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abruptio placentae

(uh-brup-tee-oh, uh-brup-shee-oh pluh-sen-tee)


premature partial or complete separation of the placenta from the uterus
acrocyanosis
(ak-row-sigh-ih-no-sis)
bluish color of the hands and feet, not pathological in newborns
acupressure
(ak-you-preh-shur)
treatment method that involves therapeutic massage of points along the
bodys energy pathways
acupuncture
(ak-you-punk-shur)
treatment method that involves therapeutic stimulation of points along the
bodys 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 after its developer, Virginia Apgar
areola
(air-ee-oh-luh, uh-ree-uh-luh)
the pigmented tissue around the nipple
asphyxia
(as-fix-ee-uh)
inadequate oxygenation that causes unconsciousness and, without
intervention, death
atony
(at-on-nee)
lack of muscle tone
bilirubin
(bil-uh-rue-bin, bil-ee-rue-bin)
yellow or orange product of the breakdown of hemoglobin
Braxton-Hicks contraction
(braks-tin hiks kin-trak-shin)
painless, ineffective uterine contractions that occur during late pregnancy
cervix
(sir-viks)
the low narrow end of the uterus that contains its opening
circumcision
(sir-cum-sih-jin)
surgical removal of the foreskin of the penis
colostrum
(cul-aah-strum)
white to yellowish fluid that precedes breast milk
counterpressure
(count-er-preh-shur)

application of pressure to the sacrum during contractions


cradle cap
(cray-dul cap)
infant scalp dermatitis manifesting as thick yellowish scales
cyanosis
(sigh-uh-no-sis)
a bluish discoloration, especially of the skin and mucous membranes, due to
excessive concentration of deoxyhemoglobin (hemoglobin not combined with
oxygen) in the blood
dilation
(dye-lay-shin)
stretching of the opening of the cervix to accommodate childbirth
ecchymosis
(ek-ih-mow-sis)
hemorrhagic spot, or bruise, caused by bleeding under the skin and
irregularly formed in blue, purple, or brown patches
edema
(uh-dee-muh)
accumulation of excess fluid, causing swelling in the cells, in intercellular
spaces within tissues, or in potential spaces inside the body
effacement
(ef-face-mint)
thinning and shortening of the cervix in preparation for childbirth
effleurage
(ef-lure-ahj)
light massage or stroking, usually on the patients 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
fetus
(fee-tis)
unborn child still inside the uterus
fetoscope
(feet-uh-scope)
a stethoscope for listening to fetal heart tones
friable
(fry-ible)
easily broken
fundus
(fun-dis)
rounded upper portion of the uterus
hematoma
(he-ma-toe-ma)

localized collection of blood underneath the tissues, appearing as a swelling


or mass often characterized by a bluish discoloration
hydramnios
(high-dram-nee-ose)
excessive amniotic fluid
hyperemesis gravidarum
(high-per-em-ih-sis grav-ih-dar-um)
complication of pregnancy that involves excessive vomiting, electrolyte
imbalances, weight loss, nutritional deficits, and ketonuria
hyperglycemia
(high-per-gly-see-mee-uh)
an elevated blood glucose level
hyperventilation
(high-per-ven-til-ae-shun)
excessively 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 expected reference range
lanugo
(luh-new-go)
fine, downy hair on the fetus after 20 weeks of gestation
Leopold maneuvers
(lee-uh-pold mih-new-vers)
a series of four types of abdominal palpitation for determining fetal position
let-down reflex
(let-down ree-fleks)
release of breast milk in response to oxytocin, also called the milk-ejection
reflex
lightening
(lite-in-ning)
descent of the uterus into the pelvic cavity about 2 weeks before term labor
lochia
(low-key-uh)
vaginal discharge following childbirth
meconium
(mih-coe-nee-um)
odorless, green-tinged, black, sticky initial stools of a newborn
milk-ejection reflex
(milk ee-jek-shin ree-fleks)
release of breast milk in response to oxytocin, also called the let-down reflex
Moro reflex
(more-oh ree-fleks)

