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NUR318 - Exam II - Maternal Health Nursing

Chapter 8: Maternal and Fetal Nutrition
Chapter 8: Maternal and Fetal Nutrition
Adequate Intakes (AIs)
Recommended nutrient intakes estimated to meet the needs of almost all healthy people in the population; provided for nutrients or age-group categories for which the available information is not sufficient to warrant establishing recommended dietary allowances
anthropometric measurements
Body measurements, such as height and weight
body mass index (BMI)
Method of calculating appropriateness of weight for height (BMI = weight/height2)
Dietary Reference Intakes (DRIs)
Nutritional recommendations for the United States, consisting of the recommended dietary allowances, adequate intakes, and tolerable upper intake levels; the upper limit of intake associated with low risk in almost all members of a population
intrauterine growth restriction (IUGR)
Fetal undergrowth from any cause
Kilocalorie; unit of heat content or energy equal to 1000 small calories
lactose intolerance
Inherited absence of the enzyme lactase
physiologic anemia
Relative excess of plasma leading to a decrease in hemoglobin concentration and hematocrit; normal adaptation during pregnancy
Unusual oral craving during pregnancy (e.g., for laundry starch, dirt, red clay)
A burning sensation in the epigastric and sternal region from stomach acid (heartburn)
Recommended Dietary Allowances (RDAs)
Recommended nutrient intakes estimated to meet the needs of almost all (97%-98%) of the healthy people in the population
• Good nutrition before and during pregnancy helps prevent neonatal problems, such as low birth weight and prematurity.
• Nutritional care during the preconception period and pregnancy includes nutrition assessment, diagnosis of nutrition-related problems or risk factors (such as diabetes, phenylketonuria, and obesity), intervention based on the dietary goals and plan, and evaluation.
• If the mother is significantly underweight or overweight when pregnancy begins, maternal and fetal risks are increased.
• During pregnancy, physiologic changes influence the need for additional nutrients.
• The optimal rate of weight gain depends on the stage of pregnancy. Total maternal weight gain and the pattern of weight gain affect the pregnancy outcome.
• Nutritional risk factors include adolescent pregnancy, multifetal pregnancy, frequent pregnancies, previous poor fetal outcome, poverty, nicotine use, alcohol or drug use, poor diet habits, problems with weight gain, and weight loss.
• By 12 weeks of gestation, the pregnant woman should start taking 30 mg of ferrous iron daily. Depending on nutritional risk factors, a woman may need other supplements.
• Moderate exercise during pregnancy improves muscle tone, which may shorten the course of labor, and promotes a sense of well-being.
• Chronic conditions, such as diabetes mellitus, renal disease, liver disease, cystic fibrosis, seizure disorders, hypertension, and phenylketonuria, may affect a woman's nutritional status and dietary needs.
• The only nutrition-related laboratory test most women need is a hematocrit or hemoglobin measurement to screen for anemia.
• Nutrition-related discomforts of pregnancy include nausea and vomiting, constipation, and heartburn. Dietary adaptation can help ease these discomforts.
Critical Thinking/Clinical Decision Making

Nutrition and the Overweight Pregnant Woman

Tamara, of African-American and Asian heritage, is 3 months pregnant and comes to her initial appointment for diagnosis and care. She appears to be overweight for her height. To provide optimal care for her, you plan to calculate her prepregnancy body mass index. When her pregnancy is confirmed, you are asked to plan a diet with Tamara that meets the minimum daily requirements and allows for growth of the pregnancy. You know the importance of including consideration of personal preferences and cultural factors in your plan. With Tamara, identify barriers to implementing the plan.
1. Evidence—Is evidence sufficient to draw conclusions about an appropriate nutrition plan, taking into consideration personal preferences and cultural factors?
Yes. A dietary assessment using a food intake questionnaire should be conducted and a physical assessment of nutritional status performed. Based on these data, the desired pattern of weight gain during pregnancy, and a knowledge of characteristic food patterns of African-American and Asian people, planning can begin.
2. Assumptions—Describe the underlying assumptions about each of the following issues:
a. Dietary reference intakes for pregnancy and lactation
b. Indicators of nutritional risk in pregnancy
c. Daily food guide for pregnancy and lactation
d. Sources of calcium for women who do not drink milk
a. A list of dietary reference intakes (RDIs) for pregnancy and lactation can be shared with Tanisha. Through discussion, you can determine whether Tanisha is ingesting adequate amounts of these important elements and whether supplementation of vitamins and minerals is necessary.
b. While reviewing indicators of nutritional risk in pregnancy with Tanisha, problem areas can be identified, and recommendations for change provided as needed.
c. The daily food guide for pregnancy and lactation can be shared with Tanisha. It can provide a basis for planning appropriate menus to provide the necessary nutrients and avoid consuming more energy (calories) than is desired.
d. As someone of African-American and Asian heritage, Tanisha may be lactose intolerant and may need sources of calcium other than milk. Through careful questioning, her lactose status can be determined and counseling can be provided about nonmilk sources of calcium.
3. What implications and priorities for nursing care can be drawn at this time?
As part of her prenatal care, Tanisha (and all pregnant women) should receive nutrition counseling. Tanisha is currently overweight. Although reduction diets may be contraindicated in pregnancy, Tamara can be assisted to plan menus that allow a slow but adequate weight gain to support growth of the pregnancy and the fetus and avoid excess weight gain.
4. Does the evidence objectively support your conclusion?
Yes, there is ample evidence about DRIs in pregnancy and lactation. Nutrition counseling should be part of the plan of care for Tanisha.
5. Do alternative perspectives to your conclusion exist?
Tanisha could have metabolic problems, including diabetes mellitus, that contribute to her weight. Ethnic and cultural patterns of eating and fast food choices could also be factors. Enlisting the support of her family would likely be helpful in planning appropriate meals.
1. When planning a diet with a pregnant woman, the nurse's first action would be to:
A. Review the woman's current dietary intake.
B. Teach the woman about the food pyramid.
C. Caution the woman to avoid large doses of vitamins, especially those that are fat-soluble.
D. Instruct the woman to limit the intake of fatty foods.
A. Review the woman's current dietary intake.

Reviewing the woman's dietary intake as the first step will help to establish whether she has a balanced diet or whether changes in the diet are required. Teaching about the food pyramid is a correct action on the part of the nurse, but the first action should be to assess the woman's current dietary pattern and practices because instruction should be geared to what she already knows and does. Cautioning the woman to avoid large doses of vitamins is a correct action on the part of the nurse, but the first action should be to assess the woman's current dietary pattern and practices because instruction should be geared to what she already knows and does. Instructing the woman to limit intake of fatty foods is a correct action on the part of the nurse, but the first action should be to assess the woman's current dietary pattern and practices because instruction should be geared to what she already knows and does.
2. A pregnant woman with a body mass index (BMI) of 22 asks the nurse how much weight she should be gaining during pregnancy. The nurse's best response would be to tell the woman that her pattern of weight gain should be approximately:
A. A pound a week throughout pregnancy.
B. 2 to 5 pounds during the first trimester, then a pound each week until the end of pregnancy.
C. A pound a week during the first two trimesters, then 2 pounds per week during the third trimester.
D. A total of 25 to 35 pounds.
B. 2 to 5 pounds during the first trimester, then a pound each week until the end of pregnancy.

A pound a week is not the correct guideline during pregnancy. A BMI of 22 represents a normal weight. Therefore, a total weight gain for pregnancy would be about 25 to 35 pounds or about 2 to 5 pounds in the first trimester and about 1 pound per week during the second and third trimesters. A pound per week the first two trimesters and 2 pounds per week the third trimester are not accurate guidelines for weight gain during pregnancy. The total weight gain of 25 to 35 pounds is correct, but the pattern of weight gain needs to be explained.
3. A pregnant woman at 7 weeks of gestation complains to her nurse midwife about frequent episodes of nausea during the day with occasional vomiting. She asks what she can do to feel better. The nurse midwife could suggest that the woman:
A. Drink warm fluids with each of her meals.
B. Eat a high-protein snack before going to bed.
C. Keep crackers and peanut butter at her bedside to eat in the morning before getting out of bed.
D. Schedule three meals and one mid-afternoon snack a day.
B. Eat a high-protein snack before going to bed.

Fluids should be taken between (not with) meals to provide for maximum nutrient uptake in the small intestine. A bedtime snack of slowly digested protein is especially important to prevent the occurrence of hypoglycemia during the night that would contribute to nausea. Dry carbohydrates such as plain toast or crackers are recommended before getting out of bed. Adding peanut butter would not be helpful. Eating small, frequent meals (about five or six each day) with snacks helps to avoid a distended or empty stomach, both of which contribute to the development of nausea and vomiting.
4. A pregnant woman's diet consists almost entirely of whole grain breads and cereals, fruits, and vegetables. The nurse would be most concerned about this woman's intake of:
A. Calcium.
B. Protein
C. Vitamin B12.
D. Folic acid.
C. Vitamin B12.

This diet is consistent with that followed by a strict vegetarian (vegan). Vegans consume only plant products. Because vitamin B12 is found in foods of animal origin, this diet is deficient in vitamin B12.
5. A pregnant woman reports that she is still playing tennis at 32 weeks of gestation. The nurse would be most concerned that during and after tennis matches this woman consumes:
A. Several glasses of fluid.
B. Extra protein sources such as peanut butter.
C. Salty foods to replace lost sodium.
D. Easily digested sources of carbohydrate.
A. Several glasses of fluid.

If no medical or obstetric problems contraindicate physical activity, pregnant women should get 30 minutes of moderate physical exercise daily. Liberal amounts of fluid should be consumed before, during, and after exercise, because dehydration can trigger premature labor. The woman's calorie intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise. Extra protein would not be needed. The woman's calorie intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise. It would not be necessary to replace lost sodium. The woman's calorie intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise. Adding easily digested carbohydrate sources would not be necessary.
6. Women with an inadequate weight gain during pregnancy are at higher risk of giving birth to an infant with:
A. Spina bifida.
B. Intrauterine growth restriction.
C. Diabetes mellitus.
D. Down syndrome.
B. Intrauterine growth restriction.

Spina bifida is not associated with inadequate maternal weight gain. Both normal-weight and underweight women with inadequate weight gain have an increased risk of giving birth to an infant with intrauterine growth restriction. Diabetes mellitus is not associated with inadequate maternal weight gain. Down syndrome is not associated with inadequate maternal weight gain.
7. Which minerals and vitamins usually are recommended to supplement a pregnant woman's diet?
A. Fat-soluble vitamins A and D
B. Water-soluble vitamins C and B6
C. Iron and folate
D. Calcium and zinc
C. Iron and folate

Fat-soluble vitamins should be supplemented as a medical prescription, because vitamin D might be needed for lactose-intolerant women. Water-soluble vitamin C sometimes is consumed in excess naturally; vitamin B6 is prescribed only if the woman has a very poor diet. Iron generally should be supplemented during pregnancy, and folic acid supplements often are needed because folate is so important to the growing fetus. Zinc is sometimes supplemented during pregnancy. Most women get enough calcium.
8. With regard to nutritional needs during lactation, a maternity nurse should be aware that:
A. The mother's intake of vitamin C, zinc, and protein can be lower than during pregnancy.
B. Caffeine consumed by the mother accumulates in the infant, who therefore may be unusually active and wakeful.
C. Critical iron and folic acid levels, higher than during pregnancy, must be maintained to ensure the health of the infant.
D. Lactating women can go back to their prepregnant calorie intake.
B. Caffeine consumed by the mother accumulates in the infant, who therefore may be unusually active and wakeful.

Vitamin C, zinc, and protein levels need to be moderately higher during lactation than during pregnancy. A lactating woman needs to avoid consuming too much caffeine. The recommendations for iron and folic acid are somewhat lower during lactation. Lactating women should consume about 500 kcal more than their prepregnancy intake, at least 1800 kcal daily overall.
9. When counseling a patient about getting enough iron in her diet, the maternity nurse should tell her that:
A. Milk, coffee, and tea aid iron absorption if consumed at the same time as iron.
B. Iron absorption is inhibited by a diet rich in vitamin C.
C. Iron supplements are permissible for children in small doses.
D. Constipation is common with iron supplements.
D. Constipation is common with iron supplements.

The beverages listed inhibit iron absorption when consumed at the same time as iron. Vitamin C promotes iron absorption. Children who ingest iron can get very sick and even die. Constipation can be a problem when iron intake is increased.
10. After you complete your nutritional counseling for a pregnant woman, you ask her to repeat your instructions so you can assess her understanding of the instructions given. Which statement indicates that she understands the role of protein in her pregnancy?
A. "Protein will help my baby grow."
B. "Eating protein will prevent me from becoming anemic."
C. "Eating protein will make my baby have strong teeth after he is born."
D. "Eating protein will prevent me from being diabetic."
A. "Protein will help my baby grow."

Protein is the nutritional element basic to growth. An adequate protein intake is essential to meeting the increasing demands of pregnancy. These demands arise from the rapid growth of the fetus; the enlargement of the uterus, mammary glands, and placenta; the increase in the maternal blood volume; and the formation of amniotic fluid. Iron intake prevents anemia. Calcium intake is needed for fetal bone and tooth development. Glycemic control is needed in diabetics; protein is one nutritional factor to consider, but this is not the primary role of protein intake.
11. Obstetricians today are seeing more morbidly obese pregnant women (those that weigh 400 pounds or greater). A new medical subspecialty referred to as __________ obstetrics has subsequently arisen.

To manage the conditions of morbidly obese pregnant women and to meet their logistical needs, the subspecialty of bariatric obstetrics has been developed. Extra wide BP cuffs, surgical tables and scales that can hold these patients are necessary to deliver safe patient care. Special techniques for ultrasound and longer surgical instruments are also required.
Chapter 10: Management of Discomfort
Absence of pain without loss of consciousness
Partial or complete absence of sensation with or without loss of consciousness
Pressure applied to the sacral area of the back during uterine contractions
Gentle stroking used in massage, usually on the abdomen
epidural block
Type of regional anesthesia produced by injection of a local anesthetic alone or in combination with a narcotic analgesic into the epidural (peridural) space
epidural blood patch
A patch formed by a few milliliters of the mother's blood occluding a tear in the dura mater around the spinal cord that occurs during induction of spinal or epidural block; its purpose is to relieve headache associated with leakage of spinal fluid
gate-control theory of pain
Pain theory used to explain the neurophysiologic mechanism underlying the perception of pain: the capacity of nerve pathways to transmit pain is reduced or completely blocked by using distraction techniques
local perineal infiltration anesthesia
Process by which a local anesthetic medication is deposited within the tissue to anesthetize a limited region of the body
neonatal narcosis
Central nervous system depression in the newborn caused by an opioid (narcotic); may be signaled by respiratory depression, hypotonia, lethargy, and delay in temperature regulation
opioid (narcotic) agonist analgesics
Medications that relieve pain by activating opioid receptors
opioid (narcotic) agonist-antagonist analgesics
Medications that combine agonist activity (activates or stimulates a receptor to perform a function) and antagonist activity (blocks a receptor or medication designed to activate a receptor) to relieve pain without causing significant maternal or fetal or newborn respiratory depression
opioid (narcotic) antagonists
Medications used to reverse the central nervous system depressant effects of an opioid, especially respiratory depression
pudendal nerve block
Injection of a local anesthetic at the pudendal nerve root to produce numbness of the genital and perianal region
spinal anesthesia (block)
Regional anesthesia induced by injection of a local anesthetic agent into the subarachnoid space at the level of the third, fourth, or fifth lumbar interspace
systemic analgesia
Pain relief induced when an analgesic is administered parenterally (e.g., subcutaneous [SC], intramuscular [IM], or intravenous [IV] route) and crosses the blood-brain barrier to provide central analgesic effects
• The way each woman perceives or interprets the pain of childbirth is influenced by physical, emotional, psychosocial, cultural, and environmental factors.
• The gate-control theory of pain helps explain how the pain-relief techniques taught in childbirth preparation classes work.
• Effective nonpharmacologic techniques for managing discomfort include focusing and relaxation, breathing techniques, and water therapy.
• Used together, pharmacologic and nonpharmacologic measures increase pain relief and create a more positive labor experience for the woman and her family.
• A woman who experiences a prolonged latent phase of labor and needs to decrease anxiety or promote sleep may be given a sedative.
• Analgesic drugs used for the pain of childbirth include opioid (narcotic) agonists and opioid (narcotic) agonist-antagonists.
• Opioid agonist analgesics relieve severe, persistent, or recurrent pain.
• In appropriate doses, opioid agonist-antagonist analgesics provide adequate analgesia without causing significant respiratory depression in the mother or neonate.
• Opioid agonist-antagonist analgesics are not suitable for women with an opioid dependence because the antagonist activity could precipitate withdrawal symptoms in both the mother and her newborn.
• Opioid antagonists, such as naloxone (Narcan), can reverse opioid effects, especially respiratory depression.
• The nurse must understand the expected effects, adverse reactions, and methods of administration of the drugs given to the mother.
• During spinal and epidural nerve blocks, the mother's fluid balance must be maintained.
• Using epidural anesthesia and analgesia is the most effective pharmacologic method for relieving the pain of labor. In the United States, it is the most commonly used method.
• General anesthesia is rarely used for vaginal birth but may be used for cesarean birth.
Critical Thinking/Clinical Decision Making

Laboring Without an Epidural
Jamie is a 16-year-old G1 P0 who has been admitted with severe preeclampsia (HELLP syndrome) at 34 weeks of gestation. Jamie's physician plans to induce labor and anticipates a vaginal birth. Jamie has not attended any childbirth preparation classes and has been planning to have an epidural for labor and birth. Unfortunately, because her platelet count is very low (28,000), the anesthesia care provider refuses to place an epidural block. Jamie bursts into tears and says, "I can't make it through labor without an epidural! It's going to hurt too much! Help me!!
1. Evidence—Is evidence sufficient to support the anesthesia care provider's decision to avoid epidural anesthesia for Jamie?
Yes. Jamie's platelet count of 28,000 is considered very low. Because of her thrombocytopenia Jamie is at risk for excessive bleeding if a blood vessel were to be damaged during insertion of the epidural catheter. Bleeding in the epidural space could cause the formation of a hematoma that might compress the cauda equina or the spinal cord and lead to serious CNS complications.
2. Assumptions—What assumptions can be made about the following methods for relieving pain during labor that would likely be available to Jamie?

