Unit Nine &Ten Immediate Care of the Newborn Assessment and Interventions: Immediately after delivery, dry the infant “a wet small newborn loses up to 200 calories/kg/minute in the delivery room through evaporation, convection and radiation” drying the infant cuts this heat loss in half. Aspirate mucus from the mouth and pharynx with suction catheter. Evaluate infant’s condition by Apgar Scoring System at 1-5 minutes after birth. Dr. Areefa SM Albahri PhD in MCH Dr. Areefa SM Albahri PhD in MCH

Apgar Scoring Chart Infants scoring (7-10): are free of immediate stress Infants scoring (4-6): are moderately depressed Infants scoring (0-3): are severely depressed

Cord care: cord is tied off approximately 2 Cord care: cord is tied off approximately 2.5 cm from abdominal wall using a cotton cord tie, plastic clamp or rubber band. Count the number of vessels, fewer than three vessels has been associated with renal and cardiac anomalies Eye care: prophylactic treatment against Ophthalmia Neonatorum (Gonorrheal conjunctivitis). Two drops of 1% silver nitrate solution or erythromycin is placed in the conjunctival sac of the infant’s eye. The infant of a mother with known gonorrheal disease should receive penicillin intramuscularly.

Vitamin K: 1mg may be administered in the delivery room or nursery. The newborn has no intestinal flora to manufacture vitamin K which is important in preventing hemorrhagic disease in the newborn period. Identification: Apply ID band or bracelet to infants arm, include mothers name, hospital number, infants sex and time and date of birth Apply bracelet with the same information on the mothers wrist After cleaning the soles of the infants feet, take footprints of the infant and fingerprints of the mother Weight and measure the infant Assess the infant for gestational age and general wellbeing  

Unit Ten Care of the Mother and Newborn during the Postpartum Period The Puerperium: Is the period beginning after delivery and ending when the woman's body has returned closely as possible to its pre-pregnant state. The period lasts approximately 6 weeks

Physiologic changes: Uterine changes (Involution): uterus returns to pregravid status The fundus is usually midline and about at the level of the umbilicus after delivery. The level of the fundus descends about 1cm each day until the 10th day, it has descent into the pelvic cavity and can no longer be palpated

Post delivery Lochia (a vaginal discharge) consisting of fatty epithelial cell, shreds of membranes, deciduas and blood is red (Lochia Rubra) for about 2-3 days. It then progresses to a pallor or brownish color (Lochia serosa ) followed by a whitish or yellowish color (Lochia Alba) in the 7th-10th day. Lochia usually ceases by three weeks and the placental site is completely healed by the 6th week.

Postpartum diuresis occurs between the 2nd and 5th postpartum day as extracellular water accumulated during pregnancy begins to be excreted. Diuresis may also occur shortly after delivery if urinary output was obstructed by presenting part or I.V fluids were given during labor.

Breasts: With loss of the placenta, circulating level of estrogen and progesterone will decrease, while increase level of prolactine thus initiating lactation in the postpartum woman. Colostrum: a yellowish fluid containing more minerals and protein but less sugar and fat than mature breast milk and having a laxative effect on the infant is secreted for the first 2 day postpartum. Mature milk secretion is usually present by the 3rd postpartum day but may present earlier if a woman breast-feeds immediately after delivery Breast engorgement with milk, venous and lymphatic stasis and swollen, tense and tender breast tissue may occur between day 3 and 5 postpartum.

Ovulation: immediately after delivery, blood level of estrogen and progesterone severely diminished, F.S.H level is still low for 7-10 days after delivery. F.S.H increase by the 3rd week. Ovulation reoccur in the non lactating woman by the 10th to 12th week, and she may menstruate 6-8 weeks post delivery (usually there is no ovulation at the first menstruation)

In the lactating woman ovulation and menstruation may not occur by 3 months or more. It is important to educate patients that since ovulation can precede menstruation, breastfeeding is not a reliable method of contraception.

Involution is a term that describes the process whereby the uterus returns to the nonpregnant state. The uterus undergoes a dramatic reduction in size although it will remain slightly larger than its size before the first pregnancy. Note : Involution of the uterus may be delayed by many causes as infection and the term subinvolution is used . Subinvolution is the failure of the uterus to return to the nonpregnant state.

Cardiovascular system: immediately after delivery, the pulse rate will be decreased around 50 beats per minute and restored after 48 hours after delivery due to vagal stimulation. The intravascular blood volume increased due to shifting of fluid to the blood vessels. Blood volume returns to prepreganacny state by the end of the second week.

G.I.T: there is an increased tendency for constipation. Skin: increase perspiration (diaphoresis) and diminished skin discoloration.