expected newborn response to a loud noise or other readily perceived


stimulus, demonstrated as arm flexion and an embracing posture
oxygen saturation
(ok-sih-jun sah-chuh-ray-shun)
a clinical measurement of the percentage of hemoglobin that is bound with
oxygen in the blood
oxytocic
(ok-see-toe-sik, ok-see-toks-ik)
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 skin- 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 cervix
popliteal
(pop-lih-tee-ul)
referring to the posterior part of the leg behind the knee joint
pre-eclampsia
(pre-eh-clamp-see-uh, pre-eh-clamp-shuh)
a complication of middle to late pregnancy that involves hypertension,
proteinuria, and hemoconcentration
quickening
(kwik-in-ing)
perception of fetal movement
preterm
(pre-turm)
referring to the period of a pregnancy prior to 37 weeks of gestation
rooting reflex
(roo-ting ree-fleks)
expected newborn response that involves moving toward whatever touches
the mouth and initiating sucking motions
sitz 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
exerting pressure on the ascending vena cava
symphysis pubis
(sim-fih-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-tik touch)
an energy therapy that is useful for promoting relaxation and healing and
involves a practitioner moving hands over the patients 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 3 months each, that comprise a
pregnancy
umbilical cord
(um-bil-ik-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 Whartons jelly
uterus
(you-ter-is)
the hollow, muscular female reproductive organ where a fetus develops
vernix caseosa
(ver-niks cass-ee-oh-suh, case-ee-oh-suh)
a grayish white protective substance that coats fetal skin and has a creamcheese-like consistency
viability
(vie-uh-bil-ih-tee)
capability of living outside the uterus, generally at 20 weeks of gestation and
beyond

Pregnancy
Pregnancy is a time of profound physiological and emotional change. It is beyond
the scope of this skills module to present a comprehensive review of pregnancy.
However, to meet your patients learning needs during its various trimesters, it is
essential have to basic understanding of what she might experience during each of
these phases.
The first trimester
When you first encounter a patient in her early weeks of pregnancy, she has
probably just found out that she is pregnant. She may have any of a wide range of
emotional responses and might not be prepared to take in a lot of information about
pregnancy and childbirth at this time. Besides answering any questions she might
have, your priority will be to point out any danger signs indications she must
report to her provider because they might warrant intervention.
Your patients first question is likely to be about when her baby will arrive. To
calculate this, use Ngeles rule. Take the first day of the womans last menstrual
cycle, subtract 3 months, and then add 7 days and adjust the year as needed to
make it a future date. So, if the first day of her last menstruation was November 20
of the current year, subtracting 3 months takes you to August, and adding 7 days
and one year makes her due date August 27 of the following year.
Many women develop morning sickness during early pregnancy; indeed, your
patient might tell you that she does feel nauseated from time to time. Make sure
she knows to report severe vomiting, as it could be hyperemesis gravidarum, a
serious complication that involves weight loss, fluid and electrolyte imbalances, and
nutritional deficits.
Tell your patient to report abdominal cramping and any vaginal bleeding at all. In
the first trimester, these could indicate miscarriage or ectopic pregnancy.
Another major consideration during the first trimester is infection. Burning with
urination could mean a urinary tract infection. Diarrhea could mean a
gastrointestinal infection. And fever and chills could indicate a systemic infection.
All require prompt reporting and intervention.
Also instruct your patient to avoid taking any prescription or over-the-counter
medications or supplements without first checking with her provider. Be sure she is
aware of the dangers to her fetus from her ingestion of alcohol or other dangerous
substances.
The second trimester
During the second trimester, many women undergo an ultrasound examination and
find out their babys gender. It can be an exciting time, particularly as women feel
their babys movement, or quickening, for the first time. Your patient may also look
to you for help with some of the common discomforts of pregnancy that develop
from her ever-expanding uterus.

The danger signs from the first 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 fluid from the vagina indicates a rupture of the amniotic
membranes a serious complication this early in pregnancy.
Once a woman is accustomed to the pattern and frequency of fetal movement, she
must report any significant increase or decrease. Either could be a fetal response to
inadequate oxygenation.
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. Classic manifestations
include headache, vision changes, epigastric or abdominal pain, and edema,
especially of the face and hands.
Gestational diabetes is another complication of pregnancy that manifests with
specific warning signs. Instruct your patient to report the concurrent occurrence of
flushed dry skin, fruity breath, rapid breathing, increased thirst and urination, and
headache. These are manifestations of hyperglycemia. Clammy pale skin,
weakness, tremors, irritability, and lightheadedness are manifestations of
hypoglycemia.
It is also important at this time to teach your patient about the benefits of
breastfeeding and of taking childbirth preparation classes.
The third trimester
During the third trimester, when women are preparing for the birth of their baby,
they will want to know how they can tell the difference between true and false
labor.
During true labor, your patient will have regular contractions that gradually become
stronger and closer together. She will feel the pain of true labor in her lower back,
and it will move forward across her lower abdomen. Her cervix will dilate and efface,
and as the cervix dilates, she will pass what is called a bloody show vaginally and
feel the baby moving down into the birth canal.
With false labor, contractions are usually irregular, although they can be regular for
short periods. Walking and other activities will stop false labor, as will comfort
measures and hydration. (These do not stop true labor.) And of course, with false
labor, the cervix does not dilate and it does not efface.
The previous danger signs still apply, although after 37 weeks, ruptured membranes
are likely to signal an imminent onset of term labor and not a danger sign of
preterm labor.

