abruptio placentae (uh-brup-tee-oh, uh-brup-shee-oh pluh-sen-tee) premature premature partial or complete separation of the placenta from the uterus acrocyanosis (ak -row-sigh-ih-row-sigh-ih-no-sis) bluish color of the hands and feet, not pathological in newborns acupressure (ak -you-you-preh-shur) treat treatme ment nt metho method d that that involv involves es therap therapeut eutic ic massag massage e of points points along along the body’s energy pathways acupuncture (ak -you-you-punk -shur) -shur) treatment method that involves therapeutic stimulation of points along the body’s energy pathways with thin needles Apgar scoring (app-gar score-ing) an assignment of numbers to assessment parameters of a newborn at 1 and 5 minutes after birth, named na med after its developer, Virginia Apgar areola (air-ee-oh-luh, uh-ree-uh-luh) the pigmented tissue around the nipple asphyxia (as-fx-ee-uh) inad inade eua uate te o!yge !ygena nati tion on that that caus causes es unco uncons nsci ciou ousn snes ess s and, and, with withou outt intervention, death atony (at-on-nee) lac" of muscle tone bilirubin (bil-uh-rue-bin, bil-ee-rue-bin) yellow or orange product of the brea"down of hemoglobin Braxton-Hicks contraction (braks-tin hiks "in-trak -shin) -shin) painless, ine#ective uterine contractions that occur during late pregnancy cervix (sir-vi"s) the low narrow end of the uterus that contains its opening circumcision (sir-cum-sih-$in) surgical removal removal of the fores"in f ores"in of the penis colostrum (cul-aah-strum) white to yellowish %uid that precedes breast mil" counterpressure (count-er-preh-shur)
application of pressure to the sacrum during contractions cradle cap (cray-dul cap) infant scalp dermatitis manifesting as thic" yellowish scales cyanosis (sigh-uh-no-sis) a bluish discoloration, especially of the s"in and mucous membranes, due to e!cessive e!cessive concentration of deo!yhemoglobin deo!yhemoglobin (hemoglobin not combined with o!ygen) in the blood dilation (dye-lay-shin) stretching of the opening of the cervi! to accommodate childbirth ecchymosis (e"-ih-mow-sis) hemo hemorrrhagi hagic c sp spot ot,, or brui bruise se,, caus caused ed by blee bleedi ding ng unde underr the the s"in s"in and and irregularly irregularly formed in blue, purple, pu rple, or brown patches edema (uh-dee-muh) accumulation of e!cess %uid, causing swelling in the cells, in intercellular spaces within tissues, or in potential spaces inside the body eacement (ef-ace-mint) thinning and shortening of the cervi! in preparation for childbirth eeurage (e -lure-ah$) -lure-ah$) light massage or stro"ing, usually on the patient’s abdomen, in rhythm with breathing during contractions engagement (en-gage-mint) entrance of the fetal presenting part into the upper pelvic channel or birth canal etus (ee-tis) unborn child still inside the uterus etoscope (eet-uh-scope) a stethoscope for listening to fetal heart tones riable (ry-ible) easily bro"en undus (un-dis) rounded upper portion of the uterus hematoma (he-ma-toe-ma)
locali&ed collection of blood underneath the tissues, appearing as a swelling or mass often characteri&ed by a bluish discoloration hydramnios (high-dram-nee-ose) e!cessive amniotic %uid hyperemesis gravidarum (high-per-em-ih-sis grav-ih-dar-um) complication of pregnancy that involves e!cessive vomiting, electrolyte imbalances, weight loss, nutritional de'cits, and "etonuria hyperglycemia (high-per-gly-see-mee-uh) an elevated blood glucose level hyperventilation (high-per-ven-til- ae-shun) e!cessively rapid or deep breathing hypoglycemia (high-poe-gly-see-mee-uh) a low blood glucose level hypothermia (high-poe-ther-mee-uh) body temperature below the e!pected reference range lanugo (luh-new-go) 'ne, downy hair on the fetus after wee"s of gestation eopold maneuvers (lee-uh-pold mih-new-vers) a series of four types of abdominal palpitation for determining fetal position let-down re!ex (let-down ree-%e"s) release of breast mil" in response to o!ytocin, also called the milk-ejection refex lightening (lite-in-ning) descent of the uterus into the pelvic cavity about wee"s before term labor lochia (low-"ey-uh) vaginal discharge following childbirth meconium (mih-coe-nee-um) odorless, green-tinged, blac", stic"y initial stools of a newborn milk-e"ection re!ex (milk ee- "ek -shin ree-%e"s) release of breast mil" in response to o!ytocin, also called the let-down refex #oro re!ex (more-oh ree-%e"s)
e!pected newborn response to a loud noise or other readily perceived stimulus, demonstrated as arm %e!ion and an embracing posture oxygen saturation (ok -sih-$un sah-chuh-ray-shun) a clinical measurement of the percentage of hemoglobin that is bound with o!ygen in the blood oxytocic (ok -see-toe-si", ok -see-toks-i") a drug that stimulates uterine contractions perinatal (peh-ree- nate-ul) referring to the time or process of birth perineum (peh-rih-nee-um) a s"in- and muscle-covered area over pelvic structures, usually meaning the area between the vagina and the anus in females placenta previa (pluh-sen-tuh pree-vee-uh) implantation of the placenta low in the uterus and completely or partially covering the cervi! popliteal (pop-lih-tee-ul) referring to the posterior part of the leg behind the "nee $oint pre-eclampsia (pre-eh- clamp-see-uh, pre-eh-clamp-shuh) a complication of middle to late pregnancy that involves hypertension, proteinuria, and hemoconcentration $uickening (kwik -in-ing) perception of fetal movement preterm (pre-turm) referring to the period of a pregnancy prior to *+ wee"s of gestation rooting re!ex (roo-ting ree-%e"s) e!pected newborn response that involves moving toward whatever touches the mouth and initiating suc"ing motions sit% bath (sits bath& immersion of the perineum in warm water in a tub or basin supine hypotension (sue-pine high-poe-ten-shin) a drop in blood pressure due to altered venous return from a gravid uterus e!erting pressure on the ascending vena cava symphysis pubis (sim-'h-sis pew-bis)
