hours before the blood is
obtained for best results.
If, for some reason, blood testing is not done before
discharge, alert parents that they need to schedule
screening tests at an ambulatory visit in 2 to 3 days’ time.
Always assess at a newborn’s first health supervision visit
that screening was done.
HEPATITIS B VACCINATION
 All newborns born in a hospital or a birthing
center receive a first vaccination against hepatitis
B within 12 hours after birth;
 a second dose will then be administered at 1
month and a third one at 6 months.
 Infants whose mothers are positive for the
hepatitis B surface antigen (HBsAg) also receive
hepatitis B immune globulin (HBIG) at birth (AAP,
2015a).
VITAMIN K ADMINISTRATION
 Newborns are at risk for bleeding disorders
during the first week of life because their
gastrointestinal tract is sterile at birth and
therefore unable to produce vitamin K, a
vitamin necessary for blood coagulation.
 A single dose of 0.5 to 1.0 mg of vitamin K
administered intramuscularly within the first
hour of life helps prevent such problems
CIRCUMCISION
 surgical removal of the foreskin of the penis.
 Except for a baby who has constriction
(phimosis) of the foreskin that obstructs the
urinary meatal opening (rare), there are few
medical indications to circumcise a male
newborn.
Some parents elect not to have their male infant
circumcised because the operation is painful and
increases the risk of cold exposure and infection.
Scientific evidence shows that circumcision reduces the
risk of HIV, human papillomavirus (HPV), and cancer in
the male as well as cervical cancer in a female sexual
partner, suggesting that the preventive health benefits of
male infant circumcision may outweigh the risks
KEY POINTS FOR REVIEW
 A newborn history and physical examination
yields important information on the infant’s
appearance, gestational age, and any factors that
suggest additional care is needed.
 Using a standardized method of assessment,
such as an Apgar score, is important to assess
and document that an infant is adjusting well to
extrauterine life.
 Converting from fetal to newborn respiratory
function is a major step in extrauterine
adaptation. Newborns need particularly close
observation during the first few hours of life to
determine if this adaptation occurs.
 Maintaining body heat is a second major
challenge for newborns. When a procedure
requires undressing an infant for an extended
period of time, the procedure should be done
under a radiant heat source to guard against
chilling and hypothermia.
 Newborns may suffer hypoglycemia in the first
few hours of life because they use so much
energy to establish respirations and maintain
heat. Signs of jitteriness and a blood glucose
level of less than 40 mg/100 ml by heel stick help
to identify hypoglycemia.
 A great deal of nurses’ responsibility for
newborns is being certain a mother and her
partner spend some time with their newborn in
the birth setting and give some of the care, so
they feel confident in giving care at home. Be
certain they are well informed about controversial
topics such as circumcision and prophylactic
antibiotic eye drops because this helps in
planning nursing care that not only meets QSEN
competencies and also meets a family’s
comprehensive needs.
NEONATAL PERIOD II
DISCHARGE PLANNING
THE ASSESSMENT OF A FAMILY’S
READINESS TO CARE FOR A NEWBORN AT
HOME
It is important to assess how prepared each family is to
care for their newborn at home to be certain the newborn
will remain safe and develop a sense of security.
Parents may need to plan changes in their routine, such as
shifting their usual dinner time.
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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
Their sleep schedules are certain to be disrupted because
infants wake during the night for one or more feedings
for about the first 4 months of life. The physical
environment of the home to which a newborn will be
discharged is important to explore with parents.
Pertinent questions and areas to consider include:
- How many other people live in the home?
(Infections spread more rapidly in crowded
homes.)
- Are there any pets in the home? Will a large dog,
for example, be a safe pet around the baby?
- Is there a bed for the baby? (A separate baby bed
helps prevent SIDS.)
- Who will be the primary caregiver? (This is the
person who needs to be given discharge
instructions.)
- Does the mother have anyone to turn to if she
has questions about the baby? (This is especially
important at night
- Is there a refrigerator in the home? (Formula or
breast milk will need to be stored.)
- Is there adequate heat? (An infant needs a
temperature of 70° to 75°F during the day and
60° to 65°F at night.)
