MCN Midterms PDF

MCN (MIDTERMS) TRUE VS. FALSE LABOR L1: LABOR LABOR True...

MCN (MIDTERMS) TRUE VS. FALSE LABOR L1: LABOR LABOR True False - Process by which the fetus and products of conception are expelled as the result of regular, progressive, frequent, strong uterine contractions. Uterine contraction Begins irregular-regular Begins and remains irregular - Coordinated sequence of involuntary, intermittent uterine contractions. Location Felt first in the lower back Felt first abdominally and THEORIES OF LABOR and sweep around the remain confined to the abdomen in wave abdomen and groin 1. Uterine stretch theory - Based from an idea that a hollow body organ when stretched to its capacity Pain Continue no matter what is Often disappear with will inevitably contract and expel its content the woman’s level of activity ambulation and sleep - The uterus which, a hollow organ, becomes stretched due to the growing fetal structures; in return, the pressure increases, causing physiologic change Frequency, intensity, Increased frequency and Do not increase in duration, (uterine contraction) which initiates labor duration, interval, bloody intensity frequency, or intensity 2. Oxytocin theory show - Pressure on the cervix stimulates the hypophysis to release oxytocin from PPG Cervical dilatation Achieve cervical dilatation Does not achieve cervical - As pregnancy progresses, the uterus becomes more sensitive to oxytocin dilatation due to irregular 3. Prostaglandin theory contractions - Fetal membranes and uterine decidua increase prostaglandin levels - This hormone is secreted from the lower area of the fetal membrane - A decrease in progesterone elevates prostaglandin, initiating uterine Uterine contraction - surest sign of labor contraction Cervical dilatation - surest sign of true labor 4. Progesterone deprivation theory Bloody show - 2nd sign; surest sign of dilatation - Rising cortisol level inhibits progesterone production Rupture of membrane - Reduced progesterone formation initiates labor - Ask what time BOW ruptured 5. Aging placenta / Placental age - Risk for infection & umbilical prolapse - Advance placental age decreases blood supply to the uterus; this triggers - Prolapse affects fetal oxygenation; 10-12 movements/hr;fetal distress uterine contractions, thereby starting labor COMPONENTS OF LABOR PRELIMINARY SIGNS OF LABOR 1. Lightening A. PASSENGER ➔ Pelvic pain Head ➔ Easier breathing - Has the largest diameter; ➔ Shooting leg pain - Comprises of 8 bones: ➔ More vaginal discharge a. 4 superior bones ➔ Frequent urination - frontal, ➔ Back pain - 2 parietal ➔ Diarrhea - occipital 2. Increase in level of activity b. Other 4 bones 3. Slight loss of weight - Sphenoid 4. Braxton hicks contraction - Ethmoid 5. Ripening of the cervix - 2 temporal  Fetal Presentation - Body part that is in 1st contact to the cervix A. CEPHALIC Suture lines - overlaps/compresses - Vertex, brow, face, mentum Sagittal suture - Divides B. BREECH Lambdoidal suture - Occipital & 2 parietal - Complete, frank, footling C. SHOULDER Fontanelle - Membranous space between suture lines D. COMPOUND Anterior fontanelle (bregma) - Closes between 12-18 mos. - More than 1 presenting part Posterior fontanelle - Closes between 2-3 mos. - May happen due to pendulous abdomen Vertex - Space between anterior and posterior fontanelle Fetal Lie Diameters of the Skull - Degree of flexion the fetus assumes during labor - The shape of the skull causes it to be wider in its anteroposterior diameter than its A. GOOD FLEXION transverse diameter - Convex back - To fit to the birth canal, the fetus must present the smaller diameter (transverse) to the - Arms are flexed and folded fn the chest smaller diameter of the maternal pelvis - Thighs are flexed to the abdomen - The diameter of the anteroposterior fetal skill depends on where the measurement is - Good attitude taken B. MODERATE FLEXION A. SUBOCCIPITOBREGMATIC DIAMETER - Chin is not touching the chest - Approx. 9.5 cm - Military position - From the inferior aspect of the occiput to the center of the anterior C. PARTIAL EXTENSION fontanelle - Presents the brow of the head to the birth canal - Narrowest diameter D. POOR FLEXION B. OCCIPITOFRONTAL DIAMETER - Back is arched/concave - Approx. 12 cm - Neck is extended - Front he bridge of the nose to the occipital prominence - Occipitomental diameter is being represented to birth canal / face C. OCCIPITOMENTAL DIAMETER presentation / mentum - Approx. 13.5 cm - Bad attitude - Measured from the chin to the posterior fontanelle - Widest anteroposterior diameter  Mechanisms of Labor (EDFIrEErE) Station Engagement - Occurs when the largest diameter of the fetal head fits into the largest diameter of the maternal pelvis - As the fetal head engages, the head moves towards the pelvic brim in either the left or right occipito-transverse position - This allows the widest part of the fetal head to fit through the widest part of the pelvic inlet ➔ Engaged - Presenting part entered the pelvic inlet ➔ Floating - Not yet engaged ➔ Dipping Position - Descended but not yet in the ischial spine - Degree of flexion the fetus assumes during labor Below the ischial spine = (+) A. 1ST LETTER Above the ischial spine = (-) - Defines the landmark of the mother “Crowning” = +3 (determined through internal examination) ➔ Right (R) / Left (L) Descent B. 2ND LETTER - Downward movement of the biparietal diameter to the pelvic inlet - Denotes the fetal landmark - The babe descends through the pelvic inlet towards the pelvic floor ➔ Occiput - Occurs due to: ➔ Mentum ➔ Uterine contractions ➔ Acromion ➔ Amniotic fluid pressure ➔ Sacrum ➔ Abdominal muscle contraction C. 3RD LETTER Flexion - Defines whether the landmark points: - Fetal head bends forward into the chest ➔ Anteriorly - As the fetal head comes into contact with the pelvic floor, cervical flexion occurs ➔ Posteriorly - This allows the presenting part of the fetus to be su-occipitobregmatic ➔ Transversely - In this position, the fetal skull has a smaller diameter, which assists passage through - Most common position = LOA/ROA (anterior position) the pelvis - Anterior Internal Rotation - Baby in prone position; baby’s head looks down; back is at the - The pelvic floor has a gutter shape, with a forward and downward slope anterior of the mom’s abdomen - This allows the head to rotate form a left or right occipito-transverse position to an - Most preferable; takes shorter time for the head to rotate occipito-anterior position - Posterior Extension - Baby in supine position; baby’s back at the posterior abdomen - The occiput slips beneath the suprapubic arch as the head extends and the nape of - Mom may experience back/sacral pain as sacral nerve is being the neck is pivoting against the arch compressed due to fetal position - Occiput is born, face and chin are born - Intervention: warm compress - Head is out Caput succedaneum External Rotation & Restitution - Presence of edema on baby’s head due to pressure from - The head externally rotates to face the right or left medial thigh of the mother uterus/vaginal wall or contraction - Back to diagonal/transverse position - Shoulder aligned with fetal head - Physician delivers shoulder by:  - Anterior shoulder = downward, pulling Interval - Posterior shoulder = upward, lifting - resting phase Expulsion Length of phases and stages of normal labor in hours: NULLIPARA Phase Average Upper normal Latent phase 8.6 20 Active phase 5.8 12 Second stage 1 1.5 MULTIPARA Phase Average Upper normal Latent phase 5.3 14 Active phase 2.5 6 Second stage 0.25 - B. POWER Acme - Highest point, peak - Best time to push Contour Increment Upper portion - “Crescendo”; increasing intensity/building up of u.c. - Thicker and active Decrement Lower portion - “decrescendo”; decreasing intensity - Thin and passive Round Duration - Ovoid, elongated - starts and ends in same contraction (sec) Frequency Cervical changes - starts from one contraction until the start of another contraction (min) Effacement  - Shortening and thinning of the cervical canal 4. Coccyx ➔ Primipara = E-D 5. ➔ Multipara = D-E - Just below the sacrum is composed of 5 very small bones fused together Dilatation - Enlargement of the cervical canal FALSE PELVIS - Transfer to delivery room: (Superior Half) ➔ Primi = 10cm dilated - Supports the uterus during the late months of pregnancy and aids in directing the fetus ➔ Multi = 8cm dilated into the true pelvis for birth True Labor - Divided from the true pelvis by an imaginary line (linea terminalis) Uterine contraction - From the sacral prominence at the back of the pelvis to the superior aspect of Show the symphysis pubis at the front Rupture of membrane TRUE PELVIS (Inferior Half) Inlet - Entrance to the true pelvis or the upper ring of bone through which the fetus must pass C. PASSAGE to be born vaginally - Route that the fetus must travel from the uterus through the cervix and vagina to - At the level of the linea terminalis external perineum - Marked by sacral prominence in the back, ilium on the sides, and the superior aspect - Good prognosis: android & gynecoid of the symphysis pubis in the front - Wider transverse diameter than anteroposterior diameter (APD) Pelvis Outlet - Bony ring formed by 4 united bones - Inferior portion of the pelvis a. 2 innominate (flaring hips) bones which forms the anterior and lateral position - Bounded in the back of the coccyx on the sides by the ischial tuberosities and in front of the ring by the inferior aspect of the symphysis pubis b. Coccyx and sacrum which form the posterior aspect; serves to support and - Wider APD protect the pelvic organs Pelvic Cavity - Each innominate bone is divided into 3 parts: - Space between the inlet and outlet a. Ilium - Not straight but a curved passage (to slow and control the speed of birth) b. Ischium - The snugness of the cavity also serves to compress the chest of the fetus while c. pubis passing through 1. IIlium - Helps to expel lung fluid and mucus - Forms the upper and lateral position 2. Ischium TYPES OF PELVIS: - Inferior portion 1. ANDROID - The lowest portion are 2 projections - Male pelvis a. Ischial tuberosities - Pubic arch forms an cute angle making the lower dimensions of the pelvis - Part of the bone on which the person sits extremely narrow - Important markers used to determine lower pelvic width - Fetus may have difficulty exiting from this type b. Ischial spines 2. ANTHROPOID - Small projections that extend from the lateral spaces of the - Apelike pelvis pelvis into the pelvic cavity - Transverse diameter is narrow, the APD of the inlet is larger than usual (but - Marked the midpoint of the pelvis does not accommodate fetal head) - Used to assess the level to which a fetus has descended 3. PLATYPELLOID into the birth canal - Flattened pelvis 3. Sacrum - Has a smooth, curved, oval inlet - Upper posterior portion of the pelvic ring - APD is shallow  - Fetal head might not be able to rotate to march the curves of the pelvic cavity - During prenatal visit = encourage the woman to ask questions and attend childbirth 4. GYNECOID classes in preparation for labor - Female pelvis ➔ Culture - Inlet is well-rounded forward and backward ➔ Preparation - With wide pubic arch ➔ Support system - Ideal for childbirth ➔ Previous births ➔ Current pregnancy ➔ Pain, fear, anxiety PELVIC MEASUREMENTS Diagonal conjugate Ischial tuberosity - Measurement between the anterior - Distance between the ischial surface of the sacral prominence tuberosites or the transverse and the posterior surface of the diameter of the outlet symphysis pubis - Made at the medial and lowermost - Avg measurement = 10.5-11 cm aspect of the ischial tuberosities at the level of the anus - Adequate = 11 cm - To pass freely through the outlet = 9 cm D. PSYCHE - Psychological state or feeling that women bring into labor - Feeling of apprehension or fright - Sense of excitement - Who can manage are those who have strong self-esteem and support persons - Women without support can experience fright and stress, leading them to post traumatic stress syndrome L2: MATERNAL AND FETAL RESPONSES DURING LABOR - a week before labor, considerable additional softening causes the symphysis pubis and sacral/coccyx joints to be even more relaxed and movable, allowing them to stretch apart