the semi-rigid articulation or union of the two pubic bones in the midline of the lower anterior part of the abdomen therapeutic touch 'ther-ih-pew-ti" touch) an energy therapy that is useful for promoting rela!ation and healing and involves a practitioner moving hands over the patient’s body to detect energy imbalances and then directing balanced energy toward the patient translucent (trans-loo-sent) allowing the passage of light trimester (try-mes-ter) one of three periods of time, about * months each, that comprise a pregnancy
umbilical cord (um-bil-i"-cul cord) the long structure that connects a fetus with the placenta and encases two arteries and one vein surrounded by a clear gel called harton’s $elly uterus (you-ter-is) the hollow, muscular female reproductive organ where a fetus develops vernix caseosa (ver-ni"s cass-ee-oh-suh, case-ee-oh-suh) a grayish white protective substance that coats fetal s"in and has a creamcheese-li"e consistency viability (vie-uh-bil-ih-tee) capability of living outside the uterus, generally at wee"s of gestation and beyond
(regnancy regnancy is a time of profound physiological and emotional change. /t is beyond the scope of this s"ills module to present a comprehensive review of pregnancy. 0owever, to meet your patient’s learning needs during its various trimesters, it is essential have to basic understanding of what she might e!perience during each of these phases.
)he frst trimester hen you 'rst encounter a patient in her early wee"s of pregnancy, she has probably $ust found out that she is pregnant. he may have any of a wide range of emotional responses and might not be prepared to ta"e in a lot of information about pregnancy and childbirth at this time. 2esides answering any uestions she might have, your priority will be to point out any danger signs 3 indications she must report to her provider because they might warrant intervention. 4our patient’s 'rst uestion is li"ely to be about when her baby will arrive. o calculate this, use 67gele’s rule. a"e the first day of the woman’s last menstrual cycle, subtract * months, and then add + days and ad$ust the year as needed to ma"e it a future date. o, if the 'rst day of her last menstruation was 6ovember of the current year, subtracting * months ta"es you to August, and adding + days and one year ma"es her 8due date9 August + of the following year. :any women develop 8morning sic"ness9 during early pregnancy; indeed, your patient might tell you that she does feel nauseated from time to time. :a"e sure she "nows to report severe vomiting, as it could be hyperemesis gravidarum, a serious complication that involves weight loss, %uid and electrolyte imbalances, and nutritional de'cits. ell your patient to report abdominal cramping and any vaginal bleeding at all. /n the 'rst trimester, these could indicate miscarriage or ectopic pregnancy. Another ma$or consideration during the 'rst trimester is infection. 2urning with urination could mean a urinary tract infection.
)he second trimester
he danger signs from the 'rst trimester still apply; however, in this trimester, vaginal bleeding can also indicate placental problems such as placenta previa and abruptio placentae. Abdominal pain or cramping can mean preterm labor, and a sudden gush of clear %uid from the vagina indicates a rupture of the amniotic membranes 3 a serious complication this early in pregnancy. =nce a woman is accustomed to the pattern and freuency of fetal movement, she must report any signi'cant increase or decrease. >ither could be a fetal response to inadeuate o!ygenation. At this time, be sure to instruct your patient to report any indications that her blood pressure has risen and she has developed pre-eclampsia. ?lassic manifestations include headache, vision changes, epigastric or abdominal pain, and edema, especially of the face and hands. @estational diabetes is another complication of pregnancy that manifests with speci'c warning signs. /nstruct your patient to report the concurrent occurrence of %ushed dry s"in, fruity breath, rapid breathing, increased thirst and urination, and headache. hese are manifestations of hyperglycemia. ?lammy pale s"in, wea"ness, tremors, irritability, and lightheadedness are manifestations of hypoglycemia. /t is also important at this time to teach your patient about the bene'ts of breastfeeding and of ta"ing childbirth preparation classes.
)he third trimester
Auscultating fetal heart tones Toward the end of the first trimester, usually around the 10th or 11th week of gestation, it is possible to hear fetal heart tones with an ultrasound fetoscope or stethoscope. A regular stethoscope or fetoscope can detect and transmit fetal heart sounds at 18 to 20 weeks and beyond.
To auscultate fetal heart tones, apply conductive gel to the patients skin, then position the device at midline !ust above the symphysis pubis and apply firm pressure. "f you do not detect heart tones right away, move the device around the abdomen slowly until you hear them. #ount the fetal heart rate for 1 full minute, listening to its $uality and rhythm as well. "nform the provider immediately if you cannot hear the fetal heart.
%etal heart tones are difficult to hear when a patient has an e&cessive amount of amniotic fluid 'hydramnios( or e&cessive subcutaneous fat in the abdomen. %or optimal hearing later in the pregnancy, use abdominal palpation ')eopold maneuvers( to determine the position of the fetus. *lacing the ultrasound device over the fetal back often improves the ability to hear the heart tones.