a. Breathing and relaxation techniques
b. Application of heat and cold
c. Intradermal water block
d. Systemic analgesia
a. Breathing techniques provide distraction, thereby reducing the perception of pain and helping Jamie maintain control throughout contractions. In the first stage of labor, such breathing techniques can promote relaxation of the abdominal muscles and thereby increase the size of the abdominal cavity. This lessens discomfort generated by friction between the uterus and abdominal wall during contractions. Because the muscles of the genital area also become more relaxed, they do not interfere with fetal descent. Although Jamie has had no prior preparation, she can be given instruction in simple breathing and relaxation techniques early in labor and will likely find these techniques to be helpful.
b. Warmed blankets, warm compresses, heated rice bags, a warm bath or shower, or a moist heating pad can enhance relaxation and reduce pain during labor. Heat relieves muscle ischemia and increases blood flow to the area of discomfort. Cold application such as cool cloths or ice packs applied to the back, the chest, and/or the face during labor may be effective in increasing comfort when the woman feels warm. They may also be applied to areas of pain. Cooling relieves pain by reducing the muscle temperature and relieving muscle spasms. Heat and cold may be used alternately for a greater effect.
c. An intradermal water block involves the injection of small amounts of sterile water into four locations on the lower back to relieve back pain. It is simple to perform and is effective in early labor and in an effort to delay the initiation of pharmacologic pain relief measures. Relief of back pain for up to 2 hours has been reported. Effectiveness of this method is probably related to the mechanism of counterirritation.
d. Systemic analgesics cross the maternal blood-brain barrier to provide central analgesic effects. They also cross the placenta and are transferred to the fetus. Effects on the fetus and newborn can be profound (e.g., respiratory depression, decreased alertness, delayed sucking), depending on the characteristics of the specific systemic analgesic used, the dosage given, and the route and timing of administration. Intravenous (IV) administration is preferred to intramuscular (IM) administration because the medication's onset of action is faster and more predictable; as a result, a higher level of pain relief usually occurs with smaller doses. Ideally, birth should occur less than 1 hour or more than 4 hours after administration of systemic analgesia so that neonatal CNS depression is minimized.
3. What implications and priorities for nursing care can be drawn at this time?
The nurse's priority at this time is to do everything possible to keep Jamie comfortable during labor and assist her in achieving a satisfying birth experience, even though she will not be able to use her desired method of pain relief. Jamie can be informed that there are many methods for relieving pain in labor other than epidural anesthesia, and that we will keep trying until we find the methods that work best for her. Jamie's satisfaction with her labor and birth experience will be determined in large part by the quality of support and interaction she receives from her caregivers. Therefore, it is critical that the nurse, along with any support persons present, remains at the bedside to provide assistance in coping with each contraction. The nurse may need to try a variety of nonpharmacologic methods of pain relief in order to identify those that are most effective for Jamie.
4. Does the evidence objectively support your conclusion?
Yes. Many studies done over the years have shown that there are many nonpharmacologic methods available to effectively relieve labor pain.
5. Do alternative perspectives to your conclusion exist?
Yes. Although there are many nonpharmacologic methods that effectively relieve labor pain, epidural anesthesia and analgesia is the most effective pharmacologic pain relief method for labor that is currently available. As a result, it is the most commonly used method for relieving pain during labor in the United States, and its use has been increasing. Currently, nearly two thirds of American women giving birth choose epidural analgesia.
1. A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to:

A. Encourage the woman to breathe more slowly.
B. Help the woman breathe into a paper bag.
C. Turn the woman on her side.
D. Administer a sedative.
B. Help the woman breathe into a paper bag.

Just telling her to breathe more slowly does not ensure a change in respirations. The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her exhaled air would increase the carbon dioxide level. Turning her on her side would not solve this problem. The side-lying position would be appropriate for supine hypotension. Administration of a sedative could lead to neonatal respiratory depression because this woman, being in the transition phase, is nearing the birth process.
2. A woman in active labor receives an analgesic, an opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease?

A. Meperidine (Demerol)
B. Promethazine (Phenergan)
C. Butorphanol tartrate (Stadol)
D. Nalbuphine (Nubain)
A. Meperidine (Demerol)

Meperidine used to be the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Other medication options with fewer side effects are now available for use during labor. Promethazine is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Butorphanol tartrate is an opioid agonist-antagonist analgesic. Nalbuphine is an opioid agonist-antagonist analgesic.
3. A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use:

A. Counterpressure against the sacrum.
B. Pant-blow (breaths and puffs) breathing techniques.
C. Effleurage.
D. Conscious relaxation or guided imagery.
A. Counterpressure against the sacrum.

Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Breathing techniques are usually helpful during contractions because they provide distraction; they are not necessarily targeted at back pain. Effleurage is usually helpful for relieving pain from contractions per the gate-control theory. Conscious relaxation or guided imagery techniques are usually helpful during contractions because they provide the opportunity to focus on a more pleasant situation; they are not targeted specifically toward back pain.
4. Nurses should be aware of the differences experience can make in how labor pain is perceived, such as:

A. Sensory pain for nulliparous women often is greater than for multiparous women during early labor.
B. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor.
C. Women with a history of substance abuse experience more pain during labor.
D. Multiparous women have more fatigue from labor and therefore experience more pain.
A. Sensory pain for nulliparous women often is greater than for multiparous women during early labor.

Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous women during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.
5. With regard to breathing techniques used by a woman during labor, maternity nurses should be aware that:

A. Breathing techniques used in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.
B. By the time labor has begun, it is too late for instruction in breathing and relaxation.
C. Controlled breathing techniques are most difficult to adhere to near the end of the second stage of labor.
D. The patterned-paced breathing technique can help prevent hyperventilation.
A. Breathing techniques used in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.

First-stage breathing techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Providing instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult to adhere to in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation.
6. With regard to systemic analgesics administered during labor, nurses should be aware that:

A. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier.
B. Effects on the fetus and newborn can include decreased alertness and delayed sucking.
C. Intramuscular administration (IM) is preferred over intravenous (IV) administration.
D. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.
B. Effects on the fetus and newborn can include decreased alertness and delayed sucking.

Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. Effects depend on the specific drug given, the dosage, and the timing. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in decreased use of an analgesic.
7. With regard to spinal and epidural (block) anesthesia, nurses should know that:

A. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births.
B. A high incidence of after-birth headache is seen with spinal blocks.
C. Epidural blocks allow the woman to move freely.
D. Spinal and epidural blocks are never used together.
B. A high incidence of after-birth headache is seen with spinal blocks.

Spinal blocks may be used for vaginal births, but the woman must be assisted while she is in labor. A high incidence of after-birth headache can occur; headaches may be prevented or mitigated to some degree by a number of methods. Epidural blocks limit the woman's ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.
8. Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the patient's blood pressure if hypotension occurs? Choose all that apply.

A. Place the woman in a supine position.
B. Place the woman in a lateral position.
C. Increase intravenous (IV) fluids.
D. Administer oxygen.
E. Perform a vaginal examination.
B. Place the woman in a lateral position.
C. Increase intravenous (IV) fluids.
D. Administer oxygen.

Placing the woman in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman's legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are stable. A sterile vaginal examination has no bearing on maternal blood pressure.
Chapter 13: Maternal Physiologic Changes
afterpains (afterbirth pains)
Painful uterine cramps that occur intermittently for approximately 2 or 3 days after birth and that result from contractile efforts of the uterus to return to its normal involuted condition
The self-destruction of excess hypertrophied tissue
diastasis recti abdominis
Separation of the two rectus muscles along the median line of the abdominal wall
Return of the uterus to a nonpregnant state after birth
Vaginal discharge during the puerperium consisting of blood, tissue, and mucus
lochia alba
Thin, yellowish to white, vaginal discharge that follows lochia serosa on approximately the tenth day after birth and that may last from 2 to 6 weeks postpartum
lochia rubra
Red, distinctly blood-tinged vaginal flow that follows birth and lasts 2 to 4 days
lochia serosa
Serous, pinkish brown, watery vaginal discharge that follows lochia rubra until approximately the tenth day after birth
pelvic relaxation
Lengthening and weakening of the fascial supports of pelvic structures
Period between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state; fourth trimester of pregnancy
Failure of the uterus to reduce to its normal size and condition after pregnancy
• The time between birth and the return of the reproductive organs to their nonpregnant state is called the postpartum period, the puerperium, or the fourth trimester of pregnancy.
• Involution, the process of returning the uterus to its nonpregnant state, begins immediately after placental expulsion.
• The most common causes of subinvolution, the failure of the uterus to return to a nonpregnant state, are retained placental fragments and infection.
• During the first 2 hours after birth, the amount of uterine discharge, called lochia, should be similar to the amount during a heavy menstrual period.
• After placental expulsion, estrogen and progesterone levels decrease dramatically, triggering anatomic and physiologic changes.
• In women who breastfeed, ovulation may be delayed for a long period of time.
• After childbirth, total blood volume declines by about 16%, resulting in transient anemia.
• Vessel damage, immobility, and elevated levels of coagulation factors during the immediate postpartum period predispose the woman to thromboembolism, especially after a cesarean birth.
• Normally, few changes in vital signs occur after birth.
• Kidney function returns to normal within 1 month after birth.
• Pregnancy-induced hypervolemia allows most women to tolerate considerable blood loss during childbirth.
Critical Thinking/Clinical Decision Making
Assessment of Postpartum Bleeding

You are the nurse assigned to care for Margarita, a G9 P9 who gave birth vaginally 1 hour ago to twins. Twin A weighed 7 pounds, 4 ounces, and Twin B weighed 6 pounds, 12 ounces. Margarita did not have an episiotomy and sustained no lacerations requiring repair. You are at the nurse's station when Margarita calls and asks for her nurse to "come quick!" When you arrive in her room, you find Margarita lying in a puddle of blood. The disposable pad underneath her, as well as Margarita's perineal pad, are completely soaked with blood.
1. What other immediate assessment is necessary to determine the cause and management of Margarita's excessive bleeding?
The most likely cause of Margarita's excessive bleeding is uterine atony. Therefore, the nurse's first assessment is to palpate Margarita's uterus. If the uterine fundus initially feels boggy rather than firm and well-contracted, uterine atony is confirmed as the probable cause of the excessive bleeding.
2. What assumptions can be made about the following issues:
a. Normal amount of lochia expected at this time (1 hour after birth)
b. Margarita's risk factors for uterine atony
c. Immediate nursing interventions for Margarita
d. Other possible causes for Margarita's excessive bleeding
a. For the first 2 hours after birth, the amount of lochial flow should be approximately that of a heavy menstrual period. If Maria is lying in a puddle of blood and both the disposable pad underneath her and her perineal pad are completely soaked, she is obviously bleeding excessively.
b. Margarita has at least two risk factors for uterine atony. She is a grand multipara (G9 P9). She has also given birth to twins whose combined birthweight is 14 pounds.
c. Once uterine atony is confirmed, the nurse should continue to massage Margarita's fundus until it feels firm, like a hard ball. If an IV is already in place, the rate should be increased to provide additional volume. The intravenous fluid should contain oxytocin to further encourage uterine contraction. Next, vital signs should be obtained, especially blood pressure and heart rate. While obtaining vital signs, the nurse will also assess Margarita's skin temperature and mental status.
d. Other possible causes for Margarita's excessive bleeding include retained placental fragments or membranes or undiscovered, and thus unrepaired, genital tract lacerations.
3. Using the situation-background-assessment-recommendation (SBAR) technique, how would you report to Margarita's health care provider about her current status?
S: Margarita H., in Room 312, has excessive vaginal bleeding. Her underpad and perineal pad are both completely soaked, and she is lying in a puddle of blood.
B: Margarita is a G9 P9. She gave birth vaginally 1 hour ago to twins with a combined birthweight of 14 pounds. Margarita did not have an episiotomy and sustained no lacerations requiring repair.
A: Margarita's uterus was initially boggy to palpation, but firmed after fundal massage. Her bleeding has now decreased. Her most recent vital signs are BP 110/50, pulse 100, rate 22, temp 36.8° C. Her skin feels cool and dry. She is alert and oriented. An intravenous infusion of 500 ml D5LR with 30 units of oxytocin added is currently running at 50 ml per hour. I have just changed her underpad and perineal pad.
R: Please come ASAP to evaluate this patient for other sources of bleeding. In the meantime, do you want her to receive any other medications? Do you want to order a stat hematocrit or hemoglobin?
4. Does the evidence objectively support your conclusion?
Yes. Margarita's excessive bleeding was likely the result of uterine atony, probably caused by the huge expansion of her uterus necessary for her to give birth to two normal-sized term babies. Also, because Margarita is a grand multipara, her uterus will most likely not contract postpartum as well as it would if she had only given birth once or twice before.
5. Do alternative perspectives to your conclusion exist?
Uterine atony is the most likely cause of Margarita's excessive bleeding. However, other possible causes of postpartum hemorrhage such as retained placental fragments or membranes or unrepaired genital tract lacerations need to be ruled out.
1. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1 day postpartum. An expected finding would be:

A. Presence of soft, nontender colostrum.
B. Leakage of milk at let-down
C. Swollen, warm, and tender on palpation.
D. A few blisters and a bruise on each areola.
A. Presence of soft, nontender colostrum.

Breasts are essentially unchanged for the first 2 to 3 days after birth. Colostrum is present and may leak from the nipples.
Leakage of milk occurs around day 2 or 3. Engorgement occurs at day 2 or 3 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used.
2. A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:

A. Urinary tract infection.
B. Excessive uterine bleeding.
C. A ruptured bladder.
D. Bladder wall atony.
B. Excessive uterine bleeding.

A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.
3. Which statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth?

A. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter."
B. "My first menstrual cycle will be heavier than normal, and my period will return to my prepregnant volume within three or four cycles."
C. "I will not have a menstrual cycle for 6 months after childbirth."
D. "My first menstrual cycle will be heavier than normal and then will be light for several months after."
B. "My first menstrual cycle will be heavier than normal, and my period will return to my prepregnant volume within three or four cycles."

She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles. Saying the first menstrual cycle will be heavier than normal and the subsequent three or four cycles will return to prepregnant volume is an accurate statement and indicates her understanding of her expected menstrual activity. Most women experience a heavier than normal flow during the first menstrual cycle, which occurs by 3 months after childbirth. She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.
4. Which description of postpartum restoration or healing times is accurate?

A. The cervix shortens, becomes firm, and returns to form within a month postpartum.
B. The vagina gradually returns to prepregnancy size by 6 to 10 weeks after childbirth.
C. Most episiotomies heal within a week.
D. Hemorrhoids usually decrease in size within 2 weeks of childbirth.
B. The vagina gradually returns to prepregnancy size by 6 to 10 weeks after childbirth.

The cervix regains its form within days; the cervical os may take longer to return to form. The vagina returns to prepregnancy size by 6 to 10 weeks; however, lubrication may take longer to return to prepregnancy level. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.
5. The breasts of a bottle-feeding woman are engorged. The nurse should tell her to:

A. Wear a snug, supportive bra.
B. Allow warm water to soothe the breasts during a shower.
C. Express milk from breasts occasionally to relieve discomfort.
D. Place absorbent pads with plastic liners into her bra to absorb leakage.
A. Wear a snug, supportive bra.

A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners keep the nipples and areola moist, leading to excoriation and cracking.
6. With regard to afterbirth pains, nurses should be aware that these pains are:

A. Caused by mild, continuous contractions for the duration of the postpartum period.
B. More common in first-time mothers.
C. More noticeable in births in which the uterus was overdistended.
D. Alleviated somewhat when the mother breastfeeds.
C. More noticeable in births in which the uterus was overdistended.

The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations, which persist throughout the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. A large baby or multiple babies overdistend the uterus and this accounts for afterbirth pains. Breastfeeding intensifies afterbirth pain because it stimulates contractions.
7. Postbirth uterine/vaginal discharge, called lochia:

A. Is similar to a light menstrual period for the first 6 to 12 hours.
B. Is usually greater after cesarean births.
C. Will usually decrease with ambulation and breastfeeding.
D. Should smell like normal menstrual flow unless an infection is present.
D. Should smell like normal menstrual flow unless an infection is present.

Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births. Lochia usually increases with ambulation and breastfeeding. An offensive odor usually indicates an infection.
8. Although all other joints return to their normal prepregnancy state, those in the parous woman's feet do not. The new mother may notice a permanent increase in her shoe size. True or False?
9. Changes in the maternal immune system during the postpartum period account for the profuse diaphoresis that new mothers experience. True or False?
Chapter 14: Nursing Care of the Family during the Fourth Trimester
couplet care
One nurse, educated in both maternal and newborn care, functions as the primary nurse for both mother and neonate (also known as mother-baby care or single-room maternity care)
Swelling of the breast tissue brought about by an increase in blood and lymph supplied to the breast, occurring as early milk (colostrum) transitions to mature milk, at approximately 72 to 96 hours after birth
uterine atony
Relaxation of uterine muscle possibly leading to excessive postpartum bleeding and postpartum hemorrhage
warm line
A help line, or consultation service, for families to access, most often for support of newborn care and postpartum care after hospital discharge
• Postpartum care is family-centered.
• Nursing care in the early postpartum period includes helping the mother rest and recover, assessing her physiologic and psychologic adaptation, preventing complications, teaching self-care and infant care, and supporting the mother and her partner as they make the transition to parenthood.
• The nurse starts preparing the new mother for discharge at their first postpartum contact.
• The care plan includes periodic assessments to detect deviations from normal physical changes, measures to relieve discomfort, and safety measures to prevent injury and infection.
• In the postpartum period, nursing interventions include preventing excessive bleeding, bladder distention, and infection; relieving pain and discomfort; and promoting or suppressing lactation.
• The most important interventions for preventing excessive bleeding are maintaining good uterine tone and preventing bladder distention.
• Common causes of discomfort include pain from uterine contractions (afterpains), perineal lacerations, episiotomy, hemorrhoids, sore nipples, and breast engorgement.
• Early ambulation is associated with a reduced incidence of venous thromboembolism.
• The mother should void spontaneously within 6 to 8 hours after giving birth.
• To help meet the psychosocial needs of a new mother, the nurse assesses the parents' reactions to the birth experience, feelings about themselves, and interactions with the baby and other family members.
• A woman's cultural background strongly influences her behavior during the postpartum period.
• After uncomplicated vaginal births, women are commonly scheduled for a 6-week postpartum follow-up examination.
• Early discharge classes, telephone follow-up, home visits, warm lines, and support groups can facilitate physiologic and psychologic adjustments in the postpartum period.
Critical Thinking/Clinical Decision Making
Cultural Influences during the Postpartum Period

