OB Exam 2 Objectives

3.1
 Evaluate the effect of the five major factors (“5 P’s) on the labor process including (but not
limited to)
o The five major P’s=
 Passageway
 Bony pelvis
o Size of the pelvis
o Shape of the pelvis
o Ability of soft tissue to permit passage of fetus
 Soft tissues
 Passenger
 fetus
 Powers
 Primary powers=Contractions (involuntary)
 Secondary= Bearing down/ pushing (voluntary)
 Position
 psyche
o Describe the anatomic structure of the bony pelvis.
 Android
 Heart shaped, prominent, narrow interspinaous diameters w/
convergent sidewalls; increased risk for CPD= increased risk for c-
section
 Anthropoid
 Male shaped; oval, narrow, prominent ischial spines, but straight
sidewalls and longer anterior/ posterior than android, more often
associated with OP position
 Gynecoid
  Female shape, round, blunt, somewhat widely spaced ischial
spines w/ deep, curved sacrum, spontaneous vaginal birth/ OA
 Platypelloid
 Flat; widely separated ischial spines, shallow A-P diameter (baby
may not engage), more likely to have transverse arrest, opposite
of android
o Explain why the pelvis of an adolescent mother may increase the risks in labor.
 Shape is a problem
o Describe the anatomic structure of the head of the term fetus.
 The bones of the head are not fused, they are held together by
connective tissue called sutures
 Results in cone head shape when baby is born but that will go away after
about 3 days
 Sutures and fontanels make the skull somewhat flexible- allowing for
molding during birth and continued brain growth during infancy

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 o Explain the significance of the size and position of the fetal head during labor and
birth.
 Given a diagram, identify:
o Lie- relationship of the long axis (spine) of the fetus to the long axis (spine) of
the mother
 ROP
 ROT
 ROA

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 o Fetal presentation-the part of the fetus that enters the pelvic inlet first and leads
through the birth canal during labor
 A cephalic presentation w/occiput presenting is most common and is
referred to as a VERTEX presentation
 Cephalic (occiput, sinciput, brow), breech (sacrum, feet/foot), shoulder
=scapula
 Complete breech= sacrum and feet presenting
 Frank breach= sacrum presenting
 Single footling breach
 Occiput is the best presentation = vertex
o Fetal presenting part- that part of the fetal body that is closest to the internal os
of the cervix, it is the part first felt by the examining finger during a vaginal exam
o Fetal attitude= relationship of the fetal body parts to each other (posture)
 Vertex= flexion
 Sinciput= military
 Brow= partial extension
 Face= full extension
o Fetal position
 R or L= right or left side of MOTHER’s pelvis
 Presenting part= O for occiput, S for sacrum, M for mentum (chin), Sc for
scapula

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 Most likely location to auscultate FHR
o
 Contrast primary and secondary powers of labor.
o Primary power= involuntary contractions
 Involuntary ctx originate a certain pacemaker points in upper uterine
segment... from these points, the ctx move downward over the uterus in
waves
 when the presenting part of the fetus reaches the perineal floor, stretch
receptors in the posterior vagina cause release of endogenous oxytocin
that triggers the maternal urge to bear down, known as the Ferguson
reflex. Totally involuntary urge.
o Secondary powers of labor= voluntary pushing
 Evaluate the effect of maternal position on labor progress.
o Position affects the woman’s anatomic and physiologic adaptations to labor
o Frequent changes relieve fatigue, increase comfort and improve circulations

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 o Helps with fetal descent
o Change position every 30 minutes in labor
o Upright: gravity promotes fetal descent; ctx are generally stronger and more
efficient resulting in shorter labor, maternal CO is increased which improves
blood flow to placenta and maternal kidneys
o All fours: good for backache and to rotate an OP fetus, may also help with should
dystocia
o Squatting- moves the uterus forward to align fetus w/birth canal and increases
the pelvic outlet
o Semi-recumbent position- requires adequate body support or push effectively bc
her weight will be on her sacrum, moving the coccyx forward and reducing pelvic
outlet
o Sitting or squatting- abdominal muscles work in greater synchrony w/ uterine ctx
during pushing efforts
o Lateral- help rotate fetus in posterior position or when there is a need to
decrease the force of the expulsion
 Describe how maternal state of mind impacts the progress of labor.
o Her perception of the process of labor and birth
o Psychologic and physical prep for childbirth
o Sociocultural heritage
o Previous childbirth experience
o Support from sig others
 Identify signs of impending labor.
o True labor= pain in lower back that radiates to abdomen, pain accompanied by
regular rhythmic ctx, regular ctx, ctx that intensify with ambulation, progressive
cervical dilation and effacement
o Signs of impending labor= lightening (presenting part descends into pelvis)-
breathe easier but urinary frequency returns, increase in Braxton hicks, cervical
changes-softens, partially effaced, may begin to dilate, loss of mucus plug
(bloody show), rupture of membranes, sudden burst of energy, greater frequency
of urination, wt. loss 1-3lbs, increased backache and sacroiliac pressure
(relaxation of pelvic joints), possibly N/V/D (prostaglandins)
 Explain the stages and phases of labor.
o 1st

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  Latent/early phase 0-5cm, most of progress is effacement and dilation
with less progress in fetal descent
 Active phase 6cm-10cm- more rapid dilation and increased rate of fetal
descent
o 2nd
 Latent or passive phase (laboring down)-period of physiologic lull; period
of peace and rest, fetus continues to descend passively and rotatoes to an
anterior position as a result of ongoing ctx. No urge to bear down yet 0-
+2
 Descent phase (active pushing)- strong urge to bear down (ferguson
reflex) station +2- +4, significant dark red bloody show
o 3rd- delivery of baby to delivery of placenta
o 4th= delivery of placenta to about 1-2hrs
 Summarize the cardinal movements of the mechanism of labor for a vertex presentation.
o Turns and adjustment that the fetus has to make in order to be born are termed
the mechanisms of labor
o Seven cardinal movements slide 44
 1. Engagement
 2. Descent
 3. Flexion
 4. Internal rotation
 5. Extension
 6. External rotation (restitution)
 7. expulsion
 Explain the maternal and fetal adaptations to labor.
o Maternal:
 CO: look at slide 45
 HR, R, Tempincrease
 BP increase during ctx
 WBC increase (from stress)
 Blood glucose increase
 Respiratory: increased O2 consumption

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  GI: motility and absorption of solid food is decreased, stomach emptying
is slowed, N/V
 Renal: decreased awareness of full bladder, inability to void, proteinuria
+1 due to breakdown of muscle tissue for energy
o Fetal:
 Molding of head
 Oxygenation- circulatory: preferential streaming: highly oxygenated blood
is directed or shunted to the brain and myocardium, characteristic FHR
patterns
 Fetal reserve= ability of the fetus to compensate for periods of stress
(decreased O2)
 Respirations:
 Production of fetal lung fluid stops and absorption begins
 Pressure on fetal thorax during birth aids in clearance of fluid from
airways
 PO2 decreases
 PCO2 increases
 pH decreases
 fetal resp movements decrease

3.2 Labor Pain

 Discuss the causes of pain in childbirth.
o Sources of pain=stretching, pressure, muscle hypoxia, distention, emotional
tension
 Examine factors which affect a laboring woman’s response to pain.
o Psychological state, if she accepts the pain as natural, she is more likely to cope
with it. If she associates it with suffering, she is likely to become distressed and
lose control
o Knowledge, culture, personal experience, fatigue/ sleep deprivation, anxiety,
attention and distraction, emotional support, age
 Outline adverse effects of pain on maternal and fetal well-being.
 Explain the behavioral cues and verbal indicators of pain in the woman during labor and
birth.