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 just above the symphysis pubis and apply firm pressure. If you do not detect
heart tones right away, move the device around the abdomen slowly until you hear them. Count
the fetal heart rate for 1 full minute, listening to its quality and rhythm as well. Inform the
provider immediately if you cannot hear the fetal heart.

Fetal heart tones are difficult to hear when a patient has an excessive amount of amniotic fluid
(hydramnios) or excessive subcutaneous fat in the abdomen. For optimal hearing later in the
pregnancy, use abdominal palpation (Leopold maneuvers) to determine the position of the fetus.
Placing the ultrasound device over the fetal back often improves the ability to hear the heart
tones.

The fetal heart typically beats from 120 to 160 times a minute. Rates outside of this reference
range can indicate fetal distress.

Measuring fundal height


During 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. From weeks 18 to 32, the number of
centimeters of fundal height is just about equivalent to the weeks of gestation. Thus this
measurement can help you assess fetal growth and estimate gestational age. After 32 weeks, it
no longer reflects gestational age as the fetus is growing more in weight than in length.

Make sure the patient has emptied her bladder because a full bladder can change the
measurement by as much as 3 cm. Have her lie supine with her head slightly elevated on a
pillow, or her knees in a flexed position, or both. Be sure the patients position is the same for
each fundal height measurement, and ideally the same clinician should measure the fundus each
time. Using 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.

Fundal height measurements below the estimated gestational age might suggest a miscalculation
in due dates, intrauterine growth restriction, or a fetal anomaly. Measurements above the
patients gestational age might indicate hydramnios, a large-for-gestational-age fetus, a
miscalculation in due dates, or a multiple pregnancy.

Leopold maneuvers
For your patients who are pregnant, Leopold 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 maximal intensity
(PMI) of the fetal heart rate on the patients abdomen.

The four Leopold maneuvers are:


Identifying the fetal part in the uterine fundus to determine fetal lie and the presenting

part
Palpating the fetal back to identify fetal presentation

Determining which fetal part lies over the pelvic inlet to identify fetal attitude

Locating the fetal cephalic prominence to identify the attitude of the head

Begin the procedure by asking your patient to empty her bladder so that she wont feel any
discomfort during palpation. Position a small rolled towel under one hip to shift her uterus away
from large blood vessels and thus prevent supine hypotensive syndrome. If you are righthanded, stand on the patient's right side facing her. Use the flat palmar surfaces of your fingers
to perform Leopold maneuvers.

For 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. Palpate for the fetal part that occupies the
fundus to help identify fetal lie and presentation. Feel 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.

For the second maneuver, position the palms of your hands on the side of the patients abdomen.
Use 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.

For the third maneuver, use your right hand to grasp the lower section of the patients abdomen
between your index finger and thumb and press inward over the inlet to the true pelvis. Note any
movement and determine whether the presenting part is soft or firm. If there is movement, the
presenting part is not engaged. If the head is the presenting part, determine fetal attitude, that
is, whether the head is flexed or extended.

For the fourth maneuver, face the patients feet and place both hands on both sides of her
uterus. Outline the fetal head with your fingertips. Palpate both sides of her abdomen to
determine the cephalic prominence, or brow. Note that this maneuver applies only to cephalic
presentations. If you find the cephalic prominence on the same side as the feet, hands, and
elbows, the head is flexed and the vertex is presenting. If you find the cephalic prominence on
the same side as the back, then the head is extended and the face is presenting.

After the procedure, assess the patient's response and then assess fetal well-being. Do this by
checking the fetal heart tones and by noticing any changes in fetal position. Document the
procedure and discuss the results with your patients provider.