The fetal heart typically beats from 120 to 1+0 times a minute. ates outside of this reference range can indicate fetal distress.
Measuring fundal height -uring the second trimester, the uterus becomes part of the abdomen, a development that makes it easy to assess fundal height. The duration of pregnancy at this time generally correlates with the height of the fundus above the symphysis pubis. %rom weeks 18 to 2, the number of centimeters of fundal height is !ust about e$uivalent to the weeks of gestation. Thus this measurement can help you assess fetal growth and estimate gestational age. After 2 weeks, it no longer reflects gestational age as the fetus is growing more in weight than in length.
/ake sure the patient has emptied her bladder because a full bladder can change the measurement by as much as cm. ave her lie supine with her head slightly elevated on a pillow, or her knees in a fle&ed position, or both. e sure the patients position is the same for each fundal height measurement, and ideally the same clinician should measure the fundus each time. sing a disposable metric tape measure, note the distance from the symphysis pubis to the top of the fundus. The result in centimeters is a rough estimate of gestational age.
%undal height measurements below the estimated gestational age might suggest a miscalculation in due dates, intrauterine growth restriction, or a fetal anomaly. /easurements above the patients gestational age might indicate hydramnios, a large3for3gestational3age fetus, a miscalculation in due dates, or a multiple pregnancy.
Leopold maneuvers %or your patients who are pregnant, )eopold maneuvers comprise a stepwise method of abdominal palpation you can use to determine the number of fetuses, the presenting part, the fetal lie, the fetal attitude, the fetal position, the degree of the descent into the pelvis, and the best location for auscultating fetal heart tones. That location is the point of ma&imal intensity '*/"( of the fetal heart rate on the patients abdomen.
The four )eopold maneuvers are4 "dentifying the fetal part in the uterine fundus to determine fetal lie and the presenting •
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part *alpating the fetal back to identify fetal presentation
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-etermining which fetal part lies over the pelvic inlet to identify fetal attitude
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)ocating the fetal cephalic prominence to identify the attitude of the head
egin the procedure by asking your patient to empty her bladder so that she wont feel any discomfort during palpation. *osition a small rolled towel under one hip to shift her uterus away from large blood vessels and thus prevent supine hypotensive syndrome. "f you are right3 handed, stand on the patient5s right side facing her. se the flat palmar surfaces of your fingers to perform )eopold maneuvers.
%or the first maneuver, face your patient and place both hands on her abdomen, cupping your hands around the fundus or the top of the uterus. *alpate for the fetal part that occupies the fundus to help identify fetal lie and presentation. %eel for shape, consistency, and mobility. The fetal head will feel firm and round. The breech, that is, the buttocks and legs, will feel softer and less defined.
%or the second maneuver, position the palms of your hands on the side of the patients abdomen. se the palmar surface of one hand to locate the fetal back and the various irregularities to identify hands, feet, and elbows. The fetal back will feel smooth and hard. The smaller fetal parts, such as the hands, feet, and elbows, will feel like irregular nodules when you palpate them. This also helps you identify the fetal presentation.
%or the third maneuver, use your right hand to grasp the lower section of the patients abdomen between your inde& finger and thumb and press inward over the inlet to the true pelvis. 6ote any movement and determine whether the presenting part is soft or firm. "f there is movement, the presenting part is not engaged. "f the head is the presenting part, determine fetal attitude, that is, whether the head is fle&ed or e&tended.
%or the fourth maneuver, face the patients feet and place both hands on both sides of her uterus. 7utline the fetal head with your fingertips. *alpate both sides of her abdomen to determine the cephalic prominence, or brow. 6ote that this maneuver applies only to cephalic presentations. "f you find the cephalic prominence on the same side as the feet, hands, and elbows, the head is fle&ed and the verte& is presenting. "f you find the cephalic prominence on the same side as the back, then the head is e&tended and the face is presenting.
After the procedure, assess the patient5s response and then assess fetal well3being. -o this by checking the fetal heart tones and by noticing any changes in fetal position. -ocument the procedure and discuss the results with your patients provider.
Nonpharmacological pain management /any patients base their perception of the birth e&perience not so much on the amount of pain they feel but on how well they achieve their goals for managing it. /ost e&pect some pain and will count on you to help minimie it. 6onpharmacologic methods of pain management are ideal for this purpose. They are simple, safe, and easy for you to teach to your patients and their support people. %or those who have learned and practiced these strategies prior to labor, you can remind them to use them.
Breathing techniques reathing techni$ues promote rela&ation, provide distraction, and improve coping during uterine contractions. They begin and end with a cleansing or focused breath 9 a slow, rela&ing breath in through the nose and gently out through the mouth. :low3paced breathing is e&actly that 9 the patient inhales slowly through the nose and e&hales slowly through the mouth 9 usually si& to nine times per minute and no fewer than three to four. ;ith modified3paced breathing, the patient breathes slowly in and out through her mouth, and, as each contraction reaches its peak, she breathes faster 9 usually 2 to <0 breaths per minute. As the contraction subsides, the patient returns to slow breathing. *attern3paced breathing re$uires more concentration as the patient sets up a pattern of breathing to help her through the final centimeters of cervical dilation. reathing in and out of her mouth, she takes $uick panting breaths and then e&hales or blows forcefully. 7ne method is to make a =hee> or =hoo> sound in a pattern. The pattern may vary, but typically after the cleansing breath, the patient breathes in a 3to31 pattern 9 =pant3 pant3pant3blow> or =hee3hee3hee3hoo> throughout the entire contraction and ends with a cleansing or focused breath. The rate is usually the same as with modified3paced breathing. The nurse and the support person can coach her by breathing with her, counting the breaths, reminding her to use the cleansing breaths, and making sure she takes even breaths to avoid hyperventilation.
