Postpartum Assessment PDF

**Postpartum Assessment** **Vital signs** - BP \90/60 - HR 60-100 - RR 12-20 - Temp \ or more 95% on RA **Postpartum Assessment** - Complete Blood Count (CBC)- will be taken after giving birth. Results will go down because of bleeding - Vaginal birth less than 500 -...

**Postpartum Assessment** **Vital signs** - BP \90/60 - HR 60-100 - RR 12-20 - Temp \ or more 95% on RA **Postpartum Assessment** - Complete Blood Count (CBC)- will be taken after giving birth. Results will go down because of bleeding - Vaginal birth less than 500 - C-section less than 1000 - White blood cells (WBCs) 5.67-17 - Hemoglobin (Hgb) 11-15.5 - Hematocrit (Hct) 36-48 - Platelets (Plt) 100,000-400,000 - Rubella status - Immune/Equivocal/Nonimmune - MMR vaccine can be given after birth not during because if during it can affect fetus by giving malformations. MMR is a live vaccine. - Wait a month before they can have a baby again because MMR has just been given - Rh status - Positive/Negative - If negative give Rhogan **Postpartum Assessment** - Tetanus, diphtheria, acellular pertussis (Tdap) - Influenza (flu) - Pneumococcal - COVID-19 **\*\*\*\*Postpartum Assessment** - Breasts - Uterus - Bowels - Bladder - Lochia - Episiotomy, laceration, perineum, hemorrhoids - Lower Extremities - Emotional Status, bonding, fatigue, psychosocial factors **Changes during postpartum period** *and corresponding nursing assessment and care needed* - Reproductive system: - Uterus (location, position, tone of the fundus) - Tone of fundus should be firm, if soft can cause hemorrhage - The position should be midline, if deviated to right side it means it's a full bladder. Must empty bladder, after void check again to make sure it is now midline. - Location 6-12 hrs after postpartum should be at 0. - If fundus is firm, but patient is continuously bleeding out you should give pt. oxytocin because it can help contract uterus and help keep uterus firm. - If she is firm but still bleeding out you need to evaluate what the cause of the bleeding is. It can indicate a genitourinary tract laceration or hematoma of vulva or vagina - monitor frequently based on hospital protocols by fundal massage- if soft - Endometrium (lokia) - Vagina - Perineum - Breasts **Postpartum Hemorrhage** - Primary hemorrhage (early) - happens within the first 24 hours after birth - Secondary hemorrhage (late) - happens from 24 hours to 12 weeks postdelivery - most prevalent the first 7 to 14 days following birth - Vaginal delivery \>or equal to 500 mLs QBL( means quantified blood loss) = hemorrhage - Cesarean section \> or equal to 1000 mLs QBL = hemorrhage A person measuring the stomach Description automatically generated with medium confidence **Uterine Atony (does not have tone)** - Most common cause of postpartum hemorrhage - Treated with fundal massage - Followed by drugs that promote uterine contraction such as oxytocin (pitocin) **Endometrium** - Mucous membrane that lines the uterus - Regenerates after the placenta is delivered - Lochia - a bloody discharge from the uterus that contains red blood cells (RBCs), sloughed-off decidual tissue, epithelial cells, and bacteria A chart with text and images Description automatically generated with medium confidence  **Lochia** Lochia is described as scant, light, moderate, or heavy (Fig. 12--3). Scant is less than 1 inch on the pad. Light is less than 4 inches on the pad. Moderate is less than 6 inches on the pad. Heavy is when the pad is saturated within 1 hour; is excessively heavy when a pad is soaked within 15 minutes. - Check front and back of pad because pooling of the blood happens in the back - Positional changes can affect the amount of pooling they have. - Ex. If they have been sitting in the same position for the last 12hrs. have patient lay flat to check the amount of blood. - If pt. continues to bleed after change of position could indicate hematoma. \*\*\*\*Table 12-2 Stages and characteristics of lochia A diagram of a white object with red spots Description automatically generated with medium confidence **Vagina and Perineum** A second-degree laceration involves the vaginal mucous membranes, perineal skin, and the fascia of the perineal body. A third-degree laceration involves the perineal skin, vaginal mucous membranes, fascia of the perineal body, and the rectal sphincter. A fourth-degree laceration involves the perineal skin and fascia, vaginal mucous membranes, rectal