Maternal Postpartum Period Review PDF

MATERNAL REVIEWER PRE-FINAL **POSTPARTUM PERIOD** - - - - Care during puerperium: - - - - - - \- the return of the uterus to its normal size after childbirth 3 processes involved in involution 1\. muscle fiber contraction : uterus firmly contracts to control bleeding f...

MATERNAL REVIEWER PRE-FINAL **POSTPARTUM PERIOD** - - - - Care during puerperium: - - - - - - \- the return of the uterus to its normal size after childbirth 3 processes involved in involution 1\. muscle fiber contraction : uterus firmly contracts to control bleeding from area of placental attachment 2\. catabolism : enlarged muscle cells of the uterus experience catabolic changes in protein cytoplasm that reduce the size of each cells 3\. regeneration : endometrium is generated within 2-3 weeks, except for the placental site, which is healed and regenerated approximately 6 weeks. Psychological Changes - - - **PHYSIOLOGY OF PUERPERIUM : Specific body changes** - - 1. palpated after delivery ***below the umbilicus,*** the uterus regresses approximately 1 fingerbreadth (1cm) per day until by the end of the **2^nd^ week postpartum , it is a pelvic organ** and cannot be palpated through the abdominal wall. 2. The endometrial surface is sloughed off as lochia, in three stages: **B. CERVIX** : flabby immediately after delivery; closes slowly 1\. Admits one fingertip by the end of one week after delivery. 2\. Shapes of external os changed by delivery from round to slitlike opening. **C. VAGINA/ PERINEUM** 1\. Edematous after delivery. Inspect episiotomy daily for normal healing; observe for **redness, edema, ecchymosis, discharge approximation (REEDA) , and hematoma.** 2\. May have small lacerations. 3\. Smooth-walled for 3-4 weeks, then rugae appear **D. OVULATION/MENSTRUATION** 1\. First cycle is usually anovulatory. If not lactating, menses may resume in 6- 10 wks, ave of 4-6 weeks. 2\. If lactating, menses less predictable ; may resume in 12-24 weeks. **E. BREASTS** **1. NON LACTATING WOMAN** a\. Prolactin levels fall rapidly. b\. May still secrete colostrums for 2-3 days. c\. Engorgement of breasts tissue resulting from temporary congestion of veins and circulation occurs on third day , lasts 24- 36 hours, usually resolves spontaneously. d\. Client should wear tight bra to compress ducts & use cold applications to reduce swelling. - **a.** High level of **prolactin** immediately after delivery of placenta continued by frequent contact with nursing baby. **b.** Initial secretion of **colostrums**, with increasing amount of true breast milk appearing bet. 48- 96 hours**.** **c. Milk " let down" reflex** caused by oxytocin from posterior pituitary gland released by sucking**.** d\. Successful lactation results from complex interaction of infant sucking reflexes & the maternal production and let down of milk. Breast feeding - - - \- helps establish normal intestinal flora and has a laxative effect that assists in the passage of meconium. The 3 E's in breastfeeding 1. 2. 3. Advantages : - - - - - - - - - - - Disadvantages : - - - - - - Positions for feeding infants: 1. Cradling 2. Football hold 3. Lying down 4. Across the lap Signs of good positioning are: - Baby in line with ear, shoulder and hip in a straight line - Close to the mother's body so the baby is brought to the breast rather than the breast taken to the baby - Baby is supported at the head, shoulders, and if newborn the whole body is supported - Baby is facing breast with the baby's nose close as possible to the nipple **Signs of good attachment** a. Areola more visible above than below the mouth b. Mouth wide open c. Chin touching breast d. Lower lip turned outward II\. ABDOMINAL WALL/ SKIN A. May need 6 weeks to re establish good muscle tone. Sexual intercourse can be resumed. B. Stretch mark gradually disappears or fade to silvery