Touch /assage is an effective techni$ue for enhancing rela&ation and comfort. /assaging the patients head, hands, feet, and back provides comfort and communicates caring. #ounterpressure is steady pressure a support person applies to the sacral area of the patients back. This is especially helpful for patients who have pain and internal pressure in the lower back because the fetal head is in a posterior position. The coach or the nurse uses the heel of the hand or a fist to achieve ade$uate counterpressure. ?ffleurage is light massage or stroking, usually on the patients abdomen in rhythm with breathing during contractions. The support person uses the fingertips with enough pressure to avoid tickling sensations. %or patients who have a monitoring belt across the abdomen, the chest and the thigh are appropriate alternatives. ?nergy work, such as healing or therapeutic touch, involves manipulating energy fields to help reduce an&iety and pain during labor. #ertified practitioners perform these techni$ues.
Positioning %re$uent position changes enhance comfort and rela&ation and promote more effective contractions. pright positions such as walking, sitting, or s$uatting take advantage of gravity to encourage fetal descent. #ombining positions and activities like rocking and slow dancing with rela&ation can help reduce pain perception.
Water therapy :howering, bathing, and sitting in a whirlpool bath can improve comfort, provide a rela&ing atmosphere, improve circulation and o&ygenation, soften perineal tissues, and make it easier for women in labor to cope with pain. %acility policies vary, but as long as a patient in active labor has no contraindications for these techni$ues, she can generally stay in the bath for as long as she wishes. ecommendations for !et hydrotherapy are usually for 0 to +0 minutes. ;arm water can cause diiness, however, so it is important to assist patients in and out of the shower or tub. Also be sure to provide a shower stool, so they can sit down easily during showering.
7ther therapies vary with the practice setting, the provider, and the patients preferences. :ome, such as biofeedback, hypnosis, acupressure, acupuncture, and transcutaneous electrical nerve stimulation, re$uire trained practitioners and sometimes specialied e$uipment. 7thers such as aromatherapy, imagery, heat and cold applications, and musi c therapy are easy to implement, re$uire no special certification, and can provide some uni$ue benefits for patients in labor.
Gestational age assessment To determine the appro&imate gestational age of a newborn, youll assess si& neuromuscular and si& physical characteristics. This assessment, the 6ew allard :core, is appropriate for newborns from 20 to << weeks of gestation, with the characteristics to assess varying with the stage of maturity. ?ach parameter scores from minus 2 to @, with the cumulative score correlating with a gestational age between 2+ and << weeks.
Timing of the gestational assessment influences the accuracy of its results. %or newborns younger than 2+ gestational weeks, perform the assessment sooner than 12 hours after birth. %or newborns beyond 2+ gestational weeks, perform the e&amination within + hours of birth. 7verall, it is best to perform the e&amination within <8 hours of birth. This assessment information is essential because gestation relates directly to the likelihood of complications during the newborn period. )ower scores correlate with prematurityB higher scores correlate with postmaturity. #ommercially printed worksheets are available to use when performing this assessment.
The components of the neuromuscular assessment are posture, s$uare window, arm recoil, popliteal angle, scarf sign, and heel to ear. *erform all assessments with the newborn lying supine. efer to the scoring sheet to base the specific scores on your findings for each parameter.
Assess posture for the degree of fle&ion of the e&tremities. At term, a newborns legs and arms are moderately fle&ed at rest.
*reterm newborns show lesser degrees of fle&ion4 the younger the gestational age, the less fle&ion the newborn demonstrates.
Assess s$uare window by grasping the newborns forearm and gently fle&ing the wrist toward the inner arm. -o not allow rotation of the wrist.
/easure the angle that forms where the hand meets the wrist. At term, the hand should touch the wrist, resulting in a 03degree angle.
*reterm newborns show greater angles of fle&ion at the wrist4 the younger the gestational age, the less fle&ibility at the wrist. Cery preterm newborns have an angle of wrist fle&ion of 0 degrees or more.
/easure arm recoil by first fle&ing and holding both forearms for @ seconds, then e&tending the arms and hands fully at the newborns side.
6e&t, release the hands and allow the arms to recoil 'return to fle&ion(.
Term newborns demonstrate full recoil to a position of fle&ion while preterm newborns show less fle&ion. /easure the angle of fle&ion at the elbow to determine the arm recoil score.
;ith the newborns thigh pressed against his abdomen, measure the popliteal angle by moving the foot gently toward the head until you meet resistance. At this point, measure the angle behind the knee in the popliteal area. Term newborns are less fle&ible, with about a 03degree angle. ;ith very preterm newborns, the leg straightens to a 1803 degree angle.
Assess the scarf sign by grasping the newborns hand and attempting to cross the arm over his body at the neck. The arms of term newborns meet resistance before crossing midline, while preterm newborns cross the elbow past midline.
Assess heel to ear by raising the newborns heel toward his head in an attempt to bring the foot to the ear. -o not raise the newborns buttocks off of the e&amination surface. :top when you meet resistance and measure the degree of e&tension of the leg. ;ith preterm
newborns, youll come close to touching the heel to the ear, while youll meet resistance almost immediately with term newborns.