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 o Symptoms= culturally dependent and individualized
o Request for medications or epidural, ineffective use of pain control control
measures/ loss of control, screaming, thrashing, crying, hyperventilation,
sweating, shaking, inability to relax
o Reactions= increased pulse and RR, dilated pupils,increased BP, muscle tension
o Effects of pain in labor= increased maternal O2 consumption, increased
catecholamine secretion, decreased progress in labor, decrease mom’s self
confidence
 Explain the theoretical basis of nonpharmacologic pain relief methods. (Fear-tension-pain;
gate control theory)
 Use appropriate nonpharmacologic strategies to enhance relaxation and decrease
discomfort during labor:
o Hydrotherapy: physiological and psychological benefits, stop or enhance labor,
warm, clean
 Disadv: infection (contraindicated w/ ROM), EFM, cleaning, birth
attendant discomfort, universal precautions, overheating, underwater
birth
o Breathing & relaxation techniques: help avoid hyperventilating, type of breathing
is based on how she is coping rather than stage of labor
o Massage / Effleurage: effleurage= light massage in a circular manner, fingertips
touch the skin on the abdomen, gentle strokes
o Environmental control
o Positioning
o Pressure and counter pressure
o Encouragement and support- Doula
 Analyze pharmaceuticals (systemic analgesics and regional anesthetics) used to relieve
labor pain, including drug classification, route(s) of administration, therapeutic effects, side
effects, contraindications and nursing implications
o Should be implemented before pain becomes so severe that catecholamines
increase and labor is prolonged
o Systemic analgesics:
 Opioid agonists: stimulate both major opioid receptors, create a feeling of
euphoria,delayed gastric emptying, increased N/V, bladder and bowel
elimination can be inhibited. HR, BP, respiratory effort may be effected…

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 birth should occur less than 1 hour or more than 4 hours after admin to
minimize CNS depression on the baby
 Meperidine (Demerol)= metabolite
 Fentanyl (Sublimaze)
 Ramifentanil (Utiva)
 Opioid agonist-antagonist: (agonist= agent that activates or stimulates a
receptor to act; antagonist= agent that blocks a receptor or a medication
designed to activate a receptor, in labor they provide adequate analgesic
w/o causing significant resp depression in the mother or neonate. Less
likely to cause N&V but sedation may be just as great or greater than w/
pure agonists, IV route preferred
 Not suitable for women w/ an opioid dependence because the
antagonist activity could precipitate withdrawal symptoms in both
mother and newborn
 Butorphanol (stadol)
 Nalbuphine (Nubain)
o Regional anesthetics: complete pain relief and motor block slide 35
o Regional analgesia: some pain relief and motor block
o Opiate antagonist:
 Naloxone (Narcan)=used to reverse the CNS depression caused by
narcotic analgesics, it also counters the effect of the stress-induced levels
of endorphines
 Not effective in reversing respiratory depression caused by
normeperidine (an active metabolite of merperidine)
 Describe nursing responsibilities during and immediately after the administration of
obstetric analgesia or anesthesia.
o Know type of drug and pharmacology
o Onset, peak, and duration of action
o Advantages and disadvantages
o Side effects for mother and fetus
o Safety issues
o Informed consent of patient
o Documentation

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 o Nursing implications for opiate agonist & agonist/ antagonist
 Do not give PO; IV preferred
 Remifentanil = PCA only
 IV admin : onset= 5 min or less, peak at 30 min, duration 1-2 hours
 IM= O: 30 min, P= 1-3 hr, D= 4-6hr
 Give SLOW IV push, during a contraction, explain the purpose; warn pt.
that pain will return, after admin-monitor VS, FHR, ctx every 15 mins for 1
hr
 Document med admin on maternal and neonate record
 Be prepped with naloxone at birth esp if birth is during the peak of drug
action
 Do not give to patient w/ narcotic dependency
o Read/ study med guide pp 343-345
 Prioritize nursing interventions for complications of regional anesthetics.
 Discuss the use of naloxone (Narcan).
o Naloxone (Narcan)=used to reverse the CNS depression caused by narcotic
analgesics, it also counters the effect of the stress-induced levels of endorphines
o Warn patient that pain will return
o Monitor for loss of effectiveness (duration of narcotic is longer than duration of
Narcan)
 Compare and contrast general anesthesia, local anesthesia and regional anesthesia.
 Recognize symptoms and prioritize nursing care for a patient experiencing side effects or
toxic effects of regional anesthesia.
o Tingling of extremities, metallic taste, confusion/ uneasy feeling, convulsion
o First act would be to turn epidural off
o Second act= contact HCP
 Explain the indications for an antilogous epidural blood patch.
o Treat postdural puncture headaches (PDPH)
 Develop a nursing plan of care for a laboring woman with an epidural anesthetic.
o Complications= hyperthermia, length of labor, second stage, malpositions, use of
oxytocin, operative birth, toxicity, total spinal/high spinal, hypotension, post
dural headaches, neuropathy, backache

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 o Adv: effective, decrease catecholamines, decrease hyperventilation, awake, and
alert
o Disadv: cost, continuous EFM, IV, loss of sensation and limited movement,
bladder atony with urinary retention, increased risk of PP hemorrhage, operative
vaginal birth (forceps, vacuum)
o Epidurals increase length of labor because it relaxes pelvic muscles which makes
it harder for baby to turn which leads to malpositions
o Mom cannot feel the effects of pushing
o Greater risk of c-section, forceps, etc.
o C/I= actual or anticipated serious hemorrhage, hypotension, coagulopathy,
infection at the insertion site, increased ICP, allergy, refusal or inability to
cooperate, certain cardiac conditions, if pt cannot stay still long enough to get it
put in
o Nursing responsibilities: assess mother/ fetal baseline VS and FHR, assess
maternal labs (platelet count), maternal hydration, positioning/monitoring
during placement, pain control/effectiveness, bladder distention (side effect of
not being able to feel bladder), mobility/positioning, ongoing fetal/ maternal
assessment
o 500 mL of IV fluid before start of epidural
o Maternal hypotension= 20% decrease from baseline of 100mm Hg systolic, fetal
bradycardia, decreased FHR variability
 Turn woman to lateral position
 Maintain IV infusion, increase rate/bolus
 Admin O2 at 10-12L/min
 Elevate legs
 Noticy HCP
 Admin IV vasopressor (ephedrine 5-10mg)
 Monitor maternal BP and FHR q 5 mins until stable
 Develop a nursing plan of care for a post Cesarean birth patient with epidural/intrathecal
medications and for a post Cesarean birth patient with patient controlled analgesia.
 Provide nursing care for a woman using nitrous oxide for pain management in labor.
o Systemic drug
o Mother is the only one allowed to adm, when ctx begins,during it and then
removes after it ends, should not be mixed with other narcotics

