NSG210 Week 10 Class Notes: OB Lecture 4 - Postpartum, Newborn, and Women’s Health

Class notes from the October 28, 2026 OB lecture (OB Lecture 4), expanded with explanations after class. This is Exam 3 content. Points marked “(lecture)” were stated in class; “(slide N)” points come from the slide deck; values from the textbook are marked “Durham Ch. N”. Other added detail is standard nursing teaching (AAP, ACOG, CDC, AWHONN guidance) and is not from the course materials. Where the lecture, slides, and textbook disagree, the note says so; check with the instructor which value the exam uses.

Companion pages: Week 10 lecture (slide summary) and Exam 3 lecture vs textbook differences.

Postpartum

postpartum period: delivery to 6 weeks
- also called the puerperium or “fourth trimester”
- in that time the reproductive organs return to their pre-pregnancy state (involution takes about 6 weeks)
- ends with the postpartum checkup; ACOG now recommends contact within 3 weeks and a full visit by 12 weeks
involution: the uterus returns to its pre-pregnancy tone, size, and position (slide 4)
- begins as soon as the placenta delivers; duration 6 weeks (lecture and slide 4) - the same 6 weeks as the postpartum period
- mechanism: contraction of the uterine muscle (clamps the open vessels at the placental site), shrinking of the enlarged muscle cells, and regrowth of the endometrium
- fundal height
  - right after delivery: halfway between the symphysis pubis and the umbilicus (lecture and slide 4)
    - the “same as 20 weeks” comparison belongs to the 1-hour position (umbilicus); halfway between the symphysis and umbilicus matches about 16 weeks of pregnancy
  - 1 hour after delivery: fundus approximately at the umbilicus, or up to 1 cm above it (lecture and slide 4) - same height as at 20 weeks of pregnancy
    - it rises slightly from its position right after delivery as the uterus fills with clots and the ligaments relax, then stays near the umbilicus for about the first day before descending
  - then descends about 1 cm (one fingerbreadth) per day
  - about 1 week: at the pubic bone per slide 4; by day 14: in the pelvis, no longer palpable
  - 6 weeks: back to pre-pregnancy status (lecture) - the uterus shrinks from about 1000 g at birth to about 60-70 g, its non-pregnant size
- normal fundus is firm and midline; boggy means massage it, and deviated means check the bladder
- helped by breastfeeding (oxytocin) and an empty bladder; slowed by retained placenta, infection, overdistention (large baby, twins, polyhydramnios) - see subinvolution
lochia: vaginal discharge after birth as the uterine lining (decidua) at the placental site sheds and heals (slides 7, 15)
- rubra: days 1-4; dark red, blood with small clots, fleshy odor
- serosa: days 4-10; pink to brown, thinner (old blood, serum, leukocytes)
- alba: after day 10; yellowish-white to clear (mostly leukocytes), can last until about week 6
- amount: scant (under 1 inch on the pad), light (under 4 inches), moderate (under 6 inches), heavy (a saturated pad within 1 hour)
- normal: it flows in sequence, never goes backward, and has a fleshy (not foul) odor; it increases a bit on standing or with breastfeeding
- report
  - foul odor: infection (endometritis)
  - return to rubra after serosa or alba: subinvolution or retained placental fragments
  - large clots, or saturating a pad in 1 hour or less: hemorrhage
  - steady bright red bleeding with a firm fundus: suspect a laceration
- after cesarean: usually less lochia, since the uterus is wiped during surgery
temperature
- up to 0.5 C (about 1 F) elevation in the first 24 hours is normal (slide 6)
  - from dehydration and the exertion of labor; should not exceed 100.4 F (38 C)
- day 3-4: a slight rise can come from breast engorgement (milk coming in) (slide 6)
- fever of 100.4 F (38 C) or higher on any 2 days after the first 24 hours (within the first 10 days) = postpartum infection until proven otherwise; a rise after day 3 usually means infection (slide 6)
  - check the uterus (endometritis: tender uterus, foul lochia), breasts (mastitis), incision or perineum (wound infection), urine (UTI), and legs (thrombophlebitis)
postpartum assessment: BUBBLE-HE, done each assessment and continued over the next 2 weeks (lecture)
- B - Breasts: soft, filling, or engorged; nipples (cracks, soreness, flat or inverted); latch; signs of mastitis (red, hot, wedge-shaped area, fever)
- U - Uterus: fundal height (fingerbreadths above or below the umbilicus), firm vs boggy, midline vs deviated; massage if boggy
- B - Bladder: voiding, amount, retention (distended bladder, displaced fundus), UTI symptoms
- B - Bowel: bowel sounds, flatus, first BM, constipation, hemorrhoids
- L - Lochia: color (rubra, serosa, alba), amount, clots, odor
- E - Episiotomy/perineum (and cesarean incision): REEDA - Redness, Edema, Ecchymosis, Discharge, Approximation
- H - Homans sign/hemorrhoids: legs for DVT (unilateral calf pain, swelling, warmth, redness; Homans sign is unreliable), and hemorrhoids
- E - Emotional: bonding, mood, Rubin’s phase, blues vs depression (EPDS), support at home
- also vital signs and pain each time
- frequency (slide 7): every 15 minutes x 1 hour, every 30 minutes x 1 hour, every 4 hours until 24 hours, then every shift; more often if not within normal limits
weight loss
- typical loss 10-13 lb, over about 6 weeks (lecture; slide 8 gives 10-13 lb)
- at birth: fetus, placenta, and amniotic fluid (slide 8 attributes the 10-13 lb to these)
- first week: about 5 more lb through diuresis and diaphoresis as the extra pregnancy fluid is shed
- return to pre-pregnancy weight varies; it is more likely by 6 months with a gain in the recommended range, and breastfeeding helps (extra 500-700 kcal/day used)
episiotomy and lacerations (slide 9)
- episiotomy: a surgical incision of the perineum to enlarge the vaginal opening at birth; no longer routine (it raises the risk of 3rd and 4th degree tears)
  - midline (median): straight down toward the anus; heals faster, less pain and blood loss, but can extend into a 3rd or 4th degree tear
  - mediolateral: cut at a 45-degree angle away from the anus; protects the sphincter but has more pain, blood loss, and slower healing
  - main complication of both: infection
- perineal lacerations (spontaneous tears), by degree
  - 1st: vaginal mucosa and perineal skin
  - 2nd: 1st plus perineal fascia and muscle (most common repaired tear)
  - 3rd: 2nd plus the anal (rectal) sphincter
  - 4th: 3rd plus the rectal mucosa, into the lumen
- nursing
  - assess with REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation), with her in side-lying (Sims) position, lifting the upper buttock
  - watch for a hematoma: severe perineal or rectal pain or pressure out of proportion, a tense bulging bluish mass, possibly with stable fundus and normal lochia but falling BP and rising pulse
  - comfort: ice packs for the first 24 hours (10-20 minutes at a time), then sitz baths (warm, 15-20 minutes, 2-4 times a day), witch hazel pads, lidocaine or benzocaine spray, NSAIDs, peri-bottle and front-to-back cleansing, change pads often
  - 3rd and 4th degree tears: stool softeners, no rectal temperatures, suppositories, or enemas; watch for infection and fecal incontinence
postpartum comfort measures (slide 23)
- perineal care: ice pack or cold gel pack to the perineum for 10-20 minutes to reduce swelling and pain, mainly in the first 24 hours; witch hazel pads (Tucks) for swelling and hemorrhoids (slide 23)
- sitz baths: warm water, 15-20 minutes, 2-4 times a day; after the first 24 hours (heat increases blood flow and healing) (slide 23)
- pain medication: NSAIDs (ibuprofen) - also good for afterpains; lidocaine spray or cream (topical anesthetic) (slide 23); acetaminophen; opioids short term after cesarean
- bowel movements: docusate (Colace) stool softener to prevent constipation and straining on stitches or hemorrhoids (slide 23); fluids and fiber
- sitting: a pillow or padded ring (slide 23); tightening the buttocks before sitting down also helps
- cleaning: peri-bottle with warm water after every void and stool; cleanse front to back (slide 23); pat dry; change pads often
- perineal (Kegel) exercises: start gently after 12 hours (slide 23); improve circulation and healing and restore pelvic floor tone
- rest: as much as possible (slide 23); sleep when the baby sleeps
- afterpains: worse in multiparas and during breastfeeding (oxytocin); empty bladder, lie prone with a pillow under the abdomen, NSAID about 30-60 minutes before nursing
- breast comfort: see engorgement (warm before feeds, cold after; supportive bra); lanolin or expressed breast milk for sore nipples
- hemorrhoids: witch hazel pads, sitz baths, topical anesthetic, stool softeners, avoid prolonged sitting
subinvolution (slide 12): failure of the uterus to involute (shrink and descend) as expected
- the superficial arteries at the placental site do not close or slough off properly, so bleeding continues
- causes: retained placental fragments, infection (endometritis), an overdistended uterus (large baby, multiples, polyhydramnios), fibroids
- signs: fundus higher than expected for the day and soft or boggy; prolonged or excessive lochia, or a return to rubra; abdominal pain and distension; lower back pain; can be late PPH (24 hours to 12 weeks after birth)
- diagnosis: ultrasound for retained tissue
- treatment: conservative medical care first - uterotonics such as methylergonovine (Methergine), antibiotics if infected, D&C for retained fragments; fertility-sparing uterine artery embolization; hysterectomy as a last resort
- nursing: track daily fundal height and lochia; teach her to report heavy bleeding, return of red lochia, clots, foul odor, or fever after discharge
postpartum hemorrhage (PPH) (slides 13-17)
- ACOG definition: cumulative blood loss of at least 1000 mL, or blood loss with signs or symptoms of hypovolemia within 24 hours of birth, regardless of route (vaginal or cesarean)
  - older definition was over 500 mL vaginal and over 1000 mL cesarean; may still appear in questions
- early (primary) PPH: within 24 hours; late (secondary): 24 hours to 12 weeks (subinvolution, retained fragments)
- causes - the 4 Ts
  - Tone: uterine atony (boggy uterus) - the most common cause
  - Trauma: lacerations, hematoma, uterine rupture or inversion
  - Tissue: retained placenta or clots
  - Thrombin: clotting disorders (DIC, von Willebrand)
- lecture: the 2 common causes of PPH are uterine atony and bladder displacement
  - they are linked: a full bladder pushes the uterus up and to the side, which keeps it from contracting, so it becomes boggy (atony) and bleeds
  - so with a boggy or displaced fundus: massage the fundus and empty the bladder (void, or straight cath), then reassess
- uterine atony = boggy uterus (lecture): the uterine muscle fails to contract, so the open vessels at the placental site keep bleeding
  - feels soft and spongy instead of firm; fundus often higher than expected and may be deviated (full bladder); heavy lochia with clots
  - first actions: fundal massage until firm (support the lower uterus), express clots, empty the bladder, then notify and give uterotonics
- atony risk: overdistended uterus (large baby, twins, polyhydramnios), long or rapid labor, oxytocin induction, magnesium, grand multiparity, chorioamnionitis, full bladder
- rule of 30 (slide 13): any of these means significant hemorrhage, about 30% of blood volume lost, and moderate (class III) shock
  - Hct falls 30% (for example, 36% to about 25%)
  - systolic BP falls 30 mm Hg
  - blood loss of 30% of blood volume (blood volume is about 70 mL/kg in adults, so about 1500 mL or more for most women)
  - other versions add a heart rate rise of 30 beats/min
  - why it matters: pregnancy adds about 40-50% to blood volume, so vital signs stay normal until a lot of blood is lost; by the time BP falls 30 mm Hg, she has lost about 30%
- signs appear late: tachycardia first, hypotension late; a loss of 1500 mL or more is likely with tachycardia, hypotension, or ongoing bleeding (slide 13)
- quantify blood loss (QBL) by weighing pads and linens (1 g = 1 mL) rather than estimating
- treatment (slide 17)
  - fundal massage first (support the lower uterus with the other hand), and empty the bladder (Foley)
  - uterotonics: oxytocin IV; methylergonovine (Methergine) IM - not in hypertension; carboprost (Hemabate) IM - not in asthma; misoprostol (Cytotec) rectal or buccal
- PPH treatment escalation (lecture): uterotonics, then tamponade, then TXA, then massive transfusion protocol (MTP); fundal massage, bladder emptying, IV access, and fluids run alongside from the start
  - 1. uterotonics: oxytocin first, then methylergonovine, carboprost, or misoprostol (see below)
  - 1. tamponade, if uterotonics fail: pressure from inside the uterus compresses the bleeding vessels
      - Bakri balloon: inserted into the uterus and filled with sterile fluid (up to about 500 mL); stays in up to 24 hours; watch output from its drain, fundal height, and vital signs
      - vacuum device (Jada): suction collapses the uterus so it contracts
      - uterine packing (gauze) is the older method
      - often with a Foley in place and antibiotics; removed gradually per provider
  - 1. TXA (tranexamic acid): antifibrinolytic that keeps formed clots from breaking down; 1 g IV over 10 minutes, may repeat once after 30 minutes; reduces deaths when given within 3 hours of birth (slide 17); ACOG advises it early, alongside uterotonics, so it may come sooner than this order
  - 1. MTP (massive transfusion protocol): the blood bank sends coolers of products in fixed ratios without waiting for each lab
      - RBCs, plasma (FFP), and platelets, roughly 1:1:1; cryoprecipitate for low fibrinogen (under 200 mg/dL)
      - watch for hypocalcemia (citrate in stored blood binds calcium; calcium is needed for clotting), hypothermia (use a blood warmer), hyperkalemia, and fluid overload
      - triggered by ongoing bleeding with unstable vital signs, usually blood loss over about 1500 mL
  - if all fail: arterial embolization (interventional radiology), surgery (B-Lynch compression suture, uterine artery ligation), hysterectomy
- uterotonics explained: drugs that make the uterus contract, which clamps the bleeding vessels at the placental site; used to prevent and treat atony. Doses from Durham Ch. 14
  - oxytocin (Pitocin) - first line
    - synthetic version of the hormone that causes contractions; given routinely after the placenta delivers
    - dose: 10-40 units in 500-1000 mL IV solution, titrated; or 10 units IM
    - never IV push undiluted (hypotension, tachycardia); large doses cause water intoxication (antidiuretic effect): watch for headache, confusion, low urine output, hyponatremia
    - check: fundus firm, bleeding, BP, pulse
  - methylergonovine (Methergine) - ergot alkaloid
    - causes a sustained (tetanic) contraction of the uterus
    - dose: 0.2 mg IM, may repeat every 2-4 hours; can be given PO afterward
    - causes vasoconstriction and raises BP: contraindicated in hypertension and preeclampsia (also heart disease); check BP before giving and hold if elevated
    - side effects: hypertension, headache, nausea, cramping
  - carboprost (Hemabate) - prostaglandin F2-alpha
    - stimulates strong uterine contractions
    - dose: 250 mcg IM (deep muscle or into the uterus), may repeat every 15 minutes, maximum 8 doses
    - causes bronchospasm: contraindicated in asthma
    - side effects: diarrhea (common - premedicate per order), nausea, vomiting, fever, chills
  - misoprostol (Cytotec) - prostaglandin E1
    - stimulates contractions; cheap, stable at room temperature, no IV needed
    - dose: 800-1000 mcg rectal, 600 mcg PO, or 800 mcg sublingual
    - side effects: fever and shivering, diarrhea, nausea
    - can be used with asthma or hypertension
  - tranexamic acid (TXA) - not a uterotonic but given alongside them
    - antifibrinolytic: stops clots from breaking down
    - 1 g IV over 10 minutes, may repeat once after 30 minutes; works best within 3 hours of birth (slide 17)
  - order usually: oxytocin first, then add methylergonovine, carboprost, or misoprostol depending on her BP and asthma history
  - key contraindications: Methergine raises BP, so no hypertension or preeclampsia; Hemabate narrows the airways, so no asthma
- supportive care throughout: 2 large-bore IVs, fluid resuscitation, oxygen (nonrebreather 10-12 L/min per Durham Ch. 14), and frequent vital signs
postpartum labs to follow
- CBC: H&H usually checked on postpartum day 1 and compared with the prenatal or admission value
  - Hgb falls about 1-1.5 g/dL and Hct about 3-4% per 500 mL of blood loss (Durham Ch. 12)
  - postpartum anemia: Hgb under 11 g/dL and Hct under 32% (Durham Ch. 12); treat with oral iron, IV iron, or transfusion if symptomatic
  - Hct rises back to normal in 3-5 days as diuresis clears the extra plasma (slide 3); dehydration raises Hct and blood loss lowers it
  - WBC: leukocytosis up to about 20,000-25,000 is normal in the first 10-14 days (stress of labor), so a high WBC alone does not mean infection; look for fever, foul lochia, and a tender uterus
  - platelets: especially with preeclampsia or HELLP, or after a large bleed
- blood type and Rh status, plus antibody screen
  - Rh-negative mother with an Rh-positive baby: give Rh(D) immune globulin (RhoGAM 300 mcg IM, or Rhophylac IM or IV) within 72 hours of birth (Durham Ch. 12)
  - a Kleihauer-Betke test measures fetal blood in her circulation and decides whether more than one dose is needed after a large bleed
- rubella status: if non-immune, give MMR before discharge and teach her to avoid pregnancy for 4 weeks (live vaccine); safe with breastfeeding (Durham Ch. 12)
- infection screens from prenatal care, mainly for the newborn: hepatitis B surface antigen, HIV, syphilis (RPR), GBS status
- vaccine status: Tdap, influenza, COVID-19, pneumococcal as needed (Durham Ch. 12)
- situation-specific labs
  - hemorrhage: coagulation studies (PT/INR, PTT, fibrinogen), type and crossmatch; fibrinogen under 200 mg/dL suggests DIC
  - preeclampsia: platelets, liver enzymes (AST, ALT), creatinine, uric acid, urine protein; magnesium level if on magnesium sulfate
  - gestational diabetes: glucose checks after delivery, then a 2-hour 75 g oral glucose tolerance test at 4-12 weeks postpartum to screen for type 2 diabetes
  - infection: urinalysis and urine culture (UTI), blood cultures, wound or lochia culture as indicated
postpartum care after cesarean section (slides 18-19)
- major abdominal surgery plus a postpartum patient: do routine postpartum care (BUBBLE-HE, fundus, lochia) and post-op care together
- maternal morbidity is doubled compared with a vaginal birth; hospital stay about 3 days; full recovery 6 weeks or longer (slide 18)
- complications: infection (incision, endometritis, UTI), hemorrhage, anemia, DVT/PE, bladder trauma, ileus, atelectasis and pneumonia, spinal headache (slides 18-19)
- fundus: assess gently, supporting the incision with a pillow or your other hand; lochia is usually less than after a vaginal birth
- respiratory: cough and deep breathing, incentive spirometry, splint the incision with a pillow; early ambulation (atelectasis and pneumonia prevention)
- VTE prevention: SCDs, early ambulation, leg exercises, anticoagulant prophylaxis as ordered; do not massage the legs (slide 18 lists a positive Homans sign, but it is unreliable)
- GI: watch for ileus (distension, absent bowel sounds, no flatus), nausea and vomiting; advance diet as tolerated; chewing gum and walking help return of bowel function
- urinary: Foley usually removed within 12-24 hours; then measure voids for retention
- incision: REEDA; dressing per protocol; teach no heavy lifting (nothing heavier than the baby), no driving while on opioids, report redness, drainage, or fever
- pain: scheduled NSAIDs and acetaminophen plus opioids as needed; after spinal or epidural morphine, monitor sedation and respiratory rate (delayed respiratory depression for up to 24 hours), itching, and allergic reaction (slide 19)
- anesthesia: watch for spinal headache (worse sitting up, better lying flat), return of sensation and movement in the legs (prolonged numbness is a neurologic deficit), and seizures (slide 19)
- IV therapy, analgesics, antibiotics, and increasing activity (slide 19)
- post-op management - cesarean (lecture, slide 19), by area
  - priority order (lecture): ABCs first, then deep breathing exercises
    - A - airway: patent airway as she recovers from anesthesia; position to prevent aspiration if nauseated or drowsy; suction at hand
    - B - breathing: respiratory rate, depth, and SpO2; sedation level (especially after spinal or epidural morphine); oxygen as ordered
    - C - circulation: BP, pulse, skin color, capillary refill; fundus and lochia for hemorrhage; dressing for bleeding; IV site and fluids; urine output (at least 30 mL/hr)
    - then deep breathing exercises: once ABCs are stable, start deep breathing, coughing (splint the incision with a pillow), and incentive spirometry to re-expand the lungs and prevent atelectasis and pneumonia
  - 1. involution and bleeding: assess the uterus for involutional changes and signs of complications; monitor for hemorrhage (fundus, lochia, dressing, vital signs); the uterus may be less firm after surgery, and oxytocin infusion usually continues for several hours
  - 1. pulmonary function: atelectasis and pneumonia are risks after anesthesia and with incision pain that limits deep breaths; turn, cough, deep breathe, incentive spirometer every hour while awake, splint the incision; listen to lung sounds
  - 1. thromboembolism prevention: sequential compression devices until she is walking well, early ambulation (usually within 6-12 hours), leg exercises, anticoagulant prophylaxis as ordered
  - 1. GI: assess for ileus, cholecystitis, persistent nausea and vomiting, and intestinal obstruction (slide 19); check bowel sounds, distension, flatus; start clear liquids and advance as tolerated
  - 1. IV therapy, analgesics, antibiotics, and increasing activity (slide 19): IV fluids until she drinks well; prophylactic antibiotics (given before the incision); pain plan; progress from dangling to walking
  - 1. anesthesia effects: monitor level of sedation, seizures, spinal headache, and neurologic deficits such as prolonged decreased sensation in the legs; monitor for allergic reactions to morphine (MSO4) given in the spinal or epidural (slide 19)
      - neuraxial morphine: respiratory rate and sedation checks (often every hour for 12-24 hours), itching, nausea; naloxone at hand
      - after a C-section, watch for headache (lecture): post-dural puncture headache (spinal headache) from the spinal or epidural anesthesia
        