appearance. - **III. CARDIOVASCULAR SYSTEM/ CIRCULATORY SYSTEM** a. Normal blood loss in delivery of single infant is from 500 cc up to 1000 cc for Ceasarean section and 300cc to 500cc in vaginal birth. b. Hematocrit usually returns to prepregnancy value within 4-6 weeks c. WBC count increases. d. Increased clotting factors remain for several weeks \> risk for problems with thrombi 4. Inspection of lower extremities Varicosities (varicose veins) Are swollen veins just below the skin caused by the increase in blood during pregnancy resulting from the increase of hormone progesterone, which also softens the tissues of the veins, and the weight of the growing uterus putting pressure on the veins to the legs and slowing the flow of blood. Some have blue or purple spot Some veins are bulging - Edema - Also water retention and swollen limbs - Swollen feet, ankles, legs and hands are common symptoms of pregnancy. You may notice the rings on your fingers feel tight. This swelling happens when the body retains water, which is caused by a couple of changes in the body during pregnancy. If you suffered from water retention during your pregnancy, it may last for a few days after you deliver the baby as your hormones return to normal. The swelling in your legs and feet will reduce as you pass urine and flush the water out of your body - Milk leg / phlegmasia alba dolens -- is classical puerperal thrombophlebitis involving the lower extremities - Occasionally reflects arterial spasm, causes a pale, cool extremity with diminished pulsation - Common during early puerperium as the consequence of inappropriate contact between the cuff and the delivery table leg holders 5\. Early ambulation **IV. URINARY SYSTEM** A. May have difficulty voiding in immediate postpartum periods due to urethral edema. B. Mark diuresis begins within 12 hours of delivery; increase vol of urinary output & perspiration C. Lactosuria in nursing mothers D. Slight proteinuria during 1-2 days of involution \- full bladder is as hard or firm area just above the symphysis pubis \- during pregnancy as much as 2000ml-3000ml excess fluid accumulates in the body Urine output - Check for bladder distention of unable to void (risk for UTI) - Apply warm compress on hypogastric area - Difficulty of urination may be caused by traumatized urinary meatus during labor and delivery - Full bladder displaces the uterus up and to the side, resulting in uterine atony or inability of the uterus to contract and this is the primary cause of excessive bleeding **HORMONAL SYSTEM** \- levels of HCG and HPL (human placental lactogen) are almost negligible by 24 hours \- FSH is low for about 12 days and rises to initiate a new menstrual cycles - HPL -- HELPS PREPARE THE BODY FOR BREASTFEEDING. IT ALSO REGULATES METABOLISM AND INSULIN SENSITIVITY TO MAKE SURE THE FETUS GETS ENOUGH NUTRIENTS. V. GASTROINTESTINAL TRACT 1\. Mother usually hungry after delivery; good appetite is expected. 2\. May still experience constipation from lack of muscle tone in abdomen and intestinal tract, & perineal soreness. **VI. VITAL SIGNS CHANGES** **TEMPERATURE:** slightly increased during the first 24 hours after birth because of dehydration that occurred during labor. If she receives adequate fluid during the first 24 hrs, temp elevation will return to normal. **BLOOD PRESSURE:** If decreased= BLEEDING; If elevated = to 140/90 mmHg = Pregnancy Induced hypertension, a serious complication of puerperium. **PULSE:** is slightly slower than normal due to the increased stroke vol brought about by the increasing blood vol returning to the heart. As diuresis diminished blood vol & causes blood vol to fall, the **pulse rate increases,** and by the 1^st^ week, it will be normal. **POST PARTUM ASSESSMENT** 1. Check fundus frequently and massage gently if fundus is not firm 2. Inspect perineum frequently for visible signs of bleeding. a\. note color, amount and odor of the lochia b\. count the number of pads that are saturated in each 8-hour period. 