- Are the windows draft free and screened to keep
out insects such as mosquitoes?
- If housing is in poor condition, is there a danger
that rodents might attack the baby?
- Is there a danger of lead poisoning? (An older
home may have lead-based paint on the walls,
which chips and can be eaten by infants.)
- Does the family have a source of income? (If not,
what sort of referral is needed to care for the
child?)
- Does the mother have a concrete plan for
continuing health care for the infant?
CARE OF THE MOTHER AND NEWBORN AFTER BIRTH
● Some women will give birth in the home with a
skilled attendant; others may not have a skilled
attendant present. Some women who give birth in
the facility will spend time there following
childbirth.
● WHO recommends that a women not be
discharged before 24 hours after birth.
Regardless of the place of birth, it is important
that someone accompanies the woman and
newborn for the first 24 hours after birth to
respond to any changes in her or her baby's
condition.
● Many complications can occur in the first 24
hours. Following childbirth at home, it is important
that the mother and baby receive a postnatal
examination as early as possible, preferably
within 24 hours of birth. If the birth was at a
facility, mother and baby should receive a
postnatal examination before discharge
TIMING OF POSTNATAL VISITS
● Following childbirth the woman and newborn
should be examined within 24 hours by a health
worker. At this time also discuss with the woman
and family the timing of subsequent visits and the
immunization schedule for the baby. WHO
recommends that the mother and baby be visited
at home by a trained health worker, preferably
within the first week after birth.
● If your facility does not carry out home visits,
discuss with the mother how she will come to the
facility or local clinic for these scheduled visits.
These visits early in the postnatal period are
important for the mother and baby. It is also an
important opportunity to ensure the establishment
of breastfeeding and address any difficulties with
attachment and positioning.
SCHEDULE OF POSTNATAL VISITS FOR MOTHER
AND NEWBORN
● First Visit = within 1 week, preferably 3 day
● Second visit = 7-14 days after birth
● third visit = 4-6 weeks after birth
Providing adequate care in the home
● In the immediate weeks following childbirth
women need extra care, including partner and
family support. Labour and childbirth are
physically demanding, as is breastfeeding and
looking after a newborn baby. It is therefore very
important that women regain their strength and
maintain their health as they adjust to life with
their new baby.
● Women in the postnatal period need to maintain a
balanced diet, just as they did during pregnancy.
Iron and folic acid supplementation should
also continue for 3 months after birth.
● Women who are breastfeeding require additional
food and should drink sufficient clean water. You
should spend more time on nutrition counselling
with women who are very thin and with
adolescents who may need additional information
to help them get a balanced diet.
● In some cases you may need to refer women to a
nutrition counsellor, where available. It is
important to note that poverty may prohibit
women from accessing certain foods. Exploring
less expensive options can be a helpful part of
the counselling session.
COUNSELLING ON NUTRITION
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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
● Advise the woman to eat a greater amount and
variety of healthy foods, such as meat, fish, oils,
nuts, seeds, cereals, beans, vegetables, cheese
and milk to help her feel strong and well (give
examples of how much to eat).
● Reassure the mother that she can eat any normal
foods - these will not harm the breastfeeding
baby.
● Discuss any taboos that exist about foods which
are nutritionally healthy.
● Talk to her partner or other family members to
encourage them to ensure that the woman eats
enough and avoids hard physical work.
Danger signs for the woman
● All women and their families need to be aware of
danger signs during the postnatal period. Review
the emergency plans they made during
pregnancy and see whether they are still valid.
Remind women to bring their maternal health
record with them even for an emergency visit. It is
important that you discuss danger signs with
every woman as the majority of maternal deaths
occur in the first week after birth. Consider
making a tool or an aid for women to take home
with them following birth.
● She should go to the hospital or health center
immediately, day or night.
SHE SHOULD NOT WAIT if she has any of the following
danger signs:
● vaginal bleeding has increased
● fits • fast or difficult breathing
● fever and too weak to get out of bed
● severe headaches with blurred vision
● • calf pain, redness or swelling; shortness of
breath or chest pain.