Mingyu is a 29 year old from China who gave birth to her first child last evening. Her husband is completing postdoctoral study at the local university. Both Mingyu and her husband speak some English, although he is more fluent than she is. Her mother and father have come from China to be with her for 3 months. When the nurse enters the room, she notices immediately that the room temperature is rather warm and Mingyu is lying in bed with several layers of covers pulled up to her neck. She also has a blanket around her head. She has eaten nothing from the breakfast tray. The nursing assistant had reported that Mingyu refused to shower this morning. Although Mingyu's chart indicates that she intends to breastfeed, she requests formula for her baby.
1. Evidence—Is evidence sufficient to draw conclusions about the cultural beliefs of Asians as they relate to the postpartum period and breastfeeding?
Yes. Potential sources of information include journal articles, books, and interviews with women who are members of that cultural group. Information regarding how traditional Asian beliefs may be adapted by women who immigrate to other countries is also available from these sources.
2. Assumptions—What assumptions can be made about the following issues?
a. Culturally appropriate diet, activity, and hygiene for the postpartum Asian woman
b. Providing appropriate care for the newborn, including breastfeeding, in the Asian culture
c. Role of other family members and friends in providing care to the postpartum woman and newborn
d. Difficulty in establishing lactation if breastfeeding is not begun immediately
a. In the postpartum period, Asian women are concerned with maintaining balance between hot and cold within the body and in the environment. Blood is considered "hot," so when blood is lost through childbirth, she is considered to be in a "cold" state. A major focus in the postpartum period is keeping the new mother warm. Asian women typically prefer warm foods and hot drinks after giving birth and refuse anything cold. Warm food and drinks help to restore balance in the woman's body by facilitating the return of the "hot" state. The environmental temperature is kept warm; even in summer, the air conditioning is turned off and windows are closed. The postpartum woman is expected to stay in bed to prevent cold air from entering her body. Baths, showers, or washing hair are not permitted. During the 30-day confinement period after birth, the new mother is not to be walking about and cannot leave her home. She is expected to take a passive role. Household tasks are done by female relatives or live-in helpers.
b. Because of the prevalent belief among Asians that the mother should rest and remain in bed to protect herself immediately after childbirth, routine baby care is usually provided by another female. In several cultures, including Asian cultures, colostrum is viewed as unnecessary and unhealthy for newborns. Breastfeeding is begun only several days after birth, when the "true milk" has come in. Before that time, babies may be fed prelacteal food. Asian parents often request infant formula for their infant while they are in the hospital.
c. In many cultures, female family members and friends play an essential role in providing care for the new mother and baby immediately after birth. In the Asian culture, new mothers observe specific diet and activity restrictions for several weeks. Following these traditional cultural practices in a different country may prove to be extremely difficult if family members or friends are not available. In the home country, males are often not expected to assist in caring for new mothers and babies. Even if a woman's husband is willing to do so, he may need much instruction and encouragement to provide even minimal care for his wife and baby.
d. Women are routinely taught that the ideal time to initiate breastfeeding is within the first hour after birth. During this time the baby is usually in the quiet alert state. However, women from cultures that wait hours or days to initiate breastfeeding are able to do so successfully.
3. What implications and priorities for nursing care can be drawn at this time?
The priority for nursing care at this time is to assist Mingyu in recovering from childbirth in a way that is congruent with her cultural beliefs. Every effort should be made to determine Mingyu's preferences with regard to diet, activity, and hygiene, and to honor them as much as possible. Although Mingyu's beliefs may seem unusual, they should be encouraged as long as she wants to conform to them and she and the baby suffer no ill effects. Culturally appropriate accommodations that can be made for Mingyu on the postpartum unit include providing a sponge bath if desired, offering only warm food and drink, and encouraging family members or friends to bring in especially desired foods if the hospital's dietary department is unable to provide them. If Mingyu desires, family members or friends can be encouraged to stay with her as much as possible to assist with her care and the baby's care.

Breastfeeding will also need to be addressed with Mingyu. A good way to determine the information Mingyu needs is to discover why she prefers to feed her baby infant formula. Discussing the benefits of colostrum for newborns may cause Mingyu to change her mind about delaying breastfeeding. Asian women may decide to breastfeed and offer formula as a supplement after breastfeeding. It is helpful for the nurse or lactation consultant to observe a breastfeeding session to identify any potential issues.
4. Does the evidence objectively support your conclusion?
There is a significant amount of information available concerning culturally appropriate care during the postpartum period for Asian women. Women who receive culturally appropriate care during this time will likely be more satisfied with their care. They will also be better able to assume care for themselves and their babies in the future if their early needs for passive nurturing are met.
5. Do alternative perspectives to your conclusion exist?
Not all women belonging to a particular cultural group will desire to use the traditional health practices that represent that group. Many young women who are first- or second-generation Americans follow their cultural traditions only when older family members are present or not at all. Adherents to the "melting pot" theory of acculturation in the United States would assert that women, regardless of their cultural heritage, should "act like Americans" if they live in America.
Critical Thinking/Clinical Decision Making
Weight Loss after Birth

Wendy, a primipara, is postpartum 3 days after giving birth by cesarean to a 9-pound son. She has had an uncomplicated recovery thus far, and breastfeeding is going well. During a discharge teaching session, Wendy expresses concern to the nurse about regaining her figure after childbirth and states that she is worried that she cannot fit into her business clothes when she returns to her job as an administrative assistant in 6 weeks. Before pregnancy, her weight was appropriate for her height. However, during pregnancy, she gained 46 pounds.
1. Evidence—Is evidence sufficient to draw conclusions about counseling women with regard to regaining their nonpregnant appearance?
Yes. Normal weight gain during pregnancy is approximately 25 pounds. Because Wendy gained almost twice that much weight during her pregnancy, she will need to make changes in her diet and exercise regularly in order to reach her prepregnant weight. There are multiple sources of information about diet and exercise during the postpartum period, including health care professionals, dietitians, web sites, television programs, and magazines available to Wendy. Although making changes in her diet and exercise regimen will not be easy, with determination and persistence Wendy can certainly succeed at regaining her prepregnant appearance.
2. Assumptions—What assumptions can be made about the following issues?
a. Appropriate diet for the postpartum mother who wants to improve her appearance
b. The relationship between breastfeeding and postpartum weight loss
c. Exercises for the postpartum woman who wants to improve her appearance
d. The relationship between perceived body image and self-esteem in postpartum women
a. The postpartum woman will lose weight gradually if she consumes a balanced diet that provides slightly fewer calories than her daily energy expenditure. Most women rapidly lose several pounds during the month after birth. Because fat is the most concentrated source of calories in the diet, the first step in weight reduction is to identify sources of fat in the diet and explore ways to reduce them.
b. In general, the breastfeeding mother should eat a healthy, well-balanced diet that includes an extra 200 to 500 calories per day over nonpregnant requirements. According to the Institute of Medicine (IOM) (2005), the estimated energy requirement (EER) for a lactating woman during the first 6 months is 2700 kcal/day; during the next 6 months, the EER is 2768 kcal/day. Even with the increased caloric intake, women who are breastfeeding tend to lose weight more quickly than those who are formula feeding (Becker & Scott, 2008). Rapid weight reduction while breastfeeding may result in decreased milk supply; it is best to lose weight gradually while consuming a nutritious, well-balanced diet.
c. Women can begin exercising soon after birth, although they are encouraged to begin with simple exercises and gradually progress to more strenuous ones. Because Wendy has had a cesarean birth, she should not be doing any strenuous exercise for at least 4 to 6 weeks and has been cleared by her health care provider. The nurse might recommend walking as a beneficial form of exercise for Wendy during the next few weeks.
d. A woman's self-esteem is often related to her perceived body image. How a new mother feels about herself and her body may affect her behavior and adaptation to parenting.
3. What implications and priorities for nursing care can be drawn at this time?
Priority for nursing care at this time is to educate Wendy regarding a weight reduction diet for a breastfeeding woman and a sensible exercise plan for a postpartum cesarean mother. She should be encouraged to follow the same balanced diet recommended during pregnancy and urged to avoid overly strict dieting. In addition, Wendy can be encouraged to eliminate "empty" calories, such as sugar-sweetened drinks, desserts, and chips from her diet. She will likely be surprised and pleased to learn that she will burn about 500 calories per day through milk production. Wendy's individual dietary preferences should also be considered. It is important to inform Wendy that dieting can cause her milk supply to decrease; she should monitor the baby's intake and output to see whether the infant is receiving adequate nutrition. If her milk production is declining, she may need to add more calories to her diet.

Wendy can be encouraged to begin simple nonstrenuous exercises after discharge, waiting to begin more strenuous exercises until she sees the health care provider at her 6-week follow-up visit. Taking the baby for a walk each day would provide both an opportunity for exercise and help in regaining a normal routine.

In terms of body image and self-esteem, if Wendy voiced concerns about feeling unable to cope, having no support, or perceiving that things are now very different and will "never return to normal," a referral for more extensive evaluation and counseling would be warranted.
4. Does the evidence objectively support your conclusion?
There is a significant amount of information available concerning diet and exercise for the postpartum woman who is breastfeeding. Data regarding self-esteem in new mothers also exist.
5. Do alternative perspectives to your conclusion exist?
Most postpartum women are eager to regain their nonpregnant figures quickly. It can be discouraging when diet and exercise efforts fail to produce the desired results immediately.
1. When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:

A. Massage the fundus.
B. Administer Methergine, 0.2 mg PO, that has been ordered prn.
C. Assist the woman to empty her bladder
D. Recognize this as an expected finding during the first 24 hours following birth
C. Assist the woman to empty her bladder

A firm fundus should not be massaged because massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case because it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. A Firm fundus that is 2 fingerbreadths above the umbilicus and deviated to the left of midline is not a normal finding, and an action is required.
2. Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum?

A. Postural hypotension
B. Temperature of 100.4° F
C. Bradycardia—pulse rate of 55 beats/min
D. Pain in left calf with dorsiflexion of left foot
D. Pain in left calf with dorsiflexion of left foot

Postural hypotension is an expected finding related to circulatory changes after birth. A temperature of 100.4° F in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. Findings of pain in the left calf with dorsiflexion of the left foot indicate a positive Homan's sign and are suggestive of thrombophlebitis and should be investigated.
3. The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to:

A. Place her on a bedpan to empty her bladder.
B. Massage her fundus.
C. Call the physician.
D. Administer Methergine, 0.2 mg IM, which has been ordered prn.
B. Massage her fundus.

There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.
4. Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman:

A. Uses soap and warm water to wash the vulva and perineum.
B. Washes from symphysis pubis back to episiotomy.
C. Changes her perineal pad every 2 to 3 hours.
D. Uses the peribottle to rinse upward into her vagina.
D. Uses the peribottle to rinse upward into her vagina.

Washing the vulva and perineum with soap and water is an appropriate measure. Washing from symphysis pubis back toward episiotomy is an appropriate measure. Changing the perineal pad every 2 to 3 hours in an appropriate measure. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix.
5. Which measure would be least effective in preventing postpartum hemorrhage?

A. Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered.
B. Encourage the woman to void every 2 hours.
C. Massage the fundus every hour for the first 24 hours following birth.
D. Teach the woman the importance of rest and nutrition to enhance healing.
C. Massage the fundus every hour for the first 24 hours following birth.

Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage.
6. While admitting the pregnant woman, the nurse should be aware that postpartum hospital stays that are becoming shorter are primarily the result of the influence of:

A. Health maintenance organizations (HMOs) and private insurers.
B. Consumer demand.
C. Hospitals.
D. The federal government.
A. Health maintenance organizations (HMOs) and private insurers.

The trend for shortened hospital stays is based largely on efforts to reduce health care costs. Secondarily consumers have demanded less medical intervention and more family-centered experiences. Hospitals are obligated to follow standards of care and federal statutes regarding discharge policies. The Newborns' and Mothers' Health Protection Act provided minimum federal standards for health plan coverage for mothers and their newborns. Under this act, couples were allowed to stay in the hospital for longer periods.
7. Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins:

A. At the time of admission to the nurse's unit.
B. When the infant is presented to the mother at birth.
C. During the first visit with the physician in the unit.
D. When the take-home information packet is given to the couple.
A. At the time of admission to the nurse's unit.

Discharge planning, the teaching of maternal and newborn care, begins on the woman's admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.
8. The __________ test is used to detect the amount of fetal blood in the maternal circulation.

If more than 15 ml of fetal blood is present in maternal circulation, the dose of Rh immune globulin must be increased.
Chapter 16: Physiologic and Behavioral Adaptations of the Newborn
Peripheral cyanosis; blue color of hands and feet in most infants at birth that may persist for 7 to 10 days
brown fat
Source of heat unique to neonates that is capable of greater thermogenic activity than ordinary fat; deposits are found around the adrenals, kidneys, and neck; between the scapulae; and behind the sternum for several weeks after birth
caput succedaneum
Swelling of the tissue over the presenting part of the fetal head caused by pressure during labor
Extravasation of blood from ruptured vessels between a skull bone and its external covering, the periosteum; swelling is limited by the margins of the cranial bone affected (usually parietals)
cold stress
Excessive loss of heat that results in increased respirations and nonshivering thermogenesis to maintain core body temperature
erythema toxicum
Innocuous pink papular neonatal rash of unknown cause, with superimposed vesicles appearing within 24 to 48 hours after birth and resolving spontaneously within a few days
Psychologic and physiologic phenomenon whereby the response to a constant or repetitive stimulus is decreased
Yellow color of skin due to increased level of bilirubin in body tissues
Greenish black, viscous first stool formed during fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin), and cells (shed from the mucosa)
Small, white sebaceous glands, appearing as tiny, white, pinpoint papules on the forehead, nose, cheeks, and chin of the neonate
mongolian spots
Bluish gray or dark nonelevated pigmented areas usually found over the lower back and buttocks that are present at birth in some infants, primarily nonwhite, usually fading by school age
sleep-wake states
Variation in states of newborn consciousness from deep sleep to extreme irritability
Phosphoprotein necessary for normal respiratory function that prevents alveolar collapse (atelectasis)
Creation or production of heat, especially in the body
Control of temperature; a balance between heat loss and heat production
transition period
Period from birth to 4 to 6 hours later in which the infant passes through a period of reactivity, sleep, and a second period of reactivity
vernix caseosa
Protective gray-white fatty substance of cheesy consistency covering the fetal skin
• At birth, a full-term infant's anatomic and physiologic systems allow extrauterine life.
• During the first 6 to 8 hours after birth, newborns go through a transition period between intrauterine and extrauterine life.
• The most critical adjustment a newborn makes at birth is establishing respirations.
• Signs of respiratory distress include nasal flaring, intercostal or subcostal retractions, and grunting with respirations.
• The cardiovascular system changes significantly after birth.
• The newborn's average systolic blood pressure is 60 to 80 millimeters of mercury (mm Hg); the average diastolic pressure is 40 to 50 mm Hg.
• In the healthy term newborn, heat loss may exceed the capacity to produce heat, leading to metabolic and respiratory complications.
• In the newborn, heat loss results from convection, radiation, evaporation, and conduction.
• At birth, the lower intestine is filled with meconium, which is formed from amniotic fluid and its constituents, intestinal secretions including bilirubin, and cells shed from the mucosa.
• At birth, a protective covering, called vernix caseosa, is fused with the epidermis.
• During the first year of life, the infant's skeletal system undergoes rapid development.
• Within 24 hours of birth, the newborn undergoes a complete physical examination.
• Baseline measurements include weight, head circumference, and body length.
• A healthy infant must accomplish behavioral and biologic tasks to develop normally.
• Sleep-wake states and other factors influence the newborn's behavior.
• From birth, infants have sensory capabilities that indicate a state of readiness for social interaction.
• Habituation is a protective mechanism that allows the infant to become accustomed to environmental stimuli.
Critical Thinking/Clinical Decision Making
Near Term Infant with Physiologic Jaundice

Veronica gave birth vaginally with the assistance of vacuum extraction to a 7-lb baby boy 36 hours ago. The baby was estimated to be at 35 to 36 weeks of gestation. As a result of the vacuum extraction the baby's occiput is bruised and slightly edematous (his condition appeared much worse yesterday). For the first 24 hours, he was very sleepy and difficult to arouse for feedings, but for the last 12 hours, he has breastfed every 2 to 3 hours for approximately 15 minutes. He has voided twice and passed only one small meconium stool since birth. Randy was holding his baby this morning and stated, "Look at his handsome skin tones! Why, he looks like he has been on vacation and started to get his suntan."
1. Evidence—Is evidence sufficient to draw conclusions about the baby's skin color?
The nurse can assess the newborn for the presence of jaundice by blanching the skin over the baby's forehead, chest, abdomen, and legs. At this point, the baby is over 24 hours of age and would likely be experiencing physiologic jaundice.
2. Assumptions—What assumptions can be made about the following?
a. The baby's skin color
b. Baby's intake and output since birth
c. The parents' understanding of physiologic jaundice
a. At 36 hours of age, the newborn is likely exhibiting physiologic jaundice. He is at risk for development of physiologic jaundice because of the bruising of his head and because he is preterm.
b. The baby has not been feeding well thus far and has had only one stool. Because bilirubin is excreted primarily through the stool, it is important that his bowel movements increase. Because he is preterm, he may be more difficult to awaken for feedings than a full-term infant. The more he feeds, the greater his output will be.
c. Randy noted the appearance of his son's skin color as evidenced by his comment. The nurse can explain why the baby appears somewhat "yellow" and describe physiologic jaundice in terms that the parents can understand.
3. What implications and priorities for nursing care can be drawn at this time?
The infant's level of jaundice should be assessed and the health care provider notified. The nurse may be able to determine a transcutaneous measurement of hyperbilirubinemia if equipment is available. The health care provider may order a serum bilirubin measurement to establish a baseline and reassess bilirubin levels periodically to determine whether hyperbilirubinemia is increasing. It is important to closely monitor the infant and to intervene to prevent the development of kernicterus.

Feeding is important because it promotes excretion of excess bilirubin. The parents may need to be encouraged to awaken the baby for feedings, and breastfeeding should be observed to determine the mother's ability to feed and to assess for milk transfer. Assistance is given as needed. The baby's output is closely monitored; parents may be instructed to keep a log of feedings, urination, and stooling.

The parents will likely need some explanation about physiologic jaundice. First, the nurse will assess their knowledge and proceed to provide needed information. They are encouraged to ask questions of the nurse and the health care provider.
4. Does the evidence objectively support your conclusion?
If bilirubin levels are measured, there may be evidence to support the conclusion that the baby is experiencing physiologic jaundice. If this is the case, the baby will appear more jaundiced over the next 2 or 3 days.
5. Do alternative perspectives to your conclusion exist?
Jaundice could also be caused by blood incompatibilities or liver anomalies; however, this type of jaundice is considered pathologic and usually appears within the first 24 hours of life.
1. What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge?

A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active
B. Acrocyanosis
C. Harlequin color sign
D. Weight loss representing 5% of the newborn's birth weight
A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active

The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn.
2. When caring for a newborn, the nurse must be alert for signs of cold stress, including:

A. Decreased activity level.
B. Increased respiratory rate.
C. Hyperglycemia.
D. Shivering.
B. Increased respiratory rate.