sphincter, and the rectal mucosa and lumen. A midline episiotomy is an incision that is midline on the perineum. This type of incision tends to heal more quickly and cause less pain than a mediolateral episiotomy. A mediolateral episiotomy is an incision that is made at a 45-degree angle to the perineum. \*\*\*\*\*REEDA (redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration) \*\*\*\*\*Clinical Judgment: Assessment and Management of Pain in the Postpartum Period **Breasts** - Box 12-3 Breast Care and Assessment - Engorgement (physiological vs pathological) - What is it? - Breast engorgement: caused by an increase in the vascular and the lymphatic systems within the breast and milk accumulation. - Physiological: breast are swollen - Pathological: - breast are hard, swollen, red, and tender, or painful - Breast feel warm to touch - Woman may feel a throbbing sensation in the breasts - Woman may have an elevated temperature - Infant may have difficulty latching on if severe engorgement - How to treat it? - For breastfeeding mothers: - Frequent feedings to empty the breasts and prevent milk stasis - Warm compressions to the breast and breast massage to facilitate flow of milk before feeding sessions - Express milk by breast pump or manually if the infant is unable to nurse - Ice packs after feedings to reduce inflammation and discomfort - Pain medications - Supportive bras - For non- breastfeeding mothers: - Supportive bra - Avoid stimulating breast - Ice packs to breast - Pain medications - Subsides within 48-72 hrs. - For plugged nipples - Frequent positions - Change infant feeding positioned - Massage before feedings - Mastitis (occurs typically 3-4 weeks post birth) - What is it? - Infection caused by bacterial entry through cracks of nipples and is associated with milk stasis, engorgement, stress, fatigue, and long intervals between feedings - How to treat it? - Encourage hand hygiene - Empty affected breast - Antibiotic therapy - Analgesics - Rest - Adequate nutrition - Hydration - Symptoms: fever, chills, malaise, unilateral breast pain **Changes during postpartum period** *and corresponding nursing assessment and care needed* - Box 12-2 The Maternal Early Warning Sign - [Cardiovascular system] - Assess for HR and BP - Mews -- the higher the score the higher the risk is for hemorrhage - HR: 60-100 - BP: Higher than 90/ lower than 60 - Blood loss? - Should be less than 500 for vaginal - Should be less than 1000 for C-section - DVT? - Increased coagulability is associated with pregnancy and continues into postdelivery period + venous stasis may occur - Symptoms include muscle pain, tenderness, redness or increased warmth to touch, edema, swelling of veins, decrease circulation of blood - Orthostatic hypotension - Change of blood pressure when standing up - Have them stand up slowly with dangling legs to the side of the bed for a couple of minutes to prevent OH. - Postpartum chills - If experiencing chills with temperatures in normal ranges, they can be offered a blanket. - If experiencing chills with temperatures out of normal ranges, it may be a sign to infection and PCP should be informed. - [Respiratory system] - Diaphragm pressure is reduced - Assess RR - Breath sounds - Breath sounds should be listened to anterior, posterior, and sides (at least 4 sides), especially in the back because that is where you are able to listen to diminished lung sounds. - [Immune system] - Mild temperature increase - A temperature greater than 100.4°F (38°C) after the first 24 hours on two occasions may be indicative of postpartum infection and requires - Rh isoimmunization: Rh-negative woman develops antibodies to Rh- - Rhogan should be given 72 hours - Mom's antibodies attack baby's RBC\>hemolysis - Assess temperature - Drink fluids - Meds: MMR vaccine, RhoGAM - [Urinary system] - Bladder distention, urinary distention - Can be expected if patient is taking meds like anesthesia, need to make sure to get them up if they are able to walk - If they are not don't force them. - The woman should be able to void at least 300 mL within 2 to 4 hours of delivery. \*\*\* - What if she isn't voiding? - Use bladder scan if the ladder scan says patient has 1000ml of urine retention patient be placed on straight catheter. Urine should be removed slowly because it can cause fainting. - Assess for frequency, urgency, and burning on urination - Meds that can be given are pain meds, dermaplast spray to help with