        cause: CSF leaks through the hole in the dura, lowering CSF pressure so the brain sags and stretches pain-sensitive structures; more likely after an accidental dural puncture with an epidural needle
        
        onset usually within 1-3 days (up to 5 days)
        
        key sign: positional - worse sitting or standing, better lying flat; may have neck stiffness, nausea, ringing in the ears, light sensitivity, double vision
        
        nursing: report it; lie flat for comfort, oral or IV fluids, caffeine, analgesics (acetaminophen, NSAIDs)
        
        definitive treatment if it persists: epidural blood patch - the anesthesiologist injects her own blood into the epidural space to seal the leak; relief is often fast
        
        rule out other causes: always check BP - a severe postpartum headache with high BP or vision changes is postpartum preeclampsia, which is an emergency
  - also: Foley out within 12-24 hours then measure voids; incision check (REEDA); I&O; vital signs on the postpartum schedule; support bonding and breastfeeding positions that avoid the incision
- breastfeeding: football hold or side-lying to keep the baby off the incision
- emotional: may feel disappointment or a sense of failure after an unplanned cesarean; review the birth with her
lactation - benefits
- mother
  - uterine involution: suckling releases oxytocin, which contracts the uterus (afterpains during feeds), speeding involution and reducing bleeding
  - amenorrhea: suckling raises prolactin, which suppresses FSH/LH, so ovulation and periods are delayed (lactational amenorrhea)
    - lactational amenorrhea method (LAM) is about 98% effective only if all three hold: exclusive breastfeeding, no return of menses, and baby under 6 months
- baby
  - nutrition: complete nutrition for the first 6 months; colostrum first (high protein, low fat), mature milk by about day 3
  - immune system: colostrum and milk carry maternal antibodies (mainly IgA), which protect against infection
milk production (slides 2, 20)
- hormones: in pregnancy, high estrogen and progesterone (from the placenta) prepare the breasts but block milk release; when the placenta delivers, they fall and prolactin rises, which starts milk production (slide 20)
  - prolactin (anterior pituitary): makes the milk; released with suckling, so more feeding = more milk (supply and demand)
  - oxytocin (posterior pituitary): let-down (milk ejection) reflex - squeezes milk out of the alveoli into the ducts; also contracts the uterus (afterpains); let-down can be triggered by the baby crying and blocked by stress or pain
  - retained placental fragments can delay milk coming in (hormones stay high)
- stages
  - colostrum: thick, yellow; more protein, minerals, and antibodies (IgA), less sugar and fat than mature milk; secreted the first 2 days; small amounts fit the newborn’s small stomach; laxative effect helps pass meconium (lowers jaundice risk) (slide 20)
  - transitional milk: from about day 3
  - mature milk: present by day 3 or earlier; fully available by the end of the second week (slide 20)
    - foremilk (start of feed): watery, quenches thirst
    - hindmilk (end of feed): higher fat, satisfies and drives weight gain - let the baby finish one breast before switching
- volume: 500-800 mL/day; needs about 700 extra kcal/day (slides 2, 8)
- engorgement: days 3-5 - milk, venous and lymphatic stasis; breasts swollen, tense, tender (slide 20)
  - breastfeeding: feed often (8-12 times a day), warm compress or shower before feeding, cold packs after, express a little to soften the areola for latch
  - not breastfeeding: supportive bra, ice packs, cabbage leaves; avoid nipple stimulation and warm water on the breasts (they signal more milk)
- nursing: frequent feeding, good latch, hydration, rest; signs of adequate intake - 6-8 wet diapers a day by days 5-7, regular stools, weight regained by about 2 weeks
discharge instructions (slide 21, “After Discharge”)
- vaginal pain: tears take a few weeks or longer to heal; report fever or increasing pain (slide 21)
- vaginal bleeding: lochia should keep getting lighter; heavy bleeding with uterine tenderness and fever suggests endometritis (slide 21)
- breastfeeding: check latch, swallowing, and nipple condition; fever, breast tenderness, and redness mean a clogged duct vs mastitis (slide 21)
  - clogged duct: tender lump, no fever, keep nursing; mastitis: fever and flu-like symptoms, red wedge-shaped area, keep nursing on that side, antibiotics per provider
- breast engorgement: relieved by frequent feedings (slide 21)
- bladder and bowel: void every 3-4 hours, because the bladder can overfill without symptoms; stool softeners or laxatives for constipation (slide 21)
- contraception (slide 21)
  - breastfeeding: start after 6 weeks; progestin-only methods, because estrogen reduces milk supply
  - not breastfeeding: no estrogen-containing methods before 3 weeks, because of thromboembolism risk
  - ovulation: breastfeeding - prolactin suppresses FSH and LH, ovulation returns at about 6 weeks; not breastfeeding - a few weeks or longer after birth; she can get pregnant before her first period
- call the provider for (standard warning signs; AWHONN POST-BIRTH list)
  - pain in chest, obstructed breathing or shortness of breath
  - seizures
  - thoughts of hurting herself or the baby
  - bleeding soaking a pad in an hour or less, or clots the size of an egg or larger
  - incision that is not healing (red, draining, separating)
  - red or swollen leg that is painful or warm
  - temperature of 100.4 F (38 C) or higher
  - headache that does not get better with medicine, or with vision changes (postpartum preeclampsia)
- activity: rest when the baby sleeps; increase activity gradually; no heavy lifting (nothing heavier than the baby), especially after a cesarean; no driving while taking opioids
- sexual activity: usually after bleeding stops and the perineum or incision has healed (often around 4-6 weeks), and with contraception in place
- nutrition: well-balanced diet with fluids; extra 500-700 kcal/day if breastfeeding; continue prenatal vitamins and iron
- perineal care: peri-bottle, front-to-back cleansing, change pads often, sitz baths
- emotional: blues are normal in the first 2 weeks; report sadness lasting longer than 2 weeks, inability to cope or care for the baby, or any thoughts of harm
- follow-up: postpartum visit (ACOG: contact within 3 weeks, full visit by 12 weeks); baby’s pediatric visit within 1-2 days of discharge
- vaccines and medications before discharge: rubella (MMR) if non-immune, Rh immune globulin if Rh-negative with an Rh-positive baby, Tdap and flu if due
breastfeeding basics (slide 25)
- positioning: hold the baby belly-to-belly with full body support; head, shoulder, and hip aligned (slide 25)
  - holds: cradle, cross-cradle (good for newborns - more head control), football (after cesarean, large breasts, twins), side-lying (rest, after cesarean)
  - bring the baby to the breast, not the breast to the baby
- latch: nose, cheek, and chin touch the breast, with part of the areola in the mouth; a good latch does not hurt (slide 25)
  - wide-open mouth (like a yawn), lips flanged out, more areola visible above the top lip than below
  - tickle the upper lip with the nipple to get the mouth to open wide
  - pain past the first few seconds, or a pinched or flattened nipple after the feed, means a shallow latch - break suction and relatch
- signs of a good latch: slow, deep sucks with pauses, audible swallowing (slide 25); cheeks rounded, not dimpled; no clicking
- removing the baby: insert a finger into the corner of the baby’s mouth to break the suction (slide 25) - pulling off causes nipple trauma
- frequency: at least 8-12 times every 24 hours in the first weeks (slide 25); about every 2-3 hours, counted from the start of one feed to the start of the next; wake a sleepy newborn to feed
- when to feed: at the first hunger cues, not when crying (slide 25)
  - early cues: rooting, hand to mouth, sucking motions, lip smacking, stirring
  - crying is a late sign and makes latching harder - calm the baby first (slide 25)
- duration: AAP recommends exclusive breastfeeding for 6 months, then continuing with solid foods as long as mother and baby want (slide 25); about 10-20 minutes per breast early on - let the baby finish the first breast (hindmilk) before offering the second
- adequate intake: 6-8 or more wet diapers a day by days 5-7, yellow seedy stools by day 4-5, audible swallowing, baby content after feeds, breasts softer after feeding; weight loss up to 7-10% in the first days is normal, birth weight regained by 10-14 days
- mother’s care: extra 500 kcal/day (slide says 700 kcal) and fluids to thirst; continue prenatal vitamins; most medications are compatible, but check each one; avoid alcohol around feeds and smoking
- contraindications to breastfeeding: HIV (in the US), active untreated TB, HTLV, galactosemia in the infant, illicit drug use, some medications (chemotherapy, radioactive isotopes); herpes lesion on the breast (that side); methadone is not a contraindication (slide 58)
- tongue-tie (ankyloglossia): the frenulum (band under the tongue) is short, tight, or attached near the tip, limiting tongue movement
  - signs in the baby: can’t stick the tongue past the lower gums; heart-shaped or notched tongue tip when extended; can’t lift the tongue to the roof of the mouth; clicking, slipping off the breast, poor weight gain, long or constant feeds, fussiness
  - signs in the mother: nipple pain and damage (cracks, blanched or creased nipple after feeds), engorgement or low supply from poor milk removal, plugged ducts or mastitis
  - assess during the newborn exam (mouth) and when watching a feed
  - management: lactation consultant first (positioning, deeper latch); if it still interferes with feeding, frenotomy - a quick clip of the frenulum by the provider, often in the office with little bleeding; the baby can nurse right after (comfort)
  - not every tight frenulum needs a frenotomy - only if it causes feeding problems
- common problems: sore or cracked nipples (fix latch, lanolin or breast milk on nipples), engorgement, plugged duct, mastitis (keep feeding), thrush (white patches in the baby’s mouth, nipple pain - treat mother and baby)
breastfeeding vs formula - pros and cons (slide 24)
- breastfeeding pros
  - baby: lower risk of SIDS, asthma, skin allergies (eczema), ear infections, stomach bugs (GI infections), and type 1 diabetes (slide 24); antibodies (IgA) from colostrum and milk; easy to digest; changes to meet the baby’s needs
  - mother: lower BP, weight loss, lower risk of breast cancer, diabetes, and cardiovascular disease (slide 24); faster uterine involution and less bleeding (oxytocin); delays ovulation
  - bonding; reduces the harmful risks of smoking exposure for the baby (slide 24)
  - free and convenient - always ready, right temperature (slide 24)
- breastfeeding cons (slide 24)
  - time commitment; only the mother can feed unless she pumps
  - nipple pain (cracking, soreness)
  - mastitis
  - milk supply issues
  - imbalance of labor between parents
  - thrush
  - she must watch medications, alcohol, and diet
- formula pros (slide 24)
  - convenience: others can feed the baby; fathers can feel more involved in feedings
  - flexibility: can feed anywhere
  - formula babies usually need to feed less often (formula digests more slowly)
  - mother does not have to watch what she eats
  - intake can be measured exactly
- formula cons (slide 24)
  - lacks antibodies; cannot match the complexity of breast milk
  - expense
  - planning needed (supplies, bottles, sterilizing)
  - GI upset in the infant (constipation, gas)
- formula teaching: mix exactly as directed (too much water can cause water intoxication and low sodium; too little causes dehydration and kidney strain); do not microwave (hot spots); discard any milk left after a feed within about 1 hour; hold the baby during feeds, never prop the bottle (choking, ear infections, and tooth decay); iron-fortified formula; about 2-3 oz every 3-4 hours early on
- the nurse supports the mother’s informed choice either way; non-breastfeeding mothers need lactation suppression teaching (supportive bra, ice, avoid stimulation)

maternal adaptation and role attainment (slides 26-29; Durham Ch. 13)

the most important psychosocial changes: bonding, attachment, maternal touch and verbal behaviors, adaptation, and maternal role attainment (slide 29)

KEY - emphasized in lecture: Rubin’s phases - TAKING-IN, TAKING-HOLD, LETTING-GO

Phase	When	Mother’s focus	Nursing / teaching
TAKING-IN	First 3 days	Her own needs - sleep, food, comfort; passive, dependent; retells the birth	Do NOT teach baby care yet; meet her physical needs; listen to her birth story
TAKING-HOLD	Days 4-10	Baby care and her own body - independent, in control, wants to do it right; may doubt herself	BEST time to teach; demonstrate, then let her do it; praise and reassure
LETTING-GO	After day 10 (weeks)	New role and family - accepts motherhood; grieves the pregnancy and old role; teens torn between roles	Support role change and relationships; watch for depression

exam cues: “wants to talk about the delivery” or “asks for food and rest” = taking-in; “asks how to bathe the baby” or “wants to try changing the diaper” = taking-hold; “adjusting to life as a mother,” “misses her old life” = letting-go
priority question pattern: teaching in the first day or two will not be retained - the best time to teach is taking-hold

