Transcript Postpartum & Newborn

Postpartum & Newborn
Nursing Theory and Practice
MOTHER
 What
is the first thing that comes to mind?
 Words
 Images
 Day
to day life of mothers (and parents) is
often in contrast to our idealized concepts
The “Fourth” Trimester
Defining the Postpartum Period
 Postpartum


period is a time of change
Medical/Physiologic change
Psychosocial (developmental) change
 Duration
of changes is variable
 Duration of coping with changes is
variable
Defining the Postpartum Period
 Physiologically
defined as the six week
period of uterine involution


Begins with the birth of the placenta
Includes resolution of anatomic and
physiologic changes of pregnancy
• return of all systems to (nearly) pre-pregnant state
 Psychosocial
tasks of the postpartum
period take longer than six weeks to
accomplish
Physiologic Changes
Reproductive System
 Uterine

Involution
Muscle fibers contract with the birth of
placenta
• Stops bleeding of large uterine vessels
• Massage gently to maintain firmness



Can be taught to woman
Much more comfortable if woman does herself
Must be effective or clots can collect in the uterus
Reproductive System
 Uterine
Involution
 Uterus progressively smaller

over ~2 weeks
• 1 – 2 finger breadths below umbilicus immediately
postpartum
• At umbilicus on days one and two
• Progressively smaller until not palpable
abdominally by day 10; may take slightly longer
with cesarean section
Reproductive System
 Uterine

Involution
Afterpains can be intense!
• Especially for multipara
• May need narcotic analgesia in addition to NSAID
• Narcotics are constipating

•
•
•
•
prevention is important
Void regularly
Prone position (NOT knee-chest)
Heat
Worse with suckling, pre-medicate prn

Education/understanding is critical
Reproductive System
 Oxytotic



agents (↑ afterpains)
Pitocin (given almost routinely IV or IM after
all births)
Hemabate (PGF2a, not in asthmatics)
Methergine
•
•
•
•
IM & PO most common, IV if life threatening
Causes sustained uterine contraction
Increases BP
Obtain baseline BP before each administration
Reproductive System
 Endometrial

Sloughing
Lochia
• Rubra (Red) 1 – 5 days 
• Serosa (Pinkish Tan) 5 days – 2 weeks 
• Alba (White) 2 to 6 weeks


Lochia has strong smell, not a foul smell
In the first three days
• Small amount of small clots are normal
• ONE larger clot after long period supine is normal
Reproductive System
 Placental

Site
Heals by exfoliative shedding. Lochia is a
combination of shed tissues.
• Lochia is made up of blood, decidua, serous fluid,
and leukocytes with the proportion of each
changing as the lochia changes

Lack of scar tissue important for placental
implantation in future pregnancies
Reproductive System
 Cervix





Floppy (patulous) immediately after birth
May be visible at vaginal introitus
Closes, firms as uterus involutes (~2 weeks)
Os (opening) changes from round to slit like
after birth of first child
Cervix not routinely inspected for laceration.
Lacerated cervix can be cause of continued
postpartum bleeding w/ firm uterus.
Reproductive System
 Vagina




Edematous after delivery (external ice pack)
May have lacerations that may or may not
need repair (hemostasis and approximation)
Smooth walled x several weeks, then ruggae
reappear
Mucosa thinned and dryer secondary to ↓
estrogen  continues until ovulation and
menstruation resume. Counsel for lubrication
Reproductive System
 Perineum

May have lacerations or incision (episiotomy*)
• 1st degree mucosa only
• 2nd degree mucosa and underlying muscle*
• 3rd degree mucosa, underlying muscle and partial
tear of anal sphincter
• 4th degree mucosa, underlying muscle, anal
sphincter and tear of anal mucosal capsule
Reproductive System
 Perineum


After 30 years of research there is no
evidence to support routine episiotomy
Episiotomy should be used selectively only if
• Birth needs to be expedited
• Access to the baby is essential
• Clear evidence of uncontrolled tear (debatable)

Episiotomy increases the risk of severe tear
(fabric demo)
Reproductive System

Perineum (continued)