Infants experiencing cold stress would have an increased activity level. An increased respiratory rate is a sign of cold stress in the newborn. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.
3. The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by:

A. Telling the mother not to worry because all breastfed babies have this type of stool.
B. Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements.
C. Asking the mother what she ate at her last meal.
D. Suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.
B. Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements.

This thick dark stool, known as meconium, is typical of the first stool of all newborns, not just breastfed babies. At this early age, this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. The mother's nutritional intake is not responsible for the appearance of meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.
4. When weighing a newborn, the nurse should:

A. Leave its diaper on for comfort.
B. Place a sterile scale paper on the scale for infection control.
C. Keep a hand on the newborn's abdomen for safety.
D. Weigh the newborn at the same time each day for accuracy.
D. Weigh the newborn at the same time each day for accuracy.

The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above, not on, the abdomen for safety. Weighing a newborn at the same time each day allows for accurate weights.
5. Vitamin K is given to the newborn to:

A. Reduce bilirubin levels.
B. Increase the production of red blood cells.
C. Enhance ability of blood to clot.
D. Stimulate the formation of surfactant.
C. Enhance ability of blood to clot.

Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K is required for the production of certain clotting factors. Vitamin K does not stimulate the formation of surfactant.
6. The nurse notes that, when the newborn is placed on the scale, he immediately abducts and extends his arms and his fingers fan out with the thumb and forefinger forming a "C." This response is known as a:

A. Tonic neck reflex.
B. Moro reflex.
C. Cremasteric reflex.
D. Babinski reflex.
B. Moro reflex.

Tonic neck reflex refers to the "fencing posture" a newborn assumes when he is supine and turns his head to the side. These actions show the Moro reflex. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.
7. A newborn male, estimated to be 39 weeks of gestation, would exhibit:

A. Extended posture when at rest.
B. Testes descended into scrotum.
C. Abundant lanugo over his entire body.
D. Ability to move his elbow past his sternum.
B. Testes descended into scrotum.

The newborn's good muscle tone will result in a more flexed posture when at rest. A full-term male infant will have both testes in his scrotum and rugae on his scrotum. The newborn will exhibit only a moderate amount of lanugo, usually on his shoulders and back. The newborn would not have the ability to move his elbow past midline.
8. While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a click sound when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has:

A. Polydactyly.
B. Clubfoot.
C. Hip dysplasia.
D. Webbing
C. Hip dysplasia.

Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. The Ortolani maneuver is used to detect the presence of hip dysplasia. Webbing, or syndactyly, is a fusing of the fingers or toes.
9. A patient feels too warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is:

A. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him."
B. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him."
C. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him."
D. "Your baby will get cold stressed easily and needs to be bundled up at all times."
A. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him."

Saying the baby will lose heat by convection is an accurate statement. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is loss of heat that occurs when a liquid is converted into a vapor. In the newborn, heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss, but this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infant's temperature.
10. All of these statements describe the first phase of the transition period except:

A. It lasts no longer than 30 minutes.
B. It is marked by spontaneous tremors, crying, and head movements.
C. It includes the passage of meconium.
D. It may involve the infant suddenly sleeping briefly.
D. It may involve the infant suddenly sleeping

The first phase is the shortest, lasting less than 30 minutes. Spontaneous tremors, crying, head movements, and also spontaneous startle reactions are expected exploratory behaviors in the first phase. In the first phase, in addition to passing meconium, the newborn also produces saliva. The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase.
11. The shivering mechanism of heat production is rarely functioning in the newborn. Nonshivering __________ is accomplished primarily by metabolism of brown fat, which is unique to the newborn, and by increased metabolic activity in the brain, heart, and liver.

Hypothermia from excessive heat loss is a common and dangerous problem in neonates. The newborn infant's ability to produce heat (thermogenesis) often approaches that of the adult; however, the tendency toward rapid heat loss in a cold environment is increased in the newborn and poses a hazard.
Chapter 17: Assessment and Care of the Newborn and Family
Apgar score
Numeric expression of the condition of a newborn obtained by rapid assessment at 1 and 5 minutes of age; developed by Dr. Virginia Apgar
Excision of the prepuce (foreskin) of the penis, exposing the glans
Elevation of unconjugated serum bilirubin concentrations
Temperature that falls below the normal range, that is, below 35° C, usually caused by exposure to cold
Pathologic process characterized by deposition of bilirubin in the brain
late preterm infant
Infants born at 34-0/7 to 36-6/7 weeks of gestation
ophthalmia neonatorum
Infection in the neonate's eyes usually resulting from gonorrheal, chlamydial, or other infection contracted when the fetus passes through the birth canal (vagina)
Use of lights to reduce serum bilirubin levels by oxidation of bilirubin into water-soluble compounds that are processed in the liver and excreted in bile and urine
physiologic jaundice
Yellow tinge to skin and mucous membranes in response to increased serum levels of unconjugated bilirubin; not usually apparent until after 24 hours; also called neonatal jaundice, physiologic hyperbilirubinemia
• Immediately after birth, the nurse focuses on assessing and stabilizing the newborn's condition, while the physician or midwife focuses on care of the mother.
• The immediate assessment includes Apgar scoring and a general evaluation of physical status.
• The Apgar score is based the nurse's assessment of the neonate's heart rate, respiratory rate, muscle tone, reflex irritability, and skin color.
• The initial physical assessment includes a brief review of systems.
• Immediately after birth, nursing care includes maintaining an open airway, preventing heat loss, instilling a prophylactic agent into the eyes, administering vitamin K intramuscularly, providing umbilical cord care, and promoting parent-infant interaction.
• Gestational age and birth weight are related to perinatal morbidity and mortality rates.
• A complete physical examination is performed within 24 hours of birth.
• Common problems in neonates include soft tissue injuries, skeletal injuries, physiologic jaundice, hypoglycemia, and hypocalcemia.
• Common tests for neonates include newborn screening tests and measurements of blood glucose, bilirubin, and drug serum levels.
• Ensuring a protective environment for the neonate includes following identification procedures and taking precautions to prevent infection.
• During phototherapy, the unclothed infant is placed under a bank of lights.
• Suggested benefits of circumcision include a decreased incidence of urinary tract infection and decreased risks of sexually transmitted infection, penile cancer, and human papillomavirus infection.
• The goals of neonatal pain management are to minimize the intensity, duration, and physiologic cost of the pain and to maximize the neonate's ability to cope with and recover from the pain.
• To set priorities for discharge teaching, the nurse follows parental cues.
• The nurse should teach parents the signs of illness in newborns, especially jaundice in newborns discharged early.
• All parents should be taught infant cardiopulmonary resuscitation.
Critical Thinking/Clinical Decision Making
Sudden Infant Death Syndrome and Infant Sleep Position

Marlys gave birth to a full-term male infant named Daniel. They are being discharged today. The nurse has given her instructions about placing the baby on his back for sleep. Marlys said that she had noticed that the nurses placed Daniel on his side in the nursery and wondered why they did that when she was instructed to place Daniel on his back.

Michelle gave birth to Michael at 32 weeks. During the stay in the nursery the nurses placed Michael on his abdomen to sleep. At discharge, Michelle was instructed to place Michael on his back to sleep. Michelle asked why she had to place Michael on his back to sleep when he was used to sleeping on his abdomen. How should the nurses respond to these questions?
1. Evidence—Is evidence sufficient to draw conclusions about the safety and efficacy of the supine position for sleep in reducing the incidence of sudden infant death syndrome (SIDS)?
Yes. There is ample evidence that the supine position for sleep reduces the incidence of sudden infant death syndrome (SIDS). The nurses should cite the evidence as well as explain that in preterm infants, use of the prone position can assist breathing in the early phases of recovery from respiratory distress. However, as the infant matures, he should be placed on his back to sleep.
2. Assumptions—What assumptions can be made about the following factors related to infant positioning?

a. Role modeling by nurses
b. Sleep position in the nursery versus sleep position at home
c. Sleep position for preterm versus term infants
d. Nurses' knowledge and use of research evidence
a. Role modeling by the nurses is a powerful teacher. Stastny and colleagues (2004) found that only 30% of nursery staff placed babies on their backs to sleep and cited fear of aspiration as the reason. Continued staff education is necessary to promote the use of the supine position for sleep.
b. In the newborn nursery, nurses may place an infant on his or her side to promote drainage of secretions, although there is no evidence that this is effective. In the neonatal intensive care unit (NICU), infants in respiratory distress may breathe more easily in the prone position. As the distress lessens and the infant matures, the infant should be placed on his or her back for sleep. Parents should be counseled to place infants on their backs for sleep. During waking hours, while the parent is supervising, the infant can be placed on his or her side or abdomen.
c. Discuss sleep position for preterm versus term infants. Preterm infants may be placed in prone position to facilitate respiration; however, they should be on a cardiorespiratory monitor.
d. Not all nurses read research reports and use research evidence in their practices. Therefore they do not place infants on their backs to sleep and do not instruct parents in sleep positioning. Continuing education programs for nurses working in nurseries should address the latest findings related to the prevention of SIDS by use of positioning infants on their backs to sleep.
3. What implications and priorities for nursing care can be drawn at this time?
The nurse needs to reinforce the importance of placing the infant on his or her back to sleep and discuss with the parents the acceptability of placing the infant on the side or abdomen while the infant is awake. The nurse can also advocate for continuing education programs for the nurses to update their clinical knowledge. Signs could be posted in the nursery to remind nurses of the correct positioning.
4. Does the evidence objectively support your conclusion?
There is ample evidence of the efficacy of sleeping on the back in prevention of SIDS. There is also documentation that many nurses do not follow these recommendations. Stastny and colleagues (2004) found that Latina and Pacific Islander mothers were less likely than Caucasian mothers to be instructed in positioning the infant on his or her back to sleep.
5. Do alternative perspectives to your conclusion exist?
Nursery nurses may have had experience with babies choking on mucus and used the prone or side-lying position to promote drainage of mucus. Based on that experience, they may fear that the back-lying position will promote aspiration. They may rely on experience rather than research evidence in their care of infants. Continuing education programs should address research findings. Nurse managers can implement programs of reward for those nurses who base their practice on evidence.
1. At 1 minute following birth, a newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose was stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as:

A. 5.
B. 7.
C. 9.
D. 10.
C. 9.

The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for color because he exhibits acrocyanosis. The point total is 9.
2. The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should:

A. Instill within 15 minutes of birth for maximum effectiveness.
B. Cleanse eyes from inner to outer canthus before administration.
C. Apply directly over the cornea.
D. Flush eyes 10 minutes after instillation to reduce irritation.
B. Cleanse eyes from inner to outer canthus before administration.

Instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. The newborn's eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment. Erythromycin should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation of the erythromycin.
3. Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to:

A. Place newborn on abdomen (prone) after feeding and for sleep.
B. Avoid use of pacifiers.
C. Use a rear-facing car seat until the infant weighs at least 20 lb.
D. Use a crib with side-rail slats that are no more than 3 inches apart.
C. Use a rear-facing car seat until the infant weighs at least 20 lb.

The prone position is no longer recommended because it may interfere with chest expansion and lead to sudden infant death syndrome. Approved pacifiers are safe to use and fulfill a newborn's need to suck. If the newborn is breastfed, the use of pacifiers should be delayed until breastfeeding is well established to avoid the development of nipple confusion. The APA recommends using a rear-facing car seat until a baby weighs 20 lb. Slats in a crib should be no more than 2 inches apart.
4. Following circumcision of a newborn, the nurse provides instructions to his parents regarding postcircumcision care. The nurse should tell the parents to:

A. Apply topical anesthetics with each diaper change.
B. Expect a yellowish exudate to cover the glans after the first 24 hours.
C. Change the diaper every 2 hours and cleanse the site with soap and water or baby wipes.
D. Apply constant pressure to the site if bleeding occurs and call the physician.
B. Expect a yellowish exudate to cover the glans after the first 24 hours.

Topical anesthetics are applied before the circumcision. Infant-comforting techniques are generally sufficient following the procedure. Parents should be taught that a yellow exudate will develop over the glans and should not be removed. The diaper is changed frequently, but the site is cleansed with warm water only because soap and baby wipes can cause pain/burning and irritation at the site. Intermittent pressure is applied if bleeding occurs.
5. When placing a newborn under a radiant heat warmer to stabilize temperature after birth, the nurse should:

A. Place the thermistor probe on left side of the chest.
B. Cover probe with a nonreflective material.
C. Recheck temperature by periodically taking a rectal temperature.
D. Prewarm the radiant heat warmer and place the undressed newborn under it.
D. Prewarm the radiant heat warmer and place the undressed newborn under it.

The thermistor probe should be placed on the upper abdomen away from the ribs. The probe should be covered with reflective material. Rectal temperatures should be avoided because rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced. The radiant warmer should be prewarmed so the infant does not experience more cold stress.
6. With regard to umbilical cord care, nurses should be aware that:

A. The stump can easily become infected.
B. A nurse noting bleeding from the vessels of the cord should immediately call for assistance.
C. The cord clamp is removed at cord separation.
D. The average cord separation time is 5 to 7 days.
A. The stump can easily become infected.

The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.
7. During the complete physical examination 24 hours after birth:

A. The parents are excused from the room to reduce their normal anxiety.
B. The nurse can gauge the neonate's maturity level by assessing its general appearance.
C. Once often neglected, blood pressure is now routinely checked.
D. When the nurse listens to the heart, the S1 and S2 sounds can be heard; the first sound is somewhat higher in pitch and sharper than the second.
B. The nurse can gauge the neonate's maturity level by assessing its general appearance.

Having the parents present during the examination actively involves them in child care and gives the nurse a chance to observe interactions. The nurse is able to gauge maturity level by assessing appearance. The nurse will be looking at skin color, alertness, cry, head size, and other features. Blood pressure is not usually taken unless cardiac problems are suspected. The second heart sound is higher and sharper than the first.
8. With regard to laboratory tests and diagnostic tests performed in the hospital after birth, nurses should be aware that:

A. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases.
B. Federal law prohibits newborn genetic testing without parental consent.
C. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.
D. Hearing screening is now mandated by federal law.
C. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.

All states test for PKU and hypothyroidism, but other genetic defects are not universally covered. Federal law mandates newborn genetic screening, but not screening for hearing problems (although more than half the states do mandate hearing screening). If done very early, genetic screening should be repeated. Federal law mandates newborn genetic screening, but not screening for hearing problems (although more than half the states do mandate hearing screening).
9. The nurse is performing a blood glucose test every 4 hours on an infant born to a diabetic mother. This is to assess the infant's risk of hypoglycemia. The nurse becomes concerned if the infant's blood glucose concentration falls below _________ mg/dl.
36 mg/dL

If the newborn has a blood glucose level below 36 mg/dl, intervention such as breatfeeding or bottle-feeding should be instituted. If levels remain low after this intervention, an intravenous infusion with dextrose may be warranted.
Chapter 18: Newborn Nutrition and Feeding
Early milk, produced from approximately 16 weeks of pregnancy into the first postpartum days; rich in antibodies, higher in protein, and lower in fat than mature milk, with laxative effect to clear meconium and promote excretion of bilirubin
demand feeding
Feeding in response to feeding cues exhibited by the infant that indicate the presence of hunger
Painful swelling of breast tissue as a result of rapid increase in milk production and venous congestion causing interstitial tissue edema; impaired milk flow results in accumulation of milk in breasts; most often occurs between the third and fifth postpartum days
feeding-readiness cues
Infant behaviors (mouthing motions, sucking fist, awakening, and crying) indicating that the infant is interested in feeding
growth spurts
Times of increased neonatal growth that usually occur at approximately 6 to 10 days, 6 weeks, 3 months, and 6 months; increased caloric needs of the infant prompt more frequent feedings
inverted nipples
Nipples invert rather than evert when stimulated; may interfere with effective latch
lactation consultant
Health care professional who has specialized training and experience working with breastfeeding mothers and infants
Process of breast milk production
Placement of the infant's mouth over the nipple, areola, and breast, making a seal between the mouth and breast to create adequate suction for milk removal
Inflammation of the breast, often associated with infection, characterized by influenza-like symptoms and redness and tenderness in the affected breast
milk ejection reflex (MER)
Release of milk caused by the contraction of the myoepithelial cells surrounding the milk glands in response to oxytocin; also called the let-down reflex
plugged milk duct
Blockage of milk duct causing ineffective emptying of breast
rooting reflex
Normal response of the newborn to move toward whatever touches the area around the mouth and to attempt to suck; usually disappears by 3 to 4 months of age
supply-meets-demand system
Physiologic basis for milk production; milk volume is produced in response to amount removed from the breast
• The American Academy of Pediatrics (AAP) recommends breast milk only for the first 6 months of life and breast milk as the only source of milk for the second 6 months.
• Breast milk provides immunologic protection against infections and diseases.
• The benefits of breast milk continue after weaning and extend beyond childhood.
• During the prenatal period, expectant parents should be taught the benefits of breastfeeding for infants, mothers, families, and society.
• Breastfeeding beliefs and practices vary across cultures.
• Milk production is a supply-meets-demand system; as the baby removes milk from the breast, more milk is produced.
• Prolactin and oxytocin are called the mothering hormones because they affect the mother's emotions as well as her physical state.
• The composition of breast milk changes with each stage of lactation, during each feeding, and as the infant grows.
• Feeding-readiness cues include hand-to-mouth or hand-to-hand movements, sucking motions, the rooting reflex, and mouthing.
• The four basic positions for breastfeeding are the football or clutch-hold, cradle, modified cradle or across-the-lap, and side-lying positions.
• As the baby begins sucking on the nipple, the milk ejection, or let-down, reflex is stimulated.
• Newborns need to breastfeed 8 to 12 times a day.
• Initially, preterm milk contains higher concentrations of energy, fat, protein, sodium, chloride, potassium, iron, and magnesium than term milk.
• Depending on gestational age and physical condition, many preterm infants can breastfeed for some of their daily feedings.
• Mothers commonly use breast milk expression to obtain breast milk that someone else can feed to the baby.
• Engorgement typically occurs 3 to 5 days after birth and lasts about 24 hours.
• The nurse should teach inexperienced parents who are using formula feedings about the types of formulas, formula preparation, and correct feeding technique.
• The four main categories of infant formulas are cow's milk-based formulas, soy-based formulas, casein- or whey-hydrolysate formulas, and amino-acid formulas.
• The infant's individual growth pattern helps determine the right time to start solid foods.
Critical Thinking/Clinical Decision Making
Breastfeeding: Engorgement and Nipple Soreness

