Postpartum Assessment and Immunization Guidelines Part 3

Newborn Characteristics Newborn Reflexes ***Need to know how to elicit and the expected response: NEWBORN MEDICATIONS  Erythromycin and Vitamin K o known as " eyes and thighs " o erythromycin is given as a prophylaxis treatment for gonococcal/chlamydial eye infection  an ointment is given from the inner to the outer canthus o vitamin K to prevent hemorrhage disease in the neonate  given via an IM injection on the vastus lateralis muscle  Hepatitis B vaccine o 3 series:  1st dose: before discharge  2nd dose: 1-2 months  3rd dose: 6-18 months  Hepatitis B immune globulin (HBIg) is given within 12 hours with the Hepatitis B vaccine if mom is Hepatitis B positive o BOTH given via an IM injection on the vastus lateralis muscle Screening Tests  Newborn screening AKA Phenylketonuria (PKU) o blood test o heel stick  it is a blood test used to test blood glucose, hematocrit, and serum bilirubin and to conduct the GDS. Which tests for infections, genetic diseases, and metabolic disorders.  Hearing screening o do not do when they are born right away because there could be amniotic fluid in ears and waiting allows there to be more correct testing. Do it once in patient and twice out patient. If they keep failing can indicate baby has a hearing problem.  CCHD screening AKA Critical Congenital Heart Defects o pulse oximetry test: 95o2 and above becomes normal after 10 minutes o it is a pulse oximetry test that compares preductal and post ductal oxygen saturation levels as well as the overall oxygenation levels, recommended to be taken after 24hrs of age. o It is take on both the right hand (preductal) and either foot (post ductal). A “passing” test is typically when oxygen saturation levels are 95% or greater in either extremity and there is 3% or less difference between the preductal and postdoctoral readings. o Which of the following test is passing 90 and 95 is it passing? No because they have to both have to be above 95% or above Circumcision  Elective surgery to remove the foreskin of the penis o Gomco clamp (may be safest because the gomco helps protect the head of the penis) o Plastibell*  plastic bell is left  do not remove the yellow crust for healing process o Mogen clamp  Monitor for signs of bleeding and void. o Stop bleeding by putting pressure Newborn Care  bathing  bulb syringe  clothing : based on weather  cord care: do not submerge baby ' s cord, cord clamp is removed when the cord is dry, actual cord falls off in 2 weeks  colic: ***never shake a baby, can lead to pediatric abusive head trauma  diaper dermatitis (diaper rash) zinc oxide (desitin), Aquaphor  diapering/elimination: cord is left exposed not covered, check and change o should not be covered because it is moist can cause bacteria and infection  diapers frequently (before and after feeding), ***urate crystals (red orange color) may be a sign of dehydration  follow-up care: within 2 to 4 days after hospital discharge o closer to 1-2 days  subsequent visits: 1,2, 4, 6, 9, and 12 months of age  Jaundice o Should be seen 1-2 days  pediatric abusive head trauma  safe infant sleep: on their backs, in a firm, flat surface, with no stuffed animals or thick blankets, no co-sleeping o should be supine  safety  accident prevention  car seats  fall prevention  poisoning prevention  baby-proof!  cut those grapes! To prevent choking can occlude airway  sibling attachment: older sibling may regress, include the older sibling  skin care: avoid daily bathing, no baby powders (can be inhaled), no lotions (unnecessary)  Swaddling to comfort  soothing babies  nonnutritive sucking: using a pacifier or the infant' s fist and fingers to soothe and calm the infant o use of pacifier less chances of developing SIDS but can cause nipple confusion  5S' s by Dr. Karp: o swaddling o side positioning or stomach position (only if supervised) o shushing o swinging o sucking  Helps calm baby down  temperature taking: digital thermometers can be done axillary or rectal (rectal temperature needs a Dr. order)  dental decay: sweetened liquids are given to infants and remain in the mouth for a period of time  uncircumcised male: do not force the foreskin over the penis; gently cleanse when bathing and changing the diaper; once the foreskin retracts around age 3, gently clean between the foreskin and glans of the penis when bathing the child  circumcision care o Gomco/Mogen clamp o Plastibell  ***no lubricants can displace the plastic ring  the plastic ring falls off in 7 to 10 days on its own When to call the provider: temp of 100.4F (38C), loss of appetite, refuses to eat, lethargic, sleepy and not active as usual, does not wake on their own during feedings/not interested in feeding, does not cry/has a weak cry, watery green stools, vomiting, decrease in # of wet diapers, skin rash with pus, sunken or bulging fontanels, bleeding from circumcision and/or cord site (stop bleeding by putting pressure), foul odor from circumcision and/or cord site Chapter 16 Breastfeeding *Box 16-1 Position statements on breastfeeding Benefits of breastfeeding Newborn Mother Contraindications for breastfeeding  Benefits o infants: [short-term] decreased risk of gastroenteritis, RSV, otitis media, NEC, SIDS, UTI, [long-term] decreased risk of asthma, atopic dermatitis, CVD, celiac disease, childhood inflammatory bowel disease, obesity, sleep disorders, antibodies o woman: [short-term] decreased blood loss, decreased risk of infection, [long-term] decreased risk of diabetes, metabolic syndrome, osteoporosis, autoimmune disease, ovarian and breast cancer, [psychological] enhanced maternal-infant attachment, decreased risk of PPD  Contraindication o active and untreated TB, receiving diagnostic/therapeutic o radioactive isotopes, antimetabolites/chemotherapeutic agents, o herpes simplex lesions on the breast, HIV+, cocaine, galactosemia Breastmilk Composition  Composed of fats, carbohydrates, proteins, lactose, vitamins, minerals, and hormones.  