Chapter 14: Preparation for Childbirth and Parenting
Childbirth Education
• Childbirth educators
• Childbirth teaching methods
• Efficacy of childbirth education classes
• Preconception classes
• Expectant parenting classes
– Sibling education classes
– Breastfeeding classes
– Preparation for childbirth classes
• Pain management education
– A woman needs to come into labor informed about
what causes labor pain and prepared with breathing
exercises to use to minimize pain during contractions.
– A woman experiences less pain if her abdomen is
relaxed and the uterus is allowed to rise freely against
the abdominal wall with contractions.
– Using the gating control theory of pain perception,
distraction techniques can be employed to alter how
pain is received.
• Birth setting education
– Woman’s health and that of her fetus
– Couple’s preferences
– How much and what kind of supervision couple wants
for birth
Assessing a Family Preparing for Childbirth and
Parenting
Nursing Diagnoses: Preparation for Childbirth and
Parenting
• Health-seeking behaviors related to learning more
about childbirth and newborn care
• If there is a lack of a support person
– Ineffective coping related to lack of a support person
– Anxiety related to absence of significant other
• For a couple unable to make a decision about a
childbirth setting
– Decisional conflict related to lack of information about
advantages and disadvantages of various childbirth
settings
• If there are older children in the family
– Anxiety related to sibling role in pending birth event
and sibling ability to welcome new family member
Nursing Care for a Family Preparing for Childbirth and
Parenting
• Prenatal exercises
– Prenatal yoga- to manage stress throughout life not
only pregnancy - caution on balancing
– Perineal and abdominal exercises - to strengthen
pelvic and abdominal muscles to make these muscles
stronger and more supple for labor
– Perineal and abdominal exercises
• Abdominal muscle contractions- help prevent
constipation, and help restore abdominal tone after
pregnancy.
• Strong abdominal muscles can also contribute to
effective second-stage pushing during labor
Tailor Sitting
- Stretches perineal muscles without occluding
blood supply to the lower leg
Squatting
- Kegel’s Exercise - are helpful in the postpartum
period to reduce pain and promote perineal
healing. They also have long-term effects of
increasing sexual responsiveness and helping
prevent stress incontinence
Pelvic Rocking
- Helps relieve backache during pregnancy and
early labor by making the lumbar spine more
flexible It not only increases her flexibility but
also helps relieve back pain and make her more
comfortable during the night.
Birthing Aids
• use for distraction such as playing cards or
listening to specific music;
• further into labor, she should plan what she could
use as a greater distraction for even stronger
contractions such as singing out loud, having her
partner massage her back, or center intently on
breathing exercises.
• can use an exercise ball, a Jacuzzi tub, or change
of position such as squatting, swaying with a
partner, or rocking in a chair
Pain Management Methods
Also known Childbirth Preparation Class
– Bradley (partner coached)
– Psychosexual
– Lamaze philosophy
– Dick-Read
CHILDBIRTH PREPARATION CLASSES
1. Bradley (Partner-Coached) Method
- stresses the important role of the husband
during pregnancy, labor and early newborn
period
- woman uses muscle toning exercises
- limits or omits food that contain preservatives,
animal fat and high salt content
- abdominal breathing exercise
- woman is encouraged to walk during labor
- use of dissociation technique
2. Dick-Read Method
- tension (psychic and muscular) is aroused by
fear and anticipation of pain tension
>>>fear >>>Pain
- sympathetic stimulation brought about by fears ➢ Level 5 – continuous chest panting (60cpm),
causes contraction of the circular muscle of the strong contraction and 2nd stage of labor
cervix
Breathing Patterns During a Single Contraction
- prenatal courses and training reduce fear,
educate and boost self-confidence
- Covers:
- fetal development and childbirth
- pain relief methods
- muscle strengthening exercises
- breathing techniques - abdominal breathing
contraction
- physical and emotional health for children
-mother gets emphatic understanding from
partner, nurse,and physician
3. Lamaze Method (Psychoprophylactic method)
- based on stimulus – response conditioning
- (Pavlov Theory of Classical Conditioning)
- where unfavorable responses are replaced by
favorable conditioned responses
- high level of activity can excite higher brain
centers to inhibit other stimuli as pain
- woman is taught to replace responses of
anxiety, fear and loss of control with more Effleurage Patterns
useful activity

Lamaze techniques

Conscious relaxation

Cleansing breath

Conscious controlled breathing

Effleurage

Focusing

Second-stage breathing

➢ Conscious Relaxation – learning to relax

muscles deliberately
➢ Cleansing Breath – woman breathes in
deeply and exhales deeply
➢ Consciously Controlled Breathing (Set
breathing Patterns)
➢ Level 1 – full respiration, 6 – 12cpm, early
contraction
➢ Level 2 – lighter, 40cpm, 4-6cm dilated
➢ Level 3 – more shallow, 50 - 70cpm,
transition contraction
➢ Level 4 – pant blow pattern, 3-4 quick
breaths then forceful expiration
Lamaze method….
- Covers: practice of breathing techniques during
labor; controlled perception;
- relaxation of involved muscles;
- mouthing silently words or songs with
rhythmical tapping of fingers; supportive person
nearby in a calm environment
Nursing Care for a Family Preparing for Childbirth and
Parenting
 – Alternative birth center

– Home birth

• Birth setting

– Hospital birth

– Hydrotherapy and water birth

– Unassisted birth
Alternative Birthing Methods

Leboyer Method

- The contrast of intrauterine environment and

the external world causes infant to suffer
psychological shock at the time of delivery
- Birthing room is darkened
- Soft music
- Gentle controlled delivery
- Covers: Relaxing the craniosacral axis by
supporting the head, neck and sacrum
- Restoring body heat loss by warm bath
- Allowing infant to breathe spontaneously
- Delaying cutting of cord to permit placental
blood flow
- Bonding mother and infant by skin to skin
contact
– Hydrotherapy -Infant placed I
mmediately into warm-water bath
– Unassisted birth

Nursing Care for a Family Preparing for Childbirth and

Parenting
Chapter 15 Caring for a Family During labor and Birth

LABOR AND DELIVERY

➢ Labor is a process is a process whereby with

time regular uterine contractions brings about
progressive effacement and dilatation of the
cervix, resulting in the delivery of the fetus and
expulsion of the placenta.

Critical factors affecting the process of labor:

- Passage
- Passenger
- Power Components of Labor
- Psyche: Psychological outlook
- Position  Passageway

THEORIES OF LABOR ONSET  Passenger

1. Uterine Stretch Theory – Any hollow muscular  Power

organ when stretched to the capacity will
contract and empty The uterine muscle
stretches from the increasing size of the fetus,
which results in release of prostaglandins
2. Oxytocin Theory – The fetus presses on the
cervix, which stimulates the release of oxytocin
from the posterior pituitary.
3. Progesterone Deprivation Theory – as
pregnancy nears term, estrogen increased while
progesterone level drops, hence uterine
contraction occurs.
- Rising fetal cortisol levels reduce progesterone
formation and increase prostaglandin
formation.
- Changes in the ratio of estrogen to
progesterone occurs, increasing estrogen in
relation to progesterone, which is interpreted
as progesterone withdrawal.
4. Prostaglandin Theory – when pregnancy
reaches term, the fetal membranes , the fetal
membrane begins to produce prostaglandins,
which stimulate contractions.
5. Theory of the aging Placenta – as the placenta
ages it becomes less efficient
The placenta reaches a set age, which triggers
contractions.
Assessing for Preliminary Signs of Labor
 Psyche
I. Passageway (maternal)
- Route from uterus to external perineum
– size and type of pelvis, ability of the cervix
to efface and dilate, and distensibility of
vagina and introitus
• Pelvis – the bony ring through
which the fetus passes during labor
and delivery;
• Measurements – may be obtained
by internal and external pelvic
examination
• x-ray pelvimetry (used rarely in
pregnancy and only late in third
trimester or in labor), and
ultrasound
Pelvic types:
a. Gynecoid
o classic female pelvis inlet, well rounded
(oval); ideal for delivery
o most ideal for childbirth (50% of
women)
b. Android
o resembling a male pelvis, narrow and
heart-shaped; usually requires
cesarean section or difficult forceps
delivery (20% of women)
c. Platypelloid
 oflat, broad pelvis; usually not adequate
for vaginal delivery (5% of women)
Molding
d. Anthropoid
o similar to pelvis of anthropoid ape;
long, deep, and narrow; usually
adequate for vaginal delivery (25% of
women)
• Station
- is overlapping of skull bones along the suture
lines, which causes a change in the shape of the
fetal skull to one long and narrow, a shape that
facilitates passage through the rigid pelvis.
- sagittal and coronal sutures
• Fetal skull

• Size – primarily related to fetal skull

Fetopelvic relationships
Pelvic Inlet and Outlet • Lie – relationship of spine of fetus of spine
of mother;
-longitudinal (parallel)
-transverse (right angles)
-oblique (slight angle off a true transverse lie)
Station

Types of fetal presentation

II. Passenger (fetal)
– Structure of fetal skull
– Diameters of fetal skull
– Molding
– Fetal presentation and position
• Attitude
• Fetal lie
• Engagement
 • Presentation
- part of fetus that presents to (enters) maternal
pelvic inlet
1. Cephalic/vertex – head presentation (>95% of
labor)
2. Shoulder
3. Breech presentation
- Complete – flexion of hips and knees
- Frank (most common) – flexion of hips and
extension of knees
- Footling/incomplete – extension of hips and
knees

• Position
- relationship of fetal reference point to mother’s
pelvis
• Attitude/ habitus
- relationship of fetal parts to each other; usually Fetal reference point
flexion of head and extremities on chest and
➢ Vertex presentation – dependent upon degree
abdomen to accommodate to shape of uterine
of flexion of fetal head on chest;
cavity
- Vertex – head is maximally flexed - full flexion–occiput (O);
full/complete flexion
- Military – head is partially flexed full extension–chin (M);
- Brow – head is maximally extended moderate extension–brow (B)
- Face – head is partially extended
➢ Breech presentation – sacrum (S)  Shoulder
presentation – scapula (SC)
➢ Relation of the presenting part to a specific
quadrant of a woman’s pelvis
Right anterior
Left anterior
 Right posterior Right occiput anterior (ROA)
Left posterior
➢ Maternal pelvis is designated per her
-right/left
-anterior/posterior

FETAL POSITION

Left occiput transverse (LOT)

Right occiput transverse (ROT)

Occiput posterior (OP)

Occiput Anterior (OA)

Left occiput anterior (LOA)

Left occiput posterior (LOP)

 - Engagement refers to the settling of the
presenting part of a fetus far enough into the
pelvis that it rests at the level of the ischial
spines, the midpoint of the pelvis.