All stitches absorb on their own after ~ 2 weeks
May see knots on peripad as they dissolve
Nursing care is directed toward
• Assessment of injured site (visualization, approximation,
bruising, bleeding, edema, infection s/sx)
• Decreased edema (ice x 24 hours, then heat prn)
• Pain Management (assessment, positioning, Rx)
• Nutrition/Rx support to prevent constipation
• Exercise of injured muscle to improve blood flow and
strength (kegel)
Reproductive System
 Return

to Menstruation/Ovulation
Pregnancy can occur prior to first menses!
• Contraceptive options are an essential part of
discharge teaching

Lactating women
• Prolactin suppresses ovulation. Return to menses
unpredictable; from 6 weeks to 1 year or more

Non-Lactating women
• Menses usually resume by 6 – 8 weeks
Lactation
 Lactating


women
Sudden drop in estrogen & progesterone with
birth of placenta
↑ Prolactin 
• milk production
• maternal feelings and wellbeing
• supported by frequent contact with baby

Rooming in with support
• suppresses ovulation, delays menstruation
Lactation
 “Let
down” reflex: suckling  oxytocin
• Milk ejection, uterine involution
• Afterpains  ibuprofen 600mg safe
 Colostrum
x 3 days
• Baby’s “first vaccine” (high in IgA antibodies)
• Nutrient dense  only small amounts needed
milk days 3 – 6
 Mature milk day 6 on
 Transitional

Composition of milk changes over time
Lactation
 Breasts
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immediately postpartum
Soft texture
May or may not leak small amount of
colostrum
Check nipples if breastfeeding: erect, everted
Lactation
 Breasts
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
on day one and two
Soft texture, may begin to fill and feel firmer
Check nipples if breastfeeding: erect, everted,
intact
Lactation
 Breasts
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
on day three to five
Entire breast feels taut, warm, erythematous,
larger
Check nipple is erect, everted, intact
Note any nodules (plugged duct, cyst, cancer)
Lactation
 Breasts



Firm when just about time to nurse
Softer after baby nurses effectively
May spray milk with let down
 Week


day 6 to week 6
6 onward
Breasts much softer, even when full
Softness is not a sign of less milk
Lactation
 Mastitis

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Wedge shaped area
Local pain
Redness
Firm nodule
Fever
Exhaustion
Lactation
 Non-Lactating


Women
Still have colostrum, may leak
Milk will still come in on ~ day 3
• Engorgement!


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Congestion of veins and lymphatic circulation
Breasts taut, erythematous, painful, hot
• ibuprofen 600 mg safe; Cold compress; tight bra
• no breast stimulation or milk expression
• Green Cabbage leaves
Prolactin levels ↓ quickly without suckling
Lactation
 Breast
milk is the best food for human
infants
 Formula is safe in US



But does NOT have the benefits of breast milk
Formula may not be safe developing
countries
Formula is unsafe in poor countries
Lactation

Goal is to increase the number of women who
initiate and sustain breastfeeding


ongoing intense support and education essential
“Increased duration of breastfeeding confers
significant health and developmental benefits for
the child and the mother...” (AAP Policy
Statement 2005)
Lactation
 Nursing
actions directly affect
breastfeeding initiation




Encourage rooming in
Effective, accurate information
Referral to community resources
Including the mother’s support system
Bottle Feeding
 Based
on modified cow milk or soy
 Cost approx $1200/ year



Powdered or concentrate – mix w/ boiled
water
More $ if “ready to eat”
WIC does not cover the entire cost of formula
 Contains
supplemental vitamins and iron
 Wash nipples and bottles daily
 Discard unused portion of bottle
Cardiovascular System
 Normal


blood loss
Vaginal birth = up to 500cc (2 cups)
Cesarean birth = up to 1000cc
 WBC
count up to 20,000
 Increased propensity for clotting makes
postpartum women at increased risk for
thrombi
 Varicosities regress
Cardiovascular System
 Blood



Pressure
Q 15 minutes x 1 hour postpartum, then
hourly x 4 hours, then q shift
>140 systolic or >90 diastolic can suggest
postpartum pre-eclampsia and deserves
further investigation
Orthostatic hypotension can occur with acute
blood loss or dehydration (pulse bumps 20
bpm and BP falls 15-20 mmHg positionally)
Cardiovascular System
 Pulse



