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POSTPARTUM

stage 4 - 6 wk after delivery


involution

- uterus reduced to prepregnant size


- fundus - check position, should be at

lochia is

leave of umbilicus first 12 h, then


descend 1 finger breadth each
succeeding day; is pelvic organ by day
10
if deviations, check bladder and have pt
void; if deviation continue, massage
fundus

endometrial sloughing
- day 1-3 rubra (bloody, fleshy odor,
clots)
- day 4-9 = serosa (pink/brown, fleshy
odor)
- day 10 = alba (yellow-white)
- if foul odor = infection

lochia blood loss greater than


500ml after vaginal birth or
1000mL after cesarean birth

perineum

moderate blood flow is

greater than 4in but less than 6 inche of


flow on peri-pad within 1 h
= (apx 25-50mL in 1 hr)

large flow

greater than 6 inches to saturated peripad within 1 hour


= appx 50-80mL

accurate measurement of
blood loss

weigh peri-pad

possible discomfort, swelling,


ecchymosis
managed with

monitor episiotomy/laceration

- teach to prevent infection =


- change pads regular basis
- peri care (front to back using peri-

analgesics;
topical anesthetics,
ice packs for first 12-24 h ;
then 20 min sitz baths 3-4 times/day
- tightening buttocks before sitting

breasts

progress from soft to filling


with potential for
engorgement

bottle or surgigator after each voiding


and BM
sitz bath

engorgement

vascular congestion related to increased


blood and lymph supply;
- breasts are larger, firmer, painful

non nursing woman

to suppress lactation ***


- wear tight fitting brassiere
- ice packs
- minimize breast stimulation

nursing woman

successful lactation dependent on infant


sucking and maternal production and
delivery of milk (letdown/milk ejection
reflex)

problems for nursing moms nipple irritation/cracking

nipple care
= clean with warm water, no soap, dry
thoroughly
- use absorbent breast pads if leaking
- ice before breastfeeding
- apply breast milk to nipples and areola
after each feeding and air dry;
- warm compress after each feeding and
air dry
position nipple so infants mouth covers
large portion of areola and
- release infants mouth from nipple by
inserting finger to break suction
rotate breastfeeding positions

engorgement

nurse frequently q 30min - 3 h 5 min on each breasts is good at first


- long enough to empty
feeding - use proper way to break suction
breasts completely
breast empty when

see sucking without swallowing

warm shower or compresses


to stimulate letdown
alternate starting breast at
each feeding
mild analgesic 20 min before
feeding
ice packs bt feedings for
pronounced discomfort
plugged ducts

tenderness area and lumpiness


- associated with engorgement

plugged ducts relieved by

heat and massage prior to feeding

expression of breast milk

- to collect for supplemental feedings


- to relieve breast fullness or build milk
supply

- can manually expressed or pumped by


-

device
refridgerated for no more than 48h
frozen in plastic bottles
in fridge or freezer for 2 wk and
deep freezer for 2 mo
dont thaw in microwave or on stove

most meds cross into breast


milk
elimination

afterpains

urinary

increased output (aka postpartum


diuresis)
- urethral trauma
- decreased bladder sensation
- inability to void in recumbent position ay
cause bladder distention
- incomplete emptying and urinary stasis
increase risk of uterine relaxation and
hemorrhage and/or UTI
- monitor I&O
- encourage voiding q 24 h
- early ambulation and pouring warm
water over perineum
- catheterization necessary if no voiding
after 8 h

GI

cramps d/t uterine


contractions

last 2-3 d

bowel sluggishness
decreased abdominal muscle tone
perineal discomfort lead to constipation
early ambulation
increase dietary fiber and hydration
stool softeners

more common in multipara with nursing

rubella vaccine
psychosocial adjustment

relieved by

lying on abdomen with small pillow,


- heat,
- ambulation
- mild analgesic (if breastfeeding, take
analgesic 1h before nursing)

for susceptible moms; Rh -

give Rho(D) Immune globulin (IGIM)

attachment/bonding

influenced by maternal psychosocialcultural factors


- infant health status
- temperament
- behaviors
- circumstances of prenatal, intrapartal,
postpartal, neonatal course

attachment/bonding evidence
by first

touching and cuddling,


- naming
- en face positioning for direct eye
contact

taking in/dependency

day 1-2 after delivery


- preoccupied with self and own needs
(food and sleep)
- talkative and passive
- follows directions
- hesitant about making decisions
- retells perceptions of birth experience

taking hold/dependencyindependency

day 3
- performing self care
- express concern for baby and self
- open to instructions

letting go/independnce

by wk 5-6
- taking on new role responsibilities
- may be grief for relinquished roles
- adjustment to accommodate for infant
in family