Rubin’s phases of maternal adaptation (slide 29) - details
- taking-in (first 3 days, about 1-2 days in newer sources)
  - mother is passive and dependent; focuses on her own needs (sleep, food, comfort)
  - needs time to talk about and interpret the birth experience - let her tell her story
  - NOT the optimum time to teach about baby care - meet her physical needs first
- taking-hold (days 4-10)
  - more independent and in control; begins to take on the tasks of mothering
  - IS the optimum time to teach about baby care; she wants to do things right and may need reassurance
  - may feel anxious about her competence; blues often appear here
- letting-go (after day 10, over weeks)
  - accepts the new role and lets go of the old one (and of the fantasy baby and the birth); may feel a deep sense of loss of the pregnancy
  - may be caught between dependent and independent roles; teen mothers may be conflicted between the maternal and teen roles (slide 29)
  - adjusts relationships with partner and family
newer view (Mercer, “becoming a mother”): role attainment continues over months, through commitment and preparation, getting to know the baby, a new normal, and maternal identity
bonding vs attachment (slides 27-28)
- bonding: mother-driven; the mother’s feelings and emotions toward the infant; forms in the hours, days, and weeks after birth, through the first year; measured with self-rated questionnaires (MIBS, PBQ)
- attachment: the child’s emotional bond to the caregiver, used as a safe, secure base to explore from and a source of comfort; broader time frame; measured by the Strange Situation test at 1 year
promote bonding: skin-to-skin right after birth, early breastfeeding, rooming-in, delay routine procedures in the first hour, point out the baby’s responses (“she’s looking at you”)
signs of positive bonding: en face position (face to face, eye contact), progression of touch (fingertips, then palms, then whole-hand holding), talking to the baby in a higher pitch, calling the baby by name, noticing family features, responding to cues
warning signs of impaired bonding (report and refer): avoids holding or looking at the baby, negative comments about the baby, not responding to cries, disinterest in learning care, calling the baby “it”, unrealistic expectations
risk factors for difficulty: unplanned or unwanted pregnancy, adolescent mother, lack of support, history of depression, substance use, intimate partner violence, a sick or premature infant separated in the NICU, traumatic birth, financial stress
partner and family: partners go through their own adjustment (engrossment - the father’s absorption with the newborn); siblings may regress or feel jealous - prepare them, let them help, give them one-on-one time

postpartum blues vs depression vs psychosis (slide 31)

	Postpartum blues	Postpartum depression (PPD)	Postpartum psychosis
How common	Most mothers (about 50-80%)	About 10-15% (1 in 7); most common postpartum psychiatric disorder (slide 31)	Rare, about 1-2 per 1000 births
Onset	Days 2-5 (peaks around day 4-5)	Any time in the first year; often within the first weeks to months	Sudden, usually within the first 2 weeks (slide 31), often days 3-14
Duration	A few days; resolves by 2 weeks	2 weeks or more; can last months without treatment	Until treated
Symptoms	Mild, short-lived emotional lability: tearfulness, frequent crying, irritability, anxiety, confusion, feeling overwhelmed (slide 31); still enjoys the baby and can function	Persistent sadness, loss of interest or pleasure, guilt and worthlessness, anxiety, sleep problems even when the baby sleeps, appetite change, trouble bonding, feeling like a bad mother, thoughts of self-harm; causes significant distress and dysfunction (slide 31)	Extreme confusion, paranoia, delusions (often about the baby), hallucinations, rapid mood swings, severe insomnia, disorganized behavior (slide 31); may have thoughts of harming herself or the baby
Cause	Rapid drop in estrogen and progesterone, fatigue, the stress of birth	Hormones plus risk factors: history of depression or anxiety, prior PPD, poor support, stress, unplanned pregnancy, complications, sick infant	Strongest link is bipolar disorder (personal or family history) or prior postpartum psychosis
Treatment	Reassurance, rest, help with the baby, support; teach that it is normal - and to report if it lasts past 2 weeks or worsens	Screening (EPDS, PHQ-9), counseling or therapy, antidepressants (SSRIs, sertraline compatible with breastfeeding), brexanolone or zuranolone (approved for PPD), support groups	Medical emergency (slide 31): do not leave her alone with the baby, ensure safety of mother and infant, hospitalize, antipsychotics and mood stabilizers, ECT if needed

key distinctions for exams
- blues: under 2 weeks, mild, she still functions - reassure and teach
- depression: 2 weeks or longer, interferes with function and bonding - screen and refer
- psychosis: loss of touch with reality (hallucinations, delusions) - emergency; risk of suicide and infanticide; never leave her alone with the baby

illusion vs hallucination vs delusion (terms used for psychosis)

Term	What it is	Real stimulus?	Example
Illusion	A misperception of something that is really there	Yes - misread	Sees a coat on a chair and thinks it is a person; hears the fan and thinks the baby is crying
Hallucination	A sensory perception with no stimulus at all (hearing, seeing, feeling, smelling, tasting)	No	Hears a voice telling her the baby is evil when no one is speaking (command hallucination - dangerous)
Delusion	A fixed false belief, not changed by evidence or reasoning, and not shared by her culture	Not a perception - a belief	Believes the baby is possessed, or was switched at birth, or that she must save the baby from the world

quick memory: illusion = misinterpreting something real; hallucination = perceiving something not there (a senses problem); delusion = believing something false (a thinking problem)
illusions can happen to anyone (fatigue, dim light, delirium); hallucinations and delusions are hallmarks of psychosis
nursing: do not argue with a delusion or agree with it; acknowledge her feelings and present reality simply (“I don’t hear a voice, but I can see you are frightened”); ask about command hallucinations directly (“are the voices telling you to do anything?”); safety first - for postpartum psychosis, never leave her alone with the baby

postpartum anxiety and OCD also occur: intrusive, unwanted thoughts of harm coming to the baby that horrify her (ego-dystonic) and lead to avoidance or checking; unlike psychosis, she knows the thoughts are not real and does not want to act on them
partners can develop postpartum depression too

postpartum depression screening: EPDS and PHQ-9 (slide 30)
- EPDS (Edinburgh Postnatal Depression Scale)
  - 10 self-report questions about the past 7 days, each scored 0-3; total 0-30 (slide 30)
  - focuses on psychological symptoms (mood, anhedonia, guilt, anxiety, self-harm); it leaves out the 3 physical symptoms of major depression - fatigue, changes in weight or appetite, and psychomotor change - because these are normal after birth (slide 30)
  - slide 30 score bands: 0-6 none or minimal; 7-13 mild; 14-19 moderate; 19-30 severe; also “10 or higher: minor depression” and “13 or higher: major depression”
    - the bands overlap (19 is in two; 10 and 13 have two meanings); the most commonly used cut-offs are 10 or more = possible depression, needs follow-up, and 13 or more = probable depression, refer
  - question 10 asks about thoughts of self-harm: any positive answer needs immediate safety assessment, no matter the total score
  - validated in pregnancy and postpartum, in many languages; also used for partners
- PHQ-9 (Patient Health Questionnaire)
  - 9 questions matching the DSM criteria for major depression, about the past 2 weeks, each scored 0-3; total 0-27; screens for the severity of depression (slide 30)
  - score bands (slide 30)
    - 0-4: none to minimal
    - 5-9: mild
    - 10-14: moderate
    - 15-19: moderately severe
    - 20-27: severe
  - 10 or more is the usual cut-off for referral; question 9 (thoughts of being better off dead or of self-harm): any positive answer needs immediate safety assessment
  - includes physical symptoms (sleep, energy, appetite), so it can over-score in the early postpartum weeks
  - PHQ-2 (first 2 questions: little interest or pleasure, feeling down) is a quick pre-screen; positive leads to the full PHQ-9
- why moderate depression can be more critical than severe (lecture point)
  - suicide risk and energy: in severe depression the person often has too little energy and too much psychomotor slowing to plan and act on suicidal thoughts; in moderate depression (or as severe depression starts to lift with treatment, often in the first weeks of an antidepressant) she still has the hopelessness but now has the energy to act - so suicide risk can be highest
  - easy to miss: a mother with moderate depression can still function, care for the baby, and “look fine,” so she is less likely to be noticed or referred than one with obvious severe symptoms
  - treatment threshold: a score in the moderate range (PHQ-9 10 or more; EPDS 13 or more) is where referral and treatment start, so it is the decision point
  - safety in practice: at any level, ask directly about thoughts of self-harm or harming the baby; watch closely when mood suddenly improves or energy returns, and when starting antidepressants
- EPDS vs PHQ-9: EPDS is specific to the perinatal period and avoids normal postpartum physical symptoms; PHQ-9 is a general depression tool, also used to track response to treatment
- when: ACOG - screen at least once in pregnancy and again at the postpartum visit; AAP - pediatricians screen mothers at well-baby visits (1, 2, 4, and 6 months)
- a screen is not a diagnosis: a positive screen leads to a full assessment by a provider
- nursing: give the tool privately (without the partner present), explain it is routine, review the self-harm item before she leaves, know the referral path and crisis resources (988 Suicide and Crisis Lifeline; National Maternal Mental Health Hotline 1-833-852-6262)
return of menstruation
- non-breastfeeding: menses return at 6-8 weeks postpartum
- breastfeeding: lecture said menses can also return at 6-8 weeks
  - the slides differ: slide 2 says usually 4-5 months or later (depends on how often and how exclusively she nurses); slide 21 says ovulation returns at about 6 weeks
  - Durham Ch. 12: non-lactating women - menses at 7-9 weeks, mean ovulation at 10 weeks, first cycle usually anovulatory; lactating women - return of menses depends on how long and how much she breastfeeds, mean ovulation at 17 weeks; ovulation can come before the first period, and breastfeeding is not an effective contraceptive
  - confirm which value the instructor wants for the exam
- ovulation can come before the first period, so she can get pregnant before menses return; contraception teaching matters either way
renal changes
- kidneys enlarge in pregnancy (higher blood volume and GFR); the increased volume shrinks back to pre-pregnancy size in 4-8 weeks postpartum (slide 2)
- the ureters and renal pelvis are also dilated in pregnancy (progesterone relaxes smooth muscle) and return to normal over the same weeks, which raises UTI risk meanwhile
- postpartum diuresis (slide 22)
  - what: the body removes the excess fluid and salt built up during pregnancy (pregnancy adds about 40-50% to blood volume plus extra tissue fluid)
  - why: estrogen and aldosterone fall after the placenta delivers, venous pressure in the legs drops, and fluid moves from the tissues back into the blood to be excreted
  - timing: begins about day 2 and lasts 3-4 days (slide 22); can start within 12 hours
  - amount: urine output up to about 3000 mL/day is normal (slide 22); also night sweats (diaphoresis) in the first week
  - effects: Hct rises back to normal in 3-5 days as plasma is lost (slide 3); weight drops about 5 lb in the first week; edema in the legs resolves
  - nursing
    - measure the first several voids and record I&O: output should be large; small frequent voids suggest retention with overflow, not diuresis
    - empty bladder often (every 3-4 hours), because a full bladder displaces the uterus and causes bleeding
    - fluids: drink enough water; the slide suggests lemon, lime, or cucumber in the water (slide 22)
    - comfort for night sweats: change linens and gown, fluids; reassure that sweating is normal
    - watch: little or no diuresis with rising BP, edema, or headache can be preeclampsia; with magnesium sulfate, urine output under 30 mL/hr is a toxicity warning
- hematuria (blood in urine): in the first 24 hours after a vaginal birth it is usually from bladder trauma during delivery and is expected; hematuria after 24 hours suggests UTI or other pathology and should be reported (slide 2)
- bladder tone is decreased, so watch for retention: a full bladder pushes the fundus up and to the side (usually right) and causes atony and bleeding; encourage voiding every 3-4 hours
- full bladder displacing the uterus
  - signs: fundus above the umbilicus and deviated to one side (usually right), boggy uterus, increased lochia, palpable bladder above the symphysis, frequent small voids (overflow)
  - first: help her void (up to the bathroom, privacy, running water, warm water over the perineum), then reassess the fundus
  - if she cannot void: straight cath (in-and-out) per order or protocol to empty the bladder, then recheck the fundus - it should move back to midline and firm up
  - first void should come within 6-8 hours after birth; measure the first few voids (aim for at least 150 mL per void) to rule out retention
  - an indwelling Foley is used if retention keeps recurring or during hemorrhage management
hematologic changes - Hct
- Hct (hematocrit) = percent of blood volume that is red cells, so it moves with plasma volume as well as with red cell loss
- high Hct: dehydration (hemoconcentration - less plasma, same red cells)
- low Hct: blood loss (hemorrhage) - also falls with fluid overload or hemodilution from IV fluids
- postpartum: Hct may drop at first, then rises and returns to normal in 3-5 days as diuresis removes the extra plasma (slide 3)
- Hct lags in acute hemorrhage: it can look normal at first because whole blood is lost; watch tachycardia, BP, and bleeding first (rule of 30: a 30% fall in Hct is a PPH sign, slide 13)
- compare to the pre-delivery value; check H&H on day 1 postpartum
cardiovascular changes - back to normal in 2-6 weeks
- cardiac output rises right after birth (blood from the contracted uterus returns to circulation, and the caval compression is gone), then falls back to pre-pregnancy level by about 2 weeks (slide 3)
- heart rate: pre-pregnancy rate by 6 weeks (slide 3)
  - pulse may be elevated for a few hours after delivery (exertion, excitement, pain) and is normal by day 2 (lecture and slide 8)
  - some women have a slow pulse (50-70) in the first week as cardiac output falls; this is normal
  - a pulse that stays high or keeps rising is an early sign of hemorrhage (tachycardia comes before hypotension) or infection - report it
- BP: may be up from pain or excitement; back to baseline by 16 weeks per slide 3; a new high BP postpartum can be postpartum preeclampsia, so report it
- blood volume: the extra pregnancy volume is shed through diuresis and diaphoresis in the first days
- pregnancy is a hypercoagulable state that persists 8-12 weeks postpartum, so DVT/PE risk is high; early ambulation and SCDs (slide 3)
- orthostatic hypotension: dangle and rise slowly the first time up
GI changes
- in pregnancy, progesterone relaxes smooth muscle, which slows GI motility (constipation) and relaxes the lower esophageal sphincter (acid reflux)
- progesterone drops within 24 hours of delivery; symptoms improve and return to normal in 3-4 days postpartum (slide 2)
- first bowel movement often takes 2-3 days; delayed by perineal pain, fear of pain, hemorrhoids, opioids, dehydration, and low intake
- full bowel function is normal by the end of the second postpartum week (slide 7)
- nursing: stool softener (docusate), fluids, fiber, ambulation; care for hemorrhoids (witch hazel pads, sitz baths)

Newborn

Apgar score (slides 33, 36)

rapid check of how the newborn is transitioning to life outside the uterus; done at 1 and 5 minutes after birth (slide 36); repeat every 5 minutes up to 20 minutes if the 5-minute score is under 7

5 signs, each scored 0, 1, or 2; total 0-10 (memory: APGAR)

Sign	0	1	2
Appearance (color)	Blue or pale all over	Body pink, hands and feet blue (acrocyanosis)	Pink all over
Pulse (heart rate)	Absent	Under 100	100 or more
Grimace (reflex irritability)	No response	Grimace	Cry, cough, sneeze, or pulls away
Activity (muscle tone)	Limp	Some flexion	Active motion, well flexed
Respiration	Absent	Slow, weak, irregular cry	Good, strong cry

interpretation
- 7-10: normal; routine care (most healthy newborns score 8-9 - acrocyanosis usually costs a point, so a 10 is uncommon)
- 4-6: moderately abnormal; may need stimulation, airway clearing, oxygen
- 0-3: severely depressed; needs resuscitation
the most important sign is heart rate, then respiratory effort; color is the least reliable (and harder to judge in darker skin - look at mucous membranes, palms, and soles)
resuscitation is NOT delayed to get the 1-minute Apgar; start NRP steps based on breathing, tone, and heart rate right away
the 1-minute score shows how the baby tolerated birth; the 5-minute score shows how well the baby is adapting (more meaningful); neither predicts long-term neurologic outcome on its own
lower scores are expected with prematurity, maternal anesthesia or opioids, and congenital anomalies
document the score and what it was based on