She should go to the health center as soon as possible if
she has any of the following signs:
● swollen, red or tender breasts or nipples
● problems urinating, or leaking
● increased pain or infection in the perineum
● infection in the wound (redness, swelling, pain, or
pus in wound site)
● smelly vaginal discharge
● severe depression or suicidal behavior (ideas,
plan or attempt)
POSTPARTUM CARE
After the very exhausting phase of giving birth, the
newborn is not the only one who needs to be taken care
of. It is also essential to make sure that the woman is in a
stabble condition because the immediate postpartum is a
critical stage for both the woman and her baby
Care within the First 24 Hours
Providing nursing care to a postpartum woman during the
first 24 hours entails the following:
❖ Assess the woman’s family profile to determine
the impact that the newborn would give to the
family and to the woman.
❖ Assess the woman’s pregnancy history,
especially if the pregnancy was planned or
unplanned as it will determine the ability of the
woman to bond with the newborn.
❖ Assess the labor and birth history such as the
length of labor and if any analgesia or anesthesia
was used to determine any necessary procedures
to be done.
❖ Determine the infant’s data and profile to help
with planning the care of the newborn and
promote bonding between the parents.
❖ The woman would also need a postpartum
course such as her activity level after birth, any
difficulties or pain felt, and if she is successful
with infant feeding to determine any need for
anticipatory guidance in home care.
❖ Assess any laboratory data of the woman to be
certain that she is recovering well and if any
procedures or additional diagnostic tests need to
be performed.
❖ Assess the woman’s general appearance
because it is a reflection of how well the woman
is moving into the taking hold phase of recovery.
❖ Assure the woman that losing a quantity of her
hair is not a sign of illness but because she is
returning to her nonpregnant state, as hair grows
rapidly during pregnancy because of increased
metabolism.
❖ Assess for facial edema, especially for a woman
with pregnancy-induced hypertension.
❖ Advise the woman to purchase a nursing bra that
is one to two sizes larger than her pregnancy size
to allow for increase.
❖ Assess the woman’s breast for any cracks or
fissures, and avoid squeezing the nipple. Also,
assess for signs of mastitis such as inflammation
of a certain part of the breast.
❖ Assess the location, consistency, and height of
the fundus through palpation.
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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS
❖ If the uterus is not firm upon palpation, massage
it gently. Placing the infant on the mother’s breast
also aids in stimulating contractions.
❖ Lochia is expected in a postpartum woman for 2
to 6 weeks, so assessment of its characteristics is
necessary to determine if it is the normal lochia or
not.
❖ Observe the perineum for ecchymosis,
hematoma. Edema or any drainage and bleeding
from the stitches.
Care in Preparation for Discharge
Before the woman is discharged, she must be educated
properly regarding the care of the newborn and herself at
home.
● Assess first the ability of the mother to absorb
new instructions and to listen.
● Conducting group classes regarding newborn
care could greatly help mothers learn not only
what the instructors teach but also from the
experiences that some mothers could share to
the group.
● It is also recommended for fathers to attend such
classes so the mother would have someone she
can rely on with the newborn care.
● Individual instruction is also sought after
postpartum, as the family will need to know how
to care for the woman and the newborn after
discharge.
● Teaching should not always be formal; it may
come in the form of comments during classes or
procedures.
● Instruct the woman to avoid lifting heavy objects
for the first three weeks after birth.
● Advise the woman to allot a rest period every
day, or to rest and sleep while her newborn is
also asleep so she can regain her energy.
● Be certain that the woman is aware that she must
return to the healthcare facility after 4 to 6 weeks
for examination and that she must arrange an
appointment for her baby to be examined by a
pediatrician at 2 to 4 weeks of age.
● Make sure that the woman and the family
understood the discharge instructions amidst all
the frenzy of the new baby; review instructions
with parents before they leave.
● Calling or visiting 24 hours after discharge is the
best way to evaluate whether the family has been
able to grasp all instructions and integrate the
newborn into the family.
Care after Discharge
Discharge from the healthcare facility usually occurs after
2 to 3 days after birth.
❖ The woman can rest better at home and may eat
better if she has cultural preferences regarding
food.
❖ The newborn can also be exposed earlier to the
routines of the family, and make it easier for her
to adjust to extrauterine environment.