to increase the size of the pelvic ring by as much as 2 cm PHYSIOLOGIC EFFECTS OF LABOR ON THE MOTHER - increased back pain or irritating nagging pain at the pubis as the woman walks or turns in labor Cardiovascular System - Labor involves strenuous work and effort, causing an increase in: Gastrointestinal System ➔ cardiac output - fairly inactive during labor ➔ blood pressure - probably due to the shunting of blood to more life-sustaining organs and also to ➔ pulse rate pressure on the stomach and intestine from the contracting uterus - digestive and emptying time of the stomach is prolonged Hematopoietic System - some experience a loose bowel movement - Leukocytosis or a sharp increase in the number of circulating white blood cells - At the end of labor, the average woman has a WBC count of Neurologic And Sensory Responses 25,000/mm3-30,000/mm3 cells (normal of 5,000/mm3 to 10,000/mm) - responses related to pain (increased pulse and respiratory rate) - Early in labor = registered in uterine and cervical nerve plexuses (at the level of the Respiratory System 11th & 12th thoracic nerves) - Hyperventilation - At birth, the pain is centered on the perineum as it stretches to allow the fetus to move - Appropriate breathing patterns helps to avoid severe hyperventilation past it - Total oxygen consumption increases about 100% during the second stage of - perineal pain is registered at S2 to S4 nerves labor - comparable to that of a person performing a strenuous exercise such as running FETAL RESPONSES TO LABOR Temperature Regulation - Slight elevation in temperature Neurologic System - Diaphoresis (excessive/abnormal sweating) - uterine contractions exert pressure on the fetal head, so the same response involved with that of any instance of increased intracranial pressure occurs Fluid Balance - FHR decreases by as much as 5 bpm during a contraction as soon as contraction - increase in rate and depth of respirations (causes moisture to be lost with each breath) strength reaches 40 mmHg. and diaphoresis, insensible water loss increases during labor - This decrease appears on a fetal heart monitor as an early deceleration pattern - affected by the withholding of oral intake to only sips of fluid or ice cubes or hard candy Cardiovascular System - the combination of increased losses and decreased intake - unaffected by the continual variations of heart rate that occur with labor - a slight - intravenous fluid replacement necessary if labor is prolonged slowing and then a return to normal (baseline) levels - during a contraction, the arteries of the uterus are sharply constricted Urinary System - nutrients, including oxygen, exchanged during this time is reduced, causing fetal - kidneys begin to concentrate urine to preserve both fluid and electrolytes hypoxia - Specific gravity: high normal level of 1.020 to 1.030 - increased intracranial pressure from uterine pressure on the fetal head serves to keep - not unusual for protein (trace to 1+) circulation from falling below normal during the duration of a contracti - reduce bladder tone or the ability of the bladder to sense filling Integumentary System Musculoskeletal System - petechiae or ecchymosis - relaxin - caput succedaneum - Cephalhematoma Musculoskeletal System ➔ an increase in the systolic pressure = > 30 mmHg; diastolic pressure - Full flexion = > 15 mmHg (the basic criteria for pregnancy-induced hypertension) Respiratory System - falling blood pressure = 1st sign of intrauterine hemorrhage - the process of labor appears to aid in the maturation of surfactant production by alveoli - falling blood pressure is often associated with other clinical signs of shock in the fetal lung such as apprehension, increased pulse rate, and pallor - the pressure applied to the chest from contractions and passage through the birth canal clears it of lung fluid 2. Abnormal Pulse - Most pregnant women have an avg pulse rate of 70-80 bpm - Pulse normally increases during 2nd stage of labor due to exertion involved - Maternal pulse > 100 bpm during the normal course of labor is unusual and FETAL DANGER SIGNS should be reported 1. High or Low Fetal Heart Rate - May be another indication of hemorrhage - sign of possible fetal distress ➔ FHR = >160 bpm (fetal tachycardia) 3. Inadequate / Prolonged Contractions ➔ FHR = 140 mmHg; diastolic pressure = >90 mmHg - Warings of psychological fanger during labor - A woman who is becoming increasingly apprehensive despite clear L3: PREPARATION FOR CHILDBIRTH AND PARENTING explanations of unfolding events may only be approaching the 2nd stage of labor PERINEAL AND ABDOMINAL EXERCISES - She may, however, not be “hearing” because she has a concern that has not been met 1. Tailor Sitting - Using an approach such as, “You seem more and more concerned. Can you - done 15 mins/day tell me what is worrying you?” may be helpful 2. Squatting - Increasing apprehension also needs to be investigated for physical reasons - stretches perineal muscles because it can be a sign of oxygen deprivation or internal hemorrhage - useful position in the 2nd stage of labor - done 15 mins/day 3. Pelvic Floor Contraction (Kegel exercise) - muscle strengthening - promote perineal healing - increased sexual responsiveness - prevents stress incontinence 4. Abdominal Muscle Contractions - prevents constipation - restore abdominal tone - strengthen abdominal muscles - effective in the 2nd stage = pushing during labor 5. Pelvic Rocking - helps relieve backache - done 5x METHODS FOR PAIN MANAGEMENT 1. Bradley (Partner-coached) method - developed by Robert Bradley - stresses the important role of husband during pregnancy, labor, and early newborn period - pain is reduced in labor by: - abdominal breathing - walking during labor 2. Psychosexual method - developed by Shiela Kitzinger - stresses that pregnancy, laor, and birth, and early newbon period are important points in the woman’s life cycle - includes programs of contentious relaxation and levels of breathing that encourages woman to flow with rather than struggle against contractions 3. Dick-read method - proposed by Grantly Dick-Read - fear leads to tension - reduced pain by