newborn transition: intrauterine to extrauterine life (slides 32-35; Durham Ch. 15)
- a complex process that needs many rapid physiological changes in every organ system (slide 34); the major changes are a rise in cardiac output and the switch from fetal to adult circulation (slide 34)
- respiratory: must clear lung fluid, secrete surfactant, and begin regular breathing (slide 34)
  - first breath triggered by the squeeze of the chest in the birth canal (pushes out fluid), cold, touch, sound, and falling oxygen and rising CO2
  - surfactant keeps the alveoli from collapsing; deficient in preterm babies (RDS)
  - cesarean babies without labor keep more lung fluid (transient tachypnea of the newborn)
  - normal: RR 30-60, with periodic breathing (pauses under 20 seconds); abnormal: grunting, flaring, retractions, apnea over 20 seconds
- cardiovascular: the heart must close the fetal shunts and adjust to new blood flow and pressures; pulmonary vessels dilate (slide 34)
  - lungs expand, oxygen rises, pulmonary resistance falls, so blood flows to the lungs
  - cord clamped, so systemic resistance rises
  - foramen ovale (between the atria) closes because left atrial pressure becomes higher than right
  - ductus arteriosus (pulmonary artery to aorta) constricts as oxygen rises, closes in days
  - ductus venosus (bypassing the liver) closes when the cord is cut
  - cardiac output increases to meet the higher demands of metabolism, breathing, and heat production (slide 34)
  - normal HR 110-160 (up to 180 crying, down to about 100 sleeping)
- metabolism: metabolic rate rises; catecholamines and glucagon surge; insulin falls (slide 34)
  - glucose falls after birth (the maternal supply stops) and should return to baseline in 30-60 minutes (slide 34)
  - risk of hypoglycemia: infants of diabetic mothers, SGA, LGA, preterm, cold stressed
- temperature: newborns can’t generate their own heat by shivering; they rely on brown fat metabolism (non-shivering thermogenesis) and skin-to-skin contact (slide 34)
  - heat loss by evaporation (wet skin - dry right away), conduction (cold surfaces), convection (drafts), radiation (cold nearby walls or windows)
  - prevent: dry immediately, remove wet linen, hat, skin-to-skin, warm blanket, radiant warmer
  - cold stress uses up oxygen and glucose (see cold stress in the high-risk section)
- renal: increased urine production because the kidneys can’t concentrate urine; GFR doubles in the first 2 weeks (slide 35); first void within 24 hours
- GI: sterile at birth, colonized by microbes from the mother and environment (slide 35); stomach holds 50-60 mL (slide 35); first meconium stool within 24-48 hours
- neuro: reflexes - sucking, startle (Moro), stepping, gag, cough, blink, sneeze (slide 35); the autonomic nervous system keeps cardiovascular and respiratory function stable (slide 35)
- hepatic: immature liver conjugates bilirubin slowly (jaundice); needs vitamin K because gut bacteria that make it are absent at birth
- periods of reactivity (typical timeline)
  - first period of reactivity: birth to about 30-60 minutes - alert, active, crying, rapid HR and RR; best time for first breastfeed and bonding
  - period of decreased responsiveness (sleep): about 60 minutes to 2-4 hours - sleepy, hard to wake, HR and RR slow down
  - second period of reactivity: about 2-8 hours - awake again, may gag on mucus, pass meconium, be interested in feeding
initial newborn assessment (slide 36)
- immediately at birth: Apgar at 1 and 5 minutes (heart rate, respirations, tone, reflexes, color) (slide 36); dry, warm, skin-to-skin; airway clear
- general appearance: activity level, alertness, tone (flexed posture is normal), color, respiratory status (slide 36)
- vital signs (slide 36)
  - temperature: axillary 97.7-99.5 F (36.5-37.5 C); slide 37 gives 96.8-99.5 F
  - heart rate: 110-160 (apical, full minute)
  - respirations: 30-60 (full minute; periodic breathing normal; slide 37 gives 40-60)
  - BP: not routine; normal about 60-80/30-45 (slide 37)
- measurements: weight 2500-4000 g; length about 45-55 cm (18-22 in); head circumference 33-35 cm, about 2 cm larger than the chest
- skin: color, texture, nails, rashes (slide 36)
  - normal: acrocyanosis (first 24-48 hours), vernix, lanugo, milia (white bumps on the nose), erythema toxicum (harmless red blotchy rash with white centers), Mongolian spots (blue-gray, lower back - document so they are not mistaken for bruises), stork bites (pink patches on the neck or eyelids)
  - abnormal: central cyanosis, jaundice in the first 24 hours, pallor, petechiae beyond the face
  - also check for polydactyly (extra fingers or toes) (slide 36)
- head and neck: shape, molding, fontanels, range of motion (slide 36)
  - anterior fontanel: diamond-shaped, soft and flat, closes by 12-18 months; posterior fontanel: triangle, closes by 2-3 months
  - bulging fontanel = increased ICP; sunken = dehydration
  - caput succedaneum: swelling of the scalp that crosses suture lines, present at birth, gone in days
  - cephalohematoma: blood under the periosteum, does NOT cross suture lines, appears hours after birth, lasts weeks; raises jaundice risk
- eyes: light reflex, alignment (slide 36); red reflex; subconjunctival hemorrhage can be normal from birth pressure; erythromycin ointment
- ears: location, shape, canal, skin tags (slide 36); top of the ear should be level with the outer corner of the eye - low-set ears go with chromosomal problems (such as trisomy 21) and kidney anomalies
  - ear inspection and ear drops - pulling the pinna (lecture)
    - infants and children under 3: pull the pinna DOWN and BACK - the infant ear canal is short and points upward
    - children over 3 and adults: pull the pinna UP and BACK - the adult ear canal curves upward and forward
    - memory: “down for the little ones, up as they grow up”
    - straightens the canal for the otoscope view and lets ear drops reach the eardrum
    - ear drops: warm to room temperature first (cold drops cause dizziness and pain), child on the side with the affected ear up, instill without touching the dropper to the ear, keep the position for a few minutes, gently massage in front of the ear (tragus)
    - newborns: hearing screen before discharge (slide 42); inspect for position, shape, canal patency, skin tags, and pits (slide 36)
- mouth: symmetry, completeness, size, color, intact hard and soft palate (slide 36) - feel with a gloved finger for cleft palate; check suck and rooting; Epstein pearls (small white cysts on the palate) are normal; check the tongue (tongue-tie)
- chest: symmetric; breast swelling from maternal hormones is normal; clavicles intact (fracture risk with large babies or shoulder dystocia - crepitus, asymmetric Moro)
- abdomen: masses or hernias; presence or absence of bowel sounds (slide 36); round and soft; umbilical cord with 3 vessels (2 arteries, 1 vein - AVA); a 2-vessel cord goes with kidney and heart anomalies
- genitals and anus: open passage of urine and stool; hypospadias and undescended testes (slide 36)
  - male: testes descended, urethral opening at the tip (hypospadias = underside; no circumcision until assessed)
  - female: swollen labia and pseudomenstruation (small blood-tinged discharge from maternal hormones) are normal
  - anus patent: first meconium within 24-48 hours
- arms and legs: movement and development (slide 36); equal movement, palmar creases (single crease with trisomy 21)
  - count fingers and toes (lecture): 10 and 10; extra digits = polydactyly (slide 36), fused or webbed digits = syndactyly; both can go with genetic syndromes
- rectum and anus (lecture): check that the anus is present, patent, and in the normal position (imperforate anus); passage of meconium within 24-48 hours confirms patency; do not take rectal temperatures in newborns (perforation risk) - use axillary
  - hips: Ortolani and Barlow maneuvers for developmental dysplasia (click or clunk, uneven gluteal folds, unequal leg length)
- spine: straight, no dimples, tufts of hair, or sacs (neural tube defects)
- reflexes: Moro (startle), rooting, sucking, palmar and plantar grasp, stepping, Babinski (fanning of toes is normal in infants), tonic neck (fencing)
- gestational age: New Ballard score (slides 38-40)

gestational age - New Ballard (Dubowitz/Ballard) score (slides 38-40)

two parts, each with 6 items: physical maturity (done within the first 2 hours, slide 39) and neuromuscular maturity (done within 24 hours, slide 40); the two scores are added to estimate gestational age (slide 40)
general rule: preterm babies are floppy and extended (low tone); term babies are flexed with resistance (good tone) - tone develops from the legs up (caudal to cephalad)

neuromuscular maturity (slide 40)

Item	How it’s done (slide 40)	Preterm	Term
Posture	How the baby holds arms and legs at rest, supine	Arms and legs extended, limp	Arms and legs fully flexed
Square window	How far the hand flexes toward the inner wrist	Wide angle (90 degrees)	Hand folds flat to the wrist (0 degrees)
Arm recoil	Flex the arms, extend them, release - how much they spring back to flexion	Slow or no recoil (stays extended)	Quick, brisk return to flexion
Popliteal angle	Thigh held against the abdomen, extend the knee - how far it straightens	Wide angle, near 180 degrees	Small angle, 90 degrees or less
Scarf sign	Pull the hand across the chest toward the opposite shoulder - where the elbow goes	Elbow passes the midline easily	Elbow does not reach the midline
Heel to ear	Bring the foot toward the ear on the same side	Foot reaches the ear easily	Strong resistance; foot stays far from the ear

physical maturity (slide 39)
- skin: sticky and red (very preterm), then smooth pink with visible veins, then cracking and peeling (term and post-term)
- lanugo (soft downy hair): absent in very immature babies, abundant mid-preterm, thins near term, gone in post-term babies
- plantar creases: absent in preterm; cover the whole sole at term
- breast: barely visible tissue in preterm; raised areola with a 5-10 mm bud at term
- eyes and ears: eyelids fused in very preterm; ear soft, flat, stays folded in preterm; firm cartilage and instant recoil at term
- genitals
  - male: testes undescended and scrotum smooth (preterm); testes descended with deep rugae (term)
  - female: prominent clitoris and labia minora (preterm); labia majora cover the clitoris and labia minora (term)
classification by gestational age: preterm under 37 weeks; term 37-41 6/7 weeks (early term 37-38 6/7, full term 39-40 6/7, late term 41-41 6/7); post-term 42 weeks or more
combined with weight to classify SGA (under 10th percentile), AGA, or LGA (over 90th) (slide 45) - guides glucose monitoring and risk assessment

meconium
- the baby’s first stool: thick, sticky, tar-like, greenish-black and odorless; made of amniotic fluid, mucus, bile, skin cells, lanugo, and intestinal cells swallowed in utero; sterile
- first passage: within 24 hours for most term babies (up to 48 hours); no meconium by 48 hours suggests obstruction
  - possible causes of delay: meconium plug, Hirschsprung disease (missing nerve cells in the colon), meconium ileus (thick meconium blocking the ileum - often the first sign of cystic fibrosis), imperforate anus
- stool progression
  - meconium: days 1-2, black-green, sticky
  - transitional: days 3-4, greenish-brown to yellow, looser
  - breastfed: by day 4-5, mustard yellow, seedy, loose, sweet smell; often a stool after each feed early on
  - formula-fed: pale yellow to tan, firmer, pasty, stronger smell, less often
- feeding helps pass meconium: colostrum is a natural laxative; passing it removes bilirubin from the gut (less jaundice)
- care: clean with water or mild wipes (sticky - a little petroleum jelly on the skin makes the next change easier); note the time of the first stool
- meconium in the amniotic fluid (meconium-stained fluid): green or brown fluid at rupture of membranes
  - the fetus passed meconium before birth; more common in post-term babies and with fetal hypoxia or stress (hypoxia relaxes the anal sphincter and increases gut movement)
  - risk: meconium aspiration syndrome (MAS) - partial airway blockage with air trapping, chemical pneumonitis, surfactant inactivation (slide 51)
  - signs of MAS: meconium-stained skin, nails, and cord; respiratory distress at birth or within hours; meconium seen below the vocal cords; chest X-ray with atelectasis and hyperinflated areas (slide 51)
  - treatment: surfactant, ventilation, cooling, antibiotics (slide 51)
  - current NRP: a vigorous baby (good tone, breathing or crying) gets routine care at the mother’s side; a non-vigorous baby gets standard resuscitation starting with ventilation - routine intubation and suctioning below the cords is no longer recommended
- meconium also matters in labor: report the color of fluid at rupture of membranes (thick meconium is more concerning than thin)

newborn reflexes, GI, and renal (slide 35)

reflexes: sucking, startle, step, gag, cough, blink, sneeze (slide 35); the autonomic nervous system keeps heart and breathing stable (slide 35)

reflexes show an intact nervous system; absent, weak, or asymmetric reflexes suggest neurologic injury (asymmetric Moro: fractured clavicle or brachial plexus injury)

Reflex	How to elicit / what you see	Disappears
Rooting	Stroke the cheek; baby turns toward it and opens mouth	3-4 months
Sucking	Object in mouth; strong rhythmic suck	Becomes voluntary by about 4 months
Moro (startle)	Sudden loss of support or loud noise; arms extend and abduct, fingers fan, then arms come together as if hugging, often with a cry	4-6 months
Palmar grasp	Finger in the palm; baby grips tightly	3-4 months
Plantar grasp	Press the sole below the toes; toes curl down	8-12 months
Babinski	Stroke the sole from heel up the outside; toes fan out and big toe extends (normal in infants)	About 1 year (abnormal after walking age)
Stepping (walking)	Hold upright with feet on a surface; baby makes stepping motions	3-4 months
Tonic neck (fencing)	Turn the head to one side; arm and leg on that side extend, opposite side flexes	4-6 months
Galant (trunk incurvation)	Stroke along one side of the spine with baby prone; trunk curves toward that side	4-6 months
Crawling	Placed prone; baby makes crawling motions	About 6 weeks
Protective: gag, cough, sneeze, blink	Clear the airway and protect the eyes	Persist for life

exam tips: Moro is the most tested - symmetric response is normal; absent Moro suggests CNS problem, one-sided suggests clavicle fracture or brachial plexus (Erb) palsy; a positive Babinski is NORMAL in a newborn but abnormal in adults; most primitive reflexes are gone by 4-6 months - persistence suggests a neurologic problem (such as cerebral palsy)

GI (slide 35)
- the GI tract is sterile at birth; microbes from the mother and environment colonize it after birth (slide 35) - that is why vitamin K is given (gut bacteria normally make it)
- stomach holds 50-60 mL (slide 35); day-1 stomach is much smaller (about 5-7 mL per feed), so small frequent feeds; colostrum fits this
- immature lower esophageal sphincter: spitting up is common
- limited enzymes for digesting complex carbohydrates and fats; breast milk is easiest to digest
- bowel sounds within the first hour; meconium within 24-48 hours
- normal weight loss up to 7-10% in the first days (fluid loss, small intake); birth weight regained by 10-14 days
renal (slide 35)
- kidneys are immature: can’t concentrate urine, so urine is dilute and output is high relative to size (slide 35); also can’t handle large fluid or salt loads, so mix formula exactly
- GFR doubles in the first 2 weeks as renal blood flow increases (slide 35)
- first void within 24 hours - report if none by 24 hours (possible obstruction or kidney anomaly)
- wet diapers: about 1 on day 1, 2 on day 2, rising to 6-8 or more a day by days 5-7 (adequate intake)
- normal output: 1-2 mL/kg/hr; under 1 mL/kg/hr = oliguria; weigh the diaper dry and wet (1 g = 1 mL)
- pink or brick-dust stains (uric acid crystals) are normal in the first days; persisting past the first few days suggests dehydration
- pseudomenstruation in girls is from maternal hormones, not the urinary tract

newborn medications: erythromycin eye ointment and vitamin K (slide 41)
- erythromycin ophthalmic ointment 0.5%
  - purpose: prophylaxis against gonococcal (and chlamydial) eye infection - ophthalmia neonatorum, which can cause blindness; the baby is exposed in the birth canal (slide 41)
  - timing: slide 41 says within 24 hours; Durham Ch. 15 says within 1 hour of birth - often given after the first hour of skin-to-skin so it doesn’t blur the baby’s vision during bonding
  - how: a 1 cm ribbon along the lower conjunctival sac of each eye, inner to outer canthus; don’t touch the eye with the tube; wipe excess after 1 minute; do not rinse
  - given even after cesarean birth (hospital policy; required by law in many states); parents may decline in some states with informed refusal
  - side effects: temporary blurred vision, mild redness or swelling (chemical conjunctivitis) for 24-48 hours
- vitamin K (phytonadione, AquaMEPHYTON)
  - why: newborns are vitamin K deficient - the gut is sterile at birth (bacteria normally make vitamin K), little crosses the placenta, the liver is immature, and breast milk is low in vitamin K (Durham Ch. 15); vitamin K is needed for clotting factors II, VII, IX, and X
  - prevents vitamin K deficiency bleeding (VKDB, formerly hemorrhagic disease of the newborn) (slide 41)
    - early onset: first 24 hours (day 1) - often from maternal drugs (anticonvulsants, warfarin, some antibiotics)
    - classic onset: days 2-7 - GI, umbilical, or circumcision bleeding
    - late onset: day 8 to 6 months - mostly in exclusively breastfed babies who did not get vitamin K; often intracranial hemorrhage, can be fatal
  - dose: 0.5-1 mg IM once (0.5 mg if under 1500 g), in the vastus lateralis (anterolateral thigh) - the preferred IM site in newborns
  - timing: slide 41 says within 6 hours; Durham Ch. 15 says IM within 1 hour of birth; must be given before circumcision
  - oral vitamin K is less effective (multiple doses needed); parents who refuse need teaching on the risk of late VKDB and its signs
- hepatitis B vaccine is the other routine newborn medication: first dose within 24 hours of birth (plus HBIG within 12 hours if the mother is HBsAg-positive), IM in the thigh, with parental consent
- nursing: check orders and consent, document, and use opposite thighs if giving both vitamin K and hepatitis B vaccine
newborn screenings (slide 42)
- metabolic screening (heel stick, “newborn screen”): all babies born in New Jersey are tested for 61 disorders within 48 hours of birth (lecture and slide 42); identifies infants at risk for metabolic disorders before symptoms
  - common tests (slide 42): PKU (phenylketonuria), congenital hypothyroidism, galactosemia, sickle cell disease, cystic fibrosis; slide also lists toxoplasmosis; others include maple syrup urine disease, congenital adrenal hyperplasia, hemoglobinopathies, SCID (severe combined immunodeficiency), SMA
  - timing: collect between 24 and 48 hours of age (lecture) - after 24 hours so feeding (protein intake) has started and PKU is not missed, and by 48 hours so results come back early enough to treat; if the baby goes home before 24 hours, collect before discharge and repeat the test (by 1-2 weeks of age)
  - how: warm the heel, puncture the lateral or medial side of the heel (avoid the center - bone and nerve), wipe the first drop, fill each circle on the filter card completely from one side with a single drop (no layering, no squeezing, don’t touch the circles), dry flat away from heat
  - parents get results through the pediatrician; a positive screen needs a confirmatory test - it is not a diagnosis
  - why it matters: early treatment prevents disability or death - PKU (special low-phenylalanine diet prevents intellectual disability), hypothyroidism (levothyroxine), galactosemia (lactose-free formula; no breastfeeding)
- hearing screening: identify hearing loss as early as possible (slide 42); done before discharge (OAE or ABR); goal 1-3-6: screen by 1 month, diagnose by 3 months, intervene by 6 months
- critical congenital heart disease (CCHD) screening (slide 42): pulse oximetry after 24 hours of age, right hand (pre-ductal) and either foot (post-ductal)
  - pass: 95% or higher in either site and a difference of 3% or less; a fail needs an echocardiogram
  - detects 7 defects (slide 42): hypoplastic left heart syndrome / coarctation of the aorta, double outlet right ventricle, tetralogy of Fallot, pulmonary atresia, transposition of the great arteries, total anomalous pulmonary venous return (TAPVR), tricuspid atresia
- also before discharge: bilirubin check (TcB or TSB), blood glucose for at-risk babies
circumcision (slide 60 - video only)
- surgical removal of the foreskin (prepuce); elective; parents decide after informed consent (benefits: fewer UTIs in infancy, lower risk of some STIs and penile cancer; risks: bleeding, infection, injury)
- exceptions - do NOT circumcise (contraindications)
  - hypospadias or epispadias: the urethral opening is on the underside (or top) of the penis - the foreskin is saved for later surgical repair; the most commonly tested exception
  - chordee (downward curve of the penis), buried or webbed penis, micropenis
  - ambiguous genitalia
  - bleeding disorders or a family history of them (hemophilia, von Willebrand) - check before; vitamin K must have been given
  - sick, unstable, or preterm infant - wait until the baby is stable and growing
  - not yet voided (some protocols want a first void to show the urinary tract is working)
- before: consent signed, vitamin K given, baby has voided, NPO about 1-2 hours before (aspiration risk), pain control - dorsal penile nerve block or ring block, sucrose on a pacifier, topical anesthetic cream; restraint board with the baby kept warm
- methods: Gomco or Mogen clamp (petroleum jelly gauze afterward); Plastibell (plastic ring stays on and falls off in 5-8 days - no petroleum jelly)
- after
  - check for bleeding every 15-30 minutes for the first hour, then with each diaper change for 24 hours; small spots are normal, steady bleeding is not (apply gentle pressure, notify)
  - first void after the procedure - document (swelling can block urine flow)
  - yellow-white exudate (granulation tissue) forms in 2-3 days - normal, not pus; do not wipe it off
  - care: petroleum jelly with each diaper change (Gomco/Mogen) to keep it from sticking, fasten the diaper loosely, clean with warm water only (no wipes with alcohol), heals in 7-10 days
  - call for: bleeding that does not stop, no void within 12 hours, fever, increasing redness or swelling, foul drainage, Plastibell that slips or has not fallen off by 8-10 days
- uncircumcised care: wash the outside only; do not retract the foreskin (it separates naturally over years)