Mary was discharged from the birthing center at 48 hours postpartum with her newborn son, Matthew. He is now 4 days of age, and she has brought him to the clinic for a follow-up visit. Mary states that her milk came in yesterday, and her breasts have been hard and painful ever since. Latching the baby on has been difficult. She reports that breastfeeding is very painful and that her nipples are cracked and so sore that she "can hardly stand to feed the baby." Matthew has had only one wet diaper and no bowel movements in the last 24 hours. He is crying most of the time and never seems to settle down to sleep for very long. Mary states, "I am ready to give up on this breastfeeding thing and just switch to formula."
1. Evidence—Does the nurse have sufficient evidence at this time to draw conclusions about the feeding difficulties experienced by this mother and infant?
Mary is experiencing a crisis that involves physical discomfort from engorged breasts and sore nipples, physical exhaustion from the demands of a fussy infant who is not sleeping well, frustration in being unable to successfully latch her baby on and provide milk to satisfy him, such that she is questioning her commitment to breastfeeding and considering formula for her infant.
2. Assumptions—What assumptions can be made about the following issues?
a. Mary's milk supply
b. Mary's sore nipples
c. Matthew's urinary output and bowel elimination pattern
d. Mary's commitment to breastfeeding
a. This mother has experienced the onset of mature milk production at the expected time, approximately 3 days after birth. Her breasts are engorged, the tissues surrounding the milk glands and milk ducts are edematous, and the milk is not flowing well from the breasts because of the compression of the milk ducts. She is producing mature milk, but has a problem with milk transfer to the baby.
b. The sore nipples are likely to be the result of a problem with latching the baby onto the breast. This most likely began during the first 2 days after birth and has grown more severe with the increased pressure in the breasts because of fullness, which tends to flatten the nipple and make it more difficult for the baby to latch on. She is experiencing pain with latch-on, which can inhibit her milk ejection or let-down reflex.
c. The urinary output and number of stools are signs that the baby has not received sufficient feeding. After the milk has come in, from about the fourth day of life, the baby should have at least six to eight wet diapers and at least three or four bowel movements every 24 hours. His fussiness and lack of sleep are evidence that he is not being satisfied when he nurses; he is hungry and needs more milk to feel satiated.
d. Mary's frustration, fatigue, and mental exhaustion are causing her to question her desire to breastfeed. She is tired and her breasts are painful. The discomfort intensifies when the baby tries to breastfeed on the very sore nipples. She may be wondering whether breastfeeding is worth all this.
3. What implications and priorities for nursing care can be identified at this time?
The major priority at this time is to feed the baby. He is at risk of becoming dehydrated because of inadequate intake. If the engorgement can be treated quickly, he may be able to breastfeed. Otherwise, he needs to be fed some infant formula via syringe or slow flow bottle until she can express milk or get him to nurse. Mary needs help with her engorgement; ice packs can be applied to the breasts for 20 minutes to help reduce the tissue swelling. She can also take an antiinflammatory medication such as ibuprofen. After the ice is applied, Mary can use a hospital-grade electric breast pump to try to express milk to begin softening the breasts. Even with the pumping of just a half ounce or so, the nipples may soften enough for the baby to latch on and continue softening the breasts. Ideally, the infant will latch on and the milk will flow sufficiently to provide him with enough milk to feel satisfied and to allow Mary's breasts to feel more comfortable. If the ice and pumping do not result in milk flow, cabbage leaves may be used on the breasts for 20 minutes, followed by pumping. The cracked, sore nipples need to be treated. Hydrogel pads can be applied after feeding or pumping. If the nipples are too uncomfortable for the baby to nurse, Mary may pump her breasts with an electric breast pump for 24 hours to allow the nipples some time to begin healing; the expressed breast milk can be syringe fed or fed with a slow flow nipple or bottle. As the nipples improve, the baby can be gradually reintroduced to the breast, with a nurse or lactation consultant assisting Mary with proper latch-on technique.

Mary needs emotional support at this time. The nurse can provide her an opportunity to express her frustrations and concerns. It is important that Mary is aware that what she is experiencing is not uncommon; the breasts of many women become engorged. It is a temporary condition, usually lasting no more than 24 to 48 hours. She may be feeling as if she is failing as a mother. Empathetic concern from the nurse can help to boost Mary's self-esteem and increase her confidence as a mother.
4. Does the evidence objectively support your conclusion?
Yes, according to the American Academy of Pediatrics (AAP) (2005) guidelines for breastfeeding, the infant is not receiving adequate feedings. Mary is experiencing primary engorgement, a common problem that is temporary and should resolve with appropriate interventions.
5. Do alternative perspectives to your conclusion exist?
Mary could have a history of breast surgery, in which case the milk ducts may have been severed, and there is no outlet for the milk to be emptied from the breasts. The baby may be the source of the latch problem because of some physical characteristic such as a tight frenulum ("tongue-tied"). The baby needs to be assessed to determine whether there are factors that may inhibit successful latch-on. In addition, Mary may be lacking in her commitment to breastfeed and may be looking for an excuse to stop. In her mind, the difficulties she is experiencing may provide her with enough reason to switch to formula.
1. The birth weight of a breastfed newborn was 8 pounds, 4 ounces. On the third day the newborn's weight was 7 pounds, 12 ounces. On the basis of this finding, the nurse should:

A. Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs.
B. Suggest that the mother switch to bottle-feeding because the breastfeeding is ineffective in meeting the newborn's needs for fluid and nutrients.
C. Notify the physician because the newborn is being poorly nourished.
D. Refer the mother to a lactation consultant to improve her breastfeeding technique.
A. Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs.

Weight loss of 8 ounces falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 ounces. Breastfeeding is effective at this time. Breastfeeding is effective, and bottle-feeding does not need to be initiated at this time. The infant is not undernourished, and the physician does not need to be notified. The weight loss is within normal limits; breastfeeding is effective.
2. Which action of a breastfeeding mother indicates the need for further instruction?

A. Holds breast with four fingers along bottom and thumb at top
B. Leans forward to bring breast toward the baby
C. Stimulates the rooting reflex and then inserts nipple and areola into newborn's open mouth
D. Puts her finger into newborn's mouth before removing breast
B. Leans forward to bring breast toward the baby

Holding the breast with four fingers along the bottom and the thumb at top is a correct technique. To maintain a comfortable, relaxed position, the mother should bring the baby to the breast, not the breast to the baby. The mother would need further demonstration and teaching to correct the ineffective action. Stimulating the rooting reflex is correct technique. Placing the finger in the mouth to remove the baby from the breast is correct technique.
3. The nurse taught new parents the guidelines to follow regarding the bottle feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse's instructions if they:

A. Wash the top of the can and the can opener with soap and water before opening the can.
B. Adjust the amount of water added according to weight gain pattern of the newborn.
C. Add some honey to sweeten the formula and make it more appealing to a fussy newborn.
D. Warm formula in a microwave oven for a couple of minutes prior to feeding.
A. Wash the top of the can and the can opener with soap and water before opening the can.

Washing the top of the can and the can opener with soap and water before opening the can of formula is a good habit for parents to get into to prevent contamination of the formula. Directions on the can for dilution should be followed exactly and not adjusted according to weight gain to prevent nutritional and fluid imbalances. Honey is not necessary and could contain botulism spores. The formula should be warmed in a container of hot water because a microwave can easily overheat it or heat it unevenly.
4. Benefits to the mother associated with breastfeeding include all except it:

A. Decreases risk of breast cancer.
B. Is an effective method of birth control.
C. Increases bone density.
D. May enhance postpartum weight loss.
B. Is an effective method of birth control.

Women who breastfeed have a decreased risk of breast cancer. Breastfeeding delays the return of fertility, but it is NOT an effective birth control method. Women who breastfeed display an increase in bone density. Women who breastfeed report a quicker weight loss postpartum.
5. With regard to the special qualities of human breast milk, nurses should be aware that:

A. Frequent feedings during predictable growth spurts stimulate increased milk production.
B. The milk of preterm mothers is the same as the milk of mothers who gave birth at term.
C. The milk at the beginning of the feeding is the same as the milk at the end of the feeding.
D. Colostrum is an early, less concentrated, less rich version of mature milk.
A. Frequent feedings during predictable growth spurts stimulate increased milk production.

Growth spurts (at 10 days, 3 weeks, 6 weeks, 3 months) usually last 24 to 48 hours, after which infants resume normal feeding and milk production returns to previous production level. The milk of mothers of preterm infants is different from that of mothers of full-term infants, which is necessary to meet the needs of these newborns. The composition of milk changes during feeding. The fat content of the milk increases as the infant feeds. Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals (but not fat).
6. Nurses should be able to tell breastfeeding mothers that all of the following are signs that the infant has latched on correctly to her breast except:

A. She feels a firm tugging sensation on her nipples but not pinching or pain.
B. The baby sucks with cheeks rounded, not dimpled.
C. The baby's jaw glides smoothly with sucking.
D. She hears a clicking or smacking sound when the infant feeds.
D. She hears a clicking or smacking sound when the infant feeds.

The tugging sensation without pinching is a good sign. The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. Rounded cheeks are a good sign. The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. A smoothly gliding jaw is a good sign. The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing.
7. With regard to basic care of the breastfeeding mother, nurses should be able to advise her that she:

A. Will need an extra 1000 calories a day to maintain energy and produce milk.
B. Can go back to prepregnancy consumption patterns of any drinks as long as she gets enough calcium.
C. Should avoid trying to lose large amounts of weight.
D. Must avoid exercising because it is too fatiguing.
C. Should avoid trying to lose large amounts of weight.

A breastfeeding mother need add only 200 to 500 extra calories to her diet to provide extra nutrients for the infant. This is true only if she doesn't drink alcohol, limits coffee to no more than two cups (caffeine is also found in chocolate, tea, and some sodas), and reads the herbal tea ingredients carefully. Large weight loss would release fat-stored contaminants into her breast milk. It would also likely involve eating too little and/or exercising too much. She needs her rest, but moderate exercise is healthy.
8. Examples of appropriate techniques to wake a sleepy infant for breastfeeding include (choose all that apply):

A. Unwrapping the infant.
B. Changing the diaper.
C. Talking to the infant.
D. Slapping the infant's hands and feet.
E. Applying a cold towel to the infant's abdomen.
A. Unwrapping the infant.
B. Changing the diaper.
C. Talking to the infant.

Unwrapping the infant is an appropriate technique to use when trying to wake a sleepy infant. Changing the diaper is an appropriate technique to use when trying to wake a sleepy infant. Talking to the infant is an appropriate technique to use when trying to wake a sleepy infant. Slapping an infant's hands and feet is not appropriate. The parent can gently rub the infant's hands or feet to wake the infant. Applying a cold towel to the infant's abdomen may lead to cold stress in the infant. The parent may want to apply a cool cloth to the infant's face to wake the infant.
- epidurals:
fluid bolus before 1000ccs, monitor BP (vasodilation), decreased O2 to baby. positioning: fetal position.

Epidural anesthesia or analgesia (block)

Relief from the pain of uterine contractions and birth (vaginal and cesarean) can be relieved by injecting a suitable local anesthetic agent (e.g., bupivacaine, ropivacaine), an opioid analgesic (e.g., fentanyl, sufentanil), or both into the epidural (peridural) space. Injection is made between the fourth and fifth lumbar vertebrae for a lumbar epidural block (see Figs. 10-8, B, and 10-10, A). Depending on the type, amount, and number of medications used, an anesthetic or analgesic effect will occur with varying degrees of motor impairment. The combination of an opioid with the local anesthetic agent reduces the dose of anesthetic required, thereby preserving a greater degree of motor function.

Epidural anesthesia and analgesia is the most effective pharmacologic pain-relief method for labor that is currently available. As a result, it is the most commonly used method for relieving pain during labor in the United States and its use has been increasing. Nearly two thirds of American women giving birth choose epidural analgesia (AAP & ACOG, 2007; Bucklin et al., 2005; Hawkins et al., 2007). For relieving the discomfort of labor and vaginal birth, a block from T10 to S5 is required. For cesarean birth, a block from at least T8 to S1 is essential. The diffusion of epidural anesthesia depends on the location of the catheter tip, the dose and volume of the anesthetic agent used, and the woman's position (e.g., horizontal or head-up position). The woman must cooperate and maintain her position without moving during insertion of the epidural catheter so as to prevent misplacement, neurologic injury, or hematoma formation (Cunningham et al., 2005).


Epidural anesthesia effectively relieves the pain caused by uterine contractions. For most women, however, it does not completely remove the pressure sensations that occur as the fetus descends in the pelvis.

For the induction of an epidural block, the woman is positioned as for a spinal block. She may sit with her back curved or she may assume a modified Sims position with her shoulders parallel, legs slightly flexed, and back arched (see Fig. 10-11). A large-bore needle is inserted into the epidural space. A catheter is then threaded through the needle until its tip rests in the epidural space. Then the needle is removed and the catheter is taped in place. After the epidural catheter is inserted, a small amount of medication, called a test dose, is injected to be sure that the catheter has not been accidentally placed in the subarachnoid (spinal) space or in a blood vessel (Hawkins et al., 2007).

After the epidural has been initiated the woman is positioned preferably on her side so that the uterus does not compress the ascending vena cava and descending aorta, which can impair venous return, reduce cardiac output and blood pressure, and decrease placental perfusion. Her position should be alternated from side to side every hour. Upright positions and ambulation may be possible, depending on the degree of motor impairment. Oxygen should be available if hypotension occurs despite maintenance of hydration with IV fluid and displacement of the uterus to the side. Ephedrine or phenylephrine (vasopressors used to increase maternal blood pressure) and increased IV fluid infusion may be needed (see Emergency box). The FHR, contraction pattern, and progress in labor must be monitored carefully because the woman may not be aware of changes in the strength of the uterine contractions or the descent of the presenting part.

Several methods can be used for an epidural block. An intermittent block is achieved by using repeated injections of anesthetic solution; it is the least common method. The most common method is the continuous block, achieved by using a pump to infuse the anesthetic solution through an indwelling plastic catheter. Patient-controlled epidural analgesia (PCEA) is the newest method; it uses an indwelling catheter and a programmed pump that allows the woman to control the dosing. This method has been found to provide optimal analgesia with better maternal satisfaction during labor while decreasing the amount of local anesthetic used (Saito et al., 2005).

The advantages of an epidural block are numerous: The woman remains alert and is more comfortable and able to participate, good relaxation is achieved, airway reflexes remain intact, only partial motor paralysis develops, gastric emptying is not delayed, and blood loss is not excessive. Fetal complications are rare but may occur in the event of rapid absorption of the medication or marked maternal hypotension. The dose, volume, type, and number of medications used can be modified to allow the woman to push and to assume upright positions and even to walk, to produce perineal anesthesia, and to permit forceps-assisted, vacuum-assisted, or cesarean birth if required (Cunningham et al., 2005).

The disadvantages of epidural block also are numerous. The woman's ability to move freely and to maintain control of her labor is limited, related to the use of numerous medical interventions (e.g., an IV infusion and electronic monitoring) and the occurrence of orthostatic hypotension and dizziness, sedation, and weakness of the legs. CNS effects (Box 10-4) can occur if a solution containing a local anesthetic agent is accidentally injected into a blood vessel or if excessive amounts of local anesthetic are given. High spinal or "total spinal" anesthesia, resulting in respiratory arrest, can occur if the relatively high dose of local anesthetic used with an epidural block is accidentally injected into the subarachnoid space. Women who receive an epidural have a higher rate of fever (i.e., intrapartum temperature of 38° C or higher), especially when labor lasts longer that 12 hours; the temperature elevation most likely is related to thermoregulatory changes, although infection cannot be ruled out. The elevation in temperature can result in fetal tachycardia and neonatal workup for sepsis, whether or not signs of infection are present (see Box 10-4).

Severe hypotension (more than a 20% decrease in baseline blood pressure) as a result of sympathetic blockade can be an outcome of an epidural block (Anim-Somuah, Smyth, & Howell, 2005) (see Emergency box). It can result in a significant decrease in uteroplacental perfusion and oxygen delivery to the fetus. Urinary retention and stress incontinence can occur in the immediate postpartum period. Pruritus (itching) is a side effect that often occurs with the use of an opioid, especially fentanyl. A relationship between epidural analgesia and longer second-stage labor, use of oxytocin, and forceps-assisted or vacuum-assisted birth has been documented. Research findings have been unable to demonstrate a significant increase in cesarean birth associated with epidural analgesia (Anim-Somuah et al.). For some women, the epidural block is not effective, and a second form of analgesia is required to establish effective pain relief. When women progress rapidly in labor, pain relief may not be obtained before birth occurs.

BOX 10-4 Side Effects of Epidural and Spinal Anesthesia

• Hypotension
• Local anesthetic toxicity
• Light-headedness
• Dizziness
• Tinnitus (ringing in the ears)
• Metallic taste
• Numbness of the tongue and mouth
• Bizarre behavior
• Slurred speech
• Convulsions
• Loss of consciousness
• High or total spinal anesthesia
• Fever
• Urinary retention
• Pruritus (itching)
• Limited movement
• Longer second stage labor
• Increased use of oxytocin
• Increased likelihood of forceps- or vacuum-assisted birth

Combined spinal-epidural analgesia
In the combined spinal-epidural (CSE) analgesia technique, sometimes called a "walking epidural," an epidural needle is inserted into the epidural space. Before the epidural catheter is placed, a smaller-gauge spinal needle is inserted through the bore of the epidural needle into the subarachnoid space. A small amount of opioid or combination of opioid and local anesthetic is then injected intrathecally to provide analgesia rapidly. Afterward the epidural catheter is inserted as usual. The CSE technique is an increasingly popular approach that can be used to block pain transmission without compromising motor ability. The concentration of opioid receptors is high along the pain pathway in the spinal cord, in the brainstem, and in the thalamus. Because these receptors are highly sensitive to opioids, a small quantity of an opioid-agonist analgesic produces marked pain relief lasting for several hours. If additional pain relief is needed, medication can be injected through the epidural catheter (see Fig. 10-10, A). The most common side effects of CSE are pruritus and nausea (Hawkins et al., 2007). CSE analgesia may also be associated with fetal bradycardia, necessitating close assessment of fetal heart rate (Cunningham et al., 2005).

Although women can walk, they often choose not to do so because of sedation and fatigue, abnormal sensations perceived in their legs, weakness of the legs, and a feeling of insecurity. Health care providers are often reluctant to encourage or assist women to ambulate for fear of injury. However, women can be assisted to change positions and use upright positions during labor and birth. Upright positioning is associated with less pain, more efficient labor progress, and a lower incidence of forceps- or vacuum-assisted birth (Albers, 2007; Berghella et al., 2008). Laboring upright also conveys a sense of normalcy, autonomy, and personal control (Albers).