• Station
- level of presenting part of fetus in relation to
imaginary line between ischial spines (zero
Right occiput posterior (ROP)
station) in midpelvis of mother
- –5 to –1 indicates a presenting part above zero
station (floating);
- +1 to +5, a presenting part below zero station
- +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).
- Engagement – when the presenting part is at
station zero

Anterior Fontanel
o The bones of the fetal scalp are soft and
meet at "suture lines." Over the
forehead, where the bones meet, is a
gap, called the "anterior fontanel," or
"soft spot.“
o will close as the baby grows during the
1st year of life, but at birth, it is open.
12 to 18 months
o The anterior fontanel is an obstetrical
landmark because of its' distinctive
diamond shape
Posterior Fontanel
o The occiput of the baby has a similar III. Power – force expelling the fetus and
obstetric landmark, the "posterior placenta
fontanel.“ 1. Primary – involuntary uterine
o This junction of suture lines in a Y shape contractions
that is very different from the anterior o Three phases
fontanel. ✓ Increment – steep crescent
slope from beginning of a
contraction until its peak
✓ Acme/peak – strongest
intensity
✓ Decrement – diminishing
intensity

• Engagement
 ➢ Dilation – opening and enlargement of the
cervical canal; measured in centimeters 0-10 cm
(10 cm is fully dilated)

EFFACEMENT AND DILATION OF CERVIX

Powers of labor

– Uterine contractions

• Origins

• Phases

• Contour changes

– Cervical changes

• Effacement

• Dilatation IV. Psyche of labor

Characteristics of contractions
1. Frequency – from the beginning of one contraction to
the beginning of the next one; frequency of less than
every 2 min should be reported
2. Duration – beginning of a contraction to its
completion; more than 70- 90s should be reported
because of potential risk of uterine rupture or fetal
distress
3. Intensity – the strength of a contraction at acme; may
be assessed by subjective description from the woman
and palpation
-mild contraction -feel like the tip of the nose,
- moderate like the chin,
- strong like the forehead
POWERS
2. Secondary – voluntary bearing-down
efforts
Cervical changes
➢ Effacement – thinning and shortening of the
cervix during late pregnancy and/or labor;
measured in percentages (100% is fully effaced)
– Women who manage best in labor
typically have a strong sense of self-esteem
and a meaningful support person with
them.
– Women without adequate support can
have a labor experience so frightening and
stressful that they develop symptoms of a
posttraumatic stress disorder.
- fear and anxiety may lead to increased
perception of pain and impede progress of
labor; preparation and support for
childbirth
- may enhance coping efforts
➢ Preparation for childbirth education about the
birthing process and methods to decrease
discomfort and tension
➢ Always begin and end with “cleansing” or
“relaxing” breath (inhale deeply through nose
and exhale passively through relaxed, pursed
lips)
➢ Hyperventilation – may cause maternal
respiratory alkalosis and compromise fetal
oxygenation; characterized by light-headedness,
dizziness, tingling of fingers ; managed by
having woman breathe into her cupped hands
or a paper bag
➢ Support person/”coach” should be involved in
the formal preparation
 ➢ Position (maternal)
➢ Side-lying enhances blood flow to the utero-
feto-placental unit and maternal kidneys ( left)
vena cava syndrome
➢ Upright (standing, walking, squatting) enlists
gravity to aid in fetal descent through the birth
canal
➢ Frequent changes relieve fatigue and improve
circulation

Cardinal mechanisms/ movements of labor

▪ usually flow smoothly and often overlap;

▪ failure to accomplish one or more usually
requires obstetrical intervention
▪ (ED FIrE ErE)
➢ Engagement - movement of the presenting
part below the plane of the pelvic inlet
➢ Descent – progress through the maternal
pelvis; continuous throughout labor
➢ Flexion – as a result of resistance from
maternal pelvis and musculature, the head Signs of Labor
flexes so that a smaller diameter enters  Signs of true labor
pelvis
➢ Internal rotation – head rotates from Uterine contractions
occiput transverse or oblique position
Show - operculum, bloody
(usual position as it enters the pelvis) to
anterior/posterior at pelvic outlet; head is Rupture of membranes
under symphysis pubis and neck is twisted
➢ Extension – the head is moved backward as
it proceeds under the symphysis pubis and
baby is born by extension over the
perineum
➢ Restitution and external rotation –
movement of head to align itself with face
and shoulders (restitution) and then
rotation bringing shoulders into
anteroposterior diameter appears as one
movement
➢ Expulsion – first the anterior shoulder
under the symphysis pubis, then the
posterior shoulder over the perineum,
followed rapidly by the rest of the body;
time of birth is recorded at this time Signs and symptoms of labor:
MECHANISM OF LABOR & CARDINAL MOVEMENTS OF A 1. Impending – may begin several weeks prior to
FETUS labor
Lightening “the baby dropped” settling
of uterus and fetal presenting part into pelvis
 ▪ sensation of decreased abdominal
distention
▪ Increase Braxton-Hicks contractions
▪ mild, intermittent, irregular, abdominal
contractions
▪ decrease/disappear with activity
▪ May be heightened anxiety, and
anticipation, fatigue
▪ Weight loss of about 2-3 lb 3-4 days
before onset of labor; related to
changes in estrogen and progesterone
levels
▪ Increased vaginal mucus discharge
▪ Fetal movements may appear less
active
▪ May be episodes of false labor
2. Onset Stages of Labor
▪ Expulsion of mucous plug; pink/brown-
❖ First stage – from start of true contraction to
tinged discharge (bloody show)
full cervical
▪ Regular contraction increasing in
DILATATION
frequency, duration, and intensity
➢ Latent phase
▪ Spontaneous rupture of membranes
➢ Active phase
(SROM) may occur before or during
➢ Transition phase
▪ Check FHR by auscultation for 1 min
❖ Second stage
and with next contraction
➢ Period from full dilatation and cervical
▪ May be a gush or trickle; report
effacement to the crowning and birth of
strong/foul odor (infection), meconium-
the infant
stained (in vertex presentation, may
❖ Third stage – from the birth of the baby to
indicate fetal anoxia) or wine-colored
complete placental expulsion
(indicative of premature separation of
➢ Placental separation
placenta)
➢ Placental expulsion
▪ Questionable leakage of amniotic fluids
should be tested for alkalinity to
differentiate from urine:
– Nitrazine tape turns blue/gray/green Friedman’s Division of Labor
(alkaline); urine (acidic) does not Stages of Labor:
change the yellow color
– A mixture of cervical mucus and 1) First stage (dilating/ Cervical stage) – from onset
amniotic fluid dried on a slide looks like of regular contraction to full cervical dilation
crystallized ferns by microscopic ➢ AVE: 13-18 h for nulliparas
examination 8-9 h for multiparas
a. Latent phase (0-4 cm) – the cervix
DIVISIONS OF LABOR/ FRIEDMAN’S CURVE begins effacing and dilating and
contractions become increasingly
stronger and more frequent
DURATION: nulliparas 7-10 hrs
multiparas 5-6 hrs
 b. Active phase (5-7 cm) – more rapid
dilation of cervix and descent of
presenting part
DURATION: approximately 3-4 h for
both
c. Transition (8-10 cm) – contractions may
be every 1.5 to 2 min and last 60-90sec
DURATION: should not >3 h for
nulliparas 1h for multiparas
▪ May be accompanied by irritability and
restlessness, hyperventilation, and dark heavy
show, as well as leg cramps, nausea/vomiting,
hiccups, belching
▪ Possible rectal pressure creating a desire to
push; should discourage before full dilation
because it may cause maternal exhaustion and
cervical and fetal trauma
▪ Monitor vital signs and FHR
▪ Provide comfort measures
- (ambulate if tolerated and if BOW is not
ruptured yet;
- side lying is usually most comfortable,
- sacral pressures, back rubs)
▪ Breathing technique during transition phase:
Take a deep breath and exhale slowly and
completely.
At beginning of contraction, take a fairly deep
breath. Then engage in shallow breathing. If
there is an urge to push, puff out every 3rd, 4th,
or 5th breath. Take deep breath at the end of
contraction.
2) Second stage (stage of expulsion) - from
complete dilation of cervix to delivery of the
baby
➢ AVE: 2 h for nulliparas
20 min for multiparas
Contractions are now severe, lasting 60-
90 sec at 1.5 to 3 min intervals
▪ Bearing down/pushing increases intra-
abdominal pressure from voluntary contraction
of maternal abdominal muscles and pushes the
presenting part against the pelvic floor, causing
a stretching, burning sensation and bulging of
the perineum;
▪ “crowning” occurs when the presenting part
appears at the vaginal orifice, distending the
vulva
▪ Timing of transfer to delivery room
Nulliparas – during second stage when the
presenting part begins to distend the perineum
Multiparas – at the end of first stage when the
cervix is dilated 8-9 cm
3) Third stage (placental stage) - from delivery of
the baby to delivery of the placenta; if more
than 30 min, placenta is considered retained
➢ AVE: < 30mins
▪ Signs of placental separation:
1. uterus becomes firm and globular
and rises in the abdomen, Calkin’s
sign
2. a sudden gush/trickle of blood
3. lengthening of the umbilical cord
▪ Expulsion of the placenta through
the vagina by uterine contractions
and pushing by mother or by gentle
traction on the umbilical cord
Placental delivery make take 5-10 minutes (maximum
30 minutes) types:
➢ Duncan – margin of the placenta
separates first and the dull, red, rough
maternal surface emerges from from
the vagina first (dirty presentation)
➢ Schultze – center portion of the
placenta separates first and the shiny
and glistening fetal surface emerges
from the vagina
➢ Crede’s maneuver – gentle pressure on
the contracted uterine fundus (never on
a non contracted uterus; uterus may
evert and lead to hemorrhage)
➢ Contraction of the uterus following
delivery controls uterine hemorrhage
and produces placental separation
4) Fourth stage - immediate recovery period from
delivery of placenta to stabilization of maternal
systemic responses and contraction of the
uterus
DURATION: from 1 to 4 h
– Mother begins to readjust to non-pregnant
state
 Areas of concern include discomfort due to:
- contraction of uterus or after pains)
- episiotomy,
- fatigue or exhaustion, hunger, thirst,
- excessive bleeding,
-bladder distention,
-parent-infant interaction
Chapter 16: Nursing Care of a Postpartal Woman and - Position – even to 1 cm/finger breadth above
Family the umbilicus for the first 12 h, then descends
by one finger breadth each succeeding day,
Postpartal Period
pelvic organ usually by day 10
- Puerperium: 6-week period after childbirth If with deviations, check bladder and have
✓ Retrogressive maternal changes patient void; if deviations continue, massage
 Involution of uterus and vagina fundus
 Exhaustion
 Weight loss
 Vital signs- Temperature, Pulse & Blood
pressure
✓ Progressive maternal changes
 Production of milk for lactation,
 restoration of normal menstrual cycle
 beginning of a parenting role

Physiologic Changes of the Postpartal Period

❖ Reproductive changes
o – Uterus
o – Lochia
o – Cervix
o – Vagina
o – Perineum

Lochia – (endometrial sloughing)

– day 1-3 rubra (bloody with fleshy odor; may
be clots)
– day 4-9 serosa (pink/brown with fleshy odor)
– day 10+ alba (yellow-white)
at no time should there be a foul odor (indicates
infection)