Increased stroke volume due to increased
circulating volume (loss of placental/uterine
sinuses)  lower pulse rate (60 – 70)
Diuresis less volume  pulse returns to
normal usually by the end of the first week
Warning! In a postpartum woman, you may
see “normal” vital signs in a patient at risk for
hypovolemia
Temperature Regulation
 May


see slight ↑ immediately postpartum
Physical effort
Dehydration
 Temperature
>100.4 at any time triggers
further assessment for infection and report
of the findings
 Days 3 – 5 may see slight temperature ↑
due to breast engorgement (<100.4)
Weight Loss
 +/-
12 lbs lost at birth from baby, fluids,
placenta
 +/- 5 lbs fluid loss from diuresis from days
two to five
 2-3 lbs loss from shedding lochia
 Total by 6 weeks +/- 20 pounds
 Extra weight remains as fat deposits to
make milk
 Lactating women need +500 cal/day
Integumentary System
 Woman
may appear about 6 months
pregnant when standing


Skin and underlying muscle are stretched
Diastasis recti visible about 2 – 4 cm wide
• Abdominal crunches starting about 3 days if
vaginal birth
Integumentary System
 Stretch


marks “striae” appear purple to red
Commonly on abdomen, breasts, hips
Over time fade to silvery tan-white, do not
disappear
 Linea
nigra and other estrogen mediated
skin markings gradually fade, may not
disappear
 May have new scars and altered body
image
Striae and Linea Nigra
Integumentary System

Conjunctiva


Sclera


May be pale in anemia
May have hemorrhages due to pushing
Lacerations of the perineum/vagina

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
May see bruising or hematoma
Edema
Should be well approximated and hemostatic without
discharge
Sitz baths, peri care
Urinary System
 Difficulty



voiding immediately postpartum
Edema
Decreased intra-abdominal pressure
Residual effects of epidural if used
• Running water, stroking lower back, peppermint oil
• Catheterization if bleeding uncontrolled
• Uterus deviated to right often indicates full bladder
Urinary System
 Marked



diuresis of ↑’d fluid volume
Beginning about 12 hours postpartum
Urinary losses
Also diaphoresis profuse
Gastrointestinal System
 Usually

VERY hungry after birth
Most L&D units keep snack boxes
• birth often occurs outside of regular meal service

Birth centers often have kitchens
• Families prepare meals
• Birthday cake!
Gastrointestinal System
 At



risk for constipation
Still have poor abdominal and intestinal
muscle tone
Fear of passing stool due to laceration(s)
Fiber, fluid, stool softener, anticipatory
guidance
Gastrointestinal System
 Hemorrhoids


Pressure from pushing
Common
•
•
•
•
Ice packs
Ointment
Witch hazel pads
Anesthetic spray
Psychosocial Aspects of
Postpartum
Adaptation to Parenthood

Learning new skills



New physical demands



Feeding, holding, diapering, bathing, umbilical and
possibly circumcision care
Soothing, interpreting baby’s communication
New skill acquisition occurs just as all of the physical
adaptations are taking place
Sleep deprivation
Postpartum changes affect all aspects of life
Three Phases of Puerperium
Next three slides based on work of:
 Reva Rubin, 1977
 A classic body of work
 Describes maternal behavior in three
phases



Taking In
Taking Hold
Letting Go
Three Phases of the Puerperium
 Taking





In
Passive, uncertain, exhausted
Reviewing birth experience, baby explored
and experienced with wonder, unfamiliar
Often touch baby with only fingertips at first,
then move to caress and explore entire baby
Gaze at baby “en face”
Vulnerable physically and emotionally
Three Phases of the Puerperium
 Taking





hold
Beginning to take tentative action, building
confidence, gaining familiarity
Strong interest in taking care of her baby
herself
Coming to accept birth experience
Gaining familiarity with baby, still feels unsure
Praise and positive reinforcement welcome
Three Phases of the Puerperium
 Letting

go
Acceptance of fantasy and reality in
• birth experience
• baby
• new roles (mother, lover, worker, etc)




Grief work
Confident, independent action
Forms own opinions
Ongoing . . . duration measured in years
Postpartum Blues

