Maternal Care PDF

WEEK 7: INTRAPARTAL CARE (LECTURE) NCMA 217 - CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENT) 2ND YEAR - BS NURSING (MIDTERMS) Padayon, SN. THEORIES OF LABOR ONSET urine...

WEEK 7: INTRAPARTAL CARE (LECTURE) NCMA 217 - CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENT) 2ND YEAR - BS NURSING (MIDTERMS) Padayon, SN. THEORIES OF LABOR ONSET urine production can lead to a weight loss Labor normally begins when a fetus is sufficiently between 1 and 3 pounds. mature to cope with extrauterine life yet not too ○ Braxston Hicks Contraction - woman large to cause mechanical difficulty with birth. usually notices extremely strong Braxton Several theories including a combination of factors Hicks contractions. originating from both the woman and fetus have Ripening of the cervix - At term, been proposed to explain why progesterone the cervix becomes still softer withdrawal begins: (described as “butter-soft”), and it ○ Uterine muscle stretching, which results tips forward. Cervical ripening this in release of prostaglandins (reason why way is an internal announcement u feel pain) that labor is very close at hand. ○ Pressure on the cervix, which stimulates the release of oxytocin from the posterior SIGNS OF TRUE LABOR pituitary. Signs of true labor involve uterine and cervical ○ Oxytocin stimulation, which works together changes. with prostaglandins to initiate contractions. ○ Uterine Contraction - The surest sign that ○ Change in the ratio of estrogen to labor has begun is productive uterine progesterone (increasing estrogen in contractions. Because contractions are relation to progesterone, which is involuntary and come without warning, interpreted as progesterone withdrawal) their intensity can be frightening in early ○ Placental age, which triggers contractions labor. Helping a woman appreciate that at a set point. she can predict when her next one will ○ Rising fetal cortisol levels, which reduces occur and therefore can control the degree progesterone formation and increases of discomfort she feels by using prostaglandin formation breathing exercises offers her a sense of ○ Fetal membrane production of well-being. prostaglandin, which stimulates ○ Show - As the cervix softens and ripens, contraction. the mucus plug that filled the cervical canal during pregnancy (operculum) is expelled. SIGNS OF LABOR The exposed cervical capillaries seep PRELIMINARY SIGNS OF LABOR - Before labor, blood as a result of pressure exerted by a woman often experiences subtle signs that signal the fetus. This blood, mixed with mucus, labor is imminent. It is important to review these takes on a pink tinge and is referred to as with women during the last trimester of pregnancy “show” or “bloody show.” Women need so they can more easily recognize beginning signs. to be aware of this event so that they do ○ Lightening - In primiparas, lightening, or not think they are bleeding abnormally. descent of the fetal presenting part into the ○ Rupture of Membranes - Labor may pelvis, occurs approximately 10 to 14 days begin with rupture of the membranes, before labor begins. This fetal descent experienced either as a sudden gush or as changes a woman’s abdominal contour, scanty, slow seeping of clear fluid from the because it positions the uterus lower and vagina. Early rupture of the membranes more anterior in the abdomen. Lightening can be advantageous as it can cause the gives a woman relief from the fetal head to settle snugly into the pelvis, diaphragmatic pressure and shortness of shortens labor. Two risks associated with breath that she has been experiencing and ruptured membranes are intrauterine “lightens'' her load. infection and prolapse of the umbilical ○ Increase in Level of Activity - This cord, which could cut off the oxygen increase in activity is related to an increase supply to the fetus (Lewis et al., 2007). In in epinephrine release initiated by a most instances, if labor has not decrease in progesterone produced by the spontaneously occurred by 24 hours after placenta. This additional epinephrine membrane rupture and the pregnancy is at prepares a woman’s body for the work of term, labor will be induced to help reduce labor ahead. these risks. ○ Slight loss of weight - As progesterone level falls, body fluid is more easily COMPONENTS OF LABOR excreted from the body. This increase in A successful labor depends on four integrated concepts:  a. A woman’s pelvis (the passage) is of engagement). If the presenting part is above the adequate size and contour. spines, the distance is measured and described as b. The passenger (the fetus) is of minus stations, which range from 1 to 4 cm. If the appropriate size and in an advantageous presenting part is below the ischial spines, the position and presentation. distance is stated as plus stations (+1 to +4). At a c. The powers of labor (uterine factors) are +3 or +4 station, the presenting part is at the adequate. (The powers of labor are perineum and can be seen if the vulva is separated (i.e., it is crowning). strongly influenced by the woman’s position during labor.) d. A woman’s psychological outlook is preserved, so that afterward labor can be viewed as a positive experience. 1. PASSAGE a. The passage refers to the route a fetus must travel from the uterus through the cervix and vagina to the external Fetal Attitude - Attitude describes the degree of perineum. Two pelvic measurements are flexion a fetus assumes during labor or the relation important to determine the adequacy of the of the fetal parts to each other. A fetus in good pelvic size: the diagonal conjugate (the attitude is in complete flexion: the spinal column is anteroposterior diameter of the inlet) and bowed forward, the head is flexed forward so much the transverse diameter of the outlet. At that the chin touches the sternum, the arms are the pelvic inlet, the anteroposterior flexed and folded on the chest, the thighs are diameter is the narrowest diameter; at the flexed onto the abdomen, and the calves are outlet, the transverse diameter is the pressed against the posterior aspect of the thighs. narrowest. This normal “fetal position” is advantageous for birth because it helps a fetus present the smallest anteroposterior diameter of the skull to the pelvis and also because it puts the whole body into an 2. PASSENGER ovoid shape, occupying the smallest space a. The passenger is the fetus. The body part possible. of the fetus that has the widest diameter is A fetus is in moderate flexion if the chin is not the head, so this is the part least likely to touching the chest but is in an alert or “military be able to pass through the pelvic ring. position”. Whether a fetal skull can pass depends on A fetus in partial extension presents the “brow” of both its structure (bones, fontanelles, and the head to the birth canal. suture lines) and its alignment with the Descent - means that the widest part of the fetus pelvis. (the biparietal diameter in a cephalic presentation; Molding is a change in the shape of the fetal skull the intertrochanteric diameter in a breech produced by the force of uterine contractions presentation) has passed through the pelvis inlet or pressing the vertex of the head against the the pelvic inlet has been proved adequate for birth. not-yet-dilated cervix. Fetal Lie - Lie is the relationship between the long Engagement – refers to the settling of the (cephalocaudal) axis of the fetal body and the long presenting part of a fetus far enough into the pelvis (cephalocaudal) axis of a woman’s body; in other to be at the level of the ischial spines, a midpoint of words, whether the fetus is lying in a horizontal the pelvis. (transverse) or a vertical (longitudinal) position. Station - refers to the relationship of the presenting part of a fetus to the level of the ischial spines. When the presenting fetal part is at the level of the ischial spines, it is at a 0 station (synonymous with BATCH 2025 TRANSCRIBED BY: AJ & CM | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 2  TYPES OF FETAL PRESENTATION Fetal presentation denotes the body part that will first contact the cervix or be born first. This is determined by a combination of fetal lie and the degree of fetal flexion (attitude). 