soothing, irritation - Tucks pads help with healing process - If they have a hemorrhoid give them hemorrhoid cream - Cystitis is a bladder inflammation or infection. - Symptoms: Frequency, urgency, pain or burning on urination, suprapubic tenderness, hematuria (blood in urine), and malaise - Treatment: Antibiotic therapy, increased hydration, rest - Cystitis moved to the bladder and if it moves up it can go to kidneys. Important to treat infections right away. - [Endocrine system] - After delivery of the placenta, estrogen, progesterone, and prolactin levels decrease. - Estrogen levels begin to rise after the first week postpartum. - Prolactin levels - If the patient is not feeding prolactin levels will go down. - Prolactin is milk production - Nonlactating vs lactating women - Lactation suppresses menses, likely due to hormonal changes, including elevated prolactin levels. - Return of menses depends on the length and amount of breastfeeding. - Is breastfeeding an effective contraceptive method? - You can still get pregnant because you are still able to release egg. Educate them to not have sex or tampons for 6 weeks to allow body to heal. - Diaphoresis occurs during the first few postpartum weeks in response to decreased estrogen levels. - This profuse sweating, which often occurs at night, assists the body in excreting the increased fluid accumulated during pregnancy. - Assess temperature - Muscular and nervous systems - Assess for: - Diastasis recti abdominis - This is the separation of abdominal muscles- it is normal and will diminish overtime. - Mild core exercises can help - Muscle soreness - Decreased body nerve sensation - Can be from anesthesia or other - Headache - Fatigue - Comfort measures? ice, heat, warm shower, analgesia  - [GI system] - Constipation - Because of anesthesia or opioid medications that have been taking. Make sure they are given fluids, increase of fiber, laxatives, stool softeners, ambulating - Hemorrhoids - Appetite - Weight loss - Assess for bowel sounds, bowel movement, nausea, vomiting - Increase fluid intake, encourage ambulation - Meds: stool softeners, laxatives **Contraception** - Natural family-planning methods - Barrier methods - Hormonal methods - Long-acting reversible sterilization \*\*\*\*Table 12-3 Methods of Contraception A close-up of a chart Description automatically generated  A table with text on it Description automatically generated **Follow-Up Care** - Postpartum (vaginal) - 6 weeks after delivery - Post-operative (c-section) - 1-2 weeks after delivery - Newborn - 1-2 days after delivery **Discharge Teaching** - What needs to be reported to the doctor? - Heavy lochia, saturating in less than 1 hr - Bright-red heavy bleeding after lochia has decreased (secondary postpartum) - Foul-smelling lochia - Increased temperature - Pelvic/abdominal pain - = signs of infection - Cystitis, Mastitis - Preeclampsia. - Pulmonary embolism. - Postpartum depression **Health Promotion** - Nutrition and fluids - Activity and exercise - Rest and comfort - Sexual activity - Contraception - Smoking cessation and relapse prevention Chapter 13 **Transition to parenthood** - Parental Roles - Motherhood - Maternal phases - \*\*\*Table 13-1 - Fatherhood - Conflicting tasks - stressful life experience - taking on the role responsibilities of being a parent while working through the developmental tasks of being a teenager **Maternal Phases** - Taking in - about the mom - Taking hold - transitioning from mom to baby - Letting go - baby is integrated with mom's life - **know the definition of each one and examples** **Fatherhood** - The meaning of "father" varies based on the man's interpretation of the role and its expectations and responsibilities. This is influenced by: - How he was fathered - How his culture defines the role - In some cultures, men are not expected to be involved in the birthing process or care of the infant. - By friends and family and by his partner **Bonding and Attachment** - Skin-to-skin contact AKA kangaroo care - Maternal touch - En-face - Engrossment - Communication  **Sibling Rivalry** - Include the older sibling with the newborn - Allow them to hold the newborn under supervision - The addition of a new family member can be stressful - Need to adjust to incorporate a new family member - Depending on the age of the sibling and birth order, they may feel displaced - Should be introduced ASAP during hospitalization - Stuffed animal should be given to older sibling as if newborn brought to give to them.  **Postpartum Blues** - AKA baby blues, occurs during the first few postpartum weeks, last for a - During this period, the woman feels sad and cries easily but is still able to - Possible causes of postpartum blues include: - Changes in hormonal levels - Fatigue - Stress from taking on the new role of mother - Signs and symptoms of postpartum blues are: - Anger - Anxiety - Mood swings - Sadness - Weeping - Difficulty sleeping **Postpartum Depression** - PPD is a mood disorder characterized by severe depression that occurs within the first 6 to 12 months postpartum - PPD is classified as a major depressive disorder when the woman has a depressed mood or a loss of interest or pleasure in daily activities for at least 2 weeks in addition to four of the following symptoms: - Significant weight loss or gain: a change of more than 5% of - body weight in a month - Insomnia or hypersomnia - Changes in psychomotor activity: agitation or retardation - Decreased energy or fatigue - Feelings of worthlessness or guilt - Decreased ability to concentrate; inability to make decisions - Decreased interest in normal activities **Postpartum Psychosis** - According to the DSM-5, brief psychotic disorder with peripartum onset is the official diagnosis for postpartum psychosis. - The onset of symptoms is rapid and can occur as early as 2 to 3 days after childbirth. - Diagnostic criteria include the presence of at least one or more of the following symptoms: delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior Chapter 15 **Vital Signs** - Temperature 36.5-37.2C 97.7-99F - Respirations 30-60 - Pulse 110-160 - Blood pressure - done in NICU - Pain - NIPS scale in PP - N-PASS scale in NICU Transition to extrauterine life and related nursing care - Respiratory system - establish extrauterine respirations: breath right when they come outside of the womb. - First thing they need to do when out is cry= breathing - mechanical vs chemical stimuli - vaginal deliveries experience mechanical stimuli due to thoracic pressure - c-section babies have more respiratory issues because they don't get enough thoracic squeeze. Tend to hold more fluid in their system, because when you cut through the incision the baby does not pass through any bone. Vs. vaginal delivery they have to pass through the uterus and vaginal canal where they get that squeeze. - signs of respiratory distress - central cyanosis: bluish discoloration of the body and visible mucus membranes - abnormal respiratory pattern - Apnea: cessation of breathing (15 secs or more) - tachypnea: rapid breathing greater than 60 - retractions of the chest wall: intercostal and sub muscles - nasal flaring - hypotonia: low tone (floppy) late sign of respiratory distress - Grunting: singing - Circulatory system - ductus venosus - permanently closed within 2 weeks - Connects the umbilical cord to the inferior vena cava, diverts most blood away from the lungs. - foramen ovale - closes when left atrial pressure is higher than the right atrial pressure - ductus arteriosus - closes within 15 hours - can sometimes be heard as a murmur upon auscultation - sometimes it does not close right away even if you have the right equipment/ stethoscope. If you can't hear their heart murmur anymore it probably means it closed. - A murmur should be reported because of in the case it doesn't close it could mean there is a congenital issue - permanent closure 3 months  - Thermoregulatory system \*\*\* - neutral thermal environment (NTE) - brown adipose tissue (BAT), aka brown fat or non-shivering thermogenesis - mechanisms of heat loss: - Evaporation: loss of heat that occurs when moisture on the neonate's skin is converted to vapors, such as during bathing or directly after bathing. - How to prevent: drying, swaddling, under warmer, - Conduction: Transfer of heat to cooler surface by direct skin contact, such as cold hands of caregivers or cold equipment - How to prevent: wash hands with warm water, warm up hands or stethoscope - Convection: loss of heat for the neonate's warm body surface to cooler air currents, such as air conditioners or oxygen masks. - Don't place directly underneath air conditioner - Radiation: transfer of heat from the neonate to cooler objects that are not in direct contact with the neonate, such as cold walls of the isolette or cold equipment near the neonate \*\*\*MUST know nursing actions to prevent heat