using abdominal breathing during contraction 4. Lamaze method - by Ferdinand Lamaze  - based n the theory that through stimulus response conditioning women an L4: POSTPARTUM learn to use controlled breathing and therefore reduces pain during labor - psychoprophylactic method = preventing pin labor (prophylaxis) by the use of - Also termed puerperium, which refers to the 6-week period following childbirth. the mind (psyche) - Healing process, a time wherein maternal changes occur. - helps the woman to relax and to make labor manageable exercise - changes are either retrogressive (involution of uterus) or progressive such as production of breast milk, beginning of parenting role, etc. - Promoting maternal well-being during this period is essential for preserving future childbearing functions and for ensuring that she is physically well enough to help NON PHARMACOLOGICAL TECHNIQUE FOR PAIN RELIEF IN LABOR incorporate her new child into the family. 1. Conscious relaxation - learning to relax body portions for the woman not to be tense and cause PHASES OF POSTPARTUM unnecessary muscle strain and fatigue 1. Taking-in Phase (2-3 days) 2. Consciously controlled breathing - time of reflection - set breathing patterns at specific rates - Woman is passive; letting other people do things for her & making decisions - prevents putting pressure to the growing uterus for her - inhales and exhales - Dependence is probably due to physical discomfort and exhaustion from the 3. Effleurage labor process - light abdominal massage - Woman may want to talk about her labor experience - serves as distraction technique and decreases sensory stimuli transmission - Encourage her to talk about the wonderment of birth from the abdominal wall 2. Taking-hold Phase - helong limit local discomfort - Begins to initiate action herself 4. Focusing, imagery - Unlike in previous stage, here, the woman has great interest on caring for the - focusing intently on an object baby - sensate focus - Although this increased independence is good, the woman during this phase - using a picture of her partner or children, concentrates on looking at the may still feel insecure about her abilities in caring for the child picture during contraction - This is the time when the nurse should provide relevant instructions and - don’t ask question during concentration adequate praise for the things she does well to help increase her confidence 5. Hydrotherapy 3. Letting-go Phase - Woman finally defines her new role - She gives up the fantasized image of her child for the real one (acceptance) ALTERNATIVE METHODS OF BIRTH 1. Leboyer method POSTPARTUM REPRODUCTIVE CHANGES - birthing room is dark to prevent sudden contrast of light, warm, with soft UTERUS music playing Involution - uterus returns to its nonpregnant state - infant should be handled gently 2 main processes involved: - cord is cut late 1. Sealing of the portion where placenta came from - infant is placed immediately into a warm water bath 2. Rapid contraction of the uterus following placental expulsion 2. Hydrotherapy and water birth - Usually takes 6 wks to complete - baby is born underwater and immediately brought to the surface for the first - Measured by fingerbreadths: breath 1 hr after delivery to 24 hrs = above umbilicus Then, a decrease of 1 fingerbreadth/day (approx. 1 cm) Should no longer be detected by the 8th or 10th postpartum day - Faster in breastfeeding women due to release of oxytocin = promotes contraction - Process may be retarted secondary to:  - Hydramnios - By week 1, progestin, estrone, and estradiol are at pre pregnancy levels - Grand Multiparity - Multiple fetuses URINARY SYSTEM After pains are cramps similar to that felt with menstrual period, which is caused by the - Pressure of the fetal head during childbirth may leave the bladder with a transient loss contraction of the uterus. Most common in women who are multiparous, and mothers of tone who delivered large babies - Assess woman’s bladder frequently in the immediate postpartum - Positive excess diuresis on immediate postpartum to excrete excess fluids Lochia (2000ml-3000ml) - Uterine flow, consisting of blood, fragments of decidua, WBC, mucus, and - Urine tends to contain more nitrogen than normal probably as a result of the increased some bacteria muscular activity during labor - The sloughing off cleanses the uterus and will return to its reproduction state in 3 wks CIRCULATORY SYSTEM - Placental implantation site takes approximately 6 wks to be cleansed and - Reduced blood volume as a result of blood loss assoc. w/ labor and excessive diuresis healed apparent on 2nd to 5th postpartum day. Bvol returns to its prepregnant value by the 3rd to 4th wk TYPE COLOR DURATION COMPOSITION - Immediately after birth, the PR, stroke vol, and CO remain elevated for 30-60 mins as a result of the return to he general circulation of blood that was shunted through the Rubra red 1-3 days Blood fragments of uteroplacental circulation throughout pregnancy decidua and mucus Vital Signs: Serosa pink to brown 3-10 days Blood, mucus, and - There may be a small, transient rise in both systolic blood pressure and invading leukocytes diastolic blood pressure lasting up to 4 days after delivery. Alba white 10-14 days Large mucus, leukocyte - Respiratory functions return to non-pregnant levels by 6 mos after delivery. Even until 6 wks count increase - PMI and ECG are normalized as a result of the lesser pressure on the diaphragm by the emptied uterus. CERVIX Blood Components: - soft and malleable post pregnancy - Hct and Hgb: Increased Hct by 3rd to 7th day postpartum due to decreased - Contraction begins at once. plasma volume during the first 72 hours and the increased RBC mass of - After 7 days, the external os is narrowed and it feels firm and non-gravid again. pregnancy. - There is formation of new muscle cells - WBC: There are normal leukocytes averaging about 12,000/mm3 during the first 10-12 days. Neutrophils are the most numerous. VAGINA - Coagulation Factors: Clotting factors and fibrinogen normally remain - Soft, few rugae, diameter is considerable less than normal elevated in the immediate