Involution – (uterus reduced to prepregnant

size)
- Fundus – midline, firm

Perineum
 possible discomfort, swelling, and/or
ecchymosis
 Managed with analgesics and/or topical
anesthetics,
- ice packs for first 12-24hrs and then 20
min sitz baths 3-4 times/d,
- tightening buttocks before sitting 
 Monitor episiotomy/laceration
episiorraphy – teach techniques to
prevent infection, e.g., change pads on
regular basis, peri care (cleaning from
front to back after each voiding and
bowel movement),
- Sitz baths
Breasts
- progress from soft filling with potential for
engorgement (vascular congestion related to
increased blood and lymph supply; breasts are
larger, firmer, and painful)
- E.O 51
 Non-nursing woman – suppress
lactation
Mechanical methods – tight-fitting
brassiere, ice packs, minimize breast
stimulation
 Nursing woman – successful lactation is
dependent on infant sucking and
maternal production and delivery of
milk (letdown/milk ejection reflex);
-monitor and teach preventive
measures for potential problems
- Discomforts:
1) Nipple – irritation/cracking
 Nipple care – clean with water, no soap,
and dry thoroughly; absorbent breast
pads if leaking occurs; expose to air
 Position nipple so that infant’s mouth
covers a large portion of the areola and
release infant’s mouth from nipple by
inserting finger to break suction
 Rotate breastfeeding positions
2) Engorgement
 nurse frequently (every ½-3 h) and
long enough to empty breasts
completely (evidenced by sucking
without swallowing)
 warm shower or compresses to
stimulate let down
 alternate starting breast at each
feeding
 mild analgesic 20 min before
feeding and ice packs between
feedings for pronounced discomfort
Plugged ducts – area of tenderness and lumpiness often
associated with engorgement; may be relieved by heat
and massage prior to feeding
Expression of breast milk
o to collect milk for supplemental feedings
o to relieve breast fullness or to build milk supply
o may be manually expressed or pumped by a
device and refrigerated for no more than
-48 h or frozen in plastic bottles (to maintain
stability of all elements)
- in refrigerator freezer for 2 wk and
- deep freezer for 2 mo (do not thaw in
microwave or on stove)
o Medications – most drugs cross into breast
milk; check with physician before taking any
medication
Physiologic Changes of the Postpartal Period • By touching and cuddling, naming, “en face”
positioning for direct eye contact, later by
❖ Systemic changes
reciprocity and rhythmicity in maternalinfant
o – Hormonal
interaction
o – Urinary
o – Circulatory • Positive family relationships
o – Gastrointestinal
– Rooming-in
o – Integumentary
– Sibling visitation
Elimination
Assessing a Postpartal Woman and Family
 Urinary
- increased output (postpartum diuresis),
- urethral trauma, decreased bladder sensation,
and
- inability to void in the recumbent position may
cause bladder distention,
- incomplete emptying and/or urinary stasis
increasing the risk of uterine relaxation and
hemorrhage and/or UTI
Interventions:
▪ Monitor I and O
▪ Encourage voiding for 1st 24 h
(early ambulation and pouring
warm water over perineum);
▪ catheterization may be necessary if
no voiding after 8 h
Psychological Changes
 Gastrointestinal –
-bowel sluggishness, ➢ Phases
- decreased abdominal muscle tone, o Taking-in
- perineal discomfort may lead to constipation; o Taking-hold
 Managed by early ambulation, increased dietary o Letting-go
fiber and hydration, stool softeners
 After pains Phases of adjustment
-cramps due to uterine contractions lasting 2-3 1) “Taking in”/dependency (day 1-3 after delivery)
days; ▪ preoccupied with self and own needs
-more common in multipara and with nursing; -(food and sleep);
 May be relieved by lying on abdomen with small -talkative and passive;
pillow, heat, ambulation, mild analgesic (if -follows directions and is hesitant about
breast feeding, 1 h before nursing) making decisions;
 Rubella vaccine – for susceptible woman; -retells perceptions of birth experience
 RhoGam as appropriate 2) “Taking hold”/dependencyindependency (by
day 4
▪ Performing self-care; expresses concern
Psychosocial adjustment for self and baby;
▪ open to instructions
✓ Attachment/bonding – influenced by maternal
3) “Letting go”/independence (evident by weeks
psychosocial-cultural factors, infant health
5-6)
status, temperament, and behaviors,
▪ -assuming new role responsibilities;
circumstances of the prenatal, intrapartal,
▪ may be grief for relinquished roles;
postpartal, and neonatal course;
 ▪adjustment to accommodate for infant
in family
4) “Postpartum blues” (day 3-7)
▪ normal occurrence of “roller coaster”
emotions, weeping, “let-down feeling”;
usually relieved with emotional support
and rest/sleep;
▪ report if prolonged or later onset
▪ Other: abandonment , disappointment
• Preparing for discharge
– Group classes
– Individual instruction
– Discharge planning
– Postpartal examination
• Relief of discomforts

Assessing a Postpartal Woman and Family – Afterpains

First 24 hours – Muscular aches

– Health history – Hot and cold therapy

• Family profile – Perineal exercises

• Pregnancy history – Episiotomy care

• Labor and birth history

• Infant data

• Postpartal course

– Laboratory data

– Physical assessment

• General appearance

• Hair

• Face

• Eyes

– Reproductive system physical assessment

• Breast

• Uterus

• Lochia

• Perineum

Nursing Care During the Postpartal Period

• Perineal care • Perineal self-care • Rest • Adequate

fluid intake • Urinary elimination •
Constipation/haemorrhoids

• Assess peripheral circulation. • Prevent/alleviate

breast engorgement. • Promote breast hygiene. •
Promote uterine involution.
 • Patient states degree of pain is tolerable; patient
demonstrates knowledge of measures for adequate
pain relief.

• Patient maintains vital signs within normal range;

fundus is firm to palpation; lochia discharge is small
to moderate with a minimum of clot formation.

NURSING DIAGNOSIS

• Nursing diagnoses during the postpartal period

are often “risk for” diagnoses and concerned
with a family’s ability to accept and bond with a
new child or with physiologic considerations.
• Health-seeking behaviors related to care of
newborn
• Fear related to lack of preparation for child care
• Risk for deficient fluid volume related to
postpartal hemorrhage
• Risk for altered family coping related to an
additional family member
• Risk for complications in human
lactation/breastfeeding
• Uncertainty regarding the infant’s well-being if
there are congenital anomalies

Outcomes: The Postpartal Period

• Patient states she is able to sleep and feels rested

during postpartal period.

• Patient’s temperature remains below 100.4°F;

lochia is present and without foul odor.
Chapter 17: Nursing Care for the Family in Need of
Reproductive Life Planning
Reproductive Life Planning
▪ Includes all decisions an individual or a couple
make about having children, including
– If and when to have children
– How many children to have
– The length of time between having children
Counseling may include the topics of avoiding
conception, increasing fertility, and/or what to
do if contraception has failed.
Contraceptive
▪ Any device used to prevent fertilization of an
egg
An ideal contraception is...
▪ Safe
▪ Effective
▪ Compatible with spiritual and cultural beliefs
and personal preferences
▪ Free of bothersome side effects
▪ Convenient to use/ easily obtainable
▪ Affordable
▪ Needs few instructions
▪ Free of effects after discontinuation
Areas to Assess in Making Choices About
Contraceptive Methods
▪ Personal values
▪ Ability to use method correctly
▪ Impact on sexual enjoyment
▪ Financial factors
▪ Length of projected relationship (short term
versus long term)
▪ Past experience with contraception Future
plans regarding pregnancy
Areas to Assess in Making Choices…
▪ Vital signs, Pap smear, gonococcal and
chlamydial screening
▪ Obstetric history, including STIs, past
pregnancies, previous elective abortions, failure
of previously used methods, and compliance
history with past methods
▪ Patients’ beliefs, needs, feelings, and
understanding of conception
▪ Current and anticipated sexual practices,
number of partners, feelings, and body image
Categories of Commonly Used Birth Control Methods
▪ Natural family planning
▪ Barrier methods
▪ Hormonal contraceptives
▪ Intrauterine devices (IUDs)
▪ Surgical methods
NATURAL FAMILY PLANNING
1. Periodic abstinence methods
– No chemical or foreign material into body
– Failure rate ranges from 2% to 25%
– Need for couple to be conscious of time
period when woman is most likely to be fertile
Abstinence:
– 0% failure rate
– Most effective method to prevent
sexually transmitted infections (STIs)
2. Lactation amenorrhea method
▪ Failure rate - 1 to 5%
▪ Under six months of age
– Breastfeeding with no supplements
– Menses has not returned
▪ Totally breastfed at least daytime -q
4hours night- q 6 hours
• no supplementary feedings
▪ Not dependable- woman may be fertile
even if she has not had a period since
childbirth
▪ After 6 months, she should use another
method of contraception
3. Coitus interruptus (Withdrawal)
▪ Oldest method
▪ Couple proceeds with coitus until the
moment of ejaculation, then the man
withdraws and spermatozoa are
emitted outside the vagina
▪ Offers little protection because
ejaculation may occur before
withdrawal is complete and despite the
care used, spermatozoa may be
deposited in the vagina
▪ Effective – 82%
▪ does not prevent STIs
Side effects of NFP ▪ First unsafe day: subtract 18 from
the number of days in your shortest
▪ None
cycle
▪ Not choice of adolescents
▪ Last unsafe day: subtract 11 from
▪ Issues on
the number of days in your longest
-perimenopausal women
cycle
- postpartal woman
▪ Ex: shortest: 26 – 18 = day 8
4. FERTILITY AWARENESS METHODS
longest: 31 – 11 = day 20
▪ Detecting when the woman will be
▪ UNSAFE PERIOD!! Days 8 -20
capable of impregnation so abstinence
-Avoid coitus or use a
can be used.
contraceptive
▪ sperm survival – 3 to more than 5 days
▪ Ova- 1 day (last up to 48 hours)
▪ Fertile period- 5 days before ovulation
to 1 day after.
i. Calendar (rhythm) method
ii. Basal body temperature
iii. Cervical mucus (Billings)
method
iv. Symptothermal method
v. Ovulation awareness/detection
vi. Standard days method: Use of
Cycle beads
vii. 2 Day method
viii. Marquette model
i. Calendar/ Rhythm (Natural Family ii. Basal Body Temperature
Planning) ▪ Involves taking the temperature
▪ Action – periodic abstinence from every morning BEFORE the woman
intercourse during fertile period; gets out of bed and recording it
based on the regularity of ▪ The temperature drops slightly 0.5 F
ovulation; 24 hours before ovulation, then
▪ variable effectiveness rises to about half a degree higher
▪ Entails keeping a day-by-day record than normal and remains thus for
of your cycle for 6 consecutive up to three days: UNSAFE period!
months ▪ Not a very efficient method unless
▪ This 6 month record will show you combines with calendar and mucus
your longest and shortest cycles- methods
from which you can calculate your ▪ 3 to 25% failure rate
FERTILE days iii. Cervical Mucus (Billings) Method
▪ The first day of menstrual bleeding ▪ Involves becoming aware of the
(day 1 of your period) counts as the normal changes in the cervical
first day of the cycle. secretions that occur throughout
▪ Approximately 14 days (or 12 to 16 your cycle by inserting the
days) before the start of the next forefinger into the vagina first thing
period, an egg will be released by in the morning
one of the ovaries. ▪ A few days after menstrual
▪ While the egg from the woman lives bleeding: little secretion, vagina is
for only around 24 hours, sperm dry
from the man can survive for up to
3 days, possibly longer.
 ▪ Gradually, secretion increases and hormonal fertility monitor and their
becomes thicker, cloudy white and cervical mucus.
sticky ▪ 98% effective
▪ As ovulation approaches, this viii. Post coital douching
secretion or mucus becomes ▪ Ineffective
copious, clear, thin, less viscous,
more liquid, slippery or stringy; as
soon as this change begins and for 3 BARRIER METHODS
to 4 days later: UNSAFE PERIOD!!
➢ Barrier methods are those that place a chemical
Cervical Changes or latex barrier between the cervix and
advancing sperm.
 Spinnbarkeit test =
– Spermicides
o Cervical mucus is thin, watery and can
– Male and female condoms
be stretched into long strands
– Diaphragm
o high level of estrogen: ovulation is
– Cervical cap
about to occur
1. SPERMICIDES
 Ferning
o of cervical mucus
o At the height of estrogen stimulation
just before ovulation
o Ferning- due to crystallization of sodium
chloride on mucus fibers
iv. 2-day Method
▪ Assessing vaginal secretions daily
for 2 days
▪ Suggests fertility
▪ Avoids coitus
▪ 12 days per month
Goal: death of the sperm before the sperm
v. Symptothermal method
enters the cervix
▪ Combines BBT and cervical mucus
- Changes the vaginal ph to strong acid level
methods
- No protection for STIs
▪ Observes for other signs of
-Nonoxynol-9
ovulation
-gel, creams, films, foams, suppositories
- cervical mucus
- 1hour before coitus
-BBT
- CI: women with acute cervicitis]
- cervix position and softness
**developed in 1990
2. MALE CONDOM
vi. Ovulation awareness
▪ Use of over-the-counter OTC
ovulation test kit which detects the
midcycle LH (luteinizing hormone)
surge in the urine 12 to 24 hours
before ovulation
▪ 98 to 100% accurate
vii. Marquette Model
▪ is a fertility awareness method that
teaches women to identify their
fertile window and their periods of - 2 to 15 % failure rate
infertility by using an electronic - Advantages: male responsibility
 - No prescription
- for couples not engaged in monogamous
relationship
3. FEMALE CONDOM
- Latex or polyurethane made
- inserted before coitus
- One time use only
- No prescription needed
- Not use together with male condom
- 5 to 15% FR
- Protects from STIs
- Not popular – bulky, difficult to use
- Sensitivity or allergy to latex
4. DIAPHRAGM
-mechanically halt sperm from entering the
cervix
-soft latex dome supported by a metal rim
- maybe added with spermicidals can be
inserted 2 hours before intercourse;
removed at least 6 hours after coitus or
within 24 hours -size must fit the individual
- initially fitted by a doctor
-washable, may be used for 2 years
- 6 to 18% FR
5. CERVICAL CAP
- similar to diaphragm but smaller
- thimble-shaped rubber cap held onto the cervix
by suction can be left for 48 hours
- Failure rate- 23 to 35%
Contraindications/side effects
▪ Abnormal uterus and cervix
▪ High incidence of UTIs
▪ Other infection
▪ Allergies
Chief method for adolescents
HORMONAL CONTRACEPTIVES
➢ Hormones that cause fluctuations in the normal
menstrual cycle to prevent ovulation or normal
transport
– Oral contraceptive (combination of hormones)
– Oral contraceptives (progestin only)
– Transdermal patch
– Intravaginal ( vaginal rings)
– Intramuscular injections
– Subdermal hormone implants
1. Oral contraceptives (combination of hormones)
▪ Aka: OC, COC
▪ Composed of varying amounts of
estrogen combined with small amount
of progesterone
▪ Estrogen suppresses FSH and LH,
thereby suppressing ovulation
▪ Progesterone decreases the
permeability of cervical mucus
▪ 99.5% effective
Types: ▪ Breast or reproductive tract malignancy
▪ Diabetes Mellitus
Monophasic- - Fixed doses of estrogen and
▪ Elevated cholesterol or triglycerides
progesterone ; 21 day cycle
▪ High blood pressure
Biphasic- - Constant amount of estrogen with varrying ▪ Mental depression
progesterone ▪ Migraine or other vascular type headaches
▪ Obesity
Triphasic & Tetraphasic- Varying levels of estrogen and ▪ Pregnancy
progesterone ▪ Seizure disorders
Oral contraceptives (progestin only) ▪ Sickle cell or other hemoglobinopathies
▪ Smoking Use of drug with interaction effect
How to start:

▪ Sunday start Quick start

▪ 1st day start 1. Estrogen-progesterone transdermal patch
▪ After childbirth ▪ Highly effective, weekly hormonal birth control
patch that’s worn on the skin
Not effective for 1st 7 days- Provide back up ▪ Combination of estrogen and progestin
contraceptive ▪ Absorbed on the skin and then transferred into
Benefits of OC’s: the bloodstream
▪ Can be worn on the upper outer arm, buttocks,
DECREASED incidences of: trunks or abdomen
▪ Worn for 1 week, replaced on the same day of
✓ Dysmenorrhea
the week for 3 consecutive weeks. No patch-4th
✓ Premenstrual dysphoric syndrome
week
✓ Iron deficiency anemia
▪ Less effective for obese women
✓ Acute PID with tubal scarring
✓ Endometrial and ovarian cancer and ovarian
cysts
✓ Fibrocystic breast disease 2. Vaginal estrogen /progestin rings
▪ Inserted vaginally and left for 3 weeks
Side Effects and removed for 1 week for
menstruation
▪ Nausea
▪ Absorb directly by mucus avoiding “
▪ Weight gain
first pass” through the liver
▪ Headache
▪ Not removed for intercourse
▪ Breast tenderness
▪ As effective with COC
▪ Breakthrough bleeding
▪ If removed > 4 hours – replace with new
▪ Monilial vaginal infections
▪ Mild hypertension
▪ Depression

Absolute Contraindications to OC’s

▪ Breastfeeding
▪ Family history of CVA or CAD
▪ History of thromboembolic disease
▪ History of liver disease
▪ Undiagnosed vaginal bleeding

Possible Contraindications to OC’s

▪ Age 40+
 ▪ Every 12 week, inhibits ovulation, alters
endometrium and thickens cervical
mucus
▪ 100% effectiveness- popular
▪ Can be used during breastfeeding
▪ Advantages- reduce ectopic pregnancy,
endometrial cancer, others
▪ Side effects: headache, weight gain ,
depression, Menstrual problem

3. Subcutaneous implants

e.g Norplant

▪ 6 non biodegradable Silastic implants with

synthetic progesterone embedded under
the skin on the inside of the upper arm
INTRAUTERINE DEVICES (IUDs)
▪ Inserted within 7 days of menses
▪ Slowly release the hormone over the next 5 – Copper T380
years – Levonorgestrel-releasing intrauterine system
▪ Suppress ovulation, stimulating thick (Mirena or Liletta)
cervical mucus and changing the – Levonorgestrel-releasing intrauterine system
endometrium so implantation is difficult 13.5 mg (Skyla)
– Levonorgestrel-releasing intrauterine system
Implant side effects
19.5 mg (Kyleena)
▪ Weight gain ▪ A small plastic device inserted into the
▪ Irregular menstruation uterus to prevent fertilization and/or
▪ Depression decrease sperm motility
▪ Scarring ▪ T-shaped plastic device with copper
▪ Need for removal ▪ With progesterone
▪ CI: desire for pregnancy within 1 year ▪ Mechanism of action not fully
understood
▪ Must be fitted by physician, nurse
4. Intramuscular Method practitioner or midwife
▪ DMPA - Depo Provera
 ▪ Insertion performed in ambulatory
setting after pelvic examination and pap
smear
▪ Maybe used with within 5 days of
unprotected sex
▪ Device is contained within uterus –
string protrudes into vagina
▪ Effective for 5 years (Mirena type) or 10
years (Copper T380)
▪ Almost 100% effective -28% of all women in US
-fallopian tubes are cut,/tied/
cauterized to block passage of ova and
sperm
- 99.5% effective
 Laparoscopy for tubal sterilization

II. Vasectomy

Side Effects:

▪ Spotting or uterine cramping

▪ Increased risk for PID
▪ Heavier menstrual flow
▪ Dysmenorrhea Ectopic pregnancy
11% of all men in US
Emergency Postcoital Contraceptives
- incisions are made in the sides of scrotum;
▪ For use in emergency only (such as vas deferens is cut and tied, then plugged or
rape) “Morning-after pills” MAP High cauterized
dose progestin based pills Insertion of - blocks passage of sperm
copper IUD Ulipristal acetate ( Ella) - viable sperm for 6 months post op
Must be initiated within 72 hours of - 99.5% effective
unprotected intercourse - reversible 95%
- 2 (-) sperm report at 6 and 10 weeks

SURGICAL METHODS III. Elective Termination of Pregnancy (Induced

Abortion)
I. Tubal Ligation Procedure to deliberately end a pregnancy
before fetal viability
▪ Induced (mifepristone-progesterone
antagonist; misoprostol-prostaglandin
analog
- 97% effective during 1st 63 days of
pregnancy
▪ Medically induced D&C, D&E, saline
induction, Hysterotomy
Nursing Diagnosis