Epidural and intrathecal (spinal) opioids
Opioids also can be used alone, eliminating the effect of a local anesthetic altogether. The use of epidural or intrathecal opioids without the addition of a local anesthetic agent during labor has several advantages. Opioids administered in this manner do not cause maternal hypotension or affect vital signs. The woman feels contractions but not pain. Her ability to bear down during the second stage of labor is preserved because the pushing reflex is not lost, and her motor power remains intact.

Fentanyl, sufentanil, or preservative-free morphine may be used. Fentanyl and sufentanil produce short-acting analgesia (i.e., 1.5 to 3.5 hours), and morphine may provide pain relief for 4 to 7 hours. Morphine may be combined with fentanyl or sufentanil. Using short-acting opioids with multiparous women and morphine with nulliparous women or women with a history of long labor would be appropriate. For most women, intrathecal opioids do not provide adequate analgesia for second-stage labor pain, episiotomy, or birth (Cunningham et al., 2005). Pudendal nerve blocks or local perineal infiltration anesthesia may be necessary.

A more common indication for the administration of epidural or intrathecal analgesics is the relief of postoperative pain. For example, women who give birth by cesarean can receive fentanyl or morphine through a catheter. The catheter may then be removed, and the women are usually free of pain for 24 hours. The catheter is occasionally left in place in the epidural space in case another dose is needed.

Women receiving epidurally administered morphine after a cesarean birth may ambulate sooner than women who do not. The early ambulation and freedom from pain also facilitate bladder emptying, enhance peristalsis, and prevent clot formation in the lower extremities (e.g., thrombophlebitis). Women may require additional medication for pain during the first 24 hours after surgery. If so, they will usually be given oral analgesics (e.g., oxycodone/acetaminophen [Percocet]), rather than IV or IM narcotics.

Side effects of opioids administered by the epidural and intrathecal routes include nausea, vomiting, pruritus, urinary retention, and delayed respiratory depression. These side effects are more common when morphine is administered. Antiemetics, antipruritics, and opioid antagonists are used to relieve these symptoms. For example, naloxone (Narcan), nalbuphine (Nubain), or metoclopramide (Reglan) may be administered. Hospital protocols or detailed physician orders should provide specific instructions for the treatment of these side effects. Use of epidural opioids is not without risk. Respiratory depression is a serious concern; for this reason the woman's respiratory rate should be assessed and documented every hour for 24 hours, or as designated by hospital protocol. Naloxone should be readily available for use if the respiratory rate decreases to less than 10 breaths per minute or if the oxygen saturation rate decreases to less than 89%. Administration of oxygen by facemask also may be initiated, and the anesthesia care provider should be notified.

Contraindications to epidural blocks
Some contraindications to epidural analgesia include the following (Cunningham et al., 2005; Hawkins et al., 2007):
• Active or anticipated serious maternal hemorrhage (Acute hypovolemia leads to increased sympathetic tone to maintain the blood pressure. Any anesthetic technique that blocks the sympathetic fibers can produce significant hypotension that can endanger the mother and baby.)
• Coagulopathy (If a woman is receiving anticoagulant therapy or has a bleeding disorder, injury to a blood vessel may cause the formation of a hematoma that may compress the cauda equina or the spinal cord and lead to serious CNS complications.)
• Infection at the injection site (Infection can be spread through the peridural or subarachnoid spaces if the needle traverses an infected area.)
• Increased intracranial pressure caused by a mass lesion.
• Maternal refusal.
• Some types of maternal cardiac conditions.

Epidural block effects on the neonate
Analgesia or anesthesia during labor and birth has little or no lasting effect on the physiologic status of the neonate. Currently, no evidence has been found that the administration of analgesia or anesthesia during labor and birth has a significant effect on the child's later mental and neurologic development (AAP & ACOG, 2007).
- pain: individualized response. culturally expressive. visceral and somatic pain.

Neurologic Origins
The pain and discomfort of labor have two origins, visceral and somatic. During the first stage of labor, uterine contractions cause cervical dilation and effacement. Uterine ischemia (decreased blood flow and therefore local oxygen deficit) results from compression of the arteries supplying the myometrium during uterine contractions. Pain impulses during the first stage of labor are transmitted via the T-1 to T-12 spinal nerve segment and accessory lower thoracic and upper lumbar sympathetic nerves. These nerves originate in the uterine body and cervix (Blackburn, 2007).

The pain from cervical changes, distention of the lower uterine segment, stretching of cervical tissue as it dilates, and pressure on adjacent structures and nerves during the first stage of labor is visceral pain. It is located over the lower portion of the abdomen. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, gluteal area, thighs, and lower back (Blackburn, 2007; Zwelling et al., 2006).

During the second stage of labor the woman has somatic pain, which is often described as intense, sharp, burning, and well localized. Pain results from stretching and distention of perineal tissues and the pelvic floor to allow passage of the fetus, from distention and traction on the peritoneum and uterocervical supports during contractions, and from lacerations of soft tissue (e.g., cervix, vagina, perineum). Other physical factors related to pain during second stage labor include fetal position, rapidity of fetal descent, maternal position, interval and duration of contractions, and fatigue (Zwelling et al., 2006). Pain impulses during the second stage of labor are transmitted via the pudendal nerve through S2 to S4 spinal nerve segments and the parasympathetic system (Blackburn, 2007).

Pain experienced during the third stage of labor and the afterpains of the early postpartum period are uterine, similar to the pain experienced early in the first stage of labor. Areas of discomfort during labor are shown in Fig. 10-1.

Perception of Pain
Although the pain threshold is remarkably similar in all persons regardless of gender, social, ethnic, or cultural differences, these differences play a definite role in the person's perception of and behavioral responses to pain. The effects of factors such as culture, counterstimuli, and distraction in coping with pain are not fully understood. The meaning of pain and the verbal and nonverbal expressions given to pain are apparently learned from interactions within the primary social group. Cultural influences impose certain behavioral expectations regarding acceptable and unacceptable behavior when experiencing pain.

Expression of Pain
Pain results in physiologic effects and sensory and emotional (affective) responses. During childbirth, pain gives rise to identifiable physiologic effects. Sympathetic nervous system activity is stimulated in response to intensifying pain, resulting in increased catecholamine levels. Blood pressure and heart rate increase. Maternal respiratory patterns change in response to an increase in oxygen consumption. Hyperventilation, sometimes accompanied by respiratory alkalosis, can occur as pain intensifies. Pallor and diaphoresis may be seen. Gastric acidity increases, and nausea and vomiting are common in the active phase of labor. Placental perfusion may decrease, and uterine activity may diminish, potentially prolonging labor and affecting fetal well-being.

Certain emotional (affective) expressions of pain are often seen. Such changes include increasing anxiety with lessened perceptual field, writhing, crying, groaning, gesturing (hand clenching and wringing), and excessive muscular excitability throughout the body.

Factors Influencing Pain Response
Pain during childbirth is unique to each woman. How she perceives or interprets that pain is influenced by a variety of physical, emotional, psychosocial, cultural, and environmental factors (Zwelling et al., 2006).

Physiologic factors
A variety of physiologic factors can affect the intensity of pain that women experience during childbirth. Women with a history of dysmenorrhea may experience increased pain during childbirth as a result of higher prostaglandin levels. Back pain associated with menstruation also may increase the likelihood of contraction-related low back pain. Other physical factors include fatigue, the interval and duration of contractions, fetal position, rapidity of fetal descent, and maternal position (Zwelling et al., 2006).

Endorphins are endogenous opioids secreted by the pituitary gland that act on the central and peripheral nervous systems to reduce pain. Beta-endorphin is the most potent of the endorphins. Endorphin levels increase during pregnancy and birth in humans. Endorphins are associated with feelings of euphoria and analgesia. Increased endorphin levels may increase the pain threshold and enable women in labor to tolerate acute pain (Blackburn, 2007).

The obstetric population reflects the increasingly multicultural nature of U.S. society. As nurses care for women and families from a variety of cultural backgrounds, they must have knowledge and understanding of how culture mediates pain. Although all women expect to experience at least some pain and discomfort during childbirth, their culture and religious belief system determines how they will perceive, interpret, and respond to and manage the pain. For example, women with strong religious beliefs often accept pain as a necessary and inevitable part of bringing a new life into the world (Callister, Khalaf, Semenic, Kartchner, & Vehvilainen-Julkunen, 2003). An understanding of the beliefs, values, and practices of various cultures will narrow the cultural gap and help the nurse to assess the woman's pain experience more accurately. The nurse can then provide appropriate culturally sensitive care by using pain-relief measures that preserve the woman's sense of control and self-confidence (see Cultural Considerations box). Recognize that although a woman's behavior in response to pain may vary according to her cultural background, it may not accurately reflect the intensity of the pain she is experiencing. Assess the woman for the physiologic effects of pain and listen to the words she uses to describe the sensory and affective qualities of her pain.

Cultural Considerations
Some Cultural Beliefs about Pain
The following examples demonstrate how women of different cultural backgrounds may react to pain. Because they are generalizations the nurse must assess each woman experiencing pain related to childbirth.
• Chinese women may not exhibit reactions to pain, although exhibiting pain during childbirth is acceptable. They consider accepting something when it is first offered as impolite; therefore pain interventions must be offered more than once. Acupuncture may be used for pain relief.
• Arab or Middle Eastern women may be vocal in response to labor pain. They may prefer medication for pain relief.
• Japanese women may be stoic in response to labor pain, but they may request medication when pain becomes severe.
• Southeast Asian women may endure severe pain before requesting relief.
• Hispanic women may be stoic until late in labor, when they may become vocal and request pain relief.
• Native American women may use medications or remedies made from indigenous plants. They are often stoic in response to labor pain.
• African-American women may express pain openly. Use of medication for pain relief varies.

Anxiety is commonly associated with increased pain during labor. Mild anxiety is considered normal for a woman during labor and birth. However, excessive anxiety and fear cause additional catecholamine secretion, which increases the stimuli to the brain from the pelvis because of decreased blood flow and increased muscle tension; this action, in turn, magnifies pain perception (Zwelling et al., 2006). Thus, as fear and anxiety heighten, muscle tension increases, the effectiveness of uterine contractions decreases, the experience of discomfort increases, and a cycle of increased fear and anxiety begins. Ultimately this cycle will slow the progress of labor. The woman's confidence in her ability to cope with pain will be diminished, potentially resulting in reduced effectiveness of pain-relief measures being used.

Previous experience
Previous experience with pain and childbirth may affect a woman's description of her pain and her ability to cope with the pain. Childbirth, for a healthy young woman, may be her first experience with significant pain, and as a result, she may not have developed effective pain-coping strategies. She may describe the intensity of even early labor pain as a "10" on a 10-point scale. The nature of previous childbirth experiences also may affect a woman's responses to pain. For women who have had a difficult and painful previous birth experience, anxiety and fear from this past experience may lead to increased pain perception.


Visit a birthing center and a high risk hospital labor and birth unit in your community. Compare the types of pain management used in each facility for laboring mothers, including both nonpharmacologic and pharmacologic methods. Describe how information about pain management is taught. Is the information culturally appropriate? If not, state how teaching might be improved.

Sensory pain for nulliparous women is often greater than that for multiparous women during early labor (dilation less than 5 cm) because their reproductive tract structures are less supple. During the transition phase of the first stage of labor and during the second stage of labor, multiparous women may experience greater sensory pain than nulliparous women because their more supple tissue increases the speed of fetal descent and thereby intensifies pain. The firmer tissue of nulliparous women results in a slower, more gradual descent. Affective pain is usually increased for nulliparous women throughout the first stage of labor but decreases for both nulliparous and multiparous women during the second stage of labor (Lowe, 2002).

Parity may affect perception of labor pain because nulliparous women often have longer labors and therefore greater fatigue. Because fatigue magnifies pain, the combination of increased pain, fatigue, and reduced ability to cope may lead to more use of pharmacologic support.

Gate-control theory of pain
Even particularly intense pain stimuli can, at times, be ignored. This phenomenon is possible because certain nerve cell groupings within the spinal cord, brainstem, and cerebral cortex have the ability to modulate the pain impulse through a blocking mechanism. This gate-control theory of pain helps explain the way hypnosis and the pain-relief techniques taught in childbirth preparation classes work to relieve the pain of labor. According to this theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Using distraction techniques such as massage or stroking, music, focal points, and imagery reduces or completely blocks the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished.

In addition, when the laboring woman engages in neuromuscular and motor activity, activity within the spinal cord itself further modifies the transmission of pain. Cognitive work involving concentration on breathing and relaxation requires selective and directed cortical activity that activates and closes the gating mechanism as well. As labor intensifies, more complex cognitive techniques are required to maintain effectiveness. The gate-control theory underscores the need for a supportive birth setting that allows the laboring woman to relax and use various higher mental activities.
- positioning of fundus post partum: 2 fingerwidths above umbilicus, goes down every 24hrs

Involution process
The return of the uterus to a nonpregnant state after birth is known as involution. This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle.

At the end of the third stage of labor the uterus is in the midline, approximately 2 cm below the level of the umbilicus, with the fundus resting on the sacral promontory. At this time the uterus weighs approximately 1000 g.

Within 12 hours the fundus rises to the level of the umbilicus, or slightly above or below (Fig. 13-1). Thereafter the fundus descends approximately 1 cm every day. By 1 week after birth the fundus is located 4 to 5 fingerbreadths below the umbilicus. The uterus should not be palpable abdominally after 2 weeks and should have returned to its nonpregnant location by 6 weeks after birth (Blackburn, 2007).

The uterus, which at full term weighs approximately 11 times its prepregnancy weight, involutes to approximately 500 g by 1 week after birth and to 350 g by 2 weeks after birth. At 6 weeks, it weighs 60 to 80 g (see Fig. 13-1).

Increased estrogen and progesterone levels are responsible for stimulating the massive growth of the uterus during pregnancy. Prenatal uterine growth results from both hyperplasia, an increase in the number of muscle cells, and from hypertrophy, an enlargement of the existing cells. Postpartally, the decrease in these hormones causes autolysis, the self-destruction of excess hypertrophied tissue. The additional cells laid down during pregnancy remain, however, and account for the slight increase in uterine size after each pregnancy.

Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection (see Chapter 23).
- multipara mom is going to have greater pain than primipara

In first-time mothers, uterine tone is good, the fundus generally remains firm, and the mother usually perceives only mild uterine cramping. Periodic relaxation and vigorous contraction are more common in subsequent pregnancies and may cause uncomfortable cramping called afterpains (afterbirth pains) that persist throughout the early puerperium. Afterpains are more noticeable after births in which the uterus was overdistended (e.g., large baby, multifetal gestation, polyhydramnios). Breastfeeding and exogenous oxytocic medication usually intensify these afterpains because both stimulate uterine contractions.
- know all the lochias (rubra, serosa, alba) and duration

Post-childbirth uterine discharge, commonly called lochia, is initially bright red (lochia rubra) and may contain small clots. For the first 2 hours after birth the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time the lochial flow should steadily decrease.

Lochia rubra consists mainly of blood and decidual and trophoblastic debris. The flow pales, becoming pink or brown (lochia serosa) after 3 to 4 days. Lochia serosa consists of old blood, serum, leukocytes, and tissue debris. The median duration for lochia serosa discharge is 22 to 27 days (Katz, 2007). In most women, approximately 10 days after childbirth the drainage becomes yellow to white (lochia alba). Lochia alba consists primarily of leukocytes and decidual cells but also contains epithelial cells, mucus, serum, and bacteria. Lochia alba may last until 6 weeks after birth (Blackburn, 2007).

If the woman receives an oxytocic medication, the flow of lochia is often scant until the effects of the medication wear off. The amount of lochia is typically smaller after cesarean births. Flow of lochia usually increases with ambulation and breastfeeding. Lochia tends to pool in the vagina when the woman is lying in bed; on standing the woman may experience a gush of blood. This gush should not be confused with hemorrhage.

Persistence of lochia rubra early in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. Recurrence of bleeding approximately 7 to 14 days after birth is from the healing placental site. Approximately 10% to 15% of women will still be experiencing normal lochia serosa discharge at the 6-week postpartum examination (Katz, 2007). In the majority of women, however, a continued flow of lochia serosa or lochia alba by 3 to 4 weeks after birth may indicate endometritis, particularly if fever, pain, or abdominal tenderness is associated with the discharge. Lochia should smell similar to normal menstrual flow; an offensive odor usually indicates infection.

Not all postpartal vaginal bleeding is lochia; vaginal bleeding after birth may be a result of unrepaired vaginal or cervical lacerations. Table 13-1 distinguishes between lochial and nonlochial bleeding

TABLE 13-1 Lochial and Nonlochial Bleeding

- Lochia usually trickles from the vaginal opening. The steady flow increases as the uterus contracts.
- A gush of lochia may result as the uterus is massaged. If the lochia is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium).

- If the bloody discharge spurts from the vagina, damage to a blood vessel may have occurred during birth. If so, some of the bleeding is not just normal lochial flow.
- If the amount of bleeding continues to be excessive and bright red, a vaginal or cervical tear may be the source.
- diaphoresis during labor normal: releasing accumulated blood volume. normal to lose up to 2kg during labor.
Postpartal Diuresis

Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Profuse diaphoresis often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis, caused by decreased estrogen levels, removal of increased venous pressure in the lower extremities, and loss of the remaining pregnancy-induced increase in blood volume, also aids the body in ridding itself of excess fluid. Fluid loss through perspiration and increased urinary output accounts for a weight loss of approximately 2.25 kg during the puerperium.

Profuse diaphoresis that occurs in the immediate postpartum period is the most noticeable change in the integumentary system.
- clotting factors increase during pregnancy. increased risk for DVT.
Coagulation factors
Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated in the immediate puerperium. When combined with vessel damage and immobility, this hypercoagulable state causes an increased risk of thromboembolism, especially after a cesarean birth. Fibrinolytic activity also increases during the first 1 to 4 days after childbirth (Katz, 2007).

Circulation and coagulation times
The circulation time decreases slightly by week 32. It returns to near normal by near term. The blood tends to coagulate (clot) during pregnancy because of increases in various clotting factors (factors VII, VIII, IX, X, and fibrinogen). This change, combined with the fact that fibrinolytic activity (the splitting up or the dissolving of a clot) is depressed during pregnancy and the postpartum period, provides a protective function to decrease the chance of bleeding, but it also makes the woman more vulnerable to thrombosis, especially after cesarean birth.
- when in doubt, massage the fundus
- care of episiotomy: ice packs, sitz baths
An episiotomy is an incision made in the perineum to enlarge the vaginal outlet (Fig. 12-23). It is performed more commonly in the United States and Canada than in Europe. The side-lying position for birth, used routinely in Europe, reduces tension on the perineum, making possible a gradual stretching of the perineum with fewer indications for episiotomies. Different types of episiotomies are performed, depending on the site and direction of the incision (see Fig. 12-23). The type of episiotomy that provides the best outcome is unknown (Berghella et al., 2008). Midline (median) episiotomy is most commonly used in the United States. It is effective, easily repaired, and generally the least painful. However, midline episiotomies also are associated with an increased incidence of third- and fourth-degree lacerations. Sphincter tone is usually restored after primary healing and a good repair. Mediolateral episiotomy is used in operative births when the need for posterior extension is likely. Although a fourth-degree laceration can be prevented using this technique, a third-degree laceration may occur. The blood loss is also greater and the repair more difficult and painful than with midline episiotomies. It is also more painful in the postpartum period, and the pain lasts longer.