Normal reaction (70% in some sources) to






Sleep deprivation
Grief work
Life change
Conflict between expectation and reality
Physiologic changes, including endocrine changes
Usually worst around days 3 - 5
 Characterized by labile mood, tearfulness, and
reality based passing feelings of inadequacy
 Early onset and resolution
Bonding Behaviors
 En
face positioning
 Baby talking (high pitched, sing song)
 Fingertips  open palm  enfolding
 Eye gazing
 Entrainment (baby moves in rhythm with
adult speech)
 Encouraging rooming in with support is
essential
Postpartum Nursing Care
 Is
based on an understanding of the
physiology and psychology of the
postpartum period
 Nursing
interventions include:
Nurse’s Role in Postpartum Care
 Change
agent
 Skilled observer
 Thoughtful teacher
 Expert time manager
 Coach
 Scientist
 Care taker
Nursing Activities
Birth – 2 hours


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







obtaining/assessing frequent vital signs on two patients
supporting and assessing the baby’s transition to the extra-uterine
environment
assessing the mother for bleeding, pain, uterine tone
supporting breastfeeding initiation
supporting initial bonding
helping the provider prepare for any suturing
planning for vitamin K and erythromycin for the baby
facilitating formation of the new family unit
completing paperwork, often needed by clerk, OB provider and
pediatrician
preparing to give report and arranging for transport to new unit(s)
disposing of the placenta
accounting for all instruments, sharps and sponges used during the birth
ensuring that the nurse’s other laboring patient is under RN care
Nursing Care from 2 – 48 hours
 Directed
by a knowledge of the stages of
the puerperium
 Monitoring safety
 Intensive discharge planning
 Repetitive anticipatory guidance
 Increasing self care and self confidence
 Increasing independence with baby care
 Closing knowledge deficits
Nursing Care from 2 – 48 hours
 Group

Classes
Nurses lead group classes on postpartum
units
• Baby care
• Breastfeeding
 Group
classes are not a substitute for
individualized care planning
Special Situations
 Stillbirth


Woman may choose to be on a gyn floor
Still needs discharge teaching
• Rewrite the form if you need to!


Often special door markers to ID to all staff
Baby kept available for several hours
•
•
•
•
Some autopsy tissue obtained quickly
Dress baby as attractively as possible
Exploration follows fingertip  enfolding order
Mementos kept on file
Special Situations

Surrendering infant for adoption




Adoptive parenting


Immediate postpartum not a time to re-evaluate
Examine/clarify your own values
Private room, may or may not be on maternity unit
Many of the same stages Rubin describes
The ill infant



Encourage bonding
Private room appreciated
Breast pump
Special Situations
 The







ill mother
Private room
Snapshots
Telephone
Family support
Education
Nursery staff and volunteers
Breast pump
Newborn Nursing
Audrey Gives Birth!

The nurse dries the baby immediately
 Places the baby on Audrey’s belly skin to skin or
on a pre-warmed infant warmer prn
• To prevent heat loss by



Evaporation
Convection
Conduction
• To stimulate respirations

Removes wet towels
 Covers with dry towel and warmed hat
 Rapid evaluation of infant’s transition
Rapid Initial Evaluation
 Color
 Tone
 Respirations
 Heart

rate (often by palpation of cord)
Counted for six seconds and multiplied by ten
 General
survey for major anomalies
 General sense of presence in the body
Apgar Scoring
 Score
to assess neonatal wellbeing at
birth
 Obtained at 1 and 5 minutes of life

May be obtained at 10 minutes if still under 7
 A maximum

ten point scale
Five items worth 0, 1 or 2 points each
 High
correlation with low 5 minute apgar
score and morbidity/mortality
Apgar Scoring


Points are 0, 1, 2 for a total of 10
Heart Rate


Respiratory Effort


Flaccid, some flexion, well flexed
Reflex Irritability


Absent, slow-irregular-weak, good-strong
Muscle Tone


Absent, slow (<100), good (>100)
No response, grimace, cry and response
Color

Blue/pale, extremities only blue, all good color
Newborn Identification
 Identiband