loss - Dry immediately after birth - Remove wet blankets form the neonate's direct environment - Place a stocking cap on head - Provide skin to skin contact with mother or partner a warm blanket over both - Use prewarmed blanket and clothing - Prewarm radiant warmers and heat shields - Delay initial bath until their temperature is normal - Bathe under a radiant heat source - Place away from outside walls and windows - Should only bathe baby if mom has hepatitis B and the medications given are vitamin K, repromyacin, hep B vaccine to baby, - cold stress occurs when there is a decrease in environmental temp that causes a decrease in the neonate\'s body temp which can read to resp distress - possible consequences: hypoglycemia, hypoxia, metabolic acidosis. Decreased surfactant production, respiratory distress, apnea, death, poor feeding, weight loss  - Metabolic system - Hypoglycemia - less than 40-45 mg/dL - Anything less than 40 is considered hypoglycemia for exam - \*\*Critical component box - risks for hypoglycemia - infant of diabetic mothers (IDM) - macrosomic babies, LGA (large for gestational age), SGA (small for gestational age) - post-term (more than 42 weeks), preterm (less than 37 weeks) - hypothermia (less than 36.5 C / 97.7 F) - infection (fever (100.4F) - respiratory distress - neonatal resuscitation - birth trauma - signs and symptoms: - jitteriness - What would you do if baby is showing signs of jitteriness? You would check blood sugar. If blood sugar is 35 (hyperglycemia) breast feed or formula feed the baby to help increase blood sugar. - hypotonia (floppy) - irritability - apnea - lethargy - temperature instability: more likely than not will have low temperature - Hepatic (Liver) system - liver functions - metabolism: carbs, proteins, lipids - plasma protein synthesis - blood coagulation \*\* - Vitamin K : helps with clotting factors - Neonates are at risk for delayed clotting and hemorrhage due to a temporary vitamin k deficiency after birth called vitamin k deficiency bleeding. This is due to liver immaturity, short life of maternal acquired vitamin K, and lack of needed intestinal flora\> it is synthesized in the intestinal flora which is absent at birth. - A single dose of vitamin k within the first 2 hours of birth to decrease risk of bleeding. - bilirubin \*\* (should be less than 6 in 24 hrs, and in 48 hrs less than 7) - direct vs indirect - hyperbilirubinemia - phagocytosis - storage of fat-soluble vitamins A, D, E, K, and iron - detoxification - Gastrointestinal system - ingestion, digestion, absorption, and elimination - Stool - Meconium: begins to form during the fourth gestational month and is the first stool eliminated by the neonate. It is sticky, thick, greenish-black, and odorless. It is first passed within 24-48 hrs - Transitional: begins around the third day and continue for 3-4 days. The stool transitions from black to greenish black to greenish brown to yellow. This phase of stool is characteristics occur in both breastfed and formula-fed neonates. - Breastfed: yellow and semi formed. Later it becomes a golden yellow with a pasty consistency "seedy" appearance and sour odor - Formula-fed stool: firmer and more formed and breast fed stools. It is a paler yellow or brownish yellow and has an unpleasant odor. - Diarrhea: loose, watery, and green - See table 15-1 A table with text and numbers Description automatically generated - Renal (Kidney's) system - overhydration - dehydration\* : if baby is very concentrated needs to have mother feed more and ask how often they are feeding. Blood on diaper can indicate dehydration - electrolyte disorders - drug toxicity - See table 15-1 - Immune system - active humoral immunity - acquired immunity from vaccines - natural immunity from antigens (antibodies) - passive immunity - natural passive immunity placental transmission of antibodies - artificial passive immunity is gamma globulin - lymphocytes - immunoglobulins - maternal IgGs\*\* - cross the placenta and provide passive immunity for neonate. These antibodies temporarily protect the neonate from bacterial and viral infections, for which the mother has developed antibodies. - IgA\*\*: do not cross the placenta but are found in colostrum and breast milk. Have anti-inflammatory properties and play a role in development of the immune system. - IgM\*\*: primary antibodies produced in utero by the fetus in response to pathological organisms. Do not cross