POSTPARTUM blues

day 3-7

normal occurrence of roller coaster


emotions, weeping, let down feeling
- relieved with emotional support and
rest/sleep
- report if prolonged or later onset

sexual activities

abstain from intercourse until


- episiotomy is healed and
- lochia ceased
- around 3-4 wk

phases of psychosocial
adjustment

can be affected by fatigue


- fear of discomfort
- leak of breast milk
- concern about another
pregnancy

assess and discuss couples


desire for and understanding
about contraceptive methods

- breast feeding don't give adequate


protection

- oral contraceptives dont use during


breastfeeding

NEONATE UNIT 5
assessment - physical
exam

VS of neonate

wt

6-9 lb = 2,750g - 4, 082 g


- normal wt loss 5-10% in first few days
**
- regained wt in 1-2 wk

length

19-21 inche = 48-53cm

head circumference

13-14 in = 33-35 cm
- 1/4 body length

chest

12-13 inch (30.5-33cm)


- is 1 inch (2.54cm) less than head
circumference

temperature

- no rectal bc rectal mucosa irritation and


increased risk perforation
axillary = 97.7 - 98.6F (36.5 - 37C)
- thermometer remain in place at least
3min unless electronic therm is used

posture of neonate

apical rate

100BPM (sleep)
- 120-140BPM (awake)
- up to 180 = crying
- auscultate for 1 min when not crying

respirations

30-60/min
- mostly diaphragmatic and abdominal
synchronous with chest movements
- get periods of apnea = less than 15s
- neonate is obligatory not breather,
important to keep nose and mouth clear

BP

avg. 65/41 (arm and calf) in full term


resting
- thigh BP be 4-8 higher than arm or calf
BP

fetal position for

several days

resistance to extension of
extremities
skin of neonate

sensitive to drying
erythematous (beefy red)
color for few hours after birth

then pink or as expected for race

acrocyanosis

bluish discoloration of hands and feet


- normal for 24 h

vernix caseosa

- protective gray-white fatty substance


- cheesy consistency covering fetal/
newborn skin

- do not attempt vigorous removal

head of neonatal

lanugo

-light distribution of downy, fine hair


- over shoulder, forehead, cheeks
- if have a lot = indicative of prematurity

milia

distended sebaceous glands


- tiny, white, pinpoint papule on forehead,
nose, cheeks, chin of neonate
- disappear spont. in few days or weeks

pigmentation

mongolian spot- bluish gray or dark


nonelevated pigmentation over lower back
and buttocks at birth in some
- AA
- hispanic
- asian

birthmarks

telangiectatic nevi (stork bites)


- cluster of small, flat, red localized areas
of capillary dilation
- on eyelids, nose, nape of neck
- can be blanched by pressure of finger
- fade during infancy

nevus vasculosus

strawberry mark
- raised, demarcated
- dark red
- rough-surfaced capillary hemangioma
in dermal and subdural layers
- grows rapidly for several mouths then
begins to fade
- disappears by 7yo

nevus flammeus

appear asymmetrical bc of
overriding of cranial bones
during labor and delivery =
molding

head lag less than 45 degrees

fontanelles

soft spots at junction of cranial bones

port wine stain


reddish flat discoloration
on face or neck
does not grow
does not fade

anterior fontanelle

diamond shaped
- easily felt
- usu. open and flat (may be moderate
bulging with crying/stooling)
- sustained bulging occur with increased
intracranial pressure
- depression with dehydration
- slight pulsation
- closes by 18mo of age

posterior fontanelles

- triangular
- not easily palpated
- closes bt 8-12 wk of life

head of neonatalcephalhematoma

collection of blood under


periosteum of cranial bone

appear 1-2 d
- does not cross suture line
- disappears in wks to months

caput succedaneum

-localized soft swelling of


scalp associated with long
and difficult birth

- present at birth
- overrides suture line
- fluid reabsorbed within hours to days
after delivery

face

symmetrical distribution of
movement of all features

eyes

-edematous
- yellow-white drainage ass.
with silver nitrate drops
(chemical conjunctivitis)
- should disappear 1-2 d
without treatment
- see subconjunctival
hemorrhage

mouth

sucks well
- hard and soft palate intact

ears

tops (pinnae) parallel with


inner and outer canthi of eyes

- low set ears ass. with chromosomal

hearing eval by

arousal response to loud or moderately


loud nose without vibration

chest

breast engorgement last up to


2wk in both male and females

abdomen

cylindrical and slightly


protuberant
umbilical cord

asymmetry signify paralysis of facial


cranial nerve = bells palsy

abnormalities, intellectual delay, internal


organ abnormalities

initial= white and gelatinous


- shriveled and black by 2-3 d
- falls off within 1-2 wk
- foul smell discharge = infection = imm.
tx to prevent septicemia

first stool

dark green or black, tarry = meconium


- passed within 12-24h
- then thin brown-green transitional stools
for first 2-3 d