Physical maturity The components of the physical maturity assessment are skin, lanugo, plantar surface, breast, eyeDear, and genitals. ase your scores for these parameters on your assessment findings.
The skin ranges from translucent and friable in preterm newborns to leathery, cracked, and wrinkled in post3term newborns. Assess the skin for transparency, cracks, veins, peeling, and wrinkles.
)anugo is very fine body hair. ?&tremely premature newborns h ave none. -uring the mi ddle of the third trimester, most fetuses have plentiful lanugo. #loser to term, this body hair begins to thin. Terms newborns have very little, and it is nearly absent in post3term newborns.
"nspect the plantar surface of the foot for creases. Term newborns have creases over the entire plantar surface, while the creases of a preterm newborn range from absent to faint red markings.
"nspect the breast to assess the sie of the breast bud in millimeters and the development of the areola. *reterm newborns lac k developed breast tissue. Term newborns have a raised to a full areola with breast buds that are to 10 millimeters in diameter.
The eyeDear assessment is an analysis of the ear cartilage and shape of the pinna. The pinna is less curved in preterm newborns, while term newborns have a well3curved pinna with firm cartilage. -etermine ear recoil by folding the pinna down and assessing how $uickly it returns to its previous position. Also, very preterm newborns may have fused eyelids. Eoull score the degree of fusion for these newborns.
7bserve the genitals for physical maturity. ;ith males, the testes usually descend near term and rugae 'ridges or folds( are visible on the scrotum. *alpate the testes to determine if they have descended and note the rugae. ;ith e&treme prematurity, the scrotum is flat and smooth. ;ith female newborns at term, the labia ma!ora are larger than the clitoris and the labia minora. *reterm newborns have a prominent clitoris and small labia minora. ase your scores on the degree of development of the labia.
Neworn care ;hen a patient and her newborn are ready to leave the facility varies with their physiologic status, type of delivery, feeding success, safety, and various other factors. ?arly discharge is common, with some women and newborns at low risk for complications leaving the hospital within 2< to + hours after an uncomplicated delivery. owever, federal legislation ensures that all health plans allow for a minimum of <8 hours of hospitaliation after a vaginal birth and + hours after a cesarean birth. egardless of the length of stay, parents must learn the skills of feeding, clothing, bathing, and protecting their infant before they leave. Eoull ensure that they learn these skills with instruction, demonstration, and observation, along with encouragement and support to help them develop confidence in their ability to care for their newborn.
!milical cord care Teach parents to keep the newborns umbilical cord clean and dry. emove the cord clamp when the cord is dry, usually at about 2< hours of age, then assure them that they may clean the stump with water as long as they allow it to dry afterward. :ome providers and facilities recommend soap and water. *arents should watch for swelling, redness at the base of the stump, purulent drainage, and a foul odor from the stump at each diaper change. :how them how to fold the upper edge of the front of the diaper down below the umbilicus so the stump remains e&posed and dry. )et them know that the stump will probably fall off somewhere between 10 and 1< days after birth.
"ircumcision care %or newborns who have had a circumcision, apply petroleum !elly to the penis for the first 2< hours to keep the diaper from adhering to the circumcision site. ;ith the *lastibell method, petroleum !elly is unnecessary. Administer acetaminophen 'Tylenol( as needed for pain. 7bserve the penis for bleeding and ade$uate urination. #leanse the penis with warm water and apply the diaper loosely. -emonstrate this for the parents, and make sure that understand that they should not use soap or commercial cleansing wipes until the circumcision has healed 'about @ or + days later(. #aution them about the yellow e&udate they may see on the glans after 2< hours and for the ne&t 2 to days. They should not remove it, as it is part of the healing process. Tell them they may control minor bleeding with gentle pressure from a sterile gaue pad. "f bleeding continues or if they notice redness, s welling, pus, or a foul odor, they should notify the provider.
Bathing athing is an opportunity for interaction and bonding. ave parents start with a simple sponge bath, a practice they should continue periodically until the umbilical cord stump falls off. Then they may progress to tub baths. -aily bathing is unnecessaryB in fact, it can disrupt skin integrity and the acid mantle, which comprises the uppermost layer of the skin plus amniotic fluid, superficial fat, micro3organisms, sweat, and other metabolic products. A good time for a bath is when the newborn awakes and before a feeding. ?mphasie that parents must never leave an infant alone during bathing, not even for a second or two. Fo over the following instructions with them, first with a demonstration and then with a return demonstration.
To prevent heat loss, perform the bath $uickly in a warm room, e&posing only a portion of the body at one time. :uggest they use a bath thermometer to ensure that the water temperature is in the appropriate range4 about +.+G # to H.2G # '8G % to G %(. se soft, clean washcloths, not cotton balls or swabs. egin by washing the face with plain water. #leanse the eyes from the inner to the outer canthus, using separate parts of the washcloth for each eye. ;rap the infant in a blanket when washing the hair and scalp. se one hand or a soft brush to wash the scalp with water and a mild, unscented, p3neutral soap. This and regular hair brushing prevent scalp des$uamation, or cradle cap. ;ash the creases in the neck and under the arms and legs and in the groin as well as the rest of the body with soap and water. se corners of a washcloth to clean the ears and nose. e sure to wash between the fingers and toes. -ry the newborn thoroughly to prevent heat loss.