postpartum. This increases risk of - hymen is permanently torn and heals in small separate tags of tissue thromboembolism especially when combined with vessel damage and immobility PERINEUM - Varicosities: Commonly occurs during pregnancy but varices rapidly empties - Portions may show ecchymosis (bruises) from the rupture of surface capillaries immediately after childbirth. - L majora and minor typically remain atrophic and softened - Presence of episiotomy incisions GASTROINTESTINAL SYSTEM - Digestion and absorption begin to be active again after birth except who has cs. - Bowel sounds are active POSTPARTUM REPRODUCTIVE CHANGES - Passage of stools is slow-due to the effect of relaxin ( still present) HORMONAL SYSTEM - Bowel evacuation is difficult due to episiotomy sutures/hemorrhoids - Pregnancy hormones produced by placenta = no longer present - HCG in urine is negligible in 24 hrs INTEGUMENTARY SYSTEM  - Striae gravidarum appears POSTPARTUM ASSESSMENT - Chloasma and linea nigra will disappear after 6 weeks. HEALTH HISTORY - Diastasis recti = overstretching and separation of the abdominal musculature Family profile - area will appear to be indented; back after 6 weeks Pregnancy history Labor and birth history POSTPARTUM PROGRESSIVE CHANGES Length of labor LACTATION Position of the fetus - Estrogen stimulates milk glands Type of birth - Breast increases in size bec of the larger glands, accumulated fluids, extra adipose Any analgesia or anesthesia used tissue Problems during labor - Midway: Colostrum = thin, watery pre lactation secretion - 3rd day: breast becomes full and feel tense or tender as milk forms within the breast INFANT DATA ducts. Sex - Breast milk forms due to the decrease E and P that follows the delivery of the placenta Weight Any difficulty at birth RETURN OF MENSTRUAL FLOW Plans to breastfeed - With the delivery of the placenta = E and progesterone ends Congenital anomalies - Cause the rise of the FSH= initiates menstrual cycle - Not breastfeeding= expect her menstrual flow to return in 6-10- weeks after birth. POSTPARTAL COURSE - Breastfeeding = menstruation may not return for 3-4 months General health - The absence of menstrual flow does not guarantee that a woman will not conceive Activity level since the birth during this time, bec she may ovulate well before menstruation returns. Description of lochia Presence of perineal, abdominal or breast pain MATERNAL CONCERNS AND FEELINGS IN THE POSTPARTUM PERIOD Difficulty with elimination 1. Shifting of roles such as that from being a daughter to being a parent and mother Success with infant feeding herself. Response of support person to parenting 2. Abandonment - during pregnancy and actual labor, the mother is the center of everybody’s LABORATORY DATA attention. This changes soon after the baby comes out, attention shifts to the Hgb and hct 12-24 hours after birth = to determine blood loss at birth baby and the mother may feel abandoned. This should be addressed by Urinalysis encouraging the mother to verbalize her feelings. They may ask themselves that how can a good mother feel jealous of her baby and they should be PHYSICAL ASSESSMENT properly explained General Appearance 3. Disappointment 1. Hair - this occurs when the newborn does not meet exactly the parents’ - Deficient nutrients = listless and stringy expectations. When this occurs, the woman may blame herself for these - Lose quantity of hair = metabolism was increased and hair growth was rapid, unmet expectations. A nurse can offer support emotionally and many hairs reached maturity at same time. psychologically, which can improve the coping abilities of the mother. - As she returns to normal metabolism level = hair is lost. 4. Postpartum Blues 2. Face - Most women experience a certain degree of overwhelming sadness, which - Assess for edema and puffy eyelids = evident with PIH and accumulated fluid they cannot account for during the postpartum period. This is commonly - Facial edema is most apparent early in the morning if a woman is lying termed as baby blues. supine with her head level during night 3. Eyes - Color and texture of the inner conjunctiva - If dehydrated = area appears dry  4. Breast - 10th-14th day = descended to the pelvic cavity and can no longer be palpated. - Breast tissue should feel soft on palpation on the 1st and 2nd day postpartal day. - Palpation should not cause pain, should be gentle. - 3rd day = should begin to feel firm and warm (Filling) - Never palpate a uterus without supporting the lower segment = could invert - 3rd-4th day= breast appears large and reddened with taut, shiny skin (engorgement) = massive hemorrhage - On palpation = warm, tense and painful; - Fundal massage = for uterine contraction - If one breast is warm or reddened = mastitis of inflammation, infection of glands or - Reasons for having uncontracted uterus: milk ducts - Nipples are normally erect and not inverted 6. Lochia - Avoid squeezing the nipples = painful - 2-6 weeks - Unnecessary nipple manipulation may increase the risk of mastitis. - From red-pink-white - Check every 15 minutes for the 1st hour SIGNS OF GOOD ATTACHMENT - Assess the volume by peripad saturation: - Chin touching the breast ➔ Scant amount - only on tissue when wiped or less than 1 inch (2.5 - Mouth wide open cm) stain on peripad - Lower lip turned outward ➔ Light amount - less than 4 inch (10 cm) stain on peripad. - More areola visible above than below the mouth ➔ Moderate amount - less than 6 inch (15.2 cm) stain on peripad. ➔ Heavy amount - saturated peripad within 1 hour. SIGNS OF GOOD POSITIONING 7. Perineum - Infant's neck is straight or bent slightly back - Sim’s position - Infant's body is turned towards the mother - Observe ecchymosis, hematoma, erythema, edema, intactness and presence - Infant's body is close to the mother of drainage or bleeding from any episiotomy stitches. - Infant's whole body is supported. - Episiotomy = 1-2 inches long B - EST FOR BABIES R- redness R - EDUCE INCIDENCE OF ALLERGENS E- edema E - CONOMICAL E- ecchymosis (purplish patch of blood flow) A - NTIBODIES PRESENT D- discharge S - TOOL INOFFENSIVE (GOLDEN YELLOW) A- approximation, or