Locks and must be cut be removed
May have a chip in it for further security
# corresponds to mother’s #
Other identifying demographic information
Two bands are used (wrist and ankle)
 Footprints

obtained
Unique like fingerprints
Giving Report



Time of birth
Brief synopsis of labor and birth
Respirations spontaneous or assisted



Apgar scores (include why points taken off)
Any medications administered

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If assisted in what way and for how long
Including Vitamin K and erythromycin
General condition of the neonate
Number of vessels
Relevant lab tests (cord bloods, maternal labs, cultures)
Notation of void or meconium passage that occurred
Understanding the Physiologic
Transition from Fetus to Newborn
Physiologic Transition
 Circulatory



changes
In utero, lungs are like wet plastic bags stuck
together with minimal blood flow
With the first few breaths lungs expand and
blood flow for gas exchange begins
Circulatory changes occur that allow blood
flow to change from fetal to neonatal flow
Physiologic Transition
 Umbilical


vein and ductus venosis
(connection to vena cava)
constricts after cord clamped; become
ligaments (takes months)
 Some
babies don’t cry until the cord is
clamped
Physiologic Transition
 Circulatory

Changes
Foramen ovale (rt atrium  aorta) closes
functionally with onset of respirations
• Permanent closure takes several months

Ductus Arteriosis (pulm artery  aorta)
constricts with onset of respirations
• Becomes a ligament (takes months)
Physiologic Transition
 Heart
murmurs are understandably
common


usually clinically insignificant
should be reported
 Heart


rate remains 120-160 bpm
sleep (slower)
activity (higher)
Physiologic Transition
 Circulatory

Changes
Peripheral circulation established slowly over
the first 24 hours
• Acrocyanosis normal (blueish hands and feet)

BP averages 78/42
• not usually checked in L&D

RBC count high initially
• Falls over the first week
• Breakdown of RBC related to neonatal jaundice
Physiologic Transition
 Establishing

respirations
Thoracic squeeze with vaginal birth pushes
excess fluids out of lungs
• Birth by cesarean section ↑ risk for transient
tachypnea of the newborn (TTN)

Surfactants present in full term babies
• Allow lungs and alveoli to expand with first few
breaths
• Prevent alveolar collapse and RDS
Physiologic Transition
respiratory rate is 30 – 60
breaths/min
 Normal

Short periods of apnea are normal
• <15 seconds duration
• must count for a full minute to assess accurately
 Obligate
nose breather
 Chest & abdomen rise simultaneously
Physiologic Transition
 Renal

System
Urine present in bladder at birth
• 1st void within 24 hours
• In breastfed baby one void for each day of life until
milk in (usually day 3-5), then 6-10 voids/day
• In bottlefed baby, one void per day for first 48
hours, then 6-10 voids/day
Physiologic Transition
 Renal

System
Kidneys do not concentrate urine for first
three months
• Attention to adequate hydration essential


Urine pale and straw colored
Uric acid crystals common initially
• May leave brick red spots in diaper
Physiologic Transition
 Gastrointestinal

System
Newborns can establish suckling instinctively
• Help with this is still appreciated!




“Baby cheeks” (fullness) d/t sucking pads
May develop sucking blister on upper lip
Minimal saliva
Cannot move food from lips to pharynx, nipple
must be far into mouth
Physiologic Transition

Gastrointestinal System

Variable feeding patterns
• Usually active in the first hour after birth
• Then ~ 4 hours sleep time
• Then active again

Feeding is a learned skill
• May take a few days to learn how to nurse
• Walking is natural too, and that also takes time

Feeding is emotional area for many moms
• May be interpreted as rejection by her infant if difficult
• Nursing support and knowledge is essential
Physiologic Transition
 Gastrointestinal


System
Circumoral pallor while sucking normal
Stomach capacity small (15–30cc)
• Frequent feedings essential
• Learn early hunger behaviors
• Waiting for late feeding cues interferes with
establishing breastfeeding


Breastfed babies usually feed every 2 hours
Bottlefed babies usually feed every 3-4 hours
• Watch baby, not clock!
Physiologic Transition
 Gastrointestinal


System
Can digest simple carbohydrates and
proteins, may have difficulty with fat in
formulas
Immature cardiac sphincter
• Reflux of food when burped
• Projectile vomiting needs to reported