Routine performance of episiotomies has declined in the United States since the 1990s. The practice in many settings now is to support the perineum manually during birth and allow the perineum to tear rather than perform an episiotomy. Tears are often smaller than an episiotomy, are repaired easily or not at all, and heal quickly. Routine use of episiotomy is associated with increased posterior perineal trauma, suturing and healing complications, and later pain with intercourse. Therefore episiotomy should be avoided if at all possible (Berghella et al., 2008).

When the third stage of labor has been completed the primary health care provider examines the woman for any perineal, vaginal, or cervical lacerations requiring repair. If an episiotomy was performed, it will be sutured. Immediate repair promotes healing, limits residual damage, and decreases the possibility of infection.
- bladder distention can affect fundus: boggy, bleed more. empty bladder
- s/s lactose intolerance: GI distress
One problem that can interfere with milk consumption is lactose intolerance, the inability to digest milk sugar (lactose) caused by the absence of the lactase enzyme in the small intestine. Lactose intolerance is relatively common in adults, particularly African-Americans, Asians, Native Americans, and Inuits. Milk consumption may cause abdominal cramping, bloating, and diarrhea in such people, although many lactose-intolerant individuals can tolerate small amounts of milk without symptoms. Yogurt, sweet acidophilus milk, buttermilk, cheese, chocolate milk, and cocoa may be tolerated even when fresh fluid milk is not. Commercial lactase supplements (e.g., Lactaid) are widely available to consume with milk. Many supermarkets stock lactase-treated milk. The lactase in these products hydrolyzes, or digests, the lactose in milk, thus enabling lactose-intolerant people to drink milk.

Women with lactose intolerance and those who do not include milk in their diet for any reason are at risk for vitamin D deficiency.
- high C2+ foods: small fish (sardines, anchovies), green leafy vegetables avoid high mercury fish,
The DRI shows no increase of calcium during pregnancy and lactation, in comparison with the recommendation for the nonpregnant woman (see Table 8-1). The DRI appears to provide sufficient calcium for fetal bone and tooth development to proceed while maintaining maternal bone mass.

Milk and yogurt are especially rich sources of calcium, providing approximately 300 mg per cup (240 ml). Nevertheless, many women do not consume these foods or do not consume adequate amounts to provide the recommended intakes of calcium. One problem that can interfere with milk consumption is lactose intolerance, the inability to digest milk sugar (lactose) caused by the absence of the lactase enzyme in the small intestine. Lactose intolerance is relatively common in adults, particularly African-Americans, Asians, Native Americans, and Inuits. Milk consumption may cause abdominal cramping, bloating, and diarrhea in such people, although many lactose-intolerant individuals can tolerate small amounts of milk without symptoms. Yogurt, sweet acidophilus milk, buttermilk, cheese, chocolate milk, and cocoa may be tolerated even when fresh fluid milk is not. Commercial lactase supplements (e.g., Lactaid) are widely available to consume with milk. Many supermarkets stock lactase-treated milk. The lactase in these products hydrolyzes, or digests, the lactose in milk, thus enabling lactose-intolerant people to drink milk.

BOX 8-4 Calcium Sources for Women Who Do Not Drink Milk

Each of the following food items provides approximately the same amount of calcium as 1 cup of milk.

• 3-oz can of sardines
• 4.5-oz can of salmon (if bones are eaten)

• 3 cups cooked dried beans
• 2.5 cups refried beans
• 2 cups baked beans with molasses
• 1 cup tofu (calcium is added in processing)

• 1 cup collards
• 1.5 cups kale or turnip greens

• 3 pieces cornbread
• 3 English muffins
• 4 slices French toast
• 2 waffles (7 inches in diameter)

• 11 dried figs
• 1.125 cups orange juice with calcium added

• 3 oz pesto sauce
• 5 oz cheese sauce

In some cultures, adults rarely drink milk. For example, Puerto Ricans and other Hispanic people may use milk only as an additive in coffee. Pregnant women from these cultures may need to consume nondairy sources of calcium. Vegetarian diets may also be deficient in calcium (Box 8-4). If calcium intake appears low and the woman does not change her dietary habits despite counseling, a daily supplement containing 600 mg of elemental calcium may be needed. Calcium supplements may also be recommended when a pregnant woman experiences leg cramps caused by an imbalance in the calcium/phosphorus ratio. Bone meal supplements are not recommended in pregnancy.
- breast engorgement: read in book. lymphatic
Engorgement is a common response of the breasts to the sudden change in hormones and the onset of significantly increased milk volume. It usually occurs 3 to 5 days after birth when the milk "comes in" and lasts approximately 24 hours. Blood supply to the breasts increases and causes swelling of tissues surrounding the milk ducts. The milk ducts may be pinched shut so that milk cannot flow from the breasts. The breasts are firm, tender, and hot and may appear shiny and taut. The areolae are firm, and the nipples may flatten, creating difficulty for the infant in latching on to the breast. Because back pressure on full milk glands inhibits milk production, if milk is not removed from the breasts, the milk supply may diminish.

When engorgement occurs, it is a temporary condition that is usually resolved within 24 hours. The mother is instructed to feed every 2 hours, softening at least one breast, and pumping the other breast as needed to soften it. Pumping during engorgement will not cause a problematic increase in milk supply.

Because of the swelling of breast tissue surrounding the milk ducts, ice packs are recommended in a 15 to 20 minutes on, 45 minutes off rotation between feedings. The ice packs should cover both breasts. Large bags of frozen peas or niblet corn make easy packs and can be refrozen between uses.

Fresh, raw cabbage leaves placed over the breasts between feedings may help reduce the swelling. The cabbage leaves are washed, chilled in the refrigerator or freezer, and then placed over the breasts for 15 to 20 minutes (Fig. 18-14). This treatment can be repeated for two or three sessions. Frequent application of cabbage leaves can decrease milk supply. Cabbage leaves are often very effective for formula-feeding mothers who want their milk to "dry up"; they are advised to wear the cabbage leaves constantly while engorged, replacing the leaves with fresh ones as they become wilted. Cabbage leaves should not be used if the mother is allergic to cabbage or sulfa drugs or develops a skin rash.

Antiinflammatory medications, such as ibuprofen, may help reduce the pain and swelling associated with engorgement. Ibuprofen also helps reduce fever and aching in the breasts that are often associated with engorgement.

Because heat increases blood flow, application of heat to an already congested breast is usually counterproductive. Occasionally, however, standing in a warm shower will start the milk leaking, or the mother may be able to manually express enough milk to soften the areola sufficiently to allow the baby to latch on and feed.

Estrogen and progesterone levels drop markedly after expulsion of the placenta and reach their lowest levels 1 week after childbirth. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. In nonlactating women, estrogen levels begin to rise by 2 weeks after birth and by postpartum day 17 are significantly higher than in women who breastfeed (Katz, 2007).

• If breasts are engorged, have woman apply ice packs to breasts (15 minutes on, 45 minutes off), and apply cabbage leaves in same manner to relieve discomfort (use only two to three times). Use warm compresses or take a warm shower before breastfeeding to stimulate milk flow and relieve stasis. Hand express milk or pump milk to relieve discomfort if infant is unable to latch on and feed.
• If pain is from breast and woman is not breastfeeding, encourage the use of a well-fitted, supportive bra or breast binder and application of ice packs and cabbage leaves to suppress milk production and decrease discomfort.
- if mom doesn't want to breastfeed: avoid breast stimulation, tight bra, ice packs. leave them alone
- breastfeeding benefits: helps with antibody, readily available, free
- normal amount of wet diapers for babies to see if breastfeeding is effective: 6-8/day
- breastfeed every 2 hours to avoid engorgment
Breastfeeding Mothers
During the first 24 hours after birth, little, if any, change occurs in the breast tissue. Colostrum, a clear yellow fluid, may be expressed from the breasts. The breasts gradually become fuller and heavier as the colostrum transitions to milk by approximately 72 to 96 hours after birth; this breast change is often referred to as the "milk coming in." The breasts may feel warm, firm, and somewhat tender. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples. As milk glands and milk ducts fill with milk, breast tissue may feel somewhat nodular or lumpy. Unlike the lumps associated with fibrocystic breast disease or cancer, which may be consistently palpated in the same location, the nodularity associated with milk production tends to shift in position. Some women experience engorgement, but with frequent breastfeeding and proper care, this condition is temporary and typically lasts only 24 to 48 hours (see Chapter 18).

Non-Breastfeeding Mothers
The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. Palpation of the breasts on the second or third day, as milk production begins, may reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement may occur. The breasts are distended (swollen), firm, tender, and warm to the touch (because of vasocongestion). Breast distention is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line may be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A breast binder or well-fitted, supportive bra, ice packs, fresh cabbage leaves, and mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.
- breastfeeding storage: look in powerpoint we haven't covered in class
Storage of breast milk

The preferred containers for long-term storage of breast milk are hard sided, such as hard plastic or glass, with an airtight seal. For short-term storage (<72 hours), plastic bags designed for human milk storage can be safely used.

For full-term, healthy infants, freshly expressed breast milk can be safely stored at room temperature for up to 8 hours, and it can be refrigerated safely for up to 5 days. Milk can be frozen for up to 6 months in the freezer section of a refrigerator with a separate door and for up to 12 months in a deep freeze. Storage guidelines for hospitalized infants are somewhat stricter. When breast milk is stored, the container should be dated, and the oldest milk should be used first (Jones & Tully, 2006).

Frozen milk is thawed by placing the container in the refrigerator for gradual thawing or in warm water for faster thawing. It cannot be refrozen and should be used within 24 hours. After thawing the container needs to be shaken so as to mix the layers that have separated (Academy of Breastfeeding Medicine [ABM], 2004; Jones & Tully, 2006) (see Patient Instructions for Self-Management Box).

Breast Milk Storage Guidelines for Home Use
• Before expressing or pumping breast milk, wash your hands.
• Containers for storing milk should be washed in hot, soapy water and rinsed thoroughly; they can also be washed in a dishwasher. If the water supply may not be clean, boil the containers after washing. Plastic bags designed specifically for breast milk storage can be used for short term storage (<72 hr).
• Write the date of expression on the container before storing the milk. A waterproof label is best.
• Store milk in serving sizes of 2 to 4 ounces to prevent waste.
• Storing breast milk in the refrigerator or freezer with other food items is acceptable.
• When storing milk in a refrigerator or freezer, place the containers in the middle or back of the freezer, not on the door.
• When filling a storage container that will be frozen, fill only full, allowing space at the top of the container for expansion.
• To thaw frozen breast milk, place the container in the refrigerator for gradual thawing, or place the container under warm, running water for quicker thawing. Never boil or microwave.
• Milk thawed in the refrigerator can be stored for 24 hours.
• Thawed breast milk should never be refrozen.
• Shake the milk container before feeding baby, and test the temperature of the milk on the inner aspect of your wrist.
• Any unused milk left in the bottle after feeding is discarded.

Method | Healthy Infant | Hospitalized Infant
Room temperature (77° F or 25° C): <6 hours: <4 hours
Refrigerator (39° F or 4° C): <8 days: <8 days
Freezer compartment of a one door refrigerator: 2 weeks: Not recommended
Freezer compartment of a two door refrigerator (23° F or −5° C) (not in door): <6 months: <3 months
Deep freezer(−4° F or −20° C): <12 months: <6 months

Breast milk is never thawed or heated in a microwave oven. Microwaving does not heat evenly and can cause encapsulated boiling bubbles to form in the center of the liquid, which may not be detected when drops of milk are checked for temperature. Babies have sustained severe burns to the mouth, throat, and upper GI tract as a result of microwaved milk. In addition, microwaving (72°-98° C) significantly destroys the antiinfective factors and vitamin C content. The safety of low-temperature microwaving is questionable (Lawrence & Lawrence, 2005).
- normal weight loss for newborn?: 3% is normal.
Acceptable weight loss: 10% or less infirst 3-5 days

Weight loss over 10% to 15% (growth failure, dehydration); assess breastfeeding sucess.

The newborn is usually weighed shortly after birth. This assessment may be performed in the labor and birthing area, the mother's room, or on admission to the nursery. Care must be taken to ensure that the scales are balanced. The totally unclothed neonate is placed in the center of the scale, which is usually covered with a disposable pad or cloth to prevent heat loss via conduction to prevent cross-infection. The nurse should place one hand over (but not touching) the neonate to prevent the infant from falling off the scales (p. 460). Weighing the infant at the same time every day is common during the hospital stay. Birth weight of a term infant typically ranges from 2500 to 4000 g.

The presence of decreased caloric intake (less milk), weight loss of more than 5% to 7% in the first 5 days of life, increasing serum bilirubin (unconjugated) levels, decreased stooling, and increased jaundice is also sometimes called starvation jaundice or nonbreastfeeding jaundice. To prevent this pattern the following measures are suggested: initiation of breastfeeding within the first few hours of life, continuous rooming-in with the mother, breastfeeding 10 to 12 times per day, no supplements, and recognition of and response to hunger cues.
- how to avoid cold stress: warmer, blankets, hats, avoid drafts
The care given immediately after the birth focuses on assessing and stabilizing the newborn. The nurse's main responsibility at this time is the infant because the primary health care provider is involved with the delivery of the placenta and the care of the mother. The nurse must watch the infant for any signs of distress and initiate appropriate interventions should any appear.

Perform a brief assessment of the newborn immediately, even while the mother is holding the infant. This assessment includes assigning Apgar scores at 1 and 5 minutes after birth (see Table 17-1). Maintaining a patent airway, supporting respiratory effort, and preventing cold stress by drying the newborn and covering the newborn with a warmed blanket or placing him or her under a radiant warmer are the major priorities in terms of the newborn's immediate care. You can postpone further examination, identification procedures, and care until later in the third stage of labor or early in the fourth stage.
- mongolian spots.
Mongolian spots
Mongolian spots, bluish-black areas of pigmentation, may appear over any part of the exterior surface of the body, including the extremities. They are more commonly noted on the back and buttocks (Fig. 16-5). These pigmented areas are most frequently noted in newborns whose ethnic origins are in the Mediterranean area, Latin America, Asia, or Africa. They are more common in dark-skinned individuals but may occur in 5% to 13% of Caucasians as well (Blackburn, 2007). They fade gradually over months or years.
- acrocyanosis: normal., blue hands and feet at birth
The hands and feet appear slightly cyanotic (acrocyanosis) [at birth], which is caused by vasomotor instability and capillary stasis. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days, especially with exposure to cold. Acrocyanosis is a normal finding in the neonate, but central cyanosis indicates poor oxygenation.
- at birth: suction mouth first, then nose.
Suction the mouth and nasopharynx with a bulb syringe as needed; clean the nares of crusted secretions to clear the airway and prevent aspiration and airway obstruction.
- vernix caseosa
The epidermis begins as a single layer of cells derived from the ectoderm at 4 weeks. By the seventh week, two layers of cells have formed. The cells of the superficial layer are sloughed and become mixed with the sebaceous gland secretions to form the white, cheesy vernix caseosa, the material that protects the skin of the fetus. The vernix is thick at 24 weeks but becomes scant by term.

Vernix caseosa is a product of the sebaceous glands. Removal of the vernix is followed by desquamation of the epidermis in most infants. Vernix has been shown to be an epidermal barrier with positive benefits for neonatal skin such as decreasing the skin pH, decreased skin erythema, and improved skin hydration.

Vernix caseosa may be present between the labia and should not be forcibly removed during bathing.

Allowing vernix caseosa to remain on the infant's skin has not been associated with a decrease in axillary temperature in the first hour after birth.

Vernix caseosa has benefits for the preterm infant's skin. Vernix acts as an epidermal barrier, decreases bacterial contamination of the skin through its antimicrobial peptides and proteins, and decreases transepidermal water loss.
- how to calculate BMIs. what are the ranges
Weight gain
The optimal weight gain during pregnancy is not known precisely. However, the amount of weight gained by the mother during pregnancy has an important bearing on the course and outcome of pregnancy. Adequate weight gain does not necessarily indicate that the diet is nutritionally adequate, but it is associated with a reduced risk of giving birth to a small-for-gestational-age (SGA) or preterm infant.

The desirable weight gain during pregnancy varies among women. The primary factor to consider in making a weight gain recommendation is the appropriateness of the prepregnancy weight for the woman's height. Maternal and fetal risks in pregnancy are increased when the mother is either significantly underweight or overweight before pregnancy and when weight gain during pregnancy is either too low or too high. Severely underweight women are more likely to have preterm labor and to give birth to LBW infants. Women with inadequate weight gain have an increased risk of giving birth to an infant with intrauterine growth restriction (IUGR). Greater-than-expected weight gain during pregnancy may occur for many reasons, including multiple gestation, edema, preeclampsia, and overeating. Obesity (either preexisting or developed during pregnancy) increases the likelihood of macrosomia and fetopelvic disproportion; operative birth; emergency cesarean birth; postpartum hemorrhage; wound, genital tract, or urinary tract infection; birth trauma; and late fetal death. Obese women are more likely than normal-weight women to have gestational hypertension and gestational diabetes; their risk of giving birth to a child with a major congenital defect is double that of normal-weight women.

A commonly used method of evaluating the appropriateness of weight for height is the body mass index (BMI), which is calculated by the following formula: BMI = weight/height^2 where the weight is in kilograms and height is in meters. Therefore for a woman who weighed 51 kg before pregnancy and is 1.57 m tall: BMI = 51/(1.57)^2, or 20.7.

Prepregnant BMI can be classified into the following categories: less than 18.5, underweight or low; 18.5 to 24.9, normal; 25 to 29.9, overweight or high; and greater than 30, obese (www.nhlbisupport.com/bmi/).

For women with single fetuses, current recommendations are that women with a normal BMI should gain 11.3-15.9 kg during pregnancy, underweight women should gain 12.7-18.1 kg, overweight women should gain 6.8-11.3 kg, and obese women should gain 5.0-9.1 kg (Institute of Medicine, 2009). Adolescents are encouraged to strive for weight gains at the upper end of the recommended range for their BMI because the fetus and the still-growing mother apparently compete for nutrients. The risk of mechanical complications at birth is reduced if the weight gain of short adult women (shorter than 157 cm) is near the lower end of their recommended range.