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3.3 intrapartum nursing care
 Assess the intrapartum family to fulfill human needs.
 Distinguish true and false labor.
 Use the Maternal Fetal Triage Index (MFTI) to screen and prioritize the pregnant woman
presenting to the health care facility.
o Slide 8 PRINT OUT AND STUDY
o Shows how urgently the patient needs interventions, how urgently to notify
provider, helps determine the need for immediate action
o If a woman is to be admitted= prenatal record, patient interview, completion of
physical exam
o Admission assessment should be completed w/ in first hour of admission and
documented by RN
 Use Leopold’s Maneuvers to identify:
o Fetal lie
o Fetal presentation
o Fetal presenting part
o Fetal position
 Most likely location to auscultate FHR:
o Heard loudest on fetus’s back
o If heartbeat is above mom’s umbilicus then baby is breach
 Evaluate initial assessment data of the intrapartum family to identify risk factors and
develop the labor plan of care.
o Review prenatal record for risk factors
 Outline the standard of nursing care for assessment of the woman and fetus in each
stage of labor and maternal risk status.
o 1st stage
 Ongoing assessments: continuously checking for indicators of a problem
because they can occur fast
 Change of status/ complications (mom or baby)
 Labor progress
 Interventions:
 Comfort and pain management

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  Patient/ family teaching
 Psychosocial support
o Ongoing Assessments in 1st stage=low risk (if high risk everything would be done
twice as often)
o Latent phase
 BP,P,R= q 30-60min
 T= q 4hr if BOWI (bag of water intact); q 2 hr if ROM (rupture of
memranes); q 1hr if PROM
 FHR and UA q 30 -60min
 Vag exam as needed
 Psycho/emotional exam and partner every 30 mins
 *once membrane has ruptured you lose most important protective
barrier from infection
 Chorioamnionitis= infection inside uterus with baby and causes for
delivery
o Active phase
 BP, P, R= q 30 min
 T= q 4hr if BOWI, q 2hr if ROM, q 1hr if PROM
 FHR and UA q 15-30 min
 Vag exam as needed
 Psycho/emotional and partner= q 15 min
o Oxygenation and circulation
 Maternal
 Maintain CO (position, hydration)
 Control anxiety and fear (control catecholamine release and
vasoconstriction)
 Control hyperventilation and adequate respiration
 Fetal
 Maintain maternal O2 to supersaturate plasma prn
 Fetus will show sx of decreased O2 before momw ill
 ROM- assess for prolapsed cord
o All phases of stage 1

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  Data: maternal VS, color, cap refill, breathing patterns, FHR
o Safety and comfort:
 Hygiene (comfort and infection control)
 Diaphoresis, leakage of fluid, vaginal secretions, clean linen
and peri care prn, showers, baths, for hydrotherapy and
hygiene, socks/ slippers for feet, elimination
 Oral care- toothbrush, mouthwash, breath spray, chapstick
 Pain management
o Psychological
 Understanding, order, predictability
o Social: care of the partner/ support person and family members present
o SECOND STAGE LABOR ASSESSMENT (Nurse prepare for birth with supplies,
equipment, warmer)
o Mom: BP & P q 5 to 15 mins, palpate bladder for distention
o Baby: FHR
 Latent (passive fetal descent) every 15 min
 Active pushing = q 5-15 min
o Labor:
 Ctx, observe perineal area for increased blood show, bulging
perineum and anus, visibility of presenting part, amniotic fluid (color
and consistency)
o Support persons- may need a chair to sit in (in case they feel faint?),
encouragement, give instructions
o
o

 Interpret the results of a cervical exam of a laboring woman.

 Evaluate the progress of labor during the first, second, third and fourth stages.
 Evaluate the laboring woman’s behavioral adaptations to the phases and stages of labor.
 Identify the nurse’s role in promoting the progress of labor.
o Position changes and movement (upright is best position)
o Pain management/ comfort (if pain is out of control then cervix will not dilate)

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 o Adequacy of ctx pattern (if ctx are not firm let provider know)
 Prioritize nursing interventions for a woman in each phase of first stage labor.
 Describe the role of activity and positioning in the progress of first stage labor.
o Helps in pain management, labor progression, and fetal descent
o Latent= ambulation, rocking, UPRIGHT
o Active= ambulatory with rest breaks; sitting; laying lateral; if epidural, position
changes q 1 hour
o OP position= hands and knees, may promote rotation; definitly promotes relief of
back pain
 Select appropriate positions for the laboring woman based on assessment data.
o for people without epidurals, upright positions during the second stage of labor
provide several benefits: a lower risk of abnormal fetal heart te patterns, less
pain, and less use of vacuum/forceps and episiotomy. Upright birthing positions
may also shorten the second stage of labor and reduce the use of augmentation
with synthetic oxytocin.
o In terms of risks of upright birthing positions, studies have found an increase in
second-degree tears from upright birthing positions, but some would consider
that a reasonable trade-off for a lower rate of episiotomies. Also, it may be
possible to reduce the rate of tears by using evidence-based pushing methods in
the second stage of labor.
o Women should be upright (> 30 degrees) or lateral
 Use delegation appropriately in providing care to a woman in labor.
 Describe the pathophysiology and nursing interventions for hyperventilation in labor.
 Describe symptoms of and nursing interventions for a woman laboring with a fetus in
the “OP” position.
 Coach and support the laboring woman and her partner throughout labor and birth.
o Holding, application of heat/cold, giving ice chips, oral care, lip balm, helping
with personal hygiene, massage, hydrotherapy, helping with positioning ,
assisting with ambulation
 Prioritize nursing care for a woman during and immediately after spontaneous or
artificial rupture of the amniotic membranes.
o Always assess for cord prolapse with SROM or AROM
o Assess FHR during/ immediately after ROM

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 o Mom releases prostaglandins = contribute to uterine ctx also gets the baby’s
head to push against cervix, which can be better force to get the cervix to dilate
 Develop a nursing change of shift report for a woman in labor.
 Develop a safe & comprehensive plan of care for women experiencing:
o Spontaneous labor with and without Epidural anesthesia.
 Identify physical and nonverbal signs of second stage of labor for nursing assessment.
o Increase frequency and intensity of ctx
o Urge to push; feel need to have BM; involuntary bearing down
o Vomiting
o Increased bloody show
o Shaking/ shivering
o Restlessness; verbalizations (“I can’t do this)
o Latent phase AKA delaying pushing, laboring down, or passive descent
 Vaginal exam : complete dilation (10cm); complete effacement (100%)
 Change in mood- tired, yet relieved
o Active phase: bloody show, urge to push (Fergusons’s reflex), grunting and
expiratory vocalizations (swearing, screaming, prayers or stoic), perineal bulging
 Compare and contrast spontaneous and directed pushing techniques for second stage
labor. Look at slide 51
o Spontaneous/ open glottis
 Push w/ urge to push, instinctive, spontaneous
 Push whle exhaling, 6-8 seconds
 Noise/ grunting is OK
 Nurses role- encouragement, assurance of progress
o Directed/ closed glottis (bad way)
 Hold your breath, push w/o making noise for 3 counts of 10 w/each
ctx,harmful to momand fetus
 Nurses role= direct
 This method is discouraged because it may trigger the Valsalva maneuver,
which occurs when the woman closes her glottis, causing an increase in
intrathoracic and CV pressure, thus reducing cardiac output and
decreasing perfusion of the uterus and placenta