May signal pyloric stenosis
Physiologic Transition
 Gastrointestinal

System
Meconium
• First stool—black, tarry, sticky

Usually passed within the first 24 hours
• Sterile gut– needs Vitamin K injection



Given within hours of birth
Prevents Hemolytic Disease of the Newborn
Transitional stool is thin, brownish-green
Physiologic Transition
 Normal

newborn stool
Breastfed
• When milk established (days 3-5)
• Loose, golden yellow, seedy, unformed, minimal
odor
• May occur after each nursing

Formula fed
• Formed, pale yellow
• May vary from 1/day to after each feeding
Physiologic Transition
 Hepatic

Liver metabolizes excess hemoglobin
• From breakdown of unneeded fetal RBC
• Unconjugated bilirubin
• Conjugated bilirubin 

(H2O soluable)
• Excreted
Physiologic Transition
 Immature

liver function
Unconjugated bilirubin accumulates
• Jaundice

Lab assessment
• Normal <12mg/dl


Heel stick or transdermal assessment on baby
Clinical Assessment
• Physiologic (normal) begins at >24 hrs of life
• Proceeds head to toe
Physiologic Transition

Pathophysiologic jaundice

Multiple etiologies
•
•
•
•
•



Blood incompatibility
Infection
Trauma
Hypothermia
medications
Indirect coombs test for maternal antibodies (done on
cord blood)
Risk for Kernicterus if severe/sustained
Intervention (light therapy)
Physiologic Transition
 Temperature

Regulation
Newborn cannot shiver to produce heat
• Heat production



Metabolism of brown fat
Increased metabolic rate
Increased activity
Physiologic Transition
 Temperature


Regulation
Newborn has large surface area and large
head – significant source of heat loss
Rapid temperature drop with birth
• Cold stress occurs easily




↑ O2 consumption 
can lead to metabolic acidosis 
respiratory distress
Body temperature stabilizes about 10 hours of
life (if unstressed)
Physiologic Transition
 Immunologic



IgG transplacentally
IgA in colostrum and breast milk
Greatest risk of infection in first six weeks
• s/sx may not be same as in adult



Immunity acquired sequentially
Vaccinations may start in hospital and are
ongoing
http://www.cispimmunize.org
Neurologic/Sensory
 States






of Consciousness
Deep sleep: no body movements, palms open
Light sleep: some body movements
Drowsy: startle, eyes open, “no one home”
Quiet alert: few movements, intent, focused
Active alert: body movements, facial
movements, fussy periods
Crying: active body movements, eyes open or
closed
Neurologic/Sensory

Periods of Reactivity

First
• Begins at birth
• Continues for 1 – 2 hours


Alert, good suck reflex, irregular heart rate and respirations
Second
• Begins around 4 hours





May spit up mucus
Pass meconium
Suck well
Equilibrates by 8 hours of age
Newborns typically sleep ~17/day in short bursts
Neurologic/Sensory
 Impact

on Nursing Interventions
Early discharge timing
• Accommodate periods of reactivity
• Accommodate mother’s level of energy

Teaching
• Consideration of periods of reactivity
• Consideration of newborn’s state
Neurologic/Sensory
 Sight

Newborns can see
•
•
•
•
•
•
•
Best at about 18 inches
“en face” is perfect
Love faces
Enjoy high contrast (black & white)
Will gaze or fix on objects
Uncoordinated eye movements
May mimic slow, repeating facial movements
Neurologic/Sensory
 Hearing


Begins in utero (24 weeks)
Enjoys speech cadence
• Entrainment
• “baby talk” singsong

Teaching
• Talk to the baby!
• Watch baby for “I need a break” cues
Neurologic/Sensory
 Taste



Amniotic fluid has taste and baby has been
tasting in utero
Prefers sweet
Sucking is essential
•
•
•
•
•
Reduces pain and stress
Satisfying
Nourishment
May improve brain development
May decrease SIDS
Neurologic/Sensory
 Smell



Sense present at birth
Newborns can identify their own mother’s
breast pads by smell alone
Newborns may use smell to help establish
nursing
• Not washing their hands right away
Neurologic/Sensory
 Touch