❖ A home visit after the discharge is usually
recommended to check on how the family is
doing now that they have a newborn in the house.
❖ High-risk newborns, newborns born to adolescent
mothers, and newborns with mothers who have
abused drugs during pregnancy need to have a
specially planned discharge and home visit.
❖ Pregnancy history is assessed during the
postpartum visit and if there are any difficulty with
the bonding between the mother and the baby,
and allow the woman to relate her labor and birth
experiences.
❖ Assess the newborn history and if there are any
concerns about the newborn that the woman has
noticed.
❖ Assess the woman’s future plans, whether she is
going back to work outside home and if she had
already arranged the care of her newborn while
she is away.
❖ Conduct a family assessment and ask if other
members of the family are adapting well with a
newborn in the house.
❖ Examine both the mother and the newborn
physically to note any signs of postpartum
complications or defects.
❖ Remind the mother about the health maintenance
visit of the newborn once she reaches 2 to 4
weeks old, and her return checkup 4 to 6 weeks
after birth.
REMINDER
● It is important to provide mothers, fathers and
families with practical advice on how to care for
the baby during the first few days.
● Keep the baby warm - a baby should wear 1-2
layers more than an adult. If cold, put a hat on the
baby's head.
● Care for the umbilical cord. Do not put anything
on the stump.
● Keep the baby clean. It is not necessary to wash
the baby every day but wash baby's face and
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 NCM107 CARE OF MOTHER, CHILD, ADOLESCENT AND WELL CLIENTS

bottom when needed. Make sure the room is placed curl 1 year of
warm when undressing baby. under the age
toes
● Provide nothing but breast milk day and night. MORO the infant will extend 6 months of
REFLEX hears a the arms age
● You should see a health worker on day 3 and sudden with palm
between 7 and 14 days and 4-6 weeks after birth. Startle loud noise up and then
At the 6-week visit the baby will be immunized. reflex or move the
experience arms back
● Let the baby sleep on his/her back or side. s to the body.
unexpecte Sometimes
● Keep the baby away from smoke.
d crying is
● It is not recommended to expose the baby to movement noted
afterwards.
direct sun
ROOTING cheek or head will 4 months
DANGER SIGNS FOR THE NEWBORN
REFLEX side of turn of age
Advise the mother and family to seek care immediately, mouth is towards it,
stroked and the
day or night. They should not wait if the baby has any of
infant’s
these signs:
mouth will
❖ difficulty in breathing or indrawing open to
attempt to
❖ fits suck.
SUCKING something will begin to 4 months
❖ fever REFLEX touches suck, of age
the top of
❖ feels cold infant’s
mouth
❖ bleeding BABINSKI bottom of big toe 1 year of
REFLEX the foot is dorsiflexes age
❖ not feeding
stroked (bends
❖ yellow palms and soles of feet from heel back) and
upward the other
❖ diarrhea along the toes spread
outward out.
The mother and family should go to the health center as part of the
soon as possible if a baby has any of the following signs: foot
CRAWLIN Placed on Infant will First weeks
● difficulty feeding (poor attachment, not suckling G REFLEX stomach attempt to to months
well) and push after birth
Bauer pressure is against the
● is taking less than 8 feeds in 24 hours Crawling applied to hand and
Reflex the sole of move the
● pus coming from the eyes or skin pustules • foot arms and
irritated cord with pus or blood legs in a
crawling
● yellow eyes or skin. like motion
STEP Infant Move the 3-4 months
● ulcers or thrush (white patches) in the mouth -
REFLEX uprights legs like of age
explain that this is different from normal breast
with leg taking
milk in the mouth and feet steps or
touching a walking
NEONATAL REFLEXES surface
TONIC Infant;s Leg and 4 months of
NECK head is arm on that age
REFLEX turned on a side will
REFLEX ACTION RESPONS DISAPPEA
particular extend and
E R
side leg and arm
GRASP placing a hand will 4-6 months
on opposite
REFLEX finger or close of age
side will
stroking around it.
flex
Palmar the inside
of the
infant’s
palm

Plantar finger is toes will 9 months to

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