newborn differences: vaginal birth (through the birth canal) vs cesarean birth

	Vaginal birth	Cesarean birth
Lung fluid	The squeeze of the chest in the birth canal pushes fluid out of the lungs; labor hormones (catecholamines) also help the lungs absorb fluid	No chest squeeze (and often no labor if scheduled), so more fluid stays in the lungs - higher risk of transient tachypnea of the newborn (TTN) and respiratory distress; labor before a cesarean lowers the risk
First breath and transition	Labor stress hormones prepare the baby for breathing, temperature control, and glucose; usually smoother transition	Less catecholamine surge; may need more stimulation, suctioning, or oxygen; slower transition
Gut bacteria (microbiome)	Colonized by the mother’s vaginal and gut bacteria (Lactobacillus) as the baby passes through - helps immunity and digestion	Colonized first by skin and hospital bacteria; linked to slightly higher risk of asthma, allergies, and obesity later
Head shape	Molding (overlapping skull bones), caput succedaneum, possible cephalohematoma - resolve in days to weeks	Round head, no molding (unless labor came first)
Birth injuries	Bruising, clavicle fracture, brachial plexus injury (shoulder dystocia), forceps or vacuum marks, scalp hematoma	Fewer; possible small cuts from the scalpel
Medications	Less exposure to anesthesia (unless epidural); fentanyl in labor can cause sleepiness	Spinal or general anesthesia - general can cause a sleepy, depressed baby at birth
Bonding and breastfeeding	Immediate skin-to-skin and early breastfeeding are easier	Skin-to-skin may be delayed (often possible in the OR); milk may come in a bit later; mother’s pain and mobility limit early feeding
Gestational age	Usually labor begins when the baby is ready	Scheduled cesarean before 39 weeks raises the risk of breathing problems - elective cesarean is not done before 39 weeks
Low glucose and temperature	Less risk	Somewhat higher risk of hypothermia (cold OR) and hypoglycemia

nursing for a cesarean baby: watch breathing closely (rate over 60, grunting, flaring, retractions), suction as needed, keep warm, start skin-to-skin as soon as possible, support early breastfeeding

car seat instructions (part of newborn discharge teaching)
- the baby must go home in an approved, properly installed car seat; parents bring it and install it (nurses teach and check but usually do not install it, per hospital policy)
- rear-facing in the back seat, as long as possible - until the child reaches the seat’s highest rear-facing height or weight limit (AAP), at least to about age 2
- never in the front seat in front of an active airbag
- middle of the back seat is safest if the seat can be installed tightly there
- installation: use either the seat belt or the LATCH system (not both unless the seat allows it); the base should move less than 1 inch side to side or front to back at the belt path
- recline: about 45 degrees for a newborn (use the seat’s angle indicator) so the head does not fall forward and block the airway
- harness
  - straps at or below the shoulders for rear-facing
  - snug: pinch test - you should not be able to pinch a fold of strap at the shoulder
  - chest clip at armpit level
- no bulky coats or snowsuits under the harness (they compress in a crash and leave the straps loose); put a blanket over the buckled harness instead
- no add-on products (head inserts, strap covers, mirrors) that did not come with the seat
- do not use a seat that is expired (check the date on the label), recalled, or has been in a moderate or severe crash; avoid used seats with unknown history
- never leave the baby alone in the car; the car seat is not for sleep outside the car - move the baby to a flat crib (positional asphyxia)
- infants born before 37 weeks or with low birth weight need a car seat challenge (car seat tolerance screening) before discharge: observed in their own car seat for 90-120 minutes, or the length of the ride home, for apnea, bradycardia, or oxygen desaturation
- free checks: certified child passenger safety technicians (fire departments, police, hospitals)

bilirubin and newborn jaundice (slides 47-50; Durham Ch. 15, 17)

what bilirubin is: a yellow pigment from the breakdown of red blood cells (heme)
- unconjugated (indirect): fat-soluble, cannot be excreted; can deposit in skin (jaundice) and cross the blood-brain barrier
- the liver conjugates it (enzyme glucuronyl transferase) into conjugated (direct) bilirubin, which is water-soluble and excreted in bile and stool
- total serum bilirubin (TSB) = unconjugated plus conjugated (Durham Ch. 17)
why newborns get jaundiced (physiological causes, Durham Ch. 17)
- more RBCs with a shorter life span, so high bilirubin production
- immature liver: less conjugating enzyme
- sterile gut and slow stooling: bilirubin is reabsorbed from the intestine (enterohepatic circulation) - why early, frequent feeding and passing meconium matter

physiological vs pathological jaundice - side by side (slide 48)

	Physiological	Pathological
Onset	After 24 hours (30-72 hours) - never before 24 hours	Within the first 24 hours - always abnormal
Peak	Day 4 term (day 5-6 preterm)	Any time; rises fast
Rate of rise	Slow	More than 5 mg/dL per day or 0.5 mg/dL per hour
Total bilirubin	Not over 15 mg/dL (lower in preterm)	Over 15 mg/dL; or any rise in conjugated (direct) bilirubin
Duration	Gone by day 7-10 term, day 14 preterm	Over 1 week term, over 2 weeks preterm
Extent	Face and upper body	Spreads to palms and soles
Stool and urine	Normal	Clay or white stool, dark urine that stains the diaper (conjugated - liver or biliary problem)
Cause	Normal newborn physiology: high RBC breakdown, immature liver, gut reabsorption	Disease: hemolysis (Rh or ABO incompatibility - Coombs test if mother is type O or Rh-negative), G6PD deficiency, infection or sepsis, hepatitis, biliary atresia, bruising or cephalohematoma, polycythemia
Treatment	None needed; frequent feeding; resolves on its own	Find and treat the cause; phototherapy; IVIG for hemolysis; exchange transfusion if severe
Risk	Low	Kernicterus if untreated

one-line rule: jaundice in the first 24 hours is pathological until proven otherwise - report it right away

breastfeeding jaundice vs breast milk jaundice - side by side (slide 48)

	Breastfeeding jaundice	Breast milk jaundice
Other names	Lack-of-breastfeeding jaundice, starvation jaundice, suboptimal intake jaundice (slide 48)	Late-onset jaundice
Onset	Early - first week (days 2-4)	Later - slide 48 says appears 2-5 days after birth; most sources say after the first week (days 5-7)
Peak and duration	Resolves once intake improves	Peaks day 10-14; may remain high for several weeks or months (slide 48)
Cause	Not enough milk: infrequent or ineffective breastfeeding means low calories and few stools, so bilirubin is reabsorbed from the gut (slide 48)	Something in the mother’s milk (possibly an enzyme or factor that increases gut reabsorption of bilirubin); cause unknown (slide 48)
Problem is	The amount of breastfeeding	The milk itself
Baby	Signs of poor intake: weight loss over 7-10%, few wet diapers and stools, sleepy	Healthy, feeding well, gaining weight
How common	Common	Rare (slide 48)
Treatment	Breastfeed more often (8-12 times a day), improve latch, lactation consultant; supplement with expressed milk or formula only if needed; phototherapy if levels are high	Usually continue breastfeeding with monitoring; if levels are high, may stop breastfeeding briefly (24-48 hours) and give donor milk or formula to reduce bilirubin (slide 48), pumping to keep supply; phototherapy if needed; level drops quickly when breast milk is paused - which also confirms the diagnosis

memory: breastFEEDING jaundice = a FEEDING problem (too little, early) - fix with more feeding; breast MILK jaundice = a MILK problem (the milk, late, baby thriving) - rare, may pause breast milk
neither is a reason to stop breastfeeding permanently

types (slide 48)
- physiological: appears after 24 hours (30-72 hours), peaks day 4 in term babies (day 5-6 preterm), TSB not over 15 mg/dL, gone by day 7-10 (term) or 14 (preterm), no treatment needed
- pathological: appears within the first 24 hours - always abnormal; rises more than 5 mg/dL per day (0.5 mg/dL per hour) or TSB over 15; yellow palms and soles; clay-colored stool, dark urine that stains the diaper; lasts over 1 week (term) or 2 weeks (preterm)
  - causes: hemolytic disease (Rh or ABO incompatibility - Coombs test if mother is type O or Rh-negative), infection or sepsis, G6PD deficiency, bruising or cephalohematoma, polycythemia, liver disease; conjugated (direct) hyperbilirubinemia is always pathological
- breastfeeding (lack-of-breastfeeding) jaundice: early, first week; from too little intake (infrequent or ineffective feeding) - fix by feeding more often (8-12 times a day)
- breast milk jaundice: later, appears around day 5-7 (slide: 2-5 days), peaks day 10-14, may last weeks; rare; cause unknown (a factor in the milk); may need a short break with donor milk or formula
assessment
- jaundice spreads head to toe (cephalocaudal): face first, then chest, abdomen, legs; the lower it goes, the higher the level
- check in natural light: press on the nose or chest (blanch) and look at the skin color; also sclera and gums (useful in darker skin)
- transcutaneous bilirubin (TcB) meter as a screen, then TSB blood test to confirm
- plot the level by the baby’s age in hours on a nomogram (Bhutani; AAP hour-specific thresholds) to judge risk and need for treatment (Durham Ch. 17)
- labs for pathological jaundice: TSB with direct and indirect fractions, blood type and Coombs (antiglobulin) test, CBC and reticulocytes
- risk factors: prematurity, exclusive breastfeeding with poor intake, ABO or Rh incompatibility, sibling who needed phototherapy, cephalohematoma or bruising, East Asian ancestry, infant of a diabetic mother
complication: acute bilirubin encephalopathy and kernicterus - irreversible deposit of unconjugated bilirubin in the brain (Durham Ch. 17)
- early signs: lethargy, poor feeding, hypotonia, high-pitched cry; later: arching (opisthotonos), seizures
- long-term: hearing loss, cerebral palsy, motor delay, intellectual disability
treatment
- feed frequently (8-12 times a day): stools carry bilirubin out
- phototherapy: most common and effective treatment (Durham Ch. 17); blue light changes bilirubin in the skin into a water-soluble form excreted in urine and stool
  - nursing: undress the baby (diaper only) to expose as much skin as possible; cover the eyes with eye shields (check for eye drainage and remove during feeds for bonding); turn every 2-3 hours if using overhead lights; no lotions or oils on the skin (burn risk)
  - watch temperature (hyper- or hypothermia), hydration (insensible fluid loss: weigh daily, count wet diapers, extra feeds), and skin
  - expected: loose green stools (bilirubin excretion), temporary rash; bronze baby syndrome if conjugated bilirubin is high
  - keep lights on except for brief feeds; TSB checked regularly (skin color is not reliable during phototherapy); fiber-optic blanket allows holding and home treatment
- exchange transfusion: for very high or rapidly rising levels or signs of encephalopathy; needed less often since RhoGAM and phototherapy (Durham Ch. 17)
- IVIG for isoimmune hemolytic disease (Rh or ABO) per provider
discharge (release) advice for jaundice and bilirubin
- before discharge: every newborn gets a bilirubin check (TcB or TSB) plotted by age in hours, plus a risk factor review; this sets the follow-up date (AAP 2022)
- why it matters: bilirubin peaks on day 3-5, usually after the baby is home (most go home at 24-48 hours), so parents are the ones who see it rise
- follow-up: a visit with a bilirubin and weight check within 1-2 days of discharge (sooner if the level was near the treatment line or the baby has risk factors); keep this appointment
- feeding: 8-12 feeds a day (every 2-3 hours, wake the baby if needed); stools carry bilirubin out; do not give water or sugar water (no benefit, and can cause low sodium)
- output to count: by days 5-7, 6 or more wet diapers and 3-4 yellow stools a day; stools change from black meconium to green to yellow by about day 4-5
- check skin daily in natural light: press on the forehead, nose, or chest and look at the color as it blanches; also the whites of the eyes
- sunlight: do not put the baby in direct sunlight to treat jaundice (sunburn and overheating risk; not a safe treatment)
- call the pediatrician the same day for: yellow skin spreading to the belly, arms, or legs; yellow whites of the eyes; jaundice in the first 24 hours; a baby too sleepy to feed or feeding poorly; fewer wet or dirty diapers; pale or clay-colored stools or dark urine (signs of liver or biliary problems)
- call 911 or go to the ER for: a high-pitched cry, arching of the back or neck, stiffness or floppiness, fever, or a baby who is very hard to wake (signs of bilirubin encephalopathy)
- home phototherapy (fiber-optic blanket) may be ordered for mild cases: keep it on except for diaper changes, with daily bilirubin checks

spitting up, reflux (GER vs GERD), and gas in the newborn
- GER (gastroesophageal reflux): normal “spitting up” - the lower esophageal sphincter is immature and the stomach is small (holds about 50-60 mL at birth, slide 35)
  - very common, peaks around 4 months, usually gone by 12 months
  - “happy spitter”: effortless spit-up, baby comfortable and gaining weight - no treatment needed
- GERD (gastroesophageal reflux disease): reflux that causes problems
  - signs: poor weight gain, feeding refusal, arching and crying during feeds, irritability, choking or coughing, wheezing or recurrent pneumonia (aspiration), blood in spit-up
  - management: smaller, more frequent feeds; burp often; hold upright 20-30 minutes after feeds; thickened feeds or a hypoallergenic formula trial per provider (cow’s milk protein allergy can look like GERD); medications (acid suppressants) only if needed, per provider
- safe sleep with reflux: always on the back, flat, in a crib - do not raise the head of the mattress or use wedges or positioners (SIDS and suffocation risk) (AAP)
- red flags, not just reflux: projectile vomiting at 2-8 weeks (pyloric stenosis); green (bilious) vomit - always an emergency (obstruction, malrotation; duodenal atresia in the first 1-2 days, slide 62); blood in vomit or stool; fever; lethargy; a distended belly; poor weight gain or dehydration
- gas
  - from swallowed air (crying, poor latch, fast flow, bottle angle) and an immature gut
  - signs: fussiness, pulling the legs up, a firm belly that relaxes after passing gas
  - relief: burp during and after feeds (over the shoulder, sitting up, or across the lap); check latch; paced bottle feeding and a nipple with the right flow, holding the bottle so the nipple stays full of milk; bicycle the legs; tummy time while awake; gentle clockwise belly massage
  - simethicone drops are often used and safe, but the evidence that they help is weak
- colic: crying over 3 hours a day, 3 or more days a week, for 3 or more weeks in an otherwise healthy, growing baby; peaks about 6 weeks and resolves by 3-4 months; soothing (swaddling, white noise, rocking, pacifier); support for parents - teach never to shake the baby (put the baby down safely and step away if overwhelmed)