Infants are highly sensitive to touch
Startle easily
Treat with respect
 Bonding

Touch progression
 Swaddling

Seems to calm some babies
Physical Assessment

Weight



Obtained initially soon after birth
Obtained daily
Initial loss of up to 10% body weight normal
• Should be regained by 2 weeks of age

Length

Babies are curled up in utero
• Need some time to stretch out, not measured immediately
• Make sure leg is completely extended when measuring

Average is 45.7 – 60 cm (18-22 inches)
Physical Assessment

Head Circumference



Measure biparietal diameter
33 – 33.5 cm (13-14 inches)
May need to re-measure in a few days if
• Significant molding and caput



Head circumference should be 2 cm> chest
circumference
Report findings > or < the 2cm difference
Chest Circumference


2 cm less than head circumference (3/4 inch)
Measure at level of the nipples
Physical Assessment

Skin



Skin color varies with ethnicity, pigment ↑ after birth
Lanugo and vernix present (↑ with younger GA)
Skin may be dry/peeling in term/post-term
• Palms, soles, possibly cracks/crevices






Acrocyanosis normal x 24 hours
Erythema toxicum neonatorum (“flea bites”)
Mongolian spots (common in African, Asian ancestry)
Harlequin sign
Nevus flammeus “Stork bite”
Milia
Physical Assessment

Head

Caput succedaneum
•
•
•
•

Edema of the scalp (presenting part)
Present at birth
Crosses suture lines
Resolves in a few days
Cephalohematoma
•
•
•
•
•
Blood collection between periosteum and the skull
Often appears by 24 hours of life
Does not cross suture lines
Resolves slowly over several weeks
Increased risk of jaundice from additional blood breakdown
Physical Assessment

Fontanels



Ears




Should be flat (not sunken or bulging)
Open
Even with canthi of eyes
Cartilage present and springy at term
Look at the parents!
Eyes


Slate blue
Some edema/irritation from medication
• Less common with erythromycin than silver nitrate
Physical Assessment
 Mouth

Inspect gums and lips
• Intact
• No teeth

Inspect hard palate
• Intact
• Small white bumps normal (Epstein’s pearls)
Physical Assessment
 Neck




Short
Skin folds
Muscles not strong enough to support head
Abnormalities
• Toriticollis (injury to sternocleidomastoid muscle)
• Webbing
• Masses
Physical Assessment
 Chest


Rounded (transverse and AP diameter =)
Areola edema “breast buds”
• “witches milk”


Circumference 2 cm less than head
Abnormalities
• Clavicle separation/crepitus
• retractions
Physical Assessment
 Abdomen

Rounded, protuberant
• If sunken report immediatelydiaphramatic hernia

Umbilicus
•
•
•
•
One vein, Two arteries
Air dry, alcohol swaps, triple dye
No bleeding, cord clamp secure, base dry
Cord dries, turns black and falls off

Usually by 2 weeks
Physical Assessment
 Genitalia

Male
•
•
•
•
•
•
Scrotum edematous, ruggae present
May be darkly pigmented
Palpate that both testes are descended
Penis small (2 cm), meatus at tip
Do not attempt to retract foreskin
Circumcision



Elective surgery, pain relief necessary
May be part of religious ritual
Should not be done if hypospadias/epispadias
Physical Assessment
 Genitalia

Female
• Maternal hormones may affect genitalia



Vulva edematous
May see vaginal discharge
• Mucus
• Blood tinged (pseudo menstruation)
Labia majora cover labia minora and clitoris
Physical Assessment

Extremities

Short arms and legs
• Fingers reach over proximal thigh



Flexed tone, springs back when extended
Bowed legs
Fat, clenched hands
• Holds grip securely (able to raise up)


Fingernails at least to the tips of the fingers
Hip abduction tests
• Ortolani sign “clunk” of femur head in socket
• Barlows sign “feeling the hip slip out of socket”
Physical Assessment
 Feet



Able to be manipulated into midline easily
Creased over two-thirds of sole
Fat pads make feet appear chubby and flat
 Fingers


and Toes
Syndactaly– fused digits
Polydactly– extra digit (often like a skin tag)
Physical Assessment
 Spine/Back