3\. Assess bladder. Birth trauma, anesthesia, and pain from lacerations and episiotomy 4. Assess vital signs 5. Assess breast engorgement and condition of nipples if breast feeding. 6. Assess bladder and bowel elimination. NURSING INTERVENTIONS FIRST HOUR AFTER DELIVERY (4th stage of labor) Evaluate woman's v/s every 15minutes Evaluate fundal height Inspect perineum for signs of bleeding including hematoma formation Evaluate the amount of vaginal bleeding. **B. PERINEAL CARE** 1. Teach out women to carry out perineal care. 2. Sitz bath may be used for the same purpose. **C. VOIDING** **D. BREAST CARE** 1. Inspect nipples for reddening, erosions or fissures. 2. Teach woman to wash her breast with warm water and NO soap. E. DIET AND ELIMINATION Emphasize food high in iron, protein and vitamins to aid the healing the healing process. Foods high in fiber will help reestablish normal bowel habits. Hemmorhoids and episiotomy and laceration pain may cause the woman to delay her first bowel movement. Promoting frequent ambulation, ensuring adequate fluid intake and providing diet with fresh fruits and fibers encourage regular bowel elimination. Hygiene - Advise regular perineal care - After delivering the baby, the perineum must be kept clean. Lochia may drain for up to four weeks, so pads should be changed frequently: - Take a bath or a shower once or twice daily. A sitz bath should be used after every [bowel](http://www.emedicinehealth.com/script/main/art.asp?articlekey=2508) movement. A sitz bath involves sitting in shallow water, only deep enough to cover the hips and buttocks. - - Urinating can be painful after delivery. Squirting warm water (or guava decoction) over the perineum during urination may ease the pain. When finished urinating, gently pat the perineum dry. - May also use betadine feminine wash Bowel movement - Assessment of bowel, assess the patient's bowel sounds - Assess return of bowel function - Assess for flatus - Assess for color and consistency **F. EXERCISE** 1. Toe stretch 2. Kegel's exercise **G. REST AND AMBULATION** **H. RESUMPTION OF SEX** 1. Healing occurs within 2-4 weeks 2. Intercourse may be resumed when perineal and uterine wounds have healed. **MATERNAL CONCERNS AND FEELINGS IN THE POST PARTAL PERIOD** 1. Abandonment 2. Disappointment Postpartal blues  **POSTPARTAL PSYCHOSOCIAL CHANGES** 1. **ADAPTATION TO PARENTHOOD** MOTOR SKILLS - New parents must learn new physical skills to care for infant ( eg. feeding, holding, burping, changing diapers, skin care) ATTACHMENT SKILLS A. **BONDING:** the development of a caring relationship with the baby. Behaviors include: a\. Claiming: identifying the ways in which the baby looks or acts like members of the family. **Rubin's Post partum phases of regeneration** **[Taking-in Phase: First 3 days]** **-Mother focuses on her own primary needs, such as sleep and food** **-This phase is not an optimum time to teach the mother about baby care** **[Taking-hold Phase: Days 3-10]** - **The woman is more in control of independence** - **The woman begins to assume the tasks of mothering** - **This phase is an optimum time to teach the mother about baby care** **[Letting-go Phase]** - **Mother may feel deep loss over separation of the baby from the part of the body and may grieve over the loss \-\-\--Mother may be caught in the dependent/independent role, wanting to make decisions** **[The Newborn]** **[PROFILE OF THE NEWBORN]** - Newborn Period / Neonatal Stage -- from birth to 4 wks or 28 days. - Neonate -- newborn infant APGAR SCORE - was devised in 1952 by [Dr. Virginia Apgar](http://en.wikipedia.org/wiki/Virginia_Apgar) as a simple and repeatable method to quickly and summarily assess the health of [newborn](http://en.wikipedia.org/wiki/Newborn) children immediately after [birth](http://en.wikipedia.org/wiki/Childbirth). - Apgar was an [anesthesiologist](http://en.wikipedia.org/wiki/Anesthesiologist) who developed the score in order to ascertain the effects of [obstetric](http://en.wikipedia.org/wiki/Obstetrics) [anesthesia](http://en.wikipedia.org/wiki/Anesthesia) on babies. - Evaluates the newborn baby on five simple criteria on a scale from zero to two, then summing up the five values thus obtained. - The resulting Apgar score ranges from zero to 10. - The five criteria are summarized using words chosen to form (Appearance, Pulse, Grimace, Activity, Respiration). **Interpretation of Score**: - The test is gen done at 1 and 5 mins. after birth, & may be repeated later if the score remains low. **. The FIRST APGAR score detects cardio- respiratory nervous functioning of the NB.** **b. The SECOND APGAR score is used for planning nursing care; to determine the NB adjustment to extrauterine life.** - Result: Scores 3 and below - critically low- medical attention needed; needs resuscitation 4 to 6 fairly low-suctioning & oxygenation needed 7 to 10 generally normal/good --needs only admisssion care , no special care **New Ballard Score Maturational Assessment of Gestational Age** - The New Ballard Score is a set of procedures developed by **Dr. Jeanne L Ballard** to determine Gestational Age through neuromuscular and physical assessment of a newborn fetus. - Physical characteristics are also key in determining gestational age. **Anthropometric measurement** - A. WEIGHT 1\. Ave bet 2750g and 4000g (6-9 lb) at term. 2\. under 2750 g (5 1/2 lb): Small for gestational age (SGA) 3\. Over 4100 g (9 lb): large for gestational age. 4\. Initial loss of 5%-10% of body weight normal during first few days; should be regained in 1-2 wks. - **B. LENGTH** 1\. Ave 46 -- 55.9 cm ( 18-22in) 2\. Under 45.7 cm (18 in); SGA 3\. Over 55 cm ( 22 in) :LGA **C. HEAD CIRCUMFERENCE** 1\. Ave circumference 33 -- 35.5 cm ( 13- 14 in); equal to or 2-3 cm slightly larger than chest; remeasure after several days if significant molding or **caput succedaneum present.** 2\. Under 31.7 cm ( 12in): **Microcephaly/SGA** 3\. Over 36.8 cm ( 14 in): **Hydrocephaly / LGA** **D. CHEST CIRCUMFERENCE** Average is 30-33cm. (12-13 inches) or 1.9 cm (3/4 in) less than head. - E**. ABDOMEN** 1\. Shape -- cylindrical protrudes slightly, moves synchronously with chest in respiration. **NEWBORN SCREENING** Profile of a Newborn 1. HEAD - Disproportionately larger than the body - ¼ larger than the body - In adult head 1/8: body Common features found: 1. Fontanelles 2. Sutures 3. Molding 4. Caput Succedum 5. Cephalhematoma 6. Craniotabs FONTANELS (Soft spot) - A space or opening where skull bones join - soft spot where sutures cross meet - Too easily felt or identified - Should be flat and open; enlarged or bulging may indicate **increased intracranial pressure**, sunken often indicates **dehydration.** 2 types: 1. Anterior Fontanel -- diamond shaped ; closes in 12-18 month 2. Posterior Fontanel- triangular shaped; closes in 2-3 months 1. Anterior Fontanel Is located at the junction of two parietal bones and the two fused frontal bone. It is diamond shape Measures 2-3 cm in length Closes at 12-18 mos. 2.Posterior Fontanel - Located at the junction of parietal bones and the occipital bones - Triangular in shape - 1 cm in length - Closes at 2-3 mos SUTURES - Skull sutures - The separating line of the skull - May override at birth because of extreme pressure exerted by the passage of fetus thru the canal. - Overriding of sutures is a normal phenomenon MOLDING ( Dunce Cap) - Overlapping of skull bones caused by compression during labor and delivery. - The part of the infant's head (vertex) that engages in the cervix - The head molded to fit in the cervical contour - At birth appears prominent - Head becomes assymmetrical - Common in primi baby CAPUT SUCCEDANEUM - swelling of the soft tissues of the scalp because of pressure from the cervix against presenting part. Usually caused by continuous pressure of undelivered head against the partially dilated cervix. - Edema of the presenting part (head) - Edema is gradually absorbed - Disappears at **3^rd-4th^ day** of life without intervention. - Requires no treatment CEPHALHEMATOMA - A collection of blood beneath the periosteum of the skull bone and the bone itself caused by the rupture of periosteum capilliary due to the pressure at birth. - Occurs 24 hours after birth - Prolonged labor and tight passage (bruising) - Discolored- black, blue, or red (accumulation of blood) - Absorbed and disappears after several weeks - Not harmful, requires no treatment CRANIOTABS - Is the localized softening of the cranial bones - Pressure of fetal skull against the pelvic bones - Corrected after few months - Normal in newborn, pathologic in older child- faulty metabolism or kidney dysfunction 2. EYES Newborns cry tearlessly- immature lacrimal duct, matures at 3 mos. Color of eyes gray or blue Sclera- blue, thinness Permanent color 3-12 mos ASSESSMENT OF THE EYES - Lay on supine position, lift the head - Eyes should appear clear without redness or purulent discharge - Administer antimicrobial ointment to prevent: 1. Chlamydia infection 2. Opthalmia neonatorum (gonorheal conjunctivitis)- purulent discharge - Redspot or red ring- subconjunctival hemorrhage, needs no treatment, absorbed at 2-3 weeks - Edema- orbit of the eyelids, 2-3 days, eliminated by the kidneys - Cornea round and proportionate in size, larger cornea -- glaucoma - Pupil- dark, white- cataract - May have Strabismus eyes (cross eyes) or Myetagmus eyes (twitch) , should not be persistent up to **4-6 mos.** - Chinky eyes and slanted eyes- Down's syndrome or Mongolian syndrome Chlamydia, Glaucoma, Edema, Opthalmia neonatorum, Trabismus and Twitch   3. EARS - Newborn's ears are not completely formed, the pinna tends to bend easily. - The level of the top part of the external ear should be in line with inner canthus of the eyes. - Larger for the face - Normally flat - Flaring- obstruction of airway with mucus - Test for choanal atrisia- blockage of nose ( close newborn's mouth, compress one nare, assess for discomfort or stress) 5. MOUTH - Opens evenly when crying - Epstein Pearl/s- one or two small round, glistening, well circumscribed cyst on the palate as a result of the extra load of calcium during pregnancy. - Epithelial Pearl- benign inclusion cyst, seen on the gum margin. No tx. - Natal teeth- 1-2 teeth, if loose should be extracted **GROWTH AND DEVELOPMENT OF INFANT** **WEIGHT**- @ 4-6 mos.- doubles birth wt. \- @ 1 yr- triples wt. 1 lb per month 4-6 mos.- 1 yr- F- 9.5 kg -M- 10 kg **HEIGHT**- 1 year- 50% increase in ht, use measuring board **HEAD CIRCUMFERENCE-** Increases due to brain development, 2/3 adult size- end of the yr., asymmetry of head- malpositioning during sleep **BODY PROPORTION**-Lower jaw is prominent, chest circumference- head and chest are even (6mos up to 12 mos.), abdomen- remains protuberant, cervical, thoracic and lumbar spine develops- in preparation for lifting head, sitting, and walking. Lengthening of lower extremities (last 6 mos.) **BODY SYSTEMS**: **HR**- 100-120 B/M **B/P**- 100/60 mmHg **Hg**- 2-3 mos. decreased physiologic anemia destruction of fetal RBC(3 mos life span) and new cells are not yet produce, preventable, give oral iron **RR**- 20-30 b/m, prone resp. infection, severe than adult due to small anatomical and inefficient mucus production **GIT**: 1-2 mos.- deficient in amylase- complex carbohydrates 1 yr- decreased lipase -- saturated fat Swallowing coordination until 6 mos. Extrusion reflex present until 3-4 mos **LIVER**- immature, iadequate conjugation of drugs 6. Neck - Short, chubby, with creased skin fold - Congenital torticolis- rigidity of the neck, injury to sternocleidomastoid muscle during birth 7. CHEST - Looks small because infant's head is larger - Breast engorgement (M&F)- hormone, subsides after a week - Witch's milk- a thin watery fluid secreted by newborn's breasts, subsides without treatment - 2 inches less than the head - Symmetrical - RR- 30-60 b/m - Supernumerary nipple- found below and in line normal nipple, maybe removed later for cosmetic reason - Retraction- chest in drawing should be absent 8. ABDOMEN - Protuberant - Scaphoid or sunken- missing abdominal contents or diaphragmatic hernia - Bowel sound present after 1 hour - Umbilical cord -Wharton's jelly- a gelatinous substance within the umbilical cord. Its main function is to insulate and protect the umbilical cord in the womb. \- cord clamp \- 1^st^ day- dry and shrink, brown color \- 2^nd^ -- 3^rd^ day- black color \- **6^th^-10^th\ day-^** ^breaks\ freely^ 9\. ANAL AND GENITAL AREA - Inspect to ensure that it is that it is present, patent, and not covered by a membrane (IMPERFORATE ANUS) - How?.. Gloved and lubricated little finger, insert the tip in the anus - Meconium- first stool should be passed out in the first 24 hours, imperforate anus or meconeum ileus 9. GENITALIA A. MALE GENITALIA - Scrotum in most male newborn is edematous and rugae - Both testes should be present in scrotum - 2 cm long - Urethral opening on ventral surface - Urethral meatus on the dorsal aspect 3. **ACROCYANOSIS --** bluish discoloration of the extremities 4. **CUTIS MARMORATA --**normal , mottled color of the skin- exposure to cold temp\|  **5. Harlequin color change** -- pink color of half side of the body **6.Milia --** tiny white ,hard, pale keratinous nodule formed on the cheeks, chin and nose typically by a blocked sebaceous gland 7\. JAUNDICE yellowing of the skin or whites of the eyes, arising from excess of the pigment bilirubin caused by hyperbilirubinemia. a\. Physiologic --occurs 2^nd^--3^rd^ wk of life ( Phototherapy) b\. Pathologic -- occurs 24 hours after delivery (RH incompatibility) 8\. **BIRTHMARKS** - marks on the skin of a lot of newborn babies - A. Mongolian spots -- blue- black macule found at the buttocks area - B. Telegiectatic nevus / Stork bite -- flat deep pink in nape / eyelids. - C. Nevus flammeus / Port wine stain -- flat purple red present at birth in face or extremities. - D. Nevus Vasculosus /Strawberry hemangioma --red rubbery nodules with rough surface. **CRYPTORCHIDISM** - males with one or both undescended testes **Causes:** 1. Agenesis- absence of one organ 2. Ectopic testes- closed scrotal sac, testes cannot enter/ descend 3. Undescended testes- too short vas deferens **IMMUNE SYSTEM-** Functional at 2 mos., IgG and IgM after 1 year Ability to adjust to cold at 6 mos **Shivering present-** increase muscle activity, providing warmth **Brown fat-** protect newborn from cold decreases in 1 year **Kidneys, endocrine immature**.. More intracellular fluid 40% protection from dehydration **TEETH**- 6 mos.- first tooth eruption, followed by new one monthly Natal teeth- baby's born with Neonatal teeth- erupts at 4 weeks Mandibular central incisor **The Normal Newborn Assessment and Care** **Three transition phases** - Phase One: the first hour - Phase Two: from one to three hours - Phase Three: from two to 12 hours **Priorities in first hour** - Cardiovascular assessment and support - Thermoregulation - Assessment and support of blood glucose - Identification - Observing urinary/meconium passage - Observing for major anomalies and for apparent gestational age concerns **APGAR ASSESSMENT** - One and five minutes - Meant to identify the need for neonatal resucitation **Additional signs of respiratory