Narm Exam: Newborn Exam, Immediate Postpartum Care

Front 1

Newborn Exam- Head

Back 1

size
molding
hematoma
caput
sutures
fontanels

Front 2

Newborn Exam- Eyes

Back 2

Jaundice
pupil reactivity
tracking
spacing
clarity
hemorrhage
discharge

Front 3

Newborn Exam- Ears

Back 3

Position
Response to sound
patency
cartilage

Front 4

Newborn Exam- Mouth

Back 4

Palate
lips
tongue/ lip tie

Front 5

Newborn Exam- Nose

Back 5

Patency
flaring nostrils

Front 6

Newborn Exam- Neck

Back 6

Glands (thyroid, lymph)
Swelling
Range of motion

Front 7

Newborn Exam- Chest

Back 7

clavicles
symmetry
nipples
enlargement of breast tissue/ discharge
measurement
heart rate/ sounds
lungs- sounds, rate of breathing
equal bilateral expansion
take temperature axillary or skin

Front 8

Newborn Exam- Abdomen

Back 8

umbilicus
enlarged organs
masses
hernia
bowel sounds
rigidity

Front 9

Newborn Exam- Groin

Back 9

femoral pulses
swollen glands

Front 10

Newborn Exam- Genitalia

Back 10

Appearance
position of urethral opening (meatus)
testicles- descent, ruggae, herniation
labia- patency, maturity

Front 11

Newborn Exam- Rectum

Back 11

patency
meconium

Front 12

Newborn Exam- Hips

Back 12

Abduct for dislocation- "hip clicks"

Front 13

Newborn Exam- Legs

Back 13

symmetry of creases
equal length
muscle tone
feet/ankles

Front 14

Newborn Exam- Feet

Back 14

Digits
Webbing
Creases

Front 15

Newborn Exam- Arms

Back 15

Structure
Movement
Muscle tone

Front 16

Newborn Exam- Hands

Back 16

digits
webbing
palm crease
fingernails

Front 17

Newborn Exam- Backside

Back 17

Symmetry of hips
Spine straightness, completion

Front 18

Newborn Exam- Reflexes

Back 18

sucking
Moro (startle)
Babinski (toes fan)
plantar (toes grasp)
palmar (fingers grasp)
stepping
rooting
blinking

Front 19

Newborn Exam- Skin

Back 19

color
lesions
birthmarks
milia (baby acne)
vernix (white coating)
lanugo (body hair)
peeling
rashes
bruising
Mongolian spots

Front 20

Newborn Exam- Measurements

Back 20

Length
Head circumference
Chest circumference

Front 21

Support Family Bonding

Back 21

Skin-to-skin contact with mother at first
Skin-to-skin with dad later or when mom is unable
Herbal bath with baby
Initiate breastfeeding within 1h of birth
Give privacy as appropriate
Encourage mom and dad to talk to baby

Front 22

Facilitate Breastfeeding

Back 22

Educate parents about colostrum/ size of NB stomach
Educate about positions for BF
Skin-to-skin, tummy to tummy
Wide open latch, flanged lips
Educate mother about the importance of maternal nutrition adequate hydration and rest
Educate about feeding patterns- on demand is best, at least every 2-3 hrs, longer stretches ok at night
Educate about milk coming in, let-down reflex, emotional changes
Milk expression
Engorgement comfort measures

Front 23

Assess mother's bladder

Back 23

-Distended bladder S/S:
Abdomen dips @umbilicus, large suprapubic bulge
Hemorrhage
Fundus displaced above the U and to the R
Increased cramping

-Encourage urination
Peppermint oil in toilet
Blowing on thumb
Trickling water sounds @ sink
Arnica 200C

-Consider catheterization

Front 24

Estimate Blood Loss

Back 24

-Most people overestimate small amounts, underestimate large amounts

-Practice by measuring blood/ pouring on a pad

-Measure if possible when unsure

-Include clots in measurement

Front 25

Postpartum Hemorrhage
Management

Back 25

Nipple stimulation/ breastfeeding
Fundal massage
Bring mother's attention to hemorrhage
Express clots
Administer meds:
-Pitocin 10 units
-cytotec 200 mcg
Non-allopathic remedies:
-angelica tincture
-shepherd's purse
-copaiba EO
-helichrysum EO
Bimanual compression
Call 911
Start oxygen/ fluids
treat for shock
Follow up: be prepared to increase postpartum care

Front 26

Trickle Bleed
Management

Back 26

Lazy, sporadic flow of blood in the 4th stage

-Assess origin
-Assess fundal height/ size of uterus
-Fundal massage
-Assess vitals
-Empty bladder
-Frequent breastfeeding/ nipple stimulation
-Express clots
-Non-allopathic: angelica, shepherd's purse, copaiba EO, helichrysum EO
-Meds: Pitocin/ methergine

Front 27

S/S Impending 3rd Stage

Back 27

-usually delivers within 30 minutes
-monitor bleeding throughout
-remind mother of 3rd stage

S/S:
separation gush
increased contractions/ cramping
cord lengthening
urge to push
rise in fundus

Front 28

Facilitate delivery of placenta

Back 28

Active management includes giving Pitocin soon after birth.