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  Provide labor support for second stage labor, including teaching and supporting the
woman’s significant other.
 Differentiate first, second, third- and fourth-degree perineal lacerations. Discuss nursing
implications.
o 1st- laceration that extends through the skin and vaginal mucous membrane but
not the underlying fascia and muscle
o 2nd- laceration that extends through the fascia and muscles of the perineal body,
but not the anal sphincter
o 3rd- laceration that involves the external anal sphincter
o 4th- laceration that extends completely through the rectal mucosa, disrupting
both the external and internal anal sphincters
 Recognize signs of potential complications in labor
o Infection: fetal tachy (HR >160), maternal temp (fever 100.4F), foul smelling
discharge
o IUP > or equal to 80mm Hg
o Resting tone > or equal 20 mm Hg
o Ctx > or equal to 90 sec duration
o >5 ctx in a 10 minute period
o Relaxation time <30 sec
o FHR BL <110 or >160
o FHRV absent or minimal
o FHR late, variable, prolonged decels
o Appearance of meconium stained or blood fluid from vagina
o Perisstnet bright or dark red vaginal bleeding
 Recognize indicators of placental separation. (3rd stage)
o A firmly contracting fundus
o A change in the uterus from a discoid to a globular shape
o A sudden gush of dark blood
o Apparent lengthening of the umbilical
o The finding of vaginal fullness on vaginal exam, or of fetal membranes at the
intoitus
 Identify the nursing role in third and fourth stages of labor.

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 o 3rd-- document exact time of birth (when the entire body is out of the mother
and must be recorded), immediate skin-to skin, delayed cord clamping
 Immediate assessment + interventions: APGAR, airway maintenance,
respiratory effort support, thermoregulation support
o 3rd- before placental separation = BP, IV site
 Q 15 min= BP, P, R
 Assist with APGAR, neonatal care prn
 Maternal/ partner response to birth/ NB
 As placenta separates, instruct mother to push gently, administer oxytocic
medication per protocol, pain management, ask provider for blood loss
and document, collect umbilical cord blood for lab, document
assessments and interventions, promote family attachment
o
 Recognize complications in the third and fourth stages of labor and provide appropriate
nursing interventions.
o 3rd= hemorrhage, rupture of pre-existing cerebral aneurysm, cardiac
decompensation (if hx of cardiac disorders), pulmonary embolism, amniotic fluid
embolism
 Risk factors for PP hemorrhage:
 Bladder distention
 Uterine overdistention
 Regional anesthesia
 Pitocin induction/ augmentation
 Uterine hyperstimulation
 Magnesium sulfate therapy- smooth muscle relaxant for
preeclampsia
 Dystocia (difficult labor)
 s/s of uterine atony:
 soft, boggy uterine fundus on palpation, uterine fundus displaced
above and to the right of the umbilicus, excessive lochia rubra
 interventions= fundal massage, empty bladder (1st priority ,
recheck q 15 min x 1 hr; q 30 min x 2 hr
o

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  Prioritize nursing assessments in fourth stage for vaginal and operative delivery.
o Initial:
 TPR, BP, fundus, bladder, lochia, perineum, pain, PAR
 Q 15 min x 1hr; q 30 min x 1hr
 P, BP, fundus , bladder, lochia, perineum, pain, PAR add T at 1 hr and 2hr
 Hourly assessments until stable
 Postanesthesia recovery score
 Activity, resp, BP, LOC (level of consciousness), color
 If the woman received general anesthesia, she should be awake and alert
and oriented to time, place, and person. Her respiratory rate should be
within normal limits, and her oxygen saturation level at least 95%, as
measured by a pulse oximeter. If the woman received epidural or spinal
anesthesia, she should be able to raise her legs, extended at the knees,
off the bed, or flex her knees, place her feet flat on the bed, and raise her
buttocks well off the bed. The numb or tingling, prickly sensation should
be entirely gone from her legs. The length of time required to recover
from regional anesthesia varies greatly. Often it takes several hours for
these anesthetic effects to disappear completely.
 Immediate care of a woman after birth= clean pt, provide clean bed and
gown, position her comfortably, offer PO fluids, food if not C/S, assist
woman to hold and position baby for eye-to-eye contact; assist with
breastfeeding, assess VS, fundus, lochia, PAR q 15 min
 Post C/S pts will have clear liquids and ice chips
 Promote elimination, maintain safety, comfort, hygiene, assess
episiotomy or laceration repair, apply ice to reduce edema
 Assess pain per rating scale, sensory and motor function if epidural meds
were used; assist with removal of epidural catheter if indicated
 If post C/S: also monitor IV fluids, urine output per foley catheter, oxygen
sats, incision dressing, epidural pump functioning
 Meet emotional needs, listen to her birth story or concerns, encourage
family members to visit,support her interactions with the baby, support
feelings of shock, disbelief, grief, promote family time with significant
other and baby
 Provide family centered nursing care during the fourth stage of labor.
Lesson 4 postpartum complications

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  Describe the anatomic and physiologic changes that occur during the postpartum
period.
o Uterus
 Involution process, ctx, afterpains, placental site
 Decreases in wt from 2.2 lbs @ birth to 1.1lbs during the first wk
 Uterus should be midline, firm @ the umbilicus or below the umbilicus
o Placenta
 Immediately following delivery, placental attachment site on uterine wall
is open, hemostasis of bleeding is accomplished by ctx of the
myometrium, results in blood clotting and sealing raw, opened areas
 After birth of the placenta, uterus is at about a -2, but rises w/in 12 hours
to approx. +1. By 24 hours, it should be near the umbilicus, then goes
down by 1 cm/day. By 6 days PP, should be about ½ way between
symphysis & umbilicus & non palpable by 2 weeks PP

o Perineum
 Immediately postpartum, tender, swollen, with bruising, may have
sutures, if have laceration repair or episiotomy
 Edges should be approximate if episiotomy is done
 Ice reduces swelling, perineal pads, anti-inflammatory creams,local pain
control
o Breasts
 Prepare for lactation due to estrogen and progesterone
 Colostrum present: yellowish fluid high in protein and minerals, provides
initial infant immunities, breast milk production begins approx.. day 3-5
PP, may experience engorgement
o Abdomen:
 Soft, flabby
 May exercise to strengthen abdomen as per provider instructions
 Striae gravidarum fade from original color to silver
 Diastasis recti
o CV and Hemo
 Blood loss = EBL est blood loss

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  Increase circulating volume 15-30%
 Autotransfusion from placenta, increase venous return, loss of
vasodilating effects of pregnancy hormones, shift in ECF into systemic
circulation
 Increase volume= diuresis, diaphoresis, hemodilution (decrease H/H x 3-4
days)
 Increase WBC during labor and immediately after birth, decrease to
normal by 4-7 days
 Thromboplastin released @ placental site; plasma fibrinogen remains
elevated
 EBL vaginal= 200-500ml; C/S= 700-1000ml
o Endocrine
 Slide 20
o Urinary
 Aids in removal of excess fluids PP, may void as much as 3L/day, may
experience bladder distention r/t trauma, bruising, and edema of urethra,
usually will void within 4-6hrs after delivery
o GI
 Hunger following birth, bowels tend to be sluggish, fear of pain inhibits
elimination; BM should occur 2-3 days
 C/S- liquids until bowel sounds are present
 Flatulence after c/s
 Stool softeners, decrease opioid pain med
o M/S
 Immediately PP muscle soreness present
 Usually experiences PP chills: trembling and feeling cold secondary to
sudden physiologic changes
 Diastis recti
o Integumentary
 Pigmentation change during pregnancy fade
 Diaphoresis- periods of profuse sweating
 usually occurs in the first few days PP
 Normal response: aids kidneys with removal of excess fluids