the closeness of the skin edges T - EMPERATURE ALWAYS IDEAL - Based on a 3 point scale. F - RESH MILK NEVER GOES OFF - Score of 3 = very poor wound healing E - MOTIONALLY BONDING - 1st day = 0-3 E - ASY ONCE ESTABLISHED - 2nd postpartum week = 0-1 D - IGESTED EASILY I - MMEDIATELY AVAILABLE Good method to remember how to check postpartum changes: N - UTRITIONALLY OPTIMAL B - Breast G - ASTROENTERITIS GREATLY REDUCED U - Uterus B - Bladder 5. Uterus B - Bowel - Position the woman in supine = the height of the uterus is not influenced by L - Lochia the elevated position. E - Episiotomy - Observe for contour to detect distention, for appearance of striae or a R - Emotional response diastasis (slightly indented bluish tint groove in the midline of the abdomen) S - Homan’s sign measure the width and length by fingerbreadths. Palpate: - 1st hour = ht is at umbilicus/slightly above it - Within 12 hours = fundus is ½ inch (1 cm) above the umbilicus. - Descends one fingerbreadths/day L5: PHYSIOLOGIC FUNCTION The presence of fluid in the lungs : - eases the surface tension on alveolar walls and makes a first breath easier CARDIOVASCULAR SYSTEM - allows the alveoli to inflate more easily than if the lung walls were dry - lungs now oxygenate the blood that was formerly oxygenated by the placenta. - Breathing becomes much easier for the baby requiring only about 6-8 cm - Cord is clamped = lungs inflate for the first time H2O pressure. ➔ Pressure decreases in the chest and in the pulmonary artery - abt 1/3 of the fluid is forced out of the lungs by the pressure of vaginal birth. = closure of ductus arteriosus [permanently closes at 2-3 wks] - A baby born by CS does not have as much lung fluid expelled at birth ➔ As pressure increases in the left side of the heart - Many have more difficulty establishing effective respiration = promotes closure of the foramen ovale (because of the pressure against the lip of the structure [permanently closes at 6 mos- 1 yr] Within 10 minutes = newborn has established a good residual volume (amt of air that ➔ Umbilical vein, 2 umbilical arteries and ductus venosus closes, and no can’t be expelled causing the alveoli to remain open) longer receive blood, blood within them clots, vessels atrophy; [permanently By 10 to 12 hours of age = vital capacity is established at newborns proportion closes at 1-3 mos] Immature newborn and whose alveoli collapse each time they exhale because of lack ➔ Circulation remains sluggish for the 1st 24 hrs. of pulmonary surfactant have trouble establishing effective residual capacity and ➔ Acrocyanosis - feet to feel cold to touch (pink body; blue extremities) respirations. Blood values If the alveoli do not open well = cardiac system is compromised because closure of the Blood volume = 80 – 110 ml/kg body wt or 300 ml foramen ovale and ductus arteriosus depends on free blood flow through the Erythrocyte ct = 6 m/cubic ml pulmonary artery and good oxygenation of blood. Hct = bet. 45 and 50% Capillary heel stick may reveal a false high hematocrit or hgb because of GASTROINTESTINAL SYSTEM sluggish peripheral circulation - Usually sterile at birth Hgb = 17-18 mg/dl - Bacteria may be cultured from the intestinal tract in most babies and within 5 hours WBC = 15,000- 30,000cells/mm3 (High as 40,000 cells/mm3 may be seen if after birth and from all babies at 24 hours of life. the birth is stressful) - Bacteria enters the tract through: Leukocytosis is the response to the trauma of birth and is nonpathogenic = ➔ newborn’s mouth an increased in WBC should not be taken as evidence of infection ➔ airborne sources Blood Coagulation ➔ Vaginal secretions at birth - Most newborns are born with a prolonged coagulation or prothrombin time ➔ Hospital bedding because their blood levels of Vitamin K are lower than normal ➔ Contact at the breast - Vit K synthesized through the action of intestinal flora = necessary for the - Accumulation of bacteria in the gastrointestinal tract is necessary for the digestion and formation of: synthesis of vit K. ➔ factor II (prothrombin) - Milk = the infant’s main diet is low in Vit. K ➔ factor VII (proconvertin) - Newborn’s stomach holds 60-90 ml ➔ factor IX (plasma thromboplastin) - Has limited ability to digest fat and starch = deficiency in lipase and amylase ➔ factor X (Stuart prower factor) (pancreatic enzymes) in first few months - Takes 24 hours for the flora to accumulate and for vitamin K to be - Newborns regurgitate easily because of an immature cardiac sphincter between the synthesized. stomach and esophagus - Newborns have diminished blood coagulation ability so VIT K is administered - Immature liver functions may lead to lowered glucose and protein serum levels. IM at the lateral anterior thigh. Stools RESPIRATORY SYSTEM - first stool within 24 hours: MECONIUM - THE FIRST BREATH OF A NEWBORN is initiated by a combination of: - a sticky tar like, blackish-green, odorless form from mucus, vernix, lanugo, - cold receptors hormones and carbohydrates that accumulated during intrauterine life. - lowered PO2 (PO2 falls from 80 mmHg to as low as 15 mmHg) - A newborn who did not pass a stool within 24-48 hours should be examined, - increased PCO2 ( PCO2 rises as high as 70mmHg) for the possibility of meconium ileus, imperforate anus, or bowel - First breath requires a tremendous amount of pressure (about 40-70 cm H2o) obstruction.  - 2nd or third day of life: TRANSITIONAL STOOL NEUROMUSCULAR SYSTEM - green and loose, may resemble diarrhea - MATURE NEWBORNS demonstrate general neuromuscular function by moving their - 4th day: extremities, attempting to control head movement, exhibiting strong cry. ➔ breastfed babies - LIMPNESS = total absence of muscular response to manipulation is never normal - pass 3-4x light yellow stools per day and suggests narcosis, shock or cerebral injury - sweet smelling because breast milk is high in lactic acid which - Occasionally makes twitching or flailing movements of the extremities in the absence reduces the amount of putrefactive organisms in the stool. of stimulus because of immaturity of the nervous system. ➔ Fed with formula - passes 2-3x with bright yellow stools a day REFLEXES: - have a slight noticeable odor than breastfed babies 1. Blink Reflex - Placed under phototherapy = bright green stools because of increased bilirubin - to protect the eye from any object coming near it by rapid eyelid closure. excretion. 