▪ Readiness for enhanced knowledge regarding

contraception options

• Deficient knowledge RT to different methods of

contraception

• Decisional conflict

• Powerlessness

• Altered sexuality pattern

• Risk for ineffective health maintenance

Examples of Nursing Diagnoses and Outcomes Related

to Reproductive Life Planning

Interventions Related to Reproductive Life Planning

Evaluating Outcomes Related to Reproductive Life

Planning
Chapter 18: Care of The newborn
Establishment of respiration for newborn
Establishment of Open Airway and Circulation
❑ As the fetal chest passes through the birth
canal it is compressed, squeezing excess fluid
out of the lungs prior to the baby taking its
first breath
❑ Majority of babies cry at birth and take
spontaneous respirations
For a well, term newborn, usually warming, drying, and
stimulating the baby by rubbing the back is enough to
initiate respirations.
❑ After birth, babies will cough and sneeze,
mobilizing additional fluid that may be in their
lungs
❑ A crying infant is a breathing infant, because
the sound of crying is made by a current of air
passing over the larynx.
❑ The more lusty the cry, the greater the
assurance the newborn is breathing deeply and
forcefully.
❑ Vigorous crying also helps blow off the extra
carbon dioxide that makes all newborns slightly
acidotic, so it helps to correct this condition.
❑ Ineffective respirations creates failure of fetal
circulatory shunts, particularly the ductus
arteriosus, to close.
How long does it take for a baby to take its first
breath?
❑ The baby takes the first breath usually within
ten seconds of birth. These first few breaths,
initiated by the newborn, are the most difficult.
❑ Most full-term infants will gasp spontaneously
within seconds of birth.
❑ 90-95% of newborns will complete this
transformation without any help.
What stimulates a newborn’s first breath?
❑ Taking the first breath is a primal reflex
essential for keeping the baby alive and is
triggered by the change in air temperature and
environment.
➢ Only 5-10% of babies require basic stimulation,
such as drying and rubbing, to initiate breaths
➢ 3-6% require basic resuscitation steps (bag and
mask ventilation)
➢ Less than 1% of babies require advanced
resuscitation (cardiac compressions or drugs)
❑ A newborn who does not breathe
spontaneously or who takes a few quick,
gasping breaths but is unable to maintain
respirations needs resuscitation as an
emergency measure. An infant with grunting
respirations needs careful observation for
respiratory distress syndrome
❑ Common factors predisposing infants to
respiratory difficulty in the first few days of life
✓ Low birth weight
✓ Intrauterine growth restriction
✓ Maternal history of diabetes
✓ Premature rupture of membranes
✓ Maternal use of barbiturates or
narcotics close to birth
✓ Meconium staining - poses a problem –
a condition known as meconium
aspiration syndrome and makes
breathing more difficult
 ✓ Irregularities detected by fetal heart
monitor during labor
✓ Cord prolapse
✓ Lowered Apgar score (<7) at 1 or 5
minutes
✓ Postmaturity (postterm)
✓ Small for gestational age
✓ Breech birth
✓ Multiple birth
✓ Chest, heart, or respiratory tract
anomalies
❑ The American Academy of Pediatrics (AAP) has
instituted a Neonatal Resuscitation Program
updated at intervals that lists steps and
rationales for newborn resuscitation should
follow an organized process:
✓ Establish an airway
✓ Expand the lungs
✓ Initiate and maintain effective
ventilation
❑ If respiratory depression becomes so severe
that a newborn’s heart begins to fail (heart rate
is less than 60 beats/min) despite effective
positive pressure ventilation, resuscitation
should then also include chest compressions
❑ A rubber bulb syringe is a standard piece of
equipment often used in the past to suction
infants’ noses and mouths, but
because bradycardia can be associated with
bulb suctioning, routine suctioning of the
nose and mouth is no longer recommended
unless there is concern that the airway
is obstructed
❑ Mechanical suctioning should occur only if
there is an obstruction such as a mucus plug
that is interfering with effective breathing;
otherwise, it may cause bradycardia
❑ An infant who still makes no effort at
spontaneous respirations after
mechanical suctioning steps may require
insertion of an endotracheal tube to be certain
the airway is not obstructed so air can be
effectively administered
❑ A healthcare provider skilled in laryngoscope
and endotracheal tube insertion should be
present at the birth of all infants identified as
high risk so a laryngoscope can be quickly
inserted into the airway as necessary
❑ If an infant needs air or oxygen by bag and mask
to aid lung expansion, be certain the mask
covers both the mouth and the nose. Make
sure it doesn’t cover the eyes because eye
injury could occur from either pressure of
the mask on the eyes or from drying of the
cornea from air or oxygen administration
❑ Air (or oxygen if needed) should be
administered at a rate of 40 to 60 ventilations
per minute. To prevent unnecessary cooling or
drying, the oxygen that is administered should
be both warmed (between 89.6° and 93.2°F [32°
and 34°C]) and humidified (60% to 80%).
❑ If the resuscitation has continued for over 2
minutes, insert an orogastric tube (through the
mouth to the stomach instead of through the
nose to the stomach because babies are
obligate nose breathers)
❑ If heart rate continues to be inadequate (less
than 60 beats/min), epinephrine 1:10,000 may
be administered intravenously (IV) to stimulate
heart action
❑ Preterm infants may receive surfactant to
replace the natural surfactant that has not yet
formed in their lungs
Maintenance of patent airway
Promote Adequate Breathing Pattern and Prevent
Aspiration
❑ To allow a newborn to adjust to and maintain
the cardiovascular changes that occur at birth,
effective ventilation (continued respirations)
must be maintained. Healthy newborns
accomplish this task on their own.
❑ Use of pulse oximetry is crucial to be certain
oxygen saturation remains adequate; infants
 this young do not have dramatic skin color newborn babies, as they are better equipped to
changes as do older infants and can be mildly deal with their new world.
hypoxic (low in oxygen)
Why is the first breath of a newborn the most difficult?
without becoming cyanotic.
❑ The first breath immediately after birth is
Those who have difficulty establishing respirations at
mechanically the most difficult for a newborn
birth need to be carefully observed in the first few
because it’s the first time the lungs are being
hours after birth to be certain respirations
used.
are maintained.
❑ Within a couple of breaths, the baby’s lungs
will inflate. They become filled with air, and
push out the fluid inside them.

❑ Only after this is done can the lungs effectively

take in oxygen and eliminate carbon dioxide.

❑ Imagine blowing up a balloon for the first time.

The baby who is crying can receive routine care
Keep warm
❑ Position skin-to-skin with the neck slightly
extended
❑ Cover head and body
CHECK BREATHING
❑ Listen, look at or feel movement of chest
Why do preterm babies have trouble breathing?
❑ Preterm babies haven’t had as much time
produce surfactant – a substance that keeps the
air sacs in the lungs from sticking together when
exhaling. Surfactant also helps the lungs to
inflate and prevents them collapsing in on
themselves, which makes breathing harder.
The balloon is like the newborn’s lungs. Your
first attempt to blow up the balloon takes a lot
of effort, but once you get started it becomes
easier. The next time you blow it up, it’s easier
still.
❑ Once their lungs have begun working, the
muscles involved in breathing don’t have to
work so hard to keep them inflated.
A steadily increasing respiratory rate, grunting,
and nasal flaring are often the first signs of obstruction
or respiratory compromise in newborns.
If these are present, undress the baby’s chest and look
for intercostal retractions (inward sucking of the
anterior chest wall on inspiration).
Pulling in the chest muscle this way reflects the degree
of difficulty the newborn is having in breathing in air
(tugging so hard to inflate the lungs that the anterior
chest muscles are pulled inward).

❑ A baby normally begins to produce surfactant

from 24-28 weeks of pregnancy. Most will
produce enough to breathe normally by week
34

❑ Some babies born at this point, however, will

still struggle to maintain breathing for
themselves and might require respiratory
support from a breathing machine or ventilator.

❑ The lungs aren’t considered mature until

around 36 weeks. Generally the longer the
gestation, the better it is for the health of
If a newborn does not initiate
spontaneous breathing following gentle stimulation,
place the infant under a radiant heat warmer in
a “sniffing” position (head slightly tipped back) and
rub and dry his or her back and hair again to see if this
additional stimulation initiates respirations.

Ventilation with bag and mask is the most effective

way to help the baby who is not breathing or is
gasping

BEGIN TO VENTILATE

❑ Follow your facility’s routine for when to clamp

or tie and cut the cord
A baby who is breathing well
❑ Place the baby on the area for ventilation
❑ Crying or
• Beside the mother if the cord is not cut
❑ Breathing quietly and regularly
• A separate area if the cord is cut
A baby who is not breathing welL
❑ Stand at the baby’s head
❑ Gasping or
❑ Check that the mask size is correct
❑ Not breathing at all Babies with shallow,
irregular, slow or noisy breathing or chest A newborn whose amniotic fluid was meconium stained
indrawing need continued monitoring at birth but is breathing does not need suctioning to
clear the airway. If the newborn whose amniotic fluid
If secretions accumulating in the respiratory tract was meconium stained at birth presents with
appear to be creating ineffective breaths, an infant may poor muscle tone and inadequate breathing,
need additional suctioning. “Bagging” the infant with a it is important to begin the initial steps of resuscitation
mask and positive-pressure ventilation bag for a under the warmer.
minute before suctioning will usually improve the
infant’s oxygen level and prevent it from desaturating to
dangerous levels during suctioning.

VENTILATE WITH BAG AND MASK

❑ Position the head slightly extended

❑ Apply the mask to the face

❑ Make a tight seal between the mask and face

 ❑ Squeeze the bag to produce gentle movement
of the chest

❑ Give 40 ventilation breaths per minute If the

chest is moving with each ventilation breath,
continue ventilation for 60 seconds or until the
baby begins to breathe

If the baby is not breathing, continue ventilation

Call for help

❑ Ask for a skilled helper, if available

IF THE CHEST IS NOT MOVING IMMEDIATELY IMPROVE VENTILATION IF THE CHEST IS NOT MOVING
❑ Reapply the mask ❑ Reapply mask
❑ Reposition the head ❑ Reposition head
IF THE CHEST IS MOVING WELL, CONTINUE TO ❑ Clear mouth and nose of secretions
VENTILATE FOR ONE MINUTE OR UNTIL THE BABY
BEGINS TO BREATHE ❑ Open mouth slightly

❑ Crying or ❑ Squeeze the bag harder. Cut the cord if not

already done
❑ Breathing quietly and regularly Stop ventilation
and monitor with mother

IF THE BABY IS NOT CRYING OR BREATHING WELL THE

BABY MAY BE

❑ Gasping

❑ Not breathing at all. Continue ventilation with

good chest movement

OR the baby may be

EVALUATE HEART RATE AFTER 1 MINUTE TO DECIDE IF
❑ Taking fast, irregular, or shallow breaths VENTILATION IS ADEQUATE

❑ Grunting with chest wall indrawing. Monitor ❑ Feel the umbilical cord pulse
with mother and provide more help to breathe
OR
if needed
❑ Listen to the heartbeat with a stethoscope

❑ Decide quickly if the heart rate is normal or

slow

▪ Normal > 100 beats per minute

▪ Slow < 100 beats per minute


IF THE HEART RATE IS NORMAL AND THE BABY IS NOT
BREATHING OR IS GASPING
❑ Continue ventilation
❑ Re-evaluate breathing continuously and check
heart rate every 3-5 minutes
❑ Seek consultation to decide on advanced care
IF THE HEART RATE IS SLOW
❑ Improve and continue ventilation
❑ Re-evaluate breathing continuously and check
heart rate every 3-5 minutes
❑ Seek consultation to decide on advanced care
IF THE HEART RATE IS SLOW OR THE BABY DOES NOT
BREATHE AFTER 20 MINUTES
❑ Discuss with parents
❑ Consider stopping ventilation
A BABY WHO RECEIVED VENTILATION NEEDS
CONTINUED MONITORING
❑ Breathing
❑ heart rate
❑ color
❑ Temperature
IF A BABY NEEDED HELP TO BREATHE
❑ Prolong skin-to-skin care
❑ Continue with immediate essential newborn
care
❑ Make a note of care provided in the clinical
record
IF REFERRAL IS NEEDED, TRANSPORT MOTHER AND
BABY TOGETHER
❑ Continue skin-to-skin care
❑ Monitor the baby
❑ Communicate with the receiving facility
❑ Consider alternative methods of feeding
Support the family
❑ Communicate in a way appropriate for the
culture and religion
PREPARE FOR THE NEXT TIME A BABY NEEDS HELP TO
BREATHE
❑ Review the actions taken with other team
members (debrief)
❑ Disinfect the equipment used
❑ Store the equipment in a place where
Changing of diapers
Diaper Area Care
❑ Preventing diaper dermatitis is a practice that
parents need to start from the very beginning
with their newborns.
❑ With each diaper change, the area should be
washed with clear water and dried well, to
prevent the ammonia in urine from irritating
the infant’s skin and causing a diaper rash.
❑ After cleaning, a mild ointment such as
petroleum jelly or A + D Ointment may be
 applied to the buttocks. The ointment keeps ❑ Squeeze a line of ointment along the lower
ammonia away from the skin and also facilitates conjunctival sac, from the inner canthus
the removal of meconium, which is sticky and outward
tarry.
❑ Close the eye to allow the ointment to spread
❑ Wear gloves for diaper care as part of standard across the conjunctiva
precautions.