1. Cephalic Presentation - A cephalic presentation is the most frequent type of presentation, occurring as often as 95% of the time. With this type of presentation, the fetal head is the body part that will first contact the cervix. The four types of cephalic presentation (vertex, brow, face, and mentum). FETAL POSITION Position is the relationship of the presenting part to a specific quadrant of a woman’s pelvis. For convenience, the maternal pelvis is divided into four quadrants according to the mother’s right and left: (a) right anterior, (b) left anterior, (c) right posterior, and (d) left posterior. POSSIBLE FETAL POSITION Vertex Breech Face Shoulder Presentatio Presentatio Presentatio Presentatio n n (sacrum) n n (acromion (occiput) (Mentum) process) LOA, left LSaA, left LMA, left LAA, left occiput sacroanteri mentoanteri scapula anterior or LSaP, or LMP, left anterior LAP, left mentoposter LOP, left left 2. Breech Presentation - A breech presentation sacroposteri ior LMT, left occipitopost or LSaT, mentum scapula means that either the buttocks or the feet are the erior LOT, posterior left sacrum transverse first body parts that will contact the cervix. Breech left transverse RMA, right RAA, right presentations occur in approximately 3% of births RSaA, right mentoanteri scapula occipitotrans and are affected by fetal attitude. A good attitude sacroanteri or RMP, anterior verse ROA, brings the fetal knees up against the fetal or RSaP, right RAP, right right occiput right mentoposter scapula abdomen; a poor attitude means that the knees are anterior sacroposteri ior RMT, posterior extended. Breech presentations can be difficult ROP, right occiput or RSaT, right births, with the presenting point influencing the posterior right mentum degree of difficulty. Three types of breech ROT, right sacrum transverse presentation (complete, frank, and footling) are occiput transverse possible. transverse 3. Shoulder Presentation - In a transverse lie, a fetus lies horizontally in the pelvis so that the longest fetal axis is perpendicular to that of the mother. The presenting part is usually one of the shoulders (acromion process), an iliac crest, a hand, or an elbow. BATCH 2025 TRANSCRIBED BY: AJ & CM | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 3  transverse one) in line with the wide transverse diameter of the inlet. Extension ○ As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. The head extends, and the foremost parts of the head, the face and chin, are born. External Rotation ○ In external rotation, almost immediately after the head of the infant is born, the MECHANISM OF LABOR (CARDINAL MOVEMENTS) head rotates (from the anteroposterior position it is assumed to enter the outlet) Passage of a fetus through the birth canal involves back to the diagonal or transverse position several different position changes to keep the of the early part of labor. This brings the smallest diameter of the fetal head (in cephalic aftercoming shoulders into an presentations) always presenting to the smallest anteroposterior position, which is best for diameter of the pelvis. These position changes are entering the outlet. The anterior shoulder is termed the cardinal movements of labor: descent, born first, assisted perhaps by downward flexion, internal rotation, extension, external flexion of the infant’s head. rotation, and expulsion. Expulsion Descent ○ Once the shoulders are born, the rest of ○ Descent is the downward movement of the the baby is born easily and smoothly biparietal diameter of the fetal head to because of its smaller size. This within the pelvic inlet. Full descent occurs movement, called expulsion, is the end of when the fetal head extrudes beyond the the pelvic division of labor dilated cervix and touches the posterior vaginal floor. Descent occurs because of POWERS OF LABOR pressure on the fetus by the uterine fundus. The pressure of the fetal head on The second important requirements for a successful the sacral nerves at the pelvic floor causes labor are effective powers of labor. This is the the mother to experience a pushing force supplied by the fundus of the uterus, sensation. Full descent may be aided by implemented by uterine contractions, a natural abdominal muscle contraction as the process that causes cervical dilatation and then woman pushes. expulsion of the fetus from the uterus. After full Flexion dilatation of the cervix, the primary power is ○ As descent occurs and the fetal head supplemented by use of the abdominal muscles. It reaches the pelvic floor, the head bends is important for women to understand they should forward onto the chest, making the not bear down with their abdominal muscles until smallest anteroposterior diameter (the the cervix is fully dilated. Doing so impedes the suboccipitobregmatic diameter) present to primary force and could cause fetal and cervical the birth canal. Flexion is also aided by damage abdominal muscle contraction during Uterine Contraction - The mark of effective pushing. uterine contractions is rhythmicity and progressive Internal Rotation lengthening and intensity. ○ During descent, the head enters the pelvis Phases - A contraction consists of three phases: with the fetal anteroposterior head the increment, when the intensity of the diameter (suboccipitobregmatic, contraction increases; the acme, when the occipitomental, or occipitofrontal, contraction is at its strongest; and the decrement, depending on the amount of flexion) in a when the intensity decreases diagonal or transverse position. The head flexes as it touches the pelvic floor, and the occiput rotates to bring the head into the best relationship to the outlet of the pelvis (the anteroposterior diameter is now in the anteroposterior plane of the pelvis). This movement brings the shoulders, coming next, into the optimal position to enter the inlet, putting the widest diameter of the shoulders (a BATCH 2025 TRANSCRIBED BY: AJ & CM | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 4  Cervical Changes – Even more marked than the changes in the body of the uterus are two changes that occur in the cervix: effacement and dilatation. Effacement - it is shortening and thinning of the cervical canal. Normally, the canal is approximately 1 to 2 cm long. With effacement, the canal virtually disappears. Dilatation refers to the enlargement or widening of the cervical canal from an opening a few millimeters wide to one large enough (approximately 10 cm) to permit passage of a fetus. PSYCHE The fourth “P,” or a woman’s psychological outlook, refers to the psychological state or feelings that a woman brings into labor. For many women, this is a feeling of apprehension or fright. For almost everyone, it includes a sense of excitement or awe. BATCH 2025 TRANSCRIBED BY: AJ & CM | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 5 WEEK 8: STAGES OF LABOR (LECTURE) NCMA 217 - CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENT) 2ND YEAR - BS NURSING (MIDTERMS) Padayon, SN. STAGES OF LABOR In a birth setting, allow her to continue to Labor is traditionally divided into three stages: be active (Greulich & Tarrant, 2007). 