High-Risk Neonate

cold stress (slide 44)
- what: excessive heat loss that forces the newborn to use extra oxygen and energy to make heat
- susceptibility (slide 44)
  - newborns cannot increase activity enough and lack a shivering response to cold
  - heat is made by metabolism: brown fat (non-shivering thermogenesis) and glycogen stores
  - oxygen and energy are diverted from the brain, heart, and growth to thermogenesis
  - also: large surface area for body weight, thin skin, little insulating fat
  - highest risk: preterm, SGA, low birth weight, asphyxiated, infants of diabetic mothers, sick or sedated babies
- how heat is lost (4 ways)
  - evaporation: wet skin after birth or bath - dry immediately, remove wet linens
  - conduction: contact with cold surfaces - warm the scale, blankets, stethoscope, hands
  - convection: drafts and cool air - keep away from vents and doors, use a hat and swaddle
  - radiation: to cold nearby objects not touching the baby (windows, walls) - keep the crib away from outside walls and windows
- the cold stress chain: cold leads to more brown fat metabolism and more oxygen use, so hypoxia; anaerobic metabolism, so metabolic acidosis; glycogen and glucose used up, so hypoglycemia; pulmonary vasoconstriction, so worse hypoxia (can reopen fetal shunts); less surfactant production, so respiratory distress
- assessment (slide 44)
  - mottled skin or cyanosis; cool to touch; axillary temperature under 97.7 F (36.5 C)
  - abnormal blood gases (metabolic acidosis), hypoxia, hypoglycemia
  - also: tachypnea, grunting, lethargy, poor feeding, jittery, weak cry
- causes and related conditions (slide 44): hypoxemia (PO2 under 50 torr), intracranial hemorrhage or any CNS abnormality, hypoglycemia (under 40 mg/dL)
- treatment and prevention (slide 44)
  - keep the infant dry
  - heated environment right after birth: radiant warmer, skin-to-skin; neutral thermal environment (the temperature at which the baby uses the least oxygen and calories to stay warm); cover the head
  - rewarm slowly (rapid rewarming can cause apnea and hypotension); check temperature every 15-30 minutes while rewarming
  - check blood glucose and treat hypoglycemia (feed, or IV dextrose); give oxygen if hypoxic
  - delay the first bath until temperature is stable (WHO and AAP: about 24 hours, at least 6)
- neutral thermal environment (NTE) - the slide says “neuro-thermic environment,” which is the same idea (slide 44)
  - the environmental temperature at which the baby keeps a normal body temperature with the least oxygen use and the lowest metabolic rate - no energy spent making heat or cooling down
  - why it matters: calories and oxygen go to growth and healing instead of heat production; especially important for preterm and sick babies
  - how: radiant warmer or incubator (isolette) on servo control - a skin probe on the abdomen (not over a bone or brown fat area, and not under the baby) adjusts the heater to keep skin temperature about 97.7 F (36.5 C); skin-to-skin (kangaroo care) also provides it
  - nursing: check the probe is attached and the axillary temperature matches; keep incubator portholes closed; warm anything that touches the baby; hat; weigh daily (poor weight gain can mean energy is being spent on heat)
- hyperthermia is also dangerous: overheating raises metabolic rate and fluid loss; do not over-bundle at home

birth weight variations (slides 45-46)

normal birth weight: 2500 g (about 5.5 lb) or more (lecture; slide 45 says over 2500 g); typical term range 2500-4000 g

Category	Weight
Extremely low birth weight (ELBW)	Under 1000 g (2.2 lb)
Very low birth weight (VLBW)	Under 1500 g (3.3 lb)
Low birth weight (LBW)	Under 2500 g (5.5 lb)
Normal birth weight (NBW)	2500 g or more
High birth weight (HBW, macrosomia)	Over 4000 g (8.8 lb)

by gestational age (weight percentile for age, slide 45)
- SGA (small for gestational age): under the 10th percentile
- AGA (appropriate for gestational age): 10th-90th percentile
- LGA (large for gestational age): over the 90th percentile
- LBW and preterm are not the same: a term baby can be LBW (SGA), and a preterm baby can be AGA
risks (slide 46)
- LBW babies have about 20 times the risk of dying compared with babies over 2500 g
- LBW is linked to long-term neurologic disability, impaired language development, impaired academic achievement, and higher risk of chronic disease (cardiovascular disease, diabetes)
- SGA and LBW: hypoglycemia (small glycogen stores), hypothermia (little fat), polycythemia, meconium aspiration (if from placental insufficiency)
- LGA and macrosomia: birth trauma (shoulder dystocia, clavicle fracture, brachial plexus injury), hypoglycemia (especially infants of diabetic mothers), cesarean birth

LBW vs HBW comparison

	Low birth weight (LBW)	High birth weight (HBW, macrosomia)
Weight	Under 2500 g (5.5 lb)	Over 4000 g (8.8 lb)
Main causes	Prematurity (most common); IUGR from placental insufficiency (hypertension, preeclampsia), smoking, substance use, poor nutrition, infection, multiples, teen or older mother, poor prenatal care	Maternal diabetes (pre-existing or gestational - fetal hyperinsulinemia drives growth), maternal obesity, excess weight gain, post-term pregnancy, prior large baby, multiparity, genetics (large parents), male sex
Birth risks	Asphyxia, meconium aspiration (if IUGR), poor tolerance of labor	Shoulder dystocia, clavicle fracture, brachial plexus (Erb) palsy, birth trauma, cesarean birth, maternal PPH (overdistended uterus) and perineal tears
Newborn risks	Hypothermia (little fat and brown fat), hypoglycemia (low glycogen stores), RDS if preterm, polycythemia (SGA), jaundice, infection, NEC, feeding difficulty	Hypoglycemia (especially infants of diabetic mothers - high insulin after the maternal glucose supply stops), polycythemia, jaundice, RDS (infant of diabetic mother - insulin delays surfactant), hypocalcemia
Long-term	20x mortality risk; neurologic disability, language and learning problems, chronic disease later (slide 46)	Childhood obesity and later type 2 diabetes
Nursing focus	Thermoregulation (neutral thermal environment), glucose checks, feeding support (may need gavage), infection prevention, growth monitoring	Glucose checks (first 24 hours per protocol), assess for birth injury (clavicles, symmetric Moro, arm movement), early feeding, watch for jaundice

both need early and frequent glucose monitoring and feeding: the LBW baby because stores are low, the HBW baby (especially infant of a diabetic mother) because insulin is high

IUGR (intrauterine growth restriction) (slide 46)
- symmetric: head, length, and weight all small; starts early in pregnancy; genetic, structural (chromosomal), or infectious causes (TORCH); worse prognosis
- asymmetric: most common; normal head circumference with low weight (brain sparing - blood goes to the brain); starts later in pregnancy; from uteroplacental insufficiency (hypertension, preeclampsia, smoking)

IUGR - more detail

definition: the fetus does not reach its growth potential; estimated fetal weight under the 10th percentile for gestational age on ultrasound (the newborn is then usually SGA); IUGR describes the fetus, SGA describes the newborn
causes
- maternal: hypertension, preeclampsia, diabetes with vascular disease, smoking, alcohol and drugs (cocaine), malnutrition, anemia, high altitude
- placental: insufficiency, abruption, previa, infarcts, single umbilical artery
- fetal: chromosomal anomalies (trisomies), congenital infections (TORCH), multiple gestation

symmetric vs asymmetric (slide 46)

	Symmetric	Asymmetric
Pattern	Head, length, and weight all proportionally small	Normal head and length, low weight - head looks large for the thin body (brain sparing)
Onset	Early in pregnancy (first or early second trimester)	Later (third trimester)
Cause	Genetic, structural (chromosomal), or infectious - reduces cell number	Uteroplacental insufficiency - reduces cell size and fat stores
How common	Less common (about 20-30%)	Most common (about 70-80%)
Outlook	Worse; more long-term developmental problems	Better if caught; catch-up growth common

diagnosis: fundal height lagging 3 cm or more behind gestational weeks (after 20 weeks); serial ultrasounds; umbilical artery Doppler; nonstress tests and biophysical profile for fetal well-being
management in pregnancy: treat the cause, stop smoking, nutrition, rest; close fetal surveillance; corticosteroids if early delivery likely; delivery timed when risk inside the uterus outweighs prematurity
newborn problems: hypoglycemia (low glycogen), hypothermia (little fat), polycythemia (chronic hypoxia increases RBCs), meconium aspiration (fetal stress), asphyxia, hypocalcemia, infection
newborn appearance (asymmetric): thin, wasted look, loose dry skin, little subcutaneous fat, large-looking head, wide anterior fontanel, thin umbilical cord, often meconium stained

nursing: weigh in grams on a warmed, zeroed scale; plot weight, length, and head circumference on a growth chart; glucose checks for SGA, LGA, and infants of diabetic mothers per protocol; temperature support for small babies

meconium aspiration syndrome (MAS) vs respiratory distress syndrome (RDS) (slides 51-54)

	MAS	RDS
Who	Term and post-term babies (slide 51)	Preterm babies (slide 53), especially under 34 weeks; also infants of diabetic mothers and multiples (slide 53)
Cause	Fetus passes meconium in utero (stress, hypoxia) and inhales it before or at birth; associated with neonatal asphyxia and breech presentation (slide 51)	Surfactant deficiency - immature lungs (slide 53); surfactant production matures around 34-36 weeks; maternal diabetes (high fetal insulin) delays it
Mechanism	Meconium partly blocks the lower airways - ball-valve effect with air trapping; chemical pneumonitis; inactivates surfactant (slide 51)	Without surfactant the alveoli collapse at each breath (atelectasis); breathing gets harder and harder; hyaline membranes form
Onset	Respiratory depression at birth or within a few hours (slide 51)	Labored breathing after several minutes or hours of normal breathing (slide 53), worsening over 24-72 hours
Assessment	Meconium-stained amniotic fluid; staining of skin, nails, and umbilical cord; meconium seen below the vocal cords; barrel chest (slide 51)	Tachypnea over 60, grunting (keeps alveoli open), nasal flaring, retractions, cyanosis; unresponsive or apneic episodes (slide 53)
Chest X-ray	Patchy atelectasis mixed with hyperinflated areas throughout the lungs (slide 51)	Ground-glass appearance, air bronchograms, poorly defined heart border and pulmonary vessels (slide 53)
Complications	Pneumothorax (air trapping), persistent pulmonary hypertension of the newborn (PPHN), infection	Pneumothorax, bronchopulmonary dysplasia (from long ventilation), intraventricular hemorrhage, PDA
Treatment	Surfactant, ventilation, cooling (therapeutic hypothermia for asphyxia), antibiotics (slide 51); oxygen; NRP - non-vigorous baby gets ventilation first, no routine tracheal suctioning	Maintain body temperature / neutral thermal environment; parenteral nutrition (PO feeding contraindicated - risk of aspiration with fast breathing); patent airway and ventilation (CPAP, mechanical ventilation); surfactant via ET tube; antibiotics, diuretics, vitamin E (reduces oxidative stress) (slide 53)
Prevention	Avoid post-term pregnancy; monitor fetal status in labor	Antenatal corticosteroids (betamethasone) to the mother at 24-34 weeks when preterm birth is likely - speeds fetal lung maturity; control maternal diabetes

memory: MAS = term or post-term, meconium, mixed X-ray (hyperinflated plus collapsed); RDS = preterm, no surfactant, ground-glass X-ray
transient tachypnea of the newborn (TTN) is the milder third option: term or near-term, often cesarean without labor, retained lung fluid, resolves in 24-72 hours with supportive care

necrotizing enterocolitis (NEC) (slide 55)
- what: inflammation and death (necrosis) of part of the bowel wall, which can lead to perforation and sepsis; the most common GI emergency in newborns, mainly preterm babies
- onset: usually within the first 2 weeks of life (slide 55), often after feeds have started
- causes and risk factors (slide 55): cause unknown; immature digestive system; bacterial or viral infection; decreased intestinal blood flow (underdeveloped vessels, low oxygen at birth, poor regulation of blood flow to the gut); perinatal asphyxia; IUGR
  - also: prematurity (biggest risk), formula feeding (breast milk is protective), rapid advancement of feeds, polycythemia, exchange transfusion, umbilical catheters
- assessment (slide 55)
  - feeding intolerance: increasing gastric residuals, bile-colored (green) vomiting
  - abdominal distension (measure abdominal girth), tenderness, visible bowel loops, red or shiny abdominal skin
  - bloody stools (or occult blood)
  - temperature instability / hypothermia, lethargy, apnea, bradycardia - signs of sepsis
  - abdominal X-ray: air in the bowel wall (pneumatosis intestinalis) - the hallmark (slide 55); free air in the abdomen means perforation (surgical emergency)
- treatment (slide 55)
  - NPO - stop all feeds (bowel rest), usually for 7-14 days
  - nasogastric (orogastric) tube to low suction for decompression
  - IV fluids and TPN (nutrition), IV antibiotics
  - serial abdominal X-rays and girth measurements; labs (CBC, platelets, blood gases, cultures)
  - surgery for perforation or worsening: bowel resection, possible ostomy; long-term risk of short bowel syndrome and strictures
- NPO and nasogastric tube - the key treatment (lecture)
  - NPO (nothing by mouth): rests the bowel - no milk means no substrate for bacteria and no work for the damaged gut; usually 7-14 days; nutrition by TPN through a central line meanwhile; pacifier for non-nutritive sucking and comfort
  - nasogastric or orogastric tube to low intermittent suction: decompresses the stomach and bowel (removes air and fluid), relieves distension and pressure on the bowel wall, prevents vomiting and aspiration
    - newborns breathe through the nose (obligate nose breathers), so an orogastric tube is often preferred in small babies
    - measure length: nose (or mouth) to earlobe to midway between the xiphoid and umbilicus (NEX)
    - confirm placement by X-ray first, then per policy (aspirate pH); mark and tape at the nares or lip
    - record the color and amount of drainage (bilious or bloody output is significant); replace losses with IV fluids as ordered
    - keep the tube patent; mouth and nose care; check the skin under the tape
  - feeds restart slowly (often breast milk, small amounts) when the abdomen is soft, bowel sounds return, and X-rays clear
- nursing: measure abdominal girth at the same spot every shift (or before feeds), check residuals and stools for blood, no rectal temperatures, position on the side or back (not prone) to avoid pressure on the abdomen, strict I&O, watch for sepsis and shock
- prevention: breast milk (mother’s or donor), slow feed advancement in preterm babies, probiotics in some NICUs, antenatal steroids
neonatal abstinence syndrome (NAS) (slides 56-59)
- what: a group of signs and neurological behaviors in a newborn after abrupt discontinuation of exposure in utero to substances such as heroin, nicotine, alcohol, cannabis, opiates, cocaine, and methamphetamines (slide 56); when only opioids are involved it is also called neonatal opioid withdrawal syndrome (NOWS)
- how severe and when it starts depends on the timing of the last exposure, the type of substance, and the substance’s half-life (slide 56)
  - alcohol: withdrawal within 3-12 hours after birth (slide 56)
  - narcotics (short-acting opioids such as heroin): within 48-72 hours (slide 56); methadone and buprenorphine (long half-life): often later, up to 5-7 days - so these babies are watched in hospital for several days
  - barbiturates: between day 1 and day 14 (slide 56)
- signs of withdrawal (slide 57)
  - CNS: high-pitched, excessive crying; tremors; increased muscle tone; hyperactive reflexes; poor sleep; seizures (severe)
  - GI: excessive sucking (frantic sucking of fists) but poor feeding; vomiting; diarrhea; poor weight gain
  - autonomic: sneezing, yawning, nasal stuffiness, sweating, fever, mottled (blotchy) skin, tachypnea
  - skin breakdown on knees, elbows, and face from rubbing; diaper rash from diarrhea
  - memory: WITHDRAWAL - Wakefulness, Irritability, Tremors and temperature instability, Hyperactivity, high-pitched cry, Diarrhea and diaphoresis, Respiratory distress and rhinorrhea, Apnea, Weight loss, Alkalosis (respiratory), Lacrimation
- fetal alcohol syndrome (FAS) (slide 57): facial deformities, heart defects, neurological, cognitive, and behavioral issues, vision and hearing problems
  - a lifelong condition caused by alcohol crossing the placenta and damaging the developing brain and organs - not withdrawal (though a baby can also withdraw from alcohol at 3-12 hours)
  - FAS is the most severe form of fetal alcohol spectrum disorders (FASD); the leading preventable cause of intellectual disability
  - no safe amount, no safe time, and no safe type of alcohol in pregnancy; damage can happen before a woman knows she is pregnant (weeks 3-8 are the highest risk for structural defects)
  - three key features
    - facial: small eye openings (short palpebral fissures), smooth philtrum (no groove between nose and upper lip), thin upper lip (vermilion border); also flat midface, small head, epicanthal folds, low nasal bridge, small jaw
    - growth: low birth weight and poor growth (height or weight under the 10th percentile)
    - CNS: small head (microcephaly), intellectual disability, learning and memory problems, hyperactivity and attention problems, poor judgment and impulse control, seizures, poor coordination
  - other: heart defects (septal defects), kidney and bone problems, vision and hearing problems
  - newborn: irritability, poor suck and feeding, tremors, sleep problems, hypotonia
  - care: early diagnosis and early intervention services; feeding support; developmental follow-up; no cure - prevention is the only answer
  - nursing: screen all pregnant women for alcohol use nonjudgmentally at every visit; teach complete abstinence; refer for treatment
- assessment: a scoring tool quantifies how severe the withdrawal is (slide 58) - Finnegan scale (scored every 3-4 hours) or the newer Eat, Sleep, Console approach (can the baby eat 1 oz or breastfeed well, sleep 1 hour or more, and be consoled within 10 minutes); maternal history and infant urine, meconium, or umbilical cord drug testing
- treatment (slide 58)
  - non-drug care first: quiet, dim room; swaddling; holding, skin-to-skin, gentle rocking; pacifier; small frequent feeds (high-calorie formula if needed); cluster care to limit stimulation; rooming-in with the parent; protect the skin
  - medications when there are seizures, weight loss, dehydration, poor feeding, diarrhea, vomiting, fever, or inability to sleep (slide 58)
  - opioid withdrawal: morphine, methadone (slide 58); also buprenorphine; clonidine and phenobarbital as add-ons (slide 58); dose is weaned slowly
  - alcohol withdrawal: benzodiazepines (slide 58)
- breastfeeding is not contraindicated with methadone (or buprenorphine) use if the mother is in treatment and not using other drugs (slide 58); breast milk can ease withdrawal; infants of mothers on methadone must be weaned gradually to avoid withdrawal (slide 58)
  - contraindicated with ongoing illicit drug use or HIV
- nursing: nonjudgmental care for the mother, involve her in soothing the baby, social work referral and follow-up, safe sleep teaching, watch weight daily
cleft lip and cleft palate (slide 61)
- what: congenital malformations from incomplete fusion of the lip and/or palate during weeks 4-12 of gestation (slide 61); can occur alone or together; cleft lip (with or without palate) is more common in boys, isolated cleft palate in girls
- assessment (slide 61)
  - cleft lip: a small notch to a large fissure in the upper lip, up to the nasal septum and including the anterior maxilla; one-sided (unilateral) or both sides (bilateral) - obvious at birth
  - cleft palate: midline, lateral, or bilateral fissures in the hard or soft palate - may be missed unless the palate is felt with a gloved finger and looked at with a light
- causes: congenital malformation in weeks 4-12 (slide 61); genetics plus environment - maternal smoking, alcohol, anticonvulsants (phenytoin, valproate), steroids, folic acid deficiency, diabetes; can be part of a syndrome
- repair timing (slide 61)
  - lip: 1-3 months (often by the “rule of 10s”: 10 weeks old, 10 lb, Hgb 10)
  - palate: 12-18 months, before the child develops speech (to prevent altered speech) (slide 61)
- problems: feeding (can’t create suction - milk comes out the nose), aspiration, ear infections and hearing loss (eustachian tube dysfunction), speech problems, dental problems, parental grief and bonding
- considerations (slide 61)
  - maintain adequate nutrition
    - feed upright (sitting position) to reduce aspiration and milk through the nose
    - special bottles and nipples (squeezable bottle, Haberman or Pigeon feeder, cross-cut nipple) placed away from the cleft; breastfeeding may work with cleft lip only (breast tissue fills the gap)
    - small frequent feeds, burp often (swallows lots of air), feeding takes longer (limit to about 20-30 minutes to avoid fatigue)
    - weigh regularly
  - assess for respiratory distress, aspiration, blockage, and swallowing (slide 61); suction at the bedside
  - after repair: minimize crying (slide 61) - crying stresses the suture line; comfort, pain medication, parent holding
    - lip repair: position on the back or side - never on the stomach (rubs the incision); protect the suture line (Logan bow); elbow restraints (no-nos) so hands stay away from the mouth - release one at a time every 2 hours; clean the suture line as ordered
    - palate repair: nothing in the mouth - no straws, pacifiers, spoons, or suction catheters; feed with a cup or side of a spoon; may lie on the stomach (prone) after palate repair to drain secretions
  - emotional support (slide 61): parents may grieve the visible defect; show before-and-after photos, emphasize the baby’s normal features, model holding and feeding, involve the cleft team (surgeon, speech therapist, dentist, ENT, audiologist, social work)
atresia (slide 62): a congenital defect that results in complete obstruction (closure or absence) of a body opening or lumen
- intestinal atresia is one of the most frequent causes of bowel obstruction in the newborn and can occur at any point in the GI tract (slide 62)
- duodenal atresia - the most common intestinal atresia (slide 62)
  - bilious (green), projectile vomiting in the first 24-38 hours after birth (slide wording; usually stated as the first 24-36 hours), usually noted after the first feeding (slide 62)
  - associated with polyhydramnios (the fetus can’t swallow and absorb amniotic fluid) and trisomy 21 (Down syndrome) - about 30% (slide 62)
  - X-ray: “double bubble” sign (air in the stomach and the first part of the duodenum, no air beyond)
  - abdomen often NOT distended (the block is high), unlike lower obstructions
  - treatment: NPO, NG or OG tube to suction, IV fluids and electrolytes, surgical repair (duodenoduodenostomy)
- other atresias to know
  - esophageal atresia with or without tracheoesophageal fistula (TEF): the esophagus ends in a blind pouch
    - the 3 Cs: coughing, choking, and cyanosis with feeding; excessive drooling and frothy saliva; can’t pass an NG tube; polyhydramnios
    - immediately: stop feeding (NPO), suction the pouch, keep the head elevated (prevents reflux of stomach acid into the lungs through the fistula); surgery
  - jejunal and ileal atresia: lower obstruction - abdominal distension, bilious vomiting later, no meconium
  - anal atresia (imperforate anus): no anal opening or it ends in a pouch; no meconium in 24-48 hours, no rectal temperature possible; may have a fistula (meconium in the urine or vagina); surgery, sometimes a temporary colostomy
  - choanal atresia: blockage of the back of the nasal passage; newborns breathe through the nose, so cyanosis at rest that improves with crying (mouth opens); can’t pass a catheter through the nose; oral airway, surgery
  - biliary atresia: bile ducts blocked or absent - jaundice after 2 weeks with clay-colored stool and dark urine (conjugated bilirubin); Kasai procedure, often liver transplant
- general rule: green (bilious) vomiting in a newborn is a surgical emergency until proven otherwise - stop feeds and notify right away