Nonpharmacological pain management


Many patients base their perception of the birth experience not so much on the amount of pain
they feel but on how well they achieve their goals for managing it. Most expect some pain and
will count on you to help minimize it. Nonpharmacologic 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. For those who have learned and practiced these strategies prior to labor, you can
remind them to use them.

Breathing techniques
Breathing techniques promote relaxation, provide distraction, and improve coping during uterine
contractions. They begin and end with a cleansing or focused breath a slow, relaxing breath in
through the nose and gently out through the mouth. Slow-paced breathing is exactly that the
patient inhales slowly through the nose and exhales slowly through the mouth usually six to
nine times per minute and no fewer than three to four. With modified-paced breathing, the
patient breathes slowly in and out through her mouth, and, as each contraction reaches its peak,
she breathes faster usually 32 to 40 breaths per minute. As the contraction subsides, the
patient returns to slow breathing. Pattern-paced breathing requires more concentration as the
patient sets up a pattern of breathing to help her through the final centimeters of cervical
dilation. Breathing in and out of her mouth, she takes quick panting breaths and then exhales or
blows forcefully. One 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 3-to-1 pattern pantpant-pant-blow or hee-hee-hee-hoo throughout the entire contraction and ends with a
cleansing or focused breath. The rate is usually the same as with modified-paced 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
Massage is an effective technique for enhancing relaxation and comfort. Massaging the patients
head, hands, feet, and back provides comfort and communicates caring. Counterpressure 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 adequate counterpressure. Effleurage 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. For patients who have a monitoring
belt across the abdomen, the chest and the thigh are appropriate alternatives. Energy work, such
as healing or therapeutic touch, involves manipulating energy fields to help reduce anxiety and
pain during labor. Certified practitioners perform these techniques.

Positioning
Frequent position changes enhance comfort and relaxation and promote more effective
contractions. Upright positions such as walking, sitting, or squatting take advantage of gravity to
encourage fetal descent. Combining positions and activities like rocking and slow dancing with
relaxation can help reduce pain perception.

Water therapy
Showering, bathing, and sitting in a whirlpool bath can improve comfort, provide a relaxing
atmosphere, improve circulation and oxygenation, soften perineal tissues, and make it easier for
women in labor to cope with pain. Facility policies vary, but as long as a patient in active labor
has no contraindications for these techniques, she can generally stay in the bath for as long as
she wishes. Recommendations for jet hydrotherapy are usually for 30 to 60 minutes. Warm
water can cause dizziness, 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.

Other therapies vary with the practice setting, the provider, and the patients preferences. Some,
such as biofeedback, hypnosis, acupressure, acupuncture, and transcutaneous electrical nerve
stimulation, require trained practitioners and sometimes specialized equipment. Others such as
aromatherapy, imagery, heat and cold applications, and music therapy are easy to implement,
require no special certification, and can provide some unique benefits for patients in labor.

Gestational age assessment


To determine the approximate gestational age of a newborn, youll assess six neuromuscular and
six physical characteristics. This assessment, the New Ballard Score, is appropriate for newborns
from 20 to 44 weeks of gestation, with the characteristics to assess varying with the stage of
maturity. Each parameter scores from minus 2 to 5, with the cumulative score correlating with a
gestational age between 26 and 44 weeks.

Timing of the gestational assessment influences the accuracy of its results. For newborns
younger than 26 gestational weeks, perform the assessment sooner than 12 hours after birth.
For newborns beyond 26 gestational weeks, perform the examination within 96 hours of birth.
Overall, it is best to perform the examination within 48 hours of birth. This assessment
information is essential because gestation relates directly to the likelihood of complications
during the newborn period. Lower scores correlate with prematurity; higher scores correlate with
postmaturity. Commercially printed worksheets are available to use when performing this
assessment.

The components of the neuromuscular assessment are posture, square window, arm recoil,
popliteal angle, scarf sign, and heel to ear. Perform all assessments with the newborn lying
supine. Refer to the scoring sheet to base the specific scores on your findings for each
parameter.

Assess posture for the degree of flexion of the extremities. At term,


a newborns legs and arms are moderately flexed at rest.

Preterm newborns show lesser degrees of flexion: the younger the gestational age, the less
flexion the newborn demonstrates.

Assess square window by grasping the newborns forearm and gently flexing
the wrist toward the inner arm. Do not allow rotation of the wrist.