2. Rooting reflex - With bile duct obstruction = clay colored stool ( gray) because the bile pigment does - Serves to help the baby find food. not enter the intestinal tract. - Newborn’s cheek is brushed or stroked near the corner of the mouth, the - Anal fissure = blood flecked stools child will turn the head in that direction. - Disappears abt the 6th wk = at this time, the eyes can already focus and can - Occasionally, a newborn swallows some maternal blood during birth and will either already see. vomit fresh blood immediately after birth or pass tarry stool in 2 or more days 3. Sucking Reflex - Maternal blood may be differentiated from the fetal blood by a dipstick Apt test - When a newborn’s lips are touched, the baby makes a sucking motion. - if the stools remain black or tarry = intestinal bleeding should be suspected - Diminish at 6 months of age - Disappears immediately if not stimulated. URINARY SYSTEM 4. Swallowing reflex - average newborn voids within 24 hours after birth. - Food that reaches the posterior portion of the tongue is automatically - Didn’t void within 24 hours = possibility of urethral stenosis or absence of kidneys or swallowed. ureters - Gag, cough, and sneeze reflex are also present to maintain a clear airway in - Possibility of obstruction in the urinary tract can be assessed by observing the force of the event that normal swallowing does not keep the pharynx free of the urinary stream: obstructing mucus Male – void with enough force to produce a small projected arc 5. Extrusion Reflex Females – should produce a steady stream - Extrude any substance that is placed on the anterior portion of the tongue. Kidneys do not concentrate urine well thus the urine is light colored and - This protective reflex prevents the swallowing of inedible substances. odorless - Disappears about 4 months of age = until then, an infant may seem to be 15 ml = single voiding of a newborn spitting out or refusing solid food placed in the mouth Spec gravity = 1.008-1.010 6. Palmar Grasp Reflex Daily urine output for the 1st or 2nd days is 30-60 ml - Grasp an object placed in their palm by closing their fingers on it. By week 1= total daily volume is 300 ml - Mature newborns grasp so strongly they can be raised from a supine position The first voiding may be pink or dusky because of uric acid crystals that and be suspended from the examiner’s fingers. were formed in the bladder in utero. - Disappears at 6 weeks to 3 months = begins to grasp meaningfully at about 3 Small amount of protein is normally present for the first few days of life until months kidney glomeruli are more fully mature. 7. Step (Walk) in place Reflex - Newborns who are held in a vertical position with their feet touching a hard IMMUNE SYSTEM surface will take a few quick alternating steps. - Have difficulty forming antibodies against invading antigens until they are about 2 - Disappears by 3 months of age months of age = prone to infection - At 4 months, babies can bear a good portion of their weight unhindered by - The reason that most immunizations against childhood diseases are not given to this reflex. infants younger than 2 months and since they have that passive antibodies (IgG) from the mother that have crossed the placenta. 8. Placing Reflex 16. Landau Reflex - Similar to the step-in-place reflex, except it is elicited by touching the - A newborn who is held in a prone position with a hand underneath supporting anterior surface of a newborn’s leg against the edge of a bassinet or table. the trunk should demonstrate some muscle tone. - newborn will make a few quick lifting motions as if to step onto the table. - Babies may not be able to lift their head or arch their back (at 3 months), but 9. Plantar Grasp Reflex they sag into an inverted “U” position. - When an object touches the sole of a newborn’s foot at the base of the toes, 17. Deep tendon Reflex the toes grasp in the same manner as the fingers do. - Tapping the patellar tendon with the tip of the finger. - Disappears at about 8-9 months of age in preparation for walking. - Biceps reflex: test for spinal nerves C4 and C6 - May be present during sleep for a longer period. - Patellar reflex: test for spinal nerves L2 through L4 10. Tonic neck Reflex - When newborn’s lie on their backs, their head usually turns to one side of the SENSES other. Hearing - The arm and the leg on the side to which the head turns extend, and the - Able to hear in the utero opposite arm and leg contract - Hearing is acute - when the amniotic fluid drains or absorbed from the middle ear thru - Movement is evident in the arms the Eustachian tube within hours after birth - Also called the Boxer or fencing reflex - Appear to have difficulty in hearing sound - Disappears between the 2nd and 3rd month of life. - They respond with generalized activity to a sound such as a bell ringing a short 11. Moro / Startle Reflex distance from the inner ear. - Can be initiated by startling the newborn with a loud noise or by jarring the - If actively crying when the bell is rung, they will stop crying and seem to attend bassinet - Recognize the mother’s voice immediately. - most accurate method to elicit reflex is to hold newborns in a supine position Vision and allow their heads to drop backward an inch. - Newborns demonstrate sight at birth by blinking at a strong light or following the bright - They abduct and extend their arms and legs. light or toy a short distance with their eyes - Fingers assume a typical “C” position - They focus best on black and white objects at a distance of 9 -12 inches - The reflex stimulates the action of someone trying to ward off an attacker, - A pupillary reflex is present from birth. then covering up to protect himself. - They cannot follow past the midline vision - Strong for the 1st 8 weeks - They lose track of objects easily - Disappears at the end of 4th or 5th month