1. a first stage of dilatation, which begins with Encourage her to continue or begin the initiation of true labor contractions and alternative methods of pain relief such as ends when the cervix is fully dilated; aromatherapy or distraction. 2. a second stage, extending from the time of full dilatation until the infant is born; and 3. a third or placental stage, lasting from the time the infant is born until after the delivery of the placenta. 4. The first 1 to 4 hours after birth of the placenta is sometimes termed the “fourth stage” to emphasize the importance of the close maternal observation needed at this time. These designations are helpful in planning nursing interventions to ensure the safety of both a woman and her fetus. Friedman (1978), a physician who studied the process of B. Active Phase labor extensively, used data to divide the first two stages of During the active phase of labor, cervical labor into phases: latent and active labor. dilatation occurs more rapidly, increasing from 4 to 7 cm. I. First Stage Contractions grow stronger, lasting 40 to Three separate divisions mark the first stage of 60 seconds, and occur approximately labor: the latent, the active, and the transition every 3 to 5 minutes. phase. This phase lasts approximately 3 hours in a nullipara and 2 hours in a multipara. A. Latent Phase Show (increased vaginal secretions) and The latent or preparatory phase begins at perhaps spontaneous rupture of the the onset of regularly perceived uterine membranes may occur during this time. contractions and ends when rapid cervical This phase can be a difficult time for a dilatation begins. woman because contractions grow strong, Contractions during this phase are mild last longer, and begin to cause true and short, lasting 20 to 40 seconds. discomfort. It is also an exciting time, Cervical effacement occurs, and the cervix because something dramatic is suddenly dilates from 0 to 3 cm. happening. It can be a frightening time as The phase lasts approximately 6 hours in a a woman realizes labor is truly progressing nullipara and 4.5 hours in a multipara. and her life is about to change forever. A woman who enters labor with a “nonripe” The active stage of labor in a Friedman cervix will have a longer than usual latent graph can be subdivided into the following phase. Although women should not be periods: acceleration (4 to 5 cm) and denied analgesia at this point, analgesia maximum slope (5 to 9 cm). given too early may prolong this phase. During the period of maximum slope, Measuring the length of the latent phase is cervical dilatation proceeds at its most important because a reason for a rapid pace, averaging 3.5 cm per hour in prolonged latent phase is cephalopelvic nulliparous and 5 to 9 cm per hour in disproportion (a disproportion between the multiparas. fetal head and pelvis) that could require a Encourage women to remain active cesarean birth. participants in labor by assuming what A woman can (and should) continue to position is most comfortable for them walk about and make preparations for during this time (Albers, 2007). birth, such as doing last minute packing for her stay at the hospital or birthing center, preparing older children for her departure and the upcoming birth, or giving instructions to the person who will take care of them while she is away.  As the fetal head touches the internal side of the perineum, the perineum begins to bulge and appears tense. The anus may become everted, and stool may be expelled. As the fetal head pushes against the perineum, the vaginal introitus opens and the fetal scalp appears at the opening to the vagina. At first, the opening is slitlike, then becomes oval, and then circular. The circle enlarges from the size of a dime, then a quarter, then a half-dollar. This is called crowning. C. Transition Phase The need to push becomes so intense that she During the transition phase, contractions reach cannot stop herself. She barely hears the their peak of intensity, occurring every 2 to 3 conversation in the room around her. All of her minutes with a duration of 60 to 90 seconds and energy, her thoughts, her being are directed toward causing maximum cervical dilatation of 8 to 10 cm. giving birth. As she pushes, using her abdominal If the membranes have not previously ruptured or muscles to aid the involuntary uterine contractions, been ruptured by amniotomy, they will rupture as a the fetus is pushed out of the birth canal. rule at full dilatation (10 cm). If it has not previously occurred, show occurs as the last of the mucus plug III. Third Stage from the cervix is released. The third stage of labor, the placental stage, begins By the end of this phase, both full dilatation (10 cm) with the birth of the infant and ends with the delivery and complete cervical effacement (obliteration of of the placenta. Two separate phases are involved: the cervix) have occurred. placental separation and placental expulsion. During this phase, a woman may experience After the birth of an infant, a uterus can be palpated intense discomfort, so strong that it is accompanied as a firm, round mass just inferior to the level of the by nausea and vomiting. Because of the intensity umbilicus. After a few minutes of rest, uterine and duration of the contractions, a woman may also contractions begin again, and the organ assumes a experience a feeling of loss of control, anxiety, discoid shape. It retains this new shape until the panic, or irritability. placenta has separated, approximately 5 minutes The peak of the transition phase can be identified after the birth of the infant. by a slight slowing in the rate of cervical dilatation when 9 cm is reached (termed deceleration on a A. Placental Separation labor graph). As a woman reaches the end of this As the uterus contracts down on an almost stage at 10 cm of dilatation, a new sensation (i.e., empty interior, there is such a an irresistible urge to push) occurs. disproportion between the placenta and the contracting wall of the uterus that folding and separation of the placenta occur. Active bleeding on the maternal surface of the placenta begins with separation; this bleeding helps to separate the placenta still farther by pushing it away from its attachment site. As separation is completed, the placenta sinks to the lower uterine segment or the upper vagina. II. Second Stage The second stage of labor is the period from full dilatation and cervical effacement to birth of the infant; with uncomplicated birth, this stage takes about 1 hour (Archie, 2007). A woman feels contractions change from the characteristic crescendo–decrescendo pattern to an overwhelming, uncontrollable urge to push or bear down with each contraction as if to move her The following signs indicate that the bowels. She may experience momentary nausea or placenta has loosened and is ready to vomiting because pressure is no longer exerted on deliver: her stomach as the fetus descends into the pelvis. ○ Lengthening of the umbilical cord She pushes with such force that she perspires and ○ Sudden gush of vaginal blood the blood vessels in her neck may become ○ Change in the shape of the uterus distended. ○ Firm contraction of the uterus BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 2  ○ Appearance of the placenta at the doing so may cause the uterus to evert vaginal opening and hemorrhage. This is a grave If the placenta separates first at its center complication of birth, because the maternal and last at its edges, it tends to fold onto blood sinuses are open and gross itself like an umbrella and presents at the hemorrhage could occur (Poggi, 2007). vaginal opening with the fetal surface If the placenta does not deliver evident. Appearing shiny and glistening spontaneously, it can be removed from