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 o Neuro
 Changes result from reversal of maternal adaptations to pregnancy and
from trauma during labor and childbirth
 Pregnancy induced neuro discomforts abate after birth
 Headaches are common
o Immune system
 Mildly suppressed during pregnancy, gradually returns, can trigger flare
ups of autoimmune conditions
o
 Explain characteristics of uterine involution and lochial flow and describe ways to
measure them.
o Involution is complete in 5-6wks
o Lochia= when innermost lining of the decidua becomes necrotic and sloughs off,
combines with RBCs, WBCs, cervical mucous, and bacteria cells
o Lochia rubra= days 1-3, dark or bright red, small clots, musty odor, variable flow,
like a heavy period for first two hours then slows down
o Lochia serosa= days 4-10, pink or pinkish -brown, no clots, less odor, moderate-
scant flow
o persistence of lochia rubra in the postpartum period suggests continued bleeding
as a result of retained fragments of the placenta or membranes. It is not
uncommon for women to experience a sudden, but brief, increase in bleeding 7
to 14 days after birth when sloughing of eschar over the placental site occurs. If
this increase in bleeding does not subside within 1 to 2 hours, the woman needs
to be evaluated for possible retained placental fragments (Isley & Katz, 2017).
o About 10% to 15% of women still have normal lochia serosa discharge at their 6-
week postpartum examination (Isley & Katz, 2017). However, the continued flow
of lochia serosa or lochia alba by 3 to 4 weeks after birth can indicate
endometritis, particularly if the woman has fever, pain, or abdominal tenderness.
Lochia should smell like normal menstrual flow; an offensive odor usually
indicates infection. P 418
o Lochia alba= days 10-14, light-yellow to creamy, no clots, no odor, scant flow
 Differentiate normal and abnormal physical assessment findings during the postpartum
period. Identify probable causes for deviations from normal.
o Uterus that is lateral to midline or higher than the umbilicus (suspect full bladder,
which can interfere with uterus tone)

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  Explain the cause and nursing management of “afterpains”.
o Usually experienced 2-3days PP
o Increased risk of experience with multiparas, mother’s of large infants, multiple
gestation
o Caused by ctx of the uterus as it decreases in size
o Increases with breastfeeding due to stimulation of breast tissue causes release of
oxytocin from the posterior pituitary gland, causes uterus to contract more
vigorously
 Differentiate “baby blues” and postpartum depression.
o Blues: emotionally labile, cry easily for no reason, depressed mood, let-down
feeling, restless, fatigue, insomnia,headache, anxiety, sadness and anger, feeling
overwhelmed, loss of appetite
 Contributing factors= hormonal fluctuations, major psychological
adjustments necessary during transition to parenthood, perineal and
breast discomfort, exhaustion, mother’s poor self concept about her body
 Self limiting w/spontaneous recovery
 Most frequently in first 6wks, may recur
 Interventions= teach about it and coping strategies, follow up phone calls
o PPD
 Worsening of sleep disturbances
 Appetite changes; eating problems
 Increase intensity and duration of depressed feelings
 No compensatory measures to deal with fatigue and exhaustion
 Withdrawal and social isolation
 Thoughts of harming the baby
 Lack of interest in baby
 Id women at high risk, listen actively, compassionate care, teach
symptoms, and to call for help
 Discuss parental attachment, bonding and acquaintance.
o Attachment behaviors:
 Touch
 Call baby by name

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  Claiming behaviors
 Displays of affection
 Responsiveness
 Comforting techniques
o
 Identify parental and infant behaviors that facilitate and those that inhibit parental
attachment.
o Inhibit: inability or refusal to discuss labor experience, refusal to care for or
interact with infant, excessive preoccupation with self, marked depression, lack
of support system
 Compare maternal adjustment and paternal adjustment to parenthood.
o Maternal
 Reva rubin slide 74
 Taking in -> taking hold -> letting go
o Paternal- slide 83-85
 Engrossment: touch, eye contact, awareness of features unique and
similar to himself; describes the father’s absorption, preoccupation, and
interest in the baby
 Stage 1: expectations
 Stage 2: reality
 Stage 3: transition to mastery
 Stage 4: reward
 Implement nursing interventions that facilitate parent-infant adjustment.
o Developing of a relationship between parent and infant requires
 Contact
 communication
o
 Plan nursing care to support maternal role attainment.
 Examine factors that affect parenting responses and behavior (parental age, social
support, culture, socioeconomic conditions, same sex parenting, personal aspirations
and sensory impairment).
 Provide parent teaching to facilitate sibling adjustment.

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 o Sibling acquaintance: looking, eye contact, touch (first head,then progress)
o Attachment dependent on Age and developmental level
o Behavior results from separation from mother, changes in parent behavior,
response to infant coming home
o Positive behaviors: interest in and concern for infant, increased independence
o Negative behaviors: regression in toileting and sleep habits, aggression toward
baby, attention seeking behaviors
o Strategies for facilitating sibling acceptance = p. 456
 Prioritize nursing care for the postpartum patient and family.
 Evaluate a patient/family for early postpartum discharge.
 Explain the influence of culture on postpartum care.
o Rest,seclusion, dietary restrictions, and ceremonies honorng the mother are
common practices
o Avoid cold: bathing, dietary
 Develop nursing care plans for a postpartum woman during the 1st 24 hours after birth:
o Who delivered vaginally, without an episiotomy.
o Who delivered vaginally, with an episiotomy.
 Inspection : REEDA, hemorrhoids, bruising and edema may suggest
hematoma, assess perineum and anus q 4 hrs, then q 8-12 hrs untill d/c
o Who delivered by cesarean birth and has epidural/intrathecal analgsia ordered
for PP pain management.
o Who delivered by cesarean birth and has systemic analgesia ordered for PP pain
management.
 Prepare a plan for postpartum discharge teaching for self-management for:
o A woman who had a vaginal birth and one who had a Cesarean birth.
o Breast care & management of common problems associated with breast feeding.
 Nipple care, prevention of engorgement + tmt, support bra, manage
leaking
o Breast care & management of common breast problems of the woman who will
formula feed her baby.
 Suppress lactation= tight bra or breast binder 24x7 for 72 hrs+, avoid
stimulation (running warm water on breasts in shower, newborn suckling,

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 pumping), ice packs 15min on and 45 off, fresh cabbage leaves, analgesic
if needed
o Anticipated changes in lochia.
o Perineal/episiotomy care.
 Rinse w/ clear water each void; heat or cold application, sitz bath, side-
lying positions, kegel’s, no “donuts’ rubber rings=they cause separation of
the perineal tissue
o Kagel exercises.
 Strengthens pelvic muscle tone
o C/S incisional care.
 Watch for REEDA
o Diet.
 Id risk status, energy adequate for self and infant care
o Rest & exercise.
 Relaxation: back rubs,imagery, music
 Limit visitors prn
 Adjust routine
 Comfort of partner
 Encourage and assist w/ ambulation
o Anticipated emotional changes.
o Warning signs of problems.
 Lochia- heavy, clots, odor
 Temp> 100.4
 Red, warm, lump in breast
 Pain on urination
 Tenderness in calf
 Change in eating pattern
 Inability to sleep despite exhaustion
 Withdrawing from others
o Disease prevention (PP immunizations: Tdap, Rubella, RhoGam).