placenta. **Neonatal Assessment** - prepare for assessment - \*\*Clinical judgment on how to reduce heat loss during assessments - general survey, APGAR score ( will not be on quiz 4) - gestational assessment (GA) - pain assessment - physical assessment - posture: flexed - head circumference: 12.5-14 in (32-36 cm) - chest circumference: done in NICU - length: 18-20.5 in (46-52 cm) - weight: 2500-4100g (5.5 to 9 lbs) - integumentary/skin - acrocyanosis (hands and feet are blue), milia (sebaceous glands), lanugo( hair on their back), Mongolian spots (congenital dermal melanocytosis) (bruising spots), newborn rash (erythema toxicum), vernix caseosa (looks like cream cheese in axillary area and genital areas of full term) - head - molding, overriding sutures, fontanels (anterior-diamond, posterior-triangle) - caput vs cephalohematoma - neck: short with skin folds, + tonic neck reflex - eyes: equal and symmetrical in size and placement, iris is blue-gray/brown, sclera is white/bluish white, no tear production until 2 months. - Usually, jaundice appears first in sclera - ears: pinna is aligned with external canthus of eye - nose: patent, nose breathers - how to check patent you would close one side of nostril and then do the same to the other - mouth: lips, gums, tongue, palate, and mucous membranes are intact, pink, and moist, + suck and swallow reflexes, Epstein's pearls may be present - chest/lungs: barrel-shaped and symmetrical, breast engorgement, may have clear/milky fluid, lungs are clear and equal, scattered crackles due to retained amniotic fluid most likely c-section baby - cardiac: PMI by nipple line, murmurs may be heard but disappear in 2 days, peripheral pulses are present - abdomen: soft, round, protuberant, and symmetrical, bowel sounds present 5 minutes but may be hypoactive in the first few days, passage of stool in 24-48 hours, cord dries and detaches in 2 weeks - rectum: patent, passage of stool in 24-48 hours - GU (female): labia major and minora may be edematous, blood in discharge - GU (male): urinary meatus at the tip of the penis, hypospidia (below) epispedia (above), scrotum may be edematous, testicles are both palpated in the scrotum, urinate within 24 hours - musculoskeletal: arms and legs are symmetrical and equal in strength, 10 fingers, 10 toes, full range of motion, no hip clicks, equal gluteal folds, C curve of spine with no dimpling - extra fingers or toes is called polydactomy - neurological: flexed position, rapid recoil of extremities to flexed position, + newborn reflexes **Newborn Characteristics**   **Newborn Reflexes** \*\*\*Need to know how to elicit and the expected response:  A close-up of a baby\'s birth Description automatically generated  **NEWBORN MEDICATIONS** - Erythromycin and Vitamin K - known as \" eyes and thighs \" - erythromycin is given as a prophylaxis treatment for gonococcal/chlamydial eye infection - an ointment is given from the inner to the outer canthus - vitamin K to prevent hemorrhage disease in the neonate - given via an IM injection on the vastus lateralis muscle - Hepatitis B vaccine - 3 series: - 1st dose: before discharge - 2nd dose: 1-2 months - 3rd dose: 6-18 months - Hepatitis B immune globulin (HBIg) is given within 12 hours with the Hepatitis B vaccine if mom is Hepatitis B positive - BOTH given via an IM injection on the vastus lateralis muscle **Screening Tests** - Newborn screening AKA Phenylketonuria (PKU) - blood test - heel stick - it is a blood test used to test blood glucose, hematocrit, and serum bilirubin and to conduct the GDS. Which tests for infections, genetic diseases, and metabolic disorders. - Hearing screening - do not do when they are born right away because there could be amniotic fluid in ears and waiting allows there to be more correct testing. Do it once in patient and twice out patient. If they keep failing can indicate baby has a hearing problem. - CCHD screening AKA Critical Congenital Heart Defects - pulse oximetry test: 95o2 and above becomes normal after 10 minutes - it is a pulse oximetry test that compares preductal and post ductal oxygen saturation levels as well as the overall oxygenation levels, recommended to be taken after 24hrs of age. - It is take on both the right hand (preductal) and either foot (post ductal). A "passing" test is typically when oxygen saturation levels are 95% or greater in either extremity and there is 3% or less difference between the preductal and postdoctoral