the fetal membranes, this is called a manually. With delivery of the placenta, the Schultze presentation. Approximately 80% third stage of labor is complete. of placentas separate and present in this way. If, however, the placenta separates MATERNAL AND FETAL RESPONSES TO LABOR first at its edges, it slides along the uterine 1. Physiologic Effects of Labor on a Woman surface and presents at the vagina with the a. Cardiovascular System maternal surface evident. i. Labor involves strenuous work and effort and requires a response from the cardiovascular System. Cardiac Output Each contraction greatly decreases blood flow to the uterus because the contracting uterine wall puts pressure on the uterine arteries. This increases the amount of blood that remains in a woman’s general circulation, leading to an increase in peripheral resistance, which in turn results in an increase in systolic and diastolic blood pressure. In addition, the work of pushing during labor may increase cardiac output by as much as 40% to 50% above It looks raw, red, and irregular, with the the prelabor level. Cardiac output then gradually ridges or cotyledons that separate blood decreases from this high level, within the first hour collection spaces showing; this is called a after birth, by about 50%. An average woman’s Duncan presentation. A simple trick of heart adjusts well to these sudden changes. If she remembering the presentations is has a cardiac problem, however, these sudden associating “shiny” with Schultze (the fetal hemodynamic changes can have implications for membrane surface) and “dirty” with her health. Duncan (the irregular maternal surface) Blood Pressure With the increased cardiac output caused by contractions during labor, systolic blood pressure rises an average of 15 mm Hg with each contraction. Higher increases could be a sign of pathology. When a woman lies in a supine position and pushes during the second stage of labor, pressure of the uterus on the vena cava causes her blood pressure to drop precipitously, leading to hypotension. An upright or side-lying position during the second stage of labor not only makes pushing more effective but also can help avoid such a problem. Bleeding occurs as part of the normal consequence of placental separation, b. Hematopoietic System before the uterus contracts sufficiently to The major change in the blood-forming system that seal maternal sinuses. The normal blood occurs during labor is the development of loss is 300 to 500 mL. leukocytosis, or a sharp increase in the number of circulating white blood cells, possibly as a result of B. Placental Expulsion stress and heavy exertion. At the end of labor, the After separation, the placenta is delivered average woman has a white blood cell count of either by the natural bearing-down effort of 25,000 to 30,000 cells/mm3, compared with a the mother or by gentle pressure on the normal count of 5000 to 10,000 cells/mm3. contracted uterine fundus by a physician or nurse midwife (Credé’s maneuver). Pressure must never be applied to a uterus in a non contracted state, because BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 3 C. Respiratory System contractions grow strong, similar to what they may Whenever there is an increase in cardiovascular experience with menstrual cramps. parameters, the body responds by increasing the respiratory rate to supply additional oxygen. Total I. Neurologic and Sensory Responses oxygen consumption increases by about 100% The neurologic responses that occur during labor during the second stage of labor. Women adjust are responses related to pain (increased pulse and well to this change, which is comparable to that of a respiratory rate). Early in labor, the contraction of person performing a strenuous exercise such as the uterus and dilatation of the cervix cause the running. It can result in hyperventilation. Using discomfort. At the moment of birth, the pain is appropriate breathing patterns during labor can help centered on the perineum as it stretches to allow avoid severe hyperventilation. the fetus to move past it. D. Temperature Regulation The increased muscular activity associated with 2. Psychological Responses of a Woman to Labor labor can result in a slight elevation (1° F) in A. Fatigue temperature. Diaphoresis occurs with a. By the time a date of birth approaches, a accompanying evaporation to cool and limit woman is generally tired from the burden excessive warming. of carrying so much extra weight. In addition, most women do not sleep well E. Fluid Balance during the last month of pregnancy (Beebe Because of the increase in rate and depth of & Lee, 2007). It can make the process of respirations (which causes moisture to be lost with labor loom as an overwhelming, each breath) and diaphoresis, insensible water loss unendurable experience unless they have increases during labor. Fluid balance is further competent support people with them. affected if a woman eats nothing but sips of fluid or ice cubes or hard candy. Although not a concern in B. Fear usual labor, the combination of increased fluid Women appreciate a review of the labor process losses and decreased oral intake may make early in labor as a reminder that childbirth is not a intravenous fluid replacement necessary if labor strange, bewildering event but a predictable and becomes prolonged. well-documented one. Being taken by surprise—labor moving faster or slower than the F. Urinary System woman thought it would or contractions harder and With a decrease in fluid intake during labor and the longer than she remembers from last time—can increased insensible water loss, the kidneys begin lead a woman to feel out of control and increase the to concentrate urine to preserve both fluid and pain she experiences. Explain that labor is electrolytes. Specific gravity may rise to a high predictable, but also variable, to limit this kind of normal level of 1.020 to 1.030. It is not unusual for fear. Be sure to explain that contractions last a protein (trace to 1) to be evident in urine because of certain length and reach a certain firmness but the breakdown of protein caused by the increased always have a pain-free rest period in between. muscle activity. Pressure of the fetal head as it descends in the birth canal against the anterior C. Cultural Influences bladder reduces bladder tone or the ability of the Cultural factors can strongly influence a woman’s bladder to sense filling. experience of labor. In the past, American women were accustomed to following hospital procedures G. Musculoskeletal System and the medical model of care; therefore, they All during pregnancy, relaxin, an ovarian-released followed instructions during labor with few hormone, has acted to soften the cartilage between questions. Today, women are educated to help plan bones. In the week before labor, considerable their care. In addition, every woman responds to additional softening causes the symphysis pubis cultural cues in some way. This makes her and the sacral/coccyx joints to become even more response to pain, her choice of nourishment, her relaxed and movable, allowing them to stretch apart preferred birthing position, the proximity and to increase the size of the pelvic ring by as much as involvement of a support person, and customs 2 cm. related to the immediate postpartal period individualized (Price, Noseworthy, & Thornton, H. Gastrointestinal System 2007). The gastrointestinal system becomes fairly inactive during labor, probably because of the shunting of 3. Physiologic Effects of Labor to a Fetus blood to more life sustaining organs and also A. Neurologic System because of pressure on the stomach and intestines Uterine contractions exert pressure on the