when the infant can roll from danger. - Sometimes reported that they can’t see 12. Babinski Reflex Touch - When the side of the sole of the foot is stroked in an inverted “J” curve from - Well developed at birth the heel upward - Demonstrate it by quieting at a soothing touch and by positive sucking and rooting - This reaction occurs because nervous system development is immature. reflexes - Remains positive until 3 months of age - React to painful stimuli 13. Magnet Reflex Taste - If pressure is applied to the soles of the feet of a newborn lying in a supine - Has the ability to discriminate taste because taste buds are developed and functioning position, he or she pushes back against the pressure. before birth Test of spinal cord integrity (Moro, babinski, and magnet reflex) - In the utero = swallows amniotic fluid more rapidly if glucose is added to sweeten its 14. Crossed Extension Reflex taste - One leg of a newborn lying supine is extended and the sole of that foot is - The swallowing decreases if a bitter flavor is added irritated by being rubbed with a sharp object. Causes the newborn to raise Smell the other leg and extend it as trying to push away the hand irritating the first - Present as soon as the nose is clear of mucus and amniotic fluid. leg. - Turns toward their mother’s breast partly out of recognition of the smell of breast milk 15. Trunk Incurvation Reflex and partly as a manifestation of the rooting reflex - When the newborn lies in a prone position and is touched along the - Their ability to respond to odors can be used to document alertness. paravertebral area by a probing finger, they will flex their trunk and swing their pelvis toward the touch. L6: PROFILE OF A NEWBORN ➔ Kangaroo Care – placing the newborn against the mother’s skin and covering the newborn to help transfer heat from the mother to VITAL STATISTICS the newborn. 1. Weight B. PR - Ave birth wt = 50th percentile - Transient murmurs = incomplete closure of fetal circulation shunts - White female: 3.4 kg (7.5 lb) - Immediately after birth = 180 bpm - White male : 3.5 kg ( 7.7 lb) - Within an hour after birth = 120-140 bpm - Other races: approx..5 less - Irregular because of the immaturity of the cardiac regulatory center - 1st few days: 5-10% wt loss in the medulla. - NB weight = 75-90% fluid - Femoral pulses can be felt readily 2. Length - If absent= suggests possible coarctation (narrowing) of the - Female = 53 cm (20.9 in) aorta. - Males = 54 cm ( 21.3 in) - Radial and temporal pulses are difficult to palpate - Head circumference= 34-35 (13.5 to 14 inches) - >37 cm or less than 33 cm (14.8 0r 13.2) = with neurologic involvement C. RESPIRATION - Chest circumference = 2 cm less than the head circumference - 1st few minutes of life = 80 breaths/min 3. Vital signs - Ave= 30-60 breaths/min A. Temperature - Respiratory depth, rate and rhythm are irregular and short periods of - 99F (37.2 C) at the moment of immature temperature regulating apnea sometimes called PERIODIC RESPIRATIONS which are mechanisms normal. - Because NB have been confined in an internal body organ - Coughing and reflexes are present at birth to clear the airway. HEAT LOSS MECHANISMS: - Nose breathers ➔ Conduction - transfer of heat to a cooler object in contact - Short periods of crying = beneficial to the newborn with the baby - Long periods of crying = not beneficial; exhausts the CVS & serve ➔ Convection - flow of heat to body surface to cooler no purpose surrounding air ➔ Evaporation - loss of heat through conversion of a liquid to D. BLOOD PRESSURE a vapor - at birth = 80/46 mmHg ➔ Radiation - transfer of heat to a cooler solid/object not in - 10th day = 100/50 mmHg contact with the baby - loses heat easily APPEARANCE OF A NEWBORN - has difficulty conserving heat under any circumstances. SKIN - INSULATION: effective for adults; not for newborns d/t little A. Color subcutaneous fats to provide insulation - Ruddy/red (term) = RBC and less SQ fats - Constricting blood vessels - Cyanosis = decrease oxygenation - BROWN FAT: special tissue found in mature newborns helps to - Yellow/jaundice = hyperbilirubinemia conserve or produce body heat by increasing metabolism. - Pallor/Pale = anemia - Found in the intrascapular region, thorax, perineal area - Harlequin sign (asymmetric flushing) = immature circulation - Because newborns have difficulty conserving heat, exposure to cold B. Birthmarks is detrimental 1. Hemangiomas - vascular tumors of the skin - newborns tend to kick and cry = increase metabolic rate = produce a. nevus flammeus - macular purple dark red lesions on the face more heat. b. strawberry H. - elevated formed by immature capillaries and HOW TO CONSERVE HEAT: endothelial cells, present among term babies; d/t increased estrogen ➔ Drying and wrapping newborns - Enlarge in size up to 1 yr old then shrinks in size after 1 yr ➔ Placing them in a warmed crib - At 7 y/o = 50-75% of the lesions disappear ➔ Placing them in a radiant heat source - At 10 y/o = completely disappeared  c. Cavernous H. EARS - dilated vascular spaces - not completely formed - Resembles a strawberry H. - Term: pinna recoils - don’t disappear in time - visualizing tympanic membrane is difficult - Subcutaneous infusion of inferon LPH 2a- to reduce size NOSE = large - Removed via surgery MOUTH = opens evenly C. Vernix caseosa - large tongue D. Lanugo - Epstein pearls (palate) - fine downy hair; covers NB’s shoulders, back, upper arms, forehead and ears NECK = short and chubby, rotates freely - disappears by 2 weeks CHEST = witch’s milk (milky discharge on nb’s nipples); rhonchi (gurgling/bubbling sounds) E. Desquamation ABDOMEN = slightly protuberant - dryness (palms of the hand soles of the feet) ANOGENITAL AREA - No need treatment EXTREMITIES - seen on postmature babies F. Milia ASSESSMENT FOR WELL-BEING - Pinpoint white papule found on the cheeks and on the bridge of the nose APGAR SCORING - Disappear by 2-4 weeks (maturation of sebaceous glands) - Done At 1 minute and 5 minutes after birth - Don’t squeeze or scratch - Standardized infant evaluation and serves as a baseline for further evaluation G. Erythema Toxicum Interpretation: