NCMA-REVIEWER-MIDTERMS PDF

**Week 7: INTRAPARTAL CARE (ASSESSMENT OF THE LABORING MOTHER)** **THEORIES OF LABOR ONSET** Labor normally begins when a fetus is sufficiently mature to cope with extrauterine life yet not too\ large to cause mechanical difficulty with birth. Several theories including a combination of factors\ o...

**Week 7: INTRAPARTAL CARE (ASSESSMENT OF THE LABORING MOTHER)** **THEORIES OF LABOR ONSET** Labor normally begins when a fetus is sufficiently mature to cope with extrauterine life yet not too\ large to cause mechanical difficulty with birth. Several theories including a combination of factors\ originating from both the woman and fetus have been proposed to explain why progesterone withdrawal begins: Uterine muscle stretching, which results in release of prostaglandins\ Pressure on the cervix, which stimulates the release of oxytocin from the posterior pituitary\ Oxytocin stimulation, which works together with prostaglandins to initiate contractions\ Change in the ratio of estrogen to progesterone (increasing estrogen in relation to progesterone,\ which is interpreted as progesterone withdrawal)\ Placental age, which triggers contractions at a set point\ Rising fetal cortisol levels, which reduces progesterone formation and increases prostaglandin\ formation\ Fetal membrane production of prostaglandin, which stimulates contraction **Age of viability:** 20 weeks or 22 weeks of amenorrhea (WHO)\ **Extremely Preterm:** 23-28 weeks\ **Preterm:** less than 259 days (37 weeks)\ **Term:** 257 days-293 days (37-41 weeks)\ **Post-term:** 294 days (42 weeks)  **SIGNS OF LABOR** **[Lightening] -** In primiparas, lightening, or descent of the fetal presenting part into the pelvis, occurs approximately 10 to 14 days before labor begins. Lightening gives a woman relief from the diaphragmatic pressure and shortness of breath that she has been experiencing and "lightens" her load. **[Increase in Level of Activity] -** This increase in activity is related to an increase in epinephrine release initiated by a decrease in progesterone produced by the placenta. This additional epinephrine prepares a woman's body for the work of labor ahead. **[Slight loss of weight] -** As progesterone level falls, body fluid is more easily excreted from the body. This increase in urine production can lead to a weight loss between 1 and 3 pounds. **[Braxston Hicks Contraction] -** woman usually notices extremely strong Braxton Hicks contractions. **[Ripening of the cervix] -** At term, the cervix becomes still softer (described as "butter-soft"), and it tips forward. Cervical ripening this way is an internal announcement that labor is very close at hand. **SIGNS OF TRUE LABOR** **[Uterine Contraction]** - The surest sign that labor has begun is productive uterine contractions. **[Show]** - As the cervix softens and ripens, the mucus plug that filled the cervical canal during pregnancy (operculum) is expelled. The exposed cervical capillaries seep blood as a result of pressure exerted by the fetus. This blood, mixed with mucus, takes on a pink tinge and is referred to as "show" or "bloody show." **[Rupture of Membranes]** - Labor may begin with rupture of the membranes, experienced either as a sudden gush or as scanty, slow seeping of clear fluid from the vagina. **[Risks]** - intrauterine infection and prolapse of the umbilical cord, which could cut off the oxygen supply to the fetus. **COMPONENTS OF LABOR** A successful labor depends on four integrated concepts: 1\. A woman's pelvis (**[the passage]**) is of adequate size and contour. 2\. The passenger (**[the fetus]**) is of appropriate size and in an advantageous position and presentation. 3\. The powers of labor (**[uterine factors]**) are adequate. (**[The powers of labor are strongly influenced by the woman's position during labor.)]** 4\. A woman's psychological outlook is preserved, so that afterward labor can be viewed as a positive experience. **1. PASSAGE** The passage refers to the route a fetus must travel from the uterus through the cervix and vagina to the external perineum. Two pelvic measurements are important to determine the adequacy of the pelvic size: - diagonal conjugate (the anteroposterior diameter of the inlet) and the transverse diameter of the outlet. - At the pelvic inlet, the anteroposterior diameter is the narrowest diameter; at the outlet, the transverse diameter is the narrowest. A diagram of pelvic inlet Description automatically generated **2. PASSENGER** - The passenger is the fetus. The body part of the fetus that has the widest diameter is the head, so this is the part least likely to be able to pass through the pelvic ring. Whether a fetal skull can pass depends on both its structure (bones, fontanelles, and suture lines) and its alignment with the pelvis. **Molding** - is a change in the shape of the fetal skull produced by the force of uterine contractions pressing the vertex of the head against the not-yet-dilated cervix.\ **Engagement** -- refers to the settling of the presenting part of a fetus far enough into the pelvis to be at the level of the ischial spines, a midpoint of the pelvis. **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 engagement). If the presenting part is above the spines, the distance is measured and described as minus stations, which range from 1 to 4 cm. If the presenting part is below the ischial spines, the distance is stated as plus stations (+1 to +4). At a +3 or +4 station, the presenting part is at the perineum and can be seen if the vulva is separated (i.e., it is crowning). **Fetal Attitude** - Attitude describes the degree of flexion a fetus assumes during labor or the relation of the fetal parts to each other. A fetus in good attitude is in complete flexion: the spinal column is bowed forward, the head is flexed forward so much that the chin touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed onto the abdomen, and the calves are pressed against the posterior aspect of the thighs.  A diagram of a fetus in the womb Description automatically generated\  **Descent** - means that the widest part of the fetus (the biparietal diameter in a cephalic presentation; the intertrochanteric diameter in a breech presentation) has passed through the pelvis inlet or the pelvic inlet has been proved adequate for birth.  **Fetal Lie** - Lie is the relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis of a woman's body; in other words, whether the fetus is lying in a horizontal (transverse) or a vertical (longitudinal) position. Diagram of a baby in the uterus Description automatically generated **TYPES OF FETAL PRESENTATION** **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). **A face presentation birth can result in birth injuries, such as:** - Asphyxia (oxygen deprivation) - Trauma to the face and head. - Spinal cord injuries. - Fetal heart rate issues. - Cerebral palsy and other brain injuries. - Breathing problems (due to tracheal and laryngeal injuries) - Fetal distress. - Facial bruising or swelling.  **2. Breech Presentation** - A breech presentation means that either the buttocks or the feet are the first body parts that will contact the cervix. Breech presentations occur in approximately 3% of births and are affected by fetal attitude. A good attitude brings the fetal knees up against the fetal abdomen; a poor attitude means that the knees are extended. Breech presentations can be difficult births, with the presenting point influencing the degree of difficulty. Three types of breech presentation (complete, frank, and footling) are possible. **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. **Possible causes:** - Grand multiparity (5 deliveries or more) - Uterine malformation - Twin pregnancy - Prematurity - Placenta previa - Foeto-pelvic disproportion A baby in the womb Description automatically generated **3. 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. **MECHANISM OF LABOR** **(CARDINAL MOVEMENTS)** - **Descent** - Descent is the downward movement of the biparietal diameter of the fetal head to within the pelvic inlet. Full descent occurs when the fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor. - **Flexion** - As descent occurs and the fetal head reaches the pelvic floor, the head bends forward onto the chest, making the smallest anteroposterior diameter (the suboccipitobregmatic diameter) present to the birth canal. - **Internal Rotation** - 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 transverse one) in line with the wide transverse diameter of the inlet. - **Extension -** he 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 head rotates (from the anteroposterior position it assumed to enter the outlet) back to the diagonal or transverse position of the early part of labor. This brings the aftercoming shoulders into an anteroposterior position, which is best for entering the outlet. The anterior shoulder is born first, assisted perhaps by downward flexion of the infant's head. - **Expulsion** - Once the shoulders are born, the rest of the baby is born easily and smoothly because of its smaller size. This movement, called expulsion, is the end of the pelvic division of labor **Uterine Contraction** - The mark of effective uterine contractions is rhythmicity and progressive lengthening and intensity. - **Phases** - A contraction consists of three phases: the increment, when the intensity of the contraction increases; the acme, when the contraction is at its strongest; and the decrement, when the intensity decreases - **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.  **\ 4. 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 **Week 8: STAGES OF LABOR AND DELIVERY, DANGER SIGNS OF LABOR** **STAGES OF LABOR** Friedman (1978), a physician who studied the process of labor extensively, used data to divide the first two stages of labor into phases: latent and active labor. I. **First Stage**\ Three separate divisions mark the first stage of labor: the latent, the active, and the transition phase. **A. Latent Phase** - Preparatory phase and ends when the cervical dilatation occurs. - Contractions - **mild and short** - **Lasting 20 to 40 seconds.** - Cervical effacement occurs during this time - Cervix dilates **from 0 to 3 cm.** - Duration - **6 hours in a nullipara and 4.5 hours in a multipara** **B. Active Phase** - Cervical dilatation occurs more rapidly, increasing from 4 to 7 cm. - Contractions grow stronger, lasting 40 to 60 seconds, - Interval - every 3 to 5 minutes. - Duration - 3 hours in a nullipara and 2 hours in a multipara. - Show (increased vaginal secretions) and perhaps spontaneous rupture of the membranes may occur during this time. - Cause true discomfort - Frightening time - Exciting time **C. Transition Phase** - Contractions reach their peak of intensity, occurring every 2 to 3min. - Duration of 60 to 90 seconds - Maximum cervical dilatation of 8 to 10 cm. - If the membranes have not previously ruptured or been ruptured by amniotomy, they will rupture as a rule at full dilatation (10 cm). - By the end of this phase, both full dilatation (10 cm) and complete cervical effacement (obliteration of the cervix) have occurred. - May experience intense discomfort, so strong that it is accompanied\ by nausea and vomiting. Because of the intensity and duration of the contractions, a woman may also experience a feeling of loss of control, anxiety, panic, or irritability. **CARE OF A WOMAN DURING THE FIRST STAGE OF LABOR** **Six major concepts to make labor and birth:** **1. Labor should begin on its own, not be artificially induced.** **2. Women should be able to move about freely throughout labor, not be confined to bed.** **3. Women should receive continuous support during labor.** **4. No interventions such as intravenous fluid should be used routinely.** **5. Women should be allowed to assume a nonsupine (e.g.,upright, side-lying) position for birth.** **6. Mother and baby should be together after the birth, with unlimited opportunity for breastfeeding.** **1. Respect Contraction Time** - Do not interrupt a woman who is in the middle of breathing exercises during labor because, once her concentration is disrupted, she will feel the extent of the contraction. **2. Promote Change of Positions** - Because the bed is the main piece of furniture in a birthing room, many women assume that they are expected to lie quietly in bed during labor. \- If medication such as a narcotic is given, educate a woman to remain in bed for approximately 15 minutes afterward to avoid a fall if she should become dizzy from the medication. While a woman is in bed, encourage her to lie on her side, preferably the left side. This position causes the heavy uterus to tip forward, away from the vena cava, allowing free blood return from the lower extremities and adequate placental filling and circulation. **3. Offer Support -** There is no substitute for personal touch and contact as a way to provide support during labor. Patting a woman's arm while telling her that she is progressing in labor, brushing a wisp of hair off her forehead, wiping her forehead **4. Respect and Promote the Support Person** - Admit a woman's support person to the birthing area and allow him or her to remain with a woman throughout the birth. Having someone with her during labor is important, because everything is new and unexpected. **5. Support a Woman's Pain Management Needs** Many women plan on using nonpharmacologic pain relief measures such as aromatherapy during labor. **II. Second Stage** - Is the period from full dilatation and cervical effacement to birth of the infant;\ uncomplicated birth, -this stage takes about 1 hour. 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 bowels. - Momentary nausea or vomiting. - Perspires and the blood vessels in her neck may become distended. - The perineum begins to bulge and appears tense. - Anus may become everted, and stool may be expelled. - 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. - All of her energy, her thoughts, her being are directed toward giving birth. - As she pushes, using her abdominal muscles to aid the involuntary uterine contractions, the fetus is pushed out of the birth canal **CARE OF A WOMAN DURING THE SECOND STAGE OF LABOR** **Full cervical dilatation to birth of the newborn:\ 1. Preparing the Place of Birth** - opening the sterile packs of supplies on waiting tables when the cervix has dilated to 9 to 10 cm. A table set with equipment such as sponges, drapes, scissors, basins, clamps, bulb syringe, vaginal packing, and sterile gowns, gloves, and towels can be left, covered, for up to 8 hours. Be certain that drapes and materials used for birth are sterile.\ **2. Positioning for Birth** - Women can choose a variety of positions for birth. At one time, the lithotomy position was the major position for birth, but it is no longer the position of choice in birthing rooms or alternative birth centers---although the labor beds in these locales have attached stirrups to allow birth in a lithotomy position. Alternative birth positions include the lateral or Sims' position, the dorsal recumbent position (on the back with knees flexed), semi-sitting, and squatting. - Because pushing becomes less effective in a lithotomy position, the top portion of the table should be raised to a 30-to 60-degree angle, so that the woman can continue to push effectively. Lying for longer than 1 hour in a lithotomy position leads to intense pelvic congestion. **3. Promoting Effective Second-Stage Pushing**\ - a woman should wait to feel the urge to push even though a pelvic examination has revealed that she is fully dilated. She should push with contractions and rest between them. Pushing is usually best done from a semi-Fowler's, squatting, or "all-fours" position rather than lying flat, to allow gravity to aid the effort. **4. Perineal Cleaning** - To remove vaginal or rectal secretions and prepare the cleanest environment for the birth of the baby, clean the perineum. with a warmed antiseptic such as Iodophor (cold solution causes cramping) and then rinse it with a designated solution before birth, according to the policy of the physician, nurse-midwife, or agency. - Always clean from the vagina outward (so that microorganisms are moved away from the vagina, not toward it), using a clean compress for each stroke. Be sure and include a wide area (vulva, upper inner thighs, pubis, and anus). **5. Introducing the Infant** - After the cord is cut, it is time for the new parents to spend some time with their newborn. Take the infant from the physician or nurse-midwife and wrap the 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; II. **Third Stage** - The placental stage, begins with the birth of the infant and ends with the delivery of the placenta. - Two separate phases are involved: placental separation and placental expulsion. - After the birth of an infant, a uterus can be palpated as a firm, round mass just inferior to the level of the umbilicus. After a few minutes of rest, uterine contractions begin again, and the organ assumes a discoid shape. It retains this new shape until the placenta has separated, approximately 5 minutes after the birth of the infant. A. **Placental Separation** - 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. - The following signs indicate that the placenta has loosened and is ready to deliver:\ - Lengthening of the umbilical cord\ - Sudden gush of vaginal blood\ - Change in the shape of the uterus\ - Firm contraction of the uterus\ - Appearance of the placenta at the vaginal opening - If the placenta separates first at its center and last at its edges, it tends to fold onto itself like an umbrella and presents at the vaginal opening with the fetal surface evident. Appearing shiny and glistening - this is called a Schultze presentation. Approximately 80% of placentas separate and present in this way. If, however, the placenta separates first at its edges, it slides along the uterine surface and presents at the vagina with the maternal surface evident. - It looks raw, red, and irregular, with the ridges or cotyledons that separate blood collection spaces showing; this is called a Duncan presentation. A simple trick of remembering the presentations is associating "shiny" with Schultze (the fetal membrane surface) and "dirty" with Duncan (the irregular maternal surface) - Bleeding occurs as part of the normal consequence of placental separation, The normal blood loss is 300 to 500 mL. B. **Placental Expulsion** - After separation, the placenta is delivered either by the natural bearing-down effort of the mother or by gentle pressure on the contracted uterine fundus by a physician or nurse midwife (Credé's maneuver). - Pressure must never be applied to a uterus in a noncontracted state, because doing so may cause the uterus to evert and hemorrhage. This is a grave complication of birth, because the maternal blood sinuses are open and gross hemorrhage could occur (Poggi, 2007). - If the placenta does not deliver spontaneously, it can be removed manually. With delivery of the placenta, the third stage of labor is complete. **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.\ **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. **MATERNAL AND FETAL RESPONSES TO LABOR** 1. **Physiologic Effects of Labor on a Woman** a. **Cardiovascular System** b. **Hemopoietic System**\ The major change in the blood-forming system that occurs during labor is the development of leukocytosis, or a sharp increase in the number of circulating white blood cells, possibly as a result of stress and heavy exertion. At the end of labor, the average woman has a white blood cell count of 25,000 to 30,000 cells/mm3, compared with a normal count of 5000 to 10,000 cells/mm3. c. **Respiratory System**\ Whenever there is an increase in cardiovascular parameters, the body responds by increasing the respiratory rate to supply additional oxygen. Total oxygen consumption increases by about 100% during the second stage of labor. Women adjust well to this\ change, which is comparable to that of a person performing a strenuous exercise such as\ running. It can result in hyperventilation. Using appropriate breathing patterns during labor can help avoid severe hyperventilation. d. **Temperature Regulation**\ The increased muscular activity associated with labor can result in a slight elevation (1° F) in temperature. Diaphoresis occurs with accompanying evaporation to cool and limit excessive warming. e. **Fluid Balance**\ Because of the increase in rate and depth of respirations (which causes moisture to be lost with each breath) and diaphoresis, insensible water loss increases during labor. Fluid balance is further affected if a woman eats nothing but sips of fluid or ice cubes or hard candy. Although not a concern in usual labor, the combination of increased fluid losses and decreased oral intake may make intravenous fluid replacement necessary if labor becomes prolonged. f. **Urinary System**\ With a decrease in fluid intake during labor and the increased insensible water loss,\ the kidneys begin to concentrate urine to preserve both fluid and electrolytes. Specific gravity may rise to a high normal level of 1.020 to 1.030. It is not unusual for protein (trace to 1) to be evident in urine because of the breakdown of protein caused by the increased muscle activity. Pressure of the fetal head as it descends in the birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling. g. **Musculoskeletal System\ **Relaxing, an ovarian-released hormone, has acted to soften the cartilage between bones. symphysis pubis and the sacral/coccyx joints softens h. **Gastrointestinal System**\ Inactive during labor, probably because of the shunting of blood to more life sustaining organs and also because of pressure on the stomach and intestines from the contracting uterus. Digestive and emptying time of the stomach become prolonged. Some women experience a loose bowel movement as contractions grow strong, similar to what they may experience with menstrual cramps. i. **Neurologic and Sensory Responses**\ The neurologic responses that occur during labor are responses related to pain\ (increased pulse and respiratory rate). At the moment of birth, the pain is centered on the perineum as it stretches to allow the fetus to move past it. 2. **Psychological Responses of a Woman to Labor** a. **Fatigue\ **By the time a date of birth approaches, a woman is generally tired from the burden of carrying so much extra weight. In addition, most women do not sleep well during the last month of pregnancy. Needs support person **b. Fear**\ Women appreciate a review of the labor process early in labor as a reminder that childbirth is not a strange, bewildering event but a predictable and well documented one. Explain that labor is predictable, but also variable, to limit this kind of fear. Be sure to explain that contractions last a certain length and reach a certain firmness but always have a pain-free rest period in between. **c. Cultural Influences\ **Cultural factors can strongly influence a woman's experience of labor. In the past, American women were accustomed to following hospital procedures and the medical model of care; therefore, they followed instructions during labor with few questions. Today, women are educated to help plan their care. In addition, every woman responds to cultural cues in some way. This makes her response to pain, her choice of nourishment, her preferred birthing position, the proximity and involvement of a support person, and customs related to the immediate postpartal period individualized. 3. **Physiologic Effects of Labor to a Fetus** a. **Neurologic System\ **Uterine contractions exert pressure on the fetal head - increased intracranial pressure on fetus. The fetal heart rate (FHR) decreases by as much as 5 beats per minute (bpm) during a contraction, as soon as contraction strength reaches 40 mm Hg. This decrease appears on a fetal heart monitor as a normal or early deceleration pattern. b. **Cardiovascular System**\ The ability to respond to cardiovascular changes is usually mature enough that the fetus is unaffected by the continual variations of heart rate that occur with labor---a slight slowing and then a return to normal (baseline) levels. During a contraction, the arteries of the uterus are sharply constricted and the filling of cotyledons almost completely halts. The amount of nutrients, including oxygen, exchanged during this time is reduced, causing a slight but inconsequential fetal hypoxia. c. **Integumentary System**\ The pressure involved in the birth process - minimal petechiae or ecchymotic areas on a fetus (particularly the presenting part). There may also be edema of the presenting part (caput succedaneum). d. **Musculoskeletal System**\ The force of uterine contractions tends to push a fetus into a position of full flexion, the most advantageous position for birth. e. **Respiratory System**\ The process of labor appears to aid in the maturation of surfactant production by alveoli in the fetal lung. The pressure applied to the chest from contractions and passage through the birth canal helps to clear it of lung fluid. For this reason, an infant born vaginally is usually able to establish respirations more easily than a fetus born by\ cesarean birth. **MATERNAL DANGER SIGNS** **1. High or Low Blood Pressure** Normally, a woman's blood pressure rises slightly in the second (pelvic) stage of labor because of her pushing effort. A systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg, or an increase in the systolic pressure of more than 30 mm Hg or in diastolic pressure of more than 15 mm Hg (the basic criteria for pregnancy- induced hypertension), should be reported. Just as important to report is a falling blood pressure, because it may be the first sign of intrauterine hemorrhage. **2. Abnormal Pulse** - Most pregnant women have a pulse rate of 70 to 80 bpm. This rate normally increases slightly during the second stage of labor because of the exertion involved. A maternal pulse rate greater than 100 bpm during the normal course of labor is unusual and should be reported. It may be another indication of hemorrhage. **3. Inadequate or Prolonged Contractions** - Uterine contractions normally become more frequent, intense, and longer as labor progresses. If they become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion (inertia). If this problem cannot be corrected, a cesarean birth may be necessary. A period of relaxation must be present between contractions so that the intervillous spaces of the uterus can fill and maintain an adequate supply of oxygen and nutrients for the fetus. As a rule, uterine contractions lasting longer than 70 seconds should be reported. **4. Pathologic Retraction Ring** - An indentation across a woman's abdomen, where the upper and lower segments of the uterus join, may be a sign of extreme uterine stress and possible impending uterine rupture. For this reason, it is important to observe the contours of a woman's abdomen periodically during labor. Fetal heartbeat auscultation automatically provides a regular opportunity to assess a woman's abdomen. **5. Abnormal Lower Abdominal Contour** - If a woman has a full bladder during labor, a round bulge on her lower anterior abdomen may appear. **This is a danger signal for two reasons:** first, the bladder may be injured by the pressure of a fetal head second, the pressure of the full bladder may not allow the fetal head to descend. To avoid a full bladder, women need to try to void about every 2 hours during labor. **6. Increasing Apprehension -** Warnings of psychological danger during labor are as important to consider in assessing maternal well-being as are physical signs. A woman who is becoming increasingly apprehensive despite clear explanations of unfolding events may only be approaching the second stage of labor. She may, however, not be "hearing" because she has a concern that has not been met. Increasing apprehension also needs to be investigated for physical reasons, because it can be a sign of oxygen deprivation or internal hemorrhage. **FETAL DANGER SIGNS** **1. High or Low Fetal Heart Rate.** As a rule, an FHR of more than 160 bpm (fetal tachycardia) or less than 110 bpm (fetal bradycardia) is a sign of possible fetal distress. An equally important sign is a late or variable deceleration pattern (described later) on a fetal monitor. The FHR may return to a normal range in between these irregular patterns, giving a false sense of security if FHR is assessed only between contractions. **2. Meconium Staining -** Meconium staining, a green color in the amniotic fluid, is not always a sign of fetal distress but is highly correlated with its occurrence. It reveals that the fetus has had loss of rectal sphincter control, allowing meconium to pass into the amniotic fluid. It may indicate that a fetus has or is experiencing hypoxia which stimulates the vagal reflex and leads to increased bowel motility. Although meconium staining may be normal in a breech presentation, because pressure on the buttocks causes meconium loss, it should always be reported immediately so that its cause can be investigated. **3. Hyperactivity** - Ordinarily, a fetus is quiet and barely moves during labor. Fetal hyperactivity may be a sign that hypoxia is occurring, because frantic motion is a common reaction to the need for oxygen. **4. Oxygen Saturation** - If a fetus is assessed for oxygen saturation level by a catheter inserted next to the cheek, a low oxygen saturation level (under 40%) or if fetal blood was obtained by scalp puncture, the finding of acidosis (blood pH 7.2) suggests that fetal well-being is becoming compromised. Oxygen saturation in a fetus is normally 40% to 70% **WEEK 9: THE NEWBORN** **PROFILE OF NEW BORN** I. **Vital Statistics** - **Weight** 3.4 kg (7.5 lb) - mature female newborn in the United States. 3.5 kg (7.7 lb) - mature male newborn. Newborns of other races weigh approximately 0.5 lb less. The birth weight of newborns varies depending on the racial, nutritional, intrauterine, and genetic factors that were present during conception and pregnancy. - **Length\ **53 cm (20.9 in) - mature female neonate. 54 cm (21.3 in) - For mature males. - **Head Circumference\ **34 to 35 cm (13.5 to 14 in) - mature newborn - **Chest Circumference\ **The chest circumference in a term newborn is about 2 cm (0.75 to 1 in) less than the head circumference. II. **Vital Signs** **Temperature\ **99° F (37.2° C) - The temperature of newborns. **Brown fat** - a special tissue found in mature newborns, apparently helps to conserve or produce body heat by increasing metabolism. Found in the intrascapular region, thorax, and perirenal area. Brown fat is thought to aid in controlling newborn temperature similar to temperature control in a hibernating animal. **Drying and** wrapping newborns and placing them in warmed cribs, or drying them and placing them under a radiant heat source, are excellent mechanical measures to help conserve heat. **Pulse** 120 to 160 beats per minute (bpm) -- The averages heart rate of a fetus in utero. 180 bpm - Immediately after birth, as the newborn struggles to initiate respirations 120 to 140 bpm - the heart rate stabilizes **Respiration** 80 breaths per minute 30 to 60 breaths per minute when the newborn is at rest. **Blood Pressure** 80/46 mm Hg at birth. By the 10th day, it rises to about 100/50 mm Hg. Blood pressure tends to increase with crying (and a newborn cries when disturbed and manipulated by such procedures as taking blood pressure). III. **Physiologic Function** **Cardiovascular System**\ When the cord is clamped, a neonate is forced to take in oxygen through the lungs. As the lungs inflate for the first time, pressure decreases in the pulmonary artery (the artery leading from the heart to the lungs). This decrease in pressure plays a role in promoting closure of the ductus arteriosus, a fetal shunt. As pressure increases in the left side of the heart from increased blood volume, the foramen ovale between the two atria closes because of the pressure against the lip of the structure (permanent closure does not occur for weeks). With the remaining fetal circulatory structures (umbilical vein, two umbilical arteries, and ductus venosus) no longer receiving blood, the blood within them clots, and the vessels atrophy over the next few weeks. **Hematocrit** is between 45% and 50%. **Bilirubin** is a byproduct of the breakdown of red blood cells. An indirect bilirubin level at birth is 1 to 4 mg/100 mL. - Any increase over this amount reflects the release of bilirubin as excessive red blood cells begin their breakdown.\ A newborn has an equally high white blood cell count at birth, about 15,000 to 30,000 cells/mm3. Values as high as 40,000 cells/mm3 may be seen if the birth was stressful. **RESPIRATORY SYSTEM** All newborns have some fluid in their lungs from intrauterine life that will ease the surface tension on alveolar walls and allows alveoli to inflate more easily than if the lung walls were dry. - Once the alveoli have been inflated with a first breath, breathing becomes much easier for a baby, requiring only about 6 to 8 cm H2O pressure. Within 10 minutes after birth, most newborns have established a good residual volume. - A newborn who has difficulty establishing respirations at birth should be examined closely in the postpartal period for a cardiac murmur or other indication that he or she still has patent fetal cardiac structures, especially a patent ductus arteriosus **GASTROINTESTINAL SYSTEM** - Usually sterile at birth bacteria may be cultured from the intestinal tract in most babies within 5 hours after birth and from all babies at 24 hours of life. - Most of these bacteria enter the tract through the newborn's mouth from airborne sources. Others may come from vaginal secretions at birth, from hospital bedding, and from contact at the breast. - Accumulation of bacteria in the gastrointestinal tract is necessary for digestion and for the synthesis of vitamin K. - **Meconium -** First stool - passed within 24 hours after birth. It consists of, a sticky, tarlike, blackish-green, odorless material formed from mucus, vernix, lanugo, hormones, and carbohydrates that accumulated during intrauterine life. If not pass within 24-48 hrs. - meconium ileus, imperforate anus, or volvulus should be suspected. **URINARY SYSTEM** - Voids within 24 hours after birth. - 24-hour point is a good general rule. - Newborns who do not void within this time - urethral stenosis or absent kidneys or ureters. - A single voiding - 15 mL and may be easily missed in a thick diaper. - Specific gravity ranges from 1.008 to 1.010. - The daily urinary output for the first 1 or 2 days is about 30 to 60 mL total. - By week 1, total daily volume rises to about 300 mL. - **The first voiding** - pink or dusky because of uric acid crystals that were formed in the bladder in utero. **IMMUNE SYSTEM** - Have difficulty forming antibodies against invading antigens until about 2 months of age - Newborns are prone to infection. - This inability to form antibodies is the reason that most immunizations against childhood diseases are not given to infants younger than 2 months of age. - Newborns do have some immunologic protection, because they are born with passive antibodies (immunoglobulin G) from their mother that crossed the placenta. - In most instances, these include antibodies against poliomyelitis, measles, diphtheria, pertussis, chickenpox, rubella, and tetanus. - Newborns are routinely administered hepatitis B vaccine during the first 12 hours after birth to protect against this disease **NEUROMUSCULAR SYSTEM** **Demonstrate neuromuscular function by:** - Moving their extremities - Attempting to control head movement. - Exhibiting a strong cry. - Demonstrating newborn reflexes. - Limpness or total absence of a muscular response to manipulation is never normal and suggests narcosis, shock, or cerebral injury **Blink Reflex** - A blink reflex in a newborn serves the same purpose as it does in an adult---**to protect the eye from any object coming near it by rapid eyelid closure**. It may be elicited by shining a strong light such as a flashlight or an otoscope light on an eye. A sudden movement toward the eye sometimes can elicit the blink reflex. A baby lying on a blue blanket Description automatically generated **Rooting Reflex** - If the cheek is brushed or stroked near the corner of the mouth, a newborn infant will turn the head in that direction. **This reflex serves to help a newborn find food:** when a mother holds the child and allows her breast to brush the newborn's cheek, the reflex makes the baby turn toward the breast.  **Sucking Reflex** - When a newborn's lips are touched, the baby makes a sucking motion**. The reflex helps a newborn find food:** when the newborn's lips touch the mother's breast or a bottle, the baby sucks and so takes in food. The sucking reflex begins to diminish at about 6 months of age. It disappears immediately flex disappears at about the sixth week of life. A baby sleeping on a white blanket Description automatically generated **Swallowing Reflex** The swallowing reflex in a newborn is the same as in the adult. Food that reaches the posterior portion of the tongue is automatically swallowed. Gag, cough, and sneeze reflexes also are present in newborns to maintain a clear airway in the event that normal swallowing does not keep the pharynx free of obstructing mucus.  **Extrusion Reflex** A newborn extrudes any substance that is placed on the anterior portion of the tongue. This protective reflex prevents the swallowing of inedible substances. It disappears at about 4 months of age. Until then, the infant may seem to be spitting out or refusing solid food placed in the mouth **Palmar Grasp Reflex** Newborns grasp an object placed in their palm by closing their fingers on it. Mature newborns grasp so strongly that they can be raised from a supine position and suspended momentarily from an examiner's fingers. This reflex disappears at about 6 weeks to 3 months of age. A baby begins to grasp meaningfully at about 3 months of age. A baby\'s hand holding a baby\'s hand Description automatically generated **Step (Walk)-in-Place Reflex** Newborns who are held in a vertical position with their feet touching a hard surface will take a few quick, alternating steps. This reflex disappears by 3 months of age. By 4 months, babies can bear a good portion of their weight unhindered by this reflex. A baby walking on the beach Description automatically generated **Plantar Grasp Reflex** When an object touches the sole of a newborn's foot at the base of the toes, the toes grasp in the same manner as do the fingers. This reflex disappears at about 8 to 9 months of age in preparation for walking. However, it may be present during sleep for a longer period. A baby\'s foot in a person\'s hand Description automatically generated **Tonic Neck Reflex** When newborns lie on their backs, their heads usually turn to one side or the other. The arm and the leg on the side toward which the head turns extend, and the opposite arm and leg contract. If you turn a newborn's head to the opposite side, he or she will often change the extension and contraction of legs and arms accordingly. This is also called a boxer or fencing reflex, because the position simulates that of someone preparing to box or fence. It may signify handedness. The reflex disappears between the second and third months of life. A baby lying on a white sheet Description automatically generated **Moro Reflex** A Moro (startle) reflex can be initiated by startling a newborn with a loud noise or by jarring the bassinet. The most accurate method of eliciting the reflex is to hold newborns in a supine position and allow their heads to drop backward about 1 inch. In response to this sudden head movement, they abduct and extend their arms and legs. Their fingers assume a typical "C" position. It is strong for the first 8 weeks of life and then fades by the end of the fourth or fifth month, at the same time an infant can roll away from danger.  **Babinski Reflex** When the sole of the foot is stroked in an inverted "J" curve from the heel upward, a newborn fans the toes (positive Babinski sign) (Fig. 18.8). This is in contrast to the adult, who flexes the toes. This reaction occurs because nervous system development is immature. It remains positive (toes fan) until at least 3 months of age, when it is supplanted by the downturning or adult flexion response. A baby\'s foot in a person\'s hand Description automatically generated **Magnet Reflex** If pressure is applied to the soles of the feet of a newborn lying in a supine position, he or she pushes back against the pressure. This reflexes are tests of spinal cord integrity.  **Crossed Extension Reflex** If one leg of a newborn lying supine is extended and the sole of that foot is irritated by being rubbed with a sharp object, such as a thumbnail, the infant raises the other leg and extends it, as if trying to push away the hand irritating the first leg. **Trunk Incurvation Reflex** When newborns lie in a prone position and are touched along the paravertebral area by a probing finger, they flex their trunk and swing their pelvis toward the touch. A baby on the back of a person Description automatically generated **Landau Reflex** A newborn who is held in a prone position with a hand underneath, supporting the trunk, should demonstrate some muscle tone. Babies may not be able to lift their head or arch their back in this position (as they will at 3 months of age), but neither should they sag into an inverted "U" position.  **Vision.** "seeing" light and dark in utero Newborns demonstrate sight at birth by blinking at a strong light (blink reflex) or by following a bright light or toy a short distance with their eyes. **Touch**. Well developed at birth. They also react to painful stimuli. **Taste.** A newborn has the ability to discriminate taste, because taste buds are developed and functioning even before birth. **Smell**. The sense of smell is present in newborns as soon as the nose is clear of lung and amniotic fluid. Newborns turn toward their mothers' breast partly out of recognition of the smell of breast milk and partly as a manifestation of the rooting reflex. **IV. Appearance of a Newborn** 1. **Skin A. Color** **Ruddy Complexion-** because of the increased concentration of red blood cells in blood vessels and a decrease in the amount of subcutaneous fat, which makes the blood vessels more visible. ruddiness fades slightly over the first month. **Cyanotic** - Infants with poor central nervous system control, newborn's lips, hands, and feet are likely to appear blue from immature peripheral circulation. **Acrocyanosis** (blueness of hands and feet). with usual skin color on one side and blue on the other. Acrocyanosis is a normal phenomenon in the first 24 to 48 hours after birth. **Central cyanosis**, or cyanosis of the trunk, is always a cause for concern. Central cyanosis indicates decreased oxygenation. It may be the result of a temporary respiratory obstruction or an underlying disease. **Gray -** color in newborns generally indicates infection. **Generalized mottling** - of the skin is common. **Hyperbilirubinemia** - Hyperbilirubinemia leads to jaundice, or yellowing of the skin (Beachy, 2007). occurs on the second or third day of life in about 50% of all newborns, as a result of a breakdown of fetal red blood cells (physiologic jaundice). - The infant's skin and the sclera of the eyes appear noticeably yellow. - This happens because the high red blood cell count built up in utero is destroyed, and heme and globin are released. - Many newborns have such immature liver function that indirect bilirubin cannot be converted to the direct form; it therefore remains indirect. - Observe infants who are prone to extensive bruising (large, breech, or immature babies) carefully for jaundice, because bruising leads to hemorrhage of blood into the subcutaneous tissue or skin. - **Cephalhematoma** is a collection of blood under the periosteum of the skull bone. As the bruising in these locations heals and the red blood cells are hemolyzed, additional indirect bilirubin is released and can be another cause of jaundice **Pallor** - Pallor in newborns is usually the result of anemia. caused by excessive blood loss when the cord was cut. - inadequate flow of blood from the cord into the infant at birth. - fetal--maternal transfusion. - low iron stores caused by poor maternal nutrition during pregnancy. - blood incompatibility in which a large number of red blood cells were hemolyzed in utero. It also may be the result of internal bleeding. A baby who appears pale should be watched closely for signs of blood in stool or vomitus. A baby lying on its back Description automatically generated **Harlequin Sign** Occasionally, because of immature circulation, a newborn who has been lying on his or her side appears red on the dependent side of the body and pale on the upper side, as if a line had been drawn down the center of the body. This is a transient phenomenon; although startling, it is of no clinical significance. The odd coloring fades immediately if the infant's position is changed or the baby kicks or cries vigorously.  **B. Birthmarks** Hemangiomas are vascular tumors of the skin. Three types occur. **A. Nevus Flammeus** - is a macular purple or dark-red lesion (sometimes called a portwine stain because of its deep color) that is present at birth. Appear on the face, although they are often found on the thighs as well. Those above the bridge of the nose tend to fade; the others are less likely to fade. **Nevus flammeus** lesions also occur as lighter, pink patches at the nape of the neck, known as stork's beak marks or telangiectasia. These do not fade, but they are covered by the hairline and therefore are of no consequence.  **B. Strawberry hemangioma** - refers to elevated areas formed by immature capillaries and endothelial cells. Term neonate Typically, they are not present in the preterm infant because of the immaturity of the epidermis. Tx: Hydrocortisone ointment may speed the disappearance. A close-up of a baby\'s face Description automatically generated **C. Cavernous Hemangiomas** - Are dilated vascular spaces. - They are usually raised and resemble a strawberry hemangioma in appearance. - They do not disappear with time as do strawberry hemangiomas. Such lesions can be removed surgically. - Tx: Steroids, interferon-alfa-2a, or vincristine can be used to reduce these lesions in size - Children who have a skin lesion may have additional ones on internal organs. A close up of a baby\'s back Description automatically generated **Mongolian Spots** - Are collections of pigment cells (melanocytes) that appear as slate-gray patches across the sacrum or buttocks and possibly on the arms and legs. - They tend to occur in children of Asian, southern European, or African ethnicity. - They disappear by school age without treatment. A baby with a spot on its back Description automatically generated **C. Vernix Caseosa** - White, cream cheese--like substance that serves as a skin lubricant in utero. - Document the color of vernix, because it takes on the color of the amniotic fluid. A person holding a baby Description automatically generated **D. Lanugo** Fine, downy hair that covers a newborn's shoulders, back, and upper arms. Found also on the forehead and ears. A baby born between 37 to 39 weeks of gestation has more lanugo than a newborn of 40 weeks' gestational age. Postmature infants (more than 42 weeks of gestation) rarely have lanugo. **E. Desquamation** Within 24 hours after birth, the skin of most newborns has become extremely dry. The dryness is particularly evident on the palms of the hands and soles of the feet. Similar to sunburn.  **F. Milia** All newborn sebaceous glands are immature. At least one pinpoint white papule (a plugged or unopened sebaceous gland) can be found on the cheek or across the bridge of the nose of almost every newborn. Such lesions, termed milia, disappear by 2 to 4 weeks of age, as the sebaceous glands mature and drain. Close up of a child\'s face Description automatically generated **G. Erythema Toxicum** In most normal mature infants, a newborn rash called erythema toxicum can be observed. This usually appears in the first to fourth day of life but may appear up to 2 weeks of age. It begins with a papule, increases in severity to become erythema by the second day, and then disappears by the third day.  **2. Head** - One-fourth of the total body length; in an adult, a head is one eighth of total height. - Well-nourished newborns have full-bodied hair; poorly nourished and preterm infants have thin, lifeless hair. **Fontanelles** - The fontanelles are the spaces or openings where the skull bones join. - The anterior fontanelle is diamond shaped and measures 2 to 3 cm (0.8 to 1.2 in) in width and 3 to 4 cm (1.2 to 1.6 in) in length. - The posterior fontanelle is triangular and measures about 1 cm (0.4 in) in length. - The anterior fontanelle can be felt as a soft spot. It should not appear indented (a sign of dehydration) or bulging (a sign of increased intracranial pressure) The anterior fontanelle normally closes at 12 to 18 months of age. **Sutures** - The separating lines of the skull, may override at birth because of the extreme pressure exerted on the head during passage through the birth canal. - Suture lines should never appear widely separated in newborns. - Wide separation suggests increased intracranial pressure because of abnormal brain formation - Abnormal accumulation of cerebrospinal fluid in the cranium (hydrocephalus) - An accumulation of blood from a birth injury such as subdural hemorrhage. **Molding** The part of the infant's head that engaged the cervix (usually the vertex) molds to fit the cervix contours during labor. **Caput Succedaneum** Caput succedaneum is edema of the scalp at the presenting part of the head. **Cephalhematoma** A cephalhematoma, a collection of blood between the periosteum of a skull bone and the bone itself, is caused by rupture of a periosteal capillary because of the pressure of birth. Swelling usually appears 24 hours after birth. It often takes weeks for a cephalhematoma to be absorbed. It might be supposed that the blood could be aspirated to relieve the condition. **Craniotabes** Craniotabes is a localized softening of the cranial bones that is probably caused by pressure of the fetal skull against the mother's pelvic bone in utero. **3. Eyes** - cry tearlessly, lacrimal ducts do not fully mature until about 3 months of age. - the irises of the eyes are gray or blue; the sclera may be blue because of its thinness. Infant eyes assume their permanent color between 3 and 12 months of age. **4. Ears** - external ear is not as completely formed as it will be eventually - the pinna tends to bend easily. In the term newborn - The level of the top part of the external ear should be on a line drawn from the inner canthus to the outer canthus of the eye and back across the side of the head. Ears that are set lower than this are found in infants with certain chromosomal abnormalities, particularly trisomy 18 and 13, syndromes in which low-set ears and other physical defects are coupled with varying degrees of cognitive challenge. **5. Nose** - A newborn's nose tends to appear large for the face. As the infant grows, the rest of the face grows more than the nose does, and this discrepancy disappears. - Note any discomfort or distress while breathing this way. Nasal flaring upon inspiration is another indication of respiratory distress and should be further evaluation. **6. Mouth** - A newborn's mouth should open evenly when he or she cries. - If one side of the mouth moves more than the other, cranial nerve injury is suggested. - A newborn's tongue appears large and prominent in the mouth. Because the tongue is short, the frenulum membrane is attached close to the tip of the tongue, creating the impression that the infant is "tongue tied." - (Epstein's pearls) are present on the palate, a result of extra calcium that was deposited in utero. Be sure to inform parents that these pearl-like cysts are insignificant, require no treatment, and will disappear spontaneously within 1 week. **7. Neck** - The neck of a newborn is short and often chubby, with creased skin folds. - The head should rotate freely on it. If there is rigidity of the neck, congenital torticollis, caused by injury to the sternocleidomastoid muscle during birth, might be present. - Nuchal rigidity suggests meningitis. - The neck of a newborn is not strong enough to support the total weight of the head but in a sitting position. Close-up of a person\'s mouth with a tool Description automatically generated **8. Chest** - 2 years of age the chest measurement exceed that of the head. - The clavicles should be straight. - A crepitus or actual separation on one or the other clavicle may indicate that a fracture occurred during birth and calcium is now being deposited at that point. - Newborn's chest should appear symmetric side to side. - Respirations are normally rapid (30 to 60 breaths per minute) but not distressed. - Supernumerary nipple (usually found below and in line with the normal nipples) may be present. If so, it may be removed later. - In both female and male infants, the breasts may be engorged. Occasionally, the breasts of newborn babies secrete a thin, watery fluid popularly termed witch's milk. - Engorgement develops in utero as a result of the influence of the mother's hormones. As soon as the hormones are cleared from the infant's system (about 1 week), the engorgement and any fluid that is present subside. - Retraction (drawing in of the chest wall with inspiration) should not be present. - An abnormal sound, such as grunting, suggests respiratory distress syndrome; a high, crowing sound on inspiration suggests stridor or immature tracheal development. **9. Abdomen** - The contour of a newborn abdomen looks slightly protuberant. - A scaphoid or sunken appearance may indicate missing abdominal contents or a diaphragmatic hernia (bowel positioned in the chest instead of the abdomen). - Bowel sounds should be present within 1 hour after birth. - The edge of the liver is usually palpable 1 to 2 cm below the right costal margin. - The edge of the spleen may be palpable 1 to 2 cm below the left costal margin. Tenderness is difficult to determine in a newborn. If it is extreme, however, palpation will cause the infant to cry, thrash about, or tense the abdominal muscles to protect the abdomen. - 1st hour after birth, the stump of the umbilical cord appears as a white, gelatinous structure marked with the blue and red streaks of the umbilical vein and arteries. When the cord is first cut, the vessels are counted to be certain that one vein and two arteries are present. - Inspect the cord clamp to be certain it is secure. - After the first hour of life, the cord begins to dry and shrink, and it turns brown like the dead end of a vine. By the second or third day, it has turned black. It breaks free by day 6 to 10, leaving a granulating area a few centimeters wide that heals during the following days - A moist or odorous cord suggests infection. If present, infection should receive immediate treatment or it may enter a newborn's bloodstream and cause septicemia. **Anogenital** Area Inspect the anus of a newborn (imperforate anus). Test for anal patency by gently inserting the tip of your gloved and lubricated little finger. Also note the time after birth at which the infant first passes meconium. If a newborn does not do so in the first 24 hours, suspect imperforate anus or meconium ileus. **Male Genitalia** The scrotum in most male newborns is edematous and has rugae (folds in the skin) Both testes should be present in the scrotum. - **Cryptorchidism** - If one or both testicles are not present, referral is needed. - **Agenesis** - (absence of an organ), - **Ectopic testes** - (the testes cannot enter the scrotum because the opening to the scrotal sac is closed) Undescended testes - (the vas deferens or artery is too short to allow the testes to descend). **Female Genitalia** The vulva in female newborns may be swollen because of the effect of maternal hormones. - **Pseudomenstruation** - mucus vaginal secretion, which is sometimes blood-tinged this is caused by the action of maternal hormones. The discharge disappears as soon as the infant's system has cleared the hormones. The discharge should not be mistaken for an infection or taken as an indication that trauma has occurred. **11. Back** - The spine of a newborn typically appears flat in the lumbar and sacral areas. - The curves seen in an adult appear only after a child is able to sit and walk. - Inspect the base of a newborn's spine carefully to be sure there is no pinpoint opening, dimpling, or sinus tract in the skin, which would. suggest a dermal sinus or spinal bifida occulta. - True neural tube defects in newborns are greatly decreased in incidence because of the recognition that lack of folic acid during pregnancy. **12. Extremities** - The arms and legs of a newborn appear short. - The hands are plump and clenched into fists. - Newborn fingernails are soft and smooth, and usually long enough to extend over the fingertips. - The fingertips should reach the proximal thigh. - Unusually short arms may signify achondroplastic dwarfism. - Observe for unusual curvature of the little finger, and inspect the palm for a simian crease (a single palmar crease, in contrast to the three creases normally seen in a palm). Although curved fingers and simian creases can occur normally, they are commonly associated with Down syndrome. - **Webbing** - (syndactyly) 2 or more digits are fused together. - extra toes or fingers (polydactyly), or unusual spacing of toes. - Newborn legs are bowed as well as short. - The sole of the foot appears flat because of an extra pad of fat in the longitudinal arch. - **Ortolani\'s Test -** Used to confirm the hip dislocation. Flex the hips and knees to 90 degree, then apply an anterior pressure over the greater trochanter and gently adduct the leg with your thumbs. If the hip was dislocated, a distinctive clunk will be heard as the hip relocates.  **Week 10: POSTPARTUM** **PHYSIOLOGICAL CHANGES OF THE POSPARTAL PERIOD** **Reproductive System Changes** **Involution**- is the process whereby the reproductive organs return to their nonpregnant state. By the time involution is complete (6 weeks), the uterus is completely return to its prepregnancy state. **The Uterus**\ The sealing of the placenta site is accomplished by rapid contraction of the uterus immediately after delivery of the placenta. - Immediately after birth, the uterus weighs about 1000 g.\ First week, it weighs 500 g. By the time involution is complete (6 weeks), it weighs approximately 50 g, similar to its prepregnancy weight. - Uterus size decreases (Uterine involution) one fingerbreadth per day---on the first postpartal day, and so forth. By the ninth or tenth day, the uterus will no longer be detected by abdominal palpation. **Uterine atony** - relaxed uterus after the first hour after birth. She will lose blood very rapidly, because no permanent thrombi have yet formed at the placental site. **Lochia** - Uterine flow, consisting of blood, fragments of decidua, white blood cells, mucus, and some bacteria. - For the first 3 days after birth, a lochia discharge consists almost entirely of blood, with only small particles of decidua and mucus.\ Lochia rubra - mainly red color **Lochia serosa** - flow becomes pink or brownish. **Lochia alba** - colorless or white - Lochia alba is present in most women until the third week after birth. - Saturating a perineal pad in less than 1 hour is considered an abnormally heavy flow and should be reported. - Lochia should contain no large clots. Clots may indicate that a portion of the placenta has been retained and is preventing closure of the maternal uterine blood sinuses. - Lochia should not have an offensive odor. - Lochia has the same odor as menstrual blood. - An offensive odor usually indicates that the uterus has become infected. A diagram of different types of blood vessels Description automatically generated **The Cervix** - Immediately after birth, a uterine cervix is soft and malleable. - By the end of 7 days, the external os has narrowed to the size of a pencil opening; the cervix feels firm and nongravid again. - Like the fundus, the cervix does not return exactly to its prepregnancy state. The internal os closes as before, but after a vaginal birth the external os usually remains slightly open and appears slitlike or stellate (star shaped), whereas previously it was round  **The Vagina** - vagina is soft, with few rugae, and its diameter is considerably greater than normal. The hymen is permanently torn and heals with small, separate tags of tissue. - Because a woman who is breastfeeding may have delayed ovulation, she may continue to have thin-walled or fragile vaginal cells that cause slight vaginal bleeding during sexual intercourse until about 6 weeks' time. - Like the cervix, the vaginal outlet remains slightly more distended than before. If a woman practices Kegel exercises, the strength and tone of the vagina will increase more rapidly **The Perineum** - The perineum feels edematous and tender immediately after birth. - The labia majora and labia minora typically remain atrophic and softened after birth. **BREAST** - Beast distention becomes marked, and this often is accompanied by a feeling of heat or pain. - The distention is not limited to the milk ducts but occurs in the surrounding tissue as well, because blood and lymph enter the area to contribute fluid to the formation of milk. This feeling of tension in the breasts on the third or fourth day after birth is termed primary engorgement. It fades as the infant begins effective sucking and empties the breasts of milk. **Systemic Changes** - Pregnancy hormones begin to decrease as soon as the placenta is no longer present. - Levels of human chorionic gonadotropin (hCG) and human placental lactogen (hPL) are almost negligible by 24 hours. - By week 1, progestin, estrone, and estradiol are all at prepregnancy levels. - Folliclestimulating hormone (FSH) remains low for about 12 days and then begins to rise as a new menstrual cycle is initiated. **The Urinary System** - During pregnancy, as much as 2000 to 3000 mL excess fluid accumulates in the body. - This marked increase in urine production causes the bladder to fill rapidly. - During a vaginal birth, the fetal head exerts a great deal of pressure on the bladder and urethra as it passes on the bladder's underside. This pressure may leave the bladder with a transient loss of tone that, together with the edema surrounding the urethra, decreases a woman's ability to sense when she has to void. - To prevent permanent damage to the bladder from overdistention, assess a woman's abdomen frequently in the immediate postpartal period. **The Circulatory System** - The usual blood loss with a vaginal birth is 300 to 500 mL. With a cesarean birth, it is 500 to 1000 mL. - Women usually continue to have the same high level of plasma fibrinogen during the first postpartal weeks as they did during pregnancy. This is a protective measure against hemorrhage. However, this high level also increases the risk of thrombus formation. **The Gastrointestinal System** - Digestion and absorption begin to be active again soon after birth unless a woman has had a cesarean birth. Almost immediately, the woman feels hungry and thirsty and she can eat without difficulty from nausea or vomiting during this time. - Hemorrhoids (distended rectal veins) that have been pushed out of the rectum because of the effort of pelvic-stage pushing often are present. - Bowel sounds are active, but passage of stool through the bowel may be slow because of the still-present effect of relaxin on the bowel. Bowel evacuation may be difficult because of the pain of episiotomy sutures or hemorrhoids. **The Integumentary System** - After birth, the stretch marks on a woman's abdomen (striae gravidarum) still appear reddened and may be even more prominent than during pregnancy. - Excessive pigment on the face and neck (chloasma) and on the abdomen (linea nigra) will become barely detectable in 6 weeks' time. **Vital Sign Changes** **Temperature** - Slight increase in temperature during the first 24 hours after birth because of dehydration that occurred during labor. If she receives adequate fluid during the first 24 hours, this temperature elevation will return to normal. - Any woman whose oral temperature rises above 100.4° F (38° C), excluding the first 24-hour period, is considered by criteria of the Joint Commission on Maternal Welfare to be febrile. In such women, a postpartal infection may be present. **Pulse** - A woman's pulse rate during the postpartal period is usually slightly slower than normal. - During pregnancy, the distended uterus obstructed the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. This increased stroke volume reduces the pulse rate to between 60 and 70 beats per minute. **Blood Pressure** - Blood pressure should also be monitored carefully during the postpartal period, because a decrease in this can indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal pregnancy-induced hypertension. - Oxytocics, drugs frequently administered during the postpartal period to achieve uterine contraction, cause contraction of all smooth muscle, including blood vessels that can increase blood pressure. **Progressive Changes** **Lactation** - The formation of breast milk (lactation) begins in a postpartal woman whether or not she plans to breastfeed. - Since midway through pregnancy, she has been secreting colostrum, a thin, watery, prelactation secretion. She continues to excrete this fluid the first 2 postpartum days. On the third day, her breasts become full and feel tense or tender as milk forms within breast ducts. - Breast milk forms in response to the decrease in estrogen and progesterone levels that follows delivery of the placenta (which stimulates prolactin production and, consequently, milk production. **Return of Menstrual Flow** - With the delivery of the placenta, the production of placental estrogen and progesterone ends. The resulting decrease in hormone concentrations causes a rise in production of FSH by the pituitary, which leads, with only a slight delay, to the return of ovulation. This initiates the return of normal menstrual cycles. - A woman who is not breastfeeding can expect her menstrual flow to return in 6 to 10 weeks after birth. If she is breastfeeding, a menstrual flow may not return for 3 or 4 months (lactational amenorrhea) or, in some women, for the entire lactation period. However, the absence of a menstrual flow does not guarantee that a woman will not conceive during this time, because she may ovulate well before menstruation returns. **NURSING RESPONSIBILITIES** a. **Perineal Care** - Observe for ecchymosis, hematoma, erythema, edema, intactness, and presence of drainage or bleeding from any episiotomy stitches. b. **Provide Pain Relief for After pains** - Pain from uterine contractions can be intense, but you can assure a woman that this type of discomfort is normal and rarely lasts longer than 3 days. c. **Relieve Muscular Aches** - Many women feel sore and aching after labor and birth because of the excessive energy they used for pushing during the pelvic division of labor. A backrub is effective for relieving an aching back or shoulders d. **Administer Cold and Hot Therapy -** Applying an ice or cold pack to the perineum during the first 24 hours reduces perineal edema and the possibility of hematoma formation, thereby reducing pain and promoting healing and comfort. sitz bath. e. **Episiotomy Care -** heals 5 or 6 days. f. **Inspect Lochia -** Check the Consistency: Lochia should contain no large clots. Clots may indicate that a portion of the placenta has been retained and is preventing closure of the maternal uterine blood sinuses. **Observe the Pattern**: Lochia is red for the first 1 to 3 days (lochia rubra), pinkishbrown from days 4 to 10 (lochia serosa), and then white (lochia alba) for as long as 6 weeks after birth. The pattern of lochia (rubra to serosa to alba) should not reverse **PSYCHOLOGICAL CHANGES** - **Postpartal Blues** During the postpartal period, as many as 50% of women experience some feelings of overwhelming sadness. They may burst into tears easily or feel let down or irritable. This temporary feeling after birth has long been known as the **"baby blues."** - This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurs with delivery of the placenta. For some women, it may be a response to dependence and low self-esteem caused by exhaustion, being away from home, physical discomfort, and the tension engendered by assuming a new role, especially if a woman is not receiving support from her partner. - The syndrome is evidenced by tearfulness, feelings of inadequacy, mood lability, anorexia, and sleep disturbance. - Anticipatory guidance and individualized support from health care personnel are important to help the parents understand that this response is normal. You can assure a woman that sudden crying episodes may occur; otherwise, she may have difficulty understanding what is happening to her. **Phases of the Puerperium** Reva Rubin, a nurse, divided the puerperium into three separate phases (Rubin, 1977). 1. **Taking-In Phase** A time when the new parents review their pregnancy and the labor and birth, a time of reflection. During this 2- to 3-day period, a woman is largely passive. This dependence results partly from her physical discomfort because of after pains; partly from her uncertainty in caring for her newborn; and partly from the extreme exhaustion that follows childbirth. 2. **Taking-Hold Phase** After a time of passive dependence, a woman begins to initiate action. Now, she begins to take a strong interest. , it is always best to give a woman brief demonstrations of baby care and then allow her to care for her child herself---with watchful guidance. 3. **Letting-Go Phase** In the third phase, called letting-go, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth) **Nursing Care of a Woman and Family during the first 24 hours after birth** 1\. Provide Pain Relief for After pains 2\. Relieve Muscular Aches. 3\. Administer Cold and Hot Therapy. 4\. Promote Perineal Exercises. 5\. Give Episiotomy Care\ 6. Administer Sitz Baths 7\. Provide Perineal Care. 8\. Promote Rest in the Early Postpartal Period. 9\. Assess Peripheral Circulation 10\. Prevent/Alleviate Breast Engorgement. 11\. Promote Breast Hygiene\ 12. Promote Breast Hygiene **8-POINT POSTPARTUM ASSESSMENT INSTRUCTIONS** **1. Breast** a\. Gently palpate each breast b\. If you feel nodules in the breast, the ducts may not have been emptied at last. c\. Stroke downward towards the nipple, then gently release the milk by manual. d\. If nodules remain, notify the doctor. e\. Take this opportunity to explain the process of milk production, what to do about engorgement, how to perform self breast examinations, and answer any questions she may have about breastfeeding. What is the contour? Are the breast full, firm, tender, shiny? Are the veins distended? Is the skin warm? Does the patient complain of sore nipples? Are breasts so engorged that she requires pain medication? **2. Uterus** a\. Palpate the uterus b\. Have the patient feel her uterus as you explain the process of involution c\..If uterus is not involution properly, check for infection, fibroids and lack of tone. d\. Uterus should the firm decrease approximately one finger breadth below. **3. Bladder** a\. Inspect and palpate the bladder simultaneously while checking the height of the fundus. b\. An order from the physician is necessary cauterization may be done. An order for culture and sensitivity test since definitive treatment may be required. c\. Talk to mother about proper perineal care. Explain that she should wipe from front to back after voiding and defecating. d\. Bladder distention should not be present after recent emptying. e\. When bladder distention does occur, a pouch over the bladder area is observed, felt upon palpation; mother usually feels need to urinate. f\. It is imperative that the first three post-partum voiding be measured and should be at least 150cc. Frequent small voiding with or without pain and burning may indicate infection or retention. **4. Bowel Function** a\. Question patient daily about bowel movements. She must not become constipated. If her bowels have not functioned by the second postpartum day, the doctor may start her on a mild laxative b\..Encourage patient to drink extra fluids. c\. Have patient select fruits and vegetables from her menu **5. Lochia** a\. Assess the amount and type of lochia on pad in relations to the number of postpartum days. First 3 days of postpartum, you should find a very red lochia similar to the menstrual flow (lochia ruba). b\. During the next few days, it should become wateryserous (lochia serosa). Onthe tenth day, it c\. should become thin and colorless (lochia alba). d\..Inform the mother about what changes she should expect in the lochia and when it should cease. e\. Tell the mother when her next menstrual period will probably begin and when she can resume sexual relations. f\. Discuss family planning at this time. g\. Notify the doctor if the lochia looks abnormal in to color or contains clogs other than small ones. **6. Episiotomy** a\. Inspect episiotomy thoroughly using flashlight if necessary, for better visibility. b\. Check rectal area. If hemorrhoids are present, the doctor may want to start on sitz bath and local analgesic medication. Reassure patient and answer questions she may have regarding pain, cleanliness, and coitus.