Measure the angle that forms where the hand meets the wrist. At term, the hand should touch
the wrist, resulting in a 0-degree angle.

Preterm newborns show greater angles of flexion at the wrist: the


younger the gestational age, the less flexibility at the wrist. Very
preterm newborns have an angle of wrist flexion of 90 degrees or
more.

Measure arm recoil by first flexing and holding both forearms for 5
seconds, then extending the arms and hands fully at the newborns
side.

Next, release the hands and allow the arms to recoil (return to
flexion).

Term newborns demonstrate full recoil to a position of flexion while preterm newborns show less
flexion. Measure the angle of flexion at the elbow to determine the arm recoil score.

With 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 flexible, with about a 90-degree
angle. With very preterm newborns, the leg straightens to a 180degree 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. Do not raise the newborns buttocks off of the examination surface.
Stop when you meet resistance and measure the degree of extension of the leg. With 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, eye/ear, and genitals. Base 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 post-term newborns. Assess the skin for transparency, cracks, veins, peeling, and
wrinkles.

Lanugo is very fine body hair. Extremely premature newborns have none. During the middle of
the third trimester, most fetuses have plentiful lanugo. Closer to term, this body hair begins to
thin. Terms newborns have very little, and it is nearly absent in post-term
newborns.

Inspect 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.

Inspect the breast to assess the size of the breast bud in millimeters and the development of the
areola. Preterm newborns lack developed breast tissue. Term newborns have a raised to a full
areola with breast buds that are 3 to 10 millimeters in diameter.

The eye/ear 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 well-curved pinna with firm
cartilage. Determine ear recoil by folding the pinna down and assessing how quickly it returns to
its previous position. Also, very preterm newborns may have fused eyelids. Youll score the
degree of fusion for these newborns.

Observe the genitals for physical maturity. With males, the testes usually descend near term and
rugae (ridges or folds) are visible on the scrotum. Palpate the testes to determine if they have
descended and note the rugae. With extreme prematurity, the scrotum is flat and smooth. With
female newborns at term, the labia majora are larger than the clitoris and the labia minora.
Preterm newborns have a prominent clitoris and small labia minora. Base your scores on the
degree of development of the labia.

Newborn care
When 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. Early discharge is
common, with some women and newborns at low risk for complications leaving the hospital
within 24 to 36 hours after an uncomplicated delivery. However, federal legislation ensures that
all health plans allow for a minimum of 48 hours of hospitalization after a vaginal birth and 96
hours after a cesarean birth. Regardless of the length of stay, parents must learn the skills of
feeding, clothing, bathing, and protecting their infant before they leave. Youll 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.

Umbilical cord care


Teach parents to keep the newborns umbilical cord clean and dry. Remove the cord clamp when
the cord is dry, usually at about 24 hours of age, then assure them that they may clean the
stump with water as long as they allow it to dry afterward. Some providers and facilities
recommend soap and water. Parents should watch for swelling, redness at the base of the stump,
purulent drainage, and a foul odor from the stump at each diaper change. Show them how to
fold the upper edge of the front of the diaper down below the umbilicus so the stump remains
exposed and dry. Let them know that the stump will probably fall off somewhere between 10 and
14 days after birth.

Circumcision care
For newborns who have had a circumcision, apply petroleum jelly to the penis for the first 24
hours to keep the diaper from adhering to the circumcision site. With the Plastibell method,
petroleum jelly is unnecessary. Administer acetaminophen (Tylenol) as needed for pain. Observe
the penis for bleeding and adequate urination. Cleanse the penis with warm water and apply the
diaper loosely. Demonstrate 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 5 or
6 days later). Caution them about the yellow exudate they may see on the glans after 24 hours
and for the next 2 to 3 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 gauze pad. If bleeding
continues or if they notice redness, swelling, pus, or a foul odor, they should notify the provider.

Bathing
Bathing is an opportunity for interaction and bonding. Have 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. Daily bathing is unnecessary; in fact, it can disrupt skin integrity
and the acid mantle, which comprises the uppermost layer of the skin plus amniotic fluid,
superficial fat, micro-organisms, sweat, and other metabolic products. A good time for a bath is
when the newborn awakes and before a feeding. Emphasize that parents must never leave an
infant alone during bathing, not even for a second or two. Go over the following instructions with
them, first with a demonstration and then with a return demonstration.