- then 1-2 formed pale

- with formula feeding

yellow stools/day

genitourinary

trunk and extremities

or loose golden yellow stools

with q feeding for breast feeding

urine present in bladder at


birth but neonate not void for
12-24h

brick red spots on diaper from passage of


uric acid crystals
- then get pale yellow urine 6-10x/day

female

labia large and approximated


- thick white discharge = normal
- white cheese line substance (smegma)

pseudomenstruation

blood tinge

male

tests palpated in scrotum

arms and legs symmetric in


shape and function
hips abduct to greater than
60degrees

symmetric inguinal and buttock creases


indicating no hip dislocation

foot in straight line


reflexes

rooting and sucking

turns toward any object touching/stroking


cheek/mouth, opens mouth and sucks
when finger/nipped inserted into mouth
- disappears by 4-7 mo

pupillary

constrict on exposure to light

palmar grasp

pressure on palm elicits grasp


-fade by 3-4 mo

plantar grasp

pressure on sole behind toes elicit flexion


= lessens by 8 mo

tonic neck

fencing position
- lying on back with head turned on one
side, arm and leg on that side of body
will be in extension
- while extremities on other side flexed
- disappear by 3-4 mo

moro reflex

elicited by sudden disturbance in infants


immediate environment
- body stiffen
- arms tense extension
- then embrace gesture with thumb and
index finger in a C formation
- disappear after 3-4 mo

positive- supporting reflex

infant will stiffen legs and appear to stand


when held upright

stepping reflex

help upright with one foot touching a flat


surface
-will step alternatingly
- fades 4-5 mo

babinski sign

stroking sole foot from heel upward across


ball of foot cause all toes to fan
-normal for under 12 mo
- by 12 mo toes will flex like adults

ROUTINE CARE FOR


NEWBORNS
VS at least once per shift
monitor feeding schedule
before start first formula
feeding, check readiness

- active bowel sounds


- absence of abdominal dissension
- lusty cry
- absence of gagging, choking,
regurgitating ass. with
tracheoesophageal fistula or
esophageal atresia
- by giving small amt sterile water
- (glucose is irritating to lungs)

since colostrum is readily


absorbed by GI

breastfeeding can start imm.

umbilical cord care

clean cord daily

no tub baths until cord falls off


- fold diapers below to keep area dry
- report redness, drainage, foul odor

care of penis

uncircumcised

dont force retraction of foreskin


- complete separation of foreskin and
glans penis takes 3-5y
- tell parents to gently test for retraction
occasionally during bath, when it has
occurred, gently clean glans with soap
and water

circumcised

surgical removal of prepuce/foreskin

- ensure signed permission before


procedure

- pain control during and after procedure

postprocedure of circumcision monitor bleeding and voiding


-apply A and D ointment or petroleum jelly
(except when pastibell is used)
- teach to clean area with warm water
squeezed over penis and dry gently
- whitish yellow exudate - normal and
dont remove
if pastibell used - report to HCP when not
called off in 8 d
admin prophylactic meds
for newborns

eye prophylaxis

.5% erythromycin or 1% tetracycline


immediate after birth

IM aquamephyton

neonate unable to synthesize vit K imm.


after birth

antepartum risk factor

maternal hx

- smoking, alcoholism
- infection
- psychosocial problems

risk factors of fetal

birth asphyxia

HIGH RISK
CHILDBEARING TO
NEONATAL

characteristics of preterm
births

- little subcutaneous fat


- hair-fine and feathery (lanugo)
- poor resistance on infection
- sole foot smooth and fine
- limbs relaxed and extended
- weak, underdeveloped muscles
- weak sucking and swallowing
- absorption problems
- ear cartilage poorly developed - ears
fold easily
- female - clitoris prominent; labia majora
poorly developed
- male - scrotum underdeveloped;
minimal rugae
- immature respiratory system
- potential impairment of renal functioning
- grasp reflex - grasp is weak

post term birth

more than 42 wk gestation

small for gestational age

birth wt below 10% percentile expected for


gestational age

kaplan - the basics - exam 2 material - postpartum, newborn and peds

SGA characteristics

- reduced subcutaneous fat; loose and


dry skin; sparse scalp hair

- diminished muscle mass


- sunken abdomen (normal is well
rounded)

- thin, yellowish, dry dull umbilical cord


- wide skull sutures (inadequate bone
neonatal with respiratory
distress syndrome

growth)
chronic intrauterine hypoxia
LGA birth wt 4000g or more
congenital anomalies
apgar score less than 7
early or severe jaundice; get in first 24 h
bilirubin above 15mg/100ml in full
term newborn

deficiency of surfactant in
immature lung
assessment

labored breathing - retractions, tachypnea,


expiratory grunting, nasal flaring
cyanosis
develop flaccidness, unresponsiveness,
apnea episodes
breathing satisfactory imm. after birth;
distress develops 6-8h or 2-3 d after birth
carries highest risk of long-term neuro
complications
pO2 less than 50
- pCO2 greater than 60 mmHg

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