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  For women who have not had rubella or who are serologically
nonimmune (titer of 1:8 or less or enzyme immunoassay level <0.8), a
subcutaneous injection of rubella vaccine is recommended in the
postpartum period prior to hospital discharge to prevent the possibility of
contracting rubella in future pregnancies; this is given as the measles,
mumps, rubella (MMR) vaccine. Women are cautioned to avoid becoming
pregnant for 28 days after receiving the rubella vaccine because of the
potential teratogenic risk to the fetus. The live attenuated rubella virus is
not communicable in breast milk; therefore breastfeeding mothers can be
vaccinated. However, because the virus is shed in urine and other body
fluids, the vaccine should not be given if the mother or other household
members are immunocompromised. Fever, transient arthralgia, rash, and
lymphadenopathy are common side effects of the rubella vaccine
 varicella vaccine be administered before discharge in postpartum women
who have no immunity. A second dose is given at the postpartum follow-
up visit (4 to 8 weeks after the first dose)
 Tetanus-diphtheria-acellular pertussis (Tdap) vaccine is recommended for
postpartum women who have not previously received the vaccine; it is
given before discharge from the hospital or as early as possible in the
postpartum period to protect women from pertussis and to decrease the
risk for infant exposure to pertussis. Women should be advised that other
adults and children who will be around the newborn should be
vaccinated with Tdap if they have not previously received the vaccine.
This vaccination should occur at least 2 weeks before contact with the
infant in order to allow time for immunity to be established. Women who
receive the vaccine can continue to breastfeed
 Injection of Rh immune globulin (a solution of γ globulin that contains Rh
antibodies) within 72 hours after birth prevents sensitization in the Rh-
negative woman who has had a fetomaternal transfusion of Rh-positive
fetal red blood cells (RBCs) (see the Medication Guide). Rh immune
globulin promotes lysis of fetal Rh-positive blood cells before the mother
forms her own antibodies against them (Aitken & Tichy, 2015).
Administration of Rh immune globulin is intended to prevent problems in
future pregnancies should the Rh-negative woman have an Rh-positive
fetus.

 5.1 Newborn transition
 Analyze the physiologic adaptations that the neonate must make during the period of
transition from the intrauterine to the extra uterine environment.

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 o Est and maintain respirations
o Adjust to circulatory changes
o Reg temp
o Eliminate waste
o Ingest, retain and digest nutrients
o Regulate weight
 Contrast the characteristics of the periods of neonatal transition.
o First period of reactivity
 Up to 30 min after birth
 HR increased to 160-180 (falls within 30 min to 100-120)
 Respirations 60-80; irregular
 Possible respiratory crackles
 Possible brief periods of apnea
 Alert, exploratory behavior, eyes open
 Decreased body temp, increased motor activity and muscle tone
 Gastro intestinal: bowel sounds (+ or -), meconium, saliva
 Strong such reflex frequently present
o Period of decreased responsiveness
 Last from 60-100min
 Unresponsiveness; frequently accompanied by sleep
 Color is pink
 Respirations are rapid and shallow (up to 60 bpm, but unlabored)
 Bowel sounds generally audible
o Second period of reactivity
 2-8hrs after birth, can last 10 min to several hours
 Tachycardia, tachypnea
 Increased muscle tone
 Changes in skin color
 Mucus production may be copious (requires supervision)
 Frequently passes meconium

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  Preterm infants do not experience this phase due to immaturity
 Explain the factors involved in initiation of respirations in the newborn.
o Maturity:
 Surfactant: phospholipid, decreased alveoli surface tension, preventing
collapse on expiration
 PG of += mature, L/S=2:1 ratio= mature
 Pulmonary vascular bed
 Central nervous system
o Initiation of resp.
o Chemical stimuli, sensory stimuli, thermal stimuli, mechanical stimuli
 Evaluate respiratory transition of a newborn.
o Nose breathing w/o flaring
o Quiet, shallow, irregular w/ brief periods of apnea (<20 sec)
o Rate 30-60 beats/min at rest after 1st period of reactivity
o Respiratory movements are abdominal; shallow chest expansions synchronous
w/rise and fall of abdomen
o Characteristics of abnormal respirations: nasal flaring, chest retractions, grunting,
see-saw respirations, crackles, tachypnea, central cyanosis
o Tachypnea can be a respiratory problem, cardiac, metabolic; cold stress,
infectious illness
 Evaluate cardiovascular transition of a newborn.
o Closure of foramen ovale: pressure in left side of heart increases, right side
pressure decreased closes the flap
 1st breath inflates lungs, and decreases pulmonary vascular resistance,
increased blood return from lungs to L atrium, increase SVR w/ clamping
of cord
o Closure of ductus arteriosus
 Increased PaO2 causes DA constriction
o Closure of ductus venosis: clamping of the cord, umbilical vessels become
ligaments
o Heart rate
 Normal= 110-160

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  Point of maximum impulse @ 3rd to 4h intercostal space and left of
midclavicular line
 murmurs
o BP: approx. 60-80/ 40-50
 MAP= EGA
o Blood volume: delayed cord clamping recommended for term and especially
preterm babys
o Signs of problems in CV:
 Abnormal rate,murmurs, alteration and differentials in skin color
(juandic,cycnosis, pallor), tachypnea
o Know that the baby cannot produce certain clotting factors
o
 Recognize symptoms and potential consequences of hypothermia in the neonate.
 Differentiate neonatal heat loss via conduction, radiation, convection and evaporation.
o Conduction-loss of heat from the body surface to cooler surfaces in direct
contact (all surfaces that will touch baby is pre warmed)
o Radiation- loss of heat from the body surface to a cooler solid surfaces not in
direct contact but in relative proximity ( keep bassinets and exam tables away
from outside windows and walls if possible)
o Convection- flow of heat from body surface to cooler ambient air (temp in
nursery is kept at 75F)..keep baby away from drafts
o Evaporation- loss of heat that occurs when a liquid is converted to vapor. In
newborn, this type of heat loss occurs as a result of vaporization of moisture in
the skin. This is invisible and is called insensible water loss. This heat loss can be
intensified by failure
 Evaluate urinary output in a newborn.
o 5% -10% wt loss 1st 3-5days; regain by 10-14days
o An infant should void within 24 hours of life
o If a newborn has not voided within 48hrs of life it may indicate renal impairment
o Normal void: straw colored, odorless, minimum of 1 wet diaper/ day of age up to
day 4
o Then 6-8/day
o Uric acid crystals= OK for 1 wk (looks red?)