Assessment Immediate postpartum assessment: The first hour after delivery of the placenta (4th stage) is a critical period; postpartum hemorrhage is most likely to occur at this time 1. Check fundus frequently. 2- Inspect perineum frequently for visible signs of bleeding 3. Evaluate V/S at frequent intervals 4. Avoid leaving the woman alone at this time since changes in condition can occur precipitously

Subsequent postpartum assessment: 1. Check firmness of the fundus at regular intervals 2. Inspect the perineum regularly for frank bleeding a- Note color, amount and odor of the Lochia b- Count the number of perineal pads that are saturated in each 8 hours period 3. Assess V/S at least once daily and more frequently if indicated.

Nursing Diagnosis: Potential bleeding related to vaginal delivery, episiotomy, uterine atony, complication… Discomfort (backache, uterine cramping, breast engorgement…) related to process of labor Urinary retention related to bladder trauma Constipation related to episiotomy, decreased muscle tone of intestine Risk for infection related to prolonged labor, vaginal delivery, laceration… Knowledge deficit related to inadequate childbirth / parenting preparation, lack of self-confidence. Anxiety related to chronic fatigue, adapting anew family member, inability to integrate that with labor experience

Nursing intervention go to your book!!!!!!!

Nursing Care of Newborn In some hospitals the newborn infant is transferred from delivery room to traansitional nursery for intensive observation. When stabilized, the infant is admitted to a regular nursery or mother’s room. Infants designated as high risk are admitted to an ICU. The immediate care of the newborn infant after arrived in the nursery room:

Just remove the excess of vernix and sponge away the dried blood. Cleansing and assessment: Baby’s hair is frequently matted with dried blood; the body may have areas with heavy deposits of vernix caseosa. Just remove the excess of vernix and sponge away the dried blood. This called dry-skin care to reduce heat loss and potential damage to delicate skin. General assessment beside axillary temperaure, respiration and pulse are measured at this time. Prevent undue exposure, provide warn environment.

The newborn is weighed after arrival to nursery. Weighing and measuring: The newborn is weighed after arrival to nursery. The scales are balanced with a protective paper on which the naked infant is placed. Great care is taken to protect the infant from falling off the scales. Accuracy is vital, since it is a part of the baseline data. 5% - 10% weight loss is normal. After 3 – 5 days the baby begins to gain weight and reach their birth weight after 2 weeks. Measurement of the head and chest circumferences and length.

Ability to survive is affected by the maturity of the infant. Estimation gestational age: Ability to survive is affected by the maturity of the infant. Accurate assessment of gestational age is vital to effective care planning. Gestational age is determined by standardized measurements of physical growth as: (preterm, term, post term), (SGA = small for gestational age, AGA = appropriate for gestational age, LGA= large for gestational age). The Ballard Gestational Age by Maturity Rating tool includes a neuromuscular maturity and a physical maturity component

In few days (7 - 10 days) the cord shrinks and falls off. Cord care: About 2 inches (5cm) of umbilical cord usually is extending from the abdomen with some type of clamp.... In few days (7 - 10 days) the cord shrinks and falls off. Observe for signs of hemorrhage, other clamp may be used. Protect from infection. As a precaution against such an infection, the area around the umbilicus stump is scrubbed and 70% alcohol may be applied.

Provide warm environment 24 – 27Cº. Never leave the infant alone. Clothing and cover: It is not desirable to constrict their movement with heavy clothes or blankets. Positioning and environment ; The baby is placed in a preheated incubator usually on the side with head slightly lower than the rest of the body; this helps to drain any remaining amniotic fluid or mucus from the stomach and nasopharynx. Provide warm environment 24 – 27Cº. Never leave the infant alone. Extra oxygen is not administered unless indicated because retinal fibroplasia, a condition producing blindness, may result from excessively high oxygen concentration.

Recording and identifying: All the observations, measurements and care given to the newborn should be carefully recorded on the chart. It is important to label the incubator with a clearly marked card having the mother’s name, room number, baby’s sex, birth time and date and the physician’s name. It is customary to give the card to the mother when she takes her baby home.

The nurse takes the baby to the mother’s bedside. Feeding and rest: After birth the primary need is for rest, so infant is kept NPO for 4 – 6 hours. Test blood glucose, infant may be hypoglycemia and require feeding sooner than usual. Discharge planning: The nurse takes the baby to the mother’s bedside. The mother watches the nurse – cut off the baby’s ID. band and together they check the number against the mother’s band.

Give instructions about : ● Cord care. ● Follow up. ● Bathing, diapering. ● Breast and formula feeding. ● Measuring body temperature. ● Recognizing reportable signs and symptoms " pallor, cyanosis, vomiting, diarrhea, abdominal respiration, fever, hypothermia….". Encourage the parents to ask questions and participate in discussion.