fetal from the contracting uterus. Digestive and emptying head, so the same response that is involved with time of the stomach become prolonged. Some any instance of increased intracranial pressure women experience a loose bowel movement as occurs. The fetal heart rate (FHR) decreases by as BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 4  much as 5 beats per minute (bpm) during a during the normal course of labor is contraction, as soon as contraction strength unusual and should be reported. It may be reaches 40 mm Hg. This decrease appears on a another indication of hemorrhage. fetal heart monitor as a normal or early deceleration 3. Inadequate or Prolonged Contractions. pattern. Uterine contractions normally become more frequent, intense, and longer as B. Cardiovascular System labor progresses. If they become less The ability to respond to cardiovascular changes is frequent, less intense, or shorter in usually mature enough that the fetus is unaffected duration, this may indicate uterine by the continual variations of heart rate that occur exhaustion (inertia). If this problem cannot with labor—a slight slowing and then a return to be corrected, a cesarean birth may be normal (baseline) levels. During a contraction, the necessary. arteries of the uterus are sharply constricted and A period of relaxation must be present the filling of cotyledons almost completely halts. The between contractions so that the amount of nutrients, including oxygen, exchanged intervillous spaces of the uterus can fill and during this time is reduced, causing a slight but maintain an adequate supply of oxygen inconsequential fetal hypoxia. and nutrients for the fetus. As a rule, uterine contractions lasting longer than 70 C. Integumentary System seconds should be reported, The pressure involved in the birth process is often 4. Pathologic Retraction Ring. reflected in minimal petechiae or ecchymotic areas An indentation across a woman’s on a fetus (particularly the presenting part). There abdomen, where the upper and lower may also be edema of the presenting part (caput segments of the uterus join, may be a sign succedaneum). of extreme uterine stress and possible impending uterine rupture. For this reason, D. Musculoskeletal System it is important to observe the contours of a The force of uterine contractions tends to push a woman’s abdomen periodically during fetus into a position of full flexion, the most labor. Fetal heartbeat auscultation advantageous position for birth. automatically provides a regular opportunity to assess a woman’s E. Respiratory System abdomen. The process of labor appears to aid in the 5. Abnormal Lower Abdominal Contour. maturation of surfactant production by alveoli in the If a woman has a full bladder during labor, fetal lung. The pressure applied to the chest from a round bulge on her lower anterior contractions and passage through the birth canal abdomen may appear. This is a danger helps to clear it of lung fluid. For this reason, an signal for two reasons: first, the bladder infant born vaginally is usually able to establish may be injured by the pressure of a fetal respirations more easily than a fetus born by head; second, the pressure of the full cesarean birth. bladder may not allow the fetal head to descend. To avoid a full bladder, women MATERNAL DANGER SIGNS need to try to void about every 2 hours 1. High or Low Blood Pressure. during labor. Normally, a woman’s blood pressure rises 6. Increasing Apprehension. slightly in the second (pelvic) stage of Warnings of psychological danger during labor because of her pushing effort. A labor are as important to consider in systolic pressure greater than 140 mm Hg assessing maternal well-being as are and a diastolic pressure greater than 90 physical signs. A woman who is becoming mm Hg, or an increase in the systolic increasingly apprehensive despite clear pressure of more than 30 mm Hg or in explanations of unfolding events may only diastolic pressure of more than 15 mm Hg be approaching the second stage of labor. (the basic criteria for pregnancy-induced She may, however, not be “hearing” hypertension), should be reported. Just as because she has a concern that has not important to report is a falling blood been met. Increasing apprehension also pressure, because it may be the first sign needs to be investigated for physical of intrauterine hemorrhage. reasons, because it can be a sign of 2. Abnormal Pulse oxygen deprivation or internal hemorrhage. Most pregnant women have a pulse rate of 70 to 80 bpm. This rate normally increases FETAL DANGER SIGNS slightly during the second stage of labor 1. High or Low Fetal Heart Rate. because of the exertion involved. A As a rule, an FHR of more than 160 bpm maternal pulse rate greater than 100 bpm (fetal tachycardia) or less than 110 bpm BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 5  (fetal bradycardia) is a sign of possible A woman needs to feel that she has some control over her fetal distress. An equally important sign is situation during labor to face this big event in her life. Most a late or variable deceleration pattern women accomplish this by stating their preferences, (described later) on a fetal monitor. The breathing with contractions, and changing their position to FHR may return to a normal range in the one that makes them most comfortable. In contrast, between these irregular patterns, giving a some women handle the stress of labor by becoming false sense of security if FHR is assessed extremely quiet and passive. Others feel most comfortable only between contractions. when they can show their emotions by shouting or crying. 2. Meconium Staining. Help a woman express her feelings in her own way, one that Meconium staining, a green color in the works the best for her. amniotic fluid, is not always a sign of fetal distress but is highly correlated with its 1. Respect Contraction Time. Do not interrupt a occurrence. It reveals that the fetus has woman who is in the middle of breathing exercises had loss of rectal sphincter control, during labor because, once her concentration is allowing meconium to pass into the disrupted, she will feel the extent of the contraction amniotic fluid. It may indicate that a fetus 2. Promote Change of Positions. Because the bed is has or is experiencing hypoxia, which the main piece of furniture in a birthing room, many stimulates the vagal reflex and leads to women assume that they are expected to lie quietly increased bowel motility. Although in bed during labor. In early labor, however, a meconium staining may be normal in a woman may be out of bed walking or sitting up in breech presentation, because pressure on bed or in a chair, kneeling, squatting, or in whatever the buttocks causes meconium loss, it position she prefers should always be reported immediately so a. A woman whose membranes have that its cause can be investigated. ruptured should lie on her side until a fetal 3. Hyperactivity monitor shows good baseline variability Ordinarily, a fetus is quiet and barely and no variable decelerations or until she moves during labor. Fetal hyperactivity has been checked by a physician or may be a sign that hypoxia is occurring, nurse-midwife, because, unless the head because frantic motion is a common of the fetus is well engaged (firmly fitting reaction to the need for oxygen. into the pelvic inlet), the umbilical cord may 4. Oxygen Saturation. prolapse into the vagina if she walks. If a fetus is assessed for oxygen saturation b. If medication such as a narcotic is given, level by a catheter inserted next to the educate a woman to remain in bed for cheek, a low oxygen saturation level approximately 15 minutes afterward to (under 40%) or if fetal