To prevent heat loss, perform the bath quickly in a warm room, exposing only a portion of the
body at one time. Suggest they use a bath thermometer to ensure that the water temperature is
in the appropriate range: about 36.6 C to 37.2 C (98 F to 99 F). Use soft, clean washcloths,
not cotton balls or swabs. Begin by washing the face with plain water. Cleanse the eyes from the
inner to the outer canthus, using separate parts of the washcloth for each eye. Wrap the infant in
a blanket when washing the hair and scalp. Use one hand or a soft brush to wash the scalp with
water and a mild, unscented, pH-neutral soap. This and regular hair brushing prevent scalp
desquamation, or cradle cap. Wash 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. Use corners of a washcloth to clean
the ears and nose. Be sure to wash between the fingers and toes. Dry the newborn thoroughly to
prevent heat loss.

Clean the diaper area with each change. For girls, gently separate the labia and carefully wash
from the pubic area toward the anus. For uncircumcised boys, gently retract the foreskin until
you feel resistance. Wash the tip (glans) with warm soap and water and replace the foreskin.
Once healed, the circumcised penis requires no special care, just gentle washing of the genital
area.

Do not use creams, lotions, powders, or ointments routinely. For excessive dryness, apply a nonalcohol-based, unscented lotion. Newborn skin is fragile; excessive scrubbing can injure it.
Always rub gently and pat the skin dry. If stool has dried on the skin, soak the area to make it
easier to remove. Do not rub it off. And do not expose the skin to direct sunlight.

Diaper rash
Bacteria that cause diaper dermatitis thrive in moist dark areas. To treat diaper rash, clean the
area after each urination and bowel movement. Exposing the buttocks to air helps prevent
bacterial growth. For infants prone to diaper rash or to help heal a rash, apply zinc oxide
ointment to protect the skin. A fungal rash from Candida albicans requires treatment with an
antifungal ointment and possibly oral medication. Signs of this type of diaper rash include severe
erythema in the perianal area, inguinal folds, and lower abdomen.

Nail care
It is not necessary to trim a newborns nails until they have grown long enough to extend 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.

Clothing
Parents should dress the infant for comfort and security. A cap can help minimize heat loss and
protect the infant from the sun. Swaddling 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. Make sure all clothing is flameretardant.

Safety
Parents may not be aware of many potential dangers for their newborn. Provide instructions such
as these to promote safety.

Do not leave an infant alone on a bed, table, or other furniture.

Place infant carriers on the floor, never on high places such as counters and beds.

Set the water heater to 49 C (120 F) or less. Test bath water temperature with a bath

thermometer.
Pick an infant up gently and never swing, throw, or shake him.

To prevent respiratory illnesses, never expose an infant to tobacco smoke.

Make sure crib slats are no more than 6 cm (2.375 inches) apart and the mattress fits
snugly against the sides. A mattress is too small if two adult fingers fit between it and the

sides of the crib.


Position the crib on interior walls to prevent drafts.

Keep window cords out of reach.

Keep the crib away from heaters to prevent fire.

To prevent suffocation, do not place pillows, stuffed animals, or loose bedding in the crib

with an infant.
Use a sleep sack to keep the infant warm instead of loose bedding or comforters.

Do not leave a bib or a pacifier with a string around an infants neck during sleep.

Use a firm mattress covered with a sheet.

Position the infant supine to reduce the risk of sudden infant death syndrome.

Do not put an infant to sleep on a waterbed or in the same bed with sleeping adults.

Install smoke detectors and replace their batteries regularly.

Learn infant cardiopulmonary resuscitation.

Never leave an infant in a parked car.

Car seats
Use only a federally approved, rear-facing car seat and secure it in the rear seat of the vehicle.
Make sure the harness is snug and the clip is at axillary level and not across the infants neck or
abdomen. Follow federal and state regulations for age and weight parameters for car seat types
and positions. Many local agencies offer car seat information and actual installation and
verification of adherence to safety regulations.

Comforting techniques
Newborns use nonnutritive sucking to self-soothe. They suck on their own fingers and some use
a pacifier. Instruct 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). Caution parents to use
only safety-tested commercial pacifiers.

Infants cry to communicate hunger, discomfort, illness, and boredom. They may cry only a few
minutes or for 2 hours or more. Encourage parents to interpret what a cry means and respond
accordingly. A fussy period each day, usually in the late afternoon or evening, is quite common.
During these times comforting measures may not help. It is likely that the infant will fuss until he
releases enough energy to fall asleep.