omphalocele vs gastroschisis (slides 63-64): abdominal wall defects where bowel (and sometimes other organs) is outside the body

	Omphalocele	Gastroschisis
Location	Through the umbilicus (belly button) - the cord inserts into the sac (slide 63)	Beside the umbilicus, usually to the right (slide 63); cord is normal
Covering	Covered by a thin membrane (sac) of peritoneum and amnion - intestines easily seen through it (slide 63)	No membrane - bowel is exposed directly to amniotic fluid and air (slide 63)
Contents	Intestines and often liver and other organs	Usually intestines only; bowel may look thick, matted, and inflamed (from amniotic fluid exposure)
Associated problems	More likely to have other anomalies: cardiac malformations and chromosomal abnormalities (trisomy 13, 18, 21), Beckwith-Wiedemann syndrome (slide 63)	More likely to have GI problems such as intestinal atresia (slide 63), malrotation, poor bowel motility; few other anomalies
Mother	Often older	Often young (teen) mother; linked to smoking, drugs
Prognosis	Depends on the associated anomalies	Usually good after repair; feeding may be slow to start

memory: Omphalocele = Over the umbilicus, Organs in a sac, Other anomalies; Gastroschisis = Gut out, no covering, to the right
often found on prenatal ultrasound (and raised maternal AFP) - plan delivery at a center with pediatric surgery
immediate care at birth (both)
- cover the exposed bowel or sac with sterile, warm, moist saline dressings and then plastic wrap, or place the lower body in a sterile bowel bag - keeps it moist, warm, and clean; do not apply pressure
- position: side-lying or supine with the defect supported so the bowel does not kink and blood supply is kept (check bowel color - pink is good, dark or dusky means poor blood flow)
- prevent heat and fluid loss: radiant warmer, monitor temperature closely (large exposed surface), IV fluids (big fluid losses)
- NPO, OG or NG tube to suction (decompress the gut)
- IV antibiotics (infection risk), monitor glucose
- protect the sac in omphalocele from rupture; avoid latex
surgery: primary closure if small; staged repair with a silo (a pouch that slowly returns the bowel into the abdomen over days) if large; TPN until the gut works
after surgery: watch for abdominal compartment syndrome (tight abdomen, poor breathing, low urine output, poor leg circulation) as organs return to a small abdomen

neural tube defects (NTDs) (slides 65-68)

the neural tube (which becomes the brain and spinal cord) fails to close; occurs during the first month of pregnancy (slide 65) - closes by about day 28, often before she knows she is pregnant
the two most common defects are spina bifida and anencephaly (slide 65)
spina bifida (opening in the spine) - from least to most severe (slide 65)
- spina bifida occulta (“hidden”): a gap in the spine (vertebrae did not fully close), but the spinal cord is not involved; causes no disability (slide 65)
  - the mildest and most common form; no sac, no opening - the skin is closed over it
  - usually at the lower back (lumbosacral); often found by chance on an X-ray later in life
  - skin clues over the lower spine: a dimple or pit, a tuft of hair, a birthmark or hemangioma, a fatty lump - report these at the newborn exam
  - usually no treatment; rarely linked to a tethered spinal cord (cord stuck to the spine) - signs later include back pain, leg weakness, foot changes, or bladder problems, and an ultrasound or MRI is done if skin clues are present
  - teaching: reassure parents it usually causes no problems; folic acid is still recommended for future pregnancies
- meningocele: fluid-filled sac with meninges and CSF, but the spinal cord is not involved (slide 65); usually few or no neurologic deficits after repair
- myelomeningocele (open spina bifida): incomplete neural tube closure with a fluid-filled sac protruding from the back containing part of the spinal cord, meninges, nerves, and CSF; the most severe and most common form (slide 65)
  - effects: paralysis below the level, urinary and bowel control problems (slide 65), clubfoot, hip dislocation, loss of sensation
  - most also have hydrocephalus (Chiari II malformation) - watch head circumference, bulging fontanel, sunset eyes, high-pitched cry, vomiting; usually needs a VP shunt

meningocele vs myelomeningocele - side by side (slide 65)

	Meningocele	Myelomeningocele
Sac contains	Meninges and CSF only - spinal cord NOT involved (slide 65)	Meninges, CSF, spinal cord and nerves (slide 65)
Word clue	“mening-“ = meninges only	“myelo-“ = spinal cord + meninges
Covering	Usually covered by skin	Often open or thin membrane - leaks CSF
How common	Less common	Most common and most severe form (slide 65)
Neurologic deficit	Usually none or mild	Paralysis and loss of sensation below the level; bowel and bladder dysfunction (slide 65); clubfoot, hip dislocation
Hydrocephalus	Uncommon	Common (about 80-90%; Chiari II) - often needs a VP shunt
Light test	Sac transilluminates (lets light through - fluid only)	Does not transilluminate as clearly (nerve tissue inside)
Prognosis	Good after surgical repair	Lifelong disability; depends on the level (higher = more deficit)
Care before surgery	Same for both: protect the sac with a sterile moist dressing, prone or side-lying, latex precautions, prevent infection, early surgical closure

memory: MYelomeningocele = MY cord is in it, the worse one

anencephaly: the top of the neural tube does not close, so the skull, scalp, and brain do not develop normally - parts of the brain and skull are missing (slide 67); not compatible with life (stillbirth or death within hours to days); comfort care and family grief support
encephalocele: brain tissue protrudes through an opening in the skull (often the back of the head)
screening and diagnosis: maternal serum AFP at 15-20 weeks - high AFP suggests an open NTD; ultrasound; amniocentesis (AFP and acetylcholinesterase)
risk factors and prevention (slide 68)
- folate (folic acid, vitamin B9) lowers the risk by improving DNA and RNA function and repair in neural cells (slide 68)
  - all women who could become pregnant: 400 mcg (0.4 mg) daily, starting at least 1 month before conception
  - prior NTD-affected pregnancy: 4 mg (4000 mcg) daily
  - food sources: leafy greens, legumes, citrus, fortified grains
- certain antiseizure medications are linked to NTDs: carbamazepine (Tegretol), valproic acid (Depakote) (slide 68)
- uncontrolled diabetes increases the risk (slide 68)
- obesity increases the risk (slide 68)
- opioids in early pregnancy increase the risk (slide 68)
- also: prior NTD pregnancy, family history, high maternal temperature (hot tubs, fever) in early pregnancy
nursing care of a newborn with myelomeningocele (before surgery - usually closed within 24-72 hours)
- protect the sac: cover with a sterile, moist (saline), nonadherent dressing; keep it from drying, rupture, and infection; no diaper over it
- position: prone (on the stomach) or side-lying with hips slightly flexed and legs apart (abducted) - never on the back; head slightly lower than the sac to reduce CSF pressure on it
- latex precautions from birth (high risk of latex allergy from repeated procedures)
- prevent infection: keep stool away from the sac (a barrier drape below it); watch for meningitis (fever, irritability, lethargy)
- measure head circumference daily, check fontanels (hydrocephalus)
- assess movement and sensation of the legs, urine and stool output (neurogenic bladder - may need clean intermittent catheterization)
- support parents; hold the baby in the prone position if possible for bonding