blood was obtained avoid a fall if she should become dizzy by scalp puncture, the finding of acidosis from the medication. While a woman is in (blood pH 7.2) suggests that fetal bed, encourage her to lie on her side, well-being is becoming compromised. preferably the left side. This position Oxygen saturation in a fetus is normally causes the heavy uterus to tip forward, 40% to 70%. away from the vena cava, allowing free blood return from the lower extremities and Care of a woman during the First Stage of Labor adequate placental filling and circulation. Labor is a natural process and nurses can be c. Some women have learned to do instrumental in keeping labor as free of breathing exercises in a supine position unnecessary interventions as possible (Sleutel, and may need additional coaching to do Schultz, & Wyble, 2007). Six major concepts to them in a side-lying position. If a woman make labor and birth as natural as possible are: must turn to her back during a contraction 1. Labor should begin on its own, not be artificially to make her breathing exercises effective, induced. help her to remember to return to her side 2. Women should be able to move about freely between contractions. throughout labor, not be confined to bed. 3. Offer Support. There is no substitute for personal 3. Women should receive continuous support during touch and contact as a way to provide support labor. during labor. Patting a woman’s arm while telling 4. No interventions such as intravenous fluid should her that she is progressing in labor, brushing a wisp be used routinely. of hair off her forehead, wiping her forehead with a 5. Women should be allowed to assume a non supine cool cloth—these are indispensable methods of (e.g.,upright, side-lying) position for birth. conveying concern 6. Mother and baby should be together after the birth, 4. Respect and Promote the Support Person. Admit with unlimited opportunity for breastfeeding (Amis & a woman’s support person to the birthing area and Green, 2007). allow him or her to remain with a woman throughout the birth. Having someone with her during labor is BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 6  important, because everything is new and the back with knees flexed), semi-sitting, unexpected. Acquaint the woman and her support and squatting. person with the physical facilities, and point out ○ Because pushing becomes less effective where supplies such as towels,washcloths, and ice in a lithotomy position, the top portion of chips are stored, so the support person can get the table should be raised to a 30-to them when necessary. 60-degree angle, so that the woman can 5. Support a Woman’s Pain Management Needs. continue to push effectively. Lying for Many women plan on using nonpharmacologic pain longer than 1 hour in a lithotomy position relief measures such as aromatherapy during labor; leads to intense pelvic congestion, ask what the woman has planned and what your because blood flow to the lower role should be (Burns et al., 2007). Some women extremities is impeded. Pelvic congestion believe that using a prepared childbirth method will may lead to an increase in create a pain-free, effortless labor. When this does thrombophlebitis in the postpartum period. not happen, they may panic and lose the ability to It may also contribute to excessive blood use prepared breathing. Sometimes, simply the loss with birth and placental loosening. For support of a person, such as a nurse, who is these reasons, place the woman’s legs in confident that breathing can be effective in reducing a lithotomy position only at the last the discomfort of labor is all a woman needs to moment. resume her breathing exercises with success. 3. Promoting Effective Second-Stage Pushing ○ For the most effective pushing during the Care of a woman during the Second Stage of Labor second stage of labor, a woman should The second stage of labor is the time from full wait to feel the urge to push even though a cervical dilatation to birth of the newborn. Even pelvic examination has revealed that she is women who have taken childbirth education classes fully dilated. She should push with are surprised at the intensity of the contractions in contractions and rest between them. this phase of labor. Because the feeling to push is Pushing is usually best done from a so strong, some women react to this change. in semi-Fowler’s, squatting, or “all-fours” contractions by growing increasingly argumentative position rather than lying flat, to allow and angry or by crying and screaming. Other gravity to aid the effort. A woman can use women react by tensing their abdominal muscles short pushes or long, sustained ones, and trying to resist, making the sensation even whichever are more comfortable. Holding more painful and frightening. the breath during a contraction could cause a Valsalva maneuver or temporarily 1. Preparing the Place of Birth impede blood return to the heart because ○ For a multipara, convert a birthing room of increased intrathoracic pressure. This into a birth room by opening the sterile could also interfere with blood supply to packs of supplies on waiting tables when the uterus. To prevent her from holding her the cervix has dilated to 9 to 10 cm. For a breath during pushing, urge her to breathe primipara, this can be delayed until the out during a pushing effort. head has crowned to the size of a quarter 4. Perineal Cleaning or half-dollar (full dilatation and descent). A ○ To remove vaginal or rectal secretions and table set with equipment such as sponges, prepare the cleanest environment for the drapes, scissors, basins, clamps, bulb birth of the baby, clean the perineum. with syringe, vaginal packing, and sterile a warmed antiseptic such as Iodophor gowns, gloves, and towels can be left (cold solution causes cramping) and then covered, for up to 8 hours. Be certain that rinse it with a designated solution before drapes and materials used for birth are birth, according to the policy of the sterile, so that no microorganisms can be physician, nurse-midwife, or agency. accidentally introduced into the uterus. ○ Always clean from the vagina outward (so 2. Positioning for Birth that microorganisms are moved away from ○ Women can choose a variety of positions the vagina, not toward it), using a clean for birth. At one time, the lithotomy position compress for each stroke. Be sure and was the major position for birth, but it is no include a wide area (vulva, upper inner longer the position of choice in birthing thighs, pubis, and anus). If a physician or rooms or alternative birth nurse-midwife plans to use sterile drapes, centers—although the labor beds in these help place them around the perineum. locales have attached stirrups to allow 5. Introducing the Infant birth in a lithotomy position. Alternative ○ After the cord is cut, it is time for the new birth positions include the lateral or Sims’ parents to spend some time with their position, the dorsal recumbent position (on newborn. Take the infant from the physician or nurse-midwife and wrap the BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 7  infant in a sterile blanket. Be sure to hold newborns firmly, because they are covered with slippery amniotic fluid and vernix. Both the mother and her partner usually want to see and touch their newborn immediately; this assures them the baby is well and is an important step in establishing a parent–child relationship. Care of a woman during the Third and Fourth Stage of Labor 1. Placenta Delivery 2. Oxytocin Administration 3. Perineal Repair 4. Immediate Postpartum Assessment and Nursing Care Obtain vital signs (i.e., pulse, respirations, and blood pressure) every 15 minutes for the first hour and then according to agency policy. Pulse and respirations may be fairly rapid immediately after birth (80 to 90 bpm and 20 to 24 respirations per minute) and blood pressure slightly elevated because of the excitement of the moment and recent oxytocin administration. Palpate a woman’s fundus for size, consistency, and position and observe the amount and characteristics of lochia. Perform perineal care, and apply a perineal pad.If the birth was in a birthing room, return the birthing bed to its original position. Offer a clean gown and a warmed blanket, because a woman often experiences a chill and shaking sensation 10 to 15 minutes after birth. 