Eye pRophylaxis

Administer Eye Care.

❑ Although the practice may shortly become

obsolete (as it is in Europe), every U.S. state still
requires that newborns receive prophylactic eye
treatment against gonorrheal conjunctivitis
(Raab,2007).

❑ Such infections are usually acquired from the

mother as the infant passes through the birth
canal. Formerly, eye prophylaxis was applied
immediately after birth.

❑ Parents who know that they are free

of agonococcal or chlamydial infection can ask
to have eyeprophylaxis omitted entirely.

❑ Silver nitrate was exclusively used for

prophylaxis in the
past. Today, erythromycin ointment is the drug
of choice. Erythromycin ointment
has the advantage of eliminating not only the
organism of gonorrhea
but that of Chlamydia as well
❑ Always use a single-use tube or package of
ointment, to avoid transmitting infection
from one newborn to another
❑ To instill the ointment, first dry the face of
the newborn with a soft gauze square so
that the skin is not slippery
❑ The best procedure to open a newborn’s eyes
is to shade them from the overhead light and
open one eye at a time by pressure on the
lower and upper lids.
Cord care
Inspect and Care for Umbilical Cord
❑ The umbilical cord pulsates for a moment after
an infant is born as a last flow of blood passes
from the placenta into the infant
❑ Two clamps are then applied to the cord about
8 inches from the infant’s abdomen, and the
cord is cut between the clamps. Some fathers
choose to do this as their responsibility. The
infant cord is then clamped again by a
permanent cord clamp, such asa Hazeltine or a
Kane clamp
❑ The clamp on the maternal end of the cord
should not be released after the cord is cut, to
prevent blood still remaining in the placenta
from leaking out. This loss is not important,
because the mother’s circulation does not
connect to the placenta. It is messy, however,
and that is why the clamp is left in place

❑ Cords begin to dry almost immediately, and the ❑ Cord clamping and cutting
vessels may be obscured by the time of the
infant’s first thorough physical examination in
the nursery. Vitamin k

❑ Wiping the cord with alcohol at each diaper
change helps to hurry drying and possibly
reduce the development of infection.
❑ Until the cord falls off, at about day 7 to 10 of
life, a newborn should receive sponge baths
rather than be immersed in a tub of water to
keep the cord dry.
❑ Be certain that diapers are folded below the
level of theumbilical cord, so that, when the
diaper becomes wet,the cord does not become
wet also.
❑ Newborns are at risk for bleeding disorders
during the first week of life because their
gastrointestinal tract is sterile at birth and
unable to produce vitamin K, which is necessary
for blood coagulation.
❑ A single dose of 0.5 to 1.0 mg of vitamin K is
administered intramuscularly within the first
hour of life to prevent such problems.
Infant born outside a hospital also should
receive this important protection

❑ Remind parents to continue to keep the cord

dry until it falls off after they return home.

❑ The use of creams, lotions, and oils near the

cord should be dis-couraged, because they tend
to slow drying of the cord and invite infection.

❑ Some health care agencies recommend

applying rubbing alcohol to the cord site once
or twice a day to hasten drying. Others
prefer the cord be left strictly alone, because
manipulation could invite infection.

❑ After the cord falls off, a small, pink,

granulating area about a quarter of an inch in
diameter may remain. This should also be left
clean and dry until it has healed (about 24 to 48
additional hours).

❑ If the ulcerous area has remained as long as 1

week, it may require cautery with silver nitrate
to speed healing Regulation of temperature

❑ Observe for the oozing of blood. If blood oozes,
place a second tie between the skin and the
clamp
Keep Newborn Warm
❑ Gently rub a newborn dry, remove the wet
linen, then swaddle loosely with a clean, warm,
 and dry blanket. Be certain to place a cap on
the infant’s. These actions all help to prevent
heat loss.

❑ Swaddling helps to mimic the tight confines of

the uterus and appears to offer
a sense of security as swaddled infants sleep fo
r longer periods (Bregje et al., 2007)
❑ The period immediately after birth is an
important time for parents to begin interaction
with their child.
❑ Any extensive procedures, such as
resuscitation, should be done under a radiant
heat source to reduce heat loss.
❑ Conduction is the transfer of body heat to a
cooler solid object in contact with a baby. For
example, a baby placed on the cold base of a
warming unit quickly loses heat to the colder
metal surface. Covering surfaces with a warmed
blanket or towel is necessary to help minimize
conduction heat loss.

❑ At the end of the first hour of life, reassess the

newborn’s temperature.

❑ If the temperature is subnormal and the baby is

in a bassinet, he or she should be placed in a
heated bassinet or under a radiant warmer for
additional heat.
❑ Evaporation is loss of heat through conversion
❑ During the first day of life, a newborn’s of a liquid to a vapor. To prevent this type of
temperature is usually taken every 4 to 8 heat loss, lay a newborn on the mother’s
hours. Thereafter, unless the temperature is abdomen immediately after birth and cover
elevated or subnormal, or the infantappears to with a warm blanket for skin-to-skin contact). In
be in distress, measurement once a day while in addition, drying the infant especially the face
the health care facility is enough and hair also effectively reduces evaporation
because the head, which is a large surface area
The majority of heat loss occurs because of four
in a newborn, can be responsible for a great
separate mechanisms:
amount of heat loss. Covering the hair with a
❑ Convection is the flow of heat from the cap after drying further reduces the possibility
newborn’s body surface to cooler surrounding of evaporation cooling
air. Eliminating drafts, such as from air
conditioners, is an important way to reduce
convection heat loss.

Breastfeeding
❑ Radiation is the transfer of body heat to a
cooler solid object not in contact with the baby, THE INITIAL FEEDING
such as a cold window or air conditioner.
❑ The Baby-Friendly Hospital Initiative (BFHI) is a
Moving an infant as far from the cold surface as
global program sponsored by the WHO and the
possible helps reduce this type of heat loss.
United Nations Children’s Fund (UNICEF) to
 encourage and recognize hospitals and birthing
centers that offer an optimal level of care for
Why Should You Burp Your Baby?
infants that promotes breastfeeding.
To qualify as a Baby-Friendly–designated facility, a
setting must:
1. Maintain a written breastfeeding policy that is
routinely communicated to all healthcare staff.
2. Educate all healthcare staff in skills necessary to
implement the written policy.
3. Inform all pregnant women about the benefits
and management of breastfeeding.
When Should You Burp Your Breastfed Baby?
4. Help mothers initiate breastfeeding within 1
hour of birth.
5. Show mothers how to breastfeed and how to
maintain their milk supply, even if they are
separated from their infants.
6. 6. Offer breastfed newborns no food or drink
other than breast milk unless medically
indicated.
7. 7. Practice “rooming in” or allow mothers and
infants to remain together 24 hours a day.
8. 8. Encourage unrestricted or “on-demand”
breastfeeding.
9. 9. Give breastfeeding infants no pacifiers or
artificial nipples.
10. 10. Foster the establishment of breastfeeding
support groups and refer mothers to them
on discharge from the birth setting (UNICEF,
2016).
11. After a first feeding in the birthing room, both
formula-fed and breastfed infants do best with
an “on-demand” schedule (i.e., are fed when
they are hungry). Many need to be fed as often
as every 1.5 to 2 hours in the first few days and
weeks of life. Chapter 19 discusses techniques
of both breastfeeding and formula feeding.
Nurses can play an important role in helping
new mothers establish breastfeeding during the
infant’s first weeks of life.
12. Observe the newborn for feeding cues
13. Breastfeeding Attachment
Burping
❑ When a newborn or an infant swallows air
during feeding, that air gets trapped in the
stomach. It can be uncomfortable, and it can
make baby feel full. Burping helps to remove
that air. Once newborn burps and gets that air
out of their belly, they will feel better. They may
even start breastfeeding again, since removing
the air will make room in their stomach for
more breast milk.
❑ Some babies don't take in very much air during
feedings, so they don't need to burp as much.
However, if the mother has a strong let-down-
reflex or an over abundant breast milk supply,
the fast flow of the breast milk can cause baby
to swallow more air. In these situations, the
baby need to burp more often.
❑ A good time to burp breastfed baby is after they
stop nursing, or if they become fussy during a
feeding. The newborn will often stop nursing
and seem uncomfortable if they need to burp. If
mother breastfed from both sides at each
feeding, burp baby in between alternating
breasts, and after each feeding.
❑ If breastfeed from just one side at each
feeding, burp baby when they stop
feeding. After burp of newborn, encourage
mother to offer the same breast again to see if
baby wants more. Then, when the feeding is
complete, burp baby again.
❑ Burping is also helpful if baby is
sleepy. If newborn falls asleep at the breast,
burping may help to wake them up and keep
them breastfeeding a little longer.
❑ If baby is breastfeeding well and actively
sucking, no need to stop for a burp. Wait until
they stop nursing on their own, and then burp
them.
❑ Some babies need to be burped between
feedings, too. If teh newborn is fussy and can't
sleep, a burp may be all that they need. Babies
also swallow air when they cry. Because some
 babies cry more than others, especially if they ➢ Meconium – passed within 24-48 hours
have colic, they will need to be burped more
often

How to Burp Your Baby

❑ Babies sometimes burp on their own without

any help or special positioning. However, it's
natural to want to help the process along, and
there are many ways to do that. ➢ Transitional Stool (2nd or 3rd day)

Greenish brown to yellowish brown, with some

Here are three popular burping techniques.
milkcurds
1. Over your shoulder: Hold your baby
upright, in a vertical position with their
head over your shoulder.

2. Lying on your lap: Place your baby on

their belly across your lap and support
their head with your lap, arm, or hand.

3. Sitting on your lap: Sit your baby on ➢ Milk Stools (4th day)
your lap, facing away from you. Lean
❑ Breast-fed: 3 – 4 x/day
them forward and support his head,
neck, and chest with your hand.3 Light yellow to golden, soft consistency or pasty,
sour milk (lactic acid) odor or no foul smell
❑ First, place a burp cloth, bib, or cloth diaper
under child's head before start burping to
protect clothing and catch anything that comes
up. Then, when baby is in position, gently rub or
pat them on the back. Don't have to rub or pat
hard. Pounding harder on child's back will not
make them burp better or faster.