distress** **Maintaining thermoregulation** - Referred to as maintaining a neutral thermal environment - Heat loss is minimal - Oxygen consumption needs are at their lowest - Hypothermia can cause - Hypoglycemia - Increased oxygen needs **Four mechanisms of heat loss\ and corresponding interventions** - **Evaporation: *this is the loss of heat from a newborn's wet skin to the surrounding air*** - **Dry infant immediately** - **Conduction: *this is a the loss of heat when the newborn lies on a cold surface*** - **Place on mothers body skin to skin** - **Convection: *this is the loss of heat from the newborn's skin to the surrounding air*** - **Cover with a blanket, wear a cap** - **Radiation: *radiation is the transfer of heat between two objects that are not in direct contact with each other*** - **Keep away from cold windows and cold objects** **Vital Sign Normals** - 97.7-98.6 F (36.5-37 C) - 110-160 - A soundly sleeping baby can go to 80 bpm - A crying baby may be as high as 180 - 30-60 **Voids and Stools** - Document from the moment of birth - Urination sometimes missed in early minutes - Generally expect both within the first 24 hours - One really wet diaper per day of age until milk is fully in. **Observation for Gestational Age** - Thorough assessment with Ballard Scale done later - A quick assessment is done in the delivery room - This enables infants earlier admission to the nursery and anticipatory intervention to the problems of pre and post term infants **Quick Assessment of Gestational Age** - Skin - Vernix - Hair - Ears - Breast tissue - Genitalia - Sole Creases - Resting Posture **Hypoglycemia** - Criteria vary from source to source - LPN book says \ - Bulb suctioning: RN 731 LPN 286 - Umb cord care: RN 733 LPN 219 - Heel Sticks: RN 741-43 LPN219 - Circumcision: RN 755 See patient teaching page 757 LPN 290 NEWBORN REFLEXES - **Reflex or reflex action** is an involuntary and nearly instantaneous movement in response to a [stimulus](http://en.wikipedia.org/wiki/Stimulus_(physiology)). It helps identify normal brain and nerve activity. A. **FEEDING REFLEXES** 1\. ROOTING REFLEX- TURNS HEAD TO THE DIRECTION OF THE STIMULI; OPENS LIPS TO SUCK WHEN OBJECT TOUCHES HIS CHEEKS OR MOUTH \- REFLEX NEEDED FOR LOCATING FOOD - DISAPPEARS - 3-4 MONTHS BUT MAY EVEN DISAPPEAR UNTIL 7 MONS. - 2\. SUCKING REFLEX -- ANYTHING THAT TOUCHES THE LIPS IS SUCKED - \- NEEDED FOR PHYSIOLOGIC & PSYCHOLOGIC NEEDS - DISAPPEARS - BY 6 MONTHS OR EARLIER - 3.SWALLOWING REFLEX -- SWALLOWS ANYTHING THAT TOUCHES THE POSTERIOR TONGUE. - 4\. EXTRUSION REFLEX ( SPITTING UP)- ANYTHING THAT TOUCHES THE ANTERIOR TONGUE IS EXTRUDED; \- ALSO A PROTECTIVE REFLEX THAT PROTECTS INFANT FROM SWALLOWING INEDIBLE SUBSTANCES - DISAPPEARS AT ABOUT 4- 6 MONTHS **extrusion reflex** - a normal response in infants to force the tongue outward when it is touched or depressed. The reflex begins to disappear by about 3 or 4 months of age B. **Protective Reflexes** - 2\. SNEEZING,COUGHING REFLEX -- PROTECTS/ CLEARS THE AIRWAY - 3\. YAWNING REFLEX- act of opening the mouth wide ;PROTECTS CELLS FROM DEPLETED OXYGEN - 4\. GAGGING- LIFELONG REFLEX TO PROTECT AIRWAY C. **MORO/STARTLE REFLEX** - EMBRACING MOTION OF THE ARMS; ABDUCTION FOLLOWED BY ADDUCTION OF THE ARMS AND LEGS IN RESPONSE TO A SUDDEN JARRING OF THE CRIB, FALLING SENSATIONS , & A LOUD NOISE. - or Moro reflex after its discoverer, pediatrician Ernst Moro. - THIS IS THE MOST SIGNIFICANT INDEX OF THE CNS INTEGRITY ( IT'S ABSENCE INDICATES BRAIN DAMAGE OR CNS PROBLEMS - DISAPPEARS-BY THE END OF THE 4TH OR 5TH MONTH WHEN THE INFANT CAN ALREADY ROLL AWAY. D. **BABINSKI REFLEX** - FANNING OR HYPEREXTENSION OF THE TOES WHEN THE SOLE IS STROKED FROM THE HEEL UPWARDS; DUE TO CNS IMMATURITY - MOST ACUTE IN THE FIRST MONTH & GRADUALLY DISAPPEARS UNTIL THE 12TH MONTH **Testing plantar reflex**