Provide parents with education about techniques to quiet their infant. These include swaddling,
soothing noise, skin-to-skin contact, patting, back rubbing, or other mild rhythmic movement
such as with a cradle or a rocking chair. Outings in a stroller or a motor-vehicle often help.

Sensory stimulation
Sensory stimulation promotes development. Encourage 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.

Signs of illness
Make sure parents know when to contact their provider, for example, for significantly high or low
axillary temperatures, frequent 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 newborns


Optimal nutrition during the neonatal period supports newborn growth and development. Feeding
also provides an opportunity for parents to bond with their newborn. Current recommendations
are for exclusive breastfeeding for the first 6 months of life, followed by a combination of solid
foods and human milk until 12 months of age. Parents may also choose to feed their newborn
commercially prepared formula. To help parents make an informed decision, offer them
evidence-based information about the nutritional needs of newborns, the benefits of breast milk,
and the potential risks of formula feeding.

Fluid and calories


For their first 2 days, newborns need 60 to 80 mL of fluid per kilogram (kg) of body weight per
day. For the next 4 days, they need 100 to 150 mL/kg/day. For the remainder of their first
month, they need 120 to 180 mL/kg/day. They lose fluid through urination and respiration. It is
essential to monitor their intake and output carefully, as they have little tolerance for fluctuations
in fluid balance.

Caloric intake, measured in kilocalories (kcal), provides energy for growth, physical activity, and
metabolic function. For the first 3 months of life, infants require 110 kcal/kg/day. Each ounce of
breast milk and of formula contains about 20 kcal.

Increases in a newborns appetite generally correlate with growth spurts. Parents usually notice
these changes at 10 days, 3 weeks, 6 weeks, 3 months, and 6 months of age. During these
times, they should increase the frequency or duration of feedings to accommodate their infants
nutritional needs.

Breastfeeding
Human 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.

When helping a patient get started with breastfeeding, assess the newborn for feeding-readiness
cues, including rooting, sucking motions, and hand-to-hand or hand-to-mouth movements. It 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. Putting the newborn and the mother in direct skin-to-skin contact
(kangaroo care) facilitates the first breastfeeding experience for the mother-infant pair.

Common positions for breastfeeding are the cradle, the modified cradle or across-the-lap, the
football or clutch hold, and the side lying position. Encourage 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.

Encourage the patient to express 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. Suggest 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. Be sure his mouth
covers the nipple and an area about 2 to 3 cm (1 inch) around the nipple. When the newborn has
latched on and is sucking effectively, his chin, cheeks, and tip of the nose all touch the breast;
his cheeks are rounded and not dimpled; and you can hear him swallow. His mother should feel a
tugging sensation, not pain. The newborns jaw should also move smoothly when he sucks.

Breastfeeding patterns vary among newborns, but in general, they should breastfeed eight to 12
times in each 24 hour period. Although newborns are often sleepy during the first few days,
parents should attempt feedings every 3 to 4 hours. After this initial period, when their newborn
is feeding regularly and gaining weight, it is appropriate for them to shift to on-demand feedings.

The duration of feedings also varies. Also, some newborns feed from one breast per feeding,
while others switch easily during a feeding. For 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.

For parents who need to wake their newborn for feedings or during feedings, suggest these
strategies.

Unwrap the newborns blanket.

Massage his chest or back.

Stroke the soles of his feet and the palms of his hands.

Change his diaper.

Sit him upright.

Speak to him.

Parents are often concerned that their infant isnt receiving enough nourishment from
breastfeeding. Tell them to look for the following signs of adequate nutrition.

Periods of contentment after feedings alternate with periods of wakefulness.

The newborn feeds eight to 12 times in 24 hours.

The newborn latches on easily and swallows audibly.

The newborn has at least one wet diaper and one stool per day for the first 3 days, then

six to eight wet diapers and at least three stools every 24 hours.
The milk supply is in by the newborns third or fourth day. Breasts are full before

feedings, and the mother feels the let-down, or milk ejection, sensation during feedings.
The newborn has returned to his birth weight by 10 to 14 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.

Expressing and storing breast milk


Some 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. Mothers can express breast milk by hand, with a
manual pump, or with an electric pump.