❑ Formula-fed Infant: 2 - 3 x/day

Elimination
Pale yellow or bright yellow or light brown, soft or
❑ Should void within 24 hrs (good renal function) firmer; offensive odor
❑ Expected output for 1 to 2 days: 30 to 60
ml. 15 ml will stretch bladder resulting to as
many as 20 voidings per day

❑ pink or dusky (uric acid crystals)

❑ The total volume of urine per 24 hours by

1st wk: 200 – 300 ml

❑ Limited ability to concentrate urine, until

about 3 months when kidneys mature

❑ Odorless & colorless

Cuddling
❑ Specific gravity: 1.001 – 1.020
• It’s great if newborn cuddled often, especially in
Change in Stooling Patterns the three months after giving birth. The first
 three months of your child’s life are known as
the “fourth trimester” This is because the
newborn emerged from a dark, warm and
comfortable place.
• Cuddling helps replicate the womb
environment. The newborn feel safe and warm.
Cuddling helps baby develop a secure
attachment. The bond developed has effects
later in your child’s life in terms of self-
confidence, healthy individuation and
exploration, expression of empathy, social
relationships and ability to cope with life
stressors.
• Babies who don’t experience cuddling have
been found to have markedly lower levels of
oxytocin and vasopressin. These two hormones
are thought to play key roles in stress and social
behaviors. Lower levels may explain why these
children have difficulties forming attachments
in adulthood.
Kangaroo care can help baby by:
✓ Encouraging successful breastfeeding
and milk production
✓ Encouraging weight gaining (When your
baby depends on your body to stay
warm, they use fewer calories to stay
warm on their own)
✓ Maintaining their body temperature
✓ Regulating their heart and breathing
rates
✓ Spending more time in deep sleep
✓ Spending more time being quiet and
alert rather than crying (Brain wave
patterns associated with happiness
have been shown to double when
model Kangaroo care done with
newborn)

Health benefits to child and parent include:

❑ Creating a healthy sense of personal

boundaries

❑ Encouraging calmness and relaxation

❑ Improving muscle tone and circulation

❑ Improving pulmonary and immune

functions
❑ Improving sleep patterns
❑ Lowering anxiety and stress
❑ Reducing discomfort from teething,
congestion, colic and emotional stress
❑ Strengthening digestive, circulatory and
gastrointestinal systems
Model Kangaroo Care
❑ skin-to-skin contact between baby’s front and
mother chest. If baby is very small or sick,
parents may be afraid they'll hurt him or her,
but they won't. Baby knows parents scent,
touch and the rhythms of parents speech and
breathing. Holding the baby also promotes
breastfeeding because it helps develop the
parent-child bond.
Planning and Intervention
Discharge Planning
❑ Before hospital discharge, nurses provide
anticipatory
guidance for parents regarding feeding and
elimination
patterns; positioning and holding; comfort
measures;
car seat safety; bathing, skin care, cord care,
and nail
care; and signs of illness.
Recommendations for the discharge of healthy term
newborns
It is recommended that the following minimum criteria
be met before discharge of a term newborn following
an uncomplicated gestation and delivery:
✓ Healthy term newborns should not be
discharged before 48 hours from birth if
delivered vaginally or 72–96 hours if delivered
by caesarean section.
✓ Absence of evidence of abnormalities in the
newborn during the hospital stay and the
routine physical examination. This examination
must be performed by a physician with a
pediatrics specialty at least once, or by a
physician with documented experience in
neonatal care and under the supervision of a
pediatrics specialist.
✓ It is recommended that the weight, hydration
and nutritional status of the newborn be
assessed prior to discharge, especially in
exclusively-breastfed newborns or those
delivered by caesarean section.
✓ Normal and stable vital signs for at least
12 hours prior to discharge; axillary
temperature between 36.5 and 37.4°C,
respiratory rate below 60bpm and no other
signs of respiratory distress and an awake heart
rate of 100–160bpm. A resting heart rate of up
to 70bpm with no signs of circulatory
compromise and adequate responsiveness is
also acceptable. A heart rate close to or above
the upper bound of the normal range requires
further assessment.
✓ The newborn has urinated regularly and passed
at least one stool spontaneously.
✓ The newborn has completed at least two
successful feedings, with assessment to verify
that the newborn is able to coordinate sucking,
swallowing and breathing while feeding.
✓ Routine bilirubin measurement in all newborns
is not indicated. If the newborn presents with
significant jaundice before discharge or is
discharged before 48h (early newborn
discharge) the total serum bilirubin levels must
be measured and compared with risk charts to
determine whether the newborn needs
phototherapy. Under these circumstances, an
appropriate follow-up plan must be instituted.
Newborns at risk of significant hyperbilirubinaemia
must be identified and assessed:
a. Gestational age of less than 38 weeks.
b. A previous sibling with neonatal jaundice
requiring phototherapy.
c. Mother's intention to breastfeed exclusively.
d. Visible jaundice in the first 24h of life.
✓ The risk factors for infection have been
assessed, and, when present, the newborn
has been evaluated appropriately and
according to established guidelines for the
management of newborns with suspected
early-onset bacterial sepsis.
✓ The results of maternal blood tests,
newborn blood type and direct Coombs
test have been reviewed.
✓ Due to the change in the vaccination
calendar and delay in the first dose of the
Hepatitis B vaccine, a high level of cover
must ensure a high coverage for the
prenatal screening of pregnant women,
with vaccination and immune globulin
prophylaxis of newborns of HBsAg+
mothers in the first 24 hours post birth.
✓ Newborn metabolic and hearing screenings
have been completed according to the
specific protocols established for each.
✓ The mother has been given information
and education on how to provide adequate
care for her infant, and the acquisition of
this knowledge and competencies has been
confirmed.
✓ Instructions have been given in regard to
the subsequent follow up of the newborn,
emphatically recommending a first visit in
primary care within 72 hours
of discharge. Directions to follow in case of
a complication or emergency must also be
given.
✓ It is advisable to ensure that there have
been no misinterpretations of the provided
information on the part of the family due
to language barriers or physical, psychical
or sensory impairments.
✓ Social risk factors have been
assessed. When any are identified,
discharge should be delayed until they are
 resolved or a plan has been developed to specialty and ruled out anomalies that could
guarantee the safety of the newborn require a longer stay.

Recommendations for the discharge of late preterm ✓ Potential social risk factors have been assessed.
newborns When such factors are identified, discharge
should be delayed until they are resolved or
The minimum criteria for discharge are similar to those
social services become involved.
for healthy term newborns, although the following
points must be emphasised: ✓ The mother and other potential caregivers have
received sufficient information and education to
✓ Gestational age has been calculated through
provide adequate care to the infant after
appropriate methods.
discharge, with particular emphasis on specific
✓ The length of stay after birth must be issues pertaining to late preterm newborns.
determined on a case-to-case basis and be
✓ Information on the prevention of sudden infant
based on feeding ability, adequate
death has also been provided.
thermoregulation and the absence of disease
and social risk factors. Late preterm newborns
may not have developed the abilities required
for discharge before 48 hours post birth.

✓ Medical follow up in primary care 24–48 hours

after discharge must be arranged prior to
discharge. The recommended schedule of
weekly check ups until 40 weeks’ postmenstrual
age.

✓ Adequate breastfeeding or bottle feeding for a

minimum of 24 hours has been verified, with
evidence of adequate coordination, suction and
breathing during feedings. The recommended
weight loss during the hospital stay do not
exceed 7% of the birth weight.

✓ Feeding technique has been assessed

thoroughly during the hospital stay following
birth.

✓ A feeding plan has been established, and the

family understands it.

✓ The risk of developing severe

hyperbilirubinaemia has been assessed.
Combining the findings of the medical
examination with the total serum bilirubin
measurement helps predict the risk of severe
hyperbilirubinaemia. In this regard,
measurement of total serum bilirubin prior to
discharge is recommended in all late preterm
newborns, especially those that are exclusively
breastfed.

✓ The physical examination of the newborn was

conducted by a physician with a pediatrics
Chapter 19: NURSING CARE OF A FAMILY WITH
NEWBORN
• Within 24 hours- neurologic, renal, endocrine,
gastrointestinal, metabolic must operate competently
to sustain LIFE.
• Factors for EFFECTIVE FUNCTIONING:
• Genetic composition
• Competency of the recent intrauterine life
• Gestational duration
• Presence of fetal anomalies
• The care received during labor and delivery
• The care received during newborn or neonatal period
ASSESSMENT OF A NEWBORN
• Review of mother’s pregnancy
• Physical exam of the infant
• Laboratory analysis (hct, bilirubin, bt)
• Assessment of parent-child interactions
PROFILE OF A NEWBORN
• Weight – varies
• girl- 3.4 kg
• boy- 3.5 kg
• Other race- less than .5 kg
• Average- 2.5kg to 3.4 kg
• Deviation: > 4.7 kg- 7. macrosomia , DM of mother
• Physiologic weight loss - 5 to 10% loss due to:
- no longer on influence of maternal hormones
- diuresis
- passes stool
- limited caloric intake of breastfed babies
• Weight loss → stable weight for 1 day → wt gain
• Breastfed infants- recaptures BW within 10 days
• Formula fed- within 7 days
• 2lbs per month for 6 months
• LENGTH
• Average: female = 49cm
• Average: male = 50cm
• Lower limit = 46cm
• HEAD CIRCUMFERENCE
• Mature: 34 to 35cm
• Greater than 37cm or less than 33 cm = carefully
assess for neurologic involvement
• CHEST CIRCUMFERENCE
• 2cm less than head circumference
VITAL SIGNS
TEMPERATURE - 37.2C at birth
• Falls to below normal due to:
• Heat loss
• Immature regulating mechanisms
• Temperature of birthing homes
PULSE
• HR of fetus in utero averages 110 – 160bpm
• Within 1 hour after birth = 120 – 140bpm
• HR irregular due to immaturity of cardiac regulatory
center
• Transient murmurs maybe present due to incomplete
closure of fetal circulation shunts
• If crying- up to 180bpm
• If sleeping- 90 to 110 bpm REASON FOR HEAT LOSS

• Femoral pulse - palpable • Has no insulation

• If femoral pulse is absent- suggestive of coarctation of • No shivering mechanism

aorta
• Conserve heat thru brown fat –intrascapular region,
thorax, behind the kidneys

4 MECHANISMS OF HEAT LOSS

1) CONVECTION RESPIRATION

• Flow of heat from the newborn’s body surface to • At birth- up to 90 breaths

cooler surrounding air
• 30 to 60 breaths at rest
• Eliminating air drafts such as from air conditioners
• Irregular, with short periods of apnea = Periodic
2) RADIATION respirations

• Transfer of body heat to a cooler solid object not in • use of diaphragm and abdominal muscles
contact with the baby such as cold window or AC.
• Coughing and sneezing reflexes are present at birth
• Moving infant as far from the cold surface
= help clear the airway
3) CONDUCTION
• Obligate nose breathers
• Transfer of body heat to a cooler solid object in
contact with a baby.
BLOOD PRESSURE
• Cover cold surfaces with a warmed blanket
• Approx 80/46 mmhg
4) EVAPORATION
• 10th day- 100/50mmhg
• Heat loss through conversion of a liquid to a vapor.

• Lay newborn on the mother’s abdomen immediately

after birth and cover with a warm blanket for skin to CARDIOVASCULAR FUNCTIONS
skin contact.

• Drying the infant especially the face and hair.

• Covering the infant’s hair with a cap after drying.

• Increased blood flow to the heart causes the foramen

ovale to close.