#lean the diaper area with each change. %or girls, gently separate the labia and carefully wash from the pubic area toward the anus. %or uncircumcised boys, gently retract the foreskin until you feel resistance. ;ash the tip 'glans( with warm soap and water and replace the foreskin. 7nce healed, the circumcised penis re$uires no special care, !ust gentle washing of the genital area.
-o not use creams, lotions, powders, or ointments routinely. %or e&cessive dryness, apply a non3 alcohol3based, unscented lotion. 6ewborn skin is fragileB e&cessive scrubbing can in!ure it. Always rub gently and pat the skin dry. "f stool has dried on the skin, soak the area to make it easier to remove. -o not rub it off. And do not e&pose the skin to direct sunlight.
#iaper rash acteria that cause diaper dermatitis thrive in moist dark areas. To treat diaper rash, clean the area after each urination and bowel movement. ?&posing the buttocks to air helps prevent bacterial growth. %or infants prone to diaper rash or to help heal a rash, apply inc o&ide ointment to protect the skin. A fungal rash from Candida albicans re$uires treatment with an antifungal ointment and possibly oral medication. :igns of this type of diaper rash include severe erythema in the perianal area, inguinal folds, and lower abdomen.
Nail care "t is not necessary to trim a newborns nails until they have grown long enough to e&tend beyond the skin of the tip of the fingers and toes. Then, parents should use manicure scissors or clippers to trim them straight across or use an emery board to file them and keep them short. The best time to trim the nails is while the infant is sleeping.
"lothing *arents should dress the infant for comfort and security. A cap can help minimie heat loss and protect the infant from the sun. :waddling in a blanket provides a secure feeling and helps maintain body temperature. Avoid overdressing the newborn. A general guideline is to dress the newborn as warmly as the parents would dress themselves. /ake sure all clothing is flame3 retardant.
$afety *arents may not be aware of many potential dangers for their newborn. *rovide instructions such as these to promote safety.
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-o not leave an infant alone on a bed, table, or other furniture.
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*lace infant carriers on the floor, never on high places such as counters and beds.
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:et the water heater to <G # '120G %( or less. Test bath water temperature with a bath
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thermometer. *ick an infant up gently and never swing, throw, or shake him.
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To prevent respiratory illnesses, never e&pos e an infant to tobacco smoke.
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/ake sure crib slats are no more than + cm '2.H@ inches( apart and the mattress fits snugly against the sides. A mattress is too small if two adult fingers fit between it and the
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sides of the crib. *osition the crib on interior walls to prevent drafts.
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Ieep window cords out of reach.
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Ieep the crib away from heaters to prevent fire.
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To prevent suffocation, do not place pillows, stuffed animals, or loose bedding in the crib
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with an infant. se a sleep sack to keep the infant warm instead of loose bedding or comforters.
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-o not leave a bib or a pacifier with a string around an infants neck during sleep.
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se a firm mattress covered with a sheet.
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*osition the infant supine to reduce the risk of sudden infant death syndrome.
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-o not put an infant to sleep on a waterbed or in the same bed with sleeping adults.
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"nstall smoke detectors and replace their batteries regularly.
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)earn infant cardiopulmonary resuscitation.
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6ever leave an infant i n a parked car.
"ar seats se only a federally approved, rear3facing car seat and secure it in the rear seat of the vehicle. /ake sure the harness is snug and the clip is at a&illary level and not across the infants neck or abdomen. %ollow federal and state regulations for age and weight parameters for car seat types and positions. /any local agencies offer car seat information and actual installation and verification of adherence to safety regulations.
"omforting techniques 6ewborns use nonnutritive sucking to self3soothe. They suck on their own fingers and some use a pacifier. "nstruct parents who give their newborn a pacifier to clean it and replace it regularly and not to coat it with sweet solutions. Advise women who breastfeed to delay the use of a pacifier until breastfeeding is well established 'generally about 1 month(. #aution parents to use only safety3tested commercial pacifiers.
"nfants cry to communicate hunger, discomfort, illness, and boredom. They may cry only a few minutes or for 2 hours or more. ?ncourage parents to interpret what a cry means and respond accordingly. A fussy period each day, usually in the late afternoon or evening, is $uite common. -uring these times comforting measures may not help. "t is likely that the infant will fuss until he releases enough energy to fall asleep.
*rovide parents with education about techni$ues to $uiet their infant. These include swaddling, soothing noise, skin3to3skin contact, patting, back rubbing, or other mild rhythmic movement such as with a cradle or a rocking chair. 7utings in a stroller or a motor3vehicle often help.
$ensory stimulation :ensory stimulation promotes development. ?ncourage parents to hold their infant close while face to face, to provide toys and mobiles with black and white contrasting designs, and to incorporate singing, playing music, massaging, and walking using a stroller into their daily routines.
$igns of illness /ake sure parents know when to contact their provider, for e&le, for significantly high or low a&illary temperatures, fre$uent vomiting, poor feeding, diarrhea, decreased urination or bowel movements, cyanosis, breathing difficulties, lethargy, inconsolable crying, eye drainage, or bleeding from the umbilical cord or circumcision.
Nutritional needs of neworns 7ptimal nutrition during the neonatal period supports newborn growth and development. %eeding also provides an opportunity for parents to bond with their newborn. #urrent recommendations are for e&clusive breastfeeding for the first + months of life, followed by a combination of solid foods and human milk until 12 months of age. *arents may also choose to feed their newborn commercially prepared formula. To help parents make an in formed decision, offer them evidence3based information about the nutritional needs of newborns, the benefits of breast milk, and the potential risks of formula feeding.