5. Aftercare This is the beginning of the postpartal period or the fourth stage of labor. Because the uterus may be so exhausted from labor that it cannot maintain contraction, there is a high risk for hemorrhage during this time. In addition, a woman often is so exhausted that she may be unable to assess her own condition or report any changes. BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 8 WEEK 9: NEWBORN CARE NCMA 217 - CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENT) 2ND YEAR - BS NURSING (MIDTERMS) Padayon, SN. PROFILE OF A NEWBORN days; a formula-fed infant accomplishes this gain It is not unusual to hear the comment “all newborns within 7 days. After this, a newborn begins to gain look alike” from people viewing a nursery full of about 2 lb per month (6 to 8 oz per week) for the babies. In actuality, every child is born with first 6 months of life. Length individual physical and personality characteristics The average birth length (50th percentile) of a that make him or her unique right from the start. mature female neonate is 53 cm (20.9 in). For mature males, the average birth length is 54 cm I. Vital Statistics (21.3 in). The lower limit of normal length is Vital statistics measured in a newborn are arbitrarily set at 46 cm (18 in). Although rare, babies weight, length, and head and chest with lengths as great as 57.5 cm (24 in) have been circumference. Be sure all health care reported. providers involved with newborns are aware of safety issues specific to newborn care when taking these measurements such as not leaving a newborn unattended on a bed or scale. Weight The birth weight of newborns varies depending on the racial, nutritional, intrauterine, and genetic factors that were present during conception and pregnancy. The weight in relation to the gestational age should be plotted on a standard neonatal graph, this way helps identify newborns who are at risk because of their small size. This information also separates those who are small for their gestational age (newborns who have suffered intrauterine growth restriction) from preterm infants Head Circumference (infants who are healthy but small only because In a mature newborn, the head circumference is they were born early). usually 34 to 35 cm (13.5 to 14 in). A mature Plotting weight in conjunction with height and head newborn with a head circumference greater than 37 circumference is also helpful because it highlights cm (14.8 in) or less than 33 cm (13.2 in) should be disproportionate measurements. For example, a carefully assessed for neurologic involvement, newborn who falls within the 50th percentile for although occasionally a well newborn falls within height and weight but whose head circumference is these limits. in the 90th percentile may have abnormal head Head circumference is measured with a tape growth. A newborn who is in the 50th percentile for measure drawn across the center of the forehead weight and head circumference but in the 3rd and around the most prominent portion of the percentile for height may have a growth problem. posterior head. The average birth weight (50th percentile) for a white, mature female newborn in the United States is 3.4 kg (7.5 lb); for a white, mature male newborn, it is 3.5 kg (7.7 lb). Newborns of other races weigh approximately 0.5 lb less. The arbitrary lower limit of normal for all races is 2.5 kg (5.5 lb). Birth weight exceeding 4.7 kg (10 lb) is unusual, but weights as high as 7.7 kg (17 lb) have been documented. If a newborn weighs more than 4.7 kg, the baby is said to be macrosomic and a maternal illness, such as diabetes mellitus, must be suspected (Kwik et al., 2007). Second-born children usually weigh more than first-born. Birth weight continues to increase with each succeeding child in Chest Circumference a family. The chest circumference in a term newborn is about After this initial loss of weight, a newborn has 1 day 2 cm (0.75 to 1 in) less than the head of stable weight, then begins to gain weight. The circumference. This is measured at the level of the breastfed newborn recaptures birth weight within 10 nipples. If a large amount of breast tissue or edema  of breasts is present, this measurement will not be accurate until the edema has subsided. Pulse The heart rate of a fetus in utero averages 120 to 160 beats per minute (bpm). Immediately after birth, as the newborn struggles to initiate respirations, the heart rate may be as rapid as 180 bpm. Within 1 hour after birth, as the newborn settles down to sleep, the heart rate stabilizes to an average of 120 to 140 bpm. The heart rate of a newborn often remains slightly irregular because of immaturity of the cardiac regulatory center in the medulla. Transient murmurs may result from the incomplete closure of fetal circulation shunts. During crying, the rate may rise again to 180 bpm. In addition, heart rate can II. Vital Signs decrease during sleep, ranging from 90 to 110 bpm. You should be able to palpate brachial and femoral Vital sign measurements begin to change pulses in a newborn, but the radial and temporal from those present in intrauterine life at the pulses are more difficult to palpate with any degree moment of birth of accuracy. Therefore, a newborn’s heart rate is always determined by listening for an apical Temperature heartbeat for a full minute, rather than assessing a The temperature of newborns is about 99° F (37.2° C) at pulse in an extremity. birth because they have been confined in an internal body organ. The temperature falls almost immediately to below Respiration normal because of heat loss and immature temperature The respiratory rate of a newborn in the first few minutes of regulating mechanisms. The temperature of birthing rooms, life may be as high as 80 breaths per minute. As respiratory approximately 68° to 72° F (21° to 22° C), can add to this activity is established and maintained, this rate settles to an loss of heat. average of 30 to 60 breaths per minute when the newborn A newborn loses heat easily because of difficulty is at rest. Respiratory depth, rate, and rhythm are conserving heat under any circumstance. Insulation, likely to be irregular, and short periods of apnea (without an efficient means of conserving heat in adults, is cyanosis) which last less than 15 seconds, sometimes called not effective in newborns because they have little periodic respirations, are normal. subcutaneous fat to provide insulation. Shivering, a Respiratory rate can be observed most easily by means of increasing metabolism and thereby watching the movement of a newborn’s abdomen, providing heat in adults, is rarely seen in newborns. because breathing primarily involves the use of the Newborns can conserve heat by constricting blood diaphragm and abdominal muscles. vessels and moving blood away from the skin. Brown fat, a special tissue found in mature Blood Pressure newborns, apparently helps to conserve or produce The blood pressure of a newborn is approximately 80/46 mm body heat by increasing metabolism. The greatest Hg at birth. By the 10th day, it rises to