Women’s Health

menstrual disorders (slides 69-70, 85; Durham Ch. 19)
- amenorrhea: absence of menstruation or menarche (slide 69)
  - primary: menarche has not occurred by age 15 (slide 69); causes - genetic (Turner syndrome), low body fat, low estrogen levels, structural problems
  - secondary: normal cycles followed by 3 months of no periods (slide 69); causes - hormonal factors, PCOS, excessive exercise, very low body weight (anorexia, female athlete triad), stress, thyroid or prolactin problems; the primary cause is pregnancy (slide 69) - always rule out pregnancy first
- dysmenorrhea: pain with menstruation that begins 1-2 days before bleeding starts (slide 69)
  - primary: no pelvic disease; from prostaglandins making the uterus contract; starts in the teens; treat with NSAIDs (block prostaglandins - start 1-2 days before), heat, exercise, oral contraceptives
  - secondary: from pelvic disease (endometriosis, fibroids, PID, adenomyosis); usually starts later in life
- endometriosis: functioning endometrial tissue outside the uterine cavity (ovaries, pelvic lining, bowel) (slide 69); most likely in women 30-40 years old (slide 69)
  - the tissue bleeds with each cycle, causing inflammation and scarring
  - signs: painful periods, painful intercourse (dyspareunia), pelvic pain, infertility (slide 85)
  - treatment: NSAIDs, oral contraceptives (slide 69), other hormone therapy (progestins, GnRH agonists), surgery (laparoscopy - also how it is diagnosed)
- polycystic ovary syndrome (PCOS) (slide 69)
  - chronic anovulation in the presence of obesity, hyperinsulinemia (insulin resistance), type 2 diabetes, lipid abnormalities, hirsutism (from increased testosterone), infertility, and ovarian cysts
  - the most common cause of female infertility (slide 69)
  - increased risk of breast, ovarian, and uterine (endometrial) cancer from higher estrogen levels unopposed by progesterone (slide 69)
  - also: acne, irregular or absent periods, acanthosis nigricans
  - treatment: weight loss, oral contraceptives (regulate cycles, lower androgens), metformin (insulin resistance), spironolactone (hirsutism), clomiphene or letrozole (fertility)
- abnormal uterine bleeding (AUB): a change in the normal bleeding pattern - heavier, between cycles, longer, or more often; causes include uterine fibroids, endometrial cancer, and infection (slide 70); also polyps, hormonal problems, bleeding disorders, pregnancy complications
  - any postmenopausal bleeding needs evaluation (endometrial cancer)
- premenstrual syndrome (PMS): occurs regularly in the luteal phase (about 2 weeks before menses) - irritability, bloating or fluid retention, heart palpitations, mood swings, migraines; cause unknown, likely hormonal fluctuations in estrogen and progesterone (slide 70)
  - care: exercise, limit salt, caffeine, sugar, and alcohol, calcium, NSAIDs, stress reduction; symptom diary
- premenstrual dysphoric disorder (PMDD): the severe form - marked depression, anxiety, affective lability, decreased interest in activities, suicidal thoughts; occurs regularly and symptoms are absent the last week of the cycle (slide 70); cause unknown, hormone fluctuations; treated with SSRIs, oral contraceptives
- ovarian cysts: benign fluid-filled sacs (slide 70); pressure, pain, dyspareunia (slide 85); treatment NSAIDs, oral contraceptives, surgical removal (slide 70); sudden severe pain can mean rupture or torsion (emergency)
- uterine fibroids (leiomyomas): benign tumors of the uterine muscle wall (slide 75); cause heavy bleeding, pressure, dyspareunia, anemia, infertility (slide 85)
  - note (fibroids): slide 85 defines fibroids with the endometriosis wording (“tissue similar to the lining of the uterus grows outside of the uterus”) - a slide error; fibroids are benign smooth muscle tumors, as slide 75 correctly says
pelvic floor disorders and prolapse (slides 71-74)
- pelvic floor disorders occur when the pelvic muscles can’t adequately support the pelvic organs, resulting in organ prolapse (slide 71)
- organs that can prolapse: bladder, uterus, rectum, small intestine (slide 71)
- causes and risk factors (slide 71)
  - after menopause the pelvic muscles atrophy or lose elasticity (low estrogen)
  - muscle damage from vaginal birth of a large baby or a difficult delivery; multiple vaginal births
  - obesity, chronic constipation (straining), strenuous exercise or heavy lifting (slide 71); chronic cough (COPD, smoking); aging; family history
- types (slide 71)
  - cystocele: bladder herniates into the front wall of the vagina - urinary symptoms
  - rectocele: rectum protrudes into the back wall of the vagina - constipation, incomplete emptying (may need to press on the vagina to pass stool)
  - enterocele: small intestine bulges into the vagina (top or back wall)
  - uterine prolapse: protrusion of the uterus into the vagina (slide 71) - the cardinal and uterosacral ligaments and pelvic floor muscles that hold the uterus up are weakened or stretched
    - grades (by how far the cervix descends)
      - 1st degree: cervix drops into the upper vagina
      - 2nd degree: cervix reaches the vaginal opening (introitus)
      - 3rd degree: cervix and part of the uterus outside the vaginal opening
      - 4th degree (procidentia): the whole uterus is outside the body
    - risk factors: multiple vaginal births (main cause), large baby or long pushing stage, menopause (low estrogen), aging, obesity, chronic cough or constipation, heavy lifting, connective tissue disorders
    - signs: heaviness or pulling in the pelvis, a bulge or tissue felt or seen at the vaginal opening, low back ache, worse with standing or lifting and better lying down, urinary problems (often with a cystocele), difficult bowel movements, painful intercourse, ulceration and bleeding of exposed tissue in severe prolapse
    - treatment: mild - Kegel exercises, weight loss, treat constipation, avoid heavy lifting; vaginal estrogen after menopause; pessary (good for women who want more children or are poor surgical candidates); surgery - vaginal hysterectomy with repair, or uterine suspension (uterus-sparing)
    - nursing: teach Kegels, pessary care, protect exposed tissue (keep clean and moist), watch for UTI and urinary retention; after vaginal hysterectomy - bleeding, voiding, no lifting or intercourse for about 6 weeks
  - vaginal vault prolapse: the top of the vagina drops after a hysterectomy
- can lead to dyspareunia, urinary incontinence, and bowel dysfunction (slide 71)
- symptoms of prolapse (slide 73)
  - pelvic pressure or heaviness (“something is falling out”), often worse at the end of the day or after standing, better lying down
  - painful intercourse
  - urinary difficulties: difficulty voiding, incomplete bladder emptying, frequent bladder infections, urinary incontinence (stress incontinence with cough, sneeze, laugh)
  - constipation or incomplete defecation
  - back pain
- treatment (slide 74)
  - Kegel exercises: tighten the pelvic floor muscles (as if stopping urine flow - but do not practice while actually voiding), hold 3-10 seconds, relax, repeat 10-15 times, 3 times a day; results take weeks to months
  - estrogen replacement (often vaginal estrogen) may benefit postmenopausal women by reversing atrophy of vaginal tissue and improving tone (slide 74)
  - pessary: a rubber or silicone ring or disc inserted into the vagina to support the prolapsed uterus or bladder (slide 74); teach removal and cleaning on schedule, watch for discharge, odor, bleeding, or erosion; regular follow-up
  - surgical intervention (slide 74): anterior or posterior repair (colporrhaphy), hysterectomy, vaginal vault suspension, mesh or sling for incontinence
  - also: weight loss, treat constipation (fiber, fluids), avoid heavy lifting, stop smoking, pelvic floor physical therapy, bladder training
infertility (slides 75-76): inability to achieve pregnancy after a year or more of unprotected intercourse (slide 75); after 6 months if the woman is 35 or older; male factors contribute in about 40-50% of couples, so both partners are evaluated
- female factors (slide 75): ovulatory, tubal/pelvic, or uterine factors; PCOS; hyperprolactinemia; declining ovarian reserve with age; endometriosis and prior ectopic pregnancy; PID (leading cause of tubal factor infertility, usually from chlamydia or gonorrhea); fibroids; congenital uterine anomalies
- male factors (slide 76)
  - genetic
    - Klinefelter syndrome (47,XXY): small firm testes, low testosterone, very low or no sperm
    - Noonan syndrome: often undescended testes
  - congenital
    - cryptorchidism: failure of the testes to descend into the scrotum - leads to oligospermia (low sperm count) if not corrected (slide 76); higher temperature in the abdomen damages sperm production; surgery (orchiopexy) by about 6-12 months of age; also raises testicular cancer risk
    - varicocele: abnormal dilation of the veins in the spermatic cord (“bag of worms” feel); the most common correctable cause of male infertility; usually on the left side (slide 76) - the left testicular vein drains at a right angle into the left renal vein; warms the testis and lowers sperm quality; surgical repair
  - acquired
    - infections: chlamydia, gonorrhea (scarring and blockage), mumps orchitis after puberty (slide 76)
    - medications and drug use: illegal drugs, chemotherapy (slide 76); also anabolic steroids and testosterone supplements (shut down sperm production), marijuana, alcohol, smoking, radiation; sperm banking before cancer treatment
    - testicular torsion: needs correction within 6 hours to preserve testicular function (lecture and slide 76)
      - the testis twists on the spermatic cord, cutting off its blood supply; after about 6 hours the chance of saving it drops sharply (most are lost by 12-24 hours)
      - who: most common in adolescents (12-18) and newborns; often during sleep or after activity or minor trauma; “bell clapper” deformity (testis not attached to the scrotal wall) raises risk
      - signs: sudden, severe one-sided scrotal pain, often with nausea and vomiting, lower abdominal pain; swollen, tender, high-riding testis lying sideways (horizontal); absent cremasteric reflex on that side; elevating the testis does NOT relieve pain (negative Prehn sign - unlike epididymitis, where it may help)
      - diagnosis: clinical; Doppler ultrasound shows no blood flow - but do not delay surgery for imaging if the picture is clear
      - treatment: surgical emergency - detorsion and fixation of both testes (orchiopexy, since the other side is at risk too); orchiectomy if the testis is dead
      - nursing: NPO, pain control, prepare for surgery quickly, notify the surgeon; teach boys and parents that sudden scrotal pain is an emergency - go to the ER right away, do not wait
      - why it matters for fertility: a lost or damaged testis lowers sperm production
    - heat exposure (hot tubs, laptops on the lap), obesity, environmental toxins
  - sperm transport problems: ejaculatory disorders from spinal cord injury, surgery (prostate), or medications - antihypertensives, antidepressants, sedatives (slide 76); retrograde ejaculation (semen goes into the bladder - diabetes, prostate surgery); blocked or absent vas deferens (cystic fibrosis)
  - erectile dysfunction: cardiovascular disease, diabetes, neurologic disease, medications (slide 76); also hypertension and obesity (slide 85)
  - hormonal: low testosterone, high prolactin, pituitary problems
- male evaluation: semen analysis first (sperm count, motility, morphology, volume) - abstain 2-5 days before, collect the whole sample, deliver within 1 hour at body temperature; hormone levels; scrotal ultrasound; genetic testing if very low count
- teaching: healthy weight, stop smoking and drugs, limit alcohol, avoid heat to the scrotum, loose underwear; treatment depends on cause - surgery (varicocele), hormones, IUI, IVF with ICSI (single sperm injected into the egg)
- emotional: infertility causes stress, grief, guilt, and relationship strain for both partners - offer counseling and support groups
breast cancer (slides 82-83)
- most common cancer in women (after skin cancer); second leading cause of cancer death in women; about 1 in 8 women over a lifetime; men can get it too (about 1%)
- types
  - invasive ductal carcinoma (IDC): the most common type, 70-80% of breast cancers; starts in the milk ducts and can spread to other parts of the breast, lymph nodes, or bloodstream (slide 82)
  - invasive lobular carcinoma (starts in the milk-making lobules)
  - ductal carcinoma in situ (DCIS): non-invasive, confined to the duct - early stage
  - inflammatory breast cancer: rare, aggressive - red, swollen, warm breast with peau d’orange (orange-peel skin); often mistaken for mastitis
  - receptor status guides treatment: estrogen and progesterone receptor (ER/PR) positive, HER2 positive, or triple negative (hardest to treat)
- symptoms (slide 82)
  - a lump in the breast (often hard, painless, irregular, fixed) - most common sign; often upper outer quadrant
  - change in breast shape or size
  - dimpling or puckering of the skin
  - fluid coming from the nipple (especially bloody, one-sided); milk rejection (the slide’s wording)
  - a newly inverted nipple
  - a red or scaly patch of skin
  - also swollen lymph nodes in the armpit
- risk factors (slide 82): family history of breast cancer; inherited genetic mutations (BRCA1 and BRCA2 - also raise ovarian cancer risk); pharmacology/chemotherapy (prior chest radiation, hormone therapy)
  - also: female sex and aging (biggest risks), early menarche (under 12), late menopause (over 55), no pregnancies or first pregnancy after 30, not breastfeeding, dense breasts, obesity after menopause, alcohol, inactivity, combined hormone replacement therapy
  - protective: breastfeeding, early full-term pregnancy, exercise, healthy weight, limiting alcohol
- survival rate: 99% when caught in its earliest, localized stages (slide 82) - why screening matters
- screening guidelines (slide 83)
  - average risk: mammogram every year or two starting at age 40 and continuing through age 75 (slide 83) - matches USPSTF 2024 (every 2 years, ages 40-74); ACS allows yearly from 40-45
  - high risk (slide 83): women who have had breast cancer, have genetic mutations that increase cancer risk, have had high-risk breast lesions on previous biopsies, or had high-dose chest radiation before age 30 - start earlier (often by 30) with yearly mammogram plus breast MRI
  - breast self-awareness: know how the breasts normally look and feel and report changes; clinical breast exam per provider
  - mammogram teaching: schedule 1 week after the period (less tenderness); no deodorant, powder, or lotion on the breasts or underarms that day (shows up as spots)
- diagnosis: diagnostic mammogram and ultrasound, then biopsy (core needle) - the only way to confirm; staging (TNM), sentinel lymph node biopsy
- treatment (slide 82): surgery, radiation therapy, and medications
  - surgery: lumpectomy (breast-conserving, usually with radiation) or mastectomy; sentinel node biopsy or axillary node dissection
  - medications: chemotherapy; hormone therapy for ER/PR-positive cancer (tamoxifen - raises endometrial cancer and clot risk; aromatase inhibitors such as anastrozole after menopause - bone loss); targeted therapy for HER2 (trastuzumab - watch heart function)
- nursing after mastectomy or node removal
  - drain care (empty and record output, strip tubing), watch the incision and flap
  - lymphedema prevention on the affected side: no BP, IVs, or blood draws on that arm (per policy), elevate the arm, gradual arm exercises (squeezing a ball, wall climbing) to restore range of motion, protect from cuts and burns, report swelling
  - body image and grief: let her look at the incision when ready, discuss reconstruction and prostheses, support groups
dyspareunia: painful intercourse - pain in the genitals or pelvis during or after sex
- a symptom, not a disease; appears across this lecture as a sign of: endometriosis, uterine fibroids, ovarian cysts (slide 85), pelvic organ prolapse (slides 71, 73), endometrial cancer (slide 87)
- types
  - superficial (entry) pain: at the vaginal opening - vaginal dryness, infection (yeast, STIs), vulvar conditions, vaginismus (involuntary muscle spasm), a healing episiotomy or tear
  - deep pain: with deep penetration - endometriosis, PID, fibroids, ovarian cysts, prolapse, pelvic adhesions
- causes especially relevant to this lecture
  - postpartum: perineal tears or episiotomy, low estrogen while breastfeeding (vaginal dryness), fatigue, fear of pain - common in the first months; most resume sex around 4-6 weeks when bleeding has stopped and tissue has healed
  - menopause: vaginal atrophy (genitourinary syndrome of menopause) from low estrogen - thin, dry tissue
  - infections: STIs, bacterial vaginosis, yeast, PID
  - psychological: anxiety, past trauma or abuse, relationship problems
- nursing: ask about it directly and without judgment (many women won’t bring it up); assess when it occurs, location, and history (births, menopause, infections, trauma); screen for abuse
- treatment depends on cause: water-based lubricant (safe with condoms), vaginal moisturizers, vaginal estrogen (postpartum breastfeeding or menopause), treat infections, pelvic floor physical therapy (vaginismus, postpartum), position changes to limit deep penetration, treat endometriosis or fibroids, counseling or sex therapy

female reproductive cancers (slide 87)

	Endometrial (uterine)	Cervical	Ovarian
What	Cancer of the lining of the uterus (slide 87)	Cancer of the cervix; 4th most common cancer in women worldwide (slide 87)	Cancer of the ovaries, fallopian tubes, or peritoneum (slide 87)
Key fact	Most common gynecologic cancer in the US; usually found early because it bleeds	Mostly preventable with HPV vaccine and screening	Deadliest gynecologic cancer - “silent,” usually found late
Symptoms	Unusual vaginal bleeding - between periods or after menopause (the classic sign); pelvic pain; dyspareunia (slide 87)	Typically no symptoms early; may have vaginal bleeding (slide 87) - after sex, between periods; discharge	Vague: pelvic or abdominal pain, bloating, loss of appetite or feeling full quickly, bowel changes, frequent urination (slide 87)
Cause / risk factors	Unopposed estrogen: metabolic syndrome (obesity, diabetes, hypertension), tamoxifen, estrogen-only medications (cause endometrial hyperplasia - progestin reduces it), positive family history (slide 87); also PCOS, never pregnant, early menarche, late menopause, Lynch syndrome	Persistent HPV infection (types 16 and 18) (slide 87); smoking, multiple partners, early sexual activity, immunosuppression (HIV), long-term oral contraceptive use	Age (slide 87), reproductive history - menarche before 12, first pregnancy after 35 or never pregnant (slide 87), estrogen hormone replacement therapy (slide 87); BRCA1/2 and Lynch syndrome, family history; protective: oral contraceptives, pregnancy, breastfeeding, tubal ligation
Screening	No routine screening; evaluate any postmenopausal bleeding (transvaginal ultrasound, endometrial biopsy)	Pap test from age 21 every 3 years; ages 30-65: Pap every 3 years, HPV test every 5 years, or both every 5 years; HPV vaccine at 11-12 (catch-up through 26)	No effective screening for average risk; CA-125 and transvaginal ultrasound for high risk or symptoms; risk-reducing surgery for BRCA carriers
Treatment	Surgery (hysterectomy), radiation, immunotherapy, chemotherapy, hormone therapy (slide 87)	Surgery, radiation, immunotherapy, chemotherapy (slide 87); early lesions (LEEP, cone biopsy)	Surgery (debulking), chemotherapy (slide 87)

Gardasil 9 (HPV vaccine)
- protects against 9 HPV types: 16 and 18 (cause about 70% of cervical cancers), 31, 33, 45, 52, 58 (more cancer types), and 6 and 11 (cause about 90% of genital warts)
- prevents cervical, vaginal, vulvar, anal, penile, and throat (oropharyngeal) cancers and genital warts - for boys and girls
- schedule (CDC)
  - routine at age 11-12 (can start at 9)
  - started before age 15: 2 doses, 6-12 months apart
  - started at 15 or older (or immunocompromised): 3 doses (0, 1-2, and 6 months)
  - catch-up through age 26; ages 27-45 by shared decision with the provider
- slide 81 wording: CDC recommends vaccination of all 11- and 12-year-olds, with catch-up for females through 26 and males through 21 - that male age limit is outdated; CDC now recommends catch-up through 26 for everyone
- best given before any sexual activity (before exposure); it prevents infection but does not treat existing HPV
- IM in the deltoid; side effects - sore arm, fever, headache; fainting can occur in teens, so have them sit or lie down for 15 minutes after
- not recommended during pregnancy (finish after delivery); safe while breastfeeding
- vaccinated women still need Pap and HPV screening (the vaccine does not cover every cancer-causing type)
memory: bleeding after menopause = endometrial until proven otherwise; HPV = cervical; vague bloating in an older woman = think ovarian
nursing: teach screening and HPV vaccination; report postmenopausal bleeding and persistent bloating; internal radiation (brachytherapy) precautions - private room, limited visitor time and distance, no pregnant visitors or children; support body image and sexuality after surgery

male reproductive cancers (slide 88)

	Prostate	Testicular	Penile
Key fact	Most common male cancer; 2nd leading cause of cancer death in US men (slide 88); usually slow-growing	Rare; typically ages 15-35 (slide 88) - the most common cancer in young men; highly curable (over 95%)	About 80% occur in men aged 55 or older (slide 88); rare in the US
Symptoms	Sometimes no symptoms; weak urine flow or frequent urination (slide 88); also nocturia, hesitancy, blood in urine or semen; late - bone pain (back, hips) from metastasis	Lump, swelling, pain, or heaviness in the testicle or scrotum; dull ache in the abdomen; back pain (slide 88); usually a painless, hard lump	Develops on or under the foreskin; sores, discharge, bleeding (slide 88); a lump or color change on the penis
Cause / risk factors	Cause unknown (slide 88); age over 50, Black men (higher rate and death), family history, BRCA mutations, high-fat diet	Cause unknown (slide 88); undescended testis (cryptorchidism) - the main risk, family history, Klinefelter, white men	Linked to HPV, smoking, phimosis (tight foreskin that can’t retract), age, HIV/AIDS (slide 88); poor hygiene, uncircumcised
Screening / detection	PSA blood test and digital rectal exam - shared decision ages 55-69 (USPSTF); earlier (40-45) for Black men or family history	Testicular self-exam monthly from puberty: after a warm shower, roll each testis between thumb and fingers; report lumps, swelling, heaviness; tumor markers (AFP, hCG, LDH), scrotal ultrasound	Inspect the penis; HPV vaccine and circumcision lower risk
Treatment	Surgery (prostatectomy), radiation, hormone therapy (androgen deprivation), chemotherapy, cryotherapy (slide 88); active surveillance for low-risk	Surgery (orchiectomy - removal of the testis through the groin), radiation (slide 88); chemotherapy; sperm banking before treatment	Surgery, radiation, chemotherapy (slide 88)
Nursing	After prostatectomy: catheter care, urinary incontinence (Kegels help), erectile dysfunction - discuss options	Body image, fertility (sperm banking), prosthesis option; the remaining testis usually keeps fertility and hormones normal	Body image, sexuality, urinary function after surgery

memory: older man with urinary symptoms = prostate; young man with a painless lump = testicular; foreskin sore in an older man with HPV or smoking = penile
other male reproductive disorders (slide 85): premature ejaculation (most common male sexual disorder - psychological, hormones, infections); male infertility (absent or low sperm count - infections, blockages, hormone imbalance); erectile dysfunction (diabetes, hypertension, medications, obesity)

Ethics

ethical considerations (slide 90)
- the four main principles of ethics (slide 90)
  - autonomy: the patient’s right to make her own decisions - informed consent, the right to refuse treatment
  - beneficence: promoting the patient’s best interests - doing good
  - non-maleficence: do no harm to the patient
  - justice: ensuring fairness and balance - equal access and fair distribution of care
  - related: veracity (truth-telling), fidelity (keeping promises), confidentiality (HIPAA)
- maternal autonomy vs fetal well-being: a competent pregnant person has the right to refuse treatment (such as a cesarean or blood transfusion), even if the fetus may be harmed; courts and ACOG generally support her decision
- the only three reasons a health-care provider should question a maternal decision - all three must be present (slide 90)
  1. the fetus is susceptible to irrevocable harm if treatment is not given
  2. the treatment is properly indicated and likely to work
  3. there is minimal risk to the pregnant person
- even then, the approach is discussion, consultation, and the ethics committee - not forced treatment
- nursing role: make sure consent is informed (risks, benefits, alternatives, in her language with a medical interpreter); advocate for the patient; document refusals and teaching; respect cultural and religious beliefs (for example, Jehovah’s Witness refusal of blood); involve the ethics committee for conflicts
- common maternal-newborn ethical issues: refusal of treatment, substance use in pregnancy (care, not punishment), prenatal genetic testing and termination, assisted reproduction and embryo storage, care at the limits of viability (extremely preterm infants), confidentiality for adolescents, newborn screening and vitamin K refusal