Expectant management includes:
Breastfeeding/ nipple stimulation
Change of position
Guarded cord traction
Empty bladder
Non-allopathic: angelica
Verbally encourage release

Consider manual removal- call 911
Consider transport for removal

-After placenta
monitor bleeding
massage fundus/ assess for position/ firmness

Front 29

Inspect Placenta

Back 29

-Note mechanism of delivery
Shultz- fetal side first
Duncan- maternal side first

-Maternal side: cotyledons (lobes), pull away clots, check for completion, examine margin, note calcifications, infarctions

-Fetal side: 3 vessel cord (2 arteries/ 1 vein), notify pediatrician if not 3 vessels, Wharton's jelly at insertion of cord, membranes for completeness, insertion of cord- marginal (battledore), central, eccentric, velamentous
Succenturiate lobes
margin

Front 30

Assess condition of Vagina, Vulva, Rectum, Perineum

Back 30

-Cystocele: prolapsed bladder. Appears as distension of vaginal wall near the urethra.

-Rectocele: prolapsed rectum. Appears as distension of vaginal wall near the perineum.

-Hematoma: pooling of blood just underneath the skin. Bluish, asymmetrical, painful swelling

-Tears/ Lacerations: evaluate need for repair

-Hemorrhoids: ice pack, witch hazel

-Bruising: arnica, ice pack

-Prolapsed cervix: replace, stay off feet, do kegels, Homeopathic Sepia 200C

Front 31

Assess Perineum for Tearing

Back 31

-1st degree: perineal skin only
-2nd degree: skin and muscle
-3rd degree: skin, muscle and sphincter (various stages of involvement)
-4th degree: skin, muscle, sphincter and rectal mucosa

-Do not repair if wound approximates well (1st degree)

-Use minimal suture material

-Lidocaine for analgesia

-Use sterile technique

-Clamp/ tie off bleeders

-Evaluate for labial or periurethral tear

-Evaluate need for transport (extensive repair)

Front 32

Assess Lochia

Back 32

Normal: dark, sporadic flow that should not be in excess of a heavy menstrual period. Thick, substantial, similar to mucus. Small clots, especially after rising.

Abnormal: Constant dark red bleeding, bright orange-red (artery), large clots, thin and watery bleeding (coagulation issue), Soaking > 3 pads in 2 hrs

Judged in relation to total EBL.

Front 33

Provide Instructions: Care of Perineum

Back 33

Get plenty of rest, keeping legs together

Use good hygiene: use peri-bottle with mild soap, rinse, pat-dry.

Resume kegels, elevator exercises the day after birth (if repaired, wait 2 weeks)

Notify midwife if you notice excessive pain, heat, redness, foul odor, oozing or bleeding at wound site

Front 34

Immediate NB care and assessment

Back 34

-Keep baby warm- skin to skin, warm towels, warm room, keep dry

-Initital NB assessment- evaluate need for suction, stimulation, resuscitation

-APGAR 1m, 5m, 10m

-Mother and baby together for most procedures

-Monitor respiratory and cardiac function:
symmetry of chest/ abdomen when breathing
sound and rate of heart tones/ respirations
s/s of resp distress: nasal flaring, grunting, retreactions
cyanosis

Front 35

APGAR

Back 35

Heart Rate
Respiration effort
Color
Muscle tone
Grimace

Front 36

Stimulate NB respiration

Back 36

Rub up baby's spine
Encourage parents to touch, talk to baby
Flick soles of feet (or rub)
Keep baby warm
Rub skin with blanket/ towel
Apply percussion/ postural drainage for wet lungs

Lung sounds:
Rales- crackling
Rhonchi- deep snoring sound

Front 37

NB Resuscitation

Back 37

Indications:
Little or no resp effort
Poor muscle tone
Bradycardia <100 bpm
Tachypnea
Persistent cyanosis

Management:
Keep baby warm, cord intact
Mouth to mouth breaths
PPV for 15-30 sec, reassess
Administer oxygen

NNR:
Airway: warmth, stimulation, open airway, suction
Breathing: PPV (HR <100bpm), Call 911, administer oxygen
Circulation: chest compressions
"one and two and three and breathe, one and two and three and breathe"

Front 38

Immediate cord care

Back 38

Clamp cord after pulsing stops (or after placenta delivers)
Clamp baby's side first, then placenta side.
Cut between clamps
Evaluate cord stump
Collect blood sample if needed

Front 39

Meconium Aspiration Syndrome

Back 39

Causes: Inhalatiion of mec-stained fluid

Presents as resp distress:
shallow and irregular breathing
tachypnea
barrel-chest
retractions
rales and rhonchi
cyanosis
s/s of infection

-Administer oxygen as needed
-Prepare for transport, skin to skin, suction as needed, percussion, postural drainage
-Prevention includes suctioning on the perineum with mec-stained fluid

Front 40

Assess gestational age

Back 40

New Ballard Score

-Intact reflexes

-Physical maturity: skin tone, lanugo, plantar creases, breast tissue, eyelid formation, ear cartilage recoil, genitals

-Neuromuscular maturity:
Posture (flexion of limbs)
Square window (wrists)
Scarf sign
Arm recoil
Popliteal angle
Heel to ear

Refer for assessment <37 weeks GA

Front 41

Neurological Problems

Back 41

-Peculiar facial expression
-Paralysis, waiter's tip, weak grasp, lower limb weakness
-Absent reflexes
-Diaphragm paralysis- resp distress
-Seizure, abnormal eye movements
-Rigid postures
-Unequal pupil dilation
-Stupor, lethargy, hyperirritability
-high pitched cry