readings. - Which of the following test is passing 90 and 95 is it passing? No because they have to both have to be above 95% or above **Circumcision** - Elective surgery to remove the foreskin of the penis - Gomco clamp (may be safest because the gomco helps protect the head of the penis) - Plastibell\* - plastic bell is left - do not remove the yellow crust for healing process - Mogen clamp - Monitor for signs of bleeding and void. - Stop bleeding by putting pressure **Newborn Care** - bathing - bulb syringe - clothing : based on weather - cord care: do not submerge baby \' s cord, cord clamp is removed when the cord is dry, actual cord falls off in 2 weeks - colic: \*\*\*never shake a baby, can lead to pediatric abusive head trauma - diaper dermatitis (diaper rash) zinc oxide (desitin), Aquaphor - diapering/elimination: cord is left exposed not covered, check and change - should not be covered because it is moist can cause bacteria and infection - diapers frequently (before and after feeding), \*\*\*urate crystals (red orange color) may be a sign of dehydration - follow-up care: within 2 to 4 days after hospital discharge - closer to 1-2 days - subsequent visits: 1,2, 4, 6, 9, and 12 months of age - Jaundice - Should be seen 1-2 days - pediatric abusive head trauma - safe infant sleep: on their backs, in a firm, flat surface, with no stuffed animals or thick blankets, no co-sleeping - should be supine - safety - accident prevention - car seats - fall prevention - poisoning prevention - baby-proof! - cut those grapes! To prevent choking can occlude airway - sibling attachment: older sibling may regress, include the older sibling - skin care: avoid daily bathing, no baby powders (can be inhaled), no lotions (unnecessary) - Swaddling to comfort - soothing babies - nonnutritive sucking: using a pacifier or the infant\' s fist and fingers to soothe and calm the infant - use of pacifier less chances of developing SIDS but can cause nipple confusion - 5S\' s by Dr. Karp: - swaddling - side positioning or stomach position (only if supervised) - shushing - swinging - sucking - Helps calm baby down - temperature taking: digital thermometers can be done axillary or rectal (rectal temperature needs a Dr. order) - dental decay: sweetened liquids are given to infants and remain in the mouth for a period of time - uncircumcised male: do not force the foreskin over the penis; gently cleanse when bathing and changing the diaper; once the foreskin retracts around age 3, gently clean between the foreskin and glans of the penis when bathing the child - circumcision care - Gomco/Mogen clamp - Plastibell - \*\*\*no lubricants can displace the plastic ring - the plastic ring falls off in 7 to 10 days on its own **When to call the provider:** temp of 100.4F (38C), loss of appetite, refuses to eat, lethargic, sleepy and not active as usual, does not wake on their own during feedings/not interested in feeding, does not cry/has a weak cry, watery green stools, vomiting, decrease in \# of wet diapers, skin rash with pus, sunken or bulging fontanels, bleeding from circumcision and/or cord site (stop bleeding by putting pressure), foul odor from circumcision and/or cord site Chapter 16 **Breastfeeding** - Benefits - infants: \[short-term\] decreased risk of gastroenteritis, RSV, otitis media, NEC, SIDS, UTI, \[long-term\] decreased risk of asthma, atopic dermatitis, CVD, celiac disease, childhood inflammatory bowel disease, obesity, sleep disorders, antibodies - woman: \[short-term\] decreased blood loss, decreased risk of infection, \[long-term\] decreased risk of diabetes, metabolic syndrome, osteoporosis, autoimmune disease, ovarian and breast cancer, \[psychological\] enhanced maternal-infant attachment, decreased risk of PPD - Contraindication - active and untreated TB, receiving diagnostic/therapeutic - radioactive isotopes, antimetabolites/chemotherapeutic agents, - herpes simplex lesions on the breast, HIV+, cocaine, galactosemia **Breastmilk Composition** - Composed of fats, carbohydrates, proteins, lactose, vitamins, minerals, and hormones. - Human milk contains 87% water, 1% protein, 3.8% fats, and 7% lactose. - Fat content ranges from 3.5% to 4.5% and is considered the most important component of breast milk. Fats are a source of energy and help central nervous system development. - Fats provide 50% of the total calories (energy) of breast milk and lactose provides 40%. **Stages of Breastmilk** - Stage 1: Colostrum---This is considered the first milk and is present in the breast beginning in the second trimester. Colostrum is a thick, clear to golden yellow fluid with higher levels of protein and lower levels of fats, carbohydrates, and calories than mature breast milk. - Stage 2: Transitional milk---During this stage, the milk will gradually change from colostrum to mature milk, with decreasing levels of protein and - Stage 3: Mature milk---Arriving approximately 12 days after birth, mature milk is composed of 20% solids and 80% water and contains approximately 22 to 23 calories per ounce. Mature milk is whiter and thinner, appearing - **Foremilk** is the milk produced and stored between feedings and is released at the beginning of a feeding. It is more dilute and satisfies thirst. - **Hindmilk** milk produced during a feeding session, is received toward the end of the feeding and has a higher fat content. **Breastmilk Production** - Mammogenesis - Lactogenesis I - Lactogenesis II - Galactopoiesis - Involution - Hormones involved: - Prolactin - milk production - Oxytocin - milk letdown - focus on the hormones\*\*\* \*\*Critical Component: Lactogenesis and Supply and Demand A close-up of a document Description automatically generated **Breastmilk Production** - Skin-to-skin (kangaroo care) - Initiating breastfeeding - Latching the newborn - Feeding cues - Licking their lips - Smacking their lips - Extending their tongue - Putting their hand to their mouth - Sucking on their fingers - Turning their head to their mother's voice - Entering a quiet alert stage - Positioning the newborn at the breast - Crying baby you should calm them down first by swaddling, skin to skin, or other methods before trying to feed them. **Breastfeeding Process** 1\. check diaper 2\. determine when to feed; hunger cues 3\. assume a comfortable position 4\. latch on 5.support with pillows 6.stimulate the baby to breastfeed 7\. offer both breasts 8\. unlatch baby \- by scooping nipple out because it can cause irritation and hurt 9\. burp baby 10\. check diaper Breastfeeding Positions \*\*\*what is most comfortable for mom and baby? - lying down - sitting - cross-cradle - football/clutch hold cradle - this is best for C-section patients because it doesn't put pressure on abdomen.  **Determining effective feeding** - "L" represents how well the newborn latches on the breast. - "A" represents audible swallowing. - "T" identifies the type of mother's nipple. - "C" represents the mother's degree of comfort (breast or nipple). - "H" describes the amount of assistance needed to hold or position the newborn at the breast to maintain an effective latch. - The lower the score the higher need for support \*\*\*\* **Nipple Assessment** - Everted: Protrudes outward from the areola. - Inverted: Drawn below the skin surface. A true inverted nipple does not evert with stimulation. - Flat: Even in appearance with the areola. - Retracted: Drawn inward but are usually easily stimulated to evert. **Milk Expression and Breast Pumps** - Hand washing - Hand expression - Massaging breast for milking breast - Selecting a breast pump (hand pump, electric pump, etc.) - Storing breastmilk - Should be placed in the back of fridge for consistent temperature - Do not microwave because it can destroy nutrients. - Engorgement **Bottle-feeding** - Advantages vs disadvantages of formula - Advantages: provides an opportunity for partner to assist with feedings, allows mother to take a break, decreases frequency of feedings because digestion of formula is slower. - Disadvantages: increase cost for purchase of formula, time consuming for prepping, increase risk of infection due to lack of antibodies that are present in breast milk. - Increase risk of obesity, and insulin dependency - Remove bottle after feeding immediately because it can cause tooth decay. - Intolerance to formula - Some cannot tolerate a milk protein called casein in formula - Can cause vomiting, diarrhea with mucus or blood present, weight loss or slow weight gain, colic - Bootle needs to be disposed of if it has been opened for more than an hour because of bacteria growth. Burp baby after feeding because of air. - when preparing infant formula, must follow the exact directions for proper dilution - check for expiration date - read instructions for when to discard \*\*\*Critical component: Preparing infant formula \*\*\*Critical component: Decreasing the risk of baby bottle tooth decay