Spine has “C” curve not “S” like in adults
Posture is affected by fetal position
Inspect the base of the spine
• Hairy tuft
• Dimple
• Pinpoint opening

Gluteal folds even
Physical Assessment
 Anus

Inspect to confirm
• Present
• Patent


Insert gloved, lubricated pinkie finger
Meconium should pass by 24 hours
Physical Assessment
 Reflexes








Blink
Extrusion
Swallowing
Rooting
Sucking
Tonic Neck (Fencing)
Moro
Landeau (U)
Physical Assessment
 Reflexes






Stepping/Placing (Foot/Shin)
Palmar/Plantar grasp
Crossed Extension (Pushing away)
Magnet (pressure against pressure)
Trunk Incurvation
Babinski
 Assessing
neurologic integrity
 Understanding newborn behavior
Gestational Age Assessment
 Standardized
forms for assessing
gestational age. Most common:


Dubowitz
Ballard
 Help
to identify infants who are small for
gestational age versus those who are of
young gestational age
 Guides clinical care and expectations
Gestational Age Assessment
Gestational Age (weeks)
FINDING
0-36
37-38
39+
Sole Creases Ant trans only Ant 2/3
Entire sole
Breast
nodule
Scalp Hair
2mm
diameter
Fine, fuzzy
4mm
diameter
Fine, fuzzy
7mm
diameter
Silky, coarse
Ear Lobe
Pliable, no
cartilage
Some
cartilage
Cartilage stiff
and shaped
Testes &
scrotum
Testes in
canal, few
rugae
intermediate
Scrotum full,
rugae covers
Crying

Infants tend to cry a lot




Infant cry is supposed to be distressing




About 2 hours of each day
“Fussy” time of day
Peaks around 6 weeks
Purpose is to get your attention
Infant can’t talk to express needs
Parents learn specific cries for specific needs
Pacifiers


Individual decision
Not to be used as a plug
Bathing
 Initial


bath
Wear gloves until after first bath
Usually within 1–2 hours of birth
• Important in newborns of HIV+ mothers



Bath should be delayed until after first nursing
Initial bath is complete
Subsequent daily baths may be just face,
neck, hands, diaper area
Bathing
 Always
proceed from cleanest to most
soiled areas of the body
 Gather all equipment ahead of time

NEVER leave an infant unattended
 Protect




neonate from excessive heat loss
Prewarm the room if possible
Expose only one part at a time
Dry well
Hat if cool temperature
Diapering

Nurses wear gloves
 Modern disposable diapers


Very absorbant
Difficult to determine if wet
• Feel for gel to form: “pinch”
• Weigh if uncertain

Urine is very irritating (ammonia)

Wash with clear water and dry well
• Many infants irritated by wipes

Mild barrier ointment (A&D, Vaseline)
• Also helps get sticky meconium off their bottoms!
Sleeping
 “Back

to Sleep”
Always place infant on back to sleep
• Rare syndromes require prone position




Side lying is NOT as safe as supine
Protecting the airway is not a concern
Nurses’ attitudes and teaching directly affect
parents behavior
50% decrease in SIDS deaths
SIDS Facts
 SIDS
is leading cause of death in infants
from 1 month to 1 year
 Most SIDS deaths occur between 2
months and 4 months of age
 African American risk is 2 times that of
white babies
 American Indian/Alaskan Native almost 3
times higher than white babies
SIDS Facts











www.nichd.nih.gov/sids
Always on back
Firm surface
Keep soft objects out
No smoking
Sleep close, but separate
Pacifier
Temperature
Smart shopper, big $ for untested products
Home monitors not necessary to prevent SIDS
Tummy time while awake and adult present
Car Seat Safety
 Usually
required for discharge home
 CHOP has car seat subsidy program




Requires a prescription
Watch video
Pay nominal fee
Can trade up as baby grows when return seat
 Many
fire/police departments have car
seat installation days
Discharge
 Assess

Social worker to assist with issues
 Assess


home environment
support systems
Know community resources
Use the hospital social worker prn
 Assess
knowledge of newborn care
 Parent to schedule f/u visit (2 weeks)

Sooner if concerns or early discharge
Finally Home