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  Explain normal newborn weight loss.
 Evaluate the gastro-intestinal transition of a newborn.
o Digestion- missing enzymes are present in colostrum
o Stomach size= ,30ml day 1 - 90ml day 3
o Regurgitation (spitting up)
 Distinguish stool patterns of neonates.
o Meconium- usually w/in 12-24 hr
o Transitional stool- greenish brown to yellow brown, thin, less sticky than
meconium, may contain some milk curds
o Breast milk stool: yellow to golden, pasty, “mustard and cottage cheese”, less
offensive odor than bottle fed
o Formula stool: pale yellow to light brown, firmer consistency, more offensive
odor than breast fed
o Know omphalocele( associated with genetic issues) and gastroschisis
 Compare and contrast physiologic, pathologic and breastfeeding jaundice.
o Physiologic- increased bilirubin production due to increased RBC mass, decreased
life span of RBC, immature liver, reabsorption of bilirubin from small intestines,
occurs after 24hrs of life, serum levels peak @6 mg/dl by 72 -96hrs
o Pathologic: occurs before 24 hrs of age, TSB increased > 0.2 mg/dl/hr, TSB >95 th
percentile for age, causes= hemolytic disease of the newborn (Rh incompatibility,
ABO imcompatibility)
o Breastfeeding: 2-5days, lack of effective breastfeeding
 Distinguish normal, variations of normal and abnormal characteristics of newborn skin.
o Vernix caseosa
o Plump
o Lanugo
o Creases in palm and feet
o Desquamation= peeling
o Milia- clogged sebaceous gland
o Mongolian spots (typically baby’s with African or mediterannean heritage)
o Telangiectatic nevi (“stork bites”)
o Erythema toxicum/ erythema neonatorum (“flea bite”, “newborn rash”)

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 o Nevus vasculosus (“strawberry birth mark”)
o Nevus flammeus (“port wine stain”)
o Pre-auricular skin tag
 Differentiate caput succedaneum and cephalhematoma.
o No treatment for either
o Caput= scalp edema
o Cephalhematoma=bleeding under the periosteum (thin lining that covers the
bone) of one of the parietal bones, unilateral
 Increased risk for hyperbilirubinemia because of the extra collection of
blood
 Identify signs that the neonate is at risk related to problems with each of the major body
systems.
 Differentiate normal and abnormal newborn reflex responses. (study table 23-1, pp 477-
481)
o Rooting & Sucking
o Grasp (palmer & plantar)
o Extrusion
o Tonic neck (“fencing”)
o Moro
o Stepping/Walking
o Babinski
 Describe the behavioral adaptations that are characteristic of the newborn.
o Hierarchy of developmental challenges
 Regulate physiologic or autonomic system
 Motor organization
 State regulation (sleep wake cycles)
 Attention and social interaction
o Purposeful behavior
 Actively withdrawing by increasing physical distance
 Rejecting by pushing away with hands and feet

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  Decreasing sensitivity by falling asleep or breaking eye contact by turning
the head
 Using signaling behaviors such as fussing and crying
o
 Provide parent education on behavioral states in the newborn.
 Evaluate newborn sleep/wake states.
o Deep sleep
o Light sleep
o Drowsy
o Quiet alert- optimal state, teach parents to recognize because this is the state
parents should play and interact with baby, eyes are wide open, making
vocalizations
o Active alert- cranky, fidgeting
o Crying
o State modulation
 Discuss the sensory and perceptual functioning of the neonate.
o When baby is overstimulated they start crying
o Sensory behavior: vision, hearing, smell (strong sense of smell), taste (prefer
sweet), touch (very sensitive esp in soles of feet, palms, and face)
5.2 Newborn nursing care
o Explain the purpose and components of the Apgar score.
o Number that gives clues about how well the baby is adapting to extrauterine life
o Know 5 characteristics: HR, rep effort, muscle tone, reflex irritability, color,
o Done at 1 minute and 5 minutes of life..if less than 7 it is repeated every 5 mins
until it reaches 7 up to 20 mins
o Assign and interpret Apgar scores.
o Slide 6
o Prioritize immediate care of the neonate at birth.
o Wipe mouth and nose if necessary (airway), clear mouth before nose
o Thermoregulation: quickly dry infant and place skin to skin with mom or under
radiant heat source (pre heated), remove wet linens

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 o Explain neonatal resuscitation protocol.
o Promote attachment of the new family to the neonate at birth.
o First 1-2hr= golden hour to stay with parents to promote bonding
o Explain considerations for the physical exam of a newborn compared to the exam of an
older child or adult.
o Must provide warmth to prevent cold stress so they don’t revert back to fetal
circulation
o Try to assess the baby when they are quiet
o Describe danger signals or signs in the neonate that indicate actual or potential
problems.
o Apply the nursing process to facilitate need fulfillment of the normal newborn.
o Differentiate normal and abnormal physical (incl. VS), neuromuscular and gestational
age assessments of the newborn.
o Know both farenheit and celsius for temp
o Normal weight = 2700-4000g (6-9lb)
o Normal length 48-53cm (19-21in)
o Head circumference (32.5-37.5cm)
o Chest circumference (2-3cm <head), molding can cause head and chest to be the
same,but after 2-3 days it should level out
o KNOW WHEN FONTANELS CLOSE
o Recognize common variations of normal assessment findings in the newborn.
o Study table 24-3, pp 492
o Circumoral cyanosis is NOT normal
o Mottling can be normal or abnormal
o Provide nursing interventions to promote neonatal airway maintenance, oxygenation
and thermoregulation.
o Identify neonatal cold stress and provide appropriate nursing interventions.
o Provide nursing care for an infant receiving phototherapy for hyperbilirubinemia.
o Overbed light or blanket that baby is wrapped in
o Dress baby in diaper only- expose skin
o Protect eyes if under lamp, put a blindfold on with baby’s eyes closed

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 o Avoid ointments, creams, lotions= increased risk of burns
o Monitor temp and urine output and stool
o Clean buttocks thoroughly with diaper change
o Maintain hydration with frequent feeds (no H20, breast milk or formula)
o Debate the risks and benefits of circumcision.
o Benefits: decrease UTI in males less than a yr old, decrease risk of penile cancer,
decrease risk of heterosexual acquisition of STI, especially HIV
o Risks: cold stress, hypoglycemia (NPO before), aspiration, bleeding, infection,
cutting off too much or too little of foreskin
o Compare and contrast methods of circumcision.
o Provide postoperative care of the circumcised patient.
o Every time diaper is changed, cover glans with petroleum and then put diaper on
o Don’t use pre-packaged diaper wipes(have alcohol)
o Cleanse with water to remove urine/feces
o Reapply Vaseline if needed
o Change diaper at least q 4hrs
o Do not remove yellow exudate that appears in 24hrs
o Provide comfort
o For bleeding: gentle pressure w/sterile gauze
o Baby has to void before he is D/C (risk of edema or clot at meatal opening)
o Provide parent teaching for circumcision care.
o Explain the indications for use, therapeutic effects, side effects, dosage, route of
administration, contraindications and nursing implications of medications administered
during the neonatal period.
o Describe indications, procedures and possible complications of newborn heel sticks.
o Heel stick= collect capillary blood
o Suggested: warm heel (do not warm anything for the baby in a microwave),
cleanse with alcohol, restrain foot, puncture site, wipe away first drop w/ sterile
gauze, obtain sample, pressure with sterile gauze; adhesive bandage, comfort
infant
o Complications: necrotizing osteochondritis= happens when you stick the bone;
babies that get a lot of stick= scarring on walking surface= walking problems

36
 o

o Maintain a safe environment for the neonatal patient.