• Peripheral circulation for 24 hours is sluggish

• Acrocyanosis maybe seen

• Newborn’s feet = cold to touch GASTROINTESTINAL

• Blood volume- 300 ml • Sterile at birth

• Hgb- 17 to 18g/100ml • Within 5 hours- bacteria maybe cultured in the GI

tract of some babies.
• Ind bilirubin- 1 to 4 mg/100 ml
• 24 hours- for most babies
• WBC- 15,000 to 30,000cells/mm3.
• Sources of bacteria: airborne sources
• 40,000 cells/mm3- if stressful delivery
~ vaginal secretions

~ hospital beddings

~contact with the breasts

• Importance of bacteria

• Stomach – holds 60 to 90 ml

• Deficient pancreatic enzymes

• immature cardiac sphincter – > regurgitation

• Immature liver- lower glucose and protein levels

STOOLS

• Meconium - 1st 24 hours after birth

- sticky, tarlike, blackish-green, odorless, material from :

- mucus
BLOOD COAGULATION
• Low Vit k- leads to prolonged coagulation or - vernix
prothrombin time
- lanugo
• Vit K synthesis thru the action of normal intestinal
flora to form clotting factors - hormones

• 24 hours- for flora to accumulate in the intestine - carbohydrates

• Need of Vit K injection. * Imperforated anus, meconium ileus, volvulus

• Transitional stools – 2nd or 3rd day of life

RESPIRATORY SYSTEM - green and loose

• Within 10 minutes- good residual volume is - may resemble diarrhea

established.
• A baby born via CS does not have as much as lung
fluid expelled at birth as one born vaginally so they have
more difficulty establishing respiration because
excessive fluid blocks air exchange space.
• Normal stools- 4th day
breastfed – 3 to 4x light yellow stools, sweet smelling
formula fed - 2 to 3x , bright yellow stools ,
- more noticeable odor

Variation: on phototherapy – green

bile duct obstruction - clay colored stools(gray) • Blink reflex

blood flecked - anal fissure - swallowed maternal blood • Rooting reflex

If mucus is mixed with stool or the stool is watery and • Sucking reflex
loose = milk allergy, lactose intolerance
• Swallowing reflex

• Extrusion reflex – fades at 4months

URINARY SYSTEM
• Palmar grasp reflex – disappears at about 6 weeks to
• Voids within 24 hours 3months of age

- may extend a little for other babies • Step (walk)-in-Place reflex – disappears by 3 months

• If no output - urethral stenosis, absent of kidneys or • Placing reflex

ureters
• Plantar grasp reflex – disappears at about 8 to 9
• Male - small, projected arc months

• Female - steady stream urine • Tonic neck reflex – disappears between 2nd and 3rd
month
• Characteristics - light colored and odorless, 15 ml,
• Moro reflex – fades at the end of 4th or 5th month
- 30 to 60 ml for 1st 2 days.
• Babinski reflex – remains positive until at least 3
after 1 week - 300 ml daily output
months of age
First voiding can be pink or dusky – because of uric acid
• Magnet reflex – test for spinal cord integrity
crystals formed in the bladder in utero.
• Crossed extension reflex

• Trunk incurvation reflex

IMMUNE SYSTEM
• Landau reflex
• Not able to produce antibodies until about

2 months (the reason most immunizations are not

administered until 2 months of age). THE SENSES

• Born with passive anitbodies (IgG) • Already developed at birth

• Antibodies against poliomyelitis, measles, diphtheria, • Hearing - within an hour, hearing becomes acute after
pertussis, chickenpox, rubella, tetanus. fluid has been drained or absorbed.

Ø difficulty in locating the sounds

NEUROMUSCULAR SYSTEM Ø Recognize the mother sound immediately.

Newborns demonstrate neuromuscular function by:

• moving extremities VISION

• attempting to control head movement • See as soon as they are born.

• strong cry and newborn reflexes • May have seen light and dark inside the utero

• Most actions are reflexive • Blinking reflex and pupillary reflex

• Following a bright light or toy

REFLEXES
• Could not follow past the midline
• Focus at black and white best at 9 to 12 inches. - 70 to 90% of all infants

Scores:

TOUCH - 0- no RD

• Well develop at birth - 4 to 6- moderate distress

• They react to painful stimuli - 7 to 10- severe distress

TASTE

• Has the ability to discriminate taste because taste

buds are develop and functioning even before birth

• Prefers sweet taste and turn away from bitter taste.

SMELL

• Present as soon as nose is clear from lung and

amniotic fluid.

• Ability to respond to odors is a sign of alertness.

ASSESSMENT OF GESTATIONAL AGE

PHYSIOLOGIC ADJUSTMENT TO EXTRAUTERINE LIFE
• Term = 37 to 42 weeks
• Periods of reactivity (page 436 – table 18.1)
• Ballard or Dubowitz test
ASSESSMENTS FOR WELL BEING
• (page 439)
APGAR SCORING

• 1 minute and 5 minutes after birth

• HR – by stethoscope or counting the pulsations of the

umbilical cord at the abdomen if still uncut

• Respiratory effort – observing chest movements

• Muscle tone – hold their extremities tightly flexed,

simulating their intrauterine position

• Reflex irritability – response to suction catheter in the GESTATIONAL ASSESSMENT

nostrils or response to soles of the feet slapped.

• Color

• < 4 – serious danger, needs resuscitation

• 4 to 6 – guarded condition

- may need clearing of the airway and supplementary

O2

• 7 to 10- adjusting well to extrauterine life

APPEARANCE OF A NEWBORN • Low iron stores caused by maternal nutrition during
pregnancy
SKIN
• Blood incompatibility leading to destruction of RBCs in
• Color-ruddy; accumulation of RBC and less
utero
subcutaneous fats darker skinned – cyanosis may
appear as dusky grey or whitish around the child’s • Fetal - maternal transfusion
mouth
• Inadequate flow of blood from the cord into the infant
➢ Cyanosis before the cord was cut

- mottling is common • Excessive blood loss when the cord was cut

- lips, hands, and feet due to immature peripheral • Internal bleeding

circulation
➢ HARLEQUIN SIGN
Acrocyanosis - normal on 1st 24 to 48 hours
• A transient phenomenon
Central cyanosis - trunk
• red appearance on the dependent side and pale on
- indicates decreased oxygenation the upper side = due to immature circulation

Action: suctioning - oronasal (mouth before nose) • Action: reposition baby

➢ HYPERBILIRUBINEMIA

• Leads to jaundice

• Physiologic jaundice: 2nd or 3rd day of life on 50% NB

- due to breakdown of RBC

- affects skin and sclera

➢ HEMANGIOMAS
- may also be added by cephalhematoma
• Vascular tumors of the skin
- intestinal obstruction can also increase the level of
indirect bilirubin • Nevus flammeus – port wine stain
Pathologic jaundice- appears within 24 hours • Telangiecatasia or stork beak mark
➢ Kernicterus or acute bilirubin encephalopathy • Strawberry hemangiomas
• Can cause permanent neurologic damage, including • Cavernous hemangioma
cognitive, vision, hearing problems.

• Indirect bilirubin is about 20mg/100mL

• 10 – 12mg/mL = phototherapy (to initiate maturation

of liver enzymes)

• Breastfed babies have more difficulty in converting

bilirubin due to presence of pregnanediol in breast milk

Pregnanediol- depresses the action of glucuronyl

transferase

➢ MONGOLIAN SPOTS
➢ PALLOR
 ➢ FORCEPS MARKS

➢ VERNIX CASEOSA

SKIN TURGOR

• Skin should feel resilient

• Feels elastic when pinched

➢ LANUGO
HEAD

• Disproportionately large

• Forehead appears large and prominent

• Chin appears to be receding, and quivers easily

FONTANELLES

• Anterior – diamond shaped

➢ DESQUAMATION
• Closes at 12 – 18 months

• Posterior – triangular

• Closes at end of 2nd month

SUTURES

• Override at birth due to extreme pressure exerted on

the head during delivery.
➢ MILIA
• May subside in 24 to 48 hours.

MOLDING

• Head molds to fit cervix contour

• Head shape return within few days

➢ ERYTHEMA TOXICUM
• Appears in the first to fourth day of life but
may appear as late as 2 weeks of age

CAPUT SUCCEDANEUM
CEPHALOHEMATOMA
• Collection of blood between the periosteum of the
skull bone and the bone itself.
CRANIOTABES
• softening of the cranial bones that is probably caused
by pressure of the fetal skull against the pelvis.
• Common among 1st born due to the position of the
fetal head in the pelvis during the last 2 weeks of
pregnancy.
• Self-correcting after few months.
EYES
• Cry tearlessly due to not fully developed lacrimal
ducts (about 3 months)
• Iris- gray or blue
• Sclerae- may be blue because of its thinness.
• Assumed permanent color between 3 months and 12
months
• Should be inspected in supine position.
• Clear, without redness or purulent discharge.
• Use of erythromycin – protects against chlamydial
infection and ophthalmia neonatorum.
EARS
• Not completely formed, pinna bends easily
• Should be in line with the eyes.
• Lower set ears- trisomy 18 and 13
• Presence of Skin tag –can be removed after 1 week
• Preauricular dermal sinus-remove around school age
• Testing- ringing of bells 6 inches away
• A hearing infant will blink, attend to the bell’s sound,
and possibly startle.
NOSE
• Appear large for the face.
• Presence of milia
• Test for CHOANAL ATRESIA (blockage at the rear of
the nose)
• Close the infant’s mouth while compressing one naris
at a time with your fingers. Note any distress with
breathing while one side of the nose is blocked this way.
MOUTH
• Tongue is large, presence of frenulum
• Opens evenly
• Epstein pearl - small, round, glistening circumscribed
cysts at the palate due to extra calcium, disappears in a
week
• Thrush - a Candida infection on tongue and sides of -breaks free at 6 to 10 days.
check as white or gray patches
Abdominal reflex- test for spinal nerve T8 to T10
• Natal teeth- extracted if loose
ANOGENITAL AREA

• Check for imperforate anus, no output for 24 hours.

• Time of meconium passes

MALE GENITALIA
NECK • Scrotum is edematous and has rough rugae on the
surface.
• Short and chubby
• Both testes should be present-small, 2cm long
• Head should rotate freely and with an effort to control
• Cryptorchidism – undescended testes
• Prominent trachea and thymus gland
• Agenesis – absence of testes
CHEST
• Epispadias- urethral opening at dorsal surface
• Smaller than head until 2 years
• Hypospadias- urethral opening at ventral side
• Clavicles should appear straight and smooth
• Cremasteric reflex –maybe present at 10 days
• Crepitus (crackling sound) suggests fracture
• Circumcision may be delayed
• Supernumerary nipples

• Usually found below and in line with the normal

nipples.

• Maybe engorged around 1 week

• + witch milk-
FEMALE GENITALIA
• Retraction- should not be present
• Vulva maybe swollen
• Rhonchi (sound of air passing over mucus) may be
present • pseudomenstruation

THE BACK

• Flat in the lumbar and sacral area

• Should be no pinpoint, opening, dimpling or sinus

tract(spinal bifida)

ABDOMEN EXTREMITIES

• Slightly protuberant • Appears short and move symmetrically

• Scaphoid- missing abdominal content, diaphragmatic • Legs are bowed and short, flat sole, covered with 2/3
hernia creases

• - presence bowel sound within 1 hour • Hands are plump and clenched

• -spleen and liver may be palpable. • Nails are soft, long and smooth

• Umbilical stump- dry and shrink later then brown to • Check for simean crease- single palmar crease
black . • Tonic neck reflex, capillary refill
• Check for syndactyly, polydactyly , unusual spacing of
toes, talipes,

• Hip subluxation

Ortolani sign – presence of clunk sound

Barlow’s sign- slipping of from the socket.