%luid and calories %or their first 2 days, newborns need +0 to 80 m) of fluid per kilogram 'kg( of body weight per day. %or the ne&t < days, they need 100 to 1@0 m)DkgDday. %or the remainder of their first month, they need 120 to 180 m)DkgDday. They lose fluid through urination and respiration. "t is essential to monitor their intake and output carefully, as they have little tolerance for fluctuations in fluid balance.
#aloric intake, measured in kilocalories 'kcal(, provides energy for growth, physical activity, and metabolic function. %or the first months of life, infants re$uire 110 kcalDkgDday. ?ach ounce of breast milk and of formula contains about 20 kcal.
"ncreases in a newborns appetite generally correlate with growth spurts. *arents usually notice these changes at 10 days, weeks, + weeks, months, and + months of age. -uring these times, they should increase the fre$uency or duration of feedings to accommodate their infants nutritional needs.
Breastfeeding uman milk offers many health benefits for newborns, including enhanced immunity, maturation of the gastrointestinal tract, and reduced risks of diabetes mellitus and childhood obesity. Advantages for the mother include reduced risks of ovarian and breast cancer, promotion of postpartum weight loss, convenience, and minimal cost.
;hen helping a patient get started with breastfeeding, assess the newborn for feeding3readiness cues, including rooting, sucking motions, and hand3to3hand or hand3to3mouth movements. "t is important to initiate breastfeeding when the newborn demonstrates these cues rather than waiting until he is sleeping or crying. The optimal time for initiating breastfeeding is immediately after an uncomplicated birth. *utting the newborn and the mother in direct skin3to3skin contact 'kangaroo care( facilitates the first breastfeeding e&perience for the mother3infant pair.
#ommon positions for breastfeeding are the cradle, the modified cradle or across3the3lap, the football or clutch hold, and the side lying position. ?ncourage your patient to use a position she finds comfortable and easily achieves latch, that is, a seal between the newborns mouth over the nipple, areola, and breast that creates enough suction to remove breast milk.
?ncourage the patient to e&press colostrum to spread over her nipple. Then, have her support the breast with one hand while bringing the babys mouth to it with the other hand. :uggest that she gently stimulate the newborns lower lip with her nipple to prompt him to open his mouth. As he does this and his tongue moves down, have her position him on her breast. e sure his mouth covers the nipple and an area about 2 to cm '1 inch( around the nipple. ;hen the newborn has latched on and is sucking effectively, his chin, cheeks, and tip of the nose all touch the breastB his cheeks are rounded and not dimpledB and you can hear him swallow. is mother should feel a tugging sensation, not pain. The newborns !aw should also move smoothly when he sucks.
reastfeeding patterns vary among newborns, but in general, they should breastfeed eight to 12 times in each 2< hour period. Although newborns are often sleepy during the first few days, parents should attempt feedings every to < hours. After this initial period, when their newborn is feeding regularly and gaining weight, it is appropriate for them to shift to on3demand feedings.
The duration of feedings also varies. Also, some newborns feed from one breast per feeding, while others switch easily during a feeding. %or those who do not resume sucking when moved to the other breast, make sure your patient alternates breasts from feeding to feeding. Teach parents how to determine when the newborn is finished feeding. The breast's( will feel softer, the newborn will suck slowly or release the breast, and he will appear content or will fall asleep. These cues help parents determine the appropriate duration of feedings.
%or parents who need to wake their newborn for feedings or during feedings, suggest these strategies. •
nwrap the newborns blanket.
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/assage his chest or back.
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:troke the soles of his feet and the palms of his hands.
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#hange his diaper.
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:it him upright.
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:peak to him.
*arents are often concerned that their infant isnt receiving enough nourishment from breastfeeding. Tell them to look for the following signs of ade$uate nutrition.
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*eriods of contentment after feedings alternate with periods of wakefulness.
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The newborn feeds eight to 12 times in 2< hours.
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The newborn latches on easily and swallows audibly.
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The newborn has at least one wet diaper and one stool per day for the first days, then
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si& to eight wet diapers and at least three stools every 2< hours. The milk supply is =in> by the newborns third or fourth day. reasts are full before
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feedings, and the mother feels the let3down, or milk e!ection, sensation during feedings. The newborn has returned to his birth weight by 10 to 1< days.
Tell the parents not to feed their newborn formula or water unless there is some medical indication for it. They should also avoid the use of pacifiers for at least 1 month, when breastfeeding is well established.
&'pressing and storing reast mil( :ome patients wish to pump and store breast milk because of engorgement, to prepare feedings for others to give the newborn, or because they will be away from the newborn. This is also appropriate when the infant is premature or unstable and must remain in a neonatal intensive or special care unit after the mother goes home. /others can e&press breast milk by hand, with a manual pump, or with an electric pump.
"nstruct these patients to store their breast milk in glass containers or plastic containers or bags free of bisphenol A 'a chemical that hardens plastics( with the collection date on the label. To prevent waste, they should store only +0 to 120 m) '2 to < o( in each container and should use the oldest milk first. They may keep freshly e&pressed breast milk at room temperature for up to 8 hours and in a refrigerator up to 8 days. They may store breast milk in the freeer of a two3 door refrigerator for up to + months and in a separate freeer up to 12 months. Tell them to place breast milk containers in the middle or the rear of the refrigerator or freeer, and to thaw froen breast milk in r unning water or in their refrigerator, never in a microwave oven.