Human milk contains 87% water, 1% protein, 3.8% fats, and 7% lactose.  Fat content ranges from 3.5% to 4.5% and is considered the most important component of breast milk. Fats are a source of energy and help central nervous system development.  Fats provide 50% of the total calories (energy) of breast milk and lactose provides 40%. Stages of Breastmilk  Stage 1: Colostrum—This is considered the first milk and is present in the breast beginning in the second trimester. Colostrum is a thick, clear to golden yellow fluid with higher levels of protein and lower levels of fats, carbohydrates, and calories than mature breast milk.  Stage 2: Transitional milk—During this stage, the milk will gradually change from colostrum to mature milk, with decreasing levels of protein and increasing levels of fats, carbohydrates, and calories until the mature milk comes in around day 12 following birth.  Stage 3: Mature milk—Arriving approximately 12 days after birth, mature milk is composed of 20% solids and 80% water and contains approximately 22 to 23 calories per ounce. Mature milk is whiter and thinner, appearing watery and often with a bluish cast.  Foremilk is the milk produced and stored between feedings and is released at the beginning of a feeding. It is more dilute and satisfies thirst.  Hindmilk milk produced during a feeding session, is received toward the end of the feeding and has a higher fat content. Breastmilk Production  Mammogenesis  Lactogenesis I  Lactogenesis II  Galactopoiesis  Involution  Hormones involved: o Prolactin  milk production o Oxytocin  milk letdown  focus on the hormones*** **Critical Component: Lactogenesis and Supply and Demand Breastmilk Production  Skin-to-skin (kangaroo care)  Initiating breastfeeding  Latching the newborn  Feeding cues o Licking their lips o Smacking their lips o Extending their tongue o Putting their hand to their mouth o Sucking on their fingers o Turning their head to their mother’s voice o Entering a quiet alert stage  Positioning the newborn at the breast - Crying baby you should calm them down first by swaddling, skin to skin, or other methods before trying to feed them. Breastfeeding Process 1. check diaper 2. determine when to feed; hunger cues 3. assume a comfortable position 4. latch on 5.support with pillows 6.stimulate the baby to breastfeed 7. offer both breasts 8. unlatch baby - by scooping nipple out because it can cause irritation and hurt 9. burp baby 10. check diaper Breastfeeding Positions ***what is most comfortable for mom and baby? o lying down o sitting o cross-cradle o football/clutch hold cradle o this is best for C-section patients because it doesn’t put pressure on abdomen. Determining effective feeding  “L” represents how well the newborn latches on the breast.  “A” represents audible swallowing.  “T” identifies the type of mother’s nipple.  “C” represents the mother’s degree of comfort (breast or nipple).  “H” describes the amount of assistance needed to hold or position the newborn at the breast to maintain an effective latch. ***Table 16-1 LATCH Scoring System o The lower the score the higher need for support **** Nipple Assessment  Everted: Protrudes outward from the areola.  Inverted: Drawn below the skin surface. A true inverted nipple does not evert with stimulation.  Flat: Even in appearance with the areola.  Retracted: Drawn inward but are usually easily stimulated to evert. ****Clinical Judgment: Prevention of sore nipples, tissue breakdown, and mastitis ****Clinical Judgment: Promoting successful breastfeeding ****Clinical Judgment: Baby-Friendly Hospital Initiative Milk Expression and Breast Pumps  Hand washing  Hand expression  Massaging breast for milking breast  Selecting a breast pump (hand pump, electric pump, etc.)  Storing breastmilk  Should be placed in the back of fridge for consistent temperature  Do not microwave because it can destroy nutrients.  Engorgement Bottle-feeding  Advantages vs disadvantages of formula  Advantages: provides an opportunity for partner to assist with feedings, allows mother to take a break, decreases frequency of feedings because digestion of formula is slower.  Disadvantages: increase cost for purchase of formula, time consuming for prepping, increase risk of infection due to lack of antibodies that are present in breast milk.  Increase risk of obesity, and insulin dependency  Remove bottle after feeding immediately because it can cause tooth decay.  Intolerance to formula  Some cannot tolerate a milk protein called casein in formula  Can cause vomiting, diarrhea with mucus or blood present, weight loss or slow weight gain, colic o Bootle needs to be disposed of if it has been opened for more than an hour because of bacteria growth. Burp baby after feeding because of air. o when preparing infant formula, must follow the exact directions for proper dilution o check for expiration date o read instructions for when to discard ***Critical component: Preparing infant formula ***Critical component: Decreasing the risk of baby bottle tooth decay