Instruct 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 60 to 120 mL (2 to 4 oz) in each container and should use
the oldest milk first. They may keep freshly expressed 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 freezer of a twodoor refrigerator for up to 6 months and in a separate freezer up to 12 months. Tell them to
place breast milk containers in the middle or the rear of the refrigerator or freezer, and to thaw
frozen breast milk in running water or in their refrigerator, never in a microwave oven.

Bottle feeding
Parents of formula-fed 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 ready-to-feed 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.

Have them hold their newborn in a semi-reclining position for all feedings. Propping of bottles
during feedings can result in choking, tooth decay, and loss of interaction opportunities. Have
them hold the bottle so that the nipple is filled with fluid, not air. Cues that the newborn is

satisfied after feeding include turning his head away, stopping sucking, or falling asleep. Teach
parents to recognize these cues to help prevent overfeeding and obesity.

During and after each feeding, parents should facilitate burping because newborns swallow air
during bottle feeding. Make sure they understand that they must discard any formula that
remains in the bottle after a feeding.

During the first 24 hours of life, newborns usually drink 15 to 30 mL of formula at each feeding.
The amount gradually increases during the first week. Parents should feed them every 3 to 4
hours, with six to eight feedings in each 24-hour period.

Instruct 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
During postpartum, the time between delivery and the return of the reproductive system to its
pre-pregnancy state, youll assess your patients vital signs, breasts, fundus, bladder, lochia,
perineum, legs, and any incisions.

Measure vital signs with the frequency your facilitys policies specify or according to the
providers prescription. Include 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 24 hours, however, elevations in temperature
warrant further investigation as they suggest infection. Pulse rates may be somewhat elevated
but should return to their pre-pregnant status gradually. A sustained rapid pulse can indicate
hemorrhage. Respiratory rates may be low after epidural anesthesia and after a cesarean birth
but should gradually return to the expected range. Orthostatic hypotension is common after
delivery. Hypotension can indicate hemorrhage, and hypertension may persist in women who
have had pre-eclampsia.

Assess your patients pain, including location, type, quality, and severity. Administer pain
medication to keep the patients pain at a manageable level. For perineal pain, apply cold during
the first 24 hours, including cool sitz baths. This helps reduce swelling and irritation. After the
first 24 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 just before sitting. This
reduces pressure on healing perineal tissues.

Encourage your patient to urinate prior to assessing her fundus. Assist her to a supine position.

First, inspect and gently palpate her breasts for redness, pain, and engorgement. Inspect the
nipples for redness, cracks, and bleeding. If she is breastfeeding and her breasts are engorged,
suggest warm compresses or a warm shower before breastfeeding to stimulate milk flow. Or, if
her newborn isnt emptying both breasts, suggest she pump her breasts to relieve discomfort. If
she is not breastfeeding, suggest ice packs to help suppress milk production and reduce
discomfort.

Next, check your patients fundus. Assess uterine height, location, and consistency. Determine
the fundal height by placing one hand at the base of the uterus and the other at the umbilicus.
Measure how many fingerbreadths, which are roughly equivalent to centimeters, you can place
between the fundus and the umbilicus above or below it. If 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 approximately 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. If the fundus is boggy, gently massage

the uterus with a rotating motion while supporting the lower uterine segment until it feels firm.
Without stabilization of the lower segment, the uterus could invert, and severe hemorrhaging
could result.

Assess and palpate the bladder at this time as well. Determine whether the fundus is at midline
in the pelvis or displaced laterally due to a full bladder. If the bladder is full, encourage the
patient to urinate and monitor her fluid intake and output. For some patients, insertion of a
straight urinary catheter may become necessary.

Examine the patients perineal pad for bleeding, noting the character, quantity, presence of clots,
and odor. Lochia rubra is typical 1 to 3 days following delivery, and small clots are common.
Determine the amount of saturation as scant, light, moderate, heavy, or excessive. Be sure to
check under the patients buttocks to be sure blood is not pooling beneath her. Lochia typically
increases with breastfeeding and ambulation. If bleeding is excessive, the patient will soak an
entire perineal pad within 15 minutes or so. For that finding as well as for numerous large clots
or a foul odor, notify the provider immediately.

If the patient has had a cesarean delivery, examine the incision for redness, edema, ecchymosis,
drainage, and approximation of its edges. If the patient has had an episiotomy, have her lie on
her side and assess the episiotomy incision for approximation, 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.
Notify the provider immediately if you find any of these. Check for edema of the hands, the face,
and the lower extremities.

Finally, assess your patients comfort level and emotional status.