Bottle feeding *arents of formula3fed newborns also need education and support for their choice and about the feeding process. They should use commercially prepared formula, either the powder, concentrate, or ready3to3feed type, for all feedings. Although manufacturers of infant formula provide detailed instructions for using these products, it is important to make sure parents understand how to use them.
ave them hold their newborn in a semi3reclining position for all feedings. *ropping of bottles during feedings can result in choking, tooth decay, and loss of interaction opportunities. ave them hold the bottle so that the nipple is filled with fluid, not air. #ues that the newborn is
satisfied after feeding include turning his head away, stopping sucking, or falling asleep. Teach parents to recognie these cues to help prevent overfeeding and obesity.
-uring and after each feeding, parents should facilitate burping because newborns swallow air during bottle feeding. /ake sure they understand that they must discard any formula that remains in the bottle after a feeding.
-uring the first 2< hours of life, newborns usually drink 1@ to 0 m) of formula at each feeding. The amount gradually increases during the first week. *arents should feed them every to < hours, with si& to eight feedings in each 2<3hour period.
"nstruct parents to wash bottles in warm soapy water using a bottle and nipple brush and then to rinse them thoroughly. They do not need to boil them unless there are environmental risks, such as an issue with safety of the water supply.
Postpartum assessment -uring postpartum, the time between delivery and the return of the reproductive system to its pre3pregnancy state, youll assess your patients vital signs, breasts, fundus, bladder, lochia, perineum, legs, and any incisions.
/easure vital signs with the fre$uency your facilitys policies specify or according to the providers prescription. "nclude temperature, heart rate, respiration, blood pressure, and pain level. Temperature may rise due to the dehydration that can accompany labor and sometimes as a result of epidural anesthesia. After the first 2< hours, however, elevations in temperature warrant further investigation as they suggest infection. *ulse rates may be somewhat elevated but should return to their pre3pregnant status gradually. A sustained rapid pulse can indicate hemorrhage. espiratory rates may be low after epidural anesthesia and after a cesarean birth but should gradually return to the e&pected range. 7rthostatic hypotension is common after delivery. ypotension can indicate hemorrhage, and hypertension may persist in women who have had pre3eclampsia.
Assess your patients pain, i ncluding location, type, $uality, and severity. Administer pain medication to keep the patients pain at a manageable level. %or perineal pain, apply cold during the first 2< hours, including cool sit baths. This helps reduce swelling and irritation. After the first 2< hours, warmth is helpful for promoting circulation and healing. To help reduce pain from sitting down, suggest that your patient compress or tighten her buttocks !ust before sitting. This reduces pressure on healing perineal tissues.
?ncourage your patient to urinate prior to assessing her fundus. Assist her to a supine position.
%irst, inspect and gently palpate her breasts for redness, pain, and engorgement. "nspect the nipples for redness, cracks, and bleeding. "f she is breastfeeding and her breasts are engorged, suggest warm compresses or a warm shower before breastfeeding to stimulate milk flow. 7r, if her newborn isnt emptying both breasts, suggest she pump her breasts to relieve discomfort. "f she is not breastfeeding, suggest ice packs to help suppress milk production and reduce discomfort.
6e&t, check your patients fundus. Assess uterine height, location, and consistency. -etermine the fundal height by placing one hand at the base of the uterus and the other at the umbilicus. /easure how many fingerbreadths, which are roughly e$uivalent to centimeters, you can place between the fundus and the umbilicus above or below it. "f none, then the fundus is at the umbilical level. At 12 hours after delivery, the fundus is typically 1 cm above the umbilicus, but this does vary. The uterus descends into the pelvis appro&imately 1 to 2 cm per day. About a week after delivery, the fundus should be halfway between the umbilicus and the symphysis pubis. Also, assess whether the fundus is boggy or firm. "f the fundus is boggy, gently massage
the uterus with a rotating motion while supporting the lower uterine segment until it feels firm. ;ithout stabiliation of the lower segment, the uterus could invert, and severe hemorrhaging could result.
Assess and palpate the bladder at this time as well. -etermine whether the fundus is at midline in the pelvis or displaced laterally due to a full bladder. "f the bladder is full, encourage the patient to urinate and monitor her fluid intake and output. %or some patients, insertion of a straight urinary catheter may become necessary.
?&amine the patients perineal pad for bleeding, noting the character, $uantity, presence of clots, and odor. )ochia rubra is typical 1 to days following delivery, and small clots are common. -etermine the amount of saturation as scant, light, moderate, heavy, or e&cessive. e sure to check under the patients buttocks to be sure blood is not pooling beneath her. )ochia typically increases with breastfeeding and ambulation. "f bleeding is e&cessive, the patient will soak an entire perineal pad within 1@ minutes or so. %or that finding as well as for numerous large clots or a foul odor, notify the provider immediately.
"f the patient has had a cesarean delivery, e&amine the incision for redness, edema, ecchymosis, drainage, and appro&imation of its edges. "f the patient has had an episiotomy, have her lie on her side and assess the episiotomy incision for appro&imation, edema, and ecchymosis. Also check her rectum for hemorrhoids and assess bowel function by auscultating bowel sounds.
Assess for thrombophlebitis by checking the patients calves for pain, tenderness, or redness. 6otify the provider immediately if you find any of these. #heck for edema of the hands, the face, and the lower e&tremities.
%inally, assess your patients comfort level and emotional status.