about 100/50 mm Hg. amounts of brown fat are found in the interscapular Because measurement of blood pressure in a newborn is region, thorax, and perirenal area. Brown fat is somewhat inaccurate, it is not routinely measured unless a thought to aid in controlling newborn temperature cardiac anomaly is suspected. For an accurate reading, the similar to temperature control in a hibernating cuff width used must be no more than two thirds the length of animal. In later life, it may influence the proportion the upper arm or thigh. Blood pressure tends to increase with of body fat retained. crying (and a newborn cries when disturbed and manipulated Newborns exposed to cool air tend to kick and cry by such procedures as taking blood pressure). A Doppler to increase their metabolic rate and produce more method may be used to take blood pressure. heat. This reaction, however, also increases their need for oxygen and their respiratory rate III. Physiologic Function increases. An immature newborn with poor lung development has trouble making such an Cardiovascular System adjustment. Changes in the cardiovascular system are necessary after Drying and wrapping newborns and placing them birth because now the lungs must oxygenate the blood that in warmed cribs, or drying them and placing them was formerly oxygenated by the placenta. When the cord is under a radiant heat source, are excellent clamped, a neonate is forced to take in oxygen through the mechanical measures to help conserve heat. In lungs. As the lungs inflate for the first time, pressure addition, placing a newborn against the mother’s decreases in the pulmonary artery (the artery leading from skin and then covering the newborn with a blanket the heart to the lungs). This decrease in pressure plays a helps to transfer heat from the mother to the role in promoting closure of the ductus arteriosus, a fetal newborn; this is termed skin-to-skin care. shunt. As pressure increases in the left side of the heart from increased blood volume, the foramen ovale between the BATCH 2025 TRANSCRIBED BY: AJ | PLEASE DO NOT REMOVE THIS TO GIVE CREDIT FOR THEIR EFFORTS. 2 two atria closes because of the pressure against the lip of The first stool of a newborn is usually passed within the structure (permanent closure does not occur for weeks). 24 hours after birth. It consists of meconium, a With the remaining fetal circulatory structures (umbilical vein, sticky, tarlike, blackish-green, odorless material two umbilical arteries, and ductus venosus) no longer formed from mucus, vernix, lanugo, hormones, and receiving blood, the blood within them clots, and the vessels carbohydrates that accumulated during intrauterine atrophy over the next few weeks. life. If a newborn does not pass a meconium stool The hematocrit is between 45% and 50%. A by 24 to 48 hours after birth, the possibility of some newborn also has an elevated red blood cell count, factor such as meconium ileus, imperforate anus, or about 6 million cells per cubic millimeter. Once volvulus should be suspected. proper lung oxygenation has been established, the About the second or third day of life, newborn stool need for the high red cell count diminishes. changes in color and consistency, becoming green Therefore, within a matter of days, a newborn’s red and loose. This is termed transitional stool, and it cells begin to deteriorate. Bilirubin is a byproduct of may resemble diarrhea to the untrained eye. By the the breakdown of red blood cells. An indirect fourth day of life, breastfed babies pass three or bilirubin level at birth is 1 to 4 mg/100 mL. Any four light yellow stools per day. They are increase over this amount reflects the release of sweet-smelling, because breast milk is high in lactic bilirubin as excessive red blood cells begin their acid, which reduces the amount of putrefactive breakdown. organisms in the stool. A newborn who receives A newborn has an equally high white blood cell formula usually passes two or three bright yellow count at birth, about 15,000 to 30,000 cells/mm3. stools a day. These have a slightly more noticeable Values as high as 40,000 cells/mm3 may be seen if odor, compared with the stools of breastfed babies. the birth was stressful. Urinary System Respiratory System The average newborn voids within 24 hours after birth. A A first breath is a major undertaking because it requires a newborn who does not take in much fluid for the first 24 tremendous amount of pressure (about 40 to 70 cm H2O). It hours may void later than this, but the 24-hour point is a is initiated by a combination of cold receptors; a lowered good general rule. Newborns who do not void within this time partial pressure of oxygen (PO2), which falls from 80 to as should be examined for the possibility of urethral stenosis or low as 15 mm Hg before a first breath; and an increased absent kidneys or ureters. partial carbon dioxide pressure (PCO2), which rises as high A single voiding in a newborn is only about 15 mL as 70 mm Hg before a first breath. and may be easily missed in a thick diaper. Specific All newborns have some fluid in their lungs from gravity ranges from 1.008 to 1.010. The daily intrauterine life that will ease the surface tension on urinary output for the first 1 or 2 days is about 30 to alveolar walls and allow alveoli to inflate more easily 60 mL total. By week 1, total daily volume rises to than if the lung walls were dry. About a third of this about 300 mL. The first voiding may be pink or fluid is forced out of the lungs by the pressure of dusky because of uric acid crystals that were vaginal birth. Additional fluid is quickly absorbed by formed in the bladder in utero; this is an innocent lung blood vessels and lymphatics after the first finding. breath. Once the alveoli have been inflated with a first Immune System breath, breathing becomes much easier for a baby, Because they have difficulty forming antibodies against requiring only about 6 to 8 cm H2O pressure. Within invading antigens until about 2 months of age, newborns are 10 minutes after birth, most newborns have prone to infection. This inability to form antibodies is the established a good residual volume. reason that most immunizations against childhood diseases A newborn who has difficulty establishing are not given to infants younger than 2 months of age. respirations at birth should be examined closely in Newborns do have some immunologic protection, because the postpartal period for a cardiac murmur or other they are born with passive antibodies (immunoglobulin G) indication that he or she still has patent fetal cardiac from their mother that crossed the placenta. In most structures, especially a patent ductus arteriosus. instances, these include antibodies against poliomyelitis, measles, diphtheria, pertussis, chickenpox, rubella, and Gastrointestinal System tetanus. Newborns are routinely administered hepatitis B Although the gastrointestinal tract is usually sterile at birth, vaccine during the first 12 hours after birth to protect against bacteria may be cultured from the intestinal tract in most this disease. babies within 5 hours after birth and from all babies at 24 hours of life. Most of these bacteria enter the tract through Neuromuscular System the newborn’s mouth from airborne sources. Others may Mature newborns demonstrate neuromuscular function by come from vaginal secretions at birth, from hospital bedding, moving their extremities, attempting to control head and from contact at the breast. Accumulation of bacteria in movement, exhibiting a strong cry, and demonstrating the gastrointestinal tract is necessary for digestion and for newborn reflexes. Limpness or total absence of a muscular the synthesis of vitamin K.