Pattern of weight gain
Weight gain should take place throughout pregnancy. The risk of giving birth to an SGA infant is greater when the weight gain early in pregnancy has been poor. The likelihood of preterm birth increases when the gains during the last half of pregnancy have been inadequate. These risks exist even when the total gain for the pregnancy is in the recommended range.

The optimal rate of weight gain depends on the stage of pregnancy. During the first and second trimesters, growth takes place primarily in maternal tissue; during the third trimester, growth occurs primarily in fetal tissues. During the first trimester the average total weight gain is only 1 to 2.5 kg. Thereafter the recommended weight gain increases to approximately 0.4 kg per week for a woman of normal weight. The recommended weekly weight gain for overweight women during the second and third trimesters is 0.3 kg and for underweight women is 0.5 kg.

In twin gestations the recommended weight gain for women in the normal BMI category is 16.8 to 24.5 kg, for women who are overweight, 14.1 to 22.7 kg, and for obese women 11.3 to 19.1 kg (Institute of Medicine, 2009). The ideal weight gain for higher multiples is likely to be greater, but no specific recommendations have been issued (Malone & D'Alton, 2009).

The recommended caloric intake corresponds to this pattern of gain. For the first trimester, no increment is necessary; during the second and third trimesters an additional 340 kcal per day and 462 kcal per day, respectively, over the prepregnant intake is recommended. The amount of food that provides the needed increase is not great. The 340 additional kcal needed during the second trimester can be provided by one additional serving from any one of the following groups: milk, yogurt, or cheese (all skim milk products); fruits; vegetables; and bread, cereal, rice, or pasta.

The reasons for an inadequate weight gain (less than 1 kg per month for normal-weight women or less than 0.5 kg/month for obese women during the last two trimesters) or excessive weight gain (more than 3 kg per month) should be evaluated thoroughly. Possible reasons for deviations from the expected rate of weight gain, besides inadequate or excessive dietary intake, include measurement or recording errors, differences in weight of clothing, time of day, and accumulation of fluids. An exceptionally high gain is likely to be caused by an accumulation of fluids, and a gain of more than 3 kg in a month, especially after the twentieth week of gestation, often indicates the development of gestational hypertension.

Hazards of restricting adequate weight gain
Figure-conscious women can have difficulty making the transition from guarding against weight gain before pregnancy to valuing weight gain during pregnancy. In counseling these women the nurse can emphasize the positive effects of good nutrition, as well as the adverse effects of maternal malnutrition (demonstrated by poor weight gain) on infant growth and development. This counseling includes information on the components of weight gain during pregnancy (Table 8-2) and the amount of this weight that will be lost at birth. Because lactation can help to reduce maternal energy stores gradually, this discussion provides an opportunity to promote breastfeeding.

In the United States, 20% of women who give birth are obese (Paul, 2008). However, pregnancy is not a time for weight-reduction. Even overweight or obese pregnant women need to gain at least enough weight to equal the weight of the products of conception (fetus, placenta, and amniotic fluid). If overweight women limit their caloric intake to prevent weight gain, they may also excessively limit their intake of important nutrients. Moreover, dietary restriction results in catabolism of fat stores, which, in turn, augments the production of ketones. The long-term effects of mild ketonemia during pregnancy are not known, but ketonuria has been found to be correlated with the occurrence of preterm labor. The idea that the quality of the weight gain is important should be stressed to obese women (and to all pregnant women), with emphasis placed on the consumption of nutrient-dense foods and the avoidance of empty-calorie foods.

Adolescent pregnancy needs
Many adolescent girls have diets that provide less than the recommended intakes of key nutrients, including energy, calcium, and iron. Pregnant adolescents and their infants are at increased risk of complications during pregnancy and parturition. Growth of the pelvis is delayed in comparison with growth in stature, which helps to explain why cephalopelvic disproportion and other mechanical problems associated with labor are common among young adolescents. Competition for nutrients between the growing adolescent and the fetus may also contribute to some of the poor outcomes apparent in teen pregnancies. Pregnant adolescents are encouraged to choose a weight gain goal at the upper end of the range for their BMI.

Dietary management during diabetic pregnancy must be based on blood (not urine) glucose levels. The diet is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. The dietary goals are to provide weight gain consistent with a normal pregnancy, to prevent ketoacidosis, and to minimize wide fluctuation of blood glucose levels.

For nonobese women, dietary counseling based on preconceptional body mass index (BMI) is 30 kcal/kg/day (Cunningham et al., 2005). In contrast, for obese women with a BMI greater than 30, experts recommend that the caloric intake total 25 kcal/kg/day (Moore & Catalano, 2009). The average diet includes 2200 calories (first trimester) to 2500 calories (second and third trimesters). Total calories may be distributed among three meals and one evening snack or, more commonly, three meals and two or three snacks. Meals should be eaten on time and never skipped. Going more than 4 hours without food intake increases the risk for episodes of hypoglycemia. Snacks must be carefully planned in accordance with insulin therapy to prevent fluctuations in blood glucose levels. A large bedtime snack of at least 25 g of carbohydrate with some protein or fat is recommended to help prevent hypoglycemia and starvation ketosis during the night (Moore & Catalano).
- how to calculate APGAR score
Initial Assessment and Apgar Scoring
The initial assessment of the neonate is performed immediately after birth using the Apgar score (Table 17-1) and a brief physical examination (Box 17-1). A gestational age assessment is completed within the first hours of birth in a stable newborn. A more comprehensive physical assessment is completed within 24 hours of birth (see Table 16-4).

TABLE 17-1 Apgar Score
Heart rate:
0: Absent
1: Slow (<100)
2: >100

Respiratory rate
0: Absent
1: Slow, weak cry
2: Good cry

Muscle tone
0: Flaccid
1: Some flexion of extremities
2: Well flexed

Reflex irritability
0: No response
1: Grimace
2: Cry

0: Blue, pale
1: Body pink, extremities blue
2: Completely pink

Apgar score
The Apgar score permits a rapid assessment of the newborn's transition to extrauterine existence based on five signs that indicate the physiologic state of the neonate: (1) heart rate, based on auscultation with a stethoscope or palpation of the umbilical cord; (2) respiratory rate, based on observed movement of respiratory efforts; (3) muscle tone, based on degree of flexion and movement of the extremities; (4) reflex irritability, based on response to bulb syringe or catheter inserted in the nasopharynx; and (5) generalized skin color, described as pallid, cyanotic, or pink (see Table 17-1). Evaluations are made at 1 and 5 minutes after birth and can be completed by the nurse or birth attendant. Scores of 0 to 3 indicate severe distress, scores of 4 to 6 indicate moderate difficulty, and scores of 7 to 10 indicate that the infant is having minimal or no difficulty adjusting to extrauterine life. Apgar scores do not predict future neurologic outcome but are useful for describing the newborn's transition to extrauterine environment (Box 17-2). If resuscitation is required, it should be initiated before the 1-minute Apgar score (American Academy of Pediatrics [AAP] and American College of Obstetricians and Gynecologists [ACOG], 2007).

BOX 17-2 Significance of the Apgar Score

The Apgar score was developed to provide a systematic method of assessing an infant's condition at birth. Researchers have tried to correlate Apgar scores with various outcomes such as development, intelligence, and neurologic development. In some instances, researchers have attempted to attribute causality to the Apgar score, that is, to suggest that the low Apgar score caused or predicted later problems. This use of the Apgar score is inappropriate. Instead the score should be used to ensure that infants are systematically observed at birth to ascertain the need for immediate care. Either a physician or a nurse may assign the score; however, to avoid the real or perceived appearance of bias, the person assisting with the birth should not assign the score. Lack of consistency in the assigned scores limits studies of the Apgar's long-term predictive value. Prospective parents and the public need education on the significance of the Apgar score, as well as its limits. Because infants often do not receive the maximal score of 10, parents need to know that scores of 7 to 10 are within normal limits. Attorneys involved in litigation related to injury of an infant at birth or negative outcomes, either short term or long term, also need education about the Apgar score, its significance, and its limits. This useful tool needs to be used appropriately; health care providers, parents, and the public may need education to ensure appropriate use of the score.
- what is a cephalhematoma: more at risk for jaundice than caput

Cephalhematoma is a collection of blood between a skull bone and its periosteum; therefore a cephalhematoma does not cross a cranial suture line. Caput succedaneum and cephalhematoma often occur simultaneously.

Bleeding may occur with spontaneous birth from pressure against the maternal bony pelvis. Low forceps birth and difficult forceps rotation and extraction may also cause bleeding. This soft, fluctuating, irreducible fullness does not pulsate or bulge when the infant cries. It appears several hours or the day after birth and may not become apparent until a caput succedaneum is absorbed. A cephalhematoma is usually largest on the second or third day, by which time the bleeding stops. The fullness of a cephalhematoma spontaneously resolves in 3 to 6 weeks. It is not aspirated because infection may develop if the skin is punctured. As the hematoma resolves, hemolysis of RBCs occurs, and jaundice may result. Hyperbilirubinemia and jaundice may occur after the newborn is discharged home.
- caput succedaneum
Caput succedaneum

Caput succedaneum is a generalized, easily identifiable edematous area of the scalp, most commonly found on the occiput. The sustained pressure of the presenting vertex against the cervix results in compression of local vessels, thereby slowing venous return. The slower venous return causes an increase in tissue fluids within the skin of the scalp, and an edematous swelling develops. This edematous swelling, present at birth, extends across suture lines of the skull and disappears spontaneously within 3 to 4 days. Infants who are born with the assistance of vacuum extraction usually have a caput in the area where the cup was applied.
- pica
Pica and food cravings

Pica, the practice of consuming nonfood substances (e.g., clay, dirt, laundry starch) or excessive amounts of foodstuffs low in nutritional value (e.g., cornstarch, ice, baking powder, baking soda), is often influenced by the woman's cultural background (Fig. 8-2). In the United States, pica appears to be most common among African-American women, women from rural areas, and women with a family history of pica. Regular and heavy consumption of low-nutrient products may cause more nutritious foods to be displaced from the diet, and the items consumed may interfere with the absorption of nutrients, especially minerals. As an example, cornstarch ingestion is popular among African-American women. It is a source of "empty" calories; one half cup (64 g) provides 240 kcal (57 kJ) but almost no vitamins, minerals, or protein. Grotegut, Dandolu, Katari, Whiteman, Geifman-Holtzman, and Teitelman (2006) reported a case of a 31-week gestation multigravida ingesting a box of baking soda (454 g of sodium bicarbonate) each day, which resulted in severe hypokalemic metabolic alkalosis and rhabdomyolysis. More than one substance may be ingested (Ngozi, 2008). Women with pica have lower hemoglobin levels than those without pica.

Moreover, a risk exists that nonfood items are contaminated with heavy metals or other toxic substances. Among Mexican-American women, consumption of "tierra" includes both soil and pulverized Mexican pottery (Klitzman, Sharma, Nicaj, Vitkevich, & Leighton, 2002; Shannon, 2003). Lead contamination of soils and soil-based products has caused high levels of lead in both pregnant women and their newborns. Regular household use of Mexican pottery in cooking or serving food or ingestion of ground pottery must be included in interviews or questionnaires regarding nutritional intake of pregnant women. The possibility of pica must be considered when pregnant women are found to be anemic, and the nurse should provide counseling about the health risks associated with pica (Corbett, Ryan, & Weinrich, 2003).

One hypothesis proposes that pica and food cravings (e.g., the urge to consume ice cream, pickles, or pizza) during pregnancy are caused by an innate drive to consume nutrients missing from the diet. However, research has not supported this hypothesis.
- know when to take iron: at bedtime with orange juice to increase absorption. avoid taking it with dairy. sip through straw if liquid suspension to avoid staining teeth.
Iron is needed both to allow transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell (RBC) mass. The RDA of iron during pregnancy is 27 mg per day (National Institutes of Health, 2007). Pregnant women should receive a supplement of 30 mg of ferrous iron daily, starting by 12 weeks of gestation. (Iron supplements may be poorly tolerated during the nausea that is prevalent in the first trimester.) Iron supplementation of women with iron deficiency can improve maternal hematologic indices and appears to reduce LBW births. If maternal iron-deficiency anemia is present (preferably diagnosed by measurement of serum ferritin, a storage form of iron), increased doses (60-120 mg daily) are recommended. Certain foods taken with an iron supplement can promote or inhibit absorption of iron from the supplement. See the Patient Instructions for Self-Management box regarding iron supplementation. Even when a woman is taking an iron supplement, she should include good food sources of iron in her daily diet (see Table 8-1).


Iron Supplementation
• Iron absorption is promoted by a diet rich in vitamin C (e.g., citrus fruits, melons) or "heme iron" (found in red meats, fish, and poultry).
• Iron supplements are best absorbed on an empty stomach; to this end, they can be taken between meals with beverages other than milk, tea, or coffee.
• Bran, milk, egg yolks, coffee, tea, or oxalate-containing vegetables such as spinach and Swiss chard will inhibit iron absorption if consumed at the same time as iron.
• Some women have gastrointestinal discomfort when they take the supplement on an empty stomach; therefore a good time for them to take the supplement is just before bedtime.
• Constipation is common with iron supplementation.
• Iron supplements should be kept away from any children in the household because ingestion of these supplements could result in acute iron poisoning and even death.
• Iron may cause black, tarry stools.

Zinc is a constituent of numerous enzymes involved in major metabolic pathways. Zinc deficiency is associated with malformations of the central nervous system in infants. When large amounts of iron and folic acid are consumed the absorption of zinc is inhibited, and serum zinc levels are reduced as a result. Because iron and folic acid supplements are commonly prescribed during pregnancy, pregnant women should be encouraged to consume good sources of zinc daily (see Table 8-1). Women with anemia who receive high-dose iron supplements also need supplements of zinc and copper.

Vitamin C, or ascorbic acid, plays an important role in tissue formation and enhances the absorption of iron. The vitamin C needs of most women are readily met by a diet that includes at least one daily serving of citrus fruit or juice or another good source of the vitamin (see Table 8-1), but women who smoke need more. For women at nutritional risk, a supplement of 50 mg/day is recommended. However, if the mother takes excessive doses of this vitamin during pregnancy, a vitamin C deficiency may develop in the infant after birth.
- care of circumcision
Procedural pain management
Circumcision is painful. The pain is characterized by both physiologic and behavioral changes in the infant (see discussion that follows). Four types of anesthesia and analgesia are used in newborns who undergo circumcisions: ring block, dorsal penile nerve block (DPNB), topical anesthetic such as eutectic mixture of local anesthetic (EMLA) (prilocaine-lidocaine) or LMX4 (4% lidocaine), and concentrated oral sucrose. Nonpharmacologic methods such as nonnutritive sucking, containment, and swaddling may be used to enhance pain management. The Cochrane group exploring pain relief for neonatal circumcision (Brady-Fryer, Wiebe, & Lander, 2004) found that DPNB was the most effective intervention for decreasing the pain of circumcision. Studies exploring the use of several strategies concurrently, such as that conducted by Razmus, Dalton, and Wilson (2004), which included groups receiving both concentrated oral sucrose and ring block compared with ring block alone, have the most potential to clarify optimal strategies.

A ring block is the injection of buffered lidocaine administered subcutaneously on each side of the penile shaft. A DPNB includes subcutaneous injections of buffered lidocaine at the 2 o'clock and 10 o'clock positions at the base of the penis. The circumcision should not be performed for at least 5 minutes after these injections.

A topical cream containing prilocaine-lidocaine such as EMLA can be applied to the base of the penis at least 1 hour before the circumcision. The area where the prepuce attaches to the glans is well coated with 1 g of the cream and then covered with a transparent occlusive dressing or finger cot. Just before the procedure the cream is removed. Blanching or redness of the skin may occur.

After the circumcision the infant is comforted until he is quieted. If the parents were not present during the procedure, the infant is returned to them. The infant can be fussy for several hours and can have disturbed sleep-wake states and disorganized feeding behaviors. Oral acetaminophen may be administered after the procedure every 4 hours (as ordered by the practitioner) for a maximum of five doses in 24 hours or a maximum of 75 mg/kg/day.

Care of the newly circumcised infant
Post-circumcision protocols vary. In many settings, the circumcision site is assessed for bleeding every 30 minutes for the first hour and then hourly for the next 4 to 6 hours. The nurse monitors the infant's urinary output, noting the time and amount of the first voiding after the circumcision. If bleeding is noted from the circumcision, the nurse applies gentle pressure to the site of bleeding with a folded sterile gauze square. A hemostatic agent such as Gelfoam® powder or sponge may be applied to the circumcision site to help control the bleeding. If bleeding is not easily controlled, a blood vessel may need to be ligated. In this event, one nurse notifies the physician and prepares the necessary equipment (i.e., circumcision tray and suture material), while another nurse maintains intermittent pressure until the physician arrives. If the parents take the baby home before the end of the observation period, they must be taught proper home care (Teaching Guidelines box).


Care of the Circumcised Newborn at Home
• Wash hands before touching the newly circumcised penis.

• Check circumcision for bleeding with each diaper change.
• If bleeding occurs, apply gentle pressure with a folded sterile gauze square. If bleeding does not stop with pressure, notify primary health care provider.

• Check to see that the infant urinates after being circumcised.
• Infant should have a wet diaper 2 to 6 times per 24 hours the first 1 to 2 days after birth, then 6 to 10 times per 24 hours after 3 to 4 days.

• Change the diaper and inspect the circumcision at least every 4 hours.
• Wash the penis gently with warm water to remove urine and feces. Apply petrolatum to the glans with each diaper change (omit petrolatum if a PlastiBell was used).
• Use soap only after the circumcision is healed (5 to 6 days).
• Apply the diaper to prevent pressure on the circumcised area.

• Glans penis is dark red after circumcision then becomes covered with yellow exudate in 24 hours, which is normal and will persist for 2 to 3 days. Do not attempt to remove it.
• Redness, swelling, discharge, or odor indicates infection. Notify the primary health care provider if you think the circumcision area is infected.

• Circumcision is painful. Handle the area gently.
• Provide extra holding, feeding, and opportunities for nonnutritive sucking for a day or two.

Nursing actions are planned and implemented to prevent infection. Prepackaged commercial wipes for cleaning the diaper area should not be used because they contain alcohol, which delays healing and causes discomfort. Instead, the nurse washes the penis gently with water to remove urine and feces and, if necessary, applies fresh petrolatum around the glans after each diaper change. The glans penis, normally dark red during healing, becomes covered with a yellow exudate in 24 hours, which is part of normal healing, not an infective process. No attempt should be made to remove the exudate, which persists for 2 to 3 days. Parents should be taught to apply the diaper so that it does not press on the circumcised area. They should be encouraged to change the diaper at least every 4 hours to prevent it from sticking to the penis.