o Describe newborn screening tests and discuss their importance in preparation for
discharge.
o Assess for pain signals in the newborn.
o Appropriately manage neonatal pain
o Develop appropriate parent teaching discharge plans pp 522-530
o ways to comfort a fussy baby: PREVENTION, positioning, watch ways that upset
baby, fluid enticement at breast, skin-to-skin, change diaper between breast,
calm at the breast
o safe sleep environment
o bathing a baby
o waking a sleepy baby: skin-to-skin, unwrap or undress to diaper, change diaper,
hold infant upright, attempt eye contact (dimming lights may be necessary), talk

37
 to infant quietly (DO NOT BOUNCE BABY), stroke torso and extremities, warm
wash rag to face
o dressing a baby
o indications to call neonatal care provider: few or no wet diapers or urine is
concentrated, few or no stools, baby is lethargic and difficult to wake or feeds,
baby is constantly fussy and seems hungry after feeds, nipple soreness remains
unresolved or worsens, painful or unrelieved engorgement
o closure of fontanels (“soft spots”)
Nutrition
o Describe current recommendations for infant feeding.
o 0-6mos= exclusive human breast milk
o 6-12mo= human breast milk w/ appropriate complementary solid food
o After 12mo- continued as desired by mom and baby
o Not appropriate to feed cow milk less than 12mos
o Explain the nutritional requirements of the newborn
o Energy
 First 3mos: 110 kcal/kg/day
 3-6mos= 100 kcal/kg/day
 6-9mos= 95 kcal/kg/day
o .
o Provide supportive guidance to the family choosing an infant feeding method.
o Provide patient/family teaching on the benefits of breastfeeding/risks of formula
feeding.
o Infant
 Decreased incidence of infectious diseases
 Reduced infant mortality including SIDS
 Decreased incidence of type 1 and type 2 diabetes
 Decreased incidence of leukemia and lymphomas
 Reduced risk of obesity and hypercholesterolemia
 Decreased incidence of asthma and allergies
 Enhanced cognitive development

38
  Analgesic effect for painful procedures

o mom
o Recognize newborn feeding-readiness cues.
o Head moves toward voice
o Lips smack and tongue reaches out
o Hand move randomly
o Fist moves to mouth
o Awakening from sleep: undressing, skin to skin, attempt eye contact, hold
upright, talk to him, stroke torso
o

o Describe the anatomy and physiology of breastfeeding.

o Prolactin and oxytocin
 Stimulated by infant suckling
 Prolactin = milk production
 Oxytocin= let down
o Lactogenesis= milk production
 Occurs with or w/o suckling by infant until about day 3
 When the placenta is delivered, progesterone and estrogen level drop
rapidly
 Prolactin levels rise stimulating the alveolar cells to make milk
o
o Provide nursing interventions to facilitate and promote successful breastfeeding.
o Football hold= best hold for most mothers, give support of the breast and baby,
moms usually have good control of baby
o Support of the breast throughout the entire breastfeeding is necessary for a baby
to stay latched onto the breast, also allows mom to make a “nipple sandwich” to
thin out the areola= deeper latch..if mom is having difficulty lifting breast, roll a
cloth diaper or wash rag and place underneath mom’s breast

39
 o Correct latch: notice baby’s nose and mouth are far apart, lips are flanged out,
not tucked under lips,chin into breast and nose tilted back, CHIN SHOULD NOT BE
TUCKED ONTO INFANT’S CHEST
o Good latch= nipple is rounded and soft with no distortion, softening of the breast
is noted, infant ends feeding with sign of satiety, latch is comfortable, no biting or
pinching
o Analyze common problems associated with breastfeeding and nursing interventions to
help resolve them.
o Engorgement= breast heavy and tender, mother may have a slight fever, skin is
stretched, nipples flatten, difficult or impossible for baby to latch, pain or
discomfort, resolves in approx. 24hrs,if left untreated can cause a diminished
supply
 Tmt: apply warm, moist compresses to breast prior to feeding (longer
than 3-5mins increases swelling), gently massage and stroke the breast
going towards the areola, hand express or use mechanical pump for
about 1-3mins to soften, feed frequently, wear supportive bra around the
clock (no under wires), schedule ibuprofen around the clock, ice packs are
moms new best friend, green cabbage, sometimes one really good pump
will resolve it
o Flat or inverted nipples= prenatally, do pinch test (normal nipple will evert with
stimulation, flat will evert slightly, inverted nipple will appeat flat or inverted
when not stimulated and will invert or go into breast when pinch test is done)
 Nipple rolling prior to latch, pumping for 1-2mins prior to latch attempt,
nipple shields or breast shells
o Plugged ducts: inflammation of one area of the breast due to poor milk drainage,
usually develops gradually,localized tenderness and pain, may have a palpable
lump, unrelieved engorgement
 Continue to nurse frequency, begin feedings on affected breast, comb
breast (in shower or warm basin of water, apply food grade oil over
affectd breast, lean over and using a wide tooth comb GENTLY stroke over
affected breast toward areola, blot breast and either feed or pump,
repeat several times for 24hrs, gently massage during feeding, change
positions
o Mastitis: causes= usually preceded by nipple trauma, untreated plugged ducts
and or engorgement, overabundant milk supply, stress, fatigue. S/s: sudden
onset, hot, reddened, tender area with/without streaking, intense, localized
breast pain, fever of >101F, flu like symptoms (muscular aching, headache,
general malaise)

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  Antibiotics and antipyretic, continue to breastfeed or pump affected
breast every 2-2 ½ hrs, suggested bed rest for 24hrs, apply moist heat to
involved breast before feedings, ice after breastfeeding to reduce
swelling, drink fluids to satisfy your thirst
o Sore cracked nipples: poor positioning or latch, suction lesions, traction on
nipple, engorgement issues, mechanical problems, (pump issues), tongue issues,
infection, dermatitis, acute or chronic skin conditions
 Refer to LC for latch assessment and improvement, use of appropriate
medication
 Topical: mother’s milk, lanolin, polysporin, bactroban for severe
trauma or wound that won’t heal
 Systemic: antibiotics might be necessary in severe nipple trauma with
early symptoms of infection
o weaning
o Evaluate maternal and neonatal indicators of effective breastfeeding.
o P 544, box 25-2
o Good latch: nipple is rounded and soft with no distortion, softening of the breast
is noted, infant ends feeding with sign of satiety, latch is comfortable, no biting or
pinching
o
o Compare and contrast powdered, concentrated and ready-to-use forms of commercial
infant formula.
o All equal in nutrients but differ in price
o Powder= least expensive, some bottled water is not appropriate, tap water is
okay as long as water is treated
o Concentrated= more expensive than powder, make sure can is properly cleaned
before opening it
o Do not feed an infant if respiratory rate is >60; It could use extra energy that the
baby needs, aspiration = HESI HINT… use oral gastric tube instead
o Calculate recommended amount of formula per feeding for a newborn (based on wt).
o First 3 mos= 110 kcal/kg/day
o All full term newborn formula contains 20 cal/oz (on label)
o Know conversion for kg- pounds and oz to pounds, reported to ounces
o Provide parent teaching for formula and breast feeding families.

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 o Feed every 1 ½ to 3 hrs
o 8-12 feedings in 24 hrs
o Night feeding beneficial for mother and infant: meets infants physical needs,
decrease engorgement for mother, mother’s prolactin levels are higher
o Adequate breast feeding
o NORMAL ELIMINATION PATTERN
o Weight gain, emptying of breasts when nursing, satisfied after nursing

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